Aural hematoma / Ear hematoma

An aural hematoma, also called an ear hematoma, is a collection of blood that accumulates between the skin and cartilage of a cat's ear pinna (ear flap), causing the ear to swell and become distorted. This condition develops when blood vessels within the ear flap rupture, typically as a result of trauma from vigorous head shaking or scratching in response to ear irritation. The resulting blood pocket creates a fluid-filled swelling that can range from small and localized to involving nearly the entire ear flap. While not life-threatening, aural hematomas cause significant discomfort and, if left untreated, can result in permanent ear deformity commonly known as cauliflower ear.

Aural hematomas occur most commonly in cats with underlying ear conditions that prompt head shaking or ear scratching. Ear mite infestations represent one of the most frequent underlying causes, particularly in younger cats or those with outdoor access. Bacterial or yeast ear infections create intense itching and discomfort leading to self-trauma. Allergic skin disease affecting the ears triggers scratching and head shaking. Foreign bodies in the ear canal cause acute irritation prompting violent head shaking. In some cases, the immediate cause of blood vessel rupture may be a single incident of vigorous shaking, while in others, cumulative trauma from ongoing scratching eventually causes vascular damage.

The impact of an aural hematoma on a cat extends beyond the ear itself to affect overall comfort and quality of life. The swollen ear is heavy and uncomfortable, often causing the cat to hold its head tilted or continue scratching at the affected ear. The underlying ear condition that caused the hematoma typically continues to cause irritation, perpetuating the cycle of scratching and potentially worsening the hematoma or preventing healing. Untreated hematomas eventually organize and scar, leaving permanent thickening and distortion of the ear pinna that, while cosmetically concerning, may not significantly affect the cat functionally.

Treatment of aural hematomas focuses on draining accumulated blood, preventing recurrence, and addressing the underlying cause that triggered the head shaking or scratching. Without addressing the root cause, hematomas frequently recur even after successful drainage. Surgical treatment provides the most reliable outcomes but requires anesthesia and creates visible suture lines. Conservative approaches may be appropriate for some cases but carry higher recurrence rates. The prognosis for complete resolution is generally good with appropriate treatment, though some ear distortion may persist even with optimal management. Early treatment offers the best cosmetic outcomes and fastest return to comfort.

The primary cause of aural hematomas is mechanical trauma to the ear flap that ruptures blood vessels within the pinna tissue. This trauma most commonly results from vigorous head shaking or scratching in response to ear irritation. When cats shake their heads forcefully, the ear flaps whip back and forth, creating shearing forces that can tear small blood vessels. Similarly, repeated scratching at the ears with hind claws causes direct tissue damage. The cumulative effect of ongoing self-trauma eventually exceeds the tissue's ability to heal, resulting in blood accumulation between the skin and underlying cartilage. Once bleeding begins into this potential space, continued head shaking prevents clotting and can worsen the hemorrhage.

Underlying ear conditions represent the true root cause of most aural hematomas, as they create the irritation driving head shaking and scratching behavior. Ear mites (Otodectes cynotis) are among the most common underlying causes, particularly in younger cats, outdoor cats, or those exposed to other infested animals. These microscopic parasites cause intense itching and produce dark, crusty discharge within the ear canal. Bacterial and yeast infections of the ear canal cause inflammation, discharge, and discomfort prompting scratching. Allergic otitis from food allergies or environmental allergies creates chronic ear inflammation. Foreign bodies such as grass seeds or debris lodged in the ear canal trigger violent head shaking. Less commonly, ear tumors or polyps may cause irritation.

Environmental and lifestyle factors influence a cat's risk of developing conditions that lead to aural hematomas. Outdoor access increases exposure to ear mites from contact with other animals. Multi-cat households facilitate parasite transmission between cats. Environmental allergens including pollen, dust mites, and mold spores can trigger allergic ear inflammation. Humid environments may predispose to ear infections. Cats that fight or engage in rough play may sustain direct ear trauma. Living conditions affecting stress levels can influence immune function and susceptibility to ear infections.

Several risk factors predispose individual cats to developing aural hematomas. Cats with large, pendulous ears have more ear tissue subject to shearing forces during head shaking. Cats with chronic ear conditions including ongoing infections or untreated allergies face ongoing risk. Previous aural hematomas increase the risk of recurrence, particularly if the underlying cause was not addressed. Cats on anticoagulant medications or with bleeding disorders may develop hematomas more readily from minor trauma. Immunocompromised cats may be more susceptible to ear infections that trigger scratching. Senior cats with age-related immune decline may have increased ear infection susceptibility.

