cauliflower ear
This topic reviews the assessment and management of auricular hematoma focusing on
an approach that best avoids the long-term complication of cauliflower ear. The
assessment and management of auricle (ear) lacerations is discussed separately.
(See "Assessment and management of auricle (ear) lacerations" .)
When traumatic hematoma occurs, the blood accumulates within the subperichondrial
space (between the perichondrium and cartilage). This collection of blood is a mechanical
barrier between the cartilage and its perichondrial blood supply [ 1 ]. Deprived of
perfusion, the underlying cartilage necroses and may become infected. These pathologic
changes result in cartilage loss followed by fibrosis and neocartilage formation. This
healing process is disorganized and results in the cosmetic deformity of cauliflower ear
( picture 1 ). Early drainage of the hematoma and re-apposition of the perichondrial
layer to the underlying cartilage restores perfusion to the cartilage and reduces the
likelihood of cauliflower ear.
By contrast, cauliflower ear is a chronic, bulbous deformity of the pinna in the area of a
former auricular hematoma ( picture 1 ).
Most auricular hematomas result from an isolated blow to the ear during sports and have
few associated injury. Less commonly, auricular hematomas may accompany serious
injury to the head, ear drum, or middle ear during motor vehicle collisions or other high
energy mechanisms. The assessment and management of these injuries are discussed
separately. (See "Assessment and management of auricle (ear) lacerations", section on
'Evaluation' and"Evaluation and management of middle ear trauma", section on 'Clinical
features' and "Minor head trauma in infants and children", section on 'Clinical
features' and "Concussion and mild traumatic brain injury", section on 'Clinical
features' .)
Perichondritis, chondritis, or auricular abscess present with pain, swelling, and erythema
of the overlying skin. Fluctuant swelling indicates an abscess. These infections typically
accompany a recent helical ear piercing or laceration but have physical findings that may
be difficult to differentiate from an auricular hematoma in some patients. The presence
of pus rather than blood at the time of drainage indicates an auricular abscess. A prior
break in the skin followed by erythema often identifies perichondritis or chondritis.
Further therapy includes antibiotic treatment which is discussed separately.
(See"Assessment and management of auricle (ear) lacerations", section on
'Perichondritis or chondritis' .)
PREPARATION
Evaluation and patient counseling — The patient’s ear should be examined both
visually and by palpation to determine the location and extent of the hematoma. Physical
findings determine the type of drainage (needle aspiration versus incision and drainage)
and the surgical approach. (See 'Approach'below.)
The patient or caregiver should be informed regarding the need for drainage to reduce,
but not eliminate the chances of cauliflower ear, and the need for appropriate follow-up.
They should also be counseled regarding the need to avoid reinjury to the ear while it is
healing; this is important in the case of athletes who are anxious to return to training.
The clinician should emphasize that re-accumulation of blood will result in a poor
cosmetic outcome. (See'Return to sports' below.)
Additional risks that should be reviewed during the informed consent process include
bleeding, infection, pain, scar formation, and need for further surgery. For
anticoagulated patients, consultation with a hematologist is advised to guide
management of anticoagulation before and after hematoma drainage.
(See "Management of anticoagulation before and after elective surgery", section on
'Problem overview' .)
The technique for performing a regional auricular block is discussed in detail separately
( figure 2 ). (See "Assessment and management of auricle (ear) lacerations", section on
'Regional auricular block' .)
Procedural sedation is infrequently required for drainage of auricular hematoma, unless
the patient is young or otherwise uncooperative. The performance of procedural sedation
in children and adults is discussed in more detail elsewhere. (See "Procedural sedation in
children outside of the operating room"and "Procedural sedation in adults" .)
