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Middle ear polyps: results of traction avulsion after a lateral approach to the ear canal in 62 cats (2004–2014)
中耳息肉:62例猫经耳道外侧通路牵引撕脱的结果(2004-2014)
作者：Sara DS Janssens, Annika N Haagsman1 and Gert Ter Haar
翻译：王帆
Abstract
Objectives The objective of this study was to report the surgical outcome and complication rate of deep traction avulsion (TA) of feline aural inflammatory polyps after a lateral approach (LA) to the ear canal. Methods This was a retrospective analysis of data retrieved from an electronic database of 62 cats treated with TA after an LA (TALA) for removal of ear canal polyps. Long-term outcome was assessed via a telephone questionnaire survey with the owners.
Results Domestic shorthair cats (48%) and Maine Coons (37%) were over-represented. The most common presenting clinical signs were otorrhoea, ear scratching and head shaking. Video-otoscopic examination confirmed a polypous mass in the ear canal in all patients. All 62 cats underwent TALA with a mean surgical time of 33 mins for experienced surgeons (n = 4) and 48 mins (n = 12) for less experienced surgeons. The recurrence rate of polyp regrowth for experienced surgeons was 14.3% vs 35% for the less experienced surgeons. Postoperative complications included Horner’s syndrome (11.5%) and facial nerve paralysis (3%). Otitis interna was not observed.
Conclusions and relevance A lateral approach to the ear canal in combination with deep TA of an aural inflammatory polyp is an effective first-line technique that results in a low recurrence and complication rate.
摘要
目的 报道猫耳炎性息肉经耳道外侧通路深部牵引撕脱(TA)的手术效果及并发症发生率。
方法 回顾性分析电子数据库中62只猫耳道息肉切除术后经TA治疗的资料。通过电话问卷向宠主调查评估长期结果。
结果 家养短毛猫(48%)和缅因猫(37%)的比例过高。最常见临床表现为耳道分泌物、抓耳和甩头。视频耳镜检查证实所有患猫耳道均有息肉样肿物。所有62只猫都接受了TALA手术，经验丰富的外科医生平均手术时间为33分钟(n = 4)，经验较少的外科医生平均手术时间为48分钟(n = 12)。经验丰富的医生的息肉再生复发率为14.3%，而经验不足的医生的复发率为35%。术后并发症包括霍纳综合征(11.5%)和面神经麻痹(3%)。未观察到内耳炎。
结论与相关性 耳道外侧通路联合深部耳道炎性息肉TA是一种有效的一线技术，其复发率和并发症发生率低。
Introduction
介绍
Middle ear polyps in cats are relatively common benign masses that arise from the mucosal lining of the middle ear, Eustachian tube or the nasopharynx. Whereas many cats will not demonstrate any specific clinical signs associated with middle ear polyps, extension of the polyps beyond the boundaries of the middle ear leads to signs of otitis externa, otitis interna or nasopharyngitis. Diagnosis of polyps is relatively straightforward when polyps have protruded into the ear canal or into the nasopharynx where they can easily be demonstrated using otoscopy and nasopharyngoscopy. Advanced imaging in the form of CT or MRI is advised for cats that have disease confined to the middle ear cavity, and have concomitant nasal disease or otitis interna.
猫的中耳息肉是一种相对常见的良性肿块，起源于中耳、咽鼓管或鼻咽的内衬粘膜上皮。虽然许多猫不会表现出任何与中耳息肉相关的特有临床症状，但息肉的延伸超过中耳边界会导致外耳炎、内耳炎或鼻咽炎的症状。当息肉突出到耳道或鼻咽部时，使用耳镜和鼻咽镜检查可以很容易地观察到，则息肉的诊断相对简单。如果猫的疾病局限于中耳腔，并伴有鼻部疾病或内耳炎时，建议进行CT或MRI高级影像学检查。
The treatment of middle ear polyps that have protruded beyond the middle ear cavity is surgical in all cases. Described techniques for polyp removal from the ear canal include traction avulsion (TA), ventral bulla osteotomy, lateral ear resection and total ear canal ablation with lateral bulla osteotomy, although the latter two techniques are not commonly advised. TA is the least invasive technique, yet has the highest documented recurrence rate (up to 50%). Recently, however, better results have been reported using a per-endoscopic transtympanic traction technique, which resulted in polyp recurrence in only 13.5% of the 37 cats treated. Complications are minimal with these techniques. A ventral bulla osteotomy (VBO) is the most invasive technique with the highest associated complication risks but with the lowest recurrence rates (0–8%). In one relatively large study with 19 cats treated with VBO, reported postoperative complications included Horner’s syndrome (n = 11), otitis interna (n = 2) and facial nerve paralysis (n = 5), and the recurrence rate was 3–5%. Venker-van Haagen introduced TA after a lateral approach (LA) to the ear canal (TALA) as a simple, quick and effective method bypassing complications seen with VBO and generally leading to a low recurrence rate. Whereas this technique has been used for decades, postoperative complications, long-term outcome and recurrence rates using this technique have so far not been reported in the veterinary literature. Therefore, the aim of the present study was to report epidemiological data, clinical signs, postoperative complications and long-term surgical outcomes of TALA for removal of middle ear polyps.
