Otitis

OTITIS (from Greek ous, otos-ear), inflammation of the ear; since anatomically the ear is divided into external (auricle, external auditory canal), middle (Eustachian tube, tympanic cavity) and internal (labyrinth), otitis externa, media, and interna are distinguished. External O. Since the auricle is lined with skin, it can be affected by common skin diseases (eczema, dermatitis, herpes, erysipelas), which are recognized and treated the same as in other areas of the body. - Inflammation of the perichondrium - perichondritis - is caused by infection when the cartilage is injured, most often during radical surgery; the auricle turns red, swells, and becomes sensitive to pressure; the swelling gradually increases, the contours of the auricle become smoothed out, a pustule and necrosis of the cartilage form; the process ends with severe wrinkling and disfigurement of the auricle. Perichondritis is almost always caused by the rod of blue pus; it is initially treated with cold or compresses of Burrow's solution; when pus appears, wide incisions and loose tamponade are performed. - Ot hematoma is called bleeding under the perichondrium in the upper half of the anterior surface of the auricle; it is often observed in the mentally ill, most often as a result of trauma, less often spontaneously; it appears as a smooth, fluctuating tumor of blue-crimson color, slightly painful on pressure; the bleeding, disrupting the nutrition of the cartilage, leads to its resorption, necrosis, and wrinkling. Treatment - pressure bandage and aspiration of blood with a syringe. The skin of the external auditory canal, which has hairs and sebaceous glands in the cartilaginous part of the canal, can become inflamed both in the area of the hair follicles and glands, forming limited external O., and in the bony part of the canal, forming diffuse external O. Otitis externa circumscripta, also called furuncle of the auditory canal, is caused by the introduction of staphylococcus into the hair roots or into the openings of the sebaceous glands, as a result of which inflammation develops either in the superficial layers of the skin or in the deep layers, reaching the perichondrium; mechanical factors that disrupt the integrity of the epidermis (scratching, trauma when removing wax), maceration of the skin in chronic discharge and the instillation of irritating drops into the ear, and the internal administration of bromine and iodine contribute to this introduction; sometimes the appearance of furuncles takes on an epidemic nature. Furuncules are most often located on the lower and posterior walls of the canal, less often on the upper and anterior. In superficial furuncles, limited elevations of the skin form, very painful on pressure; the skin over them turns red, and over time a yellow spot of the pustule appears on the top; in deep furuncules, diffuse, hard thickenings of the skin form, filling the lumen of the auditory canal; inflammation of the deep layers of the skin in furuncles of the posterior wall sometimes leads to infiltration and edema of the tissue behind the auricle, which is thereby protruded, as in acute mastoiditis (false mastoiditis). The symptom of a furuncle is pain in the ear, especially severe in deep furuncles and in furuncles of the upper and anterior walls; the pain increases when pressing on the tragus, pulling on the auricle, and when chewing; the pain is stronger at night than during the day. Deep furuncles sometimes cause edema of the skin in the bony part of the canal and the eardrum, which leads to a decrease in hearing. Narrowing of the lumen of the auditory canal, pain when pressing on the tragus and when pulling on the auricle make the diagnosis of superficial furuncles easy; difficulties can arise in cases of deep furuncules that appear in the presence of chronic purulent O. and are accompanied by swelling behind the auricle; in such false mastoidites, the swelling begins immediately behind the auricle, and the transitional fold is smoothed out, whereas in true mastoidites this fold is well expressed, and the swelling begins somewhat away from the attachment of the auricle; in addition, pressure on the bone of the mastoid process is painful in true and painless in false mastoidites. Suppurations in parotis, opening into the auditory canal, can for some time simulate a deep furuncle. - A superficial furuncle can either resolve under the influence of treatment or after 4-6 days turn into suppuration; when the abscess opens (spontaneously or with the help of an incision), pus and a piece of necrotic tissue are discharged. Deep furuncles can also resolve, but the transition to suppuration occurs more slowly and is accompanied by severe pain and edema of the surrounding tissues. After