THANK YOU! A Review of Otitis - VETgirl · 7/13/17 1 A Review of Otitis Tips from a dermatologist to help you manage these Kacie Blessing, DVM, DACVD Animal Dermatology Clinic, San
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7/13/17
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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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