Acute bilateral otitis media: exudative, catarrhal, purulent

Bilateral otitis is an inflammatory disease in which the tissues of the ears of the left and right sides are affected. At the same time, the pathological process can spread deep down, causing inflammation of not only the middle and inner ear, but also other areas of the brain area of the head.

[1], [2],

Epidemiology

The statistics of occurrence of bilateral otitis indicates that children are mainly affected by this disease. The anatomical immaturity of the tympanum, labyrinth and eustachian tube stimulate a high incidence rate at an early age. However, their appearance is also possible in people of young and mature age. The most common type is the pathology of the middle ear. As a rule, 80% of children under the age of 3 years have at least once transferred otitis media. Further on the frequency of onset otitis of the external ear, which is about 20%, and the smallest incidence is inherent in the otitis of the inner ear - 10%.

[3], [4], [5], [6], [7],

Causes of the bilateral otitis media

The main cause of bilateral otitis media is viral and bacterial agents. Due to the violation of the immune system, the body loses its resistance to various microorganisms. There are exogenous (external) and endogenous (internal) risk factors for bilateral otitis media. Exogenous factors include subcooling, ingress of dirty water into external auditory canals, bilateral traumatic damage to the ears. Endogenous factors are changes in local or general immunity, in which there is a violation of the reactivity of the organism. Bilateral otitis often acts as a secondary pathology and arises from the presence of acute inflammatory processes in the upper respiratory tract. Also, to the factors of occurrence of bilateral otitis can be attributed to congenital anomalies of development, which create a predisposition to the appearance in this area of inflammatory processes.

[8], [9], [10], [11], [12], [13], [14]

Pathogenesis

The pathogenesis of bilateral otitis can be explained by two theories, and both of these concepts suggest a change in the structure of the auditory (Eustachian) tube. The first theory says that the Eustachian tube lends itself to mechanical obstruction (blockage) due to the proliferation of lymphoid tissue of the nasopharyngeal (adenoid) or tubal tonsils. According to the second theory, with acute inflammatory processes in the upper respiratory tract, the mucous membrane of the Eustachian tube swells, thereby narrowing its lumen. Due to the fact that the inner volume of the tube decreases, a negative pressure is created in the tympanic cavity. In connection with the presence of negative pressure, the liquid bleeds into the Eustachian tube and, subsequently, the bacterial flora attaches to the effusion. This promotes active migration of lymphocytes and neutrophils to this area, causing a catarrhal stage of otitis media. As the infectious load increases, the catarrhal process is replaced by a purulent process, aggravating the state of the organism.

[15], [16], [17], [18], [19], [20], [21], [22]

Symptoms of the bilateral otitis media

The onset of bilateral otitis is always sudden and acute regardless of the age at which it occurs. The first signs are dizziness, headache, stuffy ears, heaviness in the head, tinnitus, body temperature rises to subfebrile values. In the ears there is a burning pain of shooting character, the phenomena of intoxication in the form of weakness, apathy, nausea increase. Out of the ears are purulent masses, the hearing decreases.

Bilateral otitis in adulthood is less pronounced than in children, the effects of intoxication manifest themselves in varying degrees, depending on the state of the body and its immune system. A characteristic feature of acute purulent bilateral otitis media in adults is a less pronounced course of the process. The development of complications occurs less often due to the formed barriers in the form of a lymphoid ring and mature connective tissue.

Bilateral otitis in children proceeds with bright symptoms. Raising body temperature to 40 ° C and apathetic behavior of the child indicates an intoxication syndrome, which also includes headache, nausea, vomiting. Against this background, meningeal symptoms may appear, manifested in the inhibition of consciousness and disappearing with a decrease in organism intoxication. When pressing on the tragus of the ear, the child has severe pain, which helps to establish the localization of inflammation. This is due to the fact that at an early age there is still no bone auditory canal. The peculiarity of this pathology in children is a high probability that there will be a recovery without a perforation of the auditory membrane (due to the high resistance of the membrane and the best outflow of exudate from the wide eustachian tube).

