Itchy, smelly ears can be incredibly uncomfortable for dogs and cats with ear infections. Diego had such horrible ear infections, he was living in constant pain. This episode’s guest, veterinary dermatologist Dr. Meagan Painter, joins Dr. Brittany Lancellotti to discuss common tests, such as ear exams, cytology, and culture and what these tests tell your veterinarian. They describe common treatments, such as oral and topical medications, and how these treatments allowed Diego to live his best life, no longer in pain.
Welcome Back Dr. Painter!
[00:01:04] Dr. Lancellotti: Welcome, everyone, to today’s episode of Your Vet Wants You To Know. In the last episode, I was joined by Dr. Megan Painter, and we talked about how to figure out types of causes there are to your animal’s ear infections. That includes primary, secondary, perpetuating, and predisposing causes. If you haven’t had a chance, I would encourage you to go back and listen to that episode, so that you can have a better understanding of the PSPP classification system and why we use this when we’re trying to figure out how an animal develops ear infections. Dr. Painter is a board certified veterinary dermatologist at Angel West in Boston, Massachusetts. She is also the founder of an online course for family veterinarians called The Allergic Dog, where they can get more information about how to treat these frustrating allergic skin and ear diseases with 8 hours of race-approved CE. I would definitely encourage anyone to check that out if they are interested in having more resources. So I’m excited to have back Dr. Painter, who’s going to talk more about what veterinarians might do in the diagnosis and treatment of ear infections. Welcome back, Dr. Painter.
[00:02:16] Dr. Painter: So glad to be back. Dr. Lancellotti. Thank you for having me. This is going to be a very fun and comprehensive episode for our listeners.
[00:02:26] Dr. Lancellotti: Yeah, absolutely. I think this is really important. Not just for pet owners, but to help other veterinarians who might be listening to come up with a systematic way to organize their thoughts when they’re treating animals with chronic ear infections.
Causes of Ear Infections: Primary, Secondary, Perpetuating, Predisposing
Dr. Lancellotti: Dr. Painter, can you quickly review for our listeners what the PSPP classification system is?
[00:02:45] Dr. Painter: Sure. when we think of ear disease, we want to make sure that we’re keeping in mind that there are four main categories of why ear disease could occur in a dog. The first of which is the primary cause. This is the “why.” Why is this happening to my dog? Usually, this is something like your dog having allergies or a fox tail in the ear. Or your dog has some type of metabolic disorder that can affect the skin of the ear. So that’s the “why.” That is the cause of the ear infection or inflammation. Secondary causes all revolve around the type of infection that’s present. Do you have bacterial infection, yeast infection, or both? What type of infection, if any, is occurring in your dog’s ears? That’s a secondary cause of otitis externa. Perpetuating causes are situations within the ear, itself, that promote infection and inflammation. These can be changes like calcification of the ear canal, hyperplasia of the glands within the canal, middle ear infection and involvement, and many other things that work to make our job harder to resolve that infection. Even if we understand what the primary cause is, and we have the secondary under control, the perpetuating causes are what make our battle uphill. Then, predisposing causes of otitis externa are those risk factors. Is your dog an avid swimmer and loves to go in the water all the time? That’s not your primary cause of ear disease. That’s a risk factor. Not every dog who swims gets ear infections, but allergic dogs who swim might now have an added risk factor for developing otitis externa. We can also see examples of different types of anatomy of the head and the ear that can predispose a dog to developing ear infections. Again, this PSPP system is very useful at providing a systematic organization for us all (veterinarians and pet owners alike) to think about ear disease in dogs, so that we can work within that framework to try to make your dog more comfortable.
How Does a Veterinarian Diagnose an Ear Infection?
[00:04:58] Dr. Lancellotti: This is so beautifully laid out. And you talked last episode about one of your very special cases, Diego. Do you think that we could use Diego as an example for how to look at each one of these factors in our PSPP classification system, to determine what factor is going on for that individual pet?
[00:05:22] Dr. Painter: Absolutely. Diego represents every problem that ever existed in the ear, except maybe (luckily) a foreign body. And he did not have any sort of cancer in his ear, thank goodness! But Diego had severe ear disease and I was very concerned that if we could not fix his ear medically, he would end up needing surgery. And that’s something that both the owners and I really wanted to avoid, because we wanted him to be comfortable, but we didn’t want him to have to go through surgery to make him comfortable.
