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Ear Surgery for dogs
Ear canal ablation in Chow
Hemimandibulectomy - ear problems after surgery
Surgical correction of chronic ear problems
Surgical ear modification procedures
also see ear problems
Ear canal ablation in ChowQuestion: Dear Dr. Richards:
My chow named China and I debated over undergoing total ear canal ablation.
After careful deliberation with our vet we decided to do it. FYI - She had
already undergone a lateral resection and after one month the growth
returned. Three biopsies taken of the pollups (sp?) revealed a reaction to
chronic infection and E. Coli bacteria. Our Dr. was concerned that possible
tumors were causing the infection in the middle ear. After her total ear
canal ablation the Dr. removed a big chunk of tissue and cleaned out the
middle ear completely. He did not send the chunk in for a biopsy claiming
that it was the same tissue sent out before. I trust in my Dr. enough to
trust his judgment.It's been a little over a month since her surgery and she's recovered well,
and has been well. No head tilt, rare scratching of the ear or pawing or head
shaking. It's been wonderful. However, one day, and it literally happened in
one day, Mon. 10/23 she seemed very sick. The next day she developed a slight
cough and heavy breathing. The Dr. diagnosed her with some kind of
respiratory something, basically being a cold. At the time she also developed
a head tilt, excessive shaking of the head, occasional pawing, all in
relation to her surgery ear. I'd like to note that she occasionally paws at
her other ear as well, however, the tilt and shaking seems related to her
surgery ear. I'm unsure as to whether the ear problem developed as a result
of her cold, vice versa, or if they are independent problems. It is strange
that they both came about the exact same time.China has been taking Cephalexin for three days, but since the Dr. is
concerned that it might be the same infection as before, he switched her to
300 miligrams of Antirobe per day plus 10 miligrams of Prednisone for seven
days.She seemed to be improving yesterday, but ear was a little more bothersome
today. Tonight she has scratched her ear in about a matter of 10 minutes and
it bled. A little more than 2 tablespoons. We spend hours trying to clean
it up and figure out where it was coming from. It appears to have started
somewhere near where her scar begins, the lower yet inner part of her ear.
There is no puss. The Dr. on call at her hospital, not her treating
physician, instructed us to put gauze and pressure on it to stop the
bleeding. At the moment, we've followed his instructions and also put the
Elizabeathen collar on. I plan to leave it on until tomorrow when we drop
her off at the vet.I would like to know more about post total ear canal ablation information,
anyone's experience regarding this type of surgery, the possibilities of
recurrence and the alternative treatments in the event of a recurrence. Now
that her canal is closed, her ear cannot be readily accessed unless, I'm
assuming by some powerful x-ray.I understand that it is difficult for you to diagnose her. But what I'm
really looking for are your perspectives on the problems and what I should
emphasize with my Dr. Should I press to to have x-rays taken, etc.Your anticipated response would be greatly appreciated. As long as my poor
baby China is uncomfortable, I will be as well.Thank you.
Very truly yours,
ElizabethP.S. I know that you are convinced that most ear infections are the result
of allergies. I stressed this to my Dr. before her total ear canal ablation,
but he believed that since we live in Hawaii, seasonal allergies are
difficult to diagnose and allergy testing is usually unsuccessful since there
are so many things that dogs can be allergic to, etc.
Answer: Elizabeth-
I'm flattered that you read our site so carefully.
Total ear canal ablation (TECA) is removal of the entire ear canal. The
vertical portion, which is the portion from the ear opening that is visible
until the ear canal turns toward the middle of the head and the horizontal
portion which ends at the ear drum, are both removed during this surgery.
