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Otitis Techniques to Improve Practice
耳炎技术临床进展
作者：Craig E. Griffin, DVM, DACVD
翻译：王帆
摘要
Successful management of otitis externa requires recognition of changes in the anatomy and physiology of the external and middle ear, as well as the adequate tools and examinations to detect changes from normal. Otoscopy and methods for assessing the normalcy of the tympanum, collection of samples for cytologic evaluation or culture, and myringotomy are diagnostic techniques important in practice. Treatment tubes and intralesional triamcinolone injections are techniques that improve the response in some cases.
成功治疗外耳炎需要认识外耳和中耳的解剖和生理变化，以及足够的工具和检查来发现与正常情况不同的变化。耳镜检查和评估鼓室正常状态的方法，采集样本进行细胞学检查或培养，以及鼓膜切开术是临床上重要的诊断技术。在某些病例中，治疗导管和病变内注射曲安奈德是提高治疗效果的技术。
KEYWORDS otitis, dog, techniques, ear flush, intralesional injections, otoscopy, fiberoptic video enhanced otoscopy, FOVEO
关键词:耳炎、犬、技术、耳道冲洗、病变内注射、耳镜、光纤视频增强耳镜，FOVEO
Otitis externa is a common problem of dogs and cats that often is a diagnostic and therapeutic challenge. Detecting and treating changes in the normal anatomy, physiology of the ear canal, microflora, tympanic membrane, and middle ear cavity are essential for successful treatment of otitis. Thorough visualization of the ear, use of ear loops and tubes within the ear and the collection of appropriate samples are the basis for detecting the changes. Effective treatment also requires adequate delivery of therapeutic agents to the site in the ear where they are needed. This paper reviews some equipment and techniques that improve the chances of detecting and treating the changes in the ear.
外耳炎是一种犬猫常见疾病，往往在诊断和治疗上具有挑战。耳炎治疗成功的关键在于，对耳道正常解剖、耳道生理、微生物群、鼓膜和中耳腔的异常变化的检查和治疗。对耳道进行详细的观察，根据检查到的变化，使用耳环和耳内导管，采集适当的样本。有效的治疗还需要将治疗药物充分地输送到耳道中需要的部位。本文综述了一些提高耳部疾病检出率和治愈率的设备和技术。
Otoscopy
耳镜检查
Otoscopy is the examination of the ear canal with an otoscope. Otoscopy is used to detect foreign bodies, lesions, exudate, and pathologic changes that have occurred in the ear canal. It may also be helpful in assessing the tympanic membrane though in many cases of chronic otitis routine otoscopy alone is often not sufficient for detecting all changes in the tympanic membrane or otitis media. Repetitive otoscopic examinations are often required to determine if normal ear cleaning is occurring and when the ear is healed. Otoscopy also allows for direct observation of various procedures that can be performed through the otoscope. These include use of ear loops, ear cleaning, biopsies, intralesional injections, and myringotomy.
耳镜检查是用检耳镜检查耳道。耳镜检查用于检测耳道的异物、病变、分泌物和病理性改变。虽然在许多慢性耳炎病例中，常规的耳镜检查往往不足以发现鼓膜或中耳炎的所有变化，但也能帮助评估鼓膜。经常需要反复进行耳镜检查，来确定耳道是否清洁正常和耳部何时恢复。耳镜检查还可通过检耳镜进行各种手术操作中直接观察。这些操作包括使用耳环采样、清洗耳道、活组织检查、病变内注射和鼓膜切开术。
Successful otoscopy requires adequate equipment. Numerous and various types of otoscopes are available but there are several major requirements for any to be adequate. The otoscope must have a strong light and power source combined with at least 10*magnification. The depth of field should allow clear focus within the normal length of the ear canal through otoscope cones designed for dogs and cats. If any of these components is not present otoscopic examinations may not be totally effective. Successful management of chronic otitis cases requires at least one otoscope that is powered directly from an electrical outlet with a strong bulb or light source. This otoscope should be available when procedures are going to be performed in or near the tympanum or middle ear. The rechargeable battery, portable hand held otoscopes are sufficient for examining relatively normal ears but are inadequate for most cases with chronic otitis especially if there is pathology of the tympanum or middle ear.
成功的耳镜检查需要足够的设备。有多种和各种类型的耳镜可用，但要适用所有耳病需要几个主要需求。耳镜必须有强光源和放大功能，至少有10倍的放大倍数。犬猫使用的耳镜锥形头视野范围应允许清晰观察到正常耳道的长度。如果不满足这些条件，耳镜检查不可能完全有效。要想成功治疗慢性耳炎病例需要至少有一种能插电式，有强光源的耳镜。当手术要在鼓室或中耳内或附近进行时，耳镜更适用。这种可充电的便携式耳镜足以检查相对正常的耳道，但不适用于大多数慢性耳炎患者，尤其是有鼓室或中耳病变的患者。
Most otoscopes sold to veterinarians were originally designed for human medicine, where there are 2 main types of otoscope heads the diagnostic or medical and the surgical head. They differ in the size of the magnifying lens that one looks through as well as the shape of the cone holders (Fig. 1A-C). Additionally the diagnostic head can be made relatively airtight so a puff of air with a rubber bulb attached to the nipple of the otoscope head may be sent to the tympanic membrane. This technique called pneumotoscopy is used to create and observe movement of the tympanic membrane, which implies the tympanum is intact. This is rarely done in veterinary medicine and has not been shown to be accurate in the determination of a ruptured tympanum. The surgical otoscope head is designed so that there is space between the magnifying eyepiece and the cone holder. It is also advantageous for the eyepiece and cone holder to be rotateable (Fig. 1C). These features allow instruments to be placed down the cone and into the ear while visualizing the ear canal. The ability to rotate the cone holder and eyepiece allows greater manipulation and angulation of instruments or tubes passed through the cone down the ear canal. Otoscope cones of various sizes, including 4 mm and 5 mm, are needed to be able to examine the different size and breeds of dogs and cats seen in practice. Reusable plastic otoscope cones should be cleaned then soaked at least ten minutes in an acceptable disinfectant. A study showed mechanical cleaning and wiping with alcohol or disinfectant is not sufficient to remove potential pathogens.
