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Diagnosis and medical treatment of otitis externa in the dog and cat
犬猫外耳炎诊断和药物治疗
作者：L S Jacobsona
翻译：王帆
ABSTRACT
摘要
Otitis externa is no longer viewed as an isolated disease of the ear canal, but is a syndrome that is often a reflection of underlying dermatological disease. Causes are classified as predisposing (increase the risk of otitis); primary (directly induce otitis), secondary (contribute to otitis only in an abnormal ear or in conjunction with predisposing factors) and perpetuating (result from inflammation and pathology in ear, prevent resolution of otitis). Common primary causes include foreign bodies, hypersensitivity (particularly atopy and food allergy), keratinisation disorders (most commonly primary idiopathic seborrhoea and hypothyroidism) and ear mites, particularly in cats. A systematic diagnostic procedure is required to identify causes and contributing factors. This should include history, clinical examination, otoscopy and cytology in all cases and culture and sensitivity as well as otitis media assessment and biopsy in severe and recurrent cases. Ancillary tests may be required depending on the underlying cause. Treatment consists of identifying and addressing predisposing and primary factors; cleaning the ear canal; topical therapy; systemic therapy where necessary; client education; follow-up; and preventive and maintenance therapy as required.
外耳炎不再被视为只是局限的耳道疾病，而是一种综合征，往往反映了存在潜在皮肤疾病。病因分为易感因素(增加耳炎的风险)、原发因素(直接引发耳炎)、继发因素(仅在异常耳道中或与易感因素一起促进耳炎发展)和持久因素(因为耳炎和病理学变化，阻碍耳炎消退)。常见的原发病因包括异物、过敏反应(尤其是特应性皮炎和食物过敏)、角化异常(最常见于原发性特发性皮脂溢和甲状腺功能减退)和耳螨，尤其是猫。需要一个系统的诊断程序来确定病因和促成因素。这应包括所有病例的病史、临床检查、耳镜检查和细胞学检查，以及严重和复发病例的细菌培养和药敏试验以及中耳炎评估和活检。根据潜在病因，可能需要辅助检查。治疗包括识别和处理易感因素和原发因素;清洁耳道;外部治疗;必要时进行全身治疗;客户教育;随访;根据需要进行预防和维持治疗。
Key words: cat, diagnosis, dog, otitis externa, review, treatment
关键词：猫、诊断、犬、外耳炎、综述、治疗
CAUSES, PATHOPHYSIOLOGY AND DIAGNOSTIC APPROACH
病因、病理生理学和诊断方法
Classification and causes of otitis externa
外耳炎分类和病因
Otitis externa is a syndrome, not a diagnosis. The term refers to inflammation of the external ear canal, rather than to a specific disease process. Clinically, otitis externa can be unilateral or bilateral, acute or chronic, mild to severe, non-recurrent or recurrent and amenable or resistant to routine therapy. It has been classified according to the type of exudate as erythema to ceruminous or suppurative, with the former subgrouped as parasitic or nonparasitic .
外耳炎是一种综合征，不是诊断。该术语指的是外耳道炎症，而不是特定的疾病过程。临床上，外耳炎可为单侧或双侧，急性或慢性，轻度到重度，非复发或复发，常规治疗有效或耐药。根据分泌物的类型分为红斑性至耵聍性或化脓性，前者分为寄生虫亚型和非寄生虫亚型。
Otitis externa can be caused and perpetuated by many conditions and factors, frequently more than 1 at a time. These have been classified as predisposing factors (increase the risk of otitis), primary causes (directly induce otitis) and perpetuating factors (result from inflammation and pathology in ear that prevents resolution of otitis) and this has become standard usage. The classification was recently adapted to include secondary causes, which were previously included as perpetuating factors. Secondary causes contribute to otitis only in an abnormal ear or in conjunction with predisposing factors. Table 1 lists and defines causes of otitis, and indicates which are most common. As illustrated in the table, primary causes can be local or generalised, while secondary causes and predisposing or perpetuating factors are more likely to be local. Most microbial infections of the ear are secondary to another disease or factor and are usually opportunistic.
外耳炎可由许多疾病和病因引起和持续存在，经常不止一个。这些因素被分为易感因素(增加耳炎的风险)、原发病因(直接引发耳炎)和持久因素(由耳炎和病理导致，妨碍耳炎恢复)，这已经成为标准用法。最近对分类作了调整，把继发病因包括在内，以前把继发病因列入持久因素。继发病因只在不正常的耳或与易感因素一起导致耳炎。表1列出并定义了耳炎的病因，并指出了最常见的病因。如表1所示，原发病因可以是局部的或全身的，而继发病因和易感或持久因素则更可能是局部的。大多数耳的微生物感染是继发于另一种疾病或因素，通常是条件致病性。
Pathology and pathophysiology
病理学和病理生理学
The pathophysiology of otitis externa is not complex – in fact perhaps the opposite. Fig. 1 shows the self-perpetuating nature of the condition if untreated or inadequately treated.
外耳炎的病理生理并不复杂——事实上可能恰恰相反。图1显示了如果不治疗或不适当的治疗导致顽固性疾病。
The detailed pathology of otitis, particularly early on, differs to some extent according to the cause, but in general, changes are rather stereotyped. Acute inflammation and oedema, if not resolved, progresses over time to chronic inflammation, characterised by glandular changes, fibrosis and scarring, and, eventually, progressive stenosis and occlusion of the ear canal. Permanent changes such as calcification and later ossification of cartilage can occur. Possible sequelae are otitis media and aural cholesteatoma (both also perpetuating factors). Chronic changes favour proliferation of bacteria and yeasts, further perpetuating pathology. Ulceration of the ear canal can occur, usually in association with Pseudomonas infection. The secondary lesions of chronic otitis are due to chronic irritation and microbial overgrowth.
耳炎的详细病理，特别是早期，根据病因在一定程度上有所不同，但总的来说，变化是千篇一律的。急性炎症和水肿如果不能消除，随着时间的推移会发展为慢性炎症，其特征是腺体改变、纤维化和瘢痕，进一步耳道狭窄和阻塞。可能会发生永久性的变化，如钙化和后来的软骨骨化。可能的并发症是中耳炎和耳胆脂瘤(两者都是持久因素)。慢性变化有利于细菌和酵母菌的增殖，进一步持久性病理变化。可发生耳道溃疡，通常与假单胞菌感染有关。慢性耳炎的继发病变是由于慢性刺激和微生物过度增殖所致。
Diagnostic approach
诊断方法
‘Diagnosis and clinical management of otitis externa is often frustrating because there are numerous factors and diseases that predispose to otitis and numerous secondary pathogens that perpetuate the process’.
“外耳炎的诊断和临床管理常常令人沮丧，因为有许多因素和疾病都容易导致耳炎，还有许多继发性病原体使这一过程持续下去。”
In the light of the widely divergent causes of otitis externa, a systematic diagnostic assessment is essential. The approach to the ear 2 decades ago was to examine and treat it in isolation . The current approach differs substantially, as the ear canal has now been given its proper place as a specialised extension of the skin and otitis externa is now recognised as a dermatological condition. Diagnosis of the syndrome is straightforward – it can be recognised by variable degrees of head-shaking, pruritus, pain, odour and exudation from the ear. Othaemotoma may result from pruritus. The diagnostic challenge in otitis is to determine the primary cause and identify secondary and perpetuating factors. It is difficult to assess how often it is possible to make a specific primary diagnosis, as little data are available. A primary cause was identified in 8/12 cases of chronic, proliferative Pseudomonas otitis and Griffin asserts that, ‘In the majority of chronic ear cases I can find historical or physical evidence of the primary disease.’ It seems likely that the primary cause can be found in a reasonable number of cases and that predisposing, secondary and perpetuating causes can be identified and controlled in most. Identifying a primary cause is more important in chronic or recurrent otitis than acute otitis.
