Auricular Haematoma

A collection of blood between the auricular cartilage and its overlying perichondrium, usually on the anterolateral surface, caused by shearing or blunt trauma.

Why it must be drained

Auricular cartilage is avascular and derives its entire nutrient supply by diffusion from the perichondrium. A subperichondrial collection separates the two, and the cartilage begins to necrose. Simultaneously, the elevated perichondrium is stimulated to lay down disorganised neocartilage and fibrous tissue.

The result is a thickened, contracted, irregular pinna, the cauliflower ear deformity, which is permanent and difficult to correct surgically. The collection also provides a culture medium for infection, and Pseudomonas aeruginosa perichondritis in this setting causes rapid cartilage destruction.

Timing determines outcome. Drainage within 48 to 72 hours gives the best cosmetic result. Beyond about 7 days the haematoma organises and requires open evacuation of clot and neocartilage rather than simple aspiration.

Mechanism: wrestling, rugby, boxing, mixed martial arts, assault, and in the elderly minor trauma on anticoagulants. Consider non accidental injury in a child with an auricular haematoma, particularly bilateral, since this is a recognised pattern of inflicted injury and the ear is not commonly injured accidentally in young children.

• Painful, tense, fluctuant swelling on the anterolateral surface of the pinna, obscuring the normal contours of the antihelix, scaphoid fossa and triangular fossa.
• Purple or bluish discolouration.
• Loss of the sharp definition of the helical and antihelical folds, which is the earliest and most useful sign.
• The lobule is spared, since it contains no cartilage.
• Tenderness disproportionate to the appearance.

Assessment beyond the ear

• Examine the canal and drum for coexisting perforation, and test hearing, since the same blow may have caused a middle ear injury.
• Assess for temporal bone injury, facial nerve function, and head injury where the mechanism warrants.
• Ask about anticoagulants and antiplatelet agents.
• In children, document the history carefully and consider safeguarding.

Signs of established infection, which change management

• Spreading erythema beyond the collection, increasing pain, fever, and purulent discharge.
• Lobule sparing erythema of the whole pinna indicates perichondritis.

Clinical. No imaging is required for the haematoma itself.

• Distinguish a haematoma from a seroma, which is a clear straw coloured collection following repeated minor trauma, and from an abscess, which is purulent and systemically symptomatic.
• Distinguish from relapsing polychondritis, which produces recurrent bilateral inflammation of the cartilaginous pinna with lobule sparing, without trauma, and is associated with nasal, laryngotracheal, ocular and joint involvement. Recurrent bilateral auricular inflammation without trauma requires investigation with erythrocyte sedimentation rate, antineutrophil cytoplasmic antibody and rheumatology referral.
• Coagulation studies and full blood count where there is a bleeding tendency, anticoagulation or a disproportionate haematoma after minor trauma.
• Computed tomography only if temporal bone or head injury is suspected on other grounds.

Drainage plus a compressive dressing that prevents reaccumulation. Drainage alone without effective compression fails.

Anaesthesia

• Local infiltration or an auricular block, which is preferable for larger collections. Block the great auricular, auriculotemporal and lesser occipital nerves with a ring of local anaesthetic around the base of the ear.
• Lidocaine 1 or 2 percent, maximum 3 mg/kg plain or 7 mg/kg with adrenaline. Adrenaline containing solutions are acceptable in the ear given its rich blood supply, and reduce bleeding.
• General anaesthesia for children and for large organised collections.

Drainage technique

• Needle aspiration with an 18 gauge needle is acceptable only for small, acute collections under 2 cm presenting within 48 hours. Reaccumulation is frequent and the patient must be reviewed within 24 hours.
• Incision and drainage is preferred for anything larger or older. Make a curvilinear incision along the natural contour of the helix or antihelix, parallel to the fold, to conceal the scar. Evacuate the clot completely, irrigate with saline, and remove any organised neocartilage.
• For a haematoma older than 7 days, an open approach with excision of fibrous tissue and neocartilage is required.
• Consider a small drain or leaving the incision partly open for 24 hours in a large collection.

Compression, which is the part most often done badly

• Through and through mattress sutures over dental rolls, silicone splints or cotton bolsters, placed on both anterior and posterior surfaces so that the skin is held against the cartilage. Use 3-0 or 4-0 non absorbable sutures, tied over the bolster, and leave for 7 to 10 days.
• Alternatively, thermoplastic splints, silicone putty moulded to the auricular contours, or a magnet based compression system.
• A conventional pressure bandage alone is unreliable and frequently slips. It should not be the sole method.
• Warn about pressure necrosis of the skin under an over tight bolster, which is why the sutures should be snug rather than strangulating and the ear should be inspected at 48 hours.

Antibiotics

• Cover Staphylococcus aureus and Pseudomonas aeruginosa given the cartilage risk, particularly in wrestlers and after open drainage.
• Ciprofloxacin 500 mg orally twice daily for 5 to 7 days is the usual choice for antipseudomonal cover in adults.
• Add or substitute flucloxacillin 500 mg orally four times daily where staphylococcal infection predominates, or use co amoxiclav 625 mg three times daily.
• Clindamycin 300 to 450 mg four times daily in penicillin allergy.
• In children, ciprofloxacin is used where pseudomonal cover is essential despite the general caution about quinolones in children, since cartilage loss is the greater risk. Discuss with a paediatric specialist.
• Established perichondritis requires intravenous therapy with ciprofloxacin 400 mg every 8 to 12 hours or piperacillin with tazobactam 4.5 g every 6 to 8 hours, and surgical drainage.

Follow up

• Review at 24 to 48 hours to detect reaccumulation, which is common and requires repeat drainage.
• Remove bolsters and sutures at 7 to 10 days.
• Review again at 2 weeks for cosmetic outcome and infection.
• Advise avoidance of contact sport for 2 to 4 weeks depending on the sport and on healing.

Prevention

• Properly fitted headgear for wrestling, rugby and mixed martial arts, worn consistently, which is the only effective prevention.
• Early presentation after any injury with swelling, since the outcome depends almost entirely on the interval to drainage.

Established cauliflower deformity

Correction requires reconstructive surgery with excision of fibrous and neocartilaginous tissue, recontouring of the cartilage framework and sometimes cartilage grafting. Results are variable and never restore normal anatomy, which is the argument for prompt treatment of the acute haematoma.