Treatment of otogenic intracranial complications and otogenic sepsis

The main pathogenetic principle of treatment of intracranial otogenic complications is the elimination of the purulent focus in the ear.

The goal of treating otogenic intracranial complications is to improve the general condition of the patient and eliminate existing neurological symptoms. To achieve these goals, regardless of the severity of the patient's condition, drainage of the infectious focus and adequate intensive antibacterial therapy are necessary.

Indications for hospitalization

Indications for hospitalization are a history of acute or chronic ear diseases, occurrence of acute or exacerbation of chronic purulent otitis media, seizures, mental disorders, complaints of headache, nausea, vomiting, fever, detection of meningeal symptoms. Patients with suspected intracranial complications require urgent hospitalization in a specialized medical institution, and if the diagnosis is confirmed, they are subject to emergency surgical treatment.

Non-drug treatment

In recent years, the following types of non-drug treatment have been used in the treatment of otogenic intracranial complications:

1. extracorporeal blood irradiation, stimulating specific and non-specific immunity;
2. hyperbaric oxygenation in the postoperative period in order to activate tissue metabolism under conditions of increased partial oxygen pressure. After hyperbaric oxygenation sessions, a decrease in intracranial hypertension is observed. The effect of hyperbaric oxygenation is also manifested in a more rapid decrease in body temperature, positive dynamics of reparative processes in the surgical wound, which is associated with more rapid lysis of necrotic tissue and activation of regenerative processes;
3. plasmapheresis;:
4. hemosorption;
5. blood transfusion;
6. transfusion of fresh frozen plasma.

Drug treatment of otogenic intracranial complications and otogenic sepsis

One of the important aspects of postoperative treatment of patients with otogenic intracranial complications is complex intensive drug therapy. Drug treatment of otogenic intracranial complications includes, first of all, the use of antibiotics. Antibacterial therapy should begin with large doses of antibiotics and is carried out using all the main routes of drug administration (intravenously - to create the maximum concentration of antibiotic in the blood; intramuscularly - to ensure a supporting antibacterial effect). The most effective is regional administration of antibiotics into the cerebrospinal fluid pathways or the arterial system of the brain.

Patients with purulent-inflammatory lesions of the brain usually receive urgent care, and before the start of antibacterial therapy it is impossible to determine the specific pathogens of the infection. Therefore, the choice of empirical antibacterial therapy should be based on knowledge of the most likely pathogens and data on antibiotic resistance in the region

When prescribing antibacterial therapy to a patient with an intracranial complication of otogenic origin, it is necessary to take into account both the activity of this drug against the suspected pathogens (especially resistance to beta-lactamases) and its ability to penetrate the blood-brain barrier.

Bacterial culture and antibiotic sensitivity testing should be performed as soon as possible. However, until the results of the bacteriological examination are obtained, empirical therapy should be prescribed, including the administration of two or three antibiotics simultaneously. A highly effective treatment regimen includes two antibiotics, one of which may be a semisynthetic penicillin or a second-generation cephalosporin, and the second is an aminoglycoside antibiotic. Antibiotics are administered in maximum therapeutic concentrations. After receiving the results of the bacteriological examination of the cerebrospinal fluid and identifying the pathogen, targeted therapy can be prescribed. When using benzylpenicillin as the main antibiotic, its sodium salt is used at a dose of 30-50 million U/day, evenly distributed over 6-8 doses. It should be noted that penicillin has not lost its therapeutic value in many infections to this day. It is also necessary to take into account the fact that it is one of the cheapest antibiotics. Depending on the effect, this therapy continues for 3-5 days, followed by a transition to maintenance doses of 12-18 million U/day.

Among the semi-synthetic broad-spectrum penicillins resistant to beta-lactamases, the most well-known combinations are amoxicillin + clavulanic acid and ampicillin + sulbactam, which also have antianaerobic activity.

If anaerobes are identified or suspected among the pathogens, metronidazole is used intravenously in combination with antistaphylococcal penicillin (oxacillin). This combination is widely used and has repeatedly proven its high efficiency in providing emergency care to the most severe patients with purulent-septic complications of the brain. Quite a satisfactory clinical effect, confirmed by bacteriological studies, is also achieved in patients with severe intracranial complications when using cephalosporins of the III-IV generation.

