LABYRINTHITIS

From Big Medical Encyclopedia

LABYRINTHITIS (labyrinthitis; grech, labyrinthos a labyrinth + - itis) — the inflammatory disease of an inner ear, a cut results from penetration into it of pathogenic microbes or their toxins and is shown by the combined disturbance of functions of peripheral receptors of acoustical and vestibular analyzers.

L. distinguish on etiol, to a factor — nonspecific and specific (tubercular, syphilitic); on a pathogeny — timpanogenny, meningogenny, hematogenous; on a current — acute, chronic (explicit, latent); on prevalence — limited, diffusion; on the nature of inflammatory process — serous, purulent, necrotic. In 20 century the percent of complications labirintipy acute and hron, purulent average otitises practically remains invariable. According to aggregated statistical data, at the beginning of 20 century timpanogenny L. made 1,3 — 5,03%, and by the end of the 50th — 1,4 — 5,4% of total number of purulent average otitises. Modern antibacterial therapy approximately by 4 — 5 times reduced the frequency of meningogenny L.

The etiology

the Labyrinthitis can be caused by various viruses, bacteria and their toxins. A source of an infection most often is the center of an inflammation located in close proximity to a labyrinth in tympanic cavities or skulls. The Timpanogenny Labyrinthitis develops owing to hit in inner ear (see) florae, the fish soup found on average at a purulent inflammation. The dominating role belongs to a mucous streptococcus, staphylococcus, a tubercular mycobacterium. More often activator of meningogenny L. is meningokokk, the pneumococcus, a tubercular mycobacterium, a pale treponema, an influenza virus, epidemic parotitis is more rare. To emergence of L. also the injury can promote (mechanical, chemical, thermal).

Pathological anatomy

Distinguish a serous, purulent and necrotic Labyrinthitis. Morfol, changes at serous L. have diffusion character, in mild cases come down to endolymphatic hypostasis with precipitation in perilymphangeal, and in hard cases and in endolymphatic spaces. Swelling, vacuolation and disintegration of a neuroepithelium is sometimes observed. At purulent L. in the beginning accumulation of polymorphonuclear leukocytes in perilymphangeal space and bacteria against the background of expanded blood vessels is noted. Then these changes happen also in endolymphatic space. Endolymphatic hypostasis progresses, the necrosis webby, and further and bone walls of a labyrinth joins. At a happy end fibrosis and formation of a new bone tissue are observed that leads to destruction of all nervous elements which remained still. Necrotic L. it is characterized by existence of the alternating sites of a purulent inflammation and necrosis of soft tissues and a bone labyrinth. Outcome, double: substitution of the necrotic site granulyatsionny fabric with the subsequent new growth of a bone or sequestration of a bone labyrinth. Inflammatory process can take all labyrinth as it is observed at acute purulent average otitises, or to be limited to one of parts of a labyrinth. Process comes to the end with a labyrinth sclerosis.

At a specific infection the Labyrinthitis has some morfol, features. So, changes at tubercular L. are, as a rule, shown in two forms: proliferative and exudative and necrotic. Formation of the tubercles which are gradually destroying both webby, and bone formations of a labyrinth is characteristic of the first. The second form more often happens serous, is more rare than purulent. Damage of an inner ear at syphilis is shown as meningoneyrolabirintit, an osteitis of a temporal bone with involvement of a webby labyrinth. Morfol, a picture is characterized by hypostasis, the accruing dystrophy of a webby labyrinth, sites of proliferation of fibrous fabric along with a resorption of a bone.

A pathogeny

On the mechanism of development of L. a number of factors — the general and local reactivity of an organism, character and degree of virulence of the activator, feature of manifestation of inflammatory process on average to fish soup and a head cavity, a way of penetration of an infection to an inner ear influences. Distinguish timpanogenny L., when the tympanic cavity is a source of infection of an inner ear; meningogenny L., the inflammations arising upon transition from subarachnoid space; hematogenous L., developing at some general inf. diseases of preferential virus etiology (flu, epidemic parotitis) when the hematogenous way of implementation of an infection to a labyrinth is supposed. Transition of inflammatory process of a middle ear is possible on any site of a wall of a labyrinth, but there is it, as a rule, through webby formations of windows of a labyrinth and the lateral semicircular channel. At an acute purulent inflammation of a middle ear patol, process extends more often through windows of a labyrinth without disturbance of their integrity or by break of a secondary tympanic membrane that causes development of acute diffusion serous or purulent L. The similar way is possible at an aggravation hron, a purulent mesotympanitis. At hron, purulent attic diseases distribution of an inflammation is carried out by destruction patol. process of a bone labyrinth of an inner ear, it is frequent in combination with break of webby formations of windows. Transition of an infection to a labyrinth from a middle ear on preformirovanny ways is possible.

