Hello, it's Anthony Chadwick from the webinar that welcoming you to our webinar tonight which is about beyond antibiotics navigating otitis management. This webinar has been sponsored by Verback. We have Ellie Wyatt, Eleanor Wyatt, who's one of our speakers today, who's going to be speaking about this topic.
Ellie graduated from Liverpool University in 2016, spent a number of years in small animal practise in Yorkshire. She returned to Liverpool in 2019 to undertake a small animal rotating internship. Following this, she undertook a European College of Veterinary Dermatology alternate track residency, allowing experience to be gained in university and private practise.
She obtained a European diploma in veterinary dermatology in 2024 and is a European and RCVS specialist in veterinary dermatology. Since the completion of her residency, she has enjoyed providing dermatology services for a number of institutions in both the UK and Ireland. And her main interest is clinical dermatology and she's also authored several papers, er she enjoys passing on information to both students and general practitioners, which in turn will help a wider number of pets and their owners, and then, We also have Ollie who is the veterinary field advisor for Verback.
He graduated from the University of Nottingham in 2019, spent some time in small animal companion practise, whilst returning to Nottingham as an apprentice where he obtained both a certificate in in advanced veterinary practise and a Master's of Veterinary Science. He now bridges the gap between frontline clinical practise and the commercial advancements shaping the future of animal health. In his role as a field advisor for Verbach, Ollie also brings vision to life by translating complex science into actionable insights for practise veterinarian practising veterinarians.
Ensuring they have the evidence based support necessary to optimise patient outcomes, so really looking forward to Eleanor and Ollie's presentation, so er over to you. You're standing in your consult room about to see the 2nd case of canine otitis externa today. You've already seen one this morning and looking at your list, you know you have one this afternoon.
You know you need to treat the patients in front of you, but in the back of your mind you're aware of your role as an antimicrobial steward. Hi, I'm Ellie Wyatt, a diplomat of the European College of Veterinary Dermatology and an RCVS specialist. Let's discuss beyond antibiotics, navigating otitiss management.
So what is otitis externa? Otitis externa is a really common problem in dogs. It accounts for about 7% of the consults that we see and can be described as inflammation anywhere from the external auditory meatus down to the tympanic membrane.
Sometimes the ear pinna can be involved too. So when we're taught about otitis externa, we're often taught the PPPS system, and this stands for predisposing factors, primary factors, and perpetuating factors. This then can lead to secondary infections, but I do think one P is missing, and in the veterinary field, we're very good at recognising it in other forms of disease, and that is pain.
So we should always remember that ear disease can be extremely painful and remember to include pain relief in our treatment plans for these cases. So what are predisposing factors? Predisposing factors are those conditions which potentially allow otitis externa to occur in patients if there's a primary factor involved in that case as well.
So these can be anatomical in nature. Your patient could have really hairy ears or naturally narrow ear canals like Sharpes or French bulldogs. They can also be lifestyle factors, the patients that swim a lot or have owners that do some overzealous cleaning.
Then we come on to the primary factors. These are the conditions that allow the inflammation to occur in otitis externa. And there's a wide, wide variety of them.
They could be due to atopic dermatitis, which is actually the most common underlying condition in otitis externa. But you could have foreign bodies or endocrine disease such as hypothyroidism that can account as a primary factor as well. Perpetuating factors are those that develop due to the chronicity of the disease.
In early stages, you get mild serumous gland hyperplasia, but this can progress to cause gradual narrowing of the canal until you get complete stenosis in some cases. Sometimes these changes are irreversible, such as mineralization of the ear canal cartilages themselves, and often advanced imaging is used to assess how chronic these conditions have got. So when are we often presented these cases to try and treat in the clinic?
Actually, using this graph, we can show that we have the severity up the vertical axis over time on the horizontal axis. These cases often present at the peak of a flare and you have a lot of work to do to get them back down under that lesion threshold. But if we could teach owners the signs of these conditions early, head shaking, scratching at the ear, malodorous discharge, we could catch them early and try and treat them before the ears become too sore and get secondary infections.
Even better, after that flare of disease has been treated, what we could do is put in place maintenance therapy that addresses that primary condition to try and prevent flares in the first place, which would be better for both the patient, the owners and ourselves. When I get a case of otitis externa present to the clinic, I do a general clinical examination. This could give us clues to the underlying primary disease, but also assessing the pinna.
Sometimes the pinna is the only part of the ear that's affected with otitis externa. Sometimes we need to address this alongside the canal itself, but if the pin is affected, also gives us great clues as to the underlying primary cause. I always palpate the ear canals because you're assessing whether there's still pliability to it or is it really firm, stenotic, and actually probably mineralized.
Whilst I'm doing that, I'm assessing how uncomfortable the patient is and the likelihood that I'm gonna get an otoscope into that ear. If I deem that the patient's too sore to pass an otoscope, why don't we give them a course of steroids, if clinically suitable, some pain relief, and get them back to the clinic in a few days. What I generally manage though, is to take some cytology.
