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Pemicu: Otitis Media Akut

Seorang ibu datang melawat anak perempuanya, yang berusia 5 tahun, ke praktek dokter umum dengan keluhan telinga kanan berair sejak 1 hari yang lalu, carian berwarna putih kekuningan. Sebelumnya pasien mengeluh sakit pada telinga kanan sejak 4 hari lalu disertai demam dan berkurang setelah pasien minum obat parasetamol. Riwayat pilek sejak 1 minggu yang lalu. Ibu pasien mengeluh anak sering tidak mendengar kalau dipanggil.

Status Lokalisata Pada Pemeriksaan: Otoskopi telinga kanan: Pada liang telinga dijumpai mukoid, mebran timpani tampak perforasi sentral yang kecil Otoskopi telinga kiri: Liang telinga normal, membran timpani utuh, refleks cahaya (+) Pada pemeriksaan rinoskopi anterior: mukosa hidung hiperemis, konka inferior dan media eutrofi, sekret dijumpai Pemeriksaan rinoskopi posterior dan laringoskopi indirek normal Pemeriksaan kultur sensitifitas: Streptokokkus sp. Tes pendengaran sederhana: Telinga kanan: Rinne Test (-), Weber lateralisasi kanan, Scwabach memanjang Telinga kiri: Rinne Test (+), Scwabach sama dengan pemeriksa Play audiometri: Telinga kanan: Tuli konduktif rinagn 30 dB Telinga kiri: Normal

Apakah kesimpulan anda mengenai penyakit pasien ini sekarang?

1. 2. 3. 4.

Anatomi telinga Histologi telinga Fisiologi pendengaran Otitis Media Akut


Definisi, Faktor Resiko, Klasifikasi Etiologi dan Patogenesis Gejala Klinis dan Patofisiologi Diagnosa Diagnosa Banding Penatalaksanaan Farmakolgis dan Nonfarmakologis Komplikasi, Prognosis dan Inidikasi Rujuk.

1. External Ear 2. Middle Ear 3. Inner Ear

Pinna (Auricle)

Meatus acusticus externa

Irregularly shaped plate o/t elastic cartilage covered by thin skin The canal that extends f/t pinna into the temporal bone to the external surface o/t tympanic membrane Superficial portion is composed of elastic cartilage, which is continuous with the cartilage o/t pinna. Temporal bone replaces the cartilage as support in the inner 2/3 o/t canal Is covered with skin containing hair follicles, sebaceous glands, ceruminous glands (modified sweat glands)

Tympanic membrane Tympanic cavity Auditory ossicles


malleus (hammer) incus (anvil) stapes (stirrup)

Auditory (Eustachian) tube Muscle


Tensor tympani muscle Stapedius muscle

Tympanic membrane

surface is covered by epidermis; Collagen and elastic fibers, fibroblasts interposed btw 2 epithelial layers Internal surface is covered by simple squamous to cuboidal epithelium

External

Is an air filled space located i/t petrous portion o/t temporal bone Posterior: mastoid air cell Anterior: auditory (eustachian) tube Medial wall: oval window and round window Lateral wall: tympanic membrane Bony ossicles spans the distance btw tympanic membrane and the membrane o/t oval window. Is lined mostly by simple squamous epithelium, and pseudostratified ciliated columnar ep (near auditory tube) Lamina propria

Muscles M tensor tympani: movement o/t tympanic membrane M stapedius: movement o/t bony ossicles

Bony wall: Adheres to bony wall and has no glands Overlaying cartilage portions: has many mucous glands whose ducts open into tympanic cavity

Malleus Incus

Is attached to tympanic membrane

Stapes

Interposed btw malleus and stapes


Is attached to the oval window

Are articulated in series by synovial joints lined with simple squamous ep.

THE INNER EAR


The inner ear consists of 2 labyrinthine compartments: The bony (osseous) labyrinth, in the petrous portion of the temporal bone The membranous labyrinth, within the bony labyrinth Spaces of the inner ear There are 3 fluid filled spaces in the inner ear: The endolymphatic spaces, within the membranous labyrinth The perilymphatic space, in which the membranous labyrinth is suspended The cortilymphatic space, lying within the organ of Corti

The bony labyrinth consists of: The vestibule: the central space of the bony labyrinth, containing the utricle and saccule of the membranous labyrinth The semicircular canals extending from the vestibule posteriorly The cochlea, extending from the vestibule anteriorly The semicircular canals lie at about right angles to each other in superior, posterior and horizontal planes, and each has an expanded ampulla at their lateral end. The cochlea is a conically shaped helix that spirals about 2.5 turns around a bony core called the modiolus, which contains the spiral ganglion of the vestibulocochlear nerve (CN VIII).

