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20TH ANNIVERSARY Vol. 21, No.

8 August 1999

CE Refereed Peer Review

Medical Management
FOCAL POINT of Chronic Otitis
★Successfully managing chronic
otitis involves determining and
resolving (if possible) the primary
in Dogs
cause, determining the amount of
middle-ear involvement, and Atlanta Veterinary Skin & Allergy Clinic, PC, Atlanta, Georgia
identifying and controlling the Patricia D. White, DVM, MS
perpetuating factors; unless a
cause is identified and treated, ABSTRACT: The frustrations inherent in treating chronic otitis in dogs are an everyday chal-
resolution is unlikely. 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
KEY FACTS 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.
■ Ears with highly proliferative,
chronic disease require deep
cleaning and flushing before any

E
topical therapy can help resolve ar disease is common in dogs. Otitis externa is inflammation of the ear
the condition. canal from the pinna to the tympanic membrane; otitis media is inflam-
mation of the middle ear, including the tympanic membrane and tympan-
■ Systemic antibiotics are ic bulla. Obstacles that contribute to poor response to treatment of chronic otic
mandatory for chronic otitis and conditions include uncooperative patients and/or owners, inability to adequately
may be required uninterrupted for examine the external ear canal and tympanic membrane, chronic middle-ear dis-
8 to 12 weeks with otitis media. ease, inappropriate selection of medication, and failure to identify and treat a
primary or predisposing condition.
■ Enrofloxacin, silver sulfadiazine, The sheer number and variety of topical ear cleaner formulations, flushing
polymyxin B in a commercial and drying agents, and topical antibiotic/antifungal/steroid combinations are
otic or ophthalmic solution, or testaments to the significance of otitis. Although a great deal of science has gone
tromethamine–EDTA combined into developing these products, there is no single topical otic preparation that
with an aminoglycoside are will satisfactorily treat all conditions. Practitioners tend to dispense a product
effective alternative topical based on clinical impressions or pick a favorite product rather than selecting one
preparations used to treat chronic that has specific application for the current condition. This hit-or-miss clinical
resistant bacterial otitis. 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
■ Owners should be taught to occur. The best way to choose the most appropriate treatment is by having a
properly clean their pets’ ears working knowledge of the individual ingredients in the product chosen plus a
to help resolve infection and full understanding of the clinical condition being treated. This knowledge and
minimize recurrence. 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.

