Otitis Techniques to Improve Practice

Craig E. Grifn, DVM, DACVD

Successful management of otitis externa requires recognition of changes in the anatomy and physiology of the external and middle ear, as well as the adequate tools and examinations to detect changes from normal. Otoscopy and methods for assessing the normalcy of the tympanum, collection of samples for cytologic evaluation or culture, and myringotomy are diagnostic techniques important in practice. Treatment tubes and intralesional triamcinolone injections are techniques that improve the response in some cases. Clin Tech Small Anim Pract 21:96-105 2006 Elsevier Inc. All rights reserved. KEYWORDS otitis, dog, techniques, ear ush, intralesional injections, otoscopy, beroptic video enhanced otoscopy, FOVEO

titis externa is a common problem of dogs and cats that often is a diagnostic and therapeutic challenge. Detecting and treating changes in the normal anatomy, physiology of the ear canal, microora, tympanic membrane, and middle ear cavity are essential for successful treatment of otitis. Thorough visualization of the ear, use of ear loops and tubes within the ear and the collection of appropriate samples are the basis for detecting the changes. Effective treatment also requires adequate delivery of therapeutic agents to the site in the ear where they are needed. This paper reviews some equipment and techniques that improve the chances of detecting and treating the changes in the ear.

Otoscopy
Otoscopy is the examination of the ear canal with an otoscope. Otoscopy is used to detect foreign bodies, lesions, exudate, and pathologic changes that have occurred in the ear canal. It may also be helpful in assessing the tympanic membrane though in many cases of chronic otitis routine otoscopy alone is often not sufcient for detecting all changes in the tympanic membrane or otitis media.1 Repetitive otoscopic examinations are often required to determine if normal ear cleaning is occurring and when the ear is healed. Otoscopy also allows for direct observation of various procedures that can be performed through the otoscope. These include use of ear loops, ear cleaning, biopsies, intralesional injections, and myringotomy. Successful otoscopy requires adequate equipment. Numerous and various types of otoscopes are available but there are several major requirements for any to be adequate. The otoscope must have a strong light and power source comAnimal Dermatology Clinic and Animal Allergy Specialists, San Diego, CA. Address reprint requests to Craig E. Grifn, DVM, Dipl. ACVD, Animal Dermatology Clinic, 5610 Kearny Mesa Rd., San Diego, CA 92111. E-mail: skinvet44@aol.com

bined with at least 10 magnication. The depth of eld should allow clear focus within the normal length of the ear canal through otoscope cones designed for dogs and cats. If any of these components is not present otoscopic examinations may not be totally effective. Successful management of chronic otitis cases requires at least one otoscope that is powered directly from an electrical outlet with a strong bulb or light source. This otoscope should be available when procedures are going to be performed in or near the tympanum or middle ear. The rechargeable battery, portable hand held otoscopes are sufcient for examining relatively normal ears but are inadequate for most cases with chronic otitis especially if there is pathology of the tympanum or middle ear. Most otoscopes sold to veterinarians were originally designed for human medicine, where there are 2 main types of otoscope heads the diagnostic or medical and the surgical head. They differ in the size of the magnifying lens that one looks through as well as the shape of the cone holders (Fig. 1A-C). Additionally the diagnostic head can be made relatively airtight so a puff of air with a rubber bulb attached to the nipple of the otoscope head may be sent to the tympanic membrane. This technique called pneumotoscopy is used to create and observe movement of the tympanic membrane, which implies the tympanum is intact. This is rarely done in veterinary medicine and has not been shown to be accurate in the determination of a ruptured tympanum.2 The surgical otoscope head is designed so that there is space between the magnifying eyepiece and the cone holder. It is also advantageous for the eyepiece and cone holder to be rotateable (Fig. 1C). These features allow instruments to be placed down the cone and into the ear while visualizing the ear canal. The ability to rotate the cone holder and eyepiece allows greater manipulation and angulation of instruments or tubes passed through the cone down the ear canal. Otoscope cones of various sizes, including 4 mm and 5 mm, are needed to be able to examine the different size and breeds of dogs and cats

