Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Ear Avulsions and Lacerations. For the rest of the Mangled Mondays series, [click here].
What Is It?
Ears are delicate, beautiful structures. They are also easy targets.
Ear avulsion is the term for a character whose ear is either significantly cut or hacked off completely. While this entry is aimed at larger-scale removal of whole chunks of ear, the general principles also apply to smaller injuries and tearing off of chunks, including lobe amputations and injuries made by impromptu removal of ear piercings.
The ear is a delicate structure. The auricle, or external ear, is fed by three separate arteries. Therefore, ear wounds tend to bleed fairly freely and can be quite dramatic to onlookers. The structure is designed to amplify sound before it enters the ear canal. (Ear canal injuries are not covered in this section.)
What’s unique about the ear is that it’s a layer of highly vascular skin laid tightly and directly over completely avascular cartilage – it has no blood vessels at all in it. The cartilage gives the ear its structure, while the skin protects it. The earlobe itself has no cartilage to it.
Those who, like me, have piercings in both the cartilage and the lobe of an ear will recognize how different the healing times are for these piercings. So it is with repairing lacerations and avulsions; cartilage takes some time to heal, whereas the skin tends to heal fairly quickly by comparison.
The human ear. Gray’s Anatomy, 1918. Public domain.
Because of the range of injuries, from split earlobe and laceration to total avulsion, or amputation, of the ear, the outcomes vary fairly dramatically. For characters with split earlobes caused by earring removal, the earlobe can simply be stitched and may be able to be repierced as soon as six weeks after the injury.
For those with amputations, there is a significant risk that replanted tissue might not get enough blood flow to survive, and may have to be removed.
- Missing or lacerated ear.
- Some level of hearing loss due to lack of amplification. This may not be profound, however.
How Does It Happen?
In fiction, …
…ear avulsions usually happen because of an enemy’s knife blade. But in reality, auricular lacerations often occur because of sports injuries, animal bites, or accidents.
The same applies to ripping injuries, such as intentional ripping by a human or the tearing action of a predator bite. In fact, one study of auricular avulsions showed that human bite was the inciting injury in 42% of cases.
Mike Tyson, eat your heart out.
Care for ear injuries has three goals.
First, stop the bleeding. This can be accomplished with a dressing and direct pressure. The dressing is often tied or wrapped in place over the whole head; the bandaging can look dramatic.
That also accomplishes the second goal: protect the injury site. Bleeding and damaged ears are not only sensitive but at risk for infection from particulates such as gravel or dirt.
Third, if any piece of ear has been avulsed, save it for later reattachment. This will involve wrapping it in gauze and putting it in a small bag with ice, if these items are available. There may, however, be great dramatic value in a character fumbling in a pocket before pulling out her ear to offer to her medic.
Surgery / Hospitalization
Lacerations of the ear, including split earlobes, can be managed in the Emergency Department, forward field hospital, or even (as below) in the austere environment.
Because the skin and cartilage are so closely bound together, sutures that connect skin to skin can work out just fine; sutures implanted in the cartilage itself are, surprisingly, not a good idea.
Ear avulsions, on the other hand, are trickier. When the avulsion is only partial – the ear is hanging on by a scrap of intact tissue – the outcome will depend on the blood supply to the portion of the ear that remains attached to the head.
If blood supply is good, evidenced by a quick reflushing when pinched (a test for capillary refill, the speed at which blood flows into small blood vessels), the avulsion can be managed with sutures to repair or reattach the damaged flap. However, if not, a specialist will be needed to work with the small blood vessels in the ear.
Total avulsions, where a portion of the ear is completely separated from the rest of the head, will likely require some form of reconstruction and are best managed by specialists. That’s because in cases where the blood vessels have been damaged, reconnecting them is a delicate art, and decisions might have to be made weighing function against appearance.
Reconstructive surgery will leave drains in the wound. The character will get IV and oral antibiotics, and they will stay in hospital for 7–10 days following successful replantation to monitor the reattached tissue. Because the ear must heal, it will initially be stored under a skin flap in the scalp rather than left free; removing it from the scalp is a separate procedure, which will follow approximately 3 months later.
Ideally, replantation should occur within 4 hours of the injury, with decreasing odds of success as time wears on; the longest reported time between injury and successful replantation is 33 hours.
All of that, of course, assumes that the avulsed portion of ear is available. If the piece is missing, the wound will be closed with sutures and will later require reconstruction by a plastics specialist.
If the character chooses not to have surgery, prosthetic ears are available. They won’t have sensation, and may feel like an ornament or a piece that is separate from the character’s body, but for characters who don’t undergo surgery to repair the ear, they can help reduce the social consequences of a highly visible deformity.
Characters who opt for reconstructive surgery will need two things to make it work: hard cartilage or a cartilagelike material, and skin to cover it. The cartilage is either borrowed from the costal cartilage, which connects ribs to the sternum, or a synthetic is used; either is modeled after the remaining ear.
