Secretory otitis media is a non-purulent inflammatory disease of the middle ear characterized by fluid accumulation in the middle ear and hearing loss, also known as exudative otitis media, non-purulent otitis media, mucus otitis media, catarrhal otitis media, tympanic chamber effusion, plasmacytosis, plasmacytosis-mucus otitis media, and aseptic otitis media. If the fluid accumulation and viscous and jelly-like, it is also called glue ear. The main symptoms are stuffy ear, distant hearing and hearing loss after infection in the upper whistle. Because the ear pain is not obvious and the child’s complaints are unclear, parents only find out when the child’s hearing is affected, which often delays diagnosis and treatment. The otologic examination may reveal an amber or orange color of the eardrum, as well as planes of air and fluid or bubbles, and reduced mobility of the eardrum. Secretory otitis media is common in children. It can cause hearing loss and affect speech and language development in children and should be treated with high vigilance and prompt observation. In adults with unilateral lesions, the cause should be clarified as soon as possible to exclude occupying tumors in the nasopharynx and surrounding spaces, to relieve symptoms and improve quality of life as soon as possible.
Etiology
In patients with normal tympanic membrane, the eustachian tube is the only tube that communicates between the middle ear and the external environment. Eustachian tube obstruction is an important cause of secretory otitis media. Under normal conditions, the air pressure inside and outside the middle ear is basically equal. When the eustachian tube becomes dysfunctional due to various reasons, the gas in the middle ear is absorbed by the mucous membrane, resulting in negative pressure in the middle ear, which leads to dilatation of the veins of the middle ear mucosa, increased permeability, and leakage of serum and accumulation of fluid in the middle ear.
Eustachian tube ventilation dysfunction is divided into two types: mechanical dysfunction and functional dysfunction.
1.Mechanical obstruction
Special infections such as nasopharyngeal diphtheria, tuberculosis, syphilis and AIDS can cause the disease due to direct compression, blockage of the pharyngeal opening or affect lymphatic flow, resulting in swelling of the mucosa of the lumen of the eustachian tube.
2.Functional ventilation dysfunction
In children, the muscles of the palatine sail tensor, palatine sail raphe and pharyngeal pharyngeal muscles are weak and contracted, and the pharyngeal canal cartilage is not mature enough and has poor elasticity. Bacterial and viral infections, radioactive damage, congenital mucosal ciliary dyskinesia, and primary ciliary dyskinesia can cause a decrease in the active material on the surface of the eustachian tube, resulting in increased resistance to the opening of the eustachian tube, which is also considered a cause of secretory otitis. In addition, type I and III allergic reactions may cause secretory otitis media, which may be related to allergy-induced edema of the mucosa of the eustachian tube and occlusion of the tube lumen.
Clinical manifestations
The clinical manifestations of secretory otitis media are mainly hearing loss, which may vary with body position, mild ear pain, tinnitus, ear stuffiness and occlusion, and the sound of water can be heard by shaking the head. On examination, the tympanic membrane may be sunken, amber or darkened, with air-fluid planes or bubbles, and reduced mobility of the tympanic membrane.
Infants and toddlers show poor response to surrounding sounds, ear scratching, easy awakening from sleep, and irritability. Infants do not respond to peripheral sounds and cannot turn their heads accurately to the source of sound; even if the child does not complain of hearing loss, family members find that the child is rambunctious, has altered behavior, does not respond to normal conversation, and always turns up the sound when watching television or using hearing devices; in recurrent acute otitis media, one should be alert to the possibility of persistent secretory otitis media during interictal periods; poor academic performance; poor balance poor ability and unexplained clumsiness; delayed speech and language development.
Examination
1. Air otoscopy or microscopic examination
Air otoscopy is convenient and easy to perform and is the main diagnostic method for secretory otitis media and the preferred method for community examination of the tympanic membrane. It can change the air pressure in the external ear canal and observe the activity of the tympanic membrane. The diagnosis is made if the tympanic membrane is found to be hypokinetic, accompanied by tympanic membrane invagination, a change in color from normal grayish translucent to orange or amber, and the sight of air-fluid planes or bubbles. Compared with ordinary otoscopy, pneumatic otoscopy has higher sensitivity and specificity.
