Pseudomonas otitis

RE: Pseudomonas otitis

Anthony Todd — Wed, 02 Sep 2015 13:57:59 GMT

[quote user="Rob Davis"]an hour flushing an hear[/quote]

Geez, you want to listen to some of the guff on 'ear

RE: Pseudomonas otitis

Evelyn Barbour-Hill — Wed, 02 Sep 2015 13:26:50 GMT

Why would it take an hour? Or, to put it another way, how is the originator of this protocol deciding that flushing has been completed?

RE: Pseudomonas otitis

Rob Davis — Wed, 02 Sep 2015 11:44:19 GMT

Fair enough - I think I'd die of boredom if I spent an hour flushing an hear! The protocol was very interesting though, thanks for posting it.

RE: Pseudomonas otitis

Kara Gibson — Wed, 02 Sep 2015 02:21:56 GMT

This was taken verbatim from some CPD, I've never spent that long flushing an ear, usually 20mins or so!

RE: Pseudomonas otitis

Rob Davis — Tue, 01 Sep 2015 14:51:21 GMT

[quote user="Kara Gibson"]Copious amounts (can take up to an hour of flushing)[/quote]

How much do you charge for spending an hour flushing an ear....!

RE: Pseudomonas otitis

Kara Gibson — Tue, 01 Sep 2015 10:49:41 GMT

I got he following regime from some online CPD by Sue Paterson. She recommended all Pseudomonas had a flush under GA to start. I have not always done this, it depends on the severity of the ear infection, owner's finances and concurrent health problems. Also with this case there would be real concerns about using systemic steroids. I have to admit I have had pretty good success using this regime.

Cleaning under GA:

STEP 1:

Water used initially
6FG urianry catheter best
Copious amounts (can take up to an hour of flushing)
External canal and middle ear should be flushed

STEP 2:

Acid flush - allow ear to soak for 2 minutes
Acetic acid - safe (Malacetic aural good product)

STEP 3:

Secondary TrizEDTA flush (crystals or TrizChlor)
Well tolerated
Will neutralise acidic cleaner
Potentiates flouroquinolones, aminoglycosides
Limited antibacterial activity

STEP 4:

Instil antibiotic and glucocorticoid into ear canal including into the middle ear (often acts as a nidus of infection). Introduce down the flushing catheter.
Depending on size of dog use:

0.5mls flouroquinolones (empirically enrofloxacin or marbofloxacin injectable whilst waiting for C&S results)
0.5mls steroid - dexamethasone injectable

Before waking up give i.v. glucocorticoids (0.1mg/kg dexamethasone)

Home treatment:

Flush: TrizEDTA/Chlor
Topical antibiotics: fluoroquinolones
Glucocorticoids: dexamethasone topically and prednisolone orally

Recipes:

TrizEDTA/Chlor:

Use 12mls qith 4mls of added flouroquinolone
Use 0.5 - 1ml SID after cleaning (with Triz)

Steroids:

2-4mls topical dexamethasone (2mg/ml) can be added to Triz.

RE: Pseudomonas otitis

Rob Loxley — Sat, 29 Aug 2015 15:18:42 GMT

[quote user="Stephen Courtney"]Has anyone got a recipe for a Baytril or Marbocyl based intra aural mixture? [/quote]

I usually refer to some good recipes from Tim Nuttall in 2009 BSAVA proceedings

RE: Pseudomonas otitis

Anthony Todd — Sat, 29 Aug 2015 13:11:56 GMT

[quote user="Stephen Courtney"]

His bullae are clear on CT and his tympani are intact.

part of the problem now is that the ear canal is always soggy .

[/quote]

Classic indication for a LWR surely, at worst it will make things much better.

[ BTW, Is "Aural resection" the greatest misnomer of all time?]

