Good evening, everybody, and welcome to tonight's webinar. My name is Bruce Stevenson, and I have the honour and privilege of chairing this evening's webinar on a topic that I'm sure gets a lot of us vets, tangled and muddled and frustrated. But before we get into that, a huge big thank you to Verbek, our sponsors tonight.
I know they have a number of really great products, related to this topic, so that is really fantastic. But a big thank you to Verbek. For their generous sponsorship of this evening.
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So it is my pleasure this evening to welcome Doctor Jason Pieper. He is a board certified veterinary dermatologist, currently working at Iowa State University as an assistant professor for dermatology. At the Iowa State University College of Veterinary Medicine, where he also graduated in 2009.
He completed the dermatology residence at the University of Illinois and became a diplomat of the American College of Veterinary Dermatology while also completing his master's degree. Jason was a clinical assistant professor and the dermatology and ontology service head at the University of Illinois until 2020 when he returned to his alma mater. Jason, welcome to the webinar, vet, and it's over to you.
All right, thank you very much, Bruce. All right. So today we're gonna talk about otitis externa.
You know, it's, it's not necessarily just rinse and repeat. It's not the same stuff again and again. So, hopefully, I'll kind of show that quite often here.
You know, with our cases today and kind of overview, we're gonna look at just a variety of presentations, clinical signs that you see with otitis. I'm also gonna step into the aspect of acute versus chronic otitis cause those are very different cases, very different management. And then probably even more problematic is the recurrent ones.
So the ones that resolve, they go away for an amount of time and then they come back. So those are the ones that are those chronic recurrent otitis externna that are more considerate, you gotta think about what else to do there. And as a whole, we're gonna do this kind of a case-based approach today.
I kind of like to go through the cases, because I'm sure you all can kind of envision cases just like this that you've seen out there. So without further ado, we'll start with our first case. So this is Morgan, Morgan's 3 year old female spayed Labrador retriever, and this is Morgan, at her pool at her house, jumping off.
She loves to go swimming, at the home there, so. She had a history of just an acute onset of head shaking. So the last two months only is when she started shaking her head.
So it's kind of a recent acute otitis type situation. Prior to that point, never had any issues with ears or skin for that matter. At that time, they went ahead and the referring vet went ahead and compounded, a variety of products with ear cleaner of resotra plus keto flush, but then added in arofloxacin, as well as dexamethasone.
And they were doing this twice weekly for about 2 months, you know, ahead of time prior to presentation to me. And as I mentioned before, she does like to swim and swim quite regularly. In fact, these owners had 5 Labrador retrievers and they built this pool in the backyard only for the dogs.
No humans swimming, just the dogs. So, you know, you can imagine how much she loves swimming. So we kind of looked in the ears, this one on the left, this is gonna be her left ear, and here on the right is gonna be the right ear.
So it's a little bit fuzzy, but you can see what's going on. You can see some erythema, some debris exudate present within there. You can see definitely here all the debris here as well as some deeper down in the ear canal.
So, you know, we got definitely some inflammation going on there with that, you know, as well as just kind of that discharge. When I did cytology, this is what we saw for the left as well as the right. So, as you can see here, there's a mixture population, a bacterial population.
You have your nice rods here, and then you see your cocci here, so you're seeing these pairs. So we got a mixed bacterial population of rods as well as cocci. They're present in both ears.
They're extremely the same. This debris in the background is very likely what we call nuclear streaming from the neutrophils as they're broken down. So we see that present in there as well.
So we got definitely inflammation and active infection. Now, one thing that's kind of being pushed a little bit more in kind of a consideration is, in general, just kind of for us with dermatology patients, is treatment complexity. It becomes a huge issue because you have to think about the more you give the owner to do, the increased amount of caregiver burden.
It was shown by this study that was done, you know, about 4 or 5 years ago, that they, the more they did, higher caregiver burden. And just in our dogs with the wordic and atopic dermatitis. So again, not a surprise, you know, definitely higher amount of complexity, the higher amount of burden that's on them.
Not a surprise at all. They actually took a next step though, not only looking at caregiver burden and treatment complexity, but they actually then looked at veterinary-client relationship. And it was kind of interesting because, I mean, it makes sense, the more you give them to do, the more caregiver burden you have.
And actually, it has a negative opinion and negative effect on the veterinary-client relationship. So there's kind of that aspect, the more you give them that may actually alter and affect your relationship with the client. And so they actually said, you know, efforts to reduce your caregiver burden by using the simplest effective treatment may benefit your veterinary client relationship.
Obviously, it needs to be effective as well, but just something else to think about. Now, with Morgan, definitely, I'm gonna say we need to clean the ears. We need to clean the ears and kind of deal with that.
Now, when we're talking about cleaning ears, a big proponent of that, you know, there's a study that was done years ago, there in Europe where they actually looked at antimicrobial efficacy of a variety of ear cleaners. Again, some of these products are available in the US, some are just in Europe. But these are kind of all the options that they had.
They looked at staff. Previously called Amedius, now Sue Emedius, as well as Pseudomonas. And, you know, there's things just to look at.
What I mainly look at this and see is that Triz EDTA. I know a lot of people use Triz EDTA as an air cleaner, and I think it can work for its additive effect, but it's purely an antimicrobial activity. It did not kill bacteria whatsoever.
And then we have a couple of other products, the Clean Oral as well as Mak HC that were also, all three were at the bottom of both charts, kind of looking at that. So, again, not great effect for those. Another study, and this was actually done by Verbe.
This was at one point when they had Epiotic advanced as well as epiotic. They actually kind of just compared the two of, if we use this product twice daily for 2 weeks, will cleaning alone take care of things. And you can see the number of yeast.
Toxide, as well as rods, did decrease significantly over 2 weeks. So we know ear cleaning could be beneficial, but again, this study is based off twice daily for 2 weeks. So that's quite a bit of work if you kind of sit there and think about that.
Because some people very commonly say, hey, let me just give them this ear cleaner and see how that works. It probably needs to be done more often than that once a week that people may recommend or even twice a week to actually have that microbial activity. What about treatments?
So if we're sitting there thinking treatment-wise, you know, Verbe did a study and this is kind of looking at social media, and they looked at posts by owners as well as veterinarians, and they kind of compared the language about ear infections versus the language in general, just to kind of say, you know, what is their opinion? What is the owner's opinion? What is a veterinarian's opinion?
