Received: 29 November 2018 

|  Revised: 7 July 2019 

|  Accepted: 26 July 2019

DOI: 10.1111/sms.13530

ORIGINAL ARTICLE

Cauliflower ear among Finnish high‐level male wrestlers and

judokas is prevalent and symptomatic deformity

Iida‐Kaisa Manninen1   | Karin Blomgren1   | Rauno Elokiuru2  | Mika Lehto3   |

Laura K Mäkinen 1
  | Tuomas Klockars 1

1
Department of Otorhinolaryngology, Head
and Neck Surgery, Helsinki University
Our research aimed to study the prevalence, concerns, and treatment practices related
Hospital and University of Helsinki, to cauliflower ear among Finnish wrestlers and judokas. In total, 32 Finnish wrestlers
Helsinki, Finland and 31 judokas completed a questionnaire at training sessions or at a competition.
2
KIHU ‐ Research Institute for Olympic
All participants were adults competing at the national or international levels. We also
Sports, Jyväskylä, Finland
3 took lateral digital photographs of participants’ ears. A senior author graded the over-
Heart and Lung Center, Helsinki
University Hospital, Helsinki, Finland all appearance of the auricles on a scale from 0 to 5 (0 = normal auricle, 5 = extreme
cauliflower ear). Cauliflower ear was more prevalent among male athletes (84%,
Correspondence
Iida‐Kaisa Manninen, Department of
46/55) than female athletes (0%, 0/8, P < .001). Almost all (96%) had sought treat-
Otorhinolaryngology, Head and Neck ment for an auricular hematoma. The most prevalent treatment modality was needle
Surgery, Helsinki University Hospital and aspiration (96%). Most (76%) had received treatment from individuals not represent-
University of Helsinki, Kasarmikatu 11‐13,
Helsinki, PL 263, 00029 HUS, Finland. ing the healthcare profession. Only one athlete reported receiving successful treat-
Email: iida-kaisa.manninen@helsinki.fi ment. No complications from treatment were reported. Almost all participants (96%)
reported some symptom from the cauliflower ear, typically pain. None regretted their
Funding information
Research special state subsidy funding cauliflower ear(s), and 41% of athletes with cauliflower ear considered it desirable.
Cauliflower ear is a common and symptomatic deformity among high‐level Finnish
wrestlers and judokas. Despite the symptoms, it is accepted and sometimes even
desired among the athletes.

KEYWORDS
ear deformity, judo, sport injury, wrestler's ear, wrestling

1  |   IN T RO D U C T ION outcome.7 Treatment options include aspiration or incision

with post‐drainage interventions such as suturing, dressings
Cauliflower ear, or wrestler's ear, is an acquired deformity or splints to prevent the re‐accumulation of the hematoma.8
of the auricle caused by blunt trauma, occurring most fre- In addition, protective headgear is suggested to reduce the
quently among martial arts athletes,1-4 with a prevalence occurrence of cauliflower ear.1
among wrestlers of 39%‐44%.1,2 Injury to the auricle causes a Our research aimed to study the prevalence, concerns, and
hematoma between the perichondrium and the auricular car- treatment practices related to cauliflower ear among Finnish
tilage, thus decreasing perichondrial blood flow resulting in wrestlers and judokas.
cartilage necrosis followed by fibroneocartilage formation.5
Cauliflower ear may cause aesthetic discomfort.3 In addition,
possible ear canal obstruction may cause cerumen accumula- 2  |  M ATERIAL S AND M ETHO D S
tion, external ear infections, and even hearing loss.2,3,6
Auricular hematomas should be evacuated promptly to We distributed a four‐page hardcopy questionnaire (see
avoid the formation of cauliflower ear and a poor cosmetic Appendix S1) including a written informed consent form

Scand J Med Sci Sports. 2019;00:1–5. wileyonlinelibrary.com/journal/sms © 2019 John Wiley & Sons A/S.     1 |
Published by John Wiley & Sons Ltd
 |
2       MANNINEN et al.

F I G U R E 1   Examples of cauliflower
ear and the grading of them from 0 to
5 (0 = normal auricle, 5 = extreme
cauliflower ear). The image on the left was
graded 1, the middle image reflects grade 3,
and the right image was identified as grade 5

