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0MODERN CONCEPT OF ETIOPATHOGENESIS AND TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA
(LITERATURE REVIEW)
Mukhitdinov U.B.
Tashkent Pediatrical-Medical Institute, Department of Otorhinolaryngology, Doctor of Medical
Sciences, Associate Professor https://doi.org/10.5281/zenodo.13637070
Abstract. The given article provides a detailed understanding of the etiopathogenesis and treatment of chronic suppurative otitis media.
Keywords: chronic suppurative otitis media, etiopathogenesis of chronic suppurative otitis media, tympanoplasty.
It is important to suggest that despite the achievements of modern otolaryngology, chronic suppurative otitis media (CSOM) remains a common pathology and reaches 1% [23]. The author notes that in the general structure of diseases of the organ of hearing, CSOM is 27.2%. According to O.G. Khorova (2010), the prevalence of CSOM among ear diseases reaches 50%. In Uzbekistan, in the general structure of ENT diseases, CSOM is 6.7-7% [22,23].
The medical and social significance of CSOM is determined by the long course of the disease, leading to hearing loss or hearing impairment, to disability, loss of ability to work, which is important for young people [19,25,32,48,76,88]. In addition, the number of people suffering from hearing loss due to CSOM does not tend to decrease [47,55].
In the pathogenesis of CSOM, an important role belongs to factors influencing the course of the purulent process, as well as contributing to the formation of purulent inflammation [39]. These are anatomical features of the structure, topographic relationships of the middle ear and nasopharynx organs, genetic predisposition, and the state of the immune system [89]. According to modern concepts, one of the causes of the development of CSOM is a change in general and local immunity, which is confirmed by changes in the content of cytokines in the blood serum, as well as in morphological, histochemical, and immunomorphological studies of the mucous membrane of the ear [45]. According to V.P. Shpotin (2012), the results of studies of the concentration of cytokines IL-2, IL-6, TNFa and the leukocyte intoxication index (LII) allow us to judge the severity of the inflammatory process in the middle ear. Research by G.V. Vlasova (2005) in children with CSOM showed that the level of IL-8 in ear washes during destructive processes is 9 times higher than with mucositis. The author concludes that the level of local cytokine production more accurately reflects the nature and activity of the process in the middle ear, which can be used for a more detailed diagnosis of CSOM. One of the key factors in the development and chronicity of middle ear diseases is the imbalance in the "LPO-antioxidants" system [5]. Oxidative destruction of membrane PL is accompanied by the release of lysosomal enzymes, and inactivation under the influence of products - LPO protease inhibitors - is accompanied by an increase in the destructive effect of proteolytic enzymes, the excess of which is characteristic of the inflammatory process [6]. Neutrophils and macrophages play a certain role in the pathogenesis of inflammation of the middle ear, producing active forms of oxygen, initiating lipid peroxidation processes and directly participating in cytokine formation [5,33].
Till today the role of nitric oxide in cellular pathology has attracted attention. Nitric oxide exhibits cytotoxic/cytostatic activity, acts as one of the main effectors of the cellular immune system and plays an important role in the mechanism of oxidative stress initiation [6,10,44].
H. Forman, et al. (2002) studied the role of lipid peroxidation in changing the metabolism of the connective tissue membrane of the middle ear and in its destruction.
According to the concept of "developmental programming", the formation of pathology begins at the genetic level before birth [88]. Research by I.A. Tikhomirova (2009) showed that the fact of identifying the polymorphism of the CC16-AA gene and a high level of IgE in blood plasma in a child indicates a dominant role of allergy in the occurrence of exudative otitis media (EOM). Low plasma IgE levels, polymorphism of the CC16-GG gene in the presence of an endoscopic picture of adenoids indicate the predominance of the role of anatomical obstruction of the auditory tube in the formation of EOM. Studies have also been conducted on the role of GST genes in the pathogenesis of neurodegenerative diseases, including acquired sensorineural hearing loss of vascular, traumatic and infectious genesis [8]. A correlation has been shown between mutations in the GSTM1 gene and the incidence of sensorineural hearing loss of toxic etiology.
Factors contributing to the development of the purulent process include environmental pollution, professional activity, diabetes mellitus, malignant tumors and other processes in which purulent inflammation becomes chronic [25, 88].
According to a number of authors, children most often develop CSOM [11, 78]. However, as observations show, among patients requiring treatment for CSOM, the majority are adults, which indicates ineffective detection and treatment of the disease [47, 88]. According to D. Marchioni et al. (2010) and A. Jahn (1991), the main mechanism for the formation of CSOM and its long-term course are foci of purulent infection that form in the middle ear, which are difficult to treat due to anatomical inaccessibility [77].