one furuncle, a second, third, etc. often appears nearby; such furunculosis is usually observed in people with poor nutrition (diabetes), after infectious diseases. - At the beginning of the disease, tight tamponade of the auditory canal with cotton, dry or moistened in various disinfecting liquids and ointments, is applied; tamponade and a heating compress of Burrow's solution; repeated smearing with tincture of iodine; irradiation with a Sollux lamp, proteino- and autogenous blood therapy. When an abscess has formed, it is opened. Otitis externa diffusa affects the skin in the bony part of the external auditory canal; it is caused by the entry of cauterizing or irritating liquids, foreign bodies, or damage to the skin by various instruments into the auditory canal. The skin turns red, swells, the epidermis peels off, and serous-purulent fluid weeps out (desquamative form); sometimes the process also extends to the eardrum; rarely it penetrates into the deep layers of the skin and causes phlegmonous inflammation. Subjectively, diffuse external O. manifests itself as severe itching and pain in the auditory canal. In its recognition, it can easily be confused with an exacerbation of purulent middle O.; the history, the presence of itching and perforation-noise during insufflation help in the diagnosis. - Treatment. A heating compress of Burrow's solution is prescribed; if it doesn't help - cold on the ear; the auditory canal is smeared with a solution of argyrol (2-5%) and precipitate ointment; for severe pain and itching, drops with cocaine (3-5%) are instilled into the ear. Otitis externa parasitica (otomy-cosis). In the external auditory canal of people living in damp, dark, and dusty rooms, mold fungi can be found, most often of the genus Aspergillus; they can develop only on skin deprived of the epidermis, which happens in eczema and maceration of the skin with pus from the tympanic cavity; the mycelium of the fungus then covers the walls of the auditory canal in the form of a grayish coating, and the sporangia of the hyphae appear in islands of black, yellow, or blue color, depending on the species of fungus (Aspergillus niger, flavus, fumigatus); the mycelium of the fungus from the walls of the auditory canal can also spread to the eardrum (otitis media parasitica), and if there are perforations in it, it can also crawl into the tympanic cavity ('myringomycosis aspergillosa'; Wreden, 1868). The fungal lesion of the external auditory canal proceeds painlessly and unnoticed by the patient as long as the mycelium grows only into the superficial layers of the skin; with deeper growth (to rete Malpighii), severe itching, shooting pain, deafness, noise, and corrosive discharge appear. On otoscopy, it is noted that the bony part of the auditory canal and the eardrum are covered as if with soot (A. niger) or with a yellow coating (A. flavus); microscopic examination of the coating determines its parasitic nature. Treatment consists in periodically instilling a 2% solution of salicylic acid in alcohol into the ear. Middle O. are acute and chronic. Acute O., depending on the spread of the process and the strength of the infection, are divided into 1) acute inflammation of the Eustachian tube, 2) the eardrum, 3) acute catarrh, and 4) acute inflammation of the tympanic cavity. 1. On inflammation of the Eustachian tube - see Eustachianitis. 2. Inflammation of the eardrum is rarely an isolated independent disease (see Eardrum, pathological changes), but in most cases it is the beginning of inflammation of the tympanic cavity. 3. In acute catarrh, there is dilation of the vessels of the mucous membrane of the tympanic cavity and transudation of fluid poor in cellular elements. 4. In acute inflammation of the tympanic cavity, the mucous membrane thickens sharply due to round-cell infiltration and dilation of the small vessels, and exudate appears, consisting mostly of purulent cells. Etiology and pathogenesis. Acute inflammation of the mucous membrane of the middle ear rarely arises primarily in the tympanic cavity, which (according to Preysing) is free of bacteria; more often it is a continuation, a consequence of a disease of the Eustachian tube; the walls of this tube, which is a narrow canal for ventilation of the tympanic cavity, swell in inflammation of the mucous membrane, the lumen of the canal narrows, ventilation is disrupted, air in the tympanic cavity is absorbed, the air pressure in it decreases, and serous fluid weeps out (acute catarrh of the middle ear). The disease of the Eustachian tube, in turn, can be caused by pathological processes in neighboring areas of the nasopharynx, pharynx, nose (adenoid vegetations, tonsillitis, acute rhinitis, suppuration of the accessory nasal sinuses).

