A review of treatments for aural hematomas in dogs Review question: When treating aural hematomas in dogs, what is the evidence that the inclusion of the use of steroids, alone or in combination with other treatments reduces the number of dogs that must be retreated? Bottom line. There are many ways that aural hematomas are treated in dogs. The articles reviewed examined hematoma drainage in combination with either oral or local injections of steroids, and traditional surgical treatment. There was no evidence that adding steroids to treatment protocols reduced the number of dogs that needed to be retreated. The quality of the evidence was poor which limits any interpretation that may be made. Key elements of the review question? • Population of interest: Dogs with aural hematoma • Intervention of interest: Therapies that include the use of steroids, alone or in combination with other therapeutic options • Comparison of interest: Therapies that do not include the use of steroids, alone or in combination with other therapeutic options • Outcome of interest: A reduction in the number of dogs that must be retreated. Plain language summary: It was not possible to answer the question if the use of steroids, alone or in combination with other therapeutic options, was associated with improved resolution of aural hematomas in dogs as only two poorly described and, possibly poorly executed studies, included a comparison group. One comparative study did not report the numerical results, enrolled only 4 dogs per group, did not report inclusion criteria for the dogs, did not report randomization to group and blinding of outcome assessment. The other study did not conduct a statistical analysis comparing groups (the study was likely underpowered), did not report inclusion criteria for the dogs, reported using inadequate randomization methods to allocate animal to group ( i.e., no blocking or stratification resulting in uneven group sizes (4 to 13) and no blinding of outcome assessment. The majority of available studies were case series with unspecified rationale for inclusion of dogs. None of the case series reported using methods to mask the person assessing the outcome to the treatment received. The absence of blinding increases the potential that the estimates of response to therapy in the case series are higher than might be expected in a controlled trial. Evidence profile: The level of evidence for support the use of steroids to be very low quality which means we remain very uncertain about the true prevalence of recovery from aural hematoma and impact of the addition of steroids. It is likely the effect is substantially different from those reported due to potential for bias. This determination was based on the following characteristics 1 recommended by the GRADE working group 1) Design – Initial quality of evidence is considered very low because the majority of designs were case series or lower-powered comparative trials, 2) Risk of bias- The risk of bias is considered very serious as most studies did not report enrollment criteria, lacked a control group or used no or inadequate randomization and no blinding. 3) Inconsistency – The impact of inconsistency could not be assessed, as there were only 2 comparison studies, 4) Indirectness bias – This was considered very serious, as subjective outcomes such as fair, good poor were used by many studies 5) Imprecision bias - The impact of random error was considered very serious because the comparative studies were very small. 6) Publication bias - The risk of publication bias is very serious because the studies were small and case series strongly favor positive outcomes Prepared by Dr. Teresa Hershey and Dr. Annette O'Connor with the assistance of Nicole Hershberger for the EBVMA practitioner committee. 