Vet Dermatol 2014; 25: 530–e92

DOI: 10.1111/vde.12163

A pilot study to develop an objective clinical score for canine otitis externa Tim Nuttall* and Emmanuel Bensignor† *The Royal (Dick) School of Veterinary Studies, Easter Bush Veterinary Centre, University of Edinburgh, Roslin, EH25 9RG, UK †Veterinary Dermatology Referral Service, Paris, 75003, France Correspondence: Tim Nuttall, The Royal (Dick) School of Veterinary Studies, Easter Bush Veterinary Centre, University of Edinburgh, Roslin EH25 9RG, UK. E-mail: [email protected]

Background – The lack of an accepted clinical scoring system in canine otitis externa makes it difficult to compare clinical trials. Hypothesis/Objectives – To develop a score that is clinically relevant, reliable and sensitive to change. Animals – Client-owned healthy dogs (n = 55) and dogs with otitis externa (n = 60). Methods – We compared 0–3 and 0–5 assessments of erythema, oedema/swelling, erosion/ulceration, exudate and pain of the ear canals with a reference 0–2 scale. Additional data included odour, pruritus scores, tympanic membrane condition, treatment outcome and neutrophil, bacterial and Malassezia counts. Results – There were no significant differences between the vertical and horizontal canal scores (correlation coefficients >0.93). Correlation coefficients for the 0–3 and 0–5 scales were also >0.9 for all parameters, but the 0–2 scale was more variable. Pain and pruritus did not correlate well with the lesion scores and were associated with suppurative and erythroceruminous otitis, respectively. Neutrophil and microbial counts were variable and could not be used to generate cut-off values to differentiate healthy and affected ears or determine the response to therapy. Total scores ≥4 differentiated affected from healthy ears with 91.1% sensitivity and 100% specificity; scores ≤3 were 100% sensitive and 91.9% specific for clinical success. The intra- and interobserver reliability was high (intraclass correlation coefficients >0.95 and Cohen’s kappa coefficients >0.65). Conclusions and clinical importance – This pilot study showed that the 0–3 Otitis Index Score (OTIS3) for erythema, oedema/swelling, erosion/ulceration and exudate is suitable for further validation by a larger group of clinicians.

Introduction The lack of an accepted clinical scoring system in canine otitis externa makes it difficult to compare clinical trials. This was highlighted by an evidence-based review of treatment for Pseudomonas otitis that could not recommend for or against any therapeutic interventions.1 Published clinical trials have used a variety of different inclusion criteria and outcome measures, including quantitative or semi-quantitative assessments of erythema, pain, pruritus, swelling, ulceration, odour and discharge, as well as cytology and culture.2–10 To the best of our knowledge, these scores were not internally or externally validated. Outcome measures have used a variety of statistical analyses of the changes in clinical scores, cytology and culture following treatment, with and without subjective assessments of clinical success or failure. The former are more objective, but may not reflect the success or

Accepted 7 June 2014 Sources of Funding: This study was funded in part by Novartis Animal Health. Conflict of Interest: Both authors have received other unrelated consultancy fees, lecture fees and research funding from Novartis Animal Health. 530

otherwise of treatment. The latter may better reflect the response to treatment but preclude comparison between trials. Moreover, interobserver reliability of clinical scores was reported in only one trial.6 There is therefore a need for validated inclusion criteria and outcome measures that can objectively and accurately reflect the efficacy of tested interventions for otitis externa. Since 1997, objective lesion scores for canine atopic dermatitis (AD) have been developed and evaluated.11,12 The International Task Force on Canine AD [now the International Committee on Allergic Diseases of Animals (ICADA)] established the fourth version of the Canine Atopic Dermatitis Extent and Severity Index (CADESI-4) in 2014.13 The CADESI-4 assesses erythema, lichenification, and alopecia/excoriations over 20 body regions on a 0–3 severity scale. This scale was shown to have acceptable content, construct, criterion, inter- and intra-observer reliability and sensitivity to change. Cut-off scores for dogs with mild, moderate and severe AD or disease in remission have also been established. More recently, a pruritus score combining a visual analog scale (VAS) with grade descriptors was validated.14 These outcome measures are now recommended for clinical trials of therapeutic interventions for canine AD.13 The use of accepted outcome measures has greatly facilitated evidence-based medicine in canine AD. Such scales have been validated © 2014 ESVD and ACVD, Veterinary Dermatology, 25, 530–e92.

