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The Metropolitan New Jersey Veterinary Medical Association 1 2008-2009 Continuing Education Lecture Series Wednesday, February 25, 2008 at 8 PM “Facial and Otic Dermatoses & Otitis Externa/Media” Karen Helton Rhodes, DVM , DACVD Riverdale Veterinary Dermatology, LLC WHERE: Schering-Plough Corporation 2000 Galloping Hill Road, Kenilworth NJ 07033 Garden State Parkway – Exit 138 Turn right at light. Go ½ mile to entrance to Schering-Plough on right. Refreshments and Social Hour Starts at 7:30 PM MNJVMA web site: http://www.geocities.com/mnjvma/mnjvma.html Please check the website for possible cancellation due to inclement weather or other causes. ***THANKS TO THE FOLLOWING SPONSORS*** SCHERING PLOUGH NOVARTIS HILL’S MERIAL STOKES PHARMACY ANTECH IAMS ABAXIS ROYAL CANIN MERCK RED BANK VETERINARY HOSPITAL 2 Facial and pinnal dermatoses Facial & Otic Dermatoses Facial and Pinnal dermatoses & Otitis externa/ media Allergy/ Hypersensitivity • food/ contact/ airborne • Allergic blepharitis • Nasal eosinophilic furunculosis • Eosinophilic granuloma complex • Canine sterile eosinophilic pinnal furunculosis • “hot spot” peri-pinnal • Aural hematoma • • • • • • • Allergy IMSD Thrombovascular EM, TEN, drug Keratinization Parasitic fungal • • • • Viral Bacterial alopecia Neoplasia (pre/ para) • Systemic disease Food allergy/ intolerance • Immunologic vs. idiosyncratic • Varied incidence (3-5% vs. 10-15%) • Glycoproteins offending substance • Intestinal parasites predispose • Serum testing • Food trial 8-12wks • Novel protein diet + one carb OR hydrolyzed diet • Beware placebo! 3 Contact Allergy • Rare • Irritant vs. allergic • At risk: poodles, shepherds, goldens • Plants, mulch, cedar • Leather, metal, concrete • Fabric, rugs, carpets • Deodorizers, floor cleaners, detergents • Fertilizers, herbicides • Flea collars, topical flea products (Promeris- PF like rxn) • Shampoos, topicals Inhalant/ percutaneous allergy • Seasonal, 75% become nonseasonal • Ear infections 86% • Bacteria/ yeast 80% • Conjunctivitis 50% • Seborrhea 12-23% • Hyperhidrosis 20% • Rhinitis/ sneezing Inhalant/percutaneous allergy “diagnostics” • • • • IDST vs. serum Malassezia IDST Dust mites Storage mites (tyrophagus) • Pollens • Molds • Cats/ dogs/ wool/ feathers/ tobacco/horse Greer survey: dust mites/ storage mites • • • • • • • • • • • DUST MITES: Wash bedding Vaccum Boric acid Mattress covers Filters Remove carpet Keep off furniture Bathing pet Dehumidifiers Discard pet bedding • STORAGE MITES: • Tyrophagus, acarus, lepidoglyphus) • Canned foods • Freeze food • Small bags food • Routine clean food bin • Airtight food storage • Home cooked diets 4 Allergic dermatitis therapy • Claritin (loratidine) • Zyrtec (ceterizine) • Benadryl (diphenhydramine) • Tavist (clemastine) • Chlortrimeton (chlorpheniramine) • • • • • • • • • • • Atarax (hydroxyzine) Elavil (amitryptyline) Sinequan (doxepin) Periactin (cyproheptadine) Neurotin (gabapentin) Atopica (cyclosporine) Allegra (fexofenadine) Singulair (montelukast) Trental (pentoxyfylline) Prozac (fluoxetine) Temaril-P Allergic dermatitis therapy capsaicin • • • • Zostrix, HEET, etc. blocks substance P causes pain/itch release triggered by antigen challenge & histamine • SubP receptors on mast cell • Chemotactic for inflammatory cells Allergic dermatitis therapy topicals • Corticosteroids • Analgesics • Calcineurin inhibitors • Capsaicin • Aloe vera • DMSO Allergic dermatitis therapy topicals • ALOE VERA: • salicyclic acid • bradykinase activity lower pain & edema • magnesium lactate decrease histamine release • anti-PG • protease inhibitor • DMSO: • decrease PG synthesis • stabilize lysosomal enzymes • FINACEA gel: • azelaic acid 15% gel 5 Allergic blepharitis/ staphylococcal blepharitis • Common in small breed dogs • Secondary bacterial folliculitis (also primary) • Chalazion: chronic inflammation leading to granulomatous rxn of meibomian glandnodule on palpebral conjunctiva Eosinophilic Granuloma Complex • Multifactorial etiology: food, inhalant, flea, mosquito, genetic, idiopathic, viral? • Eosinophilic plaque • Linear granuloma • Indolent ulcer Nasal Eosinophilic Furunculosis • • • • • • Acute (severe in 24hr) Insect/ spider Spares nasal planum +/- pruritus Initially sterile Alopecia, erythema, erosive, nodular • Tx- steroids EGC eosinophlic plaque • Severely pruritic • Form most often assoc. w/ allergy • Tx: cyclosporine, allergy vaccine, steroids, leukeran, etc. 6 EGC indolent ulcer • Maxillary lip margin • Hard palate • Non-pruritic/ nonpainful • Often refractory to therapy (may require chemotherapy) Canine sterile eosinophilic pinnal furunculosis • Typically