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External ear injuries
CONCEPTS, COMPONENTS, AND CONFIGURATIONS
External Ear Injuries Stephen L. Uston, MD* Edwin A. Cortez, MDt W. Kenda# McNabney, MDt Kansas City, Missouri
The unique shape of the external ear depends on the underlying cartilaginous framework. Injuries of the external ear are common. In dealing with lacerations, subperichondrial hematomas, perichondritis, burns and frostbite, particular care should be taken to maintain the cartilaginous framework and to prevent infection. In this way cosmetic deformities of the external ear can be prevented. Liston SL, Cortez EA, McNabney WK: External ear injuries. JACEP 7:233-236, June, 1978. ear, injury, external
INTRODUCTION Complexities in t r e a t i n g injuries from t r a u m a to t h e e x t e r n a l e a r are related to the ear's special s t a t u s a m o n g facial structures. The e a r is second to the nose as the most p r o m i n e n t facial structure. But the e a r is a paired s t r u c t u r e a n d m a i n t e n a n c e of s y m m e t r y is i m p o r t a n t . Because of the ear's c a r t i l a g i n o u s framework, h e m a t o m a and p e r i c h o n d r i t i s can occur and lead to severe deformity. The unique convoluted shape of the e a r cartilage m a k e s it most difficult to replace. This p a p e r is a general discussion of the care of these injuries. HISTORY AND PHYSICAL EXAMINATION In the history, the presence of other injuries, especially in the h e a d and neck region, should be ascertained. A p a s t medical history, including medication, is also necessary to assess the p a t i e n t ' s g e n e r a l medical status. Specifically, the time, method, and i n s t r u m e n t t h a t produced the e a r injury should be elucidated. Of course, an a s s e s s m e n t of the p a t i e n t ' s h e a r i n g is also necessary. Physical e x a m i n a t i o n should e v a l u a t e injuries to the facial bones, skull, cervical spine, t y m p a n i c m e m b r a n e , a n d facial nerve and should include a t h o r o u g h e x a m i n a t i o n of the e x t e r n a l and i n t e r n a l ear. Specific a t t e n t i o n should also be l~aid to the head and neck region because of the propensity for associated injuries in this area. A d i a g r a m of the e a r on the medical record showing all injuries m a y prove helpful later. ANATOMY The e x t e r n a l e a r is supported by a single thin sheet of convoluted, yellow elastic cartilage, which is responsible for the ear's characteristic shape (Figure 1). 1 The lobule contains no cartilage. The s k i n on the l a t e r a l surface is t i g h t l y bound to the perichondrium and lacks the u s u a l loose subcutaneous layer. The s k i n on the medial aspect does have a l a y e r of loose subcutaneous tissue. The p o s t a u r i c u l a r a r e a is richly supplied with sebaceous glands and is a common location for epidermoid cysts. From the Section of Otolaryngology, Department of Surgery* and the Department of Emergency Medicine, I Truman Medical Center, Kansas City, Missouri. Address for reprints: S. Liston, MD, Department of Surgery, Truman Medical Center, 2301 Holmes, Kansas City, Missouri 64108. 7:6 (June) 1978
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Concha\ ~~
Helix~ ~
~
Auriculotemporal
Upperlateraltwo thirds Scapha
Antheiix
Lesseroccipital ~'~ ~ Uppermedialtwo thirds~
External auditory
n
meatus. .~Tragus
titragus Greaterauricular ~ Lowermedialand lateral one third \
I Lobule I /
Auricularbranch of vagus O Siteof injectionof local anesthetic Fig. 1. Anatomical features of the external ear showing nerve supply and sites of injection of local anesthetic.