Otitis clinical score

for feline allergic diseases (SCORFAD)15 and are under development for other dermatoses (e.g. MalDESI for Malassezia dermatitis). The aim of this pilot study was to develop and initially assess a clinical score for canine otitis externa that is clinically relevant, has good inter- and intraobserver reliability, is sensitive to change and able to distinguish affected ears from healthy ears or ears in remission. We therefore evaluated affected and healthy ears to select the criteria that best described the disease, established a proper measurement of the severity by testing different scales and assessed the relevance of the selected outcome measures. Cytology in particular has been frequently used for inclusion and the assessment of the clinical response,2,3,5,7,9,10 and we sought to correlate cytological findings with clinical scores and outcomes.

Table 1. Clinical assessments and clinical scores used in the study

Materials and methods

The proposed Otitis Index Scores (OTIS) used 0–3 (OTIS3) and 0–5 (OTIS5) assessments of clinical parameters derived from previously published studies.2–10 The US2 score was included as a reference scale; it is a clinical scoring system for otitis externa required by the US Food and Drug Administration for regulatory purposes. The vertical (VC) and horizontal ear canals (HC) were scored separately with the EU3 and EU5 scales, and one score was recorded for the US2 scale. Where appropriate, the scores were ranked from 0 (= none) to the most severe score (2, 3 or 5) in each case. The visual analog scales (VAS) were 10 cm horizontal lines marked with either ‘not itchy’ or ‘not painful’ at the left edge and either ‘very itchy all the time’ or ‘extremely painful’ at the right edge; the owners were asked to place a short vertical line at the point they believed was the best indication of the severity of the parameter over the preceding 24 h. Abbreviation: n.d., not determined.

Dogs were recruited and assessed at two independent referral centres by the authors. Healthy dogs were presented to other clinicians at the centres for nondermatological reasons and had no clinical signs or history of skin conditions or otitis. Affected dogs had to have been presented to the attending clinician with otitis in at least one ear. The attending clinician divided these cases into erythroceruminous or suppurative otitis based on the clinical signs and type of exudate at presentation. The tympanic membrane had to be sufficiently visible to determine its status, but there were otherwise no restrictions on the severity of the clinical signs and amount or type of exudate. Cytology was performed by collecting a small amount of exudate from the junction of the vertical and horizontal ear canals and making a thin smear on a glass slide. The cytological preparations were airdried before staining using a modified Wright–Giemsa stain with five to 10 dips for ~1 s each time. The stained slides were rinsed with water, allowed to dry and inspected under 91000 magnification. The mean numbers of micro-organisms and cells in five random fields were recorded (from 0 to a maximum of 100). All the dogs with otitis were given appropriate treatment by the attending clinician. Clinical assessments and cytology were performed at visit 1 for both healthy and affected dogs, and again at visit 2 for the affected dogs. The date of visit 2 was determined by therapeutic need. The clinical assessments and scores are described in Table 1. The Otitis Index Score (OTIS) scales were designed to assess the severity of the otitis and the response to therapy. They included 0–3 (OTIS3) and 0–5 (OTIS5) assessments of clinical parameters derived by the authors from their clinical experience and previously published studies.2–10 The US2 score was included as a reference scale because it is a clinical scoring system for otitis externa used by the US Food and Drug Administration when evaluating veterinary products for regulatory purposes. The global response to treatment was subjectively assessed as ‘success’ or ‘no success’ by the attending clinician. An image atlas and grade descriptors were used to train all the observers in the study. A further 10 healthy (20 ears) and 10 affected dogs (20 ears) were assessed by two observers at one centre using the OTIS3 clinical scores for erythema, oedema/swelling, erosion/ulceration and exudate. The observers initially graded the otitis subjectively as none, mild, moderate or severe. The main observer assessed each ear at presentation and again between 3 and 4 h later. The second observer assessed the ears within 90 min of the first observation. All the assessments were blinded. The second observer was not specifically trained using the image atlas. The statistical analyses were performed using SASâ software version 9.1.3 (SAS Institute Inc., Cary, NC, USA) and SPSSâ version 20 (IBM UK Ltd, Portsmouth, UK). Pearson product–moment correlation coefficients were calculated to give the r value for the appropriate data sets. Receiver operating characteristic curves were used to

© 2014 ESVD and ACVD, Veterinary Dermatology, 25, 530–e92.

