• Otitis( inflammation of the middle ear) symptoms and treatment

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    Otitis is a general definition of various inflammatory diseases of the ear.

    The middle ear is a system of airway cavities, which includes: the tympanum, auditory tube, cave entrance, mastoid cave and mastoid cells opening into it.

    In inflammatory diseases of the middle ear, all its departments are usually involved in the pathological process, however, the severity and localization of disorders in various diseases differ. An important role in pathology is played by the topographic and anatomical features of the middle ear.

    The upper bone wall of the tympanic cavity and mastoid cave lies at the bottom of the middle cranial fossa, where the temporal lobe of the brain is located. In this bone plate in adults, there are dehydration, and in children of the first years of life on the border of the stony and scaly parts of the temporal bone in the region of the drum's roof there is an uncontaminated stony-scaly fissure( fissura petrosquamosa).The contact of the mucosa of the middle ear with the dura mater makes it possible to spread the infection into the cranial cavity.

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    Medial( labyrinth, promontorial) wall delimits the tympanum from the inner ear, here are the windows of the vestibule and the cochlea. Through the membranous formations of labyrinthine windows, the infection can penetrate into the inner ear and cause the development of the labyrinthite.

    Here, on the medial wall, there is a channel of the facial nerve( canalis n. Facialis) in the bone bed, in which its horizontal knee passes. The defeat of the facial nerve( paresis or even paralysis) with various forms of otitis can occur due to exposure to microbial toxins, direct compression of the nerve or even destruction of its trunk with cholesteatoma.

    The posterior part of the middle ear is represented by the mastoid processus( processus mastoideus), in which there are numerous air-bearing cells connected to the tympanic cavity by an antrum mastoideum. The ostoid cave is an airy cell of round shape that is constantly present in the mastoid process, regardless of its shape and structure. This is a reliable anatomical landmark for operations on the ear. In the children of the first year of life, the mastoid process is not developed, but the mastoid cave is already present at birth. In newborns, it is located superficially( at a depth of 2-4 mm) and somewhat above the auditory canal. The development of the mastoid process in the child begins in the 2nd year of life and is completed by the beginning of the 7th year, with the cave gradually shifting back and forth.

    Depending on the number, size and location of cells in the mastoid process, several types of its structure are distinguished: pneumatic, diploid and sclerotic. The character of the emerging pathology largely depends on the nature of the structure of the mastoid process. Thus, in the sclerotic structure of a man, from childhood suffering from chronic purulent otitis media, an underdeveloped mastoid process is formed;the pneumatic structure of the shoot is more likely to develop mastoiditis.

    To the posterior surface of the mastoid process is a sigmoid sinus( sinus sigmoideus) - the venous sinus, through which blood is drained from the brain into the jugular vein system. Under the bottom of the tympanic cavity, the sigmoid sinus forms an extension - the bulb of the internal jugular vein. Sinus is delimited from the cellular system of the mastoid process by a thin, but sufficiently dense bony plate( lamina vitrea).Developing in the mastoid process with some diseases of the middle ear, a destructive-inflammatory process can lead to the destruction of this plate and the penetration of infection into the sinus and posterior cranial fossa.

    The anterior wall of the tympanic cavity is called the tubular, or carotid, wall( paries tubaria s. Caroticus).The upper half of this wall is occupied by two apertures, the larger of which is called the tympanic mouth of the auditory tube( ostium tympanicum tubae auditivae).Above it opens the semicircle of the muscle, which stretches the eardrum( t. Tensor tympani).In the lower part, the anterior wall is formed by a thin bone plate separating the tympanic cavity from the trunk of the internal carotid artery passing through the same channel. This wall is permeated with thin tubules, through which the inflammatory process can pass from the tympanum to the carotid artery.

    The mucous membrane of the tympanic cavity is a continuation of the mucous membrane of the nasopharynx and is represented by a single-layered flat and transitional ciliary epithelium with few goblet cells. Covering the auditory ossicles and ligaments, the mucous membrane forms many communicating pockets and sinuses, among which the most significant in clinical terms are the drum and facial sinuses. The drum sinus( sinus tympani) is under a pyramidal elevation and extends to the bulb of the jugular vein and the snail's window. The sinus facialis is limited by the medial canal of the facial nerve, posteriorly by a pyramidal elevation and in front by a cape.

    Inflammation of the outer ear often occurs due to infection and affects the skin of the outer ear, which includes not only the visible ear, but also a part of the ear canal leading to the inner parts of the ear. Sometimes inflammation has a localized character. Although inflammation can be painful and unpleasant, it is often well treatable. However, in diabetic patients, elderly people and people with weakened immunity, the disease can lead to malignant otitis media of the external ear, a rare non carcinogenic( despite the name) disease. How to treat otitis in children look here.

    • Moisture in the ear promotes the development of fungal and some types of bacterial infectious diseases. Swimming, especially in contaminated water, increases the risk of otitis externa;bathing in the shower, washing hair, or being in the rain practically do not increase the risk of the disease.

    • Diseases of the skin, for example eczema or seborrheic dermatitis, can cause inflammation.

    • Items inserted in the ear, such as cotton swabs, can create small cuts that are vulnerable to infection.

    • Excessive sulfur production makes the ear more vulnerable to infection.

    • Sulfur remover, hair dye, shampoo, lacquer or chlorinated water may irritate the ear canal.

    The doctor examines the ear canal using an otoscope. An analysis of the culture of liquid discharge from the ear can be made.

    • Itching in the ear canal in the early stages.

    • Pain in the ear that can become severe. The ear becomes sensitive to touch, and the pain worsens when the auricle is pulled back.

    • Isolation of fluid or pus from the ear canal.

    • Redness and swelling of the skin of the ear canal( and sometimes the outer ear), which leads to occlusion of the ear canal.

    • Small, painful lump or furuncle in the ear canal.

    • Temporary hearing loss due to swelling and accumulation of pus in the ear canal.

    • Fever.

    • You can take painkillers that are sold without a prescription. Children should take acetaminophen, not aspirin.

    • Your doctor may use a small suction device to remove fluid and pus from the ear canal.

    • Antibiotics or antifungal ear drops can be prescribed to fight infection;in addition to these, corticosteroids are used to reduce inflammation. A spongy wick can be inserted into the ear to allow drugs to penetrate deep into the ear canal.

    • In case of severe infection, oral antibiotics may be taken.

    • Surgical removal of dead tissue may be required in the treatment of severe otitis media of the external ear.

    • Codeine or drugs can be prescribed to reduce severe pain.

    • After the symptoms disappear, avoid ingesting water in the ear canal for three weeks;protect your ears when taking a shower, and do not swim.

    • In case of recurrence of the disease, continue using prescribed ear drops to relieve symptoms.

    • Consult a doctor if symptoms persist for more than one or two days.(People with diabetes should consult a doctor at the first sign of an ear infection.)

    • Do not put anything in your ear, even cotton swabs, and do not brush your ear with alcohol or with solutions sold over the counter. Your doctor can remove sulfur.

    • If you frequently experience itching in the ear canal, consult a doctor. Treatment of skin disease will help prevent secondary infection.

    • Avoid swimming in water that can be contaminated.

    • If you swim in water that could cause otitis media, flush your ears with water acidified with vinegar;this can prevent infection.

    The primary development of pathological changes in this or that part of the middle ear determines the existence of various nosological forms of the disease. Thus, the localization of disturbances, mainly in the auditory tube, is interpreted as eustachiitis or catarrhal otitis media;inflammation, which developed mainly in the tympanic cavity, is referred to as "otitis media", and pathology in the mastoid cave and adjacent cells is called mastoidite.

    Diseases of the middle ear are rarely primary. An important role in their development is played by dysfunction of the auditory tube, which is usually a reflection of pathological changes in the upper respiratory tract. Therefore, medical measures are aimed primarily at restoring the normal functioning of the auditory tube.

    Because of the peculiarities of the anatomical and morphological structure of the middle ear, the inflammatory changes developing in it are characterized by the predominance of the exudative form of inflammation, in which the reactions of the microcirculation system prevail over the processes of alteration and proliferation. The amount of protein and cellular composition of the exudate can fluctuate depending on the degree of impairment of vascular permeability.

    Among the different types of exudative inflammation of the mucosa of the middle ear, most often there are catarrhal, serous and purulent.

    Inflammation of the middle ear is a disease of the cavity between the tympanic membrane and the delicate structures of the inner ear. Typically, it occurs when viruses that cause the disease of the upper respiratory tract( eg, runny nose), or the bacteria migrate along the eustachian tube( the passage between the nasal canals and the middle ear).Infection often leads to blockage of the tube, interfering with mucus, pus and other fluids produced during illness, flowing out of the middle ear. It hurts because these fluids put pressure on the eardrum and can break it. Infections of the middle ear are very common in children( because they have a less Eustachian tube) and tend to repeat, especially in winter. With quick treatment, there are all possibilities for full recovery. In the absence of treatment, chronic otitis media of the middle ear can eventually cause a serious structural disturbance to the ear and skull, which results in irreversible hearing loss or weakness of the facial nerve.

    • Viral infection of the upper respiratory tract is the most common cause.

    • Allergic rhinitis or adenoids can cause blockage of the Eustachian tube.

    • The ruptured eardrum makes it easier for the carriers of the infection to enter the middle ear.

    • Children with congenital anatomical facial defects( such as the "hare lip") or children with

    Down syndrome are at greater risk of infectious diseases of the middle ear.

    • Some groups of people have a hereditary predisposition to infectious diseases of the ear.

    • Passive smoking increases the risk of infectious diseases of the middle ear in children.

    • Repeated bacterial diseases of the ear can result in chronic inflammation of the middle ear.

    • Feeling of fullness of the ear, which ultimately leads to severe pain.

    • Temporary hearing loss in the patient ear.

    • Fever.

    • Dizziness.

    • Nausea and vomiting.

    • Clicks or other sounds in the ear when the jaw moves.

    • Pain when back draining the ear.

    • Persistent effusion of pus and mild hearing loss often without ear pain( primary signs of chronic middle ear inflammation).

    • The doctor should examine the ear canal with a nasal instrument - a small instrument with lighting. An analysis of the culture of liquid discharge from the ear can be made.

    • Antibiotics may be needed to treat bacterial infection.

    • Aspirin or acetaminophen is taken to relieve pain and fever.

    • Your doctor may recommend decongestants or antihistamines.

    • A small incision in the tympanic membrane( myringotomy) can be made to release pus. This incision heals in two to three weeks. With myringotomy, a tube can be inserted to drain the middle ear during the period of fluid accumulation.

    • Enlarged adenoids can be removed surgically.

    • Sometimes an infectious disease affects the mastoid process( the bone behind the ear), which must be surgically removed.

    • Consult your doctor if you or your child feel pain in the ear that persists despite treatment, especially if the symptoms worsen or are accompanied by a swelling around the ear, a twitching of the face or severe ear pain that suddenly stops( indicating a rupture of the drumwebbeds).

    • Hand washing with soap in warm water must be mandatory for children and adults in schools and children's institutions.

    • At home, wash your bed linen, towels and hot water bottles regularly to prevent re-infection from the remains of pus. Discard the cotton balls after use.

    Catarrh of the mucous membrane of the middle ear, which developed as a result of dysfunction of the auditory tube, is denoted by the term "tubo-otitis," or "eustachiitis."There is usually no free effusion in the tympanum with this disease. The main role is played by the pathological process in the auditory tube, leading to a disruption of its functions, a violation of the ventilation of the tympanic cavity and moderately pronounced inflammation in the latter. Infection of the mucous membrane of the auditory tube occurs with acute respiratory infections, influenza, and in children also with acute infectious diseases accompanied by catarrh of the upper respiratory tract. The causative agents of tubotitis are viruses, streptococci, staphylococci, etc.

    Tubular dysfunction is more resistant in adenoid vegetations, various chronic diseases of the nasal cavity and paranasal sinuses( chronic purulent or polyposis rhinosinusitis, choanal polyps, curvature of the septum of the nose, hypertrophy of the posterior ends of the inferior nasal conchae andetc.), as well as with a nasopharyngeal tumor. The cause of some forms of tubotitis can be sudden changes in atmospheric pressure during the ascent and descent of an airplane( aerotitis), when immersed and surfaced divers and submariners( mareotite).

