Rupture and dislocation of the auditory ossicles. Trauma to the eardrum and ossicles Destruction of the ossicles

6000 0

Along with the presence of an air-bone gap and the above-mentioned indicators of tonal suprathreshold and speech audiometry, various forms of conductive hearing loss are characterized by various impedance characteristics.

Otosclerosis

In patients with the initial stages of the otosclerotic process, so-called "on-off" reflexes can be registered, which are short-term contractions of muscle fibers at the beginning and at the end of acoustic stimulation.

Rupture of the ossicular chain

Quite informative is the registration of a W-shaped tympanogram when using high frequencies of the probing tone (660 Hz and above).

As noted, when the ossicular chain is broken, no acoustic reflex is recorded. The exception is cases when the rupture is localized distal to the place of attachment of the tendon of the stapedius muscle (for example, a fracture of the anterior leg of the stirrup), and a contralateral reflex is recorded from the healthy ear (the probe is located in the diseased ear).

In case of violation of the ventilation function of the auditory tube, type C tympanograms are recorded.

exudative otitis media

With conductive hearing loss, contralateral reflexes from the healthy ear and the location of the impedancemeter probe in the ear with a conductive lesion are not recorded. At the same time, when the probe is placed in a healthy ear and the ear with a conductive lesion is stimulated, contralateral reflexes from the diseased ear are recorded.

An example of a "vertical" acoustic reflex characteristic of a peripheral lesion. The ipsilateral reflex on the left and the contralateral reflex on the right ear are not registered. In this case, we can talk about either a minor conductive lesion on the left, or a lesion in the efferent part of the reflex arc, i.e. facial nerve injury.

Characteristic for "pure" forms of conductive damage is the lengthening of the LA of the general AP of the auditory nerve, recorded during electrocochleography, as well as the LA of all components of the short-latency SEP. Peak-to-peak intervals do not change.

Vertical type of reflex, determined with unexpressed conductive hearing loss (left)

With all forms and degrees of conductive hearing loss, none of the types of otoacoustic emission is recorded.

The need to improve the effectiveness of differential diagnosis, in particular, in retrocochlear pathology and in the assessment of auditory function in children with congenital anomalies in the development of the outer and middle ear, determines the feasibility of studying the dynamics of the parameters of auditory evoked potentials in conductive hearing loss.

This is due to the fact that, as a rule, when interpreting ABR parameters in patients with retrocochlear pathology, observations with the presence of an air-bone gap are excluded from the analysis. And, indeed, the presence of even a slight conductive hearing loss (in contrast to the sensory component) significantly lengthens the LA of the auditory nerve and ABR components (in particular, the LA of the PI and Pv waves).

In clinical practice, in these cases, as a diagnostic criterion, not the difference in the LP of the Pv ABR wave recorded on both sides is used, but the interaural difference in the inter-peak intervals of the PI and Pv waves. This, in turn, imposes requirements for a clear recording of the PI wave, which is often absent in pathological records. To optimize its registration, the use of an intra-ear electrode or extratympanic ECoG is recommended.

Another way is to register ABR when stimulated with bone conduction sounds. However, the interpretation of the results of registration with this type of stimulation is very difficult due to the combined effect of resonance and vibration of the skull bones during stimulation with high-frequency clicks, although the use of lower-frequency signals and filtered clicks partially eliminates a number of issues that arise during bone stimulation.

The most promising way to compensate for the additional delay caused by the conductive component is the determination of the air-bone interval. However, the main condition for using this approach should be the determination of the significance of the information obtained during psychophysical studies and the possibility of its use in order to correct the LP values.

When registering ABR and constructing LA functions/intensity and amplitude/intensity in patients with conductive hearing loss, a function shift towards higher intensities (corresponding to the degree of conductive hearing loss) is determined, as well as a clear relationship between the lengthening of the LA Pv wave from the affected ear and the intensity of stimulation (in dB nPS) (at high levels of stimulation intensity, LA elongation is less pronounced).

