›Subcutaneous ring of 5 to 10 ml around the base of the auricle
›Blocks the great auricular, auriculotemporal, and lesser occipital nerves and the auricular branch of the vagus
›Onset 5 to 10 minutes; supplement at the planned incision if needed
›Maximum lidocaine 4.5 mg per kg, not exceeding 300 mg for the plain solution
›Bupivacaine 0.25 percent without epinephrine for a longer block
›Onset 10 to 20 minutes and duration up to 8 hours
›Maximum bupivacaine 2 mg per kg, not exceeding 175 mg
›Useful when prolonged bolster discomfort is expected
›Local infiltration at the incision site
›Small-volume lidocaine 1 percent into the skin only when a full block is impractical
›Avoid large-volume infiltration into the collection, which distorts anatomy and obscures the tamponade assessment
›Epinephrine-containing solutions
›Classic teaching avoids epinephrine in the pinna because the auricle is supplied by end arteries and vasoconstriction risks skin and cartilage ischemia
›If used at all, restrict a low concentration to the skin incision and never circumferentially
›Procedural sedation
›Not routinely required; a field block is sufficient for incision and drainage
›If used for an anxious child or extensive debridement, apply standard fasting, monitoring, and end-tidal CO2
›Avoid deep sedation when serial neurologic assessment for head injury is needed
›Appropriate candidates
›An acute hematoma under 48 hours old and smaller than about 2 cm
›Fluctuant and non-organized on palpation or ultrasound
›Technique
›An 18 to 20 gauge needle entered at the most dependent fluctuant point under aseptic technique
›Milk the collection to complete evacuation and record the volume and character
›Apply a compression bolster immediately, because aspiration without compression fails
›Limitations
›Recurrence after aspiration alone is reported up to 60 to 70 percent
›Convert to formal incision and drainage on the first reaccumulation
›Inadequate for an organized clot, a recurrent hematoma, or a collection older than 48 hours
›Indications
›A hematoma larger than about 2 cm, present longer than 48 hours, organized, or recurrent after aspiration
›The preferred definitive emergency department technique for most auricular hematomas
›Technique
›Aseptic preparation and an incision placed within the natural curve of the helical rim or antihelical fold to hide the scar
›Incision length just adequate to evacuate the clot and irrigate the pocket
›Evacuate all clot, irrigate with saline, and inspect for ongoing bleeding
›Do not resect cartilage in the emergency department; refer organized neocartilage to ENT or plastic surgery
›Dead-space obliteration
›Through-and-through mattress sutures over bolsters, or a contoured splint, to appose perichondrium to cartilage
›Tissue adhesive or fibrin sealant into the pocket is a described adjunct to reduce reaccumulation
›A small drain wick or a partially open incision allows continued drainage of a large collection
Compression, bolstering, and dressings
›Purpose
›Eliminate the subperichondrial dead space so the perichondrium re-adheres to the cartilage
›Inadequate compression is the main cause of reaccumulation
›Options, grouped
›Anterior and posterior dental-roll or gauze bolsters secured with through-and-through 3-0 or 4-0 non-absorbable mattress sutures contoured to the auricular relief
›A thermoplastic or plaster-of-Paris splint moulded to the auricular contours
›Silicone or magnet compression devices, or commercial clips, where available
›A fitted mastoid head compression dressing as a less reliable alternative
›Care and duration
›Keep the bolster in place about 7 days, with a range of 5 to 14 days depending on size and technique
›Recheck within 24 to 48 hours for reaccumulation and skin integrity
›A bolster tied too tight causes skin pressure necrosis; too loose permits reaccumulation, so check the capillary refill of the skin edges
›Keep the dressing dry and remove sutures and bolster only at the follow-up visit
Antibiotics, tetanus, and associated wound care
›Prophylaxis after drainage
›Cover Staphylococcus aureus and Pseudomonas aeruginosa, especially in athletes and after instrumentation
›Ciprofloxacin
›Ciprofloxacin 500 mg PO twice daily for 7 days in adults
›Reduce to 250 to 500 mg every 18 to 24 hours if creatinine clearance is under 30 ml/min
›Cautions include tendinopathy, QT prolongation, aortic aneurysm risk, and CNS effects
›Amoxicillin-clavulanate 875 mg with 125 mg clavulanate PO twice daily for 7 days when Pseudomonas risk is low or a fluoroquinolone is contraindicated
›Add MRSA cover where local prevalence is high or purulence is present
›Trimethoprim-sulfamethoxazole 160 mg with 800 mg PO twice daily, or doxycycline 100 mg PO twice daily
›Established perichondritis or chondritis
›Systemic signs, spreading erythema that spares the lobule, or purulence require intravenous anti-pseudomonal therapy
›Ciprofloxacin 400 mg IV every 12 hours, or piperacillin-tazobactam 3.375 g IV every 6 hours
›Urgent ENT consultation and operative debridement if cartilage is necrotic
›Send a Gram stain and culture of purulent fluid and narrow therapy to sensitivities
›ECG and electrolyte check with fluoroquinolone therapy
