Total ear canal ablation in the dog: Part 2

Tim Charlesworth MA VetMB DSAS(ST) MRCVS

EASTCOTT REFERRALS, EDISON PARK, DORCAN WAY, SWINDON. SN3 3FR

ABSTRACT: Total Ear Canal Ablation (TECA) is the treatment of choice for end stage otitis externa, refractory
otitis media, and many aural neoplastic conditions. The technique for TECA-LBO is described and the most
commonly encountered perioperative complications are discussed.DOI: 10.1111/j.2044-3862.2012.00237.x

INTRODUCTION
This is the second part of a two part article on Total
Ear Canal Ablation (TECA) in the dog.The first part
of this article (UKVet Companion Animal Vol 17.7
16pp) discussed relevant anatomy, preoperative
assessment and anaesthetic regimes. This second part
will describe the surgical technique itself and review
the possible intraoperative and postoperative
complications that may be encountered. TECA is an
advanced surgical procedure, the execution of which
requires a solid grasp of regional anatomy if
potentially devastating perioperative complications
are to be avoided.

PATIENT POSITIONING
The dog is placed in lateral recumbency with the
affected ear uppermost. In breeds with pendulous
ears e.g. Cocker Spaniels, the ear can be prepped as
Fig. 1: Initial TECA incision, Gelpi retractors have
a ‘hanging ear prep’ to facilitate aseptic preparation
been placed into the wound.
of both surfaces of the pinna.

SURGICAL PROCEDURE
An elliptical incision is made around the opening of
the external ear canal staying ventral to the anthelix.
The incision needs to be through the skin and
underlying cartilage but some care should be taken
not to lacerate tissues medial to the auricular
cartilage or to incise ‘full thickness’ (Fig. 1).
Bleeding will be moderate, especially in chronically
inflamed ears and haemostasis can be achieved with
judicious diathermy once the incision is complete.
Gelpi retractors are placed in the wound and Allis
tissue forceps placed on the distal ear canal and
passed to an assistant (Fig. 2).
SMALL ANIMAL l SURGERY HHH

Fig. 2: An assistant holds two pairs of Allis Tissue

Forceps attached to the ear canal.

If you would like to submit an

Dissection proceeds proximally (medially) using a
article for publication
combination of sharp and blunt dissection to remove
contact the editorial panel at any adhesions and to dissect the ear canal free of the
ukvet@ukvet.co.uk surrounding tissues including the overlying parotid
salivary gland. Dissection should proceed as close to
the cartilage as possible to minimise the risk of

14 Companion Animal Vol 17 October 2012 © 2012 Blackwell Publishing Ltd


Fig. 3: Medial branch of auricular artery inserting into the vertical ear canal.
inadvertently compromising any of the adjacent
neurovascular structures. Bipolar diathermy should
be used as necessary to maintain a bloodless surgical
field. A branch of the auricular artery is often seen
inserting into the medial border of the vertical canal
and this will need ligating or sealing with diathermy
(Fig. 3) although this can often be obscured by
surrounding adhesions.
Dissection is greatly facilitated by repeated
repositioning of the Gelpi retractors and an assistant
retracting the ear canal in various directions to
tension remaining attachments to the ear canal
(Fig. 4).
Dissection should proceed cautiously as the
horizontal canal is approached. The facial nerve
(exiting the stylomastoid foramen caudal to the
bulla) is often seen coursing rostroventrally at this
point. The nerve should be identified and retracted
(Fig. 5). Indirect retraction should be used whenever
possible i.e. the retractors placed around soft tissue
adjacent to the nerve rather than around the nerve
Fig. 4: Dissection proceeds medially/proximally and is
aided by retraction of the wound edges and ear canal.
© 2012 Blackwell Publishing Ltd
itself. Overzealous retraction will cause neuropraxia.
It is not always necessary to retract the facial nerve
during the surgery as maintaining the plane of
dissection as close to the auricular cartilage as
possible should be sufficient to prevent inadvertent
damage to the nerve. Early identification and
retraction of the nerve will, however, help alert the
surgeon to cases in which the nerve has become
entrapped in fibrous adhesions surrounding the ear
canal. When entrapped, the facial nerve should be
carefully dissected free from the ear canal whenever
possible. Rarely, the facial nerve is so entrapped in
periaural calcification that it is not possible to
preserve it and in these circumstances it can be
severed, however this will result in permanent facial
paralysis.
Dissection is then continued until the junction
of the ear canal with the tympanic bulla is
reached. Again, landmarks are checked to confirm
the anatomy and then the ear canal is amputated
close to the bulla wall as possible. It is safest to cut
in a rostral direction i.e. away from the facial nerve
(Fig. 6).
Fig. 5: The facial nerve (arrow) can be seen going rostroventrally to the ear
canal (left ear).
Fig. 6: The ear canal is amputated cutting away from the facial nerve.
Companion Animal Vol 17 October 2012 15
 The ear canal is visually inspected (Fig. 7) and
submitted for histopathology.