Be that with a cotton bud like we're all used to, or if you have a gloved finger, often the dog actually is quite tolerant of you popping that in its ear after a bit of a head scratch, even in the cases that are quite sore. When I perform the otoscopic exam, what I'm generally looking for is how much discharge is there, what colour is it? What's the consistency of it?
How much discharge is present. But not only that, I need to assess the walls. The walls of the canal will tell us how chronic this condition is.
Is there seruminous gland hyperplasia? Can I actually see all the way down the ear to the tympanic membrane, but it's erythematous or ulcerated or eroded. And make a note of that in your clinical records because then the next person that checks the patient can see have we improved in any or all of these areas.
Ear disease is a spectrum, you go from erythroceuminous otitis externa, where you have erythema, often seruminous discharge, brown waxy discharge, and is often associated with either malasthesia or bacterial overgrowth, usually Staphylococcus. Then you get to suppurative otitis externa. The ear canal is full usually of sticky, horrible off-white green discharge and is often associated with bacteria.
One for example would be Pseudomonas. Erythros ruinousceratitis externa is extremely common in canine patients, and we have both retrospective and prospective studies that have shown this. So in the retrospective studies, about 75% of patients with otitis externa had erythroseruminous otitis externa, and that's quite similar to the prospective studies that have been done, where on average about 81% of patients that presented with otitis had erytheroseruminous otitis externa.
And this raises a question, if we're treating these cases with antibiotics, could we potentially be overtreating them? So let's move on to the key to ot Titus management. Cytology.
You can't come to a dermatology lecture and not expect us to discuss it somewhere. So let's go through it together now. Cytology in cases of otitis is essential.
It lets us know what is going on down that ear. It's usually cheap, quick, and gives us such broad ranges of information. Generally with ear cytology, we're doing indirect impression smears, so you roll your sample on your cotton bud or your glove finger along your slide.
Pick off any lumps. Before you put them in your diff quick, otherwise they'll sit at the bottom. Stain your slides as normal as you would for a haematology sample for example.
Dry it thoroughly and then assess it under the microscope. Let's go through some hints of staining these samples. Generally, I'm doing 5 dips of 2 seconds in each of our pots of dip quick.
But a handy hint, if you share these pots with your haematology samples or FNAs and you're a bit worried about all the bits of seruminous discharge going into the pots, you can actually flood the slides. So just use a syringe, take 2 mLs out of the first pot and flood the slide. Tip it into the sink.
Repeat with the 2nd and 3rd, and it will stain really well. But just a word of caution, it will also stain your sink, so do wash it down quickly, to save trouble later on in the practise. Then, when you move over to the microscope, there are a couple of hints to make life easier here as well.
Look after your 40 times objective. Once you get oil onto it, it's really hard to get off and will make subsequent looking down that lens a little bit fuzzy all the time. And when you're trying to pick out fine details, it can make a difference.
Just to let you know, usually you can actually take the objective off the microscope and give it a really good clean before just screwing it back on. Also, that 40 lens is due to be used with a cover slip, and that will sharpen up all of your images. And a piece of the microscope that people forget about using is the condenser.
So the condenser is the part of the microscope, often just under the stage that you can open or close to allow more light to go through it. Now when you have a really open condenser, you're allowing lots of light to flood through and that really helps when you're getting down to the high powers but can bleach out those earlier lenses. On the other hand, closing the condenser makes your slide really dark and actually gives you a lot of contrast to the slide, which is what you want to use for trichoscopy when you're looking at hair samples.
So as you go up the objective lenses, just open that condenser a little bit each time and it will make your images clearer. So microscopes actually on the condenser tell you how open it should be with each of your objective lenses. So when we're looking at our cytology, what are we looking for?
You could be looking for mites, usually, ear mites or Demodex. And just as a reminder, don't stain them samples if you're going to be looking for your mites, cos they'll end up sitting at the bottom of your pots. Then when we come onto the stain slides, we're looking for inflammation and we want to grade how much inflammation there is and what sort of inflammation it is.
Generally in ears, it's going to be neutrophils, suppurative inflammation. The neutrophils are probably gonna be streaked along your slide because they've done a hard job, they've tried to kill off bacteria and yeast that are present. We're also gonna look for their microbes, coccoid bacteria, rod-shaped bacteria, malacasia, and in some cases we're going to look for biofilm formation as well.
And biofilm often looks like a lacy overview over the slide, or you'll see little halos around your microbes where otherwise there was inflammation everywhere. So why are we looking for inflammation? Well this will actually tell us, do we have overgrowth or infection?
You can have overgrowths of microbes in ears, they're not sterile. Sometimes there are too many microbes and you've got this overgrowth, sometimes you'll just see a few. Infection is present when there's inflammation.