Sterile gloves
Surgical mask
Eye protection
Buffered 1 percent lidocaine or similar local anesthetic ( table 2 )
Moderate volume syringe (eg, 5 or 10 mL)
Small gauge needle (eg, 27 or 30 gauge, 1.5 inch if performing an auricular
block) for infiltration of local anesthetic
Sterile saline
18 gauge needle attached to a small to moderate volume syringe (eg, 3 to 6 mL)
if needle aspiration is performed
18 gauge intravenous catheter if needle aspiration with indwelling catheter
technique is used
Suture material: for skin- 5-0 absorbable (eg, Monocryl or fast absorbing gut), for
bolster, 4-0 or 3-0 non-absorbable (eg, nylon or Prolene)
Needle holder
Hemostat
Scalpel with handle (#15 blade or #11 blade)
Tissue forceps
Scissors
Sterile 4 x 4 gauze
Absorbent towels
Sterile field drapes
Emergency departments generally are well equipped with minor surgical or suture trays
that contain the instruments, sterile gauze, towels, and drapes listed above.
PROCEDURE
Approach — Evidence for the best treatment of auricular hematomas is limited and
based largely upon case reports and anecdotal experience [ 5 ]. Our approach depends
upon the size and age of the auricular hematoma [ 1,4,6,7 ]. Auricular hematomas that
are more than seven days old warrant referral to a surgical subspecialist for debridement
of new perichondrial growth and any remaining hematoma [ 4 ]. (See 'Indications for
treatment and subspecialty consultation or referral' above.)
We suggest that patients with auricular hematomas that are <2 cm in diameter and
present for up to 48 hours undergo needle aspiration rather than either incision and
drainage, or evacuation using an intravascular catheter [ 4,6 ]. (See 'Small, acute
auricular hematomas' below.)
Some experts favor incision and drainage over needle aspiration for all auricular
hematomas to avoid recurrent hematoma and its sequelae. In one small observational
study of 22 patients undergoing 28 treatments, hematoma reaccumulation occurred in
three out of seven patients after needle aspiration (18 to 22 gauge needles were used)
versus two out of 21 patients undergoing incision and drainage, although this difference
was not statistically significant [ 8]. However, outcomes were not controlled for age and
size of the hematomas. Our experience suggests that needle aspiration of small, acute
auricular hematomas is frequently successful.
Thus, limited observational evidence suggests that either incision and drainage or
evacuation with an indwelling intravenous catheter effectively treats large auricular
hematomas (≥2 cm) with similar rates of reaccumulation or development of cauliflower
ear.
Small, acute auricular hematomas — The clinician may perform needle aspiration for
small (less than approximately 2 cm in diameter) and acute hematomas that are 24 to
48 hours old as follows [ 4,6 ] (see 'Approach' above):
Place sterile gauze with the center cut out to provide padding behind the ear.
Mold sterile petrolatum-impregnated gauze or saline-soaked cotton balls within
the contours of the auricle. If the skin was incised, this portion of the dressing
needs to reapproximate the skin at the incision site.
Place sterile gauze over the entire ear.
Wrap the ear and head with sterile rolled gauze to hold in place.
Larger auricular hematomas — For larger (≥2 cm) hematomas up to seven days old,
the clinician may perform incision and drainage or evacuation with an intravenous
catheter [ 1,4,6,7 ]:
If mattress sutures are used, appose the skin and perichondrial flap to the
underlying cartilage using absorbable (eg, 5-0 Monocryl or fast absorbing gut)
or nonabsorbable suture (eg, 5-0 nylon or Prolene) and place the mattress
stitch through and through the cartilage [ 3,9 ]. Leave a small area open to
drain.
If a bolster is used, we typically use sterile petrolatum-impregnated gauze which
is molded to the ear and sutured into place with through and
through nonabsorbable suture (eg, 3-0 or 4-0 nylon or Prolene)
[ 1,3,5,8,10 ]. Alternatively, the bolster can be molded from thermoplast
splinting material and sutured into place. Bolsters are typically removed at
seven days.
To prevent continued bleeding, patients should also avoid aspirin and other nonsteroidal
antiinflammatory drugs. For anticoagulated patients, consultation with a hematologist is
warranted to guide adjustment of anticoagulant therapy after hematoma drainage.
