What is the proper procedure for draining a cauliflower ear (perichondral hematoma)?

Proper Procedure for Draining Cauliflower Ear (Perichondral Hematoma)

The most effective treatment for cauliflower ear is prompt drainage of the hematoma followed by compression to prevent reaccumulation, ideally using incision and drainage with through-and-through absorbable mattress sutures. 1

Understanding Cauliflower Ear

Cauliflower ear (auricular hematoma) is a collection of blood between the cartilage and perichondrium of the ear, typically resulting from blunt trauma during contact sports like wrestling, boxing, and rugby. Without proper treatment, it can lead to permanent deformity through fibrocartilage formation during scarring. 2

Treatment Procedure

Step 1: Assessment

• Evaluate for signs of auricular perichondritis (painful swelling, warmth, redness) which may indicate infection rather than simple hematoma 3
• Acute tenderness on deflecting the auricular cartilage helps distinguish deeper perichondrial infection from superficial skin infection 3

Step 2: Drainage Procedure

• Clean the ear with antiseptic solution 1
• Administer local anesthesia (without epinephrine) to the affected area 3
• Choose one of these evidence-supported drainage methods:

Option A: Incision and Drainage with Mattress Sutures (Preferred Method)

• Make a small incision along the edge of the hematoma 1
• Completely drain all blood/fluid 1
• Place through-and-through absorbable mattress sutures to eliminate dead space and prevent reaccumulation 1
• This method has shown superior outcomes with rare reaccumulation compared to other techniques 1

Option B: Needle Aspiration with Compression

• Use a large gauge needle (18-20G) to aspirate the hematoma 2
• Apply firm compression immediately after aspiration 2
• Note: This method has higher reaccumulation rates (3 out of 7 cases required additional procedures in one study) 1

Step 3: Post-Drainage Compression

• Apply compression to prevent reaccumulation using one of these methods:
  • Compression dressing with dental rolls or cotton bolsters 1
  • Silicone mold (offers ease of application and better patient acceptance) 4
  • Magnets with adapted disc (minimally invasive option) 2
  • Button technique with tie-through sutures 5

Step 4: Aftercare

• Prescribe appropriate analgesics for pain management 3
• Monitor for signs of infection (increasing pain, fever, purulent drainage) 3
• If infection is suspected, treat with fluoroquinolone antibiotics (ciprofloxacin or levofloxacin) as they cover the most common pathogens (Pseudomonas aeruginosa, S. aureus, and S. pyogenes) 3
• Schedule follow-up within 24-48 hours to check for reaccumulation 1
• Keep the area dry until healing is complete 3

Complications and Management

Infection

• If perichondritis or abscess develops, surgical incision and drainage may be necessary 3
• Treat with appropriate antibiotics (fluoroquinolones are first-line) 3
• Note that once an abscess develops, good cosmetic preservation of the auricular cartilage becomes difficult 3

Reaccumulation

• If fluid reaccumulates, repeat drainage procedure 1
• Consider switching to a more definitive method (e.g., from needle aspiration to incision with mattress sutures) 1

Established Deformity

• For established cauliflower ear deformity, surgical correction may be required 6
• Treatment depends on the zone and degree of deformity, potentially involving shaving deformed cartilage or cartilage grafting 6

Important Considerations

• Early intervention (within 24-48 hours) is critical to prevent permanent deformity 2
• Incision and drainage with mattress sutures appears superior to needle aspiration alone 1
• Compression after drainage is essential to prevent reaccumulation 1, 5, 4
• Monitor closely for infection, as auricular cartilage has limited blood supply and infections can lead to significant deformity 3