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Diagnosis and Management of Cholesteatomas in Dogs
犬胆脂瘤诊断和管理
作者：Marije Risselada, DVM, PhD
翻译：王帆
KEYWORDS
关键词
Cholesteatoma；Middle ear；Diagnosis；Imaging；Surgical management
胆脂瘤；中耳；诊断；影像；手术管理
KEY POINTS
重点
Aural cholesteatomas are expansile lesions of the middle ear.
Clinical symptoms are draining tracts, pain on opening the mouth, and neurologic impairment.
Imaging findings include soft tissue density in the middle ear and destruction of the bone of the bulla with characteristics of an aggressive lesion.
Patients with neurologic signs have a poorer prognosis.
Long-term medical treatment of recurring or persisting signs is possible.
耳胆脂瘤是中耳的扩张性病变。
临床症状为窦道、开口疼痛和神经功能障碍。
影像学表现包括中耳软组织密度和鼓泡骨质破坏，伴有侵袭性病变特征。
有神经症状的患病动物预后较差。
可能需要长期治疗复发或持续症状。
INTRODUCTION
介绍
Nature of the Problem
疾病本质
A middle ear cholesteatoma is an expansile lesion of the middle ear; it presents as a lesion that can be locally destructive, giving the appearance of an aggressive tumor, although it is a non-neoplastic condition.
中耳胆脂瘤是一种中耳的扩张性病变。它表现为一种局部破坏性的病变，具有侵袭性肿瘤的外观，但它是非肿瘤性疾病。
This lesion consists of an epidermoid cyst that contains keratin debris and is lined by keratinizing squamous epithelium. The keratotic material is accumulated because of secondary hyperkeratosis from misplaced keratinizing stratified squamous epithelium within the lesion. This accumulation leads to gradual enlargement of the cyst causing compression and potentially destruction of the surrounding tissues.Expansion and rupture of the cyst cause an inflammatory condition and can become infected, as evidenced by positive cultures in most cases. This secondary infection of the cyst will then increase the inflammatory reaction exacerbating the response.
病变由含有角蛋白碎片的表皮样囊肿组成，内衬角化鳞状上皮细胞。角化物质是由于病变中错位的角化层状鳞状上皮细胞继发过度角化所致。这种堆积导致囊肿逐渐增大，造成压迫和周围组织的潜在破坏。囊肿的扩张和破裂可引起炎症，并可发生感染，大多数病例细菌培养为阳性可证明这一点。囊肿的继发感染会增加炎症反应，加剧反应。
In veterinary patients, this condition was initially thought to be secondary to a failed total ear canal ablation-lateral bulla osteotomy (TECA-LBO) procedure for otitis externa and media but has been proven to develop as a primary condition or component of otitis externa/media without prior surgery or iatrogenic trauma, as shown in a large case series. The incidence of cholesteatoma in dogs with otitis media could be as high as 11%.
在兽医患病动物中，这种疾病最初被认为是失败的全耳道消融-外侧鼓泡截骨术(TECA-LBO)治疗外耳炎和中耳炎的继发性疾病，但在一篇大项病例分析中已被证明是外耳炎/中耳炎的原发疾病或没有既往手术或医源性创伤病史的外耳炎/中耳炎的病因之一。犬胆脂瘤伴中耳炎的发病率可高达11%。
Although the etiopathogenesis is not completely understood, by consensus, 2 broad categories are currently recognized: congenital and acquired (Table 1). The congenital form is rare and has not been reported in dogs. It is defined as a expanding cystic mass assumed to be present at birth but usually diagnosed in infancy or early childhood.
虽然病因尚不完全清楚，但目前公认的两大类是:先天性和后天性(表1)。先天性形式很罕见，在犬中未见报道。它的定义是一种扩大的囊性肿块，假定在出生时就存在，但通常在婴儿或儿童早期被诊断出来。
The development of the congenital form can be further subclassified in the epithelial rest theory and the acquired inclusion theory. In the epithelial rest theory, it is proposed that a nest of epithelial cells pathologically persist in the fetal temporal bones. If the cells are implanted into the middle ear because of a childhood event affecting the tympanic membrane (TM) or middle ear, it is termed acquired inclusion.
先天型的发展可进一步细分为上皮滞留理论和获得性包含理论。在上皮细胞休息理论，提出上皮细胞巢病理性停留在胎儿颞骨中。如果细胞因为童年时期的事件植入中耳影响了鼓膜(TM)或中耳，这被称为获得性包含。
Acquired cholesteatomas can be categorized according to their proposed pathogenesis into 4 different categories: a primary form and 3 secondary forms. The primary form is thought to develop secondary to a dysfunction of the eustachian tube and chronic misventilation of the auditory tube, which in turn leads to invagination of the TM into the bulla (invagination or retraction theory). Ligation of the eustachian tube in gerbils did induce cholesteatomas in 75% of animals in one study, but experimental ligation of the eustachian tube in other studies did not induce cholesteatomas.
