ENT diseases. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets
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ENT diseases. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets

Table of contents

1. Examination of the ear. Otolaryngological examination

External examination reveals deformity of the auricle, swelling, hyperemia in the area of the mastoid process, discharge from the ear, impaired facial expressions in case of damage to the facial nerve, enlarged lymph nodes in the area of the tragus, mastoid process, below the auricle, postoperative scars, condition of the entrance to the external auditory canal . On palpation, soreness, volume and consistency of tissue in places of inflammation and pathological changes are noted.

Otoscopy is performed using a frontal reflector and an ear funnel. The reflector is aimed at the membrane so that the light beam does not change its position when the left eye is closed and opened.

To examine the right ear, the ear funnel is gently inserted with the right hand into the initial section of the cartilaginous part of the auditory canal, and the auricle is slightly pulled back with the left hand (with otoscopy of the left ear, vice versa) upwards and backwards in adults, and downwards in young children. This straightens the ear canal and the membrane becomes visible.

For better visibility of the membrane, it is advisable for an inexperienced doctor to remove secretions in the ear canal (sulfur, epidermal crusts, dried pus) using an ear cotton holder or Voyachek's attic probe. In the auditory canal, the presence of secretions (pus, blood), swelling of its walls in the cartilaginous or bone part, narrowings are noted.

При отоскопии обращается внимание на опознавательные пункты барабанной перепонки - рукоятку молоточка, его короткий отросток, световой конус, переднюю и заднюю молоточковые складки. Отмечается цвет перепонки (в норме перламутрово-серый, а при отитах - различная степень гиперемии). Определяется положение перепонки (втянута, выбухает) и подвижность с помощью оптической воронки или импедансометра. При наличии перфорации отмечают ее размеры, форму, характер краев (при хроническом отите края рубцовые) и локализацию по квадрантам (передневерхний, передненижний, задневерхний и задненижний). Различают ободковые и краевые перфорации. При первой из них сохраняется ткань перепонки около барабанного кольца, а вторая доходит до кости.

The color, smell (of rotten cheese with cholesteatoma), consistency, degree of discharge from the middle ear, the state of the mucous membrane of the tympanic cavity during perforations are characterized. With marginal perforations, primarily in the shrapnel part of the membrane, probing is performed using the Voyachek attic probe to determine bone caries and cholesteatoma. After a thorough toilet of the ear canal and tympanic cavity, otoscopy data can be better evaluated. Discharge from the ear is subjected to bacteriological examination in order to determine the pathogen and its sensitivity to antibiotics.

2. Furuncle of the external auditory canal

The furuncle of the external auditory canal is considered limited external otitis, which occurs only in the membranous-cartilaginous part of the auditory canal, where there are hair and sebaceous glands.

Etiology, pathogenesis

Most often, a staphylococcal infection invades the glands and hair follicles due to skin trauma and is a manifestation of general furunculosis due to certain diseases (diabetes mellitus, hypovitaminosis).

Clinic

Characterized by severe pain in the ear, radiating to the eye, teeth, neck, sometimes throughout the head. The pain depends on the pressure of the inflamed infiltrate on the perichondrium, which is closely soldered to the skin and richly supplied with sensitive nerve fibers. The pain is aggravated by movements of the jaw, chewing, touching the tragus and pulling the auricle. Hearing is not changed, but when the ear canal is obstructed, conductive hearing loss occurs. The furuncle can resolve itself by resorption of the infiltrate.

The tympanic membrane is not changed. Tissue infiltration may extend to the parotid region, the posterior surface of the auricle, and the mastoid region. Often, the lymph nodes are enlarged and painful on palpation in front, below and behind the auricle, depending on the location of the boil. Body temperature is often subfebrile. The average duration of the disease is 7 days.

Differential diagnosis

With severe behind-the-ear lymphadenitis, the furuncle is differentiated from mastoiditis, which is a complication of acute otitis media. Its difference is changes in the tympanic membrane and hearing loss, as well as a characteristic symptom of mastoiditis - the overhang of the posterior superior bone wall of the auditory canal. The furuncle is localized in the cartilaginous part of the auditory canal. With the introduction of a thin funnel behind the obturating ear canal, the furuncle restores hearing. Treatment

At the onset of the disease, antibacterial drugs are used: penicillin 500 IU 000 times a day intramuscularly or ampicillin, oxacillin, ampiox 6 g 0,5 times a day, erythromycin or tetracycline 4 IU 100 times a day inside. A turunda soaked in 000% boric alcohol is introduced into the ear canal, and after the furuncle is opened, a turunda soaked in a hypertonic solution of sodium chloride and a solution of penicillin in novocaine is introduced. Assign acetylsalicylic acid, analgin.

The furuncle is opened under local infiltration anesthesia with an eye scalpel in the region of the tip of the rod. Having expanded the incision, the purulent rod is removed and turunda with hypertonic sodium chloride solution is introduced into the ear canal.

With recurrent furunculosis, it is advisable to use autohemotherapy, brewer's yeast, general UVI. In some cases, an autovaccine, staphylococcal toxoid is prescribed.

3. Diffuse purulent otitis externa

Purulent inflammation of the skin of the ear canal also extends to the bone part of the ear canal, the subcutaneous layer, and often to the eardrum.

Etiology, pathogenesis

The cause of diffuse otitis is infection of the skin of the ear canal with mechanical, thermal or chemical trauma, purulent otitis media, influenza, diphtheria. Contributes to the introduction of infection maceration of the skin. Metabolic disorders and allergic manifestations in the body favor the development of infection.

Clinic

Наружный отит протекает в острой и хронической формах. В острой стадии отмечаются диффузная гиперемия, инфильтрация стенок слухового прохода, болезненность при отоскопии, надавливании на козелок. Процесс более выражен в хрящевой части, но распространяется на костную часть и барабанную перепонку, вызывая сужение слухового прохода. Отмечаются зуд, выделения десквамированного эпидермиса и гноя с гнилостным запахом.

Differential diagnosis

Дифференцируют наружный отит со средним по тщательному туалету уха. При наружном отите не нарушена острота слуха. После исключения фурункула наружного слухового прохода основное внимание должно быть направлено на дифференциальную диагностику диффузного гнойного наружного отита сэкзематозным, грибковым и вирусным отитами. Для этого проводят посев отделяемого из уха на флору и чувствительность ее к антибиотикам, исследование на грибы.

Treatment

A diet is prescribed with the exception of spicy and spicy dishes, rich in vitamins. Carry out hyposensitizing therapy.

In the acute form of the process, the ear is washed with a warm 3% solution of boric acid, a 0,05% solution of furacilin. With itching, a 2-5% white mercury ointment or 1-2% ointment with yellow mercury oxide, 1% menthol in peach oil is prescribed. Apply lubrication with a 3-5% solution of silver nitrate, 1-2% alcohol solution of brilliant green or methylene blue. A good effect is the use of hydrocortisone emulsion, 1% prednisolone ointment, oxycort, 1% synthomycin emulsion. UHF, UHF and UVI are combined with drug therapy.

In the chronic form, staphylococcal toxoid, antiphagin and vaccines are effective. Polymyxin M (0,5-1% ointment or emulsion) is used to suppress Pseudomonas aeruginosa. With persistent, refractory diffuse external otitis media, laser therapy and X-ray therapy are used. To increase the body's resistance, autohemotherapy and multivitamins are prescribed.

Antibiotics and sulfonamides are recommended only for deep and chronic pyoderma, taking into account the sensitivity of the microflora to them.

4. Perichondritis and exostoses of the outer ear

Perichondritis of the outer ear is a diffuse inflammation of the perichondrium involving the skin of the outer ear.

Etiology, pathogenesis

Perichondritis is caused by an infection, most commonly Pseudomonas aeruginosa. There are purulent and serous perichondritis.

Clinic

В области ушной раковины появляются болезненность, отечность и гиперемия, постепенно охватывающие всю ее поверхность, за исключением мочки, не содержащей хряща. При нагноении и скоплении гноя между хрящом и надхрящницей отмечаются флуктуация, болезненность при пальпации. Температура тела повышена. Затем хрящ расплавляется гнойным процессом, погибает, и наступает рубцовая деформация раковины.

Differential diagnosis

Perichondritis is differentiated with erysipelas and hematoma. With erysipelas, hyperemia covers not only the shell, but also its lobe, and also often extends beyond the outer ear. Othematoma occurs more often after injury, is localized in the area of the anterior surface of the upper half of the auricle, has a purple color, is not painful on palpation, and proceeds with normal body temperature.

Treatment

В начальной стадии заболевания проводят местное и общее противовоспалительное лечение. Назначают полимиксин М (1 %-ную мазь или эмульсию), внутрь тетрациклин, олететрин или окситетрациклин по 250 000 ЕД 4-6 раз в сутки, эритромицин по 250 000 ЕД 4-6 раз в сутки, стрептомицин по 250 000 ЕД 2 раза в сутки внутримышечно.

With suppuration, a wide tissue incision is made parallel to the contours of the auricle, the necrotic parts of the cartilage are removed, the abscess cavity is scraped out with a spoon and a swab with antibiotics is injected into it.

Экзостозы представляют собой костные образования, являющиеся следствием остеодистрофиче-ских процессов височной кости. Экзостозы растут медленно, часто бессимптомно в виде экзо- и гиперостозов. При обтурации слухового прохода появляются ушной шум, понижение слуха, нарушается процесс выделения серы или гноя приотитах.

Наблюдаются две формы экзостозов - на ножке и плоские. Экзостозы на ножке исходят из наружного кольца костной части слухового прохода. Их диагностируют при отоскопии и рентгенографии, часто в качестве случайной находки. Экзостозы на ножке легко сбиваются плоским долотом под местной инфильтрационной анестезией эндаурально.

Flat exostoses often occupy almost the entire length of one of the walls of the auditory canal. Sometimes they form in the region of the tympanic ring, causing thickening of the wall of the tympanic cavity.

5. 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. The etiological factor is viruses, streptococci, staphylococci.

Pathogenesis

Воспаление верхних дыхательных путей быстро распространяется в слуховую трубу и барабанную полость. В результате воспаления слуховой трубы нарушаются ее функции: вентиляционная, дренажная, барофункция и защитная. Причины нарушения этих функций бывают постоянными и временными. К постоянным причинам относятся аденоидные вегетации, гипертрофия задних концов нижних носовых раковин, хронические риниты. К временным причинам относятся острые воспалительные процессы верхних дыхательных путей.

In acute tubo-otitis caused by an infection, extravasation is not prolonged and pronounced, since an exudative stage of inflammation occurs. A dull color and retraction of the tympanic membrane are noted.

Clinic

Во время острой респираторной вирусной инфекции или сразу после этого больной жалуется на одно- или двустороннюю постоянную или перемежающуюся тугоухость, шум в ушах. Отмечается втянутость барабанной перепонки, характерными признаками которой являются кажущееся укорочение рукоятки молоточка, выступ его короткого отростка наружу, деформация или исчезновение светового конуса, более отчетливые передняя и задняя молоточковые складки. Слух снижен вследствие изменения гидродинамики ушной лимфы. При импедансометрии определяются отрицательное давление в барабанной полости. При незначительной гиперемии барабанной перепонки допустимо проведение продувания уха после тщательной анемизации слизистой оболочки носа. Характерным для острого тубоотита является восстановление слуха после продувания уха. Лечение

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.

6. 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. The causative agents of otitis are viruses, staphylococci, streptococci, pneumococci.

Pathogenesis

Воспалительный процесс из верхних дыхательных путей распространяется на слизистую оболочку трубы и в барабанную полость. Слизистая оболочка слуховой трубы инфильтрируется, мерцательный эпителий частично погибает, воспаленные стенки смыкаются, и нарушаются ее вентиляционная, а также дренажная функции.

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. Due to retraction or protrusion of the membrane and a decrease in the mobility of the sound-conducting apparatus, conductive hearing loss is noted.

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.

Nasal vasoconstrictor drops are used. It is advisable to lubricate the mouth of the auditory tube with vasoconstrictor agents, and then with astringents.

В барабанную полость вводят посредством ушного металлического катетера через слуховую трубу протеолетические ферменты, показано введение глюкокортикоидов. После ликвидации острого ринита проводится продувание уха по Политцеру или с помощью ушного катетера. Показано применение антиги-стаминных препаратов поливитаминов, ацетилсалициловой кислоты и симптоматических средств.

Хирургические методы для эвакуации секрета из барабанной полости - тимпанопункцию, миринготомию (парацентез) или тимпанотомию с отсасыванием секрета и введением в барабанную полость лекарственных препаратов. Тимпанопункцию и миринготомию проводят в задненижнем квадранте барабанной перепонки. К тимпанопункции прибегают как к однократному вмешательству, но иногда ее проводят повторно. После миринготомии в отверстие барабанной перепонки вводится шунт из тефлона или полиэтилена.

7. Acute purulent otitis media. Etiology. Pathogenesis

Acute purulent otitis media is a fairly common disease. Acute purulent otitis media occurs even more often in children, especially infants and young children.

Etiology

An acute inflammatory process in the middle ear is caused by streptococci, all types of staphylococci and pneumococci. In addition, otitis media can be caused by viruses, fungi, Pseudomonas aeruginosa, Proteus, Escherichia coli, etc.

Pathogenesis

Acute otitis media develops mainly against the background of an acute respiratory viral infection or other infectious disease and is their complication. For its occurrence, general and local predisposing factors are of great importance.

A decrease in the overall resistance of the body as a result of hypothermia, hypovitaminosis, overwork and a complex of other factors leads to the development of an acute respiratory viral infection, accompanied by an inflammatory process in various parts of the upper respiratory tract, including the nasopharynx. Inflammatory edema of the pharyngeal mouth of the auditory tube and its mucous membrane disrupts the ventilation of the middle ear. It creates a place of least resistance, since the constant negative pressure in the tympanic cavity contributes to the swelling of the mucous membrane of the tympanic cavity and the cells of the mastoid process. A decrease in local resistance against the background of viremia leads to the development of inflammation in the ear. This route of infection is called hematogenous. A common cause of inflammation of the middle ear is the microflora of the nasopharynx, which enters it through the auditory tube - by the tubal route. With injuries of the tympanic membrane, the infection can be brought transtympanally.

The occurrence of acute otitis is promoted by chronic diseases of the nose and paranasal sinuses, which violate the respiratory and protective functions, adenoids that cover the nasopharyngeal mouths of the auditory tubes.

Inflammation of the mucous membrane occurs in all parts of the middle ear - the auditory tube, the tympanic cavity and the mastoid process. The thickness of the epithelial layer in it increases by 15-20 times. Exudate accumulates in the cavity, which is first serous and then purulent. With influenza otitis exudate is hemorrhagic. Swelling of the epithelium and abundant exudation in violation of the drainage function of the auditory tube lead to the outward protrusion of the tympanic membrane, melting of its walls and perforation with the release of the contents to the outside. Abundant mucopurulent discharge gradually becomes less abundant, acquiring a purulent character. After the cessation of suppuration from the ear, the perforation of the eardrum may heal.

8. Acute purulent otitis media. Clinic. Complications

Clinic

Acute otitis media is characterized by rapid development and a pronounced general reaction of the body. Body temperature rises to 38-39 °C. The number of leukocytes in the blood reaches 12 g · 109 -15 g · 109 L1.

In the clinical course of acute otitis media, three stages are distinguished: preperforative, perforative and reparative.

The preperforative stage is characterized by pain syndrome.

The next symptom is ear congestion, noise in it as a result of inflammation and limited mobility of the eardrum and auditory ossicles. Hearing loss is objectively noted according to the type of sound conduction disturbance.

There are objective symptoms on otoscopy. First, retraction of the tympanic membrane appears, accompanied by shortening of the light cone, injection of vessels along the handle of the malleus and radial vessels of the membrane. Then the limited hyperemia becomes diffuse, the identification points of the membrane disappear. It protrudes and is often covered with a whitish coating.

The perforative stage occurs on the 2-3rd day from the onset of the disease. After perforation of the eardrum, the pain subsides and suppuration from the ear appears. General well-being improves, body temperature decreases.

Репаративная стадия. При нормальном течении болезни гноетечение из уха прекращается, и перфорация барабанной перепонки самостоятельно рубцуется. Все субъективные симптомы стихают, гиперемия барабанной перепонки постепенно исчезает. Однако в течение 5-7 дней еще наблюдаются втянутость барабанной перепонки и заложенность уха.

