I usually see a dog with ear problems after the ears blows up like a water balloon or the scratching, whining, and head shaking has kept the whole family awake for a night or two. Family holidays are also a popular time after the in-laws ask, "Does your dog always do that?" It’s usually not an emergency but it is uncomfortable and certainly worth looking into sooner rather than later.
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What causes dog ear problems?
It’s almost always an underlying allergy. True, I’ve found things like parasites (bot fly larva, demodex mites, etc.), something the toddler decided to hide in there (good dog for staying still for the toddler!), middle ear infections (behind the ear drum), and masses (tumors) causing the problem... but it’s almost always allergies.
While us humans get red/itchy eyes and sneezes, dogs usually have ear problems as the first sign of an allergic problem. Don't worry, we’ll discuss allergies in another post soon! But for now, let’s focus on the ears.
It’s a design problem.
Dogs aren’t small people (or large cats, or peaceful honey badgers). For us humans, it’s pretty much a straight shot to the ear drum. This path is called the "External Ear Canal". For dogs (and cats), their ear canal goes down (you can feel this as a ridge underneath the ear opening) and then takes a sharp turn in towards the head to reach the ear drum.
Allergies lead to inflammation. Inflammation leads to a warmer, more humid, less acidic environment deep down in the ear canal where you can’t see without a special magnifier (called an otoscope) and some training on how to get in there without hurting anything. Rest assured, once you can see an ear problem on the outside part of the ear canal, it’s a big problem deep down in there where you can’t see.
In most dogs, it takes some underlying inflammation before yeast and/or bacteria start having a party. Where did those nasties come from? They normally live in there... just in small enough numbers that they don’t cause a problem. It's like the difference between a sleep over and a house party for high schoolers.
Ear problems usually aren't an issue of excess hair or recent swimming. Plucking the ears isn’t recommended by most of the veterinary dermatologists with whom I’ve worked. Plucking causes pain, tissue irritation, and doesn’t fix the underlying problem (allergies).
Regular physical cleaning of the ears is discouraged both because it can irritate the delicate tissue inside the ear (causing inflammation) and you’re unlikely to safely reach the deepest part of the ear without damaging something (like the ear drum). So please, keep the Q-tips, and all manner of ear scrapers out of your dogs ears!
Why does my dog’s ear feel more like a water balloon?
In some dogs (and any species with long ears), if they shake their head hard enough, they rupture some blood vessels and the space inside the ear fills like a balloon (called a hematoma). Have you ever whacked your finger with a hammer accidentally and gotten a blood filled “blister” under the skin? If you haven’t, I don’t recommend it. It hurts. But it is the same reason your dog’s ear is all puffy and squishy.
Why are they shaking their head in the first place? I hate to tell you if you haven’t noticed, but your dog doesn’t have fingers and isn’t very good at scratching inside their ear. Your dog’s solution is to shake their head as hard as possible. But since this doesn’t fix the problem and so they just keep shaking while scratching the outside of the ear and causing more damage and more pain over time.
While a ballooned ear doesn’t constitute a real emergency (it’s not life threatening), it certainly is off-putting (especially when the in-laws get all judgy). Also consider: the problem will resolve faster and the ear will get more comfortable the sooner we treat it. But if we don’t treat the cause of the ear itching in the first place (usually allergies), treating the ballooned ear is about as useful as rotating the air in your car’s tires (pro tip: just say no if the oil change place ever offers this).
What’s the Textbook approach?
First, you see a veterinarian. Ideally a general practitioner if they are available (vaccines, itchy pets, and diarrhea are kind of their thing). If they say, "No", come on by the the ER! Just remember, since we don’t do appointments, you may be waiting a while. Note: The nice people at the front desk (we call them CSRs) have no medical training. While it’s tempting to ask them questions and they are tempted to give you answers, it’s best to wait for someone from the back to come and chat with you. It also helps make sure those nice CSRs don’t quit... which would be a bad thing... because then you’ll be waiting even longer with no one to awkwardly stare at in the lobby.
Now, we’re going to ask you some things. Has this happened before? If so, when was it last treated and with what? How long has this been going on? Have you noticed any other changes? So before you send your spouse, or grandma, or Door Dash driver to wait in our lobby (it happens), please try and provide them with this information. The answer to these questions determines both the diagnostic and treatment recommendations. If your dog is a first time offender, let’s try treating what we see and recheck the ears in a few weeks. If you’ve been treating your dog for ear infections that aren’t getting better for the last 9 months, it’s time to do something different and diagnose the problem so we can fix it!
