I. Acute otitis media
1. Acute secretory otitis media
2. Acute purulent otitis media
II. Chronic otitis media
1. Chronic secretory otitis media
2. Chronic purulent otitis media
①Static period ②Active period
Cholesteatoma of the middle ear
4. Complications of otitis media
(a) Extracranial complications
1. Extra-temporal bone complications
①Subperiosteal abscess ②Bezold abscess ③Mouret abscess
2. Intra-temporal bone complications
①Peripheral facial nerve palsy
②Vaginitis a. Vagal fistula b. Septic vaginitis
(iii) apophysitis
(ii) Intracranial complications
1. Epidural abscess
2. subdural abscess
3. meningitis
4. Sigmoid sinus thrombophlebitis
5. Brain abscess
①Brain abscess
②Cerebellar abscess
6. Hydrocephalus
V. Post otitis media diseases
1. Non-tensor/adhesive otitis media
2. Sclerosis of the tympanic chamber
3. Middle ear cholesterol granuloma
4. Occult otitis media
VI. Special types of otitis media
1. Tuberculous otitis media
2. AIDS otitis media
3. Syphilitic otitis media
4. Fungal otitis media
5. Necrotizing otitis media
6. Radiation otitis media
7. Pneumatic otitis media
According to the elements of disease course, pathology, pathogenesis, sequelae and complications, there are 6 categories: acute otitis media, chronic otitis media, middle ear cholesteatoma, complications of otitis media, sequelae of otitis media and special types of otitis media.
1. Acute otitis media: The time of onset is defined as within 4 weeks. It can also be divided into acute non-suppurative otitis media and acute suppurative otitis media. The clinical definition of both is based on whether purulent secretions appear in the tympanic chamber and mastoid process, and the gold standard for their judgment is whether bacteria are cultured in the tympanic effusion.
1.1. Acute secretory otitis media: The pathogenesis is due to malfunction of the eustachian tube, immune-mediated and bacterial infection; the pathogenesis is mainly due to negative pressure in the tympanic chamber; the main pathological manifestation is early exudative effusion in the tympanic chamber; the clinical symptoms are stuffiness and swelling in the ear, hearing loss, and may be accompanied by otalgia; the clinical examination shows tympanic membrane invagination, effusion in the tympanic chamber, and may be accompanied by tympanic membrane congestion; the audiological examination shows the presence of air-bone conduction spacing, middle ear The imaging shows an increase in the density of the tympanic papillae. There are mainly acute suppurative otitis media with bacterial infection, chronic secretory otitis media if it does not heal, occult otitis media with no clinical symptoms but with imaging images of increased density in the tympanic papillae, and complete clinical healing.
1.2. Acute suppurative otitis media: The main cause of the disease is bacterial infection; the pathogenesis is the transformation of bacteria and viruses through the eustachian tube, bony gaps in the middle ear mastoid, hematogenous, infected tympanic membrane or acute non-suppurative otitis media; the main pathological manifestations are suppurative inflammation of the mucosa, periosteum and bone of the middle ear mastoid cavity and purulent secretions in the tympanic mastoid; the main clinical symptoms are ear pain, ear stuffiness and swelling, hearing The main clinical symptoms are otalgia, stuffiness and swelling of the ear, and hearing loss; clinical examination shows congestion, bulging, or fluctuating perforation of the tympanic membrane; audiological examination shows the presence of air-bone conduction spacing, middle ear impedance mostly shows a “B” curve, and imaging shows a hyperdense shadow of the tympanic papillae; its regression mainly includes acute perforation of the tympanic membrane, chronic purulent otitis media if it does not heal, no clinical symptoms but The main types of otitis media are acute perforation of the tympanic membrane, chronic suppurative otitis media if it does not heal, occult otitis media without clinical symptoms but with the imaging appearance of increased density in the tympanic chamber and complete clinical healing.
2. Chronic otitis media: The onset of otitis media is defined as more than 4 weeks. The clinical definition of both is based on the presence or absence of purulent discharge from the tympanic chamber and mastoid process, and the gold standard is whether bacteria are cultured in the discharge.
