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GETTING THE BEST RESULTS TREATMENT OF CANINE OTITIS

EXTERNAROYAL CANIN DERMATOLOGY MONTH: OCTOBER 2016

DEBBIE SIMPSON FANZCVS (VETERINARY DERMATOLOGY)

09 216 6222 THETEAM@THESKINVET.CO.NZ

THANKS!

• TO ROYAL CANIN FOR MAKING THESE DERMATOLOGY WEBINARS POSSIBLE

• THE WEBINARS ARE FOR BOTH VETS & VET NURSES – GREAT TO HAVE NURSES INVOLVED

• THANKS TO DR STEPHEN WHITE & DR DANIELLE HOOLAHAN FOR MANY PHOTOGRAPHS

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OTITIS EXTERNA

• VERY COMMON IN DOGS – UP TO 20% OF DOGS CAN BE AFFECTED

• ANY AGE, SEX OR BREED

• SOME BREEDS ARE AT INCREASED RISK – PREDISPOSING FACTORS

• SOME BREEDS OF DOG (LONG HAIRED) HAVE MORE GLAND TISSUE IN THEIR EARS

• – LONG HAIRED BREEDS CAN GET MORE OTITIS PROBLEMS

• COCKER SPANIELS HAVE MORE HAIR FOLLICLES IN HORIZONTAL CANAL THAN OTHER DOGS

• SHAR PEIS HAVE VERY NARROW EAR CANALS

HOW DO WE KNOW A DOG HAS EAR INFECTION?

• HEAD SHAKING

• REDNESS

• SCRATCHING

• DISCHARGE

• CARRYING THE EARS IN AN ABNORMAL POSITION

• OTHER DOGS LICKING THE EARS

• AURAL HAEMATOMA OR BLEEDING EAR TIPS

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DOES THIS DOG HAVE EAR INFECTION?HORNERS SYNDROME

ANATOMY & PHYSIOLOGY

• THE EARS ARE MADE UP OF THE EXTERNAL EAR CANAL, MIDDLE EAR AND INNER EAR

• THE EXTERNAL EAR CANAL IS L – SHAPED AND HAS A VERTICAL & HORIZONTAL PART

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ANATOMY & PHYSIOLOGY

• AT THE END OF THE CANAL IS THE EARDRUM, BEYOND THAT IS THE MIDDLE EAR

• THIS CONNECTS TO THE INNER EAR WHERE THE NERVES ARE FOR HEARING & BALANCE

ANATOMY & PHYSIOLOGY

• IF THE DOG HAS NEUROLOGICAL SIGNS LIKE NYSTAGMUS OR HEAD TILT

• OR SIGNS OF FACIAL NERVE INVOLVEMENT EG DROOPING EYELID & LIP ON ONE SIDE

• THE MIDDLE EAR OR AREA AROUND THE EAR CANAL CAN BE INVOLVED

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FACIAL NERVE

• FACIAL NERVE CROSSES THROUGH THE MIDDLE EAR

• THEN LEAVES SKULL JUST BEHIND THE EAR OPENING

• IF MIDDLE EAR PROBLEM CAN HAVE REDUCED LACRIMATION (TEAR PRODUCTION)

• FACIAL NERVE IS MOTOR TO MUSCLES OF FACIAL EXPRESSION

• PROBLEMS AFFECT THE MUSCLES OF EARS, EYELIDS, NOSE, CHEEKS AND LIPS

• CAN MEAN CANT CLOSE EYELIDS PROPERLY ESPECIALLY LOWER EYELID,

• OTHER SIGNS ARE A PARALYSED OR DROPPED EAR & LIP

IS IT OTITIS EXTERNA OR MEDIA OR BOTH?

• WHY IS THAT IMPORTANT? CHOICE OF MEDICATION, HOW SEVERE DISEASE COULD BE…

• HOW CAN YOU TELL IF FACIAL NERVE / MIDDLE EAR INVOLVED?

• CLINICAL SIGNS = DEAFNESS, HEAD TILT, NYSTAGMUS, CIRCLING, ATAXIA, HORNERS

• LOSS OF BALANCE AND OR HEARING

• WHAT IMAGING DO YOU HAVE AVAILABLE?

