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A case of bilateral auricular haematoma in a ewe-lamb with sarcoptic mange
Small Ruminant Research 110 (2013) 145–149
Contents lists available at SciVerse ScienceDirect
Small Ruminant Research journal homepage: www.elsevier.com/locate/smallrumres
A case of bilateral auricular haematoma in a ewe-lamb with sarcoptic mange夽 V. Tsioli ∗ , R. Farmaki, A. Papastefanou, A.D. Galatos, M. Marinou, D. Tontis, V.S. Mavrogianni, D. Doukas, M.N. Saridomichelakis, G.C. Fthenakis Veterinary Faculty, University of Thessaly, Karditsa, Greece
a r t i c l e
i n f o
Article history: Available online 30 November 2012 Keywords: Anaesthesia Auricular haematomas Ear Pinna Sarcoptic mange Sheep Surgery
a b s t r a c t A Lacaune ewe-lamb was referred with bilateral pinnal swelling and intense head-shaking. Soft, fluid-filled, painless swellings were present on the concave surface of both ear pinnae. Needle aspiration revealed sero-sanguineous fluid, confirming the clinical suspicion of auricular haematomas. Cutaneous lesions characteristic of sarcoptic mange were present on the nasal planum; diagnosis was confirmed based on the results of microscopic examination of skin scrapings (i.e., presence of Sarcoptes scabiei); for treatment of the disorder, moxidectin was administered twice, 11 days apart. The animal was operated under injectable anaesthesia. Auricular haematomas were drained by using Penrose tubes. However, and despite repeated post-surgical otic cleansing and administration of broad-spectrum antibiotics, local infection developed post-operatively. Subsequently, a second operation was performed, under inhalational anaesthesia, where the incisional technique was applied. Post-operative care included otic cleansing and broad-spectrum antibiotic administration, coupled with light bandaging of the ears. After 40 days, the animal recovered completely; sarcoptic mange was successfully treated and no relapse of the haematomas was seen. During the subsequent breeding period, the ewe was mated for the first time and became pregnant. The findings support the hypothesis that the highly pruritic sarcoptic mange induced head-shaking and self-inflicted traumas of the pinnae, resulting in the development of auricular haematomas. Treatment required extensive surgical and long post-operative care. From a health management viewpoint, the above treatment schedule can only be justified in young, high-value animals. © 2012 Elsevier B.V. All rights reserved.
1. Introduction There are few reports of surgical operations specifically described for sheep. Hence, surgical methods and approaches, which have been developed for other animal species, are often applied in these animals. Nevertheless, there is a scope in describing methods and techniques
specifically for sheep, in order to support treatment of various disorders and thus to improve their welfare. The present paper describes a case of bilateral auricular haematomas and, as well as the potential association with sarcoptic mange, the surgical treatment and the long-term outcome of the procedure. 2. Case presentation
夽 This paper is part of the special issue entitled “Lectures of the 1st European Conference on Small Ruminant Health Management”, held in Athens, Greece, October 2011. Guest Edited by G.C. Fthenakis. ∗ Corresponding author. E-mail address: [email protected] (V. Tsioli). 0921-4488/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.smallrumres.2012.11.023
2.1. Clinical and laboratory examinations 2.1.1. Animal A 2-month-old, pure-bred Lacaune ewe-lamb from a semi-intensively managed flock in Central Greece, was
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presented with bilateral pinnal swellings. There was no history of external trauma, but intense head-shaking and gradual increase in the size of the swellings was noticed during the previous 10 days. Sarcoptic mange had been previously diagnosed in other animals of the flock. 2.1.2. Laboratory examinations Initially, a general physical examination was performed (Lovatt, 2010). Clinical findings were as follows; bodycondition score: ‘2’ (on the 5-point scale), bodyweight (bw): 12.5 kg, appearance of mucosae: normal, rectal temperature: 40.2 ◦ C, heart rate: 80 min−1 , respiratory rate: 19 min−1 , capillary refill time: <2 s. Cutaneous lesions characterized by alopecia, hypotrichosis, erythema, few small papules, crusts and lichenification were present on the dorsal surface of the nasal planum. Bilateral, soft, fluid-filled, painless swellings, 2.8 cm wide, were observed on the concave surface of the pinnae (Fig. 1); dark brown exudate was noticed filling the entrance of both ear canals. Mild erythema and a small quantity of ceruminous exudate covering the tympanic membrane were found during otoscopy (Operating otoscope; Welch Allyn, Skaneateles Falls, NY, USA). Skin scrapings obtained from facial skin at the area of lesions, were examined under light microscopy at low power magnification (Bowman, 1995). Presence of numerous Sarcoptes scabiei mites was evident. Parasitological examination of otic exudate revealed body particles of dead Sarcoptes mites, whereas keratinocytes and few cocci were seen upon cytological examination of the ear canal. The content of the ear swellings was aspirated using a 21 G needle and was found to be sero-sanguineous. Finally, a blood sample was collected for haematological (QBC Vet Autoreader; IDEXX Laboratories Inc., Westbrooke, MN,
Fig. 1. Facial lesions and bilateral swellings on the concave surface of the pinnae of a ewe-lamb with sarcoptic mange and bilateral auricular haematomas on the day of admission.
