CHOLESTEATOMA of the EAR (Greek cho-1yo bile + stear, steatos fat, fat N — a bt) — the tumorous education developing in tissues of a middle ear. Unlike a cholesteatoma of other localization (see the Cholesteatoma) the cholesteatoma of an ear represents accumulation of a keratin, crystals of cholesterol and from a shelled keratosic epithelium, surrounded with the capsule.
In 1829 Zh. Kryuvelje for the first time found on opening formation of white color with a brilliant surface in an arachnoid membrane of a brain and called it a pearl tumor. In 1838 I. Müller described a similar tumor and called it a cholesteatoma, including characteristic availability of cholesterol (see) between epidermal scales. In 1840 Pappengeym (S. The m of Pappenheim) reported about a cholesteatoma of a drum cavity and a mastoid. The cholesteatoma of an ear often develops against the background of hron. purulent inflammation of a middle ear. So, according to Sheybe (A. Scheibe, 1917), it is found in 91% of cases hron. purulent epimezotim-panit. Hron. the purulent average otitis (see) complicated by a cholesteatoma makes, according to F. V. Kastorsky (1962) observing adults and children from 7-year age, about 50% of all forms of otitis which are subject to surgical treatment; at children, according to V. P. Gamov (1965), it makes 60,9%.
There are several theories of emergence of a cholesteatoma of an ear. According to the tumoral theory it is formed of the remains of germinal epidermis, exfoliating of cells of a flat epithelium and their hit in a drum cavity during the closing with a weld wignonette of a branchial aperture. Supporters of other theory consider that emergence of a cholesteatoma of an ear is connected with penetration through perforative openings in a tympanic membrane of the harmful substances leading to a metaplasia of an epithelium of a drum cavity in multilayer flat keratosic. The greatest recognition was gained by the theory of growing offered by Gabermann (L. Na-bermann, 1888) and F. Betsoljd (1890), Berberi-ha confirmed with pilot studies (J. Berberich, 1927), T. N. Milyi-teyn (1936) and I. V. Filatova (1940). This theory explains formation of a cholesteatoma of an ear as a result of growing of epidermis of outside acoustical pass (see. Outside ear) into a drum cavity (see. A middle ear) through regional perforation in a tympanic membrane (see) as a result of long inflammatory process on average to fish soup. Reinforced epidermis of an upper wall of outside acoustical pass grows in the form of a tyazh through regional defect in a tympanic membrane into supratympanic deepening (attic) and a mastoidal cave (antrum), is implemented in the form of tyazhy into depth of fabrics. Constant exfoliating and accumulation in tympanic cavities of the keratosic cells of a flat epithelium leads to formation of compact weight, edges can fill all tympanic cavities. Putting the constant pressure upon surrounding bone walls, growing into them the cover that is promoted by influence and compound chemical components of a cholesteatoma and products of its disintegration, it destroys a bone tissue.
Microscopically ground mass of a cholesteatoma of an ear consists of the nuclear-free cells of a flat epithelium and various number of cholesteric masses located concentrically between them. On the periphery of mass of a cholesteatoma are surrounded with a cover. Its inner layer reminds epidermis on a structure. The outside connective tissue layer adjoins to a bone, is poor in cellular elements, contains plentifully branching vessels and a small amount of elastic fibers.
Most of patients with a cholesteatoma of an ear complain of the stupid, aching, holding apart, pressing or shooting ear pains, a headache in half of the head on the party of defeat, in frontal, temporoparietal or occipital areas. At the same time or after a headache there can be a dizziness caused by a labyrinthitis (see) owing to destruction of a wall of a bone labyrinth. The severe headache at such patients can testify to an intracranial complication. Allocations from an ear more often happen scanty, especially at perforation in a loose part of a tympanic membrane. Approximately at 40% of patients constantly for many years suppuration is observed. In purulent separated, possessing an unpleasant putrefactive smell, it is possible to find whitish curdled lumps.
