SUBPERICHONDRIAL HEMATOMA
Characteristic appearance of an extensive subperichondrial hematoma due to direct
blunt trauma.
Introduction
Blunt trauma to the pinna of the ear may cause bleeding between the auricular
cartilage and the perichondrium, known as auricular hematoma or subperichondrial
hematoma.
If not adequately treated this condition may cause abnormal growth of the underlying
cartilage resulting in significant permanent cosmetic deformity, known as
“cauliflower ear”
The goal of treatment is to completely evacuate subperichondrial blood and to prevent
its re-accumulation. This will greatly reduce that chance of deformity, but does not
completely eliminate it.
Anatomy
The outer ear (or pinna or auricle) is the outer visible aspect of the ear.
The middle ear is the air-filled cavity behind the tympanic membrane.
The inner ear is the bony and membranous labyrinths, within the petrous temporal
bone.
Components of the outer ear, (Drake, Gray’s Anatomy for Students).
Skin → perichondrium → cartilage.
The skin overlying the cartilaginous auricle, or pinna, is thin, without significant
subcutaneous adipose tissue, and is densely adherent to the underlying perichondrium.
The perichondrium, in turn, supplies nutrients to the deeper auricular cartilage.
When traumatic hematoma occurs, the blood accumulates within the subperichondrial
space (i.e between the perichondrium and cartilage).
Pathology
The perichondrium is a dense connective tissue layer which surrounds the cartilage
and contain the germ cells from which new cartilage is formed.
Shearing forces to the anterior auricle can lead to separation of the anterior auricular
perichondrium from the underlying, tightly adherent cartilage leading to tearing of
perichondrial blood vessels and subsequent hematoma formation.
The torn perichondrial vessels compromise the viability of the underlying avascular
cartilage resulting in cartilage necroses which may also become infected.
Healing is by fibrosis and neocartilage formation, (the presence of a subperichondrial
hematoma has been found to stimulate new and often asymmetric cartilage growth).
This healing process however is imperfect and disorganized and so results in
significant permanent scarring and deformity known as “cauliflower ear”.
Clinical Features
The diagnosis of auricular hematoma is made by the characteristic clinical appearance
in patients with a history of blunt trauma to the auricle.
Important points of history:
1.
The usual settings of the injury direct blunt trauma sustained in:
●
Violent assault
♥
Always consider the possibility of domestic violence.
●
Accidental trauma
●
Contact sports injuries:
♥
In particular, wrestling, boxing, rugby, martial arts.
2.
When the history is obscure, especially with women or children, keep in mind
the possibility of domestic violence.
3.
Check if the patient is taking anticoagulants.
Important points of examination:
1.
Features of acute auricular hematoma include:
●
A tender, tense, fluctuant collection of blood.
●
Typically within the region of the scaphoid fossa, the depression
between the helix
and antihelix
●
The overlying skin can be erythematous or ecchymotic.
●
If the hematoma has begun to clot and organize (approximately 24
hours after
injury), it may become firmer.
2.
Asses the hearing
3.
Assess for associated injuries.
Left: The commonest sites for Auricular
Haematoma:
●
Scaphoid Fossa
●
Helix
●
Antihelix
Investigations
None are usually required as most auricular hematomas result from an isolated blow
to the ear and have few associated injuries.
Less commonly, auricular hematomas may accompany more serious injury to the
head, were ear drum, or middle ear damage may also occur.
Investigation therefore is primarily to rule our associated injuries.
Coagulation studies may be required for those patients taking warfarin.
Management
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.
The goal of treatment is to completely evacuate subperichondrial blood and to prevent
its re-accumulation. This will greatly reduce that chance of deformity, but does not
completely eliminate it.
All auricular hematomas should be drained as soon as possible after injury.
1.
Analgesia is given as clinically indicated:
●
Avoid aspirin (or similar NSAIDs) for analgesia, as this may
aggravate bleeding.
●
A regional auricular block with local anaesthetic will be required, if
catheter
drainage or incision and drainage is to be undertaken.
Note that adrenaline may be used with a local anaesthetic regional
block, but it should not be used for any direct infiltration of the ear
itself.
●
Procedural sedation is not usually required for drainage of auricular
hematomas, unless the patient is young or otherwise very anxious.
2.
Drainage:
Options include:
Needle Aspiration:
●
This technique is suitable for smaller lesions (< 2cm) of short duration,
(< 48 hours old).
