Ear magnetic discs to prevent cauliflower ear: a case gone wrong

Background

An auricular haematoma is defined as a collection of blood underneath the perichondrium of the ear, typically secondary to trauma, seen in those involved in contact sports such as wresting or boxing.1 In a survey of college wrestlers, the incidence was demonstrated to be roughly 52% for wrestlers without headgear versus 26% for those who wore ear protection.2

If auricular haematoma is diagnosed, it should be treated promptly to prevent complications such as long-term pinna deformity, also known as ‘cauliflower ear’. Blood supply to the auricular cartilage comes from the adjacent perichondrium, thus disruption of this plane can cause avascular necrosis of the cartilage. The principle of treatment therefore involves removing the collection of blood (either through direct aspiration or incision and drainage) and restoring blood supply to the pinna cartilage, to prevent long-term deformity.3 Following drainage, it is also important to close the dead space between the perichondrium and underlying cartilage to prevent reaccumulation of blood. Accepted techniques for this include tie-through dressings, pressure dressings, bolsters, silicone splinting, clips or sutures.4 The aim is to achieve evenly distributed pressure across the haematoma site. Ineffective technique may lead to haematoma recurrence, requiring further drainage and increasing the risk of infection.5

Based on the principle of reducing dead space, ear magnetic discs, such as Caulicure or CauliBuds, have been developed as a non-medical tool to prevent cauliflower ear. Once the haematoma is drained, these magnetic discs can be placed across either side of the affected area to prevent refilling of the dead space. Although principally sound, this can lead to excessive pressure on the tissues, resulting in poor wound healing, infection and even necrosis.

Case presentation

A man in his 20s presented to accident and emergency (A&E) with posttrauma left-sided otalgia. He had sustained an injury to his left ear during a training wrestling match 1 week earlier. His coach diagnosed auricular haematoma and aspirated the swelling. He provided the patient with a pair of magnetic discs to be placed over the swelling site, to prevent haematoma reaccumulation. This method is used commonly by wrestlers, and the patient did not seek medical attention at the time of injury.

The patient continued using the magnetic discs across the wound site for 5 consecutive days, as advised by the manufacturers. On day 5, he removed the magnets and noticed reaccumulation of haematoma, which he attempted to aspirate multiple times using a needle. As the aspiration attempts were not successful, he decided to attend A&E. Other than otalgia, the patient was asymptomatic on systemic review. He had no relevant medical history and took no regular medications. On examination of the ear, there was a circular, well-demarcated area of skin necrosis on the scaphoid fossa, underlying the area of magnet placement (figure 1). Anteriorly and posteriorly, the skin was black, avascular and insensate (figure 2). The underlying cartilage had been eroded and there was associated deformity of the antihelix. The rest of the pinna appeared swollen and inflamed, with signs of perichondritis and infection around the sites of repeated needle aspirations. The ear was extremely tender to touch, and the wound was discharging serosanguineous fluid. The infection was localised, and the patient was clinically well otherwise with no signs of sepsis. Bedside observations were normal, with a National Early Warning Score of 0. Blood tests were taken which demonstrated mildly raised inflammatory markers (see below in Results section).

Anterior pinna drainage via incision in the crease of the helical rim was performed under local anaesthetic using a ring block, which released the blood and exudate. A bolster, using dental rolls placed anteriorly and posteriorly across the wound site, was sutured in place (figure 3). This was done in clinic using sterile techniques. He was prescribed a course of oral antibiotics: 625 mg amoxicillin/clavulanic acid, to be taken three times a day for 7 days. He was reviewed 2 days later in clinic, whereby the pinna oedema and erythema had improved and there was no haematoma reaccumulation. The dental rolls were removed a week later in clinic without complication. A further course of antibiotics was required 2 weeks later as otalgia and erythema increased; 500 mg oral ciprofloxacin two times per day for 7 days was prescribed. Weekly clinical review continued for 2 weeks. The patient was advised to keep the wound clean and dry and to avoid contact sports while it was healing. By day 32 after the initial injury, the wound had begun to heal, with granulation tissue forming around the wound site (figure 4).

Investigations

His blood tests demonstrated inflammatory markers within an acceptable range, with a total white cell count of 7.65 × 10⁹/L (4.00–10.00 × 10⁹/L), neutrophil count of 4.62 × 10⁹/L (2.00–7.00 × 10⁹/L) and C reactive protein level of 5 mg/L (<5 mg/L). No samples were taken for microbiology. The patient had normal observations.

Outcome and follow-up

Three months after initial presentation, the patient was reviewed in a consultant-led otology clinic. The pinna skin had fully healed, with slight purple discolouration. The helical rim had a notable superior notch due to the loss of underlying (necrosed) cartilage (figure 5).

The patient was concerned about the appearance of his ear and was keen to explore options to improve it. Concealers were advised to cover the skin discolouration, and surgical reconstruction options were discussed. Cartilage augmentation was discussed including the risks and benefits of the procedure, and the patient was keen to proceed. Unfortunately, the patient then moved out of the area and was not followed up further, although he planned to request surgical reconstruction at his new local hospital.