    If the ventilation of the tympanic cavity is impaired, the air contained in it is absorbed by the mucous membrane, and the replenishment of the air reserve is hampered by the compression of the mouth of the tube. As a result, the pressure in the tympanum cavity falls, the air in it becomes sparse. In this case, the tympanic membrane is retracted, and the transudate may appear in the tympanic cavity.

    Clinic. A patient with tubo-otitis complains of a feeling of ear congestion, a decrease in hearing, sometimes noise in the ear, autophony( resonating his own voice in the patient's ear).Ejaculation of the ear can occur during an acute respiratory viral infection or during a reconvalescence after it, as well as after a shift in atmospheric pressure, for example, after flying in an airplane. Pain in the ear is usually absent or slightly expressed, the general condition suffers little.

    Diagnostics of the .With otoscopy, the tympanic membrane can be observed, as indicated by the apparent shortening of the hammer handle, a sharp distance to the ear canal of the short process, more pronounced anterior and posterior folds, disappearance or deformation of the light cone. Sometimes a radial injection of the tympanic vessels along the handle of the malleus or a circular injection of vessels in the annulus tympanicus region is determined.

    Rumor in acute tubootitis is reduced slightly( up to 20 -30 dB), mainly due to disturbance of sound at low frequencies. Sometimes patients notice improvement in hearing after yawning or swallowing of saliva, which is accompanied by opening the lumen of the auditory tube.

    Treatment of tubo-otitis is primarily aimed at eliminating adverse factors affecting the state of the pharyngeal ear of the auditory tube. To reduce the swelling of the mucosa in this area, the patient is prescribed vasoconstrictive drops in the nose( naphthysine, sanorin, tizin, nazivin, etc.).Anti-histamine drugs( suprastin, astemizole, claritin, etc.) also contribute to the reduction of edema of the mucous membrane. To prevent the transfer of infected mucus from the nasopharynx through the auditory tube into the tympanum, the patient should be cautioned against too vigorous blowing.

    If there are inflammatory changes in the nasopharynx, do not blow the ear tubes through the Politzer;preference is given to the catheterization of the auditory tube, performed after careful anemization of its pharyngeal mouth. Through the catheter, a few drops of 0.1% solution of adrenaline or dexamethasone can be injected into the lumen of the auditory tube. The complex of therapeutic measures includes various physiotherapeutic procedures: UFO, UHF on the nose, laser therapy on the mouth of the auditory tube, pneumomassage of the tympanic membrane.

    Acute tubo-otitis with adequate treatment usually takes place in a few days. The effectiveness of therapy depends on the timely elimination of the pathology of the nasal cavity, paranasal sinuses and nasopharynx, which contribute to the emergence and maintain the flow of tubo-otitis.

    This disease develops against the background of dysfunction of the auditory tube and is characterized by the presence of a serous-mucous effusion in the tympanic cavity.

    The leading pathogenetic factor of exudative otitis media is a persistent violation of the ventilation function of the auditory tube. The very name of this form of the disease indicates an increased secretion of mucus and a prolonged course. In this regard, its characteristic features include the appearance in the tympanic cavity of a thick viscous secretion, the slowly increasing hearing loss and the long absence of a defect of the tympanic membrane.

    In the basis of exudative otitis media, in addition to persistent tubal dysfunction, there is a change in the immunobiological properties of the body, a reduction in overall and local resistance. The cause may be a transferred respiratory viral infection, an unreasonably broad and irrational use of antibiotics. An important role is played by immunopathological reactions, which indicate the development of sensitization of the mucosa of the middle ear.

    Given the dynamics of the inflammatory process and the corresponding pathomorphological changes, four stages of the disease are distinguished.

    I stage - catarrhal. At this stage, due to a violation of the ventilation function of the auditory tube and the formation of a negative pressure in the tympanum cavity, conditions are created for the appearance of the transudate. There is a migration of a small amount of neutrophilic leukocytes and lymphocytes, the secretory elements show a readiness to release mucus. Clinically, in this case, the tympanic membrane is retracted. Its color varies from cloudy to pink, light autophony appears, slight decrease in hearing( the thresholds of air sound do not exceed 20 dB, the thresholds of bone conduction remain normal).The duration of the catarrhal stage is up to one month.

    II stage - secretory. It is characterized by intensive secretion and accumulation of mucus in the tympanum. Metaplasia of the mucous membrane of the middle ear develops with an increase in the number of secretory glands and goblet cells. Subjectively this is manifested by a feeling of fullness and pressure in the ear, sometimes by noise in the ear and more pronounced conductive hearing loss( up to 20-30 dB).Often the patient feels a transfusion in the ear of a liquid( splash) when the position of the head changes and simultaneously hears improvement in hearing. This can be explained by the fact that when the head tilts the liquid in the tympanic cavity moves, while the niches of the windows of the labyrinth are released and hearing is improved.

    When otoscopic note that the tympanic membrane is retracted, its contours are expressed, the color depends on the contents of the tympanic cavity and changes from pale gray to cyanotic with a brownish hue. Sometimes, with otoscopy through the membrane, the level of fluid in the form of an arcuate line is visible, which moves when the position of the head changes. The duration of the secretory stage can be from 1 to 12 months.

    III stage - mucous. This stage is different in that the contents of the tympanic cavity( and sometimes other cavities of the middle ear) become thick and viscous. At the same time, hearing loss increases( with thresholds up to 30-50 dB), in some cases the thresholds of bone sound conduction are increased. If the entire tympanic cavity is filled with exudate or if the whole becomes viscous and dense, the symptom of the movement of the liquid disappears. To refer to such otitis( with sticky, sticky contents in the tympanic cavity), some authors use the term "sticky ear".Mucous stage develops with the total duration of the disease from 12 to 24 months.

    IV stage - fibrous. It is characterized by the predominance of degenerative processes in the mucous membrane of the tympanic cavity. At the same time, the production of mucus is reduced, and then completely stops, fibrous transformation of the mucosa begins with involvement of the auditory ossicles in the process. Mixed hearing loss progresses. The development of scar process in the tympanic cavity leads to the formation of an adhesive middle otitis.

    Diagnostics. When diagnosing exudative otitis media, factors that can cause tubal dysfunction must be considered. First conduct research nasal cavity to reveal obvious abnormalities, such as the nasal septum deformation, inflammatory changes in the paranasal sinuses, hypertrophy of the rear ends of the lower turbinate et al. Also take into account any changes architectonic nasal cavity accompanied by obstruction of airflowon inhaling and exhaling.

    Otoscopy and omicroscopy allow you to assess the color of the tympanic membrane, its transparency, thickness, elasticity, mobility and vascularity. Tonal threshold audiometry reveals a violation of sound in the speech frequency zone and allows us to determine the bone-to-air rupture to 30-40 dB.

    A highly informative method for diagnosing this form of the disease is acoustic impedance-sometry - measuring the acoustic resistance( compliance) of the outer, middle and inner ear. The technique allows to assess the elasticity of the tympanic membrane, the level of pressure and the presence of exudate in the tympanic cavity, the function of the auditory tube.

    Pathognomonic for exudative otitis media are tympanogram of type C( which show decrease in peak height tympanogram and reduced tympanic pressure) and type B( reduced amplitude tympanogram sometimes to the horizontal line).

    In the diagnosis of exudative otitis media, acoustic reflexometry is also used - the registration of the compliance of the sound-transmitting apparatus with the reduction of the stremna muscle. The threshold of the acoustic reflex is normally 80-100 dB.With conductive hearing loss, an acoustic reflex on the side of the ear is usually absent.

    Treatment. The effectiveness of treatment of exudative otitis media is higher the earlier it was started. First of all, you should strive to restore the function of the auditory tube. This is achieved by sanation of inflammatory diseases of the nose, paranasal sinuses and pharynx.

    order to avoid infection of the tympanic cavity, oral preparations carried nasal irrigation Physiomer or aqua maris and irrigation of the nasal cavity and pharynx bioparoks or Polydex with phenylephrine. An important role is played by proper cleaning of the nasal cavity. Alternate( on exhalation), each half of the nose should be marked without tension.

    Anemization of the pharyngeal mouth of the auditory tube is performed as follows. Metal probe quilted jacket, moistened with 0.1% epinephrine solution and 10% lidocaine solution, 5 - 10 is supplied to the pharyngeal mouth of the auditory tube. The procedure is repeated for 7-10 days.

    To reduce edema and exudation mucosa in the nasal cavity, paranasal sinuses, the auditory tube and tympanic cavity short course( 6 - 7 days) use systemic decongestants - phenylephrine hydrochloride. It is a part of a number of combined drugs - rhinoproton, koldreksa, rynza.

    To improve tubarnoy function is carried out by blowing the ears Politzer ear or through a catheter with simultaneous massage of the eardrum by a funnel Siegel. Through the catheter into the lumen of the auditory tube, dexamethasone, antibiotics, trypsin, chymotrypsin are administered. It is quite effective to conduct endaural electrophoresis with the introduction of proteolytic enzymes and lidase. The appointment of antihistamines is recommended in cases where serous otitis media develops against the background of allergies.

    The acute stage of the disease shows the appointment of glucocorticoids, which have a pronounced anti-inflammatory effect, reduce exudation and edema of tissues. Prednisolone is prescribed by 30 mg orally or by injection for 6 days. A pronounced anti-inflammatory effect is also possessed by fenspiride( erespal), it is administered orally 80 mg twice a day for 10 days.

    Shows restorative means, vitamins;in the complex of therapeutic measures, immunocorrectors( for example, polyoxidonium, 0.006 g intramuscularly every other day, in total 6-10 injections) are increasingly included.

    If the function of the auditory tube is not restored, the exudate does not resolve and the hearing does not improve, surgical methods are used to evacuate secretions from the tympanic cavity. The most widely used shunting of the tympanum. The incision of the tympanic membrane is performed in the posterior quadrant, and a shunt made of bioinert material - Teflon, silicone, polyethylene - is inserted through the incision. There are many forms of shunts: a drainage tube with apertures, a coil, a tube with a semipermeable membrane, etc. Usually, drainage is left in the ear until the recovery and improvement of the tubular function, i.e., come about.from a few weeks to 1 -2 years.

    Effective is the procedure of shunting through the subcutaneous tunnel, formed in the area of ​​the posterior wall of the auditory canal - percutaneous( meatotimpanal) shunting of the tympanum. The drainage silicone tube is carried under the annulus tympanicus, without injuring the tympanic membrane. At the entrance to the auditory canal, it is fixed to the skin with a silk suture. Through this drainage tube, aspiration of the secretion from the tympanic cavity is carried out, various medications are administered.

    In some cases, exudative inflammation is not limited only to the tympanic cavity, but extends to the antrum and cells of the mastoid process, and sometimes the block of entry into the mastoid cave develops. In this case, perform anthotomy, enter the drainage tube into the antrum and leave it there for 2 -4 weeks. Sometimes an anthotomy( behind-the-back approach) and intrameatal tympanotomy are simultaneously performed with the introduction of one drainage tube under the meatotympanal flap for a long time, and the other in the mastoid cave for 3 to 4 weeks.

    It should be noted that exudative otitis media in the initial stages does not always have vivid clinical manifestations, however, with prolonged progressive course, the disease can lead to persistent hearing loss and cochleovestibular disorders. Currently, there are highly informative methods for diagnosing exudative otitis media, which allow timely recognition of the disease and monitor the effectiveness of its treatment.

    This is an acute inflammation of the muckeroper of the tympanum, in which all parts of the middle ear are involved in the process to some extent. The disease is widespread, it can take place in a light form, then, rapidly developing, cause a severe general inflammatory reaction of the body.

    The cause of the disease is a combination of factors such as lowering local and general resistance and getting the infection into the tympanum. The main pathogens of acute otitis media( up to 80% of cases) in adults and children are S. pneumoniae and H. influenzae, somewhat less often M. catarhalis, S. pyogenes, S. aureus or associations of microorganisms( Figure 8.8).Viral otitis often develop in epidemics of viral diseases.

    Infection into the tympanic cavity can occur in various ways: tubogenic, hematogenous, through a damaged eardrum with trauma or through a mastoid wound, as a result of the retrograde spread of the infection from the cranial cavity or from the labyrinth.

    The most common route of infection is tubogenic - through the auditory tube. The hematogenous pathway of infection in the middle ear is comparatively rare, it is possible with such infectious diseases as influenza, scarlet fever, measles, typhoid, tuberculosis and others, and is usually associated with a violation of the resistance of the organism.