USA) and biochemical (Vet Test 8008; IDEXX Laboratories Inc., Westbrooke, MN, USA) examination. Laboratory results, found to be within reference values (Braun et al., 2010; Polizopoulou, 2010), were as follows—haematocrit: 28.4%, haemoglobin concentration: 9.8 g dL−1 , white blood cell count: 12,900 cells L−1 , platelet count: 289,000 L−1 , total solids: 6.2 g dL−1 , glucose concentration: 71 mg dL−1 . 2.2. Diagnosis and case management On the basis of the above findings, a diagnosis of bilateral auricular haematomas was made. Moreover, otoscopic findings pointed out to mild otitis externa. Finally, skin lesions and related laboratory results supported a diagnosis of sarcoptic mange. The owner mentioned that he wished to maintain the animal as a replacement and was willing to support any procedure for complete recovery. Moxidectin, which has a confirmed efficacy against sarcoptic mange (Fthenakis et al., 2000; Plant and Lewis, 2011), was prescribed at a dose rate of 0.2 mg kg−1 bw (2 subcutaneous administrations, 11 days apart) to control sarcoptic mange. For treatment of the haematomas, it was decided to perform a surgical operation. 2.3. Surgical management of auricular haematomas 2.3.1. Initial surgical treatment Food and water were withdrawn for 12 h before surgery. Following pre-medication with acepromazine (Acepromazine; Alfasan, Woerden, The Netherlands) (0.02 mg kg−1 bw, im) and butorphanol (Butador; Richter Pharma, Wels, Austria) (0.05 mg kg−1 bw, im), general anaesthesia was induced and maintained with propofol (Propofol-Lipuro 1%; B/Braun, Melsungen, Germany) (9.6 mg kg−1 bw, iv). The surgical approach followed was to drain both haematomas by using Penrose tubes. One stab incision was done in each of the proximal and the distal border of each haematoma. Haematoma content was removed and the cavity was flushed with sterile normal saline. One Penrose drain (Kendall Tyco, Mansfield, MA, USA) (6 mm) was inserted through the cavity, exiting each stab incision and was sutured to the skin with simple interrupted sutures using non-absorbable suture (Ethilon 2/0; Ethicon, New Jersey, USA) (Fig. 2). Both ear pinnae were bandaged. Duration of surgery (‘skin-to-skin’) was 20 min; time from first to last injection of propofol was 25 min; the animal recovered uneventfully within 15 min after that. Post-operative analgesia was achieved with carprofen (Rimadyl; Pfizer Animal Health, New York, NJ, USA) (2.4 mg kg−1 bw, iv). 2.3.2. Post-operative care Ear bandages were removed after 3 days, as the ewe developed head-shaking and was displacing them. Twice daily, cleansing of the surgical trauma was performed with 0.05% chlorexidine solution (Hibitane 5%; Regent Medical Ltd., Manchester, UK). Marbofloxacin (0.2 mg kg−1 bw, sc) (Marbocyl; Vétoquinol, Lure, France) and lincomycin (5.0 mg kg−1 bw, im) (Lincocin; Pfizer Animal Health, New York, NJ, USA) were administered every 12 h.
