Hello everybody. My name is Sue Patterson. I'm a Royal College and European specialist in veterinary dermatology, and I'm the director of Virtual Veterms, which is a telemedicine company, and we aim to give vets advice in practise on difficult cases, including, of course, ear disease, which is what we're going to talk about today.
And I'm delighted that Bayer have invited me to give you this presentation today on Netra, which is a new and really exciting product, which I really do think is going to change the way that we manage cases in practise. Let's talk about our learning learning objectives today and then hopefully we can work our way through these in the course of this presentation first of all. So what I want to do is I want to talk about the approach to a notitis case, but I just don't want to talk about how we investigate it.
I just don't want to talk about how we make informed decisions on the most appropriate drugs because those are all hugely important. But what I also want to talk about, which I actually feel is really important and possibly as important, is optimising the experience for the dog and for the owner. I think those are really, really important factors that often get neglected in our urge to make these dogs comfortable and treat these animals effectively as we can.
So what I want us to do is I want us to consider a typical a typical client. This is Mr. Smith, and Mr.
Smith is taking his dog Hercules out for a walk when he noticed that Hercules has got smelly ears. He's an attentive owner, and he's sure Hercules has never had problems before. And so of course, the minute he gets home, like all good owners, he books an appointment at his local vet to get Hercules checked out.
So what I want to talk about is I want to talk about first of all, what client and vet expectations are in their approach to this case. And what I want to talk about is the effect of that otitis on the owner as well as the pet. And then what I also want to talk about is the effect of the veterinary experience on the owner and the pet.
So what I want to do is I want to refer to this case first of all, which was published in the literature in 2016, and this is a prospective study of the effect of otitis externa, both before and after treatment on 20 owners, and it's their assessment of their own and their dog's quality of life. And this is something that we're starting to take much more notice of now, the quality of life of how diseases affects the quality of life and how treatment can improve the quality of life. And what was really interesting is when you look at the data from that study, it shows that 85% of owners found their dog's ears, ear disease time consuming.
And of course, that by implication means if they find it time consuming, if they have a busy, active life, it may well be that compliance may be reduced if this is something that they have to take time out of their day to do. 70% found it unpleasant and that was due to the fact that there was usually a bad odour associated with the ear disease, or sometimes, of course, we've seen it in the consulting room. The dog shakes their head and then they get discharged all over their all over their furniture and sometimes all over themselves.
And again, that again is going to make perhaps some less compliant when we're looking at treatment. And then a massive 85% of owners were also stressed or very stressed by their dog's ear disease. And we know that many of, many owners are very close to, close to their pets.
This actually meant that many were worried that when they were giving the medication to the dog, they might be hurting the dog. And of course, if the dog backs off, if the dog shows signs of fear. When the owner is medicating them.
Then again, this is another reason why an owner might back off and not treat the the dog appropriately. And again, that causes problems with completion of the therapy, potentially, of course, things like encouraging antimicrobial resistance. So really important factors when we're considering how we manage these cases.
In addition, other things attorneys reported, well, they noticed that when dogs had otitis, they weren't as keen to interact with them. There was a reduction in their willingness to play. Often these dogs had difficulty settling at night.
They could hear them. They were restless in their baskets. And then, of course, more worrying, they also found that dogs showed signs of aggression towards their owners when they tried to touch their ears.
And worse still, where dogs had got inbuilt behavioural problems associated perhaps with previous knowledge of something, they also had aggression directed towards their owners just when they picked up the ear medication. So an indication that there were owners who actually had dogs, potentially who'd had previous episodes of otitis, and they were starting to develop signs of ear phobia associated. With medication applied to those ears.
And of course, once we get to this stage, once we start to get an animal that becomes a phobic, it makes it really difficult for us as veterinary surgeons to examine them, and it makes it even more challenging for the owners to actually apply medication into those dogs. So another factor that leads towards a reduction in compliance when it comes to medicating these dogs. So let's look at client expectations.
Things that this this gentleman wants when he goes to the vet. First of all, he's expecting that Hercules can be successfully examined by the vet. What's really important to that client, I would suggest, is that Hercules's veterinary experience is not traumatic.
He's not frightened. He's not hurt. The last thing he wants to do is have to drag the dog in through the door.
He wants the vet to tell him what's wrong, so he's he's got an expectation that the vet is going to be able to examine the dog and give him an indication as to what's going on. And then of course, referring back to what we've just talked about, he wants that treatment to be effective, of course, he wants it to be safe, I think that goes without saying, but also he wants it to be easy to administer. He doesn't want it to be time consuming and because he doesn't want to hurt his dog, he doesn't want to defect that owner pet bond.
So important factors which we're going to come back and deal with when we talk about therapy a little bit later on. So expectations around treatment, we've said, effective, safe, reasonable cost, easy to administer. But let's look at a few more little bits of data there.
What we know is that 50% of owners struggle to administer ear treatment twice a day. So when we're saying easy, it certainly doesn't want to be twice a day when we're looking at medicating these animals if we can help it. And what we also know is that most owners want this to make it, make this job as easy as they possibly can, and if possible, If they're given a complete choice, they'd rather not treat the animal themselves.
They'd like the vet to do it in the practise with a single dose of treatment. And of course, this all goes back to what we were saying before, that a very high percentage of owners want this to be a stress free process, so the animal is treated and goes away without that really bad experience of the of what's actually happened in the veterinary surgery. So, equally important, what's a vet's expectation when we're looking at managing this case?
It happens to so many of us, we need to be able to examine the dog without him or her, for that matter, becoming upset and aggressive. And of course, it's hugely challenging when you're faced with a dog who is a phobic to get near it, to actually examine it, to take adequate cytology, and then to do things like Assess the tympanic membrane to look at the discharge in the ear. So it's really important as professionals that we are able to examine the dog without them becoming upset or aggressive.
We want to make a tentative diagnosis. We're going to talk about cytology in a minute when we move on further through this presentation. So it's really important that we're able to take cytology from this ear to get us in in as to what may be the most appropriate treatment that we can prescribe because if we prescribe the right drugs, we're gonna make this dog comfortable quickly.
