Preventing Scarface: Pearls for Complicated Facial Lacerations – Ear Lacerations

Authors: Zachary Sletten, MD (EM Attending, Brooke Army Medical Center) and Simon Sarkisian, DO (EM Attending, Cooper University Hospital/US Army, Camden, NJ) // Reviewed by: Alexander Y. Sheng, MD, MHPE (@theshenger); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

You are a busy emergency medicine (EM) attending physician, and you hear about a facial laceration that just checked in. The intern asks you for help repairing the laceration, and you eagerly accompany them into the room excited to endow them with your wisdom on laceration repair.  After stepping into the room, you realize you might be in over your head (no pun intended).  This is not your run of the mill facial laceration.

The series will review the repair of head, eyes, ears, nose, and throat (HEENT) lacerations, with a focus on the areas where emergency physicians tend to struggle.  Today we look at ear lacerations.

Case

A 23-year-old female present to your emergency department after falling off her bike with a laceration to her ear that transects her helix.  Upon close inspection you begin to consider methods for achieving anesthesia.  You also wonder how best to repair the laceration to optimize cosmetic outcome and avoid complications.

Ear Lacerations

Repairing ear lacerations is all about effectively managing lacerations that involve the cartilage.  The pinna, or external part of the ear, is covered in thin skin which is tightly adherent to the underlying perichondrium (see Figure 1).  It is critical for the emergency physician to attempt to debride devitalized cartilage and to suture the nutrient supplying skin completely over remaining viable cartilage to avoid poor cosmetic outcomes and infection.  Up to 5 millimeters of cartilage can be removed without significant deformity, and this can be performed to allow for better skin approximation^6,7.  Primary repair is preferred if the patient presents within 24 hours.  For through-and-through lacerations, reapproximate the cartilage using 4-0 or 5-0 non-dyed absorbable buried sutures making sure to include the anterior and posterior perichondrium in your sutures and avoiding the cartilage itself if possible because it is known to tear.  Given that these buried sutures represent foreign bodies, use as few as needed to repair the cartilage.  After repair of the cartilage, considering repairing the posterior ear first (less cosmetically important) using 5-0 non-absorbable sutures followed by the anterior surface with 5-0 or 6-0 non-absorbable sutures.  Alternatively, the skin and perichondrium can be repaired together.  Take care to line up anatomic landmarks and enclose with a compressive dressing to prevent hematoma formation and eventual deformity⁶.  One well described technique for bolstering the ear involves firmly suturing two dental rolls/pieces of petroleum gauze to the ear parallel to the suture, one to the anterior portion and one to the posterior portion, using a single 4-0 non-absorbable suture as depicted in Figure 2 below.

Alternatively, one can use a piece of plaster molded to the helix/antihelix followed by loosely wrapping a bandage around the head and ear allowing a more comfortable dressing and one that can be temporarily taken down⁸. A few classically described techniques for achieving regional anesthesia of the ear are depicted below in Figure 3.  If using local anesthesia, the classic teaching is to avoid lidocaine with epinephrine to avoid necrosis, however this seems to have been debunked⁹.

It is reasonable to consider the addition of prophylactic antibiotics against Pseudomonas and skin flora to prevent perichondritis/chondritis¹⁰ although evidence to support the routine use of prophylactic antibiotics is lacking⁷.  Avulsion injuries with a narrow pedicle, lacerations with associated basilar skull fracture (which may be appreciated due to clear fluid leakage), and lacerations extending into the auditory canal should be referred to a specialist for repair^7,11.

For split earlobe repairs, often related to earrings being pulled out, good apposition of the skin edges at the margin of the ear is important.  For partial or incomplete split, extend the split to the edge/rim.  Begin the repair at the rim using 6-0 non-absorbable sutures and complete the remainder of the repair with simple interrupted sutures¹².

Stay tuned for our next piece in the series on repair of nasal lacerations.

References/Further Reading

1. Tintinalli JE, Ma OJ, Yealy DM, et al. Tintinalli’s emergency medicine: a comprehensive study guide. 2020.
2. Hollander JE, Richman PB, Werblud M, Miller T, Huggler J, Singer AJ. Irrigation in facial and scalp lacerations: does it alter outcome? Ann Emerg Med 1998;31:73-7.
3. Singer AJ, Gulla J, Hein M, Marchini S, Chale S, Arora BP. Single-layer versus double-layer closure of facial lacerations: a randomized controlled trial. Plast Reconstr Surg 2005;116:363-8; discussion 9-70.
4. Farion KJ, Russell KF, Osmond MH, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database of Systematic Reviews 2002.
5. Holger JS, Wandersee SC, Hale DB. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med 2004;22:254-7.
6. Roberts JR, Custalow CB. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 2019.
7. Williams CH, Sternard BT. Complex Ear Lacerations.StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2020, StatPearls Publishing LLC.; 2020.
8. Ear Lacerations II. (Accessed 16 JUL, 2020, at https://lacerationrepair.com/techniques/anatomic-regions/ear-lacerations-part-ii/.)
9. Häfner HM, Röcken M, Breuninger H. Epinephrine-supplemented local anesthetics for ear and nose surgery: clinical use without complications in more than 10,000 surgical procedures. J Dtsch Dermatol Ges 2005;3:195-9.
10. Walls RM, Hockberger RS, Gausche-Hill M. Rosen’s emergency medicine: concepts and clinical practice2018.
11. Lavasani L, Leventhal D, Constantinides M, Krein H. Management of acute soft tissue injury to the auricle. Facial Plast Surg 2010;26:445-50.
12. Ramakrishnan K. Surgical Repair of the Torn Ear Lobe. The Internet Journal of Family Practice. 2002.