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Y4 SA dermatology > Treating ear disease > Flashcards

Treating ear disease Flashcards

+ some miscellaneous ear diseases

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Dermatology Board Prep flashcards
1
Q

Reasons to flush the ears

A
  • Diagnostic and therapeutic
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2
Q

Ear flushing - diagnostic

A
  • See epithelium of the ear canal
    – Hyperplasia
    – Ulceration
    – Masses
    – Defects (when the drum has been touched roughly, e.g. by a foreign body, red/brown bruising is seen)
  • Check integrity of the drum (gentle back & forth flushing can be used to highlight the drum)
    – Very difficult to assess correct level of drum in many dogs
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3
Q

Ear flushing - therapeutic

A
  • Dilutes and removes bacteria, yeasts and inflammatory mediators
  • With appropriate cleaners anti-microbial effects
  • Removes pus which may inactivate antibiotics
  • Removes old treatments

Even in some apparently clean ears, material remains at the proximal end of the canal against the tympanum. This can be very firm, but recurrent otitis will continue unless removed.

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4
Q

Flushing solutions

A

Normal saline
- Safe, widely available
- Sterile

Squalene
- Oily liquid to dissolve waxy discharges
- Considered safe

Chlorhexidine (dilute)
- Known to be problematic at higher concentrations
- Considered safe in dogs – not known in cat. Use commercial products
- e.g. TRIZChlor (Dechra) and Otodine (Nextmune)

Others – for use after the drum is known to be intact
- cerumolytics emulsify ear wax for easy removal e.g. alcohols
- aqueous solutions aid in removing pus, mucus and serum from the ears
- Ear cleaning solutionsdrying agents decrease moisture in the ears and desiccate the surface keratinocytes e.g boric acid

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5
Q

Ear cleaning solutions - criteria for a product

A
  • Cleaning power
  • Antimicrobial action
  • Potential for ototoxicity
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6
Q

Ear cleaning solutions

A

General purpose cleaner
- Use in some infections, maintenance cleaning
- May not be otosafe

Specific products
- Antimicrobial aqueous flush
– Used in purulent infections
– Considered otosafe
- Dewaxing cleaner
– Usually few antimicrobial properties, but dissolves wax
- Base for other therapies
– TRIZEDTA, to which antibiotics, steroids and other products are added. Little if any antimicrobial action
-Biofilm treatments

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7
Q

General purpose cleaners

A
  • Cleanaural
  • Epiotic
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8
Q

Cleanaural (pH 6.5)

A

Ingredients
- Boric acid
- Citric acid
- Isopropanol alcohol
- Propylene glycol

Properties
- Good cleaner
- Good antimicrobial properties
- Staph killed at 1/32 Pseudomonas killed at 1/8 and Malassezia killed at 1/32

However quite ‘stingy’ in inflamed ear

Unlikely to be ‘otosafe’

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9
Q

Epiotic (pH 7.0)

A

Ingredients
- Salicylic acid 0.1%
- Parachlorometaxylenol (PCMX) 0.1%
- Disodium EDTA & Docusate sodium and Propylene glycol base
- Monosaccharides (L-rhamnose, D-galactose and D-mannose)

Properties
- Fair to good cleaner
- Fair to good antimicrobial properties
– Staph killed at ½, Pseudomonas killed at 1/8 and Malassezia killed at 1/8
- Drying effect on the canal
- Comfortable in the ear
- Probably not otosafe (PCMX and docusate sodium)
- Slows the production of ceruminous secretions

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10
Q

Purulent otitis tx - Otodine (TRIZChlor) (pH 8.0)

A

Ingredients
- Tromethamine (Tris)
- Edetate disodium dihydrate (EDTA)
- Chlorhexidine 0.15%

Properties
- Watery cleaner
- Doesn’t sting
- Poor ceruminolytic action
- Good to fair antimicrobial properties
– Staph killed at 1/2
– Pseudomonas killed at 1/16
– Malassezia killed at 1/8
- Appears otosafe in the dog – data lacking for the cat
- Good for the inflamed ear and pus

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11
Q

Waxy (ceruminous) otitis tx - Cerumaural & Otoact (squalene-based cleaners)

A

Ingredients
- squalene
- isopropryl myristate, mineral oil (C)
- salicylic acid, chamomile, tannic acid (O)

Properties
- Dissolve and mobilise waxy, greasy discharge
- No antimicrobial properties
- Considered to be otosafe
- Cerumaural greasier than Otoact

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12
Q

TRIZ EDTA (pH 7.9)

A

Base for additions or as pre-flush

Ingredients
- Tromethamine (Tris)
- Edetate disodium dihydrate (EDTA)

Properties
- Poor ceruminolytic properties
- No antimicrobial activity (by itself)
- Appears otosafe
- Pre-treatment and base for other treatments only

