Home/ENT/Auricular Haematoma

Auricular Haematoma

Urgent drainage to prevent avascular necrosis of cartilage and the permanent deformity of "cauliflower ear" — technique, pressure dressings, antibiotics, and follow-up explained.

Clinical Reminder: An auricular haematoma requires prompt drainage — ideally within 24 hours of injury. Delay leads to clot organisation and cartilage necrosis. Always ask a senior before performing this procedure if you are not yet competent. Never conduct a procedure you are unsure about.

What Is an Auricular Haematoma?

An auricular haematoma is a collection of blood in the sub-perichondrial plane — the potential space between the cartilage of the pinna (auricle) and the overlying perichondrium (the fibrous membrane that covers cartilage). This plane is disrupted by blunt trauma to the pinna, causing shearing of the blood vessels that run within the perichondrium. Blood accumulates in this space, producing the characteristic smooth, fluctuant, tender swelling of the pinna.

Because the auricular cartilage has no intrinsic blood supply of its own — it is entirely dependent on diffusion of nutrients from the perichondrium — any collection of blood that separates cartilage from perichondrium is a surgical emergency. Left untreated, the haematoma causes avascular necrosis of the cartilage, followed by fibrosis and the deposition of new irregular fibrocartilage. This results in the characteristic craggy, deformed appearance known as "cauliflower ear" (also called "wrestler's ear" or "rugby ear").

Who Gets Auricular Haematomas?

Auricular haematomas are seen most commonly in:

  • Rugby players — repeated direct trauma to the ear during scrums and tackles; the condition is so common in rugby forwards that it is considered an occupational hazard
  • Wrestlers and judoka — grappling sports involving ear-to-mat or ear-to-opponent contact
  • Boxers
  • Any patient following direct trauma to the pinna — assault, road traffic accidents, falls

Clinical Assessment

The diagnosis is clinical. The patient presents with a swollen, tense, painful, and often bruised pinna following trauma. The normal contours and ridges of the auricle (helix, antihelix, concha) are obliterated by the fluctuant haematoma. The swelling is typically anterior (lateral) to the cartilage rather than posterior.

Check the following:

  • The external auditory canal — ensure the canal and TM are not injured (associated lacerations or haemotympanum may suggest a more significant injury)
  • Hearing — a basic assessment; significant hearing loss should prompt further investigation
  • Skin integrity — if there is a laceration overlying the haematoma, this becomes an open contaminated wound requiring antibiotic cover and careful debridement
  • Signs of infection — erythema extending beyond the haematoma, warmth, fever, or cellulitis indicate secondary infection or perichondritis, which significantly worsens the prognosis
Time is cartilage: Drainage should ideally be performed within 24 hours of injury. After 48–72 hours, the clot begins to organise (becomes firmer and more gelatinous) and simple aspiration may no longer be possible — formal incision and drainage becomes necessary. After 7–10 days, the haematoma has often liquefied again but the perichondrial reaction is already established.

Management

General Principles

The goals of treatment are to: (1) completely drain the haematoma; (2) obliterate the dead space to prevent re-accumulation; and (3) prevent infection (perichondritis). All three components are equally important — draining the blood without applying a pressure dressing is likely to result in re-accumulation.

Anaesthesia

The procedure is performed under local anaesthesia (LA). A ring block of the pinna using 1% or 2% lidocaine (without adrenaline, as the ear has an end-arterial blood supply and vasoconstriction may compromise perfusion) is effective and well tolerated. Infiltrate around the base of the ear in a ring-like fashion.

Aspiration

Aspiration using a large-bore needle (18G) and syringe is the simplest approach, particularly for smaller haematomas seen early (within 24–48 hours) before significant clot organisation has occurred. The needle is introduced through the skin overlying the haematoma and the blood is aspirated as completely as possible.

Disadvantages: The haematoma re-accumulates in 30–40% of cases treated by aspiration alone if a pressure dressing is not applied. Aspiration is not appropriate for organised (clotted) haematomas.

Incision and Drainage (I&D)

Incision and drainage allows more complete evacuation of the haematoma and is preferred for larger collections, organised haematomas, or those that have re-accumulated after aspiration. Key technical points:

  • Incision placement — make a single incision rather than multiple small ones. Place the incision strategically so that the entire haematoma can be drained through one access point. Consider placing the incision at the inferior aspect of the haematoma where possible, to allow gravity-dependent drainage and reduce the risk of re-accumulation. For the sake of cosmesis, try to site the incision in a natural skin crease or the margin of a cartilaginous ridge where any scar will be less visible.
  • Incision size — avoid making the incision unnecessarily large. An overly long incision may expose the underlying cartilage during healing, which increases infection risk and may result in a poor cosmetic outcome (the very outcome you are trying to prevent).
  • Complete evacuation — gently irrigate the cavity with normal saline after evacuating the clot. Ensure all loculations are broken down and the cavity is completely empty before closing.
  • Wound closure — close the skin with interrupted non-absorbable sutures (e.g., 4-0 nylon or prolene). Leave the wound open or place a small drain if there are concerns about re-accumulation or infection.

