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Diagnosis and treatment of otitis media in dogs and cats 犬猫中耳炎诊断和治疗（2004） Louis N. Gotthelf, DVM
翻译：王帆
Otitis media, an inflammatory disease in the middle ear cavity, is a common disease process that goes unrecognized in most veterinary practices. Otitis media in dogs is much more prevalent than previously thought. In dogs, secondary otitis media occurs in approximately 16% of acute otitis externa cases and in as many as 50% to 80% of chronic otitis externa cases. The fact that otitis media is present in more than half of canine patients with chronic otitis externa should stimulate a reformulation of the thought process when faced with these cases. Just the common history that the patient has been treated repeatedly for ear infections should alert the veterinarian to think about otitis media as a possibility. Otitis media should also be considered when the veterinarian is presented with a patient showing any neurologic disease affecting the head, including vestibular disease, Horner’s syndrome, or facial nerve damage. 中耳炎是中耳腔的炎性疾病，是在大多数兽医诊所中未被发现的一种常见病。犬中耳炎比以前认为的要普遍得多。在犬中，在大约16%的急性外耳炎病例和高达50%至80%的慢性外耳炎病例会继发中耳炎。事实上，超过一半慢性外耳炎患犬患有中耳炎，当面对这些病例时，应该重新思考。仅评患病动物反复进行耳部感染治疗的这种常见病史，就应该提示兽医要考虑中耳炎的可能。当兽医看到患病动物有任何影响头部的神经系统疾病表现时，包括前庭疾病、霍纳氏综合征或面神经损伤，也应考虑中耳炎。
The diagnosis of otitis media in dogs can be quite difficult to make because of the long, bent, funnel-shaped conformation of the dog’s ear canal, which makes it hard to see the tympanic membrane (TM). In addition, many patients with otitis media have an intact TM, giving the clinician the impression that there is nothing wrong in the middle ear. Most canine patients with otitis media also have chronic otitis externa with pathologic changes to the ear canal that cause stenosis, making visual examination of the TM impossible. It is often theorized that otitis media is an extension of otitis externa that was not treated, improperly treated, or resistant to treatment. The end result is significant damage resulting in porosity to the eardrum over time. 犬中耳炎的诊断非常困难，因为犬的耳道长、弯曲、漏斗状，很难看到鼓膜(TM)。此外，许多中耳炎病例的TM完整，使临床医生认为中耳没有问题。大多数中耳炎患犬也有慢性外耳炎，耳道病理改变导致狭窄，无法观察到TM。通常认为中耳炎是没有治疗、治疗不当，或治疗无效的外耳炎的延伸。最终的结果是，随着时间的推移，鼓膜会穿孔。
The diagnosis of otitis media in cats may be easier to determine with the otoscope because of their relatively short ear canals. Otitis media in cats most often results as a sequela to respiratory disease; thus, a history of sneezing, ocular discharge, or nasal discharge may aid in providing a clue. Some cats with otitis media also have a visible polyp in the ear canal after the ear is cleaned of the dried exudates and mucus. Many feline otitis media patients have a dark, dried, crumbly exudate in the ear canal that mimics an ear mite infestation. 由于猫的耳道相对较短，耳镜下更容易诊断中耳炎。猫的中耳炎通常是呼吸道疾病的后遗症;因此，打喷嚏、眼分泌物或鼻分泌物的病史可能有助于提供线索。一些中耳炎患猫在清除了耳道内干燥分泌物和粘液后，也会看到息肉。许多中耳炎患猫耳道有一种黑色、干燥、松散的分泌物，类似于耳螨感染。
Primary otitis media in cats 猫原发性中耳炎 In the cat, primary otitis media occurs as a result of infection ascending through the Eustachian tube to the middle ear. An exact mechanism for the development of otitis media in the cat has not been reported, although the bacterial isolates from the bullae of cats with middle ear disease are consistent with respiratory pathogens. It has been hypothesized that chronic viral upper respiratory infection early in life may play a role in initiating otitis media in cats, because these infections and polyps occur in younger cats. This has not been documented with virus isolation studies, however. In one study, tissues from inflammatory polyps were assayed for feline calicivirus and feline herpesvirus-1 by polymerase chain reaction (PCR). Failure to detect either of these viruses suggests that persistence of these viruses is not associated with the development of inflammatory polyps. The presence of these viruses may change the ability of the auditory tube to protect the bulla from infection with other agents, however. 在猫，原发性中耳炎是由于感染通过咽鼓管进入到中耳。虽然猫中耳炎确切发病机制尚未见报道，但从中耳炎患猫鼓疱中分离的细菌与呼吸道病原一致。据推测，年轻时的慢性病毒性上呼吸道感染可能在猫中耳炎的发病中发挥作用，因为这些感染和息肉在较年轻的猫上发生。然而，这在病毒分离研究中没有报道。在一项研究中，通过对炎性息肉组织进行猫杯状病毒和猫疱疹病毒-1聚合酶链反应(PCR)含量检测。未能检测到这两种病毒中的任何一种，表明这些病毒的持久性与炎性息肉的发展无关。然而，这些病毒的存在可能改变了咽鼓管保护鼓疱免受其他病原体感染的能力。
In many species, including human beings, rats, pigs, and cattle, Mycoplasma has been reported as an inducing agent in middle ear disease. In addition to the more common streptococci and staphylococci isolated from clinical feline otitis media cases, organisms much more difficult to culture and identify, such as Mycoplasma and Bordetella, have also been cultured from the middle ear of cats with otitis media. It is unclear what role these upper respiratory bacteria may play in the pathogenesis of feline otitis media. It is also unclear whether anaerobic organisms may be involved when the eardrum is intact and the auditory tube swells, thus sealing these bacteria within the bulla. Cytology or cultures often do not reveal an infectious organism. This raises the question of whether allergy, viruses, or fungi have a role in feline middle ear disease. 在许多物种中，包括人类、大鼠、猪和牛，支原体已被报道为中耳疾病的诱因。除了从临床猫中耳炎病例中分离出较为常见的链球菌和葡萄球菌外，还从中耳炎患猫的中耳中培养出了更难以培养和鉴定的微生物，如支原体和博代氏杆菌。目前还不清楚这些上呼吸道细菌在猫中耳炎的发病机制中可能的作用。当鼓膜完整，咽鼓管肿胀，将这些细菌封闭在鼓疱内时，是否有厌氧菌参与也尚不清楚。细胞学检查或细菌培养往往不能显示出感染的病原。这就提出了一个问题:过敏、病毒或真菌是否在猫的中耳疾病中起作用?
Secondary otitis media in cats 猫继发性中耳炎 The cat can have a secondary otitis media as a result of eardrum damage from ear mites or extension of a polyp through the TM. Nasopharyngeal or inflammatory polyps originate from the middle ear mucosa. A polyp is a pedunculated protruding growth that results from chronic inflammation. Depending on their growth pattern, they can grow through the auditory tube toward the nasopharynx or they may grow through the TM. When found in the external ear canal, the enlarging polyp mass has created a permanent opening from the external ear canal to the middle ear. The presence of a polyp is usually associated with secondary bacterial otitis media. There is copious mucus and pus produced in these cats. When examined, the external ear canal may show liquid exudates or there may be the presence of a wax-covered mass at the eardrum. Flushing the ear canal thoroughly reveals the fleshy pink to red polyp protruding into the ear canal. 猫会因为耳螨造成的鼓膜损伤或息肉穿透TM发生继发性中耳炎。鼻咽息肉或炎性息肉起源于中耳粘膜。息肉是由慢性炎症引起的有蒂的凸起。根据它们的生长模式，它们可以通过咽鼓管向鼻咽生长，也可以穿透TM生长。当在外耳道发现肿大的息肉时，它已经在外耳道和中耳之间形成了一个永久的开口。息肉的出现通常与继发性细菌性中耳炎有关。患猫产生大量的粘液和脓汁。在检查时，外耳道可能会有液体渗出或鼓膜处可能有蜡样肿块遮挡。冲洗耳道时，耳道内突出的粉红色到红色的肉状息肉就会完全显露出来。
Secondary otitis media in dogs 犬继发性中耳炎 Exudates and infectious organisms drain into the middle ear from the external ear canal through an eroded or ruptured eardrum and get trapped in the ventral portion of the bulla. Once the medications, chemicals in earflushing products, or debris contained within the external ear canal enters the middle ear through an eroded eardrum, tissue reaction of the respiratory epithelial lining of the middle ear begins. This is called secondary otitis media. 分泌物和感染性微生物通过糜烂或破裂的鼓膜从外耳道流入中耳，并被困在鼓疱的腹侧。一旦药物、洗耳液中的化学物质或外耳道耳垢，通过被糜烂破溃的鼓膜进入中耳，中耳呼吸上皮发生组织反应。这被称为继发性中耳炎。
The pathogenesis of secondary otitis media in the dog is complex and often multifactorial. Because of the L-shaped configuration of the canine external ear canal, proteolytic enzymes within exudates produced as the result of otitis externa accumulate against the thinnest portion of the eardrum. The resulting inflammation and enzymatic destruction lead to necrosis of the epithelium and supporting collagen, which results in thinning of the TM, causing it to weaken. 犬继发性中耳炎的发病机制是复杂的，往往是多因素的。由于犬的外耳道呈L形，外耳炎分泌物中产生的蛋白水解酶聚集在鼓膜最薄的部分。由此产生的炎症和酶的破坏导致上皮和支持胶原的坏死，从而导致TM变薄、变弱。
