Exudative otitis media

The average otitis (secretory or nonnegative otitis media) is 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 syndrome, with a preserved eardrum.

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

Epidemiology

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

Over the past decade, a number of domestic authors have noted a significant increase in morbidity. Probably, there is not an actual increase in diagnostics, but an improvement in diagnostics as a result of equipping the surdological offices and centers with surdoacoustic equipment and introducing objective research techniques (impedanceometry, acoustic reflexometry) into practical public health.

[6], [7], [8], [9], [10], [11], [12], [13]

Causes of the exudative otitis media

The most common theories of development of exudative otitis media:

• "hydrops ex vacuo", proposed by A. Politzer (1878), according to which the underlying cause of the disease, contributing to the development of negative pressure in the cavities of the middle ear;
• exudative, explaining the secretion of a secretion in the tympanum by inflammatory changes in the mucosa of the middle ear;
• secretory, based on the results of the study of factors that contribute to the hypersecretion of the mucosa of the middle ear.

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

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

[14], [15]

Pathogenesis

Endoscopic examination in patients with auditory tube dysfunction shows that the cause of exudative otitis media in most cases is violation of the outflow of secretions from the paranasal sinuses, primarily from the anterior chamber (maxillary, frontal, anterior lattice), into the nasopharynx. Normally, the transport goes through the grating funnel and the frontal pocket to the free edge of the posterior part of the hook-shaped process, then onto the medial surface of the inferior nasal concha with the bypass of the mouth of the auditory tube in front and below; and from the rear latticed cells and the sphenoid sinus - from behind and above the tubular aperture, merging in the oropharynx under the influence of gravity. With vasomotor diseases and sharply increased viscosity of the secretion, mucociliary clearance is slowed. In this case, the merging of flows to the tubular aperture or pathological vortices with secretion circulation around the mouth of the auditory tube with pathological reflux into its pharyngeal estuary is noted. With hyperplasia of adenoid vegetations, the path of the posterior flow of mucus is mixed forward, also to the mouth of the auditory tube. Changes in the natural pathways of outflow may be due to a change in the architectonics of the nasal cavity, especially the middle nasal passage and the lateral wall of the nasal cavity.

In acute purulent sinusitis (especially sinusitis) and due to a change in the viscosity of the secretion, the natural outflow from the paranasal sinuses is also violated, which leads to the discharge of the discharge to 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 falls and, as a consequence, there appears a transudate. Subsequently, the number of goblet cells increases, in the mucous membrane of the tympanic cavity mucous glands form, which leads to an increase in the volume of secretion. The latter is easily removed from all parts through the tympanostoma. 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 an exudate, which is already more difficult or impossible to evacuate through tympanostoma. At the fibrous stage, degenerative processes predominate in the mucosa of the tympanic cavity: goblet cells and secretory glands undergo degeneration, the production of mucus decreases, then ceases completely, fibrous transformation of the mucosa begins with involvement of the auditory ossicles. The predominance in the exudate of the elemental elements leads to the development of the adhesive process, and the increase in the formless ones leads to the development of tympanic sclerosis.

Undoubtedly, inflammatory and allergic pathology of the upper respiratory tract, changes in local and general immunity affect the development of the disease and play an important role in the development of a recurrent form of chronic exudative otitis media.

The trigger mechanism, as mentioned above, is the dysfunction of the auditory tube, which may be due to mechanical obstruction of its pharyngeal mouth. More often it occurs with hypertrophy of the pharyngeal tonsil, juvenile angiofibroma. Obstruction occurs also with inflammation of the mucous membrane of the auditory tube, provoked by a bacterial and viral infection of the upper respiratory tract and accompanied by a secondary edema.

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

Symptoms of the exudative otitis media

Malosymptomnoe course of exudative otitis media is the reason for the late establishment of the diagnosis, especially in young children. The disease is often preceded by the pathology of the upper respiratory tract (acute or chronic). Characterized by a decrease in hearing.

