OTITIS

From Big Medical Encyclopedia

OTITIS (otitis; grech, us, ot[os] an ear + - itis) — an inflammation of an ear. Depending on localization of defeat distinguish outside otitis (see. Outside ear ), average otitis and internal otitis (see. Labyrinthitis ). Simultaneous involvement in inflammatory process of all departments of an ear is called a panotitis.

Average O. can be acute and chronic. As a special form of acute O. allocate catarral average otitis, at Krom symptoms of disturbance of ventilating function eustachian prevail (acoustical, T.) pipes in this connection it is called also tubo-otitis (see).

Acute average otitis

overcooling, inflammatory diseases of upper respiratory tracts are acute average O.'s Reasons. It develops against the background of acute respiratory diseases, various inf. diseases, at activation of microflora of an oral cavity, an injury of a tympanic membrane.

The crucial role in average O.'s development belongs to reactivity of an organism. Also the condition of a nasopharynx and a nasal cavity exert impact on its development and a current. At nek-ry inf. diseases, and also at acute respiratory diseases inflammatory process extends to a mucous membrane of an Eustachian tube owing to what the ciliary epithelium perishes. It creates conditions for penetration of contagiums into a drum cavity. There is also hematogenous way of penetration of contagiums (at sepsis, scarlet fever and other diseases) and a contact way of infection of a drum cavity at an injury of a tympanic membrane (a mechanoinjury, a barotrauma, etc.). Sometimes contagiums get into a middle ear from a head cavity through internal acoustical pass, a water supply system of a snail or perinevralno — on front and acoustical (cochlear part VIII of pair of cranial nerves, T.) to nerves. In these cases contagiums at first get into an inner ear, and then in an average. Seldom (is more often at children's age) they get from a head cavity into a middle ear through an open kamenistocheshuychaty crack.

Acute average otitis (banal)

the Aetiology

Acute average O. as primary disease meets seldom. The specific activator does not exist. It can develop in the presence of curvatures of a partition of a nose, adenoides; it inflammatory diseases of a nose, his adnexal bosoms, nasopharynxes can be the cause. In separated from an ear the mixed microbic flora containing different types of streptococci, stafilokokk, pneumococci and other microorganisms is found.

The pathological anatomy

In an initial stage of acute average O. is observed a hyperemia of a mucous membrane of a middle ear that is caused by expansion and overflow by blood of vessels of a submucosa. Further there is transuding in pneumatic cavities middle ear (see) a liquid part of blood, and then and its uniform elements — exudate appears. In the beginning it has serous character about a nek-swarm impurity of slime, and then becomes purulent, is more rare hemorrhagic. In exudate, except a significant amount of leukocytes, there are a fibrin, a desquamated epithelium, necrotic masses, microorganisms; small-celled infiltration of a mucous membrane of a middle ear is noted. In later terms on certain sites of a hyperemic mucous membrane there are hemorrhages; the epithelium is torn away by places, ulcerations are formed, at the edges to-rykh growth of granulations begins. The mucous membrane is sharply thickened (by 20 — 30 times). The tympanic membrane is also involved in inflammatory process. Vessels of a tympanic membrane are overflowed with blood, it is thickened. The epithelium of its periblast is macerated, deskvamirutsya. Sometimes there are hemorrhages under an epithelial layer why on the surface of a tympanic membrane bloody bubbles appear. All these changes of a tympanic membrane are followed by change of its color and the drawing. In the subsequent the certain changed sites of a tympanic membrane can nekrotizirovatsya that leads to its perforation or final fracture. In nek-ry cases bone walls of a drum cavity with their possible destruction are involved in inflammatory process. At the favorable course of process inflammatory reaction gradually abates, signs of proliferation begin to prevail. The epithelium of tympanic cavities is recovered, the perforative opening in a tympanic membrane cicatrizes. As a result of scarring commissures of a tympanic membrane with a medial wall of a drum cavity and an anchylosis of acoustical stones can be formed (see. Tympanosclerosis ), narrowing of a gleam of an Eustachian tube. At insufficiently expressed regenerative processes the perforative opening with callused edges remains.

