J Oral Maxillofac

Surg

50:800-802.1992

Current Concepts in the Surgical Management of Traumatic Auricular Hematoma WILLIAM J. STARCK, DDS,* AND STEVEN I. KALTMAN, DMDt There has been considerable confusion in the literature regarding the treatment of auricular hematoma. This has stemmed from an inadequate standing of the mechanisms involved in the formation and propagation condition. This article reviews the literature and gives suggestions as proper surgical management of this problem.

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collection of serosanguinous fluid stimulated the proliferation of mesenchymal cells in the overlying perichondrium by elevating it off of the cartilage. Eventually, chondroblasts formed new cartilage that tended

The prominent position of the auricle makes it a candidate for both blunt and penetrating traumatic injury. This occurs most frequently from a glancing-type blow; therefore, athletes that engage in contact sports such as boxing or wrestling, and victims of motor vehicle accidents, falls, and assaults are most frequently affected by this injury.’ If left untreated, a subperichondrial hematoma may have disastrous results, most notably “cauliflower” deformity of the pinna.2 The mechanism by which cauliflower ear develops remained controversial until the 1970s. Before then, the prevailing belief was that either a subcutaneous or intracartilaginous hematoma was to blame.3,4 This notion was contradicted, however, by an experiment Skoog, Ohlsen, and Sohn performed in 1972 that indicated that the perichondrium needed to be pulled away from the underlying cartilage by an intervening hematoma for new cartilage to foim5 They then studied the effects of blood injected both subcutaneously and subperichondrially in the ears of rabbits.6 The results of this study indicated that although a subcutaneous blood clot would resorb without incident, those ears that had been injected with blood subperichondrially developed cauliflower deformity. When these ears were examined histologically, they showed a consistent pathophysiological pattern. A subperichondrial

Received from the Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh, PA * Senior Resident. t Chairman. Address correspondence and reprint requests to Dr Starck: Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 152 12. 0 1992 American

Association

of Oral and Maxillofacial

Surgeons

FIGURE 1. Location of cosmetic incisions used in the anterior approach. I, Scaphoid; 2, conchal.

0278-2391/92/5008-0004$3.00/O

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STARCK AND KALTMAN

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FIGURE 2. Treatment of traumatic auricular hematoma. A, Ear of a 4-year-old child who sustained a traumatic auricular hematoma of the letI scaphoid fossa and helix in a motor vehicle accident. B, Elastic material ear stent fabricated after incision, evacuation of the hematoma, and placement of a Penrose drain. Note the hole in this type of stent that allows normal hearing and visualization of the tympanic membrane without removal. C, Head dressing covering the stent is maintained for 24 hours. D, Appearance 1 year postoperatively.

802 to bow the ear inwardly. This was accompanied by retraction of the perichondrium anteriorly, which contributed to further inward bowing of the auricular cartilage. The result was the classic “cauliflower” ear. In the human ear, the skin of the anterior auricle is tightly adherent to the underlying perichondrium; the skin of the posterior surface is more loosely attached to the perichondrium via intervening areolar tissue. Therefore, a blunt force applied to the auricle tends to shear the perichondrium from the underlying cartilage anteriorly while posteriorly the skin is free to glide over the perichondrium. As a result, hematomas tend to form on the anterior surface of the auricle. Treatment of Traumatic Auricular Hematoma Treatment of traumatic auricular hematoma differs depending on how soon after injury the patient seeks care. It is unlikely that significant formation of neofibrocartilage takes place before 7 to 10 days.5*6In patients that come for treatment before that time, incision and drainage followed by some form of pressure dressing or vacuum drainage will suffice. After 7 to 10 days have elapsed, debridement of newly formed cartilage and/or overlying perichondrium is usually necessary.5-8 Access to the hematoma is gained by incision. Needle aspiration is discouraged as it is seldom complete and can often lead to reaccumulation of blood or serum, even in the presence of a pressure dressing.7*9,‘0If the injury is fresh (0 to 10 days), the hematoma is evacuated through an incision on the anterior surface of the pinna at its most dependent point and a drain is placed,” followed by a suitable pressure dressing. After 10 days or more, the perichondrium is stripped and hyperplastic cartilage, if present, needs to be excised. This is most easily performed through an anterior approach. Some prefer a posterior approach, arguing that it is more cosmetically acceptable7,9,‘4; however, anterior incisions may be readily camouflaged if appropriately placed ’ ‘,I2 (Fig 1). A drain is placed after debridement has been completed, the wound is closed with nylon suture, and a pressure dressing is applied as above. Postoperative antibiotics are routinely administered. Pressure is applied after incision and drainage to prevent the reaccumulation of fluid.‘3T’4External pressure dressings are preferred to those that rely on through-and-through sutures because use of the latter increases the incidence of chondritis and/or infection.15 We most often use a removable auricular stent that we had originally designed for prevention of hematoma after procurement of auricular cartilage for use in temporomandibular joint (TMJ) reconstruction.16 It is easily fabricated from elastic dental impression materials and a cotton roll (Fig 2). The use of elastic impression materials in the treatment of acute auricular hematoma has been described previously.‘7,18

