Sometimes, despite a veterinarian’s best efforts to clear an ear infection with medicated drops and cleaners, the infection will stubbornly persist. When a veterinarian is worried about conditions such as a long-term ear infection, a mass in the ear canal, material like matted hair, a foxtail, or trapped ear wax, or a deep infection in the middle ear on the other side of the ear drum, a video otoscopy and deep ear cleaning may be recommended. Join veterinary dermatologists and ear specialists Dr. Austin Richman and Dr. Brittany Lancellotti as they discuss the video otoscopy procedure, why they recommend it, the benefits and risks, and questions to discuss with your veterinarian for your dog or cat.
Welcome Dr. Austin Richman from Veterinary Skin and Ear
[00:01:05] Dr. Lancellotti: Welcome, everyone, to today’s episode of Your Vet Wants You To Know. I am joined, today, by Dr. Austin Richman. I’m very excited to have him on the episode. He and I were resident mates together when we were first learning about veterinary dermatology, and now I have the pleasure of working alongside him every day at Veterinary Skin & Ear in Los Angeles, California. Welcome to the show, Dr. Richman.
[00:01:28] Dr. Richman: Happy to be here!
What is Video Otoscopy?
[00:01:29] Dr. Lancellotti: You and I are going to be talking about a procedure called video otoscopy. This is something that we do on a fairly regular basis, but it’s not something that’s generally done in a family veterinarian’s office. It’s more of a specialized procedure. Can you tell me a little bit about why video otoscopy is so important to you and what it is that you like about this procedure.
[00:01:54] Dr. Richman: The video otoscopy is a tool where we get a high definition picture throughout an animal’s ear canal. This tool is essential for managing severe chronic ear disease. This is definitely my favorite procedure. I’ve spent many years trying to work with as many dermatologists and experts as possible to get experience with this. It gives me great joy to do these procedures. I find it very fun and also rewarding to be able to change an animal’s life who has been suffering from an ear disease for many years, at times.
[00:02:34] Dr. Lancellotti: Yeah. I think that’s probably very much an understatement, when you say that this is fun for you. For those of you listening, when I’m doing a video otoscopy procedure and Dr. Richman is in the office, if he has even a split second to come in and see what’s happening, he is right there in our procedure room and wants to be involved. He absolutely loves doing these and seeing what a difference can be made in an animal’s life, when we actually get in there and are doing these video otoscopy procedures.
Smile's Smelly Ear Infection
Dr. Lancellotti: This is something that you’ve done on many animals, but is there one animal in particular that sticks out in your mind when you’re thinking about video otoscopies?
[00:03:11] Dr. Richman: Yes. There’s a wonderful golden retriever, named Smile, who I’ve been seeing for many years now. Originally, he came in maybe 4-5 years ago, and his ears had really terribly chronic ear infections. The smell when he walked into the door was probably a ‘top-five’ worst smell for one of the patients I’ve seen. As you know, we deal with quite a lot of smelly animals, due to their infections. But he walked in, he still bubbling, jumping around, etc, but the receptionists at the front were running to the back to tell everybody, “Hey, there’s this really bad odor.” The technicians that had gone to the room to get some history were talking about how bad he smelled. The poor guy’s rubbing against his owner, rubbing on the walls, spreading pus and bacteria everywhere. But he was still very happy. Smile had been treated with many antibiotics and different treatments for a couple years and his ears just got worse and worse. I remember touching his ears and I could feel that they were scarred and I was like, “Okay. Well, he may need to go to surgery because of how bad his ears were to have his ear canals removed.” And his owner basically begged me like, “Hey, I’ll do whatever it takes. I understand, but please try to save my dog’s ears.” And I was like, “Okay. Let’s try a video otoscope.” We had to put them on some steroids beforehand, to open up the ear canals. And we also changed his diet, which actually was key for him. He had a very resistant bacterial infection called pseudomonas, and we went in there, flushed out the ears, and did multiple different soaks with various antiseptic cleaners. After that procedure, and through steroids, antibiotics, and changing of diet, I got Smile to live (basically) a normal life now. He has some ear infections maybe once or twice a year, but we usually catch those pretty early. He’s one of the greatest successes because of how bad (his ears) were. And even at the time I thought, “I don’t know if I’m going to be able to save these ears.” He just gave me more confidence that, even in some of the worst cases, we can really turn them around. Doing the video otoscope allowed me to visualize his ears, see the swelling, and that the reason they were shut was mostly from severe inflammation. So once we were able to treat the infection with the scope and soaks, we were able to turn that around. His case also really sticks out to me because his owner is so great. I still see him and he’s just so happy every time he comes in.
