SA227

TOPICAL AND SYSTEMIC MEDICATIONS FOR OTITIS EXTERNA & OTITIS MEDIA
Lynette K. Cole, DVM, MS, Dipl. ACVD
The Ohio State University
Columbus, OH, USA

Once an otic infection has been diagnosed, treatment may include topical as well as systemic
therapy. At each recheck, the patients response to treatment should be monitored, cytology
performed, and products changed accordingly. In the majority of the cases of infectious otitis
externa, topical therapy alone is sufficient. In those ears with severe infections, or those that
have long-standing chronic otitis externa, the addition of a systemic antimicrobial agent may be
required to clear the infection that is present in the ear tissue as well as in the lumen of the ear
canal. For those dogs with infectious otitis externa and otitis media, topical and systemic
therapy is usually required.

Topical otic therapy
Topical therapies may be divided into the following categories: ceruminolytic agents, ear
cleaning and drying agents, topical glucocorticoids, and topical antimicrobial agents. It is
important to stock your veterinary clinic with at least one product from each category, since
they have different indications and uses.

Ceruminolytic agents
Ceruminolytic agents are normally used for in-hospital ear cleaning, but on rare occasion can
be dispensed for at-home ear cleaning. They work by surfactant, detergent or bubbling
activity. Most of these products are contraindicated with a ruptured tympanic membrane, since
many are ototoxic. However, they may be used in the sedated or anesthetized dog during an
ear flushing procedure followed by multiple flushes with warm sterile isotonic saline. Water
miscible preparations containing dioctyl sodium sulfosuccinate (DSS) or propylene glycol are
well tolerated. Oils, such as squalene or mineral oil are effective, however messy,
ceruminolytic agents. Products containing urea peroxide in addition to DSS are very potent
and recommended for in-hospital usage only.
1. Cerumene (Vetoquinol)
25% squalene in isopropyl myristate liquid petrolatum base******(non-ototoxic)
2. Corium-20 (Virbac)
Purified water, SDA-40B 23%, glycerol
3. Douxo Micellar Solution (Sogeval)
Phytosphingosine, nonionic surface-acting agent, polidocanol, polysaccharides,
light fragrance
4. KlearOtic (Dechra)
22% squalene

Ear cleaning/drying agents
Once the ear has been cleaned in-hospital, or for routine ear cleaning at home, it is important
to dispense a cleaning and drying agent. Most contain an acid with or without alcohol. They
are used to clean the ear, as well as keep it dry to discourage the over growth of bacterial and
yeast organisms. The frequency of their use depends on the chronicity of the otitis externa
and the severity of the infection. The goal is to begin treatment with the most frequent
Western Veterinary Conference 2013
application (i.e. daily) and over time, decrease to a maintenance frequency (i.e. weekly). In
some cases, daily treatment with an ear cleaning and drying agent (i.e. Epi-Otic) may be
effective for resolution of bacterial and Malassezia otic infections.
1. DermaPet Malacetic Otic (Dechra)
Acetic acid, boric acid, surfactants
2. Epi-Otic Advanced (Virbac)
Salicylic acid 0.2%, disodium EDTA, docusate sodium, PCMX, a
monosaccharide complex (l-rhamnose, d-galactose, d-mannose)
3. Epi-Otic Cleanser (Virbac)
Lactic acid and salicylic acid are present in encapsulated and free forms,
chitosanide is present in encapsulated form, docusate sodium and propylene
glycol base
4. Gent-L-Clens (Intervet/Schering-Plough)
Lactic acid, salicylic acid in propylene glycol
5. Nolvasan Otic (Pfizer)
Special solvent, surfactant
6. Oti-Clens

(Pfizer)
Propylene glycol, malic acid, benzoic acid, salicylic acid
7. OtoCetic Solution (Vedco)
2% boric acid, 2% acetic acid, surfactants