Next, we’re going to look at your dogs eyes. Are they darting back and forth (left to right?). Has the dog lost balance? This is likely a sign of something going on deeper in the ear causing a problem. The fancy name for this is nystagmus and it’s the same experience you get when stepping off the Tilt-a-Whirl at the state fair: dizziness and nausea. It almost always goes away with treatment after a few days but I’d have your dog avoid cliff-side hikes until it does.
If we do notice nystagmus (irregular eye movement), an abnormal buldge behind th eardrum, or the problem just keeps going on, the textbook is going to tell us we should get a CT scan (a 3 dimensional X-ray of the head) but the textbook never takes into account the cost (around $2000-3000 as of this writing). If regular X-rays are offered, I’d recommend skipping them. X-rays are 2 dimensional (like these words you’re now reading) and everything gets so overlapped that X-rays of the head are usually just a waste of $500 or so. The reason X-rays would be offered in a situation like this are:
the facility doesn’t have a CT,
the staff members who know how to run the CT aren’t working right now,
the doctor on staff is working on commission,
the doctor you’re seeing is just throwing all the available diagnostics at it because that’s their "thing",
the staff is trying to expedite things on a busy day and talks you into a bunch of diagnostics before I ever even know your dog’s in the building or have a chance to say, “How about we not do all of that right away?”
If the eyes look fine, we’re going to look in the ears. An otoscope (a fancy ear magnifier) is needed to look deep inside the ear and see if the ear drum is intact. Why is this important? Because most medications we want to put inside the ear are toxic to the things that live behind the eardrum. The toxicity risks causing the dizziness, nausea, and deafness mentioned above. Even with an otoscope (and training), it’s tough to see the eardrum in the midst of an ear problem because dogs don't want anything shoved in a painful ear and the gunk gets in the way of seeing anything.
Depending on what we see in there, we’re going to decide on the next steps. Unless we see something like a bot fly larva or a Lego®, we’re going to want to get a swab sample from inside the ear to get some gunk and smear it on a microscope slide. Then we’re going to see what we have under 100 times magnification. It’s almost always yeast and/or bacteria. Sometimes we find something else. Generally knowing what we’re up against helps us know if it’s likely the same problem should your dog become a repeat offender. It also helps us pick medications. An antibiotic won’t help much with a mite (bug) problem. And mite medication won't do much for a yeast overgrowth.
Finally, we’re going to look at the rest of your dog so we can chat about anything else we find. It's not to pad the bill. It's because we care (and it's required by law).
Possible outcomes of this ear exam:
If we find something stuck in there, we'll take it out. If all looks good, we send you and your dog home.
If the eardrum is intact and your dog is not a frequent flier with ear problems, we’re going to get that swab per the above and send you home with some ear medications (drops, pain medicine, and maybe some steroids) and instructions to have the ears rechecked with your regular veterinarian in a few weeks.
If the eardrum is ruptured, we’re going to be more careful on our pick of ear medications so we don’t cause more problems than we fix.
If your dog keeps getting ear infections and it’s been a few weeks since any antibiotics were given, I’m going to recommend a culture of the gunk be done. This grows the nasties causing the problem and checks to see what antibiotic is going to kill the bacteria. Antibiotic resistance is real. The reason the timing of antibiotics is important? Antibiotics interfere with cultures and cultures are expensive. If I’m going to spend your money, I want it to be worthwhile. We may need to do some other diagnostics depending on what we see or don’t see. Skin scrapes to look for mites buried in the skin, tissue samples if we see a mass, a CT scan if we see something behind the ear drum or the problem isn't getting better, those sorts of things.
A word on ear medications:
Oral medications usually don’t get the job done in dog ear infections. While oral amoxicillin is the go-to for ear infections in human kids, the blood supply to the dog’s external ear canal doesn’t get enough medication there to do the trick. The effective treatments are almost always topical drops and a flush to get the gunk out of the way of the ointment we’re going to put in there to treat the problem.
Most prescription ear medications have an anti-inflammatory, an anti-fungal, and an antibiotic all mixed together. There are some newer products on the market that get infused one time so you don’t need to do anything at home but they cost a lot more. Unfortunately, since shelf space is limited and ear infections aren’t a true emergency, most emergency facilities are quite limited in their choice of ear medications. There's usually only one option at the ER.
I do recommend against that purple spray you buy at the Feed and Seed as it’s quite unlikely to get deep enough to fix the problem. The only thing it really does is announce that you have horses or goats and are trying to treat something yourself. Plus, gentian violet (the active ingredient in Blu-Kote) can be toxic to the ear (most things are).
