20TH ANNIVERSARY
8 August 1999
CE Refereed Peer Review
FOCAL POINT
★Successfully managing chronic
otitis involves determining and
resolving (if possible) the primary
cause, determining the amount of
middle-ear involvement, and
identifying and controlling the
perpetuating factors; unless a
cause is identified and treated,
resolution is unlikely.
KEY FACTS
■ Ears with highly proliferative,
chronic disease require deep
cleaning and flushing before any
topical therapy can help resolve
the condition.
■ Systemic antibiotics are
mandatory for chronic otitis and
may be required uninterrupted for
8 to 12 weeks with otitis media.
■ Enrofloxacin, silver sulfadiazine,
polymyxin B in a commercial
otic or ophthalmic solution, or
tromethamine–EDTA combined
with an aminoglycoside are
effective alternative topical
preparations used to treat chronic
resistant bacterial otitis.
■ Owners should be taught to
properly clean their pets’ ears
to help resolve infection and
minimize recurrence.
Vol. 21, No.
Medical Management
of Chronic Otitis
in Dogs
Atlanta Veterinary Skin & Allergy Clinic, PC, Atlanta, Georgia
Patricia D. White, DVM, MS
ABSTRACT: The frustrations inherent in treating chronic otitis in dogs are an everyday chal-
lenge for practitioners. The key to successful management of this disease is early intervention,
identifying a cause of the condition, and employing specific and appropriate therapy. Failure to
identify and treat a primary or predisposing condition is the most common cause of chronic
recurrent otitis. This article reviews the pathogenesis of chronic otitis, provides a systematic
diagnostic and therapeutic plan, and emphasizes the role of client education in the successful
management this condition.
E
ar disease is common in dogs. Otitis externa is inflammation of the ear
canal from the pinna to the tympanic membrane; otitis media is inflam-
mation of the middle ear, including the tympanic membrane and tympan-
ic bulla. Obstacles that contribute to poor response to treatment of chronic otic
conditions include uncooperative patients and/or owners, inability to adequately
examine the external ear canal and tympanic membrane, chronic middle-ear dis-
ease, inappropriate selection of medication, and failure to identify and treat a
primary or predisposing condition.
The sheer number and variety of topical ear cleaner formulations, flushing
and drying agents, and topical antibiotic/antifungal/steroid combinations are
testaments to the significance of otitis. Although a great deal of science has gone
into developing these products, there is no single topical otic preparation that
will satisfactorily treat all conditions. Practitioners tend to dispense a product
based on clinical impressions or pick a favorite product rather than selecting one
that has specific application for the current condition. This hit-or-miss clinical
approach may result in the mismanagement of otitis. The longer otitis persists,
the more likely it is that hyperplastic changes and middle-ear involvement will
occur. The best way to choose the most appropriate treatment is by having a
working knowledge of the individual ingredients in the product chosen plus a
full understanding of the clinical condition being treated. This knowledge and
understanding are required to develop an effective treatment plan.
The causes of otic disease have been reviewed in the literature.1–3 This article
reviews the normal and abnormal physiology and pathogenesis of chronic otitis
and provides a guide for developing appropriate treatment and management
Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

(Figure 1). The tympanic

membrane is a thin, elliptic,
semitransparent band of ep-
ithelium that separates the
external canal from the mid-
dle ear. The manubrium of
the malleus can be seen
through the tympanic mem-
brane and appears as a
crooked, fingerlike projec-
tion. The membrane helps
to resonate sound to the au-
Figure 1—Otoscopic view of a normal Figure 2—Subacute otitis with suppurative exudate
ditory ossicles and protects
ear canal. and early epidermal hyperplasia.
the middle ear from the ex-
ternal environment.

Figure 3—Chronic otitis with lichenification and oc-
clusion of the canal.
plans. Early intervention with aggressive and systematic
medical management is required to terminate the cycle
inherent in chronic otic disease. Unless a cause for otitis
is identified and treated, resolution of the disease is un-
likely.
NORMAL ANATOMY AND PHYSIOLOGY OF THE
EAR CANAL
The ear canal is a cartilaginous structure lined by
skin; hair follicles, sebaceous glands, and modified
apocrine (ceruminous) glands line the entire canal to
the level of the tympanic membrane. The primary
functions of the ear canal are to conduct sound and
protect the tympanic membrane and middle ear from
the external environment. Normally, glandular secre-
tions and epithelial cells (cerumen) work together to
trap dirt and debris in the ear canal. Together with a
process called epithelial cell migration, cerumen moves
dirt and debris away from the tympanic membrane and
eventually out of the canal. Otoscopic examination of a
normal ear canal should reveal a smooth, noninflamed
epithelial lining and an intact tympanic membrane
PATHOPHYSIOLOGY OF
OTITIS EXTERNA AND
OTITIS MEDIA
In otitis externa, inflam-
mation may be acute or
chronic. Erythema and ede-
ma signal an acute inflam-
matory response. Acute otitis
without infection may be seen
with any primary process (e.g.,
Figure 4—Otoscopic view of the hypersensitivity, parasitism,
external ear canal of a dog with a foreign body, trauma). When
ruptured tympanic membrane. erythema and edema initially
occur, the microenvironment
in the ear canal is altered and
glandular secretions increase. This change will encour-
age the establishment of a bacterial or yeast infection if
the primary problem is not identified and treated. Acute
otic conditions without infection are often missed in al-
lergic patients; consequently, acute otitis with infection
is typically treated with a topical otic preparation with-
out consideration of a primary disease process.
If the inflammatory phase is missed, the condition
will progress to epidermal and glandular hyperplasia
with increased glandular secretions (Figure 2). Over a
short time, epidermal cell migration becomes impeded
and ceruminous material accumulates in the canal. The
increased heat, humidity, and accumulated keratinous
material in the canal encourage and nourish microbial
overgrowth. Hyperkeratosis and acanthosis lead to
lichenification and occlusion of the canal (chronic
phase; Figure 3). In the final stages, the auricular carti-
lage can become rigid, leading to an even more painful
ear. Ossification of the cartilage occurs in extreme cases.
A diagnosis of otitis media implies that the eardrum
(tympanic membrane) is ruptured or has been ruptured
in the past. A rupture in the tympanic membrane may

