Chronic (chronic, chronic) otitis refers to middle ear infection that lasts for more than 3 months, often with discharge. The inflammation in the middle ear and its associated mastoid space almost always reaches the outer ear canal through the perforated eardrum and manifests itself as dirty white-yellow fluid at the entrance of the ear canal.
A worse form of chronic otitis media is cholesteatoma. It is called otitis. In this disease, the outer ear canal and the skin layer covering the outer surface of the eardrum enter the middle ear cavity, where it should not normally be present, and with the addition of bacteria, cholesteatoma is formed, which eats away at the ear bone from the inside and acts like a tumor, even though it is not a tumor.
With cholesteatoma. or chronic otitis media without cholesteatoma; It generally covers a process that continues since childhood. In this disease, which has affected humanity since ancient times, periods of discharge and inflammation are followed by dry, silent periods with no discharge. The factor that causes the discharge, which is an indication that the inflammation is exacerbating, is either the lowering of the body resistance of a disease such as cold, flu, or water leakage into the middle ear through the perforated eardrum.
Anatomy
The external auditory canal or The ear canal is a blind space at the end of which the eardrum is located. In the inner part of the eardrum is the middle ear cavity, located between the external auditory canal and the inner ear. The eardrum separates this space from the external environment. The continuation of air in the middle ear cavity is provided by the Eustachian tube, which connects the middle ear to the nasopharynx (nasal area), which is the back of the nose. While yawning or swallowing, air passes from this tube to the middle ear. Thus, new air reaches the middle ear to replace the air that is absorbed and lost over time.
The middle ear also contains three very tiny ossicles, the outermost of which is connected to the eardrum and the innermost of which is connected to the inner ear window. The function of the chain formed by these three ossicles is to amplify the sound vibrations reaching the eardrum and transmit them to the inner ear fluids.
This system, consisting of very tiny ossicles, is very sensitive and chronic middle ear infection often causes permanent damage to these ossicles and leads to hearing loss.
The ear bone connects to the part of the brain called temporal lobe on its upper surface and the cerebellum on its back surface. It is adjacent to . In addition, important structures such as the inner ear, the main artery going to the brain (internal carotid artery), the main vein that carries blood from the brain to the heart (internal jugular vein), and the facial nerve are located within this bone. Chronic otitis has the potential to damage these structures.
The Formation Process of the Disease
This disease, which dates back to childhood or adolescence, occurs in two ways:
An acute infection. or as a result of the hole formed in the membrane after trauma not being closed, the middle ear cavity, which is normally an isolated environment, becomes open to external influences, and infectious factors reach this cavity and cause discharge from time to time. This process negatively affects the ossicular chain system and therefore hearing over time.
Especially the weaker upper part of the eardrum begins to collapse inwards towards the middle ear due to effects that have not been fully elucidated. This collapse causes the inner surfaces of the ear bone and tiny air cells to become covered with keratin-producing squamous epithelium of the skin that should not be there. At the same time, the three small ossicles in the middle ear are also covered with this squamous epithelium. Keratin produced by the skin epithelium creates negative effects in this space, which should not be present, over time. On top of that, micro-organisms with high disease-causing potential in the external ear canal are added, which further increases the damage and causes chronic otitis media with cholesteatoma, which occasionally manifests itself with foul-smelling discharge.
This process affects the middle ear. It occurs more frequently in cases where there is a weakness in the functioning of the Eustachian tube, which connects it to the nasopharynx (nasal area), which is the back of the nose.
Who Is It Frequently Seen?
Chronic middle age with or without cholesteatoma. Ear infections are more common in the following groups of patients:
Those born with cleft palate or other anomalies of the head and face area
Those with lower socio-economic status, growing up in a crowded family environment
Childhood in nursery, daytime Those that take place in places such as care centers made in our country Although there is no previous study, it is reported to be seen in 1% of children in the United Kingdom (England, Scotland, Northern Ireland) and 0.5% of adults.
Symptoms of the Disease
The most common symptom of this disease is ear discharge, which usually persists for many years and can sometimes smell quite bad. This discharge decreases or stops from time to time, and manifests itself when body resistance decreases or water enters the middle ear. The discharge may be clear or pink-red or yellow-green mixed with blood. As we mentioned above, it can sometimes smell quite bad.
The second most common symptom is hearing loss, which tends to increase over the years in the diseased ear. The cause of hearing loss is the perforation of the eardrum, the ossicles in the middle ear melting and being damaged over time, and the damage caused by the inflammatory process in the middle ear to the adjacent inner ear.
In this disease, signs and symptoms such as pain and high fever, which are usually seen in other infectious diseases, are not observed. . The presence of earache, redness around the ear, severe headache, dizziness, nausea, vomiting, weakness in the facial muscles on the same side, facial paralysis usually indicate that the disease is in an acute exacerbation period and even a complication (situations that occur as a result of the disease and sometimes pose serious danger).
