1. Treatment of Otitis Externa - MemberClicks

TREATMENT OF OTITIS EXTERNA

Cynthia Bauer DVM, MS, Dipl. ACVD

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LET'S BREAK DOWN COMMON QUESTIONS

? What ear drops do I use to treat this case?

? Many factors decide this answer. ? Usually not one good answer.

? Can I ever cure otitis?

? More art

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C O N S U LT S ?

? greenville@ ? 864-385-6565 ?

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UNDERSTANDING THE EXTERNAL EAR CANAL

? Formed by rolled annular cartilage

? Lined by skin ? Secretions are protective ? Bacteria and yeast normal ? Epithelial migration

? TMexternal orifice

Tabacca NE; Epithelial migration on the canine tympanic membrane, Veterinary Dermatology Volume 22, Issue 6, pages 502?510, December 2011

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UNDERSTANDING THE EXTERNAL EAR CANAL

? Vertical canal

? External orifice ? *Tragus, ? Pretragic incisure and ? Intertragic incisure

? Lumen ridge ? RostralVentral

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UNDERSTANDING THE EXTERNAL EAR CANAL

? Horizontal Canal

? Bends off medially from vertical canal ? Tympanic Membrane

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? Picture courtesy of Dr L.K. Cole and Mr T. Vojt, College of Veterinary Medicine, The Ohio State University, Columbus, OH.. From Njaa, B. L. Practical Otic Anatomy and Physiology of the Dog and Cat. Vet Clin Small Anim 42 (2012) 1109?1126

UNDERSTANDING THE EXTERNAL EAR CANAL

? Tympanic Membrane- epithelial structure ? Pars flacida

? Vascular, Buldges

? Pars Tensa

? Translucent ? Manubrium of malleous

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OVERVIEW OF OTITIS

? Common and Frustrating ? Inflammation of the ear ? Causes and Factors

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PRESENTING COMPLAINT

? Foul odor from ear ? Shaking head ? Scratching at ear ? Aural Hematoma

? Rubbing head ? Hearing loss ? Behavioral changes ? Alopecia of pinnae

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CLASSIFICATION SYSTEM

Causes ? Primary ? Secondary

Factors ? Perpetuating ? Predisposing

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PRIMARY CAUSES

? Foreign body ? Parasites ? Atopic disease ? Food allergy

? Epithelialization ? Metabolic ? Glandular disorder ? Immune mediated ? Endocrine

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SECONDARY CAUSES

Bacterial infections Malassezia sp. Yeast Drug eruption Over cleaning

"Easy"

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PREDISPOSING FACTORS

? Prior factors that alone do not cause otitis

? Conformation

? Moisture

? Obstructive

HFOC

? Systemic disease

? Tx effects

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PERPETUATING FACTORS

? Altered migration ? Edema ? Proliferation ? Hidradenitis

? Calcification ? OM ? Cholesteatoma ? Osteomyelitis

Tx continued until resolution Months, Life long, Surgical solution

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IF OTITIS IS SO COMPLEX HOW DO I TREAT CASES SUCCESSFULLY?

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OTITIS SUCCESS

? Adept at detailing factors and causes ? Formulate a plan ? Client Education IS KEY

? Reasonable expectations ? Prognosis

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OTHER QUESTIONS

? Did you get a cytology? ? What is the best way to take and prepare a cytology?

? I have culture results, now what? ? Is the culture accurate? Useful?

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HOW TO BEGIN

? Complete and thorough history ? Onset ? Seasonality ? Tx-outcome, side effects ? Diets/treats ? Concurrent diseases ? Preventive tx ? Other pets/people with issues

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DIAGNOSTICS

? Cytology ? Culture ? Biopsy ? Imaging ? Myringotomy

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CYTOLOGY

? Roll onto slide ? Heat fixing?

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? Staining

CYTOLOGY

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"HOW DO YOU DO YOUR CYTOLOGIES?"

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CYTOLOGY

? No statistically significant differences were observed in the numbers of keratinocytes, yeast, bacteria, or neutrophils among the 4 staining techniques.

? TOMA S., et al. Comparison of 4 fixation and staining methods for the cytologic evaluation of ear canals with clinical evidence of ceruminous otitis externa. Veterinary Clinical Pathology 35, 2008,194? 198.