bilateral • Erythematous • Papular eruptionsmall and pinpoint • Medial aspect of pinnae primarily • Tx- steroids EGC linear granuloma • Often non-pruritic • Caudal thigh/swollen chin • Oral cavityaggressive form • Ulcerative and proliferative, collagen necrosis Pyotraumatic dermatitis peri-pinnal “hot spot” • Large breed dogs • Caused by allergy/ otitis externa • Deep bacterial infection (furunculosis) • Requires 6-8wks of antibiotics 7 Aural hematomas • Etiology: allergy, otitis, otic neoplasia • Large breed dogs, rare in cats • Numerous sx techniques: baker punch, laser, teat cannula, penrose drain, mattress sutures • Pemphigus complex • DLE/ SLE/ SCLE • Vasculitis/ vasculopathy • Dermatomyositis • Vitiligo • Mucous membrane pemphigoid Pemphigus complex • • • • • P. foliaceus P. erythematosus P. vegetans P. vulgaris Canine benign familial chronic pemphigus (Hailey-Hailey disease) • Paraneoplastic pemphigus Immune Mediated Skin Disease • Antigens: desmoglein (desmosomal transmembrane)& envoplakin/ periplakin (intracellular desmosomal plaque proteins) • VKH • EM/ TEN • Auricular polychondritis • Hereditary lupoid dermatosis of GSP • Juvenile cellulitis • Epidermolysis bullosa aquisita Pemphigus complex • Spontaneous • Drug induced (Promeris, antibiotics, etc.) • Chronic inflammatory disease • Paraneoplastic (cross rxn btw tumor and epithelial plakin antibodies 8 Pemphigus complex treatment options • Steroids • Azathioprine (dog only) • Chlorambucil (cat and small dogs) • Cyclosporine • Tetracycline and niacinamide (dogs) • Doxycycline (cat) • Dapsone • CellCeptmycophenolate (dog) • • • • • Cutaneous (Discoid) Lupus Erythematosus • Pemphigus meds • Pentoxifylline (Trental) inhibit IL1, IL2, TNFalpha/ increase anti-inflammatory IL10, inhibit platelet aggregation, decrease adhesion of inflammatory cells to keratinocytes and endothelial cells) Cutaneous (Discoid)Lupus Erythematosus • Vitamin E-stabilizes cell membranes- 2hr before and after meal • EFA • Suncreens • Tacrolimus (Protopic (0.1 and 0.03% gel) Primarily dogs Photosensitive Depigmenting Ulcerative Loss of architecture (cobblestone planum nasale) • Typical nasal presentation • Exfoliative cutaneous LE-GSHPointergeneralized + pinnal • Ulcerative disease of Shelties- vesicular variant of CLE (serpiginous ventral lesions) Systemic LE (SLE) criteria: need 4 or more for dx • Polyarthritis • Nephropathy (proteinuria) • ANA positive • Thrombocytopenia, anemia, low WBC • Seizures/ psychosis • Pericarditis/ pleuritis • Dermatopathyerythema, oral or nasopharyngeal ulcerations, photosensitivity, vesicles, bullae, footpad ulcers/ hyperkeratosis, panniculitis 9 Systemic Vasculitis/ Vasculopathy • Juvenile Polyarteritis Syndrome (JPS) Beagles • Neutrophilic Leukocytoclastic Vasculitis of Jack Russell Terriers • Familial Cutaneous Vasculopathy of German Shepherds • FELV associated vasculitis-lip, footpad, pinnae • Cutaneous and renal glomerular vasculopathy of Greyhounds • Thrombovascular necrosis of pinnae of Dachshunds • Cold agglutinin, frost bite, etc. Vasculitis/ Vasculopathy cutaneous lesions • • • • • • • • LOCATION: pinnae face paws lips tail scrotum mucocutaneous junction • dependent regions • oral cavity • • • • • • • • LESIONS: purpura hemorrhagic bullae necrosis, ulcers urticaria, edema acrocyanosis erythema SIGNS: anorexia, fever, depression, pain/pruritus Vasculitis/ Vasculopathy • 50% are idiopathic • Infections • Vaccinations (rabies) • Immune mediated • Hereditary predisposition • neoplasia • • • • • • • • • • DRUG induced: Enalapril Furosemide Ivermectin Itraconazole Imodium Metoclopramide Phenobarbital Phenylbutasone Metronidazole Dermatomyositis Collies and Shelties • Hereditary ischemic dermatopathy • Hair follicle, dermal collagen, muscle • Face, ears, tail • Megaesophagus • Dropped gait 10 Vitiligo: idiopathic leukoderma/ leukotrichia • Dobermans, Rottweilers, Belgian Shepherds, Siamese cats, etc. • Immune destruction of melanocytes • MCJ, hair, nails, footpads Erythema Multiforme Toxic Epidermal Necrolysis • Up-regulation of MHCII, CD4, and ICAM adhesion molecules on keratinocytes • CD8+ Tcells recruited and initiate apoptosis • Epidermal and follicular keratinocytes attacked Uveodermatologic Syndrome VKH • Meningoencephalitis fever, malaise, nausea, vomiting • Alopecia, poliosis, depigmentation of the skin • Uveitis • Huskies, Akitas, Samoyeds Erythema Multiforme Toxic Epidermal Necrolysis • Focal to confluent scarring (TEN) • Severe ulceration/ necrosis • Serpigninous or coalescing lesions • Often assoc. w/ drugs: cephalexin, amoxicillin, penicillin, doxycycline, griseofulvin, gold, sulfa drugs 11 Mucous Membrane Pemphigoid: MMP • Rare • Subepidermal