Notoedres Cati

Related terms:

Antibiotics, Coccidiosis, Dermatophytosis, Butorphanol, Medetomidine, Sarcoptes,

Parasites, Mites, Ectoparasites, Ruminants

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Parasitic Diseases
Stacy Pritt, ... Heather Sedlacek, in The Laboratory Rabbit, Guinea Pig, Hamster, and
Other Rodents, 2012

Etiology
Notoedres cati is referred to in older literature sources as Notoedres minor cuniculi.
Sarcoptes scabiei (Figure 15.11) is also known as the itch or scab mite (Hofing and
Kraus, 1994). It is thought that S. scabiei from different host species are separate
varieties, however this is still being debated (Schoeb et al., 2007). It is also thought
that host specificity has arisen in the parasite so that, for example, S. scabiei infecting
a human would spread more readily to another human. Interspecies transmission
does still occur, however resulting dermatitis may be atypical and transient (Bow-
man, 2009).
Figure 15.11. Sarcoptes scabei. A is male and B is female. Viewed from the underside
(from Farmers Bulletin 1568, revised 1931;from Canestrini 1894. Used with permis-
sion from the University of North Texas Libraries, Digital Collection)

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Pruritic Skin Diseases

Lisa Akucewich, Nicola Williamson, in Handbook of Small Animal Practice (Fifth
Edition), 2008

Definition and Cause

I. Notoedres cati is a highly contagious mite that primarily infects cats, but dogs,
foxes, and rabbits can also be infected.
II. N. cati is a surface-dwelling mite that causes papules, lichenification, thicken-
ing of the skin, and tightly adherent yellow-gray crusts.
III. The disease is also called feline scabies.

IV. The mite is zoonotic.

Clinical Signs
I. Lesions first appear on the medial, proximal margin of the pinnae.

II. Lesions rapidly spread to the rest of the ear, face, eyelids, and neck.

III. Feet and perineum may be affected, and lesions can become widespread.

IV.
 Lesions consist of thickened, wrinkled skin with tightly adherent gray to yellow
crusts.
V. Intense pruritus may lead to self-mutilation and secondary bacterial infections.

VI. Peripheral lymphadenopathy may be present.

Diagnosis
I. Demonstration of the mite on skin scraping

II. BiopsyA.Thickened epidermisB.Focal, parakeratotic, hyperkeratosis and su-

perficial perivascular dermatitisC.Mite segments seen in the stratum corneum

Differential Diagnosis
I. Otodectic mange, cheyletiellosis

II. Food allergy, atopy

III. Pemphigus complex

IV. Systemic lupus erythematosus

Treatment
I. All cats in the household are treated.

II. Crusts and debris are removed with a mild shampoo, then lime sulfur (2% to
3%) dip is applied weekly for six to eight treatments.
III. Ivermectin may also be given 0.2 to 0.3 mg/kg PO, SC every 2 weeks for three
treatments.
IV. Selamectin can be applied topically for two applications, 4 weeks apart.

Monitoring of Animal
I. If no response to treatment is seen, then evaluate the animal for recurrence.

II. If recurrence has occurred, the animal may be reinfested from the environment
or from untreated dogs, cats, or rabbits.

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Mites (Acari)
Gary R. Mullen, Barry M. OConnor, in Medical and Veterinary Entomology (Third
Edition), 2019

Human Notoedric Mange

Humans occasionally become infested with Notoedres cati, a sarcoptid mite that
causes notoedric mange in cats. Cases in humans are called human notoedric mange
or human notoedric scabies. After prolonged exposure to infested cats, people can
become sensitized to this mite and develop intense pruritus within a few hours of
subsequent contact with them. The reaction is induced without the mites actually
burrowing. The most common sites of skin lesions are on the hands and legs,
reflecting the areas most likely to come in contact with pets. The lesions subside
when infested cats are either treated or removed from further contact (Chakrabarti,
1986).

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MITES (Acari)
GARY R. MULLEN, BARRY M. OCONNOR, in Medical and Veterinary Entomology,
2002

HUMAN NOTOEDRIC MANGE

Humans occasionally become infested with Notoedres cati, a sarcoptid mite that
causes notoedric mange in cats. Cases in humans are called human notoedric mange
or human notoedric scabies. Following prolonged exposure to infested cats, people
may become sensitized to this mite and develop intense pruritus within a few hours
of subsequent contact with them. The reaction is induced without the mites actually
burrowing. The most common sites of skin lesions are on the hands and legs,
reflecting the areas most likely to come into contact with pets. The lesions subside
when infested cats are either treated or removed from further contact (Chakrabarti,
1986).

