猫单侧、分阶段双侧和单期双侧鼓泡腹侧截骨术（VBO）的并发症和 ...

王帆

Comparison of complications and outcome following unilateral, staged bilateral, and single-stage bilateral ventral bulla osteotomy in cats

猫单侧、分阶段双侧和单期双侧鼓泡腹侧截骨术的并发症和结果比较

 

翻译：王帆

 

OBJECTIVE To compare complications and outcome following unilateral, staged bilateral, and single-stage bilateral ventral bulla osteotomy (VBO) in cats.

ANIMALS 282 client-owned cats treated by VBO at 25 veterinary referral and academic hospitals from 2005 through 2016.

PROCEDURES Medical records of cats were reviewed to collect information on signalment, clinical signs, diagnostic test results, surgical and postoperative management details, complications (anesthetic, surgical, and postoperative), and outcome. Associations were evaluated among selected variables.

RESULTS Unilateral, staged bilateral, and single-stage bilateral VBO was performed in 211, 7, and 64 cats, respectively, representing 289 separate procedures. Eighteen (9%), 2 (29%), and 30 (47%) of these cats, respectively, had postoperative respiratory complications. Cats treated with single-stage bilateral VBO were significantly more likely to have severe respiratory complications and surgery-related death than cats treated with other VBO procedures. Overall, 68.2% (n = 197) of the 289 procedures were associated with Horner syndrome (19.4% permanently), 30.1% (87) with head tilt (22.1% permanently), 13.5% (39) with facial nerve paralysis (8.0% permanently), and 6.2% (18) with local disease recurrence. Cats with (vs without) Horner syndrome, head tilt, and facial nerve paralysis before VBO had 2.6, 3.3, and 5.6 times the odds, respectively, of having these conditions permanently.

CONCLUSIONS AND CLINICAL RELEVANCE Findings suggested that staged bilateral VBO should be recommended over single-stage bilateral VBO for cats with bilateral middle ear disease. Cats with Horner syndrome, head tilt, and facial nerve paralysis before surgery were more likely to have these conditions permanently following surgery than were cats without these conditions.

目的

比较猫单侧、分期双侧和单期双侧腹侧鼓泡截骨术(VBO)的并发症和疗效。

动物

从2005年到2016年，在25家兽医转诊和学术医院接受VBO治疗的282只家养猫。

研究方法

回顾了猫的病历，以收集有关特征、临床症状、诊断性检查结果、手术和术后管理细节、并发症(麻醉、手术和术后)和结果的信息。对所选变量进行关联评估。

结果

单侧VBO 211只，分期双侧VBO 7只，单期双侧VBO 64只，共289次手术。术后分别有18只(9%)、2只(29%)和30只(47%)出现呼吸系统并发症。单期双侧VBO治疗的猫发生严重呼吸系统并发症和手术相关死亡的可能性显著高于其他VBO治疗的猫。289例次手术中，68.2%(197例)出现霍纳综合征(19.4%永久存在)，30.1%(87例)出现头倾斜(22.1%永久存在)，13.5%(39例)出现面神经麻痹(8.0%永久存在)，6.2%(18例)出现局部复发。与VBO前无霍纳综合征、头部倾斜和面神经麻痹症状的患猫相比，在VBO前有这些症状患猫，术后症状永久性存在的比例分别是2.6倍、3.3倍和5.6倍的概率。

结论和临床相关性

研究结果表明，对于双侧中耳炎患猫，应推荐分期双侧VBO，而不是单期双侧VBO。术前患有霍纳综合征、头倾斜和面神经麻痹的猫比没有这些症状的猫更有可能在手术后永久患这些疾病。

 

ABBREVIATIONS

缩写

CI Confidence interval

TECA-LBO Total ear canal ablation and lateral bulla osteotomy

VBO Ventral bulla osteotomy
CI 置信区间
TECA-LBO 全耳道切除及外侧鼓泡截骨术
VBO 腹侧鼓泡截骨术

 

Ventral bulla osteotomy is a commonly performed surgical procedure in cats for the management of middle ear diseases, including inflammatory polyps, otitis media, and benign and malignant neoplasia.The procedure involves exposing the osseous bulla through a ventral cervical paramedian approach, entering the ventral aspect of the osseous bulla with an intramedullary pin and rongeurs or a pneumatic drill, removing the bony septum separating the larger ventromedial and smaller dorsolateral compartments of the middle ear, curetting the epithelial lining of the osseous bulla, and excising the inflammatory polyp or tumor if indicated. Bilateral VBO is performed in cats with bilateral middle ear disease and can be staged or performed simultaneously as a single-stage procedure.

腹侧鼓泡截骨术（VBO）是猫中耳疾病的一种常用外科手术，包括炎性息肉、中耳炎和良性和恶性肿瘤。该手术包括通过腹侧颈旁正中通路暴露鼓泡骨质，使用髓内针和咬骨钳或气压钻进入鼓泡骨质腹侧，切除分隔中耳较大腹内侧和较小背外侧隔室的鼓室中隔，刮除鼓泡骨质的内衬上皮，如有需要，切除炎性息肉或肿瘤。双侧VBO是在双侧中耳疾病的猫中进行的，可以分期进行，也可以作为单期手术同时进行。

 

The most common complications following VBO in cats include persistent otic infection, Horner syndrome, vestibular signs, facial nerve paralysis, and local recurrence of the inflammatory polyp or tumor. Although complications and outcomes have been documented for cats undergoing TECA-LBO for the treatment of diseases of the middle ear and external ear canals, few reports exist of outcomes in cats following VBO, and the largest study included only 26 cats. Anecdotally, high incidences of respiratory related complications and death following single-stage bilateral VBO in cats have been noted by several surgeons participating in the Veterinary Society of Surgical Oncology listserv.

猫VBO后最常见的并发症包括持续性耳部感染、霍纳综合征、前庭症状、面神经麻痹以及炎性息肉或肿瘤的局部复发。虽然TECA-LBO治疗猫中耳和外耳道疾病的并发症和结果已被记录在案，但很少有关于猫VBO治疗的结果的报道，最大规模的研究仅包括26只猫。参与兽医肿瘤外科学会的几名外科医生发现，猫单期双侧VBO后，呼吸系统相关并发症和死亡的发生率较高。

 

 

The purpose of the retrospective study reported here was to evaluate cats with middle ear disease treated with unilateral, staged bilateral, or single-stage bilateral VBO to determine whether single-stage bilateral VBO was associated with a higher risk of respiratory complications and perioperative death; to determine rates of transient and permanent postoperative complications following VBO; and to describe the outcomes following VBO in cats for the treatment of nonneoplastic, benign, and malignant disease. We hypothesized that single-stage bilateral VBO would be associated with higher likelihood of postoperative respiratory complications and disease-related death than the other 2 VBO procedures.

本回顾性研究旨在评估患中耳疾病的猫接受单侧、分期双侧或单期双侧VBO的情况，以确定单期双侧VBO是否与较高的呼吸系统并发症和围手术期死亡风险相关;确定VBO术后暂时性和永久性并发症的发生率;并描述VBO治疗猫的非肿瘤性、良性和恶性疾病的结果。我们假设单阶段双侧VBO比其他两种VBO术后呼吸系统并发症和疾病相关死亡的可能性更高。

 

Materials and Methods

材料和方法

Animals

动物

Medical records of cats that underwent VBO at 25 veterinary referral and academic hospitals from January 1, 2005, to December 31, 2016, were obtained and reviewed. Cats with incomplete follow-up information or that were lost to follow-up within 100 days after surgery were excluded from analysis.

