Canine Aural Hematoma Repair – Pinna Surgery versus Pinna Splint
Persuasive Essay
An aural hematoma is a blood and fluid pool formed in an animal's ear flap, or pinna, after a blunt force injury causing arterial breaks forcing tissues to expand and fill. Aural hematomas represent a condition that in not mortal, but can be a contributing factor in contraction of the pinna and subsequent future ailments for animal. Traditional treatments include expensive and painful surgeries, and weeks/months of recovery. Moreover, there is often permanent damage to the ear and a good percentage of reoccurrence of future hematomas. Surgical aural hematoma treatments for removal of blood clots range from lancing, to skin section removal, to biopsy tool removal of skin allowing for holes to provide ability to draw semi-coagulated fluids out of hematoma region. All surgical remedies impart local wounds to aural canal side of pinna, and must be further addressed during post-surgical recovery. These blood pool surgical removals of fluids, along with non-surgical hypodermic needle aspiration, are intended to allow apposition of skin and cartilage tissues. Only the hypodermic needle aspiration does not impart wounding to the pinna, with aftercare required. (1)
A novel method in the treatment of aural hematoma may address some of the concerns with current surgical procedures. The purpose of this article is to inform the veterinary industry (veterinarians, technicians, and medical device suppliers) a new tool to perform corrective aural hematoma repair. Preliminary research on a novel cross-sectional study on the impact of the pinna splinting device AuralsplintTM was conducted between June 2012 and June 2017 (unpublished results). Of the 190 participants who used the Auralsplint device, there were 49 responses to the surveys (25%). The study was conducted by the creator of the device who has no academic training, but a researcher was consulted of interpretation of the results. The participants were instructed to report on the visible ear conditions before, during and after treatment. A gradient of results ranged from: Complete healing with no visible damage, lesser healing with slight visible damage, visible healing with no hematoma present, to no visible healing hematoma present. A control group of participants outside of the criteria were involved to present the need for treatment early in affliction and a comparison of results. Criteria requirements were hematoma present less than 7 days from onset without any aspiration, or hypodermic needle aspiration alone within first 7 days and subsequent hypodermic aspirations on a four day schedule thereafter. Participants willfully requested acceptance into study after they searched online for an alternative to options available. Results suggest that the Auralsplint device promotes healing for the modality with a promising future as a viable alternative to surgeries for the aural hematoma affliction. Given the potential for biases of the author, results should be interpreted with caution. Potential implications of the AuralsplintTM, with no disregard or disrespect intended to existing veterinary surgeries and procedures, the author attempts to provide surgery-free alternatives to the treatment of aural hematoma through a novel therapeutic device. In no way is the Auralsplint recommended to take the place of a professional veterinarian. Instead, canine owner with their animals depending are encouraged to talk with their veterinarians about multiple options to assist in making decisions about best practices. (2,3)
In any treatment modality we must look to the healing properties of the animal and how these properties are used. The understanding: The broken blood vessels causing expansion of the tissues in the pinna are subsequent to a blunt force injury causing the broken blood vessels. Any underlying conditions which may lead to irritation and discomfort causing shaking of the head or scratching of the ear most likely (but not always) have caused the aural hematoma, and are treatable outside of any reparative treatment for the aural hematoma tissue damages. Without any treatment to repair the torn tissues of an aural hematoma, the bulbous fluid filled into the hematoma will resolve and diminish over time. Serum fluids likely will be rapidly reabsorbed, whereas hemoglobin fluids will clot. Either way, the animal's own regenerative abilities are observed as in progress. Given this generalization and the fact the aural hematoma has not ruptured due to over expansion, at some point the animal's own abilities have sealed the broken vessels. Leaving us to examine the clot formation in the aural hematoma, rapid coagulation occurs upon ceasing of new fluids entering into the hematoma region. Granulation begins occurring in 3-6 days. This granulation process must be the precursor to the adhesion of tissues to the clot, respective both the outer skin and the inner cartilage. The interior of the clot at this point is not understood as to its purpose other than subsequent to volume of fluid generation during open vessels filling at time of active hematoma. Speculation of the migration from interior of clot to exterior of clot for