Average otitis

Description:

The middle ear represents a cavity between a tympanic membrane (internal border of an outside ear) and an inner ear; in a middle ear the Eustachian tube opens. Acute average otitis is divided into banal, secretory otitis, idiopathic гематотимпанум, acute otitis at infectious diseases, traumatic otitis. Acute otitis in certain cases (for example, at inadequate treatment) can pass into chronic. Depending on features of clinical and morphological manifestations, chronic average otitis is subdivided into a mesotympanitis, an attic disease and a mesoattic disease.

Symptoms of Average otitis:

The clinical picture of an acute inflammation of a middle ear at newborns and babies is as follows. The child often wakes up at night, is very uneasy, shouts. The postural change if it is taken on hands (so-called vestibular attention), has no the calming effect. Sometimes after half-hour shout the child calms down, and day passes safely, but the same phenomenon - concern, sharp shout repeats at night. If to give to the child a breast (or boiled water), then after greedy one-two drinks he throws a nipple of mother or a pacifier. Liquid at the same time is swallowed not completely and partially pours out from mouth corners; temperature is increased, the child mayatnikoobrazno moves the head, as if scratches ears about a pillow, sometimes reaches a hand for an ear. At increase of intoxication fleeting convulsive reductions of eye muscles can join; eyes are directed in one point up and aside. After a while from an ear pinkish liquid then the child calms down also temperature at once is shown or gradually falls. In the next days allocations from an ear gain mucous character. In several days, sometimes weeks, allocations stop.

So the uncomplicated acute inflammation of a middle ear from the outcome in recovery proceeds.

At so-called latent average otitis temperature in the beginning subfebrile, but sometimes in several days after the beginning of a disease it accepts the jumping character, and then latent otitis can become explicit.

At severe forms of acute average otitis the habit view of the child is characteristic: the person, pale with apathetic expression, the pointed nose, widely opened sunk-down eyes, the eye turned in one direction, times of a grimace of pain, the bent hands - "the conductor's hands".

Pain as reaction of a nervous system to inflammatory process is a subjective sign of an acute inflammation of a middle ear. The small child cannot complain of pain, but he expresses it variously  :  1) a shriek, 2) the pendulum movements of the head, sometimes a gnashing of teeth (children are more senior than year), 3) sleeplessness the child does not sleep or lies blindly, opening them at a touch, or sleeps is disturbing.

Pain amplifies during the swallowing and suction owing to increase in pressure on average to fish soup: increase in pressure results from the movement of a mandible and reduction of the muscles of a soft palate closing and opening the mouth of an Eustachian tube. Loss of appetite is explained, except toxicosis, by this pain.

Pain causes the following two signs: 1) the child sucks the breast opposite to side of a sore ear more willingly, i.e. sucks more willingly, lying on a sore ear; 2) pressing on a trestle causes shout, a grimace of pain and tilting of the head. But this symptom is of secondary importance as pressure upon a trestle causes pain and at an inflammation of outside acoustical pass; pressure upon a trestle can cause pain and in the child with a healthy ear at a labile nervous system. The following amendment was offered: it is necessary to press on a trestle during sleep. At response in these conditions the symptom is more reliable.

From other symptoms more increased temperature on a mastoid on the sick party deserves attention. It is noticed also that the skin taken pleated on a mastoid of the sick party is a little more dense, than on the healthy party. These two symptoms matter at distribution of process on a mastoid.

At an acute inflammation of a middle ear the nasopharyngitis picture is usually observed: plentiful allocations from a nose, accumulations of allocations in back departments of a nose, slime in a nasopharynx, an injection of vessels of a soft palate. On his hyperemic mucous membrane red dot eminences - result of an inflammation of mucous pieces of iron are visible. Sometimes there is vomiting. Occipital and side cervical lymph nodes are condensed.

It is necessary to pay attention to bystry falling in weight, especially at ponosa, but falling in weight at an ear disease can be also without ponos.

Symptoms of an acute inflammation of a middle ear at early children's age can intertwine with other symptoms depending on defeat of other bodies, for example combinations of acute average otitis with pneumonia, dyspepsia are possible. At the same time the symptomatology can be such that the attention of the doctor is fixed not on an ear which damage is looked through, and on other disease of the child. Therefore at all diseases of the child it is necessary to apply an otoskopiya for the purpose of check of a condition of ears.