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

TABLE I
Commercial Topical Solutions and Suspensions for Treating Chronic Otitis
Activity
Product Antimicrobial Antiinflammatory Indication
®
Tresaderm Neomycin 0.32%, Dexamethasone 1% Bacteria, yeast,
(Merck AgVet, Rahway, NJ ) thiabendazole moderate inflammation
Synotic® — Fluocinolone 0.01% Severe inflammation
(Fort Dodge, Fort Dodge, IA) without infection
Otobiotic Otic® Polymyxin B Hydrocortisone 0.5% Pseudomonas species
(Schering-Plough, Union, NJ) 10,000 IU/ml (gram-negative bacteria)
Cortisporin® Otic® (Glaxo Wellcome, Neomycin 0.5%, ± Hydrocortisone 0.5% Pseudomonas species
Research Triangle Park, NC) polymyxin B sulfate (gram-negative bacteria),
AK Spore Ophthalmic® (Akorn Inc., 10,000 IU/ml rarely resistant to
Abita Springs, LA) polymyxin B
(many generics available)
Xenodine® (Veterinary Products Polyhydroxydine — Pseudomonas species
Laboratory, Phoenix, AZ) complex of titratable (gram-negative bacteria)
iodine
Gentocin Otic® (Schering-Plough) Gentocin 0.3% Betamethasone 0.1% Bacterial otitis with
severe inflammation
Gentocin Ophthalmic® Gentocin 0.3% — Bacterial otitis with
(Schering-Plough) 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 include Epi-Otic® (Allerderm-Virbac, Fort Worth, TX),
any real progress in resolving the condition can be Cerumene® (EVSCO, Buena, NJ), or PanOtic® (Pfizer,
achieved. Exton, PA).
Ears with highly proliferative, chronic disease require The ceruminolytic agent is instilled 10 minutes be-
deep cleaning and flushing before any topical therapy fore the flush to soften accumulated debris. Once the
can be expected to help resolve the condition, but such animal is anesthetized and positioned in sternal or lat-
ears are extremely painful. It is not unusual for a heavi- eral recumbency, the next step is to gently flush out de-
ly sedated animal with a painful ear to be stimulated to bris and the ceruminolytic agent with copious amounts
an awake state when the ear is manipulated. Ear-flush- of warmed 0.9% saline. A soft pediatric rubber bulb sy-
ing procedures in these animals therefore require gener- ringe, a soft red rubber urinary catheter attached to a
al anesthesia. If the ear canal is markedly edematous or 12-ml syringe, or a soft plastic pipette helps remove the
stenotic, administering oral prednisone (0.5 to 1.0 mg/kg bulk of material. Care must be taken to not create too
every 24 hours) for 5 to 7 days before the scheduled much force or pressure in the ear. A gentle backflow of
procedure helps reduce the swelling and open the canal. flushing solution indicates that the right amount of
Owners should be warned before the procedure that a pressure is being applied. Excess water and debris can
possible sequela to flushing a diseased ear is the devel- be removed by suctioning with a feline open-tipped
opment of vestibular syndrome or deafness, which may urinary catheter or a soft red rubber catheter attached
be temporary or permanent. to a 12-ml syringe.
Ceruminolytic agents can be used to loosen debris be- After cleaning and flushing the ears, the canal can be
fore the flush. Samples for cytologic evaluation and bac- examined with an operating head otoscope to assess the
terial culture should be obtained before instilling the success of the flush. Large pieces of debris occasionally
ceruminolytic solution or flushing the canal. Although accumulate at the level of the tympanum. An ear
certain ceruminolytic agents and disinfectants are con- curette or loop visually guided through a sterile oto-
traindicated for ruptured tympanic membranes, it is of- scopic cone with an operating head otoscope may be
ten impossible to determine the state of the eardrum un- needed to remove large debris (Figure 6). The flush
til after the flush.6,7 Useful and gentle agents I prefer should be repeated if necessary. Extreme care should be

DID REACHING A DIAGNOSIS


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We are looking for submissions for the column, “WHAT’S
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Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

taken when using cotton-tipped applicators to remove performed only with a clear visual field. The tympanic
water and debris because they can traumatize an already rupture can be achieved with an operating head oto-
fragile epithelium; may lead to ulceration or bleeding scope; a sterile otoscopic cone; and a sterile spinal nee-
of the canal wall, preventing visualization of the tympa- dle, 20-gauge polypropylene intravenous catheter, or
num; and can force debris deeper into the canal. Calgi swab. The catheter or needle should be passed
After removing debris, the tympanic membrane through the sterile otoscopic cone and a sterile 3-ml sy-
should be examined for integrity. If the tympanic mem- ringe attached so that the contents of the middle ear
brane looks normal and the canal is clear of debris and can be aspirated as soon as rupture occurs. The aspirate
exudate, an appropriate topical antimicrobial medica- should be submitted for culture and cytology. I prefer
tion (based on cytology or culture results) can be in- to use the Calgi swab to make the rupture because it al-
stilled, parenteral prednisolone (0.5 mg/kg) adminis- lows me to take the culture sample and perform the
tered to limit postprocedural swelling, and an oral myringotomy in one step. The next step is to flush the
antibiotic dispensed to be used pending culture results. middle ear with warmed saline, tromethamine (Tris)–
The potential for incurring epithelial trauma during EDTA, dilute povidone– iodine solution, or a 4:1 solu-
the flushing procedure combined with the presence of tion of water and white vinegar using a feline, open-
pathogenic organisms in the canal warrant a course of tipped urinary catheter. Vinegar and water will kill
systemic antibiotics even if the tympanic membrane is Pseudomonas species after 2 to 5 minutes of contact but
intact. Both topical and systemic medications may be can be irritating if the epithelium is ulcerated or the so-
changed after culture results are evaluated. A follow-up lution is left in the canal.8 Theoretically, vinegar and
evaluation is required 7 to 10 days after the procedure water, povidone–iodine, or any flushing solution except
to ensure a satisfactory response to prescribed medica- saline may irritate or cause ototoxicity. The safest ap-
tions or adjust therapy if needed. proach is to remove these potentially ototoxic products
When the ear is examined during an anesthetic pro- by flushing with copious amounts of saline. Excess wa-
cedure and the tympanic membrane is discolored, ter can be removed via gentle aspiration with a feline
opaque, or bulging outward, a myringotomy should be urinary catheter. Just before the animal wakes, Tris-
considered. This procedure can be tricky and should be EDTA and a topical antimicrobial solution should be
instilled and parenteral prednisolone administered.
Both a topical and systemic antibiotic should be dis-
pensed.
Raise the Standard of Practice at Your Hospital with
MEDICAL MANAGEMENT OF CHRONIC OTITIS:

STANDARDS of CARE
ENDIU
MP
SELECTING APPROPRIATE DRUGS
M
CO

’S •

I

RE
S TA

The pathogens isolated most frequently from chronic


CA

DA
N

R D S of

EMERGENCY AND CRITICAL CARE MEDICINE external and middle-ear infections include Staphylococ-
cus intermedius, Malassezia pachydermatis, Pseudomonas
MP
ENDIU
...An exciting new publication species, Proteus species, Escherichia coli, and enterococ-
C O M P E N D I U M ’ S

I STANDARDS of CARE cus.4 Selection of both systemic and topical antimicro-


M
CO

’S •

from the trusted publishers of


RE
S TA

CA

DA
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R D S of

EMERGENCY AND CRITICAL CARE MEDICINE®


Compendium. bial medication is based on cytologic evaluation and
Feline Hepatic Lipidosis ■ Other abnormalities may be
found depending on the primary

culture and sensitivity results. Systemic antibiotics are


Sharon A. Center, DVM, DACVIM disease.
Professor, Internal Medicine
College of Veterinary Medicine Laboratory Findings
Cornell University ■ CBC.

H
epatic lipidosis (HL) is the most common cause of jaundice in cats
• Poikilocytosis (i.e., irregular
RBC shapes) is common. Expert help fast in a
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
• A mild nonregenerative anemia
accompanies primary
underlying chronic
inflammatory disorders.
• Hemolytic anemia may practical and readable format
mandatory. Oral cephalexin (22 to 33 mg/kg every 12
hours), chloramphenicol (50 mg/kg every 8 hours), and
an idiopathic disorder, it is now known to more commonly occur secondary be severe and related to
to other disease conditions. hypophosphatemia or Heinz
DIAGNOSTIC CRITERIA constipation may occur as part of body formation at presentation
Historical Information primary disease, but these signs are and/or during treatment.
■ Age/gender/breed highly variable among cats. • Leukogram reflects underlying

fluoroquinolones (enrofloxacin [5 to 10 mg/kg every


predispositions. None. disorders; HL is not a reactive

Each monthly* issue


■ Other historical considerations. Physical Examination process (no necrosis,
• Most commonly noted in Findings inflammation, fibrosis).
indoor, obese cats; most cats ■ Unkempt and in poor condition, • Icteric plasma.
have been anorectic for several jaundice, and weakness. ■ Biochemistry.
days or longer. ■ May have ptyalism without • Hyperbilirubinemia.
• On presentation, many have
lost at least 25% of pre-illness
body mass.
• Reclusiveness, affection, and
provocation or on oropharyngeal
examination.
■ Variable dehydration attributed
to anorexia, vomiting, and
• ↑↑↑ALP, ↑↑ALT, ↑↑AST,
normal or mildly ↑γGT.
Discordance between
ALP–γGT is an important
is peer-reviewed 24 hours], orbifloxacin [5 to 10 mg/kg every 24 hours],
lethargy are typical owner diarrhea. diagnostic feature. The ↑γGT