[21], [22], [23]

Forms

Currently, the mediative otitis media for the duration of the disease is divided into three forms

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

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

In accordance with the pathogenesis of the disease, various classifications of its stages have been adopted. M. Tos (1976) identifies three periods of development of maxedative otitis media:

• primary or stage of initial metaplastic changes in the mucosa (on the background of functional occlusion of the auditory tube);
• secretory (increased activity of goblet cells and metaplasia of the epithelium):
• degenerative (decrease in secretion and development of adhesive process in the tympanic cavity).

O.V. Strathieva et al. (1998) distinguish four stages of maximal otitis media:

• initial exudative (initial catarrhal inflammation);
• pronounced secretory; by the nature of the secret subdivide into:
  • serous;
  • mucous (mucoid):
  • serous-mucous (serous-mucoid);
• productive secretory (with predominance of secretory process);
• degenerative-secretory (with predominance of fibro-sclerotic process);

In the form of:

• fibrotic and mucoid;
• fibro-cystic;
• fibro-adhesion (sclerotic),

Dmitriev N.S. Et al. (1996) proposed a version based on similar principles (the nature of the contents of the drum 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 the IV stages of the course are distinguished:

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

Therapeutic tactics at the first stage of chronic otitis media: sanitation of the upper respiratory tract; in the case of surgical intervention after 1 month. After the operation, audiometry and tympanometry are performed. With preservation of hearing loss and registration tympanograms of type C, measures are taken to eliminate auditory tube dysfunction. Timely initiation of therapy at the catarral stage leads to a rapid cure of the disease, which in this case can be interpreted as tubo-otitis. In the absence of therapy, the process goes on to the next stage.

Therapeutic tactics at the second stage of maxigative otitis media: sanitation of the upper respiratory tract (if not previously performed); myringostomy in the anterior parts of the tympanic membrane with the introduction of a vent tube. Iptraoperatively verify the stage of maxedative otitis media: at stage II, the exudate is easily and completely removed from the tympanic cavity through the myrrhostomy hole.

Therapeutic tactics at the third stage of maxigative otitis media: one-stage with bypass surgery, sanitation of the upper respiratory tract (if not previously performed); tympanostomy in the anterior parts of the tympanic membrane with the introduction of a vent tube, tympanotomy with revision of the tympanum, washing and removal of a dense exudate from all parts of the tympanum. Indications for one-stage tympanotomy - the impossibility of removing a thick exudate through the tympanostoma.

Therapeutic tactics in the IV stage of exudative otitis media: sanitation of the upper respiratory tract (if not previously performed): tympanostomy in the anterior eardrum with the introduction of a vent tube; one-stage tympanotomy with removal of tympanosclerotic foci; mobilization of the auditory ossicles.

This classification - the algorithm of diagnostic, therapeutic and preventive measures.

[24], [25], [26], [27], [28], [29], [30], [31], [32]

Diagnostics of the exudative otitis media

Early diagnosis is possible in children older than 6 years. At this age (and older), complaints about ear congestion, hearing fluctuation are likely. Pain sensations are rare, short-lived.

Physical examination

When examined, the color of the tympanic membrane is variable - from whitish, pink to cyanotic, against the background of increased vascularity. You can detect air bubbles or the level of exudate behind the tympanic membrane. The latter, as a rule, is 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 tympanic membrane with exudative otitis media is severely limited, which is fairly easy to determine with the Siegles pneumatic funnel. The physical data vary depending on the stage of the process.

With otoscopy at the catarral stage, the retraction and restriction of the mobility of the tympanic membrane, the change in its color (from turbid to pink), and the shortening of the light cone are revealed. Exudate behind the tympanic membrane is not visible, but the long negative pressure due to a violation of the aeration of the cavity creates the conditions for the appearance of the contents in the form of transudate from the vessels of the nasal mucosa.

With otoscopy at the secretory stage, a thickening of the tympanic membrane, a change in its color (to the cyanotic), an upward swelling and a swelling in the lower parts are revealed, which is considered an indirect sign of the presence of exudate and the tympanum. In the mucous membrane, metaplastic changes appear and increase 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.

