Ear Lacerations, Part II

This teenager was horsing around with buddies. He landed on the side of his face and sliced his ear as shown. The laceration is small, but located in such a way that I knew careful repair would be needed for the best outcome.

The following video illustrates the procedure used for repair.

Repair procedure, outlined:

• Make sure the ear is well anesthetized.
• A few deep dermal vicryl sutures through the cartilage turned this splayed open pinna in to a more manageable, well-approximated, tension-free wound.
• The less aesthetically critical posterior ear was repaired first using simple interrupted 6-0 nylon sutures.
• After this, I completed the repair of the anterior portion of the pinna.
• Repair of a laceration like this could also be completed using a single layer of simple interrupted 5-0 nylon sutures.   By leaving out the absorbable vicryl layer, the foreign body risk is minimized, but it requires more precision. One would sew through-and-through the skin of the anterior and posterior ear and the intervening cartilage in one throw.
• The key point is to cover any exposed cartilage, as the cartilage depends on the overlying skin for vitalization.

Auricular Hematoma Prevention

Even with a meticulous repair, you still have to worry about the formation of an auricular hematoma.  Hematoma formation associated with an ear injury can lead to separation of the cartilage from the overlying perichondrium, which can in turn lead to deforming neo-cartilage formation.  This is commonly known as “cauliflower ear.”

While it’s an even more pressing concern with blunt trauma without a laceration (when there is no natural conduit for drainage), this is a risk anytime the cartilage of the ear is disrupted.

As you see here, even minutes after the repair is complete,  a small amount of hematoma is forming.

Small auricular hematoma formation after repair of an ear laceration.

Traditional teaching is to pack the contours of the anti-helix with pieces of xeroform, and then to suture these through-and-through the ear to hold them in place.  Then, the area behind the ear is buttressed with gauze, and the head is wrapped tight with coban or an ace bandage.

In my experience, this works well, but is fairly laborious.  Also, patients often complain about tension headaches provoked by the tight coban wrapping.

Here’s an alternate approach to prevention of auricular hematoma prevention that I learned from Dr. Michelle Lin’s fantastic Academic Life in EM blog, but apparently was first described in JAMA in 1933: consider creating an ear mold from plaster that can be removed and inserted by the patient.  This feels more comfortable, and has the advantage of molding exactly to fit the patient’s ear.   Bonus tip: rather than using coban, which patients always complain is too tight and uncomfortable, now that you have an ear mold you don’t really need to squeeze the patient’s head with a vice grip– you just need something to hold that mold in place.  A much looser bandage wrapped around the head will suffice.

Antibiotics and Ear Lacerations

• There is no great evidence on this topic, as noted in this Best BETs review.
• Factors to consider (as with any laceration) include age of the wound, level of contamination, & comorbidities.
• Generally, not standard of care to empirically give antibiotics to uncomplicated ear lacerations, even with cartilage involvement.

That’s all for now on ear lacerations.

This patient did great, with excellent healing and no complications.  Check out the follow up image:

Follow up on the same ear laceration at one week.