So we'll kind of go back to the study a few different times in there, but one thing that they looked at right away, pretty much owners 7.5 times more likely to use dislike when discussing treating their dog's ears. So they don't enjoy it.
And again, it's not a surprise. I mean, as somebody who has a dog that has some ear problems, definitely, that's not fun. It's not fun to treat them, you know, they talk about up here, the dog tries to bite the.
And, you know, this one says they clean and then as soon as they get mad, they go hide in their kennel, you know. So, again, just having that, that affects that relationship with the animal, you know, so which then, you know, obviously could affect the veterinary client relationship. So owners don't enjoy it, which is probably not news to anybody there.
When we talk about treatment though, I kind of break them down into short acting and long acting. And short-acting, I consider it needs to be done daily throughout the treatment period in order to have effect. So I just pulled three products.
I'm not, not, nothing necessarily one product or another, but we got Mometamax, we have Seolan, and we got Positex here. So you can see these are a variety of products, but they all need to be medicated daily. That's definitely the downside is that they're medicating every single day for these cases, which obviously increases the caregiver burden there.
Then I look at the long-acting, and some of this is kind of new and I apologise for some parts of the world that may or may not have some of these products, or they may be different names. But here in the US, you know, we have Claro, which has been out for a while, which is alanco, which you can see right here. Simplera, which is done by Bequial, same exact active ingredients for Fenacol, tbeniphine, Motazone.
And they both are good for you clean the ears, you instil them once, it lasts for 30 days. And so that's kind of the way it's based off of that. A newly approved product here in the US and just been recently launched is something called Momentumax Single by Merck.
This has gentamicin, as well as posaconazole and Moazo fluoride. So, same steroid. Difference is, you have syringes that go into this bottle and you actually pull it up and you get 33 days of efficacy.
It's also a little bit Different volume. This product is only 0.8 mLs where these products, both of them are 1 mL for the product.
So, the only concern I have is the pose console's kind of a big gun for anti-fungal, to be using as a regular type thing. But again, this is what's available currently here in the US. And I know there's some new ones that have been approved and whatnot that are soon to be launched as well.
Then I kind of think of more, you know, persistent treatments. So, two applications by Dera, we have two different products. We have Oscernia, which is forfentacol, trabeniphine, and betamethasone acetate, and duotic.
It's the same exact thing for both of these products except for the Ocernia has for fentacol. Duotic is just antifungal and steroid, which I think is a great addition to this kind of world that we deal with of just fungal or malcisioti ex. Not putting in an antibiotic that could potentially cause some dysbiosis or even resistance for that matter.
Both of these products, you instil it initially and then again on day 7, you instil a second dose, and that's where you get the 45 days efficacy. Here in the US we've had a product kind of off and on called KC Otopack by Dermazoo. It is purely another anti-fungal steroid only with Keoconazole and hydrocortisone, but you instil it weekly.
You instil once a week. It's not an FDA approved product, but you do it once a week during treatment until resolved and kind of go from there. Another product, this one's by Verva, so this is ezodic, has gentamicin, myconazole, as well as hydrocortisone aspinate.
The difference is you instil for 5 days straight, and then it has 15 days of antimicrobial efficacy. So again, you clean ahead of time like all of these, but then you don't clean again throughout that 15 days of treatment and have that antimicrobial efficacy there. Obviously, with the gentamicin, it is a contraindicated for per ATMs, just because of the potential for autotoxicity.
Now, I know typically I sit there and think of this product and I see hydrocortisone, which most of us think of hydrocortisone, we think of it as a relatively weak steroid. This one's actually pretty potent and I really like this a lot. It's one pump in each ear, you know, once a day for 5 days, and again, the pump is 1 mL worth of products, so.
Now, one of the big things that veterinarians talk about when they looked at the social media aspect was compliance. And now the big thing is most people, when we think of compliance, we think of one thing, which is putting medications in the ear. But that's not necessarily the case.
You know, again, when, when we look at social media, there is an aspect of yes, putting the medication in the ear, because people will sit there and do that, and you know, they're supposed to be doing it, and it's only part of the treatment and they're not doing it completely. I have patients all the time that do this, but probably the big thing is rechecks. Getting the animal in for a recheck, getting in for a recheck to make sure the infection's gone.
I'm sure you all have had those cases where they don't show up for rechecks, the infection's not gone, and then what does it do? It comes back right away afterwards. Why?
Because it was never truly gone. So we need to actually treat them. They need to be compliant with treatments as well as those rechecks.
So kind of scheduling those rechecks ahead of time is ideal to try to get them back in and really stress that issue of compliance there. Looking at another study, kind of looking at compliance aspect, was looking at a combination of Ezodic, and they used sirin. And so this one, you know, was done out in France, and what they actually did is they took dogs.
Surroan's dosing is 3 to 5 drops twice a day for 7 days, and then Ezodic with the 5 days, you know, once a day for 5 days. The one big thing you run into with a lot of these short-acting products is think about the tip. It's a long tip that when they put that into the ear, which is made that way so that the medication gets down the ear, they're supposed to be putting 3 to 5 drops.
Now, I'll admit, I'm probably as guilty as anybody else of, I usually say, give them a little squeeze or give them a little more squeeze, you know, but then there's the aspect of how much is a squeeze. We have no idea, you know, but Trying to count that. They said 10% of people could actually count the drops in there.
I think that's high, because I don't know who would be able to do that. But, and as a whole, you know, they actually did see that the veterinarians were rated the Eodic patients to be better improved compared to the Soroin group. But if we're talking compliance, this is kind of the reason why I bring up this article is 20% of the ESodic people were non-compliant.
78. So 4 times the amount of SIA clients were non-compliant. And if you actually look at the reason why, 14 of the 15 people that were noncompliant because they couldn't count the dose.
They couldn't count the dose, so they really weren't able to say everything there. Now, if you sit there and look at other things, looking at, you know, how happy were the owners as well as veterinarians for that, they actually looked at 100% of the Ezoic, we're very happy with the product features, or 75% of the Soroland clients. And then product easiness of use is the biggest issue.
I mean, it makes sense. Easiness of use and the product is called ezotic. It's easy to use and administer that dose.
So it's a great product. It doesn't require you to be in any direct angle, because it's not, you know, it's a pump type system that you can be, the dog can be laying down and the bottle could be upside down and it'll pump in that same dose into every single time you do it. So it's a great product for that.
