Small Animal Medicine II > Otitis Externa > Flashcards

Otitis Externa Flashcards

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1
Q

How does the external ear canal function?

A

auricular cartilage (ventral canal) overlaps annual cartilage (horizontal canal) to allow flexibility and movement to properly gather and guide sounds into the canal

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2
Q

What shape does the canine ear canal take?

A

L-shaped with a dorsal pocket and a ventral notch (“trap)

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3
Q

External ear canal:

A

L = vertical canal with pocket ventrally

R = “in the trap”, edge of annular cartilage

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4
Q

What is normal anatomy of canine ear canals?

A

depends on breed!

  • normal to see hair throughout canal
  • round opening
  • brachycephalics - narrow oval opening, closes easily
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5
Q

What are 3 differences in the feline ear canal?

A
  1. external canal doesn’t have a deep trap
  2. smaller diameter - difficult to pass some scopes
  3. bony septum separates middle ear from bulla
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6
Q

What should the tympanic membrane look like? What structures does it have?

A

clear and transparent

  • pars flaccida - moves with pressure differences
  • pars tensa - remains still
  • malleus - located between PF and PT, concave points rostrally
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7
Q

How does the feline tympanic membrane compare?

A

bony septum makes it look less transparent

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8
Q

What causes the pars flaccida to become prominent?

A

increased pressure in the ear canal

  • NOT a tumor, but may be indicative of middle ear disease
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9
Q

How do the inner and outer layers of the tympanic membrane compare?

A

INNER = cuboidal epithelium

OUTER = stratified squamous epithelium

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10
Q

What is behind the tympanic membrane?

A

MIDDLE EAR - epitympanic cavity (recess), tympanic cavity, ventral (fundic) cavity

  • lined with modified respiratory cells - ciliated, secretory
  • contains nerves, vessels, ossicles, and muscles
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11
Q

What structures of the middle ear can be seen on otoscopic examination?

A

VENT = into the bulla

PROM = vestibular window, contains inner ear

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12
Q

How does the middle ear anatomy differ in cats?

A
  • contains a septum to separate the middle ear
  • cochlea + cochlear window
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13
Q

Feline tympanum and middle ear:

A

extremely thin, less transparent membrane

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14
Q

Feline middle ear, CT:

A
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15
Q

What 6 pathological changes in the ear occur with otitis?

A
  1. inflammation - edema and cellular infiltration
  2. glandular hyperplasia
  3. epidermal hyperplasia - obstructs duct opening
  4. additional inflammation - migration of inflammatory cells, release of proteases and other cytokines
  5. fibroplasia
  6. ossification
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16
Q

Ear, epidermal hyperplasia:

A
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17
Q

Ear, folliculitis and furunculosis:

A
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18
Q

What 5 diagnostics are used for otitis externa?

A
  1. history, PE
  2. otoscopic exam
  3. cytology***
  4. culture and sensitivity
  5. diagnostic imaging
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19
Q

What is commonly necessary for in-depth otoscopic exams? What are 3 keys to proper examination?

A

sedation/anesthesia as needed - topical, systemic, complete anesthesia for manipulation or surgery

  1. examine both canals
  2. visualize the tympanic membrane
  3. do no harm
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20
Q

How do otoscopes compare to video otoscopy?

A

OTOSCOPES = 2x magnification, attachment can be used to change pressure and evaluate tympanic membrane

VIDEO = 10x magnification, better light and clarity, good for individuals with visual deficitsW

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21
Q

What is considered the key diagnostic test in ontology?

A

cytology

  • done on both ears no matter what
  • done at initial presentation and every recheck exam
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22
Q

Where should cytology samples be collected in cases of otitis?

A

right at the edge of the annular cartilage in the entrance to the horizontal canal

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23
Q

What is proper positioning of swab and head when collecting ear cytology?

A

pull out ear horizontally and keep it and the swab horizontal to the floor

  • aim past the inner tragus
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24
Q

What is proper technique when dipping cytology slides?