And then, of course, what's really important as well is as well as making the dog comfortable, we need to have a happy client. Because if we've got a happy client and that client knows that that dog's experience hasn't been too bad, coming to the vet, they're much more likely to come back for a Recheck, which is crucially important. If this dog's been hurt or upset or it's been aggressive, or you've had to fight with the dog to to examine its ears and put medication into its ears, then the owner is not going to bring that dog back for a recheck, and that, as I say, is not what we want when we're looking at getting good management of these cases and complete resolution of clinical and cytological signs.
So what are our aims when we investigate these cases and what are our aims when we're looking at therapy for these cases? Well, the first thing we need to do to manage this case effectively is we need to think about the primary causes. We need to identify and treat secondary infection.
And then the other thing which is the thing that we often forget about because we get a little bit overwhelmed looking at secondary infection, is we need to identify and correct chronic change in otitis externa. Now that in itself is a whole lecture and we don't really have the time to talk about that today in a great deal of detail. One of the things we are going to talk about when we're talking about managing ear disease is looking at the amount of swelling in the ear and actually trying to reduce the swelling and open up the lumen of the canal because For me, that's really, really important.
What we need to try and do when we treat these cases is try and re-establish the most normal anatomy that we can. So as well as treating infection, we want that here to look as normal as possible by the time we come to the end of that course of medication. So what I want us to do, I want to talk a little bit about theory, and then we're gonna come back to Hercules and we're gonna put all that theory, hopefully into practise and actually work through how we're going to approach him, how we're going to do the cytology, and how we're going to select appropriate treatment for his particular case.
So again, very briefly, primary causes, we know that primary causes are the thing that underlie every single ear disease. Every single ear problem that you see has got a primary cause. What I would say though is there is no great need to investigate a primary cause in every single case, and certainly in an acute case where that dog is coming in and it's not been seen before at all ever by anybody in the practise or another veterinary surgeon.
Then I don't think there's any need to start food trials and intradermal allergy testing and blood samples and things. But one thing I think that is important is that you need to highlight to the owner that that primary cause cause does exist and so flag the fact to them that if we do see recurrence of the disease, it is something we are going to need to go back and examine at a later stage. And of course, if we're looking at chronic disease, if we're looking at a case that's coming back for the 3rd, 4th, 5th time, then we really should be looking at investigating that primary cause, because at this stage, we've already started on that slippery downward slope, where we're going to start to see more severe infection and more long term jab damage occurring within that ear canal.
So just quickly for you, just a few of the primary causes that we may want to consider. When we're looking in canine ears and of course that's what our talk really is about today. Allergy is head and shoulders higher than absolutely everything else.
Again, we don't have time to share all the data with you today, but there's a lot of literature out there suggesting that allergy probably accounts for something like 75% of all cases of otitis externna in the dog. So if you assume every single dog that you see coming into your surgery has got canineotopic dermatitis as an underlying cause of its ear disease, you're probably going to be right in a very large number of cases. Don't forget cutaneous adverse food reactions.
Food allergy can affect ears and it's something that you should think about, particularly in young dogs. Particularly in predisposed breeds, things like Labradors, things like West Highland white terriers, and don't forget contact allergy where dogs get worse when medication is applied suggesting having some sort of contact irritant reaction or contact allergy to that particular medication. Endocrine disease, thyroid disease, particularly, we should be aware of as a primary cause in middle aged dogs, where we have middle aged dogs presenting with tiis external with no previous history of ear disease.
We should think about thyroid disease. And certainly if it's a predisposed breed, perhaps our gun dog types or giant breeds, for example. And then the only other one I would Perhaps pick out here is is parasites.
Odectes yo and Demodex are things we need to check for when we're looking in ears. Otodectes, I would suggest is more common in younger dogs. It's something certainly in the UK we don't see as a primary cause very often.
And Demodex is one we always make to make sure we don't miss because obviously if we have Demodex, On cytology, it will it will influence what we actually choose as treatment. We shouldn't be using steroids and certainly potent steroids in an area where there's demodex. So another good reason to be taking cytology for me is to look for a parasites.
So those are the diseases that you need to be considering with allergy, endocrine and ectoparasites being our most important. Let's think a little bit about infection and what we should say, of course, infection never occurs in a normal ear. If a dog is getting infection in its ear, it's because there's some sort of inflammatory change, which has been induced by that primary cause leading to the secondary infection.
And what we also know is we also know the infection changes. As the disease process changes. And so in acute disease, where we have a relatively open canal where the lumens not too occluded, where we don't have huge amounts of discharge often, we'll tend to see a bacterial population that's almost always going to be cocky, particularly Staphylococcus, Streptococcus, and of course yeast.
As the disease progresses though when we start to see change within the canal, that that population changes and gets a mixed population and then moves on to become a much more gramme negative type of population. So let's just run that through diagrammatically for you. So this might be our acute disease, you can see at the top.
We do cytology, it's mostly cocky. The canal, the some erythema, it's relatively open. There's relatively little signs of discharge there.
As that disease process moves through though, we start to see changing populations. We start to see much more mixed, so we start to see cocky and rods as that canal becomes relatively more narrow. We start to see an inflammatory infiltrate building up in the air.
And as we move down to the bottom of the Slide here you can see that canal becomes very narrowed indeed. We start to see severe ulcerative hemorrhagic discharge within this year and as this bacterial population moves through from gramme positive to mixed infection to an entirely gramme negative infection there at the bottom. And of course, what we should be aiming to do is we should be aiming to treat these dogs while they're still at the top of the page.
We should be starting to treat these dogs adequately while they've still got acute disease and while we've still got gramme positive infection. And that's why, as we suggested before, it's really important when we get these early stages that we deal with infection appropriately. We make sure it's resolved completely.
And then the other thing too is reverse the change in that ear canal. You can see from the top picture down to the bottom picture, there's a quite dramatic difference in the lumen of the canal. And as that lomen becomes more and more occluded, we'll start to see the environment inside the air change and predisposed to that gramme negative infection.
