鼓膜切开术的时机和方法-临床实践指南(1)

王帆

When and how to do a myringotomy – a practical guide

鼓膜切开术的时机和方法-临床实践指南

作者：Lynette Cole and Tim Nuttall

翻译：王帆

A myringotomy is a surgical incision made in the tympanic membrane (TM). This gives access to the middle ear for sampling, flushing and instilling topical therapy. It should be considered whenever the TM is intact and there is clinical evidence of otitis media, abnormal TMs and/or abnormal diagnostic imaging. Samples should be collected for cytological investigation and culture, and then the external ear should be cleaned and dried (if required). Myringotomies should be performed under general anaesthesia and, wherever possible, using a video otoscope; the enhanced view and instrument ports facilitate the technique and reduce the risk of complications. The myringotomy incision should be made in the caudoventral quadrant of the TM using an appropriately sized urinary catheter to collect samples and flush the middle ear cavity. A thorough understanding of the anatomy, technique and potential ototoxicity of topical therapy is needed to minimize the risk of neurological and other complications. The TM usually heals within 35 days if kept free of infection.

摘要–鼓膜切开术是在鼓膜(TM)上做的手术切口。这手术可以进入中耳进行采样、冲洗和外部治疗。当TM完整且有中耳炎、TM异常和/或影像检查诊断为异常时, 应考虑进行鼓膜切开术。应采集样本进行细胞学检查和培养, 然后 (如需要) 清洁外耳并使之干燥。鼓膜切开术应在全身麻醉下进行, 并在可能的情况下使用视频耳镜进行操作，更清晰的视野和器械端口有助于该技术, 并降低并发症的风险。应使用合适尺寸的导管在TM尾腹侧象限做鼓膜切开术切口, 采集样本并冲洗中耳腔。需要全面了解解剖结构、操作技术和外部治疗的潜在耳毒性,以将神经和其他并发症的风险降至最低。如果清除感染,TM通常在35天内愈合。

Introduction

介绍

Otitis media is common and potentially underdiagnosed. Infectious otitis media occurs in 50–82% of dogs with chronic recurrent otitis externa, particularly where there is horizontal ear canal stenosis and/or infection with Gram-negative bacteria. While the majority of these cases were a progression of an otitis externa through a perforated tympanic membrane (TM), several dogs had an intact tympanum that was thought to have healed over an active otitis media. A sterile form, primary secretory otitis media (PSOM) or otitis media with effusion (OME), was recognized in cavalier King Charles spaniels (CKCS) initially, although it can affect any brachycephalic breed. It may be present in ≤70% of CKCS with or without associated clinical signs. Otitis media in cats most commonly presents as a result of a nasopharyngeal polyp (NPP), from pharyngeal or upper respiratory infection which has extended up through the auditory (Eustachian) tube, following auditory tube dysfunction or obstruction, or associated with a sterile mucositis/sinusitis. Less commonly, otitis media occurs as an extension of otitis externa and it also has been suggested that a potential cause could be haematogenous spread.

中耳炎很常见，且可能会被漏诊。慢性复发性外耳炎患犬中有50-82%患犬发生感染性中耳炎，特别是在水平耳道狭窄和/或革兰氏阴性细菌感染的情况下。虽然这些病例中大多数是由于外耳炎进一步发展导致了鼓膜穿孔，但也有一些患犬的鼓膜完整，被认为是由于存在中耳炎发生了愈合。一种无菌型中耳炎，即原发性分泌性中耳炎(PSOM)或渗出性中耳炎(OME)，虽然最初在查理王猎犬(CKCS)中被发现，但任何短头犬品种都可能患病。≤70%的CKCS中，有或没有相关的临床症状。猫的中耳炎最常见的表现是鼻咽息肉(NPP)，由咽部或上呼吸道感染延伸至耳咽管(咽鼓管)，导致咽鼓管功能障碍或阻塞，或发生无菌性粘膜炎/鼻窦炎。少见外耳炎发展为中耳炎，有人认为血液传播也可能是一个潜在的病因。

The clinical signs of otitis media overlap with otitis externa. This can make the diagnosis challenging. Clinical signs include head shaking, scratching and rubbing the ear, dullness, avoiding head contact (e.g. petting), ear canal exudates, reluctance to eat hard foods, pain on opening the mouth, and odour. In addition, otitis media can lead to otitis interna with signs such as head tilt and deafness. Horner’s syndrome is more common in cats due to the more superficial anatomy of their sympathetic trunk. Peripheral vestibular syndrome (i.e. head tilt, ataxia and/or horizontal nystagmus) and facial nerve deficits can occur in advanced or severe cases and should be treated as an emergency.