Where did I start? By looking at his ear. That might sound funny, but I really wanted to know, “What does this ear look like?” A fancy term for this is otoscopy. This usually involves something we’re all familiar with when we go to our doctor, where they actually look (using that handheld device with a little light) to see what the canal looks like and try to visualize if there’s an eardrum, if that eardrum is in tact, and if there are any changes that you can see to the eardrum, itself. In Diego’s case, I actually couldn’t even look into the canal because it was so swollen. Simple otoscopy was not an option for him. It was just a visual examination of his ear and his pinna, both of which were severely inflamed, very red, and there was a lot of pus and waxy discharge in his ear.
I could never tell you why his ears looked like this. You don’t look at the ear and say, “Oh, it’s red, therefore it must be allergy.” What you have to do now is go through a systematic ‘rule-out’ system to really determine that primary cause. In his case, what we decided to do was say, “Okay, what are the primary causes? What is your dog’s age? How long has this been going on for?” Get a very thorough history. You really want to understand, “Is this something that came out of nowhere? Is this a problem that’s been going on for 8 years? Is this a 12 year-old dog that all of a sudden developed infection in their ear? Or is this a young dog that’s had infection since they were 8 months of age?” That will really help your veterinarian get steered in the right direction, so that they can identify a primary cause of your dog’s ear infections.
In Diego’s case, he was relatively young. He had been affected with his ear disease since he was a young dog, but the history for him was actually quite limited, since he had recently been surrendered by another owner and adopted by the new owners who I was seeing. We established that the most likely cause for him was probably some type of allergy, and because we didn’t have a sense of seasonality for him, we really wanted to determine what percentage of his problem was from food.
So, he was started on a hydrolyzed diagnostic diet trial right away and we took this very seriously. We wanted to be sure that if this was a food allergy that we identified that right away. His life would obviously be so much better, as his ears were absolutely miserable for him. And it’s silly to miss that diagnosis. You know? If it’s something as simple as changing his food- gosh, we could get so lucky. So that was his first step at identifying the primary cause. We couldn’t do anything to look and see, “Did you have a tumor in the ear?” At this point in our first visit we weren’t going to do advanced imaging. We were going to try to just use the tools that we had available to us, in terms of medical management, to make the ear more comfortable and identify common primary causes of ear disease. Of course, there were other differentials that we always kept in the back of our mind, in terms of why a dog might get ear disease, but looking at that food allergy was really our priority.
[00:09:08] Dr. Lancellotti: Yeah, I think that goes a long way towards investigation of underlying, allergic ear infections- doing that diet trial. And if you’ve listened to some of the previous episodes on food allergies (episode 2) or diet trials (episode 17, also with Dr. Painter), you’ll remember that there is no blood, saliva, hair, or skin tests that we can do to figure out if an animal has a food allergy. You really have to go through and do an elimination diet trial, under the supervision of your veterinarian, to be able to truly say whether or not an animal has a food allergy that’s contributing to these ongoing ear infections. I would encourage you to go back and listen to those episodes to get more information. But you’re right- the history is so important with these animals, because it helps us to figure out where we want to focus our time, energy, and resources when investigating the primary cause of the disease. You mentioned the older animals that don’t have a history of having ear or skin infections when they were younger- there may be more of a concern for some type of hormonal disease- things like Cushing’s disease or hypothyroidism. So rather than starting right away focusing on allergies, just do some basic blood work to see if there’s anything else going on may be something that your veterinarian recommends as they get older.
Should my dog's ear infection be treated at the ER?
[00:10:32] Dr. Painter: It’s important to remember that your primary care veterinarian is probably going to be the most equipped. I work in a specialty referral practice where we have an urgent care and emergency room, and a lot of dogs come through with ear infections. The hard part is that your emergency veterinarian is not going to be able to get a thorough history as well as someone like your primary or family veterinarian would be able to. A lot of times, getting some relief through an urgent care setting is absolutely appropriate if you’re concerned for your dog. But you really want to follow up back with primary care or a specialist (like a veterinary dermatologist) to say, “Okay. I went to the ER last week because I was really worried about my dog. I just want to talk about what’s causing these infections, so that they don’t happen again, and I don’t end up in that scenario.” Again, the history is really one of the most essential parts of helping your dog get through this and not have to go through this again.
