MANAGING THE DISEASE

Successful management of otitis externa

In Practice: first published as 10.1136/inp.i1951 on 29 April 2016. Downloaded from http://inpractice.bmj.com/ on 13 June 2019 by guest. Protected by copyright.
Tim Nuttall

Otitis is one the most common problems seen in dogs. Most acute cases ■■ Identify and manage the primary cause;
can be managed with topical polyvalent ear preparations. However, these ■■ Correct predisposing factors (if possible);
cases frequently evolve into chronic or recurrent otitis that is much harder
to resolve. Ongoing cycles of infection and inflammation will lead to chronic ■■ Remove debris and discharge;
pathological changes and select for antimicrobial resistance that make ■■ Manage the secondary infection; and
management much more challenging. Diagnosis and management of the
underlying triggers for the otitis is crucial, but clinicians must also understand ■■ Reverse chronic pathological changes.
how best to treat the ongoing infection and inflammation. Knowing how
to recognise and understanding the significance of biofilms is important, Biofilms
as these are under diagnosed and have a major impact on antimicrobial Biofilms have a major impact on treatment and
efficacy. Cytology should be performed in all cases to determine the type of antimicrobial resistance. They are common and
infection and the likely nature of the micro-organisms. Bacterial culture and under-diagnosed, although they can be easily
identified on otoscopy or cytology. Clinically, they
antimicrobial susceptibility, in contrast, are less useful. The tests are based on
form an adherent, thick and slimy discharge that
systemic treatment, and vets need to know how to interpret the results when is often dark brown or black (Fig 2). On cytology
using topical treatment. Topical therapy is generally much more effective, they appear as variably thick veil-like material
and there are a very wide range of anti-microbial and anti-inflammatory that may obscure bacteria and cells (Fig 3).
options available (although not all are licensed for use in animals). Long-term Biofilms are clinically important as
remission of recurrent otitis relies on managing the inflammation in the ear they inhibit cleaning, prevent penetration
canals to prevent flares. Getting clients to understand this is critical. Choosing of antimicrobials and provide a protected
reservoir of bacteria. Also, antimicrobials
appropriate products and demonstrating how to apply them are also
that require bacterial division will be less
important in ensuring good compliance and a good long term outcome. effective, as bacteria in biofilms are usually in
a quiescent state. Biofilms may also enhance
MOST cases of acute otitis externa can be stage otitis that requires surgical intervention. the development of antimicrobial resistance,
managed using polyvalent topical ear products The chronic inflammation makes each bout especially in Gram-negative bacteria that
that include a glucocorticoid (to manage mild of infection harder to treat and repeated acquire stepwise resistance mutations to
acute inflammation), an antimicrobial, and an antimicrobial use may select for resistance. concentration-dependent antimicrobials.
antifungal (for Malassezia). Manual cleaning is
often necessary in cases with large amounts of
General approach to chronic Potential impact of biofilms on
