Средний отит и отоскопия. Краткая учебная аудиозапись для врача-интерна.

Среднее ухо включает барабанную полость, слуховые косточки, сосцевидный отросток и слуховую, или евстахиеву, трубу. Барабанная перепонка отделяет наружный слуховой проход от среднего уха. Главная функция слуховой трубы - вентиляция среднего уха и выравнивание давления между барабанной полостью и атмосферой. Поэтому при острой респираторной инфекции, отёке носоглотки или аденоидах у ребёнка труба может работать хуже. В барабанной полости создаётся отрицательное давление, перепонка втягивается, возникает заложенность уха и иногда снижение слуха.

При отоскопии осматривайте сначала наружный слуховой проход, затем барабанную перепонку. Всегда сравнивайте правое и левое ухо. В норме перепонка серовато-перламутровая, полупрозрачная. Видны ориентиры: рукоятка молоточка и короткий отросток молоточка. Световой рефлекс имеет вид конуса, направленного вперёд и книзу: примерно к пяти часам в правом ухе и к семи часам в левом. При пневматической отоскопии нормальная перепонка должна быть подвижной.

Важно понимать, что один изменённый цвет перепонки сам по себе не доказывает бактериальный средний отит. Розоватая или несколько гиперемированная перепонка бывает при плаче, лихорадке, недавней вирусной инфекции, перепаде давления или дисфункции слуховой трубы. Для клинического решения нужно сопоставить отоскопию, жалобы, температуру, общее состояние и, при необходимости, данные обследования.

Если слуховая труба плохо вентилирует среднее ухо, давление внутри становится ниже атмосферного. Перепонка втягивается, ориентиры молоточка могут выглядеть более отчётливо, а световой конус меняет форму или исчезает. Пациент чаще жалуется на заложенность, щелчки, аутофонию. Если в среднем ухе появляется выпот, развивается экссудативный средний отит. Для него типичны снижение слуха и ощущение заложенности, но нет обязательной сильной боли, высокой температуры и выраженной интоксикации. На отоскопии возможны уровень жидкости, пузырьки, янтарная или синеватая окраска, втяжение перепонки и уменьшение её подвижности.

Острый средний отит - это остро возникшее воспаление среднего уха. Надёжные признаки включают выпячивание барабанной перепонки либо оторею, не объясняемую наружным отитом, в сочетании с острым началом и симптомами воспаления. У пациента могут быть оталгия, лихорадка, раздражительность у ребёнка, снижение слуха. При выраженном выпячивании контуры молоточка становятся сглаженными, световой рефлекс обычно исчезает, подвижность перепонки резко снижена. Не называйте диагнозом только покраснение перепонки.

На экзамене удобно разделять две ситуации. Первая: дисфункция слуховой трубы или экссудативный отит. Здесь доминируют заложенность и кондуктивное снижение слуха, а системные признаки инфекции обычно отсутствуют или слабо выражены. Вторая: острый бактериальный средний отит. Здесь ожидаются острое начало, боль, лихорадка или другие признаки воспаления и характерная отоскопическая картина, прежде всего выпячивание перепонки.

Тактика зависит от возраста, тяжести, длительности симптомов, одно- или двустороннего процесса, наличия отореи, сопутствующих заболеваний и местных рекомендаций. При боли пациенту нужна адекватная анальгезия. Не всем детям с неосложнённым острым средним отитом антибиотик требуется немедленно: у отдельных пациентов допустимо наблюдение с чёткими инструкциями и повторной оценкой. Если антибиотик показан, выбор препарата и дозы должен соответствовать локальным клиническим протоколам. Не назначайте антибиотик при любом изменении цвета перепонки без клинических критериев острого среднего отита. Назальные сосудосуживающие средства не являются универсальным лечением отита, а у детей имеют возрастные ограничения и риск побочных эффектов.