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Fig. 3. Histopathological findings of an ear pinna biopsy sample obtained 12 days post-operatively of auricular haematoma drainage; presence of fibroneocartilage formation at the perichondrium, fibrovascular granulation tissue and mild inflammatory infiltration (H&E, 400×).
Fig. 2. Drainage of auricular haematoma in a ewe-lamb with Penrose tube.
On the 4th post-operative day, increased rectal temperature (>40.5 ◦ C) and purulent exudate in both ears were observed. Bacterial culture of an exudate sample, collected under aseptic conditions, was performed by using conventional techniques (Barrow and Feltham, 1993; Euzeby, 1997). No bacteria were isolated from the samples. Penrose drains were removed. On the 12th postoperative day, there was marked thickening of the ear pinnae and biopsy samples were obtained from ear pinnae. Tissue samples were processed by standard histological techniques and stained by haematoxylin–eosin. Main histopathological findings included foci of fibroneocartilage formation at the perichondrium, fibrovascular granulation tissue and inflammation (perivascular and diffuse, mainly neutrophilic and less lymphoplasmacytic) of perichondral tissue (Fig. 3). In view of the situation, 14 days after the first operation, it was decided to operate the animal again. 2.3.3. Subsequent surgical treatment Food and water were withdrawn for 12 h before surgery. Following pre-medication with xylazine (Rompun; Bayer, Leverkusen, Germany) (0.04 mg kg−1 bw, iv) and butorphanol (Butador; Richter Pharma, Wels, Austria) (0.1 mg kg−1 , iv), anaesthesia was induced with thiopental (Pentothal; Abbott Laboratories, Abbott Park, IL, USA) (7.0 mg kg−1 bw, iv) and, following tracheal intubation with a cuffed endotracheal tube of 5.0 mm internal diameter, was maintained with isoflurane (Isoflo; Abbott Laboratories, Abbott Park, IL, USA) (1–2%) in oxygen
(1.5 L min−1 ). Intra-operative analgesia was augmented with fentanyl (Fentanyl; Janssen-Cilag, Beerse, Belgium) (0.5 g kg−1 bw min−1 , iv). The surgical approach followed was to perform the incisional technique on each pinna for complete drainage. A longitudinal incision was performed on the concave surface of each pinna (Fig. 4a). Fibrin clots were removed and the cavities were irrigated. Mattress sutures were placed through the ear (full thickness), incorporating the skin on the convex surface of the ear using non-absorbable suture (Ethilon 2/0; Ethicon, New Jersey, USA). Sutures were placed parallel to major vessels, not penetrating them; they were tightened enough to only allow apposition of the skin and cartilage, while the initial incisions were left to gap, allowing drainage (Fig. 4b). Duration of surgery (‘skin-to-skin’) was 45 min; time from induction of anaesthesia with thiopental to discontinuing isoflurane administration was 70 min; the endotracheal tube was removed 5 min after that and the animal recovered uneventfully 10 min later. Post-operative analgesia was achieved with carprofen (Rimadyl; Pfizer Animal Health, New York, NJ, USA) (2.4 mg kg−1 bw, iv). 2.3.4. Post-operative care Light bandaging was applied for 3 days. Twice daily cleansing and broad-spectrum antibiotics were administered, as above. 2.4. Final outcome After long post-operative care (40 days), the animal recovered completely. Neither relapse of the haematomas, nor pruritic dermatitis were seen. At discharge from the hospital, body weight of the ewe was 16.5 kg. During the subsequent breeding period, the ewe was mated for the first time and became pregnant. Then, the animal lambed normally.
