Introduction

Chronic Suppurative Otitis Media (CSOM)

 Persistent or intermittent infected of midlle ear
 Discharge through perforation tympanic membrane
 otorrhea : muco-purulent, thick viscosity, foul smelling
 Introduction
CSOM responsible for most hearing impairment in
children, especially in developing countries
CSOM usually begins in childhood as a spontaneous
tympanic membrane perforation due to an acute
infection of the middle earially in developing countries
 Introduction
 The incidence of mastoiditis was approximately 4
cases per 100,000 children per year over 5 years
 In Canada and the United States, the incidence was 2
cases of mastoiditis per 100,000 children per year
 Rates of antibiotic treatment for otitis in the
Netherlands, Norway, and Denmark were 31%, 67%,
and 76%
Literature Review

ANATOMY OF EAR
MIDDLE EAR
TYMPANIC MEMBRANE
8
KAVUM TIMPANI
OSSICULAR
 VASCULARISATION
 The blood supply of the middle ear and mastoid
originate from the internal and external carotid
arteries
 Vessels off the external carotid artery include the
anterior tympanic artery and the deep auricular artery
(branches of the internal maxillary artery)
 The superior petrosal and superior tympanic arteries
(branches of the middle meningeal artery)
 The stylomastoid artery (branch of the occipital artery
that runs up the stylomastoid foramen)
 INNERVATION

 Cranial nerve IX (the glossopharyngeal nerve) has a

branch that runs across the tympanic promontory called
the tympanic nerve or Jacobson's nerve
 It innervates the mucosa of the middle ear space and
Eustachian tube as well as provides parasympathetic
innervation to the parotid gland
 There is also a branch of the vagus nerve within the
middle ear cavity called Arnold's nerve, which supplies
innervation to the external auditory canal
 EUSTACHIAN TUBE
Pharyngotympanic (auditory) tube, connecting the
tympanic cavity to the nasopharynx, allow the passage
of the air between these spaces to equalize the air
pressure on the both aspects of the tympanic
membrane
 The osseous eustachian tube (protympanum) lies
completely within the petrous portion of the temporal
bone and is directly continuous with the anterior wall of
the superior portion of the middle ear
 The healthy osseous portion is open at all times, in
contrast to the fibrocartilaginous portion, which is closed
at rest and opens during swallowing or when forced open,
such as during the Valsalva maneuver
 EUSTACHIAN TUBE
Four muscles are associated with the eustachian tube:
1. tensor veli palatini
2. levator veli palatini
3. Salpingopharyngeus
4. tensor tympani

At rest, the eustachian tube is closed. It opens during

such actions as swallowing, yawning, and sneezing
 EUSTACHIAN TUBE
The eustachian tube has at least three physiologic
functions with respect to the middle ear :
1. Pressure regulation (ventilation) of the middle
ear to equilibrate gas pressure in the middle
ear with atmospheric pressure
2. Protection from nasopharyngeal sound
pressure and secretions
3. Clearance of secretions produced within the
middle ear into the nasopharynx
EUSTACHIAN
TUBE
Chronic Suppurative Otitis Media
 Chronic inflammation of the middle ear and mastoid
cavity, which present with recurrent ear discharge or
otorrhea through a tympanic perforation.
 Patients with tympanic perforations which continue to
discharge mucoid material for periods of 6 weeks to 3
months, despite medical treatment are recognized as
CSOM cases.
 Chronic Suppurative Otitis Media
Divided into two type:
1. Benign which has several other synonyms
such as tubotympanic, safe and sometimes
it is called mucosal type
The inflammatory process is limited in the
mucosal part of the middle ear without
affecting the ossicular part
The perforation is located centrally at pars
tensa
Cholesteatome is not present
2. Malignant which also known as
atticoantral, dangerous or bone type
This type is usually present with
cholesteatome and marginal or attic
perforation of tympanic membrane
This type is dangerous compared to benign
type as it caused complications to another
tissue
 Pathogenesis
Two main mechanisms which chronic perforation can
lead to continuous or repeated middle ear infections :
1. Contaminate bacteria from perforation membrane
2. Dysfunction of Eustachian tube
 Symptoms
 Mucopurulent discharge from the ear with or without
blood
 History of intense otalgia and sensation of fullness in
the ear with sudden relief
 Hearing loss
 Tinnitus
 Physical Examination
 The CAE shows maceration and littered with
granulation tissue, discharge mucopurulent, with or
without blood
 Otoscopy can be found perforation of the tympanic
membrane with cholesteatome or not
 Supportive examination
 Culture and sensitivity of discharge
 Radiologic imaging is to evaluate bony anatomy and
intracranial extension
 Audiologic test is to evaluate the function of hearing
 Management
 Aural Toilet
 Topical Antibiotics
 Systemic Antibiotics
 Symptomatic therapy
 Surgical Measures
Complications

Thieme, 2006
CASE REPORT
 Anamnesa
Name : Mrs. S
Sex : Female
Age : 44 years old
Address : Klaten, Jawa Tengah
MR : 1.56.33.79
 Anamnesa
Chief complaint : Discharge flew out from left ear
Present illness history :
Since 5 months before came to Sardjito hospital,
patient felt discharge flew out from her left ear.
The discharge yellowish, thick viscosity, foul
smelling. 14 days ago she felt pain behind her left
ear and there was discharge flew out. She also felt
pain, deafness, headache and tinnitus. There is no
complaint for vertigo. No complaint for nose and
throat.
Past illness history
 History of the discharge from left and right ear (+),
since 10 years ago. The complaint is recurrent,
especially if she felt cough and runny nose.
 History of allergy : denial
Family illness history
 History of the same disease (-)
 History of DM : denial
 Physical examination
General status : compos mentis, good nutritional status

