A Review of Techniques for the Investigation of
Otitis Externa and Otitis Media
K. Marcia Murphy, DVM
Otitis externa, inflammation of the externa ear canal, is relatively
easy to diagnose based on the history and physical examination
findings. The diagnosis of otitis media, inflammation of the mid-
dle ear cavity, is more challenging, with the work-up being both
costly and, at times, invasive. The pathogenesis of otitis externa
has been classified into predisposing, primary, and perpetuating
factors. It is critical to the management of ear disease that the
clinician recognize and investigate which factors are contributing
to each individual patient's ear disease. Failure to identify and
address the primary and/or predisposing factors is the most
common cause of chronic recurrent otitis externa. Chronic in-
flammation of the ear canal leads to the development of the
perpetuating factors, which may be the major reason for treat-
ment failure, regardless of the primary cause of the ear disease.
In this article, the predisposing, primary, and perpetuating fac-
tors involved in ear disease will be presented, along with a review
of the techniques used in the diagnosis of otitis externa and otitis
media.
O titis externa is defined as inflammation of the external ear
canal, which extends from the pinna to the tympanic
membrane; otitis media is inflammationof the middle ear cavity,
including the tympanic membrane and the tympanic bulla. In
small-animal practice, ear disease is a common, and often frus-
trating, problem in our canine patients. It is not seen as com-
monly in cats, but these cases may be equally challenging. The
diagnosis of otitis externa is relatively easy based on the history
and physical examination findings; otitis media, on the other
hand, is difficult to diagnose, with the work-up being both
costly and, at times, invaslve. August ~ proposed a useful and
practical classification scheme for the pathogenesis of otitis
externa, dividing the causes of otitis into predisposing, pri-
mary, and perpetuating factors. It is critical to the management
of otitis externa that the clinician recognize and investigate
which factors are contributing to each individual patient's ear
disease. In this article, a modified version of August's classifi-
cation scheme will be presented, with a review of the tech-
niques used in the diagnosis of otitis externa and otitis media.
Predisposing Factors
Predisposing factors increase the risk of developing otitis ex-
terna, but rarely cause ear disease on their own. They work in
From North Carolina State University, College of Veterinary Medicine,
Raleigh, NC.
Address reprint requests to K. Marcia Murphy, DVM, Clinical Assistant
Professor in Dermatology, North Carolina State University, College of
Veterinary Medicine, 4700 Hitlsborough Street, Raleigh, NC 27606.
Copyright © 2001 by W.B. Saunders Company
1096-2867/01/1603-0009535.00/0
doi:10.1053/svms.2001.27601
236 Clinical Techniques in Small Animal Practice, Vol 16, No 3 (November), 2001: pp 236-241
conjunction with primary and/or perpetuating factors to cause
clinical disease. Most predisposing factors tend to change the
microenvironment of the ear canal, favoring the development
of opportunistic infections. 2 The most common predisposing
factors encountered are ear canal conformation (stenotic ear
canals, pendulous pinna, hair in the external ear canal), exces-
sive moisture in the external ear canal (frequent swimming or
bathing, high humidity environment), and inappropriate treat-
ment (mechanical trauma to the ear canal by hair plucking
and/or use of cotton-tipped swabs; use of grooming powders;
overuse of cleaning/drying preparations, especially those con-
taining alcohol).2-5 It is important to note that not all dogs with
pendulous ears or hair-filled ear canals develop otitis, and,
conversely, some breeds with erect ears (German shepherd)
seem prone to ear problems. Animals prone to swimmer's ear
often have subclinical atopy or food hypersensitivity. 4 An of-
ten-listed, but rarely encountered, predisposing factor for the
development of otitis externa is systemic disease. For effective
management of otitis externa, the predisposing factors must be
investigated and reasonable measures taken to eliminate or
control them.
Primary Factors
Primary factors directly cause otitis externa. It is absolutely
essential to successful long-term management that the primary
cause of the ear disease be diagnosed and controlled. The epi-
thelium of the external ear canal is an extension of the skin on
the rest of the body; therefore, most cases of otitis externa are
associated with an underlying dermatologic disease/condition. 3
Hypersensitivities
Allergic skin diseases are the most common causes of chronic
otitis externa in dogs. Because of the high incidence of atopy,
and frequency of otitis associated with atopic disease, otitis
externa is more commonly associated with atopy than is food
hypersensitivity. However, ear disease is present in over 80% of
dogs and cats with food allergy, and may be the only clinical
sign in more than 20% of food-allergic dogs. >5 Some breeds
(Cocker spaniel and Labrador retriever, for example) are more
likely to present with otitis externa as the only symptom of food
hypersensitivity. 6 Dogs younger than 6 to 9 months of age with
an acute history of otitis, but no evidence of ear mites or foreign
bodies, and older dogs with no previous history of ear or skin
problems, should have food allergy as a top differential diagno-
sis. Intense facial pruritus, with or without head and ear in-
volvement, is a common clinical sign of food hypersensitivity in
the cat.
Contact hypersensitivity is a rare cause of otitis and is usually
iatrogenic. It may affect the nonhaired portion of the concave
surface of the pinna, dorsal and ventral to the external orifice,
and the external ear canal. Because this is a delayed-type hyper-
sensitivity reaction, the typical history is either: (1) a short-
term response to therapy, and then more than a week into
administration of the medication, the symptoms suddenly
worsen or a "new type of reaction" is noted; or (2) a good
response was noted previously to the medication, but a wors-
ening of the symptoms is seen with the most recent administra-
tion. r