Ulceration along the ear canal can extend to the eardrum. The ulcerated tissue leaks serum, which can cause maceration and excoriation of the epithelium. Liberation of bacterial proteases, collagenases, elastases, and lysozymes from phagocytic cells as well as epidermal maceration resulting from the excessive amount of serum in the ear canal disrupts the epithelial layers of the ear canal and can lead to erosion or rupture of the eardrum. 耳道的溃疡可延伸至鼓膜。溃疡组织渗出血清，可使表皮细胞浸渍和脱落。从吞噬细胞中释放的细菌蛋白酶、胶原酶、弹性蛋白酶和溶菌酶以及耳道中过量的血清导致的表皮浸渍会破坏耳道的表皮层，并可能导致鼓膜的糜烂或破裂。
Many cases of acute otitis media can be prevented. Special care in cleaning and attention to fluid pressure, especially with the use of bulb syringes used to flush the external ear canal, can prevent the high pressure from causing an iatrogenic rupture. Removal of exudates by careful flushing and suctioning of the ear canal eliminates the source of destructive enzymes acting on the eardrum. Specific therapy for infectious organisms based on cytology or culture results can shorten the course of the bacterial or fungal disease. Treatment of underlying skin disease, such as atopy, food allergy, and hypothyroidism, may remove or improve primary causes of otitis externa. Proper client education concerning the chronic nature of ear diseases increases owner compliance in allowing frequent rechecks to follow the progress of treatment. Recheck visits allow the veterinarian to examine the eardrum and to make changes in the treatment protocol when therapeutic response is inadequate. 许多急性中耳炎病例是可以预防的。特殊的清洁护理和注意冲洗液压力，特别是使用洗耳球冲洗外耳道时，避免压力过高引起医源性破裂。通过仔细冲洗和抽吸耳道，清除分泌物，清除作用于鼓膜的破坏性酶的来源。根据细胞学或培养结果对感染微生物进行特异性治疗可以缩短细菌或真菌疾病的病程。治疗潜在的皮肤病，如特应性皮炎、食物过敏和甲状腺功能减退，可消除或改善外耳炎的原发病因。适当进行慢性耳病的宠主教育，可以提高宠主依从性，配合经常复诊以跟踪治疗进展。复诊时配合兽医检查鼓膜，并在治疗效果不佳时配合更改治疗方案。
Whether primary or secondary, the resulting inflammation causes the lining epithelium, called the mucoperiosteum, in the bulla to change from cuboidal to pseudostratified columnar ciliated, leading to an increase in the number of secretory cells and glands, which adds to the quantity of exudate. Chronic inflammation leads to mucosal ulceration and breakdown of the epithelial lining. The lamina propria thickens in response to inflammation, and as vascularity increases, edema and granulation tissue form. As otitis media becomes more chronic, the lamina propria changes to dense connective tissue and bone spicules may develop within it. 无论是原发性还是继发性，由此引起的炎症导致鼓疱内粘膜上皮，即黏膜性骨膜，从立方形变为假复层柱状纤毛，导致分泌细胞和腺体数量的增加，从而增加分泌量。慢性炎症导致粘膜溃疡和上皮细胞内衬的破坏。固有层因炎症而增厚，随着血管增多，水肿和肉芽组织形成。随着中耳炎变得更加慢性，固有层改变为致密的结缔组织，其内部可能发生骨质沉着。
The cycle of inflammation, ulceration, infection, and granulation tissue formation may continue, destroying the surrounding bone. For example, septic arthritis of the ossicles may cause pain and decreased hearing because of the fusion of these joints. The normal air conduction of sound waves is prevented, and the patient may suffer decreased ability to detect highpitched sounds. With time, the ossicles are dissolved from osteomyelitis and irreversible hearing deficit occurs. 炎症、溃疡、感染和肉芽组织形成的循环可能会继续，破坏周围的骨质。例如，化脓性听小骨关节炎可能导致疼痛和听力下降，因为发生了关节融合。声波的正常空气传导被阻断，患病动物对高音的探测能力也会下降。随着时间的推移，骨髓炎导致听小骨溶解，出现不可逆的听力障碍。
The exudates and secretions thus formed in the bulla escape into the external ear through the ruptured eardrum and contribute to the exudate already present in the external ear canal. This large amount of liquid fills the ear canal and overflows onto the pinna when the patient shakes its head. If there is a polyp or tumor blocking the outflow of secretions and exudates from the middle ear, significant quantities of inspissated material can be present when the obstruction is removed. 因此在鼓疱中形成的渗出物和分泌物通过破裂的鼓膜进入外耳，使外耳道分泌物增加。当患病动物摇头时，大量液体充满耳道并溢出耳廓。如果有息肉或肿瘤阻塞了中耳分泌物和渗出物的流出，当阻塞物被清除时，可出现大量粘稠物质。
The fluid pressure gradient created by suppurative otitis media and increased mucus secretion prevents the eardrum from completely sealing. As the fluid pressure increases within the bulla, it is pushing against a healing eardrum with a thin tenuous covering. The pressure allows fluid to escape through the path of least resistance, and a small hole remains in the TM. As long as there is a hole in the eardrum, this condition remains in a state of flux (ie, fluid can enter or leave the bulla, carrying infectious materials and exudates in both directions). 化脓性中耳炎和粘液分泌增加所造成的液体压力变化使鼓膜无法完全封闭。当鼓疱内的液体压力增加时，它正挤压着一层薄薄的、正在愈合的鼓膜。压力使液体通过阻力最小的路径逸出，并在TM上留下一个小洞。只要鼓膜上有一个洞，这种情况就会保持流通状态(即液体可以进出鼓疱，携带感染性物质和分泌物进出流动)。
When the amount of middle ear secretion and exudate is decreased, when the infection is controlled by therapy, and when the fluid pressure is decreased, the eardrum can heal, and otitis media is resolved. Sometimes, however, the eardrum seals, but the infection is not completely resolved. If the trapped organisms lead to a return of inflammation and secretion, the eardrum can once again bulge or rupture. Patients with otitis media may have had a history of repeated episodes because of this alternating rupture of the TM and subsequent healing. A report by Cole et al demonstrated that 70% of eardrums in documented cases of canine otitis media were intact. 当中耳分泌物和渗出物的量减少，当感染经过治疗得以控制，当液体压力降低，鼓膜就能愈合，中耳炎就得到解决。然而，有时鼓膜会愈合，但感染并没有完全清除。如果被困的微生物导致炎症和分泌物复发，鼓膜可能再次膨胀或破裂。中耳炎患病动物可能有反复发作的病史，因为TM反复破裂和愈合。Cole等人的一份报告显示，有记录的犬中耳炎病例中，70%的鼓膜完整。
History and clinical signs of otitis media 中耳炎的病史和临床症状 It is uncommon for a patient to be presented to the veterinarian with a history of acute otitis media. Iatrogenic rupture of the eardrum during ear cleaning can lead to an inflammatory acute otitis media, however. A foreign body that has become lodged in the ear canal can also cause acute otitis media. For example, plant awns and foxtails often work their way through the eardrum and cause a considerable bacterial infection and inflammatory reaction in the ear canal. 动物不常因为急性中耳炎病史而就诊。然而，在洗耳过程中，医源性鼓膜破裂可导致急性炎性中耳炎。异物卡在耳道也会引起急性中耳炎。例如，草芒和狐尾草经常穿过鼓膜，在耳道引起大量的细菌感染和炎症反应。
More commonly, a dog with otitis media has a history of recurrent or chronic bacterial external ear infections. The mucous membrane lining the tympanic bulla reacts to foreign substances (eg, infectious organisms, hair, cells, cerumen from the external ear canal, chemicals and pharmaceutics used in the external canal) by producing a purulent exudate and increasing secretion of protective mucus from activated goblet cells. Dogs and cats with otitis media with an open eardrum often have a copious malodorous liquid discharge present when the ear canal is examined with the otoscope. Additionally, it is common to see copious mucoid exudate along the floor of the horizontal canal. Although this material is usually in liquid form, the mucus and pus may be inspissated and dry. Mucus is not produced anywhere along the external ear, but it oozes from the tympanic bulla into the horizontal canal through any rent in the TM. The presence of mucus means that there is a hole in the eardrum. 更常见的是，中耳炎患犬有复发或慢性细菌性外耳感染的病史。鼓疱的粘膜对异物(如感染性微生物、毛发、细胞、来自外耳道的耳垢、外耳道使用的化学物质和药物)产生反应，产生脓性分泌物，激活的杯状细胞产生的保护性粘液的分泌增加。犬猫中耳炎伴鼓膜破裂，在用耳镜检查耳道时，经常会有大量有异味的液体流出。此外，沿水平耳道腹侧可见大量粘液样分泌物。虽然这种物质通常是液体，也可浓缩和干燥形成粘液和脓汁。粘液不是在外耳道产生的，而是从鼓疱通过TM的任何裂口进入水平耳道。粘液的存在意味着鼓膜上有一个洞。
Some patients produce so much exudate that it overflows onto the periaural region of the face, or in a dog with pendulous ears, there may be dried exudate on the ear flap adjacent to the external opening of the auditory canal. Head shaking to relieve the pain and tickle associated with liquid exudate is common in otitis media. It may be wise to check for otitis media in cases of aural hematoma. 有些患病动物产生大量的分泌物，溢出到耳周区域面部，或在垂耳犬，可能在靠近外耳道开口的耳廓上有干燥的分泌物。中耳炎常以摇头来减轻因液体渗出引起的疼痛和瘙痒。如果是耳血肿，最好检查是否为中耳炎。
