海上莲舟

同赏清芬:
我在基层医院工作,做鼓膜穿刺的时候从来也没想过上麻醉,不过好象也没有不能接受的病人,而且,还没有遇到过感染的病例.
抽鼓室积液的时候,可把针管先抽进一点气,这样在抽的时候,就不会有太大阻力,因为针管和针芯接触后,本身就会产生一定的阻力.
五号长针头太细,抽的时候费劲,不容易固定,但疼痛稍轻,我用七号的长针头.

dbf056:
也听说有人用百分之十的丁卡因，但我是用激光进行鼓膜打孔的，不管怎么麻，病人总是说痛，有什么好办法吗？

中行独复:
用5号长针头穿刺鼓膜，因针头较细，病人痛苦小。2%的卡因麻醉即可。即使黏液较稠，地塞米松加靡蛋白酶也可冲洗出。注意：抽吸与注射药物两处进针。

冬天里的龙:
化妆品的好坏不只在于它用了什么这素那素的，重要的一方面是它的透皮性，波南氏液之所以起作用就因为里面有石炭酸，有它才能使麻醉药穿过上皮层，明白道理你就可以配张氏，李氏，王氏液了......
其实，多年的实践中，感觉鼓膜穿刺无麻和有麻没多大区别，消毒和不消毒也没什么区别，穿刺后，还有那么多抗生素等着呢！
鼓膜置管有条件的话住院做，传统的外耳道四点阻滞麻醉对成人效果不错，儿童当然用全麻了，可以增加科室的收入。

med_light
网上找到的关于鼓膜穿刺麻醉和镇痛的方法：
Analgesia:
Proponents of analgesic approaches to managing procedural discomfort typically cite ease of use and the potential bacteriostatic effects of topical anesthetic solutions as the primary reasons for their preference.
1. Acetaminophen with codeine seems to be the analgesic combination most often employed prior to tympanocentesis. Typical dose levels are 1 mg/kg codeine with 10 to 15 mg/kg acetaminophen.
2. Midazolam, given either orally or intranasally, is mentioned frequently for its combined analgesic, amnesic, and anxiolytic effects. This approach should not be considered without prior training in conscious sedation techniques.
3. Ketamine, at 5 to 10 mg/kg, is described as an effective procedural analgesic, but can produce some undesirable side effects. This approach also should be considered only by those trained in conscious sedation techniques.
4. Nitrous oxide is occasionally mentioned, predominately for its amnesic and anxiolytic effects, but has not attracted a measurable following to date.
5. Diazepam, meperidine, and morphine have all at one time or another been mentioned as analgesic or sedative options, but receive infrequent mention in recent literature.
Anesthesia:Proponents of anesthetic approaches to managing procedural discomfort generally cite better pain reduction and faster effect as the primary reasons for their preference.
1. A solution of 8% tetracaine applied topically to the membrane, held in place by a cotton dam or a wick, is said to provide anesthesia of the membrane in as little as 15 minutes. By taking care to remove excess solution from the canal prior to the procedure, the risk of bacteriostatic effect on acquired sample fluid is minimized.
2. A solution of 15% lidocaine, similarly employed, is said to produce comparable effect, but requires as much as 30 minutes for full anesthesia.
3. Lidocaine infiltration of either the external auditory meatus or the osseocartilaginous region of the canal is described as very effective, but can be more difficult and/or painful than the procedure itself.
4. Iontophoresis with lidocaine is said to produce local anesthesia in as little as 11 minutes, but requires specialized equipment.
5. EMLA cream is another option described as effective in less than 30 minutes, but is noted to be difficult to apply and hold in place, and also difficult to cleanse from the ear canal.
6. Phenol applied directly to the membrane is still mentioned as both a fast and effective approach, but has been described as potentially painful to the patient during application.
7. Lignocaine 10% spray is occasionally mentioned, but usually described as ineffective.
Occasionally one reads an article suggesting that pre-procedure analgesia / anesthesia for tympanocentesis is unnecessary. The most common claim seems to be that the brevity of the procedure obviates the need for pain management. Widespread acceptance of this position appears unlikely, but it is arguable that, in some cases, an obviously distressed patient presenting with a severely bulging membrane might prefer the immediate relief offered by a tap to 20 minutes of continued discomfort while waiting for an anesthetic to take effect.
bibliography:
Dudley JP. Making tympanocentesis easier. J Emerg Med. 1990;8:765-767.
Hoberman A, Paradise JL. Acute otitis media: diagnosis and management in the year 2000. Pediatric Annals. 2000;29(10):609-620.
Hoberman A, Paradise JL, Wald ER. Tympanocentesis technique revisited. Pediatr Infect Dis J. 1997;16:S25-S26.
Kaplan SL, Feigin RD. Simplified technique for tympanocentesis. Pediatrics. 1978; 62(3):418-419
Luotonen J, Laitakari K, Karjalainen H, Jokinen K. EMLA in local anaesthesia of the tympanic membrane. Acta Otolaryngol(Stockh). 1992; Suppl.492:63-7.
Schmidt, SH. Anesthesia of the tympanic membrane. Arch Otolaryngol Head Neck Surg. 1995:121(3):353-4.
Schwartz RH. Myringotomy: A neglected office procedure. Am Fam Physician. 1979; 20:102-108.
Silverstein H, Kuhn J, Choo D, Krespi YP, et al. Laser-assisted tympanostomy. Laryngoscope. 1996;106(9 Pt 1):1067-1074.
van Buchem FL, Dunk JH, van't Hof MA. Therapy of acute otitis media: myringotomy, antibiotics, or neither? A double blind study in children.
Lancet.1981; 24;2(8252):883-887.
图为channel directed typanocentesis speculum, 不知道好用不好用
[Cyberake按:该装置包括窥耳器、自抽吸的穿刺针，应该说比较方便，但是为了这样一个简单操作设计特制装置，未必值得，不过外国人的研究确实比较细腻。]

