Surgery of the Ears

Aural Hematoma

may occur in dogs or cats and are usually characterized as fluctuant swellings filled with hemorrhagic fluid

Pendulous & Erect ears

Aural Hematomas often occurs in dogs with these ears

concave surface of ear (pinna)

Aural hematomas is most apparent in this part of the ear

not clear, but the most accepted theory is that the lesion is self-inflicted from head shaking, scratching, and rubbing the ear

Aural Hematomas Etiology

great auricular arteries & veins

• The exact location of the source of

hemorrhage is not known but is thought to come from branches of the _______ within, under, or between the cartilage layers

•These vessels penetrate the scapha to supplyt h e concave surface of the ear.

Shearing forces from trauma

are believed to tear some of the vessels. Blood accumulates between the skin

and the layers of cartilage of the pinna

internal pressure = feeder arteries pressure

Bleeding continues until?

fluid-filled, sott, and fluctuant; firm & thickened

Hematomas initially appear ___, ___, & ___, but eventually may become ____ & ____ as a result of fibrosis

cauliflower appearance

Ears that had Aural hematoma may have this appearance

immediately after diagnosis

When should hematomas be treated

cosmetic alteration (ex cauliflower appearance)

Untreated hematomas usually causes

simple needle aspiration

Non-surgical management of hematomas wherein its is drained but recurrence is likely

concave, 16-20g

The ____ surface of the pinna should be clipped and prepped before a large (__-__ g) hypodermic needle is inserted in the most dependent part of the ear

Flushing with sterile saline

can be performed to facilitate removal of clots and fibrin in non surgical management of hematoma

IV, dexamethasone, 0.5-2.0mg

Daily ___ administration of ____ (___-___mg/kg) results in resolution in over 85% of cases [Aural Hematomas]

Oral, Prednisolone

_____ administration of anti-inflammatory doses of _____ can help decrease HEAD SHAKING & SCRATCHING and may help treat inflammation associated with ear disease

dexamethasone, methylprednisolone, & triamcinolone

Injection of (3) directly into the hematoma cavity following drainage of fluid has successful resolution in over 90%

• Teat cannula

• Silastic tubing

• Penrose drain

• Butterfly catheter (closed suction drainage)

Methods of Aural Hematoma Drainage

1) remove the hematoma

2) prevent recurrence

3) retain the natural appearance of the ear (minimize thickening and scarring)

goals of surgery are to

1) tissue overlying the hematoma

2) blood clots & fibrin

3) suture, scar tissue

most commonly used procedure involves

1) incising the _____

2) evacuating _____ & ____

3) and holding the cartilage in apposition with _____ until ______ can form

Longitudinal, S-shaped, Cruciate

Incisions that can be used to open Hematomas based on the surgeons preference

•curetted, saline

•vertically

•The fibrin clot is removed, and the cavity is _____ and flushed with _____

•Sutures should be placed ____ rather than horizontally for aural hematoma repair.

• They may be placed through the cartilage without incorporating the skin on the convex surface of the ear, or they may be full thickness

1. #15, longitudinal S-shaped, concave

2. FALSE, DO NOT extend

[Clinician's Brief]

1.) Using a # scalpel blade make a ____ incision over the hematoma on the _____ aspect of the pinna

2.) Extend the incision through the skin to allow draining and flushing. Extend the incision through the auricular cartilage. T or F?

flush, sterile saline

[Clinician's brief]

3. Once the hematoma has been drained ____ any remaining fluid/clots using ____

4. - nonabsorbable, monofilament;

• 3-0 or 4-0 nylon

• 8-10mm

• mattress pattern

5. slightly open

[Clinician's Brief]

4. Using _____ suture material (e.g ___) places sutures ~ __-__ mm apart using either a partial- or full-thickness _____ pattern

5. Keep the skin incision ______ for continued drainage & healing by second intention.

cosmetic alterations & recurrence

Most common complication of Aural Hematomas

-Necrosis

-Cosmetic alterations

-Reported from improper suture placement

-Result of delayed treatment, improper suture placement, & excessive suture tension

Suture lines are placed ID on one side running through the cartilage

Alternative Internal Suturing Technique for Aural Hematomas

-No recurrence

-91%

-# Recurrence documented in dogs

-% that had NO auricular deformity [Alternative Internal Suture Technique]

-Minimal need for aftercare

-Absence of discomfort/irritation caused by external suture & sutures that do NOT need to be removed

thicken, wrinkle, resemble a cauliflower

Disadvantage of Suture Technique for Aural Hematoma repair

1. elliptical, concave

2. hematoma cavity, curetted, irrigated

3. firmly taped, cast padding, taped

4. Hematoma pad, horizontal mattress

[Sutureless Technique for Aural Hematoma Repair]

1. After the pinna has been clipped, thoroughly cleaned, & prepped, an ______ incision is made on the _____ surface over the swelling.

