“Hanna” is a 9y FS Labrador Retriever who presented for an aural hematoma. Owner has had Hanna for 5 years, prior to that was surrendered to a shelter with really bad paws and ears, and they had her on a prescription diet as well as several medications.
Curtis Plowgian
Animal Dermatology Clinic, Indianapolis IN
April 2025
HISTORY
Since owner adopted her, she has had several ear infections per year, and 3 ear hematomas in the last 2 years (currently has a hematoma in the right ear). Owner thinks ears may be better in the Winter, but not obviously and consistently so. In between ear infections, owner cleans ears every day, but when cleanings are missed, ear infections come back quickly. Previously was on a grain-free salmon diet, currently on Pro Plan Sensitive Skin and Stomach. Unsure of number of BMs per day (free choice defecation in back yard), but stools are consistently solid and formed. Not much gas or borborygmus noted by owner. Aside from paws and ears, not much itching has been noted at home. Hanna is on Simparica every month, and there are no other pets in the house. In the last year, owner started a probiotic with the diet, and thought this helped the ears some, but hasn’t stopped the most recent infection and hematoma. PDVM has mostly treated ear infections with Dexamethasone injections, ear drops, and surgery for the hematomas, owner is looking to avoid a third surgery if possible.
EXAM
Skin and coat look good except for a swollen 2nd digit of the left rear paw, and a marked hematoma of the right ear, mostly occluding the ear canal (very difficult to pass a swab). White scaly debris on the swab AS, AD swabs mostly clean.
DIAGNOSTICS
An ear cytology found debris but no organisms AS, and 10-20 cocci, rods and yeast per OIF AD
ASSESSMENT
Otitis externa with aural hematoma AD, suspect underlying allergies
TREATMENT PLAN
Allergies were discussed with owner as a cause of Hanna’s recurrent ear infections. Given the lack of obvious seasonality, a diet trial was recommended to rule out food allergies. Given the owner’s desire to avoid surgery, an aggressive course of oral glucocorticoids was recommended to reduce the swelling and hematoma in the right ear.
- An elimination diet trial with Hill’s Z/D Low Fat Soy (Hydrolyzed Soy) was started to test for food allergies.
- Posatex (Orbifloxacin, Posaconazole, and Mometasone) was prescribed once daily in the right ear for 2 weeks.
- Twice weekly ear cleanings with TrizUltra+Keto Cleaner were recommended AU to remove debris from the ears and prevent future infections
- A course of oral prednisone was prescribed at 1.15mg/kg SID x 3 weeks, then 1.15mg/kg EOD until recheck 3 weeks later.
FOLLOW-UP
6 weeks later, on recheck exam, Hanna was looking much better, with a near resolution of the hematoma. The owner reported that about three weeks earlier, while playing at daycare, Hanna’s hematoma had ruptured, and the daycare employees had needed to help squeeze and wipe up the ear to facilitate drainage, but after that the pinna had healed nicely. Paw swelling had also resolved.
On repeat cytology, 0-10 cocci, rods, and yeast were found in the ear canal AD, so another 2-week course of Posatex was started, but oral prednisone was discontinued as the hematoma had resolved and Hanna had gained 6kg in the six weeks of treatment with prednisone. The owner was advised to start twice weekly mometasone drops in the ears after cleanings to minimize recurrence of allergic inflammation and infection. The owner was advised to start challenging the diet in 2 weeks if the ears were doing well per phone update (results of diet rechallenge not yet known).
DISCUSSION
Aural hematomas are a condition of the pinna resulting from trauma to the ear, resulting in a blood-filled subcutaneous swelling of part or all of the pinna1. The most common cause of aural hematomas in dogs is otitis externa, which is in turn most commonly caused by allergies, but may also be caused by autoimmune, endocrine, inflammatory, parasitic, viral, and nutritional disorders, as well as structural causes such as tumors, masses, and foreign bodies2. Aural hematomas are not a primary diagnosis, but a sequela of pruritus, inflammation, or trauma to the ear, so treatment of an underlying cause is usually essential to both short and long-term resolution1.
Treatments for aural hematomas include medical management, surgical management, and sometimes even benign neglect if/once the underlying cause of otitis is treated. Types of medical management for aural hematomas include drainage and treatment with either systemic or intralesional glucocorticoids, or a combination of both1. The author has had success managing aural hematoma cases with oral glucocorticoids alone, without the need for prior drainage or intralesional injections, although in this case the fact that the hematoma ruptured and drained on its own may have been an indication that prior drainage may have been helpful (given the owner’s desire to minimize expense and sedation of her dog, it was not performed in this case, and in several previous cases, the author has found it not to be necessary).
A classic surgical approach to aural hematomas involves opening the hematoma with an S-shaped or linear incision followed by closure with mattress sutures to appose the sides of the pinna and prevent refilling. Other surgical approaches include placement of a cannula or drain, or fenestrations in the ear with circular punch biopsies to facilitate continued drainage over time1.
Benign neglect isn’t typically a recommended method of hematoma treatment, as it can result in more severe malformation of the pinna as the blood drains and the hematoma resolves1. However, regardless of method of the immediate management of the hematoma, management of underlying disease is crucial to prevent recurrence, so discussion and treatment of allergies with this owner was a very important part of Hanna’s long-term management. While food allergies have not been confirmed by rechallenge, if present, controlling for food allergies may help minimize pruritus and inflammation of the affected ears, reducing frequency of otitis, and hopefully preventing further hematomas. If Hanna turns out not to be food allergic, symptomatic therapy for environmental atopic dermatitis with medications and/or immunotherapy would be appropriate. Since Hanna lacks generalized pruritus, symptomatic therapy for the ears and paws may be achieved with topical steroids and/or diet control (pending trial results), which is why systemic anti-pruritic medications were not started after the course of oral prednisone was completed.
REFERENCES
- Hewitt, J, Bajwa, J. Aural hematoma and it’s treatment: A review. Can Vet J. 2020 Mar;61(3):313–315.
- Miller WH, Griffin CE, Campbell KL. Muller and Kirk’s Small Animal Dermatology. 7thPhiladelphia, PA: Saunders, 2013; 743.