鉴于外耳炎有许多不同病因，必要进行系统的诊断评估。20年前对耳部的检查和治疗是各自独立的。目前的方法有很大的不同，因为耳道现在已经被赋予了适当的位置，作为皮肤的特殊延伸，外耳炎现在被认为是一种皮肤病。该综合征的诊断很简单——可以通过不同程度的甩头、瘙痒、疼痛、异味和耳部分泌物来识别。耳血肿可由瘙痒引起。耳炎诊断难点是确定原发病因和确定继发和持久的因素。由于可获得的数据很少，很难评估多久能作出具体的初步诊断。在8/12的慢性增生性假单胞菌性耳炎病例中发现了原发病因，Griffin声称，“在大多数慢性耳炎病例中，我都能找到原发性疾病的病史或体格检查证据。”“似乎在相当数量的案例中可以找到原发病因，而在大多数案例中，易感原因、继发病因和持久因素都可以确定和控制。”在慢性或复发性耳炎中确定原发病因比急性耳炎更重要。
Routine diagnostic procedures
常规诊断流程
Table 2 shows recommended diagnostic procedures for otitis. The assessment in all cases should include a general and dermatological history, physical and dermatological examination, otoscopy, and cytology. A standard dermatological questionnaire can be used to ensure that important details are obtained in all cases.
表2显示了耳炎的推荐诊断程序。所有病例的评估应包括一般病史和皮肤病史、体格检查和皮肤学检查、耳镜检查和细胞学检查。标准的皮肤病学调查问卷可用于确保在所有病例中获得重要的细节。
Proper otoscopic examination is essential. Adequate visualisation depends on patient control (sedation or general anaesthesia are often required), a meticulously clean ear, and absence of severe inflammation and oedema. In some cases, local or systemic treatment might be required for a few days before otoscopy can be performed1. Otoscopy is used to assess the diameter of the ear canal, the amount and type of exudate, the presence of ulcers, foreign bodies, parasites, tumours and other space-occupying lesions as well as the integrity of the tympanic membrane . In 1 study, otoscopic examination of the tympanic membrane was only considered adequate in 28 % of otitic ears (compared with 78 % of healthy ears). However, otoscopy was reasonably effective at diagnosing ruptured tympanic membranes, although the sensitivity and specificity were suboptimal – tympanometry had 100 % sensitivity and specificity, compared with 83 % and 93 % for otoscopy.
适当的耳镜检查是必不可少的。充分的显像取决于患病动物保定(通常需要镇静或全身麻醉)，一个非常干净的耳朵，以及没有严重的炎症和水肿。在某些病例中，在进行耳镜检查之前，可能需要局部或全身治疗几天。耳镜检查用于评估耳道的直径、分泌物的量和类型、溃疡、异物、寄生虫、肿瘤和其他占位性病变的存在以及鼓膜的完整性。在一项研究中，只有28%的耳炎患耳(与78%的健康耳相比)认为耳镜检查鼓膜就足够。然而，耳镜在诊断鼓膜破裂方面是相当有效的，但敏感性和特异性不是很理想——鼓室测量法的敏感性和特异性为100%，而耳镜的敏感性和特异性分别为83%和93%。
The odour and gross appearance of the exudate is somewhat helpful, but not very reliable. Thus, although a particular kind of exudate can increase the index of suspicion for a particular kind of otitis (Table 3), gross examination alone is inadequate.
分泌物的异味和外观是有帮助的，但不是很可靠。因此，虽然某一种分泌物可增加某一种耳炎的怀疑指数(表3)，但仅肉眼检查是不够的。
Cytology is the pre-eminent diagnostic tool in otitis externa and is recommended for all cases where exudate or debris are present. Sample collection and preparation has been covered in detail, but is essentially straightforward. A sample from the horizontal canal is collected onto a clean cotton-tipped swab, part of the sample is examined under oil and part is rolled onto a slide, dried, stained and examined for yeasts, bacteria, inflammatory and neoplastic cells. Cytology is more sensitive than culture, and culture (where indicated; see below) should never be performed without simultaneous cytology. Cytology can demonstrate the number and morphology of bacteria, number of yeasts, presence of fungal hyphae, presence of parasites, number and type of leukocytes and whether they are phagocytosing organisms, the presence of excessive cerumen, keratinaceous debris and neoplastic cells.
细胞学检查是外耳炎的首选诊断工具，推荐用于所有有分泌物或碎片的病例。我们已经详细介绍了样本的采集和准备，但基本上很简单。用干净的棉签从水平耳道中采集样本，一部分在油中检查，另一部分滚到载玻片上，干燥、染色并检查是否有酵母菌、细菌、炎性细胞和肿瘤细胞。细胞学检查比细菌培养更敏感。不要在没有同时进行细胞学检查的情况下进行细菌培养（见下文）。细胞学可以显示细菌的数量和形态、酵母菌的数量、真菌菌丝的存在、寄生虫的存在、白细胞的数量和类型以及它们是否具有吞噬作用、是否存在过多的耵聍、角质碎屑和肿瘤细胞。
Since microorganisms are present in normal ears, how does the clinician assess whether those seen on cytology are abnormal or not? The presence of inflammatory cells, particularly if phagocytosing organisms are present, generally removes any doubt, but this is not always seen in otitis, particularly in Malassezia infections. Therefore, numbers or relative numbers, of organisms are used as an index. Rausch found that otitic ears had >10 Malassezia yeasts per high-power (10 × 40) field (>4 per 10 × 100 oil immersion field), while healthy ears had ＜10 per high power field. This has since been used as the basis of recommendations. It has also been suggested that numbers of yeasts be evaluated in relation to numbers of bacteria and the clinician should thereby assess which are the major organisms present. It is useful to grade numbers of organisms using a consistent scale, preferably on a pre-printed card, for follow-up purposes.
因为正常耳道也有微生物存在，临床医生如何评估细胞学上看到的是否异常?炎症细胞的存在，特别是有吞噬微生物的存在，通常可以消除任何怀疑，但这并不总是在耳炎中出现，特别是马拉色菌感染。因此，微生物的数量或相对数量被用作指标。Rausch发现，耳炎患耳每高倍镜(10 × 40)视野马拉色酵母菌数量为＞10 （＞4个/10×100倍油镜视野），而健康耳每高倍镜视野＜10个。此后，这一直被用作各项建议的基础。也有人建议，酵母菌数量与细菌的数量有关，因此，临床医生应评估哪些是主要的微生物。使用一致的评分对微生物数量进行分级是有用的，最好是在打印好的卡片上，用于复诊评估。
As a general guideline, healthy ears contain some keratinaceous cells, may contain low numbers of Malassezia and cocci, and have no, or extremely few, inflammatory cells. Large numbers of Malassezia and/or cocci should be considered abnormal, while any rods, fungal hyphae, ectoparasites, neoplastic cells and inflammatory cells (unless extremely sparse) are abnormal. If present in sufficient numbers, Otodectes cynotis mites are easily identified under oil. Unfortunately, mites are not always detectable, particularly in dogs. This is at least in part because very few mites (2–3) can initiate pathology.