2. Incision should expose the ____ from end to end. It should be ____ & copiously ______

3. Ear is ______ so the incision is exposed & the pinna is reflected over a large roll of ____ & is _____ in place

4. ______ pad is secured to the ear using additional ______ sutures

Buster Othaematoma Compress

Commercially available Hematoma pad

Otitis externa

inflammation of the vertical/horizontal ear canal or both

Otitis media

inflammation of the tympanic cavity & membrane

Otitis interna, vestibular disease

inflammation of the inner ear that typically causes ____ diseases in dogs

Presbycusis

term used to describe age-related hearing loss

Otitis externa

characterized by an increased production of ceruminous & sebaceous material, desquamation of epithelium, pruritus, & pain

Parasites, Bacteria, Fungi

Etiolgic agents of Otitis Externa

Conformation of Ear Canal & Pinna

Can predispose to development of Acute & Chronic Otitis Externa

-High relative humidity of External ear canal

-Warmth, darkness, & enclosed nature of ear

2 Nature of Ear Canal of some Dog Breeds that provides an excellent environment for the Growth of Infective agents [Otitis Externa]

1. Irrigating & Cleansing External Ear Canal

2. Ceruminolytic agents

3. Antibiotics (aqueous solution)

4. Antifungal or Parasiticides

5. pH alteration

Otitis externa Non-surgical Treatment

1. Initial treatment

2. Additional treatment

3.Depending on the origin of the otitis; Locally/Parenterally

4. Locally

5.?

Chronic

(Chronic, Acute) Otitis externa must be treated MORE vigorously

"Swimmer's solution" (3 parts 70% Isopropyl alcohol & 1 part vinegar)

Chronic otitis externa treatment that is useful long term, provides a cleaning-drying action, & lowers the pH of the ear

Lateral Ear Canal Resection (Zepp procedure)

Indicated when the Otitis externa becomes unresponsive to medical therapy

1. Frequent recurrence

2. Inadequate/Lack of treatment

3. Ear Canal thickening that does NOT obstruct horizontal portion of External Ear canal

4. Small tumor removal

(4) Indications for Lateral Ear Canal Resection

• environmental alteration

• ventilation

• moisture, humidity, & temp

Purpose of Lateral Ear Canal Resection

-Provide ___ by means of ___ so these (3) are decreased

Drainage for exudates & moisture in Ear Canal

Lateral Ear Canal also provides ____

1. drainage, ventilation

2. topical agents, horizontal canal

[Lateral Ear Canal Resection]

1. Increases ____ & improves ____ of the ear canal

2. Facilitates placement of ____ into the ____

-Obstruction/stenosis of Horizontal ear canal

-Concurrent otitis media

-Severe Epithelial Hyperplasia

Lateral Ear Canal Resection is contraindicated in patients with the ff. conditions (3)

1. U-shaped, vertical ear canal, pretragic, intertragic, ventral most palpable portion of the canal

2. SQ, lateral wall, vertical canal, canal wall

[Lateral Ear Canal Resection]

1. Make a ___ skin incision over the _____, starting & ending at the ____ & ____ incisures & continuing VENTRALLY at least a cm below the ______

2. Dissect the ____ tissue away from the ______ of the _____ with blunt & sharp dissection until the ____ is exposed

parallel, lateral wall, lateral, incisures, junction of the canals

[Lateral Ear Canal Resection]

3. Make 2 ____ incision in the ____ of the vertical ear canal that extend from the pretragic & intertragic incisure to the _____ aspect of the junction bw the vertical & horizontal canals, starting at the ____ or ___

[Lateral Ear Canal Resection] [if starting Dorsally at incisures]

1. Stand on the dog's ____ side & grasp the skin flap or the dorsal edge of the _____ of the _____ with Allis tissue forceps

2. With _____ scissors, make a 1cm cut down the ______, starting at one incisure, & angling toward the ventral aspect of the vertical canal*

4. short cuts

5. Insert a forceps down the canal 6. bottom of the vertical canal

[Lateral Ear Canal Resection] [if starting Dorsally at incisures]

1.Stand on dog’s dorsal side . Grasp the skin flap or the dorsal edge of lateral cartilage of VEC using Allis tissue forceps

2.W/ straight Mayo, make a 1cm cut down the VEC, starting at one incisure & angling toward the V of VEC

3. Make a similar cut, starting at the opposite incisure [/]

4. Alternately extend each incision w ____ examining the interior of the canal before each cut to verify that the scissor blades are bisecting the canal along its length.