• RADIOGRAPHY, VIDEO OTOSCOPE, CT, MRI

• GOOD TO THINK ABOUT WHETHER MIDDLE EAR INVOLVED OR NOT

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IMAGING TO LOOK AT MIDDLE EAR

LOOKING AT THE EAR

• SOME DOGS DO NOT LIKE THEIR EARS BEING EXAMINED – USE A MUZZLE OR SEDATION

• CAN BE VERY HARD TO KNOW IF THE EARDRUM IS INTACT OR NOT

• IMPORTANT TO KNOW AS SOME MEDICATION SHOULD NOT BE USED IF NO EARDRUM

• EVEN IF DOG IS PERFECTLY BEHAVED & STILL IT CAN STILL BE HARD TO TELL IF TM INTACT

• ONLY DEFINITE WAY IS WITH EAR FLUSHING

• VIDEO OTOSCOPE HELPS A LOT – IF YOURE NOT SURE, OR CANT SEE

• YOU CAN REFER

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VIDEO OTOSCOPE

VIDEO OTOSCOPE

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VIDEO OTOSCOPE

• LOOKING FOR NORMAL MOVEMENT OF EARDRUM WITH FLUSHING

• CAN POKE LIGHTLY& FLUSH TO SEE IF WHITE SURFACE IS EARDRUM OR DEBRIS

• IF AIR BUBBLES COME UP FROM MIDDLE EAR THERE IS A TEAR IN THE EARDRUM

• IF FLUID COMES OUT THE NOSE THERE IS A TEAR IN THE EARDRUM

• IF YOU CAN SEE THE BONE OF THE MIDDLE EAR THERE IS NO EARDRUM

WHERE DO YOU START?

• SO A DOG HAS COME TO YOU WITH AN EAR INFECTION – WHERE TO START?

• HAVING A LOOK DOWN THE EAR IS IMPORTANT

• NEED TO KNOW IF THERE IS SOMETHING DOWN THERE LIKE A GRASS SEED OR TUMOUR

• NEED TO KNOW IF THE EAR DRUM IS INTACT OR NOT

• GUIDES YOUR CHOICE OF MEDICATION

• SO IF THE DOG IS TOO WRIGGLY OR AGGRESSIVE - SEDATION

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POLL QUESTION – IS THIS CYSTIC STRUCTURE NORMAL?

YES - PARS FLACCIDA IS NORMAL

• SOMETIMES MISTAKEN FOR MASS OR POLYP

• BULGES WITH INCREASED MIDDLE EAR PRESSURE?

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WHAT SHOULD YOU SEE?

Pars flaccida

Manubriumof the Malleus

Pars tensa

ROSTRALCAUDAL

WHAT DO YOU ACTUALLY SEE?

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CANT TELL HOW LONG A PLUG OF WAX IS…

• OR IF THERE IS ANYTHING BEHIND IT, OR IF THE EARDRUM IS INTACT OR NOT

WARN THE OWNER

• IF YOU CANT SEE THE EARDRUM, OFFER TO FLUSH THE EAR

• IF THEY JUST WANT TO TRY MEDICATION FIRST, EXPLAIN IF DRUM IS RUPTURED

• MEDICATION CAN GET INTO THE MIDDLE EAR

• IF THEY SEE HEAD TILT, ATAXIA, NYSTAGMUS, CIRCLING, LOSS OF BALANCE OR HEARING

• DON’T JUST CONTINUE GIVING DROPS

• STOP THE DROPS AND LET YOU KNOW

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HOW DO YOU TREAT OTITIS?

• CYTOLOGY IS CRITICAL – TAKE A COTTON TIP AND TAKE A SAMPLE FROM BOTH EARS

• ROLL IT OUT GENTLY ON A SLIDE

• SOME PEOPLE DO ONE SLIDE FOR EACH EAR

• SOME PEOPLE WRITE L AND R WITH THE EXUDATE

• I ALWAYS HAVE THE FROSTED PART ON THE LEFT AND LEFT EAR ON LEFT & RIGHT ON RIGHT

• USE DIFF QUIK TO STAIN THEM

• LOOK UNDER MICROSCOPE

POLL QUESTION

• WOULD YOU TAKE AN EAR CULTURE SWAB FOR CULTURE & SENSITIVITY FOR A FIRST TIME EAR

INFECTION WITH MIXED BACTERIA AND YEAST SEEN ON CYTOLOGY AND NO OTITIS MEDIA?

