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General Comments and Information about ear infections.  We see 1 or 2 cases of ear infections a day.
Ear infections are a big problem.

What to Expect at our Hospital if your Pet has an Ear Problem














Introduction:

From a treatment and frustration view point, there are 4 types of ear problems...

1.  Those caused by ear mites.  This is my favorite because it's easy to diagnose and easy to cure.  This is also the most common ear problem in cats.  We discuss the treatment of ear mites on another page.

2. First time ear problems or pets with a history of occasional ear problems that readily respond to simple treatment, and the ear tissue is normal except for being a little irritated.  These are generally easy to treat.

3.  The third type is one we vets frequently have to deal with and are very frustrating to both the pet and the owner.  This is the chronic ear infection that makes the dog miserable and smelly and even though it gets improved with treatment...keeps coming back.  And the ear tissue changes to become thicker, spongier, and more productive...secreting large amounts of inflammatory glaze and goo.

Ear infections aren't very common in cats, but they're a very, very common problem in dogs, especially in dogs with floppy ears and/or underlying allergies.

4.  Category 4 is everything else.  wounds, hematomas, cancer, deafness, sunburn, frostbite, mange, ringworm, fly strike, inner ear problems, a probably a few other rarer diseases that aren't on my radar.  We discuss several of these problems on other pages.  They are listed in the column to your left.  This page is mostly about treating infections of the ear canal.



Here's what to expect if your pet has an ear problem at our Clinic:
(Of course, other veterinarians may do things differently)

A good examination and history:  It always starts here.  Our exam includes looking closely at the rest of the body, especially for skin lesions, signs of fleas, and signs of atopy (inhalant allergies) such as paw licking.

Also, of course, we will inspect the ear canal closely  under magnification,  looking for foreign objects (like cotton balls or ticks), growths and dermoids (cysts with ingrown hair), and for pus, inflammation, and canal wall changes.  We will try to evaluate the ear drum.

New technology 2014: we now have a tiny, pen like, video camera with an ultra bright light that projects easy to see pictures of the canal and ear drum

Microscopic smear of the ear wax:  With this simple smear we can see ear mites, demodex,  and pus. 

Ear Wax/Discharge Cytology:  If we go to the trouble of fixing and staining the sample we can identify yeast and tell if the bacteria in the ear is gram positive or negative, and whether or not the bacteria are round (cocci) or flat and straight (rod).  This knowledge gives us clues as to what types of antibiotics are likely to work.  This test can be done while you wait about 15 minutes.

Bacterial Culture & Sensitivity:  Growing out the bacteria on culture plates not only lets us identify the bacteria causing the infection, but tells us which antibiotics actually are effective.  The only problem besides the cost is that the results take several days.  A C/S is ideally done when ever we choose and antibiotic.  But this test is recommended in those cases where initial treatment failed.

Food Trial: About 20% of dogs with frequent ear inflammation and infections have underlying food allergies.  Your vet may recommend a therapeutic test diet to find out if your pet is allergic to certain foods.  It's important to do these food trials correctly ... not just switch brands. 


Infected Ear
Treating Ear Infections in Cats, Dogs, and Other Pets



We can now take painless video pictures of the inside of the ear and see the ear drum much easier than ever before.  The images are projected through bluetooth to a screen that we all can see.
How cool is that?
More about ear problems on other pages:










Ear Mites in pets
(including Demodex and Sarcoptic Mites in the Ear of pets)
Other parasites of the ear including ticks and flies.
Canker Ear
Fly Strike


Ear flap Hematomas (aural hematomas), Cancer, Ear Margin Dermatitis, Sun Burn, Frost Bite, and other Injuries to the Ear Flap




If your vet has a medical laser, it's wonderful at reducing the pain, inflammation, and swollen tissue inside the ear.
It's also helpful for killing yeast and speeding healing.

Treatment
I divided the discussion of treating ear infections into 2 categories; minor ear infections that can be treated simply and cheaply... and the other kind


How we treat first time, minor ear infections

Step A.  We'll clean out the ear canal using a gentle, soothing ear cleaner.  It's important to know whether or not the ear drum is intact before using ear cleaners with added antibiotics.  This might be just a one time thing we can do for you at the clinic, or you may need to clean your dogs ears out on a regular basis to avoid recurrence.

Step B.  We'll dispense one of the more successful topical ear ointments that kill bacteria and yeast as well as reduce the swelling and inflammation of the ear canal.
My first choice is an enzyme product called Zymox.  It's highly successful in treating mild-moderate ear infections.
My partners prefer a product called OtiEase because it only takes 5 treatments... once a day for 5 days.  We do the first treatment in the exam room after cleaning out the ears leaving just 4 days treatments for you to do at home.   The ointment leaves a residue in the ear canal that lasts for 2 weeks.  Other vets use Mometamax, Posatex, Panalog, Tresaderm, custom made mixtures, or other brands.

Step C.  Oral Antibiotics may or may not be recommended depending on the severity of the infection.

