Aural Hematoma

An aural hematoma is one of the most painful-looking conditions I know of.  Aural means ear and hematoma means bloody swelling.  The pinna is the floppy, outside part of the ear (as opposed to the ear canal, the tube going down and in to the ear-drum).  The pinna is a 3-layer sandwich of skin, cartilage and skin.  When a blood vessel in the pinna breaks, it oozes fluid between the layers, separating the skin on the underside of the pinna from the cartilage.  The ear can look like it has a slight bulge, or it can look as though it has been inflated to the point of bursting.  This swelling means that the area is under a lot of pressure, and that means pain.

Affected individuals are usually holding their head sideways, and they may or may not be shaking their head. They are pretty uncomfortable, if not downright painful.

When I was in veterinary school in the seventies, the conventional wisdom was that the dog (or cat) has an ear infection.  This causes him to shake his head and scratch his ears until he finally breaks a blood vessel in the pinna, which then begins the inflation process.   Treatment would obviously need to include treatment of the ear canal infection that started the process.  Then the pinna would receive a major surgery.  If you don't drain these bloody swellings, it takes months for the body to stop the leak and absorb all the fluid.  The ear pinna gets badly scarred and deformed and "wadded up" in the healing process, much like the cauliflower ear of the boxer whose head has been pummeled hard enough to break ears, noses, and cheekbones.  Plus,the pet stays really uncomfortable for a long time.

Draining the swelling by simply puncturing it doesn't work very well.  The pocket refills quite rapidly.  You needed to keep the pocket draining until the vessels inside healed up.  In the old days (jeez, I was a kid in "the old days"), this involved cutting a sliver of skin out of the underside of the ear so that it wouldn't heal up too fast.  Then the ear pinna was sewn to a piece of some rigid material so that it wouldn't wrinkle up and "cauliflower" as it healed.  What a horrendous, messy piece of surgery that was, not to mention the mess during the healing process.

A huge advance was the development of a much less drastic technique that works ninety percent of the time and frequently doesn't even require a tranquilizer.  Using a large-bore hypodermic needle, a small (1/8 inch) incision is made in the pocket and the fluid drained out.  Then a little plastic drainage tube is sutured in place and left for a couple of weeks.  This allows the fluid to escape so that the ear can "stick back together".  You have to keep them on antibiotics during this period, as bacteria can enter the pocket through the tube that the fluid is draining from, and it's a great place for them to grow.  It's still pretty messy for a few days, but so much cheaper and easier on the dog, the owner, and the surgeon.

Here's the basic tube, designed to be put up into a cow's udder to allow nasties to drain when she has mastitis (breast infections).  It's got a little screw on cap, a little hole in the end, a little hole in the side, and two little spurs to keep it from falling out.

I cut the end a little shorter to enlarge that hole, cut the existing side-hole larger, and add another hole to the opposite side.  Then the cap is removed, and the round flange trimmed to make a flat surface that will lie against the ear when the tube is inserted.

Many dogs do not even need a tranquilizer for this.  You just poke a hole, squeeze out the gooey, pop in the tube and put in one stitch to hold it.

Even better, there has been new work that suggests some of these are NOT due to the trauma of head-shaking and scratching.  I have often seen these hematomas in animals whose ear canals appeared perfectly clean and healthy, i.e. no ear infection.  This was puzzling, but I attributed it to one good hard shake that played "crack the whip" with the ear.   New evidence suggests that many of these hematomas are immune-mediated.  This means that the body's defense system has gone a little haywire and attacked its own blood vessels, causing the damage that blows up these ears.  What this means in practical terms is that if you suppress the body's defenses long enough for it stop this self-attack, the hematoma may heal without any surgery or drainage at all. 

Many of these cases will respond to high doses of prednisone (a synthetic form of cortisone) with no other treatment.  It is amazing to see one of these ballooned-up ears return to normal just by taking pills.  The down-side would be the side-effects of the prednisone (excessive appetite, excessive urination, followed by excessive water-drinking, are the most obvious).  Worse would be a patient who gets a bad infection while you are suppressing his body defenses.  That's not common, but it certainly can happen.  It's also important to taper the dosage off slowly.  If you stop as soon as the ear swelling goes down, it's very likely to recur rapidly.

One thing is for sure: small hematomas almost always get bigger.  When you first notice that ear swelling, rapid treatment will result in a much faster and simpler healing process than if you wait until the entire pinna is involved.

