Otomastoiditis in infants: causes, symptoms, diagnosis, treatment

The study of omastoiditis in an infant was initiated by the largest German otolaryngologist A.Troltsch in 1856.

Polymorphic symptoms, frequent complications, features of the anatomical structure, significant subjective and objective complications in diagnosis and treatment in acute inflammation of the middle ear make it possible to single out this disease in a special category with specific features. In infancy, the inflammatory process, as a rule, captures all airway pathways and middle ear structures, which due to their incomplete fetal development are widely communicated and contain the remains of embryonic tissues that are not protected from infectious invasion, in which the pathogenic flora propagates with special fluffiness.

Epidemiology of omastoiditis in infants. According to the materials of the Romanian author I.Tesu (1964), most often otomastoiditis in infants occurs at the age of up to 6 months after birth, after which it exponentially decreases to the frequency of occurrence in adults. On the extensive statistical material obtained from a survey of 1062 infants who are in a children's hospital for children with various infectious diseases, the author found omoastoiditis in 112 children (10.5%), the majority of whom were under 4 months of age; 67 cases (75%) occurred in the summer during the epidemic of dysentery, while in autumn 28 (31%), and in autumn and winter - 17 (19%). These data indicate that the frequency of otomastoiditis in infants is directly dependent on the general state of the body, which can be disturbed by various common infectious diseases and the causes weakening immunity (children's diathesis, allergies, beriberi, malnutrition, dystrophies, metabolic disorders , adverse social factors, etc.).

Causes. Microbiota otomastoiditis in infants includes streptococcus, pneumococcus including mucous, less often - staphylococcus. In 50% of cases - a symbiosis of staphylococcus and streptococcus, 20% - pneumococcus, 10% pneumococcus and streptococcus and in 15% of cases - polymorphic microbiota.

Pathogenesis of otomastoiditis in infants. Local factors that contribute to the occurrence of otomastoiditis in infants are broad, straight and short auditory tubes and the entrance to the cavern of the mastoid process, which contributes to the good communication of all middle ear cavities with the nasopharynx, a large volume of the cavernous mastoid process surrounded by a spongy, copiously vascularized bone contributes to the hematogenous spread of infection in the bony systems of the Middle ear. It is known that the middle ear in the process of embryogenesis is formed from the diverticula of the nasopharynx, which grows into the forming temporal bone, and its air cavities form a single cellular system with airway pathways of the paranasal sinuses. Hence - the close pathogenetic relationship of the latter with the middle ear. In most cases, the starting point of omastoiditis in infants is the nasopharynx with numerous inflammatory processes localized in it (adenoiditis, rhinosinusitis, pharyngitis, etc.), and also as a consequence of these processes of the auditory tube disease, which is the main "supplier" of infection for the middle ear .

In addition to these anatomical features of the structure of the middle ear in a newborn, J.Lemoin and H.Chatellier described an infant diaphragm existing in infants up to 3 months of age that divides its middle ear into two parts - the upper ear, which is up and behind the above-drum depression, the cave of the mastoid process and the entrance to it, and the lower - the actual drum cavity. This diaphragm has a hole in the center, which, however, does not provide sufficient communication between the cave and the tympanic cavity, which makes it difficult to drain from the latter to the tympanum and then to the auditory tube. After 3 months, this diaphragm undergoes resorption. In addition, the infant in the submucous layer of the middle ear retains for a long time the remains of loose embryonic tissue, which is a favorable soil for the development of microorganisms. A contributing factor for the occurrence of omastoiditis in the infant is its horizontal position during feeding, because at this position the pathological contents of the nasopharynx and liquid foods and regurgitation most easily penetrate from the nasopharynx through the auditory tube in the middle ear cavity. So, the methylene blue installed in the throat can be detected after a few minutes in the tympanum.

In the pathogenesis of otomastoiditis in infants, there are three ways of spreading the infection: a "mechanical" path from the nasopharynx through the auditory tube directly into the tympanum, the lymphogenous and hematogenous pathway. The existence of a hematogenous pathway is indicated by the simultaneous occurrence of bilateral omastoiditis in infants with any general infection, for example, with measles or scarlet fever.

Symptoms of otomastoiditis in infants. There are three clinical forms of otitis media in the infant: an explicit, latent and latent, or so-called pediatric, form, since the possibility of its existence is supported mainly by pediatricians, but is rejected by most otiatrs.

