Acute otitis media

Acute otitis media is an acute inflammatory disease characterized by the involvement of the muzzle of the middle ear (auditory tube, drum cavity, cave and airway cells of the mastoid process) into the pathological process.

[1], [2], [3]

Epidemiology

Acute otitis media refers to the most frequent complications of community-acquired infections of the upper respiratory tract in children and currently occupies a dominant place in the structure of childhood pathology. This is due to the high prevalence of acute respiratory diseases, which play an important role in the pathogenesis of acute otitis media and account for up to 90% of all infectious pathogens. The incidence of influenza in 100 000 children and under 1 year of age is 2362 cases, 1-2 years - 4408 and 3-6 years - 5013 cases. Acute inflammation of the middle ear occurs in 18-20% of children suffering from an acute respiratory-viral infection.

In the first year of life, at least one episode of acute otitis media diagnoses in 62% of children, and 17% is repeated up to three times. By the age of 3, acute otitis media is transferred by 83%, by 5 years - by 91%, and by 7 - 93% by children.

In Ukraine, about 1 million people suffer from acute inflammation of the middle ear annually. The frequency of acute otitis media among children in European countries reaches 10%, in the United States this disease is registered annually in 15% of the child population. The specific weight of acute otitis media in the structure of diseases of the hearing organ is 30%. Almost every fifth (18%) child with acute otitis media has a severe or complicated course of the disease. In 12% of patients, the neuroepithelial cells of the spiral organ are affected, followed by sensorineural deafness and deafness.

[4], [5], [6], [7], [8], [9], [10]

Causes of the acute otitis media

The main etiological factors of acute otitis media include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus aureus. A definite role in the occurrence of acute otitis media is played by a viral infection. This, in particular, is confirmed by data on the correlation of the rates of respiratory infections and acute otitis media, a high frequency (59%) of detection of viruses in the nasopharynx of patients with acute inflammation of the middle ear.

[11], [12], [13], [14], [15], [16], [17], [18], [19]

Risk factors

Risk factors for acute otitis media in children:

• presence in the cavities of the middle ear of myxoid tissue (in young children);
• a wide, straight, short and more horizontally arranged auditory tube;
• significant frequency of hypertrophy and chronic inflammation of the pharyngeal tonsil;
• incompleteness of pneumatization of the temporal bone.

In addition, it should take into account the failure of the immune mechanisms of the child's body, the physiological (transient) immunodeficiency state of the newborn.

[20], [21], [22], [23], [24], [25], [26], [27], [28], [29]

Pathogenesis

The effect of pathogens (viruses, bacteria) on the mucous membrane of the nose and nasopharynx in acute respiratory diseases initiates a cascade of morpho-functional changes that play a key role in the development of inflammatory changes in the middle ear and the formation of clinical manifestations of acute otitis media. The consistent development of inflammatory changes in the middle ear in acute respiratory diseases (the most common cause of acute otitis media) is associated with the damaging effect of viruses and bacteria on the ciliated epithelium of the primary parts of the respiratory tract and the auditory tube. The main role in the emergence of acute inflammation of the middle ear is played by proinflammatory mediators, which control the intensity and direction of immune reactions, and also ensure the realization of the most important effects of inflammatory reaction (increased vascular permeability, increased mucus secretion, migration to the focus of leukocyte inflammation and their degranulation, etc.).

Clinical equivalents of these disorders are hyperemia, edema of the nasal mucosa and nasopharynx, a violation of the physiological pathways of the mucosal membrane being separated, a cluster of nasopharyngeal secretion in the region of the pharyngeal ear of the auditory coarse, the formation of nasopharyngeal reflux and dysfunction of auditory coarse. A natural consequence of morphofunctional shifts is a rapid decrease in intrapotinal pressure and partial pressure of oxygen in the tympanic cavity, disturbance of air circulation, transudation of fluid from the microcirculatory bed, microbial contamination of the cavities of the middle ear, sequential development of acute inflammatory changes. Under these conditions, probably, superinfections, a prolonged course of the inflammatory process and the formation of complications increase dramatically.

[30], [31], [32], [33], [34], [35], [36], [37], [38], [39]

Symptoms of the acute otitis media

Symptoms of acute otitis media are characterized by the appearance of complaints of pain, congestion and a sense of noise in the ear, hearing loss, autophony. In newborns and children of the first year of life, the following symptoms are noted: anxiety, sleep disturbance, screaming, the desire to lie on the sick side, refusal to eat, possibly regurgitation. Body temperature reaches 38 ° C and above. Progression of the inflammatory process is accompanied by increased pain, marked deterioration of hearing, increased symptoms of intoxication. There is a persistent increase in temperature (up to 39-40 ° C), the child becomes apathetic, does not react to toys, refuses to eat, there arises night trouble, crying. At this stage of development of acute otitis media, excitation can be replaced by adynamy, vomiting becomes more frequent, "causeless" vomiting occurs, and twitchings and short-term convulsions may occur. Otoscopic changes are characterized by pronounced hyperemia and swelling of the tympanic membrane, caused by the pressure of the exudate.

