The average otitis media is affected bymucous membranes of middle ear cavities. Exudative otitis media is characterized by the presence of exudate and hearing loss in the absence of pain syndrome, with a preserved eardrum.
Prevention of exudative otitis media
Prevention of exudative otitis media is the timely sanitation of the upper respiratory tract.
Classification of exudative otitis media
Currently, exudative 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).
Since it is difficult to recognize the onset of the disease inchildren of preschool age and tactics of treatment for acute and subacute form of exudative otitis media is identical, consider it expedient to allocate 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 exudative otitis media:
• Primary, or stage of initial metaplastic changes in the mucosa (against 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 exudative otitis media.
• Initial exudative (initial catarrhal inflammation).
• Expressed secretory; by the nature of her secret is divided into:
- mucous (mucoid);
- serous-mucous (serous-mucoid);
• Productive secretory (with predominance of secretory process).
• Degenerative-secretory (with prevalence of fibrosnosclerotic process); in the form of:
- Fibrous-adhesive (sclerotic).
N.S. Dmitriev 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 the choice of treatment tactics depending on the stage of the disease. Pathogenetically distinguish four stages of the current:
• catarrhal (up to 1 month);
• Secretory (1-12 months);
• mucous (12-24 months);
• fibrotic (more than 24 months).
Etiology 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 middle ear cavities;
• exudative, explaining the secretion of the secretion in the tympanic cavity 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.
Pathogenesis of exudative otitis media
Exudative otitis media begins withthe formation of a vacuum in the tympanum (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, mucous membranes form in the mucous membrane of the tympanic cavity, resulting in an increase in the secretion volume, which is easily removed from all parts through tympanostoma. The high density of goblet cells and mucous glands promotes greater viscosity and secret density, turning it into an exudate that is already more difficult or impossible to evacuate through tympanostoma. In the fibrous stage, degenerative processes predominate in the mucosa of the tympanic cavity: goblet cells and secretory glands undergo degeneration; the production of mucus decreases, then stops completely, fibrous transformation of the mucous membrane begins with involvement of the auditory ossicles into the process. The predominance in the exudate of the elemental elements determines the development of the adhesive process, and the increase in the formless ones - the development of tympanosclerosis.
The trigger mechanism, as mentioned above,dysfunction of the auditory tube, often due to mechanical obstruction of its pharyngeal mouth. More often it occurs with hypertrophy of the pharyngeal tonsil, juvenile angiofibroma. Obstruction is also caused by inflammation of the mucous membrane of the auditory tube, which is provoked by a bacterial and viral infection of the upper respiratory tract and is accompanied by a secondary edema.
Clinic of exudative otitis media
Malosymptomnoe course of the exudative meanotitis is the cause of late 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.
Diagnosis of exudative otitis media
Early diagnosis is possible in children. At the age of 6 years and older with widespread use of tympanometry, complaints of ear congestion, hearing fluctuation are likely. Pain sensations are rare and, as a rule, short-lived.
When examined, the color of the tympanic membrane is variable- from whitish, pink to cyanotic against the background of increased vascularization. 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 Ziegle pneumatic funnel. The physical data vary depending on the stage of the process.
With otoscopy in the catarral stage, theretraction and restriction of the mobility of the tympanic membrane, a change in its color (from turbid to pink), shortening of the light cone. Exudate behind the tympanic membrane is not visible, however, a prolonged negative pressure due to a violation of the aeration of the cavity creates the conditions for the appearance of the contents in the form of transudate from the vessels of the mucous membrane.
With otoscopy in the secretory stage, thea thickening of the tympanic membrane, a change in its color (up to the cyanotic one), entanglement in the upper and swelling in the lower parts, which is considered an indirect sign of the presence of exudate in the tympanum. In the mucous membrane, metaplastic changes appear in the form of more secretory glands and goblet cells, which leads to the formation and accumulation of mucous exudate in the tympanic cavity.
For the mucous stage, a persistent decreasehearing. 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, while the mobility of the auditory ossicles is limited.