I’d also be cautious about other over-the-counter remedies for ear infections that either just hide the problem for a little bit (active ingredient: hydrocortisone like Zymox) or may be toxic to the ear (like the Ketoconazole in Dr. Gold’s Ear Therapy for Dogs) if the eardrum isn't intact.
What would I do if it were my dog?
I’d have my wife do an exam. She’s a great veterinarian (and also does general medicine so she keeps me up on the latest allergy stuff). Sadly, I don’t think she’ll agree to see you without an appointment and an exam fee and she’s already married.
And while I have an otoscope (an ear camera) at home, if you don’t know what you’re looking at and how to get there, it’s unlikely to be helpful. You’re also unlikely to be able to get the job done without at least one helper to keep the head still and perhaps a muzzle. That said, I have an Anykit Digital Otoscope with video recording capability at home. If your dog has been seen by your veterinarian in the last year, they may be willing to get on a video conference with you and prescribe some medications without a full examination. But that is veterinarian dependent and you can’t get a diagnostic swab done this way.
I’d then treat the ear with...
What’s in my fist aid kit (that I got at the store).
For suspect ear infections: (you can usually smell them)
Gloves. The ears are gross. What I’m going to get out of them is gross. Iodine will stain your hands. I’m wearing gloves. For everything.
Muzzle (depending on the dog). I always warn new staff members that a dog can still nip a finger or nose with a muzzle on but they help keep your face and arms intact.
Digital Otoscope with Video Recording (it’s also helpful for looking up the nose and finding things our five-year-old might have stuck in the Xbox).
White table vinegar and water. A 50:50 mixture (half vinegar and half water) is cheap, safe for the ear, and makes the ear canal more acidic which is a less favorable place for the bacteria and yeast to grow in the first place. I also use this periodically at home for ear maintenance but it can sting a bit if the ear is really inflamed. I fill the ear canal up, massage the liquid in, and stand back while my dog shakes her head.
Dropper bottle for the vinegar solution above: With any external ear medication, I fill the ear canal up until it’s full and squish the liquid around in there by massaging the ridge I feel just under my dog’s ear opening (it sounds like someone is chewing gum with their mouth open when I’m doing it right). I then clean up the outside of the ear and soak up some liquid with cotton balls being careful not to shove (or leave!) any cotton balls in the ear (a guarantee for a bad ear infection). Finally, I stand back as my dog flings whatever is left everywhere. Here is a good video on the process.
I do this cleaning a few times a day (every 8 to 12 hours) when there is a problem for about a week. I also use this cleaning remedy every now and then for general maintenance. If the problem keeps going on, I get the prescription medications I need (after a swab to know what I'm up against... yeast, bacteria, mites, all of the above).
In a pinch, I might consider the risk with some liquid anti-fungal (ketoconazole) containing an acidifier (lactic acid) with an anti-inflammatory (salicylic acid) like Veterinary Formula Clinical Care Ear Formula for Dogs or Dr. Gold’s Ear Therapy for Dogs, or a steroid (hydrocortisone 1% otic) like Zymox. The prescription stuff is going to work better and is safer but more expensive. I'd stick to things I find in the pet section and make sure what I'm using is for ears and not other places on the body (like Monostat).
I won't give an over the counter ear mite treatment because pyrethrins (the ingredient that works in many over the counter treatments) may cause seizures in the dog and will likely cause seizures in and may kill a cat. Dosing is tricky and there is no antidote, just expensive supportive care (much more expensive than a vet visit to get a diagnosis for a safe and effective treatment). So I avoid pyrethrins and pyrethroids. Mistakes with pyrethrins may cost your pet's life (or your retirement savings for several days of seizure control).
Hydrocortisone Ear Solution. This brings down the inflammation (your dog's going to be much less itchy and much more happy) and helps reduce something called the “biofilm” layer that keeps other medications from getting where they need to go. I'll pick some otic (fancy word for "ear stuff") solution (usually hydrocortisone) in the pet section of somewhere like tractor supply. Just remember, steroids don't treat the problem, they just hide the symptoms. Long term oral steroids can also cause their own problems. So that’s not a good answer either. "Treating" an ear infection with long term steroids and causing diabetes isn't a good trade off.
For ballon ear (aural hematoma):
An 18g needle to poke a hole in the tip of the ear (near the lowest part where the ear would normally hang down and in a part of the ear that is obviously fluid filled). Then I gently squeeze all the stuff out of the ear: thin, bloody fluid and some blood clots re normally what I get.