CERUMEN ■ TYMPANIC MEMBRANE ■ ACUTE AND CHRONIC PHASES

Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

occur at any point in the dis- is discontinued prematurely

ease’s progression from acute Examination of the Ear Canal and a subclinical condition
to chronic. Because the tym- persists). Treatment errors,
■ Grade severity of erythema.
panic membrane is capable over- or undertreatment, or
of reepithelializing once rup- ■ Assess diameter of canal for anatomic stenosis, inappropriate use of antimi-
tured, it is common for otitis inflammatory edema, or occlusion from chronic crobial medication will also
media to be present with an hyperplasia. result in a chronically dis-
intact tympanum. 4 Otitis ■ Assess quantity, character, and color of exudate. eased ear.
media should be suspected ■ Perform cytologic examination of exudate and
any time the tympanic mem- DIAGNOSTIC TESTS FOR
obtain sample for culture/sensitivity.
brane is ruptured or absent CHRONIC OTITIS
(Figure 4) or appears discol- ■ Perform otoscopic examination: Check for Three primary diagnostic
ored or opaque, when the presence of parasites, ulcerations, foreign bodies, challenges to address when
condition is chronic or recur- and growths; assess character of tympanic evaluating chronic otitis are
rent, or if there are signs of membrane. (1) determining the primary
facial or sympathetic nerve cause and resolving it if pos-
damage. A diagnosis of chron- sible, (2) determining the
ic otitis would be reasonable when a treated condition amount of middle-ear involvement, and (3) identifying
has persisted for 2 months or longer or if the condition and controlling perpetuating factors.
responded to appropriate therapy only to recur after medi- A complete history—including details regarding on-
cations were discontinued. set, duration, and progression of the condition; a list or
summary of medications used that were not prescribed
PATHOGENESIS OF OTITIS by the current practitioner; and response to therapy—is
The pathogenesis of otitis has been divided into pre- a mandatory and fundamental part of the diagnostic
disposing, primary, and perpetuating factors.1 It is im- workup of ear disease. This information allows practi-
perative that these factors be investigated thoroughly tioners to develop a short list of diagnostic differentials.
and aggressively at the earliest sign of disease to prevent Histories are frequently overlooked in a busy practice,
the development of chronic disease. but precious time can be saved without losing this in-
Predisposing factors are risk factors that may lead to valuable information if a dermatologic history form is
otitis, including environmental conditions (e.g., mois- given to clients to complete while waiting to have their
ture, heat), inappropriate treatment (e.g., plucking hair, pets examined. Practitioners can then review the com-
using grooming powder), anatomic variations (e.g., ments, identify the points specific to the presenting
pendulous ears; stenotic canals; relative numbers of condition, and fine-tune the information in the exami-
ceruminous glands, sebaceous glands, and hair follicles nation room.
in the canal), or systemic or immunosuppressive dis- A complete dermatologic examination will provide
eases. These factors rarely cause otic disease by them- additional clues for primary and predisposing factors
selves but instead change the otic microenvironment to and will help in formulating a complete diagnostic and
favor the development of opportunistic infections. treatment plan. The results of a physical examination of
Primary factors alone can cause otitis. Examples of the ear canal (see Examination of the Ear Canal) should
primary causes include foreign bodies, neoplasia, ec- be noted in the patient’s record at the initial visit and at
toparasites (e.g., Otodectes cynotis, Sarcoptes scabeii, Dem- each subsequent examination. First, the lining of the
odex cati, Notoedres cati, ticks), juvenile cellulitis, hyper- canal should be visually evaluated for severity of erythe-
sensitivity (e.g., atopy, food allergy, contact allergy), ma. The diameter of the canal must also be assessed to
and keratinization disorders (e.g., idiopathic seborrhea, determine whether it is anatomically stenotic, edema-
endocrinopathies, autoimmune diseases, zinc- or vita- tous from acute inflammation, or occluded because of
min A–responsive dermatoses). hyperplasia or fibrosis. The quantity, character, and col-
Perpetuating factors are often the main reasons for or of exudate should be assessed and recorded.
therapeutic failure. These factors include bacterial and Cytologic evaluation of any otic material present is
yeast infections, progressive pathologic changes result- mandatory and involves a simple test that requires a
ing from chronic inflammation (e.g., edema, hyperker- minimal amount of supplies and time. This test allows
atosis, epithelial hyperplasia, fibrosis, apocrine gland practitioners to determine the severity of an infection
hyperplasia and hidradenitis, increased secretions, based on the numbers and types of cells and organisms
stenosis of the canal), and otitis media (when treatment present (e.g., budding yeast, rod or coccoid bacteria,