У детей обращайте внимание на аденоидную ткань и носовое дыхание, поскольку носоглоточная обструкция может ухудшать функцию слуховой трубы. При стойком выпоте, нарушении слуха, рецидивирующих эпизодах или подозрении на осложнение необходима оценка ЛОР-врачом. Для экссудативного отита важны контроль слуха и длительности выпота, а не автоматическое назначение антибиотика.

Помните о красных флагах. Срочная оценка нужна при токсичном виде пациента, сильной или нарастающей головной боли, рвоте, менингеальных симптомах, нарушении сознания, парезе лицевого нерва, выраженном головокружении, отёке или болезненности за ухом, оттопыривании ушной раковины, персистирующей высокой температуре или клиническом ухудшении. Такие признаки могут указывать на мастоидит, внутричерепное осложнение или другую серьёзную патологию и требуют неотложного направления.

Финальный алгоритм для интерна. Первое: уточните начало заболевания, боль, температуру, оторею, снижение слуха, симптомы ОРВИ, недавний перелёт и предшествующее лечение. Второе: оцените общее состояние и красные флаги. Третье: выполните отоскопию обоих ушей и опишите цвет, положение, целостность, ориентиры, световой рефлекс, жидкость и подвижность перепонки. Четвёртое: отличите выпот и дисфункцию трубы от острого среднего отита по наличию острого воспаления и выпячивания перепонки. Пятое: обеспечьте обезболивание, выберите наблюдение или антибактериальную терапию по показаниям и организуйте контроль. Шестое: при осложнениях, сомнительном диагнозе, повторных эпизодах или снижении слуха направьте пациента к оториноларингологу.

Эта запись создана как учебное резюме по приложенному конспекту. Она не заменяет очную оценку пациента и действующие локальные клинические рекомендации.

Otitis
Here is the transcribed handwritten text from the provided notebook pages:
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Signs of intoxication
There are different types of otitis media.
Patients will present with acute otitis media.
Patients with chronic otitis are NOT for GPs!!!
There are 2 groups of otitis
Group 1: Acute catarrhal otitis media (these are not purulent), this is a non-bacterial form
of otitis media.
Group 2: Bacterial
Differential diagnosis (must know)
Inflammatory disease of the middle ear—treatment by an ENT PHYSICIAN
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The ear is in close contact with the middle and posterior cranial fossae.
What patients die from:
From meningitis
purulent otogenic meningitis
meningoencephalitis
sigmoid sinus thrombosis
Sepsis
Catarrhal otitis media does not require antibacterial treatment.
As for inflammatory diseases—ANTIBIOTIC THERAPY IS MANDATORY!!!
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How CATARRHAL otitis differs from INFLAMMATORY otitis
Inflammatory otitis is characterized by signs of inflammation
Symptoms/signs of bacterial inflammation:
Edema
infiltration
fever
signs of intoxication
General laboratory changes
Impaired ability to work

General weakness
headache
Pain!!
hyperemia
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Impaired function, i.e., hearing loss will develop.
This is the whole complex for inflammation.
Question: when performing otoscopy
what normal identifying signs do you know???
normal identifying signs indicate a normal condition of the middle ear.
there are only 3 normal identifying signs
Color of the tympanic membrane. A normal tympanic
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membrane has a grayish-white, pale-yellow color.
2. mobility: when air pressure is applied (with pneumatic otoscopy), the membrane
should move slightly.
3. light reflex: normally, a distinct light reflex is observed, which looks like a
cone-shaped reflection of light from the clock area.
4. Anatomical landmarks: the handle of the malleus, the short process of the
malleus, and the anterior and posterior folds of the tympanic membrane are clearly visible.
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From 1 to 3 years of age, if the tragus hurts, then it is otitis media.
Insert the otoscope approximately 1 cm into the external auditory canal and illuminate the walls
of the external auditory canal (upper wall, lower wall, anterior wall); the anterior
wall borders the head of the temporomandibular joint. If people have a
PROBLEM WITH THE TEETH or with the JOINT, the PAIN will be in the EAR.
There may be referred pain.
Pathologies of the wall of the external auditory canal and
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the tympanic membrane IS AT AN ANGLE!!!
TM (tympanic membrane) separates the external ear from the middle ear.
What the middle ear consists of: the tympanic cavity, the auditory tube with 2 openings. It is very
important that this AUDITORY TUBE, through one of its openings, opens into the pharyngeal area—it
is called the pharyngeal opening of the auditory tube.
The biggest problem in children suffering from hypertrophied adenoids is
this pharynx,
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near the pharyngeal opening of the auditory tube there may be adenoids—this is a
hypertrophied pharyngeal tonsil. Behind the auricle is bone, bone
consisting of air cells; they are like little cells, small cells. And these cells are filled with
air. This is the middle ear.
The air pressure in the cavity and outside is the same: what is in the atmosphere is also in the ear. Pressure
will not be the same on an airplane, because of the abrupt pressure change.