The membranous labyrinth, suspended within the perilymph of the bony labyrinth, consists of: The membranous semicircular ducts, within the semicircular canals The utricle and saccule, contained in the vestibule, and connected by the utriculosaccular duct The membranous cochlear duct, within the bony cochlea, continuous with the saccule. The semicircular ducts, utricle and saccule and part of the vestibular system, concerned with balance and posture, whilst the cochlear duct is part of the auditory system, concerned with hearing.

There are 6 special sensory regions in the inner ear:3 cristae ampullaris, in the ampullae of the semicircular ducts, which are sensitive to angular acceleration (turning) of the head 2 maculae of the vestibule: one in the utricle (macula utriculi) and the other in the saccule (macula sacculi), both of which sense gravity, position and linear movement The organ of Corti, within the cochlear duct, that transduces sound vibrations into nerve impulses.

Hair cells of the vestibulocochlear system These non-neuronal mechanoreceptors are the common receptor cells in this system, that function to initiate nerve impulses.All hair cells are epithelial, possess numerous stereocilia (sensory hairs), are associated with both afferent and efferent nerve endings, and transduce mechanical energy into electrical energy. In the vestibular system, there are 2 types of hair cells: Type I hair cells, piriform in shape with a rounded base and thin neck, surrounded by an afferent nerve chalice and a few efferent fibres. Type II hair cells, cylindrical in shape, with afferent and efferent bouton nerve endings the synapse basally.

Both types of vestibular hair cell has one cilium called a kinocilium The hair cells of the inner ear function by the bending of their sensory hairs: Bending of stereocilia ---> stretch plasma membrane ---> changed transmembrane potential ---> conveyed to afferent nerves associated with cell. In the vestibular system, the location of the kinocilium relative to the bending stereocilia is important: Bending away from kinocilium --> hyperpolarisation of receptor cell Bending towards kinocilium ---> depolarisation --> action potential

CRISTAE AMPULLARIS Each crista is lined with the epithelium containing sensory hair cells and supporting epithelial cells.The stereocilia and kinocilium of each hair cell are embedded in a gelatinous cupula that projects into the lumen of the ampulla, and is surrounded by endolymph.During turning movements, the endolymph tends to lag behind because of its inertia, thus swaying the cupula and bending the sensory hairs that lie within, and generating nerve impulses. MACULA SACCULI AND MACULA UTRICULI Like the cristae ampullaris, the maculae are innervated sensory thickenings of the epithelium.The maculae are oriented at right angles to each other, so that when a person in standing, the macula utriculi is in a horizontal plane, and the macula sacculi is in avertical plane.The stereocilia and kinocilium of each hair cell are embedded in the gelatinous otolithic membrane, upon which crystalline particles called otoconia (otoliths) lie.Again, the stereocilia are bent by gravity in the stationary individual or linear movement in the moving individual as the otolithic membrane drags on the stereocilia due to inertia.

ORGAN of CORTI
The cochlear duct divides the cochlea into 3 scalae (compartments): The scala vestibuli, above The scala tympani below, and The scala media, which, itself, is the cochlear duct, filled with endolymph, with the organ of Corti on its lower wall. The scala vestibuli, starting at the oval window, and the scala tympani, ending at the round window, are filled with perilymph, and communicate with each other at the apex of the cochlea through the helicotrema. The scala media is a triangular space with its acute angle attached to the osseous spiral lamina that extends from the modiolus. The upper wall, separating the scala vestibuli, is the vestibular (Reissners) membrane. The lateral wall is the stria vascularis, lined by thick, vascular, pseudostratified epithelium that produces endolymph The lower wall, separating the scala tympani, is the basilar membrane.

