Overview of Complex Ear Lacerations
Facial cuts, often seen in emergency or family doctor offices, are quite usual and the ear can be particularly difficult to deal with due to its special shape. The ear, sticking out as it does over a hard bony area, is prone to getting cut, partially torn off, or injured through a hard, blunt impact. Plus, the ear is made up of special materials and has a delicate blood supply, making fixing ear cuts more challenging and requiring special care.
Anatomy and Physiology of Complex Ear Lacerations
The ear is a complex body part with a unique structure, and understanding this is crucial when a doctor needs to repair a tear or cut in the ear. Most of these injuries occur on the external part of the ear, also known as the auricle or pinna. The pinna is made of skin-covered cartilage, which is a firm, flexible kind of tissue. This part of the ear is often prone to injury, but sometimes the wound might extend into the ear canal or areas around the ear.
The lower part of the ear, known as the lobule or earlobe, is not made of cartilage but of fibrous fat tissue enveloped by skin. The pinna’s cartilage gets its blood supply from the perichondrium, a special layer of connective tissue that covers it. This tissue relies heavily on its own blood supply to stay healthy and is closely attached to the underlying cartilage, but there’s also a layer that allows some movement between this tissue and the overlying skin.
The skin of the ear gets blood from two sources – the front part is supplied by branches of the superficial temporal artery, and the back part is supplied by the posterior auricular artery. Both these arteries branch off from the external carotid artery in the neck. The back part of the ear also gets some blood supply from branches of the occipital artery.
The sensation in the ear is controlled by several nerves. The top and front parts are controlled by the auriculotemporal nerve, which comes from the trigeminal nerve running through the face. The bottom and back parts are controlled by the lesser occipital and greater auricular nerves, branching from the C2 and C3 nerves in the neck. The majority of the inner part of the ear is controlled by the vagus nerve, with some input from the facial nerve. The ear canal and the eardrum are controlled by branches of the auriculotemporal nerve, the facial nerve, the glossopharyngeal nerve, and the vagus nerve.
Why do People Need Complex Ear Lacerations
If you’ve cut your ear, it’s typically best to get it treated right away, within the first 24 hours after the injury. This is really important, especially if you can see the cartilage of your ear – that’s the firm, bendable part that gives your ear its shape. If the cartilage is open to the air, it’s important to close it up to reduce chances of complications. These can include getting an infection, damage or death to the tissues (chondritis or necrosis), or deformities like “cauliflower ear”.
If you come in after 24 hours, or if there are signs of infection, the doctor might decide to delay closing the wound. They might do the same if some parts of the ear have less blood supply than normal, or if the patient has a higher risk of getting an infection – for example, because of uncontrolled diabetes.
In some more serious cases, you might need to see a specialist. For instance, the emergency room doctors might decide to refer you to an ear, nose, and throat, or a plastic surgeon, if the injury involves a part of the ear being torn off, cuts extending into the inner part of the ear, damage to the middle or inner ear, or cuts along with a skull fracture.
Partial tearing of the ear can be treated by emergency clinicians if there’s enough healthy tissue remaining and the blood supply to the affected area is good. If the injury is more severe and the blood supply to the wound site is too small or unreliable, then a surgeon’s attention is needed.
When a Person Should Avoid Complex Ear Lacerations
If a wound in the ear is openly infected, it’s usually not safe to repair it right away. Doctors need to be cautious about other serious injuries that might occur at the same time. Some symptoms to look out for include feeling sick (nausea) and throwing up (vomiting), trouble balancing (ataxia), blood behind the eardrum (hemotympanum), leakage of brain fluid from the ear (CSF otorrhea), bruising behind the ears (Battle’s sign), or issues with the facial nerves affecting movements of the face. These are more likely to happen if the injury was caused by a high-speed accident or if the patient has multiple injuries.
Equipment used for Complex Ear Lacerations
Healing a complicated ear cut requires several medical tools and procedures. The initial supplies needed consist of tweezers, instruments to use and tie up medical threads, sterilized coverings for the wound area, a small knife or scissors, and special gauze that is clean. Besides these, a form of local anesthesia – buffered lidocaine, is provided using small thin needles (27 to 30 gauge) that are attached to syringes.
If the cut involves the flexible connective tissue in your ear (the cartilage) or the skin around it, your doctor may use a special type of dissolvable thread, made from certain synthetic materials like glycolide and L-lactide. Another option might be a kind of thread made of polyester that dissolves on its own as well. Brands of these threads could be Monocryl or PDS.
This thread can maintain its strength for up to 30 days and causes minimal irritation to the tissue. Then, the skin over the ear would be stitched together using a 5-0 or 6-0 thread size, referring to the thickness of thread used. Your doctor may choose between threads that dissolve on their own or ones that need removal – this choice is typically based on the doctor’s personal preference, the patient’s ability to return for a follow-up appointment, and whether or not the individual can have their stitches removed, which should typically be done in about a week.
Preparing for Complex Ear Lacerations
It’s important to thoroughly clean the area around a cut or tear on the ear before starting any repair effort. This can be done by washing or “irrigating” the wound with a sterile saltwater solution. For each centimeter of the wound, 50 to 100 mL of this solution should be used.