作为通用指南，健康耳含有一些角质形成细胞，可能含有少量马拉色菌和球菌，没有或极少有炎症细胞。大量马拉色菌和/或球菌应视为异常，而任何杆菌、真菌菌丝、外寄生虫、肿瘤细胞和炎症细胞(除非极其稀少)均为异常。如果有足够的数量，可以很容易地在油镜下辨认出耳螨。不幸的是，螨虫并不总是能被检测到，尤其是在犬上。这至少在一定程度上是因为极少数螨虫(2-3个)就可以引发病理变化。
Additional procedures for chronic and recurrent otitis
慢性和复发性耳炎的进一步检查
Table 2 lists additional diagnostic techniques recommended for chronic and recurrent otitis. In these cases, a record should be kept, for assessment and follow-up purposes, of the grade and severity of oedema, the degree of canal stenosis, oedema or occlusion from chronic hyperplasia, the quality, character and colour of exudate, and cytological findings.
表2列出了对慢性和复发性耳炎推荐的其他诊断技术。对于这些病例，应记录水肿的级别和严重程度、耳道狭窄程度、慢性增生引起的水肿或阻塞程度、分泌物的性质、特征和颜色以及细胞学检查结果，以便评估和随访。
The overall usefulness of culture and sensitivity in otitis externa is limited. Many research groups have studied culture and sensitivity characteristics, but the results (and, indeed, results from individual cases) are quite difficult to translate into definite treatment recommendations. Agreement between cytology and culture is not always good. The sensitivity of culture is inferior to that of cytology, with the exception of Pseudomonas infections. In vitro sensitivity is unlikely to be the same as in vivo, as drug concentrations are much higher in the ear than on sensitivity discs. In addition, most ears are treated in multiple ways. Cleaning agents, the mechanical act of flushing, antiseptics, multiple antibacterials in some preparations and vehicles will alter the microenvironment and affect bacteria in ways that cannot be predicted by testing a single drug in a laboratory. Many studies (and laboratories) include drugs such as unpotentiated penicillins and others which are rarely indicated for either topical or systemic use in otitis.
外耳炎的细菌培养和药敏试验的总体作用是有限的。许多研究小组已经研究了培养和药敏特征，但结果(事实上，来自个别病例的结果)很难转化为明确的治疗建议。细胞学和培养之间的一致性并不总是好的。除假单胞菌感染外，培养的敏感性低于细胞学。体外敏感度不太可能与体内相同，因为耳道药物浓度远高于药敏试验。此外，大多数患耳有多种治疗方法。洗耳液、机械冲洗、抗菌剂、一些制剂和载体中的多种抗菌剂会改变微环境，影响细菌的方式无法通过在实验室中测试单一药物来预测。许多研究(和实验室)包括非增强青霉素等药物，这些药物很少用于耳炎的外部或全身治疗。
For the above reasons, culture and sensitivity are only recommended in the following circumstances, which usually occur in association with recurrent and/or chronic otitis:
• Rods seen on cytology.
• Systemic antibiotics required.
• Failure to respond to initial treatment.
• Otitis media diagnosed or suspected.
• Pseudomonas infection suspected (even if rods not visualised on cytology).
基于上述原因，只建议在以下情况下进行细菌培养和药敏试验，这些情况通常与复发性和/或慢性耳炎有关:
•细胞学检查见杆菌。
•需要全身性抗生素。
•初始治疗无效。
•确诊或疑似中耳炎。
•怀疑为假单胞菌感染(即使细胞学上看不到杆菌)。
If concurrent otitis media is present, the exudate in the middle ear should be cultured separately, as different organisms and/or sensitivity patterns often occur.
如果同时存在中耳炎，中耳分泌物应单独培养，因为不同的生微生物和/或敏感性模式经常发生。
Unlike otitis externa, otitis media is difficult to diagnose. It may be secondary to chronic otitis externa and may in turn perpetuate otitis externa. The proportion of dogs with otitis externa that also have otitis media appears to vary regionally, but has been estimated to be as high as 50 %. In chronic otitis, careful attention should be given to otoscopic examination of the tympanic membrane, but even under ideal circumstances the membrane cannot be adequately visualised in many cases and it is intact in almost three-quarters of cases of otitis externa with concurrent otitis media. Myringotomy is a useful diagnostic tool for otitis media.
与外耳炎不同，中耳炎很难诊断。它可能是继发于慢性外耳炎，进而可能存在持久性外耳炎。患有外耳炎的犬同时患有中耳炎的比例似乎因区域而异，但据估计高达50%。在慢性耳炎中，应仔细注意耳镜检查鼓膜，但即使在理想的情况下，许多病例鼓膜也不能充分显示，而在几乎四分之三的外耳炎合并中耳炎的病例中，鼓膜是完整的。鼓膜切开术是诊断中耳炎的有效手段。
Radiography is likely to be diagnostic of otitis media if the condition is very chronic, neurological signs are present, and/or the tympanic membrane is perforated . However, normal radiographs do not rule out pathology in the middle ear. Computerised tomography or magnetic resonance imaging are good diagnostic tools for acute otitis media.
如果中耳炎是慢性的，有神经症状和/或鼓膜穿孔，x线摄影可能能诊断中耳炎。然而，正常的x光片不排除中耳病变。计算机断层扫描或核磁共振成像是诊断急性中耳炎的好工具。
In chronic cases, biopsy of the proximal vertical canal and/or proximal pinna can be performed. This is an underused technique, and can provide useful diagnostic and prognostic information. Any tumour or proliferative mass should be biopsied.
在慢性病例中，可以对近端垂直耳道和/或耳廓开口进行活检。这是一种未充分利用的技术，可以提供有用的诊断和预后信息。任何肿瘤或增生性肿块都应活检。
Any additional diagnostic procedures depend on the suspected or known primary problems, but might include haematology, serum chemistry profile, urinalysis, endocrine tests, allergy testing, and evaluation of the immune system.
任何额外的诊断程序取决于怀疑或已知的原发问题，但可能包括血液学，血清化学分析，尿液分析，内分泌测试，过敏测试和免疫系统评估。
MEDICAL TREATMENT OF OTITIS EXTERNA
外耳炎药物治疗
‘One of the most significant advances in the management of chronic otitis over the past 20 years is that we no longer expect that taping the ears over the head and applying a topical ointment for 7 to 10 days will take care of the problem.’.
“在过去的20年里，治疗慢性耳炎最重要的进展之一就是，我们不再指望把耳朵贴在头上，用7-10天外用药膏就能解决问题。”
Treatment of otitis is tailored to each individual case. Therapeutic agents and products should be targeted at known causes and problems, the choice being based largely on a combination of diagnostic findings and personal experience. The number of commercially available products used in the ear, the array of extralabel treatments recommended, plus the combination of types of otitis and the variety of contributing factors have precluded the establishment of a solid, objective body of literature detailing which specific treatments are most appropriate in which specific circumstances. The general approach to treatment is as follows: identify and address predisposing and primary factors; clean the ear canal; institute topical therapy; institute systemic therapy (where needed); client education; follow-up; preventive and maintenance therapy (as required). Aggressive surgical management might be indicated when intractable proliferation and stenosis of the ear canal are present. One of the aims of medical therapy in dogs with known risk factors for chronic, severe, intractable otitis externa is to prevent the condition deteriorating to the point where surgery is the only option.
