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AReviewofOtitisTipsfromadermatologisttohelp

youmanagetheseKacieBlessing,DVM,DACVDAnimalDermatologyClinic,SanDiego,Ca

THANKYOU!

GarretPachtinger,VMD,DACVECC

COO,VETgirl

IntroductionJustineA.Lee,

DVM,DACVECC,DABTCEO,VETgirl

Introduction

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KacieBlessingDVM,DiplomateACVD

IntroductionOUTLINE•Anatomy•Howtoexamine•Etiology,Clinicalsigns•Diagnosticworkup•Treatment

Anatomy

Anatomy•Verticalcanal->Horizontalcanal->TM•5-10cmlong,4-5mmwide

•Linedbyskin• Sebaceous/ceruminousglands• Hairfollicles

•Generouslyvascularized•Sensoryinnervation:

• Trigeminalnerve• Facialnerve• Vagus nerve• Secondcervicalnerve

TympanicMembrane•Separatesexternalearfrommiddleear

•Thinandslightlyopaque•Thinnerinthecenter•Thickerintheperiphery•Upperportion- parsflaccida•Larger,lowerportion- parstensa

Pars tensa Pars flaccida

TympanicMembrane- Hair

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ManubriumoftheMalleus•Attachedtotheparstensa

•Openendofthe“C”pointstowardsthenose

•Distalend– umbomembranetympani

• Germinative epithelium

•Stria mallearis – lineofthe“C”shape

CatsvsDogs•Catsmoreshortandstraighterearcanal

CatAnatomicDifferences•Manubriumislesscurved

•Middleear– ventraltympanicbulla• Dividedbyanincompleteseptum• Twocommunicatingcompartments

• Dorsal– morelateral• Ventral– moremedial

AnatomyBreedVariations•Pinnal type

• Shape,preventionofforeignmaterial

AnatomyBreedVariations•Shapeandopennessofexternalorifice•Diameterofexternalearcanal•Thicknessofskinanddegreeofglandularmaterialofearcanal•Amountandsizeofhairinearcanal

•Shapeofboneandskullcomprisingmiddleandinnerear•Amountofhair

OUTLINE•Anatomy•Howtoexamine•Etiology•Clinicalsigns•Diagnosticworkup•Treatment

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Otoscopic ExaminationTechnique

•VERYIMPORTANT!!!!•PRACTICEMAKESPERFECT

•Acquiredskill

•Atraumatic•Visualizeconeplacement

Technique•Straightenthecanal

•Pullcanalovertipofcone

• Pullpinnaeup

• Thenlateralanddown

• Towardstheotoscopecone

AuricularProjection• Painwhenpressureputagainstit

• Especiallyifinflamed

OtherExaminationTechniques•Usetwocones•Adequatelight•Don’tcrosscontaminate

•Restraint• Trainyourstaff• Treatmentroom• Sedation• Anesthesia

LightandMoreLight Otoscopes

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OtoscopeCones

5mm7mm3mm

CleanCones•Bacteria are found in cones•Ten minutes disinfectant soaks required 1

•2 cones from 50 hospitals were cultured• Contamination in 29%

• 3% pathogenic bacteria2

1Newtonetal(2006)VetDermatol,17(2),147-1502Kirbyetal.(2010).VetDerm,21,175-183

Otoscopic Examination•Patencyorstenosis•ColorChanges•Proliferativechanges•Ulcerations•Exudates•ForeignObjects•Parasites•Tumors•ExcessiveHair

DilatedParsFlaccida

OUTLINE•Anatomy•Howtoexamine•Etiology,Clinicalsigns•Diagnosticworkup•Treatment

Otitis•Inflammationoftheear•Externa• Externalearcanal,orifice,pinna

•Media•Middleear

• Interna• Innerearstructures

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ClassifyingOtitisExterna•Varietyofclassificationschemes

• Acuteorchronic• Purulent,ceruminous,erythroceruminous,ulcerative

•Etiology• Predisposing,primary,secondary• 3P’s- Predisposing,Primary,Perpetuating

PSPPSystem•Primary

•Secondary

•PerpetuatingFactors

•PredisposingFactors

Otitis- Primary•Allergy

• CAFR• Atopy• Contact• Fleaallergy

•Parasites• Demodex• Otodectes• Ticks• Chiggers

•Endocrine• Cushings• Hypothyroid• Sexhormone

•Foreignbodies• Hair• Plantawns• Foxtail• Sand/dirt

Otitis- Primary•Autoimmune

• BP• Epidermolysisbullosa• Lupus• PF

•Caninedistemper•Immunemediated

• Drugreaction• EM• Vasculitis

•Glandulardisorders• Alteredsecretions• Sebaceousglandhyper/hypoplasia

•Eosinophilicgranulomacomplex•Juvenilecellulitis

Otitis- Secondary•Bacteria•Yeast•Fungal– Aspergillus•Medicationreaction•Overcleaning

