Thank you for that kind introduction. I'm feeling sorry for you guys over there in the more northern parts of the world. I'm sitting here and it's 40 degrees, that's 40 °C, not 40 °F.
So I'm sweating, and if I happen to drip on the keyboard and things stop, we will have to somehow have the technical gurus get it working again. But it's a pleasure to speak to you about, you know, one of the commonest problems we have, in general practise, and certainly I spent a long time in general practise before going into referral dermatology. And one of the things I always did struggle with was the ear case that kept bouncing from vet to vet with a frustrated owner and an uncomfortable pet and The question that arises is, well, why does that happen?
And so I've come up with this perhaps formulative, lecture talking about 5 common mistakes that we as veterinarians make when we're managing canine Oto external. I'm leaving the cats are even harder, but fortunately cats much less to deal with. So why is Otata such a challenge?
You know, it's really common. We see it all the time, and 95 times out of a. And everything's fine.
But often those cases come back. And the owner says, Oh, well I'll just put some more drops in. But, sometimes that doesn't work and the cases get worse and worse.
And the question is, well, how do you go from a straightforward case that's no challenge, not causing anyone any stress to the cases that really the disaster that everyone wants to again, as Mandy said, hide in the back room and hope that your colleagues are going to deal with. And we as vets do contribute to this, you know, our actions or our lack of actions send a message to the clients. You know, if we don't treat this seriously at the beginning, then why would the owners think that this needs to be treated seriously?
We do things that cause the pet's pain and so therefore they're less likely to want to let, you know, the, the vet look down their ear the next time. And this becomes a negative feedback loop that we pay the penalty for down the track when we have the straightforward case of otitis, you know you can treat well, but, The pet's not gonna cooperate. So I've brought them down into sort of 5 big mistakes.
The first one is trusting owners. Now, you know, you do have to trust owners and take on faith what they're telling you, but, you know, as they say, trust but verify, you know, owners are not necessarily the best person to tell you if the otitis externer has resolved completely. They can tell you if the dog stops shaking their head, they can tell you if the dog stops scratching in his ears.
But you'll get some owners that Assess the dog based on their previous experience. So they'll tell you it's great, but when you look down the ear, it's red and inflamed and uncomfortable, and you're seeing the dog clicking his ear in the consult room, but from the owner's experience, it's so much better than it was before. And they're telling you what they truly believe.
But it's actually not the truth. So you do have to do your own checks, and you know, sometimes your colleagues can lead you up the garden path as well. The second issue.
It's forgetting that there's a dog attached to those ears. You know, sometimes we're so busy focusing on the bugs and the inflamed ears that we forget the dog and the dog does have an effect. You know If we make it uncomfortable, we cause the dog anxiety, then further treatments become harder and harder.
The third mistake is we tend to focus on the microorganisms only. You know, we'll find the bug, we'll find bacteria, we'll find malay, you'll find pseudomonas, we'll treat it. We'll congratulate ourselves when we do the cytology and the bugs are no longer there.
But if we haven't looked down and said, has this year come back to normal? Have we identified the underlying causes? Have we found out why this infection keeps coming back?
Have we got a long-term treatment plan? We're fooling ourselves and creating grief for the future. So we do need to look at the big picture.
And that leads on to the next, you know, we really need to be focused on not only killing the bacteria, not only dealing with the yeast, but we need to look at primary causes that can help deal with perpetuating factors, and you know, even the risk factors. And the final thing that so often causes more grief than we recognise is more medications is not always better. The number of cases you see in a referral practise where owners have been pouring air cleaners down the ear, using medications constantly, and the ears are, you know, a little bit better, but when you look down the ears, those ears are such a long way from being normal that you're actually better off to take away all the medications.
See where you're at, and then start in a logic process. And it's natural for owners to be tempted to say, Well, I put a bit of drops in last time, that worked really well. The time before, yeah, I put in the drops, it worked really well.
So when it's not working this time, I'll just put in more drops. And it's, it's still not working, so maybe I'll put in 3 times as many drops. And so it delays the whole process, and we can end up with a less successful outcome.
So, remember, the owner is an important part of the team. You know, sometimes they're a problem, but mostly are, they are generally trying to get good outcomes. But they have their limitations, you know, they don't necessarily understand what you're doing, and that's our fault as much as theirs.
If we don't explain it adequately, use terminology, they understand, repeat the story so they're getting it, have a consistent story, and this is one where In a group practise, you can come unstuck because different veterinarians will describe things in different ways, we use different terminology, and that will often confuse owners. Yeah, sometimes the owner really doesn't accept your, your decision. And again, that's a matter of spending the time with them to explain why you're doing things, what you're trying to achieve.