[23], [24], [25], [26], [27], [28],

Stages

For the classical course of purulent bilateral otitis characterized by 3 stages. At the initial stage, there is infiltration and accumulation of exudate in the tympanic cavity, pain in the ear, hyperemia (reddening), impaired perception of sounds, intoxication. In the results of a clinical blood test, there is an increase in the number of leukocytes, an increase in ESR. For the second stage, melting of the tympanic membrane with purulent exudate is typical, due to which there appears a perforating aperture and suppuration from the ears. Due to the outflow of pus, the patient feels relief, the symptoms subsided and the dynamics of the disease improves. The third stage is reparative, at this time the suppuration stops, the perforation of the auditory membrane becomes scarred, the middle ear cavity is cleared and the functions of the hearing aid are restored. The duration of each stage ranges from 2-3 days to 2 weeks.

[29], [30], [31],

Forms

Bilateral otitis are systematized into acute and chronic depending on the course of the disease; by severity - easy, medium and heavy; by the type of exudate - catarrhal (serous), purulent; on localization - otitis of the external, middle and inner ear.

Bilateral otitis externa is a group of inflammatory diseases of the external ear. The localized form of external otitis often manifests itself in the form of limited purulent-inflammatory processes, among which the most common is the furuncle of the external auditory canal. This purulent-necrotic inflammatory disease is clinically manifested rather aggressively: there is a sharp pain in the ear that spreads into the teeth, neck, facial and temporal areas. There is a sharp increase in pain during palpation of the ear near the furuncle. Sometimes there is an increase in regional lymph nodes, the body temperature rises. The disease ends in about 5-7 days, if it occurs without complications. Diffuse otitis is characterized by the defeat of the skin of the external ear, in which inflammation spreads to the auditory ossicles and the auditory membrane. Clinically, this form of bilateral external otitis is characterized by pain, itching in the ears, deafness. If diffuse otitis has a chronic course, then all of the above symptoms manifest to a lesser extent, and the disease becomes protracted and sluggish.

Acute bilateral exudative otitis media (serous otitis media) is an inflammation of the middle ear tissue, in which the focus of the lesion hits the mucosa of the tympanum and auditory tube. The main sign of this pathological process is the accumulation in the tympanic cavity of the catarrhal fluid. Bilateral exudative otitis is a complex concept, its course is divided into several stages. The first stage is acute bilateral catarrhal otitis (eustachiitis). In connection with the violation of air circulation in the auditory tube, air stagnation occurs in the middle ear chamber and serous inflammation develops. At this stage, there is a slight decrease in hearing, discomfort in the ear, insignificant stuffiness, autophony (a feeling that can be described as a "ringing of a voice in my head"). The second stage - acute bilateral secretory otitis, is associated with increased secretion and accumulation of mucus in the middle ear cavity. Symptomatically this is represented by pressure in the ear, a decrease in hearing (more severe than in the first stage), noise in the ear. A characteristic subjective feature for this stage is the sensation of transfusion of fluid in the ear with head inclinations and a change in the position of the body. The duration of the second stage is from 1 to 12 months. The third stage is mucous, during this period the accumulated mucus becomes more dense and viscous. Impaired perception of sound is aggravated, a symptom of fluid transfusion may be absent. The duration of the stage is from 12 to 24 months. The fourth stage - adhesive middle otitis, differs fibrous restructuring of the mucous membrane. In this case, the secretion of mucus is reduced until complete cessation, and in the tissues of the middle ear there are processes of scarring, which leads to irreversible hearing loss.

Acute bilateral purulent otitis is a purulent-inflammatory disease that involves the involvement of all parts of the middle ear in the mucosa process. The initial stage is called "pre-perforative", which indicates the integrity of the auditory membrane at this stage. However, the symptomatology of the preperforative stage is quite bright: there is a sharp, painful pain in the ears, which spreads to the temporal and parietal region. Also, the patient feels stuffiness in the ears, noise, reduced acuity of hearing. In addition, there are symptoms of intoxication: a sharp increase in body temperature to 38-39 ° C, chills, headache, weakness, leukocytosis in a clinical blood test, increased ESR. This period lasts about 2-3 days. The second stage - perforated, is characterized by a reduction in general symptoms, stifle of pain in the ears. However, during this period there is a perforation of the tympanic membrane, which provokes suppuration from the ear. This stage lasts for 5-7 days. The final stage is the reparative stage, which involves the cessation of the suppuration and cicatrization of the perforation of the tympanic membrane. It should be noted that the purulent process does not always go through all 3 stages. Practice shows that in many cases purulent inflammation becomes sluggish and protracted. In some patients in the second stage, the general condition does not improve, despite the perforation of the tympanic membrane and a free outflow of purulent contents. Recently, there are cases when acute bilateral purulent otitis becomes chronic and regularly recurs. However, most of the disease occurs no more than 2-3 weeks and ends with recovery.

