Aural hematoma in cats ear

Re: Aural hematoma in cats ear

Anthony Todd — Mon, 18 Apr 2011 16:16:29 GMT

[quote user="Andrew Mellor"]you can keep the pinna flat and minimise the kinking[/quote]

Yeah but pinnae aren't ever flat, except in spaniels perhaps, so it's critical to get the "pad" to match the pinna contour exactly or it'll end up looking funny!

You have to hunt around for the right plastic container and prepunch the holes with a leather punch or you'll bend most needles.

Re: Aural hematoma in cats ear

James Allsop — Mon, 18 Apr 2011 13:27:57 GMT

I have just seen the dog with AH ive been treating for the last 3 weeks. 6yo cross breed presented with acute AH following head shaking. On exam left pinna v swollen, bilateral otitis externa worse in the left ear and the pinna hot and painful.

Shortly after graduating I used to drain these immediately then when that failed I would operate. The last few years I have taken a different approach based on the assumption that it is a true haematoma and that removal of the pressure by drainage, followed by further head shaking will precipitate further bleeding.

My current 'protocol' for these is:

Treat the underlying otitis (with your choice of therapy) and leave the pinna for 10-14days to allow the blood vessels to heal sufficiently and the haematoma to start organising. In this case metacam injection for analgesia and Easotic.

around day 10-14 (by which time the otitis should be much improved) drain the haematoma - small bleb of local with a microfine needle, use green needle to aspirate all of the fluid - mostly thin watery blood tinged fluid by this stage. Leave the needle in situ following drainage to allow injection of 0.5ml depomedrone (depending on size of dog) without further puncture hole, remove needle and gently massage pinna to disperse the depo. Warn of possibility of refilling and possible further treatment. In this case there was still mild otitis so i changed to canaural twcie daily for 7days as there was a little wax in the ear still

Check up 7 days later - in this case full resolution of the AH and otitis (owner reported partial refilling of the pinna 24hrs after drainage but the rapid resolution). Cosmetic appearence of the pinna is fully restored. In my experience a small degree of swelling of the pinna or mild distortion of shape is common with this technique. It was the cosmetic outcome in this case that prompted me to write this post as it surprised me with how completely it has healed.

Over the last 3-4 years I cant remember having to drain an AH more than twice or have to operate (except on a dog booked in by one of the other vets - which resolved well with surgery but had more distortion than with medical management but GA did allow more full assessment of the ear canal and more thorough cleaning).

During seeing practice as a student and speaking to the various vets ive met and worked with, everybody seems to have their own way of treating this condition. some seem more keen to grab the scalple than others. I cant remember ever seeing a case that did not have head shaking and otitis as presenting factors OR a known trauma. I cant remember ever seeing an AH in a cat though.

Re: Aural hematoma in cats ear

Gillian Mostyn — Wed, 30 Mar 2011 19:27:55 GMT

so far.......

Re: Aural hematoma in cats ear

Ruta — Wed, 30 Mar 2011 08:40:33 GMT

My vote for conservative treatment. After third aspiration cat's ear recovered. Thank you everyone for reply.

Ruta

Re: Aural hematoma in cats ear

Ruta — Mon, 28 Mar 2011 14:52:37 GMT

Thanks a lot, Anthony. Sound simple and nice. I will see how does it works for me.

Ruta

Re: Aural hematoma in cats ear

Anthony Todd — Mon, 28 Mar 2011 14:43:51 GMT

If you can't access the article then the technique looks simple.

Make holes with your biopsy punch, or just a stab through the skin might do, and lead a 3-5mm Penrose drain pushing it S/C to the top of the haematoma and out through the top stab or biopsy punch hole and secure with a stitch top and bottom, leave in for 2 weeks or so.

Actually a stab might close up too much so punch holes would be better, but others who have done it may like to correct me.

If you want a perfect ear then use the "splint" idea.

Re: Aural hematoma in cats ear

Ruta — Mon, 28 Mar 2011 14:17:28 GMT

I am not BSVA member, but I would like to get more info about this Penrose drain technique. Could somebody help me?