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13
Q

Biofilm busting- TRIZ EDTA with added N-acetyl cysteine

A

Ingredients
- Tromethamine (Tris)
- Edetate disodium dihydrate (EDTA)
- N-acetyl cysteine

Properties
- Disrupts biofilm as N-acetyl cysteine breaks bonds in carb matrix
- Some antimicrobial activity
- Appears otosafe
- May be irritant in the inflamed ear

Available
- Vetruus – TRIS-NAC
- Homemade with Parvolex 200 mg/ml Concentrate for Solution for Infusion

Often used before other tx e.g. antibiotic cream

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14
Q

Anaesthesia

A
  • In severe / chronic otitis, anaesthesia is needed to perform adequate flushing
  • Endotracheal tube protects aspiration of flushing solution
  • Hearing is often present with sedation
    – Especially medetomidine
  • Adequately assess the ear
  • Pain – can be very severe
  • Otitis media common, but not diagnosed
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15
Q

Manual otoscope + syringe vs video otoscopy

A

Manual otoscope + syringe
- Spreul needle or better cut down gauge 6 urinary catheter
- Large catheter cover
- Precise, but time consuming
- Can make the ear sore through rubbing of speculum
- Equipment inexpensive

Video otoscopy
- Precise
- Able to record data if data capture technique
- Custom made curettes, biopsy and grabbing tools
- Small bore channel -> slow cleaning in some cases
- May not fit the smallest ears

Even with video otoscopy large chunks best removed manually

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16
Q

Treating OE - Plan

A
  • Remove/reduce microbes
  • Reduce swelling, discomfort or pain
  • Normalise canal lumen and function
  • Polypharmacy is the rule: medications contain
    – Antibiotic
    – Antifungal
    – Anti-inflammatory agent
  • Except for Recicort (triancimalone)
17
Q

Treating OE - Approach

A
  • History
    – Indications for atopic dermatitis, other diseases, FB etc
  • Examine ears
    – Otodectes?
    – Foreign body?
    – Inflammatory otitis
    – Cytology (± bacteriology)
  • Treat for 7-14 days
  • Repeat examination
  • Manage ear canal ? Consider underlying cause
18
Q

Drugs that are ototoxic

A
  • Gentamicin – rare using otic preparations (reduced in aqueous solutions)
  • Polymixin B – rare
  • Ticarcillin and imipenem – commonly seen, but should we be using these?
  • Propylene glycol
  • Chlorhexidine at moderate concentrations
  • If have to use ototoxic otic products avoid concurrent use of drugs that might increase risk
    – Frusemide and other loop diuretics
    – Cis-platin
    – Erythromycin
    – NSAIDS
19
Q

Erythroceruminous otitis

A

Clinically
- Red, waxy itchy ear
- Often a feature of allergic skin disease

Cytology shows cocci ± Malassezia, squames, but no neutrophils
- Microbial overgrowth

Treat
- Cleaner appropriate for the level of discharge
- Corticosteroid alone

20
Q

Purulent otitis – acute

A

Clinical signs
- Redness, pruritus, pain and discharge
- May be secondary features of lichenification on the pinna

Cytology
- Neutrophils and bacteria (intra and extracellular)

Treatment
- First-line ointment based on cytology and otoscopy
- Once to twice daily therapy for 7-14 days
– Canaural / Surolan / Easotic
– Sufficient amount (0.7-1.0 mls for a large dog)
- Alternatively, Neptra or Osurnia (once or twice respectively)
- Combined with a suitable cleaner e.g.
– Otodine/TRIZChlor – watery, disinfectant & doesn’t sting

21
Q

Purulent otitis – if severe

A
  • Consider putting a charcoal swab in the fridge at time of the first appointment
  • Send a swab off if rods regardless of time course
  • If the ear is very swollen
    – Steroids for 1-2 days before further otoscopic examination
  • If a large volume of discharge / unclear time course
    – Admit for flush etc – treat as chronic case
22
Q

Purulent otitis - Re-check

A
  • Obligatory
    – Improvement ?
    – Owner compliance
    – The next stage
  • May need to restore epithelial migration
    – Period of cleaning beyond microbiological and anatomical cure
  • Identify underlying cause
23
Q

Chronic allergic otitis

A
  • Long term Malassezia and S. pseudintermedius dysbiosis and overgrowth
  • Treat the ear prophylactically with steroids ± cleaner to prevent flares
  • Currently no products with marketing authorization for this use
  • Commonly used products include, Cortavance† (hydrocortisone aceponate spray), Recicort † (Triamcinolone drops), dexamethasone diluted in sterile water (0.25 mg /ml) or by adding dexamethasone to cleaning products †.
  • This usually results in better overall control and prevents flares

