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October 2007
7 Steps to Ear Therapy
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Table of Contents
Lou Gotthelf's Small Animal Ear Diseases
7 Steps to Ear Therapy
(PDF Version)
Gemish 1/Anti-Inflammatory
Where MalAcetic® HC is available, use it. If not available or where a stronger
product might be desired:
To a 4 ounce bottle of a TrizEDTA™ or MalAcetic® product (if mixed infection
use TrizULTRA+KET) add 40 mg of dexamethasone (sodium phosphate for solubility).
a. Some people add medical grade DMSO.
b. Some people add ivermectin for a topical treatment.
Gemish 2/Anti-Bacterial (Pseudomonas)
To a 4 ounce bottle of a TrizEDTA™ product, add 12 ml of LA Baytril or 1200
mg of another antibiotic (i.e., marbofloxin, amikacin, gentocin). Fill the ear
canal/BID/ for at least 30-180 days.
Step 1
Using MalAcetic® Otic, clean the ear thoroughly (see instructions) daily for
7-14 days (Gotthelf, L. and Young, S.: A New Treatment for Canine Otitis Externa:
Vet Forum, August, 1997, Bassett et al, Aus Vet Jour, 2004). In many cases,
daily cleansing for one week is all that is necessary. Maintenance cleansing
twice weekly should prevent a recurrence. If cutaneous Malassezia is not suspected
then use MalAcetic® products topically (i.e. shampoo, conditioner, or wet wipes
- see shampoo therapy) or, for more difficult cases, Mal-A-Ket Shampoo or Wipes.
How to clean an ear:
Apply approximately one (1) teaspoon (5 ml) of the ear skin cleanser into the
ear canal and massage thoroughly. Some people occlude the canal with a small
amount of cotton during this process to protect against drenching should the
pet shake its head. For maximum benefit, allow the solution to remain for at
least five minutes before attempting to manually clean. Clean the ear by stuffing
wads or balls of cotton in the ear and massaging so the debris sticks to the
cotton. An applicator stick may be of assistance where repetitive cleaning is
required. In dry and/or irritated ears with little debris and/or wax, the cotton
may become irritating. In these cases, a tiny bulb or a water pick can be helpful.
Be sure to wipe the pinna. In problem ears, the frequency of this process may
be increased to one (1) to three (3) times daily. Should medication be necessary,
apply after cleaning. A previously little known fact to remember is that with
most acidifying ear cleaners, the ear will be acidified and therefore may inactivate
some commonly used drugs like aminoglycosides (amikacin, gentamycin, neomycin).
In those cases, either waiting four hours or applying alkalinizing agents will
be of assistance. One alkalinizing agent that the literature reports to have
primary antimicrobial properties is TrizEDTA™ (TrizEDTA™ Aqueous or Crystals,
TrizPLUS with .15% chlorhexidine, TrizULTRA+KETO with .15% ketoconazole). To
use TrizEDTA™, one should follow the above instructions in how to clean an ear
only substituting the alkalinizing TrizEDTA™ solution. Repeating Steps 3 and
4 should then be more rewarding.
How to clean a very dirty ear:
Step 1
Apply approximately one (1) teaspoon (5 ml) of the Klearwax into the ear canal
and massage thoroughly. Add water or a cleansing substance like MalAcetic® or
TrizEDTA™ to achieve a foaming effect. Some use a positive pressure apparatus
like the Medrx Irrigator. Be sure to clean Klearwax out of the ear after using.
It may be best to use this in Step 3.
Step 2
1. Should there be inflammation or irritation due to the ear cleaning process
then use MalAcetic® HC.
2. This is the logical next step after cleansing and a "topical hydrocortisone"
such as the MalAcetic® HC fail to cause remission of signs. Follow Step 2 plus
add short term and short acting corticosteroids at anti-inflammatory doses.
After a couple of days use full strength MalAcetic® Otic.