Three nerves contribute to the sensory supply of the ear. The auriculotemporal branch of the mandibular nerve supplies the upper lateral surface of the ear and external canal. The lesser occipital n e r v e (C2-3) supplies s e n s a t i o n to the upper medial side of the ear. The greater auricular nerve (C2-3) supplies sensation to both the medial and lateral lower part of the ear. The auricular branch of the vagus may also supply a small part of the external ear near the external auditory meatus2 Local anesthesia of the external ear can be achieved by blocking the lesser occipital and greater auricular nerves over the mastoid process and the auriculotemporal nerve, b e t w e e n the tragus and helix, anterior to the upper part of the ear cartilage. The auricular branch of the vagus can be blocked by an injection in the skin of the posterior part of the external ear canal. The excellent blood supply, the superficial temporal and postauricular arteries and their accompanying veins, is ample to keep a partially avulsed fragment viable, e v e n through a small skin bridge. EAR INJURIES Lacerations
Because of its exposed position 26/234
on the side of the head, the external ear is frequently injured. 2-t The basic principles of reconstruction of the ear are irrigation of the wound followed by minimal debridement, accurate realignment of tissues, and complete coverage of all auricular cartilage. 2-4 Although cartilage should not be needlessly sacrificed, it is sometimes convenient to remove a thin rim of cartilage along the line of the incision, leaving the covering perichondrium in position. The perichondrium can then be sutured to realign the tissues, ensuring that no cartilage is exposed. Before closing a laceration in the external ear, it is useful to place a vertical mattress suture to hold the edge of the helix in its correct position. Notching of the helix is a very noticeable deformity and should be avoided. To do this, it is sometimes advantageous to use a halving technique 2 to overlap the lateral half of one side of the incision over the medial half of the other side. After the laceration has been closed, the ear should be dressed with a firm pressure bandage, Moist cotton is used to fill the crevices of the external ear and fluffs are then placed over the pinna and also between the pinna and the mastoid. A firm Kerlix roll is then placed a r o u n d the head. If the e x t e r n a l
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canal has been transected, Iodoform gauze impregnated with antibiotic ointment packed in the canal, or an acrylic stent, should be used. 2,3 The stent will serve to prevent stenosis of the e x t e r n a l canal. The wound should be checked in 48 hours, and the sutures removed in four days. Partial Avulsions
Because of the excellent blood supply of the ear, incomplete avulsions should be treated conservatively, ie, with minimum debridement. Small skin bridges should not be discarded since they contribute to the vascularity of the avulsed area. Partial avulsions should be sutured into position after t h o r o u g h , but gentle, c l e a n s i n g for r e m o v a l of foreign bodies, and the ear parts usually remain viable.2, 3 Total Avulsions
When a part of the ear less than 2 cm in size is totally avulsed, it can be sutured as a composite graft and may survive. 2 When larger segments are avulsed, an effort should be made to retain the cartilaginous framework. This can be done by implanting the c a r t i l a g i n o u s framework into a subcutaneous pocket in the skin of the mastoid region.5, 6 The skin over the auricle can be removed by dermabrasion, or by dissection, or the cartilage alone can be implanted into this pocket. If the avulsed tissue is not available or is unsuitable, the defect can be reconstructed then, or the wound can be closed and a second stage r e c o n s t r u c t i o n performed. A c h o n d r o c u t a n e o u s advancement flap can be used to close a defect in the helical rim. v Other t e c h n i q u e s involve flaps raised and transferred from the pre- and post-auricular areas. Cartilage can be implanted into these and subsequently implanted into the exterior ear with the flap.S, 9 Successful reimplantations of the entire external ear following its avulsion have been reported.lO, 11 The patients were treated with hepar, in, dextrose, and vasodilators, and multiple incisions were made t h r o u g h the skin and perichondrium of the implanted ear in an effort to improve blood flow. Microvascular r e a n a s t o m o s i s has b e e n used in the rabbit and the technique has great potential for use on the totally avulsed h u m a n ear. 1~ Surgical reconstruction of the external ear is a complicated, multi-stage procedure. Cosmetically, the results are not entirely satisfactory. 13 An alternative is for the patient to wear a 7:6 (June) 1978
prosthetic e a r a t t a c h e d to a glasses' f r a m e . P r o s t h e s e s , h o w e v e r , also have problems and the decision should be m a d e by the patient.
Subperichondrial Hematoma Because of the t i g h t a t t a c h m e n t of the skin of the l a t e r a l side of the e x t e r n a l ear, t r a u m a m a y cause the p e r i c h o n d r i u m to s h e a r off the cartilage. This causes bleeding with hematoma formation between the c a r t i l a g e and p e r i c h o n d r i u m (Figure 2). T h i s h e m a t o m a is i n v a d e d by fibrous tissue c a u s i n g t h i c k e n i n g and deformity of t h e ear. Such t r a u m a is common is w r e s t l e r s and boxers and multiple injuries produce a cauliflower ear.X4, ~5 A c u t e s u b p e r i c h o n drial h e m a t o m a s s h u l d be a s p i r a t e d with a large bore needle using sterile technique.2, a I f blood continues to acc u m u l a t e , it should be r e a s p i r a t e d . F u r t h e r a c c u m u l a t i o n is an indication for insertion of a drain. An organized h e m a t o m a should be evacuated through a small incision. 3 Following this, t h r o u g h and through, monofilament sutures are passed t h r o u g h the p i n n a and tied over cotton bolsters on both the medial and l a t e r a l sides of t h e p i n n a to a p p l y pressure and p r e v e n t deformity. 14 A pressure dressing, as previously described, is t h e n applied. The p a t i e n t should be checked 24 hours after the a s p i r a t i o n a n d e v a c u a t i o n of clot. Aseptic technique is m a n d a t o r y because perichondritis can r e s u l t from h e m a t o m a infection. ~°
Cartilage i ...................
