Exudative otitis media

Otitis media (secretory or non-purulent otitis media) is an otitis in which the mucous membranes of the middle ear cavities are affected.

Exudative otitis media is characterized by the presence of exudate and hearing loss in the absence of pain, with an intact eardrum.

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Epidemiology

The disease most often develops in preschool age, less often in school age. Mostly boys are affected. According to M. Tos, 80% of healthy people suffered from exudative otitis media in childhood. It should be noted that in children with congenital cleft lip and palate, the disease occurs much more often.

Over the last decade, a number of domestic authors have noted a significant increase in morbidity. Perhaps, it is not an actual increase that is taking place, but an improvement in diagnostics as a result of equipping audiology offices and centers with surdoacoustic equipment and the introduction of objective research methods (impedancemetry, acoustic reflexometry) into practical healthcare.

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Causes exudative otitis media

The most common theories of the development of exudative otitis media:

• "hydrops ex vacuo", proposed by A. Politzer (1878), according to which the disease is based on causes that contribute to the development of negative pressure in the cavities of the middle ear;
• exudative, explaining the formation of secretion in the tympanic cavity by inflammatory changes in the mucous membrane of the middle ear;
• secretory, based on the results of studying the factors that contribute to hypersecretion of the mucous membrane of the middle ear.

In the initial stage of the disease, the flat epithelium degenerates into a secretory one. In the secretory stage (the period of accumulation of exudate in the middle ear), a pathologically high density of goblet cells and mucous glands develops. In the degenerative stage, the secretion production decreases due to their degeneration. The process is slow and is accompanied by a gradual decrease in the frequency of division of goblet cells.

The presented theories of development of exudative otitis media are actually links of a single process reflecting different stages of chronic inflammation. Among the causes leading to the development of the disease, most authors focus on the pathology of the upper respiratory tract of inflammatory and allergic nature. A necessary condition for the development of exudative otitis media (trigger mechanism) is considered to be the presence of mechanical obstruction of the pharyngeal opening of the auditory tube.

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Pathogenesis

Endoscopic examination of patients with dysfunction of the auditory tube shows that the cause of exudative otitis media in most cases is a violation of the outflow pathways of secretion from the paranasal sinuses, primarily from the anterior chambers (maxillary, frontal, anterior ethmoidal), into the nasopharynx. Normally, transport goes through the ethmoid funnel and frontal recess to the free edge of the posterior part of the uncinate process, then to the medial surface of the inferior nasal concha bypassing the opening of the auditory tube in front and below; and from the posterior ethmoid cells and sphenoid sinus - behind and above the tubular opening, uniting in the oropharynx under the action of gravity. In vasomotor diseases and sharply increased viscosity of the secretion, mucociliary clearance is slowed. In this case, a fusion of flows to the tubular opening or pathological eddies with the circulation of secretion around the mouth of the auditory tube with pathological reflux into its pharyngeal opening are noted. With hyperplasia of adenoid vegetations, the path of the posterior mucus flow moves forward, also to the mouth of the auditory tube. Changes in natural outflow paths can also be caused by changes in the architecture of the nasal cavity, especially the middle nasal passage and the lateral wall of the nasal cavity.

In acute purulent sinusitis (especially sinusitis), due to changes in the viscosity of the secretion, the natural drainage pathways from the paranasal sinuses are also disrupted, which leads to the discharge being dumped into the mouth of the auditory tube.

Exudative otitis media begins with the formation of a vacuum and a tympanic cavity (hydrops ex vacuo). As a result of dysfunction of the auditory tube, oxygen is absorbed, the pressure in the tympanic cavity drops and, as a consequence, transudate appears. Subsequently, the number of goblet cells increases, mucous glands are formed in the mucous membrane of the tympanic cavity, which leads to an increase in the volume of secretion. The latter is easily removed from all sections through the tympanostomy. The high density of goblet cells and mucous glands leads to an increase in the viscosity and density of the secretion, to its transition to exudate, which is already more difficult or impossible to evacuate through the tympanostomy. At the fibrous stage, degenerative processes predominate in the mucous membrane of the tympanic cavity: goblet cells and secretory glands undergo degeneration, mucus production decreases, then stops completely, fibrous transformation of the mucous membrane occurs with the involvement of the auditory ossicles in the process. The predominance of formed elements in the exudate leads to the development of the adhesive process, and an increase in formless elements leads to the development of tympanosclerosis.