大多数卖给兽医的耳镜最初是为人医设计的，其中有两种主要类型的耳镜头诊断或医疗和外科头。它们的不同在于人们所看到的放大镜的大小以及锥架的形状(图1A-C)。此外，诊断头可以相对密封，因此，以便橡胶球附在耳镜头乳头可以将空气吹向鼓膜。这种技术被称为肺镜检查，用来创建和观察鼓膜的运动，这意味着鼓膜是完整的。这在兽医学中是很少使用，也没有被证明是准确的确定鼓室破裂的方法。手术耳镜头的设计使放大目镜和锥架之间有一定的空间。目镜和锥架可旋转也是有利的(图1C)。这些特征使得仪器可以放置在耳锥下并进入耳道，同时可以看到耳道。旋转锥支架和目镜的能力允许更大的操作和角度的仪器或管道通过锥下的耳道。需要不同大小的耳镜锥形头，包括4毫米和5毫米，以便能够检查不同大小和品种的犬和猫在实践中看到。可重复使用的塑料耳镜锥应先清洗，然后在可接受的消毒剂中浸泡至少10分钟。一项研究表明，用酒精或消毒剂进行机械清洁和擦拭不足以清除潜在的病原体。
 
Figure 1 (A) The photo shows diagnostic otoscope head from a lateral view showing how the cone holder is solid back to the eyepiece. (B) Shows the rear view with the eyepiece moved to open the otoscope so that a tube or instrument could be passed down into the cone. (C) Shows a surgical otoscope head that is open from the eyepiece to the cone holder. The rear view shows how the cone holder and eyepiece can be rotated in opposite directions allowing easier passage of tubes or instruments while still being visualized. (Reprinted with permission from Craig E. Griffifin Photos.) (Color version of figure is available online.)
图1 (A)诊断耳镜头的侧视图，显示圆锥支架是如何坚实地支撑目镜。(B)显示后视图，移动目镜打开耳镜，以便管子或仪器可以向下进入锥体。(C)显示手术耳镜头，从目镜到锥座是打开的。后视图显示如何锥架和目镜可以在相反的方向旋转，使管道或仪器更容易通过，而仍然是可见的。
The advent of fiberoptics, superior light sources, and miniaturization of video cameras has recently been combined with a rigid endoscope designed for use in the external ear canal of dogs and cats, the video otoscope (Fig. 2A,B) This otoscope incorporates fiber optics and a lens in the otoscope along with a channel that small instruments or tubes can be passed through, the opening to the channel can be attached to a dual port adapter so fluid can be infused or suction applied just by switching the adapter. This equipment is connected to a video monitor and possibly printer, video, or digital recorder which allows production of permanent records and the ability to show clients changes found on examination and procedures performed in the ear. The combination of this equipment has resulted in what may be termed fiberoptic video enhanced otoscopy, FOVEO. The two companies that pioneered the development of these products for veterinary medicine are Karl Storz (Tuttlingen, Germany) and MedRx (Largo, FL). The fiber optic tip with camera also magnifies greater and some units allow you to zoom in and manually focus for even better viewing. Besides improving visualization it allows closer observation and more precise use of the working end of instruments passed through the videoscope head. Videoscope heads allow visualization even when used with water or saline that can be simultaneously flushed through it and this is not possible with the standard otoscope. The use of water or saline will improve magnification, prevent fogging of the lens and help to dilate the canal, all of which further improve visualization. In some cases small tears of the tympanic membrane not readily seen with the normal 10magnified otoscope will be apparent (Fig. 3). Water or saline used in the ear with normal otoscopes prevent visualization. Photographs may be taken and used to document changes as well as for client education. Many clients shown photos of a normal ear and then what their pet’s ear looks like are more receptive to have anesthesia, cleaning of the ear canal, and follow-up examinations to see the progress made. This equipment is relatively expensive but considering the improved diagnostics and more importantly the client education and effect on gaining client support for recommended procedures is well worth the investment in a busy practice.
最近，随着光纤、高级光源和摄像机的小型化，一种专为犬和猫的外耳道设计的硬性内窥镜——视频耳镜(图2A,B)，这种耳镜包括光纤和耳镜中的透镜，以及一个小仪器或管子可以通过的通道，通道的开口可以连接到一个双端口适配器，因此只需切换适配器就可以注入液体或抽吸液体。该设备连接到视频监视器，可能还连接到打印机、视频或数字记录器，从而可以产生永久记录，并能够向客户显示在检查和耳部操作过程中发现的变化。这种设备的组合产生了所谓的光纤视频增强耳镜，FOVEO。在兽药领域率先开发这些产品的两家公司是Karl Storz 和MedRx。带有相机的光纤尖端也可以放大，一些单位允许你放大和手动对焦，以获得更好的观看效果。除了提高可视化之外，它还允许更近距离观察和更精确地使用通过视频镜头的仪器的工作端。可视镜头即使与水或盐水一起使用也可以看到，而这是标准耳镜所不能做到的。水或盐水的使用将提高放大率，防止晶状体起雾，并有助于扩大耳道，所有这些都将进一步提高视力。在某些病例中，正常的10倍放大耳镜很难看到的鼓膜小撕裂会很明显(图3)。使用正常耳镜在耳中使用水或生理盐水会妨碍观察。拍照可用于记录变化，也可用于对客户进行教育。很多顾客在看到正常耳道的照片后，对宠物的耳道进行麻醉、清理耳道、后续检查等，会更容易接受。这种设备相对昂贵，但考虑到改进的诊断，更重要的是客户教育和获得客户对推荐程序支持的效果，在繁忙的实践中投资是值得的。
Figure 2 (A) This is a otoscope with a dual port adapter attached. (B) The same otoscope with a videocamera attached and together this is the full size of the otovideoscope. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图2 (A)这是一个带有双端口适配器的耳镜。(B)相同的耳镜加上一个摄像机，这是耳镜的全尺寸。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
Figure 3 This photo shows a small tear in pars tensa of tympanic membrane detected by otovideocamera that was not readily apparent on routine otoscopy. Note the appearance of the abnormal tympanum that occupies the rest of the photo above the tear. This abnormal tympanum looks like impacted debris that may build up when there is lumen stenosis and failure of normal epithelial migration. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图3这张照片显示鼓膜紧张部有一个小撕裂，这是由视频耳镜观察到的，在常规耳镜检查中并不明显。注意异常鼓膜的外观，它占据了照片上撕裂处的其余部分。异常鼓膜看起来像阻生的碎片，当耳道狭窄和正常上皮迁移失败时，这些碎片可能会堆积起来。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
The goal of otoscopy is to visualize the complete ear canal, amount of ear wax and cerumen, and tympanic membrane. The skin and adnexa are constantly producing exfoliating corneocytes, intercellular material, and glandular secretions. This material forms the earwax and cerumen that is believed to play some protective role. The cerumen is constantly being produced throughout the ear canal. Were this material to build up blockage could result, but this is prevented as the ear has a normal clearing mechanism. The material produced in the ear canal is cleaned or cleared out by the movement of the epidermis.The surface of the skin lining the ear canal is constantly moving from the tympanic membrane laterally to the external orifice of the ear canal. With repetitive examinations it is possible to determine if normal self cleaning is occurring and this is important because some cases of chronic otitis continue to recur because self cleaning is not occurring. The examination has to be done when the ear has not recently been cleaned by the owner or groomer.