granulation and other regenerative elements exists as reduction occurs, and spent red blood cells are removed and reabsorbed. It is this author's belief the reduction of the bulbous clot by reabsorbing, along with granulation occurring at all points exterior of clot, is the greatest contributing factor to contraction of the pinna, as the bulb is reduced from the furthest point from center towards the center, thus the attached tissues are drawn toward center. By establishing the animal is using the blood pool to provide healing and regenerative elements, we must attribute the blood pool, or clot, is essential in providing the tissue elements for permanent reattachment of the skin to cartilage. Even after healing of an untreated aural hematoma, the skin and cartilage are opposed, due to the reduction of the clot leaving the space between the tissues reduced from that of full bulbous clot. The contraction due to reduction has been addressed. However, at some point a blood clot is needed between the skin and cartilage to provide the elements for granulation to occur, and thus adhesion of said skin and cartilage tissues against clot, and subsequently skin to cartilage once absorbable spent red blood cells are removed. By this premise, the amount of contraction is proportionate relative to the thickness diameter of the pooled blood clot, therefore the thinner the clot, the less the contraction. By this same premise, the greater amount of surface area adhesion, the greater the attraction. Complete granulation of all area within the hematoma region would need to be considered the most effective for adhesion of tissues. Any allowance for deviation and sporadic development of granulation would contingently provide less adhesion and potential for less permanent reattachment. The amount of blood clot needed to perform sufficient granulation is left for further studies. But, without a blood clot directly opposed to both sides the skin and cartilage predicts less abilities to heal with same efficiency as areas with adequate blood clot. Therefore, a sporadic area of blood clotting, determined by thickness and location, is less supportive to animal's own ability to regenerate than that of a blood clot continuous in size and complete in total area of damaged pinna. The aspiration of the fluid pool is set to reduce the size of the hematoma bulb, allow for apposition of skin and cartilage tissues, thus reducing the amount of contraction during healing. Aspiration can be performed in different methods. If the fluids are still fluid, then a hypodermic needle aspiration is sufficient to remove nearly all the fluids present. If the length of time from onset is greater than 6-7 days, and coagulation in the pool has started, the removal by surgical means is required to allow apposition of the skin and cartilage tissues. (1,4,5,6,11)
It is time to look at the surgical treatments themselves and how the decision to use surgery for canine aural hematoma repair compares against the other options the clinic can offer. The clinic has to assume a patient visiting a clinic knows he or she is being offered an assortment of options, and costs to treat their animal's condition. With the cost of surgery the pinnacle of pricing, the patient must assume this choice is the greatest care. Reality shows this is the greatest abilities of the veterinary surgeon to use his or her training in an operating room environment. To assume this is the best care for the aural hematoma affliction is based on perspective. With blood pool now removed, apposition by surgical method is achieved by carefully suturing the skin to cartilage by means of choice by surgeon. Critical to success is the ability of the surgeon to oppose the tissues in such a fashion to allow granulation to occur in the areas between sutures. The small segmented sporadic blood pools subsequently clot and healing begins to occur. The amount of granulation at suture penetration locations cannot be consistent with the areas between sutures due to nature of modality. As the author has already established, the more consistent the blood clot, the better the production of granulation and adhesion after healing. To summarize, the surgical aspiration has imparted wounds to the skin of the pinna and now in need of post-operative care, the sutures are providing sporadic ability to adhere, and any clot formation is now non-consistent. (2,9,10,11)
Stated here in this interpretation, surgery shows increased chance for infection with regard for surgical procedures imparting wounds to pinna, as well as sporadic development of the essential blood clot. Suture placement is critical to keep from cessation of fluids to any point interrupted. Included in surgical modalities is the continued allowance for any blood and fluids re-entering the hematoma region to flow freely out of the region through wounds or drains specifically placed for this reason. Previously established in this interpretation is the need for the blood clot to form to produce the granulation and regenerative elements required in permanently healing the aural hematoma, complete with blood vessel sealing of breaks and adhesion of skin to cartilage. It appears less than necessary to allow the essential regenerative elements to escape the area in need of said elements. It is understood the continued flow of fluids into a surgically repaired hematoma region may introduce recurrence of expansion, and therefore contribute to alteration of the surgeon's treatment modality. Finally, pinna surgery post-operative care is substantial and must be included in the considerations for its use and results. (5,6,8)
