Aural Haematoma: Penrose drain method of treatment

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Thu, 29 Jan 2015 09:45:23 GMT

[quote user="Michael Woodhouse"]You speak as though a crinkly ear in a dog is somehow the end of the world.[/quote]

In this day and age when treatment standards in all other areas are so high [just think of fracture repair, for example] and the other methods with Penrose drains etc give such obvious deformities this method will give perfect cosmetic results, much to the delight of the owner.

Cauliflower ears in rugby players may be a badge of honour but they ain't in a cat or dog.

In addition a normal upright pinna is likely to lead to less ear canal irritation, which, in many cases, led to the original haematoma.

Re: Aural Haematoma: Penrose drain method of treatment

Michael Woodhouse — Thu, 29 Jan 2015 09:30:16 GMT

[quote user="Anthony Todd"]Sorry to challenge but don't they end up with distortion of the pinna? [/quote]

Anthony - I've never had an owner even slightly upset about this post aural haematoma surgery. You speak as though a crinkly ear in a dog is somehow the end of the world.

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Dennison — Thu, 29 Jan 2015 09:27:25 GMT

Update from the cause of the OP is anyone wants to know, original ear is a little crinkled but more comfortable. Now the other damn ear has got a hameatoma, right at the base of the pinna, almost in the external canal! Owners aren't keen on surgery again, so I've gone for the drain and depot approach.

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Wed, 28 Jan 2015 18:27:23 GMT

[quote user="Yantha Smyth"]The trouble with the pad is that it doesn't match the contour of the pinna so you will end up with distortion and a "full frontal" view will show this.[/quote]

Joan Wright from Kruuse sent me some sample Buster pads and, after shaping and with the aid of a hot hairdryer they contour well and I think will be a better aid than the old plastic container cut to fit.

Did a test and, somewhere, with luck there are two pictures. in the images of the shaped pad which can then be cut to the pinna contour.

The results will be perfect , better than the old plastic container, and satisfy the modvets too; a double whammy!

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Fri, 23 Jan 2015 17:22:18 GMT

[quote user="rachaelyost"]

I used to use buttons to sutures after opening cavity but since working at the PDSA just put a penrose drain in, leave until no discharge and preds for 3-4 weeks orally, and treat ear infection if present. Very few problems and since leaving the PDSA use this technique as have good success.

[/quote]

Sorry to challenge but don't they end up with distortion of the pinna?

I'd agree and capitulate if someone would publish full frontals of both ears, particularly in cats 'cos I've never seen a perfect result without a profile "splint".

I really can't see the rationale for pred and, I wonder whether it does much.

It's strange too 'cos, when I see a post of a case crying out for steroids, there is this total abhorrence of steroids yet here, where I never used them and there seems a rather tenuous rationale , they're always recommended???

Re: Aural Haematoma: Penrose drain method of treatment

rachaelyost — Fri, 23 Jan 2015 16:21:51 GMT

Re: Aural Haematoma: Penrose drain method of treatment

Thomas Johnson — Fri, 23 Jan 2015 08:44:09 GMT

Most of the aural haematomas I've seen recently have been in older dogs. When I've discussed with their owners whether we go down the surgical route, or leave them to resolve on their own but with the likelihood of the ear ending up quite crumpled, they have all declined surgery, and all have resolved within a month. I tend to drain and inject DepoMed into the cavity once, but after that no further treatment, even if they re-fill quite quickly.

Re: Aural Haematoma: Penrose drain method of treatment

Andrew Mellor — Thu, 22 Jan 2015 19:28:25 GMT

very useful things plastic milk bottles - make a perfect tracheostomy from lower half of handle and little bit of the neck as wings to suture in place !

