Your Pet's Best Friend

Chronic Ear Infections

Last week we saw a lovely (if overlarge) cat named Baby.   She didn't look quite so bedraggled then.  This picture was taken as she awakened after her ear-cleaning procedure today.

It was Baby's first visit to our hospital and I was unhappy to learn that she had been suffering from chronic ear infections "for years".   She had been treated for various diagnoses of ear mites, ear infections, and ear polyps with every thing from long-acting cortisone injections to antibiotics to the current treatment of twice weekly home ear flushes.

Her ear canals were full of extremely hard debris.  Several passive flushes (just instilling a cleaning solution and letting the cat shake it out) removed virtually nothing.  I had to wonder how long it had been since someone actually LOOKED into these ears.  The canals were very hard, not flexible at all, and swollen so that you couldn't get a scope into them very well.

We gave her enough cortisone for about a week, and sent home drops with cortisone and anti-fungals and antibiotics, hoping to get the canals to open up a bit, and maybe soften that debris.

Today we anesthetized her and removed LOTS of junk, including this honker, which is as hard as a rock.  After cleaning this long-standing accumulation of crud out of her ears, we could see her ear-drums on the video-otoscope and were surprised to see that they appeared intact.  They were a little macerated (like your finger gets under a wet band-aid), but no obvious holes were present.  This was surprising because probably 80% of animals with long-standing ear infections no longer have an ear-drum.  A little closer observation revealed air-bubbles rising from her right middle ear and appearing through the ear drum to float up to the scope.

Fortunately, despite this small hole in the ear-drum, her middle ears looked great when we X-rayed her skull: no change in the bone, no crud on the inside.  Bottom line is that her prognosis is good to be FREE of ear infections "for years".   You have to really examine these thoroughly and really get them clean in order to effectively treat them.  "More ear drops" is not the answer.

"Fox-tail" weed awns

I put this under ear problems because today these nasty little seeds were an ear problem.  Some people call them "wild oats" (not the kind you wish you had sown, either).  They are the little grass seeds from grasses that look sort of like stalks of wheat.  In our part of the country, these are all over the place during the last couple of weeks in May and the first two weeks in June.

It's actually not that common to find them inside a pet's ears, that is, unless the pet is Jake, here.  Last year about this time, he came to us after being treated with numerous ear drops and just not getting any better.  A thorough ear-scoping revealed what looked a bit like a spider on his ear-drum. It was the little "fox-tail" spread out and poked in.  If we had not had the good instrumentation with our MedRx video ear scope, I don't know how we would have ever removed the foreign object from his ear-drum.  It still wasn't easy, even under anesthesia. 

Today, he's back, one year later with a fox-tail on BOTH eardrums.  Is he a lucky guy or what?  The somewhat dazed expression he's sporting is because the picture was taken about the time he woke up again.

More commonly, we see these things under the eyelids, in the back of the mouth, and especially between the toes.  The darn things have a point on one end, and they poke in between the toes.  The dog comes in with a painful purple bulge between his toes.

The pointy end has spines that flare out behind, and there are barbs on the little spines. 

In fact, there are barbs on the barbs.  Once these things get started in, they embed pretty firmly and don't come out very easily.  They can be pretty hard to find, even when you numb up the toes and cut into the mess to probe it.  The body tries to wall them off, and there is a lot of what our old family doctor used to refer to as "festering".  Can you imagine having this under your eyelid, rubbing your eye?

We'll be seeing a lot of these over the next couple of weeks.  There probably won't be many more down in the ears, though.

Ear Mites feel like this?

In the September 1, 1993 issue of the Journal of the American Veterinary Medical Association,  a letter to the editor appeared, entitled "Of Mites and Man".  This letter was submitted by Dr. Robert A. Lopez, and is (ostensibly) a description of the sensations he experienced after deliberately infecting himself with ear mites in 1968.  According to the letter, one of his clients had developed a skin rash which cleared up when her cat's ear mite infestation was cured.  Verified reports of natural human infection with ear mites are virtually unheard of.  Either Dr. Lopez is a dedicated scientist (sort of) or a talented writer.  These excerpts remind me of Kafka's Metamorphosis.  "One morning, as Gregor Samsa was waking up from anxious dreams, he discovered that in bed he had been changed into a monstrous verminous bug."

"...Then I ... transferred approximately one gram of ear mite exudate from the cat to my left ear.  Immediately, I heard scratching sounds, then moving sounds, as the mites began to explore my ear canal. Itching sensations then started and all three sensations merged into a weird cacophany of sound and pain that intensified from that monent, 4 PM, on and on... At first, I thought this wouldn't and couldn't last very long.  However, as the day and evening wore on, I began to worry. The pruritus [itching] was increasing.  The sounds in my ear (fortunately I had chosen only one ear), were becomng louder as the mites traveled deeper toward my ear drum. I felt helpless.  Is this the way a mite-infested animal feels?"

