Complex Ear Lacerations


Article Author:
Christopher Williams


Article Editor:
Britni Sternard


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


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
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/2/2019 5:42:18 PM

Introduction

Facial lacerations are a common complaint in the emergency or primary care setting, and the ear presents a unique challenge due to its structure. The ear is particularly susceptible to lacerations, avulsions, and blunt trauma due to the prominent position of the ears overlying a bony surface. Emergency, primary care, and sports medicine physicians should be aware of the complexities of treating ear lacerations and their potential complications.

Anatomy

An understanding of the ear's anatomy is imperative if the clinician wishes to repair an ear laceration adequately. Most ear lacerations occur on the exposed auricle, also known as the pinna. This is the area of skin-covered cartilage that forms the vast majority of the external ear and which is most prone to injury, although lacerations sometimes extend into the external auditory canal. The lobule does not have cartilage but rather is made up of fibrous adipose tissue. The cartilage that makes up the auricle is avascular and in continuum with the cartilage of the external auditory canal. The cartilage thus relies on the perichondrium, or the connective tissue that covers the cartilage, and the overlying skin, for its blood supply. In the absence of trauma, the perichondrium is tightly adherent to the overlying skin. The skin of the ear has a dual blood supply, with the anterior portion of the auricle supplied by the superficial temporal artery while the posterior auricular artery feeds the posterior aspect. Both arteries branch off of the external carotid artery. The posterior auricle also receives some blood supply from collateral branches of the occipital artery. The innervation of the ear is slightly more complicated. The superior and anterior/medial aspects of the auricle are innervated by the auriculotemporal nerve, which is a branch of the trigeminal nerve. The inferior and posterior/lateral aspects of the auricle are dually innervated by the lesser occipital and greater auricular nerves, which arise from the C2 and C3 roots of the cervical plexus. The vagus nerve innervates the majority of the concha with some scattered innervation from the facial nerve. The external auditory canal, including the tympanic membrane, is innervated by branches of the auriculotemporal nerve, the facial nerve, the glossopharyngeal nerve, and the vagus nerve. [1]

Indications

Ideally, ear lacerations should be repaired at the time of presentation, so long as the patient is not presenting greater than 24 hours after the injury occurred. If the auricular cartilage is exposed, the ear must be repaired to reduce the risk of complications such as infection, chondritis, necrosis, or deformities such as "cauliflower ear." Delayed primary closure should be considered in patients who present after 24 hours, patients with evidence of infection about the laceration, and patients at increased risk for infection, for example, people suffering with diabetes.

Contraindications

A contraindication to closing an ear laceration, as with lacerations on other parts of the body, is an infected wound. Emergency clinicians should refer the patient to otolaryngology or plastic surgery if the patient has an avulsion of the auricle, lacerations extending into the external auditory canal, lacerations associated with internal or middle ear damage, or lacerations concurrent with a skull base fracture. Partial avulsion injuries can be repaired by the primary or emergency clinician as long as there are a wide pedicle and adequate capillary refill at the most distal segment of injury. Narrow pedicle injuries need surgical attention due to a tenuous blood supply. The physician should be alert to signs of more serious injury, such as nausea and vomiting, ataxia, hemotympanum, cerebrospinal fluid (CSF) otorrhea, Battle's sign, or facial nerve dysfunction.

Equipment

As with any laceration, the primary materials for repair of a complex ear laceration include forceps, needle drivers, suture materials, sterile field drapes, buffered lidocaine, 1.5-inch, small-gauge needles and syringes for anesthesia, absorbable and nonabsorbable sutures, scalpel/scissors, and sterile gauze. For cartilage/perichondrium repair, consider using synthetic, absorbable, sterile, surgical sutures composed of a copolymer made from 90% glycolide and 10% L-lactide or a sterile, synthetic, absorbable monofilament suture made from the polyester. These will retain tensile strength for at least 30 days and have minimal tissue reactivity. The overlying auricular skin may be closed with 5-0 or 6-0 sutures. Absorbable versus nonabsorbable sutures for skin closure is a physician preference and may depend on the reliability of follow up, social situation, among other factors.