    When an infection enters the middle ear through a damaged eardrum when it is traumatized or through a mastoid wound, they speak of a traumatic average otitis media. In extremely rare cases, acute otitis media develops as a result of the retrograde spread of infection from the cranial cavity or from the labyrinth.

    The main stages of the pathogenesis of acute otitis media in acute respiratory infections are shown in Fig.8.9.With inadequate treatment or other unfavorable conditions, the process can progress and move from an acute acute catarrhal form to an acute purulent form.

    The main links of the pathogenesis of acute purulent otitis media.

    Clinic. Local and general symptoms of the disease are expressed in different ways depending on the stage and severity of the process.

    There are 3 stages of acute purulent otitis media:

    In all cases, the process necessarily goes through all three stages, in some cases the disease can already in the first stage acquire abortifacient current.

    The initial, doperperative, stage of the disease is characterized by pronounced local and general symptoms. The main complaint is pain in the ear, often very sharp, giving to the temple, the crown. Steadily growing, it sometimes becomes painful, unbearable. In some cases, tenderness is observed in palpation and percussion of the mastoid process, which is caused by inflammation of its mucous membrane. Simultaneously, as a result of inflammation and limitation of the mobility of the tympanic membrane and the chain of auditory ossicles, nasal congestion and noise occur in the ear. During this period, the general condition of the patient is often disturbed - there are signs of intoxication, body temperature rises to 38 - 39 ° C, in the peripheral blood, the shifts characteristic of the inflammatory process are revealed.

    With otoscopy, the injection of vessels along the handle of the malleus and the radial vessels of the membrane is first seen, accompanied by a shortening of the light cone. Then the hyperemia of the tympanic membrane grows, becomes diffuse, its identification points disappear, the membrane protrudes, becomes infiltrated( Figure 8.10).The duration of the initial stage of acute otitis media - from several hours to 2 - 3 days.

    The perforating stage is characterized by perforation of the tympanic membrane and the appearance of suppuration. At the same time, the pain in the ear quickly subsides, the well-being improves, the body temperature decreases. The discharge from the ear is first abundant, mucopurulent. With otoscopy, one can observe the so-called "pulsating reflex", in which pus comes through perforation in portions, synchronously with the pulse.

    After a few days the amount of secretions decreases, they become thick and get purulent. The suppuration usually lasts 5 to 7 days. Perforation with acute otitis media is usually small, more extensive perforations occur with scarlet fever, measles, tuberculosis lesions.

    The reparative stage is characterized not only by cessation of suppuration and( in most cases) by spontaneous scarring of perforation, but also by restoration of hearing. Gradually diminished, and then the discharge stops, at the same time the hyperemia and infiltration of the tympanic membrane disappear, its luster appears, and the identification contours become discernible. With normal immune status, sufficient function of the auditory tube and adequate treatment, recovery can occur, bypassing the perforating stage.

    The duration of the disease usually does not exceed 2 to 3 weeks. However, the typical course of acute purulent otitis media can be disturbed at any stage of the process. Complicated course and unfavorable outcome of acute purulent otitis media can be caused by a decrease in local and general immune defense of the organism, high virulence of the pathogen and its resistance to used antibiotics, as well as irrational therapy.

    Diagnosis with a typical course of acute purulent otitis media is not difficult. The diagnosis is based on complaints, anamnesis and otoscopic picture features.

    Treatment of a patient with acute purulent otitis media is carried out taking into account the stage of the disease, the severity of clinical symptoms and the features of the patient's somatic status. In the acute stage of the disease, an outpatient regimen is recommended, and with a marked increase in temperature, general malaise - bed rest. If there is a suspicion of a beginning complication, the patient should be urgently hospitalized.

    To restore or improve the ventilation and drainage functions of the auditory tube, prescribe vasoconstrictive drops( 0.1% solution of naphthysine, sanorin or galazoline), which are poured 5 drops in the nose 3 times a day, preferably in the patient's position "lying on the back".

    Treatment in the preperforative stage. With a severe course of otitis media with severe pain syndrome and an increase in body temperature to 38 ° C and higher, antibiotics are indicated in the preperforative stage. The drug of choice in the treatment of uncomplicated forms of otitis in adults is amoxicillin by mouth, 0.5 g 3 times a day for 7-10 days. In the absence of effect after three days of therapy with amoxicillin, the antibiotic should be changed to augmentin( 0.625 g orally 3 times or 1.0 g 2 times per day) or cefaclor cefuroxime( axetil)( 0.5 grams orally twice a day).With allergy to p-lactam antibiotics, modern macrolides are prescribed( carbide 0.15 orally 2 times a day, spiramycin 1.5 million ME orally 2 times a day).

    For local anesthesia, locally applied ear drops, containing equally 70 ° alcohol and glycerin;from patented preparations the same action is rendered by oti-pax, which includes 96 ° alcohol, glycerin, lidocaine, phenazone. This composition has analgesic and anti-inflammatory effect.

    With severe pain in the ear, endoauric meatotimpanal blockade is effective. In the posterior upper wall of the external auditory canal, 1 ml of a 2% solution of novocaine and 0.5 ml of hydrocortisone are subperiosteal at the border of the cartilage and bone sections. Correctly executed blockade is accompanied by "whitening" of the skin of the bone part of the ear canal and the tympanic membrane.

    Systemic analgesics and anti-inflammatory agents are prescribed: paracetamol( Table 500 mg);diclofenac( Table 50-100 mg, amp 75 mg / 3 mL);ketorolac( ketanes)( Table 10 mg, amp 30 mg / 1 ml);tramadol( tramal)( Table 150 mg, capsules 50 mg, suppositories 0.1 g, rr for injections 5% 2 ml).

    In the treatment of acute purulent otitis media, catheterization is used to restore the function of the auditory tube. Blowing out the auditory tube with an acute middle otitis with the help of a catheter allows draining the middle ear, eliminating the rarefied air in the tympanic cavity that always arises with this disease, and also introducing medications into it. In addition, catheterization has a beneficial effect on the course of inflammation. Fear of bringing the infection from the pharyngeal cavity to the middle ear is unreasonable, since in the acute purulent otitis media, the pharyngeal microflora has already penetrated into the middle ear, and the auditory tube has largely lost its protective function.

    Catheterization is performed from the very beginning of the disease, and this often allows abortion of the process;in the II - III stages of acute inflammation of the middle ear, blowing with a catheter also gives a good therapeutic effect. Most often after blowing into the tympanum through the catheter, a mixture of a solution of dexamethasone and an antibiotic dissolved in an isotonic solution of sodium chloride is injected.

    In addition to the basic treatment for the patient, it is desirable to prescribe immuno-correcting drugs from the very beginning. In some cases, good results are obtained from the use of physiotherapy.

    If despite the ongoing treatment the patient's condition does not improve, severe pain in the ear continues, high temperature persists, when pain is exerted on the mastoid process, soreness is pronounced, and with otoscopy, the eardrum is observed to protrude, then the paracentesis is shown - the incision of the tympanic membrane.

    Paracentesis is certainly indicated and must be performed for emergency indications if:

    In young children, paracentesis is used not only with a therapeutic, but also with a diagnostic purpose. The procedure is also shown for persons with severe concomitant pathology of internal organs, for the elderly and in the presence of signs of a decrease in immune defense in the patient.

    Paracentesis is performed under local anesthesia, very restless children are sometimes given a slight anesthetic with nitrous oxide. Local application anesthesia is carried out by injecting for 10 minutes into the external auditory canal until the cotton wick impregnated with a 10% solution of lidocaine is in contact with the tympanic membrane. However, it is more reliable to conduct infiltration anesthesia subcutaneously into the back wall of the auditory canal at the border of the transition of the membranous cartilaginous region into the bone.

    The incision with a special paracentesis needle is usually performed in the posterior quadrant of the tympanic membrane( more often this is the place of greatest bulging) from the bottom up through its entire thickness. The depth of introduction of the paracentesis needle is 1 -1.5 mm, with a deeper introduction it is possible to injure the labyrinth wall. The incision should not reach the annulus tympanicus, so that in the future there is no permanent perforation. Usually, the perforation formed artificially during paracentesis is closed independently after a few days, and all three layers coalesce. After puncturing the pus, the perforation closes worse, since there is no complete sticking of its edges and it gapes. After the paracentesis, sterile gauze turundum or cotton wool is inserted into the external ear canal. Turundas should often be changed, while clearing the auditory passage from pus.

    Treatment in a perforated stage. At this stage of acute purulent otitis media, the patient continues to receive antibiotics, antihistamines, to restore the function of the auditory tube, he is still poured vasoconstrictive drops into the nose. With thick purulent discharge mucolytics( fluimycil, ACS, fluophore, sinupret, fludutik, mucoregulating drug based on carbocysteine, affecting the quality of secretion( reduces its viscosity) and regulating its quantity( does not lead to an increase in secretion), as well as improving the evacuation of the secret fromdrum cavity and contributing to a faster recovery of hearing) and erespal - an anti-inflammatory drug that reduces hypersecretion and swelling of the mucosa and stimulating function of the ciliary epithelium of the auditory tubes. Physiotherapeutic procedures( UFO, UHF or microwave therapy, laser therapy) and warming compresses on the ear at home also give good results.

    In the presence of a perforation of the tympanic membrane, medicaments in the middle ear are injected with the help of trans -impanal injection. The above mixture of antibiotic and dexamethasone( and subsequently enzymes that prevent the formation of scars in the tympanic cavity, trypsin, chemopsin, lidazy, etc.) is poured into the external auditory canal in an amount of 1 ml and injected with a gentle indentation of the tragus into the external aperture of the auditorypassage. In this case, the drug passes through the tympanum, the auditory tube, and can enter the nasal cavity and mouth. Catheterization and transtimpanal injection of medicinal substances are effective methods of treatment.

    Local treatment in this stage of the disease is aimed at providing favorable conditions for the outflow of purulent discharge from the tympanic cavity. That the patient could independently remove 2-3 times a day a purulent secret from the depth of the external auditory canal, he should be appropriately instructed. Manipulation is carried out as follows: a piece of sterile cotton wool is wound on a probe with a thread or on the free end of the match. Adult pulling the auricle back and forth( the child - back and forth) and a probe or a match with cotton wool gently enter the depth of the ear canal to the tympanic membrane. With thick pus, a warm 3% solution of hydrogen peroxide is preliminarily poured into the ear canal. This is repeated until the cotton wool remains dry.

    After removal of a purulent secretion, a pre-warmed to 37 ° C drug solution is poured into the ear. This may be a 0.5-1% solution of dioxidine, a 20% solution of sodium sulfacil, otopate drops containing the active substance rifamycin, etc. Alcohol drops in the second stage of otitis are not recommended, since alcohol often causes irritation of the mucosashell of the tympanum.

    In addition to the main treatment, the patient is usually prescribed immuno-corrective drugs and fortifying agents.

    Treatment in the reparative stage. In the final, reparative stage, the suppuration ceases, the perforation of the tympanic membrane is usually closed with a gentle, scarcely noticeable scar.

    During this period, it is important to achieve the fullest possible restoration of hearing. Antibiotic therapy is canceled, the ear toilet and thermal procedures are discontinued. The main attention is paid to the restoration of ventilation function of the auditory tube and increase of resistance of the organism. Purge the ear tube through the Politzer or through a catheter, perform a pneumomassage of the tympanic membrane using a Zigle pneumatic funnel, and appoint an endaural iontophoresis with lidase. To make sure of restoration of auditory function, control audiometry is carried out.

    The following outcomes of acute purulent otitis media are possible.

    Tinnitus is common in children of all ages. There is a predisposition to such diseases.

    Some children may experience pain in the cold. It passes a few minutes after the child enters a warm room.

    Wear a hat for the child. Do not put cotton in your ears.

    In general, do not stop the child's ears anyway. This does not help clear them of sulfur, but can cause external otitis( otitis externa) or damage the eardrum. Some of the cotton wool may remain in the child's ear, as it is difficult to remove. In the ear aisles, clogged with cotton wool, more sulfur forms.

    Infectious ear inflammation is more common in children older than 8 years. Usually, the middle ear, that part of it that is located behind the tympanic membrane, is inflamed. Disease often precedes a cold. Inflammation, as a rule, is accompanied by fever and vomiting. Children complain of earache and hearing loss. Infants have a fever, they become whiny.

