Pseudomonas, with a ruptured ear drum

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Fri, 24 Jul 2020 08:12:36 GMT

[quote userid="13891" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224481#224481"]I do think we both need to admit that, historically, dermatologists have been guilty of some dubious use of antibiotics - long term low dose; intermittent use; and wandering off down the. Cascade without good justification.[/quote]

Yes, pulse therapy with Cephalexin for chronic deep pyodermas comes to mind

RE: Pseudomonas, with a ruptured ear drum

Judith Joyce — Fri, 24 Jul 2020 07:33:42 GMT

[quote userid="5408" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224480#224480"]but if you live in Spain at least, you can walk into any chemist and buy mupirocin ointment over the counter, no questions asked![/quote]

Oh no! Please don't go there. Does that not belong in the Brexit forum? There has been, as David, says some really good work on responsible antibiotic use, including work by David Lloyd and others on using non-antiobiotic antibacterial therapies which in the case of otitis history goes from dilute vinegar, through Dermisol to Malacetic and others for. the treatment of secondary. invaders. I do think we both need to admit that, historically, dermatologists have been guilty of some dubious use of antibiotics - long term low dose; intermittent use; and wandering off down the. Cascade without good justification.

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Fri, 24 Jul 2020 06:30:48 GMT

Maybe you should voice your concerns to Tim Nuttall, author of this relatively recent article and who, along with David Lloyd, has preached to the UK profession on antibiotic stewardship for the last 15 years so so. https://inpractice.bmj.com/content/38/Suppl_2/17

On a simlar vein, we are also told not to use mupirocin as it is used to decolonise humans carrying MRSA and some people get very hot under the collar about the veterinary use of this drug, but if you live in Spain at least, you can walk into any chemist and buy mupirocin ointment over the counter, no questions asked!

My original answer to your question was "short answer, yes". I should have expanded by saying that I usually use Gentamicin but will use enrofloxacin if I have none to hand. People get concerned about Gentamicin ototoxicty but a recent paper by Sue Patterson, using BAER testing, revealed that it was not ototoxic at the concentrations we are using.

RE: Pseudomonas, with a ruptured ear drum

David Mills — Thu, 23 Jul 2020 22:16:15 GMT

She may well have done, I don't disagree.

But isn't one of the cornerstones of intelligent discourse in fact challenge and defence? Everything ultimately comes down to a value judgement on what to do. Eminence can play a part, especially in the epistemic value of what is being testified.

But regardless of who is saying it, I maintain that using fluoroquinolones first line when seeing rods on cytology is highly irresponsible, It may work. For now. But it's your call, ultimately.

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Thu, 23 Jul 2020 22:10:55 GMT

I think Sue Patterson has done more than anyone else in this country to further our knowledge in the treatment of ear disease.

RE: Pseudomonas, with a ruptured ear drum

David Mills — Thu, 23 Jul 2020 22:00:10 GMT

[quote userid="3607" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224471#224471"]Has that been published anywhere? I have missed it - I would be interested toes it.[/quote]

No, was submitted as an abstract to a veterinary conference and rejected. Numbers reasonable at around 40 cases, 2 surgeons.

[quote userid="3607" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224471#224471"]What was your end-point/appraisal of competence?[/quote]

Minor and major complications, short term and long term when compared to the teacher-surgeon's own complication rate, and those in published studies. Follow up of at least a year post-op - one advantage of charity practice is that clients tend to stay with you and you see them relatively frequently. So enough time to see abscessation and longer term issues (one abscessated case I saw took 12m - surgery done at another hospital - grim revision surgery).

[quote userid="3607" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224471#224471"]They made up a significant part of my TECA-LBO case-load. But that is not to say that LWR is a bad procedure. Any operation performed sub-optimally or in the wrong patients is very likely to fail.[/quote]

Agree. LWRs are deceptively simple from descriptions but not necessarily easy to do well.

[quote userid="3607" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224471#224471"]Undoubtedly. How do you think we might improve things?[/quote]

God, where to start. It would take a complete revision of undergraduate and post-graduate teaching.