Valuable additional information can be obtained by using nomograms for correcting the LP values ​​of the PV wave of the ABR, which are calculated based on the normal functions of the LP/intensity (Tavartkiladze G.A. 1987). To do this, the air-bone interval at a frequency of 3 kHz is determined on the tone threshold audiogram, and then the amount of LA correction at the corresponding level of stimulation intensity is determined from the nomogram.

So, if the bone-air interval at a frequency of 3 kHz audiogram was 40 dB, then at a stimulation intensity of 80 dB, the LA lengthening will correspond to 0.75 ms, and at an intensity of 40 dB - 1.5 ms. A significant limitation for the wide use of the presented nomogram is that it is based on the premise that there is an ideal relationship between the air-bone interval at a frequency of 3 kHz and the values ​​calculated from the shift of the LP function / ABR intensity.

However, in a "pure" conductive lesion, the use of a nomogram acquires a diagnostic value and allows you to make a correction in the LA values ​​without the need to build the LA/intensity function, which is very significant. In addition, in pediatric practice, and especially in children with exudative otitis media confirmed by tympanometry, the use of a nomogram provides a definition of the degree of conductive hearing loss.

Nomogram for correction of PV wave values ​​of ABR in patients with a "pure" conductive lesion

Ya.A. Altman, G. A. Tavartkiladze

4553 0

Tympanic membrane injury. They occur with burns, due to the ingress of foreign bodies and drops of molten metal, or as a result of exposure to caustic chemicals. Trauma to the tympanic membrane can be combined with damage to the tympanic cavity and inner ear. Even with minor damage to the tympanic membrane, dislocations of the auditory ossicles are possible, causing hearing impairment and labyrinth disorders (when the base of the stirrup is dislocated from the oval window).

Indirect injuries to the eardrum occur when there is a sudden change in pressure in the external auditory canal (a blow to the ear, a kiss on the ear, etc.) or an explosion (acoustic injury). Damage to the tympanic membrane can also occur with blunt trauma to the skull.

In connection with these circumstances, for all injuries of the tympanic membrane, a detailed history should be taken, a study of cochlear and vestibular function should be carried out. If necessary, X-ray examination of the temporal bones and bones of the skull, examination by a neuropathologist and ophthalmologist.

Treatment. With a small slit-like perforation, mild hearing loss, general good condition and an uncomplicated anamnesis, it is sufficient to instill powder with antibiotics, apply a sterile dressing, carry out physiotherapy and prescribe prophylactic antibiotics under otoscopic control. Accumulated blood in the ear canal should be carefully removed with a swab or try to suck. If performing otoscopy is difficult, then it is necessary to perform a Valsalva test: the release of air will indicate the presence of perforation.

Small perforations in the eardrum usually close on their own within a few days. In all other cases, hospitalization is indicated. In the hospital, a detailed otoscopy is required, preferably with the use of optics (loupe, operating microscope). With perforations of medium size and no signs of infection and damage to the auditory ossicles (conductive hearing loss up to 15-20 dB), you can try to close the perforation using the Okunev method (multiple cauterization of the edges of the perforation with trichloroacetic acid).

If the edges of the defect are wrapped, then they are properly laid, and under the defect (until it is closed) and on it, pieces of a gelatin sponge soaked in penicillin are placed, which are left for a period of at least 3 weeks. Large defects (subtotal and total) cannot be closed in the acute period, and they can remain for a long time. In the future, it is necessary to perform myringoplasty or tympanoplasty (in case of damage to the auditory ossicles).

Damage to the auditory ossicles. Such injuries most often occur with longitudinal fractures of the pyramid of the temporal bone, blunt trauma of the skull without a fracture of the pyramid, due to a strong impact of the skull on a solid base. Medical injuries are also possible: displacement and destruction of bones during antromastoidotomy, paracentesis. A violation of the ossicular chain is suspected when there is a decrease in air conduction hearing by more than 20 dB. The presence of vestibular symptoms indicates a dislocation of the stirrup in the oval window.