Ruta

Re: Aural hematoma in cats ear

Anthony Todd — Mon, 28 Mar 2011 12:28:26 GMT

Can I timidly suggest you try my way, you could combine it with the biopsy punch [surely a 3mm punch is enough] and penrose drain.

PM me if you need help.

Re: Aural hematoma in cats ear

Gerry Henry — Mon, 28 Mar 2011 11:29:28 GMT

If you aspirate when the h/toma ... whatever, is still active, ie bleeding, then the ear will refill quickly. Did you wait until it stopped bleeding, ie until it had begun to soften very slightly? Just a thought.

Re: Aural hematoma in cats ear

Ruta — Mon, 28 Mar 2011 10:28:54 GMT

The latest news from me.

After aspiration and steroids injection kitten's ear bloated again after 3h. Today I aspirated once again and found cloudy fluid with some blood. It was sent for laboratory investigation. Temperature is normal, 38,2, he is eating and playing, but every time the ear is bigger and bigger. So I am a little bit frustrated. What I am missing? Of course, it could be not hematoma, or jus abscess. I will found out more after laboratory answer.

Maybe I am doing something wrong?

Any ideas?

Ruta

Re: Aural hematoma in cats ear

Anthony Todd — Mon, 28 Mar 2011 10:08:56 GMT

[quote user="robloxley"] treatment of haematomas in man[/quote]

Yeah, well, I'll bet they continued to play or box and a "splint" would be difficult to produce in the human ear.

Re: Aural hematoma in cats ear

Anthony Todd — Mon, 28 Mar 2011 10:06:58 GMT

Here's the Joyce reference, in the dog only but pictures of the biopsy punch method with Penrose drain. Got to be better than the big slash or S shaped incision surely?

http://onlinelibrary.wiley.com/doi/10.1111/j.1748-5827.1994.tb01711.x/pdf

Need to get it via BSAVA memebrship.

No mention of the PCV or the duration but I imagine they'd all be pretty recent as the owner would notice immediately.

Most of the cases were in breeds without pricked ears so cosmetically easier.

Re: Aural hematoma in cats ear

Anthony Todd — Mon, 28 Mar 2011 09:44:42 GMT

[quote user="robloxley"]and I'm sure 2 seconds googling would find the issue.[/quote]

Well, longer than 2 seconds but this

http://www.ebvet.com/forum/viewtopic.php?p=2180

gives the most.

Problem to me is the owners assessment of "good", and it's mainly dogs, whereas cats are mostly the ones with the crumpled ears that I have seen.

Re: Aural hematoma in cats ear

Rob Loxley — Mon, 28 Mar 2011 00:47:17 GMT

[quote user="Anthony Todd"]Ok, where is this data you've collected then, is it published??[/quote]

I seem to remember it being in JSAP, and I'm sure 2 seconds googling would find the issue.

Interestingly, the Cochrane review of the literature on treatment of haematomas in man fails to be able to reach any conclusion on the best method of treatment!

Re: Aural hematoma in cats ear

Anthony Todd — Sun, 27 Mar 2011 10:14:58 GMT

[quote user="Judith Joyce"]Along with my colleagues, I embarked on some long term research of this problem and have published/presented some findings.[/quote]

It seems the research has been done, need to look at it and decide if we need to collect more cases and data.

I certainly admit that my "success" rates, if I'm honest, are based on a rosy hued [or not] vague recollection of cases past with absolutely no tabulation or data recording [except on 6x4 cards....].

Conversely, however, research is subject to manipulation and interpretation to the same degree. Disasters not included, results massaged for the result required etc. etc. So findings need to be scrutinised.

But I have seen many buttons, drains, drip-tubing etc. and lots of post-op misshapen ears.

Data collection is so much easier with computers and this forum is the ideal place to lodge it.

Re: Aural hematoma in cats ear

Kate Richardson — Sun, 27 Mar 2011 08:35:52 GMT

I don't have any hard and fast data but I usually drain them, if they refill and need draining again the owners usually bring them back about 3-7 days later and I really can't remember having to drain for a 3rd time and haven't seen them again so (and this is an assumption as I haven't followed them up for a proper scientific study ) so I assume they haven't reformed. Owners are usually quick to bring it to your attention if things haven't worked! Unless of course they have then gone elsewhere and had surgery of course.....

