Otomastoiditis in infants: causes, symptoms, diagnosis, treatment

The research on otomastoiditis in infants was initiated by the leading German otolaryngologist A. Troltsch in 1856.

Polymorphic symptoms, frequent complications, features of the anatomical structure, significant subjective and objective difficulties in diagnostics and treatment of acute inflammation of the middle ear allow us to distinguish this disease into a special category with specific features. In infancy, the inflammatory process, as a rule, affects all airways and structures of the middle ear, which, due to their incomplete intrauterine development, widely communicate with each other and contain remnants of embryonic tissues that are not protected from infectious invasion, in which pathogenic flora multiplies with particular splendor.

Epidemiology of otomastoiditis in infants. According to the Romanian author I.Tesu (1964), otomastoiditis most frequently occurs in infants under 6 months of age, after which it exponentially decreases to the frequency of occurrence in adults. Based on extensive statistical material obtained as a result of examining 1062 infants in a children's hospital for children with various infectious diseases, the author found otomastoiditis in 112 children (10.5%), with most of them under 4 months of age; 67 cases (75%) occurred in the summer during a dysentery epidemic, while in the fall - 28 (31%), and in the fall and winter - 17 (19%). These data indicate that the incidence of otomastoiditis in infants is directly dependent on the general condition of the body, which can be disrupted by various common infectious diseases and causes that weaken the immune system (childhood diathesis, allergies, vitamin deficiency, nutritional deficiency, dystrophy, metabolic disorders, unfavorable social factors, etc.).

Causes. The microbiota of otomastoiditis in infants includes streptococcus, pneumococcus, including mucous, and less often staphylococcus. In 50% of cases, this is a symbiosis of staphylococcus and streptococcus, 20% - pneumococcus, 10% pneumococcus and streptococcus, and in 15% of cases, polymorphic microbiota.

Pathogenesis of otomastoiditis in infants. Local factors that contribute to the development of otomastoiditis in infants are wide, straight and short auditory tubes and the entrance to the mastoid cave, which contributes to good communication of all cavities of the middle ear with the nasopharynx, a large volume of the mastoid cave, which is surrounded by spongy, abundantly vascularized bone, which contributes to the hematogenous spread of infection through the bone systems of the middle ear. It is known that the middle ear in the process of embryogenesis is formed from a diverticulum of the nasopharynx, growing into the forming temporal bone, and its air cavities form a single cellular system with the airways of the paranasal sinuses. Hence the close pathogenetic relations of the latter with the middle ear. In most cases, the starting point of otomastoiditis in infants is the nasopharynx with numerous inflammatory processes localized in it (adenoiditis, rhinosinusitis, pharyngitis, etc.), as well as diseases of the auditory tube, which are a consequence of these processes, and which is the main “supplier” of infection for the middle ear.

In addition to the above anatomical features of the structure of the middle ear in a newborn, J. Lemoin and H. Chatellier described a certain ear diaphragm existing in infants up to 3 months of age, which divides the middle ear into two parts - the upper-posterior part, located above and behind the epitympanic recess, the mastoid cave and the entrance to it, and the lower part - the tympanic cavity itself. This diaphragm has an opening in the center, which, however, does not provide sufficient communication between the cave and the tympanic cavity, which complicates the outflow from the latter into the tympanic cavity and further to the auditory tube. After 3 months, this diaphragm undergoes resorption. In addition, in an infant, the remnants of loose embryonic tissue, which is a favorable soil for the development of microorganisms, are preserved for a longer time in the submucosal layer of the middle ear. A contributing factor for the development of otomastoiditis in a breastfed baby is its horizontal position during feeding, since in this position the pathological contents of the nasopharynx and liquid food products and regurgitation most easily penetrate from the nasopharynx through the auditory tube into the middle ear cavity. Thus, methylene blue installed in the pharynx can be detected in the tympanic cavity after a few minutes.

In the pathogenesis of otomastoiditis in infants, three routes of infection are distinguished: the "mechanical" route from the nasopharynx through the auditory tube directly into the tympanic cavity, the lymphogenous and hematogenous route. The existence of the hematogenous route is evidenced by the simultaneous occurrence of bilateral otomastoiditis in infants with any general infection, such as measles or scarlet fever.

Symptoms of otomastoiditis in infants. There are three clinical forms of otitis media in infants: obvious, latent and hidden, or so-called pediatric, form, since its existence is supported mainly by pediatricians, but rejected by most otologists.