Step 3
Step 3 plus ear cleansing under anesthesia.Visualization of the ruptured ear
drum or swollen tympanum should confirm otitis media. After careful and thorough
cleansing of the bulla and removal of "debris", infuse Baytril or appropriate
antibiotic and dexamethasone directly into the tympanum. In the case of a strangulated
canal, with a 1 1/2 inch 20 gauge needle, inject approximately ˝ ml of depomedrol
(depending on the size of the pet) as deep as you can between the skin and the
cartilage of the ear canal. If a corticosteroid injection is not done then,
if there is significant erythema or exudation, then place the dog on short term
(7-12 days) short acting high dose corticosteroids (1-2 mg/kg). At this stage,
some people do Culture Sensitivity.
Step 4
Step 3 plus Culture and Sensitivity.
Step 5 Protocol for Bacterial Otitis
The following treatment plan which is a modification of Step 3:
1. Flouroquinolone or start antibiotic (be specific if cultured) systemically
for at least 21 days. Recently experts decreased the importance of systemics
vs. topical antibiotics. When using high dose corticosteroids, it may be most
prudent to use systemic antibiotics.
2. Clean with TrizEDTA™ twice daily. Use TrizULTRA+KETO when a coexisting gram
negative and Malassezia infection exist.
3. Instill Baytril in either a TrizEDTA™ gemish or diluted with saline. When
using a TrizEDTA™ gemish, FILL the ear canals BID.
4. For the first 14 days, I would use systemic prednisone at 1-2 mg/kg if OM
is diagnosed. The rationale is to decrease the inflammation, mucous secretion
from the mucoperiosteum, pain and viscosity of the exudate in the tympanic cavity.
5. If OM is diagnosed, I would anesthetize and with visualization flush the
ear using KlearWax followed with a TrizEDTA™ product and directly instill Baytril
and NaDex phosphate into the tympanum. If the tympanum is present and OM is
suspected then I would do a myringontomy. The location of the myringotomy should
be ventral. Maintenance therapy would include biweekly TrizEDTA™ cleansing long-term.
Step 6 Maintenance
Clean the ear twice weekly with a TrizEDTA™ product and twice weekly with MalAcetic®
Otic. After no recurrence for 45 days then reduce to once weekly for each.
Step 7 Surgery
This is if Step 4 fails and/or calcification of the ear canal is evident, i.e.,
lateral ear canal resection, vertical ablation and total ear canal ablation
(TECA) and lateral bulla osteotomy.
o There is no simple method of diagnosing cutaneous Malassezia. Do a topical
treatment in cases where Malassezia otitis is confirmed by cytology.
o There are reports in the literature of primary microbiocidal properties of
TrizEDTA™, particularly to Pseudomonas. Those reports also indicate the evidence
for potentiation with antibiotics which otherwise are inactivated by other acidifying
ear cleansers. There are also reports of synergism when using chlorhexidine
and TrizEDTA™ (TrizPLUS) together. TrizULTRA+KETO™ with .15% ketoconazole is
designed for use against Malassezia where there is also a bacterial infection.
Proceedings, Commonwealth Vet Conference, Barbados 2007, © 2007 DermaPet Inc.
Dermatophytes
Lime-sulfur dips (LimePlus Dip) are the treatment of choice. The dip
should be preceeded with Mal-A-Ket Shampoo and, if focal areas, Mal-A-Ket
Wipes.
ACVC
This meeting has all the ingredients to succeed- excellent speakers, state of the art program, and geographically desirable location at a time of the year when people can attend. Yet, exhibitors have found the crowds diminished in the trade show hall and the most likely reason is the inconvenience of traveling from the hotel(s) by bus to the convention center adjacent to a non-casino hotel a good distance from the boardwalk. The success of the two biggest conferences in the US is largely attributed to the convenience of having the majority of the crowd staying at the host hotel.
SEVC, BARCELONA
The inaugural meeting was attended by 4,000 people from over 44countries despite rumblings from certain country associations that outspokenly felt this show was an intrusion. Still, many countries were pleased to attend to actually promote their meetings including Holland (Vorjaarsdagen) and Poland as well as the European School for Advanced Veterinary Studies. The exhibit hall had crowds of interested buyers the size of which brought memories of an early NAVC Conference. So many visited our booth that, after the first 2 hours on the opening day, we were forced to make copies of the ample handouts we brought. Of course, conference success is no stranger to NAVC Executive Director COLIN BURROWS and Conference Coordinator DAVID SENIOR who attended with a contingent of NAVC staff and board members (EARL RIPPIE, DON HARRIS, JORGE GUERRERO, DOUG MADERand more) as joint organizers of the conference.
