Vet Clin Small Anim

34 (2004) 411–424

Otic cytology in health and disease

John C. Angus, DVM
Dermatology Section of Specialty Medicine, Department of Veterinary Clinical Medicine,
College of Veterinary Medicine, University of Illinois, 1008 West Hazelwood Drive,
Urbana, IL 61802, USA

Otitis externa is a common disorder affecting 10% to 20% of dogs and

2% to 6% of cats seen by veterinarians [1–3]. Although not a directly life-
threatening condition, otitis diminishes the quality of life of affected pa-
tients. Failure to manage otitis externa appropriately often results in recur-
rent pain, inflammation, and infection, eventually progressing to chronic
end-stage disease. Successful management of otitis in veterinary patients
requires a detailed understanding of the multifactorial pathogenesis of the
disorder.
In each case, veterinarians should pursue two goals vital to effective
treatment of otitis externa: identification and management of the primary
cause (eg, atopy, adverse food reaction, Otodectes cynotis, neoplasia, foreign
objects) and identification and management of concurrent perpetuating
factors (eg, bacterial or yeast infection, edema, glandular hyperplasia,
disruption of normal epithelial migration, otitis media) [4,5]. Simply chasing
infection and inflammation without addressing the primary disease consis-
tently results in treatment failure. Likewise, elimination of the primary disease
without effective management of concurrent infection does not result in
satisfactory resolution of clinical signs. Cytologic evaluation of otic exudate is
a simple, practical, and inexpensive diagnostic test that assists veterinarians
pursuing both goals. Additionally, the information derived from cytology is
available to the veterinarian immediately, permitting rational therapeutic
decisions at the time of the initial consultation.
The principal value of otic cytology is identification and characterization
of microbial overgrowth or infection that contributes to clinical signs and
perpetuates inflammation. This information strengthens interpretation of
culture and susceptibility data, guides rationale therapeutic decisions, and
permits more accurate monitoring of response to treatment. Cytology may

E-mail address: angus@uiuc.edu

0195-5616/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cvsm.2003.10.005
412 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424

also assist in diagnosis of some of the primary causes of otitis externa,

although its value in this regard is limited relative to other diagnostic tests,
such as specific allergy testing, elimination diet trials, and parasite treatment
trials.
Practitioners may be tempted to make conclusions based on the odor and
appearance of the otic exudate rather than on cytology. For instance,
O cynotis is classically associated with dry, grainy, black discharge,
sometimes described as ‘‘coffee grounds.’’ In contrast, yellow or light brown
discharge is reported to indicate bacterial infections, whereas waxy honey-
colored or brown exudate is associated with Malassezia [6]. Unfortunately,
these observations are not consistent or reliable [7,8]. Veterinarians are
cautioned to avoid relying on the physical character of discharge, odor, or
past experience when making a diagnosis or selecting therapy. Rather, these
decisions should be based on evidence established by careful microscopic
evaluation of exudate. Failure to do so may result in inappropriate use of
antimicrobial agents, failure to recognize and treat relevant pathogens, and
an inability to monitor changes in pathogens on subsequent examinations.
The ultimate result is poor quality of case management, prolongation of
treatment, or even treatment failure and progression of disease. Veter-
inarians are encouraged to view cytology as a mandatory test for every
patient presenting for clinical signs of otitis externa.

Sample preparation
Otic cytology does not require special skills or equipment. A diagnostic-
quality slide can be prepared quickly and easily during a standard office
examination. Veterinarians may elect to have the sample collected by
a properly trained member of the support staff when the client and patient
are admitted to the examination room. The slide can then be stained and
evaluated while the veterinarian completes the history and physical exami-
nation. Valuable diagnostic information is ready for interpretation before
the end of the office call, with minimal time commitment.
Separate cytologic specimens should be prepared from each ear canal,
even if the patient presents for unilateral disease. This permits comparison
between the diseased ear and the normal ear as well as early recognition of
bacterial or yeast overgrowth in the less obviously affected ear. Independent
evaluation of each ear is also necessary in patients with bilateral disease.
Clinically relevant differences in bacteria and yeast are expected when
comparing the two ears [9,10]. Without independent evaluation, documen-
tation, and monitoring of each ear separately, veterinarians may fail to
make appropriate management decisions.
Sample collection should always be performed before introduction of any
cleaning agent or therapy. The sample can be most easily obtained using
a clean cotton-tipped applicator introduced gently into the external canal. In
most cases, material obtained from the deeper horizontal canal is more
 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424 413