A mucosal stage is characterized by persistent hearing loss. With otoscopy, a sharp drag of the tympanic membrane in the unstretched part is revealed, its complete immobility, thickening, cyanosis and bulging in the lower quadrants. The contents of the tympanum become thick and viscous, which is accompanied by a restriction of the mobility of the auditory ossicles.

With otoscopy at the fibrous stage, the tympanic membrane is thinned, atrophic, pale in color. A prolonged course of exudative otitis media leads to the formation of scars and atelectasis, the foci of myringosclerosis.

[33], [34], [35], [36], [37],

Instrumental research

The basic diagnostic approach is tympanometry. In the analysis of 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 the atmospheric pressure, so the maximum compliance of the tympanic membrane is recorded when the pressure in the external ear canal is equal to atmospheric pressure (taken as the initial one). The resulting curve corresponds to a tympanogram of type A.

With auditory tube dysfunction in the middle ear, the pressure is negative. The maximum compliance of the tympanic membrane is achieved by creating and external auditory passage of a negative pressure equal to that in the tympanic cavity. The tympanogram in this situation maintains a normal configuration, but its peak shifts to negative pressure, which corresponds to a tympanogram of type C. In the presence of exudate in the tympanic cavity, a change in pressure in the external auditory meatus does not lead to a significant change in compliance. The tympanogram is represented by an even or horizontally rising line in the direction of the negative pressure and corresponds to type B.

When diagnosing exudative otitis media, the tone threshold audiometry data is taken into account. The decrease in auditory function in patients develops by inductive type, the thresholds of perception of sound lie in the range 15-40 dB. Hearing impairment is of a fluctuating nature, therefore, during dynamic observation of the patient with exudative otitis media, repeated examination of the hearing 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 magnitude of the intratampal pressure.

At the threshold threshold audiometry at the catarral stage, airborne sound thresholds do not exceed 20 dB, bone - remain normal. The violation of the ventilation function of the auditory tube corresponds to a tympanogram of type C with a deviation of the peak towards the negative pressure to 200 mm of water. In the presence of transudate, a tympanogram of type B is determined, which often occupies the middle position between types C and B: the positive knee repeats the type C. Negative - type B.

With tonal threshold audiometry at the secretory stage, conductive hearing loss of the first degree is detected with an increase in air sounding thresholds to 20-30 dB. Thresholds of bone sound conduction remain normal. With acoustic impedance, a Type C tympanogram with a negative pressure in the drum cavity of more than 200 mm H 2 O can be obtained, however, type B and absence of acoustic reflexes are more often recorded.

The mucosal stage is characterized by an increase in the thresholds of air sound conduction to 30-45 dB with a tone threshold audiometry. In some cases, the thresholds of bone sound increase to 10-15 dB in the high-frequency range, which indicates the development of secondary NST, mainly due to blockade of the windows of the labyrinth with viscous exudate. With acoustic impedance measurement, a Type B tympanogram is recorded and the absence of acoustic reflexes on the side of the lesion.

At the fibrous stage, a mixed form of hearing loss progresses: the airborne sound thresholds increase to 30-50 dB, the bone level - up to 15-20 dB in the high-frequency range (4-8 kHz). During impedance measurement, a tympanogram of type B and a lack of acoustic reflexes are recorded.

Attention should be paid to the possible correlation of otoscopic features and tympanogram type. Thus, with tympanic membrane retraction, shortening of the light reflex, discoloration of the tympanic membrane, type C is often recorded. In the absence of a light reflex, with thickening and cyanosis of the tympanic membrane, its bulging in the lower quadrants, and translucence of the exudate, type B tympanograms are determined.

When endoscopy of the pharyngeal opening of the auditory tube, a hypertrophic granulation obstructive process can be detected, sometimes in combination with hyperplasia of the inferior nasal concha. It is this study that gives the most complete information about the causes of exudative otitis media. With the help of endoscopy, it is possible to identify a sufficiently wide variety of pathological changes in the nasal cavity and nasopharynx, leading to dysfunction of the auditory tube and supporting the course of the disease. The research of the nasopharynx should be carried out with the relapse of the disease in order to clarify the cause of the occurrence of exudative otitis media and the development of adequate therapeutic tactics.

