Otitis Externa

OTITIS EXTERNA
AN ESSENTIAL GUIDE TO
DIAGNOSIS AND TREATMENT
Richard G. Harvey
BVSc, DVD, Dip.ECVD, FSB, PhD, MRCVS
The Veterinary Centre
Cheylesmore, Coventry, UK
Sue Paterson
MA, VetMB, DVD, DipECVD, MRCVS
RCVS and European Specialist in Veterinary Dermatology
Rutland House Referral Hospital
St Helens, Merseyside, UK
aFM final2.indd 1 20/2/14 6:22 PM

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CONTENTS
Preface v
Abbreviations vi
1 The Normal Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Pinna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
External auditory meatus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Middle ear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Microscopic structure of the external ear canal. . . . . . . . . . . . . . . . . . . . . . . 6
Microclimate of the external ear canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cerumen in normal and otitic ears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 Approach to the Diagnosis of Otitis Externa . . . . . . . . . . . . . . . . . . . 13

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Signalment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Otic examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Otoscopic appearance of the external ear canal and tympanum. . . . . . . . 17
Cytological characteristics of normal and abnormal ears . . . . . . . . . . . . . 25
Biopsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3 Aetiology and Pathogenesis of Otitis Externa. . . . . . . . . . . . . . . . . . 45

Concept of primary and secondary factors, predisposing factors, and
perpetuating change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Primary causes of otitis externa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Secondary causes of otitis externa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Perpetuating factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4 Ear Cleaning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Assessing the integrity of the tympanum. . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Assessing the discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Assessing the canal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Cleaning process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Home cleaning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

iv
5 Medical Management of Ear Disease . . . . . . . . . . . . . . . . . . . . . . . . . 81

Dealing with primary triggers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Dealing with secondary causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Chronic or recurrent otitis externa in dogs. . . . . . . . . . . . . . . . . . . . . . . . . . 95
6 Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Clinical signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Major differential diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Treatment of nasopharyngeal polyps in cats. . . . . . . . . . . . . . . . . . . . . . . 113
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
7 Ototoxicity and Other Side-Effects of Otic Medication. . . . . . . . . . 115

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Meatal and tympanic inflammation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Effects within the middle ear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Ototoxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Systemic effects of otic medication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Ototoxicity of systemic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
8 Aural Ablation and Bulla Osteotomy. . . . . . . . . . . . . . . . . . . . . . . . 121

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Presurgical investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Vertical canal ablation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Bulla osteotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Special problems relating to surgery of the middle ear in cats . . . . . . . . 140
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

PREFACE
v
The investigation and management of ear disease will occupy a

significant proportion of a veterinary clinicians time. Otitis externa, in
particular, is likely to be seen by a busy small animal clinician at least
once a day. Chronic, and chronic recurrent, otitis externa is frustrating
and costly to the owner and often painful for the dog or cat.
The concept behind this book is to provide a comprehensive source of
information on the relevant structure, function, medicine, and surgery
of the ear, from Otodectes cynotis infection to Pseudomonas aeruginosa
infection, by way of atopy.
We hope that students and clinicians, in particular, will find it so
useful that their copy becomes battered and stained, the ultimate test
ofpractical relevance.

ABBREVIATIONS
vi
BAER brainstem auditory evoked response

CT computed tomography
DMSO dimethylsulfoxide
EDTA ethylenediamine tetra-acetic acid
GABA gamma-amino butyric acid
Ig immunoglobulin
LBO lateral bulla osteotomy
MIC minimum inhibitory concentration
MRI magnetic resonance imaging
MRSA methicillin-resistant Staphylococcus aureus
PCMX parachlorometaxylenol
PVA polyvinyl alcohol
TECA total ear canal ablation
tris tromethamine
VO video-otoscope

1 THE NORMAL EAR
1
KEY POINTS INTRODUCTION
QQ The external ear comprises the pinna The ear of the dog and cat is composed of
and the external acoustic meatus. It three parts: the external ear, the middle ear,
serves to collect and locate the origin and the inner ear (Figure 1.1)13. Together
of sound waves. these components allow the animal to
QQ The middle ear comprises the locate a sound and the direction from which
tympanic membrane, the ossicles, it emanates, to orientate the head in relation
the auditory tube, and the tympanic to gravity, and to measure acceleration and
cavity. It serves to transduce incoming rotation of the head. Selective breeding, of
airborne sound waves into waves in a dogs in particular, has resulted in a wide
liquid medium. variation in relative size and shape of the
QQ The inner ear comprises the cochlea, components of the external ear. Compare,
the vestibule, and the semicircular for example,theFrench Bulldog, the
canals. It interprets sound and serves Cocker Spaniel, the German Shepherd
to relate the head to gravity, allowing Dog, the St. Bernard, and the Persian cat.
the visual system to compensate for The pinnal shape and carriage, the diameter
movement and to perceive both linear of the external ear canal, thedegree of
and rotational acceleration. hair and amount of soft tissue within the
external ear canal, and the shape of the
Vestibular nerve
Cochlear nerve Semicircular canals
Cochlea Ear canal
Incus
Malleus
Tympanic
Stapes membrane
Fig. 1.1 The anatomic relationship of the components of the external, middle, and inner ear
remains constant in relation to each other and the skull.
Chapter_01 final.indd 1 20/2/14 6:24 PM

2 The Normal Ear
skull within which the middle and inner The pinna is composed of a sheet of
ear lie, vary from one breed to another. cartilage covered on both sides by skin
Despite this anatomic variation the essen (Figures 1.2, 1.3), which is more firmly
tial relationship between the various com adherent on the concave aspect than on the
ponents of the external, middle, and inner convex aspect2,3,5. The cartilage sheet which
ear is preserved1. supports the pinna is a flared extension
of the auricular cartilage. Proximally this
PINNA becomes rolled to form the vertical ear canal
and part of the horizontal ear canal6. The
The evolutionary role of the pinna has major part of the external auditory meatus
been as an aid to sound collection and is contained within the auricular cartilage.
point-of-origin location (Figures 1.2, 1.3). Generally the pinna is haired on the
However, selective breeding of dogs has convex surface and in some breeds, such as
resulted in pinnae which often appear to the Cocker Spaniel and Papillon for example,
have been designed more as lids to prevent markedly so. The concave aspect may be
access by foreign bodies (Figures 1.4, 1.5) lightly haired on the free edges and towards
or as vehicles to carry ornate displays of the tip, but towards the base it becomes
exuberant growths of hair (Figures 1.6, 1.7). essentially glabrous and is tightly adherent
Despite these changes, the functionality of to the underlying cartilage. A few fine hairs
the ear appears to have been maintained. In are usually present around the entrance to
most breeds of cats the pinna is held erect, the external auditory meatus. In breeds with
with the exception of the Scottish Fold Cat hirsute ear canals, such as Cocker Spaniels,
where the distal portion of the scapha is there may be profuse hair growth along the
folded rostroventrally4. whole length of the earcanal.
Figs. 1.2, 1.3 Archetypal pinna, in this case of a German Shepherd Dog. Note the even
distribution of short hairs on the convex aspect (1.2). There is a variable amount of glabrous,
sparsely-haired skin on the concave aspect (1.3) which is confluent with the epithelial lining of
the external ear canal.

The Normal Ear 3
Figs. 1.4, 1.5 Examples of the various pinnae which have resulted from selective breeding.
Labrador Retriever (1.4), Cocker Spaniel (1.5).
Figs. 1.6, 1.7 Examples

of the various pinnae
which have resulted
from selective breeding.
Papillon (1.6), Yorkshire
Terrier (1.7).

4 The Normal Ear
EXTERNAL AUDITORY MEATUS MIDDLE EAR
The external auditory meatus serves to The middle ear and auditory (Eustachian)
conduct sound waves to the tympanum. tube comprise a functional physiological
It is contained within the vertical and unit with protective, drainage, and venti
horizontal portions of the external ear latory capabilities9,10. The middle ear is
canal. The size of the vertical canal composed of the tympanum, the ossicles,
(length and volume) correlates with body the auditory tube, and the tympanic
weight7,8.In the dog the averagelength of cavities (Figure 1.9)1,3. The middle ear cavi
the external ear canal within the auricular ties are lined with secretory epithelium
cartilage is 4.1cm (1.6in) (2.25.7cm (Figure 1.10). Epithelia such as this not only
[0.82.2 in]) and its average diameter, at secrete liquid, but also absorb gas9. This
the level of thetragus,is 5.8 cm (2.3 in) tends to result in a slight negative pressure
(2.17.9 cm [0.83.1 in])7. within the normal middle ear cavity9. The
The vertical canal deviates medially, composition of the gas in the normal middle
just dorsal to the level of the tympanum, ear cavity of both dogs and cats has been
towards the external acoustic process. In described11. It appears to correlate closely
the dog the average length of canal within to the composition of the capillary blood,
theannularcartilage is 1.2 cm (0.5 in) rather than reflecting gaseous exchange
(0.81.9cm[0.30.7 in])7. along the auditory tube.
The epithelium and dermal tissues which The three ossicles transmit sound waves
line the bony and cartilaginous components impacting upon the tympanic mem
of the external ear canal result in a smooth brane to the oval window. At this point
inner surface to the canal (Figure 1.8). The the mechanical energy of the ossicles is
epithelium is sparsely haired in most, but transduced to pressure waves within the
not all, breeds, and it is rich in adnexal inner ear, to be interpreted subsequently as
glands (see Microscopic structure of the sound. Pressure and internal homeostasis
external ear canal). within the inner ear is equilibrated across
the round window membrane.
A B
Fig. 1.8 Otoscopic picture of a normal canine (A) and feline (B) external ear canal,
demonstrating the smooth epithelial lining. Note the occasional accumulations of cerumen.

The Normal Ear 5
Tympanum dimension is nearly vertical, the long axis

The gross appearance of the canine and is directed ventral, medial, and cranial, and
feline tympanic membrane is similar it has an area of approximately 63.3 mm2
(Figure 1.8)3,4,12. The canine tympanum is (0.1 sq in)1,2,13. The feline tympanum is more
a thin, semitransparent membrane with circular in shape (8.76 mm [0.30.2 in])
a rounded, elliptical outline; its mean and has an area of approximately 41 mm2
size is 1510 mm (0.60.4 in). The shorter (0.6 sq in)4,12,14. The majority of the external
Fig. 1.9 The caudoventral aspect of a canine skull with the bulla
removed. Three of the four ports of communication are visible:
the external acoustic meatus (arrow), the round window on the
promontory (arrow head), and the auditory tube (delineated with
a piece of nylon).
Fig.1.10 Photomicrograph of a section of normal bulla.

Note the thin bone and the secretory epithelial lining. (Sample
prepared by Finn Pathology, Diss, Norfolk,UK.)

6 The Normal Ear
aspect of the tympanum is thin, tough, and MICROSCOPIC STRUCTURE OF

glistening (the pars tensa) with the outline THE EXTERNAL EAR CANAL
of the manubrium of the malleus being
clearly visible (Figure 1.11). The manu
brium inserts under the epithelium on the KEY POINTS
medial aspect of the tympanum and exerts
tension onto it, resulting in a concave shape QQ The normal ear canal contains a
to the intact membrane, rather similar to stratified squamous epidermis, hair
the speaker cone in a loudspeaker3,15. The follicles, and associated sebaceous
pars flaccida is more opaque, pink, or and ceruminous (apocrine) glands.
white in colour. It is confined to the upper QQ Breeds of dog predisposed to otitis
quadrant of the tympanic membrane and externa, such as Cocker Spaniels, have
bound ventrally by the lateral process of increased amounts of glandular tissue
the malleus3,13. compared to other dogs.
In a study of 100 cases of canine otitis QQ Otitis externa results in increased
externa, rupture of the tympanic membrane production of cerumen with a lower
was negatively associated with underlying lipid content than normal, associated
allergic disease and positively associated with increased ceruminous gland
with grass awns, particularly in Cocker activity.
Spaniels16. QQ Chronic otitis externa results in
permanent changes.
Fig. 1.11 Otoscopic picture of a normal Fig. 1.12 Photomicrograph of a section of

tympanic membrane. The manubrium of the normal canine external ear canal illustrating
malleus is clearly visible. the thin epidermis, which is only a few cells
thick.

The Normal Ear 7
The epidermis lining the external ear Hair follicles

canal is similar in structure to that of the All breeds of dog have hair follicles
interfollicular epidermis of the skin, i.e. througho ut the length of the external
a stratified cornifying epithelium with ear canal, although in most breeds these
adnexal organs such as hair follicles and follicles are simple and sparsely distri
their associated sebaceous and ceruminous buted (Figure 1.16)3. It has been suggested
(apocrine) glands (Figures 1.12, 1.13)14. that the density of hair follicles decreases
The underlying dermis is heavily invested as one progresses toward the external
with elastic and collagenous fibres (Figures acoustic meatus 1,2, but recent studies 3,4
1.14, 1.15). Beneath the dermis and subcutis did not describe such a distribution. The
lie the rolled cartilaginous sheets of the mean proportion of integument occupied
auricular and annular cartilages which by hair follicles was found to be 1.53.6%,
contain and support the external ear canal. with no significant spatial distribution
Fig. 1.13 Photomicrograph of a section of Fig. 1.14 Photomicrograph of a section of

normal feline external ear canal. Note the thin normal canine external ear canal stained with
epidermis, the sparse hair follicles, sebaceous Gomorris stain to highlight collagen and
glands, and ceruminous glands, and the fibrous tissue in the dermis.
underlying auricular cartilage.
Fig. 1.15 Photomicrograph of a section of Fig. 1.16 Photomicrograph of a section of

normal canine external ear canal stained with normal canine external ear canal showing
Massons stain to highlight collagen and simple hair follicles.
fibrous tissue in the dermis.

8 The Normal Ear
along the canal. There was a large interdog Adnexal glands

variation4. Sebaceous glands are present in the
However, some breeds which are pre upper dermis 15,6. They are numerous
disposed to otitis externa differ from the and prominent (Figure 1.18) and have a
basic pattern 3. Thus, Cocker Spaniels similar structure to the sebaceous glands
exhibit a much higher concentration of the skin. The mean proportion of integu
of hair follicles than other breeds and, ment occupied by sebaceous glands is
furthermore, the follicles are typically 4.110.5%, gradually increasing from
compound in pattern (Figure 1.17)3. There proximal to distal and peaking at the level
is no correlation between the percentage of of the anthelix4. There is a large interdog
hair follicles within the otic integument and variation4. The sebaceous glands secrete
predisposition to otitis externa4. principally neutral lipids4. In the normal
Hair is sparse or absent in the feline dog this lipid accounts for the majority
external ear canal5. of the cerumen, along with sloughed
Fig. 1.18 Photomicrograph of a section of

normal canine external ear canal showing a
higher power view of a sebaceous gland.
Fig. 1.17 Photomicrograph of a section

of normal canine external ear canal from a
Cocker Spaniel. Note the density of the hair
follicles compared to 1.16 and that they are
compound.

The Normal Ear 9
epidermal debris7. This high lipid content MICROCLIMATE OF THE

of normal cerumen helps maintain normal EXTERNAL EAR CANAL
keratinization of the epidermis, aids in
the capture and excretion of debris both
produced within and entering the external KEY POINTS
ear canal, and results in a relatively low
humidity within the lumen of the ear canal. QQ The principal factor affecting the
In the cat the sebaceous glands become microflora within the external ear
more prevalent and crowded proximally5. canal is the microenvironment.
Ceruminous (apocrine) glands are QQ Temperature and relative humidity
located in the deeper dermis (Figure 1.19)15. within the external ear canal are very
They are characterized by a simple tubular stable.
pattern and a lumen lined by a simple QQ The mean temperature within the
cuboidal-pattern epithelium. In the normal external ear canal is between 38.2C
dog and cat the ducts of the apocrine (100.7F) and 38.4C (101.1F), some
glands are virtually nonapparent. The 0.6C (33.1F) lower than the rectal
mean proportion of integument occupied temperature.
by apocrine glands is 1.44.5%, gradually QQ The mean relative humidity in the
decreasing from proximal to distal and external ear canal is 88.5%.
peaking at the level of the tympanic mem QQ The mean pH of the normal external
brane 4. There is a large interdog vari ear canal is 6.1 in males and 6.2 in
ation4. The apocrine glands contain acid females.
mucopolysaccharides and phospholipids5. QQ Otitis externa is associated with a rise
Overall, these data4 suggest that the ratio in relative humidity and a rise in pH
of apocrine to sebaceous gland decreases within the external ear canal.
from proximal to distal, tending to produce QQ Cerumen is composed principally of
a more aqueous cerumen in the deeper lipid and sloughed epithelial cells.
ear canal, possibly more conducive to QQ In cases of chronic otitis externa,
epidermal migration. The more lipid nature the lipid component of cerumen
of cerumen at the distal end may facilitate decreases.
water repulsion.
Fig. 1.19 Photomicrograph of a section of

normal canine external ear canal showing a
higher power view of an apocrine gland.

10 The Normal Ear
Epithelial lining throughout the day6, with a recorded rise

The external ear canals are lined such that within the ear of only 2.3% compared to
the underlying cartilaginous architecture 24% in the external environment, again
and the intercartilaginous joints are illustrating the buffering effect of the
covered by a smooth, clean epithelial sur tissues surrounding the external ear canal.
face (Figure1.20). The epithelial surface Grono6 suggested that the high relative
is composed of closely apposed squames humidity in the external ear canal was such
which are covered by a variable, but usually that the meatal epithelium would readily
thin, layer of cerumen and adherent debris become hydrated and macerated, an ideal
(Figures 1.21, 1.22). There is a constant, environment for bacterial proliferation. In
outward movement of cerumen1,2. Squames cases of otitis externa, the relative humidity
detach (Figures 1.23, 1.24) and move was somewhat higher (mean 89%) than
distally in the cerumen, thus keeping the normal, but not significantly so. The
tympanum clear of debris and providing influence of a pendulous pinna was not
a mechanism for removing sloughed reported.
epithelial and glandular secretions from the
external ear canal. pH
The range of pH in normal dogs is
Temperature between 4.6 and 7.2 6. The mean pH is
In a series of studies the temperature slightly lower in males than in females
within the external ear canal of dogs was (6.1 compared to6.2). The pH rises in otitis
38.238.4C (100.7101.1F) 35 . These externa.Grono7 measured the pH in cases
studies were performed over a span of of otitis externaand found the mean to be
25years with very different technologies, 5.9 (range 5.97.2) in acute cases and 6.8
and for such close results to be achieved is (range 6.07.4) in chronic cases. Grono also
remarkable. There was no significant dif measured the pH of the external ear canals
ference between breeds of dog or whether of dogs and recorded the bacteria which
there was a pendulous pinna or not 3,4.
The temperature within the external ear
canal rises significantly if otitis externa is
present: mean 38.9C (102F)5. The temper
ature within the external ear canal is a
mean of 0.6C (33.1F) lower than rectal
temperature.
One study3 was performed in Australia
where the environmental temperature
tends to be high. Nevertheless, as the day
grew progressively hotter the temperature
within the external ear canal only rose by
0.3C (32.5F) compared to a rise of 6.4C
(43.5F) in the environment. This illustrates
very well how the environment within the
ear canal is effectively buffered from the
external environment.
Relative humidity
In one study the mean relative humidity Fig. 1.20 Otoscopic view of the normal
within the external ear canal of 19 dogs external ear canal. Note the clean, smooth
was 80.4%6. This was remarkably stable epithelial surface.

The Normal Ear 11
Figs. 1.21, 1.22 Scanning electron Figs. 1.23, 1.24 Scanning electron
micrographs of the epithelial surface of micrographs illustrating squames in the
the external ear canal of a dog (1.21, top) process of detaching in a canine ear canal
and a cat (1.22, above). Note the cerumen (1.23, top) and a feline ear canal (1.24,
coating the hair shafts and squames such above). (Electron micrographs produced by
that individual squame borders cannot clearly the Department of Anatomy, Royal Veterinary
be seen. (Electron micrographs produced by College, London,UK.)
the Department of Anatomy, Royal Veterinary
College, London, UK.)

12 The Normal Ear
were isolated from some of these cases. between the left and right ears. This vari
Nonparametric (Mann Whitney) analysis ation presumably reflects individual vari
of Gronos data by the authors showed that ation in concentration and activity of
in cases of otitis externa associated with ceruminous glands. In man, cerumen type
Pseudomonas spp., the pH is significantly (wet or dry) is a simple mendelian trait11.
higher (mean 6.85, p<0.05) than in cases of Whether there is a simple genetic control of
otitis externa in which no Pseudomonas spp. canine or feline cerumen type is not known.
are isolated (mean 5.7). Oleic and linoleic acid have antibacterial
activity12,13, although the effects of these
CERUMEN IN NORMAL AND fatty acids, and others, against bacteria
OTITIC EARS and Malassezia pachydermatis within the ear
canal is less clear10.
Cerumen coats the lining of the external ear In cases of otitis externa the lipid content
canal (Figures. 1.25, 1.26). It is composed of of the cerumen falls significantly to a mean
lipid secretions from the sebaceous glands, of 24.4%, compared to a mean of 49.7% from
ceruminous gland secretion8, and sloughed normal ears9. This fall in lipid content may
epithelial cells. The lipid component of reflect the hypertrophy of apocrine glands
dogs cerumen can vary widely, as does the which accompanies chronic otitis externa14.
type of lipid within the cerumen, although The decreased lipid component of cerumen
margaric (17:0), stearic (18:0), oleic (18:1), may account for the increase in relative
and linoleic (18:2) fatty acids are the most humidity reported in the external ear canals
common 9,10. A range of 18.292.6% (by of dogs with otitis externa6. This, plus the
weight) of lipid content was found in the decrease in antibacterial activity, may allow
external ear canals of normal dogs, and increased bacterial multiplication.
in some cases there was wide disparity
Fig. 1.25 Photomicrograph of normal Fig. 1.26 Scanning electron micrograph

cerumen. Note the high proportion of illustrating cerumen on the epithelial surface
amorphous lipid material to squame. of a cats external ear canal. (Electron
micrograph produced by the Department
of Anatomy, Royal Veterinary College,
London,UK.)

2 APPROACH TO
THEDIAGNOSIS OF
OTITISEXTERNA 13
INTRODUCTION In other cases it may be apparent that

the dog has suffered occasional bouts
The approach to a case of otitis externa is no of bilateral otitis externa before and, in
different to that of any disease: these cases, a more detailed approach
A look at the signalment will allow is necessary.
the clinician to consider breed, age,
andsex predisposition to otitis Consideration of the history and signal
externa. ment will allow the clinician to make a
A case history may be sufficient to provisional differential diagnosis, which
allow a working diagnosis of a foreign will be further amended once the physical
body to be made. examination has been performed. At this
point, a number of investigatory techniques
can be utilized to stage the otitis (Table 2.1).
Table 2.1 Investigative techniques that may be employed in order to stage

otitis externa
Visual examination and palpation of the auricular cartilages

Otoscopic/video-otoscopic examination of the external ear canal
Cytological examination of cerumen and exudate
Sampling for culture and sensitivity testing of exudate
Cleaning the ear canal to facilitate examination of the deeper canal and tympanic membrane
Radiography, including canalography
Histopathological examination of biopsy samples

14 Approach to theDiagnosis of OtitisExterna
SIGNALMENT abscess or obstructive otitis secondary to

polyps or neoplasia. Young animals are
Breed predisposed to dermatophytosis.
Some breeds, for example Cocker Spaniels In dogs, young animals (and very old
and Persian cats, are predisposed to defects animals) are under-represented in studies
in keratinization, which may be associated of the incidence of otitis externa. The
with a ceruminous otitis externa. Breeds peak incidence of otitis externa occurs
of dog recognized as particularly prone to in dogs between 3 and 6 years of age.
otitis externa include Springer Spaniels, Otic foreign bodies are unusual in young
Miniature Poodles, Shar Pei, and German animals. Underlying disease, such as a
Shepherd Dogs. Any breed predisposed to defect in keratinization, atopy, or a dietary
atopy is likely to exhibit (usually) bilateral intolerance, may cause uni- or bilateral otitis
otitis externa. Dogs with pendulous pinnae externa and may occur in young animals,
are not necessarily predisposed to otitis particularly in predisposed breeds.
externa but they may be susceptible to a
rapidly progressive infection, should otitis Sex
externa develop. Breeds with excessive There is no sex predisposition to otitis
hair within the external ear canals, such as external in general, although one study
Poodles, may be predisposed to accumu found that females were more likely than
lations of cerumen and debris, which may males to exhibit allergic pattern otitis 1.
provoke otitis externa. Yorkshire Terriers Sertoli cell tumour may be associated with
are predisposed to bilateral pinnal alopecia a greasy cerumen which adheres to the
and hyperpigmentation. Cocker Spaniels skin and hair adjacent to the orifice of the
were predisposed to grass awn-related external ear canal.
acute otitis externa in one study of100
cases1. HISTORY
Longhaired breeds of cats and show cats
are commonly affected by dermatophytosis. The key aims of history taking are:
White haired cats and dogs are predisposed In some cases to allow a definitive
to actinic radiation damage to the pinnae. diagnosis, thus allowing specific
treatment.
Age More usually, to identify whether
Young animals are often affected with or not there is any evidence of
Otodectes cynotis, but this may not be management or underlying disease
associated with pruritus, particularly in which may be predisposing the animal
kittens. In cats, the peak incidence of otitis to otitis externa.
externa is between 1 and 2 years of age,
presumably reflecting exposure to, and The history should encompass all aspects
hypersensitivity to, O. cynotis. In older cats of the dogs management and lifestyle in
bilateral otitis externa is almost always an attempt to identify the cause of the otitis
associated with O. cynotis infection, whereas externa.
unilateral otitis externa may reflect cat bite

Approach to theDiagnosis of OtitisExterna 15
Management and lifestyle Endocrinopathies may be associated

Diet: to identify deficiencies such as with a ceruminous otitis externa.
zinc and essential fatty acids. Sudden onset of severe, ulcerative
Water intake: any polyuria/ bilateral otitis, perhaps in association
polydipsia? with other skin disease, or systemic
Housing: kenneled or indoors? signs should raise the suspicion of
Exposure to sunlight: actinic radiation drug eruption or immune-mediated
damage. disease.
Exercise: swimming predisposes to ear
disease. Medications
Work: (working dogs predisposed to Topical application of otic medication
foreign bodies). may induce an irritant or allergic contact
Grooming requirements: clipper burn dermatitis. The clinical sign which might
on the pinnae, failure to pluck the suggest this is continued otitis in the face
ear canals, otic irritation following of repeated application of a medication.
plucking, contagion at clipping Neomycin is the most often cited agent in
parlour? this regard, although propylene glycol also
Presence of other animals (O. cynotis, may be irritant.
Sarcoptes scabiei, dermatophytosis).
Hunting cat (Spilopsyllus cuniculi, PHYSICAL EXAMINATION
feline poxvirus infection, ticks).
Having established the immediate and
Evidence of underlying disease past history, the dog should be given a full
Recurrent episodes of ear disease clinical examination. In particular, evidence
should raise the suspicion of an of internal disease and endocrinopathies
underlying disease, particularly if should be sought. Thus, lymph nodes
bilateral. and testes should be palpated, the oral
Facial, otic, and pedal pruritus suggest cavity examined, the chest auscultated,
atopy. the abdomen palpated, and the perineum
Erythema in the ear, facial, neck, and checked. Only after this general physical
truncal folds, and perhaps crust, scale, examination should the dermatological
and erythema on the pinnae and trunk, assessment take place.
suggest a defect in keratinization.
A seasonal pattern is most likely to Pinnal scratch reflex
reflect atopy or seasonal exposure to In some pruritic canine dermatoses, rubbing
ectoparasites such as mosquitoes, flies, the distal edge of the pinna between
harvest mites (Neotrombicula spp.), and finger and thumb nail induces a scratch
rabbit fleas (S. cuniculi). reflex from the ipsilateral hindlimb. This
Dietary intolerance is often associated positive scratch reflex is most commonly
with otitis externa. associated with scabies, although it is not
Allergic contact dermatitis may affect pathognomonic. Pediculosis, Malassezia
the concave, ventral aspect of the pachydermatis dermatitis, and atopy also
pinnae. may result in a positive scratch reflex.

OTIC EXAMINATION Malodour of the external ear canal may

be associated with M.pachydermatis
Gross examination of the pinnae infection, gram-negative bacterial
Peripheral crust and scale may infection,devitalized tissues, or
suggest scabies, pediculosis, a defect neoplasia.
in keratinization, zinc deficiency, The amount of hair around the
endocrinopathy, or fly bite or entrance to and within the external
mosquito hypersensitivity. ear canal should be assessed. The
Erythema on the convex aspect, clinician may need to remove this hair
particularly distal, suggests actinic in order to complete an auroscopic
radiation damage. examination.
Erythema on the concave aspect The areas hidden within the
suggests atopy or allergic contact cartilage folds at the entrance to the
dermatitis. ear canal should be examined for
Alopecia may be due to pruritus ectoparasites,particularly ticks and
(scabies, pediculosis, hypersensitivity) trombiculid mites.
or dermatophytosis. Erythema is often associated with
Alopecia and hyperpigmentation may swelling of the soft tissues of the
reflect an endocrinopathy. external ear canal and stenosis of the
Curling of the pinnae in the cat is lumen. In some cases the stenosisis
almost pathognomonic for relapsing so severe that it is impossible to insert
polychondritis. the cone of an otoscope into the canal.
Vesicles, pustules, and crust may Erythema of the vertical canal, in
be due to superficial pyoderma, combination with a normal, or nearly
pemphigus foliaceus, or zinc normal, horizontal canal is very
deficiency. suggestive of atopy.
Punched out ulcerations on the Ulceration of the otic epithelium is
convexaspect may be due to feline usually associated with gram-negative
cowpox. bacterial infection but it may be a sign
Punched out ulcerations on the of immune-mediated disease.
concave aspect and pinnal margin may The nature, colour, and odour of any
reflect vasculitis. discharge should be noted. However,
whether any conclusions as to the
Gross examination of the causal organism, based on the physical
external ear canal nature of the discharge, are valid is
Calcification of the otic cartilage, debatable. Cytological examination of
which can be palpated, suggests the the discharge is much more reliable in
presence of chronic otitis externa. this regard.

OTOSCOPIC APPEARANCE OF as possible. This is achieved by gently

THE EXTERNAL EAR CANAL grasping the pinna and pulling it, and the
ANDTYMPANUM attached auricular cartilage, up and away
from the sagittal plane.
Otoscopic cannulae are hard, often
KEY POINTS cold, and have sharp ends. It hurts when a
cannula is thrust into an inflamed ear canal.
QQ Do not examine the ear in isolation. Although video-otoscopes have a narrow
Obtain a history and examine the probe, the same constraints apply. In most
animal first. cases, and particularly with small dogs and
QQ Ear canals may require cleaning cats and animals with painful or tender
before a proper examination is ear canals, this process is resented and the
possible. animal will require chemical restraint or
QQ Always examine both ears, even if general anaesthesia.
aunilateral problem is suspected. McKeever and Richardson1 advocate
QQ Adequate restraint is essential; use a mixture which provides approximately
of a sedative or neuroleptanalgesia 20 minutes of sedation, sufficient to allow
is often required. Be prepared to thorough examination and cleaning of
administer general anaesthesia, if bothears:
necessary. Ketamine (1.362.2 mg/kg).
QQ Cats require general anaesthesia Midazolam (0.023 mg/kg).
before they are subjected to otoscopic Acepromazine (0.023 mg/kg).
examination. All mixed in the same syringe and
QQ Remember that the presence of hair injected slowly iv.
in the external ear canal is normal in
some dogs. An alternative would be xylazine injection
QQ Do not expect to visualize O. cynotis (12 mg/10 kg i/v), which should provide
unfailingly: otic cerumen mixed with about 20 minutes of reasonable sedation.
liquid paraffin and examined under a Another alternative is detomidine
microscope will allow a better chance (2040g/kg i/v), which will produce
of diagnosis if mite numbers are low. moderate sedation and has the great advan
tage that it can be reversed by intramuscular
injection of its antagonist atipamezole.
Sedation for otoscopy and aural Note that there are two disadvantages with
examination this regime: it is very expensive (mitigated
In order to examine the entire length of by giving buprenorphine at the same time),
the ear canal properly, adequate restraint and there is a risk of inducing a cardiac
is necessary as the external ear canal must arrhythmia if potentiated sulphonamides
be manipulated into as straight a line are administered at the same time.