[00:05:51] Dr. Lancellotti: That’s really nice to be able to have that happy, sweet golden retriever that wants to be around people and be loved (and actually be able to be around people because he doesn’t smell so badly) and he’s more comfortable. It’s really a testament to how rewarding these cases can be, when an owner and a veterinarian work well together to figure out the underlying cause.
What happens during a video otoscopy?
Dr. Lancellotti: Let’s talk a little bit about this video otoscopy procedure. What’s happening when you’re doing this?
[00:06:19] Dr. Richman: During the video otoscope procedure, we have a high definition camera with very bright lights at the end, we go into the entrance of the ear, and we can visualize all the aspects of the ear canal and get a better look at the eardrum itself. This procedure really allows us to see a lot better than a handheld otoscope, it gives us more diagnostic information, and treatment options- when we can clean the ear, remove hair or masses, etc.
Why Does My Pet Need a Video Otoscopy?
[00:06:56] Dr. Lancellotti: What are some of the reasons why a veterinarian might recommend a video otoscopy? Why might this be beneficial for a certain pet?
[00:07:05] Dr. Richman: There are many reasons why we’ll do this procedure. Sometimes, there’ll just be a little growth at the external entrance. Then, we can take the scope, clean around it, and remove it with laser, biopsy graspers, or a loop. A lot of times, animals will have severe infections that have created an almost protective layer that can’t be treated called a biofilm. Then, we can use brushes, tubes, and different soaks to get rid of the bacteria growing on the walls, allowing better success with medical treatment after the procedure. Another common reason is for matted hair. When the hair gets accumulated in the canal, sometimes, ear drops and ear flushes won’t work quite as well because the hair will be an nidus for these infections. So, we’ll go in and remove hair that’s obstructing the ear canal. Sometimes, there’ll be severe swelling. We can go in and visualize the edema, and sometimes, inject steroids further down into the ear canal. Also, one of the more common reasons is the removal of masses and ear polyps. Another common one is an entrance to the middle ear through the eardrum. We can do that through a little procedure called a myringotomy, where we make a little hole into the eardrum, and then we can flush out infections or fluid that may be built up. And in some cases, French bulldogs and other ‘smooshed-face’ breeds may get accumulations in the back of the throat, which could lead to middle ear problems.
[00:08:47] Dr. Lancellotti: Yeah. There are a lot of different reasons that we can use video otoscopy, to either figure out what’s going on or help our patients. There’s no one specific reason, but many of those reasons are pulling things out from the ear, getting a deep cleaning, figuring out what’s happening in the middle ear, and getting samples from there, as well. It’s important to talk to your veterinarian about what reason they are recommending a video otoscopy, and figure out if that’s the best plan for your animal.
Does My Pet Need a CT scan or MRI?
Dr. Lancellotti: In certain situations, we may recommend advanced imaging, with either a CT scan or an MRI, while a pet is under anesthesia for a video otoscopy. What are some reasons why you might recommend this advanced imaging when you’re doing a video otoscopy?
[00:09:36] Dr. Richman: We’ll recommend a cat scan when an animal has any neurologic signs or if an animal has an ear infection for a long time. When we do this, there are animals where we can look in the external ear and we can’t tell if there’s a problem in the bulla (hollow area that helps an animal hear). But you can get bacterial infections, sterile buildup, or even viral-induced type fluids that will build up in the ears. If we do a CT, then we know whether or not we have to go through the eardrum and flush that area out, as well. Also, it can tell us if we need to recommend a referral to a surgeon. A bacterial infection can eat away at the bones in the middle ear for a long period of time. It is actually better for the animal to get that ear removed with the surgeon, just due to risks of the infection going into the brain, or because we’re not going to be able to treat it medically. Also, there can be tumors that will grow from other areas that are not in the ear, which then grow into the ear itself. When those occur, it’s good to refer them out to an oncologist or a surgeon. Then, the imaging will allow us to plan for that and give a better prognostic indicator to owners.