The first procedure essentially buries the new ear under skin on the side of the head to keep it protected; drains are left in for the first week, and the character will wear a cup-shaped protector for 2–4 weeks. Four months later, the “lobule” is created from skin grafts and attached, and the ear is separated from the head.
All procedures to fix the ear begin with cleaning the wound. Irrigation with sterile water or tap water is a good way to wash out bacteria, with a slight advantage to using large amounts of tap water. Dead tissue, if any, will be debrided.
This will be done under a local anesthetic, usually lidocaine without epinephrine, known in the biz as “lido no epi.” A nerve block may also be given, which numbs and eliminates most, but not all, sensations from the ear.
Suture is selected, typically a 6-0 gut suture, which is a dissolvable type.
Characters with complete avulsions will likely have their wounds cared for in an operating theater; lacerations and minor avulsions can be managed in the ER.
Characters will also get a tetanus vaccine and, if the wound was caused by an animal bite, they’ll likely also receive a rabies vaccine, unless the animal can be observed by a vet to ensure that it doesn’t have rabies.
Stitches will be removed after about a week, unless absorbable suture was used. The character will need to apply a topical antibiotic every day for a week, along with gentle cleansing with an unscented soap. The wound should not be submerged in water for the next 7–10 days, and should be covered with a clean, dry dressing.
In the Austere Environment
The same principles of care hold true in the austere environment. Careful sutures by a character with a steady hand can get much the same results as an ER doctor might give, although it’s more likely that the suturing will cause scarring and nodules to form, as finding the correct suture type in the field is unlikely.
Dressing the ear wound after suturing is impressive. Gauze pads are placed behind and in front of the ear, then a large pressure dressing is wrapped around the entire head to keep firm pressure on the ear and prevent hematoma formation. This is the closest that a patient’s head will come to looking like an Egyptian mummy’s. This form of dressing is sometimes called a “turban wrap.” It is intensely disliked by characters because it’s hot and scratchy.
Also, the character will have to keep their head elevated for several days to minimize swelling and hematoma development.
Characters with total avulsions will have their ears sutured in whatever shape they’re in; the technical requirements of microvascular care in replanting the ear will be too great for the environment.
In many cases, the ear simply cannot be reattached, and the remaining portion of the ear must heal before prosthetics can be considered. Bandages will help protect the site while it heals.
The Rocky Road to Recovery
All capabilities are retained with the obvious exception of audio quality in the affected ear.
Hearing in the ear will be slightly reduced due to loss of amplification by the conch of the ear. This is proportional to the amount of damage done and amount of ear missing.
However, the bigger problem in terms of hearing is the dressing that will be used to protect the ear while it heals, which will likely muffle sound in the affected ear.
None, if reconstructed; if unreconstructed, with no prosthesis, some hearing loss as noted.
Features of Recovery: Hospital Stay
Characters who undergo reconstruction will begin their stay in the ER, but will soon be taken to an OR, then a step-down unit; they will likely not stay in an ICU for any length of time. Discharge will be within 3–10 days depending on antibiotic needs and the needs of wound care.
Surprisingly, the latter may involve the application of leeches to the ear, as they help to promote blood vessel growth in the damaged tissue.
Characters will be instructed not to sleep on the side of the injured ear and may be given a cup-type guard to protect the site. They’ll also have to sleep with their head elevated on multiple pillows or in a recliner chair.
Features of Recovery: PT/OT
The New Normal
Scarring is perhaps the biggest challenge facing a character who has successfully had their ear repaired. Potential for granulation and keloid scarring exists.
None once fully healed.
Total Recovery Time (Typical)
Split earlobe: 12 weeks
Partial avulsion: 3–5 months
Total avulsion: 4–6 months
After the injury, blood will flow steadily from the ear. What remains of the ear will usually keep its shape fairly well even in the absence of what has been removed. As it heals, an avulsed ear that has been repaired will ooze yellow serosanguinous fluid (blood and serum) from the wound site. This is normal for draining wounds in early stages of healing.
The character who underwent an ear injury no doubt heard some form of sound during the process, but what this is will depend on the exact nature of the injury.
“ENTs” are ear-nose-throat doctors, or otolaryngologists.
If the cartilage’s blood supply has been lost due to skin loss, the cartilage can become infected even weeks after the injury. This is known as erosive chondritis.
If blood collects under the skin of the external ear and compresses the cartilage, it is known as an auricular hematoma. This can develop into “cauliflower ear,” which is well known among boxers and mixed martial artists (MMA fighters).
Pressure dressings that wrap around the head may be known as “turban wraps.”
- Ear injuries can range from a split earlobe, due to an earring being removed, to a totally avulsed ear.
- If blood supply to the remaining tissue is good, it can be repaired with stitches.
- If pieces are missing, they can be replaced with a prosthetic or surgically reconstructed.
- Characters will have bandages over their ear for at least a week, which typically wrap around the head but may be isolated to wrapping around the ear for more minor injuries.
- Field repair is possible for most injuries but won’t be anywhere near as pretty as the professional counterpart.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.
The book is OUT! Nab your copy before kicking off the NaNoWriMo Season!