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1096-2867/06/$-see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.ctsap.2006.05.002

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Figure 1 (A) The photo shows diagnostic otoscope head from a lateral view showing how the cone holder is solid back to the eyepiece. (B) Shows the rear view with the eyepiece moved to open the otoscope so that a tube or instrument could be passed down into the cone. (C) Shows a surgical otoscope head that is open from the eyepiece to the cone holder. The rear view shows how the cone holder and eyepiece can be rotated in opposite directions allowing easier passage of tubes or instruments while still being visualized. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

seen in practice. Reusable plastic otoscope cones should be cleaned then soaked at least ten minutes in an acceptable disinfectant. A study showed mechanical cleaning and wiping with alcohol or disinfectant is not sufcient to remove potential pathogens.3 The advent of beroptics, superior light sources, and miniaturization of video cameras has recently been combined with a rigid endoscope designed for use in the external ear canal of dogs and cats, the video otoscope (Fig. 2A,B) This otoscope incorporates ber optics and a lens in the otoscope along with a channel that small instruments or tubes can be passed through, the opening to the channel can be attached to a dual port adapter so uid can be infused or suction applied just by switching the adapter. This equipment is connected to a video monitor and possibly printer, video, or digital recorder which allows production of permanent records and the ability to show clients changes found on examination and procedures performed in the ear. The combination of this equipment has resulted in what may be termed beroptic video enhanced otoscopy, FOVEO. The two companies that pioneered the development of these

products for veterinary medicine are Karl Storz (Tuttlingen, Germany) and MedRx (Largo, FL). The ber optic tip with camera also magnies greater and some units allow you to zoom in and manually focus for even better viewing. Besides improving visualization it allows closer observation and more precise use of the working end of instruments passed through the videoscope head. Videoscope heads allow visualization even when used with water or saline that can be simultaneously ushed through it and this is not possible with the standard otoscope. The use of water or saline will improve magnication, prevent fogging of the lens and help to dilate the canal, all of which further improve visualization. In some cases small tears of the tympanic membrane not readily seen with the normal 10 magnied otoscope will be apparent (Fig. 3). Water or saline used in the ear with normal otoscopes prevent visualization. Photographs may be taken and used to document changes as well as for client education. Many clients shown photos of a normal ear and then what their pets ear looks like are more receptive to have anesthesia, cleaning of the ear canal, and follow-up examinations to see the progress made. This equipment is relatively expensive

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Figure 2 (A) This is a otoscope with a dual port adapter attached. (B) The same otoscope with a videocamera attached and together this is the full size of the otovideoscope. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

Figure 3 This photo shows a small tear in pars tensa of tympanic membrane detected by otovideocamera that was not readily apparent on routine otoscopy. Note the appearance of the abnormal tympanum that occupies the rest of the photo above the tear. This abnormal tympanum looks like impacted debris that may build up when there is lumen stenosis and failure of normal epithelial migration. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

but considering the improved diagnostics and more importantly the client education and effect on gaining client support for recommended procedures is well worth the investment in a busy practice. The goal of otoscopy is to visualize the complete ear canal, amount of ear wax and cerumen, and tympanic membrane. The skin and adnexa are constantly producing exfoliating corneocytes, intercellular material, and glandular secretions. This material forms the earwax and cerumen that is believed to play some protective role. The cerumen is constantly being produced throughout the ear canal. Were this material to build up blockage could result, but this is prevented as the ear has a normal clearing mechanism. The material produced in the ear canal is cleaned or cleared out by the movement of the epidermis.4 The surface of the skin lining the ear canal is constantly moving from the tympanic membrane laterally to the external orice of the ear canal. With repetitive examinations it is possible to determine if normal self cleaning is occurring and this is important because some cases of chronic otitis continue to recur because self cleaning is not occurring. The examination has to be done when the ear has not recently been cleaned by the owner or groomer.

