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Case Report

ACUTE OTITIS MEDIA

Presentator : dr. M. Gima Faizal Gani


Moderator: Dr. dr. Bambang Udji Djoko R., Sp.T.H.T.K.L (K).M.Kes.

Otorhinolaryngology Head and Neck Surgery Department


Medical, Public Health and Nursing Faculty Of Universitas Gadjah Mada
Dr. Sardjito Hospital Yogyakarta
2018
INTRODUCTION incidence of otitis media is the age of the first
The most common disorder of the 6-12 months of life, and decreases after the age
middle ear is caused by inflammation. Otitis of 5 years. As many as 80% of children have
media (OM), OM is an inflammation of some otitis media, and 80% -90% of children have
or all of the middle ear mucosa, Tuba otitis media effusion before school age. In
Eustachius, Mastoid Antrum, and Mastoid adulthood otitis media is less common, except
Cells it caused by several internal factors as in adults with immune deficiency. According
well as external factors of the individual. Otitis to race / ethnicity, the highest incidence of
Media is divided into two category, which is otitis media occurs in Alaska, Australian
called Acute Otitis Media (AOM) and Otitis aborigines, and Native Americans (12% -
Media with Effusion (OME). In other 46%), then Maori in New Zealand, Nepal and
literatures, otitis media can also be Malaysia (4% -8%), followed by Korea, India
differentiated based on the presence or absence and Saudi Arabia by 1.4% -2%, and the lowest
of infection or pus, which is Supurative otitis incidence in the United States, Britain,
media and Nonsupurative Otitis Media . The Denmark and Finland (<1%).2
classification is used by the clinician to Research in Indonesia, six province in
diagnose the disorder and give the Indonesia (Bandung, Semarang, Balikpapan,
management whether it is Suppurative Otitis Makasar, Palembang, Denpasar) found that
Media or Non Suppurative Otitis Media.1 otitis media is very significant in school-aged
Generally, acute otitis media is children. The prevalence of incidence of OMA
characterized by rapid onset of signs and is 5/1000, children. The prevalence of chronic
symptoms of inflammation in the middle ear otitis media in rural areas was 27/1000 or 2.7%
accompanied by effusion in the middle ear. and in urban areas the prevalence was lower at
Inflammatory markers include bulging of 7/1000 children or 0.7%. The highest
tympanic membranes, perforation of tympanic prevalence of chronic otitis media in Indonesia
membranes with otorrhea and erythema. is Bali and Bandung compared to other regions
Symptoms include otalgia, irritability and in Indonesia. The highest active chronic otitis
fever.2,4,3,5 media is found in rural Bali ages 10-12 years
Research by Teele et al. the highest as many as 23.5 per 1000 children.3
episodes of acute otitis media in the first year The high degree of correlation between
and third year are 66% and 86% in men and AOM and upper respiratory infection suggest
53% and 77% in women. The highest that viruses are likely to have a role in the

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development of otitis media. During epidemics functions as a function of ventilation
and in isolated situation, the respiratory modulated by Musculus Tensor Velli Palatini,
syncytial virus, influenza A and B and protection function, and drainage function.
parainfluenza viruses have been cultured from Impaired tubal function occurs due to several
middle ear exudates. However, it is not known factors such as sudden air pressure changes,
if these agent can cause otitis media by allergies, infections, or blockages. If there is a
themselves or if they facilitate the malfunction of the tubal physiologic function
development of a bacterial infection.6 there will be negative pressure in the middle
A review of several large studies of ear resulting in transudate fluid effusion. Then
middle ear culture obtained during the course if the tubal disturbance is still accompanied by
of AOM identified Streptococcus pneumoniae an infection it will cause inflammation in the
(48%), Haemophilus influenzae (31%), and middle ear mucosa which will occur Acute
group A streptococci (11%), as the most Otitis Media.9,10
frequently encountered bacteria. With close to Based on disease progression, Acute
30% of all culture failing to produce any Otitis Media is divided into five stages: (1)
growth. Recently, Moraxella catarrhalis has Stadium occlusion of Tuba Eustachius /
risen as a significant pathogen in the Tubotympanitis : Nonspecific discomfort
development of AOM in children.7 occurs, during examination a retracted
There are internal risk factors and tympanic membrane with loss of mobility and
external risk factors from individuals that light reflex can be seen. ( (2) Hyperemic stages
cause acute otitis media. The examples of / Pre-suppuration : Clinically there may be
internal risk factors include age, sex, race, otalgia and fever up to 39 °C, during
prematurity, allergies, immunocompromise, examination of the ear an opaque tympanic
craniofacial abnormalities, and genetics. In membrane is observed, with decreased
external factors also referred to as mobility, (3) Stage Supuration, : There is
environmental factors include Acute severe pulsatile otalgia fever up to 40 °C with
Respiratory Infections, exposure to cigarette yellowish areas of necrosis in addition to
smoke, weather and sudden changes in air purulent or bloody otorrhea (4) Stadium
pressure.8 perforation : stage there is often a discharge
Otitis Media is closely related to the coming out of the middle ear and sometimes
impaired function of Eustachian tube. Tuba there is a pulsation due to pressure differences
Eustachius itself has three physiological inside the ear and outside the ear, and (5) Stage

