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How to achieve an optimal outcome in veterinary patients with ear infections or allergic conditions. After treating countless canine patients with otitis externa over the years, I’ve arrived at a few fundamentals that all practitioners can benefit from.
I always establish whether a dog with chronic otitis can hear since this may change my approach to a case. It surprises me how often dogs have fairly apparent hearing loss or deafness, yet the owners are not aware of it. When assessing hearing in the examination room, make sounds when the dog is not paying attention to you.
A client communication or perception problem may occur if a near deaf or deaf dog is not recognized in the examination room and then the owner is warned about deafness as a side effect to the deep ear flush and the treatment prescribed for use at home.
Brainstem auditory evoked response (BAER) testing is a more accurate way of assessing a patient’s hearing. In patients with proliferative, end-stage otitis, it is difficult to impossible to get cleansers deep into the ear canal. Topical glucocorticoids are the most common prescription drug used in treating ear disease, which makes sense because the most common causes of chronic otitis are allergic diseases (e.g. In addition, many patients with otitis have secondary bacterial or Malassezia species infections, and topical glucocorticoids may improve the response to topical antimicrobials. Eliminating or decreasing inflammation in the ear canal is an essential component of treating secondary infections and helps control the primary allergic disease as well. Since many patients with chronic end-stage otitis will require multiple ear flushes in the clinic, it is common to encounter clients reluctant to allow repeated general anesthetic episodes. Do not discontinue antiseptic, antibiotic or antifungal topical therapy until cytologic examination shows no inflammatory cells or DNA strands.
Hot topics on dvm3605 ways to wow pet owners (and pets) 10 steps to take when a practice owner dies dvm360 sits down with Dr. According to O’Reilly, risk factors include: young age, functional immaturity of the Eustachian tube, group child care, season of the year, lack of breastfeeding, the presence of adenoid tissue, environmental smoke exposure, pacifier use, allergy, sibling order, craniofacial abnormalities, genetic predisposition, and ethnicity. Up to 60% of children who have AOM will have persistent MEE 14 days after the bacteria have been eradicated. AOM is the most frequently diagnosed condition in children and the most common reason for antibiotic therapy. Complications of OM may include: tympanic membrane perforation, tympanosclerosis, otorrhea, or cholesteatoma. Williamson concluded that “Oral antibiotics, antihistamines plus oral decongestants, or mucolytics may be of no benefit in OME and can cause adverse effects”, “Ventilation tubes may improve short-term outcomes, but the clinical effect size is small” and “Ventilation tubes improve hearing for the first two years, but have no longer-term benefit, and may not improve cognition of language.” [13] Tympanostomytube insertion is the most frequently performed operation in children in the US. The great concern when a child has recurrent OME or chronic MEE is that the child’s language development may be compromised due to hearing loss. If the hearing loss is less than normal, it becomes necessary to determine if the hearing loss is sensorineural (due to loss of function in the cochlea, 8th cranial nerve, or brain), or conductive (due to interruption of sound in its travel from the external ear canal, through the malleus, incus, and stapes of the middle ear, and into the cochlea).
His initial audiogram was performed at a separate facility 9 days before starting chiropractic treatment, at the age of 6 years, 7 months (Figure 3). Treatment consisted of 6 chiropractic manipulations utilizing Gonstead and Diversified high-velocity low amplitude techniques modified to use fingertip contacts and lower force for pediatric application. The patient had no ear pain or drainage and his hearing subjectively seemed improved at the end of the treatment, and the parents chose to cancel the surgery. The prevalence for otitis media decreases after 6 years of age, which is the approximate age of cranial vault maturity [18] (Although the subject of this paper had persistent symptoms after reaching the age of 6). The likelihood of spontaneous remission of conductive hearing loss in a case like this one is small. While this represents only a single case, the suggestion it brings of normalization of auditory physiology by chiropractic manipulation is tantalizing.
Conservative therapy such as chiropractic care with referral for audiology monitoring may offer children with otitis media and hearing loss a possible benefit of recovery from their condition without the concern of antibiotic side effects, antibiotic resistance, or risks of surgery and associated anesthesia. Written informed consent was obtained from the patient for publication of this Case report and any accompanying images.
Air pollution and emergency department visits for otitis media: a case-crossover study in Edmonton, Canada.
The health care burden and societal impact of acute otitis media in seven European countries: results of an Internet survey. Effects of prenatal exposure to dioxin-like compounds on allergies and infections during infancy.
Host factors and early therapeutic response in acute otitis media: Does symptomatic response correlate with bacterial outcome?
Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors.
Osteopathic evaluation and manipulative treatment in reducing the morbidity of otitis media: a pilot study. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children.
A prospective study of the effect of gastroesophageal reflux disease treatment on children with otitis media. Improvements in hearing, speech, development and behavior following chiropractic in a 4 year old male. Improved hearing and resolution of otitis media with effusion following chiropractic care to reduce vertebral subluxation. During diving and flight elevation or landing, the pressure is changing To adapt to it, pressure of middle ear should be changed accordingly by opening up the eustachian tube. Pure tone audiogram is necessary as it usually shows conductive hearing loss.  However if inner ear is involved, sensorineural hearing loss may be seen. For blood or fluid in the middle ear, observation is suggested.  But it can be drained by myringotomy if it is not subsided after a period of time. If there is inner ear injury, conservative management such as bed rest and drugs is recommended.  But if hearing deteriorates progressively, surgical exploration and operation would be suggested.
Acute otitis media is acute infection of the middle ear which is either due to viral or bacterial infection.
After AOM, some fluid may accumulate in the middle ear resulting in conductive hearing loss. While the majority of eardrum perforation heals spontaneously, some perforations persist due to unresolved infection or Eustachian tube dysfunction. Normally the middle ear and external ear canal is separated by the thin membrane called tympanic membrane or ear drum.


It is different from the usual CSOM (chronic suppurative otitis media) that skin "grows" inside the middle ear and mastoid process and forms a "tumour-like" plague. It is usually presented as sudden onset of sustained vertigo and dys-equilibrium accompanied by a spontaneous wobbling of eyeballs lasting from 3 to 7 days followed by gradual resolution.
Basically it only needs supportive treatment with relief of dizziness during the acute episode.
The patient with BPPV (Benign Paroxysmal Positional Vertigo) experiences severe spinning associated with a change of head position. A test called Dix-Hallipike maneuver is done for eliciting nystamus (wobbling of eyeballs) and vertigo caused by posterior canal BPPV.
In general, the theory of canalithiasis, which is well accepted as the explanation of BPPV (Benign Paroxysmal Positional Vertigo)? It is a condition where a benign tumor is arising from the eighth cranial nerve which is called vestibulocochlear nerve (mostly involves the vestibular nerve rather than the cochlear nerve). The classic presentation of acoustic neuroma would be unilateral progressive sensorineural hearing loss. We can either treat it with hearing aids or operative treatment which is called stapedectomy.
Systemic steroid is the evidence based treatment of choice as it can suppress the inflammation caused by the viral infection. Most kids get sick ears (middle ear disease or Otitis Media) at some point when they are growing up.
Sound gets caught by the outside part of the ear (outer ear) and moves down the ear canal to the ear drum. Little kids pick up middle ear infection easily – often after having a sore throat or a common cold. Too much fluid in the ear puts lots of pressure on the ear drum and makes it burst, resulting in a sticky discharge – this is otitis media. But if this happens a lot, and little kids have lots of ear infections that are not treated, little kids can get permanent hearing loss. Just like middle ear infections come and go with treatment, so does the conductive hearing loss it causes.
If hearing loss seems permanent and nonreversible, then total ear canal ablation and bulla osteotomy become better treatment options.
It is important to not just see the dog respond to the sound but to determine whether it almost immediately localizes where the sound comes from.
After the procedure or treatment, the client pays closer attention and recognizes the dog does not hear well and blames the treatment when in fact the dog had been deaf before the treatment. This test allows one to assess hearing threshold, the level of sound that each ear detects. To achieve this when a dog is anesthetized, use a 3-mm otoscope cone to dilate the ear and place the cone as far into the canal as possible. This has been shown in dogs with Malassezia species otitis,1 and is supported by the fact that most topical antibiotics labeled for the treatment of otitis in veterinary patients contain a glucocorticoid. During initial therapy for or acute exacerbations of otitis, a potent topical glucocorticoid may be required, but once the inflammation or allergic reaction is controlled use the least potent topical glucocorticoid possible that is still effective prophylactically or long-term. In one study of 16 dogs with Pseudomonas species otitis externa that were treated empirically, 90% of the dogs with a resistant bacterial infection responded to a topical antibiotic that the organism was reported as resistant to, and 83% of the dogs responded when the empiric treatment involved an antibiotic that that bacteria was reported as being sensitive to.2 The favorable response may have been due to the combination approach since the ears were cleaned and antiseptic and the synergistic agent Tris-EDTA were used as well as because of the high antibiotic concentration achieved at the site of infection with topical formulations. Topical antiseptics include such ingredients as certain acids (acetic, boric, citric, lactic), alcohols, aluminum hydroxide, chlorhexidine (0.25% or lower concentration), povidone-iodine, silver sulfadiazine and sodium chlorite. The drawback to using antiseptics is they often need to have contact time in clean ears and be used multiple times a day.