Vital sign
 Blood pressure : 130/70 mmHg
 Pulse : 96 x/minute
 RR : 20 x /minute
 Temp. : 37 oC
 ENT Examination
Ear:
 Right ear : CAE with normal limit
 Otoscopy : Subtotal perforation on right tympanic
membrane
 Left ear : discharge muco-purulent, thick viscosity, foul
smelling, retroauricular fistula, touch-pain in mastoid
region
 Otoscopy : Prolapsus of canal Posterior wall and
granuloma
 ENT Examination
 Throat: With normal limit
 Nose: With normal limit
 Face : With normal limit
 Neck : With normal limit
Picture
 Supporting Examination
Examination Right Ear Left Ear

Tes Rinne AC > BC AC > BC

Tes Webber Lateralisation to the right

Tes Swabach same shortened

Conclusion: Left Ear SNHL

 Audiometri test

Left Ear Profound SNHL

Right ear Profound SNHL
 Ro Mastoid D/S
Mastoiditis Sinistra dan dextra
Culture and sensitivity Test
 Diagnosis
AS Chronic Suppurative Otitis Media with
retroauricular fistula
 Management
 Hospitalized
 Radical-mastoidectomy
 Follow Up
Tanggal Keluhan Terapi
D+1 Post Radical matoidectomy Inf. RL 20 tpm
Inj.Ceftriaxone 2x1 gr
Inj.Ketorolac 2x1 amp
D+2 Pain post op : + Inf. RL 20 tpm
Bleeding : - Inj.Ceftriaxone 2x1 gr
Fever : - Inj.Ketorolac 2x1 amp
Parese Sign n.VII : -
Vital sign : WNL

D+3 Pain post op : + Inf. RL 20 tpm

Bleeding : - Inj.Ceftriaxone 2x1 gr
Fever : - Inj.Ketorolac 2x1 amp
Parese Sign n.VII : -
 Follow Up
Tanggal Keluhan Terapi

D+4 Post Radical matoidectomy Inf. RL 20 tpm

Inj.Ceftriaxone 2x1 gr
Inj.Ketorolac 2x1 amp

D+5 Pain post op : + Patient may go home :

Bleeding : - Ampicilin-sulbactam
Fever : - 2x375 mg

Parese Sign n.VII : - Kalium diclofenac 2x50

Vital sign : WNL mg (if pain)
Problem
 Etiology
 Prognosis

Planning
 Education to the patient
 Evaluation when patient control 5 days later
 Discussion
 CSOM → chronic inflammation of the middle ear and
mastorid cavity, which present with recurrent ear
discharge or otorrhea through a tympanic perforation
 Patients with tympanic perforations which continue to
discharge mucoid material for periods of 6 weeks to 3
months
The patient had felt discharge from left ear, yellowish,
thick viscosity, foul smelling since 5 months ago. Her
complaint was recurrent since 10 years ago, especially
if she was cough and runny nose. From physical
examination, there are found discharge mucopurulent,
thick viscosity, foul smelling and retroauricular fistula.
There were found prolaps of CAE posterior wall and
granuloma from middle left ear.
The patient was diagnoses as CSOM dangerous type with
retroauricular fistula.
The complication of CSOM can be intratemporal or
intracranial. Intratemporal complication of CSOM is
mastoiditis, petrositis, facial nerve paralysis, and
suppurative labyrinthitis.
 In this case, the patient felt the pain and discharge
flew out from behind the left ear since 14 days ago.
 From the examination, we found retroauricular fistula,
touch-pain in mastoid region. Ro-mastoid showed as
mastoiditis sinistra.
 The patient was planned to radical mastoidectomy.
 From culture and sensitivitas test, we found
streptococcus viridians. This become problem because
usually the primary pathogen that responsible for
CSOM is Pseudomonas Aeruginosa, Staphilococcus
Aerius, and Proteus Sp. But in this patien’s culture test,
we found Streptococcus viridans. Based on sensitivitas
test, ceftriaxone and ampicillin-sulbactam still
sensitive for this case.
 The other problem in this case was prognosis.
 In this case, intratemporal complication of CSOM was
occurred.
 We had to education the patient to prevent the
recurrence of this disease, give the explanations the
other complication of CSOM, which the goal is to
prevent the other complications.
 Deafness was also one of the patient’s complaint. she
hoped her hearing can become normal again. But we
have educated to this patient that this operation’s
purpose was to eliminated all foci of infection in the
temporal bone and the middle ear cavity. This
operation didn’t repaired hearing function. Patient
had agreed and understood the purpose of this
operation. After 6 days hospitalized, patient may go
home and we educate that she must control 5 days
later.
 Conclusion
 Have been reported, patient, female, 44 years old,
based on anamnesis, physical examination, supporting
examination was be diagnosed AS Chronic
Suppurative Otitis Media dangerous type with
retroauricular fistula. She was be planned for radical
mastoidectomy.
 After 6 days in Hospital, pastient may go home.
 We give Ampicillin-sulbactam 2x375 mg and kalium
diklofenak 2x50 mg if patient still felt pain
 THANK YOU

Suggestions please
 Flora Normal Telinga
Flora liang telinga luar biasanya merupakan gambaran
flora kulit. Dapat dijumpai Streptococcus pneumonia,
batang gram negatif termasuk Pseudomonas
aeruginosa, Staphylococcus aureus dan kadang-
kadang Mycobacterias saprofit. Telinga bagian tengah
dan dalam biasanya steril.

