Epitympanitis is an inflammation of the epitympanic space of the middle ear, characterized by a long and persistent course. The disease leads to the destruction of the auditory ossicles and disruption of sound transmission to the receptor apparatus.

Epitympanitis is a special form chronic inflammation auditory analyzer, in which the mucous membrane and bone tissue of the epitympanic space are affected. Purulent process leads to carious bone lesions, the formation of granulations and cholesteatoma. It is difficult to cure and dangerous disease ears, despite mild symptoms, can provoke irreversible processes leading to hearing loss and life threatening sick. This pathology is characterized by perforation of the eardrum and the release of foul-smelling secretions from ear canal. Perforation makes the ear tympanic cavity vulnerable to pathological biological agents.

The stagnation of pus and the spread of infection to surrounding organs and tissues is facilitated by many folds and pockets in the mucous membrane of the upper part of the middle ear. Purulent discharge puts pressure on inner ear and the brain, which also contributes to inflammation vitally important organs, the development of complications in the intracranial space and the creation of a threat to the patient’s life.

Forms

Conventionally, chronic epitympanitis is divided into two morphological forms - carious and cholesteatoma.

• Carious form characterized by the development of destructive changes in the bone against the background of severe inflammation of the middle ear.
• Cholesteatoma form characterized by the appearance of a whitish formation resembling a tumor. Cholesteatoma consists of dense epidermal layers and has a membrane that adheres to bone structures or grows into bone tissue. As the cholesteatoma grows, the tympanic cavity becomes deformed.

Depending on the location of the lesion, left-sided and right-sided epitympanitis are distinguished.

Etiology

Epitympanitis complicates the course of ear diseases that are difficult to respond to therapy. Purulent discharge leaves the middle ear with difficulty and accumulates in tympanic cavity, causing the spread of infection.

Most often, the causative agents of epitympanitis are pneumococci, streptococci, staphylococci, Pseudomonas aeruginosa and Haemophilus influenzae, their associations, and pathogenic fungi.

Factors stimulating the development of epitympanitis:

1. Reducing the general resistance of the body,
2. Congenital and acquired immunodeficiency,
3. High virulence of the infectious agent,
4. Inflammatory processes in various departments auditory analyzer,
5. Foci present in the body chronic infection - ,
6. Frequent,
7. Obstruction auditory tube,
8. Inadequate treatment
9. Sclerotic type of mastoid process,
10. Deformation of the nasal septum and hypertrophy of the nasal turbinates,
11. Avitaminosis,
12. Blood diseases
13. Tuberculosis infection,
14. Allergy,
15. Drug addiction, alcoholism, smoking,
16. Failure to comply with sanitary and hygienic rules and regulations.

Microbes, penetrating into the middle ear cavity, cause local inflammation and destruction bone structures. Over time, osteitis leads to destructive processes and the development of granulations. The auditory ossicles are destroyed, resulting in severe hearing loss. Another sad consequence of epitympanitis is cholesteatoma. This is a tumor-like formation consisting of keratinized epithelial cells and surrounded by a connective tissue matrix.

With epitympanitis in the supratympanic space the following is often found:

• Pus,
• granulation,
• Cholesteatoma masses,
• Polyps,
• Carious process.

Symptoms

Purulent epitympanitis is characterized severe course, is difficult to treat and is accompanied by dangerous complications.

When visiting a doctor, patients present the following complaints:

1. Decreased hearing acuity,
2. Unpleasant odor from a sore ear,
3. Irradiation acute pain to the temple and darkness,
4. Bursting and pressing pain in the ear,
5. Congestion and tinnitus,
6. Nystagmus (rhythmic movements of the eyeballs),
7. Vestibular dysfunctions,
8. Purulent discharge With unpleasant smell, streaks of blood and particles of destroyed bone tissue.

The unpleasant odor of discharge from the ears is due to the attachment and presence of cholesteatoma masses. Foul-smelling discharge from the ear remains the same even after treatment.

Otoscopic signs of epitympanitis are:

• Purulent contents
• Perforation of the eardrum,
• Cholesteatoma masses,
• Sluggish osteitis.

