80 yr old male with h/o of accidental fall came with swelling over aur

80 yr old male with h/o of accidental fall came with swelling over auricle for 2 days

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Diagnosis: Auricular Hematoma (Post-Traumatic)

The clinical image shows a smooth, tense, fluctuant swelling over the anterior surface of the auricle with effacement of the normal auricular landmarks - classic appearance of an auricular hematoma following accidental fall.

Pathophysiology

Blunt trauma to the auricle causes a shearing injury that separates the auricular cartilage from its overlying perichondrium, creating a subperichondrial space into which blood collects. Since the avascular cartilage depends entirely on the perichondrium for its blood supply, this separation renders the cartilage ischemic. If untreated, fibrosis and neocartilage formation produce the permanent deformity known as "cauliflower ear."

Shambaugh Surgery of the Ear, p. 1597

Clinical Features in This Patient

Feature	Finding
Age	80 yr - elderly, at higher risk for poor healing
Mechanism	Accidental fall (blunt trauma to pinna)
Duration	2 days (still acute - within the treatable window)
Appearance	Smooth, tense anterior auricular swelling with loss of normal landmarks

The 2-day duration is still within the acute treatment window (up to 7 days). Beyond 7 days, granulation tissue makes drainage difficult and specialist referral is mandatory.

Management

Step 1 - Anesthesia

Local infiltration with 1% lidocaine WITHOUT epinephrine (epinephrine causes vasoconstriction and may worsen cartilage ischemia), or an auricular nerve block.

Step 2 - Evacuation

Incision and Drainage (preferred over needle aspiration alone)

Needle aspiration alone has a high reaccumulation rate and is no longer recommended by most authorities as sole treatment
Incision: Use a No. 15 blade along the natural skin folds at the helical edge of the hematoma, following the curvature of the pinna
Gently peel the skin and perichondrium off the hematoma and underlying cartilage
Completely evacuate the hematoma and irrigate the pocket with normal saline

Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 1535-1536

Step 3 - Pressure Dressing (CRITICAL to prevent reaccumulation)

This is the most important step. Without it, the hematoma will reaccumulate:

Place dry cotton into the external auditory canal (EAC)
Fill all auricular convolutions with Vaseline gauze or saline-soaked gauze, conforming to every crevice
Place 3-4 layers of gauze behind the ear
Cover the entire ear with multiple layers of fluffed gauze
Secure to the head with Kerlix or an elastic wrap

Alternatively: Dental rolls (bolsters) sutured through-and-through to the anterior and posterior surfaces of the auricle are a well-validated method. The bolster is left in place for 4-7 days.

Auricular Hematoma Evacuation - Step by Step

Roberts and Hedges' Clinical Procedures in Emergency Medicine - Fig. 63.23

Step 4 - Antibiotics

Prophylactic antistaphylococcal antibiotics are recommended (e.g., cefalexin or co-amoxiclav). In this elderly patient, consider the risk of infection given reduced immune response.

Step 5 - Follow-Up

Close follow-up is mandatory (every 24-48 hours in the first week) to detect and promptly drain any reaccumulation.

Special Considerations in an 80-Year-Old

Anticoagulant use? Check if patient is on warfarin, aspirin, or DOACs - this increases bleeding risk and reaccumulation
Diabetes or immunosuppression? Increases risk of secondary perichondritis (infection presenting with fever, erythema, and exquisite tenderness) - most commonly Pseudomonas aeruginosa; treat with ciprofloxacin
Skin fragility: Use gentle pressure dressings to avoid pressure necrosis of the fragile elderly pinna skin
Referral: If patient is on anticoagulants, has signs of infection, or you are not confident in the procedure, refer to ENT

If Left Untreated

Fibrosis + new cartilage formation = permanent "cauliflower ear" deformity. For chronic hematoma or established cauliflower ear, surgical debridement of fibrosis and cartilage is required by an ENT specialist.

Textbook of Family Medicine 9e, p. 401
K.J. Lee's Essential Otolaryngology

How to give auricular nerve block

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Auricular Nerve Block - Complete Guide

Nerve Supply of the External Ear (Know This First)

The pinna is supplied by 4 nerve branches - you must block all of them for complete anesthesia:

Nerve	Origin	Area Supplied
Great auricular nerve	Cervical plexus (C2, C3)	Most of posteromedial, posterolateral, and inferior auricle
Lesser occipital nerve	Cervical plexus (C2)	Posterior auricle (minor contribution)
Auriculotemporal nerve	V3 (mandibular branch of trigeminal)	Anterosuperior and anteromedial auricle
Auricular branch of vagus (Arnold's nerve)	CN X	Concha and area around auditory meatus

Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 1526

Equipment

10 mL syringe
25- or 27-gauge needle, 5-7 cm long
1% lidocaine (preferred for most cases) OR 0.25% bupivacaine (for longer procedures)
Do NOT use epinephrine if there is evidence of traumatized vascularity (as in hematoma). Epinephrine is acceptable only for a regional block in a non-traumatized area

Patient Positioning

Patient lies supine or sits upright in a comfortable position. Turn the head slightly to expose the ear.