Budiyanto MAK. Mikrobiologi Umum, 2005

Sipila melakukan penyelidikan kuman pada telinga
normal. Dia telah melakukan pemeriksaan bakteriologi
pada 20 telinga yang tidak meradang
Ternyata 45% telinga tengah dan 70% liang telinga
mengandung kuman, walaupun jumlah koloninya kecil
Jumlah koloni pada telinga tengah umumnya lebih sedikit
dibanding liang telinga
Bakteri pada telinga tengah yang tersaring adalah
Stafilokokus epidermidis dan stafilokokus aureus
Sedangkan pada liang telinga adalah Stafilokokus
epidermidis, stafilokokus aureus dan difteroid basil
 Most commonly
Organism found in otitis media
Acute otitis media: The three most common organisms found in acute
otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and
Moraxella (Branhamella) catarrhalis. Gram-negative enteric bacilli are
isolated in 20% of infants with middle ear effusions. Viruses can be
isolated in approximately 4% of middle ear effusions, with respiratory
syncytial virus and influenza virus being the most common.
Chronic otitis media: Organisms isolated in chronic otitis media vary
considerably. The predominant organisms are gram-negative bacilli, such
as Pseudomonas aeruginosa, Proteus sp., and Escherichia coli, as well
as anaerobes such as Bacteroides fragilis. These organisms, along with
Staphylococcus, are also more common in nosocomial (hospital-
acquired) infections.
 INFEKSI SALURAN PERNAFASAN ATAS
(ISPA)
GANGGUAN TUBA

OTITIS MEDIA AKUTA (OMA)

SEMBUH SEMPURNA OTITIS MEDIA EFUSI

(OME)

OTITIS MEDIA SUPURATIVA KRONIKA (OMSK)

OMSK OMSK
Tipe Benigna Tipe Maligna
57
PATOFISIOLOGI OMC (Thieme,2006)
OMSK Benigna

60
OMSK Maligna
 Aural Toilet
Aural toilet is important for the successful treatment of
CSOM, particularly when topical medication is used.
Clearing the discharge from the external auditory
canal allows the topical agent to reach the middle ear
in an adequate concentration.
 Topikal Antibiotics
Although topical antibiotics are more effective than systemic
antibiotics in the treatment of CSOM, many contain
aminoglycosides, which are potentially ototoxic.
Ototoxicity has been demonstrated in animal models, and
the use of gentamicin for vestibular ablation in Meniere
disease is well documented.

The recent availability of topical ofloxacin preparations may

prove to be as effective as topical aminoglycosides without
the ototoxic potential.
 Systemic Antibiotics
Systemic antibiotics tend to have a poor penetration of the
middle ear and are therefore less effective than topical
antibiotics.
Because P aeruginosa is the primary pathogen responsible for
CSOM, the choice of oral systemic antibiotics is limited.
Both ciprofloxacin and ofloxacin have good antipseudomonal
activity.
Unfortunately, these quinolone antibiotics are not
recommended in children owing to the possibility of
causing arthropathies.
This circumstance limits the choice of systemic antibiotics in
children to broad-spectrum penicillins, such as piperacillin
and cephalosporins.
 Ceftriaxone
Ceftriaxone is a semisynthetic, third generation cephalosporin
antibiotic.

Ceftriaxone has a wide spectrum of activity and is effective for

the treatment of infections caused by a variety of gram-
positive and gram-negative bacteria. Ceftriaxone is considered
a drug of choice for many infections caused by gram-negative
bacteria, and a principal use of the drug is for the treatment of
serious gram-negative bacterial infections, especially
nosocomial infections, when other anti-infectives are
ineffective or contraindicated.

(www.emedicine-medscape.com)
 Ceftriaxone
Ceftriaxone sodium usually is administered by IV infusion or
deep IM injection.

The usual adult dosage of ceftriaxone for the treatment of most

infections caused by susceptible organisms (except meningitis)
is 1–2 g given once daily or in equally divided doses twice
daily, depending on the type and severity of the infection.

The usual dosage of ceftriaxone for neonates and children 12

years of age or younger is 50–75 mg/kg daily given in a single
daily dose or in equally divided doses every 12 hours.

(www.emedicine-medscape.com)
 Ketorolac
Ketorolac is a prototypical nonsteroidal anti-inflammatory
agent (NSAIA) that also exhibits analgesic and antipyretic
activity.
Ketorolac tromethamine is used for the short-term (i.e., up to 5
days) management of moderately severe, acute pain

The manufacturer recommends that multiple-dose parenteral

ketorolac tromethamine therapy be both initiated and
continued with IM or IV dosages of 30 mg every 6 hours in
adults; the maximum daily dose should not exceed 120 mg.
The manufacturer recommends that only single doses of
parenteral ketorolac be used in pediatric patients.
(www.emedicine-medscape.com)
 Surgical Measures
Some cases of CSOM resolve with medical treatment,
and if the patient is asymptomatic, then no further
intervention is required.
However, if otorrhea recurs or persists despite medical
treatment or if the patient feels handicapped by a
residual conductive hearing loss, surgical therapy
should be considered.
 Terapi Pembedahan OMSK
 Tujuan utama : menghilangkan penyakit
 Tujuan mastoidektomi :
- menghilangkan jaringan infeksi
- menciptakan telinga yang kering dan aman

70
 Terapi Bedah
1. Mastoidektomi sederhana (simple mastoidektomi)
2. Mastoidektomi radikal
3. Mastoidektomi radikal dengan modifikasi
4. Miringoplasti
5. Tympanoplasti
6. Pendekatan ganda tympanoplasti
PENATALAKSANAAN OMSK (Modul, 2002)
OTOREA KRONIS

OTOSKOPI

MT UTUH MT PERFORASI

OMSK
OTITIS EKSTERNA DIFUSA
OTOMIKOSIS
DERMATITIS/EKSIM ONSET, PROGRESIVITAS, PREDISPOSISI
OTITIS EKSTERNA MALIGNA PENYAKIT SISTEMIK,
MIRINGITIS GRANULOMATOSA FOKUS INFEKSI,
RIWAYAT PENGOBATAN
GEJALA/TANDA KOMPLIKASI

KOMPLIKASI (-) KOMPLIKASI (+)

KOLESTEATOM (-) KOLESTEATOM (+)

