Vol.18, No.
7 July 1996 V
Continuing Education Article
FOCAL POINT
★ Otitis externa occurs secondary
to predisposing factors or
other diseases and is also a
primary condition caused by
microorganisms and parasites.
KEY FACTS
■ Atopic dermatitis is the most
common disease predisposing
to otitis externa.
■ Cytologic evaluation of otitic
exudate should be performed in
every case to determine the types
of microorganisms present.
■ Otitic ears should be thoroughly
cleaned of exudate, wax, and
debris so that appropriate
medication can reach diseased
tissue.
■ Detailed client education
concerning the correct methods
of cleaning and applying
medication is necessary for
successful management of otitis
externa.
Otitis Externa
University of Minnesota
Patrick J. McKeever, DVM, MS
O titis externa is inflammation of the epithelium that lines the external
auditory canal. Diagnosis of the condition can be frustrating and
challenging, as a number of causative agents can be responsible for its
development. Failure to diagnose and treat the primary cause (whether at-
tributable to disease or environment) may lead to less than satisfactory results.
The incidence of otitis externa in the canine population has been reported to
be from 4% to 16% of hospital admissions and up to 20% of the general pop-
ulation.1 In cats, the incidence has been reported to be from 2% to 6.6% of
hospital admissions.2 Such factors as time of year when the surveys were taken,
breed popularity in a given area, and varying diagnostic criteria may be respon-
sible for the wide range of reported incidence.
ANATOMY OF THE EXTERNAL EAR
The funnel-shaped pinna, which is formed from distal flaring of the auricu-
lar cartilage, receives air vibrations and transmits them by way of the ear canal
to the tympanic membrane. The pinna is covered on both sides with skin that
is tightly attached to the periochondrium. The skin that lines the inner surface
of the pinna generally contains fewer hairs. Each pinna functions independent-
ly of the other and is very mobile.3 The shape of the pinna is breed specific.
The diameter of the ear canal or external acoustic meatus formed from the
auricular and annular cartilages ranges from 5 to 10 mm, depending on the
age, breed, and size of the dog. The canal is approximately 2 cm in length and
ends proximally with the tympanic membrane or eardrum.4 The tympanic
membrane is thin, semitransparent, and elliptical (Figure 1). It serves as a wall
between the tympanic cavity and the external acoustic meatus. The membrane
is thinnest in the center and becomes progressively thicker toward its periphery.
At the periphery, the membrane is attached to a fibrocartilaginous circular pad
that is fastened to a collar of bone in the external acoustic meatus.4 The
manubrium of the malleus is a white fingerlike projection that extends into the
tympanic membrane.
The epithelial lining is thinnest on the deep, or proximal, portion of the ear
canal. The lining becomes thicker as it progresses to the distal or superficial
part of the canal and reaches its greatest thickness on the distal third of the
concave surface of the pinna.5 Close to the tympanic membrane, the epithelial
lining is aglandular. In short-haired breeds, no hair follicles may be found. In
long-haired dogs, however, very fine hairs are present.5 In the dermis of the ear
canal and especially the more distal or superficial areas of the canal, sebaceous
Small Animal
glands form the superficial glandular bed. Apocrine
glands, which form below the sebaceous glands in the
deeper dermis, open directly to the skin surface either
immediately adjacent to the opening of an associated
hair follicle or at some distance from it.6 The number
of sebaceous and apocrine glands varies. In long-haired
and fine-haired breeds (e.g., Irish setters or spaniels),
the glands are more developed and numerous than in
short-haired breeds.5
PATHOPHYSIOLOGY OF OTITIS EXTERNA
In the early acute stages of otitis, irritation caused by
the inciting or predisposing factors results in hyperpla-
sia of both the epidermis and sebaceous glands as well
as hyperkeratinization of the infundibulum of the hair
follicle. An infiltrate of lymphocytes, plasma cells, poly-
morphonuclear leukocytes, and histiocytes develops in
the superficial dermis.7
Chronic otitis is characterized by extensive epidermal
hyperplasia (five to six times normal epidermal thick-
ness) with or without formation
of distinct retepegs extending
between the dermal papillae. 6
Ulceration of the epidermis is
frequently observed in chronical-
ly affected ears, especially if
Pseudomonas or Proteus organisms
are present. Sebaceous glands are
usually smaller and less active in
cases of chronic otitis and are
displaced in the superficial der-
mis by the apocrine glands,
which become hyperplastic and
dilated. Changes in the apocrine
glands further narrow the ear
canal. If the cystic apocrine
glands rupture, they become sur-
rounded by a dense infiltrate of Figure 1—Normal ear canal and tympanic mem- appears as erythema and/or hy-
histiocytes, polymorphonuclear brane of dogs. The manubrium of the malleus is perplasia with minimal exuda-
leukocytes, mast cells, giant cells, the white, curved, fingerlike projection extending tion; however, some animals
and fibroblasts. Narrowing of into the tympanic membrane.
