Chronic otitis media in adults and children

The development of such a pathology as chronic otitis media is most often associated with incorrect treatment of an acute inflammatory process in the ear. Although, according to statistics, the disease can be provoked by other causes - for example, injuries.

The diagnosis of the chronic form is established in the presence of a permanent violation of the integrity of the tympanic membrane. Discharge from the ear is an optional symptom of pathology, since they can be both permanent and temporary.

In medical circles it is considered that in the case when the inflammation of the middle ear lasts more than a month, it is possible to diagnose chronic otitis media.

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

Epidemiology

According to information from the World Health Organization, chronic otitis can be considered a disease in which there is a constant outflow of pus from the ear for more than 2 weeks. But most otolaryngologists tend to think otherwise, ranking otitis to chronic forms only when the suppuration is observed for a month or more.

According to statistics, carried out by WHO, chronic purulent otitis affects about 1.5% of the population. In 60% of patients, there is a steady deterioration in hearing.

At each second patient the chronicle is formed even in childhood or adolescence - until the age of 18.

The greatest risk of complications is chronic suppurative otitis media, which, among other things, can lead to death.

[6], [7], [8], [9], [10], [11], [12],

Causes of the chronic otitis media

Chronic otitis develops gradually, and the reason for this can be several reasons:

• ineffectiveness of acute forms of the disease, or disregard of treatment as such;
• frequent repeated episodes of acute form, with the formation of cicatricial changes in the tympanum;
• anomalies in the development of the auditory tube that connects the hearing organ to the nasopharynx;
• infectious and inflammatory processes.

Provocative agents in the development of chronic otitis become predominantly such bacteria as staphylococcus, less often - enterobacteria, Pseudomonas aeruginosa. Long-term processes can be caused by the presence of a fungus pathogen.

The majority of patients who sought medical help for permanent gnotecheniy and hearing impairment, the disease was associated with an aggravation of the course of the acute form of the disease. Such a development of the situation is possible under the influence of certain risk factors.

[13], [14], [15], [16], [17], [18], [19]

Risk factors

• Non-cured inflammatory pathologies in the nasopharynx.
• Difficulty breathing, inability to adequately breathe through the nose (congenital anomalies, adenoids, etc.).
• Immunodeficiency conditions.
• Disorders of the endocrine system (problems with the functioning of the thyroid gland, obesity, diabetes);
• long-term treatment of other chronic diseases;
• Unhealthy Lifestyle;
• meager monotonous nutrition, hypovitaminosis.

Exacerbations of chronic otitis often occur under the influence of factors such as hypothermia or overheating of the body, water entering the auditory canal, ARI and ARVI.

[20], [21], [22], [23], [24], [25],

Pathogenesis

Pathogenetic features of chronic otitis depend on a combination of many factors - physical, infectious, thermal, chemical causes of the disease. In most patients, pathology develops as a result of an incompletely cured acute form of suppurative otitis media. Provocative moments also often become different conditions, which are accompanied by a sharp weakening of immunity.

And yet, the main reason for doctors is the ingress of the causative staphylococcus into the middle ear, against the backdrop of creating favorable conditions for the bacterium: weak immunity, frequent or chronic diseases of the nasopharynx, the paranasal sinuses.

By location, these forms of chronic middle ear disease, such as mesotympanitis and epitimpanitis, are distinguished.

Chronic purulent mesotympanitis can have different pathologic anatomical manifestations, depending on the stage of the process. For example, the stage of remission is characterized by the presence of a perforation of the membrane, with localization in a stretched area mainly in the near-central region. With a large diameter of the perforation, you can see the handle of the hammer loosely hanging over the drum cavity. The boundaries of the perforation hole are thin, or have the form of a compacted scar. Undamaged sections of the membrane look normal, with no characteristic changes. Closer to the medial wall of the cavity, the mucous tissue in the area of the cape is moist and pale.

At the acute stage of mesotympanitis, the visual picture changes dramatically. The external auditory canal is filled with a lot of purulent-mucous secretions. The stored parts of the membrane become red and thicken, and the mucous cavities swell and blush. It is possible to form granulations and small polyps.

Chronic purulent epitimpanitis has other pathoanatomical manifestations, since both the mucous tissue of the tympanic cavity and the bony tissue of the mastoid process are involved in the process. The inflammatory reaction spreads with the defeat of the auditory ossicles, antrum and cave, the walls of the above-drum space. Because of such processes, the term "epitimpanitis" refers to a pathology affecting the attico-antral zone. This variety is characterized by marginal localization of perforation in the not stretched segment of the membrane: it is on this site that there is no tendon drum ring. Because of these features, the inflammation quickly spreads to the bone tissue, which leads to the development of osteitis. Bone tissue is filled with thick pus, there is a fetid odor. In some cases, the formation of granulations.

