Pinna Haematoma

Red flags

  • Patients with superimposed infection need aggressive intervention to prevent complete destruction of the auricular cartilage
  • There may also be other facial and skull base injuries which need to be ruled out
  • A full ear examination is vital to ensure the hearing mechanism is intact
  • Cases should be seen as soon as possible due to the high cosmetic morbidity rate
  Figure 1. Anatomy of the pinna. From Wikimedia Commons. 

 

Figure 1. Anatomy of the pinna. From Wikimedia Commons. 

Why is this important?

  • The pinna is a well vascularized area.  
  • Trauma is common especially amongst rugby players, footballers, wrestlers and cage fighters
  • Shearing forces to the auricle can lead to separation of the anterior auricular perichondrium from the underlying, tightly adherent cartilage. As a result, there can be tearing of the perichondrial blood vessels and subsequently a hematoma formation 
  • If not drained early, the haematoma can compromise the viability of the auricular cartilage leading to avascular necrosis. This can stimulate new and asymmetrical cartilage growth resulting in a ‘cauliflower ear’ deformity which patients tend to find cosmetically unpleasant.

 

When to contact the ENT Registrar

Registrars do not necessarily have to be contacted out of hours. However, patients with recurrent episodes or haematomas older than 7 days should be discussed with the registrars the following day as these patients may need surgical debridement under a GA.

  Figure 2. Haematoma formation. The diagram shows a cross-sectional view of a pinna before and after trauma. Shearing forces tear the well-vascularised perichondrium off the underlying cartilage, leading to haematoma formation. This leads to loss of the vascular supply.

 

Figure 2. Haematoma formation. The diagram shows a cross-sectional view of a pinna before and after trauma. Shearing forces tear the well-vascularised perichondrium off the underlying cartilage, leading to haematoma formation. This leads to loss of the vascular supply.

 

Who to admit

  • Patients with a worsening superimposed infection should be admitted for intravenous antibiotics and may need exploration and washout under a GA
  • Patients with more serious head injuries should be admitted under the relevant teams (Maxillofacial surgery, Head Injury team, Neurosurgery) - patients with simple pinna haematomas do not need admission

 

Assessment and recognition

  • It is better to drain the haematoma before it solidifies, hence the earlier the better, eg within 24 hours of injury
  • A thorough history and examination is essential especially the mechanism of trauma
  • Ensure that other head injuries have been excluded and hearing mechanism is preserved
  • The pinna will appear swollen, fluctuant and mildly erythematous

 

Immediate and overnight management

Evacuation of the haematoma can be done in an A&E/outpatient setting under aseptic conditions, for example:

  • Site of haematoma prepared with betadine/chlorhexidine and appropriately draped
  • 5-10 mls of 1% lidocaine infiltration
  • Either aspiration with a 10ml syringe attached to a wide bore (green/white) needle or incision and drainage with a 15 blade at the helical rim
  • If incisional method is used, the haematoma is completely squeezed out and the cavity then washed thoroughly with saline - some surgeons also use betadine, hydrogen peroxide etc. Two dental rolls are then used (each on either side of the ear) and through-and-through mattress sutures passed through the dental roll using a 3/0 suture to close the perichondrial space. This aims to prevent recollection of the haematoma
  • A tight head bandage is then placed with gauze used as padding in front and behind of the ear

Early aspiration of pinna haematomas brings relief and reduces the risk of both avascular necrosis and abscess formation. Practitioners should not be afraid of learning and doing this procedure as it is pretty low risk - it is easier than placing an IV cannula.

Antibiotic practice varies - if clearly contaminated, older than 24 hours or there are signs of infection, patients should be sent home with an appropriate oral antibiotic like amoxicillin or clarithromycin. Some surgeons will give all patients antibiotics and others will not; there is no clear evidence either way.

Here is YouTube video that illustrates the general approach. Notice how uncomplicated the procedure is - although we recommend you wear gloves etc. 

 

Further management

All patients who have undergone evacuation of haematoma should be seen in the ENT clinic two to three days later. The head bandage is then removed alongside the mattress sutures and dental rolls.

If the haematoma or seroma re-accumulates, it should be drained again as above. 

Refractory cases may need aggressive interventions such as streptomycin/steroid injection or washout and debridement under GA. 

Patients with a permanently deformed ear should be counselled on the need of further cosmetic surgery (cartilage grafting).

 

 

Page last reviewed: 23 September 2016