所有突出中耳腔的中耳息肉病例的治疗都进行了外科手术。所描述的耳道息肉切除技术包括牵引撕脱术(TA)、腹侧鼓泡截骨术、耳道外侧切除术和全耳道消融加外侧鼓泡截骨术，但后两种技术通常不被推荐。TA是侵袭性最小的技术，但所记录的复发率最高(高达50%)。然而，最近有报道称，使用内窥镜下经鼓膜牵引技术取得了较好的效果，在37只接受治疗的猫中，只有13.5%的猫出现了息肉复发。这些技术的并发症最小。腹侧鼓泡截骨术(VBO)是最具侵袭性的技术，并发症风险最高，但复发率最低(0-8%)。在一项相对大型研究中，19只猫进行VBO治疗，报道的术后并发症包括霍纳综合征(n = 11)、内耳炎(n = 2)和面神经麻痹(n = 5)，复发率为3-5%。Venker-van Haagen介绍的在耳道外侧通路(LA)后进行TA作为一种简单、快速、有效的方法，可以避免VBO的并发症，通常复发率较低。尽管这项技术已经使用了几十年，但使用这项技术的术后并发症、长期预后和复发率迄今尚未在兽医文献中报道。因此，本研究旨在报道TALA去除中耳息肉的流行病学资料、临床症状、术后并发症及长期手术效果。
Materials and methods
材料和方法
Animals and data collection
动物和信息采集
Data from all cats treated surgically by a lateral approach at our department between December 2004 and June 2014 were collected retrospectively from an electronic database. Information collected included age, breed, sex, clinical signs, findings during initial physical examination, otoscopic findings, diagnostic imaging results, surgeons performing the procedure, results of histopathology and follow-up examinations. Patients were excluded from this study if digital files were incomplete or patients were lost to follow-up.
从电子数据库中回顾性收集2004年12月至2014年6月间我科所有经外侧通路手术治疗的猫的数据。收集的信息包括年龄、品种、性别、临床症状、首诊体格检查结果、耳镜检查结果、影像学诊断结果、手术医生、组织病理学结果和随访检查。如果数字文件不完整或患者失访，则排除该研究。
Surgery
手术
Preoperative protocol for all cats consisted of a thorough otoscopic examination to determine the presence of a visible polyp on the affected site.
所有猫的术前方案包括全面的耳镜检查，以确定患病部位是否存在可见的息肉。
After aseptic preparation of the surgical site, an incision was made in the skin in a dorsoventral direction over the palpable vertical ear canal, starting just cranio-ventral to the tragus over approximately 2.5 cm. The subcutaneous tissues were dissected with small scissors to free the cartilage of the vertical ear canal to the level of the junction between the auricular and annular cartilages, reflecting the parotid gland. A vertical stab incision was made ventrally to dorsally in the auricular cartilage just above this junction with a Bard Parker scalpel handle with a no. 11 blade over 7–10 mm. Stay sutures were placed on both sides of the incision in the ear canal cartilage with fine monofilament suture material to increase visualisation and avoid damaging the cartilage. Small closed curved haemostatic forceps were then introduced into the ear canal, meticulously following the direction of the horizontal ear canal until the polyp was encountered. The forceps were then opened and advanced deeper over the polyp until it could be grasped as close as possible to the osseous meatus (Figure 1). When a firm grip had been achieved, the forceps were gently rotated to make sure no other tissue than the polyp itself had been grasped and traction was applied until the polyp avulsed from its origin (Figure 2). With complete removal of a classical middle ear inflammatory polyp, a small stalk at the base of the polyp could usually be identified. The middle ear cavity was flushed with warm saline and with a small curette the osseous meatus and most lateral aspect of the tympanic cavity was ‘palpated’ to check for additional inflammatory tissue, which was removed with this curette when encountered. The stay sutures were removed and the cartilage of the ear canal was closed with 4-0 monofilament suture material in an interrupted pattern; three or four sutures were usually sufficient. The subcutis was closed in a continuous pattern with 4-0 absorbable monofilament material and the skin was closed in a subdermal suture pattern using the same material.
