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Dermatology > Otitis and Diseases of the Ear > Flashcards

Otitis and Diseases of the Ear Flashcards

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1
Q

Perpetuating Causes of Otitis Externa

A
  • Yeast
  • Bacteria (cocci, rods)
  • Chronic changes
  • Otitis media
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2
Q

Acute signs of otitis externa

A
  • Head shaking
  • Ear scratching
  • Head carriage
  • Erythema
  • Facial trauma
  • Aural hematoma (scaphe)
  • Malodor
  • Debris
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3
Q

Chronic signs of otitis externa

A
  • Lichenification
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4
Q

Pinna

A
  • THin plate of cartilage covered on both sides by skin (sandwich)
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5
Q

What is the vertical canal?

A
  • SEgment continuous with the pinna, surrounded by auricular cartilage
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6
Q

What is the horizontal canal?

A
  • Segment from the vertical canal to the tympanic membrane; surrounded by annular cartilage
  • Cartilage gives support, funnels sound, and protects the tympanic membrane
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7
Q

What is the tympanic membrane?

A
  • Semitransparent membrane that separates the external ear canal from the middle ear
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8
Q

What are the two parts of the tympanic membrane?

A
  • Pars flaccida

- Pars tensa

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9
Q

Pars flaccida

A
  • Pink, small, loosely attached region forming the upper quadrant of the TM, contains small blood vessels
  • May appear prominent and bulge in some dogs and could be mistaken for a mass
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10
Q

Pars tensa

A
  • Remainder of the membrane

- Thin, tough pearl grey structure attached to surrounding bone by a fibrocartilaginous rnig

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11
Q

Stria mallearis

A
  • Outline of the manubrium of the malleus that is visible through the TM where it attaches to the medial surface
  • Manubrium has a hook that points rostrally in the dog
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12
Q

Label the parts of the ear

A
  • Apex
  • Scapha
  • Lateral or caudal border of the helix
  • Cutaneous marginal pouch
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13
Q

Where do you insert your otoscope?

A
  • Intertragic incisure
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14
Q

Histology of the ear

A
  • Extension of the skin
  • External ear canal lined by stratified squamous epithelium, overlying the dermis
  • Dermis contains numerous sebaceous glands and fewer ceruminal glands (modified apocrine glands)
  • Density of the ceruminal glands varies among breeds, therefore so does the amount of waxy secretions
  • Canals contain hair follicles, which also vary in density among breeds
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15
Q

What is cerumen?

A
  • waxy debris in the canal consisting of sebaceous and apocrine secretions and desquamated epithelial cells
  • Functions to trap foreign matter and may be antibacterial
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16
Q

Epithelial migration

A
  • Self-cleaning mechanism of the ear canal

- Surface of the epithelium moves laterally from the inner horizontal canal to sweep debris out of the ear

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17
Q

Relative humidity and pH of the ear

A

88.5%

mean pH= 6.2

  • Relatively stable in normal ears
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18
Q

Microflora normally in the ear

A
  • The ear canal is host to lower numbers of yeast (Malassezia pachydermatis) and Gram Positive bacteria
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19
Q

What is otitis externa?

A
  • Inflammation of the external ear canal

- No insight to cause of inflammation

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20
Q

What happens to relative humidity and pH with otitis externa?

A
  • Significant rise in relative humidity and pH
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21
Q

What are the three Ps that cause otitis?

A
  • Primary causes
  • Predisposing Causes
  • Perpetuating Causes
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22
Q

Primary causes

A
  • Parasites
  • Allergies
  • Foreign bodies
  • Disorders of Keratinization
  • Neoplasia
  • Autoimmune diseases
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23
Q

Parasites that cause otitis externa?

A
  • Otodectes
  • Otobius
  • Demodex
  • Sarcoptes/notoedres
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24
Q

Otodectes cynotis - who gets?

A
  • Dogs and cats
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25
Q

Appearance of otodectes cynotis?

A
  • Coffee grounds
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26
Q

Appearance of ears with otodectes?