By the term "choleastoma" is meant a light compacted formation covered with multilayered flat epithelium. Bone tissue disintegrates under the influence of a choleastomy - previously in medicine this was called another term "caries." Increased formation can lead to severe destruction in the temporal zone, which often causes the development of intracranial complications.

[26], [27], [28], [29], [30], [31], [32], [33]

Symptoms of the chronic otitis media

In fact, chronic otitis is characterized by such symptoms as the presence of a perforated membrane, inflammatory process, painful sensations and deterioration of auditory function. Depending on the variant of the development of the disease, perforation can be located in the center or near the edges of the membrane.

Other symptoms may also differ slightly from each other.

• Purulent discharge can sometimes have an unpleasant smell, but not in all cases. In some patients, suppuration is permanent, while in others it may be periodic or absent for a long time. If the secretions are present, then there is a "plus" in it, as the probability of pus penetration into the meninges decreases.
• Deterioration of auditory capabilities is associated, first of all, with damage to the tympanic membrane. A more serious decrease in hearing may be due to the appearance of polyps in the ear.
• Pain - aching or "shooting" is more often disturbed during the active period of the disease. Feelings are quite strong in the exacerbation of the disease, but more often pain is worse at night and have a nagging character.
• Feeling of zalozhennosti - a feeling, as if the auditory course got liquid. Many patients may have a desire to clear the "stuffed" ear, but this should not be done: this way it is easy to harm, and the problem will still remain.
• Ear noise has much in common with the feeling of "stuffiness": this feeling can cause irritability, migraine and mood swings in the patient, as it is constantly and significantly worsens the concentration of attention.
• Pain in the head, dizziness - these symptoms are caused by an inflammation reaction that occurs in close proximity to the brain structures.
• Violation of the function of the facial musculature is detected when the disease lasts a long time, without adequate treatment. In a similar situation, paresis and paralysis of the facial nerve develop.
• The temperature rise is possible in the active period of the disease - at the stage of exacerbation.

The first signs of fungal damage to the ear are the appearance of itching inside the auditory passage, the increase in skin sensitivity in the ear, and the pain in the head from the side of the lesion. The pain can be as aching, or pulsating, pressing, stitching, with irradiation in the jaw, whiskey, occipital region.

[34], [35]

Chronic otitis in adults

The chronic form of the disease in adult patients can last for decades, practically without disturbing. The fact is that the bright clinical picture is present only during periods of exacerbation: if there are no such periods, then neither pain nor fever is observed. And if the disease is one-sided, many patients do not even pay attention to a decrease in hearing abilities.

The patient most often comes to the doctor only in the case of increased pus excretion - this happens on the eve of an exacerbation of the disease. Often the discharge has an extremely unpleasant odor, which is difficult to ignore. In advanced cases, there are signs of a labyrinth or intracranial lesion, and with bilateral pathology, a gradual decrease in auditory capabilities is observed.

The most serious problem in adults is chronic otitis with marginal perforation. Inflammatory reaction, localized in the upper segment of the tympanic space, is often accompanied by carious processes in the outer side of the above-drum cavity. The destruction of tissues often causes further formation of granulations, polyposis formations, and choleastomy.

Determination of chronic otitis media and evaluation of its nature (common or complex course) are based on information obtained during otoscopy and sounding procedures. The decisive role is played by the recognition of the type of perforation (in the center or along the edge).

The volume and nature of purulent discharge is also an important feature that allows one to assess the severity of pathology. It should be borne in mind that often the stench of pus does not indicate a carious necrotic process, but speaks only of the patient's non-compliance with the rules of hygiene of the affected ear. In such a situation, after a thorough cleaning of the hearing organ at the initial stage of treatment, the unpleasant odor disappears, which does not occur with carious necrosis.

Hearing in all variants of chronic ear inflammation in adults worsens due to a disturbed sound-conducting system.

[36], [37], [38]

Chronic otitis in pregnancy

Chronic inflammatory processes during pregnancy occur with the same frequency as in other physiological periods. However, the difference is that the special condition of a pregnant woman provides strong limitations in the possibility of taking medications. This applies to all diseases, including chronic otitis media, because medicines can have a negative impact on the development of the fetus.

Inflammatory process in the ear can cause a woman a lot of inconvenience. A specific situation often causes a woman to become sensitive to almost all small things. In this case, any "standard" symptom of chronic otitis media can cause nervous disorders.