(See "Management of anticoagulation before and after elective surgery", section on
'Problem overview' .)
Patients should be educated to return for treatment if swelling, redness, or pain occurs.
If sutures are placed, antibiotic ointment or other emollients can be used to dress
incisions and mattress sutures while bolsters should be kept clean until removed. Further
care depends upon the initial treatment:
Although evidence is lacking, because of the risk of infection to an area with tenuous
blood supply, we suggest that all patients who undergo auricular hematoma drainage
receive a 7 to 10 day course of empiric antibiotics with activity against skin flora
and Pseudomonas aeruginosa as follows [ 1,4 ]:
In older adolescents and adults, levofloxacin to cover skin flora and Pseudomonas
aeruginosa .
In younger children, amoxicillin and clavulanic acid to cover skin flora.
Fluoroquinolones are not recommended for routine use in children <18 years of
age because studies in immature animals have demonstrated the development
of arthropathy with erosions of the cartilage in weight-bearing joints.
(See "Fluoroquinolones", section on 'Use in children' .)
RETURN TO SPORTS — All patients should refrain from activity that places their ear at
risk for additional trauma until the ear is healed [ 1 ]. Return to sports can occur as early
as seven days after the initial injury if the hematoma does not reaccumulate [ 3,7 ].
Athletes should be strongly advised to wear protective headgear to prevent reinjury.
Cauliflower ear usually poses no functional loss to hearing. However, patients who want
an improved cosmetic appearance warrant referral to an otolaryngologist or plastic
surgeon.
Auricular hematoma occurs after direct trauma to the ear, typically during sports
(eg, rugby, wrestling, boxing, or mixed martial arts). If the hematoma is not
drained, disruption of blood supply to the auricular cartilage causes necrosis,
increases the chance of infection, and usually results in a cauliflower ear
( picture 1 ). Wrestlers, boxers, and participants in mixed martial arts are
predisposed. (See 'Anatomy and pathophysiology'above and 'Mechanism of
injury' above.)
The diagnosis of auricular hematoma or cauliflower ear is made by the
characteristic clinical appearance in patients with history of blunt trauma to the
auricle. Infections of the ear cartilage or inflammation from relapsing
polychondritis ( picture 2 and picture 3 ) may occasionally mimic these injuries.
(See 'Clinical features and diagnosis' above and 'Differential diagnosis' above.)
All auricular hematomas should be drained as soon as possible after injury.
Auricular hematomas that are more than seven days old warrant referral to an
otolaryngologist or plastic surgeon for debridement of new perichondrial growth
and any remaining hematoma. (See 'Indications for treatment and subspecialty
consultation or referral' above.)
A regional auricular block using local anesthetic, such as 1 or 2 percent
buffered lidocaine with epinephrine, usually provides adequate anesthesia for
auricular hematoma drainage in the cooperative patient ( figure 2 ). The
discomfort of infiltration may be further decreased by the use of
nonpharmacologic interventions. (See 'Analgesia' above.)
The necessary equipment and procedure for drainage of an auricular hematoma is
listed above. (See 'Equipment' above and 'Procedure' above.)
We suggest that patients with auricular hematomas that are <2 cm in diameter
and present for up to 48 hours undergo needle aspiration rather than either
incision and drainage or evacuation using an intravascular catheter ( Grade
2C ). (See 'Approach' above and 'Small, acute auricular hematomas' above.)
We suggest that patients with auricular hematomas ≥2 cm in diameter and all
hematomas present from 48 hours up to seven days receive either incision and
drainage or evacuation using an intravascular catheter rather than needle
aspiration ( Grade 2C ). (See 'Approach' above and 'Larger auricular
hematomas' above.)
After auricular hematoma drainage, patients warrant daily follow-up for three to
five days to evaluate for reaccumulation of the hematoma or infection. Further
care depends upon the technique used for drainage. (See 'Aftercare' above.)
Although evidence is lacking, because of the risk of infection to an area with
tenuous blood supply, we suggest that all patients who undergo auricular
hematoma drainage receive a 7 to 10 day course of empiric antibiotics with
activity against skin flora and Pseudomonas aeruginosa ( Grade 2C ).