Vestibular disorders can occur during manipulations performed during certain reconstructive operations, accompanied by a dislocation of the stirrup, as well as during operations for otosclerosis. At the same time, severe dizziness, nausea, sometimes vomiting, spontaneous nystagmus in the direction of the diseased ear appear; the fistula symptom may be positive, but if the stirrup is dislocated, it should not be provoked so as not to aggravate the existing disorders. The resulting hearing loss of the conductive type, with lateralization during the Weber experiment in the direction of damage. The symptoms correspond to those of the induced (due to diffusion through windows) serous labyrinth.

Treatment. Post-traumatic labyrinth reactions usually disappear after 3-6 days, subject to bed rest, dehydration and antibiotic therapy. If the symptoms of cochleovestibular disorders persist longer, then this indicates an inflammatory reaction that occurs in response to trauma to the labyrinth.

In this case, it is necessary to perform a tympanotomy with a revision of the ossicular chain and corrective plastic measures, depending on what happened - a dislocation or a fracture of the auditory ossicles. Sometimes it is necessary to partially remove the lateral wall of the attic and the posterior bone wall of the external auditory canal, and then perform an osteoplastic atticotomy.

Manipulations in the area of ​​the oval window can be complicated by infection of the inner ear and the development of meningitis, which is especially often observed with festering cholesteatoma and granulation otitis media. The impact of this kind of injury on the state of the inner ear depends on the amount of damage, the virulence of the infection, and the level of immunity in the victim.

With the appearance of these vestibular disorders, it is necessary to immediately conduct massive antibiotic therapy. In the process of surgical intervention with a dislocation of the stirrup, you should carefully try to put it in place. When introducing fragments of the auditory ossicles into the windows, it is necessary to carefully remove them without deepening.

Hematotympanum. Hematotympanum - an outpouring of blood into the tympanic cavity with an intact tympanic membrane, which at the same time has a dark blue or black-blue color. Hematotympanum may be the result of a fracture of the pyramid of the temporal bone with a rupture of the mucous membrane of the tympanic cavity.

It is also formed with a sudden increase in pressure or stagnation of blood when coughing or sneezing, accompanied by rupture of small vessels of the mucous membrane of the tympanic cavity, with aerootitis, after posterior tamponade and adenotomy (blood flow through the auditory tube). Hematotympanum must be differentiated from a glomus tumor of the middle ear and a high-standing bulb of the internal jugular vein.

The tympanic membrane is punctured, blood is aspirated and enzymes and corticosteroids are injected into the tympanic cavity.

Damage to the auditory tube. Fractures of the bone part of the tube are possible with fractures of the temporal bone and are masked by manifestations of damage to the tympanic cavity (hemorrhage, etc.). Damage to the mucous membrane of the cartilaginous tube with emphysema of surrounding tissues can occur during its forced catheterization. The pains noted at the same time when swallowing are caused by contractions of the muscles of the cartilaginous part of the tube.

Treatment. Assign vasoconstrictor nose drops, antibiotics, carry out anemia of the pharyngeal mouth of the auditory tube. Surgical intervention is performed only to eliminate the consequences of trauma - stenosis of the auditory tube.

IN. Kalina, F.I. Chumakov

Ossicular rupture and dislocation (H74.2) is a syndrome characterized by the presence of conductive hearing loss due to damage to the ossicles.

• Ear injury.
• Fracture of the base of the skull, pyramid of the temporal bone.
• Inflammatory diseases of the middle ear.
• Tumor of the middle ear.

Under the above conditions, there is a displacement of the auditory ossicles relative to each other (dislocation) or their destruction (rupture). Both lead to a complete or partial disruption of the conduction of the sound wave from the eardrum to the cochlea. Conductive hearing loss occurs.

Symptoms of rupture and dislocation of the auditory ossicles

• Persistent hearing loss.
• Sharp pain in the ear.
• Sudden dizziness, impaired coordination of movements.
• Ear congestion, feeling of fullness.
• Noise in the ear.

On examination:

• The tympanic membrane is not changed.
• Rupture or perforation of the eardrum.
• Persistent hearing loss (decrease in whispering and colloquial speech) according to the type of sound conduction.
• Negative tuning fork tests of Rine and Friderici, prolongation of bone conduction time, lateralization of sound towards the worse (affected) ear (Weber's test).