Comments

[Kim]

I have a 9 year old Weimaraner that just had surgery the 6th time in 1 year for recurrent aural hematomas. Everytime the vet corrects it, the next day, the ear blows up in a different spot. We have spent at least $200-$300 per surgery and are at our wits end. We love this dog, but can't continue to shell out the tremendous amount of money to correct this problem. She NEVER has ear infections and does not have a clotting disorder. Do you have any other suggestions for us? I will be mentioning the use of prednisone to the vet to see if we can try that. Thanks!

[Dr. Everett Mobley]

I cannot really speak to cases that I have not examined. I have re-edited the post with additional information on the drainage tube procedure. I have sent Kim a more detailed personal reply.
TEM,DVM

[jason]

hi i have a pit bull terrier that we just saved from being destroyed and she has aural hematoma we just noticed last week,it is pretty big now. and i just got laidoff from work im kicking myself not being able to afford a vet right now,is there anything i can try to do at home to help.i feel like a scumbag not being able to go to the vet right away.it doesnt seem to hurt her iv been puttin hot compresses on and i tryed a needle but she wasnt to keen of the idea .will this blister kill her.i could never live with myself if that happined.could you give me some options please!!!!!

[Doc]

Dear Jason,

No this will not kill her. It's like a big blood blister. It is uncomfortable from the pressure. Sticking a needle in it is not a good idea. It will just fill up again, and you could easily introduce germs. A blood-filled cavity is not a good place to add germs, as it would be a wonderful place for them to grow. Then you would have a nasty infection instead of just the pressure.

Heat opens blood vessels and would make them leak more. Cold causes them to close up and leak less. When something first happens, cold is best to prevent further leakage. Use a therapeutic cold pack, or just a rag soaked in ice water. Apply for 10 to 15 minutes at a time, resoaking the rag as necessary. Do not use ice directly, as it is too cold.

When the problem is a week old or more, heat may help to break up the clots and enhance resorption, but may also re-start the bleeding.

The pressure is what causes the discomfort, but additional head-shaking makes it worse. If she would let you put a soft bandage to put the ear over the top of her head, that might let things start to resolve.

If there is no ear infection that needs to be treated, the hematoma will eventually resolve. It may take several weeks, however, and the ear will look sort of "wadded up" when it finally heals with scar tissue between the ear layers. It won't be pretty, but when the pressure is gone, it won't be painful either.

Best of luck, and thanks for reading and writing.

[Julius]

Hi- My dog recently developed an aural hematoma and I immediately brought him into my vet for an exam. The first thing our vet recommended recommended was to aspirate the hematoma with a syringe. She informed me that this was only going to be a 30% success rate. We waited a few days and sure enough the pinna filled right back up again. I spoke with my vet about other options and she mentioned to either aspirate again or insert a drain with minor surgery- stating surgery would yield a 90% success rate. I opted for surgery since it seemed like my best option at the point. Like an earlier post I wish my vet would have sat me down to explain what to expect post surgery. We went ahead with the surgery and the outcome was nothing like what I expected. I brought him back to the vet 4 days post surgery because I noticed a slight odor from the bandage. The bandage was removed by a technician and she cut the tip of my dog's ear by accident. The surgery site showed signs of slight infection plus the new wound created by the technician caused my dog to go onto an antibiotic. The wound was rebandaged and a couple of days later my dog was somehow able to remove his bandage and cause a mess. A few days have gone by and I notice he is doing excessive head shaking and pawing at his 'bad' ear. I also noticed that his ear seems to be filled up again. What are my options now? My vet seems to treat me like an overconcerned parent but I really don't feel like I'm getting much direction here. Should we aspirate again? I definitely don't want to put him through surgery again. What if I leave it alone and put cold compresses on it daily?

[Doc]

I can really only give you general advice, here, as I
mentioned in another post.

http://www.yourpetsbestfriend.com/your_pets_best_friend/2007/10/second-opinions.html

That being said, if the hematoma is full, it needs to
get un-full. I am not visualizing how the ear is
bandaged. Usually when surgery has been performed,
there is either a pretty good-sized opening or a
drainage tube so that fluid does not re-accumulate.
If there is such an opening, it is common to prescribe
antibiotics until things are closed up again. Bloody
fluid is a great place for germs to grow. You are
already on antibiotics because of the unfortunate
un-bandaging accident, so stay on them. If your dog
is not receiving any type of pain medicine, I think it
would be good to ask your veterinarian about getting
some. If the ear is swollen, it's under pressure,
which means it's uncomfortable at best.

I would be very hesitant to recommend the prednisone
treatment at this point, since you have wounds to deal
with and the prednisone suppresses the body's
defenses. It is possible that the small teat-tube
surgery (simple insertion of the small drain tube, as
illustrated in the post) may be helpful at this point.
Also, aspirating (sucking out) the fluid and using a
compression bandage may be an option.