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SHOULD I TAKE AN EAR CULTURE?

• PROBABLY NOT AS A FIRST STEP

• CYTOLOGY IS MORE IMPORTANT

• CULTURE TELLS YOU WHAT GROWS WELL IN THE LABORATORY

• CYTOLOGY ON THE DAY TELLS YOU WHAT TYPE OF MICRO-ORGANISM IS DOWN THERE

• IF ITS EAR MITES, LOOKING WILL TELL YOU THE PROBLEM

• IF ITS DEMODEX A CULTURE WILL NOT BE VERY HELPFUL

• CYTOLOGY WILL TELL YOU THE PROPORTION OF RODS, COCCI, BACTERIA & NEUTROPHILS

OTODECTES CYNOTIS

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WHAT ARE THE PROBLEMS WITH EAR CULTURES?

• SENSITIVITY TELLS YOU WHETHER THE LEVEL OF DRUG ACHIEVED IN THE BLOOD IS EFFECTIVE

• WE ARENT TRYING TO TREAT THE BACTERIA OR YEAST WITH AN ORAL MEDICATION

• WE ARE PUTTING IT DIRECTLY DOWN THE EAR ON TOP OF THE BACTERIA

• THE LEVELS OF MEDICATION ACHIEVED ARE FAR HIGHER THAN IN THE BLOOD

• MOST OF THE TIME A DRUG WILL WORK EVEN IF THE SENSITIVITY PANEL SAYS RESISTANT

2010 NAVDF ABSTRACT DAVID ROBSON

• PROSPECTIVE DOUBLE BLINDED STUDY – PURPOSE TO COMPARE CLINICAL RESPONSE TO

EMPIRICALLY SELECTED EARDROPS WITH RESPONSE PREDICTED BY CULTURE & SENSITIVITY

• 16 DOGS WITH RODS IDENTIFIED ON CYTOLOGY AS PREDOMINANT MICRO-ORGANISM

• TOPICAL & STEROID TREATMENT SELECTED ON BASIS OF CYTOLOGY & CLINICAL EXAM ONLY

• NO SYSTEMIC ANTIBIOTICS WERE USED

• PSEUDOMONAS WAS ISOLATED FROM ALL CASES, EITHER PURE OR MIXED WITH OTHER BUGS

• 10/16 DOGS TESTED RESISTANT TO DROPS HOWEVER 8 OF THESE RESPONDED ANYWAY

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PITFALLS OF CULTURE & SENSITIVITY

• 2004 STUDY – GRAHAM MIZE & ROSSER

• TWO SAMPLES TAKEN FROM THE SAME EAR AND SENT TO THE SAME LABORATORY

• 20% GREW DIFFERENT MICRO-ORGANISMS

• 20% GREW THE SAME MICRO-ORGANISMS BUT REPORTED DIFFERENT SENSITIVITIES

• ONLY 60% GREW THE SAME BUGS WITH THE SAME SENSITIVITIES

• THEREFORE CAN YOU TRUST THE REPORT?

WHY ARE NEUTROPHILS IMPORTANT

• GUIDES YOUR CHOICE OF MEDICATION

• AMINOGLYCOSIDES DO NOT WORK WELL IN THE PRESENCE OF NEUTROPHILS

• IF THERE IS LOTS OF PUS (NEUTROPHILS) DON’T CHOOSE AMINOGLYCOSIDES!

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WHAT ELSE CAN YOU TELL FROM CYTOLOGY?

• IS IT A PURE GROWTH OF JUST ONE THING?

