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Clinical Procedures > Otolaryngologic and Dental Procedures
Drainage, Auricular Hematoma
Article Last Updated: Jun 23, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: Inna Leybell, MD, Staff Physician, Department of Emergency Medicine, Bellevue Hospital, New York University Hospital
Inna Leybell is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Student Association/Foundation, and Phi Beta Kappa
Coauthor(s):
Linda Regan, MD, Associate Director, Emergency Medicine Residency, Department of Emergency Medicine, Johns Hopkins Hospital and Health System
Editors: Prajoy P Kadkade, MD, Assistant Professor, Department of Otolaryngology and Communicative Disorders, North Shore University Hospital-Long Island Jewish Hospital System, Albert Einstein College of Medicine; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; 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; Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT; 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:
auricular hematoma, auricular hematoma drainage, ear hematoma, cauliflower ear, wrestler’s ear, hematoma drainage, auricular drainage, ear hematoma drainage, ear compression dressing, ear pressure dressing, anterior auricular swelling, subperichondrial blood
Auricular hematoma is a complication that results from direct trauma to the anterior auricle and is a common facial injury in wrestlers.1, 2 Shearing forces to the anterior auricle can lead to separation of the anterior auricular perichondrium from the underlying, tightly adherent cartilage. This may lead to tearing of the perichondrial blood vessels and subsequent hematoma formation.
Auricular hematoma.
The torn perichondrial vessels compromise the viability of the avascular underlying cartilage. Interestingly, the presence of a subperichondrial hematoma has been found to stimulate new and often asymmetric cartilage to form. This deformity, which is often referred to as cauliflower ear or wrestler’s ear, is often considered a badge of honor among wrestlers and rugby players. (Click here to complete a Medscape CME activity about another condition related to wrestling.)
Cauliflower ear.
The goal of treatment is to completely evacuate subperichondrial blood and to prevent its reaccumulation. The mechanism of hematoma drainage has been debated. To date, no randomized controlled trials have addressed this issue.
- Tender anterior auricular swelling after trauma, which deforms the normal anatomy of the pinna
- Presentation within 7 days after trauma (After 7 days, the formation of granulation tissue may complicate the procedure. At that point, patients should be referred to a specialist.)
- Hematomas that are older than 7 days
- Recurrent or chronic hematomas (In such cases, open surgical debridement by a specialist is indicated because the hematoma, granulation tissue, or both can be located within the cartilage instead of in the subperichondrial space.)
- Local anesthesia with lidocaine 1% with or without epinephrine can be infiltrated directly into the area to be incised.
- Many authors advocate the use of the lidocaine without the presence of a vasoconstrictive agent such as epinephrine. However, some literature supports the safety of vasoconstrictive agents in areas such as the nose or pinna.
- Alternatively, an auricular block can be performed. For more information, see Anesthesia of the Ear.
- Syringe, 3 mL, with a 23- or 27-gauge (ga) needle for anesthesia
- Syringe, 10 mL, with a 18- or 20-ga needle (if performing needle aspiration)
- Lidocaine 1% (with or without epinephrine)
- Scalpel, No. 15
- Small suction, if available
- Irrigation set-up (syringe, normal saline)
- Compression dressing materials
- Simple compression dressing: dry cotton, Vaseline gauze, 4 x 4 plain gauze, secondary dressing wrap (eg, Kling), scissors
Supplies needed to make a simple compression dressing. - Specialized compression dressing (to be made in a specialist's office; not described here): dental rolls (or cotton bolsters, silicone splints, or plaster mold), nylon or Prolene suture on straight needle
Place patient in the lateral decubitus position on the unaffected side.
Preparation
- Cleanse the skin with povidone iodine, ChloraPrep (chlorhexidine gluconate 2% and isopropyl alcohol 70%), or another cleanser.
- Anesthetize the area with lidocaine 1% or perform an auricular block. (For more information, see Anesthesia of the Ear.)
Choose the technique - Technique 1 - Needle aspiration
- Although still widely used, this method is no longer recommended by many sources because of hematoma reaccumulation. The aspiration is often inadequate and the hematoma requires additional management. Some sources recommend primary needle aspiration followed by the incision method, if reaccumulation occurs.
- Use an 18- or 20-ga needle to aspirate blood from the most fluctuant or full area.
- Technique 2 - Incision and drainage
- Incise the edge of hematoma along the natural skin folds using a No. 15 scalpel. A small (5 mm) incision is often all that is necessary.
- Gently separate the skin and perichondrium from the hematoma and cartilage and completely express or suction out the hematoma. Be careful not to damage the perichondrium.
Auricular hematoma incision and drainage. - Irrigate the pocket with normal saline.
- Optional step: Leave a small drain in the incision. This allows the wound to drain but also predisposes to infection. If a drain is placed, the patient should always be given antibiotics upon discharge. The drain should be removed in 24 hours if no significant bleeding occurs.
- Reapproximate the perichondrium to the cartilage.
Compression dressing
- Apply digital pressure for 5-10 minutes, and then apply compression dressing. A simple dressing is inadequate, as the hematoma is likely to reaccumulate.
- Compression dressings can be created in various ways. One simple method is as follows:
- Place dry cotton into the external canal.
Compression dressing: Dry cotton in external canal. - Fill all external auricular crevices with either moist gauze (soaked in saline) or Vaseline gauze.
Compression dressing: Vaseline gauze in anterior pinna. - Place 3-4 layers of gauze behind the ear as a posterior gauze pack. Prior to placement, cut out a V-shaped section of gauze so that the gauze fits snugly behind the ear.
Compression dressing: Gauze behind pinna. - Cover the packed anterior ear with multiple layers of fluffed gauze.
Compression dressing: Gauze applied to anterior ear. - Bandage the fluffed gauze into place with Kling or an elastic bandage.
Compression dressing: Bandaging dressing into place.
- Specialized compression dressings, such as a silicone splint or dental rolls sewn onto the anterior and posterior pinna, can also be made, though such dressings are normally prepared and applied by a specialist.
Aftercare
- The ear must be reexamined for hematoma reoccurrence every 24 hours for several days.
- Aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), or anticoagulants should be discontinued or avoided for several days to prevent continuing bleeding.
- Recommendations indicate that, upon discharge, patients should receive antibiotics that cover common skin flora for 7-10 days. Patients whose immune systems are compromised should receive antibiotic prophylaxis covering both Staphylococcus and Pseudomonas species.
- If infections suspicious for Pseudomonas species are discovered during follow-up, the patient should be admitted to the hospital for open drainage and intravenous antibiotics.
- Do not leave an auricular hematoma undrained unless the injury is older than 7 days.
- Apply a compression dressing rather than a simple dressing.
- Perform daily follow-up ear examinations.
- Reaccumulation of the hematoma
- Scar formation (cauliflower ear)
- Site infection
- Chondritis
UCSD Otolaryngology – Head & Neck Surgery: Ambulatory Healthcare Pathways for Ear, Nose, and Throat Disorders
Moira Davenport, MD. Department of Emergency Medicine, Department of Orthopedics, Allegheny General Hospital.
Christopher McStay, MD. Department of Emergency Medicine, New York University / Bellevue Medical Centers.
Beno Oppenheimer, MD. Department of Medicine, New York University / Bellevue Medical Centers.
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Drainage, Auricular Hematoma excerpt Article Last Updated: Jun 23, 2008
Topic originally published: Nov 1, 2006
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