Normal appearance of (Figures2.3, 2.4) may be seen in some cases

the external ear canal and and this is normal 2. Occasionally, there
tympanum may be a hair shaft in the horizontal canal
The normal external ear canal is smooth, (Figures 2.5, 2.6). In some breeds, such as
pale in colour, and contains minimal Cocker Spaniels, Miniature and Giant
discharge (Figures 2.1, 2.2). A small Schnauzers, Airedales, and other terriers,
amount of pale yellow or brown cerumen for example, there are hair follicles the
Fig. 2.1 The upper portion of the feline Fig. 2.2 A normal horizontal external ear
external ear canal. canal of a dog. There is an even, pale colour
with a smooth contour. A few fine hairs may
be seen.
Fig. 2.3 Patchy brown cerumen adhering to Fig. 2.4 Yellowish cerumen near the
the walls of a normal external ear canal. tympanum.

whole length of the external ear canal13. The normal tympanum is thin, pale
The diameter of the vertical portion of the grey in colour (described as rice paper-
external canal varies from breed tobreed like), and translucent (Figure 2.7). It is
but at its base, where it apposes the visible via otoscopy in about 75% of normal
horizontal portion, it is 510 mm (0.20.4 ears4. Cerumen, debris, or hair prevents a
in) in diameter3. The horizontal canal is clear view of the tympanum in the other
approximately 2 cm (0.8 in) in length3. ears 4. The shape of the tympanum is
Fig. 2.5 Tufts of hair emerging from the Fig. 2.6 Hair and adhering cerumen
horizontal ear canal. emerging from the horizontal ear canal.
Fig. 2.7 A normal, translucent tympanic

membrane, in this instance partially hidden
byhair and cerumen.

elliptical, mean 15 10 mm (0.6 0.4 in), the concave aspect of the pinna will also
with the short axis nearly vertical2. The be affected (Figure 2.10). In most cases the
initial otoscopic view is restricted to the inflammation affects the entire ear canal,
posterior quadrant of the pars tensa and but in some instances it will be localized
the pars flaccida5,6. Manipulation of both to either the horizontal or, more usually,
the external ear canal and the otoscope will the vertical canal. Bilateral inflammation
usually bring the majority of the manu confined to the concave aspect of the pinna
brium (Figure2.8) and the larger portion and the vertical canal, particularly if there is
of the pars tensa into view5,6. The external little discharge, is very suggestive of atopy
aspect of the tympanum, as viewed with (Figure 2.11). Indeed, erythema of the entire
an otoscope, is divided into two unequal canal in the absence of significant discharge
parts by the manubrium of the malleus. or other pathology is highly suggestive
This is attached along the medial aspect of of allergy. Atopy, dietary intolerance,
the tympanumand exerts tension onto it, and neomycin sensitivity should all be
resulting in a concave shape to the intact considered in the differential diagnosis.
membrane. Inflammation also results in increased
secretion from the glands within the epi
Abnormal appearance of the thelial lining of the canal and a shift away
external ear canal from a lipid to an aqueous constitution7,8.
Inflammation results in oedema, erythema, Continued inflammation results in macer
and warmth (Figure 2.9). Given that the ation of the stratum corneum, loss of barrier
glandular tissues of the external ear canal function, and the outward movement of
are contained within a cartilaginous tube, transepidermal fluid. Discharge accumu
any swelling will result in a reduction in lates within the external ear canal (Figures
the diameter of the lumen. In many cases 2.122.14) and microbial proliferation
Fig. 2.8 The tympanic membrane with the Fig. 2.9 Erythematous otitis in a case
manubrium of the malleus clearly visible. of atopy. There is erythema and some
degreeofswelling, resulting in loss of
luminalcross-section.

Fig. 2.10 External ear canal of an atopic Fig. 2.11 Erythema, hyperplasia, moderate
dog. There is erythema, hyperplasia, and fissure formation, and a tendency to ulcerate
lichenification. and bleed very easily, even after otoscopy, are
commonly seen in ear canals of atopic dogs.
Figs. 2.122.14 Three views showing

erythema, hyperplasia, cerumen, and
varying degrees of luminal stenosis.

occurs. The colour of the discharge may Otoscopic examination may reveal the
vary from light yellow to dark brown and presence of ectoparasites, such as O. cynotis
it may be aqueous, thin, or pus-like in or Otobius megnini (Figure 2.16). Otodectic
nature. Animals with severe or generalized mites are often accompanied by the presence
defects in keratinization may exhibit a of a crumbly brown discharge (Figure 2.17).
greasy yellow discharge that has a purulent Not all infestations are inflammatory.
appearance, but which may be free of Failure to detect otodectic mites during
pathogens and noninflammatory in nature. otoscopic examination does not preclude
Medications may result in a thin, shiny infestation, and microscopic examination of
covering over the mural epithelium. cytological samples is necessary.
The presence of erosions and ulcers Epidermal hyperplasia, nodules,
in the external ear canal should be noted tumours, polyps, and foreign bodies within
(Figure2.15). Frank ulceration is uncom the external ear canal are easily visualized
mon and is usually associated with gram- during otoscopy (Figure 2.18), although
negative bacterial infection. Rare causes of cleaning of the external ear canal may be
otic ulceration are autoimmune diseases necessary. This is particularly the case for
and otic neoplasms. The finding of ulcers cats where the whole canal may fill with
within the external ear canal mandates purulent discharge if an otic tumour or
samples for both cytological evaluation and polyp is present (Figure 2.19).
bacterial culture and sensitivity testing.
Fig. 2.15 Haemorrhagic foci associated with Fig. 2.16 Spinous ear tick, Otobious megnini,
focal ulcerations in a case of gram-negative within the vertical ear canal. (Courtesy of Dr.
infection. Louis Gotthelf, DVM; Montgomery, AL, USA.)

Fig. 2.17 Crumbly, dry, blackish brown Fig. 2.18 Grass awn, cerumen, and
cerumen associated with Otodectes cynotis associated erythema in the external ear
infestation. canalof a dog.
Fig. 2.19 Polyp in the external ear canal

ofacat.

Fig. 2.20 Acute tear in the tympanic Fig. 2.21 Chronic otitis media and otitis
membrane of a dog associated with grass externa have resulted in a thickened, opaque,
awn penetration. ruptured tympanic membrane.
The tympanum should be examined for diagnosis of otitis media, exclusively via
colour, texture, and integrity; it is usually otoscopy, is not reliable. Bulging of the
dark grey or brown in cases of otitis tympanum may indicate an accumulation
externa1. In contrast to normal dogs, it is of exudate within the middle ear, whereas
only possible to visualize the tympanum retraction (and a concave appearance)
adequately in 28% of ears affected with suggests a partially filled middle ear with
otitis externa 4. If tears or holes in the obstruction of the auditory tube5.
tympanum (Figures 2.20, 2.21) indicate that Tympanic defects may heal in the
otitis media is present (although an intact presence of infection in the middle ear.
tympanum does not rule out otitis media), Thus, diagnosing otitis media on the sole
then failure to visualize the tympanum basis of a ruptured tympanum is unreliable.
adequately, let alone a tear, suggests that

CYTOLOGICAL Introduction
CHARACTERISTICS OF NORMAL Otodectic otitis (Figure 2.22) is often
AND ABNORMAL EARS associated with a crumbly, rather dryish
discharge (Figure 2.23), similar to coffee
grounds1. However, there is no clear-cut
KEY POINTS relationship between the gross charac
teristics of any otic discharge and the
QQ Cytological samples should be taken species of micro-organism with which it
before ear cleaning is undertaken. is associated, e.g. staphylococcal, gram-
QQ Both external ear canals should negative, or malassezial2,3.
be sampled, preferably from the Cytological examination of otic exudate
horizontal canal. is a rapid, in-house test which provides
QQ There is no reliable correlation diagnostically and therapeutically useful
between the physical nature of the information 25. Reproducibility is high
discharge and a particular microbe. with regard to detecting micro-organisms
QQ Examination of unstained, oil- and is good for bacteria, but is less so for
mixed cerumen is a reliable method yeast6. In many cases, information from
of determining infestation with cytological examination of cerumen is more
O.cynotis. accurate than that from samples submitted
QQ Information on the organisms for microbiological culture and sensitivity
within the canal and the type testing. Furthermore, the clinician can
and nature of the inflammatory assess the significance of any micro-
response may be obtained from organisms in the light of other ceruminal
microscopic examination of stained characteristics, such as the presence of
smears;modified Wrights stains, nucleated squames, proteinaceous debris,
such as Diff-Quik, are ideal stains for and inflammatory cells. This is particularly
in-house use. exemplified in the case illustrated
(Figure2.24) of a Cocker Spaniel with
Fig. 2.22 Typical appearance of cerumen Fig. 2.23 The dry, crumbly nature of the
associated with Otodectes cynotis dark, dry, cerumen can be appreciated when it is rolled
and crumbly. As in this case, it is not always onto a glass slide.
associated with inflammation in the ear canal.

Fig. 2.24 External ear canal of a Cocker

Spaniel with chronic otitis externa.
Fig. 2.25 Gross appearance of an unstained Fig. 2.26 Gross appearance of a Diff-Quik-
cytologic sample thick and white. stained sample thick and blue, suggestive
ofa high cell content.
Fig. 2.27 High-power photomicrograph from Fig. 2.28 Unstained smears from normal ear
the Cocker Spaniel in Fig. 2.24. Note the yeast canals are all but invisible.
and cocci on and around the squames, and
the absence of inflammatory cells.

chronic, bilateral otitis associated with a it is not necessary unless samples are to be
thick, greasy exudate. Gross examination kept for future examination. Commercial
of the discharge (Figures 2.25, 2.26) might laboratories usually perform a Grams stain
suggest that a malassezial, or even a gram- because, although more time consuming, it
negative, infection was responsible but does allow assessment of the classification
cytological examination (Figure2.27) of organisms by both morphology (coccus,
does not support this. Although there rod, diphtheroid) and Grams stain status.
are increased numbers of squames and Generally, Gram staining is too cumber
microbes visible, the lack of any inflam some and time consuming for practitioners
matory cells suggests a ceruminous otitis to consider for a rapid, in-house stain8.
externa, probably associated with a more Knowledge of morphology and Grams
generalized defect in keratinization, rather stain status allows a recommendation for
than infection. treatment1,4. In addition to allowing visual
ization of the microbial populations of the
Samples and stains external ear canal, cytology also allows
The most useful sample for otic cytology the physical nature of the cerumen to be
is a swab taken from the ear canal, which assessed, in terms of keratinaceous debris
is then rolled onto a clean glass slide. If and the lipid content of the cerumen9,10.
feasible, samples should be taken from the Stained samples should be air-dried
horizontal portion of the external ear canal and examined for evenness of stain and
of both ears4,5. In large dogs it is usually for depth of stain, which is usually deeper
possible to collect a shielded sample in intensity as the cell count increases. A
using, for example, an alcohol-sprayed coverslip should be applied prior to micro
otoscope cone. In small dogs and cats scopic examination 5. Initial low-power
collecting a shielded sample is difficult, and examination is followed by high-power
verticalcanal samples will have to suffice5. examination, and this is usually sufficient
If otitis media is suspected, a shielded for accurate classification of any micro-
sample should be taken from the middle organisms and identification of any cells
ear in addition to that from the external ear present7,8.
canal.
Most clinicians advocate using modified Gross examination of cytological
Wrights stains such as Diff-Quik 1,4,5 . preparations
Alcohol-based stains are more useful than Gross examination of fresh and stained
aqueous preparations (e.g. new methylene smears reflects the lipid and cellular con
blue) because of the lipid nature of the otic tent of cerumen. Normal cerumen has a
discharge4. Griffin1 advocated heat fixing high lipid content and a low concentration
of obviously waxy preparations in order of intact cells, usually squames. Unstained
to prevent solvent-associated leaching preparations are all but invisible in direct
of lipid. Since all cerumen contains lipid light (Figure 2.28), reflecting the low cell
it would seem appropriate to heat fix all content of cerumen. Increasing cell content,
samples, but opinion is divided on this particularly if it is inflammatory in nature,
issue48. Subtle information may be lost if is reflected in the increased opacity of the
heat fixing is not performed, but generally cerumen.

Fig. 2.29 Photomicrograph of a cytological Fig. 2.30 Outlines of lipid are visible, even
sample from a normal ear. Note the low cell after fixing and staining with Diff-Quik.
content in the cerumen.
Fig. 2.31 Photomicrograph of a cytological Fig. 2.32 Photomicrograph demonstrating

sample from a normal ear, with a few increased numbers of squames, some of
squames apparent. which are nucleated.
Normal cytological characteristics be identified adhering to shed squames

Cerumen does not take up stain because (Figures2.33,2.34). Leucocytes are usually
of its high lipid content (Figure 2.29), absent from normal cerumen4.
although ghost outlines of lipid droplets
may be seen occasionally (Figure 2.30). Abnormal cytological characteristics
Low numbers of anucleate, epithelial cells Cerumen
may be detected, although in normal ears The lipid content of cerumen from inflamed
they are not excessive (Figure 2.31). When external ear canals is lower and the cell
there is inflammation of the epithelial count is usually higher than that in normal
lining of the external ear canal, the rate of ear canals9. This is reflected in the gross
cellular turnover increases and nucleated appearance of the stained smear, which
squames may be seen in the cerumen appears bluer in a sample from an otitic ear
(Figure 2.32). Low numbers of Malassezia (Figure 2.35) than in that from a normal ear
pachydermatis and staphylococci may (Figure 2.36).

Fig. 2.33 Photomicrograph demonstrating Fig. 2.34 Photomicrograph demonstrating a

a few anucleate squames with a few few anucleate squames with low numbers of
staphylococci apparent. yeast apparent.
Figs. 2.35, 2.36 Gross cytological samples from an otitic and a normal ear canal. The otitic ear
(2.35) contains a higher cell content and appears much bluer, when stained, than the smear
from the normal ear (2.36).
Fig. 2.37 Photomicrograph from a case

of otitis externa. There are anucleate
andnucleated squames present.
Keratinocytes atopy, the epithelial lining of the external

In acute cases of otitis externa, or cases of ear canal reacts to the inflammation and the
very short duration, there will be very hyperplasia may result in the appearance of
little change in the epithelial shedding of both anucleate and nucleated squames and
squames. In chronic cases, such as those debris (Figure 2.37).
associated with defects in keratinization or

Autoimmune disorders, in particular charge9. Cells from adenocarcinomas tend

pemphigus foliaceus, may result in to exfoliate in sheets or clusters, whereas
acantholysis. Single, nucleated, well- squamous cell carcinomas shed large,
defined acanthocytes may be shed from densely-staining individual cells with
erosions in the ear canal, often surrounded prominent nucleoli (Figure 2.41)5.
by adherent neutrophils (Figure 2.38),
i.e.apositive Tzank test. Bacteria
The normal microbial population of the
Inflammatory cells ear canal is dominated by staphylococci.
In samples taken from dogs and cats with In the early stages of otic inflammation,
acute otitis externa there may be little the numbers of staphylococci increase,
change in the cellular population, but in particularly the numbers of Staphylococcus
most cases there will be neutrophils and pseudintermedius (Figure 2.42).
proteinaceous debris (Figure 2.39). More Care should be taken when pronouncing
chronic otitis results in the appearance that staphylococci are present in cerumen
of macrophages as well as neutrophils or on the squames, as cocci may be confused
within the exudate5. In cases of bacterial with:
otitis, the increasing concentration of Debris in poorly-maintained Diff-Quik
toxins may result in the appearance of toxic (filter the stain regularly).
neutrophils (Figure 2.40) and indicates that Pigment granules within the squames
the external ear canal should be flushed (melanin granules are usually brown
before treatment is initiated1. in colour rather than the blue-black
colour of staphylococci).
Neoplastic cells
Intraluminal neoplasms may shed cells Occasionally the otic flora remains staphy
into the cerumen but it is unusual to find lococcal in nature but most commonly
diagnostically useful material in this dis it becomes dominated by gram-negative
Fig. 2.38 Photomicrograph of a stained Fig. 2.39 Photomicrograph of a small group

smear from a pustule in a case of pemphigus of squames with surrounding neutrophils.
foliaceus. Compare the clean neutrophils
and rounded-up, nucleated squames in this
Tzank test-positive smear with the cells and
neutrophils in Figs. 2.39 and 2.40.

bacilli, in particular Escherichiacoli, Proteus either staphylococci or streptococci on

spp., and Pseudomonas spp. These changes the basis ofclumping or chain formation,
in bacterial shape (i.e.coccoid to rod) are respectively, since this is not usually
easily detected by microscopic examination observed4. With experience, clinicians may
of cytological samples (Figure 2.43) 5,7. be able to detect thatstaphylococci are
Cocci cannot be reliably classified as larger than streptococci4.
Fig. 2.40 Photomicrograph illustrating Fig. 2.41 Photomicrograph of cytological

squames, proteinaceous debris, and dark, sample from an ear canal in which a
pyknotic neutrophils. squamous cell carcinoma was found. Note the
typical appearance of the cells: large, densely
staining with nucleoli.
Fig. 2.42 Photomicrograph of a dense group Fig. 2.43 Photomicrograph illustrating

of cells with large numbers of staphylococci squames and vast numbers of bacilli.
apparent.

Fig. 2.44 Photomicrograph illustrating yeast.
Fig. 2.45 Photomicrograph illustrating yeast Fig. 2.46 Photomicrograph illustrating yeast
in sufficient numbers to be associated with and inflammatory cells.
disease.
Figs. 2.47, 2.48 Photomicrograph of adult otodectic mites and an ovum recovered from the
cerumen of an ear infected with Otodectes cynotis.

Generally, even in first opinion for yeast organisms was only moderate6.
cases, the observation of bacilli should In addition to relative insensitivity, malas
promptsampling for bacterial culture and sezial culture is expensive and time con
sens it ivity testing 4. This is particularly suming, resulting in unnecessary cost and
important if Gram staining is not performed, delay in treatment compared to cytological
since clinicians cannot differentiate assessment2.
Pseudomonas spp. from Clostridium spp.,
or Bacillus spp.4. Unless a recurrent case is Ectoparasites
involved it is not usually necessary to submit It is often easy to visualize O. cynotis and
samples from otitis externa associated with O. megnini within the external ear canal
cocci for bacterial culture and sensitivity simply by using an otoscope. However,
testing. Indeed, inone study, testing since very low numbers of mites have
achieved a sensitivity of59% for gram- been associated with otitis externa13 it is
positive cocci and 69% for gram-negative not surprising that they will be missed
rods, compared with 100%sensitivity with in some cases, particularly if there is an
cytological examination8. accumulation of debris or discharge with
in the canal. Therefore, microscopic exam
Yeast ination of cytological preparations is
M. pachydermatis is a member of the normal indicated if otodectic mange is suspected.
canine otic microflora11, although it has the Cerumen is deposited on a glass slide and
potential for opportunistic pathogenicity. mixed with mineral oil prior to microscopic
At least two species of malassezial yeast examination 2. Otodectic mites have a
can be isolated from feline ear canals, characteristic appearance (Figures 2.47,
M. pachydermatis and M. sympodialis 12. 2.48).
The presence of yeast (Figure 2.44) must,
therefore, be interpreted with caution. Bacterial culture and sensitivity testing
Evidence of increased numbers of yeast In most cases, examination of cytological
(arbitrarily more than 510 per high-power samples will provide all the information
field [Figure 2.45] 1,4,5) and an associated necessary for effective treatment to be
inflammatory reaction (Figure 2.46) should instituted. Microbial culture and sensitivity
be sought before disease status is decided. testing of samples from the external ear
Malassezial yeast are flask- or peanut- canal is, however, useful in certain cases:
shaped, whereas candidial yeast are round In cases of recurrent, or refractory,
in appearance, although this distinction is otitis externa.
not easily made. If ulceration of the epithelial lining of
The importance of cytological evaluation the external ear canal is present.
was exemplified in two studies which If gram-negative infection is
reported that demonstration of malassezial suspected.
infection by culture methods achieved a If otitis media is suspected (when
sensitivity of 82% and 50% respectively1,8. samples from the middle ear will also
However, in another study looking at the be necessary).
reproducibility of cytology, the agreement

BIOPSY
Taking 4 mm (0.2 in) punch biopsy samples,

under general anaesthesia, of the vertical
ear canal or of lesions and masses within
the external ear canal is an important
method of obtaining useful information
on theprocesses underway. Biopsy of the
external ear canal has three main indica
tions:
As a means of providing information
on the degree of permanence of
epithelial changes. For example,
some apparently permanently
thickened epithelia will regress
dramatically when treated with
topical glucocorticoids to suppress
the inflammatory reaction. However,
fibrosis, in general, will not regress.
Biopsy of the luminal wall can yield
information on the degree of fibrosis
present (see Chapter 1: Microscopic
structure of the external ear canal). Fig. 2.49 Video-otoscope in a
This information can help decide consultingroom.
whether to opt for a surgical or
medical approach.
As a means of providing information
on the aetiology of ulcerated lesions
in the ear canal. Ulcers of the luminal
wall may reflect gram-negative
bacterial infection particularly,
but also autoimmune disease and
neoplasia. Biopsy of these lesions can
yield information which will influence
management.
As an adjunct to surgery. Neoplastic
changes within the ear canal may
be fibrogranulomatous, benign,
or malignant. Knowing the type
of neoplasm and being able to
predict its behaviour can help the
surgeon planthe degree of resection Fig. 2.50 Illustration of the quality of the
necessaryto remove the risk of image that can be obtained using a video-
recurrence. otoscope.

IMAGING
Video-otoscopic examination of
the ear canal
The video-otoscope (VO) is a useful and
effective tool in the management of both
canine and feline otitis. Its widespread use
is, unfortunately, limited by expense and
it is most commonly available in referral
institutions. The equipment takes up
space in the consulting room (Figure 2.49).
Although it has major advantages over
hand-held otoscopes, animals do need to
be minimally sedated but more commonly
anaesthetized in order for it to be used
successfully. Its uses and indications in
veterinary medicine have been reviewed by
different authors13. It has many advantages
over the hand-held otoscope:
The VO provides a range of
magnification lenses which allows
assessment of fine detail especially at
the level of the tympanic membrane Fig. 2.51 In-use picture showing the
(Figure 2.50). Often the inferior workinghead inserted in a dogs ear canal.
magnification of the hand-held
instruments does not allow the
clinician to see small tears in the
tympanic membrane, which can be
important when deciding on topical
therapy.
The intense light source which is
positioned at the tip of the endoscope,
rather than at the base of the cone as
is the case with hand-held devices,
provides excellent illumination
to allow more detailed evaluation
of the structures within the ear
(Figure 2.51). This also prevents
the problem of shadows within the
visual field created when instruments
are introduced down the working
channels.
The working channels facilitate fully
visualized flushing (Figure 2.52) of the Fig. 2.52 Suction head within the external
canal and removal of foreign bodies, ear canal of a dog.
such as grass awns or ceruminoliths,
using grasping forceps.

Minor surgical interventions can also KEY POINTS

be performed. Biopsies may be taken
from the canal using grasping forceps. QQ Careful positioning is the key to
Injections can be placed into the canal radiographic interpretation of the
using a long hollow needle inserted tympanic bullae.
down the working channel or by a QQ The most useful views are the
rigid spinal needle inserted down dorsoventral, rostrocaudal (open
alongside the otoscope cone. mouth), and lateral oblique views.
When samples are to be taken from QQ Given the individual variation
the middle ear, in the face of an intact between animals, comparison of one
tympanic membrane, myringotomy side with the other is often the only
can be performed safely, because way of making a diagnosis. Therefore,
important structures to be avoided, perfect positioning is essential.
such as the malleus and pars flaccida,
can be visualized.
Some VOs, especially those with wide The radiological anatomy of the petrous
working channels, can also be used temporal bones, and the associated com
with lasers which can be used to ablate ponents of the middle ear, is complex
small lesions in the walls of the canal and subject both to breed and individual
or to perform myringotomy. variation, particularly in the dog15. Conse
Modern VOs allow photographic quently, a thorough knowledge of the spatial
documentation of clinical cases which relationships between the skull and the
helps enhance the patients medical ear is essential if the radiographs are to be
record and can be used to provide interpreted correctly3. However, pathological
colleagues and the client with a changes to the region are unlikely to be
pictorial record; often the ability of symmetrical. Thus, provided a good quality,
an owner to see the ear canal of their symmetrical radiographic image is obtained,
pet, especially when comparisons useful information may be acquired by
are made with a normal ear, leads to comparing one side with the other2,3.
increased owner compliance with
therapy. Normal radiographic features
Dolichocephalic (or oligocephalic)
Virtual otoscopy for evaluating heads are long and narrow, e.g. as in
the inner ear the Rough Collie and Saluki.
The technique of virtual otoscopy depends Mesaticephalic heads are more
on manipulating computed tomography rounded, e.g. as in the Doberman
(CT) data with commercial software 1,2. Pinscher and Labrador Retriever.
Although beautiful images are generated, Brachycephalic heads are short and
the technique has little practical application wide, e.g. as in the English Bulldog
at present. and the Pekingese.
Radiography Any one of several radiographic views will

Radiographic examination is a useful tool provide information on the middle ear but
in the investigation of ear disease in both no one view can provide a completepicture.
the dog and the cat. Principally, it is utilized Therefore, at least two different radiograph
for the diagnosis of disease affecting views must be included in any radiographic
the middle ear, although there are some investigation. The three most frequently used
indications for radiographic examination radiographic views are the lateral oblique,
of the external ear canal. the dorsoventral, and the rostrocaudal (open

mouth) views. Lateral and ventrodorsal nearestthefilm. The jaw should be

views may occasionally be required. closed. Either the head is rotated around
this long axis until the sagittal plane lies
Lateral oblique view (Figures 2.53, 2.54) at about 20 to the horizontal, the bulla
Advantages: Good visualization of the to be radiographed remaining ventral,
tympanic bulla and petrous temporal bone. or the nose is elevated some 1520% to
Disadvantages: General anaesthesia is achieve separation of the bullae on the
necessary. Only one bulla can be visual plate6. Thebeam should be centred to the
ized at a time. Not easily repeatable, base of the ear to project the bulla clear of
even in the same animal, so side-to-side other structures.
comparison is difficult6. Interpretation: The bullae appear as thin-
Positioning: The animal is placed in lateral walled, crisply outlined bone struc
recumbency with the head parallel tures with a smooth external border
to the film and the bulla of interest (Figures2.55,2.56) 7 . Air shadow
Figs. 2.53, 2.54 Lateral oblique radiographs of the head of a dog (2.53) and a cat (2.54)
demonstrating optimal positioning for visualizing the tympanic bullae, which are clearly visible.
Figs. 2.55, 2.56 Close-up view of the normal tympanic bullae of a dog (2.55) and a cat (2.56)
in the lateral oblique view.

should be visible in the external ear mandible with tape8. The interpupillary
canal 7. Predominantly lytic changes line must be parallel to the film. In
on the rostroventral wall of the bulla dolichocephalic breeds the primary beam
are usually associated with chronic is centred through the open mouth parallel
inflammation7. Lytic changes within the to the hard palate5. In mesaticephalic
petrous temporal bone may reflect either breeds it may be necessary to angle the
inflammation or neoplasia7,8. hard palate slightly away from the vertical
(perhaps 10 or so4). In brachycephalic
Rostrocaudal (open mouth) view breeds the hard palate may need to be
(Figures2.57, 2.58) angled up to 20 away from the vertical in
Advantages: Good visualization of both order to avoid superimposing the bullae
tympanic bullae. Good view for diag on the wings of the atlas5. Alternatively,
nosing otitis media4,9. the centre of the beam can be angled rostro
Disadvantages: General anaesthesia is caudally, at up to 30 angling towards the
necessary and the endotracheal tube must hard palate. The beam can be centred on
be removed. Can be difficult to obtain the base of the tongue10.
perfect pictures without fine-tuning, Interpretation: The bullae appear as thin-
especially with brachycephalic breeds. walled, symmetrical bone opacities at the
Positioning: The animal must be in dorsal base of the skull (Figure 2.59)7. Overlying
recumbency. The head is positioned with soft tissues may produce the appearance
the sagittal plane and hard palate vertical of middle ear pathology. This must be
to the film. The tongue must be brought interpreted with care.
as far forward as possible and tied to the
Figs. 2.57, 2.58 Rostrocaudal (open mouth) radiographs of the head of a dog (2.57) and
acat (2.58) demonstrating how the tympanic bullae are skylined.

Optimizing the diagnosis of otitis alone, or in combination, are optimal for

media by imaging visualizing disease in the canine and feline
Several studies have tried to ascertain bulla1113. In summary:
whether radiography, ultrasound, or CT Few clinicians have access to CT.
No technique is definitively better
than any other in detecting both the
presence and severity of middle ear
disease.
Ultrasound is a very useful modality,
particularly in the case of investigating
the feline bulla.
Given that many veterinary practices
have access to both ultrasound and
radiography, the combination of both
will give added diagnostic confidence.
Dorsoventral view (Figures 2.60, 2.61)

Fig. 2.59 Close-up rostrocaudal (open Advantages: Anaesthesia may not be
mouth) view of the tympanic bullae of a cat. necess ary, although in most cases it
Near perfect positioning is important for this will allow better positioning. In some
view as one is looking for subtle changes that patients sedation may suffice. It is easier
may only be apparent by comparing one side to achieve good bilateral symmetry with
with the other. this view than with the ventrodorsal
Figs. 2.60, 2.61 Dorsoventral radiographs of the head of a dog (2.60) and a cat (2.61). Note
the appearance of the bullae and the difficulty in visualizing them using this position compared
with the lateral oblique and rostrocaudal (open mouth) views.

Figs. 2.62, 2.63 Lateral radiographs of the head of a dog (2.62) and a cat (2.63). The bullae
are visible but both left and right bullae are superimposed, making interpretation difficult.
view, as the mandibles provide stability Some distortion and masking may occur
against lateral rotation6. Provides a good due to superimposition of the petrous
view for diagnosing otitis media4. temporal bones6. Air shadow should be
Disadvantages: Because the calvarium visible in the external ear canals.
is further from the plate it is magnified
and this can induce some artefactual Lateral view (Figures 2.62, 2.63)
distortion6. However, this is more than Advantages: Standard view; lots of refer
outweighed by the advantage of having ence material.
the bullae close to the plate. Disadvantages: General anaesthesia is
Positioning: The animal is placed in ventral necessary. Not ideal for visualizing
recumbency, under general anaes individual tympanic bullae as they are
thesia or heavy sedation. Care must superimposed if a true lateral position is
be taken to ensure that the animal is achieved.
aligned symmetrically with the inter Positioning: The animal is placed in lateral
pupillary line parallel to the film6. The recumbency and the head adjusted to
hard palate must be parallel to the table true lateral, with the sagittal plane paral
and the animal adjusted so that the lel to the film and the interpupillary line
base of the skull is as close to the film vertical6. This may require foam padding
as possible6. This may require support to achieve a true lateral. The calvarium,
with radiolucent blocks of foam under nasal pharynx, and larynx should be
the rostral mandible, sandbags over included in the view. The beam should
the cervical spine, or both. The beam be centred between the ear and the eye.
should be centred at the intersection of Interpretation: The bullae appear as thin-
two imaginary lines: a sagittal line, and a walled, crisply outlined bony struc
lateral line, at right angles to the sagittal tures with a smooth external border
line, drawn through the estimated (Figures2.64,2.65), but in a true lateral
position of the tympanic membranes. view they will be superimposed, making
Interpretation: The bullae should exhibit for difficult interpretation6. Air shadow
bilateral symmetry and appear as fine, and, if present, the thickened walls of the
crisp, distinct, linear bony opacities7. horizontal ear canal, may be visible6.

Figs. 2.64, 2.65 Close-up views of the tympanic bullae of a dog (2.64) and a cat (2.65)
demonstrating the air shadow of the horizontal ear canal.
Figs. 2.66, 2.67 Ventrodorsal radiographs of a dog (2.66) and a cat (2.67). Note the
appearance of the bullae and the difficulty in visualizing them using this position compared
with the lateral oblique and rostrocaudal (open mouth) views.
Ventrodorsal view (Figures 2.66, 2.67) Disadvantages: Requires general anaes

Advantages: Standard view; lots of refer thesia. This position is not suitable for
ence material. Provides a good view for brachycephalic breeds5. The sagittal crest
diagnosing otitis media4. tends to make the skull fall laterally,
making exact positioning difficult6.

