Ear Cleaning- The UK and US Perspective (Pages 127–136)

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© 2004 European Society of Veterinary Dermatology 127

Veterinary Dermatology 2004, 15, 127– 136

BlackwellPublishing,Ltd.

Ear cleaning: the UK and US perspective

TIM NUTTALL* and LYNETTE K. COLE†

*University of Liverpool Department of Veterinary Clinical Science, Small Animal Hospital,

Crown Street, Liverpool, L7 7EX, UK†The Ohio State University, Department of Veterinary Clinical Sciences, College of Veterinary Medicine,601 Vernon L. Tharp St., Columbus, OH 43210-1089, USA

(

Received

26 March

2003; accepted

3 September

2003)

Abstract

Ear cleaning helps maintain the normal otic environment and is important in the treatment of otitis.Over cleaning, however, may trigger otitis through maceration of the epidermal lining. Simple manual cleaningis useful for routine cleansing but doesn’t remove tightly adherent debris. Bulb syringes are more vigorous butmay damage the ear in inexperienced hands. Devices using mains water pressure or dental machines are also avail-able. Thorough cleaning of the ear canals and middle ear cavity can only be achieved by retrograde flushing usingspecially adapted catheters, feeding tubes or video otoscopes under anaesthesia. Myringotomy, inspection andcleaning of the middle should be performed if the tympanic membrane appears abnormal. There are a wide vari-

ety of cleaning fluids available. Ceruminolytics soften and dissolve cerumen to facilitate cleaning. Surfactantsemulsify debris, breaking it up and keeping it in solution. Astringents dry the ear canal surface, preventingmaceration. Maintaining a low pH and incorporating antimicrobial agents can inhibit microbial proliferationand glucocorticoids can be used to reduce inflammation. Adverse effects and contraindications following earcleaning can include maceration, contact reactions, otitis media, ear canal avulsion, vestibular syndrome,Horner’s syndrome, facial nerve paralysis and deafness. Care should be exercised in selecting cleaning fluids if the tympanic membranes are ruptured.

Keywords

:

ear cleaning, flushing, otitis.

INTRODUCTION

When performed well ear cleaning helps maintain thenormal otic environment and is important in the treat-ment of otitis. Done badly it at best hinders resolutionand at worst can trigger recurrent inflammation. A widerange of cleansing preparations and techniques isdescribed. Not all are applicable to every ear and inap-propriate use can make matters worse. In this articlewe discuss the rationale behind ear cleaning and how toget the best results from different agents and techniques.

THE OTIC ENVIRONMENT

The most prominent part of the external ear in terres-trial mammals is the cartilaginous pinna. The dorsal orconvex surface is continuous with the haired skin of thehead while the glabrous ventral or concave surface iscontinuous with the vertical and horizontal ear canalsat the external ear or auditory orifice. The vertical earcanal travels ventrally and slightly rostrally beforemaking a medial turn. The horizontal ear canal is sep-arated from the middle ear by the tympanic membrane(Fig. 1). This is a concave, semitransparent membrane,

which thickens towards its periphery. It is divided intotwo sections: the small dorsal pars flaccida and the

larger ventral pars tensa. The pars flaccida is the pink,small, loosely attached upper quadrant of the tym-panic membrane that contains small blood vessels. Thepars tensa is a thin, tough, pearl grey structure with

Correspondence: Tim Nuttall, University of Liverpool Departmentof Veterinary Clinical Science, Small Animal Hospital, Crown Street,Liverpool, L7 7EX, UK. E-mail: [email protected]

Figure 1. Normal tympanic membrane viewed through a videootoscope (image courtesy of MedRx Inc.).



128 T. Nuttall and L. K. Cole

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radiating strands that forms the rest of the membrane.The manubrium of the malleus attaches to the medialsurface of the tympanic membrane forming a white C-shaped structure, the stria mallearis.

1

Canine ear canalsare typically 5–10 cm in length and 0.5–1.0 cm in dia-meter,

2

although stenosis often occurs in chronic otitis

externa. The authors also find that some dog breedssuch as shar-peis, bulldogs, bull terriers and cockerspaniels can have narrow ear canals.

The middle ear cavity is housed within the bonytympanic bulla and is normally air filled. The caninetympanic bulla is divided into dorsal and ventral com-partments by an incomplete bony shelf; in cats they arecompletely separate. It contains the auditory ossicles,their associated ligaments, muscles and nerves, and com-municates with the inner ear via the round and oval win-dows. The Eustachian or auditory tube connects themiddle ear with the nasopharynx. The sympathetic nervepasses through the periosteum of the ventral bulla.