The obvious form, as a rule, arises in children of the eutrophic constitution, with good nutrition and care, in the so-called sturdy. The disease begins suddenly - primarily or as a consequence of acute adenoiditis, most often a bilateral inflammatory process with an interval between occurrence in one and the other ear in a few hours or days. The body temperature quickly reaches 39-40 ° C. The child screams, rushes, rubs his head against the pillow, lifts the handle to the sick ear or stays in the inhibited state (intoxication), does not sleep, does not eat; often observed gastrointestinal disorders, vomiting, sometimes convulsions. Endoscopically revealed signs of acute inflammation of the middle ear. When pressing on the pre-tracheal and mastoid area, the child begins to scream with pain (Vaher's symptom). After paracentesis, the otitis can be eradicated within a few days, but can be further developed in the form of mastoidite. In the latter case, the amount of pus in the outer part of the ear canal increases, it pulsates, acquires a yellow-green color, the auditory passage narrows because of the overhang of the posterior walls, perforation can be eroded by a swollen, strongly hyperemic mucosa, creating the impression of a polyp (false or "acute" polyp ). In the behind-the-eye area, the skin's pastosity and sharp tenderness in palpation, as well as local and cervical lymphadenitis, are revealed. When mastoiditis occurs, the common signs of the inflammatory process become stronger again, as in the beginning of the disease. Timely anthro- tomia leads to a rapid cure, but the delay in its implementation causes, as a rule, the occurrence of a subperiosteal behind-the-back abscess, while the auricle protrudes anteriorly and downwards, the ear flush is smoothed out. The formation of an abscess and the penetration of pus into the subperiosteal space and then under the skin with the formation of a purulent fistula improves the overall condition of the child and often leads to spontaneous recovery. According to several authors, a subperiosteal abscess in infants in 20% of cases occurs in the absence of obvious signs of otitis with a relatively satisfactory general state of the child.

Diagnosis of subperiosteal abscess in a nursing infant, as a rule, does not cause difficulties, differentiate it from the adenophlegmo of the occipital region that occurs with external otitis.

Forms of otomastoiditis in infants.

The latent form occurs in children weakened, with a hypotrophic constitution, in unfavorable families or in children with weakened immunity, metabolic disorders that have passed the common infectious disease. Often, this form of otitis occurs in the absence of local signs of inflammation or with significant reductions. Local signs are masked by a general severe condition, the cause of which is long (days and weeks) remains unclear. The latent form of otitis in an infant may occur as one of three clinical syndromes - cholera-like, or toxic, cachectic and infectious.

Toxic syndrome is the most severe and is characterized by signs of deep intoxication of the body: the eyes are surrounded by a blue, the look is fixed, signs of enophthalmia are found. The child is motionless, does not cry, does not eat, does not sleep, on his face - expression of suffering and fright, limbs cold, cyanotic, skin pale, leaden, dry, turgor sharply lowered, fontanel retracted. Breathing is frequent, superficial, tachycardia, heart sounds are weakened, systolic murmur is sometimes audible, signs of toxic myocarditis can be observed. The abdomen is soft, the liver and spleen are enlarged. There are signs of a digestive disorder: vomiting, diarrhea up to 10-20 times a day, dehydration with a rapid decrease in body weight to 100-300 g / day, which is a threatening prognostic sign. The body temperature fluctuates around 38-40 ° C, in the terminal phase either more increases or falls below 36 ° C, which is a sign of an impending death. In the blood - leukocytosis to (20-25) x10 ⁹ / l, anemia. Urinalysis reveals oliguria, albuminuria; there are swelling of the face and limbs, indicating the defeat of the kidneys. The metabolic disorder is characterized by hyperchloremia, which is a contraindication for intravenous administration of sodium chloride solution with a preference for glucose solutions.

The cachexic syndrome is characterized by a gradual decrease in the baby's nutrition, less pronounced general symptoms, a slower decrease in body weight, body temperature is elevated and keeps at the same level (37.5 ... 38.5 ° C).

The hidden form. As noted above, this form of the so-called "occult" or "pediatric" omoastoiditis in an infant takes place without any objective local and subjective signs and is basically a "diagnosis of the assumption" in pediatricians who often insist on anthro- totomy in this general clinical the course of an objectively not established disease. Children's otiatrs (ENT specialists) for the most part reject the presence of this form. Statistics show that recovery from a certain toxic state of children during paracentesis or anthotomy (without detection of purulent discharge in the middle ear), at the insistence of the pediatrician, comes only in 11% of cases. In other cases of surgical "treatment" the clinical course of the general disease did not stop. In these cases, operative intervention not only does not suspend the general pathological process, but it can cause a sharp deterioration in the child's condition and, according to foreign statistics, causes death (50-75%).

If, nevertheless, there is a suspicion of the presence of a foci of infection in the otomastoid region, then the attention of the physician should be focused primarily on the state of the auditory tube and pharyngeal lymphadenoid formations. According to some authors, richly innervated nasopharyngeal tissues in the presence of a foci of infection can serve as a center for the generation of pathological reflexes, the cumulation of which causes an imbalance in the vegetative regulation of the organism and potentiates foci of infection, including in the upper respiratory tract, which causes some generalization of the infectious and toxic-allergic processes. This concept gives grounds to refer to the conditions described above as neurotoxicosis, which determines the use in the complex treatment of methods and means that normalize the state of the nervous system.

