Chronic purulent otitis media

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

Epidemiology

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

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Causes chronic suppurative otitis media

The flora composition in chronic purulent otitis media differs from that found in acute otitis media. Chronic purulent otitis media is often caused by several pathogens simultaneously. Among them are aerobes: Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Klebsiella pneumoniae, Ptoteus mirabilis, Pseudomonas aeruginosa. In the case of a common exacerbation of chronic purulent otitis media, anaerobes are rarely isolated, usually representatives of the genus Peptostreptococcus. However, anaerobes are more common in cholesteatoma, since the conditions inside its matrix are more favorable for their existence.

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Risk factors

Various factors lead to the development of chronic purulent otitis media: infectious (bacteria, viruses, fungi), mechanical, chemical, thermal, radiation, etc. Chronic purulent otitis media is usually a consequence of untreated or inadequately treated acute otitis media.

The causes of chronic purulent otitis media may 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. The transition of acute otitis media to chronic may also be facilitated by immunodeficiency states: acquired immunodeficiency syndrome (AIDS), long-term treatment with chemotherapy drugs, etc.), pregnancy, blood diseases, endocrine diseases (diabetes mellitus, hypothyroidism), diseases of the upper respiratory tract (curvature of the nasal septum, adenoids, etc.), iatrogenic causes.

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Symptoms chronic suppurative otitis media

Patients usually complain of periodic or constant purulent discharge from the ear, hearing loss, periodic ear pain, a sensation of noise in the ear and dizziness. However, in some cases, these symptoms may be absent. Discharge from the ear is mainly mucopurulent, in the presence of granulation and polyps - can be bloody-purulent. The course of mesotympanitis is usually more favorable compared to epitympanitis, and severe intracranial complications are observed less often. The causes of exacerbation of the process can be a cold, water getting into the ear, diseases of the nose and nasopharynx. In these cases, purulent discharge increases, body temperature rises, a feeling of pulsation in the ear appears, sometimes mild pain.

In epitympanitis, the inflammatory process is localized mainly in the supratympanic space: the attic and mastoid process, perforation is usually located in the relaxed part of the eardrum, but can also spread to other areas. Epitympanitis is characterized by a more severe course of the disease compared to mesotympanitis. The purulent process occurs in an area abundant in narrow and tortuous pockets formed by folds of the mucous membrane and auditory ossicles. In this form, damage to the bone structures of the middle ear is observed. Caries of the bone walls of the attic, aditus, antrum and mammillary cells develops.

With epitympanitis, patients usually complain of purulent discharge from the ear, usually with a putrid odor, and hearing loss. Ear pain and headache are not typical for uncomplicated epitympanitis; their presence usually indicates complications. If the capsule of the lateral semicircular canal is affected by caries, patients may complain of dizziness. Destruction of the bone wall of the facial canal can lead to facial nerve paresis. If a headache, facial nerve paresis, or vestibular disorders occur in a patient with epithymianitis, he or she should be immediately hospitalized for examination and treatment.

It is generally accepted that the characteristic symptom of chronic purulent otitis media is conductive hearing loss. However, with a long-term course of the disease, a mixed form of hearing loss is often observed. The cause of the development of a mixed form of hearing loss is considered to be the effect of inflammatory mediators on the inner ear through the windows of the labyrinth. It has been proven that the permeability of the windows in chronic purulent otitis media is increased. At the morphological level, a loss of outer and inner hair cells in the basal curl is detected. In addition, during inflammation, there is a decrease in blood flow in the cochlea. An active inflammatory mediator - 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 ionic composition of the endolymph.

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

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Forms

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

• mesotympanitis (chronic tubotympanic purulent otitis media);
• epitympanitis (chronic epitympanoantral purulent otitis media).

The fundamental difference between these forms is that in mesotympanitis the mucous membrane is affected, and the bone is always intact, while in epitympanitis the process extends to the bone structures of the middle ear. In mesotympanitis the process mainly involves the mucous membrane of the middle and lower parts of the tympanic cavity, as well as the area of the auditory tube. In this form, a preserved unstretched part of the eardrum is determined, and the perforation is usually located in the stretched part of the eardrum.

