Chr purulent otitis. Chronic otitis: treatment. Acute and chronic purulent otitis media

This is a long-term purulent inflammation of the middle ear, characterized by the presence of persistent perforation (defect, hole) of the eardrum, periodic or constant discharge from the ear, usually of a mucopurulent nature, and gradual progressive hearing loss.

Chronic purulent otitis media a very common disease, affecting up to 1% of the population. The disease is a serious danger to hearing, and if it occurs intracranial complications can become a threat to human life. In this regard, knowledge of the main principles of diagnosis and treatment for chronic suppurative otitis media is essential for every practicing physician.

Causes of chronic suppurative otitis media

Chronic suppurative otitis media is usually a consequence of acute suppurative otitis media or a rupture of the eardrum resulting from injury. More than 50% of chronic otitis media appear in childhood.

Microorganisms cultured during chronic purulent otitis media are predominantly associations of pathogens, among which aerobes such as Pseudomonas, Staph, aureus, Proteus, Escherichia coli, Klebsiella pneumoniae are mostly identified.

In recent years, research has proven the significant role of anaerobes; with the use of modern microbiological techniques, they are detected in chronic suppurative otitis media in almost all patients. With the long-term course of chronic otitis, as well as with the use of antibiotics and corticosteroids, fungi are increasingly found.

Acute otitis media becomes chronic due to a number of unfavorable causes:

A significant role in the occurrence of chronic otitis media belongs to the pathological condition of the upper respiratory tract, in particular the adenoids, deviated nasal septum, chronic sinusitis, hypertrophic rhinitis.

The resulting deterioration in the drainage and ventilation functions of the auditory tube leads to difficulties in evacuating the contents of the tympanic cavity and aerating the cavities of the middle ear.

This interferes with the normal recovery of tympanic membrane perforation after acute suppurative otitis media, which, in turn, leads to the appearance of persistent perforation.

Sometimes inflammation of the middle ear has the features of a chronic process, in particular with necrotizing forms of otitis media, weakly passing otitis with perforation in the loose component of the eardrum, tuberculosis, diabetes, and in the elderly.

Symptoms of chronic suppurative otitis media

Type pathological process in the middle ear, according to the characteristics of the clinical course and complexity of the disease, two forms of chronic purulent otitis media are determined: mesotympanitis and epitympanitis.

These forms differ in that mesotympanitis has a relatively favorable course, since the mucous membrane is involved in the inflammatory process, and epitympanitis always has a poor course, since it is accompanied by caries of bone tissue.

The main difference is that with mesotympanitis the perforation is located in the tense component of the eardrum. Epitympanitis is characterized by perforation in the loose component of the eardrum.

Descriptions of symptoms of chronic suppurative otitis media

Which doctors should I consult for chronic purulent otitis media?

Diagnosis of chronic suppurative otitis media

The diagnosis is made by an ENT doctor based on an examination of the ear. Additionally, a hearing test is performed to check the function of the auditory tube. Examination of the nasal cavity is important because, important factor normal operation the middle ear is free nasal breathing.

Treatment of chronic suppurative otitis media

Chronic purulent otitis media without bone destruction and complications can be treated with medicinal methods under outpatient observation otolaryngologist. Such drug therapy aimed at relieving the inflammatory process.

In cases where chronic purulent otitis media occurs with bone destruction, it is essentially preoperative preparation of the patient.

If chronic suppurative otitis media is accompanied by paresis facial nerve, headache, neurological disorders and/or vestibular disorders, this indicates the presence of a destructive process in the bone and the development of complications. In such a situation, it is necessary to hospitalize the patient as soon as possible and consider surgical treatment.

Considering that chronic purulent otitis media is accompanied by perforation in the eardrum, ototoxic aminoglycoside antibiotics cannot be used as ear drops. You can use ciprofloxacin, norfloxacin, rifampicin, as well as their combination with glucocorticosteroids.

For the purpose of complete sanitation and functional restoration, chronic purulent otitis media with bone destruction requires surgical treatment.

Depending on the prevalence of the purulent process, chronic purulent otitis media is an indication for sanitizing surgery with mastoidoplasty or tympanoplasty, aticoantrotomy, mastoidotomy, labyrinthotomy and labyrinthine fistula plastic surgery, and removal of cholesteatoma.

If chronic purulent otitis media is accompanied by diffuse inflammation with the threat of complications, then general ear surgery is performed.

Prognosis of chonic suppurative otitis media

Timely sanitation of a chronic purulent focus in the ear ensures a favorable outcome of the disease. The earlier treatment is carried out, the greater the chances of restoration and preservation of hearing. In advanced cases, when chronic suppurative otitis media leads to significant bone destruction and/or the development of complications, reconstructive surgery is necessary to restore hearing. In some cases, at the most unfavorable outcome patients require hearing aids.

Prevention of chonic suppurative otitis media

Prevention of chronic suppurative otitis media consists of timely and rational treatment of acute otitis media.

Chronic purulent inflammation of the middle ear causes persistent pathological changes mucous membrane and bone tissue, leading to disruption of its transformation mechanism. Severe hearing loss in early childhood leads to speech impairment and complicates the upbringing and education of the child. This disease may limit the fitness for military service and the choice of certain professions. Chronic suppurative otitis media can cause severe intracranial complications. To eliminate the inflammatory process and restore hearing, complex operations using microsurgical techniques have to be undertaken.

Chronic suppurative otitis media is characterized by three main signs: the presence of persistent perforation of the eardrum, periodic or constant suppuration from the ear and hearing impairment.

Etiology. In chronic purulent otitis media, staphylococci (mainly pathogenic) are cultured in 50-65% of cases, Pseudomonas aeruginosa in 20-30%, and Pseudomonas aeruginosa in 15-20% - coli. Often, when antibiotics are used irrationally, fungi are found, among which Aspergillus niger is more common.

Pathogenesis. It is generally accepted that chronic suppurative otitis media most often develops due to prolonged acute otitis media. Factors contributing to this include chronic infections, pathology of the upper respiratory tract with impaired nasal breathing, ventilation and drainage functions of the auditory tube, improper and insufficient treatment of acute otitis media.

Sometimes the inflammatory process in the middle ear can be so sluggish and unexpressed that there is no need to talk about the transition of acute inflammation to chronic, but it should be considered that it had the features of chronic from the very beginning. This course of otitis may occur in patients suffering from diseases of the blood system, diabetes, tuberculosis, tumors, hypovitaminosis, and immunodeficiency.

Sometimes acute otitis media suffered in childhood due to measles and scarlet fever, diphtheria, typhus lead to necrosis of the bone structures of the middle ear and the formation of a subtotal defect of the eardrum.

If acute otitis in a newborn occurs due to an abnormality in the structure of the auditory tube and the inability to ventilate the tympanic cavity, then the inflammatory process immediately becomes chronic. Sometimes a persistent dry perforation of the eardrum is formed, acting as an unnatural way of ventilation of the tympanic cavity and antrum, and suppuration does not recur. Other patients experience discomfort because the tympanic cavity communicates directly with external environment. They are worried about constant pain and noise in the ear, which intensifies significantly during exacerbations.