OMSK non kolesteatoma OMSK kolesteatoma

ALGORITMA 1 ALGORITMA 2
ALGORITMA 1
OMSK NON OMSK BAHAYA
KOLESTEATOM KOLESTEATOM

OMSK TENANG OMSK AKTIF

STIMULASI Cuci telinga

EPITELIALISASI Antibiotik sistemik
TIPE PERFORASI Lini 1 : Amoksisilin/sesuai
kuman penyebab
Antibiotik topikal
PERFORASI
PERFORASI
MENUTUP OTOREA MENETAP >1 MGG
MENETAP
Tuli Konduksi?
ANTIBIOTIK BERDASAR
TIDAK RO MASTOID PX. MIKRO-ORGANISME
(sembuh) (SCHULLER) X-RAY
AUDIOGRAM OTOREA MENETAP >3 BLN

TULI IDEAL: MASTOIDEKTOMI +

KONDUKTIF (+) TIMPANOPLASTI

IDEAL:
TIMPANOPLASTI TANPA/
DENGAN MASTOIDEKTOMI
PILIHAN
ATIKOTOMI ANTERIOR
TIMPANOPLASTI DINDING UTUH
TIMPANOPLASTI DINDING RUNTUH
ATIKOANTEROPLASTI
TIMPANOPLASTI BUKA TUTUP
ALGORITMA 2

OMSK + KOMPLIKASI

KOMPLIKASI KOMPLIKASI
INTRA TEMPORAL INTRA KRANIAL

ABSES SUBPERIOSTEAL ABSES EKSTRA DURA

LABIRINTISTIS ABSES PERISINUS
PARESIS FASIAL TROMBOFLEBITIS SINUS LATERAL
PETROSITIS MENINGITIS
ABSES OTAK
MENINGITIS OTIKUS

ANTIBIOTIK DOSIS TINGGI RAWAT INAP

MASTOIDEKTOMI PERIKSA SEKRET TELINGA
DEKOMPRESI N. VII ANTIBIOTIK I.V. DOSIS TINGGI 7-15 HARI
PTROSEKTOMI KONSUL SPESIALIS SARAF/SARAF ANAK
MASTOIDEKTOMI ANASTESI LOKAL/UMUM
OPERASI BEDAH SARAF
 Otitis Media
Supurativa Akut
(OMSA)

• Otitis Media Serosa/ Mukous

Otitis Otitis Media Non
Supurativa • Otitis Media Kataralis
Media (OMNS)

• OMSK Benigna (OMSKB)

Otitis Media
Supurativa
Kronik (OMSK)
• OMSK Maligna (OMSKM)
 • Bakteri
• Streptokokus
OMSA • Pneumokokus
• Baksilus Haemofilus Influenzae

• Bakteri OMSA (+)

• Pseudomonas Aerogimona (-)
OMSKB • Proteus (-)
Etiologi • Coli (-)

OMSKM • Kolesteatoma

• Virus
• Alergi
OMNS • Palatoskisis
• Oklusi Tuba Eustachii
• OMSA terapi tidak sempurna
 Frekuensi Banyak pada anak - anak

• ISPA
Predisposisi • Umur
• Sosial ekonomi
• Cuaca

OMA • RAS

Patologi ISPA Obstruksi Tuba

• Gangg. Ventilasi
• Drainase
• Invasi kuman (strept.,
Haemofilus influensa,
penumokokus) dari hidung
ke nasofarings ke telinga tengah

Supurative

Bulging m. tymp.
 Gejala • Otalgi, pendengaran berkurang
• Panas tinggi – kejang-kejang- muntah

• Otoskopi :
Tanda
m. tymp. Hiperaemis, udem,
melembung ke luar
OMA
Diagnosis • Otoskopi, gejala

• Parasentesis
• antibiotik
Terapi
• analgetik

Prognosis Baik
 Batasan :
• Radang Kronik Mukosa Telinga Tengah
• lebih dari 4 – 6 Minggu
• Histopatologis : Timpanomastoiditis Sup. Kronis

Etiopatogenesis :
OMSK
• Lanjutan OMSK akibat terapi yg tidaktuntas
Benigna
Otitis Media (Jinak) • Kuman Resisten (Gram negatif)
Supuratif • Perforasi m. timpani – reinfeksi
Kronik • Sumber infeksi di sal. nafas atas
(OMSK)
Patologi :
• Mukosa Telinga Tengah hipertrofi/Hiperplasia
• Tuli Sensorineural

Gejala
• Otore mukopurulen, tak berbau, kadang
OMSK disertai darah
Maligna • Tidak ada otalgia
(Ganas) • Kurang pendengaran, Tinnitus
(Tuli konduksi)
 Tanda :
• Cairan mukopurulen di Telinga Tengah, Darah
• Perforasi membrana timpani (sentral – total)

Lab & Rad.

• Kuman gram negatif & anaerob
OMSK • Ro. Foto : Mastoid Sklerotik
Benigna
(Jinak) Diagnosis : OMSK Benigna

Terapi :
• Toilet (Pembersih cairan) dgn perhidrol 3%
• Tetes telinga (Antibiotik)
Otitis
• Tidak boleh kemasukan air
Media
• Bila telah kering : Rekontruksi
Supuratif OMSK
pendengaran (Timpanoplastik)
Kronik Maligna
(OMSK) (Ganas) Komplikasi
• Mastoiditis Kronik
• Abses subperiosteal
Kolesteatoma
Terapi : Mastoidektomi
 • kolesteatosis
Sinonim • epidermosis
• keratosis
• non maligna destruktif
• kista epidermoid keratin

• Kongenital (jaringan embrional epitelium)

Kolesteatoma • akuisital
Metaplasi epitel
Jenis Invasif epitel
 Perluasan langsung epitel
meatus via perforasi marginal
m.timpani
 Retraksi m.timpani pars flaksida
 Keratosis epitel meatus postor /
supor dan epitel m.timpani yg
berdekatan. Stratum
germinativum migrasi ke sub
mukosa epitel m.timpani pars
flaksida
 Human papilloma virus (HPV)
 Gejala :
• otore berbau
• kurang pendengaran

