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Clinical Procedures > Soft Tissue Procedures
Complex Laceration, Ear
Article Last Updated: Nov 5, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Gretchen S Lent, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Coauthor(s):
Neel Kumar, MD, Chief Resident, Department of Emergency Medicine, Albert Einstein College of Medicine, Jacobi and Montefiore Medical Centers
Editors: Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
complex laceration ear, ear laceration, auricular laceration, ear injury, ear repair, laceration repair, cartilage repair, bite wound, auricle laceration, auricle injury, pinna wound, pinna laceration, pinna repair, ear avulsion, auricular hematoma, ear anesthesia, cartilage debridement, ear suture, wedge excision, pinna avulsion, rim notch, rim notching, pressure dressing, compression dressing, erosive chondritis, keloid, keloid formation, shear injury
The auricle, or external ear, develops from 6 tubercles that fuse to form the tragus, crus helices, helix, antihelix, antitragus, and lobule. The intrinsic and extrinsic musculature of the ear, if damaged, is of no significant importance.
Anatomy of the external ear.
The ear consists of exceptionally vascular skin closely applied to an avascular cartilaginous framework. Lacerations to the ear may involve the skin, the fibrocartilaginous or fatty tissues of the auricle, or any combination thereof. Lacerations to the ear generally heal well because of the area's generous blood supply.
The primary goals of wound management are the expedient coverage of exposed cartilage and the minimization of wound hematoma.1 This topic covers partial ear lacerations; however, total avulsion of the ear is also encountered. The reimplantation of total ear avulsions has met with some success2, 3(see Ear, Reconstruction and Salvage).
For more information, see the Medscape Wound Management Resource Center.
- Simple wounds and lacerations to the pinna
Lacerated ear.
Specific injuries of the ear require urgent referral to a plastic surgeon. Such injuries include the following:
- Overlying skin avulsion larger than 5 mm
- Severe crush injuries
- Complete or nearly complete avulsions or amputations
- Auricular hematoma
- Cartilage defects larger than 5 mm
- Wounds that require the removal of more than 5 mm of tissue
- Involvement of the auditory canal
- Obvious devitalization
- Total ear avulsion
For small wounds to the ear without cartilaginous involvement, local infiltration may be used (see Local Anesthetic Agents, Infiltrative Administration and Anesthesia, Ear for more information). However, local anesthesia is generally best avoided because infiltration into the relatively compact ear space causes pain and may distort landmarks that are crucial for cosmesis. Regional nerve blocks or field blocks are the preferred method of anesthesia in significant ear lacerations.4
Infiltration of local anesthesia.
Some experts suggest avoiding the use of epinephrine when anesthetizing the ear for fear of ischemic necrosis in this acral area. However, some literature supports the use of epinephrine when anesthetizing the ear; one study showed that epinephrine, along with a local anesthetic, was used in over 10,000 surgical procedures on the ear and nose without any complications.5 The use of epinephrine may be beneficial for laceration repair, as it decreases the amount of blood in the field, prolongs anesthesia, and reduces the time of procedures.
Personal protective equipment
- Gloves
- Sterile gloves
- Face shield
- Gown
Anesthesia equipment - Lidocaine without epinephrine
- Syringe, 10 mL
- Needle, 27 gauge (ga)
- Needle, 18 ga
Irrigation equipment - Sterile saline or water
- Syringe or irrigation device
- Splash shield
- Basin
Suture material6 - Absorbable sutures (eg, nylon, Ethilon), 5-0 or 6-0
- Nonabsorbable sutures (eg, Dexon, Vicryl), 5-0 or 6-0
- Suture tray
- Standard suture kit
- Fine scissors
- Clamp
- Tissue forceps
- Needle driver
- Scalpel, No. 15 blade
Dressing material - Gauze, Xeroform
- Gauze, 4 x 4 in
- Gauze, fluffed
- Kling gauze, 3 in
- Elastic bandage wrap (eg, Ace), 3 in
- The lateral decubitus position is preferred, with the injured ear facing up.
- The supine position may also be used.
Preparation
- All devitalized or contaminated tissue must be debrided.
- This step is especially important in bite wounds.
- As little tissue as possible should be debrided on the ear.
- As a result of generous vascularity, devitalization is relatively infrequent.
- Clean the wound with copious irrigation. Gauze may be placed in the external auditory canal for comfort prior to irrigation.
- Maintain sterility while preparing and draping the wound.
Cartilage
- Exposed cartilage must be either debrided or covered by skin.
- Avascular cartilage derives its blood supply from the overlying skin.
- Auricular skin often stretches to allow coverage of most defects.