Of course, inflammatory and allergic pathology of the upper respiratory tract, changes in local and general immunity influence the development of the disease and play a major role in the development of the recurrent form of chronic exudative otitis media.

The trigger mechanism, as mentioned above, is dysfunction of the auditory tube, which can be caused by mechanical obstruction of its pharyngeal orifice. This most often occurs with hypertrophy of the pharyngeal tonsil, juvenile angiofibroma. Obstruction also occurs with inflammation of the mucous membrane of the auditory tube, provoked by bacterial and viral infection of the upper respiratory tract and accompanied by secondary edema.

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Symptoms exudative otitis media

Low-symptom course of exudative otitis media is the reason for late diagnosis, especially in young children. The disease is often preceded by pathology of the upper respiratory tract (acute or chronic). Hearing loss is typical.

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Forms

Currently, exudative otitis media is divided into three forms according to the duration of the disease.

• acute (up to 3 weeks);
• subacute (3-8 weeks);
• chronic (more than 8 weeks).

Considering the difficulties in determining the onset of the disease in preschool children, as well as the identity of treatment tactics for acute and subacute forms of exudative otitis media, it is considered appropriate to distinguish only two forms - acute and chronic.

In accordance with the pathogenesis of the disease, various classifications of its stages are accepted. M. Tos (1976) identifies three periods of development of exudative otitis media:

• primary or initial stage of metaplastic changes in the mucous membrane (against the background of functional occlusion of the auditory tube);
• secretory (increased activity of goblet cells and epithelial metaplasia):
• degenerative (decreased secretion and development of an adhesive process in the tympanic cavity).

O.V. Stratieva et al. (1998) distinguish four stages of exudative otitis media:

• initial exudative (initial catarrhal inflammation);
• pronounced secretory; according to the nature of the secretion, it is divided into:
  • serous;
  • mucosal (mucoid):
  • serous-mucosal (serous-mucoid);
• productive secretory (with a predominance of the secretory process);
• degenerative-secretory (with a predominance of the fibrous-sclerotic process);

According to form, there are:

• fibro-mucoid;
• fibrocystic;
• fibrous-adhesive (sclerotic),

Dmitriev N.S. et al. (1996) proposed a variant based on similar principles (the nature of the contents of the tympanic cavity by physical parameters - viscosity, transparency, color, density), and the difference lies in determining the tactics of treating patients depending on the stage of the disease. Pathogenetically, IV stages of the course are distinguished:

• catarrhal (up to 1 month);
• secretory (1-12 months);
• mucosal (12-24 months);
• fibrous (more than 24 months).

Treatment tactics for stage I exudative otitis media: sanitation of the upper respiratory tract; in case of surgical intervention, audiometry and tympanometry are performed 1 month after the operation. If hearing loss persists and a type C tympanogram is registered, measures are taken to eliminate the dysfunction of the auditory tube. Timely therapy at the catarrhal stage leads to a rapid cure of the disease, which in this case can be interpreted as tubootitis. In the absence of therapy, the process moves to the next stage.

Treatment tactics for stage II of exudative otitis media: sanitation of the upper respiratory tract (if not performed earlier); myringostomy in the anterior parts of the eardrum with the introduction of a ventilation tube. The stage of exudative otitis media is verified intraoperatively: at stage II, the exudate is easily and completely removed from the tympanic cavity through the myringostomy opening.

