Dolittler Guest Post Chronic otitis (ear infections) and the surgical procedure we call the TECA

by Marc Wosar, DVM, MSpVM, DACVS

Miami Veterinary Specialists

Dr Khuly's note: This great article was intended as an informative piece for veterinarians but I think it works well for anyone whose pet suffers severe ear canal disease. If you find yourself medicating ears for a significant percentage of your pet's life this information is FOR YOU!

Chronic otitis is a common and frustrating disease for owners and veterinarians. For the patient, the case is much more critical – they are often in severe pain. The pain and itch associated with chronic ear infections makes the owners’ frustration (and ours) seem petty in comparison.

While appropriate medical management is often successful in curing acute otitis, all too often it only diminishes the signs temporarily, or fails altogether. Owner compliance can be a problem, and many cases go undermedicated.

In many cases, there is an underlying cause which leads to failure of medical management. In these cases, resolution of the cycle of pain, itching, headshaking, chronic medication, and owner complaints can be provided with surgical ablation of the ear canal. This technique is also useful in the treatment of other ear diseases, like neoplasia (cancer) and traumatic ear canal injuries.

Otitis can be externa (of the ear canal alone), media (involving the middle ear) or interna (involving the skull bone and its constituents: the hearing center (cochlear apparatus), balance center (vestibular apparatus and the brain).

While we usually focus on the bacterial and fungal components of the disease, most cases of chronic otitis cannot be resolved if an underlying cause is not identified and eliminated.

The underlying cause is often allergic, with environmental allergies and food allergies most common. These patients get stuck in a cycle of inflammation, infection and fibrosis which eventually leads to collapse of the ear canals, a ruptured ear drum, and debris and infection within the middle ear.

Over time, the ear canals ossify, and scar tissue occludes the canals, preventing topical medications from reaching the diseased portions. The occluded canals also prevent the natural sloughing of ear canal skin cells, sebum (wax) and hair, which accumulates in the canals, and within the middle ear.

Many surgical techniques have been described for the treatment of chronic otitis. Of these, most have been focused on “opening up” the ear canal. This approach was based on the notion that the ear canal needs air to dry, or to facilitate the instillation of medications.

Techniques like the lateral wall resection (Zepp procedure) and vertical canal ablation have been advocated in the past, but are only applicable for focal (discretely located) disease of the vertical ear canal. Most cases of chronic otitis involve the entire ear canal, extending through a ruptured ear drum and into the middle ear. For these more typical cases, these surgical techniques are contraindicated.

Only a Total Ear Canal Ablation (TECA) with a lateral bulla osteotomy (LBO) addresses the entire disease process.

The TECA is a procedure that removes the vertical and horizontal ear canals down to the level of the middle ear. Due to the high incidence of middle ear involvement with chronic otitis, the middle ear is debrided (cleaned) via a lateral bulla osteotomy.

Usually a large amount of debris, hair and pus are found in the bulla. It comes as no surprise, then, that these cases of chronic disease do not resolve medically given the amount of debris within the middle ear. The most common complications with the TECA are recurrent abscessation, facial nerve paralysis, and vertigo. The incidence of abscessation is less than 10%. Facial nerve paralysis and vertigo are usually temporary, and resolve without specific treatment.

Many owners are concerned about deafness after the surgery. While the TECA removes the apparatus that transmits sound via the air (i.e. the ear canal and ear drum) sound can still be sensed via the vibrations that come to the cochlear apparatus through the sinuses and skull. This is similar to the level of hearing one experiences when wearing earplugs. No sound reaches the cochlear apparatus through the air, but we can still hear sounds and voices.

The reality is that most dogs with chronic otitis are already hearing at this low level due to the collapse and obstruction of their ear canal and middle ear, where no sound waves are being transmitted via the air. Most owners do not report a change in their pets’ ability to hear after a TECA.

Fundamentally, the TECA is a very rewarding surgery for the patient, owner and veterinarian. Most owners report a dramatic improvement in the attitude of their pets postoperatively, claiming they see the return of social and play behaviors they have not seen in many years.

This, combined with releasing them from the drudgery of daily ear cleaning and medication administration, offers the owner a huge sense of relief. As we have gained more experience with the TECA procedure, there has been a movement to recommend it earlier during the course of the disease.

