Question of the Week # 427

427) A 32-year-old male boxer presents to the emergency room after sustaining an injury during a local boxing match.  He was punched by the opponent over his right ear about six hours ago . He complains of pain and swelling over his right ear. He has no hearing deficit or tinnitus or headaches or blurred vision. He denies nausea or vomiting. Past medical history is unremarkable. On examination, his vitals are stable. His right ear is red, warm and swollen with a medium sized anterior auricular swelling which is tender to palpation. There is no facial swelling. Which of the following is the most appropriate management?

A) Compressive dressing

B) Needle aspiration of the Hematoma

C) Cold compresses, analgesics and antibiotics

D) Incision and Drainage

E) Observe and await  spontaneous hematoma resolution

24 Responses

  1. c

  2. ccc

  3. A

    • this is a condition called Cauliflower ear, commonly encountered due to blunt trauma to the ear.the initial management would be to pack the ear with ice under moderate compression.If the hematoma has already formed..which i suppose is true in this case.. surgical drainage and compressive dressing of the ear is to be done to prevent the recurrence of the hematoma.antibiotics to be given after the surgery to prevent infection….so i am confused between D and C…but definitely not A,B/E.

      • it’s D. we don’t normally use cold compress. we use compressive bandage to keep the skin really tight against the cartilage. But for that to happen, we gotta cut it open and drain it completely. the idea is to make sure all surface of the cartilage is in contact with skin.

  4. B

  5. c

  6. c

  7. C

  8. c

  9. d, because you would want to avoid cauliflower ear . . .

  10. e

  11. c

  12. D) Incision and Drainage – prompt evacuation of the hematoma. to prevent permanent scarring

  13. D.

  14. b-needle aspiration of hematoma..drain the blood first!!!

  15. Incision and drainage, you want to prevent scarring! Even though you have the best body wrestling, bouncing at a pub, playing mui tai– the ears look ugly!

  16. In this case i will go with Needle Aspiration—if this fails then go for I&D

    However, in a select group of patients with refractory auricular hematomas that require more aggressive treatment over a fine needle aspiration. Open debridement is indicated for this group. The location of the hematoma, granulation tissue, and neo-cartilage is found to be within the cartilage itself rather than between the cartilage and perichondrium, thus explaining why a needle aspiration alone can be ineffective.
    from article:
    Ghanem T; Rasamny JK; Park SS
    Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia 22908, USA

  17. Treatment usually requires draining accumulated blood (the hematoma) through an incision in the ear and applying a compressive dressing to sandwich the two sides of the skin against the cartilage. Antibiotics are given to prevent infection.

  18. incision and drainage

  19. As per uptodate :

    needle aspiration for small (less than approximately 2 cm in diameter)
    and acute hematomas that are 24 to 48 hours old.

    larger (≥2 cm) hematomas up to seven days old, the clinician may perform incision and drainage or evacuation with an intravenous catheter.

    Since the Q says medium sized hematoma, is the answer I & D???

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