Geriatric Otology by Steven A Melman, VMD, DermaPet and the Animal Dermatology Clinic Ear diseases in older dogs and cats are frequently chronic in nature. Their treatment and development often results in diminished hearing capacity. Management of chronic ear diseases requires definitive diagnosis and control of the numerous underlying causes and perpetuating factors. Cleaning the external ear canal and middle ear cavity along with the use of oral antimicrobials, oral corticosteroids, topical antimicrobials, and topical corticosteroids may be necessary in the treatment of ear diseases (see Table 14-1). Otitis externa involves inflammation and/or infection of the outer ear where the tympanic membrane is present. Otitis media involves inflammation and infection of the middle near where frequently the tympanic membrane is ruptured. In many cases, lifelong ear cleaning and drying agents may be required to prevent relapse of ear diseases. Diseases of Pinna Lesions of the pinna may be extension of more generalized skin diseases and can be bacterial, fungal, parasitic, immune-mediated, or vascular (drug-induced) in origin (Roth, 1988). Bacterial and yeast folliculitis of the pinna with focal areas of alopecia occurs in dogs, and dermatophytosis of the pinna with focal alopecia and extensive crust formation can be found in cats. Parasitic pruritus and crusting of the margins of the pinna can be caused by Sarcoptes mites in dogs and Notoedres mites in cats. Trauma Trauma to the pinna can occur at any age. A tear in the pinna is usually the result of a fight with another dog or cat. The resulting bleeding may be impressive, and the placement of several sutures is often curative. A small, fresh tear (up to 1 cm in length) can be sutured after cleaning and removal of some of the hair. The skin on the concave side of the pinna is apposed and sutured with interrupted sutures, starting at the edge of the pinna. Then the skin on the convex side is apposed and sutured in the same way. The cartilage is not included in these sutures. Bleeding stops during suturing but a resistant artery may have to be ligated separately. In all cases, the wound should be considered contaminated, and a short period of systemic antimicrobial treatment is indicated. When the wound is not fresh and inflammation is apparent, the surgical correction is postponed and the inflammation is treated first. Surgical correction then begins with refreshening of the wound edges. Aural hematoma Aural hematomas occur at all ages. The bleeding occurs between the cartilaginous layers of the pinna and usually results from trauma, such as shaking the head or scratching the ear as a result of hypersensitivity. Other causes include immune mediated, clotting defects and hormonal imbalances. Surgical intervention is necessary, because without treatment, the pinna will shrivel, and subsequent ossification of the cartilage will cause continuous irritation. In addition, shriveling of the pinna may cause obstruction of the external ear canal and thus induce chronic otitis externa. Surgery allows for removal the blood clots and presses the layers of the pinna together long enough to effectuate reunion of the layers. A reliable surgical method consists of suturing through all layers of the pinna, placing sutures over the entire surface of the pinna. Abscesses In cats, abscesses of the pinna are usually caused by a penetrating wound inflicted by the claw of another cat. The skin over the abscess should be opened and the suppurative material removed by gentle compression, followed by flushing with copious amounts of sterile saline solution. A systemic antimicrobial agent should be administered for 10 to 14 days. In some older cats, both pinnae are shriveled because of multiple abscesses. The shriveled pinna can cause occlusion of the external ear canal and continuous otitis externa may be the result. Ossification of the pinna usually causes continuous irritation to the cat and amputation of the pinna results in remarkable relief. Abscesses of the pinna are uncommon in dogs but they are treated in the same way as in cats. The healing of the pinna can be slow and painful, and hence an analgesic agent should be given in addition to antimicrobial therapy. In addition, in the dog a shriveled pinna can cause considerable irritation and chronic otitis externa. When there are also complications in the external ear canal, such as ossification of the cartilage or chronic proliferation of the skin, removal of the pinna and the ear canal in one procedure can be the preferred long-term solution (Venker-van Haagen, 1989). This surgery may seem radical but there is no reason to exclude older dogs from radical surgery when the alternative is continuous distress and pain. Tumors of pinna Tumors of the pinna occur at all ages in dogs and cats. Tumors in dogs may include squamous cell carcinomas, basal cell tumors, lymphomas, histiocytomas, mast cell tumors, sebaceous gland adenomas, fibromas, and hemangiopericytoma (Van der Gaag, 1986). Squamous cell tumors are most commonly seen in white dogs and cats. Dog breeds most frequently represented in