A Silicone Splint for Auricular Hematoma
Sandra E. Lane, MD; Gary L. Rhame, DO; Randall L. Wroble, MD
Department Editor: William O. Roberts, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 9 - SEPTEMBER 98
Auricular hematomas are often encountered in a sports medicine practice, most commonly among wrestlers, but also in boxers, football and rugby players, and judo athletes (1). A relatively new treatment, the use of a silicone splint, offers several advantages over other treatments with regard to the risk of recurrence, observation of the site, and return to competition.
Auricular hematomas occur as a result of shearing forces to the auricle and pinna that result in a separation of the perichondrium from the underlying cartilage, leading to hematoma formation between these two layers (figure 1) (2,3). As the perichondrial blood supply is cut off by the expanding hematoma, the cartilage dies and is replaced by fibrocartilaginous scar tissue, resulting in "cauliflower ear (2)."
Treatment goals in auricular hematoma include adequate drainage followed by maintenance of compression to prevent recurrence. Many treatment options exist, including aspiration alone, aspiration and splinting with various materials, and incision and drainage with clot evacuation (1-4).
A silicone splint provides the necessary compression to prevent hematoma recurrence and potential necrosis, and the splint's see-through composition facilitates observation of the site. Further, the splint is small enough to fit under wrestling headgear, thus facilitating an early return to competition.
Applying the Splint
Splint application begins with preparation and draping of the ear in a sterile fashion. The skin surrounding the hematoma as well as the anterior and posterior auricle is then anesthetized locally with a 27-gauge needle and 1% lidocaine without epinephrine. The hematoma is aspirated with an 18-gauge needle on a 5-mL syringe. A silicone splint is then cut to fit the inner curve of the auricle and to cover the involved area. A second splint, for the posterior pinna, is cut in a similar shape. (See "Materials Used," below, for details on the silicone and other items used.)
The splints are then sewn onto the anterior and posterior surface of the pinna using 3-0 nylon suture. A curved needle may be used, but the technique is simplified if the needle is straightened using two needle holders. Three to four interrupted mattress sutures are placed 4 to 5 mm from the outer edge of the silicone splints (figure 2). Antibacterial ointment is then applied with a cotton swab along the outer edge of both splints.
The patient is instructed to keep the ear dry for 24 hours and to apply antibacterial ointment twice a day with a cotton swab. In addition, we routinely prescribe an antibiotic such as cephalexin to be administered 250 mg four times a day for 5 days to prevent infection.
Return to Participation
We allow wrestlers to return to wrestling 24 hours after splint application. The best protection from recurrence is to have the athlete wear headgear that protects the ears. Headgear helps to dampen the shearing forces that are usually to blame for cartilage damage in at-risk athletes.
A patient who plans to return to play should be instructed to make a donut-shaped foam pad to tape to the inside of the headgear (figure 3) (foam padding is usually available from athletic trainers). The ear cup can be padded with extra gauze or other soft material instead of foam. We generally recommend that this pad be used for the remainder of the season. Headgear must be properly fitted to the patient's head; ill-fitting headgear has been known to be a factor in causing auricular hematoma (5).
Follow-up and Complications
Possible complications include hematoma recurrence, scar formation, infection, and skin and cartilage necrosis. The risk of hematoma recurrence progressively declines the longer the splint stays in place. We generally remove sutures at 14 days. However, the ear should be rechecked at 7 days and the sutures removed if redness or tenderness exists. Schuller et al (4) left dental-roll splints in place 14 days with no recurrence in 19 wrestlers who had 24 auricular hematomas.
In addition to the 2-week splint placement, a mastoid bandage can be placed for the first 24 hours to decrease recurrence. The athlete should not compete or practice while wearing a mastoid dressing (2).
Because scar formation can result in cauliflower ear, recurrence should be managed aggressively, with either aspiration and resplinting for one more week or referral to an otolaryngologist for incision, drainage, and resplinting. Patients who have cauliflower ear must be treated by an otolaryngologist or plastic surgeon.
The most common infecting pathogens in patients who have auricular hematomas include Staphylococcus and Streptococcus species (4), but pseudomonads can be seenin severe cases (3). Severe infection in these patients should be treated with open drainage by an otolaryngologist and intravenous antibiotics.
Another serious complication is chondritis, a more advanced infection, which leads to necrosis of the auricular cartilage. This is best managed with debridement (1) by an otolaryngologist or plastic surgeon.
The silicone material used by the authors is No. 502-3, .080 in., firm grade SIL-TEC sheeting made by Technical Products Inc. of Georgia, USA (Decatur, Georgia; 800-226-8434). The silicone comes in sheets ranging from 4 x 4 in. to 12 x 12 in.
The authors' preferred suture for applying the silicone splint is 3-0 nylon on a PS-1 precision-point reverse cutting needle (with the cutting edge on the outer curve of the needle) for difficult-to-penetrate tissue. The suture, from Johnson & Johnson, is Ethilon nylon 3-0, 18 in. (45 cm), black monofilament on a 24-mm PS-1 needle. Reorder number is 1663G.
Dr Lane is a family physician, associate medical director, and fellowship director; Dr Rhame is a family physician and fellow; and Dr Wroble is an orthopedic surgeon and associate medical director, all at SportsMedicine Grant, Grant Medical Center, Columbus, Ohio. Dr Roberts is a family physician at MinnHealth SportsCare in White Bear Lake, Minnesota, and medical director of the Twin Cities Marathon. Dr Lane is a fellow of the American College of Sports Medicine, and Drs Wroble and Roberts are editorial board members of The Physician and Sportsmedicine.
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