Anatomical disorders of the drainage and ventilation functions of the auditory tube due to a deviated nasal septum, chronic sinusitis, hypertrophic rhinitis complicate the evacuation of the contents of the tympanic cavity, disrupt aeration of the middle ear cavities, which prevents normal healing of the perforation of the eardrum after acute purulent otitis media and contributes to the formation of persistent perforation [52]. Many endogenous and exogenous factors are involved in the development of the inflammatory process in the mucous membrane of the middle ear. The microbial response serves as a trigger for the imbalance of the LPO-antioxidant protection system, which maintains the inadequacy of the inflammatory response against the background of a genetic predisposition and is manifested by excessive synthesis of anti-inflammatory mediators. The study of gene polymorphism opens up new possibilities both in the prognosis and diagnosis of chronic suppurative otitis media, and in the choice of adequate treatment tactics [33]. It is important that CSOM is a disease that poses a danger not only to health, but also to the life of the patient due to the development of intracranial (up to 1.97%) and extracranial (1.35%) complications [27, 49]. Cholesteatoma is one of the causes of the formation of destruction of the middle ear in CSOM [58, 61, 64]. Cholesteatoma is divided into primary, acquired, and iatrogenic. Primary cholesteatoma is formed as a result of epidermal cells entering the middle ear during intrauterine development. Acquired cholesteatoma is formed in the epitympanic-antral or tubotympanic form of CSOM with pathological migration of epidermal cells into the middle ear cavity. Iatrogenic cholesteatoma is a result of mechanical transfer of epidermal cells into the middle ear cavity [55,75,85]. According
to E.V. Garova (2007), bone destruction in the presence of cholesteatoma occurs in 78.8% of patients [25], regardless of the location of the perforation of the eardrum.
Besides that, a significant percentage is also made up of vestibular disorders due to chronic otitis media, which, depending on the severity, are observed in 30-88% of patients [56].
The following clinical forms of chronic otitis media are distinguished: mesotympanitis, epitympanitis, epimesotympanitis [159, 178].
Mesotympanitis is considered a clinical variant of chronic otitis media with central or marginal perforation in the tense part of the tympanic membrane. According to literature data, chronic mesotympanitis accounts for 58-72% of cases in adults and 68-84% in children in the structure of chronic otitis media [4,20]. Mesotympanitis is characterized by damage to the mucous membrane of the middle and lower parts of the tympanic cavity with little expression of subjective symptoms [26,38].
Epitympanitis is a clinical form of chronic otitis media with marginal perforation in the relaxed part of the tympanic membrane. In epitympanitis, changes in the middle ear of a purulent-carious nature are observed in the attico-antral region, have the character of chronic catarrhal inflammation, and are manifested by edema, inflammatory infiltration of the lamina propria, increased secretion of the integumentary epithelium, and focal sclerotic changes in the mucous membrane [7,87].
Epimesotympanitis in the pathomorphological aspect represents changes inherent in the epitympanic and mesoepitympanic forms of chronic suppurative otitis media [57,59].
In recent years, among chronic suppurative otitis media, chronic tub tympanic purulent otitis media (Tubo tympanic chronic suppurative otitis media) have been distinguished, which is recognized as a benign form, and chronic attic antral purulent otitis media (Attic antral chronic suppurative otitis media), which is characterized by the presence of cholesteatoma. A similar division of forms of chronic otitis media is present in the International Classification of Diseases, 10th revision (ICD-10). Chronic tub tympanic otitis media is considered a more benign form of the process. Chronic attic-antral process, according to some authors, has a more aggressive form [77, 80].
In the attic or attic-antral region, the formation of cholesteatoma with destruction of the auditory ossicles is most likely [69, 70].
According to the literature, cholesteatoma in the middle ear is detected in 24-63% of patients with chronic otitis media with any localization of the tympanic membrane perforation [2,4,20]. The pathomorphological manifestation of cholesteatoma is a gradually progressing destructive lesion of the temporal bone, which is the cause of many complications due to erosion of adjacent structures [60,75,83].
The cholesteatoma matrix appears as an atrophied layer of epidermis with a shortened stratification cycle in the form of rapid keratinization. Above the thinned matrix there is a layer of compressed horny layers - cholesteatoma masses [58,60,85]. Histologically, cholesteatoma consists of three structural components: peri matrices, matrix, and cholesteatomata's masses. The growth of cholesteatoma and bone resorption are caused by the inflammatory reaction of the peri matrices [65].
The presence of cholesteatoma may not manifest itself with specific symptoms for a long time [61,71]. Exacerbation of otitis can cause the disintegration of cholesteatoma and lead to
serious and life-threatening complications for the patient, such as subperiosteal abscess, facial nerve paresis, meningitis, brain abscess, etc. [75,84].
According to modern concepts, congenital and acquired cholesteatoma are distinguished [60,74,77,83].
Primary cholesteatoma is divided into primary and secondary [74]. Primary acquired cholesteatoma is defined as a limited diverticulum of the relaxed part with rare otorrhea or without it. Secondary acquired cholesteatoma is formed by posterosuperior perforation of the tympanic membrane [37, 83].
At present time, there are several theories of cholesteatoma pathogenesis [28,37,60,74,83]. However, in recent years, researchers are inclined to believe that there is a combination of different models of cholesteatoma formation [61,74].