histiocytomas are retrievers and boxers, mast cell tumors are boxers and Rottweilers, and sebaceous gland adenomas are cocker spaniels. Squamous cell and histiocytomas can be removed by partial resection of the pinna. Amputation of the pinna may be necessary to prevent further extension of the tumor and potential metastasis. Mast cell tumors should be excised with a wide margin of surrounding tissue. The pinna and the external ear canal may have to be removed together. Squamous cell carcinoma is the most common tumor affecting the pinna in the cat (Roth, 1990). Older white cats seem to be especially susceptible to the development of squamous cell carcinoma, but it does occur in any colored cat. Squamous cell carcinomas first appear as a nonhealing granulomatous inflammation at the edge of the pinna and are often misdiagnosed as an inflammatory lesion. As the squamous cell carcinoma grows, hemorrhage from the lesion at the edge of the pinna becomes a frequent nuisance. Cytologic examination of material collected by fine needle aspiration biopsy or histopathologic examination of surgical biopsy material will confirm the diagnosis. Unilateral or bilateral amputation of the pinna is an effective therapy, especially since metastasis seldom occurs in an early stage. Unilateral or bilateral pinna amputation will change the appearance of the animal considerably so the owner needs to be informed of such changes prior to surgery. The surgical removal of the pinna in the cat and dog are similar, but along the base of the dog's pinna on the convex side the skin is incised and the individual arteries and veins are freed and ligated separately for effective hemorrhage control. After hemorrhage is controlled, the pinna is then removed by cutting the cartilage and the skin on the concave side and the skin edges are closed using standard suturing techniques. Diseases of External and Middle Ear Dogs and cats with recurrent otitis externa should always be evaluated for co-existing otitis media. This often requires sedation or general anesthesia to properly evaluate the external ear canal and middle ear cavity. The optimal indicator of otitis media is a ruptured tympanum. In cases where the TM is intact, a myringotomy is required. Magnetic resonance imaging or computer tomography may also be used to diagnose otitis media (Cole et al, 2000). Sudden onset of peripheral vestibular syndrome or deafness may occur after any otic flushing or dental cleaning procedure in older dogs and cats, especially when ototoxic drugs are utilized. Hearing return may take longer, if ever, when using ototoxic agents such as chlorhexidine or be more transient as when using alcohol. (Mansfield, ) Ear Evaluation The preferred method for flushing the external ear canal and middle ear cavity when the tympanic membrane is ruptured should utilize fiberoptic video-enhanced endoscopy (Cole et al, 2000). This method ensures good visualization of the ear structures and safe flushing procedure being the more delicate structures are located in the middle and dorsal areas of the middle ear cavity. Use of the myringotomy allows the examiner to collect samples directly from the middle ear cavity and, therefore, is the practical method of diagnosing an otitis media where the tympanic membrane is intact in the presence of chronic ear problems. After the myringotomy, the middle ear cavity is flushed with about 200 to 300 ml of tepid sterile saline solution followed by a solution of tris-EDTA (TrizEDTA, DermaPet, Potomac, Maryland) then packed with 22-100 mg of flouroquinolones (Baytril, Bayer, St Josephs, Missouri) and 2-6 mg of dexamethasone sodium phosphate. A serous, slightly sanguineous discharge may be observed for a few days after myringotomy. Postoperative analgesic agents can be used for at least 2 to 3 days.. Insidious damage to the facial nerve can develop because of the existing otitis media or when cleaning, medicating, or performing diagnostic procedures in an ear with a ruptured tympanic membrane. The author does not do standard culture and sensiitivity testing unless there is a treatment failure. Some experts believe a primary indication for performing standard bacterial culture and sensitivity testing is in dogs and cats diagnosed with severe proliferative otitis with bacterial rods where systemic antimicrobial therapy is indicated and management of otitis media is needed (Cole et al, 1998). Cytologic examination in these cases usually shows numerous leukocytes in stained otic smears. Because multiple potentially pathogenic organisms may be cultured, it is important to combine the cytologic examination with bacterial culture results. The bacteria that appear most numerous may be determined and it allows a more appropriate antimicrobial regimen to be chosen. Laboratories that report antimicrobial sensitivities with minimum inhibitory concentration information rather than the standard Kirby-Bauer susceptibility test allow for better determination of systemic antimicrobial dosages (Cole et al, 1998). For example, Pseudomonas organisms may show intermediate or sensitive patterns to enrofloxacin by Kirby-Bauer