    During inflammation in the middle ear, fluid and pus accumulate. Sometimes this leads to a rupture of the tympanic membrane, an aperture( perforation) appears in it, after a while the liquid is released. Often, the pain immediately disappears, because the pressure on the tympanic membrane causing pain is reduced.

    Inflammation of the middle ear is treated, usually with antibiotics, although there is another opinion on this issue. Some experts believe that pain in the ears can take place without treatment, although antibiotics contribute to a faster recovery. Paracetamol reduces pain and temperature.

    Sometimes, after the inflammation in the middle ear, there is liquid. In this case, antibiotics help, unfortunately, not always. Therefore, you should consult a doctor 6-8 weeks after recovery to make sure that there is no fluid in your ear. Perfamations usually heal by themselves, nevertheless it is necessary to check the state of the tympanic membrane from time to time. The fluid remaining in the middle ear can lead to deafness.

    Infectious inflammation of the ear canal, a short tube that connects the eardrum to the external environment, is less common, but can cause severe pain. It is called external otitis( otitis externa), which does not always appear under the influence of microbes. Sometimes this inflammation is a form of dermatitis. In such cases, pain in the ear is not accompanied by fever and other symptoms characteristic of the inflammation of the middle ear. If there is a discharge, then you need to see a doctor.

    Some children are particularly susceptible to external otitis media and can tolerate this disease several times. Sometimes you can determine the cause of the disease yourself, if, for example, you know that the child in the pool or during bathing got into the water's ear.

    The treatment is as follows: in the ears instill the medicine prescribed by the doctor. In some cases careful removal of dead cells, pus and other contents of the ear canals is necessary. This procedure is also conducted by a doctor.

    Despite the soreness, the inflammation of the outer ear, unlike the inflammation of the middle ear, does not lead to hearing loss.

    Very often, pain in the ears causes angina and toothache. In such cases, doctors talk about the reflected pain that occurs in one place, but is felt in another. Angina or a sick tooth can be the cause of earache, even if there is no sore throat or toothache.

    Reflected pain in the ears, as a rule, is changeable. Sometimes there is no certainty that the cause of the disease lies outside the ear. In this case, you should also consult your doctor.

    Furuncles in the ears are sometimes very painful. As a rule, the cause of pain in this case is obvious, although it is sometimes difficult to determine the position of the boil in the auditory canal.

    The foreign body in the ear can also cause pain and discharge from the ear.

    Contrary to the popular belief that earwax contributes to ear pain, this is extremely rare. In fact, in children, earwax does not cause any pain, although it is the most common cause of hearing impairment. Occasionally, pain causes a hard piece of sulfur that clogs the ear canal.

    Ear injury can be accompanied by pain, especially if the surrounding tissues are injured by the ear. A direct blow to the ear with a flat object, for example, the palm, can even cause a rupture of the eardrum. If your child bruises his ear, complains of ringing in the ears or hearing damage lasting longer than 5 minutes after the injury, you should consult your doctor.

    Ear pain with compartments may indicate an inflammation of the middle ear with perforation or a foreign body in the ear.

    Discharges from the ear that do not combine with pain can also be caused by some of the above reasons, but in some cases you can see semi-liquid, brown or black colored earwax fragments that are naturally removed from the ear canal. This is perfectly normal, although you should consult a doctor to rule out another disease.

    As a rule, you should consult a doctor in all cases if the child complains of pain in the ear, lasting more than 20 minutes, and also in the presence of excreta.

    Inflammation of the middle ear is one of the most common childhood diseases. According to G.L.Balyasinskaya:

    The structure of the ear of a newborn child is quite different from the structure of the adult's ear. Infants and children of the first years of life have a number of anatomical and physiological features that determine the peculiarity of the flow of otitis media at this age.

    We list the following:

    The undoubted role in the occurrence of otitis media in children of early age is played by prematurity, pathological course of pregnancy and childbirth, obstetric trauma, and artificial feeding. Otitis occurs more often in children receiving malnutrition, suffering from avitaminosis, rickets, diathesis. In the emergence of otitis media at this age, infectious diseases - measles, scarlet fever, influenza - play a big role.

    Clinic. The manifestations of acute otitis media in infants are characterized by a mild degree of local symptoms. Practically, they do not have the history data, which is an important help in diagnosing older children and adults.

    Pain syndrome in small patients is manifested by agitation, anxiety, poor sleep, pendulum movements of the head are observed. The child refuses to take a breast because of a painful swallowing, rubs a sick ear against the mother's hand. The temperature in the beginning is subfebrile, after 1 - 2 days it can rise to 39.5 -40 ° C.An important symptom is painfulness when pressing on a tragus, due to the absence of the bone part of the auditory canal and the transfer of pressure directly to the inflamed eardrum.

    The vascular connections between the middle ear and the cranial cavity, as well as the stony-scaly slit unchanged in children of the first years of life, cause the appearance of symptoms of irritation of the meninges, defined as meningism: convulsions, vomiting, head tilting, and sometimes blackout. Such a state, unlike meningitis, does not develop due to inflammation of the meninges, but due to their irritation with bacterial toxins.

    Diagnostics. Of great importance is the correct interpretation of the otoscopic picture. The slit shape of the auditory meatus, the accumulation of epidermal scales in it, the almost horizontal arrangement of the tympanic membrane - all this greatly complicates the examination. In addition, in infants the tympanic membrane is thicker, turbid and blushes easily after cleaning the ear and crying the child. Spilled hyperemia and infiltration of the tympanic membrane in the absence of distinguishable contours are signs of acute inflammation, and in the presence of other clinical manifestations - an acute purulent process and require urgent paracentesis.

    Acute otitis media in children passes through the same stages as in adults. However, in children more often than in adults, the cure can occur without perforation of the tympanic membrane. This is due to its greater resistance, high absorption capacity of the mucous membrane of the tympanum and a more light outflow of pus through a wide and short auditory tube.

    Treatment. Antibacterial therapy plays an important role in the complex of therapeutic measures for young children. In particular, at the age of up to 2 years, acute purulent otitis media is an absolute indication for prescribing antibiotics, especially with severe clinical signs of the disease and an increase in temperature to 38 ° C or higher. Parentsenthesis is shown to children at an earlier time than adults. Indications for paracentesis in each individual case are set individually. In doubtful cases, when the otoscopic picture is not convincing, and the toxicosis phenomena increase, it is better to perform paracentesis. Just like in adults, the incision is performed in the posterior quadrants of the tympanic membrane.

    In children aged 1 to 3 to 4 years, sometimes recurrent acute otitis media is observed, characterized by repeated inflammatory processes in the middle ear with a frequency of 2-5 to 12-15 times per year. Relapses are associated with the imperfection of the immune system of the child's body and the disorder of the middle ear's defense mechanisms in the pathology of the gastrointestinal tract, exudative diathesis, food and drug allergy, pathology of the pharyngeal lymphoid ring, nose and paranasal sinuses.

    With a recurrent median otitis, complex treatment is performed. In addition to the traditional local and general therapy of the purulent process, with exacerbations, the pharyngeal lymphoid ring is sanitized, the nose and paranasal sinuses are treated, the child's nutrition is normalized, and the reactivity of the organism is increased.

    Acute otitis media for infectious diseases

    Acute inflammation of the middle ear, associated with an infectious disease, is characterized by a more severe course. It can be etiologically associated with the causative agent of the infection itself;In addition, under the influence of an infectious disease, the resistance of the organism decreases. In infectious diseases, the simultaneous damage of both ears, including all elements of the middle and sometimes inner ear, is often noted, and the rapid development of the process, which is often necrotic.

    Usually, influenza otitis media can be seen during an epidemic outbreak, usually at the beginning of the flu. Inflammation of the middle ear can occur in the early period of infection, and then the process has all the characteristics of the underlying disease. Secondary otitis media develops in the late period of an infectious disease.

    For influenza otitis characterized by a hemorrhagic form of inflammation with the advent of extravasates( hemorrhages) under the epidermis of the skin of the external auditory canal in the osseous part and on the tympanic membrane - in the form of hemorrhagic or serous vesicles. Such extravasates are called hemorrhagic blisters, or bullae( hence - bullous otitis).When otoscopy against the background of diffuse hyperemia of the tympanic membrane and the skin of the auditory canal, two to three characteristic rounded hemorrhagic red-purple vesicles are visible, with the opening of which a meager saccharide discharge appears.

    Inflammatory process with influenza otitis is located mainly in the above-drum space and it is difficult, sometimes with the defeat of the inner ear and the development of intracranial complication - meningitis. Therapeutic tactics in this case involve the implementation of paracentesis and the reliable drainage of the tympanum, as well as the administration of massive doses of antibiotics and drugs that facilitate the patient's condition.

    Along with conductive hearing loss for influenza otitis in a number of cases, neurosensory lesion is detected, which requires appropriate pathogenetic therapy.

    Otitis in scarlet fever and measles is characterized by the possibility of developing bone and soft tissue necrotic damage to the middle ear, which is more common in young children. Necrotic otitis with scarlet fever and measles develops usually in the initial stage of the disease, with necrotic lesions often localized in the pharynx and nose. When measles, otitis media begins at the time of the rash or precedes it.

    The pathogenesis of necrotizing otitis is based on the development of thrombosis in the vessels of the middle ear, which causes necrosis of the mucosa of the tympanum, auditory ossicles and bone tissue of the mastoid process.

    For measles and scarlet fever, otitis media is characterized by a clinically unexplained onset, which is masked by the underlying disease. The process in the ear develops imperceptibly, the pain syndrome is often absent, which can be explained by rapid necrotic destruction of the tympanic membrane.

    The first sign of the disease is often the appearance of copious purulent discharge from the ear with a sharp putrefactive odor arising from the involvement of the bone in the process. When otoscopy is visible extensive perforation of the tympanic membrane, until its complete destruction. The process is developing very rapidly, often perforation is formed within one day. The disease usually passes into a chronic stage.

    When the necrotic process spreads to the inner ear, a serous or purulent labyrinthitis develops, sometimes with complete exclusion of the auditory and vestibular functions. In bilateral lesion of the labyrinth in children of early age, deaf mutes develops.

    Treatment is directed against the underlying disease and its local manifestations. Timely and adequate use of antibiotics in measles and scarlet fever allows a sharp reduction in the likelihood of necrotizing otitis and its inherent complications.

    Indication for surgery is the development of necrosis of the mastoid process;the purpose of the operation is to remove necrotic tissues and drain the cavities of the middle ear.

    This is a purulent inflammation of the mucous membrane and bone tissue of the mastoid process of the temporal bone, the most frequent complication of acute otitis media. Changes in the mastoid process with mastoiditis are different depending on the stage of the disease. There are two main stages of mastoiditis - exudative and alterative( destructive).

    In the exudative stage, the mucosa and the periosteum of the cells of the mastoid process are involved in the process;at this time cells are filled with exudate, and the mucous membrane is inflamed and sharply thickened.

    The alterative stage is characterized by the predominance of proliferative-alterative changes, which also extend to the bony structures of the mastoid process. In this case, the bone is destroyed by osteoclasts, the formation of granulations. The necrosis of the bone bridges between the cells develops, and they merge, forming one common cavity filled with pus, - an empyema of the mastoid process is formed.

    Mastoiditis is more common in patients with pneumatic type of mastoid process. Its development is facilitated by a number of factors: high virulence of the causative agent of the infection, a decrease in the resistance of the organism( in particular, in diabetes, nephritis, other chronic diseases), obstruction of outflow from the antrum and the tympanum. One of the reasons for the development of mastoiditis is the irrational treatment of acute otitis media.

    The process of bone destruction in the stage of alteration can reach the dura mater of the middle or posterior cranial fossa and cause various intracranial complications. Pus can break through to the surface of the mastoid process( with the formation of a subperiosteal abscess), into the malar process or into the scales of the temporal bone, into the stony part of the temporal bone pyramid, through the apex of the procession into the interfascial spaces of the neck.

    The causative agents of mastoiditis are the same microorganisms that cause the development of acute purulent otitis media.

    Clinic of the disease is characterized by general and local symptoms.

    Common symptoms - worsening of general condition, increase in body temperature, change in blood composition - do not differ significantly from manifestations of acute purulent otitis media. Diagnostic value is the analysis of the dynamics of these signs with suspicion of possible involvement in the inflammatory process of the mastoid process.

