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. 

Which At Home Product Works Best on Your Dog's Ears?

I get tons of pet care questions about ears. Both in and out of the clinic.. Ears are one of  the most common client complaints that bring pets in to see me. 

I understand most people think that a smelly, itchy (as indicated by head shaking or rubbing the ears), redness,or  pain are all the same thing; an ear infection. But the diagnosis is not so simple. Without a diagnosis it is almost impossible for any of us to give you a treatment.

Here  is one of the most common questions that I get:

Question from Chris on Pawbly.com;

"What do you think of Zymox enzymatic solution for treating dog ear infections? (My English bulldog has a red, wet ear with yellow discharge.) What about the different hydrocortisone concentrations - 0.5% vs. 1%?"

Here is my answer;

"Here is the constant dilemma with ears; you have to treat an infection that you are diagnosing. That is the reason we look in the ear and take a sample of the debris to look at it under the microscope, if there is any.

Here is where clients misdiagnose and misuse ear medications. 

In many many bulldog cases the ears are inflamed due to an underlying allergy and need both an otic and a systemic steroid or antihistamine, or a combination of both.

These guys need to see their vet when the ears flare up. Often the ears are the first sign of an impending or underlying problem. I love bulldogs to pieces but most need frequent life long management for their skin issues. It is best to start that relationship now. Don't treat on your own. If you guess wrong you will probably make it much harder  to treat the next time. In my experience there is always a next time.

Here is my blog on dogs and ears. It has a lot of important information. Ears, everyone has them, no one treats them right.

Sincerely,

Krista"

My pups, Jekyll on the left, and Charlie, on the right.
Can you guess which one has ear issues?
(Yep, the long big-eared beagle on the left).

More on Bulldogs here.

More on Ear Hematomas (what happens  if your pet keeps shaking their heads).

If you have a pet question you can ask it for free at Pawbly.com. Pawbly is a place dedicated to helping pet people by providing lots of information to help build and strengthen the bond between you and your pet. All answers are provided by people who care, and it is a community built on support and knowledge, all centered on pet care. Please join us today!

If you want to talk to me directly you can meet me on Twitter @FreePetAdvice, or in the vet clinic, Jarrettsville Vet, in Jarrettsville Maryland.

A Repeat Offender. The Ear Hematoma

How miserable does this poor kitty look? When I entered the exam room I was met by this uncomfortable face. She was a quick easy diagnosis.

I skimmed through her medical record.

• indoor cat
• spayed
• friendly
• up to date on all veterinary care
• new patient to our clinic
• previous history of ear hematomas

Her ear is full of fluid and looks like a pillow. The fluid in the ears is making them hang. Instead of having normal looking ear flaps that stand up (erect ears) she looks like a Scottish Fold that just spent ten rounds in the boxing ring.

The veterinary terminology for this condition is aural hematoma. A hematoma is a collection of blood that is stuck in a pocket. It is like a bruise.

Hematomas happen due to trauma. Either self induced trauma like scratching your ears, or shaking your head so violently that the blood vessels in your ear rupture. The blood then pools between the front and back skin and around the thin piece of cartilage in the ear flap. The pool of blood resembles a pillow. The problem with a hematoma in your ear is that the blood has no place to go. The hematoma gets stuck. Without some way to provide drainage for the hematoma it will just sit there. Over time the blood coagulates, solidifies and causes the ear flap to scar and distort. In people (boxers in particular) we call it 'cauliflower ear." In pets the ear flap contracts, shrivels, and calcifies. Pets with chronic recurrent ear hematomas develop scrunched deformed ear flaps that close off the ear canal, precluding air circulation, and trap dirt, debris, moisture, and other gook inside.

I see ear hematomas primarily for the following reasons;

Dogs;

1. Ear infections.
2. Allergies.
3. Fleas.
4. Scabies.
5. Playing or rough housing with another pet and they either run into some hard object, or the other dog is playing/biting on the ears.

Cats;

1. Allergies.
2. Fleas.
3. Ear mites.

Although if it is a wild/feral cat the above is reversed.