Clinical scores Clinical parameter Erythema Oedema/swelling Erosion/ulceration Exudate Pain Odour Pain (owner score) Pruritus (owner score) Abnormal tympanic membrane Successful treatment Type of otitis

VC HC VC HC VC HC VC HC

OTIS3

OTIS5

US2

0-3 0-3 0-3 0-3 0-3 0-3 0-3 0-3 0-3 n.d. VAS VAS Yes/no

0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 n.d.

0-2 0-2 0-2 0-2 0-2 0-2

Yes/no Erythroceruminous/suppurative

establish cut-off scores for inclusion and defining clinical success for the clinical scores and for the bacterial, Malassezia and neutrophil counts. Intraclass correlation coefficients were used to assess the reliability of the clinical scores from observers 1 and 2, as well as the correlation between the clinical scores and subjective assessment of severity. Cohen’s kappa coefficient was used to assess how reliably observers 1 and 2 differentiated healthy and affected ears. Cronbach alpha values were used to test the internal consistency of the OTIS3 scale.

Results Data from 45 healthy ears (from 20 healthy dogs and five healthy ears from dogs with unilateral otitis) and 90 affected ears (from 50 dogs with otitis) were collected at visit 1. Erythroceruminous otitis was present in 76 ears and suppurative otitis in 14 ears. Four dogs with bilateral otitis were lost to follow-up, and 82 affected ears were evaluated at visit 2. At visit 2, treatment was classed as successful in 74 ears (66 with erythroceruminous otitis and eight with suppurative otitis) and not successful in eight ears (two with erythroceruminous otitis and six with suppurative otitis). The clinical scores for the healthy ears and the affected ears at visit 1, visit 2 success and visit 2 no success are summarized in Table 2. There were no significant differences in any of the data sets between the two populations of dogs at the two centres and therefore the data sets were combined into one set for further analysis. 531

532

0.73 (0.54) 0.29 (0.46) 0 0 0 0 0.71 (0.69) 0.29 (0.51) n.d. 0

OTIS5

0.09 (0.29) 0

0.60 (0.50)

0

0

0.69 (0.47)

US2 2.16 (0.67) 1.99 (0.63) 1.58 (0.72) 1.32 (0.68) 0.33 (0.72) 0.29 (0.71) 1.79 (0.59) 1.39 (0.77) n.d. 0.42 (0.76) 17.84 (29.09) 56.72 (24.63) 23.0 (31.24) 11.92 (17.46) 9.9 (28.49)

OTIS3

Visit 1

Affected ears

3.18 (0.99) 2.86 (1.02) 2.11 (1.15) 1.71 (1.12) 0.50 (1.13) 0.43 (1.11) 2.51 (0.97) 1.94 (1.19) n.d. 0.60 (1.17)

OTIS5

0.81 (0.73) 0.37 (0.68)

1.59 (0.49)

0.28 (0.64)

1.03 (0.35)

1.82 (0.38)

US2 0.89 (0.59) 0.77 (0.61) 0.34 (0.53) 0.19 (0.46) 0 0 0.53 (0.50) 0.12 (0.33) n.d. 0.04 (0.20) 2.47 (3.62) 12.5 (9.26) 3.01 (3.46) 2.82 (2.83) 0.08 (0.52)

OTIS3

Visit 2 success

1.05 (0.77) 0.86 (0.75) 0.42 (0.70) 0.20 (0.50) 0 0.03 (0.23) 0.61 (0.68) 0.19 (0.51) n.d. 0.04 (0.20)

