A review of techniques for the investigation of otitis externa and otitis media

Otitis externa, inflammation of the externa ear canal, is relatively easy to diagnose based on the history and physical examination findings. The diagnosis of otitis media, inflammation of the middle ear cavity, is more challenging, with the work-up being both costly and, at times, invasive. The pathogenesis of otitis externa has been classified into predisposing, primary, and perpetuating factors. It is critical to the management of ear disease that the clinician recognize and investigate which factors are contributing to each individual patient's ear disease. Failure to identify and address the primary and/or predisposing factors is the most common cause of chronic recurrent otitis externa. Chronic inflammation of the ear canal leads to the development of the perpetuating factors, which may be the major reason for treatment failure, regardless of the primary cause of the ear disease. In this article, the predisposing, primary, and perpetuating factors involved in ear disease will be presented, along with a review of the techniques used in the diagnosis of otitis externa and otitis media.     

Diagnosis and medical treatment of otitis externa in the dog and cat

Otitis externa is no longer viewed as an isolated disease of the ear canal, but is a syndrome that is often a reflection of underlying dermatological disease. Causes are classified as predisposing (increase the risk of otitis); primary (directly induce otitis), secondary (contribute to otitis only in an abnormal ear or in conjunction with predisposing factors) and perpetuating (result from inflammation and pathology in ear, prevent resolution of otitis). Common primary causes include foreign bodies, hypersensitivity (particularly atopy and food allergy), keratinisation disorders (most commonly primary idiopathic seborrhoea and hypothyroidism) and earmites, particularly in cats. A systematic diagnostic procedure is required to identify causes and contributing factors. This should include history, clinical examination, otoscopy and cytology in all cases and culture and sensitivity as well as otitis media assessment and biopsy in severe and recurrent cases. Ancillary tests may be required depending on the underlying cause. Treatment consists of identifying and addressing predisposing and primary factors; cleaning the ear canal; topical therapy; systemic therapy where necessary; client education; follow-up; and preventive and maintenance therapy as required.     

Otitis externa. A disease of multifactorial etiology

Dogs and cats with long-standing otitis externa pose a difficult diagnostic challenge for the veterinarian, because chronically affected ears usually have the same appearance regardless of the underlying cause(s). In patients with chronic otitis externa, the disease is often caused by different combinations of primary, predisposing, and perpetuating factors. The unique therapeutic needs of each patient may be determined by careful interpretation of historical and physical findings, which should be supported by ancillary diagnostic tests.     

The pathology of the external ear canal in dogs and cats

A survey of factors which predispose the canine ear to otitis externa is presented. In resected ear specimens of 106 dogs, otitis externa without tumour was found on 58 occasions. In 46 dogs tumours were diagnosed in 15 cases with an otitis externa. In two dogs an inflammatory polyp was found. In the resected ear specimens of 48 cats, otitis externa was diagnosed 27 times, in 6 cases combined with an inflammatory polyp. In 21 cases neoplasia was present. The otitis externa was mainly a chronic proliferative inflammation characterised by hyperkeratinization, hyperplasia of the sebaceous and ceruminous glands, fibrosis and infiltration with plasma cells, lymphocytes and macrophages, often containing ceroid pigment.     

Diagnosis and medical treatment of otitis externa in dogs and cats

A review of otitis externa in dogs and cats is presented. Aetiology, includes primary causes: ectoparasitoses, allergic diseases, endocrine disorders, pyodermas, trauma and irritation, contact dermatitis, auto-immune skin diseases, drug eruption, keratoseborrhoeic skin disease, tumours and pseudoneoplastic lesions, as well as secondary causes: bacteria and yeasts. Clinical aspects are variable but a practical classification distinguishes two forms: erythematoceruminous otitis externa and suppurative otitis externa. Diagnosis is made in five steps which are clinical examination, direct examination of cerumen (erythematoceruminous otitis externa) or bacterial culture and sensitivity testing (suppurative otitis externa), direct impression smears, cleaning and otoscopy, and diagnosis of underlying skin disease. Medical therapy includes cleaning of the external ear canal and local therapy (acaricides, antifungal agents, antibiotics, corticosteroids, other topical agents, the appropriate selection of an optic preparation being essential). Treatment of underlying skin disease is always necessary. Otitis externa is in fact a dermatological disease complex (like pododermatitis). Although local secondary infections (bacterial and fungal) must be managed in every case, there are grounds for including otitis externa in a larger frame.     

