Middle ear disorders

Middle ear diseases affect virtually every part of the ear, whether it is the eardrum, the ossicles (small bones) or the muscles of the middle ear. The auditory ossicles are made up of a chain of three small ossicles called the hammer, the anvil and the stirrup. The middle ear can be affected by inflammatory-type diseases, purulent or non-purulent, as well as problems with polyps in this area, or the Eustachian tube is responsible for many problems and some are directly related to it.

The middle ear consists of several parts. It is separated from the outer ear by the eardrum, which is a thin membrane, and also by the tympanic cavity, which is filled with air and arches backwards. Immediately behind the eardrum are three interconnecting auditory ossicles, namely the hammer, anvil and stirrup, which are connected to the eardrum and lodged in the tympanic cavity. The plate of the stirrup touches the oval window of the inner ear and so these ossicles transmit sound from the middle ear to the inner ear.

The middle ear is connected to the Eustachian tube from below, which connects the cavity and space of the middle ear to the nasopharynx and ensures that the pressure in the middle ear is maintained and balanced with respect to atmospheric pressure. At the same time, there are also muscles in the middle ear, namely the tympanic tensioner and the stirrup muscle. The eardrum extensor is attached to the hammer and its function is to stretch the eardrum. The stirrup muscle is attached to the stirrup and fixes its plate in the oval window.

Noninfectious otitis media

The middle ear is the part of the ear that forms a system of filled cavities that are lined with mucous membranes. Its function is to convert sound into vibrations, which happens in the eardrum, and then by means of the auditory ossicles the vibrations are transmitted to the inner ear. This ability is impaired, for example, by non-purulent inflammation, whether of the acute or chronic type. These include, for example, myringitis, serous inflammation, inflammation with secretion or acute and subacute otitis media of various kinds.

Both acute and subacute non-purulent otitis media may have an allergic cause, but may also be mucoid, sanguinous or seromucinous. In addition, non-purulent inflammations include chronic serous otitis media, prolonged tubotympanic catarrh, chronic mucoid otitis media and various chronic inflammations with non-purulent discharge. The most common inflammations, which mainly affects children, but of course not only those, are acute otitis media and myringitis.

Myringitis is a viral inflammation in the middle ear that takes an acute form and affects the eardrum in the middle ear. It most often arises from progressive infection of diffuse inflammation of the ear canal, i.e. this inflammation gets here from the outer part of the ear. There is mild swelling and enlargement of the eardrum and reddening of it, but not dislocation. The inflammation is accompanied by pathological secretion, but it is non-purulent. Usually the inflammation is not painful and is manifested by hearing impairment.

This inflammation is most common in children under 5 years of age and treatment is local, and usually within a week the inflammation should resolve without major problems or sequelae with proper treatment and a simple course. However, the problem is a form of myringitis caused by Mycoplasma pneumoniae, where the microorganism enters the eardrum from the inside of the Eustachian tube. Such a form of inflammation is already more severe and very painful.

The acute and subacute form of otitis media is also a widespread inflammatory disease, and such inflammation may be accompanied by secretions of various kinds, for example, serous or effusion. It is commonly a viral inflammation caused mainly by respiratory viruses, adenoviruses, influenza A or B viruses and other types of viruses that can enter the middle ear from both the external and internal environment. Professionally, such inflammation is called catarrhal otitis.

Such inflammations occur throughout the year and are most common in children under 2 years of age, but, of course, also in adults. They are most often manifested by ear pain, temperature or fever and pricking in the ear, especially in children. Acute and subacute forms are characterised by a rapid onset of symptoms, especially at night. Conversely, in chronic forms of inflammation, which often recur, there is no temperature or fever and the symptoms are more likely to be itching and burning in the ear.

Purulent and other inflammations in the middle ear

The middle ear, whether its mucous membrane, eardrum or other parts, can also be affected by suppurative (i.e. producing pus) and other inflammations, whether acute suppurative otitis media, suppurative form of myringitis, chronic tubotympanic suppurative otitis media, benign prolonged suppurative inflammation, prolonged tubotympanic disease, chronic athcoantral suppurative otitis media, prolonged athcoantral disease or unspecified acute and chronic inflammation of unspecified type.

Bacterial suppurative myringitis is caused by bacteria that have entered the middle ear from the upper respiratory tract, and in this case it is a very painful inflammation in which pus is also formed and this drains most often through the Eustachian tube, or it is necessary to drain the pus through the eardrum. This can either rupture spontaneously or paracentesis is performed, which is a specific procedure carried out by a specialist ENT doctor to allow the pus to drain by puncturing the eardrum.

