RU2342151C2 - Treatment method for chronic purulent otitis media - Google Patents

Abstract

FIELD: medicine; otorhinolaryngology.

SUBSTANCE: in early postoperative period, after finishing antibiotic system and local therapy course, into patient's ear his own saliva is instilled. The saliva is taken fasting in the morning, after oral cavity cleaning, by spitting into boil treated glass. 3 drops of saliva 3 times a day during 20 to 45 days is instilled.

EFFECT: disease recurrence reducing due to mastoidal cavity populating with normal microflora.

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Description

The invention relates to medicine, namely to otorhinolaryngology, and can be used in the treatment of chronic suppurative otitis media after a sanitizing operation on the middle ear.

To date, the basis for the treatment of chronic purulent otitis media after a sanitizing operation is systemic and local antibiotic therapy. As a result of this treatment, the middle ear cavity, as a rule, is freed from pathogenic microflora, and, unfortunately, the saprophytic microflora at the same time suffers from vegetation on the skin of the ear canal normally. Sanitized cavities of the middle ear in the absence of competing interactions with saprophytes and a decrease in local immunity against chronic inflammation are again seeded with aggressive pathogens, which leads to a relapse of chronic purulent otitis media and the formation of diseases of the operated ear. Numerous studies have shown that persistent remission of chronic purulent otitis media involves vegetation in the cavities of the middle ear of saprophytic microflora (Tarasov DI, Fedorova O.K., Bykova VP Diseases of the middle ear. - M: Medicine 1988. - 288 p.). We examined the microbial landscape of the middle ear in 17 patients who had previously undergone radical surgery in a state of persistent clinical remission lasting at least 3 years. In 35.2% of cases, microflora was not verified, in 53% it showed moderate growth, mainly without the prevalence of its individual representatives. Abundant growth in an ear swab was observed in 2 people (11%) suffering from chronic pharyngeal pathology with carriage of Staphylococcus aureus. Saprophytes prevailed in the microbial landscape: S.epidermidis (29.4%), S.saprophiticus (23.5%), H.influensia (11.7%). Carriage of pathogenic species: S.aureus (11.7%), Str.viridans and diphtheroids (5.8% each) - p <0.05 with a ratio of the total share of saprophytes and pathogenic microbes (Shpotin V.P., Proskurin A.I. et al. Microflora with epitympanitis in the long term after sanitization operations // Abstracts of the XVII Congress of Otorhinolaryngologists of the Russian Federation. - N. Novgorod, June 7-9, 2006. - P.151-152).

Thus, there is a need to find ways to colonize postoperative cavities with non-pathogenic saprophytic microflora.

In the last decade, probiotics have become widespread - drugs containing strains of microorganisms that are beneficial to the body. Requirements probiotics must meet: compliance with a healthy human microflora, high vitality and biological activity, antagonism of opportunistic and pathogenic flora, resistance to physicochemical factors (acidity, osmotic shock, temperature, the action of bile acids, etc. .) (Khoroshilova N.V. Immunomodulating and therapeutic effect of probiotics // Immunology. - 2003. - No. 6. - S.352-356). Probiotics are widely used in veterinary medicine (Bakulina L.F., Permanova N.G., Timofeev I.V. et al. Probiotics based on spore-forming microorganisms and their use in veterinary medicine // Biotechnology. - 2001. - No. 2. - C .48-56) and gastroenterology (Uchaykin V.F., Gasparyan M.O., Novokshonov A.A. et al. Probiotics in the complex treatment of intestinal infections in children // Biologics. - 2001. No. 1. - C.2 -four). The use of probiotics in otorhinolaryngology is limited due to the absence of microorganisms in them, vegetating in healthy ENT organs.

