What is the treatment for a perichondrium hematoma due to domestic violence (DV)?

Management of Perichondrial Hematoma Due to Domestic Violence

Perichondrial hematoma due to domestic violence requires immediate surgical evacuation to prevent permanent auricular deformity. 1, 2

Definition and Pathophysiology

• A perichondrial hematoma is a collection of blood between the perichondrium and the cartilage of the ear, typically resulting from blunt trauma or shearing forces to the auricle 3
• In cases of domestic violence (DV), these injuries often present alongside other trauma patterns that may be reported as falls or accidents 4
• When left untreated, the hematoma separates the perichondrium from the avascular cartilage, disrupting the nutrient supply and leading to cartilage necrosis and the characteristic "cauliflower ear" deformity 5, 3
• Traumatic hematomas show more marked inflammatory reaction and tissue damage compared to non-traumatic hematomas, explaining their higher risk of complications 6

Initial Assessment

• Evaluate for fluctuant swelling within the cartilaginous portion of the auricle, which indicates a subperichondrial blood collection 3
• Document the timing of injury, as intervention within 7 days offers the best outcomes 3
• Assess for signs of infection such as erythema, warmth, and tenderness that may indicate developing perichondritis 1
• Screen for other injuries consistent with domestic violence patterns, as auricular trauma is rarely isolated in DV cases 4

Treatment Approach

Immediate Management

• The time elapsed between injury and surgical intervention should be minimized to prevent complications 2
• For recent hematomas (within 7 days), evacuation should be performed promptly 3

Procedural Management

• Provide adequate analgesia using an auricular block before the procedure 3
• Two primary evacuation methods are recommended:

1. Needle Aspiration with Pressure Dressing

• Use a large-bore needle (18-20 gauge) to aspirate the hematoma completely 3
• Apply a pressure dressing or bolster to prevent reaccumulation 5
• This approach is appropriate for simple, recent hematomas 3

2. Incision and Drainage with Bolster

• For recurrent or complex hematomas, surgical incision and drainage is indicated 5
• The procedure should include:
  • Creating an adequate incision over the hematoma 5
  • Complete evacuation of blood and clots 5
  • Aggressive debridement of any granulation tissue 5
  • Fenestration of the exposed cartilage to promote adherence 7
  • Application of a firm bolster dressing for 7-10 days 5, 3

Antibiotic Therapy

• Prophylactic antibiotics covering Pseudomonas aeruginosa are recommended for 7-10 days 3
• For adults, fluoroquinolones (e.g., ciprofloxacin) are the preferred agents 1
• For children, amoxicillin-clavulanate is recommended 3
• This antibiotic coverage helps prevent auricular perichondritis, which can lead to cartilage necrosis and abscess formation 1

Follow-up Care

• Re-evaluate the patient within 24-48 hours to assess for reaccumulation or signs of infection 3
• Maintain the pressure dressing for 7-10 days to ensure proper healing 3
• Advise the patient to avoid trauma to the ear for at least 2 weeks 3
• For recalcitrant cases with early deformity, referral to otolaryngology for possible reconstructive options may be necessary 7

Special Considerations in Domestic Violence Cases

• Provide appropriate resources for domestic violence victims, including safety planning and referrals to support services 4
• Document injuries thoroughly with photographs when possible, as these may be important for legal proceedings 4
• Consider screening for other injuries that may be present but not reported 4

Complications and Prevention

• Untreated or inadequately treated hematomas can lead to:
  • Perichondritis and perichondrial abscess, typically occurring within the first month 1
  • Permanent auricular deformity ("cauliflower ear") 5, 3
  • Cartilage necrosis 3
• Early and complete evacuation with appropriate pressure dressing is the key to preventing these complications 5, 3