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Biology and Diseases of Rabbits

Megan H. Nowland DVM, BS, DACLAM, ... Howard G. Rush DVM, MS, DACLAM,
in Laboratory Animal Medicine (Third Edition), 2015
Epizootiology
Sarcoptic are similar to notoedric mites (Notoedres cati) in morphology, life cycle,
and public health significance. Mites burrow and produce an intensely pruritic
dermatitis. Lesions are most common on the head (Hofing and Kraus, 1994).

All stages of sarcoptic mange mites occur on the host. The females burrow into the
skin to lay eggs. Young larvae can also be found in the skin, whereas older larvae,
nymphs, and males reside on the skin surface. Mites feed on lymph and epithelial
cells (Hofing and Kraus, 1994).

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Skin Diseases
Molly Varga BVetMed DZooMed MRCVS, in Textbook of Rabbit Medicine (Second
Edition), 2014

7.14.3.6 Sarcoptic mange

Sarcoptic mange has been reported in association with Notoedres cati and Sarcoptes
scabiei infestation in laboratory or commercial rabbits. Pruritic lesions are found,
especially on the face, nose, lips and external genitalia (Percy and Barthold, 1993).
Other areas such as the pinnae and neck may be affected (Lin et al., 1984). The skin
is covered in yellow scaly crust. Sarcoptic mange is rare in the UK, although it is
common in other parts of the world such as Africa (Scott et al., 1995). Ivermectin is
an effective treatment.

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Parasitic Skin Disorders

In Small Animal Dermatology (Fourth Edition), 2017

Features
Feline scabies is a disease that is caused by Notoedres cati, a sarcoptic mite that
burrows superficially in the skin. In multiple-cat households and catteries, more
than one cat is usually affected. Wild life, including squirrels, can serve as a source
of infection. The condition is rare in cats.
Feline scabies is noted as intensely pruritic, dry, crusted lesions that usually first
appear on the medial edges of ear pinnae and then spread rapidly over the ears, head,
face, and neck. Lesions may subsequently spread to the feet and perineum. Infested
skin becomes thickened, lichenified, alopecic, crusted, or excoriated. Peripheral
lymphadenomegaly is common. If untreated, lesions may spread over large areas
of the body, and anorexia, emaciation, and death may occur.

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Ectoparasites
In Clinical Veterinary Advisor: Birds and Exotic Pets, 2013

Basic Information 

Definition
• Major ectoparasites of rabbit include Cheyletiella parasitovorax, fleas, Notoe-
dres cati, Psoroptes cuniculi, and Sarcoptes scabei.
• Other ectoparasites include ticks, the fur mite Leporacarus gibbus (formerly
Listorphorus gibbus), Cuterebra cuniculi, lice (Haemodipsus ventricosus), and fly
larvae causing myiasis.

Synonyms
• C. parasitovorax = rabbit fur mite; “walking dandruff ”

• Fleas = Spilopsyllus cuniculi (rabbit fleas), Ctenocephalides felis (cat flea), Cteno-
cephalides canis (dog flea)
• Psoroptes cuniculi = rabbit ear mites

• Cuterebra cuniculi = Warble flies

• Haemodipsus ventricosus = Pediculosis

Special Species Considerations

• Parasites account for more than 80% of dermatologic diagnoses in exotic
species; the most common diagnosis is unspecified mite infestation.
• In the United Kingdom and Europe, P. cuniculi are the most frequent cause
of otitis in rabbits and may be the most frequent cause of dermatologic
disease. However, the prevalence of ectoparasites and dermatologic conditions
varies by region (tropic/temperate zone), country, and season (e.g., S. scabei is
frequent in tropical countries/regions).

Epidemiology

Species, Age, Sex

A survey of dermatologic conditions of small animals in general practice revealed

that rabbits with parasitic disease ranged in age from 4 weeks to 10 years, with a
median age of 2 years and a mode of <1 year. Any species, age, or sex of rabbit can
be affected by ectoparasites.

