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Otoscopy often does not cause inflammation of the eardrum, perforation or fluid in the tympanic cavity. Hearing loss depends on the retraction of the membrane due to a prolonged violation of the ventilation function of the auditory tube. In this case, we are talking about chronic tubootitis.
Pathogenesis. Violation of the function of the auditory tube may be the result of its anomaly (S-shaped, narrow isthmus, etc.), congenital or developed due to various neurological diseases (bulbar stroke, weakness of the muscles of the soft palate, opening the auditory tube during swallowing). In childhood, the most common cause of chronic tubo-otitis is adenoids that block the nasopharyngeal orifice of the auditory tubes. Violation of ear ventilation can occur not only with the II-III degree of the nasopharyngeal tonsil, but also with a fairly small amount of tube tonsils. Causes of obstruction of the tube are choanal polyp and hypertrophic posterior end of the inferior nasal concha, nasopharyngeal tumor. Hypertrophy and polypous changes in the nasal mucosa contribute to the curvature of the nasal septum, chronic rhinitis and sinusitis. Repeated untreated acute tubo-otitis with a protracted course can also be the cause of the chronic process.
Normally, the resorption of air from the tympanic cavity is periodically compensated by its ingestion again when swallowing, due to the opening of the lumen of the membrano-cartilaginous part of the auditory tube with muscles tensing and stretching the soft palate (mmtensor et levator veli palatini). Obstruction of the nasopharyngeal mouth of the auditory tube or swelling of its mucous membrane violates the mechanism of ventilation of the tympanic cavity. Negative pressure in the tympanic cavity leads to retraction of the eardrum and the deterioration of sound conduction conditions.
The absence of a noticeable inflammatory reaction in the tympanic cavity, apparently, is explained by the high general resistance of the body, the development of compensatory mechanisms that prevent the pronounced swelling of the mucous membrane and transudation with a prolonged decrease in pressure in the tympanic cavity.
Clinic. The main complaint of patients with chronic tubo-otitis is congestion of one or both ears and hearing loss. At the beginning, congestion can occur periodically and disappear when swallowing, yawning or blowing your nose, and then it becomes constant. Sometimes patients are disturbed by subjective tinnitus of a low-frequency nature.
When otoscopy, the tympanic membrane is retracted, characterized by a shortening or lack of a light cone, pronounced contouring of the short process of the malleus and the hammer folds (especially the posterior), and the apparent shortening of the handle of the malleus due to its horizontal position. The membrane is often dull or cloudy.
Hearing decreases on average by 20-30 dB as a type of disturbance in sound conduction. The experiments of Rinne and Federichi are negative. The lateralization of sound is directed to a sore or worse hearing ear. With impedanometry, a tympanogram of type C is determined, barofunction of III-IY degree or not recorded. An important differential diagnostic sign is the improvement or restoration of hearing after blowing the ears through the Politzer or through a catheter, which is controlled by the Lucy otoscope. After blowing the ear, the retraction of the tympanic membrane may disappear and its normal mobility may be restored, which is controlled by the study of a Siegle pneumatic funnel.
With prolonged chronic tubootitis, atrophy of the tympanic membrane may occur, which is adjacent to the medial wall of the tympanic cavity. The membrane becomes thin, flabby and gives the impression of its absence (defect). Only after blowing the ear, it is fully or partially displaced into the lumen of the external auditory canal.
In this case, the hearing after blowing the ear improves slightly, and with otoscopy, the excessive mobility of the eardrum is determined. With a stable violation of the ventilation function of the auditory tube, its patency is determined using contrast radiography.
Treatment of chronic tubo-otitis primarily involves the elimination of the causes of a violation of the ventilation function of the auditory tube. They remove adenoids, choanal polyp, hypertrophied posterior ends of the lower nasal concha, surgical treatment of chronic purulent sinusitis, curvature of the nasal septum, nasopharyngeal tumors and other diseases of the nose and paranasal sinuses.
To restore the function of the middle ear, regular blowing of the ears is carried out according to the Politzer with the help of a pear-shaped balloon with a rubber tube and olive at the end. Olive balloon is introduced in anticipation of the nose on one side. The other half is closed by pressing the wing against the nasal septum. The patient is asked to say the words “parachute” or “one, two, three.” With a loud percussion pronunciation of the last syllable or word, the soft palate contracts and blocks the nasopharynx from the oropharynx. At this time, the rubber balloon is sharply squeezed. An increased air pressure is created in the nasopharynx and a portion of it passes through the auditory tube into the ears, which is felt in the form of cotton when listening to the Lucy otoscope.
With congenital or acquired weakness of the muscles of the soft palate, pronouncing words does not lead to the expected result. In this case, blowing through the Politzer is carried out while the patient swallows water. With the act of swallowing, the complete dissociation of the nasopharynx with the oropharynx is facilitated by the reduction of the upper constrictor of the pharynx, which forms the Passavan ridge in contact with the raised soft palate.
Ear blowing is performed daily for 10-15 days. As the ventilation function of the auditory tube improves, it is possible to recommend self-blowing of the ears along Valsalva during the occurrence of their stuffiness. Before purging, anemization of the nasal mucosa is performed by instillation of vasoconstrictors in the patients themselves or by lubrication of the nasal concha and pharyngeal mouth of the auditory tubes. When instilling drops in the nose, the patient in a sitting position tilts his head on his shoulder towards the patient’s ear and back so that the medicine reaches the mouth of the auditory tubes.
In case of inefficiency of ear blowing according to Politzer, blowing them using a metal curved catheter after application anesthesia of the nasal mucosa is used. With anterior rhinoscopy, a catheter is inserted with its beak down the bottom of the nose to the posterior wall of the nasopharynx. Next, turn the beak 900 to the opener and pull the catheter outward until it comes in contact with it. After that, the beak is turned 1800 towards the affected ear, so that the index ring of the catheter is facing the outer corner of the eye. A balloon is inserted into the catheter's bell and squeezed easily. When air enters the tympanum, the doctor senses a blowing noise through the otoscope. An emulsion of hydrocortisone and proteolytic enzymes (trypsin, chymotrypsin) are introduced into the auditory tube through an ear catheter.
Regular anemization of the nasal mucosa using vasoconstrictive ointments is supplemented by lubrication of the mouths of the auditory tubes with astringents (1% silver nitrate solution, 2% protargolum solution, tannin).
In complex treatment, hyposensitizing drugs, UHF-therapy are used. A good prophylactic effect to prevent the development of adhesive otitis media is pneumatic massage of the tympanic membrane and endaural lidase iontophoresis.
Patients with chronic tubootitis can be treated on an outpatient basis or in the infirmary of a medical station by a military unit doctor after consultation with an otolaryngologist.
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