the ear canal is further exacer-
bated by fibroplasia of the der-
mis.6 Ossification of the external ear canal and associat-
ed cartilage may develop in long-term, very severe
cases.
EXTERNAL FACTORS AND CONDITIONS
PREDISPOSING TO OTITIS EXTERNA
Originally, otitis externa was believed to be a primary
condition caused by microorganisms and parasites. Today,
otitis externa is known to occur secondary to predispos-
ing factors or other disease states in addition to being a
PATHOPHYSIOLOGY ■ ENDOCRINE-RELATED OTITIS ■ ATOPIC DERMATITIS
The Compendium July 1996
primary condition from parasites. In dogs, various fac-
tors may be involved:6,8–11
• Foreign bodies (weed awns, seeds, excess hair, and
dried wax)
• Parasites (mites, ticks, chiggers, and biting flies)
• Physiologic disturbances (nutritional deficiencies and
concomitant disease)
• Trauma (iatrogenic or self-induced)
• Abnormally small or restrictive ear canals
• Adverse reaction to food
• Ear canal tumors
• Excessive moisture in the ear (dogs that swim fre-
quently, dogs with pendulous ears [which results in
poor air circulation], and dogs exposed to increased
environmental humidity).
Atopic Dermatitis. Otitis externa is more likely to be
secondary to atopic dermatitis than to other diseases.12
About 55% of cases of atopic dermatitis develop con-
current otitis; in 3% of the cases,
otitis is the only clinical sign of
the disease. 13 When associated
with atopic dermatitis, inflam-
mation of the pinna causes hy-
perplasia of the epidermis, dermis,
and sebaceous and apocrine
glands.10,14 The decrease in venti-
lation that occurs when the ear
canal narrows as well as the in-
crease in secretions create an ideal
environment for bacteria and
yeast to grow and reproduce. Oti-
tis secondary to atopic dermatitis
most often develops in conjunc-
tion with the pruritic skin dis-
ease. Initially, the condition
may have excessive wax produc-
tion by glands of the ear canal
and pinna. Ear lesions respond
to topical or systemic steroids or hyposensitization.
Endocrine-Related Disorders. The pathogenesis sur-
rounding the development of endocrine-related otitis is
unknown. Changes in glandular activity and kera-
tinization are probably involved, as most animals with
otitis externa related to an endocrine disorder also have
seborrhea. Some conditions that may be associated with
chronic otitis externa are hypothyroidism, male feminiz-
ing syndrome, Sertoli cell tumor, and ovarian imbal-
ances.3,9 Of these, hypothyroidism is encountered most
The Compendium July 1996 Small Animal

frequently. In two reported cases of hypothyroidism, oti- wheal and flare responses to mite antigens are found in
tis was the only clinical sign noted.9 87% of random source cats. This response is unrelated
Immune-Mediated Conditions. Diseases of the to infestation with mites.20 It has been proposed that al-
pemphigus complex and both systemic or discoid lupus most all cats are exposed to a small number of mites at
erythematosus can cause vesicular, pustular, ulcerative, a very young age. Some cats develop immune responses
or crusting lesions of the pinna and ear canal.3,9,10 Pem- that promote a hostile environment, which, in turn,
phigus foliaceus and pemphigus erythematosus are as- prevents mite colonization in the ears and clinical dis-
sociated with ear lesions and otitis more often than oth- ease. Other cats may have defective or lesser immune
er diseases of the pemphigus complex. Lesions almost reactions, thereby fostering
always involve other parts of the body as well, although mite colonization and subse- External Factors and
cases of pemphigus foliaceus involving only the ear quent clinical disease.19
have been reported.9 Clinical signs of systemic lupus Tumors. Tumors should be Diseases that
erythematosus vary considerably. If ear lesions are ob- included in the differential di- Predispose an Animal
served by the clinician, they are usually associated with agnosis when the clinician is to Otitis Externa
one or more of the following: concomitant skin lesions, confronted with a chronic
polyarthritis, fever, proteinuria, anemia, or thrombocy- case of otitis externa that does ■ Atopic dermatitis