A clinical picture

the Beginning of a disease, as a rule, sudden, quickly progressing. During acute average O. allocate three periods. In the first period the leading symptom is ear pain, in the form of a pricking in the beginning, then it accepts the shooting, pristupoobrazny character and, gradually accruing, becomes absolutely intolerable. Pain abates or stops only for a short time, amplifies at night, depriving of a sick dream, can irradiate in teeth, a neck. Ear pain is followed by a headache in parietal or parietotemporal areas. Body temperature increases to 38 — 39 °; the patient is disturbed by the general weakness, frustration of a dream and appetite. At the weakened patients and at nek-ry atypical forms of acute average O. body temperature can not increase. There are a congestion and noise in an ear. The hearing impairment, as a rule, happens considerable: the shepotny speech is not perceived by a sore ear, informal conversation is heard at an auricle. At otoskopiya (see) the hyperemia of a tympanic membrane is noted: at first its upper quadrants, then the vessels going along the handle of a hammer and in the radiarny direction are injected and, at last, red is all tympanic membrane. The drawing of a tympanic membrane is greased: the light cone disappears, there is distinguishable only a short shoot of a hammer in the form of a yellowish point. There is a protrusion of all tympanic membrane or its separate parts as a result of accumulation in a drum cavity of liquid. The purulent exudate in a drum cavity gives to a tympanic membrane yellowish or, in combination with a hyperemic mucous membrane, copper-colored color. At percussion of a mastoid its morbidity can be found (owing to involvement in inflammatory process of a mucous membrane of mastoidal cells). Sometimes on a tympanic membrane yellow bubbles are visible, to-rye are formed owing to accumulation of exudate between connective tissue and leathery its layers. Due to amotio of epidermis the tympanic membrane can get the dirty-white shade masking its hyperemia. If perforation of a tympanic membrane is about to happen, then in nek-ry cases it is possible to determine its future place by a yellow shade of the most acting part.

Transition of a disease to the second period is indicated by perforation of a tympanic membrane.

With the advent of perforation ear pain disappears, the otorrhea — allocations from an ear appears. In the first 1 — 2 day the number of allocations from an ear small, allocations blood, not purulent with impurity, then quantity them increases, and they become mucopurulent. Body temperature is normalized; there is an appetite, the dream and the general state improves. However noise in an ear and a hearing impairment still remain.

The perforative opening has the slit-like or dot form more often and is usually almost indiscernible at an otoskopiya. The pulsing reflex — the point of pus flickering synchronously with pulse on site of perforation helps to find it.

The third period is characterized by reduction of suppuration from an ear, scarring of a tympanic membrane, recovery of hearing. Duration of a disease averages 2 — 3 weeks. The general symptoms disappear usually earlier, than local.

Acute average O. can atypically proceed. At sharply reduced body resistance chances of the most acute inflammation of a middle ear when suppuration and sharply expressed morbidity from a mastoid appear during the first hours diseases. General condition of patients heavy. In blood the expressed toxic granularity of neutrocytes is noted. Sometimes fulminant distribution of process of a middle ear to a head cavity comes to an end with death, earlier than there occurs perforation of a tympanic membrane and symptoms of a mastoiditis appear (feeling of a pulsation or the pulsing noise in the depth of an ear, pain in the field of a mastoid, profuse suppuration). In some cases symptoms, characteristic of acute average O., happen a little expressed, and nek-ry of them can be absent. So, at the beginning of a disease can not be pains, and emergence of an otorrhea is unexpected for the patient. The otorrhea can quickly stop at not law-chivshemsya, and sometimes and the progressing inflammatory process in an ear. Body temperature can not increase. Sometimes in the second period instead of normalization of temperature and changes in blood secondary rise in temperature and deterioration in the general state can be observed that indicates distribution of inflammatory process to a mastoid or a head cavity.

The atypical current of O. can be observed at senile age, at exhaustion, a diabetes mellitus, the changed reactivity of an organism.

Acute average O. can give such complications as mastoiditis (see), paresis of a facial nerve (see. Facial nerve ), labyrinthitis (see), intracranial complications, etc.

Diagnosis put on the basis of characteristic complaints of the patient, a typical otoskopichesky picture, results of a research of hearing and data rentgenol, researches by means of a X-ray analysis of temporal bones.

At audiometriya (see) decrease in perception of a sound through air is noted; bone conductivity suffers a little. In Weber's experience (see. Weber experience ) lateralization of a sound towards a sore ear is defined. On roentgenograms find various intensity uneven decrease in transparency (blackout) of cells and cavities of a mastoid on side of a sore ear owing to an inflammatory thickening of a mucous membrane and accumulation of an exudate or pus. At the same time the image of partitions of cells and walls of cavities of a shoot remains accurate. Only at the osteoporosis testimonial of acute average O.'s complication a mastoiditis, density of partitions of cells decreases, their contours become indistinct. During the progressing of process and emergence of the centers of destruction of a bone tissue the image of partitions on the roentgenogram disappears, intensity and the sizes of blackout of cells of a mastoid increase and it becomes unstructured.

Differential diagnosis carry out with outside O. Bol at acute average O. is localized in the depth of an ear, has the pulsing character and is followed by a hearing impairment, a congestion of a sore ear. At acute outside O. pain amplifies from pressure upon a trestle, a pandiculation for an auricle; hearing usually does not go down. Allocations from an ear at acute average O. have mucopurulent character, at outside O. — purulent.

Treatment

Appoint a bed rest, vitamin-rich caloric food, antibiotics and sulfanamide drugs. It is necessary to avoid use of streptomycin, Monomycinum, Kanamycinum since they possess expressed from - toxic action. Duration of treatment is 10 — 14 days. At the shooting ear pains and sharply expressed hyperemia of a tympanic membrane appoint drops of 5 — 10% of solution carbolic crystal to - you in anhydrous glycerin, to-rye dig in in an ear within 2 — 3 days.