As a natural probiotic, human saliva, which is not sterile and contains saprophytic microorganisms, can be considered. The oral cavity of a healthy person is rich in microflora, characterized by relative constancy, supported by the bactericidal properties of saliva. The concentration of microbial bodies in 1 ml of saliva can be in the range of 10 ⁷ -10 ¹⁰ , and on the mucosa in the gingival pockets and 10 ¹¹ CFU (colony forming units). These include aerobic and anaerobic gram-positive and gram-negative rod-shaped and coccal saprophytes. (Bondarenko A.V., Bondarenko Vl.M., Bondarenko V.M. Ways to improve the etiopathogenetic treatment of dysbacteriosis // Journal of Microbiol., Epidemiol. And Immunobiol. - 1998. - No. 5. - P.96-101). We conducted a microbiological study of saliva in 23 people with purulent otitis media and 20 healthy people. In 32 of them, non-pathogenic saprophytic microorganisms (epidermal and saprophytic staphylococci, H.influensia) were found in saliva. In 5 patients with otitis media and 3 healthy people on nutrient media, growth of Staphylococcus aureus (4 cases), Klebsiella (2 cases), hemolytic streptococcus (1 case) and E. coli (1 case) was obtained. In all cases of pathogenic seeding, patients had either a chronic pathology of the oropharynx or multiple caries.

Since ancient times, excreta and body fluids have been used for therapeutic purposes. For millennia, the use of saliva has either ceased, then resumed in various modifications. Fasting saliva was used to remove warts, abscesses, tumors, and birthmarks. Ringworm and skin ulcers in ancient times were treated with saliva compresses. To get rid of stubborn corns, they used baking soda, which they previously spat on (Babylonian Talmud. Chapter 91). The healing features of saliva were noticed by ancient healers and were successfully used by them not only to treat external injuries, but also internal ailments. In the medical sources of the Sumerian, Egyptian, Tibetan and Greek authors, we find information about this unique substance. "This is the only substance created by the body, which is not removed from it, but like the ebbs and flows, cyclically pulsates in it, rising and falling." (Abu Ali Ibn Sina. Canon of medical science // In 3 parts / Comp. U.I. Karimov, E.U. Khurshut. - Tashkent. Fan Publishing House of the Academy of Sciences of the Republic of Uzbekistan, 1994. 400 p. + 360 p. + 232 s).

In classical and modern literature, we have not found sources indicating the use of human saliva in the treatment of chronic suppurative otitis media. In this regard, as a prototype, a method was selected for the treatment of chronic purulent otitis media using another biological fluid - autoserum (Korvyakov BC, Aboyants R.K., Scriabin A.S. Results of reconstructive operations in chronic purulent otitis media using autoserum and collagen sponges // West otorinolar. - 1998. - No. 1. - p. 56-58; Korvyakov BC, Scriabin A.S., Fedorova OK Method for the treatment of chronic suppurative otitis media // RF Patent No. 2099064 from 12.20.97).

The disadvantages of the prototype include:

- the need for several intravenous blood sampling, that is, additional invasive procedures are required;

- autoserum is sterile and does not perform the function of populating the middle ear cavity with saprophytes;

- being a good environment for microorganisms, autoserum may even provoke an exacerbation of chronic purulent otitis media in certain circumstances;

- the patient's attachment to a medical institution for a long period of time is required by limitation of disability.

The aim of the invention is to optimize the postoperative treatment of chronic suppurative otitis media and reduce the frequency of its relapses.

The proposed method for the treatment of chronic suppurative otitis media includes sanitizing surgery and instillation of body fluid in the ear after surgery. The goal of the invention is achieved by the fact that in the early postoperative period, after completing a course of systemic and local antibiotic therapy, 3 drops of the patient's saliva are received in the ear, which was received in the morning on an empty stomach in the morning after an oral toilet by spitting into a beaker treated with boiling, instillation is carried out 3 times a day within 3 weeks to 1.5 months.