A

be gentle - wax does not adhere well and material can be lost

  • use a clothespin to hold the slide
  • never skip stains –> Malassezia sticks well to red-stained material!
  • DON’T run water directly on sample
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25
What artifact is seen on this ear cytology slide?
clumping of stain --> not bacteria!
26
What are 2 normal findings on ear cytology slides?
1. cerumen - keratinocytes, sebum, ceruminous secretions from apocrine glands 2. microorganisms - low numbers of yeast and various bacteria
27
Keratinocytes, ear cytology
28
Ear cytology, yeast:
Malassezia
29
Ear cytology, mixed infection:
cocci + rods - mixed = easier to manage --> one has not been able to overpower the others
30
Ear cytology, WBCs:
epithelial damage
31
How does Diff-Quik stain compare to a Gram stain?
DIFF-QUIK - highlights bacteria, doesn't differentiate type GRAM - highly recommended for mixed infections, can differentiate between G- rods (Pseudomonas), G+ rods (Corynebacterium) and G+ cocci (Staph) --> slide has keratinocyte granules pictured
32
What are 5 indications for performing a bacterial culture and sensitivity in cases of otitis? Where are samples collected?
1. known resistant organisms 2. failure to respond to standard therapy 3. previous administration of several antibiotics 4. single population of rods 5. concurrent systemic signs cleanly from vertical/horizontal canal junction
33
What are 3 indications for diagnostic imaging in cases of otitis? What are some options?
1. clear loss of tympanic membrane 2. unable to adequately visualize TM 3. recurring infections - look for nidus radiography, U/S, MRI, CT
34
What is the purpose of cleaning out the ear before treating it?
removes debris that.... - causes irritation - blocks movement of medication into horizontal canal - interferes with self-cleansing - movement of wax from TM outward - interferes with activity of active ingredients in medication (biofilm) - increases microorganism burden
35
How does hair impact diagnosing and treating otitis? What is recommended for proper examination?
- prevents evaluation of entire ear canal and tympanum - predisposing/perpetuating factor in developing otitis - blocks penetration of medication into ear remove hair prior to topical treatment of otitis externa --> NOT routine, can cause trauma that eventually leads to otitis
36
What is biofilm? What function does it have? What 3 bacteria associated with canine otitis produce it?
matrix of proteins and organic material produced by bacteria --> EPS, polysaccharides, proteins, extracellular DNA protects microorganisms from immune system, external factors, and topical/systemic medications 1. Pseudomonas 2. Staphylococcus 3. Malassezia
37
What are considered the best cleansers for purulent and waxy debris in the ear?
PURULENT - anything! (EpiOtic, OtiRinse, TrizEDTA) WAXY - should contain ceruminolytic agents, like squalene (pH-notic, cerumene, KlearOtic, Douxo micellar solution)
38
When is deep ear cleaning/flushing indicated? What does it require? How is it performed?
tympanic membrane is unable to be clearly seen general anesthesia or heavy sedation --> need thorough (aggressive) cleaning of the ear - visually inspect canals with sterile cone and hand clean - infuse serumenolytics (Cerumen, KlearOtic, Micellar Solution) for 5 mins - flush with sterile saline and inspect - use loops/biopsy if needed - infuse medication or drying agent (Cort/Astrin)
39
Deep ear flush:
- could go another round - residual debris obstructing tympanum
40
What is Animax? What is an advantage and disadvantage to its use?
Neomycin + Thiostrepton + Nystatin + Triamcinolone - ADVANTAGE - broad-spectrum - DISADVANTAGE - ointment-based (poor esthetic)
41
What does Tresaderm contain? What are some advantages and disadvantages?
Neomycin + Dexamethasone + Thiabendazole - ADVANTAGES - mild antibacterial and yeast action, propylene glycol based, good for first occurrence - DISADVANTAGES - mild, must be refrigerated and warmed prior to use, propylene glycol can trigger increased epithelial turnover and wax production
42
What does Otomax/Mometamax contain? What are some advantages and disadvantages?
