Chronic suppurative otitis media

Chronic suppurative otitis media is a serious disease with a bacterial infection in the middle ear. As a rule, this is a consequence of untreated acute otitis media, especially in the first 5 years of a child's life, when the resulting post-inflammatory changes in the mucosa and middle ear structures contribute to the chronization of the process. WHO gives the following definition of chronic purulent otitis media: the presence of a permanent discharge from the ear through perforation in the eardrum for more than 2 weeks. The same WHO report noted that the association of otorhinolaryngologists insists on increasing this period to 4 weeks. Usually, without adequate treatment for chronic otitis, the discharge of purulent discharge is observed for months, and even years. The pathological process leads to destruction of the osteal bone structures and progressive hearing loss.

Epidemiology

According to WHO, chronic purulent otitis media affects 65-330 million people, 60% of them (39-200 million) have a significant hearing loss.

[1], [2], [3], [4], [5], [6]

Causes of the chronic purulent otitis media

The composition of the flora in chronic purulent otitis media differs from the composition, which is detected with acute otitis media. Chronic suppurative otitis media often cause several pathogens at the same time. Among them, aerobes: Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Klebsiella pneumoniae, Ptoteus mirabilis, Pseudomonas aeruginosa. In the usual exacerbation of chronic purulent otitis media, anaerobes are rarely isolated, usually representatives of the genus Peptostreptococcus. However, anaerobes are more common in cholesteatoma, since within its matrix more favorable conditions for their existence.

[7], [8], [9], [10]

Risk factors

The development of chronic purulent otitis media is caused by various factors: infectious (bacteria, viruses, fungi), mechanical, chemical, thermal, radiation, etc. Chronic purulent otitis media usually occurs as a result of untreated or untreated acute otitis media.

The causes of development of chronic purulent otitis media can be virulent strains of pathogens resistant to antibacterial drugs, cicatricial processes in the tympanic cavity due to repeated acute otitis media, dysfunction of the auditory tube. Transition of acute otitis media to chronic can also be facilitated by immunodeficiency states: acquired immunodeficiency syndrome (AIDS), long-term chemotherapy treatment, etc.), pregnancy, blood diseases, endocrine diseases (diabetes mellitus, hypothyroidism), upper respiratory tract diseases (nasal curvature septa, adenoids, etc.), iatrogenic causes.

[11], [12], [13], [14], [15]

Symptoms of the chronic purulent otitis media

Patients usually complain of periodic or persistent effusion from the ear, hearing loss, periodic pain in the ear, a sense of noise in the ear and dizziness. However, in some cases, these symptoms may be absent. Discharges from the ear are mostly muco-purulent, in the presence of granulations and polyps - can be blood-purulent. The course of mesotympanitis is usually more favorable than epitimpanitis, and severe intracranial complications are observed less frequently. Causes of an exacerbation of the process can be a cold, water in the ear, nose and nasopharynx. In these cases, suppuration, increased body temperature, there is a feeling of pulsation in the ear, sometimes an uneven pain.

With epitimpanitis, the inflammatory process can be localized mainly in the above-drum space: the attic and the mastoid process, the perforation is usually located in the not stretched part of the tympanic membrane, but it can also spread to other parts. Epitaminite is characterized by a more severe course of the disease in comparison with mesotympanitis. The purulent process proceeds in an area full of narrow and sinuous pockets formed by folds of the mucous membrane and auditory ossicles. With this form, the damage to the bone structures of the middle ear is observed. Caries of the bony walls of the attic, aditus, antrum and mastoid cells develops.

When epitimpanitis, patients usually complain of purulent discharge from the ear, usually with putrefactive odor, hearing loss. Pain in the ear and headache for uncomplicated epitimpanitis are not characteristic, their presence usually indicates the complications that have arisen. If the capsule of the lateral semicircular canal is damaged by caries, patients may complain of dizziness. The destruction of the osseous canal wall can lead to paresis of the facial nerve. If there is a headache, facial nerve paresis or vestibular disorders in a patient with epitimianitis, he should be immediately hospitalized for examination and treatment.