• IF YES, IT MIGHT BE MORE PATHOGENIC/HARDER TO TREAT

• IF A WHOLE LOT OF MIXED BACTERIA AND YEAST PROBABLY NOT JUST ONE PATHOGEN

CHOOSE AN APPROPRIATE MEDICATION

• COCCI, RODS, NEUTROPHILS, YEAST, DEMODEX, EAR MITES

• RECHECK IN 2 WEEKS

• IF THERE IS A LOT OF PUS, USE PREDNISONE (UNLESS MEDICAL REASON NOT TO)

• DECREASES THE NEUTROPHILS

• DECREASES PAIN AND SWELLING

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MEDICATION: GLUCOCORTICOIDS

• ANTI-PRURITIC, ANTI-INFLAMMATORY

• DECREASE SEBACEOUS AND APOCRINE GLAND SECRETIONS

• VERY USEFUL, WHICH IS WHY THEY ARE IN MOST EAR DROPS

• CAN USE THEM BY THEMSELVES IF THE ONLY PROBLEM IS NEUTROPHILS

• TRYING TO TREAT JUST ALLERGIC OR CERUMINOUS OTITIS

• CORTAVANCE CAN BE USEFUL TO DRY THE EARS & SETTLE INFLAMMATION

• OFF LABEL, NEED TO CHECK EARDRUMS ARE INTACT AS OTOTOXIC IF TMS COMPROMISED

EAR CLEANERS

• DON’T HAVE A GREAT SELECTION IN NEW ZEALAND

• PARTICULARLY SHORT ON GOOD CERUMINOLYTIC AGENTS

• EPIOTIC CAN BE USEFUL, BUT CAN ALSO MACERATE THE EARS IF OVER USED

• ALPHA EAR CLEANER IS GOOD IF THE DOG SWIMS TO DRY EARS AFTERWARDS

• AGAIN NEED TO MAKE SURE THE EAR DRUMS ARE INTACT AS NOT MIDDLE EAR SAFE

• SAME PRINCIPLE AS HUMANS USING DRYING AGENTS AFTER SWIMMING IF SWIM A LOT

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DO I NEED A SYSTEMIC ANTIBIOTIC?

• NOT USUALLY

• NOT VERY GOOD PENETRATION TO EAR CANAL

• HAS TO GO FROM GUT INTO BLOODSTREAM AND THEN ALL THE WAY BACK TO EAR CANAL

• NOT VERY EFFECTIVE

• MUCH BETTER TO USE TOPICALS AS THEY ARE IN HIGHER CONCENTRATION WHERE APPLIED

• DON’T AFFECT THE REST OF THE BODY

• EXCEPTIONS – MIDDLE EAR DISEASE, INFECTION OUTSIDE THE EAR CANAL AS WELL EG PINNA

WHAT ABOUT A SYSTEMIC ANTIFUNGAL?

• CAN BE USEFUL

• AZOLES METABOLISED VIA THE SKIN

• GET QUITE HIGH LEVELS IN EAR CANAL

• BUT STILL NOT AS GOOD AS A TOPICAL DROP

• MIGHT USE IT IF CANT PUT A COMMERCIAL ANTI-FUNGAL DOWN DUE TO NO TM

• OPTIMUS CAN COMPOUND TOPICAL ANTIFUNGALS THAT ARE MIDDLE EAR SAFE

• NEED TO WARN OWNERS ABOUT POSSIBLE LIVER TOXICITY OF AZOLES

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WHAT ABOUT MALASEB IN THE EARS?

• THIS WAS USED WHEN THERE WEREN’T VERY MANY OTHER OPTIONS

• MALASEB IS A GREAT ANTIFUNGAL

• BUT IT IS QUITE IRRITANT TO THE EAR AND THE DOG WILL PROBABLY HATE IT

• IT IS DEFINITELY OTOTOXIC IF THE EARDRUM IS RUPTURED, IT IS OFF LABEL

• IT WILL MAKE THE EAR VERY RED, WET AND MACERATED

• THERE ARE MUCH BETTER THINGS TO USE NOW

• I WOULD NOT USE IT IN EARS BUT I DO USE IT ALL THE TIME FOR FEET AND SKIN

SHOW THE OWNER HOW TO PUT DROPS IN

• GIVE A MEASUREMENT AND SOME SYRINGES

• HOW CAN YOU TELL HOW MANY DROPS ARE COMING OUT IF THE NOZZLE IS IN THE EAR?