topenia. not respond to appropriate ■ Parasites (Otodectes
Although drug eruptions that result in ear lesions are therapy. Ear canal tumors can cynotis, ticks, chiggers,
uncommon, they can occur if the animal is on topical develop in the skin or its ad-
and biting flies)
or systemic medication. If the reaction is to a topical nexal structures. Various epi-
otic preparation, lesions are confined to the ears. Lesions, thelial and dermal tumors ■ Foreign bodies (weed
however, also may occur on the skin of other areas of have been reported, including awns, seeds, excess
the body and at mucocutaneous junctions. Obtaining a squamous cell carcinoma, his- hair, and dried wax)
history of recent drug use and drug withdrawal response tiocytoma, sebaceous gland
■ Excessive moisture in
can confirm a diagnosis.3 adenoma and adenocarcino-
Foreign Bodies. Such foreign bodies as plant materi- ma, basal cell carcinoma, the ear
al, dirt, sand, and dried medications can cause otitis mastocytoma, chondroma, ■ Adverse reaction to
externa.9,15 The most common cause of foreign body chondrosarcoma, trichoepi- food
otitis in some geographic areas is a variety of grass awns thelioma, apocrine gland
■ Abnormally small or
(Figure 2). In most cases, the otitis externa is acute and adenocarcinoma, fibroma, fi-
unilateral; however, many dogs in areas with a high brosarcoma, and papillo- restrictive ear canals
density of grass awns may develop chronic bilateral dis- ma. 3,9,10,21
Ear canal tumors ■ Ear canal tumors
ease. Penetration of the tympanic membrane by grass generally occur more often in ■ Immune-mediated
awns can occur. dogs than in cats; however,
conditions
Otoacariasis. Otoacariasis, which is also called para- the tumors in dogs tend not
sitic otitis, is an infection of the ears of cats and dogs to be malignant.22 One excep- ■ Endocrine-related
with ear mites, chiefly Otodectes cynotis. These mites are tion is squamous cell carcino- disorders
large, white, and free moving. They live on the surface ma, which occurs more often ■ Physiologic
of the epithelial lining of the ear canal or, in rare in- in cats than dogs. These tu-
disturbances
stances, on the skin surface. Parasitic otitis is highly mors are frequently found on
transmissible. Studies have shown that Otodectes mites the pinnal margins of the ears (nutritional
lack specificity among carnivore hosts.16 Ear mites are of white-haired cats. deficiencies and
responsible for about 10% of the cases of otitis in dogs Another type of ear canal concomitant disease)
and 50% in cats.9,17,18 The actual incidence, however, tumor that is common yet
may be higher, as otitis can be produced by only two or unique to cats is the inflam-
three mites, which would be difficult to demonstrate.9 matory polyp. The stroma of this tumor comprises ei-
In addition, if severe inflammation occurs and a puru- ther myxomatous or dense fibrous connective tissue,
lent bacterial or yeast infection develops, the mites of- which contains inflammatory cells and dilated capillar-
ten abandon the ear canal.17 ies. The stroma is covered either by ciliated or noncili-
Mites feed on lymph and whole blood and thus ex- ated columnar epithelium or by stratified squamous,
pose the host to mite antigens. Animals may develop a nonkeratinizing epithelium. Inflammatory polyps have
hypersensitivity reaction and produce reagins that are been diagnosed in cats ranging in age from three
immunoglobulin E (IgE) antibodies. 19 Immediate months to five years of age. About 45% of the cats with

IMMUNE-MEDIATED CONDITIONS ■ FOREIGN BODIES ■ OTOACARIASIS ■ TUMORS

Small Animal
inflammatory polyps are young-
er than two years of age. Sex or
breed predisposition has not
been reported. If the tumor is
extensive, it may occupy the
external ear canal, middle ear,
eustachian tube, and nasophar-
ynx.23
Bacteria and Yeast. If the
presence of bacteria and yeast in
the ear canal is confirmed, clini-
cians should not automatically as-
sume these organisms are playing
a causative role in the pathogene- Figure 2—Grass awn lodged in the ear canal of a terna.24,26 In some cases, the en-
sis of otitis. A low number of dog.
