Cauliflower Ear


Article Author:
Bhupendra Patel
Keegan Skidmore
Julia Hutchison


Article Editor:
Jason Hatcher


Editors In Chief:
Jon Parham
Jon Sivoravong


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/28/2019 3:19:17 PM

Introduction

Cauliflower ear is a deformation of the ear typically caused by direct trauma to the auricula and surrounding tissue. Classically, experienced by wrestlers or boxers, the condition is caused by direct, blunt trauma where significant shearing forces lead to an auricular hematoma. The hematoma then disrupts the blood supply to auricular perichondrium and subsequently the ear’s cartilage. As a result, blood accumulates in the subperichondrial space and if left untreated can lead to necrosis, infection, and loss of cartilage. Cauliflower ear is the product of the fibrocartilage and fibrosis that occurs upon the destruction of the ears healthy cartilage once it loses its blood supply.[1][2][3]

Etiology

Description of cauliflower ear dates back to early Roman and Greek history. Literary and artistic collections from that time are littered with accounts describing the deformed or damaged ears of wrestlers, boxers, or pugilists. Medical appreciation for the affliction has a similar storied past. Though case descriptions can be found in the works of Hippocrates, more formal research into the disease did not begin until the mid-1800s. At that time, there was thought to be a second idiopathic cause behind cauliflower ear to go along with the more obvious relationship to direct trauma. The idiopathic hypothesis derived from observations of the elderly and mentally insane. It wasn’t until the late 20th century that the more conventional understanding of cauliflower developed.[4][5]

Epidemiology

The exact prevalence of cauliflower ear is not noted in the literature. From studies conducted on wrestlers, researchers approximated that between 39-45% of athletes were affected with cauliflower ear.

Pathophysiology

Historically, researchers have debated the exact mechanism behind the formation of cauliflower ear. From a series of experiments conducted in the mid-1970s when weights were dropped on the ears of rabbits, researchers concluded hematomas in the intercartilaginous space were responsible for the deformity. However, further testing (and more rabbits), showed blood accumulation in the subperichondrial space was responsible for disrupting circulation to the anterior ear from the posterior auricular and superficial temporal arteries. This buildup leads to the necrosis of the ear’s healthy cartilage. The hematoma is then replaced by chondroblasts which form neocartilage. This process sets into action a cascade of fibrosis and contracture and the subsequent development of cauliflower ear.

History and Physical

Patients present as having undergone trauma to the affected ear, usually during contact sports like wrestling, boxing, or increasingly, mixed martial arts. The ear appears red, swollen, and warm, while the patient may describe any combination of difficulty hearing, tinnitus, vision changes, pain, and/or a headache. If there is no concern for more underlying severe cranial pathology, then the practitioner should continue directly to treatment.

The strong relationship between trauma causing auricular hematomas should make practitioners suspicious of those individuals presenting with the signs described above, but who deny having undergone any reported trauma. Especially where children and the elderly are concerned, it is crucial that the possibility of abuse be entertained and screened for through a careful history and exam.

Evaluation

Cauliflower ear is a clinical diagnosis that requires no formal testing or imaging.

Treatment / Management

The management and treatment of cauliflower ear can take many forms depending on when the patient presents and the size and scope of the deformity. It should be noted from the outset that cauliflower ear is potentially avoidable through the appropriate covering and protection of the ear during contact sports. This protection reduces or eliminates the types of blunt, shearing forces the ear experiences altogether and subsequently, the formation of an underlying hematoma. According to studies of wrestlers, the use of protective headgear can reduce the prevalence of auricular hematomas by up to 50%.[6][7][8]

Any trauma to the head severe enough to injure the exterior ear mandates a thorough head and neck examination that includes the otoscopic inspection of the tympanic membranes. This exam ensures a more critical intracranial injury is not overlooked.

The primary treatment for cauliflower ear is prevention. The best possible outcomes require early identification and management of the hematoma before cartilage death has occurred. Typically, this requires a patient be seen within the first six hours of injury so that an emergency department provider can aspirate the underlying auricular hematoma. This involves anesthetizing the distribution of the greater auricular nerve using lidocaine and epinephrine. This is followed by insertion of an 18-gauge needle into the area of greatest fluctuance. If the patient is unfortunate enough to present outside the 6-hour period where aspiration is likely to be successful, a more invasive incision is required to be sure to remove free blood, but also blood that has begun to coagulate.

By removing the pocket of blood, the perichondrium can reattach to the ear’s cartilage, preventing the loss of its valuable blood supply. Further aiding in the ear’s development of healthy cartilage, is the use of compressive dressings. A variety of compressive dressings are described in the literature including cotton bolsters, dental silicone, silicone rubber splints or even auricular stents, but no one technique has been studied and deemed superior.

Unfortunately, recurrence remains a frustrating complication of treating cauliflower ear. The most successful management of an auricular hematoma comes with the high likelihood that the blood will re-accumulate. For this reason, it’s important that outpatient providers refer patients to an otolaryngologist, an ear, nose, and throat (ENT) specialist for ongoing care and treatment.

