Treatment of otogenic intracranial complications and otogenic sepsis

The main pathogenetic principle of treatment of intracranial otogenic complications is the elimination of a purulent focus in the ear.

The aim of treatment of otogenic intracranial complications is to improve the general condition of the patient, the disappearance of the existing neurological symptoms. To achieve these goals, regardless of the severity of the patient's condition, it is necessary to drain the infectious focus and conduct adequate intensive antibiotic therapy.

Indications for hospitalization

Indications for hospitalization are the presence in an anamnesis of acute or chronic ear disease, the appearance of chronic purulent otitis media, seizures, mental disorders, headache complaints, nausea, vomiting, fever, the detection of meningeal symptoms on the background of acute or exacerbation. Patients with suspicion of intracranial complications need urgent hospitalization in a specialized medical institution, and with confirmation of the diagnosis are subject to urgent surgical treatment.

Non-drug treatment

In recent years, the following types of non-drug treatment have been used in the treatment of otogenic intracranial complications:

1. zkstrakorporalnoe irradiation of blood, stimulating specific and nonspecific immunity;
2. hyperbaric oxygenation in the postoperative period in order to activate tissue metabolism under conditions of increased partial oxygen pressure. After the sessions of hyperbaric oxygenation, there is a decrease in intracranial hypertension. The effect of hyperbaric oxygenation is also manifested in a more rapid decrease in body temperature, positive dynamics of reparative processes in the operating wound, which is associated with a faster lysis of necrotic tissues and activation of regenerative regenerative processes;
3. plasmapheresis ;:
4. hemosorption;
5. blood transfusion;
6. transfusion of fresh frozen plasma.

Medicamentous treatment of otogenic intracranial complications and otogenic sepsis

One of the important aspects of postoperative treatment of patients with otogennymi intracranial complications is complex intensive medication. Medicamentous treatment of otogenic intracranial complications includes, first of all, the use of antibiotics. Antibiotic therapy should begin with large doses of antibiotics and is carried out using all the main ways of drug administration (intravenously - to create maximum antibiotic concentration in the blood, intramuscularly - to provide a supporting antibacterial effect). The most effective regional administration of antibiotics in the cerebrospinal fluid or the arterial system of the brain.

Patients with purulent inflammatory lesions of the brain usually receive urgent care, and before the initiation of antibiotic therapy it is impossible to identify specific pathogens of infection. Therefore, the choice of empirical antibiotic therapy should be based on knowledge of the most likely pathogens and data on antibiotic resistance in the region

When prescribing antibiotic therapy for a patient with intracranial complication of the otogenic nature, it is necessary to take into account both the activity of this drug with respect to the suspected pathogens (especially the resistance to beta-lactamase action) and its ability to penetrate the blood-brain barrier.

Bacterial sowing and a test for sensitivity to antibiotics should be carried out as soon as possible. However, before receiving the results of bacteriological research, empirical therapy should be prescribed, including the administration of two or three antibiotics simultaneously. A highly effective treatment regimen including two antibiotics, one of which may be semisynthetic penicillin or second-generation cephalosporin, the second is the antibiotic of the aminoglycoside group. Antibiotics are administered at the maximum therapeutic concentrations. After receiving the results of bacteriological examination of the cerebrospinal fluid and identification of the pathogen, targeted therapy can be prescribed. When using benzylpenicillin as the main antibiotic, its sodium salt is used at a dose of 30-50 million units / day with a uniform distribution at 6-8 receptions. It should be noted that penicillin has not lost its therapeutic significance to many infections so far. We have to take into account the fact that this is one of the cheapest antibiotics. Depending on the effect, this therapy continues for 3-5 days with the subsequent transition to maintenance doses - 12-18 million units / day.

Among the semisynthetic penicillins of a broad spectrum of action, resistant to beta-lactamases. The most known combinations are amoxicillin + clavulanic acid and ampicillin + sulbactam, which also possess antianaerobic activity.

If among the pathogens are identified or are expected anaerobes, in combination with antistaphylococcal penicillin (oxacillin), metronidazole is administered intravenously. This combination is widely used, and has repeatedly confirmed its high effectiveness in providing urgent care to the most serious patients with purulent-septic complications of the brain. A completely satisfactory clinical effect, confirmed by bacteriological studies, is also achieved in patients with severe intracranial complications using cephalosporins of III-IV generation.

