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Intralesional steroid injection for the management of otohematoma
Otolaryngology–Head and Neck Surgery (2008) 139, 115-119
ORIGINAL RESEARCH—GENERAL OTOLARYNGOLOGY
Intralesional steroid injection for the management of otohematoma Gi Jung Im, MD, Sung Won Chae, MD, Jun Choi, MD, Yang Soo Kim, MD, Woo Joo Kim, MD, and Hak Hyun Jung, MD, PhD, Seoul, Korea OBJECTIVES: To compare the therapeutic efficacies of aspiration plus intralesional steroid injection and aspiration plus pressure dressing for the management of otohematoma. STUDY DESIGN AND SETTING: Fifteen patients with otohematoma were treated by aspiration plus pressure dressing (the pressure dressing group) and 34 patients were treated with intralesional steroid injections followed by simple aspiration (the steroid injection group). RESULTS: Otohematoma resolved within four weeks in all 15 patients in the pressure dressing group, but eight of the 15 showed perichondrial thickening. The duration of treatment was shorter in the steroid injection group than in the pressure dressing group; 14 (41.2%) of the 34 recovered after the first injections and another 15 (44.1%) after the second, and the remaining 5 (14.7%) after the third without any complications. However, multiple steroid injections are needed due to a high early recurrence rate. CONCLUSION: Intralesional steroid injection is the treatment of choice for the management of otohematoma. The correction of causative use of a hard pillow, a helmet, and headphones is essential to prevent late recurrence. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
O
tohematoma usually occurs after direct trauma to the auricle or occurs spontaneously and results in fluid collection between the perichondrium and the cartilage of the pinna, which may result in cartilage thickening and “cauliflower ear” if it is not treated.1 Treatment regimens for otohematoma are variable and produce inconsistent results. Incision and drainage methods in combination with various types of compression have been described, and their results have been found to be satisfactory.2-7 However, invasive techniques may induce auricular thickening and present the risk of perichondritis. On the other hand, noninvasive methods or simple aspirations are convenient for patients and doctors, but these methods showed high a recurrence rate for the treatment of otohematoma.8 No definite treatment protocols have been introduced as yet.9-11 Thus, no single effective therapeutic regimen exists for the management of otohematoma. Recently, intralesional steroid injection into
the otohematoma site after aspiration has been used with satisfactory results.10-12 In the present study, the authors administered intralesional steroids to otohematoma sites after aspirating fluid to manage otohematoma and compared the therapeutic efficacy of this method with aspiration plus a pressure dressing.
MATERIALS AND METHODS Subjects This study is a retrospective study of all patients who were referred to the Korea University Anam Hospital from 1997 to 2003 for treatment of otohematoma. Patients were divided into two groups. The pressure dressing group (aspiration plus a pressure dressing) was composed of 15 patients (12 men and 3 women; mean age, 38.9 years; range, 19 to 61 years). These patients were first treated by aspiration and then by one of two methods of compression (cast immobilization in cases of conchal otohematoma or button compression in cases of scaphal otohematoma). The steroid injection group (aspiration plus intralesional steroid injection) was composed of 34 patients (27 men and 7 women; mean age, 44.8 years; range, 23 to 64 years) who received intralesional steroid (triamcinolone, 40 mg/mL) administered by tuberculin syringe. Informed consents were obtained from all of the patients. The local Institutional Review Board of Korea University Anam Hospital approved this study.
Pressure Dressing Group Patients in the pressure dressing group were diagnosed with otohematoma between 1997 and 1998. All hematomas were treated within the first 72 hours after onset. Auricles were aseptically cleaned with betadine and alcohol. Fluid was aspirated with an 18-gauge needle and syringe, the volume of fluid aspirated was measured; routine culture and sensitivity tests were also done. Patients were examined once a week after the first aspira-
Received September 19, 2007; revised December 21, 2007; accepted January 16, 2008.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2008.01.006
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Figure 1 (A) Fiberglass casting tape contoured to the configuration of the cavum concha was used as a cast splint for conchal otohematoma. (B) Scaphal otohematomas were treated by button compression. (C) In the steroid injection group, triamcinolone (40 mg/mL) was injected into otohematoma sites with a tuberculin syringe.
tion. If hematoma persisted after the first week, a second aspiration was performed at the end of the first week. In the same time, seven hematomas that developed in the conchal cartilage were additionally treated with a cast splint that was contoured to the configuration of the cavum concha after aspiration. Fiberglass casting tape was used as a cast splint for conchal otohematoma (Fig 1A). Eight hematomas in scaphal cartilage were additionally treated by button compression for a week. The sterile buttons were placed anteriorly and posteriorly and su-
tured in place (Fig 1B). In the pressure dressing group, oral antibiotics were used to prevent secondary infection.