耳镜检查的目的是观察完整的耳道、耳蜡、耳垢的量和鼓膜。皮肤和附件不断产生脱落的角质形成细胞、细胞间物质和腺体分泌物。这种物质形成了耵聍和耳垢，人们认为它们起到了保护作用。耳垢在整个耳道不断产生。如果这些物质堆积起来，可能会导致堵塞，但这是可以防止的，因为耳道有正常的清理机制。耳道内产生的物质通过表皮的运动被清洁或清除。耳道的皮肤表面不断地从鼓膜向外侧移动到耳道的开口。通过重复检查，可以确定是否发生了正常的自我清洁，这是很重要的，因为一些慢性耳炎病例继续复发是因为没有进行自我清洁。如果耳道最近没有被主人或美容师清洗过，就必须进行检查。
Basic External Ear Canal Anatomy
外耳道基本解剖
The external ear is formed from 2 pieces of cartilage and a boney canal, the external acoustic meatus (Fig. 4). These structures are lined with skin that normally is a relatively smooth surface and similar to most body regions has a thin epidermis and dermis that contains adnexa (hair follicles, sebaceous, and apocrine glands) (Fig. 5B). The larger lateral cartilage portion, auricular cartilage, forms the pinna and most of the ear canal. The external ear canal is variable in length (5-11 cm) and classically divided into the vertical and horizontal portions. The vertical portion originates from the pinnae and extends in a rostral ventral direction before bending medially and continuing until it reaches the tympanic membrane. The area from the bend extending medially is the horizontal ear canal. There is a prominent cartilaginous ridge that separates the vertical from the horizontal canal in the dog. Its prominence varies between breeds and between individuals within breeds. It creates the “corner” around which one must proceed to allow access into the horizontal canal (Fig. 5A,B). The smaller second cartilage is the annular cartilage surrounding the distal portion the horizontal canal and extends between the auricular cartilage and the external portion of the bone of the external acoustic meatus. The external acoustic meatus then is the bone that lines the last portion of the horizontal canal terminating at the tympanic membrane. The medial distal end of the external acoustic meatus is a ring of bone where the tympanum attaches and separates the external ear canal from the middle ear cavity. The tympanic membrane is an epithelial structure that separates the external ear laterally from the middle ear cavity located medially (Fig. 6A,B). The tympanic membrane of the dog is made up of the pars tensa and pars flaccida. The majority of what is seen of the tympanum when it is examined through the otoscope is the large pars tensa. A normal pars tensa is translucent, with striations seen extending from the manubrium of the malleus outward to the periphery (Fig. 6A). A whitish appearing discoloration can sometimes be seen through the lower to mid section of the tympanum. This whitish structure is the bony ridge that separates the tympanic cavity from the tympanic bulla. The manubrium of the malleus is “C” shaped with the open end of the “C” pointing toward the nose. It is located over the anterior medial aspect of the tympanum and is an important reference point when doing palpation and myringotomy. The pars flaccida is a small area of the dorsal aspect of the tympanum, above the manubrium of the malleus. It is relatively flaccid and quite vascular. This structure may bulge out, almost looking cyst like (Fig. 6B). Dr Rosychuck has speculated that this may be a product of increased air pressure within the middle ear, most commonly seen in dogs who are shaking their heads (eg, allergic). The out pouching can also be filled with fluid if the middle ear is fluid filled. Once perforated, this structure tends to heal very quickly. The tympanum is oriented at about a 30 to 45 degree angle from perpendicular (dorsal to ventral). The ventral portion of the tympanum creates a fold or groove where it connects to the ventral floor of the horizontal canal over the bone of the acoustic meatus. This area often has several hairs and is an area where small amounts of wax are noted to accumulate in normal dogs (Fig. 6B).
外耳是由2块软骨和一个骨性耳道,外耳道组成(图4)。这些结构内衬皮肤,通常是一个相对光滑的表面和类似于大多数机体区域有一个薄的表皮和真皮包含附件(毛囊、皮脂腺和顶浆汗腺)(图5 b)。较大的外侧软骨部分，即耳软骨，形成耳廓和大部分耳道。外耳道长度可变(5-11厘米)，通常分为垂直部分和水平部分。垂直部分起源于耳廓，在向内侧弯曲并继续延伸直到鼓膜。从耳弯向内侧延伸的区域是水平耳道。在犬体内有一个突出的软骨嵴将垂直耳道和水平耳道分开。它的重要性因品种而异，也因品种内的个体而异。它创造了一个拐角，人们必须绕过这个拐角才能进入水平耳道(图5A,B)。较小的第二软骨是环绕水平耳道远端部分的环状软骨，并在耳软骨和外耳道骨的外部部分之间延伸。外耳道随后连着骨骼，是位于水平耳道的最后一部分，它的末端是鼓膜。外耳道的内侧远端是一个骨环，在这里鼓膜附着并将外耳道与中耳腔分开。鼓膜是一种上皮结构，它将外耳外侧与位于内侧的中耳腔隔开(图6A,B)。犬的鼓膜由紧张部和松弛部组成。当通过耳镜检查鼓室时，所看到的大部分是鼓膜紧张部。正常紧张部呈半透明，可见条纹从锤骨柄向外延伸至周围(图6A)。有时可以透过鼓膜下半部到中部看到一种白色的变色。这个白色的结构是分隔鼓室腔和鼓泡的骨嵴。锤骨柄呈C形，C的开口端指向鼻子。它位于鼓室前内侧，是触诊和鼓膜切开术的重要参考点。松弛部是鼓膜背侧的一小块区域，位于锤骨柄上方。它相对松弛，血管相当多。该结构可能膨出，几乎看起来像囊肿(图6B)。Rosychuck博士推测，这可能是中耳气压增加的结果，在甩头(如过敏)的犬上最常见。如果中耳充满液体，则向外凸出袋也可以充满液体。一旦穿孔，这个结构会很快进行愈合。鼓膜与垂直(背侧到腹侧)方向约为30至45度。鼓膜腹侧部分与水平耳道骨质腹侧部分形成一个褶皱或沟槽。该区域通常有几根毛发，在正常犬中，这是一个注意到有少量耳垢积累的区域(图6B)。
 Figure 4 This lateral view of a dog skull shows the boney external acoustic meatus that the ear loop is passed through. The tip of the ear loop is just over the inner ring of the meatus and the metal pin seen on the inner aspect is inside the middle ear cavity and would be medial to the normal location of the tympanic membrane. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图4犬颅骨侧位图显示耳环通过的骨质外耳道。耳环的尖端刚好在耳道内环的上方，在内面看到的金属针在中耳腔内，位于正常鼓膜位置的内侧。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
Figure 5 (A) The ridge that can block access to the deep vertical then horizontal canal is shown in its normal position. (B) This figure shows the ridge after the pinna has been pulled up then lateral and ventral to straighten the ridge of cartilage and allow access of the horizontal canal. Note how there is accumulation of ear cerumen and debris but the lining of the canal is smooth. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图5 (A)显示在正常位置的软骨嵴，可以阻止垂直深处通向水平耳道。(B)这张图显示了耳廓被牵拉后的嵴，然后可直接看到软骨嵴外侧和腹侧，并允许进入水平耳道。注意耳垢和碎屑的堆积，但耳道的内衬皮肤是光滑的。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
