{"id":11716,"date":"2023-03-10T17:08:47","date_gmt":"2023-03-10T17:08:47","guid":{"rendered":"https:\/\/todaysveterinarynurse.com\/?p=11716"},"modified":"2024-01-03T18:10:24","modified_gmt":"2024-01-03T18:10:24","slug":"ear-disease-in-canine-patients","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/dermatology\/ear-disease-in-canine-patients\/","title":{"rendered":"Ear Disease in Canine Patients"},"content":{"rendered":"<div class=\"su-spacer\" style=\"height:20px\"><\/div><div class=\"su-note\"  style=\"border-color:#d8d8d8;border-radius:3px;-moz-border-radius:3px;-webkit-border-radius:3px;\"><div class=\"su-note-inner su-u-clearfix su-u-trim\" style=\"background-color:#f2f2f2;border-color:#ffffff;color:#333333;border-radius:3px;-moz-border-radius:3px;-webkit-border-radius:3px;\"><b>Abstract<\/b><\/p>\n<p class=\"p1\">Ear disease in small animals can be very frustrating for owners\u2014and veterinary healthcare teams\u2014to manage. To manage ear disease, the veterinary team must be familiar with ear anatomy and the causes of ear disease.<\/p>\n<p class=\"p1\">This article will cover basic anatomy of the ear, signalment, clinical signs, sample collection, stages of ear disease, diagnosis, cleaning, and treatment options. A basic understanding of ear disease will allow the veterinary nurse to communicate better with clients about how treatments are performed and define the expectations of managing ear disease.<\/p>\n<p><b>Take-Home Points <\/b><\/p>\n<ul>\n<li class=\"p1\">Ear disease is seen in 7% to 16% of canine cases in private practice.<\/li>\n<li class=\"p1\">Ear disease can happen at any age and involve various causes and factors.<\/li>\n<li class=\"p1\">Clinical signs of an ear infection include head shaking, ear scratching, odor, exudate, erythema, stenosis, head tilt, odd ear carriage, and hot spots on the cheek.<\/li>\n<li class=\"p1\">Collecting ear samples too aggressively can create inflammation in an already friable ear and possibly cause an ulcer.<\/li>\n<li class=\"p1\">In the early stage of ear disease, the canal is still pliable and infections are infrequent.<\/li>\n<li class=\"p1\">Chronic ear disease causes a decrease in pliability of the canal with mild stenosis and erythema; middle ear involvement is likely.<\/li>\n<li class=\"p1\">End-stage ear disease typically results from years of chronic infection, with partial calcification and completely stenotic canals.<\/li>\n<li class=\"p1\">Cleaning techniques include the \u201cpour\u201d technique, which involves filling the canal with cleaner, and the \u201ccotton ball\u201d technique, in which a cotton ball is soaked with cleaner and inserted into the canal. With either technique, the canal is then massaged.<\/li>\n<li class=\"p1\">Cleaning should be done depending on risk: as needed for normal dogs, weekly for those with skin disease or allergies, and once to twice a month for at-risk patients.<\/li>\n<li class=\"p1\">The best procedure for medical management of chronic ears with otitis media is a computed tomography scan followed by a myringotomy and bulla flush.<\/li>\n<\/ul>\n<\/div><\/div>\n<p class=\"p1\"><span class=\"s1\">E<\/span><span class=\"s1\">ar disease is seen in 7% to 16% of canine cases in veterinary hospitals.<sup>1<\/sup> There is a wide range of clinical signs and severity, and every case is unique to that patient. Because of these factors, ear disease can be very frustrating, not only to pet owners but also the veterinary team. It is a time-consuming disease that can sometimes seem futile. Ear disease treatment can be approached several ways, but the end goal is always the same: Eliminate the need for surgical intervention. <\/span><\/p>\n<h2 class=\"p3\">Anatomy and Structure of the Canine Ear<\/h2>\n<p class=\"p2\"><span class=\"s1\">The purpose of the ear pinna and canal is to funnel sound waves to the tympanic membrane and inner ear <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 1<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>.<sup>1,2<\/sup> The ear canal is an L-shaped structure made up of the vertical and horizontal canal. This structure should be pliable on palpation and feel like a milkshake straw\u2014firm but easily compressible.<sup>1,2<\/sup> The junction of the vertical and horizontal canals creates a protrusion that can be very sensitive.<sup>1<\/sup> Care must be taken to not bump or otherwise irritate this area. On otoscopic examination, the ear canals should be circular, smooth, have some blood vessels, and end in a somewhat circular tympanic membrane.<\/span><\/p>\n<div id=\"attachment_11717\" style=\"width: 460px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig1.png\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-11717\" class=\" wp-image-11717\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig1.png\" alt=\"\" width=\"450\" height=\"400\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig1.png 960w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig1-300x267.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig1-768x683.png 768w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><p id=\"caption-attachment-11717\" class=\"wp-caption-text\">Figure 1. Anatomy of a canine ear. Illustration: Kip Carter<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\">The tympanic membrane <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURES 2 AND 3<\/span><\/strong><span class=\"s1\"><strong>)<\/strong> is a thin piece of tissue that separates the external canal from the middle ear and is made up the pars flaccida and the pars tensa. The pars flaccida is the upper loose portion of the tympanic membrane that supplies blood to the bottom portion. The pars tensa is the tightly stretched lower portion that transfers sounds waves.