Ear Surgery Flashcards
What are different diseases that can affect the pinna
1) Physical injuries
-Aural hematoma
-Wounds of pinna
-Lacerations
2) Neoplasia
What are the different structures of the ear
1) Pinna
2) Vertical ear canal
3) Horizontal canal
4) Middle/Inner ear
5) Osseous bullae
What structures make up the external ear canal
1) Horizontal
2) Vertical
Aural hematomas occur within the
Cartilage clefts of the pinna
What are risk factors for aural hematoma
1) Head shaking
2) Pinna trauma / ear scratching - foreign body, allergies, etc.
3) External ear infection
4) Immune disease
How do you diagnose aural hematoma
Do ear examination. Try to find cause
1) Infection
2) Foreign body
3) Neoplasia
How do you treat aural hematomas
1) Conservative
-Aspiration +/- steroid injection
2) Surgical
-Incision, drainage, suture
-Teat tube or indwelling drain
What are advantages of treating aural hematoma with aspiration and steroid injection
No general anesthesia
Outpatient
No ear disfigurement
What are the disadvantages of treating aural hematoma with aspiration and steroid injection
1) Clots left
2) Recurrence 10-25%
3) Bandage required (head bandages hard to keep in place)
4) Requires multiple injections
Aural hematomas often require multiple steroid injections. What can you use
1) Dexamethasone (0.2-0.4mg in saline every 24 for 1-5 days
2) Methylprednisolone 0.5 to 1.0ml every 7 days for 1-3 weeks
3) Triamcinolone 0.1 to 1.0ml every 7 days for 1-3 weeks
If treating aural hematomas with aspiration and steroid injection, what is the recurrence
10-25%
How is surgical treatment of aural hematoma performed
1) S-shaped incision on concave surface
2) Massage and Lavage to remove clots
3) Multiple staggered rows of full thickness- mattresses
4) Monofilament non-absorbable suture
5) Knots on the concave side
T/F: aural hematoma surgery requires general anesthesia
True
Incisions for aural hematomas are made on what surface of the pinna
the concave surface
do a linear incision: parallel to the blood supply (S-shaped incision)
When surgically fixing an aural hematoma, how should you position your sutures
1) Multiple staggered rows of full thickness- mattresses
2) Monofilament non-absorbable suture
3) Knots on the concave side
Positioned parallel with the incision
What are other surgical techniques for aural hematomas
Punch biopsy 4 or 6 mm
1-1.5cm apart on conclave part - staggered
skin edge through each hole is tacked to the cartilage 3-0 or 4-0 absorbable suture
What are the main advantages for aural hematoma sx
1) Easy clot removal
2) Low recurrence
3) Bandage for 48 hours
What are the disadvantages of aural hematoma sx
Anesthesia
Scar +/- deformity of ear (erect ear carriage may become floppy)
What do you do for lacerations of the pinna that only are one skin surface thick
Debridement
Closure - skin over top of cartilage
What do you do for lacerations of the pinna that are one or two skin surfaces + cartilage thick
Debride
Closure both skin layers
Risk: aural hematoma
Trauma and avulsion of the pinna is typically rupture of what
rupture of cartilage between auricular and annular cartilage
What can pinna avulsion lead to
obstruction of the proximal vertical ear canal by pseudotympanic membrane and external auditory canal atresia
How do you treat pinna trauma and avulsion
Debride and repair
Suture open the annular cartilage to the skin
-TECA-LBO
What neoplasia typically occurs at the pinna
1) Squamous cell carcinoma
2) Hemangioma/ hemangiosarcoma
3) Basal cell carcinoma
4) Mast cell tumor
5) Chondroma or chondrosarcoma
6) Fibrosarcoma
7) Histiocytoma
8) Sebaceous Adenoma
What do you do for neoplasia of the pinna
-Surgical excision
-Cryosurgery (2-3 freeze thaw cycles)
-Ear amputation
If you see squamous cell carcinoma on ear of cat, what should you recommend doing
might need to also amputate the other ear
taking down to base
What diseases typically affect the external ear canal (vertical and horizontal ear canal) in dogs
1) Infection
2) Neoplasia
-Ceruminous gland adenocarcinoma
-Sebaceous gland adenoma or adenocarcinoma
-Chondroma or chondrosarcoma
-Soft tissue sarcoma
-Melanoma
T/F: External ear canal neoplasia is often benign in dogs