Figure 6 (A) This is a videoscope close up photo of a normal tympanum. Note the manubrium of the malleus and the stria on the translucent pars tensa. (B) Another normal tympanum in an atopic dog with a dilated pars flaccida because of increased air pressure in the middle ear cavity. The pars flaccida is dorsal to the manubrium and in this case bulging lateral into the canal lumen. Note the prominent vasculature of the pars flaccida. Also note the hair at the bottom of the canal coming from the fold where the canal epithelium and pars tensa meet. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图6 (A)这是一个正常鼓膜的视频特写照片。注意锤骨柄和半透明的紧张部的纹。(B)另一只因中耳腔气压增加而导致松弛部扩张的特应性皮炎患犬的正常鼓膜。松弛部位于锤骨柄背侧，在本例中向耳道外侧膨出。注意松弛部明显的血管。还要注意耳道底部的毛发来自耳道上皮细胞和紧张部相遇的褶皱处。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
The Proper Otoscopic Technique
正确的耳镜检查技术
The technique for doing proper otoscopic examination is one that allows complete as visualization as possible with minimal pain or trauma. Inflammation may make it difficult to complete an otoscopic examination without sedation though in many dogs or cats poor technique will also prevent a complete examination. Otoscopy is a learned skill though there are general guidelines that can improve results. If bilateral disease is present the good ear should be examined first. This will decrease the possibility of the dog becoming painful and resisting examination of the second ear. Examining the good ear first allows comparison of normal compared with abnormal. A different clean cone should be used for each ear. The head has to be at a height that will allow the examination to be completed throughout the range of motion of the otoscope to the horizontal position. It may also be necessary to have someone else hold the dog or cats muzzle as the natural tendency is for the head to be tilted as the examination starts. This movement may result in more pain or inability to visualize the horizontal canal. The pinna should be pulled up and out from the base of the skull, which helps to straighten the ear canal and minimize the blocking of the lumen by the cartilage fold that occurs near the junction of the vertical and horizontal canal. This cartilage fold varies in size. The tip of the otoscope cone is passed down the lumen of the ear canal while the operator is visualizing the canal through the otoscope cone. Attempting to insert the cone without visualization is a sure way to “hit” the canal epithelium, which can be painful even in a normal ear. The cone is then moved slowly into the vertical canal, visualizing as you go, then the otoscope handle is rotated downward so the cone approaches a horizontal position. The movement is best accomplished when the pinna, which is being pulled up and partly out, is pulled further out then down as the tip of the cone goes below the ridge and into the vertical canal. The two processes of moving the cone and the pinna happen simultaneously. Proper placement at the junction often allows visualization into the horizontal canal and if necessary advancement into the horizontal canal. Deep penetration into the horizontal canal is only done if necessary to visualize the tympanum. One problem often encountered in practice is the extremely painful ulcerated swollen ear that one cannot adequately examine. Even with sedation some of these cases may not be adequately examined. It may be necessary to treat the animal and reduce the swelling and inflammation and have the patient return in 4 to 7 days so that an otoscopic examination can be properly performed.
合适的耳镜检查技术是尽可能以最少的疼痛或创伤彻底观察。炎症反应可能会使在没有镇静的情况下很难完成耳镜检查，但在许多犬或猫中，技术不佳也会阻止完整的检查。耳镜检查是一项学习技能，虽然有一般的指导方针可以提高结果。如果有双侧耳病，应首先检查相对好一些的耳道。这将减少因疼痛患犬抵抗第二耳检查的可能性。首先检查好的耳道可以比较正常和不正常的耳道。每只耳道都应该使用不同的清洁锥形头。头部的高度必须允许在耳镜到水平位置的整个运动范围内完成检查。也有必要让其他人来扶住犬或猫的嘴部，因为在开始检查时，头部自然会倾斜。这种运动可能导致更多的疼痛或无法看到水平耳道。应该以头部为基准，向上向外提拉耳廓，这有助于使耳道变直，并尽量减少垂直和水平耳道交界处的软骨皱褶对耳道的遮挡。软骨皱褶的大小各不相同。当操作者通过耳镜锥形头观察耳道时，耳镜锥头向下穿过耳道。试图盲插锥形头肯定会撞到耳道表皮，即使在正常的耳道中也会感到疼痛。然后将锥形头慢慢移动到垂直耳道中，在你移动的过程中可以看到，然后将耳镜手柄向下旋转，使锥形头接近水平位置。当耳廓向上拉并部分向外拉时，当耳廓锥形头尖端在软骨嵴下进入垂直耳道时，这个动作就完成得最好了。锥体和耳廓移动的两个过程同时发生。在交叉点的适当放置通常允许可视化进入水平耳道，如果有必要，可以推进到水平耳道。只有在观察鼓膜时才深入进水平耳道。在临床中经常遇到的一个问题是非常痛苦的溃疡肿胀的耳道，一个人不能充分检查。即使使用了镇静剂，其中一些病例也可能没有得到充分的检查。可能有必要对动物进行治疗，减少肿胀和炎症，并让患犬在4到7天内复查，以便进行适当的耳镜检查。
Any tear in the tympanum indicates otitis media is likely present. A major problem is that in otitis, especially chronic cases the appearance of the tympanum or its location may change. Often the diseased tympanum becomes opaque and may appear white or have shades of yellow brown and look just like impacted cerumen, epithelial and inflammatory debris (Fig. 3). In other cases the proliferative changes that are present make visualization of the distal horizontal canal minimal or impossible. The medial wall of the tympanic bulla may be interpreted as a diseased but intact tympanic membrane. Even following lavage of the ear canal a satisfactory view of the tympanic membrane could only be obtained in 28% of the cases otoscopically examined while the pet was anesthetized. Diagnosis of intact tympanic membrane cannot be relied on by otoscopic examination only. Therefore, other techniques such as ear loops and tube palpation, discussed below, are used to assess the tympanum and middle ear.