<sup>1<\/sup> The manubrium is the white bony structure located at the junction of the 2\u00a0sections; it is the head of the malleus and transfers sound waves to the incus and stapes.<sup>1<\/sup><\/span><\/p>\n<div id=\"attachment_11718\" style=\"width: 361px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig2.png\"><img decoding=\"async\" aria-describedby=\"caption-attachment-11718\" class=\" wp-image-11718\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig2.png\" alt=\"\" width=\"351\" height=\"263\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig2.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig2-300x225.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig2-768x575.png 768w\" sizes=\"(max-width: 351px) 100vw, 351px\" \/><\/a><p id=\"caption-attachment-11718\" class=\"wp-caption-text\">Figure 2. Normal ear canal and tympanic membrane. Manubrium can clearly be seen.<\/p><\/div>\n<div id=\"attachment_11719\" style=\"width: 361px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig3.png\"><img decoding=\"async\" aria-describedby=\"caption-attachment-11719\" class=\" wp-image-11719\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig3.png\" alt=\"\" width=\"351\" height=\"263\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig3.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig3-300x225.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig3-768x576.png 768w\" sizes=\"(max-width: 351px) 100vw, 351px\" \/><\/a><p id=\"caption-attachment-11719\" class=\"wp-caption-text\">Figure 3. Abnormal ear canal with discolored, bulging tympanic membrane.<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\">The middle ear is composed of the tympanic bulla and the auditory ossicles (malleus, incus, and stapes). The bulla is a smooth, ball-shaped, hollow bony structure filled with air. The auditory tube connects the bulla to the sinuses and allows for adjustment to changes in pressure.<sup>1<\/sup> <\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">The inner ear includes the semicircular canals, the vestibule, and the cochlea, which are all used to process sound waves and present them to the brain for analysis.<\/span><\/p>\n<h2 class=\"p3\">Signalment of Canine Ear Disease<\/h2>\n<p class=\"p4\"><span class=\"s1\">Ear disease can happen at any age and involve various causes and factors:<\/span><\/p>\n<ul>\n<li class=\"p5\"><span class=\"s1\">Primary causes create disease in normal ears and induce infection without other causes; a primary cause alters the ear&#8217;s environment and allows for the development of secondary infections. <\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Secondary causes create disease in an abnormal ear due to changes in anatomy or physiology.<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Perpetuating factors occur due to inflammation. <\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Predisposing factors are present prior to ear disease and increase the risk of developing infections.<sup>1<\/sup><\/span><\/li>\n<li class=\"p6\"><span class=\"s1\">Breed predilection is due to primary causes such as atopy and predisposing factors such as increased hair in the ears, ceruminous gland hyperplasia, and pendulous pinnae.<sup>1<\/sup> <\/span><\/li>\n<\/ul>\n<h2 class=\"p3\">Clinical Signs of Canine Ear Disease<\/h2>\n<p class=\"p2\"><span class=\"s1\">Clinical signs of an ear infection include head shaking, ear scratching, odor, exudate, erythema, stenosis, head tilt, odd ear carriage, and hot spots on the cheeks.<sup>1,3<\/sup> On otoscopic examination, the health of the ear canal should always be noted by looking for ceruminous gland hyperplasia, increased vasculature, erythema, collapse of the canal walls, and the intactness of the tympanic membrane.<sup>3-5<\/sup><\/span><\/p>\n<h2 class=\"p3\">Examination and Cytology for\u00a0Canine Ear Disease<\/h2>\n<p class=\"p2\"><span class=\"s1\">To perform an otic exam, one must understand the anatomy of the ear. The canal itself will travel along the side of the face, then angle into the head toward the back of the eye. When doing the otic exam, grasp the base of the ear pinna and gently pull it perpendicular to the patient and slightly rostrally <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 4<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>. This will help straighten out the canal to allow for easier visualization of the tympanic membrane.<sup>3<\/sup> When visualizing the canals, care must be taken to not rub or bump against the canal wall as this can cause inflammation that may lead to an infection.<sup>4<\/sup> <\/span><\/p>\n<div id=\"attachment_11720\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig4.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11720\" class=\" wp-image-11720\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig4.png\" alt=\"\" width=\"350\" height=\"438\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig4.