CASE REPORT
A New Technique Using Fibrin Glue in the Management of Auricular Hematoma Shwan H. Mohamad, MBChB, MRCS, DO-HNS, MCH,* Martyn Barnes, FRCS (ORL-HNS),† Stephen Jones, FRCS (ORL-HNS),‡ and Suresh Mahendran, FRCS (ORL-HNS)§
Abstract: This study aims to describe a new technique for the management of auricular hematoma using fibrin glue. Five difficult cases of auricular hematoma were managed using this technique, including 2 recurrent and 3 delayed presentations. After skin preparation and local anesthetic, an incision was made, the hematoma was evacuated, and the cavity was washed out with saline. Fibrin glue was applied liberally; a dental roll pressure dressing was applied and secured with a prolene bead suture. The patients were given a course of oral antibiotic and reviewed after 5 days for removal of the external dressing. They were later assessed to exclude re-accumulation of the hematoma. All patients had complete resolution of the hematoma without re-accumulation; they were satisfied with the cosmetic results and experienced no complications. This case series provides evidence that fibrin glue is effective in the management of auricular hematoma. Larger studies may provide further evidence of the effectiveness of this new technique.
In this case series, we describe a new surgical technique using fibrin glue (Tisseel; Baxter Healthcare Ltd, Norfolk, United Kingdom) for the management of 5 difficult auricular hematoma cases.
CASE SERIES This was a prospective case series comprising 5 cases: 2 recurrent and 3 delayed auricular hematoma presentations. The new technique using fibrin glue was performed, and the treatment outcome was evaluated. All patients were young males with no significant medical problems. The detailed cases are shown in the Table.
Technique
Auricular hematoma is a collection of blood beneath the perichondrial layer of the pinna.1 It is a common condition and is generally caused by blunt trauma to the external ear, often seen in contact sports such as rugby, wrestling, boxing, and martial arts.2 Recurrent auricular hematoma can be a challenging medical problem, with complications resulting in ear deformity. Appropriate management of auricular hematoma should aim to achieve effective evacuation of the hematoma, prevent recurrence, and result in a good cosmetic outcome. There is no consensus on the best method of treatment, and various surgical techniques have been described.3
The skin was prepared using chlorhexidine antiseptic solution and infiltrated with 2% of lidocaine and adrenaline, 1 in 80 000 solution. In addition, the great auricular nerve was blocked, and infiltration of the pre-auricular and posterior auricular areas was performed for optimum local anesthetic benefit. Using a number 15 blade, the skin over the pinna hematoma was incised over the site of greatest swelling and fluctuance, oriented parallel to the cartilaginous creases of the pinna, to enter the plane between the perichondrium and cartilage. Full drainage of contents was achieved with blunt dissection using a hemostat. Fibrin (Tisseel) glue was applied into the cavity. Compressive dental rolls were placed on both sides of the pinna and secured with beaded prolene sutures (Ethicon Ltd, West Lothian, United Kingdom) 5-0 (Figure 1). Three different surgeons performed these cases. All patients were discharged with a course of co-amoxiclav tablets and reviewed in the clinic after 5 days, at which point the stitches and dental rolls were removed. The patients were subsequently reviewed to ensure that there was no re-accumulation of the hematoma. Cosmetic outcome was assessed by the surgeon comparing the treated ear with the untreated ear and by asking the patients for their opinion. In addition, preoperative and postoperative clinical images were compared.