• TEACH THEM NOT TO PUT THE WHOLE SYRINGE DOWN THE EAR

• CAUSES ULCERATION, HURTS THE DOG

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WHAT VOLUME OF DROPS SHOULD I USE?

• USE YOUR JUDGEMENT BASED ON SIZE OF EAR CANAL AND IF SWOLLEN CLOSED OR NOT

• AROUND 0.4 – 0.5MLS FOR A CAT OR SMALL DOG EG SHIH TSU

• ALSO AROUND 0.5MLSOR LESS FOR A DOG WITH NARROW EAR CANALS DUE TO DISEASE

• 0.75MLS FOR A MEDIUM SIZED DOG EG KELPIE

• 1ML FOR A 30-50KG DOG EG LABRADOR

• 1.5MLS IN A GREAT DANE

RECHECK IN 2 WEEKS

• ASK THEM IF THEY HAVE ANY MEDICATION LEFT

• WILL LET YOU KNOW IF THEY HAVE GIVEN IT OR NOT

• LOOK DOWN THE EAR

• TAKE ANOTHER CYTOLOGY SAMPLE

• ASK ABOUT THE CLINICAL SIGNS

• IF IT IS NORMAL SCHEDULE A RECHECK FOR A FEW MONTHS LATER

• TELL THE OWNER TO CALL IF THEY NOTICE ANY SIGNS OF A PROBLEM

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WHAT IF THE EAR DISEASE COMES BACK?

• THIS IS WHEN YOU NEED TO THINK HARDER ABOUT WHY IT HAPPENED IN THE FIRST PLACE

DID THE OWNER PUT THE DROPS IN?

• IF THEY STILL HAVE MOST OF THE BOTTLE LEFT, NOT SURPRISING THE EARS ARENT BETTER

• MAYBE THEY TRIED TO PUT IT IN BUT THE DOG RESISTED OR THEY MISSED THE EAR

• GET THEM TO SHOW YOU THEIR TECHNIQUE

• BE REASSURING – MOST OWNERS HAVE NO IDEA AND DON’T LIKE BEING WATCHED!

• REASSURE THEM THEY ARE DOING WELL AND GIVE THEM SOME POINTERS

• SEE IF THEY CAN GET SOMEONE TO HELP HOLD THE DOG

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WHY DO DOGS GET EAR INFECTIONS?

• PRIMARY, SECONDARY & PERPETUATING CAUSES

• PRIMARY CAUSES ARE THOSE THAT CAN CREATE DISEASE IN A NORMAL EAR

• IF IT IS A FIRST TIME OTITIS THE BASIC QUESTIONS I THINK ABOUT ARE

• IS THERE SOMETHING DOWN THERE?

• - GETTING THE EARS WET (SWIMMING OR GROOMING)

• - ARE THE EARS BEING PLUCKED?

• ARE THERE ANY OTHER SKIN PROBLEMS? POTENTIAL ALLERGIES ETC

ANATOMY & PHYSIOLOGY

• WITH CHRONIC DISEASE THE EARS CAN PHYSICALLY CHANGE – GET NARROWER, CALCIFY

• SEBACEOUS GLANDS AT ENTRANCE TO EAR & IN VERTICAL CANAL

• APOCRINE (CERUMINOUS GLANDS) DEEPER IN DERMIS & ADJACENT TO TYMPANUM

• IN THE HEALTHY EAR MOST CERUMEN (WAX) IS MADE BY THE SEBACEOUS GLANDS

• IN THE DISEASED EAR MOST CERUMEN (WAX) IS MADE BY THE CERUMINOUS GLANDS

• THE CERUMINOUS GLAND WAX IS MORE ACIDIC TO TRY AND KILL OFF BACTERIA

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PRIMARY CAUSES

• PRIMARY CAUSES ARE THOSE THAT CAN START AN EAR INFECTION ON THEIR OWN

• IF YOU CAN IDENTIFY AND TREAT THEM YOU MIGHT FIX THE EAR DISEASE

• MAIN ONES ARE

• - ALLERGIES (FOOD, ATOPIC DERMATITIS)