收集2005年1月1日至2016年12月31日在25家兽医转诊医院和学术医院进行VBO的猫的病历并进行回顾。随访信息不完整或术后100天内失去随访的猫被排除在分析之外。

 

Data collection

数据采集

Data were retrieved from medical records, including patient signalment (age, sex, and breed), clinical signs, diagnostic investigations (CBC, serum biochemical analysis, oropharyngeal examination, radiography, otoscopy, endoscopy, CT, and MRI) and noted abnormalities, anesthetic details, surgical procedure details, intraoperative diagnostic test (histologic evaluation and bacterial culture) results, postoperative management details, complications, and outcome. Anesthetic details included premedication, induction, and inhalant agents; intraoperative analgesics and antimicrobials; and anesthesia time (defined as the interval from induction of anesthesia to extubation). Surgical details included whether the VBO was performed as a unilateral, staged bilateral, or single-stage bilateral procedure; surgical time (defined as the interval from initiation of the incision to completion of closure of the incision); and surgical technique (intramedullary pin and rongeurs, osteotome and rongeurs, or pneumatic burr). For cats treated with staged bilateral VBO, surgical time was defined as the accumulative time to perform both unilateral VBOs. Postoperative management details included drain use and duration as well as analgesic and antimicrobial administration.

从病历中检索数据，包括患猫特征(年龄、性别和品种)、临床症状、诊断性检查(CBC、血清生化分析、口咽部检查、放射摄影术、耳镜检查、内镜检查、CT和MRI)和注意到的异常、麻醉细节、手术操作细节、术中诊断性检查(组织学检查和细菌培养)结果、术后管理细节、并发症和结果。麻醉细节包括术前用药、诱导和吸入剂;术中镇痛药和抗微生物药物;麻醉时间(定义为麻醉诱导至拔管的间隔时间)。手术细节包括:VBO是单侧、分期双侧还是单期双侧手术;手术时间(定义为从开始切口到完成缝合切口的间隔时间);外科技术(髓内针和咬骨钳，凿骨刀和咬骨钳，或气压钻)。对于分期双侧VBO，手术时间定义为完成双侧VBO的累计时间。术后管理细节包括引流管的使用和持续时间，以及镇痛药和抗菌药物的使用。

 

Complications were classified as anesthetic, intraoperative (surgical), and postoperative, with postoperative complications further classified as immediate (＜ 24 hours), short term (1 to 14 days), long term (＞ 14 days), or permanent. Permanent complications were defined as complications present at the time of patient death or loss to follow-up or at the end of the study period. Anesthetic complications were classified as hypotension, hypovolemia, cardiac arrest, bradycardia, arrhythmia, or hypothermia. For this purpose, hypotension was defined as a mean arterial blood pressure ＜ 60 mm Hg, systolic arterial pressure ＜ 90 mm Hg, or both. Postoperative complications were classified as respiratory related, neurologic (Horner syndrome, head tilt, or facial nerve paralysis), incisional (including surgical site infections), and otic. Respiratory complications were classified as mild (eg, stertor or nasal congestion without respiratory distress) or severe (eg, respiratory distress with or without cyanosis).

并发症分为麻醉并发症、术中(手术)并发症和术后并发症，术后并发症进一步分为即刻(＜24小时)、短期(1 - 14天)、长期(＞14天)，或永久性。永久性并发症定义为患猫死亡、失访或研究结束时出现的并发症。麻醉并发症分为低血压、低血容量、心脏停搏、心动过缓、心律失常或低体温。为此，低血压被定义为平均动脉血压和＜60mmHg，收缩压和＜90 mmHg，或两者兼有。术后并发症分为呼吸相关、神经系统并发症(霍纳综合征、头倾斜或面神经麻痹)、切口并发症(包括手术部位感染)和耳道并发症。呼吸系统并发症分为轻度(如鼾声或鼻塞，无呼吸窘迫)和重度(如呼吸窘迫伴或不伴发绀)。

 

Measured outcomes included local recurrence, time to local recurrence, and survival time. Local recurrence was defined as a recurrence or progression of clinical signs following VBO ipsilateral to the side of the original disease. Death was considered surgery related if it occurred during surgery or postoperative hospitalization and disease related if death occurred as a result of the underlying disease.

测量结果包括局部复发、到局部复发的时间和生存时间。局部复发被定义为VBO在原发疾病的同侧复发或临床症状进一步发展。如果死亡发生在手术或术后住院期间，则被认为与手术有关，如果死亡是由潜在疾病引起的，则被认为与疾病有关。

 

Statistical analysis

统计学分析

Statistical analyses were performed with the aid of statistical software. Continuous variables were evaluated for normality of distribution by creation of histograms and use of skewness, kurtosis, and Shapiro-Wilk tests. Normally distributed data are reported as mean and SD and nonnormally distributed data as median (range). Categorical data are reported as frequencies and percentages.

利用统计软件进行统计分析。通过创建直方图和使用偏度、峰度和夏皮罗-威尔克检验来评估连续变量分布的正态性。正态分布的数据报告为均值和标准差，非正态分布的数据报告为中位数(范围)。分类数据以频率和百分比报告。

 

Associations between the presence of specific preoperative abnormalities (ie, middle ear mass, inner ear abnormalities, middle ear abnormalities, external ear abnormalities, bulla changes, CNS extension, rhinitis, and nasopharyngeal mass) and histopathologic diagnoses were evaluated with the Fisher exact test. Differences in median anesthesia and surgery times between unilateral and bilateral VBO procedures were assessed by use of the Mood median test. Associations with disease recurrence following surgery for the histopathologic diagnoses of inflammatory polyps and malignant neoplasia were assessed with the Fisher exact test.

采用Fisher精确检验评估术前特殊异常(即中耳肿块、内耳异常、中耳异常、外耳异常、鼓泡改变、中枢神经系统延伸、鼻炎和鼻咽部肿块)与组织病理学诊断之间的关系。采用心境中位数检验评估单侧和双侧VBO手术中位麻醉和手术时间的差异。采用Fisher精确检验评估炎性息肉和恶性肿瘤的组织病理学诊断与术后疾病复发的相关性。

 

The Kaplan-Meier method was used to calculate the median duration of neurologic conditions as well as the median value and 95% CI for the time to local recurrence and overall survival time for all cats and cats with benign and malignant tumors. The log-rank test was used to test the difference between survival distributions. In addition, the overall 1- and 2-year survival rates were calculated.

使用Kaplan-Meier方法计算所有猫和良恶性肿瘤猫的神经系统疾病的中位持续时间以及局部复发时间和总生存时间的中位值和95% CI。采用log-rank检验检验生存分布之间的差异。此外，计算总1年和2年生存率。

 

Univariate logistic regression analysis was performed to test for associations with respiratory complications, severe respiratory complications, surgeryrelated death, and disease-related death for the following variables: preoperative upper respiratory tract signs, anesthesia time, premedication with buprenorphine or butorphanol, premedication with an opioid, preoxygenation, propofol induction, isoflurane anesthesia, surgical time, type of VBO procedure, and histopathologic diagnosis of inflammatory polyps, infectious disease, benign tumor, or malignant tumor. A multivariate logistic regression model was constructed by use of a stepwise procedure to determine whether associations existed between type of VBO procedure and development of respiratory complications, severe respiratory complications, and disease-related death. Variables were included in the multivariate analysis if they had a value of P ＜ 0.20 on univariate analysis and retained if they had a value of P ≤ 0.05 after controlling for other variables. The Hosmer-Lemeshow goodnessof-fit test was performed to evaluate the final selected model, and ORs were calculated with 95% Wald CIs for each included variable. Values of P ＜ 0.05 were considered significant for all analyses.