OTIS5

0.07 (0.25) 0.04 (0.20)

0.50 (0.53)

0

0.31 (0.47)

1.32 (0.81)

US2

1.75 (0.46) 1.63 (0.52) 1.75 (0.71) 1.50 (0.53) 0.75 (0.71) 0.75 (0.71) 1.63 (0.52) 1.63 (0.52) n.d. 0.88 (0.35) 21.25 (12.02) 24.63 (21.14) 42.13 (48.07) 3.75 (9.82) 39.88 (49.82)

OTIS3

2.50 (0.76) 2.00 (0.76) 2.13 (1.13) 1.63 (0.52) 1.13 (1.13) 1.13 (0.99) 2.38 (0.74) 2.00 (0.76) n.d. 1.25 (0.71)

OTIS5

Visit 2 no success

0.88 (0.83) 0.75 (0.46)

1.50 (0.53)

0.63 (0.52)

1.13 (0.35)

1.75 (0.46)

US2

Abbreviations: HC, horizontal ear canal; n.d., not determined; OTIS3, 0–3 scales; OTIS5, 0–5 scales; US2, 0–2 scales; VAS, 0–10 cm visual analog scale; and VC, vertical ear canal. Bacteria, Malassezia and neutrophil counts were the mean of the number/five 91000 magnification fields (range 0 to a maximum of 100).

Odour Pain Pain (VAS) Pruritus (VAS) Bacteria Malassezia Neutrophils

Exudate

Erosion/ulceration

Oedema/swelling

0.67 (0.48) 0.29 (0.46) 0 0 0 0 0.67 (0.60) 0.33 (0.52) n.d. 0 1.73 (2.27) 7.13 (12.49) 5.24 (5.65) 1.64 (1.38) 0

Erythema

HC VC HC VC HC VC HC VC

OTIS3

Clinical parameter

Healthy ears

Table 2. Mean (SD) values for the clinical parameters assessed in this study

Nuttall and Bensignor

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Internal validity of the Otitis Index Score Horizontal and vertical ear canal scores The correlation coefficients were r ≥ 0.93 for all clinical parameters (i.e. erythema, oedema/swelling, erosion/ ulceration and discharge) assessed in both the vertical and horizontal canals at each time point for the OTIS3 and OTIS5 scales. This suggests that the vertical and horizontal ear canal scores were highly correlated and nondiscriminatory. The two scores were therefore combined into one total ear canal score using the mean of the two ear canal scores for further analysis. Correlation between the OTIS3 and OTIS5 scales The distribution of the total clinical scores (i.e. the total of the scores for erythema, oedema/swelling, erosion/ulceration and discharge) using the OTIS3 (i.e. total score from 0 to 12) and OTIS5 scales (i.e. total score from 0 to 20) at visits 1 and 2 are illustrated in Figure 1a,b. The OTIS3 total score was highly correlated with that of OTIS5 (r = 0.97). Correlation of the individual clinical scores with the total clinical scores using the OTIS3 and OTIS5 scales The clinical scores for erythema, oedema/swelling and exudate showed the best correlation with the total clinical scores. The correlation coefficients were r = 0.93 for all three parameters with the total OTIS3 ear canal score; with the OTIS5 total score the results were r = 0.91 for erythema and oedema/swelling and r = 0.94 for exudate. The scores for erosion/ulceration were less well correlated with the total ear canal scores (OTIS3 score r = 0.58 and OTIS5 r = 0.41), because this clinical sign was largely restricted to suppurative otitis and absent in most cases of erythroceruminous otitis. These figures were superior to the reference US2 score, where the total score was less well correlated with the clinical parameters (r = 0.73 for erythema, r = 0.82 for oedema/swelling, r = 0.85 for exudate and r = 0.68 for erosion/ulceration).