In the proposed method, saliva is used in the postoperative period for 8-12 days. During the operation on the ear, performed according to the “open” version, a mastoid cavity is accessible that is visible for visual control and fluids into it, in which epidermization processes begin by 8-12 days. Usually by this time, with a favorable postoperative period, the course of systemic and antibiotic therapy ends, the sutures from the ear wound are removed and the patients are discharged for outpatient aftercare. Almost the majority of patients do not show microflora growth in an ear swab before discharge, which indicates the effectiveness of the treatment carried out in the hospital. However, against the background of reduced immunity, as a result of chronic inflammation and surgery, and the absence of competitive effects from saprophytic microflora, the postoperative cavity is again populated by pathogens, leading to a relapse of epithympanitis. To avoid this, after discharge, patients begin to drip saliva into the operated ear. The argument for using saliva as a probiotic is the vegetation of saprophytic microflora in it. In diseases of the oral cavity, salivary glands and pharynx, pathogenic microorganisms are sown in saliva, in these cases the use of saliva is contraindicated before the rehabilitation of foci of inflammation. Dosages recommended to patients - 3 drops 3 times a day, were empirically selected and fully justified themselves: at lower dosages, saliva had time to dry out, and at high dosages, due to the abundance of fluid, it slowed down the reparative processes. Saliva was taken by patients on their own, in the morning and on an empty stomach after the toilet of the oral cavity (toothpaste, tooth elixir). Patients did not change their usual way of using the oral cavity when they sow after it saprophytic microflora from the saliva. Saliva was spat on a boiled glass beaker and used for 24 hours; a new portion was collected the next day. The duration of such treatment ranged from 3 weeks to 1.5 months, depending on the individual possibilities of repair and the reactivity of the body. During this period, the complete epidermis of the postoperative cavity ends, it is cleaned of exudate. The criterion for stopping the use of saliva was not only visual control, but also microbiological examination with saprophytic microflora from the middle ear.

The proposed method is performed as follows: after discharge from the hospital (8-12 days of the postoperative period), when the systemic and local antibiotic therapy is completed and the sutures from the behind the wound are removed, patients on an outpatient basis begin to instill saliva in the operated ear. Saliva is obtained daily in the morning before meals and after the toilet of the oral cavity by spitting. A prerequisite for the use of saliva was a complete sanitation of the oral cavity and the absence of it during microbiological examination of pathogenic microflora. We recommended instillation of 3 drops 3 times a day. A constant intake of saliva was not required; a morning portion was enough, collected in a boiled glass beaker. The duration of such treatment was from 3 weeks to 1.5 months, depending on the otoscopic and microbiological dynamics. The criterion for stopping the use of saliva was either the appearance of purulent exudate, which indicated incomplete sanitation of the postoperative cavity from pathogenic microorganisms and required an extension of the local anti-inflammatory therapy and then reuse of saliva as a probiotic, or termination of exudation, complete epidermization of the postoperative cavity and seeding during control microbiological studies saprophytic microflora.

The difference of the proposed method from the prototype is:

- the use of saliva is a simple method that does not require material costs and invasive methods of sampling the material;

- the patient alone, without the participation of medical workers, at home can use this method of treatment;

- saliva due to the content of non-specific and specific protection factors in it, has anti-inflammatory and protective properties;

- non-pathogenic microorganisms are cultured in saliva, the same as on the skin, which makes it possible to use it as a probiotic to populate the postoperative mastoid cavity with microflora normal for such localization;

- the formation of a balanced microbiocenosis by instillation of saliva into the ear allows achieving stable remission of chronic purulent otitis media and avoiding the disease of the operated ear.

We compared the results of treatment of chronic purulent otitis media in groups of patients with saliva (23 people) and without saliva (31 people). Microbiological comparison criteria were: the absence of growth on nutrient media, sowing of saprophytic and pathogenic microflora in smears from the middle ear, determined before discharge, 3 weeks, 1.5 and 3 months after surgery. Clinical comparison criteria were: recurrence of the disease in the first year after surgery, epidermis of the postoperative cavity, the presence of productive elements and pathological scarring in it. The comparison results are presented in table No. 1.