If they don't understand that a diet trial won't instantly fix things, then they may be less keen. If they don't understand that a gramme of You know, corn chip Negates their diet trial, then, you know, they will just say, Oh, I only gave him a little bit of cheese. I only gave him a little bit of the crust of my pizza, but, you know, it's only a tiny bit.
And we all hear those stories, and it's a case of education and motivation for the owners. The owners will sometimes do a half-ass job of treating the ears because they're worried that it's gonna hurt the dog. And that's a perfectly valid thing to be concerned about.
It's probably worth making sure you have good pain relief. They worry about costs, and often owners will be reluctant to talk about costs because they don't want to be seen as, you know, caring more about money than their pet. But I think it's our responsibility to speak about costs, speak about options, and give the owner permission to tell you when they can't afford it, because otherwise, what happens is they just don't put the recheck or they delay the recheck by 4 weeks, in which case you're back to square one and no one's Getting any benefit from it, and, you know, it's probably costs the owner more in the long run.
Sometimes they have poor techniques when administering medication. So if you and your nurse haven't demonstrated the technique, then why is it surprising that they might have a poor success? Sometimes they've been listening to people telling them how dangerous X Y or Z drug is, and so, you know, they're worried about the drugs being dangerous.
They have concerns, so, again, you have to deal with this, talk to the clients, make sure they're comfortable with the treatment plan, and if they have concerns, you need to answer them. And of course, the big bugger this time. That in this day and age is that there's so much other advice out there.
You know, if you ask someone what colour you should paint your house, everyone will give you advice. If you ask someone, oh, I wonder what I should do about my dog's ears. Everyone will give you advice.
But these days, you've got a lot of people whispering in your client's ears, making suggestions, and you have to deal with those. So unless you come up with a good definitive approach, a confident answer, a good strategic plan, then you will find the advice coming from other people will potentially push your clients away from your treatment plan. So how do you solve it?
Well, I think the key thing is to make sure you review the treatment plan, and I like to ask the clients to repeat it back to me. I used to try and give them a written plan. I have me or a nurse will demonstrate the medicating and cleaning.
And then when you're doing the review, are some simple things like, you know, when they last gave the medication. Did they have any problems, you know, Giving doses, did they have to skip any doses? Was it hard?
If you give owners permission to tell you when they've had problems, they will probably admit it more freely than if, You haven't, and it's all about how you ask the question, you know, if you said, so have you managed to give the treatments, and they'll say yes. But if you ask them, Did you have to skip any doses? Was he wriggling?
Was he difficult to administer? How hard did you find it? Then they'll probably open up and tell you the truth.
And then you can offer options. Ask if they think they'll be able to keep the revisit appointment, you know, if there's anything stopping them doing it, and then ask them about how they perceive the dog's pain is, whether they think the pain relief is adequate. Whether, you know, he's still chewing well.
And then asking about, you know, how the costs are hitting them. Again, if they honestly can't afford to come in and have rechecks, then, you know, is there a compromise that can be managed so they can follow through with the plan? You know, I have some clients that come from a long way away, and they just can't get down to the city to see me.
And I have them post cytology samples every couple of weeks. So at least I can see what's going on and have a bit of an impression. They can send me a quick email, tell me, oh, the dog's doing really well.
I've sent you a cytology sample. I get a cytology sampling and say, yeah, it's looking good, but there's still a few pussels around the place, so we're not stopping treatment yet. And that works for them.
So, other things you can do, you can do the medication in the clinic. And these days we have some new drugs, and I'll talk about some of these later. In Australia, we have Aunia, that may be available in some of your jurisdictions, or others, one of the other things I often use is aloxima gel, which is a base that compounding pharmacists use and you can use to add medications in, which allows you to get away with medicating ears maybe once a week.
I also sometimes have things made up in lanolin or squale basis, and they often last quite a long time. And you know, in some cases I've had owners take their pet to the local vet clinic and have the nurses administer the medications if they really aren't able to do it. I have in the past used ear wicks, which are little tiny sponges which absorb medication, and, you know, under an anaesthetic, you'll clean the ears, you'll pop the ear wick in.
It will expand and then soak up any medication and sit in place, for weeks. I haven't had much luck with it personally, but certainly other colleagues have, and I think it's worth a try if you're desperate. In the past, when I had really difficult dogs and we didn't have these long-acting medications, I have.
Put indwelling catheters into the ear canal and, you know, glue them to the inside of the pinna and add a connection behind an Elizabethan collar so that I can just squirt the medication into the ear. Not ideal, but better than not getting medication in. So, you do sometimes have to think laterally and do remember, you know, include pain relief.