Basic External Ear Canal Anatomy

The external ear is formed from 2 pieces of cartilage and a boney canal, the external acoustic meatus (Fig. 4). These structures are lined with skin that normally is a relatively

Figure 4 This lateral view of a dog skull shows the boney external acoustic meatus that the ear loop is passed through. The tip of the ear loop is just over the inner ring of the meatus and the metal pin seen on the inner aspect is inside the middle ear cavity and would be medial to the normal location of the tympanic membrane. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

Otitis techniques to improve practice

99 one must proceed to allow access into the horizontal canal (Fig. 5A,B). The smaller second cartilage is the annular cartilage surrounding the distal portion the horizontal canal and extends between the auricular cartilage and the external portion of the bone of the external acoustic meatus. The external acoustic meatus then is the bone that lines the last portion of the horizontal canal terminating at the tympanic membrane. The medial distal end of the external acoustic meatus is a ring of bone where the tympanum attaches and separates the external ear canal from the middle ear cavity. The tympanic membrane is an epithelial structure that separates the external ear laterally from the middle ear cavity located medially (Fig. 6A,B). The tympanic membrane of the dog is made up of the pars tensa and pars accida. The majority of what is seen of the tympanum when it is examined through the otoscope

Figure 5 (A) The ridge that can block access to the deep vertical then horizontal canal is shown in its normal position. (B) This gure shows the ridge after the pinna has been pulled up then lateral and ventral to straighten the ridge of cartilage and allow access of the horizontal canal. Note how there is accumulation of ear cerumen and debris but the lining of the canal is smooth. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

smooth surface and similar to most body regions has a thin epidermis and dermis that contains adnexa (hair follicles, sebaceous, and apocrine glands) (Fig. 5B). The larger lateral cartilage portion, auricular cartilage, forms the pinna and most of the ear canal. The external ear canal is variable in length (5-11 cm) and classically divided into the vertical and horizontal portions. The vertical portion originates from the pinnae and extends in a rostral ventral direction before bending medially and continuing until it reaches the tympanic membrane. The area from the bend extending medially is the horizontal ear canal. There is a prominent cartilaginous ridge that separates the vertical from the horizontal canal in the dog. Its prominence varies between breeds and between individuals within breeds. It creates the corner around which

Figure 6 (A) This is a videoscope close up photo of a normal tympanum. Note the manubrium of the malleus and the stria on the translucent pars tensa. (B) Another normal tympanum in an atopic dog with a dilated pars accida because of increased air pressure in the middle ear cavity. The pars accida is dorsal to the manubrium and in this case bulging lateral into the canal lumen. Note the prominent vasculature of the pars accida. Also note the hair at the bottom of the canal coming from the fold where the canal epithelium and pars tensa meet. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

100 is the large pars tensa. A normal pars tensa is translucent, with striations seen extending from the manubrium of the malleus outward to the periphery (Fig. 6A). A whitish appearing discoloration can sometimes be seen through the lower to mid section of the tympanum. This whitish structure is the bony ridge that separates the tympanic cavity from the tympanic bulla. The manubrium of the malleus is C shaped with the open end of the C pointing toward the nose. It is located over the anterior medial aspect of the tympanum and is an important reference point when doing palpation and myringotomy. The pars accida is a small area of the dorsal aspect of the tympanum, above the manubrium of the malleus. It is relatively accid and quite vascular. This structure may bulge out, almost looking cyst like (Fig. 6B). Dr Rosychuck has speculated that this may be a product of increased air pressure within the middle ear, most commonly seen in dogs who are shaking their heads (eg, allergic). The out pouching can also be lled with uid if the middle ear is uid lled. Once perforated, this structure tends to heal very quickly. The tympanum is oriented at about a 30 to 45 degree angle from perpendicular (dorsal to ventral). The ventral portion of the tympanum creates a fold or groove where it connects to the ventral oor of the horizontal canal over the bone of the acoustic meatus. This area often has several hairs and is an area where small amounts of wax are noted to accumulate in normal dogs (Fig. 6B).