debris. antimicrobial resistance
Cases of chronic or recurrent otitis are
or recurrent otitis
Biofilms generally inhibit antimicrobial
more challenging. Successful treatment Clinical signs and otoscopy penetration (Fig 4). Where this results in an
requires that all the underlying factors leading Most cases can be clinically divided into abrupt drop in the antimicrobial concentration,
to persistence or recurrence of the otitis are erythroceruminous or suppurative otitis (Fig 1). most bacteria will either be exposed to high
identified and managed (see pages 7 to 11 and Erythroceruminous otitis is characterised or low antimicrobial concentrations. Most will
12 to 16 for more details). In particular, it is by erythema, pruritus and a ceruminous to therefore be eliminated or unaffected. The
important to recognise the role of inflammation seborrhoeic discharge. It is most commonly unaffected bacteria in the biofilm will act as a
in otitis. Nearly all ear infections involve associated with a staphylococcal or Malassezia reservoir and lead to treatment failure, but the
commensal (eg, staphylococci and Malassezia) overgrowth. Suppurative otitis is characterised selection pressure for resistance is relatively low.
or environmental (eg, Pseudomonas) by erythema, ulceration, pain and a purulent However, with some antimicrobial penetration
organisms that are opportunists. True primary discharge. Most cases are associated with into the biofilm and a gradual decrease in
pathogens are rare and the vast majority a Pseudomonas species infection. Cytology, concentration, some bacteria will be exposed to
of infections are secondary to pre-existing including unstained cerumen preparations, intermediate concentrations. This could provide
inflammation, foreign bodies, obstruction or can be used to quickly confirm the presence of a mutant selection window in which the more
other primary problems. Otodectes mites, neutrophils, staphylococci, susceptible bacteria are killed but more resistant
Most owners and clinicians recognise other cocci, rods and Malassezia. mutants within the population survive. This will
ear infections, which are then successfully Otoscopy is important to determine the lead to treatment failure and recrudescence of
managed. However, the ongoing inflammation is state of the ear canals, the type and amount the infection with a more resistant isolate.
often missed. This leads to a cycle of recurrent of discharge and the integrity of the tympanic
infection and chronic inflammation leading to membrane. All cases of acute otitis should be
progressive pathological changes and end- carefully examined to rule out foreign bodies Bacterial culture and
and Otodectes mites. sensitivity testing
Tim Nuttall, Using cytology to predict
Head of Dermatology, Royal (Dick) School of
Underlying causes susceptibility patterns
Veterinary Studies, University of Edinburgh, Chronic or recurrent otitis should be carefully Bacterial culture and sensitivity testing is not
Easter Bush Campus, Roslin, Midlothian, UK evaluated to identify primary, predisposing and necessary in most cases of otitis externa and/
email: tim.nuttall@ed.ac.uk perpetuating causes. Successful management or where topical therapy is used. Cytology can
requires that these are all treated. The goals are: effectively identify the most likely organisms in

