Pathophysiologic analysis of the Chronic otitis media


 
 


New possibilities surgical treatment of the chronic otitis media

with recovery hearing .



 
 

Textbook:
Chronic otitis media



 


 
 
   

Abstract

This textbook: Chronic otitis media, is intended for use in the clinic and outpatient conditions . In this manual , the first held deep pathophysiologic analysis features of the development of chronic inflammation in middle ear , taking into account three types of " vicious circle " of inflammatory process that led to the formation of different pathophysiological rationale chronic forms of otitis media , in this case , they have to allocate primary and a secondary stage , with significant clinical differences . Pathophysiologic analysis of existing methods of treatment of chronic middle otitis revealed and develop the most productive methods for each of its forms . As a result , represented a reasonable pathophysiological Classification of chronic otitis media , which is much faster and it simplifies the diagnosis of various forms , which facilitates the selection efficiency treatment and helps the development of effective preventive measures . new techniques protected by Russian patents .
 



   
 

Acute otitis media

Pathophysiological features of the acute otitis media

Chronic otitis media

Tubo-tympanosclerosis and cholesteatoma as the effects of acute Evstahiit (tubootitis)

Pathophysiological features of the chronic otitis media

Variants of "Surgical Angle" of approach

to the Antrum

Method of the "Antro-Drainage"

Method of the "Slit-Like" Antro-Atticotomy

Variants of the "Surgical Angle" of Approach to Mastoid Antrum.

Method of the "Hinge-Like" Stapedoplasty

Correction of the Failures after "Hinge-Like" Stapedoplasty

Middle Ear,Tympanic Membrane, Infections (topic 205)

 

 
 
 

Pathophysiological classification
of the Chronic otitis media

 
 
 

Purulent (as perforated) forms of the chronic middle otitis media:

Epitimpanale Attica-Anthrit

Mezotimpanale Attica-Anthrit

Chronic salpingootit

Cholesteatoma of the middle ear

Not purulent (not as perforated) forms of the chronic middle otitis:

Chronic eustachiit (tubo-otitis)

Chronic serous-exudative otitis

Mucous otitis

Effects of the chronic otitis media:


Dry perforated otitis

Adhesive otitis

Timpanoskleroz (tubarny and drum)


 

Slit (fricative) Antrum-Atticotomy

 
 
 

Pathophysiological features of the chronic otitis media

Ulyanov Y.P.,Shadyev H.J.,Shadyev Ò.H. 
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)  
 
 

Actuality problem of the chronic otitis media (COM) and today remains the leading in ENT diseases.
So today, in-depth analysis of the pathophysiological COM is particularly necessary because only with its help, we can really understand the complexities of the chronic inflammatory process that develops in the middle ear conditions, when in the Attico-antral region continues chronic inflammation of bone and with perforation in the mezotimpanum.
Our experience pathophysiologic analysis of acute otitis media (AOM) has allowed more fully understand its pathogenesis and to make the most reasonable, compact classification, which greatly facilitates the accuracy of diagnosis and selection of pathogenetic treatment (HJ Shadyev, YP. Ulyanov - 2006).
At the same time, were identified atypical variants of the inflammatory process in the conditions of the middle ear, in the form of three main types of "vicious circle", which were the basis for the development of adverse inflammatory process variants.
And after three months, the adverse options turn into a chronic condition, which is clinically manifested as chronic otitis media.
Thus, pathophysiological, these species "vicious circle" of the inflammatory process in the middle ear and is owned by the main pathogenesis of the subsequent development of different forms of COM (HJ Shadyev, YP. Ulyanov, TH Shadyev [2007]).
For example, in catarrh of the middle ear, the first type of "vicious circle" of the inflammatory process which leads to an increase in the vacuum state in the middle ear, with the possible development epitimpanum perforations.
The second type of "vicious circle" of the inflammatory process is formed on stage exudative inflammation, with an increase in intra-aural pressure, and the layering of pathogenic microorganisms to exudate form the third type of "vicious circle", which in combination form the complex type "vicious circle" of the inflammatory process that leads to the development of resistant central perforation in the mezotimpanum.
With the defeat of Attico-antral area, the complex type "vicious circle" leading to the development of acute purulent exudative Attico-antrita threatening intracranial complications.
Furthermore, it became apparent that we must distinguish between primary - the primary stage of chronic otitis media, which are a direct continuation of unfavorable variants of acute otitis media, and they are not much different from each other and more mature - secondary stage, chronic otitis media, which greatly is converted to the subsequent development of chronic inflammation in the middle ear.
Such a division of the chronic otitis media on the primary and secondary can not be ignored, because it is caused by different mechanisms of pathogenesis, with different clinical manifestations.
Therefore, when analyzing the clinical manifestations of different stages of chronic inflammation in the middle ear, manifested in different forms COM should separately consider them primary and secondary stages, and which require different pathogenetic treatment.
 
