Auricular hematoma

Cauliflower ear is an irreversible condition that occurs when the external portion of the ear is hit and develops a blood clot or other collection of fluid under the perichondrium. This separates the cartilage from the overlying perichondrium that supplies its nutrients, causing it to die and resulting in the formation of fibrous tissue in the overlying skin. As a result, the outer ear becomes permanently swollen and deformed, resembling a cauliflower. Cauliflower ear is an irreversible condition that occurs when the external portion of the ear is hit and develops a blood clot or other collection of fluid under the perichondrium. This separates the cartilage from the overlying perichondrium that supplies its nutrients, causing it to die and resulting in the formation of fibrous tissue in the overlying skin. As a result, the outer ear becomes permanently swollen and deformed, resembling a cauliflower. The condition is common in martial arts such as BJJ, judo, mixed martial arts, or wrestling, and in full-contact sports such as rugby union and rugby league. People presenting with possible auricular hematoma often have additional, more impressive injuries (e.g. head/neck lacerations) due to the frequently-traumatic causes of auricular hematoma. The ear itself is often tense, fluctuant, and tender with throbbing pain. However, because of potentially more remarkable injuries often associated with auricular hematoma, auricular hematoma can easily be overlooked without directed attention. The most common cause of cauliflower ear is blunt trauma to the ear leading to a hematoma which, if left untreated, eventually heals to give the distinct appearance of cauliflower ear. The structure of the ear is supported by a cartilaginous scaffold consisting of the following distinct components: the helix, antihelix, concha, tragus, and antitragus. The skin that covers this cartilage is extremely thin with virtually no subcutaneous fat while also strongly attached to the perichondrium, which is richly vascularized to supply the avascular cartilage. Cauliflower can also present in the setting of nontraumatic inflammatory injury of auricular connective tissue such as in relapsing polychondritis (RP), a rare rheumatologic disorder in which recurrent episodes of inflammation result in destruction of cartilage of the ears and nose. Joints, eyes, audiovestibular system, cardiovascular system, and respiratory tract can also be involved. The components of the ear involved in cauliflower ear are the outer skin, the perichondrium, and the cartilage. The outer ear skin is tightly adherent to the perichondrium because there is almost no subcutaneous fat on the anterior of the ear. This leaves the perichondrium relatively exposed to damage from direct trauma and shear forces, created by a force pushing across the ear like a punch, and increasing the risk of hematoma formation. In an auricular hematoma, blood accumulates between the perichondrium and cartilage. The hematoma mechanically obstructs blood flow from the perichondrium to the avascular cartilage. This lack of perfusion puts the cartilage at risk for becoming necrotic and/or infected. If left untreated, disorganized fibrosis and cartilage formation will occur around the aforementioned cartilaginous components. Consequently, the concave pinna fills with disorganized connective tissue. The cartilage then deforms and kinks, resulting in the distinctive appearance somewhat resembling a cauliflower. Rapid evacuation of the hematoma restores close contact between the cartilage and perichondrium, thereby reducing the likelihood of deformity by minimizing the ischemia that would otherwise result from a remaining hematoma. Auricular hematoma most often occurs in the potential space between the helix and the antihelix (scapha) and extends anteriorly into the fossa triangularis. Less frequently, the hematoma may form in the concha or the area in and around the external auditory meatus. Importantly, an auricular hematoma can also occur on the posterior ear surface, or even both surfaces. Risk of necrotic tissue is greatest when both posterior and anterior surfaces are involved, although posterior surface involvement is less likely given its increased quantity of impact-dampening subcutaneous tissue. Perichondral hematoma and consequently cauliflower ear are diagnosed clinically. This means that the medical provider will make the diagnosis by using elements of the history of the injury (examples: participation in contact sports, trauma to the ear, previous similar episodes) and combine this with findings on physical exam (examples: tenderness to the area, bruising, deformation of the ear contours) to confirm the diagnosis and decide on the appropriate treatment for the patient.