Parasites
Many parasites have been associated with otitis externa, includ-
ing Otodectes cynotis, Demodex canis, Demodex cati, Sarcoptes
scabiei, Notoedres cati, and Otobius megnini (spinous ear tick).
The ear mite, Otodectes cynotis, is the most common, and is
responsible for approximately 50% of the cases of otitis in cats.
In dogs, the ear mite may initiate otitis but be difficult to
demonstrate on microscopic examination of ear swabs. One
explanation for this is that the mites can induce Arthus-type
and immediate-type hypersensitivity reactions; therefore, as
few as 2 or 3 mites can cause clinical signs of otitis. 8,9 Alterna-
tively, the mites initiate the otitis externa and then leave the Fig 1. A wax plug deep within the horizontal ear canal,
canal or are destroyed by the inflammation. 5 Demodex cati may adjacent to the tympanic membrane of a 3-year-old MC Irish
present as a ceruminous otitis externa alone, without any other setter.
cutaneous lesions, in the c a t )
Trauma
Keratinization Disorders
A rarely reported cause of otitis externa is trauma to the exter-
Breeds prone to primary idiopathic seborrhea tend to present nal ear canal. In most cases, the trauma has occurred several
with a chronic ceruminous otitis externa. Many of these breeds, months to years before clinical evidence of otitis externa. ~°
mcluding the American cocker spaniel, English springer span- (Murphy KM, unpublished observation, April and May 2001).
iel, and West Highland white terrier, are also considered aller- The author has treated two such cases. Both patients were
gic breeds; therefore, atopy or food hypersensitivity should also young to middle-aged large-breed dogs (Chesapeake Bay re-
be investigated. Endocrinopathies may be associated with triever, Labrador retriever) presenting with an acute history of
chronic ceruminous otitis, most likely by altering keratiniza- unilateral otitis externa of 2- to 4-week duration, respectively,
tion and possibly glandular [unction. 4 These diseases will have with no prior signs of ear or skin problems. A purulent exudate
other historic and/or physical-examination findings as evidence and a nodular-like lesion were noted in each affected external
for their inclusion on the differential list. ear canal (Fig 4). One of the dogs developed a para-aural ab-
scess, and both showed evidence of middle ear disease. These
F o r e i g n Bodies lesions were found using computed tomography (CT) (Fig 5).
Both dogs had a history of "hit-by-car" 1 year and 3 years,
Anything that can possibly cause obstruction or irritation of the
respectively, before the development of the otitis, but neither
ear canal can be considered as a foreign body. These would
dog had shown signs of ear trauma at the time of the accident.
include plant awns (fox tails), dirt or sand, dried-out medica-
At surgery, the auricular cartilage (vertical ear canal) was sep-
ments, loose or cross-lodged hairs, small toys, and impacted
arated from the annular cartilage (horizontal ear canal). These
wax (Fig 1). Typically, foreign bodies present as unilateral,
findings were similar to previously reported cases. ~°
acute, severely painful otitis externa, although bilateral disease
may occur. In many cases, the inciting foreign body is never
identified, because it may become coated with cerumen and no Perpetuating Factors
longer be visible, or of greater concern, it may migrate through
Perpetuating factors maintain and exacerbate the inflammatory
the tympanic membrane, resulting in the development of otitis
process within the ear canal, and are often the main reasons for
media. If immediate veterinary care is not sought by the owner,
treatment failure, regardless of the predisposing and primary
these cases rapidly develop a secondary bacterial otitis externa
factors present. The perpetuating factors include bacterial and
and present with a purulent exudate. 5
yeast infections, progressive pathologic changes resulting from
Although relatively u n c o m m o n in both dogs and cats, in-
chronic inflammation, and Otltis media. At least one or more of
traluminal tumors may also act as a foreign body in the external
these factors are present in cases of chronic otitis externa. They
ear canal (Fig 3). The most common ear canal tumors of both
must be identified and treatment directed at them specifically.
dogs and cats are the ceruminous gland tumors# These neo-
plasms are more common in cats than in dogs, and in cats are
Bacteria
malignant in about 50% of the cases. In dogs, they are usually
benign5; however, in all cases, the surgically excised tissue A diagnosis of bacterial otitis externa is usually an incomplete
should be submitted for histopathologic examination. diagnosis because the bacterial infection is secondary to the