Preparation

Care should be taken to clean the area around the ear laceration as well as possible prior to initiating repair. Sterile saline with a splash cap can be used to irrigate the wound with 50 to 100 mL of solution per centimeter of the wound. Anesthetizing the ear with a regional auricular block may provide the patient with greater comfort prior to irrigation. After the wound has been cleaned, a sterile drape should be applied to isolate the field. If necessary, the physician may need to excise macerated or dead tissue to create clean wound margins before attempting the repair.

Technique

Physicians should anesthetize the area about the laceration prior to initiating repair. Anesthesia may be achieved with a regional auricular block or by injecting anesthetic into or around the wound edges. One advantage of using a regional block is that wound edges will not be distorted by the installation of the anesthetic, and such a block will provide total anesthesia to the majority of the ear, except concha and meatus. To perform a regional auricular block, the physician will instill an anesthetic in a box or diamond shape around the ear. This will be performed by injecting an anesthetic in the shape of a "V," one inferior to the ear and an inverted "V" superior to the ear. Start by inserting the needle inferior to the ear near the lobule, aiming toward the mastoid process. Withdraw the needle while instilling 1 mL of anesthetic per inch of tissue. Using the same technique, insert the needle from the same starting point toward the skin anterior to the tragus and instill anesthetic while withdrawing the needle. Next, the physician will inject an anesthetic in an inverted "V," starting from the skin superior to the ear, again aiming towards the mastoid, followed by instillation of a line of anesthetic from the starting point above the ear towards the skin anterior to the tragus. Allow 5 to 10 minutes for complete anesthesia to occur, and be certain to test the patient's sensation prior to initiating repair. 

Once the patient's wound has been cleaned, prepped, and the area anesthetized, true repair can now begin. The key tenants of repairing a complex ear laceration are properly aligning the cartilage to maintain aesthetics and making sure that overlying skin can adequately cover the cartilage. The cartilage itself is avascular and relies on coverage by skin to receive its blood supply. To start the repair, make sure that the skin can cover the exposed cartilage. If the skin cannot stretch to cover the cartilage, up to a 5-millimeter triangular wedge of cartilage through the helix can be excised without significantly affecting ear shape/aesthetics and function. Small ear lacerations can be sutured with simple interrupted or running sutures through the overlying skin. When there is significant cartilage involvement and deformity of the ear, it is imperative that cartilage is realigned with deep sutures, such as 5-0 Vicryl. Ideally, sutures should be thrown through the outer layer of cartilage (perichondrium), rather than through the entirety of the cartilage itself, as the cartilage has a greater tendency to pull through or tear. That said, sutures through the cartilage itself can be used if there is no better way to approximate the lacerated ends. Deep suture knots should be buried. Try to use as few deep sutures as possible to get a good alignment, as each deep suture acts as a foreign body and increases the likelihood of infection. Next, the physician should close the overlying skin with 5-0 or 6-0 simple interrupted sutures at 2- to 3-millimeter intervals. Another option is to throw sutures through the overlying skin and perichondrium, together. [2]

Once the laceration has been repaired, it is important to apply a pressure dressing to the ear to prevent hematoma formation. Several modalities can be used. One common method is to apply a petroleum-soaked gauze to the area over the laceration, usually about the antihelix or scapha, and into the helix, and pack it tightly against the adjacent skin. Next, apply a wad of gauze over the entire ear and hold the gauze in place with a gauze bandage wrapped around the patient's head. Another option is to use a series of simple interrupted 5-0 or 6-0 sutures through the area of concern in a fanned out pattern. This can be done by piercing the posterior aspect of the auricle with suture and then advancing 1 centimeter superiorly before going back through the anterior aspect of the auricle, tying the knot posteriorly. Space these sutures out by a few millimeters and cover the entire ear surface that may be at risk of hematoma formation. This may also be accomplished in the form of mattress sutures. Bolstering is another option for the prevention of hematoma formation whereby a bolster is stitched against the anterior surface of the auricle. Lastly, a plaster mold of the surface of the auricle can be made to compress the skin surface and prevent hematomas; however, this is more time-intensive and may not be practical in an emergent setting. At this time, no good data supports the routine use of prophylactic antibiotics in ear lacerations, including those with exposed cartilage prior to repair. [3],[4],[5]

