本帖最后由 王帆 于 2024-5-24 11:59 编辑
Ear cleaning: the UK and US perspective 耳部清洁:英国和美国的观点 TIM NUTTALL and LYNETTE K. COLE 翻译：王帆
Abstract 摘要 Ear cleaning helps maintain the normal otic environment and is important in the treatment of otitis. Over cleaning, however, may trigger otitis through maceration of the epidermal lining. Simple manual cleaning is useful for routine cleansing but doesn’t remove tightly adherent debris. Bulb syringes are more vigorous but may damage the ear in inexperienced hands. Devices using mains water pressure or dental machines are also available. Thorough cleaning of the ear canals and middle ear cavity can only be achieved by retrograde flushing using specially adapted catheters, feeding tubes or video otoscopes under anaesthesia. Myringotomy, inspection and cleaning of the middle should be performed if the tympanic membrane appears abnormal. There are a wide variety of cleaning fluids available. Ceruminolytics soften and dissolve cerumen to facilitate cleaning. Surfactants emulsify debris, breaking it up and keeping it in solution. Astringents dry the ear canal surface, preventing maceration. Maintaining a low pH and incorporating antimicrobial agents can inhibit microbial proliferation and glucocorticoids can be used to reduce inflammation. Adverse effects and contraindications following ear cleaning can include maceration, contact reactions, otitis media, ear canal avulsion, vestibular syndrome, Horner’s syndrome, facial nerve paralysis and deafness. Care should be exercised in selecting cleaning fluids if the tympanic membranes are ruptured. 耳部清洁有助于保持正常的耳部环境，对治疗耳炎很重要。然而，过度清洁可能会导致表皮层浸润，可能成为耳炎的诱因。简单的手动清理对日常清洁很有用，但无法清除附着在上面的碎片。洗耳球清洁更有力度，但缺乏经验的操作可能会损伤耳部。也可以使用水压或牙科设备。要彻底清洁耳道及中耳腔，必须在麻醉下，使用特制的导管、饲管或视像耳镜进行逆行冲洗。如果鼓膜看上去异常，应进行鼓膜切开术检查及清洗中耳。有各种各样的清洗液可用。耵聍溶解剂可以软化和溶解耵聍，以促进清洁。表面活性剂使碎屑乳化，使其破碎并溶解在溶液中。收敛剂使耳道表面干燥，防止浸渍。维持低pH值和结合抗菌药物可抑制微生物增殖，糖皮质激素可用于减轻炎症。耳部清洁后的不良反应和禁忌证包括浸渍、接触反应、中耳炎、耳道撕脱、前庭综合征、霍纳氏综合征、面神经麻痹和耳聋。如果鼓膜破裂，在选择清洗液时应小心谨慎。
Keywords: ear cleaning, flushing, otitis. 关键词：耳部清洁、冲洗、耳炎
INTRODUCTION 介绍 When performed well ear cleaning helps maintain the normal otic environment and is important in the treatment of otitis. Done badly it at best hinders resolution and at worst can trigger recurrent inflammation. A wide range of cleansing preparations and techniques is described. Not all are applicable to every ear and inappropriate use can make matters worse. In this article we discuss the rationale behind ear cleaning and how to get the best results from different agents and techniques. 良好的耳部清洁有助于保持正常的耳部环境，对治疗耳炎很重要。如果做得不好，轻则阻碍治疗，重则诱发炎症复发。有多种清洁准备和技术。不是所有方法都适用于每只耳部，不恰当的使用会让事情变得更糟。在这篇文章中，我们讨论了耳部清洁背后的基本原理，以及如何从不同的药剂和技术中获得最佳的结果。
THE OTIC ENVIRONMENT 耳部环境 The most prominent part of the external ear in terrestrial mammals is the cartilaginous pinna. The dorsal or convex surface is continuous with the haired skin of the head while the glabrous ventral or concave surface is continuous with the vertical and horizontal ear canals at the external ear or auditory orifice. The vertical ear canal travels ventrally and slightly rostrally before making a medial turn. The horizontal ear canal is separated from the middle ear by the tympanic membrane (Fig. 1). This is a concave, semitransparent membrane,which thickens towards its periphery. It is divided into two sections: the small dorsal pars flaccida and the larger ventral pars tensa. The pars flaccida is the pink, small, loosely attached upper quadrant of the tympanic membrane that contains small blood vessels. The pars tensa is a thin, tough, pearl grey structure with radiating strands that forms the rest of the membrane. The manubrium of the malleus attaches to the medial surface of the tympanic membrane forming a white Cshaped structure, the stria mallearis. Canine ear canals are typically 5–10 cm in length and 0.5–1.0 cm in diameter, although stenosis often occurs in chronic otitis externa. The authors also find that some dog breeds such as shar-peis, bulldogs, bull terriers and cocker spaniels can have narrow ear canals. 