clinically relevant than material obtained from the superficial vertical canal
[7,11]. In well-behaved large-breed dogs, the swab can be shielded from the
vertical canal by insertion of an otoscopic cone. In awake patients, however,
safely inserting a swab into the deep horizontal canal can be challenging
under the best of circumstances. The addition of pain, stenosis, and
inflammation makes the exercise more difficult and potentially dangerous if
the patient moves suddenly or unpredictably. To obtain consistent samples
without causing undue risk to the patient’s tympanum, veterinarians should
aim for the junction of the vertical and horizontal canal, where the cartilage
bends at an angle of 75 . If the veterinarian avoids straightening the canal,
the bend should prevent the swab from advancing too deep and damaging
the tympanic membrane. Veterinarians who are gentle, cautious, and quick
can safely obtain a diagnostic sample from most patients. Obviously, in
patients anesthetized for ear flush, otoscopy, or other procedures, the
specimen can be collected from the deeper portions of the external canal.
In the case of otitis media, systemic therapy should be directed at
organisms colonizing the tympanic cavity rather than the external canal. In
one study, isolates from the tympanic cavity differed from isolates from the
horizontal canal in 89.5% of cases [9]. In the same study, the tympanic
membrane appeared to be intact in 71.1% of the ears with proven otitis
media. If otitis media is suspected and the tympanum seems to be intact,
sample collection should be performed by myringotomy—the intentional
perforation of the tympanic membrane with a sterile swab, needle, or
catheter.
Once the sample is collected, roll the swab onto a clean glass slide, evenly
distributing a thin layer of material. Care should be taken to identify which
ear was sampled by labeling the slide. Because cerumen has high lipid
content, briefly heat the slide to fix material to the glass, preventing loss of
valuable information in the stain solvent. Avoid overheating the slide,
because this may distort cells, bacteria, or yeast. Stain selection is based on
personal preference, but the same stain should be used consistently to gain
familiarity and produce more reliable results. Most specialists use a modified
Wright’s stain, such as Diff-Quik (Baxter Scientific Products, McGraw Park,
Illinois) [12]. This stain is simple, rapid, and easy to use in-house. Because
modified Wright’s stains are designed for evaluation of peripheral blood
smears, leukocytes retain easily recognized characteristics. Bacteria and yeast
appear blue or purple. Performing a Gram stain provides additional in-
formation but is often an unnecessary and time-consuming stain, because
most morphologically coccoid bacteria found in the ear canal are gram-
positive organisms and most rod bacteria are gram-negative.
After staining, rinse the slide with water and allow it to air dry. If
a permanent slide is desired for comparison during later visits, preserve the
specimen before evaluation by placing a drop of slide-mounting medium
onto the stained material, followed by a coverslip. In most cases, a detailed
written description is sufficient, and the slide can be viewed directly.
414 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424

Scan the slide at low magnification to locate an area of interest. Cerumen

and ointment-based medications do not take up stain and are of little inter-
est. Avoid areas of thick and deeply stained debris, because the confluence
makes characterization of individual organisms and cells difficult. A field
with thinly spread debris containing cellular or keratin debris is most likely
to contain significant material warranting closer evaluation. Because different
areas may yield different results, evaluate several fields to be sure clinically rele-
vant findings are not missed.
The high-dry 40 objective (400 magnification) is adequate for
identification of leukocytes, red blood cells, cornified epithelium, yeast, and
larger bacteria. After examination of the slide with the high-dry objective,
switch to the high-magnification oil immersion lens (100 objective, 1000
magnification) for detailed evaluation; otherwise, additional smaller or
lightly stained bacteria may be missed. Higher magnification also permits
better visualization of morphologic characteristics of bacteria as well as
evaluation of the cytoplasm of neutrophils and macrophages for phagocy-
tized bacteria.
Evaluate each cytologic preparation for the number and characteristics of
three specific features: yeast, bacteria, and leukocytes. To estimate the
numbers, evaluate 5 to 10 areas; record the average count per high-powered
field. A complete and consistent record of cytologic findings is necessary to
monitor progression of disease or response to therapy. These details allow
the primary clinician or any colleague following the case to determine if the
infection is resolving, changing, or worsening.
Parasites are also occasionally identified on stained specimens prepared
in this manner, but this technique is unreliable for purposeful diagnostic
evaluation for ear mites. Instead, prepare a separate slide using a direct
mineral oil technique. Set aside a glass slide with several drops of mineral oil
applied in the center. Collect a large quantity of otic exudate from any level
of the canal with a clean cotton swab, and transfer the debris to the mineral
oil on the glass slide. When evaluating for parasites, debris from both ears
can be pooled onto the same slide. Do not heat-fix or stain this slide. Place
a coverslip directly onto the mineral oil, and examine the specimen. Because
mites are usually moving while trapped in the mineral oil, low magnification
(4 or 10 objective) is sufficient for recognition of parasites. Use a
consistent and complete back and forth sweep similar to that used for
examination of fecal flotation specimens to examine the entire area defined
by the margins of the coverslip.