And usually we're looking for intracellular bacteria, be that rods or coccoid bacteria. However, in ears, think of it as a purulent soup. If there's neutrophils and there's microbes, that is an infection.
Spotting bacteria can be quite difficult, and so I came up with these tricks to convince myself whether there are bacteria there or not. So when I'm looking for bacteria, be that rods or coccoid, I always am on the 100 times oil immersion lens with some oil. If I'm seeing these on the 20 times objective, they're not bacteria.
They're also blue, properly blue. They're not purple and a bit pink, they should be blue. And all bacteria come with friends, so you should see multiple types of the same bacteria, so they should be the same size and the same shape.
You might have multiple bacteria present, i.e., different species, and so you'll see some big ones and some small ones, but each of them will have multiple.
And also, when you fine focus through them, they hang around just a little bit longer than the background stuff. Let's think about culture and susceptibility in otitis externa. What is it showing us?
Remember, the ears aren't a sterile environment, so often you will grow something if you take a sample. But to assess whether that microbe is part of the secondary infection, you need to combine that information with your cytology. If you've seen lots of malaesthesia on your cytology but grown a small number of Staphylococcus, that doesn't mean the Staphylococcus is that secondary infection.
Maybe it's your malathsia that's causing you the bother at the moment. And in that regard it's really important that we don't use it for monitoring these cases, because you should always grow something. But if you were to use cytology, you can record the decreasing amount of inflammation and the decreasing numbers of microbes and know that you're on track to treat that patient successfully.
So what does this culture and susceptibility panel tell us? This is a case of pseudomonasottitis, we've all seen them, and unfortunately, as we've seen, there are lots of resistances on the susceptibility panel. Does this change dramatically how I'm going to treat this patient?
Potentially not, because we know that in otitis externa we treat these patients topically. And so we often overcome the mechanisms of resistance in these bacteria by 10s if not 100s of thousands of times. So just a word of warning, be cautious when interpreting your culture samples.
Let's consider treatment further. So what do we have in our arsenal for treating cases of otitis externa? We have our systemic steroids, we have our topical products, we have cleaners, and don't forget we also have our pain relief.
We'll touch on each of these aspects of treatment as we go through this lecture. So let's think about steroids for a moment. I'm often choosing what type and how I'm going to deliver them steroids based on the pathological changes that are present.
The earlier forms of disease where there's just some mild seruminous gland hyperplasia, let's treat them topically. But when you're starting to get into the moderate severe stenotic ear canals, you're going to need to reach for the systemics. And generally in these cases, I'm going to use doses of about 0.5 to 1 milligramme per kilogramme of prednisolone once a day to try and reverse these changes while we can.
Because we've all seen ears that become end stage and unfortunately often they require a surgeon to help them. But let's consider for a second, do we always need the antibiotic that's in the combination products that we have to treat otitis externa? We all know antimicrobial resistance is a problem and very commonly seen.
And so associations such as the BSAVA have come up with support material to help practises try to reduce their antimicrobial use when it's not needed. So let's look at this pneumonic further. There are two parts that are really relevant when treating cases of otitis, and the first we've just discussed, using cytology to gain that information as to whether antimicrobials are needed in the first instance.
And reduce our antimicrobial use when we can. And very luckily, with ears, we can touch them, we can put products in them, and so we have a range of products available to us that aren't antimicrobials that also help treat these patients. And just as an example, here's a few papers of the hundreds that are out there that show us that bacterial resistance is a problem.
But there is also an increasing concern with resistance in Malacasia species. Wild type, generally we're susceptible to the Azoles in most cases, but we're even seeing field strains of malacasia showing azole resistance. So we need to be cautious, even with the yeast.
Together, let's go through some case study examples of how we're gonna treat Oti 6 data. We're going to use these 3 patients, a golden retriever, a Dandie Dinmont terrier, and a Labrador. They all present differently.
And we may treat them differently as well. Case number 1 is this 2-year-old golden retriever. She presented 3 months ago with head shaking and she's back today.
When we look at her ear pinna, there are subtle signs of erythema around the external auditory meatus, and actually this is extending rostrally onto her head. And when we take our cytology, this is what we see. Now it's your turn.
So what do you see on this cytology sample? For me, I'm seeing corny sites. And Malasia.
There are some melanin granules not to be confused with coccoid bacteria. Let's remember they're not blue, and so that rules them out of being bacteria. So how do you want to treat this patient?
We could use some systemic steroids and reduce the inflammation of the ear. We could use topical steroids or we could consider one of those combination products, steroids, anti-yeast and often an antibiotic involved as well. For me, I'd use topical steroids in this case.
I'm going to reduce down the inflammation and we'll probably return that microbiota back down to a more normal level. So let's consider case number 2. You'll probably smell him before you see him.
He's a 7-year-old Dandy Didmon terrier that has presented to you numerous times for otitis externa. When we look at his ear pinner, he's sore, and when we take our cytology, this is what we see. Take a second to assess the slide yourself and work out what you can see.