• Excessivemoisture•Maceration• Physicaltrauma

Otitis– PerpetuatingFactors•Epithelium

• Excessiveproduction• Alteredmigration• Failureofmigration

•Earcanal• Edema• Proliferativechanges• Stenosis

•Calcification

•Tympanum• Dilation• Rupture• Pocket

•Glandular• Apocrineblockage/dilation• Hidradenitis• Sebaceoushyperplasia

•Middleear• Filledwithdebris• Otitismedia• Osteomyelitis

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Otitis– predisposingFactors•Conformation

• Excessivehairgrowth• Hairyconcavepinna• Pendulouspinna• Stenoticcanals

•Excessivemoisture• Environment(heat,humidity)• Water

•Obstructiveeardisease• Felineapocrinecystaadenomatosis• Neoplasia• Polyp

Primaryotitismedia◦ PSOM◦ Otitismediaduetoneoplasia◦ Respiratorydisease◦ Sepsis

Systemicdisease◦ Catabolicstates◦ Debilitation◦ Immunesuppression

Treatmenteffects◦ Alteringnormalmicroflora◦ Traumafromcleaning

PSPPSystem•Primary

•Secondary

•PerpetuatingFactors

•PredisposingFactors

OUTLINE•Anatomy•Howtoexamine•Etiology,Clinicalsigns•Diagnosticworkup•Treatment

DiagnosticApproachtoOtitis•History

• Acutevschronicand/orrecurrent• Concurrentsignsoccurring?

•Physicalexamination• Typeandlocationofinflammationordischarge

• Evaluateotheranatomicallocations• Proliferativestateoftissue

CYTOLOGYCYTOLOGYCYTOLOGYCYTOLOGY

SampleCollection•Differentorganismscanbefoundfromdifferentlocationswithin• Earcanal• Middleear• Evenfromthesamelocation

•Waystocollect:• Tipofcone• Cottonswab• Earloopscrapingwallofcanal• Softtubeaspiration

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CytologyExamples•NormalEar

•Keratinocytes•Wax•Lipid•Cocci•Yeast

NormalEarCytology

Ginel,P.J.,etal.,Asemiquantitative cytologicalevaluationofnormalandpathologicalsamplesfromtheexternalearcanalofdogsandcats.VetDerm,2002.13(3):p.151-156.

Dogs(n=74) Cats(n=32)

MaximumYeast 8 (mean1.12) 5 (mean0.53)

MaximumBacteria 30(mean2.45) 10(mean1.78)

*Rodsandcocciwerenotseparated

NormalEarCytology

Tater,K.,etal.,Thecytologyoftheexternalearcanalinthenormaldogandcat.JVetMed,2003.50:p.370-374.

Dogs(n=50) Cats(n=52)

MaximumYeast 2.6 (mean0.2) 3.8 (mean0.3)

MaximumCocci 0.9(mean0) 3.8(mean0.3)

MaximumRods 0 0

Inflammatory cells 1dog/10fields

AbnormalCytology•Organismsbasedon/oif

• >5cocci/oif• >1rod/oif• Withinflammatorycells

• Anybacteriaconsidersignificant• Phagocytosisortoxicchangesissignificant

• Malassezia• Dogs>3/oif• Cats>1/oif

•Otheryeastorpseudohyphae

CytologyExamples• TNTCcocciandrods

• Neutrophils

• Nuclearstreaming

• Intracellularcocci

CytologyExamples• TNTCcocci

• Rarerods

• Malassezia

• Nuclearstreaming

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MixedInfectionsCommon

CytologyCANTOVEREMPHASIZETHE

IMPORTANCEOFTHIS•Neutrophils•Eosinophils•Cocci•Yeast•Acanotholytic cells•Dermatophyte•Demodex

Changeyourstains WHATABOUTCULTURES???????

Culture&Sensitivity•Indications

• Variesperclinician• Otitismedia– systemictherapy• Empirictherapyisineffective• LargeamountsofWBC’swithlittlebacteria

• Rods?Mixedinfection?•Alwaysdoacytologybeforeculturing• Ifmixedinfectionwanttoseepredominantorganism

• Isthereyeast,inflammatorycells?