From physiotherapeutic procedures apply heatradiation by Minin's lamp, sollyuks (1 — 2 time a day, 4 — 8 sessions), UF-radiation, UVCh, microwave therapy (microwave oven). It is necessary to avoid an excessive overheat since it strengthens pain. For deeper influence condenser plates at UVCh-tera-pii have over a mastoid and ahead of an auricle. Microwave therapy is more effective during the use of an endaural radiator. At bilateral process procedures are carried out serially (in one day) on each ear at the total duration of the UVCh and microwave Oven procedures up to 15 min. Before procedures carry out a careful toilet of an ear. Along with it for improvement of drainage function of an Eustachian tube enter vasoconstrictors into a nasal cavity (ointments or drops with ephedrine, adrenaline, cocaine, etc.).

If under the influence of treatment within 4 — 5 days symptoms of an inflammation do not weaken and temperature remains high, resort to to a paracentesis (see). At emergence of an otorrhea it is recommended to delete timely pus by careful ear irrigation with warm disinfecting solutions or instillations in an ear of 3% of solution of hydrogen peroxide with the subsequent careful osushivaniye of skin of outside acoustical pass by cotton wool or gauze turundas. Recovery of hearing can be accelerated careful ear inflations (see), however it is not necessary to begin them earlier than in 10 — 15 days after recovery of a normal type of a tympanic membrane.

The forecast

Acute average O. in most cases comes to an end with recovery. At the same time the perforative opening is closed, and there is a scarcely noticeable scar. In nek-ry cases on site of perforation the dense hem is formed. Sometimes there are unions of a tympanic membrane with a medial wall of a drum cavity between acoustical stones; the perforation opening of a tympanic membrane can not be closed. In these cases the persistent hearing impairment is noted.

Prevention acute average O. it is closely connected with prevention of acute respiratory diseases and consists in increase in body resistance, and also demands active treatment of inflammatory diseases of upper respiratory tracts, timely removal of adenoides, treatment of rhinitis, sinusitis, elimination of a curvature of a partition of a nose.

Other forms of average otitis

Fuzospirillezny average otitis the spindle-shaped stick and spirochetes of an oral cavity cause. The general symptoms are a little expressed, temperature normal or subfebrile, ear pain is absent or insignificant. It is tended to distribution of process on a mastoid. Fistulas in zaushny area are quite often formed. Extensive perforation of a tympanic membrane, plentiful allocations with off-flavor, and also formation of the bleeding polyps in a drum cavity is characteristic.

Treatment: intravenous injection of Novarsenolum, inside — potassium iodide, locally — hydrogen peroxide, powder Novarsenolum, greasing of 5 — 10% spirit solution of iodine.

Secretory average otitis (synonym: exudative O., serous O.). Especially often occurs at children aged from 1 year up to 7 years. Nek-ry researchers connect secretory O.'s emergence with dysfunction of an Eustachian tube, however such O.'s cases at its good passability are known. The disease is connected with penetration into a middle ear of adenoviruses and viruses of a parainfluenza, with diseases of a nasopharynx, nose and adnexal bosoms. Consider that secretory O. is a consequence of hyperfunction of mucous glands, in its genesis the importance is attached to an allergy. The hypertrophy of a mucous membrane of a drum cavity with existence in it of a large amount of glands producing slime is noted.

In a wedge, secretory O.'s picture the leading symptoms are unsharp ear pains, feeling of a congestion of an ear, a hearing impairment, weight in the head. They are caused by availability of liquid in a drum cavity. In most cases she is dense, viscous and therefore breaks mobility of acoustical stones. Depending on character of liquid in a drum cavity (watery or viscous) big or smaller degree of relative deafness is observed. At an otoskopiya the tympanic membrane can be from normal till intensive-blue color, its mobility is quite often limited.

Treatment is directed to recovery of function of an Eustachian tube by removal of exudate from a drum cavity and impact on her mucous membrane by pharmaceuticals. Catheterization of an Eustachian tube by a plastic catheter, transtubar-ny evacuation of exudate, administration of proteolytic enzymes, glucocorticoids, tubotimpanalny aerosol therapy, meatotubotimpanalny is applied pneumomassage (see). Transtubarny methods of treatment are combined with the general hyposensibilizing, antibacterial, stimulating therapy, sanitation of upper respiratory tracts. At insufficient efficiency of these methods so-called shunting of a drum cavity, a cut is carried out, e.g., according to Soldatov, it is performed without injury of a tympanic membrane — by a section of skin of outside acoustical pass, its separating together with a tympanic membrane and introductions to a drum cavity of a polyethylene tube.

Prevention consists in timely treatment of diseases of upper respiratory tracts.