陆生哺乳动物外耳最突出的部分是耳廓软骨。耳廓背侧或凸面与头部有毛皮肤连续，而无毛的腹侧或凹面与外耳或听孔的垂直和水平耳道连续。垂直耳道在内侧转弯前向腹侧和稍微向口侧移动。水平耳道由鼓膜与中耳分开(图1)。鼓膜是一种凹的半透明膜，周围增厚。鼓膜分为两个部分:小的背侧松弛部和大的腹侧紧张部。松弛部是粉红色的、小的、松散的位于鼓膜上半部，包含小血管。紧张部是一种薄的、坚韧的、珍珠灰色的散射线结构，占据鼓膜剩余部分。锤骨柄附着于鼓膜的内侧表面，形成一个白色的c形结构，即锤纹。犬的耳道一般长5 - 10厘米，直径0.5 - 1.0厘米，但慢性外耳炎常发生狭窄。作者还发现，一些犬种，如沙皮犬、斗牛犬、牛头㹴和可卡犬的耳道可能很窄。
The middle ear cavity is housed within the bony tympanic bulla and is normally air filled. The canine tympanic bulla is divided into dorsal and ventral compartments by an incomplete bony shelf; in cats they are completely separate. It contains the auditory ossicles, their associated ligaments, muscles and nerves, and communicates with the inner ear via the round and oval windows. The Eustachian or auditory tube connects the middle ear with the nasopharynx. The sympathetic nerve passes through the periosteum of the ventral bulla. 中耳腔位于骨性鼓泡内，通常充满空气。犬鼓泡被不完整的骨隔板分为背侧腔和腹侧腔。在猫上，两个腔被完全隔开。中耳包含听小骨及其相关韧带、肌肉和神经，并通过圆窗和椭圆窗与内耳相连。耳咽管或咽鼓管连接中耳和鼻咽。交感神经穿过鼓泡腹侧骨膜。
The concave surface of the pinna and the ear canals are lined with glabrous skin except in hirsute breeds such as poodles, Bichon frise, terriers, etc. The dermis is rich in sebaceous and apocrine or ceruminous glands. Cerumen is a complex mixture of exfoliated cells, waxes, oils, free fatty acids, esters, immunoglobulins and proteins and forms a protective and antimicrobial barrier. Debris entering the ear canal is trapped and removed with the cerumen. This is facilitated by the lateral (outward) migration of the stratum corneum. 耳廓和耳道的凹面皮肤光滑少毛，但多毛犬种除外，如贵宾犬、卷毛比雄犬、㹴犬等。真皮层有丰富的皮脂腺和顶浆腺或耵聍腺。耵聍是由脱落的细胞、蜡、油、游离脂肪酸、酯类、免疫球蛋白和蛋白质组成的复杂混合物，形成了一个保护和抗菌的屏障。进入耳道的碎片会被困住，并随耵聍一起清除。这是由角质层的横向(向外)迁移完成的。
WHEN TO CLEAN EARS 何时清耳 It is not usually necessary to clean healthy ears. Excessive cleaning can predispose to infections by increasing humidity and macerating the ear canal lining. Ear cleaning can, however, be beneficial in seborrhoeic ears with excessive cerumen production or in hairy, stenotic or pendulous ears where the flow of cerumen may be impeded. 健康的耳部通常不需要清洁。过度清洁会增加湿度，浸渍耳道内壁，从而容易感染。然而，对于耳垢过多的脂溢性耳部，或多毛的、狭窄的或下垂的耳，耵聍排除受阻，清洁耳部是有益的。
Excess hairs can be periodically removed to improve access to the ear canal. Neither author, however, recommends hair removal unless absolutely necessary as frequent depilation may result in inflammation and recurrent otitis. It is also painful and should be performed under sedation or anaesthesia; dogs may otherwise become resistant to ear treatment. Depilatory creams are not often used in the ear canals and should be avoided as they are potential irritants and sensitisers. 多余的毛发可以定期清除，以改善耳道的通路。然而，作者都不建议请除耳毛，除非绝对必要，因为频繁请除耳毛可能导致炎症反应和复发性耳炎。清除耳毛也很痛，应该在镇静或麻醉下进行。否则，犬可能会对耳部治疗产生抵触。脱毛膏不常用于耳道，应避免使用，因为它们是潜在的刺激物和致敏剂。
Effective ear cleaning is an essential part of any treatment regime because it aids treatment and speeds resolution by removing: • exudates and debris that obstruct the ear canals preventing a through diagnostic evaluation and medications contacting the ear canal epithelium; • purulent material and inflammatory debris that can protect microorganisms and inactivate some antimicrobial medications such as gentamicin and polymyxin B; • small foreign bodies, microorganisms, toxins and other inflammatory compounds, degenerate and damaged cells, which can act as foci for infection and inflammation. 有效的耳部清洁是所有治疗管理中的重要组成部分，因为它有助于治疗，并通过去除下述物质快速缓解病情: •分泌物和碎屑（堵塞耳道，阻碍诊断评估和药物与耳道上皮接触）; •脓性分泌物和炎性碎屑（可以保护微生物，使庆大霉素和多粘菌素B等抗菌药物失活）; •小异物、微生物、毒素和其他炎症成份、退行性和受损细胞（感染和炎症的病灶）。
