The Laryngoscope
Lippincott Williams & Wilkins, Inc.
© 2005 The American Laryngological,
Rhinological and Otological Society, Inc.
Rethinking Auricular Trauma
Tamer Ghanem, MD, PhD; J. K. Rasamny, BA; Stephen S. Park, MD
Objectives/Hypothesis: An unrecognized auricu-
lar hematoma can lead to a disfiguring deformity, the
cauliflower ear, but it can be prevented with prompt
and comprehensive management. Fine needle aspira-
tion with pressure bandages remains the mainstay
treatment but will occasionally fail. We review our
experience with recurrent or recalcitrant auricular
hematomas in terms of their pathophysiology and re-
vision surgery. Study Design: Retrospective chart re-
view. Methods: A review of patients undergoing sur-
gical incision, drainage, and debridement secondary
to recurrent auricular hematomas was conducted.
Demographic data was collected, intraoperative
notes were reviewed, and follow-up results were ob-
tained. Our management included an open incision,
aggressive debridement, and long term bolsters to the
ear. Results: Ten patients presented with a persistent
auricular hematoma and deformity following outpa-
tient management with either incision and drainage
or fine needle aspiration. All were male with a mean
age of 25 years, presenting for surgery on average 19
days following initial trauma. The location of the he-
matoma within this group was not limited to the po-
tential space between the cartilage and perichon-
drium. The hematoma was clearly located within the
cartilage itself and it is postulated that this is one of
the primary reasons for initial failure. Following sur-
gical incision and drainage there were no recur-
rences or complications. Conclusion: There is a select
group of patients with refractory auricular hemato-
mas that require more aggressive treatment over a
fine needle aspiration. Open debridement is indicated
for this group. The location of the hematoma, granu-
lation tissue, and neo-cartilage is found to be within
the cartilage itself rather than between the cartilage
and perichondrium, thus explaining why a needle as-
piration alone can be ineffective. Key Words: Auricu-
lar trauma, auricular hematoma, surgical manage-
ment, cauliflower ear.
Laryngoscope, 115:1251–1255, 2005
From the Department of Otolaryngology—Head and Neck Surgery,
University of Virginia, Charlottesville, Virginia, U.S.A.
Editor’s Note: This Manuscript was accepted for publication March
15, 2005.
Send Correspondence to Dr. Stephen S. Park, Department of Oto-
laryngology—Head and Neck Surgery, PO Box 800713, University of Vir-
ginia, Charlottesville, VA 22908, U.S.A.
DOI: 10.1097/01.MLG.0000165377.92622.EF
Laryngoscope 115: July 2005
INTRODUCTION
An auricular hematoma occurs because of blunt
trauma to the auricle.1,2 Unrecognized or improperly
treated, it can result in the conspicuous cauliflower ear
deformity, which has been recognized since the ancient
Greek wrestlers. In fact, the deformity remains a common
stigmata to wrestlers, boxers, and rugby players. The un-
managed auricular hematoma can lead to infection, carti-
lage necrosis, contracture, and neocartilage formation.
There are a variety of treatments aimed at preventing
these complications and returning the auricle to its pre-
trauma form.3–11 Typically, a graduated approach is un-
dertaken depending on the extent of the injury and the
time from initial insult. For small hematomas that are
discovered acutely, a needle aspiration with a bolster
dressing is recommended. For a few days postinjury, the
hematoma will become a coagulated clot, and needle aspi-
ration is often ineffective. After roughly a week, the clot
usually breaks down, and aspiration is once again possi-
ble. Larger hematomas may warrant an open approach or
placement of a drain. Postoperative antibiotic prophylaxis
against skin flora is generally recommended. Despite
these measures, treatment of auricular hematomas can be
frustrating because of their common recurrence, which
can occur several days postevacuation.
Complete extirpation of auricular hematomas is
therefore key to adequate treatment. To completely evac-
uate the auricular hematoma, it is important for the sur-
geon to have a proper understanding of the pathophysiol-
ogy of auricular hematoma. Blunt trauma causes shearing
forces between the anterior auricular skin, perichon-
drium, and cartilage. Classically, the hematoma is
thought to form in the potential space between the peri-
chondrium and ear cartilage.1 Careful studies investigat-
ing the etiology of this deformity suggest that the hema-
toma actually occurs intracartilaginously (i.e., in the ear
cartilage itself).2 The basis for these studies will be ex-
plored further in the Discussion section. Once the hema-
toma forms, it will organize with fibroblast infiltration
and eventual neocartilage formation. One reason for re-
currence or for progression to the cauliflower deformity is
incomplete removal of the hematoma, which is expected to
occur with multiloculated hematomas arising within the
cartilage proper.
The purpose of this paper is to review our experience
with the management of recurrent auricular hematomas
and to explore their pathophysiology. The study subjects
Ghanem et al.: Rethinking Auricular Trauma
1251
were limited to patients with recurrent or persistent he-
matomas of the ear.