对耳炎的治疗是有个体差异的。治疗药物和产品应针对已知的病因和问题，选择主要基于诊断结果和个人经验的结合。目前市面上用于耳部治疗的产品的数量、推荐的一系列耳部外部治疗方法，再加上耳炎的类型和各种促成因素的组合，使得我们无法建立一个坚实、客观的文献体系，详细说明哪种特定治疗方法在哪种特定情况下最合适。一般的治疗方法如下:识别和处理易感因素和原发因素;清洁耳道;制定外部治疗;开展全身治疗(必要时);客户教育;随访;预防性和维持性治疗(根据需要)。当出现顽固性增生和耳道狭窄时，可能需要积极的手术治疗。对于有慢性、严重、顽固性外耳炎危险因素的犬，医学治疗的目的之一是防止病情恶化到只能手术治疗的地步。
Treatment of predisposing and primary factors
易感因素和原发因素治疗
Management of predisposing and primary factors varies widely according to the cause(s), and is beyond the scope of this review. Recent texts and reviews should be consulted for specific information.
根据病因的不同，易感因素和原发因素的管理差异很大，这超出了本综述的范围。具体资料应参考最近的案文和审查。
Cleaning the ear canal
耳道清洁
Cleaning and drying the ear canal is an essential part of assessment and treatment. Cleaning allows optimal visualisation; removes debris; reduces the microbial population; removes microbial by-products such as toxins and enzymes; allows topical drugs to reach their site of action; increases the effectiveness of topical medications (some of which can be inactivated by exudate) and has a soothing effect. Unremoved debris can function as small foreign bodies and act as the nidus for reinfection.
清洁和干燥耳道是评估和治疗的一个重要部分。清洁可获得最佳视觉效果;清除碎片;减少微生物量;去除微生物的副产品，如毒素和酶;使外部药物到达作用部位;增加外用药的疗效(其中一些可以通过分泌物失活)，并具有舒缓作用。未清除的碎片可以作为小的异物，并作为再次感染的病灶。
In mild cases, home cleaning with a ceruminolytic is sufficient, but many cases require flushing under sedation or general anaesthesia. In very severe otitis, systemic and/or topical medication must be administered for up to 2 weeks before the canal is sufficiently open to allow adequate cleaning. Ear cleaning and drying products, and their uses, are listed in Table 4. Cleaning usually involves a ceruminolytic, a flushing agent and in some cases a drying agent. Ceruminolytics soften and emulsify waxy debris, and are usually detergents or surfactants. Examples, in decreasing order of efficacy, are dioctyl sodium sulphosuccinate, propylene glycol, glycerine and mineral oil. All ceruminolytics are potentially ototoxic and should not be used if the tympanum is known or suspected to be ruptured. Flushing solutions include saline, water, acetic acid, chlorhexidine and povidone-iodine (Table 4). Saline does not damage the middle ear even under extreme circumstances and can thus be recommended for routine use.
在轻度病例中，家庭清洁用耵聍溶解剂就足够了，但许多病例需要在镇静或全身麻醉下冲洗。对于非常严重的耳炎，全身和/或外用药物治疗必须持续2周，直到耳道充分开放，以便充分清洁。耳朵清洁和干燥产品及其用途列于表4。清洗通常涉及到耵聍溶解剂，冲洗剂和在某些病例需要干燥剂。耵聍溶解剂软化和乳化蜡样耳垢，通常是洗涤剂或表面活性剂。按功效递减顺序排列的例子有二辛基磺琥珀酸钠、丙二醇、甘油和矿物油。所有的耵聍溶解剂都有潜在的耳毒性，如果已知或怀疑鼓膜破裂，不应使用。冲洗液包括生理盐水、水、醋酸、氯己定和聚维酮碘(表4)。生理盐水即使在极端情况下也不会损害中耳，因此建议日常使用。
Ear flushing is approached as follows: the integrity of the tympanic membrane is assessed, using history, severity and clinical signs in addition to otoscopy. If the membrane is intact, the canal is filled with a ceruminolytic, massaged and left for 5–10 minutes. Omit this step if the tympanum is known or suspected to be ruptured. The canal is gently flushed with warm flushing solution, using a rubber bulb syringe or soft tube (urinary catheter or feeding tube) with a 10 m syringe. The latter apparatus is considered safest and is very effective. Use of a 3-way stopcock (attached to an infusion set leading to the saline bag, the flushing tube and an outlet tube) streamlines the process. A vacuum system can be used but is not essential. The flushing tube must be sterile, narrow enough to ensure that there is a space between it and the canal to avoid pressure build-up, and atraumatic. The tube is inserted through an otoscope cone and the flushing process visualised through the otoscope. Debris is removed by gentle flushing and suction. Large particles and hairs can be removed using alligator forceps. After the first flush, excess liquid is removed from the ear by gentle suction, and the canal and eardrum reassessed. Any obstinate debris should be carefully removed using a curette or loop inserted through the otoscope head, and the canal flushed until it is clean. Cottonwool swabs should be avoided, as they are traumatic and can compact debris in the canal. If the tympanum is ruptured, flushing fluid may enter the mouth or nasal cavity, and swallowing or fluid leakage from the nose may be seen. Intubation of anaesthetised dogs should be routine to prevent aspiration pneumonia.
耳部冲洗的方法如下:除耳镜检查外，还通过病史、严重程度和临床症状评估鼓膜的完整性。如果鼓膜是完整的，则用耵聍溶解剂灌满耳道，按摩并静置5-10分钟。如果知道或怀疑鼓膜破裂，则省略这一步。使用橡胶洗耳球或带10毫升注射器的软管(导尿管或饲管)，用温冲洗溶液轻轻冲洗耳道。后一种方法被认为是最安全且非常有效的。使用三通(连接在输液器上，通向生理盐水袋、冲洗耳道和耳道开口)可以简化这个过程。可以使用真空系统，但不是必需的。冲洗管必须是无菌的，足够窄，以确保它和耳道之间有一个空间，以避免压力积聚，并且是无创伤的。该管通过耳镜锥形头插入，并通过耳镜显示冲洗过程。通过温和的冲洗和吸入去除杂物。大颗粒和毛发可以用鳄鱼钳去除。第一次冲洗后，用轻柔的吸力将多余的液体从耳中吸出，并重新评估耳道和鼓膜。任何顽固的碎片都应该用刮匙或耳镜头插入的耳环小心地清除，并冲洗耳道，直到它干净为止。应避免使用棉签，因为棉签会造成创伤，并会挤压耳道中的碎片。如果鼓室破裂，冲洗液可能进入口腔或鼻腔，可以看到吞咽或液体从鼻子流出。麻醉犬应常规插管，预防吸入性肺炎。
If the tympanum is only discovered to be ruptured after the initial flushing, or has is ruptured during the procedure, the middle ear is gently and thoroughly flushed with saline or water to remove any traces of ceruminolytic and/or debris. Once flushing is complete, the canal is dried using gentle suction. Topical medication and/or a drying agent are instilled if required.
如果在初次冲洗后才发现鼓膜破裂，或在冲洗过程中已经破裂，则应用盐水或水轻轻地彻底冲洗中耳，以清除任何残存的耵聍溶解剂和/或碎片。冲洗完成后，用轻柔的吸力将耳道吸干。外用药和/或干燥剂注入，如果需要。
The main danger of ear flushing is inadvertent rupture of the tympanic membrane; this is most likely if the membrane is already compromised. Introduction of ototoxic substances into the middle ear through a ruptured membrane is a related hazard. Contact irritation or allergy can result from ear flushing with more caustic substances. To minimise ototoxicity and irritation, the mildest possible products should be used and if more caustic products are needed, they should be rinsed out afterwards with warm saline or water. Iatrogenic damage to the ear canal and tympanic membrane are further minimised by avoiding ‘blind’ introduction of catheters or instruments; these should always be introduced through an otoscope cone and the procedure visualised as it is being performed. Resistant pathogens can be transmitted from one animal’s ears to another through inadequately sterilised equipment; this can be avoided by proper sterilisation and by discarding equipment that cannot be properly sterilised, such as rubber tubes. Auditory or vestibular dysfunction may rarely follow ear flushing even if no ototoxic substances are used; this is more common in the cat than the dog.