Tanda :
• m. timpani perforasi :
Pars flasida (altik)
Marginal superir-posterior
Kolesteatoma • Cairan mukopurulen, bau
• Deskuamasi epitel kompleks skuamous (dempul)

Terapi : Mastoidektomi • fistel kanalis

semisirkularis
horisontal
• parese nervus
Ekstrakranial fasialis
• abses mastoid
• petrositis
Komplikasi

• Meningitis
Intrakranial • Abses otak
 Komplikasi OMSK
A. Komplikasi di telinga tengah
1. Perforasi membran tympani persisten
2. Erosi tulang pendengaran
3. Paralisis N. Fasialis
B. Komplikasi di telinga dalam
1. Fistula labirin
2. Labirinitis supuratif
3. Tuli saraf (sensorineural)
C. Komplikasi di ekstradural
1. Abses ekstradural
2. Trombosis sinus lateralis
3. Petrositis
D. Komplikasi di SSP
1. Meningitis
2. Abses otak
3. Hidrosephalus otitis
KOMPLIKASI
(Thieme, 2006)
KOMPLIKASI
(Dhillon,1999)
KOMPLIKASI INTRAKRANIAL (Dhillon,1999)
 OMSK + Komplikasi

Komplikasi Intratemporal Komplikasi Intrakranial

Abses subperiosteal Abses ekstra dural
Labirintitis Abses perisinus
Parese n. fasialis Tromboflebitis sinus lateral
petrositis Meningitis
Abses otak
Meningitis otikus

Antibiotik dosis tinggi

Mastoidektomi
Rawat inap; kultur sekret
Dekompresi N fasialis
telinga; antibiotik dosis tinggi
petrosektomi
7-15 hari; konsul anak/syaraf;
mastoidektomi; bedah syaraf
Helmi. Otitis Media Supuratif Kronik. 2005
 Subperiosteal Abscess
Postauricular abscess (the most common type) is formed by
pus spreading through the vascular channels in the
suprameatal (Macewen's) triangle and presents as a swelling
between the tip of the mastoid adn Macewen's triangle. The
auricle is displaced forward, outward, and downward.
Bezold's abscess results from the perforation of the tip of
the inner aspect of the mastoid by the pus which will track
down the sternocleidomastoid muscle and present as a
swelling in the posterior triangle of the neck.

(Lee, KJ. 3rd ed.)

 Labyrinthitis

Perilabyrinthitis (Labyrinthitis Fistula). Perilabyrinthitis may

be surgically produced (simple or radical mastoidectomy,
fenestration, labyrinthotomy, or stapedectomy) or it may occur
spontaneously due to bone erosion by cholesteatoma. A
spontaneous fistula usually results from erosion of one of the
semicircular canals, especially the lateral semicircular canal.
The most common severe complication from cholesteatoma is
fistulization of the horizontal semicircular canal.
Treatment should consist of intense antibiotic treatment and
surgical drainage of the labyrinth.
(Lee, KJ. 3rd ed.)
 Petrositis
Petrositis is an inflammation of the petrous portion of the
temporal bone, characterized by that clinical triad of otitis
media, paralysis of the sixth cranial nerve, and pain of the fifth
cranial nerve (Gradenigo's syndrome). The symptoms of
petrositis depend upon the area of the petrous pyramid
affected.
Petrositis should be suspected in any patient whose ear
continues to drain after surgery for chronic infection, or in any
patient with ear disease who complains of persistent pain that
is otherwise unexplained.
Treatment is by surgical drainage.
(Lee, KJ. 3rd ed.)
 Extradural Abscess
An extradural abscess if a collection of pus between the dura
and the bona. Apart from coalescent mastoiditis, this is the
most common complication of otitis media. It is usually
secondary to bone erosion rather than a result of
osteothrombophlebitis or via preformed pathways.

Subdural Abscess
A subdural abscess develops when pus accumulates between
the dura and the arachnoid. This is uncommon. This may
develop as a result of extension of an infection of the middle
ear and mastoid through the intact bone and the dura by means
of a thrombophlebitis of the veins or by direct extension with
erosion of bone and dura.
(Lee, KJ. 3rd ed.)
 Brain Abscess
Otogenic brain abscess occurs usually in the temporal lobe of
the cerebrum (more frequent) or in the cerebellum. It is to be
the most frequent cause of death from otitis media.

The abscess may develop as a result of direct extension of the

otologic infection, by means of thrombophlebitis, or along the
preformed pathway. It may result from a previous skull
fracture. An extradural abscess usually forms before the
development of a brain abscess. Cerebellar abscesses from
otitis media usually form through preformed pathways,
whereas temporal lobe abscess results from seeding through
bone erosion.

(Lee, KJ. 3rd ed.)

 Meningitis
Meningitis is the most common intracranial complication from
suppurative otitis media and mastoiditis. There are two types
of meningitis: localized and generalized.

Treatment of meningitis is chemotherapeutic. Surgery is

indicated in those patients developing meningitis secondary to
chronic otitis media when the patient's general condition
permits.

(Lee, KJ. 3rd ed.)

