猫慢性耳炎：原发、易感和持久因素的临床管理（4）

王帆

ChroniC otitis in Cats Clinical management of primary, predisposing and perpetuating factors

猫慢性耳炎：原发因素、易感因素和持久因素的临床管理

作者：Bailey Brame and Christine Cain

翻译：郑江涛 校对：王帆

Perpetuating factors for otitis

耳炎的持久因素

Secondary infection with yeast or bacteria

继发酵母菌或细菌感染

Malassezia otitis

马拉色菌耳炎

Malassezia species are commonly isolated from the ears of cats with otitis externa, though the exact prevalence varies by report. Malassezia species have been cultured from 58–95% of cats with otitis externa, meanwhile Malasa species were identified on cytology in 51% of stray cats with cytological otitis externa in Italy. A greater density Malassezia species are expected in patients with otitis externa than in normal cats, with a mean density 24 Malassezia organisms per HPF on cytology compared with ⩽2 per HPF in normal cat ears in one study.

从外耳炎患猫的耳朵中经常能分离出马拉色菌，但确切的患病率因报告而异。从58-95%外耳炎患猫中培养出马拉色菌，同时，在意大利，细胞学检查诊断为外耳炎的流浪猫中，51%细胞学检查是马拉色菌。与正常猫相比，外耳炎患猫中马拉色菌密度更高，细胞学检查中，平均每HPF有24个马拉色菌，而在一项研究中，正常猫耳道中每HPF有≤2个马拉色菌。

Bacterial otitis

细菌性耳炎

Cocci and rods were identified in 72% and 29%, respectively, of stray Italian cats with otitis externa, and mixed infections were common. Cocci were commonly seen on cytology in cats with allergy (87% of ear canals). Cocci in cases of feline otitis externa usually belong to Staphylococcus species. Pseudomonas aeruginosa and Pasteurella multocida have been reported as the most common bacterial rods isolated from cats with otitis externa. Other organisms isolated from bacterial otitis in multiple cats have included Streptococcus canis, Escherichia coli, Mycoplasma species, Klebsiella species and Corynebacterium species.

在患有外耳炎的意大利流浪猫中，球菌和杆菌的检出率分别为72%和29%，混合感染也很常见。在过敏症患猫（87%的耳道）的细胞学检查中，常见球菌。猫外耳炎病例中的球菌通常属于葡萄球菌。据报道，铜绿假单胞菌和多杀性巴氏杆菌是猫外耳炎最常见的杆菌。从多只猫的细菌性耳炎中分离出的其它微生物包括犬链球菌、大肠杆菌、支原体属、克雷伯氏菌属和棒杆菌属。

The authors recommend that cytology be performed in all cases of otitis to guide therapy and track progress. 作者建议对所有耳炎病例进行细胞学检查，以指导治疗和跟踪进展。

Treatment of secondary infection 继发感染的治疗 Systemic antimicrobials should be reserved for cases with otitis media or where topical treatment is not feasible due to patient temperament. 对于患有中耳炎或因患者性情而无法进行外部治疗的病例，应使用全身抗菌药物。 Some dermatologists may prefer the use of oral antimicrobials to treat feline otitis owing to concern for the risk of a contact reaction. However, it is the experience of the authors that aural infections are difficult to resolve without topical treatment, which allows for the local delivery of concentrated therapeutics. The authors recommend that the use of systemic antimicrobials be reserved for cases with otitis media or where topical treatment is not feasible due to patient temperament. Culturing the ear canal is rarely indicated in otitis externa because topical therapies can greatly exceed the breakpoint concentrations used to determine susceptibility. The authors recommend that cytology be performed in all cases of otitis to guide therapy and track progress. 由于担心接触反应的风险，一些皮肤科医生可能更倾向于使用口服抗菌剂来治疗猫耳炎。但是，根据作者的经验，如果不进行外部治疗，耳部感染很难解决。因为允许治疗浓度集中在外部。作者建议，对于患有中耳炎的病例或由于患者的性格而无法进行外部治疗的病例，应使用全身抗菌药物。外耳炎很少需要耳道培养，因为外部治疗可以大大超过用于确定药敏试验的检测浓度。作者建议对所有耳炎病例进行细胞学检查，以指导治疗和跟踪进展。 Most otic preparations include a corticosteroid to reduce inflammation. Because inflammation is what allows infection to develop, this is a necessary component of a successful treatment approach. Among topical steroids, mometasone furoate has superior anti-inflammatory activity and is unlikely to result in systemic glucocorticoid effects because very little (<1% in humans) is absorbed. Hydrocortisone aceponate is also unlikely to be systemically absorbed, though less potent than mometasone. 大多数耳药包括皮质类固醇以减少炎症反应。因为炎症使感染得以发展，所以这是成功治疗的必要成份。在外用类固醇中，糠酸莫米松具有优越的抗炎活性，并且不太可能导致全身性糖皮质激素作用，因为很少（人体<1%）被吸收。氢化可的松醋丙酯也不太可能被全身吸收，但药效不如莫米松。 Ear cleansing can allow for the removal of a proportion of the infectious burden from the canal. Some practitioners recommend the use of plain saline to reduce the risk of a contact reaction. In the experience of the authors, using a product with mild ceruminolytic properties can be helpful in cats owing to their abundant ceruminous debris. Clients should be clearly educated on appropriate cleansing technique to avoid mechanical trauma to the canal. 洗耳液可以从耳道中清除一部分感染负担。一些医生建议使用普通盐水来降低接触反应的风险。根据作者的经验，使用具有温和耵聍溶解特性的产品对猫有帮助，因为猫有大量的耵聍碎屑。应明确告知客户适当的清洁技术，以避免对耳道造成机械性创伤。 If the patient fails to respond to appropriate topical treatment, otic lavage under general anesthesia could be considered. Patients should be intubated to reduce the risk of aspiration during lavage. CT is recommended prior to otic lavage to allow for assessment of the middle ear. Lavage is performed with warm saline, ideally under direct visualization with a video-otoscope. 如果患猫对合理的外部治疗没有效果，可以考虑在全身麻醉下进行耳部灌洗。患猫应插管，以降低灌洗时误吸的风险。建议在耳部灌洗前进行CT检查，以便对中耳进行评估。用温盐水进行灌洗，最好在视频耳镜直接观察下进行。

