ear hematoma surgery

[malernee]

1: Cochrane Database Syst Rev. 2004(2):CD004166. Related Articles, Links


Interventions for acute auricular haematoma.

Jones SE, Mahendran S.

Department of Otolaryngology, Addenbrooke's Hospital, Hill's Road, Cambridge, Cambridgeshire, UK, CB2 2QQ.

BACKGROUND: Acute haematoma of the pinna is a condition where a collection of blood forms beneath the perichondrial layer of the pinna. It is usually caused by blunt trauma, and if untreated will ultimately result in a deformity commonly known as 'cauliflower ear' or 'wrestler's ear'. Various treatments are employed to relieve the haematoma but no clear consensus exists on the best way to do so in order to produce the best cosmetic result with the least permanent deformity. OBJECTIVES: To assess the effectiveness of treatment options in acute auricular haematoma. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 2, 2003), MEDLINE (1966 - 2003) and EMBASE (1966 - 2003) with pre-specified terms. The date of the last search was April 2003. SELECTION CRITERIA: Randomised controlled trials, case controlled trials and cohort studies including children and adults undergoing any intervention for acute auricular haematoma. DATA COLLECTION AND ANALYSIS: Fifty-nine references were identified from the searches. Forty-eight were retrieved and assessed for eligibility by the authors. None met the inclusion criteria. MAIN RESULTS: Due to the lack of data from trials fulfilling selection criteria no results could be presented. REVIEWERS' CONCLUSIONS: There is no clearly defined best treatment for acute auricular haematoma. There are no good quality data to determine either the optimal management strategy or even whether post-drainage intervention (such as splinting or bandaging) is necessary. Further research is required before any specific treatment may be recommended.

Publication Types:
Review
Review, Academic

PMID: 15106240 [PubMed - indexed for MEDLINE]

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So, what is your point?

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Treatment of canine aural haematoma using an indwelling drain and corticosteroids
J Small Anim Pract 35[7]:341-344 Jul'94 Clinical Study 14 Refs

J. A. Joyce
37/39 Croft Road, Blyth, Northumberland NE24 2EL
-Aural hematomas were treated using a Penrose tissue drain inserted through the hematoma and left in situ for two weeks. Oral prednisolone was prescribed at a dose of 2 mg/kg for two weeks then 1 mg/kg for a further two weeks. Twenty-nine hematomas were treated in 22 dogs. Twenty-six cases resolved after a single treatment. Three ears required a second treatment two to four weeks after the initial treatment and one dog had a postoperative infection of the drain tract. No ears required more than one repeated drainage. Good cosmetic results were achieved in all cases. (Author Abstract)

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Evaluation of a Technique Using the Carbon Dioxide Laser for the Treatment of Aural Hematomas
J Am Anim Hosp Assoc 38[4]:385-390 Jul-Aug'02 Original Report 14 Refs


Teresa L. Dye, DVM; H. Douglas Teague, DVM, MS, DACVS; Donald A. Ostwald Jr., DVM, DABVP; Steven D. Ferreira, DVM
Denver Veterinary Specialists, 3695 Kipling St., Wheat Ridge, CO 80033
An aural hematoma is a collection of blood between the cartilage layers of the pinna, seen clinically as a fluid-filled swelling of the pinna. If left untreated, fibrous contracture of the pinna will occur. Multiple techniques have been described for treatment of aural hematoma, with the goals of treatment being to remove the hematoma, prevent recurrence, and retain the normal appearance of the ear. The carbon dioxide (CO2) laser is a pulsed energy beam created by passing high voltage across CO2 gas, and it may be used to cut, ablate, or vaporize tissue. When the CO2 laser cuts the skin, it also seals off small blood vessels and lymphatics, thus decreasing postoperative hemorrhage and swelling. It also caps nerve endings, resulting in reduced postoperative pain. The purposes of this paper are to describe and evaluate a technique using the CO2 laser for the treatment of aural hematoma.
Eight dogs representing 10 aural hematomas (two dogs had bilateral disease) were treated using the CO2 laser. The laser was used to make an incision into the hematoma to allow for evacuation of the blood; then multiple, small incisions were made over the surface of the hematoma to stimulate adhesions between the tissue layers. The average operative time for aural hematoma repair using the CO2 laser was approximately 20 minutes in the 10 cases described. Follow-up time ranged from 1 to 23 months. Hematomas were resolved in all 10 cases, although two cases developed serosanguineous fluid accumulation that required percutaneous drainage in one case and a second laser treatment in the other case. Owners evaluated the cosmetic results following laser surgery as excellent in three ears, good in five ears, and fair in two ears.
The authors conclude that the CO2 laser appears to be an effective method of treating aural hematomas in the dog. [Summary]