How long do we treat for? It's always been kind of all those things, and I'll be honest, we're not really quite sure on that. I kind of look at a few different studies.
This one looked at out of France as well, looking at Horizon, as well as ESotic and kind of compared them. And what they actually did is they treated arising cases for 7 days. They had another group that did arizon for 14 days, and then they had the ESotic for 5 days.
And if you look at it realistically, the curve is all about the same. They all significantly improved for the general clinical score as well as the local one, up to 7 days and even continue to improve even now to 21 days, you know, no matter what, even though treatment was stopped somewhere around here or here, realistically looking at that. You know, they continue to improve.
So, exactly how long to treat, I don't know, but I think definitely 14 days for a typical acute otitis is probably a pretty reasonable treatment length for these cases. So going longer and that's probably not needed. And honestly, looking at this, you could even argue and say 7 days of treatment.
That was the horizon for 7 days, got the lowest score and maintained that up to 21 days. So 7 days may be effective for most of these cases for acute otitis externa. Now, one thing we talk about, you know, improvement and everything, this was a study that was recently done by Verva as well comparing Ezodic and Claro, and they compared it for a variety of reasons.
One looking at percent of success. So I think of this product, 2 weeks of treatment, about 15 days to be exact, 30 days of treatment. So, again, realistically looking at at day 7, there was more improved with the Ezoic group than Claro, and even now to day 28, even though treatment had been gone for 2 weeks, 94% successful versus 88% with Clairo in those cases.
Now here's another issue we run into, the volume. This dog's ear is nowhere near this dog's ear size. So, you know, how much are we putting in there for each ear and how much should we be putting in?
It's always a big issue and I run into it, especially with my chronic cases of maybe they're not using enough medication. And this was a study that was actually done out there in Germany, where they actually looked at, they were using sirloin as kind of the amount, recommended drops as sirloin is 3 to 5, did not depend on the size. That's what it was recommended.
And they actually did CT imaging for these dogs to see how much does it Take to coat the actual ear canal and be treatment all throughout looking at the CT images. And, you know, so they looked at 4 dogs and 2 cats. And if you just want to be just really quick looking at 3 to 5 is recommended.
Look at the dosing, 3 to 47 to 85 to 64, and 2 to 3. So, what is their biggest size dog here, this hybrid or mixed breed dog. 44 pounds or 20 kgs, which is nowhere near a large sized dog.
That's a medium sized dog here in the US, you know, and we have many that are much larger than that. 3 to 5 is about half, about half the amount of drops that are needed to actually get this here. So, Valium is gonna be extremely important when we're treating these cases to make sure you get a large enough alium in there to actually treat it.
What about swimming? Swimming is always another issue that we run into with these cases, especially with Morgan, who loves to swim. You know, in her situation, obviously, if she's swimming, she's constantly going to be A, if you use a longer-acting product, rinsing it out, or B, just constantly having liquid in the ear that is going to be causing some issues and create a perfect environment for bacteria, yeast, and everything like that to populate.
So when we sit there and look at Morgan, what did I do with her? So, I did a combination of things. I just cleaned the ears with epioic advanced there in the hospital.
And then I went ahead and started with some Ezotic. And I did that both ears, one pump per year for 5 days. Like I said, Ezodic, the dose is 1 mL per pump.
So for a lab like this, it's a good dose and should be enough alium to actually treat the dog. I rechecked her in 2 weeks. Everything was resolved at that point.
Now, obviously, the biggest concern is recurrence, recurrence of otitis in the future, you know, because a lot of cases, you know, we sit there and think, why do they have an infection, what's going on with them? You know, the big concern is, you know, is this an underlying condition? Most cases, I will say if we get ear infections, skin infection.
Pretty much I'd say almost all of them. There's some underlying problem. Maybe it was swimming, maybe that was the issue.
Or does she have underlying allergic dermatitis? And looking for that. Now, I saw Morgan for another 2 years, 2.5 years later, and had no other occurrences of otitis externa.
So why she got the one, I have no idea, but she never had none following after that, which is a huge issue. So, obviously, hers was kind of a one-off and was considered a success from there. Now the funny story about her is, while we're treating, the owners actually had to put Morgan into a minivan there, which is what they had, and drive her around the neighbourhood when all the other dogs went and swam, because otherwise she would be pounding on the door and howling to where the neighbours were concerned that Morgan was being abused in the house.
So she had, she had to go there because she would not stay out of the pool if the others are going in there. She felt like she was being abused, to be honest there. So, kind of a funny little one-off about Morgan there, so.
So here's kind of just, you know, looking at ezoic and everything and kind of what it's meant to be. It's for its high externna with yeast as well as bacteria in there. If you have any questions, you can definitely look at the QR code for prescribing information there.
So here's my second case. So, this is Mama boss. Mama boss is a 4 year old female spayed pit bull terrier.
You can see again, left ear on the left, right here, and right ear on the right, right there. I'm guessing most of you can probably guess or estimate what we might see on cytology with these ears because there's a little bit of erythema going on, but a lot of seruminous debris in there. I'm guessing most of you probably thought that there was yeast in there.
Well, guess what, there is. So you can see the maleshesia staining a little bit different depending on where you're looking, there as well as over here. So again, both ears, we have malacesia otitis externna with her.
Again, going back to ear cleaning, you know, ear cleaning is still a huge part of it, especially with Masi, I think, because you have to really get that debris out of there. If you don't get that waxy debris out of there, honestly, I think the infections just keep kind of persisting on and on. Looking back at that initial study, I showed before, looking at it, they actually looked at Malaceia as well.
And again, a lot of the same products on top as well as the bottom. So you actually have the same three on the bottom, the clean oral, mak HC and the Trez on the bottom. But you can see all of these products here on the top that were effective at killing malacesia.
This study has actually been another product of it was, or another study was done in the UK looking at a variety of other air cleaners and seeing how effective they were, and they see the top 5 are this clean oral dog, EOI Advanced. Malceic oral, san serum, and trazultra plus keto. Obviously, we have ketoconazole in there, so it should be effective at killing that.
Otherwise, a lot of these other ones have PCMX acids in there, stuff like that. They can be helpful, propylene glycol, things like that, alcohol in the top one as well that could be affected. But all of those were shown to be highly effective at killing mals in vitro.
