Eardrum reconstruction or tympanoplasty. Surgical intervention: tympanoplasty. Testimonials after surgery There may be an ESO in the operated ear

In most cases, with long-term perforation in the tympanic membrane, which has arisen after trauma or acute otitis media, the patient complains of periodic or permanent discharge from the ear, hearing loss, and discomfort in the ear. In such cases, the skin of the ear canal often grows through the perforation into the tympanic cavity, envelops the auditory ossicles, and causes bone destruction. Such a "skin tumor" is popularly known as "caries", and in medicine "cholesteatoma". Therefore, in chronic purulent otitis media with cholesteatoma, there is a risk of damage to the facial nerve during the destruction of its canal, which passes in the temporal bone, the occurrence of meningitis, life-threatening conditions, the development of progressive hearing loss.

That is why modern medicine offers timely treatment of perforated otitis media, mesotympanitis - tympanoplasty, ossiculoplasty, in order to eliminate the problem at a stage when there are still no significant destructive changes. And this reduces the time of the operation, increases its efficiency.

If earlier surgical interventions for purulent otitis media were aimed at eliminating inflammation and did not leave the possibility of preserving the patient's hearing, at the present stage everything has changed dramatically. Surgical treatment for ear pathology using microinvasive technologies has two goals: 1 - elimination of the pathological process, 2 - restoration of hearing.

We perform sanitizing operations using both open and closed techniques with the restoration of the architectonics of not only the middle, but also the outer ear.

Do not start the disease, get treatment in a timely manner, do not allow the use of radical ear surgery without indications. Modern otosurgery allows the use of sparing methods of surgical treatment for chronic suppurative otitis media, namely, sanitizing operations with the restoration of the anatomical integrity of the middle and outer ear.

Tympanoplasty

The term tympanoplasty refers to ear surgery performed to improve hearing. Tympanoplasty involves full sanitation and revision of the middle ear cavities, preservation of elements of the sound-conducting apparatus of the middle ear, and in cases of their destruction - reconstruction of the transformational ear system using various plastic materials. In this case, the eardrum can be restored using the underlay or overlay technique. In the underlay technique, the autocartilage of the patient's auricle with the perichondrium or autofasction of the temporal muscle is used. The graft is placed under the remnants of the tympanic membrane on the handle of the hammer. And the overlay technique involves placing the graft, most often - autofascia, on the de-epithelized remnants of the tympanic membrane, with unfolding the epidermal layer of the tympanic membrane on top of the graft, which makes it possible to additionally strengthen it in its natural position. Depending on the degree of damage and the nature of the pathological process, the anatomical structure of the structures of the middle and outer ear, the surgeon chooses a method for restoring the tympanic membrane in each case, which allows achieving good results.

Ossiculoplasty

Ossiculoplasty - restoration of the ossicular chain. There are three ossicles in the tympanic cavity. The ossicular chain is a connected joint:

Hammer
Anvil
stirrup

In case of violation of the integrity or mobility of the chain of the auditory ossicles, due to trauma or inflammation, hearing loss occurs - hearing loss. In case of violation of the mobility of the chain of bones after tympanotomy, scars are excised, plaques, otosclerotic foci are removed, if necessary and appropriate indications, the bones are mobilized and removed, they are replaced with artificial ossicular prostheses or autogenous material, often autocartilage of the auricle. In practice, surgeons prefer the use of autogenous materials.

Ossiculoplasty in most cases can improve hearing, provide social rehabilitation of a patient with hearing pathology.

Stapedoplasty

The patient often associates a gradual hearing loss with a sulfuric plug - probably I have a plug! However, when examining the ENT doctor, it turns out that there is no plug, the eardrum is without signs of inflammation. In this case, the doctor prescribes audiometry and impedance measurements. With neuritis of the auditory nerve, the audiogram has a descending type with an increase in the thresholds for sound conduction and sound perception. Then the diagnosis is made - "sensorineural hearing loss" and conservative treatment is prescribed. With an increase in the sound conduction threshold and the absence of the stapedial reflex, "Otosclerosis" is diagnosed. This osteodystrophic disease, most often found in women against the background of hormonal changes in the body due to pregnancy or menopause, is accompanied by metabolic disorders with the formation of otosclerotic foci, with the involvement of the foot plate of the stapes and its fixation.

In practice, it happens that the ENT doctor does not determine the nature of the hearing loss and the patient is treated for a long time for neuritis of the auditory nerve, and in fact there is a fixation of the auditory bone - the stirrup. Late diagnosis of this pathology is fraught with the development of a cochlear form of otosclerosis, when hearing loss is sensorineural in nature and hearing restoration is impossible.

Tympanic and mixed forms of otosclerosis are successfully treatable today. The efficiency of stapedoplasty is 95%. The most commonly used stapedoplasty by the piston method, stapedoplasty with partial or complete stapedectomy.

If you are diagnosed with otosclerosis, do not postpone surgical treatment - stapedoplasty!

How are ear surgeries performed?

All patients before the operation at the outpatient stage undergo general clinical and laboratory examination, in the presence of somatic chronic pathology - examination by specialists (see the section of the memo to the patient).

In the presence of purulent discharge, conservative treatment is prescribed on an outpatient basis as a preparatory stage for surgical treatment in order to increase the efficiency of the operation.

Preoperatively, preparation for the operation is prescribed - sedative therapy, preparation of the operating field, bandaging of the lower extremities with elastic bandages.

Operations are performed both under local anesthesia and under general anesthesia using Karl Zeiss microsurgical techniques and Karl Storz microsurgical instruments.

In chronic suppurative otitis media, all operations are performed behind the ear, which provides a good view of the middle ear cavities and improves the quality of the surgical intervention.

After revision of the middle ear cavities and performing sanitizing intervention, a reconstructive stage is performed. Then the ear is tamponed, postoperative sutures are applied.

How is the rehabilitation stage after ear surgery?

The success of ear surgery largely depends not only on the skill of the surgeon, but also on adherence to the recommendations for managing the postoperative period. On average, the rehabilitation period lasts 2-3 months. The patient is in the hospital for the first two days. During the first week, the patient may feel pain, discomfort in the operated ear. Pain relievers are prescribed, and over time the pain dulls and goes away. On the 7th day after the operation, the tampons are removed from the ear, the stitches are removed. After removing the tampons, the patient often feels stuffy in the ear, but this should not be scared, because such a reaction is due to reactive edema. Also, the patient may notice anemia of the tip of the auricle, all these phenomena are temporary. As a rule, the discomfort disappears within 2-3 months.

In order to prevent displacement of the graft or ossicular prosthesis after surgery, it is not recommended:

blowing your nose with your mouth and nose closed,
blowing out the eardrum,
active movements, inclinations,
water ingress on the wound and tampons
physical exercise

After removing the tampons, you must:

Protect the operated ear from water,
Avoid noise and vibration,
Once a day, treat the postoperative wound with an antiseptic solution,
Apply ear drops (the drug is selected individually),
Provide satisfactory nasal breathing

Dynamic observation:

After discharge from the hospital, the patient must visit his surgeon on the 7th day after the operation to remove the tampons. Next, audiometry is prescribed, the effectiveness of the surgical intervention is assessed. Subsequently, the patient is under dynamic observation. When epidermis and cholesteatoma are detected, as is customary throughout the world, we also adhere to the follow-up tactic for 5 years after the operation. 12-18 months after the operation, an MRI of the temporal bones is prescribed in a special mode for determining the recurrence of cholesteatoma, and if necessary, repeated surgery is performed.

Hearing problems can arise for various reasons, and in some cases, the essence of the disease is reduced to a deterioration in the functions of the middle ear. In order to restore it, tympanoplasty is used - an operation during which the eardrum itself is directly reconstructed. This form of treatment has proven its effectiveness more than once.

The essence of the problem

When it comes to such a form of surgical intervention as tympanoplasty (surgery on the middle ear), we mean a specific method of treating chronic purulent otitis media in the area of the tympanic membrane. It is important to note that this effect is complex in nature and has a significant restorative effect, allowing you to reconstruct the middle ear.

It makes sense to pay attention to the fact that chronic otitis media is diagnosed quite often. It leads to a hole in the eardrum called a perforation. For this reason, it becomes possible for pathogenic bacteria to penetrate into which, in turn, leads to the release of pus, which can disturb for more than one year.

Tympanoplasty is an operation, without which it will be extremely difficult to overcome purulent otitis media. In addition, an advanced disease of this type can result in the occurrence of an abscess and thrombosis of the cerebral vessels, and in some cases, meningitis.

Indications for surgery

There are a number of conditions under which the aforementioned surgery is necessary. The bottom line is about the following health problems:

The formation of a marginal or central perforation of the tympanic membrane, which causes the displacement of the auditory ossicles;

Polyps that develop in the middle ear;

Tympanosclerosis;

Not accompanied by inflammatory processes;

Fibrosis of the middle ear.

Obviously, there are many reasons why surgery may be relevant.

Contraindications

It is important to understand that there are cases when ear surgery (tympanoplasty) will not be able to have the desired effect. Here are the diagnoses for which the use of such a technique is strongly discouraged:

Exacerbation of chronic diseases;

Adhesive otitis media;

Complete deafness;

Severe general condition of the patient;

Sepsis and purulent complications.

Sanitizing surgery on the middle ear with tympanoplasty is also contraindicated in the case when a persistent violation of the patency of the auditory tube is recorded. This category includes congenital anomalies, as well as scars and adhesions resulting from inflammation.

Relative contraindications

In this case, we are talking about those diseases against which the operation is undesirable, but possible. In this case, the final decision will be made by the doctor, based on his experience and the condition of a particular patient. So, the contraindications themselves:

Acute inflammation in the middle ear;

Diseases of an allergic type in the stage of exacerbation;

Upper respiratory tract problems;

Epidermisation process.

Only taking into account all the contraindications described above can a type of treatment such as tympanoplasty be prescribed. Feedback after surgery is an important sign of the quality of treatment, so it is always worth asking the opinion of patients about a particular clinic. The forums can help.

It is worth remembering that the doctor is obliged to examine the other ear and make predictions about the risk of its damage. After that, a decision will be made regarding the operation on the second tympanic membrane.

A full-fledged examination of a general nature should also be carried out: coaguloramma, biochemical and general analysis of blood and urine, as well as a blood test for syphilis, HIV, hepatitis B and C. The examination program also includes an ECG.