Topical antiseptics
Topical antiseptics such as acetic acid and chlorhexidine have been used in cases of otitis.
Acetic acid works by acidification and other mechanisms as an antimicrobial agent. A 2%
solution is effective in vitro against Pseudomonas. Products containing acetic acid include:
1. Bausch & Lomb Acetic Acid 2% in Aqueous Aluminum Acetate Otic Solution
(Bausch and Lomb)
Acetic acid, aluminum acetate
2. DermaPet Ear Cleanser (Dechra)
Acetic acid, boric acid, surfactants
3. Otocetic Solution (Vedco)
2% boric acid, 2% acetic acid, surfactants

Chlorhexidine has broad spectrum activity against many gram-positive and gram-negative
bacteria and fungi; however, Pseudomonas may be resistant. Chlorhexidine may be ototoxic
and should be used with caution in ears with ruptured tympanic membranes. However, a
study done in normal greyhounds with experimentally ruptured tympanic membranes treated
twice a day for 21 days with a topical application of 0.2% chlorhexidine failed to show any
clinical vestibular or brainstem auditory evoked potential changes.
1. Hexadene Flush (Virbac)
Water, propylene glycol, 0.25% chlorhexidine gluconate, triclosan, fragrance


Indication for specific topical therapy
In most cases of otitis, specific topical therapy is indicated. The topical otic preparations
usually contain various combinations of glucocorticoids, antibiotics, and/or antifungals in a
vehicle base. For dry lesions, an oil or ointment base product is used to help moisturize the
skin, while in moist lesions a solution or lotion is recommended. Selection of the active
ingredient needed in the product should be based on cytology and culture and susceptibility
testing (C/S) results. It is important to remember that C/S results indicate the plasma level of
an antimicrobial agent. The advantage of topical therapy is that you can achieve 100 to 1000
times the plasma level of the antimicrobial agent by administering it topically. The patients
progress while on these medications should be monitored cytologically at each re-evaluation
and the topical therapy adjusted accordingly.

None of the commercially available otic topical treatments or the extra-label otic preparations is
labeled for use with a non-intact tympanic membrane. However, most all of these products
have been used to treat otic infections in dogs with otitis media. Always warn the owner of the
possibility of neurological signs of ototoxicity while administering topical medications when the
tympanic membrane is not intact. The otic topicals that I will not use in the ear with a non-
intact tympanic membrane are those in an ointment base.

Glucocorticoids
Glucocorticoids are antipruritic, anti-inflammatory, and antiproliferative. During the acute stage
of otitis, the ear canal becomes edematous and erythematous. As the inflammation
progresses, the dermis becomes infiltrated with a mixed population of cells. Apocrine glands
dilate and become hyperplastic, which leads to excessive cerumen production. Therefore,
glucocorticoids are beneficial in decreasing the pain, pruritus, stenosis, and edema associated
with otitis. In addition, they are effective in decreasing sebaceous and apocrine secretions.
They are usually in combination with other agents but may be beneficial when used alone in
allergic cases of otitis and some ceruminous otitis cases. It is important to use the lowest
potency glucocorticoid at the lowest frequency needed to control the otitis to prevent iatrogenic
hyperadrenocorticism.
1. Cort/Astrin Solution (Vedco)
Burows solution, 1% hydrocortisone

Topical antibiotic agents
Topical aminoglycosides such as neomycin and gentamicin have good activity against gram-
positive and gram-negative otic pathogens. Gentamicin may be ototoxic and should be used
with caution in ears with ruptured tympanic membranes. However, three weeks of twice daily
gentamicin sulfate (7 drops of 3 mg/ml) in buffered aqueous solution did not induce vestibular
effects or deafness in Greyhounds with either intact or surgically ruptured tympanic
membranes. Gentamicin and neomycin are available in many combination products, some
which contain an antifungal and glucocorticoid.
1. Tresaderm (Merial)
Neomycin sulfate, dexamethasone and thiabendazole
2. Otomax Ointment (Intervet-Schering-Plough)
Gentamicin sulfate, betamethasone valerate and clotrimazole
3. Mometamax Suspension (Intervet/Schering-Plough)
Gentamicin sulfate, mometasone furoate monohydrate and clotrimazole
Another aminoglycoside, tobramycin, is available as an ophthalmic suspension and is very
effective against Pseudomonas otitis infections.
1. TobraDex Ophthalmic Solution (Alcon)
Tobramycin and dexamethasone
2. Tobrex Ophthalmic Solution (Alcon and generics)
Tobramycin