Clinic. Based on the nature of the pathological process in the middle ear and the associated clinical course, two forms of chronic purulent otitis media are distinguished: mesotympanitis and epitympanitis.

Chronic purulent mesotympanitis is characterized by damage only to the mucous membrane of the middle ear.

Mesotympanitis has a favorable course. Its exacerbations are most often caused by exposure of the mucous membrane of the tympanic cavity to external unfavorable factors (water, cold air) and colds. During an exacerbation, inflammation can occur in all floors of the tympanic cavity, the antrum and the auditory tube, but due to the mild swelling of the mucous membrane and the preservation of ventilation of the pockets of the attic and antrum, as well as the sufficient outflow of discharge from them, conditions are not created for the inflammation to transfer to the bone.

Perforation of the eardrum is localized in its tense part. It can be of different sizes and often takes most its area, acquiring a bean-shaped shape (Fig. 1.7.1). Distinctive feature perforation in mesotympanitis is the presence of a rim of remnants of the eardrum around the entire perimeter, which is why it is called rim.

This type of perforation is decisive in making a diagnosis. The main criterion for distinguishing mesotypanitis from epitympanitis is the limitation of the pathological process by the mucous membrane of the middle ear.

There are periods of remission and exacerbation of the disease. With exacerbation, patients' complaints are reduced to decreased hearing and suppuration from the ear. The discharge is copious, mucous or mucopurulent, light, odorless. The mucous membrane of the medial wall of the tympanic cavity is thickened. The complicated course of mesotympanitis is characterized by the appearance of granulations and polyps of the mucous membrane, which contributes to an increase in the amount of discharge. Hearing is reduced according to the type of sound conduction disorder, and then according to mixed type. During the period of remission, suppuration from the ear stops. Hearing remains reduced and persistent perforation of the eardrum persists, since its edges are scarred and do not regenerate.

As a result of chronic recurrent inflammation of the mucous membrane of the tympanic cavity, adhesions may occur that limit mobility auditory ossicles and aggravating hearing loss.

Chronic purulent epitympanitis has an unfavorable course. This is due to the transition of inflammation to bone tissue with the occurrence of sluggish limited osteomyelitis. This course of the pathological process is due to an increased tendency to swelling, infiltration and exudation of the mucous membrane of the middle ear, as well as an unfavorable variant anatomical structure attic and cave entrance. The severity of folds and pockets in the attic and the narrow aditus ad antrum contribute to impaired ventilation of the middle ear cavities and retention of pathological discharge during inflammation. The bone walls of the attic and antrum, malleus and incus are affected. Less commonly, the stirrup is involved.

There may be a separation of the attic from the middle floor of the tympanic cavity. Then the impression of a normal otoscopic picture is created, since the stretched part of the eardrum is not changed. The mesotimanum is normally ventilated through the auditory tube and all identifying points of the tympanic membrane are well expressed. But if you look closely, then above short shoot hammer, you can notice a perforation or a crust covering it. After removing this crust, the doctor often sees a defect in the loose part of the eardrum. This is the marginal perforation characteristic of epitympanitis (Fig. 1.7.2).

In this section, perforation cannot be rim, since there is no cartilage ring, separating the membrane from the bone in the tense part. The tympanic membrane is attached directly to the bony edge of the rivinian notch. Along with damage to the bone structures of the attic, the bone edge of this notch is damaged and marginal perforation occurs.

The discharge is thick, purulent, not abundant, and may even be extremely scanty, drying into a crust covering the perforation. The absence of discharge does not indicate a favorable course of the disease. On the contrary, the destruction of bone structures deep in the ear can be pronounced. A characteristic sign of bone osteomyelitis is a sharp unpleasant odor of discharge, caused by the release of indole and skatole and the activity of anaerobic infection. In the area of bone caries, granulations, polyps, and often destruction of the chain of auditory ossicles are observed.

In addition to suppuration, patients are often bothered by headaches. When the wall of the lateral semicircular canal is destroyed, dizziness occurs. The presence of a fistula is confirmed by a positive tragus symptom (the appearance of pressor nystagmus towards the affected ear when the external auditory canal is obstructed by the tragus).

Hearing is sometimes reduced to a greater extent than with mesotympanitis, although with pinpoint perforation and preservation of the chain of auditory ossicles, it suffers little. More often than with mesotympanitis, low-frequency noise in the ear is noted. Hearing loss is first conductive, then mixed, and finally sensorineural in nature as a result of the toxic effect of inflammatory products on the receptor formations of the cochlea.

In patients with epitympanitis, secondary cholesteatoma is often detected - an accumulation of layers of epidermal masses and their breakdown products, rich in cholesterol. The main theory of the formation of cholesteatoma is the ingrowth of stratified squamous epithelium of the external auditory canal into the middle ear through the marginal perforation of the tympanic membrane. Epidermal masses are enclosed in a connective tissue membrane - a matrix, covered with epithelium, tightly adjacent to the bone and growing into it. Constantly produced epidermal masses increase the volume of cholesteatoma, which exerts a destructive effect on the bone with its pressure. In addition, bone destruction is promoted by chemical components released by cholesteatoma (enzyme - collagenase) and products of bone tissue breakdown. Cholesteatoma is most often localized in the attic and antrum.

Complications arising from epitympanitis are associated mainly with bone destruction, although granulations and polyps are observed, just as with mesotympanitis. In the presence of cholesteatoma, bone tissue breakdown occurs more actively, so complications are much more common. In addition to a fistula of the horizontal semicircular canal, paresis of the facial nerve, labyrinthitis and various intracranial complications may occur.

Radiography helps diagnose epitympanitis temporal bones according to Schuller and Mayer. In patients suffering from this disease since childhood, a sclerotic type of structure of the mastoid process is noted. Against this background, bone destruction can be determined with epitympanitis.

Treatment. The treatment tactics for chronic suppurative otitis media depend on its form. The goal is to eliminate the inflammatory process in the middle ear and restore hearing, therefore, complete treatment of chronic otitis media with hearing loss should end with hearing restoration surgery.

For mesotympanitis, conservative local anti-inflammatory therapy is carried out predominantly. The cessation of bone osteomyelitis with epitympanitis and the removal of cholesteatoma can only be carried out surgically. In this case, conservative treatment is used in the process differential diagnosis epitympanitis and mesotympanitis and preparing the patient for surgery. The occurrence of labyrinthitis, paresis of the facial nerve and intracranial complications requires urgent surgical intervention, usually in an expanded volume.

Military personnel with chronic purulent otitis media are subject to dynamic monitoring by the unit doctor and the garrison otolaryngologist.

Conservative treatment begin with the removal of granulations and polyps of the mucous membrane that support inflammation. Small granulations or highly swollen mucous membranes are cauterized with a 10-20% solution of silver nitrate. Larger granulations and polyps are removed surgically.

As with acute purulent otitis media, careful and regular cleaning of the ear is of great importance.