2.1. Chronic secretory otitis media ①Initial (causative formation) stage: the main cause of the disease is negative pressure in the tympanic chamber due to malfunction of the eustachian tube, immune-mediated and bacterial infection, but no tympanic effusion has yet formed; ②Developmental stage: tympanic effusion appears, and the tympanic chamber mucosa is usually good, which is the main pathological manifestation of the disease; most bacterial cultures of tympanic effusion have no bacterial growth, but some studies have shown that bacteria can be cultured in the effusion. However, the presence of bacteria is not the same as suppuration, which is the main difference from suppurative otitis media. The disease is named differently at different stages of pathological development, and its synonyms include: catarrhal otitis media, middle ear effusion, exudative otitis media, secretory/plasmacytic otitis media, mucus otitis media, and glue ear. Clinical symptoms are stuffiness and swelling of the ear and hearing loss; clinical examination shows tympanic membrane invagination, tympanic fluid, and yellowish tympanic membrane; audiological examination shows the presence of air-bone conduction distance, middle ear impedance is “C” curve for early negative tympanic pressure, and “B” curve when tympanic fluid is present. (3) Regression stage: the regression of secretory otitis media includes healing, transformation into occult otitis media and adhesive otitis media.
2.2. Chronic purulent otitis media: This disease is defined by pathological characteristics, referring to purulent inflammation caused by bacterial infection of the mucosa, periosteum, and bone of the middle ear mastoid cavity. The middle ear mastoid cavity is mainly composed of leukocytes, macrophages, and infected bacteria as purulent secretions, and due to the presence of inflammatory mediators, the mucosa is stimulated to produce fibroblastic granulation tissue in the middle ear mastoid cavity and erosion of bone. In some cases, there may be a combination of epithelial tissue hyperplasia and middle ear cholesteatoma; the pathways of bacterial erosion are retrograde through the eustachian tube, perforated tympanic membrane, inflammatory lesions of the tympanic membrane, middle ear ooze, hematogenous and adjacent bone gap infection of the mucosa of the middle ear mastoid cavity; the main clinical manifestations are long-term intermittent ear pus flow and hearing loss; The main clinical manifestations are long-term intermittent ear pus and hearing loss; the examination is mainly for perforation of the tympanic membrane tension, the mucosa of the tympanic chamber may be normal or edematous and granulomatous; the presence of air-bone conduction spacing in the audiometric examination, the pharyngeal canal function examination may be normal or poor, and the imaging manifestations are hyperdense shadow of the tympanic chamber papillae, which may be accompanied by bone resorption destruction. The regression includes self-healing of the tympanic membrane, at which time the mucosa of the tympanic papillae may return to normal, and the tympanic papillae may have a residual hyperdense shadow on imaging, and the hearing may return to normal or the permanent air-bone conduction spacing may remain; the other regression is cured by clinical intervention.
3. Middle ear cholesteatoma: This classification does not include congenital cholesteatoma, but refers specifically to acquired cholesteatoma. This disease refers to the growth of epithelial tissues in the middle ear and mastoid, and its generation mechanism, pathology and regression are different from chronic suppurative otitis media. Strictly speaking, this disease should not be included in the classification of otitis media, but the growth process of cholesteatoma can be accompanied by bacterial growth, and it is accompanied by chronic otitis media, and the clinical management is the same as that of otitis media, so it is still included in the classification of otitis media. The main mechanism of the disease is poor ventilation of the eustachian tube and impaired ventilation of the middle and upper tympanic chambers, resulting in negative pressure in the upper tympanic chambers, and aspiration of the relaxed tympanic membrane, which lacks a fibrous layer, into the upper tympanic chambers, where its epithelial layer accumulates to form a cholesteatoma and progresses toward the mastoid process of the tympanic sinus. Other possible causes include the formation of epithelial metaplasia in the infected middle ear mastoid cavity. The main clinical manifestations are long-term intermittent ear pus flow, foul-smelling pus, and hearing loss; the examination mainly consists of invagination and perforation of the relaxed part of the tympanic membrane and internal restriction and thickening of the tense part; the presence of air-bone conduction spacing on audiometric examination, pharyngeal function examination may be normal or poor, and imaging manifests as a hyperdense shadow of the tympanic papillae, which may be accompanied by resorption and destruction of bone and may cause intracranial and extracranial complications, usually requiring surgical intervention.