Contact reactions and other complications of treatment

接触反应和其他治疗并发症

Ototoxicity is a potential risk with many topical medications, particularly if they are permitted to make contact with the inner ear. There are few data regarding the incidence of ototoxicity in cats. Aminoglycosides have induced deafness when administered systemically to cats, and a combination of chlorhexidine and cetrimide was associated with acute vestibular signs in three cats when applied to an ear with a ruptured tympanum.

耳毒性是许多外用药物的潜在风险，特别是当它们与内耳接触时。关于猫的耳毒性发生率的数据很少。氨基糖苷类药物在猫全身给药时可诱发耳聋，给三只鼓膜破裂患猫使用氯己定和西曲溴胺联合给药时，出现急性前庭症状。

Some veterinary dermatologists consider cats to be especially susceptible to contact reactions with otic preparations, with one veterinary teaching hospital diagnosing contact reactions in 1.4% of patients presenting to its dermatology service. Contact reactions should be suspected when a patient seems to deteriorate clinically after therapy is implemented, and especially if infection is resolved on cytology while the degree of suppurative inflammation worsens.

一些兽医皮肤科医生认为猫对耳药的接触反应特别敏感，一家兽医教学医院在其皮肤科服务中诊断出1.4%的患猫有接触反应。当患猫在实施治疗后临床上似乎恶化时，应怀疑接触反应，特别是如果感染在细胞学检查上得到解决，而化脓性炎症的程度恶化。

Topical glucocorticoids cause cutaneous atrophy, which can affect the auricular cartilage in cats, resulting in a potentially permanent drooping appearance to the pinna.

外部糖皮质激素引起皮肤萎缩，可影响猫的耳廓，导致耳廓潜在的永久性下垂外观。

Ceruminoliths

耵聍石

Ceruminoliths can form in the ears of cats with chronic otitis externa and are thought to be concretions of debris and possibly ear medication and cleanser. The ceruminolith tends to be hard with irregular margins, so it can act as a foreign body, perpetuating inflammation and acting as a nidus of infection. True aural foreign bodies are not common in the cat, though they remain a possibility and should be considered in cases of unilateral otitis externa. Ceruminoliths typically require removal under general anesthesia, often with otic lavage.

在患有慢性外耳炎的猫的耳朵中可以形成耵聍石，被认为是碎片的凝结物，可能是耳药和洗耳液。耵聍石往往是硬的，边缘不规则，因此它可以作为异物，使炎症持续存在，并作为感染的病灶。真正的耳异物在猫中并不常见，但仍有可能，在单侧外耳道的病例中应考虑到。耵聍石通常需要在全身麻醉下取出，通常需要进行耳部灌洗。

Otitis media

中耳炎

While, in dogs, otitis media typically results from otitis externa, cats may have otitis media without otitis externa. Among cats undergoing necropsy, 2–10% had evidence of otitis media on gross evaluation, but 56% had histologic evidence of otitis media.

