Description

The second of 2 hours on ear disease management of dogs and cats will discuss the management of chronic secondary bacterial, yeast, mixed infections as well as allergic otitis externa & media in relation to feline and canine ear pathology, etiology, diagnosis. We will go over how to use the clinical diagnostic techniques like cytology, cultures and susceptibility, various forms of otoscopy, imagining to determine the proper clinical medical management options, topical and/or systemic. Ear surgery will be covered elsewhere in the conference Learning Objectives 1) To become familiar with of feline and canine otic secondary infectious causes and its treatments (topically, systemically) 2) Cover common treatment pit falls seen in both general and referral practice and steps to avoid them. 3) To be able to discuss available treatment options and their relative effectiveness with owners and the importance of follow up 4) To give practitioners better arguments and ways in the management of chronic feline and canine otitis problems

Transcription

Thank you. And I appreciate that and I just managed to scoff down some food so hopefully I'll be able to stay on time now. So just reiterate what I started out earlier, this is what we all do and if we don't take care of the whole patient, we will probably end up with a lot more chronic cases out there.
So, this is what we kinda covered, and here's where we're almost done with. So we'll quickly go through those and then we'll get into the diagnostications and treatments. And hopefully finish up on time.
So this is where we're at. We're just gonna finish up this little review session and then come into all the fun stuff for treatment. So, the perpetuating factors that we deal with in our clinical work and that people expect us to take care of is obviously almost always thinking about an infection.
And there are so many of those and so much of that that we have to Fear and consider when we treat and obviously, we need to look at them and identify them as best possible and then come up with the best treatment for these patients as we're being trained. And here's some surface floor of veer canal with some coxite, for example, or some little bit more interesting and challenging ones, where we start getting the biofilm really growing, and then we have the good old fashioned yeast down here on the bottom. A lot of those other rot forming bacteria that we sometimes forget and some of our labs are calling contamination or normal flora.
We probably need to maybe start looking at those, maybe not necessarily as primary pathogens, but as cohabitants and part of the the pathogenic flora of the ear in the sense that they provide. Hiding places or running interference for some of our treatments, when we're trying to medicate the primary pathogen being at a pseudomonas or a staph or otherwise. And when we start getting into these resistant ones, that is often why we really get frustrated when these infections are hard to manage.
So here's my advice when I look at a microscopic exam, when do I choose to treat? So if I look at 10 fields on average on a slide from an ear of a patient that I see in my clinics, I would consider More than 4 coxi or diplocoi for high power field and bacterial otitis externna with rod-forming bacteria being absolutely not a normal flora of the ear canal. So if they're there on average of one or close to one rod forming organism for high power field, I would definitely consider that significant.
And the same with yeast. And maybe a little higher I will allow. But if I have inflammatory cells on my ear cytology, I basically count every finding of a bacteria with a multiplier of 10, meaning that I'm much more inclined to consider the finding of a single solitary coccy plus some inflammatory cell debris, a bacterial otitis externmina and treat it accordingly.
That is my approach, but it's based on a pretty good paper from Doctor Danny Scott and Doctor Tater and a couple of other very smart people. So it's not just made up by my, seat of the pants here. But getting comfortable with cytology with your technicians or yourself doing the majority of the work is all about what you prefer, but getting good at it.
I recommend that I tend to look in the ear first before a sample for cytology, but I tend to prefer that so I don't get any artificial edoema or inflammation that I might misconstrue to be more important due to a traumatic swab or sampling. But if I look down there and I do my cytology, and it looks suspicious on cytology, I might then, before I do any further manipulation, take a culture and hold it, I might then. Choose to discard it for whatever reason, before I, I, I submit it, but at least I, I will have the sample out uncontaminated or unbiased.
Diffuk and Gramstain is the preferred ones. I definitely say most people should have a grammes possibility of ordering gramme stain if they don't have it in the house, but, diffuk is, is a must. Gramme stain can be maybe used when you have too much time on your hand, but I guess sometimes have.
When to sample or where to sample is probably even as important, because different places in the ear canal, even though that that is just that 578 centimetre long ear canal in a dog or maybe 5 centimetre long in a cat, it makes a difference if we're sampling it up on the top or closer to the eardrum. And in the context of ear disease, you want to sample it close to where you suspect the majority of the diseases. So if you haven't done an ear exam, how do you know if to sample the upper ear or the lower ear, and is that representing what you're looking for?
