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Soreness of the mastoid process - causes and diseases. Acute inflammation of the middle ear and mastoid process Inflammatory diseases of the ear of the mastoid process

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Acute catarrh of the middle ear (otitis catharralis media)

This disease is understood as inflammation of the middle ear, which develops as a result of the transition of the inflammatory process from the nasopharynx to the mucous membrane of the auditory tube and the tympanic cavity. Synonyms for middle ear catarrh are exudative otitis media, salpingo-otitis, tubo-otitis, tubotympanitis, tubotympanic catarrh, secretory otitis media.

Depending on the composition of the exudate, there are serous-catarrhal And purulent-catarrhal inflammation.

Etiology and pathogenesis. The main cause of catarrhal inflammation of the middle ear is inflammation of the mucous membrane of the auditory tube and disruption of its ventilation function. Inflammation of the auditory tube, in turn, occurs as a result of the spread of infection into it from the nasopharynx (adenoiditis, nasopharyngitis, etc.). The etiological factor of the inflammatory process in the nasopharynx can be streptococci, staphylococci, pneumococci or microbial mixtures. As a result of disruption of the ventilation function of the auditory tube and the occurrence of low pressure in the tympanic cavity, interstitial fluid leaks into the tympanic cavity. At the same time, the inflammatory process stimulates the secretion of mucous glands and gives rise to the process of exudation. Infection of the exudate causes acute purulent inflammation of the middle ear.

: ear congestion, tinnitus, autophony and hearing loss of varying degrees, ear pain. Otoscopic signs correspond to the stages of development of the inflammatory process (Fig. 1).

Rice. 1. Types of the tympanic membrane at different stages of development of acute catarrhal inflammation of the middle ear: 1 - transudate in the lower part of the tympanic cavity, 2 - injection of vessels in the relaxed part of the tympanic membrane and along the handle of the malleus, 3 - radial injection of vessels of the tympanic membrane

The stage of hyperemia is characterized by the injection of blood vessels along the handle of the malleus, retraction and radial injection of the vessels of the tympanic membrane, and shortening of the cone of light. At the stage of catarrhal inflammation, an effusion of a different nature (dull gray or xanthomatous) appears in the tympanic cavity. If the exudate is hemorrhagic, the eardrum becomes bluish or purple in color. The presence of effusion in the tympanic cavity is a pathognomonic sign of acute catarrhal inflammation of the middle ear. When the effusion is in a liquid state and has good mobility, its level remains horizontal regardless of the position of the head.

Characteristic signs of the disease: retraction of the eardrum, in which the handle of the malleus acquires an almost horizontal position, and its short process protrudes sharply into the lumen of the ear canal (index finger symptom); the relaxed part, if it is not protruded by effusion, is retracted and directly adjacent to the medial wall of the epitympanic space, the light cone is sharply shortened or completely absent.

A hearing test reveals a conductive type of hearing loss, predominantly at low frequencies. When the form is complicated by acute purulent otitis media, preceptive hearing loss also occurs due to intoxication of the inner ear. A hearing test using live speech reveals a decrease in hearing for low-octave words, while whispered speech can be perceived at the sink, or from a distance of no more than 1-2 m, spoken speech - 3-6 m.

Outcomes: self-healing, rapid recovery with targeted treatment, recovery with residual effects in the form of intratympanic scars and the transition of the process to tympanosclerosis, infection of the exudate and the development of acute purulent otitis media. Most often, with timely treatment, the disease is eliminated without a trace within 1-2 weeks.

Diagnosis based on complaints and otoscopic picture. The disease should be differentiated from acute purulent inflammation of the middle ear in the pre-perforation phase, which is characterized by severe pain in the ear and a number of other clinical and otoscopic symptoms described below. It is more difficult to differentiate this disease from latent forms of otitis in infants and acute inflammation of the middle ear in the elderly.

Forecast depends on the nature of the pathological condition of the nasopharynx and auditory tube, the general allergic background, virulence and the quality of therapeutic measures.

Treatment: elimination of chronic foci of infection in the upper respiratory tract; carrying out therapeutic measures in the presence of an allergic background and chronic inflammatory processes in the paranasal sinuses; normalization of nasal breathing in the presence of obstructive pathology (polyps, deviated nasal septum, hypertrophic rhinitis, etc.); carrying out local treatment aimed at sanitation of the auditory tube, and if it is ineffective, the use of “minor” surgical interventions (paracentesis, myringotomy, tympanotomy, shunting of the tympanic cavity).

Local treatment: introduction into the nose of vasoconstrictor solutions and aerosols (naphthyzin, sanorin, galazolin, etc.); blowing the auditory tubes with preliminary anemization of their pharyngeal mouth; injection of a hydrocortisone suspension into the auditory tube; if there is viscous content in the tympanic cavity, a freshly prepared proteolytic enzyme is introduced into it through the auditory tube; orally - antihistamines and decongestants (diphenhydramine, diazolin, pipolfen, etc.) in combination with ascorbic acid and calcium gluconate; if purulent complications are suspected (the appearance of throbbing pain in the ear, increased hyperemia of the eardrum and its protrusion), broad-spectrum antibiotics are prescribed orally.

To quickly resolve the contents of the tympanic cavity, various physiotherapeutic procedures are used (warming compress, Sollux, UHF, laser therapy, etc.).

Acute purulent otitis media (otitis media purulenta acuta)

The disease is characterized by inflammation of the mucous membrane of the tympanic cavity, including the cave and auditory tube. Occurs mainly when the infection spreads hematogenously from distant foci and in severe general infectious diseases during the period of rash. The infection can also enter the tympanic cavity from the external auditory canal, but only if the integrity of the eardrum is damaged. The disease most often occurs in childhood and adolescence.

