Middle ear catarrh: causes, symptoms, diagnosis, treatment

Acute catarrh of the middle ear (synonyms: exudative otitis media, salpingootitis, tubootitis, tubotympanitis, tubotympanic catarrh, secretory otitis, etc.).

In Russian literature, acute catarrh of the middle ear is understood as non-purulent inflammation of the middle ear, developing as a result of the transition of the inflammatory process from the nasopharynx to the mucous membrane of the auditory tube and eardrum. In foreign literature (French, German and other European countries), catarrh of the middle ear is understood as the mildest form of acute non-perforative otitis media, both rhinogenic (tubar) and any other (cold, hematogenous, infectious, etc.) origin. In essence, the inflammatory phenomena developing in the mucous membrane of the middle ear in acute catarrh of the middle ear can be identical to those occurring in banal acute otitis media at its initial stage. This is evidenced, in particular, by the pathomorphological processes occurring in catarrhal inflammation of the mucous membrane of any localization.

Catarrh, or catarrhal inflammation, is a type of exudative inflammation that differs from its other varieties not by the nature of the exudate, which can be either serous or purulent, but by the fact that it develops exclusively in the mucous membrane and is accompanied by hypersecretion of mucus, as a result of which mucus (a product of the mucous glands) and exfoliated epithelial cells are mixed with the exudate as such, as a result of which a mixture of exudate and mucous secretion flows into the inflamed hollow organ, filling part of it and forming a kind of level in it. Depending on the basic composition of the exudate, serous-catarrhal and purulent-catarrhal inflammation are distinguished, typical for banal forms of acute catarrhal and purulent otitis. When there is an abundance of desquamated cells in the exudate, the inflammation is called catarrhal-desquamative; it is most characteristic of catarrhal processes in the upper respiratory tract, pharynx and esophagus, as well as aerotitis.

Causes and pathogenesis. The primary cause of acute catarrh of the middle ear is a violation of the ventilation function of the auditory tube as a result of catarrhal inflammation of its mucous membrane, which, in turn, occurs as a result of the spread of the inflammatory process from the nasopharynx (adenoiditis, nasopharyngitis, etc.). The etiological factor of the inflammatory process in the nasopharynx can be streptococci, staphylococci, pneumococci or mixed microbiota. As a result of the minimization or complete exclusion of the ventilation function of the auditory tube and due to the absorption of the air contained in it by the mucous membrane of the tympanic cavity, a "negative" pressure is created in the tympanic cavity relative to the partial pressure of gases in the surrounding tissues. As a result, transudate begins to ooze from them in the tympanic cavity - a transparent colorless or slightly yellowish liquid, similar in composition to lymph. The transudate becomes turbid due to the deflated epithelium of the mucous membranes, fat droplets, lymphocytes, etc. The accompanying inflammatory process stimulates the secretion of the mucous glands and initiates the process of exudation, the most important component of the inflammatory reaction, which consists in the release of blood components from the vessels and tissues surrounding the inflammatory focus: fluid, proteins, formed elements (erythrocytes, leukocytes, in allergic inflammations - eosinophils, etc.). Infection of the exudate with banal microbiota leads to acute catarrhal inflammation of the middle ear, which under appropriate conditions can evolve into acute purulent perforative otitis media. However, in typical acute catarrh of the middle ear, the virulence of the microbiota is minimal.

Thus, acute catarrh of the middle ear in the pathogenetic aspect is an example of a systemic disease of the middle ear, in which such heteromodal elements as the presence of an inflammatory process in the nasopharynx and auditory tube, aerodynamic disturbances of the "auditory tube - tympanic cavity" system, the occurrence of abnormal barometric pressure in the cavities of the middle ear, an inflammatory process in the mucous membrane of the tympanic cavity and the processes of transudation and exudation take part. Since the said pathological system is formed in the organ responsible for the transmission of sound to the receptor formations of the inner ear, disturbances of the auditory function also occur.

Symptoms and clinical picture. Most often, signs of acute catarrh of the middle ear occur after a cold, manifested by a runny nose or catarrhal nasopharyngitis. The first symptom of the disease is periodic congestion of one or both ears, passing after instilling vasoconstrictor drops into the nose, blowing the nose or sneezing. Then the congestion of the ear becomes constant and is joined by low-frequency tinnitus, autophony in the "causal" ear, caused by a violation of the function of air conduction, and as a consequence - hearing loss of varying degrees. In the presence of effusion in the tympanic cavity, hearing loss can be caused by the viscosity of the transudate-exudate, increasing the impedance of the eardrum and the chain of auditory ossicles, and with a large amount of effusion, the factor of almost complete reflection of sound waves from the liquid medium also joins in. With little or no effusion, hearing loss may be due to retraction of the eardrum and the resulting increase in the rigidity of the ossicular chain. At this stage of the disease, slight ear pain may occur, more pronounced in children and radiating to the lower jaw. The pain is mainly due to the sharp retraction of the eardrum and excessive reflex contraction of the internal muscles of the tympanic cavity.

