Chronic Otitis- help!

Re: Chronic Otitis- help!

Aurelijus vet — Fri, 05 Oct 2012 20:43:27 GMT

Try these products in this case http://www.icfpet.it/informations.asp?cat=45&id=27 or this http://www.icfpet.it/informations.asp?cat=45&id=26 .I've been using them a long time ago.They are among the best.Apply Dexoryl or Canaural two weeks and everything will be fine.I had a much more severe cases than this.

Re: Chronic Otitis- help!

Evelyn Barbour-Hill — Fri, 05 Oct 2012 19:41:14 GMT

[quote user="Anthony Todd"]

[quote user="Simon Neuhoff"]certainly food for thought.[/quote]

As an aside, in our practice we have done no "aural resections" since June 2010 and that is in excess of 450 consults a month, in the three branches I've looked at.

My recollection is that, in the 70s and 80s, with similar consult numbers, I would estimate we did one a month.

As far as I know none have been referred.

Is this everyone's experience?

[/quote]

No, but I do think that preparations for first-line treatment of otitis externa have vastly improved, also that ears are better understood.

Re: Chronic Otitis- help!

Anthony Todd — Fri, 05 Oct 2012 19:07:50 GMT

[quote user="Simon Neuhoff"]certainly food for thought.[/quote]

As an aside, in our practice we have done no "aural resections" since June 2010 and that is in excess of 450 consults a month, in the three branches I've looked at.

My recollection is that, in the 70s and 80s, with similar consult numbers, I would estimate we did one a month.

As far as I know none have been referred.

Is this everyone's experience?

Re: Chronic Otitis- help!

Simon Neuhoff — Fri, 05 Oct 2012 18:06:44 GMT

[quote user="Malcolm Ness"]

[quote user="Simon Neuhoff"] It may be very helpful and even essential in managing certain cases but it never addresses the primary reason[/quote]

Not disagreeing with any of that - the OP was about a difficult case and not one of the majority that will respond to appropriate "routine" treatment - but, almost by definition, if you have a recurrent otitis then the medical treatment has not addressed the primary reason. The role of early LWR is first to make the recurrences less likely and more easily/effectively managed and in most cases it prevents the recurrent cases (in most cases these are atopics) becoming refractory/end-stage ears.

[/quote]

Thanks for that Malcolm - certainly food for thought.

Re: Chronic Otitis- help!

patrick murphy — Fri, 05 Oct 2012 17:52:57 GMT

as about 30% of my turnover is ears, I went to the NAVC to take a wet lab in TECA figuring that I should be able to have this skill, when a 30 year boarded veteran of many of these started out by saying that these can take between 1 hour or 4 hours, just depends, ,,, very quickly I realised that this should generally be in the hands of someone with better skills, and more patience than me.

Re: Chronic Otitis- help!

Malcolm Ness — Fri, 05 Oct 2012 17:31:30 GMT

[quote user="Simon Neuhoff"] It may be very helpful and even essential in managing certain cases but it never addresses the primary reason[/quote]

Re: Chronic Otitis- help!

Simon Neuhoff — Fri, 05 Oct 2012 16:56:56 GMT

[quote user="Malcolm Ness"]

It is usually ignorance and inexperience - the ones I have discussed this with have little if any experience of primary care practice and consequently no experience of seeing LWR used as advocated by Gerry, Evelyn and me as an early/prophylactic intervention. The referral ear caseload is dominated by end-stage ears and those that have had a badly timed (ie much too late) or poorly executed LWR.

[quote user="Simon Neuhoff"]my bias will be different to the surgeons like Evelyn and Malcolm[/quote]

Almost all our LWR cases come through our dermatologist who, it goes without saying, is not a surgeon.

[quote user="Simon Neuhoff"]Doing a LWR at the first or second recurrence of otitis seems a bit OTT - to me at least.[/quote]

Using a third or fourth lot of ear-wash and meds to partially control an otitis is considered OTT by our dermatologist. The medicine vs surgery thing is spurious - if a case can be effectively managed by rattling pills at it then that is always going to be my first choice but if surgery offers benefits, then that is the way to go.

[/quote]

As you point out Malcolm - I am not a specialist surgeon or a specialist dermatologist. As such I think the caseload I see is somewhat different to yours. The majority of ear cases I see do respond very well to first line treatment - clearing up the otitis is rarely the problem but keeping it clear is the challenge. The secret there is of course controlling the primary factors - something I accept is not always easily done! That said the majority of cases we see are adequately managed without surgery - the horror cases of Pseudomonas/severe stenosis/end stage ears are the exception rather than the rule. I quite agree surgery has its place - to my mind though it is a management tool for specific cases rather than simply recurrent (which is of course different to refractory) otitis. It may be very helpful and even essential in managing certain cases but it never addresses the primary reason.