You know, generally speaking, I'll use non-steroid anti-inflammatories. Sometimes I'll use steroids, sometimes I'll use tramadol, often I'll do a combination of non-steroidal anti-inflammatories and tramadol together. And it's amazing how many owners, once they see the dog without pain, recognise that the dog was actually in a lot more pain than I thought.
You will get some dogs who are actually quite anxious, and the reason they're anxious is because They've had people attacking them and poking at their sore ears for months or years. And that has made them anxious. That's built their problems.
So, in some cases, I'll use anti-anxiety medications. And I think if you're not familiar with these medications, it's maybe worth consulting a behaviourist. Some of these medications have a lot of interactions with other drugs.
So you've got to take a bit of time to learn about them, get used to them, but you'll often be surprised how much difference it makes, pre-treating before you to have a consultation about Mia. So I will often use trazodone, and I recommend usually giving it an hour before the anxiety starts. So if you've got a dog who gets anxious as soon as they start packing up at home to get in the car to come to the vets, then give it an hour before that.
If they really only get anxious when they come to the clinic, then an hour before the consultation. You must remember that trazodone interacts with azoles, and so you may find you have to give a lower dose if you're treating anti-fungal infections with any of the azo azole medications. And if you're giving non-steroidal anti-inflammatories for pain, Then trazodone does slightly increase your risk of gastrointestinal bleeding.
So you've got to decide the risk benefits. So I'll put some doses there on the notes, but I would recommend you check your own textbooks out on drugs you're not familiar with rather than relying on what I tell you in a brief, lecture. Benzodiazepines often also a good alternative.
I tend to use alprazolam. There is a bit of debate amongst the behaviourists about whether the benzodiazepines may actually, allow dogs to express more aggression. So you need to be conscious of that.
Again, 30 minutes, 60 minutes prior to the anxiety inducing event just like you would if it was a thunderstorm storm allergy, sorry, a thunder storm anxiety, . Again, works quite well, won't work for every case, but often makes a big difference, particularly once you've got the pain under control, when you can actually start looking down a dog's ear without having to say them, sedate them every time. Again, we'll flick through some of these in more detail.
Azania, it's come on the market in Australia relatively recently, and I think it's been on the market overseas in your jurisdictions much more. It is great. You put in two applications a week apart.
It's got a gel base that spreads their medication throughout the year. So even if the owners are not very good at putting the medication down, It's quite effective. The big bonus to me is the anti-inflammatory and the anti-bacterial and anti-mallahesia effect lasts for up to 45 days.
So, while at the moment, many owners tend to treat and then when it feels like they feel like the ear is doing well, they'll stop with azuria, it doesn't matter if they stop because the effects can last. But I find it really good for the normal staphylococci and malaysia, otitis, . The other great bonus for me is, there's none left over.
So you can't have the owner who decides to commence their own treatment plan. Regardless of what you are. Wanting today.
So Ploxima gel is slightly different. Ploxima gel is a liquid at refrigerator temperature but becomes a thick, gluey mess at body temperature. And your local compounding pharmacist will be able to compound it with your choice of antibiotics, antifungals, and glucocoids, glucocorticoids.
It does tend to absorb a bit of fluid. So often when you've got those really exudative wet ears, you can give the ears a good clean. Put in your prescribed foroximer gel, and it will absorb some of that extra liquid that's soaking up.
And I find it's really helpful for some of those really macerated the ears, and the treatment lasts for a week or more. So, again, you can often get the animals in once a week, apply the medication, and give the owners a break so that they don't have to do the medicating. And that's again, really good for owner compliance and a lot less, distressing for the dog.
So the second big factor limiting our treatment success is obviously the pet. And again, we talked about a lot of this already. Many dogs really hate you poking things down their ears, and that's not an unreasonable thing.
I, I think if I had a giant coming over me and sticking something down my ear with brute force, I would probably become very anxious about that looming giant at the next visit. So, You know, We have to think about those factors, and unfortunately, most of our patients are really good, most owners can get oral medications down, most owners can get topical treatments in. I find, That we're better off to apply drops of ear medication using a syringe and just dripping it into the ear slowly and then getting it down the ear by massage, rather than poking nozzles in the ear and squeezing.
The same with cleaning, I think you're better off to use the ear like a bit of a funnel and pour medication in and then massage gently, much better compliance, much less distressing for the dogs then. Doing what I was taught when I was a year graduate is poke the nozzle as far down the year as you can and can and give it a good squirt. And no wonder the dogs hate having the ears medicated.
Again, I think we're creating our own problems. Now, I mean, a lot of the resistant comes because, you know, either the dogs have got genuine pain, and we've been ignoring it or inadequately treating it, or they have anxiety. So back to those medications I spoke about earlier.