获得性胆脂瘤可根据其提出的发病机制分为4类:一种原发型和3种继发型。原发型被认为是继发于咽鼓管功能障碍和耳道慢性通气不畅，进而导致TM内陷到大泡(内陷或回缩理论)。在一项研究中，结扎沙鼠的咽鼓管在75%的动物中诱发了胆脂瘤，但在其他研究中，实验性结扎咽鼓管并没有诱发胆脂瘤。
The secondary form is considered secondary to chronic otitis media, trauma to the middle ear, or secondary to surgery of the external ear canal and middle ear. The metaplasia theory posits that the normally present modified ciliated respiratory epithelium in the bulla undergoes a metaplastic transformation into stratified squamous epithelium because of chronic inflammation. A second theory suggests that breaks in the TM (perforations, rupture, or after surgery) can lead to migration of the stratified squamous epithelium from the external ear canal into the tympanic bulla where it can lead to keratin formation and accumulation due to chronic inflammation (migration theory). The third theory (invasion theory) proposes that keratinizing epithelial cells of the TM migrate into the subepithelial space of the bulla through a basement membrane breach.
继发型被认为是继发于慢性中耳炎、中耳创伤或继发于外耳道和中耳手术。化生理论认为，由于慢性炎症，大泡中正常存在的改良纤毛呼吸道上皮发生化生转变为层状鳞状上皮。第二种理论认为，鼓膜（TM）破裂(穿孔、破裂或手术后)可导致层状鳞状上皮从外耳道迁移到鼓泡，在鼓泡中，由于慢性炎症，可导致角蛋白形成和积累(迁移理论)。第三种理论(侵入理论)提出，TM的角质化上皮细胞通过基底膜缺口迁移到大泡的表皮下空间。
Regardless of the cause, the cholesteatoma expands and gradually erodes neighboring bone structures, after which it can expand further, potentially explaining the lytic nature of the bone of the affected tympanic bulla. It has been hypothesized that osteoclasts might be activated during the formation of cholesteatomas and implicated in the bony lysis of the bulla. Osteoclasts have been found microscopically, leading to theorize about their possible involvement. However, activated osteoclasts were not identified in bone collected from dogs with cholesteatomatous otitis media in a recent case series.
不管什么原因，胆脂瘤扩张并逐渐侵蚀邻近的骨结构，之后它可以进一步扩张，这可能解释了受患病鼓泡骨质的溶解性质。据推测，破骨细胞可能在胆脂瘤形成过程中被激活，并与大泡的骨裂解有关。在显微镜下发现了破骨细胞，这导致了它们可能参与的理论。然而，在最近的一系列病例中，从患有胆脂瘤性中耳炎的犬上收集的骨中没有发现活化的破骨细胞。
Definition
定义
It is an expansile cyst containing keratotic material in the middle ear.
这是一个在中耳含有角化物质的扩张性囊肿。
Symptom Criteria
症状标准
Expansile lesion in the bulla
Chronic otitis externa/media
Presence or absence of pain on opening of the jaw
Presence or absence of neurologic signs, either due to destruction of the petrous bone or due to facial nerve palsy
大泡处的扩张性病变
慢性外耳/中耳炎
下颌张开时是否有疼痛
是否有神经症状，可能是由于颞骨岩骨质破坏，或者是面神经麻痹
CLINICAL FINDINGS
临床结果
Signalment and History
特征和病史
No significant breed predilection has been reported in the literature, although spaniels and retrievers seem to be overrepresented (pugs [3], spaniels [10], and retrievers [6]), and a higher incidence in male dogs was found; but this finding was not significant, most likely because of small patient numbers. In people, a similar, as of yet unexplained, sex bias has been reported.
文献中没有明显的品种倾向性报道，但西班牙猎犬和寻回犬似乎过多(巴哥[3]，西班牙猎犬[10]，寻回犬[6])，并且发现雄性犬的发病率更高，但这一发现并不显著，很可能是因为患人动物数量较少。据报道，在人类中也有类似的，但尚未解释的性别倾向性。
Although cholesteatomas are most commonly found in middle-aged to older dogs, the reported ages on presentation in the literature range from 2 to 12 years old. Similarly, most dogs present with a protracted history of aural disease, although the reported duration of signs is variable, ranging from 3 weeks to more than 6 years.
虽然胆脂瘤最常见于中年至老年犬，但文献中报道的发病年龄在2至12岁之间。同样，大多数犬都有长期的耳病史，但报告的症状持续时间各不相同，从3周到6年以上不等。
Presenting complaints include otitis externa, head shaking, pain on opening of the mouth or inability to fully open the mouth, and neurologic signs.
主诉包括外耳炎、甩头、张嘴疼痛或不能完全张开嘴巴，以及神经症状。
Most cases reported in the veterinary literature have unilateral disease. In the earlier large case series by Hardie and colleagues,15 out of 19 patients had unilateral disease. In subsequent more recent articles, all but one case were unilateral (Table 2).