Preparation process for surgical treatment

Before surgery, conservative treatment is performed, which is designed to prepare the ear for tympanoplasty. Various agents are injected into the cavity of the middle part, where the eardrum is located, designed to have an anti-inflammatory, vasoconstrictor and antibacterial effect. They all have a wide range of effects.

Such procedures are very important, since they allow you to cleanse the operated area from infection. It is thanks to this procedure that safe tympanoplasty becomes possible. Reviews after the operation, respectively, will also be predominantly positive, since sanitation (cleaning) initially blocks the effect of the infection on the middle ear, and subsequently contributes to the rapid healing of the postoperative wound.

Moreover, such a measure leads to an improvement in the patency of the auditory tube, which has the most direct impact on the quality of the result of the surgical intervention.

If the patient has chronic diseases, then it is necessary to consult a specialized doctor. 7 days before the operation will be performed, you must refuse to take the funds used to thin the blood. We are talking about non-steroidal anti-inflammatory drugs (Paracetamol, Aspirin) and Warfarin.

Types of exposure

There are various techniques that can significantly improve the condition of the middle ear after surgery. For this reason, tympanoplasty can also be performed in different ways. It makes sense to highlight three key areas:

- Recovery using ossiculoplasty... It is relevant for those patients in whom, due to a serious inflammatory process, the auditory ossicles were damaged, and their rehabilitation is possible only with the help of prosthetics. In this case, materials such as titanium, cement and plastic are used.

- The essence of the second type is reduced to the closure of the tympanic membrane by means of the own tissues of the middle ear... The most common and least difficult is just such a tympanoplasty. Reviews after surgery of this type are in the overwhelming majority of cases positive.

- Myringoplasty without prosthetics. It is used to treat patients with injuries, but prostheses are not used. Native bone tissue is sufficient for restoration.

Sometimes doctors are faced with such a problem as the fusion of two surfaces of the middle ear, which is caused by a complication after otitis media. In this case, both grafts and the tympanic membrane itself, more precisely, its remnants, are used to restore the tympanic cavity.

Rehabilitation period

In order for the postoperative reviews to be positive when using such a method of treatment as tympanoplasty, it is necessary to organize a high-quality recovery of the patient.

First of all, this is a stay for 1-3 days in a hospital. Rehabilitation includes the use of antibiotics during the first postoperative week. Along with these restorative measures, daily anemization is relevant. This means the introduction of vasoconstrictor drugs into the pharyngeal opening of the auditory tube.

Since the release of the ear canal from tampons occurs gradually, at first the patient must come for examinations on a regular basis.

To get back to normal after the operation as soon as possible, you need to sneeze less, blow your nose and protect the auricle from water getting into it. It is best to consult your healthcare professional about effective methods of protecting against moisture while showering. Lifting heavy objects will also have to be abandoned. In fact, it is necessary to exclude any stress that could cause severe tension in the middle ear area.

Possible complications

If we consider all facets of surgical intervention, then it is worth noting that there are certain risks during a procedure such as tympanoplasty. Complications after surgery can be completely different: damage to the labyrinth, tympanic cavity, facial nerve and even dura maze. The latter, by the way, sometimes causes bleeding from the jugular vein or otoliquorrhea.

It is also worth paying attention to the risk of aseptic ear inflammation in this condition, as a rule, accompanied by discharge, swelling and pain.

Sometimes after tympanoplasty surgery, suppuration in the ear can appear. Reviews confirm the fact that a similar problem takes place. For this reason, a stationary regimen is important during recovery, since in case of possible complications, doctors will be able to provide qualified and timely assistance.

Complications of a general nature can also include prolonged headache (consequences of a labyrinth fistula), imbalance and dizziness.

How things are with transplants

Those who have undergone surgery with the use of prosthetics should strictly follow the recommendations of doctors, since in case of inflammation of the middle ear, the process of rejection may begin.

The fact of inflammation will also affect the speed of recovery. After using tympanoplasty using prostheses, there is a risk of displacement of the latter, as well as necrosis or atrophy. So, if prosthetics has taken place, you need to take care of yourself thoroughly.

Hearing loss

The group of complications includes the manifestation of hearing loss in the operated ear, which can reach the level of complete deafness. This problem makes itself felt after complicated or non-radical tympanoplasty. Impaired sound perception is sometimes the result of reactive labyrinthitis, which can go away without treatment. If this does not happen, then competent therapy under the supervision of a doctor will help neutralize this problem.

Thus, you need to understand that the hearing impairment caused by the labyrinthitis is temporary and treatable.

But the good news is that only 3% of patients who undergo surgery have such complications. Tympanoplasty reviews are mostly positive, so you should not be afraid of this technique.

Short-term paralysis

This is another complication that can appear after middle ear surgery. The good news is that the problem is temporary. The cause of transient paralysis is postoperative facial nerve edema.

In some cases, this nerve can be damaged due to intraoperative transection. Plastic is used as a remedial measure. It is about suturing the saphenous nerve of the neck. Alternatively, the facial nerve is sutured to the hypoglossal nerve. With such an intersection during surgery, even after plastic surgery, there is a risk of residual weakness of the facial muscles.

Therefore, it is extremely important to start medical correction on time. And in many cases it is necessary to perform certain operations on the ear. What they are, why are they needed and how they are carried out - such questions are asked by patients in need of surgical intervention. But only a specialist will give a competent answer.

general information

Most often, operations are performed on the middle ear for purulent otitis media. The inflammatory process has two types of clinical course: acute and chronic. The first develops under the influence of bacterial flora, which damages the mucous membrane and provokes the formation of pus. An acute process is often transformed into a chronic one (in the form of meso- or epitympanitis). And he, in turn, is characterized by persistent disorders: rupture of the tympanic membrane, the outflow of pus (constant or periodic), progressive hearing loss.

Chronic suppurative otitis media is often accompanied by destruction of the anatomical structures of the tympanic cavity. Its walls and auditory ossicles are affected by caries or cholesteatoma (a specific epidermal tumor). And both processes cause tissue destruction. This is followed by hearing loss, and there is also a risk of purulent complications, including intracranial complications.

Surgical treatment goals

The help of surgeons is most often resorted to for chronic otitis media. But even an acute process sometimes requires treatment using invasive technologies. Such operations should pursue several goals:

Elimination of pathological foci.
Preservation and improvement of hearing.
Reconstruction of anatomical structures.
Prevention of intracranial complications.

These are the most important points, the observance of which ensures the high efficiency of surgical treatment of otitis media. They can be accounted for in one operation (in stages) or in several.

Preparation

Any invasive intervention should be carried out after appropriate preparation, especially such a responsible one as ear surgery. The patient is preliminarily examined by a doctor to determine the exact diagnosis. This process is not complete without instrumental and laboratory research:

General blood and urine tests.
Blood biochemistry.
Group analysis and Rh factor.
Analysis of ear discharge (microscopy, culture).
Otoscopy.
Audiogram.
X-ray of the temporal bone.
CT scan.

The patient is consulted by a therapist to exclude concomitant diseases. In acute otitis media and chronic mesotympanitis, conservative measures are first used: antibiotics and non-steroidal anti-inflammatory drugs, rinsing and drops with antiseptics, catheterization of the auditory tube. And if they are ineffective, surgical correction is required.

Full preparation is an important stage on which the nature of the surgical intervention and its effectiveness depend.

Varieties

There are several operations on the ear for otitis media. Based on the clinical situation, the patient is recommended to undergo the following surgical procedures:

Sanitizing (radical) operation.
Tympanoplasty.
Eardrum paracentesis.

The scope and type of intervention is determined individually for each patient. They try to use the most gentle technologies that ensure the minimum degree of trauma and quick recovery. Operations on the tympanic cavity are performed under general anesthesia.

Sanitizing operation

Radical ear surgery for otitis media allows you to cleanse (sanitize) the tympanic cavity from pathological formations (caries and cholesteatoma, polyps and granulation), destroyed tissues, purulent exudate. This avoids the spread of infection to neighboring areas: into the cranial cavity, venous sinuses, the canal of the facial nerve. Thus, the following conditions will be the absolute indications for radical intervention:

Carious process.
Cholesteatoma.
Labyrinthitis and mastoiditis.
Neuropathy of the facial nerve.
Otogenic complications (meningitis, sinus thrombosis).

The essence of surgical manipulation is to unite all floors of the middle ear (attic, meso- and hypotympanum), cave (antrum) and mastoid cells into a single common cavity. The sanitizing operation is performed in several stages:

Antrotomy - trepanation of the mastoid process.
Resection of the posterior wall of the external auditory canal and the lateral wall of the attic.
Elimination of pathological tissues and exudate.
Communication of the resulting cavity with the outer ear.

Access is through the behind-the-ear space. Bone tissue manipulations are performed using special tools: cutters, medical hammer and chisels of various thicknesses. After the surgery, the healing process begins in the middle ear. Regenerates the mucous membrane, improves the general condition of patients. Turundas with antiseptic ointments (for example, Levomekol) are introduced into the cavity, then it is irrigated with solutions. Epithelialization of the walls is completely completed in a month.

Tympanoplasty

In order to improve hearing after radical surgery, tympanoplasty is necessary. It is postponed until the signs of postoperative inflammation disappear and the patency of the Eustachian tube is normalized. During the operation, the doctor restores the integrity of the tympanic membrane (myringoplasty) and the ossicular chain (malleus, incus, stapes). If the anatomical structures are completely or partially lost (were destroyed by the pathological process), then they are reconstructed using various grafts:

Autogenous (cartilage of the auricle, temporal fascia, skin of the external auditory canal on the vascular pedicle).
Allogeneic (cadaveric tissues).
Synthetic (polyamide fiber, polyphase).

Among the indications for tympanoplasty, not only chronic otitis media of the middle ear stands out, but also injuries or abnormalities of the tympanic cavity. The scope of the operation is determined by the safety of the sound-conducting structures. Therefore, there are five types of tympanoplasty:

The first is myringoplasty (perforation of the tympanic membrane with all the bones intact).
Second, the membrane is placed on the incus (malleus defects are present).
Third, the graft is brought to the stapes (no malleus and incus).
The fourth is the shielding of the labyrinth window (from the bones there is only the base of the stirrup).
Fifth, a hole is made in the horizontal semicircular canal, covered by an improvised membrane (all sound-conducting components are absent).