(a)

20

Correlation of the state of the tympanic membrane with the total clinical scores using the OTIS3 and OTIS5 scales The assessment of the tympanic membrane was missing for two affected ears at visit 1. The tympanic membrane was assessed as abnormal in none of 45 healthy ears, 25 of 88 affected ears at visit 1, three of 74 ears with a successful outcome at visit 2 and three of eight ears with no success at visit 2. The low frequency of abnormal tympanic membranes resulted in low correlations with OTIS3 (r = 0.55) and OTIS5 (r = 0.58). This parameter did not adequately differentiate healthy from affected ears or identify clinical success. External validity of the Otitis Index Score The distribution of the total scores using the OTIS3, OTIS5 and US2 scales at visits 1 and 2 are illustrated in Figure 1a–c. The OTIS3 and OTIS5 total scores were highly correlated with the total scores using the reference US2 scale (r = 0.92). Validation of the Otitis Index Score The OTIS3 and OTIS5 scores showed strong negative correlations with healthy and successfully treated ears (r = 0.82 and r = 0.79, respectively), indicating that they reliably differentiated cases of otitis. This correlation was less strong with the reference US2 scale (r = 0.74). The OTIS3 scale was selected for further analysis because it was at least as reliable but simpler to use than the OTIS5 scale.

(b)

18 16 14

US2 total score

12 11 10 9 8 7 6 5 4 3 2 1 0

OTIS5 total score

OTIS3 total score

Correlation of the pain and pruritus scores with the total clinical scores using the OTIS3 and OTIS5 scales The OTIS3 pain, OTIS5 pain and VAS pain scores were all highly correlated with each other (OTIS3 and OTIS5 r = 0.95; and VAS r = 0.84 with OTIS3 and r = 0.88 with OTIS5). However, these pain scores were only moder-

ately correlated with the total clinical scores using the OTIS3 (OTIS3 pain r = 0.56; OTIS5 pain r = 0.58; and VAS pain r = 0.54) and OTIS5 scales (OTIS3 pain r = 0.63; OTIS5 pain r = 0.61; and VAS pain r = 0.61). Pain was mostly seen in suppurative otitis with erosion and ulceration. The pruritus VAS score was only moderately correlated with the total clinical scores (OTIS3 r = 0.60; OTIS5 r = 0.62) and often persisted in cases with underlying pruritic dermatoses. The pain and pruritus scores did not adequately differentiate healthy from affected ears and identify clinical success. For example, pruritus scores were ≤14 mm in four of eight of ears not responding to treatment, but >14 mm in 27 of 74 successful cases. All successfully treated dogs had either no pain or only mild pain after treatment, but no pain was also noted in 66 of 90 affected ears at visit 1.

12 10 8 6 4 2 0

Affected ears visit 1 Affected ears; treatment not successful

Healthy ears visit 1 Affected ears; treatment successful

Affected ears visit 1 Affected ears; treatment not successful

Healthy ears visit 1 Affected ears; treatment successful

12 11 10 9 8 7 6 5 4 3 2 1 0

(c)

Affected ears visit 1 Affected ears; treatment not successful

Healthy ears visit 1 Affected ears; treatment successful

Figure 1. Scatterplots of the OTIS3 (a), OTIS5 (b) and US2 total ear canal clinical scores (c) for erythema, oedema/swelling, erosion/ulceration and exudate (and pain and odour for the US2 score) in affected and healthy ears. The plots group affected ears from visit 1 (n = 90) with visit 2 (no success; n = 8) and affected ears from visit 2 (success; n = 74) with healthy ears (n = 45) to illustrate how the data discriminate between the healthy and affected ears.