[00:11:33] Dr. Lancellotti: Yeah, I love that. This is such a frustrating, chronic, and long-term disease. It really does require a good relationship between the pet owner and the veterinarian. An urgent care setting is certainly someplace where an animal can get relief, but for ongoing care, it’s really important to have that well-established relationship with somebody that you can trust to come up with a long-term solution.
What tests may my vet recommend for ear infections?
Dr. Lancellotti: Dr. Painter, you talked a little bit about looking at the ear. What’s the next thing that a veterinarian might do?
[00:12:04] Dr. Painter: Most of the time, veterinarians are going to perform cytology- a pretty simple test that most of us can do in our clinic right away. It involves taking a swab or a collection of cells from your dog’s ear and ear canal, usually using a cotton tip applicator (Q-tip), and you basically take that swab and roll it onto a slide. Then, that slide is stained in-house, and that stain is then used to highlight certain cells on the slide. Then, you pop that under a microscope and take a look. This is a very simple, very informative diagnostic test that helps us determine what the secondary problem is. Is this a yeast infection, a bacterial infection, or both? What are we dealing with in terms of the type of infection? Also, is there a lot of inflammation? It helps us see the cells. You can’t see cells unless you have microscope eyes- and nobody has microscope eyes! This is what veterinarians are using to determine the presence and type of infection and inflammation in your dog’s ear. And I hear a lot of times that pet owners are reluctant to allow veterinarians to perform cytology, when it’s usually a pretty affordable price. It’s something that is going to be priced according to what the clinic has, but most family practices are going to have this be something that should be affordable for most pet owners. If you can, it’s a great thing to allow your vet to do, because it allows veterinarians to say, “Your dog has a yeast infection, therefore, I don’t need to put an antibiotic into your dog’s ear.” I love performing ear cytology because it just helps me narrow down the problem, get a sense of really how bad the inflammation and infection is, and it’s something that I consider to be essential for any dog with an ear infection or otitis externa.
[00:13:54] Dr. Lancellotti: I agree 100%. You cannot stress how invaluable a tool cytology is in order to evaluate what the infection is, monitor response to treatment, and then make sure that the maintenance plan that you’re setting up is actually working long-term. I sat down with Dr. Ashley Bourgeois. Her mantra is cytology everything. And we did an episode, specifically on cytology, which was really helpful in understanding this particular diagnostic technique, and why it’s so important for veterinarians and veterinary dermatologists to do for these animals- not just for ear infections, but for skin infections, as well. If you’re interested in learning more about cytology, I would recommend that you hit that subscribe button to the podcast. That will be coming out in the near future so that you can understand why it’s so valuable to us.
What if my veterinarian recommends a culture of the ear infection?
Dr. Lancellotti: Tell me a little bit more about the tools that we have available for evaluating infection. Is cytology the only thing that we would use?
[00:14:55] Dr. Painter: It’s really not, but the majority of cases, I rely on cytology. I would say 90% of the time, when I am looking at an ear infection in a dog that I’m not performing an advanced procedure on, I’m using cytology to help me decide which treatment is best, the type of infection, etc. Sometimes, we’ll rely on what’s called a culture- a more advanced test where we take a sample of your dog’s ear and submit that to a laboratory, which then actually grows your dog’s infection in the laboratory. Then, the lab exposes your dog’s specific bacteria to different antibiotics and provides us with a report saying, “These are the 15 different antibiotics you can use to treat infection.” The downside to this test is that it’s not totally reliable for topical treatment. What this test is helping us understand is if your dog has bacteria Staphylococcus pseudintermedius, for example, it is sensitive to (or likely will respond to) an oral antibiotic. A lot of times we’re not using oral antibiotics to treat ear infections because they respond so nicely, in most cases, to topical treatments. And that tends to be the most reliable, the easiest, the most practical, direct approach to treating ear infections. So, if we are going to consider reaching for something like an oral systemic antibiotic, a culture might be necessary. But again, it’s more of an advanced technique or a diagnostic test that we would pursue in cases that have mixed inflammation or infection patterns. If I see three or four different types of bacteria on my cytology, I might consider a culture. If I have a very refractory or hard-to-resolve case, I might consider a culture. And if I’m doing advanced procedures like a video otoscopy, where we’re actually going to look into the middle ear cavity (if there’s infection there, when sampling that), then that certainly warrants systemic treatment. But cultures aren’t necessarily something that you’re going to just jump to right out of the gate but they do have some value for some of those hard-to-resolve cases of otitis.