    Usually it takes 2 to 3 weeks from the onset of acute otitis media and the general condition worsens as the clinical picture improves, the temperature rises, pain and suppuration from the ear resumes. However, it must be remembered that pyesis may be absent if the outflow of pus from the middle ear is disturbed( "aditus block").

    Pain is often localized in the ear and in the mastoid process, in some patients it covers half the head on the side of the lesion and is worse at night. With palpation and percussion of the mastoid process, tenderness is noted, more often in the region of the apex or in the area of ​​the mastoid process. There are also complaints of noise in the ear or head on the side of the patient's ear and pronounced hearing loss.

    When examining a patient, they sometimes find hyperemia and infiltration of the skin of the mastoid process, which is a consequence of periostitis. You can also observe the smoothening of the bovine fold and the protrusion of the auricle anteriorly.

    Dryness from the ear is often profuse, having a pulsing character - creamy pus fills the external ear canal immediately after cleaning the ear

    .Sometimes, to an ordinary gnotecheniyu through perforation in the tympanic membrane is added abundant secretion of pus through the back wall of the external auditory canal. The cause of this increase in suppuration can be determined only by careful cleaning of the ear and finding a fistula, from which pus is released.

    It is possible and this version of the flow of mastoiditis, in which there is no otoren. This happens when there is a violation of the outflow of pus, if the defect of the tympanic membrane is closed or the block of cave entrance is formed.

    Diagnostics. An important otoscopic sign of mastoiditis is the winding of the posterior walls of the external auditory canal in the bone marrow. The overhang is due to the development of periostitis and pressure of pathological contents in the area of ​​the anterior wall and the entrance to the cave. In the same place, sometimes a fistula is formed, through which pus enters the external auditory canal. The tympanic membrane with mastoiditis is often hyperemic, infiltrated.

    In the diagnosis of mastoiditis, radiography of temporal bones in the Schueller projection is of great importance. When mastoiditis on the roentgenogram, you can see a different intensity in the reduction of pneumatization, the veiling of the antrum and the cells of the mastoid process. In the late stages of the process, with the destructive form of mastoiditis, one can see the destruction of the osseous partitions and the formation of the areas of enlightenment due to the formation of pores made with pus and granulations.

    The spread of the process in the mastoid process and its transition to neighboring anatomical formations depends on the development of air-bearing cells in various parts of the temporal bone - in the scales, the zygomatic process, the pyramid, etc. Inflammation in these areas is sometimes accompanied by a breakthrough of pus in the surrounding soft tissues.

    Breakthrough of pus through the cortical layer on the external surface of the mastoid process leads to the formation of a subperiosteal abscess. The tumescence and pastosity of the skin in the behind-the-ear area, the smoothening of the bovine fold and the protrusion of the auricle are intensified.

    The spread of pus from the apical cells of the mastoid process into the interfascial spaces of the neck is designated as apical-cervical mastoiditis. Its various forms, named after the names of the authors, differ in the place of penetration of pus in the region of the apex of the mastoid process.

    Mastoidite Bezolda( cervico-apical) is characterized by a breakthrough of pus through the inner surface of the apex of the mastoid process under the sternocleidomastoid muscle with spreading to the neck. In this case, a dense swelling of the soft tissues of the neck is often observed - from the tip of the mastoid process to the clavicle.

    Mastoiditis of Orleansky is characterized by a breakthrough of pus through the inner wall of the apex of the mastoid process into the fascial box of the nipple muscle.

    In this case, around the place of attachment of the muscle develops a fluctuating infiltrate.

    Mastoiditis Muret( cervico-yugular) - with this form pus breaks through the incisura digastrica, spreads under the digastric muscle and penetrates into the para-pharyngeal space with the formation of a deep abscess of the neck.

    If the pus from the perisinus abscess penetrates under the soft tissues of the occiput and neck, the process is referred to as the cervico-occipital mastoidite Chitelli.

    The spread of the purulent-destructive process to the base of the zygomatic process is called the zygomatzite, on the scales of the temporal bone - the squamitis.

    It is also possible to spread pus from the mastoid process through the cellular system into the pyramid of the temporal bone. In this case, the development of petrositis, the clinical picture of which is called the Gradenigo triad, includes acute otitis media with suppuration from the ear on the side of the lesion;Trigemini with pain in the back of the head, behind the eye;paresis or paralysis of the distracting nerve.

    Atypical forms of mastoiditis are most dangerous, since they often cause various complications. Their occurrence and course is associated with such factors as the age of the patient, the general and local reactivity of his organism, the structure of the temporal bone( in particular, its cellular structure), the virulence of the pathogen.

    At an atypical course of the process, there is no pronounced sequence of stages of inflammation, individual symptoms do not have a characteristic clarity. So, the pain either does not bother at all, or it is weak. The suppuration can be expressed minimally or absent altogether. At the same time, it should be borne in mind that atypical forms are almost always accompanied by extensive bone destruction, and the development of intracranial complications is possible.

    Treatment. Distinguish between conservative and surgical treatment of mastoiditis. But in any case, it should be performed in conditions of an ENT hospital, since it is necessary to take into account the possibility of developing severe complications.

    The basis of conservative therapy, corresponding to the active treatment of acute otitis media, is antibiotic therapy, during which time broad-spectrum drugs are prescribed, with preference given to p-lactam antibiotics.

    An important component of treatment of mastoiditis is the provision of free outflow of pus from the middle ear and the local use of antibacterial drugs that need to be prescribed taking into account the sensitivity of the ear flora. Conservative treatment is successful in the initial stage of mastoiditis, bone damage has not yet occurred and the outflow of exudate has not been disturbed.

    If during objective conservative therapy objective symptomatology does not change or increase, resort to surgical treatment of mastoiditis. Absolute indications for urgent surgical intervention are the appearance of signs of intracranial complications, the emergence of complications in the areas bordering the middle ear( subperiosteal abscess, pus penetration in the apex of the mastoid process, development of the zygomatzite, squamite, petrosite).The operation is certainly indicated if a patient with mastoiditis has signs of otogenic paresis or paralysis of the facial nerve or labyrinthitis has developed. In all these cases, an anthromastoidotomy is performed-an antrum opening and a trephination of the mastoid process.

    The operation is performed under endotracheal anesthesia; in some cases, adults are operated under local infiltration anesthesia. The incision is made with a scalpel of the skin, subcutaneous tissue and periosteum, retreating 0.5 cm from the transitional fold behind the auricle;the length of the incision is 5 -6 cm. The dissector separates the soft tissues with the periosteum, exposing the cortical layer in the area of ​​the mastoid appendage, after which a retractor of the "lyre" type is applied.

    Trepanation of the bone is performed with the help of bits of various sizes, for this you can also use milling cutters. Removing the affected bone, gradually deepen towards the cave, which must necessarily be opened to ensure drainage of the tympanum. The cave is located at a depth of 1.5 - 2 cm from the surface of the mastoid process, in the projection of the place of transition of the posterior wall of the external auditory canal to the upper one. Make sure that the open cavity in the depth of the bone wound is just the cave of the mastoid process, can be probed with a button probe that passes easily through the aditus ad antrum into the tympanum. In addition, at the bottom of the cave, the ampulla of a horizontal semicircular canal is protruded.

    The further course of the operation involves careful removal of carious bone, pus and granulation. In a vast carious process, all cell groups are successively opened, including apical, perisinus, zygomatic, perifascial, etc. At the end of this stage, the operations of the bone wound edge are smoothed with a bone spoon or milling cutters.

    Elimination of the purulent focus in the mastoid process is completed by the removal of the posterior wall of the external auditory canal to the level of the ampulla of the horizontal semicircular canal, however, the annulus tympanicus is retained. Perform also the plastic of the posterior cutaneous wall of the auditory canal, the flap is hemmed in the lower corner of the wound.

    The operation is completed by washing the wound with a warm antiseptic solution, drying, tamponade with turuns soaked in levomel, and applying a wound to the wound in the BTE area of ​​the primary joints. An exception is mastoiditis with a subperiosteal abscess - the postoperative wound is left open in this case. The same is done in most cases after extensive mastoidotomy in patients with otogenic intracranial complications.

    It should be noted that during the operation for any form of mastoiditis, one should not limit oneself to opening the cave and surrounding periantral cells.

    Mandatory surgical revision of the entire cellular system of the mastoid process is necessary. Particular attention is drawn to the angular and threshold cells, as well as the cells of the apex of the mastoid process.

    With mastoidits of Bezold and Mura, the bovine incision of soft tissues is extended around the neck along the anterior margin of the sternocleidomastoid muscle. This allows draining the accumulation of pus in the fascial vagina of this muscle and in the parapharyngeal space.

    When Mastoidi Chitelli, the bovine incision is complemented by a transverse incision directed posteriorly through the middle of the cervical-neck infiltrate. After evacuation of the subperiosteal abscess, an expanded mastoidectomy with exposure and diagnostic puncture of the sigmoid sinus is performed.

    In patients with zygomatitis, the BTE of the soft tissue continues anterior and upward and, bending around the upper attachment of the auricle, expose the base of the malar bone of the temporal bone. After a typical mastoidotomy, the cortical layer of the zygomatic process is removed and, starting from the anterolateral margin of the opened antrum, the zygomatic cells with pus and granulations are removed by an acute spoon.

    When spreading the process from the mastoid process to the scales of the temporal bone( squawk), the bovine incision

    of the soft tissues is prolonged upward by 2 to 3 cm, after a typical mastoidotomy, the affected bone of the scales is removed with forceps and an acute spoon.

    In neonates and infants, the mastoid process is not developed, and the purulent process from the middle ear penetrates only into the antrum. In this case, the inflammatory process in the cave and in the surrounding tissues is designated as anthritis.

    An important feature of children's antritis is that the formation of subperiosteal abscess occurs rather quickly, sometimes even without the destruction of bone substance;while pus penetrates through uncomplicated cracks( fissura squamo-mastoidea or fissura tympano-mastoidea).

    Clinic. At anthritis the child's reaction to pain is manifested by anxiety - he often cries, at night does not sleep well, the appetite is broken;There are often signs of meningism, the temperature can rise to 38 - 39 ° C.In some cases, the pain is absent, the temperature is subfebrile or even normal, but the baby is sluggish, inhibited.

    The auditory meatus is filled with thick, creamy pus;wiping the ear with a cotton swab, it can be cleaned, but very soon the auditory passage is again filled with purulent exudate.

    Diagnostics. With otoscopy, you can see the smear of the identification points of the tympanic membrane, the change in its color - from dark purple to pink or grayish;sometimes the tympanic membrane swells, mainly in the posterior quadrant. In the area of ​​perforation, pulsation is seen. Diagnosis of anthritis is often difficult due to mild local symptoms. Assist in the diagnosis can test paracentesis, tympano or anthropuncture.

    The anthropoint is held in the position of the child "lying on the back", the head is turned towards the healthy ear. After treatment of the skin behind the auricle with 70%

    alcohol and infiltration anesthesia with a 0.25% solution of novocaine, the puncture is performed with a special thick needle equipped with a depth adjustment regulator. The reference point is a transitional fold behind the auricle, the puncture site is located behind and 2 to 3 mm above the upper wall of the external auditory canal. The smaller the child, the higher the antrum. The needle is injected anteriorly and upward to a depth of 0.5 - 1 cm. When hit in the antrum, a feeling of falling into the cavity appears. With the syringe, the contents of the antrum( pus, mucus) are sucked through the needle, after which an antibiotic dissolved in isotonic solution is injected into it. Sometimes, through the same needle, a teflon tube is inserted into the cave, which makes it possible to regularly wash the antrum and inject medications into it.

    Treatment of .Surgical treatment - anthotomy - is shown in the absence of the effect of conservative therapy of anthritis, especially when there are signs of osteomyelitis of the perianal region. The operation is performed under local anesthesia with a 0.5% solution of novocaine with adrenaline. Very carefully, layer by layer, behind the auricle make an arcuate incision of soft tissues 15 mm long. In infants, the cortical layer is very soft and thin, so the separation of soft tissues should be carried out very carefully. Antrum is projected higher and posterior from the posterior upper corner of the external auditory canal, it is superficially located and its dimensions are larger than in adults.

    After dissection of the antrum, pus and granulation are removed from it. The postoperative cavity is washed with an antiseptic solution, loosely plugged with turuns with levosin or an antibiotic solution. In the postoperative period, to ensure optimal drainage, the bandage is changed daily. The child is prescribed parenterally antibiotics, restorative therapy. Treatment usually occurs 2 to 3 weeks after surgery.

