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Feature	Detail
Risk Factors	Contact sports (wrestling, boxing, MMA, rugby), repetitive ear trauma, ear piercing through cartilage, post-auricular surgery, immunocompromised patients (for perichondritis)
Etiology	Blunt trauma causing shearing of perichondrium from cartilage (hematoma); bacterial infection of perichondrium, most commonly Pseudomonas aeruginosa (perichondritis); untreated or recurrent hematoma leading to cartilage necrosis and fibrosis (cauliflower ear)
Patient Presentation	Painful, swollen ear after trauma (hematoma); erythematous, warm, tender pinna sparing the lobule (perichondritis); chronic thickened, deformed auricle (cauliflower ear)
Classic Physical Exam	Fluctuant, tender swelling over the anterior auricular surface obscuring anatomical landmarks (hematoma); diffuse erythema and edema of the pinna that spares the earlobe (perichondritis); irregular, firm, nodular deformity of the pinna (cauliflower ear)
Key Diagnostic Results	Clinical diagnosis for all three; aspiration yields non-clotting blood (hematoma); culture of aspirate or drainage grows Pseudomonas (perichondritis); CT temporal bone if abscess suspected
Management	Incision and drainage with bolster dressing (hematoma); anti-pseudomonal antibiotics, typically fluoroquinolones (perichondritis); surgical reconstruction or otoplasty (cauliflower ear)
Keywords	"Wrestler's ear," "fluctuant swelling after blunt trauma," "erythema sparing the lobule," "loss of auricular contour," "Pseudomonas," "bolster dressing"

1. Pathophysiology

The auricle is composed of elastic cartilage covered by a tightly adherent layer of perichondrium. Unlike most tissues, auricular cartilage is avascular and depends entirely on the overlying perichondrium for its blood supply via diffusion. This anatomical reality is the key to understanding why auricular injuries can rapidly progress to permanent deformity if mismanaged.

Auricular hematoma occurs when blunt or shearing force separates the perichondrium from the underlying cartilage, disrupting the small vessels running between them. Blood collects in this potential space, forming a subperichondrial hematoma. Because the cartilage now loses its only nutritional source, it begins to undergo avascular necrosis if the hematoma is not promptly evacuated. The longer the blood sits, the more ischemic the cartilage becomes.

If the hematoma is left untreated or recurs, the body attempts repair through fibrosis and neocartilage formation within the organizing clot. This process produces the irregular, thickened, permanently deformed auricle known as cauliflower ear. The deformity is irreversible once fibrosis is established, which is why early drainage is critical.

Perichondritis represents bacterial infection of the perichondrium, most commonly caused by Pseudomonas aeruginosa. The typical entry points are cartilage-piercing ear piercings (high ear piercings through the helix or antihelix), post-surgical wounds, burns, or secondary infection of an undrained hematoma. The reason Pseudomonas dominates is its affinity for moist, damaged cartilaginous environments. If untreated, the infection can progress to a subperichondrial abscess, which strips the perichondrium further and accelerates cartilage destruction, again through the mechanism of devascularization.

A unifying concept for exam purposes: any process that separates perichondrium from cartilage threatens the viability of the cartilage itself, whether the separating agent is blood (hematoma), pus (abscess), or fibrotic tissue (cauliflower ear).

2. Classification and Clinical Manifestation

Condition	Onset	Mechanism	Clinical Appearance	Reversibility
Auricular Hematoma	Acute (hours)	Blunt/shearing trauma separates perichondrium from cartilage	Fluctuant, tense, violaceous swelling over the anterior auricle; obscures normal contours (antihelix, scaphoid fossa)	Fully reversible if drained early
Perichondritis	Subacute (days)	Bacterial infection of the perichondrium, usually after piercing, trauma, or surgery	Diffuse erythema, warmth, tenderness, and edema of the pinna; may progress to abscess with fluctuance	Reversible with early antibiotics; cartilage loss if abscess forms
Cauliflower Ear	Chronic (weeks to months)	Fibrosis and neocartilage formation in an untreated or recurrent hematoma	Firm, irregular, nodular thickening with loss of normal auricular landmarks	Irreversible; requires surgical reconstruction

The most tested clinical discriminator is lobule sparing. Because the earlobe is composed of fibrofatty tissue without cartilage, it is not involved in perichondritis or auricular hematoma. If a vignette describes diffuse ear erythema that includes the lobule, consider cellulitis or erysipelas instead.