The catarrhal exudate may over time either be resorbed or organized (into connective tissue) or, becoming infected from the nasopharynx through the tube, may turn into pus; often the transudate immediately takes on a purulent character (influenza, general infectious diseases), causing a violent clinical picture; pus, accumulating in the tympanic cavity, bulges the membrane into the auditory canal and at some point thins it and ruptures it (otitis media purulenta perforativa). Besides this tubal route of infection penetration into the middle ear, there is also a hematogenous route. Infection most rarely penetrates through the external auditory canal and the eardrum (fractures of the base of the skull, injuries to the auditory canal). In addition to the causes mentioned above, there are still a number of factors that can cause acute inflammation of the middle ear: 1) sharp fluctuations in temperature and cooling of large areas of skin (cold); 2) improper nasal irrigation when a large amount of fluid is used under high pressure; 3) strong and improper blowing of the nose; 4) nasal tamponades, especially posterior ones; 5) cauterizations and operations in the nose and nasopharynx. For all the above causal factors, the general health condition of the subject, his general and local constitution, is of great importance; weakened, exhausted people are more readily subject to the disease. Patho-anatomical changes in the mucous membrane of the middle ear at the beginning of inflammation and in its mild forms are expressed in the dilation and filling of the blood vessels with blood and the seepage of an exudate poor in cells; the epithelial layer remains unchanged. In purulent inflammation, the mucous membrane thickens sharply due to abundant cellular infiltration, dilation of the vessels, and papillomatous growth of the epithelium; this thickening can be so significant that sometimes the mucous membrane completely fills the entire cavity of the middle ear. As for the bacteriological findings in the examination of the secretions of purulent O., it has not been possible to find any one specific microbe; according to Preysing, in 84% of all cases, the cause is various types of streptococci, in particular Streptococcus mucosus, while according to other authors, diplococci (Diplococcus lanceolatus). The symptoms of acute inflammation of the middle ear, while remaining the same in most cases for all forms of inflammation, vary considerably in their intensity depending on the depth and extent of the inflammatory process. A distinction is made between subjective and objective symptoms. Subjective symptoms include pain, hearing impairment, and poor general well-being. At the beginning and in mild cases of catarrhal inflammation, pain may be completely absent; there is a feeling of fullness, pressure in the ear, and a sloshing of fluid when changing the position of the head; later, as well as when the process tends to transition to suppuration, shooting, boring, and pulsating pains appear both in the ear itself and in the surrounding area; such pains may not be constant, but periodic, replaced in the intervals by dull pains. When suppuration has begun, and in purulent forms on the very first day of the disease, severe boring pains in the ear and in the lateral part of the head appear, especially severe at night and increasing with pressure, coughing, swallowing; otitis, when serous-purulent fluid appears in the auditory canal—either spontaneously or after paracentesis of the eardrum—pains quickly subside. If, however, with free, abundant discharge of pus from the auditory canal, the pains do not subside, this indicates the involvement of the cells of the mastoid process in the process. - Fever in cases of catarrhal inflammation may be completely absent, giving slight increases in temperature when transitioning to suppuration; in purulent O. for the first 4-5 days the temperature may be elevated to 39°; after the onset of purulent discharge it usually subsides, but if it remains high, this indicates the severity of the inflammatory process and the possibility of the inflammation spreading to neighboring organs (mastoid process, sinus). - Hearing impairment represents the least tormenting symptom for the sick, receding completely into the background in purulent O.; in catarrhal forms, hearing loss is the main complaint of the patients; it has the character of a lesion of the sound-conducting apparatus [Weber (see Weber's test)—toward the affected side, Rinne—negative (see Rinne's test), Schwabach—prolonged (see Hearing)]. In addition to hearing loss, patients are often troubled by noise in the ear, which has a pulsating character. - General well-being is little affected in mild and catarrhal O., in which patients complain only of heaviness in the head, and is sharply disturbed in purulent O. depending on the high temperature and severe pains not only in the area of the ear but in the entire head. Objective symptoms. On examination of the eardrum in the beginning of catarrhal O., only dilation of the blood vessels along the handle of the malleus and the posterior fold is noted; the contours of the membrane are preserved, its color and the light cone are unchanged; in some rare cases, it is possible to notice in the lower part of the tympanic cavity an exudate, the upper boundary of which is outlined on the eardrum in the form of a semilunar line (line of exudate); when air is blown in (during insufflation), the exudate foams and appears in the form of small bubbles; with the further existence of the catarrhal process, the structure of the eardrum changes, it thickens, loses its color, taking on a reddish tint, the contours become smoothed, and bulges are noted in places. In acute purulent O., on the very first day of the disease, redness of the upper-posterior wall of the skin of the auditory canal appears, dilation of the vessels both on the handle of the malleus and on the radial ones; soon the entire membrane becomes bright red, loses its contours, its posterior part bulges outward into the auditory canal; the layer of epidermis sometimes presents blister-like bulges in places (myringitis bullosa); as the exudate increases in the tympanic cavity, bulging of the anterior part of the membrane also occurs, and at the most prominent point of it a yellowish spot is noticed—the site of the impending perforation; the