Because not all organisms you might see in cytology are necessarily patho pathologic disease causing organisms, but they're part of the picture and you wanna kind of keep that in mind. There are even some of the organisms you might see that looks the same, but are, not necessarily all, all cocci are. Equally resistant or equally pathologic.
Can it be different strains within a fairly uniform population? Definitely possible, hence why you might do a gramme stain, or why you might might do further diagnostics on these samples. There's this little paper from, Doctor, Grahame Ms from Michigan State when she was there, where she took a sample right at the junction between the horizontal and vertical, and she did it in healthy animals, I grant you that, but she took two samples, 1 millimetre apart on either side of the head of these, I wanna say 27 dogs and When she looked at not just cytology, but also on culture and then susceptibility, what she found that in only 28% of the sample locations where the organism the same both as cytologically.
And culture and susceptibility wise in all four locations. So treating on either side of the ear is not wrong. I would actually encourage people who are thinking it's OK to use the same medication if one ear has infections and didn't have time to look at the other.
You'll often be disappointed about the the sampling on the other side of the ear might be completely different. And I find on a regular basis, I'm sending animals home with two different types of ear medication because there is one yeast infection on one side and bacterial on the other side or whatnot. When to culture, well, that depends on your case load and where you need to manage your antibiotics.
I recommend these two resources up here. These are free resources that you can download and they are on the bottom. As references, but also at the end in my literature.
But these two could be either downloaded to your phone or used online, and they get updated regularly to, to kind of get some good suggestions on bacteria management and when to choose drug A, B, and C, and that can be a help in most cases. What I indicate is, culture from an otitis media or internna because I need to treat systemically and the systemical treatment will be reflected in when my cultures of ability gives me an MIC that I can work with. In the outer ear, I don't really have much use for an MIC as the minimum invasion concentration in serum is not likely to reflect what is going on on the surface area of the ear canal that is chronically inflamed.
And the topical treatment route will probably reflect a completely different pressure on those particular organisms than what the MIC indicates I should be looking for. So, culture in the outer Europe has its place, particularly if you have a lot of rods, rods, we'd like Pseudomonas, which have a high tendency of becoming resistant very quickly, that can be important for your choice of treatments, so rod forming bacteria would be a good reason for me to culture an outer ear. If I treat it appropriately with an antibiotic based on my cytology and the treatment is showing progression down the route of organism becoming more uniform or monomorph, and the owner is compliant and it's still getting worse in spite of our attempts, there I might choose, OK, we're gonna start to treat based on cultures' ability rather than empirical choices.
And with the more and more of it being indicative of a resisting population is where I find the cultures to be helpful. When I do cultures, I would say we have now instituted that here at our hospital at Angel where I work is our infectious control committee have made that a must that if you submit a culture of susceptibility from an ear or skin sample, you need to provide the laboratory with a microscopic evaluation to indicate what you saw, and that should then be used when you get your results as well. Does it match up?
Do they come back and say the same organism was found in cytology as what they grew on the organism? To do aerobic versus anaerobic, if it is a surface area, it's obviously not as relevant to do anaerobic, but if you are working in Ebola or in a abscess canal, it can be important to also consider anaerobic organisms as a possible pathogen. Then a biogram, what is included, what does your lab automatically culture for these organisms, .
Even gonna be of value to be tested against. . A lot of labs will do what we call surrogate discs, so they will not necessarily grow for all floor criollos.
They might even do, for example, ciprofloxacin rather than enrofloxacin, and is that really helpful for all our cases? It might or it might not. We do not have data on all of it.
So, talk to your lab about what they do. Do they do something that you can use clinically, Also, is there variation between your different labs you might have to use on the weekend or other days? What does that mean for your results?
What are the lab standards? Do they grow 1 or 2, or do they consider a sample and say this looks like they're likely biggest growing bug on that sample, and then they choose that one and grow that one up and work with that one only. Other labs was only kind of speciate them to a certain level, so they might say this is a staff organism and they would label it as either staff COA positive or COA negative.
And is that satisfactory for what you're trying to achieve in your care? Well, these are considerations that you probably should look into and, and look in some textbooks and say, do we do that or discuss with your local dermatologist or microbiologist, what is the best I can do for my patients. Does the lab consider things pathological, and will they culture them?