Steroid Injection Group In the steroid injection group, patients were diagnosed with otohematoma between 1999 and 2003. These patients were treated by aspiration followed by an intralesional steroid injection. All hematomas were treated within the first 72 hours after onset. Otohematomas were aspirated with an 18-gauge needle and syringe. Aspirate volumes were mea-
Im et al
Intralesional steroid injection for the . . .
sured, and routine culture and sensitivity studies were done. The same volume of triamcinolone (40 mg/mL) as aspirate was injected into otohematoma sites with the same needle and a tuberculin syringe, but cavities larger than 1.5 mL were treated with only 1.5 mL of triamcinolone to avoid auricular deformity (Fig 1C). The patients were examined weekly after the initial treatment, and if hematoma persisted after the first week, a second aspiration and an intralesional triamcinolone injection were done at the end of the first week. At weekly outpatient follow-ups, repeated aspiration and triamcinolone injection were done until complete otohematoma resolution had been achieved. In the steroid injection group, no antibiotics or analgesics were administered and no pressure dressing was applied.
Follow-up Assessments and Statistical Analysis Patients were examined at weekly intervals after the procedures. After resolution of otohematoma, patients were examined at monthly intervals over at least one year. Differences between the two groups in terms of therapeutic efficacy and duration of otohematoma treatment were assessed with a log-rank test. P values of ⬍0.05 were considered statistically significant. Statistical analyses were done with SAS software (SAS Institute Inc, Cary, NC).
RESULTS Pressure Dressing Group The average volume of initial aspirated fluid was 1.12 ⫾ 0.62 mL, but cultures of aspirate yielded no micro-organisms. Otohematoma recurred in all patients during the first week after initial simple aspiration. The average volume of second aspirations was 0.98 ⫾ 0.53 mL. Seven conchal otohematomas were treated by aspiration and cast immobilization in the first week, but five of seven conchal otohematomas recurred during the second week. However, after aspiration and repeat cast immobilization in the second week, no patient had persistent otohematoma in the third week. Mild perichondrial thickening was observed in three of these seven patients, but none showed evidence of secondary infection. Of the eight otohematomas in scaphal cartilage that were treated by incision and drainage with button compression, only one patient experienced recurrence within two weeks. This recurred patient developed a Pseudomonas aeruginosa secondary infection and was treated with intravenous antibiotics; the infection subsided after two weeks but the patient’s auricular contour was deformed and perichondrial thickening was evident. Five of eight scaphal otohematomas had mild perichondrial thickening. Overall, 9 (60%) of 15 recovered by the second week; 5 (33.3%) of 15 recovered on third week; 1 (6.7%) of 15 had pseudomonas infection until the fourth week. No recurrence
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Figure 2 Kaplan-Meier curves for the results of otohematoma treatment. Median duration of otohematoma treatment was shorter for the steroid injection group (aspiration with an intralesional steroid injection) than for the pressure dressing group (aspiration with a pressure dressing). (P ⫽ 0.0037, log-rank test).
of the otohematoma on the same site was observed over one year of follow-up after curative treatment (Fig 2).
Steroid Injection Group Average fluid volume at first aspiration was 1.06 ⫾ 0.68 mL, and no organisms were found on cultures of aspirated fluid. Fourteen (41.2%) of the 34 cases had no fluid collection during the first seven days after the first injection, but the remaining 20 showed recurrent fluid collection. These 20 patients were treated with a second aspiration and intralesional steroid injection at the end of the first week, and the average volume of aspirate obtained was 0.79 ⫾ 0.64 mL. Fifteen (44.1%) of the 34 recovered after the second injections. Five (14.7%) of the 34 who had a recurrence during the first week also had fluid collection during the second week, and the average volume of the third aspirations was 0.46 ⫾ 0.25 mL. After third injections, no residual fluids were observed in any patient at the end of the third week (Fig 2), and there were no complications that involved a secondary infection, auricular deformity, and perichondrial thickening. However, late recurrences of otohematoma at same sites over a period of three months were observed in 5 (14.7%) cases. All late recurrences were cured by correcting causative habits and by additional intralesional steroid injections. No recurrences were observed over one year of follow-up after curative treatment.
STATISTICAL ANALYSIS Differences between the therapeutic efficacies and durations of the two treatments were assessed with the log-rank test (P ⫽ 0.0037). Overall, the median duration of otohematoma treatment was shorter for the steroid injection group than for the pressure dressing group, as shown by Kaplan-Meier analysis (Fig 2). Eight (53.3%) of the 15 patients had mild perichondrial thickening in the pressure dressing group, but
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no late recurrences occurred. On the contrary, no specific complications were observed in any patient in the steroid injection group, but otohematoma recurred in 5 (14.7%) patients over a period of three months after treatment. All patients with a recurrence recovered after an intralesional steroid injection.