Me, I'm seeing rods, and many of them alongside neutrophilic inflammation. So how would you treat him? For me, I'm starting with some pain relief and systemic steroids to open up them ear canals as much as I can.
He is probably going to need a topical antibiotic. I don't use systemic antibiotics in cases of otitis externa. He'll need regular cleaning with an antimicrobial ear cleaner, but just be warned, those that contain alcohol will probably sting when you've got sore ears like this.
And maybe you'll consider video autoscopy. Case number 3 is a young Labrador. She's generally poritic but has been driven mad by her ears.
You can see the pinner and also this is the cytology sample. You'll know the drill by now. What can you see down this ear?
I can really only see corneocytes on this one. I can't find microbes, and on the entire sample, there wasn't any inflammation. So how are we gonna go about treating her?
For me, this is the perfect case to use topical steroids in again. We'll reduce down the inflammation, we'll reduce down the pruritus and bring relief to this patient. So we mentioned video otoscopy.
What is that? Videotoscopy is using cameras like endoscopy, for example, to see into the ear canal. The advantage is the magnification and the lighting that we get.
It allows us to really visualise structures, for example, serremous gland hyperplasia or the tympanic membrane. And here are some examples. You can see that we can see in detail what is going on down that ear.
But also with the working channel, we can flush out this discharge. Dilution is the solution to pollution after all. And so removing them bacteria physically, removing biofilm physically will put us in a good place to treat these ears.
So we've done the hard work, we've treated our flare of otitis externa. But what about maintenance therapy? We saw this graph earlier where we treat the patients when they have a flare of disease, but can we actually put maintenance therapy in place that targets that underlying primary cause to try and prevent flares of otitis externa in the future?
The type of treatment we'll use for maintenance therapy depends on that underlying primary cause which in the vast majority of cases is atopic dermatitis. What we have in our arsenal, cleaners and topical steroids. When we think about the cleaners, they're not always created equal.
We have ceruminolytic cleaners, those that break down wax. We have antiseptic cleaners, those with antimicrobial properties such as chlorhexidine or dilute hypochlorous acid. Sometimes you need to use both.
If you have a patient with an overgrowth in that you want to use antimicrobial cleaners on but it's full of waxy discharge, maybe use one once a week and the other once a week. Let's think about steroids. We all know we try to avoid the long-term use in the vast majority of patients systemically.
How about topically though? Often we use them daily in the face of a flare of disease, but we can often then reduce down that frequency to potentially twice a week to try and prevent cases of otitis externa coming back. So let's have a look at topical steroids in a bit more detail.
Not all topical steroids are created equal. The lower the group, the more potent. Let's take for example hydrocortisone, that is in a really high group.
Hydrocortisone aceinate is more potent, and that is because of the diester. The dyester part of the steroid allows it to break down as it goes through the skin, so you don't get a lot of systemic absorption, which is great when we're considering the adverse effect of steroids. Often we're used to using hydrocortisone epinate in cases of atopic dermatitis.
Think about those patients with perianal prurritis or those that lick their feet. We have studies that show when they're used on consecutive days, twice a week they're really good at preventing that pruritus and that inflammation coming through. So the question is, can we use it in the ear?
When considering ear disease, we have two topical steroids that we could consider hydrocortisone aceinate and triamcinolone acetonide. They're both licenced for use in cases of otitis externa up to about 14 days. But when we consider hydrocortisone as sinate.
We actually have evidence for its use as maintenance therapy. We have prospective studies that have gone into detail and worked out that if we use these down the ear. We actually will hopefully prevent flares of atopic otitis.
So let's look into some practical strategies that can be used to help the clinical team as a whole treat cases of otitis externa but potentially reduce our antimicrobial use. A large scale UK clinical audit found that before it was done, less than 20% of cases of otitis externa had cytology performed, and yet 50% were prescribed high-class antibiotics to try and treat the otitis. When we have erythros rheumonosotitis externa, why don't we consider a steroid focused plan?
We can have the patient in, assess them otoscopically, do the cytology, and if clinically suitable, clean the ear. And treat them with topical steroids, then have the patient back, review the case and plan ahead to try and prevent flares of otitis externna in the future. Internal clinical audits can be a great way to see what we as a practise are doing.
In cases of otitis, we could consider how many patients are getting cytology, how many patients are being prescribed combination products versus topical steroids. It's really important to have a no blame culture when we're doing these though, it's simply fact finding to help improve our practise as a whole. Generally, you pick a time frame of say 3 months, use the clinical software to pull all our cases of otitis externa and assess how many had cytology, how many had the topical steroid versus the combination products, and see if there's any way that we as a whole could improve.
Could we as a practise do more cytology? And if we're seeing lots of cases of erythros rheuminous otitis, should we be more focused on the topical steroid protocols? Using this information, we can then discuss as a practise team how we want to treat these cases going on.