Positioning: The animal is placed in dorsal an additional inner bony wall which
recumbency, under general anaesthesia. appears in this view (Figure 2.67)6.
Care must be taken to ensure that the
animal is aligned symmetrically. The Visualizing the external ear canal
hard palate must be parallel to the table. and assessing the tympanic
This may require support under the membrane
rostral mandible or under the cervical Radiography is not commonly employed as
spine, or both. Intraoral tape, positioned a means of assessing pathological changes in
immediately caudal to the canine teeth the external ear canal. It may be possible to see
and then tied to the table, may help in air shadows (Figures2.68,2.69) delineating
positioning the mandible. The beam the external ear canal in some of the standard
should be centred at the intersection of radiographic views of the ear, particularly
two imaginary lines: a sagittal line, and a the dorsoventral and rostrocaudal (open
lateral line, at right angles to the sagittal mouth) views. In addition, in cases of chronic
line, drawn through the estimated posi otitis externa, there may be calcification of the
tion of the tympanic membranes. cartilages of the external canal (Figures 2.70
Interpretation: The superimposition of 2.72). However, it is not possible to assess
the petrous temporal bones makes the the integrity of the tympanic membrane
bullae walls appear thicker, and this can or visualize the position of an obstructing
make evaluation of subtle changes more luminal neoplasm without using contrast
difficult. The bulla of the cat contains techniques.
Fig. 2.68 Dorsoventral radiograph of a Fig. 2.69 Dorsoventral radiograph of a West

Cairn Terrier with a normal ear. The air Highland White Terrier with chronic otitis
shadow within the external ear canal is externa. In this close-up of the right side of the
visible (arrowheads). skull, the narrow ear canal is visible between
the thickened walls of the horizontal ear canal
(arrowheads).

Otoscopic and plain radiographic the middle ear. False-negative interpreta

examinations must be performed prior tion may occur if these changes are not
to contrast studies. Significant epidermal identified prior to contrast studies14.
hyperplasia or neoplastic proliferation may A standard radiographic contrast
occlude the lumen to such an extent that medium is used, preferably a nonionic,
adequate distribution of contrast medium water-soluble iodine-based medium
is impossible. In addition, the presence of rather than an oily medium 14. The con
an exudate or mass within the bulla may trast medium may be diluted 50:50
prevent contrast medium from entering with saline prior to instilling it into the
Fig. 2.70 Dorsoventral radiograph of

an Airedale Terrier showing early signs
of calcification of the external ear canal
cartilages(arrowheads).
Figs. 2.71, 2.72 Dorsoventral and rostrocaudal (open mouth) radiographs of a Cocker Spaniel
with chronic otitis externa and otitis media. Note the extensive calcification of the ear canal
cartilages (arrowheads) and the changes around the left bulla (arrow).

externalearcanal14. Care must be taken to Ventrodorsal or, preferably, rostrocaudal

ensure that the contrast medium is distri (open mouth) radiography will allow
buted evenly along the external ear canal evaluation of the lumen of the external ear
and that none contaminates the hair on the canal and permit some deductions on the
surrounding aspects of the head3,14. Gentle state of the tympanic membrane (Figure
massage of the ear canal will ensure an 2.73)15. If contrast medium enters the middle
even distribution. Taking care to deliver ear (Figure 2.74)it is usually visualized as an
all the contrast medium into the ear canal, opacification of the inner wall of the bulla11,
and subsequently plugging the orifice with best seen on rostrocaudal (open mouth)
cotton wool, should prevent soiling of the views. Failure to detect contrast medium
area around the external ear3,14. in the bulla should not be interpreted as
indicating an intact tympanum.
Figs. 2.73, 2.74 Ventrodorsal radiographs demonstrating tympanography. In Fig. 2.73

the tympanum is intact and the concavity is apparent. In Fig. 2.74 the tympanum has been
breached and contrast fills the tympanic bulla.

3 AETIOLOGY AND
PATHOGENESIS OF
OTITISEXTERNA 45
CONCEPT OF PRIMARY AND Is there a primary cause? Primary

SECONDARY FACTORS, causes are capable of causing otitis
PREDISPOSING FACTORS, AND externa in their own right and
PERPETUATING CHANGE include allergy, autoimmune disease,
endocrine disease, ectoparasites,
August 1 proposed that the approach to epithelialization disorders, foreign
otitis externa should not be considered bodies, glandular disorders, immune-
symptomatically, but through the identifi mediated disease, micro-organisms,
cation and management of three factors. He and viral disease (Table 3.1).
proposed a triad of primary, predisposing, Are there secondary causes present?
and perpetuating factors. Although this Secondary causes normally contribute
system provided a basis for investigation to or cause pathology in an abnormal
and treatment of ear disease for many years ear. Secondary causes are the easiest
it has more recently been superseded by the to identify and in the early stages
PSPP System2: of the disease the easiest to treat.
Primary (P) and Secondary (S) causes However, where they become chronic
are diseases or infectious agents that or recurrent it is usually because a
directly cause inflammation in the ear. primary cause or a perpetuating factor
Perpetuating (P) and Predisposing has not been adequately addressed.
(P) factors are agents or elements that It is important not to focus entirely
contribute to ear disease. Factors do on the secondary cause of otitis at the
not cause ear disease in their own right expense of the primary cause. The
but can prevent resolution of disease most important secondary causes are
and can lead to recurrence. bacterial and yeast infection, the use
Both causes and factors contribute of inappropriate medication, or over
to ear disease and both need to be cleaning (Table 3.2).
identified and addressed to resolve Are there perpetuating factors?
disease. Perpetuating factors are changes in
the anatomy and physiology of the ear
This concept helps form the basis of a logi that occur as a consequence of otitis
cal approach to otitis externa and each case externa. They tend to aggravate the
should be considered in the following, non otitis and further induce pathological
exclusive classification: changes within the lining of the
external ear canal. Perpetuating
factors include changes to the ear

46 Aetiology and Pathogenesis of OtitisExterna
canal epithelium, tympanum, and may initially be mild but as the disease
glandular structures in the wall of the process progresses they often become
canal as well as otitis media, which the most significant part of the ear
may occur as a consequence of otitis disease, and accentuate secondary
externa (Table 3.3) and is commonly causes due to chronic damage creating
underdiagnosed in chronic cases of an environment within the ear to
otitis externa. Perpetuating factors enhance bacterial and yeast growth.
Table 3.1 Primary causes of otitis externa
Types
Allergy Adverse food reaction, atopic otitis, contact allergy
Autoimmune Bullous pemphigoid, epidermolysis bullosa, lupus
erythematosus, pemphigus foliaceous
Ectoparasites Otodectes cynotis, Otobius megnini, Demodex
spp., Eutrombicula spp.
Endocrine Hyperadrenocorticism, hypothyroidism, Sertoli cell tumour,
sex hormone abnormalities
Epithelialization disorders Primary idiopathic seborrhoea, sebaceous adenitis, zinc
responsive dermatosis, vitamin A responsive dermatosis,
idiopathic inflammatory otitis of the Cocker Spaniel
Foreign bodies Hair, grass awns, sand, dirt
Glandular disorders Hypersecretory states, sebaceous gland abnormalities
Immune mediated Erythema multiforme, vasculitis, drug eruption
Micro-organisms (rare) Fungi (Aspergillus spp.)
Miscellaneous Eosinophilic granuloma complex, juvenile cellulitis,
proliferative perforating otitis of kittens
Viral Canine distemper
Table 3.2 Secondary causes of otitis externa
Types
Bacteria Cocci (staphylococcus, streptococcus, enterococcus)
Baccilli (Pseudomonas spp., Proteus spp., Escherichia
coli, Klebsiella spp., Corynebacteria spp.)
Yeast Malassezia spp., Candida spp.
Medication reaction Products containing topical irritants (alcohol, low pH,
propylene glycol)
Over-cleaning Water-based solutions causing maceration (water, water-
based cleaners, antibiotics in aqueous solution); dry
cleaning with cotton wool

Aetiology and Pathogenesis of OtitisExterna 47
Are there any predisposing factors? Water within the external ear canal
Predisposing factors (Table 3.4) make either through swimming or from
otitis externa more likely by changing grooming may precipitate acute
the internal environment in such a gram-negative infection or Malassezia
fashion that humidity within the ear pachydermatis otitis externa.
canal rises, surface maceration occurs, The external environment may
and microbial proliferation follows. also be pertinent since humidity
Predisposing factors include: and high temperature are known
Conformational factors such as the to be correlated with an increased
amount of soft tissue within the incidence of ear disease.
confines of the auricular cartilage.
The presence of hair follicles, Although predisposing factors will not cause
particularly compound hair ear disease they can, on occasion, combine
follicles, within the external ear with secondary causes and engender otitis
canal. externa. For example, obstructive ear disease
Stenotic ear canals (Shar Pei) or caused by neoplastic or hyperplastic lesions
hair within the ear canal (Cocker can lead to changes in the environment in
Spaniel). the ear, predisposing to infection and sub
sequent disease.
Table 3.3 Perpetuating factors for otitis externa
Types
Ongoing pathological changes Failure of epithelial migration, oedema, proliferative
within the ear canal change, canal stenosis, calcification of pericartilagenous
fibrous tissue
Tympanum Acanthosis, dilation, rupture, diverticulum or pocket
Glandular tissue Apocrine blockage and dilation, hidradenitis, glandular
hyperplasia
Middle ear (otitis media) Material within the middle ear (granulation tissue,
infection, foreign material, primary secretory otitis media)
Table 3.4 Predisposing factors for otitis externa
Types
Conformation Hairy ear canals, pendulous pinna, stenotic ear canals,
hairy concave pinna
Excessive moisture Environment (heat and high humidity), water (swimmers
ear, grooming)
Obstructive ear disease Neoplasia, polyps, cyst
Systemic disease Debilitation, immunosuppression
Treatment effects Trauma from cleaning, over-use of antibiotics

PRIMARY CAUSES OF Otitis externa in atopic dogs often

OTITIS EXTERNA begins as erythema at the base of the
concave aspects of the pinnae and on the
Hypersensitivity vertical portions of the external ear canals
(Figures3.1, 3.2)1. The horizontal portion of
KEY POINTS the external ear canal is minimally affected
in early cases. Scott 2 reported that otitis
QQ Atopy is the most common cause of externa associated with atopy often flared
chronic canine otitis; it is a rare cause in association with the skin disease. This is
of feline ear disease. a valuable clue that an alert clinician should
QQ Otitis associated with dietary spot when taking a history.
intolerance appears to be more severe Atopy is associated with erythema and
that that seen in atopy. oedema of the ear canal but there is usually
QQ Irritant contact dermatitis of the little exudation2. Secondary changes and
external ear canal may be due to microbial proliferation result in extension
exposure to one of the common of these early clinical signs to the horizontal
vehicles in otic preparations canal and hyperplasia of the epithelial lining
(e.g.propylene glycol) or to an active (Figure 3.3). Malassezial proliferation may
ingredient (e.g. neomycin). be particularly troublesome (Figure3.4).
Although chronic otitis externa is com
monly due to atopy, it rarely results in
Atopy is an inherited predisposition to gram-negative bacterial infection.
develop immunoglobulin (Ig) E to environ Lateral wall resection or vertical canal
mental allergens resulting in disease 1. ablation should not be carried out on an
Affected dogs exhibit pruritus and otitis atopic ear in an attempt to alleviate the
externa 13. Atopy has been stated to be otitis externa, without an appreciation of
the most common cause of chronic otitis the underlying disease. The inflammation
externa in dogs3. The incidence of otitis will continue to affect the medial and lateral
externa in atopic dogs has been estimated at walls of the residual canal and the proximal
55% and in 3% of atopic dogs otitis externa aspect of the pinna (Figures 3.5, 3.6).
was the only clinical sign2. Atopy does exist
in cats and will cause otitis externa in this
species, although rarely.
Figs. 3.1, 3.2 Classic signs of a hypersensitivity affecting the proximal aspect of the concave
side of the pinna (3.1) and the upper portions of the external ear canal (3.2). There is erythema
and hyperplasia in both areas.

Fig. 3.4 Photomicrograph of a cytological

sample taken from an atopic dogs external
ear canal. There are a few squames, no
inflammatory cells, but many yeast.
Fig. 3.3 Otoscopic picture of the lower
portion of the vertical ear canal of a dog with
atopy. Note the erythema and hyperplasia.
Fig. 3.5 Failed lateral wall resection in an Fig. 3.6 Only partially successful vertical
atopic West Highland White Terrier. Persistent canal ablation in an atopic dog. Erythema
erythema and hyperplasia continue to affect and hyperplasia still affect the proximal aspect
the residual medial wall of the external ear of the pinna and the residual portion of the
canal. medial wall of the external ear canal.

Dietary intolerance due to exposure to any of the components

Dietary intolerance is a dermatosis which is of an otic preparation, provided it is used
much less common than atopy. However, for long enough. Irritant contact dermatitis
when it occurs there may be concurrent within the confines of the external ear
otitis externa. Although otitis externa may, canal may be due to exposureto one of the
on rare occasions4, be the only sign of dietary common vehicles, propylene glycol10.
intolerance, it is commonly associated with However, the most commonly impli
other signs, typically pruritus46. The otitis cated component is neomycin, although
associated with dietary intolerance appears docu m ented, published reports are
to be more severe that that seen in atopy very rare. Bilateral, erythematous otitis
and it exhibits a rapid progression. Otitis externa would be anticipated (Figure 3.8).
externa is also associated with dietary The classic history is a cat or dog with
intolerance in cats6,7. chronic, relapsing otitis externa, which
had previously responded well to a certain
Contact dermatitis medication only to deteriorate when
Allergic contact dermatitis is a rare derma exposed to the medicant again.
tosis in dogs and is almost unknown in cats8.
In dogs with very extensive or generalized
allergic contact dermatitis, the concave
aspects of the pinnae and upper portion of
the vertical ear canals may exhibit lesions
(Figure 3.7)9.
More commonly, allergic contact derma
titis or irritant contact dermatitis may occur
Fig. 3.7 Allergic contact dermatitis. Note Fig. 3.8 Allergic contact dermatitis following
the hyperpigmentation affecting the perioral, neomycin therapy. Erythematous, hyperplastic
periocular regions, in addition to the concave otitis externa. Note the lack of lesions on the
aspect of the pinna and the upper portion of concave aspect of the pinna, a pointer to this
the vertical ear canal. not being atopy, even though the changes in
the external ear canal are indistinguishable on
clinical grounds.

Autoimmune/immune mediated Ectoparasitic causes

Otodectes cynotis is the most common
KEY POINT ectoparasite involved in otitis externa.
As few as three otodectic mites have
QQ Autoimmune and immune-mediated been reported to cause otitis externa.
diseases rarely cause ear disease. Asymptomatic carriage of O. cynotis
is common in the cat and may occur,
though rarely, in the dog.
Where lesions include vesicles, bullae, O. cynotis may, very rarely, be zoonotic.
ulcers, or erosions these diseases should Other ectoparasitic causes of otitis
be considered. Pemphigus foliaceus, pem externa include Demodex spp.,
phigus erythematosus, vasculitis, and Neotrombicula autumnalis and other
systemic lupus erythematosus commonly harvest mites, and ticks such as
affect the pinnae but very rarely cause otitis Otobius megnini.
externa14. However, if vesicles, blisters,
erosions, or ulcers are found on the concave Otodectes cynotis
aspect of the pinna and in the external ear O. cynotis (Figure 3.10) is a large (0.30.4
canal (Figure 3.9), these diseases should mm [0.010.02 in]) mite which lives
be considered, particularly if bacteriology predominantly in the external ear canal of
and cytology suggest minimal microbial dogs and cats, and perhaps occasionally on
involvement. Cytological examination of the adjacent skin of the head1. The mite does
vesicular contents may reveal acanthocytes not burrow but lives on the skin surface
and neutrophils (see Figure 2.38), a com where it feeds on tissue fluid and debris2. It
bination suggestive of pemphigus foliaceus. has been suggested that otodectic mites can
Fig. 3.9 Primary lesions of pemphigus Fig. 3.10 Photomicrograph of an adult

foliaceus at the entrance to the external Otodectes cynotis mite.
ear canal and on the concave aspect of the
pinna. Cytological examination of samples
taken from these lesions reveals neutrophils
and rounded up keratinocytes, called
acanthocytes (see Fig. 2.38).

survive within the household, off the host, occurs. Although the life cycle of 3 weeks is
for weeks if not months3. confined to the host, it has been suggested
The physical presence of the mite induces that the mite can survive in the environment
a mechanical irritation which accounts for long periods3. Nevertheless, contact
for some of the pruritus experienced by with an infected host is still believed to be
infected animals. However, the saliva is the main route of transmission1.
both irritant and immunogenic and in The prevalence of O. cynotis in dogs
the cat the mite stimulates an IgE-like ears was assessed as 29.1% in one study of
antibody2, suggesting that hypersensitivity 700 ears, with a significant predisposition
contributes to the pruritus. The mite pro in dogs with pendulous and semierect
duces an antibody which cross-reacts pinnae as compared to erect pinnae7. This
with the house dust mite Dermatophagoides study also reported that there was a highly
farinae3 and may thus play a part in human significant correlation between the presence
atopy. Ear mite antigen may play a part in of mites and otitis externa. In 114 (out
inducing aural haematoma in both the dog of 700 ears) ears, mites were found in the
and cat and this might have an autoimmune absence of any indication of otitis externa,
aetiology4,5. suggesting that in dogs, asymptomatic
Zoonotic lesions may occur on in-contact carriage is possible. Fewer cases were
human members of the household1. Ves reported in the summer months. One study8
icles, wheals, erythematous papules, and suggested a seasonal incidence for the
excoriations on the arms and torso have disease; however, a very large study9 could
been reported6. find no evidence of a seasonal incidence.
Note that many of these studies on the
Lifecycle, transmission, and prevalence prevalence of O. cynotis wereperformed
Females lay eggs (Figure 3.11) and cement before the widespread useof topical and
them to the epidermal surface. These systemic ectoparasiticides.
hatch to yield six-legged larvae which Young dogs appear to be more com
undergo two moults through eight-legged monly infected than older animals9. This
protonymphs and deutonymphs. The probably reflects the fact that infected dogs
emerging deutonymph is approached are easily diagnosed, effectively treated,
by, and attached to, an adult male mite and not reinfected. The average number of
(Figure 3.12) and, if it is female, copulation mites per dog was only 5.69.
Fig. 3.11 Photomicrograph of Otodectes spp. Fig. 3.12 Photomicrograph of two

ova collected in cerumen. deutonymphs each attached to an adult
otodectic mite.

Scott8 suggested an age predilection in

young cats. In cases of chronic infection
there may be hyperplastic changes in the
lining of the external ear canal and a predis
position to secondary infection.
Clinical features
O. cynotis is typically associated with a
pruritic otitis externa7,8. However, Scott8
considered that in the cat, three syndromes
(otitis externa, ectopic infection, and asymp
tomatic carriage) might be associated with Fig. 3.13 Adult cat with Otodectes cynotis
infection with the mite. infestation. Note the typical dark brown
Very low numbers of mites, even as low colour and the dry nature of the cerumen.
as three7, may be sufficient to induce clinical Note also the lack of self-trauma in this
signs. This, together with the mites ability to asymptomatic case.
inhabit the entire external ear canal, canmake
definitive diagnosis difficult andmight make
a rule-out of otodectic acariasis, other than by
trial therapy, problematic.
The classic feature of otitis externa due
to ear mite infection is moderate to severe
otic pruritus. In addition, the external ear
canal becomes filled with a crumbly black/
brown discharge (Figures 3.133.15). Most
affected dogs exhibit chronic otic pru
ritus but Frost7 reported four dogs out of
200 which had asymptomatic infection.
Puppies are most likely to be infected from
dams, but in adult dogs the cat is a common Fig. 3.14 Otodectic mange in a pup. Note
cause of contagion1, particularly since the the presence of the dryish cerumen and
cat may well be asymptomatic8,10. evidence of some self-trauma.
Fig. 3.15 Cerumen from an ear infested with

Otodectes cynotis. Note the crumbly nature of
the cerumen and the dark brown colour.

In cats the pruritus associated with

infection may be associated with moder
ate to severe self-trauma to the head
(Figures3.16, 3.17).
In some cases, perhaps in cats more
than in dogs, the mite causes clinical signs
distant from the ear. Scott 8 considered
that this might be a consequence of cats
sleeping in a curled position so that the ear
is apposed to the tail-base. Two syndromes
may be associated with ectopic infection:
Fig. 3.16 Small area of crust and self-trauma Crusted papules, i.e. miliary
in the entrance to the external ear canal of a dermatitis.
cat with otodectic otitis. Patchy alopecia.
Asymptomatic infection may be a feature

of older cats where very high numbers of
mites may be found with apparently no
associated clinical signs10. The presence
of asymptomatic carriage in dogs has
not been considered a major problem in
veterinary dermatological texts, but in
light of the discussion above it should be
borne in mind, particularly when treatment
protocols are discussed.
Diagnosis
The mite is relatively large and may be
Fig. 3.17 Area of erythema and self-trauma easily seen in the external ear canal with
associated with otodectic otitis on the lateral the aid of an auroscope (Figure 3.18). Direct
aspect of the head of a cat. observation may not always result in a
diagnosis:
The degree of discharge may make
direct observation difficult.
There may be so few mites that direct
observation is not possible.
In these situations, microscopic examin-

ation of discharge may be necessary. Gentle
maceration of collected samples in mineral
oil will aid diagnosis, and microscopic
examination under low power should show
evidence of infestation.
Fig. 3.18 Otoscopic view of ceruminous

debris and otodectic mites in a feline external
ear canal. The mites appear small in this
unmagnified view.

Demodex canis, D. felis, and D. gatoi In cats, demodicosis is more usually

Demodex canis has been reported as a rare associated with erythema (Figure 3.20) and
cause of otitis externa in dogs. It may crusting on the pinnae and head, rather
occur as part of a generalized condition, in than otitis externa. However, D. gatoi may
isolation, or as a long-term complication be assoc iated with a ceruminous otitis
of juvenile-onset generalized demodicosis externa in cats.
which has apparently responded to treat Diagnosis is based on recovery of demo
ment11. A history of demodicosis should decid mites (Figures 3.213.23) in skin
alert the clinician to the possibility of scrapes and on cotton swabs from the
otodemodicosis but cases arising de novo external ear canal. Punch biopsy samples
should not be discounted. Typically, would also give appropriate material for a
otodemodicosis is associated with a diagnosis.
ceruminous otitis externa (Figure 3.19).
Fig. 3.19 Erythe

matous, ceruminous
otitis externa in
a Cavalier King
Charles Spaniel
withotodemodicosis.
Fig. 3.20 Feline

demodicosis causing
erythematous
dermatitis adjacent to
the entrance to the
external ear canal.
Figs. 3.21, 3.22 Photomicrographs of a

juvenile demodectic mite (3.21) and an egg
(3.22) in cerumen from the ear of a dog with
otodemodectic mange.
Fig. 3.23 Photomicrograph of an adult

Demodex canis mite in cerumen from
the external ear canal of a dog with
otodemodectic mange.

Harvest mites Ticks

Harvest mites, such as Neotrombicula The spinous ear tick, Otobius megnini,
autumnalis (Figure 3.24) and Euotrombicula (Figure 3.25) is most frequently found in
alfredugesi, are occasional causes of otitis the southern and south-western regions of
externa in both dogs and cats. The larvae the USA. However, the increased mobility
are parasitic and require a mammalian host; of owners and their pets means that the tick
they are not species specific. Larvae hatch may be found in almost any region of the
in rapid succession and usually tens or USA13,14. The larvae (six legs, yellow-pink
hundreds are involved in the parasitic attack. colour) and adults (eight legs, blue-grey
Typically, they cause a pruritic crusting colour) are parasitic and infest the external
dermatitis on the ventrum and face and in ear canal of both dogs and cats to the extent
the interdigital areas. Occasional animals that in some cases the external ear canal
exhibit larval clustering and crusting at the is entirely filled with the parasites. Acute
base of the pinnae12 or within the confines otitis externa results. Ixodic, hard ticks such
of the proximal external ear canal. Close as Demacentor spp., and the rabbit stick
examination usually reveals tiny orange, or tight flea (Spillopsyllus cuniculi) are usually
orange-red, clusters of larvae. found on the pinnae and head, rather than
The parasite is a seasonal threat to the within the external ear canal.
hunting or roaming dog and cat and it is
more common on ground composed of well
drained, chalky soil.
Fig. 3.24 Larva of Neotrombicula autumnalis. Fig. 3.25 Otobius megnini in the external ear
Note the red colour and six legs. canal of a dog. (Courtesy of Dr. Louis Gotthelf,
DVM; Mongomery, AL, USA.)

Endocrinopathies allergy is a much more common cause.

Hypothyroidism should be suspected as a
KEY POINT cause in middle aged predisposed breeds
(e.g. Labradors, Labrador Retrievers) when
QQ Endocrine disease is an uncommon they present in middle age with no pre
cause of otitis externa in the dog or cat. vious history of ear problems. Gonadal
hormone changes (e.g. Sertoli cell tumours),
in contrast, may have a profound effect on
Endocrinopathies are often cited as cutaneous glandular function and may
underlying causes of chronic ceruminous therefore be associated with ceruminous
otitis externa. However, neither hypo- otitis (Figure 3.26) in association with other
thyroidism nor hyperadrenocorticism are signs4.
commonly associated with otitis externa13;
Fig. 3.26 Otitis externa associated with

a Sertoli cell tumor. Note the ceruminous
discharge adhering to the concave aspect
ofthe pinna.

Epithelialization disorders
KEY POINTS
QQ Secondary causes of keratinization are

more common than primary causes.
QQ Idiopathic inflammatory/
hyperplastic otitis in the
CockerSpaniel is often complicated
by gram-negative infection.
QQ Hereditary defects in keratinization
have been reported in cats. Fig. 3.27 Early changes associated with
Persian cats are most commonly chronic otitis externa in a Cocker Spaniel.
affected1. Ceruminous otitis with early hyperplasia.
Epithelialization disorders include seborr White Terriers4. The relationship between

hoeic diseases which are caused by defects epidermal dysplasia and the yeast Malas
in keratinization, sebaceous adenitis, vit sezia pachydermatis in West Highland White
amin A responsive dermatosis, and zinc Terriers is complex and poorly under
responsive dermatosis. Defects in kera stood4,5. Basset Hounds also suffer from a
tinization may be primary or be secondary dermatosis which used to be classified as
to another disease. By far the most common idiopathic seborrhoea. Many of these dogs
causes of scaling and crusting dermatoses suffer from M. pachydermatis dermatitis
are secondary causes such as ectoparasites, and they show a spectacular response to
infectious agents, hypersensitivities, and antimalassezial therapy 6. Whate ver the
endocrinopathies2. Otitis externa may be exact nature of these two disorders, or their
anticipated with these disorders only if relationship, they are both associated with
the underlying disease is itself a cause of severe otitis externa4,6.
ear disease. Superficial pyoderma, der The otitis externa associated with pri
matophytosis, or demodicosis are common mary seborrhoea in Cocker Spaniels is
causes of crust and scale on the trunk or initially ceruminous (Figure 3.27), but
limbs, but they rarely cause otitis externa. In epidermal hyperplasia (Figure 3.28) soon
contrast, the inflammation caused by atopy follows. The otic discharge is typically
is generalized, as are the aberrations in thick and oleaginous (Figure 3.29). Oto
cutaneous homeostasis which accompany scopic examination of early cases reveals
an endocrinopathy. Thus, these diseases are hyperplasia, a moister appearance than
often associated with otitis externa. in an atopic ear canal (compare with
Similarly, some, but not all, of the Figures3.13.3), and a tendency to bleed
primary defects in keratinization (idio easily (Figure 3.30). Cytological exam
pathic seborrhoea) may be associated ination from many cases will reveal plenty
with otitis externa. Examples include idio of cerumen and cellular debris but only
pathic seborrhoea in Cocker Spaniels3 and a few inflammatory cells (Figure 3.31).
epidermal dysplasia in West Highland Indeed, subsequent bacterial culture from

Fig. 3.28 Cocker Spaniel with an almost Fig. 3.29 Unstained cytology smear. Note the
occluded external ear canal, a consequence thick, oleaginous nature of the cerumen.
ofchronic otitis externa.
Fig. 3.30 Otoscopic picture of theexternal

ear canal of a Cocker Spaniel with early
changes associated with chronic otitisexterna.
There is erythema and the ear canal hasa
moister appearance than the atopic ear
(compare with Figs. 3.13.3). Note thatthe
ear canal has been plucked to facilitate
cleaning.
Fig. 3.31 Photomicrograph of a stained

cytological smear from a Cocker Spaniel.
Note the increased numbers of squames,
the amount of cerumen, the lack of
micro-organisms, and the absence of
inflammatorycells.

these ears may fail to record any significant Foreign bodies

bacterial growth at all, illustrating the value
of otic cytology. However, in contrast to the KEY POINTS
otitis associated with atopy, the disease
in Cocker Spaniels is often complicated QQ Younger dogs from hunting and
by gram-negative infection (Figure 3.32), working breeds are predisposed.
perhaps a reflection of differences in QQ Otic foreign bodies usually, but not
glandular secretion. always, cause acute clinical signs of
Hereditary defects in keratinization have otitis.
been reported in cats1. Persian cats are most QQ Always examine both ears as foreign
commonly affected (Figure 3.33), although bodies may be bilateral.
the condition may occur in other breeds. QQ Grass awns are the most common
Affected animals show signs from a very foreign body entering the external
early age and either sex may be affected. earcanal.
The ears develop a ceruminous otitis QQ Rupture of the tympanum is a
externa and greasy scale may accumulate common complication of otic foreign
on the pinnae. The entire trunk is also body penetration.
affected with scale, grease, and malodour. QQ Otic foreign bodies are most
Because of the severity of the disease, many commonly seen in the summer,
cases are euthanazed at an early age as reflecting the importance of grass
there is no effective treatment. awns in the aetiology.
Fig. 3.32 Ulcerated external ear canal due to Fig. 3.33 Persian cat with an hereditary
gram-negative bacterial infection in a Cocker defect in keratinization. There is a greasy otitis
Spaniel. externa.

There is no sex predisposition to otic foreign as Stipa, Setaria, Bromus, and Avena, may be
body penetration but young dogs are involved in other areas of the world2. All
predisposed to grass awn penetration1,2. In have a similar shape (Figure 3.34) with wiry
general, all breeds of Spaniels and Golden barbs which prevent retrograde movement;
Retrievers are most commonly affected, once in the ear canal they can only move
while German Shepherd Dogs, Miniature forward (Figure 3.35).
Poodles, and Dachshunds are under- Hair shafts, particularly if they contact
represented2. the tympanum, may also act as foreign
The most common foreign body found in bodies (Figure 3.36). In one series of 120
the external ear canal of dogs and cats is the cases of otitis externa, 12.6% of the cases
grass awn1. In the USA the most common were considered to result from matted hair
species of plant awn is Hordeum jubatum, and cerumen in the external ear canal 3.
although other members of the genus, such Other foreign bodies that may enter, or be
as H. murinum, H. silvestre, and genera such put into, the external ear canal include other
Fig. 3.34 Typical shape of a grass awn; this

was removed from the external ear canal of
adog.
Fig. 3.35 Otoscopic picture of a grass awn Fig. 3.36 Accumulation of hair and cerumen
lying adjacent to the tympanic membrane. In obstructing the horizontal ear canal at the
this case the grass awn had not punctured level of the tympanum.
the tympanum; however, note the area
of erythema and erosion on the tympanic
membrane.

Fig. 3.37 Acute, erythematous, ulcerated

otitis externa associated with the penetration
of a grass awn into the external ear canal.
Fig. 3.38 Grass awn penetration of the Fig. 3.39 Grass awn penetration, picture
tympanum. Note the small piece of vegetation taken with video-otoscope, note the increase
still visible on the left, adjacent to the area of in clarity and depth of field.
haemorrhage.
pieces of vegetation and childrens toys. hyperaemia and ulceration followed

Aggregations of otic, usually proprietary, by the generation of an otic discharge
nonveterinary powders and ointments and secondary bacterial proliferation
with cerumen may also induce foreign (Figure3.37). If the foreign body penetrates
body reactions. Occasionally a clinician the epithelial lining of the external ear
is presented with a young dog exhibiting canal, it may become embedded in a
acute otic discomfort. Examination pyogranuloma4. In one study2 nearly 20%
reveals no evidence of ear disease and no of cases of otic grass awn penetration were
foreign bodies are found. It may be that associated with rupture of the tympanum
the dogs violent shaking has dislodged (Figures 3.38, 3.39), suggesting that otitis
the accumulation of cerumen that was the media should be considered in long-
cause of the irritation. standing cases, even where the tympanum
Foreign body penetration into the ear is intact.
canal is usually accompanied by acute pain. The most common bacteria associated
The dog or cat shakes its head and may with grass awns are streptococci, although
attempt to remove the object with a foot. Staphylococcus spp, Pasteurella spp., and
As the object moves down it may induce Actinomycetes spp. may also be cultured2.