5. ___ to evaluate canal depth & before continuing each cut.

6. Continue the incisions until the _____ is reached

1. ventral side

2. 2 parallel incision, #11, ventral most extent of the

3. Mayo, dorsally, ipsilateral

[Lateral Ear Canal Resection] [if starting Ventrally at incisures]

1. Stand on the dog's _____

2. Make _____ incisions w a # blade at the ____ of the proposed flap (just dorsal to the junction of the horizontal & vertical canals*

3. W ___ scissors, extend each incision _____ to the ____ incisure

extend cartilage cut towards midpoints of the horizontal canal

4. Verify that vertical canal has been cut by pulling it ventrally. Then, what should be done if a flap forms a fold that obstructs the ventral half of the horizontal canal opening?

dorsal (distal), 2/3, horizontal

5. Resect the _____ half to ___ of the lateral cartilage flap, w attached skin, leaving a 1-3 cm drain board below the ___ canal opening

3/0 or 4/0 Nylon or Propylene

Suture that can be used in Lateral Ear Canal resection

-simple interrupted

-remove additional skin

-include the cartilage in the suture

[Lateral Ear Canal Resection]

-Initially, place a ___ suture at each flap corner, & at the hinge notch on each side.

-If the flap does NOT lie flat, _____ along the ventral surgical margin to provide a Small amt of ventral tension to the flap

-If the epithelium is friable ____

[!!!]

!!! [Lateral Ear Canal Resection] Suture the remaining margins of the drain board & vertical canal walls w simple interrupted sutures of nylon/propylene or simple continuous sutures of a rapidly absorbable monofilament material

-Analgesics

-Elizebethan collars, 7 days

-10-14 days

-10-14 days

[Lateral Ear Canal Resection] Postop Considerations

-___ should be continued for several days after surgery

-__ is worn for ___ days bc self-trauma is common

-Healing time average: ____ days; If suture line breaks down, it may take longer

-Suture removal: ___days

-Dehiscence

-Extensive flap dehiscence that is NOT repaired

[Lateral Ear Canal Resection] Postop Considerations

-Occurs in about 1/4 of patients bc of self-trauma, infection, tension, or poor technique

-May result in Stenosis of the Canal opening

Vertical Ear Canal Resection

most common indication is removal of tumors & polyps that extend BEYOND lateral surface of canal

persistent/recurrent otitits externa

Vertical Ear Canal Ablation is also used to tx px w

Vertical Ear Canal Resection

removes more inflamed tissue & associated w less post op discharge & pain, fewer complications

Drooping of erect ears

VECR may cause this

FALSE, Vertical

True or False. Horizontal ECR may provide a better cosmetic appearance than its counterpart when an abundance of hyperplastic tissue is present in & around the vertical canal

1. T-shaped, tragus

2. vertical incision

3. skin flaps, lateral

4. external auditory meatus

[VECR]

1.) Make a ___ incision w the horizontal component parallel & just below the upper edge of the ____

2.) From the midpoint of horizontal incision, make a ______ that extends to the level of the horizontal canal

3.) Retract the ___, reflect LCT, & expose the ___ aspect of the Vertical canal

4. Continue the horizontal incision through the cartilage around the ______ w a scalpel blade

5. muscular & fascial attacment

6. cranially & caudally

7. ventral, 2-0 to 4-0

8. absorbable 2/0 or 3/0, T-shaped

[VECR]

5. Free the entire vertical canal from all ____

6. Incise the remnant of the vertical canal ______ & _____ to create dorsal & ventral flaps

7. Reflect the ___ flap downward, & suture it to the skin for a drainboard using absorbable/nonabsorbable monofilament sutures material (#___)

8. Suture the dorsal flap to the skin & close the SQ tissue w an ____ suture material (#) Close the skin a ____ configuration

Total Ear Canal Ablation

indicated in animals w chronic otitis externa that have failed to respond to appropriate medical management, in cases of severe calcification, or when severe epithelial hyperplasia extends beyond the pinna or vertical ear canal

-LER have failed

-severely stenotic ear canal

Total Ear Canal Ablation (TECA)

-commonly performed on animals in wc

-may benefit animals w this disease

Neoplasia of the ear canal (eg. ceruminous gland adenocarcinoma)

is also treated by TECA

True

True or False. Complications other than inadequate drainage & continued otitis externa are uncommon after LER/VECA

TECA

Potential complications of ____ are numerous & occasionally serious

-Superficial wound infection

-Facial nerve paralysis

-Vestibular dysfunction

-Horner syndrome

-Deafness

-Chronic fistulation/Abscessation

-Avascular necrosis of the skin of the pinna

Complications

[SFVHDCA]