And you can come up with scenarios and plans for cases of erythros ruinous otitis externa with malasthesia overgrowth or even what are we going to do with those suppurative otitis cases with Pseudomonas or malasthesia. So in summary, ear disease is a spectrum, and maintenance therapy should be geared towards the primary disease to prevent relapsing of otitis and further perpetuating factors developing. In cases of otitis in which the primary cause is atopic dermatitis, topical steroids, for example, hydrocortisone epinate, are crucial for the long-term control of the disease.
Preventing infections and overgrowth is the main way to reduce the need for antibiotic therapy. And consciously changing our approach to the treatment of otitis externa in dogs presents a real opportunity to significantly reduce antimicrobial prescription in practise. And I'm happy to take any questions you might have.
Hello everyone. Whether you are tuning in live or catching this on demand during a rare quiet moment in your week, it's fantastic to have you here with us. My name is Ollie.
I'm here today to share a fresh perspective on how we can manage our canine otitis cases. By introducing quatotic into our toolkit, we can completely redefine our first line approach, allowing us to deliver excellent clinical results while practising the exact kind of antimicrobial stewardship our profession needs right now. Cortotic is a unique corticosteroid only ear spray solution for dogs, designed specifically to target the clinical signs associated with acute erythro ruminous otitis externa, which for me is quite a mouthful, so let's call it echo.
Now, looking at a first line treatment like this, it naturally raises two main questions. First, what exactly is the active ingredient that makes this effective? And second, what does the true clinical reality of Echo look like in our patients?
To answer that first question, the active ingredient is hydrocortisone epinate or HCA. This is an innovative diester glucocorticoid developed specifically for dermatological applications. How does it achieve its efficacy?
HCA is highly lipophilic, which gives it excellent penetration through the stratum corneum, the outermost layer of the epidermis. Once there, it is rapidly hydrolysed into a highly potent metabolite, delivering a powerful anti-inflammatory effect right where it matters at the level of the keratinocytes. From a safety perspective, as the HCA makes its way deeper into the dermis, it is metabolised once more into hydrocortisone, which the body naturally knows as cortisol.
Ultimately, unlike other traditional glucocorticoids we're used to using, HCA is characterised by a clear dissociation between high local efficacy and negligible systemic side effects. Which brings us to our second question, what actually is erythros ruminous, otitis externa? Well, if we break down the name, erythro means red and inflamed, and eruminous means waxy, and that is exactly what we're dealing with here, red and waxy ears.
These ears more often than not, have a dysbiosis present, with yeast and Gram-positive cocky most commonly seen. However, it is vital to know that these are secondary overgrowths, not active infections. This clinical presentation isn't a rare outlier either, with Echo counting for up to 85% of all ear cases seen in general practise.
Because of that, the absolute key to success here is cytology. Assessing for the presence or absence of an inflammatory eate is the ultimate deciding factor that tells us if we are dealing with an echo or if we need to upgrade the diagnosis to a true soperative infected ear. Through this illustration, we can clearly see how this dysbiosis actually develops in our otitis patients.
When an ear case presents, it is driven by an underlying primary disease. This triggers the inflammation with predisposing factors seem to reduce the threshold of going from a healthy ear to an affected one. It is this inflammation that completely alters the microenvironment of the ear canal, creating the perfect conditions for secondary overgrowth and dysbiosis to thrive.
Historically, our clinical reflex has been at the bottom of this diagram, focusing heavily on that secondary overgrowth with triple action polypharmaceuticals. But as the cycle shows, the overgrowth is simply a symptom, not the root driver. By using quartotic to directly target and shut down that primary inflammation, we effectively break the cycle.
We change the microenvironment back to normal, which naturally resolves the secondary dysbiosis without the need for traditional antimicrobial intervention. So looking at that cycle, the obvious clinical question arises, can we really resolve these secondary overgrowths without using a topical antibiotic or topical antifungal? To answer that, this randomised controlled trial compared Cortotic directly against a traditional triple combination product containing a steroid, Polymixin B, and meconazole.
If we first look at the baseline data from the study, we can see that close to 9 out of 10 of those ears had yeast as an overgrowth and close to 6 out of 10 had bacteria. Breaking that down into a ratio of 45% of those ears with a pure yeast overgrowth, 45% with a mixed population, and the final 10% with a pure bacterial overgrowth, which might strike a chord in your caseload that you see in your practise. And as we can clearly see here, Quotic achieved a completely comparable success rate to the polypharmaceutical used throughout its application and even for 4 weeks after the course had ended.
Demonstrating that when you control that inflammation, the microcosm within the ear will improve, fully justifying our approach for first line topical steroid monotherapy. By targeting that primary inflammation directly, quatotic delivers on three crucial clinical fronts. First, it provides rapid control of the primary inflammation itself.