While myringitis affects the eardrum, the mucosa of the inner ear is affected by classic acute and chronic otitis media of bacterial origin. Such inflammation can be caused by the bacteria streptococci, but also by haemophilus, moraxella or turicella, which are special rod-shaped bacteria. Bacteria can enter the middle ear when the eardrum is injured or, more commonly, from the upper respiratory tract, possibly by the blood or, very rarely, from the intra-ear labyrinth.

In the acute form, the disease progresses relatively quickly and symptoms usually appear within 24 hours. Inflammation is most often bilateral and with the production of pus, which accumulates in the middle ear and at the inflamed site. Subsequently, there is a sharp soreness, a sensation of lying down in the ear, the person may also feel a throbbing pain. In the case of the subacute form, the onset of symptoms is even more rapid. The only effective treatment is to loosen the pus and deploy antibiotics.

In the chronic form, the symptoms are less intense, there is no temperature or intense soreness, for example, and the person is more likely to have a burning or itching sensation in the ear, or may hear noises and other sounds. Also, chronic inflammation may be with pus production, but this is less common than acute otitis affecting the middle ear. Most often, however, there is secretion of fluids other than pus, especially if the infection is of longer duration and also of viral origin.

AUditory tube disorders related to the middle ear

The auditory tube, also called the Eustachian tube, has a major influence on middle ear disease. This directly connects the nasopharynx to the middle ear and has several functions. Firstly, it has a protective function, where it prevents the passage of infections from the middle ear into the oral cavity. At the same time, it equalizes the pressure between the middle ear and the external environment, as it is normally closed but opens briefly during rapid changes. It also allows secretion to descend from the middle ear into the nasopharynx.

Even the typical and common inflammation in the middle ear can be related to problems with the Eustachian tube. In this case, the infection has passed in this direction or, conversely, the closure of the Eustachian tube has caused an infection in the middle ear. Closure of the auditory tube is very unfavourable, for example, when the tube itself becomes infected, or when swelling or a tumour of the nasopharynx overgrows into the tube and causes permanent obstruction.

At the same time, however, if the tube is too open, it is an issue in terms of increased infectious risk in upper respiratory tract infections or influenza. If, as a result of pathological changes in the walls of the tube or the influence of hormonal or radiological therapy, there is a morbid frequent opening, for example, during physical activity of the body, there is a transfer of infection to the middle ear. At the same time, the Eustachian tube does not fulfil the function of balancing the pressure, which manifests itself in the sensation of pressure directly in the ear.

Cholesteatomas in the middle ear

Cholesteatomas are cystic formations that can be located in the outer ear, but sometimes they can also occur in the middle ear. These are cysts that behave externally like tumors, but they are not actual tumours. These cysts are enlarged by layers of sloughed off epithelial cells. Initially, cholesteatoma arises in the outer ear, where the squamous epithelia of the skin form its layers, but the disease can also penetrate into the middle ear.

In worse cases, this formation does not just increase in size by adding more layers, but it is in the middle ear where a specific enzyme can activate cells that break down the surrounding middle ear bones, which become part of the cholesteatoma and also lead to inflammation of these bones. Cholesteatoma can take several forms, either primary, genuine or secondary, which is the most common type of this cyst. At the same time, this cyst is often associated with chronic suppurative inflammation in the middle ear.

Cholesteatoma is most often manifested by hearing loss, also by ear murmurs and a long-lasting and unpleasantly smelly discharge from the ear. The only treatment is surgical removal of the entire mass, and if other inflammation develops, this process can be controlled with antibiotics or corticosteroids as part of preoperative conservative treatment. The definitive solution, however, is surgical removal of the entire inflammatory lesion and cyst, and possibly also polyps.

Disorders of the tympanic membrane and auditory ossicles

The eardrum, which forms the interface between the middle and outer ear, can also be affected by various problems. For example, perforation due to post-inflammatory or traumatic perforation, or atypical perforation of the tympanic membrane, marginal perforation or complete perforation of the tympanic membrane. The tympanic membrane itself is also affected by various inflammatory diseases such as acute or bullous maryngitis, chronic maryngitis, tympanitis, etc.

Less common diseases include tympanosclerosis, discontinuity and dislocation of the auditory ossicles, various abnormalities of the auditory ossicles such as ankylosis of the auditory ossicles or partial loss of the ossicles. There may also be polyps in the ear, i.e. small benign cysts that may grow in from other surrounding tissues, but these are relatively rare.