Pain on palpation of the base of the ear canal or pain on manipulation of the pinna should also alert the clinician to otitis media. Some dogs even bite their owners while the owners are trying to administer medication because of the intense pain. Patients with otitis media may also be reluctant to have their mouth opened, and there may be a history of reluctance to chew hard food. This is a result of inflammation, swelling, and pain within the bulla, which is located adjacent to the temporomandibular joint. 触诊耳道底部疼痛或耳廓操作疼痛也应提醒临床医生注意中耳炎。有些犬甚至会在主人试图给它们喂药时咬主人，因为它们会感到剧烈的疼痛。中耳炎患病动物也可能不愿张嘴，也可能有不愿咀嚼硬食物的病史。这是位于颞下颌关节附近的鼓疱内的炎症、肿胀和疼痛的结果。
When otitis media affects the nerves that course around the base of the ear or through the tympanic bulla, the patient may show something as subtle as keratoconjunctivitis sicca on the ipsilateral side. This results from damage to the palpebral branch of the facial nerve. When otitis media affects the sympathetic nerves from the facial and trigeminal nerves coursing through the middle ear, the patient may show mild signs of Horner’s syndrome (enophthalmos, ptosis, and miosis). Some patients may show pain; head tilt; or, with facial nerve palsy, a drooped lip, drooped ear, or loss of the ability to close the eyelid, leading to exposure keratitis. Because the facial nerve courses in and around the ear canal, it is easily affected by swelling, inflammation, and trauma from the dog scratching at the base of the ear. Facial neuropathy should be suspected if there is drooping of the facial muscles and skin or drooling saliva, because the lips and facial muscles cannot create an oral seal. Peripheral vestibular disease with nystagmus and circling may be evident if the infection and inflammation have affected the inner ear. 当中耳炎影响到沿耳底或穿过鼓疱的神经时，患病动物可能会在同侧表现出轻微的干眼症。这是面神经睑支损伤的结果。当中耳炎累及经中耳的面神经和三叉神经的交感神经时，患病动物可能表现出轻微的霍纳氏综合征症状(眼球凹陷、上眼睑下垂和瞳孔缩小)。有些患病动物可能会出现疼痛、歪头，或者，面神经麻痹、嘴唇下垂、耳部下垂，或者不能眨眼，导致暴露性角膜炎。因为面神经在耳道内和周围，它很容易受到肿胀、炎症和犬挠耳底部造成的创伤的影响。由于嘴唇和面部肌肉不能使口腔闭合，如果出现面部肌肉和皮肤下垂或唾液流出，就应该怀疑是面神经病变。如果感染和炎症影响内耳，可能明显出现外周前庭疾病伴眼球震颤和翻滚。
An owner may present a patient for a hearing deficit. These cases should be evaluated for otitis media. Fluid in the middle ear dampens hearing. If this fluid is the result of previous flushing, it is usually absorbed within 7 to 10 days and the patient regains the hearing. When the eardrum is ruptured or when the ossicles of the middle ear have sclerosed, air conduction hearing is reduced. High-pitched sound waves cannot be effectively transmitted from the ear canal to the cochlea. If a tumor or a polyp has filled the middle ear, air conduction hearing is eliminated. Bone conduction hearing is usually still present in these patients, and the pet can only hear the lower range of tones (bone conduction hearing can be demonstrated by placing your fingers in your ears and listening to the sounds around you). 宠主可能描述患病动物听力下降。这些病例应评估中耳炎。中耳积水会降低听力。如果这种液体是洗耳导致的，通常在7到10天内被吸收，患病动物恢复听力。当鼓膜破裂或中耳听小骨硬化时，空气传导听力降低。高音声波不能从耳道有效地传送到耳蜗。如果肿瘤或息肉充满了中耳，则空气传导听力消失。这些患病动物通常仍然存在骨传导听力，而宠物只能听到较低范围的音调(骨传导听力即将手指放在耳朵里，听到的周围的声音)。
If there is hearing loss detected, this is usually as a result of bilateral ear disease. Unilateral hearing loss is difficult to assess in animals. If there is pharyngeal drainage of mucus and exudates resulting from otitis media, the patient may be presented for inspiratory stridor. In these cases, a pharyngeal examination may reveal a nasopharyngeal polyp interfering with breathing or thick mucus draining from the auditory ostium in the nasopharynx covering the caudal pharynx and occluding the airway. 如果发现听力消失，这通常是由于双耳疾病。动物的单侧听力消失很难评估。如果有由中耳炎引起的咽部粘液和分泌物流出，患病动物可能出现吸气喘鸣音。在这些病例中，咽部检查可发现鼻咽息肉阻碍呼吸或从咽鼓管的鼻咽开口流出粘稠粘液聚集在咽尾部，阻塞气道。
Evaluation of the patient 评估患病动物 Otoscopy 耳镜检查 Careful examination of the TM in the dog or cat with otitis media requires general anesthesia. It is recommended that the patient have an endotracheal tube placed in case there is a ruptured eardrum. Manipulation or flushing can cause material to drain through the Eustachian tube into the nasopharynx, resulting in aspiration. 对患中耳炎的犬猫的TM进行详细检查需要全身麻醉。建议鼓膜破裂的患病动物进行气管插管。操作或冲洗可导致液体通过咽鼓管流入鼻咽，导致误吸。
If there is significant stenosis of the external ear canal from inflammation or permanent pathologic changes to the ear canal, the eardrum may not be adequately visualized. Patient preparation using potent topical or systemic corticosteroids (prednisone, 1mg/lb daily for 10–14 days and then taper, or dexamethasone, 2 mg/mL, at a rate of 0.1 mg/lb intramuscularly once) may be needed to reduce otic inflammation and allow examination of the TM on a subsequent visit. If permanent changes to the ear canal prevent visual determination of the integrity of the eardrum, other techniques are used to identify disease proximal to the stenosis. 如果外耳道因炎症或耳道的永久性病理改变而出现明显狭窄，则可能无法充分观察到鼓膜。为了减少耳部炎症和允许后期进行TM检查，可能需要提前给患病动物使用强效的外部或全身糖皮质激素(泼尼松：每天1 mg /磅，每日一次，连用10-14天,然后逐渐减量，或地塞米松：2毫克/毫升,0.1毫克/磅，肌肉注射，每日一次)。如果耳道的永久性改变阻碍了对鼓膜完整性的检查，则可以使用其他技术来确定是否近端狭窄。
Recently, with the introduction of video otoscopes, it is possible to get a detailed magnified examination of the ear canal and the eardrum. The video otoscope provides excellent lighting at the tip of the tapered probe by transmitting light through the probe by a fiberoptic cable attached to a highoutput light source. Once the veterinarian is comfortable looking at normal eardrums (location, color, clarity, and the normal tension on it), using the TM to diagnose otitis media becomes much easier. If the eardrum remains translucent, the middle ear can be transilluminated with the bright light from the video otoscope and the contents of the middle ear can be visualized. 最近，随着视频耳镜的引入，可以对耳道和鼓膜进行详细的放大检查。视频耳镜通过连接高输出光源的光纤电缆将光通过探头，从而在锥形探头的顶端提供良好的照明。一旦兽医能观察到正常的鼓膜(位置、颜色、清晰度和张力正常)，就能简单通过TM诊断中耳炎。如果鼓膜保持半透明状态，则视频耳镜的强光可以穿透中耳，可观察到中耳内物质。
In obvious cases of canine otitis media, there is no eardrum present. The ear canal is filled with a liquid secretion, often with flecks of material mixed with it. A mucus-filled ear canal may alert the clinician to otitis media. Most patients with chronic otitis externa that has been present for 45 to 60 days have a coexisting otitis media. In otitis externa, purulent exudates and proteolytic enzymes elaborated by inflammatory cells have a caustic effect on the thin epithelium of the eardrum, causing it to become necrotic, weaken, and eventually rupture. When this happens, hair, ceruminous secretions, exudates, and infectious bacteria or yeast organisms in the external ear move into the middle ear. In these patients, it is difficult to visualize any part of the eardrum, because it may not be present at all. Sometimes, only a small ring of granulation tissue may be seen at the annulus fibrosus, where the eardrum attaches to the ear canal. That is where the eardrum was attached. With the otoscope, an otitis media case without suppuration looks like a deep dark hole. The mucosa becomes dark as it becomes hyperemic, and brownish ceruminous exudates fill the bulla. 在典型犬中耳炎病例中，鼓膜消失。耳道充满液性分泌物，通常还夹杂着小颗粒物质。充满粘液的耳道可能提示临床医生注意中耳炎。大多数持续45-60天的慢性外耳炎患病动物同时存在中耳炎。在外耳炎中，由炎症细胞分泌的脓性分泌物和蛋白水解酶对鼓膜薄的上皮细胞具有腐蚀作用，导致鼓膜坏死、脆弱，最终破裂。当这种情况发生时，外耳道的毛发、分泌的耵聍、分泌物以及感染性细菌或酵母菌进入中耳。在这些患病动物中，很难看到鼓膜的任何部分，因为它可能根本就不存在。有时，在纤维环处，即鼓膜与耳道相连的地方，只能看到一小圈肉芽组织。这就是鼓膜附着的地方。在耳镜下，没有脓的中耳炎就像一个深黑洞。充血时粘膜变黑，褐色的蜡样分泌物充满鼓疱。