DISCUSSION The management of otohematoma with intralesional steroid injection is straightforward, convenient, cost-effective, and safe. Kunachat and Prakunhungsit11 first described this form of treatment; they used diluted triamcinolone (10 mg/mL) because of a fear of auricular deformity and obtained excellent results without any deformity and recurrence. Miyamoto et al10 also used diluted triamcinolone (13.3 mg/mL) and obtained satisfactory results without any deformity, but three of eight cases recurred. Even though a permanent deformity of the ear was reported after steroid injection,9 Miyamoto et al found that the recurrence rate of large cyst might decrease without auricular deformity development after undiluted steroid usage.10 A multicenter study in Korea was already performed, and the result was excellent. One hundred otohematoma patients were treated with triamcinolone injection after aspiration of hematoma or seroma; 96 (96%) patients were healed without any complications. Multiple steroid injections were needed because of early recurrence, and 81 (81%) patients recovered within three injections.12 Although this study was not compared with a control group such as the pressure dressing or splinting method, this article suggests that steroid injection can be an effective alternative treatment for otohematoma. In the present study, all cases of otohematoma were successfully treated by steroid injection without complications, and the duration of otohematoma treatment was shorter than that of the pressure dressing group. However, the intralesional steroid injection had the major disadvantage of recurrence (both early and late). In the present study, 15 (44.1%) of 34 otohematoma cases received a steroid injection twice and 5 (14.7%) cases were administered steroid three times with an interval of one week. In addition to these early recurrences, 5 (14.7%) cases experienced late recurrences after initial cure. The correction of causative habits is essential to prevent late recurrences. In particular, patients should be careful not to use hard pillows, a helmet, or headphones. In the present study, we used undiluted triamcinolone (40 mg/mL) at a volume of 0.5 to 1.5 mL. Small cavities of less than 1.5 mL were administered a steroid volume that matched the cavity size, but larger cavities were administered 1.5 mL of steroid to avoid auricular deformity. In the present study, no complications including auricular deformities were observed, but there were higher early recurrence rates. These early recurrences may be associated with cavity size and time interval of steroid injection. Recurrence rate
has been suggested to increase in proportion to cyst volume.10 To reduce early recurrences, the time interval of steroid injection should be shorter than a week because the half-life of triamcinolone is about 12 to 36 hours. On the contrary, an article13 suggested that triamcinolone injected into a vitreous cavity has median residence times of 113 days. However, a time interval of steroid injection less than a week may be needed to manage cavities larger than 1.5 mL. Before use of an intralesional steroid injection, the authors used aspiration and/or promoted drainage with a pressure dressing. However, the fixation of a pressure dressing for otohematoma is uncomfortable and inconvenient. For such reasons, many modifications of pressure dressings have been suggested. Escat1 investigated aspiration and a plaster mold, whereas Kelleher et al2 incised, drained, and used cotton bolsters. Stuteville et al3 described a molded dressing reinforced with flexible collodion, and Davis4 used a postauricular incision, cartilage resection, and cotton bolster dressings. Gernon5 used white wool and webril, and Choung et al6 used dental impression material. However, these drainage methods still introduce the risk of infection and perichondritis. In the present study, we experienced a case of perichondritis (6.7%) with ear deformity in the pressure dressing group. Even without secondary infection, compression methods without a drainage procedure may induce perichondrial thickening because of long-standing inflammatory change. In the present study, 8 (53.3%) of 15 patients in the pressure dressing group experienced mild perichondrial thickening. Potential mechanisms have been described for intralesional steroid injection therapy. They are most likely to alter cellular functions by regulating cytokine expression such as platelet-derived growth factors (PDGFs) and interleukin-6 (IL-6).14 Glucocorticoids inhibit cytokine expression indirectly through promotion of a T helper cell type 2 (Th2) cytokine-secreting profile, thereby resulting in preferential blockade of proinflammatory monokine and T helper cell type 1 (Th1) cytokine expression.15,16 Hashimoto et al17 described the angiostatic effects of corticosteroid on the rabbit ear, and Zweifach et al18 suggested that corticosteroids increase vascular sensitivity to circulating vasoconstrictive agents. Wyman et al19 found that cortisone acetate produces arterial constriction, precapillary sphincter narrowing, and the coating of endothelial walls by leukocytes. These findings can be all possible mechanisms for the treatment of otohematoma, pseudocyst, hemangioma, and keloid.7 The intralesional steroid injection should not be used in cases with an infected ear, a huge otohematoma, a frequently traumatized wrestler’s ear, severe fibrous-organized otohematoma that is difficult to aspirate, or in cases that have failed to respond to steroid injections on three or more occasions. In these situations, otohematoma may be located within the cartilage itself and may be predisposed to recurrence, and therefore, in such cases a traditional surgical
Im et al
Intralesional steroid injection for the . . .