PREDISPOSING FACTORS ■ PRIMARY FACTORS ■ PERPETUATING FACTORS

 Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

neutrophils; Figure 5). A sam- cytology, and/or otitis media

ple of exudate is rolled on a is suspected or identified.
glass slide to form a thin Samples for culture should be
film; the slide is heat-fixed, taken from both the external
stained with a three-step and middle canals if the
quick stain, surveyed under eardrum is ruptured. Al-
10× for an appropriate area, though sensitivity testing is
and then examined carefully helpful in selecting appropri-
at 40× to characterize the ate antimicrobial medication,
type (yeast, bacteria, mixed) it is important to remember
and severity (presence of neu- that resistance to a particular
trophils) of the infection. antibiotic in vitro may not
Depending on the skill of correlate with clinical re-
the technician, oil immer- sponse; this is because direct
sion (100×) may be helpful Figure 5—Cytologic evaluation of exudate from a dog with a application of medication to
to illuminate the findings chronic bacterial otitis. This slide was stained with a three- the ear canal will result in a
seen at 40×. A numeric score step quick stain and shows numerous rod-type bacteria and a higher antibiotic concentra-
single budding yeast. (Original magnification, ×60)
(0 through 4) should be as- tion than that obtained with
signed to indicate the rela- systemic medication.
tive number of cells and organisms seen. The test can Otoscopic examination of both ears with a handheld
be performed at each subsequent patient visit to track or endoscopic otoscope is a mandatory part of evalua-
response to therapy and determine when the infection tion but may not be possible during the first visit if
is finally resolved. canals are severely edematous or hyperplastic. A course
Bacterial culture with antibiotic sensitivity testing of topical glucocorticoids may be required to reduce in-
should be performed when chronic infections fail to re- flammation and enable otoscopic examination. If ex-
spond to appropriate therapy, rod bacteria are present on amination of the canal is possible, the epithelium

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Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

should be evaluated for the otitis media are missed with

presence of ulcers, growths, this procedure.5
or foreign bodies. The pres-
ence of a tympanic mem- EAR CLEANING
brane should be determined Proper treatment requires
and its overall health (i.e., thorough ear cleaning. Many
normal, thickened, ruptured) cases of chronic otitis are ac-
assessed. companied by a large amount
Radiography has been of debris (e.g., sloughed ker-
shown to be of limited help atinocytes, old medication,
in diagnosing otitis media. glandular secretions, suppu-
Chronic changes, such as ration, bacteria, yeast) that
ossification of the cartilage occludes the canal. This ma-
and thickening of the bul- terial can exacerbate inflam-
lae, can be identified radio- mation, makes visualization
graphically, but a normal ra- Figure 6—An operating head otoscope, ear cones, and an ear of the tympanic membrane
loop are used to remove large pieces of debris from deep
diograph does not exclude within external ear canals. impossible, and will inacti-
otitis media. Many cases of vate the active ingredients in

Commercial Topical Solutions and Suspensions for Treating Chronic Otitis
Product
®
Tresaderm
(Merck AgVet, Rahway, NJ )
Synotic®
(Fort Dodge, Fort Dodge, IA)
Otobiotic Otic®
(Schering-Plough, Union, NJ)
Cortisporin® Otic® (Glaxo Wellcome, Neomycin 0.5%,
Research Triangle Park, NC)
AK Spore Ophthalmic® (Akorn Inc.,
Abita Springs, LA)
(many generics available)
Xenodine® (Veterinary Products
Laboratory, Phoenix, AZ)
Gentocin Otic® (Schering-Plough)
Gentocin Ophthalmic®
(Schering-Plough)
TABLE I
Activity
Antimicrobial Antiinflammatory Indication
Neomycin 0.32%, Dexamethasone 1% Bacteria, yeast,
thiabendazole moderate inflammation
— Fluocinolone 0.01% Severe inflammation
without infection
Polymyxin B Hydrocortisone 0.5% Pseudomonas species
10,000 IU/ml (gram-negative bacteria)
± Hydrocortisone 0.5% Pseudomonas species
polymyxin B sulfate (gram-negative bacteria),
10,000 IU/ml rarely resistant to
polymyxin B
Polyhydroxydine — Pseudomonas species
complex of titratable (gram-negative bacteria)
iodine
Gentocin 0.3% Betamethasone 0.1% Bacterial otitis with
severe inflammation
Gentocin 0.3% — Bacterial otitis with
severe inflammation