Culture&Sensitivity•Potentialproblems

•Multipleorganismsnotalwaysidentified• Basedonserumlevels

• Higherconcentrationsobtainedwithtopicals• Sensitivityreflectsbloodlevelsofantibiotics•Multiplestrainsofsameorganismwithdifferentsensitivities

• Costeffectiveness

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OtherIssueswithCulture&Sensitivity•Bacterialculturesfromotic samplesgrowtwo,threeandsometimesmoreisolates50%ofthetime•Corynebacterium

• Normalmicroflora orpathogen?

•Enterococcus• Normalmicrofloraorpathogen?

•BacterialC&Sdonotgrowmalassezia

DuplicateCultureStudy•15 ears sampled by loop from external ear canal

• Level near junction of vertical and horizontal canal• Bacteria, rods, neutrophils or DNA were evaluated on cytology

•Two culture swabs inoculated from same loop•Group 1 correctly labeled•Group2mislabeled

Griffin,CE(2001)Otitisdiagnosis,methodsfordeterming secondaryinfections. AAVDandACVD,Norfolk,Virginia

DuplicateCultureResults•13 cases grew bacteria•1/13 (7.7%) had the exact same strain of bacteria isolated on sensitivity

Bacteria Grownonbothsamples(n=cases)

% Differentstrains/sensitivity

Pseudomonasaeruginosa 10 70Corynebacteria species 5 60Staphintermedius 2 100

MoreStudiesSupportMixedInfectionsSchick,A.,etal.VetDermatol,2007.18p120•VariabilityoflaboratoryidentificationandantibioticsusceptibilityreportingofPseudomonasspp.isolatesfromdogswithchronicotitisexterna.• 3laboratoriesagreedonthepresenceofPseudomonasspp.in15/18(83.3%)earssampled

•Noneofthe16Pseudomonasspp.withMICdatareportedhadidenticalpatternsofantibioticsusceptibilitybetweentwolabs

TriplicateCultureStudy•3 cultures taken•Two from the same identicalswab

•Onesamplefollowingearcleaning• Earloopscrapedalongthecanalwall

ResultsofTriplicateCulture•Thetwoidenticalculturesresults:

• BothgrewStaph.Intermedius,Strepcanis,Pseudomonasaeruginosa,Proteusmirablis

• Nonehadthesamesensitivitypattern=8differentstrains

•3rd culturegrewall4ofthesameorganisms• Butdifferentstrainsthanthefirsttwo• Additionalorganismsgrown:Corynebacteria jeikeium andE.Coli.

•Totalof14differentstrainsofbacteriafromoneearcanal

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Empiricalantimicrobialselectionvs.Culture&Sensitivity•20casesofpseudomonasotitis

• TreatmentstartedempiricallywhileawaitingC&Sresults

• EarflushingwasperformedwithTris EDTA

• 7/20hadapureculture• 13/20hadamixedculture

ROBSONDC.PROCEEDINGDERM CHAPACVSC JULY2010

Empiricalantimicrobialselectionvs.Culture&Sensitivity•17casescompletedthestudy•11casessensitivityreportedresistancetoantimicrobialempiricallychosen

•10of11weretreatedsuccessfullywithonlytopical

•ProblemisappropriatetherapymaynotbeutilizedbasedonC&Sreport

ROBSONDC.PROCEEDINGDERM CHAPACVSC JULY2010

WhenDoICulture?•Otitismedia– systemictherapy• Empirictherapyisineffectiveafterafewattempts

• Iknowthattheeariscleanbutcantgetinfectionundercontrol

• LargeamountsofWBC’swithlittlebacteria– andnotconcernedabouttopicalmedication

• Fungalinfections• Samplingtechnique

OtherDx Test

•Radiographs

•CT

•MRI

AdvancedImaging- CT•Allowsmorepreciseevaluationofbonystructures•Tympanicbullacontoursevaluated•Detectionofbonyproliferationorosteolysis•Otitismedia:•Sensitivity83%•Specificity89%

AdvancedImaging- MRI•Allowsadistinctionoffluidandsoft-tissuethatCTandradiographsdon’t•InanormalbullaMRIisasignalvoidduetoair•Usedforconcernsofsofttissuechanges

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FromBenigni,L,&Lamb,C.R.(2006).Diagnosticimagingofeardiseaseinthedogandcat.InPractice,28(3),122-130

OUTLINE•Anatomy•Howtoexamine•Etiology,Clinicalsigns•Diagnosticworkup•Treatment

ImportanceofFlushing Whyflush?•Removalofforeignobjects anddebris•Mostrapidwaytoremoveinfectionrightaway•RemovewaxanddebristoevaluateTM,presenceofatumororpolyp•Removingdebrisandinfectioncanalleviatesecondaryconcernsrapidly• Underlyingconditionshouldbeassessedtoandtreated