中耳炎的临床症状与外耳炎交替出现。这使得诊断具有挑战性。临床症状包括甩头、抓挠和摩擦耳部、反应迟钝、避免头部接触(如抚摸)、耳道分泌物、不愿吃硬食物、张口疼痛和异味。此外，中耳炎可导致内耳炎的症状，如歪头和失聪。猫更常见霍纳氏综合征，因为它们的交感神经干解剖部位更浅。晚期或重症病例可发生外周前庭综合征(即歪头、共济失调和/或眼球水平震颤)和面神经损伤，应作为急诊治疗。

Otoscopic examination may reveal an abnormal TM (Figure 1). Changes include a thickened, opaque, inflamed or grey TM, material behind the TM and a convex pars tensa. It may be possible to see ruptures or tears in the TM, which typically (in the absence of traumatic or iatrogenic damage to the TM) confirms otitis media. However, small tears are almost impossible to see without the magnified image from a high-quality video otoscope. Moreover, some tears may only become visible when they open during ear flushing or other procedures. Even with video otoscopy, stenosis and/or debris in the horizontal ear canal can limit examination of the TM. In the CKCS a bulging pars flaccida obscuring some or all of the pars tensa is diagnostic for PSOM (Figure 1b), although a flat pars flaccida does not rule it out (Figure 2).

检耳镜检查可发现TM异常(图1)。异常改变包括TM增厚、不透明、炎症反应或灰色，TM后面有物质和紧张部凸出。可能会看到TM的破裂或撕裂，这通常表示能确诊中耳炎(在没有外伤或医源性损伤TM时)。但是，如果没有高质量的视频耳镜放大图像，几乎不可能看到小的撕裂伤。此外，有些撕裂只有在冲洗耳道或其他操作时才会打开。即使使用视频耳镜检查，水平耳道内存在狭窄和/或耳垢碎片也会阻碍对TM的检查。在CKCS中，松弛部鼓胀部分或全部遮盖紧张部能诊断是PSOM(图1b)，但是松弛部平坦不能排除诊断(图2)。

Figure 1. Examples of abnormal tympanic membranes (TM) that justify a myringotomy (top = dorsal; bottom = ventral; left = rostral; right = caudal). (a) Material visible in the middle ear behind the TM in a cat with an inflammatory polyp. (b) A severe bulging pars flaccida obscuring the par tensa in a cavalier King Charles spaniel with primary secretory otitis media. (c) A convex and opaque TM bulging into the horizontal ear canal in a dog with infective otitis media. Compare with the normal appearance of the TM in Figure 5.

图1。鼓膜(TM)异常需要进行鼓膜切开术举例(上=背侧;下=腹侧;左=吻侧;右=尾侧)。(a)一只炎性息肉患猫可见TM后方中耳内物质。(b)一只患有原发性分泌性中耳炎的查理王猎犬，松弛部严重肿胀掩盖了紧张部。(c)一只感染性中耳炎患犬的水平耳道凸出和不透明的TM。与图5中正常的TM外观进行对比。

Figure 2. Flat pars flaccida in a cavalier King Charles spaniel with primary secretory otitis media which was diagnosed on a CT scan (top = dorsal; bottom = ventral; left = caudal; right = rostral).

图2。一只经CT影像检查确诊患原发性分泌性中耳炎的查理王猎犬的平坦的松弛部(上=背侧;下=腹侧;左=尾侧;右=吻侧)。

Diagnostic imaging [e.g. computed tomography (CT), magnetic resonance imaging (MRI) or radiographs] of the middle ear is indicated when otitis media is suspected. CT is preferred by the authors, as it is most sensitive and specific for changes to the bony structures of the middle ear. Abnormal findings (including soft-tissue material in the tympanic bullae and changes to the bulla wall) confirm otitis media (Figure 3). However, normal findings (especially with plain radiography, which is less sensitive) do not rule it out.

当怀疑中耳炎时应进行中耳影像诊断检查[如：计算机断层扫描（CT）、磁共振成像（MRI）或x线检查。CT检查是作者的首选，因为它对中耳骨结构的改变最具敏感性和特异性。异常表现(包括：鼓疱内有软组织物质和鼓疱壁改变)表明存在中耳炎(图3)。但是，检查正常不能排除诊断(特别是X片检查，敏感性较低)。

Figure 3. Computed tomography scan of a cat with soft-tissue opacities in both middle ears. Hounsfield unit scale density analysis indicated that there was fluid in the ventromedial compartments (solid arrow) and soft tissue in the dorsolateral compartments (open arrow). Note the complete bony shelf and compare this to the incomplete bony shelf in dogs illustrated in Figures 6 and 7.

图3。一只猫的计算机断层扫描检查，可见双侧中耳内软组织密度影像。亨氏单位测量密度分析显示腹内侧腔有液体(实心箭头)，背外侧腔有软组织(空心箭头)。请完整的鼓室中隔，与图6和图7中所示的犬的不完整隔疱进行对比。

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