From a head cavity from a meninx the infection gets into an inner ear through a perilymphangeal channel and internal acoustical pass. Distribution of an inflammation through a water supply system of a threshold and on perineural and perivascular to spaces of a core of a snail is possible.

In a pathogeny of L., developed as a result of an injury, disturbance of an integrity of webby and bone labyrinths, concussion, hemorrhage in peri-and endolymphatic space matters.

The necrotic Labyrinthitis develops as a result of disturbance of blood circulation in one of final branches of an internal acoustical artery. To prelum of vessels promotes endolymphatic: the hypostasis which is noted especially often at a serous inflammation. Limited L. it is observed only at hron, a purulent attic disease with caries or a cholesteatoma. Destruction of a wall of a bone labyrinth happens under the influence of granulating osteitis (see), and also cholesteatomas (see), edges by pressure, corrosions of a bone gradually grows into it up to establishment of the direct message of cavities of a middle and inner ear. The favourite place of localization of a fistula — the lateral semicircular channel, but it can be formed also in the field of the basis of a stirrup, a promontoriya and other semicircular channels. In the period of an aggravation of an inflammation on average to fish soup there is an exudate in this connection limited L. passes into diffusion. At syphilis any way of transition of a specific inflammation to a labyrinth is possible. In a pathogeny of syphilitic L., in addition to toxic or infectious impact on a neuroepithelium, great importance the syphilitic endarteritis is.

A clinical picture

On a current distinguish acute and chronic (explicit, latent) the Labyrinthitis. In typical cases acute L. it is shown by the so-called labyrinth attack — sudden and pronounced symptoms of the combined disturbance of functions of an inner ear: dizziness (see), followed nausea (see), vomiting (see), disturbance static and dynamic balances of a body (see), noise in to fish soup (see), hearing impairment. At serous L. labyrinth symptoms remain 2 — 3 weeks and, gradually losing the expressiveness, disappear. At purulent L. after subsiding of an acute inflammation the disease can accept a long current. Sometimes the Labyrinthitis develops as initially chronic, i.e. has hron, a current (the tubercular L. limited to H.p. a fistula) it is also characterized by the periodic explicit or less expressed symptoms of labyrinth frustration. Acoustical frustration are shown by noise in an ear and a hearing impairment up to its loss. Resistant deafness (see) confirms a purulent inflammation in a labyrinth. Sharp oppression of acoustical function almost indistinguishable from deafness at diffusion purulent L., it can be observed also at diffusion serous L. Odnako for serous L. incremental and passing decrease in hearing is characteristic. At serous L., both diffusion, and limited, the hearing impairment more often happens moderate and in mild cases its perhaps complete recovery.

The most essential signs of L. spontaneous vestibulosensorny, vestibulosomatichesky and vestibulovegetativny reactions on peripheral type are (see. Vestibular reactions ). Crucial importance has spontaneous nystagmus (see). The direction and intensity of a nystagmus change according to expressiveness of an inflammation in a labyrinth. In initial stages of both a serous, and purulent inflammation the spontaneous nystagmus is directed towards the struck labyrinth. Usually it is observed within several (3 — 5) days.

At purulent L. the spontaneous nystagmus in several hours changes the direction towards a healthy labyrinth. After an acute stage of an inflammation, later 2 — 3 weeks, the spontaneous nystagmus disappears thanks to the introduction in operation of compensatory mechanisms in the central departments of a vestibular analyzer. At sick L. in Romberg's pose, during the walking forward and back the deviation towards a slow component of a nystagmus, a spontaneous harmonious deviation of hands and reaction of a promakhivaniye in the same side, and also a forced deviation of the head and trunk towards a healthy ear can be observed. Dizziness at L. has system character, arises or amplifies at change of position of the head, it is often combined with a spontaneous nystagmus, and in sharply expressed cases is followed by nausea, vomiting, plentiful sweating, decolourization of face skin etc. At a latent current of L. vestibular frustration are almost not expressed.