Fluoroquinolones have a broad spectrum of antibacterial activity against gram-negative and
gram-positive bacteria.
1. Baytril Otic Emulsion (Bayer Animal Health)
Enrofloxacin (0.5%) and silver sulfadiazine (1%)
2. Posatex (Intervet/Schering-Plough Animal Health)
Orbifloxacin, posaconazole, mometasone furoate monohydrate

Polymyxin has excellent in vitro activity against Pseudomonas with resistance rarely
developing. Inactivated in purulent debris so the ear needs to be kept clean during treatment.
1. Neomycin, polymyxin B, and hydrocortisone (generics)
2. Surolan (Vetoquinol)
Miconazole nitrate, polymyxin B sulfate, prednisolone acetate

Tris-EDTA is a topical product that enhances the activity of topical antibiotics against otic
pathogens by decreasing stability and increasing the permeability of the cell wall of the
bacteria. The product works best when applied to the external ear canal 15-30 minutes before
the topical antibiotic.
1. Triz-EDTA (Dechra)
2. TrizUltra (with ketoconazole) (Dechra)
3. TrizChlor (with chlorhexidine) (Dechra)
4. Mal-A-Ket Plus TrizEDTA Flush (with ketoconazole and chlorhexidine) (Dechra)
5. T8Keto (DVM)

Topical antifungal agents
Antifungal agents are used in cases of otitis caused by Malassezia or Candida. Ingredients
that are active against yeast include nystatin, thiabendazole, miconazole, ketoconazole, and
clotrimazole.
1. Thiabendazole (Tresaderm)
2. Clotrimazole (Otomax, Mometamax)
3. Miconazole (generics, Surolan)
4. Ketoconazole (TrizUltra)
5. Posaconazole (Posatex)

Systemic antibiotics
Systemic antimicrobial therapy for infectious otitis externa and otitis media is controversial. In
dogs with end-stage otitis externa and concurrent otitis media, bacterial organisms may be
isolated from the exudate in the lumen of the vertical ear canal and middle ear cavity as well as
from the tissue from these sites. Therefore, most agree that systemic antibiotics (based on
culture and susceptibility testing) are indicated in patients with otitis media, patients with
severe proliferative chronic otitis externa, patients with ulcerative otitis externa, patients where
inflammatory cells are seen cytologically (indicating deeper skin involvement) and in patients
where owners cannot administer topical therapy. The selection of systemic antimicrobial agent
must be made based on C/S from the external ear (for otitis externa) and middle ear (for otitis
media). However, therapy may be initiated based on cytologic results while awaiting the C/S.

Systemic antifungals
Indications for systemic antifungal agents are similar to those above for bacterial infections and
include patients with yeast otitis media, patients with severe yeast otitis externa, or in patients
where owners cannot administer topical therapy. Neither pulse-dose or daily-dose
itraconazole alone significantly decreased yeast organisms identified cytologically from otic
exudate in dogs with yeast otitis externa, suggesting that otic yeast infections require topical
therapy in addition to systemic therapy for resolution. Both ketoconazole (5 mg/kg q 24 hr)
and itraconazole (Sporanox 5 mg/kg PO q 24 hr or pulse-dosed 2 days on and 5 days off)
have been used in dogs.

Systemic glucocorticoids
Systemic glucocorticoids are used to decrease stenosis, edema, and hyperplasia of the
vertical and horizontal ear canal to allow a complete otic examination as well as allow proper
cleaning of the ear. They are also indicated in cases of allergic otitis externa. Initially, 0.5-1
mg/kg SID orally may be needed, followed by a low-dose, alternate day dosing schedule. As
with topical glucocorticoids, the lowest dose needed should be administered to prevent the
occurrence of side effects. In older patients, or those with concurrent diseases, it may be
necessary to perform blood work prior to using glucocorticoids.

