Tuberculous otitis media

Tuberculosis otitis media primarily occurs exceptionally rarely. As a rule, tuberculous otitis media develops against the background of pulmonary tuberculosis or bones.

Patients begin to notice a one- or two-sided hearing loss, accompanied by ear noise. In most cases, the patient and the doctor explain these phenomena by the action of anti-tuberculosis drugs (streptomycin, PASK, ftivazid, etc.), which is indeed the case in some cases.

The unsuccessful state of the ear is paid attention only with the appearance of purulent discharge. This delayed diagnosis is facilitated by the painless onset of tuberculous otitis media, even with a tympanic lesion. With tuberculous otitis media, a high degree of hearing loss occurs early, due not only to the destruction of the sound-transmitting apparatus, but also to the effect of toxic products of the vital activity of the MBT.

In relation to the total number of cases of chronic suppurative otitis media, tuberculous otitis media, according to different authors, varies from 1.5 to 15%, and cases of mastoid process damage range from 2 to 20%. In all persons suffering from various forms of tuberculosis, tuberculosis otitis media meets from 1 to 9% of cases, while banal chronic purulent otitis media - from 4.7 to 22% of cases. Most often tuberculous otitis media affects children aged 1 to 7 years, when the temporal bone undergoes a significant morphological rearrangement, and the immune system is not developed enough.

Ways of spreading from distant foci of infection are tubular (with open tuberculosis of the lungs), lymphogenous (with tuberculosis lesions of the lymphadenoid apparatus of the pharynx and nasopharynx) and hematogenous (with granulosa rash, intestinal tuberculosis), oral route (with per os vaccine BCG). It should be emphasized that tuberculosis otitis media usually follows the infection of the upper respiratory tract, therefore, if tuberculosis of the ear is detected, the pharynx, larynx, trachea and lungs should be carefully examined for tuberculosis.

Pathological anatomy

Pathomorphological changes in tuberculosis median otitis have not been adequately studied. Probably, they are close (if not identical) to those processes that occur with tuberculosis of the upper respiratory tract and bones, while the mucosa of the middle ear is dominated by the processes of proliferation and exudation, and in the bone tissue - processes of necrosis.

Usually, the lesion of the mucous membrane of the tympanic cavity occurs in the form of gray or yellowish-white miliary eruptions, which then undergo a caseous decay with the exposure of the bone and the occurrence of multiple perforations of the tympanic membrane through which purulent secretions seep with characteristic curd inclusions. Sometimes the fusion and the caseous disintegration of miliary eruptions lead to total destruction of the tympanum. In the secretions from the ear, MBT is detected and a banal microbiota.

Bone lesions are predominantly secondary and proceed 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 an abundant putrefactive character with a heavy fetid odor. Bony formations of the tympanum and mastoid process undergo massive necrosis and sequestration. These processes arise as a result of the appearance of primary hematogenous lesions of tuberculous osteitis in the spongy substance of the temporal bone, in which there are elements of red bone marrow, which is the most favorable medium for 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 region or outside it. There may also be a primary lesion of the synovial membrane of the ossicle joints, in which an important role is played by the allergic (immune) inflammation characteristic of the so-called Ponce polyarthritis.

Symptoms of tuberculous otitis media

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

1. periarthritic;
2. arthritic;
3. postartritic.

The first phase is characterized by the formation of tuberculous foci in the bodies of the auditory ossicles (there may be a parallel formation of such foci in the spongy areas of the temporal bone). At this stage, the patient's complaints may be absent, but when involved in the process of joints (the second phase), there are noise and ear pains of a constant noisy character, sharply increasing in a noisy environment and with a pulsation of air pressure in the external auditory canal, which is easily explained by movements in inflamed and infected joints of the auditory ossicles.

Simultaneously there are contractures of the muscles of the tympanum, and later their atrophy. These phenomena lead to stiffness of these joints and a sharp decrease in hearing by the type of disturbance in sound production. Later, destructive changes occur in the bone and cartilage of the joints, which predetermines the complete loss of the mechanism of sound production. The third phase is characterized by a sclerosing process, leading to a sharp disfigurement of the affected organ and loss of its function. Duration of tuberculous otitis media with active local and general treatment is calculated in a month or more.

A special form of tuberculous otitis media is acute tuberculous otitis without the presence of pulmonary tuberculosis, which occurs primarily and proceeds as a banal acute purulent otitis. Most often it occurs in children after acute nasopharyngitis, a common infection or after adenotomy. The onset of the disease is acute, manifested by pain in the ear, fever, hyperemia and edema of the tympanic membrane, the smoothness of its contours. The process quickly reaches a culmination, but with the intensity of pain decreases, but increases the hearing loss by the type of violation of sound. Otoscopically at the height of the stage, a wide perforation of the tympanic membrane is revealed, through which pale tubercular eruptions are visible. The process quickly passes into the chronic stage and intensively spreads in the direction of the mastoid process.

Complications of tuberculosis otitis media

The most common complication of tuberculous otitis media is paralysis of the facial nerve (according to GI Turner - 45% of all cases, according to some foreign authors, 60-65%), which occurs suddenly, within 4-6 hours. In 1 / 3 cases, there is a lesion of the ear maze, which mainly affects the cochlea. A harbinger of this complication is an ear noise, followed by deafness and deafness. Vestibular disorders are observed less often. The next most frequent complication is the bleeding caused by the damage to the inner artery of the middle ear, the sigmoid sinus and the bulb of the jugular vein. When the pyramid of the temporal bone is damaged, a triad of symptoms is described, described by F. Ramadier: periodic profuse gnotechenie from the ear, trigeminal neuralgia, paralysis of the nerve. Sometimes a lesion of limited pachymeningitis (with or without EDA) or basal leptomeningitis with signs of increased intracranial pressure resulting from compression of the liquor pathways is formed under the affected bone, bordering on the cranial cavity. With tuberculous otitis media, generalized meningitis occurs very rarely.

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

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

Diagnosis of tuberculosis otitis media

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

[6], [7], [8], [9], [10], [11], [12], [13]

Treatment of tuberculosis otitis media

Treatment of tuberculosis otitis media consists in the use of anti-tuberculosis drugs, both general and local. Locally produce a daily toilet of the ear, followed by washing it with antiseptic solutions to suppress the saprophyte microbiota, followed by drying the ear and injecting 2 times a day with 0.05 g of streptomycin dissolved in isotonic sodium chloride solution. Surgical treatment is determined by the prevalence of the pathological process and can include a wide range of procedures and surgical interventions - from curettage of the tympanum to extensive petromastoidectomy with exposure of sigmoid sinus and hard meninges. The combination of surgical and drug treatment, as a rule, gives a positive result.