C.E. Grifn
horizontal position. The movement is best accomplished when the pinna, which is being pulled up and partly out, is pulled further out then down as the tip of the cone goes below the ridge and into the vertical canal. The two processes of moving the cone and the pinna happen simultaneously. Proper placement at the junction often allows visualization into the horizontal canal and if necessary advancement into the horizontal canal. Deep penetration into the horizontal canal is only done if necessary to visualize the tympanum. One problem often encountered in practice is the extremely painful ulcerated swollen ear that one cannot adequately examine. Even with sedation some of these cases may not be adequately examined. It may be necessary to treat the animal and reduce the swelling and inammation and have the patient return in 4 to 7 days so that an otoscopic examination can be properly performed. Any tear in the tympanum indicates otitis media is likely present. A major problem is that in otitis, especially chronic cases the appearance of the tympanum or its location may change. Often the diseased tympanum becomes opaque and may appear white or have shades of yellow brown and look just like impacted cerumen, epithelial and inammatory debris (Fig. 3). In other cases the proliferative changes that are present make visualization of the distal horizontal canal minimal or impossible. The medial wall of the tympanic bulla may be interpreted as a diseased but intact tympanic membrane. Even following lavage of the ear canal a satisfactory view of the tympanic membrane could only be obtained in 28% of the cases otoscopically examined while the pet was anesthetized.1 Diagnosis of intact tympanic membrane cannot be relied on by otoscopic examination only. Therefore, other techniques such as ear loops and tube palpation, discussed below, are used to assess the tympanum and middle ear.

The Proper Otoscopic Technique

The technique for doing proper otoscopic examination is one that allows complete as visualization as possible with minimal pain or trauma. Inammation may make it difcult to complete an otoscopic examination without sedation though in many dogs or cats poor technique will also prevent a complete examination. Otoscopy is a learned skill though there are general guidelines that can improve results. If bilateral disease is present the good ear should be examined rst. This will decrease the possibility of the dog becoming painful and resisting examination of the second ear. Examining the good ear rst allows comparison of normal compared with abnormal. A different clean cone should be used for each ear. The head has to be at a height that will allow the examination to be completed throughout the range of motion of the otoscope to the horizontal position. It may also be necessary to have someone else hold the dog or cats muzzle as the natural tendency is for the head to be tilted as the examination starts. This movement may result in more pain or inability to visualize the horizontal canal. The pinna should be pulled up and out from the base of the skull, which helps to straighten the ear canal and minimize the blocking of the lumen by the cartilage fold that occurs near the junction of the vertical and horizontal canal. This cartilage fold varies in size. The tip of the otoscope cone is passed down the lumen of the ear canal while the operator is visualizing the canal through the otoscope cone. Attempting to insert the cone without visualization is a sure way to hit the canal epithelium, which can be painful even in a normal ear. The cone is then moved slowly into the vertical canal, visualizing as you go, then the otoscope handle is rotated downward so the cone approaches a

Sample Collections
Ear samples are routinely collected from abnormal ears for cytologic examination and sometimes for culture and sensitivity testing. It has been recommended to use cotton tip applicators or the tip of otoscope cones to collect samples. These samples will usually just reect the exudate in the vertical ear canal and are not effective in sampling the middle ear. In some cases what is present in the deep horizontal canal or the middle ear may differ from that in the vertical canal or even the horizontal canal from middle ear.5-7 The samples should represent the predominant exudate from the skin of the deep ear canal or the middle ear cavity. A good method for collecting samples from the deeper ear is to use an ear loop to scrape the deep canal wall. This may require a sedated patient in inamed painful ears. When a ruptured tympanum is present then attempts to sample the middle ear with the ear loop or tube. The soft tube is more readily placed into the middle ear with less risk for trauma to middle ear structures. The soft feeding tube is sometimes even tolerated in awake animals, even with painful ears. When done without visualization, which is simpler, the exact location the sample came from can not be determined. The tube technique utilizes a 5 French Sovereign Feeding Tube and Urethral Catheter (Monoject Division of Sherwood Medical, St. Louis, MO) that has been cut to about 16 cm with the large end cut so that it