单变量logistic回归分析用于检验以下变量与呼吸系统并发症、严重呼吸系统并发症、手术相关死亡和疾病相关死亡的关联:术前上呼吸道症状、麻醉时间、术前使用丁丙诺啡或布托啡诺、术前使用阿片类药物、预氧合、丙泊酚诱导、异氟醚麻醉、手术时间、VBO手术类型、炎性息肉、感染性疾病、良性肿瘤或恶性肿瘤的组织病理学诊断。采用多因素logistic逐步回归模型分析VBO类型与呼吸系统并发症、严重呼吸系统并发症及疾病相关死亡的关系。如果变量具有P值，则将其纳入多变量分析;在单变量分析中为0.20，在控制其他变量后，如果它们的值P≤0.05，则保留。采用Hosmer-Lemeshow拟合优度检验对最终选择的模型进行评估，并计算各纳入变量的or值(95% Wald ci)。P＜0.05被认为是所有分析的显著性。

 

Results

结果

Signalment

特征

A total of 282 cats (141 castrated males, 93 spayed females, 24 sexually intact males, and 24 sexually intact females) met the criteria for inclusion in the study. Most cats were classified as mixed breed, including domestic shorthair (n = 180), domestic longhair (20), and domestic medium hair (9). The remaining 73 cats were classified as Maine Coon (n = 29), Russian Blue (5), Ragdoll (4), Siamese (4), British Shorthair (3), Tonkinese (3), and Abyssinian, Bengal, Birman, Burmese, Chartreux, Cornish Rex, Devon Rex, Egyptian Mau, Himalayan, Japanese Bobtail, Norwegian Forest Cat, Ocicat, Oriental Shorthair, Persian, Snowshoe, Somali, Sphinx, and Turkish Angora (≤ 2 each). Age ranged from 0.2 to 17.0 years (median, 3.4 years), and body weight ranged from 2.3 to 8.0 kg (5.1 to 17.6 lb; median, 4.1 kg [9.0 lb]).

共282只猫(已去势雄猫141只，已绝育雌猫93只，未去势雄猫24只，未绝育雌猫24只)符合研究纳入标准。大多数猫被归为混合品种，包括家养短毛猫(180只)、家养长毛猫(20只)和家养中毛猫(9只)。其余73只猫分别为缅因猫(29只)、俄罗斯蓝猫(5只)、布偶猫(4只)、暹罗猫(4只)、英国短毛猫(3只)、东奇尼猫(3只)，以及阿比西尼亚、孟加拉、伯曼、缅甸、夏特尔猫、康沃尔卷毛猫、德文卷毛猫、埃及猫、喜马拉雅猫、日本短尾猫、挪威森林猫、奥西猫、东方短毛猫、波斯猫、雪鞋猫、索马利猫、斯芬克斯猫、土耳其安哥拉猫(各≤2只)。年龄范围为0.2-17.0岁(中位数，3.4岁)，体重范围为2.3-8.0 kg (5.1-17.6 lb;中位体重为4.1 kg [9.0 lb])。

 

Clinical signs

临床症状

The most common primary clinical signs at initial evaluation were head tilt (n = 101 [35.8%]) and upper respiratory signs (92 [32.6%]), the latter of which included stertor (64 [22.7%]), dyspnea (26 [9.2%]), cough (18 [6.4%]), stridor (10 [3.5%]), and snoring (3 [1.1%]). Other signs included sneezing (41 [14.5%]) and serous, purulent, or mucoid nasal discharge (39 [13.8%]). Ninety-one (32.3%) cats had otitis media, which was unilateral in 63 cats (right-sided in 34 cats and left-sided in 29 cats) and bilateral in 28 cats. Neurologic signs included Horner syndrome (n = 40 [14.2%]); horizontal, positional, or rotary nystagmus (31 [11.0%]); dysphagia (12 [4.3%]); and dysphonia (8 [2.8%]).

初诊时最常见的临床症状为头倾斜(101例，35.8%)和上呼吸道症状(92例，32.6%)，后者包括鼾声(64例，22.7%)、呼吸困难(26例，9.2%)、咳嗽(18例，6.4%)、喘鸣(10例，3.5%)和打鼾(3例，1.1%)。其他症状包括打喷嚏(41例[14.5%])和鼻分泌物为浆液、脓性或黏液(39例[13.8%])。91只猫(32.3%)有中耳炎，其中63只猫为单侧中耳炎(右侧34只、左侧29只)，28只猫为双侧中耳炎。神经系统症状包括霍纳综合征40例(14.2%);水平、位置或旋转性眼震31例(11.0%);吞咽障碍12例(4.3%);发声困难8例(2.8%)。

 

Preoperative findings

术前检查

A preoperative CBC and serum biochemical analysis were performed for 199 cats, of which 123 (61.8%) had abnormalities identified. Such abnormalities included hyperglobulinemia (n = 18), leukocytosis (18), anemia (16), neutrophilia (15), hypoalbuminemia (8), hypoproteinemia (4), high liver enzyme activities (17), and azotemia (7). An oropharyngeal examination was performed for all cats. Various imaging techniques were also used, including CT (n = 180) or MRI (45) of the head, otoscopy (158), radiography of the skull (35), and endoscopy of the oropharynx (12). Eighteen cats were examined via 2 and 1 cat via all 3 of the following imaging modalities: radiography, CT, and MRI. Otitis externa, otitis media, and otitis interna were diagnosed on the basis of the imaging reports from the medical records in 89 of 278 (32.0%), 195 of 233 (83.7%), and 11 of 234 (4.7%) cats, respectively. A middle ear mass was detected in 184 of 281 (65.5%) cats and a nasopharyngeal mass in 46 of 282 (16.3%) cats. Changes in the osseous bulla were identified via radiography, CT, or MRI in 55 of 235 (23.4%) cats. No changes were recorded for the remaining 54 cats that were examined by these modalities. Cats with changes in the osseous bulla identified via CT were more likely to have a malignant tumor than to not have a malignant tumor (P = 0.0497).