And, you know, if you've got really bad ears, you know, sometimes you're better off to come into an evening consult saying, OK, I'm gonna give you some pain relief tonight, and we'll book him in tomorrow morning so we can then anaesthetize him, clean the ears thoroughly, really evaluate what's going on. And get him on a good basic treatment. Preferably where the owner doesn't have to keep poking and prodding those sore ears.
Again, the worst thing I think you can do is try and manhandle the dog. It's bad for how you look, it's bad for the dog's anxiety, and, you know, it's a good risk of someone getting injured. And of course, you do have some dogs that are just big bouncy idiots.
And, you know, they're not painful, they're not, they're not really anxious. They just don't know how to sit still. And sometimes, you know, a sedative for those is quite helpful.
Often once they get to know you and it's no longer that exciting being at the vets, they will be slightly less bouncy, and often if you spend, you know, 15 minutes talking to the owner getting the history. Then they will be not quite as bad as if you try and look down the ear straight away when they walk through the door and they're just wanting to bounce up and down and say hello to you. So talking about the pain.
You know, you get in here looking like this full of puss, quite inflamed. Sometimes the owners really aren't aware how painful their dog's ears are. So I was asking about chewing, you know, dogs who no longer chew bones.
They don't want to play with the ball anymore. Sometimes the owner will notice, you know, if you palpate around the ear, or if you're trying to open their mouth and they yelp, all of these might be signs of pain coming from the ears. And observe them during the consultation.
You know, how do they react when you're looking at the ears. How do you, they react when you medicate the ears, or you try to clean the ears. So when you're using non-steroids, I'm not gonna make any specific recommendations.
I think use whichever non-steroidal you have a preference for. Obviously, remember, you may decide you want to use systemic glucocorticoids down the track because you've got, ear canal hyperplasia, in which case, maybe you don't start with NSAIDS at the beginning. You want to think about gastrointestinal health, have they had history of gut upsets?
You want to be aware of kidney function, you know, it's certainly an argument for maybe doing some screening blood tests before you start, particularly a long course of non-stero anti-inflammatories. But this loan Very commonly used for dogs have really bad, you know, it's usually indicated if you have a lot of hyperplasia. And if you are going to treat hyperplasia, usually you want to use 1 milligramme per kilogramme to start with, which is a pretty substantial prednisolone dose.
Now with that dose, you are gonna see substantial polydipsia or polyphagia, maybe a bit of muscle atrophy. So you want to do it just long enough to get the ear canal hyperplasia to reverse and then start weaning the dose down. Sometimes I use it for inflammation and pain as well.
But you've also got to remember that it is going to have an effect. On, Resistance, I think concurrent steroids and, antibiotics are usually a bad thing for, A bad, a bad thing if you're trying to prevent antibiotic resistance. So Somehow managed to go backwards there.
Do remember that giving the glucocorticoids will give you changes on haematology and biochemistry. So if you're doing some screening health checks, to rule out hypothyroidism and Cushing's syndrome and, general, you know, doing general health screens. You will have abnormalities that have been caused by the glucocorticoids.
So if you want to do these health screenings, probably better to do it earlier rather than later. When you're using these high dose of penicillin, just be conscious and warn owners that, you know, with the polyphagia, you know, you may see some guarding behaviour of food, you may see the, you know, dogs break into the, the pantry and eat, you know, a bag of flour or eat potatoes out of the potato bin. And you may find, yeah, and this is the more serious consequences, you may find a dog who suddenly gets defensive around in their food bowl and so the toddler walking past might be attacked, when he's never shown any of that sort of behaviour before.
So you do need to warn owners about potential consequences so they can test, be aware and take precautions. For pain relief, Tramadol, I really like. It's good in combination with NSAIDs.
You probably should be a bit cautious if there's any history of seizures. It does have interactions with things like ondansetron and your SSRIs and tricyclic antidepressants. But on the whole, it's a very useful medication for reducing pain.
And, I think it does improve these dogs' quality of life until you get the year under control. So again, I recommend you check standard textbooks on use of Tramadol, mostly probably already use it, but if not, have a look into it, understand how it works, understand it's contraindications, and, hopefully that will improve how we manage these ear cases. And of course, sometimes there's nothing more to be done than sedate them.
And, you know, I, again, use the sedation. I'm most comfortable with, you know, I tend to use IV metaomidine, for allergy tests. And so if I've got a young, healthy dog and I want to just have a quick sedation so I can look down their ears and do something that's not particularly painful, that's what I use.
But you can use just any sort of deep sedation you like. I think if you're going to do a thorough cleaning and examination, you do need a general anaesthetic. I think, You really need quite a deep plane of anaesthesia, when you're flushing inflamed ears or when you're performing Mingotttering.