Second, because of the speed of action, it leads to quick relief for the dog. Fantastic for patient welfare and exactly what a worried caregiver wants to see. And third, as we just saw in that data, by taking away the inflamed, waxy environment that the yeast and the bacteria are thriving in, the ear can naturally rebalance its own ecosystem.
So we've seen all the science and we've seen the clinical benefits, but let's talk about how this actually works in practise because we all know that compliance is everything. Quartotic is delivered as a fine mist spray, which ensures an even distribution of the medication throughout the ear canal. The dosing is incredibly straightforward, which clients love.
It is exactly 2 pumps per ear, no matter the size of dog. This completely removes any guessing games for the caregiver, providing a reliable, accurate dose. It is a once daily treatment used for up to 14 days, and from a practical, clinically valuable perspective, it features a generous 6 month shelf life once opened, meaning that one bottle will treat both ears for the full 2 week course.
Now changing our longstanding clinical habits isn't just about having a great product. It's about having that right ecosystem to support it. And here at Verback we have created a comprehensive suite of clinical and client resources to make this transition to Cortotic as smooth as possible for you and your team.
Here we can see some examples, we've got the digital interactive otitiss drawing, which is open access for all you guys, great for showing clients what you're actually seeing on your otoscopic exam. There is also an in-clinic flow chart which guides you clearly through the diagnostic pathways. And also because we know that client education is the backbone of treatment compliance, there are also dedicated postprescription handouts.
So, to wrap everything up, historically, it has often felt like we had to make a compromise in general practise. Either we chose a heavy handed triple action treatment to get our clinical results, or we prioritised the stewardship, worried about the efficacy. Now however, we've got Cortotic.
Cortotic completely removes that dilemma. It allows us to practise responsible, antibiotic free medicine without ever sacrificing patient care. Cortotic delivers an impressive 93.5% success rate at day 28.
So even though the product is only applied for 7 to 14 days, that clinical resolution holds strong weeks after the treatment has stopped. It truly redefines what first line ear care looks like in our everyday practise. Thank you all so much for your time.
I truly appreciate you spending it with me to explore Quartotic and the value it has for our otitis cases. Thanks very much Ellie, thanks very much Ollie as well, we've got some questions if er if you're OK to stay on and answer those. So the first question we have, what are your views on using Trislor with Dexedresson added as a treatment, and how much Dexedresone would you recommend to add to the ear cleaner to be effective?
That's one for er Ellie I think. Yeah, so we definitely used to use, a lot of spiked ear cleaners, but what I tend to find is you don't quite get the benefit of both, so. Maybe you're making the ear too wet because you're having to clean the ear so regularly because you need the steroid application so regularly, or vice versa, maybe you only want the steroid to go in the ear once or twice a week, but you're having to clean them really regularly because it's all part of the cleaner.
We're also never quite sure exactly how long these products will last when you start mixing them together. So I've completely moved away from that and now use cleaners for cleaning purposes, be that squalene or chlorhexidine, however many times a week that I want to, and then separately use my topical steroid. Exactly how many times I want to, so be that twice a week, every day, depending on the scenario, so, because I don't do that anymore, unfortunately, I don't have a bit of a recipe there for you, but would encourage kind of separating out your treatments at this stage.
No that's great and it's really great er Ollie that we've got corotic now obviously in the olden days Eiotic was er put down the ear cos we we didn't want to have that er polypharmacy, but it's great that we've got a specific . Oral drug now. Shana is asking the question, is it, where is it licenced at the moment, Olly, is it licenced in the US or will that happen soon?
So as far as I'm aware, it's not licenced in the US currently, but it's not something I, I'm. I'm aware of in terms of what the timing is for when that may change. So yeah, sadly I can't shed any light there because I personally don't know myself in terms of that.
There's always a lot of paperwork that goes in involved in that, so yeah, sadly, sadly not something I can, I can help with. But definitely in the UK and in Europe as well or just in the UK at the moment? So definitely in the UK I believe in Europe as well.
Again, I, I, I wish I could travel as much as going to Europe and other places as well to know for sure, but yes, definitely in the UK I believe Europe as well. Brilliant, . How Jane er Jane's asking the question Ellie, how do you deal or how do you approach a dog that just doesn't do eardrops?
We've all had those cases. Yeah, they're, they're really tricky because I always say to people, otitis externa is best treated topically, and that is the most effective way to treat these cases. So sometimes what you, you find is that the patients have had years of ear disease and have er kind of res resent treatment.
So often we end up using systemic medications such as systemic steroids in the short-term or the flare management period to make the patient more comfortable and then really must focus on positive reinforcement training to get the patients to accept the, the treatment in the long-term, so really the systemic systemic systemic courses of steroids just repeatedly aren't, Great for the patient, but if they keep them comfy to the point where we can then apply topicals, it's a means to an end, so going in training and having behaviourists on board can be really helpful as well. As you say, I don't think many of us would want somebody sticking a nozzle down our ear, it was painful, so taking the pain away, with steroids will certainly help, won't it? Absolutely, I mean you can combine that with your kind of pain relief of choice, alongside.