So I would say 1-2 weeks to resolve. Which is much the same time frame as surgery without the mess, costs and a GA.

Also anecdotally I would say approximately 30-50% of the AHs I have seen had no evidence of otitis or an inciting cause, so I assume an allergic/hypersensitiviy reaction in these cases?

These are the sort of common problems that it would be really good to collect some clinical data from from general practitioners as it is probably not the most exciting research project and who is going to refer one of these! Most studies are done at universities/referral centres on less common, 'more interesting' diseases (am not knocking this of course!), when info collected more widely from GPs could be very useful for common conditions. Admittedly the study may flawed in some aspects as far as 'proper study' goes, but I feel would still be really useful.

Arlo, could we set up a page where people could log data from common cases such as this, recording signalment, presentation, any test results, treatment used and outcome, so we could then look back after a year or after a certain number of cases seen, on the data and try to draw some conclusions from them? I know it wouldn't be a publishable study, and we would have to rely on people being objective about the info they submit, but I think it would still be really useful and interesting, especially in conditions where there is a big divide on the best treatment approach.

Re: Aural hematoma in cats ear

Mark Hedberg — Sat, 26 Mar 2011 21:24:47 GMT

I don't usually have problems with the surgery; still - how long would it take to go away after drain + depomed? I'm happy to have a go as long as I have a time frame I can give clients...

Re: Aural hematoma in cats ear

Stephen Courtney — Sat, 26 Mar 2011 16:38:47 GMT

I have seen the odd aural haematoma where I was pretty sure the inciting cause was a hefty thump on the pinna, much like the rugby players get!

I also feel that if the haematoma is 'fresh' the aspirated fluid is far more blood like, thereafter it becomes progressively more like blood stained fluid.

I have never forgotten telling my mother's vets, whose were my 'seeing practise' vets, about the steroid technique. this was some time after qualifying. They seemed very interested, but when our dog got one they slashed the ear open, stitched loads of buttons on, and made a pigs ear of it. Recovery was prolonged messy and painful. Clearly a technique issue, but I feel unless you have a recalcitrant AH, surgery should be a last resort. Incidentally, she had OE as the inciting cause.

Re: Aural hematoma in cats ear

Anthony Todd — Sat, 26 Mar 2011 14:18:05 GMT

[quote user="Rob Davis"] but looking at fresh evidence with an open mind rather than sticking with dogma allows progression[/quote]

So let's see this "fresh evidence" then! I'll take a small bet that, if it is ever produced, it hasn't taken into account the age of the haematomata.

[quote user="Rob Davis"]good results[/quote]

I doubt very much if you can get a perfect ear, ie without a distorted shape, unless it is "splinted" as I have described; I've certainly never seen one.

I think the Joyce/Ness method sounds quicker and easier and is better than the big slash down the inside of the pinna which always gave excess scarring and distortion although it only was meant to drain or remove what we used to call a haematoma.

Re: Aural hematoma in cats ear

Rob Davis — Sat, 26 Mar 2011 12:15:48 GMT

[quote user="Anthony Todd"]Surely it depends on the age of the haematoma; a resolving or resorbing haematoma will not remain as frank blood.[/quote]

This would also be my assumption, but looking at fresh evidence with an open mind rather than sticking with dogma allows progression. I am not saying that I necessarilly agree with the idea that these are not true haematomas (?haematomata), but that I am prepared to be open to the possibility that my previous assumptions may be wrong.

[quote user="Anthony Todd"]But does the aetiology affect subsequent treatment? [/quote]

Quite - I suspect not, and hence this is a largely academic discussion unless clarification of the underlying aetiology results in a different and preferable treatment.[quote user="Anthony Todd"]

[quote user="Rob Davis"] it always seems to take forever[/quote]

So are we just going for something that doesn't take forever or something that works and results in a non-crumpled ear?

[/quote]

I would like to know the answer too. As I said, I have always taken the traditional surgical approach, and have rarely had complications and have pretty much always had good results. If I can achieve the same results with a simper and quicker approach it would appear to be a bit of a no-brainer.