对199只猫进行术前全血细胞计数和血清生化分析，发现异常123只(61.8%)。这些异常包括高球蛋白血症(n = 18)、白细胞增多(18)、贫血(16)、中性粒细胞增多(15)、低白蛋白血症(8)、低蛋白血症(4)、肝酶活性升高(17)和氮质血症(7)。对所有猫进行了口咽检查。我们还使用了各种影像检查，包括头部CT (n = 180)或MRI(45)、耳镜(158)、颅骨x线(35)和口咽部内镜(12)。18只猫分别由2只和1只进行以下3种影像学检查:x线摄影、CT和MRI。278只猫中有89只(32.0%)根据影像学诊断为外耳炎，233只猫中有195只(83.7%)根据影像学诊断为中耳炎，234只猫中有11只(4.7%)根据影像学诊断为内耳炎。65.5%(184 / 281)的猫发现中耳肿物，16.3%(46 / 282)的猫发现鼻咽部肿物。235只猫中的55只(23.4%)通过x线摄影、CT或MRI发现了鼓泡骨质的变化。其余54只猫用这些方法检查时没有记录到变化。经CT检查发现鼓泡骨质改变的猫患恶性肿瘤的可能性高于未患恶性肿瘤的猫(P = 0.0497)。

 

Intraoperative details

术中细节

Before surgery, antimicrobials were orally administered to 92 cats and locally administered to 24 cats. Antimicrobials were administered during surgery to 264 cats. Overall, 289 separate VBO procedures were performed. Unilateral VBO was performed in 211 of 282 (74.8%) cats (right-sided in 115 cats and left-sided in 96 cats), staged bilateral VBO was performed in 7 (2.5%) cats, and single-stage bilateral VBO was performed in 64 (22.7%) cats. Median anesthesia times were 130 minutes (range, 45 to 360 minutes) for unilateral VBO, 100 minutes (range, 60 to 180 minutes) for staged bilateral VBO, and 135 minutes (range, 45 to 360 minutes) for single-stage bilateral VBO (n = 239 cats in total). No significant difference in anesthesia times was identified between unilateral or staged bilateral VBO and single-stage VBO.

术前92只猫口服抗生素，24只猫外用抗菌药物。264只猫在手术过程中使用了抗生素。共实施289例VBO。282只猫中211只(74.8%)行单侧VBO(右侧115只、左侧96只)，7只(2.5%)行分期双侧VBO, 64只(22.7%)行单期双侧VBO。共239只猫，单侧VBO中位麻醉时间为130 min (45-360 min)，分期双侧VBO中位麻醉时间为100 min (60-180 min)，单期双侧VBO中位麻醉时间为135 min (45-360 min)。单侧或分期双侧VBO的麻醉时间与单期VBO比较差异无统计学意义。

 

The VBO (n = 289) was performed with an intramedullary pin and rongeurs (240 [83.0%]), pneumatic burr (33 [11.4%]), or osteotome and rongeurs (17 [5.9%]). One VBO was performed with both an osteotome and pneumatic burr. All 46 cats with a nasopharyngeal polyp were treated with traction avulsion of the polyp through the oral cavity or ear canal followed by VBO, including 1 cat treated with staged bilateral VBO and 9 cats treated with single-stage bilateral VBO. Median surgical times were 62 minutes (range, 20 to 240 minutes) for unilateral VBO, 41 minutes (range, 20 to 120 minutes) for staged bilateral VBO (representing a median time for each unilateral surgery), and 82 minutes (range, 30 to 240 minutes) for single-stage bilateral VBO (n = 239 cats in total). Surgical time differed significantly (P ＜ 0.001) between unilateral or staged bilateral VBO and singlestage bilateral VBO. The median time between surgeries for cats treated with staged bilateral VBO was 36 days (range, 28 to 1,477 days).

VBO (n = 289)采用髓内针和咬骨钳(240例[83.0%])、气压钻(33例[11.4%])或凿骨刀和咬骨钳(17例[5.9%])进行。1例VBO患猫同时使用凿骨刀和气压钻。46只猫鼻咽息肉均采用经口腔或耳道牵引撕脱后VBO治疗，其中1只猫采用分期双侧VBO治疗，9只猫采用单期双侧VBO治疗。单侧VBO的中位手术时间为62 min (20 ~ 240 min)，分期双侧VBO的中位手术时间为41 min (20 ~ 120 min)，单期双侧VBO的中位手术时间为82 min (30 ~ 240 min)(共239只猫)。手术时间差异有统计学意义(P＜0.001)在单侧或分期双侧VBO与单期双侧VBO之间的差异有统计学意义。分期双侧VBO治疗猫的手术间隔时间中位数为36天(范围，28 ~ 1477天)。

 

Intraoperative diagnostic findings

术中诊断结果

Histologic evaluation of biopsy specimens and bacterial culture of middle ear contents were performed for 214 and 230 cats, respectively. Histopathologic diagnoses for the 214 tested cats included inflammatory polyp (n = 150 [70.1%]), inflammation or otitis media (46 [21.5%]), malignant tumor (13 [6.1%]; including squamous cell carcinoma [5], ceruminous gland adenocarcinoma [3], lymphoma [3], osteosarcoma [1], and anaplastic carcinoma [1]), and benign tumor (5 [42.8%]; including ceruminous gland adenoma [2], cholesteatoma [2], and papillary adenoma [1]). The median ages of cats with an inflammatory polyp, otitis media, malignant neoplasia, and benign neoplasia were 2.0, 5.5, 10.0, and 12.0 years, respectively. Cats with an inflammatory polyp were significantly (P ＜ 0.001) younger than cats with other middle ear diseases.

对214只猫和230只猫分别进行了活检标本的组织学评估和中耳内容物的细菌培养。214只猫的组织病理学诊断包括炎性息肉(n = 150[70.1%])、炎症或中耳炎(46[21.5%])、恶性肿瘤(13 [6.1%];包括鳞状细胞癌[5]、耵聍腺癌[3]、淋巴瘤[3]、骨肉瘤[1]和未分化癌[1])和良性肿瘤(5例[42.8%];包括耵聍腺瘤[2]、胆脂瘤[2]和乳头状腺瘤[1])。患炎性息肉、中耳炎、恶性肿瘤和良性肿瘤的猫的中位年龄分别为2.0、5.5、10.0和12.0岁。有炎性息肉的猫显著(P＜0.001)比患有其他中耳疾病的猫年龄小。

 

No bacterial growth was reported for 150 of the 230 (65.2%) tested cats, and growth of the following bacteria was obtained for the remaining 80 cats: Staphylococcus spp (20 [25.0%]), Pasteurella spp (18 [22.5%]), Streptococcus spp (15 [18.8%]), multidrugresistant bacteria (11 [13.8%]; including methicillinresistant Staphylococcus aureus [3], Pseudomonas spp [2], Bordetella spp [2], Corynebacterium spp [1], Streptococcus spp [1], Escherichia coli [1], and Corynebacterium spp and Pasteurella spp [1]), Pseudomonas spp (7 [8.8%]), Escherichia coli (6 [7.5%]), Bordetella spp (5 [6.2%]), Corynebacterium spp (3 [3.8%]), Enterococcus spp (3 [3.8%]), nonfermentative gram-negative bacilli (2 [2.5%]), and Mycoplasma spp, Enterobacteriaceae spp, Proteus mirabilis, and gram-positive anaerobe (1 [1.2%] each).

在230只接受检测的猫中，有150只(65.2%)猫没有细菌生长，其余80只猫有以下细菌生长:葡萄球菌属(20只[25.0%])、巴斯德菌属(18只[22.5%])、链球菌属(15只[18.8%])、多重耐药菌(11只[13.8%];包括耐甲氧西林金黄色葡萄球菌[3]、假单胞菌[2]、博代氏杆菌[2]、棒状杆菌[1]、链球菌[1]、大肠杆菌[1]、棒状杆菌和巴斯德氏菌[1])、假单胞菌(7株[8.8%])、大肠埃希菌(6株[7.5%])、博代氏杆菌(5株[6.2%])、棒状杆菌(3株[3.8%])、肠球菌(3株[3.8%])、非发酵革兰阴性杆菌(2株[2.5%])以及支原体、肠杆菌科、奇异变形杆菌。革兰阳性厌氧菌各1株(1.2%)。

 

Postoperative management

术后管理

A drain from the surgical site was placed following 83 of the 289 (28.7%) VBO procedures. Median duration of drain placement was 2.0 days (range, 0.1 to 10.0 days). Antimicrobials were administered to 242 cats in the postoperative period. Postoperative analgesia was recorded for 271 of the 289 (93.8%) procedures and included opioids (n = 218 cats; including buprenorphine [161], fentanyl patch [40], and tramadol [17]). Nonsteroidal anti-inflammatory drugs were administered to 98 cats, and corticosteroid drugs were administered to 31 cats. Gabapentin was used for 3 cats.