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig4-240x300.png 240w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11720\" class=\"wp-caption-text\">Figure 4. Otoscopic examination. Gently grasp the pinna and pull away from the head. Gently insert ear cone without touching the canals.<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\"><a href=\"https:\/\/todaysveterinarynurse.com\/clinical-pathology\/veterinary-ear-cytology\/\" target=\"_blank\" rel=\"noopener\">Cytology<\/a> should always be performed before treating the ears to ensure the correct treatment is recommended.<sup>1,4<\/sup> <a href=\"https:\/\/todaysveterinarynurse.com\/clinical-pathology\/how-to-collect-and-prepare-samples-for-the-laboratory\/\" target=\"_blank\" rel=\"noopener\">Collecting cytologic samples<\/a> from the ear can cause trauma if not done correctly. Often, the collection is done too aggressively or the correct sample is not obtained. Collecting a sample too aggressively can create inflammation in an already friable ear and possibly cause an ulcer.<sup>6<\/sup> The exudate outside the canals on the pinna is not diagnostic material. The sample should be taken as close to the junction of the vertical and horizontal canals as possible.<sup>4,5<\/sup> Pull the pinna perpendicular to the patient, gently insert the swab into the canal, and spin the swab on the long axis 3 to 4\u00a0times <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 5<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>. There is no need to scoop out material; if material is in there to collect, you will get it.<\/span><\/p>\n<div class=\"su-image-carousel  su-image-carousel-has-spacing su-image-carousel-crop su-image-carousel-crop-3-2 su-image-carousel-has-lightbox su-image-carousel-has-outline su-image-carousel-adaptive su-image-carousel-slides-style-default su-image-carousel-controls-style-dark su-image-carousel-align-none\" style=\"\" data-flickity-options='{\"groupCells\":true,\"cellSelector\":\".su-image-carousel-item\",\"adaptiveHeight\":false,\"cellAlign\":\"left\",\"prevNextButtons\":true,\"pageDots\":false,\"autoPlay\":5000,\"imagesLoaded\":true,\"contain\":true,\"selectedAttraction\":0.025,\"friction\":0.28}' id=\"su_image_carousel_69e8bda5e7df2\"><div class=\"su-image-carousel-item\"><div class=\"su-image-carousel-item-content\"><a href=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5A.png\" target=\"_blank\" rel=\"noopener noreferrer\" data-caption=\"Figure 5. Ear cytology. Gently grasp the pinna and pull away from the head. (A) Insert swab into the horizontal canal.\"><img loading=\"lazy\" decoding=\"async\" width=\"864\" height=\"864\" src=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5A.png\" class=\"\" alt=\"\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5A.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5A-300x300.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5A-150x150.png 150w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5A-768x768.png 768w\" sizes=\"(max-width: 864px) 100vw, 864px\" \/><span>Figure 5. Ear cytology. Gently grasp the pinna and pull away from the head. (A) Insert swab into the horizontal canal.<\/span><\/a><\/div><\/div><div class=\"su-image-carousel-item\"><div class=\"su-image-carousel-item-content\"><a href=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5B.png\" target=\"_blank\" rel=\"noopener noreferrer\" data-caption=\"Figure 5B. Spin on the long axis only.\"><img loading=\"lazy\" decoding=\"async\" width=\"864\" height=\"867\" src=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5B.png\" class=\"\" alt=\"\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5B.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5B-300x300.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5B-150x150.png 150w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5B-768x771.png 768w\" sizes=\"(max-width: 864px) 100vw, 864px\" \/><span>Figure 5B. Spin on the long axis only.<\/span><\/a><\/div><\/div><div class=\"su-image-carousel-item\"><div class=\"su-image-carousel-item-content\"><a href=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5C.png\" target=\"_blank\" rel=\"noopener noreferrer\" data-caption=\"Figure 5C. No need to scoop.\"><img loading=\"lazy\" decoding=\"async\" width=\"864\" height=\"866\" src=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5C.png\" class=\"\" alt=\"\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5C.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5C-300x300.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5C-150x150.png 150w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig5C-768x770.png 768w\" sizes=\"(max-width: 864px) 100vw, 864px\" \/><span>Figure 5C. No need to scoop.<\/span><\/a><\/div><\/div><\/div><script id=\"su_image_carousel_69e8bda5e7df2_script\">if(window.SUImageCarousel){setTimeout(function() {window.SUImageCarousel.initGallery(document.getElementById(\"su_image_carousel_69e8bda5e7df2\"))}, 0);}var su_image_carousel_69e8bda5e7df2_script=document.getElementById(\"su_image_carousel_69e8bda5e7df2_script\");if(su_image_carousel_69e8bda5e7df2_script){su_image_carousel_69e8bda5e7df2_script.parentNode.removeChild(su_image_carousel_69e8bda5e7df2_script);}<\/script>\n<p class=\"p2\"><span class=\"s1\">The most common findings on otic cytology are cocci (spherical bacteria), yeast, and bacilli (rod-shaped bacteria).