So keeping this canal open. And as you can see at the top, by using a potent steroid inside this dog, as well as appropriate antibacterial and antimycotic treatment is going to play a hugely important part in our management to prevent the disease progressing through the acute gramme positive flora through to that much more chronic gramme negative flora that you can see at the bottom. So, identifying and treating secondary infection, how do we go about doing this?
Well, we're gonna talk in a quite a lot of detail about cytology, it's absolutely crucially important. We may want to perform cultures. Certainly, again, we'll refer to this as we talk about the different organisms we may find.
I would suggest to you that when we are using topical therapy and ears, we are using high levels of drug directly onto the organisms themselves and providing the ear has been cleaned adequately, we're going to exceed the MIC many, manyfold. So there's a strong argument to suggest in many of these cases, culture is not necessary, but we'll deal with that as we go through. On the basis of our cytology, I would hope we should be able to then select our appropriate therapy.
And then just as important is using cytology to establish an end point. So taking cytology to see what's going on is important, but we need to make sure that that infection has completely resolved. And that's one of the really, really important things that we need to deal with when we're looking particularly at some of these long act.
Treatments. It's important to make sure that we get the owner back, we get the animal back to make sure the infection has resolved and that there is no need for further investigation and there is no need for further therapy. So cytology at the beginning of the process and cytology at the end of the process are really important.
So taking cytology, I've already said, I think it's absolutely impossible to prescribe therapy unless you do cytology. When we're looking at taking samples, if you can, it's nice to take a sample from the junction of the horizontal and the vertical canal because that's going to hopefully give us a fair good snapshot of what's actually going on inside that ear disease. And as I've said, if we do cytology, it allows us to make rational and appropriate decisions regarding therapy, and again, it can allow us to make decisions as to whether we need to culture, which may not always be necessary.
So how do we do it? Really straightforward. This is something that you should be able to do in every single practise.
I would hope most practises would have microscopes, but if you don't have a microscope, you can take a sample, take it back to perhaps your main surgery and look at it at a later later stage. So microscopic examination, we should take a swab, as we said, and we want to do both a direct examination, which is going to be un Stained and then we want to do a stain sample. Direct examination is really important because we're looking for those active parasites, looking for demodex and we're looking for Oyo as we said, and then stained earwax obviously to look for evidence of potential pathogens.
And then if we're going to do cultures, we need to do both aerobic and anaerobic culture if we possibly can. So here we have our swab, we roll it along the slide, which is really important. Don't wipe it, otherwise we will destroy some of the nuclear material, and then we're gonna heat fix it.
We're then going to stain it with our diff quick or rapidiff. I tend when I'm looking at is just to use the dark blue stain. I find this gives me a much more accurate result than having to go through all three.
Particularly the pale blue stain, the the alcohol based stain can sometimes take some material off the slide. So I tend just to use the dark blue stain because I'm looking at the morphology of organisms there and I'm looking for an inflammatory infiltrate. I'm not particularly looking at the morphology of the cells themselves when I'm doing is cytology.
Obviously that's very different for skin. We rinse off the excess stain from the reverse of the slide and then what we're going to do is air dry it or if you want to you can gently dry that with a hair dryer or a hand dryer and then we can have a look at that underneath the microscope. So what might we find when we're looking at cytology?
We may see something like this. Hopefully you would all recognise this. What you can see here on this particular slide is you can see large numbers of squams.
So these are the decrimated epithelial cells from the stratum corneum, and these are these large pale blue and dark blue square objects that you can see. And then in amongst that stippled amongst it, hopefully you can see large numbers of yeast. These are typical malacasia yeast, variable stains, stumps take up the stain really nicely.
If there's a lot of wax on the sample, they don't take up the stain, perhaps as well as they might do, but they're classical peanut, peanut shaped, haggis shaped organisms, if if you will, and you can see them there large numbers on this particular section. That's absolutely typical of what we would see with malocasia. Other thing to note is there's no inflammatory infiltrate.
If you tend to get malacesia infection without bacterial infection accompanying it, and that's often the case, then you will tend not to see an inflammatory infiltrate. So how do we interpret this? Well, if I find yeast like this on cytology, I would suggest to you that culture is never going to be indicated.
For me, empirical therapy is entirely appropriate. I need to use an appropriate cleaner. So something that's going to shift that wax, so something that's got a good wax removing component, perhaps something like salicylic acid, squale, as you can see, they're propylene glycol or sodium docosate, and then I can choose my antimycotic, my anti yeast drug on the, on the basis of that.
And when I'm selecting my anti-yeast drug, what I would say to you is that there are lots of, there's lots and lots of choice out there when we're, we're looking at these. So your choice of yeast drug may actually be governed by other components. It may be governed, for example, by the antibiotic in the, in the topical treatment or it may be governed by the steroid in the treatment.
And we'll talk more about that in a second. So let's look at, look at this one. This is very different.
We've very definitely got an inflammatory infiltrate here. These are large numbers of neutrophils. They're really quite degenerate neutrophils and what you can see here are free in the sample, you've got cocky and also contained within the cytoplasm of those neutrophils, you can see large numbers of cocky.
Nice to see there's good phagocytosis on the sample here. So these neutrophil. A very active gobbling up bacteria which shows the dog is mounting some sort of immune response.
But this is characteristic of what we would see, for example, with the staphylococcal infection. So they're relatively large cocky. They're arranged in twos and fours and in clumps.
And for me this is very typical of stalococcal infection on a sample taken from ear disease. So, identification of cocky on cytology, how would we how what would, what would we take from this? Well, certainly again, for me, if this is a first presentation, I would be quite comfortable treating this empirically.
The need to culture, I'd suggest may become more evident if this is a chronic case or where, for example, this is a dog who hasn't responded to rational treatment and we may be suspicious we have a multiply resistant infection. But for the most part with these cases, I'm going to be able to treat these empirically cause I know I can achieve high levels of topical therapy in that year. Cleaning is useful.
Again, with all of these cases, I would always clean first and I'm going to use something that's got good antiseptic solution. So something, for example, that contains lactic acid, chlorhexidine, PCMX or something that's got some alcohol base to it. But again, be careful if we're using something that's acidic or has got alcohol because they can be a little bit.