or ciprofloxacin [10 to 20 mg/kg every 24 hours]) are


observations. ■ Head and neck ventroflexion. indicates necroinflammatory
• Jaundiced mucous membranes, ■ Cats show some signs
consistent with severe hepatic VOLUME 2 • NUMBER 10
nonpigmented skin or sclera, and OCTOBER 2000
hyperbilirubinuria may be noted. encephalopathy (HE), such as

In each article you will find:


lethargy, collapse, obtundation, INSIDE THIS ISSUE:
• Ptyalism, vomiting, diarrhea, or
and seizure activity. Peer-Reviewed Articles on
Articles with this symbol provide
standards for canine patients.
Articles with this symbol provide
standards for feline patients.
Articles with both symbols cover canine
and feline topics.
■ Abdominal palpation discloses
nonpainful hepatomegaly.
■ Bleeding tendencies may be
evidenced by bruising around
venipuncture, palpation, or
HEPATIC DISORDERS
1 Feline Hepatic Lipidosis
6 Congenital Portosystemic Shunts
■ Danger signs
all appropriate. Treatment should continue until the in-
fection is resolved (a minimum of 4 weeks). It is not
ultrasound probe sites. 10 Correction

STANDARDS of CARE: EMERGENCY AND CRITICAL CARE MEDICINE


1
■ Guidelines
■ Step-by-step tips uncommon for treatment of otitis media to continue
Subscribe today! uninterrupted for 8 to 12 weeks.
Standards of Care: Emergency Topical antimicrobial therapy is an important part of
Call 800-426-9119. and Critical Care Medicine.
Only $69 for 11 Concise. Authoritative. Cur-
the treatment regimen, and the vehicle is as important
information-packed issues.* rent. No general practice should as the active ingredient. Most otic preparations are
*November/December is a combined issue.
be without it. 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) 5 ml in 20 ml 0.9% saline Resistant Pseudomonas species,
Escherichia coli, Proteus
Amikacin sulfate injectable (50 mg/ml) 1–2 ml in 30 ml 0.9% saline Resistant Pseudomonas species,
E. coli, Proteus
Polymyxin B sulfate injectable powder Mix with 50 ml 0.9% saline to Pseudomonas species
(500,000 IU/vial) prepare 10,000 IU/ml solution
Gentamicin sulfate injectable 1–2 ml in 30 ml 0.9% saline Resistant Pseudomonas species, E. coli,
(50 mg/ml) or Proteus with Malassezia pachydermatis
1–2 ml in 30 ml miconazole lotion
Silver sulfadiazine 1% cream 3 ml in 25 ml distilled water Pseudomonas species, Staphylococcus,
or saline Streptococcus, Proteus, Enterobacter
Tromethamine (Tris)–EDTAb 6.05 g Tris (base), 1.2 g EDTA Pseudomonas species, Staphylococcus,
(disodium salt), 1 L distilled water, Proteus, E. coli (especially effective
1 ml glacial acetic acid; adjust pH against gram-negative bacteria)
to 8.0 with additional acetic acid;
autoclave and store refrigerated
1%–2.5% Acetic acidc 4:1 water and white vinegar Pseudomonas species, Staphylococcus,
1:1 water and white vinegar Proteus, E. coli
a
These products are especially effective against Pseudomonas species.
b
Independent compounding pharmacies may prepare.
c
Higher concentrations irritate epithelium.

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

AMINOGLYCOSIDES ■ PSEUDOMONAS SPECIES ■ OTIC “COCKTAILS”


Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

added to the Tris-EDTA solution, I prefer to use Tris-


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

GLUCOCORTICOIDS ■ FOLLOW-UP EXAMINATION ■ EDUCATING OWNERS


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