犬猫耳道、鼻咽和鼻息肉管理2016

王帆

Management of Otic and Nasopharyngeal, and Nasal Polyps in Cats and Dogs

犬猫耳道、鼻咽和鼻息肉管理

作者：Valentina Greci, DVM, PhDa, *, Carlo Maria Mortellaro, DVM

翻译：王帆

KEYWORDS  

关键词

Polyps  Aural  Otic  Nasopharyngeal  Nasal  Cat  Dog

息肉、耳部、耳部的、鼻咽、鼻部、猫、犬

KEY POINTS  

Feline inflammatory polyps are benign growths, which usually arise from the tympanic cavity or the eustachian tube.  

Diagnosis is based on clinical signs, diagnostic imaging, and histopathology; both minimally invasive and surgical techniques for polyp removal are effective.  

Feline nasal hamartomas are benign lesions that arise from the native tissues of the nasal cavity; despite their expansile behavior, they have a good prognosis after surgical or endoscopic removal.  

Inflammatory polyps are extremely rare in dogs; different polypoid-like masses have been described in the middle ear and nasal cavity in dogs, but these lesions likely have a different tissue origin than cats, and the outcome after removal is less consistently successful.

重点

猫的炎性息肉是良性生长，通常发生于鼓室腔或咽鼓管。

诊断基于临床症状、影像学诊断和组织病理学。微创和外科手术都是有效的息肉切除技术。

猫的鼻错构瘤是良性病变，产生于鼻腔的固有组织，但有扩大生长趋势，手术或内窥镜切除后预后良好。

炎性息肉在犬身上极为罕见，犬的中耳和鼻腔都各有息肉样肿块的描述，但这些病变可能与猫的组织来源不同，切除治疗不总是都有效。

FELINE INFLAMMATORY POLYPS

猫炎性息肉

Introduction

介绍

Feline inflammatory polyps (FIPs) are the most common nonneoplastic pedunculated growths found in the ear canal or nasopharynx in cats. They are presumed to originate from the epithelial lining of the tympanic bulla (aural inflammatory polyps) or the auditory tube. When they originate from the auditory tube, they can grow into the tympanic cavity (middle ear polyps) or the nasopharynx (nasopharyngeal polyps) or, less frequently, in both directions. Bilateral polyps have been reported but are uncommon.

猫炎性息肉(FIPs)是在猫耳道或鼻咽发现的最常见的非肿瘤性带蒂的生长肿物。它们可能起源于鼓泡(耳部炎性息肉)或耳道的上皮细胞。当它们起源于咽鼓管时，它们可以生长到鼓室(中耳息肉)或鼻咽(鼻咽息肉)，或少见于向两个方向生长。双侧息肉有报道，但并不常见。

The cause of FIPs is still debated. It is unclear whether polyps are congenital in origin, or a response to an inflammatory process from chronic viral infection,or a consequence of chronic middle ear and/or upper respiratory inflammation.

FIPs的病因仍有争议。目前还不清楚息肉是先天的，还是慢性病毒感染引起的炎症反应，或是慢性中耳和/或上呼吸道炎症的结果。

FIPs consist of a core of loosely arranged fibrovascular tissue covered by a stratified squamous or columnar epithelium. Inflammatory cells, primarily lymphocytes, plasma cells, and macrophages, are present within the stroma and are especially dense in the submucosal areas of the tissue. The mucosa is commonly ulcerated.

FIPs核心是松散排列的纤维小管组织，被一层鳞状上皮细胞或柱状上皮细胞覆盖。炎性细胞，主要是淋巴细胞、浆细胞和巨噬细胞，存在于基质中，在组织的粘膜下区域密度特别大。粘膜常见溃疡。

Presumptive diagnosis of FIPs is based on history and physical examination, supported by imaging and endoscopic evaluation, and is confirmed by histopathological examination of biopsy samples.

FIPs的假定诊断基于病史和体格检查，辅以影像学和内窥镜评估，并通过活检采样进行组织病理学检查予以确认。

FIPs usually occur in young cats with an average age of 1.5 years, although they have been reported in cats of all ages. The authors have diagnosed FIPs in Maine coon siblings and in 2 Maine coon cats from the same bloodline but from different environmental settings. There is some suggestion that because FIPs have been diagnosed in siblings, they may have a congenital origin. FIPs in Maine coon cats might be inherited or congenital, or they might have a genetic predisposition to this condition.

FIPs通常发生在平均年龄为1.5岁的年轻猫，但在所有年龄的猫中都有报道。作者诊断过有同家族缅因血统的猫和来自同一血统但来自不同环境的2只缅因猫的FIPs。有一些建议认为，由于是在同家族中确诊了FIP，所以它们可能有先天性。缅因猫的FIPs可能是遗传的或先天性的，或者他们可能有这种情况的遗传倾向。

Clinical signs are usually progressive and chronic in nature. Aural inflammatory polyps usually result in chronic otitis externa, with cats most often exhibiting head shaking and otorrhea. Otic discharge can vary from waxy to purulent in nature. When the polyp is visible within the ear canal, it has already protruded through a ruptured eardrum, and otitis media is frequently present. Neurologic alterations, such as Horner syndrome, head tilt, ataxia, nystagmus, circling, and facial paralysis, may also be observed with middle and inner ear involvement. The most common clinical signs in cats with nasopharyngeal polyps are nasal discharge, stertorous breathing, reverse sneezing, and sneezing.