Now what about treatment wise? I'm sure most of you, and honestly I myself as well, antifungal topicals is what I'm thinking about using. Have any of you just used topical steroids only for these cases?
It's something that's out there in the literature, so I'm just kind of just talking about it briefly, is that there is actually, in Europe, there is the hydrocortisone aspinnate ear, you know, only by itself, with no antibiotic or no anti-fungal, and treating directly into the ears for that alone. And actually saw very good success treatment of 7 to 14 days of just that. Was actually able to help out with the bacterial or yeast overgrowth and significant improvement between them when they compared it to control.
And the control was the perniyanzole polym mixing combination. So you actually have an antibitic as well as the anti-fungal in there. So good results, which is clearing that.
I like to look visually at, at studies and stuff, so This is what we call the OTUS 3 score. So it's kind of like the inflammation, irritation, discharge, odour, stuff like that, that they're looking at, with these OTUS 3 scores to actually see how severe they were. But no matter what blue line, the hydrocortisone aspinnate, and the control, which is the anti-fungal steroid and antibiotic, they have very similar kind of curve going back to day 28.
And actually, when they said that there was only yeast, You can actually see that there was a similar decrease from 2.6 to 1.2 and 2.6 to 1.7 in the control.
So actually, the HCA study actually showed more improvement there. And it might be just because of the amount of yeast and grow within the waxy urinous debris. And if you can decrease the inflammation, you decrease the waxy production within the years.
Now, the big problem that we always think about myself as well is We're doing chronic steroids, is that really good? Or are we gonna cause harm or long-term issues in there? And obviously, within the years, I worry about overgrowth of other bacteria or yeast that might be causing some issues.
So, that would be the big concern with doing kind of a chronic steroid, into that area, whether that would be Any issues or have any problems with it. Now, that's that dog, mama boss. You can see all this through mis debris there, but when I did a really good cleaning of her ear and looked down, this is what I saw.
So this is what we call a big old sermonolith. So this is a chunk of debris, hair, waxy, skin, all this that kind of form this concretion or like a rock, more or less that kind of plugs this ear canal. This ear is, this is a foreign body, more or less.
This is a foreign body that's in there. Is not going to allow this infection or inflammation to decrease until it's removed. And there was actually a study looking at that, you know, out of the UK as well as Australia and saying, hey, these cases that are not responding to malaceia treatment, appropriate treatment.
What else do we need to do? Do we need to do a deep ear flush? And they actually found that 91% of those cases responded with a single deep ear flush.
And so that was significant improvement showing there. And I've seen that in those cases where you need to really just get the debris, get the nitis out, that might be sitting on the TM. If you can't get rid of that debris, this infection will not resolve.
I've had two cases recently that that was the case. And until I removed all the debris from the ear, it was never going to completely resolve. So with mama boss, that's what I did.
I did a deep beer flush, removed that sermiolith. At the time, I went ahead and used the compounded product for the ears of a comazole as well as dexamethasone to get away from using a steroids or antibiotic in there, and I did that for two weeks. Again, she didn't have any recurrence for 2 years.
So significant improvement with that. Again, why it happened, probably just that sermon that was in there, just debris that kind of filled up and compacted in. In fact, after I did the ear flush, this is what your eardrum looked like.
So you can see it's thickened, it's abnormal. There's still some debris that's right there that's getting flushed out at that point. But again, I removed that foreign body and you can actually even see some redness all throughout here of where it was adhered to the skin and causing some inflammation on that area.
So, again, one of those situations where you need to do something else for these non-responding malaesia otitis externma cases just to get it to resolve. All right. On to case three.
So, this is Gracie, 8 year old female spayed Yorkie. History of pruritus of the ear, shaking the head. Previously was treated with topical therapy, including Motomax, Clairo, Ezodic, you know, a variety of different products.
The key is, though, she has a history of atopic dermatitis. This is kind of where we shift more from those acute, these chronic cases on a regular basis. And she's treated with her adipe with cytopoint, so Mocho antibi to IL 31, which works well to help with pruritis.
So that's what she was currently receiving, when she presented it to me. When I looked in the ears, this is what I saw. So you can see we have a little bit of waxy serminus debris here within the external ear canal, more on this right ear.
But what's all this other stuff here? These are all those erminus glands, ermus gland hyperplasia, all that lumpy, bumpy kind of cobblestone appearance of the external ear canal, so they're highly inflamed in that area. So that's kind of what we're seeing there.
Now, I'm sure a lot of you are probably thinking, OK, we have yeast again there. But that was what was surprising. We actually found no infection.
So you can see cytology for both ears. We have neutrophils, we have keratinocytes. And that's it.
We have no infectious agents whatsoever in this ear. So it's purely just a sterile otitis externa, and that was all that we had going on. So we have no infection actively to treat.
Now, we do have some debris in there. So I am gonna recommend your cleaning anyway, just to kind of help remove some of that surmus debris before it builds up into something. Now, I haven't talked about this before, but why do we do ear cleaning from the get-go?
What's the reason for it? You know, looking about 20 years ago, probably a couple of the leaders in otitis in the dermatology realm, Tim Nuttall, Lynette Cole did a study kind of comparing UK versus US perspective on ear cleaning. Pretty much it comes down to Air cleaning is an essential part of any treatment regimen to aid in speed of resolution, because you're removing these three characteristics exudates and debris, purulent material, and inflammatory debris.
And also small foreign bodies, microorganisms, so all your infectious agents, as well as toxins, you know, so there's a variety of things you're trying to physically remove from the ear that can just kind of sit there and cause more and more problems as they go along. So that's kind of a big issue there. Now, how do we clean?
I mean, yes, we talk about a variety of different ways. You know, you can go with just cleaner. Putting in an ear cleaner, massage it, let the dog shake it out.
I know that's what a lot of clients will try to do. It's usually not the best. I like to fill the ear canal, plug it with a cotton ball, massage that ear canal really well, and with time, as they're massaging it, they're gonna end up kind of dislodging a lot of the debris that's in there, and it's gonna get stuck on the cotton ball and removing that.
So, I like that for my basic cases. There is a system that is called or flush. It's available, not available always, top left here is a human product initially, but it has a tip that you could put into the ear and this hooks up to your faucet, sink in the clinic, and you would pull the trigger on it and they would flush water in and suction out at the same time.
So this is a way to kind of in an awake animal to help do that. Some people really like bulb syringes. I will say I don't like them unless I am have the animal sedated and protect the airway, everything like that.
