Exudative otitis media of middle ear symptoms and treatment

Causes of symptoms and treatment of exudative otitis media

One of the diseases of the middle ear is called exudative otitis media. The name of the disease is associated with fluid or exudate. The liquid enters the person's middle ear from the external environment and becomes an excellent medium for the development of bacterial infection. During development, the number of viruses in the exudate increases, the liquid begins to thicken and turns into pus. This becomes very dangerous for a person. In addition to suppuration, exudative otitis can cause a strong thickening of the liquid and the formation of a saline solution.

Exudative otitis media can develop as an independent disease, and may become a complication of other types of otitis, for example catarrhal. In the absence of treatment, exudative otitis can turn into a more serious form of the disease - purulent otitis.

In the middle ear of each person there is an insignificant amount of serous fluid, which, if properly functioning, must be discharged through the auditory tube. Exudative otitis occurs when the functioning of the auditory tube is broken, the ear gets an infection or the amount of fluid exceeds the norm.

This disease has several forms of flow: acute, subacute and chronic.

Causes of exudative otitis media

Violation of the patency of the auditory tube and increased allocation of serous fluid and mucus may occur for a number of reasons.

The main reason for the occurrence of exudative otitis in humans is the transmitted infectious diseases that cause the development of the viral and bacterial flora and its entry into the region inner ear.

Exudative otitis often occurs in the period of hypovitaminosis and low immunity of the population, which is observed at the end of winter and early spring. Reducing the natural defense of the body leads to the fact that bacteria can freely enter the human body, especially in the ears. Within a few weeks, the infection actively multiplies and "saturates" the serous middle ear fluid, after which the disease occurs.

Signs of exudative otitis may occur with mechanical damage to the middle ear. Inflammation can occur on the background of a punch, puncture or an object falling into the ear from the outside.Bacteria that were on the subject or got into the ear with trauma lead to a rapid development of the disease.In some cases, exudative otitis can develop when swimming in the pool, especially in an open water body. Therefore, it is not recommended to swim in rivers and lakes with frequent diseases of the ears and throat, with a cold, recently transferred infectious diseases and with reduced immunity.

According to statistics, children are more likely to suffer from ear infections than adults. This is due to the low resistance of the child's organism to various infections. Children often have various allergic reactions, they react more acutely to poor environmental conditions and a low standard of living.

Bilateral exudative otitis can develop against the background of adenovirus infection, which is accompanied by adenoids. Adenoids also explain the high incidence among children. Polyps in the nose become an ideal environment for the development of bacteria, in addition, adenoids overflow nasal passages and complicate the exudate. With allergic rhinitis and a permanently stuffed nose, the removal of adenoids can cause skidding infection in the middle ear, including its movement from the inflamed parts of the larynx, nose and tonsils. Exudative otitis media and adenoids should be treated in a comprehensive manner.

Symptoms of exudative otitis media

To diagnose this otitis at the very beginning of the disease is very difficult. The clinical picture is rather unclear, especially in a child who can not clearly explain what is happening to him.

The first symptoms of development of exudative otitis media:

• hearing loss, the emergence of deafness, during the initial stage of the disease this symptom is almost invisible;
• there is a feeling that the ear has laid;
• there is a sensation of "gurgling fluid in the auditory tube, amplified by turning, shaking the head, jumping;
• at visual inspection the tympanic membrane has a non-specific bluish color;
• when the disease develops, the fluid in the ear begins to thicken and forms a sticky exudate that does not flow from the auditory tube, but stretches with a thin thread;
• the obstruction of the ear causes an incorrect sound perception, first of all, of its own voice;
• there is nasal congestion and rhinitis;
• because of all the above symptoms in young children, there is a feeling of anxiety, they can sleep badly and eat.

If there is no treatment for the final stage of the disease, the fluid practically ceases to be excreted, exudative otitis becomes chronic, which is complicated by permanent hearing loss.

.

http://www.youtube.com/watc? = xfxoF5NPOpI

Chronic form of exudative otitis media

With chronic exudative otitis, the quality of hearing is significantly reduced in a person, the sounds change. At the same time, hearing loss can progress. Chronic rhinitis may develop.

In addition, with the chronic form of the disease there is a constant feeling of bursting in the damaged ear tube, as well as the appearance of incomprehensible noise, which is intensified when the head is tilted.

The stage of chronic exudative otitis begins two months after the onset of the acute form of the disease. Most often this form develops in children of kindergarten age, since it is very difficult to diagnose a disease in an acute form. Exudative otitis in children in chronic form develops in about one in five cases of the disease. In adults, the chronic form appears in the absence of treatment or in recurrent disease.

Danger of chronic exudative otitis media:

• in young children can not only reduce the hearing, but also cause a violation of the normal development of speech and understanding of words and phrases;
• contributes to the development of serious diseases of the nasal sinuses (chronic rhinitis, sinusitis, sinusitis, nasopharyngeal tumors);
• there may be a disruption in the structure and curvature of the nasal septum;
• causes a predisposition of the body to various infectious diseases that affect the nasopharynx (tonsillitis, pharyngitis, tonsillitis and ARVI);
• can develop mastoiditis - inflammation of the mastoid process of the temporal bone of the skull.

Chronic exudative otitis requires more serious treatment than an acute form of the disease.

Treatment of exudative otitis media

Diagnosis of exudative otitis includes acoustic hearing diagnostics and visual examination by an otolaryngologist. When examined, the tympanic membrane is distinguished by a blue hue and an environment of viscous exudate. As additional diagnostic tools, X-rays and CT of the temporal part of the head can be prescribed. If the cause of the disease is an infectious disease, it is necessary to undergo a general blood test for ESR and the number of leukocytes in the blood.

Before treatment of exudative otitis, it is necessary to exclude all its causes: to cure the acute respiratory viral infection, to get rid of adenoids and inflamed tonsils, to increase the level of immunity.

If otitis is complicated by rhinitis or sinusitis, it is necessary to sanitize the nasopharynx to avoid re-infection. Diagnosis of the nasal septum is also performed. When treating otitis media, it is very important to restore proper breathing in the nose.

To reduce the deafness, an extra exudate is removed from the auditory tube. Such an operation can be carried out by the following methods:

• electrostimulation or electrophoresis;
• laser therapy;
• ultrasound;
• influence of magnetotherapy.