Stringent in years. So select your cleaners on the basis of what the ear canal looks like. It may be if it's a very sensitive, you choose a chlorhexidine based cleaner rather than anything else.
And then we then want to go on and select our antibiotics and if we can, we want to use stuff that's going to have a fairly narrow spectrum. We're going to talk more about those in a second. We may on the other hand, see something like this.
This is a very different picture again here. Again, we've got a quite marked inflammatory infiltrate, large numbers here of these multi low polymorphs. These are, these are neutrophils, very degenerate.
They're looking squashed. They're not looking like those lovely crisp neutrophils that we'd see, for example, on a blood smear. Then in amongst it we have large numbers of rods and these are Probably consistent with pseudomonas, but the thing about seeing rods on cytology, they could equally be other rods.
They could be they could be coliforms. This could be Proteus. It's very, very difficult indeed to identify the different rods on cytological sections.
But the minute we're starting to see this sort of clinical presentation on cytology, this should actually trigger a very different Approach to the ones that we've done before. For me, I would always do culture on these. Now, I'm, I'm probably going to start some empirical therapy anyway, if this is a severe case.
And again, we go back to using high levels of medication inside the ears. Culture may not be something that we need to, to use, but I would want to take some cultures on it so that I've got that information if I need to. I'm going to use a cleaner, and I'm going to use a cleaner if I can, that's got good gram-negative activity, so something like trizzyDTA.
Which has got good antibacterial properties in its own right, but we'll also potentiate the antibiotics that we're going to potentially use. And then careful selection of antibiotics is important. And when we're looking at rods on infection, and there is a high chance here of otitis media.
Then we need to be really careful that we can assess this dog's ear to make sure whether the eardrum is intact because again, that may give us an indication as to whether we're going to prescribe licence drugs or whether we're going to get off licence and use something that we've made up specifically inside this ear. However, that's a, that's a lecture all by itself, and we're not really going to deal with this. What I would say to you is that this type of infection is rare.
You know, when we're looking at infections, probably 70 to 90% of the cases that you're going to see in practise are going to be, are going to be staff, are going to be malacesia. So it's great to be able to manage these cases, but these are not the bread and butter cases that you need to have a handle on. These are the rare cases that are gonna be seen in practise.
So, when we're selecting our appropriate therapy, one of the factors that we need to think about is we need to think about the three components that are found in pretty much all of the, the products that we're going to consider. They all contain an antibiotic. They're all going to turn an antimycotic and anti yeast drug, and they're all going to contain a glucocorticoid.
And what I think is really important is that, and I'm not expecting you to know what every single air product. Contains. I think it's important to perhaps have your own baseline treatments and know what is in each of those in the same way that each of each clinic should stock a range of different air cleaners for for different jobs, you should have a range of different air products for different jobs.
So you need to know with the air cleaner that you've got what it does. We need to know with your airdrop, what It does. And of course, one of the things that we need to be aware of is if we're going to use fluoroquinolones in ears, because they're critically important antibiotics, we shouldn't be using these as routine treatments.
We should be moving away from these, except where perhaps we've got gramme negative infection. And for me, I would like to use these on the basis of culture and sensitivity. So I'm looking at empirical therapy for yeast.
What I would suggest to you that certainly in my hands, there is very little difference between the five antimycotic drugs that I've actually listed there. So the azoles, clotrimazole, myconazole, positconazole, I would suggest that are all equally good because we're using high concentrations in the ear. Nystatin is one that's often overlooked, but again, it's a good antimycotic drug and then to be again, another really excellent drug.
And for me, when I'm selecting my antimycotic drug, what often influences my selection is not the drug to kill the yeast, it's the drugs that actually accompany those drugs. And certainly when we're looking at steroid use, then that may well influence how I select the drug that I'm going to use. Now because we're putting this this lecture out to an international audience, what I've done here is I've listed some of the choice that you have as far as treatment is concerned when we're looking at antimycotic drugs and the steroids that actually accompany them.
Not all of these will be available to everybody in every, in every country, but just to give you a feel for the massive range that you've got. And what I've done is I've started at the top there with cartomazo and myconos. With products that contain no steroid at all, right the way down at the bottom to the most potent of those drugs where we have to benefit with memethazone.
Memehasone is a really potent steroid. It's an excellent steroid and one that I use. I use a lot and I recommend it's use an awful one.
So just to give you a flavour really of the different steroids that you've, you've got in the different products that you may be reaching for. If we're looking at empirical therapy for cocky, or when I'm selecting my treatment for cocky, then I really want to, if I can use something that's got a relatively narrow spectrum of activity. And certainly, the drugs that are listed there are the ones that I would tend to consider using first.
Soolanacol and then amino glycosides from my Cin, gentamicinyin, and then fusidic acid are the ones that I would use. So there is no fluoroquinolone on this list. When I'm looking at choosing my antibiotics, and that is so that we can, we can actually have an appropriate level of antimicrobial stewardship, saving these drugs for when they're really, really needed for these much, much more severe infections.
And again, we have a wide choice of drugs that we can use. And for me, when I'm selecting these, my antibiotic choice is my first line when I'm looking at it, so I Choose the antibiotic that I want first, and then what I will do is I'll then go and look at the steroid content as well. And again, I've listed for you here the wide range of products that you have available to you with varying potencies of steroids.
So something like prednisolone, a relatively weak steroid, triamcinolone, a relatively weak steroid, hydrocortisone, again, hydrocortisone by itself relatively weak with once you add a seinate to it, it becomes a much more potent product. Then the betamethasones, the dexamethasones, the isoflu predone again, relatively more and more potent steroids with memethazone and hydrocortisone is stepping out right at the top. So again, what's important with your products is to know what the antibiotic is and then appreciate the steroid content so you can select a product based on the steroid that you want to work inside that canal.
When we're looking at empirical therapy for rods, again, antibiotic selection is important, and this is slightly different to the one I've shown you before. Obviously, we have amino glycosides on our list, but now adding to that list, I have my fluoroquinolones, and I also have my polymixing. I like to reserve polymexine for my infection with rods.