Diagnostics

• Consultations of an otorhinolaryngologist, audiologist.
• Tonal audiometry, acoustic impedancemetry (tympanogram type Ad or E), CT, MRI of the brain.

Differential Diagnosis:

Treatment of rupture and dislocation of the auditory ossicles

Treatment is prescribed only after confirmation of the diagnosis by a specialist doctor. Held:

• Surgery.
• Hearing aid.

Essential drugs

There are contraindications. Specialist consultation is required.

• (analgesic, anti-inflammatory). Dosage regimen: instill into the external auditory canal 3-4 drops 3-4 times / day.
• (antiseptic, local anesthetic, anti-inflammatory agent). Dosage regimen: instill into the external auditory canal 4 drops 2-3 times / day. within no more than 10 days.
• (antibacterial and anti-inflammatory agent). Dosage regimen: instill into the external auditory canal 1-5 drops 2 times / day. within 6-10 days.

ENT diseases: lecture notes by M. V. Drozdov

4. Damage to the auditory ossicles

Damage to the auditory ossicles can be combined with a violation of the integrity of the tympanic membrane. A fracture of the malleus, anvil, their dislocation, displacement of the plate of the base of the stirrup develop.

If otoscopy and microscopy do not reveal damage to the auditory ossicles, then it is difficult to diagnose this (conductive hearing loss depends on the state of the entire circuit of the sound-conducting apparatus). With an intact tympanic membrane, a break in the ossicular chain can be detected using tympanometry when a type D tympanogram (hypercompliance of the tympanic membrane) is detected. With perforation of the tympanic membrane and a violation of the auditory ossicles, the nature of their pathology is most often recognized during the operation - tympanoplasty.

Treatment

Various types of tympanoplasty are performed depending on the nature of the traumatic injuries of the auditory ossicles and the tympanic membrane in order to restore sound conduction in the middle ear.

author Olga Ivanovna Zhidkova

From the book Urology: lecture notes author O. V. Osipova

From the book Forensic Medicine. Crib author V. V. Batalina

From the book Medical Research: A Handbook author Mikhail Borisovich Ingerleib

From the book A complete guide to analyzes and research in medicine author Mikhail Borisovich Ingerleib

From the book Your life is in your hands. How to understand, beat and prevent breast and ovarian cancer written by Jane Plant

author William and Martha Serz

From the book Your child. Everything you need to know about your child - from birth to two years author William and Martha Serz

From the book Children's Diseases. Complete reference author author unknown

From the book How to Heal Back Pain and Spinal Diseases. Best proven recipes author Ekaterina Andreeva

From the book We read on the legs. What Your Feet Say by Li Chen

From the book Berry compresses: we treat joints and skin / V. N. Kulikova author Vera Nikolaevna Kulikova

From the book Points of Disease and Health on Your Feet by Ki Sheng Yu

From the book 300 skin care recipes. Masks. Peeling. Lifting. Against wrinkles and acne. Against cellulite and scars author Maria Zhukova-Gladkova

From the book Conspiracies of the Siberian healer. Issue 32 author Natalya Ivanovna Stepanova

Epitympanitis - inflammation of the epitympanic space of the middle ear, characterized by a long and persistent course. The disease leads to the destruction of the auditory ossicles and impaired sound conduction to the receptor apparatus.

Epitympanitis is a special form of chronic inflammation of the auditory analyzer, in which the mucous membrane and bone tissue of the epitympanic space are affected. The purulent process leads to carious lesions of the bone, the formation of granulations and cholesteatoma. This intractable and dangerous ear disease, despite mild symptoms, can provoke irreversible processes that lead to hearing loss and threaten the life of the patient. This pathology is characterized by perforation of the eardrum and the release of a fetid secret from the ear canal. Perforation makes the tympanic cavity vulnerable to pathological biological agents.

The stagnation of pus and the spread of infection to the surrounding organs and tissues is facilitated by many folds and pockets in the mucous membrane of the upper part of the middle ear. Purulent discharge puts pressure on the inner ear and brain, which also contributes to inflammation of vital organs, the development of complications in the intracranial space and endangering the patient's life.