~ 1
P
u
Skin
s
or hematoma ,
i
Siteof aspiration or I andD
Perichonddum F i g . 2. Schematic diagram of site of hematoma in subperichondrial hematoma, and pus in perichondritis. b u t preserving, the s k i n on the opposite side of the pinna. Is The wound is l e f t to g r a n u l a t e . A n t i b i o t i c s a r e given according to the result of cult u r e and s e n s i t i v i t y and an e a r dressing is applied. If possible, the helical r i m should be left i n t a c t to p r e v e n t deformity.
Burns In b u r n s of t h e e x t e r n a l e a r ( F i g u r e 3), t r e a t m e n t is a i m e d a t p r e v e n t i n g c o n v e r s i o n of a p a r t i a l
Perichondritis Infection of the a u r i c u l a r cartilage u s u a l l y occurs after exposure of the c a r t i l a g e by t r a u m a , surgery, or b u r n s . T M P e r i c h o n d r i t i s can also occur as a r e s u l t of infection of an a u r i c u l a r h e m a t o m a . 2 , 3 , ~9 As t h e process evolves, the e x t e r n a l e a r becomes red, hot, and exquisitely tender. This is followed by diffuse swelli n g a n d a b s c e s s f o r m a t i o n in t h e plane between the cartilage and p e r i c h o n d r i u m (Figure 2). The infection spreads along the p e r i c h o n d r i u m and the c a r t i l a g e necroses.19, 2° The final result is a severe e a r deformity. The abscess should be drained, a plastic cannula inserted, and the sinus irrigated with an antibiotic (usually gentamicin sulfate), hyal u r o n i d a s e , a n d lidocaine.~S, ~7 Necrotic c a r t i l a g e should be r e m o v e d to p r e v e n t the infection from persisti n g a n d s p r e a d i n g . S u r g i c a l deb r i d e m e n t of the necrotic c a r t i l a g e can be performed by excising the infected s k i n a n d c a r t i l a g e down to,
7:6 (June) 1978
Fig. 3. Burned external ear. thickness b u r n to full t h i c k n e s s and perichondritis, a major complication of b u r n s of t h e e a r . a , l ~ , l s , 19 Cont i n u e d infection b e n e a t h an e s c h a r can destroy the tissue protecting the ear cartilage. Burned ears are t r e a t e d open. S t e r i l e cleansing, debridement, antibiotic cream, or topical S u l f a m y l o n c r e a m decrease the probability of perichondritis. 2° Both p a r t i a l and full t h i c k n e s s burns m a y lead to perichondritis, b u t the occurrence cannot be Predicted. In some
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full t h i c k n e s s burns, exposed cartilage is covered by ingrowing g r a n u l a t i o n t i s s u e w i t h o u t i n f e c t i o n . In others, perichondritis develops t h r e e to five weeks postburn. 2° The p a t i e n t complains of dull pain. The ear becomes red, warm, swollen, and tender and a fluctuant area appears. Abscesses should be drained. If tenderness and i n d u r a t i o n persist, more extensive d e b r i d e m e n t is necessary to remove all the necrotic cartilage, and this m a y necessitate " b i v a l v i n g t h e e a r . " T h i s is a c c o m p l i s h e d by m a k i n g an incision along the helical m a r g i n a n d s p l i t t i n g the e a r in a bivalve fashion. The necrotic cartilage is removed. A single l a y e r of fine m e s h g a u z e is p l a c e d b e t w e e n t h e m e d i a l a n d l a t e r a l s k i n flaps a n d changed daily. This allows for multiple d e b r i d e m e n t s of the cartilage as required. It is sometimes difficult to i d e n t i f y necrotic c a r t i l a g e and furt h e r d e b r i d e m e n t m a y be necessary. It is common for a b u r n e d ear complicated by perichondritis to develop some deformity. 2°
Frostbite The e x t e r n a l e a r is one of the m o s t c o m m o n a r e a s a f f e c t e d by f r o s t b i t e . 19 T h e m e c h a n i s m of frostbite injury is e i t h e r direct, by inj u r y to tissue cells from ice crystal formation, or secondary, from damage to the blood vessels. 21 At first, the frostbitten e a r a p p e a r s white and s o l i d . T h e e a r s h o u l d be t h a w e d u s i n g c o t t o n p l e d g e t s s o a k e d in w a t e r at a t e m p e r a t u r e of 32 C to 48 C (89.6 F to 118.4 F). 2~ T h a w i n g is a painful process. If the e a r is refrozen a f t e r t h a w i n g , m a s s i v e t i s s u e necrosis occurs. 21 As the e a r thaws, it becomes red and flushed. Blebs occur, but t h e y should not be ruptured. I n f e c t i o n c a n be r e d u c e d by u s i n g 0.5% s i l v e r n i t r a t e soaks. Antibiotics are not used prophylactically and are reserved for e s t a b l i s h e d infection. No a t t e m p t should be made to surgically debride the e a r because it m a y t a k e months for the line of d e m a r c a t i o n between living and dead tissue to become a p p a r e n t . 21 S m o k i n g should not be p e r m i t t e d b e c a u s e it causes vasoconstriction, 21 which will m a k e the problem worse. CONCLUSION Proper t r e a t m e n t of e x t e r n a l ear i n j u r i e s in t h e e m e r g e n c y d e p a r t m e n t can p r e v e n t the d e v e l o p m e n t of cosmetic deformities. The cartilaginous f r a m e w o r k of t h e e x t e r n a l e a r is r e s p o n s i b l e for t h e e a r ' s u n i q u e shape, and p a r t i c u l a r care m u s t be
235/27
t a k e n to m a i n t a i n t h i s c a r t i l a g i n o u s f r a m e , a n d e s p e c i a l l y to p r e v e n t i t s destruction by infection.