to Finnish wrestlers or judokas attending training camps, (HUS/2441/2017) approved the study protocol. Written in-
regular training sessions, or a competition. All participants formed consent was obtained from all participants.
were adults competing at the national or international
levels.
The questionnaire consisted of questions about possible
3  |  RESULTS
cauliflower ear, training history, and the use of headgear.
3.1  | Demography
If an athlete reported a cauliflower ear, s/he was further
asked about the laterality, the age at which it occurred, and In total, 63 athletes participated in this study, of whom 32
possible treatments. Participants were also asked to grade were wrestlers and 31 were judokas. We distributed 65 ques-
possible symptoms (pain, warmth, ulcers, infections, ear- tionnaires, of which 97% (63/65) were returned. The major-
wax problems, hearing problems, cold sensitivity, dyses- ity of participants were men (87%, 55/63), the mean age was
thesia, and sunburn) on a five‐point Likert scale (1  =  no 22 years, and participants had trained an average of 15 years
harm, 5 = a lot of harm).9 In addition, this questionnaire in their sport. Among participants, 73% (46/63) reported hav-
was designed to reveal participants’ attitudes on cauli- ing a cauliflower ear, 61% of which were bilateral (28/46;
flower ear and included both fixed‐choice and open‐ended Table 1).
questions. Wrestlers and judokas did not differ with regard to age
We also took lateral digital photographs of participants’ or years of training. None of the female athletes had a cau-
ears. These pictures were later analyzed and graded by the liflower ear (0%, 0/8), while prevalence among men was
senior author (TK) who was unaware of the participant's higher (84%, 46/55, P  <  .001). However, the prevalence
sport and responses. The auricles were subjectively graded of cauliflower ear among male wrestlers (90%, 28/31) and
on a scale from 0 to 5 (0 = normal auricle, 5 = extreme cau- judokas (75%, 18/24) did not differ statistically. One‐fourth
liflower ear, Figure 1), based on the conchal region effect, of the athletes reported at least occasional use of protec-
lateral prominence, and overall appearance. tive headgear, which was more common among judokas
An independent consultant from Elisa Appelsiini Oy (P  =  .029). None of the participants used headgear on a
(Helsinki, Finland) completed all statistical analyses. regular basis, and the use of protective headgear was not
The ethics committee of the Helsinki University Hospital gender‐dependent (Table 2).

T A B L E 1   Demographic
All Wrestlers Judokas
characteristics of participants
(n = 63) (n = 32) (n = 31)
Mean age 22.2 (SD ± 4.7) 22.7 (SD ± 5.0) 21.6 (SD ± 4.3)
Years of training 14.6 (SD ± 3.8) 15.1 (SD ± 3.5) 14.0 (SD ± 4.0)
Women 13% 8/63 3% 1/32 23% 7/31
Cauliflower ear 73% 46/63 88% 28/32 58% 18/31
Unilateral cauliflower 29% 18/63 38% 12/32 19% 6/31
ear
Bilateral cauliflower ear 44% 28/63 50% 16/32 39% 12/31
MANNINEN et al.   
|
   3

3.2  | Photographs 3.4  | Symptoms

We took lateral photographs of 73% (46/63) of participants, Almost all participants (96%, 44/46) reported some symptom
89% (41/46) of which featured both ears (in total, 87 ear pic- from the cauliflower ear, typically pain. The majority of ath-
tures). In 92% (80/87) of the photographs, the participant and letes with cauliflower ear (61%, 28/46) graded their pain at
the senior author agreed on the diagnosis of cauliflower ear. three or more on a scale from 1 to 5. Warmth was the second
The senior author assigned a mean grade of 3.0 for the par- most common symptom, graded at 3 or more by 28% (13/46)
ticipants’ worse or only cauliflower ear, indicating various of athletes with cauliflower ear. Less common symptoms in-
degrees of cauliflower ear exist. There were no significant cluded dysesthesia, ulcers, cold sensitivity, earwax problems,
differences between wrestlers and judokas. We did, how- hearing loss, and infection (Table 3). We found no difference
ever, find a correlation between a worse ear grade and ulcers regarding symptoms between wrestlers and judokas.
(r = .48, P < .01). No other symptom associated with the ear
grade.
4  |  DISCUSSION
3.3  | Treatment 4.1  | Prevalence
Among the 47 athletes who reported an auricular hematoma, Cauliflower ear is a commonly acquired deformity among
45 (96%) had sought for treatment (Table 2). Despite treat- national‐ and international‐level Finnish wrestlers and ju-
ment, the hematoma resulted in the formation of cauliflower dokas. Almost three‐quarters (73%) of our respondents
ear in all but one case (98%, 44/45). The most prevalent treat- reported at least one cauliflower ear, a finding clearly
ment modality consisted of needle aspiration (96%, 43/45), higher than previous reports in which prevalence reached
whereby the majority reported some improvement (88%, approximately 40%.1,2 Given our study design, a positive
38/43). In addition, the majority of these athletes had received bias toward cauliflower ear is possible. Our athletes had
a pressure dressing following aspiration (88%, 38/43). Other markedly longer careers (15  years of training) in martial
treatment options included ice or cold compression (36%, arts compared with previous studies.1,2 Therefore, it seems
16/45) and surgery (7%, 3/45). The number of treatments per highly probable that in wrestling and judo a male athlete
athlete ranged from 1 to over 20, with a mean of eight treat- will experience an auricular hematoma during their train-
ments. No complications from treatment were reported. ing career.
Among athletes who sought help, treatment was most Cauliflower ear is significantly more prevalent among
often provided by a medical doctor (58%, 26/45). Others male athletes given that none of the female athletes in this
providing treatment included “a friend” (42%, 19/45), them- study reported a cauliflower ear. However, the number
selves (33%, 15/45), a relative (13%, 6/45), a nurse (11%, of female athletes was small. There are several possible
5/45), and a coach (11%, 5/45). explanations for this gender difference. The most likely