Ulcerative otitis externa responsive to immunosuppressive therapy in two dogs

Two middle-aged dogs were presented with bilateral severe ulcerative otitis externa without previous history of disease or evidence of other skin disease. Based on the exclusion of microbial infection and other primary causes, histopathological findings and response to immunomodulatory treatment, a diagnosis of presumed immune-mediated ulcerative otitis externa was made in both cases. However, the two cases differed with regard to their histopathological characteristics and the course of the disease. This report indicates that primary ulcerative disease needs to be considered in cases of ulcerative otitis externa which are unresponsive to appropriate antimicrobial therapy.     

The role of Pityrosporum pachydermatis in otitis externa of dogs: evaluation of a treatment with miconazole.

The bacterial and mycotic flora were assessed in 158 ears of dogs with otitis externa and in 101 ears of healthy control dogs. Pityrosporum pachydermatis occurred in 57 per cent of ears with otitis externa and in 17 per cent of clinically healthy ears. Staphylococci and Pseudomonas aeruginosa were the predominant bacteria in otitic ears, micrococci and Bacillus spp were the most frequent isolates from clinically healthy ears. P pachydermatis, Ps aeruginosa and Candida tropicalis occurred in monoculture in a significant number of mainly chronic cases of otitis externa. A combination preparation, containing miconazole, polymyzin B and prednisolone, was highly effective in controlling the clinical signs of otitis externa and eliminating flora from the affected ears. The data presented suggest that yeasts, and especially P pachydermatis, may be significant pathogens in otitis externa and that antimycotic treatment is an essential part of the treatment of otitis externa in dogs.     

Surgical Management of Rabbit Ear Disease

Clinical signs associated with otic disease in rabbits (Oryctolagus cuniculus) are very similar to those demonstrated in dogs and cats. The surgical treatment options to resolve diseases involving the rabbit ear are also comparable with those used for canine and feline species. However, there are key anatomic and physiologic differences that must be accounted for to perform proper surgical treatment on a rabbit that has been diagnosed with ear disease. This article describes the diagnostic and treatment options for otitis externa, otitis media, and otitis interna, with an emphasis on surgical procedures and the important distinctive otic features of the rabbit patient. The ventral bulla osteotomy procedure is recommended for management of otitis media in rabbits without otitis externa. In rabbits with pathology in the external ear canal and the middle ear, total ear canal ablation and lateral bulla osteotomy should be performed. This combined procedure will allow the surgeon to address pathology in both sites, with the ultimate goal of resolution of the underlying disease etiology. Lateral ear canal resection is only appropriate in rabbits with otitis externa without otitis media; however, this surgical procedure may not resolve the otitis externa. If this is a concern, a total ear canal ablation should be done because it offers a greater chance of success.     

The pathology of the external ear canal in dogs and cats

Summary

A survey of factors which predispose the canine ear to otitis externa is presented In restected ear specimens of 106 dogs, otitis externa without tumour was found on 58 occasions. In 46 dogs tumours were diagnosed in 15 cases with an ototis externa. In two dogs an inflammatory polyp was found.

In the resected ear specimens of 48 cats, otitis externa was diagnosed 27 times, in 6 cases combined with an inflammatory polyp. In 21 cases neoplasia was present.