A pathognomonic sign limited to H.p. a fistula and the kept function of a neuroepithelium of an inner ear is the fistulous symptom, i.e. emergence of a nystagmus towards a sore ear and other vestibular disturbances at an artificial condensation (compression) and depression (decompression) of air in outside acoustical pass. According to G. M. Grigoriev (1962), at limited L. and in the residual period of diffusion L. the nystagmus of situation can be a sign of partial disturbance of vestibular function. Symptomatology of limited L. differs in variety, lability; decrease in vestibular excitability on the party of defeat is characteristic. Clinic of unilateral meningogenny L. it is similar to symptomatology of serous or purulent timpanogenny L. At a meningococcal infection both labyrinths therefore vestibular frustration are not expressed are surprised. Against the background of the heavy course of meningitis a precursory and constant symptom of L. sharp oppression of acoustical function is, up to deafness. Full loss of vestibular excitability is at the same time observed. Hematogenous L. proceed sharply, more often with hemilesion of a labyrinth. The clinic is various. For tubercular L. the latent current, the progressing oppression of functions of a labyrinth is characteristic hron.

The clinic of syphilitic L is various. At the acquired syphilis allocate three forms of a current of L.: 1) apoplektiformny — sudden and the irreversible combined or isolated switching off of both functions of a labyrinth in one or both ears, quite often is at the same time observed defeat of a facial nerve; meets in all stages of syphilis, but a thicket in the second; 2) acute — the alternating sonitus and dizziness sharply amplify by the end 2 — the 3rd week, quickly there comes sharp oppression of functions of a labyrinth; it is observed in the second and third stages of syphilis; 3) chronic — a sonitus, gradual decrease in hearing, imperceptible for the patient; disturbance of acoustical and vestibular functions quite often is found only at special researches, sometimes is followed by defeat of a facial nerve; it is observed preferential in the second stage of syphilis. Current and symptoms of JI. at inborn syphilis depend on weight of an infection and specific changes in an organism. The disease begins at children's age, is shown by symptoms of disturbance of functions of an inner ear. At late inborn syphilis the so-called fistulous symptom in the presence of an intact tympanic membrane and absence of fistula in the lateral semicircular channel often comes to light. At the same time, unlike a typical fistulous symptom, the nystagmus at a compression is directed towards opposite, healthy, fish soup, and at a decompression — towards the irritated ear.

Features of a current, symptomatology of a traumatic Labyrinthitis are defined by character and weight of the injury.

Complications

At timpanogenny and traumatic Labyrinthites the purulent infection can get into a head cavity, causing intracranial complications, most often meningitis (see) and abscess cerebellum (see). Deterioration in the general state, temperature increase, emergence of a headache if their communication with the disease which caused L is excluded., or an intercurrent disease, are always suspicious concerning emergence of an intracranial complication. Strengthening of a gomolateralny nystagmus or change of the direction of a nystagmus towards the affected ear at purulent L. points to distribution of an inflammation on a cerebellum. Also other cerebellar symptoms matter.

The diagnosis

it is necessary For recognition of the Labyrinthitis: 1) to determine the fact of a disease of an inner ear; 2) to be convinced in inf. to the nature of a disease; 3) to specify the nature of an inflammatory disease of a labyrinth; 4) to define a form of display of a disease (character and prevalence patol, process in a labyrinth). Diagnosis of L. it is easy if are available characteristic acoustical and vestibulyar the ny disturbances caused by an infection. In the absence of essential anamnestic data consider data otoskopiya (see), researches of acoustical and vestibular functions, X-ray analysis of temporal bones, comprehensive inspection of the patient (therapeutic, neurologic, etc.). Essential value has definition of character and degree of a hearing impairment (see. Audiometriya ). In respect of differential diagnosis of L. it is necessary to consider that full deafness is not characteristic of noninflammatory diseases of an inner ear. At a research of vestibular function it is important to be convinced of the peripheral nature of vestibular disturbances. In the diagnostic relation the most valuable sign is the spontaneous nystagmus, to identification to-rogo promotes elektronistagmografiya (see). For establishment of nature of vestibular dysfunction at L. and the correct forecast of a disease carry out artificial irritation of a labyrinth by colorizing, rotation, pressor test, and also by a research of a nystagmus in a certain position of the head in relation to a trunk (see. Vestibulometriya ); to successful diagnosis of L. assessment of results of all methods of a research of the patient in total promotes.