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

CT of temporal bones is a highly informative diagnostic method; it must be performed with relapse of exudative otitis media, and also in stages III and IV of the disease (according to NS Dmitriev's classification). CT of the temporal bones allows to obtain reliable information on the airiness of all the cavities of the middle ear, the state of the mucous membrane, the windows of the labyrinth, the chain of the auditory ossicles, the bone section of the auditory tube. In the presence of pathological contents and cavities of the middle ear - its localization and density.

Differential diagnosis

Differential diagnosis of exudative otitis media is performed with ear diseases. Accompanied by conductive hearing loss in the intact tympanic membrane. It can be:

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

Sometimes there is a need to differentiate exudative otitis media with a glomus tumor of the tympanic cavity and rupture of the auditory ossicles. The diagnosis of the tumor is confirmed by radiographic data, the disappearance of noise when the vascular bundle is compressed on the neck, and also by the pulsating picture of thymnograms. When a chain of auditory ossicles is ruptured, a tympanogram of type E is recorded.

Treatment of the exudative otitis media

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

The purpose of the treatment is the restoration of the auditory function.

Indications for hospitalization

• The need for surgical intervention.
• Impossibility of conservative treatment in outpatient settings.

Non-drug treatment

Blowing out the auditory tube:

• catheterization of the auditory tube;
• blowing on the Politzer;
• the Valsalva experience.

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

Medication

In the second half of the last century, it was proved that inflammation in the middle ear with an average age of otitis media is aseptic in 50% of cases. The rest consisted of patients who had Haemophilus influenzae, Branhamella catarrhalis, Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes from the exudate, therefore, antibacterial therapy is usually performed. Use antibiotics of the same series as in the treatment of acute otitis media (amoxicillin + clanulanic acid, macrolides). However, the issue of including exudative otitis media antibiotics in the therapy scheme remains controversial. Their effect is only 15%, taking in combination with tableted glucocorticoids (for 7-14 days) increasing the result of therapy only to 25%. Nevertheless, most foreign researchers use antibiotics as justified. Antihistamines (diphenhydramine, chloropyramine, hifenadine), especially in combination with antibiotics, inhibit the formation of vaccinal immunity and suppress non-specific anti-infective resistance. Many authors recommend the anti-inflammatory (fenspiride), anti-edema, nonspecific complex hyposensitizing therapy, the use of vasoconstrictors for acute stage treatment. Children with IV stage of exudative otitis media in parallel with physiotherapeutic treatment are administered hyaluronidase at 32 units for 10-12 days. In everyday practice, mucolytics in the form of powders, syrups and tablets (acetylcysteine, carbocysteine) are widely used to dilute the exudate in the middle ear. The course of treatment is 10-14 days.

An indispensable condition for conservative treatment of exudative otitis media is evaluation of the results of direct treatment and control after 1 month. To do this, threshold audiometry and acoustic impedance measurements are carried out.

Surgery

In case of ineffectiveness of conservative therapy, patients with chronic exudative otitis media undergo surgical treatment, whose goal is to remove exudate, restore auditory function and prevent recurrence of the disease. Otorhinurgic intervention is performed only after or during the sanitation of the upper respiratory tract.

Mirindgotia

Advantages of the technique:

• rapid equalization of tympanal pressure;
• fast evacuation of exudate.

Disadvantages:

• impossibility to remove thick exudate;
• rapid closing of the myringotomy hole;
• high frequency of relapses (up to 50%).

In connection with the above, the method is considered a temporary medical procedure. The indication is exudative otitis media in the stage when performing a surgical intervention aimed at sanitation of the upper respiratory tract. Tympanopuncture has a similar myringotomy deficiencies. The use of methods must be stopped because of their inefficiency and high risk of complications (trauma of auditory ossicles, maze windows).