Sterile gauze squares. These have all sorts of uses on wound care, so they’re nice to have around.
Chlorhexidine solution. This is available over the counter at any pharmacy, Tractor Supply, and online. Concentration matters, so if I get a 4% solution like Hibiclens, I'll dilute it 50:50 (half and half) with distilled water. If I get a 2% solution like a gallon of Durvet Chlorhexidine Solution, I'm good to go!
I’m very careful to not get chlorhexidine in the ear (it’s toxic if the ear drum is torn) and especially careful to keep chlorhexidine out of the eyes (really not good for the cornea). I clean the tip of the ear where I’m going to poke it with the needle (find a good, fluid-filled, squishy spot). I wipe the chlorhexidine on with some sterile gauze squares and alternate between chlorhexidine and rubbing alcohol wipes. Let it sit for a bit (a minute or two) before poking... that's how this stuff works - contact time. A fluid-filled ear is a perfect place for a bacteria party I don’t want to encourage so keeping things clean is a really good idea .
I may alternatively consider some povidone iodine. It's less toxic if it gets in the ear with a torn eardrum but good luck getting the stain out of the carpet after letting the dog inside! Iodine also needs to sit longer to be effective than chlorhexidine. I’m impatient and my wife will be cross if I stain the couch yellow so I'm likely sticking to the chlorhexidine. And avoid the hydrogen peroxide. You may have heard some good things about anti-oxidants. Well... hydrogen peroxide is an oxidant. Keep it out of wounds (but it is good for cleaning up blood stains).
Rubbing Alcohol for use in general cleaning.
Clippers if I’m working with a dog that has particularly hairy ears. It’s hard to clean (and keep clean) an ear that is all hairy. Avoid the plucking though. That just damages and irritates the skin in the ear more (and it hurts).
Dr. Larson’s Teat Tube. While these are meant to go into an infected cow nipple, they work great for ballooned ears. I just shove the tube in the hole I made with the needle and done! The awesome thing about these is that they have a cap on them that can be unscrewed a few times a day to drain the ear as needed without my dog dribbling blood all over the place. When the ear goes back to normal, the tube just pulls out and the hole usually heals up on its own. I keep the area clean and dry with some cotton balls or those gauze squares. There are lots of ways people have tried to keep the ear empty of fluid. None of them work great. This one is cheap and easy (thanks, Dr. Kinkead!).
A no-flap ear wrap. If my dog keeps shaking her ears all over the place. It’s going to be harder (or impossible) to fix the problem. I’m always careful that it’s not too tight and that my dog can breath OK.
An E-collar. I tried talking to my dog about not scratching her ears. I found that mechanical intervention works better. And I make sure the E-collar extends a few inches past her nose to keep her paws from going where they shouldn't.
Why is it so important to keep the ears treated?
Frequent, ongoing ear problems will eventually cause permanent changes in the ear. The ear canal mineralizes and narrows, the glands produce more gunk, and the bacteria and yeast have more parties. In the worst case, the result is a self sustaining ear problem that can’t be treated medically. A veterinary surgeon takes the ear canal out. No ear canal = no ear problems. But it also means your dog can’t hear and you are out lots of dollars
What to expect after treatment?
If all goes well, the ear (and the symptoms of scratching and head shaking) get better in a few days and the ear canal is healthy again in a few weeks. This is why a recheck examination is always recommended. It’s good to get the problem fully resolved before stopping treatment so the problem doesn’t come back even harder to treat!
Unfortunately, this isn't always the end of the problem since allergies are the real cause of most ear inflammation that leads to the ear problems in first place! If treatment is needed once or twice a year, no big deal. If the problem happens more than a few times a year or your dog shows other signs of allergies (purple stains on the feet, a thinning hair coat, constantly scratching), treating the allergy is the best way to reduce the ear problems. Allergy treatment is best done through your regular veterinarian or a veterinary dermatologist. Emergency veterinarians don't keep up on this sort of thing and really aren't your best option.
If your dog had balloon ear, the ear is likely to shrivel up and not look normal again. This is because of scar tissue. There’s not much you can do about it and it looks funky but it normally doesn't bother the dog. Granted, they’re unlikely to win Grand Champion at the Westminster Dog Show, but so few of us can!
References
Bajwa J. Canine otitis externa - Treatment and complications. Can Vet J. 2019 Jan;60(1):97-99. PMID: 30651659; PMCID: PMC6294027.
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