Most patients with sufficient ear infection to require total ear canal
ablation have middle ear infections as well as external ear infections, so
it is important to also open the bony cavity that enclosed the middle and
inner ears and remove the lining of the cavity and flush it thoroughly to
lessen the chances of an infection post-operatively. This is important
because with the ear canal no longer present, there is no good place for a
middle ear infection to drain after total ear canal ablation.The facial nerve runs very close to the surgical site and it is possible to
damage it during surgery. Usually this is a temporary problem but it can be
permanent in some dogs. It is possible to damage the inner ear when
cleaning out the tympanic bulla and this can lead to a head tilt and/or
balance problems. When these complications occur they usually are apparent
immediately, or very shortly after surgery.The two most common complications of TECA to show up later occur when bits
of infected residual ear canal cartilage or bone are still
present, leading to a recurrence of infection in the surgical site and
residual middle ear infections flaring up post-surgically and having no
where to drain, causing complications. I do not know if it is possible to
be sure which of these problems is occurring when there are problems but
with a head tilt and facial nerve paralysis, I would think that the
middle/inner ear infection problem is more likely. It is conceivable that
an infection could reach the middle ear area by traveling up the eustachian
tube even after surgery, so the presence of the upper respiratory infection
might be causing this problem, as well. I do not know any diagnostic test
that would reliably distinguish between these problems. I think that
surgery is usually necessary for both diagnosis and treatment if there is
not an adequate response to antibiotics.When these problems occur, it is necessary to do surgery again to try to
find any residual infection in the scar tissue and/or to open up the
tympanic bulla and drain it again. Unfortunately, when the problem involves
the tympanic bulla, it is often necessary to repeat the surgical drainage
more than once in order to finally control the problem. Usually the
complications, like head tilt or facial paralysis, will clear up when the
infection can be controlled.I know that it is less than desirable to do surgery again but if the
problem is still present it may be necessary and is important enough that
you shouldn't hesitate if and when your vet suggests it.Mike Richards, DVM
11/5/2000
Hemimandibulectomy - Ear problems and weight loss following surgery
Question: Dear Dr. Richards:
I wrote to you in September 1999 after our ten year old Rottweiller
was diagnosed with a bone tumor in his lower right jaw. He
underwent a hemi-mandiblectomy, and he is doing fine.The surgery took about three hours, twice as long as the surgeon had
estimated. This was most attributable to Nikoli's being a Rottie and to
Rottie bone structure. (Underneath this loveable pooch is one tough puppy!
I certainly never gave the strength of his jaws, muscle and bone, much
thought.) Nikoli spent three nights in the surgical hospital; we took him
home on Day Four which happened to be a Friday. My husband and I both got
the day off from work, so we were able to spend three full days and nights
with him before he had to be left alone during the day. The surgeon gave
us three prescriptions: Rimadyl (100 mg); Cephalexin (500 mg) and
Torbugesic drops.The first couple of days at home, Nikoli just wanted to sleep and relax.
The right side of his face was bristling with stitches and a couple of
drains. He was still bleeding and draining a lot, and I was concerned
that he would tear his stitches or worse, so the first day or two I
literally hand fed him soft, canned food. But as Nikoli began feeling
better and his appetite increased, he started eating for himself. A week
(or maybe two weeks) later he went back to the surgeon for a follow up and
got gold stars for his progress (best of all, he didn’t need any
restitching). Within a few more weeks he was pretty much back to his old self.The muscles on the right side of Nikoli's face have atrophied. The bones
on the right side of his face have become very pronounced, especially the
bone over his right eye. The bones on the left side of his face have
become somewhat more pronounced as well, but they aren’t as noticeable
visually.
His mouth on the right side looks normal, but of course the lips were sewn
together up to a point to help hold his tongue in place and to help him
eat. But unless you are petting him on his face you don’t really notice it.