The bottom line is that the doctor who is on the scene
is in a better position to know what is going on. I
can understand that you are not happy with the results
to date. If you feel that you and your veterinarian
are not communicating well, you need to let him/her
know that. Simply say that you don't understand what
to expect and what the options are, and you need some
help to see the big picture.

You could also consider asking him/her to refer you to
another doctor for a second opinion. Personally, I'd
much rather give a copy of the medical record to the
client and give him a list of other doctors I respect,
than to just have him pick someone at random out of
the phonebook.

I hope this is helpful. Thanks for reading and
writing.

[Stacy G]

It looks as though my dog has an aural hematoma. She has always had itchy ears and sometimes gets infections. I know the hematomas can go away on their own but there is also surgery for treatment. Is there any benefit to the surgery other than the prevention of malformation? Can i treat the infection if present and hope the hematoma will go away? How do i know if there is a chance of rupture?

[Doc]

I will answer your questions as best I can.

"She has always had itchy ears and sometimes gets infections." This is something that needs to be addressed. It would be a good idea to investigate possible underlying causes for this, like allergic problems.

"I know the hematomas can go away on their own" This is a very slow process - weeks to months.

"Is there any benefit to the surgery other than the prevention of malformation?" As long as the ear is swollen, it is under pressure, which means that it is painful. Whether the pressure is relieved by surgical drainage, a drain tube, or treatment with prednisone, it IS important to relieve the pressure so that the dog won't be painful. Just treating the infection in the ear canal won't do that.

"Can i treat the infection if present and hope the hematoma will go away?" Your dog will be painful for a longer period of time.

"How do i know if there is a chance of rupture?" Rupture is not likely to occur.

Your dog will get better sooner if she receives care from your veterinarian.

Thanks for reading and writing.

[Tim]

Hi Doc -

Great information. While there are many sites that offer information on the subject, in my opinion there are none that explain the cause and subsequent treatment options as well.

Of course on to my question . . . I have a lab who has undergone two previous "quilting" surgeries for aural hematomas and now we may be going in for number 3. There is a spot on her left ear that was not quilted as it was not affected by her previous hematomas. The area is not too large and the chance for it to spread is minimal (or so we've) been told due to the prior surgeries.

At this time the hematoma is not filled - there is some puffiness, but the area is not completely filled with any fluid. To avoid putting her through another extensive surgery I was wondering on your thoughts of treating her with prednisone.

I understand that it is very difficult to give an opinion without actually seeing the dog, however any insight you may be able to provide would be greatly appreciated.

[Teri Owens]

Our Basset Hound is 9 or 10 yrs. old. He was a rescue and the sweetest dog in the world. On Thanksgiving, he was playing with a couple of other smaller dogs and all of the sudden, this hematoma shows up on his ear. We took him to the vet on Saturday morning,and they drained it (22cc'c)and put him on prednisone (10mg. twice per day). The hematoma filled back up after 10 days and we chose to drain again (34cc's) and the vet doubled the dose of prednisone and perscribed it for a longer period of time. The vet is recommending the surgery, if this does not work. My
questions are: Can we continue draining and allow the prednisone treatment to work? Could there be complications from continuing to do it this way? The vet did mention something about inserting a tube, but really recommends the surgery where they would puncture the ear with holes and stitch in a quilted pattern. I am really unsure of which way to go, the surgery seems so invasive and with extensive recovery time.
The vet also mentioned that if the hematoma was caused by trauma, which we are not sure how it happened, that really the only thing to fix it is the surgery. What is your opinion on that statement?

Thank You, I got a lot out of your answers.

Teri Owens

[Doc]

Tim,
Since the hematoma is small, I don't think it would hurt your veterinarian's feelings to just ASK about the prednisone. Of course, we all cringe when a client says "I was looking on the internet, and...". There may be reasons why they are not comfortable with this approach for your dog. It is also possible that they have not tried it for any of their patients. I can tell you that it was a bit of a leap of faith the first time I tried it. It's by no means guaranteed to be successful, but it is worth investigating.

Thanks for reading and writing

[Doc]

Teri,

I hope I can help with your questions.

"Can we continue draining and allow the prednisone treatment to work?" Yes, providing that it actually does work. If you're not seeing improvement with the higher doses in a week or so, it's probably not going to work.

"Could there be complications from continuing to do it this way?" Yes. Everytime you poke a hole into a cavity filled with bloody fluid, you risk starting an infection there. Also, prednisone is not without side-effects.

"The vet did mention something about inserting a tube, but really recommends the surgery where they would puncture the ear with holes and stitch in a quilted pattern." The tube surgery is really rapid and fairly inexpensive. If it doesn't work, you can still go to the more extensive surgery, should it be needed.

