Chronic otitis media in adults and children

The development of such a pathology as chronic otitis is most often associated with incorrect treatment of acute inflammatory process in the ear. Although, according to statistics, the disease can be provoked by other reasons - for example, injuries.

The diagnosis of the chronic form is established in the presence of a persistent violation of the integrity of the eardrum. Discharge from the ear is an optional symptom of pathology, since it can be both permanent and temporary.

In medical circles, it is generally accepted that if inflammation of the middle ear lasts more than a month, a diagnosis of chronic otitis can be made.

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Epidemiology

According to the World Health Organization, chronic otitis can be considered a disease in which there is a constant discharge of pus from the ear for more than 2 weeks. But most otolaryngologists tend to think otherwise, classifying otitis as a chronic form only when the purulent discharge is observed for a month or more.

According to statistics conducted by WHO, about 1.5% of the population suffers from chronic purulent otitis. In 60% of patients, persistent hearing loss is observed.

In every second patient, chronicity develops in childhood or adolescence – before reaching 18 years of age.

Chronic purulent otitis media has the highest risk of complications, which can also lead to death.

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Causes chronic otitis media

Chronic otitis develops gradually, and there may be several reasons for this:

• ineffectiveness of treatment of the acute form of the disease, or ignoring treatment as such;
• frequent recurring episodes of acute form, with the formation of cicatricial changes in the tympanic cavity;
• anomalies in the development of the auditory tube, which connects the organ of hearing with the nasopharynx;
• infectious and inflammatory processes.

Provoking agents in the development of chronic otitis are mainly bacteria such as staphylococcus, less often - enterobacteria, Pseudomonas aeruginosa. Long-term processes can also be caused by the presence of a fungal pathogen.

In most patients who sought medical help for persistent suppuration and hearing loss, the disease was associated with a worsening of the acute form of the disease. Such a development of the situation is possible under the influence of certain risk factors.

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Risk factors

• Untreated inflammatory pathologies in the nasopharynx.
• Difficulty breathing, inability to breathe adequately through the nose (congenital anomalies, adenoids, etc.).
• Immunodeficiency states.
• Endocrine system disorders (thyroid problems, obesity, diabetes);
• long-term treatment of other chronic diseases;
• unhealthy lifestyle;
• poor monotonous diet, hypovitaminosis.

Exacerbations of chronic otitis often occur under the influence of factors such as hypothermia or overheating of the body, water getting into the ear canal, acute respiratory infections and acute respiratory viral infections.

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Pathogenesis

Pathogenetic features of chronic otitis depend on a combination of many factors - these are physical, infectious, thermal, chemical causes of the disease. In most patients, the pathology develops as a result of an incompletely cured acute form of purulent otitis media. Provoking moments are also often various conditions that are accompanied by a sharp weakening of the immune system.

And yet, doctors say that the main cause is the entry of pathogenic staphylococcus into the middle ear, against the background of the creation of favorable conditions for the bacteria: weak immunity, frequent or chronic diseases of the nasopharynx, paranasal sinuses.

Depending on the location, there are such forms of chronic middle ear disease as mesotympanitis and epitympanitis.

Chronic purulent mesotympanitis may have different pathological manifestations, depending on the stage of the process. For example, the remission stage is characterized by the presence of perforation of the eardrum, localized on the stretched area mainly in the pericentral part. With a large diameter of perforation, you can see the handle of the malleus hanging freely over the tympanic cavity. The borders of the perforation opening are thinned or look like a compacted scar. Intact areas of the eardrum look normal, without characteristic changes. Closer to the medial wall of the cavity, the mucous tissue in the cape area is moistened and pale.

At the acute stage of mesotympanitis, the visual picture changes dramatically. The external auditory canal is filled with a large amount of purulent-mucous discharge. The preserved parts of the membrane become red and compacted, and the mucous cavities swell and turn red. Granulations and small polyps may form.

Chronic purulent epitympanitis has other pathological manifestations, since both the mucous tissue of the tympanic cavity and the bone tissue of the mastoid process are involved in the process. The inflammatory reaction spreads with damage to the auditory ossicles, antrum and cave, walls of the epitympanic space. Due to such processes, the term "epitympanitis" is used to describe a pathology affecting the attic-antral zone. This type is characterized by marginal localization of perforation in the unstretched segment of the membrane: it is in this area that there is no tendinous tympanic ring. Due to these features, the inflammation quickly spreads to the bone tissue, which leads to the development of osteitis. The bone tissue is filled with thick pus, a foul-smelling odor appears. In some cases, granulation may form.

