鼓膜切开术的时机和方法-临床实践指南(3)

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

Myringotomy procedure

鼓膜切开术过程

Diagnostic imaging should be performed before the ear flush to evaluate the soft tissue and osseous structures of the external and middle ear. For cases of infectious otitis externa, samples should be obtained from the external ear canal for cytological evaluation and, if clinically indicated, microbial culture and antibiotic susceptibility testing (AST) before the ear flush.

在耳部冲洗前，应先进行诊断性影像学检查，以评估外耳和中耳的软组织和骨结构。对于感染性外耳炎病例，应在外耳道采样进行细胞学检查，且如有临床需要，应在耳部冲洗前先进行微生物培养和药敏试验(AST)。

For the external ear flush, the ear canal is soaked for 10 min with a non-ototoxic ceruminolytic ear cleaner (e.g. squalene) if the patency of the TM is unknown. The ear then is flushed with warm sterile 0.9% saline and a bulb syringe to remove large debris and exudate. This is followed by flushing with saline using a handheld or video otoscope (Table 1). Once the ear is clean, the ear cleaner and saline are suctioned out to dry the ear; drying the ear reduces the risk of iatrogenic contamination of the middle during the myringotomy. Once the ear canals are clean and dry, the TM can be visualized, ideally with a video otoscope. It is very difficult to assess the integrity of the TM and perform an accurate myringotomy with a handheld otoscope.

对于外耳道冲洗，如果不清楚耳道的通畅程度，应使用无耳毒性耵聍溶解剂(如角鲨烯)浸泡耳道10分钟。然后用温0.9%无菌生理盐水和洗耳球冲洗耳道，以清除大块耳垢碎片和分泌物。然后使用手持耳镜或视频耳镜进行生理盐水冲洗(表1)。一旦耳道干净，应将洗耳液和生理盐水吸出，使耳道干燥，干燥耳道可以减少鼓膜切开术中医源性污染的风险。一旦耳道清洁且干燥，就可以看到TM，最理想的是使用视频耳镜检查。在手持检耳镜下，很难评估鼓膜的完整性并进行准确的鼓膜切开术。

Table 1. Equipment required for ear flushing and myringotomy using handheld and video otoscopes

表1.使用手持检耳镜和视频耳镜进行耳道冲洗时所需设备

Cleaning the external ear canals (if required) 清洁外耳道（如果需要）

1 Cotton-tipped applicators and glass microscope slides for cytological evaluation 1 细胞学检查所需棉签和玻片 2 Sterile culture swabs and sterile containers 2 无菌培养拭子和无菌容器 3 Cleaning agent, which should be non-ototoxic (i.e. squalene or saline) [size=10.0000pt]3[size=10.0000pt] 无耳毒性清洗液（例如：角鲨烷或盐水） 4 Gauze sponges, towels and/or incontinence pads to soak up fluid and protect the face 4 纱布、毛巾和/或尿垫，吸水且保护面部 5 0.9% irrigation saline, warmed 5 0.9%温的生理盐水 6 Bulb syringes 6 洗耳球 7 Flushing/lift table (e.g. Midmark Canis Major Wet/Dental Treatment Lift table) 7冲洗台/升降台（例如：犬用处理水池/牙科治疗升降台）

Handheld otoscope手持检耳镜

1 Otoscopic cones of the appropriate diameter and length 1合适直径和长度的耳镜锥形头 2 10 or 12 cc/mL syringes 2 10或12毫升注射器 3 8-French polypropylene urinary catheters or red rubber catheters 3 8号法国聚丙烯导尿管或红色橡胶饲管

Myringotomy and middle ear flush with video otoscope (Figure 4) 视频耳镜鼓膜切开术和中耳冲洗

1 Anti-fogging agent (e.g. UltraStop) 1防雾剂（例如：UltraStop） 2 10 or 12 cc/mL syringes 2 10或12毫升注射器 3 5-French polypropylene urinary catheters or red rubber catheters 3 5号法国聚丙烯导尿管或红色橡胶饲管 4 External suction and irrigation device (i.e. Vet Pump 2) OR 10 or 12 cc/mL syringes 4 外部抽吸冲洗装置（例如：Vet Pump 2）或10或12毫升注射器