手术部位无菌准备后，触诊垂直耳道沿其背腹方向进行皮肤切口，切口从颅腹侧开始至耳屏约2.5厘米。用小剪刀剪开皮下组织，将垂直耳道软骨游离至耳廓软骨与环状软骨交界处的水平，暴露腮腺。在耳廓软骨上从腹侧到背侧使用巴德·帕克手术刀柄11刀片就在这个连接处的上方做了一个垂直的刺伤切口超过7-10毫米。在耳道软骨切口两侧用细单丝缝合材料放置缝线，以增加可见性并避免损伤软骨。然后将闭合的小型弯止血钳插入耳道，小心翼翼地沿着水平耳道的方向，直到遇到息肉。打开止血越过息肉进一步深入耳道,直到尽可能接近骨性耳道夹取息肉(图1)。当牢牢夹紧息肉时,轻轻旋转钳子,以确保除息肉外没有夹住其他组织,并进行牵引，直到息肉从根部被撕脱(图2)。完整夹除的典型中耳炎性息肉,通常可以看到息肉底部一个小柄。用温生理盐水冲洗中耳腔，用小刮匙“触诊”骨性耳道和鼓膜腔最外侧，检查是否有其他炎性组织，遇到炎性组织时用刮匙清除。取下固定缝线，用4-0单丝材料间断缝合耳道软骨;通常缝合三到四针就足够了。使用4-0可吸收单丝材料以连续模式闭合皮下组织，使用相同材料以真皮下缝合模式闭合皮肤。
Postoperative management consisted of amoxicillinclavulanic acid (Synulox; Pfizer Animal Health) or enrofloxacin (Baytril; Bayer Animal Health) for 7 days for cats without clinical signs of otitis interna and for 14–21 days for those presenting with signs of otitis interna, and meloxicam (Metacam cat; Boehringer Ingelheim) for 5 days. No corticosteroids were administrated.
术后使用阿莫西林克拉维酸钾或恩诺沙星，无内耳炎临床症状的猫连用7天，有内耳炎症状的猫连用14-21天，使用5天美洛昔康。不用皮质类固醇。
Questionnaire
问卷调查
Each owner was contacted by telephone at least 6 months after intervention (follow-up 6 months to 10 years) and asked the following questions: (1) recovery time after surgery (estimated number of weeks for clinical signs to disappear completely: 1–2, 2–3, 3–4, 5–10, >10 weeks); (2) presence of postsurgical residual signs (head tilt, ataxia, anorexia, otorrhoea, ear scratching, head shaking, facial nerve paralysis and Horner’s syndrome); (3) clinical signs fitting with recurrence of polyp growth after initial full recovery; (4) overall owner satisfaction as evaluated on a 1–4 analogue scale (1 = displeased, 4 = very satisfied). Medical terminology was explained during the conversation with the owner.
在术后至少6个月(随访6个月至10年)电话联系每位宠主，询问以下问题:(1)术后恢复时间(临床症状完全消失的估计周数:1-2、2-3、3-4、5-10、＞10周);(2)是否术后还有症状(头倾斜、共济失调、厌食、耳分泌物、抓耳、甩头、面神经麻痹、霍纳综合征);(3)初步完全恢复后符合息肉复发的临床症状;(4)宠主整体满意度进行1-4分模拟评分(1 =不满意，4 =非常满意)。在与宠主的谈话中解释了医学术语。
Statistical analysis
统计学分析
Collected data were statistically analysed using SPSS software (V.20.0; IBM). A Kaplan–Meier was performed to evaluate the disease free interval. Cox regression analysis was preformed to evaluate significant differences (P<0.05) between variables.