After toileting the ear, various medicinal substances are used in the form of drops, ointments and powder. The method of application depends on the phase of inflammation and corresponds to the dermatological principle (wet - wet, dry - dry), so solutions are used first, and in the final phase of treatment they switch to ointment forms or powder insufflations.

Use liquid water-based medications (20-30% sodium sulfacyl solution, 30-50% dimexide solution, 0.1-0.2% mephenamine solution sodium salt, 1% dioxidine solution, etc.). At an earlier time than in acute otitis, they can be replaced with alcohol solutions (3% alcohol solution boric acid, 1-5% alcohol solution salicylic acid and sodium sulfacyl, 1-3% alcohol solution of resorcinol, 1% solution of formaldehyde and silver nitrate). If the patient is intolerant to alcohol solutions ( strong pain, burning in the ear) are limited to the use of aqueous solutions.

Antibiotics are used locally taking into account the sensitivity of the microflora. With prolonged use, granulation tissue may grow and dysbiosis may occur. The use of ototoxic antibiotics should be avoided.

Glucocorticoids (hydrocortisone emulsion, prednisolone, flucinar, sinalar, etc.) have a powerful anti-inflammatory and hyposensitizing effect. It is better to use hydrocortisone emulsion at the very beginning of treatment to relieve severe swelling of the mucous membrane. Corticosteroid ointments are used in the final phase of treatment.

For liquefaction viscous secretion and improve the absorption of drugs, enzymatic preparations (trypsin, chymotrypsin) are used.

Positive results were noted when using biogenic drugs (solcoseryl in the form of ointment and jelly, 10-30% alcohol solution of propolis), antibacterial drugs of natural origin (novoimanin, chlorophyllipt, sanviritrin, ectericide, lysozyme)

In order to restore the patency of the auditory tube, vasoconstrictor drugs in the nose on an ointment basis are necessarily prescribed. Using the tragus injection method, drugs are applied to the mucous membrane of the auditory tube through the tympanic cavity. After instilling the medicinal substance into the ear in a horizontal position, the patient on his side is pressed several times on the tragus. Medicinal substances can be introduced into the auditory tube through the nasopharyngeal orifice using an ear metal catheter.

A diagnostic and therapeutic method for epitympanitis is lavage through the marginal perforation of the attic using a Hartmann cannula. This is how cholesteatoma scales and pus are washed away, which helps relieve tension in the attic and reduce pain syndrome. To wash the attic, only alcohol solutions are used, since cholesteatoma masses have increased hydrophilicity and swelling of cholesteatoma can increase pain in the ear, and sometimes provoke the development of complications.

Physiotherapeutic methods of influence are a good addition to treatment: oeuo?aoeieaoiaia iaeo?aiea yiaao?aeuii, (ooaoniue eaa?o), yeaeo?ioi?ac eaea?noaaiiuo aauanoa, OA? e a?.

Local treatment should be combined with the prescription of drugs that increase the body's reactivity. A prerequisite is a balanced diet with sufficient vitamin content and limited carbohydrates.

A patient with chronic suppurative otitis media is warned about the need to protect the ear from exposure to cold wind and water. During water procedures and bathing, close the external ear canal cotton wool moistened with Vaseline or vegetable oil. For this purpose they also use cosmetic creams and corticosteroid ointments. The rest of the time, the ear is kept open, since the oxygen contained in the air has a bactericidal effect, and blockage of the external auditory canal creates thermostatic conditions conducive to the growth of microorganisms.

Surgical treatment for chronic purulent otitis media is aimed at removing the pathological focus of osteomyelitis and cholesteatoma from the temporal bone and improving hearing by restoring the sound-conducting apparatus of the middle ear.

The objectives of surgical interventions in different situations are:

* emergency elimination of the otogenic cause of intracranial complications, labyrinthitis and facial paralysis;

* elimination of the source of infection in the temporal bone as planned in order to prevent complications;

* plastic surgery of defects in the sound-conducting apparatus in the long term after a sanitizing operation;

* immediate removal of pathology in the middle ear with plastic surgery of defects in the sound-conducting apparatus;

* liquidation adhesive process in the tympanic cavity with plastic surgery of perforation of the eardrum;

* plastic perforation of the eardrum.

In 1899, Küster and Bergmann proposed a radical (whole cavity) ear operation, which consisted in creating a single postoperative cavity, connecting the attic, antrum and cells of the mastoid process with the external auditory canal (Fig. 1.7.3). The operation was performed using a behind-the-ear approach with removal of all the auditory ossicles, the lateral wall of the attic, part of the posterior wall of the ear canal and the pathological contents of the middle ear with curettage of the entire mucous membrane.

Such a surgical intervention saved the patient’s life in case of intracranial complications, but was accompanied by large destruction in the middle ear, severe hearing loss and often vestibular disorders. Therefore, V.I. Voyachek proposed the so-called conservative radical ear surgery. It involved removing only pathologically altered bone tissue and mucous membrane while preserving intact parts of the auditory ossicles and eardrum. Since this operation was limited to connecting the attic and antrum into a single cavity with the auditory canal, it was called attico-antrotomy.

During urgent interventions for otogenic intracranial complications, they still perform radical surgery with wide exposure of the sigmoid sinus and dura meninges, but whenever possible they try to preserve the elements of the sound-conducting apparatus. The operation is completed by plastic surgery of the postoperative cavity with a meatotympanic flap. This operation combines the principle of radicalism in relation to the opening of the cellular system of the mastoid process and a gentle attitude towards the sound-transmitting structures of the tympanic cavity.

Subsequently, attico-antrotomy began to be carried out using a separate approach to the antrum and attic, maintaining inner part posterior wall of the external auditory canal. The antrum is opened through the mastoid process, and the attic through the auditory canal. This operation is called separate attico-antrotomy. A drainage is inserted into the antrum cavity, through which it is washed with various medicinal solutions. Currently, efforts are being made to preserve or plastically restore the lateral wall of the attic. Sparing the posterior wall of the ear canal and the lateral wall of the attic allows one to preserve a larger volume of the tympanic cavity and the normal position of the eardrum, which significantly improves the functional result of the operation.

Plastic surgery of the postoperative cavity was already undertaken in the first extensive version of radical ear surgery. It was planned to place a non-free meatal flap in the posterior sections of the postoperative cavity (Fig. 1.7.3). It was the source of epithelization of the cavity. With attico-antrotomy according to Vojacek, a meato-tympanic flap was created, which simultaneously served as a source of epithelization and closure of the perforation of the tympanic membrane.

Currently, tympanoplasty involves the use of preserved elements of the sound-conducting apparatus of the middle ear, and in case of their partial or complete loss, reconstruction of the transformation mechanism using various materials (bone, cartilage, fascia, veins, fat, cornea, sclera, ceramics, plastic, etc. .) The chain of auditory ossicles and the eardrum are subject to restoration.