<sup>1,7<\/sup> Occasionally, <a href=\"https:\/\/todaysveterinarypractice.com\/internal-medicine\/approaches-to-opportunistic-fungal-infections-in-small-animals\/\" target=\"_blank\" rel=\"noopener\">opportunistic fungal hyphae<\/a> or a foreign body may be present. A foreign body or mass would be easier to see on exam but can be suspected in unilateral disease or with an increased number of white blood cells (WBCs) found on cytology.<sup>4<\/sup> WBCs are not common in ear infections, except with rods, opportunistic fungi, or a foreign body or mass.<sup>4<\/sup> Yeast infections are the simplest to treat; these rarely progress into middle ear disease. Coccoid and rod bacteria will eventually set up in the bulla, causing otitis media. Opportunistic fungi and foreign bodies can travel into the bulla, but it is unlikely. A mass can be an inflammatory polyp or neoplasia (benign or metastatic, although ear masses rarely metastasize).<sup>6<\/sup> These can originate in the canal or bulla. <\/span><\/p>\n<h2 class=\"p3\">Stages of Canine Ear Disease<\/h2>\n<p class=\"p2\"><span class=\"s1\">The author likes to categorize ear disease into 3 stages: early, chronic, and end stage. <\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Early stage occurs when the canal is still pliable and infections are infrequent <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 6<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>. These infections are easy to treat and are limited to the external ear canal. There are no changes to ear canal health.<\/span><\/p>\n<div id=\"attachment_11724\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6A.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11724\" class=\" wp-image-11724\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6A.png\" alt=\"\" width=\"300\" height=\"400\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6A.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6A-225x300.png 225w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-11724\" class=\"wp-caption-text\">Figure 6A. Early stage of ear disease.<\/p><\/div>\n<div id=\"attachment_11725\" style=\"width: 309px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6B.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11725\" class=\" wp-image-11725\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6B.png\" alt=\"\" width=\"299\" height=\"274\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6B.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6B-300x275.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig6B-768x703.png 768w\" sizes=\"(max-width: 299px) 100vw, 299px\" \/><\/a><p id=\"caption-attachment-11725\" class=\"wp-caption-text\">Figure 6B. Computed tomography scan of a normal to early-stage patient. Canals are open and of normal thickness; bullae are eggshell thin and full of air.<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\">Chronic ear disease causes auricular cartilage thickening, resulting in a decrease in canal pliability. Canals with chronic ear disease can range from less pliable to firm and can have mild to severe stenosis, erythema, and\/or ceruminous gland hyperplasia <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 7A<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>.<sup>6<\/sup> By this stage, there is a high probability of middle ear involvement <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 7B<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>.<sup>6<\/sup> <\/span><\/p>\n<div id=\"attachment_11726\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7A.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11726\" class=\" wp-image-11726\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7A.png\" alt=\"\" width=\"300\" height=\"304\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7A.png 1687w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7A-296x300.png 296w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7A-1009x1024.png 1009w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7A-768x779.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7A-1514x1536.png 1514w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-11726\" class=\"wp-caption-text\">Figure 7A. Chronic stage of ear disease.<\/p><\/div>\n<div id=\"attachment_11727\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7B.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11727\" class=\" wp-image-11727\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7B.png\" alt=\"\" width=\"300\" height=\"318\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7B.png 792w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7B-283x300.png 283w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig7B-768x814.png 768w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-11727\" class=\"wp-caption-text\">Figure 7B. Computed tomography scan of chronic ear disease. Canal walls are thickened and bullae are much thicker in appearance, with material noted in both bullae.<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\">End-stage ears typically develop after many years of chronic infection <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 8A<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>. These patients are typically in great pain, but many owners do not realize this because of the length of time it took to get to this point and because owners tend to associate their pet\u2019s slowing down with advancing age rather than pain. The canal itself will be completely stenotic and unresponsive to immunosuppressive doses of glucocorticoids, with partial to complete calcification of the ear canals <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 8B<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>. There is a possibility of a resistant infection in the bulla.