Otitis Externa An Essential Guide to Diagnosis and

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 iv 

5 Medical Management of Ear Disease . . . . . . . . . . . . . . . . . . . . . . . . . 81

Dealing with primary triggers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Dealing with secondary causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Chronic or recurrent otitis externa in dogs. . . . . . . . . . . . . . . . . . . . . . . . . . 95

6 Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Clinical signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Major differential diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Treatment of nasopharyngeal polyps in cats. . . . . . . . . . . . . . . . . . . . . . . 113
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

7 Ototoxicity and Other Side-Effects of Otic Medication. . . . . . . . . . 115

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Meatal and tympanic inflammation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Effects within the middle ear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Ototoxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Systemic effects of otic medication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Ototoxicity of systemic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

8 Aural Ablation and Bulla Osteotomy. . . . . . . . . . . . . . . . . . . . . . . . 121

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Presurgical investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Vertical canal ablation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Bulla osteotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Special problems relating to surgery of the middle ear in cats . . . . . . . . 140

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

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 PREFACE
v

The investigation and management of ear disease will occupy a

significant proportion of a veterinary clinician’s time. Otitis externa, in
particular, is likely to be seen by a busy small animal clinician at least
once a day. Chronic, and chronic recurrent, otitis externa is frustrating
and costly to the owner and often painful for the dog or cat.
The concept behind this book is to provide a comprehensive source of
information on the relevant structure, function, medicine, and surgery
of the ear, from Otodectes cynotis infection to Pseudomonas aeruginosa
infection, by way of atopy.
We hope that students and clinicians, in particular, will find it so
useful that their copy becomes battered and stained, the ultimate test
of practical relevance.

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 ABBREVIATIONS
vi

BAER brainstem auditory evoked response

CT computed tomography
DMSO dimethylsulfoxide
EDTA ethylenediamine tetra-acetic acid
GABA gamma-amino butyric acid
Ig immunoglobulin
LBO lateral bulla osteotomy
MIC minimum inhibitory concentration
MRI magnetic resonance imaging
MRSA methicillin-resistant Staphylococcus aureus
PCMX parachlorometaxylenol
PVA polyvinyl alcohol
TECA total ear canal ablation
tris tromethamine
VO video-otoscope

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 1 THE NORMAL EAR
1

KEY POINTS INTRODUCTION

QQ The external ear comprises the pinna The ear of the dog and cat is composed of
and the external acoustic meatus. It three parts: the external ear, the middle ear,
serves to collect and locate the origin and the inner ear (Figure 1.1)1–3. Together
of sound waves. these components allow the animal to
QQ The middle ear comprises the locate a sound and the direction from which
tympanic membrane, the ossicles, it emanates, to orientate the head in relation
the auditory tube, and the tympanic to gravity, and to measure acceleration and
cavity. It serves to transduce incoming rotation of the head. Selective breeding, of
airborne sound waves into waves in a dogs in particular, has resulted in a wide
liquid medium. variation in relative size and shape of the
QQ The inner ear comprises the cochlea, components of the external ear. Compare,
the vestibule, and the semicircular for example, the French Bulldog, the
canals. It interprets sound and serves Cocker Spaniel, the German Shepherd
to relate the head to gravity, allowing Dog, the St. Bernard, and the Persian cat.
the visual system to compensate for The pinnal shape and carriage, the diameter
movement and to perceive both linear of the external ear canal, the degree of
and rotational acceleration. hair and amount of soft tissue within the
external ear canal, and the shape of the

Vestibular nerve
Cochlear nerve Semicircular canals

Cochlea Ear canal

Incus

Malleus

Tympanic
Stapes membrane

Fig. 1.1 The anatomic relationship of the components of the external, middle, and inner ear
remains constant in relation to each other and the skull.