Synergistic agents enhance the bactericidal effect of the agent they are mixed with to a greater extent than the additive effect of the two ingredients. Polymyxin has a cationic detergent effect and, similar to Tris-EDTA, disrupts the outer membrane of bacteria, particularly gram-negative bacteria.
For example, we raise the racks on the wet table at one end and the dog is positioned in lateral recumbency with its nose at the low end of the rack. Also as stated above, polymyxin is synergistic with miconazole for killing Malassezia species. It is common for practitioners or clients to discontinue therapy too early, especially if the ear looks reasonably good and there is no obvious odor or discharge.
Prior treatment included several rounds of antibiotics starting at 14 months and myringotomy at age 3. After 6 chiropractic adjustments, the child was asymptomatic, and remained free of otitis media symptoms on long-term follow-up.
This may suggest a role for chiropractic care the management of otitis media with conductive hearing loss.
Of children with a red or yellow tympanic membrane and distention and absence of visible landmarks on otoscopy, 91% will have a bacterial infection of the middle ear.
The presence of effusion is generally believed to be due to a pressure gradient formed by the microvascular resorption of nitrogen from the middle ear in the absence of a patent Eustachian tube. A Cochrane review concluded tympanostomy tubes for hearing loss associated with otitis media with effusion were mainly beneficial in the first 6 months after insertion, although the benefits were small and diminished over time. They also reported concern about hearing loss as measured by audiometry ordered by an ENT specialist. The test showed an obvious air-bone gap, with conductive hearing loss greater on the left than on the right.
Segments adjusted were based on static and motion palpation of the entire spine, and no attempt was made to correlate the segments adjusted with the segmental innervation of the middle ear or Eustachian tubes. Right tympanic membrane (TM) showed fluid and was immobile on insufflation, but was glossy.
The right TM was mobile with no fluid and some dullness; the left TM was dull with increased fluid but was mobile.
A review of the effectiveness of manual therapies on otitis media found the evidence to be inconclusive. This, along with craniofacial abnormality as a risk factor and the fact that myringotomy with tympanostomy tube insertion affords symptomatic relief, suggests that a dysfunctional eustachian tube plays a large role in OM.
This is implied by a controlled trial of ear tubes (grommets), involving 55 children between 4 and 10 years of age, which found that within 6 months after insertion, the grommet ear and the control ear had the same average degree of hearing loss: 16 decibels. Additionally, it may represent a new method for monitoring the results of CMT in children with MEE or recurrent OME.
For otitis externa (ear canal infection), ear toilet, topical antibiotic eardrops with or without oral antibiotic is the standard treatment.


Except paediatric cases with bilateral OME and hearing impairment, we may observe for any resolution of OME with time. The most frequently cited occurrence of this symptom follows rolling over in bed or getting into bed and assuming a lying-on-back position.
When we turn or move our head or change our positions, the stone-like substances in the ampulla ( the organ for sense of balance)moves and irritate the said organ.
Normally, the lesions are removed by excision and the specimen is then checked by pathologist. Conductive Hearing Loss happens when fluid that has built up in the middle ear (otitis media) or a hole in the ear drum prevents sound from passing freely through the ear.
Hearing loss is the main side effect of these procedures, so if hearing loss were not an issue I would spend less time and expense trying medical therapy. It is important to ask the owner about the pet’s response to doors, cars pulling up, and being called when outside and its ability to localize the sound, as well as whether the pet sleeps soundly and anything else that will help determine whether marked hearing loss has occurred. You can pass an ear loop down the canal just past the tip of the cone and then fill the cone with cleanser and slowly pull the cone out.
In cases of atopy or food allergy-induced otitis externa, the pinna is frequently affected and should also be treated. The ear can be cleaned with an antiseptic, and then the topical treatment may contain both a synergist (such as Tris-EDTA or miconazole) along with an antibiotic. In these cases, even though a patient’s laryngeal reflex may be present, it can be suppressed, so take precautions to prevent inhalation pneumonia and avoid spreading resistant Pseudomonas species and methicillin-resistant Staphylococcus species to the lungs. The newest addition to the active agents for Malassezia species infections is 1% terbinafine in the new combination weekly product, Osurnia (Elanco).