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Nuttall and Bensignor

Clinical cut-off scores for inclusion and determining clinical success using the OTIS3 scale The most reliable cut-off score for inclusion of dogs with otitis was found using a single ear canal score (i.e. one score incorporating assessment of both the vertical and horizontal ear canals) with the OTIS3 scale (Figure 1a). Clinical scores ≥4 differentiated affected ears from healthy ears at visit 1 with a sensitivity of 91.1% and specificity of 100%. This resulted in a correct classification rate of 94.1%, with all 45 healthy ears and 82 of 90 affected ears being identified correctly. Scores of ≤3 at visit 2 were 100% sensitive and 91.9% specific for clinical success. The correct classification rate was 92.7%, with all eight treatment failures being identified correctly, although six of 74 ears clinically assessed to have a successful outcome were classified as treatment failures using this score. The receiver operating characteristic curve was consistent with an excellent test, able to distinguish healthy and affected ears (Figure 2). Inter- and intra-observer reliability of the OTIS3 score The intraclass correlation coefficient for the two scores from observer 1 was 0.97 [95% confidence interval (CI) 0.94–0.98; P < 0.0001]. The intraclass correlation coefficients for the scores from observer 2 and observer 1 were 0.95 (95% CI 0.91–0.97; P < 0.0001) with observer 1’s first score and 0.96 (95% CI 0.93–0.98; P < 0.0001) with observer 1’s second score. The intraclass correlation coefficients for clinical scores and subjective assessments of the otitis (i.e. none, mild, moderate and severe) were 0.72 (95% CI 0.28–0.89; P = 0.004) and 0.71 (95% CI 0.27–0.81; P = 0.005) for observer 1, and 0.71 (95% CI 0.27–0.89; P = 0.005) for observer 2. The correlations between the two sets of 100 90

Sensitivity (true positive rate)

80 70 60 50 40 30

observers’ scores were 0.76 (95% CI 0.32–0.85; P = 0.001) and 0.77 (95% CI 0.39–0.91; P = 0.001) for observer 1’s OTIS3 scores and observer 2’s severity score; and 0.72 (95% CI 0.28–0.88; P = 0.003) and 0.69 (95% CI 0.23–0.79; P = 0.004) for observer 1’s severity scores and observer 2’s OTIS3 score. Using a score of ≥4 to differentiate healthy from affected ears, Cohen’s kappa coefficient was 0.65 (P < 0.0001) for the two scores from observer 1, 0.75 (P < 0.0001) between observer 2 and observer 1’s first score, and 0.9 (P < 0.0001) between observer 2 and observer 1’s second score. Cronbach alpha values for the three observations were 0.84–0.87, consistent with very good internal consistency. Neutrophil, bacterial and Malassezia counts Neutrophils were present in none of 45 healthy ears, 17 of 90 affected ears at visit 1, two of 74 ears with a successful outcome at visit 2, and seven of eight ears with no success at visit 2. Cytological evidence of bacteria and/or Malassezia was seen in 24 of 45 healthy ears, 88 of 90 affected ears at visit 1, 36 of 74 ears with a successful outcome at visit 2 and eight of eight ears with no success at visit 2. The bacterial and Malassezia counts displayed a continuous distribution, with most values 25 by the owners. In addition, pain scores were poorly correlated with the OTIS3 scores. The tympanic membrane was normal in all healthy dogs, but again the presence of an abnormal tympanic membrane did not adequately differentiate affected ears and clinical success. The presence of an abnormal tympanic membrane was most strongly associated with bacteria and neutrophil counts. Likewise, cytological counts of bacteria, Malassezia and neutrophils could not be used to identify affected dogs or clinical success reliably. The absence of neutrophils was 100% specific for healthy ears and a successful treatment outcome, but the sensitivity was poor because these cells were absent from the majority of affected ears at the first assessment. No neutrophils were noted in any of the healthy ears, as reported in another study.21 This was also true of most dogs following successful treatment, although occasional neutrophils were still seen in two dogs. Both dogs, however, were assessed as treatment failures using the OTIS3 scores. The reasons for the discrepancy are unclear; it is possible that they were incorrectly assessed, the neutrophils were not clinically relevant and/or they were associated with persistent inflammatory changes. Clinical remission in otitis may not equate to healthy ear status if there are chronic inflammatory changes or ongoing underlying conditions. It is important to realize that the aim of our study was to define a set of clinical features suitable for assessment and comparison of clinical trials in canine otitis externa. Our study does not imply that pain, pruritus and abnormalities of the tympanic membrane are unimportant, because pain and pruritus should be assessed and managed in individual cases. Likewise, cytological evaluation of the exudate is important in determining the type of otitis and likely organisms and in monitoring the response to treatment. In conclusion, this study identified a scale assessing erythema, oedema/swelling, erosion/ulceration and exudate of both the vertical and horizontal ear canals from 0 to 3 to give a total score of 0–12 (OTIS3) that appeared to have acceptable content, construct, criterion and reliability. This scale could be used to evaluate clinical outcomes in canine otitis externa, which would facilitate comparison of outcomes. However, further validation and fine-tuning among larger cohorts of cases by more clinicians at multiple centres is required. This would confirm that the content, construct, criterion and reliability are fit for purpose.