susceptibility tests but be resistant on the minimum inhibitory concentration tests. Otitis Externa Otitis externa has both primary and secondary causes (Logas, 1994). Primary causes of otitis externa in older dogs other than bacterial, fungal, and yeast infections are hypersensitivity such as atopic dermatitis, food allergy and contact hypersensitivity, and Otodectes infestation. Otitis externa may be the only presenting sign in atopic dogs. Often, dogs with diagnosed food allergy will show their allergic disease with only an otitis externa. Food allergy should be the primary differential consideration in any older dog with an acute onset of otitis externa without previous history of otic disease. Flea allergy does not usually cause just as an otitis externa, but causes total body skin disease. Prophylactic treatment for ear mites is essential to be certain that mites are not a component of otitis externa. Systemic therapy for ear mites is safer and easier with the use of selamectin or various ivermectin products. Secondary causes of otitis externa include topical irritant reactions and Pseudomonas or Malassezia infection. Topical irritant reactions should be considered any time a case of otitis externa fails to respond or worsens with topical therapy. Therapeutic ingredients in ear medications such as propylene glycol (>10%) may induce inflammation in the previously damaged aural epidermis. Treatment of topical irritant reactions consists of discontinuation of topical therapies and limiting topical products to normal saline solution or aqueous-based products. Systemic therapy for topical irritant reactions is preferred. Most Pseudomonas otitis externa are sensitive to polymyxin B, ticarcillin, or enrofloxacin. Polymyxin B is inactivated by purulent debris and must be applied only in clean external ear canals. Malassezia otitis externa is best treated with a non-ototoxic combination of 2% acetic and 2% boric acid (DermaPet Ear/Skin Cleanser aka MalAcetic Otic, DermaPet, Potomac, Maryland) aqueous solution by flushing daily for 7 days. Symptoms including erythema, pain and discharge as well as cytology were reversed in 17 dogs (Gotthelf and Young, 1997). Malassezia otitis media occurs infrequently and is treated with systemic antifungal agents such as ketoconazole (10 mg/kg orally once daily) or itraconazole (10 mg/kg orally once daily). Veterinarians previously have compounded enrofloxacin with a normal saline solution (4 ml of 22.7 mg/ml enrofloxacin with 8 ml to 12 ml of normal saline solution), acetic/boric acid cleanser or trisEDTA (TrizEDTA). Topical enrofloxacin may be effective even when sensitivity testing indicates a resistance because of the increased concentration achieved when applied topically. Silver sulfadiazine (2%) solution is also effective against Pseudomonas.. A formulation of enrofloxacin (5 mg/ml) combined with 1% silver sulfadiazine (Baytril Otic, Bayer) is effective for bacterial and, to a much lesser extent, Malassezia Otitis externa; it has not been proven to be safe or effective in cases where there is a ruptured tympanum.. Acetic acid (2%) is effective against Pseudomonas organisms after 1 minute of contact time. However, 2% acetic/2% boric acids are proven to be synergistic against Pseudomonas.(Benson). Ethylenediaminetetraacetic acid (EDTA) has a direct bactericidal action against Pseudomonas aeruginosa by chelating metal ions important for the integrity of its cell wall, inactivating the efflux pump in gram negative bacteria and inactivating enzymes secreted by Pseudomonas that would otherwise cause ulceration and tissue necrosis. Buffer solutions containing tromethamine (Tris) are used to enhance the effects of EDTA on the Pseudomonas aeruginosa and other gram negative organisms. The EDTA binds to metal ions, which compete with aminoglycosides for cell-wall receptors. (Ashworth). Thus, the combination of aminoglycoside and Tris-EDTA is effective against bacteria causing an otitis externa/media infection, including Staphylococcus intermedius, Proteus mirabilis, Escherichia coli, and Pseudomonas aeruginosa. The Tris-EDTA buffer solution (TrizEDTA, DermaPet, Potomac, Maryland) is less effective at inhibiting gram-positive bacteria than gram-negative bacteria. The optimal pH for the activity of aminoglycosides and Tris-EDTA buffer solution is approximately 8.0 (Wooley); many antibiotics are enhanced at alkaline pH and have diminished efficacy at an acidic pH. It is most effective as it approaches body temperature when it has been demonstrated to irreversibly bind enzymes that would otherwise cause ulceration. TrizEDTA is not considered to be ototoxic. It is not recommended for yeast infections and, therefore, is not likely to be effective against Malassezia. Tris-EDTA buffer solutions are beneficial as long-term therapy for preventing the recurrence of Pseudomonas infection, using them as either part of a regular ear-cleaning regimen or as a presoak before instilling antimicrobial solutions into the external ear canal. Such solutions are typically applied two to three times a week as needed for preventative purposes. Otitis Media Most