Table 1 The results of treatment of patients with chronic purulent otitis media, depending on the use of saliva Using saliva (n = 23) Without saliva (n = 31) Abs % Abs % No microflora growth Before discharge 22 95.6 29th 93.5 In 3 weeks 0 0 eighteen 58.1 After 1.5 months 0 0 3 9.7 In 3 months 0 0 one 3.2 Saprophytic microflora Before discharge 0 0 0 0 In 3 weeks 21 91.3 7 22.6 After 1.5 months 23 one hundred twenty 64.5 In 3 months 23 one hundred 19 61.2 Pathogenic microflora Before discharge one 4.3 2 6.4 In 3 weeks 2 8.7 6 19,4 After 1.5 months 0 0 8 25.8 In 3 months 0 0 eleven 35,4 Relapse in the first year after surgery one 4.3 8 25.8 The state of a trepanation cavity in the long-term postoperative period Epidermization 22 95.6 24 77.4 Productive Elements one 4.3 5 16.1 Pathological scarring 0 0 2 6.5

As can be seen from table 1, the vast majority of patients in both groups at the time of discharge from the hospital in smears from the cavities of the middle ear did not receive microflora growth. In the group of patients who did not use saliva (31 people), the absence of microflora in smears after 3 weeks persisted in 18 (58.1%) people, after 1.5 months - in 3 (9.7%) people, after 3 months - in 1 (3.2%) person. The postoperative cavity in patients of this group was gradually colonized with microorganisms, three months after the operation, saprophytes were sown in 19 of them (61.2%), and pathogenic microorganisms in 11 (35.4%). In all patients (100%) with chronic purulent otitis media, for the treatment of which saliva was used, only saprophytes were sown from the ear 1.5 and 3 months after surgery.

A persistent remission of epithympanitis in most patients treated with saliva can serve as an indicator of the effectiveness of our proposed method for the treatment of chronic purulent otitis media; relapse in the first year after surgery occurred in 1 patient (4.3%) with incomplete epidermization of the postoperative cavity and growth of granulations. At the same time, in patients of the comparison group, relapses in the first year after surgery were recorded 6 times more often (25.8%) and were the result of incomplete epidermis (22.6%), the formation of productive elements (16.1%) and pathological scarring with the separation of the trepan cavity (6.5%).

Our proposed method was introduced into the work of the ENT department of the Alexander Mariinsky Regional Clinical Hospital in Astrakhan and was used in the treatment and rehabilitation of 23 patients with chronic purulent otitis media. The following are examples of testing.

Example 1. Patient Ch., Born in 1980, was hospitalized in the ENT department on 02/26/06 (medical history No. 3162) with complaints of pain in the right ear, profuse suppuration from it with a sharp putrid smell, lack of hearing in the right ear. Sick since childhood. In 1997, according to emergency indications, radical surgery on the right middle ear and right-sided hemisinusotomy for secondary purulent meningitis and sepsis were performed. After discharge from the hospital, remission did not occur, purulent discharge from the right ear continued, about which he was repeatedly treated in the hospital with short-term clinical improvement. Instrumental and x-ray examination in the hospital showed that against the background of otoscopic separation of the cavities of the right middle ear in the patient, the osteomyelitis process continued in the temporal bone with the presence of cholesteatoma. In a smear from the right ear, abundant growth of Staphylococcus aureus, moderate growth of Pseudomonas aeruginosa and colony of Proteus and Enterococcus were found. In saliva, against the background of complete sanitation of the oral cavity, a moderate growth of saprophytic and epidermal staphylococci was obtained. 03/07/2006 under endotracheal anesthesia by the behind-the-ear method, a sanitizing reoperation was performed on the right middle ear using the “open” method. The large cholesteatoma, carious bone, granulation was removed, destructive bone defects with exposure of the dura mater of the middle cranial fossa and sigmoid sinus were detected. All pathological removed to a healthy bone. To increase the epidermis front, a skin flap on the feeding leg, placed on the bottom of the mastoid cavity with the covering of bone defects, was taken from the behind-the-ear region (Application for invention No. 2006102403 (002596) dated January 26, 2006). The postoperative period was uneventful. Got a course of systemic and local antibacterial therapy. In the control, before discharge, a smear from the ear of microflora growth was not obtained. On an outpatient basis, on the 12th day after the operation, I drove saliva 3 drops 3 times a day into the operated ear for 1.5 months. During the control examination 1.5 and 3 months after the operation, the epidermis was completely epidermized in the middle ear cavities, the cavities were cleaned and there was no exudate in them. Microbiological examination revealed colonies of saprophytic and epidermal staphylococci in the cavities of the middle ear.