Normal cytology
The normal ear canal contains a thin layer of waxy yellow cerumen
covering the epithelial lining. Because of the high lipid content, cerumen
does not take up stain. On gross examination, a stained slide prepared from
a normal ear should be nearly colorless.
 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424 415

Microscopic examination may demonstrate normal cornified squamous

epithelial cells seen as sheets of lightly stained basophilic keratin. These cells
may roll up on themselves during smear preparation, resulting in deeper
staining and a shard-like appearance. Desquamated keratinocytes may
contain melanin granules, which appear as tiny yellow to brown ovoid or
round structures. These granules are frequently misidentified as cocci or
small rods colonizing the surface of the keratinocyte. Unlike bacteria, mel-
anin granules do not take up stain; therefore, differentiation can be made by
focusing up and down through the cell until the true color of the structure is
recognized.
The external ear canal of dogs and cats contains small numbers of normal
resident bacteria. Coagulase-negative Staphylococcus spp, coagulase-posi-
tive Staphylococcus spp, and Streptococcus spp are the most frequently
isolated bacteria from normal ear canals (Table 1). Differentiating bacteria
from debris or stain precipitate can be challenging if there are only a few
organisms per field. On cytology, bacteria appear symmetric, smooth-
walled, and uniformly stained. In contrast, debris and precipitate vary in
size and may be asymmetric or irregular in appearance. With the exception
of Corynebacterium, rod-shaped bacteria are rarely found in normal ear
canals [6,8,13]. Any bacteria found in the presence of leukocytes should be
considered abnormal [7,8,11,12].
Another finding on normal otic cytology is basophilic staining yeast,
ranging in size from 2.0 lm  4.0 lm up to 6.0 lm  7.0 lm [14]. Charac-
teristically, these organisms exhibit unipolar budding, which creates the
commonly described ‘‘peanut,’’ ‘‘snowman,’’ or ‘‘footprint’’ shape easily
recognizable as Malassezia (Fig. 1). On cytologic preparations, Malassezia
may be clustered on exfoliated corneocytes or free in the debris. Although
these organisms are normal residents of the canine and feline ear canal,
under the appropriate circumstances, Malassezia can become important
opportunistic pathogens contributing directly to severity of clinical signs as
well as to progression and perpetuation of disease.

Table 1
Most common bacterial isolates from normal and diseased ears of dogs (ranked in order of
frequency)
Normal external canal Otitis externa Otitis media
Coag (ÿ) Staphylococcus Coag (+) Staphylococcus Coag (+) Staphylococcus
Coag (+) Staphylococcus b-Hemolytic Streptococcus b-Hemolytic Streptococcus
b-Hemolytic Streptococcus Pseudomonas spp Pseudomonas spp
Corynebacteria spp Proteus spp Proteus spp
Coliforms Coliforms Coag (ÿ) Staphylococcus
Coag (ÿ) Staphylococcus Coliforms
Corynebacteria spp a-Streptococcus
Enterococcus
Abbreviations: Coag, Coagulase.
416 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424

Fig. 1. Multiple Malassezia pachydermatis exhibiting unipolar budding (Diff-Quik).