Submitted for publication June 6, 2013; accepted December 26, 2013. From the *ENT Department, Monklands Hospital, North Lanarkshire, United Kingdom; †ENT Department, Rhinology and Anterior Skull Base Fellow, North Shore Hospital, Auckland, Australia; ‡ENT Consultant, ENT Department, Ninewells Hospital, Dundee, Scotland; and §ENT Consultant, ENT Department, St Andrew’s Hospital, Toowoomba, Australia. Presented at the Scottish Otolaryngology Society Meeting, ENT-Scotland; May 9, 2012; Dunblane, Scotland, United Kingdom. The authors report no conflicts of interest. Corresponding Author: Shwan H. Mohamad, MBChB, MRCS, DO-HNS, MCH, ENT Specialist Registrar, Monklands Hospital, Monkscourt Ave, Airdrie ML6 0JS, North Lanarkshire, United Kingdom (shwanbashoory@ yahoo.co.uk). Copyright © 2014 by Lippincott Williams & Wilkins
Five male patients were treated using this technique between September 2011 and September 2012. Three cases had developed auricular hematoma secondary to rugby injury, whereas the other 2 cases were spontaneous. The mean age was 23.2 years (range, 16-33 years). The follow-up was at 1 week and 3 months after surgery. All patients had a complete resolution of the hematoma without re-accumulation. Both surgeons and patients were satisfied with the cosmetic results (Figures 1 and 2). There were no complications, most notably nothing that could be
Key Words: auricular hematoma, fibrin glue, cauliflower ear (Clin J Sport Med 2014;24:e65–e67)
INTRODUCTION
Clin J Sport Med Volume 24, Number 6, November 2014
RESULTS
www.cjsportmed.com |
e65
Clin J Sport Med Volume 24, Number 6, November 2014
Mohamad et al
TABLE. Characteristics of the Case Series Case
Age, y
Cause of Auricular Hematoma
Duration of Hematoma
1
32
Spontaneous
6 wk
2 3
17 18
Rugby injury Rugby injury
3 wk 2 d after injury
4 5
18 33
Rugby injury Spontaneous
6d 4 wk
attributed to the use of fibrin glue or the dental rolls. Adequate anesthesia was achieved in all 5 patients.
DISCUSSION The need for this technique arose because of the difficulties faced in the management of case 1. This patient had previously undergone multiple procedures with aspiration, then incision and evacuation, followed by pressure dressings. The senior author (S.M.) proposed the use of Tisseel glue after further incision and drainage with the aim of avoiding further re-accumulation. The patient was successfully treated and was followed-up with no recurrence or ear deformity at 3 months (Figure 2). Tisseel (fibrin glue) is a fibrin sealant indicated for use as an adjunct to hemostasis in patients undergoing surgery
FIGURE 1. Dental rolls applied after the drainage of auricular hematoma.
e66
| www.cjsportmed.com
Type of Cases Re-accumulation after multiple incision and drainages No previous procedures Re-accumulation 3 d after initial aspiration No previous procedures No previous procedures
when control of bleeding by conventional surgical techniques (such as suture, ligature, and cautery) is ineffective or impractical.4 Tisseel is a 2-component tissue sealant, containing fibrinogen and thrombin, which both promote hemostasis. According to manufacture’s description, Tisseel contents are made from pooled human plasma (fibrinogen and thrombin) and a synthetic material of nonhuman/nonanimal origin (aprotinin).4 This would avoid the implications of its use in patients with certain religions that may avoid the use of certain animal products. Tisseel is indicated as a supportive treatment to improve hemostasis and promote adhesion where standard surgical techniques are insufficient.5 Tisseel was licensed as a medicinal product in the United Kingdom by the Medicines and Healthcare Products Regulatory Agency (MHRA) in 1999.6 It has been widely used in different surgical specialties. Studies have shown the effectiveness of fibrin glue in improving and providing effective hemostasis in a range of cardiac and aortic surgeries7 and in total hip replacement.8 It is commonly used in neurosurgery as an adjunct to dural closures to reduce cerebral spinal fluid leakage.9,10 There are other documented applications of fibrin sealant in orthopedic, ophthalmologic, trauma, head and neck, gynecologic, urologic, gastrointestinal, and dental surgery.11 This case series supports that the adhesive properties of fibrin glue may be useful in the prevention of re-accumulation of auricular hematoma. Documented side effects of Tisseel glue include hypersensitivity and anaphylactic reactions and a theoretical risk of transmitting infective agents, but such adverse effects are considered to be rare. The 5 cases described in this case series were potentially difficult cases. Two patients had recurrent hematoma. The other cases presented late at 6, 21, and 28 days after original injury. In both these groups, there is the potential for the cavity to become established secondary to inflammation with or without granulation tissue formation that might make recurrent presentations more likely. Compression was achieved in all our patients with dental rolls. The rolls were applied to both sides of the pinna and secured using through-and-through beaded prolene sutures (Figure 1). The technique of using dental roll compression in the management of auricular hematomas is widely used and has been reported.12–14 Our postoperative outcome was not assessed using any validated means. However, the review and assessment were undertaken by operating surgeon in the ENT clinic. As described above, this included contralateral ear comparison and patient satisfaction. Preoperative and Ó 2014 Lippincott Williams & Wilkins
Clin J Sport Med Volume 24, Number 6, November 2014
Fibrin Glue in the Management of Auricular Hematoma
FIGURE 2. Before and after drainage (3 months) (case 1).