false
60% of them are malignant
T/F: External ear canal neoplasia has no different distribution between horizontal and vertical canal in dogs
True
External ear canal neoplasia is often unilateral or bilateral in dogs
Unilateral > bilateral
What breeds are often overrepresented for External ear canal neoplasia in dogs
Cockerspaniels
T/F: external ear canal neoplasia is often malignant in cats
True- 88% are malignant
-Ceruminous gland adenocarcinoma
-Squamous cell carcinoma
-Anaplastic carcinoma
-Sebaceous gland adenocarcinoma
External ear canal neoplasia is often unilateral or bilateral in cats
Bilateral is common (unlike dogs where unilateral is more common)
What do you do for neoplasia of the external ear canal
-Biopsy
-Cryosurgery
-Lateral ear resection
-Total Ear Canal Ablation and Lateral Bulla Osteotomy (TECA-LBO)
What are the indications for surgery for external ear canal infection
1) Medical therapy failed
2) Aural integument irreversibly diseased
3) Development of cutaneous fistulas
4) Para-aural abscess
5) Otitis media or otitis interna (often failed- bc medical management still recommended)
What are the surgical approaches to external ear infections
1) Lateral wall resection +/- ventral bulla osteotomy
2) Resection of vertical ear canal +/- ventral bulla osteotomy
3) Total ear canal ablation
-Lateral bulla osteotomy
Whenever total ear canal ablation is done, it is also required to do
Lateral bulla osteotomy
What might you do in addition to 1) lateral wall resection or 2) resection of the vertical ear canal
Ventral bulla osteotomy
What are the indications for latera lwall resection
1) Otitis externa is reversible *
2) Small tumor of tragus or lateral wall of vertical canal NOT extending into the horizontal canal
3) Patent horizontal ear canal
Cockerspaniels are not good candidates for what external ear infection surgery
Lateral wall resection
high rate of failure in cocker spaniels die to underlying skin and ear condition
What are the goals of lateral wall resection
1) Opens up the horizontal canal
2) Improves canal ventilation
3) Reduces moisture, humidity, and temperature
4) Easier to medicate
If otitis externa is reversible, what external ear infection sx can you do
Lateral wall resection
How is lateral wall resection done
incision line made ventral to the tragus just superficial to the vertical canal
cartilage is then dissected so the horizontal ear canal is open
1) Opens up the horizontal canal
2) Improves canal ventilation
3) Reduces moisture, humidity, and temperature
4) Easier to medicate
Lateral wall resection has good results if
1) Done early
2) Owners must continue to treat underlying cause of otitis (allows them to treat better)
3) Not a cockerspaniel
Why is ventral bulla osteotomy also done with lateral wall resection
if they have middle ear disease, opens up the middle ear more
What are complications of lateral wall resection
1) Failure rates: 34-55% (poor patient selection like Cocker spaniels)
2) Dehiscence of incision
-Tension
-Chronic infection
-Slow healing
3) Stenosis of horizontal ear canal
4) Self trauma - manage with ecollar
What are the indications for vertical ear canal resection
1) Vertical ear canal severely diseased
2) Horizontal ear canal NORMAL
3) Trauma- ie avulsions
4) Neoplasia or otitis externa of the vertical canal only
rarely performed - unusual for otitis externa or neoplasia to be isolated to the vertical canal
Vertical Ear canal resection is rarely performed. How do
Because it is unusual for otitis externa or neoplasia to be isolated to the vertical canal
What does the vertical ear canal resection achieve
removes the vertical ear canal
__________ opens up the vertical ear canal, while ____________ removes it
Lateral wall resection ; vertical ear canal resection
How is a vertical ear canal resection performed
1) T incision made, avoid facial nerve and parotid gland
2) Vertical ear canal is removed
3) Suture horizontal ear canal to the skin
What are the indications for Total ear canal ablation + bulla osteotomy
1) Chronic disease
2) End stage external ear disease - narrowing
3) Narrow horizontal ear canal
4) Neoplasia of ear canal
5) Extensive middle ear disease