That is, conditions are created for the transmission of air vibrations from the external environment to the structures of the labyrinth (endolymph), which helps to improve hearing. The operation requires high-precision equipment (microscopes) and appropriate surgical instruments.

Tympanoplasty is used when it is necessary to restore the impaired function of the sound-conducting structures of the middle ear.

Paracentesis

In acute otitis media, the operation is performed when it is necessary to remove purulent exudate from the tympanic cavity. If conservative therapy, carried out in the pre-perforative stage, does not work, and during otoscopy, a protrusion is found in the membrane (from the pressure of the inflammatory fluid), then a manipulation called paracentesis should be performed. An emergency incision of the tympanic membrane is performed when signs of intracranial complications appear (intense headache, indomitable vomiting, dizziness). Most often, such a need arises in childhood.

After cleaning the external auditory canal and treating it with alcohol, local application anesthesia of the tympanic membrane is performed. The patient assumes a half-sitting or reclining position, his head is fixed on a pillow. The incision is made under a microscope at the site of the greatest bulging (most often this is the posterior-inferior region of the membrane). After that, the inflammatory exudate comes out, and it is necessary to ensure its free outflow. Only a cotton swab moistened with hydrogen peroxide is placed in the external auditory canal. Artificial perforation heals in a few days.

Effects

After the operation, patients may feel pain in the ear, and blood discharge will flow from it. This is a normal reaction and will last for several days. Usually, surgical intervention on the tympanic cavity is not accompanied by negative consequences. But the risk of complications still cannot be ruled out. These include:

Accession of infection.
Bleeding.
Facial nerve paresis.
Hearing impairment.

The patient should have constant communication with the attending physician and if any deviations appear during the postoperative period, inform him. The specialist will conduct an inspection and determine what needs to be done to eliminate them. To make the recovery period as easy as possible, certain actions should be limited:

Sneezing and blowing your nose.
Diving, swimming, visiting the pool.
Air travel.
Physical activity.

Purulent-inflammatory ear diseases often require surgical intervention. And in order not to bring the situation to the operation, you should consult a doctor in time for conservative therapy. If, nevertheless, you have to seek help from a surgeon, then you need to clearly follow all his recommendations. Then the treatment will be as effective as possible.

Is ear surgery scary for otitis media?

Otitis media is a common inflammatory disease of the middle ear. The disease occurs in both children and adults. With a neglected acute form, the pathology passes into a chronic stage. In childhood, otitis media leads to speech development problems, delayed psychomotor development. In a chronic form in adulthood, it contributes to the development of deafness.

The basic principles of the treatment of the disease are anti-inflammatory, analgesic and antibacterial therapy. Along with antibiotics, patients are prescribed compresses from boric alcohol and Vishnevsky ointment, various drops, warming up. Surgery may be required depending on the complexity of the disease and its form.

When is surgery required?

Surgery is performed when the disease is chronic or acute. The procedure involves an incision of the tympanic membrane. It is necessary for the outflow of purulent contents from the ear. Timely surgical care leads to an easier course of the disease and contributes to the complete recovery of the patient.

Main indications for intervention:

increased body temperature;
the formation of profuse purulent exudate;
pain in the ear;
the development of carious processes in bone tissues;
perforation of the membrane;
hearing impairment;
chronic inflammatory processes in the middle ear with severe suppuration.

Reference. In addition to the withdrawal of purulent contents, the procedure is also prescribed to restore ear functions and exclude infection.

Ear surgery for otitis media is contraindicated:

in case of a serious condition of the patient;
with chronic diseases in the active phase;
during sepsis;
with complete deafness;
with violations of the patency of the auditory tube.

Stages of the intervention

The operation is performed under local anesthesia. For young children and easily excitable patients, the use of rausch anesthesia is allowed. Features of the operation - to prevent inflammation and remove purulent contents from the middle ear.

The procedure is called myringotomy. If the tympanic membrane is perforated, it may require reconstruction. This procedure is called myringoplasty.

The main activity in preparation for surgery is a course of antibiotics. He is prescribed in a complicated situation. The course lasts no more than 4 days. After that, the procedure itself is carried out.

The operation consists in puncturing the membrane with a spear-shaped needle. Modification of the membrane requires its incision. It is usually located in the lower ear segment. Major modifications require an incision in the central segment of the membrane.

If chronic otitis media is diagnosed, the operation involves a puncture around the entire perimeter evenly. It is important that the needle does not penetrate deep into the tympanic cavity and does not damage the surface of the walls.

The final stage consists in removing purulent contents and treating the cavity with an anti-inflammatory and antiseptic composition. Finally, the incision is plugged.

If the inflammatory process is strong and purulent contents are constantly formed, it may be necessary to install a shunt - a tympanostomy tube. It prevents overgrowth of the incision and ventilates the cavity.

The shunt is removed after the inflammatory process is completely blocked and no purulent contents are released. After the tube is removed, the incision will quickly heal.

Features of rehabilitation

The operation is a quick procedure that takes place without major complications. It is important to follow proper ear care during the rehabilitation phase. In most cases, after surgery, the patient remains in a hospital. At this time, the doctor observes the incision and the formation of purulent contents.

The patient is prescribed a course of antibiotics. It lasts from 7 to 10 days. Antibiotics help avoid possible complications and infection. Taking antihistamines is necessary to relieve swelling and reduce pressure in the ear canal.

Another stage of rehabilitation is the constant replacement of tampons. The ear canal must be kept clean. Gradually, the tampons are removed. When placing tympanostomy tubes, a constant visit to a specialist will be required.

They are installed for a period from 2-3 weeks to several months. At each appointment, a hearing care professional will perform a hearing test and examine the tubes.

Important! At the stage of rehabilitation, it is necessary to avoid getting water into the ears, you should not blow your nose or sneeze. Air travel, swimming, diving and other activities involving pressure drops are not recommended.

Operation for otitis media is performed at various stages of the disease and is not serious. The main task of the patient is to properly prepare for the procedure and fulfill all the doctor's requirements at the stage of rehabilitation.

Experts note that after the operation, the quality of hearing improved in most patients. Inflammatory processes in the ear have become less acute. Otitis media does not become chronic and does not lead to perforation of the tympanic membrane.

Directory of major ENT diseases and their treatment

All information on the site is for informational purposes only and does not claim to be absolutely accurate from a medical point of view. Treatment must be carried out by a qualified doctor. Self-medication can hurt yourself!

Surgery for chronic purulent otitis media: conduct and follow-up care

For otitis media, surgery may be required in some cases. This procedure is of varying complexity, depending on the diagnosis. In addition, long-term rehabilitation after the intervention is required, which complicates the treatment process. But sometimes this is the only way to get rid of the disease and its consequences.

Indications for surgery

Surgical intervention may require an ear that is affected by inflammation, has passed into a complicated stage and is not amenable to conservative treatment. In some cases, this is the most effective way to get rid of pain and stop destructive processes in the body.

If the bone tissue of the ear is damaged and the infection further spreads, radical surgery is a necessity.

Mostly in this way, a chronic type of disease is treated. This also includes the most common diagnosis of this category - chronic otitis media. In this case, the operation allows you to solve the problem and remove the purulent secretion.

The operation is necessary in cases where otitis media is accompanied by the following symptoms:

high temperature;
profuse purulent exudate;
severe pain;
carious processes in bone tissue;
perforation of the tympanic membrane;
violation of the position and functioning of individual elements of the ear.

The ear is preliminarily examined with an otoscope, computed tomography and other necessary studies are performed.

Operation

The operation, which requires chronic purulent otitis media, is aimed at removing the focus of inflammation and preventing further accumulation of secretions. Leathery pockets inside the middle ear cavity often cause purulent secretions to accumulate in it. Due to the violation of the outflow of fluid, a favorable environment is created for the development of pathogenic microorganisms.

The operation carried out for otitis media for a child is not much different from an operation in an adult, but at the same time it is possible to distinguish such a nuance as the underdevelopment of the hearing organs, which is associated with the ongoing processes of growth of the body.

Chronic purulent otitis media of the middle ear is promptly treated as follows. To pump out the pus, the tympanic membrane is incised and then a drainage tube is inserted. After sanitation of the ear cavity, damaged areas of the epithelium are removed.

If the disease has affected the inner ear, more complex manipulations are performed in relation to those parts of the organ that have undergone changes.

Rehabilitation

Rehabilitation after surgery is more difficult than the surgery itself. Chronic purulent otitis media can worsen if hygiene rules are violated in the postoperative period. In this case, a purulent secretion forms at the site of the damaged epithelium and fills the middle ear cavity.

Recovery can take place in different ways:

Tamponade. After the initial healing of the epithelium, regular ear dressings are performed. In addition, antiseptics and antibiotics are used.
Dry method. In this case, the ear is cleaned daily and dried. For this, boric powder is blown into the ear.

If the ear does not heal properly, in addition to the risk of recurrence of chronic suppurative otitis media, granulation and scarring may occur in the middle ear cavity.

A trained surgeon and proper postoperative care will increase the chances of getting the most out of the problem.

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All information on the site is for reference only. Before any treatment, it is imperative to consult a doctor.

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What help is needed for the ear with purulent otitis media

Purulent otitis media (in accordance with the generally accepted international system ICD 10, the disease was assigned the code H66) is a complicated inflammation in the middle ear after pathogenic bacteria enter this department. The disease is usually accompanied by severe pain, fever. Discharge appears after perforation of the tympanic membrane. Provided an early start, the process of treating purulent otitis media is usually not difficult.

The classical regimen of therapy includes antibiotics and the fight against infection in the nasopharynx. Additionally, physiotherapy can be prescribed. But if the course of taking the drugs is not completed, or the disease is let go, the inflammation turns into a chronic sluggish process or spreads further. More often, with prolonged purulent otitis media, there is such a complication in the ears as hearing loss.

Pathogenesis and main causative agents of purulent otitis media

The auditory or Eustachian tube is a kind of bridge that connects the nasal cavity and ears. It is clear that any microflora from the nasopharynx can easily penetrate into the space behind the eardrum. However, the appearance of signs of purulent otitis media is hampered by the properties of the epithelium covering the inner wall of the Eustachian tube. The mucus secreted by these cells contains various components, factors of local immunity that have antimicrobial activity.