Acknowledgements The authors are grateful to Wolfgang Seewald of Novartis Animal Health for assistance with the statistical analysis and interpretation of the results and to Cindy Speranza and Jean Steffan of Novartis Animal Health for reviewing the study and the manuscript.

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sume  Re me de notation clinique valide  pour les otites externes du chien rend la Contexte – Le manque d’un syste tudes cliniques. comparaison difficile entre les e ses/Objectifs – De velopper un score cliniquement pertinent, fiable et sensible au changement. Hypothe taires (n = 55) et des chiens atteints d’otite externe (n = 60). Sujets – Des chiens sains de proprie thodes – Nous comparons l’e valuation entre 0-3 et 0-5 de l’e rythe me, œde me/gonflement, e rosions/ Me res, exsudats et douleur des conduits auriculaires avec une e chelle de re  fe rence de 0-2. Des donne es ulce mentaires comme l’odeur, le score de prurit, l’e tat de la membrane tympanique, l’effet du traitesupple ries et Malassezia ont e  te e value es. ment et le comptage des neutrophiles, des bacte sultats – Il n’y avait aucune diffe rence significative entre les scores des conduits verticaux et horizontRe lation>0.93). Les coefficients de corre lation pour les e chelles 0-3 et 0-5 e taient aux (coefficient de corre tres, mais l’e chelle 0-2 e tait plus variable. La douleur et le prurit ne corre laient >0.9 pour tous les parame sionnels et e taient associe s respectivement avec une otite suppure e et pas bien avec les scores le rythe mato-ce rumineuse. Le comptage des neutrophiles et des microbes e tait variable et n’a pas pu e ^tre e  pour ge  ne rer des valeurs limites pour diffe rencier les oreilles saines ou atteintes ou pour de terminer utilise ponse au traitement. Les scores totaux≥4 diffe rentiaient les oreilles saines des oreilles atteintes avec la re  de 91.1% et une spe cificite  de 100%; les scores ≤3 e taient de 100% de sensibilite  et une sensibilite cificite  pour l’efficacite  clinique. La fiabilite  intra et inter observateur e tait e leve e (coefficients 91.9% de spe lation intraclasse >0.95 et coefficients kappa de Cohen>0.65). de corre tude pilote montre que l’OTIS3 (0–3 Otitis Index Score) Conclusions et importance clinique – Cette e rythe me, l’œde me/gonflement, l’e rosion/ulce re et exsudat convient pour une e valuation ulte rieure pour l’e par un plus large groupe de cliniciens. Resumen  n – la carencia de un sistema de valoracio n clınico aceptado en la otitis externa canina hace Introduccio difıcil comparar distintas pruebas clınicas  tesis/Objetivos – desarrollar un sistema de evaluacio n que fuera clınicamente relevante, fiable y senHipo sible a los cambios. Animales – perros de propietarios privados sanos (n = 55), y perros con otitis externa (n = 60).