临床症状通常是进行性和慢性的。耳部炎性息肉通常导致慢性外耳炎，猫最常表现为甩头和耳分泌物。耳分泌物性质从蜡状到化脓性不等。当在耳道内可见息肉时，它已经从破裂的鼓膜中突出，经常出现中耳炎。神经病变，如霍纳综合征、头倾斜、共济失调、眼球震颤、转圈和面瘫，也可在中耳和内耳患病时观察到。在猫的鼻咽息肉最常见的临床症状是鼻分泌物、呼吸鼾声、逆向喷嚏和打喷嚏。

Other signs and related conditions associated with inflammatory polyps, such as dysphagia, megaesophagus, regurgitation, pulmonary hypertension, polyp abscess, submandibular swelling, suppurative meningoencephalitis, and severe dyspnea, have been rarely reported.

其他与炎性息肉相关的症状和疾病，如吞咽困难、巨食道、反流、肺高压、息肉脓肿、下颌肿胀、化脓性脑膜炎、严重呼吸困难等，则鲜有报道。

Aural polyps can be seen on both conventional and video-otoscopy. In some cats, aural polyps can be directly seen protruding directly from the external ear canal.

耳部息肉可以

在常规检查和视频耳镜检查中看到。在一些猫，可以直接看到耳部息肉从外耳道突出。

Nasopharyngeal polyps can be confirmed on digital palpation of the nasopharynx, rostral traction of the soft palate, or retrograde rhinoscopy. Secondary otitis media is frequently present with nasopharyngeal polyps, because the mass occludes the auditory tube, resulting in mucous accumulation in the tympanic cavity.

鼻咽息肉可通过鼻咽指触诊、软腭向吻侧牵引或逆行鼻镜检查确诊。鼻咽息肉常继发中耳炎，因为肿块阻塞了咽鼓管，导致黏液在鼓室内积聚。

Imaging

影像

Conventional radiology

常规X光检查

Radiographs can be used to identify a soft tissue mass in the nasopharynx and to evaluate loss of the air contrast of the external ear canal and thickening of the tympanic bullae; when these signs are present, they are specific for the diagnosis of middle ear disease.Nasopharyngeal polyps are usually observed on a standard lateral projection or obliqued lateral projections (Fig. 1).

x线片可用于识别鼻咽软组织肿块，评估外耳道空气对比影像的丧失和鼓泡增厚;当这些症状出现时，它们对中耳疾病的诊断是特异性的。鼻咽息肉通常位于标准侧位片或斜侧位片(图1)。

Fig. 1. Pharyngeal soft tissue density in 30 lateral view of a cat with a nasopharyngeal polyp (black arrows).

图1。一只猫患鼻咽息肉的30度侧位图上咽部软组织密度(黑色箭头)。

In cats, the tympanic cavity is unequally divided into 2 compartments by a thin bony septum, giving it a double-chambered appearance. On plain radiographs, the best images to view the tympanic bullae are right and left lateral oblique and the rostrocaudal projections. In these views, normal bullae appear as thin-walled, air-filled rounded structures at the base of the skull (Fig. 2). The rostrocaudal projections are particularly useful to evaluate both the tympanic bullae and the horizontal ear canals. Dorsoventral and ventrodorsal projections are less diagnostic due to partial superimposition of the petrous temporal bone over the bullae.

在猫上，鼓室被一个薄的鼓室中隔分成两个不均等的腔室，使其具有双室外观。在普通x线片上，观察鼓泡的最佳图像是左右侧斜位和头尾位。在这些图中，正常的鼓泡表现为位于颅底的薄壁、充气的圆形结构(图2)。头尾位重点用于评估鼓泡和水平耳道。背腹位和腹背位诊断作用不大，因为部分颞骨岩部骨骼与鼓泡重叠。

Fig. 2. Radiographic appearance of a normal ear canal and middle ear in cats: (A) 30 left lateral, (B) rostro 10 ventrocaudodorsal, (C) rostroventral-caudodorsal open mouth views.

图2。一只猫正常耳道和中耳的x线片:(A) 30度左侧位，(B) 吻部10度腹侧尾背侧，(C) 头腹侧-尾背侧开口影像。

Radiographic changes that are often evident in cats with otic polyps include loss of air contrast in the ear canal and/or the tympanic bulla, tympanic bone thickening, and the presence of a soft tissue mass in the pharynx or ear canal; sclerosis noted within the petrous bone may suggest otitis interna (Fig. 3). Some cats with FIPs have normal plain radiographs; the diagnosis of FIPs in these instances is often substantiated with endoscopic examination or advanced imaging modalities.

耳息肉患猫的x线影像变化包括耳道和/或鼓泡空气对比消失、鼓室骨骼增厚、咽部或耳道出现软组织肿块，颞骨岩骨硬化提示内耳炎(图3)。一些患有FIPs的猫x线平片正常，在这些病例中，FIPs的诊断通常通过内窥镜检查或高级影像学检查来证实。

Fig. 3. Different radiographic appearances of middle ear polyps in cats: (A) loss of air contrast within the bulla and the ear canal and mild thickening of the right bulla contour; (B) mild bulla enlargement, severe thickening of the bulla contour and septum, erosion of the petrous bone, loss of air contrast within the right bulla and the ear canal.

图3。一只猫中耳息肉的不同影像学表现:(A)鼓泡内和耳道内空气对比消失，右侧鼓泡轮廓轻度增厚;(B)鼓泡轻度增大，鼓泡轮廓和鼓室中隔严重增厚，颞骨岩部骨侵蚀，右侧鼓泡和耳道内空气对比消失。

Computed tomography

计算机断层扫描

Computed tomography (CT) allows cross-sectional imaging of the external, middle, and internal parts of the ear and nasopharynx. Skull positioning should be precise to allow comparison of symmetry; CT imaging has the advantage of allowing image reformatting in various planes, eliminating superimposition of surrounding boney structures. In addition, CT imaging shows good soft tissue contrast resolution.