Reasons of Average otitis:

The embryonal miksoidny fabric which is in a drum cavity is unstable and begins to break up and be replaced with connecting fabric soon after the birth. At microscopic examination it is possible to see that physiological process proceeds with fabric disintegration, with small-celled infiltration, with vasodilatation and formation of an exudate, i.e. histologically there is a picture of inertly proceeding inflammation of the middle ear which clinically did not prove. Under the influence of an infection there is activation of this process, and then patogistologichesky changes at small children are almost similar to changes at children of more advanced age. The mucous membrane is thickened owing to treatment of a submucosal layer by kruglokletochny infiltrate and overflow of small vessels blood. At stronger irritations there is an exudate which can be serous, bloody or purulent, containing the isolated epithelium cells, large numbers of polinuklear and fibrin. At long purulent exudate the mucous membrane of a middle ear is loosened, it is often possible to find kariozno the changed naked bone site.

The tympanic membrane infiltrirutsya sharply: the mucous, then tearing-away scales leathery layer, further and an average, steadiest connective tissue layer is exposed to infiltration at first. In formation of a perforation the significant role is played by the disturbance of a trophicity leading to thrombosis of small vessels.

The described histologic changes depend on intensity, duration of process and a condition of food of the child.

After the first days of exudation there comes the period of the organization of exudate and development of granulyatsionny fabric. In any period process can terminate in recovery or stories to heavy complications.

Everything told allows to give the following classification. acute average otitis at chest age:

1) the "physiological" otitis which is expressed in the morphological changes on average to fish soup connected with involution of miksoidny fabric;

2) pathological otitis - a purulent inflammation of a mucous membrane of a middle ear of various intensity and localization:
a) process can preferential concentrate in an Eustachian tube and a drum cavity without involvement of an antrum;
b) process can take a drum cavity and антрум;
c) process can take all tympanic cavities (an Eustachian tube, a drum cavity and антрум) - otitis-antrit;
d) the same localization, but with inflammatory reaction from marrow (osteomyelitis mastoidal areas - a mastoiditis).

Such morphological changes give various clinical picture at children with the normal or lowered condition of food.

At normotrofik these otitises usually proceed with clearly the expressed symptoms. At children with frustration of food - dystrophic persons - these otitises differ in a small symptomatology (the erased form - "latent" otitises, "mute" otitises).

Treatment of Average otitis:

In the presence of an acute inflammation of a middle ear the doctor has to set to himself the tasks: 1) to calm pain; 2) to promote a rassasyvaniye of inflammatory process on average an ear; 3) to influence the infectious beginning; 4) to recover hearing function; 5) to warn as far as it is possible, a recurrence.

At temperature increase the bed rest is necessary. Appoint easy food, usual for in the fever patients. At locks appoint enemas.

Bol can be calmed 5% solution of carbolic acid in glycerin (at the advanced children's age).

Negative side of its use is maceration of epidermis and a zatushevyvaniye of a shade of color of a tympanic membrane. It is possible to let in outside acoustical pass solution only before emergence of allocations from a middle ear: the solution of 5% of carbolic acid received from mix with pus works in a cauterizing way.

Alcohol 95 ° as fine anesthetic quickly reduces and calms pain. It greedy absorbs water and causes diffusion of exudate through the unimpaired tympanic membrane thanks to what pressure from a drum cavity decreases. Alcohol causes a necrosis of superficial cells of epidermis that even more strengthens the diffusion phenomena. Probably, there is also a diffusion of alcohol in a drum cavity as quite often after use of alcohol reduction of the toxic phenomena and virulence of an infection is noted. The tympanic membrane which is stuck out and subject to a paracentesis already the very next day after alcohol use quite often looks less intense, less eminating. Children well transfer spirit turundas. At the same time alcohol prevents formation of the middle ear of a furunculosis of outside acoustical pass which is often accompanying acute inflammations. Alcohol should be used on a cotton plug, occluding as a stopper, outside acoustical pass to all its length. It is important that the cotton plug impregnated with alcohol almost adjoined to a tympanic membrane. For maintenance of humidity of a tampon it is necessary to pour in 3 times a day on it in 10 drops 95 ° alcohol. The doctor changes a spirit tampon in 24 hours, greasing at the same time skin of outside acoustical pass with a sterile liquid paraffin, and also watches a condition of a tympanic membrane and the general course of disease.

Negative side of use of alcohol is plentiful exfoliating of epidermis of a leathery cover of a tympanic membrane and outside acoustical pass. Exfoliating usually begins for the 3-4th day when improvement during a disease is already observed or it is visible that alcohol has no appropriate effect. In the first case, despite exfoliating, it is necessary to continue treatment by alcohol if alcohol does not help, it is necessary to resort to a paracentesis. Treatment by spirit tampons often prevents need of a paracentesis. In case of break of pus through a tympanic membrane treatment by spirit tampons should be stopped.

Well pains at babies the bromic drugs appointed to mothers nursing calm.