Etiology and pathogenesis. The disease develops most often against the background of acute respiratory infections and influenza. The etiological factors are hemolytic streptococcus, staphylococcus, often in combination with Pseudomonas aeruginosa, Proteus vulgaris and various types of Escherichia coli.

The occurrence of the disease is facilitated by many reasons: adenoiditis, tubo-otitis, rhinosinusitis, chronic tonsillitis, ozena. Often the disease occurs when there is a “dry” perforation of the eardrum after washing the external auditory canal or bathing or showering.

Promote inflammatory diseases of the ear and a number of unfavorable working environment conditions: changes in atmospheric pressure (for divers, pilots, submariners, caisson workers), dampness, cooling, fatigue, etc.

Pathological anatomy. At the onset of the disease, the mucous membrane of the tympanic cavity is hyperemic and infiltrated. With the development of inflammation, it thickens greatly and hemorrhages occur in it. At the same time, serous and purulent exudate accumulates in the tympanic cavity, protruding the eardrum (Fig. 2).

Rice. 2. Types of tympanic membrane in two forms of acute otitis media: 1 - diffuse acute otitis media (mesotympanic form); 2 - acute otitis media (epitympanic form)

Subsequently, at the height of clinical manifestations, a focus of softening appears in the eardrum, and due to the pressure of the exudate, a perforation occurs in this place, most often slit-like, which reveals itself during otoscopy pulsating reflex. During recovery, inflammation in the mucous membrane subsides, hyperemia decreases, exudate from the tympanic cavity resolves or is partially evacuated through the auditory tube. The perforated hole is closed with a scar or transformed into a persistent perforation with a compacted connective tissue edge. Perforation that occurred in tensioned part eardrum is called rim, or central. Perforation in the area relaxed part called regional(with epitympanic form of otitis) (Fig. 3).

Rice. 3. Types of perforations of the tympanic membrane in acute purulent otitis media: 1 - rim perforation in the posterosuperior quadrant; 2 - rim perforation in the anterior-inferior quadrant; 3 - marginal perforation in the relaxed part of the eardrum; 4 - complete destruction of the relaxed part with exposure of the head of the malleus

With significant development of granulations in the tympanic cavity and the absence of evacuation of exudate and purulent contents, scars form in it (tympano-fibrosis). With this completion of the inflammatory process, the eardrum can be soldered to the medial wall of the tympanic cavity and completely lose mobility. The organization of exudate leads to immobilization of the auditory ossicles, which interferes with the air type of sound conduction and leads to severe conductive hearing loss.

Symptoms and clinical picture Depending on the age of the patient, they may differ in a number of features.

U newborns this disease is extremely rare and occurs 3-4 weeks after birth. Its cause may be either the penetration of amniotic fluid during childbirth into the tympanic cavity through the auditory tube, or a nasopharyngeal infection that occurs in the first days after birth, for example, with mother's milk containing staphylococci. The outcome is usually favorable. When exudate leaks from the tympanic cavity through the rocky-scaly suture, which is not consolidated at this age, into the postauricular area, a subperiosteal abscess, opening and drainage of which leads to recovery without consequences.

U infant up to 8 months, otitis occurring at this age is one of the most common diseases.

IN teenage, youthful age and adults a typical clinical picture develops, described below.

U old people acute otitis media occurs less frequently, symptoms are less pronounced, the temperature reaction is moderate (38-38.5 ° C) with a relatively satisfactory general condition. A peculiarity of the otoscopic picture is that, as a result of the natural compaction of the eardrum that occurs in old age, there is practically no hyperemia observed in it, which sometimes has an island character.

The clinical course of acute otitis media is divided into three periods, usually lasting from 2 to 4 weeks. First period(from several hours to 4-6 days) is characterized by an increase in pain, hyperemia of the eardrum, the formation of exudate and its suppuration, expressed by general reactive phenomena. Pain in the ear radiates to the crown, temple, and teeth.

Body temperature rises to 38-38.5 °C, and in children sometimes up to 40 °C and higher. Significant leukocytosis, disappearance of eosinophils, and sharply increased ESR are observed in the blood. The severity of these symptoms may not be so pronounced if at the very beginning of the disease the eardrum was perforated and conditions were created for the outflow of pus from the tympanic cavity. If the perforation is blocked, the inflammatory process worsens again, body temperature rises, ear pain and headaches intensify.

In the acute period, a peculiar reactive response from the mastoid process is often observed, especially with the pneumatic type of its structure. This is due to the fact that the mucous membrane of the mastoid cells is involved in the inflammatory process, which is manifested by swelling and pain in the area of its area. Usually this reaction disappears after the eardrum is perforated and pus is discharged from the ear.

Second period(about 2 weeks) is characterized by perforation of the eardrum and suppuration from the ear, a lytic decrease in ear pain, and a decrease in general reactive phenomena.

Third period(7-10 days) - recovery period: the amount of discharge from the tympanic cavity decreases, perforation decreases and its closure through scarring.

Before the formation of perforation, phenomena of irritation of the vestibular apparatus in the form of dizziness, nausea and vomiting may be observed. However, the main disorders manifest themselves in the organ of hearing. In this and subsequent periods

there is severe hearing loss: whispered speech is not perceived or is perceived only at the sink, spoken speech - at the sink or at a distance of no more than 0.5 m. This hearing loss partly depends on tinnitus, but mainly hearing loss is determined by a significant violation of the mechanism of airborne sound conduction. In severe cases, when induced labyrinthosis occurs (toxic damage to cochlear receptors), phenomena of perceptual hearing loss (increased thresholds for the perception of high frequencies) can also be observed.

In the third period, discharge from the ear gradually stops, the edges of the small perforation stick together, and after another 7-10 days, complete recovery and restoration of hearing occurs.