Still there is nothing like a dog’s very own jaw to keep a dog’s tongue up
in his mouth yes, Nikoli’s drops out when he is relaxed. We try not to
laugh in front of him.Nikoli takes much longer drinks than he did before, but I believe this is
because he is unable to lap up as much water in a single gulp as he used
to. He backwashes significantly more since his surgery, so we are
changing his water every day or every other day, because it gets “dog
mouth gunk” in it and begins to smell. And he also has a serious
post-drinking dribble problem. Outdoors this is no big deal. But inside,
I have begun keeping the mop next to his water station in the
kitchen. It’s that bad.He has dropped some weight. Before the surgery Nikoli’s normal adult
weight was 85 pounds. At the vet’s yesterday he was down to 75
pounds. Our vet would like to see him gain back that ten pounds . After
he recovered from surgery we switched Nikoli from a diet of soft, canned
food back to his usual dry kibble with occasional table scraps (we don’t
do a lot of home cooking, so scraps really are occasional). Now we are
thinking of incorporating a least a can of soft food a day. (I have a
question about this, but I will try to lump my questions together at the
end of this letter, so they don’t get lost in my ramblings.)The only other problem that Nikoli has now is a chronic (I think that’s
the word) ear infection. It gets better; it gets worse, but it doesn’t
seem to go away.This past week, I tried home remedies including hydrogen peroxide and
Monostat 7. Neither seemed to help, so it was back to the vet’s. The vet
examined his ears and took another culture. She confirmed that the
deeper, lower parts of his ear canals were very dirty. The culture
revealed no yeast (so the Monostat apparently did its job - maybe), but
there were several different types of bacteria thriving. After flushing
Nikoli’s ears, she sent us home with a couple of prescriptions and advised
that we stop home flushing his ears for now as this seems to be keeping
them wet while not really affecting the bacteria. Nikoli is now taking
Clavamox (250 mg tablets, 2/am, 2/pm) and Tresaderm drops in both ears (am/pm).He seems better today, but that may be due mostly to the thorough ear
flushing he got at the vet’s. It’s probably too early to tell if the
other stuff is working. He has a follow-up visit in two weeks. If this
treatment plan doesn’t seem to work, the vet suggests we try a different
type of culture that will allow her to isolate the kinds of bacteria that
are in his ears and allow us to treat for resistant bacteria if we need to.The right ear structure is more closed than it was before the
surgery. The loss of bone and muscle has apparently changed the way the
ear is supported. This makes things a little more challenging, but Nikoli
had this problem before his surgery. So this is not something that has
come up unexpectedly as a result of his operation.Well, maybe I should summarize:
Ears
Previous Treatment: Chlorhexi Derm Flush with Otomax Otic (can’t they
design a container that will make it easier to judge how much Otomax
you’re squeezing out of the tube and into the ear?)Current Treatment: Clavamox and Tresaderm
Questions:
Would Witch Hazel make an effective ear flush?
I dropped by www.vetinfo.com/dogear and read up on ear problems. After
reading your comments on home remedies, I realize that I should have been
diluting the hydrogen peroxide (ooops). I didn’t think about vinegar, but
I was wondering if witch hazel (which has an astringent quality) would be
effective. By the way, when I tried the Monostat I did realize that it
would only affect yeast (if it was present), not bacteria. I cannot say
for sure that there was yeast in Nikoli’s ears before the Monostat, but
the vet said she didn’t find any when she tested for it. However, given
that the Monostat didn’t and can't solve Nikoli's ear problem, I don’t see
any reason to use it again.What is the best way to feed Nikoli and get him back, closer to or at his
old weight?We currently feed him Kibble-N-Bits. We switched a few years ago after
reading a pet food comparison study done in Consumer Reports. Up until
then we had always fed him a “premium” dog food. As a puppy he started on
Science Diet, later we tried Iams and others (Nikoli’s “dad” usually
bought the food, and I think he got whatever sounded good to him even
though he wouldn’t be eating it. My husband would adamantly deny this, of
course.)
