Chronic Ear Problems and Vestibular Disease

I recently had an email from a reader who is fostering a dog with some pretty severe ear problems.  The dog has had head-tilt and balance problems, as well as an obvious external ear canal infection.  The situation isn't straightening out very fast, so she was looking for more information,  She knows that her veterinarian gets annoyed when clients bring in their internet search information, but she is doing it anyway. 

The problem with an internet search is that many times one finds sites posted by people with no real expertise, or an axe to grind.  This does confuse the issue.  Clients come in with printouts that are not only incorrect, but obviously (to me) illogical and self-contradictory.  It just makes things harder for all of us.

I really like Veterinary Partner. Here's the web address:
The test of "truth" is whether the information is useful.  Does it agree with other authoritative sources?  Does it WORK?

As always, I feel that the veterinarian who is examining the patient is the doctor who is in the best position to make an accurate evaluation recommendation.  However, here are some general thoughts on the problem, and a reference to a good discussion.

What is vestibular disease in the first place?  I'm not going to reinvent the wheel, here.  Read this article for background:

So, the middle ear (the tympanic bulla, a bony "bubble" on the bottom of the skull) can become infected from the outer ear canal (from the eardrum out) or (less commonly) from a blood-borne infection.  Infection in the inner ear (semicircular canals and cochlea) can come from a blood-borne agent (even a virus), or from an infected middle ear. 

The inner ear and the vestibular nuclei in the brain itself are where the balance and head-tilt problems come from.  Did it start there, or come from an ear infection?  If the dog had a nasty ear infection, that certainly has to be our top suspect as the originating cause.

If the ear was never cleaned out, then you don't know whether you have an eardrum or not. At least 60% of long-term ear infections result in a damaged eardrum. Even if the eardrum appears intact, there can still be problems in the middle or inner ear. Sometimes the eardrum heals over, trapping crud in the middle ear. Thorough cleansing of the ear canal is needed to evaluate the problem.  Then you may still need X-rays, or even MRI or C-T.  Certainly thorough cleaning (possibly requiring anesthesia) and a good scope are necessary to visualize the eardrum (or lack of one).  Before I had a video otoscope (mine is a  MedRx), I guarantee you that I was missing things and not doing an adequate job on some of these.

Sometimes we start out right away with an antibiotic which has a broad spectrum of activity and good penetration into the area.  Culturing the mess before starting antibiotics is not always helpful with ears.  Many dermatologists do not do so, but some do.  Certainly with persistent or recurring infections, one would consider a culture before starting the next round of treatment.

As noted in a previous post, cleaning the debris out of the ear (and keeping it cleaned out) is critical to success, as the biofilm protects and enhances the survival of the germs in the ear canal.  As the article suggests, when cleansing solutions get into the middle ear ear, they can affect the inner ear and cause head-tilt and balance problems (usually temporary).  Still, leaving these areas full of pus is worse than cleansing them with warm water.

Many dogs with bad ear infections have a lot of swelling in the ear canal, and this may require some treatment with cortisone (by injection or orally with pills) before you can really clean and visualize the canal. If you are going to have to anesthetize the animal to clean this painful area, you would want to do the cortisone treatment first (for several days).  If the canal is so swollen that you can't get your scope in, you're not going to see much, even with anesthesia.

If your regular doctor is not "into" ear infections, you probably do want to find someone who is.  They can be frustrating, even for the specialists.

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