A medium-sized perforation can be closed by scarring, followed by impregnation of the scar with calcium salts (Fig. 4, 1 ) or become stable with callous edges, being in different quadrants of the eardrum (see Fig. 3, 1, 2 ).

Rice. 4. Otoscopic picture of the tympanic membrane: 1 - residual effects after acute otitis media: scar tissue is impregnated with calcium salts; 2 - herpetic otitis (vesicles contain hemorrhagic effusion)

Latent forms of acute purulent otitis media most often occur in infants with not yet developed immunobiological protective reactions or in old people in whom these reactions are at a low level. Sometimes such hyperergic forms occur as a result of infection mucous pneumococcus(mucosal otitis). These forms tend to develop a chronic inflammatory process and have the property of creeping spread to the entire cellular system of the temporal bone with damage to the endosteum, bone tissue and spread into the cranial cavity, causing damage to the meninges. Predominance in microflora enterococcus often causes severe forms of otitis, fraught with serious intracranial complications. Fusospirillosis association of microbes causes severe ulcerative-necrotizing otitis with significant destruction in the tympanic cavity and the release of inflammation into the external auditory canal. Purulent discharge is bloody and has a putrid, nauseating odor.

U newborns And infants The disease often goes unnoticed by others until discharge from the ear appears. In some cases, the child is restless, wakes up at night, cries, turns his head, reaches out with his hand to the sore ear, refuses to breastfeed, because the pain in the ear intensifies when sucking and swallowing. With a pronounced clinical picture, phenomena may be observed meningism(a clinical syndrome that develops as a result of irritation of the meninges), manifested by headache, stiff neck, Kernig and Brudzinski signs, dizziness and vomiting. In this case, the child experiences an increase in body temperature, pallor of the skin, dyspepsia, and swelling of the soft tissues of the area behind the ear. Often in infants with acute otitis media, inflammation of the mucous membrane occurs antrum(at this age the mastoid process and its cellular system are not yet developed).

Diagnosis in most cases it does not cause difficulties and is based on the described clinical picture. The otoscopic picture is of decisive importance for diagnosing the disease, which allows one to assess the stage of the disease, its severity and determine the possible prognosis.

Of great importance in establishing the localization and extent of the inflammatory process and possible complications is an X-ray examination of the temporal bone in standard projections or computed tomography. In Fig. Figure 5 shows x-rays of the temporal bones in the Schüller projection that are normal and reflect the picture of acute purulent otitis media, complicated by acute inflammation of the mastoid process.

Rice. 5. X-rays of the temporal bones (in the Schüller arrangement): a - normal picture, b - acute purulent inflammation of the middle ear on the right with involvement of the cellular apparatus of the mastoid process in the inflammatory process (otomastoiditis). Aspect of the radiographic evolution of bone damage in acute purulent mesotympanitis stage I with transition to stage II. The inflammatory process has spread to the mucous membrane of the mastoid cells: decalcification of the intercellular septa and the cortical layer of the cells (+); the cellular pattern is blurred and blurred (-"); damage to the intercellular septa and the cortical layer of the cells is visible, caused by osteitis, characteristic of stage I X-ray. In the more advanced stage II, lysis of the intercellular septa and the cortical layer of cells occurs (1)

Differential diagnosis carried out in relation to myringitis (inflammation of the eardrum as a complication of acute external otitis), acute catarrhal otitis media, external otitis media and boil of the external auditory canal, herpetic inflammation (herpes simplex seu zoster oticus) and exacerbation of chronic purulent otitis media.

At myringitis There are no general phenomena of the inflammatory process and hearing remains at an almost normal level. At external diffuse otitis And boil external auditory canal there is sharp pain when pressing on tragus and during chewing, the pain is localized in the area of the ear canal, while in acute otitis media it is in the depths of the ear and radiates to the crown and temporo-occipital region.

At herpetic damage to the eardrum, vesicular rashes are detected on it (see Fig. 4, 2 ), upon opening which bloody discharge appears. The pain with influenza otitis media is localized in the external auditory canal and is burning and constant. With viral otitis media, temporary paralysis of the facial nerve, dizziness, and perceptual hearing loss may occur. With zoster oticus, herpetic vesicles are located not only on the eardrum, but also on the skin of the external auditory canal and the auricle. At the same time, rashes may be observed on the mucous membrane of the soft palate and pharynx.

Of particular importance is the differential diagnosis between acute otitis media and exacerbation of chronic purulent otitis media, since the latter can proceed torpidly and unnoticed by the patient, and with dry perforation - without significant hearing loss or even be completely unknown to the patient. Signs of exacerbation of chronic suppurative otitis media are described below.

Allergic form of acute otitis media It is characterized by the absence of a temperature reaction and hyperemia of the tympanic membrane, the presence of allergic edema of the mucous membrane of the auditory tube and the tympanic cavity. The tympanic cavity and mastoid cells contain viscous mucus, saturated with a large number of eosinophils. This form of otitis is characterized by a sluggish long-term course and occurs in people suffering from general allergies, bronchial asthma, and allergic rhinosinusopathy.

Forecast. The most common outcome of acute inflammation of the middle ear is complete recovery (restitutio ad integrum), often spontaneous, without significant therapeutic measures. In other cases, even with intensive treatment, the clinical picture can be severe with various complications or with the transition of the inflammatory process to a chronic form. If intracranial complications occur, including thrombophlebitis of the sigmoid and transverse venous sinuses, the prognosis for life is cautious and is determined by the timeliness of surgical intervention, the effectiveness of subsequent treatment and the general condition of the body. The prognosis for auditory function is determined by the degree of destruction of the eardrum, the chain of auditory ossicles and the development of scarring in the tympanic cavity.

