Lateral ear canal resection and bulla osteotomy with marsupialization to treat otitis media in rabbits: forty-eight procedures

OBJECTIVE

Describe lateral ear canal resection and bulla osteotomy with marsupialization (LECARBOM) in rabbits with otitis media (OM), and report outcomes, complications, bacteria cultured from middle ears, and their antimicrobial susceptibility testing (AST) results.

STUDY DESIGN

Retrospective clinical case series; single referral hospital.

ANIMALS

Forty-two rabbits with naturally occurring OM.

METHODS

Medical records (2011-2021) of rabbits with CT-confirmed OM undergoing surgery were reviewed for outcomes, complications, bacteria cultured from middle ears, and AST.

RESULTS

Surgery was performed on 48 ears, and outcomes determined 21 days postoperatively. All rabbits survived the procedure. Otitis externa resolved in all lop-eared rabbits. Of 29 ears with OM-associated head tilt, eight (28%) resolved, nine (31%) improved, seven (24%) remained unchanged and five (17%) worsened. Outcome was not associated with head tilt duration nor OM severity. Postoperative complications occurred in 12 (25%) cases, seven of which had wound margin dehiscence that healed by 21 days. The most frequent bacteria isolated were Pasteurella multocida (16%), Bordetella bronchiseptica (14%) and Staphylococcus aureus (14%). Bacteria were sensitive to azithromycin, marbofloxacin or enrofloxacin and resistant to penicillin.

CONCLUSION

LECARBOM is a well-tolerated surgical procedure to treat OM. It also improved or stabilized 83% of cases with head tilt and resolved all cases with otitis externa.

CLINICAL SIGNIFICANCE

LECARBOM with administration of an AST-sensitive antibiotic, or azithromycin when no AST is performed, should be effective in rabbits with OM. Postsurgically, it resolves or alleviates most secondary conditions such as otitis externa, head tilt and facial nerve paralysis.

Refractory otitis media and otitis externa in a koala (Phascolarctos cinereus) treated with total ear canal ablation and lateral bulla osteotomy

BACKGROUND

To the authors' knowledge, this is the first report fully describing the surgical and medical management of otitis media and otitis externa in the koala (Phascolarctos cinereus) treated by total ear canal ablation and lateral bulla osteotomy.

CASE REPORT

An adult male koala captured as part of a monitoring project in South East Queensland was diagnosed with chlamydial cystitis. Purulent discharge from the right ear was also observed; diagnostic imaging was consistent with otitis media and otitis externa. Yokenella regensburgei was repeatedly cultured from the site. Clinical signs resolved with topical antibiotic therapy; however, recrudesced following cessation of antibiotics. A total ear canal ablation and lateral bulla osteotomy was performed, followed by an extended period of systemic antibiotic therapy. Mild facial nerve paresis was observed for 4 weeks postoperatively and resolved spontaneously. The koala remained clinically healthy for the 6 months it was monitored following release.

CONCLUSION

Total ear canal ablation combined with lateral bulla osteotomy appears to be an appropriate surgical intervention for otitis media combined with otitis externa refractory to medical management in the koala. Transient postoperative facial nerve paresis is a possible complication, as documented in other species. To the authors' knowledge this is the first case of Yokenella regensburgei infection outside of humans and American alligators (Alligator mississippiensis); the clinical significance of this pathogen in the koala remains unknown.

Innovated surgery incision for patients of congenital malformation of the middle and outer ear with infection (CMMOEI)

BACKGROUND

It is the challenging clinical issue of combining debridement of infected lesions and retaining the blood skin flap for auricle reconstruction in patients of Congenital Malformation of the Middle and Outer Ear with Infection (CMMOEI).

AIMS/OBJECTIVES

To innovate and introduce an surgery incision to solve the challenging clinical issue of a combined debridement of infection yet retaining a well vascularized skin flap for auricle reconstruction in patients with CMMOEI.

MATERIAL AND METHODS

A combined innovated incision of ear sulcus and prefabricated earlobe was used for 23 cases (23 ears) with CMMOEI, The success in the management of the encountered infections, and the short and moderate-term outcome of the innovated incision to preserve a well-vascularized skin flap for subsequent auricle reconstruction were reviewed. The 23 cases include 10 males and 13 females, aged 4-14 years (mean 8.4 years), 7 left ears and 16 right ears. 14 ears stenosis and 9 ears atresia of the outer ear canals.

RESULTS

In all 23 cases, the infections were successfully cleared without recurrence or complication with 2-year follow-up. The local skin flap and its blood supply were well preserved for subsequent auricle reconstruction.

CONCLUSIONS AND SIGNIFICANCE

The new incision can facilitate clearance of infection in CMOMEI patients, and preserve the retroauricular tissues for subsequent harvesting of a well-vascularized skin flap for subsequent auricle reconstruction.

Short- and long-term outcomes of subtotal ear canal ablation and lateral bulla osteotomy in French bulldogs

The objective of this retrospective study was to report the overall peri-operative complications and short- to long-term outcomes of subtotal ear canal ablation and lateral bulla osteotomy in French bulldogs with otitis media. Medical records from 2018 to 2021 were reviewed for preoperative neurological signs, surgical technique, postoperative complications, and long-term outcomes. Postoperative complications, such as a head tilt, nystagmus, ataxia, facial nerve dysfunction, as well as skin or wound infection, were recorded. Eighteen client-owned dogs (20 ears) were included in the study. Postoperative complications were observed in 5/18 dogs (6/20 ears) with 2 of them being considered major complications. Referring veterinarians and owner telephone follow-up (mean: 33 mo, range: 17 to 56 mo) were obtained for all patients. Total recovery was reported in 9/18 dogs (11/20 ears) with a postoperative improvement of the vestibular signs and facial nerve paresis within 8 wk. All dogs maintained the pinnas' natural, erect morphology, and movement.

