Ear Lacerations, Part I

Traumatic ear lacerations can be intimidating. The multiple cartilaginous folds create
shadows and curves that give the ear an aesthetic that can be very hard to re-create with
even small injuries. Adding to this complexity, putting the pieces of an ear laceration
together is about more than just making it look pretty. The intricate folds and
contours assist in the amplification and acquisition of sound. A misshapen ear can affect
perception of hearing in subtle but noticeable ways for your patient.

Here’s an ear laceration that a colleague of mine saw in a resource-poor environment on

a medical mission several years ago. Because she did not have access to suture material,
the wound was cleaned and allowed to heal by secondary intention. The wound healed
as shown:

An ear laceration seen days later in a resource-poor environment. It was left

to heal by secondary intention resulting in unfortunate cosmetic deformity.

Convinced yet about the importance of treating these injuries carefully? Good. Now let’s
get in to it. In Part I, we’ll discuss ear anatomy, basic principles of repair, and I’ll share a
video of a complex repair. Part II discusses another interesting case and complications
that can arise if meticulous aftercare is not performed.

Ear Anatomy
The ear is a complicated structure, and being familiar with the terminology is important.
Especially since the most complex injuries will often require specialist involvement, it’s
important that an emergency provider can describe these wounds to a consultant.
 The external ear consists of a prominent outer rim, the helix, and a parallel, inner rim, the
anti-helix. The helix terminates in a crux immediately above the external auditory
meatus, and the antihelix terminates in to superior and anterior crura which create the
triangular fossa. The deep furrow which exists between the helix and anti-helix is known
as the scaphoid fossa. The cavity surrounded by the antihelix is the concha, which leads
directly to the acoustic meatus.

Ear Anatomy.
Key Concepts
Repair of an ear laceration involves a few basic principles:

 Cover the cartilage. The cartilage is avascular and derives its blood supply from the
skin overlying it. Thus, it is critical to ensure the cartilage is covered to ensure its
integrity. Fortunately, ear skin is pretty “stretchy” and can usually cover a defect pretty
easily.
 For very macerated wounds along the helix, it is acceptable and sometimes advisable
to perform a small triangular tissue wedge excision in order to create “surgical” wound
edges that can approximate more nicely. About 5 mm of cartilage can be removed from
this area without causing significant deformity.
If the skin overlying a laceration to the pinna does not approximate, consider wedge
excision.

The excision can be performed by cutting a triangle wedge from the ear, extending as
necessary in to the anti helix.
Attempt to allow at least a 1mm of skin “overhang” beyond the cartilage on either side to
allow approximation with skin eversion and complete cartilaginous coverage.

 For deep/extensive wounds, consider layered closure. First, close the cartilage with
simple interrupted deep dermal sutures, such as 5-0 or 6-0 vicryl. Try to approximate the
outer cartilage layer, the perichondrium, rather than piercing the mid portion of the
cartilage which is more fragile and prone to tear. Then, close the skin with simple
interrupted non-absorbable sutures such as 5-0 or 6-0 nylon or ethilon. It’s a good idea
to start by suturing along the less cosmetically noticeable posterior aspect of the ear in
order to make sure the wound comes together easily.

For less complicated closures, using a single layer of simple interrupted non-absorbable
sutures through-and-through the skin and perichondrium may suffice.

The video below details the repair of one of the worst lacerations of an ear I have ever
seen. The patient was seen by an emergency physician in my department. He conferred
with plastic surgery on this one (rightly so) but ultimately due to delays in consultation
and the patient’s preference, he performed the repair himself. Watch the video until the
end to see the remarkable outcome.
Ear Lacerations, Part II

This teenager was horsing around with buddies. He landed on the side of his face and
sliced his ear as shown. The laceration is small, but located in such a way that I knew
careful repair would be needed for the best outcome.
The following video illustrates the procedure used for repair.
Repair procedure, outlined:
 Make sure the ear is well anesthetized.
 A few deep dermal vicryl sutures through the cartilage turned this splayed open pinna
in to a more manageable, well-approximated, tension-free wound.
 The less aesthetically critical posterior ear was repaired first using simple interrupted
6-0 nylon sutures.
 After this, I completed the repair of the anterior portion of the pinna.
 Repair of a laceration like this could also be completed using a single layer of simple
interrupted 5-0 nylon sutures. By leaving out the absorbable vicryl layer, the foreign
body risk is minimized, but it requires more precision. One would sew through-and-
through the skin of the anterior and posterior ear and the intervening cartilage in one
throw.
 The key point is to cover any exposed cartilage, as the cartilage depends on the
overlying skin for vitalization.
Auricular Hematoma Prevention

Even with a meticulous repair, you still have to worry about the formation of an auricular
hematoma. Hematoma formation associated with an ear injury can lead to separation of
the cartilage from the overlying perichondrium, which can in turn lead to deforming neo-
cartilage formation. This is commonly known as “cauliflower ear.”

While it’s an even more pressing concern with blunt trauma without a laceration (when
there is no natural conduit for drainage), this is a risk anytime the cartilage of the ear is
disrupted.
As you see here, even minutes after the repair is complete, a small amount of hematoma
is forming.

Small auricular hematoma formation after repair of an ear laceration.

Traditional teaching is to pack the contours of the anti-helix with pieces of xeroform, and
then to suture these through-and-through the ear to hold them in place. Then, the area
behind the ear is buttressed with gauze, and the head is wrapped tight with coban or an
ace bandage.
 Small auricular hematoma formation after repair of an ear laceration.

Small auricular hematoma formation after repair of an ear laceration.

In my experience, this works well, but is fairly laborious. Also, patients often complain
about tension headaches provoked by the tight coban wrapping.
Here’s an alternate approach to prevention of auricular hematoma prevention that I
learned from Dr. Michelle Lin’s fantastic Academic Life in EM blog, but apparently
was first described in JAMA in 1933: consider creating an ear mold from plaster that can
be removed and inserted by the patient. This feels more comfortable, and has the
advantage of molding exactly to fit the patient’s ear. Bonus tip: rather than using coban,
which patients always complain is too tight and uncomfortable, now that you have an ear
mold you don’t really need to squeeze the patient’s head with a vice grip– you just need
something to hold that mold in place. A much looser bandage wrapped around the
head will suffice.

Antibiotics and Ear Lacerations

 There is no great evidence on this topic, as noted in this Best BETs review.
 Factors to consider (as with any laceration) include age of the wound, level of
contamination, & comorbidities.
 Generally, not standard of care to empirically give antibiotics to uncomplicated ear
lacerations, even with cartilage involvement.

That’s all for now on ear lacerations.