To make patients more comfortable, a specific type of numbing method – known as a regional auricular block – can be used on the ear before washing the wound. This method also helps keep the edges of the wound in their natural state.
Once the wound is clean, a sterile covering (or “drape”) should be placed over the area to keep it isolated. If the wound has rough or damaged tissues, the doctor might need to remove or “debride” them to create a neat wound margins that can hold stitches properly. This is done before starting the actual repair process.
How is Complex Ear Lacerations performed
Before a doctor can begin repairing a cut on your ear, they need to numb the area around it. This can be done by directly injecting a numbing medicine into or around the cut edges, or by injecting the medicine in a pattern around your ear, which is referred to as a regional auricular block. This block can numb most of your ear except for the middle part. It’s done by injecting the medicine in a shape like a box or diamond around the ear. First, the doctor will insert the needle under the ear near the lobe, aiming towards the bit of the skull behind the ear. While stepping back, they will slowly inject approximately 1ml of the medicine per inch of skin in the subcutaneous plane. This means underneath the skin but above the muscles and fat. They try to avoid injecting it into the nerves that control the muscles of the face. Using the same technique, they will then insert the needle towards the skin in front of the small protruding bit of the ear. They then repeat the process starting from the skin above the ear. It’s necessary to wait for about 5 to 10 minutes until the area is completely numb. To make sure it’s numb, the doctor will test your sensation around the cut before starting the repair.
When the area around the cut has been cleaned and numbed, the doctor can begin repairing it. They try to restrict the removal of any tissue, and only remove those that are clearly devoid of blood supply before the repair. The main aims when repairing a complex ear cut are to properly align the ear cartilage to maintain looks and to ensure that the skin can adequately cover the cartilage. The ear cartilage doesn’t have its own blood vessels and relies on the skin for its blood supply. To begin the repair, the doctor will try to cover the exposed cartilage with the skin. If the skin can’t stretch enough to cover the cartilage, up to a 5-millimeter triangular piece of cartilage through the helix can be removed without significantly affecting the ear’s shape, look, and function. Anything larger than this might require skin flaps for coverage or a staged repair. Small ear cuts can be stitched with simple interrupted or running stitches through the skin. When there is significant cartilage involvement and deformity of the ear, it’s imperative that the cartilage is realigned with deep stitches. Ideally these stitches should run through the outer protective layer of the cartilage rather than the cartilage itself as the cartilage has a greater tendency to pull through or tear. If needed, these stitches can also be applied through the cartilage in case of severe injuries. These deep stitch knots are buried. After this, the doctor will then close the skin with small but simple stitches at intervals of 2-3 millimeters.
Once the cut has been repaired, a pressure dressing needs to be applied on the ear to prevent the formation of a large pool of clotted blood under the skin, known as a hematoma. There are several ways this can be done. One common method is to apply a petroleum-soaked bandage on the area where the cut is, usually on the curved ridge of the ear, and applying it tightly against the adjacent skin. Then, a big piece of gauze is applied over the entire ear and kept in place with a bandage wrapped around the patient’s head. Another option is to use a series of simple interrupted “quilting” stitches. This involves piercing the back side of the ear with a stitch, advancing about 1cm upwards, going back through the front side of the ear, and tying the knot on the back side. These stitches will be spaced out by a few millimeters and cover the whole ear surface that may risk hematoma formation. Alternatively, the area can be bolstered, providing support and pressure. with a stitched on brace or with a mould. The brace and any non-absorbable stitches are usually removed in about 5-7 days. As of now, there is no solid evidence supporting the routine use of antibiotics to prevent infection in ear cuts. However, they are often prescribed because the consequences of a possible infection can be very serious, and these antibiotics should cover a bacteria known as Pseudomonas.
In serious cases of full-thickness cuts where only a small bit of skin is attaching the cut-off part to the remainder of the ear, it’s advisable to consult with an ear, nose, and throat doctor or a plastic surgeon for repair. Such cases might need a complex, multistage repair. This often involves stripping off any remaining skin on the avulsed segment and burying it behind the ear to allow new blood vessels to grow and supply the cartilage. A second procedure will bring this construct back onto the outer ear and might require a skin graft from behind the ear. Completely severed ears can be treated in the same way but attempts to rejoin it at the time of injury have also been described.
Possible Complications of Complex Ear Lacerations
Cuts or tears on any part of the body, including the ear, can lead to complications. These may include visible scars, infection, pain, or the need for further treatment to repair the wound. Two complications that specifically relate to ear injuries are ‘chondritis’, which is inflammation of the ear’s cartilage, and ‘hematoma’, which is a swelling of clotted blood within the tissues.
It’s important to check on the wound 24 to 48 hours after it has been treated, to make sure these complications aren’t developing. Mostly, an infection like chondritis is caused by a type of bacteria called Pseudomonas aeruginosa. If this occurs, a medicine called ciprofloxacin is usually used to treat it.
If the cut or tear is in the outer ear canal, there’s a risk that the canal could become narrow, a condition known as ‘canal stenosis’. There is also a risk of developing acute otitis externa, an infection that causes swelling and pain in the ear canal.