A
  • ears can be normal

- Often visualized during exam

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27
Q

Demodex mites that can cause otitis externa

A
  • Canis
  • Injai
  • Catai
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28
Q

Demodex implication in otitis externa?

A
  • Ear canals can be affected as part of generalized infestation and cause heavy cerumen accumulations
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29
Q

Where does Sarcoptes tend to cause problems with otitis externa?
WHat question may suggest Sarcoptic mange?

A
  • Ear pinna
  • If the owner is itchy, that’s a big clue
  • Rarely affects the canal itself
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30
Q

Notoedres - where does it tend to cause problems?

A
  • Pinna mostly
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31
Q

Most common parasite of the ear canal?

A
  • Otodectes cynotis
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32
Q

Otobius megnini - common name? where is it seen in the US?

A
  • Spinous ear tick

- SW

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33
Q

Eutrombicula alfreddugesi common names? Who gets? Lesions?

A
  • Chiggers
  • Seen on free-roaming cats
  • Pruritic papules on ears, head, and neck
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34
Q

WHat is the MOST COMMON cause of persistent or recurring otitis?

A
  • ALLERGIES (atopy, food, contact hypersensitivity)
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35
Q

Atopic pruritus areas

A
  • Face, paws, axillae, inguinal
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36
Q

Atopic dermatitis - what % of atopic pets can develop otitis?

A
  • Up to 80%
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37
Q

What % of pets with food allergies can have otitis externa?

A
  • Up to 80%
  • Some may ONLY have recurring otitis as a clinical sign (i.e. no pruritus)
  • Food allergy is an important rule out in young dogs with recurrent otitis
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38
Q

Contact hypersensitivity otitis - what agents are generally implicated?

A
  • Neomycin
  • Propylene glycol
  • Anything placed on the skin or ears can cause irritation
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39
Q

Foreign bodies as causes of otitis - examples of causes?

A
  • Grass awns or fox tails

- Concretions of medications and/or long-acting medications like compounded BNT or Otipacs

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40
Q

Clinical appearance of dogs with foreign bodies

A
  • Often acute onset, unilateral
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41
Q

Keratinization disorers that can lead to otitis?

A
  • Primary seborrhea
  • Sebaceous adenitis
  • Hypothyroidism
  • Cushing’s disease (?)
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42
Q

Primary seborrhea

A
  • Disorder of increased epithelial turnover and proliferation of sebaceous secretions
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43
Q

Who gets primary seborrhea?

A
  • Cocker Spaniels and Basset Hounds
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44
Q

What can primary seborrhea lead to that predisposes to otitis?

A
  • Increased cerumen production - environment for microbial overgrowth
  • Increased sebaceous secretions can produce altered fatty acids that are irritating to the canal
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45
Q

Sebaceous adenitis - how can it lead to otitis?

A
  • Can affect sebaceous glands in the ear canal resulting in dry, hyperkeratotic canals
  • Especially in Akitas
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46
Q

Hypothyroidism - how can it lead to otitis?

A
  • Can cause seborrhea and increased epithelial turnover and proliferation of sebaceous secretions
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47
Q

Neoplastic causes of otitis externa?

A
  • Inflammatory polyps
  • Benign
  • malignant
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48
Q

Apocrine gland cysts in cats

A
  • Little brown cerumminous cysts

- If you poke them, it’s brownish in color

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49
Q

Autoimmune causes of otitis externa?

A
  • Pemphigus foliaceus

- Systemic lupus erythematosus

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50
Q

List of primary causes of otitis?

A
  • Parasites
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51
Q

What should you primarily think with predisposing causes?

A
  • Think anatomy**
  • Think lifestyles
  • Don’t rule out primary causes those
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52
Q

Anatomical predisposing causes for otitis externa?

A
  • Pendulous pinnae (think Cocker spaniels; Bassets)
  • Stenotic ear canals (Shar Pei; Chow Chow; poor ventilation and microbial overgrowth)
  • Increased hair (trap cerumen and debris; poodles and labradoodles)
  • Increased ceruminous glands have a favorable environment for microbial overgrowth (German Shephard, Spaniels, Setters)
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53
Q

Lifestyle factors that can predispose to otitis externa?