The entrance to the tympanic bulla should now be

visible although it may be occluded with thickened
folds of mucosa or exudate.There is normally a ‘cuff ’
of epithelium +/- proximal cartilage adhered to the
opening of the bulla (Fig. 8). This can be carefully
removed with a curette or as part of the lateral bulla
osteotomy (LBO) (Fig. 9).

The LBO is performed after soft tissues are cleared

away from the ventral bulla wall. A pair of rongeurs
is used to enlarge the opening of the bulla cavity
(Fig. 10). Great care should be used as both the
external carotid artery and the maxillary vein are in
this area. Similarly, the retroarticular vein is at the
rostrodorsal aspect of the bulla opening and great
care should be taken to avoid rupturing this vein
during curettage. Once a sufficient LBO has been
Fig. 7: The amputated ear canal.
performed the bulla cavity is curetted and the
epithelial lining removed. The dorsomedial aspect of
the bulla (housing the vestibular apparatus) should
not be curetted.

Similarly, if the bulla has been eroded by otitis

media/neoplasia/cholesteatoma then curettage
should be done very carefully to avoid breaching the
medial wall overlying the internal carotid artery.

Once the LBO is complete, the surgical field is

thoroughly lavaged and a swab is taken for bacterial
culture and sensitivity if indicated (otitis media).

Fig. 8: Bulla opening obscured by mucosa/exudate.

SMALL ANIMAL l SURGERY HHH

Fig. 10: Completed LBO.

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Fig. 9: Bulla opening visible once ‘cuff’ of mucosa is
removed by gentle curettage.