Pressure Dressing — This Is Essential

After either aspiration or I&D, a compression dressing must be applied to obliterate the dead space and prevent re-accumulation. Without this step, re-accumulation is very likely regardless of how completely the blood was drained.

Several techniques are used:

  • Dental rolls (tie-over suture bolster dressing) — the most reliable method. Dental rolls (or rolled gauze) are placed on both the anterior and posterior surfaces of the pinna, matching the contours of the ear. They are held firmly in place by sutures passed through-and-through the pinna from front to back, tying the rolls against the auricle surface. This provides even, conforming compression across the entire surface of the pinna and is very effective at preventing re-accumulation.
  • Button bolsters — plastic or metal buttons can be used in place of dental rolls as the bolster material; the principle is identical.
  • Proflavine-soaked wool conforming dressing — a simpler, less reliable alternative; proflavine-soaked cotton wool is moulded into the contours of the anterior pinna and held in place with a head bandage wrapped around the ear.
  • Circumferential head bandage — whatever bolster technique is used, a circumferential head bandage is applied over the pinna to maintain the pressure. Ensure the bandage is firm but not so tight as to cause ischaemia.

Antibiotics

Prophylactic antibiotics are prescribed routinely to prevent perichondritis — a serious infection of the cartilage that can result in cartilage destruction even without haematoma formation. Recommended options:

  • Co-amoxiclav (Augmentin) 625 mg three times daily for 5–7 days — first-line broad-spectrum cover including Staphylococcus and Streptococcus species
  • Ciprofloxacin 500 mg twice daily for 5–7 days — particularly appropriate if there is any concern about Pseudomonas (more likely in contaminated wounds or contact sports injuries); also appropriate for penicillin-allergic patients

Analgesia

Regular paracetamol and NSAIDs (e.g., ibuprofen) are appropriate. Pain should improve significantly after drainage of the haematoma.

Follow-Up

The patient must be reviewed in the ENT emergency clinic within 24–48 hours to:

  • Check for re-accumulation of the haematoma (remove the dressing and inspect carefully)
  • Assess for signs of infection or perichondritis (fever, erythema, increased pain, worsening swelling)
  • Replace the pressure dressing if necessary
  • If re-accumulation has occurred, re-drainage is required; recurrent re-accumulation may require a longer period of through-and-through drainage with a soft drain in situ

Patients should be advised not to return to contact sport until the ear has fully healed, typically 4–6 weeks. Protective head gear (a scrum cap) should be recommended for future sporting activities to prevent recurrence.

Managing Re-Accumulation

If the haematoma re-accumulates despite adequate drainage and pressure dressing, further aspiration or I&D should be performed. For persistent re-accumulation, options include:

  • Placement of a through-and-through corrugated drain sutured in place, left for 48–72 hours
  • Repeated aspiration with continued pressure dressing
  • In longstanding organised haematomas that have not been treated promptly, formal surgical excision of the fibrotic tissue may ultimately be required (this is reconstructive/cosmetic work beyond the scope of an on-call junior)

Frequently Asked Questions

Why does an auricular haematoma cause cauliflower ear if left untreated?

Auricular cartilage has no intrinsic blood supply — it relies entirely on diffusion of oxygen and nutrients from the perichondrium. When blood collects between the cartilage and perichondrium, it physically separates the cartilage from its only nutrient source. The cartilage then undergoes avascular necrosis. As the haematoma organises, fibroblasts infiltrate the clot and lay down new fibrous tissue. This triggers an irregular, disorganised new cartilage formation (neochondrogenesis) that creates the characteristic knobbly, thickened, deformed auricle known as "cauliflower ear". This deformity is permanent and can only be corrected surgically (otoplasty).

Should I use aspiration or incision and drainage for an auricular haematoma?

Aspiration is simpler and less invasive, and is appropriate for small, early (under 48 hours), non-organised haematomas. However, re-accumulation rates with aspiration alone are high (up to 40%) without an excellent pressure dressing. Incision and drainage (I&D) provides more complete evacuation, allows irrigation, and is required for organised or clotted haematomas or those that have failed aspiration. Most ENT surgeons prefer I&D for all but the smallest haematomas, as it allows more thorough evacuation. Whichever method is used, the pressure dressing is equally important and must not be omitted.

What is perichondritis and why is antibiotic prophylaxis important?