In some patients, the granulation tissue (a type of healing tissue) that occurs as a result of inflammation in the middle ear can grow very large and turn into a polyp (reddish flesh growth) that fills the entrance of the ear canal.
>Complications of Otitis Media
Nowadays, when antibiotics are used extensively and reaching a physician is relatively easy, complications related to chronic otitis media (conditions that arise as a result of the disease and sometimes pose serious risks) are less common than in the past. can be seen. However, these conditions, which have the potential to cause serious and permanent consequences once they occur, should be treated using all available means before it is too late.
Complications caused by chronic otitis can occur intracranially (within the cranial cavity) and intratemporally (ear bone).
Intracranial (inside the cranial cavity) complications;
- Meningitis (inflammation of the brain membrane)
- Extradural abscess (abscess outside the brain membrane). )
- Subdural abscess (abscess under the brain membrane)
- Brain abscess
- Sigmoid sinus thrombophlebitis (inflamed clot in the brain vein)
- Otitic hydrocephalus (increased pressure of the cerebrospinal fluid)
Intratemporal (inside the ear bone) complications:
- Mastoiditis (destruction of tiny air cells in the ear bone by inflammation and inflammatory fluid accumulation)
- Petrositis (inflammation of the innermost end of the ear bone)
- Subperiosteal abscess (inflammation/abscess under the membranous sheath surrounding the outer surface of the ear bone)
- Labyrinthitis (inner ear infection)
- Facial nerve paralysis (facial paralysis)
Evaluation of the patient and examinations
A detailed ear, nose and throat examination is essential in the patient presenting with symptoms of chronic otitis media. If there is inflammation or discharge on the ear canal and membrane, it is cleaned with vacuum and the problem is tried to be clearly understood. Before planning a comprehensive treatment, examinations such as audiological examination (detailed hearing test) and radiological examinations (computed tomography and MRI) are almost always performed. These examinations help determine the treatment method to be chosen and, if surgery is to be performed, the scope and extent of the surgery.
Treatment with Medicines and Drops
The definitive treatment of chronic otitis media is often performed through surgery. However, keeping the ear dry until surgery and stopping any discharge if there is any discharge are important in the treatment of this disease. Although it is an infectious disease in which microbes are involved, systemic antibiotic therapy (using antibiotics orally or injected) has a limited place in the treatment of chronic otitis media. Systemic antibiotic treatment is on the agenda during the most exacerbated periods of the disease or if there are complications, such as the possibility of the infection crossing the borders of the middle ear and spreading into the brain or outside the ear bone.
The preferred treatment during the diarrheal period includes chemical substances (e.g., chemicals) that will prevent the proliferation of bacteria. boric acid) and antibiotics It is applied as drops to the ear canal and middle ear. This is a more effective way to deal with the infection in the discharge period of chronic otitis. In addition, if there are flesh growths (granulation tissue, polyp) in the middle ear and external ear canal, using cortisone-containing drops in addition to antibiotic drops can help the discharge heal in a shorter time. An important point here is not to choose drops containing 'aminoglycoside' type antibiotics, which can damage the inner ear, which is both the hearing and balance organ. These drugs, which are not likely to pass into the middle ear and from there to the inner ear and cause harm when the eardrum is intact, can reach the inner ear fluids through the inner eardrums, which are permeable when the eardrum is perforated.
In cases where the discharge is excessive, the middle ear cavity and the outer ear can reach the inner ear fluids. Frequently vacuuming the inflamed fluid in the ear canal by physicians and applying the drops immediately after this process will facilitate the drying of the discharge.
When the discharge ends and the middle ear and external ear canal dry out, the drop treatment has achieved its purpose. In this case, what needs to be done is to prevent water from entering the ear canal to prevent the ear from becoming inflamed again. Water entering the middle ear through the perforated eardrum may carry microorganisms in the ear canal and cause the infection to reoccur. The most common practical method to prevent this is to mix a small piece of cotton with some vaseline and place it in the ear canal entrance on the side where the eardrum is pierced before taking a bath or shower, and then remove it and throw it away after drying your hair. Additionally, soft silicone plugs can sometimes be used for this purpose.
Surgical Treatment
The treatment of chronic otitis disease with or without cholesteatoma is often surgical. Large holes in the eardrum rarely close on their own. Unless the hole is closed, upper respiratory tract infections or water entering the middle ear will lead to exacerbation of otitis, ear discharge, and serious damage to hearing in that ear over time. The way to prevent this is to repair the hole in the eardrum using the body's tissues. Unfortunately, cholesteatoma is a pathology that cannot be cured without surgery.
The first surgery performed for chronic otitis media disease is
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