EAR CLEANING TECHNIQUES 洗耳技术 Manual cleansing 手动清洗 The ear canals can be simply cleaned by introducing the cleaning fluid directly into the ear and massaging the ear canals, working debris to the surface. This does not remove tightly adherent or deep material and is best reserved for routine cleansing. A clear demonstration of the technique will help ensure effective cleaning by the owners. In general, owners should not clean the ear more frequently than every 48 h as there is a risk of maceration and infection if done too often. One of the authors (LC) has nevertheless used astringent cleaners such as Epi-Otic® (Virbac, Carros, France) daily (for cleaning) to twice daily (for its antimicrobial effect) with no adverse effects. Owners can clean directly visible parts of the ear with cotton wool or tips but deeper insertion risks leaving foreign material behind and irritating the ear canals. 将洗耳液直接灌入耳部，按摩耳道，将碎屑清除到表面，就可以简单地清洁。无法清除紧密粘附或深层分泌物，适用于日常清洁。将该技术清晰演示给宠主，有助于确保清洁有效。通常，宠主不应该比每48小时清洁一次耳部更频繁操作，因为太频繁会有浸渍和感染的风险。然而，其中一位作者(LC)使用了收敛性洗耳液，如Epi-Otic®(Virbac)每天一次(用于清洁)到每天两次(用于抗菌作用)，没有副作用。宠主可以用棉球或棉签头直接清洁耳部可见的部分，但插入更深有异物风险和刺激耳道。
Bulb syringes 洗耳球 Bulb syringes consist of a hollow plastic or rubber sphere and a variably sized nozzle. The bulb is filled with cleaning fluid, the nozzle gently inserted into the vertical ear canal and the fluid squeezed in under light pressure. It is important to leave a gap between the nozzle and the wall of the ear canal; the pressure can otherwise rupture the tympanic membrane. The fluid dislodges and washes out any debris. Bulb syringing is an effective technique that can be used in either conscious or sedated animals. Caution must be taken to avoid aspiration when using large volumes of fluid in heavily sedated animals, however. Using cuffed endotracheal tubes in anaesthetized animals reduces the risk of aspiration (see ear flushing below). Bulb syringes can be used by competent owners but it is important to fully explain and demonstrate the technique to avoid any problems. 洗耳球由一个中空的塑料或橡胶球和一个不同大小的嘴部组成。球内装满洗耳液，嘴部轻轻插入垂直耳道，轻轻加压将液体挤入耳道。重点是要在嘴部和耳道壁之间留出空隙，否则压力会导致鼓膜破裂。液体排出并冲洗掉所有碎片。洗耳球是一种有效的技术，可以用于有意识或镇静的动物。然而，在使用大量液体严重镇静的动物时，必须小心操作，避免误吸。在麻醉动物中使用有气囊的气管插管可以降低误吸的风险(见下文耳部冲洗)。有能力的宠主也可以使用洗耳球，但重要的是充分解释和演示技术，以避免任何问题。
Ear flushing 耳部冲洗 Ear flushing (Fig. 2a,b) is appropriate when the entire ear canal and/or the middle ear need thorough cleaning. If the ear canals are hyperplastic or ulcerated, 2– 3 weeks of topical and/or systemic glucocorticoids (prednisone or prednisolone 1–2 mg kg−1 orally q24 h, then taper) should be administered before performing ear flushing. Deep ear flushing should be performed under anaesthesia to prevent head shaking and damage to the ear canal. Cuffed endotracheal tubes will minimize the risk of aspiration. If the tympanic membrane is ruptured fluid will disappear from the ear canal and may flow from the nose, or mouth. The operator should wear gloves, facemask and eye protection to avoid infection from contaminated aerosols,especially if Pseudomonas is present. Swabs from the horizontal ear canal and middle ear cavity should be obtained for cytology and bacterial culture and sensitivity prior to flushing the ear. 耳部冲洗(图2a、b)适用于整个耳道和/或中耳需要彻底清洁的情况。如果耳道增生或溃疡，应在耳部冲洗前给予2-3周外用和/或全身性糖皮质激素(口服泼尼松或泼尼松龙1-2mg/kg，每24小时一次，然后逐渐减量)。耳道深部冲洗应在麻醉下进行，以防止甩头和损伤耳道。使用有气囊气管插管将减少误吸的风险。如果鼓膜破裂，液体将从耳道消失，并可能从鼻腔或口腔流出。操作人员应佩戴手套、口罩和护目镜，以避免受污染气溶胶感染，特别是在存在假单胞菌的情况下。在耳部冲洗之前，应从水平耳道和中耳腔进行拭子采样进行细胞学检查和细菌培养和药敏试验。
