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Pathogenetic aspects of exudative otitis media in children and treatment approaches
Saidov Sanjar Husenovich, Doctor, ENT Department of the Central Clinical Hospital № 2, MSA of the Ministry of Health of Uzbekistan, Tashkent, Uzbekistan
Amonov Shavkat Ergashevich, Professor, Head of ENT, pediatric ENT and dentistry Department, Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
Husanhodjaeva Dilfuza Eldarovna, Doctor, Head of the ENT Department of the Central Clinical Hospital № 2, MSA of the Ministry of Health of Uzbekistan, Tashkent, Uzbekistan
E-mail: otology_ent@bk.ru
Pathogenetic aspects of exudative otitis media in children and treatment approaches
Аbstract: Our study showed that, in most cases, exudative otitis media develops on the background of nose and nasopharynx diseases. Accordingly, the timely identification and removal of the above causes, can lead to positive dynamics. A comparative analysis of the treatment results did not show reliable differences between therapy, aimed to dysfunction of auditory tube elimination and parallel tympanic cavity bypass.
Keywords: exudative otitis media, bypass, auditory tube.
The problem of hearing organ pathology becomes more and more actual from year to year in the social-economic and health spheres [1]. Among the causes of hearing loss in patients of children's age, the frequency of occurrence of exudative otitis media is one of the leading places [5]. Exudative otitis media (EOM) — poly-etiological disease characterized by the presence of fluid in the middle ear cavities and development sluggish, recurrent, not purulent inflammation in the auditory tube and tympanic membrane, cells of the mastoid process, which subsequently leads to varying degrees of hearing reduction.
Among the causal factors in the development of exudative otitis media is the most hotly debated also infectious, allergic and immunological factors [3; 4; 5; 6; 7; 9; 10].
EOM often develops against the background of the drainage and ventilation functional disorders of the auditory tube in acute and chronic diseases of the nose, paranasal sinuses and pharynx, after suffering by acute respiratory illness, irrational use of antibiotics in the treatment of acute otitis media or allergic rhinosinusopathy.
Effects of exudative otitis media have the highest proportion (45-58 %) in the structure of infant and teen hearing loss with the annual increase in the number of patients up to 1.5 % [2].
In scientific publications remains disputable choice method of treatment of exudative otitis media. Most authors adhere to active surgical tactics of treatment of exudative otitis media, which is a long bypass tympanic cavity. According to Sedeberg-Olsen J. and co-authors [13], Fish U. [8], even timely and high-quality treatment of exudative otitis media in some cases ends with formation ofretrac-tion cholesteatoma. Last circumstance prompted the otosurgeons to search for methods to prevent complications of exudative otitis media. On the initiative ofJahnke K. [11], next phrase appeared in the foreign literature "nasal preceding cholesteatoma surgery", which literally means nasal surgery, prevent cholesteatoma. In his research the author relied on data Meyer W., Krebs A. [12], which published the work on improving the auditory tube ventilation function in patients with chronic otitis media. In our view, timely conducted restoration operation in the nasal cavity, paranasal sinuses and nasopharynx, substantially improve current and forecast exudative otitis media.
In the pathogenesis of otitis media exudative auditory tube dysfunction plays a dominant role. Therefore, timely finding and
elimination auditory tube dysfunction reasons, in many cases leads to full rehabilitation of patients.
The purpose of the study. The study of diagnostic value of different examination methods for the detection of pathology of the nose and nasopharynx, and comparative assessment of treatment methods of the exudative otitis media in children.
Materials and methods. Under our supervision were 176 children with exudative otitis media aged from 3 to 18 years, from them 110 (62.5 %) boys and 66 (37.5 %) girls. 105 children (59.7 %) was diagnosed with a double-sided, in 71 (40.3 %) a unilateral process, 115 (65.3 %) patients with acute, 61 (34.7 %) chronic otitis media exudative form.
The survey methodology included a review of complaints and patients anamnesis, otorinolaringology inspection, x-ray and MSCT of paranasal sinuses. All the patients performed nasal and nasopharynx endoscopy, otoendoskopy and otomikroskopy. Degree of retraction eardrum was determined by classification M. Tos and J. Sade (1990). The results recorded on videotape, It allowed to judge about dynamic of disease current and if you need to change treatment tactics. Mono-tympanometry were conducted using a test "Valsalva", and "Toynbee", determining the pass ability of the auditory tubes in the Eardrum perforation (after bypass surgery), type classification of tympanogram by Jerger (1970). Verification of the diagnosis of exudative otitis media was evaluated according to the classification of N. Dmitriev and co-authors (1996).
Patients were divided into two groups: the first group of patients, along with conservative therapy conducted sacrificial nose surgery and Chair to address the auditory tube dysfunction. A second group of patients received similar treatment with a shunt tympanic membrane at the same moment.
Treatment effectiveness criterions were next: normalization of data endo- and microotoscopy, tympanometry and hearing improvement.