• - FOREIGN BODIES (PLANT MATERIAL, INSECTS)

• - INFECTIOUS (RINGWORM, ASPERGILLUS, DEMODEX, EAR MITES, TICKS)

PRIMARY CAUSES: MORE UNUSUAL ONES

• EPITHELIALISATION DISORDERS

• (SEBORRHOEA, SEBACEOUS ADENITIS, ZINC RESPONSIVE DERMATOSIS)

• IF A HUSKY, THINK ABOUT ZINC RESPONSIVE DERMATOSIS

• GLANDULAR DISORDERS (SEBACEOUS GLAND HYPER OR HYPOPLASIA)

• AUTO-IMMUNE (BULLOUS PEMPHIGOID, PEMPHIGUS FOLIACEUS)

• ENDOCRINE DISEASE (CUSHINGS, HYPOTHYROIDISM)

• IF SIGNS OF ENDOCRINE DISEASE, WORK UP FURTHER

• IMMUNE MEDIATED (DRUG REACTION, VASCULITIS)

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THINK ABOUT BREED EG GOLDEN RETRIEVER…

• DOES IT LIKE SWIMMING?

• ANY SIGNS OF HYPOTHYROIDISM EG LETHARGY, HEAT SEEKING, RECURRENT PYODERMA

• ANY OTHER SIGNS OF ALLERGIES EG FOOT LICKING, RASH IN GROIN?

CASE STUDY: MILO

• 5 YEAR OLD MALE NEUTERED SPOODLE

• SUCH PAINFUL EARS WE COULD NOT USE THE OTOSCOPE TO LOOK CONSCIOUS

• NERVOUS, WHINING, DEFENSIVE, HAS LEARNED THAT EARS CAN HURT IF TOUCHED

• ONGOING PROBLEM FOR A FEW YEARS, RIGHT EAR WORSE THAN LEFT

• TREATMENT SEEMS TO FIX THE PROBLEM THEN IT COMES BACK

• FIRST STEP – CLEAN THE EARS AND HAVE A LOOK UNDER GENERAL ANAESTHESIA

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VIDEO OTOSCOPE

MILO

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MILO EAR FLUSH

• CRITICAL INFORMATION – BOTH EAR DRUMS INTACT

• DURING THE EAR FLUSH THE DRUMS MOVED NORMALLY

• NO FLUID WAS SEEN TO EXIT THE NOSTRILS

• NO AIR BUBBLES CAME UP THROUGH THE SALINE

• MEANS WE ARE FREE TO USE ANY EARDROP WE WANT

MILO EAR CYTOLOGY

• RODS YEAST & NEUTROPHILS RIGHT EAR AND YEAST ONLY IN THE LEFT EAR

• EXPLAINS WHY RIGHT EAR SO MUCH MORE ULCERATED & INFLAMED

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CHOICE OF MEDICATION

• AURIZON FOR LEFT EAR AND OTOFLUSH FOLLOWED BY AURIZON FOR RIGHT EAR

• WHY DID I CHOOSE OTOFLUSH FOR THE RIGHT EAR?

• BECAUSE THERE WERE RODS DOWN THERE

• RODS CAN BE HARD TO TREAT

• TRIS EDTA OR OTOFLUSH PRETREATS THE RODS AND MAKES IT EASIER TO KILL THEM

OTOFLUSH

• HOW DOES IT WORK?