In Practice  FOCUS  May 2016 17

17-21 Nuttall.indd 17 22/04/2016 12:58

 (a) (b)
Fig 1: Erythroceruminous (a) and suppurative otitis (b). Erythroceruminous otitis is characterised
by erythema, pruritus and a waxy to seborrhoeic discharge. Most cases are associated with
staphylococci or Malassezia species and neutrophils are rare. Suppurative ears are often
painful and ulcerated with a neutrophil-rich purulent discharge. Most cases are associated with
Pseudomonas species
most cases of otitis. This is particularly useful differentiate on cytology, eg, streptococci,
in mixed infections, where culture may identify enterococci, Escherichia coli, Klebsiella,
several organisms with different susceptibility Proteus and coryneforms. Knowledge of their
patterns. likely sensitivity patterns can then help guide
Malassezia and staphylococci are easily treatment choices.
identified and their likely sensitivity can be
estimated from a knowledge of local resistance Understanding breakpoints and
patterns and previous treatment. Gram- resistance
negative bacteria are harder to differentiate The reported antimicrobial susceptibility
on cytology alone, although Pseudomonas results are less useful in otitis, especially with
are the most common. Their susceptibility topical treatment. The breakpoints used to
pattern is harder to predict, although most determine susceptibility or resistance assume
first-time infections are susceptible to systemic treatment. These are determined
topical aminoglycosides, polymixin B, silver using pharmacokinetic data to estimate
sulfadiazine and fluoroquinolones. However, tissue levels following standard dosing. If the
Pseudomonas species readily acquire zone of inhibition around the antimicrobial
resistance and most isolates from recurrent disc representing the minimum inhibitory
infections will be multi-drug resistant. concentration (MIC) exceeds the breakpoint, it
is unlikely that the antimicrobial will attain a
Using bacterial culture and therapeutic concentration in the target tissue
antimicrobial sensitivity testing and the infection can be regarded as resistant
Bacterial culture and sensitivity testing to that antimicrobial (Fig 5). However, this does
definitively identifies the bacteria involved not necessarily mean that the bacteria are
in the infection. This can be useful for resistant to the antimicrobial, as sufficiently
less common organisms that are hard to high levels may exceed the MIC.
Sensitivity data is less
useful for topical drugs
because concentrations
in the ear canal are much
higher than those used
with in vitro tests predict.
The response to treatment
is best assessed using
clinical criteria and cytology.
Antimicrobial sensitivity data
can be used to predict the
efficacy of systemic drugs,
although the concentration
in the ear tissues is often low
and high doses are needed.
For example, enrofloxacin
would need to be given at 20
mg/kg to treat Pseudomonas
isolates with an MIC of 0.5 μg/
Fig 3: Cytology smear of the biofilm in Fig 2. Note the abundant,
variably thick purple staining filaments forming a lace-like pattern ml (middle of the susceptible
(red arrow). There are numerous staphylococci (yellow arrow) and range in Fig 5) in chronic
a single neutrophil (white arrow). Rapi-Diff stain, x 400 otitis.
18 In Practice  FOCUS  May 2016
17-21 Nuttall.indd 18
In Practice: first published as 10.1136/inp.i1951 on 29 April 2016. Downloaded from http://inpractice.bmj.com/ on 13 June 2019 by guest. Protected by copyright.
Fig 2: Biofilm from a dog with otitis externa.
Note the dark, slimy and adherent discharge
Topical and systemic
antimicrobial therapy
Choosing topical or systemic
therapy
Topical therapy is preferred wherever
possible. This results in high concentrations
in the ear canals. Moreover, systemic
antimicrobial therapy may be less effective in
erythroceruminous otitis externa as organisms
are present only in the external ear canal and
cerumen, there is no inflammatory discharge
and penetration to the lumen is poor.
Systemic treatment could be more useful in
suppurative otitis externa and/or otitis media
where there is an active inflammatory discharge
with concurrent infection in the deep ear canal
tissues and middle ear, although there is debate
over this. Systemic treatment is more clearly
indicated when the ear canal cannot be treated
topically (eg, stenosis or compliance problems
or if topical adverse reactions are suspected)
and in otitis media.
Topical antimicrobials
Polymixin B, fusidic acid, florfenicol,
gentamicin, enrofloxacin and marbofloxacin
are suitable for most bacterial infections.
Polymixin B and miconazole have synergistic
