Ear nose and throat deseases Department of ear

Ear, nose and throat deseases Department of ear, nose and throat deseases Sechenov University Moscow, Russia

1. Non-purulent ear diseases Department of ear, nose and throat deseases Sechenov University Moscow, Russia

1. 1. part 1 of the lecture: non-purulent ear diseases Lecturer: associate Professor, Ph. D. Eremeeva K. V. Department of ear, nose and throat deseases Sechenov University Moscow, Russia

Sensorineural hearing loss (SHL) a form of hearing loss in which one of the sections of the sound-receiving Department of the auditory analyzer is affected, starting from the sensory cells of the inner ear and ending with the cortical representation in the temporal lobe of the cerebral cortex.

Social and medical significance of the problem of sensorineural hearing loss • • Prevalence: 13 million people worldwide have significant hearing changes. By 2020, the population with socially significant hearing loss will increase by 30%: who forecast A significant percentage of patients are in the age groups of high social and professional activity The problem of childhood. Congenital hearing loss is, on average, 1 -2: 1000 newborns The problem of older age groups Early manifestation of presbyacoussis in residents of industrialized areas due to chronic noise injury (sound pressure level in the metro-90100 d. B)

The national program for universal hearing screening • audiological screening in the • hospital-in 1 -3 months examination in the hearing centerunified database: maternity hospital-diagnostic center-deaf center in the absence of screening, • the diagnosis is made only by the age of three - "the child does not speak because he does not hear» Таварткиладзе Г. А. , Загорянская М. Е. , Румянцева М. Г. , 2009 г. objective methods of hearing research: registration of auditory evoked potentials, otoacoustic emission

The main etiological factors of sensorineural hearing loss • vascular (ischemia and metabolic disorders: atherosclerosis, DM) • infectious (viral infection: SARS, flu, herpes, measles, rubella) - 30% acute SHL • psychoemotionaltraumatic (acoustic trauma ("noise pollution" of cities), barotrauma, traumatic brain injury), • membrane rupturesototoxic (drugs) • immunological (Wegener's granulomatosis, primary autoimmune diseases) • stress response (activation of cellular stress factors, Kappa factor B (NF-k. B) idiopathic acute SHL https: //www. youtube. com/watch? v=MT 1 ck. Ee. DN 5 w

Оtotoxicity Drug: • aminoglycoside antibiotics • diuretics (acetazolamide, ethacrynic acid) • non-steroidal anti-inflammatory drugs • anti-cancer drugs • -platinum derivatives • ACE inhibitors (enalapril, monopril) • anesthetics (lidocaine) • antidepressants (xanax, amitriptyline, nortriptyline) • antimalarial drugs (chloroquine) • calcium channel blockers (nifedipine, nicardipine) Industrial factors: • heavy metals (mercury, lead, arsenic) • solvents (nitrobenzene) • others (carbon monoxide, fluorocarbons, organic sulfur compounds) Household intoxication: • drug addiction, • Smoking, • alcoholism

Classification of sensorineural hearing loss • Congenital • Acquired For the duration of the course: • sudden (develops within a few hours) • acute (up to 1 month) • subacute (1 -3 months) • chronic (over 3 months) At the time of the occurrence: • prelingual (before speech development) • postlingual (after the appearance of speech) According to the degree of hearing loss, there are four degrees of hearing loss(speech frequency zones) and deafness: • I degree (light) - 26 -40 d. B; • II degree (moderate) - 41 -60 d. B; • III degree (moderately severe) - 61 -80 d. B; • Grade IV (severe) – more than 80 d. B; deafness-more than 91 d. B.

Clinical manifestations of sensorineural hearing loss • • hearing loss unilateral or bilateral Tinnitus The violation of intelligibility Possible vestibular symptoms (cochleovestibular syndrome)

Tuning fork tests: differential diagnosis of sensorineural and conductive hearing loss С 128 Weber test normal С 128 Violation of sound transmissionon the right. The lateralization to the side WORSE than the hearing ear Violation of sound perceptionon the right. Lateralization in the side of the BETTER hearing ear С 128 Rinne test С 128 Normal A 30” B 15” Positive (+) C 128 -tuning fork with a frequency of 128 Hz; A-air conductivity B-bone and tissue conductivity https: //www. mediccity. ru/directions/451 С 128 Violation of sound transmissionon the right В 0” К 15” Negative (-) Violation of sound perceptionon the right В 10” К 5” Positive (+)

Diagnosis of sensorineural hearing loss • study of auditory function • otoneurological examination • study of hemodynamic parameters of brachiocephalic vessels, • indicators of blood clotting system • radiodiagnostics