Treatment is aimed at reducing pain, accelerating the resorption of the inflammatory infiltrate in the cavities of the middle ear, at its drainage by improving the patency of the auditory tube or by creating an artificial perforation of the eardrum, as well as restoring auditory function and preventing intracranial complications. The nature of treatment depends on the stage of the inflammatory process and is divided into general and local.

In the pre-perforation period, broad-spectrum antibiotics are prescribed; when discharge appears from the ear, the sensitivity of the microflora to antibiotics is determined and the appropriate drug is prescribed. Warming compresses, heating pads, Sollux, microwave currents, and laser irradiation of the mastoid region are used locally. If heat increases pain, apply cold to the area behind the ear. To reduce pain in the pre-perforation period, ear drops Otipax and Otinum are used. If perforation occurs, these drugs are discontinued, as they have a cauterizing effect on the mucous membrane.

If during the day in the pre-perforation period the treatment used does not bring any effect, while the eardrum is sharply hyperemic, bulges into the external auditory canal, and the patient’s general condition continues to deteriorate, one should resort to paracentesis eardrum. This procedure speeds up recovery, prevents otogenic complications, destruction of the sound-conducting system of the tympanic cavity and helps preserve hearing.

In infants, if there are appropriate indications, you should also not hesitate to perform paracentesis, but these indications are more difficult to establish in them. The eardrum in young children with acute purulent inflammation sometimes changes little, while the tympanic cavity contains pus and inflammatory exudate. On the other hand, when a child screams, he experiences physiological hyperemia of the membrane. The membrane may be closed by desquamation of the epidermis, and finally, in a child with general toxicosis, otitis may proceed sluggishly without pronounced local changes.

Paracentesis technique. The procedure is very painful. A few minutes before surgery, Otinum or Otipax drops are injected into the external auditory canal. Instead of topical anesthesia, infiltration anesthesia can be performed by introducing 2% novocaine in small portions behind the ear, passing the needle along the surface of the posterior bone wall of the external auditory canal. The use of “short” general anesthesia is acceptable. Paracentesis is performed only under visual control with the patient sitting or lying down with his head firmly fixed.

Before surgery, the skin of the external auditory canal is treated with alcohol. Special spear-shaped paracentesis needles are used (Fig. 6). As a rule, the eardrum is punctured in its posterior quadrants, located at a greater distance from the inner wall of the tympanic cavity than the anterior quadrants, or in the place of greatest protrusion of the eardrum. They try to make a puncture with a scalpel simultaneously through the entire thickness of the membrane, starting from the infero-posterior quadrant and continuing the incision to the superoposterior quadrant. Through the resulting linear incision, purulent-bloody fluid is immediately released under pressure. It should be borne in mind that when the mucous membrane of the middle ear is inflamed, including the mucous membrane covering the eardrum, it can thicken ten times or more, so paracentesis may be incomplete. You should not try to reach the middle ear cavity, since the incision itself will accelerate the spontaneous perforation of the membrane and the effect will still be achieved with incomplete paracentesis.

Rice. 6. Paracentesis needle and left eardrum: 1 - needle blade; 2 — needle fixing screw; 3 - handle; 4 — cut line (posterior quadrants); 5 - radial hyperemia

After the paracentesis operation, a dry sterile turunda is inserted into the external auditory canal and fixed loosely at the entrance to the canal with a ball of cotton wool. Several times a day, the external auditory canal is cleaned, treating it with boric alcohol. It is allowed to lightly “pump” medicinal drops into the middle ear by pressing the tragus into the external auditory canal. The drops may contain antibiotics mixed with hydrocortisone. After paracentesis or in case of spontaneous perforation, unforced catheterization of the auditory tube with the introduction of a mixture of antibiotic and hydrocortisone solution into it and the tympanic cavity is permissible. The use of a corticosteroid reduces the likelihood of severe scarring and ankylosis of the ossicular joints.

Prevention is of particular importance in childhood, since it is in children that frequent relapses of acute otitis and chronic inflammatory process occur, often leading to severe hearing loss and associated deficiencies in speech development. Prevention measures include sanitation of the upper respiratory tract, strengthening the immune system, preventing colds, rehabilitation of nasal breathing, hardening, eliminating bad household habits, as well as minimizing the effects of harmful occupational factors (humidity, cooling, changes in barometric pressure, etc.). In childhood, a common cause of acute otitis is chronic adenoiditis and hypertrophy of the pharyngeal tonsil, which contribute to inflammation of the mucous membrane of the auditory tube, its obstruction and the penetration of infection into the middle ear.

Otorhinolaryngology. V.I. Babiyak, M.I. Govorun, Ya.A. Nakatis, A.N. Pashchinin

Ear diseases are quite common nowadays and are very diverse.

The main causes of ear diseases.

First of all, the causes of damage to the hearing aid include factors of an infectious nature. Here are the main ones: hemolytic streptococcus (causes erysipelas of the external ear), Pseudomonas aeruginosa (most often the cause of purulent perichondritis), staphylococcus (furuncle of the external ear, acute and chronic tubo-otitis), streptococcus (inflammation of the eustachian tube, otitis media), pneumococcus ( causes otitis media), molds (cause otomycosis), influenza virus (otitis) and many others, including Mycobacterium tuberculosis (ear tuberculosis) and treponema pallidum (ear syphilis).

These infections can themselves cause inflammatory lesions of the ear, or be complications of inflammatory processes in other organs - these include lesions of the sinuses (acute and chronic sinusitis, sinusitis), as a result of tonsillitis, scarlet fever, influenza and others.

Factors such as ear microtrauma, decreased local and general immunity, improper ear hygiene, and allergic reactions contribute to the infection. Also, these infectious lesions, in addition to inflammatory processes, can subsequently cause complications and cause sensorineural hearing loss.