"I am really unsure of which way to go" No kidding. Any time you find fifteen different ways to do something, it lets you know that there is not one best way for every patient.

"The vet also mentioned that if the hematoma was caused by trauma, which we are not sure how it happened, that really the only thing to fix it is the surgery. What is your opinion on that statement?" I agree that surgery may be necessary.

It sounds to me like your veterinarian is being thorough, giving you options, and doing his best to advise you as to what he feels will give your dog its best outcome.

Good luck, and thanks for reading and writing.

[Jackie]

I have a Calico cat that had a ear hematoma surgically removed today. The tube is in her ear but her ear is quite swolen again and she's bleeding through the incision the tube is in. is this normal? How do I relieve the pressure from the blood building up in her ear?

[Doc]

It sounds like the drain tube may be clogged. You should contact your veterinarian. The solution may be something as simple as taking a small needle and un-clogging the tube. DO call your veterinarian.

Thanks for reading and writing.

[Laurie]

What is a good way to bandage dogs ears after arual hemotoma surgery, my dog has been shaking head and very stressed since she has come home 2 days ago I am afraid that the stress can't be good for her she is 12 and in general good health but the vet tech has practicaly her whole head taped up very tight

[Doc]

Head bandaging is difficult. I have used ether to make the tape really sticky, then used the tape to make a "handle" from the end of the ear. The handle gets taped down to the dog's head. You need padding both under the ear and over it.

You really do want to immobilize the ear for a while so that shaking of the head doesn't spray blood everywhere, and you don't want them to scratch it.

It is certainly true that some dogs are distressed by the mere presence of a bandage. However, I would also be concerned that your dog's pain is not fully controlled. You should contact your veterinarian and ask if he/she can add some additional pain medications, and possibly a mild sedative for a few days.

I hope this is helpful.

Thanks for reading and writing.

[Tom Nelson]

My older dog (11) has what seems to be an aural hematoma on his ear. I suspect this as he had one on the other ear, although not throughout the entire ear flap like this one. I have elected to just let the swelling go down on it's own. I was also curious as whether there is something I could give for pain whether over the counter or prescription, until the swelling goes down? The dog seems to be in some discomfort by this.

Also, would repeated ice packs help with swelling?

Thanks, Tom

[Swade's Mom]

Hi Doc,

After doing extensive research, I finally came across your article. My dog, Swade, a 6-year old pitbull mix has gone through 3 hematomas back to back. Two occurred in the same ear and the most recent was in the other ear. All were treated with a drainage tube.

I've gone to 2 different vets and have been trying to find out the CAUSE of his hematomas. He does not have any ear infections, all vets have confirmed this. One technician at the vet office suggested it may be a food allergy. I did happen to change his diet about 4 months ago right around the time of his first hematoma. I have since then switched him back and been giving him vitamins daily.

No one has been able to explain the cause and I've been dishing out hundreds of dollars getting his ear drained. I'm really interested in learning more about prednisone and mostly on the cause of his reoccuring hematomas. There must be a reason. Is it a clotting problem? Both vets said there's no way to isolate the cause and that it could reoccur... sounds like I'd have to keep paying them.

To give you more history on my dog, he's never had any issues like this before. He was neutered in September... the hematomas started in october. He stays outside in the backyard until I come home. He used to sleep outside at night as well until back in August. Could it be something in my house that he is allergic to? I'm so frustrated at the incompetence of these vets. After questioning one extensively, he suggested I give my dog claritin. While I could do so, I still don't know why he is having these issues? Now, his original ear (the one that had healed back in January) looks like it might become a hematoma yet again. There are 2 small blisters right next to each other and one was bleeding.

I'm really hoping you can shed some light on this for me and at least point me in the right direction so I can learn more. As I said, you're the first I've come across that's noticed the lack of an ear infection. I live in Atlanta so if you know of a good vet, please let me know. I really appreciate your time.

Thanks,
Swade's mom

[Doc]

Hello, Tom,

It is possible that the ice-packs will help slow the swelling. Cold causes blood vessels to constrict, tightening them down, slowing leakage (conversely, heat causes them to open up). Be sure and use a therapeutic cold pack, or a rag soaked in ice water. Ice applied directly is just too cold and should not be used.

OTC pain relievers can be used, but they do have their pitfalls. Aspirin causes mild stomach bleeding, but can be used short term, one regular strength aspirin tablet per forty pounds of body weight, given two or three times daily. Tylenol can also be used short term at a similar dose rate.

Ibuprofen and naproxen are unpredictable, possibly causing severe bleeding ulcers, and I would not recommend them at all for your dog.