- If the remaining skin cannot cover the cartilage, the cartilage should be cut away from the wound margin.
- In the case of a linear laceration to the pinna in which the skin does not approximate, a wedge excision technique is necessary.
Wound that requires a wedge excision. - To perform a wedge excision, a No. 15 scalpel is used to cut a full thickness triangle from the antihelix.
Cartilage is excised, leaving a 1-mm overhang of skin. - A 1-mm overhang of the skin beyond the cartilage is recommended to allow skin eversion when closing.
After the excision, the remaining skin is closed with eversion. - Up to 5 mm of cartilage can be removed without significant deformity.
- If part of the pinna is avulsed, reattaching the amputated part is generally unwise, especially in cases of bite wounds. The margins of the defect should be trimmed, and the anterior and posterior skin should be approximated for primary healing.
- In the case of extensive wounds, the cartilage may be approximated separately from the skin in a 2-layer technique.
- This method is only used in large lesions with 5-0 or 6-0 absorbable sutures to reduce tension from the wound edges.
- Begin at the depth of the wound and continue outward.
- Cartilage is fragile; to avoid tearing, only include the perichondrium with each stitch. Only gentle approximation of the cartilage is necessary.
- To preserve normal landmarks, the first sutures placed should be in folds and ridges.
- Smaller wounds may be approximated with a single layer of sutures through the skin and perichondrium as detailed below.
Skin
- In most cases, the skin is closed with simple interrupted sutures.
The skin of the ear is sutured in a simple interrupted technique. - Loose approximation is used in cases of contaminated wounds.
- Debride any devitalized skin as necessary.
- Beginning from the depth of the wound outward, close the posterior skin first, followed by the anterior and lateral surfaces of the helix.
- For this, 5-0 or 6-0 nonabsorbable sutures may be used.
- If possible, evert the skin on the free rim to avoid later notching and to minimize cosmetic defects.
- For optimal eversion and cosmesis (eg, to avoid rim notching), vertical mattress sutures may be required for lacerations that involve the rim of the ear.
- Sutures should be placed through the skin and perichondrium, not through the cartilage itself.
- The skin of the ear and the underlying cartilage adhere to each other so well that separate closure of the cartilage is usually unnecessary.
Dressing - After repair, pack Xeroform strips into the ear crevices.
- Place a piece of gauze (4 x 4 in) behind the ear and place fluffed gauze over the ear.
- Next, apply a pressure dressing to prevent hematoma formation.
A compression dressing is placed to prevent hematoma formation. - Wrap the head and injured ear with 3-in Kling followed by a 3-in elastic bandage wrap (eg, Ace).
The final compressing dressing topped with an elastic bandage wrap. - Leave the unaffected ear free of dressing.
Aftercare - Elevate the head for several days.
- Reevaluate the wound in 24 hours for hematoma formation and possible drainage.
- Sutures are removed in 4-5 days.
- In the case of trauma, inspect the tympanic membrane for hemotympanum and examine the external auditory canal for lacerations or evidence of a CNS leak.
- Always perform a thorough examination of the facial nerve7.
- Evacuation of a hematoma may be necessary prior to closure.
- Hemostasis must be achieved to prevent subsequent formation of a hematoma.
- Tetanus vaccination should be updated, when necessary.
- Antibiotics may be prescribed for high-risk injuries, including the following:
- Contaminated wounds
- Bite injuries
- Wounds that show signs of inflammation
- Erosive chondritis
- The cartilage of the ear is avascular; with disruption or removal of the overlying skin, risk of erosive chondritis exists.
- The use of cartilage sutures increases the risk of chondritis, and they should be used only when necessary.
- Delayed chondritis may occur after burns and other injuries and may respond to antibiotic therapy.
- Auricular hematomas
- Auricular hematomas occur when a shearing injury separates the auricular cartilage from the perichondrium, creating a space for blood to collect.
- The hematoma causes fibrotic changes and the deformity known as cauliflower ear.8
- To prevent this scarring, the hematoma must be evacuated and the ear compressed for a week.
- Keloid formation
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
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Cartilage is excised, leaving a 1-mm overhang of skin. |
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After the excision, the remaining skin is closed with eversion. |
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| Media file 8:
The skin of the ear is sutured in a simple interrupted technique. |
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| Media file 9:
A compression dressing is placed to prevent hematoma formation. |
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| Media file 10:
The final compressing dressing topped with an elastic bandage wrap. |
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Complex Laceration, Ear excerpt Article Last Updated: Nov 5, 2007
Topic originally published: Oct 30, 2007
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