[00:10:57] Dr. Lancellotti: Yeah. Those CT scans give us a lot of information- more than what we can see with just our video otoscopes. So if there is significant disease on the other side of the eardrum, we know whether or not we need to do that myringotomy to go into that middle ear and get a sample, or flush out what’s going on there. It tells us whether or not we’re going to be able to make a big difference with our video otoscopy. There are some animals that have such severe disease outside of the ear canal that no matter what we do within the ear canal, we’re not going to make them better. In those cases, we would refer them to a surgeon who can help with surgically removing that ear. We collect a lot of information, and when we combine these two procedures, we can minimize the risks associated with anesthesia. And that’s what I want to talk about next.
What are the Risks of Anesthesia?
Dr. Lancellotti: We talk a lot about risk vs. benefit on this show. You’ve gone through a lot of the benefits of this procedure. What are some risks associated with anesthesia that pet owners should be aware of? And how might a veterinarian decrease those risks before putting an animal under anesthesia?
[00:12:05] Dr. Richman: For this procedure, there’s no difference in anesthetic risks. But any animal is an individual, and we need to weigh the many factors for anesthesia; whether they’re extremely young, extremely old, whether they have heart disease, etc. We work with the primary veterinarians on whether there has been a heart issue. Do they need to get some chest x-rays done with the primary veterinarian? Sometimes, we’ll have to send them to a cardiologist. But most of the time, the dogs and cats that we do video otoscopes on are otherwise (generally) healthy. We’ll check blood work to make sure there aren’t any adjustments to the anesthesia plan. And if there is ever an animal that can’t go through this, we’ll try to talk to an emergency doctor or the cardiologist about an anesthetic plan that will help. But any time there is anesthesia, there is an inherent risk that comes with it, and we try to mitigate that the best we can.
[00:13:06] Dr. Lancellotti: Yeah. Every animal is an individual, so talking to your veterinarian about what risks your particular pet has is going to be important in coming up with a plan to help minimize those risks, so that they can safely go through this procedure.
What are the Risks of Video Otoscopy?
Dr. Lancellotti: In addition to risks from anesthesia, there are also some risks associated with the video otoscopy procedure, itself. Can you describe some of those risks that we warn pet owners about?
[00:13:32] Dr. Richman: Yeah. When you’re doing this procedure, you definitely want to have an animal under anesthesia with a tracheal tube in place, due to the anatomy of the ear. Anytime you’re flushing fluids through a dog’s ear, you want to make sure that there is some pressure on the back of the throat where the eustachian tube connects to the middle ear. If there is a dog whose eardrum’s not intact, and you’re flushing a lot of fluid, that fluid can go through the ear, through the middle ear, through the eustachian tube, and then go into the lungs and they can get pneumonia. We definitely want to prevent that! One of the most important things with this procedure is having a tracheal tube in place to prevent that. There can be some pain that comes with the procedure. Usually, a lot of animals that are having this procedure have some pain already, due to the severity of their ears. But we’ll use pain medications during the procedure, even local blocks of Lidocaine to block some nerves around the ear, and send home pain medications for a few days after. If you are flushing the middle ear (there are a lot of very important nerves in that area) and you disturb those nerves or caused some more inflammation, you can get know, what’s called Horner’s Syndrome (where an animal will have a head tilt or parts of their face would be numb afterwards). Most of the time, we can catch that right after the procedure and administer some steroids, so I’ve never had any long lasting effects. But I have heard from colleagues that they’ve had cats or a dog who ends up with some neurologic dysfunction after the procedure, due to how much the nerve was disturbed. But most of the time, I’ve learned that if I catch it early, I can give them steroids and they usually do quite well.
[00:15:22] Dr. Lancellotti: Yeah. Those main risks are going to be the risk of aspirating (inhaling) that liquid. We minimize that risk by making sure that we have an endotracheal tube in place. Then, we control pain (for after the procedure) with some pain medications that your veterinarian will talk to you about, as far as how to give when the animal goes home. And then those neurologic signs- because we do have several nerves that run through the middle ear, they can become irritated and inflamed while we’re doing this procedure. Head tilts, some abnormal eye movements, and even the third eyelid may come up (it’s really rare to see that, but something that owners should be aware of as a specific risk to this procedure).
Video Otoscopy Improves Quality of Life
Dr. Lancellotti: I want to just wrap up some big takeaway points that you’d like pet owners to remember about video otoscopy: why we would recommend this, what to think about if you’re considering having your pet undergo a video otoscopy, and what important questions they might want to ask their veterinarian.
[00:16:24] Dr. Richman: Generally, I think the benefits outweigh the risks in most cases, but there are some very challenging ear cases or masses, and it could be the difference between months of struggling or more rapid resolution.