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 2 The Normal Ear

skull within which the middle and inner The pinna is composed of a sheet of
ear lie, vary from one breed to another. cartilage covered on both sides by skin
Despite this anatomic variation the essen­ (Figures 1.2, 1.3), which is more firmly
tial relationship between the various com­ adherent on the concave aspect than on the
ponents of the external, middle, and inner convex aspect2,3,5. The cartilage sheet which
ear is preserved1. supports the pinna is a flared extension
of the auricular cartilage. Proximally this
PINNA becomes rolled to form the vertical ear canal
and part of the horizontal ear canal6. The
The evolutionary role of the pinna has major part of the external auditory meatus
been as an aid to sound collection and is contained within the auricular cartilage.
point-of-origin location (Figures 1.2, 1.3). Generally the pinna is haired on the
However, selective breeding of dogs has convex surface and in some breeds, such as
resulted in pinnae which often appear to the Cocker Spaniel and Papillon for example,
have been designed more as lids to prevent markedly so. The concave aspect may be
access by foreign bodies (Figures 1.4, 1.5) lightly haired on the free edges and towards
or as vehicles to carry ornate displays of the tip, but towards the base it becomes
exuberant growths of hair (Figures 1.6, 1.7). essentially glabrous and is tightly adherent
Despite these changes, the functionality of to the underlying cartilage. A few fine hairs
the ear appears to have been maintained. In are usually present around the entrance to
most breeds of cats the pinna is held erect, the external auditory meatus. In breeds with
with the exception of the Scottish Fold Cat hirsute ear canals, such as Cocker Spaniels,
where the distal portion of the scapha is there may be profuse hair growth along the
folded rostroventrally4. whole length of the ear canal.

Figs. 1.2, 1.3 Archetypal pinna, in this case of a German Shepherd Dog. Note the even
distribution of short hairs on the convex aspect (1.2). There is a variable amount of glabrous,
sparsely-haired skin on the concave aspect (1.3) which is confluent with the epithelial lining of
the external ear canal.

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 The Normal Ear 3

Figs. 1.4, 1.5 Examples of the various pinnae which have resulted from selective breeding.
Labrador Retriever (1.4), Cocker Spaniel (1.5).

Figs. 1.6, 1.7 Examples

of the various pinnae
which have resulted
from selective breeding.
Papillon (1.6), Yorkshire
Terrier (1.7).

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 4 The Normal Ear

EXTERNAL AUDITORY MEATUS MIDDLE EAR

The external auditory meatus serves to The middle ear and auditory (Eustachian)
conduct sound waves to the tympanum. tube comprise a functional physiological
It is contained within the vertical and unit with protective, drainage, and venti­
horizontal portions of the external ear latory capabilities9,10. The middle ear is
canal. The size of the vertical canal composed of the tympanum, the ossicles,
(length and volume) correlates with body the auditory tube, and the tympanic
weight7,8. In the dog the average length of cavities (Figure 1.9)1,3. The middle ear cavi­
the external ear canal within the auricular ties are lined with secretory epithelium
cartilage is 4.1 cm (1.6 in) (2.2–5.7 cm (Figure 1.10). Epithelia such as this not only
[0.8–2.2 in]) and its average diameter, at secrete liquid, but also absorb gas9. This
the level of the tragus, is 5.8 cm (2.3 in) tends to result in a slight negative pressure
(2.1–7.9 cm [0.8–3.1 in])7. within the normal middle ear cavity9. The
The vertical canal deviates medially, composition of the gas in the normal middle
just dorsal to the level of the tympanum, ear cavity of both dogs and cats has been
towards the external acoustic process. In described11. It appears to correlate closely
the dog the average length of canal within to the composition of the capillary blood,
the annular cartilage is 1.2 cm (0.5 in) rather than reflecting gaseous exchange
(0.8–1.9 cm [0.3–0.7 in])7. along the auditory tube.
The epithelium and dermal tissues which The three ossicles transmit sound waves
line the bony and cartilaginous components impacting upon the tympanic mem–
of the external ear canal result in a smooth brane to the oval window. At this point
inner surface to the canal (Figure 1.8). The the mechanical energy of the ossicles is
epithelium is sparsely haired in most, but transduced to pressure waves within the
not all, breeds, and it is rich in adnexal inner ear, to be interpreted subsequently as
glands (see Microscopic structure of the sound. Pressure and internal homeostasis
external ear canal). within the inner ear is equilibrated across
the round window membrane.