Extra-label preparations
An extra-label topical preparation containing enrofloxacin may be formulated using 1 part of
the injectable enrofloxacin (22.7 mg/ml) added to 4 parts of an appropriate vehicle (saline,
Cort/Astrin for example). There have been no reports of clinical ototoxicity with this
formulation; however, toxicity studies have not been conducted. It appears to be very effective
for treatment of Pseudomonas otitis infections.

Silver sulfadiazine 1% (Silvadene) is available in a cream formulation. One part of the
Silvadene cream can be mixed with 9 parts water prior to application in the ear. This product
is safe and appears non-ototoxic. However, contact hypersensitivity or irritancy may occur on
rare occasions. It has been shown to be very effective against resistant Pseudomonas.

Ticarcillin/clavulanic acid (Timentin) is a semisynthetic, betalactamase--resistant penicillin. It
is supplied as 3.1 g vial (3 g ticarcillin, 100 mg clavulanic acid). To make an extra-label
preparation add 26ml of saline to get a 100mg/ml concentration solution. Draw up 0.5 cc into 1
cc syringes. You can get approximately 50-55 x 0.5 ml syringes. Thus a 3.1 g vial will provide
approximately 4 weeks of treatment of 2 ears on a q 12 hr basis, and if kept frozen will be
stable for 30 days. Have owners freeze the syringes. Keep all syringes frozen until the day of
use. On the day of use, remove 1 syringe from the freezer for each ear to be treated. Remove
the cap and apply 0.25 ml (1/2 of the amount in the syringe) of Timentin into the ear canal.
Replace the cap and store the remainder (0.25 ml) in the refrigerator until use 12 hours later.

For inflamed ears with yeast otitis without a bacterial component, topical antifungal, such as
miconazole may be mixed 1:1 with dexamethasone.

Overtreatment
In some instances, too vigorous topical therapy may result in maceration of the lining of the ear
canal. Clinically, this appears as a large accumulation of white ceruminous debris in the ear
canal. Cytologically, there is no infection, only desquamated epithelial cells. Treatment is
directed at discontinuation or reduction of the frequency of topical medications.

Maintenance ear therapy
In some cases of otitis, once the otic medications are discontinued, in time the infection will
recur. This is true in cases of chronic recurrent otitis externa where continual inflammation and
stenosis have occurred along with increased cerumen production. This may result in an
alteration in epidermal migration. In essence, the ear has lost the ability to clean itself.
Therefore, ear maintenance therapy should be aimed at keeping the ear clean with either a
ceruminolytic ear cleaner or a cleaning/drying agent along with a low-potency topical steroid to
decrease the inflammation if needed.

Pseudomonas otitis infections may cause ulcerations and subtle changes in the microanatomy
of the ear canal. Therefore, dogs that have had a previous Pseudomonas otitis infection
require ear maintenance therapy aimed at keeping the ear canal acidic and free from cerumen
to prevent recurrence. Furthermore, if the Pseudomonas infection does recur, it is usually
much more resistant to antimicrobial agents than the original infection, making resolution more
difficult and time-consuming.

Dogs which are being worked up for the primary cause of their otitis should also be started on
maintenance ear therapy. Underlying allergic diseases, such as atopy or food allergy, are the
most common cause of recurrent otitis externa in the dog. Therefore, the maintenance therapy
should consist of an ear cleaning/drying agent along with a low-potency steroid for the
inflammation and pruritus.

Monitoring
Re-evaluations include an otoscopic and/or video otoscopic evaluation to monitor response to
therapy. Cytology of otic exudate is performed at each re-evaluation, while bacterial C/S is
performed if the infection worsens or is non-responsive to therapy. Topical and/or systemic
medications are modified based on these results.

If otitis media is present, otoscopic evaluation includes monitoring healing of the tympanic
membrane. In some instances, repeat ear flushing under general anesthesia may be required
to keep the ear canal clean to monitor healing of the tympanic membrane.

Surgery is necessary if middle ear polyps, neoplasia, foreign bodies, cholesteatoma, or
osteomyelitis of the tympanic bulla is present. In addition, if there is inadequate response of
the middle ear infection to otic flushing, myringotomy, and medical management, or if the otitis
media is recurrent, surgical intervention may be necessary for resolution.