commensal bacteria and yeast
that have pathogenic potential
can be present in the ear canal of
normal dogs.24 These organisms,
however, can quickly proliferate if
the lining or microclimate of the
ear canal changes.17 Their growth
then exacerbates and perpetuates
the inflammatory reaction.17 Al-
though these bacteria and yeast
may not be the principal caus-
ative agents, there is a high prob-
ability that they are involved in
any subsequent disease process
(Figure 3).
Pseudomonas aeruginosa has Figure 3—Gram’s stain of exudate from an ear show- ears, which has created contro-
been isolated from normal ears ing yeast, gram-positive cocci, and gram-negative versy as to the role it plays in
in only 0.4% of dogs studied.11 rods.
In contrast, Pseudomonas has
been isolated in 20% of otitic
ears.17 The organism is isolated frequently from dogs
with recurrent chronic otitis and from dogs undergoing
long-term treatment with topical antibacterial drugs.17
Otitic ears populated with Pseudomonas are generally
painful and have copious amounts of a pale or light yel-
25
low secretion (Figure 4). Ulceration of the ear canal
epithelium is also commonly associated with this or-
ganism and may be extensive.
Proteus organisms have not been cultured from nor-
mal ears and have been reported in only 11% of otitic
ears.14 Proteus is often found in cases of chronic ulcerat- pathogenic, normal commensal because its incidence
ed otitis with light yellow secretions.15
In one study, coagulase-positive Staphylococcus organ-
isms were isolated from 9.6% of dogs with normal or
clean ears, 14% with waxy ears, and 22% of dogs with
otitis externa.26 Other studies show that Staphylococcus
is present in about 20% of normal ears and 40% of ears
24
with otitis externa. Ears populated with Staphylococcus
PSEUDOMONAS ■ PROTEUS ■ STAPHYLOCOCCUS ■ STREPTOCOCCUS
The Compendium July 1996
typically have exudates that are
light brown or yellow (Figure 5).
Exudates produced as a result of
copopulation of Streptococcus are
usually light in color, whereas
exudates resulting from copopu-
lation of Malassezia are brown to
dark brown.10,27,28
When data are averaged from
several studies, it is found that
Streptococcus can be isolated
from about 16% of normal ears
and 10% of ears with otitis ex-
vironment of otitis may be less
favorable for Streptococcus growth
than the environment of the nor-
mal ear. If present, Streptococcus
exudate is usually light yellow to
light brown.
Malassezia pachydermatis
(formerly called Pityrosporum
pachydermatis) is a nonlipophilic
species that forms a part of the
normal flora of animals. Malas-
sezia is an oval or peanut-shaped,
gram-positive, nonmycelial
yeastlike organism. Malassezia
has been frequently isolated
from both normal and otitic
perpetuating otitis. There is no
general agreement between vari-
ous studies as to its incidence ei-
ther in normal (15% to 49%) or otitic (2% to 80%)
ears. If data are averaged, the incidence in normal and
otitic ears would be 17% and 24%, respectively. I con-
cur with others who have found the incidence of
Malassezia in otitic ear canals to be about 50%.2 The
frequency of Malassezia in relation to the amount of
wax within the ear canal has been investigated and it
was concluded that the organism is most easily demon-
strated in ears with excess wax.2
One investigator suggested that Malassezia is a non-
was the same for both normal and otitic ears.2 Another
study, however, showed that Malassezia may be
pathogenic because clinical cures for otitis were ob-
tained in cases in which Malassezia was isolated in
monoculture and topical nystatin was the only treat-
ment.29 It was concluded that although Malassezia is
usually commensal, it may become pathogenic, thereby
Small Animal The Compendium July 1996

contributing to the development unilateral otitis is frequently as-

of lesions if the aural microcli- sociated with foreign bodies, es-
mate is favorable. Ears with a pecially grass awns. Unilateral
high population of Malassezia otitis of gradual onset is more
have copious amounts of choco- suggestive of a neoplastic pro-
late-brown waxy discharge (Fig- cess. Bilateral otitis is frequently
ure 6). associated with parasitic infesta-
tion or often occurs secondary to
DIAGNOSIS AND some other disease.
