Recurrent pseudomonas otitis - what to do?

Re: Recurrent pseudomonas otitis - what to do?

Rob Loxley — Sun, 12 Jan 2014 20:37:29 GMT

[quote user="Anthony Todd"]Why not just do a bulla osteotomy alone?[/quote]

Because the OM is likely secondary to chronic OE, and the BO will not do anything for the chronic, stenosing, painful, infected OE? If your disease process is just confined to the bulla (e.g. feline polyps) then a VBO would be appropriate.

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Sun, 12 Jan 2014 20:31:35 GMT

Tim, I'm sure the ones I remember were without a bulla osteotomy.

Why not just do a bulla osteotomy alone?

You could flush through via the horizontal canal or even use the vertical canal as a funnel....??

Re: Recurrent pseudomonas otitis - what to do?

Tim Charlesworth — Sun, 12 Jan 2014 20:22:59 GMT

[quote user="Anthony Todd"]

[quote user="Tim Charlesworth"]I'll attach a picture of an (immediate) postop TECA:[/quote]

I sort of realised that's what it would look like,

The ones I saw were some time ago and inevitably had a discharging sinus.

How does the middle ear infection and [?] tissue necrosis resolve when it didn't after massive antibiotics, swabs etc. etc with no drainage, or do you always drain via the bulla?

[/quote]

Surgeons used to perform TECA on its own without performing bulla osteotomy and this was linked to a high rate of persistent infection/sinus formation from the infected middle ear to the skin surface (there was no longer an ear canal for the discharge to come through) and so it is now routine/mandatory to combine the TECA with a lateral bulla osteotomy (LBO). Maybe the ones you saw a while ago didn't have LBO? LBO allows near complete removal of the epithelial lining from the middle ear and that, combined with vigorous lavage at the time of the surgery is usually enough to resolve any otitis media (we would also use postop ab's if sig infection). You can still see fistula formation postop even after TECA-LBO (usually referred to as a para-aural abscess) but this is usually associated with surgeon error i.e. leaving a significant part of secretory mucosa behind aot particularly nasty infection and I would regard this as a rare complication. We don't usually place surgical drains at the time of surgery (one study looked at this and there was no benefit in doing so) but some surgeons do and it doesn't seem to cause any problems so up to the individual surgeon.

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Sun, 12 Jan 2014 14:11:02 GMT

[quote user="Tim Charlesworth"]I'll attach a picture of an (immediate) postop TECA:[/quote]

I sort of realised that's what it would look like,

The ones I saw were some time ago and inevitably had a discharging sinus.

How does the middle ear infection and [?] tissue necrosis resolve when it didn't after massive antibiotics, swabs etc. etc with no drainage, or do you always drain via the bulla?

Re: Recurrent pseudomonas otitis - what to do?

Tim Charlesworth — Sat, 11 Jan 2014 16:39:51 GMT

John - thank you for clarifying this for everybody, it's very easy to presume that everybody knows what all the different abbreviations mean.

Anthony - as John has said -TECA is the complete removal of the whole ear canal and so no ear hole, no drainage etc. Postop appearance is usually very good with most owners happy. The beauty of the technique is that the dogs are so much happier following the technique as the whole source of the pain and discomfort has been removed. They obviously lose hearing in that ear but most of the cases I see have lost that a while before I get near them anyway.

I'll attach a picture of an (immediate) postop TECA:

Re: Recurrent pseudomonas otitis - what to do?

John Flynn — Sat, 11 Jan 2014 16:13:15 GMT

[quote user="Anthony Todd"]Yes, these are the only ones I ever saw and alwayst without the "spillway, so just the gungy hole full of matted hair etc.[/quote]

I don't think that's what is generally considered a "TECA" by most reading this thread, so might explain some of the differing viewpoints expressed etc.

Indeed, a gungy hole with matted hair sounds like a badly done (or inappropriately done) vertical ear canal resection (I think these work well in many cases; see Richard Harvey's text pp. 240 onwards, most of which is available at http://books.google.co.uk/books?id=DmGIsH7UVfAC&printsec=frontcover#v=onepage&q&f=false, quote "Postsurgical complications after this technique are much less common than those seen after lateral wall resection"

There's a video of a "TECA" as meant by ,most in this thread (I think) at http://www.vetsurgeon.org/media/p/67220.aspx

[quote user="Anthony Todd"]Am I correct in thinking that the "current" method should have no drainage and no discharge at all?[/quote]

That's the aim of a "TECA".

