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Examination of the Ear

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Examination of the Ear ASK THE EXPERT h OTOLOGY h PEER REVIEWED Examination of the Ear Louis Norman Gotthelf, DVM Animal Hospital of Montgomery Montgomery, Alabama Pinnal & Preauricular YOU HAVE ASKED ... 1 Skin Examination CAUSES OF How should I conduct thorough Examination of the pinnae to assess for PINNAL DISEASE primary and secondary lesions can help ear examinations in my patients? formulate a list of differential diagnoses h Trauma and diagnostic tests (see Causes of Pin- h Hematoma nal Disease). Lesions found on the pin- THE EXPERT SAYS ... h Ectoparasites nae may also suggest conditions such as A thorough physical examination of the allergy, inflammatory/autoimmune con- h Immune-mediated ear should include 3 independent parts: ditions, infections, and infestations. disease h Keratinization defects 1. Pinnal and preauricular skin Pustules on the pinnae (Figure 1) can h Malassezia examination suggest either infectious (eg, pyoderma) spp and dermatophytes 2. Otoscopic examination or sterile disease (eg, pemphigus folia- 3. Tympanic membrane assessment ceus). Cytologic examination of the pus- h Neoplasia tules may show acantholytic cells and h Atopic and contact neutrophils indicative of pemphigus. dermatitis Neutrophils and bacteria can be seen in h some infectious causes of pustules. Papu- Endocrine disorders lar eruptions may also be seen with para- sitic diseases. 64 cliniciansbrief.com December 2016 Thick scale and erythema of the pinnal folding in pendulous-eared dogs may margins, particularly the apices, may indicate fly strike or mosquito bite VISUAL indicate sarcoptic mange, especially hypersensitivity in cats. Traumatic EXAMINATION when a “pinnal-pedal” scratch reflex injury to the pinna may mimic other OF THE EAR occurs in response to rubbing of the pin- conditions. CANAL nae. In addition, erythema, crusts, and h scale may be present with demodicosis Lichenification, erythema, hyperpig- The canine ear canal consists of overlapping or dermatophytosis. Low-power exam- mentation, and glandular hyperplasia of cartilage plates in a bent, ination of skin scrapings placed in min- the concave pinnae may indicate chronic funnel-shaped, tapered, eral oil on a microscope slide may help allergic dermatitis, often with concur- cylindrical structure that identify the presence of parasites. Fun- rent otitis externa. When found in provides the “L” shape to gal culture may be indicated. cocker spaniels, this may be a manifes- the vertical and tation of primary idiopathic seborrhea horizontal ear canals. If vasculitis is suspected as a result of associated with ceruminous otitis.3 Cats have more of an arc ulceration, necrosis, notching, and/or Topical drug reactions—particularly to shape to their ear canal scarring of the pinnal margin, a biopsy neomycin-containing otic medications— than do dogs. Before may be necessary to examine for capil- may also result in pinnal erythema and/ inserting the otoscope, lary thrombosis. Ear margin seborrhea, or erosions or ulcerations. palpation of the vertical a nonpruritic primary cornification ear canal should be performed to assess defect often found in dachshunds and Many pinnal tumors exist, including cartilage plasticity. Any Yorkshire terriers, may result in kerati- ceruminous gland adenomas in dogs pain or bony changes to naceous debris or alopecia along the ear and squamous cell carcinomas in the cartilage should be 1 margins. Cytologic examination of white-eared cats. noted. secretions may disclose colonization by h Malassezia spp. Bacterial and yeast otitis externa are typically confined to the ear canal A pinna that is no longer erect may indi- and/or pinnae. However, cate ear pain. Palpation of the pinnal bacterial exudates from cartilage, especially at the ear base, may chronic otitis externa indicate bony changes suggestive of pooling in the horizontal chronicity. Aural hematoma typically canal can cause erosion indicates pain or pruritus in the ear and of the eardrum leading to can result from violent head shaking, secondary otitis media or trauma, or autoimmune diseases.2 An interna. With neoplasia, aural hematoma on one side may result trauma, or severe otitis from otitis externa in the opposite ear. externa, extension of infection to surrounding tissues (cellulitis, abscess) Excoriation of the pinnal surface indi- is possible. cates self-trauma from pruritus that is often caused by otitis externa. Pinnal dermatitis and crusting with accumula- tion of purulent material on the base of the concave pinna may result from severe suppuration with otitis externa. d FIGURE 1 Pinnal erythema on the concave Hemorrhagic crusting of the ear tips of surface in an English bulldog with atopy. Note erect-eared breeds and of the pinnal the presence of pustules and papules. December 2016 cliniciansbrief.com 65 ASK THE EXPERT h OTOLOGY h PEER REVIEWED Otoscopic Examination In most dog breeds, the narrower horizontal 2 In nonanesthetized patients, an oto- ear canal has significantly fewer hair follicles scope cone of