在犬中，中耳炎通常由外耳炎引起，而猫可能有中耳炎而没有外耳炎。在接受尸检的猫中，2-10%的猫有中耳炎的直观证据，但56%的猫有中耳炎的组织学证据。

Affected cats may display head shaking or otic pruritus, or their signs may be exclusively neurologic. Neurologic manifestations of otitis media include vestibular signs (head tilt, ataxia), Horner’s syndrome and facial nerve paralysis. On otoscopic examination, cats with otitis media may have an opaque or bulging tympanic membrane, or fluid may be visible through the tympanic membrane. If fluid is present, it may be clear, purulent or hemorrhagic. Otitis media may occur either unilaterally or bilaterally.

患猫可能会表现出甩头或耳部瘙痒，或者它们的症状可能完全是神经性的。中耳炎的神经系统表现包括前庭症状（头倾斜、共济失调）、霍纳综合征和面神经麻痹。在耳镜检查中，患有中耳炎的猫的鼓膜可能不透明或隆起，或者透过鼓膜可以看到液体。如果存在液体，可能是透明的、脓性的或出血性的。中耳炎可发生于单侧或双侧。

In cases of suspected or confirmed otitis media, a myringotomy should be performed under general anesthesia to sample fluid from the middle ear. 在怀疑或确诊为中耳炎的病例中，应在全身麻醉下进行鼓膜切开术，以采集中耳液体样本。

In cases of suspected or confirmed otitis media, fluid from the middle ear should be sampled under general anesthesia via a myringotomy procedure. Otic lavage can be performed if indicated. Advanced imaging (CT) is ideal and should be undertaken prior to myringotomy or otic lavage because lavage adds fluid to the ear canal, which can shadow soft tissue structures.

在疑似或确诊为中耳炎的病例中，应在全身麻醉下通过鼓膜切开术采集中耳液体样本。如有中耳炎，可进行耳部灌洗。高级成像（CT）是理想的，应在鼓膜切开术或耳部灌洗术之前进行，因为灌洗术会增加耳道内的液体，这会遮蔽软组织结构。

Aerobic culture is always recommended, and in many cases antimicrobial therapy can wait for culture results. In severe cases, empiric antibiotics can be considered while the culture is pending. Cytology of the fluid from the middle ear can help to guide the selection of an appropriate empiric antibiotic.

始终推荐进行需氧菌培养，在许多病例中，抗菌治疗可以等待得知培养结果后进行。在严重的病例，在等待培养期间，可以考虑使用经验性抗生素。对中耳积液进行细胞学检查有助于指导选择合适的经验性抗生素。

Progressive pathologic changes

渐进性病理改变

As a result of chronic otitis externa, patients may develop epidermal hyperplasia, hypertrophy of ceruminous glands and inflammatory infiltrates that result in proliferative tissue filling the ear canal. Though progressive pathologic changes are less commonly reported in cats relative to dogs, ceruminous gland hyperplasia is common in cats with chronic otitis externa and, in one study, was the indication for 30% of cats undergoing TECABO. Ceruminous gland tumors are thought to develop from malignant transformation of glandular hyperplasia, so controlling otic inflammation may serve as a preventive measure.

慢性外耳炎患猫，可能会出现表皮层增生、耵聍腺增大和炎性浸润，导致增生组织充满耳道。虽然与犬相比，猫的进行性病理改变较少报道，但在患有慢性外耳炎的猫中，耵聍腺增生是常见的，在一项研究中，这是30%接受TECABO治疗的猫的适应症。耵聍腺肿瘤被认为是由腺体增生恶变而来，因此控制耳部炎症可能是一种预防措施。

The presence of irregular tissue narrows the canal and can lead to pockets where microorganisms are protected from otic treatments, as well as increased susceptibility to infections due to changes in the skin barrier, disruption of the normal cleaning mechanism in the ear and discomfort for the patient. With chronicity, mineralization and ossification of the canal may occur. In patients with end-stage ear changes, TECABO is recommended; this removes the site of infection and improves patient comfort.

不规则组织的存在使耳道变窄，并可形成微生物逃逸耳药的囊袋，以及由于皮肤屏障的变化而增加对感染的易感性，破坏了耳道中的正常清洁机制并使患猫感到不适。随着慢性发展，可能会发生矿化和骨化。对于耳道发生终末期改变的患猫，推荐使用Tecabo；这消除了感染部位，提高了患猫的舒适度。

In patients with end-stage ear changes, TECABO is recommended to remove the site of infection and improve patient comfort. 对于耳部终末期病变的患猫，建议使用Tecabo去除感染部位并提高患猫舒适度。