Forms

Conditionally chronic epitympanitis is divided into two morphological forms - carious and cholesteatoma.

• carious form characterized by the development of destructive changes in the bone against the background of severe inflammation of the middle ear.
• Cholesteatoma form characterized by the appearance of a whitish formation resembling a tumor. Cholesteatoma consists of dense epidermal layers and has a membrane that adheres to bone structures or grows into bone tissue. As the cholesteatoma grows, the tympanic cavity deforms.

Depending on the localization of the lesion, left-sided and right-sided epitympanitis is isolated.

Etiology

Epitympanitis complicates the course of ear diseases that are difficult to treat. Purulent discharge hardly leaves the middle ear and accumulates in the tympanic cavity, provoking the spread of infection.

Most often, the causative agents of epitympanitis are pneumococci, streptococci, staphylococci, Pseudomonas aeruginosa and Haemophilus influenzae, their associations, and pathogenic fungi.

Factors stimulating the development of epitympanitis:

1. Decrease in the general resistance of the organism,
2. Congenital and acquired immunodeficiency,
3. High virulence of the infectious agent,
4. Inflammatory processes in various parts of the auditory analyzer,
5. Foci of chronic infection present in the body -,
6. Frequent,
7. obstruction of the auditory tube,
8. inadequate treatment,
9. Sclerotic type of mastoid process,
10. Nasal septum deformity and turbinate hypertrophy,
11. Avitaminosis,
12. blood diseases,
13. tuberculosis infection,
14. Allergy,
15. Drug addiction, alcoholism, smoking,
16. Failure to comply with sanitary and hygienic rules and regulations.

Microbes, penetrating into the middle ear cavity, cause local inflammation and destruction of bone structures. Osteitis eventually leads to destructive processes and the development of granulations. The auditory ossicles are destroyed, which ends with a pronounced hearing loss. Another sad consequence of epitympanitis is cholesteatoma. This is a tumor-like formation, consisting of keratinized epithelial cells and surrounded by a connective tissue matrix.

With epitympanitis in the epitympanic space, they often find:

• Pus,
• granulation,
• cholesteatoma masses,
• polyps,
• carious process.

Symptoms

Purulent epitympanitis is characterized by a severe course, it is difficult to treat and is accompanied by dangerous complications.

At the doctor's appointment, patients present the following complaints:

1. Decreased hearing acuity
2. Bad smell from a sore ear
3. Irradiation of acute pain in the temple and crown,
4. Bursting and pressing pain in the ear,
5. Congestion and tinnitus
6. Nystagmus (rhythmic movements of the eyeballs),
7. vestibular dysfunction,
8. Purulent discharge with an unpleasant odor, streaks of blood and particles of destroyed bone tissue.

The unpleasant smell of discharge from the ears is due to the attachment and presence of cholesteatoma masses. The fetid discharge from the ear remains so even after the treatment.

Otoscopic signs of epitympanitis are:

• purulent content,
• perforation of the tympanic membrane,
• cholesteatoma masses,
• Sluggish osteitis.

Chronic purulent epitympanitis is often asymptomatic. A cholesteatoma forms and grows without pain. Patients periodically discharge pus from the ear, and hearing is reduced. With a one-sided process, the clinic is poorly expressed, and patients do not perceive their illness for a long time and feel healthy. Despite the calm and latent course of cholesteatoma epitympanitis, the bone walls of the middle ear are destroyed. An exacerbation of the pathology can result in a generalization of the process, inflammation of the meninges, sepsis, abscess formation of brain tissue and other deadly ailments. In the absence of proper and timely treatment, serious complications can develop that lead to disability and even death.

Diagnostics

Diagnosis of epitympanitis includes the collection of an anamnesis of the disease, examination of the patient and instrumental research methods.

