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Classification of otitis • Зовнійшній External (outer) otitis, • Середній Media (middle) otitis, • Внутрішній Internal (inner) otitis • Гострий гнійний середній отит Acute suppurative otitis media, • Рецидивуючий середній отит Recurrent otitis media, • Хроніний середній отит Chronic otitis media Хроніний гнійний середній отит Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Chronic suppurative otitis media: – Mesotympanitis, – Epitympanitis, – Specific (tb) Хроніний негнійний середній отит Chronic nonsuppurative otitis media: – Сальпінгоотит (Eustacheitis, catarral, tubotympanitis); – Секреторний отит (secretory otitis, nonsuppurative otitis media with effusion); – Адгезивний отит (adhesive otitis); – Тимпаносклероз (tympanosclerosis)… (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
Гострий гнійний середній отит Acute otitis media Local sign: Complains: • 1. Вушний біль (Otalgia, earache – 1st stage). • 2. Виділення з вуха (Otorrhea - 2nd st.). • 3. Зниження слуху (Hearing loss, deafness – 1-3rd st.). • 4. Шум у вусі (Tinnitus 1-3rd st.). Otoscopy: • Гіперемія, випинання барабаної перетинки (Hyperemic, thickened eardrum, bulging - 1st stage), • Перфорація барабаної перетинки (Tympanic • Перфорація барабаної перетинки (Tympanic membrane perforation - 2nd stage), • Слизово-гнійні виділення (muco-purulent discharg - 2nd stage). Інфекційно-інтоксикаційний синдром (особливо у дитячому віці) (infectious-intoxicative syndrom (especially in childhood)): • Підвищення to тіла, інтокскація, лейкоцитоз… • (Pyrexia, Intoxication, leucytosis ...) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
Stages of Acute Otitis Media 1.1. Стадія доперфорації (prePerforative stage): • Скарги: біль, зниження слуху, шум у вусі • Отоскопія: гіперемія, потовщення барабаної перетинки 1.2. Предперфоративний период доперфоративноїх стадії (prePerforative period of the prePerforative stage): • Скарги: + нестерпний біль… • Отоскопія : + випинання барабаної перетинки… 2. Стадия перфорации (perforative stage): • Перфорация барабанной перепонки - оторрея • Зниження слуху, шум у вусі • Зниження слуху, шум у вусі 3. Наслідки (sequelae): a) одужання; b) хронізація c) ускладнення: 1) мастоідити; 2) параліч лицьового нерва; 3) лабіринтити; 4) внутрішньочерепні... Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
(Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
Acute otitis media Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
3. Sequelae of Acute Otitis Media 3.1. Одужання (Healing - healthy ear): - без залишкових ознак (full restoring of the tympanic membrain, conductive system); - кальціфікація барабанної перетинки (calcification of the tympanic membrane); 3.2. Хронізація: (chronic otitis): Хронічні гнійні перфоративні середні отити (Chronic suppurative perforative otitis media): - мезотимпаніт (mesotympanitis); - епітимпаніт (epitympanitis). Хронічні негнійні середні отити: (Chronic nonsuppurative otitis media) - Сальпінгоотит (Eustacheitis, catarral, tubotympanitis); Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. tubotympanitis); - Секреторний отит (secretory otitis, nonsuppurative otitis media with effusion); - Адгезивний отит (adhesive otitis); - Тимпаносклероз (tympanosclerosis)… 3.3. Ускладнення (complications): - Intratemporal: 1) мастоідити (mastoditis); 2) парез лицьового нерва (facial nerve paralysis); 3) лабіринтити (labyrinthitis); 4) внутрішньочепні - Intracranial: менінгіти, абсцеси мозку… (meningitis, brain absces etc.) (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
Sequelae & Complications of the Otitis Media • Sequelae a) healing and healthy ear, b) chronic otitis (mesotympanitis, epitympanitis, Atelectasis, Adhesive otitis, tympanosclerosis or perforative otitis), c) complications: • Intratemporal Complications: - Acute Mastoditis (1.4, 1.7, 1.8, 2.1, 2.2), Petrositis, - Facial nerve paralysis, - labyrinthitis (Local or diffuse). 1 - labyrinthitis (Local or diffuse). • Intracranial Complications: - Extradural abscess (1.2), - Meningitis, - Subdural abscess (1.1), - Temporal lobe brain abscess (1.3), - Cerebellar abscess (1.6), - Lateral (sygmoid) sinus thrombosis (2.3), - Otic hydrocephalus. 2
Management of Acute Otitis Media 1. Похідні карбол-гліцеринових вушних крапель (ear drops): 1st stage – феназон 0,5+лідокаїн 0,1+гліцерин 10 (Ототон) 2nd stage – антибіотик (не ототоксичний, без спирту, теплий) з димексидом 25% або кортикостероідом. 2. Назальні (топічні) деконгестанти (nasal decogestans): фармазолін 0,1% - 3 краплі 3 рази на добу в ніс 5(7) діб 3. НПЗЗ (nonsteroid antiinflamatory): діклофенак натрія 0,05-0,15 1-3 р/д 3-5 діб після їжі, запивати (Na diclofenaci 0,05-0,15 1-3 t/d 3-5 days after eating with water). 4. Антигістамінні (antihystamine): лоратадин 10 мг (Loratadinum 10 mg). 5.1. Watchful Waiting (72 hours) – спостереження без АБ-терапії initial watchful waiting without antibiotic therapy initial watchful waiting without antibiotic therapy for healthy 2-year-olds or older children with nonsevere illness (mild otalgia and fever <39°C). 5.2. Антибариальна терапія (аntibioticоtherapy): Amoxicillin (80 mg/kg with clavulanate (0.125-0.75) 6. Surgical Measures: Парацентез (tympanotomy, myringotomy) Найчастіше в задньо-нижньому відділі барабанної перетинки (mainly in posterior-inferior quadrant of the tympanic membranes) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
Особливості хронічних гнійних перфоративних середніх отитів Peculiaryties of Chronic Suppurative Otitis Media • Постійна перфорація барабанної перетинки (Chronic tympanic membrane perforation). • Постійна або рецидивуюча гноєтеча (або ні). Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. або ні). (Chronic or recurrent mucopurulent otorrhea (or not)). • Зниження слуху (hearing loss). • Шум у вусі (Tinnitus). • Грануляції, поліпи у вусі (granulation, ear polip). (Pain is not a usual feature like polyp or granulation tissue formation). (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
Chronic suppurative otitis media Chronic mesotympanitis & Chronic epitympanitis • Виділення з кров’ю, каріозним запахом, кусочками холестеатоми, кістковим піском, лусочками епідермісу (bloodstained otorrhea, with cariotic smell, pieces of cholesteatoma, bone sand, desquamous epithelium); • Крайова перфорація у ненатягнутій частині (Marginal perforation in pars flaccida); • Шорсткість кістки при ощупуванні стінок б/порожнини (probe test - rough bone of the tympanic cavity walls); • Вимивання канюлею Гартмана кусочків холестеатоми, кісткового піску, лусочoк епідермісу (cholesteatoma, bone sand, desquamous epithelium by washing attic with Hartmann canulae); • Поліпи, грануляції (polyp or granulation tissue formation); • Руйнування кістки на КТ, овальна холестеатома на МРТ (bone destruction by X-rays examinations CT, MRI); • Змішана приглухуватість (conductive & sensoneural hearing loss by audiological investigation). Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
• Remission stages, • Exacerbation stages, Chronic purulent epitympanitis • External meatus polips, • cholesteatoma in the external meatus. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
(Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
(Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
(Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
Treatment Summary for Otitis Media. Acute Otitis Media (AOM) Otitis Media with Effusion Chronic Suppurative Otitis Media Watchful waiting Up to 72 hours with analgesia / antipyretics if nonsevere and patient > 2 years old For 3 months from onset or diagnosis not indicated Medical therapy Antibiotics (amoxicillin) not indicated Aural toilet and topical antibiotics (quinolones) Surgical intervention Myringotomy for refractory AOM VT insertion if unresolved after 3 months Tympanoplasty Cortical mastoidectomy in nonresponding mastoiditis Adenoidectomy on second VT insertion Tympanomastoid surgery if refractory to medical therapy NI - not indicated; VT - ventilation tube.
Source: Menner Albert L. A Pocket Guide to the Ear / Thieme.- Stuttgart · New York.- 2003.- 145 p. Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997.) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
Classification of otitis • Acute Otitis Media Suppurative, • Recurrent, • Chronic Otitis Media • External (outer), • Media (middle), • Internal (inner) – Suppurative • Mesotympanitis, • Epitympanitis, • Specific (tb) – Nonsuppurative • Eustacheitis (catarral, tubotympanitis) • Nonsuppurative Otitis media with effusion (secretory otitis)
Factors Relevant to the Epidemiology of Otitis Media Environmental Factors • Day-care attendance. • Not being breast-fed. • Exposure to tobacco smoke. • Seasonal variation in respiratory infections. • Host Factors. Genetics • Immunodeficiency. • Birth defects. • Cleft palate. • Down syndrome.
Acute Otitis Media Essentials of Diagnosis – Local sign: • 1. Otalgia (earache). • 2. Hearing loss (deafness). • 3. Tinnitus. • 4. Otorrhea (2nd stage). Otoscopic: • Thickened, bulging, hyperemic tympanic membrane (eardrum), • Perforation (2nd stage), • Purulent discharg (2nd stage). – General sign: • Pyrexia, • Intoxication.
Stage of Acute Otitis Media • 1. Stage before perforation (preperforative) • earache • hearing loss • tinnitus Otoscopy • thickened hyperemic tympanic membrane • immobile on pneumatic otoscopy. • 2. Stage after perforation (perforative) • spontaneous rupture of the tympanic membrane or after myringotomy • resulting in otorrhea • 3. Sequelae of Acute Otitis Media a) healthy ear b) chronic otitis (Adhesive or perforative otitis media) c) complications: - Intratemporal Complications: 1) Mastoditis; 2) Facial nerve paralysis; 3) Suppurative labyrinthitis; 4) - Intracranial Complications: (meningitis, brain abscecc etc.)
Treatment of Acute Otitis Media 1. Ear drops 1st stage - Carbol-glycerinici ear drops (Otipax) 2nd stage - Antibiotoc with corticosteroid or antibiotic with 25% dimetylsulfoxid 2. Nasal drops (local or topical decongestans) or general decongestans (pseudoephedrini hydrochloridi 3. Antibiotic Therapy - Amoxicillin (80 mg/kg/d given in three divided doses for 10 days) remains the first-line therapy, - In resistant cases, amoxicillin (0.5-0.8) should be given in combination with clavulanate (0.125-0.75). or • Watchful Waiting (72 hours) initial watchful waiting without antibiotic therapy for healthy 2-year-olds or older children with nonsevere illness (mild otalgia and fever <39°C) 4. Adjunctive Therapy • analgesics and antipyretics 5. Antihistamine, antiallergic 6. Surgical Measures • - myringotomy
Essentials of Diagnosis “Acute Kataral Otitis Media” “acute eustacheitis”, “acute tubotympanitis” – Local sign: • Acute katar of airways (Acute rhynopharyngitis or rhynosinusitis). • 1. Hearing loss (deafness). • 2. Tinnitus. • 3. Fluctuation of hearing Otoscopic: • Concave tympanic membrane: – General sign: • If rhynosinusitis is viral
Management of the “Acute Kataral Otitis Media” “acute eustacheitis”, “acute tubotympanitis” • 1. Treatment of acute katar of airways. • 2. Intranasal (local) or general decongestant. • 3. Eustachian tube inflation: – 1. Toinby procedure. – 2. Valsalva’s procedure. – 2. Politzerisation. – 3. Catheterisation and inflation Technics of Politzerisation.
Management of the “Acute Kataral Otitis Media” “acute eustacheitis”, “acute tubotympanitis” • 3. Eustachian tube inflation: – 1. Toinby’s procedure. – 2. Valsalva’s procedure. – 2. Politzerisation. – 3. Catheterisation and inflation Technics of Eustachian tube catheterisation: 1 - ear catheter; 2 - ostium pharhyngeum auditory tube.
Peculiarity of the acute middle otitis in childhood – General sign (always): • 1. Intoxication, • 2. Pyrexia, • 3. Meningismus • 4. Dyspepsia, meteorismus. • 5. Lungs insufficiency. • 6. Weight insufficiency, • 7. More often middle otitis then in adult (micsoid tissue, peculiarity of Eustachian tube) – Local sign: • 1. “Tragus” sign positive. • 2. “rumination” (“mastication”) sign positive • 3. Normal eardrum with middle otitis. • 4. More often diagnostic paracentesis. • 4. Hyperemia without middle otitis.
Peculiarity of the acute viral otitis media – Local sign: Otoscopic: • 1. Hemorrhage on the normal tympanic membrane, • 2. Vesicles with water-like fluid or hemorrage, • 3. Sensoneural hearing loss. – General sign: • Pyrexia, • Intoxication.
Peculiarity of the Tb otitis – Local sign: – Otoscopic: • 1. Multiply perforstions. • 2. Discharge like Cheese. – X-rays examination • 3. Bone Secvestration. – General Tb sign: • The lungs focus, • Intoxication.
Sequelae & Complications of Otitis Media • Sequelae a) healthy ear b) chronic otitis (Atelectasis, Adhesive, Tympanosclerosis or perforative otitis media) c) complications: • Intratemporal Complications: - Acute Mastoditis - Petrositis - Facial nerve paralysis - Local or diffuse Suppurative labyrinthitis • Intracranial Complications: - Meningitis, - Subdural abscess, - Extradural abscess, - Temporal lobe of brain abscess, - Cerebellar abscess, - Lateral (sygmoid) sinus thrombosis, - Otic hydrocephalus
Chronic Suppurative Otitis Media • Chronic or recurrent otorrhea or both. • With pain (earache) or not • Hearing loss. • Tinnitus. • Chronic tympanic membrane perforation.
Pathogenesis of Chronic Suppurative Otitis Media There are two main mechanisms by which a chronic perforation can lead to continuous or repeated middle ear infections: • 1) Bacteria can contaminate the middle ear cleft directly from the external ear because the protective physical barrier of the tympanic membrane is lost. • 2) The intact tympanic membrane normally results in a middle ear "gas cushion," which helps to prevent the reflux of nasopharyngeal secretions into the middle ear via the eustachian tube. The loss of this protective mechanism results in the increased exposure of the middle ear to pathogenic bacteria from the nasopharynx.
Symptoms and Signs of Chronic Suppurative Otitis Media • history of otorrhea, intermittent or continuous, • hearing loss, • discharge is usually mucopurulent, • polyp or granulation tissue formation, • bloodstained otorrhea, • Pain is not a usual feature
Otitis chronica with cholesteatoma • Retraction of the tympanic membrane with a squamous debris collection or a whitish mass behind an intact tympanic membrane. • Squamous epithelium in the middle ear or mastoid. Testing includes computed tomography (CT) scanning
Chronic suppurative otitis media Chronic mesotympanitis & Chronic epitympanitis (or cholesteatomic or malignant) • Bloodstained otorrhea, with bad cariotic smell, pieces of cholesteatoma, bone sand, desquamous epithelium, • Marginal perforation in pars flaccida, • Probe test (Rough bone of the tympanic cavity walls), • Hartmann test (find the cholesteatoma, sand bone, desquamous epithelium by washing attic), • Polyp or granulation tissue formation, • Bone destruction by X-rays examinations, • Conductive & sensoneural hearing loss by audiological investigation,
Special Tests for diagnostic Chronic Suppurative Otitis Media • A swab of the discharge should be sent for culture and sensitivity, preferably before beginning antimicrobial therapy. • If granulations are severe and unresponsive to antimicrobial therapy, then chronic granulomatous conditions such as - Wegener granulomatosis, - mycobacterial infection, - histiocytosis X, and - sarcoidosis should be considered. Biopsy of the granulation or polyp in these circumstances is recommended.
Pathogenesis of cholesteatoma Acquired Cholesteatoma • Cholesteatoma is the presence of squamous epithelium in the middle ear, mastoid, or epitympanum. • Primary acquired cholesteatoma is the most common of these types and forms as a retraction of the tympanic membrane. In most cases, the retraction occurs in the pars flaccida, although pars tensa retractions can also occur. • Secondary acquired cholesteatoma forms as a result of either squamous epithelial migration from the tympanic membrane or implantation of squamous epithelium into the middle ear during surgery, such as ventilation tube placement or tympanoplasty. Congenital Cholesteatoma • Cholesteatomas that occur without tympanic membrane retraction or implantation of squamous epithelial material are considered to be congenital in origin. This type comprises a minority of cholesteatoma cases. • It is classically defined as an embryonic rest of epithelial tissue in the ear without tympanic membrane perforation and without a history of ear infection.
Clinical Findings (Symptoms and Signs) Patients with cholesteatomas Patients with acquired cholesteatomas typically present with • recurrent or persistent purulent otorrhea and • hearing loss. • Tinnitus is also common. • vertigo or dysequilibrium can result from the inflammatory process in the middle ear or, in rare cases, from direct labyrinthine erosion by cholesteatoma. • Facial nerve twitching, palsy, or paralysis can also result from the inflammatory process or from mechanical compression of the nerve. Physical findings are usually diagnostic in cases of acquired cholesteatoma. • In primary acquired cholesteatoma, there will be a retraction of the pars flaccida in most cases • retraction contain a matrix of squamous epithelium, • purulent otorrhea, • polyps and • granulation tissue, • and ossicular erosion. • In secondary acquired cholesteatoma, the findings depend on the cause. If the cholesteatoma developed from a tympanic membrane perforation, the squamous epithelial matrix, keratin debris, or both are usually visible through the perforation. • Congenital cholesteatomas are usually asymptomatic until the mass grows to a sufficient size that the ossicular chain function becomes disrupted and hearing loss develops.
Surgical Procedures for Cholesteatoma Procedure End Result Advantages after Surgery Disadvantages after Surgery Tympanoplasty (canal wall up) with mastoidectomy Ear canal with tympanic membrane Low risk of otorrhea Risk of recurrent pars flaccida cholesteatoma Atticotomy Ear canal with tympanic membrane and defect into epitympanum Intermediate risk of otorrhea Risk of recurrent pars flaccida cholesteatoma Modified radical mastoidectomy (canal wall down) Mastoid cavity with tympanic membrane Low chance of recurrent pars flaccida cholesteatoma Significant risk of otorrhea Radical mastoidectomy (canal wall down) Mastoid cavity without tympanic membrane Low chance of recurrent pars flaccida and pars tensa cholesteatoma Significant risk of otorrhea and poor hearing
Treatment Summary for Otitis Media. Acute Otitis Media (AOM) Otitis Media with Effusion Chronic Suppurative Otitis Media Watchful waiting Up to 72 hours with analgesia / antipyretics if nonsevere and patient > 2 years old For 3 months from onset or diagnosis not indicated Medical therapy Antibiotics (amoxicillin) not indicated Aural toilet and topical antibiotics (quinolones) Surgical interven tion Myringotomy for refractory AOM VT insertion if unresolved after 3 months Tympanoplasty Cortical mastoidectomy in nonresponding mastoiditis Adenoidectomy on second VT insertion Tympanomastoid surgery if refractory to medical therapy NI - not indicated; VT - ventilation tube.
Local or diffuse Suppurative labyrinthitis Local labyrinthitis: • Caused epitympanitis, • Fistule of the ampullae of the horizontal semicircular canal, • Fistule symptom, • Treatment like epitympanitis – radical mastoidectomy Diffuse labyrinthitis: - Serous. - Suppurative. Diffuse Serous: ill side Contralatreral side Contralatreral side Contralatreral side Contralatreral side (by both hand) Time more then 40 sec Less then 50 ml Diffuse purulent: Contralatreral side ill side ill side ill side ill side (by one hand) Time more then 40 sec More then 50 ml Sign Direction of nystagmus Direction of Falling Falling down in static tests Deviation in Dynamic tests Deviation in coordinative tests (finger-nose test) Rotatory test Caloric test
Classifacation of the mastoiditis & paramastoiditis • Acute, • Subacute, • Chronic, • Latent, Mastoiditis: • Tipical form, • Tip form, • Perisinuosus abscess, Paramastoiditis: • Subperiostal abscess, • Zygomaticitis, • Occipititis, • Squamitis, • Petrositis, • Apicitis etc.