Conofite Lotion® Miconazole 1% — Malassezia canis

(Schering-Plough)
Tobramycin Ophthalmic Tobramycin — Pseudomonas species
(Akorn Inc.) (gram-negative bacteria)
Ciloxan® (Alcon Laboratories, Ciprofloxacin — Pseudomonas species
Ft. Worth, TX) (gram-negative bacteria)

RADIOGRAPHY ■ DEBRIS ■ SOLUTIONS/SUSPENSIONS

 Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

some medications. Exudate must be removed before
any real progress in resolving the condition can be
achieved.
Ears with highly proliferative, chronic disease require
deep cleaning and flushing before any topical therapy
can be expected to help resolve the condition, but such
ears are extremely painful. It is not unusual for a heavi-
ly sedated animal with a painful ear to be stimulated to
an awake state when the ear is manipulated. Ear-flush-
ing procedures in these animals therefore require gener-
al anesthesia. If the ear canal is markedly edematous or
stenotic, administering oral prednisone (0.5 to 1.0 mg/kg
every 24 hours) for 5 to 7 days before the scheduled
procedure helps reduce the swelling and open the canal.
Owners should be warned before the procedure that a
possible sequela to flushing a diseased ear is the devel-
opment of vestibular syndrome or deafness, which may
be temporary or permanent.
Ceruminolytic agents can be used to loosen debris be-
fore the flush. Samples for cytologic evaluation and bac-
terial culture should be obtained before instilling the
ceruminolytic solution or flushing the canal. Although
certain ceruminolytic agents and disinfectants are con-
traindicated for ruptured tympanic membranes, it is of-
ten impossible to determine the state of the eardrum un-
til after the flush.6,7 Useful and gentle agents I prefer
include Epi-Otic® (Allerderm-Virbac, Fort Worth, TX),
Cerumene® (EVSCO, Buena, NJ), or PanOtic® (Pfizer,
Exton, PA).
The ceruminolytic agent is instilled 10 minutes be-
fore the flush to soften accumulated debris. Once the
animal is anesthetized and positioned in sternal or lat-
eral recumbency, the next step is to gently flush out de-
bris and the ceruminolytic agent with copious amounts
of warmed 0.9% saline. A soft pediatric rubber bulb sy-
ringe, a soft red rubber urinary catheter attached to a
12-ml syringe, or a soft plastic pipette helps remove the
bulk of material. Care must be taken to not create too
much force or pressure in the ear. A gentle backflow of
flushing solution indicates that the right amount of
pressure is being applied. Excess water and debris can
be removed by suctioning with a feline open-tipped
urinary catheter or a soft red rubber catheter attached
to a 12-ml syringe.
After cleaning and flushing the ears, the canal can be
examined with an operating head otoscope to assess the
success of the flush. Large pieces of debris occasionally
accumulate at the level of the tympanum. An ear
curette or loop visually guided through a sterile oto-
scopic cone with an operating head otoscope may be
needed to remove large debris (Figure 6). The flush
should be repeated if necessary. Extreme care should be

