02/11/2021

Otitis externa: clinical presentation,

diagnosis and treatment
Dr. Chiara Noli, DVM, Dip ECVD
Peveragno, Italy
www.dermatologiaveterinaria.it

Credits for some of the photos

• Books:
• Ghibaudo et al: Malattie dell’orecchio del cane e del gatto. Poletto
Editore per Elanco, 2015
• Arcelli, Leone: Otiti nel cane e nel gatto. Poletto Editore, 2001
• Cochet Faivre et al: Atlas de pathologie de l’oreille externe et du
tympan. Vétoquinol
• Griffin et al: Current Veterinary Dermatology, Mosby Year Book, 1993
• Veterinarians:
• Dr. Rares Capitan, Bucarest, Romania
• Dr.ssa Fabia Scarampella, Milano, Italia

Learning objectives of this lecture

• Learn the predisposing and perpetuating factors of
otitis externa
• Learn the primary and secondary causes of otitis
externa
• Learn the clinical presentations of otitis externa
• Learn the steps to diagnose otitis externa
• Learn how to treat otitis externa and the important
measures to prevent it

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Anatomy of the external ear canal

The ear canal is lined by SKIN

• sebaceous glands
• ceruminous (apocrine) glands
• hair follicles
Cerumen is formed by gland secretions
and exfoliating corneocytes
• natural migration of epithelial cells out
of the ear canal in the healthy ear

Anatomy of the tympanic membrane

1. pars tensa, 2. pars flaccida, 3. malleus, 4. anulus

Otitis externa

• Acute or chronic inflammation of the

external ear canal
• Incidence dog 10-20%, cat 2-5% of cases
seen in a general practice
• As a consequence of a single cause
• or of multiple factors (August 1988):
• predisposing, primary, secondary and
perpetuating factors

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Otitis externa
• Predisposing factors
• increase the risk of developing otitis but do not cause it
• Primary factors (found only in 68% of cases, Saridomikelakis
2007)
• are able to cause otitis on their own
• Secondary factors
• are able to cause otitis only if assciated with predisposing
or primary factors
• Perpetuating factors
• prevent the resolution of the otitis

Otitis externa - predisposing factors

• Conformation of the pinnae or of the ear canal
• pendulous, stenotic, canal full of hairs

Normal ear

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Otitis externa - predisposing factors

• Excessive moisture
• high humidity climate
• swimmer’s ear

• Iatrogenic causes
• cotton swabs
• irritant topical application

Otitis externa
predisposing factors

• Obstructive diseases
• neoplasms, polyps

Otitis externa - primary causes

• PARASITES
• Otodectes, Demodex

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Otitis externa - primary causes

• FOREIGN BODIES
• grass awns, topical ear treatments

Otitis externa - primary causes

ALLERGIC DISEASES
• atopic dermatitis
• food allergy
• contact allergy
• topical drug allergy

Atopic dermatitis

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Drug reaction

Otitis externa - secondary causes

BACTERIA:
- Staphylococcus pseudintermedius
- S. aureus
- S. schleiferi
- Proteus spp
- Pseudomonas spp
- Escherichia coli
- Klebsiella spp

Otitis externa - secondary causes

YEASTS: M. pachydermatis, (Candida albicans)

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Otitis externa - perpetuating factors

CHRONIC PROGRESSIVE INFLAMMATORY

CHANGES
• epidermal hyperplasia and hyperkeratosis
• dermal oedema, fibrosis and calcification
• ceruminous gland hyperplasia and dilation
• sebaceous gland atrophy or hyperplasia
• folliculitis and furunculosis
• calcification of the cartilage

Otitis externa - perpetuating factors

FALSE MIDDLE EAR AND CHOLESTEATOMA
• tympanic membrane folds into the middle ear
• pockets fill gradually with keratinic debris (primary cholesteatoma)
• excellent medium for bacteria and yeasts, difficult to eliminate

normal cholesteatoma

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Otitis externa - perpetuating factors

OTITIS MEDIA
• Infection in the tympanic cavity –
difficult to eradicate with topical
therapy alone

tympanic perforation

The correct approach to a patient with otitis externa

Because the ear is lined by SKIN....

....otitis externa should be considered a dermatological disease
→ the approach to otitis externa should be the same as to all
other dermatological conditions:

Signalment → history → general examination → dermatologic

examination… → and only then look at the ears!