Chronic bilateral otitis is represented by two basic forms - mesotimpanitis and epitimpanitis. Mesotypanitis is a purulent-inflammatory disease characterized by a lesion of the mucous membrane of the middle and lower sections of the tympanum and auditory tube. The peculiarity of this pathology is that the bone tissue of the auditory ossicles does not undergo destruction. The clinical picture of mesotympanitis involves the appearance of complaints about the regular occurrence of pain in the ears, hearing loss and suppuration. This type of otitis occurs with alternating periods of exacerbation and remission. Epitimpanitis is an inflammatory-destructive process that occurs in the above-drum space and the mastoid process. This disease affects the auditory ossicles, which leads to the formation of severe pathology of the auditory analyzer. The main manifestations of epitimpanitis are purulent discharge from the ear, which have a fetid odor.

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Complications and consequences

The consequences and complications of bilateral otitis are related primarily to the duration of the disease and its course. If medication is performed on time, the healing process takes place within a week. But, if the acute process has not been treated, then it can go into a chronic sluggish form, or spread to neighboring areas, including the membranes (meningitis) and sinuses of the brain.

One of the complications of bilateral otitis is acute mastoiditis, which occurs in parallel with acute otitis media. Inflammation of the mucosa of the middle ear passes to the tissues of the mastoid process, which is the initial stage of this disease. However, if the acute otitis ends with recovery, then the development of mastoiditis does not occur. If all mastoiditis has occurred, you should expect such symptoms as earache and the corresponding half of the head on the side of the lesion, pulsating tinnitus, increased symptoms at night and symptoms of intoxication. In this case, you should immediately consult a doctor.

Labyrinthitis and paresis of the facial nerve arise as complications of otitis media as a result of the penetration of inflammatory phenomena into the inner ear, accumulations of purulent exudate and melting of the structures of the facial nerve. These complications are characterized by impairment of the functions of the vestibular and auditory receptors, which is manifested by dizziness, static and coordination disorders, numbness of the corresponding half of the face, a feeling of crawling, dry eyes, and taste and salivation disorders.

Abscesses of the brain and cerebellum arise as a result of the spread of pus from the tympanic cavity or mastoid process and its abscessing in the structures of the brain. These formidable complications are manifested by symptoms of intoxication, meningitis, cardiac disorders, changes in blood composition. In the presence of the above symptoms, you need to contact a neurosurgeon.

[36], [37], [38], [39], [40], [41], [42], [43], [44]

Diagnostics of the bilateral otitis media

Diagnostic criteria for bilateral otitis are history data, basic complaints, examination, instrumental examinations and laboratory tests. If a person has previously suffered any inflammatory diseases of the ears, then the probability of their recurrence is quite high. This is due to a decrease in local immunity in the area of the transferred inflammatory process. When establishing the correct diagnosis, one should clearly understand when the first signs of the disease started and what they were provoked. After this, it is necessary to analyze the current state of the body and the main complaints (for example, pain in the ears, congestion, hearing loss, autophony, etc.).

One of the key instrumental methods is otoscopy. It allows you to assess the condition of the tissues of the middle ear, incl. Eardrum. In carrying out this procedure, you can determine the severity of the inflammatory process, the presence and localization of perforations of the auditory plate. Since the middle ear system is associated with the nasopharynx via the Eustachian tube, examination of the mucous membrane of the nasal and oral part of the pharynx is also necessary. An effective diagnostic method is purging eustachian tubes. With it, you can evaluate the functional state of the auditory tube. This is a very important procedure, since disturbance of the patency of the auditory tubes is the first link in the pathogenesis of inflammatory diseases of the ears. If suspicion of otitis media is present, tympanometry is performed, which allows to determine the mobility of the tympanic membrane; its functional abilities at the time of the disease. Audiometry is a method of evaluating the auditory function for complaints of hearing loss and decreased perception of sound. Computer tomography or magnetic resonance imaging is the most effective instrumental diagnostic methods to date. With their help, you can not only determine the presence of structural disorders of the auditory analyzer, but also to identify possible complications (mastoiditis, meningitis, purulent abscess).