Pure tone threshold audiometry normal Violation sound guides Age-related changes in hearing norm Bone sound transmission Air sound transmission Violation sound perception Mixed hearing loss

Tympanometry А 6 П. усл. ед. 4 2 0 -400 -200 0 Р, мм вод. ст. А – normal +200

Over-threshold audiometry • identifying the phenomenon of accelerated growth of the volume indicates a lesion of the hair cells of the Corti organ • it is most often detected in inflammatory or drug intoxication of the snail, the hydropse of the labyrinth

Speech audiometry

X-ray of temporal bones by Stenvers Neurinoma of the left auditory nerve. The inner ear canal on the left is expanded (arrow). https: //www. medbor. ru/metodika_i_tehnika_polucheniya. . . /golova/149. html

Acoustic neurinoma Contrast-enhanced MRI of the cerebellopontine angle (the arrow indicates the formation of) https: //radiosurgery. ldc. ru/nevrinomy-sluhovogo-nerva Characteristic audiological picture: right-sided sensorineural hearing loss

Therapeutic tactics for sensorineural hearing loss timely delivery, individual approach Drug therapy Non-drug treatment measures • • Drugs that improve cerebral blood circulation and metabolism, improve the • rheological properties of blood • (piracetam, vinpocetin, pentoxififillin) • • Drugs that affect IBD (betagistin) • • Glucocorticoids (methylprednisolone, • dexamethasone) • Vegetotropic therapy (tofizopam) • Vitamins-neurotropic agents • Dehydration therapy (diacarb) Reflexotherapy HBOT Hirudotherapy Manual therapy Hearing aid Cochlear implantation

Cochlear implantation A cochlear implant is a medical device that allows partial or complete restoration of hearing in some patients with severe or severe SHL www. myshared. ru/slide/1360262/

Cochlear implant: how it works The function of the cochlear implant –stimulation by electrical impulses of the auditory nerve fibers in the cochlea The cochlear implant consists ofexternal (wearable) and internal (implantable) parts. The wearable part contains: Microphone Microprocessor to convert the sound into electrical impulses Transmitter The implantable part contains: Receiver Signal decoder A system of electrodes that are implanted in the cochlea and located on the basilar membrane, directly in contact with the auditory nerves

Tinnitus: classification objective (vibratory) - audible to an outside observer and can be registered using auscultation and other instrumental methods of examination of the patient (5%) Reasons: Pathology of temporomandibular joints Myoclonus of the middle ear muscles, soft palate Dehiscence of the auditory tube

Tinnitus: classification Subjective (non-vibratory) - occurs in the absence of a real sound source and does not lend itself to evaluation from the outside (95%) Reasons: Metabolic (cerebral atherosclerosis, hepatitis, diabetes mellitus, hypoglycemia, Hypo - and hyperthyroidism) Diseases of the external, middle, inner ear (sulfur plug, exostosis of the external auditory canal, external otitis, otitis media, otosclerosis, nst, acoustic and barotrauma, Meniere's disease, hunt syndrome) "perception of silence" - a manifestation of endogenous somatic sounds, usually masked by environmental sounds, in a healthy person who is in a soundproof room

Acoustic, barometric trauma Damage factor Powerful short-term sound or pulse noise exceeding the pain threshold (over 130 d. B): military operations, terrorist attack, industrial emergency, use of pyrotechnics, acoustic equipment Clinical manifestations: SNT, vestibular On the audiogram-local neuritis disorders at 4000 Hz

Noise scale Db Characteristic 0 No noise 30 Quietly a whisper, the ticking of a wall clock. Permissible maximum for residential premises at night, from 23 to 7 hours. 40 Quite audible ordinary speech. Norm for residential premises during the day, from 7 to 23 hours. 55 Clearly audible colloquial speech, typewriter. The upper norm for office space 100 Extremely noisy the orchestra, on the subway, thunder. Maximum allowable sound pressure for the player's headphones 130 Pain threshold plane at the start 160 Shock, trauma shock wave from a supersonic plane Измеров Н. Ф. , Каспаров А. А. , 2010 г. Sound source

1. 1. part 2 of the lecture: non-purulent ear diseases Lecturer: associate Professor, Ph. D. Eremeeva K. V. Department of ear, nose and throat deseases Sechenov University Moscow, Russia

Meniere's Disease • t is characterized by variability of hypotheses and clinical manifestations of peripheral cochleovestibular disorders attacks of dizziness, accompanied by nausea, vomiting, • balance disorderprogressive • unilateral hearing loss (80 -90%) • noise in the affected ear As an independent nosological form identified by Prosper Menier (1861)