It's amazing how many times you, you know, you've got a dog anaesthetize, you're checking jaw tone and there's nothing there. There's no sign of them being light, and then you put a tube down the bottom of the ears and start flushing saline in and Suddenly, the heart rate goes up and they start flicking their head. So, you do need to be quite deep when you're, cleaning dog's ears.
And I do think a thorough clean at the early stages of investigation and treatment of a case of otitis is certainly indicated. And again, the worst thing that you can do is to have, you know, two nurses hold the dog down while you're trying to poke down its ears. I think that's completely, unethical and, you know, counterproductive.
So even if owners really want you to do it, you have to be the responsible person and tell them, no, it's, it's not good for the dog, it's not good for future treatment. And, you know, it's really just gonna create more problems. So then we get down to the infection, and yes, we do have to treat them and we've all got shelves full of different ear medications, you know, I have a selection that I tend to use, and I'm sure each of your practises will have a selection that I tend to use.
My recommendation would be. To have a few drugs that you use and you really understand the ingredients well. Most of the early infections are going to be malacasia or staphsu intermediates.
And they will usually respond to treatment very, very well with pretty much standard ear medications. And then when you've had ear infections for a long time, we've had recurrent episodes. You probably, because of the previous treatment, have selected for bacteria that are inherently resistant to the standard antibiotics that you've been using.
And so you're often end up with pseudomonas or MRSP, And You know, that is the nature of repeated use of antibiotics, and particularly if you let the owners do intermittent treatment without close supervision and without clearing up the infections well in between episodes. So, topical treatment is usually adequate to clear up a types of external, but if you have defects of the epithelium or a hole in the tympanic membrane, then you probably need to think systemic medication as well. And a lot of the time, if you've been using too much air cleaning, you've got a very macerated ear canal, so the ear canal is sort of soft and mushy, then think using systemic medication as well as your topical medication.
I think it's a good argument if you've got lots of rods present, also to go to systemic medications, so. In those sort of cases, then I like to do it based on Ideally a culture. Although cultures can be a bit deceptive.
I used to, when I was a recent dermatologist, religiously, every time I saw rods in the ears, I'd take the culture, I'd send it off to the lab, I'd get the results back. And obviously, while I was waiting for that, I'd start my generic treatment based on morphology and presentation, and I'd select my favourite. Anti Treatment And what I found after a few years of this is that rarely did the culture result change my treatment.
And so eventually I stopped doing routine cultures of rods. Unless I was not getting treatment, that was, sorry, unless I was failing to get success on treatment that I thought would be effective. These days, I mostly will take cultures when I see a mono, morphic population of bacteria.
And that have not responded to standard treatments. Or if I think, gee, this is a long-term problem one and I'm gonna want to do a treatment for otitis media with systemic medications, if I think it's likely pseudomonas, and what the history suggests we have resistance, then definitely our culture. The challenge is If you collect samples from ears, and you send multiple samples from the same ears to different labs, you'll often get quite different results.
And so, it may not be as helpful as you would hope. So when you've got straightforward cockeye. You know, there are standard drugs that work very well.
Ramycetin is in Canol and it works pretty well, gentamicin in most of your other standard ear drops. For Fenderol is on, is on, is in Ozunia, again works very well. Again, I tend to only reach for the systemic medications if the tympanic membranes damaged or the ether linings damaged.
Perhaps if you've got a dog with a history of MRSP then get your culture out and, treat systemically, based on that. Rob's I said, most times it'll be pseudomonas, but often you'll get Proteus lepsyella, E. Coli, and I like to pre-treat with ota flush, that's a product containing triz EDTA available in Australia.
If you don't have odour flush available, then getting riz EDTA compounded is a good option. And then I would, after that, use gentamicin, polymexin B, or the fluoroquinolones, . Obviously, if you've got a hole in the tympanic membrane, then you want to be a little bit more cautious about things like the gentamicin.
And then certainly, if I'm getting poor response, I'll organise to do a culture. So malathia much more straightforward. It's really the, infection I see most commonly in the early cases of malacesia, and often when you've had the ears well managed for a long time, this is probably what you see as the typical, infection when you have a relapse, .
And often in the early cases when you've just got a few extra malaysia in the years slightly ruinous, you can use things like epio or malacetic, which are, you know, weak acid solutions to clean the ears. I like things like malaitic wipes, unfortunately, they are not available anymore in Australia, and I have been known to send clients off to eBay to buy them from, the rest of the world where they still have them available. So you're lucky in, in your countries, and there are alternative products that do a similar thing that have perhaps an azole in there and a, weak acidic solution that owners can use to wipe around the opening of the ears on a regular basis.
I often use the same thing, wiping between toes, and that can be quite helpful for those dogs. They're very prone to malacasia infections, you know, associated with intertrigo where you've got folds of skin. That provide a local micro microenvironment that favours the yeast to develop.