If the TM is not intact, samples for cytological evaluation and bacterial AST can be collected directly from the middle ear. This is performed by passing a 5 French polypropylene urinary catheter or 5 French red rubber feeding tube attached to a 10 or 12 cc/mL syringe through the instrument port and channel on the video otoscope into the middle ear cavity. It is important to keep the position of the catheter or feeding tube on the ventral floor of the ear canal to avoid damage to the middle ear structures (Figure 8). Samples can be obtained by gentle direct aspiration of fluid from the middle ear cavity. If this is not possible saline can be flushed into the middle ear cavity and aspirated back. The fluid is placed into a sterile container for bacterial culture and AST. A second sample then can be collected for cytological evaluation. The middle ear then is gently flushed repeatedly with approximately 1 mL of saline using the catheter or feeding tube (cut to the appropriate length of 30 cm; the angle of the cut should be 90° and sharp edges should be smoothed to avoid trauma to the ear canal epidermis and middle ear mucosa) attached to a 10 or 12 cc/mL syringe or an external suction and irrigation device. It is essential that all of the mucus, pus, debris and cleaning fluids (including that from initially cleaning the external ear canals) are removed. Finally, any residual saline should be aspirated.

如果TM不完整，可直接从中耳采样进行细胞学检查和细菌AST。使用5号法国聚丙烯导尿管或5号法国红色橡胶饲管连接10或12毫升注射器，通过视频耳镜器械通道进入中耳腔。重要的是要保持导管或饲管在耳道腹侧的位置，避免损伤中耳结构(图8)。可通过从中耳腔直接温柔的吸出液体获得样本。如果这样抽吸不出，可以使用盐水冲入中耳腔并抽抽回。将抽吸液放入无菌容器中进行细菌培养和AST。然后采集第二份样本进行细胞学检查。然后用导管或饲管用约1ml生理盐水反复轻柔冲洗中耳(导管剪至大约30厘米长度;开口剪成90度角，将尖端磨平，以免损伤耳道表皮和中耳黏膜)，连接一个10或12毫升注射器或一个外部抽吸冲洗装置。必须将黏液、脓汁、碎片和洗耳液全部清除(包括最初的外耳道清洗液)。最后，应将生理盐水全部吸出。

Figure 8. Clinician (right) and technician (left) performing a myringotomy and flushing a dog’s right ear using the setup shown in Figure 4. Note the bulging pars flaccida and the caudoventral placement of the catheter in the screen image.

图8。临床医生(右)和助理(左)使用图4所示的装置，在给一只患犬的右耳进行鼓膜切开术和冲洗耳道。在屏幕图像中可看到肿胀的松弛部和尾腹侧的导管。

If the TM is intact, a myringotomy is needed to obtain samples and to flush the middle ear cavity. This can be done with a 5 French polypropylene urinary catheter. In the authors’ opinion, other instruments, such as a myringotomy needle or laser, make too small an incision, and spinal needles and buck curettes do not pass down the port of the otoscope. The catheter is placed through the instrument port and channel on the video otoscope and used to make the incision. This should be made in the caudoventral quadrant of the pars tensa of the TM, keeping the position of the catheter or feeding tube on the ventral floor of the ear canal to avoid damage to the middle ear structures (Figure 8). However, chronic changes due to severe otitis externa and/or conformation in brachycephalic dogs (especially rostral deviation of the proximal ear canal and tympanic bulla in pugs and French bulldogs) can make it difficult to visualize the TM and/or correctly align the catheter. It is possible to perform a ”blind” or ”off-target” myringotomy, by “aiming” the catheter towards the caudoventral quadrant of the pars tensa, yet this increases the risk of complications. Alternatively, the procedure can be abandoned and a surgical approach considered.