I just got a result today from a dog I did a me and got me on yesterday and they said, well, they don't want to do an anaerobic culture from Ebola. And I got quite miffed because this dog has severe meningitis, as my pathologist, correctly pointed out when she looked at the CSF we did yesterday, that there's probably something going on in here that we need to find out about and The lab had a policy that if you submit a culture from Ebola, they wouldn't do an anaerobic culture by default. And so that lab is no longer working with us, and I'm happy to say we have others to go to, but these are things that you as a clinician need to consider.
And what do they call normal flora when they write that as a reply in a test result, is that indicative of Carina bacterium or what is What is their definition and how do they get there? These can be important. And then, obviously, did you get a sample and will their degrees of freedom of what they work with help you out?
And what does it mean for biofilm? And the biofilm is probably gonna be something that we all have to learn to deal with better or in, in a different way over the coming years as resistance it becomes an increasing problem for all of us. When do I treat an ear?
Well, as much as I can get away with. Topically, absolutely. I clean first with various things, water, ear cleaners, ruinlytic, whatever I can do to get access to the ear canal.
Try to break down the biofilm. Sometimes I use mixtures with acetylcysteine, like nikiist. Sometimes I use just warm saline, sometimes I use mixtures with squale or seramine, other commercial cleaners, try to get access to the parts I need to, to treat down the road, and if I can get away with it in an unsedated or non-intestinide animal, that's great.
I will often use anti-inflammatory, anti microbials of various kinds, and then if there is any kind of parasitic concern, I will have to deal with that. And then I find myself using a whole lot of pain medications for these patients because this hurts. If you haven't had a ear disease yourself, it's hard to understand, but if you've had one, as I can attest to, it is some of the most painful things I've ever done to myself.
Systemically, anti-inflammatory drugs can be very helpful. Antifungal can be helpful, but it often takes a lot longer to reach therapeutic levels in the tissue. So topical is your go to, but it can be helpful for certain conditions to use systemic.
Antimicrobial, unless you have middle ear disease or a highly vascular outer ear disease, aerosive ulcerated otitis externa, a vascular group of tumour cells or tumour clumps or traumatised ear tissue, the systemic is not very effective in the lining of the ear canal in most otitis external cases in my experience. Antiparasitic can be helpful if you have demon X, but you can also get around that with topicals, but it comes down to What's possible Eucalytics is probably gonna be one of those things where we might be able to find certain supplements that can help us break down some of the biofilm through supplementation routes, at least that's my hope. We don't have too many studies looking at it, but there will probably be some presentation, at least in the European meeting in September.
I know a lot of European colleagues and dermatologists working on that. And I'm not sure I'm gonna be able to present anything, but I am working on these aspects too, because I find it to be hopefully helpful to break down and get to the drug, the drugs to the bugs better. Surgery like we just heard about can be an option either teas or other approaches, and then allalgesia with systemic use being very, very important because both topical and systemic pain medication can be needed.
Treatment options are Indicated or dictated by a lot of factors, but patience is obviously first. Then, is it the ear, out of part media, internal, all of the above, is it bilateral, unilateral or those are choices that you have to take into consideration and you do this every single day, I'm sure. We do it based on the history.
Can the dog or the cat handle this medication in the past? Was there problems with a similar product? Was there any reports of the patient having an First reaction or other complications.
So those are important to, to take in, was the previous cultures, previous cytologies, and so forth. Was there other health issues. So you're treating the dog, with a topical where you're worried about this dog having a super, super sensitive diabetes and you're using heavy-handed steroids.
Is that gonna be a factor? Maybe not, but is it a concern? Sure.
Is it a happy patient or a not so happy patient? Can the owner even medicate, right? Ability to afford.
Some of our medications are getting ridiculously expensive. Sometimes we can send them to other places, sometimes we can prescribe it, we can script it out, sometimes we can come up with alternatives, but the owner has to be able to complete the treatment without moving from home. At least that's a goal in, in my world.
And in a lot of practises, we also have to consider, well, can we, what do we have? Can I use this medication or the owner is coming and can't get to an alternative place for medication until 2 or 3 to 5 days later. What do we have on the shelf that we can start with and then work from there.
These are all compromises we make every day and it's not always pretty, but it is something we have to take and use. The compliance is obviously important and if you don't communicate why you're doing it, the owner will often not be able to complete the treatment successfully. And are they willing to do it, and do they understand it, and do they have the time and money to do it?
So back to treatment in the sense of how much when you're treating an ear canal, you want to treat the whole ear canal if possible after you cleaned it up and using too low volume is often the problem if we don't use enough. So here's what I I, I don't know if anybody will publish this or say that this is crazy, but if you take an Acura, ear suspension and you drop it out one drop at a time, on average, you'll find that 20 drops get you about 1 mL of medication. So medication like synotic, you know, poly HC, other more watery like ear drops, we'll get you that.
