Dermatology , Diagnostics

Otitis Externa Series Part 1: Diagnosis of Otitis Externa

Otitis Externa Series Part 1: Diagnosis of Otitis Externa
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Ashley Bourgeois, DVM, and Wayne Rosenkrantz, DVM, Diplomate ACVD

This article—the first of a 2-part series—discusses diagnosis of otitis externa. Topical therapy for treatment of otitis externa will be discussed in the November/December 2014 issue of Today’s Veterinary Practice (tvpjournal.com).

Otitis externa is a prevalent complaint in patients presented to small animal practices. This inflammatory disease of the external ear canal and/or pinna can have an acute or chronic presentation. Management of otitis externa depends on identifying and treating predisposing and perpetuating factors, as well as primary and secondary causes (Table 1).

Table 1. Common Predisposing Factors, Primary & Secondary Causes, & Perpetuating Factors of Otitis Externa
PREDISPOSING FACTORS PRIMARY CAUSES SECONDARY CAUSES PERPETUATING FACTORS
  • Abnormal external ear canal and pinna conformation, such as congenital stenosis
  • Excessive moisture within ear canal
  • Adverse effects from previous treatments, such as topical reactions
  • Atopic dermatitis (Figures 1 and 2)
  • Food allergy (Figures 3 and 4)
  • Epithelialization disorders, such as seborrhea (Figures 5 and 6)
  • Metabolic disorders, such as hypothyroidism
  • Neoplasia
  • Yeast overgrowth (Figures 1 and 2)
  • Bacterial overgrowth (Figures 3 through 6)
  • Ear canal/pinna fibrosis and stenosis (Figure 7)
  • Calcification of tissues
  • Neoplasia (polyps, tumors, cysts) (Figure 8)

 

Figure 1- Atopic dermatitis with malassezia otitis externa

Figure 1. Atopic dermatitis with Malassezia otitis externa.

Figure 2- Malassezia cytology from dog in Figure 1

Figure 2. Malassezia cytology from dog in Figure 1.

Figure 3- Adverse food reaction with mixed bacterial otitis externa

Figure 3. Adverse food reaction with mixed bacterial otitis externa.

Figure 4- Mixed bacterial cytology from dog in figure 3

Figure 4. Mixed bacterial cytology from dog in Figure 3.

Figure 5- Cocker seborrhea with Pseudomonas otitis externa. JPG

Figure 5- Cocker seborrhea with Pseudomonas otitis externa.

Figure 6- Pseudomonas cytology from dog in Figure 5

Figure 6. Pseudomonas cytology from dog in Figure 5.

Figure 7- Chronic proliferative otitis externa from atopic dermatitis

Figure 7. Chronic proliferative otitis externa due to atopic dermatitis.

Figure 8- Ceruminous gland cyst causing obstructive otitis externa

Figure 8. Ceruminous gland cyst causing obstructive otitis externa.

FACTORS & CAUSES

Predisposing Factors

Predisposing factors alone do not cause otitis externa, but increase risk for development and persistence of chronic infection. These factors work in conjunction with primary or secondary causes, allowing otitis externa to become a significant problem.

Primary Causes

Primary causes of otitis externa are the inciting agent or etiology that directly damages the ear canal’s epithelium, resulting in subsequent inflammation. To prevent recurrent episodes of otitis externa, it is critical that a primary cause be diagnosed and managed.

Secondary Causes 
Secondary causes of otitis externa do not create pathology in a healthy ear; instead, they incite disease in ears affected by a primary cause or predisposing factor. If the inciting cause or factor is inadequately controlled, secondary causes, such as bacterial or yeast overgrowth, typically become chronic issues.

Perpetuating Factors

Perpetuating factors are changes in anatomy and physiology of the ear that occur in response to otitis externa. They are most commonly seen in chronic cases and are not disease specific. These factors can accentuate development of secondary infections by providing environments and microscopic niches that favor their persistence.

In severe cases, perpetuating factors can ultimately prevent the resolution of otitis externa by leading to irreversible changes of the ear canal. They are the most common reason that otitis externa fails to respond to medical therapy and, ultimately, requires surgical intervention.

DIAGNOSTIC TESTING

Diagnostic testing begins with a minimum database of:

  • Detailed history
  • Physical examination
  • Ear canal cytology.

Cytology

Cytologic examination of ear canal discharge provides a brief overview of the aural environment, providing a foundation for therapeutic decisions and advanced diagnostics.1,2It is also the primary tool in identifying bacterial or yeast overgrowth.