如果TM是完整的，则需要进行鼓膜切开术以进行采样并冲洗中耳腔。这可以使用5号法国聚丙烯导尿管完成。作者认为，其他器械，如使用鼓膜穿刺针或激光，切口太小，脊髓穿刺针和刮刀无法通过耳镜操作口。导管可通过视频耳镜上的器械通道进入，进行切开操作。切开部位应在TM的紧张部尾腹象限，保持导管或饲管在耳道腹侧的位置，避免损伤中耳结构(图8)。但是，短头犬(特别是巴哥犬和法国斗牛犬的近端耳道和鼓疱向吻侧偏)由于严重外耳炎和/或结构发生的慢性改变，会使观察TM和/或导管正确对齐变得有难度。可能需要将导管“对准”紧张部的尾腹象限，进行鼓膜切开术的“盲切”或“脱靶切”，但这增加了并发症的风险。可以放弃操作，考虑外科手术方法取代。

Once the myringotomy incision has been made, the catheter or feeding tube is advanced until encountering bone (bulla septum) or solid soft tissue and then backed off slightly to begin flushing and suctioning. Samples then can be obtained for cytological evaluation and AST as described above. Where necessary, the initial myringotomy incision can be slightly enlarged to facilitate retrograde flow of material. Over-vigorous flushing through a small incision without adequate space around the catheter is less efficient and can lead to a build-up of pressure that may damage the TM (e.g. causing an uncontrolled tear) or middle ear structures. The middle ear then is gently flushed and aspirated through the incision with saline using a catheter or feeding tube, as described above (Figures 8 and 9).

一旦做了鼓膜切开术切口，就向前推进导管或饲管，直到触碰到骨质(隔疱)或硬质软组织，然后略微后退，开始冲洗和抽吸。然后可以进行如上所述的采样，进行细胞学检查和AST。必要时，可稍扩大最初的鼓膜切开术切口，以促进物质逆向流出。通过导管周围空间不足的小切口进行大量冲洗效率较低，并可能导致压力积聚，从而可能损伤TM(例如：导致无法控制的撕裂)或中耳结构。然后用导管或饲管通过切口，使用生理盐水对中耳轻柔的冲洗和抽吸，如上所述(图8和9)。

Figure 9. Mucus emerging from a myringotomy incision in the caudoventral quadrant in the left tympanic membrane of a dog with primary secretory otitis media.

图9。一只原发性分泌性中耳炎患犬的左耳鼓膜尾腹象限进行了鼓膜切开术后流出的黏液。

In some CKCS with PSOM the pars flaccida is so large that it completely obscures the pars tensa. To make the myringotomy incision, the catheter can be slipped under the bulging pars flaccida, directed towards the caudoventral quadrant of the pars tensa and with gentle pressure the myringotomy incision is made. However, visualizing the TM can be made easier by initially puncturing and deflating the pars flaccida, even though this results in flush fluid being expelled though the incision in the pars flaccida simultaneously when fluid is flushed through the myringotomy incision.

在一些患有PSOM的CKCS中，松弛部太大，完全遮挡了紧张部。为了做鼓膜切开术切口，导管可滑入松弛部鼓胀的下方，朝向紧张部尾腹侧象限，轻轻施压进行鼓膜切开术。但是，通过最初刺穿松弛部并放气，可以更容易地观察TM，即便这样，当通过鼓膜切开术切口进行冲洗时，松弛部的切口会同时排出冲洗液。

Contamination of the middle ear post-myringotomy can be a concern. In a study of normal canine cadavers, contamination with fluorescein-stained saline from the horizontal canal was noted in 19 of 28 (68%) of the middle ears. There was positive bacterial growth in only one of 11 (9%) of the middle ears with corresponding external ears with positive cultures.However, microbial contamination may have been rare in this study as these were normal ear canals that were first cultured, and then flushed and suctioned before myringotomy. If these ears had been infected, the microbial contamination rate may have been higher. The risk of contamination from a healthy ear canal (e.g. in cases of PSOM without concurrent otitis externa) would appear to below, and clinicians should be aware that the risk of contamination of the middle ear from the external ear canal may be much greater where there is a significant concurrent infectious otitis externa. The ear canals therefore should be cleaned thoroughly to remove any debris and micro-organisms before drying the area. This will reduce the risk of introducing residual saline, debris and/or micro-organisms into the middle ear during the myringotomy.