I worry sometimes if you get this tip in there and you seal off the ear canal, that force that comes out from the bulb syringe can actually rupture the TM. So I'm not a big fan of that. Some people will pass red rubber catheters in there into the ear.
Again, you're probably gonna have sedate, it's not gonna be highly beneficial. The dog will probably shake its head while you're doing that. There's also this human product that we've used here in the hospital here called this rhino earwasher.
And I actually really like it because you have a little trigger here. It's got a rubber tip that you can actually kind of put in the ear as you're pulling it, it helps to really get some force down there in the horizontal ear canal to help dislodge a lot of debris. So, I really like using that for my awake animals as a better way to clean than just with cleaner and a cotton ball.
And there's always a videotoscopy. So, using that, you know, with pump and flushing and everything like that, which is again, what we do usually as our last step type thing, anaesthetize going in that way. So those are a variety of different ways you can clean those ear canals.
So what do you wanna do for treatment for Gracie? So I just said we have a sterile otitis externum and we got the debris in there and that's it. So, what do we need to do?
We need to decrease the inflammation in the ear, right? You know. And one of the things that I've looked at, and I've used a decent amount, is there's a study about 3 or 4 years ago, looking at adding dexamethasone to a variety of different ear cleaners and looking at stability over 90 days, and saying, would it be stable to just have some anti-inflammatory effect topically in that ear.
And what they did is they actually found that All of the products except for one product, which I'll show the products here in a second, was stable and stable throughout those 90 days. So the dexamethasone was there and gonna be present all throughout those 90 days, which is ideal. And if you actually look at these are the four products, the Triz Ultra Plus Keto is the product that was not stable.
You can see the yellow and the blue, depending on the temperature, how it drops off and it gets outside of that 10% acceptable range, looking for it. So that becomes the issue there. But these other 3 air cleaners, the Malecat Plus Trez, EPOic Advance, and the Dukes of Mysore, were all stable with dexamethasone.
This is the this is what I usually use. I use the dexamethasone 2 Migs per mL. You can go at a lower concentration or a higher concentration, putting into the small epiotic bottle, the 4 ounce bottle, and again, it's gonna be stable for 90 days.
Now, the nice thing about this product is that there's not a lot of other ingredients that it might mess with. You start adding in res, you add in dexamethasone, there's lorhex in there as well, ketoconazole. Is the Dex, the dex may be stable, but they never looked at the Coorhexine or the ketoconazole in the Malquet plus.
Is there gonna be effects there that might be detrimental to those ingredients rather than just the steroid? So, I like the epiotic and that's kind of where I end up going quite a bit. Now, do you remember back to the first case, Morgan?
What was she getting? She was getting Triz Ultra plus keto with dexamethasone in there, plus and refloxacin. So again, is all that mixture together with the pro was the product just broken down and destabilised, and that was why it wasn't effective enough, or was it a matter they were doing it twice a week?
Rather than what may be needed and more frequent there. I don't know, but again, just kind of one of those things you think about when you start compounding products, how much issues you could cause because maybe the drugs aren't there. And I know definitely in some, some parts of the world, compounding is allowed, some are not.
Here in the US it is allowed, you know, in some situations, so. Now, this is kind of where going back to before about using steroids as a persistent product within the year. Is it gonna affect the microbiota or mycobiota, So bacteria as well as fungal.
And the nice thing is they actually showed that there was no negative effects. When they actually did memetazone topically in the ears, they didn't see any issues there as far as affecting the microbiota. So that's kind of a good aspect to think about.
It's not going to suppress anything and cause any issues there. Now, if we're thinking steroids and we're thinking anti-inflammatory, definitely, if you're looking at, this is kind of a steroid chart provided by Verbe they have with their products. Obviously, the hydrocortisone aspinnate, if you look from there down to the seria, these are all class 3 or potency glucorate class 3, so highly potent type ones.
You can see the amount of steroid over the course of the treatment that is administered for Ezoic compared to the other ones. So, significantly higher. Sean is higher, but again, it's a very weak potent steroid.
But you can see just how much stronger it is, which is the reason why I really love the E and the hydrocortisone aspinnate, and I'm extremely jealous of Europe where they have that product without the antibiotic and the anti-fungal, cause I would love to have that product here in the US for us. Now, if you look at, again, comparing Cleiro, which has a decent steroid in there as well, as far as potency with the methasone, comparing it to hydrocortisone aspinnate with the Ezodic, that same study I mentioned previously, by day 2, they saw a significant decrease in stenosis, odour, and debris within the ear by using the Ezotic compared to the claro. And actually, the odour and the dirtiness persisted up to day 7.
So again, quick, fast-acting, which is huge because if you look back at kind of the initial study where they actually looked at the relative insight for clients, what's their biggest issue? I apply it, the animal doesn't like it, they're painful, they go hide, stuff like that. So if you're doing this and it's decreasing, you know, inflammation, everything, you can see how much it decreases pain extremely quick, decreases the stenosis, very fast acting, which is gonna be highly beneficial for this product.
So what did I do with Gracie? Unfortunately, I don't have the hydrocortisone aspinnate by itself, so I use the dexamethasone in the epic Advanced. I did it twice a week for 3 weeks, and then I did weekly afterwards.
And that's kind of what I did to kind of decrease inflammation and kind of help from there. And now, the big thing with Gracie is, why does she have titi externa? That is the huge issue here.
And we know, we know initially she has atopic dermatitis. So she has adipe which affects not only the skin, but as well as the ears. And in my experience, Cytopoint does not do much for inflammation within the ears on these cases.
So if I have a case that the cyto point controls the rest of the pruritus on the body, which may be working with Gracie. Then I just try to do a topical steroid in the ear to see if I can just keep things equal and still be successful and kind of go from there. And so that's what I did with Gracie.
And again, I had some significant improvement with that. And she was just on a maintenance ear cleaner on a regular basis with a little bit of dexamethasone in there to kind of keep the ears under control and kind of keep it quiet. So, rather than making a wholesale change away from the side of point, we just tweaked her treatment plan a little bit.
All right. Last case now. Obviously, I can't do a not I just talk and not have a cocker spaniel in the case at all.
So, we have Bruno. Bruno's a six year old male New York cocker spaniel. He has had otitis for 4 years.