Treatment tactics for stage III exudative otitis media: simultaneous sanitation of the upper respiratory tract with shunting (if not performed earlier); tympanostomy in the anterior parts of the eardrum with insertion of a ventilation tube, tympanotomy with revision of the tympanic cavity, washing and removal of thick exudate from all parts of the tympanic cavity. Indications for simultaneous tympanotomy - impossibility of removing thick exudate through tympanostomy.

Treatment tactics for stage IV exudative otitis media: sanitation of the upper respiratory tract (if not performed earlier): tympanostomy in the anterior parts of the eardrum with the insertion of a ventilation tube; one-stage tympanotomy with removal of tympanosclerotic foci; mobilization of the auditory ossicular chain.

This classification is an algorithm for diagnostic, therapeutic and preventive measures.

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Diagnostics exudative otitis media

Early diagnostics is possible in children over 6 years of age. At this age (and older), complaints of ear congestion and hearing fluctuation are likely. Painful sensations are rare and short-lived.

Physical examination

On examination, the color of the eardrum is variable - from whitish, pink to cyanotic against the background of increased vascularization. Air bubbles or a level of exudate behind the eardrum can be detected. The latter is usually retracted, the light cone is deformed, the short process of the malleus sharply protrudes into the lumen of the external auditory canal. The mobility of the retracted eardrum in exudative otitis media is sharply limited, which is quite easy to determine using a pneumatic Zigls funnel. Physical data vary depending on the stage of the process.

During otoscopy at the catarrhal stage, retraction and limited mobility of the eardrum, a change in its color (from cloudy to pink), and a shortening of the light cone are detected. Exudate behind the eardrum is not visible, but prolonged negative pressure due to impaired aeration of the cavity creates conditions for the appearance of contents in the form of transudate from the vessels of the nasal mucosa.

During otoscopy at the secretory stage, thickening of the eardrum, change in its color (to bluish), retraction in the upper and bulging in the lower sections are detected, which is considered an indirect sign of the presence of exudate and the tympanic cavity. Metaplastic changes appear and increase in the mucous membrane in the form of an increase in the number of secretory glands and goblet cells, which leads to the formation and accumulation of mucous exudate, and the tympanic cavity.

The mucous stage is characterized by persistent hearing loss. Otoscopy reveals a sharp retraction of the eardrum in the relaxed part, its complete immobility, thickening, cyanosis and bulging in the lower quadrants. The contents of the tympanic cavity become thick and viscous, which is accompanied by limited mobility of the auditory ossicle chain.

During otoscopy at the fibrous stage, the eardrum is thinned, atrophic, and pale. Long-term exudative otitis media leads to the formation of scars and atelectasis, foci of myringosclerosis.

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Instrumental research

The fundamental diagnostic method is tympanometry. When analyzing tympanograms, the classification of B. Jerger is used. In the absence of middle ear pathology in a normally functioning auditory tube, the pressure in the tympanic cavity is equal to atmospheric pressure, therefore, the maximum compliance of the eardrum is recorded when creating a pressure in the external auditory canal equal to atmospheric pressure (taken as the initial pressure). The resulting curve corresponds to a type A tympanogram.

In case of dysfunction of the auditory tube, the pressure in the middle ear is negative. Maximum compliance of the eardrum is achieved by creating a negative pressure in the external auditory canal equal to that in the tympanic cavity. In such a situation, the tympanogram retains its normal configuration, but its peak shifts toward negative pressure, which corresponds to a type C tympanogram. In the presence of exudate in the tympanic cavity, a change in pressure in the external auditory canal does not lead to a significant change in compliance. The tympanogram is represented by a flat or horizontally ascending line toward negative pressure and corresponds to type B.

When diagnosing exudative otitis media, data from tonal threshold audiometry are taken into account. The decrease in hearing function in patients develops according to the inductive type, the thresholds of sound perception are within 15-40 dB. Hearing impairment is fluctuating in nature, therefore, during dynamic observation of a patient with exudative otitis media, a repeated hearing test is necessary. The nature of the air conduction curve on the audiogram depends on the amount of exudate in the tympanic cavity, its viscosity and the value of intratympanic pressure.