鼓膜切开术后中耳污染可能是个问题。在一项对健康犬尸体的研究中，观察到28例中有19例(68%)的中耳被水平耳道的荧光染色盐水污染。11例中耳中仅1例(9%)阳性细菌培养，与外耳道的阳性细菌培养一致。但是，在本研究中，微生物污染罕见，因为在鼓膜切开术前，先进行了培养，以及冲洗和抽吸，使耳道正常。如果这些耳道发生感染，微生物污染机率可能会增加。健康耳道的污染风险更低(如：在PSOM病例中没有并发外耳炎),临床医生应该意识到，在并发感染性外耳炎的情况下，来自外耳道的污染风险可能更高。因此，在干燥耳道之前，应彻底清洗耳道，清除所有耳垢碎片和微生物。这将减少在鼓膜切开术中向中耳引入残余盐水、耳垢碎片和/或微生物的风险。

Topical therapy can be instilled directly into the middle ear cavity after cleaning if there is cytological evidence of infection. The choice of medication will depend on the cause of the otitis media and the type of infection; however, ointment- and suspension-based otics should be avoided. Topical therapy may be continued at home, although it is unclear how much medication will penetrate to the middle ear; therefore, a sufficient volume of the topical treatment should be used. As it is likely that medication will penetrate, ototoxicity must be considered when selecting treatment.

如果有细胞学检查证明存在感染，在清洗后可直接将外用药注入中耳腔。药物的选择将取决于中耳炎的病因和感染类型。但是，应避免使用软膏和悬浮液类耳药。回家后要持续使用外用药，但不清楚有多少药物会进入中耳。因此，使用的外部治疗剂量要足够。因为药物可能会渗透，在选择治疗时必须考虑耳毒性。

The normal TM heals in 21 to 35 days,although in cases with complete rupture and/or chronic perforation of the TM healing can take up to 15 weeks. Therefore, if the ear is kept free of infection after the myringotomy procedure, the TM should heal. Nonhealing resulting in a permanent TM defect is a rare complication.

虽然TM正常的愈合时间为21-35天，但是在TM完全破裂和/或慢性穿孔的病例中，愈合时间最长可达15周。因此，如果鼓膜切开术后耳道没有感染，那么TM应该会愈合。不愈合导致永久性TM缺损是一种罕见的并发症。

Conclusions

结论

A myringotomy is indicated whenever there is clinical evidence of otitis media, abnormalities of the TM and/or abnormal findings on diagnostic imaging of the middle ears. Myringotomy and flushing/aspiration of the middle ear are required for cytological evaluation, ASTs, and to remove debris and/or mucus. Good technique is required to avoid neurological deficits and other complications. This relies on a thorough understanding of the TM and middle ear anatomy, accurate positioning and careful procedures. Video otoscopes should be used wherever possible as the enhanced view and instrument ports facilitate the technique and reduce the risk of complications.

临床上有中耳炎、鼓膜异常和/或中耳影像学诊断异常时，应行鼓膜切开术。需要进行鼓膜切开术，以及冲洗/抽吸中耳以进行细胞学检查、AST和清除耳垢碎片和/或黏液。需要良好的操作技术，以避免神经学损伤和其他并发症。这需要对TM和中耳解剖结构的全面了解，准确定位和细致操作。应尽可能使用视频耳镜操作，因为视野更清晰和器械通道便于操作和减少并发症的风险。

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廊坊永鑫罗玄

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廊坊永鑫罗玄

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