289例VBO手术中有83例(28.7%)手术部位引流。引流管放置的中位持续时间为2.0天(范围为0.1至10.0天)。术后对242只猫给予抗生素治疗。289例手术中有271例(93.8%)记录了术后镇痛，包括阿片类药物(n = 218只猫;包括丁丙诺啡[161]、芬太尼贴片[40]、曲马多[17])。98只猫服用了非甾体抗炎药，31只猫服用了皮质类固醇药物。加巴喷丁用于3只猫。

 

Complications

并发症

Anesthetic complications were recorded for 56 of the 289 (19.4%) VBO procedures and included hypotension (n = 39 [13.5%] procedures), bradycardia (19 [6.6%]), hypovolemia (5 [1.7%]), arrhythmia (3 [1.0%]), hypothermia (3 [1.0%]), and cardiac arrest (1 [0.3%]). No deaths occurred intraoperatively or as a result of anesthetic-related complications. Intraoperative surgical complications were recorded for 12 (4.2%) procedures and included hemorrhage (6 [2.1%]), anatomic problems (5 [1.7%]), and technical problems (1 [0.3%]). Anatomic complications included observation of a mass in the external ear canal following VBO (n = 3), observation of a mass in the middle ear attached to the malleus (1), and rupture of the dorsal wall of the tympanic bulla. No procedures were converted from a VBO to a TECA-LBO. The technical complication involved loss of normal anatomic landmarks owing to thickening of the bulla. The VBO was abandoned in this situation, and a biopsy specimen was collected from the middle ear mass following myringotomy. Histopathologic findings were consistent with an inflammatory polyp.

289例VBO中有56例(19.4%)记录到麻醉并发症，包括低血压(39例[13.5%])、心动过缓(19例[6.6%])、低血容量(5例[1.7%])、心律失常(3例[1.0%])、低体温(3例[1.0%])和心脏停搏(1例[0.3%])。无术中或麻醉相关并发症导致的死亡。12例(4.2%)术中出现手术并发症，包括出血6例(2.1%)、解剖问题5例(1.7%)和技术问题1例(0.3%)。解剖并发症包括VBO后外耳道肿物3例，中耳肿物附着于锤骨1例，鼓泡背侧壁破裂。无一例患猫从VBO转为TECA-LBO。技术并发症包括由于鼓泡增厚而失去正常解剖标志。在这种情况下，放弃VBO，并从鼓膜切开后的中耳肿物中采集活检标本。组织病理学检查结果符合炎性息肉。

 

Immediate (＜ 24 hours), short-term (1 to 14 days), and long-term (＞ 14 days) complications following surgery were summarized (Table 1). Overall, respiratory complications were reported for 18 (9%), 2 (29%), and 30 (47%) cats undergoing unilateral, staged bilateral, and single-stage bilateral VBO, respectively (Table 2). Respiratory signs were classified as mild (n = 5) or severe (34) and included respiratory distress (16), airway occlusion or swelling (11), apnea (9), and aspiration pneumonia (3). Eleven of the 34 (32%) cats with severe respiratory complications developed cardiac arrest, died, or were euthanized within 5 days after surgery: 2 cats within the first 12 hours after surgery, 5 between 12 and 24 hours after surgery, 2 between 24 and 48 hours after surgery, 1 at 3 days after surgery, and 1 at 5 days after surgery. Of these 11 cats, 9 had been treated with single-stage bilateral VBO and 2 with unilateral VBO. Tracheostomy was performed in 2 of these cats, both of which failed to improve and were euthanized owing to poor mentation and anticipated poor prognosis.

总结了手术后立即(＜ 24小时)、短期(1至14天)和长期(＞ 14天)并发症(表1)。总体而言，分别有18只(9%)、2只(29%)和30只(47%)猫发生了单侧、分阶段双侧和单期双侧VBO(表2)。呼吸症状分为轻度(n = 5)和重度(34)，包括呼吸窘迫(16)、气道阻塞或肿胀(11)、呼吸暂停(9)、34只出现严重呼吸系统并发症的猫中，有11只(32%)在术后5 d内发生心脏骤停、死亡或安乐死:2只在术后12 h内，5只在术后12 ~ 24 h, 2只在术后24 ~ 48 h, 1只在术后3 d, 1只在术后5 d。11只猫中，9只为单期双侧VBO, 2只为单期单侧VBO。其中2只猫进行了气管切开术，但没有改善，由于精神状态不佳和预期预后不良而被安乐死。

 

Single-stage bilateral VBO was associated with a significantly (P ＜ 0.001) higher odds of any respiratory complication (OR, 16.4; 95% CI, 5.9 to 45.2) and severe respiratory complications (OR, 12.9; 95% CI, 4.5 to 36.4), compared with unilateral or staged bilateral VBO, even after controlling for the presence of preoperative respiratory signs and a histopathologic diagnosis of inflammatory polyp on multivariate analysis (Tables 3 and 4). No significant difference was detected in the odds of respiratory complications for unilateral or single-stage bilateral VBO versus bilateral staged VBO (OR, 0.8; 95% CI, 0.2 to 3.6). No significant (P = 0.57) difference was found between the type of surgical technique used (intramedullary pin, osteotome, or pneumatic burr) and the development of respiratory complications (OR, 1.3; 95% CI, 0.5 to 3.8).

单期双侧VBO与显著性(P＜0.001)的任何呼吸系统并发症的发生概率较高(OR, 16.4;95% CI, 5.9 ~ 45.2)和严重呼吸系统并发症(OR, 12.9;95% CI, 4.5 ~ 36.4)，即使在多变量分析中控制了术前呼吸系统症状的存在和炎性息肉的组织病理学诊断(表3和4)。与双侧分期VBO相比，单侧或单期双侧VBO的呼吸系统并发症的概率无显著差异(or, 0.8;95% CI, 0.2 ~ 3.6)。使用的手术技术类型(髓内针、凿骨刀或气压钻)和呼吸系统并发症的发生(or, 1.3;95% CI, 0.5 ~ 3.8)。

 

Numbers of cats with transient and permanent Horner syndrome , head tilt, and facial nerve paralysis were summarized (Table 5). Cats with Horner syndrome, head tilt, or facial nerve paralysis had 2.6 times (95% CI of the OR, 1.3 to 5.5; P = 0.01), 3.3 times (95% CI of the OR, 1.2 to 9.1; P = 0.02), and 5.6 times (95% CI of the OR, 1.3 to 25.3; P = 0.02) the odds of having these respective neurologic conditions permanently, compared with cats that had no such preexisting signs. The overall median duration of these signs and the median time to their resolution were summarized (Table 6). The duration of these signs was longer for cats that had them before surgery versus those that developed them after surgery.