MATERIALS AND METHODS
A retrospective chart review was conducted for patients
with auricular hematomas treated at a tertiary care hospital
between December 2001 and May 2004. Prior approval was ob-
tained from the human investigation committee. All patients
included in this study underwent surgical incision and drainage
of their auricular hematoma. Demographic data, previous proce-
dures, intraoperative findings, follow-up results, and complica-
tions were recorded.
An anterior incision was made along the inner aspect of the
helix or antihelix, depending on the epicenter of the hematoma. A
skin flap was elevated over the underlying hematoma with care
taken to identify the precise location of the lesion with respect to
the perichondrium and cartilage. All blood, granulation tissue,
necrotic cartilage, and fibrous tissues were completely evacuated.
The skin was closed with absorbing suture and a through-and-
through bolster dressing applied for 1 week. Perioperative sys-
temic antibiotics were prescribed for 7 days.
RESULTS
Ten patients with recurrent auricular hematomas
were identified from February 2001 to March 2004 and
included in this study. All were male with a mean age of
25 (14 – 49) years. Causation in descending frequency were
wrestling (n ⫽ 4), fighting (n ⫽ 3), self-inflicted (n ⫽ 1),
and unknown (n ⫽ 2). The time interval from trauma to
the surgical intervention ranged from 2 to 38 (mean 19)
days. Five patients underwent previous unsuccessful nee-
dle aspirations: three patients underwent one previous
unsuccessful needle aspiration, and two patients had two
previous unsuccessful needle aspirations. One patient had
two unsuccessful attempts at open incision and drainage.
Laryngoscope 115: July 2005
1252
The other four hematomas were firm to palpation and
were not felt to be amenable to needle aspiration. Those
patients went directly to surgical incision and drainage,
without attempts at needle aspiration. Hematomas oc-
curred along the superior half of the ear, involving the
scaphoid fossa, triangular fossa, antihelix, concha cymba,
and concha cavum. The location of the hematoma was
determined through the operative note and found to be
intracartilagenous (i.e., sheets of native cartilage could be
found on both the anterior and posterior borders of the
hematoma). The lesions consisted of clot, serum, fibrous
tissue, and fragments of normal cartilage. There were no
complications or recurrences on follow-up of at least 1
month. All patients were specifically instructed to return
if there were any signs of erythema, tenderness, or recur-
rent swelling.
Case Presentation
A sixteen-year-old male wrestler presented 2 weeks
after suffering a right auricular hematoma in a wrestling
match. He had two previous unsuccessful fine needle as-
piration procedures with a dental roll bolster dressing by
an outside otolaryngologist. His preoperative photographs
are shown in Figure 1. He was taken to the operating room
on posttrauma day 22 for incision and drainage. The inci-
sion was made along the inside surface of the helix, and
the skin was elevated off the lesion (Fig. 2). The hema-
toma was located within the cartilage, as shown in Figure
3. The hematoma and excess cartilage were debrided, the
wound irrigated and closed, and a transauricular pressure
bandage applied (Fig. 4). On 10-month follow-up, he had
no evidence of hematoma recurrence (Fig. 5).
Fig. 1. (A) Side view of 16 year old
patient with a 2-week-old auricular
hematoma. (B) Front view.
Ghanem et al.: Rethinking Auricular Trauma
Fig. 2. (A) Incision site along the
inner aspect of the helix. (B) View
after elevation of the anterior auricu-
lar skin, showing deformed ear carti-
lage.
DISCUSSION
There is controversy in the literature as to the precise
location of the traumatic auricular hematoma, but classic
teaching is that they occur between the perichondrium
and cartilage. This dogma is derived from a study by
Ohlsen et al.1 in which they surgically injected blood clots
in different locations in the rabbit ear. When the blood clot
was placed between the skin and perichondrium, the blood
clot resorbed in 21 days. However, if the blood clot was
placed between the perichondrium and cartilage, new car-
tilage formed within the subperichondrial plane over a
4-week interval. The possibility of a hematoma originally
forming within the ear cartilage itself was not specifically
tested in this study. This study is widely cited and is the
basis for our current understanding of the pathophysiol-
ogy of auricular hematomas.
Two years before the above study, another experi-
ment was performed to address the same question. A
rabbit animal model was used to simulate auricular
hematomas by dropping a 10 g weight from a fixed
height on the lateral aspect of the pinna.2 The cartilage
was evaluated at various time points by histologic sec-
tioning and light microscopy. Hematoma formation was
more likely if the force was tangential, producing a
shearing force between skin and cartilage. The hemato-
mas were mostly found to be intracartilaginous and
associated with a tear through the cartilage. The hema-
toma was replaced by fibrous tissue, with the fibroblast
slowly producing immature neocartilage. The combina-
tion of fibrosis, contracture, and neocartilage was
thought to be the pathogenesis of the cauliflower ear
deformity seen clinically. This study, although less cited
in the literature, takes a more physiologic approach to
Laryngoscope 115: July 2005
studying auricular hematoma pathophysiology than in-
jecting blood clots in rabbit ears.