Laboratory analysis plays an equally important role in the diagnosis of bilateral otitis media. Having evaluated the clinical analysis of blood, it is possible to determine the presence of an inflammatory process in the body (leukocytosis, acceleration of ESR). With allergic reactions, there is an increase in the number of eosinophils. To determine the causative agent of the disease, a bacterial culture is carried out. Thus, it is possible to recognize the type of bacterial agent and apply rational antibiotic therapy. If the disease is in a state of remission, it is very important not to allow a relapse of the inflammatory process. For this, it is necessary to perform an immunogram and assess the level of immunity. 

[45], [46], [47], [48], [49]

Differential diagnosis

Differential diagnosis is carried out between different forms of bilateral otitis, as well as with eczema, erysipelas and perichondritis. In addition, bilateral otitis media must be distinguished from mastoiditis, labyrinthitis, meningitis and brain abscess, which were considered earlier.

Each of the forms of bilateral otitis has specific properties that make it possible to distinguish diseases from each other, to put the right diagnosis and to conduct qualitative treatment. With acute eustachitis, pain and discharge from the ear are absent, however, there is deafness, noise and autophony. The general condition is not violated. The tympanic membrane is retracted. On the basis of these data, it is possible to distinguish eustachiitis from heavier forms of otitis media. Acute catarrhal bilateral otitis is characterized by moderate pain in the ears, with no secretion from the ears. The tympanic membrane is hyperemic, thickened. Body temperature can reach subfebrile values (up to 37.5 ° C).

Acute purulent bilateral otitis in the preperforative stage is marked by severe pain in the absence of discharge from the ears. Hearing loss becomes pronounced. The tympanic membrane is hyperemic, convex. There are marked symptoms of intoxication and an increase in body temperature to 38-39 ° C. The postperforative stage is characterized by moderate pain and the presence of a purulent discharge. With otoscopy, the perforation of the tympanic membrane is determined, from which purulent contents are released. The general condition is broken insignificantly, the body temperature is at the level of subfebrile.

Adhesive otitis media is characterized by a lack of symptomatology, but with instrumental examination the structural changes of the tympanic membrane are determined, it is gray, the perforation is covered with a scar.

Erysipelas, as a rule, has a fairly vivid picture: the intense reddening of the auricle is determined, incl. Ear lobes, with palpation there is a sharp pain that does not stop after the elimination of the stimulus. Almost always erysipelatous inflammation is accompanied by an increase in body temperature to 39-40 ° C. However, it is possible to distinguish the erysipelas from bilateral otitis media only after observation for 2-3 days. In this case, if the hyperemia and swelling passes beyond the boundaries of the ear region and the mastoid process, then we are dealing with erysipelas.

Eczema of the auricle often occurs when chronic damage occurs to a certain area of the skin of the ears. This disease has quite a specific symptomatology, so its differential diagnosis rarely causes difficulties. The onset of eczema is manifested by reddening and infiltration of the ear tissue, which leads to a visually determined narrowing of the external auditory canal. A characteristic symptom is the itching of the skin of the auricle and internal auditory canal. It is worth noting that the skin itch is so intense that the person reflexively combs the problem areas. As a result, a large number of abrasions are formed, against which background small bubbles appear. Stuffed with serous fluid, the vesicles spontaneously open and the process of wetting develops in the affected area. Upon contact with the external environment, the liquid phase of the serous exudate evaporates and in its place cakes are formed.

Bilateral otitis should be distinguished from perichondritis - a spilled inflammatory disease of the perichondrium of the auricle. The main complaint with perichondritis is usually pain in the auricle, which is amplified by palpation. The main distinguishing feature is the absence of damage to the ear lobe, while the rest of the auricle undergoes hyperemia and swelling. When palpation is determined by a tuberous infiltrate.