In case of bacterial infection, medications can be injected into the cavity of the auditory tube: steroid preparations and antibiotics. If the cause of the disease is an allergy, you need to take a course of antihistamines.

In children, treatment can be performed by surgery. During surgery, a special shunt is inserted into the cavity of the ear canal, which dissects the ear canal. This element remains in the auditory tube for a month and serves as a tool for administering the drug and freeing the tube from excess fluid condensation.

.

http://www.youtube.com/watc? = kSZZVWucCq0

Treatment of exudative otitis should necessarily be accompanied by the use of vitamin complexes. They must necessarily contain vitamins A, B and C, as well as a trace element of sulfur.

lor03.ru

Exudative otitis media

The average otitis (secretory or nonnegative otitis media) is otitis, in which the mucous membranes of the middle ear cavities are affected.

Exudative otitis media is characterized by the presence of exudate and hearing loss in the absence of pain syndrome, with a preserved eardrum.

ICB-10 code H65 Pulmonary otitis media H66 Purulent and unspecified otitis media H67 * Otitis media in diseases classified elsewhere

Epidemiology

The disease often develops in preschool, less often - at school age. Mostly boys are ill. According to M. Tos, 80% of healthy people in childhood suffered exudative otitis media. It should be noted that in children with congenital cleft lip and palate, the disease occurs much more often.

Over the past decade, a number of domestic authors have noted a significant increase in morbidity. Perhaps there is not an actual increase in it, but an improvement in diagnosis as a result of equipping the surdological offices and centers and the introduction into practical public health of objective research methods (impedanceometry, acoustic reflexometry).

Causes of exudative otitis media

The most common theories of development of exudative otitis media:

• "hydrops ex vacuo proposed by A. Politzer (1878), according to which the underlying causes of the disease, contributing to the development of negative pressure in the cavities of the middle ear;
• exudative, explaining the secretion of a secretion in the tympanum by inflammatory changes in the mucosa of the middle ear;
• secretory, based on the results of the study of factors that contribute to the hypersecretion of the mucosa of the middle ear.

In the initial stage of the disease, the flat epithelium degenerates into a secreting epithelium. In the secretory (the period of accumulation of exudate in the middle ear) - the pathologically high density of goblet cells and mucous glands develops. In the degenerative - the secretion production decreases due to their degeneration. The process proceeds slowly and is accompanied by a gradual decrease in the frequency of division of goblet cells.

The presented theories of the development of exudative otitis media are in fact links in a single process reflecting the different stages of the course of chronic inflammation. Among the causes leading to the onset of the disease, most authors focus on the pathology of the upper respiratory tract inflammatory and allergic. A necessary condition for the development of exudative otitis media (trigger mechanism) is the presence of mechanical obstruction of the pharyngeal ear of the auditory tube.

Pathogenesis

Endoscopic examination in patients with auditory tube dysfunction shows that the cause of exudative otitis media in most cases - violation of the outflow of secretions from the paranasal sinuses, primarily from the anterior chambers (maxillary, frontal, anterior latticed), in nasopharynx. Normally, the transport goes through the trellis funnel and the frontal pocket to the free edge of the posterior part of the hook-shaped process, then to the medial surface of the inferior nasal concha with bypass of the mouth of the auditory tube in front and below; and from the posterior lattice cells and the sphenoid sinus - at the back and top from the tubular aperture, uniting in the oropharynx under the action of force severity. With vasomotor diseases and sharply increased viscosity of the secretion, mucociliary clearance is slowed. In this case, the merging of flows to the tubular aperture or pathological vortices with secretion circulation around the mouth of the auditory tube with pathological reflux into its pharyngeal estuary is noted. With hyperplasia of adenoid vegetations, the path of the posterior flow of mucus is mixed forward, also to the mouth of the auditory tube. Changes in the natural pathways of outflow may be due to a change in the architectonics of the nasal cavity, especially the middle nasal passage and the lateral wall of the nasal cavity.

In acute purulent sinusitis (especially sinusitis) and the connection with the change in the viscosity of secretions, natural pathways outflow from the paranasal sinuses are also disturbed, which leads to the dropping of the auditory discharge to the mouth pipes.

Exudative otitis media begins with the formation of a vacuum and a tympanic cavity (hydrops ex vacuo). As a result of dysfunction of the auditory tube, oxygen is absorbed, the pressure in the tympanic cavity falls and, as a consequence, there appears a transudate. Subsequently, the number of goblet cells increases, in the mucous membrane of the tympanic cavity mucous glands form, which leads to an increase in the volume of secretion. The latter is easily removed from all parts through the tympanostoma. High density of goblet cells and mucous glands leads to an increase in viscosity and secretion density, to transition to exudate, which is already more difficult or impossible to evacuate through tympanostom. At the fibrous stage in the mucous membrane of the tympanic cavity degenerate processes predominate: goblet cells and secretory glands are exposed degeneration, the production of mucus is reduced, then stops completely, fibrous transformation of the mucosa occurs with the involvement of auditory bones. The predominance in the exudate of the elemental elements leads to the development of the adhesive process, and the increase in the formless ones leads to the development of tympanic sclerosis.

Undoubtedly, inflammatory and allergic pathology of the upper respiratory tract, changes in local and general immunity affect the development of the disease and play an important role in the development of a recurrent form of chronic exudative mean otitis.

The trigger mechanism, as mentioned above, is the dysfunction of the auditory tube, which may be due to mechanical obstruction of its pharyngeal mouth. More often it occurs with hypertrophy of the pharyngeal tonsil, juvenile angiofibroma. Obstruction occurs also with inflammation of the mucous membrane of the auditory tube, provoked by a bacterial and viral infection of the upper respiratory tract and accompanied by a secondary edema.

Symptoms of exudative otitis media

Malosymptomnoe course of exudative otitis media is the reason for the late establishment of the diagnosis, especially in young children. The disease is often preceded by the pathology of the upper respiratory tract (acute or chronic). Characterized by a decrease in hearing.

Where does it hurt?

Earache

What's bothering you?

Noise in ears

Forms

Currently, the mediative otitis media for the duration of the disease is divided into three forms

• acute (up to 3 weeks);
• subacute (3-8 weeks);
• chronic (more than 8 weeks).