Currently, such drugs as ceftriaxone, cefotaxime, ceftazidime are widely used. Related to the third generation of cephalosporins. In particular, ceftazidime, used parenterally for 1-2 g every 8-12 hours, is the drug of choice for Pseudomonas aeruginosa infection. Cephalosporin IV generation cefepime, characterized by a wide range of effects, can be used to treat patients with neutropenia and impaired immunity. Cephalosporins are rarely combined with other antibiotics, but combinations with aminoglycosides, metronidazole are possible.

Glycopeptides represent almost the only group of antibiotics that retain high activity against resistant to other antibiotics of staphylococci and enterococci. Vancomycin is also indicated if penicillins or cephalosporins are ineffective or intolerant. It should be noted that vancomycin should be included in the reserve group and used only in situations where other antibiotics are ineffective.

Along with different types of microorganisms, in recent times, a variety of fungi (often aspergillosis, candidosis, penicillinosis, etc.) are the cause of severe purulent-inflammatory ear lesions and intracranial otogenic complications. Among antifungal drugs, the most appropriate use of triazoles (ketoconazole, fluconazole, itraconazole). In some cases, the use of amphotericin B.

Intrakarotidnoe introduction of antibiotics is carried out by puncture of the common carotid artery or by means of a standard vascular catheter inserted into the common carotid artery. The most convenient and safe is to hold a catheter in the carotid artery through the superficial temporal artery. The dose of antibiotic administered in the carotid artery is 0.5-1.0 g, the drug is administered twice a day. At the catheterization of the common carotid artery, the antibiotic is continuously administered with the aid of a drug delivery device, the daily dose of the drug can reach 2 g. The daily amount of the infusion solution is 1-1.5 l / day. The basis of infusates is Ringer-Locke solution or 0.9% solution of sodium chloride with the addition of heparin, proteinase inhibitors, antispasmodics.

Endolumbal administration of antibiotics is carried out 1-2 times a day. The drugs of choice for these purposes are cephalosporins, aminoglycosides in a dose of 50-100 mg. Excretion of 10-15 ml of cerebrospinal fluid during lumbar puncture is also an important element of sanation of cerebrospinal fluidways. Acceleration of sanation of the cerebrospinal fluid is achieved by carrying out liquorosorption. For most cases of meningitis caused by Gram-negative bacteria, a 10-14 day treatment is required after the cerebrospinal fluid has become sterile. For staphylococcal meningitis, the duration of therapy is usually 14-21 days.

Features of antibiotic therapy in the treatment of brain abscesses

The choice of antibiotics for the treatment of bacterial abscess depends on a large number of factors, the most important of which is the type of pathogen. In this regard, even before the appointment of antibacterial agents, it is necessary to sow the contents of the abscess. Other factors are the ability of antibiotics to penetrate into the abscess cavity, its bactericidal or bacteriostatic properties and spectrum of action. Before isolating the pathogen, antibiotics are prescribed against the most likely infectious agents. If the source is chronic purulent otitis media, then a mixed aerobic and anaerobic infection should be assumed, and a broad spectrum of antibiotics should be included in the treatment regimen. In this case, it is possible to prescribe metronidazole (it will cover anaerobic microorganisms), which excellently penetrates into the abscess cavity, and benzylpenicillin to act on Gram-positive bacteria (although half of the excretory agents currently excreted are resistant to it). In this regard, recommended for beta-lactamase-resistant semisynthetic penicillins or vancomycin. Weakened and pre-treated patients need the appointment of antibacterial agents that affect gram-negative bacteria.

Prolonged use of antibiotics in the stage of limited encephalitis allows to achieve success in the treatment of the disease. Good results of treatment are achieved in patients with small abscesses (average diameter 2.1 cm), especially when the source of infection is known. With multiple abscesses, antibiotics can be used as the only type of treatment for lesions less than 2.5 cm in diameter, provided that the culture of the pathogen is obtained from at least one abscess.

To wash the abscess cavity a 0.9% solution of sodium chloride is used, including broad-spectrum antibiotics that do not have epileptogenic activity, from 0.5 g per 500 ml of solution; proteolytic enzymes: inhibitors of protein decay.