One method of ear flushing is performed with a three-way tap or stopcock connected to a syringe, fluid supply and a urinary catheter, tomcat catheter or feeding tube of the appropriate length and diameter. The catheter tip is placed adjacent to the tympanic membrane or, if the tympanic membrane is ruptured, into the middle ear under visualization through an operating otoscope. It is important to angle the tip ventrally to avoid the sensitive structures in the dorsal part of the middle ear cavity. The ear canals and middle ear are alternately flushed and aspirated until completely clean. Finally, an astringent can be used to dry the ear canal. Retrograde flushing using this technique is very effective at removing deep material and is the only effective way to clean the middle ear. 耳部冲洗的一种方法是，使用三通阀连接一个连接注射器、大量液体和导尿管、公猫导尿管或适当长度和直径的饲管。导管尖端放置在鼓膜附近，或者，如果鼓膜破裂，在手术耳镜可视下放入中耳。重要的是要将鼻尖向腹侧倾斜，以避免中耳腔背侧的敏感结构。耳道和中耳交替冲洗和抽吸，直到完全清洁。最后，可以用一种收敛剂来干燥耳道。使用这种技术进行逆行冲洗对清除深部物质非常有效，也是清洁中耳的唯一有效方法。
Tightly adherent debris can be removed by initially soaking the ear canal for 10 min with a ceruminolytic ear cleanser. One of the authors (LC) prefers PanOtic® (Pfizer Inc., New York, USA). Flushing with sterile isotonic saline using a bulb syringe will remove larger fragments of debris from the ear canal. Flushing is then continued using an 8-French polypropylene urinary catheter attached to a 12 ml syringe as above to remove the remaining exudate and debris allowing visualization of the tympanic membrane with an otoscope or video otoscope (see below). 可以先用耵聍溶解剂洗耳液将耳道浸泡10分钟，清除粘附较紧的碎片。其中一位作者(LC)推荐使用PanOtic®。用洗耳球和无菌等渗盐水冲洗耳道可以清除较大的碎片。然后，使用8号聚丙烯导尿管连接12ml注射器(如上所示)继续冲洗，清除剩余的分泌物和碎片，以便用耳镜或视频耳镜观察鼓膜(见下文)。
If the tympanic membrane is ruptured, repeated flushing of the middle ear should be performed to remove the ear cleanser, as some ceruminolytic agents may be ototoxic. 如果鼓膜破裂，应反复冲洗中耳，清除洗耳液，因为一些耵聍溶解剂可能会造成耳毒性。
Samples for cytology and bacterial culture and sensitivity should also be obtained from the middle ear cavity using either a hand-held otoscope or a video otoscope. Using a hand-held otoscope, a sterile otoscopic cone is inserted into the horizontal ear canal and a sterile swab (Calgiswab®; Hardwood Products Company LP, Guildford, MN, USA) is passed into the middle ear cavity, avoiding the sensitive structures in the dorsal part of the middle ear cavity. The first swab is used for culture and sensitivity; the second for cytology. Using a video otoscope, an open-ended 3.5- French tomcat catheter attached to a 12 ml syringe is placed through the port of the video otoscope. One millilitre of sterile saline is flushed into the middle ear cavity and aspirated for culture. 用手持耳镜或视频耳镜从中耳腔采样进行细胞学检查、细菌培养和药敏试验。使用手持式耳镜，将无菌耳锥形头插入水平耳道，并使用无菌棉签通过中耳腔，避开中耳腔背侧的敏感结构。第一个拭子用于细菌培养和药敏试验，第二个拭子进行细胞学检查。使用视频耳镜，一个末端开口的3.5号公猫导尿管连接到12毫升注射器，通过视频耳镜的操作通道。1毫升无菌生理盐水冲洗至中耳腔并吸出进行培养。
If the tympanic membrane is intact but appears abnormal and otitis media is suspected a myringotomy (the deliberate rupture of the tympanic membrane) should be performed to obtain samples for cytology, culture and sensitivity and to flush the middle ear cavity. Using a standard otoscope, an incision is made in the caudoventral quadrant of the tympanic membrane with the Calgiswab® as described above. If using a video otoscope an open-ended 3.5-French tomcat catheter is used to make the incision. One author (TN) prefers to use a sterile spinal needle to make the initial incision. Experimentally ruptured normal tympanic membranes heal in 21–35 days. If the ear is kept free from infection following myringotomy the tympanic membrane should therefore heal well. 如果鼓膜完整，但外观异常，怀疑中耳炎，应进行鼓膜切开术(故意破坏鼓膜)，以采样进行细胞学检查、细菌培养和药敏试验，并冲洗中耳腔。使用标准耳镜，用无菌棉签在鼓膜尾腹象限切口如上所述。如果使用视频耳镜，则使用末端开口3.5号公猫导尿管进行切口。一位作者(TN)推荐使用无菌脊髓针进行初始切口。实验表明，正常鼓膜破裂后21-35天即可愈合。如果鼓膜切开术后耳部没有感染，那么鼓膜应该愈合得很好。