Partial vertical ear canal resection in two cats

CASE DESCRIPTION

An 18-year-old domestic medium-hair cat (cat 1) and a 16-year-old domestic shorthair cat (cat 2) were evaluated because of obstructive skin lesions involving the perimeter of the left external auditory canal.

CLINICAL FINDINGS

Otitis externa was present in affected ears secondary to obstructive soft tissue growths involving the outer margin of the external auditory canal and outer third of the vertical ear canal. Histologic examination of a preoperative biopsy sample revealed multiple ulcerated ceruminous gland adenomas in the affected ear of cat 1. Histologic examination of the submitted tissue from cat 2 confirmed ceruminous cystomatosis with surface colonization of yeast compatible with Malassezia spp.

TREATMENT AND OUTCOME

Both cats underwent partial resection of the upper third of the affected vertical ear canal and associated diseased skin. The incised margin of the pinna was sutured to the margin of the remaining portion of the vertical ear canal with absorbable sutures. Both cats were disease free over a 12-month (cat 1) or 10-month (cat 2) follow-up period. Cat 1 later developed a small ceruminous gland adenocarcinoma in the adjacent rostrolateral margin of the vertical ear canal 1 year after surgery; the mass was resected, and the patient was free of recurrence 4 months later.

CLINICAL RELEVANCE

Partial resection was an effective alternative to complete vertical ear canal resection for lesions involving the upper third of the vertical ear canal in these cats; the partial resection procedure was deemed simpler to perform and less traumatic to the cat. Functional and cosmetic results were excellent, with preservation of the overall anatomy of the external auditory canal.

Surgical Management of Ear Diseases in Rabbits

Otitis externa and media are frequently diagnosed disorders in rabbits and are particularly common in lop-eared breeds because of the specific anatomy of the ear canal. Medical management for otitis externa and media often provides only a temporary improvement in clinical signs. Surgery by means of partial or total ear canal ablation (PECA or TECA) combined with lateral bulla osteotomy (LBO) represents a feasible approach that is well tolerated and provides a good clinical outcome. Short-term complications associated with PECA/TECA-LBO include facial nerve paralysis and vestibular disease.

Malignant otitis externa in a healthy non-diabetic patient

A healthy 60-year-old male was initially treated for external otitis, and subsequently received multiple surgeries including abscess drainage, temporal bone debridement, canaloplasty of the external auditory meatus, and fistula excision and was treated with numerous antibiotics at another hospital over a 1-year period. He was seen at our hospital on February 14, 2014 with a complaint of a non-healing wound behind the left ear and drainage of purulent fluid. He had no history of diabetes mellitus or compromised immune function. Computed tomography (CT) and magnetic resonance imaging (MRI) studies at our hospital showed osteomyelitis involving the left temporal, occipital, and sphenoid bones, the mandible, and an epidural abscess. Routine blood testing and tests of immune function were normal, and no evidence of other infectious processes was found. He was diagnosed with malignant otitis externa (MOE). Bone debridement and incision and drainage of the epidural abscess were performed, and vancomycin was administered because culture results revealed Corynebacterium jeikeium, Corynebacterium xerosis, and Enterococcus faecalis. MOE should be considered in healthy patients with external otitis who fail initial treatment.

[Comparison of the results of tympanoplasty in the patients presenting with "dry" mesotympanitis obtained using different surgical approaches]

The objective of the present study was to compare the results of different surgical approaches to the treatment of tympanoplasty in the patients presenting with "dry" mesotympanitis. We compared the morphological and functional outcomes of tympanoplasty in 49 patients allocated to the three study groups. Group 1 was comprised of 28 patients that underwent tympanoplasty using the endaural (intrameatal) approach through an ear speculum. Group 2 consisted of 16 patients that underwent tympanoplasty using the endaural(intrameatal) approach through type A and B intercatilaginous incisions by the method of Heermann, Group 3 included 5 patients who underwent tympanoplasty using the postaural transcanal approach. The analysis of the outcomes of surgeries has demonstrated that the best morphological and functional results were obtained in the patients of groups 2 and 3.

Erosive external otitis: a novel distinct clinical entity of the external auditory canal in nonimmunosuppressed individuals

OBJECTIVE

We introduce erosive external otitis (EEO) as a novel erosive process of the external auditory canal in the absence of diabetes or immune suppression.

STUDY DESIGN

Case series and literature review.

SETTING

Tertiary referral center.

PATIENTS

Primary eligibility criteria included patients who had an erosive process of their external auditory canal in the absence of diabetes or immune suppression.

INTERVENTION

Surgical debridement and split-thickness skin grafting.

MAIN OUTCOME MEASURES

Uneventful wound healing and disease-free long-term follow-up after surgical debridement and skin grafting.

RESULTS

Three cases of EEO in the absence of immune suppression or diabetes were diagnosed and treated. All patients required surgical debridement and skin grafting as part of their management. All recovered uneventfully from surgery and had no evidence of recurrence on long-term follow-up.

CONCLUSION

We propose that EEO, which occurs in the absence of immune suppression or diabetes, is a clinical entity that is distinct from the more commonly diagnosed malignant external otitis and that the management of EEO is primarily surgical debridement with skin grafting.

Benign necrotizing otitis externa

Benign necrotizing otitis externa (BNOE) is a rare condition of the external acoustic meatus characterized by ulceration of the floor of the deep meatus overlying an area of bony necrosis. Recognition of this condition as different from malignant necrotizing otitis externa (MNOE) and carcinoma of the external ear is important because its treatment is very different. The best choice of treatment for BNOE is not clear because both long-term medical therapy and surgery have been advocated as first-line treatments. We describe a case involving a 50-year-old man and present what we believe to be the first published photographs of the surgical management of BNOE.