Treatment

the Diagrammatic representation of operations on a labyrinth: and — on Ginzberg's way of I; — on Ginzberg's way II; in — on Bokhon's way; — on Uffenorde's way; 1 - a snail, 2 — a threshold, 3 — the lateral semicircular channel, 4 — the back semicircular channel, 5 — the front semicircular channel, 6 — a facial nerve, 7 — windows of a labyrinth. Points shaded the opened parts of a labyrinth, with lines — the naked site of a firm meninx and facial nerve.

Treatment of sick L. it is carried out in a hospital taking into account an etiology and a pathogeny of a disease. For timpanogenny L. removal of a suppurative focus from tympanic cavities (unloading operations) is obligatory. At L. the conservative, operational and quite often combined treatment is applied. Conservative treatment includes, in addition to a bed rest, prescription of antibiotics, streptocides taking into account their permeability through a gematolabirintny barrier and possible ototoksichesky influence. Apply dehydrational means to reduction of supertension of labyrinth liquid. Reduction of vestibular frustration is promoted by ensuring good evacuation patol. contents from a drum cavity by an ishemization of a mucous membrane of an acoustical pipe vasoconstrictors, and at their insufficient efficiency — way paracentesis (see). In sick L. appoint the medicines having the hyposensibilizing effect, the normalizing exchange processes improving excitability and conductivity of nervous elements of an inner ear. During the labyrinth attack apply dehydrational, sedative, vegetotropny substances, and also the means improving blood supply of an inner ear. Operative measures on a middle ear at timpanogenny L. make quickly at emergence of intracranial complications. Mastoidektomiya at acute uncomplicated L. it is made only during the involvement in process of a mastoid (see. Mastoiditis ). Radical obshchepolostny operation of an ear is carried out at any form L., the arisen against the background of hron, purulent average otitis (see). Unloading a middle ear operations are performed not in 3 weeks from the beginning of L., as it was accepted earlier, and on average in 6 — 7 days. Operative measures on a labyrinth do not carry out at acute serous L., however they, certainly, are shown at sequestration of a labyrinth and purulent L., complicated by abscess of a cerebellum. During the developing of labirintogenny meningitis the issue of opening of a labyrinth is resolved individually depending on the changes found during an operative measure on a middle ear on a labyrinth wall of a drum cavity and data of overseeing by dynamics of L. in the postoperative period. An operative measure on a labyrinth is preceded by expanded radical operation of an ear. At a labyrinthotomy are limited to drainage of a suppurative focus in an inner ear by its opening and removal patol, contents. Operation is carried out by one of methods at which, except a snail, open one or several semicircular channels. On Ginzberg's way of I (fig., a), open a snail and a threshold, and then an ampoule of the lateral semicircular channel in the beginning. On Ginzberg's way II (fig., b), lateral and back semicircular channels in addition open all. More radical is Bokhon's way (fig., c), on Krom in a certain sequence open completely all semicircular channels therefore the threshold is widely opened. Operation is completed opening of a snail. At labirintogenny intracranial complications the described ways are ineffective. In these cases make a labyrinthectomy, in process a cut delete all array of a labyrinth, bare or even resect a firm meninx that creates a wide drainage of a head cavity. On Uffenorde's way (fig., d), widely open and delete all cavities of a labyrinth, open a bottom of internal acoustical pass, and also bare a firm meninx of a back cranial pole.

Forecast

Uncomplicated L. does not pose hazard to life. The forecast concerning acoustical and vestibular functions depends on a cause of illness and a form of an inflammation. The serous Labyrinthitis can give a resistant, but partial hearing loss; purulent and necrotic, as a rule, deafness, and at bilateral defeat in early children's age is the main reason surdomutisms (see).

Prevention

the Prevention of the Labyrinthitis comes down to actions for fight against the general inf. diseases, and also to timely rational treatment of an acute and chronic purulent inflammation of a middle ear.



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I. B. Soldatov.

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