Currently, such drugs as ceftriaxone, cefotaxime, ceftazidime are widely used. They belong to the third generation of cephalosporins. In particular, ceftazidime, used parenterally at 1-2 g every 8-12 hours, is the drug of choice for pseudomonas infection. The fourth generation cephalosporin cefepime, characterized by a broad spectrum of action, can be used to treat patients with neutropenia and weakened immunity. Cephalosporins are rarely combined with other antibiotics, but combinations with aminoglycosides and metronidazole are possible.

Glycopeptides are virtually the only group of antibiotics that retain high activity against staphylococci and enterococci resistant to other antibiotics. Vancomycin is also indicated in cases of ineffectiveness or intolerance to penicillins or cephalosporins. It should be noted that vancomycin should be classified as a reserve group and used only in situations where other antibiotics are ineffective.

Along with various types of microorganisms, recently the cause of severe purulent-inflammatory lesions of the ear and intracranial otogenic complications in some cases are various fungi (aspergillosis, candidiasis, penicillinosis, etc. are most often observed). Among antifungal drugs, the most appropriate is the use of triazoles (ketoconazole, fluconazole, itraconazole). In some cases, it is possible to use amphotericin B.

Intracarotid administration of antibiotics is performed by puncture of the common carotid artery or by means of a standard vascular catheter inserted into the common carotid artery. The most convenient and safe way is to insert a catheter into the carotid artery through the superficial temporal artery. The dose of antibiotic administered into the carotid artery is 0.5-1.0 g, the drug is prescribed twice a day. During catheterization of the common carotid artery, continuous administration of antibiotics is performed using a device for administering drugs, the daily dose of the drug can reach 2 g. The daily amount of infusion solution is 1-1.5 l/day. The basis of infusates is Ringer-Locke solution or 0.9% sodium chloride solution with the addition of heparin, protein breakdown inhibitors, and antispasmodics.

Endolumbar administration of antibiotics is performed 1-2 times a day. The drugs of choice for these purposes are cephalosporins, aminoglycosides in a dose of 50-100 mg. Removal of 10-15 ml of cerebrospinal fluid during lumbar punctures is also an important element of cerebrospinal fluid sanitation. Acceleration of cerebrospinal fluid sanitation is achieved by performing cerebrospinal fluid sorption. For most cases of meningitis caused by gram-negative bacteria, 10-14 days of treatment are required after cerebrospinal fluid cultures become sterile. For staphylococcal meningitis, the duration of therapy is usually 14-21 days.

Features of antibiotic therapy in the treatment of brain abscesses

The choice of antibiotics for the treatment of bacterial abscess depends on many factors, the most important of which is the type of pathogen. In this regard, before prescribing antibacterial agents, it is necessary to culture the contents of the abscess. Other factors are the ability of antibiotics to penetrate into the abscess cavity, its bactericidal or bacteriostatic properties and spectrum of action. Before isolating the pathogen, antibiotics are prescribed against the most likely infectious agents. If the source is chronic purulent otitis media, then a mixed aerobic and anaerobic infection should be assumed, and the treatment regimen should include broad-spectrum antibiotics. In this case, it is possible to prescribe metronidazole (will cover anaerobic microorganisms), which perfectly penetrates into the abscess cavity, and benzylpenicillin to act on gram-positive bacteria (although half of the pathogens currently isolated are resistant to it). In this regard, beta-lactamase-resistant semisynthetic penicillins or vancomycin are recommended. In weakened and previously treated patients, it is necessary to prescribe antibacterial agents that act on gram-negative bacteria.

Long-term use of antibiotics in the stage of limited encephalitis allows achieving success in the treatment of the disease. Good treatment results have been achieved in patients with small abscesses (average diameter 2.1 cm), especially when the source of infection is known. In multiple abscesses, antibiotics can be used as the only type of treatment for formations less than 2.5 cm in diameter, provided that a culture of the pathogen is obtained from at least one abscess.

To wash the abscess cavity, a 0.9% sodium chloride solution is used with the inclusion of broad-spectrum antibiotics that do not have epileptogenic activity, at a rate of 0.5 g per 500 ml of solution; proteolytic enzymes: protein breakdown inhibitors.

