Otology & Neurotology
30:116Y120 Ó 2008, Otology & Neurotology, Inc.
History of Otology
Auricular Hematoma and Cauliflower Deformation of
the Ear: From Art to Medicine
Albert Mudry and Wolfgang Pirsig
ENT & HNS, Lausanne, Switzerland; and ENT & HNS, Ulm, Germany
Abstract: Auricular hematoma and cauliflower deformation of
the ear are unique in several respects. Knowledge about it
began, in antiquity, through artists, particularly Greek and
Roman, and then Japanese in the 18th century with their repre-
sentation of cauliflower deformation of the ear on sculptures
and paintings of pugilists and wrestlers. It is only in the 19th
century that physicians began to make substantive progress in
understanding this abnormality. It was first thought to be asso-
ciated with mental disease, but by the beginning of the 20th
century, its etiology was recognized as being caused by trauma
and was then named auricular hematoma. The second step in
the understanding of this affliction was the observation that
Auricular hematoma and cauliflower deformation of
the ear, often observed in contact sports, such as boxing,
wrestling, and rugby, are unique in several respects. The
vascular supply of the auricle is diffuse and plentiful. The
perichondrium supplies nutrients to the auricular carti-
lage and can preserve tissue that initially appears devital-
ized. The collection of blood or serum resulting from a
direct blow or stretching trauma to the ear is classically
thought to form in the plane between the perichondrium
and cartilage (1). Questions have been raised with regard
to the location of the hematoma. Some authors suggested
it to be intracartilaginous (2). Nevertheless, the main
problem resulting from this auricular hematoma is that
the dissection of the nutrient perichondrium from the
underlying cartilage causes devitalized cartilage and
fibrosis distorting the anatomy leading to deformities
resembling a cauliflower, thus explaining the terminol-
ogy of cauliflower ear to such a deformity (also named
wrestler’s or boxer’s ear; Fig. 1). This evolution can
result if the hematoma is not quickly and adequately
controlled (3). It is only in the mid 19th century that
physicians began to make substantive progress in under-
Address correspondence and reprint requests to Albert Mudry,
M.D., Ph.D., ENT & HNS Specialist, Avenue de la Gare 6, CH-1003
Lausanne, Switzerland; E-mail: amudry@worldcom.ch
The two photographs in Museums were done by the authors.
Pictures from books come from A. Mudry’s personal library.
116
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auricular hematoma progresses toward cauliflower deformation
of the ear, which was named cauliflower ear. Recognition of this
evolution led to the development of therapies. During the second
half of the 20th century, different treatments were developed.
They included various hematoma drainage techniques with spe-
cial bandages to prevent hematoma recurrence and ensuing
progression to cauliflower ear. In summary, cauliflower
deformation of the ear is an old artistic affliction that has only
recently received medical attention. Key Words: Auricular
hematomaVCauliflower earVEarVHistoryVOtology.
Otol Neurotol 30:116Y120, 2009.
standing auricular hematoma. In fact, this problem,
and more precisely the auricular deformity resulting
from the hematoma, was already recognized during anti-
quity by artists. Reports on the damaged ears of wres-
tlers, boxers, or pugilists and pankratiasts (pankration is
a combination of boxing and wrestling) existed in Greek
and Roman literature and in the visual arts. The aim of
this study was to present the historical description and
medical understanding of this condition. Three periods
are clearly recognizable: the artistic description period
from c. 500 BC to the 19th century, the medical com-
prehension period from 1833 to the beginning of the 20th
century, and the therapeutic period in the 20th century.
Each period is discussed using original documents.
ARTISTIC DESCRIPTION
The head, and in particular the ears, was one of the
prime targets of the fighter’s blows in boxing (4). The
objective was to decrease the potential of the opponent.
In the literature of antiquity, there are several reports on
the damaged ears of the athletes. Aristophane, for
instance, coined the term Bear breaker,[ as an epithet
for boxers (5). Plato mentioned in Protagoras, Ball
these people getting their ears mangled aping the
Spartans,[ and in Gorgias, Bthe people you hear
say this have cauliflower ears,[ (6) to describe these
 CAULIFLOWER DEFORMATION OF THE EAR 117

and appropriate as models for artists, notably in

antiquity.