• CHANGES THE PH IN THE EAR, MAKES IT MORE ALKALINE

• AMINOGLYCOSIDES & FLUOROQUINOLONES ARE MORE EFFECTIVE AT ALKALINE PH

• CHELATES METALS WHICH ARE PART OF THE BACTERIAL CELL MEMBRANE

• PSEUDOMONAS USES A CALCIUM MEDIATED EFFLUX PUMP TO PUMP OUT DRUGS

• TRIS EDTA BLOCKS THIS PUMP

• MEANS ROD CELL MEMBRANES ARE PERFORATED AND OTHER DRUGS CAN GET IN

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WHAT OTHER DRUGS

• SYSTEMIC PREDNISOLONE – REDUCES INFLAMMATION

• DECREASES THE NUMBERS OF NEUTROPHILS

• MAKES THE DOG MORE COMFORTABLE

• WHAT DID I NOT CHOOSE DUE TO THE PRESENCE OF NEUTROPHILS

MILO 2 WEEKS LATER

• MUCH HAPPIER & MORE COMFORTABLE

• STARTED SHAKING HIS HEAD AGAIN WHEN THE EARDROPS FINISHED

• ON QUESTIONING GOES TO GROOMER & SWIMS IN ORAKEI BASIN

• SUGGESTED AVOID SWIMMING AND MAKE SURE EARS DON’T GET WET AT GROOMER

• EARS STILL CLEAN BUT RED, NO MICRO-ORGANISMS ON CYTOLOGY

• ORAL PREDNISONE AND EARDROPS GIVEN AS DIRECTED

• GOOD COMPLIANCE

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SO IS THAT IT?

• NO, YOU DEFINITELY NEED TO RECHECK ESPECIALLY IF THERE ARE STILL PROBLEMS

• EG HEADSHAKING AND RED EARS

• DECREASE PREDNISONE TO EVERY OTHER DAY, KEEP EARS DRY

• DECREASE DROP FREQUENCY TO TWICE WEEKLY

• RECHECK IN A MONTH

• LUCKILY VERY NICE AND COMMITTED OWNERS

A MONTH LATER

• BEEN FOLLOWING INSTRUCTIONS PERFECTLY – NO SWIMMING, MEDICATION ALL GIVEN

• LOOK DOWN EARS – LEFT EAR PERFECT AND EARDRUM SEEN

• RIGHT EAR BUILDING UP WAX AGAIN

• CYTOLOGY OF LEFT EAR NOTHING, RIGHT EAR NEUTROPHILS & A FEW COCCI

• TREAT WITH PREDNISONE AND EARDROPS IN RIGHT EAR ONLY

• THINK ABOUT WHAT ELSE COULD BE TRIGGERING THE PROBLEM…

• OWNERS MENTION HE HAS ALWAYS HAD A SENSITIVE STOMACH & PRONE TO GI SIGNS

• START DIET TRIAL WITH ROYAL CANIN ANALALLERGENIC

• RECHECK IN 6 WEEKS

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A MONTH LATER

• FINALLY BOTH EARS PERFECT

• EARDRUMS SEEN

• NO HEADSHAKING

POLL QUESTION

• WHAT PERCENTAGE OF FOOD ALLERGIC DOGS HAVE OTITIS AS THE ONLY CLINICAL SIGN?

• 10%

• 20-25%

• 50%

• 80%

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ALLERGY & EARS

• BILATERAL EAR PRURITUS & OTITIS EXTERNA OCCURS IN +/- 80% OF FOOD ALLERGIC DOGS

• IT CAN BE THE ONLY CLINICAL SIGN IN 20 – 25% OF DOGS

• MAKES IT VERY HARD TO MONITOR A FOOD TRIAL IF EARS ARE THE ONLY SIGN

• MUCH EASIER IF THEY ARE ALSO LICKING FEET, SCOOTING AND GETTING RASHES ETC

• THEN THE OWNERS CAN TELL IF THEY ARE RELAPSING WHEN DIET CHANGED

• ATOPIC DOGS ALSO HAVE OTITIS EXTERNA IN 50-80% OF CASES

• IT IS THE ONLY CLINICAL SIGN IN 10-20% OF ATOPIC DOGS

SECONDARY & PERPETUATING CAUSES

• DO NOT CAUSE DISEASE BY THEMSELVES BUT DO PERPETUATE THE PROBLEM

• NEED TO TREAT THESE CAUSES TO RESOLVE THE OTITIS EXTERNA

• EXAMPLES INCLUDE

• - BACTERIA

• - FUNGI OR YEAST

• - OTITIS MEDIA

• - CHRONIC CANAL CHANGES EG HYPERPLASIA

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COMMON BACTERIA

• STAPHYLOCOCCUS PSEUDINTERMEDIUS

• STREPTOCOCCI

• PSEUDOMONAS

• PROTEUS

• CORYNEBACTERIUM

YEAST & FUNGI

• MALASSEZIA COMMON SECONDARY INFECTION, CAN SEE A FEW IN NORMAL EARS

• HOW MANY IS NORMAL?