2

The concave surface of the pinna and the ear canalsare lined with glabrous skin except in hirsute breedssuch as poodles, Bichon frise, terriers, etc. The dermisis rich in sebaceous and apocrine or ceruminous glands.Cerumen is a complex mixture of exfoliated cells,waxes, oils, free fatty acids, esters, immunoglobulinsand proteins

3

and forms a protective and antimicrobialbarrier. Debris entering the ear canal is trapped andremoved with the cerumen. This is facilitated by thelateral (outward) migration of the stratum corneum.

4

WHEN TO CLEAN EARS

It is not usually necessary to clean healthy ears. Exces-sive cleaning can predispose to infections by increasinghumidity and macerating the ear canal lining. Earcleaning can, however, be beneficial in seborrhoeic earswith excessive cerumen production

5,6

or in hairy, sten-otic or pendulous ears where the flow of cerumen maybe impeded.

Excess hairs can be periodically removed to improveaccess to the ear canal. Neither author, however,recommends hair removal unless absolutely necessary

as frequent depilation may result in inflammationand recurrent otitis. It is also painful and should be per-formed under sedation or anaesthesia; dogs may other-wise become resistant to ear treatment. Depilatory creamsare not often used in the ear canals and should beavoided as they are potential irritants and sensitisers.

7

Effective ear cleaning is an essential part of anytreatment regime

2,8

because it aids treatment andspeeds resolution by removing:

•

exudates and debris that obstruct the ear canalspreventing a through diagnostic evaluation and medi-cations contacting the ear canal epithelium;

•

purulent material and inflammatory debris thatcan protect microorganisms and inactivate someantimicrobial medications such as gentamicin andpolymyxin B;

9

•

small foreign bodies, microorganisms, toxins andother inflammatory compounds, degenerate anddamaged cells, which can act as foci for infectionand inflammation.

EAR CLEANING TECHNIQUES

Manual cleansing

The ear canals can be simply cleaned by introducingthe cleaning fluid directly into the ear and massaging theear canals, working debris to the surface. This doesnot remove tightly adherent or deep material and isbest reserved for routine cleansing. A clear demonstra-tion of the technique will help ensure effective cleaningby the owners. In general, owners should not clean theear more frequently than every 48 h as there is a risk of maceration and infection if done too often.

2

One of theauthors (LC) has nevertheless used astringent cleanerssuch as Epi-Otic® (Virbac, Carros, France) daily (forcleaning) to twice daily (for its antimicrobial effect)with no adverse effects.

10

Owners can clean directlyvisible parts of the ear with cotton wool or tips butdeeper insertion risks leaving foreign material behindand irritating the ear canals.

Bulb syringes

Bulb syringes consist of a hollow plastic or rubbersphere and a variably sized nozzle. The bulb is filledwith cleaning fluid, the nozzle gently inserted into thevertical ear canal and the fluid squeezed in under light

pressure. It is important to leave a gap between thenozzle and the wall of the ear canal; the pressure canotherwise rupture the tympanic membrane. The fluiddislodges and washes out any debris. Bulb syringingis an effective technique that can be used in eitherconscious or sedated animals. Caution must be takento avoid aspiration when using large volumes of fluidin heavily sedated animals, however. Using cuffedendotracheal tubes in anaesthetized animals reducesthe risk of aspiration (see ear flushing below). Bulbsyringes can be used by competent owners but it isimportant to fully explain and demonstrate the tech-

nique to avoid any problems.

Ear flushing

Ear flushing (Fig. 2a,b) is appropriate when the entireear canal and/or the middle ear need thorough clean-ing. If the ear canals are hyperplastic or ulcerated, 2– 3 weeks of topical and/or systemic glucocorticoids(prednisone or prednisolone 1–2 mg kg

−

1

orally q24 h,then taper) should be administered before performingear flushing. Deep ear flushing should be performedunder anaesthesia to prevent head shaking and dam-age to the ear canal. Cuffed endotracheal tubes willminimize the risk of aspiration. If the tympanic mem-

brane is ruptured fluid will disappear from the earcanal and may flow from the nose, or mouth. Theoperator should wear gloves, facemask and eye protec-tion to avoid infection from contaminated aerosols,




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Ear cleaning 129

especially if Pseudomonas

is present. Swabs from thehorizontal ear canal and middle ear cavity should be

obtained for cytology and bacterial culture and sens-itivity prior to flushing the ear.One method of ear flushing is performed with a

three-way tap or stopcock connected to a syringe, fluidsupply and a urinary catheter, tomcat catheter or feed-ing tube of the appropriate length and diameter. Thecatheter tip is placed adjacent to the tympanic mem-brane or, if the tympanic membrane is ruptured, intothe middle ear under visualization through an operat-ing otoscope. It is important to angle the tip ventrallyto avoid the sensitive structures in the dorsal part of themiddle ear cavity. The ear canals and middle ear arealternately flushed and aspirated until completely clean.