收集数据采用SPSS软件(V.20.0;IBM)。Kaplan-Meier法评估无病间隔。采用Cox回归分析评价各变量间的显著性差异(P<0.05)。
Results
结果
Epidemiological data
流行病学数据
Ninety-two cats met the inclusion criteria, but only 62 owners were willing to participate in this retrospective study. Domestic shorthair cats and Maine Coons were over-represented in our population, 48% (30/62) and 37% (23/62), respectively. Other breeds that were presented more than once included the Norwegian Forest Cat (2/62; 3%) and the Oriental Shorthair (2/62; 3%). The mean age of affected cats was 3.9 years (range 0.5–14 years) with a median of 2 years. There were 27 (44%) female cats, 81% of which were neutered, and 35 (56%) male cats of which 80% were neutered.
92只猫符合纳入标准，但只有62只猫的主人愿意参与这项回顾性研究。家养短毛猫和缅因猫在我们的病例中比例过高，分别为48%(30/62)和37%(23/62)。其他不止一次出现的品种包括挪威森林猫(2/62;3%)及东方短毛猫(2/62;3%)。患猫的平均年龄为3.9岁(范围为0.5-14岁)，中位年龄为2岁。母猫27只(44%)，绝育率81%;公猫35只(56%)，绝育率80%。
Clinical signs and imaging results
临床症状和影像学结果
Presenting clinical signs related to the presence of an ear polyp are listed in Table 1. The most common clinical signs were otorrhoea, ear scratching and head shaking. Signs such as ataxia, anorexia, Horner’s syndrome and deafness were rarely seen. Diagnostic imaging in the form of a CT scan was performed in 16/62 cats included in this study. Eight cats underwent CT as part of the initial workup prior to surgery and 10 when presented with signs of recurrence (including two that had CT previously, at initial work-up). Only the first CT scan (16 cats) results were reviewed for this study. A soft tissue opacity within the tympanic bulla was seen in all cases, with additional osseous changes/thickening of the bulla wall in 9/16. Extension of soft tissue opacity from the middle ear through the external bony meatus into the ear canal was seen in 12/16 cases. In one cat the soft tissue opacity extended to the level of the external bony meatus and in three cats this specific information could not be retrieved. In six cats, in addition to the middle ear and ear canal abnormalities reported above, a protrusion of polypous tissue towards the nasopharynx was diagnosed, based on the presence of a soft tissue opacity at the level of the Eustachian tube opening in the nasopharynx (9.7%).
表1列出了与耳部息肉相关的临床症状。最常见的临床症状为耳分泌物、抓耳和甩头。共济失调、厌食症、霍纳氏综合征和失聪等症状很少出现。对纳入本研究的62只猫中的16只进行了CT扫描的诊断成像。8只猫在手术前接受了CT检查，10只猫在出现复发症状时接受了CT检查(其中2只在首诊时接受了CT检查)。本研究只回顾了第一次CT扫描(16只猫)的结果。所有病例均见鼓泡内软组织混浊，9/16例伴有骨质改变/鼓泡壁增厚。12/16例软组织混浊从中耳经外侧骨性耳道延伸至耳道。其中一只猫的软组织混浊延伸到外侧骨性耳道，另外三只猫的这一具体信息无法检索。在6只猫中，除了上述报告的中耳和耳道异常外，根据鼻咽部咽鼓管开口水平存在软组织混浊，诊断出鼻咽息肉组织突出(9.7%)。
Outcome
结果
No complications were encountered during surgery in all cases. Postoperative complications included Horner’s syndrome in seven cases and facial nerve paralysis in two. Vestibular signs were not observed. All patients were discharged from the hospital.
术中无并发症发生。术后并发症包括霍纳综合征7例，面神经麻痹2例。未观察到前庭症状。所有患猫均已出院。
Forty-seven (75.8%) cat owners indicated that their cats had completely recovered following surgery and were not exhibiting any residual signs. Clinical signs had disappeared within 1–3 weeks in 91% of these animals, with a mean of 2.6 weeks. In six of the 47 (12.7%) cats that made an initial full recovery after the surgery, clinical signs compatible with possible recurrence of polyp growth developed 12, 21, 23, 34, 41 and 101 months postoperatively, respectively. For these late recurrences the median disease-free interval was 27.5 months. All cats were re-examined at our institution and a new polyp in the external ear canal was confirmed in four cats and otitis media in two of these cats using CT and/or video-otoscopy.