There is a condition described in dogs called a false middle ear. Obstructions along the horizontal ear canal from hypertrophic or cystic glands, neoplasia, inflammation, or ceruminous plugs increase pressure on the TM, causing it to stretch and bulge into the middle ear cavity. Coupled with poor air movement through the Eustachian tube, negative pressure inside the bulla pulls the eardrum even further into the middle ear cavity. A ‘‘false middle ear’’ may develop as a result of the distended membrane ballooning into the bulla. Examination of this ear also shows the absence of an eardrum at the end of the horizontal canal. CT scans of these ears reveal a ‘‘finger’’ lesion protruding into the bulla. The invaginating eardrum may collect large amounts of debris from the external canal, such as keratin, wax, and desquamated epithelial cells. The invaginated eardrum forms a cavity, which needs to be flushed out thoroughly. Often misdiagnosed as having otitis media, these patients can be retrospectively diagnosed at a 2-week recheck when the previously unseen eardrum is back in the normal location. 犬有一种病叫假中耳。由肥大或囊性腺体、肿瘤、炎症或耵聍堆积引起的沿水平耳道的阻塞增加了对TM的压力，导致它向中耳腔伸展和膨胀。再加上通过咽鼓管的空气流动不良，鼓疱内的负压将鼓膜进一步拉入中耳腔。假中耳可能是由于膨胀的鼓膜膨胀到鼓疱的结果。对这只耳朵的检查也显示水平耳道的末端没有鼓膜。CT扫描显示这样的患耳有个“手指”样病变凸出进入鼓疱。内陷的鼓膜可能会聚集大量来自外耳道的碎片，如角蛋白、蜡样耳垢和脱落的上皮细胞。内陷的鼓膜形成一个腔，需要彻底冲洗出来。通常被误诊为中耳炎，这些患病动物可以在2周复查时再次进行诊断检查，之前看不见的鼓膜回到正常位置。
In some cases of otitis media, the eardrum is intact but may look abnormal. It may change color in response to inflammation on the medial side, becoming opaque and gray rather than pearly and translucent. Sometimes, there is fluid behind the eardrum, and examination of the intact TM may indicate that it is bulging into the external ear. Purulent material in the middle ear may be seen as yellow fluid behind the eardrum. Early polyps and tumors in the middle ear may be seen as fleshy masses through the eardrum. Therefore, the presence of an eardrum does not rule out otitis media, particularly in dogs with chronic otitis externa. These dogs may have had a ruptured eardrum that healed, trapping bacteria and yeast in the tympanic bulla. 在一些中耳炎病例中，鼓膜完整，但看起来异常。它可能会因内侧炎症而发生颜色改变，变成不透明和灰色，而不是珍珠般的半透明。有时，鼓膜后面有液体，检查看到完整的鼓膜可能提示它向外耳鼓胀。中耳脓性物质可能观察到鼓膜后面有黄色液体。中耳早期的息肉和肿瘤可以通过鼓膜看到肉质肿块。因此，鼓膜完整并不能排除中耳炎，特别是慢性外耳炎患犬。这些犬可能出现过鼓膜破裂后愈合，使细菌和酵母菌封闭在鼓疱内。
Is the eardrum ruptured? 鼓膜是否破裂？ Several techniques have been described to determine the integrity of the TM when it cannot be visualized in an ear with a stenotic external ear canal. A small-diameter 3.5- to 5-French catheter can be inserted into the ear canal until it stops. It is then extended and retracted to get a feel for the rigidity of the ‘‘stop.’’ If there is a spongy feel, the eardrum is intact. If there is a definite hard feel to the ‘‘stop,’’ the eardrum is ruptured and the catheter is hitting the medial wall of the tympanic bulla. This technique should be practiced on cadaver specimens to acquire the sensitivity. 已经描述了几种技术确定TM是否完整，当由于外耳道狭窄不能进行观察时。可在耳道插入一个直径3.5-5号的法国导管直到管停止。然后将它反复回抽和插入，以感受阻力强度，如果顶到头时有海绵状的感觉，说明鼓膜完整。如果顶到头时有明显坚硬感觉，则鼓膜破裂，导管顶到鼓疱的内壁。这项技术应该先在尸体标本上进行练习感受。
Tympanometry uses a sensor that measures the compliance of the eardrum in response to sound waves. It is not practical to perform this test in the veterinary clinic because it is still a research tool in animals. 声导抗测试，使用一种传感器来测量鼓膜对声波的顺应性。不适合在兽医诊所进行试验，因为它仍是一种动物研究工具。
An easy indirect method for determining the integrity of the eardrum is to infuse warmed and extremely dilute povidone iodine solution (or dilute fluorescein solution) into the ear canal with the anesthetized dog or cat positioned in lateral recumbency. If the orange or yellow-green flushing fluid comes out of the nose or if the patient snorts out this solution through the oropharynx when pressure is applied with the flushing fluid, the eardrum is ruptured. The fluid has flowed from the external ear canal through the ruptured eardrum into the tympanic bulla and through the auditory tube into the nasopharynx. 一种简便的间接测定鼓膜完整性的方法是将已麻醉的犬或猫侧卧，将加温的极稀释的聚维酮碘溶液(或荧光素稀释溶液)注入耳道。如果橙色或黄绿色的冲洗液从鼻子流出，或者当冲洗液加压时，患病动物通过口咽喷出这种溶液，那么鼓膜就破裂了。液体从外耳道流过破裂的鼓膜进入鼓疱，然后通过咽鼓管进入鼻咽。
Another technique is to place the patient in lateral recumbency with the suspected ruptured eardrum up and then to fill the ear with warmed saline and insert the tip of the video otoscope into the ear canal. Looking through the clear fluid, if air bubbles rise from the ear canal while the animal breathes, the eardrum is ruptured. Air from the nasopharynx rises through the auditory tube into the tympanic bulla to escape from the middle ear through a ruptured eardrum. 另一种方法是将怀疑鼓膜破裂的患病动物置于侧卧位，然后将耳朵填满温生理盐水，将视频耳镜的尖端插入耳道。透过透明的液体观察，如果动物呼吸时耳道中冒出气泡，鼓膜就是破裂。空气从鼻咽部上升，通过咽鼓管进入鼓疱，通过破裂的鼓膜从中耳溢出。
Positive-contrast canalography has been described as a method for detecting a ruptured TM in dogs with otitis media. Dilute iodinated contrast agent at a rate of 2 to 5 mL is instilled into the ear canals of these anesthetized patients while in lateral recumbency with the affected ear up. The author uses 0.3 mL of Hypaque 50% or a similar contrast agent in 2.7 mL of saline. In a stenotic ear canal, a 3.5- or 5-French catheter is threaded into the stenosis if possible. Contrast agent is then infused beyond the stenosis. An open-mouth view of the bullae is then taken using a horizontal x-ray beam. If the eardrum is intact, there is a distinct contrast/air interface at the eardrum. If the eardrum is not intact, the contrast material enters the bulla and there is a continuous column of contrast extending into the bulla. 耳道阳性造影技术已经被描述为一种检测犬中耳炎TM破裂的方法。将稀释的碘造影剂每耳2 - 5ml剂量，注入麻醉的患病动物的耳道，同时侧卧，使患耳向上。作者在2.7mL生理盐水中加入0.3mL50%的泛影葡胺或类似的造影剂。对于狭窄的耳道，如果可能，将3.5号或5号法国导管插入狭窄处。然后在狭窄处注入造影剂。然后打开口腔拍摄鼓疱X线片。如果鼓膜完整，则在鼓膜处有明显的造影剂/空气界面。如果鼓膜不完整，造影剂进入鼓疱，一个连续的造影增强影像延伸至鼓疱。
In normal ears, canalography was more accurate for detecting iatrogenic TM perforation than otoscopy. In clinical otitis media cases, positive-contrast canalography was positive in most of the cases where the eardrum was determined to be ruptured otoscopically and was positive in other cases in which the eardrum appeared to be intact otoscopically. 在正常耳道中，耳道造影对医源性TM穿孔的检测比耳镜更准确。在临床中耳炎的病例中，在耳镜下鼓膜破裂的病例中，大多数耳道造影阳性，而在耳镜下鼓膜完整的病例中，耳道造影也阳性。
Myringotomy 鼓膜切开术 To diagnose patients with otitis media, it is sometimes necessary to perform a myringotomy to get a cytology specimen and to allow for culture and antibiotic sensitivity testing on the material trapped behind the eardrum. If there is fluid pressure pushing on the eardrum or negative pressure retracting the eardrum, perforation of the eardrum using a controlled myringotomy incision immediately relieves the intense pain associated with these pressure changes. 为了诊断中耳炎患病动物，有时需要进行鼓膜切开术，以获得细胞学标本，并允许对鼓膜后面的物质进行细菌培养和药敏试验。如果鼓膜有液体压力或有负压使鼓膜收缩，使用鼓膜切开术在鼓膜上穿个孔，可立即减轻这些压力改变导致的剧烈疼痛。
To perform a myringotomy, the patient is anesthetized and the external ear canal is thoroughly cleaned with a disinfectant, such as dilute povidone iodine. The ear canal is then dried using suction. A sterile rigid polypropylene catheter is cut to an angle of 60 with a surgery blade to provide a sharp point. A long spinal needle can also be used to puncture the eardrum. The tip of the cut catheter is advanced under good visualization, and the pars tensa is punctured at either the 5-o’clock or 7-o’clock position to remain away from the germinal epithelium and blood vessels overlying the manubrium of the malleus. 在进行鼓膜切开术时，患病动物需要麻醉，并使用消毒剂彻底清洁外耳道，如稀释聚维酮碘。然后抽吸将耳道吸干。使用一个无菌硬质聚丙烯导管用手术刀片切个60度角，使末端边尖。也可用一根长脊髓穿刺针刺穿鼓膜。导管尖端在视频耳镜观察下向前伸，在时钟5点或7点位置穿刺鼓膜紧张部，切口远离位于锤骨柄上的生发上皮和血管。
Alternatively, a small Buck curette (2 mm) can be used to make a hole in the eardrum. This instrument makes a larger hole in the eardrum and is more difficult to direct to the proper site for puncture. This technique may be used to create a large hole in the eardrum to allow middle ear exudates to drain into the horizontal canal and to prevent pressure gradients from reoccurring. Larger instruments used for myringotomy cause tearing of the eardrum and should not be used. 或者，可以使用一个小的巴克刮匙(2毫米)在鼓膜上打个洞。这种设备在鼓膜上开的孔更大，很难找到合适的位置进行穿刺。这种技术可用于在鼓膜上创建一个大洞，以允许中耳分泌物流入水平耳道，并防止再次发生压力改变。鼓膜切开术中使用较大器械会导致鼓膜撕裂，不应使用。
