Acute inflammation of the middle ear

Acute inflammation of the middle ear - acute inflammation of the mucous membrane of the middle ear, resulting from the penetration into the tympanic cavity of infection from the nasopharynx through the auditory tube. Much less often this disease occurs when the hematogenous infection spreads from distant foci and in severe general infectious diseases during the rash.

In the tympanic cavity, the infection can also get from the external auditory canal, but only if the entire tympanic membrane is broken. The disease occurs more often in childhood and adolescence, equally often in males and females. As a rule, with acute inflammation of the middle ear, many cellular systems of the middle ear, including the cave of the mastoid process, are involved in the pathological process, so the disease is called otoanthritis.

[1], [2], [3], [4], [5],

What causes acute inflammation of the middle ear?

The most common acute inflammation of the middle ear occurs when infected with streptococcus (55-65%), followed by pneumococcus (10-18%), infection with staphylococcus occurs in 10-15% of cases. But in the vast majority of cases the disease is due to the association of microorganisms. In some cases, the disease is triggered by an influenza infection followed by the addition of pyogenic. Sometimes, with acute inflammation of the middle ear, a green streptococcus, diphtheria bacillus, Proteus, etc. Is isolated. Mucosal streptococcus and pneumococcus type III are associated with the development of a special kind of acute inflammation of the middle ear, characterized by persistence of the course and significant pathologic changes in the structures of the middle ear, called mucous otitis.

The emergence of acute inflammation of the middle ear contributes to a variety of risk factors and immediate causes. Among the latter, acute and chronic diseases of the upper respiratory tract (adenoiditis, tubootids, rhinosinusitis, chronic tonsillitis, ozona) are of primary importance in the development of acute inflammation of the middle ear. Various volumetric processes in the nasopharynx (angiofibroma, choanal polyp, hyperplasia of the nasopharyngeal and tubal tonsils, etc. .) The operative interventions in the nasopharynx, pharynx, in the nasal cavity and its paranasal sinuses, posterior tamponade caution of the auditory tube, and even blowing of the ears through Politzer.Of the common infections most often complicated by acute inflammation of the middle ear, one should point out the flu, scarlet fever, measles, diphtheria, rubella, bronchopneumonia.Often acute inflammation of the middle ear occurs in the presence of dry perforation after washing of the external ear canal or bathing, showering, accidental ingress of water into the tympanum.

In the emergence of the disease an important role is played by the general condition of the body, reduced immunity, the presence of exudative diathesis in children, allergies, beriberi, diabetes, tuberculosis. Syphilis, leukemia, etc. Over the past decade, it has been established that an important role in the occurrence of acute inflammation of the middle ear is played by so-called ear allergy, which is an integral part of the systemic allergy of the body as a whole and upper respiratory tracts - in particular. Often often, recurrent acute inflammation of the middle ear is observed in allergic children suffering from obstructive bronchitis, exudative diathesis, allergic rhinosinusitis.

Of the local factors contributing to the emergence of acute inflammation of the middle ear, it should be noted a number of features of the histological structure of the mucosa of the middle ear and the anatomical structure of the bone tissue of the mastoid process. So, according to a number of studies, hyperplasia of the mucosa of the tympanic cavity and the remains of embryonic myxomatous tissue remaining under it are the substrate on which the infection spreads easily. This fact was verified in children who are most often ill with acute inflammation of the middle ear, especially in infants whose myxomatous tissue is in excess of the mucosa of the middle ear. This fact also explains the frequent chronicization of acute inflammatory diseases of the middle ear. As for the structure of the mastoid process, more often than not in a more pronounced degree of acute inflammation of the middle ear occurs with the pneumatic type of the temporal bone structure.

Contribute to inflammatory diseases of the ear and a number of unfavorable conditions of the production environment: changes in atmospheric pressure (divers, pilots, submariners, caisson workers), dampness, cooling, fatigue, etc.

Pathological anatomy of acute middle ear inflammation

At the beginning of the disease, the mucous membrane of the tympanic cavity is hyperemic, infiltrated, with the development of inflammation, it thickens strongly and hemorrhages develop in it. Simultaneously, the serous and purulent exudate accumulates in the tympanic cavity, protruding the tympanic membrane. Later on, at the height of clinical manifestations, foci of softening appear in the mucous membrane of the tympanic membrane and the epithelium of the leathery layer is rejected. Due to the pressure of the exudate on the tympanic membrane and its softening, it extends in different places, depending on the localization of the center of the inflammatory process.