The organ of Corti rests of the basilar membrane, and is overlain by the tectorial membrane. It is composed of: Inner hair cells in an single row, close to the spiral lamina; Outer hair cells in a row 3-5 cells wide, farther from the spiral lamina; Phalangeal (supporting) cells for both rows of hair cells, preventing them from touching the basilar membrane. Inner phalangeal cells surround their hair cells completely. Outer phalangeal cells only surround the basal part of their hair cells, but have apical processes that covers the apical surface of the hair cells, together forming a reticular lamina that separates the endolymph-filled endolymphatic space from the cortilymph-filled cortilymphatic space. Pillar cells are "flattened" cells that rest of the tympanic lip of the spiral lamina (inner pillar cells) and on the basilar membrane (outer pillar cells), thus forming the tunnel of Corti between the hair cell rows. The tectorial membrane, attached medially to the modiolus, projects over the organ of Corti, attached to the stereocilia of the hair cells.

The basic mechanism of transduction of sound vibrations is as follows:


Sound waves ---> tympanic membrane vibrates --> stapes moves at oval window ---> vibrations in perilymph of scala vestibuli, transmitted to scala media and scala tympani ---> vibration of basilar and tectorial membranes ---> shearing of hair cells ---> generation of membrane potentials ---> afferents of spiral ganglion.

External Ear : Pinna = - Collect sound waves and channel them to the ear canal - Help person to distinguish whether a sound is coming from in front or behind Ear canal (meatus acusticus externus) = - transmit the sound wave to membran tympani - guarded by fine hairs, modified sweat glands that produce cerumen (earwax). Both,prevent airbone particles from reaching the inner portion of the ear channel

Tympanic membrane - vibrate when it struck by sound waves.

- In resting air pressure on both side (outside and inside) tympanic membran must be equal. Transfers the vibratory movement of the tympanic membrane to the fluid of the inner ear. Transfering facilited by :

Malleus bone (attached to tympanic membrane) Incus Stapes (attached to oval window)

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Cochlea Hearing reseptor / mechanoreseptor (organ of corti). Apparatus vestibularis

COCHLEA Divided into 3 compartement : Upper compartement (skala vestibuli) Middle compartement (skala media) Lower compartement (skala timpani)

Pada skala vestibuli dan skala timpani mengandung cairan perilimfe Skala media mengandung cairan endolimfe. Ujung skala vestibuli dan skala timpani bertemu = Helicotrema Skala vestibuli yang berada dekat telinga bagian tengah dibatasi oleh oval window

Skala media : Membran vestibularis Duktus kokhlearis Membran tektorial tempat terbenamnya sel- sel rambut Membran basillaris tempat melekatnya organ corti (reseptor pendengaran)

Gelombang suara ditangkap/ dikumpulkan oleh pinna merambat melalui meatus acusticus externus menggetarkan membrana tympani tulang-tulang pendengaran

1.

2.

Stapes melekat pada oval window, menutupi skala vestibuli Bila stapes bergerak oval window bergerak terdorong ke arah depan mendorong perilimfe ke depan mengelilingi helikotrema skala timpani (kompartemen bawah) Ketika stapes bergerak mundur oval window tertarik ke arah telinga bagian tengah perilimfe bergerak ke arah yang berlawanan. Gelombang tekanan di kompartemen atas dipindahkan melalui membran vestibularis yang tipis ke dalam duktus kokhlearis melalui membran basillaris ke kompartemen bawah (menyebabkan oval window keluar-masuk)

Transmisi gelombang tekanan melalui m.basilaris menyebabkan membran ini bergerak ke atas dan ke bawah atau bergetar. Organ corti dan sel-sel rambut ikut bergerak naik turun sewaktu membran basillaris bergetar o.k rambutrambut sel reseptor terbenam di dalam membran tektorial sel rambut bergerak ke depan dan ke belakang.

3. Perubahan maju mundur ini menyebabkan saluran ion gerbang mekanis di sel-sel rambut terbuka dan tertutup secara bergantian. perubahan potensial depolarisasi dan hiperpolarisasi secara bergantian

Depolarisasi sel-sel rambut (sewaktu membran basillaris bergeser keatas) meningkatkan kecepatan pengeluaran zat perantara Menaikkan potensial aksi di serat-serat aferen. Pada saat hyperpolarisasi (sewaktu membran basilaris begerak ke bawah) sel-sel rambut mengeluarkan sedikit zat perantara kecepatan pembentukan potensial aksi

5. Sel-sel rambut bersinaps membentuk saraf auditorius (koklearis). Penutupan dan pembukaan saluran di sel reseptor perubahan potensial berjenjang direseptor perubahan kecepatan Pembentukan potensial aksi

Otitis

Media adalah peradangan sebagian atau seluruh mukosa telinga tengah, tuba eustachius, antrum mastoid, dan sel mastoid. Otitis media supurativa akut yaitu infeksi akut dalam < 3 minggu yang disebabkan inflamasi pada telinga tengah.