Perichondritis is an infection of the perichondrium surrounding the auricular cartilage. It can occur as a complication of auricular haematoma (particularly if drainage is delayed or the wound becomes contaminated) or as a result of piercings, burns, or trauma. It is typically caused by Pseudomonas aeruginosa or Staphylococcus aureus. It presents with rapid onset of severe pain, erythema, oedema, and warmth of the pinna — extending beyond the earlobe (which, lacking cartilage, is spared in true perichondritis). If untreated, the infection destroys the cartilage, resulting in permanent deformity. Treatment requires systemic antipseudomonal antibiotics (ciprofloxacin) and often surgical debridement. Prophylactic antibiotics after haematoma drainage are given to prevent this serious complication.

How do you apply a tie-over pressure dressing after auricular haematoma drainage?

After complete evacuation of the haematoma, dental rolls (or rolled gauze) are placed on both the anterior and posterior surfaces of the pinna, carefully moulded to the contours of the auricle. Sutures (e.g., 2-0 nylon on a straight needle) are passed through the pinna from front to back, through the dental rolls on each side, and tied firmly enough to maintain compression without cutting through the skin. The sutures should be placed at multiple points around the haematoma to ensure even compression across the entire affected surface. The pressure dressing is then reinforced with a circumferential head bandage. The dressing is reviewed and reapplied at 24–48 hours.

Can I use lidocaine with adrenaline for local anaesthesia on the pinna?

No. Lidocaine with adrenaline (epinephrine) should not be used for ring blocks of end-arterial structures such as the pinna, fingers, toes, or penis. Adrenaline causes vasoconstriction, which may critically reduce blood flow to the area and cause ischaemia or necrosis. Use plain lidocaine (1% or 2% without adrenaline) for the ring block. The addition of sodium bicarbonate to the lidocaine solution can reduce the pain of injection and speed up the onset of anaesthesia.

ST3 interview: A rugby player presents with a swollen, fluctuant pinna 12 hours after a match. How would you manage this?

This is an auricular haematoma requiring urgent drainage to prevent avascular cartilage necrosis and cauliflower ear. I would assess the haematoma, check for any skin laceration or signs of perichondritis, examine the ear canal and TM, and perform a ring block with plain lidocaine. Within 24 hours, the haematoma is likely to be liquid and suitable for aspiration or I&D. I would prefer I&D with a small incision at the inferior aspect of the haematoma for dependent drainage, followed by saline irrigation, wound closure, and application of a tie-over dental roll pressure dressing with a head bandage. I would prescribe co-amoxiclav for 5–7 days to prevent perichondritis and analgesia. I would arrange review in the ENT emergency clinic at 24–48 hours to check for re-accumulation and remove or replace the dressing. I would also advise him not to return to rugby until fully healed and to wear a scrum cap in future.

What happens if the auricular haematoma is not treated for several days and becomes organised?

After approximately 48–72 hours, the blood clot begins to organise — it becomes firmer and more gelatinous and cannot be simply aspirated. Between days 3 and 7, aspiration is often unsuccessful and formal I&D with manual removal of the organised clot is necessary. After approximately 7–10 days the haematoma may liquefy again but perichondrial reaction and early new cartilage formation will have already begun. After several weeks, the haematoma organises fully into fibrocartilage and the deformity becomes permanent. At this stage, correction requires reconstructive surgery (otoplasty) — well beyond what can be offered in an on-call setting.

When should I consider a through-and-through drain rather than simple closure?

A through-and-through soft drain (e.g., a small corrugated drain or a Penrose drain) sutured in place is appropriate when: (1) the haematoma has re-accumulated once despite adequate drainage and pressure dressing; (2) there is concern about ongoing oozing or a particularly large haematoma; (3) the patient has a bleeding diathesis or is anticoagulated. The drain allows continued egress of blood/serous fluid for 48–72 hours while the pressure dressing prevents re-accumulation. It is removed at follow-up once drainage has ceased.

References

  1. Watkinson JC, Clarke RW, eds. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 8th ed. Boca Raton: CRC Press; 2018.
  2. ENT UK. Clinical guidance on the management of auricular haematoma. London: ENT UK; 2019.
  3. Mudry A, Pirsig W. Auricular haematoma and cauliflower deformation of the ear: from art to medicine. Otol Neurotol. 2009;30(1):116–120.
  4. Ghanem T, Smith ME. Pinna haematoma: management guidelines. J Laryngol Otol. 2005;119(4):320–324.
  5. Jones SE, Mahendran S. Interventions for acute auricular haematoma. Cochrane Database Syst Rev. 2004;(2):CD004166.
  6. Greywoode JD, Pribitkin EA, Krein H. Management of auricular hematoma and the cauliflower ear deformity. Facial Plast Surg. 2010;26(6):451–455.