The current study addresses recurrent hematomas
and does not reflect the typical patient with blunt auric-
ular trauma; a majority are probably successfully man-
aged with needle aspiration and short-term bolsters. Even
larger fluctuant hematomas can be aspirated. The location
of these common hematomas may indeed be between the
cartilage and perichondrium. Within our recurrent/persis-
tent patient group, however, the location of the auricular
hematoma was clearly described and discovered to be
within the cartilage proper. Operative dissection not only
confirmed this location but also the presence of fibrous
tissue and neocartilage. This multiloculated geometry
would predispose to failure after a single puncture and
aspiration. For this subgroup of patients, an aggressive
extirpation of the hematoma with debridement is required
to prevent recurrence. The current results are similar to
those reported elsewhere; however, the exact location
within the cartilage was not discussed.4,6,11 An aggressive
extirpation was the treatment of choice.
Long-term follow-up can be a challenge because
many patients were referred by otolaryngologists from a
distance. Each patient was specifically instructed to call or
return for any signs of recurrence, and none did. Hema-
tomas would certainly recur within a month but the fibro-
sis and contracture could be a later sequelae and more
difficult to tract. The patient in the case presentation was
followed for 10 months, and he was free of recurrence and
contracture.
Auricular hematomas can be divided in two catego-
ries to help in therapy. Fluctuant hematomas that are
discovered acutely can usually be managed with needle
Ghanem et al.: Rethinking Auricular Trauma
1253

aspiration. The second group represents those older he-
matomas that tend to be more fibrotic in nature or those
that are recurrent after needle aspiration, which often
require an open evacuation. Hematomas located within
the cartilage itself may be predisposed to recurrence and
warrant the more aggressive initial treatment.
Fig. 4. Immediate postoperative period.
Laryngoscope 115: July 2005
1254
Fig. 3. (A) The deformed ear cartilage
is opened and fibrous tissue and he-
matoma is seen. (B) The fibrous tis-
sue and hematoma is extirpated, ex-
cess native ear cartilage is held
between the forceps, demonstrating
the location of the hematoma.
CONCLUSIONS
Auricular hematomas arise from blunt trauma to the
auricle. Shearing forces between the anterior auricular
skin and underlying cartilage are believed to be responsi-
ble for the hematoma. The location of the hematoma has
been classically described as between the perichondrium
and cartilage; however, in some patient groups, the hema-
tomas can arise within the cartilage itself. These findings
are clinically useful as guidelines in the management of
auricular hematomas. First, complete evacuation of the
hematoma and fibrous tissue needs to be performed
through adequate access. All abnormal neocartilage and
fibrous tissues should be aggressively debrided.
Fig. 5. Ten-month follow-up side views: (A) right ear post incision
and drainage, and (B) left ear.
Ghanem et al.: Rethinking Auricular Trauma
BIBLIOGRAPHY
1. Ohlsen L, Skoog T, Sohn SA. The pathogenesis of cauliflower
ear. Scan J Plast Reconstr Surg 1975;9:34 –39.
2. Pandya NJ. Experimental production of ‘cauliflower ear’ in
rabbits. Plastic Reconstr Surg 1973;52:534 –537.
3. Stuteville OH, Janda C, Pandya NJ. Treating the injured ear
to prevent ‘cauliflower ear.’ Plastic Reconstr Surg 1969;44:
310 –312.
4. O’Donnell BP, Eliezri MD, Eliezri YD. The surgical treatment
of traumatic hematoma of the auricle. Dermatol Surg 1999;
25:803– 805.
5. Henderson JM, Salama AR, Blanchaert RH Jr. Management
of auricular hematoma using thermoplastic splint. Arch
Otolaryngol Head Neck Surg 2000;126:888 – 890.
6. Giffin CS. Wrestler’s ear: pathophysiology and treatment.
Laryngoscope 115: July 2005
Annals of Plastic Surg 1992;28:131–138.
7. Talaat M, Azab S, Kamel T. Treatment of auricular hema-
toma using button technique. ORL J Otorhinolaryngol Re-
lat Spec 1985;47:186 –188.
8. Schuller DE, Dankle SD, Strauss RH. A technique to treat
wrestlers’ auricular hematoma without interrupting train-
ing or competition. Arch Otolaryngol Head Neck Surg
1989;115:202–206.
9. Koopmann CF Jr, Coulthard SW. Management of hematomas
of the auricle. Laryngoscope 1979;89(7 pt 1):1172–1174.
10. Eliachar I, Golz A, Joachims HZ, et al. Continuous portable
vacuum drainage of auricular hematomas. Am J Otol 1983;
4:141–143.
11. Lee EC, Soliman AM, Kim J. Traumatic auricular hematoma:
a case report. J Cranio Maxillofac Tr 1997;3:32–35.
Ghanem et al.: Rethinking Auricular Trauma
1255