47名(75.8%)猫主人表示，他们的猫在手术后已完全康复，并无任何后遗症。91%的动物在1-3周内临床症状消失，平均2.6周。在47只术后初步完全康复的猫中，有6只(12.7%)分别在术后12个月、21个月、23个月、34个月、41个月和101个月出现了可能与息肉复发相符的临床症状。对于这些后期复发病例，无病间隔中位值为27.5个月。所有的猫都在我们的机构进行了重新检查，其中四只猫的外耳道出现了新的息肉，其中两只猫通过CT和/或视频耳镜检查证实了中耳炎。
Owners of 15 cats (24.2%) reported that their cats had not fully recovered. In these cats clinical signs such as otorrhoea, head shaking and ear scratching persisted postoperatively beyond 4 weeks. Recurrence of (or residual) polyp growth was confirmed at re-examination in our clinic using CT scan and/or video-otoscopy in 8/15 (53%) cases. Of the other seven cats with persisting clinical signs after surgery two owners declined further work-up and five cats were lost to follow-up.
15只猫(24.2%)的主人表示，他们的猫没有完全康复。在这些猫的临床症状，如耳分泌物、甩头和抓耳术后持续超过4周。在我们的临床复查CT扫描和/或视频耳镜检查中，8/15(53%)例证实息肉复发(或残留)。另外七只猫在手术后出现了持续的临床症状，其中两只猫的主人拒绝接受进一步的检查，另外五只猫没有得到随访。
Auxiliary surgery in the cats with confirmed regrowth of polyps consisted of polyp removal via TA under video-otoscopic guidance (3/12), VBO (7/12) or a second lateral approach as described above (2/12).
对于确认息肉复发的猫，辅助手术包括在视频耳镜引导下经TA切除息肉(3/12)、VBO(7/12)或相同方法的第二次外侧通路(2/12)。
An experienced ear, nose and throat surgeon had performed the polyp removal in 40 cats included in this study. In the remainder of the cases (n = 22), the procedure had been carried out by a less experienced surgeon (resident). Mean surgical time was 33 mins for experienced surgeon and 48 mins for the less experienced surgeon.
一名经验丰富的耳鼻喉外科医生对研究中的40只猫进行了息肉切除。其余病例(n = 22)由经验不足的外科医生(住院医师)进行手术。经验丰富的外科医生平均手术时间为33分钟，经验不足的外科医生平均手术时间为48分钟。
There were no significant differences in recurrence rates between the experienced surgeon, (average recurrence rate was 14.3% vs 35% for the less experienced surgeon). The cats with confirmed recurrences (n = 13) included seven domestic shorthairs, five Maine Coons and one Birman. Recurrence was seen in six females (6/27; 22%) vs seven male cats (7/35; 20%). There were no significant differences in recurrence rates between males and females, and neutered and intact cats.
经验丰富的外科医生之间的复发率没有显著差异(平均复发率为14.3%，而经验较少的外科医生为35%)。确认复发的猫(n = 13)包括7只家养短毛猫，5只缅因猫和1只伯曼猫。6例母猫复发(6/27;22%) vs 7只公猫(7/35;20%)。公猫和母猫、绝育患猫和未绝育患猫的复发率没有显著差异。
A Kaplan–Meier analysis was performed to evaluate the time between surgery and recurrence of polyp growth (disease-free interval) (Figure 3). For this purpose, a time frame between surgery (t = 0) and the time of recurrence of polyp growth, or the time at which the case was censored was used. Cases were censored when recurrence of polyp growth did not occur (48 cats). At 1 year 97% and at 2 years 88% of the cats had survived without recurrence of a polyp. Histopathological examination was performed in 39 cases (including 10 of the 12 recurrences) and confirmed the presence of an inflammatory polyp in all.
我们采用Kaplan-Meier分析来评估手术与息肉复发之间的时间间隔(无病间隔)(图3)。为此，我们使用手术之间的时间间隔(t = 0)与息肉复发的时间间隔，或病例审查的时间间隔。当息肉没有复发时，病例被审查(48只猫)。1年后97%的猫存活，2年后88%的猫没有息肉复发。经组织病理检查39例(12例复发中10例)，均证实炎性息肉。
Discussion
讨论
The aim of this study was to evaluate the efficacy, long-term outcome of and complications associated with TALA of aural inflammatory polyps in cats.
本研究旨在评价TALA治疗猫耳部炎性息肉的有效性、长期疗效及并发症。
The current study demonstrates that TALA of an aural polyp is a time-efficient surgical technique, associated with an uneventful postoperative recovery, minor postoperative complications and a low recurrence rate of 14% for experienced surgeons. Although the surgery is relatively easy to perform, a learning curve is associated with the technique as both surgical time and recurrence rates depend on the experience of the surgeon.
