What is Auricular Hematoma?
An auricular hematoma is a pool of blood under the skin of the ear usually caused by a blow to the ear. Some common causes include wrestling and boxing. When the auricular hematoma is not treated in time or improperly treated, the ear can develop a deformity that looks like a cauliflower. Normally, no special test is needed to diagnose this condition unless there are other symptoms, like hearing loss.
To avoid complications like infection or the cauliflower deformity, it’s important to remove the hematoma as soon as possible. Keeping the treated area under pressure for 5 to 7 days can prevent the hematoma from recurring. Specialists who are experts on injuries to the pinna, such as ear, nose, and throat doctors, or plastic surgeons, can provide advice on diagnosis, treatment, and follow-up care.
The external ear, or auricle, is made up of elastic cartilage wrapped in a dense layer packed with fibers, called the perichondrium, and skin. Its shape and 3D structure, which includes the helix, antihelix, scapha, concha, triangular fossa, tragus, and antitragus, is due to its fibrocartilaginous structure. An exception is the lobe of the ear, which is mainly fat and fibrous tissue.
The perichondrium plays an important role in keeping the ear’s shape and strength. Due to the cartilage’s poor blood supply, it relies on the blood supply from the perichondrium for oxygen and nutrients. This layer also helps in the repair and growth of cartilage. It has cartilage-producing cells in its internal layer and helps to attach the skin that covers it.
The ear’s skin has a few hairs, sweat and sebaceous glands, and a type of skin called keratinized stratified squamous epithelium. The front and side regions of the ear lack the fatty underlayer and are tightly attached to the perichondrium just beneath. The back and middle region have subcutaneous fat and muscle. This difference makes the front and side parts of the ear more prone to injuries than the back and middle parts.
What Causes Auricular Hematoma?
Auricular hematomas, which are the result of blunt force injuries to the ear, are typically associated with shearing impacts rather than direct hits. They are commonly seen in athletes participating in contact sports without proper ear protection, particularly wrestling and rugby, although other causes are also known.
According to a 2020 study by Dalal et al, sports injuries were the cause of 40% of ear hematomas in a study of 87 patients, with attacks and falls each accounting for another 10%. In some instances, self-harm or surgery could also lead to ear hematomas.
Ear piercings, especially those on the helix of the ear, can also lead to a hematoma, which is a blood-filled swelling, and this could result in a subsequent bacterial infection. People with certain systemic conditions, such as recurring inflammation of cartilage, known as relapsing polychondritis, and a skin disease called psoriasis, are more susceptible to developing ear hematomas.
Occurrences of spontaneous ear hematomas have been noted as well, and the risk for this increases with the use of anticoagulant medications, which thin the blood and can lead to blood accumulation after even a minor injury. Lastly, if a child repeatedly gets ear hematomas and is not involved in high-risk sports, it should be evaluated for potential non-accidental injuries or trauma.
Risk Factors and Frequency for Auricular Hematoma
An auricular hematoma is a condition that might not always be reported, as not all patients seek medical care for it. This makes it difficult to figure out how common it really is. In a 1989 survey involving over 500 US college wrestlers, it was found that wearing headgear played a significant role in determining whether an individual would develop an auricular hematoma.
- About 52% of the wrestlers who did not use headgear experienced at least one auricular hematoma, while only 26% of those who wore headgear had the same experience.
- The rate of cauliflower ear deformity — a potential outcome of an auricular hematoma — was higher in people who did not use headgear (26.6%) compared to those who did (10.6%).
- On a concerning note, more than 90% of wrestlers don’t consistently wear headgear, especially during practices which are not supervised by coaches, leading to a higher risk of developing a hematoma.
A separate study conducted in 2020 showed that 86% of auricular hematoma patients at a tertiary care medical center were male. There might also be a slightly higher risk of injuries occurring on the right side of the body, but more research is needed to confirm this.
Signs and Symptoms of Auricular Hematoma
An auricular hematoma, or a swelling filled with blood in the ear, usually has symptoms such as pain, swelling, an unusual sensation in the affected ear, and hearing difficulty. People might experience a sensation of fullness or pressure in their ear. The skin on top of the swelling might be reddish and bruised, and the outer part of the ear could appear swollen or out of shape. Severe cases might involve blood or other fluid leakage from the ear. Some people might also report headaches or dizziness if the swelling is severe or if other structures in the area are also affected.