Abnormal cytology
Malassezia yeast
Malassezia pachydermatis is widely recognized as the predominant
commensal yeast of dogs [14–17]. The genus actually consists of seven
species, however, including six distinct lipid-dependent species: M furfur,
M sympodialis, M globosa, M obtusa, M restricta, and M sloofiae. M pachy-
dermatis is the only nonlipid-dependent member of the genus [14,15].
M pachydermatis is present in 15% to 49% of normal canine ear canals
and in up to 83% of dogs with otitis externa [18–20]. Recent studies
demonstrated M furfur and M obtusa in 4.5% of cases of canine otitis
externa, whereas M sympodialis and M furfur were present in 8.9% of
diseased ear canals of cats [20,21]. M sympodialis [22,23], M globosa [23],
and M furfur [20,23,24] can be recovered from normal haired skin, ear
canals, and mucosa of healthy cats. Of these species, M sympodialis is
believed to be a normal resident of the feline ear canal [17]. The remaining
lipid-dependent species are most often isolated from large animal species
[25,26]; their role as resident, transient, or pathogenic yeast in dogs and cats
is not known. In human beings, M globosa, M sympodialis, and M furfur are
the most significant commensal and pathogenic species [27], although M
pachydermatis has the potential for zoonotic transfer from dogs to people
[14,15].
When examining cytologic preparations from dogs and cats, veterinar-
ians may recognize variations in morphologic features or staining character-
istics of the different Malassezia species. Because precise determination of
species is based on phenotypic and biochemical characteristics of cultured
specimens, the less common species may go unrecognized. Current research
focusing on virulence factors and host response indicates that different
 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424 417

species of Malassezia have variable pathogenicity [15]; however, the differ-

ences may not be clinically relevant. Unless further research demonstrates
a compelling reason to differentiate Malassezia species by laboratory tech-
niques, simple recognition of any member of genus on cytology is sufficient
for management of otitis externa.
Although more commonly isolated in the external canal, Malassezia may
also colonize the tympanic cavity. In one study, Malassezia was recovered
from 65.8% of external ear canals and 34.2% of middle ears of dogs with
chronic otitis [9]. When otitis media is suspected, cytologic evaluation of
debris from the tympanic cavity should be performed. Because Malassezia
can be found in normal patients or mixed in with predominantly bacterial
infections, veterinarians need to determine the clinical significance of
Malassezia for individual patients. Cytology is the most useful tool for
differentiating between normal resident colonization and overgrowth.
Unlike bacterial infections, suppurative inflammation is not a common
feature of Malassezia otitis [7,12] and thus cannot be used to determine
a pathologic state.
A recent study by Ginel et al [28] proposed using semiquantitative crite-
ria for the diagnosis of significant yeast otitis. By comparing cytologic
specimens from normal and diseased ears, the authors concluded that 2 or
fewer yeast organisms per high-dry field (40 objective, 400 magnifica-
tion) in the dog and cat was normal. Mean counts of 5 or more yeast
organisms per field in dogs and 12 or more yeast organisms per field in cats
were abnormal. The intermediate values were considered a gray zone (Table 2).
Using these values to diagnose otitis externa, cytology had a specificity of
95% in dogs and 100% in cats. The sensitivity was only 50% for dogs and
63% for cats because of the fact that some cases of otitis externa were
exclusively bacterial with minimal yeast involvement.
Semiquantitative estimation of numbers provides a guideline for the
clinician, but, ultimately, the decision to treat or not to treat Malassezia
depends on a combination of cytologic findings, severity of clinical signs,
past history of yeast otitis, and previous response to therapy in the individ-
ual patient.

Table 2
Recommended criteria for evaluating the significance of organisms present on otic cytology
(based on mean number of organisms per high-dry 40 field)
Normal Gray zone Abnormal
Malassezia
Dog 2 3–4 5
Cat 2 3–11 12
Bacteria
Dog 5 6–24 25
Cat 4 5–14 15
418 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424