●
This can be done under direct local anesthesia, (without the use of
adrenaline).
●
Identify and aspirate the most fluctuant part of the hematoma with an
18 gauge
needle while milking the hematoma to ensure complete
drainage.
●
After needle aspiration, apply pressure for 5 to 10 minutes and then
place a pressure
dressing, (see below).
Where the clinical expertise exists: For larger ( ≥ 2 cm) hematomas up to
seven days old, the clinician may perform incision and drainage or evacuation
with an intravenous catheter:
Catheter Aspiration:
●
Cleanse the ear with antiseptic (e.g., povidone-iodine solution).
●
Provide local anesthesia
●
Along the inferior border of the hematoma, insert an 18 gauge
intravenous catheter
that permits syringe attachment, and evacuate
the clot.
●
Remove the needle but leave the catheter in position.
●
Clip the catheter so that approximately 1 cm protrudes from the
insertion site to
allow further drainage.
●
The IV catheter should be gently removed at five days and external
compression applied for three to five minutes.
Incision and drainage:
This is best done by an ENT or plastic surgeon.
The principles of incision and drainage include:
●
Cleanse the ear with antiseptic (e.g., povidone-iodine solution).
●
Provide local anesthesia
●
Incise along the curvature of the auricle at the base of the hematoma
using a 15 or 11
blade
●
The incision should be adequate to drain clotted blood completely and
is best performed parallel to the helical curve for cosmesis.
●
Carefully evacuate the hematoma and any clots by gently using a
sterile mosquito
hemostat to bluntly open the hematoma pocket without
damaging the perichondrium.
●
Irrigate the pocket copiously with sterile saline.
●
After incision and drainage is performed, suture the incision closed
with mattress stitches or a bolster to effectively reduce the dead space and to
prevent
reaccumulation of blood or fluid.
●
Provide pressure bandaging as below.
Pressure Dressing:
This should be done for all the drainage procedures:
●
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 pack and crepe
bandage to hold in
place.
3.
Patients an anticoagulants:
Most auricular hematomas occur in healthy young athletes.
However, anticoagulated patients may develop auricular hematomas after
incidental trauma.
The approach to these patients depends upon the indication for
anticoagulation, the individual risk of thromboembolism if anticoagulation is
interrupted, and the type of anticoagulant the patient is receiving.
In some cases, referral to an otolaryngologist or plastic surgeon for delayed
drainage after anticoagulation is reduced or interrupted may be necessary.
Consultation with a haematologist is advised to guide management of
anticoagulation before and after hematoma drainage.
4.
Antibiotics:
●
Protect against perichondritis with oral antibiotics for 7-10 days.
●
Empiric antibiotics with activity against skin flora and Pseudomonas
aeruginosa
should be used.
Options include:
●
Amoxicillin and clavulanic acid
●
If infection develops after drainage while on prophylactic antibiotics,
patients should
be admitted for intravenous antibiotics that cover
Staphylococcus aureus and Pseudomonas aeruginosa (e.g. vancomycin and
ceftazidime).
5.
Avoidance of contact sports:
●
Patients should also be counselled regarding the need to avoid reinjury
to the ear
while it is healing.
●
This is especially 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
●
There should be no contact sports until fully healed, (a minimum of 7
days).
Disposition:
Larger lesions requiring catheter aspiration or incision and drainage should be
referred to ENT or plastics, were the expertise is not available in the Emergency
Department.
Hematomas greater than seven days old may have begun to organize and form
granulation tissue and should be referred directly to an ENT specialist or plastic
surgeon
Patients who have undergone evacuation of an auricular hematoma should be reevaluated every 24 hours for three to five days to evaluate for possible
reaccumulation of the hematoma or signs of infection and, if evacuation with an
indwelling catheter is performed, reapplication of the pressure dressing.
In patients who do have recurrence of an auricular hematoma, repeated incision and
drainage or catheter aspiration can be performed
Cauliflower ear in itself, usually poses no functional loss to hearing. However,
patients who want an improved cosmetic appearance should be referred to an ENT or
plastic surgeon.
Appendix 1: Ear Bandaging: 2
Top left: pack the external auditory meatus with dry gauze.
Top right: 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 re-approximate the skin at the incision site.
Bottom left: Place sterile gauze over the entire ear
Bottom right: Wrap the ear and head with sterile rolled gauze to hold in place.
Appendix 2
Technique of catheter drainage. 1