Unraveling Unexplained Auricular Hematorrhea: Challenges and Insights

Significance Statement

Hematorrhea in the auricle is relatively rare in emergency events of the otolaryngology department, especially for unknown causes. The huge amount of hematorrhea and the patient’s tense mood undoubtedly pose a challenge to otolaryngologists. We report an emergency treatment and re-flection on a case of unexplained hematorrhea in the auricle, hoping to provide some reference value for colleagues.

A 68-year-old Chinese male sought medical attention due to recurrent hematorrhea in the right auricle for 2 months. According to his description, each hematorrhea was “jet-like,” and he denied any history of ear trauma or ear mass growth, as well as any other special medical history. In the past 2 months, the patient had received Yunnan Baiyao application and compression hemostasis treatment in primary medical institutions; however, due to poor control of the condition, he continued to be anxious.

Subsequently, the patient sought medical attention from our otolaryngology department due to recurrent hematorrhea. Physical examination revealed a huge amount of hematorrhea in his right auricle, showing a pulsatile pattern (Figure 1(A)). After compressed wrapping, the gauze quickly soaked through, and the patient continued to be anxious. His blood routine and coagulation function were both normal.

Figure 1.

(A) Pulsatile hemorrhage of auricle; (B) a 1.0 mm × 1.0 mm skin rupture on the auricle; (C) intraoperative electrocoagulation; (D) sutured auricle; (E) cartilage exposure; and (F) incision fully healed.

After calming the patient’s emotions and evaluating the condition, we decided to immediately undergo surgery under local anesthesia. During the surgery, intermittent bleeding was observed at a 1.0 mm × 1.0 mm skin rupture on the auricle after the hematorrhea slowed down (Figure 1(B)). After making a shuttle-shaped incision around the rupture and separating the skin from the cartilage, a 0.5 mm × 0.5 mm bright red soft tissue was ob-served bleeding on the cartilage surface. After separating the soft tissue from the cartilage, a small blood vessel was observed piercing out of the cartilage and connecting to the soft tissue. No abnormalities were observed in the vascular morphology. After scraping off the soft tissue on the cartilage surface, we electro-coagulated the end of the remaining blood vessels in the cartilage (Figure 1(C)), and then suture the auricle skin (Figure 1(D)). In the following days, we reviewed the patient’s annual Preventive Health Assessment reports, and conducted a detailed physical examination and medical history collection again, ruling out other vascular abnormalities in the patient. The histopathological examination results indicate the inflammatory response of the excised tissue, without vascular malformations (Figure 2). Although there was no postoperative hematorrhea, he remained anxious. After removing the suture of the auricle 14 days after surgery, it was found that the incision skin had poor growth, and cartilage was exposed (Figure 1(E)). The incision was continued to be bandaged to prevent infection. After 2 weeks, the patient’s incision fully healed and his anxiety was finally been relieved (Figure 1(F)).

Figure 2.

The histopathological examination results indicate the inflammatory response of the excised tissue, without vascular malformations.

According to literature, common auricle hemorrhage is often seen in auricle hemangiomas, which are further divided into hemangiomas and vascular malformations. ¹ Patients often present with auricle masses and recurrent bleeding. In our case, there is no diagnostic basis for hemangioma, and we tend to prefer hematorrhea caused by abnormal vascular shape. The ischemia in this area following electrocoagulation, hot weather, and the age of the patient may be the reasons for slow auricular healing.

Due to the urgency of the condition and lack of prior experience, coupled with the patient’s high level of anxiety, it is a great challenge for otolaryngologists, especially young physicians, to handle it. We suggest that for patients with recurrent unexplained hematorrhea, surgical exploration is the first choice, and embolization therapy is not a necessary recommendation. Intraoperative damage to the cartilage membrane, cartilage, and skin should be reduced to avoid subsequent infections and deformities. In addition, appropriately extending the suture removal time, using absorbable sutures, and intermittent suture removal may be beneficial factors for healing. However, we do not recommend retaining absorbable sutures in the auricle without removing them, as it takes a considerable amount of time for the sutures to be absorbed by the tissue, and foreign body reactions may not be conducive to healing.