A college wrestler suffers a blow to the right ear when taken to the mat by his opponent. He develops tender swelling of the entire ear, except for the earlobe, a few hours later.
The external ear (pinna) is subject to a wide variety of injuries, no doubt because it sticks out from the side of the head. In the aftermath of a traumatic event, an ear injury can be highly visible. But all trauma patients must be stabilized before any treatment begins and their injuries must be dealt with based on their severity.
Auricular Hematoma
Auricular hematoma refers to the accumulation of blood in the space between the ear cartilage and its lining (perichondrium). It is usually the result of blunt trauma. Cartilage lacks its own blood vessels and instead relies on the blood vessels of the perichondrium to provide it oxygen and nutrition by diffusion. When the shearing forces of blunt trauma cause an accumulation of blood between the cartilage and its lining, the blood supply is cut off. As the cartilage loses its nutrient supply, parts of it die and are replaced with scar tissue. The loss of blood supply can lead to infection and further destruction of the cartilage.
Once the auricular hematoma forms, the ear looks swollen and it may feel doughy or as if there is fluid under the skin. It is often red and shows signs of the initial trauma, like broken blood vessels in the skin. The swelling hides the usual ridges of the pinna. It is essential to drain the blood collection early. Failure to promptly remove the blood clot may lead to infection and/or cartilage necrosis (tissue death) and the permanent disfigurement known as “cauliflower ear.”
In the early stages, small hematomas can sometimes be removed with a large-bore needle and syringe. But when the blood is fully clotted or there is a moderate to large accumulation, drainage of hematomas requires a surgical cut parallel with the natural skin folds. Once the skin and perichondrium lining are opened, the hematoma in this space is irrigated copiously with saline spiked with antibiotics to reduce the risk of later infection.
The key to preventing re-accumulation of blood is bandaging the skin firmly against the underlying cartilage over a period of days. Cotton soaked in antibiotic solution is molded to all ridges and valleys of the affected area. The cotton can be held in place by a bulky dressing and head wrap. Other options include sewing cotton bolsters in place with stitches that run through the entire pinna from back to front, silicon putty, and water-resistant thermoplastic splints. Through-and-through sutures without a bolster have also been used.
Lacerations
Sharp or severe blunt trauma may lead to laceration or amputation of the auricle. Immediate repair and prevention of infection are essential. Auricular lacerations should be cleansed of any foreign material prior to repair. The skin edges of simple lacerations can be closed by suturing the edges back together. If some of the tissue has been destroyed, closure may require more complex plastic surgery. This may include advancing or rotating skin flaps from adjacent areas or the use of free skin grafts.
When the entire pinna is cut from the side of the head, it may be placed in a pocket of skin made behind the usual position of the pinna to preserve the cartilage until the acute trauma is resolved and the patient is past the stage of likely infection. The cartilage can then be reattached with micro-vascular techniques. If the pinna remains hanging by a thread, that thread often contains an artery and, if so, it can be reattached immediately.
Repairs are covered with pressure dressings to prevent swelling and the formation of blood clots, and cartilage-penetrating antibiotics are often prescribed. Excellent cosmetic results can be achieved, even with extensive lacerations.
Frostbite
Freezing temperatures can directly damage skin and cartilage cells as well as block their blood supply. In the early stage, this process may be reversible, but over time, it leads to tissue necrosis (death). Temperatures below 10 °C may lead to numbness of the ear, so people are frequently unaware of impending frostbite. The ear is initially pale and then blue tinged. Ultimately, as the ear thaws, pain, redness, and skin blistering may develop as a result of fluid or blood accumulation.
The initial treatment for auricular frostbite consists of rapid rewarming of the ear using warm, 40 to 42 °C, water. Blisters that are not filled with blood may be opened and patients should be given pain medicine and antibiotics. Even though it may appear that large areas of skin have been destroyed, any removal of apparently dead tissue should be delayed for several weeks until it is absolutely clear which tissue has survived.
Burns
Thermal injury is usually classified by the extent and degree of the burn. Superficial burns involve only the outer layer of the skin (epidermis). Partial-thickness burns extend into, but not through, the dermis(deeper layer with blood vessels and fat). Full-thickness burns extend through the full thickness of the dermis. Subdermal burns extend into the tissue below the skin including fat, muscle, tendon, cartilage, and bone.
Superficial auricular burns appear red because of blood vessel congestion. These burns are painful. Patients with partial-thickness burns usually have blisters that blanch white on direct pressure and are very painful. Deep partial-thickness burns are associated with less pain, and there may be a layer of dead tissue overlying them (eschar). Full-thickness and subdermal burns are often less painful because nerve endings have been destroyed. The wound surface eschar is of varying color, but may be gray or black and charred.
Superficial burns do not scar and may be treated with moisturizing creams. The surface of blisters caused by partial-thickness burns are often removed and antibiotic ointment applied. When not deep, these burns heal without scarring as well. Full-thickness, subdermal, and deep partial-thickness burns of the auricle heal with scarring and contracture (scar deformity) and may be complicated by infection of the cartilage. These burns should be treated with both topical (usually silver-based) and systemic antibiotics (taken orally or intravenously). Early removal of dead tissue and closure with skin grafts may be necessary. Another round of reconstruction is usually performed at approximately one year after injury.