Chronic purulent epitympanitis is often asymptomatic. Cholesteatoma forms and grows without pain. Patients periodically discharge pus from the ear, and their hearing decreases. With a unilateral process, the clinic is poorly expressed, and patients for a long time do not perceive their illness and feel healthy. Despite the calm and hidden course of cholesteatoma epitympanitis, the bone walls of the middle ear are destroyed. Exacerbation of the pathology can result in generalization of the process, inflammation of the meninges, sepsis, abscess formation of brain tissue and other fatal dangerous illnesses.In the absence of the correct and timely treatment Serious complications can develop that lead to disability and even death.

Diagnostics

Diagnosis of epitympanitis includes collecting an anamnesis of the disease, examining the patient and instrumental methods research.

1. Otoscopy- one of the main diagnostic methods in otolaryngology. During an examination of the external auditory canal, an ENT doctor identifies signs of inflammation, perforation of the eardrum, granulation and cholesteatoma. Otoscopy is performed using an otoscopic microscope, an otoscopic loupe and a Siegle magnifying funnel.
2. Audiometry- a comprehensive study of hearing acuity using special equipment, carried out by an audiologist. It is possible to determine how much a patient’s hearing has decreased using live speech, tuning forks and special electroacoustic devices - audiometers. Hearing loss is the main symptom of epitympanitis, so the study auditory function is mandatory.
3. X-ray diagnostics of the temporal region allows you to assess the severity and prevalence pathological process. Cholesteatoma on x-ray It is a clearing zone - a round cavity with compacted bone walls.
4. Probing carried out using a button probe, which is inserted into the middle ear through a perforation hole. Cholesteatoma or carious masses may adhere to the tip of the probe.
5. CT scan makes it possible to make a diagnosis in cases where others diagnostic procedures turn out to be uninformative. CT scan of the temporal region determines the volume of destruction temporal bone, the prevalence of inflammation in the cranial cavity, assesses the integrity and mobility of the auditory ossicles.

Treatment

Timely and adequate treatment of epitympanitis allows the patient to hear normally and prevents the development of complications. It is aimed at suppressing inflammation and restoring sound transmission. Specialists carry out conservative and surgical treatment diseases.

Conservative treatment

Purpose conservative treatment is to prepare the sore ear for upcoming surgery. If the patient's condition does not allow surgery, or the patient himself refuses it, drug therapy becomes the only possible treatment option.

Complex treatment of an inflamed ear consists of local and systemic antibiotic therapy, physiotherapy, and ear drops, which have anti-inflammatory, analgesic and antibacterial properties.

Drug treatment must be supplemented with physiotherapeutic procedures - ultraviolet irradiation, laser exposure, oxygen therapy.

Epitympanitis, characterized by extensive destruction of bone tissue, complicated by cholesteatoma or difficult to treat drug therapy, requires surgery.

ethnoscience

Treatment of epitympanitis folk remedies- an additional method that gets rid of microbes, promotes tissue restoration, weakens Clinical signs pathologies and strengthening the immune system.

The most effective and common folk recipes:

1. Rinsing the sore ear with infusion of chamomile or ordinary tobacco.
2. Instillation of vodka or juniper alcohol into the sore ear.
3. Inserting a cotton swab soaked in alcohol tincture propolis, into the ear canal for a couple of hours.

Surgery

Indications for surgical intervention with epitympanitis:

• Damage to the bony labyrinth
• Polyposis of the auditory canal,
• Cholesteatoma,
• Spread of infection inside the skull,
• Paralysis facial nerve,
• Osteomyelitis and persistent caries of the temporal bone,
• Ineffectiveness of drug treatment.

The operation begins with sanitation of the ear - removal of the source of infection. The pockets of the ear cavity are combined, the pus is removed, the affected tissue is excised, and disinfection is carried out. Then they move on to the next stage - tympanoplasty, carried out for the purpose of prosthetics of the auditory ossicles and restoration of the eardrum by stretching a fold of skin at the site of perforation.

stages of tympanoplasty

After the operation, the patient is advised to adhere to bed or floor rest. bed rest. He is prescribed antibacterial and desensitizing agents, corticosteroids and vitamins for 7-10 days. After removing the tampons, the ear is regularly cleaned using antibacterial drops. IN postoperative period Physiotherapy is prescribed - ultraviolet irradiation, laser, magnet. After treatment of epitympanitis, many patients are recommended to purchase a hearing aid.