Like cocker spaniels, he might have had it for 5 or 6 years since he's 6 years old, but, you know, he's only had it since about 2 years of age. It definitely resolves with treatment, but then it returns in a few months. Currently, he has infection that's just not resolving with therapy.
He has been treated with clero. He's been treated with betraotic. He's also currently on Apaquil for his atopic dermatitis because he also has skin lesions and policing, stuff like that as well, along with the otitis.
When we look in his ears, this is kind of what we see. So again, they don't look horrible. There is some serous debris in there, quite a bit of erythema in through there.
Again, this one narrows down even more, more stenotic. You can see a lot of the surmus gland hyperplasia, more debris kind of stuck in there in different areas. So, definitely a little bit more issues going on there.
Now, if you look at these ears, you're probably thinking, oh, they don't look that bad, you know, that, not really. But actually, surprisingly, when I took cytology of his ears, this is what I saw. So we saw a lot of rods, and that was it.
Maybe it wasn't that bad and it was only moderately affected just because of the fact of the treatment that he's been recently receiving. But again, this is what we have. So we have a rod, otitis externna with obviously your neutrophils here as well.
Now it was non-responsive to claro. Within claro is 4 fentacle. This is probably one of the biggest issues and things you need to be aware of is that 4fentacle, which is in claro oernia as well as symplera, works well for staph.
That's what it's meant for acute otitis externa. Not the greatest for pseudomonas or rods and stuff in general. Also was on betriotic, which is then fox and silver sulfadiazine.
As I mentioned before, he probably has Pseudomonas is our suspicion, just purely if you're gonna play the numbers game as far as what's most common, when you see Rod, Pseudomonas is probably number one by far, and kind of going down from there. Now, I usually ask people, you know, do you actually do graham stain gramme stains within your clinic? And this is kind of a mixture.
Some people like to do it, some people don't. If you're sitting there looking at gramme stains as a whole, They may be beneficial for multiple reasons. A, it may help to differentiate what bacteria organism you have.
Which I kind of throw this chart up here of seeing graham positive as well as negative on the side here. But it also may help to identify Gram-positive organisms. Again, this cytology wasn't bad, but sometimes there's just sheets of stuff and you can't really see a lot.
So sometimes a Gram-positive, you know, coxite can really stand out with that. But again, now, if you're seeing rods in the gramme negative, Pseudomonas, Proteus, E. Coli, you really can't differentiate which one.
Cranny bacterium is the big one. If you see rods and it's gram-positive, it kind of tells you. Little bit more, it might be cranny bacterium there.
And the reason why it is here. I actually have a little bit of a chart. This, this is a variety of different studies kind of put together to see, you know, what's effective, what's not effective.
And you have kind of a mixture of things. But again, if you see Pseudomonas, corn finacle, relatively resistant to that, and that's where we get back to that for fentacle type aspect of it. So it can definitely be something to be aware of if you're seeing.
Gram-negative rods or just rods on cytology. Now, I will say the vast majority of times, if I think it's pseudomonas, it's usually ulcerated within the ear canal, which it wasn't in this case. Now, what about susceptibility?
You know, some people talk about doing susceptibility testing for otitis. It's kind of a controversial topic, I'll admit, even with dermatologists. Now, it kind of goes back to a couple of different reasons.
This is one study that was done years ago looking at Pseudomonas, as well as staph from dogs, and looking at ear products and what were the MICs, NBCs, and then what amount were they actually achievable within the ear. They actually showed that the concentration of the ear medication was 26 times greater than the MIC for staff as well as pseudos. And if you actually looked at polymyin B and SSD they're 27 times greater.
So again, going back to the aspect that you can achieve such a higher concentration of your ear medications that you may not, you know, it's probably irrelevant what the MIC and the NBC say. I am not someone that ever actually cultures my ears. I've done, I think, 2 or 3 in the last 10 years.
And this is actually the study, the reason why, because they actually looked at Pseudomonas, 17 cases. Originally, they had 20 affected ears, but only 17 had follow-up. And they actually saw 11 of the 17 cases were resistant.
So what they did is they just cultured the ears, and they just treated like they would normally. Of those 1711, they just chose a resistant antibiotic that was shown to be resistant on the culture. Again, they didn't see this ahead of time.
10 of those 11 complete resolved. One did not respond, but it was switched to another resistant antibiotic and responded. Are the ones that were susceptible, 6 of those were chosen as a susceptible antibiotic.
One of those failed, and they actually switched that to a resistant one and it resolved. So, in total, 12 of the 17 years were treated successfully, 70.5%, to antibiotics that were interpreted as resistant on the culture and susceptibility.
So based on that, I really don't pay attention to the susceptibility testing cause I just don't think it's extremely accurate or matter for ears when it comes to that. Skin, 100%, but ears, I just don't think it's, you know, significant there. Compounding ear meds.
This is something that's done a lot in the US, with different cases. I know, again, parts of the world it's not allowed. But, you know, the only way I will ever compound is if I have veterinary medicine, literature to support stability, everything like that.
Like this is a study that looked at enrofloxacin, and they add it to sterile water, tris ETA epiotic, and epioic advanced for 28 days. This is when both epic and epioic advanced were available at that time. What they actually found, this is where I think is very interesting.
So TC is Trescore. They actually added it on day 0, there was no growth, but when they added afloxacin, something happened, where all of a sudden, there was tonnes of growth with staph. So again, there's breakdown of the antibiotic within there.
And that's what we don't necessarily always find out unless there's a study to show it. So the, this is the exact example of why I don't compound unless I have literature to support it. Probably the bigger thing for a case like Bruno, who's had it for 4 years, what are we gonna do to prevent long-term prevention for this case?
And again, when they looked at, you know, kind of the social media, veterinarians talked about allergies, 21 times more likely than anything else when we talk about otitis. When we actually looked at Pseudomonas, a study done there in the UK by Doctor Patterson, she actually found The vast majority of cases with this allergies, most common, masses, endocrine, and then autoimmune. If you actually look at the percentages, the allergies is extremely high.
4242 cases compared to 8 masses, 7 endocrine, and 3 autoimmune. So very high prevalence that allergies were the most common thing. So I think that is what we need to address unless you see a mass or something else in there.
So, how are you gonna address the underlying issue? Obviously, in these cases, you know, we have a lot of our atopic treatments of Apaquil, cytopoint, Zenellia, new to the market, steroids, cyclosporin, immunotherapy, you know, those are options for treating that. Now, in my experience, Apaquil and cytopoint do great for antipy pyritic aspect on the skin, but nothing for the ears.