activity against Pseudomonas and other Gram-
negative organisms, and fusidic acid and
framycetin show synergistic activity against
staphylococci. Fluoroquinolones, gentamicin
and polymixin B are usually effective against
Pseudomonas. Fusidic acid and florfenicol
are effective against meticillin-resistant
Staphylococcus aureus and meticillin-resistant
Staphylococcus pseudintermedius (Nuttall and
Forster 2015). Neomycin is less potent that other
aminoglycosides, although it is usually effective
against Gram-positive bacteria.
It is important to use an adequate volume to
penetrate into the ear canals – 1 ml is sufficient
for most ears. The Easotic pump (Virbac) and
Osurnia tubes (Elanco) accurately deliver 1 ml
doses, but it is difficult to achieve consistent
dosing with other products. One solution
is to draw the product up into a syringe for
administration, ensuring that an appropriate
dose is delivered each time.
The efficacy of concentration-dependant
drugs (eg, fluoroquinolones and aminoglyco-
sides) depends on delivering concentrations
of at least 10 times the MIC once daily. Time-
dependant drugs (penicillins and cephalosporins)
22/04/2016 12:58
 require concentrations above the MIC for at
least 70 per cent of the dosing interval. This is
readily achieved with topical therapy, which
achieves high local concentrations that probably
persist in the absence of systemic metabolism.
For example, concentrations of gentamicin
have been shown to be three to 15 times and
concentrations of miconazole 1.2 to 2.0 times the
MIC90 for canine otic isolates of staphylococci
and Malassezia, respectively, 10 days after a five-
day course of Easotic. Levels of florfenicol and
terbinafine were at least 1000 times the MIC90
for staphylococci and Malassezia, respectively,
for the duration of treatment with two doses of
Osurnia (Nuttall and Forster 2015).
Removal of debris and purulent material greatly
improves the efficacy of topical antimicrobials,
especially aminoglycosides and polymixin B. The
antimicrobial activity of ear cleaners is variable,
but has been shown to be associated with isopropyl
alcohol, parachlorometaxylenol, chlorhexidine
and a low pH. Acidic cleaners may inactive some
antimicrobials (especially aminoglycosides and
fluoroquinolones), although ear canals have good
buffering capacity and the pH rapidly returns to
normal.
Systemic antimicrobials
Clindamycin, lincomycin, cefadroxil, cefalexin
and clavulanate-potentiated amoxicillin are good
first line drugs for staphylococcal infections.
Cefovecin is appropriate if compliance and/or
administration are, or are likely to be, difficult.
Fluoroquinolones are reserved for second
line use where there is culture evidence that
first-line drugs would not be appropriate.
However, tissue penetration of antimicrobials
with a low volume of distribution (eg,
penicillins and cephalosporins) can be limited.
Fluoroquinolones, which have a high volume
of distribution and penetrate well into most
tissues, may have better efficacy in infections
otherwise susceptible to other antimicrobials.
Itraconazole, ketoconazole and terbinafine (not
licensed for use in animals) can be considered
for Malassezia infections of both the external
ear canal and middle ear, although Malassezia
infections of the middle ear are rare.
Pseudomonas otitis
Pseudomonas are resistant to many anti­
microbials through low cell wall permeability,
b-lactamases, clavulanate-resistance and
efflux pumps. They readily develop further
resistance if treatment is ineffective as they have
a large genome to express resistance genes
and mutations, and are capable of plasmid,
transposon and bacteriophage transfer. Once
fluoroquinolone resistance is established other
anti-Pseudomonas antimicrobials are indicated;
these are often expensive, not licensed for
animals and have to been given intravenously if
used systemically (Table 1).
Potential toxicity of
antimicrobials
Ticarcillin, polymyxin B, neomycin, tobramycin
and amikacin are potentially ototoxic and should
be used with care if the tympanic membrane is
ruptured. Neomycin and other components of
17-21 Nuttall.indd 19
Fig 4: Potential impact
of biofilms on bacterial
resistance. There
Antimicrobial concentration
is an abrupt drop in
concentration if the
antimicrobial fails to
penetrate the biofilm
In Practice: first published as 10.1136/inp.i1951 on 29 April 2016. Downloaded from http://inpractice.bmj.com/ on 13 June 2019 by guest. Protected by copyright.
(solid line). The biofilm
protects the bacteria
leading to treatment
failure, but there is
relatively little selection
for resistance. However,
if the antimicrobial can
partially penetrate Biofilm Open ear canals
the biofilm there may