In the Consumer Reports study, Kibble-N-Bits stacked up well against the
premium stuff: same nutrition, but lower fat, lower price and increased
availability. So we switched.But now he seems to be losing weight. The vet suggested adding canned
food to his diet. We have two theories on canned food. 1) mix it with
the dry and he will eat more over all; 2) feed him the canned separately
and let him “top off” with the dry. The down-side to Theory 1 seems to be
that Nikoli might still eat less; instead of finishing his dish, he might
leave behind both the canned and the dry. The down-side to Theory 2 seems
to be that he will finish the can, but won’t top off with the dry, so he
is still eating less. We haven’t tested either of the theories on Nikoli
(but I have seen dogs in the past practically lick the canned food off the
dry kibble, leaving it right there in the bowl otherwise untouched.)While he was on a soft food diet, he was eating about three large cans a
day. Now I am thinking one can a day along with the dry food would be a
good supplement. Is one can a day enough?Should we look for a dry food with more fat in it? (Nikoli has always
been a very fit dog, never, ever fat, in part, because we never neutered
him I could not get my husband on board with that one. I must add that
to our knowledge our dog is still a virgin even at the ripe age of 10
years. I could not and would not stand to be responsible for even one
more litter of pups, planned or unplanned, in this over-populated world,
so we have been very careful to keep Nikoli away from temptation. --still
a virgin and always a very docile and gentle dog, contrary to the usual
unneutered male expectations.)What can we expect related to Nikoli’s upper right jaw now that it no
longer has its lower chewing surface? Tooth decay comes to mind, since
these teeth will get none of the cleaning benefit of dry, crunchy
food. Should we start brushing his teeth? What are your recommendations
regarding toothpaste, etc.? Will his upper teeth grow longer with not
lowers to grind them away (that sounds more like a rat problem than a dog
problem)?Are you aware of anyone doing post-mandiblectomy studies on dogs? I would
be interested in finding out more about how dogs get along after the surgery.Well, thanks for your patience. This note has turned into a bit of an ear
bender. Thanks for listening. We're looking forward to your comments and
thoughts.Lisa
Answer: Lisa-
I am pretty sure I'm going to miss some of your questions, so please feel
free to resend any that don't get answered.
The simplest way to add calories to a dog's diet is to add a tablespoon or
two of oil to the food. This adds a lot of calories without changing the
dietary balance of vitamins and minerals much. This works with either
canned or dry food. If additional calories beyond this are necessary you
can get them by feeding either canned or dry food in whatever quantity it
takes to support a weight gain. Then you need to cut back when Nikoli gets
close to his optimal weight so that his weight levels off rather than
continuing to increase. Ordinarily there is no particular advantage that I
can see to premium dog foods but they are helpful in situations like yours
in which a dog needs to gain additional weight and where it may be helpful
to feed lower volumes of a premium food rather than adding additional cups
or cans of a non-premium food. I would consider this if you think that
Nikoli won't eat larger amounts of food or can't eat more food comfortably.Teeth problems associated with hemimandibulectomies tend to be problems
with the bite on the opposite side being affected by the surgery because
the mandible becomes less stable on that side. Most of the time this isn't
a severe problem but sometimes there is enough impingement on the gums or
palate to cause problems based on literature references. We have had two or
three patients who have had this procedure and I don't recall any major
problems with tartar on the upper teeth on the side that the jaw was
removed nor do I recall serious bite problems on the opposite side. I hope
that is your experience, too.Witch hazel is OK to use in ears. It just stings if there is any ulceration
of the ear canal and should be discontinued if signs of pain occur when
using it. Diluted vinegar can also sting but is a little less likely to do
so.I suspect that you are correct that the ear problems are related to changes
in the ear canal, or possibly middle ear drainage or pressure equalization,
postsurgically. It may be necessary to use antibiotics or topical therapy
on a semi-regular basis to control this problem in the future, if these
changes make it easier for bacteria or yeast to grow in the ear. It is OK
to do this, if necessary. I am not a big fan of ear cultures but lots of
vets believe they are helpful and I do find myself doing them occasionally,
too. Using something to keep the ear environment unfriendly to yeast and
bacteria can help prolong the interval between infections. Witch hazel and
vinegar/water combinations should be helpful. I think it is worth doing
these things since I think that the benefits outweigh the risks but your
vet may have different clinical experience with this. I can't say I can
prove scientifically that I am right, it is just an observation based on my
patients.Hope this helps.