It is generally accepted that a characteristic sign of chronic purulent middle otitis media is conductive hearing loss. However, with a prolonged course of the disease, a mixed form of deafness is often observed. The cause of the development of a mixed form of deafness is the effect of inflammatory mediators on the inner ear through the windows of the labyrinth. It is proved that the permeability of windows with chronic purulent otitis media is increased. At the morphological level, the loss of external and internal hair cells in the basal curl is revealed. In addition, during inflammation, there is a decrease in blood flow in the cochlea. An active mediator of inflammation - histamine can also affect the efferent innervation of the outer hair cells, and free radicals can directly damage the hair cells. At the same time, endotoxins block Na-K-ATPase and change the ion composition of the zindolymph.

The severity of sensorineural hearing loss in chronic purulent otitis media depends on the patient's age and duration of the disease and is more pronounced at high frequencies (close proximity of hair cells responsible for high frequency perception to the window of the vestibule).

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

Forms

According to the clinical course and severity of the disease, 2 forms of chronic purulent otitis media are isolated:

• mesotympanitis (chronic tubotympanal purulent otitis media);
• epitimpanitis (chronic epitimpano-antral purulent otitis media).

The principal difference between these forms is that mesotympanitis affects the mucous membrane, and the bone is always intact, and with epitimpanitis the process extends to the bony structures of the middle ear. When mesotiminate, the mucous membrane of the middle and lower parts of the tympanum, and also the area of the auditory tube, are involved in the process. In this form, a retained, non-stretched part of the tympanic membrane is defined, and the perforation is usually located in the stretched part of the tympanic membrane.

In most cases with epitimpanitis, the cholesteatoma is diffused. Cholesteatoma is an epidermal formation of whitish pearlescent color, usually having a connective tissue membrane (matrix), covered with multilayered flat epithelium, closely adhering to the bone and often growing into it. Cholesteatoma is formed as a result of the growth of the epidermis of the external auditory canal into the middle ear cavity through the perforation of the tympanic membrane. Thus, the epidermis forms the shell of the cholesteatoma. The epidermal layer constantly grows and slides, and under the influence of the irritating action of pus and the products of decay this process intensifies. Cholesteatom masses expand, in connection with which the cholesteatoma begins to press on surrounding tissues, destroying them. Cholesteatomas by localization are divided into:

• attic;
• cholesteatomy sinus;
• retractive cholesteatomas of the stretched part.

Attic cholesteatomas are determined by retraction or perforation in the region of the unbuttoned part of the tympanic membrane. They extend into attic, aditus and sometimes anthrum, mastoid process or drum cavity.

Sinus cholesteatomas are detected with posterolateral perforations or retractions of the stretched part of the tympanic membrane. They extend into the tympanic sinus and the posterior parts of the tympanum and from here under the anvil and into the attic, aditus or antrum.

Retractive cholesteatomas of the stretched part are revealed with retractions or perforations of the entire stretched part, including the mouth of the auditory tube. They extend to the attic under the folds of the malleus and the body of the anvil or the head of the malleus.

Cholesteatomas by origin are divided into:

• retraction pocket;
• primary cholesteatoma (similarity of the epidermoid cyst);
• implantation cholesteatoma.

Retractive pockets are the cause of cholesteatoma in 80% of cases. The causes of retraction pockets development may be inflammation of the upper respiratory tract, negative pressure in the middle ear cavity, atrophy of the lamina propria of the tympanic membrane and a violation of the function of the multilayered epithelium of the tympanic membrane.

In the development of retraction pockets, three stages are distinguished:

• The first stage is a stable retractive pocket. The hearing is preserved, the bottom of the pocket can be easily viewed. The treatment is conservative.
• 2-nd stage - unstable retractional pocket. Hearing is preserved, watch the echinotrophy of the tympanic membrane. Treatment consists in stopping tympanostomic tubes.
• The third stage is an unstable retractive pocket. The framework of the bone ring is eroded. Retraction pocket is spliced with promontorial wall, signs of inflammation appear. Treatment: tympanoplasty and strengthening of the tympanic membrane.

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

Complications and consequences

Despite the use of antibacterial therapy, chronic purulent otitis media remains the main cause of hearing impairment. In addition, this process can lead to such serious infectious complications as mastoiditis, meningitis, brain abscess, thrombosis of the sinuses. A large number of anatomical structures undergo changes with each exacerbation of chronic purulent otitis media. It is because of the threat of development of these complications of the need to preserve anatomical structures that a strict algorithm of diagnosis and treatment of this disease should be observed.