No longer is the TECA viewed as strictly a salvage procedure of last resort. Many dogs and cats with chronic otitis are candidates for the surgery once it becomes clear that they are in that all-too-familiar cycle of otitis that many of us find the bane of our daily lives.

July 9th, 2008

Add Comment31 Comments

I would only add from Tuft's "Your Dog" articles, what often is missing from the original treatments for otitis is oral antibiotics in addition to the ear medications. And some have "amazingly" resolved if the (dog) pet was hypothyroid and treated for that underlying condition.

Barbara A. Albright/New Hampshire July 9th, 2008 10:13:00 PM

Barbara: This article assumes that all basic measures have been taken, including thyroid testing and proper diagnosis of the underlying conditions. Disturbingly, however, it also takes into account the fact that some owners cannot manage the treatment of these with appropriate home care. Sometimes it comes down to the behavior issues of the dog (unwillingness to be treated), often the result of the pain (which is difficult for owners to assess).

No one is assuming that surgery is a surefire solution. It's just being proposed that it shouldn't be considered a last ditch effort. The response of all my TECA patients prove to me that no amount of home care could properly alleviate them of pain. ALL of them have reverted to a more comfortable "puppy-like" demeanor within days of the surgery. For them the TECA has been nothing short of "miraculous."

Dr. Patty Khuly July 10th, 2008 08:09:00 AM

btw, one of our local dermatologists suggested Dr. Wosar write this article for our South Florida Veterinary Medical Association's newsletter. She wanted all the area vets to know that the TECA is a life-saver for some dogs and that it should be considered early on in the process. She makes big money from treating chronic ears and yet she strongly urges clients to consider this procedure. But many of our local vets still consider it a salvage procedure. I wish they wouldn't.

Dr. Patty Khuly July 10th, 2008 08:46:00 AM

My dog gets chronic ear infections but they aren't severe. He has to be sedated at least 3 times a year for an ear flush and I'm constantly on top of it at home. The last couple of times he had a lot of debris but not much in the way of redness or swelling, and there was no pus.

Of course my preference is for him to be ear irritant free but in his case surgery is probably a pretty drastic step. At what point do you recommend this surgery?

Kristie July 10th, 2008 09:53:00 AM

The service dog of one of my friends has chronic ear infections. Antibiotics and drops didn't do enough, but apparently a diet modified for allergies has had good success. I believe that surgery would not be an acceptable option as the dog would no longer be able to serve as a service animal with permanently impaired hearing.

zandperl July 10th, 2008 11:10:00 AM

zandperl: Unfortunately, dogs with chronic ear infections are found to have limited hearing as it is. Her dog should be Baer tested by a neurologist at least once a year to make sure her hearing is still up to service dog standards. Please let her know this.

Dr. Patty Khuly July 10th, 2008 11:12:00 AM

Kristie: The TECA is recommended when either owners cannot comply with effective home care (for whatever reason) or when chronic pain is present. The latter is hard to determine but it sounds like you *really* take care of these ears. Keep it up.

Dr. Patty Khuly July 10th, 2008 11:13:00 AM

Kristie, the definition of severe has to be decided upon by you and your veternarian. However, at some point, one has to consider if sedation for ear flushing every four months, and constant medications at home may not meet that definition. What we find is that we should no longer wait for the ears to be melting with pus before considering surgery, as the amount of suffering on the part of the pet and owner can be dramatic over time.

zanderperl, exploring the contribution that allergies have is very important since most ear diseases are perpetuated by an allergic skin condition.

As far as disqualifying a dog from surgery due to its status as a service dog: one has to balance their quality of life with theri job. If they have chronic ear idseae severe enough to warrant a TECA surgery, one has to ask if performing the surgery and retiring the dog from service is more humane than keeping them working in spite of a painful condition -- especialy one that can be treated and cured.

Dr. Wosar July 10th, 2008 12:46:00 PM

Ahhh, a subject near and dear to my heart.