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

Treatment of multiple abscesses

Urgent surgical intervention should be performed with multiple abscesses exceeding 2.5 cm in diameter or causing a noticeable mass effect. If all abscesses are less than 2.5 cm in diameter and do not cause a mass effect, aspiration of the contents of the largest abscess for microbiological examination is performed. From the use of antibiotics should be abstained until the material for cultivation is obtained. Prior to the results of the sowing, antibiotics of a wide range of action are used, and then antibacterial drugs are used in accordance with the results of identification of the pathogen for a minimum of 6-8 weeks, and in weakened patients for more than 1 year.

Thus, at the present time there is a significant amount of various antibacterial drugs, the separate or combined use of which allows to cover the entire spectrum of possible pathogens in severe infectious lesions of the ENT organs. When prescribing therapy, the doctor is obliged to take into account the severity of the disease, the features of the alleged pathogen, the possibility of the existence and development of resistance to the drug in use

Carrying out etiotropic antibacterial therapy must be combined with active pathogenetic and symptomatic treatment.

With degenerative surgical complications, dehydration and detoxification therapy is carried out. Intravenously inject the following drugs: mannitol 30-60 g in 300 ml of 0.9% sodium chloride solution 1 time per day, furosemide 2-4 ml per day: magnesium sulfate 10 ml; Dextrose 20 ml and sodium chloride 15-30 ml; methenamine 3-5 ml; hydroxymethyl-quinoxylindioxide - 300 mg; hemodez - 250-400 ml; ascorbic acid - 5-10 ml; glucocorticoids (prednisolone, hydrocortisone). In addition, subcutaneously and intramuscularly injected antihistamines and B vitamins, intravenously - pentoxifylline 200-300 mg.

As symptomatic therapy for indications, cardiac glycosides, analeptics and analgesics are prescribed. At a psychomotor excitation intravenously enter diazepam 2-4 ml.

In thrombosis of sigmoid sinus and otogennom sepsis appoint anticoagulants, mainly heparin sodium (from 10,000 to 40,000-80,000 units per day). Treatment with anticoagulants is carried out under the control of the time of blood clotting or the level of prothrombin of the blood. Anticoagulant therapy promotes the washing out of microcirculatory depots of microorganisms and ensures the penetration of antibiotics into the most remote parts of the vascular bed. Also use proteolytic enzymes (intramuscularly).

Since in these patients the immune system experiences significant loads and functions in conditions close to critical, special attention should be paid to immune therapy both passive and active (antistaphylococcal plasma, antistaphylococcal immunoglobulin, immunocorrectors of organic, inorganic and plant origin, etc.).

With intensive therapy of patients with otogenic intracranial complications, it is necessary to take into account the biochemical parameters of homeostasis and correct them.

Surgery

Surgical treatment is the leading method of treatment of otogenic intracranial complications. The aim of surgical intervention is to eliminate the primary purulent-inflammatory focus of the middle or inner ear. This result can be achieved by wide exposure of the dura mater and, if necessary, puncturing the brain or cerebellum, opening or draining the abscess. Operations with otogennyh intracranial complications are described in a separate chapter.

Further management

Further management of patients who have suffered from severe intracranial complications is the dynamic observation of the otorhinolaryngologist and neurologist.

Due to the high incidence of epileptic syndrome in the acute period of the disease and after surgical treatment, all patients with subdural empyema are prescribed anticonvulsants within a year after the operation.

Forecast

One of the most important factors determining the outcome is the preoperative neurological status. Mortality ranges from 0 to 21% in patients in clear consciousness, up to 60% in patients with signs of dislocation and up to 89% in patients in coma.

Each doctor in the process of treating a patient with acute or chronic purulent otitis media should remember the possibility of intracranial complications and, if suspected, immediately send the patient to the otolaryngological hospital.

The favorable outcome of the transient intracranial complications depends on timely diagnosis, surgical intervention on the affected ear, urgent elimination of the intracranial focus, the use of a complex of antibiotics sensitive to the given flora, as well as other drugs in appropriate doses and on the correct management of the patient and the postoperative period.

With sinusogenic sepsis, the prognosis is favorable in most cases. Lethality is 2-4%. With a marked decrease in resistance and changes in the reactivity of the body, fulminant forms of sepsis can be observed. The prognosis is unfavorable.

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