postoperative photographs were compared to assess cosmetic results. This is just a small case series, albeit with promising results. At present, we do feel that its use in potentially highrisk cases is justified; however, we cannot rightly suggest its use in all cases. Factors to consider would include efficacy compared with currently used methods, cost, patient and surgeon acceptability, and potentially increased surgical time. A randomized controlled trial would be needed to further support application of this new technique in routine cases.
CONCLUSIONS This case series shows that the new technique using fibrin glue is effective. Our experience is that fibrin glue is a promising adjunct to currently available techniques in the treatment of recurrent and delayed presentation auricular hematomas. However, a randomized control trial is needed to provide further evidence on efficacy and cost effectiveness of this new technique when compared with established methods before it is recommended as standard management on all cases. REFERENCES 1. Ohlsen L, Skoog T, Sohn S. Pathogenesis of the cauliflower ear: an experimental study in rabbits. Scand J Plast Reconstr Surg. 1975;9:34–39. 2. Lane SE, Rhame GL, Wroble RL. A silicone splint for auricular hematoma. Phys Sportsmed. 1998;26:77–78.
Ó 2014 Lippincott Williams & Wilkins
3. Jones SE, Mahendran S. Interventions for acute auricular hematoma. Cochrane Database Syst Rev. 2004;(2)CD004166. 4. Tisseel [Fibrin Sealant]. Important risk Information. http://tisseel.com/us/ detailed_important_risk_information.html. Accessed November 16, 2013. 5. Medicines and Health Products Regulatory Agency. http://mhra.gov.uk/ home/groups/I-unit1/documents/websiteresources/con033569.pdf. Accessed April 27, 2013. 6. Medicines and Healthcare Products Regulatory Agency. http://.mhra.gov. uk/home/groups/I-csel/documents/committee/document/con003421.pdf. Accessed April 25, 2013. 7. Rousou JA. Use of fibrin sealants in cardiovascular surgery: a systematic review. J Card Surg. 2013;28:238–247. 8. Randelli F, Banci L, Ragone V, et al. Effectiveness of fibrin sealant after cementless total hip replacement: a double-blind randomized controlled trial. Int J Immunopathol Pharmacol. 2013;26:189–197. 9. Nissen AJ, Johnson AJ, Perkins RC, et al. Fibrin glue in otology and neurotology. Am J Otol. 1993;14:147–150. 10. Shaffrey CI, Spotnitz WD, Shaffrey ME, et al. Neurosurgical applications of fibrin glue: augmentation of dural closure in 134 patients. Neurosurgery. 1990;26:207–210. 11. Spotnitz WD, Welker RL. Clinical uses of fibrin sealant. In: Mintz PD, ed. Transfusion Therapy: Clinical Principles, Practice. Bethesda, MD: AABB; 1999:199–222. 12. George A, Tassone P. Pinna haematomas of the conchal bowl. Clin Otolaryngol. 2007;32:77. 13. Choung YH, Park K, Choung PH, et al. Simple compressive method for treatment of auricular hematoma using dental silicone material. J Laryngol Otol. 2005;119:27–31. 14. Sbaihat AS, Khatatbeh WJ. Treatment of auricular hematoma using dental rolls splints. JRMS. 2011;18:22–25.