Re: Chronic Otitis- help!

Malcolm Ness — Fri, 05 Oct 2012 16:11:53 GMT

[quote user="Simon Neuhoff"]Possibly the reason for vet school lecturers condemning LWR?[/quote]

[quote user="Simon Neuhoff"]my bias will be different to the surgeons like Evelyn and Malcolm[/quote]

Almost all our LWR cases come through our dermatologist who, it goes without saying, is not a surgeon.

[quote user="Simon Neuhoff"]I don't do TECABO's and to date the two that I have observed (both done by GP's who consider themselves decent surgeons) have not gone well.[/quote]

An all too common problem. TECA-LBO is one of those procedures that many aspiring but untrained surgeons undertake. Even in well-trained and experienced hands there is a significant complication/failure rate but that is disguised by the fact that many of the complications occur weeks or months after the surgery. We see several St Elsewhere TECA-LBO cases to revise each year and typically there is an identifiable surgical technical error - most often remnants of the horizontal canal +/- an intact bulla.

[quote user="Simon Neuhoff"]Doing a LWR at the first or second recurrence of otitis seems a bit OTT - to me at least.[/quote]

[quote user="Simon Neuhoff"] it was still in significant discomfort some 6 weeks post surgery.[/quote]

That is not right - it should be investigated and sorted - primarily for the benefit of the patient but any half-decent surgeon would want to discover what was going (or perhaps, what they had done) wrong.

Re: Chronic Otitis- help!

Evelyn Barbour-Hill — Fri, 05 Oct 2012 13:23:42 GMT

[quote user="Lorna McHardy"]As an aside, and just out of interest, what suture material do you all use for these?[/quote]

Cats: 5/0 Prolene

Dogs: usually 5/0 Prolene around the doormat and the orifice, 4/0 up the sides. Bigger dog, usually all 4/0.

Re: Chronic Otitis- help!

Simon Neuhoff — Fri, 05 Oct 2012 12:54:33 GMT

[quote user="Anthony Todd"]

[quote user="Simon Neuhoff"]"here we go again" [/quote]

Was before you'd said anything!

[/quote]

The "here we go again" was written as a direct response to my words - in your post Jo Jones' name comes up but that is because of the way you edited my post.

For the rest lets leave it to lie - I hope your day improves.

Re: Chronic Otitis- help!

Simon Neuhoff — Fri, 05 Oct 2012 12:54:27 GMT

[quote user="Anthony Todd"]

[quote user="Simon Neuhoff"]"here we go again" [/quote]

Was before you'd said anything!

[/quote]

The "here we go again" was written as a direct response to my words - in your post Jo Jones' name comes up but that is because of the way you edited my post.

For the rest lets leave it to lie - I hope your day improves.

Re: Chronic Otitis- help!

Anthony Todd — Fri, 05 Oct 2012 11:08:46 GMT

[quote user="Simon Neuhoff"]"here we go again" [/quote]

Was before you'd said anything!

"one vet" can be included in "some" but not in "all others".

I'm conservative with steroid usage viz my many utterances re continuous low dose or any continuous dose use but sometimes some vets sometimes give steroids, use appropriately for the appropriate length of time at sufficient dosage which gives the most relief and quicker than anything else without compromising ongoing tests or diagnostic procedures.

Some other vets sometimes wait,without giving concurrent symptomatic relief, if you're not one of those don't take offence 'cos I'm not meaning you.

All we're trying to do is make things better, and give quick relief if we can't!

I can lose arguments with my wife so I don't need to lose them with anyone else.

I've just been to the local lab. site, as my GP had ordered a pregnancy test and screen for drug abuse, so I'm a bit delicate.

[Their computer system has just been updated.....]

Re: Chronic Otitis- help!

Simon Neuhoff — Fri, 05 Oct 2012 10:46:54 GMT

[quote user="Anthony Todd"]

[quote user="Michael Woodhouse"]

[quote user="Anthony Todd"]You must admit that sometimes some vets do spend a long time diagnosing skin irritation without giving symptomatic relief in the meantime.[/quote]

I agree 100%. Putting a Buster collar on an itchy dog without doing anything about the itch is as cruel as operating with no analgesia.

[/quote]

There you are Simon, someone realises I'm not getting personal, and I never do unless someone addresses me personally . If you read my reply again you should realise I was commenting generally and not personally.

I've been to a meeting where a vet said "I don't treat a derm case until I've got a diagnosis", and we were talking about biopsies!

The manufacturer quotes using Atopica for 4 weeks and reassessing. Does that mean it takes 4 weeks for a response? I'll bet no one gives itching relief in that period, you know, the dreaded steroids, but I have no experience of the drug.

Atopica will initially be given daily until a satisfactory clinical improvement is seen. This will generally be the case within 4 weeks. If no response is obtained within the first 8 weeks, the treatment should be stopped.