计算机断层扫描(CT)可以得到外耳、中耳和内耳和鼻咽的横断面影像。头部摆位精确可以对称比较，CT成像的优点是可以在不同的平面上图像重建，消除周围骨骼结构的叠加。此外，CT表现出良好的软组织对比分辨率。

CT allows evaluation of fluid or tissue within the external and/or the tympanic cavity, changes in the tympanic bulla contour, presence/absence of bony proliferation, and/ or evidence of osteolysis. Thin slicing provides great anatomic detail of middle ear and inner ear structures. CT is more specific in localizing the affected osseous bulla and earlier detection of small masses of both the tympanic cavity and the nasopharynx. Therefore, because of these advantages, CT imaging is superior to conventional radiography and thus allows more specific prognosis and treatment planning for cats with suspected tympanic masses.

CT可评估外耳和/或鼓室内的液体或组织、鼓泡轮廓的改变、有无骨质增生，和/或有无骨溶解。层切薄可得到中耳和内耳结构的详细解剖。CT在鼓泡局灶患病和早期鼓室和鼻咽小肿块方面更有特异性。因此，由于这些优点，CT成像优于常规x线成像，从而可以对疑似鼓室肿块的猫有更明确的预后和治疗计划。

On CT, FIPs typically appear as an oval homogenous space-occupying dense structure with well-defined borders and hard rim enhancement (Fig. 4). More aggressive infections and neoplastic conditions often exhibit both osteoproliferative and lytic lesions of the tympanic bulla. On contrast CT images, these aggressive conditions exhibit marked contrast medium enhancement compared with FIPs in cats.

在CT上，FIPs典型表现为椭圆形均匀占位性致密结构，边界清楚，高密度边缘增强(图4)。更侵袭性感染和肿瘤通常表现为鼓泡的骨质增生和溶解性病变。在CT增强图像上，与猫的FIPs相比，这些侵袭性疾病表现出明显的对比介质增强。

Fig. 4. CT appearance of FIPs. (A) Bone tissue window (BTW): the middle ear cavity and ipsilateral ear canal are filled with a homogenous soft tissue dense structure. (B) BTW: a soft tissue density is partially filling the nasopharynx, and there is ipsilateral eustachian tube enlargement (black arrow). (C, D) STW after contrast medium administration in the same cat: the lesion appears as an oval homogenous space-occupying soft tissue dense structure with well-defined borders and contrast rim enhancement. (Courtesy of [C and D] Dr Simone Borgonovo, Clinica Veterinaria Gran Sasso, Milano, Italia.)

图4。FIPs的CT表现。(A)骨组织窗(BTW):中耳腔及同侧耳道内充满均匀的软组织密度结构。(B)BTW:鼻咽部分区域软组织密度，同侧咽鼓管扩张(黑色箭头)。(C, D)同一只猫注射造影剂后的STW:病变表现为椭圆形均匀占位性软组织密度结构，边界清楚，造影剂边缘增强。

MRI

磁共振成像

Only a few reports mention the use of MRI in the diagnosis of feline ear diseases. Similar to cats with FIPs, other inflammatory middle ear diseases are often characterized by contrast enhancement along the inner margin of the tympanic bulla due to the presence of vascularized tissue lining this region. Unless osteoproliferative and/or lytic changes are evident in the tympanic bulla, it can be difficult to differentiate an inflammatory polyp from inflammatory tissue from otitis media, or early neoplastic conditions within the tympanic cavity.However, MRI is indicated in cats presenting with concurrent peripheral nerve and central nervous system disease to better evaluate the inner ear and surrounding neural structures when more aggressive lesions are suspected.

只有少数报道提到MRI在猫耳病诊断中的应用。与FIPs患猫相似，其他炎性中耳疾病的特征通常是沿着鼓泡的内缘增强，这是由于该区域存在血管化组织。除非鼓泡有明显的骨质增生和/或溶解性改变，否则很难区分炎性息肉、炎症组织和中耳炎，或鼓室内的早期肿瘤疾病。但是，在周围神经和中枢神经系统疾病同时出现的猫，MRI显示，当怀疑有更严重的病变时，可以更好地评估内耳和周围神经结构。

Endoscopy

内窥镜

When evaluating cats with FIPs, both ear canals and nasopharynx should be examined with endoscopy.

当评估FIPs患猫时，耳道和鼻咽都应进行内窥镜检查。

The presence of thick waxy cerumen or purulent exudate is often noted on otoscopy. After ear canal cleaning, aural polyps usually appear as pink pale to reddish rounded, sometimes multi lobulated or ulcerated masses in the ear canal or within the tympanic cavity (Fig. 5). When a mass is observed that does not appear as an FIP, fine-needle biopsy or pinch biopsy may be indicated first to achieve a definitive diagnosis, and for appropriate treatment planning (see Fig. 5D).

耳镜检查常发现厚蜡状耵聍或脓性渗出物。耳道清洁后,耳部息肉通常呈现粉红色的浅红色的圆形,有时呈多个小叶或溃疡的肿物位于耳道内或鼓室内(图5)。当发现一个不像FIP的肿物时,进行细针活检或夹除活检可能得到确诊,并制定适当的治疗计划(见图5D)。

Fig. 5. Different endoscopic appearances of aural inflammatory polyps: (A) polyp protruding behind the tympanum; (B) polyp protruding through a ruptured tympanum, portion of the tympanum is still visible on the right; (C) multilobulated ulcerated polyp; (D) oval pink highly vascularized polyp, given the aspect the mass was biopsied for final diagnosis.

图5。耳部炎性息肉的不同内窥镜表现:(A)鼓膜后息肉突出;(B)鼓膜破裂息肉突出，右侧仍可见部分鼓膜;(C)多分叶溃疡性息肉;(D)椭圆形、粉红色、高度血管化的息肉，考虑到肿块的外观，活检以获得最终诊断。

A thickened opaque or bulging eardrum on the contralateral side is often seen due to impairment of auditory tube drainage secondary to nasopharyngeal inflammation or pressure from the nasopharyngeal polyp. If a small polyp arising just behind a bulging tympanum is suspected, a myringotomy can be performed to explore the tympanic cavity (Fig. 6).