When this kitty came to see me her dad knew what the diagnosis was and he already knew what the treatment plan would include. He had been down this road before. 

Before I could say anything he said, "So, is it OK if I just leave her here until you can do her surgery?"

Many of us vets are happy to have a client that already understands and accepts the diagnosis and treatment plan, it saves us lots of talking and explaining.

But this vet likes to talk. More accurately I like to educate.

"Well, I think that we do need to drain this ear, but I wonder how this happened? Can we talk about that?"

He looked at me quizzically?

"Umm?...Well?...I don't know how it happened?" He replied hesitantly.

We began a discussion of her history, her diet, her in home care, her previous veterinary care and her environment. Initially her dad seemed a bit put off by the barrage of questions. He was here to drop her off and get on with the rest of his day.

We discussed the cat list above. Why would an inside, parasite free, only pet in the household have bilateral ear hematomas? Why would she get them again after a year?

He started to see the reason for my questions and the Q & A turned into a round table discussion.

Isn't it far better to not only treat this episode, BUT also prevent the next one?

Seeing your vet for a problem shouldn't be just about getting a diagnosis and a treatment plan, BUT also preventing?

Next time you are in your vets office ask them about preventative care, it's part of the healthcare plan.

Here is an article on aural hematomas, but I would not recommend treating this at home, and I do not inject steroids into ears.

If you have any questions about this or any other pet care items you can ask me, or any of the other Advisors at Pawbly.com, or @pawbly.

Other blogs on this subject: Aural Hematomas. The veterinarians guide to treating. Dog version.

When The Long Arm Steps In

I had an odd appointment the other night.

A couple in their early 30's, very informally dressed, somewhat nervous, and fidgety were sitting in the exam room with their black and white Cocker Spaniel.

The examination technician put the couple and the dog in the exam room, discussed the reason for their visit, (as we always do), then came out to talk to me about what they had discussed.

The exam technician primary tasks are to take the patients weight, temp, go over the owners concerns, if they have any and review the reason for their visit. This particular appointment she put the clients and my patient in the room, spoke to them for a few minutes and then came out with the patient file and a quizzical look.

My technicians are really exemplary. They in many cases can take care of over half of a clients needs without me. They can pull blood, trim nails, express anal glands, TPR, and get a good history for me. I up to help finish the few items they can't.

This appointment however, was not because the clients had a concern about their dog, it was because they had been ordered by a local official to bring their pet to see the vet.

I rarely receive an appointment with a letter. Before I could get my hands on the "reason for pet exam" the letter had made its way to every hand in the building. Everyone was curious to see what the letter said, and what the order was for.

The only thing that I was told, (because I am the last person on the totem pole to get to read the, or any, letter was that the letter was from the county animal control officer), and it simply stated that the owners had "7 days to get the pet to the vet for care" or they would be fined.

I was directed to the front desk to learn "the rest of the story," (should you ever need a kernel of information in a veterinary hospital go to the front desk. Those receptionists are the gate keepers to every tidbit of information about every piece of local gossip. They are the lifeline and the blood supply of every practice).

The rest of the story went something as follows; The somewhat estranged son of the couple had been begging his parents to get their Cocker Spaniel dog to the vet for care. After some time, and no action, he had decided to intervene on the dogs' behalf. It seems he felt she was being neglected and he wasn't going to listen to their excuses any longer. So he picked up the phone and called in a report of abuse/neglect on his parents. The following day a county animal control officer arrived. They looked at the dog, filed a report, and presented the parents with a summons.

Cocker Spaniels usually need to be groomed about every 6 to 8 weeks. They have a thick curly coat and if not kept clipped it will tangle. Many larger, flat-coated breeds, however, never need a bath or a grooming. For instance my beloved beagle Jekyl never needs a bath, (unless he finds ground hog poop a favorite cologne of his). Of the breeds that I see most needing routine scheduled grooming I would rank Cockers, Westies, Yorkies, and the hairless guys (they get so filthy it's almost hard to believe) highest. Many others get semi-annual baths just to cut down on shedding and keep the coat lustrous. In general the bigger breeds with the flattest coats almost never need water or shampoo,  but the smaller they get the dirtier and more maintenance they seem to have.