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disorders, may also be involved (Sullivan et al., 1994). After trauma of the pinna, haemorrhage occurs between the cartilage and the skin, resulting in the formation of haematoma. If left untreated, the haematoma matures and granulation tissue develops, which can lead to fibrosis and thickening of the ear pinna (Lanz and Wood, 2004). Therapeutic objectives consist of identifying and treating the underlying cause of ear pruritus and provision of drainage and maintenance of apposition between cartilage and skin, using one of the various surgical techniques that have been described (Lanz and Wood, 2004). Reports of auricular haematomas in sheep are rare. Morgan (1992) and Bates (1996) reported unilateral or bilateral auricular haematomas in sheep with psoroptic mange, whilst Tyler et al. (1999) reported unilateral lesions in one animal with scrapie; hence, all cases described so far have been associated with pruritic disorders. In the present case, the animal was presented with auricular haematomas and sarcoptic mange, a disease causing intense pruritus (Papadopoulos and Fthenakis, 1999; Taylor et al., 2007); the head-shaking associated with pruritus might have caused self-inflicted traumas in the ears, leading to extravasation and development of the haematomas. In previous papers, detailed descriptions of treatment of the disorder have not been reported. The tube drainage technique employed initially is the easier surgical technique that can be selected for auricular haematomas containing only serous material without fibrin. However, the technique requires post-operative bandaging, in order to prevent subsequent infections. As pruritus and skin lesions caused by sarcoptic mange take up to 95 days to resolve (Papadopoulos and Fthenakis, 1999; Fthenakis et al., 2000), persistent pruritus and head-shaking prevented effective long-term bandaging of the animal, which led to a post-operative bacterial complication. At the same time fibrotic lesions were also evident. The condition required a second surgical intervention, which was carried out by incisional drainage; this allowed improved cleaning, fibrin removal and effective drainage. As was initially estimated, the second operation took longer than the first (45 min versus 20 min), during which inhalational anaesthesia was deemed necessary to support the animal during the lengthy procedure (Galatos, 2011). Fig. 4. (a) Longitudinal incision of the inner surface of the pinna in a ewelamb with auricular haematoma; arrows indicate the thickened cartilage. (b) Sutures placed in parallel to major vessels and knots on the inner surface of the pinna, with the initial incisions left to gap for improved drainage.
3. Discussion Auricular haematomas, albeit being a frequent disorder in dogs, cats and pigs, have been rarely described in sheep. Various causes and mechanisms have been suggested as potentially leading to their development. These include self-inflicted trauma of the pinna by scratching and especially by head-shaking, usually as a consequence of otitis (e.g., due to parasites, foreign bodies, allergies, polyps or neoplasms) (Joyce and Day, 1997; Fossum, 2007). Other factors, such as increased capillary fragility and coagulation
4. Concluding remarks To the best of our knowledge, this is the first detailed description of surgical treatment of auricular haematoma in sheep. In this case, the haematomas were a consequence of sarcoptic mange. Treatment required a radical surgical intervention and long post-operative care. In cases with thickened cartilage of the pinna, the incisional technique appears to be a better choice. From a health management viewpoint, the above schedule was justified, as the animal was young and of high-value, with a potential for subsequent high milk production. Conflict of interest statement The authors have nothing to disclose.
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References Barrow, G.I., Feltham, R.K.A., 1993. Manual for the Identification of Medical Bacteria, 3rd ed. Cambridge University Press, Cambridge. Bates, P.G., 1996. Epidemiology of subclinical ovine psoroptic otoacariasis in Great Britain. Vet. Rec. 138, 388–393. Bowman, D., 1995. Georgis’ Parasitology for Veterinarians, 6th ed. Saunders, Philadelphia, 430 pp. Braun, J.P., Trumel, C., Bézille, P., 2010. Clinical biochemistry in sheep: a selected review. Small Rumin. Res. 92, 10–18. Euzeby, J.P., 1997. List of bacterial names with standing in nomenclature: a folder available on the Internet. Int. J. Syst. Bacteriol. 47, 590–592 (List of prokaryotic names with standing in nomenclature, URL: http://www.bacterio.net). Fossum, T.W., 2007. Surgery of the ear. In: Fossum, T.W. (Ed.), Small Animal Surgery. Mosby, St. Louis, pp. 289–316. Fthenakis, G.C., Papadopoulos, E., Himonas, C., Leontidis, L., Kritas, S., Papatsas, J., 2000. The efficacy of moxidectin against sarcoptic mange of sheep and the effects of the treatment on the milk yield of ewes and the growth of lambs. Vet. Parasitol. 87, 207–216. Galatos, A.D., 2011. Anesthesia and analgesia in sheep and goats. Vet. Clin. North Am. Food Anim. Pract. 27, 47–59. Joyce, J.A., Day, M.J., 1997. Immunopathogenesis of canine aural haematoma. J. Small Anim. Pract. 38, 152–158.
