Ruptured ear drum & Pseudomonas

Re: Ruptured ear drum & Pseudomonas

Andrew Kent — Sun, 27 Jan 2013 12:07:29 GMT

[quote user="frfluffybottom"]

Hi!

I have a Westie with a ruptured ear drum and positive for psuedomonas- in terms of sensitivity, susceptible to canaural, surolan, ticarcillin and tobramycin. Does anyone know if its easy to get timentin? or how have others handled these cases?

Thanks a mil :)

[/quote] In answer to your question timentin is easy to get hold of and can be added to Triz EDTA in the same way as enrofloxacin etc. looks a good plan based on your cultures. Andy

Re: Ruptured ear drum & Pseudomonas

Kate Richardson — Sun, 27 Jan 2013 11:08:17 GMT

[quote user="Sarah Keir"]Out of interest, has anyone actually see problems putting stuff down ears with no ear drum?[/quote]

Only thing I have had a problem with was saline which was too cold. Caused a temporary head tilt.

I work on the basis that if there is inflammation and infection then this is likely to do as much if not more damage than anything I put down the ear to resolve said inflammation/infection.

Re: Ruptured ear drum & Pseudomonas

Sarah Keir — Sat, 26 Jan 2013 21:17:39 GMT

Good to hear. I knew about chlorhexidine and avoid the tris-chlor (?think may be called this) that some of my collegues use. I agree, I have put canaural and probably some other stuff down ears with no ear drum.

Re: Ruptured ear drum & Pseudomonas

Evelyn Barbour-Hill — Sat, 26 Jan 2013 20:57:43 GMT

[quote user="Sarah Keir"] Out of interest, has anyone actually see problems putting stuff down ears with no ear drum?[/quote]

Only from chlorhexidine. One case of mine, a long time ago (you don't do it twice). And in one case of somebody else's , where the eardrum was apparently intact.

I have in the past deliberately introduced both Surolan and Otomax into the middle ear, with no ill effects.

Re: Ruptured ear drum & Pseudomonas

Sarah Keir — Sat, 26 Jan 2013 19:00:00 GMT

To the OP,

I assume all ear drums in Pseudomonas ears are ruptured unless I can see them which is highly unlikely as so full of shitty pus. But I don't stress. My personal choice is good dosing of steroids +/- tramadol if very painful and Tris- EDTA flushes, showing the owner how to use it effectively. Sometimes I put Baytril injectable in the tris-edta - depends how brave I am, not on the C&S.

Current case had come from another vet, owner living in Africa and dog looked after by mother. Owner reading online that nothing should go down ears if no ear drum. Unfortunately we live in a real world. Out of interest, has anyone actually see problems putting stuff down ears with no ear drum? New line of discussion please, not this counter-productive bickering please. Please don't shoot me

Sarah

Re: Ruptured ear drum & Pseudomonas

James Laidlaw — Sat, 26 Jan 2013 09:28:03 GMT

www.youtube.com/watch

Re: Ruptured ear drum & Pseudomonas

Evelyn Barbour-Hill — Fri, 25 Jan 2013 21:54:55 GMT

[quote user="Rajat"]

I think surgeons jump to surgery because the ones they see are seen too late and then they end up recommending it as a first line treatment.

[/quote]

While physicians eschew surgery because they are convinced that everything must have a medical cure, if only you could find the magic mixture? So they experiment with every weird mixture they can devise, anything as long as it's not a licensed drug with a brand name?

Re: Ruptured ear drum & Pseudomonas

Malcolm Ness — Fri, 25 Jan 2013 17:30:27 GMT

[quote user="Rajat"]

Malcolm, I did read it - you wrote

[quote user="Malcolm Ness"]I would avoid ongoing antibiotic/corticosteroid combinations, identify and treat the primary problem if possible and look to early surgery for ventilation and drainage.[/quote]

[/quote]

Perhaps we are using a different language:

1. I used the word "ongoing" on purpose. Had I wanted to say "no antibiosis, no anti fungals" then that is what I would have said.

2. I said "and look to" surgery. Had I wanted to say "and to perform surgery" then that is what I would I would have said. I thought it implicit in what I did write that surgery would not be performed if the problem had been controlled adequately had it been possible to identify and teat the primary problem.

You flatter yourself tothink that your disagreeing with me might be a source of angst.