Among other causes of ear diseases, it should be noted that there is an increased function of the glands of the auditory canal, as a result of which, with improper hygiene, wax plugs can occur.

Some medications (antibiotics of the aminoglycosin group) have a toxic effect on the ear.

Ear injuries are also common: mechanical (bruise, blow, bite), thermal (high and low temperatures), chemical (acids, alkalis), acoustic (short-term or long-term exposure to strong sounds on the ear), vibration (due to exposure to vibration vibrations produced by various mechanisms), barotrauma (when atmospheric pressure changes). Also, the causes of ear lesions can be foreign bodies (most often in children, when they push buttons, balls, pebbles, peas, paper, etc. into themselves; less often in adults - fragments of matches, pieces of cotton wool, insects).

Other causes include genetic mutations, which result in congenital abnormalities in the development of the hearing system.

Symptoms of ear diseases.

One of the main clinical manifestations of ear diseases is pain. Most often it occurs in inflammatory diseases of the auditory analyzer. It can be different (very strong with a boil, or weak with eustachitis), it can radiate to the eye, lower jaw, occur during chewing, swallowing, and there may also be a headache on the affected side.

Quite often, with inflammatory lesions, hyperemia (redness) of the ear, swelling of the auricle and fluctuation (in the presence of pus) occur.

In addition to these local manifestations, general manifestations are often also encountered: increased body temperature, chills, decreased appetite, poor sleep. In allergic diseases, burning and itching in the ear occur (with eczema).

Symptoms such as a sensation of fluid transfusion or splashing when moving the head often occur.

Discharge from the ear is also common; it can be putrefactive (with eczema), purulent constant and periodic (with otitis), bloody (with malignant neoplasms), bloody-purulent, serous, which can be with or without odor.

Also, with various ear diseases, patients complain of hearing loss, noise in the ear, autophony (perception of one’s own voice through a blocked ear), hearing loss (any weakening of auditory function) to various sound frequencies, the severity of which depends on the activity of the inflammatory process in the ear, deafness (complete absence ability to perceive sounds), dizziness accompanied by vomiting (with lesions of the vestibular apparatus).

Upon examination, you can identify redness and swelling of the outer ear, see scratching on the outer ear and in the ear canal, small blisters, and grayish-yellow crusts. During palpation, evaluate the pain symptom in more detail, in which exact place it hurts, where the pain radiates, how hard you need to press for the pain symptom to occur.

Ear research methods.

External examination and palpation of the ear. Normally, palpation of the ear is painless, but with inflammatory lesions pain appears.

Otoscopy It is performed using an ear funnel; in inflammatory diseases, changes in the ear canal occur; various discharge, crusts, and scratches can be seen; with various lesions, the eardrum also changes (normally it should be gray in color with a pearlescent tint).

Determination of the patency of the auditory tubes. This study is based on blowing and listening to the sound of air passing through the patient's auditory tube, sequentially performing 4 methods of blowing to determine the degree of patency of the auditory tube.

The first method, Toynbee's method, allows you to determine the patency of the auditory tubes when making a swallowing movement performed with the mouth and nose closed.

The second method, the Valsalva method, takes a deep breath, and then intensifies inflation with the mouth and nose tightly closed; in case of diseases of the mucous membrane of the auditory tubes, this experiment is not successful.

The third method, the Politzer method, and the fourth method is blowing out the auditory tubes using catheterization; in addition to diagnostic methods, these methods are also used as therapeutic ones.

Study of the functions of the auditory analyzer. Speech hearing test. A Study of Whispered and Spoken Speech. The doctor pronounces words in a whisper, first from a distance of 6 meters, if the patient does not hear, then the distance is reduced by one meter and so on, a study with spoken speech is carried out in a similar way.

Study with tuning forks, using tuning forks, air conduction and bone conduction are examined. Experiments with a tuning fork, Rinne's experiment, compare air and bone conductivity, a positive experience if air conductivity is 1.5 - 2 times higher than bone conductivity, negative on the contrary, positive should be normal, negative - in case of diseases of the sound-conducting apparatus.

Weber's experience, they place a sounding tuning fork in the middle of the head and normally the patient should hear the sound equally in both ears; with a unilateral disease of the sound-conducting apparatus, the sound is lateralized to the diseased ear; with a unilateral disease of the sound-receiving apparatus, the sound is lateralized to the healthy ear.

Jelle's experiment determines the presence of otosclerosis. Bing's experiment is carried out to determine the relative and absolute conductivity of sound through bone. Federici's experience: a normally hearing person perceives the sound of a tuning fork from the tragus longer than from the mastoid process; if sound conduction is impaired, the opposite picture is observed.

Hearing examination using electroacoustic equipment, the main objective of this study is to comprehensively determine hearing acuity, the nature and level of its damage in various diseases. They can be tonal, speech and noise.

Study of the function of the vestibular apparatus. Study of stability in the Romberg position, with disorders of the vestibular apparatus, the patient will fall. The study is in a straight line; in case of violations, the patient deviates to the side. An index test; if there is a violation, the patient will miss. To determine nystagmus (involuntary oscillatory movements of the eyes), the following tests are used: pneumatic, rotational, caloric.

To study the function of the otolithic apparatus, an otolith test is used.

Other methods used to examine the ear include: x-ray method. In particular, to identify traumatic injuries (fractures of the styloid process, mastoid process of the temporal bone), to identify various benign and malignant tumors of the auditory analyzer. For this purpose, both conventional radiography and computed tomography and magnetic resonance imaging are used.

You can also take discharge from the ear for research to determine the pathogen that caused a particular disease and subsequently determine its sensitivity to antibiotics for proper treatment.

A complete blood count also helps in diagnosing ear diseases. In cases of inflammatory damage to the ear, there will be leukocytosis in the blood, an increase in the erythrocyte sedimentation rate.