The mechanism by which aural hematomas form involves several tissue-level processes. The ear pinna consists of thin skin covering both surfaces of a central cartilage plate, with blood vessels running between the skin and cartilage. Trauma from shaking or scratching damages these vessels, causing bleeding into the potential space between skin and cartilage. Blood accumulates and separates these tissue layers, creating the characteristic fluid-filled swelling. Continued head shaking prevents clot formation and can extend the hemorrhage. Without intervention, the blood eventually organizes, with fibrous tissue replacing the blood clot. This fibrous tissue contracts as it matures, causing the permanent wrinkling and thickening of cauliflower ear deformity.

Early warning signs of developing aural hematoma often involve observations related to the underlying ear condition before the hematoma itself becomes apparent. Cats may show increased head shaking, often violent enough to be audible. Scratching at the ears with hind paws, sometimes causing self-inflicted wounds, indicates ear discomfort. Head tilting toward the affected ear suggests asymmetric ear irritation. Dark or malodorous ear discharge visible at the ear opening may indicate infection or mites. Redness or inflammation visible in the ear canal opening suggests ear disease. Changes in behavior including irritability when ears are touched often precede hematoma development. These early signs warrant veterinary attention to address underlying causes before hematoma formation occurs.

The appearance of an aural hematoma is typically dramatic and easily recognized by cat owners. The ear flap swells, becoming thickened and pillow-like rather than its normal thin, flexible state. The swelling may involve the entire ear pinna or only a portion, though usually affects the inner (concave) surface more prominently. The affected area feels fluctuant or fluid-filled when gently palpated, distinguishing it from other causes of ear swelling. Skin over the hematoma may appear discolored, taking on red, purple, or blue hues as blood shows through. The ear often droops or hangs differently than normal due to the weight of accumulated blood. The opposite ear may appear normal, highlighting the asymmetric swelling.

Behavioral changes accompanying aural hematoma reflect both the discomfort from the hematoma itself and ongoing irritation from underlying ear disease. Affected cats often hold their heads tilted toward the affected side due to the uncomfortable weight of the swollen ear. Head shaking may continue or intensify, potentially worsening the hematoma. Some cats resist any contact with the affected ear, moving away or becoming defensive when approached. Appetite may decrease due to general discomfort. Activity levels often decline as cats rest more to avoid jarring movements. Some cats vocalize more, particularly when the ear is touched. Grooming of the affected ear area may increase or decrease depending on whether contact provides relief or causes pain.

Physical examination findings allow veterinarians to confirm aural hematoma diagnosis and assess severity. The swelling is soft and fluctuant on palpation, indicating fluid accumulation. Gentle pressure may cause the cat to react, indicating discomfort. The ear may feel warm due to inflammation. Examination of the ear canal typically reveals evidence of underlying ear disease including discharge, redness, or parasites. Both ears should be examined, as bilateral ear disease is common even when hematoma affects only one side. Assessment of lymph nodes near the ears may reveal enlargement if infection is present. The size and location of the hematoma guide treatment planning.

Symptom progression without treatment follows a predictable course toward resolution through fibrosis but with permanent ear deformity. Initial swelling may increase over the first few days if head shaking continues and additional bleeding occurs. Pain and discomfort persist throughout the acute phase. Without drainage, the blood eventually clots and begins organizing into fibrous tissue over one to two weeks. As fibrosis progresses over several weeks, the ear gradually becomes firmer and less swollen. However, the fibrous tissue contracts, causing permanent wrinkling, thickening, and distortion of the ear pinna. This cauliflower ear deformity, while cosmetically concerning, does not typically affect hearing or cause ongoing discomfort once healing is complete.

Emergency symptoms related to aural hematoma are uncommon, as the condition itself is not life-threatening. However, certain situations warrant prompt veterinary attention. Very rapid ear swelling occurring over hours rather than days may indicate ongoing hemorrhage. Signs of infection including fever, spreading redness, or purulent discharge from the ear require assessment. Cats showing severe pain response or neurological signs including loss of balance warrant evaluation to rule out middle ear involvement. Complete loss of appetite or signs of systemic illness accompanying the hematoma suggest complications. While most aural hematomas do not constitute emergencies, timely treatment provides better outcomes than delayed intervention.