7. A n t i a NH, Buch VI: Chondrocutaneous a d v a n c e m e n t flap for the m a r g i n a l defect of the ear. Plast Reconstr Surg 39:472-477, 1967.
REFERENCES
8. C o n v e r s e JM: Kazanjian and Converses" Surgical Treatment of Facial Injuries, ed 3. Baltimore, Williams & Wil-
1. S h a m b a u g h GE Jr: Surgery of the Ear, ed 2. Philadelphia, W B Saunders, 1967, pp 42-46. 2. Gross CW: Soft tissue injuries of the lips, nose, ears, and p r e a u r i c u l a r area. Otolaryngol Clin North Am 2:292-302, 1969. 3. Spira M, Hardy SB: M a n a g e m e n t of the injured ear. Am J Surg 106:678-686, 1963. 4. English GM: Common injuries to the ear. Primary Care 3:507-520, 1976. 5. Mladick RA, Carraway JH: E a r reatt a c h m e n t by the modified pocket principle - - case r e p o r t . Plast Reconstr Surg 51:584-487, 1973. 6. Larsen J, Pless J: Replantation of sev e r e d e a r p a r t s . Plast Reconstr Surg 57:176-179, 1976.
kins, 1974, vol 2, pp 472-477. 9. B r e n t B: The acquired a u r i c u l a r deformity, a s y s t e m a t i c a p p r o a c h to its analysis and reconstruction. Plast Reconstr Surg 59:475-485, 1977. 10. C l e m o n s J E , C o n n e l l y MV: Reatt a c h m e n t of the totally amputated auricle. Arch Otolaryngol 97:269-272, 1973. 11. Potsic WP, N a u n t o n RF: Replantation of a n a m p u t a t e d pinna. Arch Otolaryngol 100:73-75, 1974. 12. Tse M i n g Tsai: E x p e r i m e n t a l and c l i n i c a l a p p l i c a t i o n of m i c r o v a s c u l a r surgery. Ann Surg 181:169-177, 1975. 13. Brent B: E a r reconstruction with an expansile framework of autogenous rib cartilage. Plast Reconstr Surg 53:619-628, 1974.
14. Eade GG: P r e v e n t i n g c a u l i f l o w e r ears. Northwest Medicine 63:99, 1964. 15. Kelleher JC, Sullivan JG, Baibak GJ, et al: The wrestler's ear. Plast Reconstr Surg 40:540-546, i967. 16. W a n a m a k e r HH: S u p p u r a t i v e perichondritis of the auricle. Trans Am Acad Ophthamol Otolaryngol 76:1289-1291, 1972. 17. Apfelberg DB, Waisbren BA, Masters FW, et al: T r e a t m e n t of chondritis in the burned ear by local instillation of antibiotics. Plast Reconstr Surg 53:179-183, 1974. 18. Stroud MH: A simple t r e a t m e n t for suppurative perichondritis. Laryngoscope 73:556-563, 1963. 19. M a r t i n R, Yonkers AJ, Yarington CT Jr: P e r i c h o n d r i t i s of t h e ear. Laryngoscope 86:664-673, 1976. 20. Dowling JA, Foley FD, Moncrief JA: Chrondritis in the burned ear. Plast Reconstr Surg 42:115-122, 1968. 21. Sessions DG, Stallings JO, Mills WJ Jr, et al: Frostbite of the ear. Laryngoscope 81:1223-1232, 1971.
Correction: In "Emergency Burn Management" by Gursel and Tintinalli (JACEP, May 1978) on page 210 the substance in plastic auto seat covers was mistakenly identified as "polyvinyl bromide." This should have read "polyvinyl chloride."