Fungal otitis is caused mainly by yeast-like fungi of the genus Candida and molds of the genus Aspergillus. The pain syndrome is not expressed, and the patient is worried about ear congestion. On the tympanic membrane, a whitish or curdled coating, spots of dark brown or black color are visible.

Viral otitis (hemorrhagic) is most often observed with influenza. During otoscopy, red-blue vesicles filled with blood appear on the eardrum and adjacent skin of the ear canal.

Complications

Complications include the following:

1) the formation of persistent dry perforation of the eardrum;

2) transition to a chronic form;

3) development of the adhesive process;

4) возникновение гнойного мастоидита, лабиринтита, менингита, абсцесса мозга, мозжечка, синус-тромбоза и сепсиса.

9. Treatment of acute suppurative otitis media

В первой стадии осуществляются купирование болевого синдрома, улучшение дренажной и вентиляционной функций слуховой трубы, а также противовоспалительная терапия. В ухо закапывают обезболивающие капли. Внутрь назначают болеутоляющие, жаропонижающие и седативные препараты. Назальные капли должны обладать длительным и выраженным сосудосуживающим эффектом. Антибактериальную терапию начинают с назначения антибиотиков пенициллинового ряда (бензилпенициллин по 500 000 ЕД 6 раз в сутки внутримышечно или ампиокс по 0,5 г внутрь 4 раза вдень). Одновременно применяют гипосенсиби-лизирующие средства. Показан полуспиртовый компресс на ухо на ночь, а днем - согревающая повязка.

Во второй стадии (перфоративной) отменяются обезболивающие спиртовые капли, компрессы и УВЧ. Продолжают антибиотикотерапию и гипосенсибилизирующую терапию, применение сосудосуживающих капель в нос. После бактериологического исследования выделений из уха назначают антибиотики, к которым чувствителен возбудитель. При стафилококковой флоре показан эритромицин.

The main task of local treatment is to provide favorable conditions for the outflow of purulent discharge from the tympanic cavity. To do this, dry toilet of the ear is performed 2-3 times a day, followed by the introduction of gauze turunda into the external auditory canal. Turunda can be dry to absorb the discharge, but most often it is moistened with antiseptic or antibacterial solutions.

Можно применять пенициллин-новокаиновую меатотимпанальную блокаду. Она заключается во введении в заушную область 250 000-500 000 ЕД натриевой соли бензилпенициллина, растворенного в 3 мл 1%-ного раствора новокаина.

If spontaneous perforation of the eardrum does not occur, the pain in the ear intensifies, the body temperature continues to rise, the protrusion of the membrane increases, then its paracentesis is performed in the posterior lower quadrant with a special spear-shaped paracentesis needle.

Treatment of fungal otitis is carried out with antifungal antibiotics (nystatin or levorin) in combination with topical application of fungicidal preparations of the imidazole group (nitrofungin, canestene or amphotericin B).

Гриппозный перфоративный отит лечится по общим правилам. Часто процесс ограничивается поражением наружного слоя барабанной перепонки и кожи слухового прохода. В таком случае буллы не вскрываются. Кожа слухового прохода смазывается оксолиновой мазью.

In the third stage of otitis media, antibiotics are canceled, the toilet of the ear and the instillation of ear drops are stopped. Hyposensitizing therapy continues.

10. Mastoiditis

Мастоидит является самым частым осложнением острого гнойного среднего отита. Он возникает при переходе воспаления со слизистой оболочки клеток (ячеек) сосцевидного отростка на костную ткань с возникновением остеомиелита.

Etiology

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

Pathogenesis

Мастоидит в большинстве случаев развивается на исходе острого отита у больных с пневматическим типом строения сосцевидного отростка. Переходу процесса на кость способствует ряд факторов. К ним относятся:

1) high virulence of the infection;

2) reduced overall resistance of the organism;

3) difficult outflow of exudate from the tympanic cavity;

4) the occurrence of a block of the entrance to the mastoid cave;

5) irrational treatment of acute otitis media.

При наличии этих неблагоприятных факторов прогрессирует мукоидное набухание слизистой оболочки отростка, мелкоклеточная инфильтрация и нарушение кровообращения, что вызывает заполнение клеток серозно-гнойным, гнойным или кровянисто-гнойным экссудатом. Затем возникает остеит - в процесс вовлекаются костные перемычки между клетками.

Clinic

More often mastoiditis is observed 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. Pain is noted on palpation or percussion of the mastoid process, more often in the antrum and apex.

At an otoscopy suppuration is observed. The pus becomes thicker, enters the ear canal in portions under pressure. The tympanic membrane is infiltrated and may be copper-red. The pathognomonic symptom of mastoiditis is the overhanging of the posterior wall of the auditory canal in the bone section due to periostitis.

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 can be noted.

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.

11. 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.

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, the auditory ossicles by 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.

Тимпаносклероз представляет собой поражение подэпителиального слоя, выражающееся в гиалиновой дегенерации соединительной ткани. Постоянными признаками этой ткани являются дистрофия слизистой оболочки и кости, а также кальцификация.

Clinic

Для адгезивного среднего отита характерно стойкое прогрессирующее понижение слуха, иногда снизкочастотным шумом в ушах. При отоскопии определяется тусклая, утолщенная, деформированная или атрофированная в отдельных участках барабанная перепонка с втяжениями, отложениями извести и тонкими подвижными рубцами без фиброзного слоя. Характерно ограничение подвижности барабанной перепонки при исследовании с помощью пневматической воронки Зигле. Слух снижен по смешанному типу с преимущественным нарушением звукопроведения. Ухудшению костной проводимости способствуют ограничение подвижности обоих лабиринтных окон и дистрофия слуховых рецепторов при длительном течении заболевания.

Treatment

В первую очередь устраняют причины, вызвавшие нарушение и препятствующие восстановлению функции слуховой трубы. Затем восстанавливают функцию слуховой трубы посредством продувания, введения в нее различных лекарственных веществ, УВЧ-терапии, местного применения сосудосуживающих препаратов в нос и перорального приема гипосенсибилизирующих средств.

12. Labyrinthitis. Etiology

Pathogenesis

Labyrinthitis is an inflammatory disease of the inner ear. Most often, the disease is an otogenic complication of otitis media.

Meningogenic labyrinthitis occurs mainly in young children against the background of epidemic cerebrospinal meningitis. Infection from the subarachnoid space to the labyrinth spreads through the cochlear aqueduct or the internal auditory meatus. The inflammation is purulent and develops rapidly, which leads to sudden deafness. Vestibular symptoms may be masked by manifestations of meningitis.

Гематогенный лабиринтит встречается при различных инфекционных заболеваниях и может быть серозным, гнойным и некротическим. Серозный лабиринтит развивается медленнее, чем гнойный менингогенный лабиринтит. При серозном характере воспаления полного угнетения слуховой и вестибулярной функций не наблюдается. Неблагоприятно протекают в лабиринте гнойный и некротический процессы. Некрозы возникают от непосредственного действия токсинов и тромбирования сосудов.

Otogenic labyrinthitis can develop in both acute and chronic suppurative otitis media.

The causative agents of otogenic labyrinthitis can be all types of polymorphic flora found in the middle ear with otitis media.

In acute purulent otitis media, favorable factors for the development of labyrinthitis are the difficulty in the outflow of discharge from the tympanic cavity and an increase in pressure in it. Under the influence of purulent exudate, the membrane of the round window of the cochlea and the annular ligament of the base of the stirrup swell and become permeable to toxins.

Хронический гнойный эпитимпанит может привести к разрушению капсулы лабиринта в области выступа латерального полукружного канала с образованием фистулы в его костной стенке. Фистула канала может возникнуть и у ранее оперированных по поводу хронического отита больных при воспалении в послеоперационной полости. Вокруг фистулы образуется защитный грануляционный вал. Значительно реже при хроническом гнойном среднем отите фистула лабиринта возникает в области мыса и основания стремени. При прогрессировании хронического отита воспаление переходит с костной капсулы лабиринта на перепончатый лабиринт.

Serous inflammation causes an increase in perilymph pressure due to the fact that the endosteum lining the bony labyrinth swells and its dilated vessels become permeable to blood plasma. A small amount of cellular elements appears in the perilymph, mainly lymphocytes, as well as fibrin.

Purulent exudate consists of leukocytes. The inflammatory process passes to the membranous labyrinth, leading to the death of auditory and vestibular receptors.

13. Labyrinthitis. Clinic and treatment

Clinic

Clinical manifestations of otogenic labyrinthitis consist of symptoms of impaired auditory and vestibular functions and depend on its clinical form.

Ограниченный лабиринтит. Первым симптомом ограниченного лабиринтита до образования фистулы лабиринта является головокружение, возникающее при резких поворотах головы и наклонах тела. У таких больных может выявляться нистагм укладывания. Понижение слуха нельзя целиком отнести за счет лабиринтита, так как хронический гнойный средний отит сам по себе вызывает выраженную тугоухость смешанного характера.

induced labyrinthitis. With this form, the symptoms of irritation of the labyrinth are manifested in spontaneous nystagmus towards the diseased ear, dizziness and pathological autonomic reactions. The appearance of these symptoms is associated with the toxic effect of the products of acute purulent inflammation in the tympanic cavity on the labyrinth through its windows.

Serous diffuse labyrinthitis. With serous labyrinthitis, there is a decrease in hearing of a mixed type with a predominant lesion of sound perception. In the initial stage of serous labyrinthitis, irritation of the receptors of the vestibular apparatus is noted, and then their inhibition. Spontaneous nystagmus is directed first to the diseased side, and then to the healthy side.

Purulent diffuse labyrinthitis is characterized by vivid clinical manifestations. Purulent inflammation in the labyrinth quickly leads to the death of auditory and vestibular receptors.

The irritation phase of the labyrinth is short-term and lasts for several hours. During it, hearing deteriorates sharply, and spontaneous nystagmus occurs in the direction of the diseased ear. Severe dizziness, nausea and vomiting are noted. Patients take a horizontal position. In the labyrinth suppression phase, nystagmus changes its direction towards the healthy ear.

After the acute purulent process subsides, a sluggish diffuse labyrinthitis can be observed. With a favorable outcome of the disease, the labyrinth subsequently grows into granulations with transformation into fibrous and bone tissues. With an unfavorable course of purulent labyrinthitis, labyrinthogenic purulent meningitis or a brain abscess may develop.

Treatment

With labyrinthitis, complex treatment is carried out.

Так как отогенный лабиринтит является осложнением острого или хронического гнойного среднего отита, то в первую очередь производят элиминацию гнойного очага в среднем ухе. Разгрузочной операцией при остром отите является парацентез барабанной перепонки, а при хроническом отите - радикальная операция уха. При наличии мастоидита производят мастоидальную операцию. Назначают дегидратационные, антибактериальные и дезинтоксикационные средства.

14. Otosclerosis

Otosclerosis is a kind of dystrophic ear disease that affects mainly the bone capsule of the labyrinth, manifested by ankylosis of the stirrup and progressive hearing loss.

Etiology and pathogenesis

Заболевание наследуется по аутосомнодоминантному типу. Отосклероз является аномалией конституции, проявляющейся в неполноценности мезенхимы организма.

Changes in the bone labyrinth capsule begin in the medullary spaces. As a result of increased activity of osteoclasts around the blood vessels, the bone tissue decalcifies, and a limited focus of cancellous bone is formed, containing an excessive amount of marrowy spaces rich in blood vessels. Subsequently, the newly formed immature spongy bone turns into a mature lamellar bone.

Clinic

When examining a patient, attention is paid to the gradual development of the disease.

При отоскопии отмечается атрофия кожи наружных слуховых проходов и барабанных перепонок за счет истончения их фиброзного слоя, снижение чувствительности кожи слуховых проходов. Через атрофичную барабанную перепонку бывают хорошо видны слуховые косточки, а иногда наблюдается гиперемированная слизистая оболочка промонториума.

In a laboratory blood test, a low content of calcium and phosphorus, proteins, and sugar is revealed. A decrease in the activity of cholinesterase in the blood serum testifies in favor of a decrease in the tone of the autonomic nervous system. The content of ACTH increases.

Hearing impairment is noted, as a rule, at the age of 16-20 years. A characteristic symptom is tinnitus, often preceded by hearing loss.

Hearing loss as a result of ankylosis of the stirrup occurs imperceptibly, progresses over many years. There may be periods of exacerbations, manifested by a sharp deterioration in hearing and increased tinnitus.

In the tympanic form of otosclerosis, ankylosis of the foot plate of the stirrup is noted. Hearing is reduced as a violation of sound conduction.

The spread of otosclerotic foci to the round window of the cochlea and deeper into it leads to the appearance of a sensorineural component of hearing loss, characteristic of a mixed form of otosclerosis.

The cochlear form of otosclerosis is diagnosed with a decrease in tonal hearing, similar to a violation of sound perception.

Treatment

Treatment of tympanal and mixed forms of otosclerosis is surgical.

Conservative treatment of otosclerosis is indicated to reduce the activity of the otosclerotic process and reduce tinnitus.

15. Meniere's disease

Meniere's disease is understood as a peripheral labyrinth syndrome of non-inflammatory origin, which develops as a result of a violation of the circulation of the ear lymph.

В основе патогенеза заболевания лежит нарушение механизма регуляции давления в лимфатических пространствах лабиринта. Повышенное внутрилабиринтное давление затрудняет проведение звуковой волны в жидкостях лабиринта, а также ухудшает трофику лабиринтных рецепторов. Периодически возникающее значительное повышение давления сопровождается лабиринтным кризом, обусловленным резким угнетением всех сенсорных клеток лабиринта. Кризы при болезни Меньера более выражены при поражении одного или преимущественно одного из лабиринтов.

Intralabyrinthine pressure may increase for a number of reasons, such as hyperproduction of endolymph by the vascular streak, disruption of its circulation through the endolymphatic ducts, and insufficient resorption in the endolymphatic sac.

Сложное строение сосудистой полоски, особенности питания рецепторных клеток ушного лабиринта, омываемых эндолимфой, определенный электролитный состав различных лимфатических сред, наличие в лабиринте гормонопродуцирующих клеток обусловливают его повышенную уязвимость при различных нарушениях нейроэндокринной, сосудистой регуляций в организме.

The clinical picture includes the following characteristic features:

1) recurrent nature and paroxysmal course;

2) brevity of attacks;

3) the presence of all signs of peripheral labyrinth syndrome;

4) the presence of signs of labyrinth hydrops and hearing fluctuations;

5) good health in the interictal period with progressive hearing loss;

6) поражение преимущественно одного уха. Больные обращаются к врачу в момент лабиринтной атаки, которая характеризуется шумом в ухе, снижением слуха, головокружением системного характера, спонтанным горизонтально-ротаторным нистагмом в сторону лучше слышащего уха, тоническим отклонением рук и промахиванием, а также отклонением тела в сторону, противоположную нистагму, тошнотой, рвотой, побледнением кожных покровов и холодным потом. Они занимают вынужденное горизонтальное положение, закрывают глаза и стараются не совершать движений.

Treatment

Купирование лабиринтного криза достигается внутримышечным введением 1 мл 2%-ного раствора промедола или 2,5 %-ного раствора аминазина в комбинации с0,5-1 мл 0,1 %-ного раствора атропина сульфата и 1-2 мл 1%-ного раствора димедрола. При болезни Меньера функция коры надпочечников несколько понижена, следовательно, применение глюкокортикоидов не оправданно. Целесообразно 60 мг преднизолона вводить внутривенно, растворяя в 200 мл изотонического раствора натрия хлорида. В раствор можно добавить 10 мл панангина, 5 мл 5%-ного раствора аскорбиновой кислоты и 3 мл кокарбоксилазы.

The microcirculation of cerebral vessels is improved with the help of intravenous injections of various blood substitutes (rheopolyglucin, rheogluman, mannitol, etc.) in the amount of 200-400 ml.

At the end of the intravenous infusion of a solution of prednisolone and blood substitutes, 1 ml of furosemide is injected to remove excess fluid from the body.

16. Sensorineural hearing loss. Etiology. Pathogenesis

Sensorineural (sound-perceiving) hearing loss is understood as a lesion of the auditory system from the receptor to the auditory zone of the cerebral cortex. Depending on the level of pathology, it is divided into receptor, retrocochlear and central (stem, subcortical and cortical).

Etiology

Sensorineural hearing loss is a polyetiological disease. Its main causes are infections, injuries, chronic cerebrovascular insufficiency, noise-vibration factor, VIII nerve neuroma, syphilis, radiation exposure, developmental anomalies of the inner ear, maternal illness during pregnancy, intoxication with certain medications.

