Ear Hematoma. The Complete Veterinarians Guide To Understanding, Treating and Avoiding Them.

I get these shaking head painful and swollen dog ear questions too often. Perhaps for me the 'old hat stuff' has progressed into dismay that I haven't adequately gotten the word out? Maybe the whole pet loving world doesn't know what an ear hematoma, or, aural hematoma is yet?

So here I go... pull out soapbox and cross fingers that I can spare a dog the excessive expense of an emergency visit, or, the worsening of a condition that allows the snowball to escalate in to needed a TECA (total ear canal ablation), and maybe even help a pet parent out there thwart a bug at the pass and save their pet from having an ear that resembles the one above.

If you think this is painful, you would be right! A hot, swollen, tender, blood filled pillow hanging off the side of your face blocking your ears from any kind of basic function, usually corking off infection inside your ears so it can stealthily fester and ferment while the world is far beyond reach, IS ouchy!

Note the perpendicular ear pinna and the head tilt.

I have seen many of these and in each case the degree of pinna damage, area of the swelling (base of ear or tip of ear), chronicity of disease (how many times has this ear flap been down this road?), and patient and client abilities and expectations.

I always discuss how the hematoma happened, or at least why I think it happened?

Possible causes include;

1. Ear Infection (about 40 % of the time). The ear is usually smelly and full of fluid, goopy soupy discharge, red, and painful. If your dog fits this description spend time talking to your vet about how the infection happened and how you can avoid it from happening again. Most of the repeat hematomas are infection or allergy. Your pet is very likely to be back here again. Avoid this if at all possible.

2. Allergies, about 40 % of the time. The ears are usually red but are not smelly or have any fluid in them. If your dog has allergies ask for a referral to a dermatologist sooner versus later.

3. Trauma, about 15 % of the time. The puppy and the adult dog are playing and the next thing you know someone needs an e-collar.

4. Idiopathic,, also known as, "we don't know?" I would guess these are about 2%

At the clinic I usually use a teat canula (this is what the dairy farmers place in the nipples of a diary cow with a clogged gland) to correct the severely swollen full pinna hematomas. For the very small fluid pockets at the ear base I remove the fluid and add a dilute steroid to stop the inflammatory process. For cats I use a through and through suture technique after an "S" incision is made on the medial side of the pinna.

This is what the ear looks like after three weeks of the canula being in place. The wrinkling and thickening of the ear pinna in these cases may be due to the chronicity of this ear hematoma, delay in seeking medical therapy, or not addressing the underlying problem adequately. This is why I advise getting these cases early and aggressively.

After 3 weeks the teat canula is removed. There should not be any discharge or swelling during the last week.

The ear is painful. We numb it with a local lidocaine block, but, we still place a muzzle.

The most important part of the treatment of an ear hematoma is to figure out what caused it. Both ears should be examined with an otoscope to look for infection, parasites, debris, polyps, and even tumors. I have found some crazy stuff in those ears, and every pet was telling me there was a problem by shaking, rubbing, or tilting their head to the side.

In many cases cytology of the ear may also be done. This allows us to diagnose the infection and more appropriately provide a focused treatment option.

The teat canula is sutured and glued into place. 

The end of the canula needs to be checked twice daily to make sure it doesn't get clogged. It is after all there to drain the fluid.

Daisy gives a shrug and smirk of disapproval.

Daisy is ready to go home.

A teat canula should stay in for three weeks. The e-collar should stay on for the first 3-5 days, and then if the head continues to shake, or the pet rubs or paws at the ear.

Here is the break down of Daisy's ear hematoma repair;
 Exam $50
 Aural Hematoma Repair $65
 Medications; NSAID and ear antibiotic $50
 E-collar $20
 Ear Cleaner $22
In most cases with client compliance we do not charge for re-checks or the canula removal.

For those pups who have itchy painful ears, or for those who have not progressed to hematomas (but are well on their way) I wrap the ear to the head. The disadvantage of this is if there is an infection in the ear. A wrapped ear needs air, monitoring, and care. Only wrap an ear that is NOT infected. And, be very careful to NOT cut these bandages off (you don't want to add injury to insult).

I always instruct my ear clients on how to clean their pets ears. Here is a video on how I recommend doing this. It should be quick, easy, stress and pain free. I also advise them on what to have ready at home if head shaking starts again. I typically advise keeping diphenhydramine on hand and starting to clean the ears as soon as a problem seems eminent. Red ears, head rubbing, pawing or scratching at the ears all indicate that it is time to look and smell under the hood.

Related blogs;

Ear Cleaning blog.

Ears; How to Treat 'Em Right.

There is a blog on cat (feline aural hematomas) here.

Another part of keeping ear healthy is removing excessive ear hair. Blog on Ear Hair Removal here.