<\/span><\/p>\n<div id=\"attachment_11728\" style=\"width: 410px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8A.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11728\" class=\" wp-image-11728\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8A.png\" alt=\"\" width=\"400\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8A.png 936w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8A-300x225.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8A-768x576.png 768w\" sizes=\"(max-width: 400px) 100vw, 400px\" \/><\/a><p id=\"caption-attachment-11728\" class=\"wp-caption-text\">Figure 8A. End-stage ear disease.<\/p><\/div>\n<div id=\"attachment_11729\" style=\"width: 309px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8B.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11729\" class=\" wp-image-11729\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8B.png\" alt=\"\" width=\"299\" height=\"299\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8B.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8B-300x300.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8B-150x150.png 150w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig8B-768x767.png 768w\" sizes=\"(max-width: 299px) 100vw, 299px\" \/><\/a><p id=\"caption-attachment-11729\" class=\"wp-caption-text\">Figure 8B. Computed tomography scan of end-stage ears. Canals are completely stenotic, with partial to complete calcification, and bullae walls are thick, with material noted in 1 bulla.<\/p><\/div>\n<h2 class=\"p3\">Diagnosis of Canine Ear Disease<\/h2>\n<p class=\"p2\"><span class=\"s1\">A culture and sensitivity documents what organisms are involved in the infection and which medication can be used for treatment. However, ear canal cultures are not useful when treating external ear infections topically.<sup>1<\/sup> The ability for antibiotics to concentrate in the skin of the canal is very low. Even if a culture shows that the infection is resistant to a certain antibiotic, it does not mean the infection will not respond to the antibiotic topically.<sup>1,5,7<\/sup> This is because topical medications place a higher concentration of the drug directly on the infection. A culture sample should only be collected from the bulla because the antibiotic needs the ability to penetrate bone.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">To obtain a culture sample from the bulla, the patient must be fully anesthetized as the myringotomy (surgery to perforate the eardrum) is very painful. Most dermatologists typically recommend a computed tomography (CT) scan first (if available) to ensure that a myringotomy is necessary. If the CT scan shows there is no material in the bulla and the tympanic membrane appears normal on examination, it is best if a myringotomy is not performed. The bulla culture can be done with an open-ended tom cat catheter or a polypropylene catheter. When performing the myringotomy, be sure to perforate the pars tensa.<sup>8<\/sup> Gently instill 0.5 to 1 mL of sterile saline into the bulla and aspirate the material. Place the entire volume of liquid into the culturette. Copious amounts of sterile saline should then be flushed into the bulla to retropulse the bulk of the infection out.<sup>5<\/sup> This is usually done under high pressure.<sup>8<\/sup> Afterward, the ear canal itself can be thoroughly cleansed. If <i>Pseudomonas<\/i> is present on cytology, the biofilm will need to be physically scraped off the canal wall.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Primary secretory otitis media (PSOM) is commonly seen in Cavalier King Charles spaniels.<sup>1,9<\/sup> It is a condition where mucus builds up in the bulla, causing a slow decrease in hearing or acute hearing loss. It is very difficult to distinguish signs of PSOM versus signs of <a href=\"https:\/\/todaysveterinarypractice.com\/neurology\/chiari-like-malformation-an-overview\/\" target=\"_blank\" rel=\"noopener\">Chiari-like malformation (CM)<\/a>, as they are virtually the same. CM is where the cerebellum is too large for the brain cavity and puts pressure on the brainstem and spinal cord. The best way to diagnose PSOM is by CT, which shows bone better than tissue and can show whether a bulla is hollow (normal) or full. A magnetic resonance imaging scan, which shows tissue much better than bone, is needed to diagnose CM but can also be used to see if the bullae are full. <\/span><\/p>\n<h2 class=\"p3\">Cleaning and Medication Techniques and Tips<\/h2>\n<p class=\"p2\"><span class=\"s1\">Any time an ear flush or medication is sent home with an owner, the owners should be shown how to properly perform the flush or treatment. Two different techniques are used.<\/span><\/p>\n<p class=\"p4\"><span class=\"s1\">The \u201cpour\u201d technique <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 9<\/span><\/strong><span class=\"s1\"><strong>)<\/strong> is used for in-hospital cleaning:<\/span><\/p>\n<ol>\n<li class=\"p5\"><span class=\"s1\">Pull the ear up to open the external portion of the ear canal.