[quote user="Rajat"]Maybe it is a cultural thing [/quote]

What, precisely, do you mean by that?

Re: Ruptured ear drum & Pseudomonas

Rajat — Fri, 25 Jan 2013 12:57:20 GMT

Hi Malcolm

Looks like you did not like me disagreeing with you. Let me reply to the points you made.

[quote user="Malcolm Ness"]They were prefaced with the word "Remember" - suggestive of a teacher to a rather dim pupil. This forum comprises mainly practising veterinary surgeons with a qualification and experience similar to yours. I found your choice of expression patronising - I suspect that I wasn't alone.[/quote]

My post was a continuation of the previous one- to quote you - read what I wrote- it started with a PS- hence it was a continuation from the post before - and if you read it carefully you'd see it was in agreement to what you said about Pseudomonas developing secondary to longterm use of medicated ear drops.I can see why someone (at a stretch) maybe offended by the word remember. I was typing as I was thinking. Sorry to those who were offended. But I was agreeing with you!! Hence it seems a stretch for you to become offended, unless you are really sensitive! Again, I was sharing my experience, and whatever knowledge I have, as I made clear not at all trying to be patronizing and I would hope most who re-read the post would deduce that readily.

[quote user="Malcolm Ness"]

[quote user="Rajat"]How can surgery cure atopy?[/quote]

Read what I wrote.

[quote user="Rajat"]improve ventilation in some with very pendulous ears[/quote]

Again, read what I wrote. Competently performed surgery improves ventilation in all ears and creates drainage in all ears.

[/quote]

Malcolm, I did read it - you wrote

I disagreed with what you wrote because you said to identify and treat the primary problem and to perform surgery for ventilation and drainage. How does the infection get treated? No ear wash no antibiosis, no anti fungals...and to identify and treat primary problem is easier said than done, as we all know. While that is worked up and investigated, most would use topicals to control infection and inflammation. Atopy or allergies take time to diagnose, and if we do end up using prednisolone/ciclosporin say for atopy, there will be a varying degree of immunosupression leading to a potential worsening of infection.I cannot understand or agree with not using antibiotics topically to treat the infection (at least as a prequel to surgery?) and I would be grateful for any literature you can provide showing successful outcomes using this approach.

The OP requested advice on treating a dog with pseudomonas and ruptured tympanic membrane. I am not sure which 'surgery' is indicated for achieving drainage and ventilation of the middle ear. Ithink a TECA/LBO would but most vets in GP would turn to LWR first. That gets rid of the veritcal canal and easier access to horizontal canal, but what if there is stenosis here? 10-14 days of trouble medicating the surgery site to follow too.

Like I said, if there is irreversible stenosis, grand, lets get them booked in for surgery. Or non responsive to 'appropriate' medical management - go ahead and operate. Or had POE flareups for years. I see these dogs too- the common denominator is they get sent home with drops every time they have OE and if the clinical signs stop they don't get seen again. This is not appropriate medical management. Investigating for underlying causes, Checking them regularly, checking the TM, cytology and where needed (relatively rarely) culture along with client ed IMHO is what is really important and constitutes appropriate medical management.

I tried to provide some information on appropriate medical management and provided further specialist conference proceedings to highlight the approach specialist dermatologists take.

[quote user="Malcolm Ness"]

[quote user="Rajat"]Conversely, I have seen dogs have TECAs and owners still complain their dogs external ear flap is red and itchy despite thousands spent on surgery - no treatment or workup for the underlying cause, mind! Dog is still allergic and still itchy[/quote]

What has that to do with anything? A random example of a poorly worked up case.

[/quote]

Sorry - my case examples are random, and yours (of seeing end stage ears not operated on early on) are concise and ordered ? This I could find offensive if I tried...I won't!

[quote user="Malcolm Ness"]You know remarkably little about my case selection when managing ear disease in dogs and cats.[/quote]

No, I only know what you have written on here, which is you advocate surgery for a case presenting with pseudomonas infection in a westie with a ruptured TM. No indication of chronicity, other history or previous medications were provided by OP. Is it too much to say this is a 'jump' to surgery without knowing all the facts? Don't we need to know more before recommending surgery ? It is common to hear people with surgiucal leanings to prefer surgical intervention in ear disease. I did not pooh-pooh this, but stated why I thought this was a reasonable bias- because they are seeing end stage ears. In fact you declare a bias for surgery for yourself,[quote user="Malcolm Ness"]But I am a surgeon so I am biased![/quote] .