Antifungal therapy of Aspergillus invasive otitis externa: efficacy of voriconazole and review

Invasive otitis externa (IOE) due to Aspergillus is a rare, potentially life-threatening, invasive fungal infection affecting immunocompromised patients. The invasive process may lead to skull base osteomyelitis with progressive cranial nerve palsies and can result in irreversible hearing and neurological impairment. We report two cases of Aspergillus IOE treated with voriconazole alone and a literature review of antifungal therapy of Aspergillus IOE. Twenty-five patients, including the two described in the present report, were analyzed. Eighteen patients were treated with amphotericin B, and nine of them received itraconazole as an additional agent. Three patients received initial therapy with itraconazole, and one patient was treated with both voriconazole and caspofungin therapy. The two patients in the present report received voriconazole therapy alone with good clinical and biological tolerance despite prolonged treatment. The last patient did not receive antifungal therapy, as the diagnosis was made postmortem. Eighteen patients underwent an initial extensive surgical debridement. The majority of the patients had a favorable outcome, 17 patients experienced a complete recovery, and 6 showed a partial improvement. Both of the patients reported on here had favorable outcomes, and no aggressive surgical debridement was required. Although voriconazole has been shown to be effective for the treatment of invasive aspergillosis, its precise role in the management of Aspergillus IOE had not been documented. These observations demonstrate that voriconazole could be an effective and well-tolerated therapeutic option for the management of Aspergillus IOE.

[The practice guideline 'Otitis externa' (first revision) from the Dutch College of General Practitioners; a response from the perspective of otorhinolaryngology]

The first revision of the practice guideline 'Otitis externa' from the Dutch College of General Practitioners describes diagnostic, therapeutic and preventive aspects of care and focuses mainly on the acute form of the disease. In comparison with the previous guideline, some modest but valuable improvements have been made with regard to diagnosis and medical treatment. For acute otitis externa, treatment with acid and corticosteroid eardrops is considered the treatment of choice, rather than treatment with acid eardrops only. The guideline clearly discusses indications for referral of patients with otitis externa to an otorhinolaryngologist. Hypersensitivity and more severe pathology should be excluded in persistent cases. For chronic otitis externa, an otorhinolaryngologist can provide surgical treatment with a good chance of success and a low recurrence rate.

Tracheolaryngeal Complications of Inherited Epidermolysis Bullosa: Cumulative Experience of the National Epidermolysis Bullosa Registry

OBJECTIVES/HYPOTHESIS

To accurately determine the frequency with which complications arise in the ears, noses, and throats of patients with inherited epidermolysis bullosa (EB) as well as the cumulative risk of tracheolaryngeal stenosis or stricture.

STUDY DESIGN

Cross-sectional study (3,280 patients) with a nested, randomly sampled longitudinal subcohort (n=450), representing data collection, stratified by major EB subtype, of the National EB Registry, an epidemiologic project focused on enrolling all EB patients within the continental United States from 1986 to 2002, to permit generalization of findings to the entire American EB population.

METHODS

Systematic epidemiologic case finding and data collection were performed throughout the continental United States, followed by subclassification of patients by EB subtype. ENT complications were quantified via contingency tables (as frequencies) and lifetable analyses. Frequencies of surgical procedures were also determined.

RESULTS

The most important clinical ENT complication in inherited EB was tracheolaryngeal stenosis or stricture, arising during early childhood and primarily within infants and children with junctional EB (JEB) (cumulative risk of 39.8% and 12.8% in Herlitz and non-Herlitz JEB, respectively, by ages 6 and 9). Other uncommon complications included chronic otitis media, chronic otitis externa, and hearing loss.

CONCLUSIONS

Given the potential risk for sudden airway occlusion and death, meticulous surveillance by a pediatric otolaryngologist is a critical part of the overall management of infants and children with EB, especially those with JEB and two rare subtypes of generalized EB simplex. Elective tracheostomy should be considered in EB infants and children with evidence of airway embarrassment.

Evaluation of a local anesthetic delivery system for the postoperative analgesic management of canine total ear canal ablation--a randomized, controlled, double-blinded study

OBJECTIVE

To determine if a constant rate local anesthetic delivery system is more effective than continuous intravenous (IV) morphine infusion for postoperative analgesia.

ANIMALS

Twenty client-owned dogs undergoing total ear canal ablation.

METHODS

Dogs were randomly assigned to the lidocaine group (LID) or the morphine group (MOR). The LID group received a constant rate infusion of lidocaine locally and a continuous IV infusion of saline, while the MOR group received a constant rate infusion of saline locally and a continuous IV infusion of morphine. The primary investigator evaluated each patient and determined a hospital behavior score, anesthesia recovery score, preoperative pain score, and serial postoperative pain and sedation scores over 38 hours. Pain and sedation observations were videotaped and scored by three additional evaluators. Evaluators were blinded to treatment assignments.

RESULTS

There were no significant differences in age, weight, hospital behavior scores or anesthesia recovery scores. The primary investigator's pain scores were not significantly different, but sedation scores were significantly lower for the LID group. Sedation and pain scores by the video evaluators were not significantly different between groups. Kappa agreement between observers was poor, but better agreement was noted between sedation scores than pain scores. Drug-related complications were significantly lower in the LID group (n = 0) compared with the MOR group (n = 5). Wound complications were not significantly different (LID = 4, MOR = 4). Intravenous delivery complications occurred in 12 (60%) patients. Local delivery complications occurred in five (25%) dogs. Delivery complications were not significantly different between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Continuous incisional lidocaine delivery was an equipotent and viable method of providing postoperative analgesia compared with IV morphine. Lidocaine delivery resulted in a trend toward lower pain scores, significantly lower sedation scores, and no dogs requiring analgesic rescue. Wound complications secondary to local infusion were minor and self-limiting. Drug-related complications occurred only in the MOR group.

Surgical treatment of medial meatal fibrosis. Report of four cases

OBJECTIVE

We describe four cases of medial meatal fibrosis, a rare condition of the external auditory canal, in which hearing improved following surgery.