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Thu, 22 Jan 2015 18:01:05 GMT

PS it was hard to charge for the edge of an old milk container but just think how much the cowboys will charge for a customised "Haematona Pad"

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Thu, 22 Jan 2015 17:59:33 GMT

[quote user="Andrew Mellor"]guarantee the haematoma would not come back or the ear not crinkle [/quote]

Hold this space 'cos the very helpful lady at Kruuse is sending me one of their haematoma pads and, hopefully, it may well soften with heat [its foam backed with 1mm plastic sheet] and therefore can be moulded to the pinna and punched with holes through which you can suture the haematoma after draining, preferably with a 20G needle.

When the sample arrives I'll see if I can mould it to an imaginary pinna. If so it will be more aesthetic than the corner of a milk container or 1litre IMS container cut to pinna shape.....

If it can be moulded I'll write the whole trick up again and admit that, just sometimes, modern kit is better than that available in the good old days.

Perfect pinnae [before the pedants attack] are possibly available to all.........

Re: Aural Haematoma: Penrose drain method of treatment

Andrew Mellor — Thu, 22 Jan 2015 17:00:56 GMT

[quote user="Anthony Todd"]

[quote user="Tim Charlesworth"]I tended to leave them alone when possible.[/quote]

Always, in a cat anyway, it'll end up with a crumpled ear.

I was never happy for that to happen, particularly when there was a guaranteed fix.

[/quote]

sorry I seem to have missed something , looked on the thread you suggested but I can not find your technique for guaranteed fix. the only way I can see you could guarantee the haematoma would not come back or the ear not crinkle would be to remove the pinna.

Re: Aural Haematoma: Penrose drain method of treatment

Mark Norcott — Thu, 22 Jan 2015 16:54:03 GMT

I have never had any joy with the administration of Depot steroid into the ear. The haematoma has always recurred.

If at all possible I much prefer not to cut or drain them (as long as not too big/uncomfortable) and treat with oral pred. Certainly, this seems to be a commonly employed strategy in the US. Start with 1mg/kg bid of pred and taper over several weeks. Anecdotally I would say that scarring has been less with this method than when employing a surgical option.

Re: Aural Haematoma: Penrose drain method of treatment

Bob Russell — Thu, 22 Jan 2015 16:31:13 GMT

Will happily use drains but always with preds. Probably because I read the original paper (thanks!!). Works a treat, dogs do well, owners happy!

That said, I will use the open up and suture if I feel in the mood. Takes longer but not a lot. I did have one that had a very nasty reaction, possibly to the latex drain. Quite dramatic but as with pretty much all of the techniques ended well.

Not sure what the argument is with the fluid. A fresh haematoma should be full of blood, a longer standing will have a clot and 'serum'?

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Thu, 22 Jan 2015 15:42:46 GMT

[quote user="Will McMullan"]

Has anyone looked at treating with oral prednisolone at 1mg/kg without putting a penrose in? If the original paper showed the ones not given steroids didn't do as well does it not follow it might be the huge doses of preds that are stopping scratching, head shaking and reducing swelling/inflammation in the pinna?

[/quote]

Surely that's how they end up with a crumpled ear?

Re: Aural Haematoma: Penrose drain method of treatment

Will McMullan — Thu, 22 Jan 2015 15:02:14 GMT

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Thu, 22 Jan 2015 02:58:31 GMT

[quote user="Tim Charlesworth"]I tended to leave them alone when possible.[/quote]

Always, in a cat anyway, it'll end up with a crumpled ear.

I was never happy for that to happen, particularly when there was a guaranteed fix.

Re: Aural Haematoma: Penrose drain method of treatment

Tim Charlesworth — Wed, 21 Jan 2015 20:54:06 GMT

I don't see these anymore (phew! ) but I remember trying pretty much all of the above - penrose drains, special "haematoma drains", stented sutures (bits of giving set), bandages, incisions of various sizes, excising a portion of skin from the concave aspect of the pinna + mattress sutures and the depomed protocol. I think that the vast range of treatment options tells you that there is no good solution to these. I tended to leave them alone when possible. The depomed "protocol" worked but whether this was anything above the normal s/c absorption stopping puritus I don't know but resolving the underlying otitis/source of irritation seems to be key to whichever treatment you employ.

