本帖最后由 王帆 于 2022-3-26 10:58 编辑
Surgical Removal of Feline Inflammatory Polyps 猫炎性息肉手术去除方法 Daniel A. Degner, DVM, DACVS Oakland Township, Michigan
翻译：王帆
Feline inflammatory polyps, most commonly found in cats younger than 2 years of age, may be evident in the ear canal or nasopharynx. 猫的炎性息肉，最常见于2岁以下的猫，可能位于耳道或鼻咽。
Feline inflammatory polyps are pedunculated benign fibrous masses that are infiltrated with inflammatory cells. Also known as nasopharyngeal, otopharyngeal, or middle ear polyps, these masses are most commonly found in cats younger than 2 years of age. The masses originate within the auditory tube or from the rostral aspect of the dorsolateral compartment of the tympanic bulla (Figure 1). Polyps may extend into the pharynx via the auditory tube, the external ear canal via rupture of the tympanic membrane, or both. 猫炎性息肉是有蒂的良性纤维肿块，炎性细胞浸润。也被称为鼻咽息肉、耳咽息肉或中耳息肉，这些肿块最常见于2岁以下的猫。肿块起源于咽鼓 管内或鼓泡背外侧腔室吻侧(图1)。息肉可通过咽鼓管延伸至咽，或通过鼓膜破裂延伸至外耳道，或两者都有。
1.Ventral view of the skull demonstrating the two possible locations of inflammatory polyps: the external ear canal and nasopharynx. 1：头腹侧图显示炎性息肉的两个可能位置:外耳道和鼻咽。
Clinical signs may include stertor, dyspnea, dysphonia, sneezing, coughing, nasal discharge, dysphagia, head shaking, vestibular signs, Horner syndrome, and purulent or bloody external ear canal discharge. Otoscopic and pharyngeal examination may reveal a mass in the ear canal or nasopharynx, respectively. Nasopharynx examination can be performed with rostral retraction of the soft palate with a spay hook. 临床症状可能包括鼾声、呼吸困难、发音困难、打喷嚏、咳嗽、鼻分泌物、吞咽困难、甩头、前庭症状、霍纳综合征和化脓性或血性外耳道分泌物。耳镜和咽部检查可分别在耳道或鼻咽发现肿块。鼻咽部检查可以用绝育钩将软腭向吻侧牵拉。
Diagnosis & Treatment Approach 诊断和治疗方法 Diagnostic testing for suspected inflammatory polyps includes CBC, serum biochemistry profile, urinalysis, and FeLV and FIV testing. A complete otoscopic evaluation is performed with the patient under general anesthesia. The soft palate should be retracted rostrally to evaluate the left and right auditory tube ostia for a protruding polyp. 疑似炎性息肉的诊断检测包括CBC、血清生化、尿液分析、FeLV和FIV检测。在全身麻醉下对患猫进行完整的耳镜检查。向吻侧牵拉软腭以评估左和右咽鼓管口突出的息肉。
Chest radiography can rule out lower respiratory and metastatic disease (if malignancy is suspected). Skull radiographs —including open-mouth,lateral, lateral oblique (left and right), and ventrodorsal views—are also obtained (Figures 2 and 3). Falsenegative results are common with bulla radiographs. Computer tomography (CT) is sensitive for the detection of middle ear involvement. 胸片检查可排除下呼吸道疾病和转移性疾病(如果怀疑为恶性肿瘤)。也可拍头部x线片，包括开口、侧位、斜侧位(左侧和右侧)和腹背侧位(图2和3)。鼓泡x线片常出现假阴性结果。计算机断层扫描(CT)是一种灵敏的检测中耳是否患病方法。 2.Open-mouth radiograph of a cat with inflammatory polyps. Note the thickened bulla (arrow) compared with the contralateral normal bulla. 2.炎性息肉的猫的口腔x光片。注意与对侧正常鼓泡相比增厚的鼓泡(箭头所指)。 3.The very large soft tissue density (arrows) in the pharyngeal region of this lateral skull radiograph represents a large inflammatory polyp.