? Other authors feel heat fixation does help fix ceruminous debris to the slide

? C Mendelsohn, W Rosenkrantz, CE Griffin Practical Cytology For Inflammatory Skin Diseases, Clinical Techniques in Small Animal Practice, Volume 21, Issue 3, August 2006, Pages 117-127

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READING THE SAMPLE

? Scan on 10x ? Examine areas of

interest under oil immersion ? Examine approx. 10 fields ? Average reading

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C U LT U R I N G

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WHEN DO I CULTURE?

? Otitis Media ? Myringotomy ? PSOM ? Flush

Caudo-Ventral

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IS MYRINGOTOMY SAFE

? Side effects ? Horner's ? Facial nerve paralysis ? Vestibular disturbances ? Deafness

? drooping of the upper eyelid on the affected side (ptosis)

? the pupil of the eye on the affected will be constricted (miosis)

? the eye on the affected side often appears sunken (enophthalmos)

? the third eyelid of the affected side may appear red and raised (prolapse of the third eyelid, conjunctival hyperemia)

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WHAT ORGANISMS ARE COMMON IN DOGS WITH OM?

? Pseudomonas aeruginosa ? Staphylococcus intermedius

? Streptococcus ? Proteus ? Klebsiella ? Escherichia coli ? Anaerobes

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WHAT ORGANISMS ARE COMMON IN CATS WITH OM?

? Staphylococcus intermedius ? Otitis media ? Polyps

? Pseudomonas ? Bordetella ? Bacteroides ? Fusobacterium ? Mycoplasma

? Resistance rarely an issue in OM cases

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I DID A CULTURE, NOW WHAT?

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CULTURE DO'S AND DON'TS

? NEVER without cytology. ? Obtained via a sterile otoscope cone ? Indicated in cases of otitis media or interna in order to aid in the choice

of SYSTEMIC antibiotics ? OM can exist even if TM is intact

? Up to 89% diff between isolates or susceptibility patterns

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HOW DO I SELECT THE BEST THERAPY FOR OTITIS

EXTERNA USING A CULTURE?

? I Don't use cultures to select topical therapy for otitis externa

? Reserved for otitis media ? Chose cytology for therapy and prognostic

information

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WHY AREN'T CULTURES USEFUL?

? Reflection of serum drug levels ? MIC may not be achieved at surface of otic epithelium ? In vitro results relate poorly to choice of topical therapy ? Topical antimicrobial concentrations exceed what is

tested

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NOW WHAT?

? If I don't need a culture to tell me what topical therapy to use, then why are my treatment recommendations not effective?

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MANAGEMENT

Control primary diseases

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MANAGEMENT

? Control perpetuating factors ? Deep cleaning- extremely

important

? removes bacterial toxins, cell debris, and FFA

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IMAGING

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MANAGEMENT

? Cleaning and drying ? Maintenance

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MANAGEMENT

? Must include topical therapy to treat

? Infections ? Inflammation ? Debris

? Oral antibiotics for otitis externa?

? If the external canals is moderately to extensively erosive to ulcerative

? Base on a culture

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MANAGEMENT

? EasOtic ? Tresaderm ? Synotic ? Conofite Lotion ? Osurnia ? Animax

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OSURNIA

? Indicated for the treatment of otitis externa ? Staphylococcus pseudintermedius,

Malassezia pachydermatitis ? In hospital application ? Owner compliance

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ANIMAX

? Nystatin, Neomycin sulfate,Thiostrepton, Triamcinolone

? Ointment indicated for wide range of fungal and bacterial organisms

? Also useful in other topical applications

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E A S OT I C

? Hydrocortisone aceponate, Miconazole nitrate, Gentamicin sulfate

? Great applicator ? Good owner complicance

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C O M P L I C AT I O N S

? Any topical can possibly affected hearing ? Important client education point

? May not always see TM in severe cases ? If not corrected with appropriate treatment using commercial products refer

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CHOOSING AND USE OF TOPICAL DROPS

? Based on cytologic and otoscopic findings ? Twice daily therapy for minimum of 7-14 days

? Inflammation ? Edema ? Hyperplasia ? Erosion/ulceration ? Sufficient volume of topical agent ? Re-evaluation at end of therapy cycle or every 2-4 weeks ? Recheck cytology and visual otoscopy exam ? Anti-inflammatory regimen of steroids

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OTOTOXICITY

? Unknown for most topical otic medications ? Aminoglycosides ? Chlorhexidine

? Many cleaners potentially ototoxic if TM ruptured ? Propylene glycol ? Ceruminolytics ? Dioctyl sodium sulfosuccinate ? Calcium sulfosuccinate ? Detergents ? Chlorhexidine ? Iodophors

? FLUSH!

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