I, I certainly think that would be the best way that I would. That I would want to use it. And again, when we're looking at these drugs, we have a wide range of different components from straight antibiotics and refloxacins sulfadiazine without steroid, ranging again through prednisolone, ranging to triamcinolone, hydrocortisone right the way up to our potent steroids.
So again, we got a wide range of products that we may want to consider when we're looking at treatment. So we've talked about using cytology to decide on treatment. We've talked about selecting appropriate therapy, so I've given you a just a, an overview really of the wide range of products that we've got.
We will, I promise, come back and apply those to our use of drugs when we're treating Hercules. And then the other part that I want to just deal with in this little section here is using cytology to establish an end point. And so things that I would hope we would never hear in a vet's waiting room when an animal is is leaving.
Things like, Give me a ring if the ear problem doesn't settle down. Finish the drops and see how he goes. We should not be having these sorts of conversations with clients when we prescribe medication.
What's crucially important is we get the animals back. The owner is not going to know if this dog's ear is psychologically normal. The dog is the owner is not.
Going to know if the ear canal is open and if the ulceration is settled down. What we should be doing is we should be making sure that when we see animals, we get them back for rechecks. So, you know, these are the sort of conversations I would like to hear.
Make a recheck appointment for Mrs. Jones to make sure it's in, it's the dog's in poo. Let's see Fluffy in 10 days.
So be a bit more dictatorial, actually tell them when the dog or the cat needs to be seen so they can actually be reassessed. And then when they get back in, as well as looking at the ear itself, what we need to do is to make sure the infection has resolved. So if this was our starting point when we looked at therapy for this dog, this is our end point.
So this is what I want to find on cytology in order for me to be absolutely comfortable that the infection has resolved, the inflammation has resolved. So the end point in this case is there's no inflammatory infiltrate. We may have the occasional random organism dotted about it, but all we've got is a little bit of wax, a few of those squams, but nothing else.
And this is a stained section. It's just not taken up stain because there's nothing to stain on it. So when we are at this point, this is the point where we're comfortable, we can stop our treatment and perhaps then switch on to some form of maintenance therapy, which may, for example, be regular cleaning or it may be we're looking at investigation of underlying primary causes.
So we've done the theory. Let's now apply that and look at how that approach actually refers when we're looking to Hercules. And let's go back and just remind ourselves of those clients expectations.
So successful examination, non-traumatic, getting some indication as to what's going along and then client expectations around that treatment, effective, safe, easy to administer when it comes to medication of the dog. So let's look at our essential steps in investigation and therapy. We need to take a history, we need to perform more physical, der dermatological and Otic examination.
We've talked about doing our cytology, we've talked a little bit about treatment. So history taking is really important again, that's a lecture in itself. We don't have time to cover that today as we're looking at physical derm and Otic examination.
Again, those are are big topics. But what I want to talk about is I want to talk about much more basic thing and that's the approach to the animal actually in the consulting. Room.
And what is really, really important is before we actually start to touch the dog is to assess that dog's body language when they come in through the door. And these pictures I'm going to show you are taken from a really excellent piece on the Blue Cross website, which I would refer you to if you're interested. So the first thing to do is to assess what we call the four Fs of fear.
That's flight, fight, freeze, or fooling. This first one's really obvious. The dog comes into the consulting room, it sits in the corner, and it looks like this.
Then the last thing that we're going to do is actually approach this dog and try and do anything with it. This dog's in a very obvious negative emotional state, and we need to do something to relax this dog, make it a little bit less fearful before we start to do anything. Obvious, but true.
This one is perhaps a little bit more subtle. So this dog that comes into the waiting room, this dog's starting to show signs of flight. This dog has got its its gaze turned away from it, it's got its tail between its legs, it's got its ears back.
This again is a dog that's showing signs of fear. Excuse me while I take a drink. And so again, if we push this dog, if we start to do things to this dog, this dog is actually again going to become fearful and this is starting us down this path of phobia in the practise and phobia of having their ears touched.
A couple more. This is one that's often misinterpreted by owners. This is where they say look, he's giving you, he's poor, he likes you.
No, he's not. This is a dog that's fooling. This is a dog that's uncomfortable.
This is a dog that's stressed, ears back. Tell between the legs, pour up and again licking their lips. So again, this is a dog again that is in a negative emotional state, and this is a dog where if we progress with our consultation, this dog is starting to become fearful and we're starting to see behaviours that are going to make our life difficult as we go on further.
And then finally, The owner says, oh look, he's trying to play. He likes you. No, again, this is another fearful dog.
This is a dog that's actually rolling over on its back. This dog is stressed. It may be licking its lips again.
It's got its tail between its legs again. This is a dog that's fearful. And again, if we push this dog, we might push this dog through to that full fight response, as we can do with any of these fear responses where they start to become aggressive.
So what's really important is when this dog comes into the consulting room, we assess it. We may do this while we're taking the history, for example, from our client just to see what this dog's body language is actually telling us. So what's really important is we need a dog that looks like the one on the right hand side here.
We need a dog that's showing a positive emotional state. It's bright, it's alert, it's tails up. It wants to see you.
It's happy, it's responsive. And if you've got a dog in this sort of state, then you're much less likely to induce fear. You're much more likely to avoid starting signs of ear phobia than if you've got a dog in a negative emotional state.
What do you do to try and establish a positive emotional state? Lots of things you can do, but something like praise and attention for the dog before you start to examine it, use of play, so getting a ball out, getting a toy out, interacting with the dog, or using food treats, using high quality food treats, food is established, food is associated with establishing a positive emotional state. So it's really, really important before we touch this dog, before we start to do anything with this dog.
We need to make sure it's going to be receptive to being touched, to being examined, to establish this positive emotional state. And if you do that before you start to look at this dog and before we start to do things to it that it doesn't particularly like, and we start and we, we, we aim to maintain that positive emotional state, this whole experience is going to be much better for you, the owner and the dog. So this is a really important first step when we're looking at examining these animals.
So once you start to examine the dog, the other thing that's going to be really important is always approach from the front, get the owner away from the dog, because often they're sending very mixed messages, you know, they want to cuddle it, they want to hold the dog and the dog is, there's no idea what's actually going on in those circumstances. So approaching the front really important, particularly with some of these little brachocephalic breeds, they need to see that you're coming, they need to see what you're doing. Use a nurse to restrain the dog because the nurse is going to restrain the dog appropriately.
