Auricular hematoma: Difference between revisions
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== Background == | ==Background== | ||
*Separation of perichondrium from underlying cartilage tears the adjoining blood vessels | [[File:Slide2COR.jpg|thumb|Ear anatomy]] | ||
** | *Caused by blunt trauma to external ear | ||
**Associated with contact sports such as boxing, wrestling, etc. | |||
*Separation of perichondrium from underlying cartilage tears the adjoining blood vessels<ref name="Roy">Roy S, Smith LP. A novel technique for treating auricular hematomas in mixed martial artists (ultimate fighters). Am J Otolaryngol. 2010 Jan-Feb;31(1):21-4.</ref> | |||
**Usually occurs on anterior surface, since skin is firmly adherent to cartilage (on posterior ear, there is underlying muscle and adipose is it loosely adherent to cartilage)<ref name="Vuyk">Vuyk HD, Bakkers EJ. Absorbable mattress sutures in the management of auricular hematoma. Laryngoscope. 1991 Oct;101(10):1124-6.</ref> | |||
**Recurrent hematomas lead to infection and/or cartilage necrosis and neocartilage formation (i.e. "cauliflower ear") | |||
**Goal of treatment is to prevent "cauliflower ear" deformity by draining the hematoma in a timely fashion | |||
== | ==Clinical Features== | ||
[[File:Cauliflower ear by dr vikram yadav.jpg|thumb|Auricular hematoma]] | |||
*Gross deformity/swelling to pinna after recent blunt trauma | |||
*Loss of typical auricular landmarks/anatomy<ref name="Giles">Giles WC, Iverson KC, King JD, Hill FC, Woody EA, Bouknight AL. Incision and drainage followed by mattress suture repair of auricular hematoma. Laryngoscope. 2007 Dec;117(12):2097-9.</ref> | |||
*[[earache|Pain]] out of proportion<ref name="Giles" /> | |||
*Hematoma most commonly collects in the scaphoid fossa and the concha | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Ear DDX}} | {{Ear DDX}} | ||
== | {{Maxillofacial trauma DDX}} | ||
==Evaluation== | |||
*Clinical diagnosis | *Clinical diagnosis | ||
== | ==Management== | ||
===Indications for drainage<ref>Laybell I et al. Auricular Hematoma Drainage. Aug 7, 2015. http://emedicine.medscape.com/article/82793-overview#a8</ref>=== | |||
*Traumatic swelling that deforms pinna | |||
*Within 7 days of trauma | |||
===Contraindications=== | |||
''In these cases, refer to ENT due to formation of granulation tissue that may require debridement'' | |||
*Recurrent or chronic hematomas | |||
*> 7 days from trauma | |||
===Procedure=== | |||
#Perform an auricular block | |||
#Evacuate the clot | #Evacuate the clot | ||
#*Make semi-circle incision inside the inner curvature of the helix or antihelix | #*Option 1: Make semi-circle incision inside the inner curvature of the helix or antihelix | ||
#*Remove hematoma by | #**Make incisions along natural auricular crease for cosmesis | ||
#Prevent re- | #**Remove hematoma by milking of the hematoma toward the incision. Suction or curettage may also be helpful | ||
#*Pack the helix | #**Use a butterfly hemostat or suture kit needle driver to break up any hematoma that is not easily coming out | ||
#*Place regular gauze both in front of and behind the ear | #*Option 2: Use large-bore needle/syringe to aspirate hematoma<ref name="Vuyk" /> | ||
#*Circle the head with a compressive wrap | #**Needle aspiration generally is not sufficient treatment<ref name="Giles" />, especially for larger hematomas as clot has usually already formed and cannot be aspirated | ||
#Prevent re-accumulation of hematoma (goal is to close the dead space between perichondrium and cartilage<ref name="Roy" />). Multiple methods available: | |||
#*Option 1: Compression dressing | |||
#**Pack the helix with petroleum jelly-impregnated gauze | |||
#**Place regular gauze both in front of and behind the ear | |||
#**Circle the head with a compressive wrap | |||
#**Generally only moderately successful, and subject to poor compliance (especially with athletes<ref name="Roy" />) | |||
#**Alternative to petroleum jelly gauze is to splint the ear with a molded piece of plaster <ref>Trick of the Trade: Splinting the ear from AliEM https://www.aliem.com/trick-of-trade-splinting-ear/</ref> <ref>Ear Lacerations, Part II from Lacerationrepair.com https://lacerationrepair.com/techniques/anatomic-regions/ear-lacerations-part-ii/</ref>which fits better and does not need as tight of a compression dressing. | |||
#*Option 2: Suture | |||
#**Use fast-absorbing sutures | |||
#**Place running or interrupted sutures through cartilage and both anterior and posterior skin of auricle in mattress fashion<ref name="Vuyk" /> | |||
#**This should reappose the perichondrium | |||
#**Consider leaving incision open (with wound edges approximated by mattress sutures) to allow for continued drainage<ref name="Roy" /> | |||
#*Option 3: Bolster sutured in place- combination of the above two methods | |||
#**Use non-absorbable 2-0 or 3-0 nylon | |||
#**Pack the helix with petroleum jelly impregnated gauze. Place a thick layer of gauze behind the ear | |||
#**Perform a running quilt stitch through the anterior gauze, through the pinna, and through the posterior gauze | |||
#Antibiotics | #Antibiotics | ||
#* | #*Often used by our ENT colleagues in all patients though it is actually only recommended for immunocompromised patients | ||
#*Cover [[pseudomonas]] and [[S. aureus]] | #*Cover [[pseudomonas]] and [[S. aureus]]- Cipro is the most commonly used | ||
==Disposition== | ==Disposition== | ||
*Discharge | *Discharge | ||
*ENT followup in 2-3 days for suture removal or dressing removal and wound check | |||
==See Also== | ==See Also== | ||
*[[Maxillofacial Trauma]] | *[[Maxillofacial Trauma]] | ||
== | ==External Links== | ||
* | *Auricular Hematoma Management https://rebelem.com/auricular-hematoma-management/ | ||
==References== | |||
<references/> | |||
[[Category:ENT]] | [[Category:ENT]] |
Revision as of 11:57, 10 November 2020
Background
- Caused by blunt trauma to external ear
- Associated with contact sports such as boxing, wrestling, etc.