Tympanoplasty is indicated for chronic purulent otitis media, less often for adhesive otitis media, injuries and abnormalities of the ear. The ear must be dry for six months before surgery. Before tympanoplasty, an audiological examination is performed to determine the type of hearing loss, cochlear reserve, and ventilation function of the auditory tube. At pronounced violation sound perception and function of the auditory tube, tympanoplasty is not very effective. Using a prognostic test - tests with cotton wool according to Kobrak, a possible increase in hearing acuity after surgery is established (hearing for whispered speech is examined before and after applying a cotton wool moistened Vaseline oil, perforation of the eardrum or into the ear canal opposite it).

Tympanoplasty is sometimes performed simultaneously with sanitizing separate atticoanthrotomy, when the surgeon is confident that the source of infection has been sufficiently eliminated. If the bone damage is extensive, then auditory restoration surgery is performed as a second stage several months after atticoanthrotomy.

There are 5 types of free plastic surgery according to Wullstein H.L., 1955 (?en. 1.7.4).

Type I – endaural myringoplasty for perforation of the eardrum or reconstruction of the eardrum if it is defective.

II oei - the mobilized tympanic membrane or neotympanic membrane is placed on the preserved incus in case of a defect in the head, neck or handle of the malleus.

Type III – myringostapedopexy. If the malleus and incus are absent, the graft is placed on the head of the stapes. A “columella effect” is created ii oeio of sound conduction in birds that have one auditory ossicle - the columella. This results in a small tympanic cavity consisting of the hypotympanum, tympanic opening auditory tube and both labyrinthine windows.

Type IV – screening of the cochlear window. In the absence of all the auditory ossicles except the base of the stapes, the graft is placed on the promontorium to form a reduced tympanic cavity, consisting of the hypotympanum, the cochlear window and the tympanic opening of the auditory tube. Hearing is improved by increasing the pressure difference across the labyrinth windows.

Type V – fenestration of the horizontal semicircular canal according to Lempert (Lempert D., 1938). Sound transmission is carried out through a graft covering the operating window of the semicircular canal. This type of tympanoplasty is used in the absence of all elements of the sound-conducting apparatus of the middle ear and the stapes is fixed.

Tympanoplasty also involves restoring the integrity of the eardrum - myringoplasty. It may be limited to closing the membrane perforation with various plastic materials or creating a neotympanic membrane.

Small persistent rim perforations of the tympanic membrane are often eliminated after refreshing the edges and gluing the egg amnion, thin nylon, and sterile paper to the membrane with fibrin glue, along which the regenerating epithelium and epidermis spread. For this purpose, you can also use BF-6 glue and Kolokoltsev glue.

Marginal perforations are closed with meatal or meatotympanic non-free flaps during radical ear surgery (Krylov B.S., 1959; Khilov K.L., 1960).

Concluding the coverage of the principles of treatment of chronic suppurative otitis media, it should be noted once again that the need for surgery both for the purpose of sanitizing the source of infection and restoring hearing requires expanding the indications for surgical intervention. Planned surgery when indicated, it should be performed simultaneously and consist of three stages: revision, sanitation and plastic surgery.

Conservative treatment of patients with mesotympanitis, uncomplicated by granulations and polyps, is carried out in a military unit as prescribed by an otolaryngologist, and in case of exacerbation of the process - in a hospital. Sanitation operations are performed in the otolaryngology department of garrison hospitals. Complex auditory surgical interventions are performed in district and central military hospitals and the ENT clinic of the Military Medical Academy.

All patients with chronic purulent otitis media, including those after ear surgery, are under the dynamic supervision of the unit doctor and the garrison otolaryngologist. Examination of military personnel is carried out according to Art. 38 Order of the Ministry of Defense of the Russian Federation N 315 of 1995

Purulent inflammatory process in the middle ear cavity, which has chronic course. Chronic suppurative otitis media is characterized by conductive or mixed hearing loss, suppuration from the ear canal, pain and noise in the ear, sometimes dizziness and headache. Chronic suppurative otitis media is diagnosed based on otoscopy, hearing tests, bacteriological culture of ear secretions, X-ray and tomographic examinations of the temporal bone, analysis of the vestibular function and neurological status of the patient. Patients with chronic purulent otitis media are treated with both conservative and surgical methods (debridement surgery, mastoidotomy, anthrotomy, labyrinthine fistula closure, etc.).

General information

Chronic suppurative otitis media is otitis media, accompanied by constant suppuration from the ear for more than 14 days. However, many specialists in the field of otolaryngology indicate that otitis media with suppuration lasting more than 4 weeks should be considered chronic. According to WHO, chronic suppurative otitis media is observed in 1-2% of the population and in 60% of cases leads to persistent hearing loss. In more than 50% of cases, chronic suppurative otitis media begins its development before the age of 18 years. Chronic purulent otitis media can cause purulent intracranial complications, which in turn can lead to the death of the patient.

Causes

The causative agents of chronic purulent otitis media are, as a rule, several pathogenic microorganisms. Most often these are staphylococci, Proteus, Klebsiella, Pseudomonia; in rare cases - streptococci. In patients with a long course of chronic purulent otitis media, along with the bacterial flora, the causative agents of otomycosis are often sown - yeast and molds. Immediate reasons:

Acute otitis media. In the vast majority of cases, chronic suppurative otitis media is the result of the transition to the chronic form of acute otitis media or the development of adhesive otitis media.
Ear injuries. The development of the disease is also possible when the tympanic cavity becomes infected as a result of ear trauma, accompanied by damage to the eardrum.
Other diseases of the ENT organs. The occurrence of chronic purulent otitis media is caused by dysfunction of the auditory tube due to eustachitis, aerootitis, adenoids, chronic sinusitis;

Various immunodeficiency conditions (HIV infection, side effects of treatment with cytostatics or radiotherapy), endocrinopathies (hypothyroidism, obesity, diabetes mellitus), irrational antibiotic therapy or unjustified reduction in the duration of treatment of acute purulent otitis contribute to the development of chronic purulent otitis media from acute.

Classification

Chronic suppurative otitis media has 2 clinical forms:

Mesotympanitis(tubotympanic otitis). It makes up about 55% and is characterized by the development of an inflammatory process within the mucous membrane of the tympanic cavity without involving its bone formations.
Epitympanitis(epitympanic-antral otitis) Epitympanitis accounts for the remaining 45% of cases of chronic suppurative otitis media. It is accompanied by destructive processes in bone tissue and in many cases leads to the formation of cholesteatoma of the ear.

Symptoms

Main clinical signs chronic suppurative otitis media are suppuration from the ear, decreased hearing (hearing loss), tinnitus, pain in the ear and dizziness. Suppuration can be constant or periodic. During the period of exacerbation of the disease, the amount of discharge usually increases. If granulation tissue grows in the tympanic cavity or there are polyps, then the discharge from the ear may be bloody.

Chronic suppurative otitis media is characterized by a conductive type of hearing loss caused by impaired mobility of the auditory ossicles. However, long-term chronic suppurative otitis media is accompanied by mixed hearing loss. The resulting disturbances in the functioning of the sound-perceiving part of the auditory analyzer are caused by decreased blood circulation in the cochlea as a result of prolonged inflammation and damage to the hair cells of the labyrinth by inflammatory mediators and toxic substances formed during inflammatory reaction. Damaging substances penetrate from the tympanic cavity into the inner ear through the windows of the labyrinth, the permeability of which increases.

