Abstract
Background
This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2004 and previously updated in 2005 and 2008.
Acute haematoma of the pinna is a condition where a collection of blood forms beneath the perichondrial layer of the pinna. It is usually caused by blunt trauma and if untreated will ultimately result in a deformity commonly known as 'cauliflower ear' or 'wrestler's ear'. Various treatments are employed to relieve the haematoma but no clear consensus exists on the best way to do so in order to produce the best cosmetic result with the least permanent deformity.
Objectives
To assess the effectiveness of treatment options in acute auricular haematoma.
Search methods
We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 13 January 2011.
Selection criteria
Randomised controlled trials, case controlled trials and cohort studies including children and adults undergoing any intervention for acute auricular haematoma.
Data collection and analysis
No studies are included in the review. We identified 59 references from the original searches; we retrieved and assessed 48 for eligibility. None met the inclusion criteria. No studies which met the inclusion criteria were identified when the search was updated in November 2005 (from 16 references), November 2008 (6) or January 2011 (10).
Main results
Due to the lack of data from trials fulfilling selection criteria no results could be presented.
Authors' conclusions
There is no clearly defined best treatment for acute auricular haematoma. There are no good quality data to determine either the optimal management strategy or even whether post‐drainage intervention (such as splinting or bandaging) is necessary. Further research is required before any specific treatment may be recommended.
Plain language summary
Interventions for acute auricular haematoma
Acute auricular haematoma is a condition where a collection of blood forms in the pinna (external ear), often following blunt trauma. If untreated it will result in the 'cauliflower ear' or 'wrestler's ear' deformity.
We searched for trials in adults or children who had sustained a haematoma. Treatments could be simple aspiration of the haematoma, incision and drainage and any post‐drainage procedures (such as splinting or bandaging) to prevent re‐accumulation of the haematoma. We found no trials of good quality to demonstrate that any one technique to remove the haematoma and prevent its recurrence gives the best cosmetic outcome. The literature, however, generally suggests that treatment is better than leaving a haematoma untreated. Well‐designed studies are required.
Background
This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2004 and previously updated in 2005 and 2008.
The outer ear (pinna) comprises cartilage covered by perichondrium, subcutaneous tissue and skin. Acute haematoma of the pinna is a collection of blood beneath the perichondrial layer of the pinna (Ohlsen 1975). It is generally caused by blunt trauma, e.g. a blow to the ear in sports such as rugby or wrestling (Wright 1997). The blood vessels within the perichondrium on the anterior aspect of the pinna are disrupted and bleeding occurs within the potential space beneath. Separation of the perichondrium from the cartilage can result in necrosis of the cartilage due to the deprivation of its blood supply. A collection of blood can also stimulate formation of fibroneocartilage (Ohlsen 1975). These processes may result in the loss of cartilaginous support for the shape of the pinna and thickening of the soft tissues and cartilage (the 'cauliflower ear' or 'wrestler's ear' deformity) (Lee 1996). It is a common condition but prompt and proper treatment should reduce the likelihood of a permanent cosmetic deformity. It is generally thought that the longer haematomas are left untreated the greater the chance of a poor cosmetic outcome (Lee 1996).
Current management generally consists of evacuation of the haematoma, either by aspiration or incision and drainage, sometimes followed by head bandaging or splinting of the pinna to prevent re‐accumulation (Giffin 1985). There is no consensus on the best method of treatment hence variation in treatment from centre to centre. These treatments have little risk other than their failure to prevent re‐accumulation and the development of a 'cauliflower ear'. However, the introduction of infection (either at the time of initial injury or during the procedure to drain the haematoma) may result in the serious consequence of perichondritis of the pinna. In severe cases tissue loss may occur.
Objectives
To assess the effectiveness of treatment options for acute auricular haematoma by systematic review of published evidence.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials, controlled clinical trials and cohort studies.
Types of participants
Adults and children who have sustained an auricular haematoma.
Types of interventions
We considered any interventions, including simple aspiration of the haematoma, incision and drainage and any post‐drainage procedures (such as splinting or bandaging) to prevent re‐accumulation of the haematoma.
Types of outcome measures
Primary outcomes
Failure to prevent accumulation of the haematoma so that further intervention was required
Secondary outcomes
Secondary outcome measures included wound infection and whether cosmetic deformity occurred as a long‐term outcome.
