Atopic dermatitis and ears

Re: Atopic dermatitis and ears

Rob Smith — Tue, 25 May 2010 21:03:58 GMT

If anyone wants their atopy management to be evidence-based, what better way to start than to read:

Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis

Available to view/print foc online at:

http://www3.interscience.wiley.com/cgi-bin/fulltext/123371643/PDFSTART

Re: Atopic dermatitis and ears

Kate Richardson — Tue, 25 May 2010 17:24:52 GMT

[quote user="Niall Taylor"]"Additive benefits of EFAs in dogs with atopic dermatitis after partial response to antihistamine therapy S. Paterson[/quote]

That's really interesting; maybe I have been a bit harsh on anti-histamines- will definitely give them a go with EFAs on board and see if improves my success rate. Thanks

Re: Atopic dermatitis and ears

Niall Taylor — Tue, 25 May 2010 12:49:06 GMT

[quote user="Niall Taylor"]

http://www3.interscience.wiley.com/journal/119239015/abstract

"Additive benefits of EFAs in dogs with atopic dermatitis after partial response to antihistamine therapy S. Paterson

[/quote]

"CONCLUSION: Relatively few dogs can be controlled exclusively on antihistamine therapy. All four antihistamines in this study were found to produce partial control of pruritus in the atopic dogs in which they were used. The relatively larger numbers of dogs in the hydroxyzine and chlorpheniramine groups demonstrate that in the author’s hands these two drugs perform consistently better than either clemastine or cyproheptadine. In every case the addition of EFA supplementation in the form of Efavet 660, at the manufacturer’s recommended dose rate, showed marked synergism to further improve clinical signs, the most significant change being the reduction of pruritus. All the dogs maintained their improvement over a period of six months, through at least two season changes, except those dogs switched to the placebo oil; a significant increase in pruritus was seen in these dogs. Further work needs to be undertaken to try to establish the mode of action of this synergism, and whether it is seen with other non-steroidal drugs."

Niall

Re: Atopic dermatitis and ears

Niall Taylor — Tue, 25 May 2010 12:44:37 GMT

[quote user="Andrew Kent"]off the top of my head Sue Patterson had a paper published in JSAP in 1995 regarding this[/quote]

http://www3.interscience.wiley.com/journal/119239015/abstract

"Additive benefits of EFAs in dogs with atopic dermatitis after partial response to antihistamine therapy S. Paterson

ABSTRACT: It has been reported that 20 to 70 per cent of atopic cases in the dog can be controlled with antihistamines, though the effective antihistamine cannot be predetermined. Combination therapy with essential fatty acids (EFAS) and antihistamines has been shown to be useful in dogs. All of the work published to date has been performed in open studies, without the use of placebo, and in dogs where the aim has been to control pruritus as a symptom rather than that caused specifically by atopy. The aim of this study was to assess the combined effects of four antihistamines; hydroxyzine, chlorpheniramine, cyproheptadine and clemastine; with both an EFA supplement and a placebo of olive oil, in 25 dogs to control pruritus in clinically proven cases of atopy."

Niall

Re: Atopic dermatitis and ears

Andrew Kent — Tue, 25 May 2010 11:50:21 GMT

[quote user="Vikki Halliday"]How does that work then? Are there any studies on it? [/quote]

Vikki,

There has been some work done on it - off the top of my head Sue Patterson had a paper published in JSAP in 1995 regarding this. I'm not sure (but would love to be corrected) that the mechanism of action of this has been established but EFA's do seem to have this effect and also a glucocorticoid sparing effect in atopics. There is however massive variation in opinion regarding the make up of EFA supplements to maximum benefit.

This months issue of European Journal of Companion Animal Practice is a dermatology special and well worth a read for anybody interested.

Andy

Re: Atopic dermatitis and ears

Kate Richardson — Mon, 24 May 2010 10:23:11 GMT

I think one of the main things to discuss with your clients at the onset of any recurrent skin problem is what their expectations are and what finances will allow long term. Always important to rule out any other cause of recurrent pyoderma/pruritus/otitis but it is always worth taking some extra time to explain at the very beginning that diagnosis and treatment or more likely management of recurrent problems will take time and patience and can be very frustrating for both owners and for us, but try to get them understanding the disease from the beginning. Finances become very important as the owners need to realise that if we diagnose an underlying allergy then we cannot cure it so long term treatment is going to be necessary and hence ongoing costs. Which is where finance becomes important (as well as comfort of the animal obviously!).