Former, some newer veterinary universities appear to have recognised this and not gone down the referral practice onsite route (Notts, Surrey) and engage private practices and charities for final year rotations (we are involved in both the rotations and examining these and have input into both), as well as having tutors that are not specialists. Still, some of the classic veterinary dogmas are still taught in earlier years (they arrive to us scared of steroids and leave amazed what you can achieve without bloods in most cases). Also a recognition that specialists are the poorest resource about the profession most will join and the cases they will see. Stephen May did a short article on a scholarship of first opinion practice which has never been followed up or developed. shame.

Latter, there is always a need to join the 'club'. So pursuing a cert will require you to answer like an undergraduate, and try to think in a way that is the opposite of expertise - hypotheticodeductively, lists of differentials, tests, diagnosis a must, therapy - whereas most cognitive psychology shows experts subconsciously pattern recognise, inform with experience, use templates to address cases, and spot inconsistencies and focus and interrogate these; then they can't even tell you how they got there! Clinical expertise is unconscious and cannot be taught other than through experience. No experienced vets work like new grads. But, to get a cert (and I imagine a diploma), you have to jump through these hoops - e.g. in one synoptic I had a simple mid diaphyseal transverse radial fracture that had been stabilised with a SOP medially - and this was supposed to be a CertAVP exam (overtreatment, excessive complication and cost, so far removed from what I would do were my responses - I didn't pass). You have to play the game, which is against the whole point and indeed spirit of the whole idea! But, on the reverse, the profession seems unwilling to accept the experience of peers but requires a post nominal to make it stick, and to invest more epistemic faith in pronouncements. This is backed up by RCVS who use specialists to opine on the work of first opinion practitioners (but the reverse would never obtain!).

One option is to actively pursue and promote first opinion based research via grants and incentives, but most want/need an academic attached (Petsavers, anything involving path labs, etc). people need motivation to do this, and they don't have the time.

Another is to divest conferences from the evidence-trumping culture of having to have a paper to back things up (one lecture had a case series of 16 cats with renal disease treated with mirtazapine and I'd treated triple that in the last month), and also have lecturers that are generalist experts lecturing to peers. The top down approach is removed in most cases from the reality.

A more difficult approach is to change the culture of eminence wherein a specialist's word is taken as sacred, and to interrogate said specialists on their case exposure and field of work.

I use 'specialists' here as a huge bucket term. It does not apply to all. Those with an active interest in first opinion cases, and a driving interest across the whole profession are fantastic - Malcolm here, for instance, I have always found to be incredibly helpful and cognisant and interested in a world beyond specialisation and referral practice. Mark Lowrie (used to post on here), similarly has always been a self-deprecating, non-bs-ing specialist. There are many others who I have found, to coin a northern phrase of praise, down to earth and on a level; without exception, these are those specialists who have spent a long time in, or in direct contact with, first opinion work, and can add both experience and useful insight to help us do it better.

RE: Pseudomonas, with a ruptured ear drum

Malcolm Ness — Thu, 23 Jul 2020 21:20:06 GMT

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224424#224424"]I submitted a clinical research abstract this year about the learning curve for primary practitioners to perform TECA-BOs, and found about 6 cases are sufficient,[/quote]

Has that been published anywhere? I have missed it - I would be interested toes it.

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224424#224424"]and found about 6 cases are sufficient[/quote]

What was your end-point/appraisal of competence?

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224424#224424"] as a charity vet for some years TECA-BOs are not within our desired procedures (they ultimately probably cost us money)[/quote]

That reflects the concerns that drew me into this in the first place. It is not as risk-free as many suggest and I am confident that the literature under-estimates the late complications and failures. Partly because late complications are always under-reported in the literature as many occur after the paper is published and also because the surgical literature almost always under-reports serious complications - the most common reason for a case being "lost to follow-up" and therefore not included in the published paper is the advent of a serious complication that has the dog unable to be included in the scheduled follow-up examinations or even dead.

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224424#224424"]failed LWRs from private practice[/quote]

They made up a significant part of my TECA-LBO case-load. But that is not to say that LWR is a bad procedure. Any operation performed sub-optimally or in the wrong patients is very likely to fail.

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224424#224424"].something amiss methinks[/quote]

Undoubtedly. How do you think we might improve things?