Finally, an astringent can be used to dry the ear canal.Retrograde flushing using this technique is very effec-tive at removing deep material and is the only effectiveway to clean the middle ear.

9

Tightly adherent debris can be removed by initiallysoaking the ear canal for 10 min with a ceruminolyticear cleanser. One of the authors (LC) prefers Pan-Otic® (Pfizer Inc., New York, USA). Flushing withsterile isotonic saline using a bulb syringe will removelarger fragments of debris from the ear canal. Flushing

is then continued using an 8-French polypropyleneurinary catheter attached to a 12 ml syringe as aboveto remove the remaining exudate and debris allowingvisualization of the tympanic membrane with an oto-scope or video otoscope (see below).

If the tympanic membrane is ruptured, repeatedflushing of the middle ear should be performed toremove the ear cleanser, as some ceruminolytic agentsmay be ototoxic.

Samples for cytology and bacterial culture andsensitivity should also be obtained from the middleear cavity using either a hand-held otoscope or a videootoscope. Using a hand-held otoscope, a sterile oto-scopic cone is inserted into the horizontal ear canaland a sterile swab (Calgiswab®; Hardwood ProductsCompany LP, Guildford, MN, USA) is passed intothe middle ear cavity, avoiding the sensitive structuresin the dorsal part of the middle ear cavity. The firstswab is used for culture and sensitivity; the second forcytology. Using a video otoscope, an open-ended 3.5-French tomcat catheter attached to a 12 ml syringe isplaced through the port of the video otoscope. Onemillilitre of sterile saline is flushed into the middle earcavity and aspirated for culture.

If the tympanic membrane is intact but appears

abnormal and otitis media is suspected a myringotomy(the deliberate rupture of the tympanic membrane)should be performed to obtain samples for cytology,culture and sensitivity and to flush the middle ear cav-ity. Using a standard otoscope, an incision is made inthe caudoventral quadrant of the tympanic membranewith the Calgiswab® as described above. If using avideo otoscope an open-ended 3.5-French tomcatcatheter is used to make the incision. One author (TN)prefers to use a sterile spinal needle to make the initialincision. Experimentally ruptured normal tympanicmembranes heal in 21–35 days.

11

If the ear is kept free

from infection following myringotomy the tympanicmembrane should therefore heal well.

Water Pik®

A Water Pik® (Waterpik Technologies Inc., USA) isdental machine attachment that directs a pulsatile flowof water into the ear to dislodge and remove debris.The fluid must be aspirated from the ear afterwards,which is facilitated by the use of a suction apparatus.It is effective in cleaning the external ear canals, butsomewhat less satisfactory at cleaning the middle ear.

2

Excessive water pressure may also damage the tym-panic membrane.

Auriflush®

The Auriflush® (Schering Plough Animal Health)(Fig. 3a,b) system is driven by tap (faucet) water

Figure 2. (a, b) Ear flushing kit: operating otoscope, urinarycatheter, 3-way tap, 10 mL syringe, intravenous infusion or giving setand 0.9% saline prior to use. Ear flush under way in a dog.





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although other cleaning fluids can be added. It has atrigger-operated nozzle that allows simultaneous flush-ing and aspiration of the canal. It can be used in con-scious, sedated or anaesthetized animals, although itdoes not clean as deeply as catheter flushing and it isdifficult to aspirate fluid with an animal in lateralrecumbancy due to gravity. The size of the nozzle maymake it difficult to use in small dogs and cats. Contrib-

utors to a recent Vetderm listserv discussion weredivided as to its usefulness, which may reflect the typeof cases seen by individual centres. One of the authors(TN) finds the Auriflush® very useful for routine

cleansing but prefers catheter flushing for thoroughcleaning of the ear canals.