Bacteria
The most common pathogens associated with otitis externa are
coagulase-positive staphylococci, B-hemolytic streptococci, Pseudomonas
spp, and Proteus spp (see Table 1). Although the same classes of bacteria are
frequently isolated from the tympanic cavity, there may be considerable
variability between the two locations within the same patient. In a study
comparing isolates from the horizontal canal and the tympanic cavity of
dogs with chronic otitis externa and media, there were differences in the
species or antimicrobial susceptibility of bacteria isolated in 89.5% of the
cases [9]. Therefore, samples for cytology and culture should be obtained
from the tympanic cavity rather than from the external canal.
The distinction between bacterial ‘‘overgrowth’’ and ‘‘true infection’’ is
subtle but clinically important. In general, overgrowth of bacteria in the
debris and on the epithelial surface of the external canal does not warrant
culture and susceptibility testing or expensive systemic therapy. Systemic ther-
apy is not necessarily more effective for these cases, because the concen-
tration of antibiotic achieved by topical medications can far exceed that
achievable by systemic routes. In contrast, in the case of bacterial infection
of the tissue of the external canal or within the tympanic cavity, high-dose
long-term systemic antibiotic therapy is necessary for successful resolution
[5,8].
Cytology assists in the determination of normal resident bacteria,
bacterial overgrowth, and true infection. There is no definitive rule for
deciding if bacteria observed on cytology are clinically relevant organisms
warranting therapeutic intervention. Veterinarians should be guided by
knowledge of common pathogens and a combination of severity of clinical
signs, cytologic findings, and identification of isolates by culture from each
patient. Semiquantitative cytologic criteria similar to those proposed for
Malassezia can be applied to bacteria (see Table 2). Based on the results
reported by Ginel et al [28], 5 or fewer bacteria per high-powered dry field
(40 objective) should be considered normal, whereas 25 or more bacteria
per field suggests an abnormally increased population (Fig. 2), with the
intermediate numbers in a gray zone subject to interpretation. For cats, 4 or
fewer bacteria per field was consistent with normal and 15 or more bacteria
per field was abnormal. Using these mean count criteria to differentiate
normal from diseased ears yielded 95% specificity and 50% sensitivity in
dogs and 100% specificity and 63% sensitivity in cats.
Another important piece of evidence supporting a diagnosis of infection
versus overgrowth is the presence of abundant leukocytes on cytology.
Leukocytes are not found in the normal canal, nor are they frequently
present during overgrowth of organisms on the surface of the external canal.
Cytology cannot reliably determine the species of bacteria observed. For
example, cocci observed on cytology are most likely Staphylococcus spp or
Streptococcus spp, but cytology cannot differentiate between the two.
 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424 419

Fig. 2. Mixed infection with Malassezia pachydermatis, rod bacteria, and coccoid bacteria
(Diff-Quik).

Bacterial culture is needed to identify species and determine antimicrobial

susceptibility of clinically relevant bacteria. Nevertheless, veterinarians
should not rely on culture alone to identify pathogens, direct therapeutic
decisions, or monitor response to therapy. Because of the complicated
nature of otitis externa, bacterial culture in the absence of cytology is an
inaccurate tool.
One of the major shortcomings of bacterial culture is the inability to
distinguish between normal resident bacteria, simple overgrowth, and true
infection. Because laboratory personnel are unable to determine which
organisms are clinically relevant, antimicrobial susceptibility is usually
reported for all organisms. The inclusion of irrelevant commensal organisms
may result in unnecessary multidrug therapy or inappropriate switching of
antibiotics. In other circumstances, laboratories may limit the number of
isolates tested for susceptibility, potentially failing to provide a complete
characterization of all pathogens.
Culture should never be used as the sole means of monitoring response to
therapy. For example, the finding of Pseudomonas aeruginosa on three
consecutive cultures provides little useful information compared with
estimation of bacterial numbers, evaluation of concurrent organisms, and
characterization of inflammatory response. Additionally, bacterial culture
may fail to isolate important organisms, potentially resulting in discontin-
uation of therapy before resolution of disease.
The best method for diagnostic evaluation of bacterial otitis is cytology in
combination with culture and susceptibility testing. Cytologic evidence is
available immediately, allowing the veterinarian to initiate rational empiric
therapy while awaiting susceptibility results. When the laboratory report
arrives 48 to 72 hours later, knowledge derived from cytology determines
which organisms are most relevant, directing alterations in the initial plan.
420 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424