Prevention of ear diseases.

Prevention of these diseases (especially of an inflammatory nature) is based on careful adherence to personal and ear hygiene, timely and correct treatment of diseases of other organs, especially those located nearby: the nose, paranasal sinuses, pharynx (especially in childhood, in which quite often the cause the occurrence of ear diseases are adenoids that close the mouths of the auditory tubes and thereby disrupt the ventilation of the middle ear), the fight against chronic infections, if the patient has a deviated nasal septum, hypertrophy of the nasal turbinates, polyps, surgical interventions must be performed to restore the functions of the upper respiratory tract and auditory pipes, among the general preventive measures one should point out the hardening of the body.

To prevent inflammatory lesions of the inner and middle ear, timely treatment of inflammatory diseases of the outer ear should be noted. When working with chemicals, observe safety precautions and use personal protective equipment.

To prevent acoustic injury, undergo annual medical examinations; if deviations are detected, it is better to change jobs, and at work use personal protective equipment (ear pads, tampons, helmets) and ensure that the room is equipped with sound-absorbing and sound-insulating means.

To prevent barotrauma, take precautions to ensure slow changes in atmospheric pressure.

To prevent vibration injuries, measures are taken for vibration isolation, vibration absorption, and vibration damping.

If any symptoms associated with the hearing analyzer occur, it is necessary to consult a specialist in order to prevent complications, one of which may be deafness, by starting treatment correctly and in a timely manner.

Diseases of the ear and mastoid process in this section:

Diseases of the external ear
Diseases of the middle ear and mastoid process
Inner ear diseases
Other ear diseases

Inflammatory lesion of the mastoid process of the temporal bone of infectious origin. Most often, mastoiditis complicates the course of acute otitis media. Clinical manifestations of mastoiditis include a rise in body temperature, intoxication, pain and pulsation in the mastoid region, swelling and hyperemia of the postauricular area, ear pain and hearing loss. An objective examination for mastoiditis consists of examination and palpation of the area behind the ear, otoscopy, audiometry, radiography and CT scan of the skull, and bacteriological culture of discharge from the ear. Treatment of mastoiditis can be medicinal and surgical. It is based on antibiotic therapy and rehabilitation of purulent foci in the tympanic cavity and mastoid process.

General information

The mastoid process is a protrusion of the temporal bone of the skull located behind the auricle. The internal structure of the process is formed by communicating cells, which are separated from each other by thin bone partitions. The mastoid process may have a different structure in different people. In some cases it is represented by large air-filled cells (pneumatic structure), in other cases the cells are small and filled with bone marrow (diploetic structure), in third cases there are practically no cells (sclerotic structure). The course of mastoiditis depends on the type of structure of the mastoid process. Those with a pneumatic structure of the mastoid process are most prone to the appearance of mastoiditis.

The inner walls of the mastoid process separate it from the posterior and middle cranial fossae, and a special opening connects it with the tympanic cavity. Most cases of mastoiditis occur as a consequence of the transfer of infection from the tympanic cavity to the mastoid process, which is observed in acute otitis media, in some cases in chronic purulent otitis media.

Causes of mastoiditis

Depending on the cause, otolaryngology distinguishes between otogenic, hematogenous and traumatic mastoiditis.

Otogenic. Most often, secondary mastoiditis occurs, caused by the spread of infection into the mastoid process from the tympanic cavity of the middle ear. Its causative agents can be influenza bacillus, pneumococci, streptococci, staphylococci, etc. The transfer of infection from the middle ear cavity is facilitated by disruption of its drainage due to late perforation of the eardrum, untimely paracentesis, too small a hole in the eardrum or its closure with granulation tissue.
Hematogenous. In rare cases, mastoiditis is observed, which developed as a result of hematogenous penetration of infection during sepsis, secondary syphilis, tuberculosis.
Traumatic. Primary mastoiditis occurs with traumatic damage to the cells of the mastoid process due to a blow, gunshot wound, or traumatic brain injury. A favorable environment for the development of pathogenic microorganisms in such cases is the blood spilled into the cells of the appendix as a result of injury.

The appearance of mastoiditis is promoted by:

increased virulence of pathogenic microorganisms
weakened general condition in chronic diseases (diabetes mellitus, tuberculosis, bronchitis, hepatitis, pyelonephritis, rheumatoid arthritis, etc.)
pathology of the nasopharynx (chronic rhinitis, pharyngitis, laryngotracheitis, sinusitis)
the presence of changes in the structures of the ear due to previous diseases (ear trauma, aerootitis, external otitis, adhesive otitis media).

Pathogenesis

The onset of mastoiditis is characterized by inflammatory changes in the mucous layer of the mastoid cells with the development of periostitis and the accumulation of fluid in the cavities of the cells. Due to the pronounced exudation, this stage of mastoiditis is called exudative. Inflammatory swelling of the mucous membrane leads to the closure of the holes connecting the cells with each other, as well as the hole connecting the mastoid process with the tympanic cavity. As a result of disruption of ventilation in the cells of the mastoid process, the air pressure in them drops. Along the pressure gradient, transudate from dilated blood vessels begins to flow into the cells. The cells are filled with serous and then serous-purulent exudate. The duration of the first stage of mastoiditis in adults is 7-10 days, in children it is often 4-6 days. Ultimately, in the exudative stage of mastoiditis, each cell has the appearance of an empyema - a cavity filled with pus.

Next, mastoiditis passes into the second stage - proliferative-alterative, in which purulent inflammation spreads to the bone walls and septa of the mastoid process with the development of osteomyelitis - purulent melting of the bone. At the same time, granulation tissue is formed. Gradually, the partitions between the cells are destroyed and one large cavity is formed, filled with pus and granulations. Thus, as a result of mastoiditis, empyema of the mastoid process occurs. The breakthrough of pus through the destroyed walls of the mastoid process leads to the spread of purulent inflammation to neighboring structures and the development of complications of mastoiditis.