MANAGEMENT Finally, based on the differen-
History tial diagnosis developed, appro-
A complete history with em- priate diagnostic plans can be
phasis on dermatology and a formed for any primary disease.
complete physical examination
are the initial steps for develop- Figure 4—Pseudomonas otitis with a light yellow Physical Examination
ing a differential diagnosis of secretion. As with a general physical ex-
primary diseases and predispos- amination of other body sys-
ing environmental factors. tems, examination of the ears
The history often provides as should be done in a systematic
many clues to the cause as any fashion and the findings record-
other diagnostic procedure. Be- ed. To minimize the time neces-
cause of time restraints of a busy sary for recording the findings, it
practice schedule, however, clini- is very helpful to have an ear ex-
cians may be unable to devote amination form.
adequate time to obtain a de- Equipment. The standard
tailed history. This problem can otoscope is the preferred piece
be avoided by having the owner of equipment for routine exam-
complete a history form either at ination of the vertical and hori-
home or in the waiting room. zontal ear canals and the tym-
This form then can be scanned panic membrane. A halogen
by the attending clinician to ob- light source is desirable, as it is
tain pertinent information. Only Figure 5—Staphylococcus otitis with pale yellow bright enough to reach to the
clarifying questions or questions exudate. depths of the long canine ear
specific to the ears would have to canal. I suggest using an operat-
be asked of the owner. Informa- ing head because it accommo-
tion pertaining to any previously dates obser vation when the
used medication and the pet’s re- clinician removes foreign matter
sponse to the drug also should be from the ear or aspirates the ear
obtained. After the animal has with suction. Cones for the vet-
been evaluated generally, focus erinary otoscope are needed in a
can be directed to the ears. variety of lengths, diameters,
Environment can be impor- and shapes to fit the various
tant, as animals that have free shapes and sizes of canine and
access to fields are more likely to feline ears. Because the lumina
have foreign bodies, such as of the ear canals are often nar-
grass awns, causing ear prob- rowed by hyperplastic tissue, I
lems. Animals that swim fre- often use a cone that is 4 mm in
quently are predisposed to otitis diameter and 5.5 cm in length.
attributable to the maceration Cones designed for examining
Figure 6—Malassezia otitis with chocolate-brown
caused by continual presence of waxy discharge. the human ear are unsatisfacto-
water in the ear. ry for use, as they are too short
Chronicity and whether the for adequate viewing of the hor-
otitis is unilateral or bilateral also are important. Acute, izontal ear canal and tympanic membrane.

DIFFERENTIAL DIAGNOSIS ■ EXAMINATION EQUIPMENT

The Compendium July 1996
Restraint. For examination of even-tempered dogs
with minimal problems and for cursory examination
of most other animals, physical restraint may be the
only measure necessary. When conducting a complete,
thorough examination of the horizontal canal and
tympanic membrane, however, almost all animals re-
quire chemical restraint. In addition, chemical re-
straint allows the clinician to clean the ear, a procedure
often necessary in order to visualize the horizontal
canal and tympanic membrane. In dogs, ketamine
(1.36 to 2.2 mg/kg) combined with diazepam (0.045
mg/kg) and acepromazine (0.023 mg/kg) mixed in the
same syringe and given intravenously has been success-
ful for restraint during the examination and cleaning
of ears. The higher dose of ketamine (2.2 mg/kg) is
preferred, as it results in sufficient restraint for about
20 minutes.
Examination of the Ear Canal and Tympanic
Membrane. To visualize the ear canal with an oto-
scope properly, the pinna should be pulled up and
away from the head so that the canal is straight. While
the clinician looks into the otoscope, the cone should
be slowly inserted to the depth necessary for examina-
tion of the horizontal canal and tympanic membrane.
The normal ear canal may contain small amounts of
pale yellow or yellow-brown wax. Some breeds of
dogs, such as the poodle, schnauzer, and terriers
(Airedale, wirehaired, and fox) typically have hair
growing in the canals. Any hair may have to be re-
moved using an alligator forceps before complete ex-
amination is possible. The normal tympanic membrane
is translucent, glistening, pearl-gray, and slightly con-
cave. Cloudiness, opacity, color changes, or bulging
are generally indicative of pathologic changes in the
middle ear. Rupture of the tympanic membrane may
appear as a small tear in its surface or may be so com-
plete that the clinician has difficulty determining
where the horizontal canal ends and the middle ear
begins.