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Journal of the American Animal Hospital Association, Vol 32, Issue 1, 36-43
Copyright © 1996 by American Animal Hospital Association


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Articles

Evaluation of closed-suction drainage for treating auricular hematomas
SF Swaim and DM Bradley


The principal and dynamics of closed-suction wound drainage lend themselves to use on auricular hematomas. This type of drainage was evaluated in the treatment of 10 auricular hematomas on nine animals. Seven animal owners rated the results of the procedure as "good," and two rated them as "fair." The two rating the procedure as having "fair" results owned dogs with allergic dermatitis, and the auricular hematomas recurred. In both dogs, auricular hematomas again recurred after other means of treatment were used. If the pocket for the vacuum tube is not secure and the animal is quite active, or if it molests the bandage, or both, it is possible for the tube to break or the needle to come off of the tubing.

***

1: HNO. 1990 Jun;38(6):214-6. Related Articles, Links



[Therapy of ear hematoma and ear seroma]

[Article in German]

Maurer J, Mann W, Welkoborsky HJ.

Universitats-HNO-Klinik Mainz.

Conservative techniques for the treatment of auricular haematomas are unsuccessful. We discuss different operative methods and compare our results with these techniques. In our opinion the method described by Kelleher is a simple and reliable method for the treatment of auricular haematoma and seroma. After incision and evacuation of the fluid, tie-over sutures over wet sponges achieve efficient obliteration of the subperichondrial space. The most important advantages of the technique are that no resection of cartilage is necessary, the obliteration of the subperichondral space is stable, the cosmetic results are good, and the complication rate is low.

PMID: 2199417 [PubMed - indexed for MEDLINE]
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1: Aust N Z J Surg. 1987 Jun;57(6):391-2. Related Articles, Links



Auricular haematoma--treatment options.

Butt WE.

Department of Otolaryngology, Christchurch Hospital, New Zealand.

The acute auricular haematoma following a blow to the external ear presents a number of treatment options. If a satisfactory final cosmetic result is to be obtained a minor surgical procedure of one sort or another must be performed to prevent a 'cauliflower ear'. Simple needle aspiration is often insufficient to prevent this complication. Different procedures are reviewed and a simple, reliable technique for treating the acute auricular haematoma is described.

PMID: 3675394 [PubMed - indexed for MEDLINE]
******
1: Cochrane Database Syst Rev. 2004(2):CD004166. Related Articles, Links


Interventions for acute auricular haematoma.

Jones SE, Mahendran S.

Department of Otolaryngology, Addenbrooke's Hospital, Hill's Road, Cambridge, Cambridgeshire, UK, CB2 2QQ.

BACKGROUND: Acute haematoma of the pinna is a condition where a collection of blood forms beneath the perichondrial layer of the pinna. It is usually caused by blunt trauma, and if untreated will ultimately result in a deformity commonly known as 'cauliflower ear' or 'wrestler's ear'. Various treatments are employed to relieve the haematoma but no clear consensus exists on the best way to do so in order to produce the best cosmetic result with the least permanent deformity. OBJECTIVES: To assess the effectiveness of treatment options in acute auricular haematoma. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 2, 2003), MEDLINE (1966 - 2003) and EMBASE (1966 - 2003) with pre-specified terms. The date of the last search was April 2003. SELECTION CRITERIA: Randomised controlled trials, case controlled trials and cohort studies including children and adults undergoing any intervention for acute auricular haematoma. DATA COLLECTION AND ANALYSIS: Fifty-nine references were identified from the searches. Forty-eight were retrieved and assessed for eligibility by the authors. None met the inclusion criteria. MAIN RESULTS: Due to the lack of data from trials fulfilling selection criteria no results could be presented. REVIEWERS' CONCLUSIONS: There is no clearly defined best treatment for acute auricular haematoma. There are no good quality data to determine either the optimal management strategy or even whether post-drainage intervention (such as splinting or bandaging) is necessary. Further research is required before any specific treatment may be recommended.

