Acute and chronic catarrhal otitis media: how and what to treat?

When otolaryngologists diagnose catarrhal otitis, from a morphological point of view, we mean a superficial type of inflammation that affects the mucous membranes of the middle ear (the tympanic cavity and Eustachian tube) and is accompanied by swelling with exudation.

Although with increased secretion of mucus, otitis media is classified as exudative, and when purulent discharge is formed - as an average purulent otitis media.

It should be noted that in otolaryngology (or otorhinolaryngology), as in many other fields of medicine, there are problems with terminological polysemy. Therefore, it is not clear to patients why catarrhal otitis can be called both acute  catarrh of the middle ear, and serous or exudative middle otitis, and tubootitis, and salpingitis ...

In addition, many ENT doctors claim that catarrhal otitis is the initial stage of inflammation of the middle ear, defined as catarrhal otitis media or  acute otitis media. And some people consider catarrh only an acute inflammatory process, although catarrhal is inflammation of the mucous membranes.

[1], [2], [3]

Epidemiology

According to clinical statistics, in four adult patients out of ten, the catarrhal otitis media of the middle ear is the result of the spread of infection from the nasopharynx with accompanying ARI rhinitis, as well as nasopharyngitis, sinusitis, sinusitis or inflammation of the tonsils.

At children on a catarrhal otitis it is necessary not less than two thirds of cases. According to recent data, about 90% of children in the first three years of life at least once have otitis (catarrhal, exudative or allergic), and in infancy - almost half. The doctors explain this by the anatomical features of the Eustachian tubes in children, the presence of a considerable volume of loose embryonic tissue in the tympanic cavity, and the insufficient development of general immunity in the first years of the child's life.

[4], [5], [6], [7], [8],

Causes of the catarrhal otitis

In most cases, the causes of catarrhal otitis are associated with a bacterial or viral infection that affects the upper respiratory tract. Among bacteria, Haemophilus influenzae (up to 25% of cases), pneumococcus Streptococcus pneumoniae (35%) and the pathogen of the mucous membranes Moraxella catarrhalis (4-13%) are most common. Additional pathogenic microorganisms are β-hemolytic pyogenic streptococcus (Streptococcus pyogenes), Staphylococcus aureus (golden staphylococcus aureus), various strains of Pseudomonas, as well as some Gram-negative intestinal bacteria. Viral pathogens of catarrh of the ears in 10-12% of cases are influenza viruses (Ortomyxoviridae of various serotypes), Adenoviridae, Human orthopneumovirus, Human rhinovirus (A, B, C), Coronaviridae, Reoviridae. In this case, viruses can contribute to bacterial superinfection, disrupting the functions of eustachian (auditory) tubes.

As a rule, inflammation of the mucosa of the middle ear in adults and catarrhal otitis during pregnancy develops against the background of inflammatory respiratory diseases with violation of the patency of the Eustachian tubes. As a result, a negative pressure is created in the tympanic cavity with transudation into it of the liquid: the infection in the middle ear gets mainly tubogenic. See - pathogenesis of  tubotitis

It is due to inflammation of the mucous membrane of the auditory tubes that the mucous exudate formed with pathogenic microorganisms or viral virions induces catarrhal otitis media.

Especially often they are sick children under five years - due to the fact that the children's hearing tube is wider and shorter than that of adults. Because of this, bacteria and viruses, together with the nasal secretion secreted in rhinitis or rhinopharyngitis, easily penetrate into the auditory tubes and the middle ear cavity, causing an inflammatory response.

Catarrhal otitis in a child can also be a complication of diphtheria, and in the case of measles and scarlet fever, the infection enters the ear in a hematogenous way.

In the neonatal period, catarrhal otitis in the infants can develop when the amniotic fluid enters the tympanic cavity during childbirth. In frequently regurgitating infants, inflammation of the ears may occur due to reflux of the contents of the stomach into the nasopharynx, and then into the auditory tubes. More information in the material -  Acute otitis media in children

[9], [10], [11],

Risk factors

Risk factors for the development of catarrhal otitis are:

• certain anatomical abnormalities in the structure of the nasopharynx and surrounding structures;
• frequent inflammatory diseases and chronic pathologies of the nasopharynx and sinuses of the nose;
• childhood;
• adenoids (hypertrophy of the pharyngeal tonsil) in children;
• in children - split palate, rickets, exudative diathesis;
• decreased body resistance; immune deficiency in diabetes, tuberculosis, leukemia and AIDS;
• vitamin deficiency (anemia).