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approach should be recommended.20 Otohematoma must be differentiated from pseudocyst, auricular effusion, and hematoma. During the early period, most otohematomas, except cases caused by severe trauma, contain only serous fluids and no real hematoma. In cases of hematoma (fresh blood), steroid injection is ineffective (data not shown). In summary, we propose a protocol that includes amounts and concentration of injected steroid, and time interval of steroid injection for the management of otohematoma. Prompt aspiration with intralesional steroid injection is less painful, less complicated, and more convenient for patients and doctors. The authors recommend an intralesional steroid injection as a first-line treatment for simple otohematoma.
2. Kelleher JC, Sullivan JG, Baibak GJ, et al. The wrestler’s ear. Plast Reconstr Surg 1967;40:540 – 6. 3. Stuteville OH, Janda CA, Pandya NJ. Treating the injured ear to prevent a cauliflower ear. Plast Reconst Surg 1969;44:310 –2. 4. Davis PK. An operation for hemetoma auris. Br J Plast Surg 1971;24: 277–9. 5. Gernon WH. The care and management of acute hematoma of the external ear. Laryngoscope 1980;90:881–5. 6. Choung YH, Park K, Choung PH, et al. Simple compressive method for treatment of auricular haematoma using dental silicone material. J Laryngol Otol 2005;119(1):27–33. 7. Edgerton MT. The treatment of hemangioma: with special reference to the role of steroid therapy. Ann Surg 1976;183:517–30. 8. Jones SE, Mahendran S. Interventions for acute auricular haematoma. Cochrane Database Syst Rev 2004;(2):CD004166. 9. Miyamoto H, Oida M, Onuma S, et al. Steroid injection therapy for pseudocyst of the auricle. Acta Derm Venereol 1994;74:140 –2. 10. Miyamoto H, Okajima M, Takahashi I. Lactate dehydrogenase isozymes in and intralesional steroid injection therapy for pseudocyst of the auricle. Int J Dermatol 2001;40(6):380 – 4. 11. Kunachak S, Prakunhungsit S. A simple treatment for endochondral pseudocyst of the auricle. J Otolaryngol 1992;21(2):139 – 41. 12. Park JY, Shin SH, Kim KH, et al. Steroid treatment of otohematoma. Korean J Otolaryngol 2000;43:155– 8. 13. Kosobucki BR, Freeman WR, Cheng L. Photographic estimation of the duration of high dose intravitreal triamcinolone in the vitrectomised eye. Br J Ophthalmol 2006;90(6):705– 8. 14. Hasan Q, Tan ST, Gush J, et al. Steroid therapy of a proliferating hemangioma: histochemical and molecular changes. Pediatrics 2000; 105:117–20. 15. Brattsand R, Linden M. Cytokine modulation by glucocorticoids: mechanisms and actions in cellular studies. Aliment Pharmacol Ther 1996;10 Suppl 2:81–90;discussion 91– 82. 16. Almawi WY, Melemedjian OK, Rieder MJ. An alternate mechanism of glucocorticoid anti-proliferative effect: promotion of a Th2 cytokine-secreting profile. Clin Transplant 1999;13:365–74. 17. Hashimoto I, Nakanishi H, Shono Y, et al. Angiostatic effects of corticosteroid on wound healing of the rabbit ear. J Med Invest 2002; 49:61– 6. 18. Zweifach BW, Shorr E, Black MM. The influence of the adrenal cortex on behavior of terminal vascular bed. Ann N Y Acad Sci 1953;56: 626 –33. 19. Wyman LC, Fulton GP, Shulman MH. Direct observations on the circulation in the hamster cheek pouch in adrenal insufficiency and experimental hypercorticalism. Ann N Y Acad Sci 1953;56:643– 58. 20. Ghanem T, Rasamny JK, Park SS. Rethinking auricular trauma. Laryngoscope 2005;115(7):1251–5.
AUTHOR INFORMATION From the Department of Otolaryngology–Head and Neck Surgery (Gi Jung Im, Sung Won Chae, Jun Choi, Yang Soo Kim, Woo Joo Kim, and Hak Hyun Jung), and Department of Biomedical Sciences (Hak Hyun Jung), College of Medicine, Korea University, Seoul, South Korea. Corresponding author: Hak Hyun Jung, MD, PhD, Department of Otolaryngology–Head and Neck Surgery and Department of Biomedical Sciences, College of Medicine, Korea University, Anam-Dong 5-Ga 126-1, Sungbuk-Gu, Seoul, South Korea, 136-705. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS Gi Jung Im, writer; Sung Won Chae, Jun Choi, Yang Soo Kim, Woo Joo Kim, data collection; and Hak Hyun Jung, study design.
FINANCIAL DISCLOSURE This study was supported by the Brain Korea Project 21 and the Institutes of Communication Disorder at Korea University.