    In middle ear injuries, 90% of patients show a rupture of the tympanic membrane. It can occur due to a sudden increase or decrease in pressure in the ear canal with an impact on the ear, falling on it, playing snowballs, diving, as a result of the action of an air wave in explosions at close range. Damage to the tympanic membrane can occur when manipulating the ear with various objects( matches, pins, etc.), when a sudden shock leads to rupture of the tympanic membrane. Possible damage to the tympanic membrane with small branches when walking or running through bushes. Sometimes an incompetent attempt to remove a foreign body from the ear canal leads to trauma.

    Damage to the tympanic membrane is accompanied by pain in the ear, noise and hearing impairment. When otoscopy observed hemorrhages in the tympanic membrane, hematomas in the tympanic cavity, often reveal defects of the tympanic membrane of various shapes and sizes. The perforation can be slit, dotted, rounded, sometimes with uneven edges;it can occupy one quadrant or more. More often it is located in the forward quadrant. Through the formed perforation with otoscopy, it is sometimes possible to see the medial wall of the tympanum, the mucosa of which, in the presence of fresh trauma, is often hyperemic.

    Treatment. The patient and the physician should be very careful not to have an infection in the middle ear through the defect of the tympanic membrane. Avoid all possible manipulations in the ear, categorically contraindicated the appointment of drops in the ear and its lavage.

    First aid should be limited to inserting a sterile turunda or cotton ball with boric alcohol into the ear canal for 5-7 days. To prevent the development of inflammation in the middle ear, antibiotics are prescribed, measures are taken to preserve the aeration of the tympanum through the auditory tube.

    Prevention of inflammatory diseases of the middle ear involves the elimination or weakening of the influence of those factors that contribute to the emergence of acute otitis media and its transition to chronic otitis. An important role in the prevention of inflammatory diseases of the middle ear is played by timely sanation of chronic foci of infection in the nose and throat, the restoration of normal nasal breathing.

    For infants it is important to breastfeed, harden to reduce the incidence of infections such as influenza, measles and scarlet fever.

    Prevention of recurrence of acute otitis media and its transition to chronic otitis is first and foremost the correct treatment of the patient. An important component of such treatment is timely performed( according to indications) paracentesis, as well as adequate antibiotic therapy, taking into account the characteristics of the pathogen and its sensitivity to existing drugs. In particular, the early cancellation of the antibiotic, its use in small doses and the lengthening of the intervals between the administration of the preparation, often contributes to the transition of acute otitis to chronic.

    Patients who have experienced acute otitis media, even with a favorable period of convalescence and with the normalization of the otoscopic picture and hearing, should be under the supervision of the doctor for 6 months. By the end of this period, they need to be re-examined, and if signs of trouble are found in the ear( small hearing loss, change in the otoscopic picture, violation of tubal function), repeat the treatment: bleed the ear tube, pneumomassage of the tympanic membrane, prescribe biostimulators, etc., up to the operation( tympanotomy, shunting the drum cavity).

    Chronic purulent otitis media( HGSO) is characterized by a triad of clinical signs:

    The combination of these signs allows confidently diagnose chronic purulent otitis media.

    However, in a number of cases, the disease can occur with minimal or even absence of one or two of these symptoms. Perforation of the tympanic membrane can be discernable only when viewed under a microscope or even covered with epidermal flakes or scar tissue. Suppuration from the ear may be absent for decades. Hearing loss can not be subjective for a long time, and it can be detected only with a careful audiological study, and in some cases, hearing is practically consistent with the age norm. In this case, the pathological process in the middle ear is steadily progressing and can lead to the development of serious complications.

    Epidemiology. Despite the decrease in the incidence of chronic purulent otitis media, which is associated with timely sanitation of the upper respiratory tract and proper treatment of acute otitis media, its prevalence in the population remains quite high and ranges from 13.7 to 20.9 cases per 1000 population. Among other diseases of ENT organs, which are treated in a hospital, the frequency of chronic otitis media is 20-25%.

    Etiology. Chronic suppurative otitis media is usually the result of acute acute purulent otitis media or a rupture of the tympanic membrane after trauma. More than half of cases of diseases begin in childhood.

    Pseudomonas, Staph, aureus, Proteus, Esherichia coli, Klebsiella pneumoniae are commonly found among the pathogens of HCG.With a prolonged course of the disease, fungi, such as Candida, Aspergillus, Mysog, are increasingly detected. Anaerobic bacteria that are present in chronic purulent otitis media in 70-90% of patients also play an important role, with most often Bacteroides, Fusobacterium, Peptococcus, Lactobacillus.

    The transition of the acute form of otitis media to chronic is associated with a number of unfavorable factors:

    The pathological state of the upper respiratory tract plays an important role in the development of chronic purulent otitis media, for example, the presence of adenoids, curvature of the nasal septum, chronic sinusitis, hypertrophic rhinitis.

    Pathogenesis. Disturbances in the drainage and ventilation functions of the auditory tube lead to difficulty in evacuating the contents of the tympanic cavity and disturbing the aeration of the cavities of the middle ear. This, in turn, prevents the normal healing of the perforation of the tympanic membrane after acute acute purulent otitis media, which leads to the formation of a stable perforation.

    In some cases, the inflammation of the middle ear acquires the features of a chronic process from the very beginning, for example, with necrotic forms of otitis media, with lethargy otitis with perforation in the not stretched part of the tympanic membrane, in tuberculosis, diabetes, in the elderly and senile.

    According to the International Classification of Diseases( ICD-10) on the nature of the pathological process in the middle ear, the features of the clinical course and the severity of the disease CHGSO are divided into two forms:

    These names reflect the presence of purulent inflammatory changes in the mucosa of the auditory tube and tympanum- in the first case, the involvement of the atticoanthral region and the cells of the mastoid process in the second process in the pathological process.

    The main clinical difference between these forms is that mesotympanitis is characterized by a relatively favorable course, the perforation of the tympanic membrane is in this case stretched in its part. Epitimpanite is characterized by a poor-quality severe course, and perforation is localized in the not stretched part of the tympanic membrane. Of fundamental importance is the fact that with mesotympanitis, only the mucous membrane participates in inflammation, and the bone is not affected by caries;with epitimipanitis, a deeper tissue damage occurs, and bone structures of the middle ear are involved in the destructive( carious) process.

    It is important to note that sometimes in patients with perforation localized in the strained part of the tympanic membrane, bone destruction in the deep middle ear can also develop, resulting in the formation of a cholesteatoma. This is usually the case when the perforation is marginal, i. E.reaches the bone ring( annulus tympanicus).

    In practice, the third form of CHGO, epimesotimpanite, is sometimes isolated, which is characterized by an extensive, "subtotal" defect of the tympanic membrane and a poor quality of epitimpanite.

    Chronic purulent mesotympanitis is observed in 55% of patients with chronic purulent otitis media. In the tympanic cavity, this form of the disease often contains a mucous or muco-purulent secret. The mucous membrane of the tympanum is thickened, and the histological analysis revealed inflammatory edema, chronic lymphoid-plasmocyte infiltration with an admixture of leukocytes, and an increase in the number of goblet cells.

    Proliferation of the mucosa is accompanied by the formation in the submucosal layer of multiple small true cysts, as well as the development of granulations or polyps. The auditory ossicles are usually preserved, but in some patients they can be partially destroyed. Cicatricial changes in the chain of the auditory ossicles are more pronounced around the stapes, as a result of which the fixation of the base of the stapes in the niche of the window of the vestibule can develop.

    Aditus block with mesotympanitis develops in 15-20% of cases, while anaerobic conditions are created in the cellular system of the mastoid process, which promote the development of aggressive microflora, which leads to destruction of the mucous membrane and caries of the bone of the mastoid process.

    Clinic. Patients complain of hearing loss and recurring suppuration from the ear. Discharges from the ear are often odorless and have a mucus-purulent character, but in the presence of granulations or polyps, blood-purulent discharge can be observed. By volume, the detachable can be meager, and when exacerbated - abundant.

    With an otoscopy, a preserved, non-stretched part of the tympanic membrane and a perforation in the pars tensa are visible. Perforation can be different in form, size and location.

    Non-perforated perforation does not reach the bone ring( annulus ty-mpanicus), and a narrow rim of the eardrum remains around the circumference, which is why this type of perforation is sometimes called a rim. The pathological process in the ear with this perforation is considered to be prognostically more favorable.

    With marginal perforation in the tightened part of the tympanic membrane reaching the bone ring, there are conditions for the growth of the epidermis into the tympanum, and this creates the prerequisites for unfavorable flow of mesotympanite.

    The opening in the tympanic membrane can be round, oval, kidney-shaped. In some cases, the edges of perforation can be spliced ​​with the medial wall of the tympanum, and connective tissue strands can grasp the auditory ossicles, disrupting their mobility.

    In the diagnosis of mesotympanitis, in addition to traditional otoscopy, a microscopy survey should be used to examine in detail the remains of the tympanic membrane and the visible portions of the tympanic cavity and assess the condition of the mucosa of the promontorial wall.

    The hearing in mesotympanitis is lowered mainly in the conjunctive type, the degree of hearing loss depends on the localization of the perforation, its size and the nature of pathological changes in the tympanum. When perforating in the anterior eardrum, hearing can be reduced by 15 -20 dB or remain within normal limits. With a long course of mesotympanitis and frequent exacerbations due to intoxication of the inner ear, the neurosensory component of deafness develops additionally.

    Chronic purulent epitimpanitis is a form of CHGO, at which bone structure of the middle ear is affected. Pathological changes are localized mainly in the above-drum space and the mastoid process, perforation usually occurs in the not stretched part of the tympanic membrane, but can also spread to other parts of the eardrum.

    Epitimpanitis is characterized by a heavier flow, in comparison with mesotimbanitis. With this form of CHGO, along with the morphological changes noted in mesotympanitis, the bone structures of the middle ear are also affected;As a result, the caries of the bony walls of the attic, aditus, antrum and cells of the mastoid process develops. In addition, with epitimpanitis, cholesteatoma( epidermal formation) is formed in most cases, which also causes pronounced destructive changes in the bone structures of the middle ear.

    Depending on which pathology prevails, carious lesions of bone tissue or changes caused by the formation of cholesteatoma, distinguish the purulent-carious and cholesteatom form of epitimpanitis. However, this division is arbitrary, since often in the affected cavities of the middle ear one can find both those and other changes.

    In the purulent-carious form the process is localized mainly in the attic - the upper part of the tympanum. The localization of inflammation in the above-drum depression is associated with the peculiarities of the structure of this department. There are numerous folds, pockets of the mucosa, the infectious process in which it is difficult to give conservative treatment. Changes in bone tissue of different degrees are most often located in the area of ​​the lateral wall of the attic and above the entrance to the cave, and auditory ossicles, which are located mainly in the above-drum space, are often affected.

    Cholesteatom form. Cholesteatoma is a tumor-like formation of whitish color, with pearlescent shine, usually having a connective tissue membrane - a matrix covered with multilayered flat epithelium, closely adhering to the bone and often growing into it. The basis of cholesteatoma is a dense layering of epidermal masses and products of their decay, mainly cholesterol, pus, bacteria.

    Cholesteatoma formation is associated with the growth of the epidermis of the skin of the external auditory canal into the middle ear cavity, which becomes possible with edge perforation of the tympanic membrane. In these conditions, between the skin of the auditory canal and the above-drum space there is no obstruction in the form of the remains of the tympanic membrane. The epidermis that grows in this way is the shell of the cholesteatoma - its matrix.

    Matrix is ​​a living formation: its epidermal layer constantly grows and slushes( which is a normal process for the skin), and under the influence of stimulation with pus and the products of decay this process only intensifies. The constant desquamation of the surface layers of the epidermis, its retention and accumulation in the narrow cavities of the middle ear - all this is the process of growth of the cholesteatoma.

    Increasingly, the cholesteatoma fills the attic and antrum and destroys the surrounding bone - the labyrinthine bone capsule, the facial nerve channel wall and the mastoid process, as a result of which the shells of the temporal lobe of the brain, cerebellum and sigmoid sinus wall are exposed. Over time, this process can lead to serious complications, including intracranial complications. Such a course of pathology is promoted by the constant pressure of the mass of the cholesteatoma, the ingrowth of the matrix into the bone cells and the empty tubules of the bone walls, and the effect on the bone tissue of the chemical components of the cholesteatoma and the products of its decay.