Search methods for identification of studies
We conducted systematic searches for randomised controlled trials. There were no language, publication year or publication status restrictions. The date of the last search was 13 January 2011, following previous search updates in 2005 and 2008, and original searches in 2004.
Electronic searches
We searched the following databases from their inception for published, unpublished and ongoing trials: the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4); PubMed; EMBASE; CINAHL; LILACS; KoreaMed; IndMed; PakMediNet; CAB Abstracts; Web of Science; BIOSIS Previews; ISRCTN; ClinicalTrials.gov; ICTRP and Google.
We modelled subject strategies for databases on the search strategy designed for CENTRAL. Where appropriate, we combined subject strategies with adaptations of the highly sensitive search strategy designed by the Cochrane Collaboration for identifying randomised controlled trials and controlled clinical trials (as described in The Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2, Box 6.4.b. (Handbook 2009)). Search strategies for major databases including CENTRAL are provided in Appendix 1.
Searching other resources
We scanned the reference lists of identified publications for additional trials and contacted trial authors where necessary. In addition, we searched PubMed, TRIPdatabase, NHS Evidence ‐ ENT & Audiology and Google to retrieve existing systematic reviews relevant to this systematic review, so that we could scan their reference lists for additional trials. We searched for conference abstracts using the Cochrane Ear, Nose and Throat Disorders Group Trials Register.
Data collection and analysis
Selection of studies
The two authors independently reviewed the studies retrieved by the search to identify studies of the types outlined above. We had planned to resolve disagreement over inclusion by discussion, with a final decision made by SJ if there was ongoing disagreement.
Data extraction and management
We planned to extract data onto standardised, pre‐piloted forms.
Assessment of risk of bias in included studies
In our protocol, we planned to assess trials fulfilling the inclusion criteria according to quality in relation to the methodology and the conclusions reached using the method described by Schulz 1995. At the update of the review in 2011, we adopted the Cochrane Collaboration 'Risk of bias' method whereby assessment of the risk of bias of the included trials would be undertaken independently by the two review authors, with the following taken into consideration, as guided by the Cochrane Handbook for Systematic Reviews of Interventions (Handbook 2009):
sequence generation;
allocation concealment;
blinding;
incomplete outcome data;
selective outcome reporting; and
other sources of bias.
Should studies be included in future updates of this review, we plan to use the Cochrane ‘Risk of bias’ tool in RevMan 5 (RevMan 2008), which involves describing each of these domains as reported in the trial and then assigning a judgement about the adequacy of each entry. This involves answering a pre‐specified question whereby a judgement of ‘Yes’ indicates low risk of bias, ‘No’ indicates high risk of bias, and ‘Unclear’ indicates unclear or unknown risk of bias.
Data synthesis
We planned to use Review Manager 5.0 (RevMan 2008) for analysis, with subgroup analysis of:
application of post‐procedure pressure dressing;
duration of post‐procedure pressure dressing;
type of post‐procedure pressure dressing;
prescription of antibiotic treatment;
duration of haematoma prior to first intervention.
If great heterogeneity in studies was found then further analysis would be required. If possible and deemed appropriate by the Ear, Nose and Throat Disorders Group and the Non‐Randomised Studies Methods Group non‐randomised analysis was to be carried out on the controlled clinical trials and cohort studies retrieved.
Results
Description of studies
No randomised controlled trials, controlled clinical trials or cohort studies were found.
Risk of bias in included studies
Not applicable.
Effects of interventions
We used a comprehensive search strategy to identify 59 potentially relevant articles. Of these 11 were clearly not applicable to the review after scanning of the abstracts as they were related to animal experiments or other conditions rather than haematoma of the pinna. We retrieved 48 in full text in order to assess the papers for inclusion and to search the bibliographies for further relevant trials fulfilling the inclusion criteria. We identified no randomised controlled trials, controlled clinical trials or cohort studies in this way. One other widely cited article was, however, identified and retrieved for examination (Kelleher 1967).
The searches identified two letters, 13 'How I do it' articles, five case reports, 18 review articles and 10 case series articles.