blistering disease • Oral cavity, nasal, ear canal, anus, eyes, genitalia • Auto-antibodies against BPAG2 Juvenile Cellulitis “puppy strangles” • Sterile granulomatous and pustular dermatosis • Face, pinnae, PLN • Age 3wks to 4 months • Rare adult onset • Pain, lethargy, fever, anorexia Epidermolysis Bullosa Acquisita • Great Danes- young • urticaria, vesicles, ulcers • face, groin, axilla, abdomen, footpads, oral, MCJ • autoantibodies against anchoring fibrils (collagen VII) • subepidermal blisters Auricular Polychondritis “relapsing chondritis” • Dogs and cats • Inflammation and destruction of auricular cartilage • Swollen painful pinnae @ onset • Scarred and folded pinnae- chronic 12 Keratinization/ Seborrheic Disorders • • • • • Primary/ idiopathic Zinc responsive Vitamin A Sebaceous adenitis Psoriasiform lichenoid dermatosis of Springers • Dirty face syndrome • Ear margin dermatosis • Idiopathic nasodigital hyperkeratosis • Hereditary nasal parakeratosis of Labs • Feline/canine acne • Malassezia overgrowth • “Fold dermatitis” Canine Keratinization Disorder • Hyperkeratosis • Follicular casts • Seborrheic patchesdry and greasy • Malodorous skin • Secondary infections: yeast!!! Canine Primary Idiopathic Keratinization Disorder • Epidermal turnover time 7 days vs. 21-23 days • Secondary bacterial and yeast overgrowth • Notice w/in 6m-2yr of age- progressive • Cocker, WHWT, Golden, Dalmatian, Lab, Fox Terrier, SharPei Zinc Responsive Dermatosis etiologies • Decreased absorption from gut • Diet low in zinc • Diet high in phytate, cereal, soy • Excessive calcium supplementation • Zinc- coenzyme in keratinization • hereditary 13 Zinc Responsive Dermatosis • Huskies, Samoyeds, Malamutes- young adults • scale, crust, erythema, alopecia • mouth, periocular, pinnae, footpads, pressure points • severe: lethargy, anorexia, PLN, edema Zinc Responsive Dermatosis therapy • • • • • • • Zinc methionine Zinc sulfate Zinc gluconate 2mg/kg elemental zn pred helps absorption EFA OHE: estrus exacerbates • Toxic levels zinc: v/d, anorexia Zinc Responsive Dermatosis Bull Terriers • Lethal acrodermatitis • Onset 1-3 months/ fatal by 6 months • Genetic • Growth retardation, diarrhea, pneumonia, tail chasing, light color • Facial pyoderma, paws • Acrodermatitis enteropathica- people Vitamin A Responsive Dermatosis • Rarely facial except folds and ears • Neck, trunk, otitis • Cockers • Keratin fronds/ plaques • Orthokeratotic • Vit.A dose @ 10-20,000iu/day 14 Lichenoid Psoriasiform Dermatosis of Springers • young dogs • erythematous papules & plaques on pinnae and groin • lesions become hyperkeratotic • wax and wane Sebaceous Adenitis • Poodles, Samoyeds, Akitas, Vizslas • Autosomal recessive • Dorsum (esp. top of head) • Phrenoderma • Cyclosporine best tx combined with topicals Nasodigital Hyperkeratosis • Idiopathic in older dogs • Hereditary nasal parakeratosis of labsclinical @ 6-12mon of age • Hyperkeratosis, fissuring, crusting, mild depigmentation Hereditary Icthyosis • Golden Retriever, WHWT, Cav. King. Chas., Doberman, Jack Russell, Norfolk Terrier, Yorkies • Tightly adhered scale • Nasal, footpad hyperkeratosis 15 Ear Margin Dermatosis • • • • • Primarily Dachshunds Idiopathic +/- vasculitis Keratin accumulation Alopecia, crust, fissures, ulcers, notching • Trental @ 25mg/kg bid • EFA, topicals • Tetracycline: niacinamide Facial Dermatitis of Persians “dirty face syndrome” • Black waxy debri in erythematous folds • Variable pruritus • Mucoid ocular dis. • Erythema of preauricular reigon • Otitis externa • Secondary infections Acne: canine and feline • disorder of follicular keratinization & glandular hyperplasia • folliculitis and furunculosis, comedones, cellulitis • Mupirocin, RetinA, clindamcyin, benzoyl peroxide Anatomic Seborrhea facial fold dermatitis • Lip folds: often bacterial component • Brachycephalic breeds • Secondary malassezia overgrowth/ hypersensitivity • Variable pruritus 16 Viral Dermatoses Feline Pox Virus • Europe, Australia, Belgium, Netherlands • Contact with rodent and cattle • Oral-nasal/ percutaneous entry • Ulcerative macules, nodules- head, oral cavity, tongue Viral Dermatoses Morbillivirus: Distemper • nasal/ digital hyperkeratosis • pustular dermatitis, fever, anorexia, oculonasal discharge, pneumonia, diarrhea, neurologic • intracytoplasmic inclusions Viral Dermatoses Papilloma virus: facial • Canine oral papillomatosis- young dogs/ cyclosporine use • Canine exophytic (horn) papilloma- Cocker, Kerry Blue • Feline oral papilloma • Bowenoid carcinoma • Feline solitary- Persian Viral Dermatoses Herpes: feline rhinotracheitis • Severe URI • Facial erosion & marked erythema • Vesicles, ulcers, crusts, stomatitis • Herpes assoc. EM in cat recently reported 17 Viral Dermatoses Retro virus: FeLV & FIV • Giant cell dermatosis- pruritic, ulcerative dermatosis of face, neck, pinnae • Epidermal hornsface, footpads • Vasculitis assoc. FeLV- necrosis of ear tips, tail • Plasma cell stomatitis & pododermatitisproliferative, painful • Plasma cell chondritissymmetrical, painful swelling of pinnae Parasitic Dermatoses Demodicosis: canine • D. canis: hair follicle • D. injai: sebaceous glands, large size • D. cornei: superficial epidermis, 50% shorter than D. canis • D. canis: typical, otitis • D. injai: oily coat on dorsum neck/ midline • D. cornei: often pruritic, similar to D. canis clinically Viral Dermatosis Calici virus • Endemic in shelters • Oral and facial vesicles/ ulcerations • URI, lameness, pneumonia, v/d, acute death OR spontaneously resolve • • • • • • • Feline Orofacial Pain Syndrome (FOP) trigeminal neuralgia Burmese, Siamese often unilateral severe pruritus assoc. w/ oral dz Gabapentin Tx Parasitic Dermatosis Feline Demodicosis • D. cati: hair follicles • D. gatoi: stratum corneum layer, 50% shorter, contagious • D. cati: alopecia, otitis, often underlying systemic disease • D. gatoi: pruritus, alopecia, contagious 18 Demodicosis Canine treatment options • Ivermectin oral:m 0.1ml of 1% soln/5#/day (400ug/kg)1/2 dose-wk1 • Breed alert- Collie, Sheltie, OES, white GS • MDR1=ABCB1 code for p-glycoprotein- if +, then dysfunctional protein • WSU lab: vetmed.wsu.edu/vcpl • Alert: spinosad (Comfortis) • • • • • • Canine Demodicosis treatment options • Interceptor-milbemycin (Novartis) @ 23mg/kg/day • MilbeMite otic (Novartis) • Acarexx otic (Boehringer) • Cydectin-moxidectin (Fort Dodge) injectable given orally @ 400ug/kg/day-breed alert Canine Demodicosis treatment options • AdvantageMulti (Bayer) “spot on” imidacloprid/ moxidectin- monthly +/- results • Doramectin weekly subQ injections @ 600ug/kg- breed alert Mitaban -amitraz Q 2 wks vs. weekly EPA pesticide Collars not effective Hyperglycemia Pro-Meris (metaflumizone & amitraz) q2wks +/- (PF induced rxns) Feline Demodicosis treatment options • LymDip 2% dips weekly (e-collar until dries) BEST • Amitraz effective yet often toxic • Doramectin injections weekly x 3 @ 600ug/kg subQ +/- • Ivermectin orally daily @ 300600ug/kg- toxicity caution • Revolution (Pfizer)not effective • Acarexx otic • MilbeMite otic 19 Parasitic Dermatoses sarcoptid mites • Sarcoptes scabei var. canis (remember incognito) • Notoedres cati • Thick heavy crusts of pinnae, diffuse erythema, excoriation, pruritus! Parasitic Dermatoses Otodectes • Most common in cats • Ear canal • Also face, neck, trunk, pinnae • Contagious to dogs, cats, man, ferrets Scabies and Notoedres treatment options • CANINE: • Ivermectin injections @ 0.1ml/10# weekly (200ug/kg) for 4 inj • Revolution- selamectinq2wks for 3 doses (+/- monthly) • Lime sulfur dips • Amitraz weekly • Steroids ok!!! • • • • FELINE: LymDip dips weekly Revolution q2wks Ivermectin inj.q3wks @ 200-400ug/kg • Amitraz- caution • Steroids ok Parasitic Dermatoses fly strike • Tip of pinnae in dogs w/ erect ears • Fold region of pendulous ears • Mild to intense pruritus • Steroid cream and fly sprays 20 Facial & Pinnal Alopecia breed related Fungal Dermatoses • Dermatophytosis • Majocchi’s granuloma/ kerion • Malassezia • Candida • Cryptococcus Alopecia: facial and pinnal hyperadrenocorticism • CANINE: alopecia of bridge of the nose • FELINE: folding of pinnae (occurs with iatrogenic steroid use as well) • • • • Mexican hairless Chinese crested Inca hairless dog American hairless terrier • Sphinx cat • Comedones and seborrhea Alopecia: facial and pinnal canine hypothyroidism • dermal mucinosis with alopecia • otitis externa • seborrheic dermatitis 21 Alopecia Follicular Dysplasia • Portuguese Water Dogs-periocular, flank, caudodorsal • Pont-Audemer Spanielbrown hair of trunk and ears • Follicular Lipidosis of Rottweilers- red points, lips <1yr • Cornish Rex cats • Progressive, waxwane, permanent, comedones Alopecia “mechanical” • Traction alopecia of toy breeds • Hair clips & rubberbands • Excessive stripping of some breeds Alopecia pattern baldness • • • • • • Dachshunds (pinnal) • Feline preauricular and pinnal: Siamese Chihuahua (pinnal) and black cats Whippets Manchester terriers Boxers Greyhounds Alopecia immune phenomenon? • Alopecia areatalymphocyte attack on hair bulb • Pseudopelade- attack of follicle isthmus • Alopecia mucinosamucinosis of hair follicle ORS • Lymphocytic mural folliculitis • Inflammatory vs. pre-neoplastic? 