There are many more details, as the letter is a full page and half of small print, but you get the idea.  He repeated the experiment two more times, having less severe signs on subsequent infections.  He recovered fully.  If this were a bad movie, it would now say

"The End?"

Rabbits get Ear Mites, too

You won't ever see a dog or cat with an ear like this. [Click the picture for a better view] Now, the inside of their ear canal gets to looking like this mess, but on the outside they look pretty much okay.  That is, until they scratch it raw. They'd love to stick something down inside their ear and scratch it, but they can't use tools in that fashion (the fashion that your mom told you never to do: "Don't put anything in your ear except your elbow!") Even when a dog or cat is really working the ear over, it just gets scraped and scratched. It never develops these huge crusts like this rabbit did.  Of course, it takes the rabbit a heck of a long time to get like this (and rabbits do have a different species of mite).  Hard to believe that someone could ignore a problem for weeks and weeks, but sometimes they do.  This guy was treated successfully, but I only got a telephone follow-up. I wish had an "after" picture. 

Even though they don't produce this type of damage, ear mites do live on the skin outside the ear in dogs and cats. Otherwise, they couldn't be transmitted by casual head-to-head contact.  Animals are not going to fish goop out of somebody's ear and put it into their own ear (they might eat it, but that's another story).

Coming soon: the story of the veterinarian who put mites in his own ear to see (hear?) how it feels.

P.S. Note on Willy P.'s comment:  This gentleman is a well-known specialist in the care of laboratory animals, including rabbits, so pay attention to what he's saying.  He's also my classmate from veterinary school, so I know whether or not to trust the guy.

Aural Hematoma

An aural hematoma is one of the most painful-looking conditions I know of.  Aural means ear and hematoma means bloody swelling.  The pinna is the floppy, outside part of the ear (as opposed to the ear canal, the tube going down and in to the ear-drum).  The pinna is a 3-layer sandwich of skin, cartilage and skin.  When a blood vessel in the pinna breaks, it oozes fluid between the layers, separating the skin on the underside of the pinna from the cartilage.  The ear can look like it has a slight bulge, or it can look as though it has been inflated to the point of bursting.  This swelling means that the area is under a lot of pressure, and that means pain.

Affected individuals are usually holding their head sideways, and they may or may not be shaking their head. They are pretty uncomfortable, if not downright painful.

When I was in veterinary school in the seventies, the conventional wisdom was that the dog (or cat) has an ear infection.  This causes him to shake his head and scratch his ears until he finally breaks a blood vessel in the pinna, which then begins the inflation process.   Treatment would obviously need to include treatment of the ear canal infection that started the process.  Then the pinna would receive a major surgery.  If you don't drain these bloody swellings, it takes months for the body to stop the leak and absorb all the fluid.  The ear pinna gets badly scarred and deformed and "wadded up" in the healing process, much like the cauliflower ear of the boxer whose head has been pummeled hard enough to break ears, noses, and cheekbones.  Plus,the pet stays really uncomfortable for a long time.

Draining the swelling by simply puncturing it doesn't work very well.  The pocket refills quite rapidly.  You needed to keep the pocket draining until the vessels inside healed up.  In the old days (jeez, I was a kid in "the old days"), this involved cutting a sliver of skin out of the underside of the ear so that it wouldn't heal up too fast.  Then the ear pinna was sewn to a piece of some rigid material so that it wouldn't wrinkle up and "cauliflower" as it healed.  What a horrendous, messy piece of surgery that was, not to mention the mess during the healing process.

A huge advance was the development of a much less drastic technique that works ninety percent of the time and frequently doesn't even require a tranquilizer.  Using a large-bore hypodermic needle, a small (1/8 inch) incision is made in the pocket and the fluid drained out.  Then a little plastic drainage tube is sutured in place and left for a couple of weeks.  This allows the fluid to escape so that the ear can "stick back together".  You have to keep them on antibiotics during this period, as bacteria can enter the pocket through the tube that the fluid is draining from, and it's a great place for them to grow.  It's still pretty messy for a few days, but so much cheaper and easier on the dog, the owner, and the surgeon.

Here's the basic tube, designed to be put up into a cow's udder to allow nasties to drain when she has mastitis (breast infections).  It's got a little screw on cap, a little hole in the end, a little hole in the side, and two little spurs to keep it from falling out.

I cut the end a little shorter to enlarge that hole, cut the existing side-hole larger, and add another hole to the opposite side.  Then the cap is removed, and the round flange trimmed to make a flat surface that will lie against the ear when the tube is inserted.

Many dogs do not even need a tranquilizer for this.  You just poke a hole, squeeze out the gooey, pop in the tube and put in one stitch to hold it.

