Dr Andrea Volk
DVM, Dr.med.vet., MVetMed, DipECVD, MRCVS
RCVS and European Specialist in Veterinary Dermatology
So, having read Part 1 of this two-part blog, you will now be familiar with George, a challenging case of recurrent otitis. Part 1 discussed the primary, predisposing and perpetuating factors that can all contribute to recurrent, refractory otitis. Having understood these…
How would you proceed with George’s work-up?
At this point, the best approach would be to get some ear swabs for cytology and recommend the use of a good ear cleaner. If the integrity of the tympanic membrane has not been confirmed, then a low concentration chlorhexidine/tris-EDTA product like “Otodine” is a good choice (as proven to be safe when used in middle ears). The ear swabs should be rolled onto a slide and air-dried then sent (unstained) to an external lab or looked at in-house by you / your colleagues.
Whilst waiting for the cytology results, as George is clearly uncomfortable, some anti-inflammatory treatment is necessary. NSAIDs have little or no effect on aural inflammation, so in this case, steroid treatment is required (this will also help to lessen the local inflammation allowing better visualisation of the canal).
Once results of cytology are available, medication can be prescribed accordingly. Topical treatments into the ear are the mainstay of otitis treatment. Systemic antibiotics will have no effect on bacterial otitis externa, and often very limited on otitis media. Should cytology show just large cocci, any miconazole or fusidic acid-containing ointment should be fine, unless there is a concern regarding already acquired resistance. Should there be more yeasts, miconazole is still a very effective treatment, when cleaning and anti-inflammatory treatment is used in conjunction.
After 2 weeks of cleaning and medication, re-examination is essential, to properly visualise the ear canal, assess progress, and repeat the cytology.
After 2 weeks, George is presented for his re-examination, but it is immediately clear that there has been little, if any, improvement. Whilst there is much less debris (due to regular cleaning), he appears more sore and uncomfortable…Your heart sinks!
This is the point when input from a Dermatology specialist would be really helpful!
Traditionally this would have meant referring George to a referral centre. However, this is a condition which may not yet require particularly complex equipment or unusual drugs or reagents. Instead, what you need most is advice and support on the case from someone with more experience and qualifications in this particular field.
So, enter our VVS Dermatology specialist, Andrea Volk!
Andrea Volk, RCVS and European Specialist in Veterinary Dermatology
How could VVS help you with this case?
Firstly, our specialist can help tease out the most important details from the owner history. Then we can perform a dermatological examination of the patient with you in real-time, and help you take samples – even if you’ve never taken them before! If you lack confidence with microscopy, we can work with you to improve your confidence of cell and parasite recognition; not to mention how to get the best results from the DiffQuik. We can look at cytology from your patient in real-time, alongside you and help you interpret the findings.
Malassezia can be seen on this ear slide (arrows). This image was taken with an iPhone camera directly through the microscope’s eyepiece. Photo copyright Dr Andrea volk.
A case like George would also be an ideal one for us to examine the ear canal together using the digital otoscope that we provide. As you examine the ear canal, we are virtually next to you seeing exactly what you see, as you see it, all in real-time. We can guide you through what to look at and how to interpret it; help you find the tympanic membrane and determine if it’s diseased or ruptured. We can even assist and advise you with ear lavages and other treatments.
Image of external ear canal taken using digital otoscope, which enables the Dermatology specialist to examine the ear canal together with you, in real-time.
Once we have identified possible underlying triggers to George’s ear problems, determined which kind of infections are present and evaluated the status of the middle ear, we can prescribe patient-tailored treatment. For example, if there is evidence of middle ear disease, management of this and safe topical agents would be discussed. We can also accompany you through the next few re-examinations of George, if you would like us to.
Our dermatologist is available and happy to discuss all aspects of the case with you. From what to sample and how to interpret results, to treatment options and case management, such as how frequently to re-examine, when to call such a case ‘healed’, and how to deal with non-compliant owners.
And a big advantage of using the VVS Dermatology service is that you can access all their expertise whilst the case management (and the revenue and client goodwill) remain with you and your practice.
So if you’ve got any patients with suspicious skin lesions, odorous otitis cases, or generally pruritic patients who are making your heart sink every time you see their names on the consult list… give us a call and see how we can make your life easier and their lives better!