由于鼻咽炎症或来自鼻咽息肉压力继发咽鼓管引流受损，常可见对侧鼓膜增厚不透明或鼓膜鼓出。如果怀疑鼓室后面有小息肉，可行鼓膜切开术探查鼓室(图6)。

Fig. 6. Otoscopic views of a cat with an aural inflammatory polyp. (A) Severe tympanum bulging is shown before myringotomy; (B) a small middle ear polyp is evident after myringotomy.

图6。猫患炎性息肉耳镜下图像。(A)鼓膜切开术前出现严重鼓膜膨出;(B)鼓膜切开术后可见小的中耳息肉。

Nasopharyngeal polyps can be seen endoscopically or by rostrally displacing the soft palate with a hooked instrument such as a spay hook (Fig. 7).

鼻咽息肉可以在内窥镜下观察到，也可以用钩状器械(如绝育钩)将软腭向吻侧牵拉可见(图7)。

Fig. 7. Visualization of a nasopharyngeal polyp after rostral retraction of the soft palate.

图7。软腭向吻侧牵拉后的鼻咽息肉。

Treatment

治疗

Both minimally invasive and traditional surgical techniques have been described to remove FIPs.

微创和传统的外科手术技术都可去除FIPs。

Minimally invasive approach

微创方法

Traction/avulsion of polyps Traction/avulsion is the simplest form of treatment, without requiring specialized equipment. The polyp is generally grasped with a toothed grasping forceps (curved clamp, Allis, or alligator forceps), and removed by firm traction with rotation until the polyp detaches at the stalk.

牵引/撕脱息肉。牵引/撕脱息肉是最简单的治疗方式，不需要特殊的设备。通常用带齿钳(弯钳、艾利斯钳或鳄鱼钳)抓住息肉，然后用力旋转牵拉，直至息肉茎部脱离取出。

Aural polyps are removed by positioning the cat in lateral recumbency after routine preparation of the ear. Removal of multilobulated polyps can be difficult because they tend to rupture and bleed from the cut surface of the mass; repeated grasping and pulling may be necessary to debulk the mass. In this instance, a portion of the stalk remnant may remain, which increases the risk of polyp recurrence. Increased exposure can be obtained by performing a lateral ear canal resection, but this is rarely necessary.

耳息肉的清除是通过将猫侧卧保定后常规耳部清洁。切除多叶性息肉是困难的，因为它们容易从肿块的切面破裂和出血，为了去除肿块，可能需要反复抓拽。在这种情况下，部分茎部残端可能会保留，这增加了息肉复发的风险。侧耳道切除可增加暴露范围，但基本不需要。

Nasopharyngeal polyps are removed by placing the cat in dorsal recumbency; the polyp can be visualized by application of digital pressure on the rostral soft palate, displacing the mass caudally, or by retracting the palate rostrally with a spay hook or preplaced stay sutures in the terminal aspect of the soft palate (Fig. 8). Additional exposure can be achieved by performing a direct incision through the soft palate midline directly over the polyp, but this is rarely necessary. If a staphylotomy is elected, attempt to leave the distal 5 mm of the palate intact to help avoid incisional dehiscence after surgery. Retracting the edges of the incision with stay sutures can help provide additional exposure. The soft palate is repaired in 2 layers with absorbable suture.

将猫背卧保定切除鼻咽息肉。通过指压软颚吻侧，将肿块向尾侧移动，可以观察到息肉。或在软腭末端用一个绝育钩或预先放置的牵引缝线向吻侧牵拉软腭(图8)。通过软腭中线直接切开也可暴露息肉，但基本不需要。如果选择了悬雍垂切开术，尝试保持腭部远端5毫米是完整的，以避免术后切口裂开。切口边缘留置缝合线牵拉可以帮助暴露创口。软腭采用可吸收缝线双层缝合。

Fig. 8. Traction-avulsion removal of a nasopharyngeal polyp. (A) Nasopharyngeal exposure can be obtained by use of anatomic forceps/clamp or gentle traction by stay sutures (shown). (B) The polyp is then grasped and pulled with hemostatic forceps until the stalk detaches. (C) A 3-cm oval, pale pink nasopharyngeal polyp with stalk attached.

图8。一个鼻咽息肉的牵引撕脱术。(A)使用组织钳/夹或轻拉牵引缝线(如图所示)可暴露鼻咽部。(B)然后用止血钳抓住并牵拉息肉，直到息肉柄脱离。(C)一个鼻咽息肉，长约3厘米，呈椭圆形，淡粉色，有柄。

Minor to moderate hemorrhage is expected following these traction/avulsion of nasopharyngeal polyps, but the bleeding generally stops spontaneously, or after applying dorsal pressure to the palatine area for several minutes.

鼻咽息肉牵引/撕脱术后可能会有轻微到中度出血，但出血一般会自行停止，或在腭部向背侧按几分钟止血。

Endoscopic removal of polyps Recently a per-endoscopic transtympanic traction (PTT) removal technique has been described. After cleaning the ear and positioning the patient in lateral recumbency, the polyp is grasped under direct endoscopic visualization with an endoscopic forceps and pulled with a rotating movement until the polyp is detached.

内窥镜切除息肉。最近，一种经内镜牵引(PTT)切除技术已被描述。清洁耳道后，将患猫侧卧保定，在内镜直接观察下，用内镜钳钳住息肉，旋转拉出直至息肉分离。

After removal, soft tissue or remnants of the polyp “footprint” within the tympanic cavity are curetted under direct endoscopic visualization with a Volkmann spoon or otologic spoon (Fig. 9). When necessary, the septum that separates the feline double-chambered tympanic cavity is removed using a pinch biopsy forceps under endoscopic visualization. Hemorrhage is usually mild, and it is easily controlled by flushing with sterile refrigerated 0.9% NaCl solution.