Meniere's disease: clinical classification In shape: • typical (classical) - a triad of signs described by Meniere: • noise in the ear and hearing loss, • balance disorders, • vegetative disordersatypical • -manifestations of individual signs of the triadcochlear vestibular Lermuaye syndrome (hearing loss and painful ear noise, dizziness attacks, during which the cochlear symptoms regress) Adrift: • attack (angioedema) • acute period • Remission • status meniericus

Meniere's disease: etiology • proximate cause – endolymphatic hydropspredominance of the tone of the parasympathetic part of the autonomic nervous system, which occurs as a result of vegetative-vascular dystoniapredisposing factor: • poor circulation in the system of vascularization of the labyrinth • metabolic disorders, in particular water-salt • dysfunction of the endocrine system development of perivascular fibrosis

The mechanism of development of hydrops of the labyrinth • hyperproduction of endolymph • reduction of endolymph resorption • violation of membrane permeability

Theories of Meniere's disease development • • • Anatomical (hypoplasia or obliteration of the vestibular water supply, sclerotic changes of the temporal bone pyramid in the immediate vicinity of the endolymphatic SAC and the vestibular water supply on the affected side, reduction in the size of the endolymphatic SAC) Genetic (autosomal dominant type of inheritance of this pathology) Immunological (detection of immune complexes in the endolymphatic SAC in patients with MD) Vascular (MD connection with migraine) Allergic (the frequency of allergic reactions in patients with MD is higher than in the General population) Metabolic (potassium retention in the endolymphatic space causes potassium intoxication of hair cells and vestibular neuroepithelium, resulting in hearing loss and dizziness)

“Obvious” Meniere's disease: definition AAO–HNS (American Academy of Otolaryngology and head and neck Surgery, 1995) • ≥ 2 spontaneous vertigo attacks lasting ≥ 20 min. • hearing loss confirmed by audiological studies in at least one case • ear noise and / or feeling of congestion in the causal ear • other reasons are excluded

Stages of Meniere's disease reversible-attacks of cochleo-vestibular-vegetative disorders, hydrops is detected only in the period immediately preceding the attack, on the tonal audiogram-the presence of a conductive componentpronounced clinical manifestations - the presence of symptoms of Meniere's disease, intra. Labirint pressure is constantly increased, hearing fluctuation, on the tonal audiogram-the predominance of the sensorineural componentthe final one is the presence of a symptom complex of Meniere's disease, progressive hearing loss, the bone-air gap disappears on the tonal audiogram, the curves acquire a descending configuration

Diagnosis of Meniere's disease • • • Computer stabilometry Video oculography Audiometry Vestibular myogenic evoked potentials (MEP) (no peaks P 13, N 23 graph as a straight line) Electrocochleography. Transtimpanal electrocochleography (violation of the ratio of values of amplitudes SP (summation potential) /PD (action potential): p>0. 3) Dehydration tests Duplex scanning of brachiocephalic vessels Variational heart rate monitoring Magnetic resonance imaging of the brain and cervical spine

Electrocochleography If there is a hydropse in the inner ear, the following signs are detected The increase in the amplitude of the negative wave summation potential (SP), a preceding action potential (AP), with a corresponding increase in the amplitude of the summation potential and action potential more 0, 42. 2. Shift of the latent period of the action potential during alternate stimulation with clicks with the initial phase of thickening and dilution by more than 0. 2 MS. 3. The change in the amplitude of the summation potential in the study of tonal parcels at a frequency of 10002000 Hz. Clinical recommendations otoacustica. com. br/eletrococleografia. html

Treatment of Meniere's disease Conservative • Betahistine hydrochloride • Dehydration therapy • Vitamin therapy • Sedative therapy • Physiotherapy • Reflexotherapy Surgical • cutting the drum string drainage, endolymphatic SAC • incision of the cochleovestibular nerve • laser destruction of the labyrinth • Intratympanal injection of a solution of gentamicin The relief of an attack • Bed rest • Exclusion of bright light, loud sounds 1 ml of 0. 1% solution of atropine sulfate p/K, 2 ml of 2. 5% solution of pipolfen b / m, betagistine 48 mg

Methods of rehabilitation measures in patients with Meniere's disease • Exercises on stabilographic complexes: training of vestibular function, vision, development of muscle and joint feeling • Physical therapy aimed at improving statokinetic stability • Correction of the patient's anxiety, uncertainty and fear • Natural factors: climate therapy, mud therapy http: //www. mbn. ru/ru/mbn-product-type/stabilometry