Your veterinarian can help you with more effective, safer alternatives for long-term pain control.

Thanks for reading and writing

[Doc]

Hello, Swade's Mom,

I am sorry that you have had such difficulty with your dog. From your description, he does sound like a possible candidate for prednisone therapy. Until I ran across this idea on Veterinary Information Network, it would never have occurred to me to try immunosuppressive doses of prednisone to treat this blood vessel leakage. These large doses of prednisone can have their own side-effects, so the treatment is far from perfect, even when it works.

While most of us cringe when a client says "I read on the internet...", you might at least mention it to your regular veterinarian.

I am sure that there are many good veterinarians in Atlanta, but I do not know any personally. You might consider a trip over to the veterinary school at Athens. I'll bet they have a veterinary dermatologist there.

Good luck with your dog. Thanks for reading and writing.

[Tracy]

My 17 yr.old cat has developed a hematoma on its ear. He has been completely deaf for over a year, thus the scratching of the ears. My problem is this, financially I just do not have the money to get him treated (which kills me, but living in Maine with the high oil prices etc...we are having all we can do to get by)is there anything I can to at home to make him more comfortable? I have been trying to keep the outside clean with peroxide, which he does not seem to mind. He has been eating, going to the bathroom, sleeps a lot (nothing new at his age). I hope you can help put my mind at rest and help me help my cat. Thanks!

[Doc]

Dear Tracy,

I wish that I had a good suggestion for you. Sometimes we recommend pain control if nothing else is feasible. Unfortunately, cats do not tolerate any over-the-counter pain medicines. Tylenol (acetaminophen) is unpredictable, and can cause massive hemolysis (rupturing of the red blood cells) and death. A healthy, ten-pound cat can tolerate one baby aspirin once every 48 hours. I would not recommend this for your cat, due partly to the age, and partly because aspirin inhibits platelet function. The hematoma could conceivably get worse, even if the aspirin didn't cause other problems (which it very well may, especially in such an ancient cat).

Your cat may or may not be a candidate for the prednisone treatment. If she has an ear infection, I guarantee you that it is constantly painful. Even without an ear infection, the hematoma is under pressure, which is uncomfortable at best.

If your cat does not have an ear infection, the prednisone treatment is very inexpensive. I urge you to get her looked at by a veterinarian.

Good luck, and thanks for reading and writing.

[Julie]

Hi,
First of all I want to thank you for your site as it has been very helpful.

Our 12 year old lab just had a drain placed today to drain his hematoma...(and he is so much more content now). He is also being treated for a mild yeast infection in both ears, which we are giving him ear drops for. My concern is that he wasn't given any other oral antibiotics. I am worried about the drain becoming infected. Is just daily cleaning with peroxide going to be enough? Thanks

[Doc]

In regard to just cleaning the drain versus systemic antibiotics:
If your pet's doctor has had good luck with that, then more power to him. I have always been afraid of leaving that bloody hole open, so have given the antibiotics. I do not have any research to support my position. Your dog may do just fine, and antibiotics DO have the potential for side effects. I would recommend that you keep it clean, and monitor for swelling, or for a change in the character of the drainage. Stay in touch with your veterinarian. The doctor who is seeing your pet is the best person to advise you.

Thanks for reading and writing.

[Golden Retriever Mom]

Dear Doc,

This was exactly the procedure they used on my Golden Retriever. He was healing very well. After they took the drainage tube out I just keep on cleaning the incision and making sure to drain out any fluid. He finished his 10 days of antibiotic (clavamox) and antiinflammatories (Previcox) and 3 days later he stated producing a lot more fluid than before, the wound closed, filled up again and he was in pain. I had to rush to the vet. They reopened the incision and took out a little abscess. they put him back again on antibiotics for another 10 days(now Antirobe) and 10 more days of Previcox. It has been now 4 days. every day a lot of transparent yellowish fluid comes out. Last night the wound closed up again and I can not get the fluid out. I can see it starting to fill back up again. He still has over one week of this new antibiotic to go. What should I do? Can you please give me some advise? should I wait couple of days and see if it stops filling up? or should I rush again to the vet?

Also his ear infection has not heal either. First they gave him synotic and conofite drops for 14 days. when he finished they did another culture and now he needed Baytril drops for another 14 days.

I have spent over $1,000 and after 3 weeks he is still not well. I would appreciate any advise you can give me. Does all of this sound normal? I have followed the vets instructions very carefully but I am getting frustrated and very broke. I am scared I take him back and maybe he needs another drainage tube and its going to cost a lot more money again.

Thank you so much in advance,

Golden Mom.