Total Ear Canal Ablation and Bulla Osteotomy
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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

Dogs that have had long-standing ear infections may develop irreversible damage to the ear canal

About 50% of the dogs that have chronic ear infections have a ruptured ear drum and infection in the middle ear

The diseased ear canal is removed entirely during the surgical procedure

Due to the delicate nature of this procedure, an experienced surgeon will have fewer complications during the surgery

Prognosis is very good following surgery


Indications for total ear canal ablation

  • Dogs that have had long-standing ear infections may develop irreversible damage to the ear canal. Due to chronic inflammation, the ear canal becomes very thickened and can turn into bone. As a result, the infection will not resolve with medication. The middle ear cavity (tympanic bulla) frequently is infected as the ear drum is commonly ruptured with chronic ear infections.
  • Cancer of the ear canal is another disease requiring this type of surgery. In dogs, surgery is usually curative for malignant cancer (adenocarcinoma) of the ear canal, if the tumor has not invaded through the cartilage or into the middle ear cavity. If your pet has an ear tumor, chest radiographs (x-rays) will be taken to help rule out the possibility of spread of the cancer to the lungs.
  • Congenital imperforate ear canal resulting in middle ear infection.

 

Benefits of surgery

  • Typically a dog that has chronic deep seated ear infections will be much less active than a normal dog because they do not feel well.
  • Most owners report that their dog is "a new dog" and act like a puppy again. 
  • Many owners report that their dog can hear better than prior to surgery.  The reality is that the hearing likely is not improved, rather the dog is feeling better and is more willing to respond to auditory stimuli such as ringing of a doorbell etc.
  • If both ears receive surgery, ear infections generally will be permanently cured.
  • Considerable cost savings on ear medications and treatments after surgery is completed.

 

Surgical procedure

  • The diseased ear canal is removed entirely.
  • The bulla (middle ear) is opened up in order to remove the infected tissue from the middle ear. This is called a bulla osteotomy.
  • Drains are inserted into the surgical site if the infection is severe. About 98% of the cases that have a bulla osteotomy do not receive drains. If drains have been placed, antiseptic may be needed to be injected through the drains and the bandages changed twice daily for 6 to 7 days.
  • Your pet will stay in the hospital for 24 hours after the surgery providing that recovery is uncomplicated.
  • The photo of a cross-section of the ear canal; take note of the ear canal that starts at the base of the ear flap and is separated from the bulla by the ear drum (labeled D); The facial nerve that is in the black circle and labeled nerve, wraps around the ear canal; the inner ear is fairly close to the bulla and controls balance.

      

  • Below is an illustration demonstrating total ear canal ablation; the thatched area shows the part that is surgically removed; after the ear canal has been removed the area is sutured closed (see below after surgery)

      

Hearing and cosmetic appearance following surgery

  • Most pets that have chronic ear disease have a significant loss of hearing. The surgery may decrease hearing, however, many dogs still respond to the ringing of a door bell etc.
  • The cosmetics following surgery on a dog with floppy ears is very good. After the surgery is complete, there will be no opening into the ear canal. Cats and dogs that have erect ears may have some drooping of the ear flap, but generally the outcome is very cosmetic.

 

Other considerations following surgery

  • Chronic ear infections are usually not just a local disease. Frequently these pets have allergies or endocrine diseases that caused the ear infections. After your pet recovers from surgery, a dermatologist should be consulted to investigate and treat underlying skin disease.
  • If one of the ear canals is healthy at the time of surgery, it is common that chronic irreversible ear disease will develop and require total ear canal ablation in future.  Chronic medical therapy such as cleaning of the ears, controlling ear infections, and controlling allergies can help to prevent end-stage irreversible ear disease.

 

Potential complications

  • Even though rare, anesthetic death can occur. With the use of modern anesthetic protocols and extensive monitoring devices (blood pressure, EKG, pulse oxymetry, inspiratory and expiratory carbon dioxide levels, and respiration rate), the risk of problems with anesthesia is minimal.
  • Facial nerve paralysis, which is the most common complication of total ear canal ablation, occurs in about 5 to 10% of the patients. The more severe the ear disease, the greater the risk of this problem. The facial nerve wraps around the base of the ear canal and is important for function of facial muscles. If this nerve is bruised from the surgery your pet will not be able to close the eyelids, and the lips will appear droopy on the operated side. Eye drops may be required to prevent drying of the eye until the nerve palsy has resolved. In most cases, facial nerve paralysis is a temporary problem and resolves within 2 months.
  • Pain upon opening the mouth or difficulty chewing can occur if the joint of the jaw, which is located just in front of the middle ear, gets inflamed from middle ear infection or from surgery.  This problem typically resolves within 2 weeks.
  • Horner’s syndrome is where the pupil becomes constricted and third eyelid covers part of the eye. This syndrome is caused by damage or inflammation of the sympathetic nerve that runs through the middle ear. This is an unusual complication as the nerve is fairly well protected in dogs.
  • Vestibular syndrome (balance problems) can occur as the balance organ is located in the inner ear. Less than 2% of patients develop this problem, but it is more common in those patients that have had previous balance problems or a head tilt.
  • Swelling after surgery is may occur and be due to oozing of blood or accumulation of clear fluid at the level of the ear.  In some cases that swelling occurs shortly after surgery and results in swelling in the throat region which results in breathing difficulty.  If this occurs a breathing tube may need to be placed until the swelling goes down.  In severe cases, a temporary tracheostomy (tube placed through neck region) may be needed.  This is an uncommon complication occurring in about 5% of the patients and usually does not result in death.
  • Recurrent infection is an uncommon complication, usually due to unresolved infection at the level of the middle ear or ascending infection from via the auditory tube, and may require a second surgery to clean the bulla.

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when they go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
    • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
    • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic facial expression
    • panting
    • restlessness and unable to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

  • Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
  • Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

  • If a dog licks the incision, the healing process may be delayed.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
    • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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