目前的研究表明，对耳部息肉进行TALA手术是一种高效性的手术技术，术后恢复平稳，术后并发症少，对于经验丰富的外科医生来说复发率低至14%。虽然该手术相对容易进行，但技术相关的学习曲线即手术时间和复发率取决于外科医生的经验。
No apparent breed or sex predilection has been reported for aural polyps, but it has been noted by many authors that polyp formation is more commonly seen in specific cat breeds like the Norwegian Forest, Sphynx, Maine Coon, Persian, Ragdoll and Abyssinian. Similar to what has been reported before, domestic shorthair cats were over-represented in our study. In contrast to previous publications, however, the Maine Coon was also over-represented (37%). Although this confirms previous anecdotal evidence, further research is needed to see if this reflects a bias in our study population or truly reflects a breed predisposition.
没有关于耳部息肉的明显品种或性别易感性的报道，但许多作者已经注意到，息肉形成更常见的特殊猫品种，如挪威森林、斯芬克斯猫、缅因猫、波斯猫、布偶猫和阿比西尼亚猫。与之前的报道类似，家养短毛猫在我们的研究中占了过多的比例。然而，与之前的出版物相比，缅因猫的比例也过高(37%)。虽然这证实了之前的传闻证据，但还需要进一步的研究来确定这是否反映了我们研究群体中的易感性，还是真正反映了一种品种的易感性。
The mean age at presentation, male–female distribution and the most common clinical findings (ie, otorrhoea, head shaking and ear scratching) were similar to those that have been previously reported. Clinical signs associated with otitis interna (ie, vestibular ataxia, anorexia and deafness) were less commonly seen in our study compared with previous reports. Only 16 cats presented with ataxia in our study, which resolved in all cats after surgical removal of the polyp and consecutive antibiotic treatment. Prognosis of animals presenting with vestibular signs did not appear to be worse than that of those presenting without. Recurrence rates were similar for both groups.
平均发病年龄、公母分布和最常见的临床表现(如耳分泌物、甩头和抓耳)与以前的报道相似。与以前的报道相比，我们的研究中与内耳炎相关的临床症状(即前庭共济失调、厌食和失聪)较少出现。在我们的研究中，只有16只猫出现共济失调，在手术切除息肉和连续的抗生素治疗后，所有猫的共济失调都消失了。有前庭症状的动物预后并不比无前庭症状的动物差。两组的复发率相似。
Advanced diagnostic imaging was not performed in most animals included in this study and diagnosis was confirmed by (video-)otoscopy in all cases with subsequent histopathological evaluation in 60% of these. In most of the cases where recurrence was suspected, advanced diagnostic imaging was performed. Even though polyps can be visualised on radiographs in many cases, for proper (surgical) treatment planning, CT of the entire skull is advised. CT also offers a higher true-positive diagnostic rate for the detection of otitis media, otitis interna and provides information on concomitant changes in the nasal cavity, nasopharynx and frontal sinuses. Findings on diagnostic imaging in our population were similar to changes associated with ear canal and middle ear polyps reported before. Eight patients received a CT before the initial surgery and involvement of the middle ear was demonstrated in all. Only three of these eight cats developed a recurrence of the polyp, despite obvious changes in the middle ear. Whereas definite conclusions cannot be drawn based on our data, it does suggest that despite middle ear involvement on CT imaging TALA is usually curative. Further studies specifically designed to evaluate the use of CT as a predictor of outcome after TALA are required in a larger population. Diagnostic imaging such as CT, based on our results, is advised for cats that require more elaborate surgical procedures such as ventral bulla osteotomy or present with recurrence after polyp removal.
本研究纳入的大多数动物未进行高级诊断影像学检查，所有病例均通过(视频)耳镜确认诊断，其中60%的动物随后进行了组织病理学评估。在大多数怀疑复发病例中，进行高级影像学诊断检查。尽管在许多病例中，息肉可以在x光片上观察到，但为了进行适当的(外科)治疗计划，建议对整个头部进行CT检查。CT对中耳炎、内耳炎的诊断具有较高的真阳性诊断率，并可提供鼻腔、鼻咽和额窦的相关改变信息。在研究群体中的诊断性影像学检查与以前报道的耳道和中耳息肉相关的变化相似。8例患猫在首次手术前行CT检查，均显示中耳患病。这八只猫中只有三只复发了息肉，但在中耳有明显的变化。虽然根据我们的数据不能得出明确的结论，但它确实表明，虽然CT图像上的中耳患病，但TALA通常是治愈的。需要在更大研究群体中进行专门设计的进一步研究，以评估CT作为TALA后预后的预测因素。基于我们的结果，建议对需要更精细的外科手术的猫，如鼓泡腹侧截骨术或息肉切除后复发的猫，进行诊断性影像检查，如CT。
In this study histopathological confirmation of the diagnosis was, unfortunately, only performed in 63% of the cases. Although this would have ideally been performed in all cases, especially in the older animals, the absence of recurrence of signs after removal of the mass in the ear canal indicates the presumptive diagnosis was correct. However, this clearly presents a limitation inherent to the retrospective study design. As a general rule, histopathology should be performed for accurate diagnosis in all cases. Histopathology was performed in 83% of the animals that presented with recurrence, which confirmed the diagnosis of inflammatory polyp in all.