Thieme, 2006
Bailey, 2006
Bailey, 2006
Bailey, 2006
ANATOMI N. FASIALIS
 Facial Nerve Paralysis
There are two mechanisms by which OM can result in facial nerve
paralysis:
(1) as a result of the locally produced bacterial toxins
(2) from direct pressure applied to the nerve by cholesteatoma or
granulation tissue
If there is a congenital dehiscence of the bony canal of the facial
nerve in the middle ear, then an episode of AOM can lead to
inflammatory edema of the nerve and a subsequent paresis.
 This situation should be managed by myringotomy with
aspiration of pus from the middle ear along with antibiotic
therapy, which will mostly result in the rapid resolution of
paralysis.
 If facial nerve paralysis occurs as a result CSOM, urgent surgical
exploration, with decompression of the facial nerve, is indicated.
 Mastoiditis
The fact that the mastoid air cell system is part of the
middle ear cleft means that some degree of mastoid
inflammation occurs whenever there is infection in the
middle ear
In most cases, this infection does not progress to clinically
apparent acute mastoiditis
However, if pus collects in the mastoid air cells under
pressure, necrosis of the bony trabeculae occurs,
resulting in the formation of an abscess cavity.
The infection may then progress to periostitis and
subperiosteal abscess, or to a more serious intracranial
infection.
 Subacute Mastoiditis
Subacute or "masked" mastoiditis may occur when
inadequate treatment of AOM results in a low-
grade infection of the mastoid air cells.
The symptoms and signs are equivalent to those of
acute mastoiditis, but are less severe and more
persistent.
Most cases resolve with ventilation of the middle ear
combined with appropriate antibiotic therapy.
If this treatment fails to resolve the infection,
cortical mastoidectomy is indicated.
 Meningitis
Acute otitis media is the most common cause of bacterial
meningitis.
It can occur as a result of hematogenous spread, of direct
extension from the middle ear through a bony dehiscence,
or through the cochlear aqueduct via the inner ear.
The most common organisms responsible for otic meningitis
are S pneumoniae and H influenzae type B.
The evaluation should include an MRI of the brain to rule out
other intracranial complications as well as a lumbar
puncture.
If meningitis is secondary to AOM, then a myringotomy
should be performed once antibiotic therapy has been
initiated.
 Extradural Abscess
Extradural abscesses are typically formed in the middle fossa
between the dura mater and the thin bony plate of the
tegmen. They can also occur in the posterior fossa, where
they are commonly associated with lateral sinus
thrombosis. The clinical features are often nonspecific and
may fluctuate if a dehiscence in the tegmen is present,
allowing the abscess to partially drain into the mastoid
cavity. As with other intracranial complications, headache
and fever are the most common features. Because of its
location, an extradural abscess can usually be drained
through a mastoidectomy approach while treating the
underlying middle ear disease.
 Timpanoplasti
 Meliputi : - miringoplasti dan atau
- osikuloplasti dan atau
- kanaloplasti.
 Jenis : Tipe I : cangkokan bersandar pada maleus
Tipe II : cangkokan bersandar pada inkus
Tipe III: cangkokan menempel padakaput stapes
Tipe IV: cangkokan menempel pada basis stapes
Tipe Va: fenestrasi pada kanalis semisirkularis
lateralis
Tipe Vb: stapedektomi
118
 Terapi OMSK
Terapi OMSK memerlukan waktu lama dan berulang,
hal ini disebabkan oleh :
1. perforasi membran timpani yang permanen
2. terdapat sumber infeksi di faring, nasofaring,
hidung dan sinus paranasal
3. sudah terbentuk jaringan ireversibel dalam rongga
mastoid
4. gizi dan higiene yang kurang
 Granuloma
Three factors are considered to play an important role in its
development: interference with drainage, hemorrhage, and
obstruction of ventilation.

The cause of the initial hemorrhage may be a hemorrhagic

inflammation or diathesis, a trauma, or some other form of
vascular disorder.

Interference with air exchange and clearance can be caused by:

tubal blockage, persistent mesenchyme, polypoid changes,
scar formations, tympanosclerosis, cholesteatoma, etc.

(Lee, KJ. 3rd ed.)

 Granuloma
The cholesterol granuloma may develop in any portion of the
pneumatic system of the temporal bone, and it can be
associated with a variety of middle ear disorders. Its principal
precursor is the chronic middle ear effusion or serous otitis
media. Its clinical expression and hallmark is the "idiopathic
hematotympanum", the dark bluish discoloration of the
tympanic membrane.

(Lee, KJ. 3rd ed.)

 Cholesteatoma
Cholesteatomas are cystlike, expansile lesions of the temporal
bone lined by stratified squamous epithelium that contain
desquamated keratin. They most frequently involve the middle
ear and mastoid, but they may develop anywhere within the
pneumatized portions of the temporal bone. They may be
congenital (infrequently) or acquired.

The accumulation of keratin may cause infection, otorrhea,

bone destruction, hearing loss, facial nerve paralysis, a
labyrinthine fistula, and intracranial complications such as
epidural and subdural abscesses, parenchymal brain abscesses,
meningitis, and thrombophlebitis of the dural venous sinuses.

(Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006)

PATHOGENESIS OF CHOLESTEATOMAS
Primary acquired cholesteatomas
Invagination theory
Basal cell hyperplasia theory
Otitis media with effusion theory
Epithelial invasion theory

Secondary acquired cholesteatomas

Implantation theory
Metaplasia theory
Epithelial invasion theory

(Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006)

 Cholesteatoma
The most common locations of origin of cholesteatomas in
decreasing frequency are the posterior epitympanum, the
posterior mesotympanum, and the anterior epitympanum.
Epitympanum cholesteatomas originate in a shallow pocket
that lies between the pars flaccida of the tympanic membrane
and the neck of the malleus. This pouch, known as Prussak's
space, has as its floor the lateral process of the malleus and its
associated mucosal folds lying in the horizontal plane.

(Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006)

 Cholesteatoma
Cholesteatomas most commonly exit Prussak's space by the
posterior route: the cholesteatoma penetrates the superior
incudal space lateral to the body of the incus. From there, it
traverses the aditus ad antrum to enter the mastoid. The
cholesteatoma may reach the middle ear by descending
through the floor of Prussak's space into the posterior space of
von Troeltsch, a pouch lying between the tympanic membrane
and the posterior mallear fold, the inferior edge of which
contains the chorda tympani nerve.

(Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006)

 SURGICAL GOALS FOR CHOLESTEATOMA
•Treat complications
•Remove diseased tissue
•Obtain a dry & safe•ear
•Preserve normal anatomy
•Improve hearing

A retraction pocket secondary to eustachian tube dysfunction

precedes the development of acquired cholesteatoma. It is
good practice to aggressively manage such retraction pockets.
A tympanostomy tube should be inserted early in an effort to
resolve the negative middle ear pressure and to return the
tympanic membrane to a neutral position.

(Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006)

 OPEN VERSUS CLOSED TECHNIQUES FOR MASTOIDECTOMY
Advantages Disadvantages
Physiologic tympanic Residual cholesteatoma may be
membrane position occult
Recurrent cholesteatoma may
Deep middle ear
occur in attic
Intact wall
Delayed canal breakdown
Incomplete exteriorization of
No mastoid bowl
facial recess
Second stage often required
Residual cholesteatoma Mastoid bowl maintenance can
visible on follow-up be a lifelong problem
Recurrent cholesteatoma Middle ear is shallow and
Canal-wall-
is rare difficult to reconstruct
down
Position of pinna may be altered
Total exteriorization of
facial recess Second stage sometimes required

(Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006)

 Radical Mastoidectomy
The radical mastoidectomy is the most aggressive of the open
cavity mastoid procedures.

The goal of radical mastoidectomy is to establish a dry, open

cavity devoid of secretory epithelium.

Indications for a radical mastoidectomy include unresectable

cholesteatoma with extension down the eustachian tube,
cholesteatoma with erosion into the cochlea or labyrinth, or
patients who have had multiple failed MRMs.

(Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006)

 Modified Radical Mastoidectomy

An operation to eradicate disease of the epitympanum and

mastoid in which the mastoid and epitympanic spaces are
converted into an easily accessible common cavity by removal
of the posterior and superior external bony canal walls. In this
operation the tympanic membrane and functioning ossicles are
left intact. Thus infection is eradicated and hearing preserved.

(Lee, KJ. 3rd ed.)

 WHO recommendations for management of
AOM and COM
COM can be prevented by treating AOM well. The current
WHO treatment recommendations for a 2 month to 5 year old
child with an acute ear infection (ear pain and/or pus draining
from the ear for less than 14 days) are to give an appropriate
antibiotic for 5 days, paracetamol for pain, dry the ear by
wicking, and follow-up in 5 days.

For chronic ear infection (pus seen draining from the ear and
discharge reported for 14 days or more) the recommendations
are to dry the ear by wicking and follow up in 5 days.

(WHO/CIBA Foundation Workshop, 2000)

Oral antibiotics
Oral antibiotics are better than aural toilet alone
A trial comparing various oral antibiotics with aural toilet
alone reported a higher otorrhoea resolution rate in the
antibiotic treated group (OR = 0.35, 95%CL = 0.14, 0.87).
Another trial comparing oral clindamycin with aural toilet
alone found otorrhoea resolution rates of 93% and 29%,
respectively

Topical antibiotics
Topical antibiotics are better than aural toilet alone

(WHO/CIBA Foundation Workshop, 2000)

Topical antibiotics
Topical antibiotics are better than systemic antibiotics
The Cochrane review found that topical antibiotics were more
effective than systemic antibiotics in resolving otorrhoea and
eradicating middle ear bacteria (OR = 0.46, 95%CL = 0.30,
0.68). Six studies used gentamicin, chloramphenicol,
ofloxacin, and ciprofloxacin as topical antibiotics; hydrogen
peroxide, and boric acid with iodine powder as topical
antiseptics; and cephalexin, flucloxacillin, cloxacillin,
amoxycillin, coamoxiclav, erythromycin, metronidazole,
piperacillin, ciprofloxacin, azactam, trimethoprim-sulfa,
ofloxacin, and intramuscular gentamicin as systemic
antibiotics.
(WHO/CIBA Foundation Workshop, 2000)
Topical antibiotics
Topical quinolones are better than topical non-quinolones
The Cochrane review showed that among topical antibiotics,
topical fluoroquinolones are more effective than other types of
topical antibiotics. Five studies found that topical ofloxacin or
ciprofloxacin was more effective than intramuscular
gentamicin, topical gentamicin, tobramycin or
neomycinpolymyxin in resolving otorrhoea (OR = 0.36,
95%CL = 0.22, 0.59) and in eradicating bacteria (OR = 0.34,
95%CL = 0.20, 0.57).

(WHO/CIBA Foundation Workshop, 2000)

Topical antibiotics
Combined topical and systemic antibiotics are no better
than topical antibiotics alone
The Cochrane review showed that combined oral-topical
antibiotics were no more effective than topical antibiotics
alone; the rates of resolution of otorrhoea were 50% and
53%, respectively. The drugs compared were clindamycin with
topical framycetin-gramicidin vs framycetin- gramicidin alone,
oral and topical ciprofloxacin vs topical ciprofloxacinalone,
and metronidazole with gentamicin vs gentamycin alone (OR
= 1.71;95%CL = 0.88, 3.34). In terms of eradication of middle
ear bacteria, oral and topical ciprofloxacin were slightly more
effective than topical ciprofloxacin alone (15% vs 5%), but this
was not statistically significant
(WHO/CIBA Foundation Workshop, 2000)
 NERVUS FASIALIS

Jalannya nervus fasialis secara umum dibagi atas 5 segmen:

• Segmen intrakranial sepanjang 24 mm dari pons ke porus

akustikus (meatus akustikus internus)

• Segmen intrakanalikular berjalan dalam kanalis akustikus

internus sepanjang 8 mm dan bergabung dengan fundus di
mana nervus fasialis melalui nervus intermedius
memepersyarafi kuadran anterosuperior

Gulya, AJ. Anatomy and Embriology of the Ear in: Clinical Otology. 3ed. Thieme. 2006.
 NERVUS FASIALIS

• Segmen labirintin (segmen terpendek) sepanjang 4 mm dari

tempat masuk kanalis falopi hingga ke ganglion genikulatum

• Segmen timpanik sepanjang 13 mm dari ganglion

genikulatum hingga eminensia piramidalis yang berjalan
pada dinding medial kavum timpani, superior dari prosesus
kokleariformis dan foramen ovalis

• Segmen mastoid, sepanjang 20 mm dari sinus timpanikus

menuju foramen stilomastoideus.

