Auricular hematoma

A cauliflower ear is a malformation of the external ear in which the normal shape of the cartilage has been destroyed and replaced by a lumpy mass of scar tissue that somewhat resembles a head of cauliflower. A characteristic injury of avid wrestlers, the cauliflower deformity is a largely preventable sports injury.

Frequently Asked Questions

A cauliflower ear results from an injury to the external ear cartilage. Typically, the cartilage has been fractured (broken) and bleeding has occurred within the tissue covering the cartilage. The blood lifts the lining away from the injured cartilage and creates a pocket of fluid called an auricular hematoma. The word auricular refers to the external ear, and the word hematoma means a mass of clotted blood. Unfortunately, the cartilage in the ear does not have a blood supply of its own and it relies upon the lining tissue, called perichondrium, to provide nourishment. If the hematoma is not immediately drained and the fractured cartilage repositioned, the cartilage may die. Over time, the dead cartilage and the hematoma are reabsorbed by the body and the remainder of the ear shrivels up like a dried prune, losing its original shape.

Most auricular hematomas and cauliflower deformities occur in contact sports that involve hitting, kicking or grabbing the head, such as boxing, wrestling, mixed martial arts, and water polo. Protective headgear is available for all of these sports, but it is not consistently worn during practice and competition. It is not uncommon for coaches and experienced athletes to look upon these injuries as battle scars. Continued pressure from parents and physicians is necessary to mandate the use of protective headgear in our children to reduce the risk of these injuries.

Correction of a fully mature cauliflower deformity is extremely difficult and consists of sculpting the remaining cartilage and existing scar tissue to try to create a shape that somewhat resembles a normal ear. The best opportunity for treatment occurs at the time of injury. For this reason, an auricular hematoma is considered a surgical emergency that should be treated within the first few days of injury.

At the time of the initial injury, the athlete should be removed from practice or competition. Direct pressure should be firmly applied for the first hour, using a soft cloth that can conform to the shape of the ear cartilage. Cold compresses may also be helpful, but direct application of ice should be avoided because the ear is prone to frost bite.

Once the initial swelling and bleeding have been controlled with direct pressure, the fluid may be evacuated using a large sterile needle. If this is successful, a firm pressure bandage may prevent reaccumulation of fluid. It is critical that the fractured cartilage be properly shaped and positioned under the pressure dressing. A consultation with a facial plastic surgeon or otolaryngologist (ear nose and throat specialist) should be obtained within 1-2 days.

If aspiration of the fluid with a needle does not completely remove and control the hematoma, then surgical intervention is necessary. Under local anesthesia, the surgeon will make an incision within the curves of the external ear. The skin will be rolled back to expose the injured cartilage and the fragments may be realigned. Any visible bleeding points may be cauterized and then the skin flap will be sewn back down, often using multiple stitches to quilt the ear into position and prevent reaccumulation of fluid. A firm pressure dressing may actually be sewn onto the ear.

Unfortunately, it takes about 6 weeks for the ear to heal. For high school athletes, that may be the majority of the season. The athlete must decide individually whether the benefit of playing the sport outweighs the risk, or even expectation, of a permanent disfigurement. The chance of reinjury in the first 6 weeks is probably greater than 50%, even with appropriate use of headgear.

Sometimes, we see patients appear to have an auricular hematoma with no history of injury. The external ear is ballooned outward with a clear amber-colored fluid that reaccumulates within 1-2 days after aspiration. When these deformities are surgically explored, the cartilage appears to be split down the middle, like a sheet of plywood that has become delaminated. The condition is called a pseudocyst because there is not a skin lined cavity containing the fluid. By definition, all true cysts have a skin or mucus membrane lining. The cavity itself has a smooth and slippery texture and it is very difficult to cause the cartilage to heal back together. The surgeon will roughen the surfaces and sometimes make small cuts or perforations in the cartilage to promote scarring and allow wound healing factors to come between the 2 layers. Recurrences and repeat surgery within the first month are common. Failure to correct a pseudocyst may lead to a cauliflower deformity, as with an auricular hematoma.

Other types of plastic surgery to the ears:

Otoplasty is the cosmetic correction, or “pinning back,” of ears that stick out too far.

Skin cancer is the most common cause of damage to the ears, but modern reconstructive techniques can often restore a nearly normal shape and function.

Torn earlobes and keloid scars are common complications of ear piercing. Most cases can be corrected in the office under local anesthesia.

Microtia and aural atresia is a rare congenital deformity in which a child is born without normal ear cartilage and without an ear canal.