perforation is usually located in the anterior-inferior quadrant, has the shape of a point or a slit; in O. after infectious diseases (scarlet fever, measles), extensive perforations are obtained, often the entire pars tensa is destroyed. Sometimes the swollen mucous membrane of the tympanic cavity bulges through the perforation into the auditory canal in the form of a red elevation or granulation (mucosal hernia). At the site of the perforation, a pulsating light spot (pulsating reflex) is often noticed on examination. Sometimes in purulent O., the inflammatory changes are concentrated mainly in the anterior-superior part in the area of the membrana Shrapnelli; here a bulge in the form of a nipple often forms, on the apex of which there is a pinpoint perforation (epitympanitis as opposed to the above-described mesotympanitis). The course of acute inflammation of the middle ear is very varied. Mild catarrhal O. with a small amount of exudate may pass without a trace in a few days; resorption of a significant amount of exudate, especially if it has a thick gelatinous consistency, takes a long time, up to several months; resorption may not occur at all, the exudate begins to organize, and the process passes into chronic adhesive inflammation of the middle ear. Sometimes the exudate may become infected through the Eustachian tube and turn into pus, causing perforation of the eardrum. The acute phenomena of acute purulent O., lasting for several days, may subside without leading to perforation of the eardrum; then the reverse development of the process begins and the gradual disappearance of all subjective and objective symptoms. If the integrity of the eardrum is violated by spontaneous perforation, then discharge of fluid from the ear occurs, first serous-purulent, and then purely purulent. With the onset of discharge from the ear, the temperature drops and the pains cease. Abundant discharge of liquid pus continues on average for about a week, then the amount of pus begins to gradually decrease and its consistency becomes thicker; by the beginning of the third week, the purulent discharge ceases, the perforation closes, the eardrum pales, its contours gradually appear, hearing is restored, and by the end of the month the process ends. Deviations from such a normal course are often observed; it happens that after the appearance of purulent discharge, the temperature does not drop and the pains do not decrease; this may occur due to insufficiently free discharge of pus with a small perforation (it may be necessary to enlarge it). If the temperature does not normalize for a long time with abundant purulent discharge, if abundant discharge of liquid pus lasts longer than three weeks, if persistent nipple-like bulges appear in the anterior-superior quadrant or if the upper-posterior wall of the bony auditory canal bulges or narrows concentrically, then all this will indicate the involvement of the cells of the mastoid process in the inflammatory process (see more under Mastoiditis). . The outcomes of acute inflammation of the middle ear can be, firstly, complete recovery, secondly, transition to a chronic state, which more often occurs in exudative forms and in purulent O. after scarlet fever, measles and other infectious diseases, and thirdly, transition to mastoiditis and intracranial complications.

Therefore, the prognosis should be made with extreme caution and may change in accordance with the course of the disease. - Recognition of acute inflammation of the middle ear in most cases presents no difficulties; the history, subjective symptoms, examination of the eardrum, and hearing examination provide sufficient data for diagnosis; some difficulties may arise in acute weeping eczema and furunculosis of the external auditory canal; in acute eczema, as in acute O., there are pains, discharge from the ear, but the severe itching, redness and swelling of the skin of the auditory canal and part of the auricle, the thick, amber-colored, drying into crusts liquid sharply distinguishes it from purulent O.; furunculosis only on the first day with its pains can give reason to suspect middle O., subsequently its objective picture becomes quite clear (see above external O.). The treatment of acute middle O. at the very beginning of the disease should be general and local; bed rest, diaphoretics, salicylic preparations and pyramidon, phenacetin for severe pains constitute the general treatment; locally - a heating compress on the ear area and drops in the ear (Ac. carbol., Cocain. mur. an 0.3, Glycer. 10.0). If t° increases, the eardrum begins to bulge, a paracentesis is performed. Regarding the latter, there is still no unanimous opinion; some otologists avoid it, preferring to wait for spontaneous rupture, and find that such O. heal more quickly than those subjected to paracentesis. However, there are persistent indications for paracentesis: severe pain in the ear, spreading to the entire head, increasing high t°, poor general condition and signs of irritation of the meninges; in addition, all O. in infectious diseases (scarlet fever, measles, typhus) require earlier paracentesis. It is performed with a special long needle, preferably without any anesthesia, since all substances proposed for anesthesia do not provide complete pain relief. Various places for the incision are recommended, but it is preferable to make it in the upper-posterior quadrants, which more reliably ensures good outflow of pus. In addition to the treatment mentioned, protein therapy (injection of milk) is also recommended, which reduces pain, shortens the course and often prevents the transition to suppuration; the same effect is produced by light therapy (Sollux lamp). In the first time after the appearance of liquid seropurulent discharge from the ear (spontaneous or from paracentesis), they limit themselves to introducing thin strips of sterile gauze into the auditory canal, then, when the discharge becomes thicker, they resort to irrigation with a 2% warm solution of boric acid with subsequent drying of the auditory canal with a thin cotton tampon and pouring into it for 5-10 minutes hydrogen peroxide or a solution (1 in 15) of Burrow's fluid. In acute catarrh, a heating compress on the ear, lubrication of the opening of the Eustachian tube with a 2% solution of cocaine or argol; then insufflation and finally paracentesis with