T A B L E 2   Use of headgear, treatment

Males
of auricular hematoma, and attitude toward
Male wrestlers Male judokas without
cauliflower ear
with cauli- with cauli- cauliflower
flower ear flower ear ear All females
(n = 28) (n = 18) (n = 9) (n = 8)
Occasional use of pro- 11% 3/28 50% 9/18 17% 1/6 20% 1/5
tective headgear
Treatment for auricular 100% 28/28 89% 16/18 11% 1/9 0% 0/8
hematoma
Treatment by a doctor 54% 15/28 61% 11/18 0% 0/9 0% 0/8
Would recommend 46% 13/28 56% 10/18 40% 2/5 88% 7/8
treatment
Would recommend use 21% 6/28 50% 9/18 20% 1/5 75% 6/8
of protective headgear
Views cauliflower ear as 43% 12/28 39% 7/18 20% 1/5 0% 0/8
a desirable deformity
Aesthetic disadvantage 0% 0/28 0% 0/18 20% 1/5 13% 1/8
Note: Not all athletes answered each question.
 |
4       MANNINEN et al.

T A B L E 3   Symptoms attitudes, 54% (25/46) of athletes with cauliflower ear re-

ported that it was disadvantageous when using earphones.
1 2 3 4 5
Almost all (93%, 43/46) athletes with cauliflower ear had
Symptom Mean grade Percentage (%) received comments concerning their ears, although none
Pain 2.74 24 13 37 17 9 viewed these as disturbing. Despite their symptoms and
Warmth 2.02 43 28 13 13 2 comments, none of the athletes regretted their cauliflower
Dysesthesia 1.63 63 15 17 4 0 ear(s) or viewed it as an aesthetic disadvantage. Thus, cau-
liflower ear is unexpectedly often (among about 40% of
Ulcers 1.59 59 28 9 4 0
athletes) considered a desired deformity, likely due to the
Cold sensitivity 1.57 72 7 17 2 2
“street credibility” associated with it among martial arts
Earwax problems 1.50 70 17 7 7 0
athletes.
Hearing problems 1.39 70 24 4 2 0
Infections 1.26 83 11 4 2 0
4.4  | Conclusions
Note: Symptoms were graded from 1 to 5 (1 = no harm, 5 = a lot of harm)
(n = 46). Cauliflower ear is a common and symptomatic deformity
among elite Finnish wrestlers and judokas, although nearly
explanation is the trauma mechanism. Male athletes are all individuals affected by it sought treatment for their injury.
stronger than females, thus causing greater injury during
training or competition. Another explanation may result
from cauliflower ear representing a desired deformity 5  |  PERSPECTIVE
among a remarkable proportion of male athletes (see Table
2). Cauliflower ear might also be generally more accept- Limited research exists on the prevalence of cauliflower
able among male athletes since it is considered a natural ear,1,2 and the symptoms and concerns related to it.2,6
consequence of their sport. Almost three‐quarters (73%) of our respondents reported at
least one cauliflower ear, a finding clearly higher than pre-
vious reports in which prevalence reached approximately
4.2  | Treatment
40%.1,2 Almost all (96%) of the participating athletes had
Almost all athletes with cauliflower ear had sought treat- sought treatment for their auricular hematoma. The he-
ment for their injury (96%, 44/46). Rather discourag- matomas are often treated by individuals not representing
ingly, in this study the treatment did not seem to prevent healthcare professionals, and instructions for draining a
the formation of cauliflower ear since only one athlete hematoma are abundantly available via Internet. Although
reported undergoing successful treatment. However, we the treatment does not seem to prevent the formation of
did not ask, if treatment was done every single time after cauliflower ear, the majority (88%, 38/43) of athletes re-
auricular injury. It is possible that proper treatment at ported benefit from aspiration.
every occasion could have prevented the formation of In our study, the cauliflower deformity is almost always
cauliflower ear. Nevertheless, we recommend treatment symptomatic, whereby 96% of our athletes with cauli-
since the majority (88%, 38/43) of athletes benefited flower ear reported some related discomfort, among which
from aspiration. Auricular hematoma was often treated pain was most prevalent. Despite their symptoms, none of
by individuals not representing healthcare professionals our athletes regretted their cauliflower ear(s) or viewed it
(76%, 34/45). Fortunately, despite this, complications as an aesthetic disadvantage.
remained scarce. Medical professionals should, how-
ever, be aware that instructions for draining a hematoma
ORCID
are abundantly available via YouTube and other Internet
resources. Iida‐Kaisa Manninen  https://orcid.
org/0000-0003-4832-3442
4.3  |  Symptoms and attitudes toward Karin Blomgren  http://orcid.org/0000-0001-8381-9174
cauliflower ear Mika Lehto  https://orcid.org/0000-0002-8691-5142

Limited research exists on the symptoms and concerns Laura K Mäkinen  https://orcid.
related to cauliflower ear.2,6 The deformity is almost al- org/0000-0001-5069-3851
ways symptomatic, whereby 96% (44/46) of our athletes Tuomas Klockars  https://orcid.
with cauliflower ear reported some related discomfort, org/0000-0003-1178-5715
among which pain was most prevalent. Reflecting current
MANNINEN et al.   
   5
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