Calms pains and well also topical administration of heat  in the form of the warming compresses or a rubber bubble with hot water which is put on area of a mastoid affects inflammatory process. The warming compresses from warm 2% of solution of soda or from mix of equal parts of boiled water and vodka impose only on mastoidalny area and around an auricle, without closing a wet gauze of the sink and an entrance to outside acoustical pass. Before a compress it is necessary to grease skin with vaseline; the compress is put only for the night, replacing it in the afternoon with a warm wadded bandage.

The compress and warm bandage are contraindicated if the child badly transfers them (a fidgets, crying, a bad dream).

From physiotherapeutic means apply a lamp with the color filter; in the subacute period - a diathermy and currents of ultrahigh frequency. From these procedures UVCh as more powerful factor should give preference.

At purpose of heat in the form of a lamp with the color filter ("blue light") the lamp should be kept at arm's length not to exchange of a half a meter that heat was not excessive.

If heat does not calm pains, it is necessary to appoint cold, especially at pains in a mastoid. The ice in a rubber bubble imposed on mastoidalny area reduces pain, causes sharp anemia and slows down development of the inflammatory phenomena. It is necessary to leave ice throughout all day with small breaks, renewing it in process of thawing. For the night on mastoidalny area it is not necessary to impose anything. To avoid auricle freezing injury, it is necessary between it and a bubble to enclose a piece of cotton wool.

At the same time appoint drops in a nose on 5 drops twice a day in each half of a nose
with the purpose to reduce a krovenapolneniye of a mucous membrane of a nose, to promote the correct ventilation of a middle ear through an Eustachian tube, to weaken life activity of microorganisms. In the subsequent at plentiful allocations pour in protargol solution on 5-6 drops in a nose 2 times a day.

To influence the infectious beginning, appoint inside sulfanamide drugs. It is noticed that receptions of small doses of sulfanamide drugs, as well as penicillin, result in adaptability of infectious activators to these medicines. It is necessary to appoint sulfanamide drugs (streptocide, Sulfazolum, Sulfodemezinum) so that the maximum dose did not exceed per day 0,15 on 1 kg of weight of the child. The daily dose should be distributed on 4-5 receptions.

If throughout 3-4 days of improvement does not come, effect of sulfanamide drugs is strengthened penicillin accession.

The penicillin therapy affects bacteriostatically and bakteritsidno gram-negative cocci which in most cases and are the activators causing an inflammation of a middle ear. Penicillin affects also a macro-organism, toning up its nervous system and increasing resilience.

The operating therapeutic concentration of penicillin consider 0,12 PIECES on 1 ml of blood. Such concentration is reached at chest age after 6-8 intramuscular injections on 10 000-15 000 PIECES. Higher concentration it is possible to receive after double introduction 100 000 PIECES of solution of penicillin in 1 ml of 0,25% of solution of novocaine in a hematoma from put banks.

Besides, administration of penicillin in a hematoma from put banks extends effect of drug therefore more rare injections are possible. Penicillin is entered on 10 000 PIECES by 2 times a day in 10-12 hours throughout 5-6 days. At. most of sick children during this time not only the course of a disease stops, but also recovery signs are noted: temperature becomes normal, pains stop, the health improves, protrusion and a hyperemia of a tympanic membrane decrease or disappear, hearing considerably improves. Depending on sensitivity of flora to this or that antibiotic or from individual portability of the child it is necessary to combine penicillin with other antibiotic or to appoint streptomycin, biomycin, oxytetracycline instead of penicillin.

The penicillin therapy has also negative properties: she often creates, especially at dystrophic persons, a picture of visible wellbeing, improves a blood picture whereas the absolute recovery does not come. In the presence of exudate rich with fibrin in an Eustachian tube and in a drum cavity of Bizalski recommends introduction through a catheter of a cortisone or in a drum cavity of 0,3-1 ml of aqueous solution of Prednisonum (by means of a timpanalny puncture) which interfere with formation of commissures and hems and by that to hearing dysfunction.

If the general condition of the child under the influence of the carried-out therapy does not improve and high temperature continues to keep, then in 24-48 hours after the beginning of a disease at the corresponding otoskopichesky picture make a paracentesis.

It is not necessary to count on spontaneous break of contents of a drum cavity as the tympanic membrane has sufficient resistance and sometimes pus can get rather into a head cavity through preformirovanny cracks, than break outside. Afterwards after spontaneous break of a tympanic membrane the bigger hem, than after a paracentesis is formed.

The paracentesis does not exert negative impact on hearing: existence of a hearing impairment can always be established to a paracentesis; besides, if exudate has no exit, the infection makes deeper destructions; sometimes there are unions immobilizing, i.e. leading to an anchylosis, a chain of acoustical stones.

The paracentesis gives vent to pus and that weakens infection force, but, except a drainage, it serves also as counteropening. The paracentesis is appointed after assessment of the general state and the local phenomena.

