The auricle consists of fibrocartilaginous subunits including the helix, antihelix, concha, tragus, and antitragus. With repetitive shearing-type trauma to the ear, a hematoma may develop, typically situated in the space between the cartilage and its blood supply. Consequently, tissue necrosis may occur if the hematoma is not drained and the blood supply restored. Over time, the healing process produces disorganized fibrotic tissue that is structurally and cosmetically different from normal tissue and is known as cauliflower ear.

The repetitive, blunt trauma responsible for auricular hematoma/cauliflower ear is typically seen in sports such as rugby, wrestling, and mixed martial arts. In the initial 24 h after onset of the auricular hematoma, the lesion is tender, erythematous, and fluctuant to palpation. Following that, persistent lesions become firmer and less painful. When the lesion has progressed to cauliflower ear, there is typically no pain associated with the firm, fibrotic remodeled tissue. Rarely, infection may occur and an abscess develops. This may be associated with piercings in the affected area.

Treatment of auricular hematoma involves prompt drainage to allow for return of blood supply to the auricular cartilage. By 7 days, remodeling can already lead to permanent deformity. The procedure for drainage begins with the fundamental principles of informed consent and sterile technique . First, a regional auricular block is typically performed using a local anesthetic like 1 % lidocaine without epinephrine. For hematomas less than 48 h old and less than 2 cm in diameter, an 18 gauge needle is used to aspirate the contents. For larger (>2 cm) hematomas and those older than 48 h, incision and drainage are the preferred technique [1]. To do so, the base of the hematoma is first incised parallel to the helical curve. Then, the contents are evacuated and the lesion flushed with saline before closing with mattress sutures. Occasionally, a bolster is used to prevent re-accumulation into the space formerly occupied by the hematoma and to provide more support for cosmetic healing [2]. The bolster may be made from gauze or thermoplastic resin and sutured into place. Another bolstering technique involves the use of magnets [3]. For lesions older than 7 days, referral to a plastic surgeon is recommended.

Following a drainage procedure, the patient should be evaluated every 24–48 h to assess for re-accumulation of hematoma or signs of infection. Sutures should be removed in 7–10 days. Empiric antibiotic prophylactic treatment consists of oral levofloxacin for 7–10 days [4]

Athletes may return to play once the site has healed—generally about 7–10 days. Use of protective headwear to prevent recurrence is recommended.

Otitis externa refers to inflammation of the external auditory canal. It is most commonly seen in children aged 5–9 years [5]. Although inflammation can result from allergy or a primary dermatologic condition , it is most commonly associated with infection. In particular, P. aeruginosa, S. epidermidis, and S. aureus are the most common pathogenic organisms [6].

Risk factors for otitis externa include swimming (particularly lake swimming), traumatic removal of cerumen from the canal, use of in-ear devices like ear plugs or headphones, and prior history of dermatologic conditions like psoriasis or eczema.

The athlete with otitis externa will often complain of ear pain or itchiness and drainage (otorrhea) . There may be apparent hearing loss but no constitutional symptoms of fever or malaise. Evaluation of the athlete for otitis externa involves visual examination with an otoscope. Generally, the canal appears erythematous, swollen, and full of debris. There should be no evidence of fluid behind the tympanic membrane.

Treatment of otitis externa begins with canal irrigation with sterile room temperature saline to remove cerumen and debris once an intact tympanic membrane is confirmed. (N.B. using cold or warm water for ear irrigation can activate the vestibulo-ocular reflex causing significant vertigo and nystagmus.) Following that, fluoroquinolone/glucocorticoid combination (e.g., Cipro HC) drops are applied four times daily for 7–14 days [7]. For moderate to severe pain, oral NSAIDs are appropriate.

If possible, athletes should refrain from exposing the canal to water until the infection has resolved. For competitive swimmers, pool training may resume within 2–3 days if ear plugs and cap are used. Athletes with a perforated tympanic membrane or those with persistent symptoms beyond 48 h of treatment should be referred to an otolaryngologist .

Acute otitis media (AOM) refers to an infection of the middle ear and manifests as otalgia and hearing changes. There may be associated or preceding upper respiratory tract infection (URTI) symptoms. Occasionally, a systemic response to the infection results in fever and increased heart rate.

Risk factors for AOM include age (most common between 6 and 18 months and between 5 and 6 years), attendance at daycare, exposure to smoke, lack of breastfeeding, and family history [8].

With the advent of pneumococcal vaccines , the incidence of AOM has decreased. Most cases of AOM now result from viruses (RSV, influenza, rhinovirus). In bacterial cases, S. pneumoniae, H. influenzae, and M. catarrhalis are most often identified as the culprit pathogens [9].