Sensorineural hearing loss may be secondary to diseases that initially cause conductive or mixed hearing loss.

Pathogenesis

При инфекционных болезнях поражаются гангли-озные клетки, волокна слухового нерва и волосковые клетки. Под влиянием инфекционных агентов нарушается капиллярное кровоснабжение во внутреннем ухе, и повреждаются волосковые клетки основного завитка улитки. Вокруг слухового нерва может образоваться серозно-фибринозный экссудат с лимфоцитами, нейтрофилами, распадом волокон и образованием соединительной ткани. Нервная ткань ранима, и уже через сутки начинается распад осевого цилиндра, миелина и вышерасположенных центров. Хронические дегенеративные процессы в нервном стволе ведут к разрастанию соединительной ткани и атрофии нервных волокон.

The basis of deafness and hearing loss in epidemic cerebrospinal meningitis is bilateral purulent labyrinthitis.

При гриппе отмечается высокая вазо- и нейротропность вируса. Инфекция распространяется гематогенно и поражает волосковые клетки, кровеносные сосуды внутреннего уха. Чаще бывает односторонняя патология. Под влиянием ототоксических антибиотиков происходят патологические изменения в рецепторном аппарате. Волосковые клетки вначале поражаются в основном завитке улитки, а затем - на всем ее протяжении. Развивается тугоухость по всему частотному спектру, но больше на высокие звуки.

The most common causes of damage to the central parts of the auditory system are tumors, chronic cerebrovascular insufficiency, inflammatory processes in the brain, trauma to the skull, etc.

Syphilitic hearing loss may initially be characterized by a violation of sound conduction, and then - sound perception due to pathology in the cochlea and the centers of the auditory system.

The progression of conductive and mixed hearing loss often leads to damage to the auditory receptor and the formation of a sensory component, and then the predominance of sensorineural hearing loss.

17. Sensorineural hearing loss. Clinic. Treatment

Clinic

Patients complain of constant unilateral or bilateral hearing loss, which occurred acutely or gradually, with progression. Hearing loss can stabilize for a long time. It is often accompanied by subjective high-frequency tinnitus from slight, periodic to constant and painful, sometimes becoming the main concern of the patient.

Treatment

Treatment of acute sensorineural hearing loss and deafness begins as early as possible, during the period of reversible changes in the nervous tissue - as an emergency. Recommended intravenous drip of drugs for 8-10 days (400 ml of rheopolyglucin, 400 ml of hemodez every other day); immediately after their administration, a drip injection of 0,9% sodium chloride solution (500 ml) is prescribed with the addition of 60 mg of prednisolone, 5 ml of 5% ascorbic acid, 4 ml of solcoseryl, 0,05 cocarboxylase, 10 ml of panangin. Etiotropic agents for toxic sensorineural hearing loss are antidotes: unithiol (5 ml of a 5% solution intramuscularly for 20 days) and sodium thiosulfate (5-10 ml of a 30% solution intravenously 10 times), as well as an activator of tissue breathing - calcium pantothenate (20% solution of 1-2 ml per day subcutaneously, intramuscularly or intravenously). In the treatment of acute and occupational hearing loss, hyperbaric oxygen therapy is used - 10 sessions of 45 minutes each. In a recompression pressure chamber, inhalation of oxygen or carbogen.

Medicines (antibiotics, glucocorticoids, novocaine, dibazol) are administered by behind-the-ear phonophoresis or endaural electrophoresis.

During the period of stabilization of hearing loss, patients are under the supervision of an otolaryngologist, they are given courses of preventive maintenance treatment 1-2 times a year. For intravenous drip, cavinton, trental, piracetam are recommended. Then cinnarizine, multivitamins, biostimulants and anticholinesterase drugs are prescribed inside.

To reduce tinnitus, reflexotherapy is used, a method of introducing anesthetics into biologically active points of the parotid region. Magnetic therapy is carried out with a common solinoid and local or endaural electrical stimulation with a constant pulsed unipolar current. With excruciating tinnitus and the ineffectiveness of conservative treatment, resection of the tympanic plexus is resorted to.

A hearing aid is usually indicated when the average loss of tonal hearing at frequencies of 500, 1000, 2000 and 4000 Hz is 40-80 dB, and conversational speech is perceived at a distance of no more than 1 m from the auricle.

If the hearing aid is ineffective, and communication is difficult or impossible, then the person is taught to contact people with the help of facial expressions and gestures.

18. Complications of purulent diseases of the middle and inner ear. Etiology. Pathogenesis

Independent forms of purulent inflammation of the middle ear are acute purulent otitis media, mastoiditis, chronic purulent epitympanitis, mesotympanitis and purulent labyrinthitis. With their unfavorable course, abscesses can develop in neighboring anatomical regions, diffuse inflammation of the meninges (meningitis) and brain matter (encephalitis), as well as a septic state of the body.

Etiology

The microflora sown from the primary source of infection is mostly mixed and unstable. Nevertheless, coccal flora most often prevails: staphylococci, streptococci, less often pneumococci and diplococci.

Pathogenesis

The pathogenesis of otogenic complications is complex and ambiguous. In addition to the virulence of the microflora, the state of the general resistance of the organism is of great importance.

The structural features of the temporal bone and the structures of the middle and inner ear located in it also predetermine the possibility of developing complications. Among them, an abundance of folds and pockets of the mucous membrane of the attic and the cellular structure of the mastoid process are distinguished, ventilation and drainage of which are significantly hampered by inflammation.

Complications of acute purulent otitis media are mastoiditis and labyrinthitis. Labyrinthitis can also develop in chronic suppurative otitis media, progressively destroying the temporal bone. The dura mater stands in the way of infection spreading into the cranial cavity, which, along with the blood-brain barrier, is a serious obstacle to the development of intracranial complications. Nevertheless, inflammation, causing an increase in the permeability of the vascular walls, helps to overcome the infection and these barriers, the inflammatory process occurs between the hard and arachnoid membranes of the brain (subdural abscess or limited leptomeningitis), as well as in the cavity of the venous sinuses (sinus thrombosis).

With the generalization of the process due to reduced resistance and altered reactivity of the body, intracranial complications may develop: purulent meningitis, meningoencephalitis or sepsis. The septic condition in acute purulent otitis in children develops hematogenously when bacteria and their toxins enter the blood from the tympanic cavity. Chronic suppurative otitis media leads to sepsis through sinus thrombosis. The stages of the process are peri-phlebitis, endophlebitis, parietal thrombosis, complete thrombosis, infection and disintegration of a thrombus, septicemia and septicopyemia.

In acute purulent otitis media, the most common route of infection to the cranial cavity is through the roof of the tympanic cavity, predominantly hematogenous. In second place is the path to the labyrinth through the cochlear window and the annular ligament of the vestibule window.

19. Complications of purulent diseases of the middle and inner ear. Clinic. Treatment

Clinic

На первом месте среди внутричерепных отогенных осложнений находится менингит, на втором - абсцессы височной доли головного мозга и мозжечка, на третьем - синус-тромбоз.

Otogenic diffuse purulent meningitis, or leptomeningitis, is an inflammation of the pia and arachnoid membranes of the brain with the formation of purulent exudate and increased intracranial pressure. As a result of inflammation of the membranes and increased pressure of the cerebrospinal fluid, the inflammatory reaction spreads to the substance of the brain. encephalitis occurs.

Общее состояние больного тяжелое. Наблюдается помутнение сознания, бред. Больной лежит на спине или на боку с запрокинутой головой. Температура тела постоянно повышена до 39-40 °C и более. Пульс учащенный.

Purulent meningitis is confirmed by pathological changes in the cerebrospinal fluid. An increase in her pressure is noted. The liquid becomes cloudy, the content of cellular elements increases to tens of thousands per 1 µl (pleocytosis). The protein content increases (norm 150-450 mg / l), the amount of sugar and chlorides decreases (sugar norm 2,5-4,2 mmol / l, chlorides - 118-132 mmol / l). When sowing the cerebrospinal fluid, the growth of microorganisms is detected.

Otogenic abscesses of the temporal lobe of the brain and cerebellum occur in the immediate vicinity of the focus of infection. These abscesses are primary in contrast to deep and contralateral secondary abscesses in sepsis.

The initial stage is characterized by mild brain symptoms: headache, weakness, nausea and vomiting, subfebrile body temperature. Its duration is 1-2 weeks.

Symptoms in the explicit stage can be divided into four groups: general infectious, cerebral, conductive and focal. The first group includes general weakness, lack of appetite, stool retention, weight loss. Cerebral symptoms are characterized by increased intracranial pressure. Focal neurological symptoms are of the greatest diagnostic value.

Поражение височной доли головного мозга (левой - у правшей и правой - у левшей) характеризуется сенсорной и амнестической афазией. При сенсорной афазии и сохранном слухе больной не понимает того, что ему говорят. Речь его становится бессмысленным набором слов. Это происходит вследствие поражения центра Вернике в средних и задних отделах верхней височной извилины. Больной не может также читать (алексия) и писать (аграфия). Амнестическая афазия проявляется тем, что пациент вместо названия предметов описывает их назначение, что связано со зрительно-слуховой диссоциацией в результате поражения нижних и задних отделов височной и теменной долей.

Cerebellar abscess is characterized by impaired limb tone, ataxia, spontaneous nystagmus, and cerebellar symptoms.

Отогенный сепсис. Генерализация инфекции при остром отите происходит нередко первично-гематогенно, а при хроническом отите - чаще всего после тромбофлебита сигмовидного синуса.

Treatment

Treatment of otogenic complications involves the urgent elimination of a purulent focus in the ear and brain, as well as intensive drug therapy.

20. Mechanical damage to the auricle and eardrum

According to the factor causing damage, ear injuries can be different. The most common damaging factors are mechanical, chemical and thermal.

Mechanical damage

Othematoma is a hemorrhage between the cartilage and the perichondrium of the auricle. The causes of hematomas are injuries of the auricle. Even a mild injury to the auricle can cause hematoma. It looks like a hemispherical smooth swelling of a purple color on the anterior surface of the auricle, it can be painful, fluctuating.

Treatment

Отгематома небольшого размера может рассосаться самостоятельно или после смазывания ее спиртовым раствором йода и наложения давящей повязки. При отсутствии обратного развития отгематомы проводят ее пункцию, отсасывание содержимого, введение нескольких капель 5 %-ного спиртового раствора йода, накладывание давящей повязки. При нагноении, развитии хондроперихондрита делают разрезы с выскабливанием грануляций, погибших тканей, промывают антибиотиками, дренируют и накладывают давящую повязку. Назначают антибиотики парентерально с учетом чувствительности к ним флоры. При переломах хряща вправляют отломки и накладывают моделирующую давящую повязку.

Ear damage

Superficial damage to the auricle occurs with bruises, bumps, cuts, insect bites. There is a partial or complete detachment of the auricle. Treatment

The skin around the wound is toileted with alcohol, primary cosmetic sutures are applied under local anesthesia, and an aseptic bandage is applied. Tetanus toxoid is injected subcutaneously. Antibiotics are prescribed intramuscularly or sulfa drugs inside.

Tympanic membrane injury

Damage to the eardrum occurs as a result of an increase or decrease in pressure in the ear canal due to hermetic closure of it during a blow to the ear.

There is a sharp pain in the ear, noise and hearing loss. With otoscopy, hemorrhages in the tympanic membrane, hematoma in the tympanic cavity, bleeding from the ear and traumatic perforation up to a complete defect of the membrane are observed.

Treatment

In case of bloody discharge in the ear canal, the doctor carefully makes a dry toilet of the ear with the help of a cotton holder or a suction device to view the eardrum. Then a sterile dry turunda is introduced into the ear canal.

Small traumatic perforations are often replaced by scar tissue spontaneously. With large fresh dry perforations, it is advisable to stick an egg amnion (film) on the eardrum.

21. Damage to the auditory ossicles and temporal bones

Damage to the auditory ossicles can be combined with a violation of the integrity of the tympanic membrane. A fracture of the malleus, anvil, their dislocation, displacement of the plate of the base of the stirrup develop.

При целой барабанной перепонке можно выявить разрыв цепи слуховых косточек с помощью тимпанометрии, когда выявляется тимпанограмма типа D (гиперподатливость барабанной перепонки). При перфорации барабанной перепонки и нарушении цепи слуховых косточек характер их патологии чаще всего распознается во время операции - тимпанопластики.

Treatment

Various types of tympanoplasty are performed depending on the nature of the traumatic injuries of the auditory ossicles and the tympanic membrane in order to restore sound conduction in the middle ear.

Fracture of the temporal bones

The longitudinal fracture corresponds to the transverse fracture of the base of the skull. With a longitudinal fracture of the pyramid of the temporal bone, there may be a rupture of the tympanic membrane, since the crack passes through the roof of the tympanic cavity, the upper wall of the external auditory canal. There is a serious condition, bleeding and liquorrhea from the ear, hearing loss. X-ray of the temporal bones confirms a fracture or fissure. Fractures of the base of the skull and the pyramid of the temporal bone in the absence of external wounds, but the outflow of cerebrospinal fluid from the ear are considered open injuries due to the possibility of infection of the cranial cavity.

Transverse fracture. With a transverse fracture of the temporal bone, the tympanic membrane often does not suffer, the crack passes through the mass of the inner ear, therefore, auditory and vestibular functions are disturbed, and paralysis of the facial nerve is detected.

A particular danger of fractures of the temporal bone is the possible development of intracranial complications (otogenic pachyleptomeningitis and encephalitis) when the infection penetrates from the middle and inner ear into the cranial cavity.

Обращают внимание на тяжелое состояние больного, спонтанные вестибулярные реакции, симптом двойного пятна на перевязочном материале при кровотечении из уха с отоликвореей, тугоухость или отсутствие слуха, паралич лицевого нерва, менингиальные и очаговые мозговые симптомы.

Treatment

First aid consists in stopping the bleeding from the ear, for which the ear canal is tamponade with sterile turundas or cotton wool, and an aseptic bandage is applied. In the hospital, with an increase in intracranial pressure, a lumbar puncture is performed. With heavy bleeding and signs of intracranial complications, a wide surgical intervention is performed on the middle ear.

The prognosis for trauma to the temporal bone depends on the nature of the skull base fracture and neurological symptoms. Extensive injuries often lead to death immediately after injury.

22. Otoliquorrhea. Foreign bodies of the ear

Otoliquorrhea usually resolves on its own. With continued liquorrhea, an operation is performed on the middle ear with exposure of the dura mater and plasticity of its defect with the temporal muscle.

Стойкий паралич лицевого нерва требует хирургической декомпрессии. Костный канал нерва в височной кости обнажается, и вскрывается его эпиневральная оболочка. При разрыве нерва края сшиваются или производится нейропластика.

Foreign bodies of the ear

Инородные тела в наружном слуховом проходе чаще встречаются у детей, которые во время игр засовывают себе в ухо различные мелкие предметы. У взрослых инородными телами могут быть обломки спичек, кусочки ваты, застрявшие в слуховом проходе. Иногда во сне в ухо проникают насекомые. Симптомы зависят от величины и характера инородных тел наружного уха. Инородные тела с гладкой поверхностью не травмируют кожу слухового прохода и долго не проявляются симптомами. Другие предметы часто приводят к появлению наружного отита с раневой и язвенной поверхностью. Одним из симптомов обтурирующего инородного тела являются кондуктивная тугоухость и шум в ухе. При частичной закупорке слухового прохода слух не ухудшается. Насекомые в момент движения в ухе причиняют неприятные, мучительные ощущения, особенно в области барабанной перепонки. При грубых, неудачных врачебных манипуляциях во время попытки извлечения инородного тела может произойти повреждение барабанной перепонки и среднего уха.

Recognition of foreign bodies does not cause difficulties in otoscopy and probing. Treatment

Free-lying foreign bodies are removed by washing the ear with warm water or a solution of furacilin from a Janet syringe with a capacity of 100-150 ml. In the presence of perforation of the tympanic membrane or purulent otitis, it is recommended to remove it with a Woyachek's bellied probe or a hook. It is not recommended to remove a foreign body with tweezers or forceps in order to avoid pushing it into the depth of the ear canal and damaging the eardrum. Insects are killed by dropping 70-degree alcohol or liquid sterile oil into the ear, then washing them out. Swollen foreign bodies are removed after reducing the volume by instillation of alcohol.