Due to the pressure and proteolytic activity of the exudate, thinning occurs and a perforation of the tympanic membrane is formed, accompanied by gnotechenie from the ear. In this case, a decrease in the intensity of pain, a gradual decrease in temperature, the disappearance of symptoms of intoxication. Hearing impairment persists. After removal of pus from the external ear canal, otoscopy often reveals a "pulsating reflex" - an impulsive (pulsating) intake of pus from the tympanic cavity through a small perforation in the tympanic membrane. In the future, with a favorable course of the inflammatory process, there is a decrease and disappearance of purulent discharge from the ear, normalization of the general condition of the patient. When otoscopy is determined by the absence of exudate in the external auditory canal, residual hyperemia, injection of the vessels of the tympanic membrane, small perforation, which in most cases is independently closed. With a favorable course of the disease, a gradual restoration of the hearing occurs.

Often there is an atypical course of acute otitis media. In some cases, acute inflammation of the middle ear can be accompanied by the absence of pain syndrome, a pronounced temperature response, the presence of a cloudy, slightly thickened with poorly identifiable eardrum identification marks. And others - a rapid rise in temperature (up to 39-40 ° C), a sharp pain in the ear, pronounced hyperemia of the tympanic membrane, a rapid increase in intoxication, the appearance of neurologic symptoms (vomiting, positive symptoms of Kernig, Brudzinsky), signs of mastoiditis and other otogenic complications. Despite the favorable course of acute otitis media in most cases, there is a high probability of development of otogenic complications. This is largely due to the lack of immune response in young children, age-related features of the structure of the middle ear, pathogenicity and virulence of the etiologically significant microflora.

[40], [41], [42], [43], [44], [45], [46], [47]

Stages

Acute otitis media is characterized by a certain sequence of development of the pathological process and symptoms. From a practical point of view, it is advisable to distinguish three stages of a typical course of acute otitis media.

I stage of catarrhal inflammation

For this stage, complaints of earache, fever, hearing loss are common; when the examination reveals the retraction and injection of vessels (hyperemia) of the tympanic membrane. The general condition (weakness, malaise, etc.) is largely determined by the severity of the symptoms of acute respiratory disease.

[48], [49], [50], [51], [52], [53], [54], [55]

II stage of purulent inflammation

• a) non-perforative. Patients noted an increase in pain, malaise, weakness, increased hyperthermia, pronounced hearing loss. On examination, protrusion, intensive hyperemia of the tympanic membrane is revealed.
• b) Perforated. This stage is characterized by the presence of purulent exudate in the external auditory canal, a "pulsating reflex", a reduction in pain, a decrease in temperature, a decrease in the severity of the symptoms of intoxication.

III stage of process resolution

Possible outcomes:

• recovery (restoration of the integrity of the tympanic membrane and auditory function);
• Chronization of the process;
• formation of otogenic complications (mastoiditis, tympanogenic labyrinthitis, etc.).

Diagnostics of the acute otitis media

The diagnosis of acute otitis media in typical cases usually presents no difficulties and is based on the results of the analysis of complaints, anamnestic information (earache, stuffiness, ear noise, hearing loss). Sharp pain in the ear in young children is accompanied by anxiety, hyperkinesia.

Laboratory diagnostics

In the peripheral blood, neutrophilic leukocytosis is determined, an increase in ESR.

[56], [57], [58], [59], [60], [61], [62], [63], [64]

Instrumental diagnostics

Depending on the stage of acute otitis media, otoscopy can determine the retraction and restriction of the mobility of the eardrum with vascular injection (stage I of catarrhal inflammation); marked hyperemia and swelling of the tympanic membrane due to exudate pressure (II and stage of purulent inflammation); "Pulsating reflex", which is an impulsive (pulsating) intake of pus from the tympanic cavity through a small perforation in the tympanic membrane into the external auditory canal (stage II of purulent inflammation).

When examining patients with acute otitis media, one should keep in mind the high probability of developing various complications. In this regard, attention should be paid to the presence (absence) of such symptoms as the pastosity of the skin in the behind-eye region, the smoothening of the bovine fold, the protrusion of the auricle, the presence of swelling (fluctuation) in the behind-eye region (anthritis, mastoiditis); asymmetry of the face (otogenic neuritis of the facial nerve): meningeal symptoms (otogenic meningitis, etc.).

Indications for consultation of other specialists

Indication for consultation of other specialists (neurologist, neurosurgeon, ophthalmologist, etc.) is a complicated course of acute otitis media.

Treatment of the acute otitis media

The goals of treatment of acute otitis media: regress of inflammatory changes in the middle ear, normalization of hearing and general condition of the patient, rehabilitation of work capacity.

Indications for hospitalization

Indication for hospitalization is the age of the patient up to two years, and also regardless of age, severe and (or) complicated course of acute otitis media.

Non-drug treatment

Anti-inflammatory and analgesic effect in the early stages of the development of the inflammatory process in the middle ear are physiotherapeutic methods of exposure: solux, UHF, warming compress to the parotid region.