在本研究中，不幸的是，只有63%的病例进行了组织病理学确诊。虽然这在所有病例中都可以进行，特别是在老年动物中，但在耳道肿物切除后没有复发的症状表明推测诊断是正确的。然而，这明显显示了回顾性研究设计固有的局限性。一般情况下，所有病例都应进行组织病理学检查以作出准确诊断。83%复发的动物进行了组织病理学检查，全部确诊为炎性息肉。
TA and VBO have been the most commonly used techniques for treatment of aural inflammatory polyps. VBO is associated with a low recurrence rate (0–8%) but is more invasive and is associated with a higher incidence of iatrogenic complications (Horner’s syndrome, facial nerve paralysis, otitis interna). In this study TALA was used as a first-choice treatment for all cases with ear canal polyps visible upon otoscopy, regardless of imaging results, indicating middle ear involvement or clinical signs indicative of otitis interna. This technique resulted in a much lower recurrence rate of 14.3% compared with other described TA techniques (around 50% recurrence) and a similar recurrence rate as perendoscopic transtympanic TA (PTT). Whereas recurrence rates are higher than reported for VBO, TALA is easy to perform, efficient and not associated with major complications (ie, bleeding, facial nerve paralysis). Another major advantage of this lateral approach is the short anaesthetic and surgical time compared with previously described surgical techniques. The average surgical time amounted to only 33 mins for experienced ear, nose and throat surgeons, and 48 mins for less experienced surgeons. The study on PTT reported a minimal surgery duration of 45 mins and a maximum of 2.5 h. Although the latter is a minimally invasive technique associated with minor complications, the present study proved to have similar results in outcome and complication rates with a significantly shorter surgical time and without the need for endoscopic equipment.
TA和VBO是治疗耳部炎性息肉最常用的方法。VBO复发率低(0-8%)，但侵袭性更强，医源性并发症(霍纳氏综合征、面神经麻痹、内耳炎)的发生率更高。本研究中所有耳镜下可见耳道息肉的病例，无论影像学结果如何，都将TALA作为首选的治疗方法，以提示中耳患病或有临床症状提示内耳炎。该技术的复发率为14.3%，与其他描述的TA技术(约50%的复发率)相比，复发率与经耳道鼓膜TA (PTT)相似。虽然复发率高于VBO，但TALA易于实施、有效且不伴有主要并发症(如出血、面神经麻痹)。这种外侧通路的另一个主要优点是与之前描述的手术技术相比，麻醉时间短，手术时间短。经验丰富的耳鼻喉外科医生平均手术时间为33分钟，经验不足的医生平均手术时间为48分钟。关于PTT的研究报告了最小的手术时间为45分钟，最长2.5小时。虽然后者是一种并发症较少的微创技术，但本研究证明，在手术时间显著缩短且不需要内镜设备的情况下，在结果和并发症发生率方面有类似的结果。
TALA is associated with minor complications of transient nature. Peri- and postoperative bleeding, and vestibular signs upon recovery were not noted in any of the cats. Horner’s syndrome was seen in seven cats (11.5%). Two cats developed postoperative facial nerve paralysis, one of which had resolved at the time of follow-up. The other cat was lost to follow-up. An inexperienced resident performed the surgeries in the latter two cats and facial nerve damage could have resulted from inadvertent ventral dissection beyond the level of the transition between vertical and horizontal ear canal. Owing to the retrospective nature of this study, it is possible that some minor complications (ie, Horner’s syndrome) were under-reported. Major complications including otitis interna and/or facial nerve paralysis most likely would have been reported. The number of complications appears comparable with previous reports on TA techniques, including the PTT study where three cats (8%) developed Horner’s syndrome, but is much higher after VBO. Horner’s syndrome is observed in 25–80% of the cases, and vestibular signs after VBO range from 4–42%. Facial nerve paralysis was seen in 16% of 18 procedures, but when accompanied by total ear canal ablation the incidence can increase up to 31%. In contrast to vestibular symptoms and/or facial nerve paralysis, Horner’s syndrome is considered only a mild complication. The condition does not affect quality of life and often resolves in 2–4 weeks.