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Small Animal/Exotics
taken when using cotton-tipped applicators to remove
water and debris because they can traumatize an already
fragile epithelium; may lead to ulceration or bleeding
of the canal wall, preventing visualization of the tympa-
num; and can force debris deeper into the canal.
After removing debris, the tympanic membrane
should be examined for integrity. If the tympanic mem-
brane looks normal and the canal is clear of debris and
exudate, an appropriate topical antimicrobial medica-
tion (based on cytology or culture results) can be in-
stilled, parenteral prednisolone (0.5 mg/kg) adminis-
tered to limit postprocedural swelling, and an oral
antibiotic dispensed to be used pending culture results.
The potential for incurring epithelial trauma during
the flushing procedure combined with the presence of
pathogenic organisms in the canal warrant a course of
systemic antibiotics even if the tympanic membrane is
intact. Both topical and systemic medications may be
changed after culture results are evaluated. A follow-up
evaluation is required 7 to 10 days after the procedure
to ensure a satisfactory response to prescribed medica-
tions or adjust therapy if needed.
When the ear is examined during an anesthetic pro-
cedure and the tympanic membrane is discolored,
opaque, or bulging outward, a myringotomy should be
considered. This procedure can be tricky and should be
Raise the Standard of Practice at Your Hospital with
STANDARDS of CARE
ENDIU
MP
M
CO
’S •
I
•
RE
S TA
CA
DA
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R D S of
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ENDIU
C O M P E N D I U M ’ S
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EMERGENCY AND CRITICAL CARE MEDICINE®
Feline Hepatic Lipidosis
Sharon A. Center, DVM, DACVIM
Professor, Internal Medicine
College of Veterinary Medicine
Cornell University
H
epatic lipidosis (HL) is the most common cause of jaundice in cats
in North America. It develops primarily in obese cats that have
recently been anorectic. By definition, HL occurs when >50% of
hepatocytes accumulate excessive triglycerides (TGs), resulting in severe cell
vacuolation, cholestasis, and liver dysfunction. Left untreated, HL progresses
to metabolic dysregulation and death. Although HL was initially considered
an idiopathic disorder, it is now known to more commonly occur secondary
to other disease conditions.
DIAGNOSTIC CRITERIA
Historical Information
■ Age/gender/breed
predispositions. None.
■ Other historical considerations.
• Most commonly noted in
indoor, obese cats; most cats
have been anorectic for several
days or longer.
• On presentation, many have
lost at least 25% of pre-illness
body mass.
• Reclusiveness, affection, and
lethargy are typical owner
observations.
• Jaundiced mucous membranes,
nonpigmented skin or sclera, and
hyperbilirubinuria may be noted.
• Ptyalism, vomiting, diarrhea, or
Articles with this symbol provide
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Articles with this symbol provide
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Articles with both symbols cover canine
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EMERGENCY AND CRITICAL CARE MEDICINE
constipation may occur as part of
primary disease, but these signs are
highly variable among cats.
Physical Examination
Findings
■ Unkempt and in poor condition,
jaundice, and weakness.
■ May have ptyalism without
provocation or on oropharyngeal
examination.
■ Variable dehydration attributed
to anorexia, vomiting, and
diarrhea.
■ Head and neck ventroflexion.
■ Cats show some signs
consistent with severe hepatic
encephalopathy (HE), such as
lethargy, collapse, obtundation,
and seizure activity.
■ Abdominal palpation discloses
nonpainful hepatomegaly.
■ Bleeding tendencies may be
evidenced by bruising around
venipuncture, palpation, or
ultrasound probe sites.
1
■ Other abnormalities may be
found depending on the primary
disease.
Laboratory Findings
■ CBC.
• Poikilocytosis (i.e., irregular
RBC shapes) is common.
• A mild nonregenerative anemia
accompanies primary
underlying chronic
inflammatory disorders.
• Hemolytic anemia may
be severe and related to
hypophosphatemia or Heinz
body formation at presentation
and/or during treatment.
• Leukogram reflects underlying
disorders; HL is not a reactive
process (no necrosis,
inflammation, fibrosis).
• Icteric plasma.
■ Biochemistry.
• Hyperbilirubinemia.
• ↑↑↑ALP, ↑↑ALT, ↑↑AST,
normal or mildly ↑γGT.
Discordance between
ALP–γGT is an important
diagnostic feature. The ↑γGT
indicates necroinflammatory
VOLUME 2 • NUMBER 10
OCTOBER 2000
INSIDE THIS ISSUE:
Peer-Reviewed Articles on
HEPATIC DISORDERS
1 Feline Hepatic Lipidosis
6 Congenital Portosystemic Shunts
10 Correction
20TH ANNIVERSARY
...An exciting new publication
from the trusted publishers of
Compendium.
Expert help fast in a
practical and readable format
Each monthly* issue
is peer-reviewed
In each article you will find:
■ Danger signs
■ Guidelines
■ Step-by-step tips
Standards of Care: Emergency
and Critical Care Medicine.
Concise. Authoritative. Cur-
rent. No general practice should
be without it.
Compendium August 1999
performed only with a clear visual field. The tympanic
rupture can be achieved with an operating head oto-
scope; a sterile otoscopic cone; and a sterile spinal nee-
dle, 20-gauge polypropylene intravenous catheter, or
Calgi swab. The catheter or needle should be passed
through the sterile otoscopic cone and a sterile 3-ml sy-
ringe attached so that the contents of the middle ear
can be aspirated as soon as rupture occurs. The aspirate
should be submitted for culture and cytology. I prefer
to use the Calgi swab to make the rupture because it al-
lows me to take the culture sample and perform the
myringotomy in one step. The next step is to flush the
middle ear with warmed saline, tromethamine (Tris)–
EDTA, dilute povidone– iodine solution, or a 4:1 solu-
tion of water and white vinegar using a feline, open-
tipped urinary catheter. Vinegar and water will kill
Pseudomonas species after 2 to 5 minutes of contact but
can be irritating if the epithelium is ulcerated or the so-
lution is left in the canal.8 Theoretically, vinegar and
water, povidone–iodine, or any flushing solution except
saline may irritate or cause ototoxicity. The safest ap-
proach is to remove these potentially ototoxic products
by flushing with copious amounts of saline. Excess wa-
ter can be removed via gentle aspiration with a feline
urinary catheter. Just before the animal wakes, Tris-
EDTA and a topical antimicrobial solution should be
instilled and parenteral prednisolone administered.
Both a topical and systemic antibiotic should be dis-
pensed.
MEDICAL MANAGEMENT OF CHRONIC OTITIS:
SELECTING APPROPRIATE DRUGS
The pathogens isolated most frequently from chronic
external and middle-ear infections include Staphylococ-
cus intermedius, Malassezia pachydermatis, Pseudomonas
species, Proteus species, Escherichia coli, and enterococ-
cus.4 Selection of both systemic and topical antimicro-
bial medication is based on cytologic evaluation and
culture and sensitivity results. Systemic antibiotics are
mandatory. Oral cephalexin (22 to 33 mg/kg every 12
hours), chloramphenicol (50 mg/kg every 8 hours), and
fluoroquinolones (enrofloxacin [5 to 10 mg/kg every
24 hours], orbifloxacin [5 to 10 mg/kg every 24 hours],
or ciprofloxacin [10 to 20 mg/kg every 24 hours]) are
all appropriate. Treatment should continue until the in-
fection is resolved (a minimum of 4 weeks). It is not
uncommon for treatment of otitis media to continue
uninterrupted for 8 to 12 weeks.
Topical antimicrobial therapy is an important part of
the treatment regimen, and the vehicle is as important
as the active ingredient. Most otic preparations are
combination drugs (glucocorticoid plus antibiotic) in
an oil or ointment base. Oils and ointments are occlu-
MYRINGOTOMY ■ TRIS-EDTA
Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE II
Off-Label Preparations for Treating Chronic Bacterial Otitisa