A B

Fig. 1.8 Otoscopic picture of a normal canine (A) and feline (B) external ear canal,
demonstrating the smooth epithelial lining. Note the occasional accumulations of cerumen.

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 The Normal Ear 5

Tympanum dimension is nearly vertical, the long axis

The gross appearance of the canine and is directed ventral, medial, and cranial, and
feline tympanic membrane is similar it has an area of approximately 63.3 mm2
(Figure 1.8)3,4,12. The canine tympanum is (0.1 sq in)1,2,13. The feline tympanum is more
a thin, semitransparent membrane with circular in shape (8.7–6 mm [0.3–0.2 in])
a rounded, elliptical outline; its mean and has an area of approximately 41 mm2
size is 15–10 mm (0.6–0.4 in). The shorter (0.6 sq in)4,12,14. The majority of the external

Fig. 1.9 The caudoventral aspect of a canine skull with the bulla
removed. Three of the four ports of communication are visible:
the external acoustic meatus (arrow), the round window on the
promontory (arrow head), and the auditory tube (delineated with
a piece of nylon).

Fig. 1.10 Photomicrograph of a section of normal bulla.

Note the thin bone and the secretory epithelial lining. (Sample
prepared by Finn Pathology, Diss, Norfolk, UK.)

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 6 The Normal Ear

aspect of the tympanum is thin, tough, and MICROSCOPIC STRUCTURE OF

glistening (the pars tensa) with the outline THE EXTERNAL EAR CANAL
of the manubrium of the malleus being
clearly visible (Figure 1.11). The manu­
brium inserts under the epithelium on the KEY POINTS
medial aspect of the tympanum and exerts
tension onto it, resulting in a concave shape QQ The normal ear canal contains a
to the intact membrane, rather similar to stratified squamous epidermis, hair
the speaker cone in a loudspeaker3,15. The follicles, and associated sebaceous
pars flaccida is more opaque, pink, or and ceruminous (apocrine) glands.
white in colour. It is confined to the upper QQ Breeds of dog predisposed to otitis
quadrant of the tympanic membrane and externa, such as Cocker Spaniels, have
bound ventrally by the lateral process of increased amounts of glandular tissue
the malleus3,13. compared to other dogs.
In a study of 100 cases of canine otitis QQ Otitis externa results in increased
externa, rupture of the tympanic membrane production of cerumen with a lower
was negatively associated with underlying lipid content than normal, associated
allergic disease and positively associated with increased ceruminous gland
with grass awns, particularly in Cocker activity.
Spaniels16. QQ Chronic otitis externa results in
permanent changes.

Fig. 1.11 Otoscopic picture of a normal Fig. 1.12 Photomicrograph of a section of

tympanic membrane. The manubrium of the normal canine external ear canal illustrating
malleus is clearly visible. the thin epidermis, which is only a few cells
thick.

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 The Normal Ear 7

The epidermis lining the external ear Hair follicles

canal is similar in structure to that of the All breeds of dog have hair follicles
interfollicular epidermis of the skin, i.e. through­o ut the length of the external
a stratified cornifying epithelium with ear canal, although in most breeds these
adnexal organs such as hair follicles and follicles are simple and sparsely distri­
their associated sebaceous and ceruminous buted (Figure 1.16)3. It has been suggested
(apocrine) glands (Figures 1.12, 1.13)1–4. that the density of hair follicles decreases
The underlying dermis is heavily invested as one progresses toward the external
with elastic and collagenous fibres (Figures acoustic meatus 1,2, but recent studies 3,4
1.14, 1.15). Beneath the dermis and subcutis did not describe such a distribution. The
lie the rolled cartilaginous sheets of the mean proportion of integu­ment occupied
auricular and annular cartilages which by hair follicles was found to be 1.5–3.6%,
contain and support the external ear canal. with no significant spatial distribution