Prognosis and sequelae 预后和后遗症 The overall prognosis for cats with chronic otitis depends broadly on the ability to identify and control the primary, predisposing and perpetuating factors. It is therefore highly patient-dependent. 慢性耳炎的患猫的总体预后在很大程度上取决于识别和控制原发性、易感性和持久性因素的能力。因此，它高度依赖于患猫病情。 In cats with severe chronic otitis, intracranial abscess (IA), intracranial empyema (IE) or meningoencephalomyelitis (ME) may occur. Though these sequelae are rare, the prognosis is guarded, which makes early identification and treatment crucial. Cats presenting with IA, IE or ME may have multifocal neurologic signs, with the most common deficits noted including dull mentation, absent menace response, Horner’s syndrome or anisocoria, proprioceptive deficits or ataxia, circling, tetraparesis and head tilt. On general physical examination, tachycardia, pyrexia, tachypnea and nasal discharge may be noted. Even in cases that occur secondarily to otitis, aural discharge may not be noted, and otoscopic examination may be normal. Only 37% of cases that occur secondarily to otitis have a known history of ear disease. 严重慢性耳炎患猫，可能会发生颅内脓肿（IA）、颅内积脓（IE）或脑膜脑脊髓炎（ME）。虽然这些后遗症罕见，但预后谨慎，这使得早期识别和治疗至关重要。表现为IA、IE或ME的猫可能具有多灶性神经症状，最常见的缺陷包括精神状态迟钝、威胁反应缺失、霍纳综合征或瞳孔大小不等、本体感觉缺失或共济失调、转圈、四肢瘫痪和头倾斜。在体格检查中，可能会发现心动过速、发热、呼吸急促和流鼻涕。即使在继发于耳炎的病例中，也可能不会注意到耳分泌物，耳镜检查也可能正常。在继发于耳炎的病例中，仅有37%的患猫有耳病史。 If any of these neurologic sequelae are suspected, advanced imaging (MRI or CT) is recommended with cerebrospinal fluid sampling for analysis and culture. Though surgery is recommended in cases of IA or IE, two recent retrospective case series suggest that medical management may be effective in some cases. Selection of an antibiotic based on culture and sensitivity is recommended; however, empiric antibiotics should be started pre-emptively in these cases. Pasteurella multocida was the most commonly cultured organism in one case series, being isolated from four cats with IA or ME, so ideally a broad-spectrum antibiotic should be selected that is effective against this organism. Amoxicillin trihydrate and clavulanate potassium (Clavamox; Zoetis) was commonly used in both case series and is a reasonable empiric choice for IA, IE or ME in the cat. 如果怀疑这些神经后遗症中的任何一种，建议进行高级成像（MRI或CT），并进行脑脊液取样分析和培养。尽管在IA或IE的病例中建议进行手术，但最近的两个回顾性病例分析表明，在某些病例中，药物治疗可能是有效的。建议根据细菌培养和药敏试验选择抗生素；然而，在这些病例中，应先经验性使用抗生素。多杀性巴氏杆菌是一个病例分析中最常见的培养微生物，从四只患有IA或ME的猫中分离出来，因此理想情况下，应选择对该微生物有效的广谱抗生素。两个病例分析中，常用羟氨苄青霉素和克拉维酸钾（Clavamox；Zoetis），是猫中IA、IE或ME的合理经验性选择。

KEY points 重点 < Chronic otitis is multifactorial; the factors that contribute to the development and persistence of otitis can be categorized as primary, predisposing and perpetuating. < A successful diagnostic approach involves a combination of history, physical examination with otoscopy, evaluation for Otodectes cynotis and cytology. When appropriate, advanced imaging can be considered. < Because most causes of chronic otitis tend to affect both ears, the presence of unilateral disease should prompt the clinician to evaluate for an inflammatory polyp or mass. < Cytology is vital to identify perpetuating bacterial and yeast infections and guide therapy. < To manage chronic otitis, it is necessary to identify and control as many primary, predisposing and perpetuating factors as possible. <慢性耳炎是多因素的；导致耳炎发生和持续存在的因素可分为原发性、易感性和持久性。 <成功的诊断方法包括结合病史、体格检查和耳镜检查、评估耳螨和细胞学检查。在适当的时候，可以考虑高级影像检查。 <因为大多数慢性耳炎往往双耳患病，所以单侧疾病的存在应提示临床医生评估是否有炎性息肉或肿块。 <细胞学检查对于识别持续存在的细菌和酵母菌感染并指导治疗至关重要。 <管理慢性耳炎，必须识别和控制尽可能多的原发性、易感性和持久性因素。

杨医生vet

感谢分享，学习了

毛毛030526

怀疑耳药引起的前庭问题偏头，除过常规的营养神经，停药，还有别的办法吗