Good evening, everybody, and welcome to tonight's webinar. My name is Bruce Stevenson and I have the honour and privilege of chairing the webinar this evening. Just a little bit of housekeeping.
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So we are very fortunate tonight, to have with us, a specialist in ears. And I know a lot of us, do worry about ears and, and the chronicity of them. So, a big welcome to Dara O'Hanlon.
From a young age, Dara was exposed to the life of a veterinary surgeon following his grandmother on calls to animals, both large and small, around the Midlands of Ireland. When the opportunity arose to join the exciting multidisciplinary team, In Nutgrove vets, Dara grasped the opportunity with both hands. Dara became an advanced veterinary practitioner in 2021 and was awarded a certificate in veterinary dermatology in 2022.
Dara enjoys all things dermatology, from ears to anal glands, with a special interest in allergies. Dara accepts dermatology referrals from all over Ireland, and in his spare time, Dara enjoys family life and is an avid Munster rugby fan. Dara, welcome to the webinar, vet, and it's over to you.
Thank you very much, Bruce for the kind introduction and thank you all of you. It's an absolute delight to join you on this fine spring evening. It's great to see the evenings getting longer.
Yes, it's absolutely true. So I'm a veterinary dermatologist with a certificate in veterinary dermatology and I'm honoured and privileged to help with animals from all over Ireland. And this evening I'm delighted to share with you, some approaches we can take to what is called malashesia otitis.
When we are talking about this with clients, we may refer to this as a yeast ear infection or something like that, or indeed an old term might have been canker. And we're going to look at two specific examples. We're going to look at acute at an acute case of malasiotiti and then our more frustrating chronic rumbling case of malathsiotitis, the type of case that might have been seen by many vets within one practise, or maybe you are seeing it as a second opinion or even a third opinion case.
During all of this, not only are we going to try and make sure that the patient remains as well as possible, but also we're going to try and keep the owner, the client as satisfied as possible. When we think about Oitus, we might look at it from the opposite way, and I'm just going to try and move forward a slide, bear with me one moment. Here we go.
Lovely. When we think of otitis, we might, appreciate that it is a common problem, and, but we might look at it at reverse. So in terms of what veterinary dermatologists, the type of advice requests that we receive from primary practitioners.
There is a great study done only a few years ago where they listed the most common advice requests received. Now for those of you with good eyesight, you'll see at the bottom that there are some very rare dermatological complaints. So things like fragile or hyperextendable skin, bullae, mucinosis, necrosis, calcinosis, cutis, these kind of things.
But interestingly, of the top 3 reasons why advice is sought of veterinary dermatologists by primary practitioners, in number 3, we have alopecia, the loss of hair. Number 2, pruritis, that sensation. Which if sufficiently strong enough, will provoke an intense desire to itch.
And number one, it is indeed otitis or ear disease. And that is not surprising. I think that I don't have to overexplain this.
We are only in Wednesday of this week, and I'd say all of us who are in clinics, we will have seen at least one otitis case this week. And this is reflected in the big data studies that we know of. So for example, the vet Compass studies that Dan O'Neill and others have done.
We know that 7.3% of all primary consultations in dogs, we are going to find otitis. Interestingly, there's an older study that suggests that owners may underreport or underappreciate otitis being present.
So we think that vets and veterinary professionals such as nurses, we are much better equipped at diagnosing this aspect of dermatological disease. So what can we expect to see? Well, when it comes to otitis, it's like all diseases, we can have mild, moderate, or chronic severe type manifestations.
And here, these, these three images will showcase very well, those type of phenotypes. So in the middle, we've got a mild case. We can see that there's some erythema or redness at the entrance to the ear canal, but the inner non-haired concave aspect of the pinna.
That appears to be relatively unaffected and we don't obviously see any discharge creeping out from the entrance to the ear canal. On the image on the left hand side. We can see that the inner non-haired concave pinna is certainly more affected.
It is erythematous. It's reddened, and we can appreciate that there is some thickening at the entrance of the ear canal, and we can see that there is some yeast poking out. And although this is not meant to be an interactive presentation.
We can almost look at the image on the right and physically smell that ear. This is a chronic severe type case. There's lichenification or drying out of the skin, fissuring of the skin at the entrance of the ear canal.
There's hyperplastic tissue at the entrance of the ear canal. The ear canal itself may well be narrower than it should be due to the level of swelling. So we are going to concentrate firstly on an acute case and we're talking specifically about a dog called Zoey.
So this Zoey was seen last summer. She's a very young cockapoo. And the owner comes in from the waiting room, and racing ahead of her is her daughter who is probably around 8, 10 years of age and is full of excitement to be in the vets.
She proudly is dragging Zoey around the consultation room and both the owner and her daughter, they are concerned that Zoey might have a right-sided ear infection. As you're listening to, to be fair, very little information coming from the mother and quite a lot of information coming from the daughter, you're surreptitiously looking through the history of Zoey and you're looking for clues as you're passing through the information coming in through one ear. And you can see that when she was very, very young, she had an episode of ear mites or otodectes cyanosis when she was around 4 months of age, one of her first visits in the clinic.
She has some gut issues, so roughly 3 to 4 times a year, she's coming in with gut issues that predominantly are diarrhoea related, sometimes some vomiting. You are hoping to get a chance to interject between the daughter's excitation and you hand her the stethoscope so she can listen to Zoey's heart and you ask the mother, listen, do you mind me asking, does Zoey swim? Mother says, well, no, not recently, but this summer now she has, or sorry, she usedn't to, but this summer she has recently started swimming.
We also know that Zoey is groomed quite fastidiously. So every 6 weeks, she goes to the groomer, and that's part of the reason that she's here during the summer evening. The the groomer was concerned that she might have had an ear infection.
So, so far we have a good idea as to what's going on. We firstly look at the apparently unaffected left ear. This is always a good idea because the affected ear might be quite painful and some dogs don't like being examined obviously in painful areas.