A
  • Swimming
  • Grooming or plucking
  • Overzealous cleaning
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54
Q

What do swimming, grooming/plucking, or overzealous cleaning tend to do to the ear that predisposes to otitis?

A
  • It can become macerated and can lose its protective lipid barrier allowing microbes to overcolonize the area
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55
Q

Perpetuating causes of otitis externa

A
  • Yeast
  • Bacterial cocci or rods
  • Chronic changes
  • Otitis media
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56
Q

Which yeast tend to be involved in otitis externa?

A
  • Malassezia pachydermatitis
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57
Q

Which bacterial cocci and rods tend to be involved with otitis externa?

A
  • cocci: Staphylococcus

- Rods: E. coli, Proteus, Klebsiella, Corynebacterium, Pseudomonas

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58
Q

What % of dogs with chronic otitis externa can have concurrent otitis media, and what is the clinical significance?

A
  • Up to 50-80% of dogs and cats with chronic otitis externa can have concurrent otitis media and can reinfect the external canal
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59
Q

Chronic pathologic/inflammatory changes associated with otitis externa as a perpetuating cause?

A
  • Hypertrophy of ceruminous glands can lead to favorable microbial overgrowth
  • Epidermal and dermal hyperplasia can lead to stenosis and decreased “Self-cleaning” leading to increased microbial overgrowth
  • Calcification of fibrous tissue surrounding the cartilage can lead to irreversible (end stage) changes to the ear canal
60
Q

Acute clinical signs of otitis externa?

A
  • head shaking
  • Ear scratching
  • head carriage
  • Erythema
  • Facial trauma
  • Aural hematoma
  • Mal-odor
  • Debris
  • Stenosis of the external (visible canal)
61
Q

Chronic signs of otitis externa

A
  • Lichenification
  • Thickening of ear canal cartilage
  • Stenotic ear canal
  • Ceruminal gland hyperplasia
62
Q

Treatment errors that can perpetuate otitis

A
  • Overtreatment can lead to maceration of the canal

- Under-treatment can lead to sub-therapeutic doses reaching the site of infection

63
Q

Signs associated with Pseudomonas otitis?

A
  • Mal-odor
  • Fluid on palpation
  • Purulent discharge
  • Ulcerated ear canal
  • Pain
64
Q

What type of diagnosis is otitis?

A
  • CLINICAL
65
Q

History questions to ask with otitis externa?

A
  • Age of onset?
  • Recurrence?
  • Pruritus?
  • History of skin infections?
  • Swimming/bathing?
  • Hiking/hunting (foreign bodies)?
  • Treatments?
66
Q

PE steps for otitis externa?

A
  • be thorough!
  • Observe gait and mentation in room
  • Palpate ear canals
  • Open mouth
  • Examine skin and paws
  • Look for neurologic deficits
67
Q

What can be suggested if a dog with an ear infection has pain opening the mouth?

A
  • Middle ear infection
68
Q

Otoscopic exam procedure for otitis?

A
  • Look at both ears!
  • Understand the anatomy
  • Practice makes perfect
  • Need a good otoscope and proper restraint
  • Try to visualize the tympanic membrane
69
Q

What neurologic deficits may be associated with otitis media/interna?

A
  • Facial paralysis
  • head tilt
  • Nystagmus
70
Q

What if you can’t see the tympanic membrane?

A
  • Evaluate what you can see
  • Are their neurologic deficits?
  • many reasons including inadequate restraint, pain, waxy material blocking TM, severe stenosis
71
Q

What should be done on all patients with otitis?

A
  • Cytology!

- Doesn’t diagnose it, but does help you figure out how to treat

72
Q

External ears for otic exam - what are you looking for?

A
  • Look at the skin at the base of the pinna and pinna itself (e.g. crusting may indicate scabies; diffuse erythema may indicate underlying allergy)
  • Smell both ears
  • Palpate both ear canals for symmetry, thickening, fibrosis, and/or calcification
73
Q

What can you consider if the canal is severely inflamed or stenotic and otic exam not possible?