我们总结了暂时性和永久性霍纳综合征、头部倾斜和面神经麻痹猫的数量(表5)。患有霍纳综合征、头部倾斜和面神经麻痹的猫的数量是猫的2.6倍(or的95% CI, 1.3 ~ 5.5;P = 0.01)、3.3倍(OR的95% CI, 1.2 ~ 9.1;P = 0.02)和5.6倍(OR的95% CI, 1.3 ~ 25.3;P = 0.02)与之前没有这些症状的猫相比，永久性患这些神经系统疾病的比例更大。我们总结了这些症状的总体中位持续时间以及症状缓解的中位时间(表6)。与术后出现症状的猫相比，术前出现症状的猫出现这些症状的持续时间更长。

 

Outcome

结果

By the end of the study follow-up period, 201 cats remained alive, 28 were lost to follow up, and 37 had died or been euthanized for reasons related to the underlying otic disease. Median duration of follow-up for the cats lost to follow-up was 3,274 days (range, 2,684 to 3,883 days). Local disease recurrence was noted following 18 of the 289 (6.2%) VBO procedures. Histopathologic diagnosis was significantly associated with recurrence. The local recurrence rate was 5% (4/88) for inflammatory polyps and 21% (10/48) for benign and malignant tumors (P = 0.006). Malignant tumors were more likely to recur (44% [4/9]) than benign tumors (15% [6/39]; P = 0.007). Median time to local recurrence for malignant tumors was 638 days and could not be estimated (ie, was not reached) for inflammatory polyps.

到研究随访期结束时，201只猫仍然存活，28只失访，37只猫死亡或因潜在的耳道疾病而实施安乐死。失访猫的中位随访时间为3,274天(范围，2,684 ~ 3,883天)。289例患猫中，18例(6.2%)出现局部复发。组织病理学诊断与复发显著相关。炎性息肉局部复发率为5%(4/88)，良恶性肿瘤局部复发率为21%(10/48)，差异有统计学意义(P = 0.006)。恶性肿瘤的复发率(44%[4/9])高于良性肿瘤(15% [6/39];P = 0.007)。恶性肿瘤的局部复发中位时间为638天，而炎性息肉的局部复发无法估计(即未达到)。

 

Median survival times and overall uncensored 1- and 2-year survival rates for cats with inflammatory polyps, benign tumors, and malignant tumors were summarized (Table 7). The median survival time for cats with malignant tumors was significantly (P ＜ 0.001) shorter than for cats with nonmalignant conditions. Disease-related deaths were reported for 37 of the 282 (13.1%) cats, including 21 (10.0%) cats treated with unilateral VBO and 16 (25.0%) cats treated with single-stage bilateral VBO. Surgery-related deaths were reported for 12 (4.3%) cats overall, including 2 (0.9%) cats treated with unilateral VBO and 10 (15.6%) cats treated with single-stage bilateral VBO. Unilateral and staged VBO had no association with disease-related deaths. Although single-stage bilateral VBO was significantly associated with surgery-related death (OR, 11.4; 95% CI, 2.0 to 66.4; P = 0.007) and disease-related death (OR, 2.7; 95% CI, 1.1 to 6.9; P = 0.04) on univariate analyses, the association with disease-related death was not significant on multivariate analysis.

我们总结了患炎性息肉、良性肿瘤和恶性肿瘤的猫的中位生存时间和总体未就诊1年和2年生存率(表7)。患恶性肿瘤的猫的中位生存时间显著(P＜0.001)比非恶性情况下的猫短。282只猫中37只(13.1%)死亡，其中单侧VBO组21只(10.0%)，双侧单期VBO组16只(25.0%)。手术相关死亡12只(4.3%)，其中单侧VBO组2只(0.9%)，双侧VBO组10只(15.6%)。单侧和分期VBO与疾病相关死亡无关。虽然单期双侧VBO与手术相关死亡显著相关(OR, 11.4;95% CI, 2.0 ~ 66.4;P = 0.007)和疾病相关死亡(OR, 2.7;95% CI, 1.1 ~ 6.9;P = 0.04)，而在多因素分析中与疾病相关死亡的相关性无统计学意义。

 

Discussion

讨论

The primary aim of the retrospective study reported here was to evaluate whether cats treated with single-stage bilateral VBO had a worse outcome than cats treated with either unilateral or staged bilateral VBO. Our hypothesis was supported by the finding that cats treated with single-stage bilateral VBO were significantly more likely to have postoperative respiratory complications, surgery-related deaths, and disease-related deaths than were cats treated with the other approaches. Severe respiratory complications were diagnosed in 31% of the 64 cats treated with single-stage bilateral VBO, compared with 14% and 5.7% of cats treated with staged bilateral and unilateral VBO, respectively; and the odds of developing severe respiratory complications for cats treated with single-stage bilateral VBO were 12.9 times those for the other cats. Cats treated with single-stage bilateral VBO were also 11.4 times as likely to have a surgeryrelated death and 2.7 times as likely to have a diseaserelated death as were cats treated with unilateral or staged bilateral VBO.

本回顾性研究的主要目的是评估接受单期双侧VBO治疗的猫的预后是否比接受单侧或分期双侧VBO治疗的猫差。我们的假设得到了以下研究结果的支持:接受单期双侧VBO治疗的猫与接受其他方法治疗的猫相比，术后出现呼吸系统并发症、手术相关死亡和疾病相关死亡的可能性显著较高。同期双侧VBO治疗的64只猫中有31%发生严重呼吸系统并发症，分期双侧和单侧VBO治疗的猫中分别有14%和5.7%发生严重呼吸系统并发症;单期双侧VBO治疗的猫发生严重呼吸系统并发症的几率是其他猫的12.9倍。与接受单侧或分期双侧VBO的猫相比，接受单期双侧VBO的猫发生手术相关死亡的可能性是前者的11.4倍，发生疾病相关死亡的可能性是后者的2.7倍。

 

Factors significantly associated with the development of respiratory complications on univariate analysis included preoperative upper respiratory signs, anesthetic induction with propofol, single-stage bilateral VBO, histopathologic diagnosis of inflammatory polyp, and positive bacterial culture results. A reported adverse effect of propofol is apnea, which usually occurs at the time of anesthetic induction.11 If apnea is improperly addressed, this can result in respiratory-related death; however, propofol appeared to be an unlikely cause of respiratory-related complications in the present study given that such complications were reported in the postoperative period for all patients. Another possibility was that the finding regarding propofol was a type I statistical error, particularly given that it did not retain a significant association with outcome in the multivariate model. It is more likely that the presence of preoperative upper respiratory signs, presence of an inflammatory polyp, and positive bacterial culture results contributed to the respiratory complications of cats in this study, although cause-effect relationships cannot be established from retrospective studies.