MEDICAL COMPREHENSION
In the Hippocratic writings, two texts (On Joints, XL,
and Instruments of Reduction, III) can be correlated with
the description of auricular hematoma, and particularly,
its complication with the formation of a tumefaction of
the auricle containing mucus or pus (10). The exact inter-
pretation is difficult. Nevertheless, one of the first known
texts found in medical textbook, clearly concerning a
deformity of the ear corresponding to an auricular hema-
toma, was by Giedinger in 1771. Giedinger (11) notably
wrote, Bthe whole anterior and posterior surface of the
left ear was extraordinary tumefied. After incision, a
great quantity of blood flew out.[ This deformity of
the auricle is clearly associated with the presence of
blood in the tissues.
In 1833, Bird, a physician responsible for treating the
insane, described six cases of Binflammation of the
auricle[ only in male subjects prone to mental derange-
ment (Fig. 4). Bird began his publication by mentioning,
BI want to make a short report on a disease of the exter-
nal ear of which nothing could be found in the litera-
ture. This is astonishing because this disease is very

FIG. 1. Cauliflower ear (boxer’s ear).

deformations of the ear. The church father Tertullian

appropriately called the traumatized ears of the pugi-
lists Baurium fungi[ (ear mushrooms or thick ear) in
De spectaculis (7). Perhaps this term is comparable to
what was known in the Talmud as a Btziman[ (one whose
ears resemble a sponge) and who was therefore unfit for
Temple service (8). These crumped or cauliflower ears
are also preserved in Greek and Roman sculpture. Dif-
ferent examples can be found throughout Antiquity (9)
mostly in serious Greek and Roman collections such as
in the National Museum in Athens (Fig. 2), the Museo
Nazionale in Rome (Fig. 3), the British Museum in
London, the Pergamon Museum in Berlin, and the
Musée du Louvres in Paris. In the last third of the 18th
century, several Japanese artists created color prints to
portray contemporary wrestlers. Katsukawa Shunsho
was one of the leading print artists and founded the Kat-
sukawa School, which produced many paintings, particu-
larly of sumo wrestlers with cauliflower ears. Some of
these paintings are collected in the Ota Memorial Museum
of Art in Tokyo and in the British Museum in London.
The study of artistic productions of cauliflower ear
demonstrates a very long relationship between artists
and the representation of this deformity of the ear. This
fact is certainly in relation to the fact that wrestlers, FIG. 2. Marble head with cauliflower ear, from the National
boxers, pugilists, and pankratiasts were very popular Museum, Athens.

