avoiding cauliflower ear

CC: Assault

HPI: 24 YO inmate s/p assault to the left face. Patient reports being hit in head by several guards multiple times. No LOC. Has left sided ear pain.  Denies visual changes. No chest or abdominal TraumaExam:
Vitals: normal
HENT: There are ecchymoses to the forehead, the patient has a laceration below his left eyelid that is superficial 3 cm in length. There is a laceration to the posterior scalp that is about 1 cm and superficial.
Ears- The left earlobe is with hematomaans markedly swollen compared to the right. TMs are clear bilaterally.
Mouth- No oral exudates, Oropharynx moist
Nose- Nose normal.
Neck- Normal range of motion, No tenderness with palpation, Supple, No stridor.
Eyes:  There is a hematoma of the left eyelid. He has a small left subconjunctival hemorrhage. PERRL, EOMI, Conjunctiva normal, No discharge.
Respiratory:  Normal breath sounds, No respiratory distress, No wheezing, No chest tenderness.
Cardiovascular:  Normal heart rate, Normal rhythm, No murmurs, No rubs, No gallops.
GI:  Bowel sounds normal, Soft, No tenderness, No masses, No pulsatile masses.

ED COURSE:
This patient had a CT of his face and brain and X-rays of his C-spine. His lacerations were repaired .
This patient left auricular hematoma was the topic of our teaching rounds.
This patient was prepped and draped and anesthesia was achieved prior to teaching rounds. The ring block was then demonstrated during teaching rounds. Drainage of the hematoma and application of the dental roll pressure dressing was demonstrated to the group in stepwise fashion. In addition the below teaching points were offered.
I did place this patient on Antibiotics, but none of the sources say you must.

Rapid fire teaching points:

1) This procedure is done to avoid cauliflower ear, it is classically seen in wrestlers.
2) If the hematoma is older than 7 days call ENT, cellulitis is a contraindication to drainage.
3) Use ring block to achieve good anesthesia (technique detailed below).
4) Sterile dental rolls sutured tightly onto the ear are an excellent pressure dressing that is not bulky (thank you Travis)
5) Know how to do this, because it will avoid unnecessary transfers and you will see this in your lifetime (thank you Colin)
6) Have suction hooked up
7) There are special pressure clips available for this complaint.

Wanna know more about auricular hematoma? Read below:

Auricular hematoma

Auricular Hematoma (also called perichondral hematoma) is a complication that results from direct trauma to the anterior auricle and is a common  in wrestlers. Shearing forces to the anterior auricle can lead to separation of the anterior auricular perichondrium from the underlying, tightly adherent cartilage. This may lead to tearing of the perichondrial blood vessels and subsequent hematoma formation.
The torn perichondrial vessels compromise the viability of the avascular underlying cartilage. Interestingly, the presence of a subperichondrial hematoma has been found to stimulate new and often asymmetric cartilage to form. This deformity, which is often referred to as cauliflower ear or wrestler’s ear, is often considered a badge of honor among wrestlers and rugby players.
For this reason drainage is indicated. COntraindication to drainage are: duration longer than 7 days.

PART 1: Achieving Anesthesia:

Ring block technique:

– The ring block, provides anesthesia to the entire ear, excluding the concha and external auditory canal.
– Disinfect skin with an alcohol swab or just prep with betadine.
– Insert the needle into the skin just inferior to the attachment of the earlobe to the head. Do not insert the needle into the earlobe itself. Direct the needle toward the tragus.
– Aspirate and then inject 3-4 mL of anesthetic while advancing the needle in a superior direction.
– Withdraw the needle but do not remove it. Redirect the needle posteriorly along the inferior posterior auricular sulcus.
– Aspirate and inject anesthetic while advancing the needle.
– Remove the needle and reinsert it just superior to the attachment of the helix to the scalp. Direct the needle anteriorly, toward the tragus, and aspirate before injecting anesthetic. Advance the needle while injecting. Inject the subcutaneous tissue, not the ear cartilage.
-Withdraw the needle but do not remove it. Redirect the needle posteriorly; aim toward the skin just behind the mid ear. Aspirate and inject anesthetic while advancing the needle.
-Be aware that the superficial temporal artery, located medial to the ear, crosses over the zygomatic arch. If the artery is cannulated, maintain firm pressure with gauze for several minutes.

PART 2: Drainage of hematoma

Equipment needed:

– Scalpel, No. 15
-Small suction, if available
– Irrigation set-up (syringe, normal saline)
Compression dressing materials
– Simple compression dressing: dry cotton, Vaseline gauze, 4 x 4 plain gauze, secondary dressing wrap (eg, Kling), scissors needed to make a simple compression dressing.
– Specialized compression dressing: dental rolls , nylon or Prolene suture on straight needle

Procedure:
-Incise the edge of hematoma along the natural skin folds using a No. 15 scalpel. A small (5 mm) incision is often all that is necessary.
– Gently separate the skin and perichondrium from the hematoma and cartilage and completely express or suction out the hematoma. Be careful not to damage the perichondrium.
– Irrigate the pocket with normal saline with an 18-ga angiocatheter.
-Reapproximate the perichondrium to the cartilage.

Compression dressing
-Apply digital pressure for 5-10 minutes, and then apply compression dressing. A simple dressing is inadequate, as the hematoma is likely to reaccumulate.

A simple compression dressing can be quickly made as follows:
– Place dry cotton into the external canal.
Compression dressing: Dry cotton in external canal.
– Fill all external auricular crevices with either moist gauze (soaked in saline) or Vaseline gauze, as depicted in the image below.
– Place 3-4 layers of gauze behind the ear as a posterior gauze pack. Prior to placement, cut out a V-shaped section of gauze so that the gauze fits snugly behind the ear, as shown below.
– Cover the packed anterior ear as shown below, with multiple layers of fluffed gauze.Gauze applied to anterior ear.
– Bandage the fluffed gauze into place with Kling or an elastic bandage.

Specialized compression dressings:
– place one or two sterile cot to roll onto the anterior pinna on 1-2 behind the pinna.
– using 4-0 Nylon suture the dental rolls in place so that good pressure on the ear is achieved.
– orientation of dental rolls is parallel to the curvature of the ear over the incision.
– if you have questions, I am available toile to demonstrate in person if you like:)

Sources:
Roberts and Hedges
medscape has a great step by step instruction with photos..check it out at http://emedicine.medscape.com/article/82793-overview

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