The program and speakers were top notch. RALF MUELLER did otology and
derm. We made the acquaintance of Spanish dermatologists PILAR SAGREDO, ANN RIOS, CARMEN LARRAZABAL and MAR BARDAGGI. We were represented by VETNOVA, operated by EDUARDO and LOURDES de SANTOS, as well as having our own booth.
There was ample refreshment in the exhibit hall and entertainment in the evenings (Flamenco dancers, bands, food, wine) that lasted hours this old geezer found a little too late. ILAN SKORINSKY invited me to an Iams party that STARTED at 1130 PM on the final Saturday nite after the Gala Ball.
The Spanish wine, in my mind, remains the most under-rated and best value
in the world; very good bottles at restaurants sold for under $30 and sweet,
after dinner muscatel went for under $10/bottle. The weather was 63-73 F daily, the beach was in sight and for those who love seafood, it was both plentiful and reasonably priced. And this doesn't include waltzing down the Ramblas, sights, tapas bars, museums and joie de vie of the Spaniards.
All in all a great start to a much needed European Conference. The organizers assure me that next year will be even better.
See at our web site "Topical
Ketoconazole Antifungal Therapy" by LOU GOTTHELF, VPN, 8/07 (for a complete
unedited version go to www.dermapet.com)
Go to KetoFlyer6.pdf
Back to top
We will be at the:
- Muller meeting in Maui in the first week of November and
-Barbados, the 4th Pan Commonwealth Veterinary Conference, November 4-8 where LOU GOTTHELF and YT lecture.
Back to top
BOB MARSHALL handles the Northwest. Bob can be contacted at
bob.dermapet@sbcglobal.net, and 916-290-3557.
DOTTIE ASMUSSEN handles IL, IA, WI, MN, NE, KS, MO, ND, and SD. Dottie lives
in Hannibal, MO and can be reached at
dottie.asmussen@gmail.com or 573-406-8616.
ROB CONN handles the southern region of the West Coast. Rob can be reached at
818.585.0632 (Cell) or rob.dermapet@sbcglobal.net
Al LINGUA is in the NE from New Jersey north. Al can be reached at 860-810-7280
or ajlingua@aol.com.
JAY MAIDEN is our TM for the SE US (FL MS, AL, TN, KY) . Jay can be reached
at 727-560-2325 or jaymaiden@verizonmail.com
.
The "old work-horse" CHUCK MICHAELS fencepostcharlie@yahoo.com or 240-447-7248,
works the Middle eastern US, PA, WV, DC, MD, VA and DE.
PATRICK RAYBURN (SW TM) ducks2003@suddenlink.net
or 817-559-7878, continues to ride with distributor reps.
All our sales are guided by the capable JACK WHITE jag6410@aol.com
or call 866-3376 or 866-DERMAPET.
For the TM nearest you please email, look at our web site or call us.
4th Quarter 2007 Specials - Buy any 3
cases of shampoo and get a case of TrizUltra+KETO 4oz Free.
Call your DermaPet Distributor or 800 755 4738 for ordering information.
TECHNICAL BULLETINS are at our web site.
Previously, we showed how our LIME PLUS Dip has 29% more lime sulfur than the new LymDip. The new LymDip is a much weaker formula that has not survived the test of time (neither for efficacy or stability). Despite their citing literature, there is not one refereed publication supporting the use of this substantially diluted product. There also is reason to believe that fragrances used in this product (the addition of which required the dilution from a 97.8% like LimePlus to 76.9% in LymDip) will cause contact irritation/dermatitis.
Lou Gotthelf's Small Animal Ear Diseases
Lou Gotthelf's Small Animal Ear Diseases 2nd Ed is out. There is a chapter by YT as well as many others. At $64.95 this is a great deal considering all the color photos and the fact that ears represent up to 20% of your business.
MedRx is offering CE with EAR Seminars
by LOU GOTTHELF. For more information call 888-392-1234
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