Complex Ear Laceration

Ear lacerations are commonly encountered from trauma, often related to sporting injuries or animal bites. ^{[1, 2, 3, 4]} Expedient wound care and closure ensures the best outcome.

Anatomy

The auricle, or external ear, develops from 6 tubercles that fuse to form the tragus, crus helices, helix, antihelix, antitragus, and lobule. The intrinsic and extrinsic musculature of the ear is of no significant importance, even when injured. See the image below.

The ear consists of exceptionally vascular skin closely applied to an avascular cartilaginous framework. Lacerations to the ear may involve the skin, the fibrocartilaginous or fatty tissues of the auricle, or any combination thereof. The superficial temporal artery and posterior auricular artery provide the blood supply to the ear. When repaired appropriately, lacerations to the ear generally heal well because of this generous dual blood supply. A single vascular pedicle, containing the upper auricular branch of the superficial temporal artery, can provide supply enough blood for the entire ear. ^[5] For more information about the relevant anatomy, see Ear Anatomy.

Goals of care

The primary goals of wound management in ear lacerations are the expedient coverage of exposed cartilage and the minimization of wound hematoma. ^[6] This topic covers partial ear lacerations; however, total avulsions of the ear also occur. ^[7] Reimplantation of total ear avulsions has been met with some success but should only be performed by an experienced professional, usually a plastic surgeon. (See Ear Reconstruction and Salvage Procedures). ^{[8, 9]}

Indications include wounds and lacerations to the pinna (see the image below).

Specific injuries of the ear require urgent referral to a plastic surgeon or ear specialist. Such injuries include the following:

• Large overlying skin avulsion (approximately 5 mm or greater)

• Severe crush injuries

• Complete or near-complete avulsions ^[7] or amputations ^{[9, 10]}

• Auricular hematomas

• Large cartilage defects (approximately 5 mm or greater)

• Wounds that require the removal of more than approximately 5 mm of tissue

• Significant involvement of the auditory canal

• Obvious tissue devitalization

Personal protective equipment is as follows:

• Gloves

• Face shield

• Gown

Anesthesia equipment is as follows:

• Lidocaine

• Syringe, 5-10 mL

• Needle, 27-30 gauge

• Needle, 18 gauge

Irrigation equipment is as follows:

• Saline or water

• Syringe or irrigation device

• Splash shield

• Basin

Suture material is as follows ^[11] :

• Absorbable sutures (eg, Dexon, Vicryl ), 5-0 or 6-0

• Nonabsorbable sutures (eg, Nylon, Ethilon ), 5-0 or 6-0

• Suture tray

• Standard suture kit

• Fine scissors

• Clamp

• Tissue forceps

• Needle driver

• Scalpel, No. 15 blade

Dressing material is as follows:

• Gauze, Xeroform

• Gauze, 4 x 4 in

• Gauze, fluffed

• Kling gauze, 3 in

• Elastic bandage wrap (eg, Ace), 3 in

The lateral decubitus position is preferred, with the injured ear facing up. The supine position with rotation of the head may also be used.

Preparation

All devitalized or contaminated tissue must be debrided. This step is especially important in bite wounds. However, be sure do debride as little tissue as necessary. As a result of generous vascularity, devitalization is relatively infrequent.

Clean the wound with copious irrigation. Recent studies have shown that wound infection rates did not differ in those irrigated with tap water or sterile saline. ^[12] Gauze may be placed in the external auditory canal for comfort prior to irrigation.

Maintain sterility while preparing and draping the wound.

Cartilage

The avascular cartilage derives its blood supply from the overlying skin. Therefore, exposed cartilage must be either debrided or covered by skin to survive. Auricular skin often stretches to allow coverage of most defects. If the remaining skin cannot cover the cartilage, the cartilage should be cut away from the wound margin to allow overlying skin closure.

In the case of a linear laceration to the pinna in which the skin does not approximate, a wedge excision technique may be used. See the image below.

To perform a wedge excision, a No. 15 scalpel is used to cut a full thickness triangle from the antihelix. See the image below.

A 1-mm overhang of the skin beyond the cartilage is recommended to allow skin eversion when closing. See the image below.

Up to 5 mm of cartilage can be removed without significant deformity.

If part of the pinna is avulsed, reattaching the amputated part is generally unwise, especially in cases of bite wounds. The margins of the defect should be trimmed, and the anterior and posterior skin should be approximated for primary healing.

In the case of extensive wounds, the cartilage may be approximated separately from the skin in a 2-layer technique. This method is only used in large lesions in order to reduce tension from the wound edges. Using 5-0 or 6-0 absorbable sutures, begin at the depth of the wound and continue outward. Cartilage is fragile; to avoid tearing, only include the perichondrium with each stitch. Only gentle approximation of the cartilage is necessary. To preserve normal landmarks, the first sutures placed should be in folds and ridges.