dogs with chronic otitis externa have concurrent otitis media and accompanied frequently by an intact tympanic membrane (Little et al, 1991). Evidence of inflammation to the tissues surrounding the middle ear cavity, or even the inner ear, indicates that otitis media may be present. The entire tympanic membrane in most older dogs and cats is difficult to completely visualize by using the standard otoscopic evaluation procedure. Even with an intact tympanic membrane, various abnormalities of the middle ear cavity in dogs and cats may be visualized by using fiberoptic video-enhanced endoscopy (Cole et al, 2000). The affected tympanic membrane is nontransparent and usually red or ruptured (Little et al, 1991). The discharge from the middle ear cavity may be mucopurulent in acute inflammation and more dry and white in chronic inflammation. If the tympanic membrane is intact and otitis media is suspected, a myringotomy may be necessary to confirm the otitis media. The tympanic membrane should close within 4 weeks when middle ear disease is cured. Tumors of External Ear Canal Tumors in the external ear canal more often occur in older cats than in older dogs. The tumors in the external ear canal of older dogs may include ceruminal gland adenomas, papillomas, ceruminal gland carcinomas, and squamous cell carcinomas (Van der Gaag, 1986). The tumors in the external ear canal in older cats may include ceruminal gland adenomas, ceruminal gland carcinomas, sebaceous gland adenomas (Fig. 14-2), papillomas, mast cell tumors, and rhabdomyosarcoma (Rogers, 1988). The unilateral or bilateral tumor can be diagnosed by otoscopic examination. Since each tumor damages the external ear canal and causes pain and continuous secondary inflammation, wide surgical excision or application of laser surgery is always indicated. Malignant tumors are especially threatening because they will eventually invade the tissues around the ear canal. Total ablation of the external ear canal is always indicated when a malignant tumor is confirmed and as long as the tumor is still confined within the cartilaginous wall. Loss of Vestibular Function The loss of vestibular function may be caused by middle ear disease, trauma, or ototoxicity in dogs and cats of all ages. Idiopathic vestibular disease commonly occurs in dogs with an average age of onset of 12.5 years (Schunk and Averill, 1983). In cats with signs of peripheral vestibular dysfunction, the seemingly idiopathic vestibular syndrome is most often associated with middle ear disease (Burke et al, 1985). The case history of idiopathic vestibular disease in dogs is characterized by a peracute onset (within hours) of head tilt, incoordination, and nystagmus. The incoordination may be so severe that the dog cannot effectively rise and walk. Vomiting that is secondary to vertigo may be seen during the first 24 to 48 hours. The neurologic examination shows a head tilt, falling and/or rolling toward the head tilt, and horizontal to rotary nystagmus. There may be spontaneous nystagmus and the fast phase of the nystagmus occurring away from the head tilt. The type of nystagmus typically does not change. There often is generalized incoordination and a base wide stance. No cranial nerve deficits will be noted, and there is no weakness or postural test deficits. If these signs are seen, then a brain stem lesion involving the central vestibular system is most likely. If the nystagmus type is vertical, a brain stem lesion is most likely to be present. On the initial day of presentation, the incoordination and disorientation is often too severe to allow for adequate assessment of strength and postural test reactions. It may take 48 hours before any assessment can be used to help separate central vestibular disease from peripheral vestibular disease. Once vestibular signs have been localized to the peripheral vestibular system, the primary differentials are otitis interna and head trauma with resultant fracture of the petrous temporal bone. If facial nerve paralysis and Horner's syndrome are present on the same side of the head tilt, this usually indicates otitis media/interna co-exists. Treatment is supportive care since the peripheral vestibular problem will resolve on its own. The resolution timetable is usually consistent from case to case and if the dog does not follow the timetable, there should be concern that the initial diagnosis was wrong. The nystagmus should disappear within 4 days, the dog should be able to rise and walk fairly well within 7 days, and the dog's gait should be normal by 3 weeks. A few dogs may have a residual head tilt and/or some incoordination after complete recovery when performing quick movements that require agility. Treatments that may be helpful during the first few days include: fluid therapy for maintaining normal hydration, diazepam (5-15 mg three times daily) for sedation if disorientation is severe, meclizine (25 mg orally once daily) for vertigo, and diphenhydramine (4-8 mg/kg orally). These treatments are usually unnecessary after 72 to 96 hours after onset of peripheral vestibular signs. Primary Middle Ear Tumors Primary