Otoscopic signs of acute catarrh of the middle ear correspond to the stages of development of the inflammatory process. The hyperemia stage is characterized by injection of vessels along the handle of the malleus and slight redness and retraction of the eardrum. Then radial injection of vessels appears, increased injection of vessels along the handle of the malleus and the relaxed part of the eardrum, shortening of the light cone.

At the stage of catarrhal inflammation, the amount of translucent exudate in the tympanic cavity increases, the color of which determines the color of the eardrum. It can be matte gray, yellowish, and with a hemorrhagic nature of the exudate of the eardrum, it acquires a bluish or purple color. Hemolysis enhances the color of the eardrum and allows for a more distinct determination of the level of exudate in the tympanic cavity, which is a pathognomonic sign of acute catarrh of the middle ear. With a liquid state of exudate and good mobility, its level remains horizontal regardless of the position of the head.

In acute catarrh of the middle ear, there is immobility of the eardrum, caused by the presence of effusion in the tympanic cavity and retraction of the eardrum. This sign is revealed using a pneumatic funnel and a Siegle magnifying glass by the absence of changes in the shape of the light reflex when blowing air into the external auditory canal.

In some cases, blowing through the auditory tube with a balloon or catheter can determine the patency of the auditory tube. If the result is positive, there is a temporary improvement in hearing and a decrease in the retraction of the eardrum.

Normally, when using a Lutze otoscope during the Valsalva maneuver or Politzer blowing, a characteristic blowing sound without tonal harmonics is heard. With a narrowed auditory tube, the sound acquires a whistling high-frequency character. With its complete obstruction, no sound phenomena are detected.

If the auditory tube is passable and there is a mobile effusion with a definable level in the tympanic cavity, then when blowing the auditory tube according to Politzer, this effusion can be smeared along the walls of the tympanic cavity, and then its level disappears for a while, but after some time it reappears. Sometimes after this test, air bubbles can appear on the inner surface of the eardrum.

A characteristic sign of acute catarrh of the middle ear is the retraction of the eardrum, in which the handle of the malleus acquires an almost horizontal position, and its short process protrudes into the lumen of the auditory canal (index finger symptom); the relaxed part of the eardrum, if it is not bulged by transudate, is retracted and almost directly adjoins the medial wall of the epitympanic space, the light cone is sharply shortened or disappears altogether. Sometimes one can see the descending branch of the incus, on which the eardrum rests.

In rare cases of acute catarrh of the middle ear, which is manifested by a sharp retraction of the eardrum, in which the pressure in the vestibule increases, the patient may feel slight dizziness, most often of a non-systemic nature.

When examining hearing, a conductive type of hearing loss is revealed, mainly for low frequencies. In the form complicated by acute purulent otitis media, preceptive hearing loss also occurs, caused by intoxication of the inner ear. When examining hearing with live speech, a decrease in hearing for low-octave words is revealed, while whispered speech can be perceived at the auricle or from a distance of no more than 1-2 m, and conversational speech - from 3-6 m.

The clinical development of acute catarrh of the middle ear can proceed in various directions: self-healing, rapid healing with minimal but targeted treatment, healing with residual phenomena, organization of exudate with the formation of intratympanic scars and the transition of the process to tympanosclerosis, infection of exudate with pathogenic microorganisms and the development of acute and chronic purulent otitis media. Most often, with etiotropic and pathogenetic treatment, the disease is eliminated without a trace in 1-2 weeks.

Diagnostics. Direct diagnostics is not difficult and is based on the patient's complaints, otoscopic picture and presence of chronic inflammatory conditions of the upper respiratory tract and auditory tube, as well as on the study of the patency of the latter and impedance and tympanometry data. Acute catarrh of the middle ear should be differentiated from acute purulent inflammation of the middle ear in the pre-perforative phase, which is characterized by severe pain in the ear and a number of other general clinical and otoscopic symptoms described below. It is more difficult to differentiate this disease from latent forms of otitis in infants and the elderly.

The prognosis for acute catarrh of the middle ear depends on the nature of the pathological condition of the nasopharynx and auditory tube, the general allergic background against which the disease of the middle ear develops, the virulence of the pathogen and the quality of treatment measures.