The obvious form usually occurs in children of eutrophic constitution, with good nutrition and care, in the so-called robust children. The disease begins suddenly - primarily or as a consequence of acute adenoiditis, most often a bilateral inflammatory process with an interval between the occurrence in one and the other ear of several hours or days. The body temperature quickly reaches 39-40 ° C. The child screams, rushes about, rubs his head on the pillow, brings his hand to the sore ear or is in a lethargic state (intoxication), does not sleep, does not eat; gastrointestinal disorders, vomiting, sometimes convulsions are often observed. Endoscopically, signs of acute inflammation of the middle ear are revealed. When pressing on the pretracheal and mastoid area, the child begins to scream in pain (Wacher's symptom). After paracentesis, otitis can be eliminated within a few days, but can further develop into mastoiditis. In the latter case, the amount of pus in the external auditory canal increases, it pulsates, acquires a yellow-green color, the auditory canal narrows due to the overhang of the posterior superior wall, the edematous, highly hyperemic mucous membrane can prolapse through the perforation, creating the impression of a polyp (false or "acute" polyp). In the retroauricular region, pastosity of the skin and sharp pain during palpation, as well as local and cervical lymphadenitis are detected. When mastoiditis occurs, the general signs of the inflammatory process again intensify, as at the onset of the disease. Timely antrotomy leads to a rapid cure, but a delay in its implementation usually causes the occurrence of a subperiosteal retroauricular abscess, while the auricle protrudes forward and downwards, the retroauricular fold is smoothed out. Formation of an abscess and breakthrough of pus into the subperiosteal space and further under the skin with formation of a purulent fistula improves the general condition of the child and often leads to spontaneous recovery. According to a number of authors, subperiosteal abscess in infants in 20% of cases occurs in the absence of obvious signs of otitis with a relatively satisfactory general condition of the child.

Diagnosis of subperiosteal abscess in an infant, as a rule, does not cause difficulties; it is differentiated from adenophlegmon of the retroauricular region, which occurs with external otitis.

Forms of otomastoiditis in infants.

The latent form occurs in weakened children, with a hypotrophic constitution, in unfavorable families or in children with weakened immunity, metabolic disorders, who have suffered a general infectious disease. Often, this form of otitis occurs in the absence of local signs of inflammation or with their significant reduction. Local signs are masked by a general severe condition, the cause of which remains unclear for a long time (days and weeks). The latent form of otitis in an infant can occur in the form of one of three clinical syndromes - cholera-like, or toxic, cachectic and infectious.

The toxic syndrome is the most severe and is characterized by signs of deep intoxication of the body: the eyes are surrounded by blue, the gaze is fixed, signs of enophthalmos are detected. The child is motionless, does not cry, does not eat, does not sleep, the face shows an expression of suffering and fear, the extremities are cold, bluish, the skin is pale, with a leaden tint, dry, its turgor is sharply reduced, the fontanelle is retracted. Breathing is frequent, shallow, tachycardia, heart sounds are weakened, sometimes systolic murmur is heard, signs of toxic myocarditis may be observed. The abdomen is soft, the liver and spleen are enlarged. Signs of digestive disorders are observed: vomiting, diarrhea up to 10-20 times a day, dehydration with a rapid decrease in body weight to 100-300 g / day, which is a threatening prognostic sign. Body temperature fluctuates around 38-40°C, in the terminal phase it either rises even more or falls below 36°C, which is a sign of impending death. In the blood - leukocytosis up to (20-25)x10 ⁹ /l, anemia. Urine analysis reveals oliguria, albuminuria; swelling of the face and extremities appears, indicating kidney damage. Metabolic disorder is characterized by hyperchloremia, which is a contraindication for intravenous administration of sodium chloride solution with preference for glucose solutions.

Cachexic syndrome is characterized by a gradual decline in the child's nutrition, less pronounced general symptoms, a slower decrease in body weight, and an elevated body temperature that remains at the same level (37.5...38.5°C).

Latent form. As noted above, this form of the so-called "occult" or "pediatric" otomastoiditis in an infant occurs without any objective local or subjective signs and is mainly a "diagnosis of assumption" by pediatricians, who often insist on antrotomy for this general clinical course of an objectively undiagnosed disease. Pediatric otologists (ENT specialists) mostly reject the presence of this form. Statistical data show that recovery from a certain toxic condition in children during paracentesis or antrotomy (without detection of purulent discharge into the middle ear) at the insistence of a pediatrician occurs only in 11% of cases. In other cases of surgical "treatment" the clinical course of the general disease did not stop. In these cases, surgical intervention not only does not stop the general pathological process, but can cause a sharp deterioration in the child’s condition and, according to foreign statistics, cause a fatal outcome (50-75%).

If there is a suspicion of a source of infection in the otomastoid region, the doctor's attention should be primarily focused on the condition of the auditory tube and pharyngeal lymphadenoid formations. According to a number of authors, richly innervated tissues of the nasopharynx, if there is a source of infection in them, can serve as a center for generating pathological reflexes, the accumulation of which causes an imbalance in the body's autonomic regulation and potentiates sources of infection, including in the upper respiratory tract, which causes a certain generalization of infectious and toxic-allergic processes. This concept gives grounds to call the conditions described above neurotoxicoses, which determines the use of methods and means that normalize the state of the nervous system in complex treatment.