Particularly aggressive are purulent (as perforated) forms of the chronic otitis media:  

1. Pathophysiological features of the chronic epitimpanale Attico-antritis    
 

Epitimpanale Attico-antrit is the most aggressive, as it develops earlier mezotimpanale Attico-antritis - another catarrhal stage of acute otitis media (AOM) (HJ Shadyev, YP. Ulyanov 2006) and are the most destructive in a cellular system Attico-antral region, because of its chronic inflammatory infiltrates insecurity, which contributes to the development of mastoiditis and intracranial complications.
Carried out by us in-depth analysis of the pathophysiology COM showed that one should distinguish between the primary stage of chronic otitis media, which are a direct continuation of unfavorable variants of acute otitis media, and they are not much different from each other and the secondary stage chronic otitis media, which significantly transformed as a result of subsequent development of chronic inflammation in the middle ear.
In the primary epitimpanale Attico-antritis, development exudative purulent inflammation manifests itself most aggressively, because the formation of a complex type " vicious circle " exudative purulent inflammation, which leads to increasing pressure of purulent exudate in a locked cell system of the mastoid process , with the possible destruction of bone intercellular structures partitions and abscess formation in the mastoid bone or purulent exudate breakthrough beyond the middle ear and the development of intracranial complications .
At the same time, despite the presence of a small central perforation epitimpanum, mezotimpanalnaya part of the eardrum looks completely intact and retains mezotimpanum complete isolation from the attic, often with preservation of hearing that may mislead physicians about the safety of that ear.
Further development of exudative purulent inflammation in Attico-antral area leads to additional secondary pathophysiological changes of character which have their clynical manifestations in the form of secondary epitimpanaly Attico-antrita, but with an edge perforation in epitimpanum.
With the continued activity of a complex type "vicious circle" exudative purulent inflammation in periantalnyh cells and antrum cavity increasing pressure purulent exudate, causing it to break under the mucous membrane with the development of caries-destructive process, reaching the edge of the eardrum epitimpanaly, with its destruction, transforming perforation into the edge.
Increasing caries-destructive process leads to destruction of the cell block anastomoses in Antrum and stroke, leading to reduced activity of exudative suppurative inflammation, promoting completion exudative inflammation, the development of its next - productive stage of inflammation, a sclerotic bone overgrowth.
Activity productive stage of inflammation in the walls of the bone and bone cells periantralnyh walls of the cavity leads to a widening of the antrum of sclerotic bone, filled with bone tissue damaged cells that, like squeezing hotbed of chronic suppurative inflammation of them, to their complete elimination.
As a result, the cavity of the antrum has been declining in volume and can be reduced to a minimum, which, according to our observations, achieve three - four millimeters in diameter.
This thickening of the antrum reduces the risk of development of intracranial complications, and lifting of the blockade with stroke in antrumsnizhaet contributes slableniyu aggressiveness exudative purulent inflammation in it.
With the penetration of purulent exudate in the submucosal space of the attic and antrum, it reaches the outer edge of the eardrum shrapnelevoy and destroys it to the central perforation of the tympanic membrane defect increasing bone to the edge.
The result is a marginal perforation of the tympanic membrane in epitimpanum when completely intact mezotimpanalnoy part of the eardrum, it is even possible to preserve hearing, which is a clear clinical manifestation of secondary epitimpanale Attico-antrita.
In connection with the caries-destructive processes in Attico-antral area, purulent discharge from the attic gets cheesy aroma, typical for secondary Attico-antrita.
In the such case, only the surgical treatment of cavity antrum is quite reasonable and necessary pathogenically.
 