And what we're going to do is we're going to try and get a look at the affected right ear. So we're lifting that ear up and away, and we can just about appreciate that there is some redness. Now we might take a closer look at this image.
And what we can appreciate here is that if we use our non-dominant hand to lift that, the apex of the pin up and away, instead of the ear canal having an L shape, it's more like a 45 degree angle. So it's going to be easier to visualise the totality of that, ear canal. As the laser pointer is showing here, we have some redness at the rostrotragal entrance to the ear canal.
So that area is somewhat inflamed. And you'd be suspicious now that there, there is some inflammation, whereas the concave pin on non-haired portion is not affected at all. We're going to now start our otoscopic examination.
We want to seat the otoscope at the what's called the intragic incisor. So this is this area here that has the least nerve endings, and as we are lifting that ear canal up and away, we put the otoscope cone in and we tip forward trying to keep the otoscope cone from touching off or jangling off that sensitive lining of the ear canal. If I could give one tip, I would say try and get used to using the smallest diameter, otoscope cone.
I myself use a 3 millimetre diameter cone, and that's more than enough to get the information we need. So, what do we find? Well, we're looking down that ear canal and we can see that there is indeed this redness of the lining of the ear canal and some cerumen or wax also.
The beauty about skin, much like architecture, is that you can look at a building and you can pass comment on it. And indeed we are quite lucky. Some of our colleagues, say for example, with an interest in heart disease, they would need X-rays or an ultrasound to get an appreciation as to what's happening within the heart.
Dermatology is beautiful. The skin is right there. You just have to reach out and examine it.
So what you are noticing with Zoey. Is that there is some mild erythema or redness on the underside of the paws. When you ask the owner the question, sorry, have you noticed that Zoey is itching or licking at her paws?
The mother is adamant, no, no, not at all. The daughter is saying, oh yeah, actually recently I think she has been licking at her paws more. So you're getting a little bit more information from the daughter than the mother.
Then you're, you're asking more questions about the sensation of itch at the ears. So, is there much, are there many signs of ear disease? And again, the daughter gives you more information than the mother.
She's saying that, OK, well, I have noticed some changes. Zoey is less interested in playing. The groomers on the penultimate visit said that she got a bit fed up and she had to go home early.
And that overall she does think that Zoey is itching more at her ears over this summer as it's going on. So you're getting more and more appreciation that maybe this is longer standing than originally thought. You ask some additional questions.
So for example, with a dietary history, she is fed predominantly a complete commercial dry chicken diet. The father, sometimes is accused of feeding the dog pork products from time to time. So what have we got so far with Zoey?
Well, we know that we've got erythema, redness of the ear canal. We know we've got serumen, and this is called erythro seruminous otitis externa. This is not surprising.
This is the most common phenotype that we will see in up to 85% of patients. Interestingly, if we follow those stats, we know that we will find malahesia in nearly 4 out of 5 of these cases. We know that the microscope will also find Staphylococcus or bacteria in just over 50% of these cases.
And in just under half of these cases, we will only find malathesia itself. Now, there is another study that Excuse me, suggests that the more wax you have, the more serumen you have, the higher the chance that you will find malascasia itself. And then sometimes as well, you'll hear from experienced colleagues that, OK, well, you know, I can smell malahesia.
And to a point that is true, malathsia does release a volatile organic compound that can be detectable by the human nose. You also may have heard about, OK, well the, the wax here is much darker, so it has to be malahesia. The challenge here is that it is really important that we use cytology and the microscope to get good samples, and in that manner, we can remove the guesswork, just take out the microscope and practise some really good evidence-based medicine.
So let's do that with Zoey. We take a cotton tipped applicator, we roll it in the lining of the ear canal, we smear it onto a microscope slide, and very simply, if you're using the diff diffu system. You, dip it very quickly for 10 seconds or 10 dips in stain 12, then 3, rinse it off with tap water and then use a heat source to, blot off the excess water and then you're ready to view the sample with some immersion oil.
Now, this is what we find. We find, and if I could be so bold as to describe this image for you, some abundant ovoid to short cylindrical yeast cells with broad-based budding amongst squams or epithelial cells. I must apologise.
I did not mean for this to be a controversial topic, but for years, scientists have disagreed on what exactly we should call these organisms. So we have heard them termed peanuts, tennis shoes, snowmen, footprints, or even Russian dolls. But I think that we can all agree that these are malasthesia.
This is a yeast organism. They are lipophilic. They gravitate towards epithelial cells and serumen.
And indeed they are commensal organisms, so we should expect to find them in around 50% of normal canine ears. If we're doing our job perfectly, as we look down the microscope, we're also able to figure out some additional information. So for example, if you have a patient where we really are just dealing predominantly or exclusively with ear disease, there only are so many reasons why it is that a dog will get ear disease.
And this is important. A lot of the time the owners will get really caught up about, oh, the infection is back or you never cleared the infection the last time or this is a joke, you know, I spent 10 amount of money last time and it's not fixed. I never worry too much about the infection itself.
I do concern myself as to what is driving the inflammatory process that an opportunistic infection occurred or ensued. As someone who's done the hard work for us, there's this great study from 2007, and if it is that you just have otitis externa, we can see that there are some disease processes that are more likely. And I will jump straight to the point here.
By looking down the otoscope, we rule out a farm body. By examining the slide before we stain it, we can rule out parasites such as demodex, very rare, or otodectes cyanosis or ear mites, which can certainly you are more likely to see in a younger animal, for example. But if it is that you've ruled out foreign bodies, you've ruled out parasites, in around 75% of cases, you can be confident that allergies, whether they be environmental or food related, are responsible as a primary factor for ear disease.
So, you're trying to convey this to the owner and the client here, this is not meant to be a commentary on, say, or a reflection on veterinary bills. This is more so the client looking at your, your proposed treatment recommendations. And this is important because amidst all this, we do have to acknowledge the role of the client.