The pain syndrome is usually moderate and occurs only during periods when chronic purulent otitis media enters the acute phase. An exacerbation can be triggered by ARVI, pharyngitis, rhinitis, laryngitis, sore throat, or fluid getting into the ear. During an exacerbation, there is also an increase in body temperature and a feeling of pulsation in the ear.

Complications

Epitympanitis has more severe course than mesotympanitis. This chronic suppurative otitis media is accompanied by bone destruction, which results in the formation of skatole, indole, etc. chemical substances, giving ear discharge foul odor. When the destructive process spreads to the lateral semicircular tubule inner ear, the patient experiences systemic dizziness. With destruction of the bone wall facial canal Facial nerve paresis is noted. Epitympanitis often leads to the development purulent complications: mastoiditis, labyrinthitis, meningitis, brain abscess, arachnoiditis, etc.

Diagnostics

Chronic purulent otitis media can be diagnosed using endoscopy, hearing analyzer studies, bacteriological culture of ear discharge, skull radiography, CT and MSCT of the skull with a targeted examination of the temporal bone.

Ear examination. Otoscopy and microotoscopy are carried out after toileting the outer ear with thorough cleansing of the external auditory canal. They detect the presence of perforation in the eardrum. Moreover, chronic purulent otitis media, which occurs as mesotympanitis, is characterized by the presence of perforation in the tense area of the tympanic membrane, while epitympanitis is characterized by the location of perforation in the loose area.
Examination of auditory function. Chronic purulent otitis media is characterized by decreased hearing according to audiometry, conductive or mixed hearing loss according to threshold audiometry, impaired mobility of the auditory ossicles according to acoustic impedance measurement. Eustachian tube patency, electrocochleography, and otoacoustic emissions are also assessed.
Research of the vestibular analyzer. Chronic purulent otitis media, accompanied by vestibular disorders, is an indication for electronystagmography, stabilography, videooculography, pressor test, indirect otolitometry.

If there are neurological disorders in the clinic, consultation with a neurologist and an MRI of the brain are necessary.

Treatment of chronic suppurative otitis media

Purulent otitis without bone destruction and complications can be treated with medications under the outpatient supervision of an otolaryngologist. This drug therapy is aimed at relieving the inflammatory process. In cases where chronic purulent otitis media occurs with bone destruction, it is essentially a preoperative preparation of the patient. If chronic purulent otitis media is accompanied by paresis of the facial nerve, headache, neurological disorders and/or vestibular disorders, then this indicates the presence of a destructive process in the bone and the development of complications. In such a situation, it is necessary to hospitalize the patient as soon as possible and consider surgical treatment.

Conservative therapy

Chronic suppurative otitis media is usually subject to conservative or preoperative treatment for 7-10 days. During this period, the ear is cleaned daily, followed by washing the tympanic cavity with antibiotic solutions and instilling antibacterial drops into the ear. Considering that chronic purulent otitis media is accompanied by perforation in the eardrum, ototoxic aminoglycoside antibiotics cannot be used as ear drops. You can use ciprofloxacin, norfloxacin, rifampicin, as well as their combination with glucocorticosteroids.

Surgery

For the purpose of complete sanitation and functional restoration, chronic purulent otitis media with bone destruction requires surgical treatment. Depending on the prevalence of the purulent process, chronic purulent otitis media is an indication for sanitizing surgery with mastoidoplasty or tympanoplasty, aticoantrotomy, mastoidotomy, labyrinthotomy and labyrinthine fistula plastic surgery, and removal of cholesteatoma. If chronic purulent otitis media is accompanied by diffuse inflammation with the threat of complications, then general ear surgery is performed.

Forecast

Timely sanitation of a chronic purulent focus in the ear ensures a favorable outcome of the disease. The earlier treatment is carried out, the greater the chances of restoration and preservation of hearing. In advanced cases, when chronic suppurative otitis media leads to significant bone destruction and/or the development of complications, reconstructive surgery is necessary to restore hearing. In some cases, with the most unfavorable outcome, patients require

Chronic purulent otitis media is a chronic purulent inflammatory process located in the middle ear cavity. Chronic purulent inflammation of the middle ear is characterized by the presence of two permanent signs: continuous discharge of pus from the middle ear and a non-healing hole in the eardrum.

Causes

The reasons for the transition of a purulent process in the middle ear to a chronic form are varied. Some forms of acute otitis media have every chance of becoming chronic from the very beginning. These are necrotizing otitis media in scarlet fever, diphtheria and measles. However, this transition is not always observed and it is not necessary. And here a cure is possible, although with the leaving of permanent defects in the eardrum or with the formation of significant scars. In chronic infectious diseases, otitis media, which has a specific character, also takes a chronic course from the very beginning.

Of great importance general state organism, which determines the possibility of a more or less successful response to an introduced infection. Therefore, in anemic, emaciated subjects or in persons with lymphatic diathesis, a frequent transition of acute otitis into a chronic form is observed. The virulence of microbes plays a very important role in this.

The fact that the nature of the bacterial flora can really influence the course of otitis in an unfavorable sense follows from the fact that chronic otitis is often the result of careless or insufficient treatment of acute processes, which contributes to the appearance of a number of microbes in the ear.

The localization of the process in the middle ear is also of certain importance, for example: suppuration in the attic is more likely to become chronic than the same process in tympanic cavity. This is facilitated by the close spatial relationships and multi-chamber attic.

There is no doubt that the features of the anatomical structure of the temporal bone are of great importance. The occurrence of chronic purulent otitis media must be preceded by a hyperplastic change in the mucous membrane of the middle ear, and this latter is observed even in infancy, as a result of amniotic fluid entering the tympanic cavity. The condition of the upper respiratory tract also plays an important role, for example: adenoids, chronic nasal catarrh and diseases of its paranasal cavities.

Poor living conditions are of great importance in this regard, since particularly virulent microbes nest in poor rooms, causing severe illness. various diseases, including otitis media. But there are still a number of cases where the reason for the transition of an acute process to a chronic one remains unclear.

In chronic otitis, the same pathogens are found as in acute forms, but in addition there are also many saprophytes. The latter causes the foul smell of discharge, often observed in chronic otitis media, especially in advanced cases.

Chronic otitis with central (tympanic) perforation

By central perforation we mean such a hole in the eardrum, which is surrounded on all sides by the preserved rim of the eardrum, although this rim is very narrow and barely noticeable. From what has been said it is clear that the central perforation should not at all be located in the geometric center of the eardrum; it can end up in any department of it. The name “tympanic” has a slightly different meaning. It indicates that the perforation corresponds to the lower parts of the tympanic cavity, as opposed to those perforations that correspond to the upper parts of the tympanic cavity - the attic and atrium. However, the tympanic opening does not have to be central, i.e., surrounded on all sides by the rim of the preserved tympanic membrane.

A distinctive feature of otitis with central (tympanic) perforations is their safety for life, since the basis of the process in such cases is only inflammation of the mucous membrane, without any participation of the underlying or surrounding bone.