18 September 2011 A review of treatments for aural hematomas in dogs Table 1: Details of studies identified by the search that reported treatment for aural hematoma in dogs. Study Design Case Series 3 Case Series 4 Case Series 5 Comparati ve Study (4 groups) 2 5 5 5 Intervention Evacuate hematoma, no drain, injectable steroid locally, 7-days oral steroids, no antibiotics, no or light bandage Evacuate hematoma, silicon rubber drain, injectable steroid locally given day 1, no oral steroids, no antibiotics, no bandage Evacuate hematoma, closedsuction drain, no injectable steroid locally, no oral steroids, no antibiotics, immobilizing bandage Evacuate hematoma, PCV drain, no injectable steroid locally, injectable steroids given day 1, antibiotics given day 1-5, pressure bandage Evacuate hematoma, latex drain, no injectable steroid locally, injectable steroids given day 1, antibiotics given day 1-5, pressure bandage Conventional surgical method, no injectable steroid locally, injectable steroids given day 1, antibiotics given day 1-5, pressure bandage Evacuate hematoma, silicon drain, no injectable steroid locally, injectable steroids given day 1, antibiotics given day 1-5, pressure bandage Outcome Healing grade not described. Failure to return for surgery interpreted as successful outcome. Healing grade not described. Assessor was not described. Recurrence reported. Follow-up Not described # Dogs 30 # Resolved (%) 29 (97%) Randomized Not applicable Blinded No Between 2 and 9 months 9 7 (78%) Not applicable No Healing graded using an undescribed scale. Assessor was the owner. Between 3 and 23 months 9 7 (78%) Not applicable No Healing graded as excellent, good, poor. Assessor was not described. Not described 4 Healing reported as poor to good No No (as above) Not described 4 Healing reported as good No No (as above) Not described 4 Healing reported as poor to good No No (as above) Not described 4 Healing reported as excellent No No Prepared by Dr. Teresa Hershey and Dr. Annette O'Connor with the assistance of Nicole Hershberger for the EBVMA practitioner committee. 18 September 2011 A review of treatments for aural hematomas in dogs Study Design Case Series 7 Comparati ve Study (5 groups) 6 7 7 7 7 Intervention Evacuate hematoma, bovine teat tube, no injectable steroid locally, no injectable steroids given, no antibiotics given, bandage Conventional surgical method, no injectable steroid locally no injectable steroids given, chloramphenicol (25mg/kg BW) PO every 8 hours for 10 days, pressure bandage Evacuate hematoma, no drain, no injectable steroid locally, 2 mg/kg BW dexamethasone injectable steroids daily until resolution, gentamicin (4mg/kg BW) daily to resolution, no bandage Evacuate hematoma, no drain, no injectable steroid locally, 0.5mg/kg BW dexamethasone injectable steroids daily until resolution, gentamicin (4mg/kg BW) daily to resolution, no bandage Evacuate hematoma, no drain, 0.2 to 0.4 mg dexamethazone and 0.25 mg of gentamicin in physiological saline injected daily in cavity,0.5mg/kg BW dexamethasone injectable daily until resolution, gentamicin (4mg/kg BW) daily to resolution, no bandage Evacuate hematoma, physiological saline flush daily in cavity, no injectable steroids, no Outcome Healing grade not described. Resolution described as no complications. Follow-up Not described # Dogs 35 # Resolved (%) 30 (86%) Randomized Not applicable Blinded No Healing graded from A (healed, no morphological changes) to D (severe morphological changes). Grades A and B regarded as satisfactory healing. Assessor was not described. (as above) 2 months 10 6 (60%) Yes No 2 months 13 11 (85%) Yes No as above 2 months 8 3 (38%) Yes No as above 2 months 9 8 (89%) Yes No as above 2 months 4 0 (0%) Yes No Prepared by Dr. Teresa Hershey and Dr. Annette O'Connor with the assistance of Nicole Hershberger for the EBVMA practitioner committee. 18 September 2011 A review of treatments for aural hematomas in dogs Study Design 8 Case Series 9 Case Series 10 Case Series Intervention antibiotics, no bandage Evacuate hematoma, Penrose drain, no local steroids, 1mg/kg BW prednisolone PO twice daily for 14 days, followed by 1 mg/kg BW once daily for 14 days, no antibiotics, no bandage described Evacuate hematoma, CO2 laser surgical approach, an unspecified course of topical steroids, 2 dogs received an unspecified course of systemic prednisilone, Cephaxalin (20 mg/kg BW or amoxacillin/clavulanic acid (15 mg/kg BW) PO q 12 hours for 10-14 days followed by 1 mg/kg BW once daily for 14 days,, no or immobilizing bandage Evacuate hematoma, no drain, 0.25 mg/kg BW of dexamethazone and 1 mg/kg BW of gentamicin injected daily in cavity every 24-48 as needed, no injectable steroids, no antibiotics, no bandage Outcome Follow-up # Dogs # Resolved (%) Randomized Blinded Successful if outcome has no recurrence i.e., repeat treatment. Assessor was not described. Not described 22 19 (87%) Not applicable No Healing graded as good, fair, poor. Good considered a success. Assessor was not described. 