Signalment - Age
• Influence of predisposing, primary and secondary factors
• polyps in young adult cats
• neoplasia in old animals
• ear mites usually in cats, especially puppies and kittens
• atopic dermatitis 0,5-3 years
• food allergy from 3 months of age
• endocrinopaties in old animals

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Examination - General
ANIMAL BEHAVIOUR
• head shaking, scratching
• head tilt
• Horner syndrome

GENERAL PHYSICAL EXAMINATION

• identification of underlying systemic diseases

Examination - Dermatologic

BODY SKIN LESIONS

• type
• distribution
• localization
• signs of pruritus
• localization of pruritus
• Atopic dermatitis, food allergy…
LESIONS OF THE PINNA

Examination - Palpation

For the evaluation of:

• proliferative changes
• calcifications
• elicitation of pain
• grass awns
• Pseudomonas
• elicitation of pruritus

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Otitis externa

CLINICAL EVALUATION OF ODOUR

• no odour: healthy ear or recent cleaning

• aromatic, rancid – yeasts, seborrhoeic otitis
• pungent – bacterial
• disgusting, nauseating - Pseudomonas

Otitis externa
otoscopic examination

• examination of the external ear canal

• observation and elimination of foreign bodies
• evaluation of the integrity of the tympanic membrane
→ perform before and after accurate ear washing
→ look at less severe ear canal first

Normal ear

Vertical canal Horizontal canal and tympanic membrane

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Otitis externa
accumulations of cerumen

Otitis externa
cleaning liquids foreign body

Otitis externa
gland hyperplasia

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Otitis externa
severe stenosis of the canal

Foreign bodies

Tympanic membrane

• opaque, whitish, sometimes bulging TM

• in up to 60% of cases of otitis media the
TM is intact!

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Tympanic membrane
ruptures

Examination - exudate

• Black and dry (coffee grounds)

→ parasitic otitis (Otodectes)

Examination - exudate

• brown, with rancid odour

→ yeasts (Malassezia)
→ bacterial overgrowth

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Examination - exudate

• creamy, yellow, foul odour

→ purulent otitis, particularly
Pseudomonas spp.(ulcers)

Pseudomonas otitis
• Purulent otitis
• Disgusting odour
• Ulcerations and blood in pus
• Very painful

Otitis externa

MICROSCOPIC EVALUATION OF CERUMEN

• mixed with a drop of mineral oil
→ Otodectes cynotis
→ Demodex spp.

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Otitis externa
cytological examination

• vertical ear canal sampling • roll the of swab on a clean

with non-sterile cotton swab glass slide. Do not smear it!

Otitis externa
cytological examination

• Heat fixation of greasy

exudates (?) • Rapid staining

Normal cerumen

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Microorganisms: what is normal?

Griffin ESVD-ECVD Meeting 2014:
• ≤5 cocci /OIF
• ≤1 rods/OIF
• ≤ 3 Malassezia/OIF
• No neutrophils
• No nuclear streaking

Bacterial overgrowth (otitis)

Purulent otitis (rods)

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Malassezia otitis

THERAPY

Therapy in 1 slide
•Predisposing factors
1. Identification and correction of predisposing,
•Anatomy,
primary,maceration, obstructions
secondary and perpetuating factors
2. Assessment
•Primary factors of the ear canal by otoscopy: open or
stenotic?
•Allergies, parasites, foreign bodies, systemic diseases
3. Assessment of the secondary microorganisms:
•Secondary
• Malassezia
factors
•Bacteria
• Bacterial
and overgrowth
yeasts
• Purulent otitis
•Perpetuating factors
•Chronic proliferative changes of the ear canal
•Otitis media

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Otoscopic examination
• Ear canal OPEN
• Ear canal STENOTIC

Therapy
OPEN EAR CANAL
• Accurate ear cleaning in the
clinic, with sedation or anaesthesia
• Ear washing at home with antiseptics,
detergents, etc. once daily for one month
• specific topical therapy for two weeks, 1 hour
after the washing, chosen following cytology

STENOTIC EAR CANAL

• 10-14 days of high dosage
prednisone or methylprednisolone
(1-2mg/kg SID), then if open start
therapy as above

Ear cleaning

IMPORTANCE OF EAR CLEANING

• removes cerumen
• removes exudates
• elimination of bacterial toxins and debris, which
contribute to inflammation
• elimination of factors which inactivate topical
medications (gentamycin, polymixin)
• allows inspection of external ear canal

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Ear cleaning
• better with general anaesthesia
• with endotracheal intubation, in order to avoid pneumonia ab ingestis
(aspiration pneumonia) though perforated tympanic membrane and
eustachian tubes
• If not possible leave the head hanging from the table margin

REMEMBER!