When wedged foreign bodies in the ear canal or their introduction into the tympanic cavity, when it is impossible to remove in the usual way, they resort to surgical treatment. Under local or general anesthesia, a behind-the-ear incision of soft tissues is made, separated, the posterior skin wall is dissected, and the foreign body is removed.

23. Non-gunshot injuries of the nose and paranasal sinuses. Clinic

Blunt trauma to the external nose is accompanied by epistaxis, hematoma around the nose and eyes, deformity of the external nose, impaired breathing and smell. In severe cases, damage captures the deep parts of the nose and the bone structures of adjacent areas.

Blunt trauma to the frontal bone leads to a fracture of the anterior wall of the frontal sinus, which is clinically manifested by depression, often corresponding to the type of traumatic object. Damage to the frontal sinuses, especially in the region of the root of the nose and the medial wall of the orbit, may be accompanied by a violation of the integrity and function of the fronto-nasal canal.

A strong direct blow applied to the root of the nose can lead to a very severe combined injury, the so-called fronto-basal (or fronto-facial) injury. In these cases, with possible minimal damage to the skin, there are numerous fractures of the bones of the external and internal nose, as well as adjacent bone formations.

Damage to the ethmoid bone and its sieve plate leads to anosmia and the appearance of subcutaneous emphysema on the face, manifested as swelling and crepitus.

Fractures in the region of the sphenoid bone may be accompanied by damage to the wall of the internal carotid artery.

In the case of a fracture of the bones of the nose, an external examination determines the deformity of the external nose, expressed to one degree or another. There is swelling and swelling of the soft tissues of the nose and adjacent areas of the face. The hematoma gradually increases, which makes it difficult to assess the magnitude of the deformity and reposition the bones of the nose.

Swelling of the soft tissues in the nose and on the face can also be caused by subcutaneous emphysema, which, on palpation, is defined as a slight crackling crackle. Palpation with fractures of the nasal bones and cartilage detects osteochondral crepitus. The diagnosis of a fracture of the bones of the nose is confirmed by X-ray examination.

Hematoma of the soft tissues of the face is often accompanied by hemorrhage in the area of the eyelids and around the orbit (a symptom of glasses). In these cases, it is necessary to perform an X-ray examination, since this symptom may be the only sign of a fracture of the base of the skull.

Fracture of the sieve of the nose may be accompanied by nasal liquorrhea, which becomes more noticeable when the head is tilted forward. On the first day after injury, a symptom of nasal liquorrhea is a symptom of a double spot. After the cessation of nasal bleeding, the discharge with nasal liquorrhea acquires a light character and becomes similar to discharge with vasomotor rhinitis.

Fractures in the cartilage and bone sections of the nasal septum are accompanied by the formation of a hematoma. The blood poured out after the blow exfoliates the perichondrium and mucous membrane, as a rule, on both sides. Symptoms of hematoma are difficulty in nasal breathing, nasal tone of voice.

24. Treatment of nasal injuries

Assistance for bruises without bone fractures may be limited to stopping bleeding with cold on the area of injury and resting the victim. With severe nosebleeds, it is necessary to carry out an anterior loop tamponade, and if it is ineffective, a posterior nasal tamponade should also be performed.

The main method of treating fractures of the bones of the nose and other bones of the skull is reposition followed by fixation of their fragments. The optimal time for repositioning the bones of the nose is considered to be the first 5 hours after the injury or 5 days after it. This is due to the development of a pronounced edema of the surrounding soft tissues, which makes it difficult to determine the correct location of the reduced fragments. Reposition is usually performed under local anesthesia. The reduction of fragments should be done in the supine position of the patient. After the reposition of the nasal bones, their fixation is necessary. In all cases, loop tamponade of both halves of the nose is performed.

When establishing a hematoma of the nasal septum, surgical treatment is performed under local anesthesia.

Fractures of the maxillary sinus that are not accompanied by visual impairment and significant damage to the walls of the sinus and orbit, confirmed by x-ray examination, are treated conservatively. If signs of inflammation appear on the 3rd-4th day after the injury (body temperature rises, swelling and pain in the area of the projection of the sinus and lower eyelid increases), one should think about the transition of hemosinus to pyosinus. After removing the pathological contents and washing the sinus with an isotonic solution or a solution of furacilin, antibiotics are introduced into its cavity.

General antibiotic therapy is prescribed. Repeated puncture is performed in accordance with the clinical dynamics.

Fracture of the paper plate of the ethmoid bone may be accompanied by damage to one of the ethmoid arteries. Bleeding from this artery leads to an increase in pressure in the orbit, exophthalmos and circulatory disorders in the eyeball, which can lead to blindness within a few hours. A timely draining medial paraorbital incision with loose tamponade of the orbital tissue can save vision.

To combat liquorrhea and prevent the development of intracranial complications, the patient is prescribed strict bed rest for 3 weeks. Regular lumbar punctures are performed to reduce intracranial pressure. Desirable, especially during the first week after injury, prolonged loop tamponade of the nose. General and local antibiotic therapy is prescribed.

For fractures of the frontal sinuses, surgical treatment is performed. Depressed bone fragments of the anterior wall, which retain their connection with soft tissues, are carefully repositioned.

25. Gunshot wounds of the nose and paranasal sinuses

Gunshot wounds of the nose and paranasal sinuses can be divided into 3 groups:

1) not penetrating into the nasal cavity and paranasal sinuses;

2) penetrating wounds with damage to the bone formations of the nasal cavity and paranasal sinuses;

3) combined injuries with damage to adjacent organs and anatomical structures. The most important feature of gunshot wounds is the wound channel with all its properties. Shrapnel wounds cause more severe damage. Also, significant damage is inflicted by a bullet with an unstable center of gravity. Numerous bone walls and formations that form the facial skull also affect the nature of the wound channel. The presence of an inlet and an outlet indicates a penetrating wound. In cases where a wounding projectile passing through soft tissues and bone gets stuck in the wound channel, they speak of a blind wound.

Isolated blind wounds to the nose and paranasal sinuses are not particularly dangerous. A bullet or fragment, having passed through the soft tissues and bones of the facial skeleton, gets stuck in one of the sinuses, causing their purulent inflammation.

Gunshot wounds of the nose and paranasal sinuses are much more dangerous for life, in which adjacent areas are damaged - the cranial cavity, eye sockets, the base of the skull, and the pterygopalatine fossa.

Small foreign bodies in blind gunshot wounds tend to encapsulate.

Large foreign bodies, especially those located near vital organs, usually lead to progressive complications.

In the diagnosis of foreign bodies of gunshot origin, various x-ray arrangements, linear and computed tomography are used.

All foreign bodies are divided into:

1) easily retrievable;

2) hard-to-recover;

3) causing any disorders;

4) do not cause any disorders. There are four combinations:

1) easily accessible, but causing disorders, - removal is mandatory;

2) easily accessible, but not causing disorders - removal is indicated under favorable conditions;

3) hard-to-reach, but not causing disorders - the operation is either contraindicated in general, or is done in case of dangers that threaten the wounded in the further course of the injury;

4) hard-to-reach, but accompanied by disorders of the corresponding functions - extraction is indicated, but due to the complexity of the operation, it must be carried out with special precautions.

26. Foreign bodies of the nose and paranasal sinuses

Most often, foreign bodies are found in children. In adults, foreign bodies enter the nose under random circumstances.

Foreign bodies of the nose and paranasal sinuses are possible as a result of gunshot wounds, when wounded with a cold weapon or some household object, the tip of which, fixed in the bone tissues of the nasal cavity, breaks off.

Foreign bodies introduced through the nasal vestibule are usually found between the inferior turbinate and the nasal septum. Foreign bodies that have entered the nasal cavity in a different way can be localized anywhere. A foreign body that is not removed in the near future is gradually overgrown with granulations. The carbonic and phosphate calcium salts that precipitate around it form a nasal stone - rhinolite. Rhinoliths can be of the most diverse shapes and sizes and sometimes form, as it were, a cast of the nasal cavity.

Clinic

A foreign body that has entered the nasal cavity reflexively causes sneezing, lacrimation, and rhinorrhea. Gradually, reflexes fade and the body adapts to a foreign object. The presence of a foreign body in the nose causes the following symptoms:

1) unilateral nasal congestion;

2) unilateral purulent runny nose;

3) unilateral headaches;

4) nosebleeds.

Diagnosis

Наличие инородного тела помогают установить анамнез, риноскопия, зондирование и рентгенография. Образование кровоточащих грануляций вокруг инородного тела, сужение носового хода и гнойные выделения могут симулировать другие заболевания. В дифференциальной диагностике имеет значение возраст: инородные тела чаще встречаются у детей, и у них воспаление околоносовых пазух вследствие их недоразвитости является исключением.

Treatment

Удаление инородных тел в свежих случаях не представляет особых затруднений. Иногда их удается удалить путем высмаркивания. Если эта процедура не увенчалась успехом, то после анемизации и анестезии слизистой оболочки носа инородное тело может быть извлечено с помощью инструмента. Наиболее подходящим для этой цели является тупой крючок, который вводится за инородное тело и при обратном движении захватывает и удаляет его. Попытки удалить инородное тело пинцетом могут привести к проталкиванию его в глубь носа. Удаление живых инородных тел желательно предварить их обездвиживанием (воздействием анестетиков), либо в случаях с пиявкой влить в полость носа 10 %-ный раствор поваренной соли, что вызовет ее сокращение. Удаление очень крупных инородных тел возможно только посредством операции.

27. Nosebleeds. Clinic and diagnostics

Causes of nosebleeds are divided into local and general. Local causes include:

1) injuries of the nose and paranasal sinuses;

2) atrophic processes of the mucous membrane of the anterior part of the nasal septum;

3) malignant tumors of the nose and paranasal sinuses;

4) benign tumors;

5) foreign bodies of the nasal cavity.

Common causes of nosebleeds:

1) arterial hypertension and atherosclerosis;

2) acute infectious lesions of the upper respiratory tract, predominantly of viral origin;

3) septic conditions (chroniosepsis), intoxication, including alcohol;

4) diseases of internal organs;

5) neurovegetative and endocrine vasopathies;

6) hypo- and beriberi;

7) decrease in atmospheric pressure, physical overstrain and overheating.

Most often, nosebleeds occur in the anteroinferior part of the nasal septum, which is associated with the peculiarity of the blood supply to this area. It is in this place that the terminal branches of the arteries that supply the nasal septum end. The arterial and venous network forms here several layers of the choroid plexus, which is easily injured.

Если кровотечение происходит из передненижних отделов перегородки носа, то его легко удается обнаружить при передней риноскопии. При кровотечении из глубоких отделов полости носа источник геморрагии в большинстве случаев установить не удается.

Nosebleeds can occur suddenly. Sometimes it is preceded by prodromal phenomena. Usually one side bleeds. The intensity of bleeding is different - from small to massive, profuse. The most severe, life-threatening are the so-called signal nosebleeds, which are characterized by suddenness, short duration and an abundance of outflowing blood. After spontaneous cessation of bleeding, severe collapse develops.

In some cases, there is a problem of differential diagnosis between nosebleeds and bleeding from the lower respiratory tract, as well as from the esophagus and stomach. Blood with pulmonary bleeding is foamy, bleeding is accompanied by a cough, with gastric bleeding - dark, clotted. It should be borne in mind that swallowing blood during nosebleeds is accompanied by vomiting with clots of dark, brown coagulated blood mixed with gastric contents, as in gastric bleeding. However, the runoff of scarlet blood along the back wall confirms nosebleeds.

28. Treatment of nosebleeds

In case of bleeding from the anterior part of the nasal septum, it should be stopped by pressing the bleeding half of the nose against the nasal septum with the fingers of the wing of the nose. In anticipation of the nose, it is better to additionally introduce an adequate lump of cotton - dry or moistened with a 3% hydrogen peroxide solution.

If the listed measures remain unsuccessful, they resort to anterior tamponade, and in case of its insufficiency, to the posterior nasal tamponade.

Anterior nasal tamponade according to Mikulich. It is carried out most quickly and simply. The corresponding nostril is expanded by the nasal planum. A tampon prepared from a gauze bandage 1-2 cm wide and up to 70 cm long, impregnated with vaseline oil, to a depth of 6-7 cm is inserted into the nasal cavity with the help of a forceps. nose, and not to its arch. The patient's head should not tilt back. Gradually, the entire tampon fits into the nasal cavity according to the "accordion" principle from the bottom up until it densely fills the corresponding half of the nose.

Posterior nasal tamponade. This type of stopping nosebleeds is resorted to when all other methods have been exhausted. The rear cotton-gauze swab for the nasopharynx is prepared and sterilized in advance. The optimal size of the tampon should correspond to the terminal phalanges of the thumbs, folded together. The tampon is tied crosswise with two thick strong threads.

After local anesthesia, a rubber catheter is inserted through the bleeding half of the nose into the oropharynx, the end of which is brought out through the mouth with the help of a forceps. Both threads are tied to the withdrawn end of the catheter. When the catheter is brought back through the nose, thanks to the threads tied to it, the tampon is inserted into the nasopharynx, tightly pulling up to the choanae. Keeping the threads taut, anterior nasal tamponade is performed. The tamponade ends by tying threads over a cotton or gauze "anchor" with a bow, which allows, if necessary, to tighten the displaced nasopharyngeal tampon. The third thread of the tampon is placed without tension between the cheek and the gum of the lower jaw and its end is fixed with a strip of adhesive plaster on the cheek or in the ear area on the side of the tamponade. For this thread, the tampon is removed from the nasopharynx

Хирургические способы остановки носового кровотечения. Используются при неэффективности тампонады и рецидивирующих носовых кровотечениях. С целью облитерации сосудов слизистой оболочки перегородки носа используются различные склерозирующие препараты.

Among the methods of stopping nosebleeds by ligation of the main vessel throughout, the most common is the ligation of the external carotid artery.

29. Deviated septum

Deviated septum is one of the most common rhinological pathologies.

The causes of frequent deformation can be anomalies in the development of the facial skeleton, as well as rickets, injuries. Due to the fact that the nasal septum consists of various cartilaginous and bone structures, limited above and below by other elements of the facial skull, the ideal and combined development of all these components is extremely rare.

Variations of the curvature of the nasal septum are very different. Possible shifts in one direction or another, s-shaped curvature, the formation of ridges and spikes, subluxation of the anterior quadrangular cartilage.

Deformation of the nasal septum, causing a violation of the function of external respiration, determines a number of physiological abnormalities.

In the nasal cavity itself, respiratory defects reduce the gas exchange of the paranasal sinuses, contributing to the development of sinusitis, and the difficulty in the flow of air into the olfactory gap causes a violation of smell.

Clinic

The leading symptom of a clinically significant curvature of the nasal septum is unilateral or bilateral obstruction of nasal breathing. Other symptoms may be a violation of the sense of smell, nasal, frequent and persistent rhinitis.

Diagnostics

It is established on the basis of a cumulative assessment of the state of nasal breathing and the results of rhinoscopy. The curvature of the nasal septum is often combined with the deformation of the external nose of congenital or acquired origin.

Treatment

Treatment is surgical only. An indication of coperation is difficulty in nasal breathing through one or both halves of the nose.

Operations on the nasal septum are performed under local or general anesthesia. Damage to the mucous membrane in adjacent areas of the septum leads to the formation of persistent, practically unrecoverable perforations. Bloody crusts dry up along the edges of the latter.

Используются различные модификации операций на перегородке носа. Первый - радикальная подслизистая резекция перегородки носа по Киллиану, второй - консервативная септум-операция по Воячеку. При первом методе удаляется большая часть хрящевого и костного остова перегородки. Достоинство этой операции - ее сравнительная простота и быстрота исполнения. Недостатки - наблюдаемая во время дыхания флотация перегородки носа, а также склонность к развитию атрофических процессов. При втором методе удаляются только те участки хрящевого и костного остова, которые нельзя редрессировать и поставить в правильное срединное положение. При искривлении четырехугольного хряща выкраивается диск путем циркулярной резекции.

30. Diseases of the nasal cavity

Bleeding polyp of the nasal septum

Its characteristic feature is the appearance in the anterior part of the nasal septum on one side of a gradually increasing polyposis formation, which bleeds easily.

Etiology

One of the reasons for the appearance of a polyp is trauma to the mucous membrane with fingernails in the area of its increased vascularization. The disease is more common in young people and in women during pregnancy and lactation, which indicates the possible importance of endocrine factors in its formation. In morphological examination, as a rule, hemangioma is observed, in more rare cases - granulation tissue.

