Acute bilateral otitis media: exudative, catarrhal, purulent

Bilateral otitis is an inflammatory disease in which the tissues of the ears on the left and right sides are affected. In this case, the pathological process can spread deep, causing inflammation not only of the middle and inner ear, but also of other areas of the brain.

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Epidemiology

Statistics on the occurrence of bilateral otitis indicate that children are predominantly susceptible to this disease. Anatomical immaturity of the tympanic cavity, labyrinth and Eustachian tube stimulate a high level of morbidity at an early age. However, their occurrence in young and mature people is also possible. The most common type is pathology of the middle ear. As a rule, 80% of children under 3 years of age have suffered from otitis media at least once. Next in frequency of occurrence is otitis of the external ear, which is about 20% and the lowest morbidity is inherent in otitis of the inner ear - 10%.

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Causes bilateral otitis media

The main cause of bilateral otitis is viral and bacterial agents. Due to the dysfunction of the immune system, the body loses resistance to the effects of various microorganisms. There are exogenous (external) and endogenous (internal) risk factors for the development of bilateral otitis. Exogenous factors include hypothermia, dirty water getting into the external auditory canals, and bilateral traumatic injury to the ear area. Endogenous factors are changes in local or general immunity, which cause a violation of the body's reactivity. Bilateral otitis most often acts as a secondary pathology and occurs due to the presence of acute inflammatory processes in the upper respiratory tract. Congenital developmental anomalies, which create a predisposition to the development of inflammatory processes in this area, can also be considered factors in the development of bilateral otitis.

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Pathogenesis

The pathogenesis of bilateral otitis can be explained by two theories, and both of these concepts suggest a change in the structure of the auditory (Eustachian) tube. The first theory states that the Eustachian tube is subject to mechanical obstruction (blockage) due to the proliferation of lymphoid tissue of the nasopharynx (adenoids) or tubular tonsils. According to the second theory, in acute inflammatory processes in the upper respiratory tract, the mucous membrane of the Eustachian tube swells, thereby narrowing its lumen. Due to the fact that the internal volume of the tube decreases, negative pressure is created in the tympanic cavity. Due to the presence of negative pressure, fluid exudes into the Eustachian tube and subsequently bacterial flora joins the effusion. This promotes active migration of lymphocytes and neutrophils to this area, causing the catarrhal stage of otitis. As the infectious load increases, the catarrhal process is replaced by a purulent one, aggravating the condition of the body.

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Symptoms bilateral otitis media

The onset of bilateral otitis is always sudden and acute, regardless of the age at which it occurs. The first signs are dizziness, headache, ear congestion, heaviness in the head, tinnitus, and body temperature rising to subfebrile values. A burning, shooting pain appears in the ears, and intoxication symptoms increase in the form of weakness, apathy, and nausea. Purulent masses are released from the ears, and hearing is reduced.

Bilateral otitis in adults is less pronounced than in children, the intoxication phenomena manifest themselves to varying degrees, depending on the state of the body and its immune system. A characteristic feature of acute purulent bilateral otitis in adults is a less pronounced course of the process. The development of complications occurs less often due to the formed barriers in the form of a lymphoid ring and mature connective tissue.

Bilateral otitis in children occurs with vivid symptoms. An increase in body temperature to 40°C and apathetic behavior of the child indicate an intoxication syndrome, which also includes headache, nausea, vomiting. Against this background, meningeal symptoms may occur, manifested in inhibition of consciousness and disappearing when the intoxication of the body decreases. When pressing on the tragus of the ear, the child experiences severe pain, which helps to establish the localization of inflammation. This is explained by the fact that at an early age, the bony auditory canal is still absent. A feature of this pathology in children is a high probability that recovery will occur without perforation of the auditory membrane (due to the high resistance of the membrane and better outflow of exudate from the wide Eustachian tube).