www.cjsportmed.com |
e67
A New Technique Using Fibrin Glue in the Management of Auricular Hematoma Shwan H. Mohamad, MBChB, MRCS, DO-HNS, MCH,* Martyn Barnes, FRCS (ORL-HNS),† Stephen Jones, FRCS (ORL-HNS),‡ and Suresh Mahendran, FRCS (ORL-HNS)§
Abstract: This study aims to describe a new technique for the management of auricular hematoma using fibrin glue. Five difficult cases of auricular hematoma were managed using this technique, including 2 recurrent and 3 delayed presentations. After skin preparation and local anesthetic, an incision was made, the hematoma was evacuated, and the cavity was washed out with saline. Fibrin glue was applied liberally; a dental roll pressure dressing was applied and secured with a prolene bead suture. The patients were given a course of oral antibiotic and reviewed after 5 days for removal of the external dressing. They were later assessed to exclude re-accumulation of the hematoma. All patients had complete resolution of the hematoma without re-accumulation; they were satisfied with the cosmetic results and experienced no complications. This case series provides evidence that fibrin glue is effective in the management of auricular hematoma. Larger studies may provide further evidence of the effectiveness of this new technique.
In this case series, we describe a new surgical technique using fibrin glue (Tisseel; Baxter Healthcare Ltd, Norfolk, United Kingdom) for the management of 5 difficult auricular hematoma cases.
CASE SERIES This was a prospective case series comprising 5 cases: 2 recurrent and 3 delayed auricular hematoma presentations. The new technique using fibrin glue was performed, and the treatment outcome was evaluated. All patients were young males with no significant medical problems. The detailed cases are shown in the Table.
Technique
Auricular hematoma is a collection of blood beneath the perichondrial layer of the pinna.1 It is a common condition and is generally caused by blunt trauma to the external ear, often seen in contact sports such as rugby, wrestling, boxing, and martial arts.2 Recurrent auricular hematoma can be a challenging medical problem, with complications resulting in ear deformity. Appropriate management of auricular hematoma should aim to achieve effective evacuation of the hematoma, prevent recurrence, and result in a good cosmetic outcome. There is no consensus on the best method of treatment, and various surgical techniques have been described.3
The skin was prepared using chlorhexidine antiseptic solution and infiltrated with 2% of lidocaine and adrenaline, 1 in 80 000 solution. In addition, the great auricular nerve was blocked, and infiltration of the pre-auricular and posterior auricular areas was performed for optimum local anesthetic benefit. Using a number 15 blade, the skin over the pinna hematoma was incised over the site of greatest swelling and fluctuance, oriented parallel to the cartilaginous creases of the pinna, to enter the plane between the perichondrium and cartilage. Full drainage of contents was achieved with blunt dissection using a hemostat. Fibrin (Tisseel) glue was applied into the cavity. Compressive dental rolls were placed on both sides of the pinna and secured with beaded prolene sutures (Ethicon Ltd, West Lothian, United Kingdom) 5-0 (Figure 1). Three different surgeons performed these cases. All patients were discharged with a course of co-amoxiclav tablets and reviewed in the clinic after 5 days, at which point the stitches and dental rolls were removed. The patients were subsequently reviewed to ensure that there was no re-accumulation of the hematoma. Cosmetic outcome was assessed by the surgeon comparing the treated ear with the untreated ear and by asking the patients for their opinion. In addition, preoperative and postoperative clinical images were compared.