28/236
JACEP
7:6 (Ju ne) 1978
External Ear Injuries Stephen L. Uston, MD* Edwin A. Cortez, MDt W. Kenda# McNabney, MDt Kansas City, Missouri
The unique shape of the external ear depends on the underlying cartilaginous framework. Injuries of the external ear are common. In dealing with lacerations, subperichondrial hematomas, perichondritis, burns and frostbite, particular care should be taken to maintain the cartilaginous framework and to prevent infection. In this way cosmetic deformities of the external ear can be prevented. Liston SL, Cortez EA, McNabney WK: External ear injuries. JACEP 7:233-236, June, 1978. ear, injury, external
INTRODUCTION Complexities in t r e a t i n g injuries from t r a u m a to t h e e x t e r n a l e a r are related to the ear's special s t a t u s a m o n g facial structures. The e a r is second to the nose as the most p r o m i n e n t facial structure. But the e a r is a paired s t r u c t u r e a n d m a i n t e n a n c e of s y m m e t r y is i m p o r t a n t . Because of the ear's c a r t i l a g i n o u s framework, h e m a t o m a and p e r i c h o n d r i t i s can occur and lead to severe deformity. The unique convoluted shape of the e a r cartilage m a k e s it most difficult to replace. This p a p e r is a general discussion of the care of these injuries. HISTORY AND PHYSICAL EXAMINATION In the history, the presence of other injuries, especially in the h e a d and neck region, should be ascertained. A p a s t medical history, including medication, is also necessary to assess the p a t i e n t ' s g e n e r a l medical status. Specifically, the time, method, and i n s t r u m e n t t h a t produced the e a r injury should be elucidated. Of course, an a s s e s s m e n t of the p a t i e n t ' s h e a r i n g is also necessary. Physical e x a m i n a t i o n should e v a l u a t e injuries to the facial bones, skull, cervical spine, t y m p a n i c m e m b r a n e , a n d facial nerve and should include a t h o r o u g h e x a m i n a t i o n of the e x t e r n a l and i n t e r n a l ear. Specific a t t e n t i o n should also be l~aid to the head and neck region because of the propensity for associated injuries in this area. A d i a g r a m of the e a r on the medical record showing all injuries m a y prove helpful later. ANATOMY The e x t e r n a l e a r is supported by a single thin sheet of convoluted, yellow elastic cartilage, which is responsible for the ear's characteristic shape (Figure 1). 1 The lobule contains no cartilage. The s k i n on the l a t e r a l surface is t i g h t l y bound to the perichondrium and lacks the u s u a l loose subcutaneous layer. The s k i n on the medial aspect does have a l a y e r of loose subcutaneous tissue. The p o s t a u r i c u l a r a r e a is richly supplied with sebaceous glands and is a common location for epidermoid cysts. From the Section of Otolaryngology, Department of Surgery* and the Department of Emergency Medicine, I Truman Medical Center, Kansas City, Missouri. Address for reprints: S. Liston, MD, Department of Surgery, Truman Medical Center, 2301 Holmes, Kansas City, Missouri 64108. 7:6 (June) 1978
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233/25
Concha\ ~~
Helix~ ~
~
Auriculotemporal
Upperlateraltwo thirds Scapha
Antheiix
Lesseroccipital ~'~ ~ Uppermedialtwo thirds~
External auditory
n
meatus. .~Tragus
titragus Greaterauricular ~ Lowermedialand lateral one third \
I Lobule I /
Auricularbranch of vagus O Siteof injectionof local anesthetic Fig. 1. Anatomical features of the external ear showing nerve supply and sites of injection of local anesthetic.