I also see a much greater incidence of skin disease in many of these "high maintneance grooming" breeds. So if you have one of the listed breeds above please talk to your vet about what kind of grooming products you use, what kind of skin lesions you see, how itchy your pet is, how they smell, how red their skin gets, and if you notice any allergy flare-ups. I tell my clients all the time, that "I know they do about 99% of the detective work for their pets ailments, it's just my job to help them recognize them, and understand what they can treat for at home, and how to hopefully avoid ever having to see me." I think many of my chronic skin guys can be managed in most part largely at home.

Cocker Spaniels are an intensively problematic skin breed, especially with respect to their ears. Those big floppy ear flaps cause a couple of things to occur in Cockers much more so than other breeds of dogs. I call it the "ear disaster perfect triangle," (you know like the fire triangle you learned in elementary school).

First, those big floppy ears may look very cute but they seal off the ear canals like  a bank vault door. Those thick heavy long ears mean that no light gets in or out. Unlike humans, (who have open erect ears therefore allowing us to get great air circulation, and sunshine), Cockers have these closed-off, dark, never see the light of day, ear canals. The lack of air flow, sunshine, and circulation causes the normal resident bacteria and yeast to go wild. They get their own little easy bake ear oven to just propagate away. And if no one ever lifts the hatch to look inside the ears just simmer away with their infections brewing away until you get a full fledged stinky, red, pus filled vat. Many Cockers get so used to the low grade ear infections that owners will come in and tell me that they had no idea the ear(s) looked so bad." I use the much repeated vet mantra advertising slogan, "flip the lip," penned by some marketing person to encourage owners to lift the lips of their pets and check out the teeth, (another ignored aspect of pet care that I will discuss later) and turned it into "flip the flap," to remind owners with floppy eared dogs to stick your nose under that ear flap every week or so. If you ever notice a red or smelly ear it's time for ear maintenance.

OK, back to the second part of the ear problem triangle.The second side of the disaster triangle is the ear flaps close out sunlight, and seal in moisture. So that dark moist environment with an already resident population of bugs only needs one more thing to "get it's party started."

The last side to the triangle is those bugs need food. Your pet provides this in the way of dirt, debris, and wax.

Those Cocker Spaniels tote around two portable incubators on each side of their cranium.

Wanna know the best way to keep your pets free from ear infections? Keep them super clean! For me that means use the heck out of a good ear cleaner. No scrubbing, no swabbing, just fill the ear and massage in. If your pet shakes out a whole wad of brown goop, just repeat the process.

I was expecting to give my "ear infection triangle speech" when I walked in the room. What I saw instead was a humongous hard to believe amount of black fur scattered in every corner of the exam room. The size of my Cocker Spaniel patient didn't seem to adequately reflect the amount of hair I was looking at. I was definitely having one of those "I can't believe what my eyes are seeing" moments.

I then understood the animal control officers letter. The mats behind this girls ears were indescribable. They were easily the size of her head, like grapefruit size, and in clusters of grapefruits.

The mats are bigger then my hand, cause her ear flap to be pushed forward,
and the mats are knotted to the skin.

Right ear mat

Left ear mat.

"How long did that take?" I secretly wondered.





Both ear pinnas shaved.

I spent some time in the exam room trying to impress upon my slightly embarrassed clients how important grooming was to these guys, and how detrimental matted hair can be. They agrred to and booked an appointment with the groomers next door to have a full head to toe beauty treatment performed, and then I asked the groomers to bring her back to me so I could finish her physical examination.


Luckily, she didn't have any skin concerns, and her ears were clean and normal. She did have some mild fungal infections between her toes that we only could identify after we have trimmed the massive amount of hair clumped between her toes.

I placed her on our 3 month reminder list. So now her parents will get a "grooming needed" post card reminder every 12 weeks. (It's a way to help them remember and an effort to keep them on the right side of the long arm of the law).