I see many cases when I think it is time to discontinue treatment, but because of the results of cytologic examination, I continue. Correlation between topical antibiotic selection, in vitro bacterial antibiotic sensitivity and clinical response in 16 cases of canine otitis externa complicated by Pseudomonas aeruginosa, in Proceedings. Full and broad-spectrum in vivo eradication of catheter-associated biofilms using gentamicin-EDTA antibiotic lock therapy. Evaluation of the impact of tromethamine edetate disodium dihydrate on antimicrobial susceptibility of Pseudomonas aeruginosa in biofilm in vitro. Antibiofilm properties of chemically synthesized silver nanoparticles found against Pseudomonas aeruginosa.
Potentiating effect of EDTA-Tris on the activity of antibiotics against resistant bacteria associated with otitis, dermatitis and cystitis.
In vitro activity of posaconazole and other antifungals against Malassezia pachydermatis isolated from dogs.
Nineteen months after commencement of treatment, a repeat audiogram was performed, showing normal hearing in both ears. This results in decreased pressure (and often a retracted tympanic membrane), causing extracellular fluid to exude into the middle ear cavity. The AAP-AAFP recommends antibiotic therapy for younger children or those with recurrent AOM. A loss only in air conduction would be diagnostic of conductive hearing loss, while combined bone and air conduction loss would be diagnostic of sensorineural hearing loss (Figure 1).
CMT was C1 right supine rotatory, C5 left supine rotatory, T7 prone double-contact diversified, and Applied Kinesiology cranial. When the child was age 8 years, 2 months, a repeat audiogram was performed at the same separate audiology facility (19 months after his initial audiogram and 18 months after completing chiropractic treatment). The adult eustachian tube is larger, contains more elastin and traverses 45 degrees from the temporal bone to the nasopharynx, compared to the child’s smaller eustachian tube with less elastin that traverses 10 degrees. Children’s behaviour at home, childcare, preschool, school and on the sports ground, may show you they are having trouble hearing. In addition, hearing needs to be assessed before ear flushing and administering topical medications when otitis media is likely.
This allows a layer of cleanser to be deposited on many canal folds as they fall back in place as the cone is removed. Antiseptics kill organisms by methods other than antibiotics, generally are inexpensive and can work in conjunction with antibiotics. In common usage, the word is used as synonymous with “ear infection,” even by many physicians, but the condition which most chiropractors confront in pediatric patients, persistent middle ear effusion (MEE) involves no culturable pathogenic bacteria in 75% of patients. He was initially treated with repeated courses of antibiotics, and then by insertion of myringotomy tubes at age 3. Results showed the patient’s air-bone gap had closed completely, and the hearing in both ears was within normal limits (Figure 4). Also, Froehle states “Eustachian tube function depends upon appropriate contraction of the tensor veli palatine muscle, which in turn depends upon proper function of the mandibular branch of cranial nerve V, which in turn is dependent upon proper alignment and movement of the occiput and upper cervical vertebrae as the nucleus of the spinal trigeminal tract extends down to the level of the upper cervical segments”. This will help you learn more about ears, how we hear, middle ear infection (otitis media), conductive hearing loss and the behaviours to look for that can help you identify a problem. Microbial resistance to antiseptics is generally not a problem, though this may be changing, which is another reason to use combination therapy.
In difficult cases in which the ears are being cleaned under sedation or anesthesia, I may leave acetic or boric acid in the ear canal for five minutes and then follow with a five-minute soak with Tris-EDTA and chlorhexidine. Attempting such examinations makes the performance of spinal manipulation more difficult due to vocalization and active resistance on the part of the patient.
Knowing what to look for can help you take steps to prevent and manage the illness and its effect on kids lives. When antiseptics are the only topical antibacterial used, then they often should be applied four to six times a day.
Prior to seeking chiropractic care, he had recently completed a course of antibiotics for an episode of AOM. The RCT was found to be of “high” quality and found significantly fewer surgical procedures compared to usual medical care. Therefore, this case report has potentially two different mechanisms of success: establishing the cranial nerve V flow at the level of the upper cervical vertebra and improvement of the child’s lymphatic drainage. The availability of independent, non-medical practitioners in the audiology profession may present an opportunity to obtain reliable, objective criteria, on a pre- and post-treatment basis, for treatment effectiveness. History included several risk factors for otitis media, including short duration of breastfeeding, parental smoking, and early day care.



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