Interesting how the one person who appears to have a higher dermatology interest than us GPs mentioned topical treatments discussed at the BVDG group but did not report surgical intervention as the number one treatment to go to with this condition. Also, all the dermatology specialists I have read from talk a lot about topical treatments, pre treatment soaks, triz-edta and silver sulfadiazaine, drug concentrations and susceptibilities of pseudomonas organisms..wonder why? Are they wrong?

[quote user="Malcolm Ness"]

[quote user="Rajat"]That's interesting, a few posts ago you said you were talking as a surgeon[/quote]

Read what I wrote.The word "reporting" was a give away.

[/quote]

I did read it. Maybe you missed the wink. I was trying to lighten your mood a little. I am aware your other half is a dermatologist (for some time now, michael, thank you). I too could argue I am reporting the view of dermatologists (though I am not in a relationship with one) as this info did not fall from the sky I read it somewhere, went to CPD and learnt it there and so on and provided some links so people can read it for themselves.

[quote user="Malcolm Ness"]

[quote user="Rajat"]Please chill out a little![/quote]

Such arrogance!

[/quote]

Wow, we must be speaking a different language. It seems disagreeing with you lightly is offensive and asking you to relax/chill out (i..e not take offense) is considered arrogant! Maybe it is a cultural thing - well at least that's the explanation that makes me feel best about this!

Adios

Re: Ruptured ear drum & Pseudomonas

Tim Browning — Fri, 25 Jan 2013 09:48:43 GMT

I support Malcolm as a humble first opinion vet who sees a huge caseload of ear disease. I see many cases of long term otitis that would have benefited from a timely LWR and may have stopped progression to TECA which are often done where long term treatment failures of medical treatments. Some cases have dozens of bottles of drops and pseudomomas comes along

Getting the air to the horizontal canal is key and good drainage. Pseudomonas hates fresh air and loves taking on antibiotics and beating them

Obviously surgery doesn't cure atopy but it helps stop the ears being the main battleground and reduces systemic treatments

Re: Ruptured ear drum & Pseudomonas

Malcolm Ness — Fri, 25 Jan 2013 09:22:28 GMT

[quote user="Rajat"]Malcolm my comments re it being a commensal were in general[/quote]

They were prefaced with the word "Remember" - suggestive of a teacher to a rather dim pupil. This forum comprises mainly practising veterinary surgeons with a qualification and experience similar to yours. I found your choice of expression patronising - I suspect that I wasn't alone.

[quote user="Rajat"]How can surgery cure atopy?[/quote]

Read what I wrote.

[quote user="Rajat"]improve ventilation in some with very pendulous ears[/quote]

Again, read what I wrote. Competently performed surgery improves ventilation in all ears and creates drainage in all ears.

What has that to do with anything? A random example of a poorly worked up case.

[quote user="Rajat"]I think surgeons jump to surgery[/quote]

An arrogant and offensive remark. You know remarkably little about my case selection when managing ear disease in dogs and cats.

Many atopics with chronic or recurrent otitis benefit from earlier surgical intervention. The condition is made manageable and the otherwise relentless progression towards end-stage ears - along with the massive discomfort, pain and suffering along that path - can be avoided or at least mitigated.

[quote user="Rajat"]That's interesting, a few posts ago you said you were talking as a surgeon[/quote]

Read what I wrote.The word "reporting" was a give away.

[quote user="Rajat"]Please chill out a little![/quote]

Such arrogance!

Re: Ruptured ear drum & Pseudomonas

Michael Woodhouse — Thu, 24 Jan 2013 22:38:25 GMT

[quote user="Rajat"]

[quote user="Malcolm Ness"]I was reporting the views someone with 20 years + as a referral dermatologist.[/quote]

That's interesting, a few posts ago you said you were talking as a surgeon

[/quote]

His wife is a dermatologist. Keep up.

Re: Ruptured ear drum & Pseudomonas

Rajat — Thu, 24 Jan 2013 17:57:36 GMT

Malcolm my comments re it being a commensal were in general and not aimed specifically at you (most if anyone for the OP) or I would have quoted you - why oh why would I patronize you? Please chill out a little!