另一篇关于鼓膜切开麻醉的文章，可以借鉴一下。
Tetracaine Topical Anesthesia for Myringotomy
Ronald A. Hoffman, MD; Chun-Lun J. Li, MD
Objectives/Hypothesis: To study the efficacy and safety of topical tetracaine anesthesia for office myringotomy and myringotomy with a tube. Study Design: Retrospective review of patients undergoing office myringotomy, with or without tube insertion, performed over a 4-year period. Methods: A topical solution of 8% tetracaine base in 70% isopropyl alcohol was used in 381 ears. Five to 10 drops of the solution were applied to the tympanic membrane for 10 to 15 minutes and aspirated. Myringotomy was performed either with a myringotomy knife or with a CO2 laser (OtoLAM). Results: Topical tetracaine was used in all 231 ears (100%) undergoing myringotomy without a tube and 150 of 212 ears (71%) undergoing myringotomy with a tube. Tetracaine alone was effective in providing tympanic membrane anesthesia in 95% of myringotomy without a tube (220 ears) and in 93% of myringotomy with a tube (139 ears). There were six complications, including five cases of severe vertigo and one unusual prolonged, transient facial nerve weakness. Conclusion: Topical tetracaine is efficacious and safe for use in office myringotomy.
Key Words: Tetracaine, myringotomy, topical anesthesia.
Laryngoscope, 111:1636–1638, 2001

Cyberake:
我们详细讨论一下布南氏液代用的问题！
一些可能用到的基本的数据：
薄荷脑分子式：C10H20O，分子量：156.27
苯酚分子式：C6H6O 分子量94.11
盐酸可卡因分子式：C17H21NO4.HCl，分子量339.82
盐酸地卡因分子式：C15H24N2O2.HCl，分子量300.83
这里我们假定配置药液时用的是质量/容积百分比浓度，否则可能不容易计算，实际上多数情况下就是这样配制的。
可卡因表麻浓度范围是1~10%，一般为4%，也就是说配置100ml表麻药应该加入4g可卡因，那么等量加入薄荷脑、苯酚各4克，相应地溶液中的薄荷脑与苯酚的浓度都是4%。
如果用地卡因替代，有两种方案：
第一种等量地卡因与等量薄荷脑、苯酚混合，最后配成地卡因1%溶液。我不赞成这样做，由于地卡因与可卡因分子量不同，表麻浓度不同，所以这样配两种溶液中的苯酚、薄荷脑的终浓度不一致。
第二种方法使得两种溶液中的苯酚、薄荷脑浓度一致，所以可以这样配置：1%地卡因溶液100ml中加入苯酚和薄荷脑各4g。我赞成这种方案。
下面讨论一下安全性、可行性的问题。可卡因、地卡因均在预计的表麻浓度范围中，没有问题。
薄荷脑 Menthol：在乙醇，氯仿，乙醚，液状石蜡或挥发油中极易溶解，在水中溶解极微。薄荷脑能选择性地刺激人体皮肤或黏膜的冷觉感受器，产生冷觉反射和冷感，引起皮肤黏膜血管收缩（实际上皮肤保持正常），对深部组织的血管也可引起收缩而产生治疗作用。外用可以消炎，止痛，止痒，促进血液循环，减轻浮肿等。
我想薄荷脑在这个制剂中是为了收缩血管的吧，我们平时用的薄荷油好像是1%的，4%浓度应改不会有太大的安全问题，关键是水溶液能不能配成4%？上面的帖中有的战友说他使用的是水溶液，不过我用的是油剂。
再看苯酚Phenol：本品稀溶液可使人体感觉神经末梢麻痹，产生局部麻醉作用，可止痒。5%的苯酚溶液用于无损伤的表皮会引起温暖和刺痛感，最后可导致局部完全麻醉。5%溶液对暴露组织有较强刺激并可导致坏死。酚甘油（1~2%）用于中耳炎。对组织的穿透力极强，仅在小面积皮肤上使用，高浓度（10%以上水溶液有腐蚀性）外用可引起皮肤组织损伤，甚至坏死。皮肤灼伤：创面初期为无痛性白色起皱，继而形成褐色痂皮。常见浅Ⅱ度灼伤。用于体表皮肤的水溶液浓度不宜超过2%，外用后不加封包。复方。浓度不超过2%。
原来这个配方中的苯酚除了增加表麻药物的穿透之外自身也有局麻作用啊！不过我产生了另一个疑问，4%的浓度在鼓膜表面短时间使用到底安全么？我曾经使用过的布南氏液确实能在鼓膜表面产生一个白色的区域。
大家看看我说的两种配制方法那种正确？配成的浓度安全性如何？另外就是水溶液还是应该配成油剂？有没有战友有详细的布南氏液配法？要不要请制剂版块的战友来发表一下意见？
PS:
我在郑中立编的《耳鼻咽喉科治疗学》P.350看到：Bonain's液（4%利多卡因30ml，石炭酸5ml，酒精45ml，加蒸馏水20ml），或可卡因、石炭酸、薄荷等分加入适当肾上腺素。
按：这个配制方法好像详细多了，不过一般苯酚是固体啊，石炭酸5ml到底浓度是多少？？不过我在国外的文章中看到了用90%的苯酚单独直接用作鼓膜麻醉剂！