SECONDARY CAUSES OF recovered from others, such as the Minia

OTITIS EXTERNA ture Poodle. The authors postulated that
Miniature Poodles presented with acute,
painful ear disease with a short time course,
KEY POINTS whereas Cocker Spaniels were notorious
for exhibiting chronic otitis externa,
QQ The bacterial flora of the canine permitting contamination with gram-
external ear canal is principally a negative organisms.
gram-positive flora, similar to that of A more rational explanation is that
the interfollicular epidermis. Cocker Spaniels are anatomically prone to
QQ The vertical portion of the external ear narrow, hirsute ear canals and to defects
canal contains more bacteria than the in keratinization. Both of these factors are
horizontal portion. likely to predispose to chronic otitis externa
QQ Not all external ear canals contain and gram-negative bacterial infection,
significant numbers of bacteria or particularly if the humidity within the
yeast. external ear canal is elevated because of a
QQ Otic inflammation is accompanied pendulous pinna.
initially by an increase in the number Miniature Poodles, on the other hand,
of bacteria and a shift towards might well have hirsute canals but they are
coagulase-positive staphylococci. often affected by atopy. Atopy is associated
QQ Chronic inflammation in dogs is with an inflamed, erythematous otitis,
accompanied by increased numbers at least at first, which is not exudative.
of gram-negative bacteria. Such changes mimic those on the skin
QQ Malassezia pachydermatis is regarded as and might be sufficiently aberrant to
an opportunistic pathogen. favour colonization by Staphylococcus
QQ Otitis media may be present in over pseudintermedius and M. pachydermatis,
80% of cases of otitis externa. but not P. aeruginosa. Support for this con
QQ The bacterial flora in the inner ear tention comes from a Brazilian study in
may be different from that of the which the microbial flora of dogs with
externalear. only bilateral otitis externa was studied19.
The most frequent organisms isolated
were Staphylococcus intermedius and
Microbiological changes M.pachydermatis exactly what would be
associated with otitis externa expected if the population contained a large
The overall changes in bacterial flora asso number of allergic dogs, who typically
ciated with otitis externa are qualitative manifest bilateral otitis externa.
and quantitative (Table 3.2); the number The most common bacteria recovered
of bacteria increases and the proportion from otitis externa in cats ears were coagu
of various species changes (compare lase-positive staphylococci (54.8%). Gram-
Tables3.1 and 3.2). The incidence of negative bacteria, such as Pseudomonas
recovery of staphylococci in general, and spp. and Proteus spp., were only rarely
of coagulase-positive staphylococci in recovered from feline otitis externa8.
particular, increases13. More particularly, M. pachydermatis is a yeast-like fungus
the incidence of recovery of Pseudomonas commonly isolated from both normal and
spp. and Proteus spp. increases418. diseased external ear canals of dogs and
Early studies1 reported that Proteus spp. cats. The number of organisms recovered
and Pseudomonas spp. were commonly varies, as does the rate of recovery of the
isolated from certain breeds of dog, par yeast from ear canals. Thus recovery rates of
ticularly the Cocker Spaniel, but not between 14.3% and 37% have been reported

for healthy dogs 38,20. There appears to the ears are erythematous, malodorous,
be the same environmental effect on the and hyperplastic (Figures 3.40, 3.41).
carriage of M. pachydermatis in normal ears Cerumen may be thick and oleaginous
as there is on gram-negative bacteria, with and vast numbers of yeast may be detected
a higher rate of recovery in tropical and when smears are stained and examined
subtropical regions compared to temperate microscopically (Figure 3.42).
areas. Currently, the organism is regarded The fungal flora of the ear canal also
as an opportunist pathogen, capable of changes in otitis externa (Tables 3.1 and 3.2)
causing inflammatory changes in the ear and almost all of the increase results from
canal, at least in the presence of moisture21. an increased incidence of M. pachydermatis.
This is not to minimize its importance Thus, Fraser10 recovered M. pachydermatis
as a potentiator of chronic, or acute, otic from 36% of normal ear canals and from
inflammation, but it serves to suggest to 44% of cases of otitis externa. However, the
the clinician that a search for underlying incidence of fungi was unchanged; indeed
causes of the inflammation should be made. the number of isolations of Aspergillus spp.,
M.pachydermatis is a common cause of otitis Penicillium spp., and Rhizopus spp. was
externa in West Highland White Terriers reduced in otitic ear canals.
and Basset Hounds. In these animals
Fig. 3.41 Greasy, erythematous, malodorous,

hyperplastic otitis externa in a Bassett Hound.
Note the extension of the lesions on the
pinna.
Fig. 3.40 Hyperplastic otic epithelium

occluding the external ear canal of a
WestHighland White Terrier.

PERPETUATING FACTORS i.e. it becomes hyperplastic1,2. There may

be surface erosions and ulceration, par
ticularly with gram-negative infections.
KEY POINTS The dermis becomes infiltrated with
inflammatory cells and fibrosis will follow.
QQ Pathological changes within the In the early stages of otitis externa there is
external ear canal are progressive. hyperplasia of the sebaceous glands, and
QQ Changes in structure their ducts may become dilated3,4. If chronic
engender changes in the local otitis persists, the apocrine glands become
microenvironment. hyperplastic with cystic dilatation of the
QQ Surgery is the inevitable consequence glands and ducts. Although this may be of
of chronic otitis externa. such magnitude that the sebaceous glands
appear displaced, with very little secretory
potential1,2, morphometric analysis reveals
Response to insult and injury no significant changes in sebaceous gland
Reactions to inflammation within size or activity4. Papillary proliferation of
the external ear canal ceruminous glands and ducts may obli
The epidermis of the external ear canal terate the lumen of the external ear canal
reacts to inflammation by increasing its in some cases2. In very chronic cases, ossi
rate of turnover and increasing in thickness, fication of the tissues may take place.
Fig. 3.42 Cytological smear demonstrating cerumen,

squames, and many yeast.

Hyperkeratosis Fibroplasia Apocrine hyperplasia
Increase in soft tissue volume
Reduced lumen
Increased humidity
Microbial proliferation Inflammation
Chronic otitis externa
Fig. 3.43 Flow chart summarizing the progression of otitis externa.
Similar changes take place in the feline It is not clear at which stage these
ear canal, although the papillary changes in changes become irreversible. Certainly,
the ceruminous glands may be sufficiently aggressive medical therapy, initially with
florid that discrete polyps occur2. antimicrobial agents and then with topical
The consequence of these changes is a glucocorticoids, can result in significant
reduction in luminal cross-section, a result reduction in soft tissue occlusion of the
of increasing soft tissue within the bounds lumen. However, the structural changes
of the containing cartilage5. The change in apocrine ducts and glands are probably
in nature of the cerumen, the reduction irreversible; certainly the progressive
in luminal diameter, and the moisture changes in glandular architecture correlate
and warmth which accompany active with the progression of the otitis externa4.
inflammation contribute to an increase in Even very early changes in the luminal
local humidity5. These changes in the otic epithelia have the potential to become
environment result in surface maceration permanent and, once these permanent
and the creation of a milieu favourable to changes occur, simple Zepp resection of the
microbial multiplication, itself a potent lateral wall of the vertical canal is unlikely
inducer of inflammation (Figure 3.43). to be successful68. Ablation of the canal is
indicated.

Fig. 3.44 Photomicrograph of a section Fig. 3.45 Photomicrograph of a section

of canine external ear canal demonstrating of canine external ear canal demonstrating
epidermal hyperplasia. epidermal hyperplasia, an inflammatory
infiltrate, and dermal oedema.
Influence of progressive pathology Subepithelial infiltration with

The soft tissues surrounding the lumen of inflammatory cells, such as
the external ear canal react in a predictable lymphocytes, neutrophils,
sequence to the inflammation associated macrophages, and plasma cells, occurs
with chronic otitis externa14: in response to inflammation. Chronic
Epidermal hyperplasia (acanthosis cellular infiltration results in local
and hyperkeratinization) is an release of inflammatory mediators,
early consequence of otic irritation cutaneous erythema, and oedema
(Figure 3.44). The basal cells of the (Figure 3.45). Early cellular infiltration
epidermis respond to inflammation is reversible but the effects of chronic
by increasing their rate of division mediator release may engender
and increasing the transit time of cells permanent changes.
moving through the epidermis. In
addition, keratinization is affected
and a thickened stratum corneum is
apparent. This reaction is reversible,
provided the initiating cause is
alleviated.

Fibroplasia of the underlying dermis gross thickening of the epidermis,

follows chronic inflammatory particularly in cats.
challenge within the lumen and Papillary proliferation of the
the epithelium. In long-standing epithelial lining occurs to such
cases the fibrosis may be extensive an extent that the lumen becomes
(Figure 3.46),and this contributes occluded (Figures3.48, 3.49). In
considerably tothe loss of luminal the external ear canals of cats this
cross-section. papillary proliferation may result in
Early sebaceous gland hyperplasia polypformation, with trapping of
is followed by massive ceruminous exudate between the polyp and the
gland hyperplasia, both of the tympanum.
duct and the glandular portion Ossification of the dermis, sometimes
(Figure3.47). The changes in extending to the auricular cartilage,
the ceruminous glands result in occurs as a final stage.
Fig. 3.46 Photomicrograph of a section Fig. 3.47 Photomicrograph of a section

of canine external ear canal stained to of canine external ear canal demonstrating
demonstrate dermal fibrosis, which in massive apocrine gland hyperplasia.
thiscase is extensive.
Fig. 3.48 Photomicrograph of a section of Fig. 3.49 Photograph of a section of a

hyperplastic external ear canal with papillary chronically hyperplastic external ear canal
fronds almost occluding the lumen. withalmost no lumen.

Influence of breed and otitis externa, will result. Increased

moisture and surface maceration creates
KEY POINTS an environment particularly favourable
to gram-negative bacteria. Theoretically,
QQ Breeds of dog predisposed to otitis the increased apocrine secretions in the
externa, such as Cocker Spaniels, have ear canals of these dogs should result in
increased amounts of glandular tissue cerumen with a lower pH than normal and
compared to normal dogs. an environment not conducive to gram-
QQ Otitis externa results in increased negative colonization. It may be that the
production of cerumen with a lower acidifying effect of increased ceruminous
lipid content than normal, associated gland secretion is not sufficient to overcome
with increased ceruminous gland the effects of humidity, inflammation, and
activity. surface maceration.
QQ Conformational factors that may Dogs with pendulous ears are pre
predispose to the development of disposed to otitis externa1,3,4 but the low
otitis externa include dogs with incidence in some breeds with pendulous
stenotic ear canals, pendulous pinnae, ears, such as Beagles and Irish Setters, in
hirsute pinnae, and hairy canals. most studies1,2 suggests factors other than
conformation at work. The presence of
hair, per se, within the ear canal does not
Fernando1 observed that the external ear correlate with otitis externa4. However,
canals of longhaired breeds of dogs and Cocker Spaniels have many compound
those with fine hair contained more seb hair follicles throughout the length of the
aceous and apocrine glandular tissue, external ear canal whereas nonpredisposed
which was also better developed, than breeds typically have fewer, predominantly
dogs with short hair. Breeds predisposed to simple follicles in their ear canals5. Certain
otitis externa also have abnormal morpho breeds, such as Cocker Spaniels and
metric ratios compared to normal dogs2. Miniature Poodles, appear on every list
Specifically, they exhibit an increase in of affected breeds 1,3, 58. However, it is
the overall amount of soft tissue within now recognized that one of the principal
the confines of the auricular cartilage, causes of otitis externa is the presence
an increase in the area occupied by the of hypersensitivities, such as atopy, and
apocrine glands, and an increase in the generalized skin disease, such as defects in
apocrine gland area compared to that of the keratinization, which predispose to otitis
sebaceous glands. externa. It is the predisposition to these
Overall, the breeds of dog predisposed diseases which accounts for the increased
to otitis externa have increased apocrine relative risk of ear disease rather than the
tissue2. If this increased volume of apo anatomy per se.
crine tissue is actively secreting, the con Only one study has recorded the
centration of lipid within the cerumen will incidence of otitis externa in cats. In this
fall3, humidity within the ear canal will series of 36 cats, Himalayans and Persian
rise, and maceration, followed by infection breeds were most commonly affected9.

Excessive moisture Finally, in man it has been demonstrated

that the incidence of asthma increases
KEY POINTS after thunderstorms6. Thunderstorms are
associated with a decrease in temperature
QQ Increases in environmental and an increase in humidity and rainfall
temperature and humidity are and, more significantly, a significant rise in
reflected in the external ear canal. the concentration of pollen allergen in the
QQ The incidence of otitis externa peaks air, secondary to osmotic rupture of pollen
in late summer and early autumn. grains7. Given that a high proportion of
QQ Gram-negative infections of the cases of otitis externa are a consequence
external ear canal are more common of atopy, it may be that some cases of
in humid and warm environments. acute otitis externa may also be related to
QQ Dogs that swim are also predisposed thunderstorms.
to developing signs of otitis externa.
Obstructive disease
Conchal neoplasia
The three main components of weather
which impact on external ear disease KEY POINTS
are temperature, humidity, and rainfall.
All three factors interact with each other QQ Neoplasia of the canine and feline
and affect the internal environment of external ear canal is rare.
the external ear canal1,2. Thus, increasing QQ Canine tumours are more likely to be
environmental temperature or relative benign, feline tumours are more likely
humidity is reflected in a small but measur to be malignant.
able increase in temperature or relative QQ The most common benign tumours
humidity within the external ear canal 1. in the dog are papillomas, basal cell
The incidence of otitis externa increases carcinomas, and ceruminous gland
as environmental temperature, relative adenomas; in the cat ceruminous
humidity, and rainfall increases, although gland adenomas are the most
there is a lag effect of 12 months 3. This common.
results in a peak incidence of otitis externa, QQ The most common malignant
in dogs in late summer and early autumn3. tumours in the dog and cat are
Variations in climate, commensurate carcinomas, adenocarcinomas, and
upon geographic location, affect both the squamous cell carcinomas.
incidence and type of otitis externa. Thus,
although temperature, relative humidity,
and rainfall all affect the incidence of Neoplasia of the external ear canal is rare1.
otitis externa, the local climate also exerts In general, otic neoplasia in cats tends to
aneffect3. be malignant1,2 and is likely to be found in
The local climate will also affect the either the vertical or the horizontal canal
microbial flora of the external ear canal. In with equal frequency 1. Otic discharge,
hot and humid environments there are fewer pruritus, and pain are common, whereas
ear canals from which no bacterial growth neurological signs are rare1. Canine conchal
can be cultured4. In man the incidence neoplasia is more likely to be benign than
of gram-negative bacterial complication feline conchal neoplasia, but distribution
of otitis externa increases in hot humid and clinical signs are similar1,2. Most benign
environments5 and thereisevidence that this tumours do not affect the bullae1. Although
is also the case indogs4. the malignant tumours, particularly in

the cat, tend to invade locally, it appears

that distant metastasis is the exception
rather than the rule1. When nervous signs
accompany otic neoplasia, a generally poor
prognosis is necessary since this usually
indicates middle ear involvement and
squamous cell carcinoma; altogether a more
malignant tumour than ceruminous gland
adenocarcinoma of the external ear canal1.
Indeed, when squamous cell carcinoma is
found in the external ear canal it usually has
its origins in the middle ear.
Papillomas, basal cell tumours, and Fig. 3.50 Obstructive otitis secondary to
ceruminous gland adenomas are the most ceruminous gland neoplasia in a cat.
commonly found benign tumours in dogs,
while in cats ceruminous gland adenomas
are most common1. Carcinomas, adeno
carcinomas, and squamous cell carcinomas
are the most common malignant tumours in
both dogs and cats. The clinical appearance
of these neoplasms is usually that of a
raised, frequently ulcerated mass which
may occlude the lumen3.
Ceruminous gland adenoma

Benign ceruminous gland neoplasia
tends to present with signs of obstructive
otitis externa (Figure 3.50): pruritus, head
shaking, malodour, otorrhoea, and occa Fig. 3.51 Large, pedunculated ceruminous
sional haemorrhage3,4. Ceruminous gland gland adenoma protruding from the external
adenomas are most commonly seen in ear canal of a dog.
middle-aged to elderly animals4,5. These
benign tumours tend to be raised and
occasionally pedunculated (Figure 3.51)
and they may occlude the external ear
canal6. They may have a melanotic appear
ance (Figure 3.52) and may be multiple5.
Aggressive surgical management is usually
curative and lateral wall resection, vertical
wall ablation, or total ablation of the
external ear canal is indicated, as dictated
by the extent of thetumour.
Fig. 3.52 Multiple, melanotic ceruminous

gland adenomas in the external ear canal
ofacat.

Ceruminous gland adenocarcinoma Squamous cell carcinoma

Malignant ceruminous gland tumours tend In cats, squamous cell carcinoma appears to
to be ulcerative and infiltrating rather than be as common as ceruminous gland adeno
occlusive4,5. Most cases tend to occur in old carcinoma1. The tumours are proliferative
animals cats: mean age 12 years; dogs: and ulcerated (Figure 3.57) and they have
mean age 9 years7,8. Otoscopically they are a tendency to grow rapidly5. Most conchal
pinkish in colour (Figure 3.53), ulcerated, tumours with otoscopically visible evidence
and friable in nature7,8. Most dogs and cats of extensive spread and histopathological
exhibit an otic discharge which is commonly evidence of local infiltration are squamous
malodorous, purulent (Figure3.54), and cell carcinomas1. Radical resection is neces
blood stained 7,8. Otic pruritus and ipsi sary and presurgical biopsy may be advan
lateral mandibular lymphadenopathy is tageous.
also commonly noted7,8. Bulla involvement
was demonstrated in nearly half the cats Non-neoplastic growths
and dogs in recent studies7,8. This tendency Pyogenic granulomas
to involve the bulla (Figures 3.55, 3.56) These have been reported to occur within
is reflected in the response to surgery: the external ear canal of cats10. Clinically the
radical, total ear canal ablation and bulla granulomas appear as fleshy masses that
osteotomy results in a longer disease-free may be covered in epithelium. However,
interval, a lower recurrence rate, and longer the epithelial surface is usually ulcerated10.
postoperative survival time than simple The prognosis for pyogenic granuloma
lateral wall resection7,8. If the tumour has is much better than for overt neoplasia.
extended through the external ear canal However, histopathological examination
into surrounding soft tissue, adjunctive of biopsy samples is essential to distinguish
radiotherapy is indicated7,9. the two.
Fig. 3.54 Malodorous, haemorrhagic

obstructive otitis secondary to ceruminous
gland adenocarcinoma in a cat. The ulcerated
Fig. 3.53 Pinkish, nodular appearance of mass of tumour may be seen protruding into
a ceruminous gland adenocarcinoma in the the lumen at the entrance to the external
external ear canal of a cat. earcanal.

Eosinophilic granulomas Cryptococcosis

Eosinophilic granuloma of the external Cryptococcosis and other fungal disease
ear canal has been reported in four dogs11. may occasionally cause granuloma
These dogs presented with chronic otitis tous lesions near the external ear canal
externa. Otoscopic examination revealed a (Figure3.58). Histopathological exam
solitary, friable mass occluding the vertical ination of biopsy samples will identify
canal. Surgical excision was curative. these lesions. Cryptococcosis has a better
prognosis than squamous cell carcinoma,
thereby justifying biopsy.
Fig. 3.55 CT scan of a 13-year-old cat. Fig. 3.56 CT scan of a 10-year-old Cocker
There is increased soft tissue opacity in the Spaniel. The left-hand side exhibits an
right external ear canal extending up to, and irregular, imprecise outline to the bulla,
perhaps across, the tympanic membrane. increased density within the bulla, loss of air
This is a ceruminous gland adenocarcinoma. within the external ear canal, mineralization
Note that the right bulla appears as normal as of soft tissue in the external ear canal, and a
the left. The bony septum dividing the feline homogenous soft tissue mass on the ventral
bulla into lateral and medial compartments is aspect of the skull. This is a ceruminous gland
clearly visible with this imaging modality. adenocarcinoma.
Fig. 3.57 Ulcerated, poorly-defined Fig. 3.58 Ulcerated granulomatous lesions

squamous cell carcinoma at the entrance to due to cryptococcosis should be considered in
the external ear canal of a dog. the differential diagnosis of conchal neoplasia.

4 EAR CLEANING
74
INTRODUCTION It removes exudate, debris, macerated

epithelial components, micro-
organisms, toxins, and some foreign
KEY POINTS bodies.
It improves visualization of the
QQ The integrity of the tympanum must proximal external ear canal and allows
be established before anything other otoscopic examination of the deeper
than water or saline is put into the regions.
external ear canal. It may permit visualization of the
QQ Many of the commonly used tympanum.
ceruminolytics exhibit ototoxic effects It facilitates subsequent therapy.
in the middle ear. It may provide relief from pain.
QQ Aural lavage and subsequent drying
are the key steps in cleaning the The procedure for cleaning the external ear
external ear canal. is straightforward and involves a number
QQ Chemical depilation and of distinct steps:
ceruminolytics/ceruminosolvents Establish the integrity of the
may be an aid to cleaning the tympanum. If this cannot be assessed,
earcanal. use cleaning agents with a high degree
of middle ear safety.
Assess the discharge both visually
Inflamed ear canals contain increased and cytologically to decide if a flush
amounts of moisture, aberrant cerumen, or ceruminolytic/ceruminosolvent is
mucous, increased numbers of micro- most appropriate.
organisms, and increased concentrations Assess the canal to decide if a
of microbial toxins. Foreign bodies, neo neutral/alkaline or acid cleaner is
plasms, or ectoparasites may be present. appropriate and whether a cleaner
There may be inflammatory cells in the with antibacterial or antiyeast activity
lumen, an inflammatory reaction within may be beneficial.
the epithelium, and erosions, or even Remove as much free fluid and
ulceration, of the epithelium. The animal discharge as possible with suction or
may well be showing signs of pain. The very gentle swabbing.
tympanum may be ruptured. Apply a drying agent if possible to
Aural lavage is beneficial for several ensure complete removal of moisture.
reasons (after Little1 and McKeever2):

Ear Cleaning 75
ASSESSING THE INTEGRITY OF which allows indirect assessment of

THE TYMPANUM the tympanum. An otoscope is used to
visualize the distal horizontal canal.
This step is critical since many cleaning A small, soft rubber feeding tube is
techniques advocate chemicals and some passed through the otoscope toward
degree of water pressure to flush the the tympanum. If it continues to pass
external ear canal. Any damage to the unhindered, the tympanum is ruptured
tympanum puts the middle and inner ear or there is false middle ear syndrome. If its
at risk3. progress is blocked and the tip remains in
Visual assessment of the tympanum is view, the tympanum is intact. Assessing
difficult in normal circumstances and often the tympanum with a Spreull needle is
impossible when otitis externa is present. not advised since such a needle has the
A variety of different techniques have been potential to rupture the tympanum.
described to assess the tympanum. One
includes filling the canal with warm water ASSESSING THE DISCHARGE
and watching to see if bubbles rise, another
suggests the instillation of warm dilute Although there are of course exceptions
povidoneiodine or dilute fluorescein into to the rule, different disease processes
the canal and looking to see if fluid appears tend to produce consistent changes in
at the back of the throat or down the nose. the appearance of the external ear canal
Auditory tympanometry, computed and in the type of discharge. Assessment
tomography or magnetic resonance imag of the discharge allows selection of the
ing are advanced diagnostic techniques most appropriate type of ear cleaner
that may also be useful but are only really (Figure4.1). Where the discharge is thick
available in referral institutions. However and waxy, as is often the case in kera
Griffin 4 described a simple technique tinization disorders, endocrine disease,
Type of Dark Pale Yellow Green

discharge brown brown
Thick waxy Moderate waxy Mild waxy Purulent

purulent purulent haemorrhagic
mucoid
Typical findings Ceruminous Malassezial Staphylococcal Pseudomonal

otitis otitis otitis otitis
The waxier the discharge the more important the ceruminolytic property of the cleaner
Ceruminolytic
activity
The more purulent and mucoid the discharge the higher the water content of the
cleaner should be to flush the ear
Flushing
activity
Fig. 4.1 Chart for the assessment of discharge.

76 Ear Cleaning
and in allergy in such breeds as the (vestibular effects) and caused inflammatory
Cocker Spaniel, then the cleaner needs changes within the middle ear. It was not clear
to have the ability to break up the wax. which component(s) of the various products
Such cleaners need potent ceruminolytic was/were responsible for the changes. In the
or ceruminosolvent (oil-based lubricant) same study the ceruminosolvent squalene
activity. Where the discharge is more was shown not to have any ototoxic effects.
purulent or mucopurulent in bacterial No in vivo or in vitro studies have been
infection, especially where there is gram- performed on canine or feline cerumen.
negative infection and/or concurrent otitis Howe ver, studies on human cerumen
media, then an aqueous-based flush is most demonstrated that aqueous alkaline solu
appropriate. tions of sodium hydroxide (0.1 molar),
sodium bicarbonate (0.5% and 1.25%),
Ceruminolytics and and sodium dodecyl sulphate (0.05%
ceruminosolvents and 0.1%) were superior to organic
Clinicians should be aware of the difference agents such as glycerine, triethanolamine
between a true ceruminolytic and a lubri polypeptide oleate-condensate, and olive
cant or ceruminosolvent: oil5. Proprietary oil-based ceruminolytics
A ceruminolytic disrupts the integrity were found to be no better than glycerine
of cerumen by inducing lysis of the or oliveoil.
squames5. None of the oil-based products had
A ceruminosolvent merely softens and any true ceruminolytic effect; all merely
loosens the cerumen. lubricated and softened the bolus of
cerumen5,9. However, softening and lubri
Many authors 2,4,68 advocate an initial cating may be just as useful as true ceru
application of ceruminolytic agents prior minolysis since a blind, controlled study10
to lavage in cases of otitis externa. The failed to show significant differences
justification for this is that the action between sterile water, sodium bicarbonate
of the ceruminolytic, and some of the solution, and a lipid-based proprietary
additives which may potentiate their ceruminolytic.
effect, softens the ceruminous debris and Water-based proprietary ceruminolytic
cerumenocellular aggregates, permitting preparations usually possess surfactant
easy removal with subsequent aural lavage. and emulsifying properties which allow
Ceruminolysis is optimal in hypo- aqueous substances to penetrate and
osmolar, alkaline solutions 5 . Proteins under-run oily masses. These are preferred
on the surface of squames dissolve into to oil-based products for two reasons:
this alkaline solution, binding with free Firstly, they are less messy7 and are
hydroxyl ions. Loss of surface proteins more easily removed from the ear
reduces the integrity of the cell membrane canal, permitting quicker cleaning and
and water enters the cell, resulting in drying.
swelling and fragmentation5. Disruption of Secondly, oil-based preparations are
the squames results in disintegration of the occlusive and may, if not thoroughly
cerumen, allowing it to be flushed from the removed, potentiate bacterial
external ear canal. infections8.
A study on commercially available
ceruminolytics3 demonstrated that glycer Dioctyl sodium sulfosuccinate and calcium
ine-based ceruminolytics, including sulfosuccinate are effective emulsifiers11
carbamide peroxide/dioctyl sulfosuccinate but they must not be used in dogs or cats
and triethanolamine polypeptide oleate- if there is a ruptured tympanum3,4. Car
condensate preparations, were ototoxic bamate peroxide is a less potent agent than

Ear Cleaning 77
the sulfosuccinates4 but is still capable of effects, particularly in the presence of a

damaging the middle ear 3. The foaming ruptured tympanum, the justification for
effect of released urea and oxygen may their use is debatable; their main indication
help to loosen adhered debris. This product is a broad-spectrum antimicrobial activity.
is probably most useful in cases of purulent However, in most cases the cleaning and
otitis externa4. irrigation procedure is a preliminary step
Oil-based proprietary ceruminosolvents whose function is to clean the ear canal in
have a lubricant, diluting effect, permitting preparation for specific topical medication.
subsequent flushing out. Squalene, tri
ethanolamine polypeptide oleate-con Chlorhexidine
densate, and hexamethyltetracosane are A 0.2% solution of chlorhexidine acetate has
more potent than propylene glycol and a broad-spectrum antimicrobial action, may
mineral oil, but are not as powerful as the have some residual activity, and is not toxic
aqueous products detailed above which in the presence of a ruptured tympanum
have a powerful surfactant activity4. These in dogs, although it may exert a transient
oil-based products soften the cerumen ototoxicity in cats12,13. An even more dilute
permitting easier removal from the preparation (0.0075%: 15 ml 2% solution in
external ear canal. Squalene appears to 4.5 litres of water) has been recommended
be well tolerated in the middle ear 3 and by one author8,11. Pseudomonas aeruginosa
was not associated with otic toxicity in may be resistant to chlorhexidine at this
Mansfieldsstudy3. lower concentration1.
Although concentrations of chlorhexi
Flushes dine diacetate over 0.013% were shown
Irrigating solutions are used to flush out to be cytotoxic to fibroblasts in vitro14, a
debris and any cleaning agents, such as concentration of 0.05% was not detrimental
ceruminolytics or chemical depilatories. to wound healing in vivo15. However, a 0.5%
They are also preferable in sensitive ears solution of chlorhexidine has been shown
especially where there is ulceration and significantly to impair granulation tissue
where there is mucous. A water-based production and wound healing16.
flush helps break up the discharge to allow On the basis of the above research a 0.05%
it to be removed more effectively from concentration of chlorhexidine would
the ear. Generally they are administered appear to be a safe product with which
in a gentle stream, the overflow being to irrigate the canine external ear canal,
monitored to assess when flushed debris although it might not be an ideal choice for
ceases to be present. Extreme care is needed postoperative irrigation following aural
if the tympanum is ruptured. A solution of surgery. Note that P. aeruginosa may be
propylene glycol and malic, benzoic, and resistant to chlorhexidine at a concentration
salicylic acids, 2% or 5% acetic acid alone, of 0.05% or lower1. Consequently, more
or 1:3 povidoneiodine (1%) solution have potent antimicrobial agents should be
been recommended if the tympanum is not used if gram-negative bacterial infection is
intact2,4,6. A solution of 0.2% chlorhexidine suspected.
has also been shown to be safe when
instilled into the middle ear of dogs7. Povidoneiodine
The bactericidal activity of povidone
Water or sterile saline iodine is related to the concentrationof
These are the agents of choice when the noncomplexed iodine in solution 17 .
integrity of the tympanum has not been Concentrations of povidoneiodine
established1,7. Given that the antimicrobial greater than 0.5% are toxic to fibroblastic
agents listed below have potential ototoxic cultures 14 , somewhat below the 1%

78 Ear Cleaning
minimum concentration required for tetra-acetic acid tromethamine (EDTA-

reliable antistaphylococcal activity 18 , tris) 1416,18,21,22, lactic acid 23,24; isopropyl
although comfortably above the 0.001% a l c o h o l 20, p a r a c h l o r o m e t a x y l e n o l
dilution reported to be staphylococcicidal (PCMX)20, cleaners that contain microbial
in another study19. However, povidone adhesion-blocking carbohydrate 25, and
iodine, particularly when combined with cleaners with a low pH20.
a detergent, is potentially ototoxic20 and it
is not recommended for use as a flushing EDTA-tris
agent7. EDTA binds divalent cations, enhances
membrane permeability, and alters ribo
Acetic acid some stability14. P. aeruginosa and Staphy
Dilute solutions of acetic acid (5% diluted lococcuspseudintermedius, which are resistant
1 in 2 or 1 in 3) have been reported to be to enrofloxacin and cephalexin (respectively),
safe for use as a middle ear flushing agent7 may be rendered sensitive by pretreatment of
and several commercial preparations of the external ear canal with EDTA-tris15. Other
2.5% or 5% solutions are available. A recent workers22 have shown EDTA-tris potentiates
study18 has shown an ear cleaner containing the activity of ampicillin, chloramphenicol,
2% acetic acid exhibited excellent activity oxytetracycline, and streptomycin up to
against Pseudomonas spp. A 5% solution fourfold. In vitro studies with Pseudomonas
kills staphylococci4, although the higher spp. isolated from cases of canine otitis have
concentration may be irritating. also demonstrated the bactericidal potential
of EDTA-tris16.
ASSESSING THE CANAL It is normally recommended that the
ear canal is treated with a minimum of 2.5
Cleaners should not only be selected ml of the EDTA-tris solution 10 minutes
on the type of discharge but also on the prior to application of antibacterial
appearance of the ear canal. Cleaners of solution (such as gentamicin, cephalexin,
low pH and those that contain alcohol can or a gyrase inhibitor), twice daily for
induce further inflammation in sensitive 710 days. In many countries, EDTA-
ears (often seen in allergic animals) or tris is available commercially in an otic
ulcerated ears, often animals with gram- preparation as either an aqueous solution
negative infection. Similarly, ceruminolytic or as a flush combined with chlorhexidine
agents tend to be more irritating than (EDTA-tris/0.15% chlorhexidine). This
ceruminosolvent-based cleaners. Where latter combination has been shown to
an irritant cleaner is used and causes dis have good activity against a range of both
comfort to the dog or cat it may not allow gram-positive and gram-negative otic
cleaning or application of ear dropsto the pathogens, the most susceptible of which
ear on a subsequent occasion. were shown to be S. pseudintermedius,
Some ear cleaners have been shown Malassezia pachydermatis, Streptococcus canis,
to have antibacterial and/or antiyeast and Corynebacterium auricanis21. The same
activity in their own right. Although it combined solution was also shown to have
is difficult to be sure which components good activity against Pseudomonas spp.18.
of an ear cleaner provide it with such
activity, certain components of cleaners Other agents with antibacterial or
such as chlorhexidine, povidoneiodine antiyeast activity
and acetic acid have been shown to have An ear cleaner containing 0.1% lactic acid
antipathogenic effects (see section on and 2.5% salicylic acid has been shown by
Flushes). Other products thought to have several studies23, 24 to have good activity
similar activity are ethylenediamine against S. pseudintermedius, P. aeruginosa,

