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标题: 猫慢性耳炎：原发、易感和持久因素的临床管理（1） [打印本页]

作者: 王帆 时间: 2022-3-26 22:09
标题: 猫慢性耳炎：原发、易感和持久因素的临床管理（1）
本帖最后由王帆于 2022-3-26 22:09 编辑

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ChroniC otitis in Cats Clinical management of primary, predisposing and perpetuating factors

猫慢性耳炎：原发因素、易感因素和持久因素的临床管理

作者：Bailey Brame and Christine Cain

翻译：郑江涛校对：王帆

Practical relevance: Chronic otitis can be one of the most frustrating diseases to manage for a small animal practitioner. While it occurs less commonly in the cat than the dog, it is no less challenging. The purpose of this review is to discuss the common and uncommon causes of chronic otitis in the cat within the clinical framework used for diagnosis and treatment. The focus is on diseases that affect the ear canal, rather than those restricted to the pinnae.

实践意义：对于小动物从业者来说，慢性耳炎可能是最令人沮丧的疾病之一。虽然它在猫中比在犬中更不常见，但同样具有挑战性。本综述的目的是在用于诊断和治疗的临床框架内讨论猫慢性耳炎的常见和不常见病因。本文重点是影响耳道的疾病，而不是局限于耳廓的疾病。

Clinical challenges: Otitis is multifactorial, which complicates management. A common clinical mistake is to focus solely on treating the infection present. Only by addressing all factors will a clinician successfully control chronic otitis. For the purposes of this review, the authors have adopted the established model of separating primary, predisposing and perpetuating causes of otitis. Primary factors are those that directly cause otitis (inflammation); predisposing factors are those that put the patient at risk for development of otitis; and perpetuating factors are those that result in ongoing clinical signs of otitis or that prevent clinical resolution.

临床挑战：耳炎是多因素的，这使治疗变得复杂。一个常见的临床误区是只专注于治疗目前的感染。只有通过解决所有因素，临床医生才能成功控制慢性耳炎。出于本综述的目的，作者采用了已建立的模型，分别讨论耳炎的原发病因、易感因素和持久因素。原发病因是那些直接引起耳炎（炎症）的因素；易感因素是那些使患病动物易患耳炎的风险；持久因素是那些导致耳炎临床症状持续存在的或阻止临床恢复的因素。

Audience: This review is aimed at veterinarians who treat cats and particularly those with an interest in feline dermatology and otology.

受众：这篇评论是针对猫科兽医，特别是那些对猫皮肤病学和耳病学感兴趣的人。

Equipment: While many practitioners rely on a hand-held otoscope, a video-otoscope can be very helpful for the diagnosis and treatment of chronic otitis.

设备：虽然许多医生依赖于手持耳镜，但视频耳镜对慢性耳炎的诊断和治疗非常有帮助。

Evidence base: This review presents up-to-date information regarding the diagnosis and treatment of chronic otitis in cats, with emphasis on the most recent peer-reviewed literature.

证据基础：这篇综述提供了关于猫慢性耳炎的诊断和治疗的最新信息，重点是最新的同行评议文献。

Keywords: Chronic otitis; otitis externa; otitis media; Otodectes cynotis; inflammatory aural polyp

关键词：慢性耳炎；外耳炎；中耳炎；耳螨；炎性耳息肉

The normal feline ear

正常的猫耳部

Anatomic features and physical examination

解剖学特征与体格检查

With the exception of the Scottish Fold, domestic cats have upright pinnae, allowing for air circulation. This makes them less vulnerable to environmental factors that predispose to otitis, such as humidity and the effects of bathing or swimming. Despite the conformational difference in the Scottish Fold, an increase in otitis has not been reported in this breed.

除苏格兰折耳猫外，家猫都有直立的耳廓，便于空气流通。这使得他们不容易受到耳炎的易感因素之环境因素的影响，如潮湿和洗澡或游泳的影响。尽管在苏格兰折耳猫中存在结构差异，但在该品种中并未报道耳炎发病率增加。

It is normal for the feline ear to have a moderate amount of dark brown ceruminous debris present in the canal. In the absence of other clinical signs, this is not suggestive of otitis externa. Cerumen may also be clear, white or yellow.

对于猫耳朵来说，耳道中有适量的深棕色耵聍碎屑是正常的。在没有其他临床症状的情况下，这并不说明有外耳炎。耵聍也可以是透明、白色或黄色。

Unlike the dog, the bulla in the cat is divided into medial and lateral compartments by a thin, bony septum with a small opening between (Figure 1). Under otoscopic guidance, it is feasible to access the lateral compartment; however, a bulla osteotomy is typically required to access the medial compartment. This affects treatment options for feline middle ear disease.

