A 22 year old male with no significant past medical history presents with left ear pain for the past hour. The patient is a college wrestler and was in a wrestling match when his ear was injured.
Vitals: WNL
Exam:
How to manage an Auricular Hematoma.
1. If the hematoma is less than 2 cm and less than 48 hours old, you can attempt needle decompression.
Supplies: Lidocaine without epi; small gauge needle to make a wheal; 18G needle, 2 dental rolls, 4-0 non-absorbable suture, 10 or 20 cc syringe
Clean and prep the area. It needs to be a completely sterile procedure. Make a skin wheal in the most fluctuant part of the hematoma. Insert 18G needle and milk the hematoma toward the needle to fully decompress.
Hold manual pressure for 3-5 minutes
Place sewn in bolster pressure dressing. One dental roll on either side of the pinna to compress the hematoma. Insert 4-0 non-absorbable suture anterior to posterior at the most superior part of the hematoma wrap around the posterior dental roll, and back through the pinna posterior to anterior and wrap around the anterior dental roll. Tie and cinch together to create pressure on the hematoma. May also want to place another stay suture on the inferior part of the dental rolls to keep it in place. Keep in place for 7-10 days.
2. If the hematoma is greater than 2 cm, or has been there for between 48 hours and 7 days, or has re-accumulated after needle decompression, then you should do an incision and drainage.
Supplies: Lidocaine without epi, long needle for auricular block, 11 blade, curved hemostat, 2 dental rolls, 4-0 non-absorbable suture.
Clean and prep the area. To perform an auricular block, you will be making a diamond of lidocaine around the ear. So enter just below the ear pointing posteriorly along the mastoid. Insert the whole needle, and inject up to 5mL of lidocaine as you pull the needle out. Next, without pulling the needle out, point anteriorly in front of the ear and follow the same steps. Then do the same thing above the ear to complete the diamond around the ear. Wait 10-15 minutes for full anesthetic affect.
Clean and prep the area. Make an incision along a natural line of their auricle for better cosmetic results. Make it big enough for full hematoma evacuation, but no bigger than 1cm. Use the curved hemostat to gently break up the clot and milk the hematoma. Irrigate with sterile saline or water.
Hold manual pressure for 3-5 minutes.
Place sewn in bolster pressure dressing. One dental roll on either side of the pinna to compress the hematoma. Insert 4-0 non-absorbable suture anterior to posterior at the most superior part of the hematoma wrap around the posterior dental roll, and back through the pinna posterior to anterior and wrap around the anterior dental roll. Tie and cinch together to create pressure on the hematoma. May also want to place another stay suture on the inferior part of the dental rolls to keep it in place. Keep in place for 7-10 days.
3. Alternative Pressure dressing methods:
Pack the auricle with petroleum impregnated or saline soaked gauze, and make sure to mold into all of the crevices of the ear. Place gauze behind the ear, and in front, then wrap the head in Kerlix gauze tightly to maintain the pressure. Only modestly effective.
After incision and drainage re-approximate the wound edges with horizontal mattress sutures that go through and through the cartilage of the ear using 5-0 absorbable or non- absorbable sutures. Leave a small opening for continued drainage. These should stay in for 7 to 10 days.
Take Away #1:
Auricular hematomas are an uncommon but serious ENT emergency that if not treated properly can lead to cartilage destruction and cauliflower ear.
Take Away #2:
If there are additional findings or concerns, then you may want to do more testing. For example, if there is decreased hearing, you make want to do a CT to rule out inner ear damage or skull fracture. If there is erythema or swelling extending beyond the pinna consider an infection of the perichondrium (perichondritis) that will require antibiotics.
Take Away #3:
All auricular hematomas require close ENT follow up, and they should be seen within 24-48 hours. There is a chance that despite your best efforts, the hematoma could re-accumulate, or if there is cartilage destruction, they will require graft.
Take Away #4:
There are conflicting thoughts about whether prophylactic antibiotics should be given. Some say only immunocompromised individuals will need antibiotics. Some say all should get 7-10 days of antibiotics that cover pseudomonas and skin flora. In adults: Levofloxacin. In kids: Augmentin.
Lyndsay Massey, MD is a current third year resident at Stony Brook Emergency Medicine.
References:
Edited by Bassam Zahid, MD