Publication Types:
Review
Review, Academic

PMID: 15106240 [PubMed - indexed for MEDLINE]

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1: J Am Vet Med Assoc. 1983 Nov 1;183(9):972-4. Related Articles, Links


Treatment of canine aural hematoma with an indwelling drain.

Kagan KG.

Department of Surgical Sciences, JHMHC, College of Veterinary Medicine, University of Florida, Gainesville 32610, USA.

Aural hematomas in 9 dogs were managed by manual expression through stab incisions in the pinna and placement of indwelling silicone rubber drains, without compression bandaging. The drains were well tolerated. Seromas developed in 2 ears when the drains were removed at 7 and 10 days, but the seromas resolved when the drains were replaced. Healing without deformation of the pinna was obtained when the drains were maintained 13 to 28 days.

PMID: 12002588 [PubMed - indexed for MEDLINE]

[guest]

1: J Am Vet Med Assoc. 1983 May 15;182(10):1081-3. Related Articles, Links


Treatment of auricular hematoma, using a teat tube.

Wilson JW.

Auricular hematomas in 35 dogs and 12 cats were treated with a drainage method utilizing a particular bovine teat tube. The method was easy to perform and required a minimum of expendable materials. Animals were quickly returned to normal activity, aftercare was simple, healing was rapid, and the healed ear was cosmetically acceptable. Complications that developed in 7 animals were related to the time of tube removal, and could be minimized in the future by following guidelines formulated from this study.

PMID: 6863118 [PubMed - indexed for MEDLINE]

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Aural Hematoma1,8
Last updated on 6/9/2003.
Contributors:
Rhea V. Morgan DVM, DACVIM, DACVO

Disease description:
An aural hematoma is the accumulation of blood or serosanguineous fluid (from rupture of a blood vessel) between the auricular cartilage and the skin of the pinna. The hematoma usually forms on the concave or inner surface of the pinna, but occasionally is found on the convex or outer surface. Self-trauma to the pinna from shaking of the head or pawing at the ears is a common cause. Otitis externa is frequently the underlying problem responsible for the head shaking. Bite wounds are occasionally incriminated as a cause. The hematoma may be a small swelling or may fill the entire subcuticular surface of the pinna.

Surgical intervention is recommended while the hematoma is present to rapidly alleviate pain and to provide the best chance of ensuring a cosmetic result. Addressing the underlying cause of the head shaking/pruritis or otitis externa is a part of the treatment. Without surgical intervention, many aural hematomas eventually resolve through contracture of the clot and fibrosis. However, the ear becomes distorted and develops a shriveled appearance, often referred to as "cauliflower ear".


Disease description in this species:
When associated with ear mites, hematomas are more often seen in young cats. Scarring and ear distortion are common in cats even with surgical treatment of the hematoma.

Etiology:
Bite wounds
Otitis
Otitis externa
Trauma



Diagnostic procedures: Diagnostic results:
Otoscopy Ear canal inflammation
Ear mites present

Needle aspirate of ear swelling Clotted blood aspirated from ear swelling
Unclotted blood aspirated from ear swelling


Treatment/Management/Prevention:
SPECIFIC
1) Small hematomas sometime respond to drainage from aspiration with a sixteen or eighteen gauge needle, but most aural hematomas recur after aspiration and require more extensive therapy.
2) Many surgical procedures (see below) have been developed to treat this condition, most of which involve drainage of the lesion and insertion of drain tubes and setons. Some of these procedures can be performed under heavy sedation, while others require general anesthesia.
3) The external ear canals are cleaned, dried and treated with an appropriate medication at the end of the procedure.
4) Bandaging the ears following surgery is not usually required in cats, and is not often tolerated.
5) The client may be instructed to clean the incision(s) and to massage out any small pockets of fluid that accumulate post-operatively.
6) An Elizabethan collar is applied and left in place until the sutures are removed and the otitis externa is resolved.
7) Adequate treatment and consistent follow-up of any underlying cause(s) must be undertaken in the weeks following surgery.