For patients who present outside the window when auricular hematoma drainage is feasible, surgical intervention remains the mainstay of treatment. In general, a surgical referral is appropriate for any patient with an existing cauliflower ear, where extensive fibrosis has already occurred. Once the surgery is settled upon, the exact approach can vary based on the degree and location of the underlying deformity. Some texts go so far as to classify cauliflower ear into four distinct types, each requiring a unique reconstructive technique. The overall goal of surgery, however, remains the same regardless of surgical method, and that is to remove the damaging fibrocartilage without compromising the ear's structural integrity or its natural contours. If damage to the ear is so severe that simply removing the malformed cartilage does not equate to the desired cosmetic outcome, costal cartilage can be used to provide greater structural integrity.

Enhancing Healthcare Team Outcomes

Patients with cauliflower ear may present to the emergency department physician, nurse practitioner, primary care provider or the sports physician. While the diagnosis is simple, the management can be difficult. In acute cases, aspiration is sufficient. The key is to educate the patient on prevention while playing sports. Unfortunately recurrences are common. The cauliflower usually imparts poor aesthetics which cannot be reversed.[9][10]


  • Image 6455 Not availableImage 6455 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

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Cauliflower Ear - Questions

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Which is true about a cauliflower ear in an adult male?



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A patient presents complaining his ear hurts. The ea is swollen, red, and painful to touch. The patient mentioned being struck in the ear. The patient has no other complaints or deficits on exam. What’s the most important question to ask that will define the correct treatment modality?



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A patient comes into the emergency room with a warm, swollen ear 12 hours after she was assaulted and hit in the head. What’s the most likely successful treatment modality for her swollen ear to prevent the formation of cauliflower ear?



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What is the primary pathophysiological problem behind cauliflower ear?



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A patient’s auricular hematoma is treated via needle aspiration with return about 10 cc of blood, which is successful in relieving the patient’s pain and revealing the ear’s natural contours. Prior to discharge, what are the next steps that can be taken to help prevent the formation of a cauliflower ear?



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A young male is seen in the emergency department complaining of a problem with his ear (see image below). What is true about this condition? Select all that apply.

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Attributed To: Contributed by Steve Bhmji, MS, MD, PhD



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When trauma occurs to the external ear blood can accumulate between in the auricle. What lymph nodes would drain the region and what is the name of the anatomical deformity that this trauma can cause?



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A 16-year-old male presents to the emergency department for evaluation, 2 hours after an assault. The patient states that he was “minding his own business” when he was punched in the head multiple times by an unknown assailant. He complains of left ear pain. He denies loss of consciousness, hearing difficulty, vision changes, or neck pain. Pulse is 99/min, blood pressure is 155/80 mmHg, the temperature is 98.7 F, and oxygen saturation is 98% on room air. On examination, the patient has a small scalp hematoma on the left side. There is no facial bone crepitus, malocclusion, hemotympanum, tympanic membrane perforation, or septal hematoma. The patient is noted to have a lumpy appearance of a portion of his external left ear with associated erythema and tenderness. What is the next best step in the care of this patient's ear?

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Cauliflower Ear - References

References

Singh LK,Mamidipalli SS,Das S,Tikka SK,Arora R, Cauliflower ear in late onset psychosis. Asian journal of psychiatry. 2019 Jan;     [PubMed]
Krogmann RJ,King KC, Auricular Hematoma 2019 Jan;     [PubMed]
Haik J,Givol O,Kornhaber R,Cleary M,Ofir H,Harats M, Cauliflower ear - a minimally invasive treatment method in a wrestling athlete: a case report. International medical case reports journal. 2018;     [PubMed]
Mohan V,Bhavani S,Subramanian SK,Maiti A, Calcified cauliflower ear in relapsing polychondritis. BMJ case reports. 2017 Apr 21;     [PubMed]
Ingvaldsen CA,Tønseth KA, Auricular haematoma. Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke. 2017 Jan;     [PubMed]
Shilpa K,Leelavathy B,Lakshmi DV,Divya G, Unilateral Cauliflower Ear due to Leprosy or Trauma - A Diagnostic Challenge. Indian journal of leprosy. 2016 Jul-Sep;     [PubMed]
Noormohammadpour P,Rostami M,Nourian R,Mansournia MA,Sarough Farahani S,Farahbakhsh F,Kordi R, Association Between Hearing Loss And Cauliflower Ear in Wrestlers, a Case Control Study Employing Hearing Tests. Asian journal of sports medicine. 2015 Jun;     [PubMed]
Mandavia R,Kapoor K,Ouyang J,Osmani H, Evaluating ear cartilage piercing practices in London, UK. The Journal of laryngology and otology. 2014 Jun;     [PubMed]
Summers A, Managing auricular haematoma to prevent 'cauliflower ear'. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association. 2012 Sep;     [PubMed]
Cuesta L,Betlloch I,Bañuls J,Toledo F,     [PubMed]

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