Hyperplastic otitis externa

RE: Hyperplastic otitis externa

Rob Loxley — Thu, 07 Jul 2016 21:07:24 GMT

[quote user="Anthony Todd"]I always thought I got a much more rapid and dramatic response with one or more dexameth injections followed by local treatment[/quote]

I'd suggest revising the pharmacokinetics of oral pred - you reach good serum level in hours

RE: Hyperplastic otitis externa

Anthony Todd — Thu, 07 Jul 2016 13:52:22 GMT

[quote user="roland bulkyn-rackowe"]+1 for the pred. I will often start on a reasonable pred dose (1+ mg/kg)[/quote]

Why start straight with tablets? I always thought I got a much more rapid and dramatic response with one or more dexameth injections followed by local treatment. Clients see the change quicker.

RE: Hyperplastic otitis externa

Beats — Thu, 07 Jul 2016 08:19:27 GMT

thanks!

[quote user="robloxley"]maybe 0.3ml[/quote]

RE: Hyperplastic otitis externa

Rob Loxley — Wed, 06 Jul 2016 20:23:18 GMT

[quote user="Beats"]what approximate dose are you using when using a syringe?[/quote]maybe 0.3ml

RE: Hyperplastic otitis externa

Emily Rainbow — Wed, 06 Jul 2016 20:14:19 GMT

yes we have TrizAural (powdered TrizEDTA)

i use 24ml Triz, 2ml dexadreson and 6ml baytril 2.5% injectable mixed together. Apply 0.5ml twice daily. Will sometimes use flamazine dilution once daily too.

will have to see how the concentrations compare to Braden's! (Do you use the 25mg/ml baytril?)

RE: Hyperplastic otitis externa

Beats — Wed, 06 Jul 2016 14:50:02 GMT

[quote user="robloxley"]You can use a syringe to draw it up from the bottle and apply it directly to the ear canal[/quote]

Rob, what approximate dose are you using when using a syringe?

Cheers,

Dave

RE: Hyperplastic otitis externa

Roland Bulkyn-Rackowe — Thu, 12 May 2016 10:11:13 GMT

+1 for the pred. I will often start on a reasonable pred dose (1+ mg/kg) and swab if possible just for cytology. I take my time to discuss possible underlying diseases at the outset. I'll also do a coat brush, wet paper test, sellotape strip and start flea control for the household.

I usually focus on reversing the hyperplasia before addressing the underlying disease unless it's stark staringly obvious. I find that to be fully back to normal appearance can take anything from a week to several months.

2nd visit in a week much the same, re smear, continue oral steroids, possibly start a topical (not always). If they're not improving then I'd consider admitting to have a better look, xray canals (calcification) and bullae (chronc OM), clean and swab. I'll try to persuade them to come back monthly initially so I don't "lose" them.

My approach with swabs is:

- cotton bud or small wire swabs if the canal's that narrow,

- look for mites on swab,

- smear on a slide, dry and 40 seconds in dark blue diff quik solution.

- If neutrophils I'll be looking for middle ear disease or ulceration (and considering antibiotics),

- if bacilli I'll offer a bacterial culture.

Re: underlying diseases, depending on the age, breed etc of the patient I'd blitz ectoparasites initially, then consider food trial, then allergy bloods (probably talking a little while down the line by then).

RE: Hyperplastic otitis externa

Braden Collins — Thu, 12 May 2016 09:46:06 GMT

Hi Lara.

We get the TrizEDTA in a powder form here (not sure what you get in the UK), but for us we add 23.6mL Enrofloxacin/Baytril injectable plus 2.36mL Dexapent (5mg/mL dexamethasone injectable) to the bottle, then top it up to 118mL total. I think it's 141mg of TrisEDTA in the bottle to start with, but don't quote me on that.

We got the recipie from a drug company a few years ago, and it is brilliant for pseudomonas. The Triz apparently helps the antibiotic penetrate the bacteria, and you hit high concentrations of the antibiotic locally which is part of the reason I don't tend to do a C and S. The steroids help settle the ear very quickly. I find we normally have a healthy, normal appearing ear 10-14 days after we start treatment.