Establishing a Diagnosis
Primary Disease. Appropriate diagnostic and labo-
ratory procedures can be conducted to rule out the var-
ious primary diseases that are potentially responsible for
or predispose an animal to otitis.
Cytology. Cytologic evaluation of otitic exudate
provides immediate diagnostic information about the
inflammatory response as well as determines the types
of microorganisms and ectoparasites present within the
ear canal. Smears stained with modified Wright’s stain
or Gram’s stain should be examined carefully for the
number and morphology of bacteria, yeast, leukocytes,
and neoplastic cells. Generally, the presence of gram-
PHYSICAL & CHEMICAL RESTRAINT ■ CYTOLOGY ■ CULTURE & SENSITIVITY ■ BIOPSY
Small Animal
positive cocci on smears is indicative of either Staphy-
lococcus or Streptococcus; gram-negative rods usually
indicate either Pseudomonas or Proteus. Yeast is typical-
ly Malassezia, but Candida is a possibility. In addition
to obtaining information from stained smears, debris
from the ear canal can be mixed with mineral oil and
examined for ectoparasites and their eggs or larvae.
Cultures. Although cytologic evaluation provides
clues as to the organisms present, culture and sensitivity
tests are still very appropriate because a greater propor-
tion of bacteria is becoming resistant to routine an-
tibacterials used for treatment of otitis.30 If gram-negative
rods (which have a high probability of being Pseu-
domonas) are present on the smears, culture and sensi-
tivity testing is mandatory because Pseudomonas organ-
isms are often resistant to many antibacterials.
Biopsy. To diagnose a tumor or confirm proliferative
tissue in the ear canal, a small pinch biopsy can be ob-
tained by passing an endoscopic biopsy forceps through
the otoscope cone.
Initial Management
Successful treatment of otitis externa is based on four
fundamental principles:
1. Diagnosing and treating or correcting the primary
disease or environmental factors predisposing to the
otitis
2. Accurately identifying specific bacteria, yeast, para-
sites, or foreign bodies in the ears (see the section on
Establishing a Diagnosis)
3. Thoroughly cleaning all debris, exudate, and wax
from the pinna and the vertical and horizontal ear
canals
4. Educating the owner about the cause of the otitis
and reviewing the anatomy of the ear as well as in-
structing the owner on proper ear-cleaning tech-
niques and application of medications at home.
Ear Cleaning
All hair, wax, debris, exudate, and foreign matter must
be removed from the horizontal and vertical ear canals to
allow complete examination of the ear canal and tym-
panic membrane as well as penetration of topical medi-
cations to affected tissue (see the box In-Hospital Cleaning
Technique). Any debris that may serve as a focus for re-
infection and any bacterial toxins, degenerating cells, and
free fatty acids that may stimulate renewed inflammation
should be removed.
Equipment. The use of a bulb syringe or a dental wa-
ter-propulsion device to flush the ears has been advocat-
ed.27,31 In my experience, however, this technique can be
messy, is more time-consuming, and fails to clean the
Small Animal The Compendium July 1996

ears as well as the suction tech- minute to loosen any debris.