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Resolution :at this stage gradually returns to emerging bacterial resistance. The
normal, no more discharge and the perforation combination drugs trimetoprim-
closed. These stages have their own sulfametoxazole and erithromycin-
characteristics of diagnosing and treatment14 sulfametoxazole or the newer macrolide
Exudative Severe otalgia with loss of antibiotics have been shown to sterilize the
anatomical references in otoscopy. The middle ear when H.influenzae was the
general treatment of AOM is that of any causative agent.4
potentially serious infection. Bed rest, There is considerable debate as to the
hydration, a light diet, avoidance of irritants benefit of myringotomy in the management of
are important. Nasal and systemic AOM. In a comprehensive review, Gates
decongestant may be symptomatically helpful, noted that many retrospective and prospective
but there is no evidence that they alter the studies were at least partially flawed because
course of the disease. The introduction of of incomplete statistical analysis and failure to
sulfonamide therapy in the late 1930s and stratify patients by age or to separate them in
shortly thereafter the discovery of penicillin group with multiple or isolated attack, as well
revolutionized the treatment of AOM by as unilateral or bilateral disease. He concluded
permitting effective management without that there was no evidence to support the
surgery. Antibiotics therapy should be routine use of myringotomy.12,13
specifically determined by bacteriologic In general agreement with these
culture and antibiotics sensitivity test. concepts, we believe that when otitis is rapidly
However, in most cases immediate treatment progressive with a red, bulging tympanic
can be instituted against the most commonly membrane, severe otalgia and fever, treatment
isolated etiologic agents : the Pneumococcus should include antibiotics and immediate
group and, especially in children 5 years old or myringotomy. Indication for myringotomy in
younger, H.influenzae.5 purulent middle ear location are the same as
Until relatively recently the drug most for incision and drainage of pus in any closed
commonly used was amoxicillin, but the cavity or viscus. When purulent secretion are
growing incidence of b-lactamase producing retained in the middle ear cleft, pressure will
bacteria has begun to limit its effectiveness. result in spread of the infection following areas
The addition of clavulanic acid to amoxicillin of less resistance.11
or the use of second-generation cephalosporins
have been used increasingly because of

3
CASE REPORT . On oropharyngeal examination there was no
A seven years old girl came to E.N.T hyperemic pharynx, T1-T1 tonsil palatine,
department of Sardjito Hospital with a chief The diagnosis for this case is auris dextra
complaint pain on the right ear Since 2 day acute otitis media, hyperemic stage. diagnosis
ago, she has felt pain on the right ear after he establish from history taking that patient feel
suffered from common cold 7 days. She also pain on the right ear, pain worse especially at
complaint Fullnes on the right ear, and night after he suffered from common cold. He
decrease of sense of hearing,and she had a also complaint fullnes on the right ear, and
fever, 4 days ago she came into the nearest decrease of sense of hearing in these patients
health facility, and had been given amoxicilin were given Pseudoephedrine hydrochloride 15
syrup, paracetamol syrup, but the complaint mg + Chloropheniramin Maleat 1 mg syrup
did not improve, There is no complain about 3x5ml, co-amoxiclav (250mg/62,5mg) syrup
discharge from the ear canal,and itching There 3x10ml, Paracetamol tablet 3x250mg.and we
is no complain about nose and throat. education the patient parent for control after 7
From the physical examination, we days.
obtained; General status : good, CM After 7 days she came to the E.N.T clinic
weight : 19 kg, pulse 80 times per minute, and she said that the pain lessen, from physical
Respiration 20 times per minute, Temperature examination within normal limit, we stop the
38,2o C. medication for this patien
Left Ear Examination was obtained normal DISCUSION
acoustic Canalis, Right ear acoustic Canalis Management of patients with Acute Otitis
examination hyperemic (-), edema (-), Media varies depending on the stage of otitis
serumen prop (-), laceration (-). otoscopic media. In the occlusion stage there has been no
examination of tympanic membrane appread infection in the middle ear. This stage is an
hiperemic (+), retraction (+), perforation (-), early stage where there is only negative
light reflex (+),Brevis processus of malleus pressure from the middle ear without the
does not seem more prominent, the appearance occurrence of fluid effusion caused by tubal
of air bubble (-), the appearance of water-fluid dysfunction. The tuba can not work as a
level (-), left Ear within normal limits. On right ventilator from the middle ear. At this stage,
and left anterior rhinoscopy examination the effective treatment is a decongestant which
presence of konka hyperemic (+), discharge(-) aims to reopen the tube so that the negative
pressure decreases in the middle ear. In