† = not considered safe in the middle ear

24
Q

Pseudomonas otitis

A
  • Common problem (≥ 35% of OE &/or OM)
  • Gram negative rod
  • Highly drug resistant capsule and bacterial wall
  • Constitutive resistance to many antibiotics
  • Rapid development of resistance
  • Often follow a poorly managed or untreated Malassezia or Staphylococcal otitis
  • Swelling, pain, ulceration and malodour common
  • Green to browny black discharge
  • May be associated with
    – immunosuppression
    – Swimming
    – Prior use of antibacterials
25
Q

Similar infections to Pseudomonas otitis

A
  • Features shared with infections by Enterobacteriaciae (e.g. E. coli (esp Extended-Spectrum Beta-Lactamases [ESBLs]), Proteus and Klebsiella spp.)
26
Q

Pseudomonas otitis CS

A
  • Redness, pruritus, pain and discharge, often accompanied by ulceration and pain
  • Often secondary features of lichenification around the pinna and perpetuating changes in the canal
  • Often obvious malodor
27
Q

Pseudomonas otitis cytology

A
  • Degenerate neutrophils, nuclear streaming and bacteria (intra and extracellular)
28
Q

Plan with severe dz

A
  • Always flush if purulent material
  • Presume drum ruptured – collagenase produced by bacteria makes this likely
  • Therefore, presume OM –possibility of OI
29
Q

Warn owner that flushing / treatment / disease risks

A
  • Horner’s syndrome / facial paralysis
  • Hearing loss
  • Cost – expensive if severe to treat medically
  • Possibility of need for TECA
  • Non-licensed products (get signed release)
  • Increased risk in the cat
30
Q

Process

A
  • Assess skin and ears / cytology / otoscopy / bacteriology
  • Flush to clean & examined (normal saline)
  • Use biofilm busting cleaner (TRIS-NAC for 5 minutes) (2-3x daily)
  • Use a disinfectant cleaner (TRIZChlor or Otodine – 5-10 minute soak) (2-3x daily)
  • Apply a suitable antibiotic (Aurizon® marbofloxacin, dexamethasone) or TRIZEDTA with 2% marbofloxaxin and 0.2% dexamethasone added)† (2-3x daily)
  • Provide anti-inflammatory and analgesia
    – Intraoperative opiate and dexamethasone 0.2mg/kg IV then
    – Prednisolone ½ -1 mg /kg SID PO
    – Paracetamol 15mg /kg TID PO initially
  • Check initially at 7-10 days – treatment is likely needed for 3 – 6 weeks

† Alternatively, gentamicin containing mixtures or Flamazine solution

31
Q

In all cases of otitis externa - After initial treatment

A
  • Use cleaners and steroids to support
    – The return of epithelial migration
    – To further reduce secondary predisposing changes
    – May need to change ear cleaner from initial aqueous treatment to a maintenance or cerumenolytic cleaner

Steroid 1-2x weekly after initial tx.

32
Q

In all cases of otitis externa - consider the underlying cause

A
  • For many dogs and cats with recurrent disease chronic intermittent steroid therapy in the ear will be useful to prevent recurrence of 2˚ infection and to treat the 1˚ inflammatory disease
  • For some further investigations will be warranted.
33
Q

The end stage ear

A
  • When any or a combination of the following becomes unacceptable
    – Welfare of pet or family
    – When ear disease is intractable or very quickly recurrent due to
    -> Stenosis, marked granulation in middle ear or hyperplasia
    – Cost of repeated medical interventions is unacceptable
    – Inability to treat the ear

Lateral wall resection
- No role in the end stage ear
- Limited role in chronic otitis
– Often worsens the situation

Total ear canal ablation
- For the chronically painful ear – welfare choice
- Low risk of complications in hands of a specialist
- Economically justified in many cases

34
Q

Which bacteria are likely to be treated by Osurnia (florifenicol)?

A
  • Cocci on cytology
    – Staphylococci
35
Q

Which bacteria are likely to be treated by Aurizon/Posatex (marbofloxacin/orbifloxacin)?

A
  • Cocci &/or yeasts
    – Staphylococci and Malassezia (not miconazole/polymyxin combination is needed to kill staph as polymyxin B alone is not useful)
  • Rods on cytology
    – Pseudomonas (but polymyxin B is inhibited by pus so need clean ear)
36
Q

Which bacteria are likely to be treated by Easotic/Otomax (gentamicin)?

A
  • Cocci &/or yeasts (Staphylococci and Malassezia)
  • Rods on cytology (Pseudomonas)
37
Q

Which bacteria are likely to be treated by Canaural (Diethanolamine fusidate and Framycetin sulphate)

A
  • Cocci &/or yeasts
    – Staphylococci and Malassezia
  • Rods on cytology
    – Pseudomonas
38
Q

Which ear creams with steroids have a high potency but with relatively reduced systemic absorption?

A
  • Posatex
    – mometasome has high potency and less systemic effect
  • Easotic
    –hydrocortisone aceponate is metabolised locally in the skin

Y4 SA dermatology (22 decks)

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