去除后,鼓室内软组织或残余息肉中的“痕迹”，使用Volkmann刮勺或耳科勺直接内窥镜刮除(图9)。必要时,在内窥镜下，使用活检钳把猫隔开两个鼓室的鼓室中隔夹除。出血通常较轻，用无菌冷藏的0.9% NaCl溶液冲洗即可止血。

Fig. 9. Step-by-step endoscopic images of PTT procedure: (A) grasping of the polyp in tympanic cavity via endoscope; (B) appearance after polyp removal with remnant tissue in upper right region of tympanic cavity; (C) use of an otologic spoon during endoscopic curettage; (D) bone surface of tympanic cavity after endoscopic curettage of remaining soft tissue remnants

图9。PTT过程的内镜分步图像:(A)内窥镜抓取鼓室息肉;(B)息肉切除后外观，鼓室右上方残留组织;(C)在内窥镜刮除术中使用耳勺;(D)内窥镜刮除残存软组织后鼓室骨面

Laser ablation of polyps Carbon dioxide laser ablation of polyps is another promising technique for aural polyp removal. This technique is performed under visualization with a video-otoscope. A special rigid laser tip, 120 mm long, is placed through the 2-mm working channel of a dedicated video-otoscope. Smaller polyps can be debulked by direct laser vaporization of the polyp; charred tissue is then removed by irrigation. This laser procedure is repeated until the stalk of the polyp is no longer visualized.

激光切除息肉。二氧化碳激光切除息肉是另一种耳息肉切除技术。这项技术是在可视耳镜下进行的。一个特殊的硬激光尖，长120毫米，通过一个专门的视频耳镜的2毫米工作通道伸入。较小的息肉可直接用激光汽化去除，然后通过冲洗去除烧焦的组织。重复这一激光程序，直到息肉茎部消失。

With larger polyps, the tip of the laser is pushed into the tympanic cavity along the floor of the horizontal ear canal under the polyp mass; laser energy is then applied to vaporize the entire polyp, or it can be partially removed to facilitate traction removal. Afterward, the laser tip is placed into the bulla cavity toward the residual stalk, and laser energy is applied until the stalk is no longer visible.

对于较大的息肉，激光的尖端沿着息肉团块下方水平耳道的底部推进鼓室;然后用激光能量蒸发整个息肉，或者部分切除息肉以促进牵引切除。随后，将激光尖端朝向残茎放入鼓泡腔，并施加激光能量，直到残茎不再可见。

Open surgical removal

手术切开清除

Ventral bulla osteotomy (VBO) has been proposed by veterinary surgeons as the treatment of choice for FIPs because of the high incidence of concurrent middle ear involvement. Because the cat has a double-chambered tympanic cavity, VBO allows full exploration of both chambers by breeching the septum that separates the 2 compartments.

腹侧鼓泡截骨术(VBO)已被兽医推荐为FIPs的治疗选择，因为同时发生中耳炎的发生率很高。因为猫有一个双室鼓室，VBO通过将分隔这两个室的鼓室中隔清除从而完全暴露两个腔室。

Some investigators suggest VBO even in the absence of radiographic middle ear involvement; some other investigators recommend VBO to improve the outcome and reduce the risk of recurrence in cats affected only by nasopharyngeal polyp. Prospective clinical trials with randomized minimally invasive versus open surgical treatment of FIPs are needed to help determine the best approach for cats with FIPs.

一些研究者即使在影像中没有发现中耳患病也建议VBO;其他一些研究者建议进行VBO可以改善预后，降低仅有鼻咽息肉患猫的复发风险。需要进行随机微创和开放手术治疗FIPs的前瞻性临床试验，以帮助确定FIPs猫的最佳治疗方法。

Cats presenting with a nasopharyngeal or aural polyp may show signs of middle ear disease even with no radiographic evidence of an ear polyp or otitis media; these signs are thought to occur because of inflammation secondary to pressure changes and mucous accumulation within the tympanic cavity. This condition usually resolves after minimally invasive techniques of polyp removal and postoperative corticosteroid administration. In these cases, open surgical removal has been questioned, and minimally invasive approaches are recommended for polyp removal. VBO is more invasive and has higher morbidity than traction/avulsion with or without lateral ear canal resection or incision of the soft palate or PTT.

猫出现鼻咽或耳息肉，即使没有耳息肉或中耳炎的影像学证据，也可能显示中耳疾病的症状;这些症状被认为是由于炎症继发于压力变化和鼓室内粘液积聚。这种情况通常在微创息肉切除技术和术后使用皮质类固醇后得以解决。在这些病例中，手术切开清除一直受到质疑，建议采用微创手术切除息肉。VBO比伴或不伴侧耳道切除或软腭切口或PTT的牵引/撕脱更有侵袭性，发病率更高。

According to the authors’ experience, VBO should be considered only when polyps recur more than twice in a short period after traction avulsion through a minimally invasive approach.

根据作者的经验，只有在采用微创方法牵引撕脱术后息肉在短时间内复发2次以上时，才应考虑VBO。

VBO may be indicated in cats that have mild to moderate stenosis of the horizontal ear canal. This stenosis would limit curettage of the mucosa lining the tympanic cavity via PTT or after lateral ear canal resection.

VBO可能表明猫有轻度到中度的水平耳道狭窄。这种狭窄会限制经PTT或侧耳道切除术后对鼓室粘膜的刮除。

Total ear canal ablation and lateral bulla osteotomy (TECALBO) is usually indicated for more invasive ear conditions; however, few chronic cases of FIPs might show severe stenosis of the horizontal ear canal or adhesions to the ear wall canal, thus not enabling extirpation of the polyp. For these cases, TECALBO might represent the best surgical technique.