Leukocytes
In addition to evaluating cytologic preparations for bacteria and yeast,
otic exudate must be carefully examined for white blood cells. Although
yeast and bacteria are normal findings, leukocytes should not be present in
otic cytology from normal patients [28]. Neutrophils, macrophages, and
other inflammatory cells only gain access to the lumen of the canal as
the result of exudative inflammation, ulceration of the epithelial lining,
or extension from the tympanic cavity during otitis media. Thus, find-
ing leukocytes on cytology suggests a more severe disease process.
As discussed in the previous section, the presence of white blood cells and
bacterial phagocytosis indicates infection rather than simple overgrowth. If
the immune system is responding to an infection with suppurative or
pyogranulomatous inflammation, systemic antibiotic therapy is almost
always indicated. In many patients with otitis externa, the only evidence of
concurrent otitis media during the initial evaluation is extension of purulent
exudate from the tympanic cavity into the external canal. Because otitis
media is present in 16% of dogs with acute otitis externa and in up to 82% of
dogs with chronic disease, any cytologic evidence of leukocytes in the
external canal should increase the clinician’s suspicion for concurrent otitis
media, warranting specific diagnostic evaluation. When appropriate,
culture and susceptibility samples should be obtained directly from the
middle ear.
White blood cells are also an excellent standard for monitoring changes
in disease state and response to therapy. Early in the course of disease when
erythema, edema, pruritus, and discharge are easily managed by short
courses of topical therapy, clients may be reluctant to pursue diagnosis of
underlying causes. Without a habit of routine cytology, veterinarians may
fail to recognize progression in disease, resulting in continuation of symp-
tomatic therapy. Similarly, if leukocytes are present during initial evalu-
ation, the disappearance of leukocytes from subsequent cytology is a clear
indication of response to therapy and movement toward resolution. Serial
cytologic records from each episode encourage veterinarians and clients to
make appropriate management decisions.
Rarely, noninfectious cutaneous diseases result in the presence of white
blood cells in the external canal. Pemphigus foliaceus is an immune-
mediated dermatitis characterized by the formation of sterile pustules in the
epidermis, including the lining of the external canal. The fragile pustules
rapidly degenerate into dry yellow to brown crusts covering superficial
erosions. Cytologic findings from a sterile pustule demonstrate large
numbers of ‘‘healthy’’ nontoxic neutrophils, well-defined acantholytic
keratinocytes (rounded nucleated keratinocytes), and the notable absence
of bacteria. Bacteria rapidly colonize under crusts and erosions, making
diagnosis more difficult if an intact pustule is not available. Diagnosis is
confirmed by biopsy.
 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424 421

Parasites
The most common parasite associated with otitis externa in dogs and cats
is O cynotis [4,8,11,29]. O cynotis is a large-bodied mite (Fig. 3) that feeds on
excretions stimulated by irritation of the epithelium lining of the external
canal. Adult mites migrate beyond the ear canal to locations elsewhere on
the host’s body. Under ideal conditions, adult mites can survive off the host
for several weeks. O cynotis is not species specific and is highly contagious
between animals. Ear mites are responsible for up to 50% of all cases of
otitis externa in cats and between 5% and 10% of cases in dogs [8].
Clinical signs result from either irritation created by large numbers of
mites or by induction of hypersensitivity reactions in the host. Both type 1
(immediate) and type 3 (immune complex) hypersensitivity reactions have
been described [30,31]. In patients with hypersensitivity to mite antigen, as
few as three mites may perpetuate clinically significant pruritus, pain, head
shaking, inflammation, and secondary infection [8,29]. In contrast, other
animals demonstrate little to no evidence of otitis in spite of the presence of
active parasite infestation. In one study, the prevalence of O cynotis in dogs
was 29.1%, but less than half of the dogs with positive cytology demonstrated
evidence of ear disease [32]. This finding suggests that subclinical carriers are
common. The prevalence in the cat population is similar: 25% to 37% [33,34].
In patients with heavy infestations, diagnosis is not usually a challenge. When
large numbers of mites are present in the external ear canal, the diagnosis can
be easily confirmed by direct visualization of the mites with a magnified
operating-head otoscope or a fiberoptic video-assisted otoscopic endoscope.
More commonly, clinicians observe mites by microscopic examination of
a mineral oil preparation. Low magnification (4 objective) is usually
sufficient. O cynotis has a psoroptiform body type similar to Sarcoptes but is