Allergic average otitis — the inflammatory disease developing against the background of the changed reactivity of an organism. In allergic average O.'s emergence the importance is attached to various food-borne allergens, especially at children of early age. N. A. Bobrovsky, V. G. Kupryunin connect allergic average O.'s emergence in 10% of cases using antibiotics. In a wedge, a picture the leading signs of allergic average O. are mucous and watery or mucous inodorous allocations from an ear, hypostasis and cyanosis of a tympanic membrane. Perforation of a tympanic membrane sbych-but happens enough big sizes. The bent to formation of polyps is noted. Allergic average O.'s current the persistent, not giving in to usual methods treatments. The bent to aggravations is noted, to-rye are not followed by either ear pain, or fervescence. The condition of a sensitization of an organism at patients comes to light by means of careful a wedge, inspections, uses eosinophilic test (see) and skin tests with various allergens (see. Skin tests ). Positive takes of the hyposensibilizing therapy confirm allergic genesis of a disease.

Treatment consists in use of the hyposensibilizing means (Dimedrol, Suprastinum, tavegil, Pipolphenum). For the purpose of consolidation of a mucous membrane of a drum cavity and reduction of its permeability for bacteria and various irritating substances locally appoint solutions of silver nitrate, a tannin.

The forecast at timely begun treatment, as a rule, favorable. The hardening of an organism is necessary.

Idiopathic gematotimpanum. It is supposed that the acute hemorrhagic inflammation of a mucous membrane of all tympanic cavities is the reason of an idiopathic gematotimpanum. Its main symptoms are incremental relative deafness and the blue coloring of a tympanic membrane found at an otoskopiya. In a drum cavity liquid of chocolate color accumulates. At X-ray inspection decrease in a pnevmatization of a mastoid and destruction of partitions between cells is noted. Treatment is operational, during operation in mastoidal cells bloody contents are found, and the bone can be black color.

Acute average otitis at infectious diseases. ^ри inf. diseases (measles, scarlet fever, flu, etc.) acute average O.'s current can be typical, however has specific features characteristic for more often given inf. diseases.

Influenzal acute average otitis meets quite often. In influenzal O.'s etiology the major role is played by the filtered virus getting into a drum cavity as through an Eustachian tube, and a hematogenous way. The hemorrhagic form of an inflammation is characteristic that is shown by sharp expansion of blood vessels, formation of extravasates in outside acoustical pass, on a tympanic membrane, in cavities of a middle and inner ear. On a tympanic membrane separate dot ecchymomas, bubbles with bloody contents can appear, to-rye, bursting, make an impression of a rupture of a tympanic membrane. At perforation of a tympanic membrane serous and bloody allocations appear in a large number. In process of development of an inflammation on average to fish soup of allocation from an ear become more plentiful and gain purulent character. Hearing goes down not only owing to disturbance of sound carrying out, but also owing to disturbance of sound perception since hemorrhages on the course of the VIII couple craniocereberal (cranial, T are quite often observed.) nerves, and also owing to intoxication. Patients complain of the severe pains in an ear which are followed by noise, dizziness, a hearing impairment, a headache. Pain can irradiate on the course of branches trigeminal and big occipital nerves; paresis of a facial nerve is sometimes observed. Body temperature is increased, oznoba are frequent. At an otoskopiya the tympanic membrane is represented red with hemorrhagic bubbles. Often tympanic membrane is changed only in a loose part, the tense its part can be almost normal. Noise in an ear and a hearing impairment can be irreversible owing to development of neuritis of cochlear part VIII of couple of cranial nerves. At influenzal acute average O. development of a mastoiditis, and also intracranial complications is possible.

Scarlatinal otitis calls the highly virulent causative agent of scarlet fever getting into a drum cavity tubogenny or more often in the hematogenous way. Scarlatinal O. usually happens bilateral. Distinguish the early and late scarlatinal Island. Early O. arises along with emergence of rash and has usually heavy current. Late scarlatinal O. has easier current and arises from the 4th week of a disease. Often scarlatinal O. develops imperceptibly and it is found only with the advent of suppuration from an ear. This results from the fact that at this disease nerve fibrils in a tympanic membrane and in a mucous membrane of a drum cavity, and also serious condition of the patient are surprised. The causative agent of scarlet fever causes toxic damage of a vascular wall, fibrinferments of small vessels. Blood circulation and a trophicity of tissues of ear, including and bone are as a result broken that leads to a necrosis of fabrics. The tympanic membrane and acoustical stones quite often completely collapse. Allocations from an ear owing to destruction of a bone have a fetid smell. Usually perforation of a tympanic membrane remains resistant, the otorrhea periodically renews, hearing is sharply lowered. Necrotic scarlatinal O. in view of big destructions seldom comes to an end with recovery and recovery of hearing.

Clumsy otitis develops only at a small part of patients, it is preferential on the 1st and 2nd week of a disease. At the same time early is caused clumsy O., as a rule, by a clumsy virus, and late — secondary microflora. The course of inflammatory process on average to fish soup at measles has much in common with O. at scarlet fever, in some cases the necrotic Island is marked out.

