Better medicine, better business: Otitis externa

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Otitis externa is a very common problem in companion animals. In most cases, the condition is caused by bacteria, ear mites, or Malassezia pachydermatis. Unless it is causing pain or severe inflammation or is caused by a mixed bacterial infection, a single acute episode of otitis externa likely does not require an extensive workup. More chronic cases require extra attention and a prudent search for an underlying etiology, such as atopy, food allergy, or hypothyroidism.

There are multiple options for managing a case of chronic otitis externa. Following are 2 options for managing these cases. (Certainly, there are more options than these, but to keep things simple, we present only 2.) The first option is what I consider minimal care for the patient, the kind of care that unfortunately is very common across our profession. The second option is what I consider the best practice—the platinum standard—one we all hope to achieve.

I understand that the platinum option may not work for every client in every practice, but the goal here is to encourage you to review what you currently do and consider whether there is room for improvement. At least some clients will accept the platinum standard in most practices. Having worked in many practices prior to opening my own hospital, I have seen this level of care offered across the income spectrum. Finally, the prices quoted here are typical of practices in my locale; the prices near you may differ.

Figure 1.

Comparing the basics vs the platinum standard

The basic approach is pretty simple. The ears appear infected, cytology may or may not be done to correctly identify the type of infection (if any), and some generic medication is dispensed with hopes that the ears will improve in 1 to 2 weeks.

The platinum approach understands that a correct diagnosis is crucial in guiding the proper treatment. Also, for chronic cases of otitis, we know that an underlying cause such as atopy, food intolerance, hypothyroidism, or some type of immune suppression that can occur with adrenal disease or diabetes may be present and must be treated if the ears are ever to improve. Finding and treating that etiology is important to cure these chronic cases of otitis. Cytology guides our treatment and helps us determine whether a culture is needed (often I routinely culture chronic cases of otitis regardless of cytological findings, but always when bacteria with or without white blood cells are seen.)

For treatment to be most effective, and if the owners are expected to treat the ears at home, a medicated ear flush is vital. Because otitis, especially chronic otitis or acute otitis with severe inflammation is painful for the pet, sedation or anesthesia (with pre-sedation EKG) is a must. To minimize the need for owner compliance, it is preferable to treat the ears in the hospital with some type of infusion (guided by cytology). To reduce inflammation and pain, and to address the underlying cause (if allergies are suspected), an anti-inflammatory injection of a short-acting corticosteroid can be administered. A follow-up exam in 7 to 10 days (with repeated cytology, flushing, and treatment) is also needed (but not included in this initial estimate.)

The platinum plan offers the best medical care for the patient, reduces noncompliance with messy and often painful ear treatment at home, and increases practice revenue. Additionally, client handouts reinforce your prescribed diagnostic and treatment plan. We have prepared several handouts with our standard diagnostic/treatment plans. The technician gives these to the owner to review before an official treatment plan and costs are presented. This better prepares owners for the actual plan and costs, thus improving client compliance.

Owners who are unable or unwilling to accept the platinum plan can always choose the basic plan and upgrade if and when that plan fails to give an acceptable resolution. Regardless of their preferred treatment plan, a progress evaluation is a must to document the case and intervene with additional treatment if needed.

Shawn P. Messonnier, DVM, owns Paws & Claws Holistic Animal Hospital in Plano, Texas, and serves on the dvm360 Editorial Advisory Board. He has written multiple books on marketing as well as holistic veterinary medicine.