Given the difficulties in determining the onset of the disease in preschool children, as well as the identity of treatment tactics in acute and subacute forms of maxillary otitis media, consider it expedient to distinguish only two forms: acute and chronic.

In accordance with the pathogenesis of the disease, various classifications of its stages have been adopted. M. Tos (1976) identifies three periods of development of maxedative otitis media:

• primary or stage of initial metaplastic changes in the mucosa (on the background of functional occlusion of the auditory tube);
• secretory (increased activity of goblet cells and metaplasia of the epithelium):
• degenerative (decrease in secretion and development of adhesive process in the tympanic cavity).

O.V. Strathieva et al. (1998) distinguish four stages of maximal otitis media:

• initial exudative (initial catarrhal inflammation);
• pronounced secretory; by the nature of the secret subdivide into:
  • serous;
  • mucous (mucoid):
  • serous-mucous (serous-mucoid);
• productive secretory (with predominance of secretory process);
• degenerative-secretory (with predominance of fibro-sclerotic process);

in the form of:

• fibrotic and mucoid;
• fibro-cystic;
• fibro-adhesion (sclerotic),

Dmitriev N.S. et al. (1996) proposed a version based on similar principles (the nature of the contents of the drum cavity by physical parameters - viscosity, transparency, color, density), and the difference lies in determining the tactics of treating patients depending on the stage disease. Pathogenetically the IV stages of the course are distinguished:

• catarrhal (up to 1 month);
• secretory (1-12 months);
• mucous (12-24 months);
• fibrotic (more than 24 months).

Therapeutic tactics at the first stage of chronic otitis media: sanitation of the upper respiratory tract; in the case of surgical intervention after 1 month. after the operation, audiometry and tympanometry are performed. With preservation of hearing loss and registration tympanograms of type C, measures are taken to eliminate auditory tube dysfunction. Timely initiation of therapy at the catarral stage leads to a rapid cure of the disease, which in this case can be interpreted as tubo-otitis. In the absence of therapy, the process goes on to the next stage.

Therapeutic tactics at the second stage of chronic otitis media: sanitation of the upper respiratory tract (if not was performed earlier); myringostomy in the anterior eardrum with the introduction of ventilation tube. Iptraoperatively verify the stage of maxedative otitis media: at stage II, the exudate is easily and completely removed from the tympanic cavity through the myrrhostomy hole.

Therapeutic tactics at the third stage of maxigative otitis media: one-stage with bypass surgery, sanitation of the upper respiratory tract (if not previously performed); tympanostomy in front sections of the tympanic membrane with the introduction of a vent tube, tympanotomy with revision of the tympanum, washing and removal of a dense exudate from all parts of the drum cavity. Indications for one-stage tympanotomy - the impossibility of removing a thick exudate through the tympanostoma.

Therapeutic tactics at the IV stage of exudative otitis media: sanitation of the upper respiratory tract (if not previously performed): tympanostomy in the anterior departments of the tympanic membrane with the introduction of a vent tube; one-stage tympanotomy with removal of tympanosclerotic foci; mobilization of the auditory chain bones.

This classification - the algorithm of diagnostic, therapeutic and preventive measures.

Diagnosis of exudative otitis media

Early diagnosis is possible in children older than 6 years. At this age (and older), complaints about ear congestion, hearing fluctuation are likely. Pain sensations are rare, short-lived.

Physical examination

When examined, the color of the tympanic membrane is variable - from whitish, pink to cyanotic, against the background of increased vascularity. You can detect air bubbles or the level of exudate behind the tympanic membrane. The latter, as a rule, is retracted, the light cone is deformed, the short process of the malleus sharply protrudes into the lumen of the external auditory canal. The mobility of the retracted tympanic membrane with exudative otitis media is severely limited, which is fairly easy to determine with the Siegles pneumatic funnel. The physical data vary depending on the stage of the process.

With otoscopy at the catarral stage, the retraction and restriction of the mobility of the tympanic membrane, the change in its color (from turbid to pink), and the shortening of the light cone are revealed. Exudate behind the tympanic membrane is not visible, but to a prolonged negative pressure due to a violation aeration of the cavity creates conditions for the appearance of the contents in the form of transudate from the vessels of the mucous membrane nose.

With otoscopy at the secretory stage, a thickening of the tympanic membrane is revealed, a change in its color (to bluish), retraction in the upper and swelling in the lower parts, which is considered an indirect sign of the presence of exudate and drum cavity. In the mucous membrane, metaplastic changes appear and increase in the form of an increase in the number of secretory glands and goblet cells, which leads to the formation and accumulation of mucous exudate, and the tympanic cavity.

A mucosal stage is characterized by persistent hearing loss. With otoscopy, a sharp drag of the tympanic membrane in the unstretched part is revealed, its complete immobility, thickening, cyanosis and bulging in the lower quadrants. The contents of the tympanum become thick and viscous, which is accompanied by a restriction of the mobility of the auditory ossicles.

With otoscopy at the fibrous stage, the tympanic membrane is thinned, atrophic, pale in color. A prolonged course of exudative otitis media leads to the formation of scars and atelectasis, the foci of myringosclerosis.

Instrumental research

The basic diagnostic approach is tympanometry. In the analysis of tympanograms, the classification of B. Jerger. In the absence of middle ear pathology in a normally functioning auditory tube, the pressure in the tympanum cavity is equal to atmospheric pressure, therefore the maximum compliance of the tympanic membrane is recorded when a pressure equal to atmospheric pressure is created in the external ear canal (taken as initial). The resulting curve corresponds to a tympanogram of type A.

With auditory tube dysfunction in the middle ear, the pressure is negative. The maximum compliance of the tympanic membrane is achieved by creating and external auditory passage of a negative pressure equal to that in the tympanum. The tympanogram in this situation retains a normal configuration, but its peak shifts toward negative pressure, which corresponds to a tympanogram of type C. In the presence of exudate in the tympanic cavity, a change in pressure in the external auditory meatus does not lead to a significant change in compliance. The tympanogram is represented by an even or horizontally rising line in the direction of the negative pressure and corresponds to type B.

When diagnosing exudative otitis media, the tone threshold audiometry data is taken into account. The decrease in auditory function in patients develops by inductive type, the thresholds of perception of sound lie in the range 15-40 dB. Hearing impairment is of a fluctuating nature, therefore, during dynamic observation of the patient with exudative otitis media, repeated examination of the hearing is necessary. The nature of the air conduction curve on the audiogram depends on the amount of exudate in the tympanic cavity, its viscosity and the magnitude of the intratampal pressure.