In tonal threshold audiometry at the catarrhal stage, the thresholds of air conduction do not exceed 20 dB, bone conduction - remain normal. Violation of the ventilation function of the auditory tube corresponds to a tympanogram of type C with a peak deviation towards negative pressure up to 200 mm H2O. In the presence of transudate, a tympanogram of type B is determined, more often occupying an intermediate position between types C and B: a positive knee repeats type C, a negative knee - type B.

In tone threshold audiometry at the secretory stage, conductive hearing loss of the first degree is detected with an increase in air conduction thresholds to 20-30 dB. Bone conduction thresholds remain normal. In acoustic impedancemetry, a type C tympanogram can be obtained with a negative pressure in the tympanic cavity over 200 mm H2O, but type B and the absence of acoustic reflexes are more often recorded.

The mucosal stage is characterized by an increase in air conduction thresholds to 30-45 dB with tonal threshold audiometry. In some cases, bone conduction thresholds increase to 10-15 dB in the high-frequency range, which indicates the development of secondary NST, mainly due to blockade of the labyrinth windows by viscous exudate. Acoustic impedancemetry records a type B tympanogram and the absence of acoustic reflexes on the affected side.

At the fibrous stage, a mixed form of hearing loss progresses: air conduction thresholds increase to 30-50 dB, bone conduction thresholds to 15-20 dB in the high-frequency range (4-8 kHz). Impedance analysis records a type B tympanogram and the absence of acoustic reflexes.

It is necessary to pay attention to the possible correlation of otoscopic signs and the type of tympanogram. Thus, with retraction of the eardrum, shortening of the light reflex, change in the color of the eardrum, type C is more often recorded. In the absence of a light reflex, with thickening and cyanosis of the eardrum, bulging in the lower quadrants, translucence of the exudate, type B tympanogram is determined.

Endoscopy of the pharyngeal opening of the auditory tube can reveal a hypertrophic granulation obstructive process, sometimes in combination with hyperplasia of the inferior turbinates. This study provides the most complete information on the causes of exudative otitis media. Endoscopy can reveal a fairly wide variety of pathological changes in the nasal cavity and nasopharynx, leading to dysfunction of the auditory tube and maintaining the course of the disease. A study of the nasopharynx should be carried out in case of a relapse of the disease to clarify the cause of exudative otitis media and develop adequate treatment tactics.

X-ray examination of the temporal bones in classical projections in patients with exudative otitis media is uninformative and is practically not used.

CT of the temporal bones is a highly informative diagnostic method; it should be performed in case of relapse of exudative otitis media, as well as at stages III and IV of the disease (according to the classification of N.S. Dmitriev). CT of the temporal bones allows obtaining reliable information about the airiness of all cavities of the middle ear, the condition of the mucous membrane, the windows of the labyrinth, the chain of auditory ossicles, the bony part of the auditory tube. In the presence of pathological contents in the cavities of the middle ear - its localization and density.

Differential diagnosis

Differential diagnostics of exudative otitis media is carried out with ear diseases accompanied by conductive hearing loss with an intact eardrum. These may be:

• anomalies in the development of the auditory ossicles, in which a type B tympanogram is sometimes recorded, a significant increase in air conduction thresholds (up to 60 dB), and hearing loss from birth. The diagnosis is finally confirmed after multifrequency tympanometry;
• otosclerosis, in which the otoscopic picture corresponds to the norm, and tympanometry records a type A tympanogram with a flattening of the tympanometry curve.

Sometimes it is necessary to differentiate exudative otitis media from a glomus tumor of the tympanic cavity and a rupture of the auditory ossicular chain. The diagnosis of a tumor is confirmed by X-ray data, the disappearance of noise when the vascular bundle on the neck is compressed, and a pulsating tympanogram picture. When the auditory ossicular chain is ruptured, a type E tympanogram is recorded.