1. 1. part 3 of the lecture: non-purulent ear diseases Lecturer: associate Professor, Ph. D. Eremeeva K. V. Department of ear, nose and throat deseases Sechenov University Moscow, Russia

Otosclerosis (greek) otos – ear, sclerosis - solidification is Described for the first time in the 18 th century Politzer coined the term 1894 a disease of the hearing organ caused by a focal pathological process of the enchondral layer of the bone capsule of the labyrinth, which leads to the fixation of the base of the stirrup in the window of the vestibule Shea JJ. , Jr Fenestration of the oval window. Ann Otol Rhinol Laryngol. 1958; 67(4): 932– 951

Epidemiology • Clinically pronounced otosclerosis affects 1 -2% of the world's population (histological otosclerosis is detected in 10%) • The disease affects the most socially active part of the population aged 15 to 45 years, women predominate

Ethiology • The etiology of the disease is not established • Among the many hypotheses of the occurrence of the disease prevail Autoimmune Hereditary (autosomal dominant heredity of a specific type of reaction to various Exo - and endogenous effects) • Alimentary • Exo-and endogenous factors: puberty, pregnancy, menopausehypofunction of the thyroid glandimpact of noise and vibration

Otosclerosis: clinical manifestations • • Symptoms: Progressive double-sided conductive bradyacuasia Ear noise (67 -98% of patients)"paracusis Willisii" (50% of patients) Toynbee symptom (lack of sulfur) Lempert's symptom (thinning of the eardrum) symptom Schwarze (focus of otosclerosis) symptom Verhovskogo-Tillo (a wide external auditory canal) Blue sclera

Classification by the nature of the audiometric picture The tympanic form is characterized by normal values of auditory sensitivity in bone conduction and the presence of a sufficient bone-air interval (BAI)

Classification by the nature of the audiometric picture Mixed form. The gentle nature of the curves, increased thresholds of auditory sensitivity in bone conduction and a sufficiently large BAI

Classification by the nature of the audiometric picture Cochlear form Descending curves of auditory sensitivity in bone and air conduction with a small BAI and-reserve of the cochlea

Audiological diagnosis of otosclerosis: reflex on stapedial muscle Reflex on the stapedial muscle when fixing the stirrup is missing (4) , in contrast to the acoustic reflex in the norm (1)

Computer diagnostics of otosclerosis Axial projection. The foot plate Mobility of the malleolus-incus joint of the stapes is thickened. In f. MSCT patients with otosclerosis, there was a thickening of the membrane of the vestibule window and a decrease in the volume of movements, as well as a decrease in the movements of the malleolusincus joint. А. С. Лопатин, Е. Н. Латышева, И. В. Бодрова, 2012

Surgical treatment of otosclerosis • Indirect mobilization of the stapes base • Direct mobilization of the stapes base • Fenestration of the labyrinth • Stapedoplasty

The result of the operation is evaluated by reducing the BAI

Exudative otitis media inflammation of the middle ear, characterized by the accumulation of non-purulent fluid in it

Causes of exudative otitis media • Acute and chronic diseases of the nose, paranasal sinuses and pharynx with the spread of inflammation to the pharyngeal mouth of the auditory tube • Adenoids • Neoplasms of the nasopharynx • Inadequate treatment of acute otitis media • Barotrauma

Theories of development of exudative otitis media • Hydrops ex vacuo – violation of the patency of the auditory tube leads to resorption of air in the cavities of the middle ear and transudation of fluid in them • Violation of the function of the atrial epithelium of the auditory tube • The inflammatory theory • Secretory theory-violation of the secretory function of the middle ear mucosa

Clinical manifestation of exudative otitis media • • Uni-or bi-lateral hearing loss fluctuating character (when changing the position of the head) Autophony Sensation of congestion and / or fluid transfusion in the ear Tinnitus

Diagnosis of exudative otitis media Otoscopy – air bubbles on the background of exudate in the tympanic cavity (arrows) Type “B” tympanogramm

Treatment of exudative otitis media Elimination of the cause of the disease • Rehabilitation of inflammatory processes in the nasopharynx, • Adenotomy, removal of neoplasms of the nasopharynx • Correction of nasal cavity architectonics • nasal cavity and paranasal sinuses • Restoration of drainage and ventilation function of the auditory tube • Topical decongestants • Blowing the auditory tube by Politzer • Catheterization of the auditory tube • Exercise therapy for auditory tubes • Pneumatic massage of the eardrum

Surgical treatment of exudative otitis media- shunting of the tympanic cavity Otoscopic picture myringotomy with aspiration of the contents of the tympanic cavity www. entusa. com/eardrum_and_middle_ear. htm Otoscopic picture of the shunting of the tympanic cavity