Mastoiditis: symptoms

In mastoiditis, there are subjective and objective symptoms. Subjective symptoms include spontaneous pain associated with involvement in the inflammatory process of the periosteum behind the auricle in the region of the mastoid process with irradiation to the parietal, occipital region, orbit, the alveolar process of the upper jaw, and the pain extends over the entire half of the head. A sensation of pulsation in the mastoid process, synchronous with the pulse, is characteristic. Objective signs are acute onset with fever, deterioration in general condition, intoxication, headache. Expressed a protrusion of the auricle, swelling and reddening of the skin of the behind-the-ear area, smoothening of the bovine skin fold along the attachment line of the auricle. When forming a subperiosteal abscess, fluctuation is noted, sharp painfulness upon palpation. As a result of involvement in the inflammatory process of the periosteum, the pain irradiates along the branches of the trigeminal nerve into the region of the temple, crown, occiput, teeth, orbit. In advanced cases, the subperiosteal abscess, exfoliating the soft tissue, can spread to the temporal, parietal and occipital areas. Thrombosis of vessels feeding the outer cortex causes necrosis of bone with a breakthrough of pus through the periosteum and soft tissues with the formation of an external fistula. In young children, pus often breaks through a still not closed scaly mastoid fissure. The formation of subperiosteal abscess depends on the structure of the mastoid process, especially on the thickness of the cortical layer.

With otoscopy, a symptom of the overhang of the posterior surface of the bone wall of the external auditory canal, which is also the anterior wall of the mastoid cavity (the Schwartze symptom) is characteristic.

The overhang of the posterior walls is a consequence of the periostitis of the anterior wall of the mastoid cavity and the pressure of the pathological contents of the entrance to the mastoid cave and the cave itself; the inflammatory changes of the tympanic membrane corresponding to acute otitis or exacerbation of chronic purulent otitis media are expressed, with perforation of the tympanic membrane - profuse purulence and pulsating reflex. The amount of purulent discharge considerably exceeds the volume of the tympanum, which indicates the presence of a source of pus other than the tympanic cavity, after a careful toilet the purulent secretions quickly fill the lumen of the external auditory canal. At the same time, the hearing on the conductive chip is broken. Mark changes in the hemogram corresponding to the inflammatory process.

The cells in the well pneumatized mastoid process have a typical group arrangement: zygomatic, angular, apical, threshold, perisinous, perifacial, perilabyrinth. Accordingly, the degree and nature of their pneumatization, the purulent process extends to certain cell groups with the development of typical symptoms. When lesions perisinuznyh cells develop periflebit, phlebitis and thrombophlebitis sigmoid sinus; destruction of perifacial cells is dangerous in terms of development of paresis of the facial nerve (with acute mastoiditis, the cause of paresis is predominantly the toxic edema of the perineural myelin sheaths and compression of the facial nerve in the fallopian canal, with mastoiditis on the background of exacerbation of chronic otitis media the carious destruction of the wall of the facial nerve channel predominates). A special group consists of apical mastoidites. From the place of penetration of pus (through the outer or inner surface of the apex of the mastoid process) depends on the direction of the spread of pus and, accordingly, clinical symptoms.

In this connection, the following forms of apical mastoiditis are distinguished.

Mastoidite of Bezold.

With this form, pus breaks through the thin inner wall of the apex, drains down into the neck and falls under the sternocleidomastoid muscle, the rib muscle, the longest muscle of the head and the deep fascia of the neck. Muscular-fascial formations make it difficult to break out of the pus; a fluctuating infiltrate is formed on the lateral surface of the bodies, the contours of the apex of the mastoid process can not be palpated. In this case, note the forced position of the head with an inclination toward the sick ear and forward, pain in the neck region with irradiation into the shoulder region. The infiltration is quite dense and does not often fluctuate; however, pressing on it causes an increase in suppuration from the ear, in contrast to the Mastoidite of Orleans. This is explained by the fact that the accumulation of pus is located under a deep cover of muscles and cervical fascia, which do not allow pus to break out outside. Although the outer surface of the apex of the mastoid process is quite dense, and the thick cortical layer is still covered by a thick muscular-fascial aponeurosis, pus may also break through to the outer surface of the apex of the mastoid process. This form of mastoiditis is dangerous in terms of the development of purulent mediastinitis, the spread of pus on the anterior surface of the cervical vertebrae with the formation of a perforating and lateral-pharyngeal abscess and phlegmon of the neck.

Mastoidit K.A. Orleans apical, cervical external

With this form of mastoiditis pus breaks into the outer surface of the apex of the mastoid process with the development of a fluctuating infiltrate around the attachment of the sternocleidomastoid muscle with pronounced inflammatory changes in the occipital region, severe pain to palpation: independent pain occurs when the head rotates due to myositis, may be torticollis. It is believed that the breakthrough of pus occurs not through the destruction of the outer cortex of the apex of the mastoid process, but because of the penetration of pus through some preformed defects (remains of the non-enlarged gap, numerous openings of blood vessels, dehiscence): therefore, in contrast to the bezold form of mastoiditis, pressure on the cervical infiltrate causes gnoculation from the ear. Purulent exudate thus impregnates soft tissues, but does not form an intra-aponeurotic muscular abscess.