Risk Factors

• Rabbits housed with other infected rabbits or with exposure to wild rabbits are
at risk of infestation.
• Rabbits housed with dogs or cats may be exposed to Ctenocephalides.

• Pregnant does and kits may be more prone to severe rabbit flea infestation
because ova of the flea mature only after the female feeds on a pregnant doe
late in gestation.

Contagion and Zoonosis

• Ectoparasites can be transmitted between rabbits.

• Cheyletiellosis is a zoonosis that causes papular dermatitis in humans and may

be transmittable to other species, including dogs and cats.
• Rabbit fleas and lice are vectors for tularemia (see Tularemia, Sec. VI). They
rarely bite humans but may bite dogs and cats.
• Ticks are important vectors of zoonotic disease (e.g., Rocky Mountain spotted
fever, tularemia, Lyme disease). Most ticks that feed on rabbits rarely bite
humans.

Geography And Seasonality

• Some ectoparasites are more commonly seen in warmer months in temperate

and cool climates (e.g., fleas).
• Cuterebra cuniculi are found in North America.

• Many tick species are specific to particular regions.

Associated Conditions and Disorders

• The rabbit flea (S. cuniculus), rabbit louse (H. ventricosus) and the fur mite (C.
parasitovorax) are vectors for myxomatosis (see Myxomatosis).
• Heavy infestations of fleas and lice may cause anemia.

Clinical Presentation

History, Chief Complaint

Pruritus is the most common clinical sign.

Physical Exam Findings

• Physical examination findings include scales and crusts, and alopecia.

• P. cuniculi are associated with inflammation (hypersensitivity reaction to mite

piercing skin to feed) and reddish-brown crusting of the external ear canal,
head shaking, ear drooping, and pruritus; inflammation and crusting may
be generalized in debilitated rabbits; severe infection can lead to eardrum
perforation and neurologic signs.
• C. parasitovorax may be subclinical but more often causes a scaly, dry, some-
times pruritic dermatitis with patchy alopecia or broken hairs over the dorsal
neck, trunk, hind end, and abdomen.
• S. scabei and Notoedres cati cause a crusty, pruritic dermatitis around the head,
neck, and trunk.
• Flea infestations may manifest as a dull coat, easily epilated hair, and patchy
alopecia with pruritus, skin erythema, and crusting, especially on the pinnae
and face. Flea droppings may be seen in the coat.
• Lice infestations may cause weight loss, alopecia, pruritus and papule forma-
tion.

Etiology and Pathophysiology

• P. cuniculi are large, obligate, nonburrowing parasites with a 3-week life cycle
and an ability to survive off the host for up to 21 days.
• The life cycle of the flea is controlled by the hormonal cycle of the host (this
explains the sudden proliferation on pregnant does and young rabbits).
• H. ventricosus life cycle is 2 to 5 weeks

• Cuterebra cuniculi hatched larvae crawl into fur and enter host through a normal
orifice and migrate to a subcutaneous site.

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Parasitic Diseases
Holly N. Burr, ... Neil S. Lipman, in The Laboratory Rabbit, Guinea Pig, Hamster, and
Other Rodents, 2012

Notoedric Acariasis

Background
Two species of Notoedres capable of infecting hamsters have been identified, Notoe-
dres cati, the cat mange mite, and Notoedres notoedres. These mites fall within the
family Sarcoptidae, along with Sarcoptes scabei. These mites, causes of notoedric
mange are no longer common parasites of laboratory animals. Literature of the
1940s and 1950s repeatedly reported cases within animal facilities (Wantland, 1955).
Today it exists as a pet hamster disease, but without cumulative data on its true
prevalence (Beco et al., 2001).

Etiology/Etiologic Agent
Notoedres spp. are small, round mites closely resembling Sarcoptes (Figure 32.16).
Female mites are larger than male mites (Table 32.3). Notoedres adults have posterior
limbs which do not protrude past the body margins (Leone, 2007). They also possess
blunt dorsal spines and a dorsal anus which aids in differentiating them from
Sarcoptes (Uzal et al., 2007). Males and females can be differentiated by the lack of a
mid-dorsal shield in females.
Figure 32.16. A photo of Notoedres mite characterized by a dorsal anus. Skin scrap-
ing; chloral lactophenol.Reproduced from Beco et al. 2001 with permission.