Many veterinary practices are using carbon dioxide lasers to make the myringotomy incision. A 0.8-mm*180-mm rigid tip or long flexible Teflon tip can be inserted through the working channel of the Video Vetscope (Med Rx, Inc., Largo, FL) and can be advanced to the eardrum. Applying a pulsed low-wattage (3–4 W) laser impulse melts the eardrum. The advantage of laser myringotomy is that the tip does not have to touch the eardrum, so there is less chance of contamination of the bulla with external ear canal material. In addition, the hole made by the laser is circular and takes longer to heal, which is sometimes beneficial in providing drainage. 许多兽医使用二氧化碳激光做鼓膜切开术切口。可通过视频耳镜的工作通道插入0.8mm*180mm的硬尖端或长而有弹性的特氟隆尖端，并可推进至鼓膜。使用脉冲低瓦(3-4w)激光脉冲熔化鼓膜。激光鼓膜切开术的优点是尖端不需要接触鼓膜，因此外耳道物质污染鼓疱的机会更小。此外，激光造成的洞是圆形的，需要更长的时间来愈合，这有时有助于引流。
Fluid under pressure may freely flow into the horizontal canal as the perforation begins, and it should be suctioned to ensure that the myringotomy incision is large enough to accommodate a 3.5- or 5-French catheter. In the case of suppurative otitis media, myringotomy serves to decrease the fluid pressure behind the eardrum. The fluid escapes into the external ear canal and may continue to drain for several days; thus during therapy, the ear canals need to be flushed to remove this debris. The catheter is advanced through the incised TM and directed ventrally into the bulla, and gentle suction is used to retrieve any material within the bulla. If a spinal needle was used, the stylet is withdrawn before suctioning. If the bulla is dry, 1 or 2 mL of normal saline can be infused into the bulla and then immediately retrieved. This material is submitted for cytology, bacterial culture, and antibiotic sensitivity. 当打孔后，压力作用下液体可自由流入水平耳道，应进行抽吸，以确保鼓膜切开术切口足够大，可容纳3.5号或5号法国导管。在化脓性中耳炎的病例中，鼓膜切开术可以降低鼓膜后面的液体压力。液体流入外耳道，可持续排出数天;因此，在治疗期间，需要冲洗耳道以清除这些碎片。导管穿过切开的TM并向腹侧导入鼓疱，轻柔的抽吸可采集鼓疱内的所有物质。如果使用脊髓针，则在抽吸前将针芯抽出。如果鼓疱干燥，可将1或2毫升生理盐水注入鼓疱，然后立即取出。此样本用于细胞学检查，细菌培养和药敏试验。
Imaging of the tympanic bulla 鼓疱影像检查 Radiographic assessment of the bullae can be helpful in determining the extent of bony involvement and determining if there is increased tissue or fluid filling the bullae. The absence of radiographic changes in the bullae does not rule out otitis media, however, especially in the more acute cases. 鼓疱的影像学评估有助于确定骨质病变程度，以及确定是否有组织或液体充满鼓疱。然而，鼓疱无影像学改变并不能排除中耳炎的可能，尤其是在比较急性的病例中。
In a dog with minimal bony changes, the bullae appear as normal thin, circular, osseous structures medial to the mandibular rami on the rostrocaudal view. If an endotracheal tube is in place, it should be temporarily removed for this view. The cortical outline should be thin, and the middle of the bullae should be radiolucent, because the bullae are filled with air. When the bulla is chronically affected, either the intraluminal or extraluminal bone should show new bone production, proliferation, or bone lysis. If lytic lesions are present, differentials include neoplasia (eg, squamous cell carcinoma) and osteomyelitis. The cartilage of the external canal may have also calcified and may be easily seen on a radiograph. Often, an entire bulla appears radiopaque, because there can be large volumes of thick exudate or tissue growths (neoplasm, polyp, or cholesteatoma) filling the air space. One or both bullae may be affected. If unilateral disease is present, a comparison between the normal bulla and the abnormal bulla makes radiographic assessment of middle ear disease easier. 在骨质变化最小的患犬，鼓疱为正常的薄的、圆形的，在影像上位于吻部尾侧下颌支内侧的骨质结构。如果放置了气管内插管，则应拍照时暂时去掉插管。由于鼓疱内充满空气，皮质轮廓应薄，鼓疱中部应透光。当鼓疱有病变时，无论是腔内还是腔外骨都应显示新骨生成、增生或骨溶解。如果有溶解性病变，鉴别诊断包括肿瘤(如鳞状细胞癌)和骨髓炎。外耳道软骨也可能钙化，在x线上很容易看到。通常，整个鼓疱在射线照射下不透明，因为可以有大量的粘稠分泌物或组织生长(肿瘤、息肉或胆脂瘤)填充空腔。一个或两个鼓疱都可能患病。如果存在单侧疾病，影像学更容易对比正常鼓疱和异常鼓疱，用于评估中耳疾病。
If large volumes of flushing solution are infused into the ear canal of a dog with a ruptured eardrum before radiographic assessment, a misinterpretation of the radiograph can occur, because the bulla became filled with the flushing fluid and appears radiopaque on the radiograph. One limitation of radiographic evaluation is that old sclerotic lesions in the bulla of aged animals cannot be differentiated from more current proliferative otitis media lesions. 如果在x线片评估前将大量洗耳液注入鼓膜破裂的患犬的耳道，可能会出现对x线片的误判，因为鼓疱充满了洗耳液，在x线片上表现为不透明。影像学评估的局限性是，无法区分是老年动物鼓疱中的老年硬化病变，还是更常见的增殖性中耳炎病变。
CT of the tympanic bullae, when available, may aid in differentiating bony lesions in the bulla from soft tissue reactions. Many teaching hospitals have access to CT. In the United States, specialty referral centers are acquiring older CT scanners from human hospitals and may be able to provide this type of radiographic examination. CT may be helpful for evaluation of the horizontal ear canal and tympanic bulla when stenosis is present. 如果可以，进行鼓疱的CT检查，可能有助于区分鼓疱中的骨性病变和软组织反应。许多教学医院都可以使用CT。在美国，专科转诊中心正在从人医购买较旧的CT扫描仪，并可能提供这种类型的放射检查。当有狭窄时，CT可能有助于评估水平耳道和鼓疱。
MRI of the ear is also being done to assess the middle and inner ear. The endolymph within the cochlea and semicircular canals can provide contrast visible on MRI examinations, which may be useful for evaluating the inner ear. Extension of infection into the meninges can also be detected by MRI. Therefore, MRI may be useful in patients with neurologic signs relating to middle or inner ear disease. At the present time, this technology is available to veterinary medicine only on a limited basis. 耳部核磁共振成像也被用来评估中耳和内耳。耳蜗和半规管内的内淋巴液可以在MRI检查中提供可见的对比，这可能对评估内耳有用。MRI也可以检测到感染蔓延至脑膜。因此，MRI可能对与中耳或内耳疾病相关的神经症状的患病动物有用。目前，这项技术只能在有限的基础上用于兽医学。
Ototoxicity 耳毒性 When the eardrum is perforated or totally absent, topical medications and the chemicals used in ear cleaners can gain access to the inner ear via the round and oval windows, resulting in neurologic ototoxicity. In addition to topical ototoxicity, many pharmacologic agents are ototoxic when administered parenterally. Careful consideration should be given to the ingredients contained in ear-flushing products and topical or systemic medications before their use. Many manufacturers of otic products are now putting warnings on the label of these products that their use should be avoided if the eardrum is not intact. 当鼓膜穿孔或完全消失时，外用药物和洗耳液中使用的化学物质可以通过圆窗或椭圆窗进入内耳，导致神经毒性。除了外用药耳毒性外，许多药物在肠外给药时也有耳毒性。在使用前，应仔细考虑洗耳液和外用或全身性药物所含的成分。许多耳药产品制造商现在在这些产品的标签上标注说，如果鼓膜不完整，应避免使用。
In acute otitis media, the thin permeable membranes of the round and oval windows provide easy access into the inner ear for many compounds. Access of ototoxins into the inner ear structures may be enhanced by inflammatory damage to the round window. Enzymes contained in otic exudates can cause maceration of the epithelium covering the round window, increasing its permeability. It is also possible for the round window to become hyperplastic and thickened after long-standing otitis media, providing a barrier to prevent these ototoxins from reaching the inner ear. If there is thick mucus found within the bulla, it may act as a barrier covering the round window, effectively shielding the toxic material from contact. Because the round and oval windows cannot be visually examined, it is difficult to know if the membrane is thinned or thickened. By using nonototoxic products, this issue becomes less important. 在急性中耳炎中，圆窗和椭圆窗的薄的渗透膜为许多化合物进入内耳提供了方便。耳毒素进入内耳结构的通路可能因炎症损害了圆窗而增强。耳部渗出液中所含的酶可浸渍覆盖在圆窗上的上皮细胞，增加其渗透性。长期中耳炎后，圆窗也有可能增生和增厚，为防止耳毒素到达内耳提供了屏障。如果鼓疱内有粘稠粘液，它可以作为屏障覆盖在圆窗上，有效地屏蔽有毒物质的接触。由于圆窗和椭圆窗无法肉眼观察到，因此很难知道薄膜是变薄了还是变厚了。通过使用无耳毒性产品，这个问题就变得不那么重要。
Ototoxicity results from damage to the hair cells in the cochlea or in the vestibular apparatus. This results in hearing deficits, vestibular disease, or both. Overt deafness or severe clinical vestibular disease (nystagmus, head tilt, and circling) may be obvious. Subtle changes in hearing or balance may not be detected by the owner or the veterinarian, however. 耳毒性是由于耳蜗或前庭器官的毛细胞受损而引起的。这会导致听力损失、前庭疾病，或两者兼有。明显失聪或明显出现严重的临床前庭疾病(眼球震颤、歪头和翻滚)。然而，宠主或兽医可能察觉不到轻微的听力改变或平衡改变。