Water Pik® A Water Pik® (Waterpik Technologies Inc., USA) is dental machine attachment that directs a pulsatile flow of water into the ear to dislodge and remove debris. The fluid must be aspirated from the ear afterwards, which is facilitated by the use of a suction apparatus. It is effective in cleaning the external ear canals, but somewhat less satisfactory at cleaning the middle ear.Excessive water pressure may also damage the tympanic membrane. Water Pik®是一种牙科器械，可以辅助使水流脉冲式流入耳道，以排出和清除碎片。随后必须用吸引泵从耳中吸出液体。此设备对清洁外耳道很有效，但对清洁中耳就不太满意了。过高的水压也可能损害鼓膜。
Auriflush® The Auriflush® (Schering Plough Animal Health) (Fig. 3a,b) system is driven by tap (faucet) water although other cleaning fluids can be added. It has a trigger-operated nozzle that allows simultaneous flushing and aspiration of the canal. It can be used in conscious, sedated or anaesthetized animals, although it does not clean as deeply as catheter flushing and it is difficult to aspirate fluid with an animal in lateral recumbancy due to gravity. The size of the nozzle may make it difficult to use in small dogs and cats. Contributors to a recent Vetderm listserv discussion were divided as to its usefulness, which may reflect the type of cases seen by individual centres. One of the authors (TN) finds the Auriflush® very useful for routine cleansing but prefers catheter flushing for thorough cleaning of the ear canals. Auriflush® 洗耳器(图3a,b)，虽然由水龙头(水龙头)驱动，但也可以添加其他洗耳液。它有一个触发器操作的喷嘴，可以同时冲洗和抽吸。它可以用于清醒、镇静或麻醉的动物，虽然它不像导管冲洗那样深入清洁，而且由于重力的原因，动物在侧卧状态下很难吸出液体。喷嘴的大小可能使它难以在小型犬和猫使用。最近Vetderm listserv讨论的参与者对它的有效性意见不一，这可能反映了各个中心看到的病例类型。其中一名作者(TN)发现Auriflush对于常规清洁非常有用，但更喜欢导管冲洗来彻底清洁耳道。
Video otoscopes 视频耳镜 The Karl Storz (Tuttlingen, Germany) video otoendoscope® and the MedRx (Largo, FL, USA) video otoscope® allow real-time imaging of the ear canals. The magnified image on the monitor is far superior to the view through a hand-held otoscope. Still images can be analysed to plan procedures or explain the condition of the ear canal to the owners. This is of enormous help in convincing some owners of the need for more aggressive treatment regimes. The video otoscope has ports for flushing and aspiration, which allows effective cleaning of the ear canal. Instruments, such as biopsy forceps, grasping forceps, etc., allow the operator to dislodge stubborn debris, remove ceruminoliths (see below) or take biopsies. The port also allows one to perform a visually guided myringotomy. The system is an excellent tool for imaging the external ear and tympanic membrane, cleaning the external ear canal and performing myringotomies. One disadvantage, however, is that the size of the otoscope head sometimes makes it difficult to use in cats, small dogs or stenosed ear canals. Karl Storz视频耳内窥镜和MedRx视频耳内窥镜可以对耳道进行实时成像。显示器上的放大图像远远优于通过手持耳镜看到的图像。静态图像可以分析，以制定操作计划或向宠主解释耳道的情况。这对于说服一些宠主需要更积极的治疗方案有很大的帮助。视频耳镜有冲洗和抽吸通道，可以有效地清洁耳道。使用活检钳、抓钳等器械，操作者可以取出顽固的碎片、去除耵聍石(见下文)或进行活检。该通道还允许可视化进行鼓膜切开术。该设备是一个极好的外耳和鼓膜成像、清洁外耳道和执行鼓膜切开术工具。然而，耳镜头的大小有时使其难以用于猫、小犬或狭窄的耳道。
Removing ceruminoliths 清除耵聍石 Ceruminoliths are concretions of cerumen, cornified material, hair, topical medications and other debris that accumulate following chronic otitis and subsequent failure of epidermal migration. They act as irritant foreign bodies and foci for infection. Ceruminoliths that are resistant to conservative cleaning methods should be removed under sedation or anaesthesia. They can be grasped using forceps through an operating or video otoscope or broken up with ceruminolytics and flushed out. Ear curettes or loops are very handy at removing adherent material but should be used under general anaesthesia to avoid damaging the ear canal or tympanic membrane. The loop is introduced into the ear through an operating otoscope and gently hooked over the obstruction. Drawing the edge outwards along the epidermal surface removes the obstruction. Alligator forceps are also useful, especially for cornified plugs, hairs and foreign bodies, but it may be difficult to open their jaws sufficiently in narrow ears. 耵聍石是由耵聍、角化物质、毛发、外用药和其他碎片凝固形成，这些物质在慢性耳炎和随后的表皮迁移失败后聚集。它们成为刺激物和感染的病灶。保守的清洁方法无法清除耵聍石，应在镇静或麻醉下清除。可以通过手术耳镜或视频耳镜用镊子抓住，也可以用耵聍溶解剂溶解开并冲洗出来。刮耳器或耳环在去除附着物方面非常方便，但应在全麻下使用，以避免损伤耳道或鼓膜。耳环通过手术耳镜进入耳部，轻轻钩住阻塞物。沿表皮向外牵拉边缘以清除阻塞。鳄鱼钳也很有用，特别是对角化栓塞物、毛发和异物，但在狭窄的耳道可能很难打开他们钳子。