Technique: Circumferential Field Block (Most Common Method)

This is a simple "ring block" around the base of the ear using 4 injection points:

Auricular field block - four injection sites encircling the ear base with nerve distribution shown in yellow

Tintinalli's Emergency Medicine - Fig. 36-17: The four needles encircle the auricular base, with yellow lines showing the nerve distribution

Injection 1 - Inferior (Starting Point)

Raise a wheal in the subcutaneous space inferior to the auricle at the lobule. This is your starting point.

Injection 2 - Anteroinferior to Anterosuperior

From the inferior wheal, redirect the needle anteriorly and superiorly in the subcutaneous plane (just anterior to the tragus). Inject 2-3 mL while slowly withdrawing the needle. This blocks the auriculotemporal nerve (anterior supply).

Injection 3 - Posteroinferior to Posterosuperior

From the same inferior entry point, redirect the needle posteriorly and superiorly along the posterior sulcus (the groove between the ear and the mastoid). Inject 3-4 mL while slowly withdrawing toward the superior pole. This blocks the great auricular nerve and lesser occipital nerve (posterior supply).

Injection 4 - Superior

From a point superior to the auricle, inject 2-3 mL subcutaneously both anterior and posterior to complete the ring superiorly. Begin each new injection in an area already anesthetized to minimize pain.

Total volume: ~10-12 mL distributed around the ear base.

Simpler 2-Point Technique (Roberts & Hedges)

For faster anesthesia covering most of the auricle:

Posterior sulcus: Insert needle behind the inferior pole of the auricle, advance superiorly along the crescent-shaped posterior contour - inject 3-4 mL while withdrawing. Blocks great auricular + lesser occipital branches.
Anterior to tragus: Place 3-4 mL just superior and anterior to the cartilaginous tragus. Blocks the auriculotemporal nerve.

Key Points

Always aspirate before injecting to avoid intravascular injection (superficial temporal artery is anterior)
Inject in the subcutaneous plane - not intradermally, not deep
Wait 3-5 minutes for onset before proceeding with the procedure
For the hematoma drainage in your elderly patient: use 1% lidocaine without epinephrine, as the auricle vascularity is already compromised
Begin each new injection within the previously anesthetized zone to reduce pain
Tintinalli's Emergency Medicine, p. 287
Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 1526-1527

Do i need to suture the incised wound

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The answer from the textbook is clear and nuanced - here's the full picture:

Do You Need to Suture the Incised Wound?

Short answer: Not in the traditional sense - but sutures are used to secure the bolster/dental roll, not to primarily close the skin.

What the Evidence Says

There are two methods of wound management after I&D, and both avoid primary skin closure:

Method 1 - Non-surgical Compression Dressing (simpler, no sutures through skin)

After evacuating and irrigating the hematoma:

Apply antibiotic ointment to the incision
The wound edges are not sutured closed
Fill all auricular crevices with Vaseline gauze
Apply a multi-layer compression bandage over the entire ear secured with Kerlix

The pressure dressing reapproximates the perichondrium to cartilage mechanically. No skin sutures needed.

Method 2 - Surgical Dental Roll Bolster (sutures used as compression, not wound closure)

This is the preferred method for reliable compression. The sutures here serve a completely different purpose - they hold the dental rolls in place, not close the wound:

Apply antibiotic ointment to the incision
Pass a 4-0 nylon suture through-and-through the full thickness of the ear over the hematoma site
Wrap the suture around a dental roll on the posterior surface, then pass the needle back through the pinna
Wrap and tie around a second dental roll on the anterior surface - this creates firm compression of the drained cavity
A second suture may secure a third dental roll
The dressing must firmly reapproximate perichondrium to cartilage without compromising vasculature
Remove in 1 week

The incision itself is left to heal by secondary intention under the antibiotic ointment.

Why Not Close the Incision Primarily?

Reason	Explanation
Allows drainage	Any residual blood/seroma can still egress through the open wound
Infection risk	Closed dead space over cartilage risks perichondritis if infected
Secondary intention heals well	The small incision along natural skin folds heals with minimal scarring
Pressure does the work	Reapproximation is mechanical, not suture-dependent

Post-procedure

Antistaphylococcal antibiotics (e.g., cefalexin) - mandatory
Inspect wound at 24 hours for reaccumulation
Watch for signs of vascular compromise or infection (erythema, warmth, fever)
If infection develops: remove dressing, surgical drainage, and IV antibiotics
Remove dental roll bolster at 1 week

Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 1536-1537

Bottom line for your 80-year-old patient: Use the dental roll bolster technique with through-and-through 4-0 nylon sutures for reliable compression. The skin incision itself is left open under antibiotic ointment. Given his age and the 2-day-old hematoma, the bolster method is more reliable than a simple dressing alone.

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