Fig. 3. Otodectes cynotis. (From Angus JC. Diseases of the ear. In: Campbell KL, editor. Small
animal dermatology secrets. Philadelphia: Hanley & Belfus; 2004. p. 364–84; with permission.)
422 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424

larger and has short unjointed pedicles extending from the legs. Female adult
mites are approximately 280 lm wide and 450 lm long [35]; the fourth pair of
legs is rudimentary and does not extend beyond the body. The slightly smaller
adult males (250 lm  320 lm) are frequently observed attached to an eight-
legged deutonymph (220 lm  320 lm). Other life stages include the
protonymph (160 lm  240 lm) and six-legged larva (115 lm  240 lm).
Numerous large eggs (100 lm  210 lm) are commonly found lodged in the
keratin debris. Identification of a single egg or mite of any life stage provides
a definitive diagnosis.
In contrast, confirmation can be challenging in hypersensitive patients
with significant clinical signs caused by a low mite burden. In patients with
copious exudate, suppurative inflammation, or secondary infections, the few
mites present in the external canal often prove difficult to find. In these
cases, the primary cause may go undiagnosed. Failure to demonstrate O
cynotis on microscopic evaluation of exudate does not definitively eliminate
parasitic infestation from the list of differential diagnoses. A treatment trial
with appropriate miticidal therapy is strongly recommended for all cases of
chronic otitis externa.
Other mites are occasionally found on cytologic preparations, including
Demodex spp, Sarcoptes scabiei, Notoedres cati, Eutrombicula alfreddugesi,
and Neotrombicula autumnalis. Demodex spp, follicular mange mites, may
be found in any hair follicle on the body, including the hair follicles present
throughout the external ear canal. In a patient with juvenile-onset or adult-
onset demodicosis, overpopulation of the resident mite population results in
alopecia, folliculitis, furunculosis, and, in severe cases, cellulitis. If this
occurs in the hair follicles of the ear canal, the patient may demonstrate
clinical signs of otitis externa. If demodex mites are found on microscopic
evaluation of otic exudate, a thorough dermatologic examination and skin
scrapings of multiple regions of haired skin are strongly recommended.
S scabiei and N cati, the sarcoptic mange mites of cats, most commonly
affect the host’s pinna and not the external canal. Inflammation, glandular
hyperplasia, and increased cerumen production of the external canal can
occur but are not common or expected features of parasitism by these mites.
Evidence of these mites on routine ear cytology is rare.
Chiggers, or harvest mites, E alfreddugesi, and N autumnalis cause a pruritic
papulocrustous dermatitis of dogs and cats. The adults are free-living mites
found preferentially in decaying vegetation. The parasitic larval stage may be
found tightly adhered to the skin, including the pinna and the opening of the
vertical canal. The large (500 lm) six-legged larvae are distinguished from O
cynotis by their different body type and bright red-orange color.

Summary
Accurate characterization of the primary cause and perpetuating factors
is essential for successful management of ear disease in dogs and cats.
 J.C. Angus / Vet Clin Small Anim 34 (2004) 411–424 423

Cytology is a simple, rapid, and practical diagnostic test that should be

performed routinely on any and all patients presented for clinical signs
consistent with otitis externa. In combination with clinical signs, otoscopic
evaluation, and diagnostic testing of primary disease, serial cytology en-
hances the ability of veterinarians to diagnose secondary infections, mon-
itor progression of disease, evaluate response to therapy, and make
appropriate management decisions.
Cytologic specimens should be evaluated for the presence, numbers, and
characteristics of three key features: yeast, bacteria, and leukocytes. More
than five yeast organisms or more than 25 bacteria per high-powered field is
suggestive of significant microbial activity warranting therapeutic interven-
tion. The presence of leukocytes, particularly with phagocytized bacteria,
indicates ‘‘true infection’’ rather than overgrowth; if suppurative discharge is
present, systemic therapy is needed. Cytology combined with culture and
susceptibility is the best method for identification of bacterial overgrowth
and infection; however, if only one test can be performed, always choose
cytology. Culture results assist in the selection of appropriate antibiotic
therapy, but cytology determines whether systemic antibiotics are indicated,
which organisms are most significant, and when therapy can be discontinued.

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