Acute mastoiditis General sign of the inflamatory process: • Intoxication, hight temperature, leucocytosis etc. Sign of otitis (acute or chronic): • (earache, discharge, tinnitus, hearing loss). Local common sign of the mastoiditis: • Painful palpation of the mastoid, • Thickness soft tissue under mastoid, • X-rays sign (cells shadow), • Thickness of the posterior-superior part the bone part of the external meatus, Special Local sign of the mastoiditis: It depend on the localisation: • Tip form, • Perisinuosus abscess, • Zigomaticitis, • occipititis, • squamitis, • petrositis, • Apicitis etc.
1. Surgical treatment: It depend on the cause of the mastoiditis!!! • If mastoiditis was caused by acute otitis the patients needs in simple mastoidotomy (“Shwart’s or cortical mastoidectomy”). • If mastoiditis was caused by chronic otitis the patients will be treated by radical mastoidectomy. 2. Conservative treatment: • Antibiotics (general & local), (especially lincosamine group), • Dehydratation, • Detoxication, • Antiinflammatory remedies, 1. Management of the mastoiditis
1. Selection of Surgery otogenic any complications: • If mastoiditis was caused by acute otitis the patients needs in simple mastoidotomy (“Shwart’s or cortical mastoidectomy”). • If mastoiditis was caused by chronic otitis the patients will be treated by radical mastoidectomy. 2. Management of the mastoiditis
Mastoidotomy
Mastoidotomy
Complications Otitis chronica with cholesteatoma The major sequelae are • bone erosion, erosion of the ossicular chain, • otorrhea, • sensorineural hearing loss, • dizziness, • facial nerve injury Suppurative complications • Intratemporal Complications: - Acute Mastoditis, Petrositis, - Facial nerve paralysis, - labyrinthitis • Intracranial Complications: - Meningitis, Subdural abscess, - Extradural abscess, - Temporal lobe of brain щк Cerebellar abscesses, - Lateral (sygmoid) sinus thrombosis
Otogenic complications of Otitis Media • Intratemporal Complications: - Acute Mastoditis, - Petrositis, - Facial nerve paralysis, - Local or diffuse Suppurative labyrinthitis • Intracranial Complications: - Meningitis, - Subdural abscess, - Extradural abscess, - Temporal lobe of brain abscess, - Cerebellar abscess, - Lateral (sygmoid) sinus thrombosis, - Otic hydrocephalus
Otogenic extradural abscess 1. Sign of Acute or Chronic Otitis media (earache, purulent discharge, tinnitus, hearing loss). 2. Sign of Acute Mastoditis (painful mastoid, thickness of posterior- superior bony part of external meatus). 3. Local sign of extradural abscess: combination of - cistern sign (a lot of purulent discharge) with - pus pulsation (double sign)
Otogenic meningitis 1. General Inflammatory sign: - Intoxication, - hypertermia, - leucocytosis… 2. Meningeal sign: - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 3. Sign of increasing intracranial pressure: - headache without benefit after using analgetics or with nasea, vomiting, - bradycardia, - papilloedema (swelling of papilla of eyes nerves) 4. Local sign of brain lession: - hemiparesis…
Otogenic temporal lobe abscess of brain 1. General Inflammatory sign: - Intoxication, hypertermia, leucocytosis… 2. Sign of increasing intracranial pressure: - headache without benefit after using analgetics or with nasea, vomiting, - bradycardia, - papilloedema (swelling of papilla of eyes nerves) 3. Meningeal sign: - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 4. Local sign of brain lession: - amnestic, motor or sensorial aphasia (left side if patient is right-handed, - contralateral paresis, - dilated pupils, ptosis and lateral rectus paralysis, - homonymous hemianopia
Stages of the brain abscess: 1. Invasive stage - stage of encephalitis. 2. Latent stage - stage of almost no symptoms. 3. Manifest stage - stage of raised intracranial tension. 4. Terminal stage - stage of rupture. on lumbar puncture, there is great pressure of cerebrospinal fluid and greater danger of coning of the medulla.
Otogenic cerebellar abscess 1. General Inflammatory sign: - Intoxication, hypertermia, leucocytosis 2. Sign of increasing intracranial pressure: - headache without benefit after using analgetics or with nasea, vomiting, - bradycardia, - papilloedema (swelling of papilla of eyes nerves) 3. Meningeal sign: - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 4. Local sign of cerebellar lession: - 1. Falling down in static tests. - 2. Deviation in Kynetic tests. - 3. Deviation in coordinative tests (finger- nose test ) - 4. Ipsilateral asynergia (dysdia- dochokinesis). - 5. Muscles hypotonia (flaccidity). - 6. Nystagmus (continuous, big amplitude, any directions till diagonalic…)
Otogenic lateral sinus trombosis signs 1. General Inflammatory sign: - Intoxication, hypertermia, leucocytosis And triad: - chills (shivering) and fever, - sweating (perspiring), - aperiodic chills&fever and sweating, 2. Sign of Acute or Chronic Otitis media: (earache, purulent discharge, tinnitus, hearing loss). 3. Sign of Acute Mastoditis: - painful mastoid, - thickness of posterior-superior bony part of external meatus. 4. Local sign: 1. Obstructive symptoms - Tobey-Ayer or Queckenstedt’s test (lumbar puncture and digital pressure on the internal jugular vein on the healthy side). 2. Infective symptoms (swinging temperature with rigors at irregular intervals, formation of pyaemic abscesses in various parts of the body chiefly lungs and joints, positive blood cultyre, enlarged spleen and marked leucocytosis) - Greisinger’s sign (If the mastoid emissary vein gets involved, there is oedema and tenderness over its site).
Stage of the otogenic lateral sinus trombosis 1. The initial stage of attack when the vein wall is inflamed and there is a mural clot inside it. 2. Stage of complete obliteration of the sinus with big thrombus. 3. Suppuration of the thrombus resulting in pyaemia and multiple abscesses in the body.
1. Surgical treatment: It depend on the cause of the complications!!! • If any complication was caused by acute otitis the patients needs in simple mastoidotomy (“Shwart’s or cortical mastoidectomy”). • If any complication was caused by chronic otitis (epitympanitis) the patients will be treated by radical mastoidectomy. 2. Conservative treatment: • Antibiotics (general & local), (especially lincosamine group), • Dehydratation, • Detoxication, • Anti-inflammatory remedies… Management of the otogenic complications
Meniere’s desease 2. Clinical Triad: 1. An attack of severe vertigo without of unconsciousness. 2. Vegetative disorders till nasea and vomiting. 3. One ear Tinnitus and deafness. 4. Nystagmus is labyrinthine in nature and to the side of the lesion, whereas in between the attacks it is to the opposite side. 1. Unknown causes due to endolymphatic hydrops. 3. Treatment: 1) absolute rest, sedatives, 2) dehydratation therapy. 3) drainage of the endolymphatical succ.
Theories of Meniere’s desease (endolymphatic hydrops) 1. It is due to focal labyrinthitis from a distant septic focus. 2. It is due to vasospasm of the vessels of the stria vascularis which leads to relative ischaemia which in turn gives rise to increased permeability of the stria. 3. It is due to allergy of the labyrinth. 4. It is due to salt and water retention in the body.
Clinical Triad of Meniere’s desease 1. Suddenly struck with an attack of severe vertigo. There is no loss of consciousness. 2. There may be vegetative disorders till nasea and vomiting. 3. There is also tinnitus in the one ear and appreciable deafness. 4. During the attack the nystagmus is labyrinthine in nature and to the side of the lesion, whereas in between the attacks it is to the opposite side. If the disease progresses, the intervals become shorter and shorter and the hearing during the free periods goes on getting worse and worse.
Differential diagnosis of Meniere’s desease I. Diseases of the external or middle ear: 1. Earwax or foreign body in the external ear which impinges on the drum can push in ossicular chain and give rise to vertigo. 2. Inflammation of the middle ear cleft may cause sympathetic irritation of the labyrinth giving rise to vertigo. 3. Even Eustachian block can give rise to this condition. II. Central or periferal nerves system lesion: 1) eighth nerve tumour, 2) thrombosis of the posterior inferior cerebellar artery, 3) syphilis of the central nervous system, 4) disseminated sclerosis etc. involving the vestibular nuclei or their connections may give rise to vertigo. III. Epilepsy: In this disease, there is loss of consciousness which seldom occurs in Meniere’s disease. IV. Diseases of the cerebellum may give rise to vertigo but there will be no remissions as in the case of Menier’s disease. V. Cardiovascular diseases: 1) hypertension, 2) arteriosclerosis, 3) anaemias or thrombosis of relevant blood vessels in the central nervous system may also give rise to vertigo.
1. Treatment of Meniere’s desease The treatment resolves itself into: 1. During the attack and 2. After the attack which may be: a) medicinal, or b) surgical. 1. During the attack: 1) The patient should be transported to a safe place and put to absolute rest. 2) He should be given sedatives. 3) The dehydratation therapy. 2. After the attack is over: a) Pharmacotherapy: I. The patient is prescribed a salt-free diet and minimum intake of fluid. This does lot of good in nearly half the cases. II. The patient is given vasodilators (nicotinic acid). Once the disease is under control, the dose of nicotinic acid should be steadily reduced. III. Antiallergic drugs are given. (In histamine sensitive patients, desensitisation with histamine is advocated. Such patients are very few). IV. Streptomycin is a general depressant to the labyrinth but its action on the cochlea which is rather uncertain, prohibits its use routinely. V. Smoking and drinking should be forbidden.
2. Treatment of Meniere’s desease I. During the attack: 1. Calm dark environment. 2. Sedativs: - diazepamum 5mg 1(2) t. a day or - diazepamum 10mg-2ml 1 t. a day or 3. The dehydratation therapy: a) The patient is prescribed a salt-free diet and minimum intake of fluid. b) hypertonic solutions: - Sol.glucosae 40%-20ml+ + sol.ac.ascorbinici 5%-2ml i/v 1t. a day - sol.magnesii hydrochloridi 25%-5ml i/m c) diuretics: - lasix 20mg-2ml i/m 1 t. a day in the morning or - Furasemidum 40mg 1(2) t. a day in the morning II. After the attack is over: I.Salt-free diet and minimum intake of fluid. II. Vasodilators (nicotinic acid 100mg x 3 t. day) III. Pharmacotherapy like sensoneural deafness.
3. Treatment of Meniere’s desease 2. After the attack: a) osmotic therapy by solt
4. Treatment of Meniere’s desease The treatment resolves itself into: 1. During the attack and 2. After the attack: a) medicinal, or b) surgical. b) Surgical treatment: I. Removal of septic foci, e.g., infected teeth, tonsils and sinuses. II. Stellate ganglion block. III. Cervical sympathectomy. These two release nervous control over the stria vascularis. IV. Drainage of the labyrinth - (Labyrinthotomy), - drainage of the endolymphatical succ V. Labyrinthectomy (destruction of the labyrinth): - surgical, - chemical (injection of alcohol into the labyrinth). Operations on the labyrinth can be considered if the hearing of the affected ear is extremely, poor and that of the unaffected ear is reasonable.
Meniere’s desease 2. Clinical Triad: 1. An attack of severe vertigo without of unconsciousness. 2. Vegetative disorders till nasea and vomiting. 3. One ear Tinnitus and deafness. 4. Nystagmus is labyrinthine in nature and to the side of the lesion, whereas in between the attacks it is to the opposite side. 1. Unknown causes due to endolymphatic hydrops. 3. Treatment: 1) absolute rest, sedatives, 2) dehydratation therapy. 3) drainage of the endolymphatical succ.
Otosclerosis 1. Unknown causes. 2. Ankilosis footplate of the stapes. 3. Conductive deafness. 4. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign). 4. Piston’s stapedoplasty.
Otosclerosis 1. Unknown causes: - Hereditary factors. - Hormonal factors (Females after Pregnancy between 20-30 years of age) - Endocrine disturbances (Ca metabolism). 2. Ankilosis footplate of the stapes. Normal bone in the middle layer of the otic capsule. is absorbed and replaced by spongy osteoid bone, which becomes thicker and less vascular at one or more constant sites. This due to Ankilosis footplate of the stapes. Morphological stage: 1. Vascularisation. 2. Osteospongious. 3. Osteosclerosis. 3. Conductive deafness. 1. Tympanal stage. 2. 2nd mixt stage 3. Sensoneural stage. 4. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign). 4. Piston’s stapedoplasty.
Predisposing factor of Otosclerosis Many theories have been advanced but none is satisfactory. 1. Hereditary factors. White races are more commonly affected than coloured. Fair complexioned persons are more prone than dark persons. There is family history in about 50% of cases. Hereditary anomalies have all been postulated but not substantiated. Common associated conditions are Van der Hoere Syndrome and Paget’s disease. 2. Hormonal factors (endocrine disturbances). The incidence of disease is much commoner in females than in males. Pregnancy may accelerate but never causes the disease. The disease generally manifests between 20-30 years of age. 3. Different factors - localized infection, - malnutrition, - general toxaemia, - abnormal labyrinthine circulation.
Morphological abnormality of Otosclerosis Normal bone is absorbed and replaced by spongy osteoid bone, which becomes thicker and less vascular at one or more constant sites. Morphological stage: 1. Vascularisation. 2. Osteospongious. 3. Osteosclerosis. This occurs in the middle layer of the otic capsule. Silent areas may be present which do not involve the oval window and do not cause deafness. Cochlea may be involved due to spread of osteoid bone. Its proximity to foot plate of stapes causes ankylosis.
Clinical features of Otosclerosis 1. Hearing loss is the cardinal symptom. 2. Paracusis Willisii: Patient generally complains that she can hear better in presence of back ground noises. The simplest explanation is that a normal person raises his voice in pitch and intensity in noisy surrounding. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign).
Clinical stage (type) of Otosclerosis 1. Tympanal stage. The deafness is of conductive type. In early stages there is an upward slope towards the right. Bone conduction shows a dip at 2000 Hz (Carhart notch) and is seen in about l/3rd of patients. 2. 2nd mixt stage High tones are only affected, if cochlea is involved. When the cochlea is invoved then there is downward slope to the right. 2. Mixt stage. 3. Sensoneural stage. Patient feels handicapped when air conduction loss exceed 50 dB.
Differential Diagnosis of Otosclerosis 1. Healed suppurative otitis media: - Adhesive (deformity of tympanic membrane); - Tympanosclerosis (hyalinic cartilages inside tympanic membrane). 2. Chronic nonsuppurative otitis media - Eustacheitis (retraction of tympanic membrain). 3. Ossicular disconnection. 4. Perceptive deafness in young adult. 5. Congenital stapes fixation (rare). Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign).
Surgical Treatment of Otosclerosis (stapedectomy) Surgical Treatment of Otosclerosis (stapedoplasty)
Surgical Treatment of Otosclerosis (piston’s stapedoplasty)
Complications surgical treatment of Otosclerosis 1. Perforation of tympanic membrane. 2. Vertigo. 3. Otitis Media. 4. Damage to facial nerve. 5. Taste disturbance. 6. Damage to membranous labyrinth. 7. Leakage of perilymph. 8. Dislocation of incus. 9. Bleeding. 10. Loss of part or whole of foot-plate into the vesitbule. Late complications: 1. Dislocation of prosthesis. 2. Meningitis. 3. Completely deaf ear. 4. Reparative granuloma.
Otosclerosis 1. Unknown causes. 2. Ankilosis footplate of the stapes. 3. Conductive deafness. 4. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign). 4. Piston’s stapedoplasty.
Sensoneural deafness 2. Sensoneural desorders by Tonal audiometry . х - bone conduction, о - air conduction. AD (Auris Dexter) RE (Right ear) AS (Auris Sinister) LE (Left ear) - Tinnitus ++ >5m WV >1m >20m CV >3m 20'' Tf (Tunning fork) 128 bone (N=20'') 10" 40'' Tf (Tunning fork) 128 air (N=40'') 20'' 30'' Tf (Tunning fork) 2048 (N=30'') 150'' + Rinne +"small" Weber Not longthened Schwabah shortened Not shortened 3. Left ear Sensoneural deafness. 1. Normal otoscopic picture. Sign: 1. Hearing loss. 2. Tinnitus. 3. Normal otoscopic picture. 4. Sensoneural deafness.
1. Causes of deafness Deafness may be classified in two ways: I. a) Congenital, b) Acquired. II. a) Conductive, b) Perceptive (sensotineural) с) Mixed - conductive and perceptive. It is two types of perceptive deafness: 1. Cochlear (sensory part) 2. Retro-cochlear or neural. I. In the inner ear. II. In the eighth nerve. III. In the central nervous system.
2. Causes of deafness Pharmacologic toxicity ototoxic drugs: eg - salicylates, quinine, - aminoglycoside antibiotics (drugs like streptomycin and quinine may affect the auditory nerve), - loop diuretics (furosemide, ethacrynic acid, - cancer chemotherapeutic agents (eg. cisplatin). Infectious - Otitis media, viral, syphilis, meningitis, Traumas: - transversal fractures pyramid of the temporal bone, - noise-induced Neurologic disorders: - vascular, demyelinating (eg. multiple sclerosis), - infectious, or degenerative disease affecting the central auditory pathways, - cerebellopontine angle tumors such as vestibular schwannomas (acoustic neuromas) or meningiomas; Vascular and hematologic disorders: - Migraine, cryoglobinemia Immune disorders: - Polyarteritis nodosa, HIV. Bone disorders: - Paget disease Inner ear deseases: - Meniere disease, - Cochlear otosclerosis, - Presbycusis (Age-Related Hearing Loss),
3. Causes of deafness Infant Infectious: - The infectious fevers in infancy (meningitis, typhoid fever, measles, mumps, whopping cough) Congenital Hearing Loss: - HIV-Related Hearing Loss (Human immunodeficiency virus (HIV) infection leads to both peripheral and central auditory system pathology. Genetic Causes: - hereditary hearing impairment (HHI) can manifest later in life. HHI may be classified as either: nonsyndromic hearing loss, in which deafness is the only clinical abnormality or syndromic hearing loss, in which deafness is associated with anomalies in other organ systems. Syndromic (More than 200 syndromes are associated with hearing loss): 1. Usher syndrome (retinitis pigmentosa and hearing loss), 2. Waardenburg syndrome (pigmentary abnormality and hearing loss), 3. Pendred syndrome (thyroid organification defect and hearing loss), 4. Alport syndrome (renal disease and hearing loss), and 5. Jervell & Lange-Nielsen syndromes (prolonged QT interval and hearing loss). Nonsyndromic: - Large vestibular aqueduct syndrome
4. Causes of deafness I. In the inner ear: 1. Meniere’s disease. 2. Senile deafness due to arteriosclerosis of the vessels supplying the internal ear. 3. Trauma. This maybe from noises, fractures of the temporal bone, or concussion of the internal ear or 4. Toxins. Drugs like streptomycin and quinine may affect the auditory nerve. Exogenous toxins like too much alcohol or endogenous toxins like those found in diabetes and septic foci are also likely causes. 5. General malnutrition and vitamin deficiency. II. In the eighth nerve: Eighth nerve tumour. III. In the central nervous system: 1. Tumours, vascular accidents, disseminated sclerosis, syphilis and mental deficiency etc. 2. Cortical lesions do not give rise to perceptive deafness unless both centres on the right and left are simultaneously affected because the nuclei in the brain stem send fibres to both cortical centres. Psychogenic deafness: It is that type of deafness in which there is no organic cause to explain it. 1. Hysterical or functional: In this case, the patient in reality cannot hear external sounds due to something in his subconscious mind. 2. Malingering, also cacalled feignet or simirfated deafness. In this case, the patient can, in reality, hear external sounds, but on account of some reason of personal gain, he pretends that he cannot hear.
Sign of Sensoneural deafness Normal tonal audiometry. х - bone conduction, о - air conduction. 2. Sensoneural desorders by Tonal audiometry . х - bone conduction, о - air conduction. AD (Auris Dexter) RE (Right ear) AS (Auris Sinister) LE (Left ear) - Tinnitus ++ >5m WV >1m >20m CV >3m 20'' Tf (Tunning fork) 128 bone (N=20'') 10" 40'' Tf (Tunning fork) 128 air (N=40'') 20'' 30'' Tf (Tunning fork) 2048 (N=30'') 150'' + Rinne +"small" Weber Not longthened Schwabah shortened Not shortened 3. Left ear Sensoneural deafness. 1. Normal otoscopic picture.