Prevention

Measures to prevent the development of epitympanitis:

1. Maintaining healthy image life,
2. Strengthening immunity,
3. Timely treatment acute otitis And common diseases– diabetes, rickets, tuberculosis, exudative diathesis,
4. Sanitation of foci of chronic infection,
5. Clinical examination under the supervision of an ENT doctor, pediatrician, therapist.

Timely and correct treatment makes the prognosis of epitympanitis favorable. Modern otolaryngology has the means and capabilities to restore the affected anatomical structures of the ear and auditory function. Hearing restoration is a fairly lengthy process that does not always achieve one hundred percent effectiveness.

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Eardrum injuries. They occur during burns due to contact with foreign bodies and drops of molten metal or as a result of exposure to caustic chemical substances. Injuries to the eardrum can be combined with injuries to the tympanic cavity and inner ear. Even with minor damage to the eardrum, dislocation of the auditory ossicles is possible, causing disturbance hearing and labyrinthine disorders (with dislocation of the base of the stapes from oval window).

Indirect injuries to the eardrum occur when there is a sudden change in pressure in the external auditory canal (a blow to the ear, a kiss to the ear, etc.) or an explosion ( acoustic trauma). Damage to the eardrum can also occur with blunt trauma to the skull.

In connection with these circumstances, for all injuries of the eardrum, a detailed history should be collected and a study of cochlear and vestibular function should be conducted. If necessary - X-ray examination temporal bones and cranial bones, examination by a neurologist and ophthalmologist.

Treatment. With a small slit-like perforation, mild hearing loss, general good condition and an uncomplicated medical history, it is enough to inject powder with antibiotics, apply a sterile bandage, carry out physical therapy and prescribe antibiotics for prophylactic purposes under otoscopic control. Blood accumulated in the ear canal should be carefully removed with a swab or attempted to be sucked out. If otoscopy is difficult, it is necessary to perform a Valsalva maneuver: the release of air will indicate the presence of perforation.

Small perforations of the eardrum usually close on their own within a few days. In all other cases, hospitalization is indicated. In a hospital, a detailed otoscopy is required, preferably using optics (magnifying glass, operating microscope). For medium-sized perforations and no signs of infection or damage to the auditory ossicles (conductive hearing loss up to 15-20 dB), you can try to close the perforation using the Okunev method (multiple cauterization of the edges of the perforation with trichloroacetic acid).

If the edges of the defect are folded, then they are placed correctly, and pieces of gelatin sponge soaked in penicillin are placed under the defect (before it is closed) and on it, which are left for a period of at least 3 weeks. Large defects (subtotal and total) should be closed in acute period is not possible and they may remain on long time. In the future, it is necessary to perform myringoplasty or tympanoplasty (if the auditory ossicles are damaged).

Damage to the auditory ossicles. Such injuries most often occur with longitudinal fractures of the pyramid of the temporal bone, blunt trauma to the skull without a fracture of the pyramid, due to a strong impact of the skull on a solid base. It is also possible medical injuries: displacement and destruction of bones during anthromastoidotomy, paracentesis. Suspicion of a violation of the chain of auditory ossicles arises when there is a decrease in hearing due to air conduction more than 20 dB. Availability vestibular symptoms indicates dislocation of the stapes in the oval window.

Vestibular disorders can occur during manipulations performed during some reconstructive operations, accompanied by dislocation of the stapes, as well as during operations for otosclerosis. At the same time there appear severe dizziness, nausea, sometimes vomiting, spontaneous nystagmus towards the affected ear; the fistula symptom can be positive, but if the stapes is dislocated, it cannot be provoked so as not to aggravate the existing disorders. The resulting conductive type hearing loss, with lateralization during the Weber experiment in the direction of damage. The symptoms correspond to those of an induced (due to diffusion through windows) serous labyrinth.

Treatment. Post-traumatic labyrinthine reactions usually disappear after 3-6 days, subject to bed rest, dehydration and antibiotic therapy. If the symptoms of cochleovestibular disorders persist longer, this indicates inflammatory reaction that occurs in response to labyrinthine trauma.

In this case, it is necessary to perform tympanotomy with revision of the chain of auditory ossicles and corrective plastic measures, depending on what happened - dislocation or fracture of the auditory ossicles. Sometimes it is necessary to partially remove the lateral wall of the attic and the posterior bone wall of the external auditory canal, and then perform an osteoplastic atticotomy.