Diagnosis of aural hematoma is typically straightforward based on characteristic clinical appearance and physical examination findings. The veterinarian will observe the swollen, pillow-like ear flap and palpate the area, feeling the fluctuant fluid accumulation characteristic of hematoma. The history of head shaking or ear scratching preceding the swelling supports the diagnosis. Physical examination differentiates hematoma from other causes of ear swelling including abscess, tumor, or inflammatory conditions. The unilateral presentation (one ear affected) is typical, though both ears can occasionally develop hematomas, particularly when severe bilateral ear disease is present.

Examination of the ear canal represents an essential component of diagnostic evaluation, as identifying the underlying cause of ear irritation is critical for successful treatment. Otoscopic examination visualizes the ear canal and eardrum, identifying discharge, inflammation, foreign bodies, masses, or parasites. Ear cytology, performed by examining a sample of ear discharge under the microscope, identifies bacteria, yeast organisms, ear mites, or inflammatory cells. Culture and sensitivity testing may be performed for suspected bacterial infections to guide antibiotic selection. Evaluation of both ears ensures bilateral ear disease is not overlooked even when hematoma affects only one side. Skin examination elsewhere on the body may reveal evidence of allergic skin disease contributing to ear problems.

Differential diagnosis for ear swelling includes conditions that may mimic or coexist with aural hematoma. Abscess from bite wounds or other penetrating trauma can cause ear swelling but typically feels firmer than the fluctuant hematoma and may have an entry wound. Ear tumors may cause swelling but usually develop more gradually and feel solid rather than fluid-filled. Insect stings or allergic reactions can cause ear swelling but typically affect both ears and resolve quickly. Cellulitis or soft tissue infection causes swelling with warmth and pain. Seroma formation (collection of serum rather than blood) produces similar appearance to hematoma. In most cases, clinical presentation clearly distinguishes hematoma from alternatives.

Additional diagnostic testing may be recommended based on individual case characteristics. If allergic disease is suspected as the underlying cause, allergy testing through blood tests or intradermal skin testing may help identify specific triggers. Cats with recurrent ear problems may benefit from evaluation for underlying conditions affecting immune function. Skin biopsy may be indicated if unusual inflammatory conditions are suspected. Blood work including coagulation testing may be appropriate for cats with unexplained or recurrent hematomas or those on anticoagulant medications. Advanced imaging is rarely needed for hematoma diagnosis but may be indicated to evaluate middle ear disease if suspected. The diagnostic approach is tailored to each cat's situation to fully characterize the condition and plan appropriate treatment.

Emergency treatment for aural hematoma is rarely needed, as the condition develops gradually and does not threaten life. However, initial management focuses on addressing cat comfort while planning definitive treatment. Pain relief may be provided through appropriate analgesics. Preventing further self-trauma with an Elizabethan collar (cone) or recovery suit protects the ear from additional scratching damage. Treatment of underlying ear disease begins immediately with appropriate ear medications to reduce the irritation driving head shaking. Initial drainage by needle aspiration may be performed to reduce pressure and provide temporary relief while planning more definitive treatment, though aspiration alone has high recurrence rates.

Surgical treatment represents the gold standard for aural hematoma management, providing the most reliable outcomes with lowest recurrence rates. The most common surgical approach involves making an incision along the inner surface of the ear to drain accumulated blood, then placing multiple mattress sutures through the ear to obliterate the potential space where blood collected. These sutures hold the skin firmly against the cartilage, preventing reaccumulation while allowing remaining fluid to drain. Variations include using drainage holes rather than a single incision, or placing a drain that exits through separate openings. Surgery requires general anesthesia and creates visible suture lines, but offers the best chance of preserving ear shape and preventing recurrence. Post-surgical bandaging stabilizes the ear during initial healing.

Conservative and minimally invasive treatments may be appropriate for selected cases or when owners decline surgery. Repeated needle aspiration with bandaging can be attempted but has recurrence rates exceeding 50%. Aspiration followed by injection of corticosteroids into the hematoma cavity aims to reduce inflammation and may improve outcomes compared to aspiration alone. Some practitioners use teat cannulas or other small drains placed through a stab incision to allow ongoing drainage. Laser therapy has been used to promote healing in some cases. Conservative approaches may be considered for small hematomas, elderly cats with anesthetic concerns, or when financial constraints preclude surgery. However, owners should understand that conservative management carries higher recurrence risk and greater likelihood of permanent ear deformity.

