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Lecture notes, cheat sheets
Лор-заболевания. Мастоидит. Адгезивный средний отит (конспект лекций)
Directory / Lecture notes, cheat sheets Table of contents (expand) Lecture number 5. Mastoiditis. Adhesive otitis media 1. Mastoiditis Mastoiditis is the most common complication of acute suppurative otitis media. It occurs when inflammation passes from the mucous membrane of the cells (cells) of the mastoid process to the bone tissue with the onset of osteomyelitis. With primary mastoiditis, the pathological process occurs immediately in the mastoid process, without affecting the tympanic cavity. Secondary mastoiditis develops against or after acute suppurative otitis media. Etiology The causative agents of mastoiditis are the same microorganisms that cause the development of acute purulent otitis media. In 52% of cases, a polyflora is sown, consisting of Proteus vulgaris, Pseudomonas aeruginosa and Streptococcus, in 48% - varieties of Staphylococcus aureus. Pathogenesis Mastoiditis in most cases develops at the end of acute otitis media in patients with a pneumatic type of mastoid structure. A number of factors contribute to the transition of the process to the bone. These include: 1) high virulence of the infection; 2) reduced overall resistance of the body due to various chronic diseases (diabetes, nephritis); 3) difficult outflow of exudate from the tympanic cavity; 4) the occurrence of a block of the entrance to the mastoid cave, preventing the outflow of exudate from the antrum; 5) irrational treatment of acute otitis media. In the presence of these unfavorable factors, mucoid swelling of the mucous membrane of the process progresses, small cell infiltration and circulatory disorders, which causes the cells to fill with serous-purulent, purulent or bloody-purulent exudate. Then osteitis occurs - bone bridges between cells are involved in the process. Since the osteoclastic and osteoblastic antagonistic processes run in parallel, their thickening can be observed before the thinning of the partitions between the cells. The destruction of the bone bridges of the mastoid process leads to the formation in it of a common cavity filled with pus. There is an empyema of the process. Sometimes the process of formation of pathological granulations predominates in the cells. The empyema of the appendix does not manifest itself until the pus has made some kind of outflow path for itself. Several ways of outflow of pus can form at the same time. Clinic More often mastoiditis is noted at the end of acute otitis media. It takes a certain amount of time for the bone to break down. Usually 2-3 weeks pass from the onset of acute purulent otitis media, and then, against the background of an improvement in the clinical picture, pain and suppuration from the ear resume again, body temperature rises and general well-being worsens. Hearing is reduced. Sometimes suppuration is absent due to a violation of the outflow of pus from the middle ear. Pain is noted on palpation or percussion of the mastoid process, more often in the region of the antrum and apex. Pastosity of tissues, smoothness of the behind-the-ear fold and protrusion of the auricle anteriorly can be observed, depending on the severity of inflammation in the process and infiltration of soft tissues. During otoscopy, suppuration is observed. The pus becomes thicker and enters the ear canal in portions under pressure (the pulsating light reflex is resumed). After the pus is removed, it again accumulates in large quantities in the ear canal (reservoir symptom). The eardrum is infiltrated and may have a copper-red color. A pathognomonic symptom of mastoiditis is the overhang of the posterior superior wall of the auditory canal in the bony region due to periostitis. In this place, a fistula sometimes forms, through which pus enters the ear canal. To confirm mastoiditis, an x-ray of the temporal bones according to Schüller is performed. On the radiograph, shading of the cells of the mastoid process, thickening or thinning of their bone walls with periostitis, and destruction of the bridges up to the formation of a cavity with empyema of the process can be noted. Sometimes there are cases of latent course of mastoiditis with serous otitis media. With all the uncertainty of symptoms, there is still hearing loss, dull pain in the ear, a feeling of stuffiness in it, and a history of inflammation of the middle ear. The tympanic membrane is discolored and infiltrated, but may even be intact, since the perforation has either not occurred or has already closed. In contrast to the overhang of the posterior wall of the external auditory canal, only the smoothness of the angle between it and the membrane is noted. With sluggish mastoiditis, osteitis often predominates with the growth of granulations, without a pronounced purulent process. Complications Mastoiditis can be complicated by labyrinthitis or various intracranial complications, the most common of which are sigmoid sinus thrombosis and abscess of the cerebellum or temporal lobe of the brain. The infection is spread by contact. There is also peripheral paresis of the facial nerve. Treatment Treatment of mastoiditis is most often surgical. Conservative treatment in the initial stage of mastoiditis corresponds to the active treatment of acute otitis media. Massive antibacterial and anti-inflammatory therapy is combined with frequent toileting of the ear and the introduction of drugs into it. 2. Adhesive otitis media The presence of a transudate or exudate in the tympanic cavity with prolonged dysfunction of the auditory tube leads to an adhesive process with the formation of adhesions and scars that limit the movements of the auditory