12 months 8 6 (75%) Not applicable No Successful if outcome has no recurrence (i.e., repeat treatment). Assessor was not described. Not described 10 8 (80%) Not applicable No Prepared by Dr. Teresa Hershey and Dr. Annette O'Connor with the assistance of Nicole Hershberger for the EBVMA practitioner committee. 18 September 2011 A review of treatments for aural hematomas in dogs Search Strategy: PubMed was searched on January 31, 2011 using key word phrases: “aural hematoma dog” retrieved 10 citations, “canine aural hematoma” retrieved 12 citations, “auricular haematoma dog” retrieved 5 citations. Some articles appeared under all or at least two of the searches with 18 unique citations identified in PubMED. We searched CAB abstracts using the terms “aural hematoma canine” which retrieved 13 citations. In CAB the search “auricular haematoma canine” yielded two already identified citations. Of the thirteen articles obtained from the CAB Abstracts five were also found in the PubMed search and seven were unique. The total of 25 unique articles found in Cab and PubMed were then screened for relevance using the criteria that the article must discuss a treatment for aural hematomas. Six articles were deemed relevant and full text obtained, several required interlibrary loans to obtain 2-6,9. The reference sections of the six relevant articles were searched for additional citations and three additional relevant studies identified 7,8,10. We also conducted searches in PubMed looking for biomedical studies using rabbits as models for “cauliflower ear” or “aural hematoma” but none of the citations retrieved were relevant to the review. The Cochrane Review database was search for aural hematoma retrieved 11 citations, none of which were relevant. Finally, we also searched the titles of presentations at the annual meeting of the American Veterinary Medical Association and The College of Internal Veterinary Medicine from 2000 to 2011 and found no relevant citations. In summary, the search identified 9 relevant citations and the data extracted are reported in Table 1 . References: 1. Guyatt G, Oxman AD, Akl EA, et al. Grade guidelines: 1. Introduction-grade evidence profiles and summary of findings tables. Journal of Clinical Epidemiology 2011;64:383-94. 2. Romatowski J. Nonsurgical treatment of aural hematomas. Journal of American Veterinary Medical Association 1994;204:1318. 3. Kagan KG. Treatment of canine aural hematoma with an indwelling drain. Journal of American Veterinary Medical Association 1983;183:972-4. 4. Swaim SF, Bradley DM. Evaluation of closed-suction drainage for treating auricular hematomas. Journal of the American Animal Hospital Association 1996;32:36-43. 5. Ahirwar V, Chandrapuria VP, Bhargava MK, et al. A comparative study on the surgical management of canine aural haematoma. Indian Journal of Veterinary Surgery 2007;28:98-100. 6. Wilson JW. Treatment of auricular hematoma, using a teat tube. Journal of American Veterinary Medical Association 1983;182:1081-3. 7. Kuwahara J. Canine and feline aural hematomas: Results of treatment with corticosteroids. Journal of the American Animal Hospital Association 1986;22:641-7. 8. Joyce JA. Treatment of canine aural haematoma using an indwelling drain and corticosteroids. Journal of Small Animal Practice 1994;35:341-4. 9. Dye TL, Teague HD, Ostwald DA, Jr., et al. Evaluation of a technique using the carbon dioxide laser for the treatment of aural hematomas. Journal of American Animal Hospital Association 2002;38:385-90. 10. Aithal HP, Kinjavdekar P, Amarpal, et al. Treatment of aural haematoma with local administration of dexamethasone in dogs. Indian Veterinary Journal 2000;77:619-22. Prepared by Dr. Teresa Hershey and Dr. Annette O'Connor with the assistance of Nicole Hershberger for the EBVMA practitioner committee. 18 September 2011
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