My current dog, a 10 year old neutered male cocker spaniel adopted 15 months ago, had such a bad ear when I first got him that he had a TECA-LBO on his right ear within a month of adoption. With cleaning, topical and oral antibiotics and anti-yeast meds, his remaining ear lasted until this May, when I decided to have a second TECA done. His remaining ear always had a low-grade infection of some sort that I managed by cleaning and antibiotics, but which could not have been comfortable for him. A culture and sensitivity showed that he had multi-drug-resistant Pseudomonas aeruginosa in that ear, and that it was only susceptible to marbofloxacin and one other "second line of defense" antibiotic. The biggest hurdle I personally had was getting over the idea that he would "wake up deaf" from the surgery, as he still had good hearing in his remaining ear. Every night was a battle as cleaning and medicating hurt him and yet it had to be done, so the prospect of ending that was a definite bonus.

The second TECA was more painful (he got 2 doses of morphine the first night in the hospital) and the recovery definitely took longer. He also developed Horner's syndrome on the left side, but he already had facial paralysis on the right side from the first TECA so he doesn't really look any worse. :) The skin on his ear flap is still oozy and irritated, which is probably due to pre-existing environmental allergies. He's already on a grain-free food, and I tried raw feeding when I got him but he would have none of it. He has seborrhea and dry-eye as well, and was just diagnosed as hypothyroid. I hope that regulating his thyroid will help with everything.

I'm glad I had the TECAs done on my dog, and I'm very happy that I had the first one done early in the disease progression, as I think it made his recovery a bit easier. I wish I'd had the second one done sooner. I believe that I tried to manage his allergic conditions to the best of my and my vet's ability, yet we still ended up with bilateral TECAs. It's definitely a major surgery but the rewards are well worth the pain and recovery time, and I agree that more dogs with chronic ear disease should have TECA suggested much earlier in the disease process. The cost is an issue to consider, as his 2 surgeries have cost me a bit over $5k, but luckily I had room on the credit card. I didn't think it fair to make him continue to suffer until I could save up the cash.

anonymous in boston July 10th, 2008 06:37:00 PM

Anon in Boston: You inadvertently proved my point(dry eye and seborrea)---sadly, it would have been better had your Cocker been diagnosed hypothyroid and treated for a period of time before jumping into surgery---but as Dr. Wosar said and I agree with very much : pain, horrid on-going deep infection, and inability to 'physically' handle & treat/manage are all HUGE factors.

Anyone else notice that some of the ear cleaners are way too irritating?

Barbara A. Albright/New Hampshire July 10th, 2008 07:25:00 PM

Barb, I respectfully but strongly disagree with your comment. My dog was tested for his thyroid as part of his "I just adopted him" bloodwork and his thyroid levels were normal at that point. I did not "jump" into surgery uninformed out of a desire to do less work maintaining his ears. The dry-eye and seborrhea (as well as the bad ears) are classic Cocker traits and are found in a majority of cockers, and a majority of TECAs are performed on cocker spaniels. I went into a lot of debt after a lot of research in order to relieve his chronic discomfort, and I don't need to be second-guessed.

Many ear cleaners contain alcohol and should not be used in irritated ears. It's best to select a cleaner that does not contain alcohol if your pet is prone to ear infections. There is also the problem that you can cause damage if your pet has a ruptured eardrum and you use certain cleaners or antibiotics.

anonymous in boston July 10th, 2008 07:50:00 PM

anon: I apologize, I wasn't inferring a second "guess" to "your" decision. I am suggesting that if he was adopted 15 mos ago & so called normal thyroid---he must have been on the low side to suddenly become "hypothyroid", and actually what is determined to be normal range is highly controversial and thought to vary breed to breed. And dry eye & seb. can be also symptoms of hypothyroidism----this is one of my pet topics of interest. And more than one Cocker breeder has told me of > incidence in the breed (Scotties are similarly affected). It is the #1 endocrine disorder in ALL breeds (according to AKC survey of breed clubs).

Again, you made the decision you had to based on the facts you had; I just wish that thyroid disorder was a more commonly suggested and routine test with ALL pet dogs. YOU did right by addressing a serious need!!

Barbara A. Albright/New Hampshire July 10th, 2008 10:20:00 PM

His thyroid levels (T4, free T4) were both high normal when first tested last year.

A year later, his T4 is very low and his freeT4 was low-normal. So we initiated treatment.

His skin had cleared up initially on 3x weekly Malaseb baths and grain-free kibble.

Now his thyroid's down, so back to the weekly baths until the meds kick in.