Fig. 1.13 Photomicrograph of a section of Fig. 1.14 Photomicrograph of a section of

normal feline external ear canal. Note the thin normal canine external ear canal stained with
epidermis, the sparse hair follicles, sebaceous Gomorri’s stain to highlight collagen and
glands, and ceruminous glands, and the fibrous tissue in the dermis.
underlying auricular cartilage.

Fig. 1.15 Photomicrograph of a section of Fig. 1.16 Photomicrograph of a section of

normal canine external ear canal stained with normal canine external ear canal showing
Masson’s stain to highlight collagen and simple hair follicles.
fibrous tissue in the dermis.

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 8 The Normal Ear

along the canal. There was a large interdog Adnexal glands

variation4. Sebaceous glands are present in the
However, some breeds which are pre­ upper dermis 1–5,6. They are numerous
disposed to otitis externa differ from the and prominent (Figure 1.18) and have a
basic pattern 3. Thus, Cocker Spaniels similar structure to the sebaceous glands
exhibit a much higher concentration of the skin. The mean proportion of integu­
of hair follicles than other breeds and, ment occupied by sebaceous glands is
furthermore, the follicles are typically 4.1–10.5%, gradually increasing from
compound in pattern (Figure 1.17)3. There proxi­mal to distal and peaking at the level
is no correlation between the percentage of of the anthelix4. There is a large interdog
hair follicles within the otic integument and vari­ation4. The sebaceous glands secrete
predisposition to otitis externa4. principally neutral lipids4. In the normal
Hair is sparse or absent in the feline dog this lipid accounts for the majority
external ear canal5. of the cerumen, along with sloughed

Fig. 1.18 Photomicrograph of a section of

normal canine external ear canal showing a
higher power view of a sebaceous gland.

Fig. 1.17 Photomicrograph of a section

of normal canine external ear canal from a
Cocker Spaniel. Note the density of the hair
follicles compared to 1.16 and that they are
compound.

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 The Normal Ear 9

epidermal debris7. This high lipid content MICROCLIMATE OF THE

of normal cerumen helps maintain normal EXTERNAL EAR CANAL
keratinization of the epidermis, aids in
the capture and excretion of debris both
produced within and entering the external KEY POINTS
ear canal, and results in a relatively low
humidity within the lumen of the ear canal. QQ The principal factor affecting the
In the cat the sebaceous glands become microflora within the external ear
more prevalent and crowded proximally5. canal is the microenvironment.
Ceruminous (apocrine) glands are QQ Temperature and relative humidity
located in the deeper dermis (Figure 1.19)1–5. within the external ear canal are very
They are characterized by a simple tubular stable.
pattern and a lumen lined by a simple QQ The mean temperature within the
cuboidal-pattern epithelium. In the normal external ear canal is between 38.2°C
dog and cat the ducts of the apocrine (100.7°F) and 38.4°C (101.1°F), some
glands are virtually nonapparent. The 0.6°C (33.1°F) lower than the rectal
mean proportion of integument occupied temperature.
by apocrine glands is 1.4–4.5%, gradually QQ The mean relative humidity in the
decreasing from proximal to distal and external ear canal is 88.5%.
peaking at the level of the tympanic mem­ QQ The mean pH of the normal external
brane 4. There is a large interdog vari­ ear canal is 6.1 in males and 6.2 in
ation4. The apocrine glands contain acid females.
mucopolysaccharides and phospholipids5. QQ Otitis externa is associated with a rise
Overall, these data4 suggest that the ratio in relative humidity and a rise in pH
of apocrine to sebaceous gland decreases within the external ear canal.
from proximal to distal, tending to produce QQ Cerumen is composed principally of
a more aqueous cerumen in the deeper lipid and sloughed epithelial cells.
ear canal, possibly more conducive to QQ In cases of chronic otitis externa,
epidermal migration. The more lipid nature the lipid component of cerumen
of cerumen at the distal end may facilitate decreases.
water repulsion.