Results and its discussion. In the study of anamnesis should note the following: The parents of 66 (37.5 %) patients connected disease of the child associated with transferred respiratory infection, 47 (26.7 %) patients were in a frequently ill children group, 34 (19.3 %) patients had burdened allergy anamnesis since early
Section 4. Medical science
childhood (exudative — catarrhal and thymicolymphatic diathesis) in 29 (16.5 %) cases, — accompanied by worm infestation.
The results of endoscopy of the nose and nasopharynx showed the following: 58 (32.9 %) patients had vasomotor symptoms — allergic rhinitis, in 38 (65.5 %) — allergic rhinitis combined with different forms of nasal septum deformation, in 73 (41.5 %) patients were defined adenoid vegetations degree II—III, including: 32 (43.8 %) surveyed adenoids combined with hypertrophy of the tonsils II—III degree, 24 (32.9 %) they were combined with hypertrophy of tubular rolls, 17 (23.3 %) — with scar changes in the nasopharynx related to previously transferred surgical interventions (ad-enotomy, re-adenotomy). In 45 (25.6 %) patients was determined a strip of pus, running down the back wall of the nasopharynx (symptoms of sinusitis) over the pharyngeal mouth of the Eustachian tube.
On MSCT of paranasal sinuses, in 86 (48.9 %) patients were diagnosed sinusitis, 39 (45.3 %) of them — maxillary and ethmoid sinuses inflamation, 31 (36.1 %) of them — ethmoiditis, 16 (18.6 %) of them -patients with unilateral sinusitis.
It is known that the endo- and microotoscopy allow assessing the state of the eardrum at the auditory tube dysfunction. At endo- and microotoscopy in 59 (33.5 %) patients was revealed the presence of vascular injection and retraction of the eardrum, in 55 (31.3 %) — vascular injection and protrusion of the eardrum, in 32 (18.2 %) — trans-illumination of horizontal liquid level, in 30 (17 %) — retraction pocket of them — in 16 (53.3 %) patients it was controlled, and in 14 (46.7 %) — uncontrolled, that increased the risk of secondary cholesteatoma. All patients underwent Valsalva and Toynbee tests to determine the mobility of the tympanic membrane and pass ability of the auditory tube: in 119 (67.6 %) patients the tympanic membrane was moving, in 57 (32.4 %) — it was almost stationary.
On the audiogram in 96 (54.5 %) of the patients was determined conductive hearing loss — I degree, in 56 (31.8 %) — II degree of
conductive hearing loss, in 24 (13.7 %) — III degree of hearing loss mixed character. In 121 (68.8 %) patient recorded tympanogram type "B", 55 (31.2 %) — the type "C". Monotympanometry had shown in 97 (55.1 %) patients good pass ability of the auditory tube, in 45 (44.9 %) — a violation of pass ability of the auditory tube.
To compare methods of treatment, the patients were divided into two groups. The first group — 91 (51.7 %) the patient received conservative therapy and needs surgery, aimed at removing the auditory tube dysfunction. Of these, 62 (68.1 %) patients diagnosed with acute, 29 (31.8 %) — chronic exudative otitis media. For elimination of the auditory tube dysfunction we have done a course of conservative (antibiotics, antiviral, anti-inflammatory, antihistamine drugs, secretolytics and decongestants, transporting drugs by Proec or puncture maxillary sinuses with the introduction of antibiotics and corticosteroids) and surgical (adenotomy, adenotonsillotomy, ultrasonic disintegration of the lower nasal concha, adhesiotomy pipe rollers, septoplasty, maxillary sinus-otomy) treatment.
The second group — 85 (48.3 %) patients who simultaneously with surgery in nasal cavity and nasopharynx conducted bypass tympanic membrane. Of these, 53 (62.4 %) are diagnosed with acute, 32 (37.6 %) — chronic otitis media exudative form. Shunt is installed as standard, in posterior-inferior quadrant of tympanic membrane that reduces the risk of injury to the medial wall of the tympanic cavity. Term shunt ranged from 2 to 4 weeks.
After the therapy, the patients of both groups repeatedly inspected and examined in 2 nd and 4 th week. As already noted above, the criteria of effectiveness of therapy was improving data otoscopy (otoendoscopy and otomicroscopy), hearing and tympanogram registration type "A" in conducting impedans. After bypass surgery was checked a permeability of the auditory tube of tympanic membrane again. Data on patients after therapy, conducted in the table 1.
Table 1. - Comparative analysis conducted therapy in patients with EOM
Groups Positive clinic- audiologic dynamics (number of patients) Without improvements (number of patients) Р
in 2 weeks in 4 weeks in 8 weeks
I (91 patients) 48 26 17 < 0.05
II (85 patients) 42 24 19 < 0.05
Total quantity (176 patients) 90 50 36 < 0.05
As can be seen from the table, according to the results of the therapy, the improvement of clinical-audiology data the two groups from each other reliably are no different. Research indicates that the bypass is not reliably tympanum improves results of treatment and outcome of EOM.