Submitted for publication June 6, 2013; accepted December 26, 2013. From the *ENT Department, Monklands Hospital, North Lanarkshire, United Kingdom; †ENT Department, Rhinology and Anterior Skull Base Fellow, North Shore Hospital, Auckland, Australia; ‡ENT Consultant, ENT Department, Ninewells Hospital, Dundee, Scotland; and §ENT Consultant, ENT Department, St Andrew’s Hospital, Toowoomba, Australia. Presented at the Scottish Otolaryngology Society Meeting, ENT-Scotland; May 9, 2012; Dunblane, Scotland, United Kingdom. The authors report no conflicts of interest. Corresponding Author: Shwan H. Mohamad, MBChB, MRCS, DO-HNS, MCH, ENT Specialist Registrar, Monklands Hospital, Monkscourt Ave, Airdrie ML6 0JS, North Lanarkshire, United Kingdom (shwanbashoory@ yahoo.co.uk). Copyright © 2014 by Lippincott Williams & Wilkins
Five male patients were treated using this technique between September 2011 and September 2012. Three cases had developed auricular hematoma secondary to rugby injury, whereas the other 2 cases were spontaneous. The mean age was 23.2 years (range, 16-33 years). The follow-up was at 1 week and 3 months after surgery. All patients had a complete resolution of the hematoma without re-accumulation. Both surgeons and patients were satisfied with the cosmetic results (Figures 1 and 2). There were no complications, most notably nothing that could be
Key Words: auricular hematoma, fibrin glue, cauliflower ear (Clin J Sport Med 2014;24:e65–e67)
INTRODUCTION
Clin J Sport Med Volume 24, Number 6, November 2014
RESULTS
www.cjsportmed.com |
e65
Clin J Sport Med Volume 24, Number 6, November 2014
Mohamad et al
TABLE. Characteristics of the Case Series Case
Age, y
Cause of Auricular Hematoma
Duration of Hematoma
1
32
Spontaneous
6 wk
2 3
17 18
Rugby injury Rugby injury
3 wk 2 d after injury
4 5
18 33
Rugby injury Spontaneous
6d 4 wk
attributed to the use of fibrin glue or the dental rolls. Adequate anesthesia was achieved in all 5 patients.
DISCUSSION The need for this technique arose because of the difficulties faced in the management of case 1. This patient had previously undergone multiple procedures with aspiration, then incision and evacuation, followed by pressure dressings. The senior author (S.M.) proposed the use of Tisseel glue after further incision and drainage with the aim of avoiding further re-accumulation. The patient was successfully treated and was followed-up with no recurrence or ear deformity at 3 months (Figure 2). Tisseel (fibrin glue) is a fibrin sealant indicated for use as an adjunct to hemostasis in patients undergoing surgery
FIGURE 1. Dental rolls applied after the drainage of auricular hematoma.
e66
| www.cjsportmed.com
Type of Cases Re-accumulation after multiple incision and drainages No previous procedures Re-accumulation 3 d after initial aspiration No previous procedures No previous procedures
when control of bleeding by conventional surgical techniques (such as suture, ligature, and cautery) is ineffective or impractical.4 Tisseel is a 2-component tissue sealant, containing fibrinogen and thrombin, which both promote hemostasis. According to manufacture’s description, Tisseel contents are made from pooled human plasma (fibrinogen and thrombin) and a synthetic material of nonhuman/nonanimal origin (aprotinin).4 This would avoid the implications of its use in patients with certain religions that may avoid the use of certain animal products. Tisseel is indicated as a supportive treatment to improve hemostasis and promote adhesion where standard surgical techniques are insufficient.5 Tisseel was licensed as a medicinal product in the United Kingdom by the Medicines and Healthcare Products Regulatory Agency (MHRA) in 1999.6 It has been widely used in different surgical specialties. Studies have shown the effectiveness of fibrin glue in improving and providing effective hemostasis in a range of cardiac and aortic surgeries7 and in total hip replacement.8 It is commonly used in neurosurgery as an adjunct to dural closures to reduce cerebral spinal fluid leakage.9,10 There are other documented applications of fibrin sealant in orthopedic, ophthalmologic, trauma, head and neck, gynecologic, urologic, gastrointestinal, and dental surgery.11 This case series supports that the adhesive properties of fibrin glue may be useful in the prevention of re-accumulation of auricular hematoma. Documented side effects of Tisseel glue include hypersensitivity and anaphylactic reactions and a theoretical risk of transmitting infective agents, but such adverse effects are considered to be rare. The 5 cases described in this case series were potentially difficult cases. Two patients had recurrent hematoma. The other cases presented late at 6, 21, and 28 days after original injury. In both these groups, there is the potential for the cavity to become established secondary to inflammation with or without granulation tissue formation that might make recurrent presentations more likely. Compression was achieved in all our patients with dental rolls. The rolls were applied to both sides of the pinna and secured using through-and-through beaded prolene sutures (Figure 1). The technique of using dental roll compression in the management of auricular hematomas is widely used and has been reported.12–14 Our postoperative outcome was not assessed using any validated means. However, the review and assessment were undertaken by operating surgeon in the ENT clinic. As described above, this included contralateral ear comparison and patient satisfaction. Preoperative and Ó 2014 Lippincott Williams & Wilkins
Clin J Sport Med Volume 24, Number 6, November 2014
Fibrin Glue in the Management of Auricular Hematoma
FIGURE 2. Before and after drainage (3 months) (case 1).