Gulya, AJ. Anatomy and Embriology of the Ear in: Clinical Otology. 3ed. Thieme. 2006.
N
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F
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 7th CRANIAL NERVE (FACIALIS)
Branchial motor
The facial nerve courses through the internal acoustic meatus. At the
lateral internal auditory canal, this nerve enters the bony fallopian
canal. It reaches the medial wall of the tympanic cavity on the
anterosuperior aspect and courses along the medial wall of the
tympanic cavity above the oval window. At the anterosuperior aspect
of the medial wall of the middle ear, there is a sharp posterior bend.
The geniculate ganglion is located in this area. Posterior to the oval
window and inferior to the horizontal semicircular canal, the nerve
turns downward to run vertically and posteriorly to the bony tympanic
anulus. It exits the skull through the stylomastoid foramen and enters
the parotid gland, where it divides into the temporal, zygomatic,
buccal, mandibular, and cervical branches.

Adapted from: Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
 7th CRANIAL NERVE (FACIALIS)

Visceral motor
Efferent fibers from the superior salivatory nucleus travel in
the nervus intermedius, where they divide in the facial canal
into two groups to become the greater petrosal nerve to
lacrimal and nasal glands and the chorda tympani to
submandibular and sublingual glands.

Special sensory
Taste, anterior two-thirds of tongue

Adapted from: Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology, 2006
N
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F
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Branchial motor

•Temporal: frontalis, corrugator supercilii, procerus, and upper

orbicularis oculi
•Zygomatic: lower orbicularis oculi
•Buccal: zygomaticus major and minor, levator anguli oris,
buccinator, and upper orbicularis oris
•Marginal mandibular: lower orbicularis oris, depressor anguli
oris, depressor labii inferioris, and mentalis
•Cervical: platysma
 Indeks FORDMAN
Pemeriksaan fungsi motori otot-otot wajah yang dipersyarafi
n. fasialis

1. m. frontalis  mengerutkan dahi /mengangkat alis

2. m. suprasilia  mengerutkan alis
3. m. piramidalis  mengangkat dan mengerutkan hidung ke
atas
4. m. orbikularis okuli  memejamkan mata kuat-kuat
5. m. zigomatikus  tertawa lebar sampai gigi terlihat
 Indeks FORDMAN

6. m. levator komunis  memoncongkan mulut ke depan

7. m. bucinator  mengembungkan kedua pipi
8. m. orbikularis oris  bersiul
9. m. triangularis  menarik kedua bibir ke bawah
10. m. mentalis  memoncongkan mulut tertutup ke depan

Yang diperiksa umumnya otot no. 1,3,4,5,8, dan 9

 Indeks FORDMAN

Derajat berat-ringannya:

0  sama sekali tidak dapat digerakkan

1  sedikit bisa digerakkan
1,5  gerakkan diantaranya
2  gerakkan normal

Tonus mempunyai nilai 2 untuk normal, jumlah nilai

keseluruhan 20 (100%).
 Indeks FORDMAN

hasil nilai
Rumus indeks fordman: x 100%
20

Kurang dari 50%  dekompresi

Lebih dari 50%  Konservatif
 Schirmer's test
Schirmer's test determines whether the eye produces enough
tears to keep it moist. This test is used when a person
experiences very dry eyes or excessive watering of the eyes. It
poses no risk to the subject.

Schirmer's test uses paper strips inserted into the eye for
several minutes to measure the production of tears. The exact
procedure may vary somewhat. Both eyes are tested at the
same time. Most often, this test consists of placing a small
strip of filter paper inside the lower eyelid (conjunctival sac).
The eyes are closed for 5 minutes. The paper is then removed
and the amount of moisture is measured.
(www.wikipedia .com)
 Schirmer's test
Untuk mengetahui fungsi serabut simpatis n. fasialis melalui
nervus petrosus superfisialis mayor setinggi ganglion
genikulatum.

Cara:
Kertas lakmus hisap dengan lebar 0,5 cm, panjang 10 cm
diletakkan di dasar konjungtiva, ditunggu 5 menit. Gunanya
untuk menstimulasi air mata & dan mengeluarkan sis air mata
pada sakus lakrimalis
Dengan pemasangan kertas lakmus pada seperti di atas,
kemudian dilakukan perangsangan dengan mencium amoniak,
gunanya untuk menimbulkan reflek nasolakrimasi
 Schirmer's test

1. Normal which is ≥15 mm wetting of the paper after 5

minutes.

2. Mild which is 14-9 mm wetting of the paper after 5 minutes.

3. Moderate which is 8-4 mm wetting of the paper after 5

minutes.

4. Severe which is <4 mm wetting of the paper after 5

minutes.

(www.wikipedia .com)
 Gustatory Test
Menilai serabut sensorik oleh nervus korda timpani (cab. N.7)

Cara:
1. Mata penderita ditutup
2. Diberi rangsang berbeda secara bergantian:
- pahit  lidah bagian belakang
- asam  sepanjang pinggir lidah
- manis  sepanjang ujung lidah
- asin  dorsoanterior lidah

Penilaian:
Sisi yang mengalami penurunan cita rasa atau tidak sama
sekali
 Tes reflek stapesdius

Gejala yang timbul pada parese muskulus stapesdius:

1. Hiperakusis
2. fotofobia

Pemeriksaan dengan garputala:

Garputala digetarkan pada telinga dengan frekuensi tinggi,
apabila terdengar bunyi lebih keras pada sisi yang paralisis
berarti lesi terletak pada bagian proksimal dari cabang m
stapesdiud di eminensia piramidalis.