Therefore, normally, these substances prevent the spread of bacterial flora and the occurrence of a disease such as purulent otitis media. However, under the influence of a number of factors, which, among other things, cause the appearance of non-genital inflammation in the ear, the rheology of mucus and the functioning of the structures secreting the secret are disrupted. As a result, pathogenic bacteria can freely enter the ear cavity. The increasing pressure usually leads to perforation of the tympanic membrane.

Identification of the pathogen in each case of purulent otitis media is difficult, since for this it is necessary to sow the secretion obtained from the middle ear cavity. This procedure is invasive and can be performed using a special puncture microneedle. Usually, a similar manipulation is done in the case of recurrent ear purulent otitis media. According to statistics, usually the inflammation in the ear is caused by strains of bacteria that are constantly present in the nasopharynx in almost every person.

These are pneumococcus and Haemophilus influenzae. Moreover, half of them release β-lactamase, which makes these microorganisms resistant to the effects of most antibiotics from the penicillin group. Less commonly, purulent otitis media is a disease caused by strains of bacteria moraxella, Staphylococcus aureus, β-hemolytic streptococcus. According to doctors' reviews, it is possible to assume the role of mycoplasma and chlamydia in the occurrence of symptoms of inflammation in the ear.

Classification of purulent otitis media

Depending on the rate of development of clinical signs, there are several stages in the course of purulent otitis media. But there is another classification of the disease. It is based on physiological changes that are noticeable only after the ears are examined by an ENT doctor. By the nature of the perforation of the tympanic membrane and the degree of involvement in the inflammatory process of the parts of the hearing organ, purulent otitis media of the following forms are distinguished:

tubotympanic (mesotympanitis), when the disease affects only the Eustachian tube and the space behind the tympanic membrane;
epitimpano - antral (epitympanitis) with damage to the auditory ossicles and tissues of the mastoid process.

The first form of the disease can be considered favorable. It is successfully treatable and does not cause severe hearing impairment. Changes after epithympano-antral type of inflammation are usually irreversible and require a complex surgical operation. Depending on the frequency of occurrence of symptoms of purulent otitis media, the disease can be acute or chronic.

Etiological factors in the development of acute and chronic purulent otitis media

All causes of purulent otitis media can be divided into several groups. These are tubogenic (or rhinotubal), that is, the penetration of infection through the auditory tube, external, affecting the ears with perforation of the tympanic membrane and hematogenous. In the latter case, the microbial flora enters the internal cavity of the hearing organ with blood from other foci of inflammation. I must say that this situation is extremely rare. The following factors can cause pain and other symptoms of acute purulent otitis media:

angina, it must be emphasized that this disease is contagious, but leads to the development of inflammation in the ear only if there are predisposing reasons;
tonsillitis;
pharyngitis;
bacterial rhinitis, sinusitis;
injury with damage to the tympanic membrane and mastoid;

In addition, purulent otitis media can be a consequence of measles, scarlet fever, diphtheria, tuberculosis. Often, a similar disease occurs after the transferred influenza virus. A retrograde pathway of transmission of pathogenic microflora is also possible in case of labyrinthitis, meningitis or an abscess in the cranial cavity. An exacerbation of a chronic inflammatory process appears against the background of respiratory infections, ingress of water through an unstretched eardrum when swimming or diving, hypothermia.

Provoking factors

As practice shows, the presence of one or even several of the listed reasons does not always cause purulent otitis media in adults and children. The predisposing factors for the onset of an acute or chronic form of the disease are the insufficient content of nutrients in the diet, vitamin deficiency. Persistent edema of the nasal cavity causes an allergic reaction, adenoid vegetations, disorders of the nervous regulation of the vessels of the mucous membrane (vasomotor rhinitis). Interfere with the normal functioning of the nasopharyngeal system - the Eustachian tube polyps, neoplasms. The risk of developing purulent otitis media increases with weakened immunity as a result of HIV infection or AIDS, under the influence of taking certain medications (cytostatics, corticosteroids, chemotherapy drugs).

Stages of purulent otitis media

Unlike other forms of otitis media, purulent is characterized by pronounced clinical signs. Their intensity and development is closely related to disorders occurring in the tympanic cavity. The disease proceeds in several stages. They are called the stage of purulent otitis media:

preperforative. An inflammatory process begins in the mucous membrane of the Eustachian tube, which gradually covers the space behind the eardrum;
direct perforation of the membrane. In accordance with all the laws of physics, the pressure in the middle ear cannot increase indefinitely. As a result, a large volume of serous fluid mixed with mucus and pus breaks through the thin membrane. In addition, the transudate contains proteolytic enzymes that contribute to the destruction of membrane tissues;
postperforated. With a favorable course at this stage, scarring of the tympanic membrane begins. This process can be compared to the healing of a small scratch. But if the size of the perforation exceeds 1 mm, the hole is tightened with mucous tissue, which is more susceptible to the influence of environmental factors.

However, this classification is not applicable for chronic suppurative otitis media. Exacerbation usually begins bypassing the first stage. It is also worth noting that long-term inflammation is characterized by the presence of mixed microflora. Therefore, this form of the disease is more difficult to treat.

Clinical manifestations and diagnosis of purulent otitis media

Symptoms of purulent otitis media in adults and children increase gradually. But in some cases, a person does not pay due attention to the first clinical signs of inflammation. Usually, an acute infection is preceded by a feeling as if water had entered the ears. Then there are such signs of purulent otitis media:

severe pain, since in the cavity of the organ of hearing there are sensitive endings of the nerves that transmit impulses to other tissues of the face, pain is felt in the jaw, temple, cheek;
discharge from the ear canal. Their nature depends on the form of the disease. So, mesotympanitis causes odorless mucous discharge, and epitympanitis causes scanty, thick, foul-smelling discharge;
hearing impairment, the symptom is subjective, since a slight deterioration in this function does not mean that the bone tissue is not affected by the infectious process;
the temperature with purulent otitis media rises to 38 ° and above, but usually decreases after perforation and exudate.

The disease can be determined by examining the tympanic membrane by an ENT doctor. Further diagnosis by X-ray and tomography methods is necessary when deciding whether to perform a surgical intervention. If the results of the examination are in doubt, blood and urine tests can give directions to find out the exact cause of the increase in temperature.

Ear drops for the treatment of purulent otitis media

It must be said that drops with purulent otitis media should be prescribed with caution. The fact is that most drugs cause irreversible hearing impairment. Therefore, the list of agents that can be used to treat the disease at the stage of tympanic membrane perforation is limited to a few medications. At the first stage, in the treatment of purulent otitis media (if there is no discharge), you can drip the following drugs:

These drops are not used for long-term treatment of purulent otitis media in adults and children, since they do not have antibacterial activity. Due to the ototoxic effect, their use is limited during pregnancy and lactation. The same can be said for antimicrobial ear drops. Contains antibiotics such medicines prescribed for the treatment of purulent otitis media:

The advantages of Anauran and Candibiotic drops are the presence in their composition, in addition to the antibiotic, of an anesthetic and an anti-inflammatory component. Therefore, they are recommended to be used in the initial stages of purulent otitis media to relieve pain instead of Otipax and its analogues. Separately, it must be said about such a drug as Otofa. This product contains the antibacterial agent rifampicin and is the only medication that can be dripped for a perforated eardrum.

Other medications for the treatment of purulent otitis media

Unlike non-suppurative forms of ear inflammation, it is contraindicated to warm up and make compresses in acute and chronic purulent otitis media. Heat provokes further reproduction of pathogenic microflora and greatly increases the risk of meningitis and other dangerous complications. Therefore, it is better to use gauze or cotton swabs soaked in antimicrobial solutions. Doctors advise using Miramistin or Dioxidin.

These drugs are not available in the form of ear drops. Miramistin is sold in vials, while Dioxidin is sold in ampoules. They can also be instilled into the ear at the same dosage as other products - 3-4 drops 2-3 times a day. It should be emphasized that regardless of whether right-sided otitis media or left-sided, both ears should be treated at the same time.

Antibiotics for systemic use - the main therapy for purulent otitis media

Treatment of purulent otitis media in most cases is not complete without antibacterial drugs. The complications that this disease can cause are much more dangerous than the possible side effects from the use of drugs in this group. Therefore, antibiotics are prescribed when severe symptoms of purulent otitis media appear, when the temperature is kept at 37.5 ° and above for two days or more. Usually drugs with a wide range of efficacy are used.

For example, during pregnancy, the use of a protected form of amoxicillin Amoxiclav is allowed. Ceftriaxone, a cephalosporin drug, is relatively safe for a newborn. Its counterpart is Zinnat. However, this antibiotic is prescribed for purulent otitis media for children over 2 years old and adults.

How long the treatment lasts depends on at what stage of the disease the antibacterial drug was started. If the medicine was prescribed at the first symptoms of pathology, this period is 7 to 10 days. With the spread of a purulent process, it is possible to prescribe a combination of antibiotics. In this case, the course of admission lasts up to two weeks.

Complications of purulent otitis media

Complications with purulent otitis media occur when the disease is improperly treated at home, or in its absence at all. In addition, ear compresses and warming can worsen the patient's condition. Therefore, timely diagnosis and adherence to the doctor's recommendations are of great importance in the prevention of complications of purulent otitis media. Otherwise, mastoiditis, labyrinthitis and otogenic intracranial pathologies may occur.

Mastoiditis

This is a defeat of all tissues of the mastoid process with bone destruction. Usually occurs at a late stage of ear inflammation (at the end of the second - beginning of the third week of the disease). Symptoms of mastoiditis are fever, hearing impairment, pain when pressing on the tragus, swelling behind the auricle, as a result of which it protrudes noticeably. Sometimes it is possible to discharge pus not only due to perforation of the tympanic membrane, but also through the posterior wall of the ear canal.

At the initial stages of mastoiditis, its therapy does not differ from the treatment of purulent otitis media in adults. But if the use of Amoxiclav or Ceftriaxone remains without effect, the administration of Levofloxacin is indicated. Surgical intervention is widely used in the treatment of the disease. However, the indication for surgery is the deterioration of the patient's condition while taking antibiotics.

Labyrinthitis and meningitis

Labyrinthitis is an acute purulent inflammation of the inner ear, which is limited or diffuse. It is dangerous by damage to the vestibular apparatus and the sound analysis system. Even with timely started treatment, several pathological outcomes are possible. This is recovery, cessation of inflammation with persistent impairment of hearing and a sense of balance, purulent labyrinthitis and the death of all cell receptors.