The otitis externa was mainly a chronic proliferative inflammation characterised by hyperkeratinisation, hyperplasia of the sebaceous and ceruminous glands, fibrosis and infiltration with plasma cells, lymphocytes and macrophages, often containing ceroid pigment.     

Surgical Management of Ossified Ear Canals in the Canine

Mineralization and ossification of the external ear canals may occur as a sequela to chronic otitis externa. These cases can be surgically managed with a lateral ear resection. The ossified cartilage is removed with wire suture scissors and/or rongeurs. The proliferative hyperplastic tissue, which often accompanies this condition, should be removed electrosurgically six to eight weeks following the lateral ear resection. This method has resulted in clinical improvement and control of infection in all of 12 cases.     

Subtotal ear canal ablation in 18 dogs and one cat with minimal distal ear canal pathology

A modified technique for performing total ear canal ablations is described. This technique requires less dissection than the standard technique and maintains a portion of the distal vertical ear canal. Subtotal ear canal ablations were performed in 18 dogs and one cat for the treatment of otitis externa or masses of the horizontal ear canal. Animals with otitis externa had minimal involvement of the distal ear canal. Dermatological problems associated with the remaining ear canal and pinnae occurred in eight animals and resolved with medical management. Normal ear carriage was maintained in all animals with erect ears. Further investigation is required before the procedure can be recommended as a treatment for otitis externa not caused by masses or anatomical abnormalities of the horizontal ear canal in dogs with pendulous ears.     

Inflammatory middle ear disease of the dog: the pathology of otitis media

Inflammation within the middle ear cavity was recognised in 62 of the ears of 42 dogs with chronic otitis externa and otitis media, after biopsy or necropsy of the middle ear. The pathological changes in the middle ear resembled those reported in other species or after the experimental induction of otitis media in dogs. Perforations in the tympanic membrane were rarely found; on the contrary, the membrane was often thickened. However, the question of whether a perforation in the tympanic membrane must occur before otitis externa can extend to otitis media was not resolved.     

Diseases of the pinna

Many diseases can affect the pinna of the dog and cat. These diseases represent most categories of cutaneous disease, from infectious to neoplastic. Although some diseases affect primarily the pinna, most pinnal dermatoses occur in conjunction with other integumentary disorders. One should approach the diagnostic work-up of pinnal disease in an organized manner, obtaining first a thorough history and physical examination. A systematic approach is required in the diagnostic evaluation in order to arrive at a tentative or definitive diagnosis. Skin scrapings, cytologic examination, and culture for dermatophytes provide the minimum database. A variety of diagnostic tests, including hematology, serum biochemical profiles, urinalysis, serology, intradermal skin testing, hypoallergenic diet trials, histopathology, and direct immunofluorescence, may be necessary in some cases before a definitive diagnosis is reached. The ears are somewhat difficult to biopsy, although in many instances histopathologic examination is essential to the diagnosis. In this author's opinion, it is preferable to use a no. 15 scalpel blade rather than a punch biopsy when obtaining a pinnal biopsy. This allows the veterinarian to obtain an elliptical or wedge biopsy, which can frequently be sutured. In some instances, biopsies are required from the ear margin and a full ear thickness biopsy is obtained. Sutures may not hold in this situation, and cautery may be necessary for hemostasis. As in other situations in which the ear is bleeding (aural hematomas, vasculitis, fly bite dermatitis, and so on), bandaging and immobilization of the ear may be necessary to prevent further trauma. Although symptomatic therapy is sometimes helpful when treating pinnal diseases, a definitive diagnosis is preferred. This is especially important following the second or third presentation of an animal for ear disease. Although ear diseases are frequently viewed as a nuisance rather than a serious condition, anyone who has owned or worked closely with an animal suffering from chronic otitis externa should appreciate the animal's discomfort and the owner's frustration. All too frequently, the chronic otitis externa is the result of a hypersensitivity (either inhalant or food) that has been overlooked in the attempt to treat the subsequent infectious otitis. Thus, in animals with recurrent otitis externa, every attempt should be made to identify and treat the underlying etiology.     