[00:17:12] Dr. Lancellotti: Yeah, I absolutely agree with you. Culture is something that we will do, but not as one of our first-line tests. We definitely want to do our cytology and use our treatments based on what we see under the microscope, but if you’re in a position where the culture is something that the animal needs, that’s definitely a time where you should be seeing if there’s a veterinary dermatologist in your area, and reaching out to a specialist for help.
Why might a video otoscopy or CT scan be used for ear infections?
Dr. Lancellotti: You talked a little bit about some of the advanced diagnostics. What do you mean when you say advanced diagnostics in treatments?
[00:17:47] Dr. Painter: As dermatologists, we see the worst of the worst. When we have moderate to severe ear disease, there are other diagnostic tests and procedures that we can consider. In most of these cases, these are going to be dogs with outstanding perpetuating issues. The majority of the time, when I’m considering things like diagnostic imaging (performing a CT scan of the head), this is a great opportunity to visualize the anatomy and to see what I’m missing. Am I missing that there’s middle ear infection and inflammation fluid in the bulla? Am I missing that there’s some sort of a tumor in the ear? What’s causing this perpetuating issue to continue? Is there something of a primary cause that I haven’t identified with the basic tests that I’ve already performed? CT imaging, and in some cases, MRI can be quite useful when we believe that middle or inner ear disease is suspected. In some cases, too, this could help set us up for performing video otoscopy, so that we know what we’re getting into. Or more specifically, in some cases, surgeons would request this for potentially having some sort of surgery or surgical resolution to the ear disease.
[00:18:59] Dr. Lancellotti: Yeah, that advanced imaging is certainly helpful. CT and MRI can tell us how much swelling there is in the ear. It can tell us if there’s fluid or infection in the middle ear. It can tell us if the ear has become calcified or if there’s been bone deposition around the cartilage of the ear. And that allows us to see how much better we can actually get these ears, because if there is significant bone being laid down in the ear canal, it’s going to be tough to get that ear comfortable. So that gives us a lot of information, as to whether or not we’re going to be able to provide this animal with relief. Usually, when those advanced diagnostics are performed, we typically combine it with a procedure called the video otoscopy. Instead of using that handheld otoscope, where we look into the ear canal, we use a specialized video otoscope that magnifies the ear canal while the animal is under anesthesia. We can really perform a deep cleaning, so that we can physically remove a lot of the gunk that’s building up in these ears with chronic disease. So if you’re interested in learning more about video otoscopy and these advanced procedures, we’ll have an episode coming up that dives deep into those particular tools, as well.
What if the infection is always in one ear and not the other?
[00:20:20] Dr. Painter: And one thing I’ll mention too (just real quick), we’re talking here like your dog has ear disease in both ears. When it’s one sided- what about that? In those cases, I really am very careful to make sure that I have an accurate diagnosis. I want to rule out that your dog doesn’t have a tumor, a foreign body- something that’s different. I don’t want to just say, “Oh. Yup. Ear infection. Must be an allergy!” and just move forward because it’s an ear infection. So, advanced imaging and video otoscopy, in those cases, is usually recommended sooner for a dog with just one side that’s affected than when a dog has both sides that are equally affected, or when it bounces back and forth. Some people will say, “It’s the left ear, then the right ear, then the left ear.” It’s just both ears, but not always at the same time. But if it’s always the right side? Gosh, I really want to know what’s going on in that right side, so these are some additional tests that might be done to actually figure that out.
[00:21:20] Dr. Lancellotti: Yeah. And that gives us the opportunity to provide relief, too. If it’s a fox tail or some type of growth, we can use our videotoscopy to remove the fox tail or the mass that’s in that ear. It’s a really helpful tool, not just for more information, but for treatment options, as well.
How should I treat my dog's ear infection?