A
  • Anti-inflammatory course/dose of prednisone and recheck in 7-14 days
74
Q

What is prognosis if canals palpate calcified (bone like)?

A
  • Poor for cure with medical management

- Strongly consider surgery like TECA-BO as a salvage procedure

75
Q

Ear cytology procedure description?

A
  • Swab vertical canal at the junction of the horizontal and vertical canal
  • Roll swab on the slide
  • Stain with Diff Quick
  • Examine at 100x (oil)
  • Should be done in EVERY case of otitis, including recheck exams
76
Q

What is the most important diagnostic test for otitis?

A
  • Cytology, but must consider patient’s clinical signs
77
Q

Mite prep for otitis?

A
  • Roll swab in mineral oil on slide to look for mites and examine at 4-10x
  • For demodex he recommends 10x and drop the condenser
78
Q

When to culture for otitis?

A
  • When you suspect pseudomonas
  • Infection persists in face of appropriate treatment
  • PMNs with no bacteria
79
Q

What does the culture and sensitivity tell us?

A
  • Systemic concentrations

- Can achieve 10-100x the concentration in the ear topically

80
Q

When to do advanced imaging for otitis?

A
  • Suspected media/interna
81
Q

What is the best modality for otitis media/interna imaging?

A
  • CT is the best modality to evaluate bone and bulla structures
  • Can be expensive
  • may need referral and anesthesia
82
Q

Radiography for otitis media/interna?

A
  • 25% of cases may not reveal abnormal changes; positioning is important; interpretation can be difficult; may need to request radiologist inteerpretation
83
Q

Baseline lab data for otitis

A
  • CBC
  • Chem
  • UA
  • IF underlying disorder
  • Might not be helpful in most cases of allergic diseases
84
Q

4 main principles for managing otitis externa?

A
  1. Look for primary causes
  2. Address any predisposing causes
  3. Reduce inflammation
  4. Treat secondary infections
85
Q

Looking for underlying disease - what are you looking for?

A
  • Identify and/or address and primary causes
  • Address or minimize any predisposing causes IF POSSIBLE

(For example, reduce swimming or excessive bathing)

86
Q

Treatment volume for toybreeds/cats?

A
  • 0.25cc
87
Q

Treatment volume for small/medium dogs?

A

0.5cc

88
Q

Treatment volume for large breeds?

A

1 cc

89
Q

Rule of thumb for length of treatment?

A
  • Twice a day (BID) for 7-14 days
90
Q

What treatments should you AVOID if tympanic membrane is ruptured or patient has neurologic deficits?***

A
  • Aminoglycosides

- Chlorhexidine

91
Q

What are safe topicals if you suspect the TM is ruptured or patient has neurologic deficits?

A
  • Enrofloxacin
  • Miconazole
  • Dexamethasone
92
Q

What are three basic properties of ear cleaners?

A
  • Ceruminolytic (break up wax)
  • Drying agents
  • Antimicrobials
93
Q

Ototoxicity of ear cleaners

A
  • Definitely possible
94
Q

What ingredient can cause contact reactions in ear cleaners?

A
  • Propylene glycol?
95
Q

What does cleaning the ear do?

A
  • Helps remove accumulated debris that can directly irritate the otic epithelium, prevents penetration of topical medications, and can inactivate some antibiotics
96
Q

What is the proper way to clean the ear canal?

A
  • Flood the canal with solution, massage the base of the ear canal for approximately 30-60 seconds, allow the pet to shake the head, wipe excess debris from pinna with a cotton ball/soft gauze/Kleenex
97
Q

Examples of ear cleaners

A
  • Epi-otic advanced

- Epiklean, etc.

98
Q

What ear cleaners to use if TM is ruptured or damaged?

A
  • Saline
  • Squalene
  • TrizEDTA (not a cleaner but more of a treatment for Pseudomonas)
99
Q

How to clean ears that are more complicated or non-responsive to simple cleaning?