[quote user="Malcolm Ness"]I see too many cases that are resolved surgically and would have been resolved many months or years earlier were it not for attending veterinary surgeons with similar opinions.[/quote]

How can surgery cure atopy? Or inflammation? I think surgery is indicated for treating stenotic irreversible O.E. Not for treating pseudomonas infection per se.But I can see why it would improve ventilation in some with very pendulous ears.

Conversely, I have seen dogs have TECAs and owners still complain their dogs external ear flap is red and itchy despite thousands spent on surgery - no treatment or workup for the underlying cause, mind! Dog is still allergic and still itchy!!

I think surgeons jump to surgery because the ones they see are seen too late and then they end up recommending it as a first line treatment.

I think unless one is treating irreversible stenosis, canal calcification, or infections thought to be primarily due to conformation medical management is indicated first.

[quote user="Malcolm Ness"]I was reporting the views someone with 20 years + as a referral dermatologist.[/quote]

That's interesting, a few posts ago you said you were talking as a surgeon

Re: Ruptured ear drum & Pseudomonas

james herriot lied — Thu, 24 Jan 2013 17:43:18 GMT

[quote user="Malcolm Ness"]

I do love being patronised.

[/quote]

Super. Have you ever thought about putting these patients on Thornit before you have a rummage with a scalpel? I read on google that it's brilliant for all kinds of ear problems.

[quote user="Malcolm Ness"]

I was reporting the views someone with 20 years + as a referral dermatologist.

[/quote]

I remember, as a lowly intern, a bunch of calves came in with oesophageal rupture following over-zealous bolusing. I was on holiday, and the resident small animal superstar performed corrective surgery, which included penrose drains. Which didn't do anything, but the resulting pus build-ups were easily lanced so no biggy.

Said superstar collared me in the cafeteria queue a couple of weeks later to ask how the calves had got on. I filled him in, and mused a little on my experience of rate of pus inspissation in cattle and whether drains were as useful in calves as they were in dogs. He didn't half take it badly, reminding me of my lowly position and his exalted seat at The Right Hand. Proper bollocking.

I was right, though

Re: Ruptured ear drum & Pseudomonas

Malcolm Ness — Thu, 24 Jan 2013 17:07:51 GMT

[quote user="Rajat"] I am not keen on surgery in a inflamed infected ear[/quote]

I see too many cases that are resolved surgically and would have been resolved many months or years earlier were it not for attending veterinary surgeons with similar opinions.

[quote user="Rajat"]If pendulous ears using a soft hairband to pin them up every day can help ventilation[/quote]

I suspect that it does almost nothing at all to ventilate anything other than perhaps the first few millimetres of the vertical canal. It can do absolutely nothing for drainage.

[quote user="Rajat"](remember it is a commensal)[/quote]

I do love being patronised.

[quote user="Rajat"]But that's just my experience.[/quote]

I was reporting the views someone with 20 years + as a referral dermatologist.

Re: Ruptured ear drum & Pseudomonas

Rajat — Thu, 24 Jan 2013 16:56:37 GMT

PS I am not keen on surgery in a inflamed infected ear. Yes if end stage stenosis +/- wall calcification. But many pseudomonas do not present with stenosis in which case surgery is not the magic answer. totally agre on controlling underlying cause- atopy by far the most common as well as hypoT/hyperA/conformation/swimming etc etc

If pendulous ears using a soft hairband to pin them up every day can help ventilation

Pseudomonas can develop secondary to overuse of abs and drops (remember it is a commensal)- so judicious use is important in routine cases... the cases I have seen have not presented after a course of ab + steroid drops however, have suffered flareups of OE over months/years..and then present with pseudo. But that's just my experience.

Re: Ruptured ear drum & Pseudomonas

Rajat — Thu, 24 Jan 2013 16:52:05 GMT

Pseudomonas with O.media= a tough rodeo. Not in the same ballpark as other Otitis cases. Pseudomonas can play catch up with antibiotics and often change tis sensitivity profiles.

Other make good points. I'd also use preds for a few weeks at .5-1mg/kg/day, use triz chlor EDTA (dechra) flamazine is a good idea, also worth remembering that often topical abs reach far greater concentrations than they test for on serum disks so the MIC of bugs is often exceeded this way.

Vetruus cleaner was the best against pseudomonas in a recent study tho.