[26], [27]

Diagnostics of the chronic purulent otitis media

A screening method for detecting chronic purulent otitis media is considered otoscopy.

Diagnostic measures for chronic purulent otitis media include:

• general otorhinolaryngological examination, with the use of endoscopy or otomicroscopy after thorough cleaning of the auditory canal:
• audiologic examination and, in particular, timnanometry, which makes it possible to evaluate the function of the auditory tube;
• Maneuver Valsalva for pushing the detachable into the ear canal:
• obligatory study of flora and its sensitivity to antibiotics;
• fistulous tests;
• CT of temporal bones.

[28], [29]

Differential diagnosis

Differential diagnostics must be carried out between mesotympapitis and zaptimpaitis.

If neurologic symptoms are present, neurologist consultation is necessary.

Treatment of the chronic purulent otitis media

The objectives of the treatment: sanation of the focus of infection and improvement of hearing.

Indications for hospitalization

Indications for emergency hospitalization are complications of chronic purulent otitis media, such as intracranial complications (cerebral abscess, meningitis, arachnoiditis, etc.), facial nerve paresis, mastoiditis, etc.

Non-drug treatment

Conservative treatment in the presence of cholesteatoma, consisting in washing the cavities of the middle ear, is not always justified, since it stimulates the growth of the epidermis and promotes the spread of cholesteatoma to deeper parts.

Conservative treatment of chronic otitis media is only valid for chronic otitis media with discharge (exacerbation of the disease, mucositis (chronic exudative process) .At the same time conservative treatment should be considered only as preoperative preparation, since each exacerbation leads to the development of fibrotic changes of varying severity in the middle ear.If the surgery is postponed for a long time, the consequences of chronic purulent otitis media do not allow obtaining the maximum functional cial effect on hearing improving surgery even for small violations of the middle ear sound-conducting system. After elimination exacerbation carried tympanoplasty or combine with tympanoplasty sanifying phase.

Conservative treatment of chronic suppurative otitis media (preoperative preparation) is carried out, as a rule, on an outpatient basis. Until hospitalization, all patients are shown the following treatment procedures:

• the therapeutic maneuver of Valsalva;
• regular ear toilet with washing and drying;
• antibiotics topically.

A careful ear toilet with subsequent washing is performed with 0.9% sodium chloride solution or ciprofloxacin solution (20 ml per wash).

This washing combines the mechanical removal of the detachable and the local action of the antibiotic on the inflamed tissues. Flushing with ciprofloxacin on an outpatient visit should be combined with topical administration of antibiotics in the form of ear drops by the patient himself at home. If the exacerbation has not been eliminated within 2-3 days of treatment or, moreover, such symptoms as pain, overhanging of the posterior-upper wall of the external auditory canal or cerebral symptoms, then this requires urgent surgical intervention.

Returning to preoperative preparation, it should be noted that its goal is to stop the inflammation in the middle ear and to create conditions for further surgical intervention.

Based on the reasonable duration of antibiotic use and to avoid the attachment of fungal infection, recommend a course of conservative treatment from 7 to 10 days.

Medication

The use of antibiotics to eliminate exacerbation of chronic purulent otitis media, preparation for surgery on the ear or for the prevention of complications after tympanoplasty is a contentious issue. Often the decision is made according to individual preferences.

Local treatment with antibiotics or antiseptics combined with a careful ear toilet is more effective for eliminating otorrhoea than the absence of any medication or just the ear toilet. Local treatment with antibiotics or antiseptics is more effective than treatment with systemic antibiotics. Combined treatment with local and systemic antibiotics is not considered more effective than treatment with local antibacterial drugs alone. The local use of quinolones is more effective than other antibiotics.

Before the operation, a 10-day course of ear drops is carried out. At present, there are many ear drops on the market, which, as a rule, are a solution of an antibiotic for topical application, sometimes in combination with a glucocorticoid. It must be remembered that many of them contain antibiotics of the aminoglycoside series (gentamicin, Framicetn, neomycin). Data on the study of the permeability of cochlea membranes in animal experiments prove the possibility of ototoxic action of aminoglycosides on the inner ear in the case of transtimipanal administration. For this reason, the use of droplets containing aminoglycosides, if there is a perforation of the tympanic membrane, should be discarded. They are used only with an external and acute average otitis without perforation of the tympanic membrane. As for drops that contain rifamycin, norfloxacin or ciprofloxacin, today they are considered to be the only ear drops that can be safely used in perforated otitis media.