RE: Pseudomonas otitis

Stephen Courtney — Sat, 29 Aug 2015 12:58:41 GMT

Has anyone got a recipe for a Baytril or Marbocyl based intra aural mixture? I've been struggling with a Spinone with a gooey left ear and the triz aural with added gentamicin and dexadreson has Not cleared it. Now the ear is pretty wet and there is an opportunistic anaerobic Bacteroides in there ( i thought I had overcooked the DiffQuick ) as well as the Pseudomonas which is still fortunately sensitive to the usual suspects.

His bullae are clear on CT and his tympani are intact.

part of the problem now is that the ear canal is always soggy . I'm starting to lose the will to live ......

RE: Pseudomonas otitis

Rob Loxley — Sat, 29 Aug 2015 10:47:00 GMT

[quote user="SAB"]was I being totally unreasonable trying to treat this medically[/quote]

No, but often these end up needing a TECA/BO, sometimes after spending more on heavy duty meds and flushing under GA etc than a TECA/BO costs upfront, and if not will often recur. What are the owner's expectations...

[quote user="Robin Grimmer"]If it does have surgery a lateral wall resection is no good. Needs teca.[/quote]

This dog has middle ear pathology from the symptoms and a BO is needed. I've not had good success with just doing a VBO in dogs. In a CKCS with middle ear signs and bulla pathology I'd also consider underlying primary secretory OM

[quote user="SAB"]What do others do for this type of Pseudomonas? [/quote]

I don't reckon you'll ever settle tese without continuing topical treatment

[quote user="SAB"]So would you still use topical treatments even with the damage to the tympanic membrane?[/quote]

Yes, I don't believe you'll fix it without, the dog already has middle ear symptoms, and if the alternative is a TECA/BO

RE: Pseudomonas otitis

Virginia Campbell — Fri, 28 Aug 2015 22:19:55 GMT

Oh yes, and don't pull any punches with the owner about the chances of this immunocompromised dog living happily ever after with medical or surgical treatment. Emphasise the unknowns- just because lab says sensitive to FQs, doesn't mean they will work. Just because bloods look OK, doesn't mean organs will cope with all its systemic disease plus drugs +-- GA and healing a surgery site if comes to it. Even if you get bug to go away, doesn't mean it will stay away. Etc,etc. Document these conversations, in case they spend a fortune in money and hope, end up euthanasing and blame you. I once knew of a vet who was notorious for gazing at the animal mournfully and saying, "You may buy a shovel" before he would treat anything, just to manage owner expectations down a few pegs before he attempted treatment. I'd do this, in gentler terms.

RE: Pseudomonas otitis

Virginia Campbell — Fri, 28 Aug 2015 22:08:07 GMT

Oh, tricky one. I would perhaps do the same as you, though would reswab halfway through the course for c+s; I've seen a couple of pseudomonas cases develop resistance to FQs disappointingly quickly. Hmm, otitis media, diabetes, cataracts... +/- mitral valve disease (amiright?)... I would quietly set euthanasia on the table as one of the options. Also, pseudomonas is not a nice thing to have spewing round your house, especially if it wins the battle against your drugs and develops resistance to more things. Have and document a discussion about zoonotic risk and any vulnerable humans exposed to the dog. If you do go for TECABO, be as sure as you can be that it hasn't got Cushings before you start, and consider its liver's ability to withstand a long GA and provide the wherewithal for healing.

RE: Pseudomonas otitis

Joyce Whitehead — Fri, 28 Aug 2015 22:00:47 GMT

I have also had a couple of chronic pseudomonas resolve after LWR, one of which the owners took quite some time to persuade to have surgery, but the dog is so much happier now, and has a lovely ear. Which got a grass seed in this week, but he is a spaniel....

RE: Pseudomonas otitis

Martin Atkinson — Fri, 28 Aug 2015 19:19:03 GMT

[quote user="SAB"]

So would you still use topical treatments even with the damage to the tympanic membrane?

And topical steroids in a diabetic dog?