    Clinic. The main complaint of patients who develop a purulent-carious process is discharge from the ear. Allocations are usually purulent, with an unpleasant putrefactive odor, sometimes( in the presence of granulations) with an admixture of blood or "crumb-like" masses. A sharp unpleasant odor of discharge from the ear is associated with the caries of the bone walls, at which purine compounds( indole, skatole) are formed.

    When otoscopy in patients with this form of epitimpanitis in the initial stage of the disease, one can see a small perforation in the relaxed part of the tympanic membrane.11increasingly increasing, the perforation completely occupies the lateral wall of the attic-the unattended part of the tympanic membrane and the bone part of the wall, often with the transition to the posterior wall of the external auditory canal. Through the resulting hole, granulation can be seen, and when probing the bone edge of the perforation, a roughness is felt.

    Patients with epitimpanitis have a more pronounced hearing loss than mesotympanitis. Caries extends to the auditory ossicles, and the articulation between the anvil and the hammer is often destroyed. In addition, the sound-receiving apparatus is damaged, which is due to intoxication of the inner ear through the secondary membrane of the cochlear window and the annular bundle of the window of the vestibule.

    Cholesteatomnaya form epitimpanita can last for a long time without significant clinical manifestations. The formation and growth of cholesteatoma occur without pain. The patient notes only a periodic suppuration from the ear and a decrease in hearing, to which( especially in a one-sided process) he gets used and therefore can for a long time not pay attention to the symptoms. But although outwardly the cholesteatom epitimpanitis proceeds relatively quietly for years, the destruction of the bone walls of the middle ear is steadily progressing. The likelihood of developing severe complications, including life-threatening complications, with this form of epitimpanitis is very high.

    For uncomplicated purulent-carious or cholesteatomic epitimpanitis, symptoms such as earache, headache, dizziness, unsteadiness of the gait are not characteristic. Their appearance indicates an emerging or already existing complication. Pain can be a consequence of intoxication of the meninges with difficulty in the outflow of pus caused by granulations, polyps, swollen cholesteatom masses. Dizziness and unsteadiness of the gait may be associated with the formation of a fistula in a labyrinth capsule, usually this happens in the ampulla of a horizontal semicircular canal. The destruction of the bone wall of the fallopian canal leads to the development of paresis of the facial nerve.

    The appearance of these complaints in a patient with chronic purulent epitimpanitis is the basis for his urgent hospitalization in an ENT hospital for examination and surgical treatment.

    In practice, sometimes there is a diagnosis of epimesotime-panit. This term usually refers to a mixed form of the disease in which a patient with chronic purulent otitis media is additionally diagnosed with a subtotal or total defect in the tympanic membrane. In this case, the process affects all parts of the tympanum, often develops cholesteatoma, granulation, signs of bone destruction. The approach to the management of such patients is the same as with epitimpanitis.

    The diagnosis of CHD is usually based on history, clinical manifestations and otoscopic pattern.

    The distinguishing features of mesotympanite are:

    The appearance of an odor of purulent discharge indicates the involvement of the bone in the carious process, which indicates the transition of the disease to a poor-quality form. With an extensive defect of the tympanic membrane, it is possible to penetrate into the attic with a button probe and feel its walls: when mesotymic, they are smooth, the sensations of roughness indicating caries will not be.

    The diagnosis of "epitimpanitis" is evident already in the detection of perforation in the not stretched part of the tympanic membrane. Violation of the integrity of the tympanic membrane can extend to the lateral lateral wall of the attic, often on the posterior wall of the external auditory canal. When probing the bone edge of the perforation, roughness is felt.

    In some cases, the defect of the tympanic membrane is very small, located in the epitimpanal part of the membrane or in the depth of its funnel-like retraction, and sometimes it can be covered with a purulent crust. To detect such perforations is possible only with otomicroscopy, the implementation of which is recommended in all cases, especially in dubious ones.

    In addition, this diagnosis is confirmed by the following symptoms:

    The nature of the flow of epitimpanitis does not depend on the size of the perforation, often with its microscopic dimensions in the bone structures of the middle ear reveals pronounced destructive changes.

    Cholesteatomy recognition is not difficult if typical white( pearly) cholesteatom masses are visible in the perforation lumen.

    In other cases, cholesteatoma can be recognized by rinsing the above-drum space through the ear cannula. The detection of floating epidermal flakes in the wash fluid indicates the presence of cholesteatoma.

    When probing through a perforation with a curved point-like probe along the edge of the lateral wall of the attic, a roughness is detected, often cholesteatomic masses adhere to the tip of the probe.

    With cholesteatoma in the osseous part of the external auditory canal, the posterior walls of the wall often hang, which is accompanied by narrowing of its deep sections. This symptom indicates the spread of cholesteatoma under the periosteum of the external auditory canal.

    An important method of investigation for various forms of CHGS is the radiography of temporal bones in the Schueller and Mayer projections, which allows to evaluate the state of the cellular system of the mastoid process and the attico-antral region. With a prolonged course of the disease, a sclerotic structure of the temporal bone is visible on the x-ray of the patient's ear.

    The underdevelopment of the temporal bone( "infantile" temporal bone) detected on the X-ray diffraction pattern suggests that the chronic purulent otitis media appeared in the patient as early as in childhood. And in a number of cases, as a result of an X-ray study, the patient can even find a destruction of the temporal bone, even with a successful otoscopic picture, which is manifested by cavity formations, signs of sequestration, and bone destruction in the atticoantral region.

    With cholesteatoma on the roentgenogram, there is a sharp outlined bone defect in the attico-antral region. It has the form of structureless enlightenment( cavity), surrounded by a thin dense bone - the wall of the cavity. In the carious process in the bone, the edges of the defect are usually blurred.

    Nowadays, computer tomography( CT) of temporal bones has acquired great importance. It allows to diagnose cholesteatoma, defects of auditory ossicles, soft tissue formations( granulations, polyps) in the tympanic cavity and cell system of the mastoid process, bone destruction in the anthrahtrum, drum cavity and sigmoid sinus bone wall, to establish the fact of the process spreading into the cranial cavity.

    Currently, the basis of treatment for all forms of CHCS is surgical intervention at the earliest possible time. The earlier it is produced, the greater the chance of complete cure of otitis media and the restoration( preservation) of the auditory function.

    Conservative treatment of a patient with CHSR is advisable only as preparation of the patient for surgical intervention and should be performed within 1-3 months before the operation. As an independent method of treatment, it can be used only in the event of patient's refusal from the operation or impossibility of carrying it out because of the patient's severe physical condition.

    Conservative treatment can be local and general.

    Local treatment begins with a thorough toilet drum cavity. It is advisable to wash it with aqueous isotonic solutions of antiseptics( furacilin, 0.5% solution of dioxidine, 2% solution of hydrogen peroxide).Improving the evacuation of pathological contents is facilitated by the use of proteolytic enzymes( trypsin, chymotrypsin, lidazy) and mucolytics( acetylcysteine, fluimycil, sinupret).

    The penetration of drugs into various parts of the tympanum is facilitated by the trans -impanal injection of medicinal substances. To reduce the edema of the mucous membrane of the middle ear cavities and better penetration of antibacterial, anti-inflammatory and other drugs, it is better to start the injection with vasoconstrictors( adrenaline, galazoline, vibrocil).

    Polyps or granulations that cover the perforation should be removed( can be done on an outpatient basis).

    In the presence of cholesteatoma in the middle ear cavities, washing with aqueous solutions of antiseptics may cause its swelling and lead to a worsening of the outflow of the pathological secret. Therefore, when suspicion of cholesteatoma, rinsing of the tympanum cavity should be carried out with alcohol-containing solutions, for example 3% alcohol solution of boric acid.

    Local or systemic antibacterial drugs can be administered only taking into account the results of the antibioticogram. Before receiving the results of the microbiological study, antibiotics of a wide spectrum of action are used, taking into account the possibility of participation in the inflammatory process of aerobic-anaerobic associations of microorganisms and fungi. It is advisable to use combinations of such antibiotics as cephalosporins, rifampicin, chloramphenicol, metronidazole with processing of the walls of the auditory passage with nitrofungin.

    Steroid hormonal drugs( hydrocortisone, prednisolone, dexamethasone) reduce edema of the mucosa, reduce the activity of exudative and proliferative processes, promote the restoration of normal cellular composition of the mucosa. However, it should be borne in mind that with prolonged use, corticosteroids can stimulate the growth of fungal flora.

    Local drug treatment for exacerbation should be supplemented with physiotherapy methods: UV, laser therapy with low-energy helium-neon laser, irrigation of the drum cavity with oxygen.

    To restore the drainage and ventilation functions of the auditory tube, transteppanal and through the catheter are administered vasoconstrictive, antibacterial, hormonal preparations;perform aeration of the auditory tube, electrostimulation of the muscles of the pharynx, laser therapy of the pharyngeal and tympanal estuaries of the auditory tube.

    The methods of general conservative treatment include the appointment of medications fortifying, immunocorrectors and hyposensitizing agents. It should also be remembered the need to normalize nasal breathing, both conservative and surgical, sanitation of foci of inflammation in the nasal cavity and near-nasal sinuses, nasopharynx, and oropharynx.

    Surgical treatment for HCG is aimed at both sanitizing the focus of inflammation and preventing intracranial complications, as well as improving or maintaining hearing. Exacerbation of chronic purulent otitis media should be regarded as a condition that can lead to the development of an ocogenic intracranial complication. Such patients are urgent, they are urgently sent to a hospital, where, if necessary, the operation is performed urgently.

    As already mentioned, the surgical method is the main one in the treatment of CHD, but radicalism in operations on the middle ear is gradually replaced by sparing sanitizing intervention with simultaneous performance of the hearing-enhancing elements( in some cases they are performed in the second stage of the operation).

    The choice of the procedure of the operation is individual and depends on the duration of HCG, the extent and severity of the pathological process, the anatomical features of the mastoid process, the degree of auditory disorders, the state of the auditory tube, intracranial and labyrinthine complications, the surgeon's qualification and the availability of modern equipment.

    Various modifications of operations are used - both sanitizing hearing-preserving and hearing-enhancing ones. Depending on the state of the auditory tube, the mucosa of the tympanic cavity, cellular system mastoid, size and location of the perforation can be performed obschepolostnuyu sanitize sluhsohranyayuschuyu operation in the middle ear( s tympanoplasty or without it), the separate attikoantrotomiyu, tympanoplasty with revision tympanum, attic and aditusaand myringoplasty. The question of the appropriateness of this or that method of surgical treatment in each patient is decided individually.

    Surgical intervention on the structures of the middle ear is performed under anesthesia and only in exceptional cases - under local anesthesia. The larger the expected volume of surgery, the greater the need for general anesthesia.

    Operations are performed using instruments for operations on the mastoid process, a set of mills, an operating microscope and micro-tools. Depending on the prevalence of the inflammatory process in the middle ear and pneumatization of the mastoid process, endaural, or BTE, surgical approach is used.

    Advantage of the endaural approach in the sparing relation to the tissues and the faster reparative postoperative period. Advantage of the BTE approach in the ability to more carefully perform the sanation of the cells of the mastoid process and the best possibilities for mastoidoplasty.

    Ways of access to middle ear structures can be transmemational and transcortical. When

    destructive process in a loft antral region common cholesteatoma, labyrinth complications and other cases of adverse medial otitis currents which manifest themselves in particular repeating 1 -2 times a year suppuration of the ear, the main method of surgical treatment is a radical conservative obschepolostnaya sanitize sluhsohranyayuschayaoperation.

    Its prototype was a radical operation on the middle ear, developed and implemented in practice in the XIX century by Tzaufal, Küstner, Bergman, L. Stack and subsequently modified by LT.Levin. The aim of the intervention is to eliminate the focus of the infection, to prevent the development of intracranial and general otogenic complications, to preserve and improve the patient's hearing, and also to prepare conditions for the performance of the most effective surgery.

    The operation is performed by BTE, in rare cases( with a limited destructive process) it is performed through the external auditory meatus.