In the place of the greatest change in the structure of the tympanic membrane, its perforation arises, most often a slit-like one, which, when otoscopic, "produces" itself with the presence of a pulsating reflex. When recovered, the inflammatory phenomena in the mastoid process go to decline, the hyperemia decreases, the exudate from the tympanic cavity dissolves or is partially evacuated through the auditory tube. The perforated hole is either closed by a scar, or transformed into a permanent perforation with a tightened connective tissue edge. The perforation, surrounded by a part of the preserved eardrum, is called obodkovoy, the perforation, directly bordering the drum ring, was called marginal. The protrusion of the tympanic membrane, perforation in its relaxed part indicate that the inflammatory process developed mainly in the above-drum space (acute epitimpanitis), a form of acute inflammation of the middle ear, most prone to prolonged clinical course and chronic inflammation.

With significant development of granulation in the tympanic cavity and difficult evacuation of exudate and purulent contents from it, these tissues germinate with a connective tissue, resulting in the formation of scars (tympanosclerosis) and adhesions to the tympanic cavity. With this end of the inflammatory process, the tympanic membrane can be soldered to the medial wall of the tympanum and completely lose mobility. The organization of exudate leads to the immobilization of auditory ossicles. Both of these largely hinder the air type of sound production.

Symptoms of acute inflammation of the middle ear

Symptoms of acute inflammation of the middle ear depending on the age of the patient may differ in a number of features.

In newborns, this disease is extremely rare and occurs during the period from 3 to 4 weeks after birth; is caused either by the penetration of amniotic fluid during labor in the tympanum through the auditory tube, or by a nasopharyngeal infection that penetrated the first days after birth, for example, milk from a mother containing staphylococci.

The outcome is favorable. Recovering occurs either as a result of resorption of the inflammatory exudate of the mucous membrane, or by spontaneous drainage of the exudate from the tympanic cavity through the unconsolidated stony-scaly seam (sutura petrosquamosa) into the BTE area with the formation of a subperiosteal abscess whose opening and draining leads to recovery, without any consequences.

Infants up to 8 months of age develop otitis media, which are extremely important for otopediatrics, which constitute one of the main pathological conditions at this age.

In adolescence, adolescence and adults, a typical clinical picture develops, which, with some characteristics, is described below.

In the elderly, acute inflammation of the middle ear occurs less frequently and proceeds subacute, the symptoms are less pronounced, the temperature response is moderate (38-38.5 ° C) with a relatively satisfactory general condition. A peculiarity of the otoscopic picture is that as a result of sclerosis of the tympanic membrane, advancing in elderly and old age, it is practically not hyperemic when acute inflammation of the middle ear or hyperemia is of an islet character in accordance with the "topography" of sclerosis.

The clinical course of acute inflammation of the middle ear can be divided into three periods, covering an average of 2-4 weeks. The first period (from several hours to 6-8 days) is characterized by initial phenomena of inflammation in the middle ear, its development, the formation of exudate, expressed by common reactive phenomena. The second period (about 2 weeks) is perforation of the tympanic membrane and suppuration from the ear, a gradual decrease in general reactive phenomena. The third period (7-10 days) is a period of recovery, characterized by a decrease in discharge from the tympanum, thickening, elimination of inflammatory phenomena in the tympanic cavity, normalization of the otoscopic pattern and fusion of the edges of the perforation, or, if the perforation was significant, the formation of a noticeable scar, followed by calcification or a stable perforation. However, at present, due to changes in the virulence of the microbiota, the presence of highly effective antibiotics and significantly improved methods of general and local treatment, this periodization is rare. So, with timely and adequate treatment, inflammation can be limited to the first period with the subsequent recovery without any residual effects.

In the first period, the symptoms of the disease grow rapidly, and already from the first hours patients complain of pulsating pain in the ear, its obstruction and general malaise. Pain in the ear grows rapidly and irradiates into the crown, temple, teeth. The pain is caused by inflammation of the nerve endings of the trigeminal nerve, abundant innervating the tympanic membrane and the mucous membrane of the tympanic cavity.