subsequent insufflation. In myringitis bullosa, it is better not to open the blisters, so as not to penetrate into the tympanic cavity and not introduce infection there. Acute middle O. in influenza is quite common and its clinical picture presents a number of features distinguishing it from simple O. It manifests itself in the form of 1) simple purulent O. and 2) hemorrhagic; in the first form, the disease begins very abruptly, with chills, high t°, severe pains both in the ear and behind the ear and rapid, sometimes on the very first day, appearance of discharge from the ear; with the appearance of purulent discharge, pains and t° do not decrease noticeably, as in usual O.; in addition, a sharp decrease in hearing is noted. On otoscopy, a mastoid bulging with perforation is noted in the upper-posterior quadrant of the eardrum; soon the descent of the upper-posterior wall of the auditory canal, its concentric narrowing, increases the pain on pressure on the mastoid process (signs of mastoiditis); during antrotomy operation, extensive bone damage with abundant granulations is found, extending to the apex of the process, the zygomatic arch, the posterior cranial fossa. Postoperative healing is extremely sluggish, prolonged. - The hemorrhagic form of O. begins with slight pains and noise in the ear, a slight decrease in hearing; on otoscopy, bluish-dark colored bubbles are found on the posterior wall of the bony part of the auditory canal; similar bubbles may also be on the eardrum (otitis externa et myringitis bullosa haemorrhagica). The contents of the blisters are gradually absorbed over time, but on the eardrum they may rupture and pour out either outward into the auditory canal or more often inward into the tympanic cavity and cause purulent O. with bloody discharge; such O. can also form without blisters on the eardrum. The clinical picture and course of such O. are the same as in simple purulent O. In scarlet fever, acute O. is a frequent and dangerous complication; it can appear at the very beginning of the disease during the rash (early form) or later, at the height of the disease (late form); the first form is of hematogenous origin, proceeds more easily, differing little in clinical picture from simple acute purulent O.; the second represents the continuation of necrotizing inflammation of the pharyngeal mucosa (in necrotic angina) through the wide and short in children Eustachian tube to the mucous membrane of the tympanic cavity, as a result of which extensive destructions and perforations of the eardrum, necrosis and prolapse of the auditory ossicles, necrotic osteitis of the walls of the tympanic cavity, cells of the mastoid process, labyrinth occur; the process can reach the sinus and cause sinus thrombosis and pyemia or the meninges and cause meningitis; neuritis of the facial and auditory nerves with subsequent deafness are often observed. - In measles, acute O. occurs less frequently and in a less severe form than in scarlet fever; it, like conjunctivitis, rhinitis, bronchitis, is a component of the general disease and occurs hematogenously; the disease of the ear may manifest itself in the period of rash or desquamation; the clinical picture depends on the severity of the general disease; in mild cases, O. of a catarrhal nature may pass even unnoticed; in more severe cases it takes the form of acute purulent O., appears more often in the period of desquamation and often leads, with the addition of secondary infection through the Eustachian tube, to mastoiditis. - Acute inflammation of the middle ear in typhoid fever occurs in 3-5% (Blohmke) of cases and most often begins on the 4-5th week of the disease; it manifests either in a mild form without perforation of the eardrum and with hyperemia of its upper-posterior quadrant or in a severe form with a rapid onset, high t°, severe pains and perforation of the eardrum, and a small round perforation occurs in the posterior half of the eardrum, not in the anterior, as in usual O.; rarely necrotic forms of O. with complete destruction of the eardrum and damage to the bony walls, as in scarlet fever, are observed. More often in typhoid fever, non-purulent diseases of the inner ear, neuritis of the auditory nerve leading to persistent deafness occur; they are caused by the typhoid toxin. Chronic inflammations of the middle ear are purulent and catarrhal; chronic purulent O. in most cases are a continuation of acute O. in infectious diseases (scarlet fever, measles, typhus), then otitis in persons with a weakened organism (tuberculosis, diabetes, syphilis) or suffering from diseases of the nose, nasopharynx (adenoids) and Eustachian tube; according to their course, they can be divided into benign, when there is destruction of the eardrum to a greater or lesser extent and inflammation of the mucous membrane of the tympanic cavity without damage to its bony walls, and malignant, when a carious process develops in the bony walls of the cavity. The first can continue for many years, accompanied only by moderate purulent discharge from the ear and not causing intracranial complications, the second lead to the formation of granulations in the ear, to the spread of carious damage and involvement of the sinus, meninges or labyrinth in the process; cases with perforation of membranae Shrapnelli and formation of cholesteatoma should also be attributed to them. In benign chronic purulent O., pus is discharged from the ear in a small amount, without odor, does not irritate the skin of the auditory canal, is easily removed when wiped, but there are cases when the discharge from the ear acquires the character of a thick light mucus, difficult to remove and stretching into threads at the same time; this happens when inflammation of the tympanic cavity is joined by inflammation of the Eustachian tube (tubotympanitis), the mucous membrane of which contains many mucous glands (there are none in the tympanic cavity). Perforations of the eardrum in simple O. are of the most varied shape and size, but have one peculiarity: the eardrum with them always remains at the place of attachment to the annulus tympanicus (central perforations). The mucous membrane of the tympanic cavity is hyperemic, slightly thickened, but has a flat, smooth surface. The auditory ossicles are mostly preserved. The edges of the perforations often grow together with the promontorium.