With tonal threshold audiometry at the catarrhal stage, airborne sound thresholds do not exceed 20 dB, bone thresholds remain normal Disturbance of ventilation function of the auditory tube corresponds to a tympanogram of type C with a deviation of the peak towards the negative pressure up to 200 mm of water. In the presence of transudate, a tympanogram of type B is determined, which often occupies the middle position between types C and B: the positive knee repeats type C. negative - type B.

With tonal threshold audiometry at the secretory stage, conductive hearing loss of the first degree is detected with an increase in air sounding thresholds to 20-30 dB. Thresholds of bone sound conduction remain normal. With acoustic impedance, a tympanogram of type C with negative pressure in drum cavity over 200 mm of water, but more often type B and lack of acoustic reflexes.

The mucosal stage is characterized by an increase in the thresholds of air sound conduction to 30-45 dB with a tone threshold audiometry. In some cases, the thresholds of bone sound increase to 10-15 dB in the high-frequency range, which indicates the development of secondary NST, mainly due to the blockade of the windows of the labyrinth viscous exudate. With acoustic impedance measurement, a Type B tympanogram is recorded and the absence of acoustic reflexes on the side of the lesion.

At the fibrous stage, a mixed form of hearing loss progresses: the airborne sound thresholds increase to 30-50 dB, the bone level - up to 15-20 dB in the high-frequency range (4-8 kHz). During impedance measurement, a tympanogram of type B and a lack of acoustic reflexes are recorded.

Attention should be paid to the possible correlation of otoscopic features and tympanogram type. Thus, with tympanic membrane retraction, shortening of the light reflex, change in color of the tympanic membrane, type C is often recorded. In the absence of a light reflex, with thickening and cyanosis of the tympanic membrane, bulging it in the lower quadrants, and translucent exudate, type B tympanograms are determined.

When endoscopy of the pharyngeal opening of the auditory tube, a hypertrophic granulation obstructive process can be detected, sometimes in combination with hyperplasia of the inferior nasal concha. It is this study that gives the most complete information about the causes of exudative otitis media. With the help of endoscopy, it is possible to identify a sufficiently wide variety of pathological changes in the nasal cavity and nasopharynx, leading to dysfunction of the auditory tube and supporting the course of the disease. The research of the nasopharynx should be carried out with the relapse of the disease in order to clarify the cause of the occurrence of exudative otitis media and the development of adequate therapeutic tactics.

X-ray examination of temporal bones in classical projections in patients with exudative otitis media is of little informative and practically not used.

CT of temporal bones - highly informative diagnostic method; it must be performed in case of relapse exudative otitis media, as well as in the III and IV stages of the disease (according to the NS classification). Dmitrieva). CT of the temporal bones allows to obtain reliable information on the airiness of all the cavities of the middle ear, the condition of the mucous membrane, the windows of the labyrinth, the chain of auditory ossicles, the bone department of the auditory pipes. In the presence of pathological contents and cavities of the middle ear - its localization and density.

What it is necessary to survey?

Middle ear

How to inspect?

Ear examination Roentgen ray and temporal bone

Differential diagnostics

Differential diagnosis of exudative otitis media is performed with ear diseases. accompanied by conductive hearing loss in the intact tympanic membrane. It can be:

• anomalies in the development of auditory ossicles, in which a tympanogram of type B is sometimes recorded, a significant increase in the thresholds of air sound conduction (up to 60 dB), a decrease in hearing from birth. The diagnosis is confirmed definitively after carrying out multifrequency tympanometry;
• otosclerosis, in which the otoscopic picture corresponds to the norm, and tympanogram of type A with a flattening of the tympanometric curve is recorded with tympanometry.

Sometimes there is a need to differentiate exudative otitis media with a glomus tumor of the tympanic cavity and rupture of the auditory ossicles. The diagnosis of the tumor is confirmed by radiographic data, the disappearance of noise when the vascular bundle is compressed on the neck, and also by the pulsating picture of thymnograms. When a chain of auditory ossicles is ruptured, a tympanogram of type E is recorded.

Who to contact?

Otolaryngologist ENT - doctor

Treatment of exudative otitis media

Tactics of treatment of patients with exudative otitis media: elimination of the causes that caused the violation of the functions of the auditory tube, and then conducting medical measures aimed at restoring auditory function and preventing persistent morphological changes in middle ear. When dysfunction of the auditory tube caused by pathology of the nose, paranasal sinuses and pharynx, the first stage in treatment should be the sanitation of the upper respiratory tract.

The purpose of the treatment is the restoration of the auditory function.

Indications for hospitalization

• The need for surgical intervention.
• Impossibility of conservative treatment in outpatient settings.

Non-drug treatment

Blowing out the auditory tube:

• catheterization of the auditory tube;
• blowing on the Politzer;
• the Valsalva experience.

In the treatment of patients with exudative otitis media, physiotherapy is widely used - in-the-ear electrophoresis with proteolytic enzymes, steroid hormones. Endaural phonophoresis of acetylcysteine ​​is preferred (8-10 procedures for treatment in stages I-III), as well as for the mastoid process with hyaluronidase (8-10 sessions for the course of treatment in II-IV stages).

Medication

In the second half of the last century, it was proved that inflammation in the middle ear with an average age of otitis media is aseptic in 50% of cases. The rest was made up of patients who had Haemophilus influenzae, Branhamella catarrhalis, Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, therefore, as a rule, an antibacterial therapy. Use antibiotics of the same series as in the treatment of acute otitis media (amoxicillin + clanulanic acid, macrolides). However, the question of including exudative otitis media antibiotics in the therapy scheme remains controversial. Their effect is only 15%, taking in combination with tableted glucocorticoids (for 7-14 days) increasing the result of therapy only to 25%. Nevertheless, most foreign researchers use antibiotics as justified. Antihistamines (diphenhydramine, chloropyramine, hifenadine), especially in combination with antibiotics, inhibit the formation of vaccinal immunity and suppress nonspecific anti-infective resistance. Many authors recommend the anti-inflammatory (fenspiride) for acute stage treatment, anti-edema, nonspecific complex hyposensitizing therapy, the use of vasoconstrictor. Children with IV stage of exudative otitis media in parallel with physiotherapeutic treatment are administered hyaluronidase at 32 units for 10-12 days. In everyday practice, mucolytics in the form of powders, syrups and tablets (acetylcysteine, carbocysteine) are widely used to dilute the exudate in the middle ear. The course of treatment is 10-14 days.