Your health care professional will ask about your medical history, including any recent instances of injury to the ear, any previous occasions where you had similar symptoms or conditions, whether you’ve experienced fever or chill, whether there’s been any fluid leakage from the ear, whether you’ve noticed any changes in your hearing, and whether you’ve had sudden saltiness in your nose or any neurological symptoms like headache, the loss of consciousness, or issues with your cranial nerves. They will also ask if you play high-risk sports – because injuries to the ear are often found in people who have also suffered trauma to the head or neck.
Your professional might also ask whether you have any medical conditions. This may include psoriasis, relapsing polychondritis, hypertension, bleeding disorders, or using blood thinners that may make you prone to auricular hematomas. It is worth noting, however, that these conditions might not always be present. In fact, in a 2020 research study by Dala et al, 31% of auricular hematomas just happened with no known cause. Therefore, you shouldn’t rule out the possibility of having this condition just because you don’t have any of the risk factors. They will also be interested in finding out how fast the symptoms appeared because auricular hematomas usually manifest suddenly – which differentiates them from keloids or other distorted shapes that are synonymous with cauliflower ear.
A physical examination of your ear will show whether you have an auricular hematoma. Your health care professional will thoroughly check your external ear, looking closely at its structure to see if there’s anything abnormal. A symptom of auricular hematoma is an irregular shape of the ear with some swellings and red or bluish patches. They might also find soft spots over the scaphoid fossa, triangular fossa, antihelix, or concha. In addition, they might notice small wounds or abrasions on your ear. It will be necessary to use an instrument called an otoscope to look into your external ear canal, as impact injuries can also cause fractures to a bone in your skull, which is usually shown by wounds in the external auditory canal and blood present in the tympanic membrane.
It is notable that an auricular pseudocyst does not usually show signs of trauma or have blue or reddish patches. However, it’s not important to distinguish auricular pseudocysts or seromas from hematomas since they share similar treatments. A condition named otitis externa, which often involves the external auditory canal, should be separated from auricular hematomas. Even though it can also present with significant swelling and redness on the outer ear.
Testing for Auricular Hematoma
If a doctor suspects someone has an ear hematoma, this is typically confirmed through a patient’s medical history and a physical examination. However, if it’s unclear or there isn’t enough information, an ultrasound can provide more certainty in making a diagnosis. In cases where skull or neck injuries are suspected, a CT (computed tomography) scan can quickly and reliably check bone condition.
If there’s a concern about a traumatic brain injury, an MRI (magnetic resonance imaging) may be needed. Tests can also be done to find foreign objects within the body. For patients who are on blood-thinning medications, tests looking at coagulation, or the ability of the blood to form clots, should be performed to check the medication’s effectiveness.
If there’s any drained material that seems infected, it should be tested with a Gram stain and a culture to facilitate the correct choice of antibiotic. In cases where a patient is experiencing hearing loss, an audiometry test can help determine the severity and type of hearing loss.
Treatment Options for Auricular Hematoma
Auricular hematomas, which are collections of blood in the ear, can be treated either in a regular patient room or in the operating room depending on their size and severity. Before starting any treatment, doctors need to talk with the patient about the risks and benefits of the proposed treatment and get their agreement.
If the hematoma is less than 2 cm in diameter and occurred within the last 6 hours, it might be possible to simply use a needle to draw out the blood. But if the hematoma is bigger or older, doctors typically have to make a small cut and drain out the blood. These two approaches tend to have similar results if carried out properly.
If a hematoma hasn’t been treated for a week to 10 days, it might be possible to draw out the blood with a needle if the clot has become liquid. However, new cartilage might have formed at this point, which could require surgery to remove. Some patients might prefer to just watch the injury and not have any treatment, even though this can lead to bad cosmetic results.
Below is a simple description of how auricular hematomas are treated:
1. Preparation: The doctor positions the patient so the ear with the hematoma is facing upward. An injection around the ear helps to numb the area and reduce swelling. The doctor then cleans the ear with an antiseptic agent and prepares the necessary tools.
2. Needle Aspiration: A needle is used to draw out the blood from the hematoma. The doctor may massage the area and move the needle in different directions to help break up any clots and reduce the hematoma. If this isn’t enough, making a small cut and draining the hematoma may be necessary.
3. Incision and Drainage: This step is often needed if the needle aspiration failed, if the hematoma is larger than 2 cm, or if it’s been present for more than 6 hours. The doctor makes a small cut, then squeezes or suctions out the blood. If necessary, a culture is taken, the area is cleaned with saline, and any bleeding is controlled. The doctor may then clear any leftover clot and close up the cut using a resorbable stitch. If necessary, a drain may be placed in the ear and removed a day or two later.