If you have a pet question please find me on Pawbly.com. The Pawbly community is free for all to use. We hope to help pets in every walk of life and in every corner of the globe. If you don't have a pet question please just stop over and give a hello to someone in need of a friend or some free advice on how to care for their companions.

If you would like to meet me I am available for appointments at the clinic, Jarrettsville Vet, in Jarrettsville Maryland. Our prices are posted every year. Here is the 2016 Jarrettsville Vet Price Guide.

I am also on Twitter @FreePetAdvice. You can also find helpful tips and more videos on my YouTube channel. 

Allergic Reaction Survival Kit, the Pet Parents Guide

Daisy

This lovely girl is Daisy. Her contagious smile should be the poster representation for the pit bull breed. She loves everyone and couldn't be more docile, affectionate and loving. She is the epitome of the majority of the rest of the pitties I know, an affable girl who prefers belly rubs to silly stick throwing or ball chasing.. What she lacks in drive and ambition she more than compensates for in charm.

Daisy is an interesting case for a few reasons. She came to see me about a year ago for her first cruciate repair presenting with the typical presentation of lameness, knee swelling and joint laxity. She was a young, healthy, active girl who slipped and blew out her knee. We did our routine blood work and x-rays and set her up for her surgery.

Her knee surgery started out routinely. The knee was indeed missing its complete cruciate ligament, but her thick, muscled, robust body compensated for her injury well after the knee was stabilized. She did very well under anesthesia but as she began to breathe deeper and faster while waking up from the anesthesia she also started to turn from her normal pink to a bright red. It was as if the shades of her skin were transitioning from quiet pink to raging lipstick red! I quickly grabbed a bottle of diphenhydramine and gave her an intramuscular injection. We watched her breathing and heart rate very closely and within minutes she blushed back into her placid pink without any further episodes. I made a note in the chart to forewarn us in the future and called her parents to report on her surgery and the mysterious red flush. They told me that "she did this pretty often and that nothing ever seemed to come of it."

She limped back into the clinic in December. This time holding up the other knee. She is yet another pup who met the 80% bilateral cruciate rupture statistic, (not exactly what her parents were rooting for I'm sure). But, sure as she flopped over for a belly rub she also had blown out the other knee!

The approach to her second surgery was a little more proactive. As a precaution we gave her a dose of diphenhydramine before we started her surgery. This time no redness occurred at all.

About two weeks after her knee surgery, on a Saturday night, Daisy's mom called worried because her eyes were very red, she was lethargic, and was covered in hives. She also sent me this photo;

This is what we call angioedema (swelling of the deep layers of the skin), and uticaria (hives). The skin swells and gets erythematous (red). It is not comfortable and therefore pets are usually quiet and subdued. We also usually see concurrent pyrexia (fever).

I sent Daisy's mom to the pharmacy to pick up diphenhydramine (generic Benadryl, an antihistamine). I told her to start Daisy at 1 mg/pound, or about 50 mgs. I also told her to get her in a bathtub to help lower her fever (I guessed based on her redness she would be hot) and in the rare case that she was having some contact allergic reaction to something in her environment it might help her if we could wash it off. I told her that she could give the diphenhydramine every 8 hours. I also instructed her to watch very closely for trouble breathing and worsening of her quietness. I didn't want her to become anaphylactic. If he started panting, fainting, or looking distressed they were to go to the ER immediately!

The next day I saw Daisy looking like this;

The raised hives had turned into welts (red spots) in her axilla (armpit). The facial swelling had resolved and she was her normal bright, happy, wagging girl waiting for a belly rub.. which gave me a good view of this..

OUCH!

It was time for a steroid to tell her skin to chill out!

It was also time for us to investigate anything that might be causing her problem.
I instructed her family to stop using the antibiotic and NSAID that I had prescribed after her knee surgery.

Her at home plan involves;
1. Monitor for flare-ups and try to correlate them to a source.
2. Keep a Daisy Emergency Kit on hand. It needs to contain diphenhydramine and her steroid.

If she continues to get these reactions we will prescribe an epinephrine pen to have on hand. I always worry that one adverse reaction might lead to an anaphylactic reaction. These can only be treated by an injection of epinephrine and you only have minutes to administer it.

Treatment Costs;

Daisy's cruciates were about $1100 per knee. We use the extracapsular lateral fabellar suture technique.

Allergic Reaction Exam, Free, she was at two weeks post-op so those are free.
Injectable steroid, $29.
Injectable diphenhydramine $24
Go home steroid $16

If you have a pet question, pet experience you would like to share, or a furry family member that you are devoted to please visit us at Pawbly.com. We are an open community dedicated to empowering and educating pet parents so they can take better care of the companions they share their lives with. We are free and open to anyone who loves pets.

You can also find me at the clinic, Jarrettsville Vet in Jarrettsville Maryland, or on Twitter @FreePetAdvice.