<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Without touching the bottle to the canal walls, fill the canal with solution.<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Massage the canal for a few minutes.<\/span><\/li>\n<li class=\"p7\"><span class=\"s1\">Let the patient shake its head.<\/span><\/li>\n<\/ol>\n<div id=\"attachment_11730\" style=\"width: 410px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig9.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11730\" class=\" wp-image-11730\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig9.png\" alt=\"\" width=\"400\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig9.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig9-300x225.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig9-768x576.png 768w\" sizes=\"(max-width: 400px) 100vw, 400px\" \/><\/a><p id=\"caption-attachment-11730\" class=\"wp-caption-text\">Figure 9. Ear cleaning: \u201cpour\u201d technique.<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\">The biggest problem with this technique\u2014and the main reason owners should not be shown how to do it this way\u2014is that the medication bottle tip can be inserted all the way into the canal, which contaminates the entire bottle with the organism in the ear. It is also important to keep patients from immediately shaking their heads. The cleaner needs some time to soften the material in the ear canal before being shaken out. <\/span><\/p>\n<p class=\"p4\"><span class=\"s1\">For owners, the simple \u201ccotton ball\u201d technique <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 10<\/span><\/strong><span class=\"s1\"><strong>)<\/strong> is usually recommended:<\/span><\/p>\n<ol>\n<li class=\"p5\"><span class=\"s1\">Soak a full-sized cotton ball until it is fully saturated and dripping.<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Gently insert the cotton ball into the opening of the ear canal.<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Massage the canal for a few minutes.<\/span><\/li>\n<li class=\"p5\"><span class=\"s1\">Use the cotton ball to wipe out any debris in the outer portion of the canal.<\/span><\/li>\n<li class=\"p7\"><span class=\"s1\">Let the pet shake its head.<\/span><\/li>\n<\/ol>\n<div id=\"attachment_11731\" style=\"width: 410px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig10.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11731\" class=\" wp-image-11731\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig10.png\" alt=\"\" width=\"400\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig10.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig10-300x225.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig10-768x576.png 768w\" sizes=\"(max-width: 400px) 100vw, 400px\" \/><\/a><p id=\"caption-attachment-11731\" class=\"wp-caption-text\">Figure 10. Ear cleaning: \u201ccotton ball\u201d technique. This technique is usually better tolerated by patients, especially those who are head shy.<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\">The centrifugal force of the patient shaking its head will remove more of the debris from the horizontal canal than can physically be removed. Cotton-tipped applicators should not be used for cleaning the ear canal\u2014not because there is a concern for rupturing the tympanic membrane but because there is a higher chance that the debris from the canal will be pushed deeper into the horizontal canal instead of being removed.<sup>1,5<\/sup> This material can harden into a ceruminolith that is usually difficult to flush out and typically will need to be physically removed.<sup>6<\/sup> <\/span><\/p>\n<p class=\"p4\"><span class=\"s1\">Cleaning can be time-consuming and should be performed depending on risk:<\/span><\/p>\n<ul>\n<li class=\"p5\"><span class=\"s1\">Normal healthy patients should only have their ears cleaned as needed.<sup>3<\/sup> <\/span><\/li>\n<li class=\"p6\"><span class=\"s1\">Patients that have a risk of getting ear infections should have their ears cleaned weekly to monthly. Those at risk include breeds known to have ear issues (e.g., basset hounds, cocker spaniels, German shepherds); breeds prone to allergic skin disease (e.g., bulldogs, Labrador retrievers, pit bulls); and those that have congenital reasons for ear disease, such as increased hair in the ear canal, heavy flopped ears, and hyperplastic ceruminous glands (e.g., basset hounds, cocker spaniels, poodles, West Highland white terriers).<sup>1<\/sup> <\/span><\/li>\n<\/ul>\n<p class=\"p2\"><span class=\"s1\">Be sure to always instruct owners to clean first, then medicate.<sup>3<\/sup> <\/span><\/p>\n<h2 class=\"p3\">Treatment and Medical Management<\/h2>\n<p class=\"p2\"><span class=\"s1\">There are many over-the-counter ear treatments that can be chosen depending on the need of the patient. There is always normal bacterial flora, whether you can see it on cytology or not. If an antibacterial ear medication is used, the normal bacterial flora can become resistant to that antibiotic. Also remember that rods can create a biofilm along the ear canal. This biofilm will protect the organisms from antibiotherapy, and many ear medications cannot penetrate this biofilm. The only way to remove this biofilm is to physically scrape it off the canal walls. This is very painful and should only be done under anesthesia. <\/span><\/p>\n<p class=\"p4\"><span class=\"s1\">Early-stage ear disease is treated topically with regular ear flushing and otic medications.