And there is this concept of treatment complexity of burden transfer. And to be very short, we need to utilise the simplest effective treatment possible. When we look at dermatological patients, the caregiver burden can be quite onerous.
So for example, if you have a well-managed allergic patient, the owner may have to check and be mindful as to which time of the year we're at in terms of what pollens are most prevalent. Maybe the patient suffers more during the winter period. They may have to use strictly adherent to diet in the case of a food allergic patient.
They may have to use topical creams, sprays, lotions, wipes, foams, etc. And they may have to use systemic medications and perhaps additional systemic medications during periods of a flare. And this is reflected in a series of studies done by Spitznagel and colleagues.
And if it is something that you're interested in, there are 3 really good papers there, talking specifically about the caregiver burden and how it is that it is in all of our interests to choose the least complex treatment possible. So We want a non-complex treatment, so what is suitable or what can we offer? Well, Let's start with the basics.
We can do ear cleaning. And here's a lovely study, admittedly around 20 years old, but this looked at patients with ear disease and the only treatment permitted was twice daily ear cleaning. And in approximately 2/3 of cases, there was no malahesia overgrowth after 2 weeks of treatment.
Now, this is reflected in national guidelines in Nordic countries or in Denmark, for example, where they would advise first line therapy of otitis with an antimicrobial ear cleaner and or topical or systemic glucocorticoids. However, keeping in mind the experience of the client. We know, for example, from this study from 2011.
This looked at owner compliance and they were comparing a medicine that was given once daily via pump into the ear and then drops given twice daily. And from this study, interestingly, only 10% of owners felt that they were compliant with twice daily medication. There's another survey, which is harder to find from 2016, and that showed that over half of owners struggle with twice daily application.
So we do know that this may, sorry, this will provide challenges for the average owner. The next question I'd have would be, OK, well, we know we've got an opportunistic ear infection, but how long do we have to treat for? Well, again, someone has done the work for us.
Here's a study from 2013, comparing the efficacy of two topical products where it was administered once daily for 5 days, for 7 days or for 14 days. And I don't think we need to delve into too much science here, but if we look at this graph, we can see that the plots of most divergence are on day 7, and I'll point an arrow here just to illustrate that point. And interestingly, they commented even in this study that if we get the opportunity to examine these patients 7 days after treatment.
That can improve success. That veterinary monitoring, the opportunity to reassess the patient, can allow us to adjust treatment depending on, say, the severity of ear disease, the response to treatment, and that will increase our likelihood of clinical cure. So a very good example would be that we may have an excessively good response and feel that maybe we do not lead.
To use systemic steroids, or it might be that we find that there's a disappointing response. We might repeat cytology and find out that hold on a second. Whereas originally we were dealing with malaesthesia, now a different population, perhaps of bacteria have taken hold.
There's another study then, which says that OK, well, 3 weeks can work, but there is a significant improvement if it is that we treat these patients for 28 days. And indeed a study only released last year shows that the meantime to resolution for otitis, it can range from anywhere from 3 weeks to much longer. Now admittedly, the top study there from 2025, it does concentrate more so on more chronic cases lasting 3 months or longer in duration.
So it probably isn't as reflective for Zoey, who is our classic acute case. So in the 2017 study, what we found was that if we have a chance to treat a patient for 28 days for 4 weeks, we're much more likely to have success. And this is what I would say to most owners, for your average opportunistic yeast ear infection, the average treatment time is 3 to 4 weeks.
So keeping all of this in mind, what kind of treatment options can we recommend to the owner in this day and age? Well, here is a list of the treatment options available. There are, there are no brand names on this table.
Instead, it is meant to illustrate the different pharmaceutical forms which predominantly are eardrops, which is the leftmost column. You will see some gels and depot depot type gels or ointments. And there is one spray there as well.
You will see that the majority of these veterinary medicinal products contain 3 ingredients. So for example, an anti-fungal, most of which are in the Azole class, antibiotics of varying degrees of potency, and then steroids again with varying degrees of potency. Generally, the heavier the colouring, the more potent the steroid is.
So for example, mometasone, an incredibly potent steroid. There's one of these products that also contains an anti-parasite medication. And generally what I would do is I would try and figure out which treatment do we need for the patient in front of us.
Now, in Zoe's case, all that we're finding is malaesthesia. We're not finding any bacteria underneath the microscope. So when we look at the current landscape of antimicrobial stewardship, when we look at the European Medicine Agencies's recommendations and categorization of antibiotics for use in animals, we can see that they have a very simple system of A, B, C, and D.
D being prudent use where we can use them in a very responsible fashion. C, we must use with caution, as in ideally after culture and sensitivity. B should be restricted use ideally under the advice of, you know, someone with increased interest in dermatology, for example, or A to be avoided at all costs because of their critical importance to human medicine.
When we whittle down this list and we look at those antibiotics that are only present in our ear medicines, we can see that the majority of these straddled between category C, use cautiously and category B, restricted use. And this is reflected in any of the national guidelines. So here in Ireland, the Veterinary Council of Ireland would advise against prudent use of antibiotics.
In Britain, you will have the Protect Me guidelines, the BSAVA, the RCVS all saying that we should employ narrow spectrum use of antibiotics. And I would argue, what is more narrow spectrum than not using antibiotics at all, if it is that we don't need to use them. And indeed this is borne out when it comes to ear infections.
We know that antibiotics are not indicated when it comes to malaesthesia and that for otitis, topical treatment is king. So if we go back to our list, what options do we have that can fulfil those criteria? Well, there is one product that only contains an anti-fungal, terbinafine, and betamethasone.
This is a targeted effective treatment. It's an otic gel that's applied on day 0 and then again on day 7, depending on the response to treatment. .