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Figure 7 Sovereign feeding tube and urethral catheter that when appropriately trimmed can be used to clean ears, palpate the tympanum, and ush the horizontal ear canal and middle ear cavity when the tympanum is ruptured. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

ts tightly over a syringe hub (Fig. 7). The tube with syringe attached is passed down the ear canal until it reaches the bottom of the ear, at this point the syringe is used to try and aspirate some of the debris into the tip of the tube. The tube is removed disconnected from the syringe, which then is lled with air, then attached again to the tube and the material in the tip of the tube can be expressed. When otitis media is suspected and the tympanum intact then a myringotomy may be necessary. When it is felt that the tube tip must be sterile until it reaches the deep canal or middle ear then a larger tube can be placed around it and passed down the canal almost to the middle ear. At that point the smaller tube can be advanced forward then material aspirated into the smaller tube.

Figure 8 This photo of the middle ear cavity shows a tomcat catheter pointing at the round window and the surrounding promontorium. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

teriorly and medially by the round window. The dorso-medial surface of this is primarily made up of the barrel shaped, cochlear promontory. The promontory is situated opposite to about the mid dorsal aspect of the tympanum. At the caudal end of the promontory is the cochlear (round) window that communicates with the bony labarynthe of the cochlea (Fig. 8). This is the structure one must avoid when

Myringotomy
Myringotomy is generally performed when there is strong suspicion of otitis media, but the tympanum is intact. Most cases where a myringotomy is performed are those with evidence of debris within the middle ear (ie, based on radiographs/computed tomography or magnetic resonance imaging) and they have not responded or continue to recur with appropriate systemic therapy and tube deep cleaning or ushing of the ear. In most of these cases, the tympanum had been perforated but has re-healed. Retrograde infections moving up the auditory canal (Eustachian tube) may also explain the nding of an intact tympanum overlying an active otitis media. A syndrome in Cavalier King Charles spaniels will also present with otitis media and an intact tympanum and lack of otitis externa.8 Before performing myringotomy it is important to learn certain anatomical features of the tympanum and middle ear. The middle ear consists of the tympanic cavity and walls, medial wall of the tympanic membrane, the auditory ossicles and associated ligaments, muscles and nerves, and the auditory tube. The tympanic cavity is divided into three parts: dorsal, middle, and ventral. The dorsal, also called epitympanic recess, is the smallest and contains the head of the malleus, incus and stapes. The stapes attaches to the oval (vestibular) window leading to the inner ear. The middle part, also called tympanic cavity proper, is adjacent to the tympanic membrane that lies anterior and laterally and pos-

Figure 9 Photo of a dog skull looking into the middle ear through an opening in the ventral bullae. You can see the ear loop going into the external acoustic meatus on the left side of the photo. The tip of the ear loop is in the round window of the promontorium. Note the ridge that separates the middle portion of the middle ear cavity from the ventral portion, the tympanic bulla. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