Classification

There are two clinical forms of mastoiditis: typical and atypical. The atypical (latent) form is characterized by a slow and sluggish course without pronounced symptoms characteristic of mastoiditis. A separate group of apical mastoiditis is distinguished, which includes Bezold's mastoiditis, Orleans mastoiditis and Mouret's mastoiditis. According to the stage of the inflammatory process, mastoiditis is classified as exudative and true (proliferative-alterative).

Symptoms of mastoiditis

Mastoiditis can appear simultaneously with the occurrence of purulent otitis media. But most often it develops 7-14 days from the onset of otitis media. In children of the first year of life, due to the structural features of the mastoid process, mastoiditis manifests itself in the form of otoanthritis. In adults, mastoiditis manifests itself as a pronounced deterioration in general condition with a rise in temperature to febrile levels, intoxication, headache, and sleep disturbances. Patients with mastoiditis complain of noise and pain in the ear, hearing loss, intense pain behind the ear, and a feeling of pulsation in the mastoid area. Pain radiates along the branches of the trigeminal nerve to the temporal and parietal region, orbit, and upper jaw. Less commonly, mastoiditis causes pain in the entire half of the head.

These symptoms of mastoiditis are usually accompanied by profuse suppuration from the external auditory canal. Moreover, the amount of pus is noticeably greater than the volume of the tympanic cavity, which indicates the spread of the purulent process beyond the middle ear. On the other hand, suppuration with mastoiditis may not be observed or may be insignificant. This occurs while maintaining the integrity of the eardrum, closing the perforation in it, and disrupting the outflow of pus from the mastoid process to the middle ear.

Objectively, with mastoiditis, redness and swelling of the area behind the ear, smoothness of the skin fold located behind the ear, and protrusion of the auricle are noted. When pus breaks through into the subcutaneous fatty tissue, a subperiosteal abscess forms, accompanied by severe pain when palpating the postauricular area and a symptom of fluctuation. From the area of the mastoid process, pus, exfoliating the soft tissues of the head, can spread to the occipital, parietal, and temporal regions. Thrombosis of the vessels supplying the cortical layer of the mastoid bone, which occurs as a result of inflammation, leads to necrosis of the periosteum with the breakthrough of pus to the surface of the scalp and the formation of an external fistula.

Complications

The spread of purulent inflammation in the mastoid process itself occurs along the most pneumatized cells, which determines the variety of complications that arise with mastoiditis and their dependence on the structure of the mastoid process. Inflammation of the perisinous group of cells leads to damage to the sigmoid sinus with the development of phlebitis and thrombophlebitis. Purulent destruction of the perifacial cells is accompanied by neuritis of the facial nerve, and of the perilabyrinthine cells by purulent labyrinthitis. Apical mastoiditis is complicated by the flow of pus into the interfascial spaces of the neck, as a result of which pyogenic microorganisms can penetrate into the mediastinum and cause the appearance of purulent mediastinitis.

The spread of the process into the cranial cavity leads to intracranial complications of mastoiditis (meningitis, brain abscess, encephalitis). Damage to the pyramid of the temporal bone causes the development of petrositis. The transition of purulent inflammation to the zygomatic process is dangerous due to further introduction of infection into the eyeball with the occurrence of endophthalmitis, panophthalmitis and orbital phlegmon. In children, especially young children, mastoiditis can be complicated by the formation of a retropharyngeal abscess. In addition, with mastoiditis, hematogenous spread of infection with the development of sepsis is possible.

Diagnostics

As a rule, diagnosing mastoiditis does not present any difficulties for an otolaryngologist. Difficulties arise in the case of a low-symptomatic atypical form of mastoiditis. Diagnosis of mastoiditis is based on the patient’s characteristic complaints, anamnestic information about trauma or inflammation of the middle ear, examination and palpation of the behind-the-ear area, results of otoscopy, microotoscopy, audiometry, culture of ear discharge, computed tomography and x-ray examination.

Otoscopy. With mastoiditis, inflammatory changes typical of otitis media are detected on the side of the eardrum; if there is a hole in it, profuse suppuration is noted. A pathognomonic otoscopic sign of mastoiditis is the overhang of the posterior superior wall of the auditory canal.
Hearing function test. Audiometry and hearing testing with a tuning fork can determine the degree of hearing loss in a patient with mastoiditis.
X-ray of the temporal bone. In the exudative stage of mastoiditis, it reveals cells veiled as a result of inflammation and unclearly distinguishable partitions between them. The X-ray picture of the proliferative-alterative stage of mastoiditis is characterized by the absence of a cellular structure of the mastoid process, instead of which one or several large cavities are determined. Better visualization is achieved by performing a CT scan of the skull in the area of the temporal bone.

The presence of complications of mastoiditis may require additional consultation with a neurologist, neurosurgeon, dentist, ophthalmologist, thoracic surgeon, MRI and CT scan of the brain, ophthalmoscopy and biomicroscopy of the eye, and chest radiography.

Treatment of mastoiditis

Therapeutic tactics for mastoiditis depend on its etiology, the stage of the inflammatory process and the presence of complications. Drug therapy for mastoiditis is carried out with broad-spectrum antibiotics (cefaclor, ceftibuten, cefixime, cefuroxime, cefotaxime, ceftriaxone, amoxicillin, ciprofloxacin, etc.). Additionally, antihistamines, anti-inflammatory, detoxification, and immunocorrective drugs are used. Complications are treated.