Meningitis is dangerous due to the rapid development of symptoms, disability and death. Typical clinical signs of the disease are a sharp increase in temperature, vomiting, not associated with food intake, photophobia, bursting headache. From the first day of the development of pathology, characteristic meningeal symptoms appear. This is a stiff neck and Kernig's syndrome.

Surgical treatment of purulent otitis media

The most common and relatively minimally invasive method used for surgical treatment of purulent otitis media in adults and children is a puncture of the tympanic membrane. It is done with a special scalpel under local or general anesthesia. Through the holes, the ear cavity is washed and a mixture of glucocorticoid hydrocortisone and an antibiotic in saline is injected. After the procedure, a sterile swab is inserted into the ear canal and pus is allowed to flow freely from the tympanic cavity. Recurrent otitis media requires other surgeries to restore hearing:

mastoidoplasty for the reconstruction of the mastoid process;
tympanoplasty, its purpose is to sanitize the ear cavity and regenerate the tympanic membrane;
atticoanthromia is intended to remove necrotic tissue;
mastoidotomy, this operation for purulent otitis media is performed to cure mastoiditis if there is no effect of drug therapy.

When the inner ear is affected in childhood and adulthood, a labyrinthotomy is indicated. In most cases, doctors try to perform hearing-preserving surgery. However, with the further development of the inflammatory process and the risk of meningitis and intracranial abscesses, a radical operation is indicated. The remnants of the ossicles and tympanic membrane are removed. The main complication of this procedure is a hearing loss of about 30 dB. This intervention is carried out only in a hospital setting after the patient is hospitalized. The doctor will show a detailed video of the operation progress during the consultation.

Traditional medicine and physiotherapy

Of the methods of physiotherapy for the treatment of purulent otitis media, helium-neon laser, washing the ear cavity with hydrogen peroxide and other antiseptic solutions, and ultraviolet radiation are widely used. It is contraindicated to warm the ear with compresses, to act on active points with acupressure for symptoms of purulent otitis media. Chronic ear inflammation can be treated with homeopathic remedies. Alternative methods of treating the disease are also widespread:

take in equal proportions the herb of celandine, St. John's wort, calendula and succession (photos of these plants can be found in the reference book). Pour 100 ml of boiling water and leave for 8 hours. Bury it in a sore ear, before that it should be rinsed with drops of hydrogen peroxide;
pour a glass of vegetable oil into an enamel pot, add a tablespoon of beeswax and bring to a boil. Then gradually stir in the pounded yolk of a boiled chicken egg and filter through a sieve or cheesecloth. Use the ointment to lubricate the skin behind the ear or apply to a cotton swab and insert into the ear canal;
chop the garlic, squeeze out its juice, dilute with warm boiled water in a 1: 1 ratio. Soak gauze turundas in this solution and inject them into the ear for 20 - 30 minutes.

The consequences of purulent otitis media are very serious, therefore, treatment with folk remedies at home is contraindicated in infants and children under 2 years of age. A child should also not be vaccinated if there is the slightest sign of an inflammatory process. Recurrent purulent otitis media requires mandatory observation by an ENT doctor. An operation performed before the development of irreversible changes will help preserve hearing.

All information on the site is presented for informational purposes only. Always consult your doctor before applying any recommendations.

Prevalence: Very common, especially in children. It occurs in approximately 1% of schoolchildren. More accurate data were obtained when examining pre-conscripts when they are older, among them this figure reaches 3-4%. More than half of adults suffered from otitis media during childhood.

In the structure of the causes of persistent hearing loss associated with damage to the sound-conducting apparatus, chronic suppurative otitis media takes about 60-70%; in about 80% of children, the onset of the disease is associated with ARVI, in 5-7% - with other childhood infections.

What provokes Chronic suppurative otitis media:

In most cases, chronic suppurative otitis media is the result of acute inflammation of the middle ear. There are general and local reasons for this development of the process.

high virulence of microflora represented by hemolytic streptococcus, Proteus, Pseudomonas aeruginosa, anaerobes (severe general infections), staphylococcal or atypical bacteria (chlamydia, mycoplasma);
malnutrition, severe vitamin deficiencies;
genetic predisposition (heredity factor);
allergy, decreased immunoreactivity of the body;
chronic diseases of the respiratory tract and gastrointestinal tract;
irrational treatment of acute otitis media;
frequent acute inflammation of the middle ear.

dysfunction of the auditory tube;
adenoid vegetation in the nasopharynx;
chronic inflammatory diseases of the nose and paranasal sinuses, nasal polyposis;
hypertrophy of the posterior and anterior ends of the inferior turbinates, leading to tubo-otitis and deterioration of the function of the auditory tube;
anatomical features of the structure of the middle ear in children: poor communication between the attic (epitympanum) and the cells of the mastoid process due to the block of the mastoid cave, easily onset edema of the mucous membrane, many folds, pockets of the mucous membrane that worsen drainage I outflow of pus from the middle ear in acute otitis media;
poor pneumatization of the mastoid process, its spongy or sclerotic type;
a close vascular connection in the child's ear between the mucous membrane and the bone marrow cavities, which leads to the development of osteomyelitis.

Symptoms of Chronic suppurative otitis media:

Chronic purulent otitis media can occur in two forms: in a relatively favorable form - mesotympanitis (about half of cases) and in a more severe form - epitympanitis (about 20% of diseases), the remaining 30% are in a mixed form - epimesotympanitis.

With a mesotympant, the pathological process affects only the mucous membrane of the middle ear, with an epitympant, bone tissue is involved in it. In this regard, it is very important to differentiate between these two forms of chronic otitis media.

The disease occurs in two variants. In the first, the symptoms of a chronic process are only constant dry perforation of the tympanic membrane and persistent hearing loss.

Periodically, usually after an infectious disease or infection of the tympanic cavity through a perforation (mainly when water gets in), an exacerbation occurs with fever, pain in the ear, symptoms of general intoxication, the appearance of secretions, hyperemia of the remnants of the tympanic membrane, sometimes with neurological symptoms.

In the second option, children with a good general condition constantly have purulent or mucous discharge from the ear. Exacerbations in these children are accompanied by general symptoms (fever, headache, signs of intoxication) and increased discharge from the ear, accompanied by pain.

Complications. With chronic suppurative otitis media, intracranial complications are possible. Such complications can develop in acute otitis media. In case of intracranial complications, urgent surgical treatment of the ear is necessary in order to sanitize the focus. Without surgery, the child can die, often dies, despite active antibacterial and other therapy.

Diagnostics of the Chronic suppurative otitis media:

Anamnesis At the first meeting with a sick child, it is not always possible to establish the chronization of the process. For differential diagnosis with recurrent or protracted acute otitis media, the history should be collected especially carefully. Find out information about previous illnesses. Egagashpanti often burns with scarlet fever, diphtheria or measles, and also after the flu. To some extent, the severity of the disease is evidenced by the frequency of recurrence of otitis media, the duration and persistence of suppuration. It is important to find out how often exacerbations occur, whether they are accompanied by fever, signs of intoxication, severe pain in the ear, neurological symptoms (headache, dizziness, static disturbance, etc.).

Find out how the child was treated during periods of exacerbation and remission, in a polyclinic or in a hospital, whether surgical intervention was previously offered. The results of previous studies of hearing (audiograms), radiographs of the temporal bones and data on the composition of the microflora are of great importance.

Otoscopy Perforation in chronic purulent otitis media can be of various shapes (round, kidney-shaped, etc.) and size. The main thing for the differential diagnosis of meso- and epitympanitis is the preservation of the edges of the tympanic membrane. If there is an edge, the perforation is called central and is characteristic of mesotympanitis. If this edge is absent and the perforation reaches the tympanic ring, it is called marginal and is typical for epitympanitis.

The nature of the discharge.Mesotympanitis causes mucous discharge, often quite abundant, but odorless. If bone tissue is involved in the process, the discharge becomes leaner, thicker, with an ichorous odor due to incipient ostemyelitis. The amount of discharge from the ear is not of great importance for diagnosis, although with mesotympanitis with the location of perforation in the lower parts near the mouth of the auditory tube, they become very abundant. This form of mesotympanitis is even isolated as chronic tubo-otitis.

Pathological changes in tissues. The osteomyelitis process with epitympanitis is often accompanied by the development of granulations. In this case, they are sometimes even visible through the perforation, and an admixture of blood appears in the discharge from the ear. Granulations can protrude through this opening into the external auditory canal and take the form of a polyp.

Ear polyps, although less often, can also form during mesotympanitis due to constant irritation of the mucous membrane of the tympanic cavity with pus.

Especially it is necessary to dwell on the formation of a kind of tumor-like formation, which is called cholesteatoma, during epitympanitis. Among all children treated for chronic otitis media, it occurs in 20-30% of cases, and in boys it is 2 times more frequent. The pathogenesis is not fully understood.

Numerous theories (tumor, epiblastic, devascular, migratory, inflammatory, etc.) do not fully explain the mechanism of its development. Some authors attach the main importance to heredity and believe that cholesteatoma arises as a result of metaplasia of the epithelium of the middle ear with certain anatomical features. Others believe that cholesteatoma is the result of invasion of the epithelium of the external auditory canal into the tympanic cavity with marginal perforation and the absence of a mechanical barrier in the form of remnants of the tympanic membrane.

Cholesteatomic masses are impregnated with cholesterol, waste products of microorganisms, desquamated epithelium and, due to the constant growth of the matrix cholesteatoma membrane), atrophy and destruction (lysis) of individual parts of the temporal bone (it was even called "cartilage") occur. This is the main danger of cholesteatoma. With mesotympanitis, cholesteatomas are rare (in about 3-5% of cases). Cholesteatoma is not always easy to diagnose. In older children, you can try to probe the attic through the perforation, while the bone is soft and rough (due to caries). Sometimes, using a special cannula, you can rinse the attic through the perforation and detect cholesteatoma scales in the fluid. In young children, this, as a rule, is impossible, and therefore an indication of cholesteatoma can only be given by an X-ray examination of the temporal bone, in which a defect in the bone tissue in the form of enlightenment is clearly defined in the images.

Cholesteatoma in children has features:

little symptom;
education in a short time;
the fastest growth in a child under 5 years of age;
more rare than in adults, damage to the roof of the tympanic cavity, caves, semicircular canals and the wall of the facial nerve canal.
an increased tendency to relapse due to a retraction pocket in the upper parts of the tympanic cavity.