Clinic

The main complaint of the patient: difficulty in nasal breathing and frequent, profuse nosebleeds, recurring when blowing the nose, touching with a finger. Rhinoscopy allows you to detect a polyposis formation of red or purple-red color. The stalk of the polyp is usually wide. When probing, the polyp bleeds easily.

Treatment

Only surgical. The polyp should be removed along with the adjacent mucosa and perichondrium of the nasal septum. After removal, it is desirable to perform electrocaustics or cryoapplication of the mucous membrane along the edge of the wound surface, followed by tamponade. Anterior dry rhinitis. Perforating ulcer of the nasal septum Anterior dry rhinitis occurs in the anterior part of the nasal septum at the site of frequent trauma to the mucous membrane.

Clinic

Patients complain of a feeling of dryness in the nose, drying of the crusts in the vestibule of the nose, which causes the need for their removal. With rhinoscopy in the anterior part of the nasal septum, a limited area of dry, thinned mucous membrane is determined, which has lost its normal wet sheen, covered with dry crusts. Then a through defect of the nasal septum may occur at this place. Perforation is usually small, rounded. It often closes with dry crusts, the removal of which may lead to bleeding, as well as wheezing, noticeable with forced breathing.

Diagnosis

Diagnosis is based on history and anterior rhinoscopy. Differential Diagnosis

The differential diagnosis is carried out with tuberculosis, syphilis and Wegener's disease. Treatment

Based on the same principles as the treatment of atrophic rhinitis.

31. Acute rhinitis

Acute rhinitis is an acute disorder of the nasal function, accompanied by inflammatory changes in the mucous membrane.

Acute rhinitis can be an independent inflammation of the nasal cavity, as well as accompany many infectious diseases.

Etiology and pathogenesis

In the etiology of acute rhinitis, low-virulent saprophytic flora, various factors of a non-infectious nature are important.

In acute traumatic rhinitis, activation of the permanent microflora of the nasal cavity is noted, the action of which is added to the irritation caused by trauma.

Cooling contributes to the activation of the saprophytic flora and the acquisition of pathogenicity by it, leads to a slowdown or complete cessation of the movement of the cilia of the ciliated epithelium. As a result, the pathogenic factor penetrates deep into the epithelium, causing an inflammatory reaction.

Clinic

Symptoms of acute rhinitis include congestion of the mucous membrane, swelling of the turbinates, feeling hot, sneezing, and watery eyes. If the turbinates are significantly enlarged, then patients may experience an unpleasant feeling of complete blockage of the nose. Nasal congestion is often accompanied by a feeling of heaviness in the head, dull pain in the forehead.

In the first period of a runny nose, the nasal mucosa is drier than normal (hyposecretion). Then it is replaced by hypersecretion, first in the form of a transudate, and then with a thicker mucopurulent discharge.

In the clinic of acute rhinitis, there are three stages. The first stage (dry stage) is characterized by a feeling of dryness, burning, feeling of tension in the nose. The mucous membrane is hyperemic, has a dry sheen. There is sneezing, coughing.

The second stage (the stage of serous discharge) begins with a copious discharge of a completely transparent watery fluid (transudate). During this period, the sensations of burning and dryness decrease. The mucous membrane acquires a cyanotic hue, its moisture increases.

The third stage (the stage of mucopurulent discharge) occurs on the 3-5th day of rhinitis, characterized by a gradual decrease in the amount of discharge, which becomes more and more thick.

Treatment

When the first signs of malaise appear, general warming (hot baths), ingestion of 2-3 glasses of hot tea, wrapping and bedding are recommended. At the same time, oral administration of acetylsalicylic acid (0,5-1,0 g) is indicated.

Медикаментозное лечение катарального ринита в основном состоит в применении сосудосуживающих препаратов в нос и назначении антигистаминных средств (димедрола, тавегила, супрастина, диазолина).

32. Chronic rhinitis. Chronic catarrhal rhinitis

Chronic catarrhal rhinitis develops as a result of recurrent acute rhinitis. Prolonged congestive hyperemia of the nasal mucosa caused by alcoholism, a chronic disease of the cardiovascular system, kidneys predisposes to the development of chronic rhinitis. In the etiology of the disease, hereditary prerequisites, malformations, violations of normal anatomical relationships that cause difficulty in nasal breathing may be important.

Clinic

The patient complains of discharge from the nose of a mucous or mucopurulent nature. Difficulty in nasal breathing is aggravated (as is discharge from the nose) in the cold. Often there is an alternating congestion of one of the halves of the nose.

With rhinoscopy, diffuse hyperemia of the mucous membrane is determined, often with a cyanotic tint. The inferior turbinates are moderately swollen, narrowing the lumen of the common nasal passage.

Chronic catarrhal rhinitis may be accompanied by hyposmia. The transition of catarrhal inflammation from the nasal cavity to the mucous membrane of the auditory tube is possible, followed by the development of tubo-otitis.

Diagnosis

The diagnosis of the disease is established on the basis of complaints, anamnesis, anterior and posterior rhinoscopy.

Differential diagnostics

To distinguish catarrhal chronic rhinitis from hypertrophic, anemization of the mucous membrane is performed with vasoconstrictor agents.

A noticeable reduction in the mucous membrane of the turbinates indicates the absence of true hypertrophy, characteristic of hypertrophic rhinitis.

Treatment

Local treatment consists in the use of antibacterial and astringent preparations in the form of a 3-5% solution of protargol (collargol), 0,25-0,5% solution of zinc sulfate, 2% salicylic ointment, etc.

Chronic hypertrophic rhinitis

Clinic

Hypertrophic rhinitis is characterized by persistent nasal congestion. Complicates nasal breathing and abundant mucous and mucopurulent discharge. Obstruction of the olfactory fissure leads to hyposmia and further anosmia. In the future, as a result of atrophy of the olfactory cells, essential (irreversible) anosmia may occur.

Treatment

Surgery is usually performed under local anesthesia. The operation ends with a loop tamponade. The tampons are removed after 2 days. However, given the possibility of significant bleeding after the removal of tampons, especially after cutting off the posterior ends of the inferior turbinates (posterior conchotomy), complete removal of the tampons can be performed at a later date.

33. Atrophic rhinitis

Simple atrophic rhinitis. This form of chronic rhinitis can be primary or secondary. Secondary atrophic rhinitis is a consequence of exposure to various adverse environmental factors.

With anterior rhinoscopy, the posterior wall of the nasopharynx is freely visible. The mucous membrane acquires a dry lacquer sheen and is covered with crusts of dried mucus. When the process captures the olfactory zone, hypo- and anosmia develops.

Treatment

It is necessary to eliminate or reduce the impact of harmful environmental factors. A course of treatment with ointments and iodine-glycerin is prescribed locally. In the morning and evening, the patient should inject Voyachek's diachilic ointment into the nose on a cotton swab for 10 minutes. 2 times a week, the doctor or the patient himself lubricates the nasal mucosa with a solution of iodine-glycerin. Such treatment is carried out for 2 months and is repeated 3 times a year.

It is also recommended to put cotton swabs with rosehip or sea buckthorn oil in olive or peach oil in a ratio of 1: 3-1: 4 or with the addition of an oil solution of vitamin A (no more than 50 IU) into the nose.

Ozena

Озена характеризуется хроническим атрофическим зловонным насморком, отличающимся глубокой атрофией всей слизистой оболочки, а также костных стенок носовой полости и носовых раковин. Для озены характерно выделение густого секрета, засыхающего в зловонные корки.

Этиология и патогенез заболевания продолжают оставаться недостаточно выясненными до настоящего времени. Инфекционная природа озены подтверждается закономерностями вегетирования клебсиеллы в организме человека. В патогенезе озены существенную роль играют наследственно-конституционные особенности, передающиеся по наследству как рецессивный признак.

Clinic

For patients with ozena, the presence of severe atrophy of the mucous membrane of the nasal cavity, a decrease in the size of the nasal conchas, especially the lower ones, are characteristic. As a result of atrophy of the mucous membrane and turbinates, the nasal cavity becomes wide. With anterior rhinoscopy, not only the posterior wall of the nasopharynx, but also the pharyngeal mouths of the auditory tubes are freely visible. Sometimes the openings of the sphenoid sinus located in the direction of the posterior and upward are visible. Often, during lakes, the entire nasal cavity is filled with crusts to such an extent that neither the mucous membrane nor even the shells themselves can be seen behind them.

Treatment

Crusts from the nose are removed by washing the nasal cavity with 2% sodium bicarbonate solution, 1% hydrogen peroxide solution, 0,1% potassium permanganate solution, or saline.

In the treatment, antibiotics are used that are active against Klebsiella ozena: streptomycin, monomycin, neomycin, kanamycin, chloramphenicol.

34. Vasomotor rhinitis

In the occurrence of the neurovegetative form of vasomotor rhinitis, the main role is given to functional changes in the central and autonomic nervous system, as well as the endocrine system.

The allergic form of vasomotor rhinitis occurs when exposed to various allergens, depending on which seasonal and permanent (year-round) forms are distinguished.

Pathogenesis

The pathogenesis of allergic rhinitis consists in a specific reaction between the allergen and tissue antibodies, resulting in the release of mediators of the allergic reaction.

Clinic

Клиника нейровегетативной формы вазомоторного ринита: затруднение носового дыхания, обильные серозные или слизистые выделения, приступы пароксизмального чиханья, ощущение зуда и жжения в полости носа. Слизистая оболочка имеет синюшный цвет. Во время риноскопии носовые раковины представляются набухшими, при надавливании на них пуговчатым зондом последний легко прогибает мягкие ткани до костной стенки без всякого сопротивления. Смазывание слизистой оболочки сосудосуживающими препаратами приводит к быстрому сокращению раковин.

Клиника сезонного аллергического ринита (поллиноза). Характерна четкая сезонность наступления обострения. В этот период отмечаются пароксизмы чиханья, зуд и жжение в полости носа, глазах, гиперемия конъюнктивы. Наступают практически полная заложенность носа и выраженная ринорея, которая приводит к мацерации кожи в преддверии носа.

The mucous membrane in the initial period is sharply hyperemic, there is a significant amount of clear liquid in the nose.

Клиника постоянной (круглогодичной) формы аллергического ринита. Заболевание носит хронический характер. Определяется выраженная отечность носовых раковин. Слизистая оболочка отличается бледностью. При задней риноскопии часто отмечается подушкообразное утолщение слизистой оболочки сошника, выраженное с двух сторон. Средние носовые раковины также отечны. При исследовании носовых раковин пуговчатым зондом определяется их тестоватая плотность, непозволяющая ощутить костную строму раковины. Для аллергической формы вазомоторного ринита характерно образование слизистых полипов, которые могут заполнять всю носовую полость.

Treatment

Treatment for the neurovegetative form of vasomotor rhinitis is to eliminate the various causes that cause this disease. Various types of intracarcinal disintegration are also used.

Treatment of allergic rhinitis includes three main areas, such as elimination therapy, immunotherapy and drug therapy. The goal of elimination therapy is to eliminate allergens. Of the drug therapy, diphenhydramine, diazolin, suprastin are most often used.

35. Acute sinusitis. Etiology. Pathogenesis. Clinic

Etiology

The etiology of both acute and chronic sinusitis is infectious. The most common way is through natural fistulas that communicate the sinus with the nasal cavity. In acute infectious diseases, infection of the sinuses is possible by the hematogenous route.

Pathogenesis

In the pathogenesis of acute and especially chronic sinusitis, the ventilation of the paranasal sinuses is important, caused by anatomical defects in the nasal cavity, as well as congenital narrowness of the nose.

When the sinus fistula is closed with an edematous mucosa, the oxygen content in the sinus will decrease, and the carbon dioxide content will increase. The oxygen content drops especially if pus is produced in the sinus.

Allergic processes and immunological deficiency play a significant role in the development of acute and chronic sinusitis.

Clinic

The characteristic symptoms for all sinusitis are congestion of the corresponding half of the nose (with a bilateral process - both halves), mucous or purulent discharge from the nose, the presence of a purulent path in the middle or upper nasal passage, and a violation of the sense of smell.

Acute ethmoiditis. The lattice labyrinth is the first to be exposed to any adverse environmental factors. The narrow excretory ducts of individual parts of the labyrinth easily overlap with swelling of the mucous membrane, which contributes to the development of the inflammatory process in the cellular structures of the ethmoid bone.

Typical symptoms: fever and headaches. Locally, the disease manifests itself in a feeling of soreness, localized in the region of the root of the nose and at the inner corner of the eye, aggravated by palpation.

Acute maxillary sinusitis (sinusitis). At the same time, sinusitis patients are worried about headache, localized in the area of the projection of the maxillary sinus. However, in many cases, its distribution was noted in the forehead, zygomatic bone.

Acute frontal. This disease, along with the general symptoms characteristic of a febrile state, is characterized by a strong, sometimes acute headache, localized mainly in the forehead, and a feeling of heaviness in the projection of the affected sinus. Percutere there is also an increase in pain, and when stroking the skin, a feeling of velvety may appear, which in this case indicates the phenomenon of periostitis.

Acute sphenoiditis is an inflammation of the sphenoid sinus. It is also often associated with inflammation of the ethmoid labyrinth, with posterior cells usually involved (posterior ethmoiditis). In acute sphenoiditis, patients complain of severe, "split head" headaches, often radiating to the back of the head and orbit. A characteristic feature is the flow of purulent mucus along the back of the pharynx, which is established during mesopharyngoscopy.

36. Treatment of acute sinusitis

Treatment of acute sinusitis, like other focal infections, consists of a combination of general and local methods. The local treatment is based on the anemization of the nasal mucosa, which can be carried out using official vasoconstrictors (naphthyzinum, sanorin, galazolin). More effective is targeted smearing by the doctor of the mucous membrane in the area of the middle nasal passage with a 3-5% solution of cocaine or an anesthetic - a 2% solution of dicaine with 3-4 drops of a 0,1% solution of adrenaline per 1 ml of the drug. Anemization of the mucous membrane and a decrease in its volume contribute to the expansion of the fistulas of the sinuses and facilitate the outflow of exudate. This is also facilitated by thermal procedures (sollux, diathermy, UHF).

The puncture of the maxillary sinuses remains one of the most common methods of conservative treatment. Other methods of conservative treatment - trepanopuncture of the frontal sinuses, puncture of the ethmoid labyrinth, puncture and probing of the sphenoid sinus - are more complex manipulations and are carried out in stationary conditions.

If repeated punctures of the paranasal sinuses are necessary, permanent drainages are used, which are thin polyethylene or fluoroplastic tubes that are inserted into the sinus for the entire period of treatment, saving the patient from unpleasant manipulations.

Through the introduced drainage tube, the sinuses are systematically washed with an isotonic or furatsilin (1: 5000) solution and other drugs (usually antibiotics) are administered. The introduction of medicinal solutions into the paranasal sinuses is possible by the method of movement. With this method, a vacuum is created in the nasal cavity with the help of surgical suction. It allows you to remove pathological contents from the sinuses, and after infusion of medicinal solutions into the nasal cavity, the latter rush into the opened sinuses.

As a general treatment for patients with acute sinusitis, analgesics, antipyretics, antihistamines and antibacterial drugs are prescribed. Penicillin can be prescribed at 500 IU 000-4 times a day, as well as other antibiotics with a wider spectrum of action (tseporin, keflin, kefzol). The prescription of antibiotics should be adjusted in accordance with the sensitivity of the microflora obtained from the focus of inflammation. Sulfa drugs (sulfadimethoxine, sulfalene, biseptol) are prescribed both independently and in combination with antibiotics.

In case of odontogenic maxillary sinusitis, the corresponding carious teeth should be removed. In this case, an undesirable opening of the maxillary sinus is possible. The resulting channel connecting the sinus with the oral cavity (oroantral fistula) can close on its own or after repeated lubrication with iodine tincture. Otherwise, they resort to plastic closure of the fistula by moving a flap cut from the soft tissues of the gums.

37. Chronic sinusitis

Chronic sinusitis usually results from repeated and insufficiently treated acute sinusitis.

Согласно классификации различают экссудативные (катаральную, серозную, гнойную) и продуктивные (пристеночно-гиперпластическую, полипозную) формы синуситов, а также холестеатомный, некротический (альтеративный), атрофический и аллергический синуситы.

