Patient Presentation
A 15-year-old male came to the emergency department with a large bump on the helix of his right ear pinna.
He was a wrestler and was not wearing his protective headgear during practice as he usually did and said that he had sustained repeated trauma to the right ear.
He said that “usually I don’t get hit that much.” He remembered a particular elbow hit to his ear just before the end of practice and that his ear was really sore.
Over several hours his ear swelled up and became more painful, but he put ice on it and took some acetaminophen.
The past medical history was non-contributory.
The review of systems was negative.
The pertinent physical exam showed a male in no acute distress with growth parameters in the 50-95%.
His right pinna showed a 2×2 centimeter tumor on the dorsal surface that was reddened, slightly compressible andvery painful. His neurological examination was normal as was the rest of his examination.
The diagnosis of an auricular hematoma was made. After discussing the need to relieve the pressure on the ear and the cartilaginous structures, and the need to wear his protective head gear for any competition and practice,
the ear was prepped and draped. A 20-gauge need was inserted and 3 cc of blood were obtained. With compression, additional blood was released through the puncture site.
A compression bandage was placed onto the ear to prevent re-accumulation of the blood or serous fluid.
The patient was instructed to return to clinic for re-evaluation with no practice or competition until he was seen. The following day, the bandage was removed and there was no re-accumulation. The cartilaginous structures appeared intact. He was reevaluated on two subsequent days and continued to have no reaccumulation.
The patient was instructed daily to wear his head gear during all competitions and practices to prevent recurrence.
Discussion
Auricular hematomas are common injuries particularly in wrestlers. They can also occur because of other direct trauma to the external ear structures which causes separation of the perichondrium from the underlying cartilage.
Auricular hematomas are potential problems because the pressure from the hematoma may cause destruction of the underlying avascular cartilagenous structures similar to nasal hematomas on the nasal septum.
Therefore it is important to relieve the pressure. Repeated trauma to the ear structures with underlying destruction and remolding of the cartilagenous structures is unfortunately common in wrestlers and is termed “cauliflower ear” because of its appearance.
Protective headgear should be used for all practices and competition and can reduce the chances of injury. The headgear itself should be properly fitted so that it does not cause injury to the ear itself.
Auricular hematomas may be on the ventral (near the ear canal) or dorsal (near the scalp) location or both. There can also be a single or multiple hematomas.
Learning Point
Acute auricular hematomas (< 7 days) should be drained completely. Lidocaine (1% usually without epinephrine, but some people use epinephrine) can be infiltrated into the incision site.
Needle aspiration can be preformed and often still is but reaccumulation occurs more often. This is accomplished using an 18 or 20-gauge needle punctured into the most fluctuant area and attempting to evacuate all of the accumulated blood.
If reaccumulation occurs then the incision and drainage technique should be performed.
Incision and drainage can be performed using a No. 15 scalpel and making a small incision (~5 mm) into the hematoma. The skin and perichondrium are separated from the hematoma and the hematoma is expressed or suctioned taking care not to injure the perichondrium.
The remaining hematoma pocket can be irrigated with normal saline. The perichondrium is then reapproximated and an optional drain may be left in place (and should be removed in 24 hours if there is no significant drainage or reaccumulation.
A compression bandage, not a simple bandage should be placed over the ear to prevent reaccumulation. Dry gauze is placed into the external canal. The rest of the external canal and anterior pinna can then be completely filled with petroleum gauze or moist gauze.
A gauze pack with 3-4 layers of gauze with a V cut out is placed between the head and the pinna with the interior part of the V against the pinna to fit snugly (i.e. the V is on its side with the point of the V directed toward the back of the head).
Gauze fluffs can be placed over the top of all bandages. The fluffs are then held in place using a gauze or elastic bandage encircling the head and coming under the chin. This is similar to a compression bandage for a head wound.
Antibiotics to cover for skin flora are recommended for 7-10 days. The patient needs to be seen every 24 hours for several days to check for reaccumulation.
If multiple lesions are present, then multiple drainages should be carried out.
Chronic auricular hematomas (> 7 days) should be referred to an otolaryngologist because of increased risk of complications.
Questions for Further Discussion
1. What other sports have an increased risk of auricular hematomas?
2. For various sports, list the proper safety gear a player should use?
Related Cases
- Disease
- Auricular Hematoma
Ear Disorders
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Leybell I, Regan L. Auricular Hematoma Drainage. Available from the Internet at http://www.emedicine.com/proc/topic82793.htm (rev. 11/3/2006, cited 6/19/2007).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, Children’s Hospital of Iowa
Date
August 13, 2007
Pediatric Education 