The term "choleastoma" refers to a light, compacted formation covered with multilayered flat epithelium. Bone tissue disintegrates under the influence of choleastoma - previously in medicine, this was called by another term "bone-eater". An expanding formation can lead to severe destruction in the temporal zone, which often causes the development of intracranial complications.

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Symptoms chronic otitis media

In essence, chronic otitis is characterized by symptoms such as the presence of a perforated eardrum, inflammation, pain, and deterioration of hearing. Depending on the variant of the disease development, the perforation can be located in the center or near the edges of the eardrum.

Other symptoms may also vary slightly from each other.

• Purulent discharge can sometimes have an unpleasant odor, but not in all cases. In some patients, purulent discharge is constant, while in others it may be periodic or absent for a long time. If discharge is present, then this has its own "plus", since the likelihood of pus breaking through into the meninges is reduced.
• The deterioration of hearing is primarily associated with damage to the eardrum. More serious hearing loss may be associated with the appearance of polyps in the ear.
• Pain - aching or "shooting" - most often bothers during the active period of the disease. The sensations can be quite strong during an exacerbation of the disease, but more often the pain intensifies at night and has a nagging character.
• A feeling of congestion is the sensation of fluid getting into the ear canal. Many patients may want to clear the "congested" ear, but this should not be done: this way it is easy to cause harm, and the problem will still remain.
• Tinnitus has much in common with the feeling of "stuffiness": such a feeling can cause irritability, migraines and mood swings in the patient, since it is constantly present and significantly impairs concentration.
• Headaches, dizziness – these symptoms arise due to the inflammatory reaction that occurs in close proximity to the brain structures.
• Facial muscle dysfunction is detected when the disease lasts for a long time, without adequate treatment. In such a situation, paresis and paralysis of the facial nerve develop.
• An increase in temperature is possible during the active period of the disease – at the exacerbation stage.

The first signs of a fungal ear infection are itching inside the ear canal, increased skin sensitivity in the ear, and pain in the head on the affected side. The pain can be either aching or pulsating, pressing, stabbing, radiating to the jaws, temples, and occipital region.

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Chronic otitis in adults

The chronic form of the disease in adult patients can last for decades, practically without causing any discomfort. The fact is that a vivid clinical picture is present only during periods of exacerbation: if there are no such periods, then neither pain nor fever is observed. And if the disease is one-sided, then many patients do not even pay attention to the decrease in hearing abilities.

The patient most often comes to the doctor only in case of increased discharge of pus - this happens on the eve of an exacerbation of the disease. Often the discharge has an extremely unpleasant odor that is difficult to ignore. In advanced cases, signs of labyrinthine or intracranial damage appear, and in case of bilateral pathology, a gradual decrease in hearing is observed.

The most serious problem in adults is considered to be chronic otitis with marginal perforation. The inflammatory reaction localized in the upper segment of the tympanic space is often accompanied by carious processes in the outer side of the epitympanic cavity. Tissue destruction often causes further formation of granulations, polypous formations, choleastoma.

The definition of chronic otitis and the assessment of its nature (banal or complex course) are based on information obtained during otoscopy and probing procedures. Recognition of the type of perforation (central or marginal) is of decisive importance.

The volume and nature of purulent discharge is also an important sign that allows assessing the severity of the pathology. It should be taken into account that often the stench of pus does not indicate a carious necrotic process, but only indicates that the patient does not comply with the rules of hygiene of the affected ear. In such a situation, after thorough cleaning of the hearing organ at the initial stage of treatment, the unpleasant odor disappears, which does not happen with carious necrosis.

In all types of chronic ear inflammation in adults, hearing deteriorates due to a disrupted sound-conducting system.

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Chronic otitis during pregnancy

Chronic inflammatory processes during pregnancy occur with the same frequency as in other physiological periods. However, the difference is that the special condition of a pregnant woman provides for severe restrictions in the possibility of taking medications. This applies to all diseases, including chronic otitis, because medications can have a negative impact on the development of the fetus.

An inflammatory process in the ear can cause a lot of inconvenience to a woman. The specific position often becomes the reason that a woman becomes sensitive to almost all the little things. At the same time, any "standard" symptom of chronic otitis can cause nervous disorders.