What I do like about this product is that it has a malleable nozzle, which facilitates compliance. If you have a very fractious animal, it's, I find it easy to get the nozzle into the actual ear canal itself. And then as well as that, because it does not need to be stored in the fridge, I find that there's less reactivity as it's a room temperature gel that's entering into the ear canal.
Sticking with Zoey, we chose to use that product and what we found was that in terms of treatment options, irrespective of cause, the majority of these patients will do very well if it is that they have anti-inflammatory dose of steroids. This will reduce swelling, reduce pain, it will improve patient compliance, and they also prevent some of the more chronic changes from kicking in, such as fibrosis or scar tissue or whatever you wish to call it. The doses can vary depending on who you talk to.
I myself will use anti-inflammatory dose of 0.5 mgs per kg, and you will see some dermatologists who will go with even higher doses of 1 to 2 mgs per kg per day. Keeping in mind the experience of the client, I think with all this information, we do need to be confident in our communication.
Using practise management software is excellent. You can also, and I would recommend this, veterinary nurses are exceptionally skilled, not only in terms of communication, but the ability. To perform cytology.
And I have heard of some clinics where for ear cases that are waiting in reception, a nurse will go take a sample, run it underneath the microscope, and then have the results up on the file. So then the veterinarian has a chance to interpret the results and make an appropriate diagnosis. If you're stuck on time, I'd recommend using practise management software.
Here we can see that a very common message that I would write. So this is actually, my actual typing speed. Once I did go for a temporary office job before I got into veterinary and during the typing test, You know, I was quite proud of myself.
I thought I did quite well. I said, Sir, your, your words per minute are excellent. And I thought, brilliant, I have this job.
And I said, I'm sorry, sir, but your error count is so high we can't possibly employ you. So that was the end of that. But The big thing here with the messaging we convey to the owner is that I would really highlight that word opportunistic.
So the microscope confirms an opportunistic yeast ear infection. So it puts in the mind of the owner, OK, but why did it happen? You know, what, what happened here that this infection took hold.
So it's a really important, subtle point. And as well as that, we want to assess the response to treatment at the recheck consultation. So it's totally different than saying come back in 7 days for, treatment, you know, so I think that that really does help in terms of bringing these cases further along, and that's exactly what happened with Zoey.
We see her seven days later. The mother and daughter are in great form. Zoey is looking brilliant.
You look down the ear and you find that there is an 85% response to treatment. That's exactly the kind of stat that you want to see. It's very subjective, but you want to see on average an 85% response to treatment.
As you're re-examining these patients 7 days after treatment, you also get an appreciation to find out, you know, how did the steroids work, you know, particularly if you have a dog who's living in an apartment and the, the increased urination, it might cause some issues, for example, with toileting. And if the patient is doing that well, it might give you a chance to reduce your frequency or dose of steroids. Some dogs will be incredibly painful.
So is it, is it that their form has improved? Has their behaviour improved? Occasionally I always get surprised with patients that they would have been quite snappy towards other dogs and all of a sudden they're really happy, very happy to interact with other dogs or less reactive in general.
How compliant were the owners of medications. This will help you to figure out how to work with these owners over time. You do repeat the dermatological examination as well.
You may recall that with Zoey, although unnoticed by the owner, you did notice some mild redness on the underside of the paws, and it's of great interest that that particular aspect of the dermatological examination is completely improved. So you say to him, OK, I'm going to repeat that gel treatment in that left ear, and I want to see, see the right ear, and I want to see you again in 3 weeks' time. I want to make sure that the opportunistic yeast ear infection is fixed, and more importantly, I want to see in the absence of infection, the state of the ear.
If it's a normal ear, we probably won't do anything. But if it is that the ear canal is inflamed, even though we have addressed an opportunistic ear infection, we may have to do more, i.e., do we have to commence an allergic ear disease workup?
So 3 weeks later, the owners are incredibly compliant. And you were looking at Zoey's ear and everything is looking brilliant. That ear looks absolutely fantastic.
The owners are both absolutely delighted and you are conscious that You have moved now from the late summer into the early autumn. And at least in Ireland, what happens is that we do have seasonality with our pollen seasons. So for example, in the spring, we have initially moulds, then they go away, then trees, they go away, then weeds.
Weeds stick around throughout the whole summer and early autumn, but in the middle of the summer, you have grasses that are dominant. By the time we see Zoey again, you can check the meteorological pollen forecast, but you know that the grass pollen count has gone down, but the weed pollen count has remained constant. So you are suspicious that, OK, there's a couple of different reasons why Zoey might have got this opportunistic yeast ear infection.
Possibly it is related to micro trauma from hair plucking at the groomers. Probably though, you are dealing with the first signs of seasonal allergic otitis. And in Zoe's case, what you're saying to the owners is, listen, we normally would see her for her vaccines around now, in the late summer.
But what we're going to recommend is that next year, she's going to come in to us in very early May of 2026. We're going to assess her ears before the summer season starts proper. And if there's any hint of redness or inflammation, we might start, say, with a medicated ear cleaner containing a small amount of steroid, or indeed there are steroid containing medicines.
So think of things like Resacort, for example. We might use that in a preventative type fashion. OK, now, we are going to move on to our next case.
If there are any questions on Zoey or any aspect of Zoe, there's no problem. I'm very happy to address those at the end of the presentation. Now we're going to move on to a more challenging type case.
Here we have Cookie. So Cookie is many things, but the most salient points would be that she is an older 12 year old female neuter cocker spaniel. And she is confirmed to be food allergic.
And she is one of these challenging cases. She has had chronic ear disease for nearly all her life. And it's not surprising to find that she is food allergic.
We know that otitis will affect up to 80% of food allergic patients. And indeed in her breed and Labradors, otitis might be the only clinical sign in up to 25% of food allergic patients. So we know that she is food allergic.
We know unfortunately also that she is allergic to items in the environment, such as the grasses, weeds, pollens we are talking about at the tail end of Zoe's discussion. Recently, we know that she is also allergic to the role of malathesia, so even small amounts of malaesthesia, her body cannot seemingly tolerate. She has been well managed by an allergy vaccine, the allergen-specific immunotherapy.