TALA与短暂性的轻微并发症有关。未发现任何一只猫的围手术期和术后出血和恢复后的前庭症状。霍纳氏综合征见于7只猫(11.5%)。两只猫术后出现面神经麻痹，其中一只在随访时已痊愈。另一只猫失踪了。后两只猫的手术是由一位经验不足的住院医生完成的，面神经损伤可能是由于无意的腹侧剥离超过了垂直和水平耳道之间的过渡水平。由于本研究具有回顾性的性质，有可能一些轻微的并发症(如霍纳氏综合征)没有得到充分报道。主要并发症包括内耳炎和/或面神经麻痹最有可能被报告。并发症的数量似乎与之前关于TA技术的报道相当，包括PTT研究，其中三只猫(8%)患上了霍纳氏综合征，但在VBO后更高。25-80%的病例观察到霍纳综合征，VBO后前庭症状在4-42%之间。在18例手术中，面神经麻痹占16%，但当同时伴有全耳道消融时，面神经麻痹的发生率可高达31%。与前庭症状和/或面神经麻痹相比，霍纳氏综合征被认为只是一种轻微的并发症。这种情况不会影响生活质量，通常会在2-4周内消失。
Recurrence of polyp growth was seen in 13 cats of the 62 included in this study. The choice between a lateral approach and a VBO for revisional surgery was made based on the size of the polyp and the owners preferences. Very small polyps that barely extend beyond the external bony meatus are difficult to grasp using the lateral approach. For polyps properly protruding beyond the external bony meatus, a lateral approach can be repeated. For very small polyps, a VBO is advised, especially when dealing with possibly multiple small polyps confined to the middle ear cavity.
在本次研究的62只猫中，有13只猫出现了息肉复发。根据息肉的大小和宠主的喜好，选择外侧通路和VBO进行修复手术。非常小的息肉仅延伸到外耳道，使用外侧通路很难抓住。对于突出于外骨性耳道的息肉，可以重复外侧通路。对于非常小的息肉，建议使用VBO，特别是当处理可能局限于中耳腔的多个小息肉时。
Conclusions
结论
Inflammatory polyps in the ear canal and middle ear are frequently encountered in cats. Whereas diagnosis heavily relies on visualisation of a polypous growth in the ear canal during otoscopy, advanced imaging such as CT can be a useful aid. First-line treatment for removal of polyps can consist of a lateral approach to the ear canal in combination with TA of the polyp. This study demonstrates this is an effective, fast and inexpensive technique that results in a low recurrence and complication rate. The technique can be performed by first-line practitioners but is associated with a higher recurrence rate if not performed by a surgeon familiar with the technique.
猫常见耳道和中耳炎性息肉。虽然诊断很大程度上依赖于耳镜检查时耳道息肉的可视化，但高级影像学检查，如CT，可以有效帮助诊断。切除息肉的一线治疗包括耳道外侧通路和息肉TA。这项研究表明，这是一种有效，快速和廉价的技术，导致低复发率和并发症。该技术可由一线医师实施，但如果不由熟悉该技术的外科医生实施，复发率会更高。
Figure 1 The forceps is gently rotated while grasping the aural polyp to make sure no other tissue has been grasped.
图1在抓住耳息肉的同时轻轻旋转钳子，以确保没有其他组织被抓住。
Figure 2 Traction is applied until the polyp avulses
图2牵引至息肉撕脱。
Figure 3 Kaplan–Meier curve of disease-free interval in months
图3月间无病间隔Kaplan-Meier曲线
Table 1 Preoperative clinical signs in 62 cats with a middle ear polyp
表1 62只中耳息肉猫的术前临床症状
临床症状 |
头倾斜 |
20（32） |
共济失调 |
16(26) |
厌食症 |
3（5） |
耳分泌物 |
55（89） |
抓耳 |
40（65） |
甩头 |
42（68） |
失聪 |
10（16） |
霍纳氏综合征 |
1（2） |
| 
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发表于 2022-10-8 09:43:11
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