<sup>1,3<\/sup> With chronic ear disease, there are new medicated coats (Claro [Elanco, <\/span><a href=\"http:\/\/elanco.com\" target=\"_blank\" rel=\"noopener\"><span class=\"s2\">elanco.com<\/span><\/a><span class=\"s1\">], Osurnia [Dechra, <\/span><a href=\"http:\/\/dechra-us.com\" target=\"_blank\" rel=\"noopener\"><span class=\"s2\">dechra-us.com<\/span><\/a><span class=\"s1\">]) that can be used in place of lanolin packs using enrofloxacin, ketoconazole, and triamcinolone. These continue to work for 4 to 5\u00a0weeks and have a gel consistency, so are not occlusive. Be sure to clean and dry the patient\u2019s ears thoroughly before instilling the product. Use caution with these products for 2 reasons:<\/span><\/p>\n<ol>\n<li class=\"p5\"><span class=\"s1\">Both products have a potent steroid that can cause problems if not used correctly.<\/span><\/li>\n<li class=\"p7\"><span class=\"s1\">There is a U.S. Food and Drug Administration warning out for both gel products to use care when instilling. <\/span><\/li>\n<\/ol>\n<p class=\"p2\"><span class=\"s1\">If either product touches your eyes, it cannot be washed off, and the medications will stay on your cornea for 30 days. <i>These products should only be used in the hospital and not sent home with owners.<\/i> Osurnia treatment must be repeated in 1 week, and Claro is a one-time treatment that lasts for up to 30 days. Do not clean or treat the ears during this time. Have the owners restrict swimming during the treatment time, and be sure to remind them to use caution around the ears when bathing. <\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Otitis media should be considered when the ears respond to topical medications but relapse within a few weeks.<sup>8<\/sup> Topical medications do not concentrate in high enough levels to treat the bulla; they will only treat the external canal.<sup>1<\/sup> Once the infection of the external canal is cleared, the material within the bulla can slowly reinfect the external canal.<sup>10<\/sup> If the bulla is not treated, the infection will never fully resolve.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">If the patient is experiencing stenosis of the canal, immunosuppressive doses of steroids for 2 to 3 weeks can be attempted to see if the stenosis can be reversed.<sup>3<\/sup> If there is no lumen, medical management will fail.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">The best procedure for medical management of chronic ear disease is a CT followed by a myringotomy and bulla flush <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 11<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>. This procedure is done under anesthesia, and a regional block of the ears can be done to decrease pain. Due to the close proximity of the ear canal to the facial nerve, irritation and paralysis of the facial nerve are a concern. Typically, this is only transient, but there is a risk of it being permanent. <\/span><\/p>\n<div id=\"attachment_11732\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig11.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11732\" class=\" wp-image-11732\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig11.png\" alt=\"\" width=\"350\" height=\"350\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig11.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig11-300x300.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig11-150x150.png 150w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig11-768x768.png 768w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11732\" class=\"wp-caption-text\">Figure 11. Bulla flush using a video otoscope, 3.5F polypropylene catheter, and pressurized saline to retropulse material out of the bulla.<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\">Once the patient is blocked, either a handheld or video otoscope is used to visualize the tympanic membrane. If the tympanic membrane is intact and material was noted on CT, a color change to the tympanic membrane should be visible.<sup>1<\/sup> Instead of being slightly transparent, it will be white to green in color, and there can be some bulging as well. A myringotomy is then performed. Once access to the bulla has been acquired, a copious amount of sterile saline, under high pressure, is retropulsed into the bulla to help flush the infection out. If a culture needs to be obtained, it should be done prior to flushing.<sup>1<\/sup> Once the bulla flushes clear, the external ear canal can be deep cleaned to remove all the pus and biofilm, if present. Always be sure to double check that your patient can blink. If there is partial paralysis, eye lubrication will need to be sent home with owners until the patient can blink again. This ability can typically take 2 to 5 days to return.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">PSOM removal is not much different than a bulla flush, except the PSOM is typically sterile and develops a thick, off-white mucus plug in the bulla. During the procedure, copious amounts of squalene are typically used to encourage the mucus to release from the sides of the bulla. How long the mucus has been in the bulla will determine the thickness of the mucus plug <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 12<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>. Thinner mucus can be retropulsed out of the bulla, whereas thicker mucus will need to be manually removed using a polypropylene catheter and a lot of negative pressure.