I always think we, we do under diagnose pain in cases of otitis and so sending the patient home away with systemic steroids and systemic pain relief, can be, can be really helpful and just allow that patient to then start to tolerate medication application. Brilliant, thanks for that, . So Rebecca has asked, some dogs really react to the spray sound the nozzle makes.
What do you suggest in those cases? A colleague has suggested drawing up the volume equivalent to two pumps and instilling into the ear. So I think I can probably answer that one because it's probably off licence treatment, but that's exactly what I do.
So I draw it up in a 1 mil syringe, walk around with it in my hand slightly for a little while just to warm it up so it's not cold, and I do that with the bottles as well, the bottles aren't so big, you know, if you can take them out of your, your cold cupboard and just warm up the the medication slightly in your hand. Prior to appli to applying it, often it's a lot more tolerated, and so yeah, I will use kind of, certain Aloquats in 1 mil syringes, and the patients tend to, accept that quite readily cos it's actually just a small, small volume in a very narrow syringe, and gets rid of the spray. Amazing, thank you.
Ellie, so how often do you see yeast resistances and how do you treat it? Yeah, so I'm quite lucky in that I'm not seeing too many and I often start looking for it in cases where they're not responding appropriately to er standard therapy and how I would expect them to, especially if I've done an ear flush. And treated them in kind of my usual fashion.
I know some practises are seeing more than others, and so it's definitely something to be aware of, I would then, it it depending on how you'd treat it would depend on kind of the ear in its entirety, and depending on what, what we're resistant to, but there would be a couple of, a couple of ways to do so and I'd probably say reach out to your local, referral centre if you think you've got a case. OK, yeah, I've got, I've got another question here, Dawn. Natalia is asking, what's the systemic effect of cortotic, I think that you did discuss it, Ollie, but perhaps if, if Ellie wants to just step in in concern of idiopathic Cushing's disease during long-term use.
Yeah, so luckily, I've used lots of hydrocortisone aceinate in years for in ears for many years and have not had systemic problems. We know that there will be minimal systemic side effects or adverse effects from this medication because of the diaser bond and how it breaks down as it goes through the skin there. So I'm often asked, can I use this alongside NSAIDs, my patient's diabetic, what do we do that way, and actually in my mind this steroid probably is the lesser of all evils because we have such little systemic absorption from it.
So I will use it on dogs with, on chronic NSAID therapy for osteoarthritis or something like that because I know actually the systemic absorption is minimal. That's great, thank you Ellie, and also, Rebecca is asking how long after cleaning the ear should owners use the courtotic, so what sort of gap would you usually leave? Yeah, so I'm not sure if Ollie has any other answer to this one, but I often say clean in the morning, apply at night, and that seems to work quite nicely for my owners and myself there.
But I imagine you can apply it quite quickly afterwards. Yeah, Ollie, do you want to come in? Yeah, it's er very much like the, the longest, the longer the break, the better really.
In reality we'd ideally want to clean those ears and let them be dry before then applying the cortotic. So that's where cleaning the ears in the morning, using cortotic in the evening would be great for that. In reality, life doesn't always work as, as, as well as that, so as long as possible is, is what we're aiming for.
If the ears are dry, that's best. Yes, brilliant. Anna is asking, can you use this product in very chronic ear infections where the ear canal is very thickened, will it penetrate well in that situation?
So for me I often combine it with systemic steroids in that case because realistically we're asking a lot of any topical steroid to return a really chronic hyperplastic ear back to normal. So usually I'm I am probably using if we can do topical therapy alongside my my systemic prednisolone, generally for myself, prednisolone wise, in really chronic ears I'm thinking about. 0.81 mg per gig once a day for a fortnight or so, reassessing how we're getting on and then trying to get them onto the systemic to kind of maintain that year in the longer term.
Yeah, great. Is Kotic, this one Fer Ollie, now licenced for use twice a week? So it's not got its licence for that, so Cortotic is only licenced in the acute erythrostruminousoitis externa, which is for 7 to 14 days' worth.
The, the data that Ellie was going through is, is really interesting on that, on that chronic aspect of where hydrocortisoneis epinate can be used. But no, it has not got its licence for that, so it would be considered off licence use. OK, thank you so much, Olly, .
Ellie, Stephen says, thank you for the lecture, you don't hear the tumultuous applause with webinars, it's one of its negatives, but, Stephen was really, pleased with the web, with the lecture. He said, I know this is on otitis externa, but have you any advice on culture and sensitivity and antibiotic use for otitis media or Internna? Yeah, so I would kind of highly stress in cases of otitis externa that I don't use systemic antimicrobials, because the penetration into the external ear canal, will, will not, not.