From the datasheet.

[/quote]

Anthony there is quite a difference between saying "some vets" and between quoting my words and going "here we go again" etc. There is the same difference as "within four weeks" and taking four weeks for a response. I think extrapolating from one vet at a meeting to all others who try to be conservative about steroid useage and look at alternatives is inappropriate and inaccurate.

Re: Chronic Otitis- help!

Anthony Todd — Fri, 05 Oct 2012 10:19:33 GMT

[quote user="Michael Woodhouse"]

[quote user="Anthony Todd"]You must admit that sometimes some vets do spend a long time diagnosing skin irritation without giving symptomatic relief in the meantime.[/quote]

I agree 100%. Putting a Buster collar on an itchy dog without doing anything about the itch is as cruel as operating with no analgesia.

[/quote]

I've been to a meeting where a vet said "I don't treat a derm case until I've got a diagnosis", and we were talking about biopsies!

From the datasheet.

Re: Chronic Otitis- help!

Simon Neuhoff — Fri, 05 Oct 2012 10:00:37 GMT

[quote user="Anthony Todd"]

With the greatest of respect and not meaning to insult anyone but if I give that impression inadvertently I apologise in advance etc. etc. [Some folk don't like being questioned, queried, let alone disagreed with....].

[/quote]

Anthony I take it that's directed at me. I have no issue whatsoever with being disagreed with, questioned, queried etc. I enjoy a robust argument and I am thick skinned. I do object to having my words misrepresented, twisted and taken out of context or of being implied of being lacking in care and allowing suffering.

Re: Chronic Otitis- help!

Anthony Todd — Fri, 05 Oct 2012 09:52:08 GMT

[quote user="Michael Woodhouse"]Every one I have done has made the dog better than it was before, and many have given an apparent cure.[/quote]

The only ones that failed with me were the [obviously now] true atopics which still itched like mad, became verrucose and thickened, without any signs of infection, and resolved with steroid creams as and when necessary.

Oh, apart from the one that was healing beautifully so i removed the stitches after 3 days...... oh, dear!

Re: Chronic Otitis- help!

Simon Neuhoff — Fri, 05 Oct 2012 08:50:24 GMT

[quote user="Evelyn Barbour-Hill"]

This is so. Possibly the reason for vet school lecturers condemning LWR? I find owners however quite receptive earlier, on average. Of course there is a wide range of owner's attitude. Broach the idea of surgery much earlier; perhaps at the first recurrence. Then sometimes they will be asking at the second recurrence "is there anything permanent can be done? You mentioned an operation?". Some owners definitely do not see it as a minor problem.

[/quote]

I think the approach on this thread here reflects peoples biases in general. I accept there is always more than one way to skin a cat - and I will also say that I am by nature medically rather than surgically inclined and therefore my bias will be different to the surgeons like Evelyn and Malcolm. That said when I see recurrent otitis externa I don't go straight to surgery - I look for underlying reasons and try to control these. Doing a LWR at the first or second recurrence of otitis seems a bit OTT - to me at least.

I don't do TECABO's and to date the two that I have observed (both done by GP's who consider themselves decent surgeons) have not gone well. The last time I saw the latest one (now "lost to follow up") it was still in significant discomfort some 6 weeks post surgery. (yes I am aware I am displaying bias based on personal experience vs proper evidence - but I am pretty loathe to encourage any further surgery at this point!)

Re: Chronic Otitis- help!

Lorna McHardy — Fri, 05 Oct 2012 07:29:46 GMT

[quote user="Mark Holmes"]

they get a £500-£800 bill

[/quote]

I suppose it depends on where you are, but that sounds a little excessive to me for what really isn't that complex a piece of surgery, even if you add analgesia and antibiotics. Are you including pre-op bloods and second sedation to remove sutures in that? The majority can be removed without, unless they're too tight... you'd have to include it in any quotation, of course.

As an aside, and just out of interest, what suture material do you all use for these?

Re: Chronic Otitis- help!

Evelyn Barbour-Hill — Fri, 05 Oct 2012 01:54:27 GMT

[quote user="Mark Holmes"]My point was that once the owners have accepted the ears are a problem and intractabłe to medical treatment often the case is beyond LWR and needing TECABO[/quote]

Yes I do see what you are saying about the owner's perspective. But

[quote user="Mark Holmes"]they get a £500-£800 bill [/quote]

Hmm. A 40 lb dog, say £400 plus VAT.

[quote user="Mark Holmes"] a dog who looks horrific[/quote]

Hmmm. Yes, things can look "horrific" to an owner that are not so bad to you and me. But done properly, not sutured with half a dozen clonking great cow sutures as some lecturers seem to do, the immediate appearance is one I just can't accept as "horrific".