nique. If the veterinary facility The carbamide peroxide has a
has a suction apparatus for In-Hospital Cleaning foaming action that helps to
surgery, this can be used. As an break down larger clumps of
alternative, a device can be easily Technique for the External debris and float them to the
and inexpensively made from Ear Canal canal opening. After the canal
supplies found in hardware has been massaged, excess
stores. Three nipples that are 1⁄4 ■ Sedate the animal. cleaning solution as well as exu-
inch in diameter (two that are 1- ■ Coat the pinna and fill the ear canal date and debris that have float-
inch long and one that is 2 inches with a cleaning solution of docusate ed to the surface should be wiped
long) and six 1⁄4-inch locknuts can sodium, carbamide peroxide, and away with a cottonball. Using a
be purchased from the hardware tetracaine. bulb syringe, the ear canal
store. First, the 2-inch nipple is ■ For ears in which the tympanic should then be flushed twice
placed through a hole drilled in a membrane is ruptured, fill the with warm water. While the
No. 6 rubber stopper and secured external and middle ear with a clinician is observing through
with a locknut on each side of solution of either propylene glycol, an operating head otoscope, the
the stopper. Next, holes that are malic acid, benzoic acid, and salicylic 8-French urinary catheter at-
1
⁄4 inch in diameter are made on acid or of diluted povidone-iodine tached to a suction apparatus
opposite sides of the snap-on lid solution (l part povidone-iodine to should be used to remove loos-
of a one-liter plastic container. 3 parts water). ened debris, exudate, and any
The 1-inch nipples should be ■ Fold the pinna on itself and massage water that remains. The clini-
threaded halfway through the lid the ear canal for 2 minutes to loosen cian should examine the ear to
and a locknut placed on either and dissolve debris. verify that it is completely
side of the lid. The lid is reat- ■ Use a cottonball to remove excess clean. If the ear is not clean, the
tached to the container, and a cleaning solution as well as exudate process should be repeated.
2- to 2.5-meter piece of appropri- and debris that have floated to the This procedure should be fol-
ately sized plastic tubing is placed surface of the ear canal. lowed for the other ear as nec-
over each nipple. An 8-French ■ Flush the ear canal twice with warm essary. After this technique has
urinary catheter that has been cut water using a bulb syringe. been mastered, both ears can
to a length of 12 cm should be ■ Use an 8-French urinary catheter (cut be completely cleaned in fewer
attached to one free end of plastic to a length of 12 cm and attached to than 20 minutes. If, however,
tubing. The other free end of one free end of plastic tubing) that is the tissue lining the ear canal is
plastic tubing is attached to the attached to a suction apparatus to so hyperplastic that the canal
nipple protruding from the outer remove loosened debris, exudate, and cannot be completely cleaned,
side of the rubber stopper. The any remaining water; this step should surgical intervention may be
stopper can be placed into a hose be done while the clinician observes necessary.
of any household vacuum clean- through an operating head otoscope. If the tympanic membrane is
er. The suction control device on ■ Examine the ear to verify that it is ruptured, a cleaning solution
the vacuum cleaner hose can be completely clean. of propylene glycol, malic acid,
adjusted to obtain the desired de- ■ Repeat the process if the ear is not benzoic acid, and salicylic acid or
gree of suction. Other necessary completely clean. of diluted povidone-iodine
equipment includes a bulb sy- solution (one part povidone-
ringe plus mosquito and alligator iodine to three parts water) can
forceps for plucking hair and for- be used for cleaning both the
eign objects from the ears. external and middle ear.15 The cleaning technique is the
Technique. With the animal sedated and in lateral same as previously described. A short-term head tilt or
recumbency, the upper ear should be filled with a solu- transient ataxia has been observed in about 1% of cases
tion containing docusate sodium, carbamide peroxide, when the middle ear is flushed.31 Owners of animals
and tetracaine. with a ruptured tympanic membrane should be
The canal should then be massaged for two minutes. warned that some animals may swallow or cough when
If the pinna has exudate or wax on its surface, the liquid solutions are instilled in their ears. This reaction
cleaning solution should be applied to it also. The pin- occurs because the solution is flowing through the
na then can be folded on itself and massaged for one ruptured tympanum, to the middle ear, and down

EAR CLEANING EQUIPMENT ■ SUCTION DEVICE CONSTRUCTION

The Compendium July 1996
the eustachian tube into the pharynx. Although a rup-
tured tympanum increases the likelihood of middle ear
infection, it is not a serious problem in a clean ear and
heals in 5 to 10 days.17,31
Although cotton swabs are useful for cleaning the
folds of the anthelix, the practice of using cotton
swabs to clean the ear canal should be abandoned.
This technique invariably packs exudate and debris
further down the canal next to the tympanum, regard-
less of how careful the clinician is. If the tympanic
membrane is diseased, pressure caused by packed de-
bris may rupture the membrane. If the tympanum is
ruptured, the debris can be pushed by the swab into
the middle ear, where it can promote development of
otitis media. The physical presence of the swab in the
canal also tends to traumatize and often ulcerate the
epithelial lining.