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Wed, 21 Jan 2015 19:42:24 GMT

[quote user="Yantha Smyth"]The trouble with the pad is that it doesn't match the contour of the pinna so you will end up with distortion and a "full frontal" view will show this.[/quote]

Sorry I've just realised that the quote is me.......

It sounds as if you may be able to put the pad in hot water to mould it to the shape of the pinna then cut it to size and shape?

If so, it would be much better than the corner of a 2L plastic container which was all we had back then.

Just remember to do your sutures parallel to the long axis of the pinna though, or you can get avascular necrosis......

And a suture at the bottom first then a stretchy one at the top to get the pinna extended makes it easier.

Re: Aural Haematoma: Penrose drain method of treatment

Yantha Smyth — Wed, 21 Jan 2015 09:38:25 GMT

I think the sigmoid shape helps prevent distortion IME and the scaffold/support of the pad keeps it in shape

The trouble with the pad is that it doesn't match the contour of the pinna so you will end up with distortion and a "full frontal" view will show this.

I find it does conform once you have the sutures in place, but would be interested to hear your description of your technique- PM me with it perhaps? I can't wade through the search results to find it in its full description! I was only vaguely aware of the possible immune-mediated aspect being a rationale for the steroid use, and somehow got the idea that the steroid reduced scarring, so in effect reduced the cauliflower effect in the non-surgical ones. Clearly a case of more than one way to skin a cat

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Wed, 21 Jan 2015 09:22:08 GMT

[quote user="Yantha Smyth"]but I gather it sounds similar but with a small hole for drainage, and a plastic pinna shaped thing instead of the pad?[/quote]

I too used to drain and depomed etc but only in haematomata that didn't cover the whole pinna. Often it worked too.

I have never understood the rationale of a large incision of whatever shape just to drain what is just an organising clot.

This always gives pinna distortion or crumpling and by using say a 20G, or even larger, and curetting the whole area one can usually empty it without the distorting effect of a large incision.

The trouble with the pad is that it doesn't match the contour of the pinna so you will end up with distortion and a "full frontal" view will show this.

I think I remember plastic pinna splints being commercially available but they were one-size-fits all and therefore didn't match the pinna contour.

Re: Aural Haematoma: Penrose drain method of treatment

Yantha Smyth — Wed, 21 Jan 2015 07:01:56 GMT

I have often started with needle draining +\- depo, but had a 3 strikes and out proposal from the outset with the owner, so they know from the start it is likely to recur and before getting fed up with the whole process know there is a surgical option. It does depend on the temperament of the dog among other things. I find majority of owners happy to try conservative first, and others surgery. I have seen both spontaneous ones with no skin disease or otitis, and ones with. When doing the surgery I have used the sigmoid incision, then the buster aural haematoma pad sutured on full thickness with the parallel sutures like Anthony describes, and cosmetic outcome has always been good. The pad is not expensive, provides some absorbency, and stenting effect too. I can't find Anthony's description of technique as I tend to get lost with the sheer volume of search results, but I gather it sounds similar but with a small hole for drainage, and a plastic pinna shaped thing instead of the pad?

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Wed, 21 Jan 2015 00:22:44 GMT

[quote user="Michael Woodhouse"]It's not.[/quote]

Sorry, wrong again. Can anyone explain what the fluid is then?

Re: Aural Haematoma: Penrose drain method of treatment

Michael Woodhouse — Tue, 20 Jan 2015 23:26:33 GMT

[quote user="Anthony Todd"]If you get them early it's pure blood; after a week it's 10%[/quote]

It's not.

I appreciate n=1 isn't a study, but I had someone bring me a dog in a mad panic as it's head had started swelling up and they thought it was going to die. Presented with a dog with an aural 'haematoma' of moderate size less than an hour old. I nicked it with a blade - drained and injected depo. The PCV of the fluid was less than 15% despite looking quite 'bloody' (didn't clot though in the bowl). The owner was with the dog all day and it was a brand new one.

