Partial Transection of the External Ear Caused by a Mask Worn for COVID-19 Protection

The COVID-19 virus has had profound impacts on daily life, including the habitual wearing of face masks. In parallel, there has been an increased number of patients with face mask-related wounds presenting at outpatient clinics. Many of the patients have only minor skin damage, however, the current authors encountered a case of an otherwise healthy male who required surgical reconstruction for mask-related injury. 

The patient was a 63-year-old male with no allergies and was a current smoker. He had been diagnosed with diabetes in the past but had not required medical treatment (HbA1c at presentation, 5.9%). The patient worked at a construction site where he wore a work helmet as well as, due to the COVID-19 pandemic, a mask at all times (except while eating or sleeping). Despite knowing his face mask was too small, the patient continued to use the same mask for approximately 1 month. Over time, the upper part of the left auricle began to detach with the pressure of the mask’s ear loop; however, the patient reported feeling very little pain and, thus, hesitated to seek medical care. 

After about 6 months, the patient presented to the authors when the left auricle wound had become a large cleft. On physical examination, about one-third of the upper left auricle was completely torn, and the wound margin was completely epithelialized except for an ulcer at its deepest point (Figure 1A). There was no infection, periauricular sensory abnormalities, or congenital morphological abnormalities of the auricle. Surgery was performed to refresh the scar and the wound was sutured in 3 layers (Figure 1B, C). Five days of prophylactic oral antibiotics (cephalexin 250mg, 3 times daily) were administered, and the patient was given an “ear saver” device to use with a face mask, which transfers the suspension of the mask from behind the ears to the back of the head and, thereby, prevents direct pressure on the wound. At 6 months postoperatively, no wound recurrence was observed (Figure 1D).

Since the outbreak of COVID-19, there have been several reports of auricular problems associated with the use of facial masks. To the best of the authors’ knowledge, 4 of these cases were severe enough to require surgical treatment.^1-4 The Table shows the details of each of these 4 cases in addition to the current patient.^1-4 The table indicates that males are more frequently affected. Four of the cases also include histories of cocaine use,¹ schizophrenia,^2,4 or coronaphobia,³ indicating that a history of mental illness may be a risk factor for delayed time to hospital presentation. Regarding pain, the patient with the history of cocaine use¹ self-reported increasing wound pain for about 2 to 3 weeks prior to presentation. Similar to the current case, the patient with coronaphobia did not experience any pain; however, there was no mention of the duration it took for the wound to develop.³

The current case differs from previous reports^1-4 in that it occurred in a healthy person with no history of mental illness. The current patient’s condition clearly differed from the case of a patient with coronaphobia,³ as the current patient was simply wearing a mask in accordance with Japanese societal expectations around mask-wearing during the pandemic. He did not report any obsessive behavior or emotional distress, and he displayed no reluctance to remove his mask during examination. Furthermore, he expressed a sense of relief upon being explicitly informed by his workplace that wearing a mask was not mandatory. The onset of the injury in this case was thought to be the result of a combination of several factors, including inappropriate mask size, duration of wear, and the work environment in which the patient had to wear a helmet. In addition, the repeated occurrence of very minor localized injury with wound healing over a long period of time, as well as the lack of subjective symptoms, were thought to be some of the factors that led to this severe case in a healthy individual. The absence of infection and the slow progression of the injury appeared to account for the absence of severe pain in the current case. Additionally, it is possible that diabetic neuropathy may have been a contributing factor, but it was not evident during the examination.

A multivariate analysis conducted by Techasatian et al⁵ showed that wearing a mask for more than 4 hours (P = .006) and using the same mask every day (P = .008) significantly increased the risk of skin problems, including auricular problems. Indeed, the ears are anatomically susceptible to localized pressure,⁶ and the skin, especially in the posterior auricular region, is thinner than most areas of the face.⁷ Thus, it is prone to troubles caused by the ear loops that hold the mask in place. Additionally, because the ears are often hidden by hair, detection of lesions in that area could be delayed,⁶ especially in an individual with schizophrenia⁸ or severe diabetes, for whom there is evidence of reduced perception.

The auricle has been noted as one of the late-onset sites of a medical device-related pressure injury, and prevention methods for this condition may be effective in the general population.^6,9 Moore et al¹⁰ have shown that an intervention involving a care bundle for health care workers had some preventive effect on mask-related skin problems. In their intervention, the skin was cleaned, moisturizers were used to reduce friction, and cushion tape was applied to areas subjected to local pressure.¹⁰

Based on the above-mentioned reports and the authors’ experience, the following recommendations to prevent mask-induced auricular problems in the general population can be suggested: (1) maintain skin hygiene, (2) select an appropriately sized mask, (3) use a new mask daily, (4) take frequent breaks from wearing a mask, (5) use moisturizers and skin cushions, and (6) use an ear-saver device to reduce localized pressure on the back of the ears. The authors of the current case report followed the above instructions with their patient; to date, there has been no injury recurrence. 

There are several limitations to the current case report. The current report is a single case, with an absence of long-term follow-up data. Furthermore, there is a scarcity of similar cases, thus it is difficult to present a comprehensive investigation into the underlying causes and contributing factors of mask-related ear trauma. 

While the COVID-19 pandemic is gradually subsiding, mask-wearing mandates and guidelines are easing. The authors believe that encountering a case like the current one again seems unlikely for some time. Nonetheless, from this case readers may learn to help ensure the appropriate use of masks in the future.