In malignant chronic purulent otitis, the discharge from the ear is more abundant, with a foul odor, sometimes mixed with blood, and irritates the skin of the auditory canal. Perforations of larger or smaller size, always reaching the annulus tympanicus (marginal), are mostly located in the upper-posterior quadrant; often a complete defect of the tympanic membrane is observed in such cases. The mucous membrane of the tympanic cavity is unevenly thickened, covered with granulations, sometimes with polyps. Perforations in the area of the membrana Shrapnelli indicate isolated caries of the head of the malleus or the presence of a cholesteatoma. In such cases, the inflammatory process is localized mainly in the upper part of the tympanic cavity (epitympanitis) in contrast to benign forms, which occupy the lower and middle parts of the cavity (mesotympanitis).-Cholesteatoma is a collection of epidermoid masses formed due to the ingrowth of epidermis from the external auditory canal through a perforation of the tympanic membrane into the epitympanum. These masses gradually grow due to the layering of new layers of epithelium, penetrate into the antrum and mastoid process, by their pressure cause resorption of bone and lead to the formation of extensive cavities reaching as far as the dura mater and cortex, while often the walls of the semicircular canals and the facial nerve canal are affected; the cholesteatoma undergoes putrefactive decay and is the cause of intracranial complications. The carious process, once starting from the walls of the tympanic cavity, can extend further into the thickness of the temporal bone or to the posterior cranial fossa and cause here sinus thrombophlebitis and pyemia or to the middle and cause meningitis and brain abscess; it can also involve the walls of the Fallopian canal and cause facial nerve paralysis. In rare cases, paralysis of the abducens nerve (n. abducentis) is observed; it depends on deep inflammatory processes in the apex of the pyramid (Gradenigo's symptom). The symptoms of benign chronic purulent otitis are purulent discharge from the ear, hearing loss, and noise in the ear; in malignant cases, a foul odor of the pus, its bloody character, irritation of the skin of the auditory canal, and pain in the ear are added. During otoscopy, the degree of destruction of the tympanic membrane, the nature of the perforation, and the condition of the mucous membrane (granulations, polyps) are determined. Special attention should be paid to the epitympanum area, to the entrance to the attic; the presence of whitish, crumbly masses there is suspicious for cholesteatoma. The appearance of persistent headaches on the side of the diseased ear, elevated temperature, as well as signs of irritation of the vestibular apparatus indicate the possibility of intracranial complications. The treatment of benign otitis consists in lubricating the mucous membrane with a solution of argyrol (3-5%), instilling drops of carbolic (3-5%) glycerin, pure hydrogen peroxide or mixed with alcohol, insufflation of powder of boric acid, and iodoform (see). For tubotympanic forms, it is first necessary to eliminate all pathological changes from the nose and nasopharynx; then inflation of the tube, and into the ear, astringent agents: 5% solution of Burrow's liquid, 1% zinc sulfate, 2% Plumbi acetici (alternating one with the other). For malignant otitis, removal of polyps and granulations, lubrication of the thickened mucous membrane with a 10-20% solution of argyrol, and washing the attic with a Hartmann's cannula are recommended; if such treatment is not successful, if the presence of cholesteatoma or signs of intracranial complications, as well as facial nerve paralysis, is established, surgical intervention is indicated (see Mastoiditis). Chronic catarrh of the middle ear is caused and maintained by pathological processes in the nose, nasopharynx, and Eustachian tube, as well as repeated acute catarrhs of the middle ear; these diseases lead to narrowing, obstruction of the tube, violation of ventilation of the tympanic cavity, and retraction of the tympanic membrane; repeated inflammations of the mucous membrane cause adhesions, the formation of connective tissue strands in the area of the oval window and between the auditory ossicles, which leads to their ankylosis. During otoscopy, a marked retraction of the tympanic membrane, a grayish-white coloration of it (cloudiness), disappearance of the light cone, and lime deposits are noted; in some cases, atrophy of the tympanic membrane is determined, identifiable by the Siegle's funnel (excessive mobility). The subjective symptom is persistent, progressive hearing loss; examination of the auditory function shows a loss of low tones with normal perception of high tones (lesion of the sound-conducting apparatus). As for treatment, it is first necessary to eliminate all pathological phenomena in the nose, nasopharynx, and treat the Eustachian tube; injections of fibrinolysin are recommended.