Re: Aural hematoma in cats ear

Anthony Todd — Sat, 26 Mar 2011 10:55:14 GMT

[quote user="Rob Davis"]I am surprised and a little disappointed[/quote]

Well I'm not surprised at this response. This is the usual disregard of years of observation and successful, more or less, treatment of a well-recognised condition dismissed because these have not been published or put on a nice spread sheet, with a coloured bar-chart next to it.

Apparently it is somewhere and I'd be glad to look at it but so far no reference.....

The difference between "our" observations and anecdotes of cause and treatment is that AH don't often get better with time, and homeopathic treatments rely on time and natural resolution for their success.

But I digress, so don't go off topic please.

[quote user="Rob Davis"] I have always assumed that these are genuine haematomas, but when I think about it, the fluid drained is generally thinne[/quote]

Surely it depends on the age of the haematoma; a resolving or resorbing haematoma will not remain as frank blood.

[quote user="Rob Davis"] it always seems to take forever[/quote]

So are we just going for something that doesn't take forever or something that works and results in a non-crumpled ear?

Sure, blood vessels rupture spontaneously and this may happen in a few or many cases and the otitis and irritation is a result and not the cause of the AH but I can't accept that there is not a primary, initial, haematoma.

But does the aetiology affect subsequent treatment?

Try telling a rugby prop that his ear is the result of a weakness or genetic incompetence, but move away quickly.

Re: Aural hematoma in cats ear

Rob Davis — Sat, 26 Mar 2011 09:10:37 GMT

I am surprised and a little disappointed at the sarcastic tone in some of the responses to Judith's / Malcolm's posts, as they appear to be the only people to post so far who have actually looked objectively at the evidence (we are generally quick to jump on the homeopaths etc when they make subjective claims without sufficient evidence base). I have always assumed that these are genuine haematomas, but when I think about it, the fluid drained is generally thinner than frank blood (although it is usually fairly dark red), though I have never measured the pcv - I will try to remember to do this on the next ones I see out of interest. I don't think I often find blood clots inside, although there are usually strands of fibrin. I would agree that most have some degree of concurrent otitis, but I can't definitively say there is a causal link (I would say that I see AH more commonly in the breeds which are more prone to OE, but is it the conformation or some other factor which increases the liklihood of both occuring concurrently without necessarilly direct causation?). I have certainly seen AH in dogs with no concurrent OE (including as mentioned previously one in a dog within hours of cartrophen injection).

I usually attempt drainage initially and instill depomedrone as desbribed by others, opting for the traditional surgical approach if this doesn't work. I am interested in Judith's approach with the penrose drain, and may try this next time (it does sound much quicker and simpler, and I never enjoy doing the mattress suture technique - it always seems to take forever!). How long do you leave the drain in situ?

Re: Aural hematoma in cats ear

Mark Hedberg — Fri, 25 Mar 2011 21:01:57 GMT

How long would you expect it to take for the hematoma to reabsorb after draining and depo-medrone?

Re: Aural hematoma in cats ear

Ruta — Fri, 25 Mar 2011 16:42:09 GMT

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Thank you for all your replies. It was really interesting and useful.

Today I aspirate kitten’s ear again. Injected Depo-Medrone and once again looked for foreign bodies or any signs of inflammation. I found none.

So hopefully, he will be fine.

Ruta

Re: Aural hematoma in cats ear

Julian Earl — Fri, 25 Mar 2011 16:36:52 GMT

Quote from CPD yesterday:

"Bleeding occurs from below the perichondrium of the scapha due to rupture of penetrating caudal auricular artery branches. Otitis externa is apparent in about 50% of cases and results in self-inflicted trauma. Some dogs have ANA antibodies or are Coombs positive leading to bleeding abnormalities."

Seems reasonable to me, and I would question the significance of the auto-immune positives; any ideas on specificity of those tests?

Also, I have a vague unsubstantiated recollection of this proposal for an inflammatory cause of AHs being disproved or dispostulated or whatever. If I have imagined this, then I apologise in advance!