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todos – se compararon valoraciones entre 0-3 y 0-5 del eritema, edema/hinchazo n, erosio n/ulceracio n, Me exudado y dolor en el canal auditivo con una referencia de una escala de 0-2. Datos adicionales incluyeron n de la membrana timp olor, valor de prurito, la condicio anica, el resultado del tratamiento, y los recuentos filos, bacterias, y Malassezia. de neutro n del canal vertical y horizontal (coefiResultados – no hubo diferencias significativas entre la evaluacio n >0,93). Los coeficientes de correlacio n para las escalas de 0-3 y 0-5 fueron tambie n ciente de correlacio >0,9 para todos los parametros, pero las escala de 0-2 fue m as variable. El dolor y el prurito no se correlaciona bien con los valores lesionales, y estuvieron asociados con otitis supurativa y eritroceruminosa, refilos y microbios fueron variables y no pudieron utilizarse para spectivamente. Los recuentos de neutro generar valores de corte para diferenciar animales sanos de animales con otitis, o determinar la respuesta al tratamiento. Valores totales ≥ 4 diferenciaron oıdos sanos de oıdos afectados con una sensibilidad del 91,1%, y una especificidad del 100%; valores ≤3 fueron 100% sensibles y 91,9% especıficos para obtener xito clınico. La fiabilidad intra e interobservador fue alta (coeficiente de correlacio n entre clase >0,95, y coe eficiente kappa de Cohen >0,65) n de otitis Conclusiones e importancia clınica – este estudio piloto muestra que un ındice de valoracio n, erosio n/ulceracio n y exudado es v entre 0-3 para eritema, edema/inflamacio alido para ser evaluado por un grupo mas amplio de veterinarios clınicos. Zusammenfassung Hintergrund – Das Fehlen von etablierten klinischen Bewertungssystemen bei der Otitis externa des Hundes erschwert den Vergleich klinischer Studien. Hypothese/Ziele – Die Entwicklung eines Beurteilungsschemas, das klinisch relevant, verl€ asslich und empfindlich auf Ver€anderungen ist. Tiere – Gesunde Hunde (n=55) in Privatbesitz und Hunde mit Otitis externa (n=60). € Methoden – Wir haben 0-3 und 0-5 Beurteilungen von Erythem, Odem/Schwellung, Erosion/Ulzera, Exsu€ € €glich date und Schmerz der Gehorgange mit einer Referenzskala von 0-2 verglichen. Zus€ atzliche Daten bezu Geruch, Juckreizwerte, Zustand des Trommelfells, Behandlungserfolg sowie eine Z€ ahlung der neutrophilen Granulozyten, Bakterien und Malassezien wurden ebenfalls erfasst. Ergebnisse – Es bestanden keine signifikanten Unterschiede zwischen Werten der vertikalen und horizont€rg€ange (Korrelationskoeffizient > 0,93). Die Korrelationskoeffizienten fu €r die 0-3 und 0-5 Beurteilalen Geho €r alle Parameter, die 0-2 Beurteilung war jedoch variabler. Schmerz bzw. ungen waren auch > 0,9 fu Juckreiz waren schlecht korreliert mit den Beurteilungen der Hautver€ anderungen, sie wurden vielmehr im €ser Otitis gesehen. Die Anzahl der Neutrophilen Zusammenhang mit suppurativer bzw. erythrozerumino und der Mikroben waren variabel und konnten nicht zur Erstellung von Cut Off Punkten verwendet werden, um gesunde und betroffene Ohren zu unterscheiden oder eine Verbesserung durch Behandlung zu evaluieren. Gesamtwerte von ≥ 4 ließen eine Unterscheidung kranker von gesunden Ohren mit einer Sensibilit€ at von 91,1% und einer 100%igen Spezifit€at zu; Werte ≤3 sprachen mit 100%iger Sensibilit€ at und 91,9%iger €r klinischen Erfolg. Die Intra- und Interbeobachter Verl€ Spezifit€at fu asslichkeit war hoch (Intraclass Korrelationskoeffizienten lagen bei >0,95 und Cohen0 s Kappa Koeffizienten lagen bei >0,65). Schlussfolgerungen und klinische Bedeutung – Diese Pilotstudie zeigte, dass der 0-3 Otitis Index Score € €r Erythem, Odem/Schwellung, €r eine weitere Evaluierung (OTIS3) fu Erosion/Ulzera und Exsudat passend fu €ßere Gruppe von Klinikern ist. durch eine gro

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© 2014 ESVD and ACVD, Veterinary Dermatology, 25, 530–e92.

Otitis clinical score

© 2014 ESVD and ACVD, Veterinary Dermatology, 25, 530–e92.

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A pilot study to develop an objective clinical score for canine otitis externa.

The lack of an accepted clinical scoring system in canine otitis externa makes it difficult to compare clinical trials...
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