1. Treatment of Sensoneural deafness I. Its depend on causes: 1. Creating a Favorable Environment for Hearing. 2. Toxic – antidot or detoxication: - Streptomycinum - Vit B15; - spiritus methylicus - spiritus aethylicis. 3. Local vasospasmus - central vasodilatators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day 4. Hypertension - peripheral vasodilatators: 5. Symptomatic hypertension: - renal - surgery; - endocrine - hormonal therapy… 6. Thrombosis: - Sol. Heparini natrici 5000 “ME”/ml – 1(2)ml i/v x 1(3) t. a day + next days s/c(abdomen) 5000 x 2 t. a day 7. Haemorrage: - tab. Ethamsilatum 0.25 x 3 t. a day; - sol. Ethamsilatum 12.5%-2ml I/v or I/m 2(3) t. a day
2. Treatment of Sensoneural deafness II. Nonspecific Pharmacotherapy: I. Nootropic: - pyracetamum 20%-5ml i/v 1t. a day or - pyracetamum 0.2 x 3t. a day II. Central vasodilators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day III. Blood desagregation: - pentoxifyllinum (trental) 0.2 x 3 t. a day x 10 days and next 0.1 x 3 t. a day x 10 days IV. For stimulating transmission nerves impulses in synapses: Anticholinestheratic: - proserinum 0.05%-1ml i/m x 1t. a day - Ipidacrinum (neiromidinum) 0.020 x 2 t. a day x10-30 days 0.5%-1ml s/c or I/m x 1 t. a day V. Nerves system energy riser: - Acidum gammaaminobutyricum (aminalon) 0.25 x 3 t. a day - ATP-long 2%-2ml i/v 1 t. a day VI. Nonspecific stimulators: - corpus vitreum 1ml i/m x 1t. a day VII. Vitamins B1 , B2 , B6 , B12: (Neurovitan, Neiron, Neurorubine)
3. Treatment of Sensoneural deafness VII. Vitamins B1 , B2 , B6 , B12: - Neurovitan Octothiaminum...................................... 25 мг Riboflavinum......................................... 2,5 мг Pyridoxini hydrochloridi......................... 40 мг Cyancobalamini.................................... 0,25 мг - Neiron Thiamini mononitrici............................... 25 мг Riboflavinum..................................….... 2,5 мг Pyridoxini hydrochloridi......................... 40 мг Cyancobalamini..................................... 0,25 мг - Neurorubine Thiamini mononitrici.............................. 200 мг Pyridoxini hydrochloridi......................... 50 мг Cyancobalamini.................................... 1 мг - Neurorubine Amp 3 ml Thiamini hydrochloridi........................... 100 мг/3 мл Pyridoxini hydrochloridi......................... 100 мг/3 мл Cyancobalamini.................................... 1 мг/3 мл
1. Prevention of Sensoneural deafness 1. Vaccination The vaccination of infants against Haemophilus influenzae type B meningitis prevents a major cause of acquired deafness, as have immunizations for measles, mumps, and rubella. A vaccine against Streptococcus pneumoniae, the most common organism associated with otitis media, is also available and is having a positive impact on the reduction in the incidence of ear infections. In addition, careful monitoring of serum peak-and-trough levels can largely prevent the loss of vestibular function and deafness due to aminoglycoside antibiotics.
2. Prevention of Sensoneural deafness 2. Noise Avoidance Ten million Americans have noise-induced hearing loss and 20 million are exposed to hazardous noise in their employment. Noise-induced hearing loss can be prevented by avoiding exposure to loud noise or by the regular use of earplugs or fluid-filled muffs to attenuate intense sound. 3. High-Risk Activities High-risk activities for noise-induced hearing loss include wood- and metalworking with electrical equipment as well as target practice and hunting with small firearms. All internal-combustion and electric engines, including snowblowers and leaf blowers, snowmobiles, outboard motors, and chain saws, require that the user wear hearing protectors. 4. Education Almost all noise-induced hearing loss is preventable through education, which should begin before adolescence. Industrial programs of hearing conservation are required when the exposure over an 8-hour period averages 85 dB on the A scale. Workers in such noisy environments can be protected with preemployment audiologic assessment, the mandatory use of hearing protectors, and annual audiologic assessments.
Sensoneural deafness 1. Patients with mild, moderate, and severe sensorineural hearing losses are rehabilitated regularly with hearing aids that vary in configuration and strength. They also have been miniaturized; the current generation of hearing aids can be placed entirely within the ear canal, thus reducing the stigma associated with their use. Digital hearing aids lend themselves to programming for the individual; (2) But, multiple and directional microphones at the ear level help some individuals with the difficulty of using a hearing aid in noisy surroundings. Since all hearing aids amplify noise as well as speech, the only absolute solution to the problem is to place the microphone closer to the speaker than to the noise source. This arrangement is not possible with a self-contained, cosmetically acceptable device; it is cumbersome and requires a user-friendly environment. 2. In many situations, including at lectures and at the theater, hearing-impaired persons benefit from assistive devices that are based on the principle of having the speaker closer to the microphone than to any source of noise. Assistive devices include infrared and FM transmission; they also include an electromagnetic loop placed around the room for transmission to the individual’s hearing aid. Hearing aids with telecoils also can be used with properly equipped telephones in the same way. Amplification
Sensoneural deafness In the event that a hearing aid provides inadequate rehabilitation, cochlear implants are appropriate. The criteria for implantation are undergoing constant revisions. Children with congenital and acquired profound hearing impairment are also appropriate candidates for cochlear implantation; many are being implanted as early as 6 to 9 months. In most cases of profound hearing impairment, the auditory hair cells are lost, but the spiral ganglion cells of the auditory division of the eighth nerve are preserved. Cochlear implants are a specialized hearing prosthesis for the rehabilitation of profound deafness that convert mechanical sound energy into electrical signals that are delivered to the neurons of the cochlear nerve. The basic operation of the implant is as follows: A microphone is used to pick up acoustic information that is sent to an external speech processor (located on the body or at ear level). This processor converts the mechanical acoustic wave into an electric signal that is transmitted via the surgically implanted electrode array in the cochlea to the auditory nerve. Bilateral cochlear implants hold the promise of enhanced sound localization and improvement in understanding speech in the presence of background noise. 1. Cochlear Implants
Sensoneural deafness Cochlear Implants consist of: 1. A microphone, which picks up acoustic information and converts it to electrical signals; 2. An externally worn speech processor that processes the signal according to a predefined strategy; 3. A surgically implanted electrode array that is in the cochlea near the auditory nerve. 2. Cochlear Implants Incision and implant site for cochlear implantation.
Sensoneural deafness 3. Cochlear Implants Location of induction coil. Trough and groove drilled for electrode implantation into mastoid.
Sensoneural deafness 4. Cochlear Implants The facial recess is bounded by the fossa incudis superiorly, the chorda tympani nerve laterally and anteriorly, and the facial nerve medially and posteriorly. A cochleostomy is created anterior and inferior to the round window.
Sensoneural deafness 5. Cochlear Implants Electrode introduced into the basal end of the cochlea.
Sensoneural deafness 6. Cochlear Implants Electrode in scala tympani (cross section of basal turn on cochlea).
Sensoneural deafness 7. Cochlear Implants Receiver-stimulator with redundant loop of electrode in mastoid.
Sensoneural deafness For individuals who have had both eighth nerves destroyed by trauma or bilateral vestibular schwannomas (eg, patients with neurofibromatosis II), a brainstem auditory implant placed near the cochlear nucleus may provide auditory rehabilitation. With additional advances in brainstem auditory implant technology, patients may eventually obtain benefits similar to individuals who have cochlear implants. Brainstem Auditory Implant
Sensoneural deafness 2. Sensoneural desorders by Tonal audiometry . х - bone conduction, о - air conduction. AD (Auris Dexter) RE (Right ear) AS (Auris Sinister) LE (Left ear) - Tinnitus ++ >5m WV >1m >20m CV >3m 20'' Tf (Tunning fork) 128 bone (N=20'') 10" 40'' Tf (Tunning fork) 128 air (N=40'') 20'' 30'' Tf (Tunning fork) 2048 (N=30'') 150'' + Rinne +"small" Weber Not longthened Schwabah shortened Not shortened 3. Left ear Sensoneural deafness. 1. Normal otoscopic picture. Sign: 1. Hearing loss. 2. Tinnitus. 3. Normal otoscopic picture. 4. Sensoneural deafness.
Classifacation of the mastoiditis & paramastoiditis • Acute, • Subacute, • Chronic, • Latent. Mastoiditis (Tipical): • Tip form (2), • Subperiostal abscess (4), • Subperiostal abscess (4), • Perisinuosus abscess (3), Paramastoiditis: • Zygomaticitis, • Occipititis, • Squamitis, • Petrositis, • Apicitis etc.
Гострий мастоїдит (Acute mastoiditis) 1. Симптоми отиту (Symptoms of otitis): - вушний біль (otalgia), - виділення (discharge), - зниження слуху (hearing loss), - шум у вухах (tinnitus). 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3. Симптоми мастоідиту (mastoiditis sign): - профузна оторрея (profuse otorrhea - “Cystern” sign); - пастозність м’яких тканин соскоподібного відростка (thickness soft tissue in mastoid region), (thickness soft tissue in mastoid region), - болючість соскоподібного відростка (painful mastoid), - потовщення задньо-верхньої стінки кісткової частини зовнішнього слухового проходу (thickness of posterior-superior wall of the bony part of external meatus). - Ro, CT затемнення комірок (X-rays, CT - cells shadow). 4. Особливі місцеві симптоми при парамастоїдитах (Specific Local sign depend on the localisation): верхівково-шийні форми, перисинуозний абсцес, зигомацитит, петрозит, апіцит… tip form, perisinuosus abscess, zigomaticitis, petrositis, apicitis etc.
1. Тактика лікування мастоїдітів залежить від характера причинного отиту. (management of the mastoiditis depend on the cause of the mastoiditis). • Якщо мастоідит викликаний гострим отитом (гнійним середнім) то виконується проста (кортикальна) антромастоідеотомія, If mastoiditis was caused by acute otitis indicated cortical antromastoidotomy (simple or “Shwart’s antromastoidectomy”). • Якщо мастоідит викликаний хронічним отитом (епітимпанітом) то виконується загальнопорожнинна (радикальна) операція на вусі (атикоантромастоідеотомія) If mastoiditis was caused by chronic otitis (epitympanitis) indicated radical Management of the mastoiditis If mastoiditis was caused by chronic otitis (epitympanitis) indicated radical atticoantromastoidectomy. 2. Медикаментозне лікування (Conservative treatment): • Антибактериальне (Antibiotics (general & local - lincosamine group). • НПЗЗ (Antiinflammatory nonsteroid remedies). • Дезінтоксикація (Detoxication). • Дегідратація (Dehydratation). • Назальні деконгестанти (nasal decongestants).
Simple (cortical) AntroMastoideotomy Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
Simple (cortical) AntroMastoideotomy Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
Simple or cortical AntroMastoidotomy (Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997)
1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3. Симптоми внутрішньочерепної гіпертензії Групи симптомів отогенного менінгіту Groups of symptoms of the otogenic meningitis 3. Симптоми внутрішньочерепної гіпертензії (Sign of the intracranial hypertension): - bradycardia, - papilloedema, - diffuse strong headache wich cann’t be controled by analgetics with - nasea, vomiting, 4. Менінгеальні симтоми (Meningeal sign): - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3. Симптоми внутрішньочерепної гіпертензії Групи симптомів отогенного менінгіту Groups of symptoms of the otogenic meningitis 3. Симптоми внутрішньочерепної гіпертензії (Sign of the intracranial hypertension): - bradycardia, - papilloedema, - diffuse strong headache wich cann’t be controled by analgetics with - nasea, vomiting, 4. Менінгеальні симтоми (Meningeal sign): - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2.Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3.Симптоми внутрішньочерепної гіпертензії (Sign of the intracranial hypertension): - bradycardia, - papilloedema, - diffuse strong headache wich cann’t be controled by analgetics with - nasea, vomiting, Групи симптомів отогенного абсцесу скроневої долі мозку Groups of symptoms of the otogenic temporal lobe brain abscess - nasea, vomiting, 4. Менінгеальні симтоми (Meningeal sign): - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 5. Local sign of brain lession: - amnestic, motor or sensorial aphasia (in case with left side temporal lobe brain leasion if patient is right-handed, - contralateral paresis, - dilated pupils, ptosis and lateral rectus paralysis, homonymous hemianopia
1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3.Симптоми внутрішньочерепної гіпертензії (Sign of the intracranial hypertension): - bradycardia, - papilloedema, - diffuse strong headache wich cann’t be controled by analgetics with - nasea, vomiting, 4. Групи симптомів отогенного абсцесу мозочка Groups of symptoms of the otogenic cerebellar abscess 4.Менінгеальні симтоми (Meningeal sign): - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 5. Local sign on cerebellar lesion side: 1. Falling down in static tests (Romberg test). 2. Deviation in Kynetic tests (step test). 3. Deviation in coordinative tests (finger-nose test). 4. Ipsilateral asynergia (dysdia-dochokinesis). 5. Muscles hypotonia (flaccidity). 6. Nystagmus (continuous, big amplitude, any directions till diagonal…)
1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром - swinging temperature with rigors at irregular intervals, - pyaemic abscesses chiefly in lungs & joints, - positive blood cultyre, - enlarged spleen and marked leucocytosis) + як паразитогенна інтоксикація при малярії (signs of infectious intoxication like parasitogenic due to malaria): + Тріада: апериодична гіпертермія з потрясаючим ознобом і проливним потом (triad: - aperiodic chills (shivering) & fever and sweating (perspiring). + плазмодій малярії у мазках крові, “+” імунохімічний тест Групи симптомів отогенного тромбозу сигмоподібного синуса Groups of symptoms of the otogenic Sigmoid (lateral) sinus thrombosis + плазмодій малярії у мазках крові, “+” імунохімічний тест (plasmodium malaria in blood, “+” immunochemical test). + And effectiveness of specific treatment (chinin+ clindamycin, artemizin, chlorchin) + Anemia, hyperbilirubinemia, ALT, AST, hypoalbuminemia 3. Симптоми мастоідиту (mastoiditis sign): - профузна оторрея (profuse otorrhea - “Cystern” sign); - пастозність м’яких тканин соскоподібного відростка (thickness soft tissue in mastoid region), - болючість соскоподібного відростка (painful mastoid), - потовщення задньо-верхньої стінки кісткової частини зовнішнього слухового проходу (thickness of posterior-superior wall of the bony part of external meatus). - Ro, CT затемнення комірок (X-rays, CT - cells shadow). 4. Obstructive symptoms 4.1. Tobey-Ayer or Queckenstedt’s test – liquor hypertension via lumbar puncture + digital pressure on the internal jugular vein on the healthy side). 4.2. Greisinger’s sign - oedema of mastoid (if the mastoid emissary vein gets involved).
1.Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3.Симптоми мастоідиту (mastoiditis sign): - профузна оторрея (profuse otorrhea - “Cystern” sign); - пастозність м’яких тканин соскоподібного відростка (thickness soft tissue in mastoid region), - болючість соскоподібного відростка (painful mastoid), -потовщення задньо-верхньої стінки кісткової частини зовнішнього слухового проходу (thickness of posterior-superior wall of the bony part of external meatus). -Ro, CT затемнення комірок (X-rays, CT - cells shadow). Gtroups of symptoms of the otogenic extradural abscess (thickness of posterior-superior wall of the bony part of external meatus). -Ro, CT затемнення комірок (X-rays, CT - cells shadow). 4. Місцеві ознаки (local sign): поєднання (combination of) - симптома «резервуара» (cistern sign) накопичення гнійного вмісту з (accumulation of purulent discharge with) - з пульсацією гнійних виділень (pus pulsation) (double sign). 5.CT, MRI – накопичення рідини гнійної щільності між кісткою черепа і твердою мозковою оболонкою (accumulation of purulent discharge between skull bone & dura mater).
1. Тактика хірургічного лікування залежить від характера причинного отиту. Management depend on the cause of the complications. • Якщо внутрішньочерепне ускладнення викликане гострим отитом (гнійним середнім) то виконується кортикальна (проста) розширена антромастоідеотомія (If any intracranial complication was caused by acute middle purulent otitis indicated extended cortical mastoidotomy (simple or “Shwart’s mastoidectomy”). • Якщо внутрішньочерепне ускладнення викликанe хронічним отитом (епітимпанітом) то показана загальнопорожнинна Management of the otogenic complications (Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997.) отитом (епітимпанітом) то показана загальнопорожнинна (радикальна) розширена операція на вусі (атикоантромастоідеотомія) If any intracranial complication was caused by chronic otitis (epitympanitis) indicated radical atticoantromastoideotomy. 2. Медикаментозне лікування (Conservative treatment): • Антибактериальне (Antibiotics (general & local - lincosamine group), • НПЗЗ (Antiinflammatory remedies), • Дезінтоксикація (Detoxication), • Дегідратація (Dehydratation), • Назальні деконгестанти (nasal decongestants).
Source: Menner Albert L. A Pocket Guide to the Ear / Thieme.- Stuttgart · New York.- 2003.- 145 p. Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997.) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
Хвороба Меньєра Meniere’s desease 2. Clinical Triad: 1. An attack of severe vertigo without of 1. Ендолімфатичний гідропс внаслідок мультифакториальних причин (Endolymphatic hydrops due to multifactorial causes). 1 An attack of severe vertigo without of unconsciousness. 2. Vegetative disorders till nasea and vomiting. 3. One ear Tinnitus and deafness. 4. Nystagmus is labyrinthine in nature and to the side of the lesion, whereas in between the attacks it is to the opposite side. 3. Treatment: 1) absolute rest, sedatives, 2) dehydratation therapy. 3) drainage of the endolymphatical succ.
2. Treatment of Meniere’s desease I. During the attack: 1. Calm dark environment. 2. Sedativs: - diazepamum 5mg 1(2) t. a day or - diazepamum 10mg-2ml 1 t. a day or 3. The dehydratation therapy: a) The patient is prescribed a salt-free diet and minimum intake of fluid. b) hypertonic solutions: b) hypertonic solutions: - Sol.glucosae 40%-20ml+ + sol.ac.ascorbinici 5%-2ml i/v 1t. a day - sol.magnesii hydrochloridi 25%-5ml i/m c) diuretics: - lasix 20mg-2ml i/m 1 t. a day in the morning or - Furasemidum 40mg 1(2) t. a day in the morning II. After the attack is over: I.Salt-free diet and minimum intake of fluid. II. Vasodilators (nicotinic acid 100mg x 3 t. day) III. Pharmacotherapy like sensoneural deafness.
Otosclerosis 1. Unknown causes. 2. Ankilosis footplate of the stapes. 3. Conductive deafness. 4. Otoscopy of Otosclerosis: 4. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign). 4. Piston’s stapedoplasty.
Clinical stage (type) of Otosclerosis 1. Tympanal stage. The deafness is of conductive type. In early stages there is an upward slope towards the right. Bone conduction shows a dip at 2000 Hz (Carhart notch) and is seen in about l/3rd of patients. Patient feels handicapped when air conduction loss exceed 50 dB. 2. 2nd mixt stage High tones are only affected, if cochlea is involved. When the cochlea is invoved then there is downward slope to the right. 2. Mixt stage. 3. Sensoneural stage.