Smaller wounds may be approximated with a single layer of sutures through the skin and perichondrium as detailed below.

Skin

In most cases, the skin is closed with simple interrupted sutures. See the image below.

Loose approximation is used in cases of contaminated wounds.

Debride any devitalized skin as necessary.

Beginning from the depth of the wound outward, close the posterior skin first, followed by the anterior and lateral surfaces of the helix.

For this, 5-0 or 6-0 nonabsorbable sutures may be used.

If possible, evert the skin on the free rim to avoid later notching and to minimize cosmetic defects.

For optimal eversion and cosmesis (eg, to avoid rim notching), vertical mattress sutures may be required for lacerations that involve the rim of the ear.

Sutures should be placed through the skin and perichondrium, not through the cartilage itself.

The skin of the ear and the underlying cartilage adhere to each other so well that separate closure of the cartilage is usually unnecessary.

Dressing

After repair, pack Xeroform strips into the ear crevices.

Place a piece of gauze (4 x 4 in) behind the ear and place fluffed gauze over the ear.

Next, apply a pressure dressing to prevent hematoma formation. See the image below.

Wrap the head and injured ear with 3-in Kling followed by a 3-in elastic bandage wrap (eg, Ace). See the image below.

Leave the unaffected ear free of dressing.

Aftercare

Elevate the head as much as reasonably possible and avoid exertion or trauma for several days.

Reevaluate the wound in 24 hours for hematoma formation and possible drainage.

Sutures are removed in 4-5 days.

Case reports demonstrate the benefits of adjunctive medicinal leech therapy for assisted revascularization of large ear wounds. ^[13] Leech therapy is indicated where edema, dark-purple discoloration, or insufficient venous drainage are seen. ^[14]

In the case of trauma, inspect the tympanic membrane for hemotympanum or rupture and examine the external auditory canal for lacerations or evidence of a CNS leak.

For injuries with significant depth or blunt trauma, a thorough examination of the facial nerve is recommended. ^[15]

Evacuation of a hematoma may be necessary prior to closure.

Hemostasis must be achieved to prevent subsequent formation of a hematoma.

Tetanus vaccination should be updated, and rabies prophylaxis should be addressed when necessary.

Antibiotics may be prescribed for high-risk injuries, including the following:

• Highly contaminated wounds

• Bite injuries

• Wounds that show signs of inflammation

Complications may include the following:

• Erosive chondritis: The cartilage of the ear is avascular; with disruption or removal of the overlying skin, risk of erosive chondritis exists. The use of cartilage sutures increases the risk of chondritis, and they should be used only when necessary. Delayed chondritis may occur after burns and other injuries and may respond to antibiotic therapy.

• Auricular hematomas: Auricular hematomas occur when a shearing injury separates the auricular cartilage from the perichondrium, creating a space for blood to collect. Auricular hematomas can causes fibrotic changes and the progressive development of a chronic deformity known as cauliflower ear. ^[16] To prevent this scarring, the hematoma must be evacuated and the ear compressed for a week.

• Other complications: These may include keloid formation and infection.

Patient education and consent

Consent for repair should be obtained from the patient or family member. ^[17] The reason the procedure is being performed (suspected diagnosis), the risks of harm, potential benefits, and alternatives to the procedure and associated risks should be discussed. The provider should allow the patient the opportunity to ask any questions and address any concerns he or she may have and should make sure the patient has an understanding about the repair so he or she can make an informed decision.

The patient should be counseled about the risks of erosive chondri­tis, infection, damage to a blood vessel, strangulation of tissue, keloid formation, and auricular hematoma formation.

The patient should also be counseled that the procedure may not be successful and additional procedures may be necessary.

The provider should also discuss how these risks can be avoided or prevented (eg, ensuring that the patient remains as still as possible during the procedure and adequate analgesia).

Anesthesia

For small wounds to the ear without cartilaginous involvement, local infiltration may be used (see Infiltrative Administration of Local Anesthetic Agents and Ear Anesthesia for more information). However, local anesthesia is generally best avoided because infiltration into the relatively compact ear space causes pain and may distort landmarks that are crucial for cosmesis. Regional nerve blocks or field blocks are the preferred method of anesthesia in significant ear lacerations. ^[18]

The pain associated with local anesthesia injections can be diminished by using a smaller-gauge needle and administering the anesthetic slowly. ^[19] See the image below.

The use of epinephrine has classically been avoided when anesthetizing the ear for fear of ischemic necrosis in this acral area. However, there are no good data showing harm in its use, and some literature actually supports the use of epinephrine when anesthetizing the ear. One study showed that epinephrine, along with a local anesthetic, was used in over 10,000 surgical procedures on the ear and nose without any complications. ^[20] The use of epinephrine may be beneficial for laceration repair, as it decreases the amount of blood in the field, prolongs anesthesia, and reduces the time of the procedure.