Complication rates reported vary (see the other thread that's been discussing the procedure), and I suspect in the hands of a modern soft tissue specialist are extremely low, thus meaning that "TECA" as Tim means it is anticipated to reliably be a one-stop cure (for that ear anyway), albeit at the expense of a fairly major procedure.

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Sat, 11 Jan 2014 14:02:35 GMT

[quote user="Tim Charlesworth"]Anthony: TECA = removal of all (or almost all) of the vertical ear canal with an ear hole remaining between the ear drum and the outside-world, either with just skin stitched to the reamining horizontal canal cartilage or part of the remnants of vertical canal used to create small cartilage flaps at top and bottom, i.e,. what I'd call a "vertical ear canal resection"[/quote]

Yes, these are the only ones I ever saw and always without the "spillway, so just the gungy hole full of matted hair etc.

Am I correct in thinking that the "current" method should have no drainage and no discharge at all?

Re: Recurrent pseudomonas otitis - what to do?

Tim Charlesworth — Sat, 11 Jan 2014 10:02:41 GMT

[quote user="John Flynn"]

[quote user="Anthony Todd"]

[quote user="Tim Charlesworth"]TECA can also be sig cheaper than LWR + 3-4 yrs of ongoing ear consults/meds/flushes etc[/quote]

Seen a number of these with a chronic hair all jammed up, sticky mess, following TECA and IMHO, otitis media or chronic horizontal canal infection easier to treat and clean with a LWR than a TECA and cosmetically better too [IMHO]

[/quote]

I'm going to go out on a limb and guess that there's the possibility that some cross-purposes talking has developed with all these TLAs and T+1LAs

Correct me if I'm wrong:

Tim: TECA = total ear canal ablation and lateral bulla osteotomy, i.e. removing the vertical and horizontal ear canals, cutting some bone out of bulla and removing anything nasty inside it also and stitching the skin closed with no ear hole left.

Anthony: TECA = removal of all (or almost all) of the vertical ear canal with an ear hole remaining between the ear drum and the outside-world, either with just skin stitched to the reamining horizontal canal cartilage or part of the remnants of vertical canal used to create small cartilage flaps at top and bottom, i.e,. what I'd call a "vertical ear canal resection"

[/quote]TECA = Total Ear Canal Ablation so yes no horizontal or vertical canal left and middle ear lining removed at surgery so no ongoing otitis externa or media (if done properly) and so no requirement for ongoing care. Always good to clarify the definitions...

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Sat, 11 Jan 2014 08:51:57 GMT

[quote user="Mark Holmes"] I used to find cutting down the horizontal canal accurately difficult.[/quote]

Yes, unless you were careful the 2 cuts ended in a "V" at the bottom so there was no "spillway! The trick, I found, was to ensure the base of both cuts was, not to the level of the horizontal canal, but about 1cm above it, flap that part of the lateral wall down and then you could dissect down to, at best outside or wider than the diameter of the horizontal canal, thus leaving a nice wide "flap" to make your spillway.

Re: Recurrent pseudomonas otitis - what to do?

Mark Holmes — Sat, 11 Jan 2014 07:50:57 GMT

My tip for LWR not sure if others will agree. I used to find cutting down the horizontal canal accurately difficult. The scissors wanting to spiral around the canal producing difficulties at the bottom. Since making the described skin incisions - blunt dissecting out the lateral wall to the base and using a scalpel to make an incision from the horizontal canal up, I can make a significantly better job of the business end of the surgery.

Re: Recurrent pseudomonas otitis - what to do?

John Flynn — Fri, 10 Jan 2014 21:47:27 GMT

[quote user="Anthony Todd"]

[quote user="Tim Charlesworth"]TECA can also be sig cheaper than LWR + 3-4 yrs of ongoing ear consults/meds/flushes etc[/quote]

[/quote]

I'm going to go out on a limb and guess that there's the possibility that some cross-purposes talking has developed with all these TLAs and T+1LAs

Correct me if I'm wrong:

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Fri, 10 Jan 2014 19:19:06 GMT

[quote user="Tim Charlesworth"]TECA can also be sig cheaper than LWR + 3-4 yrs of ongoing ear consults/meds/flushes etc[/quote]

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Fri, 10 Jan 2014 19:13:53 GMT

[quote user="Julian Earl"]We've had atopy mentioned[/quote]

Yes, as I said, those thickened red verrucose ultra itchy ones. And one ear only often too. Combine a diet trial with your steroids; topical may be enough after starting with a jab or tabs.

And remember ear mites, cherchez le chat too.