Even better, there has been new work that suggests some of these are NOT due to the trauma of head-shaking and scratching.  I have often seen these hematomas in animals whose ear canals appeared perfectly clean and healthy, i.e. no ear infection.  This was puzzling, but I attributed it to one good hard shake that played "crack the whip" with the ear.   New evidence suggests that many of these hematomas are immune-mediated.  This means that the body's defense system has gone a little haywire and attacked its own blood vessels, causing the damage that blows up these ears.  What this means in practical terms is that if you suppress the body's defenses long enough for it stop this self-attack, the hematoma may heal without any surgery or drainage at all. 

Many of these cases will respond to high doses of prednisone (a synthetic form of cortisone) with no other treatment.  It is amazing to see one of these ballooned-up ears return to normal just by taking pills.  The down-side would be the side-effects of the prednisone (excessive appetite, excessive urination, followed by excessive water-drinking, are the most obvious).  Worse would be a patient who gets a bad infection while you are suppressing his body defenses.  That's not common, but it certainly can happen.  It's also important to taper the dosage off slowly.  If you stop as soon as the ear swelling goes down, it's very likely to recur rapidly.

One thing is for sure: small hematomas almost always get bigger.  When you first notice that ear swelling, rapid treatment will result in a much faster and simpler healing process than if you wait until the entire pinna is involved.

Ear Mites are my favorite ear problem.

Ear mites ARE my favorite ear problem.  Why?  FIrst, they are so cool to show people under the microscope.  Unlike most other microscopic things (that just look like some variation of a blob), these guys are obviously bug-like and they move.  I've got a little eyepiece camera that plugs into the USB port on the lab computer station and clients can watch the computer monitor in real time instead of having to squint through the microscope.  They can SEE IT!

The second reason that I like ear mites is that they are so curable.  Unlike many ear problems that are rooted in whole-body problems (like a food allergy), ear mites are pretty much in the "what you see is what you get" category.  When you see ear mites, they are probably the root cause of that ear problem.  Plus, they don't come out of the ground or out of the sky.  You always get them by direct contact with the head of some other animal, so it's unlikely to be some lifelong chronic situation.  By contrast, when you see a yeast infection in the ears, you know that they are virtually always secondary to something else.  Yeast are always hanging around in small numbers, but something else has let them get out of hand. Now you've got to find that "something else".

That being said, how is it that some pets with ear mites do not get cured?  One of the most common reasons is that the ear gets full of dead skin, ear wax, ear mite poop and debris from secondary infections.  The mites dig tunnels beneath the surface of the skin that lines the ear canal and this causes a lot of debris to form (not to mention a lot of itching, like having chiggers inside your ears; that's why the pet shakes her head and scratches her ears).  People put medication in the ears to kill the mites, and it never gets to the mites.  It just sits on top of the debris.   

When the mites make their tunnels, they lay eggs in the tunnels, which hatch out about ten days after they are laid.  If you don't treat for a long enough period of time, new mites hatch out and start it all over again.  I like to treat daily for ten days, and repeat a single treatment on day 20 and day 30 for late hatchers.

If you have multiple pets, they are liable to pass the mites back and forth.  You have to treat ALL the pets who are in direct contact with one another.

Many medications for ear mite treatment consist of nothing more than an insecticide in an oily base.  This is fine if there are no complicating factors. Unfortunately, if the ear is full of goop, as noted above, they don't do much.  The ear must be cleaned with wax softeners and gentle flushing so that the medicine can actually contact the diseased skin.  You can't clean them with a Q-tip: it just packs stuff down instead of lifting it out.   If there are secondary ear infections, those need to be treated as well.  If the ear is sore from all this, insecticide certainly does nothing to relieve that. I like Tresaderm for ear mite treatment, as it usually kills the secondary yeast and has a little cortisone to make the ear feel better.

Milbemite otic is approved for cats and will usually eliminate an ear mite infestation with a single treatment. Cleaning the ears is optional with this product.  It doesn't seem to work well in dogs, and if you have a secondary ear infection you still need to treat that.

Revolution is a heartworm preventive that is applied topically.  It absorbs into the skin and circulates in the bloodstream overnight.  It is excreted not in the body wastes, but in the skin oils, including ear wax.  It kills fleas, flea eggs, scabies mites and ear mites.  I find it is a great preventive for those outside cats who keep getting re-infested from their low-class buddies. It's a good follow-up for those late-hatchers, too.  I don't find that it's very effective as a solo treatment for a really bad case of ear mites.

Ear mites are the only ear problem to have such a sweet simplicity.

James Herriott Moments

If you love animals and have an interest in veterinary medicine, you have probably read James Herriott's books (All Creatures Great and Small, etc.). [ If you haven't read them, you will enjoy them, so go read them.  Then you can finish reading this some other time.]