[00:16:39] Dr. Lancellotti: Yeah. We absolutely love doing video otoscopies, because we can see a big difference, just like you saw a big difference in Smile’s case. Oftentimes, these animals are living with chronic ear issues, and when we can get in there with a video otoscope, treat the ear, and have a better idea of what’s going on, we can see significant improvement following that procedure. Maybe not right away, but over the course of the animal’s lifetime, we see that big difference when we’re managing this chronic disease. Video otoscopy and a CT scan are advanced procedures that are best performed by a veterinary dermatology specialist. So if you are interested in consulting with a veterinary dermatologist who specializes in ears, there’s a link under the resources tab, so that you can find a specialist near you. You can also view the references for today’s show in the show notes, on the website, as well. I would encourage you, if your pet has had chronic ear infections or if it’s undergone a video otoscopy, to join the Facebook group, so you can share your story with other pet owners and commiserate what you’ve gone through. Share your success stories, too. We love hearing those! Dr. Richman, if pet owners would like to consult with you for video otoscopies, where might they find you?
[00:17:58] Dr. Richman: You can find me at Veterinary Skin & Ear in West Los Angeles and our Instagram is @veterinaryskinear.
[00:18:08] Dr. Lancellotti: Awesome.
Scratching the Itch
I like to end each episode with a segment that I call Scratching The Itch. This is a segment that highlights something- either a human interest story, a product, or a website. Essentially, it’s something that provides relief or just makes you feel good. Hence, scratching the itch. Dr. Richman, do you have a ‘scratching the itch’ that you’d like to share for us, today?
[00:18:29] Dr. Richman: Mine’s actually chocolate chip cookies. My wife is a pastry chef and she’s perfected her dough. But during my board studies, I needed a distraction. Over the course of many months, I would take one type of cookie a night and I would try different baking techniques to try to perfect that. So any time she’s making her chocolate chip cookies, I now have the baking technique perfected. But yeah. Chocolate chip cookies really hit the spot for me.
[00:19:03] Dr. Lancellotti: Excellent. Maybe you and Erin might be interested in sharing your chocolate chip cookie recipe with our listeners.
[00:19:10] Dr. Richman: Yeah. We’ll have to ask her for that. I think we’re going to have those in the office pretty soon. Lucky for you!
[00:19:17] Dr. Lancellotti: Yes! All right! That really scratches my itch. Thank you very much, Erin. I appreciate that. And Dr. Richman, thank you so much for coming on and talking about video otoscopies. I know this is going to be really helpful in getting people to understand exactly what it is that we’re recommending, and what to expect if their animal has to undergo this procedure. I truly appreciate your time.
[00:19:40] Dr. Richman: Happy to do it!
[00:19:41] Dr. Lancellotti: And for everyone listening, I look forward to your next visit with Your Vet Wants You To Know.
References:
- Greci, Valentina, et al. “Middle Ear Cholesteatoma in 11 Dogs.” The Canadian Veterinary Journal = La Revue Veterinaire Canadienne, vol. 52, no. 6, June 2011, pp. 631–36.
- Layne, Elizabeth A., and Cristina Miguel Garcia. “Clinical Techniques in Veterinary Dermatology: Regional Anaesthesia of the Canine Ear.” Veterinary Dermatology, vol. 30, no. 6, Dec. 2019, p. 470.
- Palmeiro, Brian S., et al. “Evaluation of Outcome of Otitis Media after Lavage of the Tympanic Bulla and Long-Term Antimicrobial Drug Treatment in Dogs: 44 Cases (1998-2002).” Journal of the American Veterinary Medical Association, vol. 225, no. 4, Aug. 2004, pp. 548–53.
- Parlak, Kurtulus, et al. “Evaluation of Video-Otoscopic, Radiographic and Computed Tomographic Examinations of Cats and Dogs with Ear Diseases.” Macedonian Veterinary Review, vol. 44, no. 1, Jan. 2021, pp. 95–101.
- Radlinsky, MaryAnn G. “Advances in Otoscopy.” Veterinary Clinics of North America: Small Animal Practice, vol. 46, no. 1, Jan. 2016, pp. 171–79.
- Usui, Reiko, et al. “Treatment of Canine Otitis Externa Using Video Otoscopy.” JOURNAL OF VETERINARY MEDICAL SCIENCE, vol. 73, no. 9, Sept. 2011, pp. 1249–52.