与犬不同的是，猫的鼓泡被一个薄的。有一个小开口的骨性鼓室中隔分为内侧和外侧两个腔室（图1）。在耳镜引导下，可以进入外侧腔室；但是，通常需要鼓泡截骨术才能进入内侧腔室。这影响了猫中耳疾病的治疗选择。

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Figure 1 CT of a 6-year-old castrated male domestic shorthair cat with unilateral otitis media and otitis externa. Note the bony septum (arrow) that divides the medial (M) and lateral (L) compartments of the tympanic bulla. On the left side, there is fluid filling the bulla, and the bulla and septum are sclerotic secondary to chronic otitis media

图1一只患有单侧中耳炎和外耳炎的6岁已去势雄性家养短毛猫的CT。注意骨性鼓室中隔（箭头）将鼓泡分为内侧（M）和外侧（L）腔。在左耳，鼓泡内充满液体，鼓泡和鼓室中隔的硬化是继发于慢性中耳炎。

Normal cytologic findings and flora

正常细胞学检查和菌群

Feline ear cytology can be challenging to interpret because cats’ cerumen can absorb stain, resulting in a stain artifact resembling bacterial cocci (Figure 2). Evaluating for pairs of cocci may help avoid misinterpretation.

解释猫的耳道细胞学检查有难度，因为猫的耵聍可以吸收染液，导致出现类似球菌的染色伪影（图2）。评估成对的球菌可能有助于避免误解。

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Figure 2： Cytology from a normal feline ear with mild staining artifact

图2：一只正常猫耳道细胞学检查，有轻微的染色伪影

Ginel et al evaluated cytologic samples from the external ear canal of healthy cats and cats with otitis externa to develop reference intervals for otic cytology. Cats were considered normal if they had two or fewer Malassezia organisms and four or fewer bacterial organisms per high-power field (HPF). The presence of cocci on cytology in healthy cats varies greatly by report, ranging from 2% to 71%, with a median density of 0.3 cocci per HPF in one study. The most commonly cultured bacteria from feral cats’ ears in Grenada, West Indies were coagulase-negative Staphylococcus species, which made up 67% of isolates.

Ginel等人评估了健康猫和外耳炎患猫的外耳道细胞学样本，以制定耳道细胞学的参考区间。如果猫在每个高倍视野（HPF）中有两个或更少的马拉色菌和四个或更少的细菌，则认为是健康猫。在健康猫的细胞学中，球菌的存在因报道的不同而有很大差异，从2%到71%不等，在一项研究中，平均密度为0.3个球菌/HPF。在西印度群岛的格林纳达，野猫耳朵中最常培养的细菌是凝固酶阴性葡萄球菌，占分离菌的67%。

On ear cytology, cats’ cerumen can absorb stain, resulting in a stain artifact resembling bacterial cocci. Evaluating for pairs of cocci may help avoid misinterpretation.

在耳部细胞学检查中，猫的耵聍可以吸收染液，产生类似球菌的染色伪影。评估成对的球菌可能有助于避免误解。

Malassezia species, most commonly Malassezia pachydermatis, can be found on aural cytology and culture in normal cats. The prevalence of Malassezia species on otic cytology reported in the literature ranges from 23% to 83%. In normal cats, the median density of Malassezia species on cytology ranges from 0.2 to 0.5 organisms per HPF. Among Belgian stray cats, 94% of those with Malassezia species on cytology had three or fewer organisms per HPF.

马拉色菌属，最常见的是厚皮马拉色菌，可以在正常猫的耳细胞学和培养中发现。据文献报道，马拉色菌在耳细胞学上的患病率为23%至83%。在正常猫中，马拉色菌在细胞学上的平均密度为0.2至0.5个/HPF。在比利时流浪猫中，94%细胞学检查为马拉色菌的流浪猫每高倍视野中有三个或更少的微生物。

Rod-shaped bacteria are rarely seen in healthy cats, so their presence suggests otic pathology. In one study, Bacillus species and Pantoea species accounted for 17% and 4% of bacterial isolates from the ears of feral cats, respectively.

健康猫很少见到杆菌，因此它们的存在提示耳部病理改变。在一项研究中，芽孢杆菌和泛生菌属分别占野猫耳朵中细菌分离物的17%和4%。

Keratinocytes and nucleated keratinocytes are a normal finding in feline otic cytology and were not increased in a group of cats with otitis externa. Low numbers of melanin clumps and saprophytes can also be seen in normal cats. However, inflammatory cells are not a normal finding in the feline ear, and their presence suggests disease.

角质形成细胞和有核角质形成细胞在猫耳细胞学中是正常的，在一组外耳炎患猫中没有增加。在正常的猫中也可以看到少量的黑色素团块和腐生菌。然而，炎性细胞在猫耳中并不是一种正常的发现，它们的存在提示疾病。

Rod-shaped bacteria and inflammatory cells are not normal findings in the feline ear, and so their presence suggests disease.

杆菌和炎性细胞在猫耳中是不正常的，因此它们的存在提示疾病。

Clinical presentation of, and diagnostic approach for, feline otitis

猫耳炎的临床表现和诊断方法

Owners often report head shaking, scratching or pawing at the ears, pain, excessive ceruminous debris and/or a foul odor. Less commonly, decreased appetite or lethargy are reported.