Treatment of the bilateral otitis media

Treatment of bilateral otitis should be individual and complex. With rational pharmacotherapy, the duration of treatment does not exceed 7 days. Therapy should include the following groups of drugs: antibiotics (if the bacterial nature of the disease is detected), antiviral (if inflammation is provoked by the viral agent), anti-inflammatory drugs, vitamins, phytopreparations, homeopathic medicines. Also, the effectiveness shows the use of physiotherapy methods and some alternative means.

Drug therapy involves the use of broad-spectrum antibiotics: Augmentin 625 mg per 1 tab. 3 times a day, Dioxydin 0.1-0.2% rr-1-2 drops in each ear 3 times a day, Sumamed 500 mg 1 tab. An hour before meals and 1 tab. After eating 1 time per day. Antiviral drugs are used when the virus origin of bilateral otitis is finally established. Ingavirin 60 mg (2 capsules of 30 mg) once a day for 5 days, Viferon 150 mg once a day for 5 days. The list of anti-inflammatory drugs shown in otitis media includes: Otipax - 3-4 drops 2-3 times a day in each ear, Otinum 3-4 drops 3-4 times a day in each ear.

Vitamin complexes play an important role in the treatment of bilateral otitis. Ascorutin, consisting of a combination of vitamins C and P, exhibits antioxidant properties and is prescribed by the course for 1-2 months. Supradin - a vitamin complex that contains all the necessary vitamins and minerals, is also taken as a course lasting 1 month. Alphabet is a vitamin preparation that contains a complex of vitamins and microelements.

In the arsenal of physiotherapeutic treatment are methods such as warming the field of the ears with a lamp of solux, UHF and microwave treatment. Particular attention should be given to warming procedures, since in the purulent stage these manipulations are categorically prohibited. But light therapy is shown at all stages of the inflammatory process in view of the manifestation of immunostimulating action.

Despite the availability of a wide range of medicines, phytotherapy is very popular. From medicinal herbs are prepared tinctures (St. John's wort, calendula, mint) tea (dog rose, rose petals, raspberry roots) juice (aloe, celandine). Phytotherapy really has a positive effect on the course of the disease, but it is not recommended to use it as monotherapy.

The question of the effectiveness of homeopathic preparations has not been finally solved. However, many of the drugs in this group have proved themselves in the treatment of various inflammatory diseases. With bilateral otitis, Aflubin drops are used. Dosage is determined individually, depending on the age. This drug can not be used in case of hypersensitivity to the components of the drug, since allergic reaction is possible. Lymphomyosot is a homeopathic drug that has lymphatic drainage, immunomodulating, anti-inflammatory effects. The only relative contraindication is thyroid disease, since the drug contains thyroxine and ferrum iodide. In addition to the above drugs, Hamomilla, Gepar Sulfur and Pulsatilla are widely used. Contraindications to the use of homeopathic medicines do not exist, but it is worthwhile to soberly assess the capabilities of this area of medicine and use it as an auxiliary therapy.

Do not forget about the alternative drugs that have a pretty strong medicinal effect. It is recommended to use a warming compress, which is a gauze impregnated with water and Burovsky liquid. Also used are compresses made of propolis, honey and other bee products.

Surgical treatment for bilateral otitis is indicated if the drug therapy was ineffective, and the purulent process spread to neighboring areas. The simplest intervention is considered to be paracentesis - a section of the tympanic membrane to create an outflow of pus from the middle ear cavity. An example of a more extensive operation is a radical operation of the ear, which inevitably affects hearing loss.

Prevention

Prevention of bilateral otitis media consists, first of all, in the elimination of foci of chronic infections, such as tonsillitis, sinusitis, pharyngitis and diseases of the oral cavity. In the presence of a curved nasal septum and enlarged adenoid vegetations, it is necessary to undergo surgical treatment in a timely manner. Also, you can add to this list a healthy lifestyle, rejection of bad habits, tempering the body.

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Forecast

The prognosis with bilateral otitis is often favorable. With timely access to the doctor and the appointment of rational treatment, a full recovery comes. However, if the disease has passed into a chronic form, then we should expect relapses. It is also important to remember about the atypical course of otitis, the outcome of which are spikes and fusion between the structures of the middle ear. These data lead to stiffness of the auditory ossicles and deterioration of hearing

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