ACUTE OTITIS MEDIA

(HYPEREMIC STAGE)

CASE
REFLECTION
&
TUTORIAL
AMRI ADHYATMA
12/335422/KU/15233
Introduction
Defined as rapid onset of signs and
symptoms of inflammation in the middle ear.
Acute otitis media (AOM) is the commonest
paediatric bacterial infection, affecting up to
75% of children at some time before age 5
years.
Bacteria commonly implicated are
Streptococcus pneumoniae, Haemophilus
influenzae, Moraxella catarrhalis,
Staphylococcus aureus, and Streptococcus
pyogenes.
Anatomy
Eustachian Tube
Physiology
Increased/decreased
Excessive production
Tympanic pressure
of middle ear secretions

Opening of
Closing of
eustachian tube

Increase/decrease
external auditory
pressure

Drained into nasopharynx

Internal auditory
pressure balancing
Nasopharyngeal secretions
/ sound pressures
Otitis Media
Inflammation occurred on some or whole part of middle
ear: mucous, eustachian tube, mastoid anthrum, and
mastoid cells.
Otitis Media

Suppurated Non suppurated

Chronic effusion otitis

Acute otitis media Acute barotrauma
media

Chronic suppurated
otitis media
Etiology
Streptococcus pneumoniae
Haemophilus influenzae,
Moraxella catarrhalis,
Staphylococcus aureus
Streptococcus pyogenes
Pathogenesis
Obstruction of the eustachian: the most important
antecedent event associated with AOM.
Normal Eustachian tube Hyperemic Suppuration stage
occlusion stage (pre-suppuration)
stage

Perforation stage Resolution stage

Sources: Color Atlas of Otoscopy; pedclerk.bsd.uchicago.edu
 Differential Diagnosis
AOE Mimic the appearance of AOM because of
erythema involving the tympanic
membrane.
Distinguishing AOE-AOM: the latter may require
systemic antimicrobials.
Pneumatic otoscopy: good tympanic membrane
mobility with AOE but will show absent or limited
mobility with AOM and associated middle-ear
effusion.
Tympanometry: normal peaked curve (type A) with
AOE but a flat tracing (type B) with AOM.
 Treatment
Analgesics
Ibuprofen and acetaminophen:effective.
Ibuprofen is preferred: longer duration of action and
its lower toxicity in the event of overdose.

Antibiotics
High-dose amoxicillin should be the initial treatment in
the absence of a known allergy. The advantages of
amoxicillin include low cost, acceptable taste, safety,
effectiveness, and a narrow microbiologic spectrum
Oral cephalosporins, such as cefuroxime (Ceftin), may
be used in children who are allergic to penicillin
1st line and alternative AOM
antibiotic
CASE REPORT
IDENTITY

Date of visit August 30th, 2016

Name AAR

Date of birth April 26th, 2004

Sex Male

Pangen, Jurutengah I/9,

Address Purworejo
ANAMNESIS

Chief Complaint

Right ear throbbing pain

History of Present Illness

The chief complaint began a day before

hospital visit, followed by hearing loss.
A week before the patient had cough and
rhinorrhrea with yellowish purulent nasal
discharge.
There were no complain of itch, discharge,
ear fullness, tinnitus, vertigo and fever.
There was no family member having the
same complaint.
ANAMNESIS

Past Illness History

Allergic history (-)

Asthma history (-)

Family Illness History

Similar disease history (-)

Allergic history (-)
PHYSICAL EXAMINATION

General Status
Compos mentis

Vital Sign
HR: 88 x/menit
RR : 20 x/menit
T : 36,5C
BW: 40kg
PHYSICAL EXAMINATION

Right ear Left ear

Auricle Normal shape & size Normal shape & size
(normotia), mass (-), (normotia), mass (-),
hyperemic (-) hyperemic (-)
Auricular pain (-) (-)
Tragus pain (-) (-)
External auditory canal Mass (-), hyperemic (-), Mass (-), hyperemic (-),
edema (-), discharge (- edema (-), discharge (-
) )
Tympanic membrane Intac, cone of light (+), Intac, cone of light (+)
hyperemic (+)
Mastoid Normal, pain (-) Normal, pain (-)
Lymph nodes No enlargement No enlargement
PHYSICAL EXAMINATION

Right ear otoscope Left ear otoscope

examination examination
revealed hyperemic revealed intact and
and intact tympanic translucent tympanic
membrane membrane.
 Dextra Sinistra
PHYSICAL EXAMINATION

THROAT EXAMINATION

Components D S

Lip Hyperemic (-), stomatitis (-)

Teeth-gum Caries (-), edema (-), hyperemic (-)
Palate Pink, shiny mucosal , mass (-), wound (-), white spots (-),
symmetric
Uvula One peak, central, deviation (-)
Palatine hyperemic (-), T1, criptae hyperemic (-), T1, criptae
tonsil widening (-) widening (-)
Lingua l tonsil unseen unseen

Posterior Wall granulae (-), post-nasal drip (-)

of pharynx
PHYSICAL EXAMINATION

NOSE EXAMINATION

Components D S
Discharge Fluid (-), Fluid (-),
blood (-), blood (-),
Dextra Sinistra
pus (-) pus (-)
Nasal Edema (-) Edema (-)
concha
Septum Deviation (-), Deviation (-),
laceration (-) laceration (-)
Tumor - -

Paranasal Pain (-) Pain (-)

sinuses
 DIAGNOSIS

Acute otitis media hyperemic stage of the

right ear

DIFFERENTIAL DIAGNOSIS

Diffuse Otitis Externa

MANAGEMENT

Pharmacotherapy
Amoxicillin/clavulanic acid 625mg, 3 dd tab 1
(Pseudoefedrin HCl 60 mg + Tripolidin HCl 2,5 mg), 3 dd tab 1/2
Parasetamol 500 mg, p.r.n

Education
keep balance nutrition
not to exhaust snot strongly if having influenza

Plan
Follow up for the next seven days.
DISCUSSION
 Environment
Host

Age
Season
Race Infection
Gender RISK Siblings
Prematurity FACTOR Day care
Allergy Passive smoker
Immunocompetence Breast feeding
Craniofacial Socio economic
abnormalities
Pacifier use
Genetic
Obesity

Patients case:
Race, gender, infection
 Tubal occlusion
PHYSICAL
Cone of light (-)
EXAM
Tympanic membrane retraction
Hyperemic
Edema (+)
Hyperemic (+)
Suppurative
Membrane bulging out
Yellow color

Perforation
Rupture of membrane
Pus drain out

Resolution
Intact tympanic membrane
Dried discharge
MEDICATIO
N

Recommended, adjusted Amoxicillin/clavulanic

Antibiotics to patient condition
High dose amoxycilin acid 625mg, 3 dd tab 1

Reducing symptoms and

increase QoL Parasetamol 500 mg,
Analgetics
Choices: acetaminophen
and ibuprofen p.r.n

Decongestant Helps with nasal allergies Pseudoefedrin HCl 60

& May prolong middle ear mg + Tripolidin HCl 2,5
Antihistamines effusion
mg, 3 dd tab 1/2
SUMMARY
A 12 years old boy was reported having right
earache and hearing loss with history of cough
and rhinorrhrea with yellowish purulent nasal
discharge.
Physical examination revealed hyperemic
tympanic membrane. AOM clinically diagnosed
by anamnesis and physical examination.
Medication of AOM were antibiotics,
decongestans+antihistamins, and analgetic-
antipyretic.
Treatment of choice was made based on clinical
consideration.
THANK YOU