鼓膜的任何撕裂都表明可能存在中耳炎。一个主要的问题是，在耳炎，特别是慢性病例，鼓膜的外观或位置可能改变。通常，病变鼓膜变得不透明，可能呈现白色或黄褐色，看起来就像耵聍、上皮和炎症碎片(图3)。在其他病例中，存在的增殖性改变使远端水平耳道可见度很小或看不到。鼓泡的内壁可以解释鼓膜患病但完整。在宠物麻醉的情况下，即使进行耳道灌洗，也只有28%的病例能获得令人满意的鼓膜视图。完整鼓膜的诊断不能仅靠耳镜检查。因此，其他技术，如耳环和耳管触诊，下文将讨论，用于评估鼓膜和中耳。
Sample Collections
采样
Ear samples are routinely collected from abnormal ears for cytologic examination and sometimes for culture and sensitivity testing. It has been recommended to use cotton tip applicators or the tip of otoscope cones to collect samples. These samples will usually just reflect the exudate in the vertical ear canal and are not effective in sampling the middle ear. In some cases what is present in the deep horizontal canal or the middle ear may differ from that in the vertical canal or even the horizontal canal from middle ear. The samples should represent the predominant exudate from the skin of the deep ear canal or the middle ear cavity. A good method for collecting samples from the deeper ear is to use an ear loop to scrape the deep canal wall. This may require a sedated patient in inflamed painful ears. When a ruptured tympanum is present then attempts to sample the middle ear with the ear loop or tube.The soft tube is more readily placed into the middle ear with less risk for trauma to middle ear structures.The soft feeding tube is sometimes even tolerated in awake animals,even with painful ears. When done without visualization, which is simpler,the exact location the sample came from can not be determined.The tube technique utilizes a 5 French Sovereign Feeding Tube and Urethral Catheter (Monoject Division of Sherwood Medical, St. Louis, MO) that has been cut to about 16 cm with the large end cut so that it fits tightly over a syringe hub (Fig. 7).The tube with syringe attached is passed down the ear canal until it reaches the bottom of the ear, at this point the syringe is used to try and aspirate some of the debris into the tip of the tube.The tube is removed disconnected from the syringe, which then is filled with air, then attached again to the tube and the material in the tip of the tube can be expressed.When otitis media is suspected and the tympanum intact then a myringotomy may be necessary.When it is felt that the tube tip must be sterile until it reaches the deep canal or middle ear then a larger tube can be placed around it and passed down the canal almost to the middle ear.At that point the smaller tube can be advanced forward then material aspirated into the smaller tube.
常规采集异常患耳样本用于细胞学检查，有时用于细菌培养和药敏试验。建议使用棉签尖端或耳镜锥形头尖端采集样本。这些样本通常只反映垂直耳道的渗分泌物，对中耳的采样无效。在某些病例中，水平耳道深处或中耳的情况可能与垂直耳道甚至中耳水平耳道的情况不同。样本应代表来自耳道深处皮肤或中耳腔为主的分泌物。从较深的耳中采集样本的一种较好的方法是用耳圈刮取较深的耳道壁。这可能需要镇静的病人炎症痛苦的耳道。当鼓室破裂时，试着用耳环或耳管取样中耳。软管更容易进入中耳，中耳结构损伤的风险更低。在清醒的动物中，软饲管有时甚至是可以耐受的，即使耳道疼痛。如果不进行更简单的可视化，就无法确定样品的确切位置。管技术利用5F喂食管和导尿管，剪到16厘米长，末端剪大便于连接注射器头(图7)。注射器连接的管深入耳道,直达耳道底部,在这一点上，注射器是用来尝试和抽吸一些碎片到软管尖端。将软管从注射器上取下，然后注射器充满空气，然后再次连接到软管上，吹出软管尖端样本。当怀疑中耳炎而鼓膜完好时，可能需要鼓膜切开术。确保尖端直达耳道深处或中耳时是无菌的，可以套一个直径更大的管，并沿管向下几乎到达中耳。到采样点后，小的软管可以向前推进，然后将样本抽吸到小管里。
Figure 7 Sovereign feeding tube and urethral catheter that when appropriately trimmed can be used to clean ears, palpate the tympanum, and flush the horizontal ear canal and middle ear cavity when the tympanum is ruptured. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图7经适当修整后的饲管和导尿管，可用于清洁耳道，触诊鼓膜，鼓膜破裂时冲洗水平耳道和中耳腔。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
Myringotomy
鼓膜切开术
Myringotomy is generally performed when there is strong suspicion of otitis media, but the tympanum is intact. Most cases where a myringotomy is performed are those with evidence of debris within the middle ear (ie, based on radiographs/computed tomography or magnetic resonance imaging) and they have not responded or continue to recur with appropriate systemic therapy and tube deep cleaning or flushing of the ear. In most of these cases, the tympanum had been perforated but has re-healed. Retrograde infections moving up the auditory canal (Eustachian tube) may also explain the finding of an intact tympanum overlying an active otitis media. A syndrome in Cavalier King Charles spaniels will also present with otitis media and an intact tympanum and lack of otitis externa. Before performing myringotomy it is important to learn certain anatomical features of the tympanum and middle ear.
鼓膜切开术通常适用于怀疑中耳炎但鼓膜完好的情况。大多数进行鼓膜切开术的病例是那些中耳内有碎片的病例(例如，根据x线片/计算机断层扫描或磁共振成像)，并且在适当的全身治疗和耳道深度清洗或冲洗后没有效果或继续复发。在这些病例中，大多数鼓膜已穿孔，但已重新愈合。沿耳咽管(咽鼓管)向上逆行性感染也可以解释活动性中耳炎和完整鼓膜的现象。查理王犬的一种综合征还会表现为中耳炎、鼓膜完整而无外耳炎。在进行鼓膜切开术之前，了解鼓膜和中耳的某些解剖特征是很重要的。
The middle ear consists of the tympanic cavity and walls, medial wall of the tympanic membrane, the auditory ossicles and associated ligaments, muscles and nerves, and the auditory tube. The tympanic cavity is divided into three parts: dorsal, middle, and ventral. The dorsal, also called epitympanic recess, is the smallest and contains the head of the malleus, incus and stapes. The stapes attaches to the oval (vestibular) window leading to the inner ear. The middle part, also called tympanic cavity proper, is adjacent to the tympanic membrane that lies anterior and laterally and posteriorly and medially by the round window. The dorso-medial surface of this is primarily made up of the barrel shaped, cochlear promontory. The promontory is situated opposite to about the mid dorsal aspect of the tympanum. At the caudal end of the promontory is the cochlear (round) window that communicates with the bony labarynthe of the cochlea (Fig. 8). This is the structure one must avoid when doing a myringotomy. The ventral portion is the tympanic bulla and is the largest portion and safest area to pass tubes and instruments into. It is separated dorsally from the tympanic cavity by a bony ridge (Fig. 9A,B). The promontorium and round window is just dorsal to this ridge that is also responsible for making passing tubes into the ventral bullae very difficult.