4. Complications of otitis media: The classification and content of complications of otitis media do not change significantly from the classic textbook content. This classification divides them into extracranial complications and intracranial complications, and extracranial complications are divided into intra- and extra-temporal bone complications, and facial nerve palsy is included in intra-temporal bone complications.
5. Otitis media sequelae: This classification includes otitis media sequelae including adhesive otitis media (middle ear opacification), tympanic chamber sclerosis, middle ear cholesterol granuloma and occult otitis media. In the past, the term “otitis media sequelae” was used, but this disease often requires clinical treatment, so the name was changed to “otitis media sequelae” to distinguish the concept of “sequelae” that does not require clinical treatment.
5.1. Adhesive otitis media: It refers to the adhesion of the tympanic membrane and tympanic chamber structure caused by long-term clinical treatment or without systematic treatment, and in severe cases, the tympanic membrane and the mucous membrane of the drum capsule are fused and epithelialized; long-term hearing loss is the main symptom, and there is air-bone conduction spacing on pure tone hearing threshold examination, poor function of the pharyngeal canal, and imaging examination may show increased density of the tympanic chamber papillae.
5.2, tympanosclerosis: The primary disease of this disease is chronic suppurative otitis media (resting phase) mostly, others include secretory otitis media, adhesive otitis media, occult otitis media, etc., which can also coexist with it. The main pathological manifestations are carbonate deposits in the fibrous layer of the tympanic membrane, the mucous membrane of the tympanic capsule, and the mucous membrane layer on the surface of the auditory bone to form calcified foci. CT examination of the tympanic cavity and mastoid cavity can be seen as hyperdense shadow, and calcification foci can be found.
5.3. Middle ear cholesterol granuloma: The main etiology of this disease is dysphagia, and the primary disease is mostly secretory otitis media, but some scholars think it is an independent disease. The main pathological mechanism is the destruction of mucosal capillaries after negative pressure in the middle ear mastoid, the exudation of red blood cells, the overflow of iron-containing heme from the cells, the accumulation of secretion in the mastoid cavity of the tympanic chamber and the proliferation of granulation tissue; clinical manifestations are long-term hearing loss, the ear overflow is yellowish or bloody; examination shows that the tympanic membrane is mostly intact and blue; audiometric examination shows the presence of air-bone conduction spacing, pharyngeal canal function examination can be normal or The CT examination of the tympanic cavity and mastoid cavity may show increased density; the differential diagnosis of this disease must exclude high jugular venous bulb, jugular venous bulb tumor or tympanic bulb tumor.
5.4. Occult otitis media: This disease usually comes from acute and chronic otitis media, with no clinical symptoms or hearing loss, and a normal tympanic membrane on examination; the air-bone conduction spacing may be present or normal on audiometric examination, and the eustachian tube function examination may be normal.
6. Special types of otitis media: tuberculous otitis media, otitis media with AIDS, syphilitic otitis media, and fungal otitis media in this category refer specifically to specific pathogenic bacteria cultured in the mastoid cavity of the middle ear; necrotizing otitis media is not osteosclerotic or granulomatous otitis media in the original sense. In this classification, necrotizing otitis media refers to the presence of necrotic tissue in the mastoid cavity of the middle ear other than the above-mentioned specific or non-specific otitis media; radioactive otitis media is aseptic radioactive tissue necrosis in the mastoid cavity of the middle ear after radiation exposure; pneumatic otitis media refers to physical damage to the middle ear structure caused by negative pressure in the middle ear cavity due to rapid changes in air pressure inside and outside the tympanic membrane and the inability of the eustachian tube to balance the air pressure in time, resulting in tympanic membrane congestion, perforation, and The tympanic membrane becomes congested, perforated, and fluid accumulates in the tympanic chamber.