Body temperature rises to 38-38.5 ° C, and in children sometimes up to 40 ° C and above. In the blood there is a significant leukocytosis, the disappearance of eosinophils, sharply increased ESR. These indicators reflect, to a large extent, the severity of the disease, the virulence of the infection and the degree of its spread across the structures of the middle ear. A sharp increase in body temperature is not observed only in weakened individuals or if at the very beginning of the disease the perforation of the tympanic membrane occurred and as a result conditions for the outflow of pus from the tympanum cavity were created. If, for whatever reason, the perforation has closed, the inflammatory process becomes aggravated again, the body temperature rises, the pain in the ear and the headache increase. The later the perforation of the tympanic membrane occurs with an increasing clinical picture, the more destructive are the effects of acute inflammation of the middle ear. At the beginning of the acute process, a peculiar reactive "response" of the mastoid process is often observed, especially in the pneumatic type of the structure. This is due to the fact that the mucous membrane of all cellular elements of the middle ear, and especially the cave and the cells of the mastoid process, actually takes part in the inflammatory process. His involvement in the inflammatory process is manifested by swelling and painfulness during palpation in the area of the site. Usually, this reaction disappears after perforation of the tympanic membrane and the beginning of discharge from the ear. In fact, the definition of "acute purulent inflammation of the middle ear" is qualified only after perforation of the tympanic membrane and the appearance of purulent discharge from the ear.

In the preperforative period, there may also be phenomena of irritation of the vestibular apparatus, which are manifested by dizziness, nausea, and vomiting. However, the main functional disorders are observed on the part of the hearing organ. In this and the subsequent period there is pronounced hearing loss: whisper speech is not perceived or perceived only at the shell, the colloquial speech is at the shell or no more than 0.5 m. In part, such a decrease in hearing depends on ear noise, but basically the hearing loss is determined by a significant disruption of the mechanism air sound conduction. In severe cases, when the induced labyrinthosis (toxic damage to the cochlear receptors) occurs, the phenomena of perceptive hearing loss can also be observed (raising the thresholds for perceiving high frequencies).

In the second period, after perforation of the tympanic membrane, the inflammation as it passes the equator and in typical cases begins to decline. The pain subsides, the body temperature decreases rapidly, the discharge from the ear, initially serous-bloody, becomes thick mucopurulent-purulent. There is a gradual decrease in leukocytosis, the appearance of eosinophils, and at the end of the third period, ESR approaches normal parameters. Discharge from the ear in the usual course of the disease lasts up to 7 days. In the third period, the discharge from the ear gradually ceases, the edges of the small perforation coalesce, and after 7-10 days complete recovery and recovery of the hearing occurs.

Perforation of medium size can be closed by scarring with subsequent impregnation of the rumen with calcium salts or becomes stalks with kalles margins, being in different quadrants of the tympanic membrane. In other cases, the disfiguring structures of the tympanic cavity are formed, the scars that solder the drum cavity to the medial wall of the tympanic cavity and immobilize the chain of auditory ossicles.

In some cases, in a typical course of acute inflammation of the middle ear, certain deviations may occur. For example, the dopforfovatyy period with increasing inflammation may be delayed for several days; in this case there is a high rise in body temperature to 39-40 ° C, a sharp increase in pain in the ear, nausea, vomiting, dizziness, in children - the phenomenon of meningism. The general condition sharply worsens. In the postperperative period, despite the perforation of the tympanic membrane and the release of pus, the general condition of the patient does not improve, the body temperature does not go down and the earaches do not subside, while the mastoid process and pastility persist. These phenomena may indicate a purulent inflammation of the mucous membrane of the cells of the mastoid process, which significantly prolongs the period of convalescence. In some cases, the perforation prolapses the edematous mucous membrane, the thickness of which at the height of the disease increases tens of times, or the granulation tissue formed on the inner surface of the tympanic membrane. These formations prevent the release of the contents of the tympanum and prolong the clinical course of the inflammatory process and indicate its severity and the possibility of significant destruction of the structures of the tympanum. One should also bear in mind the fact that if pus appears in the external auditory canal in large quantities immediately after the ear toilet, then this indicates the inflammation of the mastoid system of the mastoid process (mastoiditis).