Gentamicin + Clotrimazole + Betamethasone/Mometasone - ADVANTAGE - excellent ingredients - DISADVANTAGES - ointment based, Gentamicin is ototoxic, terrible packaging
43
What does Posatex contain? What are some advantages and disadvantages?
Orbafloxacin + Posaconazole + Mometasone - ADVANTAGES - broad spectrum, excellent anti-inflammatory, excellent antifungal - DISADVANTAGES - ointment based, terrible packaging, $$$
44
What does Baytril Otic contain? What are some advantages and disadvantages?
Enrofloxacin + silver sulfadiazine - ADVANTAGE - excellent against Pseudomonas, broad spectrum (SSD), aqueous - DISADVANTAGE - minimal anti-fungal, no glucocorticoid
45
What does easeOtic contain? What are some advantages and disadvantages?
Gentamicin + Miconazole + Hydrocortisone - ADVANTAGES - good ingredients, excellent applicator, anti-inflammatory - DISADVANTAGES - Gentamicin is ototoxic, total volume is insufficient, thicker ointment, $$$
46
What does Surolan contain? What are some advantages and disadvantages?
Polymyxin B + sulfates + Miconazole + Prednisone - ADVANTAGES - good against Psuedomonas, excellent against Malassezia - DISADVANTAGES - activity questionable in the presence of pus, ointment
47
What does Aurizon contain? What are some advantages and disadvantages?
Marbofloxacin + Clotrimazole + Prednisolone - ADVANTAGES - excellent against Pseudomonas, broad spectrum, SID (10 drops for 7-14 days) - DISADVANTAGES - not recommended for use in a first occurrence due to fluoroquinolone resistance, NOT in US
48
What does Canaural contain? What are some advantages and disadvantages?
Diethanolamine fusidate + Framycetin + Nystatin + prednisolone - ADVANTAGE - broad spectrum - DISADVANTAGE - ointment, 5-10 drops BID, NOT in US
49
Commercial otic medications in US:
50
What are long-acting topical medications used for otitis externa? What is a major advantage?
products containing lanolin (messy!), gel polymers, or lightweight oils able to be applied topically by veterinarians every 7-30 days removes problem of owner compliance
51
What are 3 options for veterinary residual products for otitis externa?
1. Claro - Florfenicol + Terbinafine + Mometasone (Simplera = generic) 2. Ketocort Otic - Ketoconazole + Hydrocortisone 3. Osurnia - Florfenicol + Terbinafine + Betamethasone leave space in ear to empty contents and pull out at the same time to avoid TM rupture
52
What are 3 important aspects of residual otic preparations?
1. great for clients who cannot treat daily 2. NOT fire and forget --> need quality control check with recheck appointments 3. may require multiple applications - cytology!
53
What are some advantages and disadvantages to topical therapy for otitis externa?
ADVANTAGES - delivers medication directly to affected areas in high concentrations, inexpensive DISADVANTAGES - deliver deep into ear may be difficult/dangerous, compliance, poor penetration if middle ear is involved
54
Is there a value to culturing cases of otitis externa?
YES - informs clinician of organisms present - identified sensitive antibiotics - provides insight into efficacy of other choices
55
What are considered the best antibiotics for S. pseudintermedius, Pseudomonas, Proteus, and Malassezia causes of otitis externa?
STAPH - Florfenicol, Aminoglycosides, Fluoroquinolones, SSD PSEUDOMONAS - Aminoglycosides, Fluoroquinolones, Polymyxin B (not with pus), SSD PROTEUS - Aminoglycosides, Fluoroquinolones, SSD MALASSEZIA - Azoles, Terbinafine, Nystatin
56
What are considered the best choices for treating ruptured tympanum, cases with client compliance issues, and first occurrence cases?
Fluoroquinolones Claro, Osurnia antiseptics --> first-line approach
57
How do antiseptics compare to antibiotics when treating otitis externa?
- broad spectrum - clincial efficacy against multi-drug resistant strains - complimentary non-antimicrobial properties - low/unknown impact on resistance - action limited to site of application/infection
58
What 4 antiseptics are recommended for cases of otitis externa?
1. SSD 2. acetylcysteine 3. aluminum acetate (Burow's solution) 4. Chlorhexidine +/- lactic acid, salicylic acid, boric acid, parachlorometaxylenol
59
What is indicated if antiseptic treatment of otitis externa fails?