Product Preparation Indication

Enrofloxacin injectable (22.7 mg/ml)
Amikacin sulfate injectable (50 mg/ml)
Polymyxin B sulfate injectable powder
(500,000 IU/vial)
Gentamicin sulfate injectable
(50 mg/ml)
Silver sulfadiazine 1% cream
Tromethamine (Tris)–EDTAb
1%–2.5% Acetic acidc
a
These products are especially effective against Pseudomonas species.
b
Independent compounding pharmacies may prepare.
c
Higher concentrations irritate epithelium.
5 ml in 20 ml 0.9% saline
1–2 ml in 30 ml 0.9% saline
Mix with 50 ml 0.9% saline to
prepare 10,000 IU/ml solution
1–2 ml in 30 ml 0.9% saline
or
1–2 ml in 30 ml miconazole lotion
3 ml in 25 ml distilled water
or saline
6.05 g Tris (base), 1.2 g EDTA
(disodium salt), 1 L distilled water,
1 ml glacial acetic acid; adjust pH
to 8.0 with additional acetic acid;
autoclave and store refrigerated
4:1 water and white vinegar
1:1 water and white vinegar
Resistant Pseudomonas species,
Escherichia coli, Proteus
Resistant Pseudomonas species,
E. coli, Proteus
Pseudomonas species
Resistant Pseudomonas species, E. coli,
Proteus with Malassezia pachydermatis
Pseudomonas species, Staphylococcus,
Streptococcus, Proteus, Enterobacter
Pseudomonas species, Staphylococcus,
Proteus, E. coli (especially effective
against gram-negative bacteria)
Pseudomonas species, Staphylococcus,
Proteus, E. coli

sive, may hold or trap exudate, and may increase the
risk of ototoxicity; such preparations are not desirable
in cases of chronic otitis in which a moist exudate is
present, the canal is stenotic, or the eardrum may be
ruptured. The goal of treating a wet ear is to dry it. So-
lutions and suspensions are primarily composed of wa-
ter; may contain an astringent (e.g., aluminum acetate);
and are designed to evaporate over time, thus helping
to dry the ear. Topical antibiotics should be selected
based on the sensitivity potential of the organisms seen
on cytology and then adjusted or changed when the
culture and sensitivity results are known.
Aminoglycosides (e.g., gentamicin, amikacin, to-
bramycin, and neomycin) are in a class of antibiotics
commonly used in both otic and ophthalmic prepara-
tions. Although this class of antibiotics is ototoxic, its
sensitivity against Pseudomonas species is well document-
ed.9,10 If the antibiotic sensitivity tests indicate that no
other antibiotic will be effective against the identified or-
ganism, then the use of aminoglycosides is unavoidable.
Polymyxin B is effective against gram-negative bacteria,
especially Pseudomonas species, and is available in several
topical preparations. Ophthalmic preparations contain-
ing polymyxin B are available as solutions with or with-
out glucocorticoids, may be used safely in the ear canal,
and are appropriate choices when a glucocorticoid is not
desirable. Table I lists commercial topical solutions and
suspensions that may be used to treat chronic otitis.
Although used off-label, in-house formulated otic
“cocktails” may be appropriate. Fluoroquinolones are
effective against Pseudomonas species. Enrofloxacin in-
jectable (22.7%) full strength or diluted 1:4 with nor-
mal saline can be placed in a dropper bottle and ap-
plied to the ear canal twice daily. Topical enrofloxacin
may achieve a higher antibiotic concentration at the
site more economically than systemic medication. Sil-
ver sulfadiazine is effective in vitro against Pseudomonas
species, Staphylococcus aureus, Proteus species, and oth-
ers11; a 0.1% to 1% emulsion10,12 every 12 hours is ade-
quate to kill Pseudomonas species. Tris-EDTA buffer so-
lution has a direct bactericidal effect on some bacteria
by chelating metal ions in the cell wall. The bactericidal
effects of Tris-EDTA are “synergized” when combined
with aminoglycosides.13 Although an antibiotic can be

AMINOGLYCOSIDES ■ PSEUDOMONAS SPECIES ■ OTIC “COCKTAILS”