Mechanisms of fluoroquinolone resistance in Pseudomonas aeruginosa isolates from canine infections

Chronic otitis externa in dogs is often associated with Pseudomonas aeruginosa infection. Fluoroquinolones are often used for treating such infections. Fluoroquinolone resistance mechanisms were characterized in 10 strains of P. aeruginosa isolated from chronic canine otitis externa. Nine out of ten strains harbored a mutation in the gyrA gene and presented an overexpression of efflux pump(s). There was a good correlation between the lipophilicity of the fluoroquinolone being tested and the effect of the efflux pump inhibitor in the final MIC. Therefore, both mechanisms, mutation in the gyrA gene and increased efflux pump(s), seem to play an important role in the acquisition of fluoroquinolone resistance in veterinary clinical isolates of P. aeruginosa. Levels of resistance to fluoroquinolones suggest that they could not be a good choice for systemic therapy of Pseudomonas otitis.     

Breed variations in histopathologic features of chronic severe otitis externa in dogs: 80 cases (1995-2001)

OBJECTIVE: To compare pathologic changes of the horizontal ear canal associated with chronic severe otitis externa between Cocker Spaniels and dogs of other breeds. DESIGN: Retrospective study. ANIMALS: 80 dogs with severe otitis externa that required total ear canal ablation with lateral bulla osteotomy. PROCEDURE: Medical records were reviewed for breed, sex, and age at time of surgery. Histologic specimens from the horizontal ear canal were evaluated by a single examiner for overall tissue response pattern and scored for sebaceous gland hyperplasia, ceruminous gland hyperplasia, ceruminous gland ectasia, fibrosis, pigment-laden macrophages, and osseous metaplasia. RESULTS: 48 of 80 (60%) dogs were Cocker Spaniels. Thirty-five of 48 (72.9%) Cocker Spaniels had a predominately ceruminous tissue response pattern; only 9 of 32 (28.1 %) dogs of other breeds had the same pattern. Other breeds most commonly had a pattern dominated by fibrosis (n = 13 [40.6%]); fibrosis was the predominant pattern in only 4 of 48 (8.3%) Cocker Spaniels. Discriminant analysis and K-means clustering of 4 histopathologic criteria correctly classified 75% of the dogs as Cocker Spaniels or all other breeds. CONCLUSIONS AND CLINICAL RELEVANCE: Cocker Spaniels are at increased risk for chronic severe otitis externa requiring total ear canal ablation with lateral bulla osteotomy, indicating that earlier and more aggressive management of the primary otitis externa and secondary inflammation is warranted in this breed. Cocker Spaniels with chronic severe otitis externa have distinct differences in pathologic characteristics of the horizontal ear canal, compared with other breeds.     

Efficacy of boric-complexed zinc and acetic-complexed zinc otic preparations for canine yeast otitis externa

The purpose of this 2-week, double-blinded, controlled clinical trial was to evaluate the efficacy of topical amino acid-complexed zinc gluconate formulated with boric acid (ZGB) or acetic acid (ZGA) versus a topical placebo in the treatment of yeast otitis externa in dogs. Included in the study were dogs with otitis externa and a cytopathological finding of yeast organisms in the affected ear. Ears were treated with the placebo, ZGA, or ZGB medications. Yeast counts as well as clinical appearance of the ears were monitored. Results revealed that ZGB significantly reduced the number of yeast organisms in cases of otitis externa.     