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Fri, 10 Jan 2014 19:08:06 GMT

[quote user="Tim Browning"]

As above I would push for LWR asap as it's not going to go away. The problem is that it does need an owner on board as wounds can breakdown more than usual and need more attention. However LWR is much cheaper than TECA and if you are practiced can almost be done in the time of a GA flush!

[/quote]Yes +1 but wish the LWR had been done months ago. Just for fun, how much have all the swabs and tests cost so far versus the cost and success of a LWR.....?

They don't take that long, always heal even in the most adverse of environments, cost less than all that's been done so far and, and, always, always, give the dog an improved aural state.

Remember not to take the stitches out too early, [I'm the master of that] and despite warnings, if you use Vetaphil [if it's still around] cut the ends in the canal at 5mm and the outer ends at 1cm and it's all good.

Re: Recurrent pseudomonas otitis - what to do?

Julian Earl — Fri, 10 Jan 2014 18:58:35 GMT

We've had atopy mentioned but what about a novel diet food trial for six to eight weeks, even with steroids initially before weaning them off? Are not food allergies a recognised cause of chronic recurrent otitis? Can be difficult to manage if the owner isn't committed but if it proved successful it would be far better than a TECA or BO. Also if it happens to be atopy, do people find the remaining vertical canal skin deteriorates now that it is more exposed to airborne allergens simply by being more physically open? There must be an underlying cause that has been missed so far for this dog.

Re: Recurrent pseudomonas otitis - what to do?

Tim Charlesworth — Fri, 10 Jan 2014 18:17:11 GMT

Hi Matt, given the chronicity of the condition, the cultures that you've had and the "less than ideal" owner I would go for TECA-LBO in this case. As you can see throughout this thread there are quite a few fans of LWR on here but I would be concerned that you prob have got middle ear extension of infection by now and although LWR may help get on top of any otitis externa (unless the horizontal canal is the problem) the dog will need probably ongoing meds/exams and wound healing will be less predictable as has already been said. The advantage of TECA is the resolution of any otitis media in addition to externa and the "curative" nature of the surgery. TECA can also be sig cheaper than LWR + 3-4 yrs of ongoing ear consults/meds/flushes etc so worth taking the likely follow up costs into consideration when you discuss this with the owner.

Best of luck with the case, do let us know how you get on if you manage to get them to surgery of any sort!

Tim

Re: Recurrent pseudomonas otitis - what to do?

Tim Browning — Wed, 08 Jan 2014 12:52:43 GMT

Re: Recurrent pseudomonas otitis - what to do?

Emma Middleton — Tue, 07 Jan 2014 22:09:23 GMT

[quote user="Matt Hilary"]aim to keep the ear comfortable with a view to operating in the future when finances allow[/quote] Hi Matt, from the discussion on here I would probably go with your latter idea. As you say, if medical treatment hasn't worked this far, it's unlikely to suddenly get better further down the line. Also from what you've said it's not clear whether an underlying disease such as atopy or hypothyroidism has already been ruled out and addressed. In any case I think the best bet for the owner is to get saving for surgery. Whether you go for LWR or TECA and LBO will depend on e.g. otitis media, state of the horizontal canal etc and your personal view - if you've looked through the thread you will see there are a few differing opinions on this! Good luck, sounds like a tricky one especially as the owner doesn't sound overly motivated.

Re: Recurrent pseudomonas otitis - what to do?

Matt Hilary — Tue, 07 Jan 2014 11:53:03 GMT

Apologies for hijacking existing thread but wanted a 2nd opinion on a Pseudomonas case (with financial limitations) and didn't feel another Pseudomonas thread was justified.

Patient is a 7y MN Springer with hx of ongoing/recurrent ear probs since 2009 - diagnosed with Pseudomonas in 2011, 2012 & 2013.
Never fully treated to cure - O is q passive so often lost to follow-up, investigation/treatment usually restarts when seen for vaccination or other problem.

Most recently had GA + ear flush in Oct '13, swab +ve for Pseudomonas, sensitive to Gentamicin, Framycetin & Neomycin. Started on Triz-EDTA + Dex (2mls) + Gent (16mls 40mg/ml) - I believe a protocol given to a colleague by a dermatologist.

Now 2-3m down the line and finishing 2nd bottle of above. Ear has improved wrt pain (prev near impossible to examine) but still uncomfortable, inflammation, mild discharge. I'm concerned by lack of progress and feel that if 2m+ of topical tx is ineffective further treatment is unlikely to be.
TM has been found intact at previous 2x previous ear flushes - not possible to examine conscious.

Ears not covered by insurance and funds limited. I'd like some advice about what to recommend - owner will likely agree to some further treatment but I'm keen not to waste money unnecessarily.