METHODS

Four patients with medial meatal fibrosis underwent surgical treatment and had been followed at the University of Tokyo during the last 5 years. We examined hearing improvement and recurrence. A patient had graft-versus-host disease (GVHD) with her urethra and vagina, and two patients had methicillin resistant Staphylococcus aureus (MRSA) infection with their affected ears.

RESULTS

All cases got hearing improvement without any major complications.

CONCLUSIONS

Medial meatal fibrosis may be treated satisfactory with surgical interventions.

[Malignant external otitis]

Malignant external otitis or skull base osteomyelitis and osteoradionecrosis of the skull base and the skull are potentially life-threatening conditions. The standard methods of treatment involve the use of antibiotics, local treatment and, where necessary, surgical excision of necrotic tissue. These approaches do not provide a complete cure in many cases. Severe functional deficits and even death can occur in advanced stages. We conducted a long-term retrospective follow-up study and report on a multimodal approach that we have been using with great success since 1987. The four cornerstones of this treatment are surgical debridement, combinations of antibiotics, specific immunoglobulins, and adjunctive hyperbaric oxygen therapy. This multimodal treatment approach has proved to be highly effective in improving the survival and quality of life of the patients concerned. These excellent outcomes justify the high costs that this therapy admittedly involves.

Subtotal ear canal ablation in 18 dogs and one cat with minimal distal ear canal pathology

A modified technique for performing total ear canal ablations is described. This technique requires less dissection than the standard technique and maintains a portion of the distal vertical ear canal. Subtotal ear canal ablations were performed in 18 dogs and one cat for the treatment of otitis externa or masses of the horizontal ear canal. Animals with otitis externa had minimal involvement of the distal ear canal. Dermatological problems associated with the remaining ear canal and pinnae occurred in eight animals and resolved with medical management. Normal ear carriage was maintained in all animals with erect ears. Further investigation is required before the procedure can be recommended as a treatment for otitis externa not caused by masses or anatomical abnormalities of the horizontal ear canal in dogs with pendulous ears.

Squamous cell carcinoma in situ of the external auditory canal

We report two cases of carcinoma in situ in the external auditory canal (EAC), presenting with symptoms such as pain, long-term itching of the ear, easy contact bleeding, canal otorrhea and hearing loss. Otoscopic examination revealed granulation tissue and a greyish-black tumour with irregular surface. The first patient had previously been diagnosed with otitis externa with persistent ear itching for the past three years. The second patient had received tympanoplasty for treatment of chronic otitis media on the right ear ten years ago. The first case was treated with wide excision, whereas the second patient received resection of the skin of the EAC together with its adjacent soft tissue, followed by skin grafting. No tumour recurrence was noted in the fourth and third post-operative year for the first and second patient respectively. We suggest that EAC carcinoma can be detected early and treated.

Malignant (invasive) otitis externa involving the temporomandibular joint

Malignant (invasive) otitis externa (MOE) is an infection involving the external auditory meatus (EAM), most often found in elderly diabetics, which carries a high morbidity and mortality. In advanced cases it may give rise to osteomyelitis and cranial neuropathies. This is a case of MOE, which invaded the posterior wall of the right temporomandibular joint (TMJ), resulting in severe trismus and pain. Subsequently, this required treatment by replacement of the glenoid fossa with a Silastic® prosthesis.

Management of stenosis and acquired atresia of the external auditory meatus

The aim of this study was to investigate the aetiology of acquired atresia and stenosis of the external auditory meatus and to present our results for surgical management. Over an 18-year period (from 1986 to 2004), data were collected prospectively from patient cohorts in Dundee and Edinburgh. Stenosis of the auditory meatus was due to chronic otitis externa in 64 per cent of cases, compared with 37 per cent of cases with acquired atresia; the latter had instead a history of chronic suppurative otitis media in 43 per cent. Surgical treatment of canal stenosis with meatoplasty alone achieved a widely patent ear canal in 80 per cent of cases, with 78 per cent of ears remaining free of discharge. Cases of acquired atresia treated with simple surgical excision of the soft tissue plug experienced a 100 per cent failure rate. The additional use of a split skin graft achieved a patent meatus in 70 per cent of cases, with hearing improvement in 79 per cent. However, the ear canal remained unstable and late recurrence was observed.

Effect of tympanic cavity evacuation and flushing on microbial isolates during total ear canal ablation with lateral bulla osteotomy in dogs

OBJECTIVE

To evaluate differences in bacterial numbers, identity, and susceptibility in samples obtained from the tympanic cavity on entry (preflush) and after evacuation and lavage (postflush) and assess perioperative and empiric antimicrobial selection in dogs that underwent total ear canal ablation (TECA) with lateral bulla osteotomy (LBO) or reoperation LBO.

DESIGN

Prospective clinical study.

ANIMALS

34 dogs.

PROCEDURE

TECA with LBO or reoperation LBO was performed on 47 ears. Pre- and postflush aerobic and anaerobic samples were obtained from the tympanic cavity. Isolates and antimicrobial susceptibility patterns were compared.

RESULTS

Different isolates (31/44 [70%] ears) and susceptibility patterns of isolate pairs (6/44 [14%] ears) were detected in pre- and postflush samples from 84% of ears. Evacuation and lavage of the tympanic cavity decreased the number of bacterial isolates by 33%. In 26% of ears, bacteria were isolated from post-flush samples but not preflush samples. Only 26% of isolates tested were susceptible to cefazolin. At least 1 isolate from 53% of dogs that received empirically chosen antimicrobials postoperatively was resistant to the selected drugs. Anaerobic bacteria were recovered from 6 ears.

CONCLUSIONS AND CLINICAL RELEVANCE

Accurate microbiologic assessment of the tympanic cavity should be the basis for selection of antimicrobials in dogs undergoing TECA with LBO. Bacteria remain in the tympanic cavity after evacuation and lavage. Cefazolin was a poor choice for dogs that underwent TECA with LBO, as judged on the basis of culture and susceptibility testing results.