Immunotherapy is great if it works (yes vaccines can be produced from IgE results - Idexx can arrange this if you've done the bloods through them) -approx 1/3 respond really well, 1/3 improve but need adjunctive treatment be it anti-histamines/EFAs/diet/baths/dare I include steroids/cyclosporin albeit if at low doses?) and 1/3 it has no benefit whatsoever. And you cannot tell which animals will respond to immunotherapy before you start. So it can be costly and potentially of little/no value which you need to make sure your clients are aware of before embarking on this route. And it can take up to 12months before you can see any benefits! So unless the client definitely wants to pursue immunotherapy, spending money on ID skin testing or serology is of little value. If you know the animal has an allergy then finding out what it is allergic too is often academic as it probably impossibe to completely avoid most allergens, and especially so if multiple allergens. An exception to this though might be animals that are allergic to only fleas (although strict flea control both on the animals and the house, remembering to make sure owners know they need to treat ALL animals in the house! can give you a 'diagnosis based on response to treatment'- sometimes if a blood test says the animal is allergic to fleas, the owners are more compliant with flea control!) or if they allergic to house dust mites only, in which case environmental treatment and exclusion of animals from the bedroom for example can help with the symptoms, but again a trial 'treatment' can help with this diagnosis. I would use strict flea control and treat the environment in any recurrent skin case regardless of whether I was doing allergy testing anyway, as I said before, any itchy animal needs no further reason to scratch! So have probably argued myself out of allergy testing now!

Anti-histamines- do work in occasional cases and again worth trying if the owner has the patience to trial different ones and is really keen to avoid steroids, but again its the education thing- they need to be aware that anti-histamines need to be given time and again may not have any benefit. What you don't want is an annoyed owner at the end of 4 x 2 week trials with a dog that is still scratchingand the next vet gives some pred and heyho it immediately stops scratching! I think the dermatologist we refer to at our practice recommends using piriton and clemastine (Tavegil) together for 2 weeks as a trial for anti-histamines, but don't quote me on that! I can check that.

I guess what I am trying to say in a very long winded way is that you need to choose which route you take very carefully and discuss, discuss, discuss the options fully and openly with the client. There is nothing wrong with opting for long term pred as long as the owner is fully aware of all the other options and pros and cons of all (and document that you have discussed the options on the records!) At the end of the day the owner simply wants their animal to be comfortable. (And I have a seasonally itchy dog- she is mid teens now and has low dose pred through out the summer and is very happy). We would all like to avoid long term steroids in an ideal world, but for some owners and their animals it is the best option. I think being constantly itchy must be one of the worst things an animal can endure, so to my mind a potentially shorter/fatter/itch free life is a lot better than a slightly longer thinner irritated one!

Re: Atopic dermatitis and ears

Vikki Halliday LLB — Fri, 21 May 2010 14:48:31 GMT

[quote user="Andrew Kent"] EFA's also have a synergistic effect with antihistamines[/quote]

How does that work then? Are there any studies on it?

I always advise EPO or other EFA supplementation for all atopics, and those clients that do comply seem to have a slightly better success rate.

Re: Atopic dermatitis and ears

Andrew Kent — Thu, 20 May 2010 21:40:34 GMT

With regards to antihistamines I do use cetirizine as part of an antihistamine trial and some dogs will respond to it. I usually use 4 different antihistamines for a 2 week period each before ruling them out. EFA's also have a synergistic effect with antihistamines. I currently use Cetirizine, Tavegil (clemastine), piriton and Hydroxyzine (Ucerax).

Immunotherapy can indeed be formulated based on IgE testing and the results are very similar to that based on ID skin testing. It is very useful in the right cases though not all cases, and it is important that other causes of pruritus are properly excluded first.

Andy

Re: Atopic dermatitis and ears

Rebecca MacMillan — Thu, 20 May 2010 21:06:55 GMT

Can I also ask about immunotherapy?

How useful do people find it? Can the vaccinations be created based on the results of IgE blood tests?

Sorry I'm if I'm being a bit dense, I'm not sure exactly how the vaccinations work

Re: Atopic dermatitis and ears

Clive Ansell — Wed, 19 May 2010 08:56:39 GMT

Does anyone recommend speying of bitches as part of the treatment plan for chronic otitis externa related to atopy?