(See 'Aftercare' above.)
All patients should refrain from activity that places their ear at risk for additional
trauma until the ear is healed. Return to sports can occur as early as seven
days after the initial injury if the hematoma does not reaccumulate. Athletes
should be strongly advised to wear protective headgear to prevent recurrence.
(See 'Return to sports' above.)
REFERENCES
1. Greywoode JD, Pribitkin EA, Krein H. Management of auricular hematoma and
the cauliflower ear. Facial Plast Surg 2010; 26:451.
2. Schuller DE, Dankle SK, Martin M, Strauss RH. Auricular injury and the use of
headgear in wrestlers. Arch Otolaryngol Head Neck Surg 1989; 115:714.
3. Roy S, Smith LP. A novel technique for treating auricular hematomas in mixed
martial artists (ultimate fighters). Am J Otolaryngol 2010; 31:21.
4. Riviello RJ, Brown NA. Otolaryngologic procedures. In: Clinical Procedures in
Emergency Medicine, 5th edition, Roberts JR, Hedges JR. (Eds), Saunders
Elsevier, Philadelphia, PA 2010. p.1178.
5. Jones SE, Mahendran S. Interventions for acute auricular haematoma.
Cochrane Database Syst Rev 2004; :CD004166.
6. Martinez NJ, friedman MJ. External ear procedures. In: Textbook of Pediatric
Emergency Procedures, 2nd edition, King C, Henretig FM. (Eds), Lippincott,
Williams & Wilkins, Philadelphia, PA 2008. p.593.
7. Brickman K, Adams DZ, Akpunonu P, et al. Acute Management of Auricular
Hematoma: A Novel Approach and Retrospective Review. Clin J Sport Med
2012.
8. Giles WC, Iverson KC, King JD, et al. Incision and drainage followed by
mattress suture repair of auricular hematoma. Laryngoscope 2007; 117:2097.
9. Kakarala K, Kieff DA. Bolsterless management for recurrent auricular
hematomata. Laryngoscope 2012; 122:1235.
10. Ghanem T, Rasamny JK, Park SS. Rethinking auricular trauma. Laryngoscope
2005; 115:1251.
Penulis
Bagian editor
Anne M Stack, MD
Allan B Wolfson, MD
Wakil Editor
Pengungkapan
Semua topik diperbarui saat ada bukti baru dan proses peer review kami selesai.
Tinjauan literatur terkini melalui: Okt 2013. | Topik terakhir diperbarui: 8 Apr 2013.
PENDAHULUAN - Bahaya hematoma biasanya diakibatkan oleh trauma tumpul pada auricle (telinga
luar) selama olahraga (misalnya gulat amatir, rugby, tinju, atau seni bela diri campuran). Waran
cedera ini meminta drainase dan tindakan untuk mencegah reakumulasi darah. Telinga kembang kol
adalah deformitas permanen yang disebabkan oleh pertumbuhan berlemak fibrokartil yang terjadi
bila hematoma aurikuler tidak terkuras habis, berulang, atau tidak diobati (gambar 1).
Topik ini mengulas penilaian dan pengelolaan hematoma aurikular yang berfokus pada pendekatan
yang paling baik menghindari komplikasi jangka panjang dari telinga kembang kol. Penilaian dan
pengelolaan laserasi telinga (telinga) dibahas secara terpisah. (Lihat "Penilaian dan pengelolaan
laserasi auricle (telinga)".)
ANATOMI DAN PATOFISIOLOGI - Sifat unik dari telinga luar membuatnya sangat rentan terhadap
trauma. Subunit tulang rawan kartun termasuk heliks, antihelix, concha, tragus, dan antitragus
(gambar 1) [1]. Lobus, atau cuping telinga, tersusun dari jaringan fibroadipose dan tidak memiliki
tulang rawan. Kulit yang menutupi auricle cartilaginous, atau pinna, tipis, tanpa jaringan adiposa
subkutan yang signifikan, dan berpegang teguh pada perichondrium yang mendasarinya.