Howtoflush?•Useceruminolytics toenhancedebrisbreak-up

•Usebodytemperaturesterilesalineorwater

•Useabulbsyringeorredrubberattachedtoaflush/suctiondevice(oftenasyringe)

•Donotcreateasuction-besurethatexcesswatercanescapearoundtheflushinginstrument

•Rinsethoroughlytodecreaseirritationandpotentialototoxicity

TypesofFlush•Essentialforsuccessfultherapy

• Ceruminolytic• Douxo Micellar®Ceva• Cerumene ®Vetroquinol• Milytic Otic ®Vetbiotek

•Antibiotic-potentiatingagent• Tris-EDTAdisruptsthebacterialcellwall• AffectstheMICofsomeantimicrobials

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BulbSyringes Tubes

TubeFlushingTechnique PositioningPatient

TechniquePositioningPatient TopicalvsSystemicMedications

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TreatmentComponentsRouteAdministered Indication

Antibiotic Topical

Systemic

Bacterialinfectionearcanal

BacterialotitismediaProliferativechangesover50%lumenTopicalreactions

TreatmentComponentsRouteAdministered Indication

Antifungal Topical

Systemic

YeastovergrowthPresentwithinflammatorycellsandnobacteria

Otitismediawithyeastfrommiddleear

Some Topical MedicationsName Antibiotic Antifungal Steroid

Posatex Orbifloxacin Posaconazole Mometasone

Mometomax Gentamicin Clotrimazole Mometasone

Otomax Gentamicin Clotrimazole Betamethasone

Surolan Polymyxin B Miconazole Prednisolone

Tresaderm Neomycin Thiabendazole Dexamethasone

Claro Florfenicol Terbinafine Mometasone

Osurnia Florfenicol Terbinafine Betamethasone

Topical Medications•Concentrationsmuchhigherthanachievedbysystemicroutes•OftenmuchhigherthanMPC•Synergyofantibiotics,antifungalsandsteroids•Needatolerantpatient•Ownermustbeabletomedicate

LongActingProductsProduct Manufacture Duration Antibiotic Antifungal Steroid

B.N.T BCP VeterinaryPharmacy

14-21 Enrofloxicin Ketoconazole Triamcinolone

Otic Armor AllAccem Inc 90 Bandage Bandage None

CameoOtic PRNPharmacal

7 Antiseptic Antiseptic None

Osurnia Elanco 1/7-45 Florphenicol Terbinafine BetamethasoneClaro Bayer 30 Florphenicol Terbinafine Mometasone

Systemictherapy•Presenceofotitismedia•Proliferativechanges

• Especiallyifcanaloccluded•Ownercapability•Failureoftopicaltreatment•Adversetopicalreactions

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SystemicAntibioticsandAntifungals•Otitismedia

•DifficultfortopicaltherapytoreachmiddleearevenwithrupturedTM

•Usuallybasedoffculture•Mayempiricallyselectbasedonoticcytologyfindings

Glucocorticoids•Inflammation,pain•Topicalmediationreactions•Intralesional•Decreaseexudate•Proliferativetissue/stenosis

•Prednisone:1-2mg/kginitiallythentaper•Triamcinolone:0.1-0.2mg/kginitiallythentaper

TreatmentDuration•DON’TSTOPTREATMENTTOOSOON

•RECHECKISVERYIMPORTANT

•Negativecytology•Ideallyuntilcanalsandtympanumhavenormalized

•Canearselfcleannormally?

•Petswithperpetuating+/- predisposingfactorsmayrequirelongtermorlifelongmaintenancetherapy

WhentoTurf?Surgery?•Polyps•Mass/neoplasia•PSOM•Neurologic•Severestenosis•Notresponding

Ototoxicity•Aminoglycosides

• Systemic• Streptomycin• Gentamicin• Amikacin

• Topical• Amikacin• Gentamicin• Neomycin• Tobramycin

•Chloramphenicol•Polymyxin BandE•Propyleneglycol•Aceticacid•Benzalkonium chloride•Benzethonium chloride•Centrimide•Chlorhexidine•Ethanol•Iodineandiodophors

TopicalReactions•Canhappenwithanymedication,flush,topical•Cytology– inflammationwithnobacteria•Tx:

• Stopalltopicals• Rinsewithwater• OralSteroids

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Summary•Challenging•Trytofindtheunderlyingcause•CYTOLOGY•EARFLUSHING•Treatsecondaryinfections•RECHECKS

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