Otology & Neurotology, Vol. 30, No. 1, 2009

Copyright @ 2008 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
118 A. MUDRY AND W. PIRSIG
FIG. 3. Bronze head with cauliflower ear, from Apollonius,
National Museum, Rome.
frequentI I report on an inflammation of the external
ear in insane people which markedly differs from the
usual type of this inflammation.[ Further on, BGradually
the auricle is getting hot; it is getting more red and even
bluish although the swelling appears moderate today;
when the swelling is complete, it will feel very hard
rather soon[ (12). This description is considered as
the first description of auricular hematoma. For Kramer,
this affection is considered as a furuncle of the auricle.
Kramer (13) wrote in 1836 that, BDr. Bird thinks he has
observed it to be especially frequent in those who are
the subjects of mental derangement; but this probably
depended on some fortuitous coincidence of unknown
circumstances.[
Fischer, in 1848, introduced the term othaematoma to
describe this abnormality as a bloody tumefaction of the
auricle (Ohrblutgeschwulst). Fischer (14) wrote, BShortly
after its developpement, the tumefaction contains fluid
black red bloodI The source of this blood is to be
found in the vessels of the perichondrium.[
Gudden (15), in 1860, explained clearly the traumatic
origin of the auricular hematoma, Bthe reason for an
auricular hematoma is always due to an external lesion.[
Virchow (16) also used the term auricular hematoma and
confirmed the conclusions of Gudden in writing: BRecent
investigations have shown the evidence that this type is
due to a mechanical mainly traumatic separation of the
partsIthus the auricular hematoma coincidences with a
violent action on the auricle.[ Virchow excluded a men-
Otology & Neurotology, Vol. 30, No. 1, 2009
Copyright @ 2008 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
tal disease as a predisposing factor in developing an
auricular hematoma.
Gruber, in 1870, described the varied spontaneous
evolution of the auricular hematoma, from recovery to
important deformation of the auricle, demonstrating
clearly the transformation of an auricular hematoma to
a cauliflower ear (Fig. 5). Gruber (17) wrote, BThe course
of an othematoma varies depending on the amount of
poured bloodI Such larger exudates finally induce
conspicuous auricle deformities, in as much if they are
associated with a fracture of the ear cartilage and a shift
of its pieces.[
In 1873, Roosa discussed an idiopathic origin among
the insane to understand why auricular hematoma was
particularly found in this group. This idiopathic form
must strictly be distinguished from the traumatic form.
Roosa stated in the first edition of his treatise that, Bto
conclude from these observations that the othaematomata
are always the result of traumatic influences, that they are
more frequent among the insane because they are very
apt to injure themselves or be injured by their attendants,
seems to me to be manifestly incorrect.[ Roosa (18)
continued, Bthere are two distinct varieties of othaema-
tomata: traumatic and idiopathic.[
At the beginning of the 20th century, auricular hema-
toma was considered as a Bspontaneous or traumatic
laceration of the blood-vessels of the perichondrium
with the formation of a fluid effusion between the carti-
lage and the perichondrium, and in the body of the car-
tilage. It is favored by softening, vacuolization, and
brittleness of the cartilage, such as occurs in old age
and in insane individuals[ (19). Progressively, the rela-
tion between auricular hematoma and trauma was clear
enough to exclude a mental disease as a predisposing
factor, but this was not so easy to establish: BEtiology.-
This is somewhat obscure. Apparently the aged and more
especially the insane are particularly prone to certain
degenerative changes in the auricular cartilage and pe-
richondrium, in which condition haematoma auris is
apparently easily induced by very slight injuries. Its
FIG. 4. Bird’s drawings of othematoma (Fig. 4 and Fig. 5 in the
image, whereas Fig. 3 is a normal ear; 1833).
 CAULIFLOWER DEFORMATION OF THE EAR
FIG. 5. Acute othematoma and cauliflower ear, from Gruber (17).
occurrence in this class of individuals has been noted
with particular frequency in Germany, and the occur-
rence there of certain cases in which no history of trauma
could be obtained had led to the belief that a certain
number of cases occur spontaneously. One wonders,
however, whether even in such casesYdepending un-
questionably in some degree upon degenerative tissue
changesYthere has not been some slight injury which,
though overlooked at the time, has been directly exciting
cause. In this country (United States of America), so far
as the writer knows, the condition is almost always due
to direct violence[ (20). The frequency of occurrence of
auricular hematoma in the insane was in direct propor-
tion to the agitated behavior of these patients and their
numerous traumas.
In the 1970s, two experimental studies in rabbits tried
to localize precisely the hematoma. The first study con-
firmed that most of the hematoma was not between the
perichondrium and the cartilage but was intracartilagi-
nous (21). Two years later, a second study rejected
these conclusions and demonstrated that the hematoma
was effectively located between the cartilage and the peri-
chondrium (22). This statement became widely accepted.
Nevertheless, this ambiguity has never been resolved, and
the discussion continues in recent literature (2).
MEDICAL THERAPY
The medical therapy of acute auricular hematoma
began in the second part of the 19th century with the
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119
acceptance of the clear relationship between auricular
hematoma and secondary deformity of the auricle. The
goals of therapy were complete removal of the fluid and
prevention of its re-accumulation and organization. Dif-
ferent treatments were used such as pressure and massage
(23) but needle aspiration or incision of the acute hema-
toma was the most widely used treatment until the
second part of the 20th century. Unfortunately, this tech-
nique was not efficient, which was the reason why varied
other techniques began to appear in medical journals.
Some of these included the window operation (24),
aspiration and plaster molding of the auricle (25), ultra-
violet exposition (26), continuous portable vacuum drain-
age (27), button technique (28), and drainage and
excision of the fibroneocartilage (29). The management
of auricular hematoma has always been a challenge for
physicians.
Kelleher (30) was one of the first to describe the most
used technique, which consisted of incision and suction
of the auricular hematoma associated with tie-through
sutures (compression sutures) over wet cotton to obliter-
ate the fluid space after evacuation of the hematoma.
Various other types of pressure dressings have proved
effective in preventing the reaccumulation of blood
such as cotton bolsters (31), silicone rubber splints
(32), removable auricular stent (33), and thermoplastic
splint (34). This will prevent the development of an orga-
nized auricular hematoma. Nevertheless, and due to lack
of good-quality data, today, there is no clearly defined
optimal management strategy for auricular hematoma.
Otology & Neurotology, Vol. 30, No. 1, 2009
120 A. MUDRY AND W. PIRSIG
Furthermore, the question of a postdrainage dressing is
questionable (35). However, the most effective preven-
11.
tion of auricular hematoma is to protect the recovering
ears from blunt trauma, particularly in sports such as 12.
wrestling, boxing, and rugby.
In hematomas older than a few days, hyperplastic 13.
fibrocartilaginous tissue and early cartilage formation 14.
can develop in the roof of the hematoma. In treating
these lesions, careful dissection of this tissue before the 15.
application of an appropriate pressure dressing must be
16.
performed to prevent the deformity of cauliflower ear
(36). To achieve a thin, normally contoured auricle, the 17.
newly formed fibroneocartilaginous layer, along with the
attached perichondrium, must be completely excised 18.
(37). Finally, when a cauliflower ear has developed,
19.
selective surgical reconstructive techniques must be
used to obtain cosmetically acceptable results, the main 20.
goal being excision of the excess fibrocartilage (38).
21.
22.
CONCLUSION
The history of auricular hematoma and cauliflower ear 23.
is an interesting travel through art history and medical
24.
science. From the classic cauliflower ear well known by
the Greek and Roman artists, to the understanding of the 25.
traumatic cause of the auricular hematoma leading to the
deformity of the ear, more than 2000 years have passed. 26.
For nearly one century, confusion persisted between phy-
27.
sicians to explain the origin of this condition. Further-
more, no final consensus in treatment exists today.
Auricular hematoma is an old artistic condition with a 28.
young medical therapy. The study of its history follows
an attractive route from art to medicine. 29.
30.
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