Treatment of underlying ear conditions must accompany hematoma treatment to prevent recurrence. Ear mites require appropriate antiparasitic treatment for the affected cat and any other animals in the household. Bacterial ear infections need appropriate antibiotic therapy based on culture results or empirical selection. Yeast infections respond to antifungal ear medications. Allergic ear disease may require ongoing management with ear cleaning protocols, topical therapies, and potentially systemic allergy treatment including diet trials for food allergies or immunotherapy for environmental allergies. Without addressing the root cause of ear irritation, hematomas commonly recur even after successful surgical treatment.

Supportive care during treatment and recovery maintains comfort and optimizes healing. Elizabethan collars prevent scratching that could disrupt healing or worsen underlying ear disease. Regular ear cleaning per veterinary instructions removes discharge and medication residue. Pain management ensures cat comfort during recovery. Bandage or wrap application may protect surgical sites. Monitoring for signs of infection at surgical sites enables early intervention if needed. Gentle handling of the affected ear minimizes discomfort during medication application.

Treatment decisions involve weighing several factors specific to each case. Hematoma size and duration influence approach selection, with larger, older hematomas often requiring surgical intervention. The cat's overall health and anesthetic risk affect surgical candidacy. Owner preferences regarding cosmetic outcome may influence decisions, as surgery typically provides better shape preservation. Financial considerations factor into treatment selection. The nature and severity of underlying ear disease affect prognosis regardless of hematoma treatment approach. Veterinary guidance helps owners make informed decisions appropriate for their cat's situation.

Recovery timeline following surgical treatment of aural hematoma typically spans two to three weeks for initial healing, with continued improvement over several weeks thereafter. The first few days post-surgery involve managing discomfort and preventing disruption of the surgical site. Sutures typically remain in place for two to three weeks, with recheck appointments to assess healing. Bandages, if applied, are usually changed or removed within the first week. Mild swelling and bruising around the surgical site are normal initially and resolve gradually. Most cats show significant comfort improvement within days as the heavy, painful swelling resolves. Full return to normal activity occurs once sutures are removed and healing is confirmed.

Post-treatment care requirements extend beyond wound healing to include ongoing management of underlying ear conditions. Elizabethan collar use continues until sutures are removed and the ear has healed sufficiently to withstand any scratching. Ear medications prescribed for underlying infection, mites, or allergies continue for the full prescribed duration and potentially longer for chronic conditions. Oral medications including antibiotics, anti-inflammatories, or pain relievers are administered as prescribed. Activity restriction is minimal beyond preventing scratching access to the ear. Keeping the surgical site clean and dry supports healing. Follow-up appointments allow monitoring of healing and adjustment of ear disease treatment as needed.

Prognosis for aural hematoma is generally good with appropriate treatment, though outcomes vary based on treatment approach and underlying cause management. Surgical treatment provides the best cosmetic outcomes, with most cats retaining reasonably normal ear shape and flexibility. Some thickening or minor wrinkling may occur even with surgery but is typically minimal. Conservative treatment carries higher risk of permanent ear deformity due to fibrosis during prolonged healing. Regardless of hematoma treatment approach, failure to address underlying ear disease leads to recurrence in many cases. Complete resolution of both the hematoma and underlying ear condition offers the best long-term outcome.

Long-term outlook following aural hematoma recovery depends primarily on successful management of underlying ear conditions. Cats with treated ear mite infestations have excellent prognosis if reinfestation is prevented through appropriate household management and prevention. Chronic allergic ear disease may require ongoing management but can usually be controlled adequately to prevent recurrence. Cats with recurrent ear infections may need investigation for underlying causes and long-term maintenance therapy. Once the ear has healed, any resulting deformity is permanent but does not typically affect function or quality of life. Most cats enjoy full return to normal activities and comfort following successful treatment.