Ear Cleaning 79
and M. pachydermatis. Of 31 ears from 16 is often too large to enter the middle ear4.
dogs, 67% of animals infection resolved Furthermore, the lack of infusion fluid can
within 2 weeks of twice daily application24. make effective cleaning difficult. The length
Cleaners containing microbial adhesion- of time involved in cleaning the equipment
blocking carbohydrates have been shown is also a disadvantage4.
to have good antibacterial and antiyeast
activity25. One study20 has suggested that Irrigation
isopropyl alcohol and PCMX provide Irrigation is necessary to remove ceru
cleaners with antibacterial properties; these minolytics or chemical depilatory com
data were not supported by a larger study18 pounds and it is very effective in cleaning
which showed ear cleaners containing the external ear canal16. Pressure irrigation
these components had inconsistent activity is potentially hazardous as a damaged
against bacteria. The same study18 showed tympanum may be ruptured by powerful
that low pH does not necessarily confer jets of fluid4,16. Curved heads on the end of
good antibacterial properties. the jets may help to prevent direct pressure
on the tympanum4. The main disadvantage
CLEANING PROCESS of many models of irrigating pump is the
lack of suction, the mess they create, and
There are three methods, not mutually the time taken to dry the dog and clean up
exclusive, to accomplish removal of the equipment6. Some models (such as the
cerum en from the external ear canal 16: OtoPet Earigator), however, allow both
mechanical removal, suction, and lavage. irrigation and suction, in an independently
adjustable manner.
Mechanical removal Griffin4 described using a soft rubber
This is the safest method for removing feeding tube attached to a syringe, which
cerumen since it does not involve any may be used alternatively to flush and
risk to the tympanum or middle ear. aspirate fluid under direct observation
Good visualization is imperative and if through the otoscope. This method is also
possible, both eyes should be used as this ideal for flushing the middle ear cavity.
increases depth perception16. A wire loop,
or blunt curette, is gently pulled along the Chemical depilatories
lining of the canal, loosening and rolling Chemical depilatory compounds have
cerumen out of the canal as it moves. occasionally been advocated as aids in
After pretreatment with lubricants or cleaning the external ear canal of dogs 12.
ceruminolytics, there should be no tightly Given that in some dogs the external ear
adherent pieces of cerumen, but if any are canal may be so hirsute that cleaning
remaining, perhaps bound to hair shafts, and adequate visualization is difficult,
they should not be subject to undue force as depilatory compounds would appear to be
this may result in erosions to the epidermis. useful. Furthermore, chemical depilatory
products, because of their alkalinity, might
Suction well be of value in helping to break down
Suction is particularly useful when some of the aggregates of hair and cerumen
cerumen is semiliquid or purulent. It is which occur in some ears.
indicated for draining the middle ear4 and Most modern chemical depilatories
is useful when the tympanum has been contain thioglycolic acid or glycolate salts,
ruptured since there is no lavage fluid presented as a cream or foam spray13. The
which might enter the middle ear cavity. depilation is accomplished by chemical
However, there is a risk of the suction tip disruption of disulphide bonds. The
becoming blocked16, and in animals the tip chemical effect requires a concentration of at

80 Ear Cleaning
least 2.5% and most contain thioglycolates or acetic acid 1,4. High concentrations of
in the range of 2.54%13. One drawback of these weak acids may be mildly irritant,
these preparations is that thioglycolates particularly in inflamed ear canals and are
require a very high pH (ideally about 12.5) therefore not suitable in all cases. Similarly
if the chemical depilation is to occur within most drying agents are ototoxic or have
a few minutes13, and as such they might be an unknown ototoxicity so should be
expected to have an irritant potential to dogs used with care if the ear drum cannot be
and cats12. However, one study12 looked visualized26.
at the post application histopathological
features of the external ear canal of dogs, HOME CLEANING
and no significant evidence of inflammation
was reported. Furthermore, experimental Animals with chronic and/or recurrent
studies comparing chemical depilation otitis externa benefit from regular ear
with shaving found no evidence of either cleaning which in most cases owners
increased bacterial colonization or delayed can perform at home, providing patient
wound healing14,15. compliance is good. The most usual can
The depilatory compound is applied didates are dogs with ceruminous otitis
via a syringe in sufficient quantity to coat externa, secondary to defects in kera
the external ear canal and it is allowed tinization or allergy4, and those recovered
to remain for 510 minutes before being from severe bacterial infection especially
flushed out. It has been suggested (Fadok, where it is has been caused by multiply
communication on VetDerm Listserv) that resistant strains of bacteria such as methi
an initial test dose should be applied to cillin-resistant Staphylococcus or Pseudo
the concave surface of the pinna as a few monas spp. Animals with recurrent
individuals may show extreme sensitivity. ceruminous otitis benefit from a cleaner
It is recommended that chemical depilatory with good ceruminolytic/ceruminosolvent
compounds do not enter the middle ear. activity. Many of the ceruminolytic clean
ers incorporate a drying agent making the
Drying agents use of a second flush unnecessary. Ceru
Once the ear canal has been cleaned it minosolvent agents often do not contain
must be dried, as residual moisture may a drying agent which should therefore be
potentiate bacterial infection. Lavage fluid employed after cleaning with a lubricant,
may be removed by suction, or even gentle when used on a long-term basis, to prevent
use of swabs (see above); however, where colonization of the ear with bacteria or
possible a drying agent should be used as a yeast. Where animals have recovered from
final rinse, and an alcohol-based product is bacterial infection, a cleaner with antiseptic
recommended1,2,6. qualities (e.g. containing EDTA-tris, acetic
Most products contain isopropyl alco acid, chlorhexidine, or lactic acid) may be
hol, often combined with a weak acid such useful.
as boric acid, benzoic acid, salicylic acid,

5 MEDICAL
MANAGEMENT OF
EARDISEASE 81
DEALING WITH PRIMARY Ivermectin is particularly useful as it will

TRIGGERS eliminate mites within the ear canal and
any ectopic mites on the body surface. It is
Ectoparasites important that all animals in the household
The most important ectoparasites to affect are treated, whether dogs or cats2.
the ears of dogs and cats are discussed Other ectoparasites to affect the ears
in Chapter 3. In the cat, Otodectes cynotis of dogs and cats include Demodex canis
accounts for up to 80% of all cases of (dog), Demodex felis and D. gatoi (cat),
otitis externa. Otodectic acariasis is a less harvest mites (Neotrombicula autumnalis,
common cause of otitis externa in the Eutrombicula alfredugesi), and ticks (Otobius
dog, perhaps because of the widespread megnini); see Chapter 3 for more details.
use of potent systemic acaricidal spot-on
medications. Ectoparasitic agents used against
Many cats develop a local hypersensitivity otic parasites
to O. cynotis1. These animals exhibit otitis Where the ear canal contains a thick ceru
externa characterized by variable erythema, minous discharge, prior cleaning of the
variable pruritus, and a crumbly black- ear with a ceruminolytic may be beneficial
brown discharge (see Chapter 3 Aetiology to remove discharge and facilitate the
and Pathogenesis of Otitis Externa). Some penetration of the topical ectoparasiticide.
animals may exhibit local self-trauma, Many different commercial otic prepar
whereas others may harbour huge numbers ations are licensed for the therapy of otic
of mites within the external ear canal and ectoparasites; the reader is referred to
show no obvious sign of discomfort. These individual product data sheets for further
are easily recognized and treated. Animals details.
exhibiting intense self-trauma with little
obvious pathology are more difficult to Monosulfiram (tetraethylthiuran
diagnose, as are those with only one or two monosulphide)
mites in the external ear canal: the mites are Indication: Otodectes cynotis.
sufficient in number to cause disease but Sulphur has been used for centuries as
very hard to see. Problems with diagnosis a scabicide and monosulfiram emulsion
may also occur in multicat households, has a long history as a topical acaricide3.
where control may be difficult and low However, it is rarely used in human derma
numbers of mites are endemic. tology as it cross-reacts with alcohol abuse
Combined environmental, otic, and treatments4. Monosulfiram also has a fungi
topical (or systemic) acaricidal treatment cidal effect and a 5 mg/ml solution is active
should be carried out in these cases. against malassezial yeast5.

82 Medical Management of EarDisease
Thiabendazole (2-(thiazol-4-yl) of 0.3mg/kg body weight12. It is given on

benzimidazole) four occasions at 7-day intervals for scabies,
Indications: Malassezia pachydermatis, Asper and once daily until remission is achieved
gillus spp., O. cynotis, ticks, feline otodemo for demodicosis 13. Ivermectin has been
dicosis. advocated for otodectic mange in cats13,14 at
Thiabendazole is an antifungal agent a dose of 0.20.3 mg/kg. Two injections at
with acaricidal properties6. Thiabendazole 1014 day intervals are curative. Although
kills all stages of the mite life cycle7 and is ivermectin may be administered topically,
thus preferred to pyrethrins and rotenone, orally, or by injection, the topical route is
for example, which have no activity against least effective14. Subcutaneous injections
eggs. Thiabendazole is useful against must only be given using the propylene
malassezial yeast and otodectic mites 7,8 glycol-based presentation 15 . For oral
and its lack of toxicity, in standard doses, dosing, particularly long-term treatment,
has made it a popular ingredient in otic it may be more appropriate to use the
polypharmaceutical preparations. A topical water-based presentation marketed for oral
otic preparation containing thiabendazole, administration to the horse, although it may
neomycin, and dexamethasone has also prove difficult to measure the exact dose.
been reported to be curative against O. This will obviate any risk of propylene-
megnini ticks 9 . Thiabendazole is also glycol toxicity which, although rare, may
effective in the treatment of feline otodemo be noted occasionally (bradycardia and
dicosis7. central nervous system and respiratory
depression).
Pyrethrin, pyrethroids, carbamates, Ivermectin should be highly effective
androtenone against other mites affecting cats and
Indications: O. cynotis, N. autumnalis, dogs 13. It has some activity against the
E.alfredurgesi, tick infestation. sucking louse of dogs (L. setosus) and some
These are relatively broad-spectrum activity against ticks; it inhibits feeding and
insecticides and acaricides. Pyrethrins the ticks fall off only partially engorged.
(natural derivatives of Chrysanthemum Certain breeds of dog are susceptible
such as cinerariaefolium), pyrethroids to side-effects when given ivermectin,
(synthetic analogues), and rotenone are and great care is warranted when con
characterized by quick knock-down and sidering its use. Informed, preferably
poor persistence. They are thus commonly signed, consent may be necessary in some
used in over-the-counter antiparasitic circumstances. Ivermectin toxicity is related
preparations for puppies and kittens. to central nervous system effects caused
These agents all have similar spectra by ivermectin-enhanced gamma-amino
of activity and a low toxicity potential, butyric acid (GABA) activity 15. In most
although if cats are treated with products canine breeds acute toxicity is seen when
marketed for dogs, toxic side-effects may be a dose in excess of 2.5 mg/kg isgiven. In
seen10,11. None of these agents kill the eggs cats the maximum dose above whichsigns
of ear mites and thus repeated treatment is of acute toxicity are seen is 0.75mg/kg
necessary. orally. Chronic toxicity begins to be noted
with doses in excess of 1 mg/kg in dogs
Ivermectin and 0.5 mg/kg in cats15. There appears
Indications: Demodex spp., O. cynotis, to be minimal risk of teratogenic effects
Sarcoptes scabiei, Notoedres cati, N. autumnalis, following administration of ivermectin
ticks, Linognathus setosus. to pregnant bitches15. Signs of ivermectin
Ivermectin is effective against demo toxicity include mydriasis, depression,
dectic and sarcoptic mange in dogs, at doses tremors, ataxia, stupor, emesis, coma,

Medical Management of EarDisease 83
and death1517. However, certain breeds of the hypothermia may be severe. The
dogs exhibit an idiosyncratic sensitivity to drug is contraindicated in Chihuahuas,
ivermectin, developing side-effects at doses for example. Precautions must be taken
as low as 0.1 mg/kg. Collies, Old English to prevent operator exposure 19 and the
Sheepdogs, and Shetland Sheepdogs are dipping should be performed in a well-
particularly susceptible15. ventilated room. The person carrying
Ivermectin dosages over 0.05 mg/kg will out the dipping should wear gloves and
kill Dirofilaria immitis larvae. Therefore, in waterproof protective clothing. Recom
heartworm-endemic areas dogs should mended treatment of canine otodemodi
be tested for heartworm before receiving cosis is 1 ml of 19.9% amitraz solution in 30
ivermectin in acaricidal dosages15. ml mineral oil, or 2 ml 5% solution in 20 ml
Many dogs with ivermectin toxicity will mineral oil7,21,22.
recover, particularly if recognized early Amitraz is also licensed (in the UK)
and treated adequately. The provision against scabies, at a dilution of 0.025%
of adequate nursing care is critical 16 and (25ml 5% solution in 5 litres of water).
treatment is based on antishock doses of Amitraz preparations are useful as
glucocorticoids and intravenous fluids16,17. a tick repellent23 and in some countries
Specific agents that may antagonize iver the chemical is marketed as an amitraz-
mectin include picrotoxin and physo impregnated collar for this purpose.
stigmine. Clinicians are unlikely to be able Accidental ingestion of amitraz-impreg
to obtain these agents easily or quickly. nated collars may prove fatal to dogs
The inability to predict with any con and prompt treatment is necessary.
fidence if an individual dog will exhibit Atipamezole (50 mg/kg i/m) should be
ivermectin toxicity is one of the main followed by oral yohimbine (0.1 mg/kg)
problems facing clinicians16. A modified every 6 hours as needed20.
dosing schedule has been proposed which
provides for a gradually increasing dose, Fipronil
allowing the opportunity to observe the Indications: Spilopsyllus cuniculi, O. cynotis,
dogs closely for toxic signs 12. Prompt S. scabies, N. autumnalis, ticks, lice.
intervention (and at the subcritical dose Fipronil is primarily marketed as a
stage) increases the chances of recovery flea control product and as such it will
from ivermectin toxicity. The modified be effective against S. cuniculi. Although
dosing scheme is as follows12: presented in both spray and spot-on
Day 1 0.05 mg/kg formulations, the spray formulation is
Day 2 0.1 mg/kg preferred for the treatment of otic parasites
Day 3 0.15 mg/kg since effective local concentrations on both
Day 4 0.2 mg/kg hair and skin surfaces may be achieved
Day 5 0.3 mg/kg rapidly. Fipronil has also been used off
license as a topical otic application. Fipronil
Amitraz is also effective against lice24.
Indications: Demodex spp., S. scabiei, ticks. Fipronil has been demonstrated under
Amitraz is a monoamine oxidase field conditions to prevent infestation with
inhibitor presented in an organic vehicle. trombiculid mites and ticks25,26. The spray
Although serious side-effects are rare, formulation of fipronil is preferred for this
owners may report transient lethargy and indication. Fipronil spray has also proven
hypothermia post dipping18,19. Bradycardia, effective against scabies27 and it may be
hypertension, and hyperglycaemia may particularly useful when clinicians are faced
be seen in some animals18,20. Problems are with scabies in very young puppies, where
most serious in very small dogs where other topical treatments are inadvisable.

Selamectin Apply topical otic glucocorticoids

Indications: S. scabiei, O.cynotis, possibly to suppress inflammation, reduce
S.cuniculi, lice. epithelial hyperproliferation, and
Selamectin is a novel avermectin with minimize fibrosis. The potency of the
considerable advantages over ivermectin: glucocorticoids should depend on the
It is safe in ivermectin-sensitive degree of erythema and hyperplasia
Collies28. in the canal. Where mild to moderate
It is effective against fleas, change is present prednisolone may
roundworms, hookworms, and be suitable; where there is more
heartworm29,30 in addition to O. cynotis severe inflammation more potent
and S. scabiei. topical drugs such as betamethasone,
It is applied topically. dexamethasone, hydrocortisone
aceponate, or mometasone may be
Selamectin must not be given to animals more suitable.
of less than 6 weeks of age and it must be Maintain remission with regular
applied topically to the back of the neck, application of otic cleansers,
even for the treatment of O. cynotis. antimicrobial ointments, and
occasional otic glucocorticoid
Allergic otitis preparations.
Canine otitis externa associated with Caution owners of breeds in which
hypersensitivity atopy is well recognized about allergic
In the dog more than 75% of cases of otitis and the importance of prompt
otitis externa are caused by allergy 31,32. attention if recurrence occurs.
The most common hypersensitivity to
affect the canine ear is atopy, although Application of topical glucocorticoids
food intolerance and contact allergy/ to these ear canals (and to the concave
irritancy may also cause otitis externa. aspect of the pinnae) can produce a spec
In the acute stages of allergy the canal tacular reduction in the degree of inflam
responds to inflammation with erythema, mation and otic stenosis which is present,
oedema, and hyperplasia, often with often obviating the requirement for
minimal microbial multiplication. When surgery. However, regular use of potent
microbial proliferation occurs it is usually glucocorticoids, even in otic prepara
staphylococcal and malassezial in nature, tions, can induce iatrogenic hyper-adreno
rather than gram negative. corticism 1. Therefore, although a potent
On the first presentation of otitis externa fluorinated steroid may initially be indi
investigation of a primary trigger is unjusti cated, the clinician should switch to a
fied, but where disease is recurrent it is minimally potent agent such as pred
essential to prevent progression to chronic nisolone, prednisone, or hydrocortisone for
change. On the first occasion, damage to maintenance.
the tympanic membrane and concurrent Where animals present with recurrent
otitis media is unlikely but the tympanum allergic otitis then investigation is essen
should still be assessed. Basic steps on the tial. All cases should be food trialled
first presentation should include: using a home cooked exclusion diet or a
Identification of secondary infection proprietary hydrolyzed diet. In vitro or
by cytology and topical therapy of in vivo allergy testing (for environmental
secondary malassezial and bacterial allergens NOT foods allergens) may also
multiplication. be useful especially where inflammation
and pruritus is present on other areas

of the body, especially the muzzle and on a resolution of the clinical signs while an
periocular areas. This gives the clinician the exclusion diet is fed. A period of 316 weeks
opportunity to use allergen specific therapy may elapse before complete recovery is noted.
immunotherapy as part of the therapeutic Allergic contact dermatitis is extraordinarily
regime to control both skin disease and the rare in cats. However, allergic contact derma
otitis externa. titis to topical neomycin is recognized by
Allergic contact dermatitis to otic medica some clinicians. Certainly, the diagnosis
tions has been reported, most commonly to should be considered in all cases of refractory
neomycin and propylene glycol. Whether otitis externa.
the reaction to propylene glycol is a true
allergic reaction and not simply an irritant Otitis externa associated with a
dermatitis is not clear. An allergic contact defect in keratinization
reaction should be suspected when the Ceruminous otitis externa is not always
application of topical medication causes an complicated by infection, but chronic
increase in discomfort or pain. Treatment cases usually are. In particular there is a
should consist of removal of all topical tendency for gram-negative bacteria to
medication and the institution of a 57-day proliferate early in the course of the disease
course of prednisolone at a dose of 1 mg/ and this must be identified and treated.
kg by mouth once daily. Subsequent topical Furthermore, there may be concurrent
therapy may be reintroduced with care, but otitis media and this must be ruled in or
a detailed knowledge of the composition of ruled outbefore long-term measures are
each product should be sought before use. instituted:
Keep the external ear canal and
Feline otitis associated with the surrounding area as clean as
hypersensitivity possible. Pluck hair regularly out of
Although atopy is a very common cause of the external ear canal, and keep the
otitis externa in dogs, it appears to be much concave aspect of the proximal pinna
less so in cats, perhaps due to differences in and surrounding area clipped short.
anatomy, such as a relatively wide canal, Local shampooing may be helpful in
lack of hair within the canal, and an upright keeping greasy scale to a minimum;
pinna8. There may also be differences in the use a degreasing, keratolytic, or
cerumen which make microbial overgrowth keratoplastic product such as benzyl
less likely, even in the face of chronic inflam peroxide or one of the tar/sulphur/
mation. Intradermal skin testing is more salicylic acid combination products.
difficult to perform in the cat compared Regular use of an acetic acid-based
to dogs, and many clinicians will make a aqueous cleanser (2.5% or 5%
provisional diagnosis of atopy on the basis concentration) will help to keep the
of ruling out all other potential diagnoses. otic pH acid and suppress gram-
Dietary intolerance (food allergy) is also negative overgrowth. Commercial
rare in the cat. However, pinnal erythema products may be used, as may equal
and otitis externa may be associated with quantities of white vinegar and water,
intolerance to dietary components33. Perhaps or alcohol2,3.
more commonly, there is facial and head Regular use of ear cleansers which
pruritus with the pinnae and periaural areas loosen cerumen and inhibit microbial
being affected, rather than the external ear growth may help to prevent accumu-
canals3335. The most common allergens in lation of such debris and prevent
proven cases of feline dietary intolerance relapse into overt otitis externa.
are beef, milk, and fish36. Diagnosis is based

Occasional, sometimes more DEALING WITH SECONDARY

frequent, use of cleansers such as CAUSES
carbamide peroxide, dioctyl sodium
sulfosuccinate, or squalene will Topical versus systemic therapy
help to flush out accumulations of
ceruminous debris, although a drying KEY POINTS
agent, such as one based on isopropyl
alcohol, should be used after these QQ Topical therapy is the key to
products37. successful resolution of otitis
Otic polypharmaceutical preparations externa which is essentially a surface
with combinations of glucocorticoids infection.
and antimicrobial agents, based on QQ Although controversial it is unlikely,
bacterial culture and sensitivity, may except possibly in situations where
be indicated if the measures outlined the canal is eroded or ulcerated, that
above fail to prevent otitis externa systemic drugs will reach therapeutic
developing. concentrations within the discharge
within the canal.
Proliferative otitis QQ It is essential to use adequate volumes
This is a rare condition, with an almost of both cleaning solution and topical
pathognomonic presentation, that can medication to ensure it penetrates the
affect both kittens and adult cats 38. The discharge.
condition typically presents as a bilateral, QQ In the initial stages of therapy,
occasionally malodorous, chronic otitis topical medication can be selected
externa. Large, dark red, brownish, almost empirically based on cytological
vegetative, proliferative plaques with examination of the discharge,
necrotic surfaces can be seen, at the base examination of the canal, and the
of the pinnae and the upper portions of the presence or absence of the tympanic
vertical ear canal (Figure 5.1). The tissue membrane.
and exudates may occlude the ear canal.
Removal of the rather loosely adherent
overlying proliferative tissue results in
ulceration and erosions to the underlying
tissue. Histopathological examination
reveals prominent hyperkeratosis and
apoptopic keratinocytes, presumably
reflecting an immune-mediated process39.
Topical tacrolimus ointment twice daily
is very effective: some cases appear to go
into full time remission, others require
maintenance therapy.
Fig. 5.1 Almost pathognomic signs of feline

proliferative otitis: vegetative plaques with
surface necrosis. (Courtesy of Dr. Brenda
Stevens, College of Veterinary Medicine, North
Carolina State University, Raleigh.)

Malassezial yeast and otitis remove thick ceruminous discharge before

externa application of otic drops (see Chapter 4 Ear
Cleaning). Many different antifungal drugs
KEY POINTS are available in a wide range of commercial
otic preparations to treat malassezial otitis;
QQ Most commonly yeast otitis externa in most are combined with an antibiotic and
the dog is caused by M. pachydermatis a glucocorticoid. Where there is yeast
and in the cat by M. pachydermatis and infection coupled with chronic change,
M. sympodialis40. especially where there is narrowing of
QQ Malassezial yeast is a common the canal with glandular hyperplasia,
secondary infection in cases of then it is advantageous if the antifungal
acute allergy and in keratinization drug is combined with a potent topical
disorders. glucocorticoid such as betamethasone,
QQ Cytology is the best method to dexamethasone, mometasone, or hydro-
identify yeast and is more specific cortisone aceponate. Once chronic change
than culture. has been reversed, therapy should be
QQ Antifungal therapy is usually curative switched to a less potent glucocorticoid
but where recurrence occurs, an such as prednisolone.
underlying primary cause should be
sought. Polyenes
Nystatin is a polyene antifungal that
works by binding to sterols in the fungal
Clinical signs cell membrane, changing permeability
Malassezial otitis is usually bilateral and and leading to fungal death by osmotic
pruritic rather than painful. Damage to destruction. Nystatin has activity against
the tympanic membrane in acute disease both Candida spp. and M. pachydermatis.
is uncommon. Underlying primary In European countries it is available as a
causes include allergy, particularly commercial drop combined with fusidic
atopy, and both primary and secondary acid, framycetin, and prednisolone.
keratinization disorders. In the dog, the
most common secondary disorder of Azoles
keratinization is endocrine disease in The azole antifungal drugs all disrupt
the form of hypothyroidism and hyper- the biosynthesis of the fungal cell wall
adrenocorticism. In the cat, malassezial ergosterol by inhibition of P450 enzyme.
infection can be seen secondary to systemic Topical azole is available as imidazoles
disease, such as pancreatic or hepatic (clotrimazole, miconazole, ketoconazole)
disease, and is commonly associated with and as triazoles (itraconazole, posa-
hyperthyroidism. Ears with ceruminous conazole). All of the azole drugs have
otitis, especially where there is epidermal excellent in vitro activity against Malassezia
hyperplasia with partial occlusion of the spp. A number of studies have rated
canal, are predisposed to developing yeast the potency of the azoles differently. A
infection. study 41 suggested itraconazole was the
most potent of the drugs followed by
Treatment ketoconazole, miconazole, and clotrima
Before application of a topical antifungal zole. A more recent in vitro study42 showed
drug it is important that the ear is cleaned that ketoconazole, itraconazole, and ter
adequately. Ceruminolytic/cerumino- binafine were equally potent. Only com
solvent cleaners are best employed to mercial studies have compared the second

generation triazole posaconazole with discharge. Allergy is the most common

the imidazole clotrimazole, suggesting underlying primary cause of infection and
posaconazole is at least 10 times more the affected ear canal is usually sensitive,
potent. Oral ketoconazole or itraconazole erythematous, and hyperplastic; changes
has been described as useful systemic often involve the medial aspect of the pinna
therapy for malassezial otitis in dogs, in addition to the canal. In chronic disease,
whereas itraconazole is preferred in cats43. ongoing or recurrent infection can lead to
otitis media. Chronic topical and systemic
Allylamines antibiotic usage can predispose to the
Allylamines disrupt ergosterol biosynthesis development of multiply resistant isolates
and therefore prevent cell wall formation of both methicillin-resistant Staphylococcus
by inhibition of the enzyme squalene pseudintermedius, MRSA, and Enterococcus
epoxidase. Terbinafine is the most widely faecalis.
available antifungal in this class; it has good
activity against malassezial species. There Treatment
are no veterinary topical preparations Therapy should be prescribed where
available, although a 1% terbinafine cream possible with topical drugs with a narrow
has been used as an otic preparation in dogs spectrum of activity. Drugs such as
off license. fluoroquinolones, carboxypenicillins, and
third generation cephalosporins should
Gram-positive otitis externa be reserved where possible for gram-
negative infections involving Pseudomonas
KEY POINTS spp., and should be prescribed on the
basis of culture and sensitivity. Drugs
QQ Gram-positive otitis externa in the such as aminoglycosides are inactive in
dog is most commonly caused by purulent material and, therefore, thorough
coagulase positive Staphylococcus cleaning of the ear should be performed
pseudintermedius. using an antiseptic flush (see Chapter4
QQ Staphylococcal infection is a common Ear Cleaning) before appli c ation of
secondary infection in cases of allergy antibacterial otic drops. Where infection
in dogs and cats; it can occur in mixed occurs in chronically damaged ears, for
growth with Streptococcus spp. and example where there is narrowing of the
M.pachydermatis. canal, topical antibiotics are best combined
QQ Both Staphylococcus and Streptococcus with a potent topical glucocorticoid
spp. appear as cocci on cytology. (see chronicchange in antifungal
QQ Bacterial culture and sensitivity therapyabove). In allergic otitiswhere
testing should be undertaken when maintenance therapy with topical
infection has failed to respond to glucocorticoids is useful, otic drops may be
rational therapy, in which case continued to be used. However, although
methicillin-resistant Staphylococcus long-term use of topical steroids may be
aureus (MRSA) or methicillin-resistant beneficial, chronic topical antibiotic usage
S. pseudintermedius may be present. should be avoided. This is often impossible
when prescription otic preparations contain
an antibiotic and a glucocorticoid. In such
Clinical signs cases off-licensedusage of an antiseptic
Gram-positive otitis externa usually pro cleaner is used by the author combined
duces mildly pruritic, unilateral or bilateral with a glucocorticoid such as injectable
otitis with a yellow brown purulent dexamethasone.