Surgical Treatment of Otosclerosis (piston’s stapedoplasty)
Sensoneural deafness 2. Sensoneural desorders by Tonal audiometry . х - bone conduction, о - air conduction. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) AD (Auris Dexter) RE (Right ear) AS (Auris Sinister) LE (Left ear) - Tinnitus ++ >5m WV >1m >20m CV >3m 20'' Tf (Tunning fork) 128 bone (N=20'') 10" 40'' Tf (Tunning fork) 128 air (N=40'') 20'' 30'' Tf (Tunning fork) 2048 (N=30'') 150'' + Rinne +"small" Weber Not longthened Schwabah shortened Not shortened 3. Left ear Sensoneural deafness. 1. Normal otoscopic picture. Sign: 1. Hearing loss. 2. Tinnitus. 3. Normal otoscopic picture. 4. Sensoneural deafness. Otoscopy. Stuttgart: Thieme; 1999)
1. Treatment of Sensoneural deafness I. Its depend on causes: 1. Creating a Favorable Environment for Hearing. 2. Toxic – antidot or detoxication: - Streptomycinum - Vit B15; - spiritus methylicus - spiritus aethylicis. 3. Local vasospasmus - central vasodilatators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day 4. Hypertension - peripheral vasodilatators: 4. Hypertension - peripheral vasodilatators: 5. Symptomatic hypertension: - renal - surgery; - endocrine - hormonal therapy… 6. Thrombosis: - Sol. Heparini natrici 5000 “ME”/ml – 1(2)ml i/v x 1(3) t. a day + next days s/c(abdomen) 5000 x 2 t. a day 7. Haemorrage: - tab. Ethamsilatum 0.25 x 3 t. a day; - sol. Ethamsilatum 12.5%-2ml I/v or I/m 2(3) t. a day
2. Treatment of Sensoneural deafness II. Nonspecific Pharmacotherapy: I. Nootropic: - pyracetamum 20%-5ml i/v 1t. a day or - pyracetamum 0.2 x 3t. a day II. Central vasodilators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day III. Blood desagregation: - pentoxifyllinum (trental) 0.2 x 3 t. a day x 10 days and next 0.1 x 3 t. a day x 10 days next 0.1 x 3 t. a day x 10 days IV. For stimulating transmission nerves impulses in synapses: Anticholinestheratic: - proserinum 0.05%-1ml i/m x 1t. a day - Ipidacrinum (neiromidinum) 0.020 x 2 t. a day x10-30 days 0.5%-1ml s/c or I/m x 1 t. a day V. Nerves system energy riser: - Acidum gammaaminobutyricum (aminalon) 0.25 x 3 t. a day - ATP-long 2%-2ml i/v 1 t. a day VI. Nonspecific stimulators: - corpus vitreum 1ml i/m x 1t. a day VII. Vitamins B1 , B2 , B6 , B12: (Neurovitan, Neiron, Neurorubine)
2. Treatment of Sensoneural deafness II. Nonspecific Pharmacotherapy: I. Nootropic: - pyracetamum 20%-5ml i/v 1t. a day or - pyracetamum 0.2 x 3t. a day II. Central vasodilators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day III. Blood desagregation: - pentoxifyllinum (trental) 0.2 x 3 t. a day x 10 days and next 0.1 x 3 t. a day x 10 days next 0.1 x 3 t. a day x 10 days IV. For stimulating transmission nerves impulses in synapses: Anticholinestheratic: - proserinum 0.05%-1ml i/m x 1t. a day - Ipidacrinum (neiromidinum) 0.020 x 2 t. a day x10-30 days 0.5%-1ml s/c or I/m x 1 t. a day V. Nerves system energy riser: - Acidum gammaaminobutyricum (aminalon) 0.25 x 3 t. a day - ATP-long 2%-2ml i/v 1 t. a day VI. Nonspecific stimulators: - corpus vitreum 1ml i/m x 1t. a day VII. Vitamins B1 , B2 , B6 , B12: (Neurovitan, Neiron, Neurorubine)
дексаметазон 4 мг в/м в/в 2 р/д; пірацетам 10,0 +фіз.розчин 200,0 в/в кр.; винпоцетін 4мл на 200 мл 0.9% NaCl в/в 1 р/д; пентоксифілін 5,0+ фіз.розчин 200,0 в/в кр.; вітаксон 2,0 в/м 1р/д; Blast Ear Injury – „Акубаротравма” глюкоза 40% 20,0 + аскорбінова к-та 5% 3,0 в/в крап.; мікстура спокою 1ст.л. 3р/д; підокісне введення 0,05% прозерину в трикутник Шипо за «піковою» схемою. курс ГБО. Берлитион 600 на 200 мл 0.9% NaCl в/в 1 р/д; нуклеоЦМФ 1.0 в/м 1 р/д; нейромидин 1.5% 1 мл в/м 1р/д;
Sensoneural deafness 2. Cochlear Implants Cochlear Implants consist of: 1. A microphone, which picks up acoustic information and converts it to electrical signals; 2. An externally worn speech processor that processes the signal according to a predefined strategy; 3. A surgically implanted electrode array that is in the cochlea near the auditory nerve. Incision and implant site for cochlear implantation. Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
Sensoneural deafness 6. Cochlear Implants Electrode in scala tympani (cross section of basal turn on cochlea). Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
Source: Menner Albert L. A Pocket Guide to the Ear / Thieme.- Stuttgart · New York.- 2003.- 145 p. Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997.) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
1
General condition Temperature Hyperemia of the mucous membrane not suffered SUBfebril posterior wall of the pharynx Differential diagnosis Acute kataral tonsillitis & Acute pharyngitis suffered febril tonsills
4 1. Diet. 2. Pharyngeal washing & resorption of oroantiseptics (pharyngosept, septefrylum, strepsils etc.). If the general condition suffered (in childhood): 3. Antibiotics (аmoxicillini 0,5х3 t. a day х7 days). 4. Nonsteroid anti-inflammatory drugs (amizoni 0,25х1t.a day х10 days). 5. Desensitation (desloratadinum 0,01х1t.a day х10 days). 6. Compress with 40-50% alcohol on neck. Treatment of the acute pharyngitis
Chronic katarrhal pharyngitis 1. Light diet, voluminous water drinking. 2. Oroantiseptics (chlorhexidini hydrochloridi 0.005 х6 t. a day х5 days resorption intrapharyngeal). 3. Local nonsteriod anti-inflammatory remedies (biclothymoli 4(6) t. a day х10 days). Chronic heperplastic pharyngitis + electrocoagulation, chemical cautery, cryodistruction, surgical remuving of lymphoid hyperplastic focus (folliculs) Chronic atrophic pharyngitis + washing mucous membrane (gargling) , + stimulation of mucous glands by Lugol’s solution, + biogenic stimulators (aloes, placentae). Chronic pharyngitis
Catarrhal [superficial] acute tonsillitis Catarrhal acute tonsillitis in childhood
 Primary,  Secondary (Miscellaneous throat conditions ): - infectious deseases (diphtheria, scarlet…) - blood deseases (mononuclear acute tonsillitis (Pfeiffer’s glandular fever), agranulocytosis …) Factor of localisation: - acute tonsillitis (of palatine tonsills) - acute tonsillitis of lingual tonsill, - acute tonsillitis of nasopharyngeal tonsill, - acute tonsillitis of tubal tonsills, - Laryngeal acute tonsillitis. 2 Classification of acute tonsillitis
1 І. Subjective: 1. Infectious [infective] (general weakness, fever (chill; shivering), hyperhidrosis, headache...) 2. Local (sore throat, hypersalivation, nasality (nasonnement)...) ІІ. Objective: 1. Infectious [infective] (hypertermia, leucocytosis, ESR...) 2. Local (hyperemia of mucose membrane of tonsills, hypersalivation, nasality (nasonnement), lymphadenitis...) + peculiarity depend on kind of acute tonsillitis: - Without intoxication (ulcerous-membranous) - Membranes by crypt ostium (membranous, lacunar tonsillitis), - With yellowish spot (follicular), - Hemorrhage (grippe, flu)... Checkup: - Swab for BL-investigation !!! (diphtheria!!!), - bulk blood analysis (leucosis, agranulocytosis, monocytosis..) Symptom of acute tonsillitis
Follicular tonsillitis lacunar tonsillitis
Ulcerous-membranous tonsillitis (Simanovsky-Plaut-Vincent) trench mouth Viral tonsillitis
Fungal tonsillitis Acute tonsillitis of nasopharyngeal tonsill (adenoiditis)
1  1. The desease is taking its like severe Infectious disease, + convulsion with hypertermia, + pseudo opisthotonus.  2. With dispepsia, nausea, vomit(ing) (retching), , meteorism (tympanism); wieght doesn’n taking normal.  3. Respiratory insufficiency (restriction of lungs excursion).  4. More often laryngitis, bronchitis, pneumonia.  5. More frequently otitis.  6. Soft palate paresis possible.  7. Maceration angle mouth skin. Peculiarity of acute tonsillitis in childhood
1 Patient can be isolated at home or infectious department. 1. Bed regime (stay in bed) for complications prevention. 2. Light diet, voluminous water drinking. 3. Antibacterial (amoxicillini 0,5х3 t. a day х7 days). 4. Oroantiseptics (chlorhexidini hydrochloridi 0.005 х6 t. a day х5 days resorption intrapharyngeal). 5. Local nonsteriod anti-inflammatory remedies (biclothymoli 4(6) t. a day х10 days). 6. Nonsteriod anti-inflammatory remedies (aspirini 0,5х3 t. a day х10 days). 7. Desensitation (loratadini 0,01х1 t. a day х10 days). 8. Neck compresses (40-50% alkohol or 25% dimethylsulfoxidi with antibiotic х5-7 days). Treatment of acute tonsillitis
1 1. Severe general condition, intoxication… 3. Localy: errosion, cyanosis, edema more than hyperemia, or dull greyish membrane formation is present on the tonsil and extends beyond e.g., on to the pillars, palate or uvula. It is not easily detachable with bleeding mucous membrane. but till the 2st day it is whitish easily detachable. or hemorrhage. Diphtheria of pharyngis 4. Face, neck edema. 5. Regional lymphadenitis. 6. Toxic lesion of the peripheral nerves – polineuritis (soft palate, vocal cord paresis..) 7. Toxic lesion of the heart muscle. 8. Toxic lesion of the kidneys. Obligated investigation Swab for BL-investigation !!!
1 Form of Diphtheria 1. Katarrhal (edema, cyanosis more than hyperemia). 2. Membraneous: - local, - diffuse (dull greyish membrane formation on the tonsills and extends beyond e.g., on to the pillars, palate, uvula. It is not easily detachable with mucous membrane bleeding. 3. Toxic: - SubToxic (I stage) – edema till half of neck. - Toxic (II stage) – edema till clavicle. - HyperToxic ( III stage) – below clavicle. 4. Hemorrhagic (+ Hemorrhage).
1 Obligated investigation: - Swab for bacteriological examination (Leffler’s bacillus ) !!! Treatment: 1. The specific drag is antidiphtheria serum. If the diagnosis is not dear, 10,000-100,000 units of antidiphtheria serum are injected intramuscularly immediately after testing the sensitivity of the patient to the antitoxin depending on the toncity of the patient. 2. Antibacterial 3. Detoxication. 4. Anti-inflammatory. 5. Antiedematic. 6. Symptomatic. Treatment of the Diphtheria
1 Infectious Mononucleosis Synonyms: Pfeiffer’s glandular fever, kissing disease 1. Assotiation with the Epstein–Barr virus (EBV). The incubation period is 7–9 days. 2. It predominantly affects adolescents. 3. System poliadenopathia. 2. Hepatosplenomegaly. 3. Peripheral blood monocytosis. 4. Paul-Bunnel (92,5%) Tomchik reaction (90,7%). 5. Long-termclinical course with relapse (till 2 month). Localy - Any form of the acute tonsillitis (katarrhal, membranous, necrotic) - Sometimes petechial rash и exantema on the mouth mucous membrane, - Hemorrhage on the margin of the soft & hard palate, cheeks. Treatment: 1. Like any acute tonsillitis & Symptomatic. 2. Anti-viral (anti-EBV serum).
2  1. Genaral condition is normal.  2. Body’s temperature is normal.  3. Pharyngeal pain is absent.  4. Lymphadenitis (painfull).  5. Dull greyish membrane formation on one tonsil. It is easily detachable. Ulcer crater with greyish fundus & Irregular border.  6. Spirochаeta buccalis + bac.fusiformis (saprophits!). Treatment: = acute tonsillitis  1. Penicillinum i/m х7 days.  2. Gargling with КМО4, Н2О2...  3. Coagulation the ulcer by 5% Iodium spirituosae, 40% AgNO3…  4. Vitaminotherapy, high-calorie diet, nourishing diet … Plaut–Vincent angina (trench mouth) Finland tonsillitis
2 Acute (catarrhal, pseudomembranous, membranous-ulceric) Trivial (light) form: - general condition is satisfactory, subfebrility, - possible spontaneous convalescence in 2-3 weeks, Serious form (like diphtheria): - Severe general condition, febrility, - regional lymphadenitis, - lingering clinical course, treatment with temporary benefit Chronic form (month - years): - often after long-term care by antibiotics, - general condition is satisfactory, subfebrility, - yelowish long-term membranes on soft palate, tonsills, posterior wall of pharynx, isn’t changed after usual treatment Fungal acute tonsillitis + stomatitis, glosittis (Candida albicans)
2 Diagnosis: - only after exclusion diphtheria, - identification of Candida, - positive benefit after proof antifungal therapy Treatment: - cessation of antibioticotherapy, - Local & system antifungal therapy (nystatinum, laevorinum, nitrofunginum, mycosporum…) - obligatory restorative & stimulative therapy Fungal acute tonsillitis + stomatitis, glosittis (Candida albicans)
2  Local: - paratonsillitis (quinsy), - parapharyngitis, - retropharyngitis, - mediastinitis...  General: - tonsillogenic sepsis, - rheumatic fever... Complications of the acute tonsillitis
Винницкий национальный медицинский университет им.Н.И.Пирогова кафедра ЛОР-болезней Барциховский Андрей Игоревич
Chronic tonsillitis – infectious-allergic desease with prevalence lesion palatine tonsills lymphatic pharyngeal tissue
1. More than 2 acute tnsillitis a year (anamnesis morbi). 2. Purulent discharge from tonsillar crypt. 3. Hyperemia, hyperplasia, edema ant.&post. palatine arch. Scar between tonsills and tonsillar pillar. 4. Regional lymphadenitis (lymphnodes before ant.margin m.sternocleudomastoideus in upper 1/3. Reliable (trustworthy) symptoms of chronic tonsillitis
Symptoms of decompensations Absent In time acute stage Continiously Lucovsky’s Compensation (stage) SubCompensation DeCompensation Preobradgensky’s Simple Toxico-allergic 1st stage Toxico-allergic 2nd stage Classification of chronic tonsillitis
1. Clinical (metatonsillar & related deseases): - local: paratonsillitis, parapharyngitis, retropharyngitis, purulent lymphadenitis, neck phlegmon... - general: rheumatic fever, miocarditis, arthritis, glomerulonephritis... 2. Laboratory: - general: “+” rheumatic-test (СRP, seromucoid..), - ECG-pathology, GBT, GUT - local: functional activity of lymphocytes after microbal antigen stimulation...) Symptoms of decompensation of chronic tonsillitis = Sign of lesion another organs and systems of ograns:
Symptoms Course of to Detection NSAID Thermoneurosis Continuously Accidental Without changing t o Infectious subfebrility Day deviations Infectious syndrom Decreasing to Differential diagnosis infectious subfebrility with central nerves system thermoneurosis NSAID – NonSteroid AntiInflammatory Drugs
Tests Crypt washing Tonsills massage Tonsillogenic Decreasing t o Increasing t о NonTonsillogenic Without changing t o Without changing t o Differential diagnosis tonsillogenic subfebrility with any infectious nonTonsillogenic subfebrility
1. Conservative: - general - local (Lucovsky’s, Kolomiychenko’s, Kischuk’s schema). 2. Surgical (tonsillectomy). 3. Half-surgical (cryotonsillotomy, ultrasound cryotonsillotomy, cript orifice cuting by spesial knife or LASER evaporator). Treatment of chronic tonsillitis
General: 1. Increasing general reactivity for prevention acute tonsillitis (regimen of work & rest, nourishing diet (high-calorie diet), physical trayning, sanatorium-and-spa treatment...); 2. Desensitation (nonspecific, specific - strptpcocci allergen on the surface of tonsills...) Local: Lukovsky’s schema: 1st week: а) - washing crypt 1t. a day, б) - painting iodine-glycerin 1t. a day; 2nd week: - а), б) - every other day, + massage of tonsills; 3d week: - а) и б) - twice a week, + snoot-quartz endooraly. Conservative therapy of chronic tonsillitis 1
Kolomiychenko’s schema: 1. 1st course = Lukovsky’s schema (but... washing by penicillini, gargling with календулой, painting by iodine solution, from 2nd week - snoot- quartz endooraly, from 3rd week - high frequency therapy on tonsills); 2. Interruption 1-3 months; 3. 2nd course - tonsillar crypt stopping (filling) (1t. in 7 days N4-8) + ultrasound therapy on tonsills N10). Kischuk’s schema: 1. Tonsillar massage (1t. a day N10). 2. Lugol’s (iodine-glycerin) solution painting (1t. a day N10). 3. Thymomimetic’s intratonsillar injection (thymogen) (1t. a day N10). 4. Magnetic therapy (1t. a day N10). + general 5. Loratadinum 0.01 (1t. a day х10). 6. Extract Alloes 1ml i/m (1t. a day х10). 7. Exinacea 2.2ml i/m every other day (N5). 8. Vit B1-B6 5% 1ml i/m every other day (N10). Conservative therapy of chronic tonsillitis (local) 2
Indications for tonsillectomy: 1. Conservative treatment twice a year 2 years without benefit, 2. Decompensation stage of chronic tonsillitis. - local sign (paratonsillitis, parapharyngitis, retropharyngitis...), - general sign (metatonsillar complications - rheumatic fever..) Contraindications for tonsillectomy: 1. General continuous: - any organs deseases in decompensation stage, - blood desease with coagulopathy, - tumor any malignancy & localisation, - psychotic deseases. 2. General temporary: (infectious deseases,pregnancy…) 3. Local temporary: (acute tonsillitis, otitis, thynitis…). 4. Local continuous: (carotid artery anomaly – tonsil’s pulsation...) Surgical treatment of chronic tonsillitis - tonsillectomy
3 If simultaneously indications & contraindications for surgical treatment (tonsillect6omy) are present: 1. Indications for tonsillectomy: - conservative treatment twice a year 2 years without benefit, - decompensation stage of chronic tonsillitis. & 2. Contraindications for tonsillectomy: - general (continuous, temporary), - local (continuous, temporary) Half-surgical treatment of chronic tonsillitis
Chronic tonsillitis Acute tonsillitis (anamnesis) Purulent discharge from crypt Changing palatine folds regional Lymphadenitis -- Hypertrophy of palatine tonsills -- -- -- -- Hypertrophy all of tonsills Differential diagnosis between Chronic tonsillitis & hypertrophy of palatine tonsills Treatment (tonsillotomy): - if the 3rd stage & - if the 2nd stage with swallowing or breathing disturbances
Hypertrophy of the nasopharyngeal tonsil (adenoids)
4
ENT LECTURES Combined.pdf
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ENT LECTURES Combined.pdf

  • 1. Classification of otitis • Зовнійшній External (outer) otitis, • Середній Media (middle) otitis, • Внутрішній Internal (inner) otitis • Гострий гнійний середній отит Acute suppurative otitis media, • Рецидивуючий середній отит Recurrent otitis media, • Хроніний середній отит Chronic otitis media Хроніний гнійний середній отит Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Chronic suppurative otitis media: – Mesotympanitis, – Epitympanitis, – Specific (tb) Хроніний негнійний середній отит Chronic nonsuppurative otitis media: – Сальпінгоотит (Eustacheitis, catarral, tubotympanitis); – Секреторний отит (secretory otitis, nonsuppurative otitis media with effusion); – Адгезивний отит (adhesive otitis); – Тимпаносклероз (tympanosclerosis)… (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
  • 2. Гострий гнійний середній отит Acute otitis media Local sign: Complains: • 1. Вушний біль (Otalgia, earache – 1st stage). • 2. Виділення з вуха (Otorrhea - 2nd st.). • 3. Зниження слуху (Hearing loss, deafness – 1-3rd st.). • 4. Шум у вусі (Tinnitus 1-3rd st.). Otoscopy: • Гіперемія, випинання барабаної перетинки (Hyperemic, thickened eardrum, bulging - 1st stage), • Перфорація барабаної перетинки (Tympanic • Перфорація барабаної перетинки (Tympanic membrane perforation - 2nd stage), • Слизово-гнійні виділення (muco-purulent discharg - 2nd stage). Інфекційно-інтоксикаційний синдром (особливо у дитячому віці) (infectious-intoxicative syndrom (especially in childhood)): • Підвищення to тіла, інтокскація, лейкоцитоз… • (Pyrexia, Intoxication, leucytosis ...) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 3. Stages of Acute Otitis Media 1.1. Стадія доперфорації (prePerforative stage): • Скарги: біль, зниження слуху, шум у вусі • Отоскопія: гіперемія, потовщення барабаної перетинки 1.2. Предперфоративний период доперфоративноїх стадії (prePerforative period of the prePerforative stage): • Скарги: + нестерпний біль… • Отоскопія : + випинання барабаної перетинки… 2. Стадия перфорации (perforative stage): • Перфорация барабанной перепонки - оторрея • Зниження слуху, шум у вусі • Зниження слуху, шум у вусі 3. Наслідки (sequelae): a) одужання; b) хронізація c) ускладнення: 1) мастоідити; 2) параліч лицьового нерва; 3) лабіринтити; 4) внутрішньочерепні... Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 4. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