Surgery

The purpose of surgery is to restore the functions of the middle ear and prevent the penetration of infection. If conservative treatment was ineffective and the aggravation could not be eliminated, then a surgical intervention that can combine sanitizing, reconstructive and hearing-improving (if possible) stages is shown. This can be a separate attico-anthotomy with tympanoplasty, atticotomy, aditotomy or, at the extreme, a radical operation, but with obligatory obliteration of the auditory tube or the formation of a small tympanum. There are no rules by which one can determine the duration of conservative treatment in an effort to achieve elimination of an exacerbation. It depends on the duration and nature of the inflammatory process before treatment, the presence of complications or the likelihood of their development. Undoubtedly, surgical intervention on the "dry" ear will be more sparing, because. It may be possible to avoid mastoidotomy. The results of such interference on the "dry" ear after tympanoplasty without mastoidectomy is better.

However, even a "dry" ear with a perforation of the tympanic membrane is a surgical field, in the aseptic of which we can not be sure. Regardless of the presence or absence of suppuration, in 20% of patients microorganisms that react weakly to conventional systemic antibiotic therapy are isolated. That is why such operations are referred to as "conditionally-seeded", they require preoperative preparation and postoperative antibiotic prophylaxis.

Traditionally, chronic purulent otitis media and cholesteatoma are treated with radical surgery on the middle ear.

Of course, the most important point is the prevention of cholesteatoma, and therefore the thesis of early ear surgery should be the very first. In most cases, strengthening the tympanic membrane in the retractive pocket area with the help of cartilage prevents the development of retraction and cholesteatoma, but the doctor in this case must convince the patient of the need for surgical intervention, since at this stage the patient's quality of life is practically not affected. However, it should be remembered that the retraction pocket will not necessarily progress and lead to the development of cholesteatoma. Nevertheless, it is possible to follow the development of the process only with adequate control. Therefore, it is necessary to monitor the patient, preferably in the same medical institution, as well as video documentation of the findings.

The second key point for choosing a strategy for surgical intervention is the CT scan of the temporal bones. Unfortunately, with respect to cholesteatoma, the diagnostic specificity and sensitivity of this method are almost equal to those for granulations and fibrous tissue. With insignificant otoscopic signs of cholesteatoma, CT loses its diagnostic significance and remains a map of the anatomical features of this particular patient. This leads to the fact that any obscuration in the area of antrum or cells of the mastoid process is often treated as cholesteatoma. In Russia, this usually moves the otosurgeons to choose the BTE and the radical intervention.

The third important point is the choice of operational access. In most cases, with a chronic process in the ear, a pronounced sclerotic process is observed in the region of perianth cells. Antrum is usually small in size and. In order to approach it in a breech manner, it is necessary to open a fairly large array of sclerotized bone. Thus, in the case of behind-the-ear approach and removal of the posterior wall of the external auditory canal, a large size of the postoperative cavity is predetermined. In this regard, the endoural approach is preferred, with the exception of cases of extensive cholesteat with fistula of the lateral semicircular canal or paresis of the facial nerve. Such access will give an opportunity to stop in time when reaching the boundaries of cholesteatoma, preserving bone structures that are not interested in the process. This, in turn, facilitates the intraoperative reconstruction of the lateral wall of the attic, aditus, and posterior wall of the external auditory canal with the aid of an autochondria taken from the tragus or the posterior surface of the auricle.

Repeated operations are necessary in case of relapses of cholesteatoma.

One should not forget about the advantages of the operation technique in the case of cholesteatoma with preservation of the posterior wall of the external auditory meatus as the most organ-preserving.

Thus, conservative treatment of chronic suppurative otitis media is considered preoperative preparation for surgical intervention in the middle ear. The earlier the integrity of the middle ear system is restored, the more secure will be the system of mucociliary transport, one of the most important mechanisms providing a normal function of the middle ear, and the less pronounced sensorineural component of hearing loss.

Further management

Postoperative management of patients is in the daily toilet and washing the ear.

Prevention

Prevention of chronic purulent otitis media consists in the timely and rational treatment of acute otitis media.

[30], [31],

Forecast

With timely surgical treatment, the prognosis is favorable.

[32], [33],