Continued on page 18

16 Companion Animal Vol 17 October 2012 © 2012 Blackwell Publishing Ltd


Fig. 11: Finished TECA-LBO wound (pendulous ear).
Dead space can be closed by tacking the parotid
gland dorsally to the subcutaneous tissues and
then the subcutaneous tissues are apposed
with monofilament absorbable sutures (e.g.
poliglecaprone) and skin sutures. Skin sutures should
not engage the cartilage of the pinna. In breeds with
pendulous ears, the wound is closed simply (Fig. 11).
In dogs with normally erect ears, the caudal wound
can be closed with a slight curl to help maintain
erect ear carriage and improve the end cosmetic
result (Fig. 12).
There is no advantage to using surgical drains for a
routine (i.e. non-abscessated) TECA-LBO.
POSTOPERATIvE CARE
Adequate analgesia must be provided. Dogs are
maintained on a combination of u-agonist opioids
(e.g. methadone, morphine) for at least 24 hours
following the surgery. This may be given as repeated
bolus injections or as part of a constant rate infusion
(CRI). Other analgesics, e.g. ketamine and lidocaine,
can also be used to make up an ‘MLK’ CRI. Patients
are usually discharged with continued opioids e.g.
tramadol and NSAIDs (unless contraindicated).
SMALL ANIMAL l SURGERY HHH
Fig. 12: Finished TECA-LBO wound (erect ear).
18 Companion Animal Vol 17 October 2012
Postoperative antibiotics are often continued for five
days following the surgery if there was evidence of
an otitis media at the time of surgery. Further
antibiotics can then be prescribed depending on the
results of bacterial culture and sensitivity.
Sutures are usually removed 7-10 days after the surgery
and a Buster Collar should be used to prevent self-
trauma to the wound until it has fully healed.
TECHNIQUE vARIATIONS
There are several variations to the technique
described above. Many textbooks still describe
making an initial ‘T shaped’ incision. This in theory
may give slightly better exposure but results in a
significantly larger wound with a suture intersection
and an increased risk of wound healing
complications. The extent of the LBO performed is
also variable. The ‘keyhole’ LBO is described above
but some surgeons will remove most of the lateral
and ventral wall of the bulla to completely expose
the cavity. The reason cited for this is to decrease the
risk of para-aural abscessation (see below) although
this does not seem to be a significant problem with
the described technique.
Recently, a modified TECA has been described
which preserves the distal part of the vertical canal.
There are few indications for this variation as most
disease processes will involve the entire ear canal.
COMPLICATIONS
Many complications following TECA-LBO have
been reported, the main complications are discussed
below:
l Intraoperative haemorrhage
The most worrying intraoperative complication is
severe haemorrhage. This can arise from the
maxillary vein or external carotid artery during LBO
or from the retroarticular vein during curettage of
the rostrodorsal bulla opening. Major haemorrhage
from any of these vessels can be life threatening. The
area should be immediately packed with sterile
swabs and pressure applied for five minutes. The
bleeding vessel should not be continually suctioned
as this will prevent an adequate clot forming and
could lead to fatal blood loss. Once haemostasis is
achieved, the surgery can carefully proceed.
Absorbable gelatin sponge (e.g. Spongostan) can be
used to augment haemostasis although the
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article for publication
contact the editorial panel at
ukvet@ukvet.co.uk
© 2012 Blackwell Publishing Ltd
 minimum amount of sponge should be used as they
may act as a nidus of infection when used in a
contaminated site. If a major (carotid) arterial bleed
is encountered then the carotid artery can be ligated
via a cervical approach.
l Facial paralysis
Overzealous retraction of the facial nerve can lead to
temporary or permanent loss of facial function. This
will result in a drooped muzzle, altered ear carriage
and most obviously a loss of blink on the operated
side. The innervation of the nictitans will remain
unaffected and this will maintain an adequate tear
film. Tear production will not be affected (see Part 1
of this article). Exopthalmic breeds may, however,
benefit from topical corneal lubrication in the
early postoperative period. Facial paralysis will
be permanent if the facial nerve was cut during
the surgery.
l Para-aural abscess
Failure to remove all of the ear canal and secretory
epithelium from the tympanic bulla may lead to
persistent infection and eventual abscess formation.
This will cause a painful swelling over the operative
site and can eventually lead to fistula formation.
These abscesses can form up to 12 months after the
surgery and will usually need further surgery to
remove the nidus of infection.
l Wound healing complications
Minor wound healing complications (e.g. partial wound
dehiscence, seroma) are encountered occasionally
and can usually be managed conservatively.
CONCLUSION
TECA-LBO is a technically demanding surgery
associated with some potentially disastrous
complications. TECA-LBO does, however, remain
the treatment of choice for a variety of aural
conditions and can lead to a dramatic improvement
in patient quality of life when done well. Potential
complications should be discussed with owners
before the surgery is performed.
REFERENCES/FURTHER READING
DEVITT, C. M., SEIM, H .B., WILLER, R. et al.: Passive drainage versus
primary closure after total ear canal ablation-lateral bulla osteotomy
in dogs: 59 dogs (1985-1995). Vet Surg 26:210–216, 1997.
MATHEWS, K. G., HARDIE, E. M., MURPHY, K. M. Subtotal ear canal
ablation in 18 dogs and one cat with minimal distal ear canal
pathology. J Am Anim Hosp Assoc. 2006 Sep-Oct; 42(5):371-80.
SMEAK, D. D. Management of Complications Associated with Total Ear
Canal Ablation and Bulla Osteotomy in Dogs and Cats Veterinary
Clinics of North America: Small Animal Practice, Volume 41, Issue 5,
September 2011, Pages 981-994.
WHITE, R. A. S., POMEROY, C. J.: Total ear canal ablation and lateral
bulla osteotomy in the dog. J Small Anim Pract 31:547–553, 1990.

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