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Lecture notes, cheat sheets
Лор-заболевания. Болезни среднего уха. Острый тубоотит. Острый серозный средний отит (конспект лекций)
Directory / Lecture notes, cheat sheets Table of contents (expand) Lecture number 3. Diseases of the middle ear Diseases of the middle ear represent the most clinically and socially important group. They often affect adults and especially children. The result of these diseases is hearing loss, leading to a decrease in social activity and professional fitness. In addition, diseases of the middle ear can cause intracranial complications that are fatal. The condition for the normal functioning of the ear is good ventilation through the auditory tube, which, in turn, depends on the condition of the upper respiratory tract. There are acute and chronic otitis media, and by the nature of the exudate - serous and purulent. Diseases of the middle ear are rarely primary. In most cases, they develop against the background of inflammatory processes of the upper respiratory tract, especially in the presence of factors contributing to the violation of ear ventilation: adenoids, nasal polyps, curvature of the nasal septum, hypertrophy of the turbinates, sinusitis and other diseases. Inflammation goes through three stages: alterative, exudative and proliferative. Acute otitis media according to the nature of the exudate is divided into mucous, serous, purulent, hemorrhagic and fibrinous. Purulent inflammation always leads to the formation of perforation of the membrane. With purulent otitis, there is a pronounced exudation with a gradual transition of the mucous exudate into serous, and then into purulent. The severity of inflammation, its prevalence and outcome depend on the degree and duration of the dysfunction of the auditory tube, the virulence of microorganisms, the resistance and reactivity of the human body. 1. Acute tubo-otitis Acute tubo-otitis is characterized by a mucous form of the exudative stage of inflammation. Since there is no free exudate in the tympanic cavity, in this pathology of the middle ear, the main role is played by the inflammatory process in the auditory tube, leading to a violation of its functions, with moderate inflammation in the tympanic cavity. Etiology The cause of acute tubootitis is an infection from the upper respiratory tract that spreads to the auditory tube and tympanic cavity. Infection of the auditory tube most often occurs with acute respiratory viral disease, influenza, and in children with scarlet fever, measles, whooping cough, diphtheria and other infections accompanied by catarrh of the upper respiratory tract. The etiological factor is viruses, streptococci, staphylococci. Pathogenesis The mucous membrane of the auditory tube, nasopharynx and respiratory region of the nasal cavity is covered with cylindrical ciliated epithelium containing many mucous glands, and in the region of the nasopharyngeal mouth of the auditory tube contains lymphoid tissue, so inflammation of the upper respiratory tract quickly spreads to the auditory tube and tympanic cavity. As a result of inflammation of the auditory tube, its functions are violated: ventilation, drainage, barofunction and protective. The reasons for the violation of these functions are permanent and temporary. Permanent causes include adenoid vegetations, hypertrophy of the posterior ends of the inferior turbinates, chronic rhinitis, choanal and other polyps, deviated nasal septum, tumors of the nasopharynx, which can close the nasopharyngeal mouth of the auditory tube and interfere with its ventilation function. Temporary causes include acute inflammation of the upper respiratory tract. The cause of tubo-otitis can be sudden changes in atmospheric pressure during the ascent and descent of the aircraft, as well as during the dive and ascent of divers and submariners. Aerootitis in pilots and mareotitis in sailors may have the character of tubo-otitis. An increase in pressure from the outside is worse tolerated, since it is more difficult for air to penetrate into the tympanic cavity through a compressed auditory tube. The functions of the auditory tube with tubo-otitis are impaired due to inflammation of its mucous membrane and constant closure of the walls. In violation of the ventilation of the tympanic cavity and negative pressure, a transudate may appear in it, containing up to 3% of protein and less often fibrin. In acute tubo-otitis caused by an infection, extravasation is not prolonged and pronounced, since an exudative stage of inflammation occurs. The exudate is scanty, mucous in nature, which gives reason to consider acute tubo-otitis as an inflammation of the middle ear with a predominance of the pathology of the auditory tube. There is no free exudate forming the fluid level in the tympanic cavity. A dull color and retraction of the tympanic membrane are noted. Clinic During an acute respiratory viral infection or immediately after, the patient complains of unilateral or bilateral permanent or intermittent hearing loss, tinnitus. Ear congestion may be the result of an uncompensated difference in atmospheric pressure (for example, after flying on an airplane). The retraction of the tympanic membrane is noted, the characteristic features of which are the apparent shortening of the malleus handle, the protrusion of its short process outwards, the deformation or disappearance of the light cone, and more distinct anterior and posterior malleus folds. Hearing is reduced due to changes in the hydrodynamics of the ear lymph. With impedancemetry, negative pressure in the tympanic cavity is determined. With a slight hyperemia of the tympanic membrane, it is permissible to blow out the ear after a thorough anemization of the nasal mucosa. A characteristic of acute tubootitis is the restoration of hearing after blowing out the ear. Sometimes patients themselves note a periodic improvement in hearing when they yawn or blow their nose. Treatment The main attention is paid to the restoration of the ventilation function of the auditory tube. For this, long-acting vasoconstrictor nasal drops (sanorin, naphthyzin, galazolin, tizin, nazivin) are prescribed 3 times a day. Antihistamines (tavegil, suprastin, diazolin) contribute to the reduction of swelling of the mucous membrane. Symptomatic treatment of acute respiratory viral disease is carried out. After careful anemization of the mucous membrane of the inferior turbinates and mouths of the auditory tubes, the ears are blown. Of the physiotherapeutic methods of treatment, UHF and pneumomassage of the tympanic membrane are recommended. With adequate treatment, acute tubo-otitis often resolves within a few days. With a prolonged course, it is necessary to make an x-ray of the paranasal sinuses to exclude acute sinusitis. 