be a gradual drop in Tympanic Opening to
concentration (dotted membrane ear canal
line). The intermediate
concentrations will kill
more susceptible bacteria but allow more resistant mutants to survive and proliferate. This will
result in treatment failure and recrudescence of the infection with a more resistant isolate. These
data are taken from theoretical and in vitro studies
topical products can cause contact reactions. Topical trizEDTA and n-acetylcysteine can
Enrofloxacin, marbofloxacin, ceftazidime and disrupt biofilms, facilitating their removal
silver sulfadiazine appear to be safe in the middle and enhancing penetration of antimicrobials.
ear. There is potential for systemic toxicity Systemic administration of n-acetylcysteine is
with silver sulfadiazine and aminoglycosides well tolerated and can help dissolve biofilms
in extensively ulcerated ears, although this is in the middle ear and other mucous surfaces.
unlikely in practice as the total body dose will be Systemic n-acetylcysteine and bromhexine
low except in very small animals. The ototoxicity of can also liquefy mucus, facilitating drainage in
gentamicin appears to depend on the preparation, cases of primary secretory otitis media in dogs
and topical application of injectable solutions and feline inflammatory otitis media (polyps).
of gentamicin appears to be safe. Systemic
aminoglycosides can be nephrotoxic and renal
function should be monitored. Fluoroquinolones TrizEDTA
can cause cartilage damage in dogs under TrizEDTA damages bacterial cell walls and
12 months old (18 months in giant breeds), increases antimicrobial efficacy, which can
neurotoxicity at high doses, and blindness in cats overcome partial resistance. It is best given 20
(especially with injectable enrofloxacin). to 30 minutes before the antimicrobial but can
be co-administered. It is well tolerated and non-
ototoxic. TrizEDTA shows additive activity with
Treatment of biofilms and
chlorhexidine, gentamicin and fluoroquinolones
mucus at concentrations of 35.6/9.4 mg/ml, but there
Biofilms can be physically broken up and is no evidence of synergy and efficacy at lower
removed by thorough flushing and aspiration. concentrations. Solutions of 0.6 per cent
Fig 5: Antimicrobial
susceptibility results for
a multi-drug resistant
Pseudomonas isolated
from a case of otitis
externa in a dog. The
results appear to indicate
that there are only four
suitable antimicrobials,
but this is only true for
systemic treatment.
The row of letters in
the reference range
represent the range of antimicrobial dilutions that the isolate is cultured with (for enrofloxacin
this is [right to left] 2.0 μg/ml, 1.0 μg/ml, 0.5 μg/ml, 0.25 μg/ml). The lower case letters refer to
the accepted standards and the upper case letters refer to the actual MIC; in this case, the MIC for
enrofloxacin is more than or equal to 2.0 µg/ml (the highest tested concentration). The lower case
‘s’ and ‘r’ ranges show the breakpoint following systemic dosing, ‘i’ refers to intermediate where
the breakpoint is uncertain – in practice regard these as resistant. If the MIC falls within the ‘r’
range, then it is unlikely that the drug will attain a therapeutic concentration in the target tissue.
Treatment is therefore unlikely to be successful and the infection should be regarded as resistant
to that antimicrobial. If, however, the MIC falls within the ‘s’ zone, then it is likely that the drug will
exceed the therapeutic concentration in the target tissue. Treatment is likely to be successful, and
the infection can be regarded as sensitive to that antimicrobial. Note that use of the term infection
rather than bacteria; these results do not mean that an antimicrobial cannot eliminate the bacteria,
only that systemic treatment would not be effective in that infection. The bacteria may still be
eliminated by a sufficiently high concentration, which is why topical therapy is often effective even
when in vitro test results show apparent resistance. This is particularly true for concentration-
dependent antimicrobials (eg, aminoglycosides and fluoroquinolones), where the efficacy is
proportional to the ratio between concentration and MIC
In Practice  FOCUS  May 2016 19
22/04/2016 12:58
 Table 1: Antimicrobials that can be effective in Pseudomonas otitis Table 2: Relative potency of topical
Antimicrobial Delivery glucocorticoids
Ciprofloxacin* 0.2% solution 0.15-0.3 ml/ear q24h Potency Glucocorticoid
Very potent glucocorticoids Fluocinolone
Enrofloxacin¶ 15-20 mg/kg orally q24h; 2.5% injectable solution diluted 1:4 with saline or Epiotic
(up to 100 x hydrocortisone)
(Virbac) topically q24h; 22.7 mg/ml solution 1 ml/ear q24h