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to (Fig. 6B). When using these instruments the tip should always be visualized, best done through a surgical otoscope head. Visualization through an otoscope is limited to one eye and looses accurate assessment of depth perception. Realizing where the tip is in the canal is facilitated by passing the loop down the ear canal while the tip is touching the canal wall (Fig. 12). Once the tip is next to some debris it can be rolled over into the wax and debris and then pulled back out of the ear canal. Pressure against the ventral aspect of the canal also is helpful in determining the location within the ear canal and for acquiring samples from the epithelium and not just the lumen of the canal. The horizontal canal within the auricular and annular cartilage will have some exibility and slightly move and can be pushed away when pressure is applied with the ear curettes. Approximately, the last centimeter of the horizontal canal, just before the tympanum is within the boney external acoustic meatus and pressure will result in no exibility or movement (Fig. 4). Care must be taken here as the metal ear loops and curettes may rupture the tympanum if pushed against it. The angled buck curette has the advantage that it allows better feel for detecting the inner ring of the external acoustic meatus. If the tip of the curette is able to be passed over the inner ring then the tympanum is not in its normal anatomic position or has been ruptured (Fig. 9). In some chronic cases where the tympanum has been destroyed or pushed back into the middle ear cavity by the build up of cerumen, keratin and inammatory debris the ear loop is useful for breaking this material up so it can be ushed out. Once removed the back of the middle ear near the promontorium or the ridge of bone in the upper ventral bulla may be felt with the tip of the curette.

Figure 10 This photo of the tympanum shows a tomcat catheter pointing toward the ventral caudal quadrant, the optimum site where a myringotomy should be performed. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

doing a myringotomy. The ventral portion is the tympanic bulla and is the largest portion and safest area to pass tubes and instruments into. It is separated dorsally from the tympanic cavity by a bony ridge (Fig. 9A,B). The promontorium and round window is just dorsal to this ridge that is also responsible for making passing tubes into the ventral bullae very difcult. Before performing myringotomy, the horizontal canal should be thoroughly cleaned. The site for performing the myringotomy is at 6 to 7 oclock, over the ventral most part of the tympanum (Fig. 10). My favorite instrument is a 22 gauge, 6 inch spinal needle (Mila International, Inc., Florence, KY) attached to a 3 cc syringe containing one cc of saline. Others have used tomcat catheters or polypropylene catheters with the end cut to a beveled point. Once the needle has been passed through the operating head of an otoscope into the middle ear, an assistant infuses the 1 mL of saline into the bulla and then re-aspirates it. The sample is transferred to a urine or blood tube then spun down in a centrifuge. The supernatant may be removed then the sample used to make cytological preparations or for culture and sensitivity. If an otitis media is encountered, a larger hole can be created to facilitate more thorough ushing (ie, passing catheter in to the middle ear). Medication (eg, enrooxacin) may be infused in to the middle ear if necessary.

Tube Palpation
Using a tube to palpate what may be a tympanic membrane or the distal horizontal canal is another method to help determine if there is an abnormal tympanic membrane, either integrity, or location. This can be done through the surgical

Ear Loops
Ear loops or curettes are also valuable tools that are helpful for cleaning material from the ear canal, acquiring samples for deep ear canals and assessing the state of the tympanic membrane. There are several types available but my two favorites are Buck ear curettes and Billeau ear loops (Fig. 11). They are effective for breaking up debris that is clumped in the deep ear canal or adhered to the canal wall. This is most often encountered near the level of the tympanum where there often are some hairs present that the debris likes to stick

Figure 11 (A) The tip of the angled Buck ear curette, (B) the straight Buck ear curette, and (C) a Billeau ear loop. (Reprinted with permission from Craig E. Grifn Photos.) (Color version of gure is available online.)

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Figure 12 (A) Drawing of ear loop in surgical otoscope cone that is placed down the vertical ear canal with the tip touching the skin of the horizontal canal wall. (B) The ear canal has been straightened and now the top of the ear loop is seen over the inner ring of the boney external acoustic meatus. This means the tympanum is dilated or ruptured as this site is medial to the normal location of the insertion of the ventral pars tensa on the lower portion of the inner ring of the external acoustic meatus. (Color version of gure is available online.)