全耳道消融术和外侧大泡截骨术(TECALBO)通常适用于更有侵袭性的耳部疾病;然而，少数慢性FIPs病例可能出现水平耳道严重狭窄或与耳道壁粘连，因此无法切除息肉。对于这些病例，TECALBO可能是最好的手术技术。

Complications and polyp recurrence among different techniques after polyp removal Regardless of the polyp removal technique, postoperative complications, such as Horner syndrome, vestibular syndrome, facial nerve paralysis, chronic otitis media, and interna, can occur; these complications can be temporary or permanent.

不同术式息肉切除后的并发症及息肉复发不论采用何种术式，术后均可发生霍纳综合征、前庭综合征、面神经麻痹、慢性中耳炎、内耳炎等并发症;这些并发症可能是暂时的，也可能是永久性的。

Minimally invasive approaches for polyp removal are preferred because complications are less common than with open surgical approaches. Horner syndrome was less frequent in cats treated by PTT (8%) than in cats treated by VBO (57%–95%) or by traction alone (43%). In some cats treated by VBO, Horner syndrome can be permanent. Temporary and permanent facial nerve paralysis has been reported with VBO and TECALBO, but not with traction alone or PTT.

微创手术是切除息肉的首选方法，因为并发症比开放手术方法少。与VBO治疗的猫(57%-95%)或单纯牵引治疗的猫(43%)相比，PTT治疗的猫发生霍纳综合征的频率较低(8%)。在一些接受VBO治疗的猫中，霍纳综合征可能是永久性的。VBO和TECALBO曾报道过暂时和永久性面神经麻痹，但没有单独牵引或PTT的报道。

Otitis media is frequently associated with FIPS; postoperative antibiotic therapy should be administered to treat concurrent and prevent secondary otitis media, and the antibiotics should be chosen based on culture and susceptibility tests. Chronic otitis media can be a long-term complication after polyp removal. In a series of cats treated by PTT, 2 cats (5.4%) had ongoing chronic otitis media as a long-term complication. The frequency of otitis media after polyp removal in other case series has not been well recorded.

中耳炎常与FIPs有关;术后应用抗生素治疗并发中耳炎，预防继发性中耳炎，并根据培养和药敏试验选择抗生素。慢性中耳炎可能是息肉切除后的长期并发症。在一系列经PTT治疗的猫中，2只猫(5.4%)患有慢性中耳炎作为长期并发症。在其他的病例中，息肉切除后中耳炎的发病率没有详细记录。

Polyp recurrence has been reported to occur from 19 days to 46 months postoperatively with all the techniques mentioned to remove FIPs.Recurrence in cats treated by simple traction was frequent when there was evidence of middle ear radiographic involvement. The percentage of recurrence for PTT (13.5%) reported is lower than the ones reported for traction alone (33%–57%) and similar to the percentages reported for VBO (0%–33%). The lower recurrence rate reported for VBO and PTT is due to the more complete extirpation of the mucosa lining the tympanic cavity compared with simple traction.

据报道，所有提到的FIPs切除技术在术后19天至46个月发生息肉复发。当影像检查有中耳患病时，通过简单牵引治疗的猫常见复发。PTT的复发率(13.5%)低于单纯牵引的复发率(33%-57%)，与VBO的复发率(0%-33%)相似。报道的VBO和PTT的复发率较低是因为与单纯牵引相比，鼓室内层粘膜被完全切除。

Recurrence rate for simple traction might be reduced by curetting the mucosa lining the tympanic cavity with an otologic spoon after traction avulsion of polyps. Polyp recurrence and postoperative complication rates following laser ablation have not been reported.

单纯牵引息肉撕脱术后，用耳勺刮除鼓室粘膜可降低复发率。激光消融术后息肉的复发及术后并发症发生率尚未见报道。

FELINE INFLAMMATORY POLYPS OF THE NASAL TURBINATES (HAMARTOMA)

猫鼻甲骨炎性息肉（错构瘤）

Inflammatory polyps of the nasal turbinates was a terminology used to describe a different polypoid-like benign growth of the nasal cavity in cats, which was once considered to be a rare manifestation of nasopharyngeal polyps. However, it has been recently reported that the histopathological appearance of these lesions resembles the human chondromesenchymal hamartoma characterized by fibrovascular tissue lined by a stratified squamous or ciliated columnar epithelium and bony cartilage structures without signs of atypia and erythrocytes-filled spaces.

鼻甲炎症性息肉是一种术语，用于描述猫鼻腔不同于息肉样良性生长肿物，曾被认为是鼻咽息肉的一种罕见表现。然而，最近有报道称，这些病变的组织病理学外观类似于人的软骨叶间性错构瘤，其特征是纤维小管组织内衬层状鳞状上皮细胞或纤毛柱状上皮细胞和骨软骨结构，无异型性和红细胞充盈的症状。

Feline nasal chondromesenchymal hamartomas (FNCMH) should be considered a separate entity, because they arise from the native tissue of the nasal cavities rather than the eustachian tube or tympanic cavity.

猫鼻软骨叶间性错构瘤(FNCMH)应该被认为是一个独立的疾病，因为它们产生于鼻腔的固有组织，而不是咽鼓管或鼓室。

The condition, originally thought to be encountered more often in Italy, was once thought to be related to genetic or environmental factor. The disease is now rarely diagnosed. Sporadic cases have been reported in the United States, and one case was cited in the United Kingdom.

这种疾病最初被认为在意大利更常见，一度被认为与遗传或环境因素有关。这种疾病现在很少被诊断出来。美国报告了零星病例，英国报告了一例。

The disease is usually diagnosed in young cats without any known breed predisposition. Cats present with progressive stertorous breathing, sneezing, open-mouth breathing, serous nasal discharge, epiphora, and epistaxis. In severe cases, cats have sinonasal deformation or a mass lesion protruding from the nostrils.

