猫慢性耳炎：原发、易感和持久因素的临床管理（3）

王帆

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

猫慢性耳炎：原发因素、易感因素和持久因素的临床管理

作者：Bailey Brame and Christine Cain

翻译：郑江涛 校对：王帆

Factors predisposing to otitis

耳炎的易感因素

Treatment errors

治疗不当

Healthy cats may have dark ceruminous debris, which can lead owners and veterinary staff to clean or treat these ears unnecessarily. Cleansing or treating a healthy ear is not recommended because it can variously interfere with the ear’s natural cleansing mechanisms, cause mechanical trauma, add moisture or result in a contact reaction.

健康的猫可能有黑色的耵聍碎屑，这可能导致主人和兽医不必要地清洁或处理这些耳朵。不建议清洁或治疗健康的耳朵，因为它会以各种方式干扰耳道的自我清洁机制，造成机械创伤，增加水分或导致接触反应。

Obstructive ear disease

阻塞性耳病

Inflammatory aural polyps

炎性耳息肉

Inflammatory aural polyps (IAPs) are benign nodules originating from the epithelium lining the middle ear, nasopharynx or Eustachian tube. Though often visible on otoscopy and, thus, seemingly amenable to traction avulsion, there is frequently a stalk present that extends from the polyp into the medial compartment of the bulla and beyond. The polyp may be confined to the middle ear, without any extension into the external ear canal. IAPs are most often unilateral, though a recent study found that 24% of cats with IAPs had them bilaterally.

炎性耳息肉（IAPS）是起源于中耳、鼻咽或咽鼓管的上皮细胞的良性结节。虽然在耳镜检查中经常可见，因此，似乎可以进行牵拉撕脱，但息肉延伸到鼓泡内侧室和更远经常有个蒂。息肉可能局限于中耳，没有延伸到外耳道。IAP通常是单侧的，但最近的一项研究发现，24%IAP患猫是双侧的。

Cats with IAPs may present initially with bacterial otitis externa, which can be refractory to treatment. In addition to signs of otitis externa, affected patients may have vestibular signs, respiratory signs, ocular discharge or blepharo spasm, or Horner’s syndrome. IAPs occur most commonly in young cats and kittens, though they can develop at any age.

IAP患猫最初可能表现为细菌性外耳炎，这可能难以治疗。除了外耳炎的症状外，患猫可能有前庭症状、呼吸道症状、眼分泌物或眼睑痉挛或霍纳综合征。IAP最常发生在年轻猫和幼猫上，但任何年龄都可患病。

If visible on otoscopy, IAPs often appear as a smooth, pink nodule in the canal at the level of the tympanum (Figure 4). CT is recommended to visualize the extent of the lesion, support the diagnosis and evaluate for bilateral disease. In one study, 4/6 cats with bilateral IAPs were identified only by CT or video-otoscopy (see box). Definitive diagnosis requires histopathology.

如果在耳镜下能看到，IAP通常在鼓膜腔水平耳道中表现为光滑的粉红色结节（图4）。建议用CT检查病变的范围，确诊，评估是否双侧患病。在一项研究中，4/6只患有双侧IAP的猫仅通过CT或视频耳镜确诊（见方框）。确诊需要组织病理学。

Figure 4 Otoscopic image of an inflammatory aural polyp in the ear canal of a 1-year-old spayed female domestic shorthair cat

图4一只1岁已绝育雌性家养短毛猫的耳道炎性耳息肉的耳镜图像。

IAPs are usually treated in one of two ways: traction avulsion or ventral bulla osteotomy (VBO). At the time of the procedure, cats should be evaluated for concurrent nasopharyngeal polyp. Complications may occur with either of these treatment approaches, including Horner’s syndrome, vestibular signs, hemorrhage and facial nerve paralysis. VBO is more invasive and may carry a greater risk of complications. Cats with bilateral polyps should be staged to reduce the risk of respiratory complications. IAP recurrence is common and occurs more often in cats that undergo traction avulsion (up to 67%) relative to VBO (5%). In one study, none of the cats that received prednisolone after traction avulsion experienced recurrence, relative to 64% of cats that did not receive a steroid.

