Evacuation of the haematoma
The procedure should be performed under regional auricular block
(5). We recommend Xylocaine 1 % with adrenaline. Good results can also be achieved with infiltration anaesthesia, but this should be reserved for the smallest haematomas (less than 2 cm). Supplemental adrenaline is recommended with regional auricular block, but must not be used with infiltration anaesthesia (5).
It is important to disinfect the ear and the surrounding skin first. Sterile sponges should be moistened with chlorhexidine spirit 5 mg/ml (0.5 %) and applied for at least two minutes. The spirit should be allowed to air dry prior to perforation of the skin. Figure 2 illustrates how to perform a regional auricular block.
Figure 2 Regional auricular block is indicated for the evacuation of larger auricular haematomas. This provides good anaesthesia while avoiding the introduction of additional volume into the already tense and traumatised tissue. Xylocaine with supplemental adrenaline is injected via a thin cannula into the skin, as shown here. Two injection sites are usually sufficient. The anaesthetic is injected in a V-shape underneath the ear and an inverted V-shape above the ear. Optimal effects are achieved after ten minutes. The nerve block anaesthetises anterior and posterior surfaces of the ear in their entirety, with the exception of the area in and around the external auditory meatus, which is innervated by branches of the vagus nerve
The recommended treatment will depend on the size and age of the auricular haematoma
(5). As stated above, if the haematoma is more than seven days old, the patient must be referred to an otorhinolaryngologist or plastic surgeon for revision and, if necessary, reconstruction.
Needle aspiration is recommended if the auricular haematoma is < 2 cm in diameter and < 48 hours old. Green (21 gg) or pink (18 gg) cannulae are suitable. The insertion site should ideally be at the base of the haematoma. It is not necessary to insert the needle into or through the cartilage. If aspiration of the haematoma proves difficult, this is probably because the blood has fully or partly coagulated. Incision and drainage should then be considered.
Incision and drainage is recommended if the auricular haematoma is ≥ 2 cm in diameter or > 48 hours old
(5, 8). The incision should be made at the base of the haematoma. If the haematoma is located in the scapha and/or fossa triangularis, the incision should be directly above the contour of the antihelix. Such incisions often yield good cosmetic results. Alternatively, the incision may be made just underneath the edge of the helix, so that the scar will be at least partially hidden. The incision must be sufficiently large to allow evacuation of the coagula. Figure 3 illustrates the surface anatomy of the ear and a typical auricular haematoma.
Figure 3 Illustration of the surface anatomy of the ear and the typical location of an auricular haematoma (in the cranial part of the scapha and extending into the fossa triangularis). The heavy lines in black are suggested incisions along the antihelix and helix
Cutting down into the cartilage should be avoided: if the haematoma empties, the incision is sufficiently deep. If necessary, the incision can be enlarged slightly using a small pair of scissors or tissue forceps. When the haematoma has been drained, the area should be rinsed with sterile saline until the liquid runs clear. The incision can then be closed with, for example, 5 – 0 non-absorbable nylon sutures. Mattress stitch is recommended. The surgical needle must pass through the skin, perichondrium and cartilage on both sides of the incision. The aim is to achieve good contact between the layers. A small area outermost in the incision is left open to allow drainage.
After surgery, a pressure dressing is applied with the vaseline-impregnated gauze innermost, followed by a sterile saline dressing and dry bandage. It is often necessary to wrap an elastic bandage around the head to ensure sufficient pressure against the surface of the ear.