Tubercular otitis as primary disease is observed seldom. More often it arises owing to a hematogenous drift of mycobacteria of tuberculosis at a pulmonary tuberculosis, limf, nodes, bones. Characteristic signs of tubercular O. are almost total absence of pains at the beginning of a disease and multiple perforation of a tympanic membrane, to-rye further can merge in one extensive perfora-radio set. Allocations from an ear have slivkoobrazny character and if the bone is involved in process, are fetid. In hard cases necroses in walls of tympanic cavities and acoustical pass, acoustical stones are observed. Quite often these necroses lead to formation of fistulas, in to-rykh there are granulations or polyps, including and in the field of the channel of a facial nerve that causes its defeat. The sharp hearing impairment at tubercular O. is caused not only by disturbance of sound carrying out, but also early involvement in process of an inner ear.

Infectious O.' treatment consists of treatment of a basic disease, napr, antituberculous remedies, and acute average O.'s treatments (see above).

Major importance in prevention heavy inf. acute average O. has timely, active treatment of a basic disease, and also careful care of a nasal cavity and a mouth. It reaches not only reduction of frequency inf. acute O., but also reduction of number hron, average O., to-rye in the majority are connected with children's infections and are followed by development relative deafness (see), and at children at early age at bilateral defeat — surdomutisms (see).

Traumatic otitis develops after blows, bruises, concussions at explosions, falling, as a result of car and aviation accidents and sports exercises, at thermal and chemical burns.

Contagiums get into a middle ear on the wound channel in bone walls of a drum cavity or through ruptures of a tympanic membrane. The blood which streamed in a drum cavity is a good medium for microorganisms and promotes bystry development of inflammatory process. Allocations from an ear carry at first bloody, and then purulent character. The Otoskopichesky picture of traumatic O. is very characteristic: perforation of a tympanic membrane has the irregular, star-shaped shape, is surrounded with hemorrhages. Damages of outside acoustical pass and soft tissues to a circle of an ear are quite often noted.

The average O. caused by a contusion is followed by a considerable hearing impairment up to deafness that is explained by an injury of c. N

of the village Mareotit — a disease of a middle ear, emergence to-rogo connect with hit of water in an ear through an Eustachian tube, blow of a wave in a tympanic membrane during the diving, a diving.

Mareotit it is characterized by a congestion and noise in an ear, a hearing impairment and unpleasant feeling owing to strong sounding of own voice (autophonia). Treatment is carried out by vasoconstrictors (in the form of drops in Nov), appoint ear inflations.

The aero-otitis arises at impact on a tympanic membrane and a mucous membrane of a middle ear of sharp differences of atmospheric pressure at air flights. At an aero-otitis severe pains in an ear, a ring and a sonitus, a hearing impairment, sometimes dizziness develop. At an otoskopiya are defined: a hyperemia of a tympanic membrane, hemorrhage, and at very strong influence — a rupture of a tympanic membrane. Unsharply expressed aero-otites of treatment do not demand.

At the traumatic otitis which is followed by perforation of a tympanic membrane, medical actions come down to processing of a wound surface and the prevention of infection of a drum cavity (e.g., introduction of the turundas moistened with solution of an antibiotic, insufflation of powder of streptocides).

Acute average otitis at children of early age

Acute average O. meets at children of early age more often, than at children is more senior age groups and at adults. Its current differs in an originality that depends on features of an anatomic structure of a temporal bone, Eustachian tube, drum cavity, and also immunol, features of a children's organism. The Eustachian tube at newborns is shorter, wider and is located more horizontally, than at adults. Lymphoid rollers at a pharyngeal opening of an Eustachian tube are developed badly. The drum cavity contains the embryonal miksoidny fabric which is a good medium for microorganisms. Components of a temporal bone are not connected among themselves by strong seams yet, and are divided by the cracks filled with fibrous fabric; impressions and cracks are available also in a roof of tympanic cavities. The mastoid is not created yet, and tympanic cavities are surrounded with the spongy bone consisting of the cavities executed by marrow and richly vaskulyarizirovanny; tympanic membrane thicker. Owing to the specified features of a structure of a temporal bone at the child contagiums easily get through a wide Eustachian tube into a middle ear and cause bystry development of an inflammation in a drum cavity. Acute average O.'s emergence at newborns and babies is promoted by also preferential position of the child on spin when slime from a nose and a nasopharynx, and also emetic masses during the vomiting easily gets through an Eustachian tube into a drum cavity.

Acute average O.'s activator at children of early age more often is the pneumococcus. The large role in its etiology is played by acute respiratory viral infections, inf. diseases, and are aged more senior than 3 years — adenoides (see). Ways of penetration of contagiums the same, as at the adult. Inflammatory process proceeds as osteomyelitis and can easily pass through the available cracks to the neighboring areas. It is promoted by also big resistance of a tympanic membrane. The miksoidny fabric which is easily breaking up under the influence of an inflammation leads to formation of granulations in tympanic cavities, to-rye complicate outflow of pus through the opening in a tympanic membrane formed at perforation or a paracentesis that leads to spread of an infection on antrum (a cave, T.) and a surrounding diploetichesky bone with development so-called. antrita (see).