2.Acoustic conductance test
Acoustic conductance testing is a fast, effective, and objective method of reflecting middle ear function. Since tympanic otoscopy is difficult to determine the condition of the tympanic membrane and middle ear in children under 2 years of age, acoustic conductance provides a convenient test. The tympanic chamber pressure map of the acoustic conductance can be type B and type C. In the beginning, the eustachian tube is malfunctioning or blocked, middle ear gas is absorbed to form negative pressure, the tympanic membrane is invaginated, and the peak pressure point of the tympanic chamber pressure is displaced to the negative side. When the lesion gradually progresses, the tympanic membrane becomes more invaginated, fluid accumulates in the tympanic chamber, the quality of the sound transmission structure increases, the sound conduction resistance increases, the strength of the tympanic chamber increases, the activity of the tympanic membrane and the auditory chain decreases, and the peak pressure point becomes more and more negative.
It is generally believed that if the tympanic chamber conductance map is type B, the diagnosis of secretory otitis media can be made in conjunction with clinical practice. However, a series of structural changes in the external ear and middle ear occur in newborns and infants after birth. For example, the increase in the size and diameter of the external auditory canal in infants within 1 year of age causes changes in its compliance, resulting in changes in the resonance gain and resonance frequency of the external auditory canal. In addition, the gradual loss of amniotic fluid and mesenchymal cells present in the middle ear cavity (which can last up to 5 months postnatally) also reduces the total middle ear mass; the stapes density decreases and the mass decreases; and the tightness of the attachment between the auditory chain joints and the stapes floor plate to the oval window changes, all of which reduce the resistance component. Therefore, conventional tympanograms with 226 Hz sound detection tests do not truly reflect the presence or absence of middle ear pathology and middle ear function in infants less than 6 months of age. Therefore, children older than 4 months of age use a 226 Hz sound probe and children younger than 4 months of age use a higher frequency sound probe (1000 Hz). This will make the test results more accurate.
3. Tympanocentesis or tympanotomy
Under an otomicroscope or endoscope, the tympanic membrane is punctured or incised at the lower part of the tympanic membrane, and the presence of plasma-like or mucus-like fluid is confirmed. It is an invasive diagnostic method, but tympanocentesis is a golden indicator in clinical diagnosis, which can not only clarify the diagnosis, but also achieve the purpose of treatment.
4.Nasopharyngeal examination
In adult patients, the nasopharynx and pharyngeal orifice of the eustachian tube can be directly observed with nasal endoscopy or multifunctional fiberoptic nasopharyngoscope. Exclude occupying lesions in the nasopharynx.
5.High resolution thin layer CT of temporal bone
Unilateral recalcitrant secretory otitis media, which is ineffective after treatment, should be alerted to submucosal nasopharyngeal carcinoma involving the parapharyngeal space and compressing the eustachian tube. If differential diagnosis is needed, or if occupancy of the nasopharynx and parapharyngeal space needs to be excluded, high-resolution thin layer CT of the temporal bone can provide information about the middle ear. Enhanced scans are required when necessary.
Diagnosis
Based on the medical history and specialist examination, the diagnosis can be clarified by combining tympanic conductance mapping and acoustic reflex, otomicroscopy or endoscopy, and tympanocentesis or dissection.
Treatment
1.Conservative treatment
(1) Nasal constrictors to improve the ventilation function of the eustachian tube, commonly used drugs such as ephedrine preparations, hydroxymetazoline hydrochloride and other drugs, but the use of this drug should be careful to prevent drug dependence, – the general course of treatment does not exceed 1 week, if frequent overuse is prone to drug rhinitis. Ephedrine-type nasal constrictors can raise blood pressure, the elderly should be observed after the use of blood pressure changes.