3.头侧位x线片咽部区非常大的软组织密度(箭头)表示一个大的炎性息肉。
When auditory polyps are confirmed, traction removal followed by medical therapy is often the first line of treatment. If the polyp recurs, a ventral bulla osteotomy may be performed. Clients should be educated regarding the risks associated with both procedures. 当确诊有耳息肉时，牵拉去除后使用药物治疗往往是治疗首选。如果息肉复发，可施行腹侧鼓泡截骨术。应告知客户这两种方法相关的风险。
Traction removal of nasopharyngeal polyps with medical treatment has a success rate of 89% to 100%, whereas traction removal of polyps extending into the external ear canal with medical therapy has a 50% success rate. The success rate for firsttime surgery with ventral bulla osteotomy is about 98%. 鼻咽息肉牵拉摘除后药物治疗的成功率为89%-100%，而外耳道息肉牵拉摘除后药物治疗成功率为50%。首次腹侧鼓泡截骨术成功率约为98%。
Traction Method of Polyp Removal 牵拉去除息肉 With nasopharyngeal traction, the soft palate is retracted rostrally with a spay hook. The polyp is grasped with curved mosquito or small right angle forceps, and slow, steady traction is applied until the polyp releases. 在鼻咽牵拉下，软腭用绝育钩向吻侧牵拉。用弧形蚊钳或小直角钳钳住息肉，缓慢、稳定地牵拉，直至息肉脱离。
With external ear canal traction, otoscopy is performed to identify polyp location within the ear canal. The scope is removed, curved mosquito or alligator forceps are placed into the ear canal to blindly grasp the polyp, and steady traction is applied until the polyp releases. 在外耳道牵拉的情况下，进行耳镜检查以确定息肉在耳道内的位置。取下镜，将弯曲的蚊钳或鳄鱼钳放入耳道内盲目抓息肉，平稳牵拉直至息肉脱离。
Analgesics are continued for 2 to 4 days after surgery. Oral antibiotics (eg, marbofloxacin) are administered for up to 1 month based on culture and sensitivity testing. If this information is not available, marbofloxacin at 2 to 4 mg/kg q24h PO is prescribed for 1 month. 术后镇痛持续2 - 4天。根据细菌培养和药敏试验，口服抗生素(如马波沙星)持续1个月。如果没有这项检查，则口服马坡沙星2-4mg /kg，每24h一次，疗程为1个月。
Prednisolone 1 to 2 mg/kg/day PO should be administered for 14 days, followed by gradual dosage tapering over 14 days. Alternatively, dexamethasone at 0.25 mg q12h PO for 1 week can be used, then 0.25 mg q24h for 1 week, followed by 0.25 mg q48h for 2 more weeks. 口服泼尼松龙1- 2毫克/公斤/天，持续14天，然后在14天内逐渐减少剂量。或者，可以口服地塞米松0.25 mg，每12h一次，连续1周，然后口服0.25 mg，每24h一次，连续1周，接着口服0.25 mg，每48h一次，连续2周。
In patients that underwent traction removal of a polyp from the external ear canal, a 50:50 mixture of fluocinolone acetonide–dimethyl sulfoxide (Synotic) and injectable enrofloxacin (Baytril, 22.7 mg/mL; bayer-ah.com) can be made as a topical ear medication administered into the affected ear q12h for 1 month. These medications can potentially be ototoxic, although to date this has not been reported as a complication. 在接受外耳道息肉牵拉摘除术的患猫中，使用50:50氟轻松-二甲亚砜(Synotic)和恩诺沙星注射液(拜尔，22.7 mg/mL)可作为耳部外用药，患耳每12h用一次，连续1个月。这些药物可能有耳毒性，但到目前为止还没有并发症报道。
Ventral Bulla Osteotomy 腹侧鼓泡截骨术 Indications 适应症 While traction with adjuvant medical therapy is a reasonable firstline treatment, ventral bulla osteotomy may be preferred for several reasons: 虽然牵拉+药物治疗是一种合理的首选方案，但腹侧鼓泡截骨术可能更受青睐，原因如下: ■ The polyp has recurred following manual traction removal and adjuvant medical therapy. ■ The polyp was incompletely removed, and the remaining portion cannot be removed with forceps via manual traction (Figure 4). ■ The polyp can be seen behind the intact tympanic membrane. ■ The client wants the pet to undergo only one procedure with the best possible success rate. ■ Marked radiographic changes have occurred in the bulla (although some cats will still respond to traction and medical therapy). ■ The polyp extends into the external ear canal (although some cats will still respond to traction and medical therapy). ■经牵拉+药物治疗后息肉复发。