Jenis kelamin ( > ) Usia Ras Anomali kongenital Faktor lingkungan : Alergi Paparan asap rokok Paparan dengan anak lain Musim

Penyebab Otitis media akut bakterial : Streptococcus sp., dll Otitis media akut viral : Rhinovirus, Respiratory Syncytial Virus (RSV) Jangka waktu otitis media akut : < 3 minggu otitis media subakut : 3 11 minggu otitis media kronik : > 11 minggu Gejala otitis media akut supuratif otitis media akut efusi / serosa

1. Stadium oklusi tuba eustachius Ditandai adanya membrana timpani retraksi dan berwarna suram Gejala : tinnitus, gangguan pendengaran dan rasa penuh di telinga 2. Stadium hiperemis Membran timpani kemerahan karena terjadi pelebaran pembuluh darah. Gejala : Selain gejala stadium oklusi, mulai didapai rasa nyeri.

3. Stadium supurasi Membran timpani bulging. Pasien tampak sakit dan suhu meningkat 4. Stadium perforasi Didapati nanah pada liang telinga yang mengalir dari kavum timpani akibat rupturnya membran timpani. Anak yang sebelumnya gelisah menjadi lebih tenang. 5. Stadium resolusi Membran timpani mulai kembali normal.

Faktor anatomi dan immunologi dengan URI Bakteri : Streptococcus pneumonia, Haemophilus influenzae, Moraxella species. Virus: Rhinovirus dan respiratory syncytial virus (RSV)

ISPA

Saat bakteri melalui saluran eustachi dpt menyebabkan infeksi disaluran trsbt Terjadi proses inflamasi Pembengkakan(odem ) disekitar saluran eustachi Saluran tersumbat dan menyempit Fungsi tuba eustachi terganggu untuk ventilasi dan drainase

Menjalar kecavum timpani melaui tuba eustachi Menyebar ketelinga tengah Menginfeksi mukosa telinga tengah Terjadi proses inflamasi

Sel-sel imun infiltrat,sprt neutrofil,monosit,dan leukosit serta sel lokal seperti keratinosit dan sel mastosit.

Mediator inflamasi

Permeabilitas dinding sel

Permeabilitas pembuluh darah,limfe.

Terjadi akumulasi selsel radang ditelinga tengah

OMA

Milla

Infeksi atau peradangan

Neutrofil mengeluarkan pirogen endogen

Prostaglandin

Set point panas meningkat di hipotalamus

Peningkatan produksi panas, pengurangan pengeluaran panas

Peningkatan suhu tubuh ke set point baru

Inflamasi

Pelepasan IL-10 memicu P6

Peningkata n permeabilit as kapiler

Edema, iritasi saraf aurikula temporal, saraf timpani dan saraf aurikula

Impuls ke medula

Persepsi rasa nyeri

Infeksi memicu neutrofil dan fagositosis

Membentuk pus

Penumpukan mukopurulen

Telinga rasa penuh

Inflamasi

Penebelan mukosa tiub eustachio dan penyumbata n

Udara diserap ke pembuluh darah mukosa

Penurunan tekanan dalam telinga

Restriksi membran timpani

Kurang pendengara n

Bacterial culture This test detects and identifies bacteria from fluid or discharge found in the middle ear. It is used to help treat acute otitis media (inflammation of the middle ear) and chronic purulent otitis media. A sample of fluid or discharge from the middle ear may be collected by sterile swab, tympanocentesis or myringotomy.

Methods used to obtain a sample for culture vary and will depend on the healthcare worker. For perforated (burst) eardrums, fluid or pus may be collected from your ear canal. The sample may be obtained using a sterile cotton-tipped swab. The sample is placed in a sterile container, and sent to the laboratory for testing.