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Treatment of multiple abscesses

Urgent surgical intervention is required for multiple abscesses greater than 2.5 cm in diameter or causing a noticeable mass effect. If all abscesses are less than 2.5 cm in diameter and do not cause a mass effect, the contents of the largest abscess are aspirated for microbiologic examination. Antibiotics should be withheld until material for culture is obtained. Broad-spectrum antibiotics are used pending culture results, and then antibacterial agents are used according to the results of pathogen identification for at least 6-8 weeks, and in weakened patients for more than 1 year.

Thus, at present there is a significant number of various antibacterial drugs, the separate or combined use of which allows to cover the entire spectrum of possible pathogens in severe infectious lesions of the ENT organs. When prescribing therapy, the doctor must take into account the severity of the disease, the characteristics of the suspected pathogen, the possibility of the existence and development of resistance to the drug used during treatment.

Etiotropic antibacterial therapy must be combined with active pathogenetic and symptomatic treatment.

In case of otogenic surgical complications, dehydration and detoxification therapy are performed. The following drugs are administered intravenously: mannitol 30-60 g in 300 ml of 0.9% sodium chloride solution once a day, furosemide 2-4 ml per day: magnesium sulfate 10 ml; dextrose 20 ml and sodium chloride 15-30 ml; methenamine 3-5 ml; hydroxymethylquinoxyline dioxide - 300 mg; hemodez - 250-400 ml; ascorbic acid - 5-10 ml; glucocorticoids (prednisolone, hydrocortisone). In addition, antihistamines and B vitamins are administered subcutaneously and intramuscularly, and pentoxifylline 200-300 mg intravenously.

As symptomatic therapy, cardiac glycosides, analeptics and analgesics are prescribed according to indications. In case of psychomotor agitation, diazepam 2-4 ml is administered intravenously.

In case of sigmoid sinus thrombosis and otogenic sepsis, anticoagulants are prescribed, mainly sodium heparin (from 10,000 to 40,000-80,000 U per day). Treatment with anticoagulants is carried out under the control of blood clotting time or blood prothrombin level. Anticoagulant therapy promotes the washing out of microorganisms from microcirculatory depots and ensures the penetration of antibiotics into the most remote areas of the vascular bed. Proteolytic enzymes are also used (intramuscularly).

Since the immune system of these patients experiences significant stress and functions in conditions close to critical, special attention should be paid to immune therapy, both passive and active (antistaphylococcal plasma, antistaphylococcal immunoglobulin, immunocorrectors of organic, inorganic and plant origin, etc.).

In intensive care of patients with otogenic intracranial complications, it is necessary to take into account biochemical indicators of homeostasis and correct them.

Surgical treatment

Surgical treatment is the leading method of treating otogenic intracranial complications. The goal of surgical intervention is to eliminate the primary purulent-inflammatory focus of the middle or inner ear. This result can be achieved by wide exposure of the dura mater and, if necessary, puncturing the brain or cerebellum, opening or draining the abscess. Operations for otogenic intracranial complications are described in a separate chapter.

Further management

Further management of patients who have suffered otogenic intracranial complications consists of dynamic observation by an otolaryngologist and neurologist.

Due to the high frequency of epileptic syndrome in the acute period of the disease and after surgical treatment, all patients with subdural empyema are prescribed anticonvulsants for a year after surgery.

Forecast

One of the most important factors determining outcome is preoperative neurological status. Mortality ranges from 0 to 21% in conscious patients, up to 60% in patients with signs of dislocation, and up to 89% in comatose patients.

Every physician in the process of treating a patient with acute or chronic purulent otitis media must remember the possibility of intracranial complications and, if they are suspected, immediately refer the patient to an otolaryngology hospital.

A favorable outcome of otogenic intracranial complications depends on timely diagnosis, surgical intervention on the affected ear, urgent elimination of the intracranial lesion, the use of a complex of antibiotics sensitive to this flora, as well as other drugs in appropriate doses, and proper management of the patient in the postoperative period.

In sinusogenic sepsis, the prognosis is favorable in the vast majority of cases. Mortality is 2-4%. With a marked decrease in resistance and a change in the body's reactivity, fulminant forms of sepsis can be observed. The prognosis for them is unfavorable.

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