Fistic Medicine: Cauliflower Ear

By Matt Pitt Nov 1, 2010
One figure in particular stands out among the beautiful sculptures of the Ny Carlsberg Glyptotek museum’s Greek antiquities wing. Amidst the marble beasts, eternally pouting graceful maidens and delicate youths, a hard faced man stares balefully at visitors. A hostile, unpretty face, he could be a soldier, a slave, a god. But by his deformed ears, we know him for what he truly is: a fighter.

No physical deformity is so inextricably bound to a specific athletic endeavor as cauliflower ear and combat sports. True, other forms of ear injury can lead to the deformity -- 19th Century opium addicts were recognizable by damaged ears born of uncounted hours lying insensate on hard wooden opium den palates -- but none as surely as the high-intensity repeated trauma of grappling. For years, the physiology and treatment of cauliflower ear was a matter of debate, and athletes had no choice but to bear their scars. Advances in surgery and a landmark 1975 study from Sweden changed all that.

In the Swedish study, investigators took two cohorts of young rabbits. In the first, they injected blood beneath the skin of the ears. In the second, they injected the same amount of blood beneath the perichodrium -- the thin layer of connective tissue that covers the cartilage of the ear. It is this cartilage that gives the pinna of the ear its distinctive curved and ridged shape. In the first group, the blood was readily absorbed; there were no complications. In the second group, where the perichondrium had been disturbed, the blood persisted, and the ears developed deformities. The study showed that not all auricular hematomas cause cauliflower ear, only those in which the perichodrium has been disrupted. Unfortunately, the shearing forces seen in grappling are very likely to cause those perichondrial injuries.

The Swedish study also elucidated what is happening at the microscopic level in the formation of cauliflower ear. When the perichodrium is torn away from the cartilage of the pinna, chondroblasts on the perichondrium are exposed to blood. In the presence of blood, chondroblasts build cartilage; in the ear, they build flexible elastic cartilage. Rapidly, new cartilage forms on top of the existing ear cartilage. When the hematoma is eventually absorbed, the taut perichodrium contracts, creating the irregular buckled appearance of cauliflower ear. The timeline for this progression is rapid: chondroblast activation occurs within hours, extensive chondroblast invasion of the hematoma occurs within days and solid cartilage is in place in less than a month.

The best approach to cauliflower ear is prevention -- the distinctive head gear of modern wrestling has proven remarkably effective at preventing ear trauma. Unfortunately, grapplers in MMA frequently forgo ear protection because it inhibits escaping chokes.

When injury does occur, treatment begins immediately. As soon as a fighter notices pain or swelling in his ear, he should ice the ear to prevent further injury; cauliflower ear pathophysiology is not strictly an inflammatory response, but similar principles apply. Firm non-traumatic pressure to the injured ear will reduce the amount of bleeding into the hematoma. The next step involves evacuation of the hematoma. While not all auricular hematomas are subperichondrial -- and thus cauliflower ear generative -- it is impossible to readily tell which are and which are not; a prudent fighter treats every auricular hematoma.

The gold standard of care for treating an auricular hematoma is surgical incision and drainage. This can be done within seven days of injury by an emergency room physician trained in the procedure or at a later point by an Otolaryngologist (ENT). After local anesthesia, an incision is made along the edge of the hematoma, following the natural contours of the ear, and the clot within is suctioned out. The skin flap is then replaced, and the ear is packed tightly with bolsters held in place using sutures sewn through the ear. Recent published research has suggested that bolstering may not be necessary: the primary risk is recurrent bleeding and the need for a repeat procedure.

An alternative technique employs needle aspiration to drain the hematoma. Long used by self-treating grapplers, this approach is gaining increasingly legitimacy in medicine. An 18- or 20-Gauge needle is used to evacuate the clot. This technique is much simpler -- simple enough that there are YouTube videos of various athletes performing the procedure on themselves with the aid of a bathroom mirror. This technique is associated with more frequent re-accumulation of fluid and incomplete evacuation of the hematoma.

When these early steps to prevent cauliflower ear formation fail or when they are never undertaken by the injured athlete, the only remaining option is cosmetic surgery. Surgery offers benefits beyond mere aesthetics: cauliflower ear can be painful and, in extreme cases, affect hearing. The auricuoplasty procedure can be done relatively cheaply, perhaps for $3,000. Even so, when balanced against the cost of protective headgear -- no more than $50 for the top-of-the-line guards -- the argument for prevention rather than treatment is difficult to refute.

There appears to be some genetic predisposition to cauliflower ears, some unfortunate combination of ear shape and perichondrial friability. But by far the greatest risk factor for cauliflower ear is the fighter’s attitude. In the subculture of grapplers -- much like German dueling scars or African ritualistic scarification -- the deformed ears may be valued for what they putatively represent: hours on the mat, endurance of pain, disinterest in the mores and aesthetics of mainstream culture. In such a culture, beauty and pathology are in the eye of the beholder.

Matt Pitt is a physician with degrees in biophysics and medicine. He is board-certified in emergency medicine and has post-graduate training in head injuries and multi-system trauma. To ask a question that could be answered in a future article, e-mail him at mpitt@sherdog.com.
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