OTITIS MEDIA Guangzhou medical college Second Affiliated Hospital Otolaryngology Ouyang shunlin The most important disease of the middle ear and mastoid are inflammations of various kinds and hearing loses. Tumors of the middle ear are rare . In this chapter we'll mainly discussed acute suppurative otitis media(ASOM), and chronic suppurative otitis media(CSOM). Acute suppurative otitis media is one of the most common infections of childhood. It may accompany any upper respiratory tract infection such as the commom cold,measles,scarlet fever,or influenza. When virulent bacteria invade the middle ear, an acute suppuration occurs. Aetiology and pathology Bacteriology The haemolytic streptococcus, staphylococcus or the pneumococcus are most commonly responsible for the infection. Infection route ①Bacteria or virus via the pharyngotympanic tube into middle ear is the maximum incidence in childhood. ②Infection via the external meatus is liable to occur when a tympanic membrance perforation is present. ③otitis media arising as a blood-borne infection is rare. Pathology 1.tubal occlusion;2.presuppuration;3.suppuration;4.resolution. Signs and symptoms symptoms severe,deep throbbing pain in the ear is the cardinal symptoms; temperature elevation(more in infants or children) hearing loss,dizziness,nausea,tinnitus purulence(a mixture of blood and pus) Signs examination shows the tympanic membrance is thick, red, and dull. If rupture has occurred, pus and the perforation may be seen. conductive hearing loss. there is usually pain during pressure over the mastoid antrum. Differential Diagnosis external otitis or furunculosis of external auditory meatus: postauricular tenderness. bullous myringitis: the earache may be intense but deafness only slight, the membrane may be obscured by a large haemorrhagic bleb or blebs. Treatment Antibiotics should be given in full dosage. Penicillin is the drug of choice for empirical selection, except when the patient is sensitive to this drug. In any case, antibiotic sensitivity studies are important. When sensitivity to penicillin is known to exist, erythromycin, or broad-spectrum antibiotics maybe used. myringotomy is indicated when there is bulging of the drumhead and pain not quickly relived by antibiotics. Myringotomy is usually performed to drain pus from the ear in patients with acute suppurative otitis media(ASOM) or to release serum from the middle ear in patients with secretory media. ear drops:① pre-rupture, 2%phenol glycerine; ②after rupture, antibiotics solution such as 0.25%chloromycetin solution,0.3%ofloxacin solution. Chronic suppurative otitis media Neglected or recurrent infection of the middle ear may eventually produce a chronic change in the mucosa of the ear or destruction of the periosteum covering the ossicles. The infection then tends to become chronic. Chronic infection of the middle ear is much more common in persons who had ear disease in early children. Disease of the ear in infancy and early children may arrest the normal pneumatization of the mastoid. It is possible that the same process alters the mucosa of the middle ear, so that it is more susceptible to recurrent infection than is the normal ear. Most patient with CSOM have a small, undeveloped, and acellular mastoid, which can be demonstrated with roentgenograms. Aetiology and pathology Characteristic of the bacteriology of chronic otitis media is a shift towards a predominance of gram-negative bacilli, most frequently isolated bacteria include Pseudomonas aeruginosa（绿脓杆菌）, staphylococcus aureus(金黄色葡萄球菌), B.proteus(变形杆菌) and corynebacterium(棒状杆菌). The prevalence of CSOM is related to social conditions. It is also known that chronic infection occurs predominantly in nonpneumatizd clefts. Here it must be said that there is a difference opinion, some authorities holding that failed pneumatization is a result of infection and not a precondition. Although a cholesteatoma may form and gradually enlarge without contamination, it is more common for infection early to supervene upon a pre-existent cholesteatoma, or for a cholesteatoma to form as a result of infectin. Cholesteatoma Histologically, cholesteatoma are of two types, epidermoid cholesteatoma (胆脂瘤上皮)and cholesterol granuloma(胆固醇肉芽肿). epidermoid cholesteatoma is a bag-like cystic structure lined by keratinizing stratified squamous epithelium resting on a fibrous stroma of variable thickness. epidermoid cholesteatoma is a by-product of keratinizing squamous epithelium . cholesterol granuloma is a granulomatous structure formed by variable numbers of cholesterol crystals, sometimes with haemosiderin, surrounded by foreign body giant cells, and embeded in fresh granulation tissue. cholesterol granuloma results from deposition of cholesterol at a site of suppuration or haemorrhage, and is often associated with a blue drum. Congenital cholesteatoma A congenital cholesteatoma is aetiologically unconnected with chronic suppurative otitis and is generally anatomically unconnected with the middle ear cleft. It arises in an embryonic cell rest in any of the cranial bones and may remain undetected for years. If it arise in the temporal bone, i.e. petrous pyramaid, it may, by extension, make anatomical connection with the middle ear cleft and become infected therefrom.. Primary acquired cholesteatoma and secondary acquired cholesteatoma The genesis of acquired cholesteatoma has been the subject of much conflicting debate. Primary acquired cholesteatoma refers to those tumors arising without a previous otitis media, while secondary acquired cholesteatoma occurs in ears known to been the seat of a previous infection, or to be currently infected. Genesis of primary acquired cholesteatoma  if a previous acute otitis media has resulted in necrosis of the tympanic membrane and of middle ear mucosa there may be a tendency, especially if the perforation is marginal, for squamous epithelium to migrate into the middle ear from the external meatus. Especially, if a marginal perforation or attic perforation exists, the alternating processes of healing and degeneration may result in the advance of squamous epithelium into the middle. Signs and symptoms The principal symptom of com is purulent otorrhoea, while the principal sign is the observation of pus coming from the middle ear via a perforation. Otorrhoea may have been proceeding for years before the patient seeks advice. Conductive deafness is inevitable in com; Increase smell or blood-staining, polypus at the meatus, pain, vertigo, or headache, that often brings the patients to the doctor, and not infrequently these symptoms are indicative of complication requiring urgent surgical intervention. The safe ear(benign com) and unsafe ear(dangerous com) safe ear unsafe ear disease area tubotympanic attic-antrum perforation anterior or central attic or marginal pus mucoid, odourless, profuse thick, fetid, scanty granulations uncommon common polypus ifpresent, usuallypale, oedematous usually hyperaemic, fleshy deafness conductive, usually slight to moderate conductive or mixed, moderate to severe cholesteatoma uncommon common Treatment Treatment has two main objectives; first to arrest disease, and second to secure conditions that will permit return of tissues to normal or that will allow recovery of function. It is, a general ideal of treatment to secure these objectives by medical, if possible, in preference to surgical means. Medical treatment Topical antibiotic application, ① 0.25%chloromycetin solution ② 0.3%ofloxacin solution ③ 4%bonic acid alcohol aural toilet is an essential precursor to any topical application, ear drops should be applied by the displacement method. Surgical treatment Primary objects of operative treatment ① to render the patient safe ② to prevent further deterioration of function operation methods cortical mastoidectomy(simple mastoidectomy, Schwartze opration) classical radical mastoidectomy modified radical mastoidectomy, attic-antrostomy anterior tympanotomy combined-approach mastoidectomy posterior tympanotomy reconstructive surgery myringoplasty, ossiculoplasty, tympanoplasty tympanoplasty tympanoplasty without mastoidectomy (Closed technique) tympanoplasty with mastoidectomy (Opened technique) Reference book Textbook of otolaryngology David d. decease, MD sixth edith Disease of the ear Stuart R. mawson fourth edith 思考题： 慢性化脓性中耳炎的临床分型及特点