Hearing research. The study of auditory function is important, and it is not a matter of the degree of its decline. With meso-tympanitis, hearing loss can also be significant due, for example, to a violation of the conduction in the ossicular chain. On the contrary, with epitympanitis, hearing can remain relatively good, since sound conduction can to some extent be carried out through granulations or cholesteatomic masses.

For diagnosis, it is important that with epitympanitis, the inner ear is much more often involved in the process, which is expressed on the audiogram by a decrease in bone conduction.

Radiography. Diagnosis of a small cholesteatoma of the middle ear is rather difficult. The choice of optimal projections is of great importance for a correct understanding of the prevalence of the process. At present, the Schüller (cave) and Mayer (attic) projections are more commonly used.

With an exacerbation of the process, a clear contour of the sclerosed bone is lost, since it is involved in the inflammatory process. In these cases, transorbital projections (along the Highway) are used, in which the superposition (overlap) of dense formations on each other is reduced and even a small cholesteatoma located in the attic and in the opening leading to the cave can be detected.

Differential diagnosis. Chronic suppurative otitis media sometimes has to be differentiated from a tumor and histiocytosis. With histiocytosis X, almost 70% of children have ear pathology. Signs of histiocytosis:

isolated or systemic damage to bone tissue with multiple defects, sequestration and areas of purulent fusion;
overgrowth of specific granulation tissue (eosinophilic granuloma);
total lymphadenopathy with hepatosplenomegaly;
damage to the skin; exophthalmos as a result of the formation of xanthoma nodes in the anterior cranial fossa along the optic nerve; defeat of the flat bones of the skull (primarily temporal).

Quite rare, but still found in childhood, middle ear sarcoma: round cell, fusiform sarcoma and lymphoangiosarcoma. It often occurs as a primary tumor in early childhood. In the external auditory canal, pale pink bleeding granulations are detected, a biopsy allows an accurate diagnosis. The spread of the process is indicated by CT data. Radiation and surgical treatment, but its effectiveness is low due to rapid metastasis.

Treatment of Chronic suppurative otitis media:

Treatment depends on the period of the disease, the choice of treatment method is associated with the duration of the disease, the frequency and severity of exacerbations, otoscopic picture, radiological data, hearing condition, etc.

In principle, it can be noted that in most cases, with chronic purulent mesotympanitis, conservative treatment is carried out, and with epitympanitis, surgical treatment.

With an exacerbation of the process with pain in the ear, the appearance or intensification of suppuration, active general anti-inflammatory antibiotic therapy is performed, as well as local therapy. During the period of remission, outside the exacerbation of the process, when the general symptoms disappear, and suppuration continues, mainly local therapy is used (antiseptic, more often alcohol, drops, injection of sulfanilamide powder).

A good effect is also observed when using low-energy radiation from a helium-neon laser. Contraindications to laser therapy: chronic otitis media with ear polyps, cholesteatoma, symptoms of mastoiditis, suspected intracranial complications. Laser irradiation leads to a decrease in otorrhea, edema and tissue hyperemia. However, the conduct of laser therapy for children requires increased attention from personnel to safety rules. There are a lot of local treatment methods, but an indispensable precondition for the action of the drug on the mucous membrane of the middle ear is the removal of pus - the so-called ear toilet. With persistent and persistent treatment of mesotympanitis, suppuration can be stopped in 80-90% of cases.

If the child turns out of exacerbation, without suppuration, then preventive measures are taken:

sanitation of the nasopharynx;
treatment of chronic inflammatory processes in the nasal cavity and paranasal sinuses;
general and local hardening for the prevention of obstructing respiratory diseases;
preventing water from entering the ear, as water can cause suppuration (when bathing a child or washing the head, close the external ear canal with cotton wool soaked in sterile vaseline oil).

To close the perforation, the same semi-surgical (refreshing the edges of the perforation, burning them) and surgical methods (high-energy laser exposure and myringoplasty) are used.

It is more difficult to carry out effective conservative treatment for chronic purulent epitympanitis, especially if it is accompanied by the development of granulations, polyps, or the formation of cholesteatoma.

Treatment methods (local and general), which are used for epitimpanitis, can, at best, eliminate the exacerbation of the process, but do not eliminate osteomyelitis. It would seem that the easiest way to treat with surgery, but the main obstacle to its widespread use is satisfactory hearing, which is usually reduced as a result of surgery.

In this regard, in recent years, limited operations are widely used, in which only carious bone is removed under the control of an operating microscope and, if possible, the sound conduction system of the middle ear is preserved (the so-called hearing-preserving operations). Such microsurgical interventions in 75% of cases allow to sanitize the ear and at the same time preserve the auditory function.

Such operations are technically difficult and require good preparation: sanitation of the upper respiratory tract, preliminary washing of the tympanic cavity, restoration of patency of the auditory tube, etc.

If the child's hearing has already been lost as a result of a chronic purulent process, then a radical general cavity operation on the ear is performed, in which all pathological contents are removed: cholesteatoma, polyps, granulations, carious bone, auditory ossicles affected by the process, etc.

Such a surgical intervention is rather difficult and requires a good knowledge of the anatomy of the temporal bone, since it is necessary to operate in a small space next to the canal of the facial nerve, labyrinth, sigmoid sinus, middle cranial fossa, etc.

In a typical case, an incision is made along the transitional fold behind the ear, after separating the soft tissues with a chisel or burs, the cave is opened, then the posterior bone wall at the external auditory canal and the lateral wall of the attic are removed. As a result, a common space is formed from the tympanic and antral cavities (therefore, the operation is called general cavity).

After the operation, the ampulla of the horizontal semicircular canal is clearly visible, since the posterior bony wall is removed to its level, the horizontal section of the facial nerve canal, the mouth of the auditory tube, the roof of the tympanic cavity and antrum, the bony wall separating the cells of the mastoid process from the sigmoid sinus. The preserved posterior skin wall of the external auditory canal is cut in such a way that pedicle flaps are formed (T- or L-shaped plastic). These flaps subsequently become the source of the epidermis. The behind-the-ear incision at the end of the operation is usually sutured, and the postoperative cavity is treated with dressings (through the external auditory canal).

At the first stage, the trepanation bone cavity is covered with a thin layer of granulations, along which there is a gradual epidermisation from plastic flaps of the posterior wall of the external auditory canal. This process is quite lengthy, lasting several months.

The postoperative period in children is more difficult than in adults, due to a tendency to excessive growth of granulations, frequent reinfection of the cavity through the auditory tube, difficulties in dressing, exacerbations of the process after infectious diseases.

In about 5-10% of cases, the purulent process in the postoperative cavity continues, although intracranial complications are practically not observed due to a good outflow.

The negative aspect of radical ear surgery is the inevitable hearing loss of about 30 dB due to the removal of carious ossicles and remnants of the tympanic membrane. However, in case of severe carious processes that are not amenable to conservative treatment, the operation is carried out, since the likelihood of developing otogenic intracranial complications, in relation to which the operation has a prophylactic significance, poses a great danger.

Tympanoplasty. Around the 50s, it was proposed not only to sanitize the middle ear with its chronic inflammation using a radical general cavity operation, but also to perform reconstructive intervention, restoring the sound-conducting apparatus to one degree or another.

These surgical interventions are performed using operating microscopes with special thinnest instruments using local or alloplastic tissues. The complex of such a hearing-improving surgery is called tympanoplasty.

Depending on the degree of destruction as a result of the inflammatory process or operation of the sound-conducting apparatus, the founder of tympanoplasty A. Volstein identified 5 types of tympanoplasty: the simplest is the elimination of the defect of the tympanic membrane (myringoplasty or tympanoplasty of type I), the most difficult is type V, when the entire sound-conducting system is destroyed. Type V tympanoplasty is rarely used.

Naturally, a prerequisite for tympanoplasty is sufficient preservation of the function of the receptor apparatus of the inner ear.

Tympanoplasty in adults is used quite often and is effective in about 70% of cases.

The attitude towards this operation is ambiguous. On the one hand, its widespread adoption is limited by:

significant difficulties in the study of hearing at an early age;
inability to determine hearing during surgery (due to anesthesia);
more frequent allergization and immune instability, frequent childhood infections;
anatomical and physiological features of the auditory tube, the difficulty of determining its functional state, examination of the nasopharynx;
features of microflora (predominance of staphylococcus, Pseudomonas aeruginosa and Proteus);
aggressive cholesteatoma;
difficulties in postoperative management.

On the other hand, bilateral hearing loss leads to impaired speech development, changes in the child's psyche, decreased intelligence, mental retardation, learning difficulties, communication with peers, etc. As a result, it is believed that tympanoplasty in children is possible from the age of 8-10, but it is better to perform it in two stages, after sanitizing surgery. At an earlier age, tympanoplasty is indicated only with a bilateral process and hearing loss.

Operation for otitis media

Ear inflammation or otitis media is a common pathology in the practice of an ENT doctor. The disease can occur not only in adults, but also in children. Quite often, the disease is accompanied by complications: the spread of infection to the structures of the brain, deterioration or complete loss of hearing. Therefore, it is extremely important to start medical correction on time. And in many cases it is necessary to perform certain operations on the ear. What they are, why are they needed and how they are carried out - such questions are asked by patients in need of surgical intervention. But only a specialist will give a competent answer.

general information

Surgical treatment goals

Elimination of pathological foci.
Preservation and improvement of hearing.
Reconstruction of anatomical structures.
Prevention of intracranial complications.

These are the most important points, the observance of which ensures the high efficiency of surgical treatment of otitis media. They can be accounted for in one operation (in stages) or in several.

Preparation

General blood and urine tests.
Blood biochemistry.
Group analysis and Rh factor.
Analysis of ear discharge (microscopy, culture).
Otoscopy.
Audiogram.
X-ray of the temporal bone.
CT scan.

Full preparation is an important stage on which the nature of the surgical intervention and its effectiveness depend.

Varieties

There are several operations on the ear for otitis media. Based on the clinical situation, the patient is recommended to undergo the following surgical procedures:

Sanitizing (radical) operation.
Tympanoplasty.
Eardrum paracentesis.

Sanitizing operation

Carious process.
Cholesteatoma.
Labyrinthitis and mastoiditis.
Neuropathy of the facial nerve.
Otogenic complications (meningitis, sinus thrombosis).

