Otitis media acuta
Acute otitis media can be divided into three stages: The first stage is exudative inflammation and lasts for 1-2 days. There is fever (39-40ºC), pain, which is more intense at night, pulsation in the ear, deafness, noise in the ears, and painful sensitivity of the mastoid to pressure. In elderly patients, this stage’s symptoms may be milder, so there may be no fever at all. The second stage is the demarcation stage and lasts from 3 to 8 days. If there is an accumulation of exudate in the middle ear, at this stage, the eardrum may perforate spontaneously, after which the temperature drops and the pain in the ear decreases. This stage may be shorter if antibiotics, analgesics, and vasoconstrictors are used in time, preventing spontaneous perforation of the eardrum. The third stage lasts 2 – 4 weeks when everything returns to normal: deafness, pain, fever, and pulsation in the ear disappear.
The diagnosis is made by anamnesis, otoscopy, and, if necessary, examinations such as acumetry, tone audiogram, tympanogram, and X-rays. In the first stage, otoscopy shows hyperemia and the eardrum surface’s turbidity. Visible structures of the malleus disappear, the triangular reflection on the eardrum is lost. In the second stage of inflammation, the entire eardrum is red, and the patient develops conductive hearing damage. In addition to redness, the eardrum may be bulging or pulsating, or the exudate level in the middle ear can be seen. The eardrum may perforate spontaneously, seen as a small diameter hole through which the exudate exits. X-rays of the mastoid, according to Schueller, may show turbidity of the mastoid cells. In the third stage, the redness disappears. The triangular reflection on the eardrum reappears, there is no more protrusion or pulsation. If the eardrum is perforated in the second stage of the disease, a scar is seen at the site of perforation. Hearing returns to normal, noises disappear. An X-ray of the mastoid shows no more clouding of the mastoid cells.
Acute otitis media treatment is usually conservative and can also be operative. Conservative therapy consists of administering broad-spectrum systemic antibiotics (e.g., amoxicillin) for 10 days. Also, analgesics are given to reduce pain, and nasal vasoconstrictor drops (e.g., ephedrine, naphazoline, etc.) decongest the nasopharyngeal mucosa, which surrounds the pharyngeal orifice of the eustachian tube. This is especially important because the permeable Eustachian tube allows for proper ventilation of the middle ear and thus faster recovery of the patient.
Otitis media chronica
Chronic otitis media occurs if acute inflammation is not treated adequately and promptly if there is a pathological process in the nose and epipharynx if the causes are highly virulent. Suppose the middle ear mucosa’s resistance is reduced, as well as the resistance of the whole organism. Also, if the Eustachian tube’s function is not normal and aeration and drainage of the eardrum are not sufficient, chronic inflammation of the middle ear can occur over time. The perforation of the eardrum usually accompanies chronic otitis media. It can form on any part of the eardrum; in the pars tensa, in the Schrapnell membrane, it can be subtotal or total. Two things happen around the perforation: mucous cells grow from the eardrum outwards, and skin cells tend to grow into the eardrum. The further course of the disease also depends on which process will prevail. Perforation may be punctate, renal, round, oval, or irregular and may occur centrally or peripherally relative to the annulus tympanic. Through perforation, in chronic otitis media, effluvium usually leaks. It is a secretion, which can be serious, mucous, purulent, and hemorrhagic. As a rule, it smells unpleasant. As it flows into the ear canal and through the ear, it can macerate the skin, resulting in the ear canal and the ear’s reactive inflammation. If this lasts longer, narrowing of the auditory canal can occur and the formation of granulations and polyps from the middle ear into the auditory canal. The middle ear’s mucous membrane is thickened, the squamous cells metastasize into cubic and cup-shaped ones, which produce secretions. The ear is moisturized, and ischemia and necrosis can occur. And not just the mucous membranes but also the middle ear bone. An ostitic process occurs, which spreads to the bones and destroys them. The most important feature of advanced chronic otitis media is cholesteatoma formation.