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Potent glucocorticoids Betamethasone
Marbofloxacin¶ 5-10 mg/kg orally q24h; Aurizon (Vetoquinol) and Marbodex (Norbrook); 1% injectable
(25-100 x hydrocortisone) Dexamethasone
solution diluted 1:4 with saline topically q24h; 20 mg/ml solution 1 ml/ear q24h
Hydrocortisone
Ofloxacin* Ofloxacin 0.3% 0.15-0.3 ml/ear q24h aceponate
Mometasone furoate
Carbenicillin* 10-20 mg/kg intravenously q8h
Moderate glucocorticoids Prednisolone
Ceftazidime*† 25-50 mg/kg intravenously q8h; 100 mg/ml 1 ml/ear q12-24h
(2-25 x hydrocortisone) Triamcinolone
Silver sulfadiazine*# Dilute 0.1-0.5% in saline or trizEDTA; apply 1 ml q24h
Mild glucocorticoids Hydrocortisone
Polymixin B Surolan (Elanco)
This table should be used for guidance only, as
Amikacin* 10-15 mg/kg subcutaneously q24h; 50 mg/ml 1 ml/ear q24h the relative potency of topical glucocorticoids
also varies with the concentration, formulation
Gentamicin 5-10 mg/kg subcutaneously q24h; Otomax (MSD Animal Health) or Easotic (Virbac)
and preparation. Topical therapy is safer than
Tobramycin* Use eye drops or 8 mg/ml injectable solution 0.15-0.3 ml/ear q24h systemic therapy but adverse effects can be seen,
for example, the hypothalamic-pituitary-adrenal
* Not licensed for animals - these drugs and preparations should only be used where clinically justified (HPA) axis can be affected for up to two to four
under the Cascade and with the informed consent of the owners weeks after otic administration of dexamethasone.
¶ Topical use in ears is not stated on the product label
† Reconstituted solution stable for up to seven days at 4ºC or one month if frozen
Hydrocortisone aceponate and mometasone
# Silver sulfadiazine shows additive activity with gentamicin and fluoroquinolones (although synergy has not
furoate show less local atrophy and systemic
absorption than other glucocorticoids. Atrophic
been proven) effects can be useful in reversing fibrosis and
stenosis early in treatment, but may later interfere
enrofloxacin, 0.2 per cent marbofloxacin, 0.3 per formed from the invagination and extension of with epidermal migration allowing debris and
cent gentamicin, 0.1 per cent amikacin, 2.8 per the tympanic membrane. This can only be done desquamated cells to accumulate in the ear canals
cent ticarcillin and 1.7 per cent ceftazidime in under general anaesthesia by passing a catheter
trizEDTA are effective against many multi-drug- into the middle ear. Otitis media may need three
resistant bacteria including Pseudomonas. to four weeks (and possibly longer) systemic conditions such as atopic dermatitis (Fig 6).
treatment, which is a problem if parenteral Glucocorticoids (particularly dexamethasone)
Ear wicks drugs are used. Pseudomonas infections, also reverse the ototoxic effect of Pseudomonas
however, usually clear quickly once effective infections.
Polyvinyl acetate ear wicks can be useful in cleansing, antimicrobial treatment and control
certain cases. These are cut to size and inserted of the primary cause are established. Using topical or systemic glucocorticoids
into the ear canal under anaesthesia, soaked with Opinion is divided on the systemic treatment The choice largely depends on the severity of
an antimicrobial, trizEDTA and/or steroid solution of otitis media; some referral clinicians the otitis. It is important to carefully assess the
and left for three to 10 days, applying the ear always use systemic treatment, others instil degree of pain, firmness, mobility, erythema,
solution once daily. The wicks absorb discharge antimicrobials directly into the middle ear every swelling, fibrosis and stenosis of the ear canals
and draw the antimicrobial solution into the three to 10 days (enrofloxacin, marbofloxacin, by palpation and otoscopy. Topical therapy is
ear canals. Steroid-soaked wicks can resolve gentamicin, clotrimazole and miconazole preferred as this delivers the drug to the affected
stenosis of the ear and prevent stenosis following appear to be safe used in this way), some use site avoiding systemic exposure, and most
sharp or laser surgery to remove polyps and other topical therapy and some a combination of polyvalent ear products contain a glucocorticoid.
masses within the ear canal. However, they may approaches. It is likely that antimicrobials Systemic treatment is necessary if there is
prevent drainage from the middle ear in cases of persist for several days following direct stenosis, severe fibrosis or mineralisation, or if
discharging otitis media and are contra-indicated application into the middle ear, because this topical therapy cannot be safely administered. It
in ears with copious exudates that need regular is effectively a blind-ending sac with limited is usually possible to switch to topical therapy
ear cleaning. Ear wicks are tolerated provided drainage into the pharynx. once the ear canals have opened. Animals
that they are kept moist. better tolerate topical therapy once the pain and
Anti-inflammatory treatment inflammation has decreased.
Treating otitis media Reducing pruritus, swelling, exudation and
It is crucially important to flush out any debris tissue proliferation is a key goal of therapy, and Topical glucocorticoids
from the middle ear cavity or pseudocavity maintenance treatment is necessary in ongoing The glucocorticoids incorporated in topical
ear medications are appropriate for managing
mild to moderate inflammation in acute otitis
externa. Use of antimicrobial-containing
Fig 6: Successful long-term
management of otitis secondary products, however, is not indicated in the
to chronic inflammatory absence of infection. There is a variety of
conditions, such as atopic glucocorticoid-containing eye drops, ear drops
dermatitis, requires ongoing and ear cleaners available, although these
Inflammation