Primary prevention of aural hematoma centers on preventing and promptly treating ear conditions that lead to head shaking and scratching. Regular ear examination during home grooming routines allows early detection of ear problems before they cause significant irritation. Learning to recognize normal ear appearance helps owners identify changes warranting veterinary attention. Avoiding unnecessary ear cleaning that could damage the ear canal or introduce infection protects ear health. Keeping ear canals dry by avoiding water entry during bathing reduces infection risk. Prompt veterinary attention for any signs of ear discomfort, including head shaking, scratching, odor, or discharge, enables early treatment before complications develop.

Environmental prevention focuses on reducing exposure to causes of ear disease. For outdoor cats, regular ear mite prevention through appropriate antiparasitic products reduces infestation risk. Minimizing contact with stray or unknown cats prevents parasite transmission. Keeping other household pets treated for ear mites prevents cross-infestation. For cats with environmental allergies, reducing exposure to identified allergens when possible and implementing appropriate allergy management reduces ear inflammation. Maintaining clean living environments reduces dust mite and mold exposure. Indoor housing eliminates exposure to many environmental hazards affecting ear health.

Dietary prevention applies primarily to cats with food allergy-related ear disease. Identifying and avoiding dietary triggers through elimination diet trials prevents allergic ear inflammation in affected cats. Feeding high-quality diets appropriate for the individual cat supports overall health including immune function and skin health. Avoiding frequent diet changes that might introduce new allergens provides stability. For cats with confirmed food allergies, strict adherence to hypoallergenic diets prevents flares. Consultation with veterinarians guides appropriate diet selection for cats with suspected or confirmed food sensitivities.

Health maintenance through regular veterinary care supports ear health and enables early intervention. Annual or biannual wellness examinations include ear examination that may detect developing problems before they cause significant irritation. Cats with history of ear problems benefit from more frequent ear assessment. Preventive antiparasitic treatments effective against ear mites should be maintained for at-risk cats. Prompt attention to any recurrence of ear symptoms prevents escalation. Senior cats, who may have decreased grooming ability, benefit from owner-assisted ear monitoring and cleaning.

Early intervention when ear problems develop provides the best opportunity to prevent hematoma formation. Seeking veterinary attention at the first sign of ear discomfort, including head shaking, scratching, or behavioral changes suggesting ear irritation, allows treatment before self-trauma causes hematoma. Following prescribed treatment protocols completely, including full courses of ear medications, ensures resolution rather than partial treatment allowing recurrence. Addressing mild ear irritation promptly prevents progression to severe inflammation triggering violent head shaking. Understanding that ear problems do not resolve on their own and require treatment prevents delays that increase hematoma risk.

Daily management during active aural hematoma treatment requires consistent attention to treatment protocols and monitoring for complications. Elizabethan collar maintenance ensures continuous protection from scratching throughout the healing period. Daily ear medication administration follows veterinary instructions regarding frequency, technique, and duration. Monitoring the affected ear for changes including increased swelling, discharge, or odor enables early detection of complications. Oral medication administration maintains consistent therapeutic levels. Keeping activity logs of eating, drinking, and behavior helps track recovery progress. Cleaning any drainage from the surgical site as directed keeps the area hygienic. Communication with the veterinary team about any concerns enables prompt guidance.

Home environment modifications during recovery support healing and prevent treatment disruption. Removing obstacles that the cat might bump against while wearing an Elizabethan collar prevents trauma to the healing ear. Providing easily accessible food and water that accommodate collar constraints ensures adequate nutrition and hydration. Maintaining comfortable resting areas with soft bedding reduces pressure on the healing ear. Separating the recovering cat from other pets who might play roughly prevents injury. Keeping the environment calm minimizes head shaking from startle responses. Ensuring warm, draft-free resting spots supports overall healing.

Quality of life considerations during treatment and recovery acknowledge temporary disruptions while maintaining comfort. Elizabethan collars are uncomfortable but necessary; choosing appropriately sized collars and providing frequent positive interaction helps cats tolerate them better. Modifying play and interaction to accommodate the collar and healing ear maintains bonding without risking injury. Providing mental stimulation through window viewing, gentle attention, and appropriate activities prevents boredom during recovery restrictions. Understanding that recovery is temporary and most cats return fully to normal activities provides perspective during the challenging recovery period.