In many ways, my first year in practice was much like his.  We both went to work for a picturesque older veterinarian in a beautiful but foreign (to us) countryside.  We both were full of scientific knowledge, but woefully short on experience in practice and in dealing with our clients, particularly since our clients came from a different cultural background than we did.  While there had certainly been many advances in medicine and technology between his first year in the 1930s and mine in 1978, some things never change.  Animals still get sick and people still care about them. Veterinarians and clients still have occasional disagreements over differing expectations and failures to communicate.  You laugh, you cry.

Herriott's books are autobiographical, but they are written as novels, rather than historical records.  This means that he leaves out a lot of dull stuff and does a great job of presenting things in a humorous or dramatic fashion, as the case demands.  Not that he is making anything up, as heaven knows truth is stranger than fiction, and there is no need to embellish it.  On the other hand, there are a lot of what I call "James Herriott Moments" where just as he is about to drive away from the farm, or just as the patient is about to die, or just as the mystery seems unsolvable, Dr. Herriott has a flash of intuition that saves the day. 

When I was a kid, my father (who was an attorney) would often comment that one of Perry Mason's dramatic tactics was actually not something that could really happen, such as presenting a "surprise witness".  I asked why they would put something so inaccurate in the program and he replied, "Because it makes a better story that way."

I have no doubt that James Herriott saved the day many times, and dramatically, too.  I do have some doubts that his flash of intuition was always so dramatic and just in the nick of time.  However, I don't begrudge his telling of the story that way, because it does make a better story that way.  Also, if you filled the book with anecdotes about how you figured things out a week later when it was too late, it would never have made the best-seller list.

I must admit that some of my James Herriott Moments have definitely come too late.  Most cases are not solved by flashes of intuition, however, but by systematic detective work.  You take a careful history that includes everything about the pet's lifestyle and what he's been doing lately.  You cross-reference the problems with known breed-related problems.  A thorough physical examination and laboratory tests (if needed) round out your collection of facts.  These get processed to give you a list of the most likely causes, and then you work through those.  If you're hitting the wall, you consult with a specialist, or send the case to the specialist if the people can go.

Sometimes, though, you DO have a James Herriott Moment, and it's pretty cool.  This apparently obscure and difficult problem presents itself and somehow you just know what's going on and what to do about it.  You still need to confirm with testing or response to treatment (because your intuition might be wrong; it has been before, sometimes), but it's pretty sweet  when this happens, especially if it's a long-standing problem that's been seeing three other doctors. Of course, a little luck doesn't hurt, either.  That luck factor is why you never bad-mouth the other doctors.  You don't know what things looked like when they saw it.

I had a James Herriott moment just the other day.  This ninety-eight pound German Shepherd came in with a history of an ear infection going on for five months.  His ears were rather sore and swollen.  The owner had never been able to put any medication in the ears at home, due to the dog's pain, size, and generally uncooperative disposition.  This is bad, as one is very unlikely to treat an ear infection successfully without touching the ear.  The previous veterinarian had been periodically anesthetizing the dog to clean and treat the ear.  Of course, it would quite an ordeal to do that every day for a week or two, which is the kind of treatment ear infections usually need.  So, they'd treat him, and then the owner would take him home and do nothing until he couldn't stand it any longer, and they'd do it again.

Even though the ears were horrible and the dog went nuts if you got close to them, I did manage to get a diagnostic swab.  They were too swollen to get a scope into, even if I had anesthetized him, so we didn't bother with that.  Under the microscope, the swab showed mostly yeast (which need to be dealt with , but are ALWAYS secondary to something else), and (here's the lucky part) half an ear mite.  The ear mite is lucky for two reasons: the first is that I found it when the other guy missed it, and I am sure he was looking; the second is that ear mites are SO treatable, as opposed to some underlying allergic condition that would have to be managed for life. 

The James Herriott Moment thing is that my plan to treat an ear infection without touching the ears worked (which was by no means a sure thing).  We put him on prednisone orally to relieve the inflammation, shrink the swelling and reduce the pain.  Ketoconazole orally to kill the yeast from the inside out as he grows a new layer of skin.  Revolution goes systemically to begin killing the ear mites by oozing out with the new ear wax he makes.

In seven days, we rechecked him, and he was ninety percent improved without ever touching his ear.  Then we put a muzzle on and I just put my finger in his ear for a few minutes. He finally quit going nuts because he realized that his ear didn't hurt any more.  After that, I was able to look into his ear canals, flush them out and medicate them, although he was still pretty wacky about it.  He's continuing his other treatment, too, and he is going to get well (after FIVE months, Whoo-Hoo!)

It's a James Herriott Moment, folks.