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Stages

The classic course of purulent bilateral otitis is characterized by 3 stages. At the initial stage, infiltration and accumulation of exudate in the tympanic cavity occurs, ear pain, hyperemia (redness), impaired sound perception, and intoxication symptoms appear. The results of a clinical blood test show an increase in the number of leukocytes and an increase in ESR. The second stage is characterized by melting of the eardrum with purulent exudate, due to which a perforation hole and purulent discharge from the ears appear. Due to the outflow of pus, the patient feels relief, the symptoms subside and the dynamics of the disease improve. The third stage is reparative, at this time the purulent discharge stops, the perforation of the auditory membrane is scarred, the middle ear cavity is cleansed and the functions of the hearing aid are restored. The duration of each stage ranges from 2-3 days to 2 weeks.

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Forms

Bilateral otitis is classified as acute and chronic depending on the course of the disease; by severity - mild, moderate and severe; by type of exudate - catarrhal (serous), purulent; by localization - otitis of the external, middle and inner ear.

Bilateral otitis externa is a group of inflammatory diseases of the outer ear. The localized form of otitis externa often manifests itself in the form of limited purulent-inflammatory processes, among which the most common is a furuncle of the external auditory canal. This purulent-necrotic inflammatory disease is clinically quite aggressive: there is a sharp pain in the ear, which spreads to the teeth, neck, facial and temporal areas. A sharp increase in pain is noted during palpation of the ear near the furuncle. Sometimes there is an increase in regional lymph nodes, body temperature rises. The disease ends in about 5-7 days if there are no complications. Diffuse otitis is characterized by damage to the skin of the outer ear, in which the inflammation spreads to the auditory ossicles and auditory membrane. Clinically, this form of bilateral otitis externa is characterized by pain, itching in the ears, hearing loss. If diffuse otitis is chronic, then all the above symptoms appear to a lesser extent, and the disease becomes protracted and sluggish.

Acute bilateral exudative otitis (serous otitis media) is an inflammation of the tissues of the middle ear, in which the focus of the lesion falls on the mucous membrane of the tympanic cavity and the auditory tube. The main symptom of this pathological process is the accumulation of catarrhal fluid in the tympanic cavity. Bilateral exudative otitis is a complex concept, its course is divided into several stages. The first stage is acute bilateral catarrhal otitis (eustachitis). Due to the disruption of air circulation in the auditory tube, air stagnation occurs in the middle ear chamber and serous inflammation develops. At this stage, a slight decrease in hearing, discomfort in the ear, slight congestion, autophony (a sensation that can be described as "ringing of a voice in the head") are felt. The second stage is acute bilateral secretory otitis, associated with increased secretion and accumulation of mucus in the middle ear cavity. Symptomatically, this is represented by pressure in the ear, hearing loss (more severe than in the first stage), and tinnitus. A characteristic subjective sign for this stage is a sensation of fluid flowing in the ear when tilting the head and changing body position. The duration of the second stage is from 1 to 12 months. The third stage is mucous, during this period the accumulated mucus becomes thicker and more viscous. Sound perception impairment worsens, the symptom of fluid flow may be absent. The duration of the stage is from 12 to 24 months. The fourth stage is adhesive otitis media, characterized by fibrous restructuring of the mucous membrane. In this case, mucus secretion decreases until it stops completely, and scarring processes occur in the tissues of the middle ear, which leads to irreversible hearing loss.

Acute bilateral purulent otitis is a purulent-inflammatory disease that involves the mucous membrane of all parts of the middle ear. The initial stage is called "pre-perforative", which indicates the integrity of the auditory membrane at this stage. However, the symptoms of the pre-perforative stage are quite vivid: there is a sharp, excruciating pain in the ears, which spreads to the temporal and parietal regions. Also, the patient feels congestion in the ears, noise, decreased hearing acuity. In addition, there are symptoms of intoxication: a sharp increase in body temperature to 38-39 ° C, chills, headache, weakness, leukocytosis in a clinical blood test, an increase in ESR. This period lasts about 2-3 days. The second stage is perforative, characterized by a decrease in general symptoms, abatement of pain in the ears. However, during this period, perforation of the eardrum occurs, which provokes purulent discharge from the ear. This stage lasts for 5-7 days. The final stage is the reparative stage, which involves the cessation of suppuration and scarring of the perforation of the eardrum. It should be noted that the purulent process does not always go through all 3 stages. Practice shows that in many cases purulent inflammation becomes sluggish and protracted. In some patients, the general condition does not improve at the second stage, despite the perforation of the eardrum and the free outflow of purulent contents. Recently, there have been increasingly more cases where acute bilateral purulent otitis becomes chronic and regularly recurs. However, most often the disease lasts no more than 2-3 weeks and ends in recovery.