Video otoscopes

The Karl Storz (Tuttlingen, Germany) video otoendo-scope® and the MedRx (Largo, FL, USA) video oto-

scope® allow real-time imaging of the ear canals. Themagnified image on the monitor is far superior to theview through a hand-held otoscope. Still images can beanalysed to plan procedures or explain the condition of the ear canal to the owners. This is of enormous helpin convincing some owners of the need for more aggres-sive treatment regimes. The video otoscope has portsfor flushing and aspiration, which allows effectivecleaning of the ear canal. Instruments, such as biopsyforceps, grasping forceps, etc., allow the operator todislodge stubborn debris, remove ceruminoliths (seebelow) or take biopsies. The port also allows one toperform a visually guided myringotomy. The system isan excellent tool for imaging the external ear and tym-panic membrane, cleaning the external ear canal andperforming myringotomies.

12

One disadvantage, how-ever, is that the size of the otoscope head sometimesmakes it difficult to use in cats, small dogs or stenosedear canals.

Removing ceruminoliths

Ceruminoliths are concretions of cerumen, cornifiedmaterial, hair, topical medications and other debristhat accumulate following chronic otitis and sub-sequent failure of epidermal migration. They act

as irritant foreign bodies and foci for infection.Ceruminoliths that are resistant to conservativecleaning methods should be removed under sedationor anaesthesia. They can be grasped using forcepsthrough an operating or video otoscope or broken upwith ceruminolytics and flushed out. Ear curettes orloops are very handy at removing adherent materialbut should be used under general anaesthesia to avoiddamaging the ear canal or tympanic membrane. Theloop is introduced into the ear through an operatingotoscope and gently hooked over the obstruction.Drawing the edge outwards along the epidermal sur-

face removes the obstruction. Alligator forceps are alsouseful, especially for cornified plugs, hairs and foreignbodies, but it may be difficult to open their jaws suffi-ciently in narrow ears.

Contraindications and side effects

Damage leading to vestibular syndrome, facial nerveparalysis, Horner’s syndrome or deafness is a potentialconcern when ear cleaning, particularly when usingmore aggressive techniques.

13

It is also possible thatvigorous struggling may lead to avulsion injuries of theear canal in unsedated animals.

14–16

In practice, how-ever, the risk appears to be small. In one series of 105

dogs assessed by brainstem auditory-evoked responses,no deficits were seen after cleaning,

17

although it is theauthors’ impression that side effects are more commonin cats. The relative safety of these techniques, however,

Figure 3. (a, b) Auriflush system: main housing attached to ashower pipe. Trigger operated nozzle being used to clean the ears of a sedated dog with ceruminous otitis externa.




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Ear cleaning 131

does rely on their skilful application and it is prudentto obtain informed consent prior to ear flushing.

CLEANING FLUIDS

The first maxim to consider when selecting a fluid is ‘dono harm’ (Table 1). Most cleansing is achieved byphysically displacing material. It makes sense, there-fore, to use nothing more potent than water or salinein most circumstances. Water or saline are particularlyappropriate for cases with ruptured tympanic mem-branes as many other compounds are potentiallyototoxic.

2

Ceruminolytics, however, may be neededoccasionally to dissolve ceruminous exudates.

Ceruminolytics, surfactants and foaming agents

Ceruminolytics are organic oils and solvents (e.g. pro-pylene glycol, lanolin, glycerine, squalane, butylatedhydroxytoluene, cocamidopropyl betaine and mineraloils) commonly included in ear cleaners to soften anddissolve cerumen. They are of most use in mildly waxyor dirty ears and are relatively safe for routine at-homecleaning if the tympanic membrane is intact. They arealso used to soften impacted or dry debris prior to earflushing or other cleaning techniques in the sedatedor anaesthetized animal. It is, however, questionableif they are of much benefit in ears with a purulentdischarge.

Ceruminolytic surfactants are effective with bothceruminous and purulent debris. Surfactants help

expedite the cleaning process by emulsifying debris,breaking it up and keeping it in solution. Some deter-gents can be irritating, particularly to the middle earmucosa, and are contraindicated if the tympanic mem-brane is ruptured. Useful surfactants include dioctylsodium sulfosuccinate (DSS or docusate), calcium sul-fosuccinate and other detergents.

Foaming agents such as urea and carbamide perox-ides release oxygen in situ

. This helps disperse debrisand aerates the ear canals. The foaming action causesanxiety in some animals though.

Astringents or drying agents

Astringents dry the ear canal surface, to prevent mac-eration. They are often combined with ceruminolyticsand surfactants in cleaning/drying products, but canalso be used separately after ear cleaning or prophylac-tically after bathing or swimming in dogs that areprone to otitis. Using ear plugs can result in macera-tion, irritation or a foreign body in the ear canals.