Through careful adherence to dietary recommendations. She receives a proprietary medicated ear cleaner. She also receives a prescription meconazole chlorhexine shampoo.
We would most commonly know this as Malaceb, although I believe Adaxio in some regions of the world is available. And then she also receives systemic prednisolone every 3rd day or so, and systemic azoles, which are to try and help with the malashesia, otitis. The challenge with Cookie is that recently her ear disease has gone out of control.
And sometimes with this breed there are some predisposing factors. So sometimes one worries with cockers that they're nearly, inbuilt ear disease will ensue. It's not strictly true.
There are some predisposing and risk factors for ear disease in this breed, so the pendulous pinna will trap in moisture and humidity. They have more wax producing glands per square inch than any other breed. And also that increased relative humidity within the ear canal, all of those things would mean that if you were unlucky enough to have allergies in this breed, The ensuing ear diseases is going to be harder to manage.
Certainly an allergic dog of this breed, it's recommended to be quite thorough in your workup. On this occasion, what's happening is that it's unusual, her ears have been at her. She was seen only 2 weeks ago and diagnosed with malashesia otitis and a long-acting polypharmacy ear medicine containing posaconazole.
So this is one of these potent antifungals of the Azole class that was used. Now that medicine should last for 4 weeks in the ear, but unusually, there's a worsening of otitis that's reported. Now there are some background issues.
The main owner is excellent at managing all of the aspects of cookie. But however, she has been holidaying recently, and there is a query as to how compliant things have been with regards to careful adherence to dietary recommendations to to the use of topicals, for example. But these are all things that you're mulling over in the back of your mind.
At the moment, you're more concentrating on trying to get cookie right. If we pause for a moment, we can look here at this lovely study from last year and what this looks at is the timeline as to how the ear may progress in these type of cases. So on the top left, you've got kind of mild erythema and exudate.
Top right, you've got moderate erythema, again, mild exudate. Then in the middle level, we've got kind of mild erythema, but severe edoema or swelling. The middle right, we've got mild erythema or redness, and then tissue hyperplasia.
Bottom left, you've got severe hyperplasia and moderate stenosis, so the ear canal is really getting narrowed. And then on the bottom right, we've got severe hyperplasia, so overgrowth of tissue within the ear canal itself, and the stenosis, the stenosis or narrowing is also quite severe. In Cookie's case, we think that we're dealing with the penultimate stage here.
So we've got this mild to moderate mural erythema or inflammation or redness of the lining of the ear canal. We've got tissue hyperplasia or seruminous hyperplasia with a cobblestone type appearance. And indeed there's no point beating around the bush here.
We do have these severe changes in Cookie's ear. Unfortunately, there is too much debris present in her ear, and we're questioning now whether anything we put in the ear will be effective due to the degree of stenosis and the sheer amount of debris within the ear canal itself. We do our due diligence.
We rule out a foreign body as best possible. We look at our slide before staining it. We do not find any evidence of Demodex or of otodectes cyanosis.
And underneath the microscope, we were expecting maybe to find bacilli or rods or cocci or round shaped bacteria, but instead all we find are malasthesia. So it remains a scape, it remains the case that we are dealing with a stubborn malasthesia otitis. So what are we going to do to try and get rid of this debris that's present in the ear?
Well, ear cleaning, that's what we need to do. And it, it's often quoted that ear cleaning is an essential part of any treatment regime. Now, the al discharge produced by otitis, so think of the wax, think of the pus, think of the blood, it's going to hamper a diagnosis, it's going to form a physical barrier between any medication we put in there and the target tissue, which is the lining of the ear canal.
It will certainly cause discomfort and it will act as a Niss for infection or indeed reinfection. Manual ear cleaning probably is only helpful for cleaning the distal third of the auditory canal or the top third of the ear canal. I will admit that I have seen plenty of veterinary nurses who are exceptionally skilled at ear cleaning, and I do believe that they will be able to be more effective in cleaning the ear canal manually.
It's not commonly used in this area of the world, in Ireland, but on the bottom right image we have what's known as a suction bulb. Now, I would be very careful in using these, especially in a case where you have a narrowed ear canal, simply because, number one, they can form a seal and the pressure when you depress the suction bulb, the ensuing air can rupture the tympanic membrane if there's nowhere for the air to escape. As well as that, there's a study that shows that roughly 12% of the suction bulbs can be contaminated with pseudomonas, so they're very hard to keep clean.
On the left image we have what's called a rhino ear washer. This is a human product that's relatively inexpensive. I think that it's always a good idea to mention ear cleaning, and I do remember in particular, clients who would have initial reservations, but then they see just how effective ear cleaning is and how impactful it is to the patient.
Now, that's all well and good, but what ear cleaners should we be thinking of? So again, someone who's done the hard work for us, we just have to look at the data. So here's a fantastic study from 2013, and it looked at admittedly the in vitro antimicrobial activity of these ear cleaners against malaesthesia.
So, in short, the greater the zone of inhibition, so the more red you see at the top of the graph, the better it is in vitro against malashesia. So you can see some commonly used ear cleaners here, so things like malacetic, otody, these kind of products, serum oral to a certain degree, but certainly malacetic, those kind of products will have a greater zone of inhibition. Now there are some limitations to this study.
So for example, the serumen and exudate present in the ear canal will dilute topicals, and it is noted that there were no dilutions in this study. In addition, in that study, there was a contact time with the plate of 48 hours, and that probably is longer than any ear cleaner we use is going to remain at an active concentration in the ear canal itself. I think the big thing here is that there is this beautiful study done in only 2021 and it looked at malasio otitis cases that were unresponsive to primary care.