The shape and position of the perforations are extremely varied. Round, oval, kidney-shaped, etc. shapes are observed; they can occupy any of the squares of the eardrum, and sometimes two or more at the same time. The kidney-shaped shape is obtained when the lower end of the hammer handle protrudes from above into the edge of the perforation. However, the end of the hammer handle does not always hang down freely; sometimes it is pulled towards protuberance in the tympanic cavity of the middle ear and fused with it. Sometimes there is also fusion of the edges of the perforation with the inner wall of the tympanic cavity over a greater or lesser extent. In this case, the epidermis of the tympanic membrane may grow on the medial wall of the tympanic cavity, which leads to epidermization of the latter. However, the growth of the epidermis in such cases never occurs high up, into the area supratympanic recess. The size of the holes can also vary: from a pinhead to almost complete destruction of the membrane. The edges of the perforation appear either thickened and rounded, or pointed. The preserved portion of the eardrum is mostly thickened, dull red or red in color, and sometimes there is a deposition of calcareous plaques in it.

Symptoms

The symptoms caused by chronic suppurative otitis media with central perforation are minor. Patients complain mainly of suppuration from the ear and, to a lesser extent, of hearing loss. The noise is either completely absent or slightly pronounced. There are also no phenomena from the vestibular apparatus: dizziness, balance disorders, nystagmus, etc. Patients do not experience pain. The appearance of the latter indicates either an exacerbation of the process or the appearance of complications from the external auditory canal (furunculosis, diffuse inflammation). There are also no headaches or fever. In young children, due to the constant ingestion of pus that enters the gastrointestinal canal through the Eustachian tubes, disorders of the digestive organs may be observed.

A functional study reveals a typical picture of a disease of the sound-conducting apparatus: Weber lateralization into the diseased ear, negative Rinne and elongated Schwabach. The lower limit of hearing is increased, while the upper limit remains unchanged. The appearance of shortened bone conduction and decreased hearing for high tones indicates involvement of the inner ear. Hearing acuity for speech is always reduced, but the degree of this latter can be varied. In addition, sharp fluctuations in hearing are possible in the same patient, depending on greater or lesser swelling of the mucous membrane, greater or lesser accumulation of secretions, the degree of patency of the Eustachian tube, pressure on the base of the stapes, etc. Noticeable fluctuations in hearing ability are also observed in depending on the state of barometric pressure and air humidity. With low pressure and excessively humid air, hearing acuity decreases.

In general, however, with pure suffering of the middle ear, the hearing ability is more or less satisfactory; sharp degrees of hearing loss also indicate, like a corresponding tuning fork study, the involvement of the inner ear.

Flow

Chronic purulent otitis media with central (tympanic) perforation can last indefinitely. Sometimes it is supported by suppuration in the Eustachian tube or diseases of the upper respiratory tract. The condition of the mucous membrane of the tympanic cavity is also important in this regard. Granulations and polyps on the mucous membrane support suppuration. However, there are also cases of spontaneous healing with a permanent hole in the eardrum remaining or scarring. Exacerbations of the process are also possible. In such cases, chronic purulent otitis media begins to occur as acute, causing pain, fever, etc. There are cases when chronic otitis media lasts for decades and is not cured. However, with adequate ear care and proper treatment, it is still possible to achieve a cure in such cases.

Pathological anatomy

The mucous membrane of the middle ear is thickened, hyperemic, and sometimes polyposis degenerated. In some places, limited thickening may be observed, as an expression of its regressive changes. Sometimes the mucous membrane appears cystic. In the mastoid process, the phenomena of so-called osteosclerosis are found, that is, bone compaction and the disappearance of pneumatic cells.

During otoscopy, in addition to perforation of one shape or another, size and location, one can also see separate parts of the middle ear, since they appear naked, as well as a larger or smaller accumulation of pus. The latter is sometimes secreted in significant quantities, but sometimes the suppuration is so scanty that the patient does not notice it. In such cases, the pus dries into crusts that may resemble accumulations of sulfur. Characteristic of discharge from the middle ear is an admixture of mucus, which, of course, can only be released from places covered with mucous membrane. With poor ear care, when discharge lingers in the ear canal for a long time, a bad odor occurs, as said, due to the activity of saprophytes.

Diagnostics

Recognition of chronic suppurative otitis media should never be based on anamnestic data alone. There are often cases when patients do not even suspect that they have a constant leak from the ear. Very often, during otoscopy, doctors do not pay proper attention to small crusts lying on the walls of the ear canal near the eardrum, mistaking them for lumps of sulfur. This happens with scanty suppuration and small perforations. In most cases, however, the perforation is striking.

Sometimes it seems quite difficult to decide what is going on: a sunken scar or a perforation? In such cases, examination with a magnifying glass is very helpful. If there is a lot of pus in the ear canal, it must first be removed. This is necessary in order to determine the nature of the perforation, since therapy depends on this. Removal of pus from the ear is done either by rinsing or by dry method. Dried crusts must first be moved from their place using a thin button-shaped probe and then removed with tweezers. On the side facing the wall of the ear canal, such a crust is always covered with liquid pus.

Treatment

Due to the fact that chronic purulent otitis media with central (tympanic) perforation is not life-threatening, treatment should be purely conservative, with the exception of minor surgical procedures that are sometimes necessary to remove granulations and polyps from the ear.

In the absence of granulations or polyps, treatment of chronic suppurative otitis media comes down to three main techniques:

1) to thoroughly remove pus from the ear;

2) to the effect of certain medicinal substances on the diseased mucosa;

3) to conduct general treatment with antibiotics.

Removal of pus from the ear is done either by douching or dry method. In addition, to remove pus from the Eustachian tube, they also use blowing through one of the existing methods, the easiest way is by Politzer’s method.

Rinsing is done either with sterile warm water or weak solution boric acid (2-4%).

The choice of antibiotics depends on the pathogen.

In cases where there are granulations, a surgical method for their removal is indicated.

Polyps emanating from the middle ear can reach a significant size, sometimes filling the entire lumen of the ear canal and even protruding outward from the external opening of the latter. In such cases they are called obstructive or obstructive. They are connective tissue tumors (fibromas) covered with columnar epithelium. They are removed using special tools.

Chronic purulent otitis media with marginal perforation

This group of chronic otitis includes diseases in which perforations in the eardrum reach the very edge drum ring and are located in upper section membranes, i.e. next to supratympanic recess m and a cave. Therefore, this includes cases with a complete defect of the tympanic membrane or with defects in the posterior superior, anterior superior segment, or in the Shrapnell membrane.

Due to the fact that with otitis of this type, not only the mucous membrane is involved in the process, but also the surrounding bone, they are classified as dangerous, since left to their own devices, in most cases they lead to serious complications from the labyrinth or the contents of the cranial cavity. Complications arise either as a result of caries alone, or as a result of the so-called cholesteatoma joining the purulent process.

The latter is understood not as a congenital tumor, which is very rarely found in the area of the temporal bone, but as a formation that occurs secondary to the ingrowth of the epidermis into the cavity of the middle ear in chronic otorrhea. It is therefore more correct to talk about false cholesteatoma or pseudocholesteatoma.

