Care should be taken to clean the area around the ear laceration as well as possible prior to initiating the repair. Sterile saline should be used to irrigate the wound with 50 to 100 mL of solution per centimeter of the wound. Anesthetizing the ear with a regional auricular block may provide the patient with greater comfort prior to irrigation, as well as avoiding tissue distortion of the laceration edges. After the wound has been cleaned, a sterile drape should be applied to isolate the field. If necessary, the physician may need to debride or excise macerated or devitalized tissue to create clean wound margins that will hold a suture before attempting the repair.

Physicians should anesthetize the area about the laceration prior to initiating the repair. Anesthesia may be achieved with a regional auricular block or by injecting anesthetic into or around the wound edges. One advantage of using a regional block is that wound edges will not be distorted by the installation of the anesthetic, and such a block will provide total anesthesia to the majority of the ear, except concha and meatus. To perform a regional auricular block, the physician will instill an anesthetic in a box or diamond shape around the ear. This will be performed by injecting an anesthetic in the shape of a "V," one inferior to the ear and an inverted "V" superior to the ear. Start by inserting the needle inferior to the ear near the lobule, aiming toward the mastoid process. Withdraw the needle while instilling 1 mL of anesthetic per inch of tissue in a subcutaneous plane to avoid anesthetizing the facial nerve. Using the same technique, insert the needle from the same starting point toward the skin anterior to the tragus and instill anesthetic while withdrawing the needle. Next, the physician will inject an anesthetic in an inverted "V," starting from the skin superior to the ear, again aiming towards the mastoid, followed by instillation of a line of anesthetic from the starting point above the ear towards the skin anterior to the tragus. Allow 5 to 10 minutes for complete anesthesia to occur, and be certain to test the patient's sensation prior to initiating the repair. 

Once the patient's wound has been cleaned, prepped, and the area anesthetized, the repair can now begin. The key tenets of repairing a complex ear laceration are properly aligning the cartilage to maintain aesthetics and making sure that overlying skin can adequately cover the cartilage. The cartilage itself is avascular and relies on coverage by skin to receive its blood supply. To start the repair, make sure that the skin can cover the exposed cartilage. If the skin cannot stretch to cover the cartilage, up to a 5-millimeter triangular wedge of cartilage through the helix can be excised without significantly affecting ear shape/aesthetics and function; anything larger than this may require local flaps for coverage or a staged repair. Small ear lacerations can be sutured with simple interrupted or running sutures through the overlying skin. When there is significant cartilage involvement and deformity of the ear, it is imperative that cartilage is realigned with deep sutures, such as 5-0 Monocryl to reapproximate the injured cartilage in a separate layer. Ideally, sutures should be thrown through the outer perichondrium, rather than through the entirety of the cartilage itself, as the cartilage has a greater tendency to pull through or tear. That said, sutures through the cartilage itself can be used if needed, and horizontal mattress sutures are less prone to cutting/tearing of the cartilage. Deep suture knots should be buried. Try to use as few deep sutures as possible to get a good alignment, as each deep suture acts as a foreign body and increases the likelihood of infection. Next, the physician should close the overlying skin with 5-0 or 6-0 simple interrupted sutures at 2- to 3-millimeter intervals. [2]

Once the laceration has been repaired, it is important to apply a pressure dressing to the ear to prevent hematoma formation. Several modalities can be used. One common method is to apply a petroleum-soaked gauze to the area over the laceration, usually about the antihelix or scapha, and into the helix, and pack it tightly against the adjacent skin. Next, apply a wad of gauze over the entire ear and hold the gauze in place with a gauze bandage wrapped around the patient's head. Another option is to use a series of simple interrupted "quilting" sutures in a through-and-through fashion. This can be done by piercing the posterior aspect of the auricle with suture and then advancing 1 centimeter superiorly before going back through the anterior aspect of the auricle, tying the knot posteriorly. Space these sutures out by a few millimeters and cover the entire ear surface that may be at risk of hematoma formation. This may also be accomplished in the form of mattress sutures. Bolstering is another option for the prevention of hematoma formation whereby a bolster is stitched against the anterior surface of the auricle. Lastly, a plaster mold of the surface of the auricle can be made to compress the skin surface and prevent hematomas; however, this is more time-intensive and may not be practical in an emergent setting. The bolster and any non-absorbable sutures should be removed in 5-7 days. At this time, no robust data support the routine use of prophylactic antibiotics in ear lacerations, including those with exposed cartilage prior to repair, however, in practice, they are routinely prescribed and should cover Pseudomonas. [3],[4],[5]

If a full-thickness laceration leaves only a small pedicle of skin attaching the avulsed portion to the remainder of the ear, consultation with an otolaryngologist or plastic surgeon for repair is indicated. This can be managed either as described above, with meticulous, multi-layer repair, or via staged repair. A staged repair often involves de-epithelializing the avulsed segment and burying it in a postauricular pocket to allow for re-vascularization of the cartilage. A second procedure elevates this construct back onto the pinna and often a posterior skin graft is required. [6] Complete avulsions of the ear can also be treated in this way, though attempts at microvascular re-implantation at the time of injury have also been described. [7]

As with all lacerations, scarring, infection, pain, and the need for additional repair are potential complications. Chondritis and hematoma formation are complications specific to ear lacerations. Patients should be reevaluated 24 to 48 hours after the repair to assess for the development of these complications. The vast majority of chondritis is provoked by Pseudomonas aeruginosa and should be treated with ciprofloxacin.[8] Lacerations of the external auditory canal put the patient at risk for canal stenosis and acute otitis externa.

While ear lacerations may appear simple, the unique anatomy and relative hypovascularity of the ear lead to several unique challenges with which the clinician must be familiar. Thus, when patients present to the emergency department, it is important to have a very low threshhold to consult with the plastic surgeon or the otolaryngologist. The emergency department physician and nurse practitioner may irrigate the wound and confirm tetanus status, but if there is any question as to the severity of the wound or potential need fo staged procedures, the wound should not be closed until seen by the specialist. A poorly repaired ear laceration can lead to hematoma formation, nerve damage, flap necrosis, and asymmetry that may be irreversible. [9][1][10]