Contraindications and side effects 禁忌症和副作用 Damage leading to vestibular syndrome, facial nerve paralysis, Horner’s syndrome or deafness is a potential concern when ear cleaning, particularly when using more aggressive techniques. It is also possible that vigorous struggling may lead to avulsion injuries of the ear canal in unsedated animals. In practice, however, the risk appears to be small. In one series of 105 dogs assessed by brainstem auditory-evoked responses, no deficits were seen after cleaning, although it is the authors’ impression that side effects are more common in cats. The relative safety of these techniques, however,does rely on their skilful application and it is prudent to obtain informed consent prior to ear flushing. 清洁耳部时，特别是使用更激进的技术时，可能会导致前庭综合征、面神经麻痹、霍纳氏综合征或耳聋。在未注射镇静剂的动物中，剧烈的挣扎也可能导致耳道撕裂伤。然而，在临床中，这种风险似乎很小。在一个由脑干听觉诱发反应评估的105只犬的病例分析中，没有发现清洁后听力下降，但作者认为在猫上副作用更常见。然而，这些技术的相对安全性确实取决于它们的熟练应用程度，在冲洗耳部之前，应谨慎地获得宠主知情同意。
CLEANING FLUIDS 洗耳液 The first maxim to consider when selecting a fluid is ‘do no harm’ (Table 1). Most cleansing is achieved by physically displacing material. It makes sense, therefore, to use nothing more potent than water or saline in most circumstances. Water or saline are particularly appropriate for cases with ruptured tympanic membranes as many other compounds are potentially ototoxic. Ceruminolytics, however, may be needed occasionally to dissolve ceruminous exudates. 选择液体时要考虑的第一条原则是“无害”(表1)。大多数洗耳液通过物质的物理置换实现的。因此，在大多数情况下，使用比水或盐水更有效的东西是有道理的。水或盐水特别适用于鼓膜破裂的情况，因为许多其他化合物有潜在的耳毒性。然而，有时可能需要使用耵聍溶解剂来溶解耵聍分泌物。
Ceruminolytics, surfactants and foaming agents 耵聍溶解剂、表面活性剂和发泡剂 Ceruminolytics are organic oils and solvents (e.g. propylene glycol, lanolin, glycerine, squalane, butylated hydroxytoluene, cocamidopropyl betaine and mineral oils) commonly included in ear cleaners to soften and dissolve cerumen. They are of most use in mildly waxy or dirty ears and are relatively safe for routine at-home cleaning if the tympanic membrane is intact. They are also used to soften impacted or dry debris prior to ear flushing or other cleaning techniques in the sedated or anaesthetized animal. It is, however, questionable if they are of much benefit in ears with a purulent discharge. 耵聍溶解剂是一种有机油和溶剂(如丙二醇、羊毛脂、甘油、角鲨烷、丁基羟基甲苯、椰油酰胺丙基甜菜碱和矿物油)，通常用于软化和溶解耵聍。它们最适用于轻度耳垢或脏的耳部，如果鼓膜完整的话，可相对安全的用于日常的家庭清洁。在对镇静或麻醉的动物进行耳部冲洗或其他清洁技术之前，它们还用于软化坚实的或干燥的碎片。然而，对于有脓性分泌物的耳部，它们是否有很大的好处，这是值得怀疑的。
Ceruminolytic surfactants are effective with both ceruminous and purulent debris. Surfactants help expedite the cleaning process by emulsifying debris, breaking it up and keeping it in solution. Some detergents can be irritating, particularly to the middle ear mucosa, and are contraindicated if the tympanic membrane is ruptured. Useful surfactants include dioctyl sodium sulfosuccinate (DSS or docusate), calcium sulfosuccinate and other detergents. 耵聍溶解表面活性剂对耵聍性和化脓性碎屑都有效。表面活性剂通过乳化碎屑，使其破碎并溶解在溶液中来加速清洗过程。有些清洁剂可能有刺激性，特别是对中耳黏膜，如果鼓膜破裂，就禁止使用。有效的表面活性剂包括多库酯钠(DSS或多库酯)、琥珀酸磺酸钙和其他洗涤剂。
Foaming agents such as urea and carbamide peroxides release oxygen in situ. This helps disperse debris and aerates the ear canals. The foaming action causes anxiety in some animals though. 发泡剂如尿素和尿素过氧化物在原位释放氧气。这有助于分散碎片和耳道通气。不过，这种起泡的作用会让一些动物感到焦虑。