And in order for us to cover the ear, canal that's affected, we need to consider the, the size of the ear we're trying to treat, and is it clean, is it's hypoplastic nodular, what is it? If there was any reactions to it in the past. And we do a cytology at the end, but the volume you put in, here's my guideline to you.
If you can use it, feel free to copy it or use it. But if I'm treating a cat, I do about 25% of a CC in the ear twice a day. If it's small animal, dog, 0.3, if it's a medium, large, like a cocker spaniel, up to, a golden retriever that size, I would probably do up to about 1210 to 1210 to 15 drops, up to about half a cc per application, and typically twice a day is better than once a day in most cases.
And the long your dogs like basset hound, coon hound. And those kind of breeds, I would go to a full CC, no question asked. There are medications out there that are more gelatinous or thick, and I'm thinking like the liniments or the ointments and the creams that are out there.
And there, again, I took some of those medications and dropped them out on a piece of paper until I had one to see. And, or I should say I put it in a syringe first and then dropped it out. And there I find that the, the volume is a little less because, well, obviously, they're more dense and so 1 mL is 30 drops, and that gives us these volumes.
So hopefully this can help you out so that when you medicate, you get enough medication to cover that ear canal. I tried to do this and I hope it works out. If it's a little clunky, I apologise.
This is the first time I've ever done it, but I basically took some cases and I said, here's what I think when I walk through a case and kind of deal with it on a daily basis. So bear with me if it's a little clunky, but if we took a young, healthy oyster that came in and had maybe a couple of ear infection in his life, but nothing major, had been treated a couple of times. And now comes in with some inflamed ears, and it's been going on for a couple of weeks.
No major issues, maybe some pedal licking going on, but nothing to the point where we're screening murderly yet. Then we looked in the ear and it looks kind of from the outside, maybe a little bit like this with some erythema and a little bit of lichenification suggesting a priors, maybe a little bit of post-inflammatory hyperation, but nothing too spectacular. And then we took a sample and we saw these little buggers here, little footprints in the snow.
We all know that this is a yeast dermatitis and we probably already guessed that when we saw it was a Westie, but nonetheless, we would definitely take our samples and look at it. And if we saw that and make the diagnosis with some of the inflammatory cells being in there, we probably want to treat it after cleaning it. In certain parts of the world where you use myconazole or clotrimazole, I don't know if always having them available with an added steroid, but you could potentially add it to yourself.
In Europe, you have the beautiful Emavaol, and then all of a sudden it escapes me, . What the chemical is, but it is, nice to have that in Europe. We don't have it available here in, in the US, but it is available in Canada and in Mexico, but not in the United States.
And the statin I find to be pretty inferior, but it is probably more the pH lowering properties that help us with the yeast. Treating it with the analgesia would be a good way to do that if it's painful in the ear, but if you have the steroid and then you find that to be effective enough. Systemic antifungal would not be in the first line, or the second line of yeast and otitis externna, but if you start getting 4 or 5 ear infection in a row with a very, very slimy, very, very yeast overgrown systemic antifungal like a ketoconazole or fluconazole could be helpful to gradually get a hand on this yeast infection.
Here's another case where we have a young, healthy, no major problems in the past going on for a couple of days. The odour is not spectacular, but it's there, and the ear looks, when we look at the scope, we can see the inflammation, and we can see the edoema, a little bit of cobblestone hyperplasia and some waxy debris kind of accumulated on the the attic wall. If you do a cytology and we see the inflammatory cells and we see some cocci and different cocci scattered in there, maybe some tunes and reinforced down here.
It's hard to tell if they're staph or strep or ancocci or what they are, but They're definitely kind of different groups of them and the different sizes and pretty, yeah, diverse, but there's enough inflammation in there that this is probably a painful year. And we would call that side as externna with cocci, or diplococci, and we would choose a treatment. And I would typically choose empirically in a first line case and I would go for the lower end of treatments.
You have different options. I don't know how many of us are still using. Iodine-based products, but it is out there and it does help.
Fussic acid is available in Europe, not in the US, in the US we now are getting reintroduced to all the amphenticols in the name of Claro and incarnia. So there's a whole bunch of first line appropriate treatment that you could empirically choose and I'll be fine with that. I would then recommend a recheck 10 or 14 days later depending on what you prefer and how severe it is for the patient and how difficult it is for them to come in for the recheck.