SURGICAL DRAINAGE TECHNIQUES
1. Penrose or silastic drains: Insert Penrose or silastic drains through a stab incision on the inner aspect of the ear at one end, and thread the drain through the hematoma and out a second incision at the other end of the ear. The use of setons such as these has been accompanied by the administration of oral corticosteroids, but the contribution of the steroids to healing of the hematoma is not well understood.
2. Teat cannula: Although insertion of a teat cannula into the hematoma has been used successfully in dogs, the cannulas are fairly large for the size of cat ears. The erect ears of cats also make dependent drainage from the cannula more difficult. For these reasons, teat cannula insertion is considered a less efficacious form of treatment for aural hematomas than the incision and drainage techniques.
3. Straight incision with sutures: A straight incision is made over (and for most of the length of) the fluctuant swelling on the inner surface of the pinna. The incision is directed from the tip of the ear towards the base of the pinna, parallel to the long axis of the ear. The skin is bluntly dissected away from the surface of the cartilage and all blood and fibrin are evacuated. Nylon sutures are then placed through the full thickness of the pinna parallel to the incision, with the incision left gaping for 2-3mm. Several rows of mattress sutures are placed on either side in a staggered pattern; about 1 cm apart until all the space once taken up by the hematoma is obliterated. The sutures are removed in 14 days if all fluid and drainage have subsided, and the skin surface appears to be tightly adherent to the auricular cartilage. If needed, the sutures may be left in place for 21 days.
4. S-shaped incision and sutures: An alternative to the straight incision is to make an S- shaped incision from the proximal to the distal extent of the hematoma and as wide as the hematoma. Sutures are placed parallel to the incision line especially in the concavity of the S configuration. Surgical staples can be used on thin ears. The long portion of each staple is on the concave surface of the ear. The crimped ends of the staple are pried up slightly so that they are not compressing the ear.
5. Punch biopsy technique: Incisional drainage can also be accomplished in some cats by the use of a skin biopsy instrument. Skin is removed from the inner surface of the pinna over the hematoma using a 3-5 mm round punch biopsy instrument. Fluid is gently expressed through the resulting hole with digital pressure, and then the skin at the edge of the hole is tacked to the underlying cartilage using a nonabsorbable, simple interrupted suture.
6. Laser treatment: Similar focal, round 2mm incisions can also be created over the hematoma by use of a carbon dioxide laser. The small incisions are supplemented with a single larger, oval 1 cm incision near the tip of the ear that allows evacuation of fibrin and clots. Because most cat ears are erect, the location of this larger incision may need to be modified to encourage better drainage. The larger incision does not penetrate the full thickness of the ear, but the small incisions often do. No suturing is required with use of the carbon dioxide laser.


Preventive Measures:
1) Adequate treatment of otitis externa and close monitoring for recurrence may alleviate pruritis and head shaking, and prevent development of an aural hematoma.
2) Once a hematoma has occurred in one ear, the other ear should be closely examined for otitis.
3) Adequate surgical treatment of the affected ear usually prevents recurrence of a hematoma. Hematoma recurrence is more likely to occur with non-incisional forms of treatment, such as aspiration, than with incision and drainage techniques.


Special considerations:
When placing sutures in the hematoma, they should be oriented parallel to the incision to avoid occlusion of the 3 main branches of the auricular artery, which could cause necrosis of the edge of the pinna.