If they're more significant than, you know, your drops containing any of the azoles, tabinophen, nystatin can all be helpful. Most of your routine drops will have the azoles in, the Azania has tabinophen in, and then sometimes if we're suspecting resistance, then we'll get a drop that has, nystatin in it. And if there's problems with administering the meds, we're not getting good response, or if I think there is malaysia got into the middle ear, or if the ear is just really macerated, I'll often add in oral antifungals.
I tend to favour the azoles, so, yoconazole or ketoconazole, obviously ketoconazole has a slightly higher risk of adverse effects, but it's cheaper. So again, that's a case for you to work out within your practise, which ones you want to stock, and have the discussion with your clients when you're starting about the potential adverse effects of using Azols. I've had slightly less success with atabinophine, that's lamazil, but certainly if you suspect resistance, it's worth a try.
So the key thing is when you are treating the infection to monitor it carefully, those clinical and psychological response. And once the infection has resolved, reassess the underlying information. You may find you strike the problem of a biofilm, or you may find you strike the problem of a type of media.
So remember, you haven't really made a diagnosis when you're dealing with a tight externna until you've identified the primary causes. And you've also identified and managed as best you can any perpetuating and predisposing problems. So, when you think about risk factors, things like swimming, humidity, obviously not a problem this week for you guys in.
The UK, but, you know, down here in Australia in this time of year, if you're in the north, we have a lot of humidity, and you have some dogs who, flare up with malas or otitis every time the weather gets humid. And in those cases, preventative used at the time when the humidity is worse can be quite helpful. You have grass horns, and again, that tends to be very seasonal.
You know, dogs with floppy and hairy ears, it's a risk factor. Perhaps not as drastic as people like to think, but again, I think there's some benefits of clipping the inside of the ears, if dogs are going to be going around in areas where there's a lot of grass seeds. Remember, the primary causes, and most commonly, I think atopic dermatitis is right up there, you know, about 50 to 80% of dogs with atopic dermatitis will develop otitis.
And, you know, some dogs with atopic dermatitis, it will be only otitis and there'll be no other significant skin problems. And these are much harder to work out. With food allergies, again, 80% of dogs with cutaneous adverse food reactions will have otitis, and about 20% of dogs with cutaneous adverse food reactions will have otitis only again.
This makes working up and doing a diet trial much harder. The simple ones, if you've got a puppy with ear mites or a dog with dermatocosis, and they have signs, these days it's relatively easy to identify using cytology. I grab a swab from the ear, identify the mites, give treatment.
These days we have some new drugs that make it much easier to treat demodex and much easier to treat ear mites. Remember, they'll often have secondary infections as well, so you may have to treat the malacisia otitis on top of the parasitic primary cause. And then you'll have the less common causes things like, you know, primary idiopathic sebrorrhea and cocker spaniels, and, you know, so totally cell tumours which cause, you know, a bit of sehea that then predisposes to all those secondary infections, you know, endocrinopathies that need to be dealt with.
So, deal with those things first. Rarely, you know, you get the old dog to have a unilateral otitis, and you see a mass, then I usually recommend you get a biopsy of it if you possibly can. And generally the treatment's gonna be a totally ear canal ablation of osteotomy.
Fortunately, the ear is a bit of a protected site where the neoplasia has to get through, the cartilage to spread locally, and so they tend to spread locally quite late. So you've got a very good prognosis for surgical resection. And then the perpetuating problems.
So, you know, you might see this ear, and you've actually done the cytology, you've treated the infection, and There's not much to see in the cytology. There's no sign of any active infection, but it's still clearly inflamed. You know, this is still not a normal ear.
And sometimes it will be caused by things like contact hypersensitivity. I've certainly seen several cases where dogs have become allergic to ear medications, and of course the old applying more of the medication becomes your your problem, not the solution. There's a little bit of hyperplasia going on.
Again, that's probably worth trying to correct. And of course, it's always possible that you've got some type of media perpetuating the problem. And in this case, I think it's likely to be chronic inflammation where the just the cytokine environment within the skin, the ear is persistently full of inflammatory mediators.
And it's going to take time to reverse. And of course, we back down to the biofilm. So you may do cytology and not actually see very many bacteria, and that may be because they've gone into a defensive mode and formed a biofilm.
So for those of you who aren't really aware of biofilm, it's the concept that you can end up with a collection of bacteria, that, Subside into a film made of various mucopolysaccharides and proteins. That act as a protective barrier. And adhere to a surface.
And if you do cytology on these things, you'll often find there aren't many bugs to see. You may get poor response to antibiotics. You may not get much sign of vacuum infection, but as soon as you ease off, it comes back.
