Auricular Haematoma

History: recent shearing or blunt trauma in a contact sport; pain, swelling, throbbing; visible deformity or bulge.

Examination:

• •Tender, fluctuant, tense swelling of the pinna, usually on the lateral surface
• •Loss of normal cartilaginous contours of the helix and antihelix
• •Reddish-purple discolouration
• •Otoscopy to inspect canal and tympanic membrane
• •Palpate for bony step or external auditory canal disruption
• •Cranial nerve VII: facial palsy after auricular trauma is a red flag

Minimum dataset: time since injury; size and site; fluctuance vs firm fibrosis (acute haematoma vs established cauliflower); skin breach or exposed cartilage; otoscopy findings; hearing and vestibular symptoms; facial nerve function; head injury screen; anticoagulation status; infection signs.

Differentials: established cauliflower ear (chronic, firm, fibrotic, painless thickening - elective ENT/plastics for otoplasty); perichondritis (diffuse erythema, warmth, fever without fluctuance - risk of cartilage necrosis); pinna abscess; pinna laceration with exposed cartilage; relapsing polychondritis (bilateral, recurrent, spares the lobule, often with saddle-nose - rheumatology); basal skull or temporal bone fracture (Battle's sign, haemotympanum, CSF otorrhoea, facial palsy, hearing loss, vertigo).

Paediatric safeguarding: unexplained or inconsistent-mechanism haematoma in a child warrants safeguarding consideration.

Auricular haematoma is a clinical diagnosis. Imaging is largely to exclude associated injuries.

Imaging indications: CT head or temporal bone if there are signs of basal skull fracture, temporal bone fracture, NICE NG232 head injury criteria, or concerning otoscopy (haemotympanum, canal blood). Bedside ultrasound is optional - can confirm a fluid collection in equivocal cases or guide aspiration; not routine.

Bloods are not routine. FBC and CRP if perichondritis or infection suspected. INR or clotting if anticoagulated. Send pus or aspirate for culture if any signs of infection or in returning competitors with recurrent haematoma. Tetanus per UK Green Book if any open wound.

The defining decisions are time since injury, size, drainage method, and post-drainage compression.

Drainage method - modern UK ENT practice generally favours incision and drainage with bolster compression over needle aspiration because of high reaccumulation rates after aspiration:

• •Incision and drainage (preferred): small linear incision parallel to the helical contour, evacuate clot, irrigate. Through-and-through mattress sutures (e.g. Prolene) tied across the pinna over bolsters to obliterate dead space. Mandatory for haematomas over 2 cm, organised clot beyond 48 to 72 hours, recurrent, or after failed aspiration
• •Needle aspiration (large-bore, 18 gauge): only for very small (under 2 cm), very acute, simple haematomas in trained hands

Procedure principles: local anaesthesia (modern evidence: lidocaine with adrenaline is safe and effective in the pinna - the old end-artery dogma is outdated; follow local trust protocol); aseptic technique; drain to dryness; compression dressing is essential; review at 24 to 48 hours.

Compression dressing - the single most important factor in preventing reaccumulation. Through-and-through mattress sutures tied tightly across the pinna over dental-roll, cotton, or silicone splint bolsters (the gold-standard technique). Magnetic or moulded auricular splints in some centres. Dressing in place for 5 to 7 days then ENT or clinic review. Snug but not ischaemic - increasing pain, blanching, dusky skin, severe headache, or excessive tightness should prompt urgent dressing review.

Antibiotics: local-protocol dependent, not automatic. Often given for I&D, exposed cartilage, signs of infection, recurrent contact-athlete haematoma, immunosuppression, or diabetes. Pseudomonas aeruginosa is a recognised perichondritis pathogen - Pseudomonas-active cover is often considered (commonly ciprofloxacin in adults). Co-amoxiclav is NOT Pseudomonas-active. Fluoroquinolones carry MHRA tendon and neuropsychiatric warnings, especially relevant in athletes, and have paediatric cartilage-arthropathy cautions. Tetanus per Green Book for any open wound. Analgesia: paracetamol; NSAIDs as appropriate (avoid if associated head injury).

Established cauliflower ear (beyond 7 to 14 days): acute drainage will not reverse fibrocartilaginous overgrowth. Refer to ENT or plastic surgery for elective otoplasty if cosmesis or function is affected.

Urgent escalation: signs of basal skull or temporal bone fracture (manage as head trauma first per NICE NG232 before addressing the pinna); perichondritis with systemic features (urgent ENT, likely admission and IV antibiotics with Pseudomonas-active cover); failed drainage or large recurrent haematoma; exposed cartilage in pinna laceration (ENT/maxillofacial; avoid suturing through cartilage).

Return to play: no contact training until the dressing is off and the ear has healed (typically 7 to 14 days). Sport-specific ear protection on return is strongly advised and often required by policy. Educate the athlete on early presentation if reinjured.

Phase 1 (drainage and dressing, 0 to 7 days): compression dressing in situ; no contact training, no immersion; analgesia; antibiotic cover per local protocol if indicated; review at 24 to 48 hours and at dressing removal.

Phase 2 (post-dressing, 7 to 14 days): inspect for reaccumulation, infection, cartilage viability; re-drainage if recurrence; continue light non-contact training.

Phase 3 (return to sport, 2 to 4 weeks): sport-specific reconditioning; sport-specific ear protection (strongly advised or required by policy); educate on early re-presentation if reinjured.

Phase 4 (long-term): repeated haematomas at the same site become harder to drain effectively because of scarring; established cauliflower ear can be electively addressed; hearing assessment if any history of associated head trauma or temporal bone injury.

• •ENT UK clinical guidelines - I&D plus bolster compression as the modern preferred technique over aspiration.
• •NICE NG232 (Head injury) - applies whenever auricular trauma is accompanied by head injury criteria.
• •MHRA fluoroquinolone safety advice - tendon and neuropsychiatric risk; relevant when ciprofloxacin is considered for Pseudomonas-active cover in athletes.
• •UK Green Book - tetanus status update for any open auricular wound.
• •BMJ Best Practice - soft tissue injuries to the head and neck.

• •Pinna cartilage is avascular - perichondrium is the sole blood supply.
• •Drain promptly (ideally within 7 days) to prevent cauliflower ear.
• •I&D with bolster compression is the modern UK preferred technique over needle aspiration.
• •Lidocaine with adrenaline is safe in the pinna - the end-artery dogma is outdated.
• •Pseudomonas cover (e.g. ciprofloxacin) for perichondritis - co-amoxiclav is NOT Pseudomonas-active.
• •Battle's sign, haemotympanum, or CSF otorrhoea = manage as head trauma first (NICE NG232).