I once noticed it on an insurance claim form as part of the treatment for recurrent and chronic OE. There was no clinical history of the condition being worse related to seasons, and it is no better since speying. ??

Re: Atopic dermatitis and ears

Clive Ansell — Wed, 19 May 2010 08:51:56 GMT

I have carried out more full skin works on Westies than I can remember, and almost all have finished up with a diagnosis of atopic dermatitis. A few are treated with Atopica, but most will inevitably finish up on prednisolone. Some have secondary bacterial, fungal or parasitic infections, but an underlying atopy or allergy.

Has anyone ever used the antihistamine Cetirizine in dogs? I take it for chronic idiopathic urticaria, and it works really well at double dose with no side effects.

Re: Atopic dermatitis and ears

Rob Smith — Tue, 18 May 2010 19:36:40 GMT

[quote user="Vikki Halliday"]

If it's a Westie, Atopy would be top of my list, for sure but also common

[/quote]

Westies are predisposed to all skin conditions, not just atopy - so what does being a westie have to do with atopy being top of your list?

Re: Atopic dermatitis and ears

Rob Smith — Tue, 18 May 2010 19:34:25 GMT

[quote user="Michael Woodhouse"]

[quote user="Vikki Halliday"]Oh and Michael if you read this, no I didn't look this one up either![/quote]

[quote user="Vikki Halliday"]At the end of the day if you have indications that the animal has atopic skin, and you don't want or can't afford to do full allergy testing, I'd still recommend the IgE screening test prior to a trial with Atopica.[/quote]

Devils advocate here - if they can't afford allergy testing will they be able to afford Atopica? How about prednisolone when needed? I have tried using Piriton and not found many dog that benefit, I tend to end up giving preds. The only dogs we have on Atopica are either well insured or there's one that pred wasn't sufficient for.

I do find Epiotic excellent stuff.

[/quote]

Don't forget the other option - Cortavance. Cheaper than Atopica and safer than preds...and works as opposed to Piriton!

Re: Atopic dermatitis and ears

Andrew Kent — Tue, 18 May 2010 13:22:39 GMT

It is an outdated view that intradermal skin testing is superior to IgE blood testing. Clinical review has shown the treatment results are virtually identical between these groups and whilst I do both I no longer push intradermal testing as being massively superior.

Vicki I agree the Idexx screen is useful in clients with financial constraints as there is no cheap way to do full allergy testing. Equally agree blood testing for food allergy is a complete waste of time and adds no useful information to the clinical picture.

In cases of recurrent otitis investigation for underlying causes is essential including - allergy, conformation/hair, seborrhea, other infections (incl mallasezia), endocrine dz etc.

Management of these on a budget is difficult but in my hands includes antihistamine trials (at least 4 types for 2 weeks each) with EFA supplementation, long term cleaning regimes etc prior to considering steroids in young animals. If localised to ear then surgical options should be considered as can be curative and work out cheaper in the long term than life long management.

Andy

Re: Atopic dermatitis and ears

Rebecca MacMillan — Mon, 17 May 2010 19:45:16 GMT

Thanks everyone, but especially Kate - your approach makes alot of sense, I was starting to get v.confused with all the different opinions!

I guess one thing to come from that would be that there are no definate hard and fast rules as to how to manage a case like this, which is true of most things really!

Re: Atopic dermatitis and ears

Kate Richardson — Mon, 17 May 2010 12:24:07 GMT

[quote user="Richard Carter"]Looking at this thread reminded me of a CPD course attended about 8 or 10 years ago where the ENT referral surgeon said 'if you are thinking of surgery, put the dog on 2 weeks of preds and think again'[/quote]

That reminds me of an australian neurologist I once spoke to who said they only kept 3 drugs on the shelf- synulox, preds and euthatal!