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AUDITORY TUBE.
respiratory diseases
edema of the mucous membrane of the upper respiratory tract. This edema will spread along
the mucosa of the nose, pharynx, and including the auditory tube.
the auditory tube maintains equal pressure. Its invaluable function is that it
maintains pressure outside and inside.
Identifying signs depend on the function of the auditory tube.
IDENTIFYING SIGNS:
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Color of the tympanic membrane.
A change in the color of the TM by itself says nothing yet. A color change indicates poor
function of the auditory tube -> changes in the tympanic cavity.
On an airplane the TM will be pinkish, because the pressure has changed!!! The inclination of the TM depends on
the function of the auditory tube! On what air pressure is in the tympanic cavity.
Light reflex—what causes it? The LIGHT REFLEX occurs because, when
illuminating the tympanic membrane, the light from the otoscope is reflected.
And why precisely in this location?
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The light reflex (reflection of the light reflex) depends on the inclination of the tympanic
membrane. What will the inclination of the TM depend on? On the function of the auditory tube. On
what air pressure is in the tympanic cavity. If the pressure is equal, the inclination
will be only one. The angle of inclination is always the same!!! If the pressure outside and inside is
normal.
Where is the light reflex located if the pressure is equal: in one ear, the
light reflex is at the level of 7–8 o’clock on the clock face (if one imagines the tympanic membrane
as a clock face).
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then in one ear it will be at 7–8 o’clock, and in the opposite ear (i.e., the other ear) on the other
side at 4–5 o’clock.
A second way to remember: when you examine an ear, always pay attention—you see
this light reflex; it is clearly visible. You see this light reflex: where is the broad
part of this triangle directed? Normally it should always be directed
anteriorly and inferiorly, i.e., toward the corner of your patient’s mouth. If the light triangle disappears or
changes its shape, this is a sign of middle-ear pathology, not only of the tympanic
membrane itself.
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And a sign of middle-ear pathology (if there is a diffuse light spot—this is also middle-ear
pathology).
3. On the tympanic membrane you will see a white contrasting band that begins from the center
of the tympanic membrane upward and anteriorly. This band is very clearly visible externally and
ends in such a small prominence on the side of the tympanic cavity.
Let us look at what is inside the tympanic cavity: inside the tympanic cavity is a chain

