This woman presented very early after her assault. Initially her right ear appeared to have only minimal swelling and bruising, but during her evaluation and observation in the ED, a small hematoma developed. This was aspirated and a compression dressing was applied to the right ear. The patient had a follow-up appointment scheduled with an ENT physician the next day. She did not have any recurrence of the hematoma, and the ear healed without deformity.
Traumatic injury to the ear is commonly seen in athletes, particularly wrestlers, boxers, and rugby players. Hematoma formation of the pinna subsequently can result in a deformity of the ear known as cauliflower or wrestler's ear.
The ear is a relatively mobile structure because of the elastic cartilage that gives the ear its characteristic shape. As you may recall, there are three types of cartilage: hyaline, elastic, and fibrous (aka fibrocartilage). Cartilage is a specialized form of connective tissue composed primarily of cells called chondrocytes, extracellular matrix, and ground substance containing proteoglycans.
The three types of cartilage are distinguished from one another by the fibrous components of their matrix. Hyaline cartilage is found in joints, connecting the ribs to the sternum and within the rings of the tracheobronchial tree. It serves as a shock absorber and to decrease friction at joints as well as provide structure. Elastic cartilage is very similar to hyaline, but contains a dense amount of elastic fibers, giving it greater flexibility. It is found in the ear, the epiglottis, and parts of the larynx and small bronchi. Fibrous cartilage is very tough, and is found primarily in the menisci and at symphyses, such as the pubic synthesis. The majority of hyaline cartilage and all elastic cartilage are surrounded by perichondrium. This layer is important for proper maintenance and growth of cartilage because it does not contain blood vessels or lymphatics.
The skin of the anterior surface of the ear is thin and tightly adherent to the underlying perichondrium and cartilage. With blunt trauma to the ear, a hematoma may develop. In the literature, the predominant theory is that shearing forces separate perichondrium from the underlying cartilage. Blood vessels within the perichondrium are damaged, and a hematoma develops in this potential space. The combination of ischemia, necrosis, and asymmetric neocartilage formation results in the deformity called cauliflower ear.
This theory is based on the study by Ohlsen et al from 1975 in which blood was injected into rabbit ears. (Scand J Plast Reconstr Surg 1975;9:34.) If the blood was placed between the skin and the perichondrium, the blood was eventually reabsorbed with no deformity. If the blood was placed between the perichondrium and cartilage, new cartilage developed. Recently, however, this belief has been called into question. A study published in 2005 by Ghanem et al demonstrated that in patients with recurrent auricular hematomas, the hematoma developed within the cartilage itself. (Laryngoscope 2005;115: 1251.) In fact, a 1973 study supported this theory as well. Pandya et al dropped weights on rabbits' ears, and the site of hematoma formation was found to be mostly intracartilaginous. (Plastic Reconstr Surg 1973;52:534.)
While debate over the exact location of the hematoma continues, there is agreement that the hematoma must be removed to help prevent deformity. This can be done in multiple ways, but in the ED, the predominant methods are needle aspiration and incision and evacuation. Both should be followed by some type of compression dressing to prevent reaccumulation. Again, there is controversy about which method of drainage is superior, and there is a lack of evidence to support one method over the other.
In 2003 Jones and Mahendran performed a systematic review to assess the effectiveness of treatment options in acute auricular hematoma. They were unable to find any randomized trials, case-controlled trials, or cohort studies to support one treatment over another. (Cochrane Database Syst Rev 2004;2:CD004166.) To the best of my knowledge, there have been no reports since that time. There is evidence that the hematoma should be removed to prevent recurrence and improve cosmetic outcome, although evidence is lacking pertaining to type of drainage. Finally, a compressive bandage should be placed and follow-up arranged.