IAP通常有两种治疗方法：牵引撕脱术或腹侧鼓泡截骨术（VBO）。在手术时，应评估猫是否同时患有鼻咽息肉。这两种治疗方法都可能出现并发症，包括霍纳氏综合征、前庭症状、出血和面神经麻痹。VBO更具侵入性，可能带来更大的并发症风险。患有双侧息肉的猫应分开进行手术，以降低呼吸系统并发症的风险。IAP复发是常见的，并且相对于VBO（5%），在经历牵引性撕脱的患猫，复发率更高（高达67%）。在一项研究中，牵引撕脱后接受泼尼松龙治疗的猫无一复发，而未接受类固醇治疗的猫复发率为64%。

Two newer techniques have been described to address IAPs. A case series reported a per-endoscopic transtympanic technique for removal of polyps with traction followed by curettage of the bulla, which resulted in a lower rate of recurrence (13.5%) as compared with conventional traction avulsion. Another procedure involved a lateral approach to the ear canal followed by deep traction avulsion. The recurrence rate varied with surgeon experience (14–35%).

已经描述了两种较新的技术来解决IAP。一病例分析报道了一种经内镜经鼓膜切除息肉的技术，先牵引后刮除鼓泡。其复发率（13.5%）低于传统的牵引撕脱术。另一种方法是耳道外侧通路，然后进行深部牵引撕脱。复发率因外科医生的经验而异（14-35%）。

Video-otoscopy 视频耳镜检查 While many practitioners rely on a hand-held otoscope, a video-otoscope can be very helpful for the diagnosis and treatment of chronic otitis (Figure 5). The magnification of the camera lens and light source both greatly improve visualization, and most video-otoscopes have ports to allow the practitioner to insert instruments for lavage and other procedures under direct visualization. 虽然许多医生依赖手持耳镜，但视频耳镜对慢性耳炎的诊断和治疗非常有帮助（图5）。.摄像机镜头和光源的放大都极大地提高了可视性，并且大多数视频耳镜具有端口，以允许医生在直接可视的情况下插入用于灌洗和其他程序的器械。 Figure 5 One of the authors (BB) examines the ear canal of a 2-year-old castrated male domestic shorthair cat with otic pruritus using a video-otoscope 图5作者之一（BB）使用视频耳镜检查一只患耳瘙痒症的2岁已去势雄性家养短毛猫的耳道

Neoplasia should be considered when unilateral disease is present in an older patient, particularly if secondary infections have not responded to appropriate therapy. 当老年患猫出现单侧病变时，应考虑肿瘤，特别是如果继发感染对合理的治疗无效时。

Neoplasia

肿瘤

Neoplastic disease within the ear canal or middle ear predisposes patients to otitis externa by obstructing the canal and preventing normal self-cleaning. Neoplasia should be considered when unilateral disease is present in an older patient, particularly if secondary infections have not responded as expected to appropriate therapy. In addition to typical signs of otitis, patients with aural neoplasia may have facial nerve paralysis, vestibular signs or pain on opening the mouth. One study found that cats with neurologic signs at the time of diagnosis had a worse prognosis.

耳道或中耳内的肿瘤疾病，会阻塞耳道并阻止正常的自我清洁，使患猫易感外耳炎。当老年患猫出现单侧病变时，应考虑肿瘤，特别是如果继发感染对合理的治疗无效时。除了典型的耳炎症状外，耳部肿瘤患猫还可出现面神经麻痹、前庭症状或张口疼痛。一项研究发现，在诊断时有神经症状的猫预后更差。

The most common aural neoplasm in the cat is ceruminous gland adenocarcinoma (CGA; 37–86% of aural neoplasms), followed by squamous cell carcinoma (SCC; 33%) and carcinoma of unknown origin (CUO; 22%). SCC and CUO are more locally aggressive and carry a worse prognosis than CGA. Most aural tumors have low metastatic rates, so out come depends on local disease progression. Cats with CGA have a longer median survival time (49–50 months) than cats with SCC (4 months) or CUO (6 months).