REFERENCES 1. Escat M. Simplified treatment of hematoma of the ear. Otorhinolaryngol Int 1946;30:181–2.
ORIGINAL RESEARCH—GENERAL OTOLARYNGOLOGY
Intralesional steroid injection for the management of otohematoma Gi Jung Im, MD, Sung Won Chae, MD, Jun Choi, MD, Yang Soo Kim, MD, Woo Joo Kim, MD, and Hak Hyun Jung, MD, PhD, Seoul, Korea OBJECTIVES: To compare the therapeutic efficacies of aspiration plus intralesional steroid injection and aspiration plus pressure dressing for the management of otohematoma. STUDY DESIGN AND SETTING: Fifteen patients with otohematoma were treated by aspiration plus pressure dressing (the pressure dressing group) and 34 patients were treated with intralesional steroid injections followed by simple aspiration (the steroid injection group). RESULTS: Otohematoma resolved within four weeks in all 15 patients in the pressure dressing group, but eight of the 15 showed perichondrial thickening. The duration of treatment was shorter in the steroid injection group than in the pressure dressing group; 14 (41.2%) of the 34 recovered after the first injections and another 15 (44.1%) after the second, and the remaining 5 (14.7%) after the third without any complications. However, multiple steroid injections are needed due to a high early recurrence rate. CONCLUSION: Intralesional steroid injection is the treatment of choice for the management of otohematoma. The correction of causative use of a hard pillow, a helmet, and headphones is essential to prevent late recurrence. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
O
tohematoma usually occurs after direct trauma to the auricle or occurs spontaneously and results in fluid collection between the perichondrium and the cartilage of the pinna, which may result in cartilage thickening and “cauliflower ear” if it is not treated.1 Treatment regimens for otohematoma are variable and produce inconsistent results. Incision and drainage methods in combination with various types of compression have been described, and their results have been found to be satisfactory.2-7 However, invasive techniques may induce auricular thickening and present the risk of perichondritis. On the other hand, noninvasive methods or simple aspirations are convenient for patients and doctors, but these methods showed high a recurrence rate for the treatment of otohematoma.8 No definite treatment protocols have been introduced as yet.9-11 Thus, no single effective therapeutic regimen exists for the management of otohematoma. Recently, intralesional steroid injection into
the otohematoma site after aspiration has been used with satisfactory results.10-12 In the present study, the authors administered intralesional steroids to otohematoma sites after aspirating fluid to manage otohematoma and compared the therapeutic efficacy of this method with aspiration plus a pressure dressing.
MATERIALS AND METHODS Subjects This study is a retrospective study of all patients who were referred to the Korea University Anam Hospital from 1997 to 2003 for treatment of otohematoma. Patients were divided into two groups. The pressure dressing group (aspiration plus a pressure dressing) was composed of 15 patients (12 men and 3 women; mean age, 38.9 years; range, 19 to 61 years). These patients were first treated by aspiration and then by one of two methods of compression (cast immobilization in cases of conchal otohematoma or button compression in cases of scaphal otohematoma). The steroid injection group (aspiration plus intralesional steroid injection) was composed of 34 patients (27 men and 7 women; mean age, 44.8 years; range, 23 to 64 years) who received intralesional steroid (triamcinolone, 40 mg/mL) administered by tuberculin syringe. Informed consents were obtained from all of the patients. The local Institutional Review Board of Korea University Anam Hospital approved this study.
Pressure Dressing Group Patients in the pressure dressing group were diagnosed with otohematoma between 1997 and 1998. All hematomas were treated within the first 72 hours after onset. Auricles were aseptically cleaned with betadine and alcohol. Fluid was aspirated with an 18-gauge needle and syringe, the volume of fluid aspirated was measured; routine culture and sensitivity tests were also done. Patients were examined once a week after the first aspira-
Received September 19, 2007; revised December 21, 2007; accepted January 16, 2008.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2008.01.006
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Figure 1 (A) Fiberglass casting tape contoured to the configuration of the cavum concha was used as a cast splint for conchal otohematoma. (B) Scaphal otohematomas were treated by button compression. (C) In the steroid injection group, triamcinolone (40 mg/mL) was injected into otohematoma sites with a tuberculin syringe.
tion. If hematoma persisted after the first week, a second aspiration was performed at the end of the first week. In the same time, seven hematomas that developed in the conchal cartilage were additionally treated with a cast splint that was contoured to the configuration of the cavum concha after aspiration. Fiberglass casting tape was used as a cast splint for conchal otohematoma (Fig 1A). Eight hematomas in scaphal cartilage were additionally treated by button compression for a week. The sterile buttons were placed anteriorly and posteriorly and su-
tured in place (Fig 1B). In the pressure dressing group, oral antibiotics were used to prevent secondary infection.