1. Otoscopy- one of the main diagnostic methods in otolaryngology. An ENT doctor during an examination of the external auditory canal reveals signs of inflammation, perforation of the tympanic membrane, granulation and cholesteatoma. Otoscopy is performed using an otoscopic microscope, an otoscopic loupe and a Siegle magnifying funnel.
2. Audiometry- a comprehensive study of hearing acuity using special equipment, which is carried out by an audiologist. It is possible to determine how much hearing has decreased in patients with the help of live speech, tuning forks and special electro-acoustic devices - audiometers. Hearing loss is the main symptom of epitympanitis, so the study of auditory function is mandatory.
3. X-ray diagnostics of the temporal region allows you to assess the severity and prevalence of the pathological process. Cholesteatoma on an x-ray is a zone of enlightenment - a rounded cavity with compacted bone walls.
4. sounding carried out using a bellied probe, which is inserted into the middle ear through a perforation. Cholesteatoma or carious masses may stick to the tip of the probe.
5. CT scan allows you to make a diagnosis in cases where other diagnostic procedures are uninformative. CT of the temporal region determines the volume of destruction of the temporal bone, the prevalence of inflammation in the cranial cavity, assesses the integrity and mobility of the auditory ossicles.

Treatment

Timely and adequate treatment of epitympanitis allows the patient to hear normally and prevents the development of complications. It is aimed at suppressing inflammation and restoring sound conduction. Specialists conduct conservative and surgical treatment of the disease.

Conservative treatment

The goal of conservative treatment is to prepare the diseased ear for the upcoming operation. If the patient's condition does not allow to perform the operation, or the patient himself refuses it, drug therapy becomes the only possible therapeutic method.

Comprehensive treatment of an inflamed ear consists of local and systemic antibiotic therapy, physiotherapy, the use of ear drops, which have anti-inflammatory, analgesic and antibacterial properties.

Drug treatment must be supplemented with physiotherapy procedures - UV radiation, laser exposure, oxygen therapy.

Epitympanitis, characterized by extensive destruction of bone tissue, complicated by cholesteatoma or poorly amenable to drug therapy, requires surgery.

ethnoscience

Treatment of epitympanitis with folk remedies is an additional method that gets rid of microbes, promotes tissue repair, weakens the clinical signs of pathology and strengthens the immune system.

The most effective and common folk recipes:

1. Washing the diseased ear with infusion of chamomile or ordinary tobacco.
2. Instillation of vodka or juniper alcohol into a sore ear.
3. The introduction of a cotton swab dipped in an alcohol tincture of propolis into the ear canal for a couple of hours.

Surgery

Indications for surgical intervention for epitympanitis:

• Damage to the bony labyrinth
• auditory canal polyposis
• cholesteatoma,
• Spread of infection inside the skull,
• Paralysis of the facial nerve
• Osteomyelitis and persistent caries of the temporal bone,
• The ineffectiveness of medical treatment.

The operation begins with the sanitation of the ear - removal of the source of infection. The pockets of the ear cavity are united, the pus is removed, the affected tissues are excised, disinfected. Then proceed to the next stage - tympanoplasty, carried out for the purpose of prosthetics of the auditory ossicles and restoration of the tympanic membrane by stretching the skin fold to the perforation site.

stages of tympanoplasty

After the operation, the patient is recommended to observe bed or semi-bed rest. He is prescribed antibacterial and desensitizing agents, corticosteroids and vitamins for 7-10 days. After removing the tampons, the ear is regularly toileted using antibacterial drops. In the postoperative period, physiotherapy is prescribed - UVI, laser, magnet. After treatment of epitympanitis, many patients are advised to purchase a hearing aid.

Prevention

Measures to prevent the development of epitympanitis:

1. Maintaining a healthy lifestyle
2. Strengthening immunity,
3. Timely treatment of acute otitis media and common diseases - diabetes, rickets, tuberculosis, exudative diathesis,
4. Sanitation of foci of chronic infection,
5. Clinical examination under the supervision of an ENT doctor, pediatrician, therapist.

Timely and correct treatment makes the prognosis of epitympanitis favorable. Modern otolaryngology has the means and capabilities to restore the affected anatomical structures of the ear and auditory function. Hearing restoration is a rather lengthy process, not always reaching 100% efficiency.