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Lanz, O.I., Wood, B.C., 2004. Surgery of the ear and pinna. Vet. Clin. North Am. Small Anim. Pract. 34, 567–599. Lovatt, F.M., 2010. Clinical examination of sheep. Small Rumin. Res. 92, 72–77. Morgan, K.L., 1992. Parasitic otitis in sheep associated with psoroptes infestation: a clinical and epidemiological study. Vet. Rec. 130, 530–532. Papadopoulos, E., Fthenakis, G.C., 1999. Administration of moxidectin for treatment of sarcoptic mange in a flock of sheep. Small Rumin. Res. 31, 165–168. Plant, J.W., Lewis, C.J., 2011. Treatment and control of ectoparasites in sheep. Vet. Clin. North Am. Food Anim. Pract. 27, 203–212. Polizopoulou, Z.S., 2010. Haematological tests in sheep health management. Small Rumin. Res. 92, 88–91. Sullivan, P.S., Grubbs, S.T., Olchowy, T.W.J., Andrews, F.M., White, J.G., Gatalfamo, J.L., Dodd, P.A., McDonald, T.P., 1994. Bleeding diathesis associated with variant von Willebrand factor in a Simmental calf. J. Am. Vet. Med. Assoc. 205, 1763–1766. Taylor, M.A., Coop, R.L., Wall, R.L., 2007. Veterinary Parasitology, 3rd ed. Blackwell, Oxford, 874 pp. Tyler, J.W., Weaver, D.M., Turk, J.R., O’Rourke, K.I., Harrington, M.G., Taylor, W., Jenny, A., 1999. Naturally occurring scrapie in Southdown sheep. J. Vet. Intern. Med. 13, 213–216.
Contents lists available at SciVerse ScienceDirect
Small Ruminant Research journal homepage: www.elsevier.com/locate/smallrumres
A case of bilateral auricular haematoma in a ewe-lamb with sarcoptic mange夽 V. Tsioli ∗ , R. Farmaki, A. Papastefanou, A.D. Galatos, M. Marinou, D. Tontis, V.S. Mavrogianni, D. Doukas, M.N. Saridomichelakis, G.C. Fthenakis Veterinary Faculty, University of Thessaly, Karditsa, Greece
a r t i c l e
i n f o
Article history: Available online 30 November 2012 Keywords: Anaesthesia Auricular haematomas Ear Pinna Sarcoptic mange Sheep Surgery
a b s t r a c t A Lacaune ewe-lamb was referred with bilateral pinnal swelling and intense head-shaking. Soft, fluid-filled, painless swellings were present on the concave surface of both ear pinnae. Needle aspiration revealed sero-sanguineous fluid, confirming the clinical suspicion of auricular haematomas. Cutaneous lesions characteristic of sarcoptic mange were present on the nasal planum; diagnosis was confirmed based on the results of microscopic examination of skin scrapings (i.e., presence of Sarcoptes scabiei); for treatment of the disorder, moxidectin was administered twice, 11 days apart. The animal was operated under injectable anaesthesia. Auricular haematomas were drained by using Penrose tubes. However, and despite repeated post-surgical otic cleansing and administration of broad-spectrum antibiotics, local infection developed post-operatively. Subsequently, a second operation was performed, under inhalational anaesthesia, where the incisional technique was applied. Post-operative care included otic cleansing and broad-spectrum antibiotic administration, coupled with light bandaging of the ears. After 40 days, the animal recovered completely; sarcoptic mange was successfully treated and no relapse of the haematomas was seen. During the subsequent breeding period, the ewe was mated for the first time and became pregnant. The findings support the hypothesis that the highly pruritic sarcoptic mange induced head-shaking and self-inflicted traumas of the pinnae, resulting in the development of auricular haematomas. Treatment required extensive surgical and long post-operative care. From a health management viewpoint, the above treatment schedule can only be justified in young, high-value animals. © 2012 Elsevier B.V. All rights reserved.