In acute average O.'s development in children there are same periods that at the adult. In the first period the child is uneasy, often cries, sleeps badly, with shout wakes up and cannot long fall asleep, refuses a breast or with shout stops sucking since suction and swallowing strengthen ear pain. The child can swing the head here and there, sometimes reaches a hand for a sore ear. The phenomena of a meningism can be observed: spasms, protrusion of a fontanel, the zaprokidyvany heads, the fixed look, vomiting. Body temperature reaches 40 ° above. Excitement of the child can be replaced by oppression, he becomes sluggish, sleeps much. After emergence of suppuration from an ear that indicates transition of a disease to the second period, the child calms down, the general state it improves. The disease proceeds of several days to 5 — 6 weeks. In a gemogramma the considerable leukocytosis and changes in uniform elements of blood is defined.

The diagnosis is made on the basis by a wedge, pictures and data of an otoskopiya. At assessment of a condition of a tympanic membrane it must be kept in mind that its hyperemia can appear during the crying or manipulations in outside acoustical pass and only the repeated otoskopiya allows to avoid a mistake. Significance is attached to a kozelkovy symptom — reaction of the child during the pressing on a trestle. However reaction during the pressing to a trestle can be manifestation of negative attitude of the child to a touch therefore it is necessary to carry out comparison of this symptom on other ear. At patients the hearing impairment as disorder of sound carrying out is noted. At Weber's experience the sound of a tuning fork of S-128 is better heard a sore ear. At early children's age it is shown by turn of eyes towards a sore ear. For diagnosis can be used: thermometry on a surface of mastoids, an antral puncture about bacterial, a research of punctate, a X-ray analysis of temporal bones. Differential diagnosis is carried out with the outside Lake.

Treatment is same, as at adults at the dosage of pharmaceuticals corresponding to age. Well calm pain at babies the drugs of bromine appointed the nursing mother, local heat in the form of the warming komgtpess and warm bandages. At serious condition the paracentesis is shown. It is not necessary to expect spontaneous perforation of a tympanic membrane since the pus which accumulated in a drum cavity can spread in a head cavity through the available degistsention and cracks in a temporal bone quicker.

Prevention generally consists in prevention acute respiratory 'diseases and inf. diseases, a hardening, the correct feeding and good nutrition of the child, and also in observance by mother a dignity. - a gigabyte. rules of feeding of the child.

BTsZh-otitis — quite rare disease; occurs at children of early age. Its development is connected with introduction of a tuberculous vaccine of BTsZh. It is confirmed by detection in BTsZh separated from an ear of bacteria of a vaccinal strain. It is characterized by the imperceptible beginning at a standard temperature, the sluggish long course, growth of plentiful granulations in a drum cavity. Treatment: removal of granulations from an ear, introduction to an ear of solution of streptomycin, insufflation of PASK.

Chronic average otitis

Chronic average O. — a slow disease, at Krom inflammatory process on average to fish soup is as if delimited. Under the influence of various provocative moments (cooling, inf. diseases of upper respiratory tracts, unfavorable conditions of life, etc.) there can occur progressing of inflammatory process. The leading role in a pathogeny hron, average O. is played by change of reactivity of an organism, and also specific features of a structure of a mucous membrane of a middle ear. Development of a disease is promoted: patol, the processes in an Eustachian tube breaking its drainage and ventilating functions; the narrowing of outside acoustical pass complicating outflow of exudate from a drum cavity; frequent recurrence of an acute inflammation of a middle ear. In nek-ry cases of O. carries primary hron, a current. Depending on patomorfol, changes and a wedge, pictures of a disease hron, divide average O. into a mesotympanitis and an attic disease.

A clinical picture

At hron, average O. constant or periodic allocations from an ear, a hearing impairment, sometimes dizzinesses, headaches are noted for a long time.

At a mesotympanitis the mucous membrane of a drum cavity is involved in inflammatory process, mucous allocations from an inodorous ear with impurity of pus appear, there can occur the central perforation of a tympanic membrane. The mesotympanitis lasts long vaguely, decades, sometimes during all life of the patient. Suppuration can periodically stop or decrease considerably. As a result of scarring formation of unions between a tympanic membrane and a medial wall of a drum cavity, acoustical stones, fusion of labyrinth windows is possible that leads to a persistent and considerable hearing impairment. The perforation opening of a tympanic membrane in nek-ry cases cicatrizes, and in nek-ry — remains. Carious process in an ear sometimes causes growth of granulyatsionny fabric and polyps in a drum cavity, to-rye can become the reason of a delay of pus in a drum cavity and cause headaches, a feeling of pressure in an ear.

At a mesotympanitis the perforation opening is located in the tense part of a tympanic membrane, has the different size and the form. Through big perforation openings the changed mucous membrane of a medial wall of a drum cavity is visible, polyps, growths of granulyatsionny fabric can be found.

At an attic disease patol, process is localized by hl. obr. in an attic. At the same time there occurs regional perforation in pe re day upper or posterosuperior quadrants of a tympanic membrane or its total defect is formed; bone walls of a drum cavity and acoustical stones are surprised; appear purulent, with off-flavor of allocation from an ear. The most dangerous and frequent (to 95%) a complication of an attic disease is cholesteatoma (see), edges in the course of growth causes big destructions of a temporal bone and leads to intracranial complications, peripheral paresis or paralyzes of the facial and taking-away nerves, burrowings in a bone labyrinth.