In itself, the inflammatory process does not pose any danger to the pregnant patient: only purulent forms of the disease can become dangerous. Chronic form can take years, without causing anxiety, and worsen during the period of gestation of the baby. And in fact the exacerbation of the disease in almost all cases involves the use of antibiotics, which are not always allowed for the treatment of pregnant women. Unequivocally in this period are contraindicated:

• Anauran (a drug based on polymyxin sulfate, neomycin and lidocaine);
• Ciprofloxacin (a phterquinolone antibiotic);
• Boric acid (antiseptic and disinfectant);
• Norfloxacin (fluoroquinolone preparation).

To avoid trouble, the treatment should appoint only a doctor. Modern pharmacology today has all the potentials to cope with the chronic process, including, and during pregnancy.

[39], [40], [41], [42], [43], [44],

Chronic otitis in the child

One of the main differences in ear inflammation in a child is that the painful process develops in an unformed hearing organ that is still in a state of continuous growth, pneumatization and differentiation. It is logical that the healthy course of the shaping process in the ear and the temporal bone, as well as in the entire body, presupposes the presence of certain conditions-in particular, the child must eat normally, be in adequate social and everyday conditions, and he must have the appropriate metabolism. Of course, the child's body more than an adult, needs some minerals needed to build a bone system. Inadequate mineral metabolism disrupts the development of bone elements - in particular, the mastoid process.

It is proved that children with normal physical development can easily tolerate inflammation in the ear. Transition of the disease into a chronic form is more often observed in children who lag behind in weight, have weak immunity, suffer from a lack of useful substances in the diet. Chronization of the process is also observed in the presence of diseases of the digestive system, infectious diseases, endocrine disorders, as well as under the condition of improper feeding.

The nature of the inflammatory pathology, as well as its course, can also depend on the type of environment in which the reaction begins - the state of the mucosal tissue, the presence of middle ear contents, the degree of pneumatization of the temporal bone, and the features of the ear canal system. These factors tend to change constantly as the child's body grows. This must be taken into account when diagnosing and prescribing a therapeutic regimen.

In infants, unlike older patients, isolated pathologies of the nasopharynx are practically not diagnosed - in most cases, inflammation also extends to the middle ear region.

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

Stages

In the period of exacerbation of a chronic disease, the following stages are distinguished:

1. The stage of inflammation, in which the initial development of the inflammatory process occurs.
2. Stage catarrhal, in which inflammation affects the shell of the middle ear.
3. The stage is deporting, in which pus begins to accumulate in the middle ear.
4. Stage postperforative, corresponding to the onset of suppuration from the ear.
5. The stage is reparative, proceeding with signs of abating the inflammatory process and scarring of damaged tissues.

[49], [50], [51], [52], [53], [54]

Forms

According to clinical and prognostic characteristics, chronic otitis is divided into processes with central perforation of the membrane and processes with marginal perforation. By the term "central perforation" is meant the appearance of a hole surrounded on all sides by the retained edges of the membrane. If we speak of edge perforation, we mean the localization of the hole near the bone element of the auditory passage, or in the Shrapnelian part of the membrane.

In shape, the perforation can be different: rounded, oval, kidney-shaped, with a different diameter.

The main classification of the disease provides for its separation into such varieties:

• Chronic otitis media - develops in the presence of bacteria and, in turn, has two more subtypes:
  • mesotympanitis (with damage only to the tympanic cavity);
  • epitimpanitis (with damage to bone tissue).
• Chronic otitis externa is an inflammatory process, the development of which most often occurs as a result of permanent mechanical damage to injuries and injuries to the ear shell and external auditory canal. External otitis may be of fungal origin.
• Chronic tubotimponal otitis is the pathology of the right ear, in which there is a persistent perforation of the membrane. The perforation can be associated with an earlier acute inflammation, or with mechanical damage to the membrane during an injury.
• Chronic purulent otitis is characterized by three basic symptoms: continuous or periodic outflow of purulent discharge from the ear hole, sustained perforation of the membrane and hearing loss to varying degrees.
• Chronic exudative otitis media is characterized by a prolonged period of accumulation of viscous secretions inside the tympanic cavity. The membrane can remain intact, but the patient has a violation of the function of the auditory tube.
• Chronic catarrhal otitis is a pathological process that occurs on the catarrhal stage of inflammation, in which the process affects the middle ear.
• Chronic adhesive otitis - characterized by the formation of scar changes in the tympanum and on the membrane. There is also a fusion of auditory ossicles and, as a consequence, a pronounced impairment of auditory capabilities. The causes of this pathology consist in frequent relapses of otitis, or in the long-term exudative form of the disease.
• Chronic serous otitis is a disease characterized by the accumulation of serous fluid inside the ear. Often, such a disease is accompanied by a deterioration of the auditory function and a sense of congestion (especially when swallowing). Serous otitis can have a bacterial or viral etiology.
• Chronic bilateral otitis is a serious form of the disease with the defeat of the middle ear. Most often bilateral otitis media - when worried both the right and left ear, are diagnosed in young children, which is associated with anatomical features of the structure of the hearing organs.
• Chronic left-sided otitis is a pathological process involving the left ear.
• Right-sided chronic otitis is a disease in which the ear is struck from the right side.

