Cauliflower ear

The external ear, or auricle, is a delicate structure composed mostly  of cartilage which provides the “shape” of the ear, perichondrium which provides the blood supply to the cartilage, and skin. The perichondrium is located between the cartilage and the skin. The softer lower part of the earlobe where earrings are traditionally placed does not develop hematomas because it is devoid of any cartilage and is composed only of skin and a fatty connective tissue underneath.

With trauma to the ear, either by rubbing or striking it during sparring, a match or other traumatic strike, a hematoma may develop between the cartilage and perichondrium (picture #2). This is a bad situation as the cartilage does not have any blood vessels running through it and is completely dependent on the perichondrium to brings the blood supply (and as such, oxygen and nutrients) to the cartilage. If the cartilage remains without this essential blood supply for a long enough period of time, the cartilage cells that were aligned perfectly to maintain the beautiful shape of the ear begins to die off resulting in the permanent deformation of the ear (picture #3) almost like a plastic bottle crumpling from the heat of a lighter underneath it. Once deformation has occurred, the ear is then called a “cauliflower ear” due to the similarity in appearance to the vegetable. Therefore, hematomas are reversible situations. Cauliflower ears require surgery to reshape the deformed cartilage, a taller order of reconstructive surgery on our part.

ear

Picture #1: Normal Ear

Picture #2: Auricular Hematoma

Picture #3: Cauliflower Ear

Such ear trauma is commonly found in wrestlers and is why headgear use is so important in these sports. However, such trauma may also occur with boxing, martial arts (UFC, Jiu Jitsu, Krav Maga, etc.), as well as any type of assault where the ear gets hit. It is important to note that in some martial arts studio there is a tendency to either “brave it out” and not get the hematomas drained or to perform the drainage on site at the studio. Clearly, braving it out will result in a permanent undesirable deformity and is highly frowned upon. Drainage in a studio can result in infection and further unwanted complications and is more painful than necessary.

Once the hematoma develops, in order to prevent cauliflower ear formation, the hematoma needs to be drained and pressure applied to allow the perichondrium to heal back attached to the cartilage. Drainage and pressure are the 2 essential ingredients for successful treatment and several strategies exist to accomplish this.

Drainage

  • Needle Aspiration: In essence, a large bore needle is used to enter the fluid filled cavity underneath the skin after proper numbing of the ear. Once inside the hematoma (the center of the fluid filled cavity),  the contents are sucked out with immediate return of the normal contour of the ear. We use a special coolant liquid that tempers the needle stick and prevents the reaccumulation of fluid into the hematoma cavity.
    • Advantage: Quick, easy, and minimal pain
    • Disadvantage: risk of the hematoma coming back.
  • Incision & Drainage (I&D): After an anesthetic is injected around the ear, a scalpel is used to create a long incision extending the entire length of the hematoma and the hematoma allowed to drain out the incision.
    • Advantage: Quick and easy. Lower chance of hematoma recurrence. Minimal discomfort
    • Disadvantage: There is a pressure type pain for two days following the procedure. Slight risk of the hematome recurring. Requires more than one visit.

Pressure

  • Head dressing: Through cotton balls, gauze, and ace/kling bandage, continuous pressure is exerted over the hematoma (after drainage), to prevent the hematoma from reaccumulating.
  • Bolster placement: A cotton plug is sutured through the ear to another cotton plug on the other side.
  • Ear splint: An ear “cast” is probably the best way of describing this method.
  • Quilting suture: An absorbable suture is performed back and forth completely through one side of the ear to the other side (like a quilt blanket). The sutures keep the skin and perichondrium in approximation to the cartilage. It is not meant to close an incision which should remain OPEN! See pictures above.

Our doctor may recommend that I&D be performed followed by quilting suture with or without a head dressing. Drain placement is not necessary. We have found that a quilting sutures offer the best chance of recovery AND allows the patient to stay active. Depending on the size of the hematoma, as many as six suture passes may need to be performed although usually less. Keep in mind that a quilting suture is NOT the same as sutures placed when closing an incision which should remain OPEN to allow drainage. To dispel some of the incorrecdt assumptions, draining a hematoma is covered by insurance and therefore not an expensive procedure.

For hematomas in the top of the ear, a good product to obtain is Caulicure , a pair of magnets that helps to maintain pressure over the drained hematoma to prevent refilling with a headband over the eralobe. It is recommended to use the magnets for a period of 3-5 days and stop if any significant pain occurs.

For heamtomas occuring on the inside of the ear lobe just behind the opening of the ear canal, another recommended product is Ear Splintz. This is a hardening type of putty material similar to the molds made for custom ear phones. It comes with a special mold that shapes a piece that goes behind the earlobe and one that goes over the earlobe. Unlike the recommendation on the product website and its respective video, however, it is recommended to use the headband over the completed mold in its casing for 3-5 days straight without removing it.

We always recommend to avoid wrestling while the ear is healing to prevent complications.

 

If you are a wrestler, boxer or are involved in martial arts, contact us at Dagan MD to prevent a Cauliflower ear today.