RE: Hyperplastic otitis externa

Lara Brunori — Thu, 12 May 2016 07:00:24 GMT

Hi Braden,

Thanks for your reply, how much enrofloxacin and dexa? I found a recipe with 0.7ml of 0.2% dexa solution (Colvasone) in 118ml of TrizEDTA, but no enrofloxacin.

Many thanks,

Lara

RE: Hyperplastic otitis externa

Braden Collins — Thu, 12 May 2016 05:00:51 GMT

We smear every case of otitis here. We always want to know if it's malassezia or bacterial, and if there are rods.

I normally will use a short course of steroids systemically for most ear problems as settling the inflamation helps control the problem.

If I find rods, I normally use a topical combination of TrizEDTA, enrofloxacin and dexamethasone, applied 1-2 times daily. I find a very high cure rate within 10 days for this combo, so rarely find the need to culture. I'll only ever culture if I can't control the infection with firstline treatments.

RE: Hyperplastic otitis externa

Aine Seavers — Thu, 12 May 2016 00:27:22 GMT

how old is the doog, its wt and breed and on a scale of 1-10-how do you rate the itch. Stating a PPI first is no longer since 2012 the ideal because of the side effects of this med, maxiumum 8weeks on it and hard to wean off-plus there were no clinical signs to indicate its use currently in this case.

RE: Hyperplastic otitis externa

Lara Brunori — Wed, 11 May 2016 19:48:48 GMT

I saw one of the two cases back (the monolateral one), little improvement, but managed to take a swab, no rods, malassezia or mites. Changed diet to salmon and potato (Barking Heads Fusspot). The problem now is that the dog has very severe corticosteroids side effects with polifagia (gained 300 gr in a week), panting and pu/pd, so dropped the dose from 1mg/kg a day to 0.5 mg/kg and started atopica + omeprazole + local cortadvance. Any experience with atopica in those cases? It was the only option I had in my mind when cortico are not well tolerated...

RE: Hyperplastic otitis externa

Aine Seavers — Wed, 11 May 2016 01:33:54 GMT

pseudomonas is an opportunist liking when moisture is present in the ear canals-so drying up the canal changes the biocenosis of the local area and makes it hostile to the pseudo hence why one must use steroids then avoid Swimmer's ears type scenario.

That said-once the bacteria are in full swing- there is pain and distress , it erodes cartilage causing ongoing isssues and it can disseminate from that site so my concern is to knock it out fast-with antibiotics-but properly selected antibiotics based on sensitivity- then address the factors that allowed it to flourish in the first place-moisture, heat, incorrect selection and overuse of of scatter wide abts thus increasing resistance, diet etc. There is a place for culture here and sensitivity and steroids and environmental modification management so as to return the painful animal back to health.

I wouldnt necessarily pulse ears with Cortavance-that I keep for feet or ventrum as under good visual observation but cleaning once a week in low humidityand twice in high Otoclens, epiotic or 50/1 malaseb mix does help maintain the restored ear and provide the cleaning system needs given the escalator mechanism in the vertical canals is usually scarred and nonfunctional in these ears.

RE: Hyperplastic otitis externa

Anthony Todd — Wed, 11 May 2016 01:09:58 GMT

[quote user="Aine Seavers"]Vet DERMATOL 2012, 23, 2-104: P-098, [/quote]

For some reason I can't pick up the link but I would have thought the results were only to be expected with any steroid locally.

As pseudomonas seems to be present in many ears I can't understand why a positive culture or finding is grounds for treatment in a non-purulent "allergic" ear which might explain why steroid creams alone cured all the ones like the OP back in the day.

[quote user="Aine Seavers"]pulse therapy on allergic dogs [/quote]

First time I've seen this expression on vetsurgeon so I hope it sticks!

This is what I've been advocating since day one for both oral, systemic or topical steroids, no taper, just a high adequate dose and pulse ie as and only when necessary. Of course with chronic allergic otitis you'll need a continuous dose for a while but the results can be dramatic, no swab, no ABs [just make sure the skin isn't broken and there are no mites!]

Being my usual devil's advocate I wonder what the incidence of pseudomonas is in totally normal dogs' ears?

Might be an embarrassing surprise for the culturalists.....