In former times, especially during periods of influenza epidemics, there were often observed acute (otitis acutissima) and lightning-like forms of acute inflammation of the middle ear, characterized by a sudden onset and rapid development of symptoms of inflammation with severe general intoxication, body temperature 39-40 ° C and higher, irritation of the meninges, convulsions, sharp inflammatory changes in the blood, loss of consciousness, often ending in death. From the point of view of pathogenesis, it is assumed that against the background of a general immunodeficiency state, a highly virulent infection affects the entire tympano-mastoid-labyrinth system (panotitis), including the meninges. Nowadays, such forms of acute inflammation of the middle ear occur less and less frequently and only against a background of severe influenza infection or other diseases that break immunity. It is also assumed that these forms are found in individuals who have had previous TBI.

There are also forms of acute inflammation of the middle ear with a latent or subacute hyperhidic course characterized by a gradual onset, significantly weakened by the general response, subfebrile body temperature, small inflammatory changes in the blood and unexpressed local changes in the tympanic membrane and the tympanum. These forms most often occur in infants with still undeveloped immunobiological protective reactions or in the elderly, in whom these reactions have faded. Sometimes the hypergolic forms of acute inflammation of the middle ear arise as a result of infection with special kinds of microorganisms or irrational treatment with the use of sulfonamides and antibiotics. These forms of acute inflammation of the middle ear tend to be chronic, have the property of creeping spread to the entire cellular system of the temporal bone with lesions of the endosteum, bone tissue and spreading into the cavity of the skull, causing damage to the membranes of the brain.

A certain importance for the definition of the clinical picture, the direction of development of the inflammatory process and its consequences is localization, size and form of perforations. Thus, the perforations that appear in the anterior or posterior quadrants, testify in most cases to the favorable clinical course of acute inflammation of the middle ear. Even if the perforation becomes permanent and the disease has passed into the stage of chronic inflammation, the latter captures only the mucous membrane, and the discharge is sometimes caused only by chronic inflammation of the CWT.

Localization of perforation in the relaxed part of the tympanic membrane with an isolated inflammatory process localized in the above-drum space indicates an unfavorable ("malignant") form of otitis media. With this localization of perforation, two topographic forms of acute epitimpanitis are considered - with localization in the posterior surface of the overdrug space and with localization in the anterolateral region of this space. The presence in this area of the hammer-ligated articulation, ligaments, BAC, pathologically formed adhesions delay the evacuation of pathological contents and contribute to the chronicization of the inflammatory process.

Each of these forms of inflammation localization in the above-drum space has its clinical features. Thus, when the process is localized in the posterior upper part of the above-drum space, hyperemia and protrusion of the tympanic membrane are noted only in the upper-posterior part of the ear, while the normal color and shape of the rest of the tympanic membrane persist for several days. This localization of the perforation of the tympanic membrane indicates the seriousness of the inflammatory process, the possibility of its transition to the chronic form and the occurrence of intracranial complications.

With inflammation localized in the anteroposterior region of the above-drum space, the tympanic membrane becomes hyperemic and extensively exudates, creating the impression of a false polyp. Perforation of the tympanic membrane occurs late, with no pronounced subjective symptoms appear. At the same time, the limited space causes a direct spread of the inflammatory process to the hammer neck, its ligaments and joint located here, which is also fraught with various complications.

Some features of the clinical course of acute inflammation of the middle ear also depend on the microbiota. So, the predominance of golden staphylococcus gives the purulent secretions a bluish-golden hue, which contains fibrin in abundance. Complications in the presence of this microorganism are relatively rare, but when they occur, they primarily affect the sigmoid sinus.

Particular attention is required otitis caused by mucous pneumococcus and streptococcus, which were called "mucous otitis." According to the Viennese otiatric school, this form of acute inflammation of the middle ear most often occurs in adult men and elderly people. The onset of the disease is sluggish with erased symptoms, signs of inflammation of the BPe and pain syndrome are not expressed, perforation of the tympanic membrane occurs early, but is quickly clogged by viscous muco-purulent secretions. Because of this, the paracentesis of the tympanic membrane is ineffective, moreover, the inflammation of the tympanic membrane becomes aggravated, it thickens, becomes hyperemic and takes on a fleshy appearance. The loss of hearing with this type of otitis is more significant than with other forms of it. A slight but constant pain in the ear and the corresponding half of the head, which is not easily controlled by analgesics, exhausts the patient. Deep palpation of the mastoid process causes pain, which indicates the involvement of its cells in the inflammatory process. The general condition suffers a little: subfebrile body temperature with insignificant intermittent lifting of it, which the patient does not attach special importance. Indifference to the environment, apathy, insomnia, a sense of fatigue are characteristic features of the general condition with this form of acute inflammation of the middle ear. Mucous otitis caused by mucocutaneous pneumococcus slowly progresses during weeks and months without interruptions, spreading into the deep bone areas of the mastoid region. This type of microorganism has an increased tropism to the bone tissue, so its destructive effect does not encounter special obstacles and can spread beyond the temporal bone, reaching the cavity of the skull.