Canalplasty for severe external auditory meatus exostoses

Exostoses of the external auditory meatus is a well known condition which infrequently requires surgical correction. However, the stenosis caused by severe exostosis can affect quality of life considerably and may require surgical intervention. Canalplasty, in such a situation, is a valid and effective management option. In our series the commonest indication for surgery was recurrent otitis externa. The detailed surgical technique is described and a retrospective analysis of 65 such procedures is presented. There were only two significant complications, both post-operative stenosis, requiring further corrective surgery. In conclusion, canalplasty for the exostosis of the external auditory meatus is a safe surgical option.

Fibro-osseous lesion of the external auditory canal: a case report

The aim of this study was to differentiate a novel type of benign circumscribed bone lesion of the external auditory canal from lesions described previously, such as exostoses and osteomas. We present a 43-year-old male patient who suffered from ear discharge of the right ear. Local findings showed bloody discharge from his right auditory canal, which was occupied by a mass-like tissue. Computerized tomography (CT) carried out before resection of the lesion disclosed the absence of a bony connection to the underlying structures. The pathologic findings showed lesions consisting of an osteoma-like bone formation with sparse osteoblastic areas. Mature lamellar bone and bone marrow containing adipose tissue were also noted. There was no evidence of a relationship to the cartilaginous tissue or bony structures of the external auditory canal. Therefore, we present this rare case and review the reported literature in which clinical, CT, surgical, and pathologic findings suggest that this lesion was unlike those previously known, and may be related to ossifying reactions in other parts of the organism.

Cosmetic results of a ventrally based advancement flap for closure of total ear canal ablations in 6 cats: 2002-2003

OBJECTIVE

To report the outcome of a modified total ear canal ablation (TECA) technique to maintain normal ear carriage in cats.

STUDY DESIGN

Case series.

ANIMALS

Six cats with external ear canal disease.

METHODS

Medical records were reviewed to identify cats in which a modified TECA using a single pedicle advancement flap was used to maintain normal ear carriage. Signalment, histopathologic diagnosis, complications, and outcome were retrieved. Owners were contacted to document long-term outcome.

RESULTS

Modified TECA procedures (7) were performed in 6 cats. Normal ear carriage was present immediately after surgery and was preserved at follow-up interview. Owners were satisfied with cosmetic appearance. Histopathologic diagnosis of excised ear masses included ceruminous gland adenocarcinoma (2 cats), ceruminous gland adenoma (2 cats, 3 ears), and inflammatory polyp (2 cats).

CONCLUSIONS

Modification of the TECA skin incision preserved normal ear carriage in all cats. Owners were satisfied with overall outcome and with cosmetic result. Rate and nature of complications were similar to previously published data.

CLINICAL RELEVANCE

A simple modification of the TECA skin incision to create a single pedicle advancement flap maintains normal ear carriage in cats.

Surgery of the ear and pinna

There are several disease processes of the ear and pinna that warrant surgical intervention. This article reviews surgical anatomy and common surgical procedures of the ear and pinna, including aural hematomas, lateral wall resection, vertical ear canal resection, total ear canal ablation and lateral bulla osteotomy, partial pinna resection, and feline inflammatory polyps. The clinical signs, diagnosis, and surgical treatment along with potential complications for each disease process are discussed.

Invasive fungal and bacterial infections of the temporal bone

OBJECTIVES/HYPOTHESIS

Objectives were to highlight the importance of surgical therapy in treating invasive polymicrobial infections of the temporal bone, to discuss the importance of antifungal therapy, and to review the differential diagnosis of ear canal granulomatous disorders.

STUDY DESIGN

Retrospective case review at a tertiary care medical center.

METHODS

A retrospective chart review of all patients diagnosed with invasive polymicrobial temporal bone infections was performed. Four patients were identified. All patients required surgical therapy for definitive management. All patients were followed for at least 1 year or until death.

RESULTS

Three of four patients had invasive fungi as pathogens. One patient had an occult squamous cell carcinoma. At the time of writing, one patient was free of disease, two were dead of disease, and one was alive with disease.

CONCLUSION

Invasive polymicrobial temporal bone infections can occur in immunocompromised patients and can possibly harbor an occult malignancy. Surgical debridement may be necessary to arrive at a correct diagnosis. Modified radical mastoidectomy with parenteral antibiotic therapy and other adjunctive measures may be necessary for disease resolution.

The Canterbury technique for canalplasty via an endaural approach in the surgical management of chronic refractory otitis externa

We describe an endaural technique for soft tissue and bony meatoplasty and canalplasty in the surgical management of chronic otitis externa unresponsive to medical treatment and out-patient microsuction. Following analysis of the surgical outcome via a retrospective review of patient records, we would recommend this surgical treatment in this patient group.

Breed variations in histopathologic features of chronic severe otitis externa in dogs: 80 cases (1995-2001)

OBJECTIVE

To compare pathologic changes of the horizontal ear canal associated with chronic severe otitis externa between Cocker Spaniels and dogs of other breeds.

DESIGN

Retrospective study.

ANIMALS

80 dogs with severe otitis externa that required total ear canal ablation with lateral bulla osteotomy.

PROCEDURE

Medical records were reviewed for breed, sex, and age at time of surgery. Histologic specimens from the horizontal ear canal were evaluated by a single examiner for overall tissue response pattern and scored for sebaceous gland hyperplasia, ceruminous gland hyperplasia, ceruminous gland ectasia, fibrosis, pigment-laden macrophages, and osseous metaplasia.

RESULTS

48 of 80 (60%) dogs were Cocker Spaniels. Thirty-five of 48 (72.9%) Cocker Spaniels had a predominately ceruminous tissue response pattern; only 9 of 32 (28.1 %) dogs of other breeds had the same pattern. Other breeds most commonly had a pattern dominated by fibrosis (n = 13 [40.6%]); fibrosis was the predominant pattern in only 4 of 48 (8.3%) Cocker Spaniels. Discriminant analysis and K-means clustering of 4 histopathologic criteria correctly classified 75% of the dogs as Cocker Spaniels or all other breeds.