otoscope head but is even more valuable when done through the video otoscope with a 5 French tube. A soft tube is trimmed as described in sample collection previously and passed to the medial aspect of the horizontal canal. In normal dog and cat ears the tip of the tube can always be visualized. If the tube tip goes to a point where it can not be seen that indicates pathology. This may occur when the tip has entered the middle ear cavity, moved into the space created when the

tympanum has been dilated and stretched so it now is within the middle ear cavity (false middle ear), has penetrated debris, or has proceeded behind proliferative tissue. Depending on the depth one has gone and what is visualized while doing the procedure one can determine more about the tympanum than by visualization alone. The normal tympanum and often abnormal tympanum will respond to the pressure of the tip by slightly moving medially and retracting when the pressure is removed. In contrast impacted debris will stop the tube but usually after the tip has penetrated into it, even if slightly. At this point infusion of saline or water will often break up some debris. The normal and even abnormal tympanum will rarely rupture from palpation with the 5 French tube described. A tympanum may respond with mild hemorrhage that when it occurs will often follow the stria if the pars tensa has been palpated (Fig. 13). Hemorrhage in the medial wall will not have this stria pattern. Practice in normal dogs allows one to develop a feel for the normal depth. Passing a tube even 0.5 to 1 cm. further indicates either otitis media or false middle ear.

Treatment Tubes
Topical agents must reach the site to be treated and in many cases even cleaning will not facilitate adequate application of topical agents. In some cases there is so much proliferative tissue that it alone blocks adequate delivery of topical agents. In other cases the patient may just be too difcult to medicate. In these situations another option is to sew in a soft rubber feeding tube (Sovereign feeding tube and urethral catheter, 5 French) down into the ear canal. The tip can be placed in the deep horizontal canal and then the tube is sewn to the skin of the external orice. The tube is placed in the canal outside of the otoscope cone that may be used to visualize the placement. Once the desired depth is reached the tube should be marked at the point of exit from the ear so if movement occurs when the

Figure 13 This digital enhanced close up shows the hemorrhage that was induced by palpation with the orange feeding tube seen in the upper right side of the photo. Note how the hemorrhage follows the stria of the pars tensa. (Reprinted with permission from Craig E. Grifn Photos.)

104 otoscope cone is removed the tube can be replaced without the need for visualization. One or two sutures are placed as deep into the vertical canal as possible and tied around the tube. A Chinese nger trap stitch is used in 1 or 2 sites just before the tube leaving the intertragal incisure or in some cases the tube may be brought out anterior to the tragus. Once leaving the external orice the tube is then sewn to the head and neck. The large end of the tube is trimmed so that a syringe hub can be put into it. An Elizabethan collar can be placed with the tip extending beyond the collar for dogs that are difcult to medicate. A dose of medication is usually 0.5 to 1 mL. This is injected into the tube and followed by some air to make sure all the medication is delivered into the ear and not left in the tube. Limit the air to just the amount that rst causes bubbling and inject gently.

C.E. Grifn

Intraotic Intralesional Injections

Severe proliferative otitis is an indication for surgery, usually a total ear canal ablation with bulla osteotomy. Many clients wish to avoid surgery so medical therapy is often attempted. The initial medical therapy of proliferative tissue causing moderate to severe stenosis of the canal lumen is systemic antimicrobial therapy for pathogens identied by cytology and possible culture and sensitivity testing. In addition potent topical glucocorticoids and systemic glucocorticoid therapy is utilized. Intra otic intralesional glucocorticoid therapy is indicated when medical therapy for 2 to 4 weeks has been totally ineffective or fails to reduce the proliferative tissue to a mild to moderate degree and clients still elects to avoid surgery. Often the decision to avoid surgery is partly based on the dog still having reasonable good hearing that may be lost with the surgical procedure. Triamcinolone acetonide is particularly effective for inhibiting broblasts and reducing collagen and anecdotally has been effective in some cases of inammatory polyps and glandular hyperplasia. It appears this is at least partially because of the local effect of the triamcinolone as some cases will only show a reduction in the proliferative tissue in the part of the canal treated. As the canal opens up then the more distal canal becomes accessible and the second treatment reduced the proliferative tissue in that area. The technique utilizes 22 gauge, 10 to 15 cm long spinal needles or long exible injection aspiration needle (Karl Storrs) The Teon coated needle results in less hemorrhage and is preferred if the injections are done through the video otoscope. A 3 mL syringe with triamcinolone acetonide injectable solution is attached to the needle. The ear canal has been ushed and cleaned before the injections. The otoscope cone attached to a surgical otoscope head is passed as far as possible into the vertical or horizontal canal. This is determined by the severity of the stenosis and rmness of the proliferative tissue. The needle is then inserted into the proliferative tissue trying to locate the tip of the needle into the dermis, medial to the cartilage (Fig. 14A,B). It is recommended that the needle be attached to a leur-locked syringe to prevent expulsion of the syringe from the needle due to the pressure that is often needed to perform the injections into the proliferative tissue. An injection of 0.05 to 0.1 mL triamcinolone acetonide is given then the needle removed and