中耳由鼓室腔和鼓室壁、鼓膜内壁、听小骨和相关的韧带、肌肉和神经以及咽鼓管组成。鼓室分为背、中、腹三部分。背侧，也称为鼓室上隐窝，是最小的，包含锤骨头、砧骨和镫骨。镫骨附着在通向内耳的椭圆(前庭)窗上。中间部分，又称鼓室腔，紧邻鼓膜，靠近圆窗的前外侧和后内侧。它的背内侧表面主要是由桶状的耳蜗隆突组成。隆突位于鼓膜背中侧面的对面。在隆突的尾端是耳蜗(圆形)窗，与耳蜗的骨迷宫相通(图8)。这是做鼓膜切开术时必须避开的结构。腹侧部分是鼓泡，是导管和器械进入的最大部分和最安全的区域。它与背侧鼓膜腔有骨嵴分隔(图9A,B)。隆突和圆形窗就在这个脊的背侧这也使得进入腹侧鼓泡的管道非常困难。
Figure 8 This photo of the middle ear cavity shows a tomcat catheter pointing at the round window and the surrounding promontorium. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图8中耳腔照片显示一条公猫导尿管指向圆窗和周围的隆突。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
Figure 9 Photo of a dog skull looking into the middle ear through an opening in the ventral bullae. You can see the ear loop going into the external acoustic meatus on the left side of the photo. The tip of the ear loop is in the round window of the promontorium. Note the ridge that separates the middle portion of the middle ear cavity from the ventral portion, the tympanic bulla. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图9犬颅骨通过腹侧鼓泡的开口拍摄中耳的照片。你可以看到耳环进入了照片左侧的外耳道。耳环的尖端在隆突的圆窗内。注意分隔中耳腔中部和腹侧的骨嵴，即鼓室大泡。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
Before performing myringotomy, the horizontal canal should be thoroughly cleaned. The site for performing the myringotomy is at 6 to 7 o’clock, over the ventral most part of the tympanum (Fig. 10). My favorite instrument is a 22 gauge, 6 inch spinal needle (Mila International, Inc., Florence, KY) attached to a 3 cc syringe containing one cc of saline. Others have used tomcat catheters or polypropylene catheters with the end cut to a beveled point. Once the needle has been passed through the operating head of an otoscope into the middle ear, an assistant infuses the 1 mL of saline into the bulla and then re-aspirates it. The sample is transferred to a urine or blood tube then spun down in a centrifuge. The supernatant may be removed then the sample used to make cytological preparations or for culture and sensitivity. If an otitis media is encountered, a larger hole can be created to facilitate more thorough flushing (ie, passing catheter in to the middle ear). Medication (eg, enrofloxacin) may be infused in to the middle ear if necessary.
在进行鼓膜切开术前，应彻底清洁水平耳道。鼓膜切开术的部位在时钟6-7点方向，鼓膜腹侧紧张部(图10)。我最喜欢的器械是一根22号、6英寸的脊髓穿刺针，连一个3毫升的注射器，注射器里有一毫升生理盐水。其他人使用公猫导尿管或聚丙烯导管的末端切成斜角。一旦针穿过耳镜的手术头进入中耳，助手将1ml的盐水注入鼓泡，然后再次抽吸。样本被转移到采尿管或采血管中，然后在离心机中旋转。去除上清液，然后样品用于细胞学检查或细菌培养和药敏试验。如果遇到中耳炎，可以创建一个更大的孔，以方便更彻底的冲洗(即，通过导管进入中耳)。必要时可将药物(如恩诺沙星)注入中耳。
Figure 10 This photo of the tympanum shows a tomcat catheter pointing toward the ventral caudal quadrant, the optimum site where a myringotomy should be performed. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图10鼓膜照片显示公猫导尿管指向尾腹侧象限，这是进行鼓膜切开术的最佳位置。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
Ear Loops
耳环
Ear loops or curettes are also valuable tools that are helpful for cleaning material from the ear canal, acquiring samples for deep ear canals and assessing the state of the tympanic membrane. There are several types available but my two favorites are Buck ear curettes and Billeau ear loops (Fig. 11). They are effective for breaking up debris that is clumped in the deep ear canal or adhered to the canal wall. This is most often encountered near the level of the tympanum where there often are some hairs present that the debris likes to stick to (Fig. 6B). When using these instruments the tip should always be visualized, best done through a surgical otoscope head. Visualization through an otoscope is limited to one eye and looses accurate assessment of depth perception. Realizing where the tip is in the canal is facilitated by passing the loop down the ear canal while the tip is touching the canal wall (Fig. 12). Once the tip is next to some debris it can be rolled over into the wax and debris and then pulled back out of the ear canal. Pressure against the ventral aspect of the canal also is helpful in determining the location within the ear canal and for acquiring samples from the epithelium and not just the lumen of the canal. The horizontal canal within the auricular and annular cartilage will have some flexibility and slightly move and can be pushed away when pressure is applied with the ear curettes. Approximately, the last centimeter of the horizontal canal, just before the tympanum is within the boney external acoustic meatus and pressure will result in no flexibility or movement (Fig. 4). Care must be taken here as the metal ear loops and curettes may rupture the tympanum if pushed against it. The angled buck curette has the advantage that it allows better feel for detecting the inner ring of the external acoustic meatus. If the tip of the curette is able to be passed over the inner ring then the tympanum is not in its normal anatomic position or has been ruptured (Fig. 9). In some chronic cases where the tympanum has been destroyed or pushed back into the middle ear cavity by the build up of cerumen, keratin and inflammatory debris the ear loop is useful for breaking this material up so it can be flushed out. Once removed the back of the middle ear near the promontorium or the ridge of bone in the upper ventral bulla may be felt with the tip of the curette.
耳环或刮匙也是有价值的工具，有助于清洁耳道中的材料，获取耳道深部的样本，并评估鼓膜的状态。有几种类型可供选择，但我最喜欢的两种是巴克耳刮匙和Billeau耳环(图11)。对于在耳道深处结块或粘附在耳壁上的碎片，它们是有效的。这通常发生在鼓膜附近，那里经常有一些毛发，碎片喜欢粘在上面(图6B)。当使用这些器械时，应始终能看到尖端，最好通过外科耳镜头来完成。通过耳镜的可视化仅限于一只眼睛，并失去了深度知觉的准确评估。当耳尖接触到耳道壁时，通过耳道下的环路，可以方便地了解耳尖在耳道中的位置(图12)。一旦耳尖靠近一些碎片，它就会滚入耳垢和碎片中，然后被拉出耳道。耳道腹侧的压力也有助于确定耳道内的位置，有助于从上皮细胞获取样本，而不仅仅是耳道。耳内的水平耳道和环状软骨会有一定的灵活性和轻微的移动，当用耳刮匙施加压力时可以被推开。约水平耳道最后一厘米,鼓膜前的骨性外耳道和施压会没有灵活性和移动(图4)。这里必须小心，因为金属耳环和刮匙如果推到鼓膜可能破裂。有角度的巴克刮匙的优点是，它可以更好地检测外耳道的内环。如果刮匙的尖端是能够通过内圈那么鼓膜不在其正常解剖位置或已经破裂(图9)。在某些慢性病例中鼓膜已破坏或推到中耳腔产生耵聍、角蛋白和炎性碎片。耳环有助于将这种物质分解，从而将其冲出。一旦清除，中耳后方鼓泡上方隆突或骨嵴可以用刮匙尖感觉到。。
Figure 11 (A) The tip of the angled Buck ear curette, (B) the straight Buck ear curette, and (C) a Billeau ear loop. (Reprinted with permission from Craig E. Griffin Photos.) (Color version of figure is available online.)