  • 5. Acute otitis media Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 6. Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 7. Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 8. 3. Sequelae of Acute Otitis Media 3.1. Одужання (Healing - healthy ear): - без залишкових ознак (full restoring of the tympanic membrain, conductive system); - кальціфікація барабанної перетинки (calcification of the tympanic membrane); 3.2. Хронізація: (chronic otitis): Хронічні гнійні перфоративні середні отити (Chronic suppurative perforative otitis media): - мезотимпаніт (mesotympanitis); - епітимпаніт (epitympanitis). Хронічні негнійні середні отити: (Chronic nonsuppurative otitis media) - Сальпінгоотит (Eustacheitis, catarral, tubotympanitis); Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. tubotympanitis); - Секреторний отит (secretory otitis, nonsuppurative otitis media with effusion); - Адгезивний отит (adhesive otitis); - Тимпаносклероз (tympanosclerosis)… 3.3. Ускладнення (complications): - Intratemporal: 1) мастоідити (mastoditis); 2) парез лицьового нерва (facial nerve paralysis); 3) лабіринтити (labyrinthitis); 4) внутрішньочепні - Intracranial: менінгіти, абсцеси мозку… (meningitis, brain absces etc.) (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 9. Sequelae & Complications of the Otitis Media • Sequelae a) healing and healthy ear, b) chronic otitis (mesotympanitis, epitympanitis, Atelectasis, Adhesive otitis, tympanosclerosis or perforative otitis), c) complications: • Intratemporal Complications: - Acute Mastoditis (1.4, 1.7, 1.8, 2.1, 2.2), Petrositis, - Facial nerve paralysis, - labyrinthitis (Local or diffuse). 1 - labyrinthitis (Local or diffuse). • Intracranial Complications: - Extradural abscess (1.2), - Meningitis, - Subdural abscess (1.1), - Temporal lobe brain abscess (1.3), - Cerebellar abscess (1.6), - Lateral (sygmoid) sinus thrombosis (2.3), - Otic hydrocephalus. 2
  • 10. Management of Acute Otitis Media 1. Похідні карбол-гліцеринових вушних крапель (ear drops): 1st stage – феназон 0,5+лідокаїн 0,1+гліцерин 10 (Ототон) 2nd stage – антибіотик (не ототоксичний, без спирту, теплий) з димексидом 25% або кортикостероідом. 2. Назальні (топічні) деконгестанти (nasal decogestans): фармазолін 0,1% - 3 краплі 3 рази на добу в ніс 5(7) діб 3. НПЗЗ (nonsteroid antiinflamatory): діклофенак натрія 0,05-0,15 1-3 р/д 3-5 діб після їжі, запивати (Na diclofenaci 0,05-0,15 1-3 t/d 3-5 days after eating with water). 4. Антигістамінні (antihystamine): лоратадин 10 мг (Loratadinum 10 mg). 5.1. Watchful Waiting (72 hours) – спостереження без АБ-терапії initial watchful waiting without antibiotic therapy initial watchful waiting without antibiotic therapy for healthy 2-year-olds or older children with nonsevere illness (mild otalgia and fever <39°C). 5.2. Антибариальна терапія (аntibioticоtherapy): Amoxicillin (80 mg/kg with clavulanate (0.125-0.75) 6. Surgical Measures: Парацентез (tympanotomy, myringotomy) Найчастіше в задньо-нижньому відділі барабанної перетинки (mainly in posterior-inferior quadrant of the tympanic membranes) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 11. Особливості хронічних гнійних перфоративних середніх отитів Peculiaryties of Chronic Suppurative Otitis Media • Постійна перфорація барабанної перетинки (Chronic tympanic membrane perforation). • Постійна або рецидивуюча гноєтеча (або ні). Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. або ні). (Chronic or recurrent mucopurulent otorrhea (or not)). • Зниження слуху (hearing loss). • Шум у вусі (Tinnitus). • Грануляції, поліпи у вусі (granulation, ear polip). (Pain is not a usual feature like polyp or granulation tissue formation). (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
  • 12. Chronic suppurative otitis media Chronic mesotympanitis & Chronic epitympanitis • Виділення з кров’ю, каріозним запахом, кусочками холестеатоми, кістковим піском, лусочками епідермісу (bloodstained otorrhea, with cariotic smell, pieces of cholesteatoma, bone sand, desquamous epithelium); • Крайова перфорація у ненатягнутій частині (Marginal perforation in pars flaccida); • Шорсткість кістки при ощупуванні стінок б/порожнини (probe test - rough bone of the tympanic cavity walls); • Вимивання канюлею Гартмана кусочків холестеатоми, кісткового піску, лусочoк епідермісу (cholesteatoma, bone sand, desquamous epithelium by washing attic with Hartmann canulae); • Поліпи, грануляції (polyp or granulation tissue formation); • Руйнування кістки на КТ, овальна холестеатома на МРТ (bone destruction by X-rays examinations CT, MRI); • Змішана приглухуватість (conductive & sensoneural hearing loss by audiological investigation). Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
  • 13. Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 14. • Remission stages, • Exacerbation stages, Chronic purulent epitympanitis • External meatus polips, • cholesteatoma in the external meatus. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
  • 15. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
  • 16. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
  • 17. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999)
  • 18. Treatment Summary for Otitis Media. Acute Otitis Media (AOM) Otitis Media with Effusion Chronic Suppurative Otitis Media Watchful waiting Up to 72 hours with analgesia / antipyretics if nonsevere and patient > 2 years old For 3 months from onset or diagnosis not indicated Medical therapy Antibiotics (amoxicillin) not indicated Aural toilet and topical antibiotics (quinolones) Surgical intervention Myringotomy for refractory AOM VT insertion if unresolved after 3 months Tympanoplasty Cortical mastoidectomy in nonresponding mastoiditis Adenoidectomy on second VT insertion Tympanomastoid surgery if refractory to medical therapy NI - not indicated; VT - ventilation tube.
  • 19. Source: Menner Albert L. A Pocket Guide to the Ear / Thieme.- Stuttgart · New York.- 2003.- 145 p. Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997.) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
  • 20. Classification of otitis • Acute Otitis Media Suppurative, • Recurrent, • Chronic Otitis Media • External (outer), • Media (middle), • Internal (inner) – Suppurative • Mesotympanitis, • Epitympanitis, • Specific (tb) – Nonsuppurative • Eustacheitis (catarral, tubotympanitis) • Nonsuppurative Otitis media with effusion (secretory otitis)
  • 21. Factors Relevant to the Epidemiology of Otitis Media Environmental Factors • Day-care attendance. • Not being breast-fed. • Exposure to tobacco smoke. • Seasonal variation in respiratory infections. • Host Factors. Genetics • Immunodeficiency. • Birth defects. • Cleft palate. • Down syndrome.
  • 22. Acute Otitis Media Essentials of Diagnosis – Local sign: • 1. Otalgia (earache). • 2. Hearing loss (deafness). • 3. Tinnitus. • 4. Otorrhea (2nd stage). Otoscopic: • Thickened, bulging, hyperemic tympanic membrane (eardrum), • Perforation (2nd stage), • Purulent discharg (2nd stage). – General sign: • Pyrexia, • Intoxication.
  • 23. Stage of Acute Otitis Media • 1. Stage before perforation (preperforative) • earache • hearing loss • tinnitus Otoscopy • thickened hyperemic tympanic membrane • immobile on pneumatic otoscopy. • 2. Stage after perforation (perforative) • spontaneous rupture of the tympanic membrane or after myringotomy • resulting in otorrhea • 3. Sequelae of Acute Otitis Media a) healthy ear b) chronic otitis (Adhesive or perforative otitis media) c) complications: - Intratemporal Complications: 1) Mastoditis; 2) Facial nerve paralysis; 3) Suppurative labyrinthitis; 4) - Intracranial Complications: (meningitis, brain abscecc etc.)
  • 24. Treatment of Acute Otitis Media 1. Ear drops 1st stage - Carbol-glycerinici ear drops (Otipax) 2nd stage - Antibiotoc with corticosteroid or antibiotic with 25% dimetylsulfoxid 2. Nasal drops (local or topical decongestans) or general decongestans (pseudoephedrini hydrochloridi 3. Antibiotic Therapy - Amoxicillin (80 mg/kg/d given in three divided doses for 10 days) remains the first-line therapy, - In resistant cases, amoxicillin (0.5-0.8) should be given in combination with clavulanate (0.125-0.75). or • Watchful Waiting (72 hours) initial watchful waiting without antibiotic therapy for healthy 2-year-olds or older children with nonsevere illness (mild otalgia and fever <39°C) 4. Adjunctive Therapy • analgesics and antipyretics 5. Antihistamine, antiallergic 6. Surgical Measures • - myringotomy
  • 25. Essentials of Diagnosis “Acute Kataral Otitis Media” “acute eustacheitis”, “acute tubotympanitis” – Local sign: • Acute katar of airways (Acute rhynopharyngitis or rhynosinusitis). • 1. Hearing loss (deafness). • 2. Tinnitus. • 3. Fluctuation of hearing Otoscopic: • Concave tympanic membrane: – General sign: • If rhynosinusitis is viral
  • 26. Management of the “Acute Kataral Otitis Media” “acute eustacheitis”, “acute tubotympanitis” • 1. Treatment of acute katar of airways. • 2. Intranasal (local) or general decongestant. • 3. Eustachian tube inflation: – 1. Toinby procedure. – 2. Valsalva’s procedure. – 2. Politzerisation. – 3. Catheterisation and inflation Technics of Politzerisation.
  • 27. Management of the “Acute Kataral Otitis Media” “acute eustacheitis”, “acute tubotympanitis” • 3. Eustachian tube inflation: – 1. Toinby’s procedure. – 2. Valsalva’s procedure. – 2. Politzerisation. – 3. Catheterisation and inflation Technics of Eustachian tube catheterisation: 1 - ear catheter; 2 - ostium pharhyngeum auditory tube.
  • 28. Peculiarity of the acute middle otitis in childhood – General sign (always): • 1. Intoxication, • 2. Pyrexia, • 3. Meningismus • 4. Dyspepsia, meteorismus. • 5. Lungs insufficiency. • 6. Weight insufficiency, • 7. More often middle otitis then in adult (micsoid tissue, peculiarity of Eustachian tube) – Local sign: • 1. “Tragus” sign positive. • 2. “rumination” (“mastication”) sign positive • 3. Normal eardrum with middle otitis. • 4. More often diagnostic paracentesis. • 4. Hyperemia without middle otitis.
  • 29. Peculiarity of the acute viral otitis media – Local sign: Otoscopic: • 1. Hemorrhage on the normal tympanic membrane, • 2. Vesicles with water-like fluid or hemorrage, • 3. Sensoneural hearing loss. – General sign: • Pyrexia, • Intoxication.
  • 30. Peculiarity of the Tb otitis – Local sign: – Otoscopic: • 1. Multiply perforstions. • 2. Discharge like Cheese. – X-rays examination • 3. Bone Secvestration. – General Tb sign: • The lungs focus, • Intoxication.
  • 31. Sequelae & Complications of Otitis Media • Sequelae a) healthy ear b) chronic otitis (Atelectasis, Adhesive, Tympanosclerosis or perforative otitis media) c) complications: • Intratemporal Complications: - Acute Mastoditis - Petrositis - Facial nerve paralysis - Local or diffuse Suppurative labyrinthitis • Intracranial Complications: - Meningitis, - Subdural abscess, - Extradural abscess, - Temporal lobe of brain abscess, - Cerebellar abscess, - Lateral (sygmoid) sinus thrombosis, - Otic hydrocephalus
  • 32. Chronic Suppurative Otitis Media • Chronic or recurrent otorrhea or both. • With pain (earache) or not • Hearing loss. • Tinnitus. • Chronic tympanic membrane perforation.
  • 33. Pathogenesis of Chronic Suppurative Otitis Media There are two main mechanisms by which a chronic perforation can lead to continuous or repeated middle ear infections: • 1) Bacteria can contaminate the middle ear cleft directly from the external ear because the protective physical barrier of the tympanic membrane is lost. • 2) The intact tympanic membrane normally results in a middle ear "gas cushion," which helps to prevent the reflux of nasopharyngeal secretions into the middle ear via the eustachian tube. The loss of this protective mechanism results in the increased exposure of the middle ear to pathogenic bacteria from the nasopharynx.
  • 34. Symptoms and Signs of Chronic Suppurative Otitis Media • history of otorrhea, intermittent or continuous, • hearing loss, • discharge is usually mucopurulent, • polyp or granulation tissue formation, • bloodstained otorrhea, • Pain is not a usual feature
  • 35. Otitis chronica with cholesteatoma • Retraction of the tympanic membrane with a squamous debris collection or a whitish mass behind an intact tympanic membrane. • Squamous epithelium in the middle ear or mastoid. Testing includes computed tomography (CT) scanning
  • 36. Chronic suppurative otitis media Chronic mesotympanitis & Chronic epitympanitis (or cholesteatomic or malignant) • Bloodstained otorrhea, with bad cariotic smell, pieces of cholesteatoma, bone sand, desquamous epithelium, • Marginal perforation in pars flaccida, • Probe test (Rough bone of the tympanic cavity walls), • Hartmann test (find the cholesteatoma, sand bone, desquamous epithelium by washing attic), • Polyp or granulation tissue formation, • Bone destruction by X-rays examinations, • Conductive & sensoneural hearing loss by audiological investigation,
  • 37. Special Tests for diagnostic Chronic Suppurative Otitis Media • A swab of the discharge should be sent for culture and sensitivity, preferably before beginning antimicrobial therapy. • If granulations are severe and unresponsive to antimicrobial therapy, then chronic granulomatous conditions such as - Wegener granulomatosis, - mycobacterial infection, - histiocytosis X, and - sarcoidosis should be considered. Biopsy of the granulation or polyp in these circumstances is recommended.
  • 38. Pathogenesis of cholesteatoma Acquired Cholesteatoma • Cholesteatoma is the presence of squamous epithelium in the middle ear, mastoid, or epitympanum. • Primary acquired cholesteatoma is the most common of these types and forms as a retraction of the tympanic membrane. In most cases, the retraction occurs in the pars flaccida, although pars tensa retractions can also occur. • Secondary acquired cholesteatoma forms as a result of either squamous epithelial migration from the tympanic membrane or implantation of squamous epithelium into the middle ear during surgery, such as ventilation tube placement or tympanoplasty. Congenital Cholesteatoma • Cholesteatomas that occur without tympanic membrane retraction or implantation of squamous epithelial material are considered to be congenital in origin. This type comprises a minority of cholesteatoma cases. • It is classically defined as an embryonic rest of epithelial tissue in the ear without tympanic membrane perforation and without a history of ear infection.
  • 39. Clinical Findings (Symptoms and Signs) Patients with cholesteatomas Patients with acquired cholesteatomas typically present with • recurrent or persistent purulent otorrhea and • hearing loss. • Tinnitus is also common. • vertigo or dysequilibrium can result from the inflammatory process in the middle ear or, in rare cases, from direct labyrinthine erosion by cholesteatoma. • Facial nerve twitching, palsy, or paralysis can also result from the inflammatory process or from mechanical compression of the nerve. Physical findings are usually diagnostic in cases of acquired cholesteatoma. • In primary acquired cholesteatoma, there will be a retraction of the pars flaccida in most cases • retraction contain a matrix of squamous epithelium, • purulent otorrhea, • polyps and • granulation tissue, • and ossicular erosion. • In secondary acquired cholesteatoma, the findings depend on the cause. If the cholesteatoma developed from a tympanic membrane perforation, the squamous epithelial matrix, keratin debris, or both are usually visible through the perforation. • Congenital cholesteatomas are usually asymptomatic until the mass grows to a sufficient size that the ossicular chain function becomes disrupted and hearing loss develops.
  • 40. Surgical Procedures for Cholesteatoma Procedure End Result Advantages after Surgery Disadvantages after Surgery Tympanoplasty (canal wall up) with mastoidectomy Ear canal with tympanic membrane Low risk of otorrhea Risk of recurrent pars flaccida cholesteatoma Atticotomy Ear canal with tympanic membrane and defect into epitympanum Intermediate risk of otorrhea Risk of recurrent pars flaccida cholesteatoma Modified radical mastoidectomy (canal wall down) Mastoid cavity with tympanic membrane Low chance of recurrent pars flaccida cholesteatoma Significant risk of otorrhea Radical mastoidectomy (canal wall down) Mastoid cavity without tympanic membrane Low chance of recurrent pars flaccida and pars tensa cholesteatoma Significant risk of otorrhea and poor hearing
  • 41. Treatment Summary for Otitis Media. Acute Otitis Media (AOM) Otitis Media with Effusion Chronic Suppurative Otitis Media Watchful waiting Up to 72 hours with analgesia / antipyretics if nonsevere and patient > 2 years old For 3 months from onset or diagnosis not indicated Medical therapy Antibiotics (amoxicillin) not indicated Aural toilet and topical antibiotics (quinolones) Surgical interven tion Myringotomy for refractory AOM VT insertion if unresolved after 3 months Tympanoplasty Cortical mastoidectomy in nonresponding mastoiditis Adenoidectomy on second VT insertion Tympanomastoid surgery if refractory to medical therapy NI - not indicated; VT - ventilation tube.
  • 42. Local or diffuse Suppurative labyrinthitis Local labyrinthitis: • Caused epitympanitis, • Fistule of the ampullae of the horizontal semicircular canal, • Fistule symptom, • Treatment like epitympanitis – radical mastoidectomy Diffuse labyrinthitis: - Serous. - Suppurative. Diffuse Serous: ill side Contralatreral side Contralatreral side Contralatreral side Contralatreral side (by both hand) Time more then 40 sec Less then 50 ml Diffuse purulent: Contralatreral side ill side ill side ill side ill side (by one hand) Time more then 40 sec More then 50 ml Sign Direction of nystagmus Direction of Falling Falling down in static tests Deviation in Dynamic tests Deviation in coordinative tests (finger-nose test) Rotatory test Caloric test
  • 43. Classifacation of the mastoiditis & paramastoiditis • Acute, • Subacute, • Chronic, • Latent, Mastoiditis: • Tipical form, • Tip form, • Perisinuosus abscess, Paramastoiditis: • Subperiostal abscess, • Zygomaticitis, • Occipititis, • Squamitis, • Petrositis, • Apicitis etc.
  • 44. Acute mastoiditis General sign of the inflamatory process: • Intoxication, hight temperature, leucocytosis etc. Sign of otitis (acute or chronic): • (earache, discharge, tinnitus, hearing loss). Local common sign of the mastoiditis: • Painful palpation of the mastoid, • Thickness soft tissue under mastoid, • X-rays sign (cells shadow), • Thickness of the posterior-superior part the bone part of the external meatus, Special Local sign of the mastoiditis: It depend on the localisation: • Tip form, • Perisinuosus abscess, • Zigomaticitis, • occipititis, • squamitis, • petrositis, • Apicitis etc.