Small Animal/Exotics 20TH ANNIVERSARY
added to the Tris-EDTA solution, I prefer to use Tris-
EDTA 5 to 10 minutes before the topical antibiotic.
The Tris-EDTA and antibiotic combination is effective
against a variety of bacteria but is ineffective against
yeast. Table II lists alternative topical preparations that
are appropriate for chronic bacterial otitis.
Topical glucocorticoids can rapidly reduce inflam-
mation and help restore the normal microenvironment
in acute conditions and are helpful in chronic condi-
tions. Topical otic products contain potent glucocorti-
coids, such as betamethasone, flumethasone, or des-
oximetasone, but are in ointment or oil bases. Synotic®
(Fort Dodge, Fort Dodge, IA), a solution containing
0.01% fluocinolone, is especially useful for acutely in-
flamed ears that are not secondarily infected. I rarely
use topical glucocorticoids stronger than prednisone
during the workup phase of treatment primarily be-
cause glucocorticoids will alter some diagnostic test re-
sults and because the degree of absorption of topical
steroids cannot be controlled. I often dispense a 7- to
10-day course of oral prednisone (0.5 mg/kg every 24
hours for 3 days, then every 48 hours for 1 week) after
an ear flush to reduce postprocedural inflammation and
ensure that an otoscopic examination can be done at
follow-up.
Follow-up examinations, including otoscopic and cy-
tologic evaluations, should be scheduled at 2-week in-
tervals until the infection is resolved. It is not unusual
for a mild opportunistic yeast infection to develop in
the ear during antibiotic treatment; this may have to be
treated specifically with a topical antifungal but will of-
ten resolve with discontinuance of the topical antibiotic.
CLIENT EDUCATION: MAINTENANCE CARE
The key to client compliance with intensive topical
therapy is education. Owners should be taught that a
dirty ear cannot be successfully medicated and that a
diseased ear must be handled gently.
Maintenance ear care prevents recurrence of acute in-
fections; ensures success in treating chronic ear disease
by removing accumulated otic debris; and maintains a
healthy microenvironment, thus ensuring that the
canals stay patent. Most owners do not know how to
properly clean their pets’ ears. Staff members should be
instructed how to teach owners to clean ears. A hand-
out describing the cleaning technique can be filled out
and handed to clients with discharge instructions (see
Sample Client Instruction Handout for Cleaning Ca-
nine Ears). Prescribed topical medication can be insert-
ed where appropriate.
Each patient is different; therefore, maintenance pro-
grams and cleaning solutions should be specific for in-
dividual clinical conditions. For example, for chronic or
GLUCOCORTICOIDS ■ FOLLOW-UP EXAMINATION ■ EDUCATING OWNERS
Compendium August 1999
Sample Client Instruction Handout
for Cleaning Canine Ears
Otitis is inflammation of the ear canal. Otitis
externa involves the ear from the ear flap (pinna) to
the eardrum, and otitis media involves the eardrum
and middle ear. Signs of ear disease include
scratching the ear, shaking the head, a foul odor or
discharge emanating from the ear canal, and swelling
or redness of the skin lining the ear canal. Otitis may
occur with a variety of conditions, including food and
pollen allergies, a foreign body, ear mites, scaly skin
conditions, and hormonal imbalance. Not all red or
diseased ears are infected ears. If left untreated or
undiagnosed, otitis can allow yeast or bacteria to
overgrow, causing infection.
[Pet’s name] has [otitis externa or media]. The
following information is designed to help you treat
your pet’s condition as we work to identify the
primary disease process.
Gather real (not synthetic) cotton balls and the
cleaning solution. Never use cotton-tipped applicators
or swabs because they push debris further into the
canal. Squirt enough [cleaner name] into the ear to fill
the canal. Massage the base of the ear until you hear
the solution “squish.” Gently grab the base of the ear,
and pull the pinna up and away from the head to
straighten the “L” shape of the canal. Wad the cotton
into a tubular shape, and gently insert it into the canal
as far as it will go. Again, gently massage the base of
the ear to help work debris and the cleaning solution
toward the cotton to dry the canal. Wait a few
minutes, then place the medication in the affected
ears as instructed below.
Place ____ drops of [medication name] in the
[right/left/both] ear(s) every ____ hours for ____
days. Do not let the tip of the medication container
touch the skin. If it does, be sure to clean the tip of the
applicator with a little alcohol to prevent cross-
contamination between ears. After placing the
medication in the ear, gently massage the ear canal as
outlined above for the cleaning procedure (listen for
the “squish”).
Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

recurring bacterial or Malassezia otitis, a 0.5% to 3% agent can cause irritation, and use of cleaning agents
chlorhexidine solution every other day is ideal. If a should be discontinued if the ear appears significantly
buildup of waxy cerumen is common, a ceruminolytic worse (more inflamed) after cleaning. If exudation is se-
agent two to three times a week should be adequate. If vere, owners should be advised to gently remove the ma-
the exudate is wet, a drying agent twice weekly may be terial with a dry cotton ball before applying medica-
the treatment of choice. tion.
Commercial otic drying Client education should also include a discussion of
ENDIU
MP agents should be avoided the potential need for surgical intervention should
M’