The etiology and pathogenesis of CSOM do not have a clear interpretation. Thus, CSOM is considered to be a consequence of inflammatory processes in the antrum [45,46]. According to the "pneumatic" theory, the cause of CSOM development is the closure of the lumen of the auditory tube and the violation of its ventilation function [15,27,43]. The cause of CSOM can be trauma, infectious diseases [86]. Most often, the formation and chronic period of the purulent process in the middle ear occur in childhood as a complication of past infectious diseases (75-80% of patients) [78,88]. The development of chronic otitis media can be facilitated by inflammatory processes localized in the nasal cavity, paranasal sinuses, and pharynx [43].
Based on the above, the diversity of etiopathogenetic factors and the diversity of the clinical picture of CSOM dictate the need to improve the existing methods of treating CSOM.
The relevance of the problem of treating CSOM is due to the fact that it is accompanied by the development of hearing loss, general intoxication of the body, temporary and permanent loss of working capacity, allegations of the body, and the possible occurrence of severe autogenic intracranial complications [1,3,20,24,29].
In terms of the number of complications, CSOM ranks first among all ear diseases, mainly these are life-threatening intracranial complications (meningitis, brain abscess, sigmoid sinus thrombosis, labyrinthitis, sepsis, facial nerve paresis) [2].
Existing conservative methods of treating CSOM are a preparatory stage of surgical intervention that helps close the perforation of the eardrum, which is very important for restoring the normal anatomy of the middle ear and hearing. According to various authors, persistent perforation of the tympanic membrane occurs in 84-392 cases per 10,000 population, therefore the primary goal of otosurgery is to restore the integrity of the tympanic membrane [15, 42].
However, at present, the problem of plastic surgery of sub and total defects of the tympanic membrane has not been finally solved [21], given the high percentage of reperforation, occurring on average from 3 to 57% of cases [27,37,81].
It is known to everyone that in the last decade, various methods of myringoplasty have been described in the literature [9,11,13,16,36]. A successful solution to this problem improves the functional result and ensures the restoration of normal anatomical relationships between the cavities of the middle ear and the external auditory canal [32, 92].
Besides that, the era of tympanoplasty associated with the name of the German scientist H. Wolstein (1972) began in the middle of the 20th century. To date, a large number of different materials have been proposed for eardrum plastic surgery, and the search for new transplants continues. This fact indicates the imperfection of the autologous materials used, with no decisive
advantages for one or another transplant [27,35,90,62,63]. To restore the integrity of the eardrum, the fascia of the temporal muscle, an ultra-thin plate of auto- and all cartilage, is mainly used. There is insufficient information on the use of perichondrium with cartilage in reconstructive outsourcery, although there is scientific information on its use in other types of reconstructive surgery, for example, in nasal septum plastic surgery [18,31]. It is known that perichondrium with cartilage, i.e. auto material obtained from the patient's own tragus, is a good auditory conductor [22].
Definitely, the analysis of the literature shows that the best anatomical and audiological results are achieved using more rigid, usually two-layer grafts consisting of autologous tragus or rib cartilage, brefo tissues, preserved ultra-thin bone or cartilage tissue, and various soft tissue autografts (most often autologous temporal muscle fascia and autologous perichondrium) that make up the upper layer of the tympanic membrane [7, 35, 37, 41]. Multilayer grafts provide more reliable closure of tympanic membrane defects, but due to the use of several different tissues, the neotympanic membrane differs in its physical and biological characteristics (rigidity, elasticity, and mass) from the normal tympanic membrane, which affects the final audiological result of tympanoplasty [37,39].
Currently, various cartilage structures, gelatin and collagen sponges, synthetic materials (silicone, mesoglea, etc.) are used to provide support for the tympanic membrane transplant, which are placed in the tympanic cavity after the completion of the sanitizing stage of tympanoplasty [14,17]. It is well known that surgical intervention in the middle ear is accompanied by deterioration of hearing function due to swelling of the mucous membrane, as well as the formation of a wound surface of varying area, increased transudation in the tympanic cavity. Under such conditions, not only is scar tissue formed, but the healing process is also hindered [67,68]. Hypotheses explaining the causes of scar formation, the formation and development of the adhesive process are similar in that the basis of such changes, in addition to dysfunction of the auditory tube, is a violation of the integrity of the epithelial lining of the middle ear, which was confirmed in experimental studies by a number of authors [51]. In addition, in modern literature some researchers consider the process of scar formation not as a local process in any one organ, but as a systemic reaction of the whole organism [12]. Currently, absorbable sponges, films made of inert and biological materials, autografts of the mucous membrane are used to prevent cicatricial-adhesive processes in the tympanic cavity [48, 82, 75]. It is known that the listed materials are imperfect and have certain disadvantages, therefore, the issue of preventing postoperative adhesive processes in the middle ear requires further research.
By summarizing it should be suggested that taking into account the above, further unification of the technique of surgical treatment of chronic tympanic membrane, in particular the search for new methods of fixation of the neo tympanic membrane, is relevant and necessary. The social significance of chronic tympanic membrane consists in preventing both life-threatening intracranial complications due to this disease, and the development of chronic forms of hearing loss, vestibular dysfunctions that reduce the quality of life, social adaptation, and professional suitability of the working population [30, 17].
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