Antrotomy - trepanation of the mastoid process.
Resection of the posterior wall of the external auditory canal and the lateral wall of the attic.
Elimination of pathological tissues and exudate.
Communication of the resulting cavity with the outer ear.

Tympanoplasty

Autogenous (cartilage of the auricle, temporal fascia, skin of the external auditory canal on the vascular pedicle).
Allogeneic (cadaveric tissues).
Synthetic (polyamide fiber, polyphase).

The first is myringoplasty (perforation of the tympanic membrane with all the bones intact).
Second, the membrane is placed on the incus (malleus defects are present).
Third, the graft is brought to the stapes (no malleus and incus).
The fourth is the shielding of the labyrinth window (from the bones there is only the base of the stirrup).
Fifth, a hole is made in the horizontal semicircular canal, covered by an improvised membrane (all sound-conducting components are absent).

Tympanoplasty is used when it is necessary to restore the impaired function of the sound-conducting structures of the middle ear.

Paracentesis

Effects

Accession of infection.
Bleeding.
Facial nerve paresis.
Hearing impairment.

Sneezing and blowing your nose.
Diving, swimming, visiting the pool.
Air travel.
Physical activity.

ENT surgery

As a result of acute inflammation of the middle ear (ear suppuration), the eardrum can rupture and perforation is formed. This perforation usually heals. If this does not occur, hearing loss is noted, which is often accompanied by noise in the ear or head and recurrent or persistent discharge from the ear. This is already a chronic inflammation of the middle ear.

The manifestations of this disease depend on what stage - exacerbation or remission - it is, whether there is a spread of the disease to the mastoid process, whether or not there is a perforation of the tympanic membrane.

These symptoms can be in the form of discharge from the ear, hearing loss, tinnitus (noise in the head), dizziness, pain, or, in rare cases, impaired facial expressions.

Normal eardrum

Chronic otitis media. Type of the tympanic membrane with various inflammations

Ear care for chronic otitis media

If there is a perforation, you should not allow water to enter the ear canal. To do this, when you shower or wash your hair, put a cotton swab soaked in petroleum jelly in your ear canal. Swimming and swimming are only permitted if you can prevent water from entering the ear canal.

If there is a discharge from the ear, in addition to taking the prescribed medications, the ear canal must be cleared of pus.

Medical treatment of chronic otitis media

Often, medication can help stop the discharge from the ear. Treatment consists of thoroughly cleaning the ear and regularly applying ear drops or blowing in powdered medicines. In some cases, oral antibiotics are prescribed.

Surgical treatment of chronic otitis media

For many years, surgical treatment for chronic otitis media was used primarily for the rehabilitation of the pathological focus and prevention of serious complications. The use of new modern surgical techniques today, in most cases, also allows you to restore the destroyed mechanism of sound conduction (eardrum and auditory ossicles).

Various tissue grafts can be used to replace or repair the tympanic membrane. The most commonly used sheath (fascia) of the temporal muscle and the sheath of the cartilage of the tragus of the auricle (perichondrium). Destroyed ossicles can be replaced with artificial grafts or by moving the patient's own viable bone debris.

In cases where the ear is filled with adhesions and scar tissue, or when all the auditory ossicles are destroyed, several operations are necessary. At the first operation, the inflammatory focus and the creation of a functional tympanic cavity are achieved. During the second operation, the final stage of hearing restoration is performed - ossiculoplasty (prosthetics of the auditory ossicles). The decision on the phased restoration of the sound-conducting apparatus is made during the first operation.

After the operation, the ear canal remains sealed for 1 week to 1 month. All this time, the patient should instill ear drops into the ear canal once a day.

Chronic otitis media: the main types of operations

Most cases of acute otitis media (acute otitis media) result in complete recovery. However, in some cases, the tympanic membrane may not heal and a permanent (permanent) perforation forms in it.

Myringoplasty is an operation to close the perforation of the tympanic membrane. The operation is performed when there is no more inflammation in the ear and the auditory ossicles are not destroyed. This operation closes the middle ear and improves hearing.

The operation is usually performed under local anesthesia, usually through the external auditory canal. For extensive perforations, a behind-the-ear approach is used.

Section views

BTE tissue is used to close a defect in the tympanic membrane.

The patient is hospitalized for several days and can return to work 1-2 weeks after discharge. Complete healing and improvement of hearing in most cases occurs in 2-3 months.

Tympanoplasty

Inflammation in the middle ear can lead to perforation of the eardrum, damage to the mucous membrane, ossicles and auditory nerve.

Tympanoplasty is an operation aimed at eliminating the inflammatory (purulent) process in the ear, closing the perforation of the tympanic membrane and restoring the transmission mechanism of the auditory ossicles. With this operation, the ear is healed and the hearing improved. When there is no need to repair the tympanic membrane, the operation is usually performed under local anesthesia through the ear canal.

Most tympanoplasty operations are performed through the behind-the-ear access under local or general anesthesia. The perforation of the tympanic membrane is closed by the fascia from behind the ear. Sound is transmitted to the inner ear by moving or replacing the ossicles.

Eardrum perforation plastic

In some cases, it is impossible to simultaneously restore both the eardrum and the transmission mechanism of the ossicles. In such cases, the eardrum is first restored, and then, after 6 months or more, the transmission mechanism is restored.

The patient is usually hospitalized for a few days, and after 2-3 weeks he can return to work. Complete healing occurs in 2-3 months. For several months, the patient may not notice an improvement in hearing.

Tympanoplasty with mastoidectomy

An active inflammatory process in some cases can stimulate ingrowth of the skin of the ear canal through the perforation of the tympanic membrane into the middle ear and into the mastoid process. This "cyst" with skin walls is called a cholesteatoma. Over time, the cholesteatoma can enlarge and destroy the adjacent bone. In cholesteatoma, the discharge from the ear is more persistent and often has an unpleasant odor. In most cases, persistent discharge is associated with the spread of inflammation to nearby bone.

When cholesteatoma or bone inflammation is found, treatment should be started as early as possible. Antibiotic ear drops and oral antibiotics are usually temporary. As soon as the treatment is stopped, the discharge from the ear resumes.

Cholesteatoma and chronic ear inflammation can go on for many years without any complications other than persistent discharge and hearing loss. However, sometimes as a result of the spread of the process, the surrounding structures can also be damaged. In this case, the patient feels pressure in the ear and a headache. Dizziness and facial asymmetry may appear, meningitis and other intracranial complications may develop. If one of these symptoms appears, an urgent need to see a doctor. An urgent operation may also be needed in order to remove the focus of inflammation and prevent serious complications.

When the destruction caused by cholesteatoma or inflammation reaches the mastoid process, surgical treatment can be difficult. The operation is performed behind the ear.

Middle ear with cholesteatoma

In most patients with cholesteatoma, it is impossible to simultaneously remove the pathological focus and restore hearing. During the first operation, the eardrum is sanitized and restored. For sanitation, it is necessary to perform an operation on the mastoid process - mastoidectomy.

Two types of operations are used on the mastoid (mastoid) process: with the preservation and with the removal of the posterior wall of the ear canal. The decision to use a particular type of surgery is usually made during the operation.

Operations with preservation of the posterior wall of the ear canal are more preferable, since the ear after such operations (after 3-4 months) is more protected and requires less care.

However, in some cases it is necessary to resort to operations with the removal of the posterior wall of the ear canal, which is associated with the peculiarities of the disease or the structure of the mastoid process. Healing after such operations is longer. As a result, the patient has a wider opening (entrance) of the ear canal, but outwardly the ear practically does not change its appearance. In the future, it is necessary to constantly monitor and cleanse the mastoid (operating) cavity, and often avoid getting water into the ear.

This operation is usually performed under general anesthesia, and hospitalization is required for 7-10 days. In 1-3 weeks after discharge, the patient can return to work.

If a second operation is necessary, it is performed 6-12 months later in order to restore hearing and re-examination of the middle ear cavities to identify the unremoved (remaining) areas of the pathological focus.

Tympanoplasty: planned second stage - ossiculoplasty

The purpose of this operation is to revise the middle ear cavities and improve hearing. The operation can be performed through the ear canal or behind the ear. The operation is usually performed under local anesthesia. The middle ear cavities are checked for any remaining lesion. Sound transmission to the inner ear is achieved by replacing the damaged ossicles with a prosthesis.

The patient is hospitalized for several days and after another 7-10 days he can start working. Hearing usually improves after 10 days and often, over time, hearing can improve further over a period of three months.

Tympanoplasty with revision of the trepanation cavity

The purpose of this operation is to try to achieve cessation of suppuration from the trepanation cavity and to improve hearing in patients who have undergone general ear surgery in the past.

The operation is performed under local or general anesthesia behind the ear. After removal of pathological formations, the mastoidal cavity can be filled with muscle and adipose tissue from the ear region or bone. Over time, the ear canal can be repaired with cartilage or bone. The eardrum is restored and, if possible, the transmission mechanism is also restored. However, in most cases, a second hearing restoration operation is necessary (see: Tympanoplasty: planned second stage).

The patient is usually hospitalized for several days and can return to work 1-3 weeks after discharge. Complete healing of the cavity inside the ear occurs after 4 months.

Operation forecast

Discharge from the ear: Closure of the tympanic membrane perforation is effective in over 90% of cases, resulting in a closed and dry ear.

Hearing: The improvement in hearing as a result of surgery depends on many factors, primarily the degree of destruction of the structures of the middle ear and the presence of conditions conducive to normal ear healing.

It happens that in order to improve or preserve hearing, it is necessary to perform two operations, and the hearing between the first and second operations may be slightly worse than it was before the operation.

What are the consequences of the operation

Any ear surgery can lead to the following symptoms.

Disturbance of taste and dryness in the mouth. Taste disorders and dry mouth are quite common after ear surgery and disappear a few weeks after surgery. However, in some patients, these disorders remain for a longer time.

Noise in the ear. A murmur in the ear (noise in the head) is often present in the patient before surgery and usually there is a short murmur after surgery. It can last for 1 to 2 months and will gradually decrease as your hearing improves. At the same time, if hearing does not improve or deteriorates, the noise may also persist or increase.

Numbness in the ear. Temporary desensitization of the skin in and around the ear is a common consequence of ear surgery. Numbness can affect the entire ear and last for about 6 months.

Drains behind the ear. During the operation, the surgeon can remove the drainage tubes behind the ear. The need for this technique is not always obvious before surgery. When necessary, tubes are passed through the skin behind the ear and after surgery, drugs are injected through them for 1-10 days.