  • 45. 1. Surgical treatment: It depend on the cause of the mastoiditis!!! • If mastoiditis was caused by acute otitis the patients needs in simple mastoidotomy (“Shwart’s or cortical mastoidectomy”). • If mastoiditis was caused by chronic otitis the patients will be treated by radical mastoidectomy. 2. Conservative treatment: • Antibiotics (general & local), (especially lincosamine group), • Dehydratation, • Detoxication, • Antiinflammatory remedies, 1. Management of the mastoiditis
  • 46. 1. Selection of Surgery otogenic any complications: • If mastoiditis was caused by acute otitis the patients needs in simple mastoidotomy (“Shwart’s or cortical mastoidectomy”). • If mastoiditis was caused by chronic otitis the patients will be treated by radical mastoidectomy. 2. Management of the mastoiditis
  • 49. Complications Otitis chronica with cholesteatoma The major sequelae are • bone erosion, erosion of the ossicular chain, • otorrhea, • sensorineural hearing loss, • dizziness, • facial nerve injury Suppurative complications • Intratemporal Complications: - Acute Mastoditis, Petrositis, - Facial nerve paralysis, - labyrinthitis • Intracranial Complications: - Meningitis, Subdural abscess, - Extradural abscess, - Temporal lobe of brain щк Cerebellar abscesses, - Lateral (sygmoid) sinus thrombosis
  • 50. Otogenic complications of Otitis Media • Intratemporal Complications: - Acute Mastoditis, - Petrositis, - Facial nerve paralysis, - Local or diffuse Suppurative labyrinthitis • Intracranial Complications: - Meningitis, - Subdural abscess, - Extradural abscess, - Temporal lobe of brain abscess, - Cerebellar abscess, - Lateral (sygmoid) sinus thrombosis, - Otic hydrocephalus
  • 51. Otogenic extradural abscess 1. Sign of Acute or Chronic Otitis media (earache, purulent discharge, tinnitus, hearing loss). 2. Sign of Acute Mastoditis (painful mastoid, thickness of posterior- superior bony part of external meatus). 3. Local sign of extradural abscess: combination of - cistern sign (a lot of purulent discharge) with - pus pulsation (double sign)
  • 52. Otogenic meningitis 1. General Inflammatory sign: - Intoxication, - hypertermia, - leucocytosis… 2. Meningeal sign: - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 3. Sign of increasing intracranial pressure: - headache without benefit after using analgetics or with nasea, vomiting, - bradycardia, - papilloedema (swelling of papilla of eyes nerves) 4. Local sign of brain lession: - hemiparesis…
  • 53. Otogenic temporal lobe abscess of brain 1. General Inflammatory sign: - Intoxication, hypertermia, leucocytosis… 2. Sign of increasing intracranial pressure: - headache without benefit after using analgetics or with nasea, vomiting, - bradycardia, - papilloedema (swelling of papilla of eyes nerves) 3. Meningeal sign: - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 4. Local sign of brain lession: - amnestic, motor or sensorial aphasia (left side if patient is right-handed, - contralateral paresis, - dilated pupils, ptosis and lateral rectus paralysis, - homonymous hemianopia
  • 54. Stages of the brain abscess: 1. Invasive stage - stage of encephalitis. 2. Latent stage - stage of almost no symptoms. 3. Manifest stage - stage of raised intracranial tension. 4. Terminal stage - stage of rupture. on lumbar puncture, there is great pressure of cerebrospinal fluid and greater danger of coning of the medulla.
  • 55. Otogenic cerebellar abscess 1. General Inflammatory sign: - Intoxication, hypertermia, leucocytosis 2. Sign of increasing intracranial pressure: - headache without benefit after using analgetics or with nasea, vomiting, - bradycardia, - papilloedema (swelling of papilla of eyes nerves) 3. Meningeal sign: - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 4. Local sign of cerebellar lession: - 1. Falling down in static tests. - 2. Deviation in Kynetic tests. - 3. Deviation in coordinative tests (finger- nose test ) - 4. Ipsilateral asynergia (dysdia- dochokinesis). - 5. Muscles hypotonia (flaccidity). - 6. Nystagmus (continuous, big amplitude, any directions till diagonalic…)
  • 56. Otogenic lateral sinus trombosis signs 1. General Inflammatory sign: - Intoxication, hypertermia, leucocytosis And triad: - chills (shivering) and fever, - sweating (perspiring), - aperiodic chills&fever and sweating, 2. Sign of Acute or Chronic Otitis media: (earache, purulent discharge, tinnitus, hearing loss). 3. Sign of Acute Mastoditis: - painful mastoid, - thickness of posterior-superior bony part of external meatus. 4. Local sign: 1. Obstructive symptoms - Tobey-Ayer or Queckenstedt’s test (lumbar puncture and digital pressure on the internal jugular vein on the healthy side). 2. Infective symptoms (swinging temperature with rigors at irregular intervals, formation of pyaemic abscesses in various parts of the body chiefly lungs and joints, positive blood cultyre, enlarged spleen and marked leucocytosis) - Greisinger’s sign (If the mastoid emissary vein gets involved, there is oedema and tenderness over its site).
  • 57. Stage of the otogenic lateral sinus trombosis 1. The initial stage of attack when the vein wall is inflamed and there is a mural clot inside it. 2. Stage of complete obliteration of the sinus with big thrombus. 3. Suppuration of the thrombus resulting in pyaemia and multiple abscesses in the body.
  • 58. 1. Surgical treatment: It depend on the cause of the complications!!! • If any complication was caused by acute otitis the patients needs in simple mastoidotomy (“Shwart’s or cortical mastoidectomy”). • If any complication was caused by chronic otitis (epitympanitis) the patients will be treated by radical mastoidectomy. 2. Conservative treatment: • Antibiotics (general & local), (especially lincosamine group), • Dehydratation, • Detoxication, • Anti-inflammatory remedies… Management of the otogenic complications
  • 59. Meniere’s desease 2. Clinical Triad: 1. An attack of severe vertigo without of unconsciousness. 2. Vegetative disorders till nasea and vomiting. 3. One ear Tinnitus and deafness. 4. Nystagmus is labyrinthine in nature and to the side of the lesion, whereas in between the attacks it is to the opposite side. 1. Unknown causes due to endolymphatic hydrops. 3. Treatment: 1) absolute rest, sedatives, 2) dehydratation therapy. 3) drainage of the endolymphatical succ.
  • 60. Theories of Meniere’s desease (endolymphatic hydrops) 1. It is due to focal labyrinthitis from a distant septic focus. 2. It is due to vasospasm of the vessels of the stria vascularis which leads to relative ischaemia which in turn gives rise to increased permeability of the stria. 3. It is due to allergy of the labyrinth. 4. It is due to salt and water retention in the body.
  • 61. Clinical Triad of Meniere’s desease 1. Suddenly struck with an attack of severe vertigo. There is no loss of consciousness. 2. There may be vegetative disorders till nasea and vomiting. 3. There is also tinnitus in the one ear and appreciable deafness. 4. During the attack the nystagmus is labyrinthine in nature and to the side of the lesion, whereas in between the attacks it is to the opposite side. If the disease progresses, the intervals become shorter and shorter and the hearing during the free periods goes on getting worse and worse.
  • 62. Differential diagnosis of Meniere’s desease I. Diseases of the external or middle ear: 1. Earwax or foreign body in the external ear which impinges on the drum can push in ossicular chain and give rise to vertigo. 2. Inflammation of the middle ear cleft may cause sympathetic irritation of the labyrinth giving rise to vertigo. 3. Even Eustachian block can give rise to this condition. II. Central or periferal nerves system lesion: 1) eighth nerve tumour, 2) thrombosis of the posterior inferior cerebellar artery, 3) syphilis of the central nervous system, 4) disseminated sclerosis etc. involving the vestibular nuclei or their connections may give rise to vertigo. III. Epilepsy: In this disease, there is loss of consciousness which seldom occurs in Meniere’s disease. IV. Diseases of the cerebellum may give rise to vertigo but there will be no remissions as in the case of Menier’s disease. V. Cardiovascular diseases: 1) hypertension, 2) arteriosclerosis, 3) anaemias or thrombosis of relevant blood vessels in the central nervous system may also give rise to vertigo.
  • 63. 1. Treatment of Meniere’s desease The treatment resolves itself into: 1. During the attack and 2. After the attack which may be: a) medicinal, or b) surgical. 1. During the attack: 1) The patient should be transported to a safe place and put to absolute rest. 2) He should be given sedatives. 3) The dehydratation therapy. 2. After the attack is over: a) Pharmacotherapy: I. The patient is prescribed a salt-free diet and minimum intake of fluid. This does lot of good in nearly half the cases. II. The patient is given vasodilators (nicotinic acid). Once the disease is under control, the dose of nicotinic acid should be steadily reduced. III. Antiallergic drugs are given. (In histamine sensitive patients, desensitisation with histamine is advocated. Such patients are very few). IV. Streptomycin is a general depressant to the labyrinth but its action on the cochlea which is rather uncertain, prohibits its use routinely. V. Smoking and drinking should be forbidden.
  • 64. 2. Treatment of Meniere’s desease I. During the attack: 1. Calm dark environment. 2. Sedativs: - diazepamum 5mg 1(2) t. a day or - diazepamum 10mg-2ml 1 t. a day or 3. The dehydratation therapy: a) The patient is prescribed a salt-free diet and minimum intake of fluid. b) hypertonic solutions: - Sol.glucosae 40%-20ml+ + sol.ac.ascorbinici 5%-2ml i/v 1t. a day - sol.magnesii hydrochloridi 25%-5ml i/m c) diuretics: - lasix 20mg-2ml i/m 1 t. a day in the morning or - Furasemidum 40mg 1(2) t. a day in the morning II. After the attack is over: I.Salt-free diet and minimum intake of fluid. II. Vasodilators (nicotinic acid 100mg x 3 t. day) III. Pharmacotherapy like sensoneural deafness.
  • 65. 3. Treatment of Meniere’s desease 2. After the attack: a) osmotic therapy by solt
  • 66. 4. Treatment of Meniere’s desease The treatment resolves itself into: 1. During the attack and 2. After the attack: a) medicinal, or b) surgical. b) Surgical treatment: I. Removal of septic foci, e.g., infected teeth, tonsils and sinuses. II. Stellate ganglion block. III. Cervical sympathectomy. These two release nervous control over the stria vascularis. IV. Drainage of the labyrinth - (Labyrinthotomy), - drainage of the endolymphatical succ V. Labyrinthectomy (destruction of the labyrinth): - surgical, - chemical (injection of alcohol into the labyrinth). Operations on the labyrinth can be considered if the hearing of the affected ear is extremely, poor and that of the unaffected ear is reasonable.
  • 67. Meniere’s desease 2. Clinical Triad: 1. An attack of severe vertigo without of unconsciousness. 2. Vegetative disorders till nasea and vomiting. 3. One ear Tinnitus and deafness. 4. Nystagmus is labyrinthine in nature and to the side of the lesion, whereas in between the attacks it is to the opposite side. 1. Unknown causes due to endolymphatic hydrops. 3. Treatment: 1) absolute rest, sedatives, 2) dehydratation therapy. 3) drainage of the endolymphatical succ.
  • 68. Otosclerosis 1. Unknown causes. 2. Ankilosis footplate of the stapes. 3. Conductive deafness. 4. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign). 4. Piston’s stapedoplasty.
  • 69. Otosclerosis 1. Unknown causes: - Hereditary factors. - Hormonal factors (Females after Pregnancy between 20-30 years of age) - Endocrine disturbances (Ca metabolism). 2. Ankilosis footplate of the stapes. Normal bone in the middle layer of the otic capsule. is absorbed and replaced by spongy osteoid bone, which becomes thicker and less vascular at one or more constant sites. This due to Ankilosis footplate of the stapes. Morphological stage: 1. Vascularisation. 2. Osteospongious. 3. Osteosclerosis. 3. Conductive deafness. 1. Tympanal stage. 2. 2nd mixt stage 3. Sensoneural stage. 4. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign). 4. Piston’s stapedoplasty.
  • 70. Predisposing factor of Otosclerosis Many theories have been advanced but none is satisfactory. 1. Hereditary factors. White races are more commonly affected than coloured. Fair complexioned persons are more prone than dark persons. There is family history in about 50% of cases. Hereditary anomalies have all been postulated but not substantiated. Common associated conditions are Van der Hoere Syndrome and Paget’s disease. 2. Hormonal factors (endocrine disturbances). The incidence of disease is much commoner in females than in males. Pregnancy may accelerate but never causes the disease. The disease generally manifests between 20-30 years of age. 3. Different factors - localized infection, - malnutrition, - general toxaemia, - abnormal labyrinthine circulation.
  • 71. Morphological abnormality of Otosclerosis Normal bone is absorbed and replaced by spongy osteoid bone, which becomes thicker and less vascular at one or more constant sites. Morphological stage: 1. Vascularisation. 2. Osteospongious. 3. Osteosclerosis. This occurs in the middle layer of the otic capsule. Silent areas may be present which do not involve the oval window and do not cause deafness. Cochlea may be involved due to spread of osteoid bone. Its proximity to foot plate of stapes causes ankylosis.
  • 72. Clinical features of Otosclerosis 1. Hearing loss is the cardinal symptom. 2. Paracusis Willisii: Patient generally complains that she can hear better in presence of back ground noises. The simplest explanation is that a normal person raises his voice in pitch and intensity in noisy surrounding. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign).
  • 73. Clinical stage (type) of Otosclerosis 1. Tympanal stage. The deafness is of conductive type. In early stages there is an upward slope towards the right. Bone conduction shows a dip at 2000 Hz (Carhart notch) and is seen in about l/3rd of patients. 2. 2nd mixt stage High tones are only affected, if cochlea is involved. When the cochlea is invoved then there is downward slope to the right. 2. Mixt stage. 3. Sensoneural stage. Patient feels handicapped when air conduction loss exceed 50 dB.
  • 74. Differential Diagnosis of Otosclerosis 1. Healed suppurative otitis media: - Adhesive (deformity of tympanic membrane); - Tympanosclerosis (hyalinic cartilages inside tympanic membrane). 2. Chronic nonsuppurative otitis media - Eustacheitis (retraction of tympanic membrain). 3. Ossicular disconnection. 4. Perceptive deafness in young adult. 5. Congenital stapes fixation (rare). Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign).
  • 75. Surgical Treatment of Otosclerosis (stapedectomy) Surgical Treatment of Otosclerosis (stapedoplasty)
  • 76. Surgical Treatment of Otosclerosis (piston’s stapedoplasty)
  • 77. Complications surgical treatment of Otosclerosis 1. Perforation of tympanic membrane. 2. Vertigo. 3. Otitis Media. 4. Damage to facial nerve. 5. Taste disturbance. 6. Damage to membranous labyrinth. 7. Leakage of perilymph. 8. Dislocation of incus. 9. Bleeding. 10. Loss of part or whole of foot-plate into the vesitbule. Late complications: 1. Dislocation of prosthesis. 2. Meningitis. 3. Completely deaf ear. 4. Reparative granuloma.
  • 78. Otosclerosis 1. Unknown causes. 2. Ankilosis footplate of the stapes. 3. Conductive deafness. 4. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign). 4. Piston’s stapedoplasty.
  • 79. Sensoneural deafness 2. Sensoneural desorders by Tonal audiometry . х - bone conduction, о - air conduction. AD (Auris Dexter) RE (Right ear) AS (Auris Sinister) LE (Left ear) - Tinnitus ++ >5m WV >1m >20m CV >3m 20'' Tf (Tunning fork) 128 bone (N=20'') 10" 40'' Tf (Tunning fork) 128 air (N=40'') 20'' 30'' Tf (Tunning fork) 2048 (N=30'') 150'' + Rinne +"small" Weber Not longthened Schwabah shortened Not shortened 3. Left ear Sensoneural deafness. 1. Normal otoscopic picture. Sign: 1. Hearing loss. 2. Tinnitus. 3. Normal otoscopic picture. 4. Sensoneural deafness.
  • 80. 1. Causes of deafness Deafness may be classified in two ways: I. a) Congenital, b) Acquired. II. a) Conductive, b) Perceptive (sensotineural) с) Mixed - conductive and perceptive. It is two types of perceptive deafness: 1. Cochlear (sensory part) 2. Retro-cochlear or neural. I. In the inner ear. II. In the eighth nerve. III. In the central nervous system.
  • 81. 2. Causes of deafness Pharmacologic toxicity ototoxic drugs: eg - salicylates, quinine, - aminoglycoside antibiotics (drugs like streptomycin and quinine may affect the auditory nerve), - loop diuretics (furosemide, ethacrynic acid, - cancer chemotherapeutic agents (eg. cisplatin). Infectious - Otitis media, viral, syphilis, meningitis, Traumas: - transversal fractures pyramid of the temporal bone, - noise-induced Neurologic disorders: - vascular, demyelinating (eg. multiple sclerosis), - infectious, or degenerative disease affecting the central auditory pathways, - cerebellopontine angle tumors such as vestibular schwannomas (acoustic neuromas) or meningiomas; Vascular and hematologic disorders: - Migraine, cryoglobinemia Immune disorders: - Polyarteritis nodosa, HIV. Bone disorders: - Paget disease Inner ear deseases: - Meniere disease, - Cochlear otosclerosis, - Presbycusis (Age-Related Hearing Loss),
  • 82. 3. Causes of deafness Infant Infectious: - The infectious fevers in infancy (meningitis, typhoid fever, measles, mumps, whopping cough) Congenital Hearing Loss: - HIV-Related Hearing Loss (Human immunodeficiency virus (HIV) infection leads to both peripheral and central auditory system pathology. Genetic Causes: - hereditary hearing impairment (HHI) can manifest later in life. HHI may be classified as either: nonsyndromic hearing loss, in which deafness is the only clinical abnormality or syndromic hearing loss, in which deafness is associated with anomalies in other organ systems. Syndromic (More than 200 syndromes are associated with hearing loss): 1. Usher syndrome (retinitis pigmentosa and hearing loss), 2. Waardenburg syndrome (pigmentary abnormality and hearing loss), 3. Pendred syndrome (thyroid organification defect and hearing loss), 4. Alport syndrome (renal disease and hearing loss), and 5. Jervell & Lange-Nielsen syndromes (prolonged QT interval and hearing loss). Nonsyndromic: - Large vestibular aqueduct syndrome
  • 83. 4. Causes of deafness I. In the inner ear: 1. Meniere’s disease. 2. Senile deafness due to arteriosclerosis of the vessels supplying the internal ear. 3. Trauma. This maybe from noises, fractures of the temporal bone, or concussion of the internal ear or 4. Toxins. Drugs like streptomycin and quinine may affect the auditory nerve. Exogenous toxins like too much alcohol or endogenous toxins like those found in diabetes and septic foci are also likely causes. 5. General malnutrition and vitamin deficiency. II. In the eighth nerve: Eighth nerve tumour. III. In the central nervous system: 1. Tumours, vascular accidents, disseminated sclerosis, syphilis and mental deficiency etc. 2. Cortical lesions do not give rise to perceptive deafness unless both centres on the right and left are simultaneously affected because the nuclei in the brain stem send fibres to both cortical centres. Psychogenic deafness: It is that type of deafness in which there is no organic cause to explain it. 1. Hysterical or functional: In this case, the patient in reality cannot hear external sounds due to something in his subconscious mind. 2. Malingering, also cacalled feignet or simirfated deafness. In this case, the patient can, in reality, hear external sounds, but on account of some reason of personal gain, he pretends that he cannot hear.
  • 84. Sign of Sensoneural deafness Normal tonal audiometry. х - bone conduction, о - air conduction. 2. Sensoneural desorders by Tonal audiometry . х - bone conduction, о - air conduction. AD (Auris Dexter) RE (Right ear) AS (Auris Sinister) LE (Left ear) - Tinnitus ++ >5m WV >1m >20m CV >3m 20'' Tf (Tunning fork) 128 bone (N=20'') 10" 40'' Tf (Tunning fork) 128 air (N=40'') 20'' 30'' Tf (Tunning fork) 2048 (N=30'') 150'' + Rinne +"small" Weber Not longthened Schwabah shortened Not shortened 3. Left ear Sensoneural deafness. 1. Normal otoscopic picture.