Ciclosporin, steroids, immunotherapy, good for anti-inflammatory for the skin as well as the ears. Then really, which is a jack. I'm starting to see some improvement with the anti-inflammatory of the ears, so it might have a little bit more anti-inflammatory than say Apaquil, the other jack that's currently out there.
I'm not quite sure on this completely yet. I've seen some cases that have success, so I think it's to be determined still there. Obviously, adverse food reactions gonna be your other one that you kind of want to sit there and evaluate and go from there.
Here's kind of again, the label for cyclosporin, for yovan. The liquid formulation, which is really nice cause you can actually titrate the exact dose to what's needed. Now, in my experience, though, it could take up to 6 to 8 weeks to work.
That's the one thing I know on the label it says once daily for 30 days and then taper it down. I go out longer cause ideally, you should go until everything's resolved and then go down from there. So what did I do with Bruno?
We did some cleaning. I did actually Amacain dexamethasone solution daily for 4 weeks, and got the infection result. I changed to cyclosporin.
And discontinue the Apaquil. And I think that was a huge aspect to prevent future infections from occurring, by changing that and going more to cyclosporin instead. And Bruno did well.
He did well with that therapy, stopped having infections every two months. He still had infection like once or twice a year, because again, he is a cocker spaniel and there's always gonna be some You know, gland or abnormalities and maybe a stenosis naturally with him from the chronicity. But overall, did very well with that change of treatment and the infection resolved relatively quick in 4 weeks.
So, in summary, I mean, otitis, again, it is highly inflammatory, so you really need a decrease inflammation in the ears. Treatment, you gotta consider, OK, what's the deal? You know, again, it's highly inflammatory, so you need to actually decrease the inflammation.
How you apply the medication and they're able to apply it, I think, is huge, as well as potentially decreasing that caregiver burden. Again, most of these cases, I will say is probably a treatment for life in the vast majority of doing something, so trying to make it as easy as possible is gonna be ideal init initially there. The other thing is you need to be proactive.
Don't treat that ottius externa every 2 months for 3 years, and kind of go from there because what ends up happening is that once it stops responding, then it become mineralized, and then you have an end-stage ear that you're not able to treat and actually resolve and change. And the only thing while then is gonna be surgical removal of the external ear, which unfortunately, is a bad outcome for those cases. Like thank Verbe for sponsoring everything, for this talk and whatnot, and has some great products kind of right in this realm.
And That'll be it then. Jason, thank you so much. That was amazing.
And yeah, as I said in the beginning, it certainly is a topic that keeps vets, irritated as well as scratching their heads. And, you've provided us with a great framework of thoughts and the process of what to go through. So a big thank you to you for sharing your knowledge with us.
Yeah, no problem. Yeah, I, I always kind of say, you know, even though you all sometimes think you're the only ones that struggle with ears, I have my own cases. I have my own cases that I struggle with on the ears as well.
So it happens to all of us. So, yeah. I'd also like to say a big thank you again to Verbek, as sponsors of this evening.
It really is, generous of them to sponsor it. And, just, heads up to everybody, you know, let's sponsor those or support those companies that sponsor our CBD, especially when their products are fantastic. Jason, we do have lots and lots of questions, as no surprise.
I'm going to paraphrase and put a whole lot of them together. We've had a lot of questions around the cleaning aspects, and you did a great job of showing all the equipment and everything else. But the, the, one of the themes that's coming through is, what about cleaning with a ruptured TM or what about cleaning if you don't know the status of the TM?
Yeah, yeah, that's a great question. I mean, that's, that's kind of the unknown and I'll be honest, a lot of times, yes, you go and you treat the ear and you have no idea because of debris and stuff like that. As a whole, I would say stuff that cleaning.
With the, the external ear, if the TM is not intact, so getting into the middle ear. EPO Avan says not to use a ruptured ear, I use it all the time. Triz EDTA would be the other one.
I think those two are probably the, the ones that I have had experience with and I would say are safe for sure. Beyond that, there's some other people that talk about using like the Dukeo MySo solution and that that would be safe. I have not used it, so I can't really comment specifically on that.
Obviously, if there's debris in there though, it is, the, the matter is diluting it and breaking it down and dislodging it and getting it out there. So I think those are probably some of your best options out there. And part of the reason why EPO Advanced versus the old version is it's a neutral pH.
Alcohol and acidic products in general are probably should not be in the middle ear because that's what's caused problems in years past, so. Excellent. Along that same theme, what drugs both cleaners and medications are a big no no with ruptured TMs or unknown TM status?
Yeah, I mean, definitely the aminoglycosides are the ones that people talk about the most and say that they should not be used in the middle ear. And actually, it's interesting, I've talked to them about ezodic and actually the The percent, I believe from the last I heard was something, it was less than 1%. I think it was like 0.02% of toxicity.
But it is a concern. It's a risk. Any of the neoglycosides is a risk.
For Fentacol, all those products, it's probably a bigger risk with them, I would say. I've seen some significant vestibular disease on those. And then again, when When it comes to ear cleaners, you're talking acidic ones, alcohol containing ones.
Those would be ones that, those would be things that I would stay away from. Definitely, you know, the 4 quinolones appear to be safe within the middle ear for sure, historically. So those are kind of what I grab to if I know it's ruptured, and I'm really trying to prevent any potential side effects, so.
Excellent. Couple of other themes coming through is about, dogs swimming and keeping them out of the water like you did in your first case and cleaning them. What do you recommend?
Do you use cleaners as a preventative, for dogs that swim, and do you do it before they swim or after they swim? Yep. So those dogs are gonna swim.
I, I think it's recommended always have some sort of an astringent ear cleaner. And have them do a good squirt in there afterwards. We're not talking full on your cleaning, just after they're done swimming, they're coming out, go ahead and give a good squirt, you know, whether it's kind of like the, the malitic products, the epiotic advanced product, you know, stuff like that, they're gonna be a little bit more drying, and again, Those are ones that typically have alcohol or acid in there.
If the TM's fine, do a good squirt in there afterwards and kind of go from there. So I, I always recommend afterwards for those cases after they've shaken their head really well, just to dry out any water or moisture that may be kind of left over afterwards. Yeah.