Fusidic acid glucocorticoids when the antibiotic in

Fusidic acid is a narrow spectrum bacterio products is the same. Despite anecdotal
static antimicrobial. Its spectrum is limited concern over the ototoxic potential of
to gram-positive cocci and therefore con gentamicin, a study in dogs designed to
stitutes a good first-line empirical choice stimulate clinical exposure via a ruptured
for staphylococcal infection. tympanic membrane failed to document
any toxicity46. Where reactions to topical
Aminoglycosides gentamicin preparations have been
Aminoglycosides are common components recorded, it may therefore have been the
of topical otic preparations. This group con vehicle that produced side-effects rather
tains among others, amikacin, framycetin, than the antibiotic. Gentamicin can be used
gentamicin, neomycin, and tobramycin. mixed with ethylenediamine tetra-acetic
Amikacin and tobramycin should, in acid tromethamine (EDTA-tris) as an off-
the authors opinion, be reserved for use license formulation when the tympanum is
against gram-negative bacteria and will be damaged47:
discussed in that section. 4 2 ml vials of 40 mg/ml can be
added to 118 ml of EDTA-tris and used
Framycetin effectively to treat both gram-positive
Framycetin is a broad spectrum bactericidal and gram-negative infections.
aminoglycoside with good activity against
Staphylococcus spp. as well as many different Gram-negative otitis externa
gram-negative organisms including Pseudo
monas spp. It is a good first-line choice for KEY POINTS
topical therapy when cocciare identified on
cytology. It is available in Europe as part of QQ Gram-negative otitis externa is
a commercial veterinary otic medication. usually acute in onset, suppurative,
and painful48.
Neomycin QQ Bathing, grooming, and foreign
Neomycin has the lowest potency of all the bodies are the most common
aminoglycosides. It has limited activity conditions associated with acute
against gram-negative bacteria, such as gram-negative otitis externa.
Pseudomonas spp., but good activity against QQ Bacterial culture and sensitivity
gram-positive cocci. Neomycin is a good testing is mandatory as multiple-
first-line drug for acute bacterial otitis resistant strains may be recovered.
when cocci predominate cytologically 44. QQ 2% or 2.5% acetic acid may be used
Neomycin is one of the most commonly for treatment on an empirical basis
implicated topical agents for contact pending laboratory results.
hypersensitivity/irritancy in the dog.
Gentamicin Clinical signs

Gentamicin has excellent activity against Most cases of gram-negative otitis externa
gram-positive cocci and some activity are acute in onset, unilateral, painful rather
against gram-negative bacteria45. A wide than pruritic, suppurative, and ulcerated49.
range of veterinary commercial products are The most common causes in one survey
available containing gentamicin combined of 550 dogs with otitis externa were otic
with a range of different antifungal drugs foreign body, grooming, and bathing,
and glucocorticoids. Selection of product rather than underlying disease 39. This
is often determined by the strength of the finding was supported in another large

study (of 752 dogs with otitis externa) in an endotracheal tube placed with the cuff
which underlying disease was not a feature inflated.
of gram-negative otitis in dogs50.
Otic inflammation, an increase in Cleaning the ear
humidity, and a rise in pH within the Where there is a ceruminous discharge then
external ear canal appear to be necessary a ceruminolytic, such as carbamide peroxide
for Pseudomonas spp. to establish48; inflam or dioctyl sodium sulphosuccinate, or
mation per se is not sufficient in the normal a ceruminosolvent, such as squalene,
external ear canal. However, predisposing can be used to clean the ears. Where the
factors, such as hirsute ear canals, narrow tympanum cannot be seen or is damaged,
ear canals, and pendulous pinnae, may squalene is the safest option. More often the
make the external ear canal more sus discharge is mucopurulent and water is the
ceptible to gram-negative infection. Hence, best initial flush. Large volumes of sterile
Cocker Spaniels are predisposed51. Gram- water or isotonic saline may be used to
negative infections of the external ear canal break up the thick tenacious mucous.
appear to be more common in tropical
climates, possibly because of increased Killing the Pseudomonas (1): disinfectant
temperature and increased humidity in flushes
the environment affecting, or potentiating, Although antibiotics can be used to kill
alteration in the otic microclimate. Pseudomonas spp. and are important in
ongoing therapy, topical antiseptics are
Treatment beneficial after an initial water flush. The
Note that, to date, there have been no authors favour a double flush in the form of
blinded studies into the optimum treatment a 5 minute acid soak followed by a second
protocol for pseudomonal otitis50, meaning 5minute potentiating disinfectant flush:
that the clinicians have only limited data on The first flush is with an acid-based
which to make a therapeutic decision; every solution such as acetic, boric, citric, or
case must be taken on merit and based on lactic acid. Vinegar diluted 50:50 with
culture and sensitivity. sterile water provides an acetic acid
The aims of therapy in pseudomonal solution of 2.5% which is an excellent
otitis should be to: flush with good activity against
Clean the ear thoroughly to pseudomonal bacteria. Acetic acid is
remove exudate which is usually the authors preferred flush especially
mucopurulent. when the ear drum is ruptured. A
Kill, or remove, the pseudomonal 2% acetic acid flush is available as a
bacteria. commercial otic cleaning solution in
Decrease inflammation and further many countries.
production of exudates. After an acid flush a second topical
Reverse chronic changes in the ear and disinfectant can be used. This may
create an environment which is hostile be an alcohol, aluminium hydroxide,
to pseudomonal bacteria to prevent chlorhexidine (0.2% or less) or EDTA-
recolonization (see section on therapy tris. In vitro studies with Pseudomonas
of chronic change later in this chapter). spp. isolated from cases of canine
otitis have also demonstrated the
Note: due to the severe ulcerative painful bactericidal potential of EDTA-tris51.
changes that typically occur within the
ear canal in these infections, the initial The authors favour a combination of
flushing of the ear is best undertaken in an chlorhexidine 0.15% with EDTA-tris as a
anaesthetized animal which should have second flush. The two components of this

solution, which is available as a commercial penem, are rarely if ever indicated and
flush, have been shown to have synergistic should only be used when all other options
antibacterial effects52. In addition, EDTA- have been exhausted.
tris has been shown to have the ability to
potentiate a range of antibiotics. Silver sulfadiazine
EDTA binds divalent cations, enhances Silver sulfadiazine has broad spectrum
membrane permeability, and alters ribo antibacterial activity especially against
some stability 53 . P. aeruginosa and S. P. aeruginosa but also has activity against
intermedius, which are resistant to enro Staphylococcus spp. 1% silver sulfadiazine
floxacin and cephalexin (respectively), may cream applied daily for 10 days is effective
be rendered sensitive by pretreatment of but, being rather viscous in nature, it is
the external ear canal with EDTA-tris54. hard to apply to the depths of the external
ear canal55. However, dilutions of the cream
Decreasing the inflammation with water, to a concentration as low as
Inflammation within the canal can be 1/100, will exceed the minimum inhibitory
reduced using both topical and sys concentration (MIC) for P. aeruginosa
temic glucocorticoids. Potent topical and are fluid enough to penetrate the
glucoc orticoids that are useful are otic depths of the ear canal56. A 0.1% solution
prepa rations containing mometasone, may be prepared by mixing 1.5 ml silver
dexa m ethasone, or betamethasone. sulfadiazine cream into 13.5 ml water or
Where the ear drum is damaged the saline57. This may be instilled into the ear
safest topical steroid is off-license usage canal twice daily. The ototoxicity of silver
of dexamethasone sodium phosphate (2 sulfadiazine is reported to be low44,58. It has
mg/ml) which can be diluted 50:50 with though been reported to produce signs of
water or sterile saline and instilled into the systemic toxicity when absorbed through
ear. Once the flushing procedure has been burn wounds in man59 so caution should be
completed 0.250.5 ml of glucocorticoid used when applied to the ears of dogs with
solution can be instilled into the ear. An extensive ulceration.
intravenous anti-inflammatory injection
of an appropriate dexamethasone solution Fluoroquinolone antibacterial agents
can be given before waking the animal up. Fluoroquinolones are bactericidal anti
biotics with good activity against a wide
Killing the Pseudomonas (2): antibiotics range of bacteria, especially gram-nega
Initial therapy of the pseudomonal infec tive bacilli and gram-positive cocci
tion can be undertaken with a range of (including Staphylococcus spp. but with
drugs. Silver sulfadiazine, continued use variable activity against Streptococcus
of acetic acid or topical polymyxin, amino spp.) 44 . Enrofloxacin, marbofloxacin,
glycosides (framycetin, gentamicin), or and ciprofloxacin are highly effective
fluoroquinolones (enrofloxacin, marbo against P. aeruginosa and Proteus spp.60,61.
floxacin, ciprofloxacin, orbifloxacin) are A topical enrofloxacin-based otic drop is
all suitable as empirical first-line therapy available in the USA, and a specific otic
after cytology has identified the presence preparation containing marbofloxacin,
of rods on cytology, pending culture and clotrimazole, and dexamethasone is
sensitivity. Other drugs, such as amikacin availa ble in some countries. There is
and tobramycin, may be used second line evidence (manufacturers internal data)
if these drugs are found to be unsuitable. that adjunctive treatment with systemic
Third-line drugs, such as carboxypenicillins administration may enhance the time to
(carbenicillin, ticarcillin), third generation cure interval. In those countries where
cephalosporins (ceftazidime), and imi a specific fluoroquinolone-based otic

preparation is not available or where stability of these products is unknown. Both

the tympanum is ruptured and such amikacin and tobramycin are potentially
products are not deemed safe, off-license ototoxic and should be used with care if the
usage of injectable fluoroquinolones has ear drum is damaged.
been employed as topical therapy. These
can be used mixed with sterile water or Other antibacterial agents
combined with an ear cleaning solution, Imipenem and carbenicillin are both active
especially EDTA-tris which has been against P. aeruginosa, although imipenem
shown to potentiate fluoroquinolone has met with resistance problems because
activity. Care should be taken to ensure of its widespread use in the human field65.
that the external ear canal is cleaned Topically applied ticarcillin, in conjunction
and thoroughly dried before instilling with prednisolone (12 mg/kg p/o
topical fluoroquinolones since they are q12 h) and an acetic acid-based topical
inactivated in an acidic environment54,62. otic cleanser, has been reported to be
Many different dilutions of antibiotic effective66. If the tympanum is ruptured, the
have been suggested by different ticarcillin is administered three times daily
authors. A dilution of the injectable intravenously until healing is observed65.
enrofloxacin solution (20 mg/ml) at the The topical solution is made by mixing a
rate of 1:6 in water or isotonic saline has 6 g vial of ticarcillin powder with 12 ml of
been recommended as being efficacious sterile water66. This may be divided into
when instilled directly into the external 2ml aliquots and frozen, where it will
ear canal 54 . Other dilutions include a remain stable for up to 3 months. The vials
1:3 dilution of 2% enrofloxacin or 1% are thawed and mixed with 40 ml saline,
marbofloxacin injectable solution mixed each again being divided into aliquots, this
with EDTA-tris 63 . Enrofloxacin made time of about 10 ml. These are given to the
up to a concentration of 0.9% can be client to freeze at home. When required
mixed with: 1) sterile water; 2) an EDTA- they are thawed for use, the surplus being
tris cleaner with and without 0.15% kept in the refrigerator for up to 7 days.
chlorhexidine; and 3) with a salicylic acid
(0.1%) and parachlorometaxlenol (0.1%) Use of ear wicks in the therapy of otitis
based cleaner with either lactic acid externa
(2.5%) or EDTA (0.5%), and maintains Ear wicks are made of polyvinyl alcohol
good chemical stability and antibacterial (PVA) which forms a hard, compact struc
activity for up to 28 days64. ture. Dry wicks can be cut and shaped
before being inserted into the external ear
Amikacin and tobramycin canal (Figure 5.2). Once positioned in the
Amikacin and tobramycin are both ear (Figure 5.3), the wick can be soaked in
aminoglycoside antibiotics with a good any aqueous solution allowing the sponge
activity against P. aeruginosa. Amikacin to expand in a controlled manner to fill the
is not available as a commercial otic contours of the ear canal (Figure 5.4). In the
preparation but the injectable solution can authors experience they are well tolerated
be used as an off-licensed product diluted providing they are cut, if necessary, to an
to a concentration of 3050 mg/ml in appropriate size and positioned correctly.
sterile saline or EDTA-tris47. Tobramycin In small dogs and cats, overly long wicks
as an injectable solution may be mixed can be felt when the animals articulate their
with sterile saline or EDTA-tris to a con temperomandibular joint, which can lead
centration of 8 mg/ml47. The long-term to some discomfort on opening their jaws.

Fig. 5.2 Earwick cut to size and ready to

insert into the external ear canal.
Fig. 5.3 Earwick placed into the external Fig. 5.4 Earwick filling the ear canal after
earcanal. absorbing the medicants.
Wicks can be used successfully in all critical when wicks are used. If the canal is
but the giant dogs. In normal ears of such not adequately flushed then the wick will
breeds the canals are too wide so that even act as a cork to bottle up infection which
when the wick is expanded they do not fill can then predispose to the development of
the whole canal. They can though be used otitis media. The principal uses of ear wicks
to treat stenotic ear canal in these breeds. in veterinary medicine are for:
The sponge has a porous interconnected Treatment of bacterial/yeast otitis
structure which gives it great tensile externa.
strength, so that it will not disintegrate or Reduction of hyperplasia/stenosis of
tear while in situ or when it is grasped to be the external ear canal (see section later
removed. The fine pores facilitate minimal on chronic change).
tissue adhesion providing it remains Postoperative packing after
soaked. Effective cleaning of the canal is nonablative surgery.

Ear wicks can be used to treat otitis externa 4 Selection of soak solution and
in cases where the dog will not tolerate or placement of the wick; an unsoaked
the owner is unable to apply otic drops. The wick should be placed deep in the
wicks can be used in combination with any vertical canal, extending into the
aqueous solution especially water-based horizontal canal where possible.
solutions of antibiotic. Successfultherapy Once positioned, the wick should be
involves several steps and is best accom soaked. A wick will normally absorb
plished on an anaesthetized animal: approximately 2 ml of aqueous
1 Assessment of the ear canal and solution, which should be gently
tympanic membrane. syringed into the ear canal. After
2 Assessment of the otic discharge with soaking, the wick should be left in
cytology +/ culture. situ for a few minutes before being
3 Thorough cleaning of the canal. rechecked. At this stage a further 0.5 ml
4 Selection of soak solution and of fluid can be applied if necessary. The
placement of wick. wick is adequately soaked when a small
5 Postflushing glucocorticoid amount of fluid is seen to be pooled on
administration. the top of it. Where bacteria have been
identified, by cytology, the wick may
1 Assessment of the ear canal and be soaked in an aqueous solution of
tympanic membrane is important to antibiotic such as injectable solutions
establish if the disease is confined to of fluoroquinolones (enrofloxacin,
the external ear canal. Where the ear marbofloxacin), trimethoprim
drum is damaged and otitis media is sulfadiazine, or aminoglycosides
present therapy may be tailored to suit (gentamicin). Where indicated by
this (see Chapter 6 Otitis Media). sensitivity, and where other drugs
2 Assessment of the otic discharge have been shown to be ineffective,
with cytology +/ culture is essential other aminoglycosides (amikacin,
to decide on the most appropriate tobramycin) and carboxypenicillins
drug to apply to the wick. Where cocci (ticarcillin) may be appropriate.
or yeast are present culture is not Where yeast is identified on cytology,
generally necessary unless the bacterial enilconazole diluted 1:5 with sterile
infection has already failed to respond water may be used to infuse the wicks.
to conventional therapy or MRSA is 5 Postflushing glucocorticoid
suspected. When rods are identified administration; flushing can cause
culture should be performed. irritation of the lining of the external
3 Thorough cleaning of the canal is ear canal which can lead to head
an important step in therapy. Careful shaking during the postoperative
selection of an appropriate cleaning period. If the dog shakes its head then
solution is essential (see Chapter 4 it is possible the wick may be lost.
Ear Cleaning). The ear canal should Therefore, unless contraindicated, an
be cleaned and ideally should then be intravenous bolus of dexamethasone
soaked in a disinfectant solution, e.g. at an anti-inflammatory dose should
acetic acid, chlorhexidine/EDTA-tris, be administered before recovering the
or lactic acid prior to placement of the animal.
wick.

The animal should be discharged and the CHRONIC OR RECURRENT

owner supplied with a small quantity (23 OTITIS EXTERNA IN DOGS
ml) of soak solution to add to the ear after
35 days, to ensure that the wick stays
hydrated. If this is not possible the patient KEY POINTS
should revisit the surgery for a nurse to
administer the additional soak solution. Most cases of chronic otitis externa are
The dog may also be sent home with a 710- bilateral.
day course of prednisolone at a dose of Defects in keratinization,
0.51 mg/kg to provide anti-inflammatory hypersensitivities, and otitis media
benefits. are the most common causes of
Reassessment should be undertaken at chronic, or recurrent, otitis externa.
710 days. The dog will need to be anaes Less common causes include allergic
thetized again at this stage. The wick can contact dermatitis and multiresistant
be easily removed if it is well soaked. micro-organisms.
Approximately 23 ml of sterile water Chronic otitis externa is usually either
should be syringed into the ear to ensure ceruminous or erythematous and
adequate hydration of the wick before hyperplastic.
attempting removal. It may then be grasped Surgery will be necessary unless
with a pair of forceps and gently removed. chronic pathological change can be
Cytology can now be repeated, the ear prevented or reversed.
reflushed and, if necessary, a further wick
applied. Often at this juncture the ear is
more comfortable and the owner can then History and signalment
administer drops. Cytology may reveal that From a practical point of view, recurrent
the infection has cleared. otitis externa and chronic otitis externa
present similar problems. Indeed, given
Liquid bandages, ear packs, and other that relapsing otitis externa will eventually
stay in place otics result in chronic disease, the former
In an effort to ensure constant concentra could be viewed as an early stage of the
tions of antibacterial agents, and with a nod latter. Both conditions have the potential
to the logistic implications for busy owners for inducing irreversible, pathological
with recalcitrant pets, pharmacological changes within the external ear canal, and
compounders are developing products in both instances the clinician is required
which are one shot ear medications. Thus, to institute a diagnostic work-up in order
for example, BNT otic contains enro to identify the underlying or predisposing
floxacin, triamcinolone, and ketoconazole cause(s).
in a lanolin anhydrous base, which absorbs Many breeds are predisposed to
water. Similarly, Polox A Gel Otic con chronic otitis externa and clinicians should
tains a similar spectrum of medicants flag even the first episode as a possible
in a preparation which is liquid while harbinger of future problems. Thus,
refrigerated but firms upon reaching Cocker Spaniels are not only predisposed
body temperature into a gel which fills the from an anatomical point of view but also
external ear canal. Otic Armors Liquid from the frequency with which defects
bandage is a residual (up to 3 months in keratinization and ceruminous otitis
activity claimed) which fills the external ear externa occur. Similarly, atopic West High
canal with a water permeable medicated land White Terriers are predisposed. Larger
polymer, designed to prevent reinfection. breeds (Basset Hounds with seborrhoea

and Labrador Retrievers with atopy, for

example) appear to have some resistance to
the onset of chronic pathological changes,
perhaps because the external ear canals
are much wider and the local microclimate
less subject to change. On the other hand,
German Shepherd Dogs are notorious
for developing chronic obstructive otitis
externa, even though they have wide
external ear canals and erect pinnae.
Physical examination Fig. 5.5 Hyperpigmentation around the base

Some animals will severely traumatize of the pinna and the opening to the external
the area around the pinnae and erythema, ear canal in this terrier with chronic otitis
alopecia, and crusting may be detected. externa.
Similarly, dogs with chronic otitis externa
will develop hyperpigmentation and
lichenification in the periaural region
(Figure 5.5). Affected dogs should be given
a thorough examination in an attempt to
identify whether the otitis is associated with
dermatological lesions. The type of change
within the external ear canal may give a
pointer to the pattern of dermatological
lesion to look for, although clinicians
should not be too dogmatic about this as
cross-over occurs.
In a dog with ceruminous otitis
(Figures5.65.8) the clinician should search
for evidence of defects in keratinization Fig. 5.6 Moderate ceruminous otitis externa
and endocrinopathies. Accumulations of in a Cavalier King Charles Spaniel. Note the
greasy scale around the nipples (Figure5.9), greasy scale adhering to the surrounding hair.
comedones, follicular casts on hair shafts
(Figure 5.10), and erythema, perhaps with
greasy scale, in the ventral neck folds, axillae,
and groin suggest a defect in keratinization.
There may be scale, crust (Figure 5.11),
and even alopecia on the dorsal trunk.
There may be secondarypyoderma and M.
pachydermatis infection.
Fig. 5.7 Moderate ceruminous otitis externa

in a German Shepherd Dog with a Sertoli cell
tumour.

Fig. 5.8 Severe hyperplasia and chronic

ceruminous otitis externa.
Fig. 5.9 Greasy scale adhering around the

nipples. Note also the comedones.
Fig. 5.10 Follicular casts adhering to hair

shafts. Follicular casts reflect abnormal
follicular keratinization.
Fig. 5.11 Erythema, alopecia, and patches

of crust in a Cocker Spaniel with a defect in
keratinization.

In a dog with erythematous hyperplastic the flexor aspect of the carpus (Figure 5.17),
changes (Figures 5.125.14) characteristic of and on the extensor aspect of the tarsus.
hypersensitivity, the clinician should look In addition, the coat may be rather harsh
for similar changes on the concave aspect and dry and be accompanied by a fine
of the pinnae (Figure 5.15), in the dorsal scale. There may be a secondary superficial
and plantar interdigitae (Figure 5.16), on pyoderma and M. pachydermatis infection.
Fig. 5.12 Erythematous, hyperplastic otitis

externa in a Rottweiler.

externa.
Fig. 5.15 Erythematous, hyperplastic changes

on the concave aspect of the pinna in a dog
with atopy.

has continued in this German Shepherd Dog
with atopy, even though the dog has been
subject to lateral wall resection.

Otic examination and other this may be not be readily apparent

investigations on gross examination, it will be visible
Most cases of chronic or recurrent otitis on histopathological examination of
externa manifest some degree of hyper biopsysamples. The epithelial lining
plasia of the epithelial lining of the may appear grossly normal or may have
external ear canal (Figure 5.18). Although a cobblestone-like pattern (Figure 5.19)
Fig. 5.16 Hyperpigmentation following Fig. 5.17 Discrete patch of erythema and
chronic inflammation in the interdigital areas alopecia immediately distal to the accessory
of a Labrador Retriever with atopy. carpal pad on the plantar aspect of the distal
limb of a German Shepherd Dog with atopy.
Fig. 5.18 Otoscopic picture of the external

ear canal of an atopic dog. Note the erythema
and early hyperplasia. Fig. 5.19 Otoscopic picture of more
advanced hyperplastic changes in an external
ear canal; the cobblestone pattern is clearly
visible.

Fig. 5.20 Otoscopic view of an external

ear canal almost completely obstructed by
hyperplastic epithelium.
if glandular and epithelial hyperplasia is degree of stenosis within the canal and
present. In some cases the canal may be that all are at risk for concurrent otitis
stenosed by proliferative epithelial changes media, the investigation should probably
(Figure 5.20), which are often localized or be performed under sedation so that
polyploid in the cat. Epithelial hyperplasia radiography of the bullae, and advanced
and accumulation of cerumen may result diagnostic imaging (where available),
in complete obstruction of the horizontal assessment of the tympanum and, possibly,
canal. The deeper portion of the horizontal myringotomy can be performed.
ear canal and tympanum is completely Otoscopic examination may reveal large
hidden from view and protected from quantities of ceruminous discharge in
topical treatment false middle ear. some cases (Figures 5.21, 5.22); in other ears
Attempting to classify the changes there may be minimal discharge. Air-dried
within the ear canal as ceruminous or smears should be examined unstained
erythematous hyperplastic, is helpful and after staining with Diff-Quik (Figures
from a management point of view. How 5.235.25). Yeast and bacteria may be
ever, the basic elements of the otic exam identified, in addition to cellular elements
ination should still be carried out. Given and variably proteinaceous exudate.
that many of these animals will have a

Figs. 5.21, 5.22 Photographs of air-dried cerumen from normal (5.21) and ceruminous-type
(5.22) ear canals demonstrating the breadth of appearance of the sample.
Figs. 5.235.25 Photomicrographs of cerumen from a hyperplastic-type ear canal. Ceruminous

debris and microbes are clearly apparent and there are no inflammatory cells.

Not all exudate contains pathogenic suggest that any micro-organisms are
micro-organisms. Microscopic examination nonpathogenic and that any discharge
of otic exudate only allows identification relates to ceruminous gland hyperactivity
of the relative number and physical (which can be prodigious) and epithelial
classification of organisms; yeast, coccus, hyperproliferation, rather than to infection.
bacillus, gram positive, or gram nega Histopathological examination of biopsy
tive, for example. The presence of a samples may be useful in identifying the
neutrop hilic infiltrate may suggest an degree of fibrosis present (Figures 5.26,
infectious process, or at least that inflam 5.27). Topical glucocorticoids may be
mation is present. Absence of such an useful in suppressing mural oedema and
inflammatory infiltrate might strongly hyperplasia, provided fibrosis is minimal.
Figs. 5.26, 5.27 Photomicrographs of

histopathological samples from a case of chronic
otitis externa. Epidermal hyperplasia, an inflammatory
infiltrate, and dermal oedema (5.26). The same section
but stained to highlight fibrosis (5.27). This degree
of fibrosis is not amenable to topical glucocorticoids;
surgery rather than medicine is indicated.

Use of glucocorticoids to treat Systemic glucocorticoids may be given

chronic change orally, e.g. prednisolone at a dose of
A careful assessment of the ear canal and 1 mg/kg daily for 14 days then on
middle ear should be undertaken in all an alternate day basis for a further
cases of chronic disease to decide if the ear 2weeks.
is irreversibly damaged or whether it can Glucocorticoids may be administered
still be managed with medical therapy. in ear wicks. The same procedure
Some of the situations where the damage is should be followed as described above
deemed irreversible include: in the treatment of infectious otitis
Where the canal is stenotic and the externa with ear wicks, but the wick
walls are calcified. may be soaked with a combination
Where severe ceruminous gland of antibiotic and glucocorticoids or
hyperplasia is present. glucocorticoids alone. Dexamethasone
Where hearing tests (brainstem 2 mg/ml injectable solution is suitable
evoked auditory evoked responses) to soak the wick. The wick may be
reveal the dog to be deaf. left in situ for 710 days before being
Where there is severe damage to the removed and, if necessary, replaced
middle ear identified on radiographs after flushing of the ear.
or advanced diagnostic techniques. Localized injection of glucocorticoid
directly into the wall of the canal may
Where changes are less severe rational use also be used. This is best accomplished
of glucocorticoids can be undertaken to using the high magnification lens of
try to reverse changes within the canal. It the video-otoscope. A flexible hollow
is important to have infection controlled needle can be inserted down the
before embarking on an extended course of working channel of the otoscope or
glucocorticoids. a long spinal needle can be inserted
Glucocorticoids can be administered in into the canal alongside the otoscope
a range of ways and several methods may to inject small blebs of glucocorticoid
be used in combination at the discretion of into the canal or into specific lesions.
the clinician: A total volume of 0.51.0 ml may be
Potent topical glucocorticoids injected into each ear canal depending
(dexamethasone, betamethasone, on the degree of change and the size of
mometasone, or hydrocortisone the dog.
aceponate) in a licensed otic drop may
be administered when the ear drum
is intact, or off-licensed injectable
dexamethasone (2 mg/ml) may be
mixed with a flush solution e.g. EDTA-
tris when the ear drum is ruptured.

6 OTITIS MEDIA
104
AETIOLOGY ever, the bacteria recovered from behind

an intact tympanum in cases of otitis
Otitis media is common and is almost media are not always the same species,
invariably accompanied by otitis externa13. or with the same antibacterial sensitivity,
Furthermore, in the vast majority of cases as those within the external ear canal 2.
the infection within the middle ear appears Bacteria (especially S. pseudintermedius and
to result from extension of otitis externa, Pseudomonas spp.) and yeast were most
rather than from ascending infection via commonly found in the external ear canal,
the auditory tube or as a result of haema whereas bacteria alone were more common
togenous infection1. However, it may be in the middle ear. A greater variety of
that the role of the auditory tube in the bacteria, including anaerobes, Group D
aetiology of canine otitis media has not streptococci, and E. coli, were found in
been fully appreciated, since its normal the middle ear compared to the external
physiological role is critical to middle ear earcanal2.
homeostasis, both microbiological and Other causes, particularly of unilateral
environmental4,5. Most cases of otitis media otitis media, include foreign bodies
appear to be missed, since in one study the which have penetrated the tympanum,
duration of the condition, before diagnosis, inflammatory polyps (especially in cats),
was in excess of 2 years in over one-half and neoplasms such as fibromas and
ofcases3. squamous cell carcinomas1.
The micro-organisms isolated from The pathological changes within the
cases of otitis media are principally infected middle ear were reported by
those associated with otitis externa, i.e. Little et al.7. All the cases in their study
Staphyloc occus pseudintermedius, Pseudo wereaccompanied by pathological
monas spp., Proteus spp., Escherichia coli, changeswithin the external ear canal, sup
and Malassezia pachydermatis1,2. However, porting the theory of an associationbetween
aerobic bacteria were isolated from nearly the two conditions. There was epidermal
one-half of the normal middle ears sampled hyperplasia with a replacement of the
in one study6, suggesting a normal flora, normal stratified squamous epithelium
presumably derivedfrompharyngeal by pseudostratified columnar type. The
flora ascendingthe auditory tube. The underlying dermis was infiltrated by a
bacteria recovered were principally E.coli, mixed inflammatory cell population and
staphylococci, and Branhamella spp., it took on the appearance of granulation
together with yeast6. tissue, occasionally with spicules of bone
Otitis media usually results as an within it. Secretory cells and gland-like
extens ion of otitis externa through the structures appeared within this inflamed
tympanum, which may subsequently heal, granulation tissue. Most of the tympanic
even in the presence of otitis media. How membranes were thickened.

Otitis Media 105
Cholesteatomas CLINICAL SIGNS

Cholesteatomas are slowly enlarging,
cystic lesions within the middle ear cavity. The most common clinical signs associated
They are lined by stratified squamous with otitis media are those of otitis externa
epithelium and keratin squames are or, rarely, of otitis interna 1,8,9. Pain may
shed into them. They are thought to arise be a feature in some cases and animals
when a pocket of the tympanic membrane may resent patting of the aural region
contacts, and adheres to, inflamed mucosa or may exhibit frantic head shaking
within the middle ear 7. Cholesteatomas (Figure6.1).Dogs may have problems
are associated with chronic otitis externa, chewing hard food or carrying a ball or toy
particularly if there is marked stenosis, due to pain in the region of the temporo
or even total occlusion, of the external ear mandibular joint. Otitis externa is often
canal. In addition to otitis externa they may present and animals commonly have
be associated with local pain, pain when a history of chronic or recurrent otitis
eating, and head tilt7. Radiographically, externa8. Neurological signs are unusual
cholesteatomas are associated with but include head tilt (Figure6.2), ataxia,
increased density within the middle ear Horners syndrome (Figure 6.3), or facial
cavity and disruption or a change in shape nerve paralysis (Figures 6.4, 6.5) 7,9,10 .
of the middle ear cavity. There is usually Keratoconjunctivitis sicca may, rarely,
stenosis and calcification of the external result from otitis media, following damage
earcanal7. to the parasympathetic innervation of the
lachrymal gland9.
Fig. 6.1 Pinnal trauma as a consequence Fig. 6.2 Dramatic head tilt to the right in
of otitis media. This dog displayed incessant a domestic longhaired cat with peripheral
head shaking. vestibular disease associated with otitis media.

106 Otitis Media
Fig. 6.3 Horners syndrome on the left-hand

side. The markedly prolapsed thirdeyelid
prevents examination of the pupil. This cat
had a nasopharyngeal polyp which passed
through the middle ear, then through
the tympanic membrane into the external
ear canal where it produced signs of an
obstructive otitis externa.
Figs. 6.4, 6.5 Horners syndrome and facial nerve paralysis in a Staffordshire Bull Terrier. There
is right-sided head tilt, a myotic right pupil, and facial paralysis resulting in drooping of the lips
on the right-hand side of the face.

Otitis Media 107
Otitis interna may occur following

extension of infection into the inner ear
via the oval window. Signs of otitis interna
include1,8: deafness, head tilt and circling
toward the affected side, nystagmus with
the fast component away from the affected
side, and asymmetrical ataxia.
MAJOR DIFFERENTIAL
DIAGNOSES
Idiopathic canine and feline vestibular syn

dromes are the most common nonmiddle
ear disorders associated with peripheral
vestibular signs10. However, in contrast to Fig. 6.6 Otoscopic view of a thickened and
otitis media these diseases usually show ruptured tympanic membrane.
signs of gradual clinical improvement in
110 days10.
DIAGNOSIS
Otoscopy
Otoscopy has good specificity but poor diagnosis difficult. However, myringotomy
sensitivity11. Otitis media should be sus can be employed to take samples from the
pected in all cases of chronic otitis externa middle ear if the tympanum is intact.
or in cases with recurrent episodes of otitis
externa. The presence of a ruptured tym Myringotomy
panic membrane is diagnostic (Figure6.6). Surgical incision of the intact tympanum
However, the presence of inflammation (myringotomy) is indicated in a number of
and exudate within the external ear canal instances:
makes meaningful examination of the To obtain samples of the effusion
tympanum difficult11. When the ear drum within the middle ear cavity for
is ruptured a sample may be taken directly microbial culture and sensitivity
from the middle ear. This can be achieved testing, if otitis media is present.
by inserting a clean otoscope cone or video- To provide a route of access to, or
otoscope head into the canal as far into the drainage of, accumulated middle
horizontal canal as possible and inserting a eareffusion.
fine catheter or a micro-swab through the To provide a means of access to
tube or working channel to guard it from the middle ear cavity to permit
discharge from the external canal. Material flushing, or to facilitate instillation
can be gathered onto the swab or suctions of medication or insertion of a
up the catheter to sample the middle ear. transtympanic ventilation tube.
The presence of an intact tympanum does Myringotomy must be carried out
not rule out otitis media since the defect under direct visual observation.
in the tympanum often heals, even in the The external ear canal must be
presence of ongoing otitis media2. These carefully cleaned and dried before
complications make definitive otoscopic myringotomy is performed.