For those of you out there with a desire to own one of these "high maintenance" breeds, please remember that grooming is a necessary part of owning them. Budget accordingly, and be nice to your kids, they might rat on you.

Ears, Everyone has 'em, no one treats 'em right




My Jekyl. His morning ritual. Jumping on the bed to say "Good Morning!"

 

The famous saying in vet school is that "90% of the problems we see as Vets is skin and gut." Problem is that every vet student  bitches about Derm (dermatology) and GI (gastroenterology) class because they are so hard. It's the bread and butter of vet business, the demise of a few vet students, and the frustration of many an owner and their pet.

At the average skin/derm appointment I have to tell my owners to be patient, talk to me alot, and try not to get frustrated. Sometimes the road we get on has many a twist, turn, pit stop, pit fall, and sometimes you just want to drive off a cliff. It can be a life long problem for many dogs and cost their parents a small fortune in the process.

I love Derm and I like GI (well I love GI surgery, does that count?), and I agree it is the bread and butter.

So I thought I would talk about a dermatology topic that I see and live everyday; Ears. You see my adorable floppy eared beagle pup Jekyl has weekly cleaning sessions because those big adorable floppy ears keep the dirt and wax in and the sunshine and air out. Versus my pit bull pup Charlie who has more erect ears.

Anatomically the bigger and floppier your ears are the more likely you are to have ear problems. The Cockers, Bassetts, and Hounds tend to have yeasty ears. The darkness, moisture, and wax (food) make the perfect environment for the yeast (aka bugs) to thrive. The Labs and Shepherds have a predisposition for bad skin, so their ear ailments arise from their skin problem. Then there are the Shar Pei's and Bulldogs who because of their smooshy faces end up having stenotic (narrow) and tortuous ear canals. Ontop of that  many of these guys have ear flaps that are jammed to their head and you get narrow, moist, dark, "I already have bad skin" and being unable to get to their closed ear canals and you have big ear problems!

Here is my ear problem kid, and his brother with out ear problems. See what I mean, genetics dictate!

I want to start with the most basic advice on ears. Keep them clean! Sounds so simple. We all wash our ears, swab them, and maintain our own personal ear hygiene, so why do we wait until our pets are fire red and stink so bad I can diagnose them from the other end of the vet hospital. Or let those ears go to the point of hematoma (the ear flap swells like a pillow). Or progress to deafness? I think it is because many people are scared to clean ears. So for every ear appointment I get I give a demo on how to clean ears.

I gave this demo the other day. I asked what they do? And got the answer that I usually get. "I squirt in some cleaner and then swab out with Q-tips." "OK," I say, "I know that most of us have been taught this way and you see us do it, but I think that there is an easier and more effective way." Then I go onto to explain, "Doctors have their own opinions on how to do everything. I mean they are entitled to them, but they are wrong with ear cleaning." I always say it jokingly, (OK, half-jokingly). I then go get a big bottle of cleaner, (I only sell the big bottles), because if you are here for an ear problem you will very likely have an ear problem again soon, so I want you to be ready before you call me.

My hope is that you won't ever have to call me again. My hope is that when your dogs ears start to bother him, (when he is at the initial inflammation stage), that you at home can clean your way out of the inflammation stage and avoid the (next) infection stage all together. My job is to educate you enough that you can keep your pet healthy and avoid seeing me.

Ok, here is the "primer" on ear cleaning. If all else fails, read the label! The label on our ear cleaner reads. "Fill ear canal until overflowing and then gently massage into ear. Let pet shake out excess." See? very simple. No poking, no swabbing, no fighting, no biting, and no hurting. Now, many pets have ears that hurt, so anytime you touch a painful ear you are hurting your pet. I don't want the ear cleaning to be a torture process that your pet hates because then it won't ever get done. So be gentle, be patient, and don't scare or upset your pet.