Mastoidite Moure

This form of mastoiditis is accompanied by a breakthrough of pus in the region of the digastric fossa on the antero-lower surface of the apex of the mastoid process with subsequent spreading into the posterior subacute space where the inner jugular vein with its bulb, IX, X, and XI cranial nerves, facial nerve, cervical sympathetic trunk and the internal carotid artery. There is a danger of phlebitis development of the bulb of the jugular vein, the paresis of the corresponding cranial nerves and the deadly arsive bleeding from the internal carotid artery. Pus under the double-abdominal muscle also extends toward the spine, mediastinum with the development of paravertebral latero- or retrofaringual abscesses. Clinically, the local tenderness is determined by palpation of the lower surface of the apex of the mastoid process, contraction and resistance of the sternocleidomastoid and duodenum muscles, swelling in the anterior part of the lateral surface of the neck, torticollis, severe pain when pressing on the sternocleidomastoid muscle immediately under the tip, turns heads are difficult and painful. Characteristic symptoms from the side of the pharynx, along the course of the pus spread: swelling of the lateral or posterior pharyngeal wall, paratonzillar area, dysphonia, pain when swallowing with irradiation in the ear, patients complain of the sensation of a foreign body in the pharynx.

Petrosite

This most severe form of mastoiditis develops with pronounced pneumatization of the tip of the pyramid of the temporal bone. With it, there are severe clinical symptoms - the so-called Gradenigo syndrome (Gradenigo). Along with the clinical picture of mastoiditis, neuralgia of all three branches of the trigeminal nerve with a marked pain syndrome is characteristic, resulting from the compression of the inflamed periosteum of the gasser node located at the apex of the pyramid in the region of trigeminal depression. Simultaneous defeat of the abducent nerve is clinically manifested by diplopia. Less common are the oculomotor, facial, glossopharyngeal and accessory nerves. The defeat of the oculomotor nerve leads to the omission of the eyelids (ptosis) and to the limitation of the mobility of the eyeball outwards and downwards. The combined defeat of III and VI cranial nerves causes complete immobility of eyeballs (ophthalmoplegia), which in some cases may serve as a symptom of thrombosis of the cavernous sinus, which complicates the course of petrositis. In rare cases, the abscess itself evacuates with a breakthrough into the tympanum, or through the base of the skull into the nasopharynx with the appearance of a purulent abscess in this area, which is determined during a posterior rhinoscopy.

Acute zygomatitis

This disease occurs during the transition of the inflammatory process to the cellular system of the zygomatic process and is characterized by spontaneous pain and pain when pressing in the area of the zygomatic process, swelling of the soft tissues in the same area, accompanied by the displacement of the auricle downward and outward, often with an intact mastoid process. Infiltration and swelling of soft tissues often extend to the area of the corresponding eye, from which the eye gap narrows. Otoskopicheski for a zygomatzit characterized by the omission of the upper wall of the bone part of the auditory canal.

Chitelev form of mastoidite

It is caused by the lesion of the angular cells of the mastoid process, which directly contact through the vitreous plate of the posterior cranial fossa and multiple vessels with the sigmoid sinus, so this form is dangerous in terms of the development of periflebit, phlebitis, thrombophlebitis and perisinus abscess. With severe destruction of the angular cells, the revision of the posterior cranial fossa is mandatory during the operation.

Cornerian form of mastoidite

This special form of mastoiditis leads to the development of septicopyemia, but without thrombosis of the sigmoid sinus. The cause of septicopyemia in these cases is thrombosis of small bony veins of the mastoid process.

Latent mastoiditis

This variety is a special group of diseases characterized by a sluggish, slow course without pathognomonic symptoms for this disease. The development of the purulent process in the mastoid process passes without the formation of exudate in the middle of the uh, without pronounced fever, without the appearance of soreness at the pressure in the region of the mastoid process. Only in later stages can there be pain in the palpation of the occipital region. Clinically note intermittent spontaneous pain, especially at night, hearing loss, persistent hyperemia of the tympanic membrane. The development of this form of mastoiditis in children and young people is promoted by the so-called masking action; antibiotics, and in old age - senile osteosclerosis. At the same time, in the depth of the mastoid process, the destructive process weakly but steadily develops, which, if not diagnosed in time, after more or less long term leads to sudden severe complications (labyrinthitis, facial nerve paresis, intracranial complications).

Mastoiditis, which complicated otomycosis

This form of the disease is characterized by a recurrent flaccid course, resistance to traditional drug therapy. However, its exacerbations can proceed violently with pronounced reactive processes, especially in the region of apical cells, and in the course of the operation they reveal rather serious changes in the form of multiple mycotic foci. In adults with otomycosis limit indications for surgical treatment; in childhood recommend the extension of indications for surgical sanitation in order to prevent the development of serious complications.

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