Three nerves contribute to the sensory supply of the ear. The auriculotemporal branch of the mandibular nerve supplies the upper lateral surface of the ear and external canal. The lesser occipital n e r v e (C2-3) supplies s e n s a t i o n to the upper medial side of the ear. The greater auricular nerve (C2-3) supplies sensation to both the medial and lateral lower part of the ear. The auricular branch of the vagus may also supply a small part of the external ear near the external auditory meatus2 Local anesthesia of the external ear can be achieved by blocking the lesser occipital and greater auricular nerves over the mastoid process and the auriculotemporal nerve, b e t w e e n the tragus and helix, anterior to the upper part of the ear cartilage. The auricular branch of the vagus can be blocked by an injection in the skin of the posterior part of the external ear canal. The excellent blood supply, the superficial temporal and postauricular arteries and their accompanying veins, is ample to keep a partially avulsed fragment viable, e v e n through a small skin bridge. EAR INJURIES Lacerations
Because of its exposed position 26/234
on the side of the head, the external ear is frequently injured. 2-t The basic principles of reconstruction of the ear are irrigation of the wound followed by minimal debridement, accurate realignment of tissues, and complete coverage of all auricular cartilage. 2-4 Although cartilage should not be needlessly sacrificed, it is sometimes convenient to remove a thin rim of cartilage along the line of the incision, leaving the covering perichondrium in position. The perichondrium can then be sutured to realign the tissues, ensuring that no cartilage is exposed. Before closing a laceration in the external ear, it is useful to place a vertical mattress suture to hold the edge of the helix in its correct position. Notching of the helix is a very noticeable deformity and should be avoided. To do this, it is sometimes advantageous to use a halving technique 2 to overlap the lateral half of one side of the incision over the medial half of the other side. After the laceration has been closed, the ear should be dressed with a firm pressure bandage, Moist cotton is used to fill the crevices of the external ear and fluffs are then placed over the pinna and also between the pinna and the mastoid. A firm Kerlix roll is then placed a r o u n d the head. If the e x t e r n a l
JACEP
canal has been transected, Iodoform gauze impregnated with antibiotic ointment packed in the canal, or an acrylic stent, should be used. 2,3 The stent will serve to prevent stenosis of the e x t e r n a l canal. The wound should be checked in 48 hours, and the sutures removed in four days. Partial Avulsions
Because of the excellent blood supply of the ear, incomplete avulsions should be treated conservatively, ie, with minimum debridement. Small skin bridges should not be discarded since they contribute to the vascularity of the avulsed area. Partial avulsions should be sutured into position after t h o r o u g h , but gentle, c l e a n s i n g for r e m o v a l of foreign bodies, and the ear parts usually remain viable.2, 3 Total Avulsions
When a part of the ear less than 2 cm in size is totally avulsed, it can be sutured as a composite graft and may survive. 2 When larger segments are avulsed, an effort should be made to retain the cartilaginous framework. This can be done by implanting the c a r t i l a g i n o u s framework into a subcutaneous pocket in the skin of the mastoid region.5, 6 The skin over the auricle can be removed by dermabrasion, or by dissection, or the cartilage alone can be implanted into this pocket. If the avulsed tissue is not available or is unsuitable, the defect can be reconstructed then, or the wound can be closed and a second stage r e c o n s t r u c t i o n performed. A c h o n d r o c u t a n e o u s advancement flap can be used to close a defect in the helical rim. v Other t e c h n i q u e s involve flaps raised and transferred from the pre- and post-auricular areas. Cartilage can be implanted into these and subsequently implanted into the exterior ear with the flap.S, 9 Successful reimplantations of the entire external ear following its avulsion have been reported.lO, 11 The patients were treated with hepar, in, dextrose, and vasodilators, and multiple incisions were made t h r o u g h the skin and perichondrium of the implanted ear in an effort to improve blood flow. Microvascular r e a n a s t o m o s i s has b e e n used in the rabbit and the technique has great potential for use on the totally avulsed h u m a n ear. 1~ Surgical reconstruction of the external ear is a complicated, multi-stage procedure. Cosmetically, the results are not entirely satisfactory. 13 An alternative is for the patient to wear a 7:6 (June) 1978
prosthetic e a r a t t a c h e d to a glasses' f r a m e . P r o s t h e s e s , h o w e v e r , also have problems and the decision should be m a d e by the patient.
Subperichondrial Hematoma Because of the t i g h t a t t a c h m e n t of the skin of the l a t e r a l side of the e x t e r n a l ear, t r a u m a m a y cause the p e r i c h o n d r i u m to s h e a r off the cartilage. This causes bleeding with hematoma formation between the c a r t i l a g e and p e r i c h o n d r i u m (Figure 2). T h i s h e m a t o m a is i n v a d e d by fibrous tissue c a u s i n g t h i c k e n i n g and deformity of t h e ear. Such t r a u m a is common is w r e s t l e r s and boxers and multiple injuries produce a cauliflower ear.X4, ~5 A c u t e s u b p e r i c h o n drial h e m a t o m a s s h u l d be a s p i r a t e d with a large bore needle using sterile technique.2, a I f blood continues to acc u m u l a t e , it should be r e a s p i r a t e d . F u r t h e r a c c u m u l a t i o n is an indication for insertion of a drain. An organized h e m a t o m a should be evacuated through a small incision. 3 Following this, t h r o u g h and through, monofilament sutures are passed t h r o u g h the p i n n a and tied over cotton bolsters on both the medial and l a t e r a l sides of t h e p i n n a to a p p l y pressure and p r e v e n t deformity. 14 A pressure dressing, as previously described, is t h e n applied. The p a t i e n t should be checked 24 hours after the a s p i r a t i o n a n d e v a c u a t i o n of clot. Aseptic technique is m a n d a t o r y because perichondritis can r e s u l t from h e m a t o m a infection. ~°
Cartilage i ...................