[55], [56], [57], [58],

Complications and consequences

Difficulties arise mainly through the fault of the patient himself - for example, if he is not in a hurry to contact a doctor, or is engaged in self-medication. Chronic inflammation in the ear is not a harmless disease at all, but rather formidable and dangerous. The consequences of carelessness for the patient can be very unfavorable.

• Mastoiditis - occurs when the inflammatory process spreads to the mastoid process, which leads to the appearance of an edema and a purulent focus on the background of severe pain and fever. If you do not help in a timely manner, the abscess is opened by yourself, causing inflammation of the meninges. Treatment - only surgical.
• The rupture of the tympanic membrane is a common type of complication, in which pus enters the auditory cavity, and not into the cranium. In a similar situation, the exacerbation of chronic otitis with perforation is indicated. With timely access to the doctor, the membrane is delayed for a week.
• Exacerbation of chronic otitis proceeds according to the type of usual acute ear inflammation, and often occurs against the background of an infection or a cold. So, if during the period of remission the affected ear did not bother the patient a little, during the exacerbation period, the temperature may rise, the pain grows, there is an outside noise, and the hearing becomes worse.
• Deafness with chronic otitis can be constant, especially in the advanced stage of the disease. This complication is especially unsafe for patients of early childhood, who, along with hearing impairment, may also lose some speech capabilities.
• Brain abscess is a purulent inflammatory process in the form of a focus in the brain tissues. The disease begins acutely, with severe pain in the head, nausea, dizziness, fever.
• Hearing with chronic otitis is reduced and with such complications as labyrinthitis it is an inflammatory reaction in the inner ear. The patient may also experience difficulties with balance, as the function of the vestibular system is impaired.

Exacerbation of chronic otitis media is not always limited to mucous tissues and can spread to bone tissue - for example, to the outer bone surface of the overdrug space. In some cases, the cortical layer of the mastoid process is destroyed, with the formation of a subperiosteal abscess.

Chronic otitis can be complicated by bone caries, spreading of granulations, growth of polyps, caries.

Exacerbation of epitimpanitis can lead to severe otogennym complications, which develops already in the initial period of the disease. Unfortunately, with the development of such a complication, deaths are not uncommon.

[59], [60], [61], [62], [63]

Diagnostics of the chronic otitis media

If there is a suspicion of a chronic ear inflammation, the doctor conducts an extended diagnosis - this is especially important if the patient complains of deteriorating hearing aids and earache.

During the initial admission, the doctor-otolaryngologist examines the patient, and then appoints a number of auxiliary studies. So, for the correct diagnosis is recommended such instrumental diagnostics:

• Otoscopy with the Zygle funnel helps to consider the reduced mobility of the membrane caused by negative pressure, or the accumulation of excretions in the cavity. With normal function at the time of creating a positive pressure in the external auditory motion, the membrane moves toward the drum space, and at the time of creating a negative pressure - toward the external auditory canal. Such a swing can be seen in the posterior upper segment of the membrane.
• Audiometry is commonly used in the diagnosis of otitis in childhood. The procedure makes it possible to identify the deafness, and also to determine the causes of recurrent otitis and lag in speech development. Diagnosis is carried out in a soundproof chamber.
• Timpanometry helps to determine the cause of the changes detected by impedance measurement. The procedure provides for evaluation of the mobility of the membrane according to the altered volume of the auditory passage against the background of the changed intra-passage pressure.
• Using a tuning fork at a frequency of oscillations of 500-1000 Hz helps to differentiate neurosensory and conductive hearing impairment. Conduct a Weber test: the tuning fork is placed on the median line, and the patient determines which side of the sound is clearer. Also conduct a tuning fork of Rinne: cover one ear and apply a sounding tuning fork to the mastoid process on the opposite side. The patient should indicate at the point at which he ceases to hear the sound. After this, the tuning fork is placed near the external auditory canal and again waiting for the moment when the patient ceases to hear the sound. Thus, bone and air sound conduction are determined. The norm is said to be when the sound aerial perception is twice the perception of the bone.