With otoscopy in the fibrous stage, the drumthe membrane is thinned, atrophic, pale in color. Due to the long course of exudative otitis media, scars and atelectasis, foci of myringosclerosis are formed.
The basic diagnostic method -tympanometry. In the absence of pathology of the middle ear with a normally functioning auditory tube, the pressure in the tympanum cavity is equal to atmospheric pressure, so the maximum compliance of the tympanic membrane is recorded when a pressure equal to atmospheric pressure is taken in the external ear canal (taken as the initial one). The resulting curve corresponds to a tympanogram of type A.
With auditory tube dysfunction in the middle earthe pressure is negative. The maximum compliance of the tympanic membrane is achieved by creating a negative pressure in the external auditory canal, the same as in the tympanic cavity. The tympanogram in a similar situation retains a normal configuration, but its peak shifts to 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 canal does not lead to a significant change in compliance. The tympanogram is represented by an equal or horizontally rising towards the negative pressure line and corresponds to type B.
When diagnosing exudative otitis mediatake into account tone threshold audiometry data. The decrease in auditory function in patients develops according to the conductive 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 in the catarral stage, airborne sound thresholds do not exceed 20 dB, bone thresholds remain normal.
With tonal threshold audiometry in the secretorystages detect conductive hearing loss of the first degree with increasing air sounding thresholds to 20-30 dB. Thresholds of bone sound conduction remain normal.
The mucosal stage is characterized by an increase in the thresholdsAir sound performance up to 30-45 dB with tonal 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 blockade of the windows of the labyrinth with viscous exudate.
In the fibrous stage, the mixed formdeafness: airborne sound thresholds increase to 40-50 dB, bone thresholds - 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.
With endoscopy of the pharyngeal opening of the auditorypipes can detect hypertrophic granulation obstructive process, sometimes in combination with hyperplasia of the inferior nasal concha. It is this study that gives the most complete information on the causes of exudative otitis media. With the help of endoscopy, it is possible to identify very diverse pathological changes and cavities of the nose and nasopharynx, which leads to dysfunction of auditory coarse and contributes to the course of the disease. The research of the nasopharynx is necessary to carry out with the relapse of the disease in order to clarify the causes of exudative otitis media and to develop adequate therapeutic tactics.
CT of temporal bones - highly informative methoddiagnostics; it must be performed with relapse of exudative otitis media, as well as in stages III and IV of the disease (according to the classification of NS Dmitriev et al.). CT of the temporal bones allows to obtain reliable information about the airiness of all the cavities of the middle ear, the state of the mucous membrane, the windows of the labyrinth, the chain of the auditory ossicles, the bone part of the auditory tube, in the presence of pathological contents in the cavities of the middle ear - its localization and density.
Differential diagnosis of exudative otitis media
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, withwhich sometimes register tympanogram type B, a significant increase in the thresholds of air sound (up to 60 dB), hearing loss from birth. The diagnosis is confirmed definitively after the multifrequency tympanometry;
• otosclerosis, in which the otoscopic picture is normal, and tympanogram type A is recorded with tympanometry with a flattening of the tympanometric curve.
Sometimes there is a need to differentiateexudative otitis media from the glomus tumor of the tympanic cavity and rupture of the auditory ossicles. Diagnosis of the tumor is confirmed by roentgenological data, the disappearance of noise when the vascular bundle is compressed on the neck, and also by the pulsating picture of the tympanogram. When a chain of auditory ossicles is ruptured, a tympanogram of type E is recorded.
Treatment of exudative otitis media
Tactics of treatment of patients with exudative meanotitis media: elimination of the causes that caused the violation of the functions of the auditory tube, and then the implementation of therapeutic measures aimed at restoring the auditory function and preventing persistent morphological changes in the middle ear. In dysfunction of the auditory tube, caused by pathology of the nose, paranasal sinuses and pharynx, the mandatory first stage in treatment should be the sanitation of the upper respiratory tract.
• Need for surgical intervention.
• Impossibility of conservative treatment in outpatient settings.