At an aggravation the cholesteatoma of an ear is exposed to purulent disintegration that quite often leads to intracranial complications. The cholesteatoma of an ear can be implemented into a mastoid (see), into a head cavity (average and back cranial poles), pushing aside substance of a brain and to lead to developing of meningitis (see), paresis of a facial nerve (see. Facial nerve), abscess of a brain or a cerebellum (see the Brain, the Cerebellum), a labyrinthitis, otogenic sepsis (see Sepsis). At children compact (cortical) substance of a mastoid with formation of a subperiosteum of lny abscess then quite often there is periodically closed fistula especially often is exposed to destruction.
Diagnosis of a cholesteatoma of an ear is based on detection of a regional perforation of a tympanic membrane, holesteatomny mass of white color and allocations with a putrefactive smell. After washing or sounding of supratympanic deepening sites of a cholesteatoma or epidermal scales come to light. At an otoskopiya (see) it is quite often very difficult to examine a tympanic membrane because of sharp narrowing of outside acoustical pass by an occlusive polyp of a pla owing to amotio and infiltration of its back wall that meets at children more often. Can point narrowing of bone department of outside acoustical pass due to sagging of its posterosuperior wall to existence of a cholesteatoma of an ear that is caused by break of a cholesteatoma under a periosteum with amotio of infiltrirovanny skin in bone, and sometimes and a cartilaginous part of outside acoustical pass.
Important diagnostic value in combination with a wedge, data has rentgenol. research. The X-ray analysis of a temporal bone is made in special projections (see. Middle ear). Valuable additional data can be received at a tomography of temporal bones in direct and side projections (see Kraniografiya). Rentgenol. the picture depends on the sizes and localization of a cholesteatoma of an ear, edges is distinguished on secondary signs — changes in adjacent bone structures. Small cholesteatomas can not give rentgenol. symptoms. The large cholesteatoma leads to increase in the sizes of a mastoidal cave and supratympanic deepening, thinning and destruction of an outside wall of the last and an entrance to a mastoidal cave. Contours of the defect of a bone formed by an uncomplicated cholesteatoma, accurate defect has the rounded or polygonal shape with a small sclerous strip on the periphery (fig). Lack of the accurate and dense capsule of a cholesteatoma is a radiological sign of an aggravation of process.
Fig. The roentgenogram of a pyramid of the left temporal bone of an ear sore with a cholesteatoma (in a projection according to Maier): the arrow specified an oval form the defect in the field of supratympanic deepening with sclerous changes on the periphery caused by a cholesteatoma.
Differential diagnosis is carried out, first of all, with a large solitary mastoidal cell, at a cut the mastoidal cave has a normal amount. At a cholesteatoma, a coming from mastoidal cave, its sizes are sharply increased, periantralny cells are destroyed.
Conservative treatment is shown only in the presence of the small cholesteatoma which is localized in the supratympanic deepening available to carrying out to lay down. manipulations. In these cases supratympanic deepening is washed out spirit solution boric to - you through a special tube with the curved end, to-ruyu entered through a perforative opening in an upper part of a tympanic membrane. For washing it is possible to use also spirit solution of Furacilin, proteolytic enzymes, etc. The termination of suppuration and the subsequent epithelization of supratympanic deepening in many cases allow to avoid an operative measure. At unsuccessfulness of conservative treatment it is necessary to resort to operation. In practice sovr. otokhirurgiya are developed accurate indications to radical a middle ear operation not only for the purpose of elimination of a suppurative focus, but also for the purpose of preservation (recovery) of function of hearing (see Otitis, chronic average otitis).
The forecast at timely diagnosis and treatment favorable.
Prevention consists in the prevention of otitis, and at its razvi-giya — timely and rational treatment of inflammatory process that is especially important at children's age.
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H. A. Preobrazhensky; V. V. Kitayev