Medication

In the first stage of the disease, the appointment of ear drops with local anti-inflammatory and analgesic action, intranasal vasoconstrictors (dekengestants), providing recovery of nasal breathing and patency of the auditory tube, is shown.

The effectiveness of topical application of antibiotics in the form of an ear stone with acute otitis media requires confirmation. First of all, this is due to the fact that when the antibiotic solution is instilled in the external auditory canal, its concentration in the cavities of the middle ear does not reach therapeutic values. In addition, one should remember about the risk of complications on the inner ear when using drops containing ototoxic antibiotics.

In the presence of inflammatory changes in the nasal cavity, it is advisable to wash the nose with a 0.9% solution of sodium chloride, evacuation (aspiration) of the nasal secretion.

Antipyretics are used when the temperature rises to 39º C and above.

Systemic antibacterial therapy is indicated in all cases of moderate and severe course of acute otitis media, as well as in children under 2 years of age and in patients with immunodeficient conditions. In a mild course [the absence of severe symptoms of intoxication, pain syndrome, hyperthermia (up to 38 ° C)] from prescribing antibiotics can be refrained. However, in the absence of positive changes in the development of the disease throughout the day should resort to antibiotic therapy. With empirical antibiotic therapy for acute otitis media, preference should be given to drugs whose spectrum of action overlaps the resistance of the most likely pathogens. In addition, an antibiotic in an effective concentration should accumulate in the inflammatory focus, have a bactericidal effect, be distinguished by safety and good tolerability. It is also important that oral antibiotics possess good organoleptic properties, be convenient for dosing and administration.

With empirical antibacterial therapy of acute otitis media, the drug of choice is amoxicillin. Alternative drugs (prescribed for allergy to beta-lactams) are modern macrolides. In the absence of clinical efficacy for 2 days, as well as patients who received antibiotics within the last month, it is advisable to appoint amoxicillin + clavulanic acid, alternatives are cephalosporins of II-III generations.

In mild and moderate flow, oral administration of antibiotics is indicated. In case of severe and complicated course of the process, antibacterial therapy should be started with parenteral administration of the drug, and after improvement of the patient's condition (3-4 days), it is recommended to switch to oral intake (so-called step antibiotic therapy).

The duration of antibiotic therapy in uncomplicated course is 7-10 days. In children under 2 years old, as well as in patients with a history of a history of severe disease, the presence of otogenic complications, the timing of antibiotic use can be increased to 14 days or more.

It is necessary to evaluate the effectiveness of antibiotic therapy in 48-72 hours. In the absence of positive dynamics during an acute otitis media, a change in the antibiotic is necessary.

An important component of pathogenetic correction of changes in the mucosa of the auditory tube and the cavities of the middle ear is the restriction of the action of proinflammatory mediators, for this purpose, the administration of fenspiride is possible.

Surgical treatment of acute otitis media

In the absence of spontaneous perforation of the tympanic membrane in patients with acute purulent otitis media (acute otitis media, stage II a), increase (maintain) of hyperthermia and signs of intoxication, paracentesis of the tympanic membrane is shown.

Approximate terms of incapacity for work in uncomplicated course of the disease are 7-10 days, in the presence of complications - up to 20 days or more.

Further management

With recurrent acute otitis media, examination of the nasopharynx has been performed to assess the state of the pharyngeal tonsil, eliminate nasal obstruction and ventilation disorders of the auditory tube associated with adenoid vegetations. Consultations of an allergist and immunologist are also necessary.

Information for the patient should contain recommendations for the proper performance of medical prescriptions and manipulations (use of ear drops, washing the nose) at home, measures to prevent catarrhal diseases.

Prevention

The primary prevention of acute otitis media is to prevent acute respiratory infections. Of great importance is the implementation of sanitary and hygienic measures aimed at eliminating hypothermia, compliance with personal hygiene rules, tempering the body.

Secondary prevention is a set of measures aimed at preventing exacerbations of existing chronic diseases of the upper respiratory tract, restoring the physiological mechanisms of nasal breathing and ventilation function of the auditory tube. First of all, we are talking about patients with disorders of intranasal anatomical structures, hypertrophy of the pharyngeal tonsil, chronic focal infection in the paranasal sinuses and palatine tonsils. Of great importance in this regard is the timely elimination of foci of chronic infection (caries, tonsillitis, sinusitis), correction of immune deficiency and other systemic disorders.

An important role is played by clinical examination, systematic medical examinations, the level of awareness of patients about the causes and clinical manifestations of acute inflammation of the middle ear, possible complications of this disease.

[65], [66], [67], [68], [69]

Forecast

The prognosis for uncomplicated course and adequate treatment of acute otitis media is favorable. In the presence of complications, concomitant diseases, the prognosis is determined by the prevalence of the process, the severity of the patient's condition, the degree of compensation of co-morbidities, and the timeliness and adequacy of therapeutic measures.

[70], [71], [72]