兽医文献中报道的大多数病例为单侧疾病。在Hardie及其同事早期的大型病例系列中，19例患病动物中有15例为单侧疾病。在随后较近的文章中，除一例外，均为单侧病例(表2)。
The incidence of prior surgery varied extensively between the different studies: Hardie and colleagues reported that 3 of the 20 included patients had had prior surgery (TECA-LBO 1, lateral wall resection 1, external ear canal mass resection 1), whereas all included cases in 2 other studies underwent surgery before presentation: The 2 patients reported by Schuenemann and Oechtering had an LBO performed previously; and of the 11 patients reported by Greci and colleagues, 10 underwent a TECA-LBO previously and one a VBO.
不同研究中手术史的发生率差异很大:Hardie和同事报告，20例纳入患犬中有3例有手术史(TECA-LBO 1例、外侧壁切除术1例、外耳道肿块切除术1例)，而其他2项研究中的所有纳入病例在发病前均有手术史:Schuenemann和Oechtering报道的2例患犬进行过LBO；Greci和同事报告的11例患犬中，10例之前接受了TECA-LBO, 1例接受了VBO。
Physical Examination
体格检查
Presenting complaints include signs related to chronic otitis externa/media (head shaking, pain on palpation, discharge, swelling, redness,±draining tracts), pain on opening of the mouth or inability to fully open the mouth, and neurologic signs, including head tilt, facial nerve palsy, ataxia, and nystagmus.
主诉包括与慢性外耳炎/中耳炎相关的症状(甩头、触诊疼痛、分泌物、肿胀、发红、±瘘道)、张嘴痛或不能完全张开嘴，以及神经系统症状，包括头倾斜、面神经麻痹、共济失调和眼球震颤。
Inability to open the mouth or discomfort on opening of the mouth is a common presenting complaint, reported in 6 out of 10 dogs and 4 out of 20 dogs. Respiratory signs can be present due to a space-occupying mass compromising the lumen of the nasopharynx/larynx, as reported by Schuenemann and Oechtering.
无法张开嘴巴或张嘴不舒服是常见的症状，10只犬中有6只，20只犬中有4只。据Schuenemann和Oechtering报道，鼻咽/喉腔内占位性肿块可引起呼吸症状。
Otoscopic Examination
耳镜检查
Most dogs showed pain on palpation of the area of the bulla (9 out of 10 dogs) and/or otorrhea (8 out of 10 dogs). Findings during an otoscopic or video otoscopic examination can resemble end-stage otitis externa. Greci and colleagues described a total occlusion of the horizontal canal in 4 out of 11 ears with end-stage otitis. In other cases the external ear canal can be patent, allowing visualization of the cholesteatoma itself. These cholesteatomas appear as a pearly white to yellow growth protruding from the middle ear cavity into the external ear canal (Newman and colleagues, 2015, one case) (Greci and colleagues, 2011, 3 cases).
大多数犬在触诊大泡区域时表现出疼痛(10只犬中有9只)和/或耳分泌物(10只犬中有8只)。在耳镜或视频耳镜检查期间的发现可以类似终末期外耳炎。Greci和同事描述了11只终末期耳炎患耳中有4只水平耳道完全闭塞。在其他病例中，外耳道可以通畅，水平耳道可看到胆脂瘤。这些胆脂瘤表现为珍珠白色至黄色的生长物，从中耳腔向外耳道突出(Newman和同事，2015,1例)(Greci和同事，2011,3例)。
Focused Neurologic Examination
关注的神经学检查
More than 50% of dogs present with concurrent neurologic signs, or neurologic abnormalities were found on physical examination (head tilt, facial nerve paralysis, ataxia) in 5 out of 10 dogs and 7 out of 20 dogs. The presence or absence of neurologic signs can serve as a prognostic indicator for recurrence of symptoms or disease after surgical treatment.
超过50%的犬同时存在神经症状，或在体检中发现神经异常(头倾斜，面神经麻痹，共济失调)，10只犬中有5只，20只犬中有7只。神经症状的存在或不存在可作为手术治疗后症状或疾病复发的预后指标。
IMAGING
影像
Although different modalities are discussed, computed tomography (CT) or alternatively magnetic resonance (MR) are the methods of choice for assessing the middle ear and middle-ear associated lesions, as they provide improved detail for lesions in areas of complex architecture (see Table 2).
虽然讨论了不同的模式，但计算机断层扫描(CT)或磁共振(MR)是评估中耳和中耳相关病变的首选方法，因为它们可以提高复杂结构区域的病变细节(见表2)。
Radiographs
X线
A radiographic evaluation might be chosen as a first-line assessment or in the absence of access to either CT or MR. It should ideally be performed under anesthesia and should include a lateral view, a 20°lateral oblique view, a dorsoventral view, and a rostrocaudal open mouth view to best visualize the individual bullae. Described radiographic features of chronic otitis media include lack of air in the bulla, thickening of the bulla wall, and with or without increased size of the bulla; however, the external ear canal can be air filled. Radiographic features of neoplasia include lysis of the bulla and bony proliferation with or without soft tissue lesion filling or extending into the bulla. These findings are nonspecific and can be found in otitis media as well as other lesions affecting the tympanic bulla.