With the otogenic nature of mastoiditis, sanitizing surgery on the middle ear is indicated; if indicated, general cavity surgery is indicated. The absence of a hole in the eardrum that provides adequate drainage is an indication for paracentesis. The middle ear is washed with medications through the opening of the eardrum. Mastoiditis in the exudative stage can be treated conservatively. Mastoiditis of the proliferative-alterative stage requires surgical opening of the mastoid process (mastoidotomy) to eliminate pus and postoperative drainage.

Prevention of mastoiditis

Prevention of otogenic mastoiditis comes down to timely diagnosis of inflammatory lesions of the middle ear, adequate treatment of otitis media, timely paracentesis of the eardrum and sanitizing operations. Correct treatment of nasopharyngeal diseases and rapid elimination of infectious foci also help prevent mastoiditis. In addition, it is important to increase the efficiency of the body’s immune mechanisms, which is achieved by maintaining a healthy lifestyle, proper nutrition, and, if necessary, immunocorrective therapy.

Disease schedule article
Disease schedule article
	Diseases of the external ear (including congenital):
	a) congenital absence of the auricle
	b) bilateral microtia
	c) unilateral microtia, eczema of the external auditory canal and auricle, chronic diffuse external otitis, external otitis with mycoses, congenital and acquired narrowing of the external auditory canal
	Diseases of the middle ear and mastoid process:
	a) bilateral or unilateral chronic otitis media, accompanied by polyps, granulations in the tympanic cavity, bone caries and (or) combined with chronic diseases of the paranasal sinuses	B (V - IND)
	b) bilateral or unilateral chronic otitis media, not accompanied by polyps, granulations in the tympanic cavity, bone caries and (or) not combined with chronic diseases of the paranasal sinuses
	c) residual effects of previous otitis media, diseases with persistent ear barofunction disorder

Point "a" also includes:

bilateral or unilateral chronic purulent otitis media, accompanied by persistent difficulty in nasal breathing;
conditions after surgical treatment of chronic diseases of the middle ear with incomplete epidermization of the postoperative cavity in the presence of pus, granulations, cholesteatoma masses;
bilateral persistent dry perforations of the eardrum, the condition after radical operations on both ears or the condition after open tympanoplasty with complete epidermization of the postoperative cavities - in relation to persons examined under columns I, II of the disease schedule.

Persistent dry perforation of the eardrum should be understood as the presence of perforation of the eardrum in the absence of inflammation of the middle ear for 12 months or more.

The presence of chronic purulent otitis media must be confirmed by otoscopic data (perforation of the tympanic membrane, discharge from the tympanic cavity), culture of discharge from the tympanic cavity for microflora, radiography of the temporal bones according to Schüller and Mayer, or computed tomography of the temporal bones.

Point “c” includes unilateral persistent dry perforations of the eardrum, adhesive otitis media, tympanosclerosis, as well as the condition after a radical operation or open tympanoplasty performed 12 or more months ago on one ear with complete epidermization of the postoperative cavity.

Persistent impairment of ear barofunction is determined based on repeated studies.

In case of vestibular disorders, examination data are assessed together with a neurologist.

Point “a” includes pronounced vestibulopathies, attacks of which were observed during examination in an inpatient setting and confirmed by medical documents.

Point “b” includes cases of vestibulopathy, the attacks of which last a short time with moderately expressed vestibular-vegetative reactions.

Point “c” includes cases of sharply increased sensitivity to motion sickness in the absence of symptoms of vestibular disorders and diseases of other organs.

The results of vestibulometry are assessed together with a neurologist. If the temporary nature of vestibular disorders is indicated, a comprehensive examination and treatment in an inpatient setting is necessary.

Disease schedule article	Name of diseases, degree of dysfunction
Disease schedule article	Name of diseases, degree of dysfunction
	Deafness, deaf-muteness, hearing loss:
	a) deafness in both ears or deaf-muteness
	b) persistent hearing loss in the absence of perception of whispered speech in one ear and when perceiving whispered speech at a distance of up to 3 m in the other ear or persistent decrease in hearing when perceiving whispered speech at a distance of up to 1 m in one ear and at a distance of up to 2 m in the other ear	B (V - IND)
	c) persistent hearing loss in the absence of perception of whispered speech in one ear and when perceiving whispered speech at a distance of more than 3 m in the other ear or persistent decrease in hearing when perceiving whispered speech at a distance of up to 2 m in one ear and at a distance of up to 3 m in the other ear

Deafness in both ears or deaf-muteness must be certified by medical organizations, organizations or educational institutions for the deaf. Deafness should be considered the lack of perception of screams at the auricle.

When determining the degree of hearing loss, special research methods are required using whispered and spoken speech, tuning forks, pure-tone threshold audiometry with the obligatory determination of barofunction of the ears.

In case of hearing loss, which determines a change in the category of fitness for military service, these studies are carried out repeatedly (at least 3 times during the examination period).

If deafness is suspected in one or both ears, the experiments of Govseev, Lombar, Shtenger, Khilov and other experiments or methods of objective audiometry (registration of auditory evoked potentials, otoacoustic emissions, etc.) are used. If the interaural difference in the perception of whispered speech is more than 3 meters, an X-ray of the temporal bones according to Stenvers or a computed tomography of the temporal bones is performed.

A good result of tympanoplasty is considered to be restoration of the integrity of the eardrum and improvement of hearing. After tympanoplasty on one ear with good results, citizens upon initial military registration, conscription for military service (military training) and upon entry into military service under a contract or into military educational institutions are recognized as temporarily unfit for military service for a period of 12 months after the operation performed. After this period, a conclusion on the category of fitness for military service is made taking into account the impairment in the perception of whispered speech. In the absence of hearing impairment, citizens are considered fit for military service. If there is hearing loss, the examination is carried out taking into account the requirements of Article 40 of the disease schedule.