Figure 14 (A) Drawing demonstrating how intralesional injections are done with a syringe and needle through a surgical otoscope head. The needle is placed in the proliferative tissue of the ear canal. (B) A diagram of a cross section of a proliferative ear canal and lumen. The needle is inserted into one area of proliferative tissue and the two X marks where the second and third injections would be given. (Color version of gure is available online.)

passed about 120 to 180 degrees around the lumen of the canal at that same level. When there is complete stenosis and tissue blocking the opening of the cone three injections are made at 120 degree intervals. If the proliferative response is less then the more prominent folds are injected and sometimes only 2 injections are made at that level. In effect then three injections (a ring of injections) are given at each depth of the canal that is treated. In some cases hemorrhage from the injections site will block visualization of the canal and repetitive ushing is needed until the canal can again be visualized. Flushing may be needed between each injection or at each level of a set of injections. The cone is then withdrawn 1 cm to 2 cm and another set of injections are made.

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This continues until the cone has been withdrawn to the level of no stenosis or the external orice of the canal is reached. A recheck examination is scheduled for 1 to 2 weeks postinjections. If the canal is opening but the distal part is still occluded or if after 2 weeks there is a good but incomplete response a second set of injections may be given. In rare cases this has been done 3 times. If there is no response to the rst set of injections then the prognosis is grave for resolution of the proliferative tissue without surgery.

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cone cleaning and disinfection procedures commonly used in veterinary medical practices: A pilot study. Vet Derm 17:147-150, 2006 Johnson A, Hawke M: An ink impregnation study of the migratory skin in the external auditory canal of the guinea-pig. Acta Otolaryngol 101: 269-277, 1986 Cole LK, Kwochka KW, Kowalski JJ, et al: Microbial ora and antimicrobial susceptibility patterns of isolated pathogens from the horizontal ear canal and middle ear in dogs with otitis media. J Am Vet Med Assoc 212:534-538, 1998 Cole L, Kwochka K, Hillier A, et al: Comparison of bacterial organisms from otic exudate and ear tissue from the middle ear of untreated and enrooxacin-treated dogs with chronic end-stage otitis. Vet Dermatol 15:9, 2004 Cole LK, Kwochka KW, Hillier A, et al: Comparison of bacterial organisms and their susceptibility patterns from otic exudate and ear tissue from the vertical ear canal of dogs undergoing a total ear canal ablation. Vet Ther 6:252-259, 2005 Stern-Bertholtz W, Sjostrom L, Hakanson N: Primary secretory otitis media in the cavalier King Charles spaniel: A review of 61 cases. J Small Anim Pract 44:253-256, 2003

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References
1. Little CJ, Lane JG: An evaluation of tympanometry, otoscopy and palpation for assessment of the canine tympanic membrane. Vet Rec 124:5-8, 1989 2. Cole L, Kwochka K, Podell M, et al: Radiography, otoscopy, pneumotoscopy, impedience audiometry, and endoscopy for the diagnosis of otitis media in the dog. Vet Dermatol 11(suppl 1):3:4, 2000 3. Newton HM, Rosenkrantz WS, Muse R, et al: Evaluation of otoscope 7.

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