耳道冲洗的主要危险是无意中鼓膜破裂;这是最有可能的，如果鼓膜已经破坏。耳毒性物质通过破裂的鼓膜进入中耳是一个相关的危险。含有更多腐蚀性物质的耳道冲洗可导致接触性刺激或过敏。为了尽量减少耳部的毒性和刺激，应使用最温和的产品，如果需要更多的腐蚀性产品，应在之后用温盐水或清水冲洗。避免“盲目”插入导管或仪器，进一步减少医源性损伤耳道和鼓膜;这些都应该通过耳镜锥形头进行，手术过程应该是可视化的。耐药微生物可以通过消毒不充分的设备从一只动物的耳朵传播到另一只动物;这可以通过适当的消毒和丢弃不能适当消毒的设备(如橡胶管)来避免。即使没有使用耳毒性物质，耳道冲洗后可能罕见听力或前庭功能障碍;这在猫上比在犬上更常见。
Owners can carry out maintenance or preventive cleaning at home, using products suited to the particular case (Table 4). A squeeze bottle or bulb syringe can be used; the latter should be cleaned with 50:50 vinegar:alcohol after each use, and should be changed at least every 2–5 weeks. In very severe otitis, or with very fractious dogs, a temporary cleaning device (see reference) can be inserted in the ear and left in place for 5–10 days. Although frequent home cleaning might be required initially, it is generally recommended that owners do not clean ears more often than once every 2 days. Frequent home-cleaning can result in continual moisture in the ear with secondary infection, and/or irritation of the ear.
宠主可根据具体情况使用适合的产品在家进行保养或预防性清洗(表4)。可使用挤压瓶或洗耳球;后者每次使用后应用50:50的醋:酒精清洗，至少每2-5周更换一次。在非常严重的耳炎，或与非常暴躁的犬，一个临时的清洁设备(见参考)可以插入耳朵，并留在那里5-10天。虽然最初可能需要频繁的家庭清洁，但一般建议宠主清洁耳朵的频率不要超过2天一次。频繁的家庭清洁会导致耳朵持续潮湿，进而导致继发性感染和/或刺激耳朵。
Topical therapy
外部治疗
Topical therapy is an important part of the treatment of otitis externa. Combination or multipurpose products are frequently indicated, particularly initially, because of the mix of microorganisms, inflammation and sometimes, parasites that are present in most ears at the time of diagnosis. Although symptomatic topical treatment is effective and can be curative alone, the short-term effectiveness of such treatment can lull practitioners and owners into a false sense of security and lead them to by pass attempts to identify factors contributing to the disease. This is considered by some to be a perpetuating factor of otitis.
外部治疗是外耳炎治疗的重要组成部分。经常使用复方或多用途产品，特别是最初，因为微生物的混合，炎症，有时，寄生虫，在诊断时存在于大多数耳朵。虽然对症外用治疗是有效的，而且可以单独治疗，但这种治疗的短期效果会使医生和宠主产生一种错误的安全感，并导致他们忽略了识别导致疾病的因素的尝试。这被一些人认为是耳炎的持久因素。
Topical therapy should be selected on the basis of clinical findings, cytology, underlying causes and personal experience. Treatment requirements may change as the case progresses. Most routine topical otitis preparations contain a glucocorticoid, antibiotic, antifungal, and sometimes an antiparasitic agent, in an oily or aqueous vehicle. Commercial products currently available in South Africa are listed in Table 5. Disinfectants, ophthalmic and self-formulated preparations are also effective in certain types of otitis. The array of products highlights the fact that there is no ‘magic bullet’ for otitis externa. There is little scientific data to show that 1 combination treatment is better than another and personal preference plays an important role.
应根据临床表现，细胞学，潜在病因和个人经验选择外部治疗。治疗要求可能随着病例的进展而改变。大多数常规的外用耳炎制剂含有糖皮质激素、抗生素、抗真菌剂，有时也含有抗寄生虫剂，有油剂或水剂。表5列出了目前南非可用的商业产品。消毒剂、眼科药品和自行配制的制剂对某些类型的耳炎也有效。这一系列的产品强调了这样一个事实:外耳炎没有“灵丹妙药”。很少有科学数据表明一种复方治疗比另一种更好，个人偏好起着重要作用。
Components of topical otic medications
外用耳药成份
Glucocorticoids
糖皮质激素
Topical glucocorticoids are considered beneficial in most cases of otitis externa, regardless of the underlying cause of inflammation and most otic preparations contain a glucocorticoid. Benefits include:
外用糖皮质激素被认为对大多数外耳炎病例有好处，无论炎症的潜在病因，大多数耳药含有糖皮质激素。优势包括:
• Potent antipruritic/anti-inflammatory action.
• Break the ‘itch-scratch-itch’ cycle.
• By reducing pain and pruritus, making it easier to medicate the animal.
• Reduce exudation and swelling, thus improving ventilation and drainage.
• In severe cases, part of pretreatment to allow visualisation of the ear canal.
•Reduce scarring and fibrosis, thus reducing hyperplastic and proliferative changes.
• Counter-intuitively, have some beneficial effects against secondary infection – allow antibiotics to reach the deep canal, reduce discharge that might inactivate antibiotics.
•有效的止痒/抗炎作用。
•打破“痒-挠-痒”的循环。
•通过减少疼痛和瘙痒，使其更容易用药。
•减少分泌物和肿胀，从而改善通风和排出。
•在严重的病例中，部分预处理可使耳道可视化。
•减少瘢痕和纤维化，从而减少增生和增殖性改变。
•与直觉相反的是，对继发性感染有一些有益的影响——允许抗生素到达耳道深部，减少可能使抗生素失活的分泌物。
Systemic absorption of topical glucocorticoids may suppress the pituitary-adrenal axis. In a randomised study of 2 ear preparations, 1 containing triamcinolone, the other dexamethasone, 4 mg glucocorticoid daily in the ear caused significant laboratory suppression of the axis after 7 days in 7/8 dogs; and in 5/7 dogs, ACTH stimulation was still inadequate 14 days after cessation of treatment (the treatment period was 21 days). However, the clinical significance of these findings was uncertain. Potentiation of ear infections by topical glucocorticoids is theoretically possible, but there is little evidence that this is a real problem. In fact, human studies have shown that secondary infections such as those that occur in otitis externa are often better controlled by combined antibiotic/ corticosteroid preparations than by antibiotics or corticosteroids alone. A syndrome of acquired folding of the pinna, apparently due to loss of cartilage, has been identified in adult cats. All these cats had been treated daily for 8 months to 2 years with topical glucocorticoid-containing otic preparations.
