In a detailed definition of the disease, it is noted that mastoiditis is an inflammation that develops in the mastoid process of the temporal bone behind the ear. Most often, it affects children aged 2-13 months, while in developing countries the number of cases is higher than in developed countries, where statistics show about 0.004% of the total population.
Due to the fact that the mastoid process is finally formed only by the age of 6, the signs of ear mastoiditis in children have their own specifics - patients quickly develop a subperiosteal abscess, but the lesion is not accompanied by bone destruction. At the same time, before the discovery of antibiotic therapy, children's mastoiditis (antritis) was one of the main causes of infant mortality.
Causes and pathogenesis
The emergence of pathology
The structure of the protrusion of the temporal bone, which is located behind the ear, is a porous communicating cell, separated by thin bony septa. From the middle and posterior cranial fossa, the protrusion of the temporal bone is separated by the inner walls. The structure of the mastoid process can vary depending on the individual characteristics of a person:
- the pneumatic structure is represented by a coarse-mesh structure, the filler of which is air,
- diploetic is a fine-mesh structure with bone marrow as a filler,
- sclerotic is described as a structure practically without cells.
The course of the disease, predisposition to mastoiditis, symptoms and treatment depend on the structural type.
People with a pneumatic structure are most prone to inflammation.
Most cases of inflammation are the result of the transition of infection to the process from the tympanic cavity, and this, in turn, most often occurs with otitis media in acute form and, less often, with otitis media in chronic purulent form.
- Primary mastoiditis usually results from trauma. The resulting blood becomes a favorable environment for the development of pathogens.
- In the secondary, more common form, when the infection spreads from the tympanic cavity, the causative agents of acute mastoiditis can be pneumococci, staphylococci, streptococci, influenza bacillus and other microorganisms. Less commonly, Pseudomonas aeruginosa and anaerobic bacteria. They penetrate when:
- impaired drainage of the middle ear,
- untimely puncture of the tympanic membrane,
- closure of the membrane with granulation tissue and a small opening.
Hematogenous penetration of infection is also possible (with sepsis, tuberculosis, secondary syphilis), but this path is recorded much less often.
In chronic disease, the causative agents are Pseudomonas aeruginosa, enterobacteria, Staphylococcus aureus, and sometimes mycobacteria.
After repeated infection, it happens that pathology occurs after the development of a capsule (cholesteatoma), consisting of keratinized epithelium.
In general, the disease is facilitated by the increased virulence of microorganisms, various pathologies of the nasopharynx and ear structures after previous diseases, weakening of general and local immunities against the background of chronic diseases.
Pathogenesis
This pathology is characterized by a pronounced phase character of the process:
- In the initial - exudative - stage of the disease, inflammatory changes in the mucous membrane of the cells occur, resulting in inflammation of the periosteum and the accumulation of fluid in the cellular tissues. The spreading inflammatory edema overlaps the openings of the communicating cells and the connecting opening between the process and the tympanic cavity. The air pressure in the cellular structures drops and transudate begins to flow into them from the blood vessels, filling the pores first with serous and then purulent-serous fluid. The exudative stage in adults lasts 1-1.5 weeks, in children - 4-6 days. At the end of the stage, each cell is filled with pus.
- The second stage - proliferative-alterative - is characterized by the spread of inflammation to the bone septa and walls with the development of purulent fusion of the bone. In parallel to this process, granulation tissue is formed, as a result of which, instead of a cellular structure, a cavity filled with granulations and pus remains. If pus breaks through the destroyed walls, complications arise associated with inflammation of the surrounding tissues.
Complications
Since inflammation spreads along the path of the location of the most pneumatized (air-filled) cavities, the variety of complications depends on the structural features of the appendix.
- With inflammation of the perisinous cell group, the sigmoid sinus is affected, which causes thrombophlebitis and phlebitis.
- The destruction of the periciphal group leads to neuritis of the facial nerve.
- The defeat of the perilabyrinth cavities provokes a purulent labyrinthitis.
- The apical forms of the disease are complicated by purulent mediastinitis due to the flow of pus into the interfascial regions of the neck.
- With inflammation of the pyramid of the temporal bone, petrositis is diagnosed.
- The spread of infection to the skull provokes meningitis, encyphalitis, and brain abscess.
- The ingress of pus on the zygomatic process creates the danger of infection of the eyeball and the development of panophthalmitis, endophthalmitis and phlegmon of the orbit.
- A typical complication in young children is a retropharyngeal abscess.
Classifications
- According to the localization of the inflammatory process, right-sided, left-sided and bilateral mastoiditis are distinguished.
- According to clinical manifestations, they are divided into typical and atypical with sluggish symptoms.
- According to the causal factor - into primary and secondary.
- By the method of infection - otogenic, hematogenous, lymphogenous and traumatic.
- In the phase of inflammation - exudative and proliferative-alterative (true).
- The apical mastoidites (Bezolda, Orleansky, Moore) are distinguished into a separate group.
Symptoms
General and local symptoms
As a rule, the first signs of mastoiditis appear 7-14 days after the onset of otitis media, but it happens that it develops in parallel with otitis media. Common symptoms of the disease include:
- temperature rise to febrile digits (38-39C),
- headache,
- intoxication (weakness, fatigue),
- insomnia.