3. Diagnostic Workup

Test	Purpose	When to Order
Clinical examination	Primary diagnostic modality for all three conditions	Always; diagnosis is clinical
Needle aspiration	Confirms hematoma (non-clotting blood), provides specimen for culture if infection suspected	Acute fluctuant swelling post-trauma
Culture and sensitivity	Identifies causative organism in perichondritis (expect Pseudomonas)	Purulent drainage or abscess
CT temporal bone	Evaluates for abscess formation, extent of cartilage destruction, or involvement of deeper structures	Suspected abscess not responding to antibiotics, or concern for extension to external auditory canal
Otoscopy	Rules out concurrent tympanic membrane perforation, external auditory canal injury, or otitis externa	All auricular trauma presentations

Auricular hematoma is diagnosed clinically when a patient presents with a fluctuant, tender swelling over the anterior pinna after blunt trauma. The best initial step is clinical inspection; no imaging is needed. If there is diagnostic uncertainty, needle aspiration yielding non-clotting blood confirms the diagnosis. The aspirated blood does not clot because it has been defibrinated by tissue contact over time.

Perichondritis is also a clinical diagnosis. The hallmark finding is erythema and swelling of the auricle that spares the lobule. When drainage is obtained (either from aspiration or spontaneous drainage), it should be sent for Gram stain and culture. Expect Pseudomonas in most post-piercing cases. In post-surgical or burn-related cases, Staphylococcus aureus may also be implicated.

Cauliflower ear is recognized on inspection alone: the auricle has a characteristic irregular, firm, nodular quality with loss of the normal concavities and ridges. No workup beyond physical examination is typically required unless surgical reconstruction is planned.

One important clinical pearl: if the vignette describes a patient with an auricular hematoma that develops increasing erythema, warmth, and fever days after the initial injury, the diagnosis has now shifted to secondary perichondritis complicating the hematoma, and antibiotic coverage (anti-pseudomonal) must be added to the management.

4. Management and Treatment

Condition	Acute Management	Follow-Up / Long-Term	Key Principle
Auricular Hematoma	Incision and drainage (preferred over needle aspiration alone for large or organized hematomas) followed by bolster/pressure dressing to prevent re-accumulation	Re-examine within 24 to 48 hours; repeat drainage if reaccumulation occurs; prophylactic oral antibiotics (e.g., cephalexin 500 mg QID for 7 days)	Bolster dressing is mandatory to prevent reaccumulation
Perichondritis (without abscess)	Oral fluoroquinolone (ciprofloxacin 500 to 750 mg BID for 7 to 14 days) to cover Pseudomonas	Warm compresses; close follow-up for abscess development	Anti-pseudomonal coverage is non-negotiable
Perichondritis (with abscess)	Incision and drainage with placement of a drain or through-and-through mattress sutures; IV anti-pseudomonal antibiotics (e.g., IV ciprofloxacin or piperacillin-tazobactam)	Transition to oral fluoroquinolone once clinically improved; total course 2 to 4 weeks depending on severity	Drainage plus antibiotics; antibiotics alone are insufficient for abscess
Cauliflower Ear	No acute treatment (chronic deformity)	Elective surgical reconstruction (otoplasty) if cosmetically desired	Prevention through proper hematoma management is far more effective than late reconstruction

For auricular hematoma, the single most tested management concept is the bolster dressing (also called a pressure dressing or dental roll bolster). After incision and drainage, cotton bolsters or dental rolls are sutured through the skin on both sides of the auricle to maintain continuous pressure and eliminate the dead space where blood would re-collect. Without the bolster, the hematoma recurs in the majority of cases, making drainage alone insufficient. Needle aspiration can be attempted for small, acute hematomas, but recurrence rates are higher compared to formal incision and drainage with bolster placement.