Steroid Injection Group In the steroid injection group, patients were diagnosed with otohematoma between 1999 and 2003. These patients were treated by aspiration followed by an intralesional steroid injection. All hematomas were treated within the first 72 hours after onset. Otohematomas were aspirated with an 18-gauge needle and syringe. Aspirate volumes were mea-
Im et al
Intralesional steroid injection for the . . .
sured, and routine culture and sensitivity studies were done. The same volume of triamcinolone (40 mg/mL) as aspirate was injected into otohematoma sites with the same needle and a tuberculin syringe, but cavities larger than 1.5 mL were treated with only 1.5 mL of triamcinolone to avoid auricular deformity (Fig 1C). The patients were examined weekly after the initial treatment, and if hematoma persisted after the first week, a second aspiration and an intralesional triamcinolone injection were done at the end of the first week. At weekly outpatient follow-ups, repeated aspiration and triamcinolone injection were done until complete otohematoma resolution had been achieved. In the steroid injection group, no antibiotics or analgesics were administered and no pressure dressing was applied.
Follow-up Assessments and Statistical Analysis Patients were examined at weekly intervals after the procedures. After resolution of otohematoma, patients were examined at monthly intervals over at least one year. Differences between the two groups in terms of therapeutic efficacy and duration of otohematoma treatment were assessed with a log-rank test. P values of ⬍0.05 were considered statistically significant. Statistical analyses were done with SAS software (SAS Institute Inc, Cary, NC).
RESULTS Pressure Dressing Group The average volume of initial aspirated fluid was 1.12 ⫾ 0.62 mL, but cultures of aspirate yielded no micro-organisms. Otohematoma recurred in all patients during the first week after initial simple aspiration. The average volume of second aspirations was 0.98 ⫾ 0.53 mL. Seven conchal otohematomas were treated by aspiration and cast immobilization in the first week, but five of seven conchal otohematomas recurred during the second week. However, after aspiration and repeat cast immobilization in the second week, no patient had persistent otohematoma in the third week. Mild perichondrial thickening was observed in three of these seven patients, but none showed evidence of secondary infection. Of the eight otohematomas in scaphal cartilage that were treated by incision and drainage with button compression, only one patient experienced recurrence within two weeks. This recurred patient developed a Pseudomonas aeruginosa secondary infection and was treated with intravenous antibiotics; the infection subsided after two weeks but the patient’s auricular contour was deformed and perichondrial thickening was evident. Five of eight scaphal otohematomas had mild perichondrial thickening. Overall, 9 (60%) of 15 recovered by the second week; 5 (33.3%) of 15 recovered on third week; 1 (6.7%) of 15 had pseudomonas infection until the fourth week. No recurrence
117
Figure 2 Kaplan-Meier curves for the results of otohematoma treatment. Median duration of otohematoma treatment was shorter for the steroid injection group (aspiration with an intralesional steroid injection) than for the pressure dressing group (aspiration with a pressure dressing). (P ⫽ 0.0037, log-rank test).
of the otohematoma on the same site was observed over one year of follow-up after curative treatment (Fig 2).
Steroid Injection Group Average fluid volume at first aspiration was 1.06 ⫾ 0.68 mL, and no organisms were found on cultures of aspirated fluid. Fourteen (41.2%) of the 34 cases had no fluid collection during the first seven days after the first injection, but the remaining 20 showed recurrent fluid collection. These 20 patients were treated with a second aspiration and intralesional steroid injection at the end of the first week, and the average volume of aspirate obtained was 0.79 ⫾ 0.64 mL. Fifteen (44.1%) of the 34 recovered after the second injections. Five (14.7%) of the 34 who had a recurrence during the first week also had fluid collection during the second week, and the average volume of the third aspirations was 0.46 ⫾ 0.25 mL. After third injections, no residual fluids were observed in any patient at the end of the third week (Fig 2), and there were no complications that involved a secondary infection, auricular deformity, and perichondrial thickening. However, late recurrences of otohematoma at same sites over a period of three months were observed in 5 (14.7%) cases. All late recurrences were cured by correcting causative habits and by additional intralesional steroid injections. No recurrences were observed over one year of follow-up after curative treatment.
STATISTICAL ANALYSIS Differences between the therapeutic efficacies and durations of the two treatments were assessed with the log-rank test (P ⫽ 0.0037). Overall, the median duration of otohematoma treatment was shorter for the steroid injection group than for the pressure dressing group, as shown by Kaplan-Meier analysis (Fig 2). Eight (53.3%) of the 15 patients had mild perichondrial thickening in the pressure dressing group, but
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no late recurrences occurred. On the contrary, no specific complications were observed in any patient in the steroid injection group, but otohematoma recurred in 5 (14.7%) patients over a period of three months after treatment. All patients with a recurrence recovered after an intralesional steroid injection.