Epizootiology
Transmission is by direct contact between animals and presumably by contact with
infected bedding (Beco et al., 2001). The nymph and larval stages are the predom-
inant transmissible stages of this highly contagious disease. It will spread rapidly
within a colony if proper treatment strategies are not initiated. Unlike Sarcoptes,
Notoedres appears to have limited zoonotic potential.

Clinical Manifestations
The clinical signs of Notoedres infections are severe pruritus, erythema, crusts, ero-
sions, and hyperpigmentation (Beco et al., 2001). These lesions may be generalized,
but are more often found on ear pinnae, face, genitalia, tail, and limbs (Beco et al.,
2001) (Figure 32.17). These lesions may result in death within 2–3 months if left
untreated (Wagner, 1987).
Figure 32.17. A photo of a hamster with lesions of Notoedres infestation on its face
and feet. Severe crusting can be observed on the muzzle, ears, and extremities.Re-
produced from Beco et al. 2001 with permission.

Pathology
Infections with N. cati cause chronic inflammatory changes in the epidermis. Extrap-
olating from N. cati infections in other species, potential changes include hyperk-
eratosis and acanthosis along with inflammatory cells, cellular debris, and mites in
the epidermis (Uzal et al., 2007). One or more mites are found within tunnels in the
stratum corneum.

Pathogenesis/Life Cycle
The life cycle of Notoedres is not clearly understood (Uzal et al., 2007). Ova are
deposited within epidermal tunnels. These ova hatch into six-legged larvae within
3–4 days. These larvae undergo several more molts, transforming into eight-legged
nymphs in approximately a 3-day period. These nymphs continue to molt as they
burrow within the skin, eventually becoming adults. The entire cycle is estimated to
take 10–20 days (Baker, 2007; Wantland, 1955). All three mobile life stages can be
found on the skin.

Epidermal burrowing by mites causes pruritus and increases potential for secondary
bacterial infections following mechanical damage to the skin by mites and the host’s
attempts to alleviate discomfort through scratching.

Diagnosis
Diagnosis is made by observation of mites and fecal pellets on skin scrapings using
light microscopy (Beco et al., 2001).

Prevention and Therapy

Along with proper sanitation and cage changing, several methods for elimination of
Notoedres infections are reported. Whole body lime-sulfur dips can be done once a
week and continued for 2 weeks after a negative skin scrape. One study compared
treatment of infected hamsters using ivermectin and moxidectin (Beco et al., 2001).
Once-weekly subcutaneous ivermectin (400 μg/kg) or once- or twice-weekly oral
moxidectin (400 μg/kg) were each given for 8 weeks. Both reduced clinical signs
dramatically, but neither treatment led to complete remission. Repeat skin scrapings
are therefore necessary to ascertain the effectiveness of these drugs. Selamectin has
also been used successfully to treat notoedric mange in cats (Itoh et al., 2004).

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The Ear1
Bradley L. Njaa, in Pathologic Basis of Veterinary Disease (Sixth Edition), 2017

Parasitic Diseases of the External Ear

Numerous ectoparasites parasitize or infest domestic and wild animals, including
mites, ticks, and nematodes (E-Table 20-1). Most affect their hosts by infesting
various parts of the integumentary system (see Chapter 17). A small proportion of
these organisms preferentially infest the ear. Reactions vary from minimal irritation
to gross deformity. External ear infections may be isolated or extend to the middle
and internal ears. The clinical signs are prototypic, including head shaking, repeated
ear twitching, excessive ear itching, and traumatization of the auricle and base of the
ear.

E-Table 20-1. Ticks, Mites, and Nematodes Affecting the External or Middle Ears of
Animals

Name Location/Type Host

Notoedres cati s, e, m Cat, rabbits, dog

Sarcoptes scabiei s, e, m Dog, cat, pigs (ear canal)

Demodex spp. s, e, m Dog, cat

Otodectes cynotis e, m Cat, dog, other carnivores

Psoroptes cuniculi e, m Rabbit, sheep, goat, horse, deer

Raillietia species e, m Cattle, buffalo, goat, others

Otobius megnini e, t Dog, cat, horse, ruminants, pigs

Otobius lagophilus e, t Rabbits

Rhipicephalus species s, e, t Dog, horse, ruminants, others

Amblyomma species s, t Dog, horse, ruminants

Amblyomma maculatum e, t Ruminants, others

Amblyomma americanum s, e, t Ruminants, others

Boophilus species s, t Ruminants, horse

Dermacentor nitens s. t Horse, ruminants

Haemaphysalis lep- s, t Horse, ruminants

orispalustris

Ixodes ricinus s, t Dog, horse, ruminant

Rhabditis spp. e, n Cattle

Mammomonogamus auris e, n Cat (otitis media)

e, Ear; n, nematode; m, mite; s, skin; t, tick.