Manipulations in the area of ​​the oval window can be complicated by infection of the inner ear and the development of meningitis, which is especially often observed with suppurating cholesteatoma and granulation otitis media. The effect of this type of injury on the condition of the inner ear depends on the extent of the damage, the virulence of the infection, and the level of immunity in the victim.

When these vestibular disorders appear, massive antibiotic therapy must be immediately administered. During surgery, if the stapes is dislocated, you should carefully try to put it back in place. When introducing fragments of auditory ossicles into windows, it is necessary to carefully remove them without deepening them.

Hematotympanum. Hematotympanum is an outpouring of blood into the tympanic cavity with an intact eardrum, which is dark blue or black-blue in color. Hematotympanum may be a consequence of a fracture of the temporal bone pyramid with a rupture of the mucous membrane of the tympanic cavity.

It is also formed with a sudden increase in pressure or stagnation of blood during coughing or sneezing, accompanied by rupture of small vessels of the mucous membrane of the tympanic cavity, with aerootitis, after posterior tamponade and adenotomy (flow of blood through the auditory tube). Hematotympanum must be differentiated from glomus tumor of the middle ear and high-standing bulb of the internal jugular vein.

The eardrum is punctured, the blood is sucked out, and enzymes and corticosteroids are injected into the tympanic cavity.

Damage to the auditory tube. Fractures of the bone part of the tube are possible with fractures of the temporal bone and are masked by manifestations of damage to the tympanic cavity (hemorrhage, etc.). Damage to the mucous membrane of the cartilaginous tube with emphysema of the surrounding tissues can occur during its forced catheterization. The pain observed when swallowing is caused by contractions of the muscles of the cartilaginous part of the tube.

Treatment. Assign vasoconstrictor drops into the nose, antibiotics, anemize the pharyngeal mouth of the auditory tube. Surgical intervention performed only to eliminate the consequences of injury - stenosis of the auditory tube.

IN. Kalina, F.I. Chumakov

Rupture and dislocation of the auditory ossicles (H74.2) is a syndrome characterized by the presence of conductive hearing loss due to damage to the auditory ossicles.

• Ear injury.
• Fracture of the base of the skull, pyramid of the temporal bone.
• Inflammatory diseases middle ear.
• Tumor of the middle ear.

In the above conditions, the auditory ossicles are displaced relative to each other (dislocation) or destroyed (rupture). Both lead to complete or partial disruption of the conduction of sound waves from the eardrum to the cochlea. Conductive hearing loss occurs.

Symptoms of rupture and dislocation of the auditory ossicles

• Persistent hearing loss.
• Sharp pain in the ear.
• Sudden dizziness, loss of coordination of movements.
• Ear congestion, feeling of fullness.
• Noise in the ear.

Upon inspection:

• The eardrum is not changed.
• Rupture or perforation of the eardrum.
• Persistent hearing loss (decreased whispering and spoken speech) by sound conduction type.
• Negative tuning fork tests Rine and Friederici, lengthening of bone conduction time, lateralization of sound towards the worse-hearing (affected) ear (Weber test).

Diagnostics

• Consultations with an otorhinolaryngologist and audiologist.
• Pure-tone audiometry, acoustic impedancemetry (type Ad or E tympanogram), CT, MRI of the brain.

Differential diagnosis:

Treatment of rupture and dislocation of the auditory ossicles

Treatment is prescribed only after confirmation of the diagnosis by a medical specialist. Conducted:

• Surgery.
• Hearing aids.

Essential drugs

There are contraindications. Specialist consultation is required.

• (analgesic, anti-inflammatory agent). Dosage regimen: instill 3-4 drops into the external auditory canal 3-4 times a day.
• (antiseptic, local anesthetic, anti-inflammatory agent). Dosage regimen: instill 4 drops into the external auditory canal 2-3 times a day. within no more than 10 days.
• (antibacterial and anti-inflammatory agent). Dosage regimen: instill 1-5 drops into the external auditory canal 2 times a day. within 6-10 days.

All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.

Tympanoplasty is a middle ear surgery aimed at preserving and restoring the sound-conducting system, with the ultimate goal of improving hearing.