Initial cytology should be performed prior to bacterial culture and sensitivity (C/S) testing because bacterial C/S is not recommended if only yeast overgrowth is noted. See In Practice: External Ear Canal Cytology for a stepwise approach to cytologic sample collection.

In Practice: External Ear Canal Cytology

  1. Carefully insert an applicator tip in the ear canal and, near the junction of the vertical and horizontal canals, collect material for cytologic examination.
  2. Collect deeper, and generally more representative, samples by passing an ear loop or pediatric feeding tube through an otoscopic cone.
  3. Transfer samples onto a glass slide, heat fix, and stain with Diff-Quik.
  4. When examining samples under the microscope, note the:
    • Number of bacteria and yeast per oil immersion field (100×)
    • Presence or absence of inflammatory cells.


Culture & Sensitivity

Indications for C/S include:

  • Suppurative inflammation (including that with bacterial rods, cocci, or no visible organisms) revealed during initial cytology
  • Lack of response to appropriate topical and systemic antibiotic therapy
  • Systemic therapy required for otitis media or deeper, soft-tissue infections of ear canal
  • Resistant strains of bacteria suspected.

Resistant bacteria should be suspected if:

  • History of chronic topical therapy
  • Rods observed on cytology
  • Bacteria persistent on cytologic examination despite appropriate therapy (ie, suspect methicillin-resistant Staphylococcus pseudintermedius).

Ideally, topical or systemic antibiotic therapy should be discontinued 3 to 5 days prior to acquisition of culture samples.

Laboratory Submission

When preparing the sample for submission, include any pertinent information regarding the organisms seen on cytology and a representative cytology slide.

In addition, if rods are observed on cytology—suggesting the presence of Pseudomonasspecies—additional antibiotic sensitivities should be requested with bacterial culture, including:

  • Polymyxin B
  • Ticarcillin
  • Third-generation cephalosporin.

Once the laboratory report is in hand, in addition to susceptibility, it is important to review the reported minimum inhibitory concentration, which helps direct the choice or dose of antibiotic required.

Middle Ear & External Ear Canal Bacterial Spectrums

The spectrum of bacteria and their sensitivity patterns seen in the middle ear (which is lined with ciliated columnar epithelium) and external ear canal (which is lined with epidermis) may differ due to variations in cellular composition. In a study by Cole and colleagues, different strains of Pseudomonas species, based on sensitivity pattern, were cultured from each location.3 Other studies have shown different strains of a bacterial species from a single sampling site.4,5

DIAGNOSTIC IMAGING 

Otoscopy

In addition to detailed history, physical examination, and ear canal cytology, otoscopy is part of a diagnostic minimum database, and can diagnose several conditions that create deeper ear canal disease (Table 2).

Table 2. Diagnostic Imaging for Ear Disease
IMAGING MODALITY EAR DISEASE/CONDITION EVALUATED 
Otoscopy Identifies:
  • Canal proliferation, masses, foreign bodies
  • Ruptured tympanic membrane
  • Changes in integrity and density of tympanic membrane
  • Large bulging pars flaccida, suggesting primary secretory otitis media (seen in cavalier King Charles spaniels)8
Radiography Detects bony involvement of bullae; has limited value in soft tissue changes, especially in acute cases
Computed axial tomography Aids in differentiation of bony lesions in the bullae from soft tissue reactions
Magnetic resonance imaging Aids in visualizing middle and inner ear and detects presence of fluids, such as endolymph within the cochlea and semicircular canals
Ultrasonography Detects fluid within the tympanic bullae

Otoscopes must have a strong light and power source, combined with at least 10× magnification that allows focusing within the normal length of the ear canal. Avoid using a battery-operated otoscope that has significantly lost power and light, which results in a diminished view of the deep ear canal.

Either a traditional diagnostic otoscope or surgical otoscope head may be used. The benefits of surgical otoscopes include, in certain cases:

  • Enhanced manipulation and angulation within the ear canal
  • Passage of tubes or other instruments into the ear canal with concurrent visualization.

Various sizes of otoscopic cones are required to properly examine ear canals based on patient size.