• AROUND ONE YEAST PER FIVE HIGH POWER FIELDS (X 100)

• CAN SEE ASPERGILLUS AND DERMATOPHYTES

• ARE THESE IMPORTANT OR CONTAMINANTS?

• LOOK AT CYTOLOGY RATHER THAN JUST RELYING ON CULTURE, LOOK AT REST OF ANIMAL

• STILL THE SAME PRINCIPLES – CLEAN THE EAR, TREAT WHAT YOU SEE, RECHECK

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NO OTHER PATHOGENS, RESPONDED TO TREATMENT

HOW DO I MAXIMISE THE CHANCE OF SUCCESS?

• LOOK PROPERLY, SEDATE OR MUZZLE IF YOU CANT EXAMINE

• DO CYTOLOGY

• CHOOSE THE RIGHT MEDICATION

• CONSIDER PAIN RELIEF IF EARS ARE SORE – PREDNISONE, CODEINE, TEMGESIC

• RECHECK WITHIN A WEEK OR TWO

• IF IT IS RECURRENT THINK ABOUT WHY, AND TREAT THE UNDERLYING CAUSE

• MIGHT NEED REFERRAL FOR FURTHER IMAGING OR EAR FLUSHING

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IS EVERY EAR INFECTION TREATABLE?

• NO – AND MANAGING OWNER EXPECTATIONS IS VERY IMPORTANT

• IF THE EARS HAVE HAD CHRONIC INFECTION FOR 10 YEARS & CANALS HAVE TURNED TO BONE

• MEDICAL MANAGEMENT IS NOT REALISTIC

• OWNERS GENERALLY DO NOT LIKE THE IDEA OF SURGERY

• BUT SOMETIMES IT REALLY IS THE BEST OPTION

• IF I SEE AN EAR LIKE THIS I WILL MENTION SURGERY

• GIVE PREDNISONE AT 1MG/KG FOR A WEEK A TRY

• IF NO LUCK, SURGERY IS GOING TO BE THE BEST OPTION

CAN RUPTURED EARDRUMS HEAL?

• YES, AND THEY USUALLY DO WITHIN A MONTH IF THEY ARE GOING TO…

• CAN A DOG STILL HEAR IF THE EARDRUM IS RUPTURED – USUALLY YES.

• IS A RUPTURED EARDRUM A REASON FOR SURGERY – NO

• YOU JUST NEED TO BE VERY CAREFUL WITH MEDICATION

• MIDDLE EAR SAFE DROPS INCLUDE OTOFLUSH AND COMPOUNDED DROPS

• NO COMMERCIAL ONES ARE SAFE, IE NOT AURIZON, OTOMAX, SUROLAN, DERMOTIC

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MIDDLE EAR SAFE EARDROPS

• DISCUSS WITH COMPOUNDING CHEMIST EG OPTIMUS

• FOR YEAST KETOCONAZOLE SOLUTIONS WITH SQUALENE CAN BE VERY GOOD BUT EXPENSIVE

• FOR BACTERIA BAYTRIL AND SALINE OR METHOPT

• EG 2% KETOCONAZOLE; 1.5% ENROFLOXACIN; 0.05% DEXAMETHASONE IN SQUALENE OR

METHOPT. THE COLLOID PRESSURE FROM THE METHOPT MAY REDUCE MACERATION.

• BAYTRIL & DEXAMETHASONE CAN MAKE YOURSELF – OF COURSE ALL OFF LABEL

• 2MLS DEX 5MG/ML; 3MLS BAYTRIL 50MG/ML & 5MLS SALINE

• WATCH OUT FOR OVER-WETTING /MACERATION AND YEAST OVERGROWTH IF NO ANTIFUNGAL

QUESTIONS?