108 Otitis Media
Needle aspiration structures of the middle and inner ear may

Given that different organisms with dif be damaged. Similarly, too forceful flushing
ferent antibacterial sensitivity patterns should be avoided. Postmyringotomy
may exist either side of an intact tympanic antibacterial cover is indicated until the
membrane2, it may be necessary to obtain tympanic defect has healed. Surgical
samples from the middle ear by puncturing defects in the tympanum of experimental
the intact tympanum and aspirating its dogs showed evidence of healing by
contents. 10days but this was not complete until
A 22 gauge spinal needle2 or a paediatric 2135 days postsurgery13.
scalp vein catheter are suitable since both Curvilinear incision provides better
are of an appropriate length to be passed drainage than a radial incision12. Using
through an otoscope. The catheter must a myringotomy knife, a curved incision
be carried to the tympanum by fine-nosed is made parallel to, but away from, the
crocodile forceps; this has the advantage of periphery of the tympanum (Figure 6.7).
providing a more flexible connection to the Radial incision allows poorer examination
5 ml or 10 ml syringe which is required to of the middle ear than curvilinear incision
aspirate the middle ear contents2,9. and makes removal of inspissated material,
There are two disadvantage of simple in particular, difficult12.
paracentesis12. Firstly, the effusion with Wire-mounted, small pharyngeal swabs
in the middle ear is often purulent or par provide an ideal method of collecting
ticulate and narrow needles may become samples for microbiology as they are
blocked; subsequently, trying to pass even flexible, do not break, and are small enough
a small swab through the first hole is nigh to permit direct visual manipulation
on impossible. Secondly, the puncture is through the otoscope. Once the laboratory
too small and it heals too quickly to permit sample is collected the effusion may be
adequate drainage of any effusion. drained with a blunt needle or washed
out with repeated cycles of flushing with
Incisional myringotomy a warmed, aqueous solution of an anti
Greater access may be required for drain bacterial agent.
ageor instillation of medication. Two types
of incision are recommended: curvilinear Imaging the middle ear
or radial12. Both are made into the inferior, Radiographic examination of the mid
caudal quadrant of the tympanum using a dle ear cannot always demonstrate
Gerzog and Sexton or Buck myringotomy changesconsistent with otitis media,
knife. Prior to myringotomy, radiographs giving false-negative findings com-
of the middle ears should be taken to assess paredtosurgery in 2530% of cases14,15. False-
the degree of effusion. Tympanometry may positive radiographic findings generally do
also be helpful as abnormal thickening not occur when compared with surgical
of the tympanum may be detected and diagnosis14,15. In an effort to minimize false-
this may have implications in that myrin negative results, clinicians and imagers have
gotomy may be more difficult and healing investigated other techniques, in particular
may be compromised. Care must be taken computed tomography (CT) and magnetic
not to incise the tympanum too deeply as resonance imaging (MRI).

Otitis Media 109
Radiography in which otitis media persisted after bulla

Radiographic techniques have good osteotomy the lateraloblique view was
specificity but poor sensitivity, being superior14,16. The normal bullae have an
able to delineate soft tissue, fluid, or identifiable air density within the tympanic
bony changes within the middle ear in cavity.Otitismedia results in increased
only about 70% of cases10. They are par soft tissue density within the bullae
ticularly useful in evaluation of bone (Figures6.8,6.9) and, if present, is a reliable
involve m ent (e.g.petrous temporal indicator of disease within the middle
bone) and in cases where neoplasia is ear1,14. Positive contrast ear canalography
suspected14. The open-mouth views are may also be used to demonstrate otitis
most useful14, although in a series of cases media17.
Fig. 6.7 Myringotomy. Note

that the controlled incision
avoids both the periphery
and the manubrium.
(Courtesy of Dr. LN Gottelf,
with permission of Waltham
Focus.)
Figs. 6.8, 6.9 Lateral oblique views of the tympanic bullae of a 3-year-old Himalayan cat with
left-sided otitis media associated with a nasopharyngeal polyp. Compare Fig. 6.8 (normal bulla,
arrow) and Fig. 6.9 (soft tissue density within the bulla, arrow).

110 Otitis Media
Computed tomography CT was able to detect early changes of otitis

CT has a resolution somewhat less than media where there was no osseous change.
conventional radiography and it takes The authors of one study, which com
muchlonger to perform, in the order of pared radiography with CT in the diagnosis
2030 minutes14,15,18. However, by taking of otitis media, concluded that CT gave too
repeated, sequential views in the same little additional information to justify the
plane, and then using computedprocessing, additional logistical and financial costs
it is possible, digitally, to remove extra incurred15.
neous superimposed structures, permitting
visualization of the middle and inner ear18 Magnetic resonance imaging
(Figures 6.10, 6.11). MRI uses a completely different principle
Precise positioning and an absolute to radiography and CT19,20 and the images
minimum of movement are prerequisites which result are best regarded as comple
for CT 18. Animals are placed in ventral mentary to, rather than replacements for, CT.
recumbency and they must be under Thus, CT gives betterdefinition of osseous
general anaesthesia to minimize move changes than MRI, whereas the latter gives
ment18. In one study, which compared CT better definition of soft tissue lesions than
with radiography in the diagnosis of otitis CT21 (Figure 6.12).
media15, CT gave 11% false positives and MRI has been used in the diagnosis of
17% false negatives (compared to surgical otitis media in dogs, although only one case
diagnosis), making the technique more report exists to date22. One experimental
sensitive but somewhat less specific than study investigated the potential of MRI to
radiography14. Neither radiography nor assess otitis media in chinchillas and cats23.
Fig. 6.10 CT scan of a cat with otitis media. Fig. 6.11 CT scan of a dog with a soft
There is an effusion within the bulla. tissue mass within the horizontal ear canal.
Note that the mass, a neoplasm, has clearly
breached the tympanic membrane (arrow).

Otitis Media 111
The authors reported superior results MANAGEMENT

using T2-weighted images (requiring
a 20 minute scanning/measurement Given that most cases of otitis media are
cycle) compared to T1-weighted images associated with otitis externa, the treatment
(taking about 5minutes). In addition, of the former cannot be considered in
using a contrast agent (gadolinium- isolation from the latter1,9,10. The approach
diethylenetriaminepenta-acetic acid) it to each case should be structured with this
was possible to visualize inflamed, swollen in mind.
middle ear mucosa.
In humans, comparative studies in Flushing and suctioning the bulla
malignant otitis (a particularly severe Flushing the bulla is key to successful
Pseudomonas spp. infection of the external therapy of otitis media. The mucus and
ear canal) and the fine structure of the purulent material within the middle ear
temporomandibular joint 21,24 , found prevents adequate penetration of topical
that CT was superior for documenting medication. Hydration of the mucus
subtle osseous changes whereas MRI was within the middle ear with a water-based
superior in detecting soft tissue aberrations. flush makes it less tenacious and easier to
Furthermore, in a study comparing CT with suction. The solution to be used to flush
MRI in detecting osteoid sarcoma, it was the middle ear should be warmed to body
recommended that MR images should not temperature before installation. Suitable
be interpreted without reference to plain flush solutions in dogs include water,
radiographs and CT if serious errors in sterile saline, dilute chlorhexidine solution
diagnosis were to be avoided25. (<0.2%) and ethylenediamine tetra-acetic
R L
Fig. 6.12 MRI of a cat with left-sided otitis media (arrows). Note that the third image is much
clearer: this is the T2-weighted image.

112 Otitis Media
acid tromethamine (EDTA-tris), all of which infection (see Chapter7 Ototoxicity and
have been shown to be very safe as flushes Other Side-effects of Otic Medication).
even when the ear drum is ruptured26. The safest antibiotics for infusion are
Although ceruminolytics are generally not fluoroquinolones (ciprofloxacin, enro
used as commonly in otitis media due to the floxacin, marbofloxacin)26,31, aqueous peni
nature of the discharge, only squalene has cillin G 26, and aqueous gentamicin 26,32.
been shown to be safe in the dog27. In the Other aminoglycosides, such as tobramycin
cat flushes should be used with care; only and semisynthetic penicillin ticarcillin,
water, sterile saline, and EDTA-tris are have been associated with severe hearing
considered safe. Chlorhexidine has been loss when used to treat otitis externa 26.
shown to have ototoxic effects even at low Antifungal drugs that are considered safe
concentrations2830. are clotrimazole26,31, miconazole, nystatin,
Tube flushing of the middle ear is and tolnaftate 31, although one author
the most effective way to clean it. A soft (SP) has seen temporary deafness caused
feeding tube or a urinary catheter may by both clotrimazole- and miconazole-
be used and can be carefully introduced based products that resolved when top
into the middle ear by sliding it along ical medication was withdrawn. The
the floor of the horizontal canal and then aqueous forms of anti-inflammatory drugs
directing it ventrally into the tympanic dexamethasone26,31 and fluocinolone31 also
bulla. Where possible the flushing tube appear to be safe in the middle ear.
should be introduced down the working Providing the ear is cleaned adequately
channel of a video-otoscope to allow better prior to application of medication, the use
visualization of the flushing process. Care of aqueous nonototoxic drugs directly
should be taken to avoid introducing the into the bulla hastens recovery from otitis
tube into the dorsal or middle aspects media. The tympanic bulla of the dog and
of the middle ear, which may result in cat is a deep blind ending bucket so that
damage to the delicate structures of the when a drug is infused in, it cannot escape
oval and round window that lie within easily and therefore provides long-acting
the promontory. Once the tube has been high-concentration effects. Most drugs are
positioned within the bulla,repeated thought to remain in the bulla for several
cycles of fluid infusion and aspiration days after infusion33.
can be performed until theflushsolution
removed becomes clear. Reducing inflammation with
glucocorticoids
Infusing topical medication into Glucocorticoids are important to reduce the
the bulla inflammation and exudation that is found
Once the external ear canal and the middle in middle ear disease. Glucocorticoids
ear have been successfully cleaned medi help to reverse some of the granulation
cation can be introduced into the middle tissue that forms within the bulla. They
ear. This can again be infused down a also help to reduce the amount and
soft feeding tube or urinary catheter. No viscosity of the mucus produced by the
medication is licensed for the therapy mucoperiosteum and reduce swelling
of otitis media; therefore, when topical within the auditory tube, which may help
medication is infused into the bulla a to improve drainage from the tympanic
careful assessment should be made of the bulla into the nasopharynx33. Care should
risks of the topical drugs causing signs of be taken to ensure that the patient is a
ototoxicity versus the benefits in resolving suitable candidate for glucocorticoid

Otitis Media 113
therapy, e.g. no history of demodicosis, 5.010.0 mg/kg once daily; enrofloxacin

diabetes, or pregnancy. Glucocorticoids 5mg/kg once daily but may be up to
can be administered in a range of ways 20mg/kg once daily; marbofloxacin
depending on the clinicians preference. 2.05.5mg/kg once daily; and orbifloxacin
One author (SP) prefers to administer 512.5 mg/kg once daily.
intravenous dexamethasone (2 mg/ml) Aminoglycosides may also be used
at a dose of 0.10.2 mg/kg at the time of systemically; like fluoroquinolones
the ear flush and then follow that up with their use should be based on culture and
anti-inflammatory doses of prednisolone sensitivity testing. All animals should have
12mg/kg daily by mouth for 2 weeks. their renal function assessed before starting
Other systemic glucocorticoids that can systemic aminoglycoside treatment. The
be used orally include methylprednisolone development of nephrotoxicity should
0.81.8 mg/kg and triamcinolone acetonide be monitored by the use of daily urine
0.10.2 mg/kg. Aqueous dexamethasone examination and sequential blood samples
or a combination of a commercial product in all cases. Drugs which may be used
containing dimethylsulfoxide (DMSO)/ are gentamicin at a dose of 68 mg/kg
fluocinolone can also be instilled into the daily subcutaneously; amakacin at a dose
bulla via a catheter at the time of flushing. of 1520mg/kg daily subcutaneously.
It is important to warn owners of the side- Another drug which may be used sys
effects of using prednisolone at such high temically is ticarcillinclavulanic acid given
doses, i.e. polyuria, polydipsia, polyphagia, intravenously at a dose of 1525 mg/kg
otherwise they may discontinue therapy three times daily33.
before the end of the 2-week course.
Where unacceptable side-effects are seen TREATMENT OF
with prednisolone, a second injection of NASOPHARYNGEAL
dexamethasone may be given as an alter POLYPS INCATS
native. Glucocorticoids should begiven for
a minimum of 2 weeks before reassessment. The key to successful therapy is the
At that stage prednisolone may be reduced removal of the polyp. In most cases polyps
to an alternate day regime or withdrawn, can be removed by traction/avulsion. The
depending on the responseto therapy. polyp is grasped using alligator forceps or
a grasping tool down the video-otoscope.
Administer systemic antibiotics The polyp is pulled and twisted to tear
The basis of topical therapy in otitis its attachment away creating minimal
media is that oral antibiotic levels in the haemorrhage. As an alternative to traction,
tympanic bulla cannot approach topical polyps can be removed by carbon dioxide
levels. However, when topical therapy is laser ablation.
unsuccessful due to lack of accessibility When cats are treated postoperatively
of the middle ear, e.g. due to stenosis of with systemic prednisolone (12 mg/kg
the canal or due to excessive discharge daily for 2 weeks, then half the initial dose
preventing adequate penetration of topical for 1 week, then every other day for a
medication, systemic medication may be further week before discontinuing) the risk
useful. of recurrence is reduced significantly34.
Oral fluoroquinolones are useful where Where removal is impossible or polyps
shown to be appropriate based on culture recur, then a ventral bulla osteotomy
and sensitivity. The most common orally should be performed.
administered drugs include difloxacin at

114 Otitis Media
PROGNOSIS nerve paralysis and Horners syndrome,

may persist.
If the inflammatory process is identified Some cases of otitis media (and, indeed,
early, the cause identified, and effective some cases of otitis interna) develop
treatment instituted, the prognosis for osteomyelitis of the osseous bulla and
recovery is good. Minor residual vestibular petrous temporal bone. Occasionally the
deficits, such as head tilt or mild ataxia, infection ascends the vestibulocochlear and
may persist but the animal soon adapts to facial nerves to the brainstem, resulting in a
the new head position. Neurological signs brainstem abscess or meningitis associated
associated with otitis media, such as facial with central vestibular signs2.

7 OTOTOXICITY AND
OTHER SIDE-EFFECTS OF
OTIC MEDICATION 115
INTRODUCTION Many types of medication are applied

to the external ear canal of dogs and cats.
In addition to specific medications, such
KEY POINTS as anti-inflammatory agents, acaricides,
antimicrobial agents, and ceruminolytics,
QQ Clinical cases of true ototoxicity there may be substances included to
following medical management of enhance penetration and to act as vehicle
otitis externa are very rare. components and preservatives.
QQ Almost all the risks associated The anatomy of the external ear canal
with otopharmacy can be obviated is such that liquid medications, in excess,
provided the clinician can document will tend to pool in the horizontal canal.
an intact tympanic membrane before High concentrations of medication may
applying the otopharmaceutical thus come into contact with inflamed
agent. epithelium and the potential for intra-
QQ Side-effects from otic administration and percutaneous absorption is readily
of chemicals include local apparent. In some circumstances this is
inflammation, otitis media, vestibular desirable. For example, the anti-inflam
or cochlear damage, and systemic matory effect of a topical glucocorticoid
absorption. must be exerted on dermal tissues. In
QQ Almost any chemical will cause contrast, an antimicrobial, antifungal, or
inflammation within the middle ear acaricidal agent will usually be applied to
or inner ear if instilled through the the external ear canal for their topical effect
tympanum. and absorption is not necessary.
QQ The round window is an important Inflammation within, and overt
portal for the passage of drugs, toxins, damage to, the tympanic and round
and inflammatory mediators from the window membranes may permit inflam
middle to the inner ear. matory mediators or drugs to enter the
QQ The nonpharmaceutical component middle ear or inner ear, respectively.
of an otic preparation (penetrance Furthermore, it is not known to what extent
enhancer, detergent) may penetration enhancers, such as propylene
significantly affect the toxic potential glycol (a common ingredient in otic
of the product. preparations), may increase the passage of
these substances across these membranes.

116 Ototoxicity and Other Side-Effects of Otic Medication
The unwanted effects of otic medication and hyperkeratosis but no histopathological

may be classified into four groups: evidence of inflammation was noted.
Direct effects on the meatal and Not surprisingly, both products also
tympanic epithelium and underlying induced a statistically significant increase
dermis. in the epidermal mitotic index. Similar
Effects within the middle ear. effects were exerted on the tympanic
Effects on vestibular and cochlear epithelium. The only noted effect of topical
functions (ototoxicity). hydrocortisone was a significant reduction
Systemic sequelae of the otic in the epidermal mitotic index. The authors
administration of medications. made the point that it was the supposedly
inactive components, rather than the
One of the greatest difficulties facing pharmacologically active ingredients, of
clinicians is assessing the relevance of commercial otopharmaceutical products
experimental studies, particularly if they which induced most change. It may be that
are performed in another species. Much these iatrogenic inflammatory effects are, in
experimental research into ototoxicity is reality, very mild in nature and are probably
performed on guinea pigs and chinchillas. masked by the more marked changes
It could be argued that these tests are so consequent upon otitis externa. Thus,
artificial, and interspecies anatomical and they may be of little clinical significance.
physiological variation is so great, that However, until definitive studies are
the conclusions drawn from experimental performed this cannot be relied upon.
animals cannot be applied to dogs with Otic maceration may result from over
clinical ear disease1. Merchant et al.2 demon enthusiastic or prolonged application
strated that chlorhexidine exhibited very of aqueous or propylene glycol-based
little ototoxic effect in dogs, in contrast cleansers. This might particularly be the
to experimental studies which reported case when otic preparations are used for
both vestibular and cochlear toxicity to the long-term management of ear disease,
chlorhexidine in guinea pigs3,4. However, such as in allergic otitis externa7. Suspicion
in a recent experimental study using guinea should be raised when examination of
pigs and dogs there was a good correlation the external ear canal reveals moderate
between the two species 5, suggesting inflammation accompanied by an accumu
that extrapolation might be valid in some lation of white, moist debris composed of
instances. sloughed squames, with no inflammatory
cells present.
MEATAL AND TYMPANIC
INFLAMMATION EFFECTS WITHIN THE
MIDDLEEAR
The effects of various constituents
of commercial otic pharmaceutical Several types of otic medication can induce
products on the meatal epithelium and inflammation within the middle ear, if
the tympanic membrane were studied in theyreach it via a ruptured tympanum.
an experimental model 6. Benzalkonium Several commercial ceruminolytic prepar
chloride (aquaternary ammonium preserva ations were recently shown to cause acute
tive) produced profound effects such as inflammation within the middle ear 5.
acanthosis and surface ulceration. Amixed Propylene glycol is well documented as an
inflammatory infiltrate in the dermis was irritant of middle ear epithelium8.
also noted. Propylene glycol (asolvent and Chronic inflammation within the
penetrance enhancer) induced acanthosis middle ear is thought to be associated

Ototoxicity and Other Side-Effects of Otic Medication 117
with cholesteatoma formation9,10. Propy inflammatory mediators, toxins, and drugs

lene glycol is the main agent used for from the middle ear to the inner ear15.
experimental induction of cholesteatomas10 The potential for a drug to cause
and it is a common ingredient in many ototoxicity will vary: the vehicle, chemical
commercial otic pharmaceuticals. Whether composition, and concentration of the
this, or other, chemotherapeutic agents are agent in question; the route, frequency,
involved in the induction of cholesteatomas and duration of administration; the con
in dogs is not known. However, many centrations of other components in the
polypharmaceutical otic preparations otic preparation used; and, in some cases,
contain glucocorticoids in addition to puta concurrent administration of other drugs12.
tive irritants, and intratympanic admin In summary:
istration of prednisolone with propylene Direct instillation of most substances
glycol has been shown to inhibit propylene into the inner ear is likely to induce
glycol-induced inflammation and sub ototoxicity.
sequent cholesteatoma formation10. Topical administration into the
external ear canal in the presence of
OTOTOXICITY a ruptured tympanum and/or otitis
media increases the risk of ototoxicity.
An ototoxic agent produces cochlear or Certain detergents may increase the
vestibular damage by injuring structures ototoxic potential of chlorhexidine.
within the inner ear 1,11. The effects may Certain agents, such as some
reflect uni- or bilateral toxicity. Clinical aminoglycosides, are selectively
signs of vestibular damage may be reflected ototoxic, by whatever route they are
very early after the insult has been effected administered.
and these include nystagmus, strabismus, Loop diuretics potentiate
ataxia, head tilt, and circling. Clinical signs aminoglycoside toxicity by increasing
of cochlear damage usually go unnoticed their relative concentration in the
until complete deafness is recognized1. endolymph.
The early signs of cochlear damage in man Salicylates may potentiate the toxicity
include tinnitus and although this would of gentamicin.
be difficult to document in dogs and cats, it Familial sensitivity to aminoglycoside
may be that an inappropriate, or unusually toxicity has been demonstrated
strong, response to an auditory stimulus is in man16 and may be relevant in
a reflection of early cochlear damage12. veterinary medicine.
In order for a drug to exert ototoxicity it
must reach the inner ear. This may be the Topical products
result of haematogenous spread following Vehicles: propylene glycol
oral or parenteral dosage. However, more Propylene glycol is a solvent and pene
commonly it follows topical application trance enhancer found in many proprietary
of ototoxic agents into the external ear otic preparations 6. When instilled into
canal and their subsequent passage into the middle and inner ear in experimental
the middle ear via a ruptured tympanum. studies it is ototoxic8,9. In one study5 some
Subsequent diffusion into the middle ear is commercial ceruminolytic preparations
enhanced by the presence of otitis media, were shown to induce inflammatory reac
which induces increased permeability tion within the middle ear. Some of the
through the round window membrane1315. dogs exhibited signs of vestibular damage
The round window membrane is an and altered brainstem auditory evoked
important portal for the passage of response (BAER). Two of the three products

which were associated with these changes ammonium compounds (cetrimide for
contained propylene glycol, although example) appear to potentiate the toxic
whether this was the sole agent responsible effects of chlorhexidine18 and commercial
for the effects is not clear. mixtures of the two compounds (Savlon
for example) should not be instilled into the
Ear cleaners external ear canal.
Ceruminolytics
Mansfield et al.5 looked at four commercial Povidoneiodine preparations
ceruminolytic preparations commonly Aqueous solutions of certain iodine
used as ear cleaners to assess their potential preparations were found to be nonototoxic
ototoxicity. He instilled squalene, dioctyl in guinea pigs 23 whereas alcohol-based
sodium succinate, carbamide peroxide, preparations of iodine23 and povidone
and triethanolamine into the middle ear iodine solutions were ototoxic. Both
of both guinea pigs and dogs. Only the ear vestibular and cochlear damage was
cleaner containing squalene showed no caused.
morphological or neurological changes.
Acetic acid
Antimicrobial flushing agents A 5% solution of acetic acid (undiluted
Chlorhexidine vinegar) is irritating within the middle ear
Chlorhexidine is readily available in and should only be used with caution when
clinical practice and is frequently used for the tympanum is ruptured24,25. Anecdotal
irrigation of the external ear canal. Care reports suggest that a 22.5% solution may
must be taken to ensure that adequate be safe in the face of a ruptured tympanic
dilution is achieved. If it is formulated too membrane25,26.
weakly, it loses its antimicrobial potency,
particularly against gram-negative bacteria; EDTA-tris
if formulated too strongly, it is ototoxic17. A EDTA-tris is widely available as both a
study by Merchant et al.2 investigated the component of commercial ear flushes and
ototoxic potential of 0.2% chlorhexidine as crystals and a ready-to-use aqueous
acetate instilled into canine ears before flush. EDTA-tris based products can
and after experimental myringotomy. be used as flushes and presoaks to help
No significant effects were noted, sug potentiate antibiotic therapy or as a
gesting that at 0.2% concentration, or carrier vehicle for aminoglycoside and
less, chlorhexidine is safe as an irrigating fluoroquinolone antibiotics. EDTA-tris has
solution in dogs, even in the presence of a been widely promoted by many different
ruptured tympanum. Chlorhexidine does authorities as a safe and efficacious therapy
not appear to be safe as a flush in cats ears: for otitis media and has rapidly become the
solutions as dilute as 0.05% cause cochlear treatment of choice for gram-negative otitis
and vestibularototoxicity and mucosal externa/media2729.
injury1820.
Aqueous solutions of chlorhexidine Topical antibacterial agents
(0.15%) combined with ethylenediamine Aminoglycosides
tetra-acetic acid tromethamine (EDTA-tris) Aminoglycosides are common components
also appear to be very safe when usedas of topical otic preparations. This group con
a middle ear flush 20. The ototoxicity of tains amongst others amikacin, framycetin,
chlorhexidine is markedly enhanced in gentamicin, neomycin, and tobramycin.
the presence of some, but not all, nonionic Many of the studies assessing the topical
or cationic detergents 21,22. Quaternary ototoxicity of this group of drugs have been

Ototoxicity and Other Side-Effects of Otic Medication 119
performed in guinea pigs and chinchillas. tologists has led to them being generally
Studies on guinea pigs have shown that accepted as nonototoxic2426,34,35.
neomycin, streptomycin, gentamicin, Topical application of a 0.2% solution
amikacin, and netilmicin show signs of of ciprofloxacin into the middle ear of
cochlear toxicity when applied topically guinea pigs was shown not to be ototoxic36.
into the middle ear30,31. One study by Morais ABAER study in dogs showed that
demonstrated that the organ of Corti was aqueous solutions of marbofloxacin failed
completely destroyed in guinea pigs after to produce any signs of vestibular or
3 months application of topical neomycin. cochlea toxicity21.
Similar work in chinchillas has also
demonstrated potent topical ototoxicity32. SYSTEMIC EFFECTS OF OTIC
Such studies have led to the extrapolation MEDICATION
of similar effects in dogs. However,
despite fears over the ototoxic potential Topically applied drugs pass easily into
of gentamicin in dogs, a canine study and through the epithelial lining of the
designed to stimulate clinical exposure external ear canal. This may be enhanced in
via a ruptured tympanic membrane failed the presence of propylene glycol and other
to document any noticeable degree of agents. The facility of systemic absorption
cochlear or vestibular toxicity after 21 days following topical otic administration, even
of therapy33. into normal ear canals, is demonstrated by
Other research looking at BAER testing the ability of locally applied glucocorticoid
and neurological assessment of dogs before to suppress the pituitary adrenocortical
and after topical administration of drugs axis37.
into the tympanic bulla21, demonstrated Systemic absorption following topical
no signs of ototoxicity when aqueous otic administration may not be limited
gentamicin solution was used over a period to glucocorticoids. Measurable serum
of 6 weeks. It is therefore possible where concentrations of gentamicin occurred
reactions to topical gentamicin preparations in humans and dogs following otic
have been recorded it may have been the administration38,39. Whether the route of
vehicle that produced side-effects rather absorption was via the epithelium of the
than the antibiotic. Little information is external or middle ear, or even if it was via
available on the topical ototoxic potential the auditory tube, is not known, although
of other aminoglycosides in dogs. The same the latter route is unlikely in view of the
study which showed that gentamicin was poor absorption of aminoglycosides
safe in the middle ear demonstrated that via the gut. Given that most topical otic
an aqueous solution of tobramycin was preparations are administered when the
profoundly ototoxic21. To date therefore, otic epithelium is inflamed, it is most
the only aminoglycoside that can be used probable that absorption was via this route.
with confidence in the middle ear of the dog
is gentamicin. OTOTOXICITY OF SYSTEMIC
DRUGS
Fluoroquinolones
Aqueous solutions of fluoroquinolones Furosemide, salicylates, and cisplatin and
are widely used in otitis media to treat aminoglycoside antibiotics (gentamicin,
gram-negative infection. Few studies amikacin) have all been reported to cause
exist demonstrating their safety, but their ototoxicity in man and experimental
widespread use and recommendation animals 1,12. Aminoglycoside ototoxcity
by otologists and board certified derma has been recorded in cats after systemic

administration of paromomycin for infec The use of systemic aminoglycosides

tious enteritis40. Combination of diuretics such as gentamicin, which are concentrated
with aminoglycoside antibiotics or cisplatin in the endolymph, should be avoided in the
in experimental animals and in humans presence of otitis media since inflammation
leads to profound permanent hearing loss41. of the round window allows increased
penetration of drugs into the inner ear.
SUMMARY Concomitant use of loop diuretics should
be avoided11.
In general, ototoxic effects are dose With regard to the flushing of the
related, vis vis the middle and inner external ear canal, it is best to assume that
ear. The first principle, therefore, is to the tympanum is not intact and to use water,
avoid using ototoxic chemicals and, if sterile saline, 0.2% chlorhexidine solution,
they must be used, reduce the dose and or aqueous EDTA-tris as flushing agents.
frequency of administration to an absolute It is important to remember that certain
minimum. Careful observation and regular detergents may potentiate chlorhexidine
follow-up examinations of the patient toxicity and concomitant use should be
may allow detection of vestibular signs avoided.
early enough to allow the clinician to If the tympanum is proven to be intact,
suspend therapy. In some circumstances cerumenolytics, foamers, and chemical
prompt action may prevent permanent depilatories may be used provided that
damage12. Unfortunately, it is difficult to the ear canal is thoroughly washed,
detect early cochlear damage 1. Indeed, flushed, and dried at the end of the clean
it may be virtually impossible to detect ing procedure. Squalene is the only ceru
unilateral cochlear damage in the clinical menolytic product that should be used if
setting without recourse to sophisticated the ear drum is ruptured.
investigatory tools, such as BAER.

8 AURAL ABLATION AND
BULLA OSTEOTOMY
121
INTRODUCTION the outcome of the surgical procedure will

be assessed by the alleviation of the chronic
otitis. For example, failure fully to assess
KEY POINTS the patient and make a definitive diagnosis
of the cause of the otitis externa is the main
QQ Surgical ablation of the ear canal is reason why lateral wall resection fails.
useful in the management of chronic Thus, if the underlying cause is atopy or
ear disease, provided a critical dietary intolerance, the otitis will continue
assessment of the individual case is to affect the remaining medial wall of the
made on each occasion. external ear canal, even after a technically
QQ Do not underestimate the medical perfect lateral wall resection or vertical
aspects of chronic ear disease. In canal ablation (Figures 8.1, 8.2).
particular, recognize the contribution Surgical management of ear disease
that dermatological conditions can cannot be divorced from the medical
make to poor surgical outcome. necessity of fully investigating all the
QQ Total ablation and bulla osteotomy components of the otic structure and
is best performed by an experienced recognizing that the epithelial lining of
surgeon. the external ear canal is an extension of
QQ Owners should be cautioned that the skin of the head and neck. Chronic
all aural resections, but particularly otitis externa, at least in the dog, is usually
those involving ablation of the entire a manifestation of a more generalized
vertical canal, may adversely affect dermatological process such as a defect
ear carriage in dogs with erect pinnae. in keratinization, hypersensitivity, endo-
crinopathy, or an immune-mediated
disease. Furthermore, many cases are asso
The various surgical resections of the ciated with otitis media. These diseases
external ear canal are generally indicated as and associated problems must all be fully
a means of resolving chronic otitis externa investigated before surgery is contem
or as aids in the management of otitis plated. Clinicians are urged to read the
media. The decision on how much of the relevant chapters and sections of this book
external ear canal to resect is crucial, since for further information.