DISCUSSION The management of otohematoma with intralesional steroid injection is straightforward, convenient, cost-effective, and safe. Kunachat and Prakunhungsit11 first described this form of treatment; they used diluted triamcinolone (10 mg/mL) because of a fear of auricular deformity and obtained excellent results without any deformity and recurrence. Miyamoto et al10 also used diluted triamcinolone (13.3 mg/mL) and obtained satisfactory results without any deformity, but three of eight cases recurred. Even though a permanent deformity of the ear was reported after steroid injection,9 Miyamoto et al found that the recurrence rate of large cyst might decrease without auricular deformity development after undiluted steroid usage.10 A multicenter study in Korea was already performed, and the result was excellent. One hundred otohematoma patients were treated with triamcinolone injection after aspiration of hematoma or seroma; 96 (96%) patients were healed without any complications. Multiple steroid injections were needed because of early recurrence, and 81 (81%) patients recovered within three injections.12 Although this study was not compared with a control group such as the pressure dressing or splinting method, this article suggests that steroid injection can be an effective alternative treatment for otohematoma. In the present study, all cases of otohematoma were successfully treated by steroid injection without complications, and the duration of otohematoma treatment was shorter than that of the pressure dressing group. However, the intralesional steroid injection had the major disadvantage of recurrence (both early and late). In the present study, 15 (44.1%) of 34 otohematoma cases received a steroid injection twice and 5 (14.7%) cases were administered steroid three times with an interval of one week. In addition to these early recurrences, 5 (14.7%) cases experienced late recurrences after initial cure. The correction of causative habits is essential to prevent late recurrences. In particular, patients should be careful not to use hard pillows, a helmet, or headphones. In the present study, we used undiluted triamcinolone (40 mg/mL) at a volume of 0.5 to 1.5 mL. Small cavities of less than 1.5 mL were administered a steroid volume that matched the cavity size, but larger cavities were administered 1.5 mL of steroid to avoid auricular deformity. In the present study, no complications including auricular deformities were observed, but there were higher early recurrence rates. These early recurrences may be associated with cavity size and time interval of steroid injection. Recurrence rate
has been suggested to increase in proportion to cyst volume.10 To reduce early recurrences, the time interval of steroid injection should be shorter than a week because the half-life of triamcinolone is about 12 to 36 hours. On the contrary, an article13 suggested that triamcinolone injected into a vitreous cavity has median residence times of 113 days. However, a time interval of steroid injection less than a week may be needed to manage cavities larger than 1.5 mL. Before use of an intralesional steroid injection, the authors used aspiration and/or promoted drainage with a pressure dressing. However, the fixation of a pressure dressing for otohematoma is uncomfortable and inconvenient. For such reasons, many modifications of pressure dressings have been suggested. Escat1 investigated aspiration and a plaster mold, whereas Kelleher et al2 incised, drained, and used cotton bolsters. Stuteville et al3 described a molded dressing reinforced with flexible collodion, and Davis4 used a postauricular incision, cartilage resection, and cotton bolster dressings. Gernon5 used white wool and webril, and Choung et al6 used dental impression material. However, these drainage methods still introduce the risk of infection and perichondritis. In the present study, we experienced a case of perichondritis (6.7%) with ear deformity in the pressure dressing group. Even without secondary infection, compression methods without a drainage procedure may induce perichondrial thickening because of long-standing inflammatory change. In the present study, 8 (53.3%) of 15 patients in the pressure dressing group experienced mild perichondrial thickening. Potential mechanisms have been described for intralesional steroid injection therapy. They are most likely to alter cellular functions by regulating cytokine expression such as platelet-derived growth factors (PDGFs) and interleukin-6 (IL-6).14 Glucocorticoids inhibit cytokine expression indirectly through promotion of a T helper cell type 2 (Th2) cytokine-secreting profile, thereby resulting in preferential blockade of proinflammatory monokine and T helper cell type 1 (Th1) cytokine expression.15,16 Hashimoto et al17 described the angiostatic effects of corticosteroid on the rabbit ear, and Zweifach et al18 suggested that corticosteroids increase vascular sensitivity to circulating vasoconstrictive agents. Wyman et al19 found that cortisone acetate produces arterial constriction, precapillary sphincter narrowing, and the coating of endothelial walls by leukocytes. These findings can be all possible mechanisms for the treatment of otohematoma, pseudocyst, hemangioma, and keloid.7 The intralesional steroid injection should not be used in cases with an infected ear, a huge otohematoma, a frequently traumatized wrestler’s ear, severe fibrous-organized otohematoma that is difficult to aspirate, or in cases that have failed to respond to steroid injections on three or more occasions. In these situations, otohematoma may be located within the cartilage itself and may be predisposed to recurrence, and therefore, in such cases a traditional surgical
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approach should be recommended.20 Otohematoma must be differentiated from pseudocyst, auricular effusion, and hematoma. During the early period, most otohematomas, except cases caused by severe trauma, contain only serous fluids and no real hematoma. In cases of hematoma (fresh blood), steroid injection is ineffective (data not shown). In summary, we propose a protocol that includes amounts and concentration of injected steroid, and time interval of steroid injection for the management of otohematoma. Prompt aspiration with intralesional steroid injection is less painful, less complicated, and more convenient for patients and doctors. The authors recommend an intralesional steroid injection as a first-line treatment for simple otohematoma.