外用糖皮质激素的全身吸收可抑制垂体-肾上腺轴。在一项随机研究中，在7/8只犬的耳朵中，1只含有曲安奈德，另一种是地塞米松，每天在耳朵中放置4 mg糖皮质激素，7天后会引起轴的实验室抑制;5/7只犬在停止治疗14天后(治疗期21天)仍出现ACTH刺激不足。然而，这些发现的临床意义尚不确定。外用糖皮质激素增强耳部感染在理论上是可能的，但几乎没有证据表明这是一个真正的问题。事实上，人类研究表明，继发性感染，如发生在外耳炎的继发性感染，联合使用抗生素/皮质类固醇制剂往往比单独使用抗生素或皮质类固醇更好地控制。一种后天耳廓折叠综合征，显然是由于软骨的丧失，已确定在成年猫。所有这些猫每天外用含糖皮质激素的耳药治疗，连续8个月至2年。
Despite the above and other theoretical disadvantages, topical glucocorticoids are relatively safe in practice. However, as with any glucocorticoids used for any condition, those used in the ear should be administered judiciously. The choice depends on the nature, severity and chronicity of the condition. The general rule is to use the least potent and shortest-acting preparation possible, for the shortest period possible. Selection is particularly important if long-term treatment (>3 months) is required. More potent glucocorticoids may be needed for acute or acutely exacerbated otitis, but once the inflammation is controlled, short-acting, low-potency drugs are preferred. The potency of the glucocorticoids is expressed relative to hydrocortisone (cortisol). The exact numbers differ in different reports, but the following is reasonably representative: hydrocortisone 1, prednisolone and triamcinolone 5, betamethasone and dexamethasone 25, fluocinolone 100. However, triamcinolone has also been considered twice as potent as prednisolone (10 vs 4).
尽管存在上述等理论缺陷，但外用糖皮质激素在临床中是相对安全的。然而，与用于任何疾病的任何糖皮质激素一样，用于耳的糖皮质激素应谨慎使用。具体的选择取决于病情的性质、严重性和长期性。一般的规则是尽可能使用效力最小和作用时间最短的制剂。如果需要长期治疗(＞3个月)，选择尤为重要。急性或急性加重的耳炎可能需要更强效的糖皮质激素，但一旦炎症得到控制，短效、低效的药物是首选。糖皮质激素的效力是相对于氢化可的松(皮质醇)表达的。具体数字在不同的报道中有所不同，但以下是比较有代表性的:氢化可的松1，泼尼松龙和曲安奈德5，倍他米松和地塞米松25，氟轻松100。然而，曲安奈德也被认为是强的松龙的两倍(10vs4)。
Antibacterials
抗细菌药
Bacterial infection is likely to be present in most cases of otitis when seen initially, and can easily be confirmed by cytology. Antibacterials are thus required in most cases initially, though they may be unnecessary in maintenance and preventive treatment. Neomycin, chloramphenicol, polymixin B and gentamicin are frequently included in topical otic medications, but a number of other drugs can be used to treat bacterial otitis. Antibacterial drugs are not the only option for treating infection, and disinfectants such as povidone-iodine, chlorhexidine, dime-thylsulfoxide and Tris-EDTA can be extremely effective. These are especially recommended, usually in conjunction with antibacterial drugs, for the treatment of resistant Pseudomonas otitis. Non-otic preparations are often used for chronic, resistant infections, and include ophthalmic antibacterials as well as self-formulated compounds.
细菌感染很可能出现在耳炎大多数病例早期，可以很容易地通过细胞学检查证实。因此，起初大多数病例需要抗菌药，但在维持和预防性治疗中可能没有必要使用抗菌药。新霉素、氯霉素、多粘菌素B和庆大霉素是常用的外用药物，但也有一些其他药物可用于治疗细菌性耳炎。抗菌药并不是治疗感染的唯一选择，聚维酮碘、氯己定、二甲基亚砜和Tris-EDTA等消毒剂可能非常有效。特别推荐使用这些药物，通常与抗菌药物一起用于治疗耐药假单胞菌性耳炎。非耳药常用于慢性耐药感染，包括眼科抗菌药和自配药。
Empirical choice of antimicrobials, based on cytological findings, is recommended except in chronic, recurrent cases, and/or if otitis media is present. (In these cases culture and sensitivity testing are indicated – see above.) The major distinction that must be made on cytology is whether cocci or rods (or both) are present. Choice of treatment is made accordingly (Table 6). Especially initially, topical drugs should be those unlikely to be needed systemically, so as not to limit the choices of systemic antibiotics for resistant cases of otitis externa, or subsequent otitis media. Some authors suggest using ‘first-line’ drugs such as neomycin or polymyxin B initially, while ‘second-line’ choices would include drugs like gentamicin or chloramphenico. Resistant Gram-negative infections, particularly of Pseudomonas, can be a therapeutic challenge. Table 7 lists treatments that have been found to be valuable in these cases.
建议根据细胞学检查结果根据经验选择抗菌素，但慢性复发病例和/或存在中耳炎的病例除外。(在这些病例中，需要进行细菌培养和药敏试验，见上文)。细胞学上必须作出的主要区分是球菌还是杆菌(或两者都有)。根据治疗方案的选择(表6)。尤其在开始阶段，外用药应选择那些不太可能全身性用药的药物，以免限制外耳炎耐药病例或随后的中耳炎的全身抗生素的选择。一些作者建议首先使用“一线”药物，如新霉素或多粘菌素B，而“二线”选择包括庆大霉素或氯霉素等药物。耐药革兰氏阴性感染，特别是假单胞菌，可能对治疗构成挑战。表7列出了在这些病例中被发现有价值的治疗方法。
Many commonly used antibacterials are potentially ototoxic if used in the presence of a ruptured tympanum and/or otitis media, particularly if use is prolonged. These include the aminoglycosides gentamicin, neomycin and amikacin, as well as chloramphenicol and polymyxin B. In practice, ototoxicity is rare in small animals and the risk is probably somewhat overstated1. However, a non-otoxotic drug must be used if the tympanum is known to be ruptured. The impairment caused by aminoglycosides is likely to be auditory rather than vestibular and might remain undiagnosed in many cases, particularly if unilateral. Inappropriate and/or long-term use of antibacterial agents can cause bacterial resistance; some authors therefore recommend that more potent and broad-spectrum antibiotics such as gentamicin and chloramphenicol should not be used as first-choice treatments Chronic topical antibiotics can also predispose to yeast infection. Follow-up examinations are important to assess efficacy of treatment and minimise the development of resistant organisms.
许多常用的抗菌药如果在鼓膜破裂和/或中耳炎的情况下使用，特别是如果长期使用，可能会造成耳毒性。这些药物包括氨基糖苷类庆大霉素、新霉素和阿米卡星，以及氯霉素和多粘菌素B。在临床中，耳毒性在小动物中很少见，其风险可能有些被夸大了。然而，如果鼓膜已经破裂，必须使用一种非毒性药物。氨基糖苷类引起的损害可能是听力而不是前庭，可能在许多情况下仍未诊断，特别是如果单侧。不适当和/或长期使用抗菌剂可导致细菌耐药性;因此，一些作者建议，更强效和广谱抗生素，如庆大霉素和氯霉素，不应作为首选治疗。慢性外用抗生素也可能导致酵母菌感染。随访检查对于评估治疗效果和尽量减少耐药微生物的发展很重要。
Antifungals
抗真菌药
Antifungal agents are indicated in most cases where yeast infection is present and probably in all fungal (as opposed to yeast) infections of the ear. In mild cases of yeast infection, glucocorticoids and flushing alone can clear the infection by normalising the environment. By far the most common fungal infection in the ear is the yeast Malassezia pachydermatis, but many otic antifungals are also effective against dermatophytes, Candida and Aspergillus spp. Antifungals effective against Malassezia are ketoconazole, econazole, miconazole, nystatin, pimaricin, clotrimazole, cuprimixin and amphoterecin B. Ketoconazole is considered the most effective of these. Nystatin may cause local hypersensitivity reactions. Griseofulvin, thiabendazole, tolcyclate and tolnaftate are ineffective in vitro, but thiabendazole appears to be clinically effective. Povidone-iodine, chlorhexidine and 2.5 % acetic acid are also effective.