Commonly employed astringents include isopropylalcohol, boric acid, benzoic acid, salicylic acid, sulfur,aluminium acetate and silicon dioxide. Acetic acid(2.0–5.0%) is an effective astringent and antimicrobialand is the preferred choice of one author (TN) in ears

with ruptured tympanic membranes or where a contactsensitivity is suspected. A 2–2.5% solution is achievedby diluting distilled malt (or white) vinegar (few impu-rities; acetic acid content usually 5–8%) with saline or

distilled water. Sulfur is astringent, antimicrobial,keratolytic and keratoplastic.

2

Salicylic acid is kerato-plastic at low concentrations and keratolytic at higherconcentrations (above 2%).

2

It is also bacteriostatic.

2

These qualities may be of use in seborrhoeic and pro-liferative ears.

Antimicrobial agents

Antimicrobial compounds are frequently incorporatedin ear cleaners to retard microbial proliferation. An earcleaner containing parachlorometaxylenol (PCMX)(Epi-Otic®) has potent in vitro

18

and in vivo

activity

10

against Pseudomonas aeruginosa

, Staphylococcus inter-

medius

and Malassezia pachydermatis

. Chlorhexidine(1–3%) is also active against Staphylococcus interme-

dius

and Malassezia pachydermatis

, but is less activeagainst Pseudomonas.

19

Solutions that maintain a lowpH (e.g. Micro Pearls Advantage Advanced pHormulaEar Cleanser; EVSCO, Buena, NJ, USA) are alsoantimicrobial.

Anti-inflammatory compounds

Anti-inflammatory compounds present in some solu-tions can help prevent recurrent otitis associated withinflammatory diseases. Glucocorticoid solutions canalso be used in conjunction with or added to earcleaning fluids. Side effects are less common thanwith systemic therapy, but hypothalamic–pituitary– adrenal axis suppression, local cutaneous atrophy andimmunosuppression can still occur.

19

One should initiallyuse more potent drugs (such as betamethasone and

dexamethasone) followed by a switch to infrequent useof less potent drugs (such as prednisolone and hydro-cortisone) for maintenance.

Contraindications and side effects

Some cleaning fluids may provoke inflammatoryreactions, especially if introduced into the middle ear.Experimental inoculation of propylene glycol, DSS,carbamide peroxide and triethanolamine initiatedinflammatory changes to the middle ear mucosa of normal dogs and guinea pigs, whereas squalane hadno effect.

20

Chlorhexidine is often regarded as

ototoxic

21,22

although experimental infusion at a con-centration of 0.05% into normal canine ears caused noill effects, whereas infusion of a 2% solution did causeototoxicity.

22

In these experiments, however, the com-pounds were directly inoculated into normal bullaewithout flushing and the effect in inflamed ears whencombined with other cleaning techniques is unknown.In a study designed to simulate a clinical situation novestibular or cochlear abnormalities were seen when0.2% chlorhexidine was placed in the external ear canalof dogs with ruptured tympanic membranes.

23

Never-theless, in the absence of firm information about theintegrity of the tympanic membranes caution should

be exercised.A number of ingredients in ear cleaning fluids are

potential contact sensitisers and/or irritants.

24

One of the authors (TN) has seen several cases of chronic otitis



©2 0 0 4 E ur o p e an S o c i e t y of V e t e r i n ar yD e r m a t ol o g y , V e t e r i n ar yD e r m

a t o l o g y ,1 5 ,1 2 7 –1 3 6

Table 1. Ear cleaning preparations

Ceruminolytics Product Ingredients Ceruminolytic Surfactant Foaming Dr

Available in UK

Canidor® (Boerhinger Ingelheim) Essential oils +

Auroclens® (Arnolds) Vegetable oil emulsion +

Specicare® cat ear cleaner (Leo) Glycerol, propylene glycol +

Cerulsolve® (Genitrix) Glycerin, polyethylene glycol, +

thymol, menthol xyleneLogic® ear cleaner (Sanofi) Xylene 2% +

Specicare® dog ear cleaner (Leo) Borax, boric acid, isopropanol, + +

propylene glycolCleaning/drying productsEpi-Otic® (Virbac) Lactic acid 2.5% + + +

Salicylic acid 0.1%Parachlorometaxylenol(PCMX) in docusate sodiumand propylene glycol base