1. Introduction There are few reports of surgical operations specifically described for sheep. Hence, surgical methods and approaches, which have been developed for other animal species, are often applied in these animals. Nevertheless, there is a scope in describing methods and techniques
specifically for sheep, in order to support treatment of various disorders and thus to improve their welfare. The present paper describes a case of bilateral auricular haematomas and, as well as the potential association with sarcoptic mange, the surgical treatment and the long-term outcome of the procedure. 2. Case presentation
夽 This paper is part of the special issue entitled “Lectures of the 1st European Conference on Small Ruminant Health Management”, held in Athens, Greece, October 2011. Guest Edited by G.C. Fthenakis. ∗ Corresponding author. E-mail address: [email protected] (V. Tsioli). 0921-4488/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.smallrumres.2012.11.023
2.1. Clinical and laboratory examinations 2.1.1. Animal A 2-month-old, pure-bred Lacaune ewe-lamb from a semi-intensively managed flock in Central Greece, was
146
V. Tsioli et al. / Small Ruminant Research 110 (2013) 145–149
presented with bilateral pinnal swellings. There was no history of external trauma, but intense head-shaking and gradual increase in the size of the swellings was noticed during the previous 10 days. Sarcoptic mange had been previously diagnosed in other animals of the flock. 2.1.2. Laboratory examinations Initially, a general physical examination was performed (Lovatt, 2010). Clinical findings were as follows; bodycondition score: ‘2’ (on the 5-point scale), bodyweight (bw): 12.5 kg, appearance of mucosae: normal, rectal temperature: 40.2 ◦ C, heart rate: 80 min−1 , respiratory rate: 19 min−1 , capillary refill time: <2 s. Cutaneous lesions characterized by alopecia, hypotrichosis, erythema, few small papules, crusts and lichenification were present on the dorsal surface of the nasal planum. Bilateral, soft, fluid-filled, painless swellings, 2.8 cm wide, were observed on the concave surface of the pinnae (Fig. 1); dark brown exudate was noticed filling the entrance of both ear canals. Mild erythema and a small quantity of ceruminous exudate covering the tympanic membrane were found during otoscopy (Operating otoscope; Welch Allyn, Skaneateles Falls, NY, USA). Skin scrapings obtained from facial skin at the area of lesions, were examined under light microscopy at low power magnification (Bowman, 1995). Presence of numerous Sarcoptes scabiei mites was evident. Parasitological examination of otic exudate revealed body particles of dead Sarcoptes mites, whereas keratinocytes and few cocci were seen upon cytological examination of the ear canal. The content of the ear swellings was aspirated using a 21 G needle and was found to be sero-sanguineous. Finally, a blood sample was collected for haematological (QBC Vet Autoreader; IDEXX Laboratories Inc., Westbrooke, MN,
Fig. 1. Facial lesions and bilateral swellings on the concave surface of the pinnae of a ewe-lamb with sarcoptic mange and bilateral auricular haematomas on the day of admission.
USA) and biochemical (Vet Test 8008; IDEXX Laboratories Inc., Westbrooke, MN, USA) examination. Laboratory results, found to be within reference values (Braun et al., 2010; Polizopoulou, 2010), were as follows—haematocrit: 28.4%, haemoglobin concentration: 9.8 g dL−1 , white blood cell count: 12,900 cells L−1 , platelet count: 289,000 L−1 , total solids: 6.2 g dL−1 , glucose concentration: 71 mg dL−1 . 2.2. Diagnosis and case management On the basis of the above findings, a diagnosis of bilateral auricular haematomas was made. Moreover, otoscopic findings pointed out to mild otitis externa. Finally, skin lesions and related laboratory results supported a diagnosis of sarcoptic mange. The owner mentioned that he wished to maintain the animal as a replacement and was willing to support any procedure for complete recovery. Moxidectin, which has a confirmed efficacy against sarcoptic mange (Fthenakis et al., 2000; Plant and Lewis, 2011), was prescribed at a dose rate of 0.2 mg kg−1 bw (2 subcutaneous administrations, 11 days apart) to control sarcoptic mange. For treatment of the haematomas, it was decided to perform a surgical operation. 