抗真菌药物是指在所有真菌感染患耳中，大多数病例存在酵母菌感染。在轻微的酵母菌感染病例中，糖皮质激素和冲洗可以通过使环境正常化来清除感染。到目前为止，耳部最常见的真菌感染是厚皮马拉色菌，但许多耳药中抗真菌药对皮肤癣菌、念珠菌和曲霉菌也有效。抗马拉色菌有效的抗真菌药有酮康唑、益康唑、咪康唑、制霉菌素、匹马霉素、克霉唑、库普利米星和两性霉素B。其中酮康唑被认为是最有效的。制霉菌素可引起局部过敏反应。灰黄霉素、噻苯咪唑、甲苯环酸酯和托萘酯体外无效，但噻苯咪唑临床有效。聚维酮碘、氯己定、2.5%醋酸也有效。
Antiparasitic agents
抗寄生虫药
By far the most common parasite in the ear is the ear mite, Otodectes cynotis. Ear mites are the major single cause of feline otitis externa. To deal effectively with ear mites, the entire animal should be treated with a standard acaricide, because the parasites can survive on other areas of the body. All in-contact animals should be treated. The minimum duration of treatment is 3 weeks, to break the parasite’s life-cycle.
到目前为止，耳朵里最常见的寄生虫是耳螨。耳螨是猫外耳炎的主要单一病因。为了有效地处理耳螨，应该用标准的杀螨剂对动物全身进行处理，因为寄生虫可以在机体其他部位生存。所有接触动物都应得到治疗。治疗的最短时间为3周，以打破寄生虫的生命周期
Lindane (the γ isomer of BHC or γ BHC) was traditionally the acaricide used to treat O. cynotis. The use of lindane in cats is controversial, with some authors advocating it but others maintaining that all chlorinated hydrocarbons are contra-indicated in this species. Concentrations over 0.1 % may cause toxic reactions in cats . One of the reasons cats are susceptible to poisoning by chlorinated hydrocarbons is their fastidious habit of licking products off their coats. Care should thus be taken to wipe away any overflow medication. No side-effects were reported in studies of lindane containing otic preparations in cats. Dogs and other mammals are quite resistant to the toxic effects of lindane. In summary, lindane should be used with circumspection in cats, and should be used with care in any animal that is young, emaciated or systemically ill.
林丹(BHC的γ异构体或γ - BHC)是传统的杀螨剂用于治疗犬耳螨。在猫上使用林丹是有争议的，一些作者主张使用林丹，但另一些作者坚持认为，所有氯化烃类在猫上都是禁忌的。浓度超过0.1%可能会引起猫的毒性反应。猫容易被氯化烃中毒的原因之一是它们挑剔地舔掉被毛上的药品习惯。因此，应小心擦拭任何溢出的药物。在猫的研究中没有报道含有林丹的耳药的副作用。犬和其他哺乳动物对林丹的毒性作用有很强的抵抗力。总之，林丹应谨慎用于猫，并应谨慎用于任何幼小、消瘦或系统性疾病的动物。
Otic preparations containing thiabendazole, rotenone, pyrethrins and carbaryl are effective against O. cynotis. All have low toxicity to mammals and are highly unlikely to cause detrimental effects at the doses used for otitis. Interestingly, a number of products without a miticide performed very well against O. cynotis, presumably due to unknown antiparasitic properties of the components or the effect of the oil base. In 1 of these studies, lindane performed substantially worse than a non-acaricide product; in another, an otherwise identical product performed equally well with or without a miticide.
含噻苯达唑、鱼藤酮、除虫菊酯和西维因的耳药对耳螨有效。它们对哺乳动物的毒性都很低，在治疗耳炎的剂量下不太可能造成有害影响。有趣的是，一些不含杀虫剂的产品对耳螨的杀灭效果非常好，这可能是由于这些成分的抗寄生虫特性或油基的效果未知。在其中的一项研究中，林丹的表现大大低于非杀螨剂产品;在另一组实验中，一种产品在添加或不添加杀螨剂的情况下表现都很好。
Systemic or topical ivermectin is effective against ear mites. Systemic ivermectin can cause mydriasis, tremors and blindness in cats, is not recommended in dogs younger than 3 months and caused fatal toxicity in a 4-month-old kitten. It can cause discomfort and pain after subcutaneous injection in cats. Ivermectin is contra-indicated in Collies and Collie crosses. Fipronil spray is effective against earmites and can be administered as a single treatment; it should also be considered for otic tick infestation. Thiabendazole can be used for Demodex otitis in cats. Topical amitraz or systemic ivermectin or milbemycin are effective against otic Demodex and tick infestations in dogs.
全身或外用伊维菌素对耳螨有效。全身使用伊维菌素可导致猫瞳孔扩大、震颤和失明，不建议对3个月以下的犬使用，对4个月大的猫可造成致命毒性。猫皮下注射后会引起不适和疼痛。伊维菌素在牧羊犬和牧羊犬杂交犬中禁用。非泼罗尼喷雾剂对耳螨有效，可单次使用;它也应该考虑到耳部蜱虫感染。噻苯咪唑可用于治疗猫的蠕形螨耳炎。外用双甲脒或全身使用伊维菌素或米尔贝肟对犬的蠕形螨和蜱虫感染有效。
Topical anaesthetics
外用麻醉剂
Topical anaesthetics are used in some otic preparations to decrease pain and pruritus. They cause superficial anaesthesia only, and their efficacy in otitis is considered doubtful.
有些耳药使用外用麻醉剂以减轻疼痛和瘙痒。它们只引起表面麻醉，对耳炎的疗效值得怀疑。
Vehicle
载体
The vehicle is a significant component of any topical preparation. Unfortunately, in many instances little is stated about the vehicle in the product information. The specific formulation of the vehicle is important, as is the question of whether it is oil-based or aqueous.
载体是任何外用药的重要组成部分。不幸的是，在许多情况下，很少在产品信息中说明载体。载体具体配方很重要，它是油剂还是水剂问题也很重要。
Water-miscible bases are often easier to apply and less messy than oil-based products. They are usually better solvents for the active agent. Ointments, creams and gels soften, hydrate, facilitate removal of scales and crusts, lubricate, protect, and facilitate penetration of the skin by the active agent. In dermatology in general, it is recommended that exudative conditions (usually acute) should be treated with a product formulated with a minimally occlusive vehicle, while chronic, usually thickened, lesions, need occlusive vehicles to rehydrate the dry, thickened surface. Most authors therefore recommend an aqueous vehicle (solutions, lotions, tinctures) in ‘wet’ ears and an occlusive vehicle (ointment/oil-based /creams) in ‘dry’ ears. However, choice of vehicle might be more dependent on factors such as active ingredients, experience and owner convenience. The type of vehicle might need to be changed as the healing process proceeds.
与油基产品相比，水相混溶的碱通常更容易使用，也不那么凌乱。它们通常是活性剂的较好的溶剂。软膏、面霜和凝胶可以软化、保湿、去除皮屑和结痂、润滑、保护和促进活性物质渗透皮肤。一般皮肤科建议，渗出性疾病(通常为急性)应使用具有最低限度封堵载体的产品治疗，而慢性病变(通常为增厚)则需要封堵载体来给干燥增厚的表面补水。因此，大多数作者推荐在“湿”耳中使用水性载体(溶液、乳液、酊剂)，在“干”耳中使用封闭载体(药膏/油基/面霜)。然而，载体的选择可能更多地取决于活性成分、体验和宠主便利性等因素。随着治疗的进行，载体的类型可能需要改变。
Many vehicles are potentially ototoxic if the tympanic membrane is ruptured. This applies particularly to oil-based preparations. Propylene glycol, which is quite commonly used in otic preparations, can be associated with hypersensitivity reactions.