postoperative photographs were compared to assess cosmetic results. This is just a small case series, albeit with promising results. At present, we do feel that its use in potentially highrisk cases is justified; however, we cannot rightly suggest its use in all cases. Factors to consider would include efficacy compared with currently used methods, cost, patient and surgeon acceptability, and potentially increased surgical time. A randomized controlled trial would be needed to further support application of this new technique in routine cases.
CONCLUSIONS This case series shows that the new technique using fibrin glue is effective. Our experience is that fibrin glue is a promising adjunct to currently available techniques in the treatment of recurrent and delayed presentation auricular hematomas. However, a randomized control trial is needed to provide further evidence on efficacy and cost effectiveness of this new technique when compared with established methods before it is recommended as standard management on all cases. REFERENCES 1. Ohlsen L, Skoog T, Sohn S. Pathogenesis of the cauliflower ear: an experimental study in rabbits. Scand J Plast Reconstr Surg. 1975;9:34–39. 2. Lane SE, Rhame GL, Wroble RL. A silicone splint for auricular hematoma. Phys Sportsmed. 1998;26:77–78.
Ó 2014 Lippincott Williams & Wilkins
3. Jones SE, Mahendran S. Interventions for acute auricular hematoma. Cochrane Database Syst Rev. 2004;(2)CD004166. 4. Tisseel [Fibrin Sealant]. Important risk Information. http://tisseel.com/us/ detailed_important_risk_information.html. Accessed November 16, 2013. 5. Medicines and Health Products Regulatory Agency. http://mhra.gov.uk/ home/groups/I-unit1/documents/websiteresources/con033569.pdf. Accessed April 27, 2013. 6. Medicines and Healthcare Products Regulatory Agency. http://.mhra.gov. uk/home/groups/I-csel/documents/committee/document/con003421.pdf. Accessed April 25, 2013. 7. Rousou JA. Use of fibrin sealants in cardiovascular surgery: a systematic review. J Card Surg. 2013;28:238–247. 8. Randelli F, Banci L, Ragone V, et al. Effectiveness of fibrin sealant after cementless total hip replacement: a double-blind randomized controlled trial. Int J Immunopathol Pharmacol. 2013;26:189–197. 9. Nissen AJ, Johnson AJ, Perkins RC, et al. Fibrin glue in otology and neurotology. Am J Otol. 1993;14:147–150. 10. Shaffrey CI, Spotnitz WD, Shaffrey ME, et al. Neurosurgical applications of fibrin glue: augmentation of dural closure in 134 patients. Neurosurgery. 1990;26:207–210. 11. Spotnitz WD, Welker RL. Clinical uses of fibrin sealant. In: Mintz PD, ed. Transfusion Therapy: Clinical Principles, Practice. Bethesda, MD: AABB; 1999:199–222. 12. George A, Tassone P. Pinna haematomas of the conchal bowl. Clin Otolaryngol. 2007;32:77. 13. Choung YH, Park K, Choung PH, et al. Simple compressive method for treatment of auricular hematoma using dental silicone material. J Laryngol Otol. 2005;119:27–31. 14. Sbaihat AS, Khatatbeh WJ. Treatment of auricular hematoma using dental rolls splints. JRMS. 2011;18:22–25.
www.cjsportmed.com |
e67