可以选择x线片评估作为首诊评估，或在没有CT或MR的情况下进行。理想情况下，应在麻醉下进行，并应包括侧位片、20°斜侧位片、背腹位片和头尾位开口位片，以最佳地观察单个大泡。慢性中耳炎的影像学表现包括鼓泡内无空气，鼓泡壁增厚，伴有或不伴有鼓泡扩张。然而，外耳道可以充满空气。肿瘤的影像学特征包括鼓泡溶解和骨增生，伴或不伴软组织病变填满或延伸至鼓泡。这些发现是非特异性的，可以在中耳炎以及影响鼓泡的其他病变中发现。
Ultrasonography
超声
The use of ultrasonography has been described in assessing middle ear lesions but has been determined to be less accurate than radiographs and highly operator dependent. It might, however, be of value for obtaining either fine-needle aspiration or true-cut biopsy samples.
超声检查用于评估中耳病变，但已确定其准确性低于x线片，且高度依赖于操作人员。然而，它可能对获得有价值的细针穿刺或true-cut活检样本。
Computed Tomography
CT
Reported findings of the tympanic bulla include osteoproliferation, lysis, and sclerosis. The bulla is expanded (Figs. 1–3) and filled with soft tissue–like material. The external ear canal can be involved and filled with fluid or soft tissue, although in other cases the external ear canal can be air filled (see Fig. 2).
据报道鼓室大泡的表现包括骨增生、松解和硬化。鼓泡扩张(图1-3)，填充软组织样物质。外耳道患病并充满液体或软组织，但在其他病例中，外耳道可充满空气(见图2)。
Fig. 1. A transverse image of a CT of a 7-year-old male castrated cocker spaniel with a leftsided cholesteatoma. (A) Before contrast and (B) after contrast administration. An expansile soft tissue mass of the left tympanic bulla is shown with sclerosis of the left temporal bone. The wall of the bulla shows lytic areas as well as thickening and remodeling. The mass itself is minimally contrast enhancing.
图1所示。7岁雄性阉割可卡犬左侧胆脂瘤的CT横断面图像。(A)对比前(B)对比后。左侧鼓室大泡的膨胀性软组织肿块伴左侧颞骨硬化。鼓泡壁可见溶解区，增厚和结构改变。肿块本身的对比度增强程度最低。
Fig. 2. A transverse image of a CT of a 6-year-old male castrated mixed breed dog with a left-sided cholesteatoma. Note the noninvolvement of the external ear canal and the expansion and destruction of the bulla. A soft tissue attenuating mass expands and fills the entire left tympanic bulla. The ventral margin of the bulla is thin and disrupted; the lesion is localized to the middle ear cavity.
图2所示。左侧胆脂瘤的6岁雄性阉割杂交犬的横断面CT图像。注意外耳道患病，鼓泡扩张和破坏。软组织密度肿块扩张并充满整个左鼓室大泡。鼓泡的腹侧边缘薄且破裂。病变局限于中耳腔。
Fig. 3. A noncontrast transverse image of a CT of a 10-year-old male castrated shih tzu is shown with a left-sided cholesteatoma. The left tympanic bulla is severely expanded and is filled with a soft tissue mass. The expanded bulla attenuates the nasopharynx and is markedly attenuating and displacing the oropharynx and larynx to the right. The temporal and masseter muscles on the left are atrophied compared with the contralateral side.
图3所示。10岁雄性已去势西施犬左侧胆脂瘤的CT未增强横切面图像。左鼓室大泡严重扩张并充满软组织肿块。扩张的鼓泡使鼻咽变细，并使口咽和喉部向右明显变细和移位。与对侧相比，左侧颞肌和咬肌萎缩。
Bone lysis within the squamous or petrosal portions of the temporal bone have been described in 25% (Hardie and colleagues1 ) to 50% (Greci and colleagues3 ) of cases.
25% (Hardie和同事1)到50% (Greci和同事3)的病例描述了颞骨岩部骨溶解内含鳞状上皮。
Initial reports indicated that the tissue in the bulla enhances after contrast administration; however, later descriptions further define the contrast enhancement to be only localized around the lining of the bulla and not to involve the entire soft tissue structure filling the bulla. Other reports indicate that contrast enhancement of the epithelial lining of the tympanic bulla in chronic otitis media cases is confined to an area directly adjacent to the bone (Garosi and colleagues), similar to cholesteatomas. Neoplastic lesions are most commonly an extension of external ear canal tumors into the bulla, and contrast enhancement of the mass within the external ear canal might allow differentiation. Aggressive neoplastic lesions originating within the tympanic bulla are extremely rare but might exhibit some of the same features, such as filling of the bulla with soft tissue and lysis of the bulla wall, but do not typically exhibit the same general expansion of the entire tympanic bulla.