CONCLUSIONS AND CLINICAL RELEVANCE

Cocker Spaniels are at increased risk for chronic severe otitis externa requiring total ear canal ablation with lateral bulla osteotomy, indicating that earlier and more aggressive management of the primary otitis externa and secondary inflammation is warranted in this breed. Cocker Spaniels with chronic severe otitis externa have distinct differences in pathologic characteristics of the horizontal ear canal, compared with other breeds.

[Chronic stenosed otitis externa: a report of 14 cases]

OBJECTIVE

To evaluate the clinical features of chronic stenosed otitis externa (CSOE) and its treatment.

METHODS

Fourteen patients with CSOE from 1992 to 2000 were analyzed retrospectively.

RESULTS

In etiologic study, otitis externa and eczema were found in nine cases, chronic suppurative otitis media in three, acetic acid burn in one, and no apparent precipitating causes in one. Ten cases were cured through single operation, 3 experienced 2 operations and one had had 3 operations. The restenosis of external auditory canal occurred in four ears.

CONCLUSIONS

CSOE is a rare disease. Surgical treatment is the main effective method for CSOE. The important items for treatment are: removing all stenotic fibrous tissue, widening bony canal, covering all bare bone with skin, preventing wound infection and close postoperative follow-up.

[Acquired fibrotic atresia of the external auditory canal]

BACKGROUND

There are very few communications on this pathologic entity, which is also called "postinflammatory medial meatal fibrosis" (PIMMF), its etiology and the adequate therapy. Apparently the cause is a chronic inflammation (or chronic ekzema) of the medial part of the external meatus or also a long-lasting otorrhea in chronic otitis media. The stratified epithelium of the eardrum and of the adjacent bony meatus is destroyed and replaced by fibrotic tissue. The lateral part of the auditory canal remains open and has the form of the finger of a glove, it may contain granulations, but often it is lined with a smooth stratified epithelium. A severe conductive hearing loss is the result of this anomaly.

PATIENTS

During the last 10 years we operated on 46 patients (52 ears) for this pathology: after retroauricular opening, which allows the best control of the anterior tympanomeatal angle, the fibrotic tissue was removed keeping the lamina propria intact. The bony canal was widened, if necessary. The eardrum and the bony canal were covered with split skin graft from the retroauricular region, then the canal filled with an antibiotic package for 3 weeks.

RESULTS

Underneath the fibrotic tissue we detected 3 cholesteatomata of the annular region, so it is important to remember, that the atresia may also cover a dangerous pathology. 6 times a second operation was necessary, besides that, we observed 14 recurrencies. All other patients had a wide epithelialized ear canal, their conductive hearing loss disappeared, and the results were stable over several years. Bacteriological and histological examinations were not helpful to clear up the etiology of this disease.

CONCLUSIONS

Surgery is the treatment of choice of the acquired atresia of the external meatus. We suppose that in these patients a individual disposition causes the formation of this excessive fibrosis, which has some similarity with keloid formation.

Outcome of 22 cases of perforated tympanic membrane caused by otomycosis

Twenty-two cases of perforated tympanic membrane due to fungal otitis externa were observed over a five-year period. The diagnosis of fungal otitis externa was made on clinical grounds due to the obvious presence of fungal bloom in the external ear canal. Some perforations were noted at the first treatment after the fungal debris had been removed from the external ear canal using a microscope. Other perforations were observed to develop over a few days. Initially, a discrete area of the tympanic membrane appeared white and opaque. As time progressed the white area disintegrated, forming a perforation. Once the otitis externa had resolved most perforations healed spontaneously. Two that were observed to develop during treatment required a myringoplasty. Another one closed significantly but a tiny persistent perforation required cauterization with trichloracetic acid to encourage it to close over completely. The only residual hearing loss was in a case with almost total disintegration of the tympanic membrane requiring a myringoplasty. Treatment of fungal otitis externa for the patients in this series was aural toilet using suction under a microscope and insertion of a gauze wick saturated in a combination of hydrocortisone, clotrimazole, framycetin and gramicidin.

Chronic otitis externa/media with total ear canal ablation and bulla curettage in a North American bison (Bison bison)

An adult female North American bison (Bison bison) with a chronic otitis externa/media of the right ear was examined because of a 4-mo history of intermittent anorexia, apparent painful behavior, and auricular discharge from the right ear. Computerized tomography (CT) demonstrated osteolysis of the tympanic, petrous, and squamous aspects of the temporal bone with soft tissue replacement and sclerosis of the right bulla. A total ear canal ablation with bulla curettage was performed, and cefazolin-impregnated polymethacrylate beads were left within the right bulla and the remnant temporal bone. Six months after the surgery, the bison had no clinical signs of otitis media.

M-meatoplasty: results and patient satisfaction in 125 patients (199 ears)

OBJECTIVE

Is M-meatoplasty the solution for chronic otitis externa caused by wax retention? This study discusses acceptance of this operation and whether sedation is necessary.

STUDY DESIGN

Between October 1994 and October 1997, 199 successive M-meatoplasties (125 patients) were studied, and 79% of the patients completed a questionnaire in which patient satisfaction with the procedure and outcome was assessed.

SETTING

Local hospital, functioning as a secondary referral center.

PATIENTS

All patients had narrowing of the lateral part of the outer ear canal resulting from anterior displacement of the cavum conchae cartilage.

INTERVENTION

The aim of M-meatoplasty is to increase the lumen of the entrance to the external ear canal by reducing the conchal cartilage on the posterior wall

MAIN OUTCOME MEASURES

Reduction of visits to the outpatient clinic, patient satisfaction on a scale from 1 (very bad) to 10 (excellent).