An indispensable condition for conservative treatment of exudative otitis media is evaluation of the results of direct treatment and control after 1 month. To do this, threshold audiometry and acoustic impedance measurements are carried out.

Surgery

In the case of ineffectiveness of conservative therapy, patients with chronic exudative otitis media undergo surgical treatment, whose goal is to remove exudate, restoration of auditory function and prevention of recurrence of the disease, otosurgical intervention is performed only after or during the sanitation of upper respiratory ways.

Mirindgotia

Advantages of the technique:

• rapid equalization of tympanal pressure;
• fast evacuation of exudate.

Disadvantages:

• impossibility to remove thick exudate;
• rapid closing of the myringotomy hole;
• high frequency of relapses (up to 50%).

In connection with the above, the method is considered a temporary medical procedure. The indication is exudative otitis media in the stage when performing a surgical intervention aimed at sanitation of the upper respiratory tract. Tympanopuncture has a similar myringotomy deficiencies. The use of methods must be stopped because of their inefficiency and high risk of complications (trauma of auditory ossicles, maze windows).

Timpakostoynya with the introduction of a vent tube

For the first time the idea of ​​tympanostomy was put forward by P. Politzer and Delby in the XIX century, but only A. Armstrong introduced a shunt in 1954. He used a straight spear-shaped polyethylene tube with a diameter of 1.5 mm, leaving it for 3 weeks in a patient with exsudative otitis media that is not resolved after conservative therapy and myringotomy. Later, the otiatrs perfected the design of the ventilation tubes, used the best materials for their manufacture (Teflon, silicone, silastic, steel, gilded silver and titanium). Clinical studies, however, did not reveal significant differences in the effectiveness of treatment with different materials. The design of the tubes depended on the tasks of the treatment. At the initial stages, tubes were used for short ventilation (6-12 weeks) A. Armstrong, M. Shepard. A. Reuter-Bobbin. Patients treated with the use of these tubes (the so-called shot-term-tubes), which are shown repeated tympanostomy - candidates for surgery using long-term tubes (so-called long-term-tubes) K. Leopold. AT. McCabe. This group of patients also includes children with craniofacial anomalies, pharyngeal tumors after palatorezection or irradiation.

At present, long-term tubes are made of a silastic with a large medial flange and flexible carinae for easier administration (J. Re-lee, T-shaped, of silver and gold, titanium). Spontaneous fallout of long-term-tubes is extremely rare (for the modification of Re-lee - in 5% of cases), the duration of wearing up to 33-51 weeks. The frequency of prolapse depends on the speed of migration of the epithelium of the tympanic membrane. Many otosurgeons prefer tympanostomy in the mediocre quadrant, while K. Leopold et al. noted that the Shepard modification tubes are preferable to be introduced into the anterior quadrant, such as Renter-Bobbin - in the anteroom. I.B. Soldatov (1984) proposes to shunt the tympanum through the incision of the skin of the external auditory canal on a limited section of its posterior wall by cutting it together with the tympanic membrane, installing a polyethylene tube through this access. Some Russian authors form a myrrhostomic hole in the posterior quadrant of the tympanic membrane using the energy of a carbon dioxide laser. In their opinion, the hole, gradually decreasing in size, completely closes through, -2 months without signs of gross scarring. Also for mnrigotmii apply low-frequency ultrasound, under the action of which occurs a biological coagulation of the edges of the incision, resulting in virtually no bleeding, decreases the likelihood infection.

Miringhotomy with the introduction of a vent tube in the anterior quadrant

Equipment: operating microscope, ear funnels, straight and curved microneedles, micro-disperser, micro-formula, micro-tips for suction with diameter and, mm. The operation is performed in children under general anesthesia in adults - under local anesthesia.

The operating field (parotid space, the auricle and the external auditory meatus) is treated according to generally accepted rules. With a curved needle, the epidermis is dissected in front of the handle in the anteroposterior quadrant of the tympanic membrane, peeled off from the middle layer. Circular fibers of the tympanic membrane are dissected, and radial fibers are expanded by a micro needle. If these conditions are properly observed, the myringotomy hole acquires a shape, the dimensions of which are corrected by the micro-disassembly in accordance with the caliber of the vent tube.

After mnrigotmii suction remove exudate from the tympanic cavity: the liquid component - without difficulty in full volume; viscous - by liquefaction by introducing into the drum cavity solutions of enzymes and mucolytics (trypsin / chymotrypsin, acetylcysteine). Sometimes it is necessary to carry out this manipulation repeatedly until the exudate is completely removed from all parts of the tympanic cavity. In the presence of a mucoid, non-evaporation exudate, a vent tube is installed.

The tube is taken with mikrofishchitsami for the flange, lead to the myringotomy hole at an angle, and the edge of the second flange is inserted into the lumen of myringostoma. The microshicles are removed from the external auditory canal, and the curved microneedle, pressing on the cylindrical part of the tube on the border with the second flange, located outside the tympanic membrane, it is fixed in the myringotomic holes. After the procedure, wash the cavity,% dexamethasone solution, inject, ml with a syringe: in the external auditory canal, increase the pressure with a rubber pear. With the free passage of the solution into the nasopharynx, the operation is terminated. When the obstruction of the auditory tube is sucked off the drug and vasoconstrictive drugs are administered; The pressure in the external ear canal is again raised with a rubber pear. Such manipulations are repeated until reaching the permeability of the auditory tube. With this technique, there is no spontaneous failure of the tube due to its tight fit between the flanges of the radial fibers of the middle layer of the tympanic membrane.

The establishment of drainage in the anteroposterior region of the tympanic membrane allows not only to achieve optimal ventilation the tympanic cavity, but also to run into a possible trauma to the chain of the auditory ossicles, which is possible when the tube is fixed in the posterior quadrant. In addition, with this form of administration, the risk of complications in the form of atelectasis and myringosclerosis is lower, and the tube itself has a minimal effect on sound production. The ventilation tube is removed according to the indications at different times, depending on the restoration of the patency of the auditory tube according to the results of tympanometry.