Modified from Thomson RG: Special veterinary pathology, Toronto, 1988, BC Deck-
er.

Ear Mite Infestations (Otoacariasis)

Mites are categorized as burrowing or nonburrowing. Many species, such as Sar-
coptes spp. (see Fig. 17-54) and Demodex spp., can cause more generalized lesions
with possible involvement of the ear. However, there are few mites that spend much
or all of their life cycle within the concave portion of the auricle or in the external
acoustic meatus.

Otodectes Cynotis.

Otodectes cynotis infests the external acoustic meatus of domestic and wild cats,
dogs, and occasionally ruminants. The main route of infestation is from dam to
offspring. Other routes of spread include contaminated combs, brushes, bedding,
or other grooming accessories. They are nonburrowing and feed on the cerumen,
keratin, and lipids. These mites are a prominent primary cause of otitis externa with
up to 50% of cats and 10% of dogs developing otitis externa. They cause intense
irritation by mechanisms not well understood. Copious cerumen production ensues
until a thick, waxy, dark brown otorrhea (exudate) obstructs the external acoustic
meatus. Auricles are often alopecic and have “scratching” wounds from trauma
that form in response to intense pruritus. These areas may also become infected
secondarily with bacteria. The epidermis becomes acanthotic with parakeratotic
hyperkeratosis and crusts that contain mites and mite detritus mixed with cerumen.
Small to moderate numbers of lymphocytes and macrophages infiltrate the dermis
and subcutis. Ceruminous glands are typically hypertrophied and hyperplastic and
may contain cellular debris and neutrophils.

Although a majority of cats are infested, a minority manifest clinical disease, possibly
owing to early exposure as kittens and the development of Arthus- and immedi-
ate-type hypersensitivity reactions.

Notoedres Cati.

Notoedres cati is primarily a cat pathogen but can infest dogs, foxes, rabbits, and
rarely human beings. Usually infestations are restricted to the auricles, head, face,
neck, and shoulders. Infestation produces alopecia, pruritus, thick crusting, and
excoriation of the rostral pinnae as the female mite burrows in the stratum corneum
and occasionally penetrates hair follicles and sebaceous glands. Microscopic lesions
include epidermal hyperplasia and spongiosis with perivascular eosinophilic der-
matitis and crusting.

Raillietia Species.

Raillietia spp. of mites occur most commonly in cattle, buffalo, and goats of nearly
every continent. Cattle are most commonly parasitized by Raillietia auris, whereas the
mite infesting goat ears is Raillietia caprae. Raillietia flechtmanni is found in buffalo
and cattle ears. These mites often go undetected because of their small size and their
tendency to reside deep in the external acoustic meatus adjacent to the tympanic
membrane, and they do not commonly cause clinical disease. When clinically ap-
parent, there is often a thick plug of cerumen and debris, with variable suppuration,
behind which the mites reside. Additionally, the external acoustic meatus may be
ulcerated. Affected animals rarely may develop central nervous system signs related
to heavy infestations that penetrate the middle and internal ear. Otitis externa is
more severe with concurrent bacterial infections or if the host is additionally infected
with Rhabditis spp. of nematodes. In goats there are often concurrent infections with
R. caprae and pathogenic Mycoplasma spp.

Psoroptes cuniculi.

Psoroptic otoacariasis is most commonly caused by Psoroptes cuniculi, infesting

sheep, goats, deer, horses, donkeys, mules, and antelope. Although capable of
feeding on any part of the animal, it prefers the ear in goats, sheep, and horses.
They live on the surface, feeding on lipids, keratin, crusts, and cerumen. Pruritus can
be intense and is related to surface irritation by infesting mites and hypersensitivity
reactions, leading to self-trauma to the auricle and periauricular skin. As described
(see Chapter 17), histologic lesions include eosinophilic perivascular dermatitis that
can be spongiotic, hyperplastic, hyperkeratotic, or exudative. In affected goats, care
must be taken to check that the infestation is not complicated by Raillietia spp.