What does TECA-LBO stand for
Total ear canal ablation + bulla osteotomy
What should you do pre-op of Total ear canal ablation + bulla osteotomy
1) Exam- document pre-op nerve deficit
2) Advanced imaging
CT-
a) especially if nerve deficits or pain on opening of the mouth
b) Concern for middle ear disease/extension
50% of chronic otitis externa cases have
otitis media
Why is it important to do CT prior to Total ear canal ablation + bulla osteotomy
concern for middle ear disease / extension
especially if nerve deficits or pain on opening of the mouth
How is Total ear canal ablation + bulla osteotomy performed
1) Inflammed proliferative tissue is removed and go around vertical and horizontal canal taking tissue out
2) Once you get down to external acoustic meatus where opening to bullae is
3) Do a Lateral Bulla osteotomy
4) Debride the entire epithelium and open the bullae up
5) Culture
What ear structure is kept with Total ear canal ablation + bulla osteotomy
pinna
When doing Total ear canal ablation + bulla osteotomy what structure is really close to the external acoustic meatus that is a complication
Facial nerve
What are complications of Total ear canal ablation + bulla osteotomy
1) Facial nerve palsy
2) Horner’s syndrome - ptiosis, miosis, enophthalmos, protusion of nictitating membrane
3) Inner ear infection - head tilt, mystagmus, ataxis
4) Hemorrhage
5) Fistula tracts
6) Loss of hearing
What are the clinical signs of Horner’s syndrome
1) Ptosis
2) Miosis
3) Enophthalmos
4) Protrusion of nictitating membrane
What are the clinical signs of an inner ear infection
1) Head tilt
2) Nystagmus
3) Ataxia
Horner’s syndrome after Total ear canal ablation + bulla osteotomy is more common in what species
Cats > Dogs
What is true of facial nerve paralysis after
36% of cases
Improves within 2-4 weeks
4-13% permanent
What is the prognosis of Total ear canal ablation + bulla osteotomy
overall success rate of 90-95%
difficult procedure
What diseases affter the middle/inner ear
Infection
Polyps (commonly cats)
Neoplasia
Foreign Bodies
Trauma
What is the most common disease of the middle ear in dogs
1) Otitis media
-Staphylococcus
-Streptococcus
-Pseudomonas
-E Coli
-Proteus mirabilis
2) Foreign bodies
How does bacteria reach the middle ear to cause otitis media
1) Tympanic membrane (from otitis externa)
2) Eustachian tubes by the nasopharynx
3) Hematogenous
T/F: bacterial middle ear infections in cats secondary to otitis externa is common
False - it is quite rare
How do you diagnose otitis media
Physical exam
Oropharyngeal exam
Otoscopic exam
Radiographs/CT scan of bulla (air density or bone density)
What does the bullae look like normally on radiographs
air filled and radiolucent
What are the surgical indications for septic otitis media / interna
1) Lack of improvement with medical management after 4-6 weeks
2) Neurologic signs requiring tympanic decompression
Why is jsut doing a ventral bulla osteotomy rare in dogs
because you typically have severe external ear canal disease do
dogs most commonly get TECA-LBO ( Total ear canal ablation + bulla osteotomy)
Ventral bulla osteotomy can be done if
the patient only has otitis media
Not very common: because you typically have severe external ear canal disease do
dogs most commonly get TECA-LBO ( Total ear canal ablation + bulla osteotomy)
Why might cats get a ventral bullae osteotomy
polyps from the middle ear that extend into the nasopharynx and through the estuchian tube
How many compartments does the cat bullae have
2
Polyps are secondary to
chronic inflammation
polyps are seen in what kind of cats
young cats
What diseases of the middle ear do cats commonly get
1) Neoplasia - do CT scan or biopsy
2) Inflammatory polyps of middle ear (more common)
occur in bulla, external ear canal, or nasopharynx
What can be a result of polyps in a cat’s nasopharynx
respiratory difficulties
What is the prognosis of polyps
good prognosis
How do you fix polyps in cats
If in nasopharynx: lift soft palate and pull out
if localized and havent left the middle ear then you can do a bulla osteotomy
What are the complications of Ventral bulla osteotomy
Horner’s syndrome
Vestibular Signs