Mike Richards, DVM
2/11/2000
Surgical correction of chronic ear problems - German Shepherd
Q: Dr. Richards - I have been reading some of the questions & answers
regarding ear problems in dogs. I have a 110 lb. white, female german
shepard that has had chronic problems with both ears since she was 5 or 6
months old (she will be 6 in November). Recent I had surgery done on both
ears to open the ear canal up more, it seems to have helped her right ear,
which prior to the surgery was the most difficult but now her left ear (the
one that had the least problems) is getting progressively worse. The left
side of her face is always swollen, usually it is must more pronounced when
her ear is acting up, she will constantly shake her head as if there is
fluid in her ear that will not come out because the ear canal is more or
less swollen shut. Recently she has taken to rubbing her head on the
ground in an attempt to either scratch her ear or ease the pressure I am
not sure which, this of course only adds more dirt and grit to the problem.
Earlier this year she had a hematoma in her left ear that was removed by
the vet and then with the surgery on the ear canal she has become very
unhappy. I have found that asprin (Bayer to be exact) helps the most, but
I do not want to keep giving her something that may or may not cause other
problems down the road. I have tried everything I can think of to help her
feel better but both myself and my vet are running out of ideas as to what
this could be and what can be done to help her. I would appreciate any
advise you can offer that would make her feel better or that could resolve
this situation once and for all.To let you know I live in West Texas where there is alot of dust in the
air, could this be part of the problem?Sincerely, R
A: R
I am not much of a fan of lateral ear resections, which is probably the
surgery that was done on your shepherd. The reason for this is that it
doesn't usually control the underlying problem, which if controlled, solves
the ear disease. I am pretty sure I am in the minority among veterinarians,
at the moment, in this opinion, though.I do see the value, in some dogs, in total ear canal ablation. This is a
surgery in which the whole ear canal is removed and the tympanic bullae
opened and drained. This surgery results in deafness on the side the
surgery is performed on and it sometimes has complications like facial
nerve paralysis, though. I view this as a last resort procedure but it may
be an option later on if other treatment doesn't work for your dog.Eliminating the underlying causes of chronic ear disease is usually not
possible. The goal is to identify the underlying disorder and then make a
plan to manage it over the rest of the dog's life.By far the most common cause of persistent or recurring ear infections is
an allergic reaction to something. This can be inhaled allergens, such as
pollen, dust mites, human dander, cat dander, etc. or it can be a food
allergy. It is possible for most vets to do allergy testing at this time
because the newer blood tests for allergies are acceptable tests. Skin
testing is better -- and it usually also gets you the opinion of the
dermatologist or allergist doing the testing -- but it can be hard to
arrange in some areas of the country.After allergies, immune mediated diseases are probably the next most common
cause of persistent ear problems. In shepherds these are more common than
in most breeds, so they do have to be considered. If other areas of her
skin are affected, such as her toes, lips, eyelids, vaginal or rectal
regions, then immune mediated disease is even more likely. Phemphigus and
lupus are both more common in German shepherds than in other dog breeds.
Biopsy of the affected areas is very useful in diagnosing immune mediated
disease and blood tests can help rule out lupus.Parasite infections (ear mites and demodectic mange in particular), chronic
bacterial infections and secondary yeast infections can all take a problem
like allergic otitis and turn it into a nightmare. It can take really
aggressive therapy with antibiotics or antifungal agents to get back to a
point in which treating the original cause will control the ear disease.I don't know what to make of the facial swelling. That is an odd
complication. There was a journal article from an author in Japan (can't
remember the name of the author or journal) that pointed out a high
correlation between hematomas of the pinna (external part of the ear) and
immune mediated disease but I don't think anyone has really followed up to
prove or disprove this theory. It might explain the facial swelling if an
immune mediated disease is present, though. I have seen cancer affecting
ear canals on several occasions and I'd want to look carefully for it, too.I think aspirin is pretty safe if it doesn't cause gastrointestinal
irritation. This is usually evidenced by a lack of appetite first and then
an active ulcer later -- so watch for a decrease in appetite. I would use
it in a pet of mine long term if it made her feel better.My basic advice is this --- allergy test if that has not been done.