The updated searches in 2005, 2008 and 2011 retrieved 16, six and 10 references, respectively, but none met the inclusion criteria for the review.
As a result of this no data could be entered for analysis but some articles are discussed below.
Discussion
We made efforts to identify all relevant studies and no study was excluded due to language. It is possible that some studies were missed but we feel that it is unlikely that we missed any higher quality published studies such as randomised controlled trials.
The studies retrieved reported a number of different types of treatment for haematoma of the pinna, including aspiration (Koopmann 1979; Talaat 1985), simple incision and evacuation (Savage 1981; Schuller 1989), anterior incision, fenestration of cartilage and evacuation (O'Donnell 1999), and posterior incision, fenestration of cartilage and evacuation (Bull 1984; Vuyk 1991). Treatments for prevention of re‐accumulation of the haematoma also varied widely and included through suturing (Bader 1985; Cochran 1980; Koopmann 1979; Savage 1981; Vuyk 1991), tie‐over dressing (O'Donnell 1999), various tie‐through dressings (Nahl 1989; Scarcella 1978; Schuller 1989; Talaat 1985; Unger 1970), silicone splints (Bingham 1987; Gross 1978; Lane 1998; Quine 1996), cotton wool and plaster of paris dressing (Spearing 1967), passive drainage (Lee 1997), suction drainage (Bull 1984; Eliachar 1983; Krugman 1989; Martin 2000) and the use of a swimmer's nose clip (Grosse 1991).
We have found no studies which show whether simple aspiration of the haematoma is adequate treatment or when more invasive evacuation techniques might be necessary. Although almost all articles found by our search strategy suggest the use of some form of post‐drainage intervention, no studies have been performed to demonstrate evidence for or against its use.
Very few of the studies identified by the searches discussed their rate of complication. Schuller et al (Schuller 1989) describe two cases of perichondritis in the 24 ears treated using a tie‐through dressing and state that this caused only minor thickening of the pinna. Koopmann and Coulthard (Koopmann 1979), Eliachar et al (Eliachar 1983), Talaat et al (Talaat 1985) and El‐Silimy and Bradley (El‐Silimy 1985) each stated that their series of patients suffered no complications. Many of the other published studies identified fail to comment on the rate of complication. Many of these studies are retrospective, review articles or expert opinion describing methods rather than prospective descriptions of actual outcomes in series of patients.
Authors' conclusions
Implications for practice.
The available literature relating to the effectiveness of the possible interventions for acute auricular haematoma is generally poor with no randomisation or controls. There is evidence from the trials that various interventions are effective at removal of haematomas and preventing their recurrence, resulting in good cosmetic outcome, but no evidence as to whether one intervention is better than another or whether post‐drainage interventions, such as pressure bandaging, tie‐through compression or application of silicone moulds, are necessary.
Many of the identified papers consisted of expert opinion only and it is therefore not possible to recommend a specific intervention as the best. However, all of the trials identified by the search demonstrated a technique for treatment and none suggested that no treatment was a better option.
Implications for research.
There is a need for a well‐designed trial comparing interventions for acute auricular haematoma. In view of the relative rarity it may be necessary to organise a multi‐centre trial so that significant numbers of patients will be identified within a reasonable time‐frame. Long‐term follow up will also be required to assess the final cosmetic outcome of the interventions being examined. A placebo‐controlled, double‐blinded study would clearly be impossible and unethical, however blinding of those assessing the outcomes of treatment should be possible.
It could be said that even a prospective study assessing the rate of complication and success of a given treatment would be of benefit when compared to the studies identified in this review.
What's new
| Date | Event | Description |
|---|---|---|
| 13 January 2011 | New search has been performed | We conducted new searches; no new studies were identified. |
History
Protocol first published: Issue 2, 2003 Review first published: Issue 2, 2004
| Date | Event | Description |
|---|---|---|
| 8 November 2008 | New search has been performed | We conducted new searches; no new studies were identified. |
| 22 October 2008 | Amended | Converted to new review format. |
| 9 November 2005 | New search has been performed | We updated the searches; no new studies were found. |
Acknowledgements
The authors would like to thank the staff of the Cochrane ENT Group for their help in writing this review. In particular to Jenny Bellorini whose advice and guidance has been invaluable.