Here is a link to a handout that explains some of the surgical procedures with visual aids: Aural Hematoma Client Education Handout

If a cat presents with a "cauliflower" type of ear without a history of swelling or previous aural hematomas, the cat may have auricular chondritis which is diagnosed by biopsy. 8

Differential Diagnosis:
Neoplasia
Ceruminous hyperplasia of external ear canal
Abscessation
Auricular chondritis

References:
1) Joyce DA, Day MJ: Immunopathogenesis of canine aural hematomas. J Small Anim Pract 1997 Vol 38 pp. 152-158.
2) Joyce JA: Treatment of canine aural haematoma using an indwelling drain and corticosteroids. J Small Anim Pract 1994 Vol 35 pp. 341-344.
3) Dye TL, Teague HD, Ostwald DA, Ferreira SD: Evaluation of a technique using the carbon dioxide laser for the treatment of aural hematomas. J Am Anim Hosp Assoc 2002 Vol 38 pp. 385-390.
4) Griffin CE, Rosenkrantz WS, Tarvin G: Diseases of the external ear and pinna. New York, Churchill Livingstone 1988 pp. 937-944.
5) Smeak DD: Surgery of the external ear canal and pinna. Saunder's Manual of Small Animal Practice, 2nd ed. WB Saunders 2000 pp. 424-432.
6) Logas D, Bellah J: Diseases of the external ear and pinna. Handbook of Small Animal Practice, 4th ed. 2002 pp. 1049-1057.
7) Kuwahara J: Canine and feline aural hematomas - Results of treatment with corticosteroids. JAAHA 1986 pp. 641-646.
Delmage DA, Kelly DF: Auricular chondritis in a cat. J Small Anim Pract 2001 Vol 42 (10) pp. 499-501.

[malernee]

on 09/15/2008 5:41:55 am ET

Add oral prednisone BID tapering dose as another treatment. I'm getting a very good response with that regimen lately, no draining or sx required.

Richard D.V.M.



"Damn it, Jim... I'm a veterinarian, not a diplomat!"



on 09/15/2008 8:48:48 am ET

I've just about switched every animal to the low dose prednisone for 1 month with great response. The ears seem to be non painful ( I add in tramadol for 5 days ) and the hematoma becomes flaccid in 1 - 2 weeks. Seems to resolve in 3 - 4 weeks

"The intelligence of the creature known as a crowd, is the square root of the number of people in it."

Terry



Cathy on 09/15/2008 10:21:14 am ET

I have not done surgery or drained a hematoma in 7 or 8 years. So...

1. Pred 0.5 mg/kg BID for 7-14 days, then SID for 7, then EOD. Usual course of treatment is 28 days. Tapering speed depends on how it looks. Usually flaccid by day 10-14.

2. Most hematomas are gone by 21-28 days. Occasionally takes up to 6 weeks to totally resolve.

3. Have not had one fail to resolve yet (in a dog).

Obvious question: What would happen if we did nothing and just let them resorb?



Richard on 09/15/2008 10:27:03 am ET

Jeez, Cathy... it took you long enough to get here. We had to do your work for you.



Richard D.V.M.





Hugh on 09/15/2008 10:50:24 am ET

My question is how do they look after the pred. Do they still scar,thicken and curl or are they nearly normal compared to the other ear.

Bud





Richard on 09/15/2008 12:52:39 pm ET

Not too bad at all. Definitely not the "cauliflower" ear we're used to.

After two weeks, the hematoma sac is deflated but still present. The ear conformation slowly starts returning to normal with no shriveling. After a month or so, the sac may still be present, but it's very tiny and the ear appears normal with minimal changes.

'Course, if you look for it, you'll see the ear may sit a little different than the other. It's definitely very very minor.

Richard , D.V.M.

Mary on 09/16/2008 7:24:09 am ET

>>> Obvious question: What would happen if we did nothing and just let them resorb? <<<

I always give that option to clients, since I view this as primarily a cosmetic problem (exception for the really tight, painful ones). They go away in a month or so, you're left with some hardness and wrinkling. It would be interesting to see results of a study comparing no Rx at all to Pred.