Local signs are more specific:
- Bursting pain behind the ear with a pulsating rhythm, worse at night, which radiates to the temporal and parietal regions or the upper jaw along the branching of the trigeminal nerve. Sometimes the pain can spread to the entire half of the head from the affected side.
- Swelling of the skin over the affected area and the smoothness of the contours of the appendix. At the same time, the ear protrudes.
- Severe suppuration from the ear canal, which is more profuse than expected based on the volume of the tympanic cavity. This is due to the spread of a purulent process with its exit beyond the middle ear. While maintaining the integrity of the membrane and a closed perforation, the amount of pus flowing out may be negligible.
- Soreness on palpation of the behind-the-ear region and the effect of fluctuation occurs when pus enters the tissue of subcutaneous adipose tissue with the formation of a subperiosteal abscess.
- Noise in the ear.
- In the case of inflammatory vascular thrombosis, necrosis of the periosteum may occur, which will result in the accumulation of purulent mass on the skin surface in the form of an external fistula.
Manifestations of pathology in children
In case of detection of pathology in children, an alternative name for the disease is often used - antritis, since in the first years of life in the place of the mastoid process there is only an elevation, inside which is a cave (antrum).
Accordingly, the purulent process from the tympanic cavity penetrates only into the antrum.
Often, antritis passes against the background of a violent general reaction of the child's body: the nervous system, the gastrointestinal tract, and the respiratory system. Clinical symptoms, in addition to profuse purulent discharge, are manifested in the form of fever, moodiness, restless sleep, and appetite disorders. Otoscopic manifestations include discoloration and bulging of the tympanic membrane, a pulsating reflex at the site of perforation.
Otitis media (as a previous stage) and antritis are usually diagnosed in premature, rickety babies who have a reduced body resistance.
Diagnostics
The main difficulty for diagnosis is the atypical form of the disease with low-symptom manifestations. The typical form is easily identified, and its diagnosis is based on the characteristic complaints of patients, information about diseases of the middle ear and injuries, palpation of the ear region, as well as on the results of laboratory and instrumental studies. For this, the patient can be prescribed:
- otoscopy and microotoscopy, in order to detect the overhang of the upper-posterior wall of the ear canal, which is an otoscopic sign of this disease,
- audiometry, to identify the degree of hearing loss,
- MRI (magnetic resonance imaging) or CT (computed tomography) of the temporal bone,
- X-ray examination to detect hidden inflammatory processes in the cells and the configuration of the partitions between them,
- laboratory study of bacterial culture of ear discharge (in cases where the patient is not being treated with antibiotics, which may affect the reliability of the results).
Surgical intervention is considered an extreme diagnostic measure, the purpose of which is to visually assess the condition of the affected tissues. In case of complications, neurologists, ophthalmologists, dentists, etc. are involved in the diagnosis.
Treatment and prevention
The medical methodology is chosen by the doctor depending on the etiology of the process, complications and the stage of development of the pathology. In general, drug therapy involves the use of broad-spectrum antibiotics, including: cefaclor, cefixime, cefuroxime, ceftibuten, cefotaxime, amoxicillin, ciprofloxacin. Also used are semi-synthetic penicillins (for example, "Ampicillin"), microlides (for example, "Azithromycin"), fluoroquinolones, anti-inflammatory, immunocorrective and detoxification drugs.
In developed countries, intravenous injections of antibiotics are used as the main therapeutic method: first, a wide spectrum, and then, after obtaining the results of inoculation, specific antibiotics to destroy the identified bacteria.
In parallel, ear drops are prescribed as a local therapy, including antibacterial and antiseptic components (for example, "Tsipromed", "Anauran").
Conservative therapy is usually sufficient to treat the disease in the exudative stage. During the transition to the proliferative-alterative stage, surgical intervention is often required: mastoidotomy, mastoidectomy, introduction of a tympanostomy tube:
- In case of insufficient effectiveness of antibiotic therapy, in addition to it, a myringotomy is performed - an incision or puncture of the tympanic membrane to release purulent contents, as well as to study its bacterial composition. For this, the antrum of the temporal bone is opened, the tympanic cavity is drained with the removal of pathologically altered elements. The middle ear is medically washed through the hole.
- When a tympanostomy tube is inserted through it, pus is drained from the middle ear, and the tube itself, as it heals naturally, spontaneously squeezes out.
- Mastoidectomy involves removing the mastoid process. The process often involves the incus, malleus, and remnants of the membrane.
The complexity of the penetration of antibiotics into the cellular structures determines the likelihood of relapses with complications due to the spread of infection to adjacent anatomical structures. However, going to the doctor at the first signs of the disease makes it possible to easily prevent its development with antibiotic therapy. The only problem is the emergence of strains of microorganisms that are resistant to traditional antibiotics.
Preventive actions are reduced to adequate treatment of primary diseases: otitis media, diseases of the nasopharynx, etc. General increase in the efficiency of immune mechanisms - healthy diet and sleep, moderate physical activity, etc. Is also an important preventive measure.