regular anti-inflammatory may not be licensed for use in animals. Soluble

treatment to maintain remission
glucocorticoid preparations can also be added
and prevent relapses of infection.
Such proactive therapy (the lower to trizEDTA solutions to create rinses with
orange line) gives a much better an appropriate glucocorticoid concentration
prognosis. Reactive treatment (eg, 0.1 per cent dexamethasone) (again, not
of each bout of infection (the licensed for use in animals).
upper red line) gives short-term Mild inflammation responds rapidly to low
relief, but misses the ongoing
Time potency topical glucocorticoids, but progressively
inflammation in the absence of
infection. This allows chronic more severe inflammation requires longer
inflammatory changes to develop that will result in more frequent and severe infections. These courses of more potent products (Table 2). Very
cases will eventually need a total ear canal ablation potent products should be avoided in severe

20 In Practice  FOCUS  May 2016

17-21 Nuttall.indd 20 22/04/2016 12:58

 bacterial infections, particularly Pseudomonas,
as they may suppress neutrophil activity. Once
the otitis has resolved, topical glucocorticoids
should be used at the lowest frequency that
controls the inflammation.
Systemic glucocorticoids and other
References and further reading
ANIYA, J. S. & GRIFFIN, C. E. (2008) The effect of otic
vehicle and concentration of dexamethasone on liver
enzyme activities and adrenal function in small breed
healthy dogs. Veterinary Dermatology 19, 226-231
BECO, L., GUAGUÈRE, E., MENDEZ, C. L., NOLI,
canine otitis externa from three European countries.
Veterinary Dermatology 24, 439-445
PYE, C. C., SINGH, A. & WEESE, J. S. (2014)
Evaluation of the impact of tromethamine edetate
disodium dihydrate on antimicrobial susceptibility
of Pseudomonas aeruginosa in biofilm in vitro.
Veterinary Dermatology 25, 120-123