<sup>11<\/sup> If PSOM was the cause of the hearing loss, once it is removed, the patient should be able to hear. Side effects of PSOM removal are no different than those from a bulla flush.<\/span><\/p>\n<div id=\"attachment_11733\" style=\"width: 359px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig12.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11733\" class=\" wp-image-11733\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig12.png\" alt=\"\" width=\"349\" height=\"376\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig12.png 1619w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig12-278x300.png 278w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig12-951x1024.png 951w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig12-768x827.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig12-1426x1536.png 1426w\" sizes=\"(max-width: 349px) 100vw, 349px\" \/><\/a><p id=\"caption-attachment-11733\" class=\"wp-caption-text\">Figure 12. Mucus plug causing deafness pulled from the bulla of a Cavalier King Charles spaniel with primary secretory otitis media.<\/p><\/div>\n<p class=\"p2\"><span class=\"s1\">The only treatment for patients with resistant infection in the bulla is a total ear canal ablation and bulla osteotomy (TECABO) <strong>(<\/strong><\/span><strong><span class=\"s2\">FIGURE 13<\/span><\/strong><span class=\"s1\"><strong>)<\/strong>.<sup>1,8<\/sup> The TECABO surgery consists of the ear canals being removed en bloc and a small opening made in the bulla to remove the infection and entire epithelial lining. (\u201cEn bloc\u201d means to surgically remove organs or tissue in their entirety without dissection.) The longer the ears are infected, the thicker the calcification gets. The facial nerve, which runs alongside the ear canal, can become trapped within the calcification. At this point, the only way to remove the canal is to cut the facial nerve, which will cause stroke-like signs. These patients will not be able to blink; therefore, they will need eye lubrication for life. Irritation to the facial nerve is also possible during surgery (even if the facial nerve is not cut); therefore, monitoring the ability to blink after surgery is important. Additional side effects of this surgery include head tilt, Horner\u2019s syndrome, facial droop, and other neurologic signs, depending on how much trauma was caused to the inner ear. Side effects of this surgery can be transient (taking up to 90 days for signs to resolve) or permanent.<\/span><\/p>\n<div id=\"attachment_11734\" style=\"width: 461px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13A.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11734\" class=\" wp-image-11734\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13A.png\" alt=\"\" width=\"451\" height=\"338\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13A.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13A-300x225.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13A-768x576.png 768w\" sizes=\"(max-width: 451px) 100vw, 451px\" \/><\/a><p id=\"caption-attachment-11734\" class=\"wp-caption-text\">Figure 13A. Total ear canal ablation and bulla osteotomy (TECABO) postsurgery and completely healed.<\/p><\/div>\n<div id=\"attachment_11735\" style=\"width: 460px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13B.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11735\" class=\" wp-image-11735\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13B.png\" alt=\"\" width=\"450\" height=\"443\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13B.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13B-300x295.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2023\/03\/Friedeck_TVNSpring23_EarDisease_Fig13B-768x756.png 768w\" sizes=\"(max-width: 450px) 100vw, 450px\" \/><\/a><p id=\"caption-attachment-11735\" class=\"wp-caption-text\">Figure 13B. Computed tomography scan of a TECABO. Note the lack of ear canal and hole in the bulla.<\/p><\/div>\n<h2 class=\"p3\">Conclusion<\/h2>\n<p class=\"p2\"><span class=\"s1\">Managing ear disease can be very frustrating and costly for owners. Some treatments are easy and inexpensive; others can get expensive and extensive. Excellent client communication and management of the underlying disease is required to properly manage the ears. If caught early, many patients with ear disease can be managed successfully long term. The trick is to catch the problem soon enough and manage the disease that is causing the infection. <\/span><\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Managing ear disease can be very frustrating and costly for owners.<\/p>\n","protected":false},"author":236,"featured_media":11736,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":0,"footnotes":""},"categories":[237],"tags":[192,145],"class_list":["post-11716","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-spring-2023","tag-continuing-education","tag-peer-reviewed","column-continuing-education","clinical_topics-dermatology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Ear 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