The predominance of microbiota in acute inflammation of the middle ear of enterococcus often causes severe forms of otitis, fraught with serious complications.

Fusospirochetoznaya association causes severe ulcer-necrotic otitis with significant destruction in the tympanic cavity and the release of inflammation in the external auditory canal. Purulent discharge has a bleeding appearance and a putrid nauseating smell.

Symptoms of acute inflammation of the middle ear in newborns and infants are somewhat different from those in adults. More often the disease flows imperceptibly for others, right up to the appearance of secretions from the ear. In some cases, the child is restless, wakes up at night, cries, turns his head, rubs a sick ear on the pillow, stretches his hand to his ear, refuses his breast, as when sucking and swallowing, earache increases due to increased pressure in the middle ear. Usually the cause of acute inflammation of the middle ear in infants is acute or chronic rhinopharyngitis. With a pronounced clinical picture of acute inflammation of the middle ear can be accompanied by meningism - a clinical syndrome that develops due to irritation of the brain envelopes and manifested headache, stiff neck, Kernig and Brudzinsky, dizziness and vomiting. In this case, the child has a rise in body temperature, pale skin, dyspeptic phenomena, swelling of soft tissues behind the ear.

Often, infants develop either as a complication of acute inflammation of the middle ear, or independently on the background of toxic dyspepsia, dysentery or any childhood infection, inflammation of the mucous membrane of the cave of the mastoid process (at this age the mastoid process and its cellular system have not yet developed).

Diagnosis of acute inflammation of the middle ear

Diagnosis in most cases does not cause difficulties, and the diagnosis is established in accordance with the symptoms described above and the clinical picture: acute on the background of a cold (acute cold, sinusitis, nasopharyngitis, etc.), earache, congestion in it and hearing loss, typical otoscopic picture of the tympanic membrane, the presence of perforation and pulsating reflex, soreness with deep palpation of the mastoid procession (projection of the cave of the mastoid process), general signs of the inflammatory process process (fever, weakness, malaise, headache, inflammation in the cellular composition of the blood, elevated erythrocyte sedimentation rate).

Great importance in establishing the localization and prevalence of the inflammatory process and possible complications has an x-ray study in standard projections or CT.

Differential diagnosis is made with regard to myringitis (inflammation of the tympanic membrane as a complication of acute external otitis), with acute catarrhal otitis media, external medial otitis and furuncle of the external auditory canal, herpetic inflammation and exacerbation of chronic purulent otitis media.

With meringitis, there are no general phenomena of the inflammatory process and hearing is maintained at a practically normal level. With external diffuse otitis and furuncle of the external auditory meatus - sharp soreness with pressure on the tragus and during chewing, the pain is localized in the region of the external auditory canal, while with acute inflammation of the middle ear - in the depth of the ear, irradiates in the crown and in the temporal- occipital region. In inflammatory processes in the external auditory meatus there is no soreness with deep palpation of the mastoid process, the discharge from the ear is of a purely purulent nature, while in acute inflammation of the middle ear they are characterized as mucopurulent, viscid. In acute inflammation of the external auditory canal, hearing loss is observed only when the lumen is fully closed, while in acute inflammation of the middle ear, hearing loss is a permanent sign. In the herpetic lesion of the tympanic membrane, vesicles are determined on it, with the rupture of which there are spotting from the external auditory canal. The pain is localized in the external auditory canal, it has a burning permanent character. With the spread of a viral infection, temporary paralysis of the facial nerve, dizziness, and hearing loss by perceptual type can occur. Herpetic vesicles are located not only on the tympanic membrane, but also on the skin of the external auditory canal and auricle in the so-called Ramsay Hunt zone, innervated by sensitive PON fibers. At the same time, eruptions can also be observed on the mucous membrane of the soft palate and pharynx, which is an important differential diagnostic feature.