• Collect samples BEFORE washing!

• Cytology
• Bacterial culture and susceptibility testing
• Direct microscopic examination for
parasites (Otodectes and Demodex)

Which product should I use?

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Ear cleaning liquids

• Ceruminolytic agents
• Help loosen and eliminate cerumen and exudates

• Antiseptic and drying agents

• Eliminate microorganisms and avoid maceration

→In many cases ear washing products contain them all

Ceruminolytics

CERUMENOLYTIC AGENTS (mild) CERUMINOLYTIC AND

• Propylene glycol SURFACTANT AGENTS
• Mineral oil • Dioctyl-sodium-sulfosuccinate
• Glycerin • Urea peroxide
• Carbamide peroxide (foaming
IF YOU SUSPECT A RUPURED TM agent – useful also in purulent
• Squalene otitis, but irritating, must be
rinsed away!)

Ear cleaning
CERUMENOLYTIC AGENTS
• Abundant flushing should follow
• Initially with warm water
• Then with an antiseptic – drying agent
• With ruptured tympanic membrane in dogs:
• physiologic solution 37-38°C
• vinegar and water 1:1 (Pseudomonas)
• chlorhexidine <0,2% (Clorexiderm oto)
• chlorhexidine + tris EDTA (purulent otitis) (Otodine)

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Antiseptic, alcoholic or acid washing solutions

✓Drying agents, prevent maceration

✓Inhibit microbial growth

• Clorhexidine
• TrisEDTA
• Salicylic acid
• Boric acid and acetic acid
• Lactic acid
• Isopropyl alcohol

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Visualization of the timpanic membrane

• Intact
• Treat topically with medicated ear drops

• Perforated
• Bacterial culture and susceptibility
• Systemic antibiotics
• Topical ear drops (not ototoxic!)

Therapy after the ear washing

• Painkillers (tramadol)

• Topical solutions in the ear canals

• Dexamethasone 0.25ml + enrofloxacin 0.25ml
• Topical ear drops
→ The same drops that the owner will apply for
the following two weeks

Therapy at home

• Instruct the owner on how to perform a correct ear washing

• Ear washing every 1-3 days with a specific product for
minimum 1 month
• After 1 hour specific medicated ear drops every day for 2-3
weeks
• Choice of the products depending on the cytological findings

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Ear cytology
• Malassezia
• Bacterial overgrowth
• Prulent otitis

Malassezia otitis

Daily washing with chlorhexidine < 0,2%

- if possibile leave 5 minutes in the ears
- one hour after washing apply ear drops with
antifungals (and corticosteroids):
• terbinafine
• posaconazole
• clotrimazole
• miconazole

Bacterial otitis
Daily washing with chlorhexidine +/- trizEDTA
- it potentiates the activity of antibiotics, particularly on Gram- bacteria,
by weakening the bacterial cell wall
- one hour after washing apply ear drops with antibiotics (and steroids):
• polymixin, neomycin, gentamicin, florfenicol
• enrofloxacin, marbofloxacin, ibafloxacin
• silver sulfadiazin 0,1% (diluted human cream)

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Topical glucocorticoids
• Decrease pruritus, erythema, oedema
• Decrease production of exudates inducing sebaceous
gland atrophy
• Decrease fibrosis of the ear canal
• Initial therapy with more potent steroids:
• betamethasone
• prednisolone
• dexamethasone
• hydrocortisone (aceponate)
• mometasone furoate

Prolierative stenotic otitis

• If the ear canals do not open up with 2 weeks of steroids,
• If they feel hard at palpation
→Perform open-mouth RX or Ct-scan
• Check for calcification of the ear canals
• Check lesions to the bullae

Open mouth RX

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Calcification of the cartilage

Severe proliferation
of the ear canal
Tympanic bullae filled
with exudate

Prognosis of chronic, proliferative stenotic

end stage otitis
• If the ear canals do not open up with steroids
• If there is calcification of the ear canals
• If there are lesions to the bullae
→ progonsis unfavourable: consider
TECALBO or permanent topical
pharmacological therapy

Otitis externa
Chronic and relapsing otitis
• incorrect identification and control of predisposing,
primary, secondary, perpetuating factors
• Consider topical proactive hydrocrotisone aceponate
• irreversible damage to the ear canals and bullae
(calcification, lysis)
• concomitant otitis media
• poor owner compliance
• Consider repositol ear preparations

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