OTITIS EXTERNA AND OTITIS MEDIA 237

Fig 2. Ruptured tympanic membrane discovered after the
removal of the wax plug noted in Fig 1.
primary cause of otitis. The most common pathogens include
Staphylococcus intermedius, and the gram-negative organisms
Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella spp, and
Escherichia coll. The 4 gram-negative organisms are not rou-
tinely cultured from the normal ear canal; however, S. interme-
dius is often present in low numbers even in normal ears. 3,5
Yeast
As with bacteria, yeast infections are considered secondary to
some primary cause, and may be found in the ear canal of up to
Fig 3. Mass in right external ear canal of a 7-year-old FS
German shepherd, diagnosed as cerumen gland adenocar-
cinoma on histopathology.
238
Fig 4. Mass in left external ear canal of 5-year-old MC Lab-
rador retriever, diagnosed as vertical and horizontal
ear canal avulsion at surgery.
49% of normal dogs and 23% normal cats. ~1 Malassezia pachy-
dermatis is the most common yeast that contributes to ear
disease, and is commonly found in allergic otitis externa. 4
Progressive Pathologic Changes
Chronic inflammation causes the lining of the ear canal to
undergo many changes (epidermal hyperkeratosis and hyper-
plasia, dermal edema and fibrosis, etc), that eventually lead to
thickening of the skin, extending to both sides of the auricular
cartilage. 4 The swelling results in stenosis of the ear canal, and
the skin is thrown into numerous folds, which inhibit cleaning
and the application of topical medications. Fibrosis and calci-
fication (Fig 6) perpetuate the inflammation, worsen the steno-
sis (Fig 7), and further inhibit the effective treatment of deep
infections.
Fig 5. CT of the patient in Fig 4. Note the soft-tissue opacity
in the left tympanic bulla. Middle ear disease was confirmed
at surgery. (For all CT figures, left and right correspond to
the reader's left and right.)
K. MARCIA MURPHY

Fig 6. CT of a 6-year-old M C Rottweiler with a 1-year history
of refractory Pseudomonas otitis externa. Note the evidence
of mineralization of the right external ear canal. There was no
evidence of middle ear disease on CT, at surgical examina-
tion, or on C & S of the bulla at surgery.
Otitis Media
Otitis media is inflammation of the middle ear, and in dogs, the
most common cause is an extension from otitis externa. In cats,
upper-respiratory infections are known causes of otitis media. 5
The presence of exudate within the tympanic cavity is difficult
to treat with topical therapy, and may remain as a source of
infection, proinflammatory toxins, and debris to "reseed" the
external ear canal. When presented with a chronic case of
refractory or recurrent otitis externa, otitis media must be con-
sidered as a possible cause, even with an intact tympanic mem-
brane. In one study, otitis media was diagnosed in 38 dog ears,
with an intact tympanic membrane present in 71% of the ears. 12
Occasionally, an animal will show neurologic signs suggestive
of otitis media or otitis interna, or exhibit pain when eating or
chewing, which is suggestive of the progression of otius media
to involve the temporomandibular joint.
A record of the examination should be kept for each visit.
The lining of the canal is evaluated for erythema, ulcers, nod-
ules, and/or foreign bodies, and the color, quality, and quantity
of the exudate is noted. The character and degree of canal
stenosis is assessed to determine whether it is edematous from
acute inflammation, thickened with a "cobblestone" appear-
ance, or occluded because of hyperplasia or fibrosis. The loca-
tion of the stenosis should also be noted (horizontal canal,
vertical canal, or both). The presence of the tympanic mem-
brane should be determined, as well as its overall appearance
(normal, thickened, ruptured).
Fiberoptic video-enhanced otoscopes improve the visualiza-
tion of the ear canal and the tympanic membrane. In Fig 2, note
the ruptured tympanic membrane discovered after the removal
of the wax plug previously discussed (Fig 1). The videooto-
scope also allows for photographic records to be kept in the
patient's medical record, and shows the client what is occurring
in his/her pet's ear canals.
Cytologic E x a m i n a t i o n
Cytologic examination of the otic exudate is mandatory. It is
the most appropriate method for determining the type and
numbers of microorganisms present (cocci, rods, or budding
yeast). The presence of 4 yeast per oil immersion field (OIF)
and 1 to 4 bacterium per OIF, especially when inflammatory
cells are also present, has been reported as clinically signifi-
cant. 5 Cytology should be performed from the deep ear canal,
and when appropriate, the middle ear cavity. One study dem-
onstrated that the cytology from the external and the middle ear
canals may vary greatly. 12 See the article in this publication for
details on collection techniques and staining protocols for cy-
tologic examination.
C u l t u r e and Sensitivity