早期报告显示，造影增强后鼓泡组织增强。然而，后来的描述进一步定义了造影增强仅局限于鼓泡周围，而不涉及填充鼓泡的整个软组织结构。其他报道表明，慢性中耳炎患犬鼓膜上皮内衬的增强仅限于与骨直接相邻的区域(Garosi和同事)，类似于胆脂瘤。肿瘤病变最常见的是外耳道肿瘤向鼓泡的延伸，外耳道内肿块的增强造影可能有助于鉴别。起源于鼓泡内的侵袭性肿瘤病变极为罕见，但可能表现出一些相同的特征，如鼓泡被软组织填充和鼓泡壁溶解，但通常不表现出整个鼓泡的相同均一性扩张。
Other findings include enlargement of the local lymph nodes (7 out 19 cases) or sclerosis of the ipsilateral temporomandibular joint in 10 of 11 patients.
其他表现包括局部淋巴结肿大(19例中7例)或同侧颞下颌关节硬化(11例中10例)。
MRI
磁共振成像
MR has been used to further define the intracranial extent of the disease or in the absence of CT imaging capabilities on site.MR is better suited to define the soft tissue structures, such as nerves, vessels, and inner ear structures, whereas CT is better suited to assess the bony structures.
MR已被用于进一步确定疾病的颅内范围，或在无CT影像的情况下。MR更适合于确定软组织结构，如神经、血管和内耳结构，而CT更适合于评估骨骼结构。
MR findings include a severely expanded bulla containing material isointense to brain tissue on T1-weighted and of mixed intensity on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images. Similar to the CT findings, the tissue in the tympanic bulla was found to be minimally contrast enhancing, with contrast enhancement localized to the area immediately adjacent to the bone, in the location of the inner (epithelial) lining of the bulla. Other findings include lysis of the petrous temporal bone. MR features of neoplasia of the tympanic bulla have been described, but the number of cases in the literature might be too low to define distinct characteristics between cholesteatomas of the middle ear and malignant neoplasia of the middle ear.
MR表现包括严重扩张的鼓泡中含有T1加权脑组织等强度的物质，T2加权和液体衰减反转恢复(FLAIR)图像强度混合。与CT结果相似，鼓泡内的组织被发现有最低程度的增强，增强定位于紧邻骨的区域，位于鼓泡的内(上皮)层。其他发现包括颞骨岩溶解。鼓室大泡肿瘤的MR特征已被描述，但文献中的病例数量可能太少，无法明确中耳胆脂瘤和中耳恶性瘤之间的明显特征。
Differential Diagnoses
鉴别诊断
Differential diagnoses to be considered are chronic otitis externa/media and aural neoplasia, either extending from the external canal into the tympanic bulla or neoplasia arising from the bulla.
需要考虑的鉴别诊断是慢性外耳炎/中耳炎和耳道肿瘤，或从外耳道延伸到鼓室大泡，或起源鼓室大泡的肿瘤。
In chronic otitis media, CT would also show a bulla filled with tissue or fluid, with or without lysis of the bone of the bulla, but lacks the expansile nature of growth and expansion of the bulla.
慢性中耳炎，CT也会显示鼓泡充满组织或液体，有或没有鼓泡骨溶解，但缺乏鼓泡膨胀生长和鼓泡扩张。
Neoplasia of the tympanic bulla in dogs is very rare. The most commonly described neoplasias extend from the external ear canal into the bulla (such as ceruminous gland adenoma, ceruminous gland adenocarcinoma, squamous cell carcinoma).Contrast enhancement of the external portion of the mass could help differentiate between these and middle ear cholesteatomas and middle ear neoplasia.
犬鼓泡肿瘤是非常罕见的。最常描述的肿瘤是从外耳道延伸到鼓泡的肿瘤(如耵聍腺瘤、耵聍腺癌、鳞状细胞癌)。增强肿块外部部分的对比度有助于与中耳胆脂瘤和中耳肿瘤进行鉴别。
Imaging findings that are described for middle ear neoplasia are similar to imaging findings for middle ear cholesteatomas but seem to have more contrast enhancement than cholesteatomas. Histologic sampling would be the only definitive differentiation between cholesteatomas and neoplastic lesions; but the otoscopic, cytologic, and imaging findings, in addition to the very rare incidence of primary middle ear neoplasia, should make middle ear cholesteatoma the primary differential.
中耳肿瘤的影像学表现与中耳胆脂瘤的影像学表现相似，但似乎比胆脂瘤有更多的增强。组织取样将是胆脂瘤和肿瘤病变之间唯一明确的鉴别方法;但是耳镜、细胞学和影像学的发现，除了非常罕见的原发性中耳肿瘤外，应该使中耳胆脂瘤成为主要的鉴别诊断。
PATHOLOGY
病理
Cytology
细胞学
Impression smears taken of a biopsy in one report revealed anucleate squamous epithelial cells, low numbers of inflammatory cells, small groups of spindle cells (presumed fibroblasts), and extracellular bacteria (cocci).
在一份报告中，活检的压片显示无核鳞状上皮细胞、少量炎性细胞、少量梭形细胞(推测为成纤维细胞)群和细胞外细菌(球菌)。
Histopathology
组织病理
Biopsy results are consistent with finding keratinizing epithelium and keratin debris (6 ears).