They're going to do it so that they're holding it securely, but they're not going to frighten the dog. And all the way through this consultation, try and maintain that positive emotional state. You can see the dog in this picture here on the right hand side is starting to show a little bit of a freeze appearance here.
This is starting to look apprehensive, reverse that positive emotional state before you go on to do anything else. So what do we do next when we, we do, when we do our examination, what we're gonna do is we're gonna talk through cytology and selection of treatment. And what I'm going to talk you through is a common presentation in primary care practise.
We're not going to talk about an exotic disease. This is a common presentation that you're going to see every single day in practise. So this is Hercules right here.
When we look at this, we've shown you something like this before. A lot of erythema, narrow canal, quite a lot of wax in there. And when we start to look at cytology on the ear, you can see there's large numbers of malaceia yeast with some squab.
So quite obviously a malacasia infection inside his ear on the right hand side. What criteria you're looking for when we're looking at therapy? Good anti-inflammatory.
This canal's narrow, it's swollen, it's erythematous. I want something that's going to damp that down. Good antimycotic activity, again, that's gonna be really important.
But also, we'll talk more about this in a second. Easy, stress-free and long acting. Let's talk about these first two components first, when we're looking at selecting our therapy.
And let's go back to the long list of drugs that I showed you before and that's narrow these down. So what I'm looking for when I'm looking at treatment is I certainly want something that's got a decent steroid in when I'm treating this particular case. So that narrows me down.
I take out the products which have got no steroid in. I take out the products with weak steroid in it takes me down to this. What I want, if I can, is I want something that's got a soft steroid in a steroid that's metabolised quickly, that's going to have minimal systemic absorption.
So this takes me down to this list. So I'm narrowing down the types of products that I want to use when I'm looking at selecting a product in for this dog's particular ear. So a good antimycotic drug on the left hand side and then a potent steroid, and I've narrowed it down to hydrocortisone isepinate or memetazone on the right hand side.
Let's look at the left ear. So the left ear again, very swollen, narrow lumen. This time we've got an inflammatory exudate here, so you can see that prevalent exudate there on the left hand side.
We're taking cytology from the ear. We've shown, we've shown you a sample like this before. Inflammatory infiltrate there with neutrophils, large numbers of Cocky suggested that we've got a staphylococcal infection here.
Again, what are we going to choose when we're looking at therapy? We want something that's got good anti-inflammatory effect. We're looking at something it's going to widen that canal up.
So it's going to dry up that discharge, dry up that powerent discharge because the steroid has got good . Is able to reduce neutrophil chemotaxis into that ear, so reduce the flow of neutrophils into the lumen. We want good gramme positive activity that's really, really important and again, easy stress free and long acting.
So here's our list of products again, our relatively narrow spectrum antistaphylococcal drugs on the left hand side and our steroids on the right hand side, and what I'm going to do again is I'm going to narrow those down. I'm going to take away the less potent steroids. I'm going to take away the steroids that aren't the soft steroids that are rapidly metabolised, and this narrows me down to just these.
So anti-aphycoccal drug on the left hand side and then there's potent steroids on the right hand side. So what I've got now is by looking at these dogs ears, but by looking, so looking at Hercules is, looking at the degree of inflammation, looking at the narrowing of the lumen, looking at the cytology that we've got there, what I'm able to do is decide on the criteria that I want for my treatment. I want Good antimycotic drug.
I want a good anti staphylococcal drug and I want a potent, safe steroid that's going to open this canal up, reduce the swelling, reduce the exudate, something that's not going to be absorbed systemically, and I can use with a hierarchy of confidence. So Anneptra Neptra fulfils all of those criteria. Neptra has memehasone, it has fullenacol, and it has tbinophine.
This is a fantastic new drug, certainly in the UK. I know in the states it's been available for quite a quite a while. It's licenced for the use in acute otitis externna and also for acute exacerbations of recurrent tis external due to those two very Common bugs that we talked about staffsu intermediate and malaciia pachydermatis.
So this is a drug that you should be reaching for first line. This is not a drug you should be saving for those difficult cases. This is a drug which is going to help you out in those early acute cases where you need good gramme positive cover, good antimycotic cover, and a potent steroid as far as therapy is concerned.
Let's just talk about the three components in a little bit more detail. I've already mentioned memetazone. We know this is a highly potent lipophilic glucocorticoid, which means it's going to work really well inside the dog's ear, particularly if there's discharge there.
It works really rapidly to reduce that swelling. It's, it's currently the most potent topical glucocort. Could we have on the veterinary market.
And we've already said before something that's really important for me, it's a soft steroid. So it's rapidly metabolised with very little systemic absorption. So it ticks all the boxes for me when I'm looking at something to put inside this dog's ear.
To benife, this may be one that perhaps you're you're not aware of, but this again is an excellent antimycotic drug. It's not an azole drug. It's an Aalamine class of drug, and it works in a slightly different way to the azole and that it it's selectively inhibits production of the ergosterol, which is in fungal cell walls and therefore leads to fungal cell death.
It's really nice again, because this has got Good penetration into keratinized tissue. So it's particularly useful where we've got the swollen inflamed ears and we've actually got a discharge there because this penetrates really well into the tissue where we want it to. So again, good activity against malathia.
Again, this ticks all the boxes for me for what I want for a first line antimycotic drug. Fluentacol Fluphenacol is derived from chlorophenacol and tentacol sorry, phenacol and this we know is a point inhibitor of micro microbial protein synthesis. It acts to bind irreversibly to the 50S subunits of the bacterial ribosome.
What we do know about this though, it is not a substrate for acetyl transferase, and that's the bacterial enzyme that's implicated in the development of the resistance of the chlorophenacol and thiphenacol, and that actually means it's Going to be a really very safe drug to use and that's why it's not listed on the WHO critically important antibiotic list. So this is not a fluoroquine alone. This is a completely different group of drugs.