A
  • Anesthesia deep ear cleaning using potent ceruminolytic agent such as squalene
  • Important to protect airway with agressive ear flushes as fluid can be aspirated through the Eustachian tube
100
Q

How useful are oral antibiotics considered for otitis externa?

A
  • Debatable
  • No longer recommended in people
  • THink the trachea; no significant concentrations in the external ear canal
101
Q

When might you use oral antibiotics with otitis? ANd how long would you use them for?

A
  • Otitis media or interna

- 6-8 weeks

102
Q

What do you base oral antibiotic selection on for otitis media and interna?

A
  • Culture and sensitivity, ideally collected from the middle ear
103
Q

Use of oral antifungals for otitis?

A
  • Debatable
  • Some dermatologists feel it helps
  • Best to treat topically he thinks
104
Q

Which oral antifungals might you use? Which is not appropriate in cats?

A
  • Ketoconazole (NOT IN CATS)

- Fluconazole

105
Q

What provides most anti-inflammatory effects?

A
  • Corticosteroids (Topical, oral, side effects?)
  • NSAIDs aren’t useful, so don’t use them
  • Chronic endstage disease
106
Q

WHen should you see improvement with steroids?

A
  • 1-2 weeks

- If no improvement by then, it’s unlikely they can be managed medically

107
Q

What will Dr. Mel use for very chronic/endstage otitis?

A
  • Lowest effective anti-inflammatory dose EVERY OTHER DAY

- NEVER uses daily dosing long-term

108
Q

What is important to communicate to the client for otitis?

A
  • Critical to convey why otitis has happened and likelihood of recurrence
109
Q

Keys to success with otitis?

A
  • Open ear canal (difficult to treat if you can’t get medications in)
  • Clean ear canal when possible
  • Use LARGE VOLUMES of topical medications; use solutions rather than ointments if the canal is stenotic
  • Frequent follow-up examinations
  • ID and address, when possible, an underlying cause for the otitis
110
Q

What age of animal tends to get ear mites?

A
  • Young animals (dogs and cats)
111
Q

Diagnosis of ear mites

A
  • Mite prep using mineral oil
112
Q

Topical treatments for ear mites

A
  • pyrethrin ear products (eradamite, otomite+)
  • Thiabendazole
  • Milbemite
113
Q

Systemic treatments for ear mites

A
  • Selamectin (revolution) or moxidectin (advantage multi) 1 tx every 2 weeks for 3 consecutive treatments
  • Isoxazolines (bravecto, Nexgard, Simparica)
114
Q

Malasezzia otitis - what should you be looking for?

A
  • Primary/predisposing causes

- It’s very common

115
Q

How to diagnose malasezzia otitis?

A
  • Cytology (Diff-Quick and 100x)
116
Q

What is the most common organism isolated from acute otitis?

A
  • Malassezia otitis
117
Q

Treatment for Malasezzia otitis

A
  • many products
  • Clotrimazole (Mometamax)
  • Miconazole
  • Terbinafine
  • Posaconazole
118
Q

Bacterial otitis - which cocci?

A
  • Staphylococcus
119
Q

Bacterial otitis - which rods?

A
  • E. coli
  • Proteus
  • Klebsiella
  • Corynebacterium
120
Q

Treatment for bacterial otitis

A
  • Aminoglycosides (tympanic membrane must be intact; part of Mometamax)
  • Florefenicol
  • Polymixin B
121
Q

What tends to be the timeframe of pseudomonas otitis?

A
  • Chronicity
  • Fluid can be heard or felt on palpation of the ear canals
  • Painful canals or upon opening of mouth
  • Ulcerative ear canal
  • Purulent discharge
  • Distinct clinical presentation (yeasty but also like death)
  • Tends to be resistant
122
Q

Mechanism of Pseudomonas resistance

A
  • Antibiotics go into the cell and through efflux pumps, the antibiotics get pumped out
123
Q

Diagnosis of Pseudomonas otitis

A
  • Suspect with history and exam findings
  • Cytology (PMNs with LOTS of rods; doesn’t play well with others)
  • If it’s purulent debris, you really should be suspecting Pseudomonas
  • if you find equal numbers of neutorphils, cocci, and rods, think non-Pseudomonas
  • Culture to ID
  • SEnsitivity is important, as it’s often resistant
124
Q

Topical treatment for Pseudomonas otitis?

