Incision, Repair of Ear Hematoma Recommended

MARCO ISLAND, FL—A procedure in which a hematoma in the ear is repaired through definitive incision and drainage appears to result in good cosmetic outcomes, researchers reported at the combined sections meeting of the Triological Society.

Kenneth Iverson, BS, a medical student at the University of South Carolina School of Medicine in Columbia, said that hematomas form in the ears generally due to blunt trauma—the kind of trauma that is associated with contact sports injuries, accidents, or barroom discussions gone bad.

“Complications that can arise from these injuries include infection, cartilage necrosis, and the dreaded cauliflower ear,” he said in an oral presentation.

“Auricular hematomas require early and effective management,” Mr. Iverson said. He said his chart review study showed that incision and drainage with absorbable mattress sutures is a superior technique to other methods. “It is a relatively simple technique; it has a low recurrence rate and has desirable cosmetic outcome,” he said.

Mr. Iverson said the diagnosis is made on the observation of the loss of landmarks to the injured ear, due to swelling. He said that patients often exhibit what appears to be a disproportionate amount of pain.

The goal of treatment, he said, is to evacuate the hematoma in order to remove the nidus for neocartilage formation. Evacuation of the hematoma also allows for the stimulation of perichondrial mesenchymal cells. The elimination of dead space is accomplished through a compression method. With the space compressed, the recurrence of the hematoma is thwarted, he suggested.

He said that treatment options in the past have been less than optimal. “Repeated needling was one of the earlier methods employed in the treatment of auricular hematoma,” he said. “It is very painful and has poor cosmetic results.”

A number of other procedures have also been tried with varying degrees of success, Mr. Iverson said. Among them:

Needle aspiration followed by casting or molding or use of absorbable mattress sutures.

Incision and drainage followed by drain placement, button compression with through-and-through sutures; thermal plastic splinting; dental roll bolsters with mattress sutures.

Retrospective Chart Review

In his retrospective five-year chart review covering the period from September 2001 to September 2006, Mr. Iverson scrutinized outcomes among patients who were treated three difference methods of treating auricular hematomas:

• In one method, an incision to allow evacuation of the hematoma is made, followed by drainage and then closure with mattress sutures.
• The second procedure involved needle aspiration techniques.
• In the third procedure, incision and drainage were followed by wick placement.

Fourteen of the 22 patients in the study were under the age of 20; 18 of the patients were under age 40; two patients were in their 70s. Twelve of the injuries occurred during wrestling bouts—the usual cause of the injuries, although they can be mitigated by wearing protective headwear. Six of the cases resulted from trauma due to automobile accidents or altercations. Four of the causes of the hematomas were not described in the charts. All but one of the patients in the study were male.

Patients presented for treatment from 2 to 60 days after the original injury occurred. Two of the patients presented at 60 days, including one person who already had manifestations of cauliflower ear. The doctors treated a total of 28 hematomas in the 24 patients.

Mr. Iverson said that 19 hematomas were treated with the incision and drainage and use of mattress suture technique—by far the most favored techniques at his institution. One revision of the operation was required. He said that seven patients were treated with needle aspiration, but three of those patients required a repeat procedure. Two people were treated with the wick placement procedure. One of those patients required a revision.

The incision and drainage procedure is performed by injecting the affected part of the ear with local anesthetic, then making an incision along a natural crease to decrease the risk of visible scarring, he said in describing the procedure before the audience of more than 500.

Following the incision, the surgeon completely evacuates the hematoma. Mattress sutures are then woven through and through, providing for the skin of the ear to lie flat and resume the normal contour of the ear. The patients were followed up at one week and then at one month, at which time the sutures had absorbed and the ear remained in its normal shape, Mr. Iverson demonstrated in his oral presentation.

Mr. Iverson said that one of the patients was lost to follow-up and one person lost part of the contour of the ear; one patient did show cauliflower ear deformity, but that was one of the patients who presented at 60 days post-injury.

Among the needle aspiration patients, two patients developed significant cosmetic changes and two patients were lost to follow-up after the second procedure. One patient who had the wick placement developed chondritis.

Mr. Iverson performed his study under the mentorship of William Giles, MD, Clinical Assistant Professor of Pediatrics at the University of South Carolina School of Medicine in Columbia.

In response to questions from the audience, Dr. Giles said that treatment with incision and drainage can be accomplished even during the wrestling season. “We perform the procedure, teach the kids how to pack the ear, and instruct them to make sure they use protective headgear when they practice or wrestle. We have had no problems with that.

“We understand that wrestling is a big deal to these kids and that they are going to keep wrestling during the season,” Dr. Giles said.

Alexander Langerman, MD, a resident in otolaryngology–head and neck surgery at the University of Chicago, said, “We see a few of these ear hematomas a year. The problem with them is that if it isn’t corrected in the right way, the patient is going to end up with an abnormal-looking ear.”

©2007 The Triological Society