猫最常见的耳部肿瘤是耵聍腺腺癌（CGA；37-86%的耳部肿瘤），其次是鳞状细胞癌（SCC；33%）和不明原因的肿瘤（CUO；22%)。与CGA相比，SCC和CUO的局部侵袭性更强，预后更差。大多数耳部肿瘤转移率低，所以结果取决于局部疾病的进展。与患有SCC（4个月）或CUO（6个月）的猫相比，患有CGA的猫的中位生存期更长（49-50个月）。

Treatment of otic neoplasia ideally involves surgical resection with a technique such as total ear canal ablation with bulla osteotomy (TECABO). In addition to the potential for definitive cure of the neoplasm, surgery may palliate the patient by removing a source of infection and pain. Depending on the tumor type and surgical margins, radiation or chemotherapy may be recommended after surgery. Radiation may also be used alone for palliative effect.

理想情况下，耳肿瘤的治疗包括手术切除，如全耳道消融术和鼓泡截骨术（TECABO）。除了可能彻底治愈肿瘤之外，手术可以通过消除感染源和疼痛来减轻患猫的症状。根据肿瘤类型和手术范围，术后可推荐放疗或化疗。放疗也可单独用于姑息治疗。

Ceruminous gland cystomatosis

耵聍腺囊瘤病

Ceruminous gland cystomatosis tends to occur in older cats, though it can occur at any age. Male cats of any breed, and Persians and Abyssinians may be over-represented. Affected cats may have a history of chronic otitis externa. On physical examination, multiple small raised cystic papules to nodules, varying in color from dark brown to gray-blue or purple, are seen in the canal and on the concave pinnae (Figure 6). The number of cysts can range from a few to so many that they obstruct the canal. Diagnosis is often presumptive, though biopsy can be considered if there is concern for malignant neoplasia. Treatment is focused on control ling secondary infections and inflammation. For patients with recurrent infection secondary to cystomatosis, laser ablation is gaining favor among veterinary derma tologists.

耵聍腺囊瘤病往往发生在年龄较大的猫，但它可以发生在任何年龄。任何品种的公猫，波斯猫和阿比西尼亚猫的比例都可能过高。患猫可能有慢性外耳道炎的历史。体检时，在耳道和耳廓上可见多个小的隆起的囊性丘疹至结节，颜色从深褐色到灰蓝色或紫色不等（图6）。囊肿的数量可以从几个到多个不等，以至于阻塞了管道。通常是推测性诊断，但如果担心恶性肿瘤，可以考虑活检。治疗的重点是控制继发感染和炎症。对于继发于囊瘤病的复发性感染患猫，激光消融术越来越受到兽医皮肤病学家的青睐。

Figure 6 Ceruminous gland cystomatosis in a 12-year-old spayed female domestic mediumhair cat

图6一只12岁已绝育雌性家养中毛猫的耵聍腺囊瘤病

For ceruminous gland cystomatosis, the number of cysts can vary, but there can be so many that they obstruct the canal. 对于耵聍腺囊瘤病，囊肿的数量可能不同，但数量可能很多，以至于阻塞耳道。

Cholesteatoma and cholesterol granulomas

胆脂瘤和胆固醇肉芽肿

There is a single case of feline cholesteatoma in the literature. Two cases of aural cholesterol granuloma have been reported in cats with otitis media, and cholesterol granulomas have been experimentally induced in cats.

文献中只有一例猫胆脂瘤。报道了两例患有中耳炎的猫耳部胆固醇肉芽肿，以及胆固醇肉芽肿已在猫中被实验诱导。

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