Pimaveclens® (Intervet) Lactic acid, propylene + + +

glycol, salicylic acid,docusate sodium

Sancerum® (Schering Plough) Lactic acid 2.5%, salicylic acid 0.1% + +

Clenderm® (Vétoquinol) Organic acids 2.4%, propylene + +

glycol 40%, salicylic acid 0.037%Dermisol® (Pfizer) Benzoic acid 0.15%, malic +

acid 2.25%, propylene glycol 40%,salicylic acid 0.0375%

Nolvasan® otic (Fort Dodge) Special solvent, surfactant + +

MalAcetic Otic® (Dermapet UK) 2% acetic acid, 2% boric acid + +

TrizEDTA® (Dermapet UK) Tris base, EDTA

Available in US

Cerulytic™ (Virbac) Benzyl alcohol, butylated +

hydroxytoluene, propylene glycol baseCerumene™ (EVSCO) 25% squalane in isopropyl myristate +

liquid petrolatum baseCleaRx® Ear Cleansing 6.5% dioctyl sodium sulfosuccinate, + + +

Solution (DVM) 6% urea peroxideCorium-20™ (Virbac) Purified water, SDA-40B +

23%, glycerolEaroxide™ Ear Cleanser (Tomlyn) 6.5% carbamide per-oxide in a + +

glycerin baseOtiFoam Ear Cleanser (DVM) Water, cocamidopropyl betaine, +

PEG 60 almond glycerides,mackalene 426, salicylic acid,oil of eucalyptus



©2 0 0 4 E ur o p e an

S o c i e t y of V e t e r i n ar yD e r m a t ol o g y , V e t e r i n ar yD e r m a t o l o g y ,1 5 ,1 2 7 –1 3 6

Pan-Otic™ (Pfizer) Purified water, isopropyl alcohol, + + +

aloe vera, diazolidinyl urea,methylparaben, dioctyl sodiumsulfosuccinate, octoxynol,

sodium lauryl sulphate,parachlorometaxylenol,propylene glycol

Cleaning/drying agents

AloCetic™ Ear Rinse (DVM) Acetic acid, aloe +

Aloeclens Otic Cleaner (Vetus) Deionized water, propylene + + +

glycol, aloe vera gel, SD alcohol40–2, lactic acid, glycerin, dioctylsodium sulfosuccinate, salicylic acid,fragrance, benzoic acid, benzylalcohol

ChlorhexiDerm™ Flush (DVM) Chlorhexidine gluconate +

DermaPet® Malacetic Otic Acetic acid, boric acid, surfactants + +

(DermaPet)TrizEDTA (Dermapet) Tris base, EDTA

Ear Cleansing Solution (Butler) Deionized water, propylene glycol, + + +

aloe vera gel, SD alcohol 40–2,lactic acid, glycerin, dioctyl sodiumsulfo-succinate, salicylic acid,fragrance, benzoic acid, benzyl alcohol

Ear Cleansing Solution Deionized water, propylene glycol, + + +

(Vet Solutions) aloe vera gel, SD alcohol 40–2, lacticacid, glycerin, dioctyl sodium sulfo-succinate, salicylic acid, fragrance,benzoic acid, benzyl alcohol

Earmed Boracetic® Flush (Davis) Boric acid, acetic acid, aloe, and +

deodorantsEarmed Cleansing Solution 50 A 40B alcohol, propylene glycol, + +

and Wash (Davis) cocamidopropyl phosphatidyl andPE dimonium chloride

Epi-Otic® (Virbac) Lactic acid 2.5% + + +

Salicylic acid 0.1%Parachlorometaxylenol (PCMX)in docusate sodium and propyleneglycol base

Euclens Otic Cleanser (Vetus) Propylene glycol, malic acid, benzoic + +

acid, eucalyptus oilFresh-Ear De-ionized water, isopropyl alcohol, + +


Table 1. Continued



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a t o l o g y ,1 5 ,1 2 7 –1 3 6

(Q. A. Laboratories) propylene glycol, glycerine, fragrance,salicylic acid, PEG 75 lanolin oil,lidocaine hydrochloride, boric acid,acetic acid

Gent-L-Clens™ (Schering-Plough) Lactic acid, salicylic acid in + +

propylene glycolMicro Pearls Advantage™ Advanced Deionized water, glycerol distearate, +

pHormula Ear Cleanser (EVSCO) alkyl benzoate, glycerin, steareth-10,sodium olefin sulphonate, cholesterol,allantoin, methylparaben, citric acid,sodium citrate, propylparaben