For the first few times it is a 2 person job. The first person holds the right hand on the pets collar and left hand firmly on the nose. Keep the nose up and don't let your pet fight out of the position hold. Be firm, be kind, be patient and be gentle, and don't let your pet fight. The second person then takes the ear flap (aka pinna) firmly and gently pulls it straight out away from the face. (Perpendicular to the eye so that you open the "L" shaped ear canal into moee of a straight line). Then fill the ear with the cleaner until it overflows. (No one ever uses enough). You want to "FLOOD" the ear canal, and that's another reason I sell the big bottles only. Remember your pet's ear canal is about 3 inches long. You need to get the cleaner to fill the whole canal. Then fold the ear flap like a burrito (always a reference to food ;-)), and massage into the head. You should be massaging against the skull and you should hear a squishy sound. It is the same concept as the agitator in your washing machine. This should not hurt. Actually, most pets love the ear massage. If it hurts then it means one of two things; 1. The ear is infected and you need a vet appointment, or 2. The ear drum is ruptured and you DEFINATELY need a vet appointment.

I don't want owners to swab the ears because if the ears are red then the swab feels like sandpaper. And a dog with a hurt ear won't want to let you clean them ever again. And the other reason we don't swab is  that we are trying to get rid of the junk in those ears, not shove it back down the ear canal. Let your pet shake out the excess ear cleaner and the junk that is causing the problem.




I also tell people that you cannot over clean, but you absolutely can over medicate. I don't care if you clean the ears daily. Some pets need daily cleaning, some weekly, some yearly. 

Everyday I see a dog in the clinic for "itchy ears." Most often these guys are here for their umpteenth time. There is a huge subset of clients who only come in because their dogs ears are to the point that their dog keeps them up all night, has blood coming out of their ears because they have been itched raw, smell like infection started brewing in them last month, or the ears are so infected and painful that the owner is in fear for their life when they try to put the medication "in that small tube I got last time," in their pets ears.


Oh, the frustration of the phone call that starts as "Hey Doc, I know we haven't been in in awhile, but Sam's ears are bothering him again, and I was hoping I could get more of that medicine he got last time?" Argh, it's a hard call to answer somedays. Firstly, because I would like to see your dog outside of the disasters so that maybe we can find an answer to the problem before it hits catastrophe stage. Secondly, because that little tube you have been using on and off over the last year is a whopper of a steroid with a big gun antibiotic/anti-fungal and I am afraid you are acting like Dr. Frankenstein and inadvertently growing a batch of superbugs in those ears. You see when you have a legitimate infection (most of the time you don't, because most of the time you simply have inflammation.) We are supposed to treat twice a day until the clinical signs (redness, itchy, smell, etc) are gone for at least three days. That way you have killed all of the bugs and not just the weak ones. If you only treat intermittently you are killing the weak bugs and allowing the most powerful bugs to reproduce. Eventually you get what we call "antibiotic resistence." The only treatment after you hit this stage is surgical removal of the entire ear canal. This is called a "salvage procedure."


I have done many ear canal resections to relieve pets of the constant pain of ear infections. It is the only way to stop the pain, and these guys are long deaf by then already.

I met one little Yorkie a few months ago with terrible chronically infected ears. She had just been rescued from a hoarder. Her ears had been so infected (a combination of ear mites and infection) for so long that one of her ear canals had closed already. She had a persistent head tilt and difficulty walking because her balance was off from her ear being so damaged for so long.

The next week I removed her unsavable ear canal. She was 4 pounds and had a tough time with her surgery and recovery. It took a few weeks before she could stand up, walk, and blink normally. Thankfully we were able to save the other ear with very aggressive steroids and antibiotics. She is a very gentle shy girl and her new family gave her the complete opposite life from where she had come from. She receives endless amounts of care, love, time, and she is finally healthy. She will probably never come out of her quiet reserved shell, because was raised being outnumbered and overlooked but she is happy and finally living the life she always deserved.

Post-op, Left TECA, aka Total Ear Canal Ablation

For more information on ears I really like the book "Small Animal Ear Diseases" by Gotthelf.


Here are some of my favorite Big-eared pictures and patients. Oh, I can't resist the ears!

Baby Jekyl, the first week we got him. Note the Sutured butt..



Jekyl, OMG do I love this beagle!