活检结果为角化上皮细胞和角蛋白碎片(6只耳)。
A core of fibrous connective tissue can be present, covered by a hyperplastic keratinizing stratified squamous epithelium. A cystic lesion lined by a multilayered intensely hyperplastic keratinizing epithelium has also been described.
可见纤维结缔组织核心，被增生性角化层状鳞状上皮细胞覆盖。已描述囊性病变内衬多层明显增生性角化上皮细胞。
In the submucosal layer, a large accumulation of cholesterol clefts was present, whereas the center of the lesion contained areas of mineralization and fragments of woven bone, leading to the histopathologic diagnosis of a cholesterol granuloma with osseous metaplasia (incisional biopsy).
在粘膜下层有大量堆积的胆固醇裂，而病变中心有矿化区和编织骨碎片，导致组织病理学诊断为胆固醇肉芽肿伴骨化生(切开活检)。
Microbiology
微生物学
The culture results reflect a similar outcome as would be expected in chronic otitis externa cases. Hardie and colleagues found positive aerobic cultures in 14 out of 16 cultured ears, with 3 dogs having more than 1 bacterial species cultured. Greci and colleagues reported positive aerobic cultures from 8 out of 12 ears, and more than one species was recovered from one ear. Staphylococcus species were the most prevalent, with Enterococcus spp, Pseudomonas aeruginosa, Staphylococcus spp (3), Proteus (2), Pseudomonas, and Escherichia coli (1) making up the remainder of reported bacteria.
培养结果反映了在慢性外耳炎病例中预期的类似结果。哈迪和他的同事们在16只培养的犬患耳中有14只需氧培养为阳性，其中3只犬培养菌种大于一种。Greci和他的同事报告了12只耳中有8只耳的需氧培养呈阳性，并且从一只耳中发现了不止一个菌种。葡萄球菌种类最常见，其余报告的细菌为肠球菌、铜绿假单胞菌、葡萄球菌(3)、变形杆菌(2)、假单胞菌和大肠杆菌(1)。
A recent retrospective study on patients with chronic otitis externa/media reported positive cultures in 89% of cultured ears (n = 127), with Staphylococcus spp in 43% of ears, and found Enterococcus spp, Pseudomonas, E coli, and Proteus mirabilis.
最近一项对慢性外耳炎/中耳炎患犬的回顾性研究报告，89%进行培养的患耳(n = 127)培养呈阳性，43%进行培养患耳中有葡萄球菌，并发现肠球菌、假单胞菌、大肠杆菌和奇异变形杆菌。
TREATMENT
治疗
Surgery
手术
Surgical treatment can be curative in 50% of cases. Early surgical intervention is preferred; but even in later stage disease, surgery is recommended to remove the diseased tissue and remove as much of the space-occupying soft tissue and lesion, both from a diagnostic and from a palliative approach. Palliation might be obtained by removing the painful stimulus by removing the material from the bulla.
手术治疗可治愈50%的病例。首选早期手术干预。但即使在疾病晚期，从诊断和姑息治疗的角度来看，也建议手术切除病变组织和尽可能多的占据空间的软组织和病变。姑息治疗可以通过去除鼓泡上的物质来消除疼痛刺激。
A caudal auricular approach has been described, but a ventral or lateral approach to the bulla is favored for the initial surgical treatment. The caudal approach was described in an attempt to preserve hearing and cosmetic outcome by preserving the external ear canal and reconstructing the ossicles. A ventral approach has been preferentially used for cases with recurrent disease, especially if a lateral approach has been used previously, as it will provide better exposure to the bulla.
已描述了耳道尾侧手术通路，但腹侧或外侧鼓泡切开通路是早期手术治疗推荐方法。尾侧通路通过保留外耳道和重建听小骨来保留听力和美观性。腹侧通路优先用于复发性疾病的病例，特别是如果以前使用过外侧通路的病例，因为它将更好地暴露大泡。
Cases with chronic otitis externa are treated by TECA-LBO, as the disease involves both the external ear canal and the bulla (see Fig. 1). In these cases, the middle ear cholesteatoma could be an extension of the chronic disease in the external ear, with destruction of the tympanic membrane, allowing ingrowth of metaplastic ear canal epithelium into the middle ear. Care is taken to create good access to the tympanic cavity allowing for aggressive removal of the diseased tissue. If the expansive lesion of the bulla cannot be adequately accessed through a lateral approach, a combination of a lateral and ventral approach can be used to maximize exposure. Complete removal is the goal of curative-intent surgery, and inspection of the bulla to check for remaining diseased tissue can be performed with an endoscope to facilitate this. Additionally, care must be taken not to transplant stratified squamous epithelium from the external ear canal into the middle ear during surgery, as this is one of proposed etiopathogeneses of canine middle ear cholesteatomas.