Treatment exudative otitis media

Treatment tactics for patients with exudative otitis media: elimination of the causes that caused the dysfunction of the auditory tube, and then implementation of therapeutic measures aimed at restoring hearing function and preventing persistent morphological changes in the middle ear. In case of dysfunction of the auditory tube caused by pathology of the nose, paranasal sinuses and pharynx, the first stage of treatment should be sanitation of the upper respiratory tract.

The goal of treatment is to restore hearing function.

Indications for hospitalization

• The need for surgical intervention.
• Impossibility of carrying out conservative treatment on an outpatient basis.

Non-drug treatment

Inflation of the auditory tube:

• catheterization of the auditory tube;
• Politzer blowing;
• Valsalva's maneuver.

In the treatment of patients with exudative otitis media, physiotherapy is widely used - intra-aural electrophoresis with proteolytic enzymes, steroid hormones. Endaural phonophoresis of acetylcysteine is preferred (8-10 procedures per course of treatment at stages I-III), as well as on the mastoid process with hyaluronidase (8-10 sessions per course of treatment at stages II-IV).

Drug treatment

In the second half of the last century, it was proven that inflammation in the middle ear with exudative otitis media in 50% of cases is aseptic. The rest were patients in whom Haemophilus influenzae, Branhamella catarrhalis, Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes were isolated from the exudate, therefore, as a rule, antibacterial therapy is carried out. Antibiotics of the same series as in the treatment of acute otitis media (amoxicillin + clonulanic acid, macrolides) are used. However, the issue of including antibiotics in the treatment regimen for exudative otitis media remains debatable. Their effect is only 15%, taking them in combination with tablet glucocorticoids (for 7-14 days) increases the result of therapy only to 25%. Nevertheless, most foreign researchers consider the use of antibiotics to be justified. Antihistamines (diphenhydramine, chloropyramine, quifenadine), especially in combination with antibiotics, inhibit the formation of vaccine immunity and suppress non-specific anti-infective resistance. Many authors recommend anti-inflammatory (fenspiride), anti-edematous, non-specific complex hyposensitizing therapy, and the use of vasoconstrictors for the treatment of the acute stage. Children with stage IV exudative otitis media are given hyaluronidase in parallel with physiotherapy at a dose of 32 U for 10-12 days. In everyday practice, mucolytics in the form of powders, syrups, and tablets (acetylcysteine, carbocysteine) are widely used to liquefy exudate in the middle ear. The course of treatment is 10-14 days.

An essential condition of conservative therapy of exudative otitis media is an assessment of the results of immediate treatment and control after 1 month. For this purpose, threshold audiometry and acoustic impedancemetry are performed.

Surgical treatment

In case of ineffectiveness of conservative therapy, patients with chronic exudative otitis media undergo surgical treatment, the purpose of which is to remove exudate, restore hearing function and prevent relapse of the disease. Otosurgical intervention is performed only after or during sanitation of the upper respiratory tract.

Myringotomy

Advantages of the method:

• rapid equalization of tympanic pressure;
• rapid evacuation of exudate.

Flaws:

• inability to remove thick exudate;
• rapid closure of the myringotomy opening;
• high recurrence rate (up to 50%).

In connection with the above, the method is considered a temporary treatment procedure. Indication - exudative otitis media in the stage during surgical intervention aimed at sanitizing the upper respiratory tract. Tympanopuncture has the same disadvantages as myringotomy. The use of methods should be discontinued due to their ineffectiveness and high risk of complications (trauma to the auditory ossicles, labyrinth windows).

Tympakostoma with insertion of a ventilation tube

The idea of tympanostomy was first put forward by P. Politzer and Delby in the 19th century, but only A. Armstrong introduced shunting in 1954. He used a straight spear-shaped polyethylene tube with a diameter of 1.5 mm, leaving it for 3 weeks in a patient with exudative otitis media that did not resolve after conservative therapy and myringotomy. Later, otologists improved the design of ventilation tubes, using better materials for their manufacture (Teflon, silicone, silastic, steel, gold-plated silver and titanium). Clinical studies, however, did not reveal significant differences in the effectiveness of treatment when using different materials. The design of the tubes depended on the treatment goals. At the initial stages, tubes for short-term ventilation (6-12 weeks) of A. Armstrong, M. Shepard, A. Reiter-Bobbin were used. Patients treated with these tubes (the so-called shot-term tubes), who are indicated for repeated tympanostomy, are candidates for surgery using long-term tubes (the so-called long-term tubes) of K. Leopold. V. McCabe. This group of patients also includes children with craniofacial anomalies, pharyngeal tumors after palate resection or irradiation.