Timpakostoynya with the introduction of a vent tube

For the first time the idea of tympanostomy was 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 1.5 mm in diameter, leaving it for 3 weeks in a patient with unresolved after conservative therapy and myringotomy exudative otitis media. Later, the otiatrs perfected the design of the ventilation tubes, used the best materials for their manufacture (Teflon, silicone, silastic, steel, gilded silver and titanium). Clinical studies, however, did not reveal significant differences in the effectiveness of treatment with different materials. The design of the tubes depended on the tasks of the treatment. At the initial stages, tubes were used for short ventilation (6-12 weeks) by A. Armstrong, M. Shepard. A. Reiter-Bobbin. Patients treated with the use of these tubes (so-called shot-term-tubes), who are shown repeated tympanostomy - candidates for surgery using long-term tubes (the so-called long-term-tubes) K. Leopold. V. McCabe. This group of patients also includes children with craniofacial anomalies, pharyngeal tumors after palatorezection or irradiation.

At present, long-term tubes are made of a silastic with a large medial flange and flexible keels for easier insertion (J.Pre-lee, T-shaped, of silver and gold, of titanium). Spontaneous fallout of long-term-tubes is extremely rare (for the modification of Re-lee - in 5% of cases), the duration of wearing up to 33-51 weeks. The frequency of prolapse depends on the speed of migration of the epithelium of the tympanic membrane. Many otosurgeons prefer tympanostomy in the median quadrant, while K. Leopold et al. Noted that the Shepard modification tubes are preferable to be introduced into the anterior quadrant, such as Renter-Bobbin - in the anteroom. I.B. Soldatov (1984) proposes to shunt the tympanum through the incision of the skin of the external auditory canal in a restricted area of its posterior wall by cutting it together with the eardrum by installing the polyethylene tube through this access. Some Russian authors form a myrrhostomic hole in the posterior quadrant of the tympanic membrane using the energy of a carbon dioxide laser. In their opinion, the opening, gradually decreasing in size, completely closes after 1.5-2 months without signs of gross scarring. Also for mnrigotmii apply low-frequency ultrasound, under the action of which there is a biological coagulation of the edges of the incision, resulting in virtually no bleeding, reduces the likelihood of infection.

Miringhotomy with the introduction of a vent tube in the anterior quadrant

Equipment: operating microscope, ear funnels, straight and curved microneedles, micro-disrupter, micro-formula, micro-tips for suction with a diameter of 0.6: 1.0 and 2.2 mm. The operation is performed in children under general anesthesia in adults - under local anesthesia.

The operating field (parotid space, the auricle and the external auditory meatus) is treated according to generally accepted rules. With a curved needle, the epidermis is dissected in front of the handle in the anteroposterior quadrant of the tympanic membrane, peeled off from the middle layer. Circular fibers of the tympanic membrane are dissected, and radial fibers are expanded by a micro needle. If these conditions are properly observed, the myringotomy hole acquires a shape, the dimensions of which are corrected by the micro-disassembly in accordance with the caliber of the vent tube.

After mnrigotmii suction remove exudate from the tympanic cavity: the liquid component - without difficulty in full volume; viscous - by liquefaction by introducing into the drum cavity solutions of enzymes and mucolytics (trypsin / chymotrypsin, acetylcysteine). Sometimes it is necessary to carry out this manipulation repeatedly until the exudate is completely removed from all parts of the tympanic cavity. In the presence of a mucoid, non-evaporation exudate, a vent tube is installed.

The tube is taken with mikrofishchitsami for the flange, lead to the myringotomy hole at an angle, and the edge of the second flange is inserted into the lumen of myringostoma. The microshicles are removed from the external auditory canal, and the curved microneedle, pressing on the cylindrical part of the tube at the border with the second flange located outside the eardrum, it is fixed in the myringotomy hole. After the procedure, wash the cavity with 0.1% dexamethasone solution, inject 0.5 ml with its syringe: increase the pressure in the external auditory canal with a rubber pear. With the free passage of the solution into the nasopharynx, the operation is terminated. When the obstruction of the auditory tube is sucked off the drug and vasoconstrictive drugs are administered; The pressure in the external ear canal is again raised with a rubber pear. Such manipulations are repeated until reaching the permeability of the auditory tube. With this technique, there is no spontaneous failure of the tube due to its tight fit between the flanges of the radial fibers of the middle layer of the tympanic membrane.

