Tuberculous otitis media

Tuberculous otitis media primarily occurs extremely rarely. As a rule, tuberculous otitis media occurs against the background of tuberculosis of the lungs or bones.

Patients begin to notice one- or two-sided hearing loss, accompanied by tinnitus. In most cases, the patient and the doctor explain these phenomena by the action of anti-tuberculosis drugs (streptomycin, PAS, ftivazid, etc.), which does indeed occur in some cases.

The poor condition of the ear is noticed only when purulent discharge appears. Such a delayed diagnosis is facilitated by the painless onset of tuberculous otitis media, even with damage to the eardrum. With tuberculous otitis media, high-degree hearing loss occurs early, caused not only by the destruction of the sound-conducting apparatus, but also by the action of toxic waste products of MBT.

In relation to the total number of cases of chronic purulent otitis media, tuberculous otitis media, according to different authors, fluctuates from 1.5 to 15%, and cases of damage to the mastoid process - from 2 to 20%. In all persons suffering from various forms of tuberculosis, tuberculous otitis media occurs from 1 to 9% of cases, while banal chronic purulent otitis media - from 4.7 to 22% of cases. Most often, children aged 1 to 7 years suffer from tuberculous otitis media, when the temporal bone undergoes significant morphological restructuring, and the immune system is insufficiently developed.

The routes of spread from distant foci of infection are tubular (in open pulmonary tuberculosis), lymphogenous (in tuberculous lesions of the lymphadenoid apparatus of the pharynx and nasopharynx) and hematogenous (in granular rashes, intestinal tuberculosis), and the oral route (when taking the BCG vaccine per os). It should be emphasized that tuberculous otitis media, as a rule, follows infection of the upper respiratory tract, therefore, when tuberculous lesions of the ear are detected, it is necessary to carefully examine the pharynx, larynx, trachea and lungs for the presence of a tuberculous process in them.

Pathological anatomy

Pathomorphological changes in tuberculous otitis media have not been studied sufficiently. They are probably close (if not identical) to the processes that occur in tuberculosis of the upper respiratory tract and bones, with proliferation and exudation processes predominating in the mucous membrane of the middle ear, and necrosis processes in bone tissue.

Usually, the first lesion to occur is the mucous membrane of the tympanic cavity in the form of gray or yellowish-white miliary rashes, which then undergo caseous decay with exposure of the bone and the occurrence of multiple perforations of the eardrum, through which purulent discharge with characteristic curd inclusions leaks. Sometimes the fusion and caseous decay of miliary rashes lead to total destruction of the tympanic cavity. MBT and banal microbiota are found in the discharge from the ear.

Bone lesions are predominantly secondary and originate from the auditory ossicles and the walls of the tympanic cavity. In severe cases, when the bone structures of the middle ear are involved in the process, the discharge from the ear acquires a profuse putrefactive character with a heavy foul odor. Bone formations of the tympanic cavity and mastoid process undergo massive necrosis and sequestration. These processes occur as a result of the appearance of primary hematogenously arising foci of tuberculous ostitis in the spongy substance of the temporal bone, which contains elements of red bone marrow, which is the most favorable environment for the dissemination and reproduction of MBT. Secondary osteitis serves as a source of further spread of the process with the formation of new tuberculous foci in the temporal bone area or beyond it. Primary lesion of the synovial membrane of the joints of the auditory ossicles is also possible, in which an important role is played by allergic (immune) inflammation, characteristic of the so-called Poncet polyarthritis.

Symptoms of tuberculous otitis media

According to available information (mainly from foreign authors), the development of the tuberculous process in the auditory ossicles undergoes three phases:

1. periarthritis;
2. arthritic;
3. post-arthritic.

The first phase is characterized by the formation of tuberculous foci in the bodies of the auditory ossicles (parallel formation of such foci in the spongy areas of the temporal bone is possible). At this stage, the patient may not have any complaints, but when the joints are involved in the process (the second phase), noise and pain in the ear of a constant aching nature occur, sharply increasing in a noisy environment and with pulsation of air pressure in the external auditory canal, which is easily explained by movements in the inflamed and infected joints of the auditory ossicles.

At the same time, contractures of the muscles of the tympanic cavity occur, and subsequently their atrophy. These phenomena lead to stiffness of the said joints and a sharp decrease in hearing by the type of sound conduction disorder. Later, destructive changes in the bone and cartilage of the joints occur, which predetermines the complete loss of the sound conduction mechanism. The third phase is characterized by a sclerosing process, leading to a sharp disfigurement of the affected organ and loss of its function. The duration of tuberculous otitis media with active local and general treatment is calculated at a month or more.

A special form of tuberculous otitis media is acute tuberculous otitis without pulmonary tuberculosis, which occurs primarily and proceeds as a banal acute purulent otitis. Most often, it occurs in children after acute nasopharyngitis, a previous general infection, or after adenotomy. The onset of the disease is acute, manifested by ear pain, increased body temperature, hyperemia and swelling of the eardrum, and smoothing of its contours. The process quickly reaches a climax, but the intensity of pain decreases, but hearing loss increases according to the type of conduction disorder. Otoscopically, at the height of the disease, extensive perforation of the eardrum is detected, through which pale tuberculous rashes are visible. The process quickly becomes chronic and intensively spreads in the direction of the mastoid process.

Complications of tuberculous otitis media

The most frequent complication of tuberculous otitis media is facial nerve paralysis (according to G.I. Turner - 45% of all cases, according to some foreign authors - 60-65%), which occurs suddenly, within 4-6 hours. In 1/3 of cases, there is damage to the ear labyrinth, mainly affecting the cochlea. The harbinger of this complication is tinnitus, followed by hearing loss and deafness. Vestibular disorders are observed less often. The next most frequent complication is bleeding caused by damage to the internal artery of the middle ear, sigmoid sinus and jugular bulb. When the pyramid of the temporal bone is damaged, a triad of symptoms described by F. Ramadier occurs: periodic profuse purulent discharge from the ear, trigeminal neuralgia, paralysis of the abducens nerve. Sometimes, a focus of limited pachymeningitis (with or without EDA) or basal leptomeningitis with signs of increased intracranial pressure, arising due to compression of the cerebrospinal fluid pathways, is formed under the affected bone bordering the cranial cavity. Generalized meningitis occurs very rarely in tuberculous otitis media.

Intracranial complications in acute tuberculous otitis without pulmonary tuberculosis are rare.

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Diagnosis of tuberculous otitis media

Diagnosis of tuberculous otitis media does not cause difficulties in people suffering from tuberculosis, especially in the open pulmonary form. The diagnosis is based on the described clinical picture, the results of X-ray examination and examination of pus and granulation from the tympanic cavity for the presence of MBT, as well as the reaction to tuberculin. Differential diagnosis is carried out in relation to banal purulent otitis, syphilis and cancer of the middle ear.

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Treatment of tuberculous otitis media

Treatment of tuberculous otitis media involves the use of anti-tuberculosis drugs, both general and local. Locally, daily ear cleaning is performed, followed by rinsing with antiseptic solutions to suppress saprophytic microbiota, followed by drying the ear and introducing 0.05 g of streptomycin dissolved in isotonic sodium chloride solution into it 2 times a day. Surgical treatment is determined by the prevalence of the pathological process and may include a wide range of procedures and surgical interventions - from curettage of the tympanic cavity to extensive petromastoidectomy with exposure of the sigmoid sinus and dura mater. The combination of surgical and drug treatment usually gives a positive result.