Currently, long-term tubes are made of silastic with a large medial flange and flexible keels for easier insertion (J. Per-lee, T-shaped, made of silver and gold, titanium). Spontaneous loss of long-term tubes occurs extremely rarely (for the Per-lee modification - in 5% of cases), the duration of wearing is up to 33-51 weeks. The frequency of loss depends on the rate of migration of the epithelium of the tympanic membrane. Many otosurgeons prefer tympanostomy in the anterior-inferior quadrant, while K. Leopold et al. noted that tubes of the Shepard modification are preferable to be inserted into the anterior-inferior quadrant, and Renter-Bobbin type - into the anterior-inferior quadrant. I.B. Soldatov (1984) suggests shunting the tympanic cavity through an incision in the skin of the external auditory canal on a limited section of its posteroinferior wall by separating it together with the eardrum, installing a polyethylene tube through this access. Some domestic authors form a myringostomy opening in the posteroinferior quadrant of the eardrum using carbon dioxide laser energy. In their opinion, the opening, gradually decreasing in size, completely closes after 1.5-2 months without signs of rough scarring. Low-frequency ultrasound is also used for myringotomy, under the action of which biological coagulation of the edges of the incision occurs, as a result of which there is practically no bleeding, the likelihood of infection decreases.

Myringotomy with insertion of a ventilation tube in the anterior upper quadrant

Equipment: operating microscope, ear funnels, straight and curved microneedles, microraspatory, microforcept, micro tips for suction with diameters of 0.6:1.0 and 2.2 mm. The operation is performed on children under general anesthesia, on adults - under local anesthesia.

The surgical field (parotid space, auricle and external auditory canal) is processed according to generally accepted rules. The epidermis is dissected with a curved needle in front of the handle in the anterior-superior quadrant of the eardrum, peeled off from the middle layer. The circular fibers of the eardrum are dissected, and the radial ones are moved apart with a microneedle. If these conditions are correctly observed, the myringotomy opening acquires a shape, the dimensions of which are adjusted with a microraspatory in accordance with the caliber of the ventilation tube.

After mningotomy, the exudate is removed from the tympanic cavity by suction: the liquid component - without difficulty in full; the viscous component - by liquefying it by introducing enzyme and mucolytic solutions (trypsin/chymotrypsin, acetylcysteine) into the tympanic cavity. Sometimes it is necessary to repeatedly perform this manipulation until the exudate is completely removed from all parts of the tympanic cavity. In the presence of mucoid exudate that cannot be evacuated, a ventilation tube is installed.

The tube is taken by the flange with microforceps, brought to the myringotomy opening at an angle, and the edge of the second flange is inserted into the lumen of the myringostomy. The microforceps are removed from the external auditory canal, and a curved microneedle, pressing on the cylindrical part of the tube at the border with the second flange located outside the eardrum, fixes it in the myringotomy opening. After the procedure, the cavity is washed with a 0.1% dexamethasone solution, 0.5 ml is injected with a syringe: the pressure in the external auditory canal is increased using a rubber bulb. If the solution passes freely into the nasopharynx, the operation is completed. If the auditory tube is obstructed, the drug is aspirated and vasoconstrictors are injected; the pressure in the external auditory canal is again increased using a rubber bulb. Such manipulations are repeated until the auditory tube is patency is achieved. With this technique, there is no spontaneous, untimely removal of the tube due to its tight fit between the flanges of the radial fibers of the middle layer of the eardrum.

