Ear Surgery for dogs

Question: 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, Elizabeth

P.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