这种疾病通常在没有任何已知品种倾向的幼猫中诊断出来。猫表现为渐进性的呼吸鼾声、打喷嚏、张嘴呼吸、浆液性鼻分泌物、溢泪和鼻出血。严重的病例中，猫有鼻窦变形或肿块从鼻孔突出。

Radiographic studies typically demonstrate soft tissue opacification of the nasal cavity, turbinate lysis, and radiolucent areas, corresponding to cystic spaces within the lesion. CT features of FNCMH are shown in Fig. 10. Turbinate and bone loss is likely to be secondary to compression atrophy given the expansile but noninfiltrative behavior of these masses.

影像学研究典型地显示鼻腔软组织密度、鼻甲溶解和可透射线区，对应于病变内的囊性空腔。FNCMH的CT特征如图10所示。鼻甲和骨质消失可能继发于压迫性萎缩，因为这些肿块具有扩张性但无浸润性行为。

Fig. 10. CT aspects of FNCMH: (A) BTW at the level of temporomandibular joint: a soft tissue dense mass is shown filling the nasopharynx and right sinonasal cavities, and partially filling the left sinonasal cavities; turbinate loss and rarefaction are also visible; (B) STW after contrast medium administration: note the patchy contrast enhancement.

图10。FNCMH的CT表现:(A)颞下颌关节水平面BTW:一软组织密度肿块充填鼻咽和右侧鼻腔，部分充填左侧鼻腔;也可见鼻甲缺失和稀疏;(B)使用造影剂后STW:注意造影增强的斑片状区域。

Endoscopically, the lesion appears as a multilobulated pink to bluish lesion occupying the nasopharynx and the nasal cavities; pinch biopsies collected endoscopically must be submitted for histopathological examination to achieve a definite diagnosis.

内窥镜下，病变呈多分叶状，粉红色至蓝色，占据鼻咽和鼻腔，必须进行内窥镜下活检采样，提交组织病理学检查以确诊。

Although spontaneous regression has been reported as well as response to corticosteroid treatment, it has been recommended that these masses be removed, endoscopically, or for more extensive lesions, by rhinotomy, to facilitate complete excision.

虽然有自发消退，以及皮质类固醇治疗有效的报道，但建议这些肿块应通过内镜切除，或对于更大病变，通过鼻切开术，以便完全切除。

Despite the potential expansile and seemingly destructive behavior of chondromesenchymal hamartomas, this disease usually has a good prognosis, and recurrence after treatment has been rarely reported.

尽管软骨叶间性错构瘤具有潜在的扩张性和看似破坏性的行为，但这种疾病通常有良好的预后，治疗后复发的报道很少。

CANINE POLYPS

犬息肉

Introduction

介绍

Canine ear and nasopharyngeal polyps are rare and generally unilateral, but few have been reported bilaterally.

犬耳和鼻咽息肉是罕见的，通常是单侧的，但有少数报道是双侧的。

Clinicians must be aware that the definition of inflammatory polyp represents a macroscopic description of a pedunculated to grossly lobulated lesion that histologically is considered benign.

临床医生必须意识到炎性息肉的定义代表了一种有蒂的大体分叶病变的宏观描述，组织学上被认为是良性的。

Macroscopic evidence of a polypoid-like lesion in the nasopharynx or in the ear in dogs likely is different in character than typical inflammatory polyps in cats.

犬鼻咽或耳息肉样病变的肉眼证据可能与猫的典型炎性息肉在特征上不同。

The definition of inflammatory polyp should be restricted to those lesions that resemble the feline and human counterpart as described for the well-known otic and nasopharyngeal inflammatory polyps and should not comprise keratinizing epithelium.

炎性息肉的定义应限于那些类似于猫和人的已知的耳和鼻咽炎性息肉病变，不应包括角化上皮细胞。

Aural polyps

耳部息肉

Inflammatory polyps arising from the ear canal wall can be removed with the narrow attachment by simple traction (Fig. 11), or they can be removed with surgical excision; they might recur as described in cats.

耳道壁产生的炎性息肉可通过简单牵引去除狭窄附着物(图11)，也可通过手术切除切除，它们可能会像在猫上描述的那样复发。

Fig. 11. Endoscopic appearance of an inflammatory aural polyp (black arrows) in a 5-yearold female spayed Belgian shepherd presenting with chronic otitis externa.

图11。一只5岁已绝育比利时牧羊犬患慢性外耳炎，内窥镜下表现为耳炎性息肉(黑色箭头)。

Canine aural polyps should not be confused with ceruminous gland adenomas; adenomas might grossly look like a polypoid growth, but they cannot be removed by traction because they have a broad attachment to the ear canal skin.

犬耳息肉不应与耵聍腺腺瘤混淆，腺瘤大体看起来像息肉样增生，但不能通过牵引去除，因为它们附着在耳道皮肤上面积较宽。

In dogs, cholesterol granulomas, cholesteatomas, and proliferative otitis media can be mistaken for polyps, so histologic confirmation before contemplating mass removal is important.

在犬上，胆固醇肉芽肿、胆脂瘤和增殖性中耳炎可能被误认为息肉，因此在考虑肿块切除前组织学确认很重要。

Clinical presentation is usually characterized by otorrhea, ear scratching, and head shaking, and clinical signs of otitis media/interna are frequently present; diagnostic imaging also differs from FIPs (Figs. 12 and 13). Treatment and prognosis depend on histologic diagnosis (Fig. 14); however, surgical removal via VBO or TECALBO is often necessary.