2. Kelleher JC, Sullivan JG, Baibak GJ, et al. The wrestler’s ear. Plast Reconstr Surg 1967;40:540 – 6. 3. Stuteville OH, Janda CA, Pandya NJ. Treating the injured ear to prevent a cauliflower ear. Plast Reconst Surg 1969;44:310 –2. 4. Davis PK. An operation for hemetoma auris. Br J Plast Surg 1971;24: 277–9. 5. Gernon WH. The care and management of acute hematoma of the external ear. Laryngoscope 1980;90:881–5. 6. Choung YH, Park K, Choung PH, et al. Simple compressive method for treatment of auricular haematoma using dental silicone material. J Laryngol Otol 2005;119(1):27–33. 7. Edgerton MT. The treatment of hemangioma: with special reference to the role of steroid therapy. Ann Surg 1976;183:517–30. 8. Jones SE, Mahendran S. Interventions for acute auricular haematoma. Cochrane Database Syst Rev 2004;(2):CD004166. 9. Miyamoto H, Oida M, Onuma S, et al. Steroid injection therapy for pseudocyst of the auricle. Acta Derm Venereol 1994;74:140 –2. 10. Miyamoto H, Okajima M, Takahashi I. Lactate dehydrogenase isozymes in and intralesional steroid injection therapy for pseudocyst of the auricle. Int J Dermatol 2001;40(6):380 – 4. 11. Kunachak S, Prakunhungsit S. A simple treatment for endochondral pseudocyst of the auricle. J Otolaryngol 1992;21(2):139 – 41. 12. Park JY, Shin SH, Kim KH, et al. Steroid treatment of otohematoma. Korean J Otolaryngol 2000;43:155– 8. 13. Kosobucki BR, Freeman WR, Cheng L. Photographic estimation of the duration of high dose intravitreal triamcinolone in the vitrectomised eye. Br J Ophthalmol 2006;90(6):705– 8. 14. Hasan Q, Tan ST, Gush J, et al. Steroid therapy of a proliferating hemangioma: histochemical and molecular changes. Pediatrics 2000; 105:117–20. 15. Brattsand R, Linden M. Cytokine modulation by glucocorticoids: mechanisms and actions in cellular studies. Aliment Pharmacol Ther 1996;10 Suppl 2:81–90;discussion 91– 82. 16. Almawi WY, Melemedjian OK, Rieder MJ. An alternate mechanism of glucocorticoid anti-proliferative effect: promotion of a Th2 cytokine-secreting profile. Clin Transplant 1999;13:365–74. 17. Hashimoto I, Nakanishi H, Shono Y, et al. Angiostatic effects of corticosteroid on wound healing of the rabbit ear. J Med Invest 2002; 49:61– 6. 18. Zweifach BW, Shorr E, Black MM. The influence of the adrenal cortex on behavior of terminal vascular bed. Ann N Y Acad Sci 1953;56: 626 –33. 19. Wyman LC, Fulton GP, Shulman MH. Direct observations on the circulation in the hamster cheek pouch in adrenal insufficiency and experimental hypercorticalism. Ann N Y Acad Sci 1953;56:643– 58. 20. Ghanem T, Rasamny JK, Park SS. Rethinking auricular trauma. Laryngoscope 2005;115(7):1251–5.
AUTHOR INFORMATION From the Department of Otolaryngology–Head and Neck Surgery (Gi Jung Im, Sung Won Chae, Jun Choi, Yang Soo Kim, Woo Joo Kim, and Hak Hyun Jung), and Department of Biomedical Sciences (Hak Hyun Jung), College of Medicine, Korea University, Seoul, South Korea. Corresponding author: Hak Hyun Jung, MD, PhD, Department of Otolaryngology–Head and Neck Surgery and Department of Biomedical Sciences, College of Medicine, Korea University, Anam-Dong 5-Ga 126-1, Sungbuk-Gu, Seoul, South Korea, 136-705. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS Gi Jung Im, writer; Sung Won Chae, Jun Choi, Yang Soo Kim, Woo Joo Kim, data collection; and Hak Hyun Jung, study design.
FINANCIAL DISCLOSURE This study was supported by the Brain Korea Project 21 and the Institutes of Communication Disorder at Korea University.
REFERENCES 1. Escat M. Simplified treatment of hematoma of the ear. Otorhinolaryngol Int 1946;30:181–2.