22 Neoplasia/ pre-neoplastic squamous cell carcinoma • Actinic dermatosespinnae, eyelid, nose of white cats/ glaborous skin of dogs • Bowenoid carcinoma “in situ”primarily cats • Overt squamous cell carcinoma Neoplasia/ pre-neoplastic histiocytoma/ histiocytosis • Histiocytoma (head, pinnae, limbs) • Cutaneous histiocytosis (bridge nose, nasal mucosa, trunk, limbs) • Systemic histiocytosis (nodules skin, PLN, lung, liver, spleen, marrow) • Malignant histiocytosis (similar to systemic yet fatal) Neoplasia/ pre-neoplastic facial mast cell tumors • Ear & head of catsmultiple, Siamese predisposed • Cats tend to be benign yet cautionmay be metastatic • Often spongy and pin-feathered Neoplasia/ pre-neoplastic CTCL: epidermotrophic • Alopecia mucinosa • Pseudopelade • Lymphocytic mural folliculitis • CTCL- erythema and depigmentation> plaques> nodules>slough skin 23 Neoplasia/ pre-neoplastic miscellaneous tumors • • • • Basal cell Cutaneous horns Melanoma Ceruminous gland adenocarcinomas (cystic) • Viral papillomas • Pigmented nevi Cutaneous manifestations of systemic disease: NME • Pinnae, face, footpads, MCJ, elbow/hock, vesicles of oral cavity • Skin lesions may precede clinical evidence of metabolic disease Cutaneous manifestations of systemic disease: NME • Hepatocutaneous • Liver cirrhosis, DM, glucogonoma, Cushing’s • Hyperkeratosis, crusting, ulceration • Metabolic defects: elevated glucagon, AA def. Zn def> epidermal necrosis Cutaneous manifestations of systemic disease: NME tx • Aminoacid (Aminosyn 10% from Abbot lab given IV slowly over 8 hrs. @ 500ml/doggiven once a week for 3-4 wks-ck blood ammonia • EFA • Egg yolks 3-6/day • Zinc supplementation • Niacinamide @ 250500mg tid 24 Pancreatic Paraneoplastic alopecia in cats • Sudden onset of hyperpigmented nodules of head, neck, limbs • Polycystic kidneys, renal cystadenomas, cystadenocarcinoma • Uterine leiomyomas • Clinical renal dysfunction up to 3yrs after skin disease • Sudden onset, progressive alopecia of face and trunk • Glistening (slick) appearance to skin • Neoplastic cells produce cytokines that kill hair follicles • Pancreatic or biliary adenocarcinoma Exfoliative dermatitis and thymoma in cats • >10yr • Non-pruritic scalinghead and pinnal initial then spreads • Progressive erythema & alopecia • Brown waxy deposits around eyes, ear canals, lips • Autoreactive Tcells in lesional skin-interface dermatitis, apoptosis Nodular Dermatofibrosis of German Shepherds • Mediastinal mass • Coughing, anorexia, dyspnea-late onset Facial and Pinnal Dermatoses • Broad overview • Northeast prevalence 25 Otitis Externa & Media Prediposing factors “risk” • • • • • • Karen Helton Rhodes, DVM, Diplomate, ACVD Riverdale Veterinary Dermatology Pendulous ears Excessive hair (ex. Poodles) Stenosis of canal (ex. Shar Pei) Humidity/ temperature Excessive cerumen (ex. Spaniels, Labs) Swimming-breaks down protective lipid barrier of stratum corneum-opportunistic microbes- maceration • Excessive ear cleaning/ hair plucking • Systemic disease-immunosuppression Etiologies of Otitis • Predisposing factors: risk factors • Primary factors: directly incite otitis • Perpetuating factors: prevent resolution Primary factors “directly incite otitis” • • • • • • • • • Parasites Hypersensitivity- atopy, food, contact Fungal Endocrine IMSD Foreign body- plant, hair, meds, etc. Keratinization disorders Polyps, tumors/etc.-obstructive Misc.- juvenile cellulitis, PSOM, etc. 26 Perpetuating factors: prevent resolution • Bacteria: Staph., Proteus, Pseudomonas, E.coli, corynebacterium….etc. • Yeast: malassezia,candida • Pathology of ear canal/ tympanum: mineralization, stenosis, altered epithelial migration, otitis media Case example allergic Labrador • Primary: allergy (edema & stimulation of ceruminous glands causes stenosis & excess wax production) • Predisposing: decreased ventilation, increased humidity, increased wax production due to increased density of glands in Labs • Perpetuating: humidity favorable for bacterial overgrowth • **must treat all factors** Historical Information • Initial episode vs recurrent/relapsing? • Seasonal? • Unilateral/ bilateral? • Swim? • Historical ear mites? • URI in past? • Skin disease? • Metabolic disease? • Reluctant to open mouth/ chew hard food? • Head tilt/ balance? • Previous medications (oral & topical) • Ear cleaning routine/hair pluckinggroomer/ owner? • Zoonosis? • Anesthesia/ plane flights? Physical examination • Complete physical • Bullae manipulation • Degree of fibrosis of canals? • Degree stenosis? • Color and odor of exudate w/in canals 27 Neurologic/ Vestibular signs middle/ inner ear affected • Lean, veer, or roll toward affected side • Ataxia • Deafness • Vomiting (acute) • Facial nerve damage: saliva/food dropping from corner of mouth, inability to blink, decreased tear production • Anisocoria (miosis of affected side) & protrusion of 3rd eyelid (Horner’s) • nystagmus Evaluation of the ear canal • Cytology every case • Culture and sensitivity(esp. rods) • Otoscopic exam • Stage the otitis (I-IV) • Evaluate need for CT/ MRI • Evaluate need for anesthetic procedure Otic Cytology look for: • Bacteria: rods vs. cocci • Yeast: malassezia • Mites (demodex, ear mites, etc.) • Inflammatory cells • Fungal elements (crypto) • Neoplastic cells • Rods-proteus, pseudomonas • Cocci- staph • Yeast- malassezia Cytology: technique visual • Moist red brownmalassezia • Yellow cream/ light brown- staph • Mucoid black or black/greenpseudomonas • Dry black-keratinization, ear mites 28 Cytology technique • Cotton swab • Sample horizontal canal (where cartilage bends @ 75 degrees-don’t straighten canal) • Roll onto slide (L&R) • Heat fix • Diff-Quick stain • • • • Cytology interpretation • Rods/ cocci/ yeast • Inflammatory cells: degenerate with infection/ intact with IMSD • Large # epithelial cells with few bacteria: keratinization, hypothyroid • Remember keratinocytes may have melanin granules Culture & Sensitivity when to culture • Normal cerumen does not stain • *aids initial Tx plan Chronic relapsing Non-responsive Rods on cytology Non-responsive cocci infection • No need to culture if ID yeast on cytology • Stop all tx 72 hours prior to C/S Otoscopic exam survey • Video-otoscopy allows owner to visualize the problem • Survey only- may not be thorough without sedation/ anesthesia 29 Stage the Otitis Level I - IV • Allows the owner to understand the progression of disease • Gives them concrete options for treatment • Makes them part of treatment decision, success, & failure Staging Otitis “remember” • Otitis media present in 82% of recurrent and chronic otitis (6mon. duration) • Leading cause of tx failure is unrecognized concurrent OM Diagnostic/ Therapeutic options • Pre-tx blood screen +/- thyroid profile • CT/ MRI • Video-otoscopy under anesthesia 30 Video-Otoscopy diagnostic & therapeutic Diagnostic Imaging • CT preferred over MRI in most cases (CT boney, MRI soft tissue) • Lumina of bullae should be gas density • Bullae have thin, well defined wall • Superior optics and magnification for diagnostics • Allows visualization of deep regions to insure thorough therapeutic flush/infusion/wick • Biopsies, mass excision, myringotomy • Culture from the bullae Diagnostic Imaging often see: • Mineralization of canal • Masses • Nasopharyngeal polyps • Fluid filled bullae • Thickened or lytic bullae wall • Fistulous tracts Indications for surgical/ anesthetic video-otoscopy • • • • • • Chronic recurrent dz Purulent exudate Painful ear Abnormal tympanum Polyps/ masses/ PSOM OM: facial nerve palsy, Horners’, hearing loss • OI: ataxia, vestibular, head tilt, nystagmus (fast away from dz ear), circle toward dz ear • As a last resort prior to TECA • *otitis media* is ALWAYS a surgical disease 31 Video-otoscopy advantages • Improved visualization • Enhanced flushing • Precise sample collection for C/S & Bx • Myringotomy • Increased accuracy of diagnosis • Specific therapeutic plan • Photographic recording for patient record • Out-patient procedure Improved visualization • Evaluate the patency of the proximal horizontal canal • Degree of stenosis/ proliferation: surface +/deep • Normal/ ruptured/ bulging tympanum? • Masses? Foreign body? Enhanced flushing of canal • Removal of exudate to allow visualization • Myringotomy: puncture of pars tensa to remove fluid pressure/ debri w/in bulla and allow infusion of meds Precise sample collection 89.5% variability: OE/OM • Cytology samples & C/S from proximal horizontal canal or bullae • Biopsy • Polyp removal • ceruminolith • cholesteatoma 32 Anesthetic Video-otoscopy therapeutic • Complete removal of debri/ prevent interference with meds • Infusion of meds directly into bullae • Wick placement • Steroids/ DMSO: antiinflammatory, decrease mucous production, decrease viscosity of otic secretions • Laser ablation • TECA if extensive • *medical nightmare • Maintenance TX Stenosis pathophysiology • Vertical canal has significant subQ & glands that respond to disease (less deep) • Apocrine & sebaceous=cerumen • Vertical canal more prone to stenosis • Fibrosis & mineralization Stenosis: therapeutic approach • Apocrine increased in inflammationgood media for bacterial growth • Sebaceous decreasedantibacterial properties Hair filled canals: therapeutic approach • Acts as trap to protect tympanum in normal ear • Reverse migration secondary to inflammation • Extraction • Laser • Nair hair remover? • Proteolytc enzymesdepilatory effect (and destroy tympanum) 33 Ceruminoliths pathophysiology • Epithelial migration failure/reversal • Sebaceous & apocrine glands produce cerumen • Damage to tympanum prevent radial movement of keratinocytes • Hairs may be included in the mass • Movement may cause discomfort • May cause rupture of tympanum or pressure may cause increase tension in bulla- vestibular Nasopharyngeal Polyps • Cats • Congenital/ viral • Grew from middle ear or eustachian tube & extend to external canal or rostral to soft palate • Trap exudates in middle ear Ceruminoliths therapeutic approach • • • • Loop curette Forceps Warm saline flush Base may be attached to tympanum • Tympanum may be eroded at site • Hyperplastic inflammatory proliferations of mucosa Nasopharyngeal polyps • • • • • Head shaking scratching ear Head tilt Nystagmus vestibular 34 Nasopharyngeal polyps treatment • Pedunculated • May be numerous • Traction and rotation 90 degrees • Snares ineffective • Laser • Bulla osteotomy • 1/3 may regrow Neoplasia • Adenocarcinoma/ adenoma • Basal cell • Chondroma/ sarcoma • Fibrosarcoma/ fibroma • MCT • Osteosarcoma • Seb.gland adenoma • SCC • trichoepithelioma Neoplasia chronic inflam. predispose • Metastasis rare from other locations • Primary often metastasize to chest and lymph nodes • Invasive into calvarium, soft tissue head, phayngeal region • Malignant tumors less aggressive in dog vs. cat • 10% are neurologic Foreign body removal • • • • plant awns Q-tips Medication Powder (hair removal) • Ticks • Etc. 35 Evaluation of tympanum • • • • Translucent Pale gray Striations Pars tensa (ventral): malleus seen dorsoventral/ free end has curve that points rostrally • Pars flaccida (dorsal): vascular Evaluation of tympanum • Pars flaccida needed for healing • P. flaccida may be edematous • Tympanum ruptured if air bubbles rise or fluid escapes from nose or oropharynx Tympanic cavity:spherical hollow petrous temporal bone • DORSAL: • auditory ossicles • chorda tympani nerve (VII branch) • eustachian tube opening (drains bulla) • Sympathetic innervation of eye • VENTRAL: • Fundus/ tympanic bullae • Diameter 3-4 times that of canal • Site of culture and sensitivity from bulla Regional Innervation • Sympathetic innervation of the eye: miosis, ptosis, enopthalmos, protrusion 3rd eyelid (Horner’s) • Facial nerve (VII): dimished menace, palpebral reflex, drooling, inability to close eyelid, loss of innervation of lacrimal gland(KCS), droop of lip & ear 36 False middle ear and cholesteatoma • Invaginated tympanum into bulla due to pressure • Collects keratin, wax, desquamated cells • Hyperproliferative epithelial tissue from the tympanum migrates into the bulla and forms cyst that grows • Rare (11%) Myringotomy: indications • • • • Recurrent disease Resistant disease Neurologic signs Abnormal tympanum • PSOM: primary secretory otitis media ( CKCS) Tympanum pressure Primary Secretory Otitis Media PSOM or “glue ear” • Normal: withstand • Intact ear drum does pressure of 300mm NOT rule out otitis Hg media (intact in 70% of dogs with OM in • Inflammed ear: only one study) 80mm Hg (weakened by • May have ruptured proteolytic enzymes) and healed trapping bacteria • normal eustachian • Blocked tube : air in tube maintains middle ear equal air pressure absorbed, change in inside and out of pressure gradient, middle ear to allow mucous collects in ear drum to vibrate middle ear and and allows drainage causes mucous plug of fluid from ear to nose 37 PSOM: CKCS & brachycephalic breeds • Pain/ guarding of the neck • Yawning • Facial pruritus • Ataxia, facial paralysis, hearing loss, seizures, fatigue • Symptoms similar to syringomyelia and progressive hereditary deafness • BAER test • Myringotomy/repeat • Tympanostomy tubes Myringotomy • Rigid polypropylene catheter @ 60 degree sharp angle • 5 or 7 o’clock site • Aspirate for C/S • warm saline flush • Direct catheter tip ventrally Myringotomy: complications • • • • • Miosis Ptosis Enopthalmos Decreased menace Decreased palpebral reflex • KCS • • • • Drooping lip/ eyelid Head tilt Nausea **rarely see complications yet always warn owner (signed consent) Healing of the tympanum • Small tear with Pars flaccida intact; 2-3 weeks • Large tear or scar tissue; may never heal….ok • Owners ALWAYS concerned 38 Infections: OE & OM cytology ID and C/S • Cytology each case/ each visit • look for bacteria type, yeast, inflammatory cells, etc. • Culture if rods, poor response to tx, recurrent disease • Sample from horizontal canal or bulla (stop meds 72hr. prior) • Increased incidence of MRS Cleansing agents goal • Remove trapped debri • Help normalize skin turnover • Decrease inflammation • Aid medications • Wait to start 1 wk after myringotomy Therapy triad cleanser, oral, topical • Numerous cleansers on the market • Specific oral therapy • Organism specific topical vs. broad spectrum (0.5-2mls of med needed to reach horizontal canal) • • • • • Ceruminolytic Drying agents Antibacterial Disinfectant Enzymatic Malassezia protocol cleansers • • • • • • • EpiOtic Advanced Malacetic Alocetic otic vinegar/water(50:50) Adams PanOtic T8 keto flush TrizUltra + keto 39 Malassezia protocol topical therapy • Miconazole 1% (Conofite) • Clotrimazole 1% (Lotrimin) • Nystatin • Terbinafine 1% (Lamisil) • Synotic: DMSO & betamethasone Topical steroids • • • • Anti-pruritic Anti-inflammatory Decrease exudation Decrease proliferation and scaring • Promote drainage and ventilation Topical steroids • MOST POTENT • Mometamax (Scherring) • Synotic (Fort Dodge) • Gentocin otic (Scherring) • Otomax (Scherring) • MODERATE • Panalog(FortDodge) • Tresaderm (Merial) • adrenal suppression Malassezia protocol oral therapy • Ketoconazole @ 5-10mg/kg/day • Itraconazole @ 5mg/kg/day • Fluconazole @ 5mg/kg/day • Terbinafine @ 15-30mg/kg/day 40 Staphylococcus sp. cleansers • EpiOtic (Virbac) • Malacetic (Dermapet) • Oticlens (Pfizer) • Oticalm (DVM) • Etc. Staphylococcus sp. topical • • • • Mupirocin slurry CiproHC Floxin (ofloxacin) Otobioic Staphylococcus sp. oral therapy Horizontal Antibiotics tested (Cole & canal % susceptible Kwochka) isolates Middle ear % susceptible isolates Cephalexin Clavamox Enrofloxacin TrimethroprimSulfa 92.9% 100% 85.7% 35.7% 77.8% 100% 96.3% 51.9% Antibiotic choices • Remember MICs do not reflect levels in the ear canal rather serum • MIC helpful but not absolute for either oral or topical choice • Often need high end of dose range for antibiotic when treating OE/OM 41 Pseudomonas sp. Topical *challenge Methicillin Resistant Staph. • MRSA, MRSS, MRSI (MRSP) • Often best choice: chloramphenicol • Other options: erythromycin, azithromycin Pseudomonas sp. cleansers • T-8 cleanser • TrizEDTA • changes permeability of bacterial cell wall by inactivating the “efflux pump” which removes antibiotics from bacteria (needs 5 minutes of exposure) • • • • • • • enrofloxacin Amikacin Imipenem Ticarcillin Polymyxin Tobramycin Silver sulfadiazine • Formulated products last for approx. one week • Expensive $$ • Often can freeze to extend activity • Many inactivated by debri Fluoroquinolones suscep. 2006 study: 15 isolates • Enrofloxacin 0/15 (0%) • Marbofloxacin 5/15 (33.3%) • Ciprofloxacin 9/15 (60%) • Increased incidence of resistance • Increased MRS in cases treated with fluoroquinolones 42 Pseudomonas 2003 study-44 cases sucess • • • • • • Ceftazidime 100% Ticarcillin 96% Imipenem 92% Polymyxin 88% Amikacin 79% Gentamicin 72% • • • • Carbenicillin 70% Ciprofloxacin 58% Cefotaxime 48% Enrofloxacin 17% (another study showed 12.5% horizontal canal/35% middle ear) Pseudomonas systemic therapy • Use the high end of the rec. dose range • Often need to use C/S meds as injectable subQ • Owners can give subQ meds at home for 2-3 weeks • Remember to check for change in cytology or sensitivity • Need oral steroids to help with swelling Factors for success: prognosis • • • • degree of stenosis degree fibrosis mineralization neurologic status Factors for success: owner • Mean time for resolution of chronic OM in 44 dogs 117+/- 86.7 days (range of 30-360 days) • Owner part of decision process- very time consuming • Compliance of owner • Pet cooperation 43 Factors for success: re-ck • Frequent re-check appointments • Repeat anesthetic procedures • Alter tx plan with each visit if needed Factors for success: sx • Otitis media is ALWAYS a surgical disease • Do not attempt to treat with debri in the canal • Discuss surgical options: videootoscopy, myringotomy, TECA, bulla osteotomy on day 1 Factors : home flushing • • • • • No Q-tips Bulb syringes Roll cotton Caution with hair removal Twice weekly unless TrizEDTA which may be daily Factors: underlying etiology • Complete physical exam • Look for underlying disease or predisposing factors • Neurologic exam • Complete blood screen (also as preanesthetic screen) 44 Factors for success: pain mangement • Tramadol • Metacam • Fentanyl patch Owners primary concerns: • Integrity of tympanum: some only heal partially and leave ring of granulation tissue • Deaf? Conduction vs. sensory deafness (BAER electrodiagnostic testing) Prospective study (Int.J. Ped. Otorhinolaryngology 2008) • 89 patients: 52 children, 37 adults • Middle ear effusion that required repeated myringotomy/ tubes • IDST: dust , animals, molds, pollens • Asthma and rhinitis in 63% • Otitis ONLY symptom in 37% • Vaccine100% resolution in 85% patients and partial improvement in 5.5% • 21 control patients refused tx- 0% improved