- Separation of perichondrium from underlying cartilage tears the adjoining blood vessels[1]
- Usually occurs on anterior surface, since skin is firmly adherent to cartilage (on posterior ear, there is underlying muscle and adipose is it loosely adherent to cartilage)[2]
- Recurrent hematomas lead to infection and/or cartilage necrosis and neocartilage formation (i.e. "cauliflower ear")
- Goal of treatment is to prevent "cauliflower ear" deformity by draining the hematoma in a timely fashion
Clinical Features
- Gross deformity/swelling to pinna after recent blunt trauma
- Loss of typical auricular landmarks/anatomy[3]
- Pain out of proportion[3]
- Hematoma most commonly collects in the scaphoid fossa and the concha
Differential Diagnosis
Ear Diagnoses
External
- Auricular hematoma
- Auricular perichondritis
- Cholesteatoma
- Contact dermatitis
- Ear foreign body
- Herpes zoster oticus (Ramsay Hunt syndrome)
- Malignant otitis externa
- Otitis externa
- Otomycosis
- Tympanic membrane rupture
Internal
- Acute otitis media
- Chronic otitis media
- Mastoiditis
Inner/vestibular
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Evaluation
- Clinical diagnosis
Management
Indications for drainage[4]
- Traumatic swelling that deforms pinna
- Within 7 days of trauma
Contraindications
In these cases, refer to ENT due to formation of granulation tissue that may require debridement
- Recurrent or chronic hematomas
- > 7 days from trauma
Procedure
- Perform an auricular block
- Evacuate the clot
- Option 1: Make semi-circle incision inside the inner curvature of the helix or antihelix
- Make incisions along natural auricular crease for cosmesis
- Remove hematoma by milking of the hematoma toward the incision. Suction or curettage may also be helpful
- Use a butterfly hemostat or suture kit needle driver to break up any hematoma that is not easily coming out
- Option 2: Use large-bore needle/syringe to aspirate hematoma[2]
- Needle aspiration generally is not sufficient treatment[3], especially for larger hematomas as clot has usually already formed and cannot be aspirated
- Option 1: Make semi-circle incision inside the inner curvature of the helix or antihelix
- Prevent re-accumulation of hematoma (goal is to close the dead space between perichondrium and cartilage[1]). Multiple methods available:
- Option 1: Compression dressing
- Pack the helix with petroleum jelly-impregnated gauze
- Place regular gauze both in front of and behind the ear
- Circle the head with a compressive wrap
- Generally only moderately successful, and subject to poor compliance (especially with athletes[1])
- Alternative to petroleum jelly gauze is to splint the ear with a molded piece of plaster [5] [6]which fits better and does not need as tight of a compression dressing.
- Option 2: Suture
- Use fast-absorbing sutures
- Place running or interrupted sutures through cartilage and both anterior and posterior skin of auricle in mattress fashion[2]
- This should reappose the perichondrium
- Consider leaving incision open (with wound edges approximated by mattress sutures) to allow for continued drainage[1]
- Option 3: Bolster sutured in place- combination of the above two methods
- Use non-absorbable 2-0 or 3-0 nylon
- Pack the helix with petroleum jelly impregnated gauze. Place a thick layer of gauze behind the ear
- Perform a running quilt stitch through the anterior gauze, through the pinna, and through the posterior gauze
- Option 1: Compression dressing
- Antibiotics
- Often used by our ENT colleagues in all patients though it is actually only recommended for immunocompromised patients
- Cover pseudomonas and S. aureus- Cipro is the most commonly used
Disposition
- Discharge
- ENT followup in 2-3 days for suture removal or dressing removal and wound check
See Also
External Links
- Auricular Hematoma Management https://rebelem.com/auricular-hematoma-management/
References
- ↑ 1.0 1.1 1.2 1.3 Roy S, Smith LP. A novel technique for treating auricular hematomas in mixed martial artists (ultimate fighters). Am J Otolaryngol. 2010 Jan-Feb;31(1):21-4.
- ↑ 2.0 2.1 2.2 Vuyk HD, Bakkers EJ. Absorbable mattress sutures in the management of auricular hematoma. Laryngoscope. 1991 Oct;101(10):1124-6.
- ↑ 3.0 3.1 3.2 Giles WC, Iverson KC, King JD, Hill FC, Woody EA, Bouknight AL. Incision and drainage followed by mattress suture repair of auricular hematoma. Laryngoscope. 2007 Dec;117(12):2097-9.
- ↑ Laybell I et al. Auricular Hematoma Drainage. Aug 7, 2015. http://emedicine.medscape.com/article/82793-overview#a8
- ↑ Trick of the Trade: Splinting the ear from AliEM https://www.aliem.com/trick-of-trade-splinting-ear/
- ↑ Ear Lacerations, Part II from Lacerationrepair.com https://lacerationrepair.com/techniques/anatomic-regions/ear-lacerations-part-ii/