Department of Otorhinolaryngology Faculty for Postgraduate Education First Moscow State Medical University. IM Sechenov. (Head of Department Professor, MD, Honorary Doctor of Russia Shadyev HJ)
Today's variety of clinical manifestations of acute otitis media and new data on the pathophysiology of the middle ear does not always correspond to each other, which affects the accuracy of the diagnosis, selection of effective treatment and the effectiveness of preventive measures.
First of all, it refers to the serous, exudative and secretory otitis, differential diagnosis which has its own complexity, which creates some difficulties, especially in outpatient settings.
To understand the features of the clinical forms of acute otitis media N.A.Preobrazhensky , in 1975 called for a closer examination of their pathogenesis, with the help of a pathophysiological analysis.
The same opinion is shared by today's leading pathophysiologist Russian Professor PF Litvitskiy , who believes that the use of a pathophysiological analysis in the study of clinical manifestations of disease, now considered necessary and obligatory.
In conducting our analysis of pathophysiological acute inflammation of the middle ear, we have identified non-standard varieties of the inflammatory process, which is already known in the literature and have been called "vicious circle". 
This "vicious cycle" of inflammation was found in a locked cavity antrum, chronic suppurative otitis media, more than 120 years ago, when it was found that it can maintain persistent course of chronic inflammatory process life .
Such a "vicious circle" of the inflammatory process reveals JK Yanov , and in a cellular system sinuses while blocking their natural anastomoses.
Similar to a "vicious circle" of the inflammatory process in the mucosa notes ENT organs YM Ovchinnikov et al , such as the cause of inflammation is the interaction of inflammatory and infectious processes that reinforce each other, supporting their long and persistent.
Varieties of "vicious circle" of the inflammatory process and clinicians find in other areas of medicine , ,  and many others.
Formation of such a "vicious circle" of the inflammatory process in the middle ear have been identified by us at the time of catarrh when catarrhal inflammatory mucosal edema of the middle ear leads to a sharp narrowing of the lumen of the auditory tube.
Limited flow of air into the middle ear leads to the development of negative pressure in it, which creates an additional - vacuum mucosal edema, further violating the patency of the auditory tube, causing a further increase in the vacuum state and this - a series of non-standard inflammatory process closes, which we considered, the first type of "vicious circle".
Continuing to develop the first type of "vicious circle" of the inflammatory process becomes full independence, which clinically manifested as acute or acute tubo-otitis evstahiit, pathogenetic basis is impaired patency of the auditory tube, in this connection, - pathogenetic treatment should be aimed at the destruction of the first type "vicious circle" of the inflammatory process.
Subsequent increase of the vacuum state in the middle ear causing it to fill with serous trassudatom that eliminates the vacuum state and destroys the first type of "vicious circle" of the inflammatory process.
At the same time, catarrhal inflammation of the mucous membrane of the middle ear continues, and it keeps the inflammatory mucosal edema of the auditory tube, preventing emptying of the middle ear serous transudate that is clinically manifested in the form of acute serous otitis media, and therefore, treatment should be pathogenetic aimed at restoring patency of the auditory tube.
Then, catarrh of the middle ear gradually ends with a transition to a more active state, in the form of exudative inflammation.
In step exudative inflammation, mucosal edema significantly increases due to its infiltration of tissue exudate that flows into the tympanic cavity and that leads to the active in-the buildup of pressure with the formation of the second type of "vicious circle" inflammatory process.
This contributes not only to reinforce the blockade exudative progressive swelling of the mucous membrane in the auditory tube, but in the epi-mezotimpanalnom space.
Growing pressure of fluid in the meso-gipotimpanum irritates the mucous membrane and activates these exudative inflammation, which increases the exudation and further increases the pressure in the middle ear, on which closes the second type of "vicious circle" of the inflammatory process.
Since fluid pressure increases only in meso-and gipotimpanum, redness and bulging of the eardrum outward occurs only in her stretched parts.
This clinical picture of inflammation in the middle ear is traditionally perceived as typical for acute otitis media.
And in fact, this clinical picture reflects the exudative stage of inflammation in the middle ear conditions, as it is exudative inflammatory process is the basis occurring in the tympanic cavity pathophysiological changes.
Therefore, this clinical picture is more suitable name exudative acute otitis media, which best reflects the exudative stage of acute inflammation in the middle ear.
And the name of acute otitis media, more consistent with the classification of otitis group consisting of successive stages of acute inflammation in the middle ear.
Under the influence of the second type of "vicious circle" of the inflammatory process, increasing pressure in the tympanic cavity leads to a point break in mezotimpanum eardrum.
After expiration of excess discharge through the perforations, the fluid pressure in the tympanic cavity dramatically reduced, which leads to rupture of the second type of "vicious circle" inflammation and subsequent visual subsiding exudative inflammation which becomes more for the deceased, with the desire to completion.