如果鼓膜破裂，许多载体都有潜在的耳毒性。这尤其适用于油基制剂。丙二醇常用于耳药，可与过敏反应有关。
Systemic therapy
全身性治疗
Systemic therapy is required if:
• Otitis externa is severe.
• There is concurrent otitis media.
• Owners are unable to administer topical treatment.
• Marked proliferative changes are present.
• Adverse reactions to topical treatments are suspected.
如:
•外耳炎很严重。
•合并中耳炎。
•主人无法进行外部治疗。
•有明显的增殖改变。
•怀疑外部治疗有不良反应。
Systemic glucocorticoids are used for severe pain and inflammation as well as chronic otitis with proliferative changes and allergic otitis. Where systemic antibiotics are needed, appropriate empirical choices are trimethoprim-sulfas, clindamycin, cephalexin and enrofloxacin (for otitis media), but where possible, selection should be based on sensitivity testing. (See also section on topical antibacterials, and Table 6.)
全身糖皮质激素用于严重疼痛和炎症，以及增生性变化的慢性耳炎和过敏性耳炎。在需要系统性抗生素的地方，适当的经验性选择是磺胺甲氧苄啶、克林霉素、头孢氨苄和恩诺沙星(用于中耳炎)，但在可能的情况下，应根据药敏试验进行选择。(请参见部分外用抗菌药和表6。)
Client education
宠主教育
The major areas of importance in client education are:
• The nature of the syndrome – first, and crucially, the fact that what seems to be a local problem is often a manifestation of a generalised condition; second, that the underlying problem cannot always be cured; and third, that the local (secondary) consequences of otitis have to be addressed as well. The client must be informed about the possibility of chronic, proliferative otitis and the need to avoid this. Proper education will allow the client to understand the need for an in-depth assessment in some cases, and the need for follow-up examinations.
• Correct methods of applying topical medication and cleaners for use at home.
客户教育的重要领域有:
•综合征的本质——首先，也是至关重要的，看起来是局部问题的事实往往是全身性疾病的表现;第二，潜在问题不可能总是得到解决;第三，中耳炎的局部(继发)后果也必须加以解决。必须告知病人慢性增生性耳炎的可能性以及避免这种情况的必要性。适当的教育使宠主了解在某些病例中进行深入评估的必要性，以及后续检查的必要性。
•在家使用外用药物和清洁剂的正确方法。
Follow-up
复诊
Follow-up checks should include progress reports from the owner and otoscopic and cytological examination. Initially, visits should be scheduled every 2 weeks, to monitor therapeutic response. Treatment often needs to change over time – initial response may not be adequate or initial therapeutic intervention may differ from long-term preventive or maintenance management. Owners and veterinarians should be aware that recurrence may be long delayed, and that a short-term improvement does not necessarily mean that the otitis is cured. In 1 study, the average time to recurrence was 3.6 months.
后续检查应包括宠主的进展报告和耳镜和细胞学检查。最初，应每2周就诊一次，以监测治疗反应。治疗常常需要随着时间的推移而改变——最初的反应可能不够充分，或者最初的治疗干预可能不同于长期的预防或维持管理。主人和兽医应该意识到，复发可能是长期延迟，短期的改善并不一定意味着耳炎被治愈。在一项研究中，平均复发时间为3.6个月。
Preventive and maintenance therapy
预防和维持治疗
Ongoing management is critically dependent on identifying the underlying cause(s) and on proper owner education, as well as on repeated evaluation. Cleaning and drying agents are often part of maintenance/prevention therapy (see Table 4). Long-term interventions are dependent on underlying causes.
持续管理在很大程度上依赖于识别潜在病因、正确的宠主教育以及反复评估。清洁和干燥剂往往是维持/预防治疗的一部分(见表4)。长期干预取决于潜在病因。
Table 1: Causes of otitis externa in the dog and cat. Common conditions are in boldface, and the most common primary causes are indicated with an asterisk.
表1犬猫外耳炎病因。粗体字为常见疾病，星号为最常见原发病因。
|
易感因素（增加发生外耳炎的风险） |
品种易感 结构 过度潮湿 环境 耵聍过度产生 阻塞性耳病 全身性疾病 治疗效果 |
例：可卡犬、贵宾犬、德牧犬 耳道狭窄、耳道耳毛、垂耳廓、耳廓凹面多毛 游泳耳 湿度高 特发性 肿瘤、猫鼻咽息肉 发热、免疫抑制、虚弱、分解代谢异常 棉签损伤、外用药刺激、双重感染影像菌群、清洁过度 |
|
原发病因（直接导致外耳炎） |
异物 过敏性疾病 角化异常疾病* 寄生虫 自体免疫疾病 腺体疾病 微生物 其他疾病 病毒性疾病 |
植物（例草芒）、毛发、砂砾、尘土、硬质药物和分泌物 特应性皮炎*、食物过敏*、跳蚤过敏、接触过敏、药物反应 原发性特发性皮脂溢、甲减、性激素紊乱、异常耵聍产生 “经典”耳螨（耳痒螨）*、蠕形螨、疥螨或耳蜱虫 红斑狼疮、落叶型天疱疮、红斑性天疱疮 汗腺增生、皮脂腺增生或发育不全、分泌率改变、分泌物类型改变 皮肤癣菌病、申克孢子丝菌 可卡犬特发性炎性/增生性外耳炎、幼犬腺疫、IgA缺乏症、头部脓皮病 犬瘟 |
|
继发病因（只在异常耳中促成或引起病变，或与易感因素一起） |
细菌 酵母菌 异物 |
种类众多，慢性耐药性耳炎中最常见葡萄球菌、假单胞菌 厚皮马拉色菌、白色念球菌 小或微小异物，包括分泌物 |
|
持久因素（阻碍耳炎消退；导致炎症和病理学改变） |
进一步病理学改变 中耳炎 鼓膜改变 |
角化过度、增生、皮肤皱褶、水肿、纤维化、狭窄、钙化 单纯化脓性、干酪样/角质化、胆脂瘤、增生性、破坏性骨髓炎 透明度、膨胀、憩室 |
表2：外耳炎诊断流程指南
|
常规 |
慢性/复发性 |
一般病史和皮肤学病史* |
√ |
√ |
体格检查和皮肤学检查* |
√ |
√ |
分泌物外观评估 |
√ |
√ |
耳镜 |
√ |
√ |
分泌物细胞学检查 |
√ |
√ |
细菌培养药敏试验 |
|
√ |
中耳炎评估 |
|
√ |
活检 |
|
√ |
原发疾病进一步检测 |
多样化 |
多样化 |
*慢性/复发性病例需要更多详细信息
表3：分泌物类型可能的病因
分泌物类型 |
疑似诊断 |
大量深棕色、蜡质、异味 |
单纯厚皮马拉色菌感染 |
深棕色至黑色、似咖啡渣样干燥 |
耳螨感染 |
深黄色至淡褐色、奶油色 |
革兰氏阳性球菌 |
气味重、异味、油腻、黄色至棕黄色（耵聍性耳炎） |
非感染病因例皮脂溢、特应性皮炎、内分泌病 |
淡黄色、厚、异味、通常量多 |
革兰氏阴性杆菌 |
| 
|Archiver|手机版|小黑屋|宠医帮
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发表于 2023-3-4 21:45:23
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