After 2 weeks held conservative therapy and surgical techniques eliminate the dysfunction of auditory tube and tympanic cavity shunting, 90 (51.1 %) positive patients clinical-audiology dynamics that led to data normalization of endo- microotoskopy, monotympanometry, improve hearing and tympanogramm registration type "A". At 50 (28.4 %) patients noted positive clinical-audiology dynamics in 4 weeks.
Our research has shown that timely and prompt surgical intervention, aimed at restoring the auditory tube dysfunction, reduces the need for shunting tympanic membrane and number of shunt related complications.
Due to the fact that, at 36 (20.5 %) patients in the observation period (within 8 weeks), there was no positive clinical-
audiology dynamics, this group of surveyed performed antroto-my with double venting antruma (based on the picture of MSCT temporal bones).
Conclusions: our study showed that exudative otitis media in children, in most cases, develops against the background of the pathology of the nose and nasopharynx, which leads to dysfunction of auditory tube. Complex diagnostics, including endoscopy of the nose and nasopharynx, otoendoscopy, as well as the MSCT paranasal sinuses, represents the most reliable information about the cause of the auditory tube dysfunction.
Analysis of the treatment results did not show reliable differences between therapy, aimed to elimination the dysfunction of auditory tube and tympanic cavity parallel shunt.
Therefore, early diagnosis and prompt surgical removal of the causes leading to the auditory tube dysfunction, combined with comprehensive conservative therapy, give positive clinical and functional results, and they are an important component in the hearing rehabilitation of such patients.
Indicators nitroxide ergic system at mycoplasma pneumonia in combination with herpes infection in children with immunotherapy
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Tadzhihanova Dono Pulatovna, Junior Researcher of Republican Specialized Scientific and Practical Medical Center of Pediatric, Republic of Uzbekistan
E-mail: evovision@bk.ru
Indicators nitroxide ergic system at mycoplasma pneumonia in combination with herpes infection in children with immunotherapy
Abstract: In children with mycoplasma pneumonia associated with herpes infection, there is overproduction of nitric oxide and peroxynitrite-related activation of the inducible form of nitric oxide synthase. It appears more pronounced in patients with MP + HSV + CMV association.
Keywords. Mycoplasma, herpes, nitrogen oxides, children.
Actuality
Currently, one of the urgent problems of Pediatrics is mycoplas-ma pneumonia, which is caused not only widespread among it early childhood, despite the widespread use of modern antibiotics [2; 4; 8]. Today emerged pneumonia is often due to the addition of herpes virus infection (HVI). In recent years there has been growth in the proportion of "intracellular" (atypical) pathogens in the etiological structure of community-acquired pneumonia in children, such as Mycoplasma pneumoniae (MP) [1; 3; 5]. Frequency of MP reaches 35-50 %. The absence of a rigid cell wall at mycoplasma determines the polymorphism of cells, resistance to penicillin, ami-noglycosides and cephalosporins. Often MP associated with herpes infection (HSV + CMV or HSV+VEB + CMV), determining the severity and recurrent nature of pneumonia [6; 7; 8]. It should be said that lip polysaccharide (LPS) of bacterial origin that trigger inflammation, interact with neutrophils, macrophages, cause accumulation in the body of a free-radical oxygen species that interact with the azo containing compound may form a nitrogen oxides [6; 10]. The radicals of these compounds (NO), superoxide and it's reaction product peroxynitrite, formed by the infectious diseases have a significant role in the development and pathogenesis of diseases: they are mediators of inflammation, modified proteins and nucleic acid damage [9; 10]. The constant change of the microbial
landscape, dynamic changes of reactivity and immune response in children with mixed infection dictate the need for adequate path genetically oriented immunostimulatory therapies. It should be a differentiated approach to the treatment according to the identified infectious agents to avoid polypharmacy. In this regard, promising a differentiated inclusion in the basic therapy MP with herpesvirus infection glycyron and anaferon. However, it is necessary to study the mechanism of action of the proposed systems of the therapy, which determined the purpose of the present study.
Objective
Influence of treatment of mycoplasma pneumonia in combination with herpes infection in children to the performance of nitric oxide system.
Material and methods
The study involved 190 infants with mycoplasma pneumonia (MP), combined with the herpes simplex virus (HSV) (40 children - group 1), cytomegalovirus (CMV) (50 children - group 2) or association (100 children - group 3) in the active phase of the disease, are hospitalized in the children's center of the RSSPMC Pediatrics of Health Ministry of Republic of Uzbekistan. The most serious disease proceeded in patients with MP + CMV + HSV. Clinical diagnosis of mycoplasma pneumonia was established based on clinical-anamnestic and additional laboratory and radiological data.