And it was a study looking at nearly 60 animals admittedly from a referral hospital. But 91% of these cases responded to a simple ear flush. So, in short, if we were to take away the most salient data from this study, if you've got a maesthesiotiis case that's lingering for 3 months, if you've got maesthesiotiis that's occurring more than 3 to 4 times a year, it is definitely a good idea to offer an ear flush under anaesthesia.
Now admittedly, this study, they were using things like otoendoscopy, which does allow for a more thorough type ear flush right down to the level of the tympanic membrane. Over half of the breeds in that study were cockers and retrievers, and within a month of ear flushing, these guys were, certainly clinically cured or coming close to it. Now you still had to do some work afterwards, which we're going to come on to.
87% of those patients, by the, by the way, only needed one ear flush. That's how impactful it was. And it's interesting, I, you know, I think we're all probably of the same mind when we're trying to convey this information to owners.
We are also mindful. As to, you know, the perception of cost, maybe some concerns about, possibly, the use of anaesthesia, but I do remember distinctly, starting, my recommendation for an ear flush, and the owner stopped me and said, oh, I was hoping you'd recommend that. I said, I hope you don't mind, but usually I do have to explain more the benefits versus the risks of this procedure.
He said, you didn't have to say anything. I myself suffer from ear disease and I begged my GP to flush my ears. It's the only thing that gives me relief.
So it certainly is something that is probably under-recognized, the type of transformative impact it can have on these patients and indeed the direction that they are going. So That's exactly what we did with Cookie and you can just see how much debris is present. You unfortunately can see as well just what level of ear disease we're dealing with.
So we did remove all of this debris before administering any ear medication. We're trying to remove any physical barrier between the medication again and that target tissue. We were concerned about the recent use of posaconazole and our ongoing use of Azoles in general, and we then decided to go back to our list of products and we wanted to move away from the Azole class and we went for terbinafine, which again is contained in that more targeted veterinary medicinal product.
We did use it off licence. So we did use it on a weekly basis for 4 separate treatments. Here is the ear canal after some thorough cleaning, we just needed to dry it after that point.
You will see that there still is stenosis, there still is seruminous hyperplasia, glandular hyperplasia, glandular dilation, epithelial hyperplasia, edoema. So this is still not a simple ear, but, after drying out this ear, we applied the turbinaffeine betamethasone product again in an off-license fashion with a good response to treatment. Now, Where do we go in these patients to try and make sure we don't slip backwards.
So we don't want one step forward, two steps back. And we all would have seen cases like Cookie. These are the challenging cases.
These sometimes are the reasons why it is that clients will change, practise because of frustrations with chronic ongoing management of skin or ear disease. So in terms of ongoing management of maesthesiotitis. There's a study here from 2023 and in short, what they did was they compared using a positive, or sorry, the positive control in this product was a polypharmacy ear medicine.
And then the, what they were comparing that medicine to was a steroid containing ear spray solution. And what they found was that the otitis scores were equivocal after one month of treatment. So in short, we know that ears.
Allergic ears, chronic allergic ear disease, malasiotitis, they will do better if it is that we use steroids topically. Now in terms of putting a finer point of that, a more recent study looked at using steroids in chronic ear disease. .
In of great interest is that for ears previously affected by maesthesiotitis, they were 79% less likely to develop new infectious episodes. So to rephrase that, 79% of ears treated with topical steroids, where the previous problem was maesthesiotiti, remained in clinical remission. And this is significant considering these are recurrent otitis cases of greater than one year duration.
The treatment, and you'll hate this answer, this is a classic dermatology answer. The treatment frequency, it depends. So if you had like the average treatment frequency was putting steroids into the ear every 1 to 7 days, in very good cases, it was every 14 days, but generally it's between that time frame of usually every 3 to 14 days, depending on how severe the case is.
So this approach is particularly effective for chronic malashesia otitis. It is somewhat effective for chronic bacterial otitis. Hot off the press is whether or not there is a role for diet in these cases.
So this study was only performed last year. They enrolled patients who had allergic skin disease, who were proven to be non-food allergic, who had erythroceruminous otitis, so the type of ear disease that we saw with Zoey. And their otitis had to be in remission before starting the study.
The test diet had, in short, increased fatty acids and the control diet was a routine commercial diet. Now, although the study does note that the otitis incidence was less in the test group versus the control group, it was not statistically significant. So I struggle to make that recommendation to owners.
I think it might help to a very small percentage, but I would be mindful that it's not to, to a statistically significant degree. So, what do we do with Cookie? Well, very much so, it depends.
We are going to redouble our efforts regarding diet. There is a suspicion that maybe that is one of the things that lapsed as Cookie is getting older. Maybe some of these things are getting relaxed in terms of strict adherence to to dietary recommendations.
We're gonna maintain the use of the allergen-specific immunotherapy or the allergy vaccine because we think that things will be worse in its absence. We're going to change the topical steroid. We had been using a medicated ear cleaner, and there is a slight concern or query as to whether or not that was macerating the ear canal, so whether or not it was adding too much moisture to the moisture to the ear canal.
So we're going to change to a simpler topical steroid containing either triamcinolone or hydrocortisone. So for example, Resacort contains triamcinolone. We're going to add in cyclosporine because after 1 month or 4 to 6 weeks, it does have great anti-inflammatory capability, which would be a bonus.
We are going to increase the frequency of veterinary recheck appointments. We had been seeing Cookie roughly every 6 months, but we're going to try and see her now every 3 months to stay on top of things and try and act in a more preventative rather than reactive type fashion. There were concerns with Cookie as to whether or not we were seeing truly an azole resistance.
So we are all well aware of antibiotic resistance in this, again, age of antimicrobial stewardship, but we should not forget. That, anti-fungal resistance is possible. It is not reported that widely.
There are studies and case reports of same, and we did work closely with the local laboratory and because we were concerned that we were dealing with a nasal resistance. There is a question about whether or not we should be doing surgery on these ears, like they are so chronically affected and they are so close to end stage that it is a reasonable discussion. The possible role of JAK inhibitors, so these be medicines like short acting anti-itch medicines.
