C09995240 / invoice 10000

New client in today for chat regarding ongoing ear infections.
Recurrent issue since early 2024, always seems to be worse in L ear, R only occasionally.
Has had mix of PMP, baytril, oral prednisolone.
Has been maintained on topical elocon 0.5ml once weekly.
Diet: Lyka, mix of beef, chicken and kangaroo (O switched from kibble to this when had gut issues).
Previous medical issues: recurrent ocular infections (now resolved), broken digit (healed), recurrent AG expression (now managed to stretch to every 7wks).
No change to environment around time ears started (no new plants, did not move house etc.)
O did notice improvement (increased interval between ear infections) when started oral probiotic mid last year, since stopped but O has now re-started this in the last few days.
Seen at Drovers on 13 Feb for vaccine, ears checked then and no infection present, O then went away and when got back L ear inflamed and sore again. O had PMP so commenced cleaning and PMP, has been on for 9 days and no improvement, still copious amounts of creamy discharge. O has not cleaned or used PMP since yesterday.
O does not feel that Maisie is an overtly allergic/itchy dog, occasional scratching but no more than a 'normal/non-allergic' dog.
Used to be a big swimmer but has not swam since January.
No current medications.

PE:
Mentation: BAR
BCS: 5/9
EENT: L vertical ear canal inflamed, +++ creamy discharge filling canal, R canal clean and no inflammation, TM intact.
Teeth: + tartar on UPM4s, otherwise clean
MM: pink, moist, CRT 1.5sec
LNs: all WNL
HR: 104
RR: 20 at rest, occasional pant
Abdomen: tense but comfortable on palpation
MSK: normal ambulation around consult.
Skin: no evidence of saliva staining, no evidence of infection.

Assessment:
Recurrent L otitis externa (cannot rule out media as cannot see TM).
R ear clean.
Discussed ongoing issue, O understandably concerned given ongoing issue, cost, Maisie's discomfort given 2yr issue.
Discussed causes of recurrent ear infections, likely underlying allergy causing irritation that is then allowing for overgrowth bacteria and yeast. Given speed of recurrence do query whether resistant bacteria is present that is not fully being resolved with each treatment.
Discussed diet, O saw no improvement in ears with diet change.
Discussed that structural abnormalities can play a role.
Discussed functional abnormalities (i.e., failure of natural cleaning).

Ideally need C&S to allow for appropriate topical treatment, then adequate length of Tx with this med, then C&S to ensure infection resolved.
Discussed allergy management, had 1x cytopoint previously to see if this would help, no response, has had preds in past, these work but not ideal long term give side effects.
Advised to trial apoquel, not specifically designed for ears but if underlying allergy playing a role then anti-inflammatory component may help.
Advised dermatology may be best option given chronicity (definitely look at referring if no response to new plan).

Plan:
Swab for C&S of L ear collected.
Apoquel as per label.
O to stop PMP.
O to clean ear with otoflush BID until results back.
O to not use elocon until infection resolved.

Vet notes requested from Drovers vet