[12], [13], [14],

Pathogenesis

To date, the pathogenesis of acute catarrhal otitis is considered in the light of two main theories. The classic explanation suggests that this disease occurs when dysfunction of the Eustachian tube, which balances the pressure between the middle and outer ear, provides cleansing and protection of the middle ear. With sustainable

Dysfunction of the auditory tubes in the middle ear - from the absorption and / or diffusion of nitrogen and oxygen into the cells of the mucous membrane of the middle ear - the pressure becomes negative, which causes a transudation of serous effusion from the mucosa. Exudate accumulates, and this is the ideal medium for the propagation of anaerobic pathogenic bacteria.

According to another, more recent theory, the inflammation of the mucosa of the middle ear is caused by a reaction to bacteria already present in the middle ear. In particular, studies have shown the presence in the middle ear of pepsin, aspirated as a result of gastroesophageal reflux. This theory suggests that the mucosa of the middle ear is sensitized by the previous exposure to bacteria, and inflammation is caused by the continuing reaction of the antigens.

[15], [16],

Symptoms of the catarrhal otitis

The first signs of catarrhal otitis may be manifested by ear congestion and autophony. At the initial stage, the inflammatory process is diagnosed as acute catarrhal otitis. As already noted above, some ENT specialists believe that this is simply the initial stage of otitis development.

As the inflammation progresses, the swelling of the mucosa increases, extending into the tympanic cavity, obturation of the eustachian tubes takes place and the tympanic membrane retracts. As a consequence, there are symptoms of acute catarrhal otitis, such as hearing loss and tinnitus; headache; otalgia (pain in the ears - shooting, pulsating, giving to the jaw and temple, increasing when swallowing, sneezing, coughing, or blowing nose); serous or mucoid secretions from the auditory canal.

At the onset of the disease in adults - against a background of worsening of the general condition - the temperature with catarrhal otitis may be subfebrile or fluctuate within + 37.8-38 ° C. But very quickly, especially in children, it rises even higher - to + 39 ° C.

Symptoms of catarrhal otitis in infants are nonspecific: increased child anxiety, unmotivated crying, frequent sharp turns of the head, refusal to feed. Parents can check for inflammation in the ear by pressing on his tragus: when otitis this causes increased pain and crying.

Exudate presses on all structures of the middle ear, resulting in perforation of the tympanic membrane with the expiration of purulent contents. The intensity of pain is significantly reduced, the temperature indicators are reduced, and the hearing is gradually restored.

If individual symptoms - hearing loss (due to the formation of fibrous scars on the site of the tympanic perforation) and a sense of noise in the ears - occur in patients longer than one to two months or if the inflammation recurs periodically, then chronic catarrhal otitis is determined.

Inflammation can be one-sided - left-sided or right-sided catarrhal otitis; in children the inflammatory process very often develops immediately in both ears, causing bilateral catarrhal otitis.

In addition, distinguish such types of the disease as

• adhesive otitis media (with sticky exudate), which is considered a consequence of chronic catarrhal otitis and the result of proliferation of connective tissue and fibrosis of the tympanic cavity and tympanic membrane;
• catarrhal purulent otitis, in which otoorea is added to all of the listed symptoms, that is, excrement from the ear of exudate purulent.

Since there is no mucous membrane in the auricle and external auditory canal, there can be no external catarrhal otitis: it is simply external otitis - acute or chronic inflammatory inflammation of epithelial tissues with localization from the auricle along the entire ear canal to the tympanic membrane that separates the outer ear from the middle. Often, this form of the disease occurs due to manipulations in the ear canal with sharp objects and traumatic skin damage. Otitis externa may appear as a furuncle localized in the ear canal or as a diffuse infection -  diffuse inflammation of the external auditory canal

[17], [18], [19], [20]

Complications and consequences

It should be borne in mind that acute catarrhal otitis of bacterial origin can easily go into a purulent form. And pus can fill the airway cells of the mastoid process of the temporal bone, causing inflammation in the form of mastoiditis, and perilabyrinth cells - with the development of inflammation of the inner ear (labyrinthitis).

Accumulating, purulent exudate can reach the layer of subcutaneous tissue. It is possible to form an atypical cholesteatoma of the middle ear - a cystic tumor-like cavity that can grow to the mastoid process of the temporal bone and lead to labyrinthitis, inflammation of the brain membranes (meningitis), brain abscess (extra- and subdural), incomplete peripheral paralysis of the facial nerve and even sepsis .

In addition, complications of catarrhal otitis include a constant tinnitus, pre-hearing loss of hearing or complete loss of hearing, and with a labyrinthitis - a violation of coordination of movements during walking.

Infection can affect the brain tissue with the development of meningitis. The consequence of catarrhal otitis of a viral origin is fraught with such complication from the tympanic membrane, as bullous myringitis.

With an adhesive median otitis, the possible consequences and complications are associated with the formation of adhesions and the violation of the patency of the auditory tube, which leads to a progressive decrease in hearing. A necrotic form of external otitis - in the elderly, as well as with diabetes and weakened immunity - can be transformed into osteomyelitis of the temporal bones of the skull.