单因素分析显示与呼吸系统并发症发生显著相关的因素包括术前上呼吸道症状、丙泊酚麻醉诱导、双侧VBO单期、炎性息肉病理诊断、细菌培养阳性。据报道，丙泊酚的不良反应是呼吸暂停，通常发生在麻醉诱导时11如果呼吸暂停处理不当，可能导致呼吸相关死亡;然而，在本研究中，丙泊酚似乎不太可能是呼吸系统相关并发症的原因，因为所有患猫均在术后报告了此类并发症。另一种可能性是关于丙泊酚的发现是I型统计错误，特别是考虑到在多变量模型中，丙泊酚与结果没有显著关联。本研究中猫的呼吸系统并发症更有可能与术前上呼吸道症状、炎性息肉和细菌培养结果阳性有关，但从回顾性研究中无法确定因果关系。

 

Compared with benign and malignant tumors, inflammatory polyps may be associated with a higher degree of inflammation given their histologic characteristics, may be more likely to have bilateral middle ear involvement, and may be more likely to be associated with some degree of nasopharyngeal involvement, whether it be microscopic or macroscopic in the form of nasopharyngeal polyps. In addition, cats with upper respiratory signs or bacterial otitis media may have substantially more inflammation of the middle ear, Eustachian tube, and pharynx than other cats. Although these factors would also contribute to pharyngeal swelling following unilateral VBO procedures and were likely responsible for the 5.7% to 14% severe respiratory complication rate noted following unilateral and staged bilateral VBO in the present study, the degree of pharyngeal swelling following single-stage bilateral VBO is more likely to be clinically relevant, compared with that following unilateral procedures. Importantly, single-stage bilateral VBO in the present study remained a significant risk factor for severe postoperative respiratory complications when adjusted for the presence of preoperative respiratory signs and histopathologic diagnosis of inflammatory polyp on multivariate analysis. Other factors that may contribute to postoperative respiratory complications that were not investigated in the present study include the proximity of the osseous bulla to the pharynx, drainage of blood or lavage fluid into the pharynx via the Eustachian tube, and bleeding and inflammation associated with traction avulsion of aural and nasopharyngeal polyps through the oral cavity or ear canal.

相对于良恶性肿瘤，炎性息肉的组织学特征可能与更高的炎症程度相关，可能更容易出现双侧中耳患病，可能更容易出现不同程度的鼻咽患病，无论是镜下还是肉眼可见的鼻咽息肉形式。此外，有上呼吸道症状或细菌性中耳炎的猫可能比其他猫有更多的中耳、咽鼓管和咽部炎症。虽然这些因素也会导致单侧VBO后的咽部肿胀，并且可能是本研究中单侧和分期双侧VBO后5.7%-14%的严重呼吸系统并发症发生率的原因，但与单侧VBO后的咽部肿胀程度相比，单期双侧VBO后的咽部肿胀程度更有临床意义。重要的是，本研究中的单阶段双侧VBO在多因素分析中校正了术前呼吸系统症状和炎性息肉的组织病理学诊断后，仍然是术后严重呼吸系统并发症的显著危险因素。本研究未探讨可能导致术后呼吸系统并发症的其他因素，包括骨鼓泡靠近咽部、血液或灌洗液经咽鼓管引流至咽部，以及耳廓和鼻咽息肉经口腔或耳道牵拉撕脱相关的出血和炎症。

 

Surgical techniques used to perform VBO in the study reported here included use of a pneumatic burr, intramedullary pin and rongeurs, or osteotome and rongeurs. In the authors’ experience, the use of a pneumatic burr has been postulated by some surgeons to cause micromotion and subsequent inflammation of the middle ear, ultimately predisposing patients to respiratory complications;however, no significant difference was found among the 3 aforementioned surgical techniques with respect to rates of postoperative respiratory complications and disease-related deaths. Regardless of the cause of pharyngeal swelling and respiratory complications, we would not recommend single-stage bilateral VBO for cats because of the increased risk of respiratory complications and of surgery- and disease-related deaths as a result of these complications.

在这里报告的研究中，用于实施VBO的手术技术包括使用气压钻、髓内针和咬骨钳，或凿骨刀和咬骨钳。根据作者的经验，一些外科医生认为使用气压钻会引起中耳微动和随后的炎症，最终使患猫容易发生呼吸系统并发症;然而，在术后呼吸系统并发症和疾病相关死亡率方面，上述3种手术技术之间没有显著差异。无论咽部肿胀和呼吸系统并发症的原因是什么，我们都不建议对猫进行单期双侧VBO，因为这些并发症会增加呼吸系统并发症以及手术和疾病相关死亡的风险。

 

The secondary aims of the present study were to determine rates of postoperative complications associated with VBO in cats and outcomes for cats with inflammatory polyps, otitis media, and benign and malignant middle ear tumors. The rate of anesthetic and intraoperative complications was low, with hemorrhage noted as the most common intraoperative complication (2.1%). The overall rates of postoperative and nonresolving complications were higher than previously reported. The overall postoperative complication rate was 81.7%, with 80.0%, 77.7%, and 66.8% of cats having immediate, short-term, and long-term postoperative complications, respectively. The most common postoperative complications were Horner syndrome, head tilt, and facial nerve paralysis.

本研究的次要目的是确定猫VBO术后并发症的发生率，以及患炎性息肉、中耳炎和中耳良恶性肿瘤的猫的预后。麻醉和术中并发症的发生率较低，出血是最常见的术中并发症(2.1%)。术后和未缓解并发症的总发生率高于既往报道。术后总体并发症发生率为81.7%，其中80.0%的猫出现术后即刻并发症，77.7%的猫出现术后短期并发症，66.8%的猫出现术后远期并发症。术后最常见的并发症为霍纳综合征、头倾斜和面神经麻痹。

 

Horner syndrome is a combination of clinical signs (miosis, ptosis, enophthalmos, or prolapsed third eyelid) caused by damage to the sympathetic fibers as they course over the promontory. The high incidence of this complication in cats versus dogs is attributed to the fragility of the feline tympanic plexus during curettage and lavage of the diseased bulla. In the present study, Horner syndrome was present in 13.8% of cats before surgery and developed in 54.3% of cats after surgery. The overall rate of postoperative Horner syndrome (19.4%) was similar to that in previous studies; however, in 1 study, only 10% of cats had permanent Horner syndrome. The most likely explanation for this difference is the higher percentage of cats with Horner syndrome prior to surgery in the present study, given the finding that cats with preoperative Horner syndrome were significantly more likely to have permanent Horner syndrome after surgery. In those situations, damage to the sympathetic fibers of the middle ear was likely caused by the underlying disease process prior to any surgical intervention and therefore VBO may not have reversed this damage. This is supported by the difference in median time to resolution of signs for cats with Horner syndrome before surgery (42 days) versus those without the condition before surgery (24 days). The longer duration of postoperative Horner syndrome in cats with this condition before surgery suggested that the underlying disease process causes chronic changes that take longer to resolve or never resolve.

霍纳综合征是由交感神经纤维在隆突上行走时受损引起的临床症状(瞳孔缩小、上睑下垂、眼球内陷或第三眼睑突出)的组合。猫与犬相比，这种并发症的发生率更高，原因是刮除和灌洗患病的鼓泡时，猫的鼓室神经丛更脆弱。在本研究中，13.8%的猫在手术前有霍纳综合征，54.3%的猫在手术后出现霍纳综合征。术后霍纳综合征总体发生率(19.4%)与既往研究相似;然而，在一项研究中，只有10%的猫患有永久性霍纳综合征。对这一差异最可能的解释是，在本研究中，术前患有霍纳综合征的猫在手术后更有可能患永久性霍纳综合征，因此术前患霍纳综合征的猫在手术前的比例较高。在这些情况下，中耳交感神经纤维的损伤可能是由潜在的疾病过程在任何手术干预之前造成的，因此VBO可能不能逆转这种损伤。术前患霍纳综合征的猫(42天)和术前无霍纳综合征的猫(24天)症状缓解的中位时间的差异支持了这一观点。术前患有这种情况的猫的术后霍纳综合征持续时间较长，提示潜在的疾病过程引起慢性变化，需要更长时间才能缓解或永远不会缓解。

 

A head tilt originates from disruption or trauma to the vestibulocochlear nerve as it courses through the inner ear, which can result from inflammation secondary to the underlying disease process or from trauma at the time of surgery. To the authors’ knowledge, the postoperative development of head tilt has not been investigated previously. During VBO, all abnormal and inflamed tissue is removed and the bulla is lavaged with sterile saline (0.9%) solution. Removal of this tissue may relieve compression of the vestibular nerve, resulting in postoperative clinical improvement in some cases. In 74% of cats in the present study, however, the head tilt was permanent. Cats with (vs without) a preoperative head tilt had 3.3 times the odds of having a permanent head tilt after surgery, suggesting that irreversible damage to this nerve and associated vestibular structures was present prior to surgical intervention. The median time to resolution of a head tilt for cats with transient head tilt was longer for those that had this condition before surgery (454 days) versus after surgery (55 days). This further supported the idea that chronic changes from the underlying disease were affecting the vestibulo-cochlear nerve and that these changes took longer to resolve or in some cases never resolved.