Topicals? Well use what you can get and what the bug is sensitive to. My last pseudo case was unresponsive to everything, including topical enrofloxacin so ended up curing it with canaural! Had a ruptured TM but no external evidence of problems with the canaural causing further middle ear irritation.

I culture every 2 weeks and repeat cytology as well.

2-3 weeks after first diagnosis and getting onto preds I GA and do a middle ear culture (the bugs and sensitivites are often different here than from external ear canal - using a soft sterile catheter you can use a slippery sam or regular urinary )and flush all debris out incl from middle ear. clean and dry the canal. If owners can get meds in properly ear wicks are useful in these cases.

Also worth getting O to demo how they are putting drops in. I find owners often dont put enough in or don't rub it in or just do it completely wrong, despite me having demo'd it to start. Also worth making sure they put enough cleaner (till overflowing) and enough medicated drops (1ml minimum maybe more for bigger dogs).

I also use systemic abs fwiw for 3-4 weeks especially if there are neutrophils on cytology.

Depending on amount of inflammation some tramadol as analgesia (or paracetamol-codeine) may not be a bad idea for a week or so.

Here area couple of conference proceedings which may be of value

www.vetsurgeon.org/.../2843.Diagnosing-and-Treating-Otitis-Externa-and-Otitis-Media-in-Dogs-and-Cats.docx

cheers

Re: Ruptured ear drum & Pseudomonas

Malcolm Ness — Thu, 24 Jan 2013 16:42:10 GMT

[quote user="Tim Browning"]I would proceed to surgery quite quickly to let the air in as these can be very difficult medically whatever initial sensitivity says. A lateral wall resection may not heal as well as normal but it will in time and topical bathing even with 10% clear vinegar is effective. If its a Westie it will probably need systemic treatment for atopy anyway but its ears won't be a problem. You need to have a good horizontal canal exposure where the nasty bug lurks...[/quote]

Our dermatologist has been heard to suggest that pseud. otitis is an iatrogenic disease - the longer you treat an inflamed ear with antibiotics AND corticosteroids the more likely you are to end up with pseud. I would avoid ongoing antibiotic/corticosteroid combinations, identify and treat the primary problem if possible and look to early surgery for ventilation and drainage. Alternatively, make up a fancy, greasy concoction with several top-shelf antibiotics plus some corticosteroids and use that daily (or even twice daily) for a month or more by which time the ears will be worse and the pseud will almost certainly still be thriving - then look to surgery for ventilation and drainage. But I am a surgeon so I am biased!!

Re: Ruptured ear drum & Pseudomonas

emma o'connor — Thu, 24 Jan 2013 16:03:49 GMT

Last years spring meeting for the BVDSG(derm study group) was all about ear disease, and some interesting points were made about treating ears with ruptured drums and Psuedomonas. Sue Patterson has apparently shown good response in resistant cases apparently using a trizedta/chlorhexidine preparation (otodine from vetruss) and suggests the low concerntration of chlorhexidine is safe in ruptured ear drums. Equally a lot of people mentioned using diluted flamazine cream (off licence of course ) applied in the ear 2-3 times daily. Also I find pred really useful as many of these have really sore sternotic canals, and a local referal dermatologist I know uses at 1mg/kg daily for this. Another suggestion for resistant Psuedomonas was injectable marbofloxacin applied topically. I think you may be able to access the proceedings on their website.

Good luck

Re: Ruptured ear drum & Pseudomonas

Tim Browning — Thu, 24 Jan 2013 13:29:46 GMT

I would proceed to surgery quite quickly to let the air in as these can be very difficult medically whatever initial sensitivity says. A lateral wall resection may not heal as well as normal but it will in time and topical bathing even with 10% clear vinegar is effective. If its a Westie it will probably need systemic treatment for atopy anyway but its ears won't be a problem. You need to have a good horizontal canal exposure where the nasty bug lurks...

Re: Ruptured ear drum & Pseudomonas

Mark Hedberg — Thu, 24 Jan 2013 12:40:11 GMT

I'd be watching out for atopy; a large number of cases show no symptoms except chronic and nasty ear infections!

My old boss made up a 1:9 dilution of enrofloxacin/saline and use that to wash the ear twice a day. Preds to control the inflammation. (Your mileage may vary on the enro/saline tric.) Remember that C&S doesn't always reflect actual sensitivity as local concentrations of antibiotic may be considerably higher than what's on a sensitivity disc!