The inflammatory process itself does not pose any danger to the pregnant patient: only purulent forms of the disease can become dangerous. The chronic form can last for years without causing any discomfort, and can worsen precisely during the period of bearing a child. But an exacerbation of the disease in almost all cases requires the use of antibiotics, which are not always approved for the treatment of pregnant women. The following are definitely contraindicated during this period:

• Anauran (a drug based on polymyxin sulfate, neomycin and lidocaine);
• Ciprofloxacin (fluoroquinolone antibiotic);
• Boric acid (antiseptic and disinfectant);
• Norfloxacin (fluoroquinolone drug).

To avoid troubles, treatment should be prescribed only by a doctor. Modern pharmacology today has all the potential to cope with the chronic process, including during pregnancy.

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Chronic otitis in a child

One of the main differences between ear inflammation in a child is that the painful process develops in the underdeveloped organ of hearing, which is still in a state of continuous growth, pneumatization and differentiation. It is logical that the healthy course of the formation process in the ear and temporal bone, as in the whole body, requires the presence of certain conditions - in particular, the child must eat normally, be in an adequate social and domestic environment, and have an appropriate metabolism. Of course, a child's body needs some minerals more than an adult's, which are necessary for building the skeletal system. Incorrect mineral metabolism disrupts the development of bone elements - in particular, the mastoid process.

It has been proven that children with normal physical development tolerate ear inflammation more easily. The transition of the disease into a chronic form is more often observed in children who are underweight, have a weak immune system, suffer from a lack of nutrients in the diet. Chronicization of the process is also observed in the presence of diseases of the digestive system, infectious diseases, endocrine disorders, and also under the condition of improper feeding.

The nature of the inflammatory pathology, as well as its course, may also depend on the type of environment in which the reaction begins - this refers to the state of the mucous tissue, the presence of contents in the middle ear, the degree of pneumatization of the temporal bone, and the characteristics of the ear vascular system. The listed factors tend to constantly change as the child's body grows. This must be taken into account when making a diagnosis and prescribing a therapeutic regimen.

In infants, unlike older patients, isolated pathologies of the nasopharynx are practically not diagnosed - in most cases, the inflammation spreads to the middle ear area.

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Stages

During the period of exacerbation of a chronic disease, the following stages are distinguished:

1. The stage of inflammation at which the initial development of the inflammatory process occurs.
2. The catarrhal stage, in which the inflammation affects the lining of the middle ear.
3. The deporforative stage, in which pus begins to accumulate in the middle ear.
4. The post-perforative stage corresponds to the onset of suppuration from the ear.
5. The reparative stage occurs with signs of abatement of the inflammatory process and scarring of damaged tissues.

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Forms

According to clinical and prognostic characteristics, chronic otitis is divided into processes with central perforation of the eardrum and processes with marginal perforation. The term "central perforation" means the appearance of a hole surrounded on all sides by preserved edges of the eardrum. If we talk about marginal perforation, we mean the localization of the hole near the bone element of the auditory canal, or in the Shrapnell part of the eardrum.

The shape of the perforation may vary: round, oval, kidney-shaped, with different diameters.

The main classification of the disease involves dividing it into the following types:

• Chronic otitis media develops in the presence of bacteria and, in turn, has two more subtypes:
  • mesotympanitis (with damage to only the tympanic cavity);
  • epitympanitis (with damage to bone tissue as well).
• Chronic otitis externa is an inflammatory process, the development of which most often occurs as a result of constant mechanical damage and trauma to the auricle and external auditory canal. Otitis externa can also be of fungal origin.
• Chronic tubotympanic otitis is a pathology of the right ear, in which there is a persistent perforation of the eardrum. The perforation may be associated with a previous acute inflammation, or with mechanical damage to the eardrum during trauma.
• Chronic purulent otitis is characterized by three basic symptoms: continuous or periodic discharge of purulent discharge from the ear canal, persistent perforation of the eardrum, and hearing loss to varying degrees.
• Chronic exudative otitis is characterized by a long period of accumulation of viscous secretions inside the tympanic cavity. The eardrum may remain intact, but the patient experiences dysfunction of the auditory tube.
• Chronic catarrhal otitis is a pathological process that is at the catarrhal stage of inflammation, in which the process affects the membrane of the middle ear.
• Chronic adhesive otitis is characterized by the formation of cicatricial changes in the tympanic cavity and on the membrane. Fusion of the auditory ossicles is also observed and, as a consequence, a pronounced deterioration in hearing abilities. The causes of this pathology are frequent relapses of otitis, or a long-term exudative form of the disease.
• Chronic serous otitis is a disease characterized by the accumulation of serous fluid inside the ear. Often, this disease is accompanied by a deterioration in hearing function and a feeling of congestion (especially when swallowing). Serous otitis can have a bacterial or viral etiology.
• Chronic bilateral otitis is a serious form of the disease with damage to the middle ear. Most often, bilateral otitis media - when both the right and left ear are bothered, is diagnosed in small children, which is associated with the anatomical features of the structure of the hearing organs.
• Chronic left-sided otitis is a pathological process involving the left ear.
• Right-sided chronic otitis is a disease in which the ear on the right side is affected.