RESULTS

The number of preoperative visits was 7 (range 1-153). The median number of postoperative visits for the same problems more than 3 months after surgery was 1 (range 0-14). The patient score for the surgery and the final result was a median of 9 (very good).

CONCLUSIONS

Wax obstruction and related external otitis can be cured by M-meatoplasty if the conchal cartilage is too prominent on the posterior wall. It is a simple outpatient operation and is very well tolerated. After the operation, there is an enormous reduction in outpatient visits.

Radical meatoplasty in the treatment of severe chronic external otitis

In the beginning, external otitis is an inflammation of the skin of the external ear canal. Partial or total obliteration of the meatus causes cleaning problems, which worsen the obliteration, and hence, the infection. Immunosuppressive medication or illness, certain dermatological problems or frequent infections may lead to irreversible changes and to the malignant form of external otitis with life-threatening sequelae. Conservative treatments in the beginning are aimed at regaining the normal skin functions by helping the cleaning process and curing the acute infection with repeated irrigation, proper antibacterial medication and corticosteroids and anti-inflammatory analgesics. In rare prolonged cases, surgical procedures are needed to help the cleaning process by removing the irreversibly thickened skin and bone affections, and using grafts. On the basis of our experience, even the removal of the diseased skin and enlarging of the external ear canal are insufficient procedures in the most difficult cases. In the present paper, we describe a new surgical method that we have performed to treat chronic bilateral obliterative external otitis in 2 patients, with favorable results.

Otitis externa sicca/fibrotising external otitis (FEO) as a complication of Sjögren's syndrome

Sjögren's syndrome (SS) is a condition characterized by sicca symptoms and by autoimmune features. We describe two SS patients with otitis externa fibroticans/sicca. One of these 2 patients developed a lesion of the tympanic membrane making it necessary to perform a tympantomy and meatoplasty. Our findings suggest firstly that the epithelial cell-mediated secretion of lamellar bodies and the production of the permeability barrier are defective in SS. Secondly, local moisturing and/or topical corticosteroid treatment in SS patients with sicca symptoms in the auditory canal could help to avoid reconstructive surgical treatment.

[Results and extraordinary complications of surgery for exostoses of the external auditory canal]

We present a retrospective study on 22 operations of exostosis of the external auditory canal in 20 patients. 8 patients were passionated by water sports. The most frequent indication for surgery (13 operations) was recurrent external otitis or ceruminal obstruction. In 7 cases the need for a wider access to the middle ear indicated surgery. Surgery was usually performed as an outpatient procedure, maximum hospitalization was 3 days. The mean healing period was 6 (3-10) weeks. Mean follow up was 43 (3-110) months. There were no severe intraoperative complications such as facial paresis, lesions of the ossicles or of the inner ear. As intraoperative complications we found 2 perforations of the tympanic membrane, 2 expositions of the capsule of the mandibular joint, one of which was followed by chronic pain. As postoperative complications we found an early soft tissue stenosis of the external auditory canal and one late soft tissue stenosis which recurred after revision surgery. No recurrence of exostosis was seen. We describe an up to now unknown complication: the appearance of bilateral petrositis caused by staphylococcus epidermidis after bilateral surgery in an otherwise healthy patient. This study confirms that severe complications are rare, minor ones however relatively common. And that also minor complications may have a troublesome follow. Therefore and because of the potential of severe complications indication for surgery must be made cautiously and risks of the operation must not be underestimated.

[Surgical treatment of auditory canal exostoses]

BACKGROUND

Although complications of surgical removal of external auditory canal exostoses are rare, reported surgical complications include tympanic membrane perforation, postoperative hearing loss, canal stenosis, and facial nerve injuries.

PATIENTS AND METHODS

We report on our experience in exostosis surgery, consisting of 59 procedures in 48 patients. Preoperative and postoperative complaints and findings, intraoperative complications, and audiologic results are described and discussed. There has been a minimum of one year of follow-up in every case.

RESULTS

Postoperative canal stenosis was seen in 2 cases of preoperative severe persistent external otitis. Temporary threshold shift was recorded in 6 patients. Persistent sensorineural hearing loss occurred in 4 patients. Six of the 10 patients with temporary or persistent hearing loss had already shown preoperative sensorineural hearing loss. Intraoperatively tympanic membrane perforation occurred in 3 cases, accidental opening of the mastoid in 1 case.

CONCLUSIONS

Exostosis surgery should be reserved for uninfected ear canals. Meatal skin preservation without circular meatal flap incision is recommended to avoid postoperative canal stenosis. Especially in cases of preexisting sensorineural hearing loss, attention should be focused on the intraoperative noise reduction by tympanic membrane protection and pauses of noise exposition.

[Malignant external otitis: 4 cases report]

OBJECTIVE

To improve the level of diagnosis and treatment of malignant external otitis (MEO).

METHOD

Four cases with MEO were reported.

RESULT

Three in four cases were followed up. One patient was cured, and the others died of intracranial infection.

CONCLUSION

Early diagnosis of MEO is very important for treatment. The patients of MEO with diabetes often died of intracranial infection.

[Benign necrotizing osteitis of the external ear canal. A report of a clinical case]

Benign necrotizing osteitis of the external ear canal is a process of unknown origin. This necrotic process with sequestration of the tympanic bone occurs in healthy, non-diabetic patients. It should be differentiated from malignant otitis externa and radionecrosis of the tympanic bone. A case is reported and the literature on this rare clinical entity is discussed.

Wound contamination and antimicrobial susceptibility of bacteria cultured during total ear canal ablation and lateral bulla osteotomy in dogs

OBJECTIVE

To detect contamination of wound sites from surgical handling of excised tissues during total ear canal ablation and lateral bulla osteotomy in dogs, and to compare susceptibility of bacterial isolates to cefazolin with susceptibility to other antimicrobial agents.

DESIGN

Prospective clinical study.