■息肉未完全切除，剩余部分不能通过钳子进行牵拉去除(图4)。
■在完整的鼓膜后面可以看到息肉。
■客户希望宠物只接受一次疗效最佳的手术治疗。
■鼓泡有明显的影像改变(但一些猫仍对牵拉+药物治疗有效)。
■息肉延伸到外耳道(但有些猫仍然会对牵拉息肉+药物治疗有效)
4.This nasopharyngeal polyp has a long thin stalk, which usually indicates that the root of the polyp has been retrieved. 4.鼻咽息肉有一个细长的柄，这通常表明息肉的根已被去除。
Postoperative Care 术后护理 IV fluids should be continued for 24 to 48 hours or until the patient is eating. Analgesia is effectively maintained with transmucosal (oral) buprenorphine. Antibiotic selection should preferentially be based on culture results and sensitivity testing. If these results are not available, a 4-week course of antibiotics (empiric choice) is prescribed. An Elizabethan collar may be needed until external sutures are removed 10 to 14 days after surgery. 静脉输液应持续24至48小时，或直到患猫进食。经粘膜(口服)丁丙诺啡可有效维持镇痛作用。抗生素的选择应优先根据细菌培养和药敏试验结果。如果没有这些结果，则应开一个4周疗程的抗生素(经验性选择)。在手术后10到14天拆除缝线之前，可能需要使用伊丽莎白圈。
Complications 并发症 Learning surgical anatomy can help minimize complications when performing ventral bulla osteotomy. Horner syndrome (Figure 5) is seen in about 80% and 40% of cats undergoing bulla osteotomy and polyp traction removal, respectively. This complication usually resolves within weeks to months after surgery. 学习外科解剖学有助于减少手术并发症。霍纳综合征(图5)在鼓泡截骨术患猫中占80%和息肉牵拉去除患猫中占40%。这种并发症通常在手术后几周到几个月就会消失。 5.Horner syndrome in a cat following ventral bulla osteotomy. Note the miotic pupil, drooping upper eyelid, and prolapsed third eyelid. 5.猫腹侧鼓泡截骨术后的霍纳综合征。注意瞳孔缩小，上眼睑下垂，第三眼睑突出。
Vestibular signs are unusual and typically result from aggressive debridement of the bulla with damage to the semicircular canals of the inner ear. This complication frequently resolves with time unless severe irreversible damage to the inner ear has occurred. Vestibular syndrome, when present prior to surgery, likely will not resolve after surgery. 前庭症状不常见，通常是由于鼓泡的强力清创术对内耳的半规管造成损伤。除非内耳发生了不可逆的严重损伤，这种并发症通常会随着时间的推移而消失。前庭综合征，如果在手术前出现，可能不会在手术后改善。
Facial and hypoglossal nerve paralyses are rare. Infection is rare with appropriate antibiotic therapy. Polyp recurrence can be reduced with adjunctive medical therapy. 面部和舌下神经麻痹很少见。在合适的抗生素治疗下罕见发生感染。辅以药物治疗可减少息肉复发。
On the Cutting Edge 前沿治疗 A CO2 laser can destroy remnants of the polyp in the middle ear via an aural approach. However, no studies have been published on the efficacy of this technique or any associated side effects.
二氧化碳激光可以通过耳道清除中耳内残留的息肉。然而，目前还没有关于这项技术的疗效或任何相关副作用的研究发表。
What You Will Need ■General surgical pack ■ Small Gelpi (2), ring (1), or Senn (2) retractors ■ Freer elevator ■ Suction with Frazier suction tip ■ Curved mosquito or alligator forceps ■ Spay hook ■ 5/64” Steinmann pin with Jacobs chuck ■ Fine curette (ie, dental/ear curette) ■ Fine Lempert rongeurs or Kerrison up-biting rongeurs 你需要什么？
■普通外科手术包
■小开张器(2个)、环(1个)或Senn(2个)开张器
■自由升降手术台
■使用Frazier吸引头抽吸
■弯钳或鳄鱼钳
■绝育钩
■5/64号骨针和手钻
■小刮匙(即牙科/耳科刮匙)
■小咬骨钳或Kerrison咬骨钳 Operating telescopes with 2.5× to 3.5× magnification and an operating headlamp will facilitate performing the procedure. 使用放大率为2.5到3.5倍的望远镜和操作前照灯将有助于手术的进行。 A ring retractor eliminates need for an assistant 使用环形牵引器不需要助手
Step-by-Step ■ Ventral Bulla Osteotomy VBO步骤 Step 1 第一步 B = bulla, FN = facial nerve, FV = facial vein, L = submandibular lymph node, LV = lingual vein, M = mandible, W = wing of the atlas bone B =鼓泡，FN =面神经，FV =面静脉，L =下颌淋巴结，LV =舌静脉，M =下颌骨，W =寰椎翼