  • 85. 1. Treatment of Sensoneural deafness I. Its depend on causes: 1. Creating a Favorable Environment for Hearing. 2. Toxic – antidot or detoxication: - Streptomycinum - Vit B15; - spiritus methylicus - spiritus aethylicis. 3. Local vasospasmus - central vasodilatators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day 4. Hypertension - peripheral vasodilatators: 5. Symptomatic hypertension: - renal - surgery; - endocrine - hormonal therapy… 6. Thrombosis: - Sol. Heparini natrici 5000 “ME”/ml – 1(2)ml i/v x 1(3) t. a day + next days s/c(abdomen) 5000 x 2 t. a day 7. Haemorrage: - tab. Ethamsilatum 0.25 x 3 t. a day; - sol. Ethamsilatum 12.5%-2ml I/v or I/m 2(3) t. a day
  • 86. 2. Treatment of Sensoneural deafness II. Nonspecific Pharmacotherapy: I. Nootropic: - pyracetamum 20%-5ml i/v 1t. a day or - pyracetamum 0.2 x 3t. a day II. Central vasodilators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day III. Blood desagregation: - pentoxifyllinum (trental) 0.2 x 3 t. a day x 10 days and next 0.1 x 3 t. a day x 10 days IV. For stimulating transmission nerves impulses in synapses: Anticholinestheratic: - proserinum 0.05%-1ml i/m x 1t. a day - Ipidacrinum (neiromidinum) 0.020 x 2 t. a day x10-30 days 0.5%-1ml s/c or I/m x 1 t. a day V. Nerves system energy riser: - Acidum gammaaminobutyricum (aminalon) 0.25 x 3 t. a day - ATP-long 2%-2ml i/v 1 t. a day VI. Nonspecific stimulators: - corpus vitreum 1ml i/m x 1t. a day VII. Vitamins B1 , B2 , B6 , B12: (Neurovitan, Neiron, Neurorubine)
  • 87. 3. Treatment of Sensoneural deafness VII. Vitamins B1 , B2 , B6 , B12: - Neurovitan Octothiaminum...................................... 25 мг Riboflavinum......................................... 2,5 мг Pyridoxini hydrochloridi......................... 40 мг Cyancobalamini.................................... 0,25 мг - Neiron Thiamini mononitrici............................... 25 мг Riboflavinum..................................….... 2,5 мг Pyridoxini hydrochloridi......................... 40 мг Cyancobalamini..................................... 0,25 мг - Neurorubine Thiamini mononitrici.............................. 200 мг Pyridoxini hydrochloridi......................... 50 мг Cyancobalamini.................................... 1 мг - Neurorubine Amp 3 ml Thiamini hydrochloridi........................... 100 мг/3 мл Pyridoxini hydrochloridi......................... 100 мг/3 мл Cyancobalamini.................................... 1 мг/3 мл
  • 88. 1. Prevention of Sensoneural deafness 1. Vaccination The vaccination of infants against Haemophilus influenzae type B meningitis prevents a major cause of acquired deafness, as have immunizations for measles, mumps, and rubella. A vaccine against Streptococcus pneumoniae, the most common organism associated with otitis media, is also available and is having a positive impact on the reduction in the incidence of ear infections. In addition, careful monitoring of serum peak-and-trough levels can largely prevent the loss of vestibular function and deafness due to aminoglycoside antibiotics.
  • 89. 2. Prevention of Sensoneural deafness 2. Noise Avoidance Ten million Americans have noise-induced hearing loss and 20 million are exposed to hazardous noise in their employment. Noise-induced hearing loss can be prevented by avoiding exposure to loud noise or by the regular use of earplugs or fluid-filled muffs to attenuate intense sound. 3. High-Risk Activities High-risk activities for noise-induced hearing loss include wood- and metalworking with electrical equipment as well as target practice and hunting with small firearms. All internal-combustion and electric engines, including snowblowers and leaf blowers, snowmobiles, outboard motors, and chain saws, require that the user wear hearing protectors. 4. Education Almost all noise-induced hearing loss is preventable through education, which should begin before adolescence. Industrial programs of hearing conservation are required when the exposure over an 8-hour period averages 85 dB on the A scale. Workers in such noisy environments can be protected with preemployment audiologic assessment, the mandatory use of hearing protectors, and annual audiologic assessments.
  • 90. Sensoneural deafness 1. Patients with mild, moderate, and severe sensorineural hearing losses are rehabilitated regularly with hearing aids that vary in configuration and strength. They also have been miniaturized; the current generation of hearing aids can be placed entirely within the ear canal, thus reducing the stigma associated with their use. Digital hearing aids lend themselves to programming for the individual; (2) But, multiple and directional microphones at the ear level help some individuals with the difficulty of using a hearing aid in noisy surroundings. Since all hearing aids amplify noise as well as speech, the only absolute solution to the problem is to place the microphone closer to the speaker than to the noise source. This arrangement is not possible with a self-contained, cosmetically acceptable device; it is cumbersome and requires a user-friendly environment. 2. In many situations, including at lectures and at the theater, hearing-impaired persons benefit from assistive devices that are based on the principle of having the speaker closer to the microphone than to any source of noise. Assistive devices include infrared and FM transmission; they also include an electromagnetic loop placed around the room for transmission to the individual’s hearing aid. Hearing aids with telecoils also can be used with properly equipped telephones in the same way. Amplification
  • 91. Sensoneural deafness In the event that a hearing aid provides inadequate rehabilitation, cochlear implants are appropriate. The criteria for implantation are undergoing constant revisions. Children with congenital and acquired profound hearing impairment are also appropriate candidates for cochlear implantation; many are being implanted as early as 6 to 9 months. In most cases of profound hearing impairment, the auditory hair cells are lost, but the spiral ganglion cells of the auditory division of the eighth nerve are preserved. Cochlear implants are a specialized hearing prosthesis for the rehabilitation of profound deafness that convert mechanical sound energy into electrical signals that are delivered to the neurons of the cochlear nerve. The basic operation of the implant is as follows: A microphone is used to pick up acoustic information that is sent to an external speech processor (located on the body or at ear level). This processor converts the mechanical acoustic wave into an electric signal that is transmitted via the surgically implanted electrode array in the cochlea to the auditory nerve. Bilateral cochlear implants hold the promise of enhanced sound localization and improvement in understanding speech in the presence of background noise. 1. Cochlear Implants
  • 92. Sensoneural deafness Cochlear Implants consist of: 1. A microphone, which picks up acoustic information and converts it to electrical signals; 2. An externally worn speech processor that processes the signal according to a predefined strategy; 3. A surgically implanted electrode array that is in the cochlea near the auditory nerve. 2. Cochlear Implants Incision and implant site for cochlear implantation.
  • 93. Sensoneural deafness 3. Cochlear Implants Location of induction coil. Trough and groove drilled for electrode implantation into mastoid.
  • 94. Sensoneural deafness 4. Cochlear Implants The facial recess is bounded by the fossa incudis superiorly, the chorda tympani nerve laterally and anteriorly, and the facial nerve medially and posteriorly. A cochleostomy is created anterior and inferior to the round window.
  • 95. Sensoneural deafness 5. Cochlear Implants Electrode introduced into the basal end of the cochlea.
  • 96. Sensoneural deafness 6. Cochlear Implants Electrode in scala tympani (cross section of basal turn on cochlea).
  • 97. Sensoneural deafness 7. Cochlear Implants Receiver-stimulator with redundant loop of electrode in mastoid.
  • 98. Sensoneural deafness For individuals who have had both eighth nerves destroyed by trauma or bilateral vestibular schwannomas (eg, patients with neurofibromatosis II), a brainstem auditory implant placed near the cochlear nucleus may provide auditory rehabilitation. With additional advances in brainstem auditory implant technology, patients may eventually obtain benefits similar to individuals who have cochlear implants. Brainstem Auditory Implant
  • 99. Sensoneural deafness 2. Sensoneural desorders by Tonal audiometry . х - bone conduction, о - air conduction. AD (Auris Dexter) RE (Right ear) AS (Auris Sinister) LE (Left ear) - Tinnitus ++ >5m WV >1m >20m CV >3m 20'' Tf (Tunning fork) 128 bone (N=20'') 10" 40'' Tf (Tunning fork) 128 air (N=40'') 20'' 30'' Tf (Tunning fork) 2048 (N=30'') 150'' + Rinne +"small" Weber Not longthened Schwabah shortened Not shortened 3. Left ear Sensoneural deafness. 1. Normal otoscopic picture. Sign: 1. Hearing loss. 2. Tinnitus. 3. Normal otoscopic picture. 4. Sensoneural deafness.
  • 100. Classifacation of the mastoiditis & paramastoiditis • Acute, • Subacute, • Chronic, • Latent. Mastoiditis (Tipical): • Tip form (2), • Subperiostal abscess (4), • Subperiostal abscess (4), • Perisinuosus abscess (3), Paramastoiditis: • Zygomaticitis, • Occipititis, • Squamitis, • Petrositis, • Apicitis etc.
  • 101. Гострий мастоїдит (Acute mastoiditis) 1. Симптоми отиту (Symptoms of otitis): - вушний біль (otalgia), - виділення (discharge), - зниження слуху (hearing loss), - шум у вухах (tinnitus). 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3. Симптоми мастоідиту (mastoiditis sign): - профузна оторрея (profuse otorrhea - “Cystern” sign); - пастозність м’яких тканин соскоподібного відростка (thickness soft tissue in mastoid region), (thickness soft tissue in mastoid region), - болючість соскоподібного відростка (painful mastoid), - потовщення задньо-верхньої стінки кісткової частини зовнішнього слухового проходу (thickness of posterior-superior wall of the bony part of external meatus). - Ro, CT затемнення комірок (X-rays, CT - cells shadow). 4. Особливі місцеві симптоми при парамастоїдитах (Specific Local sign depend on the localisation): верхівково-шийні форми, перисинуозний абсцес, зигомацитит, петрозит, апіцит… tip form, perisinuosus abscess, zigomaticitis, petrositis, apicitis etc.
  • 102. 1. Тактика лікування мастоїдітів залежить від характера причинного отиту. (management of the mastoiditis depend on the cause of the mastoiditis). • Якщо мастоідит викликаний гострим отитом (гнійним середнім) то виконується проста (кортикальна) антромастоідеотомія, If mastoiditis was caused by acute otitis indicated cortical antromastoidotomy (simple or “Shwart’s antromastoidectomy”). • Якщо мастоідит викликаний хронічним отитом (епітимпанітом) то виконується загальнопорожнинна (радикальна) операція на вусі (атикоантромастоідеотомія) If mastoiditis was caused by chronic otitis (epitympanitis) indicated radical Management of the mastoiditis If mastoiditis was caused by chronic otitis (epitympanitis) indicated radical atticoantromastoidectomy. 2. Медикаментозне лікування (Conservative treatment): • Антибактериальне (Antibiotics (general & local - lincosamine group). • НПЗЗ (Antiinflammatory nonsteroid remedies). • Дезінтоксикація (Detoxication). • Дегідратація (Dehydratation). • Назальні деконгестанти (nasal decongestants).
  • 103. Simple (cortical) AntroMastoideotomy Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 104. Simple (cortical) AntroMastoideotomy Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 105. Simple or cortical AntroMastoidotomy (Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997)
  • 106. 1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3. Симптоми внутрішньочерепної гіпертензії Групи симптомів отогенного менінгіту Groups of symptoms of the otogenic meningitis 3. Симптоми внутрішньочерепної гіпертензії (Sign of the intracranial hypertension): - bradycardia, - papilloedema, - diffuse strong headache wich cann’t be controled by analgetics with - nasea, vomiting, 4. Менінгеальні симтоми (Meningeal sign): - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 107. 1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3. Симптоми внутрішньочерепної гіпертензії Групи симптомів отогенного менінгіту Groups of symptoms of the otogenic meningitis 3. Симптоми внутрішньочерепної гіпертензії (Sign of the intracranial hypertension): - bradycardia, - papilloedema, - diffuse strong headache wich cann’t be controled by analgetics with - nasea, vomiting, 4. Менінгеальні симтоми (Meningeal sign): - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006.
  • 108. 1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2.Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3.Симптоми внутрішньочерепної гіпертензії (Sign of the intracranial hypertension): - bradycardia, - papilloedema, - diffuse strong headache wich cann’t be controled by analgetics with - nasea, vomiting, Групи симптомів отогенного абсцесу скроневої долі мозку Groups of symptoms of the otogenic temporal lobe brain abscess - nasea, vomiting, 4. Менінгеальні симтоми (Meningeal sign): - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 5. Local sign of brain lession: - amnestic, motor or sensorial aphasia (in case with left side temporal lobe brain leasion if patient is right-handed, - contralateral paresis, - dilated pupils, ptosis and lateral rectus paralysis, homonymous hemianopia
  • 109. 1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3.Симптоми внутрішньочерепної гіпертензії (Sign of the intracranial hypertension): - bradycardia, - papilloedema, - diffuse strong headache wich cann’t be controled by analgetics with - nasea, vomiting, 4. Групи симптомів отогенного абсцесу мозочка Groups of symptoms of the otogenic cerebellar abscess 4.Менінгеальні симтоми (Meningeal sign): - rigidity of the necks muscles, - Kernig’s sign, - Brudsinsky’s sign… 5. Local sign on cerebellar lesion side: 1. Falling down in static tests (Romberg test). 2. Deviation in Kynetic tests (step test). 3. Deviation in coordinative tests (finger-nose test). 4. Ipsilateral asynergia (dysdia-dochokinesis). 5. Muscles hypotonia (flaccidity). 6. Nystagmus (continuous, big amplitude, any directions till diagonal…)
  • 110. 1. Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром - swinging temperature with rigors at irregular intervals, - pyaemic abscesses chiefly in lungs & joints, - positive blood cultyre, - enlarged spleen and marked leucocytosis) + як паразитогенна інтоксикація при малярії (signs of infectious intoxication like parasitogenic due to malaria): + Тріада: апериодична гіпертермія з потрясаючим ознобом і проливним потом (triad: - aperiodic chills (shivering) & fever and sweating (perspiring). + плазмодій малярії у мазках крові, “+” імунохімічний тест Групи симптомів отогенного тромбозу сигмоподібного синуса Groups of symptoms of the otogenic Sigmoid (lateral) sinus thrombosis + плазмодій малярії у мазках крові, “+” імунохімічний тест (plasmodium malaria in blood, “+” immunochemical test). + And effectiveness of specific treatment (chinin+ clindamycin, artemizin, chlorchin) + Anemia, hyperbilirubinemia, ALT, AST, hypoalbuminemia 3. Симптоми мастоідиту (mastoiditis sign): - профузна оторрея (profuse otorrhea - “Cystern” sign); - пастозність м’яких тканин соскоподібного відростка (thickness soft tissue in mastoid region), - болючість соскоподібного відростка (painful mastoid), - потовщення задньо-верхньої стінки кісткової частини зовнішнього слухового проходу (thickness of posterior-superior wall of the bony part of external meatus). - Ro, CT затемнення комірок (X-rays, CT - cells shadow). 4. Obstructive symptoms 4.1. Tobey-Ayer or Queckenstedt’s test – liquor hypertension via lumbar puncture + digital pressure on the internal jugular vein on the healthy side). 4.2. Greisinger’s sign - oedema of mastoid (if the mastoid emissary vein gets involved).
  • 111. 1.Симптоми отиту (Symptoms of otitis): - pain, - discharge, - deafness, - tinnitus. 2. Інфекційно-інтоксикаційний синдром (signs of Infectious intoxication): - weakness, mussles pain, perspiration, - hypertermia, - leucocytosis… 3.Симптоми мастоідиту (mastoiditis sign): - профузна оторрея (profuse otorrhea - “Cystern” sign); - пастозність м’яких тканин соскоподібного відростка (thickness soft tissue in mastoid region), - болючість соскоподібного відростка (painful mastoid), -потовщення задньо-верхньої стінки кісткової частини зовнішнього слухового проходу (thickness of posterior-superior wall of the bony part of external meatus). -Ro, CT затемнення комірок (X-rays, CT - cells shadow). Gtroups of symptoms of the otogenic extradural abscess (thickness of posterior-superior wall of the bony part of external meatus). -Ro, CT затемнення комірок (X-rays, CT - cells shadow). 4. Місцеві ознаки (local sign): поєднання (combination of) - симптома «резервуара» (cistern sign) накопичення гнійного вмісту з (accumulation of purulent discharge with) - з пульсацією гнійних виділень (pus pulsation) (double sign). 5.CT, MRI – накопичення рідини гнійної щільності між кісткою черепа і твердою мозковою оболонкою (accumulation of purulent discharge between skull bone & dura mater).
  • 112. 1. Тактика хірургічного лікування залежить від характера причинного отиту. Management depend on the cause of the complications. • Якщо внутрішньочерепне ускладнення викликане гострим отитом (гнійним середнім) то виконується кортикальна (проста) розширена антромастоідеотомія (If any intracranial complication was caused by acute middle purulent otitis indicated extended cortical mastoidotomy (simple or “Shwart’s mastoidectomy”). • Якщо внутрішньочерепне ускладнення викликанe хронічним отитом (епітимпанітом) то показана загальнопорожнинна Management of the otogenic complications (Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997.) отитом (епітимпанітом) то показана загальнопорожнинна (радикальна) розширена операція на вусі (атикоантромастоідеотомія) If any intracranial complication was caused by chronic otitis (epitympanitis) indicated radical atticoantromastoideotomy. 2. Медикаментозне лікування (Conservative treatment): • Антибактериальне (Antibiotics (general & local - lincosamine group), • НПЗЗ (Antiinflammatory remedies), • Дезінтоксикація (Detoxication), • Дегідратація (Dehydratation), • Назальні деконгестанти (nasal decongestants).
  • 113. Source: Menner Albert L. A Pocket Guide to the Ear / Thieme.- Stuttgart · New York.- 2003.- 145 p. Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997.) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
  • 114. Хвороба Меньєра Meniere’s desease 2. Clinical Triad: 1. An attack of severe vertigo without of 1. Ендолімфатичний гідропс внаслідок мультифакториальних причин (Endolymphatic hydrops due to multifactorial causes). 1 An attack of severe vertigo without of unconsciousness. 2. Vegetative disorders till nasea and vomiting. 3. One ear Tinnitus and deafness. 4. Nystagmus is labyrinthine in nature and to the side of the lesion, whereas in between the attacks it is to the opposite side. 3. Treatment: 1) absolute rest, sedatives, 2) dehydratation therapy. 3) drainage of the endolymphatical succ.
  • 115. 2. Treatment of Meniere’s desease I. During the attack: 1. Calm dark environment. 2. Sedativs: - diazepamum 5mg 1(2) t. a day or - diazepamum 10mg-2ml 1 t. a day or 3. The dehydratation therapy: a) The patient is prescribed a salt-free diet and minimum intake of fluid. b) hypertonic solutions: b) hypertonic solutions: - Sol.glucosae 40%-20ml+ + sol.ac.ascorbinici 5%-2ml i/v 1t. a day - sol.magnesii hydrochloridi 25%-5ml i/m c) diuretics: - lasix 20mg-2ml i/m 1 t. a day in the morning or - Furasemidum 40mg 1(2) t. a day in the morning II. After the attack is over: I.Salt-free diet and minimum intake of fluid. II. Vasodilators (nicotinic acid 100mg x 3 t. day) III. Pharmacotherapy like sensoneural deafness.
  • 116. Otosclerosis 1. Unknown causes. 2. Ankilosis footplate of the stapes. 3. Conductive deafness. 4. Otoscopy of Otosclerosis: 4. Otoscopy of Otosclerosis: 1. Wided external meatus. 2. Skin of external meatus is thinner. 3. Earwax is absent. 4. Sensitivity of the external meatus skin is depressed. 5. The tympanic membrain is thinner. 6. Red spot on the medial wall of tympanic cavity (Schwart’s sign). 4. Piston’s stapedoplasty.
  • 117. Clinical stage (type) of Otosclerosis 1. Tympanal stage. The deafness is of conductive type. In early stages there is an upward slope towards the right. Bone conduction shows a dip at 2000 Hz (Carhart notch) and is seen in about l/3rd of patients. Patient feels handicapped when air conduction loss exceed 50 dB. 2. 2nd mixt stage High tones are only affected, if cochlea is involved. When the cochlea is invoved then there is downward slope to the right. 2. Mixt stage. 3. Sensoneural stage.