(2) Mucus promoters can regulate the physiological function of the mucous membrane in the pharyngeal canal and tympanic chamber, promote the elimination of fluid in the tympanic chamber, and improve the mucus blanket of the mucous membrane.
(3) Antibiotics during the acute period, sensitive antibiotics can be used for a short period of time.
(4) Oral glucocorticoids For patients without contraindications such as diabetes, glucocorticoids such as prednisone can be used orally, but only for short-term treatment, not for long-term use.
(5) Nasal glucocorticosteroids improve the inflammatory state of the nasal cavity and eliminate inflammatory mediators, and are safer than oral glucocorticosteroids.
(6) pharyngeal tube blowing can be used pharyngeal tube blowing device, pinch nasal puff method, Bo’s ball method or catheter method to promote pharyngeal tube patency, but also through the catheter into the pharyngeal tube pharyngeal mouth blowing prednisolone to achieve the purpose of patency and drainage. However, when applying this method, attention must be paid to the nasal cavity not to have nasal snot, otherwise it is easy to blow nasal snot into the tympanic chamber, causing acute suppurative otitis media.
2.Surgical treatment
(1) Tympanic membrane puncture and aspiration can be used as both a diagnostic and therapeutic method to effectively remove middle ear fluid and improve middle ear ventilation. Repeat puncture or injection of glucocorticoid drugs after fluid extraction can be performed if necessary.
(2) Tympanotomy is suitable for those whose secreted fluid is viscous and cannot be aspirated by tympanocentesis. It can be performed under general anesthesia in uncooperative children. Attention should be paid to protect the mucosa of the inner wall of the tympanic chamber, and all the fluid in the chamber should be aspirated after tympanotomy.
(3) Tympanic ventricle placement is suitable for those who have prolonged or recurrent disease, glue ear, and head radiation therapy, and the function of the eustachian tube is difficult to return to normal in the short term. The duration of the ventilator is usually 3 to 6 months, and the longest duration is 6 months to 1 year. The ventilator can be removed after the function of the eustachian tube is restored, and some patients can discharge the ventilator in the external ear canal by themselves.
(4) There has been a lack of effective treatment for persistent secretory otitis media. At present, laser pharyngotonsillectomy and pharyngotonsillectomy balloon dilation offer a ray of hope for this type of patients. For patients with chronic otitis media with recurrent episodes and a disease duration of more than 3 months, these methods can be used to improve the ventilation function of the eustachian tube.
Laser pharyngotonsilloplasty: The application of hose lasers such as semiconductor laser, CO2 fiber laser, and KTP laser lamp to ablate the posterior lip of the round occipital part of the pharyngotonsillar canal has been found to be more than 90% effective in clinical studies abroad in the past two years. Balloon dilation pharyngoplasty: A balloon is placed into the pharyngeal opening of the eustachian tube to dilate the cartilaginous part of the eustachian tube and improve the opening function of the cartilaginous part of the eustachian tube to treat secretory otitis media.
In patients with persistent secretory otitis media who are suspected of having obstruction of the tympanic isthmus or granulation tissue at the entrance of the tympanic sinus, simple mastoidectomy and tympanic chamber exploration surgery can be considered, along with tympanic membrane placement. For those who are about to develop adhesive otitis media and invaginated sacs, early surgical treatment should be performed to prevent complications.
Prevention
1. Strengthening exercise, enhancing physical fitness and preventing colds.
2.Avoid spicy and irritating food and tobacco and alcohol stimulation, avoid exposure to smoke and other undesirable gases to stimulate the whistling tract, and protect and enhance the resistance of the upper whistling tract mucosa.
3, prevention and treatment of allergic diseases, avoid contact with allergens, diet should avoid foods that trigger individual allergies, such as seafood foods.
4, when blowing the nose do not pinch the front nostrils with both hands at the same time to blow the nose, you should press one nostril to gently clear the nasal secretions.
5, infants should be careful not to lower their heads too much when breastfeeding.
6.Water in the ear canal should be avoided during tympanic tube placement to prevent acute purulent otitis media.