middle ear tumors are uncommon in dogs and cats (Fiorito, 1986; Indrieri and Taylor, 1984). Tumors are suspected when the external ear canal is narrowed near the osseous external meatus and the otic discharge is hemorrhagic. Clinical signs include pain on the affected side and vestibular dysfunction. Survey radiographs may show densities in and around the tympanic bulla, but these findings do not differentiate between chronic inflammatory disease and tumor. Computer tomography is helpful to detect lesions in the tympanic bulla and the petrosal bone. The destruction caused by the tumor at the time of diagnosis precludes any attempt at surgery. Systemic Antimicrobial Therapy Systemic antimicrobial therapy is indicated for management of severe otitis externa/media, topical irritant reactions, poor response to topical otic therapy, and when severe proliferative otitis externa is present and the owner cannot administer regularly scheduled topical treatments. Antimicrobial agents that are known to penetrate into bone, concentrate within inflammatory cells, and have an excellent success in the treatment of otitis media should be selected and given at doses that are at the high end of the recommended dosage range. Antimicrobial and antifungal agents should be administered for at least 14 days after a complete clinical cure is obtained, often up to 6 tp 12 weeks of therapy are necessary. Examples of systemic antimicrobial agents that are useful for the management of otitis media and proliferative otitis externa are clindamycin 7-10 mg/kg twice daily, sulfadimethoxine-ormetoprim 55 mg/kg for first day and 25 mg/kg once daily on subsequent days, enrofloxacin 5-20 mg/kg once daily, marbofloxin 2.5-5 mg/kg and orbifloxacin 2.5-12.5 mg/kg once daily. In general, fluoroquinolones in dogs are needed at higher doses for Pseudomonas aeruginosa infections such as 10-20 mg/kg enrofloxacin once daily, 5-12.5 mg/kg orbifloxacin once daily, or 5 mg/kg marbofloxacin once daily. Intralesional Therapy Stenosis of the vertical portion of the external ear canal occasionally may be nonresponsive to the administration of systemic corticosteroids. In these cases, intralesional triamcinolone acetonide (4 mg/ml) may be useful in widening the lumen of the vertical portion of the external ear canal. After effective cleaning of the external ear canal, multiple injections of triamcinolone acetonide at 0.1 ml per injection site are made as deep as possible into the proliferative tissue lining in a ring like fashion around the external ear canal. Bacterial Otitis Protocol The following is a protocol for the treatment of bacterial otitis media. 1. Start the antibiotic which cultures sensitive systemically for at least 30-60 days. The author currently prefers fluoroquinolones. 2. Clean with TrizEDTA twice daily. Do not refrigerate as one mechanism of action is to reverse the activity of elastase enzymes which are bound irreversibly at body temperature. 3. Instill topical antibiotics (the author currently prefers Baytril) in either a TrizEDTA gemish (12 ml of TrizEDTA and 50-100 ml of Baytril injectable) or diluted with saline. For first three weeks add 6mg dexamethasone SP (sodium phosphate). 4. For the first 14 days, I would use systemic prednisone at 1-2 mg/kg if OM is diagnosed. The rationale is to decrease the inflammation, mucous secretion from the mucoperiosteum, pain and viscosity of the exudate in the tympanic cavity. 5. If OM is diagnosed, I would anesthetize and with visualization flush the ear with TrizEDTA and directly instill Baytril and NaDex phosphate into the tympanum. If the tympanum is present and OM is suspected then I would do a MYRINGOTOMY. The location of the myringotomy should be ventral. Maintenance therapy would include biweekly TrizEDTA cleansing long-term. Surgical Intervention for Ear Diseases In dogs with recurrent otitis, surgical intervention may be indicated. Such instances may include: Progressive otic changes such as calcification, proliferation, and stenosis of the external ear canal that result in permanent ear canal occlusion and is nonresponsive to intralesional therapy. Otitis media that fails to respond to myringotomy, ear canal flushing, and aggressive medical management. Inadequate response of the recurrent otitis to medical management because of poor owner compliance or the presence of resistant bacterial or fungal agents. Loss of Hearing Loss of hearing in older dogs and cats is well recognized. The cause of hearing loss may be related to a loss of spiral ganglion cells in the cochleas and secondary to hair cell loss (Knowles at al, 1989; Schuknecht et al, 1965). Hearing in older dogs and cats can be tested most effectively by using brain stem auditory evoked responses (Sims, 1988; Venker-van Haagen et al, 1989). The case histories provided by owners of older dogs and cats examined for hearing deficits usually suggest a progressive elevation of the hearing threshold rather than acute total hearing loss. However, hearing loss may be associated with existing otitis media, sudden onset immune-mediated otitis media/interna or ototoxicity. Click to begin.......