ANIMALS

13 dogs.

PROCEDURE

Dogs were treated surgically for otitis externa and media via total ear canal ablation and lateral bulla osteotomy. Specimens for aerobic bacterial culture were obtained from SC tissue immediately following skin incision, tissues excised from the osseous bulla (after transection of the horizontal ear canal and lateral bulla osteotomy), and from SC tissue prior to skin closure. Antimicrobial susceptibility of bacterial isolates to various antibiotics was determined by use of a broth dilution assay.

RESULTS

There was a significant association between isolation of Streptococcus canis and Escherichia coli from specimens from the osseous bulla and specimens from the SC tissues prior to skin closure, indicating contamination of the SC tissues during surgery. Seventy percent of bacterial isolates were susceptible to cefazolin.

CLINICAL IMPLICATIONS

Measures to limit bacterial contamination resulting from tissue handling during total ear canal ablation and lateral bulla osteotomy are necessary. Bacteriologic culture of tissue of the osseous bulla and determination of antimicrobial susceptibility are recommended. Administration of cefazolin alone may not be efficacious for antimicrobial prophylaxis.

Postinflammatory acquired atresia of the external auditory canal: treatment and results of surgery over 27 years

Postinflammatory, acquired atresia of the external auditory meatus is a relatively rare consequence of chronic otitis media or recurrent external otitis with an annual incidence of 0.6 cases per 100,000 inhabitants. Primary and late results after operative treatment of this condition in 53 ears over 27 years are presented. Perioperative findings are described, and an outline of applied surgical technique is given. Six patients had bilateral involvement. The male-to-female ratio was 1:2, median age at surgery was 46 years, and the median follow-up period was 5 years (range, 4 mo to 13 y). In 11% of the cases, recurrent atresia developed. Early operation is recommended, because cholesteatoma behind the atresia was found in 9%. Hearing improvement has been considerable after removal of the atresia with primary closure of airbone gap within 20 dB in 90% of the cases.

Treatment of chronic otitis externa by KTP/532 laser

The traditional meatoplasty operations performed for chronic otitis externa, which has entered the 'fibrotic' phase, are often unsatisfactory because the results in terms of canal patency, hearing gain and patient satisfaction are variable. Although the use of laser in chronic ear surgery is well recognized, it has not been previously reported as a meatoplasty technique. Ten KTP laser meatoplasty operations were performed on eight patients with chronic otitis externa. This pilot study shows the technique to be effective, fast and with a high patient satisfaction rate in the short-term (mean follow-up period 9.3 months). The average increase in hearing thresholds was 24 dB HL. Significant patient benefit was obtained in at least six out of eight patients using the Belfast rule of thumb. The technique has many advantages over the traditional meatoplasty operations but the long-term results require evaluation.

Necrotizing external otitis: aminoglycoside and beta-lactam antibiotic treatment combined with surgical treatment

Necrotizing external otitis is a life-threatening condition that still causes therapeutic problems. A retrospective analysis of 22 patients who were all treated with a short standard course of aminoglycoside and beta-lactam antibiotic with through local debridement was carried out; 50% (11/22) had diabetes mellitus, and all had a positive culture of Pseudomonas aeruginosa. The frequency of recurrence was 14% (3/22), and 95% (21/22) were eventually cured. The treatment course lasted 17 days on average. Side effects caused by the drug treatment were seen in 14% (3/22), but they were mild and transient consisting of a reversible increase of the serum creatinine level. It was concluded that the treatment was short, efficient, safe, and as successful as treatment with quinolones or third-generation cephalosporins which has been reported during the past years. In our opinion, therefore, these drugs should be reserved for cases of treatment failure, development of resistance, or side effects.

Passive drainage versus primary closure after total ear canal ablation-lateral bulla osteotomy in dogs: 59 dogs (1985-1995)

OBJECTIVE

Compare passive wound drainage to primary closure of total ear canal ablation-lateral bulla osteotomy (TECA-LBO) in dogs.

STUDY DESIGN

Retrospective analysis of medical records.

SAMPLE POPULATION

Fifty-nine dogs with end-stage otitis externa or neoplasia of the external and middle ear.

METHODS

Medical records of dogs with TECA-LBO were reviewed. Dogs were divided into postoperative drain and primary closure groups. Statistical analyses were performed to identify differences in data for signalment, preoperative treatment, duration of hospitalization, immediate complications, and long-term complications between groups.

RESULTS

No significant differences were detected in signalment, diagnosis, and duration of medical management between groups (P > .05). Duration of hospitalization was greater for dogs in the drain group (P < .05). Immediate postoperative complications occurred in 26 of 59 dogs and included ipsilateral facial palsy, incision swelling, vestibular signs, premature drain removal, and one dog died of aspiration pneumonia. Long-term (> 6 months) complications were identified in 12 of 50 dogs and included dermatitis of the medial aspect of the pinna, chronic fistula formation, and permanent facial paralysis. No association between immediate or long term complications and method of closure was identified.

CONCLUSIONS

Primary closure is an acceptable alternative in dogs undergoing TECA-LBO when surgical wound dead space can be managed with meticulous hemostasis, complete debridement of devitalized tissue, and accurate apposition of tissue planes.

Radiographic appearance of the middle ear after ventral bulla osteotomy in five dogs with otitis media

Radiographs of the middle ear were made in five dogs 60 to 78 months after ventral bulla osteotomy was performed to treat otitis media. The clinical results of surgery were considered satisfactory in four dogs and unsatisfactory in one. In 4 dogs with satisfactory results, radiographs demonstrated complete reformation of the bulla in 3 operated middle ears (3 dogs), with partial bulla reformation in the three middle ears (3 dogs). Radiographs in one dog with unsatisfactory results showed complete bulla reformation with no increase in lumen opacity. The proliferative bony response obliterating the middle ear previously reported in normal dogs after ventral bulla osteotomy was not seen in any of these patients.