The clinical course of otomastoiditis in an infant is determined by its general physical condition, the activity of the immune system, the presence or absence of chronic foci of infection and latent general diseases (rickets, diathesis, vitamin deficiency, hypotrophy, etc.). The better the general physical condition of the child, the more obvious are the signs of the inflammatory process in the middle ear, but also the more effectively the body fights the infection and the more effective are the treatment methods used. In weakened children, the inflammatory process is more torpid, but its consequences can be more dangerous and fraught with formidable complications.

The prognosis for the above-described forms of otomastoiditis in infants is very serious and is determined by the effectiveness of the treatment.

The prognosis is determined by the form of the disease. In the overt form, it is generally favorable, and with adequate treatment, recovery occurs in 10-15 days without any morphological or functional negative consequences. In the latent form, as described above, the prognosis is very serious, since the percentage of fatal outcomes in it, according to foreign statistics, in the middle of the 20th century fluctuated from 50 to 75.

Complications of otomastoiditis in infants. The most dangerous complication is meningoencephalitis, which manifests itself in convulsions, agitation or depression, increased intracranial pressure, and bulging of the fontanelle. When the latter is punctured, the cerebrospinal fluid gushes out under high pressure. Its cytological, biochemical, and microbiological examination indicate the presence of meningitis.

Complications such as sinus thrombosis, brain abscess, labyrinthitis, and facial nerve damage occur extremely rarely.

Complications "at a distance" in the late period of the disease or at the height of the process may be bronchopneumonia, pyoderma, multiple point subcutaneous abscesses, abscesses in the injection area. General complications manifest themselves in the form of toxicosis and sepsis.

Diagnosis of otomastoiditis in infants is in all cases very difficult due to the prevalence of general toxic phenomena over local changes masking the latter, as well as due to the difficulties of otoscopic examination. An important role in establishing the diagnosis is played by questioning parents to establish previous acute or chronic diseases that could have caused the current disease. Otoscopy reveals inflammatory changes in the eardrum, the presence of pus in the external auditory canal, narrowing of the external auditory canal (overhang of its posterior superior wall), postauricular signs of mastoiditis, etc. The diagnosis is supplemented by radiography of the temporal bones, which reveals typical signs of otoantritis and mastoiditis.

Treatment of infants suffering from various forms of otomastoiditis involves the use of non-surgical and surgical methods.

Non-surgical treatment includes, first of all, combating dehydration by subcutaneous, intrarectal or intravenous administration of appropriate isotonic solutions of sodium bicarbonate, glucose, as well as plasma and its substitutes (according to differentiated indications taking into account the biochemical parameters of the blood and the child's body weight). In case of anemia, blood transfusion in small quantities (50-100 ml) is indicated.

Oral nutrition in the acute phase of the disease should be limited to giving a few teaspoons of glucose solution. The functions of the main body systems (cardiac, urinary, immune, digestive, etc.) should be under the supervision of appropriate specialists. Antibacterial treatment is effective only in the case of obvious inflammation in the middle ear and as preoperative preparation in case of need for surgical treatment.

Surgical treatment involves the use of paracentesis, trepanopuncture of the mastoid process, including the cave, antrotomy and antromastoidotomy.

The above-mentioned surgical interventions are performed according to strict indications and only in rare cases for ex jubantibus diagnostics and in cases where clear signs of otomastoiditis are detected. The main surgical intervention is antrotomy, which can then, if indicated, be continued as mastoidectomy.

Antrotomy begins with local anesthesia by infiltrating the surgical area with 0.5-1% novocaine solution in a dose corresponding to the child's body weight, with the addition of 1 drop of 0.1% adrenaline solution per 1 ml of novocaine solution. The tissue incision in the retroauricular area is made layer by layer very carefully.

The periosteum is cut crosswise, which facilitates its separation and prevents its damage. Trepanation of the bone is performed 3-4 mm posterior to the posterior wall of the external auditory canal. A grooved chisel, a sharp spoon or a cutter are used for this.

After opening the mastoid process cave, the pathologically altered bone and granulations are carefully removed. Then the mastoid process cave is widened, with the risk of dislocation of the incus and damage to the facial canal and the horizontal part of the lateral semicircular canal. If mastoidectomy is necessary, there is a risk of trauma to the sigmoid sinus. The wound in the retroauricular area may remain unstitched or 2-3 sutures with a graduate are applied to it. The skin around the wound is treated with Vaseline.

Postoperative treatment is carried out under the supervision of a pediatrician. It consists of systematic dressings, symptomatic and pathogenetic general treatment, sanitation of identified chronic foci of infection, general strengthening measures in accordance with the child's condition.

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