With exudative forms, a pattern of diffuse inflammatory infiltration by lymphocytes, neutrophils and plasma cells is observed. It is more pronounced with purulent than with catarrhal and serous forms.

In hyperplastic forms, the thickening of the mucous membrane is more pronounced than in previous forms. Pathological changes are predominantly proliferative in nature due to the growth of connective tissue elements of the proper layer of the mucous membrane. The formation of granulation tissue and polyps is noted. The development of connective tissue in some areas can be combined with sclerosis and thickening of the mucous membrane in other places.

Clinical symptoms in chronic sinusitis outside the stage of exacerbation are less pronounced than in acute ones. Headache in chronic sinusitis is less severe, it may be indefinite. Nasal congestion is usually moderate, more pronounced in allergic polyposis and fungal forms of sinusitis. Often, patients note a violation of the sense of smell.

The nature of nasal discharge also depends on the form of sinusitis. With mold mycoses, the discharge is usually viscous, sometimes jelly-like, has a whitish-gray or yellowish color. With aspergillosis, the discharge is gray, blackish blotches are possible, which can be thick, resembling cholesteatoma masses. With candidiasis, the discharge is similar to a whitish curd mass.

With exacerbation of chronic sinusitis, the clinical picture resembles an acute process of damage to one or another paranasal sinus and often depends on the presence or absence of complications.

The diagnosis of chronic sinusitis and variants of its manifestations are established on the basis of clinical and radiological data.

Treatment

The tactics of treating chronic sinusitis is determined by the clinical form of the disease. With an exacerbation of chronic sinusitis, its exudative forms (catarrhal, serous, purulent) are usually treated conservatively. In this case, the same means and methods of treatment are used that are used in the treatment of acute sinusitis. Productive forms of chronic sinusitis (polypous, polypous-purulent) are treated promptly. Regardless of the form of chronic sinusitis, in the presence of visual and intracranial complications, the main method should be surgical treatment.

38. Orbital complications. Classification. Treatment

Classification

There are the following types of complications:

1) reactive edema of the tissue of the orbit and eyelids;

2) diffuse non-purulent inflammation of the tissue of the orbit and eyelids;

3) periostitis (osteoperiostitis);

4) subperiosteal abscess;

5) eyelid abscess;

6) fistulas of the eyelids and orbital wall;

7) retrobulbar abscess;

8) phlegmon of the orbit;

9) thrombosis of the veins of the ophthalmic tissue.

Кроме того, к данной классификации можно добавить такие нозологические формы, как неврит зрительного нерва, ретробульбарный неврит и оптохиазмальный арахноидит, представляющие, в сущности, различные стадии одного заболевания. Зрительные нарушения могут быть вызваны и кистоподобным либо воздушным растяжением околоносовых пазух.

Treatment

Treatment of rhinogenic ophthalmic complications must be carried out in a hospital with the participation of otorhinolaryngologists and ophthalmologists. It should be comprehensive and often quite urgent, covering a wide range of activities depending on the nature of the lesion of the orbit and the pathological process in the paranasal sinuses.

In non-purulent forms of orbital complications resulting from acute sinusitis, conservative treatment is carried out, which should include active sanitation of the paranasal sinuses through their effective drainage, antibiotic and antihistamine therapy. With the same complications, but developed as a result of exacerbation of chronic inflammation of the paranasal sinuses, conservative methods of treatment can be combined with sparing surgical intervention.

In case of purulent processes in the orbit or in the presence of symptoms of visual impairment, regardless of the nature of the pathological process in the paranasal sinuses, a wide opening of the affected paranasal sinuses and the simultaneous elimination of a purulent focus in the orbit are necessary.

Treatment of mucocele and pyocele is surgical. With damage to the frontal sinus and the ethmoid labyrinth, both extranasal paraorbital and endonasal accesses are possible. The same lesion of the sphenoid sinus requires its opening by endonasal transseptal access for guaranteed sanitation. In case of atrophy of the optic nerves caused by the pneumatosinus of the sphenoid sinus, endonasal transseptal opening of the sphenoid sinus with careful curettage of the mucosa is also recommended.

39. Clinic of ophthalmic complications

Orbital complications and visual disturbances are manifested by general and local symptoms, the severity of which depends on the nature of the pathological process in a particular paranasal sinus, the type of complication and the localization of the focus in the orbit itself.

Reactive swelling of the tissue of the orbit and eyelids, as well as their diffuse non-purulent inflammation, especially often develops in childhood with acute ethmoiditis that occurs against the background of a respiratory infection. In this disease, swelling and redness of the skin in the eyelid area, narrowing of the palpebral fissure, hyperemia and edema of the conjunctiva, eyelids and eyeball are clinically noted.

Periostitis (osteoperiostitis). There are simple (non-purulent) and purulent forms. Simple periostitis is clinically difficult to distinguish from reactive edema and diffuse non-purulent inflammation of the tissue of the orbit and eyelids. It is observed with catarrhal inflammation of the sinuses, purulent - with empyema. It is clinically manifested by inflammatory infiltration of tissues in the form of eyelid edema and injection of conjunctival vessels.

Purulent periostitis is more severe. It is characterized by a pronounced general reaction: high body temperature, general weakness, headache.

The anatomical features of the structure of the tissues of the orbit determine the direction of the spread of pus, which, as a rule, does not occur inside the orbit, but outward, forming a purulent fistulous tract. The localization of a subperiosteal (periorbital) abscess becomes clear after the formation of a fistulous tract. With frontal sinusitis, such a spontaneous opening of the abscess occurs in the middle of the upper orbital margin or in the region of the upper inner corner of the orbit, above the internal ligament of the eyelids.

Orbital phlegmon is the most severe and dangerous of all rhinosinusogenic orbital complications. Its development is always accompanied by a violent general reaction of the body: the body temperature rises significantly (up to 39-40 ° C), headache intensifies, nausea and vomiting may occur. Pain in the orbit increases, swelling and hyperemia of the eyes increase, chemosis becomes significantly pronounced. There is always exophthalmos with limited mobility of the eyeball.

Visual disturbances caused by cyst-like deformations (expansion) of the paranasal sinuses can manifest as a displacement of the eyeball.

Cyst-like enlargements of the paranasal sinuses include mucocele and pyocele. The development of a cystic expansion of the sinuses is characterized by the closure of the anastomosis between the sinus and the nasal cavity, and therefore sterile mucus (mucocele) or pus containing low-virulent flora (pyocele) accumulates in it.

When the disease is localized in the area of the ethmoid bone, the function of the lacrimal ducts is disrupted, which is accompanied by lacrimation. Thinning of the bone walls caused by cystic expansion of the sinus is observed on palpation as a symptom of a parchment crunch.

40. Rhinogenic arachnoiditis

Rhinogenic arachnoiditis usually develops in patients suffering from sluggish latent sinusitis without distinct clinical symptoms. The defeat of the paranasal sinuses can be manifested by a slight parietal thickening of the mucous membrane or a slight decrease in transparency, as well as individual symptoms of rhinitis.

В развитии арахноидита наряду с инфекционным началом существенную роль играет аутосенсибилизация организма к продуктам распада тканей мозга и его оболочек, что обусловливает пролиферативный характер и вялое, но прогрессирующее течение воспалительного процесса.

Патоморфологические изменения при арахноидите определяются как пролиферативно-экссудативный процесс. В результате развиваются два основных морфологических варианта арахноидита (слипчивый и кистозный), приводящие к нарушению нормальной циркуляции цереброспинальной жидкости, выраженному в той или иной мере.

The clinical picture of arachnoiditis depends on the localization of the process and the degree of its prevalence. Basal rhinogenic arachnoiditis, localized in the anterior cranial fossa, proceeds without significant focal symptoms and therefore is not always recognized. Patients complain of constant headache in the forehead and bridge of the nose, which is accompanied by a feeling of slight dizziness, especially when tilting the head. The headache is aggravated by nasal congestion, coughing, prolonged physical, mental and visual stress, often when reading.

A characteristic of basal rhinogenic arachnoiditis is the appearance of a sensation of pain in the eyes when the eyeballs are moved upward, which indicates reflex irritation of the meninges.

Localization of basal arachnoiditis in the region of the optic chiasm and chiasmal cistern of the brain leads to the development of optochiasmal arachnoiditis.

Optochiasmal arachnoiditis is the most unfavorable variant of basal arachnoiditis. The clinical picture is dominated by visual disturbances. A progressive decrease in visual acuity is combined with a concentric narrowing of the visual fields, the appearance of cattle, often central, and a violation of color vision.

Arachnoiditis of the convex surface of the brain is usually localized in the region of the Sylvian furrow. In his clinical picture, the main place is occupied by epileptic seizures, as well as mono- and hemiparesis. Arachnoiditis of the posterior cranial fossa is characterized by hypertensive syndrome, which is manifested by attacks of headache, vomiting, dizziness.

Treatment of patients suffering from rhinogenic arachnoiditis should be comprehensive, including surgical debridement of all affected paranasal sinuses, as well as massive anti-inflammatory, hyposensitizing and dehydration therapy. Sanitizing surgery (polysinusotomy) is best done as early as possible.

41. Extradural and subdural abscesses

Extradural and subdural abscesses - limited purulent inflammation of the dura mater.

Extradural abscess, as a rule, occurs when the infection spreads by contact as a result of osteoperiostitis and carious process in the wall of the paranasal sinuses, for example, in chronic frontal sinusitis, less often in ethmoiditis and sphenoiditis. Initially, there is inflammation of a limited area of the outer layer of the dura mater, which acquires a purulent or necrotic character. Gradually, with the development of the process, an abscess is formed, located between the bone and the dura mater, limited by adhesions and granulations. Depending on the localization of the purulent focus, an extradural abscess can be in the anterior (with frontal sinusitis and ethmoiditis) and in the middle (with sphenoiditis) cranial fossae. The main symptom of an extradural abscess is headache, which can be regarded as an exacerbation of sinusitis. Sometimes an extradural abscess is asymptomatic and is an incidental finding during surgery on the affected paranasal sinus, which is explained by the free emptying of the abscess through a fistula that opens into the sinus.

If the emptying of the abscess is difficult, it gradually increases in size, which can lead to the appearance of symptoms characteristic of a volumetric process and associated with an increase in intracranial pressure: headache, nausea and vomiting unrelated to food intake, congestive optic nerve papilla on the side of the lesion, and also bradycardia.

With an extradural abscess, a violation of the sense of smell is possible, as well as a violation of the function of the cranial nerves.

Субдуральный абсцесс возникает как осложнение острых или обострившихся хронических синуситов. Он может развиваться в результате распространения экстрадурального абсцесса через твердую мозговую оболочку либо при гематогенном распространении воспалительного процесса. Образующийся в субдуральном пространстве абсцесс ограничивается слабым демаркационным валом, состоящим из спаек паутинной оболочки, соединительно-тканных и глиальных элементов. Обычный исход такого абсцесса при отсутствии лечения - распространение инфекции по поверхности мозговых оболочек с развитием разлитого лептоменингита или же инфицирование тканей мозга с развитием внутримозгового абсцесса. Субдуральный абсцесс протекает не столь бессимптомно, как экстрадуральный. Выраженность симптомов зависит от степени барьеризации процесса. К симптомам повышения внутричерепного давления присоединяются признаки поражения мозговых оболочек и вещества мозга.

Treatment of extra- and subdural abscesses is surgical. A wide opening of the affected paranasal sinuses is performed by external access to expose the dura mater within healthy tissues. The discovered abscess is drained. Active antibiotic therapy is carried out.

42. Sinus thrombosis

Sinus thrombosis. The transition of the inflammatory process to the wall of the venous sinuses leads to the development of sinus phlebitis with their subsequent thrombosis.

Sinus thrombosis of the cavernous sinus most often develops with furuncle and carbuncle of the nose, diseases of the sphenoid sinus and posterior ethmoid cells, as well as with intracranial complications.

Синус-тромбоз проявляется симптомами общесептического характера: интермиттирующей лихорадкой с потрясающими ознобами и проливными потами при общем крайне тяжелом состоянии больного. Опасность представляет попадание в малый, а затем и в большой круги кровообращения кусочков инфицированного тромба. В результате возможно метастазирование гнойного процесса и появление новых гнойных очагов в различных органах.

In addition to general septic symptoms, thrombosis of the cavernous sinus is characterized by local, ocular symptoms caused by impaired circulation of the ophthalmic veins. They can be bilateral, but are most pronounced on the side of the lesion. Eye symptoms are manifested by exophthalmos, swelling of the eyelids and conjunctiva in the form of increasing chemosis, loss of corneal reflexes. Due to the inflammatory focus of the orbital tissue and paresis of the oculomotor nerves, the movement of the eyeball becomes limited or impossible. Violation of the blood supply to the optic nerve and retina leads to optic neuritis and blindness.

A distinctive feature of sinus thrombosis from orbital phlegmon, which manifests itself with similar symptoms, is the absence of pain with pressure on the eyeball. With sinus thrombosis, bilateral changes in the tissues of the orbit are also possible as a result of the spread of thrombosis to the other half of the sinus. Often, thrombosis of the cavernous sinus is complicated by purulent meningitis, meningoencephalitis.

Тромбоз верхнего продольного синуса является гораздо более редким осложнением. Как и при всяком синус-тромбозе, заболевание верхнего продольного синуса проявляется общесептическими симптомами. Из общемозговых симптомов у больных отмечаются головная боль, спутанность или потеря сознания, присутствует менингиальный синдром. Местные признаки заболевания проявляются отечностью мягких тканей лба и темени. Тромбоз верхнего продольного синуса, так же как и тромбоз кавернозного синуса, может осложниться менингитом, менин-гоэнцефалитом, абсцессом мозга, а также абсцессом мозжечка, что затрудняет диагностику и усугубляет прогноз заболевания.

Treatment of sinus thrombosis requires not only antibiotic therapy and surgical sanitation of the affected paranasal sinuses, but also the active use of anticoagulants.

Antibiotics are administered intramuscularly, intravenously and intraarterially (preferably three types of antibiotics). For their endovascular administration, the superficial temporal artery and subclavian vein are usually catheterized.

43. Nonspecific angina

Nonspecific angina - catarrhal, when only the mucous membrane of the tonsils is affected, follicular - purulent damage to the follicles, lacunar - pus accumulates in the lacunae. It is usually caused by group A streptococcus. However, there are pneumococcal tonsillitis, staphylococcal tonsillitis and tonsillitis, in the etiology of which lies mixed coccal flora.

Catarrhal angina affects the mucous membrane of the tonsils and arches, while hyperemia of these parts of the pharynx is noted, but there are no raids. The patient notes pain when swallowing, burning in the pharynx. Has a bacterial or viral etiology. The temperature is subfebrile, fever is less common. Regional lymph nodes may be moderately enlarged. The disease lasts 3-5 days. Treatment - rinsing with soda, sage, lubricating the tonsils with iodine-glycerin, ingestion of aspirin.

Follicular and lacunar tonsillitis are caused by the same pathogens and are similar both in clinical course and in the general reaction of the body and possible complications. The difference lies in the different form of raids on the tonsils. With follicular angina, suppuration of the follicles occurs, and dead white blood cells shine through the mucous membrane. With lacunar angina, inflammation begins with lacunae, where pus accumulates, then protruding from the lacunae to the surface of the tonsils. After 1-2 days, raids spread over the entire surface of the tonsils, and it is no longer possible to distinguish between two types of tonsillitis. Patients feel severe pain when swallowing, discomfort in the throat, refuse food. The cervical lymph nodes are sharply enlarged, the temperature rises to 39 and even 40 ° C.

Treatment of follicular and lacunar tonsillitis consists in rinsing the pharynx, a cervical semi-alcohol compress, prescribing analgesics, desensitizers (diphenhydramine, suprastin, tavegil), and broad-spectrum antibiotics intramuscularly. Patients are recommended a sparing diet.

Angina, caused by adenoviruses, proceeds in the form of diffuse acute pharyngitis, although it can also be accompanied by raids on the tonsils. Typical for adenovirus infection is a widespread lesion of the lymph nodes and a very frequent combination with conjunctivitis.

Acute inflammation of the tonsils of another localization. Angina of the lingual tonsil has characteristic symptoms - pain in the region of the deep pharynx, which increases sharply when you try to protrude the tongue. The diagnosis is made by indirect laryngoscopy using a laryngeal mirror.

Angina of the nasopharyngeal tonsil. Pain is localized in the nasopharynx, a thick mucous discharge is released from the nose, an acute runny nose is noted. With posterior rhinoscopy, an edematous tonsil of a cyanotic color is visible, sometimes with raids, thick mucus flows down the back of the pharynx.