Astringents or drying agents 收敛剂和干燥剂 Astringents dry the ear canal surface, to prevent maceration. They are often combined with ceruminolytics and surfactants in cleaning/drying products, but can also be used separately after ear cleaning or prophylactically after bathing or swimming in dogs that are prone to otitis. Using ear plugs can result in maceration, irritation or a foreign body in the ear canals. 收敛剂干燥耳道表面，防止浸渍。在清洁/干燥产品中，它们通常与耵聍溶解剂和表面活性剂结合使用，但也可以在清洗耳部后单独使用，或在易患耳炎的犬洗澡或游泳后进行预防性使用。使用耳塞会导致耳道浸渍、刺激或异物。
Commonly employed astringents include isopropyl alcohol, boric acid, benzoic acid, salicylic acid, sulfur, aluminium acetate and silicon dioxide. Acetic acid (2.0–5.0%) is an effective astringent and antimicrobial and is the preferred choice of one author (TN) in ears with ruptured tympanic membranes or where a contact sensitivity is suspected. A 2–2.5% solution is achieved by diluting distilled malt (or white) vinegar (few impurities; acetic acid content usually 5–8%) with saline or distilled water. Sulfur is astringent, antimicrobial, keratolytic and keratoplastic. Salicylic acid is keratoplastic at low concentrations and keratolytic at higher concentrations (above 2%). It is also bacteriostatic. These qualities may be of use in seborrhoeic and proliferative ears. 常用的收敛剂包括异丙醇、硼酸、苯甲酸、水杨酸、硫、醋酸铝和二氧化硅。醋酸(2.0-5.0%)是一种有效的收敛剂和抗菌剂，是一位作者(TN)对鼓膜破裂或怀疑接触致敏的耳部的首选。使用盐水或蒸馏水稀释蒸馏麦芽(或白)醋(少量杂质;醋酸含量通常为5 -8%)，得到2-2.5%溶液。硫是收敛、抗菌、角质溶解和角质形成剂。水杨酸在低浓度时可促进角质形成，在高浓度时(高于2%)可促进角质溶解。它也是抑菌剂。这些特性可能对脂溢性耳部和增生性耳部有用。
Antimicrobial agents 抗菌药物 Antimicrobial compounds are frequently incorporated in ear cleaners to retard microbial proliferation. An ear cleaner containing parachlorometaxylenol (PCMX) (Epi-Otic®) has potent in vitro and in vivo activity against Pseudomonas aeruginosa, Staphylococcus intermedius and Malassezia pachydermatis. Chlorhexidine (1–3%) is also active against Staphylococcus intermedius and Malassezia pachydermatis, but is less active against Pseudomonas. Solutions that maintain a low pH (e.g. Micro Pearls Advantage Advanced pHormula Ear Cleanser; EVSCO, Buena, NJ, USA) are also antimicrobial. 抗菌成份经常被加入到洗耳液中，以阻止微生物的增殖。一种含有对氯间二甲苯酚(PCMX) (Epi-Otic)的洗耳液，在体外和体内对铜绿假单胞菌、中间型葡萄球菌和厚皮马拉色菌有抑制活性。氯己定(1-3%)对中间型葡萄球菌和厚皮马拉色菌也有活性，但对假单胞菌的活性较低。维持低pH值也能抗菌。
Anti-inflammatory compounds 抗炎成份 Anti-inflammatory compounds present in some solutions can help prevent recurrent otitis associated with inflammatory diseases. Glucocorticoid solutions can also be used in conjunction with or added to ear cleaning fluids. Side effects are less common than with systemic therapy, but hypothalamic–pituitary– adrenal axis suppression, local cutaneous atrophy and immunosuppression can still occur. One should initially use more potent drugs (such as betamethasone and dexamethasone) followed by a switch to infrequent use of less potent drugs (such as prednisolone and hydrocortisone) for maintenance. 某些溶液中的抗炎成份有助于预防与炎性疾病相关的复发性耳炎。糖皮质激素溶液也可以联用或加入洗耳液中使用。副作用比全身治疗更少，但仍可发生下丘脑-垂体-肾上腺轴抑制、局部皮肤萎缩和免疫抑制。初期应该使用更强效的药物(如倍他米松和地塞米松)，然后使用中低强效药物替换(如泼尼松龙和氢化可的松)降低使用频率用于维持。
Contraindications and side effects 禁忌症和副作用 Some cleaning fluids may provoke inflammatory reactions, especially if introduced into the middle ear. Experimental inoculation of propylene glycol, DSS, carbamide peroxide and triethanolamine initiated inflammatory changes to the middle ear mucosa of normal dogs and guinea pigs, whereas squalane had no effect. Chlorhexidine is often regarded as ototoxic although experimental infusion at a concentration of 0.05% into normal canine ears caused no ill effects, whereas infusion of a 2% solution did cause ototoxicity. In these experiments, however, the compounds were directly inoculated into normal bullae without flushing and the effect in inflamed ears when combined with other cleaning techniques is unknown. In a study designed to simulate a clinical situation no vestibular or cochlear abnormalities were seen when 0.2% chlorhexidine was placed in the external ear canal of dogs with ruptured tympanic membranes. Nevertheless, in the absence of firm information about the integrity of the tympanic membranes caution should be exercised. 一些洗耳液可能会引起炎症反应，特别是如果进入中耳。实验接种丙二醇、DSS、过氧化脲和三乙醇胺可引起正常犬和豚鼠中耳黏膜炎性改变，而角鲨烷无影响。氯己定常被认为有耳毒性，但将0.05%浓度的氯己定输注于正常犬耳中无不良反应，而2%浓度的氯己定输注于正常犬耳中则有耳毒性。然而，在这些实验中，这些成份是直接接种到正常鼓泡内而不冲洗，当与其他清洁技术结合在一起时，对发炎的耳部的效果尚不清楚。本研究模拟了在鼓膜破裂的犬外耳道内放置0.2%氯己定，未见前庭或耳蜗异常的临床情况。然而，在没有关于鼓膜完整性的确切信息的情况下，应该谨慎行事。
