1. Management of Auricular Hematoma Matthew Doyle, MS, LAT, ATC

2. Goals for today • Definitions • Pathogenesis • Pathophysiology • Treatment options • What we do at the University of Iowa and why

3. Cauliflower Ear Deformity Untreated or mismanaged auricular hematoma Fibro-neocartilage formation starts @ 7-10 days

4. Wrestler’s Ear

5. Auricular Hematoma • Caused by blunt trauma • Tangent/shearing forces, commonly occurs: • during a takedown or from the neutral position • when athlete isn’t wearing headgear or wears a poor fitting protector and fails to adjust it properly

6. Auricular Hematoma • Classic teaching- Located between the perichondrium and cartilage • Within cartilage itself? • Scaphoid fossa, helix, anti-helix, conchal bowl

7. Prevention of Cauliflower Ear • Proper management of auricular hematoma • Protection • Headgear use became mandatory for NCAA wrestling competition in the late 1960s • Mandatory for wrestling practice in 2004 • Not used in international competition or post collegiate wrestling; Rugby rules? • Compliance?

8. Modified Headgear

9. Background • No randomized controlled trials, clinical trials, or cohort studies • 48 Articles: Reviews, expert opinions, case series, case reports • Jones SE, Mahendran S. Interventions for acute auricular hematoma (Review). Cochrane Database of Systematic Reviews 2004 (2).

10. Summary • Treatment: Remove hematoma and prevent recurrence • No clear consensus exists for best treatment • Various interventions are effective • Literature generally agrees that treatment is better than no treatment • Small risk other than failure, leading to re-accumulation or deformity • Infection (acquired or induced by tx) may result in serious consequences of perichondritis and severe tissue loss

11. Complications • Perichondritis and chondritis; erythema, tenderness, recurrent swelling • Cartilage necrosis, contracture, and neocartilage

12. More Complications • Cosmesis • Reconstructive plastic surgery for cauliflower deformity • Functional • Hearing loss • Wax transport from the ear canal • Increased risk of otitis externa • Difficulty wearing earphones

13. Treatment Barriers • Time consuming • Missed training and competition • Viewed as cosmetic problem not worthy of time loss • “A mark of pride and distinction” • Cauliflower Ear Deformity remains a common stigmata to wrestlers, boxers, and rugby players • Noncompliance due to refusal to stop training

14. Treatment Goals • Adequate removal of hematoma • Simple and effective method of maintaining pressure to prevent recurrence • Satisfactory aesthetics • Appropriate follow up • Minimal impact on patient activity

15. Treatment Options • Removal of hematoma • Needle Aspiration • Incision and drainage • Incision and drainage with resection of cartilage • Prevention of reaccumulation • Non-invasive • Invasive

16. Preventing Reaccumulation • Invasive • Bolsters (Cotton, buttons, thermoplastic splint) • Through and through suturing • Tie over dressings • Placement of drains (passive or suction) • Antibiotic prophylaxis • Noninvasive • Application of plaster mold, silicone splints, cotton/wool impregnated with collodion, swimmer’s nose clip

17. Silicone Ear Splints

18. Dental Silicone

19. Simple Gauze Packing

20. Cotton Bolster Dressing

21. Thermoplastic Splint

22. Leonard Buttons and Drain

23. Through and through Buttons

24. Removal of Neocartilage

25. Treatment Algorithm • Divide into two categories • Fluctuant hematoma discovered acutely • Chronic, more fibrotic, recurrent after needle aspiration • Multiloculated geometry • Ghanem et al. Rethinking auricular trauma. Laryngoscope. 2005 .

26. Acute Hematoma • First line of treatment approved by Otolaryngology • Needle aspiration • Collodion Casting (Jaffee) • Simple, effective, cosmetically satisfactory, allow quick return • Many just want reduction of pain

27. Chronic and Recurrent • Koopman (1979) and Schuller et al (1989) technique preferred • Cotton dental roll bolster sutured through and through, treatment with antibiotics • Allowed to continue as tolerated

28. Short Videos • Collodion Casting • Modified Headgear