Is this new incident somehow caused by the surgery, or the weather, or just simple aging changings? Impossible to pinpoint. Just onward to more management and relief of itchiness and discomfort.

anonymous in boston July 11th, 2008 12:28:00 AM

Don't get me started on the issue of irritating ear cleansing solutions! Most of the cleansers on the market are *horrible* for inflamed, infected ears--not to mention for the animal whose hurting ears just got more painful from all that alcohol, acetic acid or whatnot.

Please use professional products if you must buy something. Ask your vet what's best. Eschew all heavy alcohol and heavy acetic acid (vinegar) products.

For routine home cleaning of most ears? One part distilled white vinegar to ten parts water. That's how dilute it should be.

For a kick in the disinfection direction use a chlorhexidine-based product (the blue disinfectant) but never flush the ears with this if the ear drum may be ruptured (a common problem with chronic ear infections) as this product is toxic to the hearing apparatus of the ear.

Dr. Patty Khuly July 11th, 2008 07:14:00 AM

Our company processed approximately 6,300 claims for otitis externa in 2007. It was #1 on our top 10 claims for 2007. Having worked in vet clinics for over 10 years, I saw many animals suffer from chronic ear infections. The animals who received TECA, definitely got relief.
Every noticed how dogs run when you pull out the alcohol based ear cleaner? They are vocalizing that it hurts their ears. Dr. Khuly, thank you for the vinegar solution. We need to respect out pets feelings.

Becky July 11th, 2008 08:16:00 AM

Can no one seriously consider allergies, and the treatment of them for a dogs ear issues??
I have battled severe allergies in one of my dogs for 3 + years now, and I can say that allergies (which are rampant these days) can cause alot of health problems you /they may not think of, at first. Before reaching for the knife try having a dog tested (blood and skin, intradermal testing) for allergies, keep a food log and watch closely!
Dr Khuly, I really do respect what you have to say very nearly all of the time - but this is a case where I want to see some caution. Skin and ear issues are so often caused by an allergic reaction and I hate to see a conclusion jumped into and surgery reccomended - shouldn't we take a conservative approach and try non invasive methods first???

carmen July 11th, 2008 11:00:00 AM

I've tried 4 times to make a post--what gives?

If all my posts who up at a later time, my apologies.

robyn w July 11th, 2008 02:41:00 PM

Carmen, I apologize If I did not make it abundantly clear in my article, but I did say: "While we usually focus on the bacterial and fungal components of the disease, most cases of chronic otitis cannot be resolved if an underlying cause is not identified and eliminated. The underlying cause is often allergic, with environmental allergies and food allergies most common. "

That is explicitly echoing what you are saying: allergies must be evaluated and treated first, as they are usualy the reason ear "infections" do not resolve. If you do control the allergies, a large percentage of dogs no longer have issues with ear disease and, of course, will then never need a TECA surgery.

However, as most of us who have dealt with allergic skin disease know, allergic skin disease is not an easy cure. Often there is no cure, even with the best, most concerted treatment approach. It is those dogs that suffer, and whose suffering can be greatly alleviated (or eliminated) with one procedure.

Dr. Wosar July 11th, 2008 04:20:00 PM

carmen: I tried allergy management. My dog's ear canal was starting to calcify and it was full of pus. I did not feel that making him wait out the 6 months for allergy shots to maybe work was worth it. I tried several different diets and finally settled on a grain-free kibble that has him better but not cured. Nobody's advocating a TECA for every dog with a run of the mill ear infection. But some dogs with "really bad ears" can have less pain on a daily basis if they have a TECA. If you have a cure for allergies to everything I would love to know what it is. Sometimes the drastic answer is the best answer when it comes to the bottom line: your pet's pain level.

anonymous in boston July 11th, 2008 06:31:00 PM

I'll echo the last two comments: If allergies could be "cured" in all cases the board certified dermatologist would not be sending so many of her patients to Dr. Wosar for this procedure.

Dr. Patty Khuly July 12th, 2008 07:59:00 AM

Can anyone recommend a local vet (Pinellas County, Florida)who can do this procedure? My 11 year old lab, after 10 1/2 years of 3-8 ear infections per year, has developed an ear canal tumor (benign) that has made cleaning her ear impossible. She, and we, are suffering so much..I am ready to do something drastic to alleviate her pain.

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