Right auricular hematoma in a man who had trauma to the right ear. CamachoMD
Right auricular hematoma in a man who had trauma to the right ear.

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Summary for auricular hematomas:

Trauma to the outer ear can cause bleeding underneath the skin.

In some cases, the bleeding can be significant and can cause a collection of blood under the skin, which is known as a hematoma.

Hematomas of the ear are known as auricular hematomas.

These are common in contact sports such as boxing, wrestling, and mixed martial arts.

Treatment includes draining the blood by using a needle or by making an incision and draining.

A dressing or sutures are placed to prevent re-accumulation of the blood.

Repeated trauma or inadequate treatment can cause a cauliflower ear.

Auricular hematoma of the upper third of the ear, side view. Note that hematoma can be larger or smaller than the one shown. ChicoMD.com
Auricular hematoma of the upper third of the ear, side view. Note that hematoma can be larger or smaller than the one shown.

Background for auricular hematomas:

What is an auricular hematoma?

First, the term auricular refers to the outer ear (or pinna).

Second, a hematoma is a collection of blood underneath the skin (it can be superficial or deep depending on what was damaged).

Trauma to the outer ear can cause bleeding underneath the skin.

In some cases, the bleeding can be significant and can cause a collection of blood under the skin, which may start off looking like a bruise, or the it can clearly appear to be a large collection of blood.

What is the anatomy and physiology for auricular hematomas?

The traditional teaching is that auricular hematomas form when there is a collection of blood between the cartilage and the skin (with perichondrium).[1]

However, some studies have shown that there may actually be a collection of blood within the cartilage itself in more serious or traumatic injuries.[2, 3]

The perichondrium is a very thin layer of tissue that carries very small blood vessels.

Perichondrium sits directly on top of the cartilage but is deep to the skin.

Areas that are predisposed to hematomas are those with cartilage (the top two-thirds of the ear) which include the helix, anti-helix, concha, tragus, and anti-tragus.[1]

The earlobe does not have cartilage, so it is less susceptible to hematoma formation.

How are auricular hematomas diagnosed?

Auricular hematomas typically occur after acute trauma, such as from trauma from boxing, wrestling or mixed martial arts.

Trauma to the ear from a baseball. ChicoMD.com
Trauma to the ear from a baseball.

Signs and symptoms

Classically, it is not difficult to diagnose an auricular hematoma.

Patients sustain trauma to the ear with subsequent swelling and associated ear pain.

Hematoma of the ear from trauma. ChicoMD.com
Hematoma of the ear from trauma.

How are auricular hematomas treated?

Observation

Doing nothing is always an option.

However, a problem with doing nothing is that the cartilage relies on the perichondrium for bringing blood to the cartilage.

So, if the perichondrium is lifted away from the cartilage, there is an increased risk of developing an infection (possibly even a severe infection known as an abscess) and scarring.

If the hematoma is within the cartilage itself, then the cartilage may undergo changes that make it thicker and harder and this can lead to ear deformity.

Depending on how bad the injury is, there may be a mild deformity or a significant deformity if nothing is done.

Cauliflower ear is the description given to the appearance of the ear after repeated auricular hematomas or after a significant untreated hematoma.

Cauliflower ear on both sides. This can happen to people who have repeated trauma to their ears and do not have the hematomas drained properly. CamachoMD
Cauliflower ear on both sides. This can happen to people who have repeated trauma to their ears and do not have the hematomas drained properly.

What are the surgical options for draining an auricular hematoma?

There are two main ways to drain an auricular hematoma:

  • needle aspiration; or
  • incision and drainage[4]

How is a needle aspiration of an auricular hematoma performed?

Needle aspirations are performed in the following steps:

  • consent is obtained;
  • the ear is prepped with a disinfection solution;
  • a local anesthetic is injected into the ear;
  • the needle is placed into the hematoma and the blood collection is suctioned out; and
  • a splint, a drain, a dressing (bolster) and/or sutures may be placed.[2, 5]

How is an incision and drainage of an auricular hematoma performed?

Auricular hematoma with a blade for incision. ChicoMD.com
Auricular hematoma with a blade for incision

Incision and drainage is performed in the following steps:

  • consent is obtained;
  • the ear is prepped with a disinfection solution;
  • a local anesthetic is injected into the ear;
  • a blade is used to make an incision that goes through the skin and perichondrium (sometimes through a portion of the cartilage too if the blood is inside the cartilage) and the hematoma (blood collection) is suctioned out; and
  • a splint, a drain, a dressing (bolster) and/or sutures may be placed.[2, 5]
Hematoma of the ear immediately after making an incision. Note that the blood can be expressed from the incision site. ChicoMD.com
Hematoma of the ear immediately after making an incision. Note that the blood can be expressed from the incision site.

How long are the drains, dressings and/or sutures left in place after treating an auricular hematoma?

Drains may be left for a few or even several days.

Typically, absorbable sutures are placed to help prevent re-accumulation of a hematoma.

Mattress sutures shown in blue, being placed after incision and drainage of auricular hematoma. ChicoMD.com
Mattress sutures shown in blue, being placed after incision and drainage of auricular hematoma.

However, if the sutures are used to hold a bolster dressing, then they are likely going to need to be cut.

Dressing placed in front and behind the ear after incision and drainage. Note, the blue sutures are holding the dressing in place and will be cut at the clinic visit. ChicoMD.com
Dressing placed in front and behind the ear after incision and drainage. Note, the blue sutures are holding the dressing in place and will be cut at the clinic visit.

Bolster dressings can be left for several days to help prevent the re-accumulation of a hematoma.

When should an incision and drainage be performed instead of a needle aspiration?

In a study evaluating patients with persistent auricular hematomas after needle aspiration (19 days on average after the initial trauma), Dr. Ghanem and colleagues found that the hematomas were located within the cartilage itself.[2]

In these cases, they found that incisions and drainage of the cartilage itself were indicated.[2]

Do patients need to go on antibiotics after the drainage of an auricular hematoma?

Each healthcare provider will determine the need for antibiotics after an auricular hematoma is drained.[5]

The decision for antibiotics will include how large the hematoma is, the method of injury, the extent of treatment (such as needle aspiration vs. incision and drainage).

Government Disclaimer: The views expressed in this website are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

References:

1.            Greywoode, J.D., E.A. Pribitkin, and H. Krein, Management of auricular hematoma and the cauliflower ear. Facial Plast Surg, 2010. 26(6): p. 451-5.

2.            Ghanem, T., J.K. Rasamny, and S.S. Park, Rethinking auricular trauma. Laryngoscope, 2005. 115(7): p. 1251-5.

3.            Pandya, N.J., Experimental production of “cauliflower ear” in rabbits. Plast Reconstr Surg, 1973. 52(5): p. 534-7.

4.            Shakeel, M., et al., Open surgical management of auricular haematoma: incision, evacuation and mattress sutures. J Laryngol Otol, 2015. 129(5): p. 496-501.

5.            Krogmann, R.J. and K.C. King, Auricular Hematoma, in StatPearls. 2020, StatPearls Publishing StatPearls Publishing LLC.: Treasure Island (FL).