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Complications and consequences

Complications arise mainly due to the patient's own fault - for example, if he is in no hurry to see a doctor or self-medicates. Chronic inflammation in the ear is not a harmless disease at all, but rather a formidable and dangerous one. The consequences of carelessness for the patient can be very unfavorable.

• Mastoiditis - occurs when the inflammatory process spreads to the mastoid process, which leads to the appearance of edema and a purulent focus against the background of severe pain and fever. If timely assistance is not provided, the abscess opens on its own, causing inflammation of the meninges. Treatment is only surgical.
• A ruptured eardrum is a common complication in which pus flows into the ear canal rather than into the cranium. This situation indicates an exacerbation of chronic otitis with perforation. If you see a doctor in a timely manner, the eardrum will heal within a week.
• Exacerbation of chronic otitis occurs as a common acute ear inflammation, and often occurs against the background of an accompanying infection or cold. So, if during the period of remission the affected ear did not bother the patient much, then during the period of exacerbation the temperature may rise, pain increases, extraneous noise appears, and hearing becomes worse.
• Hearing loss in chronic otitis can be permanent, especially in the advanced stage of the disease. This complication is especially dangerous for early childhood patients, who, along with hearing loss, may also lose some speech abilities.
• A brain abscess is a purulent inflammatory process in the form of a lesion in the brain tissue. The disease begins acutely, with severe headaches, nausea, dizziness, and fever.
• Hearing is reduced in chronic otitis and in such a complication as labyrinthitis - this is an inflammatory reaction in the inner ear. The patient may also experience difficulties with balance, since the function of the vestibular system is impaired.

Exacerbation of chronic otitis is not always limited to mucous tissues and can spread to bone tissue - for example, to the outer bone surface of the epitympanic space. In some cases, the cortical layer of the mastoid process is destroyed with the formation of a subperiosteal abscess.

Chronic otitis can be complicated by bone caries, the spread of granulation, the growth of polyps, and caries.

Exacerbation of epitympanitis can lead to severe otogenic complications, which develop already in the initial period of the disease. Unfortunately, fatal cases are not uncommon when such complications develop.

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Diagnostics chronic otitis media

If chronic ear inflammation is suspected, the doctor will conduct an extended diagnosis – this is especially important if the patient complains of deterioration in hearing and ear pain.

During the initial appointment, the otolaryngologist examines the patient and then prescribes a number of additional tests. Thus, for a correct diagnosis, the following instrumental diagnostics are recommended:

• Otoscopy with a Ziegle funnel helps to examine the reduced mobility of the eardrum caused by negative pressure or accumulation of secretions in the cavity. In normal function, at the moment of creating positive pressure in the external auditory canal, the eardrum moves toward the tympanic space, and at the moment of creating negative pressure, toward the external auditory canal. Such oscillation can be seen in the posterior superior segment of the eardrum.
• Audiometry is commonly used to diagnose otitis in children. The procedure helps to identify hearing loss, as well as determine the causes of recurrent otitis and speech development delays. The diagnostics are performed in a soundproof chamber.
• Tympanometry helps to determine the cause of changes detected by impedancemetry. The procedure involves assessing the mobility of the eardrum based on the changed volume of the auditory canal against the background of changed intracanal pressure.
• Using a tuning fork with an oscillation frequency of 500-1000 Hz helps differentiate sensorineural and conductive hearing loss. The Weber test is performed: a sounding tuning fork is placed along the midline, and the patient determines from which side the sound is clearer. The Rinne tuning fork test is also performed: one ear is covered and a sounding tuning fork is placed against the mastoid process on the opposite side. The patient must indicate the moment when he stops hearing the sound. After this, the tuning fork is placed near the external auditory canal and the moment is again waited for when the patient stops hearing the sound. In this way, bone and air sound conductivity are determined. The norm is said to be when air sound perception is twice as high as bone perception.