Nolvasan Otic (Fort Dodge) Special solvent, surfactant + +

Oticalm™ Cleansing Solution (DVM) Benzoic acid, malic acid, salicylic +

acid, oil of eucalyptusOtic Clear (Butler) Deionized water, isopropyl alcohol, + +

propylene glycol, glycerine, fragrance,salicylic acid, PEG 75 lanolin oil,lidocaine hydrochloride, boric acid,acetic acid

Oti-Clens® (Pfizer) Propylene glycol, malic acid, benzoic + +

acid, salicylic acidOtipan® Cleansing Solution Propylene glycol, hydroxypropyl + +

(Harlmen) cellulose, octoxynol and a phosphatebuffer system

OtiRinse™ Cleansing/Drying Water, propylene glycol, SD alcohol + +

Ear Solution (DVM) 40, DSS, glycerine, nonoxynol-12,salicylic acid, benzoic acid, benzylalcohol, fragrance, aloe vera

OtoCetic Solution (Vedco) 2% boric acid, 2% acetic acid, + +

surfactantsSoothables™ Crystal-Ear (A. A. H) Purified water, poly ethylene glycol, +

iso-propyl alcohol, lactic acid,polyoxyethylene 20-sorbitanmono-laurate, tea tree oil, aloe vera

Swimmer’s Ear Astringent SD-alcohol 40, de-inoized

water, butylene glycol, carbomer,chloroxylenol, AMP, fragrance

+

(Vet Solutions)

Hexadene® flush (Virbac) Propylene glycol, 0.25%chlorhexidine gluconate,triclosan, fragrance

+ +

*Depending on the concentration.


Table 1. Continued



© 2004 European Society of Veterinary Dermatology, Veterinary Dermatology, 15, 127–136

Ear cleaning 135

with contact dermatitis to various proprietary earcleaners and topical medications. Because these con-tain a variety of ingredients, it is often difficult to deter-mine the offending substance. It is also unclear if thiswas a primary cause of the otitis or became a perpetu-ating factor after resolution of the initial problem;

inflammation and breakdown of the normal epidermalbarrier may enhance the risk of subsequent sensitiza-tion and/or irritation. Switching to a saline or a saline/vinegar solution was curative in each case.

In some instances, excessive topical therapy resultsin maceration of the lining of the ear canal. Clinically,this appears as an accumulation of white ceruminousdebris in the ear canal. Cytologically, there is no infec-tion, only desquamated epithelial cells with occasionalmature, nondegenerate neutrophils. Treatment isdirected at discontinuation of topical medications.9

CONCLUSION

Most proprietary ear medications contain a variety of ingredients. Choosing the most appropriate product isakin to selecting a shampoo. The product and tech-nique of choice very much depends on the individualpatient and they may change as treatment progresses. Itis of crucial importance to fully evaluate the primary,predisposing and perpetuating factors that contrib-ute to the burden of disease in each patient. Thisinformation can then used to select the compoundsthat will counter these problems. Only then can the

clinician choose between the wide array of productsavailable. Proper application of the appropriate tech-nique is vital; this again will change as the conditionevolves. Ongoing training and support will also helpclients maintain ear-cleaning regimes that will be effec-tive in resolving otitis and preventing recurrence.

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© 2004 European Society of Veterinary Dermatology, Veterinary Dermatology, 15, 127–136

Résumé Le nettoyage auriculaire aide à maintenir l’environnement normal de l’oreille et représente un aspectimportant du traitement des otites. Des nettoyages trop importants peuvent toutefois provoquer une otite enfavorisant la macération. Un nettoyage manuel simple est utile en routine, mais il ne permet pas d’éliminer lesdébris adhérents. L’utilisation de poires à lavement est intéressante mais peut abimer l’oreille. Des machinesenvoyant de l’eau sous pression ou l’utilisation d’appareils dentaires est également possible. Un nettoyage completdu canal auriculaire et de l’oreille moyenne n’est possible qu’avec un flushing rétrograde en utilisant des cathétersspéciaux ou des vidéootoscopes sous anesthésie générale. Une myringotomie suivie d’une inspection et d’un

nettoyage de la bulle tympanique doivent être réalisés si le tympan apparait anormal. Il existe de multiplespréparations nettoyantes auriculaires. Les produits cérumenolytiques adoussicent et dissolvent le cérumen cequi facilite le nettoyage. Les surfactants émulsifient les débris, en les cassant et en les mettant en solution. Lesastringents assèchent le canal, ce qui prévient la macération. L’utilisation de produits à pH bas et d’agentsantimicrobiens peuvent inhiber la prolifération microbienne; les glucocorticoïdes sont utilisés pour diminuerl’inflammation. Les effets secondaires et les contre-indications d’un lavage auriculaire sont: macération, réactionsde contact, otite moyenne, avulsion du canal auriculaire, syndrome vestibulaire, syndome de Horner, paralysiedu nerf facial et surdité. Il est nécessaire d’être précautionneux dans le choix de la solution de lavage si la mem-brane tympanique est rompue.