主人经常描述甩头、搔抓或用爪子抓耳朵、疼痛、耵聍碎屑过多和/或异味。较少见食欲减退或嗜睡。

On physical examination, a cat with otitis externa may have excoriations, erythema, crusting and edema of the pinna or ear canal. The quantity and character of discharge is variable. The cat may exhibit pain on manipulation of the ear or opening the mouth, and a scratch response can be seen during evaluation of the ear. Aural hematoma is sometimes seen in cats secondary to otic pruritus.

体格检查时，外耳炎患猫可能会出现耳廓或耳道的抓痕、红斑、结痂和水肿。分泌物量和性质多变。猫在活动耳朵或张嘴时可能会表现出疼痛，并且在评估耳朵时可以看到抓挠反应。猫耳血肿有时可见，继发于耳部瘙痒。

On otoscopic examination, erythema and edema of the canal are typically present. The tympanic membrane can be thickened or opaque. If otitis media is present, fluid may be visible through the tympanum, or the tympanic membrane may bulge outward (see ‘Otitis media’ section later). Purulent debris can impede evaluation of the tympanum or horizontal canal.

在耳镜检查中，典型地存在耳道发红和水肿。鼓膜可增厚或不透明。如果存在中耳炎，通过鼓膜可以看到液体，或者鼓膜可以向外鼓出（见后面的“中耳炎”部分）。脓性分泌物会妨碍对鼓膜或水平耳道的评估。

Distribution (unilateral or bilateral) of otitis, lesion character and the presence of concurrent neurologic signs or systemic illness can aid in differentiating between causes (see Table 1). The overall diagnostic approach to otitis is summarized in the box on page 436.

耳炎的分布（单侧或双侧）、病变特征和同时存在的神经系统症状或全身性疾病有助于区分病因（见表1）。第436页的方框中总结了耳炎的整体诊断方法。

Prevalence of feline otitis

猫耳炎的患病率

The reported prevalence of otitis externa, media or interna varies greatly in the literature. Among cats presenting to general practice in a UK study, 2.8% were evaluated for otitis. Ten percent of cats presenting to a dermatology service of a US veterinary teaching hospital were diagnosed with diseases of the ear canal. Among a population of Italian stray cats, 55% had otitis externa based on cytologic criteria.

文献中报道的外耳炎、中耳炎或内耳炎的患病率差异很大。在英国的一项研究中，全科诊所患猫中，耳炎发病率2.8%。在美国一家兽医教学医院的皮肤科，猫耳道疾病发病率10%。在意大利一群流浪猫中，根据细胞学检查标准，55%患有外耳炎。

Whether otitis is unilateral or bilaterial, the lesion character and the presence of concurrent neurologic signs or systemic illness can aid in differentiating between causes.

耳炎是单侧还是双侧，病变的性质和并发的神经系统症状或全身性疾病的存在有助于鉴别病因。

Multifactorial approach When evaluating a patient presenting for otitis, it is important to consider all factors that may be contributing to the patient’s ear disease. Here the authors use the traditional model describing primary factors, which directly cause otitis (inflammation), predisposing factors, which put the cat at risk for developing otitis, and perpetuating factors, which result in ongoing clinical signs of otitis or prevent clinical resolution .

多因素方法。在评估耳炎患猫时，重要的是要考虑可能导致患猫耳病的所有因素。在这里，作者使用传统的模型描述了直接引起耳炎（炎症）的原发病因，使猫易患耳炎风险的易感因素，以及导致耳炎临床症状持续存在或阻碍临床缓解的持久因素。

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作者: xiaosa 时间: 2022-3-27 23:38
很不错呢

作者: 何元飞 时间: 2022-3-29 19:33
学习

作者: zhangenzyme 时间: 2022-3-29 22:38
学习学习

作者: 余小果 时间: 2022-4-3 00:20
炎性息肉可以直接撕脱吗，还是也需要麻醉去做处理

作者: Vet武 时间: 2022-4-17 08:26

作者: 王帆 时间: 2022-4-17 08:32

余小果发表于 2022-4-3 00:20
炎性息肉可以直接撕脱吗，还是也需要麻醉去做处理

很疼的

……还是镇静或者麻醉吧

作者: 余小果 时间: 2022-4-24 03:22

王帆发表于 2022-4-17 08:32
很疼的……还是镇静或者麻醉吧

好的～谢谢老师指导

作者: xiaocao 时间: 2023-3-11 22:56
张老师，如果猫耳道细菌培养出来金黄色葡萄球菌阳性，这个菌需要处理吗？

作者: 王帆 时间: 2023-3-13 18:13

xiaocao 发表于 2023-3-11 22:56
张老师，如果猫耳道细菌培养出来金黄色葡萄球菌阳性，这个菌需要处理吗？ ...

虽然我不是张老师，但是需不需要处理不是根据菌种鉴定是什么，是根据耳道感染情况而决定，而且外部治疗和细菌培养药敏试验没有关系，药敏是指导全身性抗生素使用的

作者: xiaocao 时间: 2023-3-22 22:39

王帆发表于 2023-3-13 18:13
虽然我不是张老师，但是需不需要处理不是根据菌种鉴定是什么，是根据耳道感染情况而决定，而且外部治疗和 ...

谢谢王老师

作者: Drzyb 时间: 2023-3-27 19:06
学习使我充实

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