So Don't be fooled, you know, when you do your culture and you think, gee, this is really inflamed, looks like there's got to be something going on. I'll do a swab and nothing driess. Doesn't absolutely mean you've got no infection there.
You may still have a biofilm. So, generally, we clean using surfactants, maybe soak the ear with TriTA. I usually like to use acetylcysteine at 1 to 2% soak.
And, you know, I've never used chloride or silver, but some dermatologists recommend that, . And then you may want to continue your topic land systemic antibiotics a bit longer than you normally would. Now, if you haven't identified, the other problems, do remember you've got to rule out things like architi media, and I would definitely recommend, more advanced imaging, CT scan or MRI, to get a good view of the middle ear.
Randy grass will show up more severe cases, but probably not nearly as sensitive as a CT scan. It really depends on what's available to you. Obviously, a nooscopic examination is pretty basic.
And I think if you're in doubt, and you have some suspicion, performing a meringotomy, flushing some saline in, grabbing out the material and culturing that, can hopefully give you a bit of an idea of what's going on and perhaps identify an appropriate antibiotic to use for long-term treatment. So in this CT scan, you can see pretty easily on the right-hand side, there's a fluid throughout the ear canal and the middle ear, and the left-hand side looks pretty normal. And that's just the other view.
So again, right ear full of fluid, left ear, full of air, which is the way you want it to be. So the final bit I talk about is really more medications are better, aren't they? And, you know, the obvious answer is no.
We all know that. I think epiotic is the one that I have most problems with, probably because it's the most popular out there, and it's very good at what it does, but on its instructions, it suggests you might use it multiple times a day. And I find owners who do this run the risk that we're going to end up with maceration of the ear canal, and that damaged epithelial layer produces a weakness where, the bacteria can get an easier foothold and it prevents the reintroduction of the normal ear self cleaning mechanism.
So the natural tendency of owners is to often do more and more of something they've been told to do once, and we definitely got to watch out for that. The other thing where I find more medications can be a problem is that some of these dogs who have long-term allergies, and we haven't worked out what the cause is yet, or the owners just don't want to be bothered, and they might have, you know, atopic dermatitis. It really just affects the ears.
And so you've decided, you know, quite reasonably that you're gonna treat the allergic otitis with topical steroids. And so you've heard somewhere around the place that you can use quarter arts or you can use Elecon lotion, and you're putting that down the ear maybe a couple of times a week. And that works very well.
But if you're not careful, things like Elecon or court of Arts, which are quite potent steroids, will cause significant skin atrophy. And of course, if it's down inside the ear canal, no one's looking. And of course, once you have skin atrophy, it can be very, very hard to resolve and take a very long time to come back to normal.
So you may be better to, to use a nice weak prednisolone. Drop, but avoid the ones that are included in your standard ear drops that also have an antibiotic and an antifungal, because that's obviously going to favour the introduction of antibiotic resistance. So, I quite often will have a lanolin drop or a squale drop with 0.5% prednisolone that I use a couple of times a week to maintain these dogs.
And owners seem to find that quite a good easy way of maintaining control for those constantly relapsing tis where there's really nothing much else. So When I'm managing otitis. From my perspective, you've got to really spend as much time managing the dog and the owner as the disease.
And I think that's where we mostly come adrift. You just got to spend more time with the owner, more time educating them. We also need to try and establish clinic-wide consistency, so everyone's doing the same thing, and we don't confuse the client.
Identify your risk with treatment, you know, are the owners going to be able to put the medications down? Are the dogs going to cooperate in accepting the medication? What are the risk factors of, the medications themselves?
Are there any triggers that you can identify, you know, should you be stopping the dog swimming or should you, when the dog does go swimming, do an air clean afterwards or apply an extra dose of the steroid you drop afterwards and make sure you've identified and treated any perpetuating factors. So obviously, resolve the simple primary disease in your foreign body ear mites then next do that quick. But then when they come in for that first visit, just warn them that, you know, sometimes these allergies will respond really well to treatment.
But if it relapses, Partic if it relapses frequently. Then an allergy workup is going to be necessary. And that repeating the same medication over the long term may result in antibiotic resistance and chronic changes to the ear.
So if you consistently tell owners that, and then when they come in the second time, you start talking about getting the allergy investigation happening, you're gonna make much better, and have much better success. I want you to avoid relying on owners to decide if the infections resolved, you know, try and get them in for the rechecks, try and repeat the cytology. And make sure that they keep those appointments.
And when they recur, monitor it and make sure That you know, others, same thing, trying to identify the causes, rule out the underlying allergies and treat those. And then if there are potentially perfecting problems, you know, do the CT scan, treat the middle ear infection, and do what you can to control them. So if you have to use steroids or cyclosporin to control hyperplasia, do that.