Operational risk and complications. Fortunately, serious complications are rare in ear surgery for chronic suppurative otitis media.

Ear infection. As a rule, after the operation, there is aseptic inflammation of the ear with discharge from it, swelling and pain. This can sometimes lead to slow wound healing and poor graft healing. In some cases, a second operation may be necessary to correct the inflammation.

Hearing impairment. In 3% of cases, further hearing impairment may occur in the operated ear, which is associated with further progression of the disease or with complications in the process of ear healing. Complete hearing loss in the operated ear is very rare. In most cases, a two-stage operation is necessary to improve hearing and completely remove the pathological focus. At the same time, hearing after the first operation is usually worse than before the operation.

Dizziness. In the first days after surgery, you may experience dizziness associated with swelling in the ear and a reaction to the inner ear (labyrinth) surgery. There may be slight instability (imbalance) during the first week. In rare cases, these phenomena can be more prolonged. 10% of patients with chronic purulent otitis media in combination with cholesteatoma have a labyrinth fistula - an opening in the capsule wall of the vestibular apparatus. If there is such a complication, dizziness after surgery may last 6 months or more.

Facial paralysis. The facial nerve pathway runs through the ear. It is located next to the auditory ossicles, and lies in the wall of the tympanic cavity and mastoid process. A rare postoperative complication of ear intervention is short-term paralysis of one half of the face. This can happen if the facial nerve passes in an unusual place for it or with edema, which usually develops spontaneously, especially if the integrity of the wall of the facial nerve canal is violated. In very rare cases, the facial nerve may be damaged during surgery, or it may need to be transected to completely debride the ear.

Complications associated with mastoidectomy. Cerebrospinal fluid (fluid that washes the brain) leak is an extremely rare complication. In this case, reoperation may be necessary.

Intracranial (cerebral) complications of chronic suppurative otitis media, such as meningitis, brain abscess, and even paralysis, were common before antibiotics were used. These complications are extremely rare today.

All materials on the site have been prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and cannot be applied without consulting your doctor.

Tympanoplasty is an operation on the middle ear aimed at preserving and restoring the sound-conducting system, and ultimately its goal is to improve hearing.

As you know, sound is waves of compressed air, alternating with sections of its rarefaction, acting on our ear with different frequencies. The human ear is a very complex system, consisting of three sections, the main functions of which are: capturing sound, conducting it and its perception. If at least one of the departments cannot fulfill its function, the person will not hear. At the same time, the quality of life is sharply reduced.

Tympanic cavity- this is the middle section of the ear, performs the function of conducting sound. It consists of the eardrum, a chain of three ossicles (malleus, incus, and stirrup), and labyrinth windows. It is the normal functioning of all these three divisions that ensures the conduction of sound waves from the environment into the inner ear for their further conversion into signals perceived by the brain as sound.

middle ear structure

For normal sound conduction:

The tympanic cavity should be free (without pathological contents), hermetically closed.
The eardrum should be sufficiently taut and free from defects.
The ossicular chain must be continuous.
The connection between the bones must be loose and elastic.
There should be adequate aeration of the tympanic cavity through the Eustachian tube.
Labyrinth windows should also be flexible and not fibrosed.

The tympanoplasty operation is aimed at creating such conditions or as close to them as possible.

When is tympanoplasty indicated?

The operation is indicated in the following cases:

Chronic otitis media.
Sclerosis and fibrosis of the middle ear.
Malformations of the sound-conducting apparatus.

The most common indication for tympanoplasty is otitis media with exudation (epitympanitis or mesotympanitis). It usually has a hole in the tympanic membrane, destruction of the auditory ossicles, adhesions and fibrosis, the presence of cholesteatoma (epidermal neoplasm).

Preparing for tympanoplasty

Tympanoplasty is performed some time after sanitizing surgery (usually after 5-6 months). This period is expected to completely subside the inflammatory process, to stop exudation, to improve the drainage and airway function of the auditory tube.

Preoperative examination:

X-ray of the temporal bones.
CT of the temporal bones.
Endoural endoscopic examination.
Audiometry.
Determination of the sound-perceiving function of the cochlea (using a sound probe).
Study of the functioning of the auditory tube.
Standard preoperative examination (blood tests, urine tests, coagulogram, blood biochemistry, testing for HIV, hepatitis and syphilis, ECG, fluorography).
Examination by a therapist.

It must be said that the diagnosis of irregularities in the sound-conducting apparatus is rather complicated and cannot always be established before the operation. In addition, the causes of hearing impairment are often multiple. Therefore, doctors do not give any guarantee, the operation may not always give the expected effect.

According to statistics, the effect of tympanoplasty is 70%.

Contraindications to surgery

The operation is performed for the following diseases:

Decompensated somatic diseases.
Severe form of diabetes mellitus.
Purulent inflammation in the middle ear.
Acute infectious diseases.
Labyrinthitis.
Violation of the patency of the Eustachian tube.
Decrease in the sound-perceiving function of the cochlea (in the last two cases, the operation will be ineffective).

The main stages of tympanoplasty

There are several stages of tympanoplasty:

Access to the tympanic cavity.
Ossiculoplasty.
Myringoplasty.

The systematization of tympanoplasty methods was developed by Wolstein and Zellner (50s of the 20th century). They proposed methods of tympanoplasty with a skin flap taken from behind the ear or cut out of the ear canal.

According to this classification, 5 types of tympanoplasty are distinguished:

When the ossicular chain is functioning normally and there is only a defect in the tympanic membrane, endoural myringoplasty (closure of the defect) is performed.
When the malleus breaks, the newly formed membrane is placed on the incus.
With the loss of the malleus and incus, the graft adjoins the head of the stirrup (imitation of the likeness of a thorn in birds).
When all bones are lost, the cochlear window is shielded (closing it from direct sound waves). The stirrup plate is left uncovered. In the modern version of this operation, transplantation of artificial prostheses of the auditory ossicles is carried out.
When fibrosis of the oval window of the cochlea is observed in combination with the complete immobility of the stapes base, the semicircular canal is opened and the opening is covered with a skin flap. Currently, it is practically not used.

stages of tympanoplasty

The operation is usually performed under general anesthesia, but local anesthesia is also widely applicable (with any type of access). Surgeons prefer local anesthesia, since hearing can be tested directly during surgery.

Access to the tympanic cavity

There are three ways to reach the tympanic cavity:

Intrameatal access. This is accessed through an incision in the tympanic membrane.
Through the external auditory canal.
Retroauricular access. The incision is made immediately behind the ear, the back wall of the external auditory canal is opened with a bur or cutter.

Ossiculoplasty

This is the restoration of the ossicular chain for the maximum possible transmission of sound vibrations to the cochlea.

All manipulations in the tympanic cavity are performed using an operating microscope and microinstruments.

Basic principles of ossiculoplasty:

The contact of the restored auditory ossicles with each other must be reliable so that there are no displacements.
The newly created chain of transmission of sound vibrations must be sufficiently mobile.
It is necessary to prevent the development of fibrosis and ankylosis in the future (ensuring sufficient aeration of the tympanic cavity, transplantation of the mucous membrane in its absence, the introduction of silastic).
The method of ossiculoplasty is selected individually for each patient, focusing on both preoperative examination and intraoperative findings.

ossiculoplasty

In addition to replacing the auditory ossicles with a skin flap, other methods of prosthetics of the lost auditory ossicles have been developed.

Materials used in ossiculoplasty to replace the ear ossicles:

Own or cadaveric bone tissue
Cartilage.
Areas of the patient's own nail.
Artificial materials (titanium, teflon, proplast, plastiphor).
Fragments from their own hammer and anvil.
Cadaveric auditory bones.

Myringoplasty

The tympanoplasty operation ends with the restoration of the tympanic membrane -. Sometimes myringoplasty is the only stage of such an operation (if the chain of sound-conducting bones is preserved).

The main materials used for myringoplasty:

Skin flap. It is usually taken from the skin behind the ear or the inner surface of the shoulder.
Vein wall (from the lower leg or forearm).
Fascial flap. It is taken from the fascia of the temporalis muscle during the operation itself.
Perichondrium from the cartilage of the auricle.
Cadaveric tissue (dura mater, perichondrium, periosteum).
Synthetic inert materials (polyamide fabric, polyphasic).

The main types of myringoplasty

After operation

The ear canal is tamponed with sterile tampons soaked in antibiotics and hydrocortisone emulsion.

During the day, bed rest is prescribed. The patient receives antibiotics for 7-9 days. The stitches are removed on the 7th day.

The mouth of the auditory tube is irrigated daily with vasoconstrictor agents.

Tampons from the ear canal are removed gradually. On the 2nd, 3rd, 4th and 5th day, only the outer balls are changed. Internal, adjacent to the eardrum, do not touch until 6-7 days. Usually by this time the engraftment of the tympanic flap occurs. Complete removal of deep tampons is completed by 9-10 days. By this time, the rubber drainage is also removed.

Somewhere from 6-7 days, blowing of the auditory tube begins.

Do not allow water to enter the ear for several months.
You can't blow your nose too much.
The development of any rhinitis should be avoided as much as possible.
Limit strenuous physical activity.
Airplane flights are not recommended for 2 months.
Avoid very loud sounds.
Do not take a steam bath or sauna.
In order to prevent fungal infection, antifungal drugs are prescribed.

Possible complications of tympanoplasty

In some cases, tympanoplasty is fraught with the following complications:

Damage to the facial nerve. It is manifested by paralysis of the facial muscles on the side of the lesion. Paralysis of the facial nerve can also be temporary - as a result of postoperative edema.
Labyrinthitis. Manifested by dizziness and nausea.
Intra- and postoperative bleeding.
Inflammation.
Graft disease. It can become inflamed, partially or completely necrotic, and dissolve.

Main conclusions

Let's summarize the main results:

A thorough examination is required before the operation. Doctors must be convinced that poor hearing is associated precisely with the pathology of the sound-conducting apparatus of the middle ear.
With correct indications, hearing improves in 70% of cases after surgery.
The importance of tympanoplasty should not be overstated. Even a slight improvement in hearing after it is already a success.
This operation is rather complicated, there are many contraindications and potential complications. All pros and cons should be weighed.
The clinic should be chosen based on reputation, reviews, the number of operations performed, the percentage of complications.