Treatment. The most effective results in relation to both the current disease and relapses and chronicity of the process are achieved by etiotropic and pathogenetic treatment, which consists of the following measures: elimination of chronic foci of infection in the nasopharynx and pharynx (chronic adenoiditis, chronic tonsillitis, chronic tubootitis, etc.); implementation of therapeutic measures in the presence of an allergic background and chronic inflammatory processes in the paranasal sinuses; normalization of nasal breathing in the presence of polyps, deformations of the nasal septum; local treatment, and if it is ineffective - "minor" surgical interventions (paracentesis, myringotomy, tympanotomy, shunting of the tympanic cavity using a Teflon liner inserted into the incision of the eardrum for a long time (from 2-3 weeks to 2-3 months).

Local treatment consists of a series of sequential measures aimed at restoring the patency of the auditory tube, removing transudate from the tympanic cavity, normalizing the state of the sound-conducting system and restoring hearing. It is advisable to begin treatment with the introduction of vasoconstrictor solutions and aerosols (naphthyzinum, sanorin, galazolin, etc.) into the nose. In a polyclinic or hospital setting, the auditory tube is blown out with preliminary anemization of their pharyngeal opening, and then they are catheterized with the introduction of 10-15 drops of hydrocortisone suspension into the tympanic cavity per administration daily for 3-5 days, and if there is viscous content in the tympanic cavity - and a freshly prepared proteolytic enzyme such as chymotrypsin (10 mg per 5 ml of sterile isotonic sodium chloride solution). Usually 1 ml of the enzyme solution is used. At the same time, antihistamines and decongestants are prescribed (diphenhydramine, diazolin, pipolfen, etc. in combination with ascorbic acid and calcium gluconate per os). If a purulent complication is suspected (the appearance of pulsating pain in the ear, increased hyperemia of the eardrum and its protrusion), broad-spectrum antibiotics are prescribed per os.

To quickly dissolve the contents of the tympanic cavity, various physiotherapeutic procedures are used (warming compress, sollux, UHF, laser therapy, etc.).

Chronic catarrh of the middle ear. Chronic catarrh of the middle ear is understood as a primary or secondary chronic catarrhal inflammation of the mucous membrane of the middle ear, complicated by the organization and sclerosis of the exudate, as a result of which adhesions and scars appear in the middle ear cavity, limiting the mobility of the elements of the sound-conducting system and causing hearing loss by the type of sound conduction disorder. Secondary chronic catarrh of the middle ear is a consequence of the chronicization of acute catarrhal otitis media, occurring in individuals whose tissues have the property of false keloid scarring. The same factors contribute to the occurrence of chronic catarrh of the middle ear as the occurrence of acute catarrh of the middle ear.

Symptoms and clinical picture. As a rule, the anamnesis often includes recurrent tubootitis and acute catarrh of the middle ear, the treatment of which gave only a temporary and incomplete effect. The main complaint is slowly progressing unilateral, more often bilateral hearing loss. Otoscopy reveals signs of adhesive otitis, sharp retraction and deformation of the eardrum, its immobility when blown with a pneumatic Ziegle funnel. When blowing through the auditory tube according to Politzer or with a cannula, its obstruction is revealed. With the organization of transudate and its scarring, ankylosis of the joints of the auditory ossicles and contractures of the internal muscles of the tympanic cavity occur, which leads to pronounced conductive hearing loss. Gradually, the adhesive process in the middle ear passes into the stage of tympanosclerosis with immobilization of the base of the stapes, and in some advanced cases, into sclerosis of the vestibule of the cochlea. Such patients are doomed to grade III-IV hearing loss or even complete deafness.

Treatment. The arsenal of treatment measures for chronic catarrh of the middle ear includes the same means as for the treatment of acute catarrh of the middle ear. These include attempts to blow out the auditory tube, catheterize and block it, introduce proteolytic enzymes, hydrocortisone suspension, electrophoresis of lidase or potassium iodide, pneumatic massage of the eardrum, etc. V. T. Palchun (1978) recommends introducing lidase into the tympanic cavity through a catheter or by injection through the eardrum (0.1 g dissolved in 1 ml of 0.5% novocaine solution) to increase the elasticity of scars and restore the mobility of the auditory ossicles. The course of treatment is 4 injections with an interval of 4 days.

If non-surgical treatment is ineffective, tympanotomy and, under a microscope, dissection and removal of scars during patency of the auditory tube are used. However, even such invasive treatment rarely gives a positive result, since scars develop again in the tympanic cavity and are often more pronounced. Many patients do not agree to surgical treatment, and then they are offered hearing aids.

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