Ongoing monitoring after initial healing ensures continued ear health and early detection of any recurrence. Regular ear examination during normal interactions checks for early signs of returning problems. Watching for resumption of head shaking or scratching behaviors that might indicate recurring ear irritation enables prompt veterinary attention. Maintaining prescribed ear cleaning or medication protocols if indicated for chronic underlying conditions prevents recurrence. Scheduled follow-up appointments allow professional assessment of long-term ear health. Understanding the cat's normal ear appearance following recovery helps identify future changes.

Caregiver support during treatment acknowledges the demands of managing aural hematoma recovery. The need for consistent medication administration, collar management, and monitoring requires organization and commitment. Financial aspects of treatment, particularly if surgery is required, may cause stress. Emotional concern about the cat's comfort and recovery is natural. Connecting with veterinary team members for guidance and reassurance helps caregivers navigate the recovery period. Understanding that most cats recover fully from aural hematoma with appropriate treatment provides encouraging perspective during the challenging treatment period.

Aural hematomas can occur in cats of any breed, with risk determined more by ear type and susceptibility to underlying ear conditions than by breed genetics specifically. Cats with large ear pinnae may have slightly elevated risk due to greater tissue subject to shearing forces during head shaking. Scottish Fold cats have unique ear anatomy but do not appear to have elevated hematoma rates. Breeds prone to allergic skin disease may have increased risk due to allergic otitis leading to scratching and head shaking. However, the overwhelming majority of aural hematomas occur in domestic shorthair and longhair cats simply due to their prevalence in the cat population.

Risk factors beyond breed significantly influence aural hematoma development. Cats with chronic ear conditions including recurrent infections or ongoing allergies face elevated risk regardless of breed. Outdoor cats have higher exposure to ear mites, increasing hematoma risk from mite infestation. Cats in multi-pet households may have higher parasite transmission rates. Immunocompromised cats may be more susceptible to ear infections. Senior cats with decreased grooming ability may have higher rates of ear problems. Cats with previous aural hematomas have elevated recurrence risk, particularly if underlying conditions remain uncontrolled. Understanding individual risk factors allows targeted prevention efforts.

Screening recommendations focus on regular ear health monitoring rather than breed-specific testing. All cats benefit from periodic ear examination during routine veterinary visits. Cats with history of ear problems warrant more frequent assessment. Regular home monitoring of ear appearance by owners enables early detection of developing problems. Cats showing any signs of ear discomfort including head shaking, scratching, or behavioral changes should receive prompt veterinary evaluation. Cats with known allergies benefit from proactive ear management as part of overall allergy control. Prompt treatment of ear conditions when detected prevents escalation to the severe irritation that triggers hematoma-causing head shaking and scratching.

Several conditions commonly co-occur with or directly lead to aural hematoma development, and understanding these relationships guides comprehensive management. Ear mite infestation (Otodectes cynotis) represents one of the most common underlying causes, creating intense itching that drives head shaking and scratching. Bacterial otitis externa (outer ear infection) causes inflammation and discomfort leading to self-trauma. Yeast infections of the ear canal produce similar irritation. Allergic otitis from food or environmental allergies creates chronic ear inflammation and scratching behavior. Ear polyps or tumors can cause irritation triggering violent head shaking. Addressing these underlying conditions is essential for preventing hematoma recurrence after treatment.

Conditions with similar presentation to aural hematoma require differentiation during diagnosis. Ear abscesses from bite wounds or other trauma can cause ear swelling but typically feel firmer and may have visible entry wounds. Ear tumors cause swelling but develop gradually and feel solid. Cellulitis or soft tissue infection produces warm, painful swelling. Allergic reactions can cause ear swelling but typically affect both ears symmetrically. Seroma formation produces similar-appearing fluid accumulation. Inflammatory conditions of the ear pinna including solar dermatitis may cause swelling. Accurate differentiation ensures appropriate treatment selection.

Complications of aural hematoma and its treatment warrant awareness for comprehensive management. Cauliflower ear deformity results from untreated hematomas or treatment failure, causing permanent cosmetic changes but typically not functional impairment. Recurrence following treatment commonly results from failure to address underlying ear disease. Surgical site infection can occur following operative treatment, requiring additional antibiotic therapy. Suture line reactions occasionally develop. Ongoing ear disease despite hematoma treatment causes continued discomfort and potential repeated hematoma formation. Understanding these potential complications emphasizes the importance of comprehensive treatment addressing both the hematoma and underlying ear conditions.