of auditory ossicles. One of these ossicles is the malleus; it is woven into the
tympanic membrane from within, on the tympanic-cavity side.
Look up the functions of the auditory ossicles yourselves—this is sound conduction.
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The main point is that the malleus is woven in from the tympanic-cavity side by its two
parts: the handle of the malleus and the short process of the malleus. This white band is the
handle of the malleus, which ends in a prominence—the short process of the malleus, 2
parts!!! Must be seen. The attachment site will be equally pronounced in every
person. Yes, everyone has their own anatomy, but there are two ears, and these two ears allow you
to compare how you see this attachment site of the handle and short process of the malleus.
What significance does this have when in the tympanic cavity...
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Outside, the pressure is equal and auditory-tube function is good—we will see the contour
of the handle and short process of the malleus. But we must be sure to compare it with the
opposite ear, because they should be equally pronounced—this is with
good auditory-tube function.
And now, if the pressure in the tympanic cavity is very low relative to atmospheric pressure (in
what cases will this occur?). When the pressure in the tympanic cavity is low—it all comes down to the
auditory tube, when its function is impaired in respiratory diseases.
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If there is edema in the nasopharynx and auditory tube, the pressure outside and inside the tympanic
cavity will be different. Where will the pressure be lower? Of course, in the ear, because the auditory
tube does not let air through; there will be low pressure in the tympanic cavity. How will we see
these contours on the tympanic membrane? More clearly, with contrast, or blurred? If the pressure in
the tympanic cavity is low, the tympanic membrane will, as if covered with silk, contour
this ossicle and move toward the low pressure. We say: the tympanic membrane is retracted,
and the ossicles remain in place,
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so we will see these contours more clearly, with greater contrast. But for comparison we have
the second ear (the tympanic membrane is retracted).
And if the pressure in the tympanic cavity is high? When does this occur? It occurs when
fluid accumulates in the tympanic cavity—transudate, and then exudate. And
the tympanic membrane, like a bubble, like a balloon, bulges into the lumen of the external auditory
canal, protrudes away from the tympanic cavity, i.e., the tympanic membrane is bulging. And
therefore the angle of inclination of the tympanic membrane changes, the light...
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reflex will appear somewhere (where it will appear cannot be said), because everything depends on
the degree of this bulging. The main point is that the light reflex will respond.
2. If there is fluid in the tympanic cavity, the color of the tympanic membrane will change.
The tympanic membrane will have the color of the exudate. The color can be very different; it may
be bluish. Why? Because the exudate contains formed elements of blood. And if the exudate in
the tympanic cavity contains many formed elements of blood, red blood...
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cells—you will see a bluish tympanic membrane. This is simply such an exudate—
hemorrhagic exudate.
The color will change, but this does not indicate bacterial inflammation. How will we see the malleus with such
bulging? The contours of the malleus, of course, will be blurred (the contours are present, but
not as in normal conditions).
Another case is when the tympanic membrane becomes edematous, infiltrated; like a
thick schnitzel, it covers all the sites of attachment of the malleus, and we DO NOT SEE the malleus
(the contours cannot be determined).
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Young children have one problem—hypertrophied adenoids. And these
hypertrophied adenoids are located in the nasopharynx. (In children, they enlarge up to the age of 9
and the adenoids disappear completely by age 16). The adenoids are located near the
pharyngeal opening of the auditory tube. Therefore, all children will have a pink tympanic
membrane. Why? Because when pressure is low, adenoids interfere with air
ventilation. When pressure is low, how do the vessels behave? The vessels there become
injected!
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We say: injected vascular pattern. Normally we do not see these vessels on the tympanic
membrane, but with low pressure we will see them, even to the extent that a dense network
covers the tympanic membrane. Therefore, the tympanic membrane in children with adenoids
may be pinkish. The main thing is not to confuse it and to understand why there is such
pinkness—it is not a sign of inflammation; it is simply a functional condition of the vessels
of the tympanic cavity itself. In children, as a result of the pressure difference, there is ear fullness.
Only when the auditory tube opens and the adenoids are removed...
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surgically, will the auditory tube open; air from outside will go toward
the tympanic cavity, the pressure will equalize, the vessels will return to normal and there will be a feeling of comfort, and
only then will the child say “good.”
Chronic otitis: let us distribute the functions. If this is a catarrhal form (tubo-otitis belongs
to the catarrhal forms), then against the background of tubo-otitis, fluid, exudate, accumulates in the tympanic
cavity. Otitis media with effusion is also a catarrhal form: there is no pain,
no intoxication, the blood test is normal, the temperature is normal, but changes are present...
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on the tympanic membrane—these are patients (for GPs). We prescribe anti-edema therapy.
The most important thing is to restore auditory-tube function. If a child has persistent
tubo-otitis, then the adenoids must be removed.
5 signs of inflammation: tumor, rubor, calor, dolor, functio laesa. This is the most severe
form of otitis—bacterial. Antibiotics are not prescribed for catarrhal otitis, but for these
bacterial otitides (for example, streptococcus), antibiotics are prescribed. Children often have
bacterial streptococci, streptococcal otitis media, to the extent that children must be vaccinated...
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against streptococcus. These otitides are dangerous because of complications. (The weak, serious site in the middle ear is the
tympanic cavity, the upper wall of the tympanic cavity). Compare: the upper wall of the
tympanic cavity and the upper wall in the external auditory canal. On this wall there are
openings for vessels and nerves—this is in an adult, whereas in a child there are unclosed