~ 1
P
u
Skin
s
or hematoma ,
i
Siteof aspiration or I andD
Perichonddum F i g . 2. Schematic diagram of site of hematoma in subperichondrial hematoma, and pus in perichondritis. b u t preserving, the s k i n on the opposite side of the pinna. Is The wound is l e f t to g r a n u l a t e . A n t i b i o t i c s a r e given according to the result of cult u r e and s e n s i t i v i t y and an e a r dressing is applied. If possible, the helical r i m should be left i n t a c t to p r e v e n t deformity.
Burns In b u r n s of t h e e x t e r n a l e a r ( F i g u r e 3), t r e a t m e n t is a i m e d a t p r e v e n t i n g c o n v e r s i o n of a p a r t i a l
Perichondritis Infection of the a u r i c u l a r cartilage u s u a l l y occurs after exposure of the c a r t i l a g e by t r a u m a , surgery, or b u r n s . T M P e r i c h o n d r i t i s can also occur as a r e s u l t of infection of an a u r i c u l a r h e m a t o m a . 2 , 3 , ~9 As t h e process evolves, the e x t e r n a l e a r becomes red, hot, and exquisitely tender. This is followed by diffuse swelli n g a n d a b s c e s s f o r m a t i o n in t h e plane between the cartilage and p e r i c h o n d r i u m (Figure 2). The infection spreads along the p e r i c h o n d r i u m and the c a r t i l a g e necroses.19, 2° The final result is a severe e a r deformity. The abscess should be drained, a plastic cannula inserted, and the sinus irrigated with an antibiotic (usually gentamicin sulfate), hyal u r o n i d a s e , a n d lidocaine.~S, ~7 Necrotic c a r t i l a g e should be r e m o v e d to p r e v e n t the infection from persisti n g a n d s p r e a d i n g . S u r g i c a l deb r i d e m e n t of the necrotic c a r t i l a g e can be performed by excising the infected s k i n a n d c a r t i l a g e down to,
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Fig. 3. Burned external ear. thickness b u r n to full t h i c k n e s s and perichondritis, a major complication of b u r n s of t h e e a r . a , l ~ , l s , 19 Cont i n u e d infection b e n e a t h an e s c h a r can destroy the tissue protecting the ear cartilage. Burned ears are t r e a t e d open. S t e r i l e cleansing, debridement, antibiotic cream, or topical S u l f a m y l o n c r e a m decrease the probability of perichondritis. 2° Both p a r t i a l and full t h i c k n e s s burns m a y lead to perichondritis, b u t the occurrence cannot be Predicted. In some
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full t h i c k n e s s burns, exposed cartilage is covered by ingrowing g r a n u l a t i o n t i s s u e w i t h o u t i n f e c t i o n . In others, perichondritis develops t h r e e to five weeks postburn. 2° The p a t i e n t complains of dull pain. The ear becomes red, warm, swollen, and tender and a fluctuant area appears. Abscesses should be drained. If tenderness and i n d u r a t i o n persist, more extensive d e b r i d e m e n t is necessary to remove all the necrotic cartilage, and this m a y necessitate " b i v a l v i n g t h e e a r . " T h i s is a c c o m p l i s h e d by m a k i n g an incision along the helical m a r g i n a n d s p l i t t i n g the e a r in a bivalve fashion. The necrotic cartilage is removed. A single l a y e r of fine m e s h g a u z e is p l a c e d b e t w e e n t h e m e d i a l a n d l a t e r a l s k i n flaps a n d changed daily. This allows for multiple d e b r i d e m e n t s of the cartilage as required. It is sometimes difficult to i d e n t i f y necrotic c a r t i l a g e and furt h e r d e b r i d e m e n t m a y be necessary. It is common for a b u r n e d ear complicated by perichondritis to develop some deformity. 2°
Frostbite The e x t e r n a l e a r is one of the m o s t c o m m o n a r e a s a f f e c t e d by f r o s t b i t e . 19 T h e m e c h a n i s m of frostbite injury is e i t h e r direct, by inj u r y to tissue cells from ice crystal formation, or secondary, from damage to the blood vessels. 21 At first, the frostbitten e a r a p p e a r s white and s o l i d . T h e e a r s h o u l d be t h a w e d u s i n g c o t t o n p l e d g e t s s o a k e d in w a t e r at a t e m p e r a t u r e of 32 C to 48 C (89.6 F to 118.4 F). 2~ T h a w i n g is a painful process. If the e a r is refrozen a f t e r t h a w i n g , m a s s i v e t i s s u e necrosis occurs. 21 As the e a r thaws, it becomes red and flushed. Blebs occur, but t h e y should not be ruptured. I n f e c t i o n c a n be r e d u c e d by u s i n g 0.5% s i l v e r n i t r a t e soaks. Antibiotics are not used prophylactically and are reserved for e s t a b l i s h e d infection. No a t t e m p t should be made to surgically debride the e a r because it m a y t a k e months for the line of d e m a r c a t i o n between living and dead tissue to become a p p a r e n t . 21 S m o k i n g should not be p e r m i t t e d b e c a u s e it causes vasoconstriction, 21 which will m a k e the problem worse. CONCLUSION Proper t r e a t m e n t of e x t e r n a l ear i n j u r i e s in t h e e m e r g e n c y d e p a r t m e n t can p r e v e n t the d e v e l o p m e n t of cosmetic deformities. The cartilaginous f r a m e w o r k of t h e e x t e r n a l e a r is r e s p o n s i b l e for t h e e a r ' s u n i q u e shape, and p a r t i c u l a r care m u s t be
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t a k e n to m a i n t a i n t h i s c a r t i l a g i n o u s f r a m e , a n d e s p e c i a l l y to p r e v e n t i t s destruction by infection.