The alternative modality presented is Pinna Splinting. Splinting of the auricle is a therapeutic treatment modality process allowing the animal's own abilities to re-grow the tissues in an environment suitable for the least amount of contraction after healing. By all indications in this interpretation, a consistent thickness blood clot throughout the entirety of the hematoma region provides the greatest chance of non-sporadic granulation and adhesion of tissues. The uniformity of the thickness of the blood clot, or more accurately presented thinner blood clot, provides lesser ability for contraction during recovery. Pinna splinting treatment occurs without wounding imparted to animal, therefore the post-operative care is lessened and the chance of infection therefore lessened. Also, for those patients unable to afford surgery or are unable due to health or general anesthesia complications, pinna splinting allows the animal owner the option for corrective clinical treatment, and for the clinic the additional income. (4,9,11)
Pinna splinting is achieved by locating the pinna in a fixed position where, after aspiration by hypodermic needle, a rigid device is attached by medical dressings to the pinna, presenting a wall against the damaged tissues, preventing the uncontrolled expansion of fluids into the hematoma. Once the small area of hematoma refills into a thin layer and equalization of fluid pressures is achieved, rapid coagulation and granulation begins to occur, without interruption or sporadic locations, but instead throughout the entirety of the hematoma. As per the previous evidence established, the animal now can function as though the hematoma has been left untreated, and can begin to and fully regenerate the needed tissues to seal the broken blood vessels and form the permanent attachment tissues between skin and cartilage at all points directly adjacent to blood clot layer. Once absorption of the spent red blood cells in clot layer occurs, the distance between skin and cartilage tissues being of a small size, the reduction and contraction is limited, relative to thickness of clot layer. The treatment duration for splint device in place has been established as 14 days consecutive. (11)
It would be difficult to describe the need for a new modality in a clinical environment without addressing the costs associated. A Veterinary Clinic needs revenue to not only survive but to thrive. The licensed veterinarian needs to charge appropriately for his or her services to generate revenue to employ the manpower to sustain the business model. By this standard, the amount of revenue per treatment generated is based upon the need of the clinic's business model. The larger the revenue generation per treatment equals the better the outcome for the business. This support for the business model can be altered by the number of patients treated against the number of patients not treated (due to lack of financial means). To sum this relationship, the more patients treated for less revenue equals the lesser amount of patients treated with higher revenue. (2,3)
The author, Daniel Whitton, is President of Auralsplint Inc. PBC, an aural hematoma researcher, inventor, and advocate for better animal healthcare through improvements in current modalities. The AuralsplintTM treatment is proprietary through US Patent 7,153,313 awarded to Daniel Whitton 2006. Subsequent patent protection is at present in place for further intellectual property and proprietary rights. The Auralsplint, through voluntary Pre-Market Approval, has been concluded by the FDA “the animal medical class 1 device is safe as prescribed for use under supervision of licensed veterinarians”. Without establishing a concrete analysis by dissection of both modalities in post mortal studies, the author is left to make interpretations of scientific expectations. However, having a tool to bridge the gap in treatment modalities could and should be used to satisfy the needs of the clients. The AuralsplintTM introduces a non-invasive, cost-effective, pain-free clinical device providing an alternative solution to surgery. Although study results are preliminary and non-casual, there is support for future clinical trials with this device as part of a whole purposed industry treatment. (6,11)
Author: Daniel Whitton
Auralsplint Inc. PBC
Editor:
Krista Best, PhD
Professeure adjointe/ Assistant professor
Faculté de médecine / Faculty of Medicine
Université Laval
Sources Cited:
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8. Aural Hematoma. American College of Veterinary Surgeons. https://www.acvs.org/small-animal/aural-hematoma
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11. AuralsplintTM – Descriptive Report, author: Daniel Whitton; Researchgate.com DOI:
10.13140/RG.2.2.13717.55520