Of particular importance is the differentiation between acute inflammation of the middle ear and exacerbation of chronic purulent otitis media, as often the latter can go unnoticed for the patient, and with dry perforation and satisfactory hearing it is completely unknown to the patient. Distinctive signs of exacerbation of chronic purulent otitis media are described below.

When differential diagnosis of banal acute inflammation of the middle ear should be borne in mind more and more often in recent years, the so-called allergic otitis media, characterized by the absence of a temperature reaction and hyperemia of the tympanic membrane, allergic edema of the mucous membrane of the auditory tube and the tympanum. The tympanic membrane is pale, edematous, its contours are blurred. In the tympanum and cells of the mastoid process there is a viscous mucus saturated with a large number of eosinophils. This form of otitis is characterized by a sluggish prolonged course and occurs in persons suffering from general allergy, bronchial asthma, allergic rhinosinusopathy; treatment is difficult to give and only after a decrease in the severity of the general allergic background and allergic manifestations in other organs.

[6], [7], [8]

Treatment of acute inflammation of the middle ear

Treatment is aimed at reducing pain, accelerating the resorption of the inflammatory infiltrate in the middle ear cavity, draining it by improving the permeability of the auditory tube, or by creating an artificial perforation of the tympanic membrane by its paracentesis, as well as restoring the auditory function and preventing tympanal and intracranial complications. The nature of treatment depends on the stage of the inflammatory process and is divided into general and local.

The patient is prescribed complete rest and bed rest, according to the indications, he is hospitalized. In the preperforative period antibiotics of a wide spectrum of action are appointed, at occurrence of vydeleny from an ear define sensitivity of a microbiota to antibiotics and appoint a corresponding preparation. According to indications for stimulation of immunity immunoprotectors of the thymalin series are prescribed. At a high body temperature and pain - modern analgesic, antipyretic and anti-inflammatory agents - derivatives of salicylic acid and other compounds. The diet is easy, well digestible, rich in vitamins. Local warming compresses, warmers, solux, UHF currents, laser irradiation of the region of the mastoid process are applied locally. If the heat increases the pain, then the cold is assigned to the BTE area with a special bladder, which has a clipping for the auricle. A short-term (for 20-30 min) disinfectant and analgesic effect renders 96% ethyl alcohol in the form of warm drops in the ear. Y.S. Temkin recommends in the preperforatory period to let warm 5% carbolic-glycerin drops in the ear for 8-10 drops 2-3 times a day. These drops increase the elasticity of the tympanic membrane and thereby relieve tension in it from the pressure from within the exudate. To enhance the analgesic effect, cocaine hydrochloride, dicaine or some other analgesic for application anesthesia is added. After the appearance of perforation, the introduction of carbolic-glycerin drops is stopped, because when combined with water, the glyceric-linked carbolic acid passes into water and can cause a burn of the skin of the external auditory canal.

Paracentesis of the tympanic membrane. If during the day in the pre-perforating period the applied treatment (provided it is of full value) does not bring the effect, while the eardrum is sharply hyperemic, swells into the external auditory canal, and the general condition of the patient continues to worsen, then one should resort to paracentesis - artificial perforation of the tympanic membrane first applied in 1800 A. Cooper for improving hearing in the obstruction of the auditory tube, in 1862 was introduced by the outstanding German otiatrist H.Schwartze in practice for the removal of inflammatory exudate from the bar bath cavity). This procedure speeds up recovery, prevents otognennye complications and damage the sound-conducting system of the tympanum and helps to maintain hearing. Therefore, with the increasing severity of the disease, one should not take a wait-and-see attitude, because after a successful paracentesis, there are practically no traces left on the tympanic membrane, and after spontaneous perforation, which in itself can be of considerable size, rough scars remain on the tympanic membrane affecting the function of the drum webbeds.

In infants with appropriate indications, too, you should not hesitate with the paracentesis, but the testimony of them is more difficult to establish. First, the eardrum in young children with acute inflammation of the middle ear sometimes varies little, while the tympanum contains pus and inflammatory exudate; secondly, when the child screams, he develops a physiological hyperaemia of the tympanic membrane; thirdly, the eardrum can be closed with desquamated epidermis, and, finally, fourthly, acute inflammation of the middle ear in a child suffering from general toxicosis can proceed lethargic without pronounced local changes. As noted by Ya.S. Temkin (1961), under such circumstances, poor symptoms and the child's inability to check the condition of the auditory function, the question of paracentesis is very difficult to solve, especially if there are other data to explain the increase in body temperature and other signs of the general disease.