Position the patient in ventral recumbency, and place a small rolled towel on the dorsal aspect of the cranial neck. Incise the skin over the palpable extents of the tympanic bulla (B, dotted line). This incision should extend through a thin layer of muscle over the bulla, which includes the platysma and sphincter coli muscles. Be careful to minimize transection of the large lingual (LV) and facial (FV) veins located over the lateral and caudal aspects of the bulla. The hypoglossal nerve (not shown) is frequently visualized and can be gently retracted in a medial direction. 将患猫置于腹侧卧位，将卷好的小毛巾置于头颈背侧。在可摸到鼓泡的上方切开皮肤(B，虚线)。这个切口应该延伸到鼓泡上的一层薄薄的肌肉，包括颈阔肌和括约肌。注意尽量避免切断鼓泡外侧和尾部的舌静脉(LV)和面静脉(FV)。经常可以看到舌下神经(图中未显示)，可以轻轻地向内侧牵拉。
Step 2 第二步 Using a Steinmann pin, make an initial hole in the bulla. Direct the pin laterally to avoid penetrating the oval promontory or other vital structures. 使用骨针，在鼓泡上打一个孔。将针尖朝向外侧，避免刺穿椭圆形隆凸或其他重要结构。
Step 3 第三步 Use a Lempert rongeur to continue the bulla osteotomy via the initial hole. Remove a sufficient amount of the bulla wall to expose the ventromedial compartment of the bulla and the septum of the dorsolateral compartment of the bulla. 使用咬骨钳通过开孔继续对鼓泡截骨。切除足够多的鼓泡壁，暴露鼓泡腹内腔室和鼓泡背外侧腔室的鼓室中隔。
Author Insight 作者提醒 In cats, the bulla is an easily palpable, spherical protrusion located over the caudoventral aspect of the skull; additional landmarks for incision usually are not needed. Some surgeons, however, reference the wing of the atlas as a landmark caudal to the bulla and the caudal aspect of the mandible as a landmark craniolateral to the bulla. A ventral approach to the tympanic bulla is used to expose the bulla. 在猫上，很容易触摸到鼓泡，位于头骨尾部腹侧的球形突起;通常不需要额外的切口标志。然而，一些外科医生将寰椎翼作为鼓泡尾侧的标志，将下颌骨尾侧作为鼓泡头外侧的标志。采用鼓泡腹侧通路暴露鼓泡。
Step 4 第四步 Penetrate the septum with a Steinmann pin in order to enter the dorsolateral compartment. Be sure not to disturb the sympathetic nerve fibers (yellow lines) that pass through the occipitotemporal fissure located on the dorsal caudomedial aspect of the bulla. In cats, these fibers are spread along the promontory, run dorsal to the bony septum, and exit the bulla rostrally via another foramen. 用骨针穿透鼓室中隔，以进入背外侧腔室。注意不要损伤到交感神经纤维(黄线)，这些神经纤维穿过位于鼓泡尾背侧的枕颞裂。在猫上，这些纤维沿着隆凸伸展，向鼓室中隔背侧，并通过另一个孔从吻侧出鼓泡。
Step 5 第五步 Remove the septum with the Lempert rongeur. The most dorsal aspect of the septum can remain intact, thus protecting the sympathetic nerves as they pass through this region. Submit fluid from the bulla and a portion of the polyp for bacterial, fungal, and mycoplasmal culture. 用咬骨钳切除鼓室中隔。鼓室中隔的最背面可以保持完整，从而保护交感神经通过该区域。从鼓泡和部分息肉中采样进行细菌、真菌和支原体培养。
Step 6 第六步 Remove the remaining root of the polyp located in the dorsolateral compartment using a small dental or ear curette or Kerrison up-biting rongeur. The polyp root may be located at the entrance to the auditory tube. Care must be exercised to prevent damage to the sympathetic nerve fibers. Lavage the bulla using saline and close the muscle layer, SC layer, and skin routinely. Surgical drains are not required. 使用小型牙科或耳科刮匙或Kerrison咬骨钳去除位于背外侧腔室的剩余息肉。息肉的根部可能位于咽鼓管入口处。必须注意防止交感神经纤维受到损伤。用生理盐水灌洗鼓泡，常规关闭肌肉层、皮下层和皮肤。不需要手术引流。
Author Insight 作者提醒 Large polyps should be extracted from the nasopharynx or external ear canal using mosquito or alligator forceps immediately before a ventral bulla osteotomy. Smaller polyps extending down the external ear canal may be extracted via the bulla osteotomy. 鼻咽或外耳道的大息肉，应在施行腹侧鼓泡截骨术前先用蚊钳或鳄鱼钳取出。外耳道向下延伸的较小息肉可通过鼓泡截骨术清除。
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发表于 2022-3-25 16:16:37
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