Auricular Haematoma

A collection of blood between the pinna’s perichondrium and cartilage (or within the cartilage itself), almost always from blunt trauma. Time matters more than any other factor — a haematoma drained within hours has a good cosmetic outcome; one left even a week risks permanent “cauliflower ear” deformity from new (neo)cartilage formation.

Clinical presentation

Most commonly a shearing blow to the ear in unprotected contact sport (wrestling, rugby) — 40% of cases in one series were sports-related, 10% each from assault and falls. Anticoagulation increases spontaneous haematoma risk and haematoma size after minor trauma. A child with recurrent auricular haematoma who isn’t in a high-risk sport should be assessed for non-accidental trauma.

Presentation: pain, swelling, tenderness and paraesthesia over the pinna; a sense of fullness or reduced hearing; the skin over the haematoma looks red and bruised, with the pinna visibly swollen or distorted.

Assessment

Diagnosis is clinical, from history and examination. Ask about the mechanism, previous episodes, fevers, ear discharge, hearing change and any neurological symptoms (headache, loss of consciousness) — high-risk sporting injuries can coincide with head or cervical spine trauma. Check for a bleeding disorder or anticoagulant use (needs coagulation studies before draining). Ultrasound can help when findings are ambiguous; CT if skull or cervical spine injury is suspected; imaging also identifies a foreign body. Hearing loss warrants audiometry.

Management

Drain promptly — the technique depends on how old the haematoma is.

• Under 6 hours old, and under 2 cm: needle aspiration with an 18-gauge needle and 10 mL syringe, into the most fluctuant area, draining until no more fluid returns. Gentle massage and in-and-out fanning can break up loculated clot.
• Older than 6 hours, or over 2 cm, or aspiration fails: incision and drainage — a curvilinear incision along the medial helical margin or within the conchal bowl (incisions in concave areas heal more cosmetically than on convex surfaces), extended to the haematoma, blood expressed or suctioned out, closed with a single-layer running absorbable suture (e.g. 5-0 plain gut), with or without a drain (removed at 24–48 hours if placed).
• Between about 7–10 days: the clot may have re-liquefied enough for aspiration again, but neocartilage may already be forming — surgical removal may be needed by this point.

A pressure dressing after drainage is what actually prevents recurrence, not the drainage method itself — options include cotton dental rolls anterior and posterior to the auricle secured with mattress sutures, moulded dental splinting material with a headband, or through-and-through quilting sutures (favoured in athletes since no external dressing is needed). Bolster/dressing removal is typically at 5–7 days. Antibiotic use is at clinical discretion.

Referral to an otolaryngologist (or plastic/facial plastic surgeon) substantially reduces reaccumulation — 25% vs 77% compared with other clinicians, and 14% vs 60% when a bolster is used after drainage. Refer for drainage, or for follow-up if drainage is done in-house, and always refer an established cauliflower ear deformity (needs otoplasty).

Follow-up

Patients need review within the first week to confirm blood hasn’t re-accumulated. Advise no strenuous exercise or contact sport for 10–14 days. Tight blood pressure control and correcting any supratherapeutic anticoagulation reduce recurrence risk.

Prevention is genuinely effective: appropriately worn ear protection in contact sport roughly halves haematoma incidence (52% vs 26% in one wrestling cohort) and more than halves cauliflower-ear rates (26.6% vs 10.6%) — worth mentioning to any patient in a contact sport, since headgear is worn inconsistently even by people who own it.