RE: Hyperplastic otitis externa

Rob Loxley — Tue, 10 May 2016 13:49:05 GMT

[quote user="Lara Brunori"]loads of rods (pseudomonas?) and cocci + neutrophils... very very rewarding, also sent for culture and sensitivity in one case since owner was insured[/quote]

It's well worth aiming to do culture on all the cases with rods since sensitivities vary lot; for cocci most of you 1st line treatments will be fine

RE: Hyperplastic otitis externa

Lara Brunori — Tue, 10 May 2016 09:04:45 GMT

Thank you so much for all your contributions!! That's great to receive so many inputs

Yesterday I did my first 4 ear swabs in two acute otitis cases and I found no mites but loads of rods (pseudomonas?) and cocci + neutrophils... very very rewarding, also sent for culture and sensitivity in one case since owner was insured. One of the two was a Dashound with years of skin issues, already on Atopica but now on hypoallergenic diet as well

Will definitely try Cortadvance as well for the chronic cases, better syringe it in the ear canal (if accessible) then rather than spray?

I also guess no much point in systemic abx if I can't do imaging of the middle ear since most of the time I don't have good penetration in the external ear canal?

Again huge thank you to all of you!!!

RE: Hyperplastic otitis externa

Aine Seavers — Tue, 10 May 2016 08:02:58 GMT

Vet DERMATOL 2012, 23, 2-104: P-098, Bensignor E, Pattyn J, Reme C Réduction of relapses of recurrent otitis externa in atopic dogs with twice weekly topical application of hydrocortisone aceponate in the ear canal : a randomized blinded controlled study).

0.15 to 0.25 milliliter of the product to be applied with a syringe directly on the horizontal canal (not using the spray delivering system) twice a week is usually effective AFTER the infection has been controlled with a "classical" ear product.

With Cortavance it is about the degree that gets absorbed systemically more than the 'potency'of the active ingredient- which stays powerful locally to great effect with minimal atrophy of tissue compared to other steroids which is its selling point and why I use it but not steriod creams. Here in Oz it has a 7 day continous use licence but newer stuff from europe showing 70days without issue- and so i use it as pulse therapy on allergic dogs feet to great effect so 7 days then on weekends- gets them off orals and injectables- always follow 20mins later with a hydrating lotion like aloveen to neutralise the effect on TEWL cortavance has on the area sprayed (but that could depend on the location of the lesion and that locations own TEWL rating). Sometimes in the foot dips I add in a Malaseb foot dip as well pre spray.

RE: Hyperplastic otitis externa

Aine Seavers — Tue, 10 May 2016 07:49:48 GMT

havent done surgery on these since BSAVA 92 Prof Ed Rosser converted us to this so often being a marker for food intolerance. so change diet-trial zd. They need glucocorticoids-again a volte face for those of us scared off the drugs due to the horrors of betamethasone overuse in the 70s and 80s but these ears need preds or if too painful then a shot of 7 day dexafort and review. I have gone back to c/s- inherited too many cases week in week out on cytology that didnt clear until swabbed and found the correct antibiotic. There was an interesting article with the rise of antibiotic resistance linked to the reduction in c/s being done... so a sobering thought. For ear mires- stick a swab in ear- roll around, roll on a slide with drop of oil-coverslip- there they blow- usually multiples, often mating and hyperactive- the mites are wonderful to show owners on a videoscope as scurry every where- you can see them also on a good plain hand held auroscope. if in doubt-add in Advocate every 21days x 3 occassions to cover your bases. So swab, clean, change diet, use preds and advocate and identify your infectious population and target them.

Re cleaning- flush to flooding, rub in as if rubbing broken glass so light enough not to damage the canals but enough to break up debris- tilt head up, use gravity to flow it back out, wipe with lump of cotton wool- use cotton bud across top of canal at right angles then flip up so cleans out the curves and niches of dorsal canal and medial pinna- wait 20mins and apply the medication-or at least have owner do that if cleaning at home as they have the time to wait- and clean once every 4th day on medication not daily. The poor penetration of oral antibiotics for ears not of much call when only otitis externa.

check anal sacs-often an issue as well if ears + and diet wrong.