Localization of myringostomy cut can be different: 53% of otolaryngologists apply tympanostoma in the posterior quadrant, 38% in the anterior region. 5% in the anteroposterior and 4% in the posterior quadrant. The latter option is contraindicated because of the high probability of trauma to the auditory ossicles, the formation retraction pocket or perforation in this zone, which leads to the development of the most pronounced hearing loss. Lower quadrants are preferable to tympanostomy because of the lower risk of injury to the promontory wall. In cases of generalized atelectasis, the only possible place for the introduction of the vent tube is the anterolateral quadrant.

Shunting the tympanum with exudative otitis media is highly effective in terms of exudate removal, improvement of hearing and prevention of recurrence only in the II (serous) stage (according to the classification of NS Dmitriev et al.), provided that the dispensary observation in for 2 years.

Tympanotomy

After the imposition of tympanostomy in the anteroposterior quadrant of the tympanic membrane, injection is made with lidocaine solution 1% on the boundary of the outer wall of the external auditory canal in order to facilitate the separation of the meatotypalnal flap. By a dead knife, the skin of the external auditory canal is cut under the magnification of the operating microscope, having retreated 2 mm from the tympanic ring along the posterior wall in the direction from 12 to 6 h according to scheme dial. With a micro-dissector, a me- talic flap is removed, a tympanic ring with an eardrum is extracted with a curved needle. The whole complex is diverted anteriorly until a good view of the windows of the labyrinth, promontorial wall and auditory ossicles is obtained; access to gipotimpanuma and perabarabannomu deepening. The exudate is removed by sucking, the drum cavity is washed with acetylcysteine ​​(or enzyme), and then the evacuation is again evacuated. Particular attention is paid to the overdrilling and located in it on the forging hammer It is in this place that a muft-shaped deposit of the formed exudate. At the end of the manipulation, the tympanum is washed with dexamethasone solution. The meatotimponal flap is placed in place and fixed with a strip of rubber from the surgical glove.

Further management

If the ventilation tube is established, the patient is warned about the need to protect the operated ear from water ingress. After its removal, inform about the possibility of recurrence of exudative otitis media and the need to visit a surdologist-otorhinolaryngologist after any episode of an inflammatory disease of the nose and upper respiratory ways.

Audiologic control is performed one month after the surgical treatment (otoscopy, otomicroscopy, with indications - assessment of the patency of the auditory tube). With normalization of hearing acuity and function of the auditory tube after 2-3 months. the vent tube is removed.

After the treatment, a long, careful and competent dispensary observation by an otorhinolaryngologist and a surdologist is necessary, since the disease is prone to recurrence. It seems rational to differentiate the nature of observation of patients, respectively, the established stage of exudative otitis media.

In the case of stage I, after the first stage of treatment and at stage II, the first examination with audiometric control should be performed 1 month after the sanitation of the upper respiratory tract. Among the characteristics of children, we can note the appearance of a semilunar spot in the anterior quadrants of the tympanic membrane and the recording of Type C tympaograms with acoustic impedance measurements. Monitoring of children in the future should be carried out once in 3 months for 2 years.

After the shunting of the tympanum, the first examination of the patient should be carried out also 1 month after discharge from the hospital. From the indicators of otoscopy, attention should be paid to the degree of infiltration of the tympanic membrane and its color. By the results of tympanometry in the mode of examining the patency of the auditory tube, one can judge the degree of its recovery. Further audiological control is carried out once in 3 months for 2 years.

At the sites of introduction of ventilation tubes in patients with stage II and III of exudative otitis media, the appearance of myringosclerosis is possible.

With otoscopy in patients with IV stage of exudative otitis media, atelectasis of the tympanic membrane, perforations, secondary NST can be expected. In the presence of these complications, it is necessary to conduct courses of resolving, simulating and improving microcirculation therapy: injections of hyaluronidase, fibs, vitreous intramuscularly in the age-related dose, phonophoresis with hyaluronidase endaurally (10 procedures).

At all stages of the cured exudative otitis media, the patient or his parents are warned about mandatory audiologic control after episodes of long-term rhinitis etiology or inflammation of the middle ear, as these conditions can trigger an aggravation of the disease, untimely diagnosis of which leads to the development of a more severe stage.

American otolaryngologists recommend observing patients with exudative otitis media with a preserved tympanogram of type B not more than 3-4 mcch. further shows tympanostomy.

In cases of recurrence of the disease before repeated surgical intervention, it is recommended to perform CT of the temporal bones in order to assess the condition of the auditory pipes, verification of the presence of exudate in all cavities of the middle ear, the preservation of the chain of auditory ossicles, the exclusion of the cicatricial process of the drum cavity.

Approximate terms of incapacity for work depend on the stage of the course of the disease and are 6-18 days.

In addition to treatment

Physiotherapy for otitis Antibiotics for otitis Than to treat? Tzedex Galazolin

Prevention

Prevention of exudative otitis media - timely sanitation of the upper respiratory tract.

Forecast

Dynamics in the first stage of the disease and adequate treatment lead to complete cure of patients. The primary diagnosis of exudative otitis media in the second and subsequent stages and, as a consequence, the belated initiation of therapy lead to a gradual increase in the number of adverse outcomes. Negative pressure, the restructuring of the mucous membrane in the tympanum cavity causes a change in the structure of both the tympanic membrane and the mucosa. Their primary changes create prerequisites for the development of retractions and attelectasis, mucositis, immobilization of the chain of auditory ossicles, blockade of labyrinthine windows.