lq9189:
一位在美国行医近20年的老前辈介绍，可用6%的丁卡因点入外耳道，放置30分钟进行鼓膜麻醉。

lanzhijie:
Bonaine's液我用过，效果不错。对付穿刺没有问题。但是对于外耳道较窄的患者，给与置管时，有时器械不小心碰倒外耳道骨段的皮肤，会很痛。Bonaine's还有一个问题是，做鼓膜切开的时候，麻醉液接触过的地方会变得张力很低，切开时没有支撑的力量，如果切开刀不是很锋利，会造成撕裂。好处是基本没有出血，而且用量少，我95年从北医大人民医院带回来一瓶500ml的，用了将近6年。
在日本是用鼓膜麻醉机，先在外耳道内灌入4%利多卡因，外耳道和耳周放置电极，用离子导入的方法进行麻醉，效果非常好，不过不知道国内有没有得卖。

大雪纷飞蓝天白云：
三种方法：1.不麻醉，当然会疼的；2.的卡因麻醉，效果虽然差些，但是也有效；3.布难氏液麻醉，效果不错。
无锡的卖鼓膜置管器械的程冯卖布南氏液，就是贵了点。

gloom2000：
我们医院的鼓膜穿刺时先用地卡因麻醉五分钟，然后是酒精消毒只是擦拭外耳道和鼓膜，在我穿的一些病例中，我发现感觉疼痛非常明显的都是４０岁以上或１０几岁的女性，而且在有充分的心理准备的病例中，感觉疼痛的明显减少，所以我想穿刺的疼痛感多数还是心理的因素吧，但是，良好的麻醉肯定是有用的．

wzhx007 ：
其实鼓膜穿刺的麻醉，我想最关键的是要熟悉鼓膜的神经分布，鼓膜外侧面的神经支配来自耳颞神经和迷走神经耳内支，鼓膜内侧面的神经支配来自舌咽神经鼓室支。鼓膜外侧面的神经纤维分布以松弛部和锤骨柄较为密集，鼓脐以下分别较少。我们常于鼓膜后下部行鼓膜穿刺，疼痛较轻。成人可用7号长针头于无菌操作原则下直接穿刺，不用麻醉。儿童则视情况予以粘麻或全麻下进行。

advance98254：
我用“布南（包宁）氏液”做过鼓膜修补，麻醉效果很好！我们科主任不知道从哪里弄来的一瓶，听说一瓶是要100来元钱。

Cyberake：
不少人对布南液感兴趣，前面的帖子已经说过了，可卡因可以用地卡因代用，我也引用了有关配方，问题是我提出的问题还是没有解决，三种成分都是固体，最后溶解在什么溶液里？浓度多少？
我以前用的好像是类似油剂的东西。

drcj2663：
鼓膜麻醉剂:石炭酸,可卡因,丁卡因. 1:1:1等量调和。

Cyberake：
布南（包宁）氏液：石炭酸、可卡因、薄荷脑等量调和。
问题是可卡因是不是搞不到？换成地卡因可以么？

bcww：
我对布南氏液的配制很干兴趣，有什么好方法吗？我现在都是用丁卡因表麻，说实在的，效果差！

Cyberake：
有些置管器械商如无锡程冯代卖布南氏液，好像70元可用100次。我没买过。
布南氏液麻醉效果确实好。我用“古董”布南氏液给一个病人麻醉，穿刺时她全无反应，我以为她不太怕痛，第二次无麻下穿刺，她眼泪也出来了！

drcj2663:
换成地卡因可以 。

Cyerake:
地卡因、石炭酸、薄荷脑等量？
溶解在甘油中？多少浓度？
ZT:
[药品名]包宁氏麻醉剂
[英文名]Anaesthesia Baonini
[处方]盐酸可卡因、苯酚、薄荷脑各等量。
[作用与用途]为局部麻醉药。用于耳、鼻、喉小手术如鼓膜穿刺、切开、插管、修补等。
[用法与用量]用小块棉片蘸本品，贴于鼓膜，10分钟后即可进行手术。
[注意事项]盐酸可卡因也可以盐酸丁卡因代。
[贮藏]避光，密闭保存。