2. Pathophysiological features of the chronic mezotimpanale Attico-anthrit  


Mezotimpanalny Attica-anthrit develops much later epitimpanalny Attica - anthrit - on stage exudative inflammation of acute otitis media (AOM) (Shadyev Ulyanov 2006), but the defeat of Athens-antral area makes it no less aggressive than epitimpanalny Athens-Antrim, with the possible mastoiditis formation and development of intracranial complications. Carried out by us in-depth analysis of the pathophysiological COM showed that one should distinguish between the primary stage of chronic otitis media, which are a direct continuation of unfavorable variants of acute otitis media, and they are not much different from each other and secondary stage, chronic otitis media, which significantly transformed as a result of subsequent development of chronic inflammation in the middle ear. In the primary mezotimpanalnom Attica-anthrit, development exudative purulent inflammation with formation of a complex type "vicious circle" exudative purulent inflammation primarily manifested in mezotimpanum with forming central perforation, which is the most visible feature of the primary- mezotimpanale Attica-anthrit. Central perforation vetrhnem department mezotimpanum razivivaetsya the rising pressure in the tympanic cavity exudate, which actually is a complication of already developed purulent exudative inflammation, mainly affecting the Attica -anthral area still under AOM . At the same time, the development of exudative purulent inflammation manifests itself most aggressively, because the formation of a complex type "vicious circle" exudative purulent inflammation, which leads to increasing pressure of purulent exudate in a locked cell system of the mastoid process, with the possible destruction of bone structures and intercellular partitions abscess formation in the mastoid bone, or purulent exudate to a breakthrough beyond the middle ear and the development of intracranial complications. Further development of exudative purulent inflammation of the middle ear causes additional pathophysiological changes the secondary nature which have their cynical manifestations in the form of the secondary mezotimpanalnogo Attica-anthrita, but with an edge perforations in the upper mezotimpanum. This is due to the penetration of purulent exudate in submucosal space antrum, attic and mezotimpanum where destroys the upper edge of the eardrum to its central perforation in the upper mezotimpanum, transforming it into a marginal perforation. With the continued activity of a complex type "vicious circle" exudative purulent inflammation in periantalnyh cells and antrum cavity exudate increasing pressure leads to the destruction of the mucosa and the development of caries-destructive process. Destructive properties of carious process remove the blockade of cellular system Attica-anthral cavity area and antrum, which leads to reduced activity of exudative purulent inflammation, contributing to the completion of exudative inflammation, with the development of its next - productive stage of the inflammatory process, which is particularly evident in the bone mastoid as sclerotic bone growths. Through the activity of the productive stage of inflammation in the walls of the bone and bone cells periantralnyh cavity walls antrum sclerotic bone growth occurs, with the filling of the bone tissue of the affected cells, which, as if squeezing hotbed of chronic suppurative inflammation of them, to their complete elimination. As a result, the cavity of the antrum has been declining in volume and can be reduced to a minimum, which, according to our observations, achieve three - four millimeters in diameter. This thickening of the antrum reduces the risk of development of intracranial complications, aided and weakening aggressiveness exudative purulent inflammation in the form of a third form of "vicious circle". At the same time, limited purulent discharge from the attic can go to the Eustachian tube to the medial wall of the tympanic cavity without reaching the perforation of the eardrum, which dries, creating the impression of apparent well-being that keeps doctors from antrotomii that remains necessary for the surgical sanitation of Attica-anthral area.