A. Ivanov. Internal Otitis. Diseases of the inner ear - see Inner ear, Deafness, Deaf-mutism, Labyrinthitis. Otitis in early childhood. Inflammation of the middle ear in children, especially in infancy and early childhood, has its own peculiarities. Hecht (A. Hecht) considers even children's otitis a special childhood disease. This view is not shared by other authors, who consider children's otitis in connection with the general constitution of the child's body, in connection with the diseases he undergoes, and who attach great importance to the anatomical and physiological peculiarities of the child's ear. Children's otitis is usually divided into 1) otitis media acuta simplex, 2) otitis media acuta purulenta, 3) otitis media concomitans. The first two, similar to otitis in adults, represent different degrees of the same process, while the third is a particular feature of early childhood. Otitis media acuta simplex in infants begins with the child's restlessness, especially at night. The restlessness is expressed by crying, which ends and begins again without any apparent reason. Even older children (from 2 to 5 years old) often cannot understand that their ear hurts. Often at this time the child refuses the breast or drops it as soon as he makes the first sucking movements, and more often sucks the breast on the opposite side of the diseased ear. At this time the temperature of the continuous type reaches 38-38.5°. Often when pressing on the tragus on the affected side, the child cries out with pain. Rosenfelder points out that if in an infant with suspected otitis, pressure is applied on the affected side near the posterior angle of the small fontanelle, a clear Babinski reflex appears on the same side. The otoscopic examination with a short funnel suitable in caliber to the child's auditory meatus decides the matter. It must be remembered that in children up to the beginning of the second year, the bony auditory canal is not yet developed, while the cartilaginous part of the external auditory canal is fully developed. In early childhood, the eardrum is equal in size to that of an adult, but is significantly thicker, more resistant, and inclined to the observer at a certain angle. Its color in normal condition is grayish-white, there is no light cone; the anterior and posterior folds are clearly visible, the short process is well visible, colored in a denser color than the membrana tensa. The handle of the malleus is not always visible due to the oblique position of the eardrum. Otoscopy in the beginning of otitis indicates that the eardrum is colored dark pink due to hyperemia, which is most sharply expressed in the posterosuperior quadrant. As the process develops, the hyperemia becomes more intense; at the same time the pr. brevis disappears and the anterior and posterior folds become partially smoothed out. Due to the thickness of the eardrum (its skin and mucous layers), the exudate in the cav. tympani may not shine through. Spontaneous perforation in this form of otitis is rare, as the process tends to reverse development. At this time the temperature gradually falls, the exudate is absorbed in the cav. tympani, the hyperemia of the eardrum disappears and its details reappear. The cycle of this form of otitis is determined by several days. In otitis med. acuta purul. the temperature can reach 39.5-40°, of the continuous type; the child's general condition suffers more severely. Often a picture of meningism appears: vomiting, clouding of consciousness and rigidity of the neck muscles (nape). On otoscopy - sharp hyperemia of the eardrum; all its details quickly become smoothed out, the eardrum becomes less oblique due to the pressure of exudate from the cav. tympani. Hearing is reduced to such an extent that it becomes noticeable to those around. On average on the 4-6th day, most often at the border of the 2 posterior or 2 anterior quadrants of the eardrum, a dark necrotic spot appears - the site of spontaneous perforation, after which in the first 12-18 hours a sero-sanguineous fluid is discharged from the ear, which then turns purulent. When examining such an ear after thorough cleansing with cotton wool or washing with warm physiological solution, a pulsating reflex is visible as a perforation. After the appearance of perforation the temperature falls to normal either immediately or by lysis. A feature of children under two years of age is that in the vast majority of cases, when one ear becomes diseased, the other also becomes diseased; accordingly, the ear that remains healthy for the time being should be under careful observation. In purulent otitis, spontaneous perforation is not uncommon. The cycle of this form of otitis under favorable conditions is from 3 to 4 weeks. It should be noted that in healthy children all the phenomena of otitis run more acutely and end earlier than in weak children. In terms of restitutio ad integrum, in terms of complications and in the frequency of recurrent forms of otitis, all hypotrophics, rachitics, children with exudative diathesis constitute the main contingent of unfavorable cases. The causative agents of children's otitis, as shown by studies of the flora of the middle ear in perforations, are most often pneumococci, less often Streptoc. lanceol. and mucosus. The soil for the occurrence of otitis is all acute infections and especially influenza. The anatomical-physiological peculiarities of the child's organism and particularly of the ear provide favorable conditions for the frequent development of this disease. Recurrent otitis is a striking example of this: a new wave of influenza - a new occurrence of otitis in the same children. In the treatment of children's otitis, it is first of all necessary to keep the