Mastoiditis

Description:

Mastoiditis - a purulent inflammation of a mucous membrane and bone tissue of a mastoid of a temporal bone.

Mastoiditis symptoms:

The mastoiditis is characterized by the general and local symptoms. The general symptoms - deterioration in the general state, fervescence, change of composition of blood - significantly do not differ from displays of acute purulent average otitis. The analysis of dynamics of these signs has diagnostic value at suspicion on possible involvement in inflammatory process of a mastoid. Often there pass 1-2 weeks from the beginning of acute average otitis and against the background of improvement of a clinical picture overall health worsens again, temperature increases, pain and suppuration from an ear renew. Sometimes suppuration is absent because of disturbance of outflow of pus from a middle ear. In certain cases the mastoiditis can arise not later, and together with acute average otitis.

Rise in temperature can be insignificant, however even subfebrile temperature attracts attention after its normalization which occurred after a perforation of a tympanic membrane at acute average otitis. In peripheral blood the moderate leukocytosis is noted, the shift in a leukocytic formula to the left, gradual increase in SOE appears. At the same time the general condition of the patient worsens, appetite goes down.

Pain is quite often localized in an ear and in the field of a mastoid, at some patients it covers a half of the head on the party of defeat and amplifies at night. An important sign of a mastoiditis is morbidity at a palpation and percussion of a mastoid, a thicket in the field of a top or the platform of a mastoid. There are also complaints to noise in an ear or in the head on side of a sore ear and the expressed relative deafness.

At inspection of the patient the hyperemia and infiltration of skin of a mastoid owing to a periostitis sometimes is defined. The smoothness of a zaushny fold and an ottopyrennost of an auricle of a kpereda can be also observed. At an otoskopiya pay attention to suppuration from an ear. Quite often it happens profuse, the pulsing character, slivkoobrazny pus fills outside acoustical pass right after cleaning of an ear. Sometimes plentiful release of pus through a back wall of outside acoustical pass joins usual suppuration through perforation in a tympanic membrane. It is possible to establish the reason of such strengthening of suppuration only at careful cleaning of an ear and detection of fistula from where pus is emitted. Also such option of a current of a mastoiditis when there is no otorrhea is possible - it is a sign of disturbance of outflow of pus when closing defect of a tympanic membrane or at the block of an entrance to a cave.

Important otoskopichesky sign of a mastoiditis is the overhang of a posterosuperior wall of outside acoustical pass in its bone department.

Overhang it is connected with development of a periostitis and pressure of pathological contents in the field of a front wall and an entrance to a cave. In the same place the fistula through which pus comes to outside acoustical pass is sometimes formed. The tympanic membrane at a mastoiditis is often hyperemic, an infiltrirovana.
In diagnosis of a mastoiditis the X-ray analysis of temporal bones in a projection according to Schueller is of great importance, at the same time compare a sore and healthy ear. At a mastoiditis on the roentgenogram decrease in a pnevmatization, a zavualirovannost of an antrum and cells of a mastoid is defined various intensity. In late stages of process, at a destructive form of a mastoiditis, it is possible to see destruction of bone partitions and formation of sites of an enlightenment due to formation of the cavities executed by pus and granulations.

Distribution of process in a mastoid and its transition to the next anatomic educations depend on development of pneumatic cells in various departments of a temporal bone - scales, a malar shoot, a pyramid, etc. The inflammation in these parts sometimes is followed by break of pus in surrounding soft tissues.
The break of pus through a cortical layer on an outside surface of a mastoid leads to formation of subperiosteal abscess. The swelling and pastosity of skin preceding it in zaushny area, a smoothness of a zaushny fold and an ottopyrennost of an auricle at the same time amplify.

Distribution of pus from apical cells of a mastoid in interfascial spaces of a neck is designated as an apical and cervical mastoiditis. Its various forms called on names of authors differ in the place of break of pus in the field of a top. Betsold's mastoiditis is characterized by distribution of pus through an internal surface of a top of a mastoid under neck muscles. At the same time the dense swelling of soft tissues of a neck, sometimes on an extent from a mastoid top to a clavicle is observed. Turns of the head are painful therefore the patient keeps the head in forced situation, inclined in the sick party. On kletchatochny spaces of a neck pus can reach a mediastinum and cause a mediastinitis.

The break of pus through an outside wall of a top is designated as a mastoiditis Orleans, distribution of pus through incisura digastrica medialny a biventral muscle with formation of deep abscess of a neck - Mouret's mastoiditis. Distribution of inflammatory process on the basis of a malar shoot is called a zygomaticitis, on scales of a temporal bone - skvamity. At the same time inflammatory reaction of skin of the respective area (a hyperemia, infiltration, local morbidity) is observed.

Distribution of pus from a mastoid on cellular system in a pyramid of a temporal bone is possible, then the petrositis which clinical picture is designated as Gradenigo's triad develops: acute average otitis, trigeminit, paresis or paralysis of the taking-away nerve.

The greatest danger on the frequency of development of complications is constituted by atypical forms of a mastoiditis. Their emergence and a current is connected with a number of biological factors (age of the patient, the general and local reactivity of an organism), virulence of the activator, a structure of a temporal bone, in particular its cellular structure. The special role in development of atypical forms of a mastoiditis belongs to irrational therapeutic tactics. At the atypical course of process there is no expressed sequence of stages of development of an inflammation, separate symptoms have no characteristic clearness. So, pain either does not disturb absolutely, or happens weak. Suppuration can be expressed minimum or be absent absolutely. At the same time it is necessary to consider that atypical forms are almost always followed by extensive destruction of a bone, at the same time development of intracranial complications is possible.