Many ear-cleaning solutions contain a mixture of ototoxic substances that may gain access to the inner ear, resulting in alterations of vestibular and cochlear function. Of these compounds, chlorhexidine is probably the most toxic, especially in cats. Severe prolonged vestibular signs can be caused by chlorhexidine, and its use in the ears is strongly discouraged. 许多洗耳液含有可能进入内耳的复方耳毒性物质，导致前庭和耳蜗功能的改变。在这些化合物中，氯己定可能是毒性最大的，尤其是对猫。氯己定可导致前庭症状严重延长，强烈建议不要用于耳道。
The aminoglycosides, polymyxins, detergents, and most alcohols routinely used in the treatment of the external ear canal are known to be toxic to the nervous structures of the inner ear. Potentially ototoxic antimicrobial pharmaceutics are present in most topical formulations for treatment of otitis externa. An assessment of the risks of topical use of a drug or ear-flushing solution that may cause ototoxicity versus the therapeutic benefit must be considered when using these formulations to treat otitis media. For example, the aminoglycoside tobramycin has been shown to be an effective antibiotic for many multidrug-resistant Pseudomonas organisms. Although it is an aminoglycoside with potential ototoxic side effects, it is often infused into the bulla to treat the bacterial infection because of its efficacy. 众所周知，用于外耳道治疗的氨基糖苷类、多粘菌素、洗涤剂和大多数酒精对内耳的神经结构是有毒的。大多数外耳炎外用药中都含有潜在的耳毒性抗菌药物。在使用这些耳药治疗中耳炎时，必须考虑外用药或洗耳液可能引起耳毒性的风险，与治疗效果对比评估。例如，氨基糖苷类的妥布霉素已被证明对许多耐药假单胞菌是一种有效的抗生素。虽然它是一种氨基糖苷类药物，具有潜在的耳毒性副作用，但由于其疗效，常将其注入鼓疱治疗细菌感染。
Many common topical antibiotics can cause ototoxicity. Gentamicin, for example, concentrates in the hair cells of the organ of Corti in the cochlea when administered parenterally. It may also cause vestibular signs when administered topically in the middle ear, however. The cell permeability is altered such that the hair cells swell and become deformed. They are rendered rigid and are unable to respond to movements of the endolymph within the semicircular canals. Ataxia, head tilt, and circling can result. A similar situation occurs in the cochlea when neomycin or kanamycin concentrate is administered. The cochlear nerve cells are damaged and cannot respond to vibrations, leading to hearing loss. 许多常见的外用抗生素可引起耳毒性。例如，庆大霉素在肠外给药时，浓度集中在耳蜗科尔蒂器官的毛细胞中。然而，在中耳外部给药时也可能导致前庭症状。细胞的渗透性被改变，以致毛细胞膨胀和变形。它们变得僵硬，不能对半规管内的内淋巴的运动作出反应。可导致共济失调、歪头和翻滚。当给予新霉素或卡那霉素溶液时，耳蜗也会出现类似的情况。耳蜗神经细胞受损，无法对震动做出反应，导致听力丧失。
There is a short list of products that can be infused into the tympanic bulla without the risk of ototoxicity. Before selecting a product to use in the bulla, a study of the ingredients contained in the preparation should be evaluated to determine the ototoxic potential. For antibiotics, the fluoroquinolones (ciprofloxacin, enrofloxacin, and ofloxacin), aqueous penicillin G, some semisynthetic penicillins (carbenicillin and ticarcillin), and some cephalosporins (ceftazidime and cefmenoxime) are safe to use in middle ear disease. The antifungals clotrimazole, miconazole, nystatin, and tolnaftate can be safely infused. The aqueous forms of the anti-inflammatories dexamethasone and fluocinolone are safe in the middle ear. Most cerumenolytics cannot be used in the bulla. The exception is squalene (Cerumene), which has been shown to be safe. Tris-EDTA is also a safe flushing agent. 有少量可以用于鼓疱且没有耳毒性风险的产品列表。在选择用于鼓疱的产品之前，应评估制剂中所含成分的研究，以确定潜在耳毒性。在抗生素方面，氟喹诺酮类药物(环丙沙星、恩诺沙星、氧氟沙星)、青霉素G溶液、部分半合成青霉素(羟苄青霉素和替卡西林)，部分头孢菌素(头孢他啶和头孢甲肟)可安全用于中耳疾病。抗真菌药克霉唑、咪康唑、制霉菌素和托萘酯可安全使用。抗炎药地塞米松和氟轻松溶液在中耳是安全的。大多数耵聍溶解剂不能用于鼓疱。唯一的例外是角鲨烯(Cerumene)，它已被证明是安全的。Tris-EDTA也是一种安全的冲洗液。
Treatment of otitis media 中耳炎治疗 Planning treatment of otitis media requires a stepwise protocol for maximal effect. An organized approach allows the clinician to formulate treatment or to change existing treatment based on observations. The steps outlined provide a framework for treating otitis media: 1.Access middle ear. 2.Perform cytology and bacterial culture. 3.Flush bulla. 4.Infuse topical medications into the bulla. 5.Reduce inflammation with corticosteroids. 6.Administer systemic and topical antimicrobials. 7.Recheck weekly, and retreat two to three times. 8.Consider surgery. 中耳炎的治疗计划需要一个循序渐进的方案，以达到最佳疗效。系统的方法允许临床医生制定治疗方案或根据观察改变现有的治疗方法。按顺序概述治疗中耳炎的框架: 1.进入中耳。
2.进行细胞学检查和细菌培养。
3.冲洗鼓疱。
4.向鼓疱内注入外用药。
5.使用皮质类固醇减少炎症反应。
6.给予全身和外用抗生素。
7.每周复诊一次，重复两到三次。
8.考虑手术。
Access middle ear 进入中耳 Accessing the middle ear by otoscopy and myringotomy was discussed previously. 通过耳镜检查和鼓膜切开术进入中耳之前已经讨论过。
Sample collection 采样 To get a culture or cytology sample from the bulla in an ear without an eardrum, a sheathed catheter is used. A sterile 3.5-French polypropylene urinary catheter is threaded into a 5-French polypropylene urinary catheter. With the closed irrigating ends removed, the 5-French catheter is first threaded through the external ear canal until it reaches the bulla. This acts as a shroud to prevent contamination of the sample with debris from the external ear canal. It should be inserted into the bulla along the floor of the horizontal canal and directed ventrally into the bulla. After this catheter is placed, the 3.5-French catheter is threaded into the 5-French catheter and is extended beyond the cut end. The sample is aspirated with a syringe or suction apparatus using the flanged end of the 3.5-French catheter. If no liquid is in the bulla, 1 mL of sterile saline can be infused and suctioned back. Any fluid or mucus that enters the lumen of the 3.5-French catheter is submitted to the laboratory for cytology and culture and sensitivity testing. 要从没有鼓膜的耳道鼓疱中获得细菌培养或细胞学检查的样本，需要使用一套导管。一个3.5号法国聚丙烯无菌导管穿入一个5号法国聚丙烯导管。将封闭的冲洗端剪掉，先将5号法国导管穿过外耳道，直到到达鼓疱。这就像一个保护套，防止样本被来自外耳道的碎片污染。应该沿着水平耳道的底部插入鼓疱，并向腹侧进入鼓疱。在导管放置后，3.5号法国导管穿过5号法国导管并伸到切口末端。使用注射器或抽吸器，用3.5号法国导管的末端抽吸样品。如果鼓疱内没有液体，可注入1毫升无菌生理盐水并抽吸。任何进入3.5号法国导管内的液体或粘液都要送到实验室进行细胞学检查、细菌培养和药敏试验。
If a myringotomy incision was made with a sharp pointed 5-French catheter, as the incision is made, the catheter is extended into the bulla and the contents are aspirated. The lumen contents are submitted to the laboratory. If a laser myringotomy was made, a sterile catheter is inserted through the hole and a sample is taken. 如果使用尖的5号法国导管切开鼓膜，在切开的过程中，导管伸入鼓疱并抽吸内容物。管内物质提交实验室。如果做了激光鼓膜切开术，无菌导管就可穿过这个孔并采集样本。
Cytology and bacterial culture 细胞学检查和细菌培养 It is important to obtain samples for cytology and bacterial culture. Many infections are polymicrobial, including mixed infections of bacteria (rods or cocci) and yeasts. Cytology of a middle ear specimen may reveal Malassezia yeasts, which would not be reported if only bacterial culture was submitted to the laboratory. Additionally, cytology may not reveal bacteria because they are often protected from the cytology stains by mucus. Many cytologically negative specimens have been reported as culture-positive. In ear disease, laboratory assessment based on culture and sensitivity does not always correlate to clinical response (see section on systemic and topical antimicrobial therapy). 获得细胞学检查和细菌培养样品很重要。许多感染是多种微生物的，包括细菌(杆菌或球菌)和酵母菌的混合感染。中耳样本的细胞学检查可能显示马拉色菌，如果仅进行细菌培养，则为阴性。此外，细胞学检查可能无法发现细菌，因为它们经常被粘液染色保护。许多细胞学检查阴性的样本细菌培养结果是阳性。在耳病中，基于细菌培养和药敏试验的实验室评估并不总是与临床效果相符(见全身性和外部抗菌治疗部分)。