At an attic disease through a regional perforation opening of a tympanic membrane it is possible to enter the bellied attikovy probe of Voyachek into supratympanic space and to make its audit. At the same time find a roughness of bone walls at their caries or the holeste-atomic masses filling to a greater or lesser extent an attikoantralny cavity. Quite often during the sounding parts of a cholesteatoma in the form of white scales with a putrefactive smell, small sequesters are taken. In nek-ry cases at hron, a purulent attic disease change of outside acoustical pass at the expense of an overhang of its posterosuperior wall is observed that happens at destruction of a bone a cholesteatoma. With a pressure quite often holesteatomny masses and pus are forced out by the probe in a middle ear.

At hron, purulent O. inflammatory process can pass to a drum string or a drum texture that is shown by disorder of taste or pains in an ear. At an otoskopiya find an otorrhea of the purulent or mucous character, and quantity separated not always corresponds patol, to changes. If inflammatory process is limited to a mucous membrane, then the discharge has no smell, has mucous character, sometimes with impurity of pus; emergence in separated blood is connected with development of granulyatsionny fabric; purulent discharges with off-flavor demonstrate involvement in patol, process of a bone tissue of a middle ear.

The hearing impairment at patients hron, purulent O. is caused not only disturbance of sound carrying out owing to damage of separate links of the sound carrying out device, but also, to a lesser extent, sound perception by the toxins which got into an inner ear.

The diagnosis

Diagnosis hron, average O. is based on complaints of the patient, the anamnesis of a disease, data of an otoskopiya, results of a research of hearing, and also special methods of a research, among to-rykh the greatest value has rentgenol. the research, a cut is based on identification of changes of lightness of mastoidal cells, size and transparency of a drum cavity and an antrum, emergence of a sclerosis of a temporal bone, and also destruction of acoustical stones and walls of an attic. At a mesotympanitis owing to damage only of a mucous membrane of the main tympanic cavities transparency of a drum cavity and an antrum goes down, the form and their outlines remain usual. Sometimes antrum it is much reduced, however thanks to an intaktnost of bone walls the originality of its form remains. Acoustical stones because of reduction of lightness of a drum cavity in pictures do not differ. At the attic disease which is followed by defeat of bone walls of tympanic cavities in pictures defect of an outside wall of an attic and sharp expansion of an entrance in antrum, having an appearance of the wide light strip connecting an attic and antrum comes to light. Owing to destruction of walls the sizes of an attic and antrum sometimes sharply increase up to merge among themselves. At a long current hron. Islands note sharp disturbance of a pnevmatization of cells of a temporal bone and reduction of an antrum. With well developed cellular system of a temporal bone it can remain with persons concerning a pnevmatizire-bathroom, despite a long-term hron, the inflammation which is followed by reorganization of cells and a thickening of their partitions. At the same time the sizes of an antrum a long time can not change. Apply to specification of localization and the profound characteristic of changes in the bones arising at an attic disease and its complications tomography (see).

Differential diagnosis carry sometimes out with tumors of a middle ear, to-rye can mask inflammatory changes of a mucous membrane, and also with the changes in an ear observed at tuberculosis, syphilis. In these cases great diagnostic value is attached serol. and bacterial, to researches, results of a biopsy.

Treatment

Treatment hron, purulent average O. is subdivided on conservative and operational. A mesotympanitis, as a rule, treat conservatively, at an attic disease apply generally operational treatment.

Conservative treatment consists in appointment in the period of an aggravation of pharmaceuticals and physiotherapeutic procedures. Treatment of diseases of a nose, nasopharynx and throat is at the same time necessary. Topical treatment consists in systematic removal of pus of outside acoustical pass with the subsequent introduction to a drum cavity for impact on a mucous membrane disinfecting and astringents (4% of solution of boric alcohol, 2 — 3% of solution of protargol, 3% of solution of liquid of Burov, 1% of solution of zinc sulfate, spirit solution of Furacilin — 1: 1500 etc.). Apply antibiotics, before appointment to-rykh reasonable to produce bacterial. a research of microflora in an ear and to define its sensitivity to antibiotics. Spirit solutions of antibiotics have favorable effect. Along with antibiotics and in combination with them apply proteolytic enzymes (trypsin, chymotrypsin, a lidaza, a deoxyribonuclease, hyaluronidase, etc.), to-rye liquefy a discharge, soften commissures and hems, have antiinflammatory effect. It is reasonable to carry out giposensi-biliziruyushchy nonspecific therapy by antihistaminic drugs (Dimedrol, Pipolphenum, Suprastinum, Diazolinum, tavegil, delagil, etc.), and also drugs of calcium (calcium chloride, calcium lactate, a gluconate of calcium). Hormonal drugs should be used carefully.