图11 (A)有角度的巴克耳刮，(B)直巴克耳刮，(C) Billeau耳环。(经Craig E. Griffin Photos授权转载)(图片彩色版可在网上查询)
Figure 12 (A) Drawing of ear loop in surgical otoscope cone that is placed down the vertical ear canal with the tip touching the skin of the horizontal canal wall. (B) The ear canal has been straightened and now the top of the ear loop is seen over the inner ring of the boney external acoustic meatus. This means the tympanum is dilated or ruptured as this site is medial to the normal location of the insertion of the ventral pars tensa on the lower portion of the inner ring of the external acoustic meatus. (Color version of figure is available online.)
图12 (A)手术耳镜锥形头内耳环图，耳环置于垂直耳道下方，耳尖接触水平耳道壁皮肤。(B)耳道已经拉直，现在可以看到耳环的顶部在骨性外耳道的内环上。这意味着鼓室扩张或破裂，因为这个部位位于正常位置的张力腹侧部插入位置的内侧，位于外耳道内环的下部。(图的彩色版本可在网上查询)
Tube Palpation
导管触诊
Using a tube to palpate what may be a tympanic membrane or the distal horizontal canal is another method to help determine if there is an abnormal tympanic membrane, either integrity, or location. This can be done through the surgical otoscope head but is even more valuable when done through the video otoscope with a 5 French tube. A soft tube is trimmed as described in sample collection previously and passed to the medial aspect of the horizontal canal. In normal dog and cat ears the tip of the tube can always be visualized. If the tube tip goes to a point where it can not be seen that indicates pathology. This may occur when the tip has entered the middle ear cavity, moved into the space created when the tympanum has been dilated and stretched so it now is within the middle ear cavity (false middle ear), has penetrated debris, or has proceeded behind proliferative tissue. Depending on the depth one has gone and what is visualized while doing the procedure one can determine more about the tympanum than by visualization alone. The normal tympanum and often abnormal tympanum will respond to the pressure of the tip by slightly moving medially and retracting when the pressure is removed. In contrast impacted debris will stop the tube but usually after the tip has penetrated into it, even if slightly. At this point infusion of saline or water will often break up some debris. The normal and even abnormal tympanum will rarely rupture from palpation with the 5 French tube described. A tympanum may respond with mild hemorrhage that when it occurs will often follow the stria if the pars tensa has been palpated (Fig. 13). Hemorrhage in the medial wall will not have this stria pattern. Practice in normal dogs allows one to develop a “feel” for the normal depth. Passing a tube even 0.5 to 1 cm. further indicates either otitis media or false middle ear.
使用导管触诊鼓膜或远端水平耳道是另一种确定鼓膜是否异常、完整性或位置的方法。这可以通过外科耳镜头完成，但更有价值的是通过视频耳镜与5号饲管。如前所述，将修剪后的软管伸入水平耳道的内侧。在正常的犬和猫耳道中，管尖端总是可以看到。如果管尖到一个点，它不能看到，这表明是病理性的。这种情况可能发生在管尖进入中耳腔，进入鼓膜扩张和拉伸所形成的空间，因此它现在在中耳腔(假中耳)内，穿透了碎片，或进入了增生组织的后面。根据手术的深度以及手术过程中所看到的情况，我们可以比单纯的观察更多地了解鼓膜。正常的鼓膜和异常的鼓膜会对管尖的压力作出反应，当压力消除时，会轻微地向内侧移动并缩回。相反，冲击碎片将阻塞软管，但通常是在尖端已经渗透到它，即使轻微。这时，盐水或水的注入通常会打碎一些碎片。正常甚至异常鼓室很少会从触诊5法国管描述。鼓室可表现为轻度出血，如果触诊到紧张部，通常会随纹出血(图13)。内壁出血不会出现这种纹状。在普通的犬上练习可以让人对正常深度有一种感觉。通过一个管0.5至1厘米。进一步提示中耳炎或假中耳。
Figure 13 This digital enhanced close up shows the hemorrhage that was induced by palpation with the orange feeding tube seen in the upper right side of the photo. Note how the hemorrhage follows the stria of the pars tensa. (Reprinted with permission from Craig E. Griffin Photos.)
图13这张数字增强特写图显示了图片右上方橙色饲管触诊引起的出血。注意出血是如何沿着张力部纹的。(经Craig E. Griffin Photos授权转载。)
Treatment Tubes
治疗性导管
Topical agents must reach the site to be treated and in many cases even cleaning will not facilitate adequate application of topical agents. In some cases there is so much proliferative tissue that it alone blocks adequate delivery of topical agents. In other cases the patient may just be too difficult to medicate. In these situations another option is to sew in a soft rubber feeding tube (Sovereign feeding tube and urethral catheter, 5 French) down into the ear canal. The tip can be placed in the deep horizontal canal and then the tube is sewn to the skin of the external orifice. The tube is placed in the canal outside of the otoscope cone that may be used to visualize the placement. Once the desired depth is reached the tube should be marked at the point of exit from the ear so if movement occurs when the otoscope cone is removed the tube can be replaced without the need for visualization. One or two sutures are placed as deep into the vertical canal as possible and tied around the tube. A Chinese finger trap stitch is used in 1 or 2 sites just before the tube leaving the intertragal incisure or in some cases the tube may be brought out anterior to the tragus. Once leaving the external orifice the tube is then sewn to the head and neck. The large end of the tube is trimmed so that a syringe hub can be put into it. An Elizabethan collar can be placed with the tip extending beyond the collar for dogs that are difficult to medicate. A dose of medication is usually 0.5 to 1 mL. This is injected into the tube and followed by some air to make sure all the medication is delivered into the ear and not left in the tube. Limit the air to just the amount that first causes bubbling and inject gently.