Chronic bilateral otitis is represented by two main forms - mesotympanitis and epitympanitis. Mesotympanitis is a purulent-inflammatory disease, which is characterized by damage to the mucous membrane of the middle and lower parts of the tympanic cavity and the auditory tube. The peculiarity of this pathology is that the bone tissue of the auditory ossicles is not subject to destruction. The clinical picture of mesotympanitis involves the appearance of complaints of regular ear pain, hearing loss and purulent discharge. This type of otitis occurs with alternating periods of exacerbation and remission. Epitympanitis is an inflammatory-destructive process that occurs in the epitympanic space and mastoid process. With this disease, the auditory ossicles are affected, which leads to the formation of severe pathology of the auditory analyzer. The main manifestations of epitympanitis are purulent discharge from the ear, which have a foul odor.

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Complications and consequences

The consequences and complications of bilateral otitis are primarily related to the duration of the disease and its course. If drug therapy is administered in time, the recovery process occurs within a week. However, if the acute process is not treated, it can become chronic and sluggish, or spread to adjacent areas, including the membranes (meningitis) and sinuses of the brain.

One of the complications of bilateral otitis is acute mastoiditis, which occurs in parallel with acute otitis. Inflammation of the mucous membrane of the middle ear passes to the tissues of the mastoid process, which is the initial stage of this disease. However, if acute otitis ends with recovery, then mastoiditis does not develop. If mastoiditis occurs, you should expect symptoms such as pain in the ear and the corresponding half of the head on the affected side, pulsating noise in the ears, increased symptoms at night and symptoms of intoxication. In this case, you should immediately consult a doctor.

Labyrinthitis and facial nerve paresis occur as complications of otitis media as a result of the penetration of inflammatory processes into the inner ear, accumulation of purulent exudate and melting of facial nerve structures. These complications are characterized by dysfunction of the vestibular and auditory receptors, which manifests itself as dizziness, static and coordination disorders, numbness of the corresponding half of the face, a crawling sensation, dry eyes, taste and salivation disorders.

Brain and cerebellar abscesses occur as a result of the spread of pus from the tympanic cavity or mastoid process and its abscessation in the brain structures. These formidable complications are manifested by symptoms of intoxication, meningitis, cardiac dysfunction, and changes in the blood composition. If the above symptoms are present, it is necessary to consult a neurosurgeon.

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Diagnostics bilateral otitis media

Diagnostic criteria for bilateral otitis include anamnesis data, main complaints, examination, instrumental examinations and laboratory tests. If a person has previously suffered from any inflammatory diseases of the ears, then the probability of their recurrence is quite high. This is due to a decrease in local immunity in the area of the previous inflammatory process. When establishing the correct diagnosis, it is necessary to clearly understand when the first signs of the disease began and what provoked them. After this, it is necessary to analyze the current state of the body and the main complaints (for example, ear pain, congestion, hearing loss, autophony, etc.).

One of the key instrumental methods is otoscopy. It allows you to assess the condition of the middle ear tissue, including the eardrum. This procedure can determine the severity of the inflammatory process, the presence and localization of perforations of the auditory plate. Since the middle ear system is connected to the nasopharynx through the Eustachian tube, it is also necessary to examine the mucous membrane of the nasal and oral parts of the pharynx. An effective diagnostic method is blowing the Eustachian tubes. With its help, you can assess the functional state of the auditory tube. This is a very important procedure, since obstruction of the auditory tubes is the first link in the pathogenesis of inflammatory diseases of the ears. If otitis media is suspected, tympanometry is performed, which allows you to determine the mobility of the eardrum, i.e. its functional capabilities at the time of the disease. Audiometry is a method for assessing the auditory function in case of complaints of hearing loss and decreased sound perception. Computed tomography or magnetic resonance imaging are the most effective instrumental diagnostic methods today. With their help, it is possible not only to determine the presence of structural disorders of the auditory analyzer, but also to identify possible complications (mastoiditis, meningitis, purulent abscess).