Re: Aural Haematoma: Penrose drain method of treatment

Anthony Todd — Tue, 20 Jan 2015 19:15:44 GMT

Here we go again I guess.

[quote user="Judith Joyce"]with the addition of prednisolone at 2mg/kg daily in divided doses for two weeks followed by 2mg kg daily for two weeks with drain removal at 14 days.[/quote]

Never needed to use oral steroids at all, ever ,and only a single shot of my favourite antibiotic of the time; probably clamoxyl., although, to be fair, if the cause of the broken blood vessel giving the haematome was otitis then the local treatment of that would probably contain steroids.

[quote user="Judith Joyce"] Outcome results were good compared with surgical and conservative techniques published by Kuwahara.[/quote]

Didn't get any full frontals last time and probably won't this time, and 80% is way below mine although now, 20 years later, I have no evidence at all.

[quote user="Judith Joyce"]haematoma has a tendency to as well[/quote] (recur)

Never with my method

[quote user="Judith Joyce"]there is no 100% treatment for all cases [/quote]

Yes there is, with the proviso that, if it is only the lower 50% or the upper 50% of the pinna then, yes, recurrence of the "un-sutured" half can happen if the initial cause isn't corrected, or there is further bleeding.

[quote user="Judith Joyce"]less than 10% (i.e. not a haematoma) [/quote]

If you get them early it's pure blood; after a week it's 10%

[quote user="Judith Joyce"]I did halve the dose of prednisolone[/quote]

Crikey for what I believe is a purely traumatic aetiology, ie a "bruise in an area without tissue to absorb the blood, why would even the most rabid steroid protagonist use it? [and that includes me]

[quote user="Judith Joyce"]increased purulent discharge. [/quote]

Never a problem with the method I have outlined in 2012 and previously.

I'd just love to see some comparative full-frontal pictures, cats particularly, of the penrose drain or button method.

One is heartened somewhat by the response:

Anthony Todd:

Cats, particularly, show gross distortion and the longer the medial [or inside] incision, for "drainage", the more distortion there is.

So?

It's just a pet.

So others really aren't looking for a cosmetically perfect result which I always strived for.

Re: Aural Haematoma: Penrose drain method of treatment

Judith Joyce — Tue, 20 Jan 2015 18:37:17 GMT

Hi,

I published a Penrose technique for the treatment of aural haematoma in 1994. It is a modification of other less surgical techniques published in the 1980s, with the addition of prednisolone at 2mg/kg daily in divided doses for two weeks followed by 2mg kg daily for two weeks with drain removal at 14 days. Outcome results were good compared with surgical and conservative techniques published by Kuwahara. The reason that the subject recurs is that the haematoma has a tendency to as well, also it is a common condition that there is no100% treatment for all cases (my figures were better than 80% non-recurrence (60% for various standard surgical techniques) and good cosmetic outcome presumably due to lack of interference with the pinnal cartilage I still use it, as do the surgeons and other vets in our practice. Although various authors in the earlier part of the 20th century stated that it was caused by trauma to the ear during head-shaking (one even presenting a formula for the sinusoidal wave created) this is not consistent with the histories of some presenting dogs (no otitis externa, skin disease, head shaking, etc reported by the owner). It is also not consistent with findings that haematoma fluid has an average PCV of less than 10% (i.e. not a haematoma) and that a consistent finding of pinnal cartilage erosions filling with granulation tissue in AH.. Kuwahara proposed an immune pathogenesis but insufficient evidence in either his or subsequent papers to confirm that, so it will remain a recurrent subject - it pops up in dermatology forums every now and then too. Sometime after publication I did halve the dose of prednisolone used due to prevalence of side-effects, but not the duration as colleagues who tried to avoid four weeks of prednisolone experienced considerably more recurrence. I have found buster collars, no/reduced prednisolone dosage and overenthusiastic wound batheing by clients with various substances have all increased purulent discharge. That last bit is not evidenced, just my subjective observation.