2.3. Surgical management of auricular haematomas 2.3.1. Initial surgical treatment Food and water were withdrawn for 12 h before surgery. Following pre-medication with acepromazine (Acepromazine; Alfasan, Woerden, The Netherlands) (0.02 mg kg−1 bw, im) and butorphanol (Butador; Richter Pharma, Wels, Austria) (0.05 mg kg−1 bw, im), general anaesthesia was induced and maintained with propofol (Propofol-Lipuro 1%; B/Braun, Melsungen, Germany) (9.6 mg kg−1 bw, iv). The surgical approach followed was to drain both haematomas by using Penrose tubes. One stab incision was done in each of the proximal and the distal border of each haematoma. Haematoma content was removed and the cavity was flushed with sterile normal saline. One Penrose drain (Kendall Tyco, Mansfield, MA, USA) (6 mm) was inserted through the cavity, exiting each stab incision and was sutured to the skin with simple interrupted sutures using non-absorbable suture (Ethilon 2/0; Ethicon, New Jersey, USA) (Fig. 2). Both ear pinnae were bandaged. Duration of surgery (‘skin-to-skin’) was 20 min; time from first to last injection of propofol was 25 min; the animal recovered uneventfully within 15 min after that. Post-operative analgesia was achieved with carprofen (Rimadyl; Pfizer Animal Health, New York, NJ, USA) (2.4 mg kg−1 bw, iv). 2.3.2. Post-operative care Ear bandages were removed after 3 days, as the ewe developed head-shaking and was displacing them. Twice daily, cleansing of the surgical trauma was performed with 0.05% chlorexidine solution (Hibitane 5%; Regent Medical Ltd., Manchester, UK). Marbofloxacin (0.2 mg kg−1 bw, sc) (Marbocyl; Vétoquinol, Lure, France) and lincomycin (5.0 mg kg−1 bw, im) (Lincocin; Pfizer Animal Health, New York, NJ, USA) were administered every 12 h.
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Fig. 3. Histopathological findings of an ear pinna biopsy sample obtained 12 days post-operatively of auricular haematoma drainage; presence of fibroneocartilage formation at the perichondrium, fibrovascular granulation tissue and mild inflammatory infiltration (H&E, 400×).
Fig. 2. Drainage of auricular haematoma in a ewe-lamb with Penrose tube.
On the 4th post-operative day, increased rectal temperature (>40.5 ◦ C) and purulent exudate in both ears were observed. Bacterial culture of an exudate sample, collected under aseptic conditions, was performed by using conventional techniques (Barrow and Feltham, 1993; Euzeby, 1997). No bacteria were isolated from the samples. Penrose drains were removed. On the 12th postoperative day, there was marked thickening of the ear pinnae and biopsy samples were obtained from ear pinnae. Tissue samples were processed by standard histological techniques and stained by haematoxylin–eosin. Main histopathological findings included foci of fibroneocartilage formation at the perichondrium, fibrovascular granulation tissue and inflammation (perivascular and diffuse, mainly neutrophilic and less lymphoplasmacytic) of perichondral tissue (Fig. 3). In view of the situation, 14 days after the first operation, it was decided to operate the animal again. 2.3.3. Subsequent surgical treatment Food and water were withdrawn for 12 h before surgery. Following pre-medication with xylazine (Rompun; Bayer, Leverkusen, Germany) (0.04 mg kg−1 bw, iv) and butorphanol (Butador; Richter Pharma, Wels, Austria) (0.1 mg kg−1 , iv), anaesthesia was induced with thiopental (Pentothal; Abbott Laboratories, Abbott Park, IL, USA) (7.0 mg kg−1 bw, iv) and, following tracheal intubation with a cuffed endotracheal tube of 5.0 mm internal diameter, was maintained with isoflurane (Isoflo; Abbott Laboratories, Abbott Park, IL, USA) (1–2%) in oxygen
(1.5 L min−1 ). Intra-operative analgesia was augmented with fentanyl (Fentanyl; Janssen-Cilag, Beerse, Belgium) (0.5 g kg−1 bw min−1 , iv). The surgical approach followed was to perform the incisional technique on each pinna for complete drainage. A longitudinal incision was performed on the concave surface of each pinna (Fig. 4a). Fibrin clots were removed and the cavities were irrigated. Mattress sutures were placed through the ear (full thickness), incorporating the skin on the convex surface of the ear using non-absorbable suture (Ethilon 2/0; Ethicon, New Jersey, USA). Sutures were placed parallel to major vessels, not penetrating them; they were tightened enough to only allow apposition of the skin and cartilage, while the initial incisions were left to gap, allowing drainage (Fig. 4b). Duration of surgery (‘skin-to-skin’) was 45 min; time from induction of anaesthesia with thiopental to discontinuing isoflurane administration was 70 min; the endotracheal tube was removed 5 min after that and the animal recovered uneventfully 10 min later. Post-operative analgesia was achieved with carprofen (Rimadyl; Pfizer Animal Health, New York, NJ, USA) (2.4 mg kg−1 bw, iv). 2.3.4. Post-operative care Light bandaging was applied for 3 days. Twice daily cleansing and broad-spectrum antibiotics were administered, as above. 2.4. Final outcome After long post-operative care (40 days), the animal recovered completely. Neither relapse of the haematomas, nor pruritic dermatitis were seen. At discharge from the hospital, body weight of the ewe was 16.5 kg. During the subsequent breeding period, the ewe was mated for the first time and became pregnant. Then, the animal lambed normally.