RE: Pseudomonas, with a ruptured ear drum

Mark Holmes — Thu, 23 Jul 2020 21:16:12 GMT

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224465#224465"]And painstaking suturing with suitable material – 5/0 Prolene is perfect. Maybe change to 4/0 in the easier more dorsal region. Nice tidy little simple sutures with short ends.[/quote]

Actually I differ here. I like Vicryl Rapide as taking them out is so much easier. Bringing me onto another tip.

The worst thing about Vicryl is that it unravels. This is simply fixed with a dot of tissue glue on the knot.

RE: Pseudomonas, with a ruptured ear drum

David Mills — Thu, 23 Jul 2020 21:14:53 GMT

It's apples and pears. I agree systemic use is rarely if ever indicated. But just because topical use is less dangerous doesn't make it right. It creates inevitably a resistance selection pressure and those genes can move into other bacteria on that dog, other dogs, in the hospital - go take a look at MRSP and MRSA resistance profiles. All somewhat pales in significance to what a veterinary politician says, really.

I just cannot justify first line fluoroquinolone usage. I struggle, actually, to support ANY fluoroquinolone usage in veterinary patients.

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Thu, 23 Jul 2020 21:07:22 GMT

I don’t think use of a fluoroquinoline topically in a ear is as dangerous re stewardship compared to systemic use. With ears we are limited to what antibiotic we can use due to risk of ototoxicity. I think you will find that the past president of BSAVA is a proponent of their use topically in ears.

RE: Pseudomonas, with a ruptured ear drum

David Mills — Thu, 23 Jul 2020 20:57:10 GMT

This reply doesn't fit with the former reply in terms of antibiotic stewardship.

If the topical mic will overcome resistance on normal panels, then why jump to a fluoroquinolone? We don't use them, and haven't had an outbreak of terrible ears. As per previous posters I rarely use antibiotic ear drops anymore.

I'd dearly love for fluoroquinolone usgae in veterinary medicine to be restricted.

RE: Pseudomonas, with a ruptured ear drum

Evelyn Barbour-Hill — Thu, 23 Jul 2020 20:38:27 GMT

[quote userid="7232" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224339#224339"]Isn’t it strange how experience differs. I’m LWR fan.[/quote]

[quote userid="7232" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224339#224339"]in my experience LWR makes a dramatic difference, particularly if performed early[/quote]

I agree. This is my experience too.

Of course if the "lichenification" of the canal has already gone too far, it can't help so much.

[quote userid="7232" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224339#224339"] I now start from the bottom cutting up with a number 11 blade. [/quote]

This is definitely the way to do it.

And painstaking suturing with suitable material – 5/0 Prolene is perfect. Maybe change to 4/0 in the easier more dorsal region. Nice tidy little simple sutures with short ends.

And never a lampshade.

RE: Pseudomonas, with a ruptured ear drum

Joyce Whitehead — Thu, 23 Jul 2020 20:29:29 GMT

[quote userid="5408" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224458#224458"]e you checking cytology before making that decision[/quote]

Yes we are, mostly finding malassezia, but I find that they clear well with cleaner and steroids.

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Thu, 23 Jul 2020 20:28:34 GMT

If see rods will usually use either a fluoroquinolone or gentamicin mixed in TrisNAC. Doesn’t always work. If severe biofilm I’ve found need more NAC. Had a case today that was a week late for check up (owner compliance also possibly suspect) and still some rods (although much reduced) and many inflammatory cells on cytology so have added Flamazine, which works well but I find it builds up and needs extra cleaning at check ups.

RE: Pseudomonas, with a ruptured ear drum

Malcolm Ness — Thu, 23 Jul 2020 20:21:55 GMT

[quote userid="9515" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224452#224452"]Uncalled for.[/quote]

I disagree. Shortly before you offered your trite aphorism I had written, "If non-surgical management is effective then surgery, any surgery is not indicated"

As a surgeon I am used to being the butt of the banter of unimaginative medics and anaesthetists though the joke wore too thin quite some time ago. Regrettably, I have seen some junior surgical colleagues quite upset when such patronising and ignorant nonsense was spouted by senior medics. Serious points were being made and your comment offended that process. For those reasons, I retain the view that the aphorism was trite and unhelpful.

Your remark was neither accurate, bleeding obvious nor particular pleasant. It warranted a robust rebuttal.