anti-inflammatory agents
Prednisolone (1 to 2 mg/kg every 12 to 24 hours)
or methylprednisolone for one to three weeks is
sufficient to control inflammation and stenosis
in most cases. Patients with severe fibrosis
and stenosis, however, may respond better to
betamethasone or dexamethasone (7.5 to 10 times
as potent as prednisolone). Ciclosporin has also
been shown to be effective in some cases of chronic
otitis. Long-term treatment usually involves
prednisolone, methyl-prednisolone or ciclosporin
used at the lowest frequency and dose that
prevents recurrence of the otitis (particularly as
this helps to manage underlying allergic conditions
that give rise to the otitis). Dexamethasone can be
used with care twice weekly.
Compliance and adherence
Poor compliance or adherence will compromise
efficacy and encourage resistance. Compliance
problems include under-dosing, missed doses
and stopping treatment early. Discussing potential
problems openly and honestly with owners helps
to select the most appropriate drug and dosing
regime. Compliance can be improved by:
■■ Using long duration topical or injectable,
once daily and/or palatable medication;
■■ Using drugs that the owner is able to and
wants to administer;
■■ Convincing the owner of the importance of
correct treatment;
■■ Giving written instructions;
■■ Demonstrating how to administer topical
therapy and how to clean ears;
■■ Using precise terminology, eg, ‘every 12
hours’ instead of ‘twice daily’;
■■ Good follow up and communication;
■■ Minimising the number of different drugs or
treatments;
Using analgesia to facilitate cleaning and
■■
topical medication;
■■ Recommending regular revisits to assess
the ear disease; and
■■ Emphasising that management and control
is the aim, not usually cure of chronic otitis.
C., NUTTALL, T. & VROOM, M. (2013) Suggested
guidelines for using systemic antimicrobials in
bacterial skin infections: part 1 – diagnosis based
on clinical presentation, cytology and culture.
Veterinary Record doi:10.1136/vr.101069
BECO, L., GUAGUÈRE, E., MENDEZ, C. L., NOLI,
C., NUTTALL, T. & VROOM, M.(2013) Suggested
guidelines for using systemic antimicrobials in
bacterial skin infections: part two – antimicrobial
choice, treatment regimens and compliance.
Veterinary Record doi:10.1136/vr.101070
BOYEN, F., VERSTAPPEN, K. M., DE BOCK,
M., DUIM, B., WEESE, J. S., SCHWARZ, S.,
HAESEBROUCK, F. & WAGENAAR, J. A. (2012)
In vitro antimicrobial activity of miconazole and
polymyxin B against canine meticillin-resistant
Staphylococcus aureus and meticillin-resistant
Staphylococcus pseudintermedius isolates.
Veterinary Dermatology 23, 381-385
BUCKLEY, L. M., MCEWAN, N. A. & NUTTALL, T. (2013)
Tris-EDTA significantly enhances antibiotic efficacy
against multi-drug-resistant Pseudomonas aeruginosa
in vitro. Veterinary Dermatology 24, 519-e122
COLE, L. K., PAPICH, M. G., KWOCHKA, K. W.,
HILLIER, A., SMEAK, D. D. & LEHMAN, A. M.
(2009) Plasma and ear tissue concentrations
of enrofloxacin and its metabolite ciprofloxacin
in dogs with chronic end-stage otitis externa
after intravenous administration of enrofloxacin.
Veterinary Dermatology 20, 51-59
DÉGI, J., IMRE, K., CATANA, N., MORAR, A., SALA,
C. & HERMAN, V. (2013) Frequency of isolation and
antibiotic resistance of staphylococcal flora from
external otitis of dogs. Veterinary Record
doi: 10.1136/vr.101426
HENNEVELD, K., ROSYCHUK, R. A., OLEA-POPELKA
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Competing interests
In the past five years, the author has received
lecture, consultancy, research fees or other support
from Virbac, Elanco Animal Health, Zoetis, Royal
Canin, Iams (Proctor & Gamble Pet Care), IDEXX
Laboratories, Avacta Animal Health, Vétoquinol,
CEVA and Dechra Veterinary Products.
doi: 10.1136/inp.i1951

Tim Nuttall graduated from the University of Bristol in 1992. After three years in general practice he joined the
dermatology service at the University of Edinburgh as a resident and later studied for a PhD on canine atopic dermatitis.
He joined the University of Liverpool in 2001 and in 2004 was made senior lecturer in veterinary dermatology. Tim
developed a busy referral dermatology clinic, which now sees over 1000 appointments each year. He also had an
active research programme, studying antimicrobial resistance, host-pathogen interactions and the genetics of canine
atopic dermatitis. In August 2013, he returned to the Royal (Dick) School of Veterinary Studies in Edinburgh as head of
dermatology. He has written over 70 clinical and scientific publications, is a co-author of the second edition of A Colour
Handbook of Skin Diseases of the Dog and Cat, and has presented over 100 lectures throughout the world. In addition,
he has served on BSAVA, ESVD and Defra scientific committees, the International Committee on Atopic Diseases in
Animals, is a scientific adviser to the Bella Moss Foundation and has been a co-editor of Veterinary Dermatology. He is
a RCVS Specialist in Veterinary Dermatology.

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