  • 118. Surgical Treatment of Otosclerosis (piston’s stapedoplasty)
  • 119. Sensoneural deafness 2. Sensoneural desorders by Tonal audiometry . х - bone conduction, о - air conduction. (Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) AD (Auris Dexter) RE (Right ear) AS (Auris Sinister) LE (Left ear) - Tinnitus ++ >5m WV >1m >20m CV >3m 20'' Tf (Tunning fork) 128 bone (N=20'') 10" 40'' Tf (Tunning fork) 128 air (N=40'') 20'' 30'' Tf (Tunning fork) 2048 (N=30'') 150'' + Rinne +"small" Weber Not longthened Schwabah shortened Not shortened 3. Left ear Sensoneural deafness. 1. Normal otoscopic picture. Sign: 1. Hearing loss. 2. Tinnitus. 3. Normal otoscopic picture. 4. Sensoneural deafness. Otoscopy. Stuttgart: Thieme; 1999)
  • 120. 1. Treatment of Sensoneural deafness I. Its depend on causes: 1. Creating a Favorable Environment for Hearing. 2. Toxic – antidot or detoxication: - Streptomycinum - Vit B15; - spiritus methylicus - spiritus aethylicis. 3. Local vasospasmus - central vasodilatators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day 4. Hypertension - peripheral vasodilatators: 4. Hypertension - peripheral vasodilatators: 5. Symptomatic hypertension: - renal - surgery; - endocrine - hormonal therapy… 6. Thrombosis: - Sol. Heparini natrici 5000 “ME”/ml – 1(2)ml i/v x 1(3) t. a day + next days s/c(abdomen) 5000 x 2 t. a day 7. Haemorrage: - tab. Ethamsilatum 0.25 x 3 t. a day; - sol. Ethamsilatum 12.5%-2ml I/v or I/m 2(3) t. a day
  • 121. 2. Treatment of Sensoneural deafness II. Nonspecific Pharmacotherapy: I. Nootropic: - pyracetamum 20%-5ml i/v 1t. a day or - pyracetamum 0.2 x 3t. a day II. Central vasodilators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day III. Blood desagregation: - pentoxifyllinum (trental) 0.2 x 3 t. a day x 10 days and next 0.1 x 3 t. a day x 10 days next 0.1 x 3 t. a day x 10 days IV. For stimulating transmission nerves impulses in synapses: Anticholinestheratic: - proserinum 0.05%-1ml i/m x 1t. a day - Ipidacrinum (neiromidinum) 0.020 x 2 t. a day x10-30 days 0.5%-1ml s/c or I/m x 1 t. a day V. Nerves system energy riser: - Acidum gammaaminobutyricum (aminalon) 0.25 x 3 t. a day - ATP-long 2%-2ml i/v 1 t. a day VI. Nonspecific stimulators: - corpus vitreum 1ml i/m x 1t. a day VII. Vitamins B1 , B2 , B6 , B12: (Neurovitan, Neiron, Neurorubine)
  • 122. 2. Treatment of Sensoneural deafness II. Nonspecific Pharmacotherapy: I. Nootropic: - pyracetamum 20%-5ml i/v 1t. a day or - pyracetamum 0.2 x 3t. a day II. Central vasodilators: - vinpocetinum (cavinton) 0.01-2ml i/v x 1t. a day or 0.01 1t. x 3 t. a day III. Blood desagregation: - pentoxifyllinum (trental) 0.2 x 3 t. a day x 10 days and next 0.1 x 3 t. a day x 10 days next 0.1 x 3 t. a day x 10 days IV. For stimulating transmission nerves impulses in synapses: Anticholinestheratic: - proserinum 0.05%-1ml i/m x 1t. a day - Ipidacrinum (neiromidinum) 0.020 x 2 t. a day x10-30 days 0.5%-1ml s/c or I/m x 1 t. a day V. Nerves system energy riser: - Acidum gammaaminobutyricum (aminalon) 0.25 x 3 t. a day - ATP-long 2%-2ml i/v 1 t. a day VI. Nonspecific stimulators: - corpus vitreum 1ml i/m x 1t. a day VII. Vitamins B1 , B2 , B6 , B12: (Neurovitan, Neiron, Neurorubine)
  • 123. дексаметазон 4 мг в/м в/в 2 р/д; пірацетам 10,0 +фіз.розчин 200,0 в/в кр.; винпоцетін 4мл на 200 мл 0.9% NaCl в/в 1 р/д; пентоксифілін 5,0+ фіз.розчин 200,0 в/в кр.; вітаксон 2,0 в/м 1р/д; Blast Ear Injury – „Акубаротравма” глюкоза 40% 20,0 + аскорбінова к-та 5% 3,0 в/в крап.; мікстура спокою 1ст.л. 3р/д; підокісне введення 0,05% прозерину в трикутник Шипо за «піковою» схемою. курс ГБО. Берлитион 600 на 200 мл 0.9% NaCl в/в 1 р/д; нуклеоЦМФ 1.0 в/м 1 р/д; нейромидин 1.5% 1 мл в/м 1р/д;
  • 124. Sensoneural deafness 2. Cochlear Implants Cochlear Implants consist of: 1. A microphone, which picks up acoustic information and converts it to electrical signals; 2. An externally worn speech processor that processes the signal according to a predefined strategy; 3. A surgically implanted electrode array that is in the cochlea near the auditory nerve. Incision and implant site for cochlear implantation. Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
  • 125. Sensoneural deafness 6. Cochlear Implants Electrode in scala tympani (cross section of basal turn on cochlea). Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
  • 126. Source: Menner Albert L. A Pocket Guide to the Ear / Thieme.- Stuttgart · New York.- 2003.- 145 p. Source: Sanna M, Russo A, DeDonato G. Color Atlas of Otoscopy. Stuttgart: Thieme; 1999) Source: Hughes GB, Pensak MP. Clinical Otology. New York: Thieme; 1997.) Source: El-Guindy A.The ear slide show.- The department of Otolaryngology - Head and Neck surgery university of Tanta, school of medicine.- 2006. Ballenger’s Otorhinolaryngology. Head and Neck Surgery / James B. Snow Jr,, John Jacob Ballenger // Sixteenth Edition.- BC Decker Inc.- 2006.- 1616 p.
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  • 148. General condition Temperature Hyperemia of the mucous membrane not suffered SUBfebril posterior wall of the pharynx Differential diagnosis Acute kataral tonsillitis & Acute pharyngitis suffered febril tonsills
  • 149. 4 1. Diet. 2. Pharyngeal washing & resorption of oroantiseptics (pharyngosept, septefrylum, strepsils etc.). If the general condition suffered (in childhood): 3. Antibiotics (аmoxicillini 0,5х3 t. a day х7 days). 4. Nonsteroid anti-inflammatory drugs (amizoni 0,25х1t.a day х10 days). 5. Desensitation (desloratadinum 0,01х1t.a day х10 days). 6. Compress with 40-50% alcohol on neck. Treatment of the acute pharyngitis
  • 150. Chronic katarrhal pharyngitis 1. Light diet, voluminous water drinking. 2. Oroantiseptics (chlorhexidini hydrochloridi 0.005 х6 t. a day х5 days resorption intrapharyngeal). 3. Local nonsteriod anti-inflammatory remedies (biclothymoli 4(6) t. a day х10 days). Chronic heperplastic pharyngitis + electrocoagulation, chemical cautery, cryodistruction, surgical remuving of lymphoid hyperplastic focus (folliculs) Chronic atrophic pharyngitis + washing mucous membrane (gargling) , + stimulation of mucous glands by Lugol’s solution, + biogenic stimulators (aloes, placentae). Chronic pharyngitis
  • 151. Catarrhal [superficial] acute tonsillitis Catarrhal acute tonsillitis in childhood
  • 152.  Primary,  Secondary (Miscellaneous throat conditions ): - infectious deseases (diphtheria, scarlet…) - blood deseases (mononuclear acute tonsillitis (Pfeiffer’s glandular fever), agranulocytosis …) Factor of localisation: - acute tonsillitis (of palatine tonsills) - acute tonsillitis of lingual tonsill, - acute tonsillitis of nasopharyngeal tonsill, - acute tonsillitis of tubal tonsills, - Laryngeal acute tonsillitis. 2 Classification of acute tonsillitis
  • 153. 1 І. Subjective: 1. Infectious [infective] (general weakness, fever (chill; shivering), hyperhidrosis, headache...) 2. Local (sore throat, hypersalivation, nasality (nasonnement)...) ІІ. Objective: 1. Infectious [infective] (hypertermia, leucocytosis, ESR...) 2. Local (hyperemia of mucose membrane of tonsills, hypersalivation, nasality (nasonnement), lymphadenitis...) + peculiarity depend on kind of acute tonsillitis: - Without intoxication (ulcerous-membranous) - Membranes by crypt ostium (membranous, lacunar tonsillitis), - With yellowish spot (follicular), - Hemorrhage (grippe, flu)... Checkup: - Swab for BL-investigation !!! (diphtheria!!!), - bulk blood analysis (leucosis, agranulocytosis, monocytosis..) Symptom of acute tonsillitis
  • 156. Fungal tonsillitis Acute tonsillitis of nasopharyngeal tonsill (adenoiditis)
  • 157. 1  1. The desease is taking its like severe Infectious disease, + convulsion with hypertermia, + pseudo opisthotonus.  2. With dispepsia, nausea, vomit(ing) (retching), , meteorism (tympanism); wieght doesn’n taking normal.  3. Respiratory insufficiency (restriction of lungs excursion).  4. More often laryngitis, bronchitis, pneumonia.  5. More frequently otitis.  6. Soft palate paresis possible.  7. Maceration angle mouth skin. Peculiarity of acute tonsillitis in childhood
  • 158. 1 Patient can be isolated at home or infectious department. 1. Bed regime (stay in bed) for complications prevention. 2. Light diet, voluminous water drinking. 3. Antibacterial (amoxicillini 0,5х3 t. a day х7 days). 4. Oroantiseptics (chlorhexidini hydrochloridi 0.005 х6 t. a day х5 days resorption intrapharyngeal). 5. Local nonsteriod anti-inflammatory remedies (biclothymoli 4(6) t. a day х10 days). 6. Nonsteriod anti-inflammatory remedies (aspirini 0,5х3 t. a day х10 days). 7. Desensitation (loratadini 0,01х1 t. a day х10 days). 8. Neck compresses (40-50% alkohol or 25% dimethylsulfoxidi with antibiotic х5-7 days). Treatment of acute tonsillitis
  • 159. 1 1. Severe general condition, intoxication… 3. Localy: errosion, cyanosis, edema more than hyperemia, or dull greyish membrane formation is present on the tonsil and extends beyond e.g., on to the pillars, palate or uvula. It is not easily detachable with bleeding mucous membrane. but till the 2st day it is whitish easily detachable. or hemorrhage. Diphtheria of pharyngis 4. Face, neck edema. 5. Regional lymphadenitis. 6. Toxic lesion of the peripheral nerves – polineuritis (soft palate, vocal cord paresis..) 7. Toxic lesion of the heart muscle. 8. Toxic lesion of the kidneys. Obligated investigation Swab for BL-investigation !!!
  • 160. 1 Form of Diphtheria 1. Katarrhal (edema, cyanosis more than hyperemia). 2. Membraneous: - local, - diffuse (dull greyish membrane formation on the tonsills and extends beyond e.g., on to the pillars, palate, uvula. It is not easily detachable with mucous membrane bleeding. 3. Toxic: - SubToxic (I stage) – edema till half of neck. - Toxic (II stage) – edema till clavicle. - HyperToxic ( III stage) – below clavicle. 4. Hemorrhagic (+ Hemorrhage).
  • 161. 1 Obligated investigation: - Swab for bacteriological examination (Leffler’s bacillus ) !!! Treatment: 1. The specific drag is antidiphtheria serum. If the diagnosis is not dear, 10,000-100,000 units of antidiphtheria serum are injected intramuscularly immediately after testing the sensitivity of the patient to the antitoxin depending on the toncity of the patient. 2. Antibacterial 3. Detoxication. 4. Anti-inflammatory. 5. Antiedematic. 6. Symptomatic. Treatment of the Diphtheria
  • 162. 1 Infectious Mononucleosis Synonyms: Pfeiffer’s glandular fever, kissing disease 1. Assotiation with the Epstein–Barr virus (EBV). The incubation period is 7–9 days. 2. It predominantly affects adolescents. 3. System poliadenopathia. 2. Hepatosplenomegaly. 3. Peripheral blood monocytosis. 4. Paul-Bunnel (92,5%) Tomchik reaction (90,7%). 5. Long-termclinical course with relapse (till 2 month). Localy - Any form of the acute tonsillitis (katarrhal, membranous, necrotic) - Sometimes petechial rash и exantema on the mouth mucous membrane, - Hemorrhage on the margin of the soft & hard palate, cheeks. Treatment: 1. Like any acute tonsillitis & Symptomatic. 2. Anti-viral (anti-EBV serum).
  • 163. 2  1. Genaral condition is normal.  2. Body’s temperature is normal.  3. Pharyngeal pain is absent.  4. Lymphadenitis (painfull).  5. Dull greyish membrane formation on one tonsil. It is easily detachable. Ulcer crater with greyish fundus & Irregular border.  6. Spirochаeta buccalis + bac.fusiformis (saprophits!). Treatment: = acute tonsillitis  1. Penicillinum i/m х7 days.  2. Gargling with КМО4, Н2О2...  3. Coagulation the ulcer by 5% Iodium spirituosae, 40% AgNO3…  4. Vitaminotherapy, high-calorie diet, nourishing diet … Plaut–Vincent angina (trench mouth) Finland tonsillitis
  • 164. 2 Acute (catarrhal, pseudomembranous, membranous-ulceric) Trivial (light) form: - general condition is satisfactory, subfebrility, - possible spontaneous convalescence in 2-3 weeks, Serious form (like diphtheria): - Severe general condition, febrility, - regional lymphadenitis, - lingering clinical course, treatment with temporary benefit Chronic form (month - years): - often after long-term care by antibiotics, - general condition is satisfactory, subfebrility, - yelowish long-term membranes on soft palate, tonsills, posterior wall of pharynx, isn’t changed after usual treatment Fungal acute tonsillitis + stomatitis, glosittis (Candida albicans)
  • 165. 2 Diagnosis: - only after exclusion diphtheria, - identification of Candida, - positive benefit after proof antifungal therapy Treatment: - cessation of antibioticotherapy, - Local & system antifungal therapy (nystatinum, laevorinum, nitrofunginum, mycosporum…) - obligatory restorative & stimulative therapy Fungal acute tonsillitis + stomatitis, glosittis (Candida albicans)
  • 166. 2  Local: - paratonsillitis (quinsy), - parapharyngitis, - retropharyngitis, - mediastinitis...  General: - tonsillogenic sepsis, - rheumatic fever... Complications of the acute tonsillitis
  • 167.
  • 168. Винницкий национальный медицинский университет им.Н.И.Пирогова кафедра ЛОР-болезней Барциховский Андрей Игоревич
  • 169. Chronic tonsillitis – infectious-allergic desease with prevalence lesion palatine tonsills lymphatic pharyngeal tissue
  • 170. 1. More than 2 acute tnsillitis a year (anamnesis morbi). 2. Purulent discharge from tonsillar crypt. 3. Hyperemia, hyperplasia, edema ant.&post. palatine arch. Scar between tonsills and tonsillar pillar. 4. Regional lymphadenitis (lymphnodes before ant.margin m.sternocleudomastoideus in upper 1/3. Reliable (trustworthy) symptoms of chronic tonsillitis
  • 171. Symptoms of decompensations Absent In time acute stage Continiously Lucovsky’s Compensation (stage) SubCompensation DeCompensation Preobradgensky’s Simple Toxico-allergic 1st stage Toxico-allergic 2nd stage Classification of chronic tonsillitis
  • 172. 1. Clinical (metatonsillar & related deseases): - local: paratonsillitis, parapharyngitis, retropharyngitis, purulent lymphadenitis, neck phlegmon... - general: rheumatic fever, miocarditis, arthritis, glomerulonephritis... 2. Laboratory: - general: “+” rheumatic-test (СRP, seromucoid..), - ECG-pathology, GBT, GUT - local: functional activity of lymphocytes after microbal antigen stimulation...) Symptoms of decompensation of chronic tonsillitis = Sign of lesion another organs and systems of ograns:
  • 173. Symptoms Course of to Detection NSAID Thermoneurosis Continuously Accidental Without changing t o Infectious subfebrility Day deviations Infectious syndrom Decreasing to Differential diagnosis infectious subfebrility with central nerves system thermoneurosis NSAID – NonSteroid AntiInflammatory Drugs
  • 174. Tests Crypt washing Tonsills massage Tonsillogenic Decreasing t o Increasing t о NonTonsillogenic Without changing t o Without changing t o Differential diagnosis tonsillogenic subfebrility with any infectious nonTonsillogenic subfebrility
  • 175. 1. Conservative: - general - local (Lucovsky’s, Kolomiychenko’s, Kischuk’s schema). 2. Surgical (tonsillectomy). 3. Half-surgical (cryotonsillotomy, ultrasound cryotonsillotomy, cript orifice cuting by spesial knife or LASER evaporator). Treatment of chronic tonsillitis
  • 176. General: 1. Increasing general reactivity for prevention acute tonsillitis (regimen of work & rest, nourishing diet (high-calorie diet), physical trayning, sanatorium-and-spa treatment...); 2. Desensitation (nonspecific, specific - strptpcocci allergen on the surface of tonsills...) Local: Lukovsky’s schema: 1st week: а) - washing crypt 1t. a day, б) - painting iodine-glycerin 1t. a day; 2nd week: - а), б) - every other day, + massage of tonsills; 3d week: - а) и б) - twice a week, + snoot-quartz endooraly. Conservative therapy of chronic tonsillitis 1
  • 177. Kolomiychenko’s schema: 1. 1st course = Lukovsky’s schema (but... washing by penicillini, gargling with календулой, painting by iodine solution, from 2nd week - snoot- quartz endooraly, from 3rd week - high frequency therapy on tonsills); 2. Interruption 1-3 months; 3. 2nd course - tonsillar crypt stopping (filling) (1t. in 7 days N4-8) + ultrasound therapy on tonsills N10). Kischuk’s schema: 1. Tonsillar massage (1t. a day N10). 2. Lugol’s (iodine-glycerin) solution painting (1t. a day N10). 3. Thymomimetic’s intratonsillar injection (thymogen) (1t. a day N10). 4. Magnetic therapy (1t. a day N10). + general 5. Loratadinum 0.01 (1t. a day х10). 6. Extract Alloes 1ml i/m (1t. a day х10). 7. Exinacea 2.2ml i/m every other day (N5). 8. Vit B1-B6 5% 1ml i/m every other day (N10). Conservative therapy of chronic tonsillitis (local) 2
  • 178. Indications for tonsillectomy: 1. Conservative treatment twice a year 2 years without benefit, 2. Decompensation stage of chronic tonsillitis. - local sign (paratonsillitis, parapharyngitis, retropharyngitis...), - general sign (metatonsillar complications - rheumatic fever..) Contraindications for tonsillectomy: 1. General continuous: - any organs deseases in decompensation stage, - blood desease with coagulopathy, - tumor any malignancy & localisation, - psychotic deseases. 2. General temporary: (infectious deseases,pregnancy…) 3. Local temporary: (acute tonsillitis, otitis, thynitis…). 4. Local continuous: (carotid artery anomaly – tonsil’s pulsation...) Surgical treatment of chronic tonsillitis - tonsillectomy
  • 179. 3 If simultaneously indications & contraindications for surgical treatment (tonsillect6omy) are present: 1. Indications for tonsillectomy: - conservative treatment twice a year 2 years without benefit, - decompensation stage of chronic tonsillitis. & 2. Contraindications for tonsillectomy: - general (continuous, temporary), - local (continuous, temporary) Half-surgical treatment of chronic tonsillitis
  • 180. Chronic tonsillitis Acute tonsillitis (anamnesis) Purulent discharge from crypt Changing palatine folds regional Lymphadenitis -- Hypertrophy of palatine tonsills -- -- -- -- Hypertrophy all of tonsills Differential diagnosis between Chronic tonsillitis & hypertrophy of palatine tonsills Treatment (tonsillotomy): - if the 3rd stage & - if the 2nd stage with swallowing or breathing disturbances
  • 181. Hypertrophy of the nasopharyngeal tonsil (adenoids)
  • 182. 4