Help your patient. Otiti media and interna is different, and we could do a whole lecture on, on that, but generally, in very brief summary, I'm performing video otoscopy, cleaning out the external ear, performing a miangotomy, taking a cytology sample, depending on the ear, then starting treatment or waiting for my culture and susceptibility to come back and treating based on culture and susceptibility. Brilliant, Natalie, just to kind of follow on from that question and say, what do we do if we cannot see the tympanic membrane, I think people get really nervous about putting something down the ear, don't they?
Yeah, they do. So, for me, if I don't see a tympanic membrane, I do start to worry about products that are going in the ears. So, I'm often, well, everything is off licence, and I'm often using medications that can be used IV, so intravenously in, in that, in that case, just because you, the, if the tympanic membrane's not present, you're worried about, autotoxicity.
Yeah, of course, Jackie, another really great question from Jackie, what is your view on plucking versus not plucking a very hairy ears, e.g., poodles and, and doodles as Jackie's calling, Calabradoodles.
Yeah, I mean we see so many of them nowadays, and unfortunately they are plagued with the curse of A to P and they do get otitis externa, very often. Actually, I generally don't advocate or pluck the ears because we know that when we pluck the ears, we will be causing folliculitis, we will be causing inflammation of that hair follicle, and it, it will grow back. And so what I try and do is maintain that your environment as a whole, so we could be using cleaners that are a little bit more drying that maybe have some alcohol content in, or just treating the environment, treating that patient as a whole, rather than plucking cos it, it would be painful conscious, and so I, I don't want to do it conscious and I know I'm about to cause a lot of inflammation by doing so.
Yeah, brilliant, . Right, OK, I think, let me see if there are any other questions, some of them I think people will have, will have had, maybe go to Laura's question, what do you do if the tympanic membrane is not intact? She's saying she's used Trizor or spiked with Dexedrisin, which we were talking about before, and added, appropriate antibiotic indicated by so culture and sensitivity.
This is more for suppurative otitis, is this still OK? Yeah, so I suppose the big question is, do you have otitis media, otitis interna, are we seeing any of them signs associated with it? For myself, I'm lucky because generally we will do advanced imaging on these cases.
So either if we have a concern that there are neurological deficits, we'll probably be advising an MRI scan. If not, and I've got concerns that there might be otitis media, we'll be doing a CT scan and then I would, treat as above with the mirangotomy, the sampling, the culture and susceptibility. I think again I'd pull apart your risoral I believe was said and dexamethasone and use them separately so that you can clean as much as you need and you can apply exactly as much steroid as you need.
And unless there's a specific concern, cause, or I've noted otitis media, I don't empirically treat with systemic antibiotics in that case, even if there's a tympanic membrane rupture, I've seen many that have a clear CT otitis media wide, a ruptured tympanic membrane floating in the wind on my videootoscopy, and I, I wouldn't treat them systemically. Thank you again Ellie. I think there's a sort of theme in some of these questions about cytology, you know, people refusing cytology, er, the vet isn't doing cytology, you know, I mean cytology is just so massively important in, in, managing these cases, isn't it, so a, a, a good microscope with a, with good magnification is, is almost essential to look after these cases really properly, isn't it?
It is, and I'm really lucky in that I have a microscope with a screen in the consult room, and I'm happy doing my psychology in front of people, so I'll get the owners to come round, they'll gather round and we'll have a look to see what's down there, and actually the owners very quickly start to realise if there's improvement or deterioration cos they can, they can see it in front of them. And I appreciate I'm probably very lucky in that regard, but I used to take pictures with my mobile down the, down the microscope, run back to the consult room and show them, so there are often ways of kind of getting visuals in there to try and engage clients as well. Brilliant, I think that is pretty much all the questions, oh, we've got just one final question coming through, how do we get the team on board with audits?
You were talking about them during your presentation to try and reduce the use of antibiotics, you know, particularly in this case in ears. Yeah, so I think with, with anything where it's a team, trying to get as many people involved as possible. So gathering the team, team meetings, showing people why it's so critical and how it can help, I think is always, always beneficial, and if you have.
One person that's keen on, on doing it, if you can get some pictures of cytology and say, look, if we see this, this, this, this is how we're gonna treat, let's get the microscope out from the attic or the basement and clean it off and let's all really try and use it. Let's get some in-house CPD going and just try and engage people. Brilliant, Ellie, Ellie, thank you so much for that presentation, it was really excellent, and Ollie obviously also for your presentation and for Verbach, for making this possible, he is.
Frustrating cases for, for, vets, and I, I think this has really helped to make it more clear how, how we can treat ear infections and, and ear problems in, in dogs, much better, so really appreciate your, your presentations today and Vervac for sponsoring the event. Thank you very much. Cheers, take care and hopefully see you on a webinar very soon.
Thanks everyone for attending and we will be having this on the site within the next 24 hours, so if you want to look at it again, you've got friends who need to look at it, it will be on the site, and similarly with the certificates, we can get those sorted within the next 24, 48 hours, so thanks for attending and hope you have a great rest of the day, bye bye.