Exudative inflammation subsided in the tympanic cavity is accompanied by a significant reduction in inflammatory edema that leads to a lifting of the blockade in these mezotimpanum-and auditory tube, followed by emptying all the departments of the middle ear exudate and the restoration of their aeration.
As a result, favorable conditions for recovery, and which contribute to spontaneous overgrowing point perforation of the eardrum.
That is why, quite often, an acute inflammation of the middle ear, the eardrum with a breakthrough, with the active anti-inflammatory treatment may end in recovery, with overgrowth of perforation of the eardrum and hearing restoration.
Therefore, timely paracentesis, with an increase in pressure in the middle ear, is quite pathogenic because destroys the second type of "vicious circle" of the inflammatory process.
However, an unfavorable course of acute otitis media effusion, after breaking the eardrum, most likely because the inflammatory exudate in the tympanic cavity is a good breeding ground for the development of pathogenic organisms deep as from the nasopharynx and through the perforations of the eardrum.
Layering pathogens on exudate translates exudative inflammation exudative purulent, which dramatically activates exudative inflammatory process, resulting in mucosal irritation purulent exudate, with increasing amounts of exudate in which pathogenic microflora develops with greater activity.
As a result, formed a third type of "vicious circle" of the inflammatory process, typical cases of infection by layering pericardial inflammation.
Pyogenic flora leads to the melting of the weakened tissue of the tympanic membrane with a significant increase in the size of its perforation, acquiring consistent, clinically corresponds perforated otitis, which generates its own varieties, depending on the further spread of purulent exudative inflammation to the adjacent sections of the middle ear.
Firstly, purulent exudate filling the bone separated auditory tube penetrates peritubal cells which leads to their blockade with the formation of the second type "vicious cycle" of the inflammatory process, which is laminated on the third type of "vicious circle" and, together, they support each other form a complex type "vicious circle" of the utmost destructive activity.
This manifests itself in uncontrollable increased pressure in closed peritubal cells, due to the active production of purulent exudate, which periodically erupts into the lumen of the auditory tube, causing irritation surrounding mucosa, which is responsible reflex defensive reaction to its mucous glands, aimed at flushing stimulus.
As a result, there is an abundant amount of secreted mucus, which, mixed with purulent exudate fills the tympanum and poured into the ear canal, which corresponds clinically secretory otitis and pathogenesis. - Is the result of a complex type "vicious circle" of the inflammatory process causes excessive secretion of protective mucus.
Special perseverance during secretory otitis media due to the fact that mistakenly seek cure protective mucosal response of the auditory tube, which is not a disease and therefore not amenable to any treatment.
Therefore, secretory otitis pathogenetic treatment should be aimed at the destruction of a complex type "vicious circle" of the inflammatory process in the blocked peritubal cells.
Besides peritubal area exudative purulent inflammation of mezotimpanum can overcome epi-mezotimpanany block and penetrate-anralnuyu Attica region, which leads to the formation of a complex type in it "vicious circle" has a particularly aggressive destructive properties.
Such active exudative purulent inflammation in Attica-antral area clinically acute-antritom Attica, in which, acute mastoiditis develops man-especially aggressive - as an independent form of perforated otitis media, in which increasing pressure exudate easily melts bone baffles periantralnyh cells and capturing the entire mastoid threatens breakthrough exudate behind the ear or in the development of intracranial complications.
Pathogenetic treatment of acute mastoiditis man-must be directed to the rupture of a complex type "vicious circle" of the inflammatory process Attica-antral area with an active anti-inflammatory and antibiotic treatment , , , with failure which pathogenetic treatment is surgical drainage cavity type antromii antrum , ,  and others.
When identifying suspected development of intracranial complications pathogenetic treatment is an autopsy and audit Attica-antral area.
1. Catarrhal stage of acute inflammation in the middle ear produces two varieties of acute otitis media, in the form of a vacuum state tubootitis supported the first type of "vicious circle" of inflammation and serous otitis media in the form, which is the most relaxed form of acute otitis media.
2. Exudative stage of inflammation in the middle ear generates the most active - exudative otitis media, with increasing pressure fluid supported by a second type of "vicious circle" of the inflammatory process.
3. Layering pathogens on exudative inflammation exudative forms purulent inflammation supported by the third type of "vicious circle" destructive inflammatory process that leads to aggression perforated otitis.
4. Under the conditions of the middle ear cavities blocked exudative purulent inflammation forms a complex type "vicious circle" of the inflammatory process, which peritubal cells clinically manifested in the form of secretory otitis media, and in Attica-antral area leads to acute mastoiditis man-threatening intracranial complications development.
5. Using pathophysiological analysis for acute otitis media allows more detailed understanding of the different forms of its manifestation, more accurately identifies features of pathogenesis, promotes refine their differential diagnosis and facilitate the selection of pathogenetic treatment.
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