SURGICAL TREATMENT OF AURICULAR

HEMATOMA

This type of stent is worn by the patient for 7 days, but the drain is removed after 2 days. The head dressing may be removed after 24 hours because the stent provides precise pressure and remains in place without fixation. In addition, the stent may be comfortably worn under athletic head gear, and the patient can hear normally with it in place. The patient may also remove, clean, and replace it with ease. Summary If one adheres to the previously mentioned principles of hematoma management, the result should be a pliable, resilient auricle that shows minimal fibrosis and resultant thickening. The treatment need not disrupt the life-style of active patients. Surgical management of this entity is well within the scope of the oral and maxillofacial surgeon, and may be provided on an outpatient basis. The proper treatment of this injury is a great service, as it prevents needless cosmetic deformity and difficult secondary reconstruction. References 1. &huller DE, Dankle SK, Martin M, et al: Auricular injury and the use of headgear in wrestlers. Arch Gtolaryngol Head Neck Surg 115714, 1989 2. Converse JM, Brent B: Acquired deformities of the auricle, in Reconstructive Plastic Surgery (ed 2). Philadelphia, PA, Saunders, 1977, pp 1732-1735 3. Kelleher JC, Sullivan JG, Baibak GJ, et al: The wrestler’s ear. Plast Reconstr Surg 40:540, 1967 4. Stuteville OH, Janda C, Pandya NJ: Treating the injured ear to prevent a cauliflower ear. Plast Reconstr Surg 44:3 10, 1969 5. Skoog T, Ohlsen L, Sohn SA: Perichondrial potential for cartilaginous regeneration. Stand J Plast Reconstr Surg 6:123,1972 6. Ohlsen L, Skoog T, Sohn SA: The pathogenesis of cauliflower ear. Stand J Plast Reconstr Surg 9:34, 1975 7. Bull PD, Lancer JM: Treatment of auricular hematoma by suction drainage. Clin Otolaryngol 9:355, 1984 8. Scarcella JV: Tie-over dressing to prevent recurrence of a hematoma of the ear. Plast Reconstr Surg 6 1:610, 1978 9. Davis PKB: An oneration for hematoma auris. Br J Plast Sum 241277, 1971 10. Koopmann CF, Coulthard SW: Management of hematomas of the auricle. Laryngoscope 89: 1172, 1979 11. Nahl SS, Kent SE, Curry AR: Treatment of auricular hematoma by silicone rubber splints. J Laryngol Otol 103: 1146, 1989 12. Templer J, Renner GJ: Injuries of the external ear. Otolaryngol Clin North Am 23: 1003, 1990 13. Escat M: Simplified treatment of hematoma of the ear. Otorhinolaryngol Intemationale 30: 18 1, 1946 14. Tamer RC: The prevention of post operative hematoma with a note on the use of compression suture. Surg Forum 2:510, 1951 15. Schuller DE, Dankle SD, Strauss RH: A technique to treat wrestler’s auricular hematoma without interrupting training or comnetition. Arch Otolaryngol Head Neck Surg 115:202,1989 16. Starck WJ, McNeir DM: A semirigid stent for use after auricular cartilaae eraft harvest. J Oral Maxillofac Sure, 50:95, 1992 17. Bit&am-Bi Chevretton EB: Silicone ear splints in the management of acute hematoma auris. J Laryngol Otol 101:889, 1987 18. Powers MP, Bet-& J, Fonseca RJ: Management of soft tissue injuries, in Fonseca RJ, Walker RV (eds): Oral and Maxillofacial Trauma. Philadelphia, PA, Saunders, 199 1, pp 635636.

Current concepts in the surgical management of traumatic auricular hematoma.

There has been considerable confusion in the literature regarding the proper treatment of auricular hematoma. This has stemmed from an inadequate unde...
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