wild fissures, through which the mucous membrane is in the closest contact with
the meninges. What will the course of otitis, both catarrhal and
purulent, depend on? First of all, it depends...
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on patency of the auditory tube!!!
If an ENT physician treats a patient who has middle-ear inflammation, what will they prescribe
after antibiotics?
Decongestants (these are anti-edema vasoconstrictors), nasal drops for 3, 4, or 5
days. What for? To artificially reduce the edema of the nasopharynx and restore
auditory-tube patency. The faster the pathological secretion leaves the middle ear
through the auditory tube into the nose, the faster the patient will recover. Whatever antibiotics
may be prescribed, if the adenoids are protruding...
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in the child, this will not help at all, because there is an inflammatory process here, and pus does not
resolve; it will only SEEK AN EXIT FOR ITSELF. And for pus, the best and most convenient
place here is where there are many openings! And everything goes into the middle cranial fossa.
Exudate will not always be demonstrable in a person, so use the history as your guide! What
new thing will appear in a person if there is exudate in the ear? Hearing will be reduced! In
tubo-otitis, when there is no fluid, the patient will say: “I...
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hear well, only my ear feels blocked,” but if there is already fluid there, the patient will say: “Yesterday
my ear felt blocked, but I heard well, and today I hear poorly”—this is
EXUDATE!!!
Differential diagnosis of catarrhal and inflammatory diseases
(bacterial inflammations) depends on the history. If you see changes—a “pinkish
tympanic membrane”—you need to ask the patient: “How do you hear? Does your ear hurt? Do you
have a fever?” Then you will be able to differentiate.
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And if it is completely unclear, you will do a complete blood count.
EXAMPLE:
You come to a patient, and the patient says: “I have a sick-leave certificate; the sick-leave certificate
was issued by the ENT physician. I had ear problems” (the patient was treated for some time,
the clinical picture is blurred, but the patient says): “I was supposed to go today to have my
sick-leave certificate extended, but today I developed a fever, my
head started hurting, and there was even vomiting (or perhaps nausea).” Take out the otoscope,
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compare one ear with the other. Yes, there are some changes in one ear (it does not matter what
you saw in this situation; the main thing is that you saw a difference!). The patient was receiving treatment
for an ear problem; what matters is that against this background severe headache,
fever, vomiting appeared—as marked general intoxication, i.e., the condition worsened + you
saw changes on the tympanic membrane. A complication will be suspected; these are
symptoms of purulent meningitis, meningeal...
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symptoms. Check for meningeal symptoms!!! Nuchal rigidity
(know how to do this in practice!). Kernig sign, Brudzinski sign. And in
small children under one year of age (suspension sign / Lesage sign). Use the fontanelle as a guide:
when intracranial pressure is elevated in a child, the fontanelle will be tense and bulging.
There will be doubt—are there complications or not? In your opinion, complications are present.
Tumor: Swelling caused by fluid buildup.
Rubor: Redness caused by increased blood flow.
Calor: Heat caused by increased blood flow.
Dolor: Pain caused by nerve pressure and chemical irritation.
Functio Laesa: Loss of function caused by pain and swelling.