[quote user="Mark Holmes"]likely to be irritated by the sutures for a week or so[/quote]

Yes, sometimes that's true. Although, again, it helps if......... you know. And good analgesia helps.

[quote user="Mark Holmes"]he swelling reduced[/quote]

I wouldn't say the swelling was more than with any plastic surgery?

Re: Chronic Otitis- help!

Mark Holmes — Thu, 04 Oct 2012 23:49:32 GMT

[quote user="robloxley"]

[quote user="Mark Holmes"]significant operation financially and cosmetically and analgesically[/quote]

Is a LWR really significantly expensive (especially compared to treating recurrent OE) and is the cosmetic appearance really that bad and do we not have good analgesics at our disposal?

[/quote] You are not seeing it from the owners perspective again. They had a dog with itchy ears, they get a £500-£800 bill and a dog who looks horrific and is likely to be irritated by the sutures for a week or so. Once the hair grows back, the sutures are out and the swelling reduced they can look great but when you bring it up it sounds like an expensive and dramatic op for what is perceived at least to be a minor problem. My point was that once the owners have accepted the ears are a problem and intractabłe to medical treatment often the case is beyond LWR and needing TECABO

Re: Chronic Otitis- help!

Michael Woodhouse — Thu, 04 Oct 2012 23:40:51 GMT

[quote user="Anthony Todd"]You must admit that sometimes some vets do spend a long time diagnosing skin irritation without giving symptomatic relief in the meantime.[/quote]

I agree 100%. Putting a Buster collar on an itchy dog without doing anything about the itch is as cruel as operating with no analgesia.

[quote user="David Mills"]How early is early for LWR? Do people do it when there's narrowing of vert canal? How many recurrences would you give?[/quote]

I will start talking about it once an animal has been back a few times with its ears in a period of a few months. My perception is clients start getting pissed off bringing the dog back time after time with the same ailment. I will bring it up very quickly in some of the 'spaniel ears' and if really stenotic ears (after trying steroids).

Every one I have done has made the dog better than it was before, and many have given an apparent cure.

[quote user="robloxley"]Is a LWR really significantly expensive?[/quote]

Don't know what people charge for these but if things go well it's easily achieved in ~half an hour. Allowing for the fact that some dogs need sedating for suture removal - couple of hundred pounds? Not crazy money.

Re: Chronic Otitis- help!

Rob Loxley — Thu, 04 Oct 2012 23:04:00 GMT

[quote user="Mark Holmes"]significant operation financially and cosmetically and analgesically[/quote]

Is a LWR really significantly expensive (especially compared to treating recurrent OE) and is the cosmetic appearance really that bad and do we not have good analgesics at our disposal?

Re: Chronic Otitis- help!

Evelyn Barbour-Hill — Thu, 04 Oct 2012 22:30:36 GMT

[quote user="David Mills"]Funny how these things go. At college (4-5 years ago) it was drummed into us that lateral walls were pretty useless, just around the time that Teca-Bos were on the rise it seemed.[/quote]

Indeed. Funny how wrong colleges can be. (Cf. "catgut is negligence").

LWR are especially rewarding in cats, by the way. (Though that's a bit off thread).

[quote user="David Mills"]Do people do it when there's narrowing of vert canal?[/quote]

Yes.

[quote user="David Mills"]How many recurrences would you give?[/quote]

I'm not ducking the question, but.......... there's no hard and fast rule. It depends on so many factors, of both animal and owner, it comes down to the old "clinical judgment". Which I freely admit might make it a matter of "when I feel like it". Shall we say, when it becomes obvious that the recurrences are not going to cease and that the ear canal is progressing slowly but surely towards occlusion.

[quote user="David Mills"] Do with concurrent 'roid tx or stop that?[/quote]

Sorry?

Re: Chronic Otitis- help!

David Mills — Thu, 04 Oct 2012 21:05:19 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Mark Holmes"]That said suggesting what is a significant operation financially and cosmetically and analgesically as a prophylactic procedure takes some courage.[/quote]

Assuming it's done well, when it's healed the cosmetic effect is minimal and cannot be described as adverse.

Takes courage? Yes.

[/quote]

Funny how these things go. At college (4-5 years ago) it was drummed into us that lateral walls were pretty useless, just around the time that Teca-Bos were on the rise it seemed. We don't do any at my current place, but do a couple of TECAs a week.

How early is early for LWR? Do people do it when there's narrowing of vert canal? How many recurrences would you give? Do with concurrent 'roid tx or stop that?

Re: Chronic Otitis- help!

Evelyn Barbour-Hill — Thu, 04 Oct 2012 19:24:23 GMT

[quote user="Mark Holmes"]That said suggesting what is a significant operation financially and cosmetically and analgesically as a prophylactic procedure takes some courage.[/quote]

Assuming it's done well, when it's healed the cosmetic effect is minimal and cannot be described as adverse.

Takes courage? Yes.