nose, nasopharynx and pharynx in order (frequent drinking, instillation into the nose of a 1:10,000 adrenaline solution, 40% sugar). A heating compress is applied to the diseased ear, changed every 3-4 hours. Carbolic glycerin should be avoided in early childhood, as it causes intense maceration of the external auditory canal and eardrum. When there is a discharge of pus from the ear, the cleanliness of the auditory meatus is maintained by frequently changed loosely inserted cotton wool plugs in the external opening. The insufflation of Acid. borici subtiliss. pulver. into the auditory meatus from a special powder blower of Rauchfus is recommended. Hydrogen peroxide should be avoided due to its instability and its cauterizing effect on the child's skin. The skin of the auricle and its surroundings must be carefully watched, eliminating any beginning dermatitis. As a practical rule, it must be remembered that if pus with an admixture of mucus comes from the ear, its source is the middle ear (Gomperz). - High temperature, general poor health and restlessness of the child and especially the phenomena of meningism are an indication for an incision (paracentesis) of the eardrum. It is important that the child is well fixed. With a needle through the ear funnel, an incision is made from below upwards in the most protruding part of the eardrum; then the ear is filled with sterile cotton wool and a heating compress is applied for about 12 hours. Then the treatment is carried out as indicated above. Sometimes in purulent otitis the protrusion of the eardrum, especially in its posterosuperior part, persists obstinately despite repeated paracenteses; the pus takes a serous character, the auditory canal begins to narrow concentrically near the eardrum, covering it. At the same time, a painful swelling appears in the area of the mastoid process; in infants it appears directly above the external auditory canal, sometimes spreading to the processus zygomaticus and accompanied by edema of the orbit. It must be remembered that in children of this age the antrum lies directly above the external auditory canal; in older children the swelling in mastoiditis appears behind the auditory canal, in the area of the planum tympanici, i.e. again in accordance with the position of the antrum at this age. The child in this form of mastoiditis has a moderate fever, his general condition suffers little. This subacute form of mastoiditis develops most often on the 3-4th week after the disease of otitis. Another form of mastoiditis arises almost together with acute otitis. In the very first days of the disease, severe pain, puffiness, and then typical swelling appear in the mastoid area; the eardrum remains protruded, the auditory canal narrows and the temperature remains high, of the continuous type. In infants, an acute mastoiditis with an abscess behind the ear develops literally in one day; at this time the eardrum may not be perforated. In the diagnosis of mastoiditis, it is necessary to distinguish it from the swelling behind the ear in otitis externa ascendens and from the abscess in the lymph glands of the process in impetiginous eczemas of the head. In recent times, X-ray examination of the temporal bone has been of some service in the diagnosis of mastoiditis (Meyer). - At the beginning, at the first signs of mastoiditis, ice behind the ear for 2-3 days together with the usual treatment of otitis is sometimes successfully applied. With clear signs of mastoiditis, antrotomia is performed according to the usual rules. At this time it should be remembered that the middle cranial fossa in children is lower than in adults, and that the fissura mastoidea in infants is not yet completely closed. Pediatricians and pediatric otolaryngologists often encounter cases of hidden otitis and mastoiditis in early childhood. The difficulty of diagnosis depends on the fact that the eardrum in an infant may not be protruded and may be little changed in appearance. The symptoms of the tragus are not clear. The general clinical examination of the child leads to the conclusion that there are no reasons for his restlessness and elevated temperature.

In such cases, paracentesis of the suspected ear gives brilliant results in a large percentage of cases. In 'hidden' otitis, the necessity and benefit of paracentesis are evident, and one cannot agree with A. Gecht, who generally does not attribute special importance to it in childhood otitis. Also in 'hidden' mastoiditis, without firm reference points in special diagnostics, one has to be guided by the presence of fluctuations in temperature, retardation in weight, poor condition of the child, and dyspeptic phenomena (vomiting, diarrhea) that find no explanation in the child's diet. The occurrence of partial paralysis of the facial nerve (VII) in acute childhood otitis and mastoiditis is not so alarming from a prognostic point of view; another matter is if they appear in chronic otitis. Otitis media concomitans occurs exclusively in infancy in hypo- and atrophic children and in tuberculous ones. Its onset is imperceptible, since the exhausted child does not react to his illness either with temperature or with painful sensations; only purulent discharge from the ear reveals the disease. The eardrum has no reactive changes and often already has a large perforation (defect). Subsequently, such otitis often reveals its true nature: from the middle ear appear lush, bluish granulations, quite prone to bleeding. Often, the auditory ossicles are detached at this time. In short, a picture of tuberculosis of the middle ear is revealed. The case can lead to complete sequestration of the entire inner wall of the tympanic cavity with complete paralysis of the facial nerve (VII).