44. Angina as a syndrome of common infectious diseases

Ангина при скарлатине может протекать по-разному. Чаще всего это ангина катаральная и лакунарная. При классическом течении скарлатины отмечаются характерная краснота мягкого неба в окружности зева, нераспространяющаяся за пределы мягкого неба, набухание шейных лимфатических желез и беловатый густой налет на языке с последующим его очищением, когда язык принимает яркую окраску.

There are severe forms of scarlet fever, occurring in the form of:

1) pseudo-membranous angina with the formation of a fibrinous exudate widespread on the mucous membrane of the tonsils, pharynx, nasopharynx and even cheeks in the form of a thick grayish film tightly soldered to the underlying tissue;

2) ulcerative necrotic angina, characterized by the appearance of grayish spots on the mucous membrane, quickly turning into ulcers. There may be deep ulceration with the formation of persistent defects of the soft palate.

3) gangrenous tonsillitis, which is rare. The process begins with the appearance of a dirty gray plaque on the tonsils, followed by deep tissue destruction up to the carotid arteries. Angina with diphtheria can occur in various clinical forms. With diphtheria, plaques go beyond the arches. For angina, the pathognomonic is the strict border of the distribution of raids within the tonsils.

Angina with measles proceeds under the mask of catarrh in the prodromal period and during the rash.

Во втором случае диагноз кори не вызывает затруднений, в продромальном периоде необходимо следить за появлением коревой энантемы в виде красных пятен на слизистой оболочке твердого неба, а также пятен Филатова-Коплика на внутренней поверхности щек у отверстия стенонова протока.

Angina with influenza proceeds in the same way as catarrhal, however, diffuse hyperemia captures the tonsils, arches, tongue, back wall of the pharynx.

Erysipelas is a serious disease that often occurs along with facial erysipelas. It starts with a high temperature and is accompanied by severe pain when swallowing. The mucosa is colored bright red with sharply defined reddening borders, it seems varnished due to edema.

Angina with tularemia begins acutely - with chills, general weakness, reddening of the face, enlargement of the spleen. Angina with tularemia in most cases occurs when infected by the alimentary route - when drinking water, food after an incubation period of 6-8 days in an infected patient. Another differential diagnostic sign is the formation of buboes - packets of lymph nodes in the neck, sometimes reaching the size of a chicken egg.

45. Angina in blood diseases

Моноцитарная ангина (инфекционный мононуклеоз или болезнь Филатова) может клинически протекать разнообразно - от катаральной до язвенно-некротической. Клинически: увеличение печени и селезенки (гепатолиенальный синдром), наличие уплотненных и болезненных на ощупь лимфатических узлов. Патогномоничным симптомом является появление в периферической крови атипичных мононуклеарных клеток.

Agranulocytic angina is associated with the complete or almost complete disappearance of granulocytes in the peripheral blood with the preservation of monocytes and lymphocytes against the background of severe leukopenia. The clinical picture is usually severe and consists of symptoms of acute sepsis and necrotic tonsillitis, since the microbes that inhabit the pharynx belong to the opportunistic flora and, when the leukocyte protection is turned off and other adverse circumstances, they become pathogenic and penetrate the tissues and blood. The disease is severe, with high fever, stomatitis, gingivitis, esophagitis. The liver is enlarged. The diagnosis is made on the basis of a blood test: severe leukopenia, below 1000 leukocytes per 1 mm3 of blood, absence of granulocytes. The prognosis is serious due to the development of sepsis, laryngeal edema, necrosis of the tissues of the pharynx with severe bleeding. Treatment consists of the fight against a secondary infection - the appointment of antibiotics, vitamins, care for the pharynx, intravenous transfusion of leukocyte mass.

Алиментарно-токсическая алейкия характерна тем, что в отличие от агранулоцитоза, когда из периферической крови исчезают только гранулоциты (нейтрофилы, эозинофилы), исчезновение касается всех форм лейкоцитов.

From the side of the pharynx, necrotic sore throat is pronounced, when the tonsils look like gray dirty rags, and a sharp, nauseating smell is released from the mouth. The number of leukocytes in the peripheral blood is up to 1000 or less, while granular leukocytes are completely absent. Characterized by high fever, the appearance of a hemorrhagic rash. Treatment at an early stage consists of gastric lavage, enemas, the appointment of a laxative, a sparing diet, intravenous infusions of saline with vitamins, hormones, glucose, blood transfusion, leukocyte mass. In the stage of angina and necrosis, antibiotics are prescribed.

Ангины при острых лейкозах протекают с различной степенью тяжести в зависимости от стадии лейкоза. Начало заболевания ангины (как правило, катаральной) протекает относительно благоприятно, начинается на фоне видимого благополучия, и только анализ крови позволяет на этой ранней стадии заболевания заподозрить острый лейкоз, что еще раз доказывает обязательное исследование крови при ангинах. Ангины при развившихся лейкозах, когда число лейкоцитов крови достигают 20 000 и более, а количество эритроцитов падает до 1-2 млн., ангина протекает крайне тяжело в виде язвенно-некротической и гангренозной формы с высокой лихорадкой и тяжелым общим состоянием.

46. Angina with infectious granulomas and specific pathogens

Tuberculosis of the pharynx can occur in two forms - acute and chronic. In the acute form, hyperemia is characteristic with a thickening of the mucous membrane of the arches, soft palate, tongue, resembling a sore throat, body temperature can reach 38 ° C.

Of the chronic forms of tuberculosis, it is more often ulcerative, developing from infiltrations, often proceeding without symptoms. The edges of the ulcer are raised above the surface, the bottom is covered with a gray coating, after its removal, juicy granulations are found. Most often, ulcers are observed on the back of the pharynx. The treatment of tuberculosis of the pharynx, as well as its other forms, has become relatively successful after the advent of streptomycin, which is administered intramuscularly at 1 g per day for an average of 3 weeks.

Syphilis of the throat. Primary syphilis most often affects the palatine tonsils. Hard chancre is usually painless. Usually, on a red limited background of the upper part of the tonsils, a solid infiltrate is formed, then erosion, turning into an ulcer, its surface has a cartilaginous density.

Secondary syphilis appears 2-6 months after infection in the form of erythema, papules. Erythema in the pharynx captures the soft palate, arches, tonsils, lips, surface of the cheeks, tongue. The diagnosis of syphilis at this stage is difficult until the appearance of papules from a lentil grain to a bean, their surface is covered with a touch of greasy sheen, the circumference is hyperemic.

The tertiary period of syphilis manifests itself in the form of gumma, which occurs, as a rule, several years after the onset of the disease. More often, gummas are formed on the back of the pharynx and soft palate. First, limited infiltration appears against the background of bright hyperemia of the pharyngeal mucosa.

Fusospirochetosis. The etiological factor is the symbiosis of the spindle-shaped rod and spirochete in the oral cavity. A characteristic manifestation of the disease is the appearance of erosions on the surface of the palatine tonsils, covered with a grayish, easily removable coating. The ulcer progresses, and only after 2-3 weeks do mild pains appear when swallowing. With pharyngoscopy during this period, a deep ulcer of the tonsil is found, covered with a gray fetid plaque, easily removed.

The best treatment is a plentiful lubrication of the ulcer with a 10% solution of copper sulphate 2 times a day.

Кандидомикоз глотки вызывается дрожжеподобными грибами. Возникают боли в горле, лихорадка, на фоне гиперемии слизистой оболочки глотки появляются мелкие белые налеты с дальнейшим обширным некрозом эпителия миндалин, дужек, неба, задней стенки глотки в виде сероватых налетов, после удаления которых остается эрозия. Лечение предусматривает обязательную отмену всех антибиотиков, ирригацию глотки слабым содовым раствором, смазывание очагов поражения раствором Люголя на глицерине.

47. Peritonsillary abscess

Between the capsule of the tonsil and the pharyngeal fascia is paratonsillar tissue, and behind the pharyngeal fascia, laterally, is the fiber of the parapharyngeal space. These spaces are filled with fiber, the inflammation of which, and in the final stage - and abscess formation determine the clinic of the named disease. An abscess is most often caused by nonspecific flora as a result of a tonsillogenic spread of infection.

The disease begins acutely, with the appearance of pain when swallowing, often on one side. Usually, a paratonsillar abscess occurs after suffering a sore throat during the recovery period. When examining the pharynx, there is a sharp swelling and hyperemia of the tissues around the tonsil, protrusion of the tonsil from the niche, and displacement to the midline. An abscess is formed on average about 2 days. Common symptoms are weakness, fever, enlargement of the cervical lymph nodes on the side of the abscess. The classic triad of paratonsillar abscess was noted: profuse salivation, trismus of masticatory muscles and open nasality. Combined treatment of abscesses is prescribed: antibiotics intramuscularly, taking into account pain when swallowing and forced fasting, aspirin, analgesics, a half-alcohol compress on the side of the neck (on the side of the abscess), antihistamines. Simultaneously, surgical treatment is carried out.

There are anteroposterior abscesses (pus accumulates behind the anterior arch and soft palate near the upper pole of the tonsil), posterior (with accumulation of pus in the region of the posterior arch), external (accumulation of pus between the tonsil capsule and pharyngeal fascia). Anesthesia, as a rule, is local - lubrication of the mucous membrane with a 5% solution of cocaine or a 2% solution of dicaine. A napkin is wound around the scalpel in such a way that the tip protrudes no more than 2 mm, otherwise the main vessels of the carotid pool can be injured. An incision is made with an anterior abscess strictly in the sagittal plane at the middle of the distance from the posterior molar to the tongue, then a blunt probe or a hemostatic clamp (Holsted) is inserted into the incision and the edges of the incision are separated.

При удалении гноя состояние больного, как правило, значительно улучшается. Через сутки края разреза вновь разводят зажимом для удаления скопившегося гноя. Таким же образом производится вскрытие заднего абсцесса через заднюю дужку. Труднее и опаснее вскрытие наружного абсцесса, который залегает глубже и требует большей осторожности ввиду опасности ранения сосудов. После любого разреза в глотке производится полоскание фурацилином. Очень редко встречается заглоточный абсцесс - скопление гноя в области задней стенки глотки. У детей это связано с наличием лимфатических узлов в ретрофарингеальном пространстве, у взрослых- как продолжение наружного паратонзиллярного абсцесса.

48. Hypertrophy of the tonsils

Adenoids

In children, there is a tendency to hypertrophy of the tonsils of the pharynx, especially the nasopharyngeal (the so-called adenoids). During puberty, the tonsils usually atrophy, with the exception of the palatine tonsils. The clinic and symptoms of adenoids are due to their special location on the vault of the nasopharynx, therefore they impede or completely exclude nasal breathing, ventilation of the auditory tubes, disrupt the function of the pharynx, which has an extremely adverse effect on the overall development of the child's body. This condition is characterized by a change in facial features, an open mouth, thickening of the wings of the nose, abnormal development of the dental system, sleep disturbance, coughing fits, a tendency to tonsillitis, otitis media, and pneumonia. V. I. Voyachek suggested that if adenoids are suspected, anterior rhinoscopy should be performed, while the adenoids are quite clearly visible, and when the patient pronounces the number "3", the soft palate moves to determine the lower border of the adenoids. The doctor stands behind the sitting child, fixes the head with his left hand, pressing it to himself, and examines the nasopharynx with the index finger of his right hand. The amount of hypertrophy is determined by III degrees.

I degree - to the upper edge of the vomer.

II degree - to medium turbinates.

III degree - to the lower shells and below. Conservative treatment of adenoids with various oils, 0,25% silver nitrate solution, ultraviolet or laser beam therapy rarely gives a lasting therapeutic effect. The adenotomy operation is more effective, especially with concomitant pathology of the ENT organs or lungs. It is performed more often under local application anesthesia by lubricating the nasopharynx with a special cotton brush on a probe - a cotton holder. An assistant holds the child, pre-wrapped in handsheets, on his lap. The surgeon presses the tongue with a spatula and carefully inserts the adenoid behind the soft palate into the nasopharynx under visual control, gently resting against the vault, then removes the adenoids with a quick sliding circular motion of the adenoid.

Hypertrophy of the palatine tonsils

Гипертрофия небных миндалин встречается у детей реже. Различают III степени гипертрофии в зависимости от сужения зева.

I degree - narrowing by 1/3.

II degree - narrowing by 2/3.

III degree - the tonsils are in contact along the midline.

Enlargement of the tonsils is accompanied by coughing, choking, nasal voice, increased gag reflex, and in combination with chronic tonsillitis - frequent tonsillitis. Treatment is operative. Under local anesthesia, parts of the tonsils protruding beyond the arches are cut off with a special tonsillotome. There are practically no complications.

49. Chronic inflammatory diseases

Chronic pharyngitis

Inflammation of the mucous membrane of the pharynx is sluggish, manifested by an intermittent sensation of pain, dryness and discomfort in the pharynx, and rapid fatigue of the voice. When examining the pharynx, flaccid hyperemia, moderate dryness of the mucous membrane are noted, on the back wall - often thick mucus.

Hypertrophic pharyngitis is characterized by an increase in granules on the back of the pharynx to the size of a lentil grain (granular pharyngitis) or lateral ridges (lateral pharyngitis).

atrophic pharyngitis. The mucous membrane of the pharynx is pale, thinned, looks like varnished, palatine tonsils, as a rule, are also atrophic. Manifested by constant dryness in the throat, perspiration, rarely pain, fatigue.

Chronic tonsillitis

Chronic tonsillitis is a chronic inflammation of the palatine tonsils; if other tonsils are affected, localization is indicated - chronic adenoiditis, tonsillitis of the lingual tonsil. According to the classification, two forms of chronic tonsillitis are distinguished: compensated and decompensated. Objective symptoms are of a non-permanent nature: soldering of the arches with the tonsils, their swelling, thickening, hyperemia. Two symptoms are more reliable - the presence of caseous plugs in the lacunae and an increase in regional (anterior cervical) lymph nodes. Exacerbation of chronic tonsillitis always proceeds in the form of a sore throat.

Conservative treatment: antibiotics, sulfonamides, desensitizing drugs, inhalation, hormonal therapy, special mixtures (mephiditis, anginol), washing the lacunae of the tonsils with a thin cannula on a syringe with saline or an antibiotic, irradiating the tonsils with ultraviolet rays (the so-called tube quartz), laser irradiation of the tonsils.

Tonsillectomy is performed mainly under local, less often under general anesthesia. The arches of one of the tonsils, the back wall of the pharynx, the root of the tongue are lubricated with a 2% solution of dicaine or a 5% solution of cocaine, then in the region of the anterior arch along the transitional fold, three injections are made with a 1% solution of novocaine at the poles of the tonsils and in the middle between them , lateral to the tonsil capsule into the paratonsillar space. The incision is made with a scalpel along the transitional fold at the upper pole, then the upper pole is detached with a special raspator, separated from the arches and separated with a capsule in the paratonsillar space. The lower pole is cut off with a special loop. Bleeding during the detachment of the tonsil and then stops with gauze cotton balls, pressing them to the tonsil niche with a clamp.

50. Foreign bodies and damage to the pharynx

Foreign bodies, which are a variety of objects, enter the pharynx when breathing or swallowing. The outcomes of a foreign body in the pharynx are different: it can be coughed up, thrown out with exhalation, spit out, lie freely in the pharynx without injuring the mucous membrane, move further and become a foreign body of the larynx, trachea and bronchi, esophagus.

Small piercing foreign bodies, such as thin fish bones, often pierce the palatine tonsils, are visible with pharyngoscopy, and are usually easily removed with forceps. It is more difficult when removing foreign bodies from the laryngopharynx using indirect laryngoscopy and laryngeal forceps, and if this fails, then with direct laryngoscopy. If the foreign body is injurious at the same time, then emphysema and edema of the prevertebral cellular space occur, then such a severe complication as mediastinitis may develop. In addition, as a result of edema, an overhang of the posterior pharyngeal wall occurs, making it difficult to examine the laryngopharynx and manipulate in this area. Large foreign bodies get stuck in the oropharynx during the act of swallowing, because they cannot slide into the esophagus from the epiglottis, which at this time closes the entrance to the larynx. If such a foreign body is not able to expectorate the patient with a strong exhalation or vomiting, loss of consciousness and death may occur.