Cholesteatoma
The diagnosis of otitis media is made by otorhinolaryngological examination, which determines changes in the eardrum and auditory canal and possible changes in the ear and around it. You should pay particular attention to the mastoid area. If necessary, in addition to classical otoscopy with an ear funnel, optics and a microscope can also be used. After that, if necessary, X-ray processing of the mastoid according to Schueller or the pyramid according to Stenvers, and CT or MR of the middle ear are performed. If effluvium is present, it is advisable to perform a biopsy and antibiogram. If the ear canal is filled with desquamated epithelium or dried secretion, an ear micro toilet must be made, which cleans it all, after which we get a good insight into the condition of the ear. After that, we examine the hearing, first isometrically and then with tone audiometry, which gives us insight into the condition of the inner ear’s sensory cells and an assessment of what the hearing could be like after the chronic inflammation has healed. Vestibulometric treatment may also be performed.
Therapy for chronic otitis media can be conservative and surgical. Conservative therapy can be local and systemic. Topical therapy consists of rinsing the ear with a 3% boric acid solution, cleaning the ear with microtoilets, and applying ear drops or powder. Ear drops contain an antibiotic (geocorton or neomycin) and a corticosteroid (dexamethasone), and the powder is usually chloramphenicol or boric acid. If fungi are present, antifungal drops are applied after rinsing the ear. Systemic therapy consists of the systemic administration of antibiotics, targeted, based on ear swabs. Since the most common bacterium is isolated in Pseudomonas smear, pefloxacin or ciprofloxacin is administered parenterally for 10 days. After the ear is stabilized by local or systemic antibiotic therapy, it is advisable to treat it surgically. The operation eradicates the pathological process from the middle ear, prevents the spread of the process and the involvement of surrounding structures (dura, labyrinth, sigmoid sinus, facial), and reconstructs structures eardrum or chain of auditory ossicles after surgery. The surgical procedure may be sparing when structures such as the auditory canal’s posterosuperior wall are preserved if this can be technically performed. It may be radical when the eardrum and mastoid become one cavity after the surgical procedure.
The type of surgery depends on the pathological process and the disease’s extent. Some of the operations’ names are tympanoplasty, mastoidectomy, osiculoplasty, myringoplasty, tympanomastoidectomy, and the like.
Otoscopic changes of the eardrum
Otoscopic changes in the middle ear are classified into acute inflammatory, chronic inflammatory, and cicatricial changes. The presence of one change does not preclude other changes. For example, a cicatricial change (scar) can be acutely or chronically inflamed.
Acute otitis media
Acute otitis media generally creates acute inflammatory changes of the eardrum. The eardrum is thickened, erythematous, and less transparent than normal. The eardrum’s transparency shows individual variations, so this is not a reliable sign. The swelling and thickening of the eardrum give it an irregular surface that is no longer smooth and reflective but darker. The typical triangular reflection of light is either absent or fragmented. When fluid collects in the middle ear, the eardrum may bulge forward. The protrusion is most often first seen on the pars flaccida. As the inflammation progresses and fluid pressure rises, the eardrum may perforate. Generally, perforation begins in a small area of the eardrum, allowing fluid to drain into the external auditory canal. If there is an open connection between the acutely inflamed middle ear and the discharge in front of the eardrum, pulsations can be transmitted from the inflamed mucosa. Pulsatile discharge is, therefore, a sign of acute otitis media.
Effusion in the middle ear
Effusion in the middle ear is an accumulation of fluid in the middle ear without perforating the eardrum and signs of acute inflammation. In partial effusion of the middle ear, air bubbles appear at the fluid-air boundary marking air entry, confirming some degree of ventilation through the auditory tube. In general, partial effusion means subacute serous inflammation with a good prognosis typically found after the upper respiratory tract’s viral infections. Complete effusion of the middle ear, without air, can be detected indirectly by observing the immobile eardrum by otoscopy or tympanometry. Most of these effusions are chronic. The color of the effusion changes from yellowish to gray, darker or bluish. If otitis media with effusion persists for more than 3 months and the eardrum becomes significantly thickened, there is little chance that the inflammatory effusion will soon regress on its own. For these cases, there is a procedure called a myringotomy, where a tube is inserted into the anteroinferior quadrant of the eardrum and gives ventilation to the Eustachian tube through the ear canal.
Chronic eardrum perforations
Chronic eardrum perforations are usually easily recognized by otoscopy. In general, the eardrum has a large capacity for self-healing. However, various scarring and atrophic changes in the middle ear can result in non-healing of the perforation, which is considered a major feature of chronic otitis media. The tympanic cavity is seen through the perforation. The rest of the eardrum may have a different otoscopic appearance: scarred, thickening of the hyperplastic mucosa and mucosal secretion, and acute inflammatory changes with significant erythema and purulent discharge.