The clinical course of omastoiditis in an infant is determined by its general physical state, the activity of the immune system, the presence or absence of chronic foci of infection and latent current general diseases (rickets, diathesis, avitaminosis, hypotrophy, etc.). The better the overall physical condition of the child, the more obvious are signs of the inflammatory process in the middle ear, but also the more effective the body is fighting with the infection and the more effective the methods of treatment that are used. In weakened children the inflammatory process proceeds more rapidly, but its consequences can be more dangerous and fraught with dangerous complications.

The prognosis with the above forms of omastoiditis in infants is very serious and is determined by the effectiveness of the treatment.

Prognosis is determined by the form of the disease. At the explicit form, in general, it is favorable, and at adequate treatment recovery comes in 10-15 days without any morphological and functional negative consequences. With the latent form, as described above, the prognosis is very serious, since the percentage of deaths with her, according to foreign statistics, in the mid-20th century. Ranged from 50 to 75.

Complications of otomastoiditis in infants. The most dangerous complication is meningoencephalitis, manifested by convulsions, excitation or depression, increased intracranial pressure, protrusion of the fontanel. When puncture the latter, the spinal cord appears to flow under high pressure. Its cytological, biochemical and microbiological research indicates the presence of meningitis.

Complications such as sinus thrombosis, cerebral abscess, labyrinthitis, facial lesions are extremely rare.

Complications "at a distance" in the late period of the disease or at the height of the process can be bronchopneumonia, pyoderma, multiple point subcutaneous abscesses, abscesses in the area of injections. Complication of a general nature manifests itself in the form of toxicosis and sepsis.

Diagnosis of omastoiditis in infants is very difficult in all cases due to the prevalence of general toxicity over local changes masking the latter, and also due to the difficulties of otoscopy. An important role in the diagnosis is played by the parents' questioning about the establishment of previous acute or chronic diseases that could have caused the current illness. With otoscopy, inflammatory changes in the tympanic membrane, the presence of pus in the external auditory canal, the narrowing of the external auditory canal (overhang of the posterior walls of its wall), bovine signs of mastoiditis, etc. Diagnostics is supplemented by radiography of temporal bones, in which typical signs of otoanthritis and mastoiditis are revealed.

Treatment of infants suffering from various forms of otomastoiditis involves the use of nonoperative and surgical methods.

Non-surgical treatment includes, first of all, the fight against dehydration of the body by subcutaneous, intrarectal or intravenous administration of the corresponding isotonic sodium bicarbonate, glucose, and plasma and its substitutes (according to different indications taking into account the biochemical parameters of blood and the body weight of the child). In anemia, blood transfusion is shown in small amounts (50-100 ml).

Oral nutrition in the acute phase of the disease should be limited to giving a few teaspoons of glucose solution. Functions of the body's basic systems (cardiac, urinary, immune, digestive, etc.) should be monitored by appropriate specialists. Antibiotic treatment is effective only if there is a clear inflammatory process in the middle ear and as preoperative preparation in case of need for surgical treatment.

Surgical treatment involves the use of paracentesis, trepanopuncture of the mastoid process, including caves, anthro- tomia and anthro- mastoidotomy.

These surgical interventions are performed according to strict indications and only in rare cases for the diagnosis of ex jubantibus and in those cases when obvious signs of omastoiditis are revealed. The main surgical intervention is anthrotomy, which then, in the presence of indications, can be continued in the form of mastoidotomy.

Anthotomy begins with local anesthesia by infiltration into the operating area of 0.5-1% solution of novocaine in a dose corresponding to the body weight of the child, with 1 drop of 0.1% solution of adrenaline per 1 ml of novocaine solution added. The incision of tissues in the behind-eye region is layered very carefully.

The poregrass is dissected crosswise, which facilitates its removal and prevents its damage. Trepanation of the bone is performed 3-4 mm behind the back wall of the external auditory canal. To do this, use a slotted chisel, sharp spoon or cutter.

After opening the cave of the mastoid process, the pathologically altered bone, granulation, is carefully removed. The cave of the mastoid process is then expanded, with the risk of dislocation of the anvil and damage to the facial canal and the horizontal part of the lateral semicircular canal. If mastoidotomy is necessary, there is a risk of injury to the sigmoid sinus. A wound in the behind-the-ear area may not be sewn, or 2-3 seams with a graduate are applied to it. The skin around the wound is treated with petroleum jelly.

Postoperative treatment is performed under the supervision of a pediatrician. It consists in systematic dressings, symptomatic and pathogenetic general treatment, sanation of the identified chronic foci of infection, general strengthening measures in accordance with the state of the child.

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