And then I do a recheck cytology or exam and if it's clear, I stopped the treatment. Obviously, if the treatment didn't take and we now have More bacteria I might choose then if it looks like this one on the cytology, I start getting worried if he starts to look pretty uniform, he's kind of paired up cocy, then I might choose to do a brand stain to make sure that they're truly similar or monomorphic, and if that's the case, I would then be kind of worried about it, because if they start to look like they're the clones of the returning, Star Wars clones, I would probably either culture it or prefer it, or at least do something to help me get a better handle on this treatment. But if I, for whatever reason, I want to decline chose to do something just based on, well, I got it, but I wanna try to treat it with something before I refer it, then I might just go one step up on the glyco said.
I wouldn't go too much higher and I would make sure it had a steroid in there for all this inflammation. And recheck again, if clear stop treatment and obviously start talking to the owner about this is important, if this is a reoccurring problem, we need to start figuring out if this is an allergic young dog that is progressing down the ladder of food allergies or adipe or some combination. Referral and recheck would be needed if we got more problems.
Here's a 3rd option, and I'm not gonna go through all of them, but there are definitely many ways to approach this, and I hope that this gives you a little bit of a sense of what I would consider a starting point and hopefully that can help you in your care. If we have, here a case with, an older cocker spaniel with ectopic dermatitis, middle of the seasonal flare that had happened a number of times, and, it's been treated again and again with both topicals and various other drugs, the ears stinks and the owner is, unhappy because the pain of the ears is keeping them up at night and the dog won't even eat a treat in the exam room. And when we look under the ear, we see this kind of Slimy, foul smelling, we can almost smell it as we're sitting here, different parts of the world.
And obviously this year is not a happy year and we do this cytology and you can see there's some rods here, but you can also see this beautiful picture of a biofilm on a cytology with the mixed in inflammatory cells and probably also some red blood cells in there. So here we can really get a sense of how this biofilm is probably like coding everything like glue and why we sometimes have a very hard time reaching through that makes perfect sense to me at least. So here we would have an a tiny sternum with rods on cytology, and we're worried about this being a rod forming something like a pseudomonas.
So if we choose to treat it empirically, which we could, and I wouldn't object to it if you were in a situation where they were saying, well, we don't want a culture yet, we can't afford it or whatnot, then I would pre-treat that ear with an ear flush with something EDTA containing and it could be trace EDTA or other products along those lines. And then use some sort of neomycin or at least in that family with some form of steroid. It doesn't have to be dexamethasone, it could be hydrocortisone or other forms of steroid that is available in your end of the world.
Obviously, you want to see this one back. Maybe not even in 10 days, but sooner. And if it is all miraculously better, you can celebrate and tell them, OK, we need to stop that treatment and maybe transition over to other treatments that is more designed for maintenance.
But if not better, you want to most likely recommend cultures of ability. Because if the organisms start to look bad, you are probably looking at some sort of resistant infection that is likely no longer gonna be just budging on an empirical choice alone. You might actually guess wrong a couple of times before you get the right drug and that would be expensive and not helpful.
So if the cytology is not showing clearing and you still have otitis externum with rods, you probably should either. And maybe do something different than that, but if you wanted to, again, keep going while you're waiting for a culture, could you do something along these lines, I would be OK, but I would probably not expect a huge improvement on that, unless you have the culture to support it. Some of the options I sometimes skip and go straight down and do something like neo polymexin B because polymixin B has in some cases been effective for first line rod forming bacteria.
So it's a possibility, but again, be careful that you're telling the owner, you need to come back, you need to consider culture, you need to consider figuring out what's going on. And obviously, you might even have to do deeper flushes and other things in that context. Each case is different.
Here's just a little tablet that I sometimes give to my young colleagues. I would say doing rock-forming bacteria often will make us look for fluoroquinolones, but fluoroquinolones should not be in a major drug, in most cases because we might End up with a resistant strain more than we already had, but sometimes pom pomix and B, as I said, but also silver sulfadiazine is, is a fairly underutilised, fairly innocuous drug that helps us, particularly with pseudummonas, and that can maybe hold us over while we're getting culture. So that's a consideration, and I wouldn't object to that either.