RE: Pseudomonas, with a ruptured ear drum

David Mills — Thu, 23 Jul 2020 20:13:19 GMT

So are you using fluoroquinlones first line after seeing rods on cytology?

As an aside, do you have any idea why commercial labs don't differentiate between topical and systemic abx concentrations? Seems very odd to me. Huge market for former.

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Thu, 23 Jul 2020 20:09:33 GMT

Short answer, yes . No choice other than making up a off licence concoction of TrisEDTA plus antibiotic etc if ruptured TM. Don’t forget that the concentration of the antibiotic is 1000s times more than the MIC and even if the isolate is “resistant “ that concentration will overcome the resistance. Usually will only do this in Pseudomonas cases. C&S not really necessary if intact TM...cytology much more important. With otitis media then there is an argument to do C&S if going to add systemic treatment.

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Thu, 23 Jul 2020 20:00:07 GMT

Are you checking cytology before making that decision?

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Thu, 23 Jul 2020 19:56:56 GMT

I had an email exchange with Louis Gotthelf following this thread and with 42 years experience I think he may disagree regarding drainage. He, like me was/is a GP vet for a very long time so seeing cases for the first time and doesn’t do LWR unless for removing a mass.

I suspect this debate about LWR will go on for many more years!

What about doing a vertical canal ablation? Far fewer ear skin -haired skin sutures, so less post op irritation ...I did quite of few of those years ago also and still do for tumours (although now have a laser which will hopefully prevent the need a a fair few cases.)

RE: Pseudomonas, with a ruptured ear drum

Joyce Whitehead — Thu, 23 Jul 2020 19:56:37 GMT

I find I’m using fewer and fewer antibiotics in ears these days, by far our most used ear drops are Recicort. I’d been saying to reps for years we needed a steroid only ear drop and it is so good. Along with ear wash it can clear up so many apparent infections. (Well I guess there is infection present but it is secondary).

RE: Pseudomonas, with a ruptured ear drum

Judith Joyce — Thu, 23 Jul 2020 19:08:40 GMT

I don't think you are pointing out the obvious, I think you are voicing your opinion. I disagree with it. Evidence - I'm the dermatologist (medically inclined) who suggested LWR as a treatment option for stubborn recalcitrant Pseudomonas otitis

RE: Pseudomonas, with a ruptured ear drum

David Bentley — Thu, 23 Jul 2020 19:08:19 GMT

Yes, you can see a lot more with a video otoscope. With a hand held otoscope it can be very difficult to tell the difference sometimes between an opaque TM and the “tip of an iceberg “of a cholesteatoma. I used to flush with a hand held years ago and with middle ear flushing it was always a worry and difficult to do without risking damage to ossicles etc.

RE: Pseudomonas, with a ruptured ear drum

Sarah Keir — Thu, 23 Jul 2020 18:56:33 GMT

[quote userid="3607" url="~/001/veterinary-clinical/small-animal/dermatology/f/discussions/29238/pseudomonas-with-a-ruptured-ear-drum/224384#224384"]trite aphorisms are unhelpful.[/quote]

Just as well I've had a G&T and I'm not a millennial otherwise I would be torn between giving you a tongue lashing or breaking down and crying. Uncalled for. Just pointing out the b***ding obvious.

RE: Pseudomonas, with a ruptured ear drum

Julian Earl — Thu, 23 Jul 2020 09:29:38 GMT

For Pseudomonas infections, it used to b recommended to flush the ears with Dermisol solution on the grounds that necrotic debris would be lifted plus the acidic nature was ubfacourable for Pseudomonas to thrive.though no bacteriocdal ctivity was claimed [off-licence] as I recall. I tried this numerous times and whilst debris couldbe removed, the ulceration seemed to persist regardless. I am convinced hat drainage and aeration is the real solution to theeears , hence surgry seems optimal. That is my experience and information gleaned from assorted CPD.

The Dermisol recommendation came from the rep. so make what you will of that!!

RE: Pseudomonas, with a ruptured ear drum

Sara Ramsey — Thu, 23 Jul 2020 03:09:27 GMT

Wow, these videos are great. It's really interesting to see the view and detail which can be achieved. And highlights the limitations of what you are able to achieve without this equipment.

I have found I can (hopefully) do a decent job in most cases...as long as we have that initial conversation about how long it is going to take and the need for repeated procedures.