Step D. I will often dispense a very short period of prednisone and/or an antihistamine to reduce the irritation and itch to make the patient more comfortable.  Other vets prefer to avoid steroids like prednisone.  There is a new medication called Apoquel that is supposed to work as well as steroids without the risk of side effects.  (Apoquel was released for sale in Jan 2014, but as of July 2014, we are unable to obtain this new medication.  Pfizer/Zoetis has promised to start making it available sometime in the next 12 months.  It seems their management has been taken over by people who couldn't cut it as government workers.)

Step E.  Recheck if not all better soon.  Hey, rechecking is important...getting things right requires following up and perseverance until the patient is better.

Treating Ear mites: If we find ear mites under the microscope when we examine the ear discharge, we rejoice because this problem is easy to treat.  It's always nice to make an animal feel much better so easily.
I have a separate page devoted to the treatment of ear mites, fly strike, frost bite and sunburn, and canker ear.  Please click here to go to this page.

How we treat chronic, more serious ear infections:

For really bad or chronic ear infections, successful treatment requires aggressive care against all the major underlying causes.  These include not only the bacteria causing the infection, but also the secondary yeast infection, the underlying flea, inhalant, and food allergies, and the inflammation, pain, and discomfort.

Infection due to bacteria.  The bacteria involved is usually Staph, but sometimes the bacteria is pseudomonas or proteus or other types of bacteria that require long term treatment with potent antibiotics. This is why a culture and sensitivity test is so helpful.  For most mild-moderate ear infections, treating for 10 days is often adequate.  But for severe ear infections, antibiotic therapy is usually required for many weeks.  It's often the case that an antibiotic called cephalexin works well (confirmed by the culture/sensitivity test) and this is fortunate because this particular antibiotic is now extremely inexpensive.

Secondary infection from yeast.  Yeast organisms thrive in infected ear canals and cause severe irritation.  Most of the topical ear treatments that vets use kill yeast well in the ear canal but MAY NOT kill yeast deep in the tissue.  A systemic anti fungal may be needed

Allergic inflammation due to fleas.  Some pets are so sensitive that just a few flea bites can cause severe skin and/or ear allergies. Aggressive flea control may be needed.

Allergic inflammation due to pollens, molds, dust mites, etc.  Dogs and cats are allergic to the same air born allergens we humans are sensitive too, but whereas most sensitive people develop respiratory symptoms, most dogs and cats develop skin, anal gland, and/or ear allergies.

Allergic inflammation due to certain foods.  About 20% of dogs and cats with skin, anal gland, or ear allergies improve when fed carefully chosen hypo-allergenic diets and snacks.

Pain and discomfort. Ear infections are very uncomfortable. Treating the pain not only makes your pet feel better ... it speeds healing.

The pictures above, below, and to your right are all examples of fairly serious ear infections that require aggressive treatment if you want your dog to be comfortable.  The ear on your right may not have a lot of discharge or be obviously red, but notice the texture of the skin on the inside of the ear flap and the thickness of the tissues in the canal.  The inside of the ear flap should be baby butt smooth.  Dogs can hide their pain, but this patients has to be miserable
Breeds with heavy skin folds or heavy ear flaps are especially prone to ear infections.  But the number one thing that dogs with frequent ear infections have in common is underlying allergies.
Allergies either to pollens, dust mites, and other inhalants.... to fleas.... to certain foods .... or any combination of the above.  And the professors tell us that stress is also a factor.
Exposure to water when swimming or getting a bath is NOT a major factor.
Exposure to water when swimming or getting a bath is NOT a major factor.
However, breeds of dogs that we associated with loving the water are often prone to ear infections for other reasons.
The picture above is an electron microscope image of pollen and some unidentifed organism or protein that looks like a sea ray.  Pollens and other allergens are WAY to small to see under a regular microscope, but we and our pets are exposed to millions or billions of these tiny proteins and sometimes our immune systems over react to the invasion.  When I went to vet school in the early 1980's it was thought that it was the inhaled allergens that caused skin and ear allergies.  Newer evidence indicates that it may be that allergens in direct contact with the skin are the cause.  Either way, underlying allergies are the cause of most skin and ear inflammation in dogs.  The picture below is an electron micrograph of pollen (purple) attached to hairs.

How I Treat severe ear infections:

Step A.  Getting the ear canal cleaned out and if possible inspecting the ear drum.  Sometimes sedation or light anesthesia is needed to do this well.

Step B.  Getting a culture and sensitivity so we can choose the right ear cleaner and the right antibiotic.  If the bacteria is pseudomonas we will use Tris/EDTA ear wash, often with a potent antibiotic (Baytril) added. 

Step C. If the ear is so painful that the owner can't easily clean and medicate the ear canal, we pack the ear canal with a compounded mixture of lanolin, steroids, enrofloxacin, and an antifungal that stays in the ear for a week.  This is often successful at calming the ear canal, greatly reducing the surface infection, and reducing the pain enough that the ear can then be treated by the owner.  We often dispense a few days of light sedatives and/or pain medications to make treatment less of a battle.