4. Aftercare: Pressure is applied to the ear to prevent additional fluid from accumulating. This can be done using dental splinting material shaped to fit the ear and held in place with a headband, applying a special medical glue, or sewing through the ear with absorbable stitches. Removing the stitches or dressing usually happens after 5 to 7 days, and antibiotics may be given based on the doctor’s judgment.
If a hematoma keeps coming back, a technique often used in dogs may be used, which involves removing a small section of cartilage from the ear. This has been shown to be very effective in preventing hematomas from coming back in human patients. If the ear develops a deformity called a cauliflower ear, reconstructive surgery may be needed, and the patient would be referred to a specialist.
What else can Auricular Hematoma be?
When a patient has a swollen ear, doctors need to first ensure the swelling is not caused by infections, autoimmune diseases, or injury. Several conditions can cause the ear to swell and it can sometimes be difficult to differentiate between them.
Here are some conditions that can resemble a swollen ear but each requires different types of assessment and handling:
- Hemangioma (a benign tumor caused by abnormal growth of blood vessels)
- Cauliflower ear (a deformity of the ear generally caused by repeated injury)
- Perichondritis (an infection of the skin and tissue that surrounds the cartilage of the ear)
- Otitis externa (an infection of the outer ear canal)
- Abscess (a localized collection of pus)
- Pseudocyst (a fluid-filled sac)
- Seroma (a pocket of clear fluid that can develop after surgery or injury)
- Cellulitis (a skin infection)
- Keloid (a raised overgrowth of scar tissue)
- Winkler disease (a condition marked by repeated inflammations of the ear’s cartilage)
- Laceration (a tear in the skin)
- Erysipelas (a skin infection often caused by strep bacteria)
- Sunburn
- Skin cancer
By considering these conditions, doctors can ensure they correctly diagnose the cause of the ear swelling and thus treat it appropriately.
Possible Complications When Diagnosed with Auricular Hematoma
Cauliflower ear deformity is an unwanted condition resulting from an ear hematoma, which is basically a collection of blood outside of blood vessels. It can form due to some damage or injury. This condition can give the ear an abnormal shape, which might lead to discomfort when using headphones or other ear protection devices. Earphones or earplugs might not fit properly if the conchal bowl, that’s the biggest indentation in the ear, is affected. If the opening of the ear, also known as the external auditory meatus, narrows, it can lead to hearing problems and increase the chance of earwax getting impacted.
Untreated hematomas can increase the risk of getting a cauliflower ear, particularly if the condition comes back after the initial drainage treatment. Based on studies, treatment by an ear, nose, and throat specialist (also known as an otolaryngologist), can reduce the chances of the problem recurring when compared to treatment by other specialists or general practitioners. The chances are even lower if a bolster, a kind of pad, is used after the draining process.
For the reconstruction of a cauliflower ear, it is recommended to seek help from an otolaryngologist, plastic surgeon, or a facial plastic surgeon.
Recovery from Auricular Hematoma
If you have an auricular hematoma, also known as an ear hematoma, it can usually be treated without a hospital stay. It’s a good idea to get advice from a specialist, such as an ear, nose, and throat doctor, plastic surgeon, facial plastic surgeon, or a oral and maxillofacial surgeon. Whether to use pain relief and antibiotics depends on what the treating doctor thinks is best. Any drains put in place should be removed within a day or two, but bandages used to apply pressure should stay on for about a week. During treatment, it’s important to take it easy, particularly avoiding contact sports, for about two weeks.
Preventing Auricular Hematoma
To help prevent ear hematomas (a swelling filled with blood that can form in the ear), it’s a good idea to wear protective headgear during activities that could result in head or ear injuries. This is particularly important for people participating in martial arts, wrestling, American football, boxing, and skateboarding. For martial arts and wrestling, ear protectors are recommended, while those engaged in football, boxing, and skateboarding should consider special helmets. Using ear protectors have reduced the occurrence of ear hematomas in college wrestling by half. Applying a cold compress to the ear every 15 to 20 minutes can also help, especially after unprotected ear trauma.
If someone does get an ear hematoma, it’s crucial to drain it promptly to prevent more blood from accumulating and to reduce the risk of developing a cauliflower ear (a deformity that can occur after repeated ear injuries). After this, it’s recommended that people avoid strenuous exercise and contact sports for about 10 to 14 days. This might be difficult for athletes but it’s important for healing. Additionally, maintaining normal blood pressure levels and proper blood-thinning medication, if required, is also vital. Using pressure dressings like bolsters sutured to the ear, dental silicone splints, certain types of stitches, and magnetic buttons can reduce the risk of the hematoma coming back by 75%.