RE: Hyperplastic otitis externa

Anthony Todd — Tue, 10 May 2016 05:54:30 GMT

[quote user="Thomas Johnson"]

According to the manufacturers the potency of hydrocortisone aceponate is 100 times that of hydrocortisone.

http://www.virbac.co.uk/home/products/dermatology/main/virbac-p

[/quote]

Very potent or superpotent (up to 600 times as potent as hydrocortisone)

Clobetasol propionate
Betamethasone dipropionate

from::

http://www.dermnetnz.org/treatments/topical-steroids.html

RE: Hyperplastic otitis externa

Anthony Todd — Tue, 10 May 2016 01:05:40 GMT

[quote user="Thomas Johnson"]According to the manufacturers the potency of hydrocortisone aceponate is 100 times that of hydrocortisone.[/quote]

It may well be, but I'd be grateful to see some sort of comparisons with the "more potent", according to all the charts I can find, as it isn't mentioned.

After all it's not hard to be more potent than hydrocortisone......

RE: Hyperplastic otitis externa

Thomas Johnson — Mon, 09 May 2016 17:19:37 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Cortavance is an extremely potent topical steroid that achieves very high therapeutic concentrations in the skin with minimal systemic side effects.[/quote]

Well not according to this [very long, so link only]

https://www.psoriasis.org/about-psoriasis/treatments/topicals/steroids/potency-chart

I stand to be corrected or advised 'cos they just list all the "hydrocortisones" but not the full chemical name, right at the "least potent" bottom.

[/quote]

According to the manufacturers the potency of hydrocortisone aceponate is 100 times that of hydrocortisone.

http://www.virbac.co.uk/home/products/dermatology/main/virbac-product-list-2/cortavance.html

RE: Hyperplastic otitis externa

Anthony Todd — Mon, 09 May 2016 14:44:17 GMT

[quote user="Robin Grimmer"]Pseudomonas is an opportunist infection. It is normally present in soil and wet environments. Quite how it gets in to the ear in the first place I'm not entirely sure, but it won't cause an infection in a healthy ear.[/quote] [my italics]

Exactly why I asked, and it would explain why steroids alone work, in this particular allergic otitis, as in the photo I linked. If you get damage to the skin lining the ear, rare in these cases then Pseudomonas would establish and you'd have a totally different condition.

RE: Hyperplastic otitis externa

Anthony Todd — Mon, 09 May 2016 14:19:40 GMT

[quote user="Robin Grimmer"]Cortavance is an extremely potent topical steroid that achieves very high therapeutic concentrations in the skin with minimal systemic side effects.[/quote]

Well not according to this [very long, so link only]

https://www.psoriasis.org/about-psoriasis/treatments/topicals/steroids/potency-chart

I stand to be corrected or advised 'cos they just list all the "hydrocortisones" but not the full chemical name, right at the "least potent" bottom.

RE: Hyperplastic otitis externa

David Mills — Mon, 09 May 2016 09:44:35 GMT

[quote user="Robin Grimmer"]

Cortavance is an extremely potent topical steroid that achieves very high therapeutic concentrations in the skin with minimal systemic side effects.

http://www.noahcompendium.co.uk/Virbac_Limited/Cortavance/-46225.html

[/quote]

Ah but it was made after Uncle Clive died and costs more than 3 bob, so it's automatically inferior.

A dermatologist I used to work with always started on 1.5-2mg/kg q12h preds for these , felt 1mg/kg didn't cut it.

For cytology, as John says, roll the bud on the slide. Have never found need to heat fix cyto preps, they all dry by themselves if an OCD nurse doesn't throw them first, but can see the rationale if you want an answer patient-side. A tip for Diff-Quik or similar is to leave the slide in the fixative (no1) and first stain (no2) continuously for about a minute each before dipping 6 x 1s in purple stain and washing off. This will give you much better staining and fixation which won't be removed by water.

RE: Hyperplastic otitis externa

Robin Grimmer — Mon, 09 May 2016 09:36:31 GMT

[quote user="Anthony Todd"]

[quote user="robloxley"]

[quote user="Anthony Todd"]you won't get the spray down the stenosed canal[/quote]

You can use a syringe to draw it up from the bottle and apply it directly to the ear canal

[/quote]

Surely better to use a much more potent steroid in topical form

[/quote]

Cortavance is an extremely potent topical steroid that achieves very high therapeutic concentrations in the skin with minimal systemic side effects.

http://www.noahcompendium.co.uk/Virbac_Limited/Cortavance/-46225.html