Regarding the ear issue, any recurrent problem obviously has an underlying cause as long as you are sure you have treated it adequately in the first instance. I tend to treat any Pseudomonas otitis quite aggressively with both topical and systemic antibiotics, ideally based on C&S, sometimes plus ga/ear flushing, sometime with systemic pred also if very painful/inflamed. I generally treat for 2 weeks then ideally repeat C&S and contine treating for at least 2 weeks beyond the point of a negative culture. I was led to believe that the infection can get into the cartilage of the ear canal and as this has a poor blood supply it can appear to have resolved even if C&S is negative. (Correct me please if that is complete garbage!) If it recurs (or any form of Otitis) despite aggressive treatment and compliance with appropriate ear cleaners, then I will advise looking for an underlying cause. Usually if I suspect an underlying allergy (which IMO is quite common to have just ears affected and to have pseud rather than yeasts, but will often find subtle signs of pedal pruritus also if question the owners) but only the ears are really causing a problem, unless it is severe I will just try to manage to clinical signs. If severe will either work up fully if finances allow, manage with cleaners/intermittent ear drops/possibly systemic pred trial, but would definitely consider a TECA as the dog's comfort has to be the priority and possibly a good economic choice for long term control, and I don't think some owners really appreciate what it must be like for their dog to have chronically infected ears, whether it is pseudomonas or not.

Regarding allergy testing, I feel it is really only useful once all other causes are ruled out and you can then say, yes this is due to an allergy, and if de-sensitisation is being considered. I advise strict flea treatment in all recurrent skin/ear cases, pets and house. I have yet to have to do an allergy test to prove flea saliva exposure but would not rule out doing this if necessary. I usually say, regardless whether fleas are the cause or not, the last thing this itchy cat/dog needs is more reason to scratch!

Last point- Easotic definitely rules- since starting to use it, more 'chronic' problems have resolved, and I believe this is due to compliance being soooooo much better. Owners and their pets like it!

Re: Atopic dermatitis and ears

Richard Carter — Mon, 17 May 2010 11:30:17 GMT

Looking at this thread reminded me of a CPD course attended about 8 or 10 years ago where the ENT referral surgeon said 'if you are thinking of surgery, put the dog on 2 weeks of preds and think again'

Re: Atopic dermatitis and ears

Rob Loxley — Sun, 16 May 2010 23:09:47 GMT

[quote user="PATRICK MARSHALL"].I attended the excellent pre-BSAVA ISFM&S day where one of the lectures was on the surgical treatment of feline hyperthyroidism[/quote]

This really needs a different thread.
Is the issue not that there is limited evidence of any reduction in postop complications between simultaneous and staged bilateral procedures, not the rate per se? Your low complication rate might therefore be expected to be the same if you did simultaneous rather than staged surgeries, and saved the cat 2 GAs? The only hypocalcaemias in our patients have been in cases where another practice has done the 1st and us the 2nd of a 'staged' procedure, but we always discuss the risks with clients, and 'there but for the grace of god go I'.
As for dealing with postop hypocalcaemia the FAB advice sheet is a very useful reference.

Re: Atopic dermatitis and ears

Rebecca MacMillan — Sun, 16 May 2010 21:10:56 GMT

[quote user="robloxley"]

How many people see hypothyroid dogs presenting with recurrent otitis?

[/quote]

I'm also wondering this, as I have another case which has been diagnosed hypothyroid (and is on treatment) but has had bouts of recurrent otitis externa. I wondered if there may be a link between the two.

Re: Atopic dermatitis and ears

Rob Loxley — Sun, 16 May 2010 19:01:53 GMT

[quote user="Rebecca Benge"]I'm just wondering what everyones thoughts are on investigating dogs with recurrent ear infections but with no generalised signs of atopic dermatitis[/quote]

How many people see hypothyroid dogs presenting with recurrent otitis? Also spaniels with primary keratinisation disorders - obviously not in this dog! Have you looked for grumbling OM as a cause of the recurrent pseudomonas OE?

Re: Atopic dermatitis and ears

Vikki Halliday LLB — Sun, 16 May 2010 16:53:08 GMT

[quote user="Malcolm Ness"] Incidentally, the dermatologist in question has more than quarter of a century's experience of primary care practice dermatology as well as a post grad qualification[/quote]

Without turning this thread into a two-party disagreement, I do feel that I have to defend my post here. I am well aware of Judith's excellent experience and have regularly sent cases to her that were beyond my expertise. Even if not referring, I have often appreciated advice from her, as I have done when sought from all your staff.

[quote user="Malcolm Ness"] These silly faux-superior comments about the "real world" are misjudged.[/quote]

A bit unfair Malcolm as you know precisely where I am coming from, some clients are just not able to have things "done by the book", and we all try very hard to get a result with the means we have available to our disposal.