Impedansometry with chronic otitis allows at one time to assess the mobility of the membrane and auditory ossicles, as well as determine the degree of patency of the auditory tube. The essence of the procedure is as follows: a device with an integrated sound source, a detector and an output of an automatic supercharger is introduced into the external path. The device with the sensor seals the auditory passage. With the change in pressure, the motor activity of the membrane and auditory ossis changes, which is estimated by the doctor according to the degree of reflected and absorbed sound energy. The result is drawn in the form of a graph of the curves of the dependence of the mobility of the membrane on the intra-passage pressure. The procedure is carried out in an outpatient setting and can be used to diagnose auditory function in adults and children from 7 months of age.

In addition, it is necessary to pass some tests:

• biochemical and serological analysis of blood for infection;
• bakposov vydeleny on the microflora with a simultaneous assessment of sensitivity to antibacterial drugs;
• microscopic examination of excreta;
• immunological tests and other analyzes.

If the information obtained during the examination of the patient indicates the presence of an atopic disease, then an immunological study is prescribed. If a patient has had frequent infectious diseases of the upper respiratory tract, he is recommended to take tests for IgA, IgM, IgG, and also to conduct a functional test of the state of humoral immunity. When ineffective treatment of chronic otitis media (especially one that is combined with chronic bronchitis and / or sinusitis), differential diagnosis should be considered, eliminating primary ciliary dyskinesia.

[64], [65], [66], [67], [68]

Differential diagnosis

Differential diagnosis, in the first place, is based on the localization of perforation, on the nature of the discharge. In addition, the radiography of the region of the mastoid process is carried out.

With purulent discharge from the ear with an unpleasant odor differentiation is carried out with epitimpanitis: it is necessary to clarify the presence of a carious process or a choleastomy. In some cases, mesotympanitis may give similar symptoms, but an unpleasant smell in this situation disappears after cleaning the ear, since it has no connection with pathological processes in bone tissue.

Epitimpanitis is characterized by complete damage to the tympanic membrane, or perforation in m. Shrapnelli. Therefore, an important diagnostic procedure is otoscopy, carried out with great care. Before otoscopy, it is necessary to completely clear the auditory passage from the secretions, since even small amounts of them can cover the perforation and prevent the correct diagnosis.

Radiography will help to examine the broken structure of the mastoid process, and also see the choleastoma - in the form of cavity education.

Treatment of the chronic otitis media

About methods of treatment of a chronic average otitis at home and in a hospital read in this article.

Prevention

Chronic otitis gives a sick person a lot of unpleasant sensations. Therefore, whenever possible, it is better to prevent the disease in advance in order to avoid suffering. Everyone who cares about their own health should know about such preventive measures.

• Supercooling should be avoided. If you still catch a cold, then you should immediately begin treatment, without waiting for the aggravation of the disease.
• Strong immunity is the key to successful protection of the body from many diseases. Therefore, it is important to maintain your own immune forces in "full combat readiness." To do this, you need to lead a healthy lifestyle, eat fully, and if necessary - for example, in early spring, take multivitamin complex preparations.
• Particularly useful for the body are hardening, walking outdoors, active games. It is known that a sedentary lifestyle increases the risk of morbidity - including, this also applies to the development of chronic otitis media.

[69], [70], [71], [72], [73], [74]

Forecast

Chronic otitis requires long-term treatment. However, if you strictly adhere to medical prescriptions, then the disease can be cured. At belated address to the doctor after a therapeutic course can remain unpleasant consequences in the form of deterioration of hearing, vestibular violations.

Especially often hearing impairment is observed with frequent repetition and long duration of relapses.

To avoid the development of complications, you need to contact the doctor in a timely manner, and after the completion of treatment it is important to periodically carry out preventive diagnostics in the ENT department.

[75], [76],

Chronic otitis and the army

With a diagnosed chronic otitis media, chronic purulent otitis, mesotiminate, the young person is assigned a category B, which means that he is exempt from compulsory recruitment into the army in peacetime.

A complete list of ear diseases that fall into this category is as follows:

• chronic otitis media one or two;
• chronic purulent otitis with signs of persistent obstruction of nasal breathing.
• The category is assigned based on:
• otoscopic conclusion (perforating damage to the membrane, the presence of secretions);
• sowing of discharge from the ear to the flora;
• X-ray of the temporal bones according to Schueller and Mayer;
• CT of temporal bones.

The indication for the exemption is also chronic otitis, which was operated 12 or more months ago (if there was a radical intervention or tympanoplasty of the open type with complete epidermisation of the operating cavity).

[77], [78], [79], [80], [81], [82]