Yeah. I'm a scuba diver, and, when we're away on diving boats, every time we get out the water, we don't wag our tails as well, but you give your head a shake, and then you put an ear spray in there because if you're out on a boat and you get ear problems, it's a disaster. Yes, yes, definitely.
Another question, or, could you expand on what you talk about, cortisones being a strong cortisone or a weak cortisone? Yeah. So yeah, there's a glucocoricoid class that you actually look at and, you know, kind of looking at those like the prednisolone acetate, stuff like that is a relatively weaker steroid.
It's in the lower class of one versus if you look at, say, the hydrocortisone aspinnate, memetazone, betamethasone, those are on the class 3, which are more potent steroids. And so they have a little bit stronger effect there. I personally, I will say if I'm worried about any systemic problems, you know, and I definitely don't wanna have any systemic absorption.
I do like the hydrocortisone aspinate because it's gonna stay local and the memetazo. I think those are two products that can stay within the skin and not be systemically absorbed. Affect your HPA access, cause any other side effects, especially if they're diabetic or anything like that.
It's been shown with dexamethasone, that, that can actually affect the HPA access still with chronic use and chronic use is probably every single day versus like once a week or twice a week in ear cleaner, but definitely there is a risk in those cases. So. Yeah, fantastic.
And, and the classifications of the steroids are easy to find. I'll be honest, I'm not 100% sure. I mean, definitely Verba provided me with those before.
I'm pretty sure they are cause I know I've looked in some pharmacology books, but as far as like easily accessible, Other places, I'm not exactly sure where would be a good resource. But as you're asking, I will quick scan up on my laptop while we're chatting. And what people can also do is go back and watch the recording of this webinar and look at your wonderful table that you put up, because I think that is a, a fantastic thing to have.
While you're busy looking that up, Jason, there's a lot of questions coming through about your great images and what equipment you use and whether GPs should have access to that and, and, you know, also pertaining to showing clients, because let's face it, if you put an otoscope down in there and try and get a client to look in it, it's often a, a comedic event, shall we call it. Yeah, no, I, I definitely, ours is the store, otoscope. I mean, we have, I'll be honest, I have a high-end one over $100,000 for HD scope, that I use for deeper flush mask removal, stuff like that.
I don't think people need that. Unless they're doing procedures, which that takes training and years of skill to kind of get there. But I do think having some sort of a videooscope is great.
The one I showed on there is called bed Ovation. It's not what I have, but it's, I put it on there because historically, I found that for over $1000 that people can. Hook up to like an iPhone or something like that, which would be a great way to look in the ear and snap a picture, show the client right there, what it looks like.
They have a lot of other like USB ones like Firefly and stuff like that. That'd be good that, again, you can put it on a computer in the room or whatever, because there's nothing like a visualisation to say they're clean, they're cleaning, they're cleaning, and you're like, Well, I'm glad you're clean, but look what's left. We need to actually sedate and do a little bit more of a deep ear flush or look, that infection is not resolved.
Look at what it looks like now. So, I 100% agree. I think it's something that most people should have some sort of access to, even if it's kind of the lower end ones just to show the visualisation of, look how much debris is in here, or look how narrow and stenotic that ear canal is.
I need to open it. If I don't open it, it's gonna close down and the dog's gonna have more problems. Yeah.
Great question come through here. When or how often or why would you reach for oral products? Be that antibiotics, antifungals, and or steroids?
Yeah, great question. When it comes to otitis externa, I never grab for orals unless the ear canal is completely closed down and I can't do anything else as far as getting products in there, because most of those oral antibiotic antifungals are gonna be within the blood and the blood's not gonna make it to the lumen of the ear canal. In the vast majority of cases.
I know some people will do it when there's a compliance issue and they're not able to get your meds in because it's aggressive dog or whatever, which I think we have some good products now they're longer acting and make those maybe better options. Steroids, I do on a regular basis. If it's really stenotic, I will use steroids to open up the ear canal cause that oral steroids cause that's gonna be your best.
Most potent activity to open up that ear canal completely. Now, if I have middle ear infection, otitis medial otitis internna, and I'm seeing some head tilt, vestibular signs, stuff like that, unless the eardrum is ruptured and open, orals are gonna be needed to get in there. And that's where I usually will use orals to kind of go along with that therapy.
So, excellent, excellent. What about hair plucking of the ears? Yeah, great question.
I usually get that on a regular basis. I will admit I do not recommend plucking the ears whatsoever, unless there is active infection. And the reason why is because if there's active infection, you already have enough inflammation going on.
But as soon as you pluck hairs, or Has out, it causes inflammation within the hair follicle, which that we've actually seen two cases within the last 56 years that purely they had otitis because the owners were plucking the ears. Once we stopped the plucking, the ear infection stopped occurring. So it's definitely a huge aspect there.
OK. We are running out of time, but I'm gonna throw one more hand grenade in here. What about cats?
Cats. Oh yes, they're, they are hand grenade in its own. So, cats are tough because there is not any, there's two licenced products here in the US at least, Tressoderm and Animax, but there's not really licenced products out there.
And obviously, administering stuff into a cat's ear is difficult. I will admit I use most of the dog. Products for cats.
The ones I do not like to use in cats though, is the 4 Fentacol products, because we have seen some pretty significant vestibular disease in cats and that some that did not resolve, even though the eardrum was actually intact, we don't know why it exactly happened in that case. So, but again, otherwise, you take the same grand scheme of things of treatment and whatnot, and underlying disease and going there, but the actual administration of drugs is much more difficult. There's no doubt, no doubt about that.
But I use the products. I will still use the ezodic, the Moa Max, things like that, even though they're not licenced for cats. So.
Jason, I'm sure that the hundreds of people that are logged in tonight as well as those that are going to be watching this recording, would agree with me. We could go on and on and on, but we, unfortunately have run out of time. So it's, just up to me to thank you once again for your time, and I sincerely hope we get you back again.
Talking more about skin and, it, it's just been fascinating, so thank you, Jason. Yeah, my pleasure. I hope everybody took something away from this and have a great rest of your night.
And again, a big thank you to our sponsors, Vervak. Without their generous sponsorship, we would not be able to be here. To all of you that took time out to be with us.
I hope you have learned as much as I have and appreciated, Jason sharing some great tips with us. And last but not least, to back my controller in the background, thank you for making everything run smoothly. From myself, Bruce Stevenson, it's goodnight.