In Practice: Ear Cleaning & Flushing

  1. Patient restraint is often required for thorough otoscopic examination; sedation or general anesthesia may be required.
  2. For client education and medical documentation, take an initial photograph prior to cleaning and then one after the procedure for comparison.
  3. Use a handheld otoscope to determine the severity of disease and type and amount of debris in the external ear canal.
  4. Use a combination of cleaning techniques to facilitate more rapid and effective removal of debris from the canals (Table 3):
    • Utilize forceps and ear curettes through a handheld otoscope head to remove larger debris.
    • After large debris is removed, typically a bulb and/or tube is used for flushing, with or without ceruminolytics (see Common Ceruminolytics).
    • Consider FVEO for deeper cleaning and evaluation of the ear canal. Deeper therapeutic flushes can be especially beneficial in cases of otitis externa with biofilm-producing organisms, such as Pseudomonas species (Figure 6), in which manual removal of debris is essential.9 Utilize a 5F feeding tube, cut to the appropriate size for the patient, for deep flushing and suctioning through the FVEO port.
  5. If necessary, aspirate a sample of debris from the deeper ear canal, as well as the middle ear if the tympanic membrane is ruptured, for both cytologic examination and C/S testing. Use the FVEO port for passage of biopsy forceps or an appropriately modified ear curette.
Table 3. Additional Equipment for Diagnostic or Therapeutic Procedures
USE EQUIPMENT
COLLECTION OF SAMPLES
Break up concretions and remove small pieces of cerumen, debris, or foreign bodies
  • Ear curettes or loops (especially useful for material located near the tympanic membrane)
Collect large samples for histopathology
  • Large forceps that can pass through the handheld otoscope
Collect smaller samples for histopathology
  • Narrow alligator or biopsy forceps
  • Smaller diameter forceps that can pass through the FVEO port
Collect cytology samples from middle ear
  • Long, thin needles that can be passed through the otoscope cone and reach the deep ear canal (eg, 22-gauge spinal tap needles)
FLUSHING OF EAR CANALS
Initial flushing of ear canals
  • Bulb syringes and cleaning solutions
Flushing of ear canals
  • Tomcat catheters or infant feeding tubes
Deep flushing through handheld otoscope or FVEO
  • Feeding tubes trimmed down to allow better manual control but long enough to reach the deep ear canal (eg, 5F, 8F, and 10F)
Aggressive, deep ear flushingprocedures that allow consistent fluid availability
  • Intravenous tubing and 3-way stopcocks
  • FVEO units with continuous flushing and suction options
THERAPEUTIC PROCEDURES
Intralesional injections
Myringotomy
  • Long, thin needles (see Collection of Samples)
Myringotomy
  • Tomcat catheters, if the tip is cut at a sharp angle

If you encounter any problems related to use of FVEO, refer to Table 4.

General anesthesia is preferred for more aggressive flushing procedures, as placement of an endotracheal tube avoids aspiration of fluids (ie, those that may pass through a ruptured tympanic membrane into the middle ear, through the auditory canal, and into the posterior pharynx). For greatest safety, inflate the endotracheal tube cuff and pack the pharynx with gauze, which is removed prior to anesthetic recovery.

Table 4. Common Problems with FVEO Use & Possible Solutions
PROBLEM POSSIBLE SOLUTION
Lens fogging Remove the probe and clean tip
Use defogging solution
Obstruction of lens with debris Warm probe tip in water
Wipe the lens with a cotton ball soaked in 70% isopropyl alcohol or a defogging solution
Decreased magnification & visualization Flush with water or saline during use

Common Ceruminolytics

Ceruminolytics help break down larger pieces of waxy debris, such as ceruminoliths, and are gentle and soothing to the epithelium of the ear canal.

  • Squalene Urea peroxide
  • Carbamide peroxide
  • Hexamethyl tetracosane
  • Dioctyl sodium/calcium sulfosuccinate
  • Triethanolamine polypeptide elite condensate

Fiberoptic Video-Enhanced Otoscopy

Advancement of fiberoptics, improved lighting, and miniaturization of video cameras, combined with rigid endoscopy, has led to development of fiberoptic video-enhanced otoscopy (FVEO). FVEO, despite its expense to purchase and maintain, is extremely beneficial for improved diagnostics, therapy, and client education.

The camera within the fiberoptic tip significantly magnifies and improves visualization of the ear canal. FVEO also facilitates permanent recordings via picture or video of the ear canal—including debris, foreign bodies, and masses—which can be shared with clients and other veterinarians.

Compared with handheld otoscopy, FVEO allows:

  • Thorough flushing with water or saline, providing better visualization and magnification
  • Observation of fine details, such as small tears of the tympanic membrane, consequently recognized as air bubbles extruding from the middle ear cavity through the tympanic membrane.