So for me, when I'm managing a scientist. It's really a case of developing a plan for the acute flare-ups. Developing in a maintenance plan, that might be a maintenance plan for the underlying allergy or it might be a maintenance plan for just the years.
Develop a monitoring regime. So, you know, at, at the front, you get the owners and say, right, you know, your dog's got a tyres and they're gonna keep having recurrent Otis, so we're going to see you every 6 months, and during the rechecks, this is what we're going to do. And the challenge is, and this is probably the hardest thing to owners to take it on board as a priority.
Now, it's easier for a referral veterinarian to do this than guys in general practise, because I've already had the less caring, less enthusiastic donors filtered out before they come to me. But the same principle applies, you know, you've got to get the owners to take on board this as a priority so that we can get on and treat and If they'll accept it, then they will book in those checks and keep them. Whereas if they really don't think it's necessary, then they just won't show up.
And then the first time you see them is suddenly it's back to being a putrid pussy mess, and you're back to square one. And if things go wrong, go back to the plan and make a change to the plan so that you can have a long-term, good outcome and try and avoid having the total ear canal ablation for the osteotomy that so often happens with these guys. So, hopefully, that's a bit of a general overview of my approach, and I think the key thing is to be very, very focused on that.
It's owners, pets, and the ears that need to be looked at, not just one of those factors. So if there are any questions, I would be pleased to answer them. Andrew, thank you very much for that talk.
It was very, very informative and sitting here I can think of a couple of cases off the top of my head where I'm kicking myself about little things that I've missed, like thinking about the anxiety of the pet when you're trying to show the owners about the ears and everything else. So thank you for that insight. Julie wants to know.
Yeah, I've got. Yeah, so Julie wants to know, would you twice weekly cleaning to long term problems? I think for some patients that can be helpful, but again, you run the risk that cleaning may not quite cut it.
I think it's worth doing, for some dogs, and certainly I have in the past recommended, you know, using an air cleaner, maybe adding a bit of steroid into it. These days I've switched. Away from doing that, I'll often get people to use malaitic wipes, even though that means for me, I've got to send them off to eBay to buy the, the tube of them from the US or the UK, because, you know, they've stopped importing them to Australia for whatever reason, the business has.
Because that is easy. I have so often seen the dogs where they've used too much of the air cleaner, and that's probably spoiled my view. I know a lot of dogs do benefit from just, you know, the once a week, twice a week cleaning.
A lot of my chronic ear cases where, you know, they've got perfectly healthy otherwise, they've got, we assume atopic dermatitis or they've got food allergy, but the owners have not been willing or able to complete a diet trial yet. Particularly where it's just titis and doing the diet trial and interpreting that can be really quite hard, I will often use a, a 0.5% prednisolone, in a lanolin base or a squale base, you know, two sequential days a week to try and keep the ear information under control for 5 or 6 months.
And then I might say, well, Let's see what happens when I drop the ears and does it start coming back. And often I'll combine that with actually doing the diet trial when I say, right, we've got the information under control, we've got the infection under control, we'll do the diet trial, we'll run that, and towards the end of the 8 weeks, we'll, we'll drop the medication. See what goes over the next month.
And then drop the diet trial and see if we get an acute flare to convince ourselves that, hey, it was food all along. But I find with ears where there's no other skin signs to give the hint, doing that diet trial can be really challenging. Yeah, yeah.
What is your, your feeling on routine plucking of ears like by the the pooch parlours? I tend to discourage it. I think on the whole, the, there are some good reasons to pluck in the ear, usually it's so that the person who's looking down the ear can see what's going on and make an assessment.
But I think the plucking can itself cause problems. And I've certainly seen some, some dogs which have had incredibly heavy. Ears, that have been perfectly normal, or that have had episodes of otitis, and then I haven't kept plucking the ears, and we've managed the otitis in other ways and it's been fine.
But there are certainly cases where the really hairy ears make it hard to see what's going on, hard to administer the medication. Certainly, if you end up using the lanolin base drops, the heavy waxes in that tend to glue to the hairs that are in the ear canal, and you end up with an ear canal that has, a big lump of wax adherent to those few tufts of hair that are sitting, right by the eardrum. And so that can be a bit disconcerting.
You look down there and think, oh crap, what's this horrible big black blob down there. But clinically it doesn't seem to affect the dogs. So my rule of thumb is pluck the ears if they've got a good reason to, but be aware that plucking could actually trigger inflammation and could trigger the next episode of otitis.
So you have to pluck it as part of your treatment regime for a specific reason, not as a routine. So I tend to not pluck ears at all. Excellent.
Andrew, thank you so much for joining us on the Virtual Congress 2018 and for sharing such insightful tips to us. We really do appreciate your time.