慢性外耳炎病例采用TECA-LBO治疗，因为该疾病涉及外耳道和鼓泡(见图1)。在这些病例中，中耳胆脂瘤可能是慢性疾病在外耳道的延伸，伴有鼓膜的破坏，允许化生耳道上皮细胞向中耳生长。注意为鼓室创造良好的通道，以便积极清除病变组织。如果鼓泡的扩张病灶不能通过外侧通路充分暴露，可以使用外侧和腹侧通路的联合通路以最大限度地暴露。完全切除是治疗性手术的目标，可以用内窥镜检查鼓泡以检查剩余的病变组织。此外，手术中必须注意不要将外耳道的层状鳞状上皮细胞移植到中耳，因为这是犬中耳胆脂瘤的病因之一。
In some cases the cholesteatoma of the middle ear can be contained within the middle ear, without overt external ear canal involvement (see Fig. 2). In such cases, a ventral approach (ventral bulla osteotomy [VBO]) can be used. Care must be taken to ensure that there is no diseased tissue in the external meatus. Magnification, such as surgical loupes, could help guide surgical dissection and removal of the tissue.
在某些病例中，中耳胆脂瘤可被包含在中耳内，而没有明显的外耳道患病(见图2)。在这种病例中，可采用腹侧通路(腹侧鼓泡截骨术[VBO])。必须注意确保外耳道内没有病变组织。放大镜，如手术放大镜，可以帮助指导手术解剖和移除组织。
Regardless of the approach used, care is taken to remove as much of the diseased tissue as possible. Microscopic or endoscopic visualization, or a combination of both,is used in the surgical management of people with middle ear cholesteatomas.This visualization might also help identify neurovascular structures more readily.
无论采用何种方法，都要小心去除尽可能多的病变组织。显微镜或内窥镜显示，或两者的结合，用于手术治疗中耳胆脂瘤。这种可视化也可能有助于更容易地识别神经血管结构。
No difference in outcome was found between cases managed by a lateral approach or ventral approach. Cases managed with a TECA-LBO, or LBO only if a TECA had been performed previously, were evenly distributed over the 2 groups in the article by Hardie and colleagues.They found that the cured cases had a lateral approach in 5 and a ventral approach in 4 cases, whereas the cases with recurrence had a lateral approach in 8 and a ventral in 2 patients. Three cases that had a second surgery all had a lateral approach in the revision surgery.
经外侧通路或腹侧通路治疗的病例结果无差异。在Hardie及其同事的文章中，通过TECA-LBO(或仅在之前进行过TECA时才进行LBO)管理的案例平均分布在两组中。他们发现治愈的病例中有5例经外侧通路，4例经腹侧通路，复发的病例中有8例经外侧通路，2例经腹侧通路。3例第二次手术的病例在二次手术中均采用外侧通路。
It is key to remove all diseased/affected tissue to prevent recurrence. However, even in cases whereby removal was incomplete because of proximity of vital structures, a long-term survival was achieved despite needing chronic intermittent broad-spectrum antibiotics.
切除所有病变/患病组织以防止复发是关键。然而，即使在因靠近重要结构而切除不完全的病例中，虽然需要慢性间歇性广谱抗生素，但仍能获得长期生存。
Postoperative complications include facial nerve palsy/paresis/paralysis, recurrence of signs, development of draining tracts, and failure to resolve the preexisting neurologic signs. These numbers are similar to the reported postoperative complication rates for TECA-LBO in dogs for otitis externa/interna or VBO in dogs.
术后并发症包括面神经麻痹/麻痹/瘫痪、症状复发、出现瘘道和无法解决先前存在的神经症状。这些数字与报道的犬外/内耳炎TECA-LBO或犬VBO术后并发症发生率相似。
Medical Management
药物管理
Chronic antibiotic therapy has been described for management in cases with recurrence after surgery or in cases whereby surgery was declined. The disease unfortunately is progressive, and the continued expansion of the cholesteatoma will lead to worsening of neurologic and/or respiratory signs over time.
慢性抗生素治疗已被描述为手术后复发或拒绝手术的病例管理。不幸的是，这种疾病是进行性的，胆脂瘤的持续扩大将随着时间的推移导致神经和/或呼吸症状的恶化。
PROGNOSIS/RECURRENCE
预后和复发
The combined reported rate of ears without recurrence after surgical therapy is 50%. In the case series by Hardie and colleagues, 9 dogs had no recurrence and 10 had persistent or recurrent signs, whereas in the case series by Greci and colleagues, 7 ears had no recurrence.
手术治疗后患耳无复发率为50%。在Hardie和同事的病例系列中，9只犬没有复发，10只有持续或复发的症状，而在Greci和同事的病例系列中，7只耳朵没有复发。
Greci and colleagues reported a mean time until recurrence of 7.5 months (range 2–13 months postoperatively, 5 ears, confirmed in 4). Of the noncured animals in the study by Hardie and colleagues, 5 dogs were readmitted for neurologic signs 1 to 16 months postoperatively. Three dogs were readmitted for inability to open the mouth at 2, 16, and 31 months postoperatively and underwent a second surgery (lateral approach) and, although requiring chronic intermittent antibiotic therapy, did not die of their cholesteatoma (37, 40, >52 months after the first surgery).