A
  • TrizEDTA
125
Q

MOA of TrizEDTA

A
  • Punches holes in the wall of Gram negative bacteria
  • Binds to calcium channels
  • Chelates
  • ALlows the bacteria to be more susceptible to treatment (use 15-20 min before treatment)
126
Q

Antibiotics to use for Pseudomonas

A
  • Enrofloxacin** (secret weapon)
  • Tobramycin
  • Silver sulfadiazine (SSD)
  • Ticarcillin
  • Polymixin B
  • Corticosteroids
127
Q

Components of the middle ear canal

A
  • TM
  • Tympanic bulla
  • Auditory (Eustachian tube)
  • Auditory ossicles
  • Facial nerve
128
Q

What is the Auditory tube?

A
  • Short passage from the nasopharynx to the middle ear
129
Q

Relationship of facial nerve and parasympathetic and sympathetic nerves to middle ear?

A
  • Facial nerve courses near it

- Parasympathetic and sympathetic nerves course through the middle ear

130
Q

Pathogenesis of Otitis media

A
  • Often seen in patients with chronic otitis externa
  • TM is composed of collagens Type 1 and 2, which weakens with infections
  • RARELY develops through extension from auditory tube (cats with URIs)
  • RARELY from hematogenous spread
131
Q

Infectious organisms implicated with otitis media?

A

Most often bacterial infection

  • Staph
  • Streptococcus
  • Pseudomonas
  • E. coli
  • Proteus
  • Otherwise, fungal (Malasezzia, Aspergillus, Candida), foreign bodies, inflammatory polyps (cats), and masses
132
Q

Clinical signs of Otitis media?

A
  • history of chronic otitis - up to 50-80% can have OM
  • +/- pain on opening of mouth (manipulation of TM joint affects the bulla)
  • +/- Ruptured tympanic membrane
  • +/- facial paralysis, Horner’s syndrome, head tilt
  • Some may seem normal!
133
Q

Diagnosis of otitis media

  • What about the history might suggest?
A
  • Chronicity

- Poor response to treatment (primary causes addressed)?

134
Q

What on otoscopic exam suggests otitis media?

A
  • mass
  • Bulging, ruptured, or colored tympanic membrane
  • Usually pars flaccida distending
135
Q

What % of patients with Otitis media can have intact TM?

A
  • 70-80%
136
Q

Advanced imaging for diagnosis of OM, and what is preferred?

A
  • CT** (allows you to evaluate bullae)
  • Radiography
  • MRI
  • Ultrasound
137
Q

What is the name of the procedure often done to collect fluid and material from the middle ear?

A
  • Myringotomy
138
Q

What is the purpose of the myringotomy?

A
  • Fluid/material collection from the middle ear

- Helps you collect a sample for culture and sensitivity

139
Q

Cost of myringotomy

A

$1500-3000

140
Q

Why is a culture and sensitivity important for otitis media?

A
  • Up to 90% can have different external/middle ear results
141
Q

What is the purpose of flushing the middle ear during a myringotomY?

A
  • Diagnostic and therapeutic
142
Q

How quickly can TM heal if ruptured?

A

Within 12 days (2-4 weeks)

143
Q

What are you aiming to puncture with a myringotomy?

A
  • Pars tensa
144
Q

Treatment of otitis media?

A
  • 6-8 weeks with a systemic antimicrobial ideally based on C&S from middle ear
  • Topical treatment (non-ototoxic; TrizEDTA, saline, squalene, Baytril, miconazole)
  • Want high volume topicals
145
Q

Prognosis for otitis media?

A
  • Guarded
  • Recurrences are possible
  • VBO (Ventral bulla osteotomy) may need to be considered
  • still need to look for primary causes
  • May need symptomatic treatment if facial nerve is involved and secondary exposure keratitis develops (e.g. artificial tears)

Dermatology (15 decks)

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