This is this is related more to chlorophenacol, but it is a safe form of chlorophenacol that you can use with a huge amount of assurance that you're not going to create resistance to other related drugs. And of course, it's got really great activity against staff pseudose intermediates. What else are we looking at then?
Here, we're looking at easy and stress-free application of the drug. And again, this comes back to us maintaining this positive emotional state. This is not what we want to create with Hercules.
We don't want him to be running and hiding behind the chair. When the owner appears in the room, when that, when the eardrops appear out of the cupboard, we don't want them to become frightened or stressed or worse still, become aggressive towards the owner or become aggressive towards the vet. So this is where making this as easy as possible has got to be hugely, hugely important.
And the great thing about Neptra is we know it's a one mil dose and it's suitable for all breeds of dog. And the great thing about it is this is applied in the consulting room by the vet into the dog's ear. So we examine it, we do our cytology, we do culture if we feel it's appropriate.
We do cleaning of the ear with an appropriate cleaner and then we apply it in the consulting room and job done. Why one mil dose? Why is a 1 mil dose suitable for all dogs' ears?
Well, there's a little bit in the literature about the volume of dog's ears, and I pulled this very old paper out of the literature for you just to illustrate that for you. This is a study that goes back to 1985 and it's looking in the measurement of ear canal volumes of 50 dogs with quite a wide weight range here, you can see between 4 and 38 kg. And what this study particularly Found was the volume increased with weight up to 10 kilogrammes.
But beyond 10 kilogrammes, what they found that that volume did not increase. And they found that within that weight range of 4 to 38 kg, that the volume of the air was relatively constant 0.8 centimetres cubed.
So one mil really is going to treat pretty much all of the species that you're going to see coming in through the door of the clinic. The other thing that's also important again is when we're talking about a single application is that it is long acting. And again, we have quite a high degree of assurance when we're looking at NETA, that it is a long acting mode of action, which gives us that, as I say, that assurance that we can apply just a single application that is going to do the job for us.
What that doesn't mean is that we should be applying the treatment in the consulting room and then sending the owner off on their, on their travels. We've already Talked about this reassessment. We've already talked about getting the client in for a recheck.
That may be a week, that may be 10 days, that may be 2 weeks, depending on the severity of the air condition and how confident you are of the appropriateness of your therapy, depending on what your cytology findings were. So whilst one application is great for treatment, you should still get these people back in for reassessment. And we talked about if this is stress free, they're far more likely to come back for recheck than they would be otherwise.
When we're looking at activity down persistent of nectar, we know that fluenacol has got great activity against staff whose intermediates, and we know that when we look at the MIC of staff, the fluorphenacol exceeds that manyfold when it's applied topically. Similarly with Tabeniphine, excellent activity against Malanes pachydermomeist, and again, it exceeds that MIC manyfold after application. Better still, when you look at ear flush studies that have been done and you look at the concentration of fluorenacle 10 days after it's been applied to the ear, it is still, still twice the MIC 90 for staff whoseudins after 10 days and we're to Beine again, really excellent high levels maintained within that ear, 80 times the MIC 90 at 10 days.
And so good activity but prolonged activity with this drug after a single application into this dog's ear. So, finally, have we fulfilled everybody's expectation when we look at the way that we've managed this case? Hercules has been successfully examined by the vet because we took it nice and steady.
We established our positive emotional state. He was happy and relaxed throughout his consultation. We were able to do our cytology and actually identify the type of infection that was going on, and we have had a bit of a conversation with our clients at the same time about primary cause.
The potential need to to investigate those. We chose appropriate treatment based on test results. We gave a single treatment.
The owner can be assured that they do not need to do any further treatment, but we've made sure as a veterinary surgeon that the animal's coming back for that recheck in 10 to 14 days' time, just to make sure that it has completely cleared up. Vet expectation. We assessed that by assessing the dog's body language and establishing a positive emotional state, the vet was able to examine the dog.
Cytology helped establish the infection and the vet was able to prescribe the appropriate drugs. So we've ticked all the boxes for our clients. We've ticked all the boxes as a vet.
Hopefully our client is happy because we've got a happy dog. The dog's infection is under control and we're able to get these animals back for reassessed to make sure that it's gone as well as we could possibly expect. So our final take home messages from this presentation.
What I hope I've managed to stress to you is a successful therapy is not just about using the right drugs in the right way to achieve a clinical cure. Please don't get me wrong. It's really important to do cytology.
It's really important to use an appropriate anti-inflammatory drug, a potent steroid to open the canal up, make these dogs comfortable. It's right. To use a narrow spectrum anti-stalococcal drug in these acute cases.
It's right to use a good antimycotic drug. But what's really, really important is also how we get there. What's really important is when we're looking at treating these animals that we make it stress and fear free, so that journey is much more satisfying for the vet, the owner, and of course the dog.
And that is why for me when we're looking at the use of Necttra, the future really is long-acting. Well, a big thank you to Bayer, our sponsors for tonight, for bringing us this recording. And as I said to you before, we have our presenter who recorded this for us.
Sue, on with us tonight. Sue, thank you very much for a hugely informative and very logical presentation. Thank you.
It was a bit, bit unnerving listening to myself, I have to say. I learned quite a lot. Well, I, I, I, I'm glad you learned a lot because it was an incredibly good and knowledgeable speaker, so.
Thank you very much. Folks, just a couple of technical things. Unfortunately, I am not able to answer questions that are not in English.
I am multilingual, but I do not speak any of the languages that this is being translated into. So if you do have questions, by all means, send them in and we will have them translated and answered. But for tonight, we will only be able to answer those in English.
Also, if you have technical questions about Netra, please contact your local area Bayer representative, and product manager. They certainly are in the best position to answer the technical questions for you. But we will run through a whole lot of questions.
I'm not sure we'll get through all of them tonight, Sue, because there are a lot of them coming through, as well as comments saying, what a fantastic webinar and thank you so much for sharing. And I learned a lot. So thank you for all of those positive comments and thank you, Sue, for sharing with us tonight.
A. There are a couple of themes that are running through here. So I'm going to kind of bastardise some of these questions a little bit, but a lot of them are coming through about the cleaning before you medicate with a long-acting product.