Step D. applying a topical medicated otic ointment.  I often use Posatex which is fairly expensive but seems to work better than other formulations on very serious infections.  I usually recommend using both a medicated ear wash and Posatex on a daily basis until the ear is all better.  The type of medicated ear wash I recommend will depend on the type of bacteria in the ear.  If the bacteria is a gram negative rod shaped organism or the culture and sensitivity comes up positive for pseudomonas, the ear wash has to have a high pH and contain a potent antibiotic to work well.  If, on the other hand, we identify a staph organism, the medicated ear wash needs to have a low pH.
I won't pretend to really understand the biochemical cascade that makes some dogs itch and others not be affected when invaded by allergens.... but it's certainly too complicated to explain in a one paragraph box.  What is important is that allergies to fleas, pollens, dust mites, microscopic mode spores, and certain foods have to be addressed; they're a major underlying cause of the infection.
These are my favorite ear products I use on a regular basis for dogs with ear infections.  Inexpensive Zymox works well on most mild-moderate infections and is excellent at preventing recurrence in severe ear infection cases once we get the ear all better.  Expensive Posatex is what I recommend for severe ear infections or for those few cases where Zymox doesn't work well enough.
Most ear infections in dogs are caused by one of 4 different species of bacteria.  (usually in combination with a yeast organism called Malassezia) It's important to identify which of the 4 bacteria is causing the problem because the treatment is different depending on the bacteria.  Inexpensive cytolgy can give us helpful clues within minutes.  More expensive culture and sensitivity testing takes a few days for results, but not only allows us to positively identify the bacteria but also tells us which antibiotic in our arsenal is effective for the strain of bacteria in your dog's ear.   We do both tests at our clinic.  The picture above is a culture plate of Psuedomonas which is a tough organism to kill.
Step C.  High quality oral antibiotics for at least 3 weeks.
For most severe ear infections I use cefpodoxime ( a new generation once a day cephalosporin antibiotic).  But if the infection is due to pseudomonas, I use one of the fluoroquinolone antibiotics. But this decision depends on knowing which bacteria is causing the problem and we learn that from doing cytology and a culture-sensitivity.

Step D.  Antihistamines to help control the underlying allergies and irritation.

Step E.  Short term steroids to help reduce the swelling and inflammation and to give the poor patient some relief from the allergies.  Other vets avoid steroids even for short term use or substitute Atopica which works as well as prednisone without the side effects.  (But very expensive)

2014 Update: a new anti-inflammatory medication called Apoquel will soon be available.  It is reported to work as well as prednisone or other steroids without the the risk of so many potential side effects.

Step F.  Sometimes a hypoallergenic diet is needed.  Figuring out what your pet is allergic to takes patience and effort.  Your vet will explain. 
There is a lot of much mis-information about this subject.  The present fad is to blame grains and pet stores are selling "grain free" diets like crazy.

Step G.  Pain control.  Luckily we have a several good options for pain management in dogs. 

Step H.  Laser Therapy:  This is new at our clinic in 2014.  Laser therapy is at least somewhat helpful with almost any tissue that is swollen, red, painful, or inflamed.  It also helps fight infection and speeds healing.  Results have been mixed; great and obvious results in some cases and only modest improvement in others.

Step I.  Possible referral to an allergy specialist for allergy testing and desensitization.

Step J. Recheck if not improving soon.  And understanding that we rarely cure this problem; we manage it.  Maintenance and being ready to treat flare ups early are usually needed.  Because allergies are involved, you may find that the flare ups are seasonal.

Surgery:  See pictures below.  Sometimes the ear problem is so severe that surgery is needed to prevent recurrence and to make the patient comfortable.


The cytology image above are gram - rods telling us the bacteria is likely to a strain of pseudomonas.  The cytology image below are gram + peanut shaped organisms typical of malassezia (yeast).
Laser therapy is almost always helpful in reducing pain, inflammation, and healing time.
This has nothing much to do with treating ear infections, but you might enjoy or page in tribute to Dr Harvey Cushing. In the picture above, he is performing brain surgery. Dr Cushing was one the few pioneers doing brain surgery in the early 1900's and a major investigator into the diseases caused by malfunction of the pituitary gland.  Click here to go to our page about Cushing's Disease ... a common problem a lot of vets miss during exam
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We don't see very many Cocker Spaniels any more.... they used to be extremely popular.  But this breed is so prone to having really, really severe ear infections that we refer to the problem as "Cocker Ear".
An example of a really, really severe ear infection most commonly seen in Spaniels.  The tissue has become so thickened from chronic inflammation that the ear canal is all clogged up and extremely painful.  Sometimes we can't make the patient comfortable with medical treatment alone.  Luckily we can open up the ear canal with surgery.  But it's critical that we avoid surgery while the ear has a raging infection... so we get the ear canal infection and the tissue inflammation under control as best we can with aggressive therapy and THEN we perform the surgery that opens up the ear canal.  The laser is especially helpful in super painful and swollen ears like the one above.