头倾斜的原因是前庭耳蜗神经在通过内耳时受到损伤或创伤，而前庭耳蜗神经损伤可能是由基础疾病过程继发的炎症或手术时的创伤引起。据作者所知，术后头倾斜的发展在以前没有研究过。在VBO过程中，清除所有异常和炎症组织，用无菌生理盐水(0.9%)冲洗鼓泡。切除该组织可解除前庭神经压迫，使部分病例术后临床症状改善。然而，在目前的研究中，74%的猫是永久性的头倾斜。术前有(比无)头部倾斜的猫在手术后发生永久性头部倾斜的概率是3.3倍，这表明该神经和相关前庭结构在手术干预前就存在不可逆的损伤。与手术后(55天)相比，手术前(454天)有这种情况的猫的头倾斜的中位时间较长。这进一步支持以下观点:基础疾病引起的慢性变化正在影响前庭-耳蜗神经，并且这些变化需要较长的时间才能消退，在某些情况下从未消退。

 

The overall prevalence of facial nerve paralysis in the cats of the present study (13.5%) was lower than that identified in cats treated with VBO or TECA-LBO in another study (42.9%),3 which might be expected given the inclusion of cats treated with TECA-LBO in the other study and the anatomic course of the facial nerve in relation to the osseous bulla. Cats with (vs without) facial nerve paralysis before surgery in the study reported here had 5.6 times the odds of having permanent facial nerve paralysis following surgery. Similar to the situation for head tilt, this finding was likely due to irreversible damage to the facial nerve by the underlying disease process prior to any surgical intervention.

本研究中猫的面神经麻痹总体患病率(13.5%)低于另一项研究中接受VBO或TECA-LBO治疗的猫的患病率(42.9%)3，考虑到另一项研究纳入了接受TECA-LBO治疗的猫，以及与鼓泡骨质相关的面神经解剖走行，这可能是意料之中的。在这里报告的研究中，术前有(与无)面神经麻痹的猫在手术后出现永久性面神经麻痹的几率是5.6倍。与头倾斜的情况类似，这一发现可能是由于在任何手术干预之前，潜在的疾病过程对面神经造成了不可逆的损伤。

 

Most cats in the present study had a histopathologic diagnosis of inflammatory polyp or otitis media. The local recurrence rate for cats with inflammatory polyps was 5%, which was similar to the rate in another study3 but higher than the rate in other studies.4–6 This difference was most likely due to the duration of postoperative follow-up. The median follow-up time in the present study was 9.0 years, whereas follow-up times were ≤ 3 years in previous studies; consequently, late-occurring recurrent disease was more likely to be captured in the present study. The outcome for cats with benign tumors was good to excellent, with a local recurrence rate of 8% and a median survival time of 1,244 days. Although the uncensored 1- and 2-year survival rates for cats with benign tumors were 60% and 30%, respectively, most deaths accounted for in these calculations were unrelated to the tumor. Cats with malignant tumors had a significantly higher local recurrence rate (44%), similar to previous findings,and a significantly shorter median survival time of 855 days than cats with nonmalignant disease, but a 2-year survival rate of 75%. The high local recurrence rate suggested that adjunctive treatment options, particularly radiation therapy, should be considered following VBO for cats with malignant middle ear disease.

在目前的研究中，大多数猫的组织病理学诊断为炎性息肉或中耳炎。患有炎性息肉的猫的局部复发率为5%，这与另一项研究的比例相似3，但高于其他研究的比例。这一差异很可能是由于术后随访的持续时间。本研究中位随访时间为9.0年，既往研究随访时间≤3年;因此，本研究更有可能捕捉到晚期发生的复发性疾病。猫良性肿瘤局部复发率为8%，中位生存时间为1244天。尽管患有良性肿瘤的猫的未截尾的1年和2年生存率分别为60%和30%，但在这些计算中，大多数死亡与肿瘤无关。患恶性肿瘤的猫有显著较高的局部复发率(44%)，这与之前的研究结果相似。与患非恶性肿瘤的猫相比，患恶性肿瘤的猫的中位生存时间显著较短(855天)，但2年生存率为75%。猫恶性中耳疾病VBO术后局部复发率高，提示VBO术后应考虑辅助治疗，尤其是放射治疗。

 

Limitations of the study reported here were related to its retrospective nature in that imaging interpretation, surgical technique, postoperative management, and follow-up were not uniform. No histologic evaluation was performed for a large proportion (30.0% [75/289]) of procedures, and results may have been different had all cats received a histopathologic diagnosis. A strength of the study was inclusion of data from multiple institutions to allow a large sample size; however, this also allowed greater variability in the methods of treatment and management of cases.

本研究的局限性在于其回顾性，影像学解释、手术技术、术后处理和随访均不统一。很大比例(30.0%[75/289])的手术没有进行组织学评估，如果所有猫都接受了组织病理学诊断，结果可能会有所不同。该研究的优势在于纳入了来自多个机构的数据，以允许较大的样本量;然而，这也使得病例的治疗和管理方法具有更大的可变性。

 

Regardless of any limitations, the present study revealed that cats treated with single-stage bilateral VBO had significantly higher risks of respiratory complications and surgery- and disease-related death than cats treated with unilateral VBO or staged bilateral VBO. On the basis of these findings, we recommend that cats with bilateral middle ear disease be treated with staged bilateral VBO rather than single-stage bilateral VBO. Cats that already had Horner syndrome, head tilt, and facial nerve paralysis were more likely to have these conditions permanently after VBO than were cats without these conditions before surgery. A thorough preoperative physical and cranial nerve examination should therefore be performed for cats with middle ear disease to identify preexisting neurologic conditions, if present, and inform owners of the risk of postoperative complications accordingly.

无论有什么局限性，目前的研究表明，与单侧VBO或分期双侧VBO治疗的猫相比，单期双侧VBO治疗的猫有显著更高的呼吸系统并发症和手术和疾病相关死亡的风险。基于这些发现，我们建议对双侧中耳疾病的猫进行分期双侧VBO，而不是单期双侧VBO。已经患有霍纳综合征、头部倾斜和面神经麻痹的猫在VBO后比在手术前没有这些情况的猫更有可能永久性地患这些疾病。因此，对患有中耳疾病的猫应进行全面的术前体格检查和颅神经检查，以识别先前存在的神经系统疾病，如果存在的话，并告知主人术后并发症的风险。

 

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