By establishing drainage in the anteroposterior region of the tympanic membrane, it is possible not only to achieve optimal ventilation of the tympanic cavity, but also to run into a possible trauma of the auditory ossicle chain, which is possible when the tube is fixed in the posterior quadrant. In addition, with this form of administration, the risk of complications in the form of atelectasis and myringosclerosis is lower, and the tube itself has a minimal effect on sound transmission. The ventilation tube is removed according to the indications at different times, depending on the restoration of the patency of the auditory tube according to the results of tympanometry.

Localization of myringostomy cut can be different: 53% of otolaryngologists apply tympanostoma in the posterior quadrant, 38% in the anterior region. 5% in the anteroposterior and 4% in the posterior quadrant. The latter variant is contraindicated because of the high probability of trauma of the auditory ossicles, the formation of a retractive pocket or perforation in this zone, which leads to the development of the most pronounced hearing loss. Lower quadrants are preferable to tympanostomy because of the lower risk of injury to the promontory wall. In cases of generalized atelectasis, the only possible place for the introduction of the vent tube is the anterolateral quadrant.

Shunting of the tympanic cavity with exudative otitis media is highly effective in terms of exudate removal, improvement of hearing and prevention of relapse only in the II (serous) stage (according to NS Dmitriev et al.), Provided that the clinic is under observation for 2 years.

Tympanotomy

After the imposition of tympanostomy in the anteroposterior quadrant of the tympanic membrane, an injection of 1% lidocaine solution is made at the border of the outer surface of the external auditory canal in order to facilitate the separation of the mitotimpanal flap. With a heavy knife, the skin of the external auditory canal is cut under the operation microscope magnification, having retreated 2 mm from the drum ring along the posterior wall in the direction of 12 to 6 hours according to the dial scheme. With a micro-dissector, a me- talic flap is removed, a tympanic ring with an eardrum is extracted with a curved needle. The whole complex is diverted anteriorly until a good view of the windows of the labyrinth, promontorial wall and auditory ossicles is obtained; access to gipotimpanuma and perabarabannomu deepening. The exudate is removed by sucking, the drum cavity is washed with acetylcysteine (or enzyme), after which the discharge is again evacuated. Particular attention is paid to the over-drilled groove and the hammer-to-hammer joint located in it, since it is in this place that the muff-shaped deposition of the formed exudate is often observed. At the end of the manipulation, the tympanum is washed with dexamethasone solution. The meatotimponal flap is placed in place and fixed with a strip of rubber from the surgical glove.

Further management

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

Audiologic control is performed one month after the surgical treatment (otoscopy, otomicroscopy, with indications - assessment of the patency of the auditory tube). With normalization of hearing acuity and function of the auditory tube after 2-3 months. The vent tube is removed.

After the treatment, a long, careful and competent dispensary observation by an otorhinolaryngologist and a surdologist is necessary, since the disease is prone to recurrence. It seems rational to differentiate the nature of observation of patients, respectively, the established stage of exudative otitis media.

In the case of stage I, after the first stage of treatment and at stage II, the first examination with audiometric control should be performed 1 month after the sanitation of the upper respiratory tract. Among the characteristics of children, we can note the appearance of a semilunar spot in the anterior quadrants of the tympanic membrane and the recording of Type C tympaograms with acoustic impedance measurements. Monitoring of children in the future should be carried out once in 3 months for 2 years.

After the shunting of the tympanum, the first examination of the patient should be carried out also 1 month after discharge from the hospital. From the indicators of otoscopy, attention should be paid to the degree of infiltration of the tympanic membrane and its color. By the results of tympanometry in the mode of examination of the permeability of the auditory tube, one can judge the degree of its recovery. Further audiological control is carried out once in 3 months for 2 years.