7. A n t i a NH, Buch VI: Chondrocutaneous a d v a n c e m e n t flap for the m a r g i n a l defect of the ear. Plast Reconstr Surg 39:472-477, 1967.
REFERENCES
8. C o n v e r s e JM: Kazanjian and Converses" Surgical Treatment of Facial Injuries, ed 3. Baltimore, Williams & Wil-
1. S h a m b a u g h GE Jr: Surgery of the Ear, ed 2. Philadelphia, W B Saunders, 1967, pp 42-46. 2. Gross CW: Soft tissue injuries of the lips, nose, ears, and p r e a u r i c u l a r area. Otolaryngol Clin North Am 2:292-302, 1969. 3. Spira M, Hardy SB: M a n a g e m e n t of the injured ear. Am J Surg 106:678-686, 1963. 4. English GM: Common injuries to the ear. Primary Care 3:507-520, 1976. 5. Mladick RA, Carraway JH: E a r reatt a c h m e n t by the modified pocket principle - - case r e p o r t . Plast Reconstr Surg 51:584-487, 1973. 6. Larsen J, Pless J: Replantation of sev e r e d e a r p a r t s . Plast Reconstr Surg 57:176-179, 1976.
kins, 1974, vol 2, pp 472-477. 9. B r e n t B: The acquired a u r i c u l a r deformity, a s y s t e m a t i c a p p r o a c h to its analysis and reconstruction. Plast Reconstr Surg 59:475-485, 1977. 10. C l e m o n s J E , C o n n e l l y MV: Reatt a c h m e n t of the totally amputated auricle. Arch Otolaryngol 97:269-272, 1973. 11. Potsic WP, N a u n t o n RF: Replantation of a n a m p u t a t e d pinna. Arch Otolaryngol 100:73-75, 1974. 12. Tse M i n g Tsai: E x p e r i m e n t a l and c l i n i c a l a p p l i c a t i o n of m i c r o v a s c u l a r surgery. Ann Surg 181:169-177, 1975. 13. Brent B: E a r reconstruction with an expansile framework of autogenous rib cartilage. Plast Reconstr Surg 53:619-628, 1974.
14. Eade GG: P r e v e n t i n g c a u l i f l o w e r ears. Northwest Medicine 63:99, 1964. 15. Kelleher JC, Sullivan JG, Baibak GJ, et al: The wrestler's ear. Plast Reconstr Surg 40:540-546, i967. 16. W a n a m a k e r HH: S u p p u r a t i v e perichondritis of the auricle. Trans Am Acad Ophthamol Otolaryngol 76:1289-1291, 1972. 17. Apfelberg DB, Waisbren BA, Masters FW, et al: T r e a t m e n t of chondritis in the burned ear by local instillation of antibiotics. Plast Reconstr Surg 53:179-183, 1974. 18. Stroud MH: A simple t r e a t m e n t for suppurative perichondritis. Laryngoscope 73:556-563, 1963. 19. M a r t i n R, Yonkers AJ, Yarington CT Jr: P e r i c h o n d r i t i s of t h e ear. Laryngoscope 86:664-673, 1976. 20. Dowling JA, Foley FD, Moncrief JA: Chrondritis in the burned ear. Plast Reconstr Surg 42:115-122, 1968. 21. Sessions DG, Stallings JO, Mills WJ Jr, et al: Frostbite of the ear. Laryngoscope 81:1223-1232, 1971.
Correction: In "Emergency Burn Management" by Gursel and Tintinalli (JACEP, May 1978) on page 210 the substance in plastic auto seat covers was mistakenly identified as "polyvinyl bromide." This should have read "polyvinyl chloride."
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