Complications

As with all lacerations, scarring, nerve damage, infection, pain, and the need for additional repair are potential complications. Chondritis and hematoma formation are common complications specific to ear lacerations. Patients should be reevaluated 24 to 48 hours after the repair to assess for development of these complications. The vast majority of chondritis is provoked by Pseudomonas aeruginosa and should be treated with ciprofloxacin.[6] Lacerations of the external auditory canal put the patient at risk for canal stenosis.

Clinical Significance

Ear lacerations are commonly encountered by the sports physician caring for participants of combat sports, such as MMA or boxing, or contact sports without closed headgear.

Enhancing Healthcare Team Outcomes

While ear lacerations may appear simple, not knowing the anatomy can lead to severe complications. Thus, when patients present to the emergency department, it is important to consult with the plastic surgeon or the ENT specialist first. The emergency department physician and nurse practitioner may irrigate the wound and confirm tetanus status, but the wound should not be closed until seen by the specialist. A poorly closed ear laceration can lead to hematoma formation, nerve damage, flap necrosis and asymmetry.[7][1][8]


  • Image 6732 Not availableImage 6732 Not available
    Contributed from Gray's Anatomy Plates (Public Domain)
Attributed To: Contributed from Gray's Anatomy Plates (Public Domain)

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Complex Ear Lacerations - Questions

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A patient was playing with his dog and sustained a bite injury to the right ear. He reported to the emergency department approximately 2 hours after sustaining the injury. He has a portion of his avulsed pinna on ice. Which of the following is the most appropriate management?



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A 55-year-old man who is homeless presents with an ear laceration that occurred shortly before arrival at the emergency department. The wound is relatively clean appearing and does not violate the auricular cartilage. Which of the following is an appropriate course of action after anesthetizing the area and thoroughly irrigating the laceration?



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Which portion of the ear will not be anesthetized by a diamond-shaped, regional auricular block?



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Which of the following ear lacerations should prompt an emergent otorhinolaryngology consultation?



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A 31-year-old male presents with a laceration to his left ear through the helix that was sustained while playing rugby 2 hours ago. The wound is free of erythema or purulence but is quite macerated. There is exposed cartilage and loss of auricular skin. Initial attempts at bringing the auricular skin back together to cover the cartilage have been unsuccessful and suturing leaves 2 mm of uncovered cartilage. What is the best next course of action?



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Complex Ear Lacerations - References

References

Fisher CG,Kacica MA,Bennett NM, Risk factors for cartilage infections of the ear. American journal of preventive medicine. 2005 Oct     [PubMed]
Greywoode JD,Pribitkin EA,Krein H, Management of auricular hematoma and the cauliflower ear. Facial plastic surgery : FPS. 2010 Dec     [PubMed]
Roy S,Smith LP, A novel technique for treating auricular hematomas in mixed martial artists (ultimate fighters). American journal of otolaryngology. 2010 Jan-Feb     [PubMed]
Giles WC,Iverson KC,King JD,Hill FC,Woody EA,Bouknight AL, Incision and drainage followed by mattress suture repair of auricular hematoma. The Laryngoscope. 2007 Dec     [PubMed]
Osetinsky LM,Hamilton GS 3rd,Carlson ML, Sport Injuries of the Ear and Temporal Bone. Clinics in sports medicine. 2017 Apr     [PubMed]
Lavasani L,Leventhal D,Constantinides M,Krein H, Management of acute soft tissue injury to the auricle. Facial plastic surgery : FPS. 2010 Dec     [PubMed]
Menon A,G A, Traumatic Partial Avulsion of Pinna Reconstruction with Limberg Flap. World journal of plastic surgery. 2018 May;     [PubMed]
Brown DJ,Jaffe JE,Henson JK, Advanced laceration management. Emergency medicine clinics of North America. 2007 Feb;     [PubMed]

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