Diagnosis Culture and sensitivity (C & S) should not be a routine part of

an otitis diagnostic plan. The primary indiction for C 6¢ S is if
History and Physical Findings
A fundamental part of the diagnostic work-up is a complete
history, including the details of the onset, duration, and pro-
gression of the ear disease (for example: unilateral or bilateral?
other areas of the body affected? seasonal or nonseasonal?);
medications previously used; and response to therapy. A com-
plete physical and dermatologic examination will provide ad-
ditional information to determine predisposing and primary
factors. Each external ear canal and tympanic bulla should be
palpated. Thickened, firm, less pliable canals are associated
with chronic proliferative changes, and suggest a more guarded
prognosis. Mineralized or ossified ear canals are rock hard,
while pain on palpation of the tympanic bulla implies the pres-
ence of otitis media.

Otoscopic E x a m i n a t i o n
An otoscopic examination should be performed at the initial
visit and at each recheck visit thereafter. One should have
multiple aseptic otoscopic cones of varying sizes available, and
use a different cone in each ear canal. At times, an ear canal is
too painful, ulcerated, and/or swollen to be adequately exam-
ined. In such cases, the ear should be treated, to reduce the
inflammation and swelling, and reexamined in 7 to 14 days, at Fig 7. Erosions and severe stenosis of the lining of the right
which time a proper otoscopic examination can be performed. external ear canal of the patient in Fig 6.

OTITIS EXTERNA AND OTITIS MEDIA 239

Fig 8. Myringotomy of left tympanic membrane of a dog
diagnosed with otitis media. Fig 9. Thickened, ruptured right tympanic membrane in the
right ear canal of a 12-year-old domestic shorthair. Note the
appearance of a mass bulging from the tympanic bulla.
systemic therapy is going to be prescribed, for example, when
otitis media is present or for severe otitis externa with rod-like
and which provides superior image contrast in comparison
bacteria. Otic culture should not be performed without first
with radiography. In one study, it was described as a more
performing cytology to demonstrate the presence of bacteria
sensitive test for the detection of otitis media in the dog.13 In the
and inflammatory cells within the exudate. When topical ther-
author's experience, CT is a valuable diagnostic tool. It is rou-
apy alone will be used, C & S is not cost-effective. Recall that
tinely used in our practice to rule out mineralization of the
resistance to a particular antibiotic in vitro may not correlate to
external ear canal (Fig 6), otitis media (Figs 5, 9), and to
clinical response, because direct, topical application of the
evaluate the extent of chronic changes in the external and
medication results in a higher antibiotic concentration than can
middle ear canals before surgical procedures (Figs 9, 10).
be achieved with systemic medication.
If the tympanic membrane is intact, myringotomy (Fig 8)
may be used to obtain a specimen for bacterial CaS, as well as a Summary
sample for cytologic analysis. A thorough flushing of the exter-
The diagnosis of otitis externa is relatively easy, but chronic
nal ear canal should be performed before the myringotomy to
otitis is often a frustrating condition to treat. Primary, predis-
reduce the chance of introducing infection into an unaffected posing, and in cases of chronic disease, perpetuating factors, all
middle ear cavity. It is important that the tympanic membrane
contribute to the pathogenesis of otitis externa. By ensuring
is incised or punctured, using a sterile culture swab passed
through a sterile otoscopic cone, in the caudoventral quadrant
below the attachment to the manubrium. A second swab should
then be passed through the original incision to collect a sample
for cytology. Following sample collection, the middle ear may
then be flushed using isotonic sterile saline.

Radiography and CT
Radiography is indicated in refractory or recurrent cases of
otitis externa, in which otitis media and/or mineralization of
the external ear canal is suspected, and in cases in which sur-
gical intervention is contemplated. Unfortunately, radiography
has been of limited use in diagnosing otitis media. Chronic
changes, such as ossification of the cartilage and thickening of
the bulla, can be identified radiographically; however, normal
radiographic findings do not exclude middle ear disease.
More recently, CT has come into use for evaluating middle
ear disease, and chronic changes involving the external ear Fig 10. CT of the patient in Fig 9. Note the soft-tissue opacity
canal in veterinary patients. CT is a noninvasive diagnostic confined to the right tympanic bulla, diagnosed as an inflam-
imaging technique that can be performed under heavy sedation, matory polyp on histopathology.

240 K. MARCIA MURPHY

that these factors are addressed in the diagnostic, and subse-
quent therapeutic plan, this need not be the case. Successful
management and resolution of ear disease is very rewarding,
both to the clinician and the patient.
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