临床表现通常以耳分泌物、抓耳和甩头为特征，常伴有中耳炎/内耳炎的临床症状，诊断性影像学也不同于FIPs(图12和图13)。治疗和预后取决于组织学诊断(图14)，然而，通常需要通过VBO或TECALBO进行手术切除。

Fig. 12. CT imaging of canine middle ear polypoid-like lesions. (A) BTW: the right bulla is slightly enlarged and filled with a soft tissue density in the tympanic cavity; moderate thickening and mottled lysis of the bulla, erosion of the petrous bone, and temporal-mandibular joint thickening are visible. The left bulla is filled by the same soft tissue density; note the mild thickening of the bulla contour and minimal petrous bone erosion. There is bilateral loss of air contrast of the ear canal. (B) Soft tissue window (STW) after contrast medium administration (acma): minimal contrast enhancement is bilateral. The dog was diagnosed with bilateral cholesteatoma. (C) BTW: a soft tissue density is filling the right tympanic cavity and protruding into the ear canal; mild enlargement of the tympanic bulla, mild thickening of the bulla contour, and loss of air contrast of the horizontal ear canal are also visible.(D) STW acma: heterogenous contrast enhancement. The dog was diagnosed with cholesterol granuloma. (E) BTW: loss of air contrast in the left tympanic cavity and ear canal, thickening and calcification of the external ear canal; loss of air contrast of the right external ear. (F) STW acma: minimal contrast enhancement of the left external ear canal. The dog was diagnosed with chronic otitis externa and chronic left otitis media.

图12。犬中耳息肉样病变的CT表现。(A)BTW:右侧鼓泡稍大，鼓室内充满软组织密度;可见鼓泡中度增厚和斑点状溶解，颞骨岩部骨侵蚀，颞下颌关节增厚。左侧鼓泡被相同密度的软组织填充;注意鼓泡轮廓轻度增厚和轻微的颞骨岩部骨侵蚀。双侧耳道空气对比消失。(B)注射造影剂(acma)后软组织窗(STW):双侧轻度对比增强。这只犬被诊断为双侧胆脂瘤。(C)BTW:软组织密度填充右侧鼓室，并向耳道突出;鼓泡轻度增大，鼓泡轮廓轻度增厚，水平耳道空气对比减弱。(D) STW acma:非均匀增强。这只犬被诊断出患有胆固醇肉芽肿。(E)BTW:左鼓室、耳道空气对比消失，外耳道增厚、钙化;右外耳气对比消失。(F) STW acma:左外耳道轻度增强。犬被诊断为慢性外耳炎和慢性左侧中耳炎。

Fig. 13. Polypoid-likelesion of the middle ear cavity of dogs. (A,B) Cholesteatomas: pearly lesion to pink oval mass protruding from the middle ear. (C) Cholesterol granuloma: pink bluish oval lesion protruding from the middle ear cavity. (D) Otitis media: mass lesion filling the middle ear cavity

图13。犬中耳息肉样病变。(A,B)胆脂瘤:从中耳突出的珍珠状病变到粉红色椭圆形肿块。(C)胆固醇肉芽肿:从中耳突出的粉红色蓝色椭圆形病变。(D)中耳炎:填充中耳的肿块

Fig. 14. Microscopic appearance of (A) cholesteatoma: presence of a hyperplastic and hyperkeratotic keratinizing squamous epithelium lining a cystic cavity filled with keratin debris and resting on a dense fibrous stroma (hematoxylin and eosin [H&E],*100). (B) Cholesterol granuloma: fibroconnective tissue, subepithelial inflammatory infiltration, areas of hemorrhages, and cholesterol cleft (H&E,*100). (C) Otitis media: fibrovascular tissue with subepithelial inflammatory infiltration lined by a simple epithelium (H&E,*100). (Courtesy of Dr Chiara Giudice, Universita` Veterinaria di Milano, Milano, Italia.)

图14。显微镜下(A)胆脂瘤:存在增生和过度角化的角质化鳞状上皮细胞，囊腔内充满角蛋白碎片，位于致密的纤维基质上(苏木精和伊红[H&E]，100倍放大)。(B)胆固醇肉芽肿:纤维结缔组织，上皮细胞下炎性浸润，出血区，胆固醇裂隙(H&E， 100倍放大)。(C)中耳炎:纤维小管组织中有上皮细胞下的炎性浸润，内衬单层上皮细胞(H&E，100倍放大)。

Nasal and nasopharyngeal polyps

鼻部和鼻咽息肉

Canine nasal and nasopharyngeal polyps that histologically resemble the feline and human inflammatory polyps should be treated as described for inflammatory polyps in cats. Different nasal hamartomas have been described in dogs, which macroscopically look like a polypoid mass. Histopathologically, they are characterized by connective tissue with inflammatory cells infiltrates, and they do not show any evidence of neoplasia and are thought to arise from native tissue of the nasopharyngeal cavities.

犬鼻部和鼻咽息肉在组织学上类似于猫和人炎性息肉，治疗应按照猫炎性息肉描述的治疗方案。在犬上描述与鼻错构瘤不同，其宏观上看起来像一个息肉样肿块。组织病理学上，以结缔组织伴炎性细胞浸润为特征，不显示任何瘤变的表现，被认为起源于鼻咽腔的原生组织。

CT appearance of the reported cases of canine polyps resembles nasal hamartomas. Treatment planning depends on the definitive diagnosis; endoscopic or surgical intervention may be considered and full excision is often curative.

在已报告的犬息肉病例CT表现类似于鼻错构瘤。治疗计划取决于明确的诊断;内窥镜或外科治疗可以考虑，完全切除通常是可治愈的。

Recently, neoplastic transformation of adenomatoidchondro-osseous nasal hamartoma has been described in humans; therefore, prompt diagnosis and treatment should be considered to avoid possible neoplastic transformation of a chronic benign disease.

最近，在人医上描述了腺瘤软骨骨性鼻错构瘤的肿瘤化，因此，应考虑及时诊断和治疗，以避免慢性良性疾病可能的肿瘤化。

七又十分之九