The formation of pseudocholesteatoma occurs by ingrowth of the epidermis into the cavity of the middle ear from the side of the auditory canal. This is possible under two conditions: when the hole in the eardrum is located marginally and when there is a granulating surface in the tympanic cavity, devoid of epithelial cover. The growth of the epidermis on the granulating surface of the mucous membrane of the tympanic cavity is primarily a healing process, and in those cases where it does not extend beyond the limits necessary for this purpose, it actually leads to epidermization of the tympanic cavity and the cessation of suppuration as a result. However, in most cases, the ingrowth of the epidermis occurs without limit, that is, to a greater extent than is necessary to cure the disease. Simultaneously with the continuous ingrowth of the epidermis, its increased desquamation also occurs. Thus, the layer lying directly on the bone walls, the so-called matrix, is constantly changing.

Due to the small spatial relationships in the cavities of the middle ear, as a result of the continuous growth of the epidermis and its constant peeling, concentric layers are obtained, reminiscent of layers of onion peel. Since the layers of ingrown epidermis are located in the infected and secerated area, they begin to swell and decompose. Therefore, the presence of cholesteatoma in the ear causes a foul odor that is not amenable to conventional therapeutic manipulations.

Under the influence of the continuous growth of cholesteatoma in a tight space, not only does it spread to the attic, antrum and mastoid cells, but also a slow and constant usurization of the bone, due to the constant pressure of the cholesteatoma masses on the underlying bone.

In addition, cholesteatoma causes caries of the surrounding bones due to the spread of the inflammatory process on them and ingrowth into the Haversian canals, which further contributes to the destruction of the bone walls separating the middle ear cavities from the ear labyrinth and the skull. As soon as the integrity of the dividing walls is violated, the suppurative process spreads to the labyrinth and the contents of the cranial cavity, which is accompanied by the occurrence of serious and life-threatening complications. This is the danger of chronic purulent otitis media with marginal perforations in the upper part of the tympanic cavity.

As for independent processes in the bone - caries, such changes are possible in the auditory ossicles, the lateral wall of the attic, the posterior-superior wall of the ear canal, etc. However, in most cases, we are talking about already cured processes. Bone necrosis and sequestration occur only under the influence of long delay pus.

Total defects of the eardrum occur with necrotizing otitis (scarlet fever). The formation of marginal perforations in the superior posterior segment is explained by a disease of the surrounding bone. As a result of the suppurative process in the latter, the edge of the eardrum is separated from the bone ring and thus a marginal perforation is obtained. The occurrence of perforations in the area of the Shrapnell membrane is explained by previous long-term closures of the Eustachian tube. Due to the constant excess of pressure in the ear canal, Shrapnell's membrane first collapses and then ruptures. However, an isolated violation of the integrity of the Shrapnell membrane is also possible due to the transfer of inflammatory processes to it from the ear canal or from the tympanic cavity.

Symptoms

Subjective symptoms in chronic otorrhea with marginal perforations can be the same as in otorrhea with central perforations, very little expressed. Noises are usually either absent or very weak. Sometimes patients complain of a dull feeling of stuffiness. More often there are complaints of decreased hearing and suppuration from the ears. Either way happens, however, it is expressed in varying degrees. Hearing is best preserved in limited diseases of the attic with perforations of the Shrapnell membrane, since in this case the chain of auditory ossicles can be changed relatively little. In other cases, hearing may be reduced to the ability to distinguish whispered or colloquial speech in the most auricle or complete deafness is observed. The latter often depends on the presence of cholesteatoma and is then called “cholesteatoma deafness.”

With marginal perforations in the eardrum, the formation of crusts is especially often observed, depending on the drying of the poorly secreted secretion. This especially applies to perforations in the Shrapnell membrane. No matter how varied the amount of discharge from the middle ear is, pus almost always with marginal perforations produces a foul odor, depending on the decomposition of cholesteatoma masses. The addition of putrefactive microbes causes diffuse inflammation of the walls of the ear canal and even ulceration, which is accompanied by pain. The ulcerated walls of the ear canal subsequently become scarred, which leads to the formation of strictures in the ear canal and even to its complete closure. Such strictures sometimes consist not only of scar tissue, but also of a bone base. Eliminating them is fraught with great difficulties.

Pain in chronic otorrhea, without corresponding phenomena from the ear canal, indicates either an exacerbation of the process or a delay in discharge, which is usually caused by cholesteatoma masses, especially when they are suddenly swollen or by granulations and polyps in a close attic.

Sudden swelling of cholesteatoma can occur when water gets into the ear while swimming or washing, or when some drops are poured into the ear. In such cases, sometimes, simultaneously with the appearance of pain, paralysis of the facial nerve is observed, caused by the pressure of cholesteatoma masses on its canal. But, of course, facial nerve paralysis can be observed without sudden swelling of cholesteatoma in the process of slow growth and enlargement. Facial nerve paralysis is in such cases one of the indications for radical intervention.

In addition to the facial nerve, cholesteatoma may also affect the mixed branch of the facial nerve, which lies in the supratympanic recess between the handle of the malleus and long shoot anvils. The consequence of damage to the mixed branch is loss of taste in the anterior two-thirds of the tongue on the corresponding side. The appearance of dizziness indicates an abnormality of the external semicircular canal on the medial wall of the mastoid process, or processes in the area of the labyrinthine windows. Rare complications of chronic otorrhea include bleeding from the internal carotid artery.

The suppurative process in the bone that accompanies cholesteatoma, as well as periodic retention of pus, can lead to partial necrosis of the bone and discharge of the latter in the form of sequestration. Sometimes this is observed in the area of the outer wall of the attic, which is destroyed and thus allows cholesteatoma masses to escape, which in turn can lead to self-healing. Sometimes the process of necrosis and sequestration of the bone extends to the medial part of the posterior wall of the auditory canal and the adjacent parts of the mastoid process, as a result of which the final result is a cavity that is quite reminiscent of the cavity of an artificially performed radical operation, i.e., a natural cure of the process is obtained. However, a similar phenomenon with cholesteatoma is extremely rare. Usually, left to its own devices, cholesteatoma leads to the formation of a fistula on the mastoid process after preliminary accumulation of pus under the periosteum. In rare cases it is observed gas gangrene this area.

Diagnostics

When diagnosing chronic suppurative otitis media, first of all, pay attention to the nature and location of the perforation and possible availability cholesteatomas. It is not always easy to determine the location of the perforation. Sometimes it is so insignificant that it can only be recognized with a magnifying glass and repeated examination. It can also be difficult to recognize marginal perforations in the superior posterior segment if the inner wall of the tympanic cavity in this place is epidermal and thus differs little from the epidermal eardrum. However, long-term observation, probing, and an unpleasant odor that does not disappear despite therapy help in recognition.

Determination of a marginal perforation in the eardrum almost certainly indicates the presence of cholesteatoma. However, in each individual case, a more precise definition of this complication is desirable.