Laboratory tests play an equally important role in the diagnosis of bilateral otitis. By evaluating a clinical blood test, it is possible to determine the presence of an inflammatory process in the body (leukocytosis, increased ESR). In allergic reactions, an increase in the number of eosinophils is observed. Bacterial culture is performed to determine the causative agent of the disease. In this way, it is possible to identify the type of bacterial agent and apply rational antibiotic therapy. If the disease is in remission, it is very important to prevent a relapse of the inflammatory process. To do this, it is necessary to perform an immunogram and assess the level of immunity stability.

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Differential diagnosis

Differential diagnostics are performed between various forms of bilateral otitis, as well as with eczema, erysipelas and perichondritis. In addition, bilateral otitis must be distinguished from mastoiditis, labyrinthitis, meningitis and brain abscess, which were discussed earlier.

Each form of bilateral otitis has specific properties that allow us to distinguish between the diseases, make a correct diagnosis and carry out high-quality treatment. In acute eustachitis, there is no pain or discharge from the ear, but there is hearing loss, noise and autophony. The general condition is not impaired. The eardrum is retracted. Based on these data, eustachitis can be distinguished from more severe forms of otitis. Acute catarrhal bilateral otitis is characterized by moderate ear pain, but there is no discharge from the ears. The eardrum is hyperemic and thickened. Body temperature can reach subfebrile values (up to 37.5 ° C).

Acute purulent bilateral otitis at the pre-perforative stage is characterized by severe pain in the absence of discharge from the ears. Hearing loss becomes pronounced. The eardrum is hyperemic and convex. There are pronounced symptoms of intoxication and an increase in body temperature to 38-39 ° C. The post-perforative stage is characterized by moderate pain and the presence of purulent discharge. Otoscopy reveals perforation of the eardrum, from which purulent contents are released. The general condition is slightly disturbed, the body temperature is at a subfebrile level.

Adhesive otitis media is characterized by the absence of symptoms, but during instrumental examination, structural changes in the eardrum are determined, it is gray in color, the perforation is covered by a scar.

Erysipelas, as a rule, has a rather vivid picture: intense redness of the auricle, including the earlobe, is determined, sharp pain occurs upon palpation, which does not stop after the irritant is removed. Almost always, erysipelas is accompanied by an increase in body temperature to 39-40 ° C. However, it is possible to distinguish erysipelas from bilateral otitis media only after observation for 2-3 days. Moreover, if hyperemia and swelling go beyond the boundaries of the ear region and mastoid process, then we are dealing with erysipelas.

Eczema of the auricle is often encountered when a certain area of the skin of the ears is chronically damaged. This disease has quite specific symptoms, so its differential diagnosis rarely causes difficulties. The onset of eczema is manifested by redness and infiltration of the tissues of the auricle, which leads to a visually determined narrowing of the external auditory canal. A characteristic symptom is itching of the skin of the auricle and internal auditory canal. It is worth noting that the itching of the skin is so intense that a person reflexively scratches the problem areas. As a result, a large number of abrasions are formed, against the background of which small bubbles appear. Vesicles filled with serous fluid spontaneously open and the process of weeping develops in the affected area. Upon contact with the external environment, the liquid phase of the serous exudate evaporates and crusts form in its place.

Bilateral otitis should be distinguished from perichondritis, a diffuse inflammatory disease of the perichondrium of the auricle. The main complaint with perichondritis is usually pain in the auricle, which intensifies with palpation. The main distinguishing feature is the absence of damage to the earlobe, while the rest of the auricle is subject to hyperemia and edema. A tuberous infiltrate is determined upon palpation.