Is this essential, isn't it? And are you not worried that a cleaning before you put these products in is going to dilute the product? No, I, I don't think so.
Cleaning is essential, really. You need to get rid of, the discharge, that's in there, whether it's a waxy discharge, if you've got a malacasia infection, or whether you've got a, a pollent discharge if it's a bacterial infection. Now, cleaning is really important and you won't leave a huge amount of cleaner in the ear if you use some cotton wool, cotton wool swab afterwards and absorb the material onto it.
No, definitely not. Cleaning is, is important, so I would certainly do that in all cases. Excellent.
Another question that's come through on a couple of different formats is about, ruptured eardrums. Indeed, and the question is related to the safety of air cleaning or the safety of nectar. I think.
So, so first of all, what I would say is that in an acute case, you're very unlikely to have a ruptured eardrum. Ruptured eardrums come with chronicity of disease and come as you start to see more severe infections. Gramme negative infections.
Naptra isn't licence for use where the eardrum is ruptured. So if I was if I had a dog with a ruptured eardrum, I would probably look to use something that was an off licence use. But in a in a ute case with staff or with Malaysia, you're just not going to see a ruptured eardrum unless there's a foreign body there like a A grass horn, for example, but you're just not going to see it.
But in ruptured eardrums, that's a different lecture. That's, you know, that's almost always going to be a gramme negative infection. We've almost certainly got a tight this media.
That's a completely different kettle of fish, and that's an unusual presentation, you know, probably less than 5% of the cases that you see are gonna be, we're gonna fit that criteria. I'm trying to look, there's quite a lot of technical questions coming through, folks, as I said before, the technical questions, please contact your local Bayer representative, or area manager, and they will be able to discuss the technical licencing products. .
Can, can you give me a flavour of what those are? Can I, can I help on any of them? How has it been successful?
How long does it, how long does it last? I think they're asking? Oh, several weeks.
Apologies if I've misled people. You wouldn't put nectar in, and then the client clean it every day. Absolutely, definitely not.
I would clean before I would put nectar in, then I would then I would send the client away and I would get them back in for recheck, perhaps after 10 to 14 days' time. Couple of Questions coming up about the, the cleaning pre-treatment when you see them and the question of how thoroughly do you do the ears need to be cleaned and should those animals seeing the ears are inflamed and painful, should they not be sedated to clean it before you treat? And there is no one answer to that particular question because anybody who's in practise will know you'll see a wide range of different, presentations when you're looking at ears.
And of course, you'll get a wide range of reactions with different dogs. You know, you may find a small toy toy breed will be a lot more sensitive to having its air clean in the great big robust Labrador that really doesn't care as long. We should continue to give it tidbits.
So, if the ear is inflamed, if the ear is ulcerated, I would very definitely consider sedation, not just sedation, though some pain relief as well, because there's no point making it just sleepy. You want to make it pain free as well. Yeah, you have to use your common sense.
If you feel it's going to be easy to state that animal, give it some pain relief before it's cleaned, the better. And obviously if you're looking at cleaning the air, you need to choose something that's probably got a relatively neutral pH. You want to select something that's perhaps alcohol free, something that's acid free.
So again, selection of air cleaner is going to be really important to be sympathetic to make sure we keep that dog as comfortable as possible. That's a that's a whole, that's a whole new lecture. There have been a couple of questions that have come through saying, what is your favourite air cleaner?
Oh well, there's no such thing as my favourite air cleaner because, it depends on the case, of course. So it depends what I'm dealing with as to which air cleaner I would use. That's like saying, what's my favourite shampoo.
The shampoo that I would use to treat a bacterial pyoderma is different to the one that I'd use to treat a an atopic. Lots of different cleaners for lots of different things. So I talked about the components.
I like squale based air cleaners for de-waxing, low, low to moderate amounts of squale, I think, are really useful as an air cleaner. I like chloroxidine, lactic acid is good, providing the dog will tolerate it in an air cleaner. I like trizzy DTA if we're looking at a gramme negative infection, and there are lots of different products in different countries that will contain many of those ingredients.
If you refer back to the Slides, I've mentioned the actives that I like to see in an air cleaning product when I'm dealing with each of those types of infections. And then find the appropriate one in the country that you're listening from. Yeah, absolutely.
It's looking at the ingredients in it and deciding on, on what you want. And of course, some of it's based on experience as well. I mean, there will be some dermatologists who will tell you they love air cleaner A, and then I'll tell you I love Air cleaner B.
A lot of it is what works, what works for you, what works best in your hands, really. Yeah, yeah. Sue, we've got so many comments coming through about how fantastic this was and how much people have learned and everything else.
I can't read them all out, but there is one that I would like to read out to you because I believe it epitomises and encompasses what everybody is saying. It's from, and excuse me if I don't get your name right, Athena Sokhana says, dear Sue Patterson, this is not a question. Just to tell you that I really like you.
I have firstly heard you at SAEVC at Barcelona. You are unique. You are my ear idols.
Greetings from Mykonos, Greece. Stop now please, immediately. You'll just make me very conceited.
Well, the, the, the, hopefully, this is, this has been aimed to be a practical approach. Hopefully this will have helped people and one of the things I'm really passionate about is being to treat animals that's fear free and hopefully the approach will allow you to Prevents developing dogs with ear phobia because we all know that once dogs become airphobic, they are absolutely impossible to treat. And those are sadly the ones who often end up having surgery, who end up having to canal ablations or lateral wall resections.
And it's not because we can't manage the cases, it's because we can't get ear drops into them. And I think that is really, really sad. So if it's been useful, then My work is complete.
So, it's been more than useful. It's been absolutely fantastic. So thank you to you for your time and thank you to Bayer for their sponsorship tonight.
Also, a huge big thank you to everybody for attending tonight. We really hope that you have enjoyed. And you have learned from it.
Remember the recording will be up on the website from tomorrow probably and all the translations if you want to listen to it in any of the other 6 languages. Sue, thank you once again for your time tonight. And to my controllers in the background, and Holly, thank you for all your help and support from Bruce Stevenson.
It's good.