A certain significance is also attached to the picture of blood. Complicated chronic purulent otitis media is characterized by neutrophilia, while simple lymphocytosis is of no significance.

On a radiograph, cholesteatoma and defects in the bone are reflected by the formation of clearing nests, and the discontinuity of the line roof of the tympanic cavity indicates a violation of the integrity of the bone in this area. The presence of a fistula on the mastoid process, the appearance of facial paralysis, dizziness, a fistula symptom or signs of an intracranial complication also indicate cholesteatoma.

If possible, a CT scan is performed to confirm the diagnosis.

Treatment

Treatment of chronic purulent otitis media with marginal perforation can be conservative and surgical.

A. Conservative treatment

Conservative treatment is permissible only in cases where there is reason to assume that there is no cholesteatoma at all or it is so small that it can be removed through an existing perforation in the eardrum. Since, however, such a diagnosis is always associated with great difficulties and sometimes impossible, conservative therapy for this disease is always associated with a certain risk. But even in favorable cases, relapses are always possible and the patient must be constantly under medical supervision.

If the inflammation is purulent, antibiotics are indicated. The measures used for otitis with central perforations - washing the ear with a regular syringe or syringe, instilling drops or blowing - are invalid here, since the affected cavities of the epitympanic space are not very accessible to therapeutic manipulations. To make it possible for drugs to penetrate into the attic or antrum, it is necessary to use a specially curved cannula.

Of the various models, it is best to use a bayonet-shaped cannula, which can be tightly fitted onto a Record syringe.

Sometimes in the attic and atrium, in addition to cholesteatoma, there are small granulations that may not be visible, hiding behind the edge of the marginis tympanici. This can be judged only because previously invisible granulations are torn off by a stream of washing liquid and fall into the tray placed under the ear. In other cases, the presence of granulations in the attic may be suspected when, after wiping with a curved probe, blood appears from the attic. Finally, sometimes a small margin of granulation is visible. Removal of granulations sitting in the attic is possible only with the help of an appropriately curved ring-shaped knife, since inserting a polyp loop into the attic is impossible.

The described method of removing granulations from the attic is, strictly speaking, no longer a conservative, but a surgical method of treatment, which, however, is conditionally classified in this group in contrast to the large surgical interventions practiced for the treatment of chronic otorrhea.

B. Surgical treatment

Surgery is indicated if unsuccessful conservative methods treatment of chronic purulent otitis media with marginal perforation. The technique of radical surgery varies depending on the method used. In this regard, a distinction is made between typical radical surgery from the outside, typical radical surgery from the inside, radical surgery from the side of the ear canal, and so-called conservative-radical surgery.

The information provided in this article is for informational purposes only and is not intended to substitute for professional advice and qualified advice. medical care. At the slightest suspicion of the presence of this disease Be sure to consult your doctor!

Chronic suppurative otitis media (H66.1-H66.3) is a chronic purulent inflammation of the middle ear, which is characterized by a triad of symptoms: persistent perforation of the eardrum, suppuration from the ear, progressive hearing loss, as well as a cyclical course with alternating periods of exacerbation and remission lasting more than 3 months.

This is a widespread disease - 0.8-1% of the world's population. This pathology poses a great danger to hearing, and with the development of intracranial complications, to human life.

Etiology: microbial flora, polyflora (at least 2 pathogens), the presence of anaerobic flora, the presence of antibiotic-resistant flora, fungi, viruses.

Routes of entry:

Tubogenic (through the auditory tube).
Contact (through perforation in the eardrum).
Hematogenous.

Factors contributing to the process becoming chronic:

Decreased immunity (AIDS).
Diseases endocrine system (diabetes).
Intoxication.
Tumors.
Chronic infections.

2. Local:

Diseases of the ENT organs: sinusitis, rhinitis, tonsillitis, adenoiditis, deformation of the nasal septum. Carious teeth.
Incorrect treatment of acute otitis media.
Necrotizing forms of otitis media (measles, scarlet fever, diphtheria).
Anatomical features of the structure of the middle ear.

Classification by stream:

Mesotympanitis (chronic tubotympanic otitis media). The mucous membrane is inflamed, the bone is intact, the course is benign.
Epitympanitis (chronic epitympanic-antral otitis media). Inflammation affects the bone elements of the middle ear (the walls of the tympanic cavity, the chain of auditory ossicles with their subsequent destruction, the fallopian canal, semicircular canals, with the development of the labyrinth, labyrinth fistula), cholesteatoma develops, and is characterized by an unfavorable course.

Symptoms of chronic suppurative otitis media

Dumb, It's a dull pain in the ear.
Persistent hearing loss.
Pathological discharge from the ear with an unpleasant odor.
Hyperthermia, weakness, lethargy.
Noise in ears.

Exacerbation is provoked by hypothermia, moisture getting into the ears, inflammatory diseases ENT organs.

Upon inspection:

Perforation of the tympanic membrane in the mesotympanic/epitympanic parts.
Hearing loss (perception of whispered and spoken speech).
Mucopurulent discharge in the ear canal.
Hyperemia of the remnants of the membrane, mucous membrane of the tympanic cavity.
Caries of the bone walls of the tympanic cavity, auditory ossicles. Cholesteatoma masses are whitish-purple in color, granulating polypous masses (with epitympanitis).
Symptom of fistula (when pressing on the tragus, dizziness and imbalance develop).
During the blowing of the auditory tube, air and pathological secretions escape through the perforation in the membrane.

Diagnosis of chronic suppurative otitis media

Consultation with an otorhinolaryngologist.
Hearing examination using whispered and spoken speech.
Tuning fork tests.
Vestibulometry.
Fistula tests.
Smear and culture of ear discharge.
Pure-tone audiometry.
Tympanometry.
X-ray of the temporal bones according to Schuller.
CT, MRI of the brain.

Differential diagnosis:

Treatment of chronic suppurative otitis media

Treatment is prescribed only after confirmation of the diagnosis by a medical specialist.

1. Drug treatment:

Vasoconstrictor nasal drops.
Antibacterial drops in the ear (“Candibiotic”, “Sofradex”, “Normax”, “Albucid” 20%, “Dioxidin”, “Polidexa”, etc.). Alcohol ear drops contraindicated.
Rinsing the ear with antiseptic solutions.
Semi-alcohol compress on the ears.
Antihistamines.
Antibiotic therapy.
Physiotherapy.

2. Surgical methods treatment (indications: epitympanitis; complications).

Essential drugs

There are contraindications. Specialist consultation is required.

(local antifungal, antibacterial, anti-inflammatory agent). Dosage regimen: 4-5 drops into the external auditory canal, 3-4 times/day. The course of treatment is 7-10 days.
(a drug with antibacterial and anti-inflammatory effects). Dosage regimen: 2-3 drops are instilled into the external auditory canal 3-4 times a day. Use no more than 7 days.
(local antibacterial agent). Dosage regimen: 2 drops are instilled into the external auditory canal 4 times a day. Use no more than 10 days.
(antihistamine). Dosage regimen: orally, during meals, at a dose of 25 mg 3-4 times a day.