• Atelectasis is the retraction of the tympanic membrane due to prolonged dysfunction of the auditory tube.
• Atrophy - thinning of the tympanic membrane, accompanied by a weakening or cessation of its function due to the inflammation.
• Miringosclerosis is the most frequent outcome of the course of the exudative middle, otitis media: characterized by the presence of white tumors membranes located between the epidermis and the mucous membrane of the latter, developing as a result of the organization of exudate in fibrous layer. In surgical treatment, the foci can easily be detached from the mucous membrane and the epidermis without the release of blood.
• Retraction of the tympanic membrane. Appears due to prolonged negative pressure in the tympanic cavity, can be localized both in the loose part (panflaccida) and in the strained (pars tensa), be limited and diffuse. Atrophic and retracted tympanic membrane is sagging. The retraction precedes the formation of the retraction pocket.
• Perforation of the tympanic membrane.
• Adhesive otitis media. Characterized by cicatrization of the tympanic membrane and proliferation of fibrous tissue in the tympanum, immobilization a chain of auditory ossicles, which leads to atrophic changes in the latter, up to the necrosis of a long process anvil.
• Timpanosclerosis - the formation of tympanosclerotic foci in the tympanum. Most often located in epitimpanuma. around the auditory ossicles and in the niche of the window of the vestibule. In surgical intervention, the tympano-sclerotic foci exfoliate from the surrounding tissues without the release of blood.
• Deafness. It is manifested by conductive, mixed and neurosensory forms. Conductive and mixed, as a rule, are due to the immobilization of the auditory ossicles' chain by scars and tympanosclerotic foci. HCT - a consequence of intoxication of the inner ear and blockade of the windows of the labyrinth,

These complications can be isolated or in various combinations.

The creation of an algorithm for the treatment of patients, depending on the stage of exudative otitis media, made it possible to achieve restoration of auditory function in the majority of patients. At the same time, observations of children with exudative otitis media for 15 years showed that 18-34% of patients develop relapses. Among the most significant reasons noted the persistence of chronic mucosal disease of the nasal cavity and the later onset of treatment.

ilive.com.ua

Exudative otitis media - causes, symptoms, diagnosis, treatment of exudative otitis media

Exudative otitis media should not be confused with acute middle otitis media, which consists in inflammation of the middle ear caused by an infection. A distinctive feature of the exudative form of the disease is the accumulation in the cavity of the middle ear of an adhesive fluid - exudate. In addition, the disease is accompanied by a decrease in hearing and the preservation of the tympanic membrane on the background of a complete absence of pain syndrome. Exudative otitis, as well as other ear diseases, are more often affected by children, because of the greater vulnerability of childhood immunity.

Types and causes of exudative otitis media

Depending on the duration of the disease, distinguish between chronic, subacute and acute exudative otitis media. The acute form is observed in the period up to three weeks, chronic - is diagnosed after eight weeks from the moment of the disease. Subacute form is intermediate, and is usually not used in diagnosis.

The multiple and numerous causes of exudative otitis media, or the so-called "sticky ear can be divided into two groups of factors: general and local.

Causes of a general nature include:

• Low immunity due to chronic diseases;

• Allergic reactions;

• Poor ecology and living conditions;

• Infectious diseases.

It should be noted that among the factors provoking exudative otitis in children, adenovirus infection accounts for approximately 30% of cases.

The main reason for the local nature is a mechanical or functional violation of the ventilation properties of the auditory tube. Usually, this is due to hypertrophy of the pharyngeal tonsil or a subtle inflammatory process occurring in it.

Symptoms and pathogenesis

Exudative otitis in children is not easy to diagnose. Symptoms, as a rule, are not clearly expressed. In fact, the only sign of the disease is a decrease in hearing, sometimes accompanied by noise. Given that small children are unlikely to complain about hearing loss - the diagnosis of exudative otitis media is, most often, accidental. The main danger of this trend is in serious complications. If the disease in time to not identify or ignore mild symptoms, it is likely irreversible sad consequences - atrophy of the tympanic membrane and stable, practically incurable deafness.

Finally, the pathogenesis of the disease is not clear, but it is most likely that the mechanism of exudative otitis origin is associated with insufficient ventilation and emptying of the tympanic cavity. This, in turn, may result from improper treatment of otitis media or various functional disorders of the soft and hard palate.

Diagnosis of exudative otitis media

For successful diagnosis, the history of the transferred ear diseases is of particular importance. Pay special attention to the course of the disease and the prescribed treatment. Regular otoscopy can provide fairly clear data on changes in the tympanic membrane, which may appear slightly thickened, bulging and have a cyanotic hue. Sometimes, the membrane can be so thin that through it you can see the level of accumulated transudate.

In addition to otoscopy, the following measures are important for diagnosis:

• Study of ventilation functions of the auditory tube;

• Acoustic tubosonometry;

• Determination of the level of mobility of the tympanic membrane.

The final and decisive word belongs to the study of hearing. With exudative otitis, hearing loss, as a rule, is moderate, within 30-40 dB.

Today, due to acoustic impedance measurement, it is possible to conduct a full diagnostic of the damage to the auditory sound-receiving and sound-conducting apparatus, including in the smallest patients.

Help in diagnosis can also X-ray, with the help of which a certain cellular pathology can be detected. If there are difficulties in diagnosing, you must resort to computed tomography of temporal bones.

A detailed study of the pharyngeal mouth and auditory tubes is provided by means of hard and soft endoscopes that allow us to establish the exact cause and nature of the obstruction of the auditory tube. Usually, it is the results of this study that determine the choice between conservative and surgical treatment.

Treatment of exudative otitis media

The tactics of treatment is reduced to the preliminary elimination of the causes that caused the auditory tube to malfunction, with the subsequent restoration of hearing and the prevention of morphological processes in the middle ear. Thus, with the detection of choanal polyps, adenoids, tonsillar hypertrophy, their mandatory elimination is required, as well as sanation of the paranasal sinuses.

Further, to improve the patency of the auditory tube, the patient may be assigned the following procedures:

• Electrostimulation of the muscles of the soft palate

• Lidase electrophoresis;

• Magnetotherapy;

• Ultrasound;

• Laser therapy.

Most often, to restore the tone and patency of the auditory tube and remove the exudate, use a blow on the Politzer, diadynamic currents or pneumomassage of the tympanic membrane. All these methods require active support and complicity of the patient, and therefore are not suitable for very young children.

Surgical methods include myringotomy and tympanopuncture, which serve for a single removal of serous fluid. Constant drainage and administration of medications is provided by tympanotomy, which involves the introduction of a special polyethylene tube for several weeks.