As you know, sound is waves of compressed air, alternating with areas of its rarefaction, acting on our ear at different frequencies. The human ear is a very complex system, consisting of three sections, the main functions of which are: capturing sound, conducting it and perceiving it. If at least one of the departments cannot perform its function, the person will not hear. At the same time, the quality of life decreases sharply.

Tympanic cavity- This middle section ear, performs the function of conducting sound. It consists of the eardrum, a chain of three auditory ossicles (malleus, incus and stapes), and the windows of the labyrinth. It is the normal functioning of all these three departments that ensures the implementation of sound waves from environment into the inner ear to further convert them into signals perceived by the brain as sound.

structure of the middle ear

For normal sound transmission:

• The tympanic cavity must be free (without pathological contents), hermetically sealed.
• The eardrum should be sufficiently tight and without defects.
• The chain of auditory ossicles must be continuous.
• The connection between the bones should be loose and elastic.
• There must be adequate aeration of the tympanic cavity through the Eustachian tube.
• Labyrinth windows must also be elastic and not fibrous.

It is to create such conditions or as close as possible to them that the tympanoplasty operation is aimed.

In what cases is tympanoplasty indicated?

The operation is indicated in the following cases:

1. Chronic otitis media.
2. Sclerosis and fibrosis of the middle ear.
3. Malformations of the sound-conducting apparatus.

Most frequent indication to tympanoplasty - this is otitis media with exudation (epitympanitis or mesotympanitis). It usually involves a hole in the eardrum, destruction of the auditory ossicles, adhesions and fibrosis, and the presence of cholesteatoma (epidermal neoplasm).

Preparation for tympanoplasty

Tympanoplasty is performed some time after the sanitizing operation (usually 5-6 months). This period is waited for complete subsidence. inflammatory process, stopping exudation, to improve the drainage and pneumatic function of the auditory tube.

Preoperative examination:

• X-ray of the temporal bones.
• CT scan of the temporal bones.
• Endoural endoscopic examination.
• Audiometry.
• Determination of the sound-perceiving function of the cochlea (using a sound probe).
• Study of the functioning of the auditory tube.
• Standard preoperative examination (blood tests, urine tests, coagulogram, blood biochemistry, testing for HIV, hepatitis and syphilis, ECG, fluorography).
• Examination by a therapist.

It must be said that the diagnosis of disorders in the sound-conducting apparatus is quite complex and cannot always be established before surgery. In addition, the causes of hearing loss are often multiple. Therefore, doctors do not give any guarantee; surgery may not always give the expected effect.

According to statistics, the effect of tympanoplasty is 70%.

Contraindications for surgery

The operation is not performed for the following diseases:

1. Decompensated somatic diseases.
2. Severe form of diabetes mellitus.
3. Purulent inflammation in the middle ear.
4. Acute infectious diseases.
5. Labyrinthitis.
6. Impaired patency of the Eustachian tube.
7. Decreased sound-perceiving function of the cochlea (in the last two cases, the operation will be ineffective).

Main stages of tympanoplasty

There are several stages of tympanoplasty:

• Access to the tympanic cavity.
• Ossiculoplasty.
• Myringoplasty.

A systematization of tympanoplasty methods was developed by Wulshtein and Zellner (50s of the 20th century). They proposed methods of tympanoplasty using a skin flap, which is taken from the area behind the ear or cut out from the ear canal.

According to this classification, there are 5 types of tympanoplasty:

1. When the ossicular chain is functioning normally and there is only a defect in the eardrum, endouring myringoplasty (closure of the defect) is performed.
2. When the malleus is destroyed, the newly formed membrane is placed on the incus.
3. If the malleus and incus are lost, the graft is adjacent to the head of the stapes (imitating the resemblance of a columella in birds).
4. When all the bones are lost, the cochlear window is shielded (closing it from direct sound waves). The stirrup plate is left uncovered. In the modern version of this operation, artificial prosthetic hearing ossicles are transplanted.
5. When fibrosis of the oval window of the cochlea is observed in combination with complete immobility of the base of the stapes, the semicircular canal is opened and the hole is covered with a skin flap. Currently practically not used.

stages of tympanoplasty

The operation is usually performed under general anesthesia, but local anesthesia is also quite widely applicable (for any type of access). Surgeons prefer local anesthesia, since you can check your hearing directly during surgery.