Perichondrium, pada gilirannya, memasok nutrisi ke tulang rawan aurikular.
Ketika terjadi hematoma traumatis, darah terakumulasi di dalam ruang subperichondrial (antara
perichondrium dan tulang rawan). Kumpulan darah ini adalah penghalang mekanis antara tulang
rawan dan suplai darah perikondriumnya [1]. Kehilangan perfusi, necroses tulang rawan yang
mendasari dan bisa menjadi terinfeksi. Perubahan patologis ini menyebabkan hilangnya tulang
rawan diikuti oleh fibrosis dan pembentukan neokartilase. Proses penyembuhan ini tidak teratur dan
berakibat pada deformitas kosmetik dari telinga kembang kol (gambar 1). Pengeringan awal
hematoma dan aposisi ulang lapisan perikondrial ke kartilago yang mendasari mengembalikan
perfusi ke tulang rawan dan mengurangi kemungkinan telinga kembang kol.
MEKANISME INJUR - Basis hematoma dan kembang kol adalah cedera olahraga yang umum terjadi.
Sementara data epidemiologi kurang, rugby, tinju, gulat, dan seni bela diri campuran atau
"pertarungan terakhir" adalah olahraga yang biasanya dikaitkan dengan cedera ini. Pejuang yang
tidak memakai pelindung gigi berada pada risiko lebih besar. Sebagai contoh, dalam sebuah survei
pegulat perguruan tinggi, cedera aurikular terjadi lebih sering di antara pegulat yang tidak memakai
tutup kepala (52 banding 26 persen untuk hematoma hemataris dan 27 banding 11 persen untuk
telinga kembang kol). [2]. Pejuang dengan hematoma hemataris juga cenderung mengabaikan
cedera dan, bahkan jika diobati, berisiko mengalami cedera rekuren dengan perkembangan akhir
dari telinga kembang kol [3].
FITUR KLINIK DAN DIAGNOSA - Diagnosis hematoma aurikular atau telinga kembang kol dibuat oleh
penampilan klinis khas pada pasien dengan riwayat trauma tumpul pada auricle.
Hematoma aurikular akut hadir sebagai koleksi darah yang lembut, tegang, fluktuatif, biasanya pada
aspek anterior pinna dan seringkali di dalam fosa skafoid, depresi antara heliks dan antihelix (gambar
1). Kulit di atasnya bisa eritematosa atau ekimotik. Jika hematoma mulai menggumpal dan mengatur
(kira-kira 24 jam setelah cedera), mungkin akan menjadi lebih kencang.
Sebaliknya, telinga kembang kol adalah deformitas kronis dan berat pada pinna di daerah hematoma
aurikular mantan (gambar 1).
Sebagian besar hematoma aurikular diakibatkan oleh pukulan terisolasi ke telinga selama olahraga
dan sedikit mengalami cedera. Yang kurang umum, hematoma aurikular dapat menyertai cedera
serius pada kepala, gendang telinga, atau telinga tengah selama tabrakan kendaraan bermotor atau
mekanisme energi tinggi lainnya. Penilaian dan pengelolaan luka-luka ini dibahas secara terpisah.
(Lihat "Penilaian dan pengelolaan laserasi telinga (telinga)", bagian 'Evaluasi' dan "Evaluasi dan
pengelolaan trauma telinga bagian tengah", bagian 'Gambaran Klinis' dan "Trauma kepala ringan
pada bayi dan anak-anak", bagian ' Gambaran klinis 'dan "Gegar otak dan cedera otak traumatis
ringan", bagian tentang' Gambaran klinis '.)
DIAGNOSIS DIFERENSIAL - Pada kebanyakan pasien, diagnosis hematoma aurikular atau telinga
kembang kol sangat mudah. Infeksi tulang rawan telinga atau pembengkakan dari polychondritis
kambuh kadang kala meniru luka ini.