Mastoiditis reasons:

Activators of a mastoiditis are the same microorganisms which cause development of acute purulent average otitis.

Treatment of the Mastoiditis:

Distinguish conservative and surgical treatment of a mastoiditis. Anyway, taking into account a possibility of development of heavy complications, treatment has to be carried out in the conditions of a LOR-hospital. Conservative treatment usually makes success in an exudative stage of a mastoiditis when there is no destruction (alteration) of a bone yet and exudate outflow is not broken. The basis of the conservative therapy corresponding to active treatment of acute average otitis is made by an antibioticotherapia, drugs of a broad spectrum of activity are appointed, preference is given to beta-laktamny antibiotics. An important component of treatment of a mastoiditis is ensuring free outflow of pus from a middle ear and local use of antibacterial drugs taking into account sensitivity of flora from an ear. Also pay attention to a condition of a nose, nasopharynx and okolonosovy bosoms.

If within a day after the beginning of conservative treatment the main symptoms considerably did not decrease (body temperature, pain at a palpation of zaushny area, the reactive phenomena in an ear, etc.), it is necessary to pass to surgical treatment. Partial improvement of a condition of the patient allows to prolong conservative treatment, with its certain optimization. However if the main symptoms remain also after second day of treatment, with operation it is impossible to hesitate.
Detection at the patient at primary survey of signs of the second stage (alterativny) of a mastoiditis is the indication to urgent surgical treatment. The absolute indication to urgent surgical treatment are emergence of signs of intracranial complications, emergence of complications in areas, boundary with a middle ear (subperiosteal abscess, break of pus in the field of a mastoid top, development of a zygomaticitis, skvamit, petrositis). Operation, certainly, is shown if the patient with a mastoiditis had symptoms of otogenic paresis or paralysis of a facial nerve, the labyrinthitis developed.
At a mastoiditis operation an antromastoidotomiya - opening of an antrum and a mastoidotomy is carried out. Removal of pathological fabrics has to be full therefore sometimes operation comes to an end with removal of all shoot together with its top - a mastoidektomiya. At children up to three years the mastoid is not developed therefore operation carries the name of an antrotomy.

Operation pursues the aim of elimination is purulent - destructive process in a mastoid with simultaneous drainage of a drum cavity. Intervention is carried out under an endotracheal anesthesia, adults in some cases operate under a local infiltration anesthesia.

By scalpel do a section of skin, hypodermic cellulose and a periosteum, receding on 0,5 cm from a transitional fold behind an auricle, length of a section of 5-6 cm. At subperiosteal abscess do at first a small section by a scalpel tip to give outflow to pus which is usually under pressure. The wide raspatory otseparovyvat soft tissues with a periosteum, baring a cortical layer in the field of the platform of a mastoid, impose a ranorasshiritel of the lira type. The bone wound has to be limited from above to linea temporalis, in front the rear edge of acoustical pass, from below - a mastoid top. Trepanation of a bone is carried out by means of chisels of various sizes, for this purpose it is possible to use also mills or Voyachek's chisels. After opening of a cortical layer of a kzada from spina suprameatum on 6-8 mm. and below linea temporalis on 4-5 mm. the cells executed by pus and granulations are usually opened. Deleting the affected bone, gradually go deep towards a cave which has to be surely opened for providing a drainage of a drum cavity. The cave is located at a depth of 1,5-2 cm from a surface of a mastoid and is proyektsionno defined kzad from the place of transition of a back wall of outside acoustical pass to upper. To be convinced that the opened cavity in the depth of a bone wound is a mastoid cave, it is possible by means of sounding by the bellied probe which through aditus ad antrum easily gets into a drum cavity. Besides, at the bottom of a cave protrusion of a smooth ampoule of the horizontal semicircular channel from which kpered there is a bone channel of a facial nerve is visible. The further course of operation assumes careful removal kariozno of the changed bone, pus and granulations. The scraping of a cave demands big care that at manipulations in its front departments not to dislocate an anvil which short shoot is located at the bottom of aditus. Also carefully it is necessary to delete kariozno the changed bone near the channel of a facial nerve, the semicircular channel and a sigmoid sine. At extensive carious process all cellular groups, including apical, perisinuozny, malar are consistently opened. Upon termination of this stage of operation the surface of a bone wound smoothes out a bone spoon or mills.

Elimination of a suppurative focus in a mastoid comes to the end with wrecking of a back wall of outside acoustical pass to the level of an ampoule of the horizontal semicircular channel, but with preservation of annulus tympanicus. Also the plastics of a back skin wall of acoustical pass is carried out, the rag is hemmed in a bottom corner of a wound. After a bathing of the wound warm solution of an antiseptic agent, drying and a tamponade the turundas impregnated with a sterile liquid paraffin or levomekoly operation comes to the end with imposing on a wound in zaushny area of primary seams. The tampon is removed through acoustical pass for 2-3 day after operation. At small processes the back wall of acoustical pass is not removed. After operation the zaushny wound is conducted in the open way.

The postoperative wound after an expanded mastoidotomy at patients with otogenic intracranial complications In the postoperative period usually is openly conducted continue an antibioticotherapia, appoint vitamins, fortifying treatment, carry locally out ultra-violet radiation. The wound is tied up daily. During bandaging delete from a turunda wound, drain it, wash out antiseptic solution, then again enter turundas and apply a bandage. In process of emergence of an epidermization of a turunda do not enter, excessive granulations delete with the curette. At a favorable current of the postoperative period the wound repair and treatment comes usually by 20th day.