Appendices
Appendix 1. Search strategies
| CENTRAL | PubMed | EMBASE (Ovid) | CINAHL (EBSCO) |
| #1 MeSH descriptor Ear Cartilage explode all trees #2 MeSH descriptor Ear Deformities, Acquired explode all trees #3 wrestler* OR cauliflower #4 (ear* OR auric* OR pinna*) NEAR (haematoma* OR hematoma*) #5 (#1 OR #2 OR #3 OR #4) | #5 #1 OR #2 OR #3 OR #5 #4 "Ear Cartilage"[Mesh] #3 (ear* OR pinna* OR auric*) AND (hematoma* OR haematoma*) #2 (cauliflower OR wrestler*) AND ear* #1 "Ear Deformities, Acquired"[Mesh] | 1 exp EXTERNAL EAR/ 2 ear injury/ 3 1 or 2 4 (hematoma* or haematoma*).tw. 5 4 and 3 6 exp EXTERNAL EAR MALFORMATION/ 7 ((auric* or auris or ear* or pinna*) and (hematoma* or haematoma* or cauliflower or wrestler* or boxer* or rugby or football*)).tw. 8 6 or 7 or 5 | 3 s1 OR s2 2 TX ((ear* OR pinna* OR auric*) AND (hematoma* OR haematoma*)) 1 TX ((cauliflower OR wrestler*) AND ear*) |
| Cochrane Ear Nose and Throat Disorders Group Trials Register (ProCite database) | ISI Web of Science/BIOSIS Previews (Web of Knowledge) | CAB Abstracts (Ovid) | ICTRP |
| haematoma OR hematoma OR bruis* OR wrestler* OR cauliflower* | #3 #2 OR #1 #2 TS=((ear* OR pinna* OR auric*) AND (hematoma* OR haematoma*)) #1 TS=((cauliflower OR wrestler*) AND ear*) | 1 ((auric* or auris or ear* or pinna*) and (hematoma* or haematoma* or cauliflower or wrestler* or boxer* or rugby or football*)) | auric* AND haematoma* OR auric* AND hematoma* OR pinna* AND haematoma* OR pinna* AND hematoma* OR ear AND hematoma* OR ear AND haematoma* OR cauliflower AND ear* OR wrestler* AND ear* |
Characteristics of studies
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
|---|---|
| Backous 1996 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Bader 1985 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Bingham 1987 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Bull 1984 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Butt 1987 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Cochran 1980 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Davis 1971 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Dimeff 1989 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Eichel 1978 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| El‐Silimy 1985 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ letter |
| Eliachar 1983 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Elsahy 2002 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Federspil 1970 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Gernon 1980 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Giffin 1985 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Giffin 1992 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Gross 1978 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Grosse 1991 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Henderson 2000 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case report |
| Holmes 1999 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Hwang 2001 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ animal study |
| Kelleher 1967 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Kirsch 1991 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Koopmann 1979 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Krucoff 1996 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Krugman 1989 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case report |
| Lane 1998 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Lee 1996 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Lee 1997 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case report |
| Martin 2000 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case report |
| Maurer 1990 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Nahl 1989 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| O'Donnell 1999 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Parlette 1995 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Pinto 1978 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case report |
| Punjabi 1997 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Quine 1996 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Rotermundt 1976 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Savage 1981 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Scarcella 1978 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case report |
| Schuller 1989 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Spearing 1967 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Starck 1992 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Stiernberg 1986 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Stuteville 1969 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Talaat 1985 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Templer 1990 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ review article |
| Unger 1970 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ case series |
| Vuyk 1991 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ expert opinion |
| Zohar 1990 | ALLOCATION: Not a randomised controlled trial, controlled clinical trial or cohort study ‐ letter |
Differences between protocol and review
See Assessment of risk of bias in included studies. Should studies be included in future updates of this review, we will use the Cochrane 'Risk of bias' method for assessment of study quality.
Contributions of authors
SJ ‐ lead author, protocol development, design of search strategy, quality assessment, data extraction and analysis, writing of review.
SM ‐ protocol development, quality assessment, data extraction and analysis.
Declarations of interest
None known.
New search for studies and content updated (no change to conclusions)
References
References to studies excluded from this review
Backous 1996 {published data only}
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