Access to the tympanic cavity

There are three ways to reach the tympanic cavity:

• Intrameatal access. This is accessed through an incision in the eardrum.
• Through the external auditory canal.
• Retroauricular access. An incision is made immediately behind the ear, opened with a bur or cutter back wall external auditory canal.

Ossiculoplasty

This is the restoration of the chain of auditory ossicles for maximum possible transfer sound vibrations to the snail.

All manipulations in the tympanic cavity are performed using an operating microscope and microinstruments.

Basic principles of ossiculoplasty:

1. The contact of the restored auditory ossicles with each other must be reliable so that there is no displacement.
2. The newly created chain of transmission of sound vibrations must be sufficiently mobile.
3. It is necessary to prevent the development of fibrosis and ankylosis in the future (ensuring sufficient aeration of the tympanic cavity, transplanting the mucous membrane in its absence, introducing a silastic agent).
4. The ossiculoplasty method is selected individually for each patient, focusing on both preoperative examination and intraoperative findings.

ossiculoplasty

In addition to replacing the auditory ossicles with a skin flap, other methods of prosthetics for lost auditory ossicles have been developed.

Materials used in ossiculoplasty for ossicular replacement:

• Own or cadaveric bone tissue
• Cartilage.
• Parts of the patient's own nail.
• Artificial materials (titanium, Teflon, Proplast, Plastifor).
• Fragments from one's own malleus and incus.
• Cadaveric auditory ossicles.

Myringoplasty

The tympanoplasty operation ends with the restoration of the eardrum -. Sometimes myringoplasty is the only stage of such an operation (if the chain of sound-conducting ossicles is preserved).

Main materials used for myringoplasty:

1. Skin flap. It is usually taken from the skin behind the ear or inner surface shoulder
2. Vein wall (from the lower leg or forearm).
3. Fascial flap. It is taken from the fascia of the temporalis muscle during the operation itself.
4. Perichondrium from the cartilage of the auricle.
5. Cadaveric tissue (hard meninges, perichondrium, periosteum).
6. Synthetic inert materials (polyamide fabric, polyphasene).

Main types of myringoplasty

After operation

The ear canal is tamponed with sterile tampons soaked in antibiotics and hydrocortisone emulsion.

Bed rest is prescribed for 24 hours. The patient receives antibiotics for 7-9 days. The stitches are removed on the 7th day.

The mouth of the auditory tube is irrigated daily with vasoconstrictors.

Tampons are removed from the ear canal gradually. On the 2nd, 3rd, 4th and 5th days, only the outer balls are changed. The internal ones, adjacent to the eardrum, are not touched until 6-7 days. Usually by this time the tympanic flap has healed. Complete removal deep tampons are completed by day 9-10. By this time, the rubber drainage is also removed.

Somewhere from 6-7 days, the auditory tube begins to blow.

1. Avoid getting water into your ear for several months.
2. You can't blow your nose too much.
3. The development of any runny nose should be avoided as much as possible.
4. Limit heavy physical activity.
5. Airplane flights are not recommended for 2 months.
6. Avoid very loud sounds.
7. Do not take a steam bath or sauna.
8. To prevent fungal infections, antifungal drugs are prescribed.

Possible complications of tympanoplasty

In some cases, tympanoplasty is fraught with the following complications:

• Damage to the facial nerve. It manifests itself as paralysis of the facial muscles on the affected side. Facial nerve paralysis can also be temporary – as a consequence of postoperative swelling.
• Labyrinthitis. Manifested by dizziness and nausea.
• Bleeding intra- and postoperatively.
• Inflammation.
• "Graft disease." It can become inflamed, partially or completely necrotize, and resolve.

Main conclusions

Let's summarize the main results:

1. A thorough examination is necessary before surgery. Doctors must be convinced that poor hearing is associated precisely with pathology of the sound-conducting apparatus of the middle ear.
2. At correct readings in 70% of cases, hearing improves after surgery.
3. The importance of tympanoplasty should not be exaggerated. Even a slight improvement in hearing after it is already a success.
4. This operation is quite complex, there are many contraindications and potential complications. You should weigh the pros and cons.
5. You should choose a clinic based on its reputation, reviews, number of operations performed, and the percentage of complications.