›Baseline ECG if there are other QT-prolonging drugs, known long QT, or an electrolyte abnormality
›Correct potassium below 4.0 mmol/l and magnesium below 0.8 mmol/l before and during therapy
›Avoid co-prescribing with ondansetron or a macrolide where possible
›Topical otic agents
›Ofloxacin 0.3 percent otic solution, 5 drops twice daily, only for an associated canal laceration or a tympanic membrane perforation
›Avoid aminoglycoside-containing otic drops when the tympanic membrane is not intact, because of ototoxicity
›Tetanus prophylaxis
›Tdap 0.5 ml IM if the wound is tetanus-prone and the last dose was more than 5 years ago, or for any clean wound if more than 10 years ago
›Tetanus immunoglobulin 250 units IM, or 500 units if the wound is more than 24 hours old or heavily contaminated, when fewer than 3 prior doses or an unknown history
›Associated soft-tissue injury
›Irrigate and close skin lacerations and cover any exposed cartilage
›For a human or animal bite of the ear, leave the wound open, cover Pasteurella and Eikenella with amoxicillin-clavulanate 875 mg with 125 mg PO twice daily, and complete a rabies risk assessment
›For near-total or complete avulsion, keep the segment cool and moist and arrange urgent ENT or plastic surgery for replantation or banking
Iatrogenic risks and interventions to avoid or modify
›Airway and breathing support
›Intubation is only for an associated head, neck, or facial injury, not for the ear
›Avoid nasotracheal intubation with midface or basilar skull fracture and maintain in-line cervical stabilization
›Supplemental oxygen has no role without hypoxia or significant TBI and routine hyperoxia is avoided
›Sedation and analgesia
›A field block is sufficient, so avoid procedural sedation unless debridement is extensive or a child cannot cooperate
›Avoid opioids and deep sedation while serial neurologic assessment for head injury is ongoing
›Avoid NSAIDs until hemostasis is confirmed, and in renal impairment, anticoagulation, or significant concurrent bleeding
›Circulatory interventions
›Isolated auricular hematoma does not cause shock, so do not fluid-load for the ear and treat hypotension as another injury
›Vasopressors, mechanical circulatory support, and intra-aortic balloon pump have no role in this condition
›Hemostatic and anticoagulant decisions
›Do not start new anticoagulation
›Therapeutic anticoagulation and antiplatelet therapy promote reaccumulation, so coordinate the timing of drainage with the prescriber
›Do not routinely reverse anticoagulation for a minor drainage; reserve reversal for uncontrolled bleeding
›Fibrinolytics are contraindicated in this traumatic setting and have no therapeutic role
›Local measures that harm
›Circumferential epinephrine-containing local anesthetic around the pinna risks end-arterial skin and cartilage ischemia
›Aminoglycoside otic drops with a non-intact tympanic membrane cause ototoxicity, so use a quinolone otic instead
›A bolster tied too tight causes skin pressure necrosis
›Needle aspiration without compression gives false reassurance and a high recurrence rate
›Cartilage resection in the emergency department risks contour deformity, so refer organized neocartilage to a specialist
Reaccumulation, treatment failure, and bleeding-disorder management
›Reaccumulation at follow-up
›Repeat evacuation and escalate needle aspiration to formal incision and drainage
›Replace and re-mould or tighten the compression bolster or splint and extend antibiotics
›Refer to ENT or plastic surgery if it recurs a second time
›Organized or chronic hematoma older than 7 days
›Fibrous organization and neocartilage will not evacuate with a needle
›Refer for operative debridement and contouring, because emergency department aspiration will fail
›Progressive infection despite antibiotics
›Increasing pain, spreading erythema, fever, or purulence means switching to intravenous anti-pseudomonal therapy and admitting
›Urgent ENT review for possible operative debridement of necrotic cartilage
›Reconsider the diagnosis when drainage keeps failing
›Recurrent or bilateral auricular swelling that spares the lobule with an elevated ESR or CRP suggests relapsing polychondritis
›Refer to rheumatology; repeated drainage is not the treatment
›Underlying bleeding tendency
›Hemophilia A
›Factor VIII replacement to about 50 percent activity before incision and drainage
›Weight-based factor dosing per hematology
›Do not delay drainage of a tense hematoma while replacement is arranged
›Von Willebrand disease
›Desmopressin 0.3 mcg per kg IV in 50 ml saline over 30 minutes as a single dose
›Maximum 20 mcg per dose
›Fluid-restrict for 24 hours and recheck serum sodium, because of the risk of hyponatremia and seizure, especially in young children and older adults
›Avoid a second dose within 48 hours because of tachyphylaxis and hyponatremia risk
›Anticoagulant-associated spontaneous hematoma
›Coordinate the timing of drainage with the prescriber
›Do not routinely reverse anticoagulation for a minor drainage unless bleeding is uncontrolled
›Antiplatelet therapy or uremia
›Expect a higher reaccumulation rate
›A normal INR does not predict hemostasis