外用药必须到达待处理的部位，在许多病例中，甚至洗耳也不能促进外用药的充分使用。在某些情况下，有很多增生性组织，它本身就阻碍了外用药的充分递送。在其他病例中，患病动物可能只是难以进行治疗。在这种情况下，另一种选择是将软橡胶饲管缝进耳道。尖端可以放置在水平耳道深处，然后管缝到外耳道开口的皮肤。管被放置在耳镜锥形头外的耳道中，耳镜锥形头可以用来观察管的放置。一旦达到所需的深度，应在耳开口的管上标记，因此，如果在拿出耳镜锥形头时发生移动，即可更换管，而无需观察。将一到两根缝线尽可能缝到垂直耳道深处，并将其绑在管周围。在软管离开耳屏切迹前使用中国指套缝法固定1或2个部位，在某些病例中，软管可能固定在耳屏前。一旦离开外耳道开口，软管可固定在头部和颈部。修剪软管的头，以便可以连注射器。难以进行治疗的患犬，可以佩戴伊丽莎白项圈，尖端延伸超出项圈。药物的剂量通常为0.5到1毫升。这是注射到软管中，随后一些空气，以确保所有的药物被送进耳道，而不是留在软管中。将空气的量限制在最初产生气泡的量，然后轻轻注入。
Intraotic Intralesional Injections
耳内病变内注射
Severe proliferative otitis is an indication for surgery, usually a total ear canal ablation with bulla osteotomy. Many clients wish to avoid surgery so medical therapy is often attempted. The initial medical therapy of proliferative tissue causing moderate to severe stenosis of the canal lumen is systemic antimicrobial therapy for pathogens identified by cytology and possible culture and sensitivity testing. In addition potent topical glucocorticoids and systemic glucocorticoid therapy is utilized. Intraotic intralesional glucocorticoid therapy is indicated when medical therapy for 2 to 4 weeks has been totally ineffective or fails to reduce the proliferative tissue to a mild to moderate degree and clients still elects to avoid surgery. Often the decision to avoid surgery is partly based on the dog still having reasonable good hearing that may be lost with the surgical procedure. Triamcinolone acetonide is particularly effective for inhibiting fibroblasts and reducing collagen and anecdotally has been effective in some cases of inflammatory polyps and glandular hyperplasia. It appears this is at least partially because of the local effect of the triamcinolone as some cases will only show a reduction in the proliferative tissue in the part of the canal treated. As the canal opens up then the more distal canal becomes accessible and the second treatment reduced the proliferative tissue in that area.
严重增殖性耳炎是外科手术的适应症，通常采用全耳道消融合并鼓泡截骨术。许多客户希望避免手术，因此经常尝试药物治疗。对于引起中重度耳道狭窄的增生组织，最初的药物治疗是对通过细胞学和可能的细菌培养和药敏试验确定的病原体进行全身抗菌治疗选择。此外，还使用了强效的外用糖皮质激素和全身糖皮质激素治疗。当药物治疗2-4周完全无效或无法将增生性组织减少到轻至中度，患犬仍选择不手术时，建议采用耳道内糖皮质激素治疗。通常情况下，不做手术的决定在一定程度上是基于犬仍然有合理的良好听力，而手术过程可能丧失听力。曲安奈德在抑制成纤维细胞和减少胶原蛋白方面特别有效，而且在一些炎性息肉和腺体增生的病例中也有效果。这似乎至少部分是由于曲安奈德的局部作用，因为在某些病例中，只显示治疗部位的增生组织减少。当耳道打开暴露更远端耳道时，就可以进行第二次治疗，以减少该区域的增生组织。
The technique utilizes 22 gauge, 10 to 15 cm long spinal needles or long flexible injection aspiration needle (Karl Storrs) The Teflon coated needle results in less hemorrhage and is preferred if the injections are done through the video otoscope. A 3 mL syringe with triamcinolone acetonide injectable solution is attached to the needle. The ear canal has been flushed and cleaned before the injections. The otoscope cone attached to a surgical otoscope head is passed as far as possible into the vertical or horizontal canal. This is determined by the severity of the stenosis and firmness of the proliferative tissue. The needle is then inserted into the proliferative tissue trying to locate the tip of the needle into the dermis, medial to the cartilage (Fig. 14A,B). It is recommended that the needle be attached to a leur-locked syringe to prevent expulsion of the syringe from the needle due to the pressure that is often needed to perform the injections into the proliferative tissue. An injection of 0.05 to 0.1 mL triamcinolone acetonide is given then the needle removed and passed about 120 to 180 degrees around the lumen of the canal at that same level. When there is complete stenosis and tissue blocking the opening of the cone three injections are made at 120 degree intervals. If the proliferative response is less then the more prominent folds are injected and sometimes only 2 injections are made at that level. In effect then three injections (a ring of injections) are given at each depth of the canal that is treated. In some cases hemorrhage from the injections site will block visualization of the canal and repetitive flushing is needed until the canal can again be visualized. Flushing may be needed between each injection or at each level of a set of injections. The cone is then withdrawn 1 cm to 2 cm and another set of injections are made.This continues until the cone has been withdrawn to the level of no stenosis or the external orifice of the canal is reached. A recheck examination is scheduled for 1 to 2 weeks postinjections. If the canal is opening but the distal part is still occluded or if after 2 weeks there is a good but incomplete response a second set of injections may be given. In rare cases this has been done 3 times. If there is no response to the first set of injections then the prognosis is grave for resolution of the proliferative tissue without surgery.
该技术采用22号、10 - 15厘米长的脊髓穿刺针或长柔性注射吸出针。聚四氟乙烯涂层的针出血少，首选通过视频耳镜注射。将装有曲安奈德注射液的3ml注射器附在针头上。在注射前，耳道已经冲洗干净了。附在手术耳镜头上的耳镜锥尽可能地进入垂直或水平耳道。这是由狭窄的严重程度和增生组织的硬度决定的。然后将针插入增生性组织，试图将针尖插入真皮软骨内侧(图14A,B)。建议将针头连接到一个带leur锁紧的注射器上，以防止注射器由于注射到增生组织时经常需要的压力而从针头上排出。注射0.05 - 0.1 mL曲安奈德，然后取下针，在相同水平耳道环绕约120 - 180度。当有完全狭窄和组织阻塞锥口时，每隔120度注射三次。如果增生效果较低，则注射较突出的褶皱，有时在该水平耳道只注射2次。实际上，在治疗的耳道的每个深度进行三次注射(一个环形注射)。在某些病例中，注射部位的出血会阻碍对耳道观察，因此需要重复冲洗，直到再次可以看到耳道。可能需要在每次注射之间或在一组注射的每一级进行冲洗。然后圆锥被抽出1到2厘米，并进行另一套注射。这一过程会一直持续下去，直到耳道没有狭窄或外耳道可观察到。注射后1至2周进行复检。如果耳道已经开放，但远端仍然阻塞，或2周后疗效良好但不完全，则可进行第二次注射。在极少数病例中，这样做了3次。如果第一次注射无效，那么不手术解决严重的增生性组织，预后严重。
 Figure 14 (A) Drawing demonstrating how intralesional injections are done with a syringe and needle through a surgical otoscope head. The needle is placed in the proliferative tissue of the ear canal. (B) A diagram of a cross section of a proliferative ear canal and lumen. The needle is inserted into one area of proliferative tissue and the two X marks where the second and third injections would be given. (Color version of figure is available online.)
图14 (A)展示了如何用注射器和针头通过手持耳镜头进行病灶内注射。针被刺入耳道的增生组织中。(B)增生性耳道和耳道的横切面示意图。针头插入增生组织的一个区域和两个X标记，在那里将进行第二次和第三次注射。(图的彩色版本可在网上查询)
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发表于 2023-3-5 21:10:58
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