Additional Imaging

In chronic otitis cases, the following imaging techniques may be helpful diagnostic tools. Table 2 lists these additional imaging modalities as well as the types of conditions they can diagnose and evaluate. However, the cost and availability of these diagnostics may make them prohibitive for some clients.

Computed tomography (CT) and magnetic resonance imaging (MRI) have been shown to be more reliable and accurate than radiography.6 CT is most commonly used due to efficiency and expense; however, if soft tissue masses or vestibular disease is suspected, MRI is more accurate. In one study, diagnosis of otitis media by CT was found to have an 86% sensitivity and 89% specificity compared with the gold standard of histopathologic diagnosis.6

Ultrasound has been used for the detection of fluid within the tympanic bulla, with 80% to 100% sensitivity and 74% to 100% specificity compared with the gold standard of CT.7

EAR CLEANING & FLUSHING

Cleaning and flushing the ears is critical for:

  • Proper visualization and examination of ear canal
  • Determination of disease extent
  • Indications for additional diagnostics and case management
  • Determination of disease resolution.

See In Practice: Ear Cleaning & Flushing for a stepwise description of appropriate cleaning and flushing. Typically, patients can be maintained with once to twice weekly flushing, but frequency of flushing should be determined on a case-by-case basis.

SUMMARY

Otitis externa is a multifactorial inflammatory disease of the ear canals and pinnae that may become chronic. Chronicity is usually due to inadequate control of the primary cause or the presence of a perpetuating factor. Detection of a primary cause and any perpetuating and predisposing factors is essential for complete resolution and prevention of recurrence of otitis externa.

Identification of infectious organisms through cytology is an essential first step for initial treatment. Thorough ear cleaning and flushing coupled with appropriate antimicrobials, based on C/S when necessary, enhance treatment success.

C/S = culture and sensitivity; CT = computed tomography; FVEO = fiberoptic video-enhanced otoscopy; MRI = magnetic resonance imaging

References

  1. Ginel PF, Lucena R, Rodriguez J, Ortega J. A semiquantitative cytological examination of normal and pathological samples from the external ear canal of dogs and cats. Vet Dermatol 2002; 13(3):151-156.
  2. Tater K, Scott D, Miller W, Erb H. The cytology of the external ear canal in the normal dog and cat. J Vet Med A Physiol Pathol Clin Med 2003; 50(7):370-374.
  3. Cole L, Kwochka K, Kowalski J, Hillier A. Microbial flora and antimicrobial susceptibility patterns of isolated pathogens from the horizontal ear canal and middle ear in dogs with otitis media. JAVMA1998; 212(4):534-538.
  4. Schick A, Angus JC, Coyner K. Variability of laboratory identification and antibiotic susceptibility reporting of Pseudomonas spp. isolates from dogs with chronic otitis externa. Vet Dermatol 2007; 18(2):120-126.
  5. Graham-Mize C, Rosser E Jr. Comparison of microbial isolates and susceptibility patterns from the external ear canal of dogs with otitis externa. JAAHA 2004; 40(2):102-108.
  6. Rohleder J, Jones J, Duncan R, et al. Comparative performance of radiography and computed tomography in the diagnosis of middle ear disease in 31 dogs. Vet Radiol Ultrasound 2006; 47(1):45-52.
  7. Doust R, King A, Hammond G, et al. Assessment of middle ear disease in the dog: A comparison of diagnostic imaging modalities. J Small Anim Pract 2007; 48(4):188-192.
  8. Cole LK. Primary secretory otitis media in Cavalier King Charles Spaniels. Vet Clin Small Anim Pract N Am 2012; 42(6):1137-1142.
  9. Pye C, Yu A, Weese J. Evaluation of biofilm production by Pseudomonas aeruginosa from canine ears and the impact of biofilm on antimicrobial susceptibility in vitro. Vet Dermatol 2013; 24(4):446-449.

F01_bAshley Bourgeois, DVM, recently completed her residency at Animal Dermatology Clinic in Tustin, California. She has served as education chair with the American College of Veterinary Dermatology (ACVD). She received her DVM from University of Missouri and completed a small animal internship at Purdue University.

F01_cWayne Rosenkrantz, DVM, Diplomate ACVD, is co-founder of Animal Dermatology Clinic. He is a clinical instructor for Western Veterinary Medicine College and an instructor for European School of Advanced Veterinary Studies. He is past president of the ACVD and a board member of the World Association for Veterinary Dermatology. He received his DVM from University of California—Davis.

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>Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Réunion' >Réunion</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' 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