[/quote]You have a balance between that and chronically infected ear full of pus/discharge that isn't clearing up which is going through the tympanic membrane anyway. I would favour the drops so long as there is nothing obviously ototoxic in them like neomycin. And I don't think the amount of steroid in the drops is going to over-worry a diabetic. You need to consider your options an see if there is a practical alternative. Read my signature below!

RE: Pseudomonas otitis

Michael Woodhouse — Fri, 28 Aug 2015 18:40:38 GMT

[quote user="Robin Grimmer"] If it does have surgery a lateral wall resection is no good. Needs teca.[/quote]

I'm not sure I agree. We've had a number of these massively improve with a LWR - can do quickly and easily in house for not a lot of money. Not expensive and can make a huge difference to QOL, CF TECA as a referral op with four figure price tag and heap of risks.

I've operated on ~half a dozen hooching with active psudomonas and never had an infection issue afterwards. If they are going for a TECA then I'm not sure that is a worry.

RE: Pseudomonas otitis

Anthony Todd — Fri, 28 Aug 2015 18:29:42 GMT

[quote user="Robin Grimmer"]Needs teca.[/quote]

What, even with a probable middle ear infection, what are the chances of that resolving??

RE: Pseudomonas otitis

Hannah Wynne Richards — Fri, 28 Aug 2015 18:14:26 GMT

Oops sorry. I forgot that.

Wynne

RE: Pseudomonas otitis

Robin Grimmer — Fri, 28 Aug 2015 17:47:47 GMT

I'm pretty sure the triz edta and baytril is fine with ruptured eardrum - as the timpanum is mostly ruptured in these cases. I would avoid steroids in a diabetic dog.

RE: Pseudomonas otitis

SAB — Fri, 28 Aug 2015 17:33:59 GMT

So would you still use topical treatments even with the damage to the tympanic membrane?

And topical steroids in a diabetic dog?

RE: Pseudomonas otitis

Martin Atkinson — Fri, 28 Aug 2015 17:22:24 GMT

[quote user="Robin Grimmer"]I think there's a regime for topical Tris edta and Baytril which has better results.[/quote]Indeed . Otodine drops should help plus Aurizon drops (Marbofloxacin). Then keep on with Otodine daily in the longer term..

RE: Pseudomonas otitis

Hannah Wynne Richards — Fri, 28 Aug 2015 17:18:18 GMT

Another wh'd be reluctant to rush into surgery with this one. I've had some good results by mixing 50/50 Baytril and soluble steroid, and using as ear drops.

Wynne

RE: Pseudomonas otitis

Robin Grimmer — Fri, 28 Aug 2015 17:12:34 GMT

I think there's a regime for topical Tris edta and Baytril which has better results. The triz edta damages the cell wall of Pseudomonas and makes it more susceptible to antibiotics.

I agree this dog is not the best surgical candidate and that I would try medical treatment first. If it does have surgery a lateral wall resection is no good. Needs teca.

RE: Pseudomonas otitis

Anthony Todd — Fri, 28 Aug 2015 17:04:45 GMT

[quote user="SAB"]there is never any point in medically managing these cases [/quote]

I must say I'd agree with this and, although that might be best practice etc, most of these were certainly vastly improved with even a lateral wall resection although the middle ear seemed to discharge asymptomatically for ever more.

Local cleaning and antiseptics seemed to improve the quality of life for the animal and the smell and discharge for the owner.

What chance of a cure would the forum give the best of medical treatment and at what cost?

RE: Pseudomonas otitis

Tracy Arend — Fri, 28 Aug 2015 16:43:30 GMT

I personally wouldn't have rushed for surgery, especially with co-morbidities. I am not great soft tissue surgeon but my understanding is that TECA's are salvage procedures, and come with numerous risks. And if you don't reduce/treat the infection first, surely surgery at the first instance would lead to breakdown? And surely imaging to check tympanic bulla or considering VBO would be better than going straight for a TECA?

I would personally would have done similar to you and followed a medical route first.