Dr. Lancellotti: You talked a lot about the perpetuating factors on the last episode. These are the things that are chronic changes to the ear canal that make it really tough for us to get things under control. Examples are swelling of the ear canal, or when those ear wax producing glands that are just working overtime, trying to pump out more and more ear wax, in response to a secondary infection. Tell me a little bit about some of the treatment options that a veterinarian might consider in those animals that have a lot of these significant, chronic, perpetuating changes.
[00:22:11] Dr. Painter: I think that can be broken down into something that you’re giving systemically. An example would be a medication like a steroid or a drug like Apoquel or Atopica– some of the drugs that help us reduce inflammation (which drives some of these perpetuating factors), helping to address the primary cause, and reducing the symptoms that result from the primary cause. Systemic medication would be one bucket of a treatment type, and topicals would be another.
Topicals refers to ear washes and also ear drops. When it comes to ear washes and ear drops, there’s no book that you can read to find ‘Fluffy’s perfect eardrops solution.’ It’s very individualized. And that can make it really difficult because there are like 600 different drops that are out there. There’s a lot of options that are available commercially. Some veterinarians will compound medications (make them in-house) to treat a specific type of bacteria with a specific antibiotic that they mix up, just for your dog, in the clinic.
There are lots of different treatments that are available topically, but the goal for all of them is to typically address the type of infection (antifungal or antibiotic medication, or sometimes both). The inflammation is also addressed by using a topical steroid. And those can be very effective. Those eardrop topical solutions are very effective at treating inflammation and infection at the same time, and help bring a lot of comfort to your dog.
In terms of like how long they’re used for, it’s going to really depend on your dog and what your veterinarian recommends. So follow their advice! They’re the ones who have looked at your dog, understand the type of infection that’s present, how severe that infection is, and how long it’s likely going to take to get better with those topical medications. Your real cornerstone to treatment for ear disease is going to be some sort of topical antibiotic with a steroid (in most cases) that’s utilized.
Then, we think about these washes helping to remove the debris that’s in the ear. One of the perpetuating issues that we see (which I think is really interesting) is the fact that the ear can actually lose its ability to move ear wax and debris out. Someone actually did a study where they looked at the progression of cells out of the ear. They stained skin cells and they watched them move. And in dogs with chronic ear disease, they’re not going to move. They’re just going to sit there. And you can imagine how much gunk you can have in your ear that just never goes away. If you’re not helping the dog remove that, by doing a gentle cleaning, then it’s really just going to become one of those perpetuating factors that never gets better.
So a lot of times, we’re using gentle wash or ear cleaning solutions to help address the buildup of debris and wax in the ear, which will sit there and promote infection in a vicious cycle for your dog. There are lots of different types of washes that are available, all with their own proprietary blend of what they contain. The basic guideline is to use that wash to help rid the ear canal of debris and also to support the health of the ear canal itself, so that you’re putting something in there that’s very restorative for the ear, helping the ear get better. Those are your two topical-style treatments.
Systemic treatments are a whole other bag of worms, and that’s something that we’ve talked a lot about in this podcast. There are so many different options, but it’s really important that the primary cause of the ear infection is identified before treatment can really be used, systemically. If your dog has hypothyroidism causing their ear disease, something like Apoquel might not actually help them address the primary cause, because that’s a drug for dogs with allergy. So you want to be sure that the diagnosis for your dog’s ear disease is as accurate as possible, so that you can get the right systemic treatment, if that’s something that’s needed.
How were Diego's ears treated?
[00:26:28] Dr. Lancellotti: I want to go back to Diego one more time. You started him on a diet trial and you used some steroids to open up his ear canal, and then what happened from there?
[00:26:55] Dr. Painter: Oh, Diego! He had a recheck about 4 weeks in and was already 60 or 70% improved. He was wildly more comfortable and doing so much better. And again, this was only because the steroids were on board, plus or minus the food. So I do think that he clearly has a food allergy component to his symptoms. Basically, he transitioned over to a drug called cyclosporine (Atopica), and he’s been managed on that.