In most cases, epitympanitis is accompanied by cholesteatoma spillage. Cholesteatoma is an epidermal formation of a whitish pearly color, usually having a connective tissue membrane (matrix) covered with stratified squamous epithelium, tightly adjacent to the bone and often growing into it. Cholesteatoma is formed as a result of the ingrowth of the epidermis of the external auditory canal into the middle ear cavity through the marginal perforation of the eardrum. Thus, the epidermis forms a cholesteatoma membrane. The epidermal layer constantly grows and peels off, and under the influence of the irritating effect of pus and decay products, this process intensifies. Cholesteatoma masses grow, due to which the cholesteatoma begins to press on the surrounding tissues, destroying them. Cholesteatomas are divided by localization into:

• attic;
• sinus cholesteatomas;
• retraction cholesteatomas of the pars tensa.

Attic cholesteatomas are defined by retraction or perforation in the pars flaccidum of the tympanic membrane. They extend into the attic, aditus, and occasionally the antrum, mammillary process, or tympanic cavity.

Cholesteatomas of the sinus are found in posterosuperior perforations or retractions of the tense part of the tympanic membrane. They extend into the tympanic sinus and posterior portions of the tympanic cavity and from there under the incus and into the attic, aditus, or antrum.

Retraction cholesteatomas of the pars tensa are found in retractions or perforations of the entire pars tensa, including the orifice of the auditory tube. They extend to the attic under the malleus folds and the body of the incus or the head of the malleus.

Cholesteatomas are divided by origin into:

• retraction pocket;
• primary cholesteatoma (similar to an epidermoid cyst);
• implantation cholesteatoma.

Retraction pockets are the cause of cholesteatoma development in 80% of cases. The causes of retraction pockets development may be inflammatory processes of the upper respiratory tract, negative pressure in the middle ear cavities, atrophy of the lamina propria of the eardrum and dysfunction of the multilayered epithelium of the eardrum.

There are 3 stages in the development of retraction pockets:

• Stage 1 - stable retraction pocket. Hearing is preserved, the bottom of the pocket can be easily examined. Treatment is conservative.
• Stage 2 - unstable retraction pocket. Hearing is preserved, hypotrophy of the eardrum is observed. Treatment consists of stopping the tympanostomy tubes.
• Stage 3 - unstable retraction pocket. The bone ring frames are eroded. The retraction pocket is fused with the promontory wall, signs of inflammation appear. Treatment: tympanoplasty and strengthening of the eardrum.

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Complications and consequences

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

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Diagnostics chronic suppurative otitis media

Otoscopy is considered a screening method for detecting chronic purulent otitis media.

Diagnostic measures for chronic purulent otitis media include:

• general otolaryngological examination, using endoscopy or otomicroscopy after thorough cleaning of the ear canal:
• audiological examination, including tymnanometry, which allows assessing the function of the auditory tube;
• Valsalva maneuver to push secretions into the ear canal:
• mandatory study of flora and its sensitivity to antibiotics;
• fistula tests;
• CT scan of the temporal bones.

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Differential diagnosis

Differential diagnosis must be made between mesotympapitis and epitympapitis.

If there are neurological symptoms, a consultation with a neurologist is necessary.

Treatment chronic suppurative otitis media

Treatment goals: to eliminate the source of infection and improve hearing.

Indications for hospitalization

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

Non-drug treatment

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

Conservative treatment of chronic otitis media is only appropriate 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 fibrous changes of varying severity in the middle ear. If surgery is postponed for a long time, the consequences of chronic purulent otitis media do not allow obtaining the maximum functional effect from hearing-improving surgery, even with minor disturbances in the sound-conducting system of the middle ear. After eliminating the exacerbation, tympanoplasty is performed or the sanitizing stage is combined with tympanoplasty.

Conservative treatment of chronic purulent otitis media (preoperative preparation) is usually carried out at the outpatient stage. Before hospitalization, all patients are shown the following treatment procedures:

• therapeutic Valsalva maneuver;
• regular ear hygiene by rinsing and drying;
• antibiotics locally.

A thorough cleaning of the ear followed by rinsing is carried out with a 0.9% sodium chloride solution or a ciprofloxacin solution (20 ml per rinsing).

This type of lavage combines mechanical removal of discharge and local action of the antibiotic on the inflamed tissues. Irrigation with ciprofloxacin at an outpatient appointment should be combined with topical use 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, symptoms such as pain, overhang of the posterior-superior wall of the external auditory canal or general cerebral symptoms have appeared, then this requires urgent surgical intervention.

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

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

Drug treatment

The use of antibiotics to treat an exacerbation of chronic purulent otitis media, to prepare for ear surgery, or to prevent complications after tympanoplasty is a controversial issue. Often the decision is made based on individual preference.