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disorders, may also be involved (Sullivan et al., 1994). After trauma of the pinna, haemorrhage occurs between the cartilage and the skin, resulting in the formation of haematoma. If left untreated, the haematoma matures and granulation tissue develops, which can lead to fibrosis and thickening of the ear pinna (Lanz and Wood, 2004). Therapeutic objectives consist of identifying and treating the underlying cause of ear pruritus and provision of drainage and maintenance of apposition between cartilage and skin, using one of the various surgical techniques that have been described (Lanz and Wood, 2004). Reports of auricular haematomas in sheep are rare. Morgan (1992) and Bates (1996) reported unilateral or bilateral auricular haematomas in sheep with psoroptic mange, whilst Tyler et al. (1999) reported unilateral lesions in one animal with scrapie; hence, all cases described so far have been associated with pruritic disorders. In the present case, the animal was presented with auricular haematomas and sarcoptic mange, a disease causing intense pruritus (Papadopoulos and Fthenakis, 1999; Taylor et al., 2007); the head-shaking associated with pruritus might have caused self-inflicted traumas in the ears, leading to extravasation and development of the haematomas. In previous papers, detailed descriptions of treatment of the disorder have not been reported. The tube drainage technique employed initially is the easier surgical technique that can be selected for auricular haematomas containing only serous material without fibrin. However, the technique requires post-operative bandaging, in order to prevent subsequent infections. As pruritus and skin lesions caused by sarcoptic mange take up to 95 days to resolve (Papadopoulos and Fthenakis, 1999; Fthenakis et al., 2000), persistent pruritus and head-shaking prevented effective long-term bandaging of the animal, which led to a post-operative bacterial complication. At the same time fibrotic lesions were also evident. The condition required a second surgical intervention, which was carried out by incisional drainage; this allowed improved cleaning, fibrin removal and effective drainage. As was initially estimated, the second operation took longer than the first (45 min versus 20 min), during which inhalational anaesthesia was deemed necessary to support the animal during the lengthy procedure (Galatos, 2011). Fig. 4. (a) Longitudinal incision of the inner surface of the pinna in a ewelamb with auricular haematoma; arrows indicate the thickened cartilage. (b) Sutures placed in parallel to major vessels and knots on the inner surface of the pinna, with the initial incisions left to gap for improved drainage.
3. Discussion Auricular haematomas, albeit being a frequent disorder in dogs, cats and pigs, have been rarely described in sheep. Various causes and mechanisms have been suggested as potentially leading to their development. These include self-inflicted trauma of the pinna by scratching and especially by head-shaking, usually as a consequence of otitis (e.g., due to parasites, foreign bodies, allergies, polyps or neoplasms) (Joyce and Day, 1997; Fossum, 2007). Other factors, such as increased capillary fragility and coagulation
4. Concluding remarks To the best of our knowledge, this is the first detailed description of surgical treatment of auricular haematoma in sheep. In this case, the haematomas were a consequence of sarcoptic mange. Treatment required a radical surgical intervention and long post-operative care. In cases with thickened cartilage of the pinna, the incisional technique appears to be a better choice. From a health management viewpoint, the above schedule was justified, as the animal was young and of high-value, with a potential for subsequent high milk production. Conflict of interest statement The authors have nothing to disclose.
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