Greci和同事报告的平均复发时间为7.5个月(范围为术后2-13个月，5只耳朵，4只耳朵确认)。在Hardie和同事研究的未治愈的动物中，5只犬在术后1 - 16个月因神经症状再次入院。3只犬在术后2、16和31个月再次因无法张开嘴巴而入院，并接受了第二次手术(外侧通路)，尽管需要慢性间歇抗生素治疗，但没有死于胆脂瘤(第一次手术后52个月)。
Clinical signs on presentation or imaging that were found to have a significant effect on the development of recurrence (univariate analysis) were inability to open mouth, neurologic signs, lysis of the tympanic bulla wall, and lysis within the temporal bone. However, only neurologic signs were shown to be a statistically significant predictor for the development of recurrence when using stepwise multivariable analysis.
以下这些临床症状或影像学表现出现时，提示复发(单因素分析)，包括无法开口、神经症状、鼓泡壁溶解和颞骨内溶解。然而，当使用逐步多变量分析时，只有神经症状被证明是复发发展的统计显著预测因素。
Of the neurologic signs reported by Greci and colleagues, facial palsy and ataxia resolved after surgery, whereas preoperative head tilt persisted postoperatively.
在Greci及其同事报告的神经症状中，面瘫和共济失调在术后得到缓解，而术前头倾斜在术后持续存在。
Risk factors that were identified for recurrence or nonresolution of clinical signs were inability to open mouth in 19 cases (1 cured, 7 not cured), lysis of the bone of the tympanic bulla was present in 11 out of 18 cases imaged (4 cured, 7 not cured), expansion of the bulla was present in 11 out of 18 cases imaged (4 cured, 7 not cured), and bone lysis of the temporal bone was present in 6 out of 18 cases imaged (0 cured,6 not cured). Pseudomonas was only cultured in cases that were not cured. Factors not associated with recurrence were osteoproliferation (6 out of 9 cured, 6 out of 9 not cured), lymph node enlargement (4 out of 9 cured, 3 out of 9 not cured).
风险因素即复发或未缓解的临床症状是无法开口，有19例(1治愈,7未治愈),鼓泡骨质溶解，18例影像中有11例(4治愈,7未治愈),鼓泡扩张，18例影像中11例(4治愈,7未治愈),以及颞骨骨溶解，18例影像中有6例(0治愈,6未治愈)。假单胞菌只在未治愈的病例中培养得到。与复发无关的因素有骨增生(9例治愈6例，9例未治愈6例)，淋巴结肿大(9例治愈4例，9例未治愈3例)。
Of the dogs with recurrence reported by Greci and colleagues, 2 were successfully treated (no recurrence at 32 and 42 months after second surgery). Two other dogs that had recurrence had a combination of multiple surgeries and continued medical management: one dog was treated surgically 4 times (LBO once, VBO 3 times) and still had persistent signs after the fourth surgery and one dog had 2 surgeries and medical management (anti-inflammatory dose of steroids in conjunction with broadspectrum antibiotics) after its second recurrence.
在Greci和同事报告的复发犬中，2只治疗成功(第二次手术后32和42个月均未复发)。另外两只复发的犬接受了多次手术和持续的药物管理:一只犬接受了4次手术治疗(LBO 1次，VBO 3次)，在第4次手术后仍然有持续的症状，一只犬在第二次复发后接受了2次手术和药物管理(抗炎剂量的类固醇联合广谱抗生素)。
Of the cases with recurrence described by Hardie and colleagues, 3 of the 5 dogs with neurologic signs were euthanized without a revision surgery and 2 were managed with chronic systemic antibiotic therapy (one alive at the time of writing, one died of unrelated causes 29 months after the initial surgery). All 3 dogs presenting for inability or reluctance to open the mouth had a second surgery, and all required chronic intermittent systemic antibiotic therapy. Two died of unrelated causes at 37 and 40 months after the initial surgery, whereas the third was alive at the time of writing (52 months after the first surgery).
在Hardie及其同事描述的复发病例中，5只有神经症状的犬中有3只在没有二次手术的情况下被安乐死，2只接受了慢性全身抗生素治疗(其中一只在撰写本文时仍活着，一只在初次手术后29个月死于原因无关病因)。所有3只表现为不能或不愿张开嘴的患犬都进行了第二次手术，所有犬都需要慢性间歇性全身抗生素治疗。两名患犬在首次手术后37个月和40个月死于无关病因，而第三名患犬在撰写本文时(第一次手术后52个月)仍活着。
SUMMARY
总结
Surgical intervention can be curative. Dogs with early stage disease have a better outcome than dogs with more chronic disease and with temporal bone involvement. Dogs with recurrent disease can be reoperated or managed medically with long-term resolution or palliation of clinical signs.
手术干预可以治愈。患有早期疾病的犬比患有慢性疾病和颞骨患病的犬有更好的结果。有复发性疾病的犬可以二次手术或药物治疗，能长期解决或缓解临床症状。 | 
|Archiver|手机版|小黑屋|宠医帮
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发表于 2023-2-20 21:25:37
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