Fig. 1.19 Photomicrograph of a section of

normal canine external ear canal showing a
higher power view of an apocrine gland.

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 10 The Normal Ear

Epithelial lining throughout the day6, with a recorded rise

The external ear canals are lined such that within the ear of only 2.3% compared to
the underlying cartilaginous architecture 24% in the external environment, again
and the intercartilaginous joints are illustrating the buffering effect of the
covered by a smooth, clean epithelial sur­ tissues surrounding the external ear canal.
face (Figure 1.20). The epithelial surface Grono6 suggested that the high relative
is composed of closely apposed squames humidity in the external ear canal was such
which are covered by a variable, but usually that the meatal epithelium would readily
thin, layer of cerumen and adherent debris become hydrated and macerated, an ideal
(Figures 1.21, 1.22). There is a constant, environment for bacterial proliferation. In
outward movement of cerumen1,2. Squames cases of otitis externa, the relative humidity
detach (Figures 1.23, 1.24) and move was somewhat higher (mean 89%) than
distally in the cerumen, thus keeping the normal, but not significantly so. The
tympanum clear of debris and providing influence of a pendulous pinna was not
a mechanism for removing sloughed reported.
epithelial and glandular secretions from the
external ear canal. pH
The range of pH in normal dogs is
Temperature be­tween 4.6 and 7.2 6. The mean pH is
In a series of studies the temperature slight­ly lower in males than in females
within the external ear canal of dogs was (6.1 compared to 6.2). The pH rises in otitis
38.2–38.4°C (100.7–101.1°F) 3–5 . These externa. Grono7 measured the pH in cases
studies were performed over a span of of otitis externa and found the mean to be
25 years with very different technologies, 5.9 (range 5.9–7.2) in acute cases and 6.8
and for such close results to be achieved is (range 6.0–7.4) in chronic cases. Grono also
remarkable. There was no significant dif­ measured the pH of the external ear canals
ference between breeds of dog or whether of dogs and recorded the bacteria which
there was a pendulous pinna or not 3,4.
The temperature within the external ear
canal rises significantly if otitis externa is
present: mean 38.9°C (102°F)5. The temper­
ature within the external ear canal is a
mean of 0.6°C (33.1°F) lower than rectal
temperature.
One study3 was performed in Australia
where the environmental temperature
tends to be high. Nevertheless, as the day
grew progressively hotter the temperature
within the external ear canal only rose by
0.3°C (32.5°F) compared to a rise of 6.4°C
(43.5°F) in the environment. This illustrates
very well how the environment within the
ear canal is effectively buffered from the
external environment.

Relative humidity
In one study the mean relative humidity Fig. 1.20 Otoscopic view of the normal
within the external ear canal of 19 dogs external ear canal. Note the clean, smooth
was 80.4%6. This was remarkably stable epithelial surface.

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 The Normal Ear 11

Figs. 1.21, 1.22 Scanning electron Figs. 1.23, 1.24 Scanning electron
micrographs of the epithelial surface of micrographs illustrating squames in the
the external ear canal of a dog (1.21, top) process of detaching in a canine ear canal
and a cat (1.22, above). Note the cerumen (1.23, top) and a feline ear canal (1.24,
coating the hair shafts and squames such above). (Electron micrographs produced by
that individual squame borders cannot clearly the Department of Anatomy, Royal Veterinary
be seen. (Electron micrographs produced by College, London, UK.)
the Department of Anatomy, Royal Veterinary
College, London, UK.)

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