Then, he started to show some seasonal signs of flaring, so we allergy tested him. He’s on sublingual immunotherapy, food, cyclosporine, and a very low dose of steroids (at this moment in time) because he recently had a small ear flare up. Overall, he does quite well with his cyclosporine, diet, and sublingual immunotherapy. And by quite well, I mean “living the life.” This isn’t a dog who’s just still suffering with ear disease and they’re super inflamed. You look at his ears and they’re pretty much normal. So we were able to transform a severely, hyperplastic, painful ear down into an ear that’s very comfortable- something that the owners can touch. He (now) loves to be handled, pet, hugged, and all of the things that he never wanted to be before, because his ears are more comfortable. And that’s all because we identified the primary cause for his ear disease, which is a mixed allergy of both food and environmental triggers, and also because we got a medical management plan on board for him that worked to reduce the inflammation.
The perpetuating issue for him is that he’s always going to have some chronic change to his ear. He does have some calcification to the external ear canal, but basically, we’re doing the best that we can with the medical management that we have on board. The biggest thing is that he comes in now to his visits and he can actually be touched. Before he would panic. He was just a different dog than he is now.
If you’re a dog with severe ear infection, it’s hard to say that we’re going to cure you and bring you back to normal. Our goal is really to help this dog (and other dogs) achieve an excellent quality of life, to the best of our ability, with the options we have available to us. I believe we did that, but it’s always a work in progress for some of the more severe cases.
But yeah, he’s a great dog. The owners are really just the best. They’re so committed to him and to his brother. All that they’ve done for him, it just brings me so much joy to be part of their family, as their veterinarian. I guess I just included myself in their family, but hey, I’ve seen them enough. It feels like it. Right? But it is something where you all just get to know each other so well. And every time he flares up, or if there’s ever any sort of setback, we really just get right on that. It’s important not to get frustrated by that, but to just recognize that it can and will happen. So, yeah. He’s an awesome dog and I’m really glad that we crossed paths in this lifetime.
[00:29:50] Dr. Lancellotti: And did I hear you correctly when you said that his ear is looking pretty much normal, at this point?
[00:29:55] Dr. Painter: Oh, yeah! The ears were so severe and now you would look at them and just see them as normal. They look and feel as normal as they can be. The inflammation is significantly reduced. And if I had to put my finger on what did that, it was probably the steroids and the food. It happened in August, which is really a prime time for a lot of dogs with environmental allergens (especially weeds) that’ll contribute to their flares. So it all seemed to be consistent with an environmental flare up. But yeah, this dog looks fantastic.
Does your dog have ear infections?
[00:30:38] Dr. Lancellotti: For those of you listening, if you have a pet that has ear infections, I would encourage you to work with your family veterinarian. Have that open line of communication, so that you can figure out what’s going on with your animal together, as far as this PSPP classification system. There is also a link to find a veterinary dermatologist near you under the resources tab so you can check that out and find someone to work with. If you have a pet that has had ear infections and you want to commiserate with other people in the community, you can join our Facebook group, Your Vet Wants You To Know, or follow us on Instagram @yourvetwantsyoutoknow. For those family veterinarians and other veterinary professionals, I would encourage you to check out Dr. Painter’s online course, The Allergic Dog, where you can get 8 hours of race-approved CE about how to treat allergic skin and ear disease, and to get a better understanding of how to provide relief for these animals and improve their quality of life. Dr. Painter, thank you so much for your time. I really appreciate it.
[00:32:12] Dr. Painter: Absolutely. It was truly my pleasure to be here. And don’t get overwhelmed. I know this information is a lot. As doctors, we think in these systems and all of this. Just remember that your veterinarian is here for you. Your dermatologist is here for you. We’re all here to help your pet feel better. And if you need help, certainly reach out. There are so many different types of resources for you to help address whatever problem you’re facing with your dog or cat. Thank you so much for having me on as a guest today, Dr. Lancellotti. You are doing so much for pets and pet owners out there, and I can’t thank you enough.
[00:32:48] Dr. Lancellotti: Aw, Dr. Painter, it is a pleasure to have you on. I am happy to have you back anytime you would like. You are a wealth of knowledge and a really amazing science communicator. I’m so pleased to have you as a colleague and a friend.
[00:33:03] Dr. Painter: Thank you.
[00:33:05] Dr. Lancellotti: And for everyone out there listening, I look forward to your next visit with Your Vet Wants You To Know.