How To Drain an Auricular Hematoma

• Tender focal swelling on the pinna within 7 days after trauma

If it has been longer than 7 days since the injury, the patient should be referred to an otolaryngologist for management of the ongoing perichondral inflammation and possible surgical intervention (evacuation or debridement) to prevent cartilaginous thickening.

Absolute contraindications

• None

Relative contraindications

• Cellulitis or other soft-tissue infections near the area of hematoma

• Unrepaired laceration, particularly with exposed cartilage (repair the cartilage and laceration)

• Chronic or recurrent hematoma (refer to an otolaryngologist)

• Bleeding diatheses

• Infection

• Chondritis

• Reaccumulation of the hematoma, which can lead to scar formation and if untreated, eventually cauliflower ear

• Sterile gloves

• Antiseptic solution (eg, chlorhexidine, povidone iodine)Antiseptic solution (eg, chlorhexidine, povidone iodine)

• Lidocaine 1%, without epinephrine, 3-mL syringe, 25-gauge needleLidocaine 1%, without epinephrine, 3-mL syringe, 25-gauge needle

• Scalpel, #15

• Hemostat or similar tool for dissection

• Small suction

• Syringe

• Sterile normal saline

• Optional: Sterile mineral oilOptional: Sterile mineral oil

• Compression/bolster dressing material: Dental rolls, dry cotton, petrolatum gauze, or 4 × 4 plain gauze, gauze wrap dressing, and tape

• Antibiotic ointment

• Hematomas may be anterior, posterior, or both.

• The skin of the auricle is normally densely adherent to the perichondrium, and if it is not held down with pressure, the cartilage below can necrose or deform over time.

• The cartilage configuration of the auricle is relatively symmetric in most people, and this can help determine where to apply bolstering of a large anterior hematoma.

Anatomy of the External Ear

Image

• For a posterior hematoma: Lateral decubitus position on the unaffected side

• For an anterior hematoma: Supine with a slight head turn to the unaffected side

• While wearing sterile gloves, cleanse the pinna and adjacent skin with antiseptic solution.

• Anesthetize the pinna with 1% lidocaine without epinephrine using an Anesthetize the pinna with 1% lidocaine without epinephrine using anauricular block or direct infiltration around the hematoma. Topical anesthesia may be provided with lidocaine-prilocaine cream in addition or as an alternative method. or direct infiltration around the hematoma. Topical anesthesia may be provided with lidocaine-prilocaine cream in addition or as an alternative method.

• Incise the skin along the posterior edge of the hematoma using the #15 scalpel blade. Follow the curvature of the pinna in a skin crease or at the edge of a change in the cartilage shape to hide the scar.

• Gently separate the skin and overlying perichondrium from the hematoma and underlying cartilage using a hemostat or similar tool.

• Manually evacuate the hematoma completely.

• Irrigate the hematoma pocket with sterile normal saline.

• Dry the area using gauze.

• Apply antibiotic ointment to the incision edge.

• Gently press the perichondrium back onto the cartilage with a finger; the pressure dressing will keep them in close proximity.

• Place dry cotton into the external auricular canal.

• Fill all external auricular crevices with petrolatum gauze, dental rolls, or gauze moistened with sterile saline or mineral oil.Fill all external auricular crevices with petrolatum gauze, dental rolls, or gauze moistened with sterile saline or mineral oil.

• Hematomas that are both anterior and posterior require the bolsters to be sutured together with monofilament suture; dental rolls are particularly suited for this maneuver.

• Place several layers of gauze behind the ear to support the back of the ear against the pressure dressing. Cut a V-shape or curve out of the gauze first to allow for a close fit to the ear.

• Cover the external ear with multiple layers of fluffed-up 4 × 4 gauze, and hold them in place by wrapping elastic or gauze bandages around the head and taping the bottom edge of the dressing over the ear lobule.

• Prescribe oral antibiotics (eg, cephalexin) effective against staphylococcus for 7 days.Prescribe oral antibiotics (eg, cephalexin) effective against staphylococcus for 7 days.

• The dressing should be kept dry for 1 week; a shower cap should be used when bathing.

• Reevaluate for recurrence of the hematoma 24 hours after removal of the dressing.

• Remove the dressing after 1 week.

• Patients should not manipulate the ear for 1 month after the dressing is removed to optimize healing and cosmetic results.

• The pressure dressing must be snug enough to prevent hematoma recurrence and/or fluid accumulation, but not so tight as to impede circulation. Typically, if the patient feels the dressing is increasing the pain or causing a headache, the dressing is too tight and should be loosened. If the patient does not feel pressure on the ear after the wrap is placed, it is too loose.

• Ensure adequate anesthesia is administered for proper positioning of the perichondrium after hematoma evacuation.

• The cotton or gauze bolsters should be placed in small pieces to conform precisely to the shape of the ear cartilage. This presses the perichondrium firmly against the cartilage, allowing it to heal without reaccumulation of the hematoma or deformity.

• A properly applied head wrapping is necessary to prevent its impinging uncomfortably on the patient's eyebrow and contralateral ear. This can be mitigated by wrapping umbilical tape or an unfolded 4 × 4 gauze around the dressing above the ipsilateral eye and the opposite ear to prevent the head wrapping from pressing on the eyebrow or opposite ear.