more aggressive treatments (antibiotics) - continued presence of organisms at 10-14 days - worsening of clinical signs (pain, swelling)
60
What flushes should be used for otitis externa caused by Malassezia?
those containing NO antibiotics --> antifungal + glucocorticoid - Ketocort Otic - KTZ + hydrocortisone - DuOtic - Terbinafine + Betamethasone
61
What is indicative of allergic otitis? What is the key to success?
inflammation/pruritus without infection seen early in condition glucocorticoids
62
What volume of otic medication is recommended based on weight of dogs?
- <10 kg = 0.4-0.5 mL - 10-20 kg = 0.5-0.7 mL - <30 kg = 1.0 mL - <40 kg = 1.5 mL constitutes extra-label use, higher cost than labeled dose, increased systemic effects
63
How can owners be sure how much medication they ar putting in their pet's ears/
bottle adapter cap connected to syringe
64
What position is recommended for proper installation of ear medications?
lateral recumbency
65
What are some indications for systemic therapy in cases of otitis externa?
- recurring or severe infection - concurrent infection elsewhere - owners incapable of medicating patient - patients refuse to cooperate - hyperplastic lesions prevent topical application - known otitis media - inflammatory cells seen on cytology - ulcers present on otoscopic exam - single population G- rods in recurring infection - systemic signs NOT recommended as sole therapy for infectious agents
66
How long should patients be on systemic medication for otitis externa if indicated/
3-4 weeks
67
What 2 doses of systemic glucocorticoids (Prednisone) are recommended for different cases of otitis externa?
1. ANTI-INFLAMMATORY - 1.1 mg/kg SID, PO for 5-7 days, alternate days for 5 doses 2. HYPERPLASIA - 2 mg/kg SID, PO for 5-7 days, then EOD for 5-7 doses, then reduce dose
68
What is considered best practice for glucocorticoid treatment in the ears?
use aggressively initially then back off - decrease frequency and potency (dexamethasone to hydrocortisone) - use antiseptics for long-term management - avoids systemic effects on HPA axis
69
What should be done on recheck exams in cases of otitis externa?
- history - PE + otic exam - cytology - culture
70
What 3 things should be done if treatment failure is seen on recheck exams?
1. review treatment options 2. review application of medications - have client demonstrate! 3. consider additional diagnostics - culture or cytology for new agents, MDR bacteria, or resistant yeast
71
What 3 things should be done if treatment success is seen on recheck exams?
1. work on maintenance plans 2. first time - client education 3. recurring - identify primary factor
72
How long should maintenance therapy be continued following initial treatment?
until primary factors are identified AND controlled - long-term to reduce flare-ups
73
What are 3 parts of maintenance strategies for otitis externa?
1. intermittent cleaning with products with antimicrobial activity 2. antiseptics or astringents - vinegar and water, aluminum acetate, enzymatic systems, chlorhexidine 3. intermittent use of glucocorticoids - switch from potent agents to those with fewer systemic effects (hydrocortisone, mometasone)
74
What database should be collected in first occurrence cases of otitis? What treatment approach is recommended?
history + otoscopy + cytology - clean ears with antiseptics - treat with appropriate medication based on cytology for 21 days OR intermittently (2-3x weely) with cleansers --> first time cases will most likely by Staph or Malassezia - recheck in 21 days
75
What database should be collected in recurrent or non-responding cases of otitis? What treatment approach is recommended?
cytology + video otoscopy + culture + imaging - clean ears - more aggressive topical therapy - ingredients, duration, methods - rechecks!! - referral
76
What are 12 guidelines for effectiveness evaluation of topical/otic animal drugs?
1. amount of drug interfacing with skin 2. concentration/dilution 3. vehicle 4. solubility in vehicle 5. rate of release, penetration, absorption 6. surface area medicated 7. frequency and manner of application 8. contact time 9. degree of excoriation 10. accuracy of diagnosis 11. quantity of hair 12. presence of organic matter
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