Treatment bilateral otitis media

Treatment of bilateral otitis should be individual and comprehensive. With rational pharmacotherapy, the duration of treatment does not exceed 7 days. Therapy should include the following groups of drugs: antibiotics (if the bacterial nature of the disease is detected), antivirals (if the inflammation is provoked by a viral agent), anti-inflammatory drugs, vitamins, herbal remedies, homeopathic medicines. The use of physiotherapeutic methods and some folk remedies also shows effectiveness.

Drug therapy involves the use of broad-spectrum antibiotics: Augmentin 625 mg, 1 tablet 3 times a day, Dioxidine 0.1-0.2% solution, 1-2 drops in each ear 3 times a day, Sumamed 500 mg, 1 tablet an hour before meals and 1 tablet after meals once a day. Antiviral drugs are used when the viral origin of bilateral otitis is finally established. Ingavirin 60 mg (2 capsules of 30 mg) once a day for 5 days, Viferon 150 mg once a day for 5 days. The list of anti-inflammatory drugs indicated for otitis includes: Otipax - 3-4 drops 2-3 times a day in each ear, Otinum - 3-4 drops 3-4 times a day in each ear.

Vitamin complexes play an important role in the treatment of bilateral otitis. Ascorutin, consisting of a combination of vitamins C and P, exhibits antioxidant properties and is prescribed in a course of 1-2 months. Supradin is a vitamin complex that contains all the necessary vitamins and minerals, also taken in a course lasting 1 month. Alphabet is a vitamin preparation that contains a complex of vitamins and microelements.

The arsenal of physiotherapeutic treatment includes such methods as warming the ear area with a Sollux lamp, UHF and microwave treatment. Particular attention should be paid to warming procedures, since these manipulations are strictly prohibited in the purulent stage. But light therapy is indicated at all stages of the inflammatory process due to the manifestation of an immunostimulating effect.

Despite the availability of a wide range of medicines, phytotherapy is very popular. Tinctures (St. John's wort, calendula, mint), tea (rose hips, rose petals, raspberry roots), and juice (aloe, celandine) are prepared from medicinal herbs. Phytotherapy does have a positive effect on the course of the disease, but it is not recommended to use it as monotherapy.

The question of the effectiveness of homeopathic drugs has not yet been finally resolved. However, many drugs in this group have proven themselves to be effective in the treatment of various inflammatory diseases. Aflubin drops are used for bilateral otitis. The dosage is determined individually, depending on age. This drug cannot be used in case of hypersensitivity to the components of the drug, as an allergic reaction is possible. Lymphomyosot is a homeopathic drug that has lymphatic drainage, immunomodulatory, and anti-inflammatory effects. The only relative contraindication is thyroid disease, since the drug contains thyroxine and ferrum iodide. In addition to the above drugs, Chamomilla, Hepar sulfur, and Pulsatilla are widely used. There are no contraindications to the use of homeopathic drugs, but it is worth soberly assessing the capabilities of this area of medicine and using it as an adjuvant therapy.

Do not forget about folk remedies, which have a fairly strong medicinal effect. It is recommended to use a warming compress, which is gauze soaked in water and Burov's solution. Compresses from propolis, honey and other bee products are also used.

Surgical treatment for bilateral otitis is indicated if drug therapy has proven ineffective and the purulent process has spread to adjacent areas. The simplest intervention is paracentesis, which is an incision in the eardrum to create an outflow of pus from the middle ear cavity. An example of a more extensive operation is radical ear surgery, which inevitably affects hearing loss.

Prevention

Prevention of bilateral otitis consists, first of all, in eliminating foci of chronic infections, such as tonsillitis, sinusitis, pharyngitis and oral diseases. In the presence of a deviated nasal septum and enlarged adenoid vegetations, it is necessary to undergo surgical treatment in a timely manner. Also, a healthy lifestyle, giving up bad habits, and hardening the body can be added to this list.

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Forecast

The prognosis for bilateral otitis is often favorable. With timely treatment and rational treatment, a full recovery occurs. However, if the disease has become chronic, then relapses should be expected. It is also important to remember about the atypical course of otitis, the outcome of which is adhesions and adhesions between the structures of the middle ear. These formations lead to stiffness of the auditory ossicles and hearing loss.

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