So Remembering that when we have that dog resolved, when you come back in for the recheck and there's no infection, and you then see them back a couple of weeks later, a month later with just inflammation, get on top of it before it slides back to that infection and Remembering that allergy causes inflammation first and then likely a bacterial or yeast overgrowth. And so if you don't eliminate the inflammation, it will become infected at some point in the near future. So using Topical treatments for local inflammation is definitely high on my list.
I do it every day. Chronic allergic otitis externum manage with the topical steroid alone, probably keeps a lot of these dogs very, very happy and cats too, basically, because we can do local treatment with just impact within the ear canal, not the whole animal. Here's some of my suggestions.
With the chronic cases as we saw earlier, this is what tend to happen if we don't get on top of the biofilm evolves, the ear canal become more and more constricted. The hyperkeratosis and thickening of the lining makes it harder and harder for us to reach all aspects of it, the nooks and crannies makes it deeper and deeper. The vas.
Or support if we have to treat systemic they become even more inferior. The hypertrophic glandular tissue encroaches on the ear canal, makes it harder for us to reach a deeper aspect. The fibrosis andization around the ears now interfere with the functionality of the ear and the pain and the discomfort, of the ear creates decreased duration.
Accumulation of organic matter in the ear wax and other things, and the ear canal start looking like this, and obviously you can clean it out, but the quality of life of these animals are often severely impacted. They can't hear as much. It's expensive to treat and can require surgery.
And here's the case with severe end-stage ear disease that's completely minimised and included. This is actually my first vancomycin resistant infection I ever had to treat, and now it's not a good idea. .
Chronic otitis externna, as many as 16% of them will progress to otitis media. So, for me to say 6 weeks or longer of a chronic otitis externna, I expect 1 in 8 to have otitis media during these 6 weeks. And these will often require nengotomy and systemic treatment and pain medication and other follow-up.
Here's a. Westy that many, many years ago took an X-ray out where the ear canal is severely minimised. It's probably one X-ray I can remember I used for something.
And here's a cocker spaniel where you can see the left-hand side of droopiness and the, as I like to call it, the flying nun where the ear canal is so minimised that the ear flap is now altered on its ankle on the head, and you flip an ear like up that and you're supposed to see the. You're opening down here and the pins sticking up. You're supposed to have the, the trachus opening and the entrance to the, vertical ear canal here.
It's hard to imagine any medication getting in there. He's obviously a tumour on the ear canal too, but you can imagine the smell from that ear, . The changes here, sorry about the typo, makes this end-stage ear disease really, really hard to manage and the bulking it is no longer possible.
Yes, you can take that mass off, but trying to cut into these folds will be often impossible. The TGA is the way to go, and it's obviously. Important for you to understand that if you don't treat the whole animal, the allergic part is still present.
There's another angle of a cocker spaniel. What is Tika recommended? Well, it is a good surgery because it does decrease the complications down the road, when you do the surgery, or have it done, I should say.
You have less of the complications that you otherwise would have to encounter, with facial paralysis, abscess formation in that ear canal that might rupture out through the side of the ear canal, . KCS as it happens to be a complication to chronic otitis media in particular cocker spaniels, deafness, comes off, as a consequence of the ear canal is completely obliterated, by scar tissue or damaged. And if you get on top of the rest of the allergic disease, you obviously will have a decreased risk for having to use infectious control all the time and therefore less resistant infection all the time.
Pain-free. Well, obviously they have to go through some pain for the surgery, but after a surgery, and it's pretty rapid in some of those TA patients where they've been in pain for months or even years, and you do the surgery and they almost come back a week. Later for the suture check or follow up, and you can all of a sudden pat them on the head instead of them trying to bite you, is quite remarkable in a lot of those cases.
The quality of life could be life changing for both owner and pet and for doctor. . Reduce complication from other treatments, topically, irritations and otherwise.
The cons. They're there. There's surgery risk for general anaesthesia that goes without saying, and that's why I have luckily for me, a very, very good anaesthesia team, taking care of my patients before they go in and deal with the surgery team.
But that's important for you to consider. Is that worth the risk for the patient to go through a lengthy two hour 3 hour surgery. The cost is substantial.
It's not cheap, several $1000 or even 4 plus, with or without CTs and other imaging first. Post-surgically, can there be complications? We heard some of those.
So if it does not have paralysis before the surgery, can it happen? Yes. Probably Anywhere from 5 to 10% depending on the surgeon and the degree of complications due to chronic disease prior to the surgery.