The challenge with JAK inhibitors is that they seem to have some limitations when it comes to managing allergic ear disease. So for example, for the original JAK inhibitor, it was of great interest that In its regulatory studies, there was an increased incidence of otitis in the treatment group rather than the control group. So it sometimes it there are some limitations to its effectiveness, specific for ears.
Again, there are other medicines like these long acting monoclonal anti-IL 31 cytokine antibody, injections, and they would similarly have some limitations. We think that there might be a different cytokine profile when it comes to allergic ear disease. The next thing you may say, OK, well, I feel well equipped, but like, what do I do if these cases really escape me?
Well, certainly the greater the duration of ear disease, then the poorer the outcomes will be, and certainly if you've got dogs with otitis for more than 6 months, the prognosis will be poorer. There is another concept which is the rule of 3, so if you have 3 visits for ear disease and you don't feel you're getting anywhere, then that's equally a good time to consider referral to someone with increased interest in dermatology. Sometimes as well, you'll have patients where you really are dealing with autophobia or otalgia, that concept of pain in the ear, and again, I'm happy to take pains on either of those topics.
And, but that might be a reason that a patient is referred. And then again, there is the access to those additional, treatments and investigations. So for example, a full allergic workup, potentially looking at novel treatments or atypical use of treatments.
And it's important to remember that, you know, 80% of dogs with allergies, they actually get worse or more challenging or they progress throughout life. And so it is something that we need to put in place a plan so that we can help to manage these cases on an ongoing basis. Here's an example of biofilm, that would be another reason for a referral in terms of using biofilm busting agents if you're unfamiliar with their use.
The additional investigations that may be deployed will be things like auto endoscopy, and that affords increased light magnification. And indeed sometimes it's required to make a meringotomy or to make an incision into the ear, into the eardrum to gain access to the middle ear. Investigating for primary and perpetuating factors, equally important.
And I would note that unfortunately, when you look at cockers like Cookie, they are 24 times more likely to require surgical removal of the ear canal than any other breed. So they are certainly more challenging patients. Just to recap, we know that otitis is the most common complaint in dogs, and we know that it's often missed by the client and also as veterinary professionals, we are incredibly well placed to comment on the health status of ears.
We don't worry about ear infections. Owners will worry about ear infections. We know that they don't occur by themselves.
There must be an underlying cause or causes. It's interesting when you go back to that 202007 study. 32%, nearly one third of otitis ear disease cases, they did not have the primary factor factors identified.
So we need to work really, really hard as clinicians to find those, but For the average case where you're dealing predominantly with ear disease, we know that the majority of those cases, if you rule out foreign bodies, if you rule out parasites, you can say with a huge degree of confidence, 75% certainty that you're dealing with allergic ear disease. And as always, the microscope will help to figure out what type of treatments are going to be of most benefit to the patient. Specific for anesthesio Titus.
When you're dealing with your acute case, get the diagnosis right with your microscope, treat appropriately, repeat your exam after 7 days. Most of these cases will benefit from systemic steroids as well. And then 4 weeks after initial treatment, reassess the patient, make sure the opportunistic yeast and ear infection is gone.
And if it is that there's any persistent inflammation or signs of allergic ear disease, work with the owners either with managing the allergic ear, so we talked about the use of topical steroids, or potentially embarking upon further investigations. We know that for example, ear disease will affect. And up to 80% of dogs with food allergies.
If it is that we are dealing with our more chronic type case. So we have either a case that's rumbling for more than 3 months or it's getting more than 3 to 4 opportunistic yeast ear infections per year. Then certainly we know that 79% of these guys will do really well if it is that we can get on top of the opportunistic yeast ear infection, but then manage them with topical steroids on an ongoing basis.
And if it is that you have those cases that are just really tricky to manage, they just keep coming back. Don't be afraid to offer an ear flush. 91% of cases will respond well to an ear flush.
87% of those will respond well to just one simple ear flush. In terms of resources that I find useful, you have the World Association for Veterinary Dermatology with two excellent webinars from Rod Rossachchuk on otitis externa. You've got an excellent book by Sue Patterson and Richard Harvey, which, although only 168 pages long, is packed full of pragmatic, actionable knowledge.
You've got a meteor book from Got Health, and then you've got Decker Academy. I am active on social media in terms of short form, content as well. And I'm delighted to take any questions that you may have now.
Thank you very much. Dara, that was absolutely fascinating. I, I cannot thank you enough for chatting to us about this and, to highlighting the benefits of, of cleaning.
It's, it's incredible how many people miss that simple, yet essential part of Oitu. So thank you to you for your time and sharing your, your expertise with us. Also, a big thank you once again to our sponsors, DECR.
Without them, we wouldn't be able to bring you this webinar, so thank you to DECR. We have loads of questions, as was expected. Oh Titus is, the big bogeyman that, so many people worry about.
I, I'm going to paraphrase a lot of them because a lot of them have a similar theme. The first one that is recurring and and stands out to me is the difference between the use of topical and systemic. And the questions are topical systemic steroids, topical systemic antibiotics, topical systemic anti-fungals.
You your presentation focused on on all the topical stuff. Do you ever reach for systemic drugs besides steroids? It's a great point, and a great question.
My preference would be for topical above all else, and certainly I have found myself propelling myself more and more towards embracing topicals more and more. As I gain more experience. That being said, I think for the average maesthesia otitis case, they will benefit at least initially from systemic steroids.
Again, usually at that dose of 0.5 mgs per kg is what I find useful. In terms of other systemics that I would use, I at this point, incredibly rarely will use Systemic antibiotics, and, and I know we're talking about maesthesiotitis, but really the only indication for that with ear disease would be if you had middle ear disease and you had sampled bacteria from the middle ear itself.