Wounds of the pharynx distinguish between internal and external. Internal injuries are associated, as a rule, with foreign bodies or random objects (more often in children). Tactics of treatment - removal of a foreign body, anti-inflammatory therapy, sparing diet. External injuries of the pharynx occur with incised, stab or gunshot wounds of the face and neck and differ in a variety of symptoms and degrees of severity depending on the location of the wound and the course of the wound channel, which determine damage to other organs of the neck, large vessels, and spine. In the diagnosis of damage to the pharynx, in addition to pharyngoscopy, external examination, radiography is of great importance for determining foreign bodies and damage to the spine. Therapeutic measures must begin with stopping the bleeding. Here, tamponade of the nasopharynx can be successfully applied in case of bleeding from it or tamponade through the wound channel. If necessary, they also ligate the main vessels - the external and even the common carotid arteries.

Another vital issue is the provision of respiratory function, which can be impaired both by the injury itself and its consequences (hematoma, edema, inflammation). Here, decongestant therapy can be applied, and if necessary, a tracheotomy.

After hemostasis and restoration of breathing, it is necessary to treat neck wounds, remove damaging accessible foreign bodies. The patient's nutrition should also be provided by a doctor, since most often such injuries require the insertion of a probe into the esophagus.

51. Anomalies in the development of the pharynx. Foreign bodies of the larynx

Anomalies in the development of the pharynx are quite rare. First of all, this is the non-closure of the soft palate, which leads to a violation of the function of swallowing (the ingress of food and liquid into the nasopharynx and nasal cavity) and the function of speech (open nasality). On examination, a sagittal cleft of the soft palate is determined in the middle of it, often the tongue is absent or, conversely, bifurcated. The treatment of this anomaly is surgical - plastic surgery of the soft palate.

Другая аномалия развития связана с незаращением второй жаберной щели и образованием разветвляющегося канала, ведущего из надминдаликовой ямки в глубь мягкого неба. Такой канал имеет определенное значение в патогенезе паратонзиллярных абсцессов.

Третья разновидность аномалий связана с незаращением эмбриональных каналов и возможным образованием у взрослых лиц срединных и боковых свищей (кист) шеи. Эти каналы берут начало в глотке и простираются в нижние отделы шеи. Средний канал - от корня языка через тело подъязычной кости к щитовидной железе. Он при незаращении и образует срединную кисту шеи. Другой канал берет начало в грушевидном синусе гортаноглотки и опускается вниз вдоль кивательной мышцы, из него может образоваться боковая киста шеи. Обе кисты могут проявить себя после перенесенной инфекции или травмы шеи, когда появляется опухолевидное образование, безболезненное, подвижное, постепенно увеличивающееся в размерах. Далее оно, как правило, нагнаивается и опорожняется через свищ на коже.

Treatment of this pathology is surgical - removal of cysts of the neck, in the case of a median cyst, resection of the body of the hyoid bone is required, otherwise there may be relapses.

Objects that can be foreign bodies of the larynx are very diverse. They can lie freely or be introduced into the soft tissues of the larynx.

Имеются отличия в клинике инородных тел в зависимости от их локализации. Инородные тела верхнего этажа гортани, включая вестибулярные складки и морганиев желудочек, главным образом приводят к отеку слизистой оболочки, явления стеноза здесь редки, только в случае развития гортанной ангины. Инородное тело, находясь на уровне голосовой щели, может привести к острому стенозу из-за спазма голосовых мышц и смыкания голосовых складок. Исходом инородного тела гортани, как и глотки, может быть естественное отторжение в результате кашля, рвотных движений или резкого выдоха, а при необходимости - с помощью непрямой или прямой ларингоскопии. В других случаях инородное тело проглатывается при попадании в пищевод или проникает в трахею, бронхи. В этом случае может наступить смерть в результате асфиксии.

If a foreign body has fallen into the trachea, then the immediate danger of asphyxia, as a rule, does not arise. The danger lies in the possible blockage of the pulmonary or lobar bronchi, followed by atelectasis of the lung. Foreign bodies of the trachea and bronchi are removed by tracheobronchoscopy.

52. Acute laryngitis

Acute laryngitis is an inflammation of the mucous membrane of the larynx, which, as a rule, is affected a second time in acute respiratory infections, is less often an independent disease, while there is always inflammation of the mucous membrane of the trachea. In the first place are the defeat of the voice (dysphonia or aphonia), perspiration and burning in the larynx, cough, fever. On examination - hyperemia of the mucous membrane of the vocal folds, other parts of the larynx, sometimes - mucus in the folds. Dysphonia is explained by swelling of the mucous membrane of the folds, swelling of the tissues of the blinking ventricles, which disrupts the free oscillations of the folds. Aphonia occurs with paresis of the vocal muscle, the glottis does not close completely, taking an oval shape during phonation. With influenza, hemorrhagic laryngitis is observed when hemorrhages occur under the mucous membrane of the vocal folds. The main method of treating acute laryngitis is inhalation: alkaline, alkaline-oil, inhalations with an individual inhaler (for example, Bioparox), according to indications, analgesics, antihistamines, vitamins are prescribed, rarely antibiotics. Not bad help phonophoresis with hydrocortisone on the larynx or electrophoresis with potassium iodide, especially with aphonia. The infusion of various medicinal mixtures is also used with the help of a laryngeal syringe, which has a special long curved tip. For example, sea buckthorn oil, menthol oil and an alkaline mixture for inhalation are taken in equal parts.

Subglottic laryngitis (false croup). This type of acute laryngitis usually affects children. These features are explained by the structure of the larynx in children - the presence of loose fiber between the cricoid and thyroid cartilages outward from the mucous membrane of the larynx, which disappears with the growth of the larynx during puberty. This fiber is characterized by rapid (20-30 minutes) swelling with inflammation of the larynx, which occurs most often at night when the child is in a horizontal position. At the same time, the child wakes up in fear, rushes about, cries, stridor breathing appears, with a clear voice - a "barking" cough. When examining the larynx, there are, as it were, three floors of folds - vocal, vestibular, and below - swelling of the subglottic space in the form of third folds. During an attack of false croup, the child should be immediately picked up, giving him a vertical position, lower his legs into a hot bath (42-45 ° C), inhalation of a mixture of hydrocortisone and galazolin, mustard plaster on the chest, inside - antihistamines. Inspection of the pharynx and larynx is necessary, although laryngoscopy in children is extremely difficult and sometimes fails. By itself, false croup is not dangerous, an attack sometimes goes away even without treatment when the patient is in an upright position. Enlarged cervical lymph nodes, a hoarse voice, and epidemiological data speak in favor of diphtheria.

53. Throat throat

Throat angina (submucosal laryngitis). The disease is more often caused by vulgar flora with mechanical and thermal injuries, or with the transition of purulent processes from the tonsils, with pharyngeal processes. Laryngeal angina has three forms: such as inflammatory edema, laryngeal abscess, phlegmon of the larynx.

При отеке гортани общее состояние нарушено мало. При ларингоскопии обнаруживаются участки стекловидного отека, чаще в области надгортанника и (или) черпаловидных хрящей. Глотание не затруднено, умеренно болезненно, дыхание свободное. Однако при резком отеке могут быть умеренные нарушения голоса и дыхания. Своевременная терапия дает хороший эффект. Рекомендуются аспирин, антигистаминные препараты, согревающий компресс на шею, дегидратационная терапия, например внутривенные вливания (преднизолон - 30 мг, 5 %-ный раствор аскорбиновой кислоты - 5 мл, раствор панангина, физраствор - 400 мл, лазикс - 1,5-2 мл). Эффект от лечения обычно наступает быстро, прогноз благоприятный.

Abscess of the larynx. Symptoms are similar to the previous disease, but much more pronounced. With laryngoscopy, one can see not only the epiglottis and arytenoid cartilages, but also the spread of edema to the vallecules, piriform sinuses. Salivation and aphonia are noted due to severe pain in swallowing and voice formation. After 3-4 days from the onset of the disease, the formed abscess spontaneously opens, relief comes. Otherwise, the abscess is opened with a special laryngeal knife.

Флегмона гортани - заболевание очень тяжелое и относительно редкое. Процесс охватывает подслизистую ткань всей гортани. На фоне резкой лихорадки наблюдается расстройство глотания из-за непереносимых болей. При ларингоскопии определяются инфильтрация и гиперемия всех стенок гортани. В различных местах могут вскрываться гнойные очаги с выделением густого темного (геморрагического) гноя. Лихорадка протекает с высокой температурой, ей может сопутствовать обезвоживание из-за невозможности глотания, поэтому такие больные требуют парентерального питания и введения солевых растворов (например, бисоли, трисоли). Из-за угрозы асфиксии требуется ранняя трахеотомия. Противовоспалительное лечение интенсивное: большие дозы современных антибиотиков, гормоны, антигистаминные препараты, анальгетики. Летальные исходы редки, однако часто наступает инвалидизация в виде афонии, рубцовых стенозов гортани, требующих затем оперативных вмешательств, поскольку наряду с другими факторами (специфическими инфекциями, травмами, инородными телами) флегмона гортани может быть причиной хондроперихондрита хрящей гортани. Наряду с травмой (тупой, острой, огнестрельной) частой причиной стало длительное пребывание в гортани интубационной трубки (более 3-5 суток) для ИВЛ. Результат - стойкие стенозы гортани, требующие хирургического лечения.

54. Chronic laryngitis

The picture of chronic catarrhal laryngitis is similar to acute, but their symptoms can be smoothed out. They, as a rule, are combined with chronic pharyngitis, the course is undulating. Causes - chronic inflammatory diseases of the trachea, bronchi, lungs, sinusitis, vasomotor rhinitis, adverse environmental factors (frequent or constant cooling, impurities in the air, alcohol abuse). In 100% of smokers, the larynx is affected (smoker's laryngitis), but passive smoking (presence in a smoky room) is also quite harmful. Chronic laryngitis is expressed in persistent dysphonia, fatigue of the voice, its hoarseness, coarsening (the voice of a smoker). A kind of chronic laryngitis - atrophic, occurring with lakes, pharyngopathy; blanching and thinning of the mucous membrane are noted. Treatment is the same as for acute laryngitis, but preventive measures are of decisive importance: refusal of cold food and drink, bad habits, elimination of unfavorable factors of work and life, treatment of lung diseases.

Hypertrophic laryngitis is diffuse and (more often) limited. When diffuse, the vocal folds are not only enlarged, but also covered by enlarged vestibular folds, which close during phonation, forming a kind of voice timbre ("dog's voice").

Limited hypertrophic laryngitis is more common.

1. Nodules of singers. Occurs with improper use of the voice, very often found in singers with an incorrectly delivered voice (hence the name), actors, lecturers, teachers and anyone who overloads the vocal apparatus. There is an overgrowth of the epithelium and connective tissue on the border of the middle and posterior thirds of the vocal folds, no larger than a millet grain. The glottis does not close completely.

2. Pachydermia - limited outgrowths in the form of nodules and tubercles in the posterior parts of the vocal folds or in the interarytenoid space.

3. Subglottic laryngitis - a symmetrical thickening in the subglottic space (as with false croup) without signs of suffocation, but only with a change in the timbre and sonority of the voice.

4. Prolapse of the Morganian ventricle - it can be one- and two-sided, when a roller is visible between the vestibular and vocal folds, sometimes obscuring the latter for inspection.

Prevention and treatment are the same as for the forms of chronic laryngitis described above.

55. Stenosis of the larynx

Stenosis of the larynx and trachea lead to severe respiratory disorders (up to death from asphyxia).

Острые стенозы возникают чаще всего в результате отека клетчатки в области вестибюля гортани, морганиевого синуса, а у детей - и подскладкового пространства, реже - из-за инородного тела. Гортанная ангина (подслизистый ларингит) - заболевание, при котором очень быстро начинается отек вестибюля гортани, именно здесь и расположена миндалина Воячека. Отек может нарастать очень быстро: от нескольких часов до 2-3 суток и даже приводить к внезапной асфиксии. Ложный круп (подскладковый ларингит) бывает только у детей, поскольку у них диаметр внутреннего полукольца щитовидного хряща гораздо больше перстня, и это пространство выполнено рыхлой клетчаткой. Отек здесь развивается в течение 15-30 мин, как правило, ночью во время сна, когда ребенок принимает горизонтальное положение. Истинный круп - дифтерия гортани - является второй причиной стеноза - инородным телом гортани, поскольку здесь образуются пленки в результате некроза слизистой оболочки, перекрывающие просвет гортани.

In the etiology of chronic stenosis of the larynx and trachea lie tumors of the larynx and trachea, trauma, infectious granulomas. With compensated chronic stenosis, tracheotomy is rarely done. A special kind of stenosis of the larynx occurs as a result of paralysis of the vocal folds (unilateral or bilateral) due to damage to the lower laryngeal (recurrent) nerves, especially often occurs during strumectomy (in 2,5-4% of operated patients), which is explained by the passage of the recurrent nerve through the thyroid gland.

There are conservative and surgical treatment of stenosis. The first includes the treatment of the underlying disease and the stenosis itself, as a rule, the parenteral use of drugs: diuretics, antihistamines, hormones. With fulminant stenosis, conicotomy is used - a horizontal dissection of the conical ligament connecting the thyroid and cricoid cartilages. Fulminant stenosis occurs when the larynx is blocked either at the level of the laryngopharynx, where a large foreign body gets stuck during swallowing and fixes the epiglottis in the lower position (they say - the person choked), or (more often in children) the foreign body enters the glottis, there is a spasm of the vocal folds in middle position.

Tracheotomy - the imposition of a stoma on the trachea in three classic places - between the 2nd and 3rd tracheal rings (upper), between the 3rd and 4th - middle, between the 5th and 6th - lower. In the first and third cases, the isthmus of the thyroid gland is displaced up or down, and in the second case, the isthmus is dissected. The technique of tracheotomy is simple - a skin incision is made from the edge of the thyroid cartilage down, not reaching the jugular notch. There is also a method of longitudinal section of two cartilages of the larynx (longitudinal tracheotomy) with the subsequent introduction of the tube.

56. Damage to the larynx

Injuries to the larynx are relatively rare. Distinguish between closed and open injuries, while closed are divided into internal and external. Internal injuries occur as a result of foreign bodies, medical manipulations (for example, tracheal intubation). External closed injuries - bruises, compression of the larynx, fractures of cartilage, hyoid bone, tears of the larynx from the trachea. The victim often loses consciousness, shock occurs, local hemorrhages, subcutaneous emphysema, which can be superficial, and if it spreads into the laryngopharyngeal tissue, there is a danger of asphyxia, in such cases a tracheotomy is required.

The prognosis for contusions of the larynx, especially with cartilage fractures, is always serious. The patient is in danger of strangulation not only due to stenosis of the larynx, but also possible tamponade of the trachea and bronchi with outflowing and gore blood, and in the following days mediastinitis may develop due to the penetration of infection there. Tracheotomy in such cases is necessary not only to restore breathing, but also to suck blood from the bronchial tree. Treatment of such patients is carried out exclusively in a hospital. If necessary, in case of significant crushing of the cartilage, a laryngofissure is performed to remove fragments, hemostasis. Patients are fed through a probe.

Cut damage to the larynx occurs when the neck is cut, usually in a horizontal plane (from ear to ear), while depending on the height of the cut, the thyroid-hyoid membrane or conical ligament is cut. In the first case, the wound gapes, the laryngopharynx is clearly visible, breathing is not disturbed, and with a low cut, breathing may be disturbed due to blood flow. The death of the wounded comes quickly only in the case of cutting the carotid arteries.

Stab wounds of the neck with damage to the larynx are applied with thin, narrow, long objects and leave a narrow channel, which, when the injuring object is removed, is blocked along its length by the fascia of the neck (coulis syndrome), which contributes to the formation of emphysema and the development of mediastinitis, so such a channel has to be dissected. With neck injuries of any origin, especially with damage to blood vessels and nerves, shock develops, which also requires adequate therapy.

Gunshot wounds of the larynx are most often combined, since other organs of the neck are also damaged. With penetrating wounds, a wounding projectile (bullet) pierces both walls of the larynx and goes beyond it, with a blind one, the bullet remains in the cavity of the larynx, moving further either into the pharynx or into the trachea. With a tangential wound, the bullet only hits the wall of the trachea without tearing it.

Emergency care includes providing breathing, stopping bleeding, treating a gunshot wound (if necessary, a laryngofissure), removing a foreign body (a wounding projectile), inserting a food probe.

Автор: Дроздов А.А., Дроздова М.В.

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