KCS can happen independent of the breed, but also as a result of surgery, . You can have post-op infections in the surgery site if there was any kind of contamination of the surgery site before or during or after, and that can lead to fistula or to hiss, but it's pretty rare, but it does occur. And then you can have deafness and you can have permanent head tilt due to, .
Vertigo-like symptoms due to either swelling, scar tissue, pressure on the cochlea, and so forth. And here's one of my last post-surgical complications from a tia where we, about 6 months later got, what we suspect some sort of sequestered or necrotic material that led to these two fistulas forming where the surgeon had worked, 6 months earlier. Deep ear flush and video cyscopy is important for chronic ear disease management with the CT or MRI being helpful prior to the videotoscopy, in my experience, it does require general anaesthesia typically, because you can manipulate the patient better when you're doing your ear flush.
The analgesia is better controlled with general anaesthesia in my experience, than what I can accomplish, with any other techniques, . You could do some pretty good stuff in getting material that is otherwise really hard to manipulate out when the patient is laying still for you for the time taken, and you can remove even almost cement-like material, and then obviously get to masses or other material that, you're concerned about down below. Here's the immili which impacted probably wax and hair and medicine all together.
And then, Yeah, this is actually an extra slide, so I apologise that should have been taken out. For the chronic diseases systemic treatment, Analgesia, analgesia, analgesia. Go talk to a pain specialist if you need to attend lectures and hear them talk about it till you have some good options in your booklet because it can't be stressed enough.
Ear disease and chronic disease is a painful condition and the quality of life can be helped tremendously with drugs. Systemic treatment can be helpful if you're dealing with the middle ear. Yosporin works in dogs with some frequency of prohibitative early stages, ear disease.
If it becomes too fibrotic, I don't think we can reverse it too much, but it can be used. Acetylecysteine, as I mentioned, can work sometimes for primary secretorial otitis media of the King Charles Spaniels. We think.
We don't have enough data to prove it, but it might help us manage some of those after we've done the initial meotomy and flushing. Glucocorticsteroids are key for management of ear disease in the early part and to help with the, condition of allergies if it's there, but also to open up the ear if possible, and so using systemic and topical steroids in some form or shape becomes almost, Yeah, key, but obviously there are patients out there who can't handle that because they're diabetic or have other health issues that make steroids complicated. So if you have the possibilities, you should use it at least topically, maybe less is needed systemically, but somewhere around 5 to a whole make per cake for dogs and at least up to a whole make per cake for cats in my experience, and I use pronisolone exclusively or methyl pronisolone for cats with dogs, I do.
Use prednisone at times or other steroids, but prednisolone seems to be my go to because it's easy for everybody to know that that's what I dispense. And just quickly going back over what we have covered, and I hope I have covered most of this by now. If not, I'm glad to see if I can help you, answer any questions if you have them.
Here's some of the helpful links that I would encourage you to use if you have interest in. Using some of the available conferences, the North American meeting in April, the Academy of Veterinary Dermatology is for people that are non-boarded but have a special interest in dermatology. I have to disclose that I am the current treasurer of that organisation so I can, be blamed for various things there.
European, I'm also a member of and I come from Europe and I wish I had more time to attend the European Congress just because they're typically very, very high quality. The World Congress in 2020 will be in Sydney and you can see a lot of that information there. The International Society of Veterinary Dermato Pathology has a very, very cool organisation and some really active British people working there, with, David Shearer being one of them, and, they do some pretty amazing stuff.
The Canadian group is a lot of presence on the internet and they have some really helpful information there that's free for everybody. And then these free books that I mentioned earlier, there's also on the Canadian, website, a nice, compendium on veterinary drugs that is free if you go looking on it. There's a lot of really good information out there for helping us in the daily work of veterinarian dermatology and management.
If you are, are inclined or have, questions, you can look me up or email me at my primary workplace at Angel, a little organisation. Here in Boston, it's been around for 150 some years, small hospital which last year we managed to get 860,000 appointments through not in Durham, thank God, but the whole hospital as a whole. So we do have some cases that sometimes require me to drink some caffeine and I will do that as we speak to you guys here.
So, any further questions, I will gladly see if I can answer them if you have any. Thank you. Chris is saying, if it takes 3 mLs of sterile saline to fill an ear canal to the tragus, what volume of eardrops would you apply when applying and treating otitis externa, e.g.
10%? 3 of 4.5, etc.
Is there a good rule of thumb? I think you did sort of mention it, but just if you could go over that again. So, yeah, let's see if I can get my computer to react here because I seem to be frozen right now.