Such symptoms as concern, loss of a dream and appetite, vomiting, diarrhea, the general serious condition, high temperature, drowsiness, existence of a meningism matter at the corresponding otoskopichesky picture.

At an otoskopiya there can be following variations: a hyperemia, protrusion of a tympanic membrane, sagging of a verkhnezadny wall at normotrofik or opacification of all or parts of a tympanic membrane, protrusion of some segment of a tympanic membrane and disappearance of a light cone at gipotrofik.

It is necessary to attach significance and degrees of a hearing impairment. Disorder of hearing at an acute inflammation of a middle ear differs in the features characterizing defeat of the sound carrying out device. At Weber's experience the sound of a tuning fork of C128 is heard better a sore ear. At early children's age it affects turn of eyes towards a sore ear. We suggest to call this symptom "mute weber". Rinne's experience is negative, i.e. air conductivity is shortened in comparison with bone.  Shvabakh's experience  is extended, i.e. bone conductivity is more than normal. The Shepotny speech at patients with heavy otitis is heard only near an ear; worst of all words on low tones are heard.

Full akumetrichesky inspection can take place only at the advanced children's age.

The paracentesis is made a lanceolate two-edged needle. Ear speculums and a paracentesis needle have to be prokipyachena or are put in 95 ° alcohol for 10-15 minutes. Outside acoustical pass has to be cleared of sulfur and слущившегося epidermis and is wiped with pure alcohol; cotton wool has to be sterile, hands of the doctor are washed up, as for operation.

The child is held on a lap by the assistant, fixing the legs his legs, holding one hand both hands of the child and pressing him to the breast, and the second hand immobilizing the child's head.

The local anesthesia is made the mix recommended by T. I. Gordyshevsky for anesthesia. The cotton plug impregnated with this solution is entered through outside acoustical pass before contact with a tympanic membrane for 2-3 minutes. After that the tympanic membrane grows white and becomes a little sensitive to a section. After removal of cotton wool it is necessary to dry up outside acoustical pass. The paracentesis is made under sight control. The ear speculum has to be so wide as far as it resolves a gleam of outside acoustical pass.

It is not necessary to do a paracentesis too highly as pus in gravity aims to reach the lowest position in a cavity.

The puncture in the lower part of a tympanic membrane less important for hearing and easier hemming, than upper is more favorable to hearing of the child. Most favourably for a drain of exudate and for preservation of acoustical function to do a paracentesis in a zadnenizhny quadrant.

It is the best of all to do incision vertical (perpendicularly to circular fibers). The needle should be entered, without concerning walls of outside acoustical pass, to the membrane, then it is necessary to puncture with the short movement a membrane and to increase a section, lifting the end of a needle from below up and trying to cut the most part of a tympanic membrane (tympanotomy).

Beginners have to avoid the following mistakes: 1) it is not necessary to prick the skin of a posterosuperior wall of outside acoustical pass which is mistakenly taken for a tympanic membrane; 2) it is not necessary to make only scarification of a tympanic membrane (beginners often scratch a needle only blankets of a reinforced tympanic membrane) - it is necessary to receive feeling that the needle passed through; 3) it is not necessary to do too small section.

Danger at a paracentesis minimum. Wound of the atypical located bulb of a jugular vein occurs very seldom.

Bleeding at such wound is stopped a tamponade of outside acoustical pass.

Sometimes at a paracentesis wound of a drum string is observed: it gives temporary decrease or lack of flavoring feelings on the relevant party of language.

Results of a paracentesis: 1) pus (or bloody allocations) is shown immediately after a puncture - it gives confidence that the paracentesis is made timely; 2) pus from an ear appears in several hours after a paracentesis or does not appear at all - it means that the otoskopichesky picture was incorrectly regarded.

After independent break of a tympanic membrane or a paracentesis enter a wick or a ribbon of a sterile gauze or cotton wool into outside acoustical pass. Such wicks it is necessary to change in process of treatment them pus.

Instead of a paracentesis sometimes make a timpanalny puncture which in certain cases can replace a paracentesis. For this purpose pierce with a long fine needle under control of sight a lower part of a tympanic membrane and by means of the syringe enter into a drum cavity 3-4 drops of solution of penicillin (100 000 PIECES in 1 ml of normal saline solution). The assistant fixes the child in lying situation.

The otorrhea after several days or weeks (to 6) stops, the opening in a membrane grows, the hyperemia and opacification disappear, hearing is recovered.

It is easy to check recovery of hearing at children of advanced age and it is difficult at early children's age. Recovery of hearing can be accelerated careful blowing off. It is only necessary to resort to blowings off after all acute phenomena in a nose and on average an ear disappear.