the proper diameter is gently with minimal glands. The exceptions are the inserted into the vertical ear canal. Once the American cocker spaniel, which has more ear canal lumen is centered in the eyepiece, glandular tissue density along the ear canal the otoscope cone is advanced deeper into the than do many other breeds,4 and the stan- ear canal. This technique avoids painful dard poodle, which anecdotally seems to scraping of the sides of the ear canal. have a higher density of hair follicles along the ear canal. As the canal narrows and bends, the pinna is grasped gently and moved outward and downward to straighten out the ear canal. After making the bend into the horizontal ear canal and advancing the speculum, the eardrum should be visualized (Figure 2). In nonclinical dogs without any apparent signs of otitis externa, only a quick otoscopic examination is necessary. After a veterinar- ian becomes familiar with the normal canine and feline ear, pathologic changes should be easy to identify. Some patients—healthy or otherwise—will require sedation or anesthesia. Sedation is also recommended for any patient that is markedly painful and/or fails to respond to d FIGURE 2 Examination of the ear with an otoscope. The empiric therapy. This is especially important pinna is elevated to examine the vertical ear canal and is for patients with unilateral ear disease as a gently pulled down and out to examine the horizontal source of discomfort (eg, foreign body lodged ear canal. in the ear canal). The Ear Canal The ear canal is lined by a modified epidermis. The wide vertical ear canal con- tains hairs surrounded by sebaceous glands, as well as aprocrine glands unassociated with hair follicles. The normal vertical ear canal glistens because of the cerumen coating (Fig- ure 3). On examination of the ear canal with the otoscope, the skin of the vertical and hor- izontal ear canals should be nonerythema- tous. The epithelium of the ear canal is d FIGURE 3 Normal canine vertical canal. Blood vessels smooth. A network of blood vessels in the are visible in the dermis through the thin epithelium. A dermis is present. glistening coating of cerumen is present on the epithelial surface. 66 cliniciansbrief.com December 2016 Cerumen Cerumen is composed of apocrine (watery) and sebaceous (lipid) secretions as well as desquamated keratinocytes. Normal ceru- men coats the epithelium, protects against pathogens, and aids in prevention of water loss from the ear canal epithelium. Its sticki- ness helps trap particles and other debris. In human cerumen, antimicrobial lipids (eg, sapienic and lauric acids) and antimicrobial peptides can be beneficial against many fungi d FIGURE 4 Cerumen gland hyperplasia. Inflammation in and bacteria. These substances have yet to be the ear canal results in increased secretions from the identified in canine or feline cerumen.5 Ceru- apocrine glands, which enlarge above the epithelial men changes its composition in the presence surface. of disease; it becomes less waxy and more hydrated. Normal cats have scant, thin ceru- Parasites men but may produce excessive cerumen in Live ear mites may be seen via otoscope response to diseases such as atopy or endo- crawling along the epithelial surface when crine disease. a patient’s head is held as still as possible. Cats tend to have larger numbers of mites; Removal of mild cerumen accumulations in the white-colored mites in the ear canal are normal ears using ear cleaners is not recom- seen crawling along the dark brown otic mended. The normal process of epithelial secretions. Other parasites (eg, ticks, flies) or migration removes accumulated ceruminous foreign material (eg, grass awns, seeds) may secretions as the surface epithelial cells be seen in the canal. move toward the outside of the ear canal to maintain ear health. In many ear diseases, Stenosis & Swelling this physiologic cleaning mechanism is dis- Any change in the epidermis, such as with rupted and copious cerumen accumulates in ceruminous gland hyperplasia or ulceration, the ear canal. is significant and should be noted Figure( 4). In a patient with inflammatory ear disease, Hair Loss thickening of the epithelium may obscure Clinical signs of otitis with exudate in the ear visualization of blood vessels. The clinician canals may result in a depilatory effect from should assess for presence of stenosis. caustic enzymes dissolving the keratin that Some dog breeds (eg, shar-peis, pugs) have comprises the hairs—similar to the hair loss small-diameter ear canals as part of their seen on the body in the form of an acute, moist standard conformation. Differentiation dermatitis or hot spot. Clinically, this is iden- between swelling and stenosis is necessary. tified as an absence of hair found in the ear Stenosis results from permanent pathologic canal during the acute phase of otitis externa. changes within the epidermis of the ear canal With resolution of ear disease, hairs will (Figure 5, next page). regrow as the epithelium returns to normal, and new hair growth can be seen on otoscopic examination at recheck.
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