By installing drainage in the anterior-superior part of the eardrum, it is possible not only to achieve optimal ventilation of the tympanic cavity, but also to avoid possible injury to the auditory ossicle chain, which is possible when fixing the tube in the posterior-superior quadrant. In addition, with this type of introduction, the risk of complications in the form of atelectasis and myringosclerosis is lower, and the tube itself has a minimal effect on sound conduction. The ventilation tube is removed according to indications at different times, depending on the restoration of the patency of the auditory tube according to the results of tympanometry.

The localization of the myringostomy incision may vary: 53% of otolaryngologists place the tympanostomy in the posteroinferior quadrant, 38% in the anteroinferior quadrant, 5% in the anterosuperior quadrant, and 4% in the posterosuperior quadrant. The latter option is contraindicated due to the high probability of injury to the auditory ossicles, formation of a retraction pocket, or perforation in this area, which leads to the development of the most pronounced hearing loss. The lower quadrants are preferable for placing the tympanostomy due to the lower risk of injury to the promontory wall. In cases of generalized atelectasis, the only possible site for inserting the ventilation tube is the anterosuperior quadrant.

Shunting of the tympanic cavity in exudative otitis media is highly effective in terms of removing exudate, improving hearing and preventing relapse only at stage II (serous) (according to the classification of N.S. Dmitriev et al.) subject to dispensary observation for 2 years.

Tympanotomy

After tympanostomy is applied in the anterosuperior quadrant of the eardrum, 1% lidocaine is injected at the border of the posterior superior wall of the external auditory canal to facilitate separation of the meatotympanic flap. Using a pulverizing knife under magnification of an operating microscope, the skin of the external auditory canal is cut, retreating 2 mm from the tympanic ring along the posterior superior wall in the direction from 12 to 6 o'clock according to the clock face pattern. The meatal flap is separated with a microraspatory, and the tympanic ring with the eardrum is isolated with a curved needle. The entire resulting complex is retracted anteriorly until a good view of the labyrinth windows, promontory wall and auditory ossicles is achieved; access to the hypotympanum and epitympanic recess. The exudate is removed by suction, the tympanic cavity is washed with acetylcysteine (or enzyme), after which the discharge is evacuated again. Particular attention is paid to the epitympanic recess and the coccoid-malleoral joint located in it, since it is in this place that a muff-shaped deposit of formed exudate is often observed. At the end of the manipulation, the tympanic cavity is washed with a dexamethasone solution. The meatotympanic flap is put back in place and fixed with a strip of rubber from a surgical glove.

Further management

If a ventilation tube is installed, the patient is warned about the need to protect the operated ear from water. After its removal, they are informed about the possibility of recurrence of exudative otitis media and the need to visit an audiologist-otorhinolaryngologist after any episode of inflammatory disease of the nose and upper respiratory tract.

Audiological monitoring is performed one month after surgical treatment (otoscopy, otomicroscopy, and, if indicated, assessment of the patency of the auditory tube). When hearing acuity and the function of the auditory tube are normalized, the ventilation tube is removed after 2-3 months.

After the treatment, long-term, careful and competent dispensary observation by an otolaryngologist and audiologist is necessary, since the disease tends to recur. It seems rational to differentiate the nature of observation of patients according to the established stage of exudative otitis media.

In case of stage I, after the first stage of treatment and in stage II, the first examination with audiometric control should be carried out 1 month after the sanitation of the upper respiratory tract. Among the features in children, it is possible to note the appearance of a crescent-shaped spot in the anterior quadrants of the eardrum and the registration of a type C tympanogram with acoustic impedancemetry. Observation of children in the future should be carried out once every 3 months for 2 years.

After the tympanic cavity shunting, the first examination of the patient should also be carried out 1 month after discharge from the hospital. From the otoscopy indicators, attention should be paid to the degree of infiltration of the eardrum and its color. Based on the results of tympanometry in the mode of studying the patency of the auditory tube, one can judge the degree of its restoration. In the future, audiological monitoring is carried out once every 3 months for 2 years.