[quote user="Malcolm Ness"]LWR is a technique well within the grasp of any competent bitch-spayer who is prepared to learn the technique properly and the case selection is straight forward.[/quote]

I only referred to referral for TECA as Rebecca stated in her original post that she was a new graduate, and when I qualified I would have been very reluctant to carry out a TECA myself. Never mentioned LWR, as your own ear surgical specialist adviced at a CPD event that many dogs with deep and nasty infections, are better going straight for a TECA, as LWR does have a higher complication rate!

Re: Atopic dermatitis and ears

Anthony Todd — Sun, 16 May 2010 09:02:54 GMT

I remember a cartoon by the noted veterinary cartoonist R M Miller where the owner said to the vet:

"I just want the dog to get better Doc, so skip the lab tests"

I went to a lecture where the lecturer said "I never commence treatment until I have a diagnosis"

Me, myself wouldn't have been able to start treatment often......

Modern Vet. Med. sometimes seems to put the cart before the horse

Re: Atopic dermatitis and ears

PATRICK MARSHALL — Sun, 16 May 2010 08:41:17 GMT

It would appear that this thread is highlighting two themes that interest / infuriate me;

Firstly, the perceived difference between the "real" world of first-opinion practice and the (equally real) world of referral /specialist practice: and secondly, the seemingly increasing reluctance to perform relatively straightforward surgical procedures in general practice.

With regard to the first .....My colleague Sally Everitt is at present doing a PhD at Nottingham University on the broad theme of Clinical Decision-making in Veterinary Practice and we have spent many a happy hour discussing some of her findings along the way as she has looked at all types of practices around the UK. The first blindingly obvious point to emerge is that all of our unwell patients come with an owner/client attached. The animal has a problem ,of whatever sort, which the client wishes to be resolved. How we resolve that problem will be coloured by, amongst other things, the "value" that the owner places on the animal, the time and effort they are prepared to put in to resolving the problem, economic considerations and how far it is necessary to go down the diagnostic pathway to come up with an effective therapeutic solution. Therein lies the tension.

In first opinion practice we have to accept that (despite what seems to be drilled into us at University):

1. A diagnosis is not necessarily required to come up with an effective therapeutic plan/solution

2. Diagnosis by response to therapy is perfectly acceptable

3. The proportion of cases that need to be referred for specialist investigation/treatment is a relatively small one. The value the owner places on the animal, economic considerations, and diagnostic/therapeutic effort required will be totally different from those that apply to the vast majority of cases that we see daily.

Secondly ...........I have seen a couple of "recurrent anal gland" cases as second opinions recently where the reason that the client had sought a second opinion was that they had been unsettled by the emphasis that had been put on possible post-op complications (i.e. faecal incontinence) and had been advised that the surgery should be done by a specialist (at considerably greater cost than in first opinion practice, longer distance to travel etc.etc.). Are we becoming worryingly risk averse and practising defensive medicine more and more? Whilst I agree the potential complications should be discussed; surely this is the sort of surgery (like LWR's in properly selected cases) that should be being done in general practice? Despite being only a moderately competent surgeon I have yet to render a dog incontinent as a result of removing its anal glands - and I was pretty ambi-sinistrous when I did my first one 25 or so years ago.

I can't help wondering if the CPD industry has any part to play in this trend. Whilst purporting to widen the surgical horizons of the participants there can be a tendency to put some relatively routine procedures into the "don't attempt this at home" bracket.

Lastly.........I attended the excellent pre-BSAVA ISFM&S day where one of the lectures was on the surgical treatment of feline hyperthyroidism. My surgical technique has been greatly enhanced as a result. However the recommendation was that bilateral thyroidectomy should be performed as required rather than two "staged" procedures. The reasoning was that there is only a 5-6% complication rate (i.e. 1 in 20).

Thoughts....

1. We do 1 or 2 thyroidectomies a month

2.We always stage ours and have had no anaesthetic deaths or complications in the last 10 years - despite a reasonable number not being euthyroid at the time of Sx

3. If complication rate is 1 in 20 we will create one (to a greater or lesser extent) tetanic cat a year

4. When asked how she dealt with the complications the lecturer said that they were treated by the medics ..... that's going to be me then with the tetanic cat at 3am ......or worse still one of my colleagues thinking less than Christian thoughts about me.

Or am I just getting old and crusty?