A number of ingredients in ear cleaning fluids are potential contact sensitisers and/or irritants. One of the authors (TN) has seen several cases of chronic otitis with contact dermatitis to various proprietary ear cleaners and topical medications. Because these contain a variety of ingredients, it is often difficult to determine the offending substance. It is also unclear if this was a primary cause of the otitis or became a perpetuating factor after resolution of the initial problem; inflammation and breakdown of the normal epidermal barrier may enhance the risk of subsequent sensitization and/or irritation. Switching to a saline or a saline/ vinegar solution was curative in each case. 洗耳液中的一些成分是潜在的接触致敏和/或刺激物。其中一名作者(TN)曾见过几例使用各种自备洗耳液和外用药导致的慢性耳炎伴接触性皮炎病例。因为这些含有多种成分，通常很难确定有害物质。目前还不清楚这是导致耳炎的原发原因，还是在最初问题解决后成为了持久因素。炎症和正常表皮屏障的破坏可能会增加随后使用的致敏物和/或刺激物的风险。换用生理盐水或生理盐水/醋酸溶液在每种病例中都能有效。
In some instances, excessive topical therapy results in maceration of the lining of the ear canal. Clinically, this appears as an accumulation of white ceruminous debris in the ear canal. Cytologically, there is no infection, only desquamated epithelial cells with occasional mature, nondegenerate neutrophils. Treatment is directed at discontinuation of topical medications. 在某些情况下，过度的外部治疗会导致耳道内壁的浸渍。临床上，这表现为耳道内白色耵聍碎片的堆积。细胞学上，没有感染，只有脱落的上皮细胞，偶尔有成熟的、非退行性中性粒细胞。治疗方法是直接停止外用药。
CONCLUSION 结论 Most proprietary ear medications contain a variety of ingredients. Choosing the most appropriate product is akin to selecting a shampoo. The product and technique of choice very much depends on the individual patient and they may change as treatment progresses. It is of crucial importance to fully evaluate the primary, predisposing and perpetuating factors that contribute to the burden of disease in each patient. This information can then used to select the compounds that will counter these problems. Only then can the clinician choose between the wide array of products available. Proper application of the appropriate technique is vital; this again will change as the condition evolves. Ongoing training and support will also help clients maintain ear-cleaning regimes that will be effective in resolving otitis and preventing recurrence. 大多数耳药都含有多种成分。选择最合适的产品就像选择香波一样。选择的产品和技术在很大程度上取决于患病动物个体情况，它们可能随着治疗的进展而改变。重点是要对每位患病动物的原发病因、易感因素和持久因素进行充分评估。这些信息可以用来选择对抗这些问题的成份。只有这样，临床医生才能在各种各样的产品中进行选择。恰当地应用适当的技术是至关重要的，随着病情的发展，这种情况也会改变。进行宠主教育和持续提供支持，使宠主掌握洗耳方法，这将有效地解决耳炎和防止复发。
Figure 1. Normal tympanic membrane viewed through a video otoscope (image courtesy of MedRx Inc.). 图1。通过视频耳镜观察正常的鼓膜。 Figure 2. (a, b) Ear flushing kit: operating otoscope, urinary catheter, 3-way tap, 10 mL syringe, intravenous infusion or giving set and 0.9% saline prior to use. Ear flush under way in a dog. 图2。(a, b)耳部冲洗设备:手术耳镜、导尿管、三通阀、10ml注射器、静脉输液器，备用的0.9%生理盐水。一只犬使用此方法进行耳部冲洗。 Figure 3. (a, b) Auriflush system: main housing attached to a shower pipe. Trigger operated nozzle being used to clean the ears of a sedated dog with ceruminous otitis externa. 图3。(a, b)Auriflush设备:主机连接淋浴水管。扳机操作的喷嘴，用于清洁患有耵聍性外耳炎的已镇静的患犬。
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发表于 2022-7-9 18:51:48
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