Operation technique. The procedure is very painful, so before using it, local anesthesia should be provided. To do this, a few minutes before the operation in the external ear canal admits the drops of the following composition:

• Acidi carbolici 0.5
• Mentholi2.0
• Cocaini hidrochlorici 2,0
• Spiriti aethylici rectificati 10.0

This procedure of complete anesthesia can not be achieved, so the operation is tried quickly. Instead of application anesthesia, infiltration anesthesia can be performed by ear injection, injecting a 2% solution of novocaine in small portions, passing the needle along the surface of the posterior bone wall to the tympanic ring. This procedure requires the skill of a surgeon-otiatrist. When properly performed, complete pain relief occurs. It is also acceptable to use "short" general anesthesia. Children less than 2 years of age are paracentized without any anesthesia.

Paracentesis is produced only under the control of vision in the position of the patient sitting or lying with rigid fixation of his head. Before the operation, the skin of the external auditory canal is treated with ethyl alcohol. Use special spear-shaped paracentesis needles, the ends of which are similar to a two-edged scalpel; such a needle not only pierces the eardrum, but also cuts it. As a rule, the puncture of the tympanic membrane is produced in its posterior quadrants, which are located at a greater distance from the inner wall of the tympanum than the front quadrants, or at the site of the largest protrusion of the tympanic membrane. Puncture is tried at one time through the entire thickness of the tympanic membrane, starting from the lower-posterior quadrant and continuing the incision to the upper-to-poster quadrant. Through the resulting linear incision immediately under pressure, a purulent-bloody fluid is released. It should be borne in mind that with inflammation of the mucosa of the middle ear, including the covering of the eardrum, it can thicken tenfold or more, so the paracentesis may not be complete. Try to reach the cavity should not be, since the cut itself will accelerate the spontaneous perforation of the drum membranes and the effect of incomplete paracentesis will still be achieved.

After paracentesis, a dry sterile turunda is inserted into the external auditory canal and fixed loose at the entrance to the passage with a wad of cotton wool. Several times a day, the toilet is produced from the external auditory canal, treated with boric alcohol or furacilin. Allowed non-forced washing of the external auditory canal with antiseptic solutions, followed by drying it with sterile dry cotton wool, then inject drugs when the head is tilted toward the healthy ear. It is permissible to pump lightly in the middle ear in the presence of perforation of drops used, for example, a mixture of antibiotic solution with hydrocortisone, by pushing the tragus in the external auditory canal or using a bottle of the earwax olive. In the postperperative period, catheterization of the auditory tube is also permissible with introduction of a mixture of a solution of the corresponding antibiotic and hydrocortisone into the tympanum cavity. The use of the latter prevents the formation of rough scars and ankylosing of the ossicular joints. With the steady-state phase of suppuration, the "dry" bandaging technique is applied using a sterile dressing. To do this, a dry turunda is brought to the perforation or incision of the tympanic membrane and its end is led out into the scaphoid fossa, then a dry cotton-gauze dressing is applied to the ear, which is changed 3 times a day. The patient is recommended to lie as far as possible with the patient's ear to the cushion to improve the outflow from the tympanic cavity of the purulent contents. Otiatric treatment from the very beginning should be accompanied by procedures aimed at sanation of the nasopharynx and auditory tube. For this purpose, various nasal installations are performed, nasopharyngeal irrigation with antiseptics, vasoconstrictor substances in aerosol form. It is necessary to inject medicinal substances into the tympanum through the catheter carefully and only after paracentesis or spontaneous perforation of the tympanic membrane, otherwise an increased pressure is created in the tympanic cavity, as a result of which the infection can spread beyond the middle ear in the degeneration, perineural and perivasal spaces. After the closure of the perforation or paracentesis and the cessation of discharge from the ear for 5-7 days without special need, it is not necessary to blow the ear through the Politzer or in any other way, as increasing the pressure in the tympanum can lead to a divergence of the edges of the perforation and prolong the healing process . Ventilation of the auditory tube can be recommended if there is a retraction of the tympanic membrane and stiffness in the joints of the auditory ossicles, manifested by hearing loss. In this state, the pneumomassage of the tympanic membrane is also shown, beginning with a low intensity of pulsating pressure in the external auditory canal.