For intact eardrums, a tympanocentesis may be done. An ear speculum and a special magnifying tool called an operative otoscope are used to locate and inspect your eardrum. The healthcare worker will puncture your eardrum with a needle, and remove the fluid using a syringe. The fluid sample from the middle ear is collected using a sterile swab, and placed in a container to be tested.

If a myringotomy is done, an ear speculum and a special magnifying tool called an operative otoscope are used to locate and inspect your eardrum. The healthcare worker will make a small cut on your eardrum. The fluid sample from the middle ear is collected into a sterile suction trap or device. It is gathered using a sterile swab, and placed in a container for testing.

Bacterial culture The Quellung Reaction Stained Smears Complete Blood Count

Penyakit
Otitis media dengan effuse - Infeksi pada telinga tengah dengn efusi non purulen. - Etiologi: S pneumoniae 35% kasus, H influenza 20% kasus, Disrupsi pada opening of the eustachian tube orifice

Diagnosa
Gejala klinis: Effusi non-purulen (mucoid/serous), Tiada inflamasi ekstensif Otoscopic: Tiada pengurangan mobilitas membran timpani, kekuningan atau kemerahan (hipervaskuler), Efusi tidak purulen.

Otitis Eksterna Inflamasi atau infeksi pada telinga luar (meatus akustikus eksterna) Etiologi: Trauma telinga, infeksi bakteri, jamur

Gejala Klinis: Nyeri apabila struktur telinga luar disentuh Otoscopic: Meatus akustik eksterna terlihat eritema, edema dan menyempit. Gejala Klinis: Demam, nyeri ke telinga (refered pain), dysphagia

Faringitis akut Inflamasi atau iritasi pada faring atau/dan tonsil

RISHI

Centers for Disease Control and Prevention published 6 principles of appropriate antibiotic use in an attempt to bring precepts of good public health and responsible therapy and minimize resistant strains of bacteria
Classify episodes of OM as AOM or OME. Antimicrobials are indicated for treatment of AOM; however, diagnosis requires documented middle ear effusion and signs or symptoms of acute local or systemic illness. Uncomplicated AOM may be treated with a 5- to 7-day course of antimicrobials in certain patients older than 2 years. Antimicrobials are not indicated for the initial treatment of OME; treatment may be indicated if effusions persist for longer than 3 months. Persistent OME after therapy for AOM is expected and does not require re-treatment with antimicrobials. Reserve antimicrobial prophylaxis for controlling recurrent AOM, defined as 3 or more distinct, well-documented episodes in 6 months or 4 or more episodes in 12 months.

ANTIBIOTICS

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Amoxicillin (Amoxil, Trimox, Wymox) DOC for management of AOM. Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Dosing Adult 250-500 mg PO q8h Pediatric 90 mg/kg/d PO q8-12h for all initial therapy for AOM Amoxicillin/clavulanate (Augmentin) Combination drug that includes a blocking agent (clavulanic acid). Dosing Adult 250-500 mg amoxicillin with 62.5-125 mg clavulanate PO q8h Pediatric 90 mg/kg/d PO of Amoxicillin component for recurrent AOM

Erythromycin ethylsuccinate/sulfisoxazole (E.E.S. 400) Doses supplied in 200 mg/5 mL (erythromycin) and 600 mg/5 mL (sulfisoxazole). Widely used for individuals who are penicillin-sensitive. Well absorbed from GI tract but best administered on full stomach to avoid GI upset. Dosing Adult
Not used Pediatric 50 mg/kg/d of erythromycin component divided PO q8-12h

Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS) Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Dosing
Adult 160 mg TMP with 800 mg SMZ PO bid Pediatric 8 mg/kg TMP with 40 mg/kg SMZ PO divided q12h

Cefixime (Suprax) Dosing

By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth. Adult 400 mg PO qd or divided bid

Pediatric 8 mg/kg PO qd or divided bid

Cefuroxime Axetil (Ceftin) Second-generation cephalosporin that maintains gram-positive activity of first-generation cephalosporins; adds activity against

Proteus mirabilis, H influenzae, E coli, Klebsiella pneumoniae, and M catarrhalis.

Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration. Dosing
Adult 250-500 mg PO q12h Pediatric 15-30mg/kg/po

Cefprozil (Cefzil) Binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity. Dosing
Adult 250-500 mg PO q12h Pediatric 15-30 mg/kg/d PO divided q12h

Cefpodoxime (Vantin) Indicated for management of infections caused by susceptible mixed aerobic-anaerobic microorganisms. Dosing
Adult 100-200 mg PO q12h Pediatric 10 mg/kg/d PO divided q12h

Cefdinir (Omnicef) Third-generation cephalosporin indicated for treatment of uncomplicated skin infections. Dosing Adult 600 mg PO qd or divided bid Pediatric 14 mg/kg PO qd or divided bid Clindamycin (Cleocin HCl) Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Dosing Adult 600-1800 mg/d PO divided q6-8h Pediatric 10-25 mg/kg/d PO divided q6-8h

Clarithromycin (Biaxin) Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Dosing Adult 250-500 mg PO q12h Pediatric 15 mg/kg/d PO divided q12h Azithromycin (Zithromax) Broad-spectrum macrolide antibiotic. Absorption markedly reduced when taken with food. Dosing Adult 500 mg on day 1; then 250 mg/d on days 2-5 Pediatric 10 mg/kg on day 1; then 5 mg/kg on days 2-5

Ceftriaxone (Rocephin) Third-generation cephalosporin. Manufacturer has heavily promoted IM use of this drug to physicians and directly to the public for routine treatment of AOM. Subsequently, MDRSP resistance has emerged, making this less effective in many communities. Author believes this drug is best reserved for IV use for management of severe infections. Avoid widespread use for AOM. Dosing Adult 1-2 g/d IM for 3 d Pediatric 50 mg/kg/d IM for 3 d

Diagnostic procedure gives access to acute or chronic middle ear effusions for culture and other evaluations
Performed without anesthesia, after sterilization of ear canal with isopropyl alcohol or povidone-iodine solution. Insert needle through anterior portion of the tympanic membrane, and aspirate the contents of the middle ear into a sterile trap for identification of microbes and their properties.

Considered in:

1. Immunosuppressed or immunocompromised children 2. Neonates 3. Patients in whom antimicrobial therapy has failed and who continue to experience local or systemic signs of sepsis 4. Patients who have had a complication of AOM

Valuable research tool in the evaluation of new antimicrobial agents for efficacy in AOM and for identification of host defense mechanisms or flaws in the middle ear immunochemistry

A tympanocentesis may be converted to a myringotomy and become therapeutic by enlarging the hole in the tympanic membrane, often by spreading the edges with microalligator forceps or suction tip. Instilling antibiotic drops and suctioning the middle ear are possible Patient experiences prompt relief of local symptoms

Culture results must be obtained before extension of the incision The use of a carbon dioxide laser in myringotomy has been promoted widely and directly, but emerging studies demonstrate little or no change in efficacy over standard myringotomy.

If the patient has a suppurative complication of the temporal bone and requisite prolonged drainage seems likely General anesthesia or sedation is necessary in older children because topical anesthesia is relatively ineffective in acutely inflamed tympanic membranes Can be expected to increase in the coming years with increasing antimicrobial resistance

Sebelum ada antibiotika, OMA dapat menimbulkan komplikasi, yaitu abses subperiosteal sampai komplikasi yang berat (meningitis dan abses otak). Sekarang setelah ada antibiotika, semua jenis komplikasi itu biasanya didapatkan sebagai komplikasi dari OMSK.

Prognosis pada pasien OMA adalah baik Sembuh bila terapi adekuat (antibiotika tepat dan dosis cukup).

Indikasi Rujuk

Anak dgn OMA yg sering. Definisi sering adalah lebih dari 4 kali dlm sebulan. 4 sumber lain mengatakan sering adalah lebih dari 3 kali dlm 6 bulan atau lebih dari 4 kali dalam 1 tahun.

Anak dgn efusi selama 3 bulan atau lebih, keluarnya cairan dari telinga, atau berlubangnya gendang telinga. Anak dgn kemungkinan komplikasi serius seperti kelumpuhan saraf wajah/mastoiditis (mastoiditis: peradangan bagian tulang tengkorak , kurang lebih terletak pd tonjolan tulang di belakang telinga). Anak dgn kelainan kraniofasial (kraniofasial: kepala dan wajah), sindrom down, sumbing, atau dgn keterlambatan bicara. OMA dgn gejala sedang-berat yg tdk memberi respon terhadap 2 antibiotika.

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