It is widely used in the treatment of exudative otitis in children, an operation consisting in the introduction of a shunt through a dissected eardrum. The shunt remains in the ear for 3-4 months, and serves both for the aeration of the tympanum and for the administration of medications. Often, with a dysfunctional auditory tube, one aeration by shunting is sufficient for a complete cure.

medportal.su

Exudative otitis in children: causes, manifestations and treatment of the disease

Treatment of exudative otitis should be done correctly and not be delayed with this. After all, it is an inflammatory process, which is characterized by the accumulation of glutinous transudate in the cavity of the middle ear as a result of infection. The most common disease affects children aged 3 to 8 years. Exudative otitis in children, whose treatment should be started as soon as possible, can lead to serious impairment of the function of the auditory tube and, as a rule, has a bilateral character. Exudate is the optimal medium for the development of pathogenic microorganisms and bacteria, and over time it thickens, contributing to the formation of mucus and pus.

Types of exudative otitis media

By duration, the exudative otitis media is classified into:

• acute;
• subacute (intermediate stage);
• chronic.

Given the dynamics and intensity of the inflammatory process, the disease can have 4 stages, namely:

1. Catarrhal.
2. Secretory.
3. Mucous.
4. Fibrous.

The acute form is diagnosed from 3 to 5 weeks, after which the disease gradually passes into an intermediate form and a chronic stage, which is diagnosed at week 8 after the disease develops.

Causes

Exudative otitis media can develop under the influence of a variety of adverse factors and causes that can be conditionally divided into general and local. Any form of the disease begins when the infection enters the middle ear cavity through the nasopharynx, after which the disease develops rapidly.

Common factors of pathology development:

1. Reduction of immune and protective functions due to the transferred viral diseases (tonsillitis, acute respiratory infections).
2. Allergic reactions (allergic rhinitis, sinusitis).
3. Unfavorable ecological situation.
4. Frequent infectious diseases (recurrent diseases of the upper respiratory tract - chronic rhinosinusitis).
5. Neoplasms in the nasopharynx.
6. Adenoids.

Local factors include a violation of the ventilation ability of the auditory tube with negative effects of mechanical, functional factors or hypertrophic degeneration of the pharyngeal tonsil. Violation of the ventilation capacity leads to the formation of a vacuum in the tympanic cavity and the gradual accumulation of pathological serous exudate therein. As a rule, the transudate is liquid, but as a result of increased formation of goblet cells, their hyperfunction, the exudate becomes more viscous and dense.

What is the clinical picture?

It should be noted that in children the symptoms at the initial stage of the disease are poorly expressed.Body temperature can be within normal limits, there is no acute pain, so the most characteristic symptoms are decreased hearing and a slight increase in parotid lymphatic nodes. Over time, the disease begins to progress, note a sharp increase in temperature to 39 ° C, severe itching in the ear, acute pain. If untimely treatment, the disease goes to a chronic stage, and after three or four years, a persistent or permanent stage of hearing loss may develop, followed by atrophy of the tympanic membrane.

The main symptoms of the disease include:

• a decrease in the auditory function of the Eustachian tube;
• autophony (when a person hears himself);
• permanent nasal congestion;
• discomfort, noise and feeling of stuffiness of the ears;
• transfusion of fluid in the ear canal.

Diagnosis of the disease includes visual otoscopy, impedance measurement, tympanometry, examination of the function of the auditory tube using tuning forks and audiometry.

Modern methods of treatment

Treatment of exudative otitis media is complex, and it is carried out only after diagnosis and establishing the cause and factors that led to the development of the disease. The choice of methods of treatment depends on the intensity of the course, the degree of the disease, the physiological characteristics of the organism.

First of all, the treatment of this pathology is aimed at restoring the auditory function. For this purpose, sanation of the paranasal sinuses, blowing the ears along the Politzer or with the help of an ear catheter with the massage of the tympanic membrane using the funnel Zigle is carried out.

To restore the patency of the ear canal, electrophoresis of lidase, electric stimulation of the muscles of the soft palate, ultrasound therapy, magnetotherapy are prescribed. In the early stages of the disease, exudative otitis can be effectively treated with the use of laser therapy.

In small children, as a rule, mainly conduct a catheterization or bougie of the ear canal, which allows you to eliminate the transudate and restore the function of the auditory tubes. In addition, transthumbnail is used in the cavity of the auricle of drugs that prevent the development of pathogenic microflora and eliminate the inflammatory process.

For the treatment of otitis media caused by allergic factors, in addition to the main methods, steroid or antihistamines are prescribed.

Surgical techniques (tympanopuncture, adenotomy, septoplasty, myringotomy) are used in rare cases and for a single extraction of the transudate. As a rule, after carrying out tympan shunting (dissection of the tympanic membrane), the hearing is completely restored for several days. The shunt serves to aerate the cavity of the tympanic membrane and introduce medications that dilute the transudate. Leave him in his ear for three or four months,

Treatment with folk methods

Treatment of exudative otitis folk remedies is to eliminate the causes that contributed to the development of pathology, as well as in the restoration of auditory function. You can treat exudative otitis only under the supervision of your doctor.

A rather effective treatment for this disease is oil based on the tincture of walnut leaves. For its preparation in the 20-th of June (it is best to number 23) it is recommended to pick up the leaves, rinse, grind them, put them in a container and fill with sunflower oil. The bank is closed and placed in a dark, cool place for 90 days. Ready oil is smeared in shallow in the middle and behind the ear.

To treat an average otitis it is possible compresses on the basis of leaves of a Kalanchoe or spirit tincture from leaves of a wormwood.

The inflammatory process will also help eliminate hare fat. Before using it, the ear is heated using warm salt pouches or an infrared lamp, after which a few drops of warmed warm fat drip into the diseased ear.

Treatment of exudative otitis media using folk remedies can be done using herbal preparations, which are prepared on the basis of various medicinal herbs. For this, in equal proportions leaves of plantain, eucalyptus, yarrow inflorescence, lavender are good stir, one spoon of medicinal raw material is poured into 400 ml of boiling water and insisted in a thermos for 8 hours. Take the inside 3 times a day for 50 ml of broth, and in the ear insert the soaked cotton tincture in the tincture, keeping it in your ear for at least 20 minutes.

Before carrying out this procedure, it is recommended to carefully clean the ear canal with a cotton swab.

It is also quite effective to eliminate the symptoms of the disease helps oil basil mint leaves, which can be purchased from pharmacies or cook yourself from fresh leaves and flower buds. To do this, the medicinal raw material is ground and poured with 150 ml of olive oil. Insist for a week in a dark place, then instill in the ear 2-3 drops of heated oil in the morning and in the evening or around the sick ear apply warm compresses on its basis.

lor03.ru

Similar articles