2. Acute serous otitis media Acute serous otitis media is characterized by a serous form of exudative inflammation. Etiology The cause of acute serous otitis media is most often an infection of the upper respiratory tract, which enters the tympanic cavity through the auditory tube. This usually happens during an acute respiratory viral infection, influenza and other diseases that occur with inflammation of the respiratory tract. The causative agents of otitis are viruses, staphylococci, streptococci, pneumococci. In children, the causes of otitis are measles, scarlet fever, whooping cough, diphtheria, etc. Serous otitis often has a protracted course, especially in children, which depends on the nature and virulence of the pathogen, the morphofunctional state of the middle ear and the immunobiological resistance of the organism. Pathogenesis The inflammatory process from the upper respiratory tract extends to the mucous membrane of the tube and into the tympanic cavity. The mucous membrane of the auditory tube is infiltrated, the ciliated epithelium partially dies, the inflamed walls close, and its ventilation and drainage functions are disturbed. Negative pressure in the tympanic cavity leads to venous stasis and the appearance of transudate, and then serous exudate. The mucous membrane is infiltrated by lymphocytes. The squamous epithelium metaplasias into a cylindrical epithelium, is replaced by goblet secretory cells, the mucous glands secrete a copious secret. Free fluid appears in the tympanic cavity. This fluid may be mucoserous, serous, or gelatinous with few cells and often sterile. The secret can dissolve or evacuate into the nasopharynx when the function of the auditory tube is normal, but, thick and viscous, it is more often organized into connective tissue scars. The adhesive process leads to persistent hearing loss. Clinic There is a decrease in hearing, noise in the ear, sometimes pain, as well as a feeling of transfusion of fluid in the ear when the position of the head changes. When otoscopy, a yellowish, milky, brownish or bluish color of the eardrum is observed, depending on the color of the translucent fluid. Sometimes the transudate has the form of foamy bubbles formed when air enters through the auditory tube. When it partially fills the tympanic cavity, the fluid level can be seen as a dark gray line. Often, the symptom of translucence of the secret through the tympanic membrane goes unnoticed due to the initially seemingly favorable course of otitis media. Body temperature is normal or subfebrile. Due to retraction or protrusion of the membrane and a decrease in the mobility of the sound-conducting apparatus, conductive hearing loss is noted. In the presence of fluid in the region of the labyrinth windows, bone and tissue conduction deteriorates, and the tonal perception of high frequencies also suffers. With the disappearance of fluid in the tympanic cavity, hearing improves, bone and tissue conductivity is restored. Treatment Treatment consists primarily in the elimination of acute inflammatory phenomena in the upper respiratory tract to normalize the function of the auditory tube and evacuate the pathological secret from the tympanic cavity by the transtubal or transtympanic route. In the absence of a pronounced general reaction of the body, antibiotics and sulfa drugs are not prescribed, since they can contribute to a more sluggish course of the inflammatory process in the ear and thickening of the secret. Vasoconstrictor nose drops are used (sanorin, galazolin, naphthyzin, nazivin, tizin, imidine). You can not use tableted preparations for the common cold such as rhinopront or coldact, containing anticholinergics and reducing mucus secretion, as this also makes the secret more viscous and difficult to remove from the tympanic cavity. It is advisable to lubricate the mouth of the auditory tube with vasoconstrictor agents, and then with astringents (1-2% silver nitrate solution or 2% protargol solution). Proteolytic enzymes (trypsin, chymotrypsin - 1-2 mg per 1 ml of isotonic sodium chloride solution) are introduced into the tympanic cavity through an ear metal catheter through the auditory tube, which help to thin the secretion. To improve the drainage function of the auditory tube, the introduction of glucocorticoids is indicated. In order to prevent the adhesive process, lidase is introduced at a later period. The introduction of proteolytic enzymes and lidase through electrophoresis is quite effective. The development of the adhesive process is prevented by pneumomassage of the tympanic membrane using the ear apparatus or the Siegl funnel. After the elimination of acute rhinitis, the ear is blown through the Politzer or using an ear catheter. Its effectiveness is evaluated using the Luce otoscope. The use of antihistamines (tavegil, suprastin, diazolin, claritin, diphenhydramine), multivitamins, acetylsalicylic acid and symptomatic agents is shown. If the exudate does not resolve, the function of the auditory tube is not restored and the hearing does not improve, then surgical methods are used to evacuate the secret from the tympanic cavity - tympanopuncture, myringotomy (paracentesis) or tympanotomy with secretion suction and the introduction of drugs into the tympanic cavity. Tympanopuncture and myringotomy are performed in the posterior inferior quadrant of the tympanic membrane. Tympanopuncture is resorted to as a single intervention, but sometimes it is repeated. After myringotomy, a Teflon or polyethylene shunt is inserted into the opening of the tympanic membrane, resembling a spool of thread with protruding edges in shape. Shunting of the tympanic cavity can also be carried out with a polyethylene tube 7-8 mm long. Through the shunt, the secret is repeatedly sucked out from the tympanic cavity and medicinal substances are injected into it. The usual paracentesis of the tympanic membrane with suction of the secret is also justified. Prevention Prevention of acute serous otitis media consists in the prevention of acute inflammatory diseases of the upper respiratory tract and surgical sanitation of the ENT organs. Authors: Drozdov A.A., Drozdova M.V. << Back: Diseases of the external ear (Furuncle of the external auditory canal. Diffuse purulent external otitis media. Perichondritis of the external ear. Exostoses of the external auditory canal) >> Forward: Middle ear diseases. Acute purulent otitis media
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