In cats with otitis media and polyps, the most common bacterial organism was Staphylococcus intermedius. Other bacteria have been isolated from feline middle ears, including Pseudomonas, Bordetella, Bacteroides, Fusobacterium, and Mycoplasma. Fortunately, bacterial resistance problems are not usually a feature of feline otitis media. The most common microbes recovered from chronic otitis media in the dog include Pseudomonas aeruginosa and S intermedius. In one study, one or the other of these two bacteria was isolated in more than 70% of the cases. Other isolates include Streptococcus, Proteus, Klebsiella, Escherichia coli, and some anaerobes. When microbiologic samples from the middle ear were compared with the same bacterial isolates found in the horizontal canal, the antibiotic sensitivity of organisms isolated from the horizontal ear canal was different from that of organisms isolated from the middle ear. This occurred in almost 80% of these cases. 在患有中耳炎和息肉的猫中，最常见的细菌是中间型葡萄球菌。从猫的中耳中还分离出了其他细菌，包括假单胞菌、博戴氏杆菌、拟杆菌、梭杆菌和支原体。幸运的是，细菌耐药性问题通常不是猫中耳炎的特征。犬慢性中耳炎中最常见的微生物包括铜绿假单胞菌和中间型葡萄球菌。在一项研究中，超过70%的病例中分离出了这两种细菌中的一种。其他的分离菌包括链球菌、变形杆菌、克雷伯氏菌、大肠杆菌和一些厌氧菌。将中耳的微生物样本与水平耳道的相同菌株进行比较，水平耳道分离的微生物与中耳分离的微生物的抗生素敏感性不同。这些病例中有近80%发生了这种情况。
Flushing and suctioning the bulla 鼓疱灌洗和抽吸 The most important technique for treating otitis media is probably flushing the bulla. Topical otic medications cannot penetrate through the thick exudate that fills the middle ear during otitis media; thus, this exudate and secretory material must be removed. Additionally, many destructive enzymes that are trapped in the mucoid secretions in the bullae remain in contact with the mucoperiosteum, which prolongs the disease. Hydrating the mucus with the water in flushing solutions makes it less dense and easier to suction. 治疗中耳炎最重要的方法可能是冲洗鼓疱。中耳炎期间，外用药物无法穿透有粘腻分泌物的中耳;因此，这些渗出物和分泌物质必须被清除。此外，许多被困在鼓疱粘液样分泌物中的破坏性酶与粘膜骨膜接触，使疾病时间延长。用冲洗液稀释粘液，使其密度降低，更容易抽吸。
Using fluid under pressure to irrigate the bulla loosens mucus from the tissue. This material does not stick to the mucous membrane as cerumen sticks to the epithelium in the external ear canal. The fluid the author uses for flushing the bulla is warmed extremely dilute povidone iodine solution in warm tap water. If there is an identifiable bacterial infection, warmed Tris-EDTA is also infused into the bulla. Acidic solutions should be avoided in the middle ear so as to prevent pain and irritation. Using a device that delivers the fluid under high pressure allows the mucus and pus to flush out of the bulla either into the external ear canal, where it can be suctioned out, or through the auditory tube into the throat. The MedRx Earigator (MedRx, Seminole, Florida) (Fig. 1) makes flushing and suctioning the tympanic bulla a simple and efficient procedure. A 5-French or smaller polypropylene catheter connected to the irrigation/suction unit is placed into the 2-mm working channel built into the Video Vetscope (Fig. 2). The entire cleaning process is observed on the video monitor. The catheter is advanced along the floor of the horizontal canal and is directed ventrally into the bulla. A less rigid red rubber feeding tube can be used for flushing, but it may collapse when used for suctioning. Without this equipment, catheter placement and evaluation of the efficiency of cleaning are hard to determine, but that should not deter the attempt to flush the bulla. 将液体加压灌洗鼓疱，可使组织中的粘液松动。这种物质不像耳垢粘附在外耳道的上皮细胞上那样粘附在粘膜上。作者用于冲洗鼓疱的液体是温的极稀的聚维酮碘溶液，在温自来水中。如果确认有细菌感染，也将加温的Tris-EDTA注入鼓疱。应避免酸性溶液进入中耳，以防止疼痛和刺激。使用加压冲洗设备，可以让粘液和脓液从鼓疱中冲出来，要么进入外耳道，然后被抽吸干净，要么通过咽鼓管进入喉咙。MedRx Earigator (MedRx, Seminole, Florida)(图1)使鼓疱冲洗和抽吸变的简单有效。将一个5号或更小的聚丙烯导管连接到冲洗/抽吸设备，放置到视频耳镜的2毫米工作通道中(图2)。整个清洗过程可以在视频显示屏上观察。导管沿水平耳道底推进，沿腹侧进入鼓疱。可以用一个不太硬的红色橡胶鼻饲管冲洗，但用它抽吸时可能变瘪。没有这种设备，很难确定导管的位置和评估清洗效果，但并不要放弃选择冲洗鼓疱。 Fig. 1. The Earigator. This flush and suction unit provides adjustable flflushing volumes adequate for irrigating the tympanic bulla. Trumpet valves in the handpiece allow flushing and suctioning with one hand. 图1所示。Earigator。这种冲洗和抽吸装置提供冲洗鼓疱的可调冲洗量。手持冲洗阀允许单手冲洗和抽吸。
Fig. 2. To flush the tympanic bulla, a 5-French polypropylene catheter attached to the Earigator is extended through the 2-mm working channel of the video otoscope and directed ventrally into the tympanic bulla. 图2所示。为了冲洗鼓疱，将连接在Earigator上的5号法国聚丙烯导管通过视频耳镜的2mm工作通道伸入鼓疱腹侧。
Bulla infusion 鼓疱给药 Removal of the mucus and pus within the tympanic bulla during the treatment of otitis media allows topical medications to penetrate in and around the thickened and folded mucoperiosteum. The use of aqueous formulations of nonototoxic topical antibiotics, steroids, or antifungals placed on the mucoperiosteum hastens recovery from otitis media. Topical levels of these drugs may be many times the level that can be achieved using parenteral therapy, even when there is severe hyperemia of the mucoperiosteum. Antibiotic concentrations are high in inflamed tissues, because the increased blood flow allows increased serum levels of antibiotic to perfuse the inflamed tissue. Even these levels may not achieve the minimum inhibitory concentration (MIC) necessary to kill the bacterial target, however. 中耳炎治疗过程中，鼓疱内的粘液和脓液被清除，使得外用药物可以穿透厚的、粘膜骨膜皱褶。将非耳毒性外用抗生素、类固醇或抗真菌溶液用在粘膜骨膜上，可加速中耳炎的恢复。这些药物的外用浓度可能是肠外给药浓度的许多倍，即使是有严重粘膜骨膜充血的时候。炎症组织中的抗生素浓度很高，因为血流的增加使得炎症组织中抗生素的血清浓度增加。然而，即使是这些浓度也可能达不到杀死细菌的所需的最低抑菌浓度(MIC)。
Infusing drugs into the bulla is an effective method of providing longacting high-concentration effects. The tympanic bulla in the dog and cat is a deep blind pouch. When the bulla is filled with antibiotic, the fluid cannot escape easily. Because of the small diameter of the swollen auditory tube and its location high on the medial wall of the bulla, drainage from the auditory tube is unlikely. Depending on the amount of eardrum present, fluid has to traverse a jut in the petrous temporal bone, which forms the floor of the horizontal ear canal and extends into the bulla. Fluid escape from the bulla is difficult and requires severe changes in head position to allow drainage through the eardrum. If a myringotomy incision was made, it would be difficult for fluid to escape the middle ear because of the surface tension across the incision. There may be a small movement of the infused antibiotic solution into the external ear canal, which actually may be beneficial, but most of the topical antibiotic solution can remain within the bulla for several days after infusion. 鼓疱内给药是一种长效高浓度作用的有效方法。犬和猫的鼓疱是一个很深的盲袋。当鼓疱充满抗生素时，液体不会轻易排出。由于肿胀的咽鼓管直径较小，且位于鼓疱内壁较高位置，不太可能从咽鼓管流出。依靠剩余的鼓膜，液体必须穿过颞骨岩凸起，该凸起形成水平耳道的底部并延伸到鼓疱。液体很南从鼓疱排出，需要很大程度改变头部位置，才能通过鼓膜流出。如果做鼓膜切开术切口，由于切口表面张力，液体很难从中耳流出。注入的抗生素溶液可能会部分流出到外耳道，实际上这可能有好处，但大多数外用抗生素溶液可以在注射后在鼓疱内保留几天。
The antibiotic, antifungal, or corticosteroid solution is infused into the bulla through a small catheter placed into the bulla until the fluid overflows into the external ear canal. During the first bulla infusion, less than 1 mL of solution can be infused into the inflamed bulla. The entire procedure of flushing, suctioning, and bulla infusion should be repeated weekly during therapy. With each successive treatment, the mucoperiosteum should retract slightly, increasing the volume of fluid the bulla can accommodate. 抗生素、抗真菌药，或皮质类固醇溶液通过小导管注入鼓疱，直到液体溢出外耳道。在第一次鼓疱输注时，可向炎症鼓疱内输注少于1ml的溶液。整个冲洗、抽吸和鼓疱给药过程应在治疗期间每周重复一次。每次连续治疗后，粘膜骨膜应轻微消肿，增加鼓疱可容纳的液体量。
Reduce inflammation with corticosteroids 使用皮质类固醇降低炎症反应 Corticosteroids slow the intense inflammation and exudation found in middle ear disease. As described earlier, the mucoperiosteum undergoes severe pathologic changes in response to inflammation. Corticosteroids can reverse some of the extensive granulation that forms in the bulla, which enhances the ability of topically applied antibiotics to penetrate into the infected tissue. The tympanic cavity is crowded out by this hyperemia and proliferating granulation tissue; thus, the amount of free space within the bulla decreases. Reducing the inflammation helps this lining membrane to retract back toward the bone, increasing the volume within the bulla. When the eardrum heals, this space should refill with air. 皮质类固醇可以减缓中耳疾病中严重的炎症和渗出。如前所述，粘膜鼓膜在炎症反应中会发生严重的病理改变。皮质类固醇可以逆转鼓疱中形成的大面积肉芽肿，增强外用抗生素穿透感染组织的能力。鼓膜腔被充血和增殖的肉芽组织挤出;因此，鼓疱内的游离空间减少。减少炎症有助于内衬的粘膜向骨质回缩，增加鼓疱内的容积。当鼓膜愈合时，这个空间应该充满空气。