Haven't yet repeated in-house cytology or lab C&S (£80 so not trivial in cost terms) - this is probably the next step but likely only if planning further topical ab treatment.
Should I scale back topical abs altogether and maintain on Triz +/- steroids (topical or PO) - unlikely to fix but at least won't cause further probs.
Is there a superior option to Triz + distilled water (e.g. Otodine?).
Given ear is now much clearer than previously is 2nd GA + flush worthwhile?
Should I aim to keep the ear comfortable with a view to operating in the future when finances allow (costs prohibitive at present).

Thanks for any views.

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Wed, 18 Dec 2013 16:37:00 GMT

[quote user="Tim Browning"]

OK will have to agree to disagree! There is obviously a range in the success rate. The ear you describe would be a challenge, as advanced, but I feel the LWR will usually slow progression and will never worsen remaining pathology.

A unilateral severe hypertrophic otitis without other allergic signs is not the usual presentation but I would probably have a crack at it, expose it with LWR and if still a problem progress to TECA (or possibly straight to TECA if completely closed up but that would be a late presentation)[/quote]

Post a picture when you get another one and, just for me, try it on topical triamcinolone or similar for a couple of weeks first; you may be surprised.

Even the really advanced ones improved very dramatically even after the LWR, which was really my point.

Apart from that point of difference I reckon your protocol will save loads of animals from months or years of discomfit and the owners loads of money....

Re: Recurrent pseudomonas otitis - what to do?

Tim Browning — Wed, 18 Dec 2013 16:29:36 GMT

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Wed, 18 Dec 2013 16:08:44 GMT

[quote user="Tim Browning"]I wish I had outcome audited our cases over the years, long term follow up is difficult as they only come back if unsuccessful![/quote]

So do I.

Unless we are talking about 2 different presentations or descriptions I just must strongly disagree.

I used to see them with just one ear involved and no other signs of allergy at all.

If you are saying that the otitis externa per se is improved, then, for sure, but they still have a swollen verrucose intensely itchy external ear going black over time and extending beyond the external canal sometimes too, which the LWR/Zepps hasn't changed at all.

Have you got any pictures so that we know we are talking about the same thing?

I'm thinking about ears that are really itchy as opposed to painful; they used to run their head and ear along the carpet??

Re: Recurrent pseudomonas otitis - what to do?

Tim Browning — Wed, 18 Dec 2013 15:53:08 GMT

Not sure about what this means. As I see it, atopic dogs with otitis externa often have other skin irritations in other locations as is a generalised condition. The ear is often a weak point as the enclosed moist environment stimulates secondary problems and then this then encourages self inflicted trauma. If the inflamed ear is opened up the inflammation reduces somewhat. If you are lucky to densensitise or remove allergen than underlying atopy will be improved, but if this is not possible steroids et al will still be needed.

However the ear will not be such a weak point and source of discomfort and topical ear drops not needed. Systemic doses of steroids or other anti allergic medications can often be reduced after surgery. Progression of hypertrophy is slowed or halted. Traditionally LWR in atopic ears was supposed to be only effective in early or mild cases but I have tried some more severe cases and have often been amazed how severe hypertrophy is improved and SIT reduced. I wish I had outcome audited our cases over the years, long term follow up is difficult as they only come back if unsuccessful!

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Wed, 18 Dec 2013 15:17:50 GMT

[quote user="Tim Browning"] Has had a diagnosis of atopy[/quote]

Oh dear, can't agree with this at all. Many are the dogs with "chronic OE" which was actually atopic, or with an allergic otitis, you know the one, bright red swollen canal.

These end up after a Zepps with a bright red or callused external canal but without the lateral wall!!

Totally a waste of time. Brilliantly respond to topical steroids though with concurrent search and removal of allergen [fleas, ear mites] if possible though.

Re: Recurrent pseudomonas otitis - what to do?

Anthony Todd — Wed, 18 Dec 2013 15:11:38 GMT

[quote user="Tim Charlesworth"]If somebody out there is doing lots of LWR's in early-affected dogs and getting good results then write them up! [/quote]

There won't be any!! The procedure now [correct me, if I'm wrong, all you graduates in the last 10 years] is:

1. GA clean, plus culture and sens.

2. Prolonged local and systemic antibiotics

3. repeat, at intervals as necessary until client demands referral.

4. GA clean, plus culture and sens. by referee

5. 2 again by referee

6 TECA-LBO

We would recommend a Zepps after the second recurrence of OE in susceptible breeds.

Sometimes refused and sometimes there was no recurrence but often the surgery proved totally successful after loads of recurrences.