The physical therapy is carried out out of an aggravation in the form of the general UF-radiations, air bathtubs, flourishes, etc. A contraindication to physiotherapeutic treatment are deeply come damages of a bone tissue and the labyrinth phenomena. Out of an aggravation of purulent process carry locally out an electrophoresis of zinc, Furacilin, silver, UF-radiation of a drum cavity through a tube or UF-radiation of a collar zone, mud cure of area of an ear and neck.

In the presence in a drum cavity of granulations and polyps it is necessary to remove them by means of an ear conchotome and the curette or an ear polipny cutting loop. Small single granulations are quite often liquidated at use of spirit drops, and also tushirovaniy 10 — 20% by solution of silver nitrate.

Operational treatment

At an attic disease, especially with a cholesteatoma, with big bone destructions, conservative treatment is ineffective and treatment can be reached only in the operational way. As perhaps bystry development of life-threatening intracranial complications, ear operation it is shown not only in medical, but also in the preventive purposes. The issue of terms of operation shall be resolved on the basis of studying of dynamics of a disease. If there are symptoms of intracranial complications, then operation is done quickly according to vital indications. The purpose of operation consists in removing patol, the center and instead of a complex system of a middle ear to create the uniform endaural bone cavity which is reported with outside acoustical pass and having the smooth walls covered with skin. Such operation received the name obshchepolostny or radical. Typical radical operation consists of the following stages: a zaushny section of skin and soft tissues, their separating from a front surface of a mastoid and from a back and posterosuperior wall of bone acoustical pass; removal of a bone tissue for opening of an antrum and an attic and knocking down of a back wall of bone acoustical pass together with the bridge; surgical treatment of the opened cavities and a drum cavity (removal of a carious bone, granulations, cholesteatomas, smoothing of ledges etc.); plastics of outside acoustical pass; suture on a wound. For each of these stages many ways are offered, combinations to-rykh give a large number of options of radical operation. So, the operational section can be made behind an auricle, in outside acoustical pass, in front between a curl and a trestle. In these cases speak about zaushny radical operation, endaural or eidauralny radical operation, front radical operation. Among options of the specified operation are available such, at to-rykh keep untouched acoustical stones, the remains of a tympanic membrane etc., call such options conservative radical operation. If at operation delete only necessary amount of bone substance sufficient for successful recovery, then such option is called the sparing radical operation.

At the isolated defeat of an attic and antrum that is quite often observed at a cholesteatoma, make opening only of an attic and an antrum; such operation is called a radical attikoantrotomiya.

There are three options of opening of an attic and an antrum: antrum open through an outer surface of a mastoid, then delete a bone over an entrance to a cave, force down the bridge and in the last turn delete a sidewall of an attic (across Shvarttsa); originally delete a sidewall of an attic in the depth of outside acoustical pass, then open a bone over an entrance to a cave and to the last turn antrum (across Shtakka); force down a posterosuperior wall of bone outside acoustical pass towards an entrance to a cave, at the same time open an entrance to a cave and an attic (according to Wolff).

There are also numerous ways of plastics of outside acoustical pass (see. Otoplasty ). It is possible to find a big lower rag or big upper. The plastics is begun or with a slit of a back wall, or with cross section. Rags on a wall of a bone wound shall lay down freely, without tension. In nek-ry cases for acceleration of an epidermization of walls of a cavity find for plastics a rag (free or on a leg) from zaushny area near a section. After plastics of outside acoustical pass the wound is prokhmyvat solution of an antibiotic, through outside acoustical pass enter a gauze turunda into a drum cavity; the zaushny wound is sewn up. Operation comes to an end with imposing of a kolonchaty bandage. The first bandaging at a normal current of the postoperative period is done on 5 — the 7th day, seams at the same time remove. Since 8 — the 9th day after operation of bandaging do daily. Process of healing after radical operation continues of 3 weeks to several months depending on the size of an ear wound, size of plastic rags, viability of a bone tissue, the general condition of sick, correct care of a wound etc. Typical radical operation quite often leads to a hearing impairment since at the same time the mechanism of sound carrying out is roughly broken. Due to a possibility of use operative microscope (see) ear operation combine with plastic recovery of the mechanism of sound carrying out — tympanoplasty (see).

After a middle ear operation at sharply expressed inflammatory reaction in the first days appoint radiation a lamp sollyuks and UV rays in suberythema doses; at inertly healing wounds — UVCh until filling of a wound with granulations, UF-radiation at first in hyper erythematous, and then in suberitem-ny doses and darsonvalization. After slukhovosstanovitelny operations apply microwave therapy and diadynamic currents to elimination of the inflammatory reactive phenomena, more bystry healing and the prevention of formation of rough hems.

The forecast

At uncomplicated forms meso - and an attic disease the forecast at timely begun treatment favorable. In the presence of a cholesteatoma timely treatment prevents development of life-threatening intracranial complications.

Prevention hron. The lake consists in timely and rational treatment of acute Lakes.



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H. I. Kostrov, V. P. Fomina-Kosolapov; M. I. Antropova (fizioter.), A. N. Kishkovsky (rents.).

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