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addition, the source of infection should be Normally the discharge will disappear and the
treated. Antibiotics are given if the cause of the perforation will close again within 7-10 days.4
disease Bacteria, not by virus or allergy.2,9,10 At the stage of tympanic membrane
Treatment at the presuppuration stage is resolution gradually returns to normal, no
antibiotics, decongestants, and analgesics. more discharge and the perforation closed.
Antibiotic is recommended from the class of This stage has no specific treatment given If
penicillin or ampicillin. Initial therapy can be there is no resolution in the middle ear it will
done intramuscular penicillin in order to obtain appear secret through the membrane tympanic.
adequate concentration in the blood, so there is This may be due to persistent middle ear
no hidden mastoiditis, hearing loss as a mucosal edema. in such circumstances
sequelae, and recurrence. Provision of antibiotics can be continued for up to 3 weeks.
antibiotics is recommended for at least seven If 3 weeks after the discharge treatment there
days. When the patient is allergic to penicillin are still many possibilities of mastoiditis.1,4
then given erythromycin. In children, If Acute Otitis Media continues within 3
ampicillin is given a dose of 50-100 mg/kg weeks to 12 weeks, it can be called subacute
daily divided by 4 doses, or amoxicillin 40 suppurative otitis media. If symptoms are
mg/kg per day divided into 3 doses, or obtained more than 12 weeks it can be called
erythromycin mg/kg per day.1,2 Chronic Suppurative Otitis Media (CSOM) .1,4
In Stage of suppuration, there appears to be This patient is given an oral
a bulging in the middle ear. At this stage the pseudoephedrine which aims to open the tube
patient is very complaining of severe ear pain eustachian tube so that the pressure in the
due to high pressure from the inside of the ear. middle ear can be the same as the pressure on
Giving the drug at this stage ideally antibiotics the outside air and to reduce the secretion of
coupled with miringotomy action. With mucus and congestion in the nose and tuba for
miringotomy clinical symptoms are more improved tubal patency and the clearance of
rapidly gone and rupture can be avoided.4 the middle ear, ambroxol is given in this
At the perforation stage there is often a patient aims as mucolytic because the patient
discharge coming out of the middle ear and had cough colds since 7 days ago. Cetirizine is
sometimes there is a pulsation due to pressure as an antihistamine because this patient has a
differences inside the ear and outside the ear. history of allergies. In addition, decongestant
Treatment given is to wash the ear using H2O2 administration combined with
3% for 3-5 days with adequate antibiotics. pseudoephedrine has been proven effective in

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dealing with cases of acute tubal occlusion. 3. Asmuni S, Anggraeni R, Hartanto
Antibiotics in this case given because there are WW, Djelantik B, et al. Otitis media in
signs of infection from the middle ear such as Indonesian Urban and Rural School
hyperemia in the tympanic membrane, fever, Children. The Pediatric Infections
pain. Disease Journal. 2014
SUMMARY 4. Djaafar ZA, Helmi, Restuti RD.
Reported a seven years old female patient Kelainan Telinga Tengah. Dalam:
diagnosed with acute otitis media hyperemic Soepardi EA, Iskandar N, Bashiruddin
stages, she has felt pain on the right ear after J, Restuti RD. Buku Ajar Ilmu
he suffered from common cold 7 days, we give Penyakit Penyakit Telinga Hidung
Pseudoephedrine hydrochloride 15 mg + Tenggorok Edisi ketujuh. Balai
Chlorpheniramine Maleat 1 mg syrup 3x5ml, Penerbit FK UI, Jakarta, 2016. h: 57-
co-amoxiclav (250mg/62,5mg) syrup 3x10ml, 61.
Paracetamol tablet 3x250mg. education the 5. Probst R, Grevers G, Iro H. Basic
patient for control after 7 days. After 7 days Otolaryngology: A Step-by-Step
she came to the E.N.T clinic and she said that Learning Guide. Thieme. Erlangen,
the pain lessen, from physical examination Germany. 2006. P: 234-239
within normal limit, we stop the medication for 6. Rettig E, Tunkel DE. Contemporary
this patient concepts in management of acute otitis
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