Example 2: Patient Yu., Born in 1962, suffers from left-sided chronic purulent otitis media since childhood. Repeatedly undergone a course of conservative anti-inflammatory therapy with temporary clinical improvement. Last hospitalization on November 9, 2005 (medical history No. 18207) in connection with the continued otorrhea, abundant with a sharp putrid odor, and paresis of the facial nerve that occurred three days before hospitalization. With otoscopy: AD - without pathology. AS - in the auditory canal, profuse purulent discharge with a putrefactive odor. The eardrum is scarred, hyperemic, and a subtotal marginal defect is visualized. Hearing of SR: AD = 6 m, AS = 1.5 m. On radiographs of the temporal bones against the background of the sclerotic type of structure of the left mastoid process, a destructive cavity with sequestration is determined. During microbiological examination, associations of pyogenic streptococcus, Pseudomonas aeruginosa, yeast and protea were seeded from the cavities of the middle ear; from saliva - saprophytic staphylococcus and H.influensia. The sanitation operation was performed by the behind-the-ear approach according to the “open” method with tympanoplasty of type II. During the operation, carious and cholesteatomic masses were removed, a naked facial nerve was found, which was covered with a flap on a feeding leg cut from the skin of the ear region (Application for invention No. 2006102403 (002596) dated 01/26/06). The postoperative period is smooth. Having received a course of local and systemic antibiotic therapy, the patient was discharged from the hospital for 9 days with minor symptoms of paresis of the facial nerve. Microbiological examination revealed a slight increase in pyogenic streptococcus and Proteus before discharge in the postoperative cavity. Starting from the 8th day after the operation, for 3 weeks, the patient dripped in her ear her own saliva 3 drops 3 times a day. A follow-up examination after a month: the middle ear cavities are pronounced, dry, completely epidermized, the non-tympanic membrane is in a satisfactory condition, the phenomena of paresis of the facial nerve have completely disappeared, whispering speech to the operated ear is 4.5 meters, and moderate growth of saprophytic staphylococcus has been found in ear swabs. Using the proposed treatment method, we are able to achieve:

- optimization of postoperative treatment of chronic suppurative otitis media and reducing the frequency of its relapses;

- full rehabilitation of the mastoid process due to the content of specific and non-specific protection factors in saliva;

- simplification of treatment and convenience in the use of saliva due to the exclusion of invasive techniques for collecting biological fluids;

- colonization of the middle ear cavities with normal microflora, which allows to reduce the rehabilitation time and achieve stable remission;

- the absence of aggressive chemical compounds in saliva does not lead to local pain during its use;

- reduction of economic costs due to lower costs for the purchase of antiseptic ear drops in the early postoperative period and reduction of episodes of exacerbation in the late.

Claims (1)

A method of treating chronic purulent otitis media, including a sanitizing operation and instillation of body fluid in the ear after surgery, characterized in that in the early postoperative period after completing a course of systemic and local antibiotic therapy, 3 drops of the patient’s saliva obtained in the morning on an empty stomach after an oral toilet are instilled by spitting into a beaker treated with boiling, instillation is carried out 3 times a day for 3 weeks to 1.5 months