At the sites of introduction of ventilation tubes in patients with stage II and III of exudative otitis media, the appearance of myringosclerosis is possible.

With otoscopy in patients with IV stage of exudative otitis media, atelectasis of the tympanic membrane, perforations, secondary NST can be expected. In the presence of these complications, it is necessary to conduct courses of resolving, simulating and improving microcirculation therapy: injections of hyaluronidase, fibs, vitreous intramuscularly in the age-related dose, phonophoresis with hyaluronidase endaurally (10 procedures).

At all stages of the cured exudative otitis media, the patient or his parents are warned about mandatory audiologic control after episodes of long rhinitis of any etiology or inflammation of the middle ear, as these conditions can trigger an aggravation of the disease, untimely diagnosis which leads to the development of a more severe stage.

American otolaryngologists recommend observing patients with exudative otitis media with a preserved tympanogram of type B not more than 3-4 mcch. Further shows tympanostomy.

In cases of recurrent disease prior to re-surgery, CT scan of the temporal bones is recommended to assess the condition of the auditory tube, verify the presence of exudate in all the cavities of the middle ear, preserve the auditory ossicles, and eliminate the scar process of the tympanic cavity.

Approximate terms of incapacity for work depend on the stage of the course of the disease and are 6-18 days.

Prevention

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

[38], [39], [40], [41], [42],

Forecast

Dynamics in the first stage of the disease and adequate treatment lead to complete cure of patients. The primary diagnosis of exudative otitis media in the second and subsequent stages and, as a consequence, the belated initiation of therapy lead to a gradual increase in the number of adverse outcomes. Negative pressure, the restructuring of the mucous membrane in the tympanum cavity causes a change in the structure of both the tympanic membrane and the mucosa. Their primary changes create prerequisites for the development of retractions and attelectasis, mucositis, immobilization of the chain of auditory ossicles, blockade of labyrinthine windows.

• Atelectasis is the retraction of the tympanic membrane due to prolonged dysfunction of the auditory tube.
• Atrophy - thinning of the tympanic membrane, accompanied by a weakening or cessation of its function due to the inflammation.
• Myringosclerosis is the most frequent outcome of the exudative secondary otitis media: it is characterized by the presence of white tumors of the tympanic membrane located between the epidermis and the mucous membrane of the latter, developing as a result of the organization of exudate in the fibrous layer. In surgical treatment, the foci can easily be detached from the mucous membrane and the epidermis without the release of blood.
• Retraction of the tympanic membrane. Appears due to prolonged negative pressure in the tympanic cavity, can be localized both in the unstretched part (panflaccida) and in the strained (pars tensa), be limited and diffuse. Atrophic and retracted tympanic membrane is sagging. The retraction precedes the formation of the retraction pocket.
• Perforation of the tympanic membrane.
• Adhesive otitis media. Characterized by cicatrization of the tympanic membrane and proliferation of fibrous tissue in the tympanum, immobilization of the auditory ossicle, which leads to atrophic changes in the latter, down to the necrosis of the long process of the anvil.
• Timpanosclerosis - the formation of tympanosclerotic foci in the tympanum. Most often located in epitimpanuma. Around the auditory ossicles and in the niche of the window of the vestibule. In surgical intervention, the tympano-sclerotic foci exfoliate from the surrounding tissues without the release of blood.
• Deafness. It is manifested by conductive, mixed and neurosensory forms. Conductive and mixed, as a rule, are due to the immobilization of the auditory ossicles' chain by scars and tympanosclerotic foci. HCT - a consequence of intoxication of the inner ear and blockade of the windows of the labyrinth,

These complications can be isolated or in various combinations.

The creation of an algorithm for the treatment of patients, depending on the stage of exudative otitis media, made it possible to achieve restoration of auditory function in the majority of 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 noted the persistence of chronic mucosal disease of the nasal cavity and the later onset of treatment.

[43], [44]