ossicles, tympanic membrane and labyrinth windows. Such a hyperplastic reaction of the mucous membrane with its subsequent fibrosis is interpreted as adhesive otitis media. As such, adhesive otitis media is an unfavorable outcome of several ear diseases. Especially often it develops in acute serous otitis, not accompanied by perforation of the eardrum, when viscous mucus cannot drain independently through the auditory tube and creates the so-called sticky ear. A long delay in the recovery of the function of the auditory tube in acute purulent otitis media after spontaneous closure of the perforation of the tympanic membrane also contributes to the organization of the remnants of inflammatory exudate into scar tissue. Acute serous otitis media with inadequate treatment can also turn into an adhesive process. Exudate in chronic purulent otitis media, as a rule, eventually leads to the formation of scars and adhesions in the tympanic cavity, especially in the attic region, sometimes completely delimiting it from the mesotympanum. Adhesive otitis is divided into perforative and non-perforative. Pathogenesis When the pressure in the tympanic cavity is reduced for a long time, the mucous membrane swells and is infiltrated by lymphocytes with the formation of mature connective tissue. Inflammatory exudate or transudate is organized into fibrous bands. This leads to the formation of adhesions, adhesions, calcifications and ossifications in the middle ear cavity. Hyalinization of the mucous membrane surrounding the auditory ossicles, as well as adhesions between the tympanic membrane, auditory ossicles and the medial wall of the cavity, lead to the restriction or complete immobility of the sound-conducting system of the middle ear. A pronounced adhesive process with the overgrowth of the attic, the development of scar tissue in the region of the labyrinthine windows, leading to ankylosis of the stirrup and immobility of the round window, is called tympanosclerosis. Tympanosclerosis is a lesion of the subepithelial layer, which is expressed in hyaline degeneration of the connective tissue. Permanent signs of this tissue are degeneration of the mucous membrane and bone, as well as calcification. There are two types of tympanosclerosis: 1) sclerosing mucositis; 2) osteoclastic mucoperiostitis. After removal of foci of tympanosclerosis, granulations and scars often form in their place. A third of patients who have had chronic inflammation of the middle ear have tympanosclerotic plaques in the tympanic cavity. They are usually localized in areas of narrow spaces with insufficient aeration and a more pronounced inflammatory reaction (in the region of the entrance to the cave, vestibule window, on the auditory ossicles, especially the stirrup). Clinic Adhesive otitis media is characterized by persistent progressive hearing loss, sometimes with low-frequency tinnitus. Otoscopy reveals a dull, thickened, deformed or atrophied tympanic membrane in some areas with retractions, lime deposits and thin mobile scars without a fibrous layer. There are adhesive otitis media with an almost normal otoscopic picture and severe hearing loss after serous otitis media and tubo-otitis media. Typical limitation of the mobility of the tympanic membrane during the study using a pneumatic funnel Sigle. Blowing out the ears does not give a noticeable improvement in hearing. The ventilation function of the auditory tubes is often disturbed. Hearing is reduced according to the mixed type with a predominant violation of sound conduction. The deterioration of bone conduction is facilitated by the limitation of the mobility of both labyrinthine windows and the degeneration of auditory receptors with a long course of the disease. Gellet's experience with ankylosis of the stapes can be negative, as with otosclerosis, and in other cases of adhesive otitis it is inconclusive. Using impedance audiometry, low pressure in the tympanic cavity, limited mobility of the tympanic membrane (tympanogram type B) or, in case of extensive scars, its hyper-compliance (tympanogram type D) are determined. The acoustic reflex of the stirrup is not recorded. With the help of contrast radiography of the auditory tube, a violation of its patency is determined. Treatment First of all, the causes that caused the violation and prevent the restoration of the function of the auditory tube are eliminated. Then the function of the auditory tube is restored by blowing, introducing various medicinal substances into it (lidase, hydrocortisone emulsion, trypsin), UHF therapy, topical application of vasoconstrictor drugs in the nose and oral administration of hyposensitizing agents. In the presence of a helium-neon laser, the walls of the auditory tube are irradiated by means of a light guide inserted into the ear catheter. In order to increase the elasticity of adhesions and reduce their number, lidase (0,1 g of dry matter diluted in 1 ml of a 0,5% solution of novocaine), chymotrypsin (1 ml at a dilution of 1: 1000), an emulsion of hydrocortisone by tympanopuncture. Lidase can be administered by endaural electrophoresis or behind the ear meatotympanic injection. The introduction of these drugs is combined with vibromassage of the tympanic membrane or its pneumomassage using a Sigle funnel. With adhesive otitis media, tympanosclerosis, in the absence of the effect of conservative treatment, surgical treatment is performed. Prevention Prevention of adhesive otitis media is the timely adequate treatment of inflammatory diseases of the middle ear. Authors: Drozdov A.A., Drozdova M.V. << Back: Middle ear diseases. Acute purulent otitis media >> Forward: Diseases of the inner ear. Labyrinthitis. Otosclerosis
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