At the sites of insertion of ventilation tubes in patients with stages II and III of exudative otitis media, myringosclerosis may occur.

During otoscopy in patients with stage IV exudative otitis media, one can expect the appearance of atelectasis of the eardrum, perforations, secondary NST. In the presence of these complications, courses of resorption, simulating and improving microcirculation therapy should be carried out: injections of hyaluronidase, FiBS, vitreous body intramuscularly in an age-appropriate dose, phonophoresis with hyaluronidase endaurally (10 procedures).

At all stages of cured exudative otitis media, the patient or his parents are warned about mandatory audiological monitoring after episodes of prolonged rhinitis of any etiology or inflammation of the middle ear, since these conditions can provoke an exacerbation of the disease, the untimely diagnosis of which leads to the development of a more severe stage.

American otolaryngologists recommend monitoring patients with exudative otitis media with a preserved type B tympanogram for no more than 3-4 months. Then tympanostomy is indicated.

In cases of relapse of the disease, before repeated surgical intervention, it is recommended to perform CT of the temporal bones in order to assess the condition of the auditory tube, verify the presence of exudate in all cavities of the middle ear, the integrity of the chain of auditory ossicles, and exclude the cicatricial process of the tympanic cavity.

Approximate periods of incapacity depend on the stage of the disease and range from 6 to 18 days.

Prevention

Prevention of exudative otitis media is timely sanitation of the upper respiratory tract.

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Forecast

Dynamics in stage I of the disease and adequate treatment lead to complete recovery of patients. Primary diagnostics of exudative otitis media in stages II and later and, as a consequence, late initiation of therapy lead to a progradient increase in the number of unfavorable outcomes. Negative pressure, restructuring of the mucous membrane in the tympanic cavity cause changes in the structure of both the eardrum and the mucous membrane. Their primary changes create prerequisites for the development of retractions and attelectasis, mucositis, immobilization of the auditory ossicular chain, blockade of the labyrinthine windows.

• Atelectasis is a retraction of the eardrum due to long-term dysfunction of the auditory tube.
• Atrophy is a thinning of the eardrum, accompanied by a weakening or cessation of its function due to inflammation.
• Myringosclerosis is the most common outcome of exudative otitis media: it is characterized by the presence of white formations of the eardrum, located between the epidermis and the mucous membrane of the latter, developing due to the organization of exudate in the fibrous layer. During surgical treatment, the lesions are easily separated from the mucous membrane and epidermis without bleeding.
• Retraction of the tympanic membrane. Occurs as a result of prolonged negative pressure in the tympanic cavity, can be localized both in the unstretched part (panflaccida) and in the stretched part (pars tensa), and can be limited and diffuse. An atrophic and retracted tympanic membrane sags. Retraction precedes the formation of a retraction pocket.
• Perforation of the eardrum.
• Adhesive otitis media. Characterized by scarring of the eardrum and proliferation of fibrous tissue in the tympanic cavity, immobilization of the chain of auditory ossicles, which leads to atrophic changes in the latter, up to necrosis of the long process of the incus.
• Tympanosclerosis is the formation of tympanosclerotic foci in the tympanic cavity. They are most often located in the epitympanum, around the auditory ossicles and in the niche of the vestibular window. During surgical intervention, tympanosclerotic foci are separated from the surrounding tissues without bleeding.
• Hearing loss. Manifested by conductive, mixed and neurosensory forms. Conductive and mixed, as a rule, are caused by immobilization of the auditory ossicle chain by scars and tympanosclerotic foci. HCT is a consequence of intoxication of the inner ear and blockage of the labyrinthine windows,

The listed complications can be isolated or in various combinations.

The development of a treatment algorithm for patients depending on the stage of exudative otitis media allowed to achieve restoration of hearing function in most patients. At the same time, observations of children with exudative otitis media for 15 years showed that 18-34% of patients develop relapses. Among the most significant reasons are the persistence of manifestations of chronic disease of the mucous membrane of the nasal cavity and late start of treatment.

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