Treatment
Initial treatment should be based on the results of the
stained smears of exudate. If gram-positive cocci are
present, neomycin, gentamicin, or chloramphenicol
would be appropriate. If gram-negative rods are pre-
sent, gentamicin, polymyxin B, enrofloxacin, or
amikacin would be the antibacterials of choice. Because
of their ototoxicity, the aminoglycosides (neomycin,
polymyxin, amikacin, and gentamicin) should not be
used for treatment of otitis if the tympanic membrane
is ruptured. If yeast is found, such topicals as micona-
zole or clotrimazole should be used. After culture and
sensitivity findings are known, treatment can be
changed, if necessary, to more appropriate antibacterial
or antifungal agents. If at any point response to therapy
is not as anticipated, additional culture and sensitivity
testing should be conducted.
Another approach to treatment is use of 2% to 5% so-
lutions of acetic acid to lower the pH within the ear
canal. This treatment is especially beneficial against Pseu-
domonas infection if the organism becomes resistant to
antibacterials. Inflammation, sometimes severe, is an oc-
casional side effect of otic treatment with acetic acid.
The inflammation is more likely to occur when a 5% so-
lution is used.
Silver sulfadiazine is another antibacterial frequently
used for the treatment of otitis caused by Pseudomonas.
A 1% solution of silver sulfadiazine is made by combin-
ing 1 gram of silver sulfadiazine powder and 100 ml of
water and shaking well. Depending on the size of the
ear canal, from 4 to 12 drops should be instilled twice
daily. I have used this solution to treat animals with
ruptured tympanic membranes, and no adverse effects
have been noted.
In most cases of otitis, topical glucocorticoids reduce
OTODECTES CYNOTIS ■ CLIENT INSTRUCTIONS
Small Animal
tissue inflammation in the ear canal, resulting in less
pruritus, swelling, exudation, and tissue proliferation.
Fluocinolone acetonide in 60% dimethyl sulfoxide is
especially beneficial for treatment because the dimethyl
sulfoxide allows penetration of fluocinolone into the
tissue. This treatment often reduces the tissue hyperpla-
sia associated with chronic otitis externa. Owners
should be instructed to fill the affected ear canal with
the solution and massage the canal for 30 to 60 seconds
two to three times daily. This treatment has also been
beneficial in decreasing wax buildup, which often results
in concomitant Malassezia infection. Even if an infected
ear is completely cleaned and treated with appropriate
medication, small amounts of exudate or wax may per-
sist. Owners can prevent wax or exudate from accumu-
lating and interfering with successful treatment by per-
forming in-home cleaning. Ear cleaners can be
dispensed to the owner, who should be instructed to
clean the animal’s ears by filling the canal with cleanser,
massaging the ear canal for one to two minutes, and
then using a cottonball to wipe the cleansing solution
and debris from the outer ear and pinna. The interval
between cleanings will vary from three to seven days,
depending on the state of the ears and the rate of wax
or exudate accumulation.
If Otodectes cynotis infestation is diagnosed, the ears
should be cleaned and treated for 20 days with a mix-
ture containing 1 ml of rotenone and 10 ml of a solu-
tion containing procaine penicillin G, neomycin sulfate,
polymyxin B, and glucocorticoids. Alternatively, a 300
µg/kg dose of ivermectin can be given subcutaneously
and repeated two weeks later.32 All contact animals, both
dogs and cats, should be treated because asymptomatic
carriers may often be sources for reinfection.
Client Education
Regardless of how thorough the clinician is
throughout the diagnosis and treatment procedures,
successful management of otitis depends on owner co-
operation. The owner must be prepared to complete
home treatment measures. To ensure owner compli-
ance, the clinician should carefully explain and
demonstrate the cleaning and treatment methods and
then watch the owner repeat the process. All instruc-
tions pertaining to the cleaning and treatment of the
ears should be typed or clearly printed for the owner.
To save time, the instructions can be printed on a
form so the clinician only has to fill in the names,
amounts, and frequency of medications to be used.
Finally, reexaminations should be scheduled so that
treatment progress can be monitored and any prob-
lems with home cleaning or treatment measures can
be addressed.
Small Animal
About the Author
Dr. McKeever is Professor of Veterinary Comparative
Dermatology, Department of Small Animal Clinical Sci-
ences, College of Veterinary Medicine, University of Min-
nesota, St. Paul, Minnesota. He is a Diplomate of the
American College of Veterinary Dermatology.
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