So that would be one reason to use, systemic antibiotics for ear disease. Generally you can reach such huge concentrations within the ear canal itself of Your active substance of choice, whether it is an anti-yeast medicine or an antibiotic that we shouldn't need to worry about. Using anything systemically.
I will acknowledge that there are some cases of what's known as a maesthesia hypersensitivity. So cookie is one of those cases. They are challenging cases.
They are exceptionally rare. They are not common, and generally how you find out those cases is one of three ways. Either A, it is that you are looking down the microscope, you're seeing an incredibly inflamed ear, but all you find are very scant numbers of malathesia.
So it's almost like the punishment doesn't fit the crime. Now if it's a bit arbitrary this, but if you kept on finding that very low numbers of yeast, yet disproportionately. High levels of inflammation, it may well be that you're dealing with a malaesthesia, hypersensitivity, or a yeast allergy, and this is a challenging one because yeast are designed to be on dogs, you know, they're, they're increased in concentration in the glabrous regions, in the ears, in the lip folds.
So it's almost like you are about to announce that this dog is allergic to itself. You could also find that same information indirectly through either a skin test where you find that the malahesia extract. Caused histamine release and a reaction on your intradermal test or similarly you might find it on the serology, the blood test.
Excellent, excellent. Speaking of testing and that sort of thing, there's a couple of questions come through about, doing culture anti-biogram. You've, you've touched on ear smears and looking at them under the microscope with Diffu and everything else, but do you use, swabs for culture and sensitivity, and in what indications?
Another great question. So you will find that dermatologists will differ in their opinions of this. I think if you always do your cytology first, if it is that you are only finding yeast, there is little point in sending off a sample to a lab because it's only going to tell you what you already know, which is that you're dealing with malahesia, pachydermatis.
And then you just need to choose an anti-fungal topically, and you should have success. Now again, you'll still have to search for the primary cause for yeast overgrowing in the first place. It is.
Possible, sorry, Bruce, you might remind me of that question again. The taking swabs for culture and sensitivity. Yeah, the, the one reason that you might, do culture and sensitivity is if you say, for example, you saw that there were cockeye and malahesia, you treated with a polypharmacy product, and then unusually you still find cockeye.
It could be that you are dealing with a resistant population and it might be that for example the florphenacol that is in the product that you chose, maybe those cockey have resistance against florphenacol so that would be a reason to perhaps look at At doing cultural sensitivity. The main reason, to be honest with you, in, in real life, in your classic cases that you will see is that, say for example, you found that there were rods underneath the microscope. You did an ear flush.
You chose a topical product that maybe contains something like gentamicin, which usually would work against most rods. And next thing you saw it again, and it was almost like there wasn't a good response, then certainly we should be looking at submitting a sample to a laboratory. We must keep in mind that the laboratories are not infallible.
There is a great study showing that when you send off pseudomonas to three separate laboratories, that, you will get, you won't get absolute agreement between the three laboratories. So really, I would say concentrate on your cytology, treat what you see in front of you first, and really reserve culture and sensitivity if it is that you've got a challenging case that's escaping you, you have persistent rods, maybe you've taken rods from the middle ear, then certainly it would be a good idea to culture and sensitivity. Yeah, so, so use them as a, a specialised tool rather than just a blind gunshot with a shotgun, in, into trying to figure out what's going on.
Loads of other questions coming through as well about the ear cleaner, which ear cleaner you prefer, and then about adding steroids to ear cleaners and or to other ear products, and sort of almost like a a a compounded ear product rather than a a a commercial one. Yeah, another great question, Bruce, and it's really great to see those coming through. There are many ear cleaners that you can use.
So for example, you have, generally you want one that will have, good activity against microbes, including yeast and bacteria, good drying out activity because say for example, you've got a Labrador who keeps jumping in and swimming and you're worried that it's over macerating the ear canal. Generally they have some type of alcohol in them to try and help dry out the ear canal afterwards. It merits its own topic nearly in terms of what ear cleaners are available, but some commonly used ones will be things like Tris chlor, otody, epiotic, any of those tend to be good all-rounders in that they do lots of jobs very, very well.
In terms of what steroids you can add to them, . That Sue Patterson book that I referred to certainly has some really good recipes in it, in terms of what you may add, but generally what most vets will do is that they will add a certain amount of, say, dexamethasone, which is a potent steroid, and in terms of, I think you asked a question as well about like how long it might last for or the compounding effects. We do have to be careful.
There are studies looking at this, looking at how long dexamethasone will remain, stable for, and generally the thought process is that after 3 months, it starts to degrade in its effectiveness, but it doesn't become any less safe or anything like that. I would also acknowledge that depending on where you are practising, you may be limited by the regulations. So for example, it might be that you might have to first use a veterinary medicinal product and then use a proprietary medicated ear cleaner.
So again, there are some products that will contain hydrocortisone, so these come in either a spray or a kind of a pump type product, or you might use a product that contains triamcinolone. And also contains salicylic acids. This is more commonly known as resort.
The benefit of that would be that, if it is that you had an ear that was a moist type ear, the salicylic acid would help to dry out that ear quite a lot as well. Yeah, yeah. And remember to talk to the owner, let them get them on board with you and, if you need to use your off-license consent forms.
Yeah. Dara, we could carry on all night. This is a fantastic topic, lots of great questions, but unfortunately, we have run out of time.
So, thank you, Dara, for your time and your knowledge and sharing with us tonight, and thank you again to DECRA for sponsoring this webinar. We would love to have you back on again, talking more about skin. We know that it's a topic that a lot of vets battle with and scares the daylights out of most of our colleagues.
That's brilliant. Well, thank you so much, Bruce. It's been an absolute pleasure.
Folks, thank you for your attendance tonight. I hope you enjoyed that as much as I did, and, you got as much benefit out of it as what I did. To my controller, Becca in the background, thank you for making things work nicely, and from myself, Bruce Stevenson, it's good night.