How to prevent acute inflammation of the middle ear?

Preventive measures are of particular importance in children, because they often experience frequent recurrences of acute inflammation of the middle ear and chronic inflammation, often leading to pronounced hearing loss and related deficiencies in speech development. They include measures to sanitize the upper respiratory tract, strengthen immunity, prevent colds, restore nasal breathing, harden, eliminate harmful household habits, and minimize the impact of harmful occupational factors (humidity, cooling, barometric pressure changes, etc.). As noted by V.T. Palchun and N.A. Preobrazhensky (1978), a great value for the prevention of acute inflammation of the middle ear has a rational treatment (nonoperative or surgical) of purulent sinuits. In childhood, quite often the cause of acute inflammation of the middle ear is chronic adenoiditis and hypertrophy of the pharyngeal tonsils, which contribute to the inflammation of the mucous membrane of the auditory tube, its obstruction and penetration of infection in the middle ear. Complications of acute inflammation of the middle ear. The proximity of the tympanum and the cells of the temporal bone to the cranial cavity under certain conditions of development of the inflammatory process in the middle ear (immunodeficiency, diabetes, blood disease, virulence and penetration of pathogenic microorganisms), a number of anatomical features (excessive pneumatization of the temporal bone, degeneration, and others) can contribute to the occurrence of a number of intracranial complications, as well as the spread of infection within the temporal bone. The first are described in the section on complications in chronic purulent inflammation of the middle ear; in this section we will focus on acute mastoiditis and inflammation of the temporal bone pyramid, as well as on some forms of atypical mastoiditis.

Prognosis of acute inflammation of the middle ear

The most frequent outcome of acute inflammation of the middle ear is complete morphological and functional recovery, even spontaneous, without any significant therapeutic or surgical interventions. In other cases, even with intensive treatment, the clinical picture can be difficult with various complications or with the transition of the inflammatory process to a chronic form. Such an outcome is possible with a sharp depletion of the body with a serious previous disease, with diabetes, weakening of immunity, during periods of flu epidemics, etc. Often the perforation of the tympanic membrane leaves behind scars of various sizes, which in the subsequent period are saturated with calcium salts and acquire a yellowish or white color. Cessation of discharge from the ear, increased pain, increased body temperature and the resumption of other signs of acute inflammation of the middle ear indicate a delay in the tympanum and cellular system of the middle ear of pus and exudate and may indicate the onset of any complication. A sharp rise in body temperature, persistent headaches, hyperleukocytosis, a significant increase in ESR, severe weakness, apathy, indifference to the surrounding and to its condition with good drainage of the tympanic cavity indicate a marked intoxication of the body and the possibility of intracranial complications. This condition, which has arisen against the background of the positive dynamics of acute inflammation of the middle ear and continues to worsen, is a direct indication for surgical treatment with a wide opening of the entire cellular system of the temporal bone, while the direction of elimination of the tissues affected by the purulent process indicates a pathological change in their continuation. In the absence of complications that have already arisen and develop (mastoiditis, apyxis, sinus thrombosis, meningitis, abscess of the temporal lobe of the brain, etc.), early surgical intervention in such a clinical picture prevents, like the paracentesis of the tympanic membrane, the destruction of the sound system and, its elements allows you to keep your hearing. When intracranial complications arise, including thrombophlebitis of sigmoid and transverse venous sinuses, the prognosis regarding life is cautious and is determined by the timeliness of the corresponding surgical intervention, the effectiveness of the subsequent treatment and the general condition of the organism.

The prognosis for auditory function is determined by the degree of alteration of the tympanic membrane and the chain of auditory ossicles. Small marginal in the lower parts of the tympanic membrane and rimmed perforations without disturbing the acoustic conductivity of the auditory ossicles chain practically do not change the auditory function. Perforations located in the relaxed part, and inflammatory ankylosing of the hammer-anvil joint cause hearing loss by conductive type of different degrees. Extensive cicatricial changes (tympanosclerosis) sharply worsen the auditory function, and if vestibular disturbances, high frequency tone ear noise (intoxication of the cochlear receptors) during the peak period, then in the period of convalescence to conductive hearing loss, in many cases progressive perceptual deafness joins.