    Milestones obschepolostnoy sluhso-sanitizing operations not conserve:

    the first stage is carried BTE otseparovku incision and soft tissue is exposed lateral wall of the mastoid process, detachment is carried out and the rear part of the upper wall of the external auditory passage until the annulus tympanicus;

    perform a bone operation in the second stage;it is carried out with the help of electric milling cutters, a hammer and long chisels with different widths of the cutting end are also used.

    The guidelines for the opening of the mastoid cave serve: from above - the bony protrusion of the temporal line, in front - spina suprameatum;behind - a line that delimits the triangular area of ​​the mastoid process. A number of other anatomical formations help to orientate themselves in the operating wound. So, above the temporal line and above the level of the upper bone wall of the external auditory canal in the middle cranial fossa is the temporal lobe of the brain covered by the dura mater. Behind the triangular area of ​​the mastoid process is a sigmoid sinus. At the entrance to the cave on the medial wall is the vertical knee of the facial nerve, and behind it is the ampulla of the horizontal semicircular canal, below which the canal of the facial nerve continues.

    The bark or chisels remove the cortical bone layer, reveal the cells of the mastoid process and the mastoid cave. The carious bone is removed to a healthy bone tissue, then the posterior wall of the external auditory canal and the medial site of the posterior bone wall( "bridge") above the entrance to the cave are removed. It should be borne in mind that the demolition of this area is associated with the risk of injury to the facial nerve and a horizontal semicircular canal located on the medial wall of the entrance to the mastoid cave. It is also important not to damage or dislocate the short ankle and its ligament apparatus located at the entrance to the cave. Therefore this and subsequent stages of the operation are performed using an operating microscope and micro-tools.

    Perform an examination of the entrance to the cave, removal of the lateral wall of the attic, revision of the tympanic cavity, removal of granulations, polyps, cholesteatoma, revision of the auditory ossicle, carefully release them from granulation, retaining functioning sound elements and ligamentous apparatus. Even the caries-damaged auditory ossicles in the vast majority of patients play a significant role in the conduct of sound. And, as shown by the observation of such patients decades after the operation, the preservation of auditory ossicles( including those affected by caries) in its course does not have any negative consequences.

    From the skin of the back wall of the external auditory canal, cut( according to AA Mironov) a U-shaped meatotimpanal flap on feeding legs from the skin of the upper and lower walls of the external auditory canal. This flap is placed on an antrum, an anvil and a "spur" - a site of a back wall of an external acoustical passage, smoothed down to level of a horizontal semicircular canal. From the remnants of the skin of the posterior wall of the external auditory canal, the lower L-shaped flap is cut out, which is laid on the lower part of the mastoid trepanation cavity.

    The postoperative cavity is swabbed with turuns with antiseptics on an ointment base( levomecol, dihydroxy, antibiotic with vaseline) or an inflatable balloon. On the behind-the-back wound sutures are applied, and on the ear - bandage.

    The first dressing with the change of tampons is performed for 2 -3 days. In the future, swabs are changed every 2 to 3 days, periodically leaving the cavity open and irrigating it with antiseptics. After the restoration of the epidermal cover of the tympanum( ie, after 3 to 4 weeks), the discharge from it completely ceases. If the process of restoring the epidermis is delayed due to excessive growth of granulations, they are removed with surgical spoons and curettes and cauterized with a 30-40% solution of silver nitrate or tri-chloroacetic acid.

    In the future, the cavity should be periodically observed to exclude accumulation of epidermal masses in it and relapses of suppuration from the ear.

    In patients with intracranial and labyrinthine complications of CHGS, patients undergo an extensive radical vesicular surgery. Use a BTE approach with exposure of the mastoid process. With the help of burs open all the cells of the mastoid process, antrum, attic, remove the posterior upper wall of the auditory canal, bone bridge, smooth the spur, if necessary remove the carious changes of the auditory ossicles, reveal the dura mater of the middle and posterior cranial fossa and the sigmoid sinus. The further stages of the operation and the management of the postoperative wound depend on the type of complication.

    This type of operation is shown with a limited destructive process in the attic area and the stored stretched part of the tympanic membrane. It is performed through the external auditory canal with the use of an ear funnel or retractors. After opening the drum cavity with an intramealic incision( according to Rosen), with the help of boron or bits, the lateral wall of the attic is removed for revision of this region, auditory ossicles and their ligamentous apparatus. Ventilation of the antrum is carried out from the mesotimbanum through the Isthmus.

    In the presence of a limited( cystic) cholesteatoma or carious stones, all pathological contents are removed to healthy tissues and various materials repair the chain of auditory ossicles and the distant lateral wall of the attic( closed version).

    With the impossibility of careful removal from the attic of the creeping cholesteatoma, the area of ​​the attic is left open, delimiting the mesohypothympanum and antrum with an autophascial graft to prevent the spread of the cholesteatoma.

    Used in destructive process in the attic area and antrum with the preserved( or partially preserved) stretched part of the tympanic membrane. The method of its implementation provides for "widening of the atticotomy" in the posterior direction with a transmeal approach. For this endaural incision is used according to N. Heermann. After applying the retractors and cutting off the meal flap, the posterior wall of the auditory canal is opened. With the help of boron, remove the lateral wall of the attic and aditus, after which the antrum is opened. Further, a resection of the posterior walls of the auditory canal is performed, which leads to a gradual expansion of the antrum( endouragal operation by L. Stacke).The operation is terminated by plasticizing the cavity with a meal flap.

    Transmeal approach in sclerotic mastoid process and small antrum allows the formation of a small mastoid cavity, which ensures its rapid epithelium behind. After the opening of the tympanic cavity, it is audited and pathological tissues are removed.

    The reconstructive stage of the operation( tympanoplasty I-IV type according to Vulynteyn) is possible with the use of various plastic materials( autofascia of the temporalis muscle, autochondria of the tragus), which are taken through the access previously made.

    This operation is indicated for limited cholesteatoma and granulations in the overdrug space and stubborn sluggish HCGO with mucositis. It consists in the separate removal of the lateral wall of the attic and the opening of the cells of the mastoid process and antrum with preservation of the back wall of the auditory canal.

    • At the first stage intrameatal access( according to Rosen) is opened by a tympanic cavity, it performs revision and removes abnormal tissues( scars, granulations, cholesteatomas, carious auditory ossicles, thickened mucous membrane).

    • In the second stage, the mastoid and mammary cells of the mastoid process are transcutally opened by the Bose method in the bursal approach. An obligatory condition for this method is the revision and expansion of the area of ​​the aditus due to its frequent block.

    The operation is terminated with a different type of tympanoplasty. To prevent a repeated block of aditus, a silicone film is placed in it for two weeks. On the behind-the-back wound superimposed suturing seams. To ensure the drainage of the tympanum, the behind-the-back wound is open for two weeks. Currently, this kind of operations are performed infrequently due to a complicated postoperative period.

    It should be remembered that CHGSO is characterized by a prolonged course, and although sometimes the disease is accompanied by very scant symptoms, the likelihood of developing serious, often life-threatening complications, exists continuously. These complications develop more often against the background of an exacerbation of the pathological process in the ear, often with a violation of outflow from the middle ear cavity. The most dangerous of them include:

    The most reliable way to prevent these complications and keep the patient's hearing is the timely execution of a sanitizing operation on the ear.

    Surgical ear interventions performed to improve hearing are referred to as "tympanoplasty."It is indicated for various forms of chronic purulent otitis media, traumas, anomalies of ear development, with adhesive median otitis.

    The question of tympanoplasty is decided depending on the operational findings and the condition of the muckeroper. It can be performed simultaneously with a sanitizing operation or postponed to the second stage - after the normalization of the function of the auditory tube and the subsidence of inflammatory changes in the postoperative and tympanic cavities.

    Timpanoplasty involves the use of ordinary elements of the sound-conducting apparatus of the middle ear, and in case of their partial or total loss, the reconstruction of the transformation system with the help of various materials. For this purpose, they use:

    Before the operation, an audiological examination is carried out, the type of hearing loss, the functional reserve of the cochlea( the difference between the air and bone conduction thresholds on the audiogram), ventilation and drainage functions of the auditory tube. With pronounced disturbance of the sound perception and functions of the auditory tube, the tympanopic eraser is ineffective. For the purpose of predicting its results, a sample with fleece is used - they establish a possible increase in the severity of hearing after the operation. On the perforation of the tympanic membrane or in the ear canal opposite her, put a cotton wool soaked with paraffin oil, and find out how the hearing changes.

    For tympanoplasty to be successful, the following conditions are necessary: ​​

    Contraindications to tympanoplasty are labyrinthitis and intracranial or septicopyemic complications.

    Hearing improvement with tympanoplasty can be achieved in the following ways:

    Various methods of tympanoplasty were systematized by H. Woollytein, who distinguished five types of surgery.

    I type tympanoplasty - endaural myringoplasty( restoration of the integrity of the tympanic membrane) is performed in the presence of perforation in the tympanic membrane and the normal functioning of the chain of auditory ossicles and an auditory tube. The operation is performed through the external auditory meatus using an ear funnel or retractors. First de-epithelialize the edges of the perforation. After the opening of the drum cavity, an intramealic incision( according to Rosen) is performed by the revision of all its departments( the mouth of the auditory tube, the attic, the aditus, the retromimipanal pocket, the hypothympanum, the chain of the auditory ossicles and the labyrinth windows) with excision( or incisions) of the hyperplastic parts of the mesohypothympanum mucosa. As a transplant, a meatotimpanal flap or plastic materials( autophasia of the temporalis muscle, an autochthonous auricle) are used, which are taken through additional incisions in the behind-eye region.

    II type - perform if there is a defect in the head, neck or handle of the hammer. In this case, the mobilized tympanic membrane or neotympanal membrane is laid on the surviving anvil.

    III type - perform in the absence of a hammer and anvil. The transplant is laid directly on the head of the stirrup, thus creating a "columella effect" - a sound-conducting type of bird( in birds there is only one hearing bone - columella).

    IV type - screening of the cochlea - is performed in the absence of all auditory ossicles, except the base of the stapes. The neotympanal flap is laid on the promontoryum and delimits the niche of the snail's window, the hypothympanum and the mouth of the auditory tube. Hearing is improved by increasing the pressure difference to the labyrinth windows.

    V type - fenestratsiyu horizontal semicircular canal - perform in the absence of all sound elements and a fixed base of the stirrup. The operation window is covered with a graft;simultaneously screen the window of the cochlea to form a small tympanal cavity, the aeration of which is carried out through the lower section of the tympanum.

    At replacement of missing elements of a sound-conducting system now along with autografts all the more widely use various biologically inert materials, for example bioceramic prosthetics of auditory ossicles or artificial limbs made of titanium.

    Prevention of inflammatory diseases of the middle ear involves the elimination or weakening of the influence of those factors that contribute to the emergence of acute otitis media and its transition to chronic otitis. Prevention of otitis should start from the earliest childhood.

    In infants, the level of natural resistance is directly dependent on the mode of feeding. With breast milk, the child receives substances that provide nonspecific humoral protection, for example lysozyme, immunoglobulins, which is very important for the adaptation of the child to environmental conditions. Therefore, an important measure of preventing colds and middle otitis is the feeding of the baby with breastmilk.

    Until recently, the incidence of otitis media in infants was mainly due to childhood infectious diseases, but today, thanks to mass specific prevention, the incidence of infections such as measles and scarlet fever has been reduced.

    The incidence of otitis media in children and adults is affected by a number of other factors:

    Elimination of adverse effects of these factors will reduce the incidence of inflammatory diseases of the middle ear.

    In the development of acute otitis media and in its transition to a chronic important role, chronic foci of infection in the nose and throat play. Timely sanation of such foci of infection and the restoration of normal nasal breathing are necessary components in a complex of measures to prevent otitis media.

    The best prevention of chronic purulent otitis media is correct treatment of a patient with acute otitis media. An important component of such treatment is timely( according to indications) performed paracentesis, as well as adequate antibiotic therapy, which is prescribed taking into account the characteristics of the pathogen and its sensitivity to antibiotics.

    It should be borne in mind that long-term remissions that last for many years during chronic otitis often create a semblance of well-being for both the patient and the doctor. However, even with a calm clinical picture of chronic purulent otitis media, a patient may develop cholesteatoma or an extensive carious process in the middle ear cavities, which can lead not only to increasing hearing loss, but also to the development of severe, often life-threatening complications. Therefore, the earlier the ear is sanitized, the greater the chances of maintaining and improving hearing.