So, see if I can get to that screen part. I'm not sure why my computer is completely dead right now. .
Yeah, so if I were to treat, let's, let's say a medium sized dog, cocker spaniel sized dog, I'd probably say 8 to 10 drops would typically give you A satisfactory coverage of that ear canal, you can treat it twice a day. But if you're not sure you got enough, there's nothing in my world that says you're gonna be overdoing it by putting 15 drops in there. Obviously, it's gonna cost more money and the client might be inclined to, to object to that.
But if you're worried about the, your kill rate of a certain organism, To exceed a a concentration on a, on a certain microbe, the, the more drug that's in there in the surface area is probably gonna kill the bacteria better than underdoing it. So my volume is basically saying if, if I take an ear canal of a medium sized dog, I assume that. Acc, about 10 drops would cover that ear fairly well for a period of time that hopefully will get sufficient bacteria to.
I hope that answers the question. Great, Jane is saying, what is your preferred systemic analgesia in otitis externna in dogs? Mhm.
That's a great question. Yeah, so depends a little bit of what I'm afraid of to happen next. So if I have a dog with any kind of risk for further progression down the ladder of getting vestibular episodes or having otitis media where I, I could suspect that I might have to add in systemic.
Steroids shortly or in conjunction with a GP or flush. I might choose to use either Tramadol or gabapentin or pre-gabapentin as my go to, but amendedine and, and other things that could allow me to combine with a steroid without interfering with the non-steroidal steroid. Whereas if it's more in a chronic phase and I don't have any systemic steroids on board, I will often if the, the, the patient can handle, I will use, meloxicam or, or other uhOx2 inhibitors, no problem.
But I often go and talk to our, our, we have a, a pain group at our hospital. So if I have, Geriatric patients with concerns, I often can forward to them and say if they have particular concerns they want me to avoid, I I'll listen to them. Yeah, we just have to be careful, obviously, there's some Brits on, it's the cascade system as well, so it's just the sort of drugs that .
You know, we can use as well. Well, you, you guys have actually like gabapentin is, is, should be available for, for the cascade rule, right? You, you guys have access to that, no problem.
Yeah, we can use it as you know, but it's obviously, it's human preparation, it's not veterinary. Yeah, true. Yeah.
And then, and here in the US now with the tramadol, with the opioid crisis, now it's been considered a controlled substance that we here at our house actually have a rule that we are not allowed to dispense more than 7 days' worth of tramadol at any time. And that is, is obviously a sad fact that people are, are, using their pet's medication for their own, can do. Because it's, it's obviously the addiction part of it that's, that's our, our concern, but we have this policy now, we had it now for a year that anything more than 7 days have to be dispensed through a human pharmacist.
No longer will we refill tramadol long term. And these are, these are the sad facts of of New England having a huge like we are. The opioid crisis in the in the east coast of the US is is impacting in ways I've never thought about until.
Oh, interesting. Christopher's got another question, he's saying, do you think it's better to use a one mil syringe to deliver a known volume into the ear rather than just use the dropper? Absolutely, yes, that is a great question.
Actually, I, I do that all the time. I have a whole assortment of little adapters to, to put onto bottles. I very rarely use like The, the, the long nozzled tips of various products, be it Otomax or Motomax or Animax or what have you, I will often Tell the client and show them that here we can do this much easier.
We give them a syringe so they can plunge in the ear from above without inserting it into the triggers or into the vertical canal. A, because there's no need to. B, because the patient often will learned.
That this might hurt if the plastic part of the ear canal is rubbing against an inflamed ear canal. And the nasty tip being dragged from the left ear to the right ear is always my biggest nightmare. So, I, I would say probably 50-60% of my patients go home with the medication being dispensed in with a syringe attached to or two syringes if it's for 2 years.
And a little label on it to show how much they have to pull out. They have these little stickers that go on like a line, and I just say, here you go, this is the easiest way, and if your syringe gets nasty, throw them out and grab a new one. I think that's all the questions we've had.
It's, it's about 3:100. We're gonna be cracking on and getting started again at at probably about just just before 4, where we're gonna be talking about ophthalmology. So, Klaus, thanks so much for the, for the sessions.
Both you and Arthur have given us a really great great session. I know we've got a few of the Aussies and Kiwis and a few Americans and Canadians in as well, so I hope you have all enjoyed it. That will probably still get you sticking around for the next session as well.
And, yeah, just thank you again Kys for a great session and a really practical and thought provoking.

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