Comparison of ear canal microbiome in rabbits with and without otitis externa using next generation DNA sequencing

BackgroundContemporary research has increasingly explored the clinical applicability of next-generation DNA sequencing (NGS) technologies in veterinary medicine, which has provided new and practical opportunities for rabbit otitis externa clinical interventions. The objectives of this study were to characterize the normal external ear canal microbiome of clinically healthy rabbits compared to otitis externa presenting rabbits, and to assess the diagnostic viability of NGS in aural veterinary medicine.MethodsSwabs from the external ear canal of 34 clinically healthy rabbits and 16 rabbits diagnosed with otitis externa were collected. Alongside bioinformatic analysis, library preparation was performed targeting the V1-V3 region of the 16S rRNA bacterial gene and the ITS-2 region for fungal DNA analysis.ResultsIn the clinically healthy group, the bacterial species with the highest relative abundances were an uncharacterized Phytoplasma from the family Acholeplasmataceae (8.74%) and Staphylococcus epidermidis (5.56%), while in the otitis group the species with the highest relative abundances were Staphylococcus aureus (12.59%), Corynebacterium lactis (9.27%), and Corynebacterium mastitidis (7.92%). Fungal species with the highest relative abundances in the healthy group were a species from the genus Cladosporium (14.46%), while in the otitis externa group the fungal species with the highest relative abundances were a species from the genus Cladosporium (9.89%) and Malassezia restricta (4.76%). Additionally, there was a significantly higher number of different bacterial and fungal species in the clinically healthy group compared to the otitis group (P = 0.00 and P = 0.00, respectively).Conclusions and clinical relevanceThis study provided evidence that the rabbit aural microbiome profile is distinctly different between a clinically healthy and an otitis state. It also highlighted new bacterial and fungal organisms of note in rabbits diagnosed with otitis externa compared to those previously thought to be the primary disease-causing organisms. Understanding the microbial population dynamics in the rabbit aural microbiome is particularly critical for helping clinicians recognize, prevent, or revert the progression of otitis.     

Topical ear treatment – options,indications and limitations of current therapy

Topical otic products form an integral part of the overall management of otitis externa. With an ever increasing array of ear drops and cleaners to choose from, appropriate selection of therapy can be difficult. The investigation of all cases of otitis externa should consider primary and secondary causes and predisposing and perpetuating factors. This article considers topical therapy under these same broad headings and discusses, through literature review, the various properties of the components of the ear cleaning solutions and drops.     

Total ear canal ablation combining bulla osteotomy and curettage in dogs with chronic otitis externa and media

Ear canal ablation combining bulla osteotomy and curettage was performed on 44 dogs (n = 72 ears). Indications for the procedure included one or more of the following: chronic nonresponsive otitis externa and/or media (n = 71), tumor in the horizontal portion of the ear canal (n = 1), failed lateral ear resection (n = 11), ossified auricular cartilages secondary to chronic otitis externa (n = 22), failed previous total ear canal ablation (n = 1), and otitis interna (n = 1). In 40 dogs, the surgery was successful in alleviating all clinical signs of otitis externa and media. During the immediate postoperative period, 2 dogs died of causes unrelated to otitis. Complications related to the surgery developed in 9 of the surviving 42 dogs. Ultimately, 95% (40 of the surviving 42) of the dogs were cured by use of this procedure. Surgery successfully resolved the original problems in 97% (66 of 68) of the surgically treated ears of these dogs.     

Otitis externa induced with Malassezia pachydermatis in dogs and the efficacy of pimaricin.

Eight beagles were experimentally inoculated intraotally with Malassezia pachydermatis to induce acute otitis externa. Three or 4 days after the inoculation, the animals showed the symptoms of otitis externa. All ear canals were erythematous and the dogs were shaking their heads. A large number of M. pachydermatis was noticed in exudate taken from every ear canal. Clinical signs of otitis externa were reduced after treatment with 0.1 ml (per canal) of 1% pimaricin suspension twice a day for 3 days. The amount of exudate decreased gradually and 12 of the 16 ear swabs examined, thereafter, were found to be negative for M. pachydermatis within 10 days. No side effects were observed in all the treated cases. These results suggested that M. pachydermatis could induce the canine otitis externa, and that pimaricin is effective agent for M. pachydermatis infection in ear canals.