Blowing out the auditory tube:
• catheterization of the auditory tube;
• Polytzer blowing;
• the Valsalva experience.
When treating patients with exudative otitis mediawidely used physiotherapy - in-the-ear electrophoresis with proteolytic enzymes, steroid hormones. Endaural phonophoresis of acetylcysteine is preferred (8-10 procedures for the course of treatment in stages I-III), as well as a mastoid process with hyaluronidase (8-10 sessions per course of treatment in II-IV stages).
• Antibacterial therapy (amoxicillin + clavulanic acid, macrolides). However, the question of including antibiotics in the scheme of treatment of exudative otitis media remains discrete.
• Antihistamines (diphenhydramine, chloropyramine, hifenadine).
• Anti-inflammatory (fenspiride), decongestant, nonspecific complex hyposensitizing therapy, use of vasoconstrictors.
• Enzyme therapy (children with IV stage of exudative otitis media, in parallel with physiotherapeutic treatment, they are administered hyaluronidase at 32 units for 10-12 days).
• Mucolytic therapy in the form of powders, syrups and tablets (acetylcysteine, carbocysteine) for dilution of exudate in the middle ear. The course of treatment is 10-14 days.
When conservative therapy is ineffectiveThe patient with chronic exudative otitis media undergoes surgical treatment, whose goal is to remove the exudate, restore the auditory function and prevent recurrence of the disease. Otorhinurgic intervention is performed only after or during the sanitation of the upper respiratory tract.
• Timpanostomy with the introduction of a vent tube.
Audiologic control is carried out in a monthafter surgical treatment (otoscopy, otomicroscopy, with indications - assessment of patency of the auditory tube). After normalizing the acuity of hearing and the function of the auditory tube after 2-3 months, the vent tube is removed.
In cases of recurrence of the disease before repeatedsurgical intervention is recommended to perform CT of the temporal bones in order to assess the condition of the auditory tube, verify the presence of exudate in all cavities of the middle ear, maintain the integrity of the auditory ossicles, exclude cicatricial process in the tympanic cavity. Approximate terms of incapacity for work depend on the stage of the course of the disease and are 6-18 days. Forecast
Dynamics in the I stage of the disease and adequatetreatment contribute to the complete cure of patients. Primary diagnosis of exudative otitis media in II and in later stages and, as a consequence, the delayed onset of therapy lead to a gradual increase in the number of adverse outcomes. Negative pressure, reorganization of the mucous membrane in the tympanum cavity causes changes in the structure of the tympanic membrane and mucous membrane. Their primary changes create prerequisites for the development of retractions and atelectasis, mucositis, immobilization of the chain of auditory ossicles, and blockade of labyrinthine windows.
• Atelectasis - the tympanic membrane retraction 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 an inflammation.
• Meningosclerosis is the most frequent outcomeexudative otitis media; characterized by the presence of white formations on the tympanic membrane, located between the epidermis and the mucosa of the latter, develops due to the formation of exudate in the fibrous layer. In surgical treatment, the foci can easily be detached from the mucous membrane and the epidermis without the release of blood.
• Retransmission of the tympanic membrane. Appears due to prolonged negative pressure in the tympanic cavity, can be localized both in the unstrung (pars flaccida) and in the strained part (pars tensa), it is 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 of the auditory ossicles, which leads to atrophic changes in the latter, down to the necrosis of the long process of the anvil.
• Timpanosclerosis - educationtympanosclerotic foci in the tympanic cavity, which are more often located in the epitimpaneum, around the auditory ossicles and in the niche of the vestibule. In surgical intervention, the tympano-sclerotic foci exfoliate from the surrounding tissues without the release of blood.
• Hearing loss. It is manifested by conductive, mixed and neurosensory forms. Conductive and mixed forms, as a rule, are caused by immobilization of the auditory ossicles' chain by scars and tympanosclerotic foci. NST - a consequence of intoxication of the inner ear and blockade of the windows of the labyrinth.
The complications listed can be isolated or occur in various combinations.