Resumen La limpieza de las orejas ayuda a mantener el microambiente ótico normal y es importante en eltratamiento de la otitis. Un exceso de limpiezas puede, sin embargo, generar una otitis debido a la maceracióndel epitelio. Los lavados manuales simples son útiles para una limpieza rutinaria pero no eliminan los detritos

fuertemente adheridos. El uso de jeringas ejerce una mayor presión pero pueden dañar el canal auditivo en manosno experimentadas. Existen también otros dispositivos que utilizan la presión de agua corriente o maquinariadental. Sólo puede conseguirse una limpieza exhaustiva de los canales auditivos y de la cavidad del oído mediomediante un flushing retrógrado utilizando catéteres especialmente adaptados, tubos de alimentación u otoscopiosde vídeo bajo anestesia. La miringotomía, inspección y limpieza del oído medio debería realizarse si la membranatimpánica parece anormal. Existe una gran variedad de líquidos de limpieza. Los ceruminolíticos ablandan y dis-uelven el cerumen para facilitar la limpieza. Los surfactantes emulsifican los detritus, rompiéndolos y mantenién-dolos en la solución. Los astringentes secan la superficie del canal auditivo, evitando la maceración. Mantenerun pH bajo e incorporar agentes antimicrobianos puede inhibir la proliferación de microorganismos y los glu-cocorticoides pueden utilizarse para reducir la inflamación. Los efectos adversos y las contraindicaciones quepueden surgir de la limpieza del oído pueden inducir maceración, reacciones por contacto, otitis media, avulsióndel canal auditivo, síndrome vestibular, síndrome de Horner, parálisis del nervio facial y sordera. Debería selec-cionarse con cuidado los líquidos de limpieza utilizados si las membranas timpánicas se encuentran rotas.

Zusammenfassung Die Ohrreinigung hilft, ein normales Milieu im Ohr zu erhalten und ist wichtig bei derBehandlung von Otitis. Übermäßiges Reinigen kann jedoch durch Mazeration der auskleidenden EpidermisOtitis auslösen. Das einfache manuelle Reinigen ist zur Routinereinigung nützlich, entfernt jedoch nicht festanheftendes Ohrsekret. Gummispülbälle sind effektiver, können jedoch in unerfahrenen Händen Schaden amOhr anrichten. Außerdem sind Geräte, die mit dem Druck von Leitungswasser arbeiten oder Dentalgeräteverfügbar. Eine sorgfältige Reinigung des Gehörkanals und Mittelohrs kann nur durch eine retrograde Spülungmit speziell angepassten Kathetern, Ernährungssonden oder Video-Otoskopen unter Anästhesie vollbrachtwerden. Erscheint das Trommelfell anormal, sollte eine Myringotomie, Inspektion und Reinigung des Mittelohrsdurchgeführt werden. Es steht eine große Anzahl von Reinigungsflüssigkeiten zur Verfügung. Ohrschmal-zlösende Substanzen weichen das Cerumen auf und lösen ihn, was die Reinigung erleichtert. OberflächenaktiveSubstanzen emulgieren Ohrsekret, spalten es auf und halten es in Lösung. Adstringentien trocknen den Ohrkanalund verhindern Mazeration. Ein niedriger pH-Wert und antimikrobielle Substanzen können die mikrobielleProliferation hemmen, und Glukokortikoide können benutzt werden, um die Entzündung zu reduzieren. Neben-

wirkungen von und Kontraindikationen für Ohrspülungen umfassen Mazeration, Kontaktreaktionen, Otitismedia, Ohrkanalabriß, Vestibularsyndrom, Hornersyndrom, Gesichtsnervenlähmung und Taubheit. Bei ruptu-rierten Trommenfellen sollte man bei der Auswahl von Reinigungsflüssigkeiten Vorsicht walten lassen.

Documents

Ear Cleaning- The UK and US Perspective (Pages 127–136)