Local treatment with antibiotics or antiseptics combined with thorough ear hygiene is more effective in eliminating otorrhea than no treatment or ear hygiene alone. 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. Local use of quinolones is more effective than other antibiotics.

Before the operation, a 10-day course of ear drops is administered. Currently, there are many ear drops on the market, which, as a rule, are a solution of an antibiotic for local use, sometimes in combination with a glucocorticoid. It is necessary to remember that many of them contain aminoglycoside antibiotics (gentamicin, framycetin, neomycin). Data on the study of the permeability of the cochlear membranes in animal experiments prove the possibility of an ototoxic effect of aminoglycosides on the inner ear when administered transtympanically. For this reason, the use of drops containing aminoglycosides in the presence of a perforated eardrum should be abandoned. They are used only for external and acute otitis media without perforation of the eardrum. As for drops containing rifamycin, norfloxacin or ciprofloxacin, today they are considered the only ear drops that can be safely used for perforated otitis media.

Surgical treatment

The goal of surgical intervention is to restore the functions of the middle ear and prevent infection from penetrating into it. If conservative treatment has proven ineffective and the exacerbation has not been eliminated, then surgical intervention is indicated, which may combine sanitizing, reconstructive and hearing-improving (if possible) stages. This may be separate attico-antrotomy with tympanoplasty, atticotomy, aditotomy or, in extreme cases, radical surgery, but with mandatory obliteration of the auditory tube or formation of the small tympanic cavity. There are no rules by which one can determine the duration of conservative treatment in attempts to eliminate the exacerbation. It depends on the duration and nature of the inflammatory process before treatment, the presence of complications or the likelihood of their development. Of course, surgical intervention on a "dry" ear will be more gentle, since it may be possible to avoid mastoidectomy. The results of such intervention on a "dry" ear after tympanoplasty without mastoidectomy are better.

However, even a "dry" ear with a perforated eardrum is a surgical field in the asepsis of which we cannot be sure. Regardless of the presence or absence of purulent discharge, 20% of patients are found to have microorganisms that react poorly to conventional systemic antibiotic therapy. That is why such operations are considered "conditionally seeded"; they require preoperative preparation and postoperative antibiotic prophylaxis.

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

Of course, the most important point is considered to be the prevention of cholesteatoma, and therefore the thesis on early ear surgery should be the very first. In most cases, strengthening the eardrum in the area of the retraction pocket with cartilage prevents the development of retraction and cholesteatoma, but in this case the doctor 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 monitor 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 findings.

The second key moment for choosing a surgical intervention strategy is considered to be CT of the temporal bones. Unfortunately, in relation to cholesteatoma, the diagnostic specificity and sensitivity of this method are almost equal to the indicators 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 a particular patient. This leads to the fact that any darkening in the area of the antrum or mastoid cells is often interpreted as cholesteatoma. In Russia, this, as a rule, prompts otosurgeons to choose a behind-the-ear approach and radical intervention.

The third important point is the choice of surgical access. In most cases, with a chronic process in the ear, a pronounced sclerotic process is observed in the area of the periantral cells. The antrum, as a rule, is small in size and in order to approach it via the behind-the-ear route, it is necessary to open a fairly large mass of sclerotic bone. Thus, in the case of a 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, an endaural approach is preferred, except for cases of extensive cholesteatomas with a fistula of the lateral semicircular canal or paresis of the facial nerve. Such access will make it possible to stop in time upon reaching the boundaries of the cholesteatoma, preserving the bone structures that are not affected by the process. This, in turn, facilitates intraoperative restoration of the lateral wall of the attic, aditus and posterior wall of the external auditory canal using autologous cartilage taken from the tragus or posterior surface of the auricle.

Repeated operations are necessary in case of recurrence of cholesteatoma.

One should not forget about the advantages of the technique of surgery for cholesteatoma with preservation of the posterior wall of the external auditory canal as the most organ-preserving.

Thus, conservative treatment of chronic purulent otitis media is considered preoperative preparation for surgical intervention on the middle ear. The sooner the integrity of the middle ear system is restored, the more intact the mucociliary transport system, one of the most important mechanisms that ensure normal function of the middle ear, will be, and the less pronounced the sensorineural component of hearing loss will be.

Further management

Postoperative care of patients consists of daily toilet and ear rinsing.

Prevention

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

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Forecast

With timely surgical treatment, the prognosis is favorable.

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