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68 DERMATOLOGY DETAILS PEER REVIEWED Antifungals Antifungal agents can sometimes be used in severe cases of Malassezia otitis or cases with poor response to topical agents alone. Oral antifungals commonly used include ketoconazole (Nizoral, nizoral.com ), fluconazole (Diflucan, pfizer.com ), and itraconazole (Sporanox, janssen.com ). All are dosed at 5 to 10 mg/kg q24h or q12h (divided). Terbinafine (Lamisil, lamisilat.com ) may also be used at 30 mg/kg q24h. Glucocorticoids Glucocorticoids are usually indicated in cases of markedly inflamed and painful otitis with chronic pathologic changes, such as marked hyperplasia and stenosis of the canal. Oral anti-inflammatory dosages of prednisone or prednisolone (0.5 to 1 mg/kg q24h) can be used initially and then tapered to the minimum alternate-day dosage that controls the clinical signs. I typically recommend oral glucocorticoids for cases of Pseudomonas otitis and for dogs that have undergone deep ear flushing. Oral glucocorticoids can also be helpful to reduce pain and discomfort, particularly a few days before the owners clean and medicate the ears. I often combine opioids, such as oral tramadol at 2 to 4 mg/kg q84 to q12h, with oral glucocorticoids in severely painful cases. When longer-term treatment is expected, alternate-day glucocorticoid therapy may be indicated, with careful monitoring for adverse effects. Cyclosporine Oral cyclosporine (Atopica, us.atopica.com ) may be considered a medical option for dogs with severe proliferative otitis externa when surgery is not an FIGURE 8. End-stage otitis. TABLE 3 Surgical Techniques for Chronic Otitis and Otic Masses/Tumors 9 SURGERY INDICATIONS COMMENTS Lateral ear canal resection • Congenital ear canal stenosis • Resection of masses located in the vertical ear canal • Facilitation of medical management • Possible improvement of local environment factors and facilitation of topical treatment • Associated with frequent failures for treatment of chronic otitis externa, particularly with chronic pathologic changes to the ear canal or failure to control the underlying cause of otitis • Failure rates are higher in cocker spaniels Vertical ear canal resection • Disease limited to the vertical canal, such as masses or neoplasia • Not recommended for chronic proliferative cases involving horizontal canal and middle ear • Less invasive than TECA-BO Ventral bulla osteotomy • Diseases, such as tumors or polyps, present in bulla • Not recommended for chronic proliferative cases involving horizontal canal and middle ear • Less invasive than TECA-BO TECA-BO • Severe chronic end-stage otitis externa/ media • Chronic recurrent otitis externa/media unresponsive to long-term proper medical therapy • Masses or neoplasia of ear canal and/ or bulla that cannot be removed by alternative methods • Most commonly recommended by dermatologists • Associated with highest success rate and best prognosis of all surgical procedures for chronic severe otitis • Ideally should be performed by a board- certified surgeon to minimize potential surgical complications TECA-BO, total ear canal ablation + lateral bulla osteotomy.