Corticosteroids also reduce the amount of mucus produced in the bulla and decrease the viscosity of the secretions from the inflamed mucous membrane in the bulla. Changing the character of the mucus aids in its removal. Corticosteroids may also function in reducing the swelling in the auditory tube, increasing lumen diameter, which has the beneficial effect of offering limited drainage of mucus into the nasopharynx. 皮质类固醇也会减少鼓疱中粘液的分泌量，并降低鼓疱中发炎的粘膜分泌物的粘稠度。改变粘液的性质有助于清除粘液。皮质类固醇也可以减少咽鼓管的肿胀，增加管腔直径，为少量粘液从鼻咽部流出提供有利条件。
Aqueous topical corticosteroids, such as dexamethasone sodium phosphate (4 mg/mL) or a dimethyl sulfoxide (DMSO)/fluocinolone combination (Synotic) may be infused through a catheter placed into the cleaned and dried bulla. These potent topical anti-inflammatories are not ototoxic. Other potent injectable topical corticosteroids are formulated with ototoxins, such as benzyl alcohol or propylene glycol, or they are in suspension. These should not be used in the bulla. 外用皮质类固醇溶液，如地塞米松磷酸钠(4mg /mL)或二甲基亚砜(DMSO)/氟轻松混合液(Synotic)可通过导管注入清洁和干燥的鼓疱。这些有效的外用抗炎药无耳毒性。其他强效外用皮质类固醇注射液制剂中有耳毒性的成份，像是苯甲醇或丙二醇，或是悬浮液。这些不应该在鼓疱中使用。
If there is bacterial or fungal disease and the space in the bulla is needed for antibiotic or antifungal topical therapy, systemic corticosteroids may be used for a few weeks during the recovery phase of otitis media. High initial doses of corticosteroid are required, which mirror those used for other diseases, such as inflammatory bowel disease. Patients should be screened for diabetes, hyperadrenocorticism, demodicosis, and potential pregnancy before using the high doses of corticosteroids. Prednisone or prednisolone, 1 to 2 mg/lb daily for 2 weeks and then decreasing to 0.5 mg/lb every other day, provides high enough levels to decrease inflammation within the bulla. Owners of these animals need to be warned that there will be side effects of prednisone at this high dose. Many owners discontinue the medication when the side effects occur. The author prefers to use a 0.1-mg/lb intravenous dose of dexamethasone (2 mg/mL) at the time of treatment and then to repeat this injection weekly at the recheck appointment if there is significant exudate that needs to be suctioned from the bulla. This has fewer mineralocorticoid-related side effects and prevents the owners from having the choice of stopping the medication. Because many dogs with otitis media also have concurrent otitis externa, systemic corticosteroids aid in reducing the swelling and pain from otitis externa. In addition, they reduce the signs associated with atopic disease, which is a primary cause of otitis externa in the dog. 如果有细菌性或真菌性疾病，需要在鼓疱内用抗生素或抗真菌进行外部治疗，在中耳炎的恢复阶段，可以使用全身皮质类固醇数周。需要初始剂量较高的皮质类固醇，这与用于其他疾病，如炎性肠病的剂量相同。在使用高剂量皮质类固醇前，患病动物应筛查糖尿病、肾上腺皮质激素亢进、蠕形螨病和是否潜在妊娠。泼尼松或泼尼松龙，每天1到2毫克/磅，持续2周，然后降到0.5毫克/磅，隔日一次，提供足够的浓度，以减少鼓疱内的炎症。需要提醒宠主，高剂量的泼尼松会有副作用。当副作用发生时，许多宠主会停止用药。作者倾向于在治疗时使用0.1毫克/磅的静脉注射地塞米松(2 毫克/毫升)，每周在复诊时重复注射一次，如果有明显的渗出需要从鼓疱中抽吸。这降低了盐皮质激素相关的副作用，并防止宠主选择停药。由于许多中耳炎患犬也同时患有外耳炎，全身皮质类固醇有助于减轻外耳炎引起的肿胀和疼痛。此外，它们还能减少与特应性疾病相关的症状，而特应性疾病是导致犬外耳炎的原发病因。
Systemic and topical antimicrobials 全身性和外用抗生素 The dilemma facing the clinician treating otitis media is that systemic drug levels may not reach sufficient MIC in the bulla and topical treatment requires frequent applications. Using maximal doses of oral antibiotics along with weekly bulla infusions of a fresh supply of antibiotic increases the therapeutic successes. 临床医生治疗中耳炎面临的困境是，全身用药在鼓疱内的浓度可能达不到足够的MIC和外用治疗需要频繁给药。使用最大剂量的口服抗生素，同时每周鼓疱注入新鲜配置抗生素，可增加治疗成功率。
Topical antibiot ic treatment of otitis media has gained recent favor in veterinary medicine. The use of topicals is based on the high levels of antibiotic that can be placed into the bulla coupled with the poor drainage of the tympanic bulla. Aqueous solutions of nonototoxic antibiotics can be placed directly onto the infected mucoperiosteum. Infused antibiotics can remain in contact with the inflamed granulating middle ear mucosa much longer, because the fluid filling the bulla cannot readily escape. When topical therapy of otitis media fails, it is usually the result of inability of the antibiotic to get to the bacteria. For example, there may be sequestration of bacteria within folds or pockets of granulation tissue unexposed to the topical antibiotic. 目前兽医更喜欢外用抗生素治疗中耳炎。外用药物的使用是基于鼓疱内可注入高浓度抗生素，再加上不易从鼓疱流出。无耳毒性抗生素溶液可直接接触感染的粘膜骨膜。注入的抗生素可以与发炎的中耳粘膜肉芽组织保持更长的接触时间，因为充满鼓疱的液体不能轻易流出。当中耳炎的外用治疗失败时，通常是由于抗生素对细菌不起作用。例如，可能有细菌在褶皱或肉芽组织缝隙内未接触外用抗生素。
Antibiotic sensitivity patterns are important for treating otitis media when systemic antibiotics alone are used to get levels within the bulla. Unlike topical antibiotics, which can achieve many times the blood MIC, systemic antibacterial therapy for otitis media relies on lower levels of antibiotics arriving in the middle ear hematogenously or through inflammatory cells. Because of the poor blood supply in the external ear canal and middle ear, there is limited diffusion of antibiotic from the serum into the lumen of the ear canal or tympanic bulla. Specific systemic and topical medications for otitis media are discussed in another article in this issue. 治疗中耳炎时，仅靠使用全身性抗生素达到鼓疱内浓度时药敏试验很重要。与外用抗生素不同，外用药的浓度是血液MIC的很多倍，中耳炎的全身性抗细菌治疗依靠通过血液或炎症细胞进入中耳的较低浓度的抗生素。由于外耳道和中耳的血液供应不佳，从血清中到达耳道或鼓疱的抗生素有限。中耳炎的特异性全身和外用药物治疗将在本刊的另一篇文章中讨论。
Rechecks 复诊 With successive recheck visits, the eardrum and the horizontal canal should be examined for fluid, mucus, and pus. If there is fluid within the bulla, it should be flushed out and the bulla suctioned to prepare it for reinfusion. When the weekly examination reveals a dry canal and little liquid within the bulla, the inflammation and infection within the bulla have subsided. At this point, bulla infusion treatments can be discontinued. Subsequent 2-week recheck intervals should reveal a healing eardrum. 连续复诊时，应检查鼓膜和水平耳道是否有液体、粘液和脓汁。如果鼓疱内有液体，应将液体冲洗出来，并抽吸鼓疱，后再用药。当每周复诊发现耳道干燥，鼓疱内少量液体时，说明鼓疱内的炎症和感染已清除。此时，可停止鼓疱灌洗治疗。随后每2周复查，应看到鼓膜愈合。
Surgery 手术治疗 Medical therapy of otitis media in the author’s practice is 75% successful. A small number of chronic otitis media cases require total ear canal ablation and bulla osteotomy in spite of proper medical therapy. Surgical techniques (including options for inflammatory polyp removal) are discussed in another article in this issue. 中耳炎的药物治疗在作者的医院中成功率为75%。少数慢性中耳炎病例需要全耳道切除术和鼓疱截骨术，但也要适当的药物治疗。手术治疗技术(包括炎性息肉切除)将在本期刊的另一篇文章中讨论。
Summary 总结 Otitis externa/media is commonly found in dogs with chronic ear diseases and in cats with upper respiratory disease and polyps. Diagnosis of otitis media requires attention to history and clinical signs, but it also requires other methods of determining disease within the bulla. If the integrity of the eardrum cannot be determined, assume that there is middle ear disease and proceed accordingly. It is prudent to take necessary precautions to avoid the use of potentially ototoxic ear cleaners or topical medications in suspected otitis media cases. Therapeutic success is possible using systemic and topical treatment within the cleaned bulla. Referral to a dermatology specialist or a radiologist for a CT scan may be indicated in some refractory cases. Surgical intervention may be required to cure these difficult cases. 外耳炎/中耳炎常见于患有慢性耳病的犬和患有上呼吸道疾病和息肉的猫。中耳炎的诊断需要注意病史和临床症状，但也需要其他方法来确定鼓疱内疾病。如果不能确定鼓膜的完整性，就假设存在中耳疾病，然后进行相应的检查。在怀疑中耳炎的病例中，应谨慎采取必要的预防措施，避免使用可能有耳毒性的洗耳液或外用药物。使用全身治疗和外用治疗清洗鼓疱可能会治疗成功。在一些难治性病例中，推荐转诊皮肤科专家或影像科医生进行CT扫描。治疗这些疑难病例可能需要手术干预。
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发表于 2021-11-5 11:36:29
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