For perichondritis, the cornerstone of treatment is anti-pseudomonal antibiotic coverage. Ciprofloxacin is the most commonly tested first-line agent. Standard anti-staphylococcal antibiotics like cephalexin or dicloxacillin are incorrect choices because they do not cover Pseudomonas. If the perichondritis occurred after a burn or surgical site, dual coverage for both Pseudomonas and Staphylococcus may be warranted (e.g., ciprofloxacin plus an anti-staphylococcal agent).

A contraindication worth knowing: fluoroquinolones should be used with caution in pediatric patients and pregnant women due to concerns about cartilage toxicity in developing joints. In these populations, alternatives include IV anti-pseudomonal beta-lactams such as piperacillin-tazobactam or ceftazidime.

For cauliflower ear, there is no acute medical treatment. The deformity is structural and fixed. The only intervention is elective surgical reconstruction, which involves excising the fibrotic tissue and reshaping the auricular framework, sometimes requiring cartilage grafting. The far more testable point, however, is that cauliflower ear is preventable through prompt and proper management of the initial hematoma.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Auricular cellulitis	Erythema and swelling of the ear after trauma or piercing	Cellulitis involves the lobule and surrounding soft tissue; perichondritis spares the lobule
Relapsing polychondritis	Bilateral auricular erythema and cartilage inflammation	Relapsing polychondritis is bilateral, recurrent, involves multiple cartilaginous sites (nose, trachea, joints), and is autoimmune; perichondritis is unilateral and infectious
Otitis externa (swimmer's ear)	Ear pain with erythema, especially after water exposure	Pain with tragal pressure, discharge from the external auditory canal; the pinna itself is not swollen or deformed
Chondrodermatitis nodularis helicis	Painful nodule on the ear	Small, tender nodule on the helix or antihelix, typically in elderly patients who sleep on the affected side; no antecedent trauma, no fluctuance
Sebaceous cyst	Fluctuant swelling on the ear	Non-tender, well-circumscribed, mobile nodule with a central punctum; no preceding trauma; no erythema unless secondarily infected
Contact dermatitis	Erythema and pruritus of the auricle	Bilateral, pruritic, often associated with earring metal allergy (nickel); involves the lobule; vesicles and scaling present

The most commonly tested distractor pairing is perichondritis versus cellulitis. Both present with a red, swollen, painful ear. The discriminating feature is lobule involvement: perichondritis spares it, cellulitis does not. Additionally, perichondritis requires anti-pseudomonal antibiotics, while cellulitis is treated with anti-staphylococcal/streptococcal coverage. Choosing the wrong antibiotic class is a frequent source of lost points.

6. Traps and High-Yield Pearls

The most common way students lose points on auricular trauma questions falls into three categories.

First, failing to recognize the urgency of auricular hematoma drainage. A vignette describing a wrestler or boxer with a swollen, painful ear after a match is testing whether you know to perform incision and drainage with a bolster dressing immediately. Choosing "observation" or "ice and NSAIDs" leads directly to cauliflower ear. The bolster dressing is the detail that separates the correct answer from a partially correct one; drainage without compression is incomplete management.

Second, selecting the wrong antibiotic for perichondritis. The reflex to choose cephalexin or amoxicillin-clavulanate for a skin and soft tissue infection will fail here because the causative organism is Pseudomonas, not Staphylococcus. Whenever the vignette mentions ear cartilage piercing followed by progressive auricular erythema sparing the lobule, the answer is ciprofloxacin (or another fluoroquinolone).

Third, confusing perichondritis with cellulitis based on lobule involvement. This is often tested with a subtle detail buried in the vignette. If the erythema extends to the lobule, it is cellulitis. If the lobule is explicitly spared, it is perichondritis. This single finding changes both the diagnosis and the antibiotic selection.

The core competency being tested across all auricular trauma questions is the ability to connect anatomy (avascular cartilage dependent on perichondrium) to clinical reasoning (why delayed treatment causes permanent damage) and to select management steps in the correct sequence (drain, bolster, cover Pseudomonas when infected). Recognizing the lobule as the anatomic dividing line between perichondritis and cellulitis is the single highest-yield discriminator in this topic.

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