Consider a food trial for food allergies if the problem is year round. Have
a smear of the exudate from the ear examined for yeast and for bacteria. It
is often possible to identify the major group the bacteria is from (gram
positive cocci or gram negative rod) from the smear. That is enough for me
to choose an initial antibiotic. I am not a huge fan of ear cultures since
there are lots of questionable cultures from ears BUT they can be useful in
some cases and it sounds like desperate measures might be called for here.
In any case, the doses for ear disease often have to be higher than those
for systemic infections since the antibiotic has to penetrate the ear
tissue, which is harder than achieving adequate levels in the blood stream.
I like cephalexin for gram positives and a fluoroquinolone like
enrofloxacin (Baytril Rx) for gram negative infections. It can be pretty
expensive to use a fluoroquinolone long term but they do often work better
than other medications for chronic ear problems. Your vet may have another
preference that works well for him or her, though. Biopsy, if there are
good sites for this and other tests don't point to a really strong
candidate as the underlying disease.If there is a veterinary dermatologist in your area, it may be time to seek
their help. Ear infections are really skin infections and the dermatologist
has the most experience with them.Hope this helps. It is expensive to get to the bottom of these problems but
your shepherd may live another six or more years with this problem so in
the long run it is really worth it.Mike Richards, DVM
9/10/99
Surgical ear modification procedures - Dalmatian
Q: Dear Dr. Mike, I have a 8 1/2 year old dalmation who has had chronic ear infections. I have been told she needs to have a surgery called Lacoix-Zepp. What can you tell me about this procedure and what kind of results can I expect? I was quoted a price of $1200. for the surgery. Is this a reasonable price? I live in Washington DC area . Any information reguarding this surgery would be appreciated. Thank you
A: Uhhh....
Once in a while someone stumbles across one of my biases as a veterinarian.
You just did.
I do not believe that the surgical ear modification procedures are justified in very many patients. There is a reason that these dogs have ear problems and finding the reason and treating the reason is very much better than removing part of the ear so that you are treating a smaller problem area, in my personal opinion.
Almost all the vets I know disagree with me.
I think they're wrong. But when you're in a small minority in a situation like this, you do have to admit that maybe everyone else sees something about the situation you don't.
Other vets tell me that doing these procedures makes it easier for the client to care for the dog. My personal observation, based on the dogs I see in my practice who have had these procedures done elsewhere, is that it just makes it easier for the client to ignore the problem, since it now affects a smaller, less visible portion of the ear canal. Other vets genuinely believe that these surgeries make the dog more comfortable, even if the owners do not continue to care for the ear. I guess I have to admit that if the client won't care for their dog's ear, or can't care for the ear, the surgery may make some sense. On the other hand, the dog is still likely to be bothered by whatever is making the ear stay chronically infected and I am not actually certain that there is a great deal of improvement in patient comfort. The last thing that gets said in promoting this procedure is that the damage to the ear has gotten so severe that it is not possible for the dog to recover from it. That does seem to happen sometimes but I think many people give up too easily. I really think that if a client truly wants to do what is best for their pet it is better to seek a diagnosis and appropriate treatment and to make the effort necessary to make the treatment work.
I am willing to admit that I might be way off base on this one. It is important that you understand that I believe that most vets do not agree with me on this issue.
But I'd still ask for a referral to Dr. Bruce Hansen, a board certified veterinary dermatologist, if he still practices in the DC area. If not, I'd seek another veterinary dermatologist's opinion.
I hope this helps even though I'm sure it makes the decision harder to make.
Mike Richards, DVM
Last edited 01/31/05