20th

CO

medical therapy fail. Surgery is an appropriate alterna-

S

9 9 9
in inflamed, chronically
9 - 1
1 9 7

ANNIVERSARY
A LookBack
Chronic otitis in dogs is as Each of these products
common today as it was 20
years ago. One of the most
significant advances in the
management of chronic otitis
over the past 20 years is that we vinegar–alcohol solution
no longer expect that taping the will help kill and control
ears over the head and applying
a topical ointment for 7 to 10
days will take care of the
problem. Today, the recognition
that successful management
requires the identification and
treatment of a primary cause,
visual assessment of the canal
and tympanic membrane to
establish prognosis, selection of EDTA used two to three
medications based on specific
cytologic and cultural findings, an infection from occur-
and need for long-term topical
and systemic antibiotics has no
doubt saved a lot of ears from
surgery. Although some dogs still
need surgery after a primary
cause has been identified, the
condition will be reversed in
many dogs with proliferative
otitis when an accurate
diagnosis is made and
aggressive, appropriate
therapies employed.
diseased ears because most
contain isopropyl alcohol
and varying concentra-
tions of benzoic, acetic,
salicylic, or boric acid.
individually can be ex-
tremely irritating to an
already traumatized ep-
ithelium. A 50:50 white
yeast and Pseudomonas
species infections but
should be used only if
the ear canal is not in-
flamed. Dogs with chron-
ic disease (e.g., atopy, id-
iopathic seborrhea) will
be predisposed to recur-
rent otitis; a topical an-
tibiotic solution or Tris-
times weekly may prevent
ring with each flare-up of
the primary disease.
Rarely should owners
be instructed to clean
their pets’ ears with a
cleaning agent more than
every other day. If ears
are cleaned more often
than this, the ear does
not have an opportunity
to dry, the owner causes
more irritation than is
conducive to healing, and
client compliance dimin-
ishes. It is important to
inform owners that more
frequent cleaning is not
necessarily better for dogs,
overuse of any cleaning
tive when tissue proliferation has been unresponsive to
medication, the auricular cartilage is mineralized, tu-
mors or masses occlude the canal, or owners or patients
cannot tolerate medical management.
SUMMARY
Chronic otitis is a common and frustrating condition
to treat. Using early recognition of recurring otic infec-
tions as an indicator of a primary disease allows clini-
cians to focus attention on treating a specific disease
rather than a vague clinical condition. Treatment for
secondary infections is selected based on cytologic and
culture results. Clients must be informed of the prog-
nosis and taught how to successfully manage their pets’
condition. Regular reevaluations to monitor and adjust
therapy as needed will ensure client compliance and the
best possible patient outcome.
REFERENCES
1. August JR: Otitis externa: A disease of multifactorial etiolo-
gy. Vet Clin North Am Small Anim Pract 18:731–742, 1988.
2. Griffin CE: Otitis externa and otitis media, in Griffin CE,
Kwochka KW, McDonald JM (eds): Current Veterinary
Dermatology. St Louis, Mosby, 1993, pp 245–262.
3. Rosychuk AW: The management of canine and feline otitis
externa. Ear Care Symp Proc: 1990 Can Vet Med Assoc/1991
Eastern States Vet Conf:15–39, 1992.
4. Cole LK, Kwochka KW, Kowalski JJ, Hillier A: Microbial
flora and antimicrobial susceptibility patterns of isolated
pathogens from the horizontal ear canal and middle ear in
dogs with otitis media. JAVMA 212:534–538, 1998.
5. Hoskinson JJ: Imaging techniques in the diagnosis of middle
ear disease. Semin Vet Med Surg (Small Anim) 8(1):10–16,
1993.
6. Mansfield PD: Ototoxicity in dogs and cats. Compend Con-
tin Educ Pract Vet 12(3):331–377, 1990.
7. Mansfield PD, Steiss JE, Boosinger TR, Marshall AE: The
effects of four commercial ceruminolytic agents on the mid-
dle ear. JAAHA 33:479–486, 1997.
8. Scott DW, Miller WH, Griffin CE (eds): Diseases of the
eyelids, claws, anal sacs, and ear canals, in Muller and Kirk’s
Small Animal Dermatology, ed 5. Philadelphia, WB Saunders
Co, 1995, pp 956–989.
9. Hariharan H, McPhee L, Heaney S, Bryenton J: Antimicro-
bial drug susceptibility of clinical isolates of Pseudomonas
aeruginosa. Can Vet J 36:166–168, 1995.
10. Kowalski JJ: The microbial environment of the ear canal in
health and disease. Vet Clin North Am Small Anim Pract
18(4):743–754, 1988.

FREQUENT CLEANING ■ SEVERE EXUDATION ■ SURGERY

Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

11. Hamilton-Miller JMT, Shah S, Smith S: Silver sulfadiazine:

A comprehensive in vitro reassessment. Chemotherapy 39:
405–409, 1993. About the Author
12. Noxon JO, Kinyon JM, Murphy DP: Minimal inhibitory Dr. White is the owner of the Atlanta Veterinary Skin & Al-
concentration of silver sulfadiazine on Pseudomonas aerugi- lergy Clinic, PC, Atlanta, Georgia, and is a Diplomate of
nosa and Staphylococcus intermedius isolates from the ears of
the American College of Veterinary Dermatology.Z
dogs with otitis externa. Proc 13th Annu Meet AAVD/ACVD:
72–73, 1997.
13. Wooley RE, Hones MS: Action of EDTA-Tris and antimi-
crobial agent combinations on selected pathogenic bacteria.
Vet Microbiol 8:271–280, 1983.