Re: Atopic dermatitis and ears

Malcolm Ness — Sun, 16 May 2010 01:14:46 GMT

[quote user="Vikki Halliday"] (i would go for bloods, Malcolm I know would prefer you to refer to a dermatologist for intradermal testing, but some of us have to live in the real world.......). [/quote]

In the real world, blood testing without an understanding of the (typically severe) limitations of th the tests is a waste of time, effort and money. Incidentally, the dermatologist in question has more than quarter of a century's experience of primary care practice dermatology as well as a post grad qualification. These silly faux-superior comments about the "real world" are misjudged.

[quote user="Vikki Halliday"]Agree Malcolm, however as porr surgical technique and case selection is more likely to occur in first opinion practice than at the hands of your top soft tissue surgeon, I would argue that unless th pet is on treatment and relatively stable with regards to the otitis, and the individual vet is skilled in LWR, TECA or rather referral for asessment for TECA is the best option. [/quote]

LWR is a technique well within the grasp of any competent bitch-spayer who is prepared to learn the technique properly and the case selection is straight forward. Hardly any of the TECAs we do are in cases treated in our own primary care practice - early agressive diagnostic assesment then medical and/or surgical management of recurrent otitis usually avoids the progression to end stage ears.

Re: Atopic dermatitis and ears

Vikki Halliday LLB — Sat, 15 May 2010 20:31:37 GMT

[quote user="Michael Woodhouse"]

*coughs* I did actually say Epiotic not Easotic, but I like that too!

[/quote]

OOPs! well it was well AFTER MIDNIGHT on a Friday night and we were being a bit sad being the only buggers on the forum. Guess tiredness was affecting my eyeshite...........

[quote user="Rebecca Benge"]The case I mentioned in my original post is a 4 year old female GSD, with no history of pruritus anywhere else, and according to her owners doesn't even seem to scratch at her ears that much[/quote]

I'm sure higher minds than myself, aka Mrs and Mrs Ness, will agree that this does not mean that there is not some skin pathology!

[quote user="Rebecca Benge"]

This is why I thought I'd mention this case, it seemed unusual to me too, as I also believed that most atopic cases tend to have Malasezzia as the main organism. I have had other cases with continuing ear problems that I believe may have some underlying cause, but no other owners have shown much interest in exploring other options and would rather just have another course of preds, which I guess is fair enough.

[/quote]

I'd argue that in my experience it is unusual to get a pure pseudomonas as a secondary pathogen to atopy, however there will be a percentage for sure that this is the main pathogen isolated.

[quote user="Rebecca Benge"]

So, is it not typical for an atopic dog to just show signs with just it's ears then, would you normally expect to see feet licking, pruritus etc too? Would you only pursue further investigations if dogs were showing these other signs too?

[/quote]

No, if you have grounds to suspect atopy on some of the pointers I mentioned previously, like seasonality, other subtle indications of skin pathology, then I would definately be thinking atopy.

If you have a dog which has recurrent painful otitis, I would suggest to the client that you rule out atopy by allergen testing, (i would go for bloods, Malcolm I know would prefer you to refer to a dermatologist for intradermal testing, but some of us have to live in the real world.......). That way if you get a positive result you can impart the good news to the clients that the test has been more than worthwhile.

[quote user="Malcolm Ness"]The typical approach to these cases is a proper diagnostic work up of the condition [/quote]

As Malcolm says, a full workup does not start and finish with culture and sensitivity, however,

[quote user="Malcolm Ness"]ideally by somebody fully informed of the limitations of the various diagnostic tests on the market. [/quote]

I would have to disagree. Sure referral to a dermatologist can be useful, but unless the owner is wealthy or the dog is insured, you may have to be realistic and carry out some testing yourself.

As I would hesitate to advise anyone to use the intradermal tests unless they are very familiar with them, purely as they need experience to be able to interpret accurately, but I maintain, (probably much to Judith's annoyance), that I seem to be getting good and accurate results to the Idexx Allercept tests.

[quote user="Malcolm Ness"]In the case of dogs presenting early with recurrent otitis externa consideration is given to lateral wall resection - while not curative of the atopy, this will typically render the ears easily controllable and prevent the progression towards chronic "end-stage" ears. (lateral wall resection has earned itself a bad name but failures are almost always due to poor surgical technique or poor case selection).[/quote]

Agree Malcolm, however as porr surgical technique and case selection is more likely to occur in first opinion practice than at the hands of your top soft tissue surgeon, I would argue that unless th pet is on treatment and relatively stable with regards to the otitis, and the individual vet is skilled in LWR, TECA or rather referral for asessment for TECA is the best option.