[21], [22], [23], [24], [25]

Diagnostics of the catarrhal otitis

The main diagnosis of catarrhal otitis is history, analysis of clinical symptoms in patients and examination of the ears.

The key diagnostic method is otoscopy in catarrhal otitis, which allows to assess the state of the tympanic membrane and to reveal the effusion (effusion) of the middle ear. Details are highlighted in the publication -  Ear study

To clarify the nature of pathology, instrumental diagnostics (X-ray, CT) is also conducted; In the chronic form of the disease, audiometric methods are used to study hearing functions.

[26], [27],

Differential diagnosis

The task performed by differential diagnosis is to distinguish between acute otitis media and otitis media of the middle ear with effusion, since in the presence of pus containing exudate it is not recommended to use antibiotics.

Treatment of the catarrhal otitis

As the otolaryngologists point out, the treatment of catarrhal otitis should be aimed at ensuring as soon as possible the patency of the auditory tubes and cleansing the secretion of the middle ear from the effusion - for ventilation of the tympanic cavity in order to avoid possible complications.

The drugs that are used in the therapy of catarrhal otitis, in principle, are the same as with any inflammation of the middle ear. Their names and methods of application are described in detail in the article -  What to do with otitis?

One of the most important components of treatment is antibacterial therapy. In particular, it is necessary to prescribe antibiotics to children under the age of two. What antibiotics are prescribed for catarrhal otitis? Amoxiclav (Augmentin), Ciprofloxacin, Cefixime, Roxithromycin, etc. For more details on their dosage, contraindications and side effects, see  Antibiotics for Otitis

In the absence of additional adverse factors - hyperthermia for three days from the start of treatment and / or severe intoxication - catarrhal otitis is treated without antibiotics: the patient is prescribed local analgesics (usually in the form of ear drops with anesthetic components). For example, containing the phenazone and lidocaine droplets Otipaks with catarrhal otitis are instilled in the ear (including infants) - 3-4 drops, no more than three times a day. Contraindication is damage to the tympanic membrane.

Universal antimicrobial and antiviral drops - Sulfacil sodium (Sulfacetamide). But the preparations of Otof and Polidex contain antibiotics: accordingly rifamycin and neomycin. Otof drops during catarrhal otitis can also be used in cases of acute and chronic external and middle otitis media, including perforation of the tympanic membrane. They are buried during the week: adults - five drops three times a day: children - two drops three times a day.

Also, to reduce puffiness and restore the patency of the auditory canal, vasoconstrictor drops in the nose (Galazolin, Nazivin, Otrivin, etc.) can be effective in otitis media. But these drugs can not be used for more than five days in a row.

What other drops for catarrhal otitis appoint doctors, more details in the article -  Drops with otitis

In addition, semi-alcoholic compresses are made, the ear is heated by a blue lamp. However, the heating procedures can be carried out only at normal body temperature.

Taking vitamins A, C and E during any inflammatory diseases, we reduce the oxidative stress of the organism at the cellular level, and the inflammation passes faster.

Physiotherapeutic treatment of catarrhal otitis is carried out with the help of UHF, electrophoresis, tube quartz, darsonvalization, etc. For more details see  Physiotherapy in otitis

With worsening of the general condition and protrusion of the hyperemic eardrum, surgical treatment is required - in the form of its paracentesis (puncture), which allows significantly improving the clearance of the middle ear effusion (remove accumulated exudate, most often purulent) and thereby eliminate the inflammation focus and protect the patient from complications.

For the treatment of catarrhal otitis homeopathy offers to instill in the diseased ear mullein oil scepter-like (Verbascum phlomoides).

Alternative treatment is also carried out with the use of this plant, the flowers of which should be prepared by extracting oil by infusion of fresh inflorescences on refined vegetable oil (sunflower or olive) - for a month.

In addition, relieve pain and inflammation in the ear such oils as almond, walnut and tea tree (it is recommended to dig in two drops twice a day).

Prevention

The main prevention of catarrhal otitis is the timely treatment of diseases of the upper respiratory tract and strengthening of immunity.

An important role is played by the  prevention of adenoids in children.

[28], [29], [30],

Forecast

As with any inflammatory process in otolaryngology, the prognosis of inflammation of the mucosa of the middle ear depends on the degree of its damage and functional damage. With the perforation of the tympanic membrane, there is a threat of significant thickening and atrophy (due to scarring), and, consequently, a worsening of the hearing.

Acute catarrhal otitis can become chronic, in which there is often a temporary and sometimes permanent sensorineural hearing loss. Although, in general, the prognosis for moderate catarrhal otitis is good.

[31], [32], [33], [34], [35], [36]