Ticks
Ticks and tick-borne diseases rank as some of the most important health constraints
of livestock in many parts of the world. Ticks serve as vectors for the spread of
disease, affect production parameters such as weight gain or milk production, can
lead to significant anemia, may impair individual or herd immunity, and can be
a source of aggravation or irritation. Sites of attachment and feeding may occur in
multiple locations, but many species of ticks have preferred sites. What follows is a
discussion of a few species of ticks that preferentially feed in the ears.

Rhipicephalus Species.

The brown ear tick, Rhipicephalus appendiculatus, is found most commonly in south-
ern and southeastern African countries. Adults primarily attach to the ears of do-
mestic and wild ruminants, whereas larvae and nymphs attach to ears, head, and
neck of most ruminant species, as well as equids, carnivores, and hares. Bos indicus
cattle become fairly resistant to tick infestations, but exotic Bos taurus cattle can
have severe production losses and very significant ear damage. R. appendiculatus
secretes proteins in its saliva, some of which react with the host animal enzymes
to form a hard feeding cone and others have inherent enzymatic activity. The
protein that forms the cone is called cement, and it provides an anchor for feeding
ticks and may interfere with a robust inflammatory reaction by the host animal.
Affected ears can range from minimally injured to very deformed and sometimes
can appear shredded. Microscopically, at the feeding sites, neutrophils predominate
in the dermis immediately surrounding the brightly eosinophilic cement layer and
are also mixed with macrophages and variable numbers of eosinophils. Brown ear
tick toxicosis is a poorly understood condition that occurs in susceptible cattle,
presumably the result of tick saliva toxins. Some saliva-derived toxins have an
immunosuppressive effect, although the exact mechanism is not understood. These
animals may have suppression of adaptive immune responses and lose protection
against other environmental pathogens that they have encountered and resisted. In
some instances, tick toxicosis can be fatal.

Gulf Coast Ear Tick.

Another tick that preferentially infests the ear is variably named the Gulf coast
tick or Gulf coast ear tick. Amblyomma maculatum is native to North, Central, and
South America. In North America, this tick can be found all along the Gulf coast,
extending as far inland as Oklahoma, Kansas, and Arkansas, and along the southern
 Atlantic coast. Adult ticks preferentially feed on cattle, sheep, horses, and mules by
attaching to the external ears but can also infest deer, cats, foxes, dogs, and pigs.
Heavy infestations cause intense auricular inflammation and swelling and may even
cause the destruction of the auricular cartilage, resulting in a droopy ear sometimes
referred to as “gotch ear”5 (Fig. 20-32). A. maculatum is an experimental vector for
transmitting Ehrlichia ruminantium, the causative agent for heartwater disease, but
it has not been implicated in field outbreaks in North America. It has also been shown
that the Gulf coast ear tick in Florida, Georgia, Kentucky, Mississippi, Oklahoma, and
South Carolina may serve as a reservoir for Rickettsia parkeri.

5“Gotch ear” is a colloquial term with Spanish roots coined by cowboys and defined
as a type of earmark used to identify cattle that resulted in severe rostral, medial,
and ventral flexion of the auricle.

Spinose Ear Tick.

Otobius megnini, the “spinose ear tick,” has a broad host range, including ungulates,
sheep, goats, cattle, horses, dogs, and human beings. Adults are free living and
nonparasitic, but nymph and larval stages are parasitic. Newly hatched larvae remain
in the environment until they climb onto a suitable host. Owing to their small size
and propensity for living very deep in the external acoustic meatus, larvae are rarely
identified in host ears. As these ticks molt and mature, some can be found attached
to and blood feeding in the more shallow portions of the external acoustic meatus
or attached to the auricular skin (Fig. 20-33). After several months of feeding in or on
host ears, nymphs drop off the host, seeking dry, sheltered places where they molt
into adults. Lesions are attributable to blood feeding, which results in local irritation
and secondary otitis externa. As has already been described, local reactions to the
feeding sites include perivascular to interstitial dermatitis laden with neutrophils and
eosinophils. Infested animals may develop clinical symptoms such as head shaking
and pruritus related to nymph feeding on blood and lymph of the skin of the external
acoustic meatus.

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