122 Aural Ablation and Bulla Osteotomy
Fig. 8.1 Results of a lateral wall resection in Fig. 8.2 Results of a vertical canal ablation in
an atopic German Shepherd Dog. The surgeon a German Shepherd Dog. As in the previous
failed to appreciate that the atopic lesion case the underlying condition of atopy was
would continue on the residual lateral and not appreciated.
medial walls of the vertical ear canal.
PRESURGICAL INVESTIGATIONS are to be drawn. Visual examination via an

otoscope can provide information on the
Presurgical assessment of the entire struc state of the epithelial lining of the otic canal,
ture of the ear is essential13. In many cases the degree of stenosis of the lumen and,
some of the procedures advocated below sometimes, an indication that neoplasia
will have been performed by way of routine is present. The status of the tympanic
management and work up of a case of otitis membrane cannot always be assessed fully
media or externa. A fuller description of by otoscopy, even in a normal external ear
these procedures can be found elsewhere in canal4.
this book. Neurological examination of the facial,
Palpation of the external ear canal may oculosympathetic, and vestibular nerves
reveal thickening and ossification of the provides a baseline for assessing the sig
cartilaginous components. Local thickening, nific ance of any postoperative neuro-
particularly in the parotid area, or the logical signs. Similarly, assessing a dogs
presence of a sinus adjacent to the external auditory ability preoperatively may give a
ear canal may reflect para-aural abscess4,5. useful measure againstwhichtocompare
Changes to the vertical part of the external postoperative deafness.
ear canal are often accompanied by chronic Bacteriological culture and sensitivity
changes to the concave aspect of the pinna, testing will often have been performed
which may be thickened and lichenified. before surgery is considered. However,
Otoscopy is essential and a clear view repeated use of various topical anti
is mandatory if meaningful conclusions bacterial agents may well influence the

Aural Ablation and Bulla Osteotomy 123
bacterial population and its antibacterial VERTICAL CANAL ABLATION

susceptibility 5. Preoperative sampling
to provide an up-to-date antibacterial The purpose of vertical canal ablation is
susceptibility is advisable if postoperative to remove the portion of the external ear
infection is to be managed effectively 6. canal which contains the most potential
However, if otitis media is present, intra for chronic hyperplastic change. In reality,
operative sampling is essential since it has most surgery is performed in patients
been shown that in the presence of otitis with irreversible changes already in place,
media there is little correlation between the i.e. it is salvage surgery rather than pre-
flora of the horizontal ear canal and that of emptive surgery. Furthermore, most cases
the middle ear7. of chronic otitis externa exhibit varying
Radiographic assessment of the exter degrees of luminal stenosis within the
nal ear may reveal ossification of the horizontal portion of the external ear canal,
auricular cartilage and absence of the in addition to changes within the vertical
luminal air shadow, both findings sug portion, and in theory this should also be
gestive of chronic, inflammatory, pro removed. However, the horizontal canal
liferative otitis externa8,9. Positive contrast is short and ablation of the vertical canal
ear canalography may be useful in (provided a good drainplate is fashioned)
establishing the status of the tympanum establishes good drainage, resulting in an
if tympanometry is not available or is improvement of the microenvironment
impracticable, for instance if the external within the remaining portions of the canal.
ear canal is stenosed 8,10. Radiographic Vertical canal ablation is indicated in the
examination of the middle ear is essential following circumstances1315:
in the work up of otitis media911, although Chronic, or recurrent, otitis externa
ultrasound and computed tomography associated with irreversible,
(CT), perhaps in combination, may be more hyperplastic changes in the luminal
sensitive for evaluation of otitis media than epithelium.
radiography12. Neoplasia of the vertical ear canal.
Biopsy of the epithelial lining of the
external ear canal is rarely performed Total ear canal ablation (and
but, conceivably, it may help to influence lateral bulla osteotomy)
whether surgery takes place. For exam Total ear canal ablation (TECA) is always
ple, if the histopathological pattern is performed with a lateral bulla osteotomy
inflammatory, with little evidence of (LBO). The removal of the entire external
fibrosis and glandular hyperplasia, ear canal can only be accomplished if the
aggressive glucocorticoid therapy may external canal is resected to the level of the
reduce luminal stenosis, thus obviating tympanum, which marks the boundary
the need for surgery. Biopsy of neoplastic between the external and the middle ear.
lesions may provide information which This necessitates resection of bone.
influences the type of surgical resection TECA and LBO are rarely indicated in
required, and it is therefore a useful pre cats2,16. Although bulla osteotomy alone
surgical investigation, particularly if the (usually ventral) may be indicated for
lesion is accessible. Cytological exam the management of polyps, for example,
ination of otic cerumen may help provide the otitis externa usually resolves and
information on the tumour type but it chronic changes are rarely severe enough
cannot grade malignancy; this requires to warrant vertical canal ablation. TECA
histopathological examination of biopsy and LBO are indicated in the following
samples. circumstances2,3,14,17:

Chronic, or recurrent, otitis externa incision may be performed; this results

associated with irreversible, in a crescent-shaped base for the pinna
hyperplastic changes in the luminal and helps to maintain a normal carriage
epithelium. postoperatively20.
Failure of more conservative surgery Incision through the auricular cartilage is
to alleviate otitis externa or media. made, taking care not to penetrate the lateral
Neoplasia of the external ear canal. aspect of the pinna. The trumpet of conchal
Otitis media. cartilage is grasped with tissue forceps and
a combination of blunt and sharp dissection
Vertical ear canal ablation is used to isolate the vertical canal, which
The crucial steps in this procedure are: can be pulled free from the underlying
Construction of an effective tissues (Figure 8.4). It is essential to keep
drainplate. the dissection as close to the cartilage
Careful closure of all dead space. as possible as this minimizes iatrogenic
damage to blood vessels and nerves.
An initial T-shaped incision is made. The The excised canal is sectioned above
lower point of the incision, the base of the the level of the horizontal canal to allow
T, is just below the level of the horizontal creation of a drainplate (Figure 8.5). The
portion of the external ear canal3,1719. The ligamentous connection between the
bar of the T follows a circumferential annular and conchal cartilages is used as
path across the medial wall of the conchal a hinge to allow reflection of the cartilage,
cartilage (Figure 8.3), immediately dorsal as in the lateral wall resection described
to the large antihelicine tubercle 13. In above. At the new acoustic meatus,
dogs with erect pinnae, a dorsally curved exact closure of skin to canal epithelium
Fig. 8.3 Vertical canal ablation. A T-shaped Fig. 8.4 Circumferential dissection of the soft
incision is made over the vertical ear canal. tissues is performed keeping as close to the
cartilaginous ear canal as possible.

with 4/0 absorbable monofilament (Figure8.7), incorporating subcutaneous

subcuticular sutures is attempted so as to tissues deep to the excised conchal
minimize stricture at the site (Figure 8.6). cartilages with the sutures to eliminate
Skin suturesare placed if necessary. The dead space13. Failure to close dead space
suture line isclosed above the drainplate may result in postoperative dehiscence.
Fig. 8.5 The base of the freed vertical ear

canal is resected at a level below the diseased
tissue, at the level of the horizontal ear canal.
Fig. 8.6 A permanent stoma is constructed Fig. 8.7 The rest of the incision is closed,
by ensuring that the cartilaginous portion of ensuring that dead space is eliminated.
the horizontal ear canal remains patent when
sutured to the skin.

Fig. 8.8 Tigari modification. A circumferential

incision is made at the entrance to the vertical
ear canal.
Figs. 8.9, 8.10 Using traction and blunt

dissection, the vertical ear canal is gradually
freed from its surroundings.
Pull-through modification21 vertical canal is freed from its soft tissue

This modification of vertical canal ablation attachments and exposed via the dorsal
results in less incised tissue to suture than incision (Figures 8.9, 8.10).
with standard techniques, less trauma to The skin is palpated at the level of the
subcutaneous tissues, less risk of damage horizontal canal (Figure 8.11) and a circular
to associated structures such as the salivary incision, roughly one and a half times the
glands, less postoperative discomfort, diameter of the horizontal canal, is made
fewer sutures, more rapid healing, and less (Figure 8.12).
dead space. Although the original authors The entire, exposed conchal cartilage
did not describe the creation of a drainplate, trumpet, which was previously exposed
it is generally considered appropriate to by blunt dissection, is pulled through this
doso. ventral incision (Figure 8.13) and cut 1.5cm
The circumferential incision is identical (0.6 in) above the level of the horizontal
to that described above except that a sub canal (Figure 8.14).
sequent vertical incision is not made A drainplate is constructed as described
(Figure 8.8). Instead, the conchal cartilage is above (Figure 8.15) and the distal incision
gradually worked free by digital and blunt closed (Figure 8.16).
dissection until the entire trumpet of the

Fig. 8.11 The level of the horizontal ear canal Fig. 8.12 The skin is incised at the level of the
is palpated. horizontal ear canal.
Fig. 8.13 The entire, already freed, conchal Fig. 8.14 The exposed vertical ear canal is
cone is pulled through the incision. excised at the level of the horizontal ear canal.

Fig. 8.15 The stoma at the horizontal ear Fig. 8.16 The initial circumferential incision is
canal is closed, taking care to ensure that the closed in a routine manner.
drainplate keeps the opening patent.
Postoperative care
Postoperative analgesia is mandatory.
Postoperative antibacterial therapy should
be continued for at least 10 days, or until the
sutures are removed14.
Postsurgical problems
Postsurgical complications with this
technique are much less common than
those seen after lateral wall resection13,14,19.
Furthermore, improper patient selection
occurs less frequently than with lateral wall
resection17. In one study19, dehiscence of the
suture line occurred in 12% of cases, with
stenosis of the external acoustic meatus
occurring in 7% of cases. Damage to the
facial nerve is possible, particularly if deep
Fig. 8.17 Stenosis of the horizontal ear canal sectioning of the external acoustic meatus
following inadequate construction of the is attempted. Stenosis of the external
drainplate. The problem was exacerbated by acoustic meatus (Figure 8.17) is usually a
a failure to identify underlying atopy, which consequence of inadequate construction
resulted in ongoing disease in the remnants of the drainplate, resulting in a failure
of the vertical ear canal and concave aspect of to support the canal and impairment of
the pinna. natural drainage19.

Postsurgical problems can be addressed Although the pain associated with chronic
as follows: otitis externa was largely controlled in the
Postoperative, acute, inflammatory dogs subjected to this procedure24, most
stenosis of the external acoustic required occasional treatment to clean the
meatus may be suppressed if the ear canals.
lumen is packed with glucocorticoid- The technique for dissecting out the
impregnated gauze for a few days13. ossifications is as follows (after Hobson23
Dehiscence is best treated and Elkins et al.24):
aggressively with systemic If the vertical canal is still present
antibacterial agents and drainage19,22. (and is to be ablated, as described
Consideration should be given to above), it is exposed and the
obtaining a culture and sensitivity dissection is continued ventrally to
report if dehiscence occurs in dogs expose the ventral wall of the ossified
receiving postoperative antibacterial horizontal canal, taking great care to
therapy. Surgical closure is indicated avoid the facial nerve.
as soon as infection is under control6. In the presence of an ossified vertical
Stenosis of, or impaired drainage canal, ronguers are used to remove
from, the external acoustic meatus ossified cartilage from the lateral
warrants investigation since it surface of that portion of the vertical
implies one of two problems, neither canal destined to form the drainplate.
mutually antagonistic: inadequate In effect, the drainplate is constructed
drainplate construction or ongoing from the epithelial components of the
otitis media. vertical canal rather than from the
cartilaginous portion.
Ossification of the external ear An incision is made on the distal
canal aspect of the junction of the annular
Mineralization of the cartilaginous com and auricular cartilages. This allows
ponents of the external ear canal may occur an osteotome (or a small rounded
as a consequence of chronic inflammation23. periosteal elevator) gradually to
The initial changes appear to occur in the elevate the soft tissue lining of
horizontal canal23, although with time, and the horizontal canal. The ossified
in particular in Cocker Spaniels, the vertical cartilage can then be gradually
canal may also become ossified. Although removed with ronguers while
the ossified vertical canal may be removed leaving the soft tissue lining of the
relatively easily by ablation, the surgical ear canal intact.
resection of ossified horizontal canals is Once the ossified material has been
more difficult. removed a drainplate is created from
A surgical technique has been described the remnants of the lateral wall of the
for dissecting out the ossified portions of the vertical canal, taking care to ensure
horizontal and vertical canals23,24, although that the horizontal canal is patent.
if the condition has progressed to this stage,
total ablation and bulla osteotomy may be
indicated. However, since total ablation
and bulla osteotomy sometimes results
in loss of hearing, owners may want to
avoid such a radical step, particularly if the
contralateral ear has already been ablated.

Total ear canal ablation and Total ablation and bulla osteotomy
lateral bulla osteotomy should render the ear deaf but, somewhat
The crucial steps in this procedure are: surprisingly, this does not always occur31,32.
Avoid damage to the round window It is wise to try and assess the dogs auditory
and the facial nerve. ability preoperatively and to demonstrate
Ensure that all secretory epithelium this to the owner2 in an attempt to forestall
is removed from the bulla and from unwarranted accusations of surgical
the site of the horizontal ear canal. ineptitude.
Treat tissues gently; ensure good Systemic antibacterial therapy is indi
haemostasis and close all dead space. cated both pre- and postoperatively,
beginning 714 days preoperatively30. The
It is now generally accepted that it is patient is anesthetized and the surgical area
prudent to perform a LBO with every prepared as described above. The pinna is
TECA 15,2527. Given the difficulty of defi hung with atraumatic forceps and a full
nitively documenting otitis media by draping of the field is performed. A small
radiography8, or even by CT28 (see Chapter rolled towel placed under the neck of the
2 for discussion on imaging the bulla), it is dog, to elevate the head to the level of the
almost impossible to justify not performing chest wall, facilitates exposure2.
a bulla osteotomy. Any residual discharge or A circumferential incision is made
secretion which might result from continuing around the acoustic meatus, severing the
otitis media, or indeed any portions of auricular cartilage but not penetrating the
epithelial tissue inadvertently left behind, will lateral skin surface of the pinna. The incision
accumulate and may well result in para-aural is continued to the level of the junction of the
abscessation3,26. Most authorities recommend horizontal and vertical ear canals (Figure
LBO in association with ablation of the 8.18). It may be necessary to resect large
external ear canal, since to perform ventral areas of infected, hyperplastic tissue in some
bulla osteotomy would require repositioning cases, with consequent implications for
of the animal during surgery, an unnecessary postoperative pinnal carriage.
complication since the ventral approach has Blunt dissection is used to expose
no advantage over the lateral29. the lateral surface of the vertical canal
Presurgical evaluation of the facial, (Figure8.19). The vertical canal is freed
oculosympathetic, and vestibular (cranial from the surrounding tissue using a
nerve VIII) nerves is useful28,30 as it provides combination of blunt and sharp dissection
a baseline for assessing the significance (Figures 8.20, 8.21). A dry gauze sponge
of any postoperative neurological signs. can be helpful for bluntly rubbing the
Bilateral total ear canal ablation (TECA) connective tissue from the vertical canal.
performed simultaneously has been Care should be taken to avoid haemorrhage
reported to cause pharyngeal swelling2, from the rostral auricular artery and vein
a complication of hypoglossal nerve and from the auriculopalpebral (branch of
damage. This complication may necessitate the facial) and auriculotemporal (branch of
a tracheostomy to alleviate upper airway the trigeminal) nerves in the cranial aspect
obstruction. For this reason some surgeons of the dissection30. Damage to blood vessels
stage the procedure by allowing at least 23 in this area may lead to avascular necrosis of
weeks to lapse before performing a second the pinna2. Haemorrhage may be controlled
TECA on a patient. However, other surgeons with electrocautery in the area around the
take the view that the advantages of a single vertical canal but not the horizontal canal;
episode of anaesthesia and a single period of the risk to the facial nerve is too great23.
postoperative pain outweigh the small risk Blunt dissection, keeping as close to the
of pharyngeal problems. perichondrium as possible, is continued

Fig. 8.18 Total ear canal ablation and bulla Fig. 8.19 The vertical ear canal is exposed,
osteotomy. The initial incisions are made. using blunt dissection.
Figs. 8.20, 8.21 The external ear canal is

gradually freed.
Fig. 8.22 Blunt dissection and gentle traction

is used to enable the surgeon progressively to
free the external ear canal to the level of the
bony acoustic meatus.
around the angle that forms the transition (Figure 8.22). Care should be taken to
between the vertical and horizontal canals, identify the facial nerve as it exits from
which represents the transition from the stylomastoid foramen and curves
auricular cartilage to annular cartilage rostroventrally around the horizontal

Fig. 8.23 The external ear canal is excised to Fig. 8.24 Using rongeurs, the bony external
expose the tympanic aperture. acoustic meatus is removed to expose further
the tympanic cavity.
canal. It should be carefully retracted this level (Figure 8.23). If chronic disease
ventrally. The advantage of performing this has caused ossification of the horizontal
dissection after freeing the vertical canal is canal, a small osteotome may be necessary
that there is maximal tissue laxity, which to transect the ear canal. A clamp across
allows the fullest retraction 17. In some the base of the horizontal canal before
cases the facial nerve may be intimately transection minimizes contamination from
associated with perichondrial connective debris within the canal.
tissue or even buried within the reactive A bone curette is used to scrape all
tissue surrounding ossified cartilage 1,26. epithelial tissue from the osseous external
This will require careful dissection if signi acoustic meatus27,30,33. It is critical that all
ficant postoperative morbidity is to be secretory tissue is removed as failure to
avoided. Gelpi retractors may be useful at achieve this will result in postoperative
this point. If the facial nerve proves hard para-aural abscessation. The bony external
to find, Smeak17 advocated searching the acoustic meatus is removed (Figure 8.24)
caudal and more superficial aspect of the using a sharp, small rongeur (such as
horizontal ear canal for small branches of a Lempert rongeur) or an air drill. This
the internal auricular nerve which penetrate will allow increased visualization of the
the cartilage; these may be followed back tympanic cavity. When enlarging the
to the facial nerve trunk. Gentle traction external auditory meatus it is best to stay
and tissue manipulation in this area is rostral and ventral to avoid the oval and
mandatory. round windows (on the opposite wall of
Blunt dissection is continued along the the bulla to the tympanum) and the facial
horizontal canal to the level of the skull. nerve33.
The entire horizontal canal is exposed to The ventrolateral portion of the tym
the level of the bony acoustic meatus, and panic bulla is removed (Figure 8.25) with
then sharply transected, with scissors, at rongeurs or an air-driven burr. It may

Fig. 8.25 The ventrolateral wall of the Fig. 8.26 After the tympanic cavity has been
tympanic bulla has now been breached. curetted it is flushed to ensure removal of all
debris.
prove necessary to extend the osteotomy removed earlier. Care should be taken not
rostrally and caudally in order to visualize to evulse the stapes off the oval window;
the caudal aspects of the tympanic cavity peripheral vestibular problems may result.
adequately. It is imperative that the shelf Paradoxically, removal of chronically
of bone ventromedial to the external inflamed epithelia is often more easily
acoustic meatus is removed if adequate accomplished than removal of minimally
exposure is to be achieved for optimum inflamed tissue. Extreme care should be
curettage33. taken not to disrupt the epitympanic recess,
The surgeon should avoid advancing the round window (mid-dorsal aspect), or
onto the ventral aspect of the bulla. Some the oval window (craniodorsal). Samples
ventral retraction of the soft tissues will from the middle ear should be submitted
have been performed to allow dissection for bacterial culture and sensitivity.
of the annular cartilage, but both the facial Note: This part of the procedure is
nerve and the external carotid artery are critical, for if infected secretory tissue is left
in this area and extreme caution is war within the bulla, postoperative abscessation
ranted. If haemorrhage is encountered, and fistulation can be expected.
definitive haemostasis is important; use The tympanic cavity is thoroughly
haemostaticclips33. flushed with warmed saline solution
Suction is usually necessary at this (Figure 8.26). A drain (latex, active, or
point to maintain adequate visibility of ingress/egress) (Figure 8.27) may be
the surgical field. The tympanic cavity placed, entering via the tympanic orifice
is curetted or abraded, using a dry gauze and exiting the tympanic cavity through the
sponge wrapped on the end of a haemostat osteotomy and passing through the skin via
to remove any inspissated contents, a stab incision. This is beneficial if clearing
secretory epithelium, and remnants of the of the bulla is not complete or if a large
tympanic membrane and the malleus, if not amount of discharge is expected2. Drainage

Fig. 8.27 A drain tube is placed (through a

separate stab incision) and closure begun.
may not be necessary with strict adherence be taken to ensure that they are not used
to good surgical techniques34. concurrently with nonsteroidal anti-
Closure is performed using mono- inflammatory drugs as there is an increased
filament absorbable sutures in the subcu risk of gastric ulceration.
taneous tissue (Figures 8.288.30). Great Generally, it is not necessary to irrigate
care must be taken to close all potential postoperatively; the drains are placed
dead space as this will help to minimize (Figures 8.31, 8.32) to allow local exudate
postoperative cellulitis. Routine skin to clear the surgical site rather than to
closure is performed in the shape of a T, facilitate flushing30. If a drain is inserted,
with care taken to effect a cosmetic ear soft, padded dressings should be used to
carriage when closing the area of the former cover the surgical site and the drain egress
tragus and antitragus. until the drain is removed, typically after
25 days. Care should be taken that these
Postsurgical care dressings do not constrict the pharynx17.
Postoperative analgesia is mandatory. Sutures are removed after 1014 days.
Postoperative systemic antibacterial Careful neurological observations
therapy is usually warranted and must should be made. In the immediate post
be continued for 1021 days 2,30 . The operative period, hypoglossal damage
choice of antibacterial agent may need may be apparent and although it does
to be reviewed in the light of bacterial not usually require specific treatment,
culture and sensitivity testing of tissue animals should be closely observed for
obtained at surgery. Postoperative the 24 hours immediately postsurgery2.
glucocorticoids have been recommended23. Respiratory function, in particular, should
Used in anti-inflammatory doses be monitored postoperatively as significant
(0.51.0 mg/kg dividedq12 h) prednisolone pharyngeal swelling may occur following
may help to decrease postoperative bilateral surgery17. Ocular lubricants may
swelling. Glucocorticoids should not be be indicated until normal blink reflex is
used for more than 3 days and care must regained.

Figs. 8.288.30 Routine closure, ensuring

elimination of dead space, ends the surgery.
Figs. 8.31,8.32 Passive and active drains, put in place after surgery, ensure that any exudate is
removed.

Postsurgical problems postoperative neuropathy 2,27,30,34. Mild,

Postsurgical problems are a reflection of transient paresis of the auriculopalpebral
two main factors: the surgical complexity nerve is also common21. Ninety percent
of the procedure and the degree of bacterial of these cases resolve within a few weeks
contamination of the surgical site2,21,35. of surgery and they can be managed
Discharge from the surgical site is by application of artificial tears, for
common 2,2628,33 . Discharge and post example35,36. However, absence of blink
operative swelling may be treated with hot reflex, lip paralysis, or pinnal paralysis
compresses for 5 minutes, three times daily. may be long term, and the prognosis
Drainage may be facilitated by removing is poor if no evidence of improvement
the most ventral sutures. Fistula formation is apparent 4 weeks postsurgery17. The
(para-aural sinus) may occur 312 months practical consequences of long-term facial
postsurgery in cases in which incomplete nerve damage are minimal provided tear
removal of infected and secretory tissue production is normal and exophthalmia is
was achieved. Para-aural sinuses (Figure not present17.
8.33) may create more clinical problems Postoperative Horners syndrome
than the original otitis17,35. and damage to the facial nerve (ptosis,
Pinnal necrosis (which is usually midriasis, nystagmus, head tilt, flaccid
limited to the caudal aspect of the pinna) facial paralysis) is usually confined to
is a consequence of compromised blood the cat and will resolve within a few
supply. Management is based on local weeks,aslongas the otitis media has
cleansing, debridement if necessary, and resolved2.
awaiting re-epithelialization. Short-term complications, such as
Postoperative nerve damage is relatively incisional abscess, dehiscence, or swell
common, and in about 10% of cases some ing, can be seen with TECA-LBO. Most
degree of permanent neuropathy can be are short lived and resolve with con
expected2,27,30,34. Hypoglossal nerve damage servative treatment, although extensive
(drooling, dysphagia) is usually short term. complications may require surgical
Facial nerve damage is the most common revision. If damage to the epitympanic
recess, oval window, or round window
occurs, abnormalities such as nystagmus,
head tilt, and general vestibular abnor
malities can occur. This complication is
often temporary, and resolves within 710
days with only supportive care. If a patient
displayed a head tilt prior to surgery, it
will often persist in the acute postoperative
period, with some patients remaining
persistently abnormal.
Long-term complications usually
involve abscessation of the middle ear
and/or fistulation of tissues ventral to the
middle ear. Most commonly this is due to
incomplete excision of the membranous
lining of the bulla3,34. Medical therapy of
persistent or recurrent infection is rarely
Fig. 8.33 Para-aural sinus following curative. Surgical re-exploration of the
incomplete removal of all secretory tissues at bulla to remove remaining epithelial tissue,
surgery. combined with debridement of infected

tissue and appropriate drainage, is used Gentle, ventral retraction of the

to control infection and this is effective parotid gland should reveal the facial
in up to 85% of dogs with recurrent nerve, which is carefully retracted
postoperativeotitis36,37. caudoventrally to reveal the lateral
Deafness and loss of hearing ability aspect of the tympanic bulla.
after total ablation and bulla osteotomy The bulla is further exposed using
is a common concern of owners. Studies a periosteal elevator and broached
vary, but patients with severe proliferative with a Steinmann pin in a hand
canal disease tend to retain the same level chuck. Care is needed here because
of hearing they had prior to surgery, hence the density of the bulla varies and is
the value of preoperative assessment31. This unpredictable; too much pressure
also is true in most cases when comparing and the pin may impact on the
preoperative and postoperative brainstem opposite side of the tympanic cavity.
auditory evoked responses4,37. The pin enters on the caudolateral
aspect of the bulla and is directed
BULLA OSTEOTOMY from a caudoventral direction so
that if it impacts on the medial wall it
Indications avoids the mediodorsal wall.
The principle indication for bulla oste The osteotomy site is enlarged with
otomy is the treatment of refractory rongeurs, observing the precautions
otitis media 29,30,33 . The procedure is outlined above.
most commonly performed in the dog Samples for microbiological culture
in association with total ablation of the and sensitivity testing are taken and
external ear canal, in which case a lateral the tympanic cavity is flushed with
bulla osteotomy is performed. The warm isotonic saline until the run-
alternative approach to the bulla is a ventral out is clear of debris.
approach, most often performed in the cat If purulence is evident in the
in the management of inflammatory polyps tympanic cavity, a drain tube is
arising from the middle ear. Other, much sometimes placed. This is sutured to
less common, indications are the excision adjacent soft tissues with 4/0 catgut
of neoplastic masses and the removal of and exited adjacent to the initial skin
cholesteatomas17. incision. Twice daily flushing with
an appropriate antibacterial agent is
Surgical technique performed until the drain is removed
Lateral bulla osteotomy as a after 7 days. Flushing may not
separate procedure always be effective unless an ingress
LBO is more easily performed after TECA (dorsal via the tympanic opening)/
has been carried out, principally because egress (ventral) drain is used26.
of increased visualization38. The surgical Passive ventral drainage may suffice
technique is as follows (after Krahwinkel in many cases.
et al.37, Barrett and Rathfon39, and Boothe40):
A skin incision is made over the
external ear canal and extended
ventrally beyond the level of
the horizontal ear canal. The
subcutaneous tissues are gently
dissected to reveal the apposition of
the parotid salivary gland and the
horizontal ear canal.

Ventral bulla osteotomy A sagittal incision is made

Ventral bulla osteotomy provides less immediately medial to the
opportunity for iatrogenic nerve damage, mandibular salivary gland, at a level
better visualization of the tympanic cavity, midway between the angle of the
and more consistent ventral drainage than mandible and the wings of the atlas
the lateral approach41,42. The reason that (Figure 8.34). The thin myelohyoid
this approach is not used more frequently muscle is split.
in dogs is that in most cases middle The digastricus muscle is separated
ear infection is associated with chronic from the hyoglossal and styloglossal
external ear disease and both areas are then muscles by blunt dissection.
addressed in a unified field. Furthermore, The hypoglossal nerve and branches
in one study29 there was little difference of the internal carotid artery are
in postoperative complications compared identified on the lateral aspect of
with the lateral approach. the hyoglossal muscle and carefully
Ventral bulla osteotomy is the most retracted medially.
freq uently used approach in the cat, a Further retraction of the digastricus
reflection of otitis media occurring in the muscle (laterally) and of the
absence of chronic otitis externa in this hyoglossal muscle (medially) reveals
species. Note that the bulla of the cat differs the rounded bulge of the bulla
from that of the dog. The surgical technique between the jugular processes of the
is as follows (after Fossum3, Harari15, Smeak skull (caudal to the bulla) andthe
and de Hoff26, Boothe41, Seim42, Denny43, angular process of the mandible
and McNutt and McCoy44): (rostral).
Fig. 8.34 The bulla has been exposed. Fig. 8.35 A Steinmann pin has been used to
broach the bulla.

The thin muscular covering of the A drain tube is placed if necessary

bulla is incised and reflected with a (see above) in the tympanic cavity,
periosteal elevator. sutured to adjacent soft tissues with
The bulla is broached with a 4/0 catgut, and exited adjacent
Steinmann pin in a hand chuck to the initial skin incision. Twice
(Figure 8.35). Care is needed here daily flushing with an appropriate
because sudden penetration may antibacterial agent is performed until
result in the pin impacting on the drain removal after 7 days.
dorsal aspect of the tympanic cavity
and damaging the oval or round Postsurgical problems
windows. Possible complications to bulla osteotomy
The pin is removed and the are principally neurological 39. As with
osteotomy site enlarged with those encountered after TECA and bulla
rongeurs (Figures 8.36, 8.37). osteotomy (described above), these relate
Samples for microbiological culture principally to the hypoglossal nerve
and sensitivity testing are taken and (drooling, dysphagia) and branches of the
the tympanic cavity is flushed with sympathetic and parasympathetic nerve
warm isotonic saline until the run- supply (ipsilateral Horners syndrome and
out is clear of debris. keratoconjunctivitis sicca, respectively).
Figs. 8.36, 8.37 The osteotomy is progressively enlarged with rongeurs.

SPECIAL PROBLEMS RELATING The two chambers communicate via

TO SURGERY OF THE MIDDLE the space between the septum and the
EAR IN CATS caudomedial wall of the tympanic cavity41.
The round window of the cochlea, the
Middle ear disease in cats usually promontory, and the postganglionic fibres
relates to otitis media or inflammatory of the cervical sympathetic trunk are in
polyps,although neoplasia may occur this region of the medial wall and are thus
rarely45. vulnerable to damage, particularly if the
The tympanic bullae of cats are easily septum is removed. Horners syndrome will
palpable on the ventral aspect of the feline result if the sympathetic fibres are damaged. It
skull and they are easily accessible with a may be necessary to open the septum if access
straightforward dissection (Figure8.38), to inflammatory polyps in the dorsolateral
as outlined above. However, the ventral chamber is required or to facilitate drainage
chamber of the tympanic cavity is charac and, if so, care should be taken to avoid
terized by an incomplete bony septum41. the region adjacent to the promontory16.
It is this septum which is visible upon Postoperative Horners syndrome occurred
opening the ventral wall of the tympanic in 4257% of cases in one series45,46. Although
bulla and it divides the ventral cavity into the majority of cases resolved within 8 days of
two. The larger ventromedial chamber is surgery, the signs persisted, albeit mildly, after
entered via the bulla osteotomy and the 4 weeks in 21% of cases. Some facial paresis
smaller dorsolateral chamber, in effect the and inner ear disease (head tilt, ataxia) may
tympanic cavity proper, lies beyond the also be noted postoperatively in a proportion
septum. of cases, again usually temporary16.
Fig. 8.38 Feline ventral

bulla osteotomy. The
surgical site.
Digastric muscle
Hypoglossal
nerve
Tympanic bulla
Sublingual gland
Soft rubber
tubing

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OTITIS EXTERNA

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2014 by Taylor & Francis Group, LLC

No claim to original U.S. Government works

International Standard Book Number-13: 978-1-4822-2458-0 (eBook - PDF)

Visit the Taylor & Francis Web site at

and the CRC Press Web site at

1 The Normal Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Approach to the Diagnosis of Otitis Externa . . . . . . . . . . . . . . . . . . . 13

3 Aetiology and Pathogenesis of Otitis Externa. . . . . . . . . . . . . . . . . . 45

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5 Medical Management of Ear Disease . . . . . . . . . . . . . . . . . . . . . . . . . 81

6 Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

7 Ototoxicity and Other Side-Effects of Otic Medication. . . . . . . . . . 115

8 Aural Ablation and Bulla Osteotomy. . . . . . . . . . . . . . . . . . . . . . . . 121

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The investigation and management of ear disease will occupy a

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BAER brainstem auditory evoked response

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KEY POINTS INTRODUCTION

Cochlea Ear canal

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Figs. 1.6, 1.7 Examples

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EXTERNAL AUDITORY MEATUS MIDDLE EAR

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Tympanum dimension is nearly vertical, the long axis

Fig.1.10 Photomicrograph of a section of normal bulla.

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aspect of the tympanum is thin, tough, and MICROSCOPIC STRUCTURE OF

Fig. 1.11 Otoscopic picture of a normal Fig. 1.12 Photomicrograph of a section of

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The epidermis lining the external ear Hair follicles

Fig. 1.13 Photomicrograph of a section of Fig. 1.14 Photomicrograph of a section of

Fig. 1.15 Photomicrograph of a section of Fig. 1.16 Photomicrograph of a section of

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along the canal. There was a large interdog Adnexal glands

Fig. 1.18 Photomicrograph of a section of

Fig. 1.17 Photomicrograph of a section

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epidermal debris7. This high lipid content MICROCLIMATE OF THE

Fig. 1.19 Photomicrograph of a section of

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Epithelial lining throughout the day6, with a recorded rise

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Fig. 1.25 Photomicrograph of normal Fig. 1.26 Scanning electron micrograph

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INTRODUCTION In other cases it may be apparent that

Table 2.1 Investigative techniques that may be employed in order to stage

Visual examination and palpation of the auricular cartilages

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SIGNALMENT abscess or obstructive otitis secondary to

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