Impedancemetry in chronic otitis allows to simultaneously assess the mobility of the eardrum and auditory ossicles, and also to determine the degree of patency of the auditory tube. The essence of the procedure is as follows: a device with a built-in sound source, a detector and an automatic pump output is inserted into the external passage. The device with the sensor hermetically seals the auditory canal. With a change in pressure, the motor activity of the eardrum and auditory ossicles changes, which is assessed by the doctor according to the degree of reflected and absorbed sound energy. The result is drawn in the form of a graph of the curves of the dependence of the mobility of the eardrum on the intraductal pressure. The procedure is carried out in an outpatient setting and can be used to diagnose the hearing function in adults and children from 7 months of age.

Additionally, it is necessary to take some tests:

• biochemical and serological blood tests for infection;
• bacterial culture of secretions for microflora with simultaneous assessment of sensitivity to antibacterial drugs;
• microscopic examination of secretions;
• immunological tests and other analyses.

If the information obtained during the patient examination indicates the presence of an atopic disease, then an immunological study is prescribed. If the patient has had frequent infectious diseases of the upper respiratory tract, he is recommended to take tests for IgA, IgM, IgG, and also to conduct a functional test of the state of humoral immunity. In case of ineffective treatment of chronic otitis (especially one that is combined with chronic bronchitis and/or sinusitis), attention should be paid to differential diagnostics, excluding primary ciliary dyskinesia.

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Differential diagnosis

Differential diagnostics is primarily based on the localization of perforation and the nature of discharge. Additionally, X-ray of the mastoid process is performed.

In case of purulent discharge from the ear with an unpleasant odor, differentiation is made with epitympanitis: it is necessary to clarify the presence of a carious process or choleastoma. In some cases, mesotympanitis can also give similar symptoms, but the unpleasant odor in this situation disappears after cleaning the ear, since it has no connection with pathological processes in bone tissue.

Epitympanitis is characterized by complete damage to the eardrum, or perforation in m. Shrapnelli. Therefore, an important diagnostic procedure is otoscopy, performed with particular care. Before otoscopy, the ear canal should be completely cleared of discharge, since even small amounts of it can cover the perforation and prevent the correct diagnosis.

X-rays will help to examine the damaged structure of the mastoid process, as well as to see cholecystoma – in the form of a cystic formation.

Treatment chronic otitis media

Read about methods of treating chronic otitis media at home and in hospital in this article.

Prevention

Chronic otitis brings a lot of unpleasant sensations to the sick person. Therefore, if possible, it is better to prevent the disease in advance to avoid suffering. Everyone who cares about their own health should know about such preventive measures.

• You should avoid hypothermia. If you do catch a cold, you should start treatment immediately, without waiting for the illness to worsen.
• Strong immunity is the key to successful protection of the body from many diseases. Therefore, it is important to maintain your own immune forces in "full combat readiness". To do this, you need to lead a healthy lifestyle, eat well, and if necessary - for example, in early spring, take multivitamin complex preparations.
• Hardening, walks in the fresh air, and active games are especially beneficial for the body. It is known that a sedentary lifestyle increases the risk of illness, including the development of chronic otitis.

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Forecast

Chronic otitis requires long-term treatment. However, if you strictly follow the doctor's instructions, the disease can be cured. If you visit a doctor late after the therapeutic course, unpleasant consequences may remain in the form of hearing loss and vestibular disorders.

Hearing loss is especially common with frequent and long-lasting relapses.

To avoid complications, you need to see a doctor in a timely manner, and after completing treatment, it is important to periodically undergo preventive diagnostics in the ENT department.

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Chronic otitis and the army

In case of diagnostically confirmed chronic otitis media, chronic purulent otitis, mesotympanitis, the young man is assigned category B, which means that he is exempt from compulsory military service in peacetime.

The complete list of ear diseases that fall into this category is as follows:

• chronic otitis media, unilateral or bilateral;
• chronic purulent otitis with signs of persistent difficulty in nasal breathing.
• The category is assigned based on:
• otoscopic conclusion (perforation of the eardrum, presence of discharge);
• culture of ear discharge for flora;
• radiography of the temporal bones according to Schuller and Mayer;
• CT scan of the temporal bones.

An indication for exemption from conscription is also considered to be chronic otitis, which was operated on 12 or more months ago (if a radical intervention or open tympanoplasty with complete epidermization of the surgical cavity was performed).

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