1) Otitis Media

OTITIS MEDIA(O.M) 

Definition: Mucosa part of middle ear infection

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Types: o Acute suppurative O. M.  acute infection caused by bacteria o Acute infection by virus (viral otitis media) o Acute necroticans O.M. o Allergic O.M. o Chronic tuberculous O.M. o Chronic Suppurative O.M.

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Predisposition Factors o Age ( 6-12 year old) o Socio-economic o Season (winter) o Respiratory tract diseases o Allergy o Deficiency syndrome o Palatoschisis

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Incidence of OM: o Highest incidence 6-12 months o second peak age 4-5 years o Indonesia (National Survey 1996)  3.8% Primary school  3.4% o

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Complications: o Intracranial Complications: 1. Thrombophlebitis sinus sigmoideus 2. Perinus abscess 3. Meningitis 4. Sub-dural abscess 5. Epidural Abscess 6. Brain abscess 7. Hydrocephalus otitis o Intratemporal complications: 1. Mastoiditis 2. Petrositis 3. Labyrintitis 4. Retroauricular abscess 5. Facial nerve Parese / paralysis 6. Bezold abscess 7. Citelli abscess

Types

Acute Suppurative O.M (ASOM)

Chronic Suppurative O.M (CSMOM) Benign CSOM

Acute inflammation bacteria

Etiology

Bacteria:   – Strep.pneumoniae(18%) – H.influenza (18%) – M.catarrhalis(11%) Bacteria enter the tympanic cav. via : – Eustachian tube – Tympanic membrane(perforation /ruptur) – Hematogenous 1. Std. Hyperemic 2. Std. Exudation ( serum + fibrin + RBCs + PMN) 3. Std. Suppuration (because of miringotomy/ perforation) 4. Std. Coalescence & mastoiditis 5. Std. Complication 6. Std. Resolution

Pathology

caused

by o Chronic inflammation o a cool type o without cholesteatoma

Description

Chronic Tuberculosis O.M (CTOM)

Malignant CSOM o Chronic inflammation o dangerous type o with cholesteatoma

ears of active benign CSOM all are aerobic gram negative:  Proteus mirabilis  Klebsiella sp.  Proteus vulgaris

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Rare Characteristic: typical tympanic membrane with multiple perforation progressive hearing loss & Severe M.tuberculosis

Clinical Features

1. Std. Hyperemic –  Earache  Obstructive sensation in the ear  – tube occlusion  Fever  Hearing : nearly normal 2. Std. Exudation  Earache & fever  increased  Hearing loss  In baby : vomiting, seizure, meningismus  Mastoid  pain on palpation 3. Std. Suppuration  Ear discharged (serosanguinolent  mucopurulent)  Earache is decreased  Fever ( + / - )  Hearing loss  General status is good 4. Std. Coalescence & mastoiditis  Earache  nokturnal  Fever +  Mastoid pain on palpation / abscess (+)  Ear discharged > 2 weeks ( some  profused) 5. Std. Complication  Sigmoid sinus Thrombophlebitis  Brain abscess  Meningitis  Petrositis

Moderate hearing loss

–

Mucoid/mucopurulent discharged

ear –

Severe hearing loss Ear discharged foetor

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severe + hearing loss

progressive

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Subperiosteum retro-aurikuler abscess  Facial nerve Parese/paralysis  Labiryntitis  Perisinus/extradural abscess 6. Std. Resolution  Ear discharged diminished  Normal Hearing Diagnosis

Ortoscopy: 1. Std. Hyperemic  arterial injection on tympanic membran around manubruim M. on the border of pars tensa and flaccida 2. Std. Exudation  MT bombans, hyperemic 3. Std. Suppuration  Perforation (small) pars tensa + ear discharged 4. Std. Coalescence & mastoiditis  narrowing of external meatus caused by a “sagging ” of the postero-superior wall 5. Std. Complication 6. Std. Resolution  Perforation  central/small  closed X-ray mastoid : cellulae mastoid become clouded(std. exudation)

Ortoscopy: Ortoscopy: – Typical perforation: Central – Typical Perforations: ( small -- wider/total ) marginal, post-sup, attic (pars – Mucosa of Tympanic flaccida), total cavity: hyperemic, thick – Granulation tissue /polyps – Exacerbation of acute infection will recur X-Ray mastoid : – radiolucent area (+) (cholesteatoma) White piece floating on ear spooling water

Ortoscopy: – typical tympanic membrane with multiple perforation

Chest x-ray, PPD, & culture / swab, biopsy

Management

1. Antibiotic(attention to resistance) – ASOM limited episode: First line antibiotic – Persistent infection : Second line or broad spectrum antibiotic **Consider tympanocentesis if unresponsive – Recurrent episodes (> 3 episodes in 6 months): Antibiotic prophylaxis 2. Symptomatic(antipiretic, analgetic) 3. Nasal decongestant / allergy treatment 4. Operation : – Myringotomy for drainage – Mastoidectomy in Coalescence and complication std. (simple mastoidectomy) Otolaryngology referral – Failed medical therapies – Hearing loss (> 20 dB) – Tympanic membrane changes – Mastoiditis – Persistent ear discharge – Intracranial complications

Response medicine therapy

Unresponsive medicine therapy Suspected TB O.M. : (unhealed ) Chronic O.M. unresponsive to routine therapy / TB Patients + chronic infection in the ear

Treatment: antibiotic(penicillin) Eustachian tube dysfunction (causative)

Treatment: Treatment: Radical mastoidectomy in order Anti-TB to : 1. Stop bone erosion 2. Antrum + cellulae, and tympanic cavity (United together with exter. meatus to one bigger cavity, dried, “inactive skin-lined cavity”)

Complication

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Information

w/o complication Sigmoid sinus Thrombophlebitis Brain abscess Meningitis Petrositis Subperiosteum retro-aurikuler abscess Facial nerve Parese/paralysis Labiryntitis Perisinus/extradural abscess

Antimicrobial agents for ASOM: – First line(Amoxicillin) – Second line  Amoxicillin-clavulanate  Trimethoprimulfamethoxazole  Erythromycin sulfamethoxazole – Broad spectrum  Cefixime  Azithromycin  Clarithromycin

Associated with complication

Cholesteatoma: – Characteristic: epidermoid cyst containing keratin – Two types (histological is not differ): – 1. Congenital Cholesteatoma 2. Acquired Cholesteatoma akuisita : a. Primary cholesteatoma

b. Secondary cholesteatoma

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Erosive to bone layer