Restraint and Pain Management

Diagnosis and management of otitis externa (OE) may require restraint through anesthetics and/or analgesics, with the latter often being recommended as part of the treatment protocol when the patient leaves the hospital as well. Practitioners should explore options for restraint and analgesia when diagnosing or managing affected patients. For patients that may be sensitive or have inflamed, painful ears, before manipulation of the external ear consider the use of an alpha-2-adrenergic sedative or, alternatively, an N-methyl-D-aspartate (NMDA) antagonist, both in combination with an opioid. Use of anesthetics and/or analgesics can allow for more thorough otoscopic examination of the horizontal canal and tympanic membrane and more thorough flushing of the horizontal and vertical canal while creating a less stressful and painful visit for the patient. 

In severe cases, those with stenotic ear canals, or in anticipation of prolonged cleaning or diagnostic efforts, general anesthetics and maintenance with inhalant anesthesia may be warranted and are common practice for many veterinary dermatologists. Routine monitoring is recommended in all cases where anesthetics are utilized, and endotracheal intubation is mandatory when patients are under general anesthesia to avoid aspiration – especially when a ruptured tympanic membrane is identified. In regard to the risk of aspiration during general anesthesia, patient positioning can also help minimize risk. Consider placing the patient’s head at a downward angle with the goal of limiting the aspiration of fluid present in the auditory tube. 

Some clients may be reluctant to authorize general anesthesia for a case of OE. Be sure to discuss that anesthesia allows for a more thorough and comfortable experience for the patient, decreases the risk of aversion to treatment at home, and enhances safety for both the patient and staff. 

Analgesics are often of value at home, even if all of the treatment can be completed in the clinic: it is important to remember that OE patients are often in pain at presentation and vigorous cleaning and examination may exacerbate discomfort. Systemic glucocorticoids offer significant benefit in reducing swelling, erythema, and pruritus; in patients where systemic glucocorticoid therapy may be contra-indicated, a non-steroidal anti-inflammatory medication (NSAID) may present an alternative and can benefit patients with swelling or pain associated with OE. As always, NSAIDs should not be used in combination with systemic glucocorticoids. In cases where an NSAID or glucocorticoid is not sufficient alone, use of medications such as tramadol in combination with anti-inflammatory therapy may be of value in managing pain. Ultimately, consideration of quality of care, patient comfort, and patient/staff safety are of the utmost concern. Proper use of sedation, analgesia, and anesthesia can contribute significantly to all facets of diagnosing, treating, and managing cases of OE.