Acute Otitis MediaA Case Presentation

Supervisor:dr. Oscar Djauhari, Sp. THT-KL

Presented by:Julius Candra (2015-061-103)

Georgia Nadia Winardi (2015-061-110)

The Case

 A 7-years old boy came to ENT clinic with a complaint of right earache since 7 past days. He was also having cold, runny nose, fever since 2 week days, and hearing loss since 1 week.

Identity and Complaint

Name : X Gender : male Age : 7 years

old Occupation : primary school student Address : sukabumi Chief complaint : earache on the right ear

since 7 days Additional complaint : runny nose, cough, fever

since 2 weeks ago, and hearing loss since 1 weeks ago

History of Present Illness

A 7-years-old boy came to ENT clinic with right earache since 7 past days. The earache was felt insidiously and continuously all day. The pain was increasing in severity, from mild pain at the beginning until severe pain at the time of presentation

History of Present Illness

The boy also felt a sensation of fullness at the right ear, and hearing loss since 1 week prior to admission. There was a high-grade fever following this earache. History of ear discharge, foul-smell discharge, facial pain was denied.

History of Present Illness

Two weeks before admission, the child suffered from runny nose, cold, and fever. The nasal discharge was yellowish, mukoid, and massive in amount.

History of previous treatment was denied

History of previous illness was denied History of family illness was denied

Physical Examination(Generalized Status) General condition : Appear ill Body weight : 20 kg Height : 120 cm Blood pressure : 100/60 mmHg Pulse : 130 beat

per minute Respiratory rate : 24 times per

minute Temperature : 38, 5oC

Physical Examination (Ears) Auris dextra : Auricle : normal External auditory canal:

hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (+)

Tymphanic membrane: Intact, hyperemic (+), bulging (+), light reflex

↓

Physical Examination (Ears) Auris sinistra : Auricle : normal, no deformities External auditory canal:

hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (+)

Tymphanic membrane : intact, bulging (-), light reflex (+)

Tuning Fork test : Rinne test. (-)/(+) Webber lateralitation to the right, schwabach prolonged/same to the examiner.

Physical Examination (Nose)Right Nose : Mucous membrane : hyperemic (+), edema (+), mass (-),

laceration (-), crust (-) Inferior concha: eutrophy Discharge : (+), mukoid, green yellowish Septum : normal, no deviation Air passage : +/+

Left Nose : Mucous membrane : hyperemis (+), edema (+), mass (-),

laceration (-), crust (-) Inferior concha: eutrophy Discharge : (+), mukoid Septum : normal Air passage : +/+

Physical Examination (Throat and Neck) Oropharynx

Posterior pharynx : hyperemic (-) Palatine tonsils : T1 / T1, cripta dilatation (-), detritus

(-) Uvula : symmetrical Dental : no abnormatlities

Maxillofacial : symmetrical

Neck : mass (-), lymphadenopathy (-)

Working Diagnosis Acute otitis media dextra, suppurative stage Workup

Pneumatic otoscopy Tympanometry Audiometry

Therapy Outpatient care Antibiotic : Amoxicilin 3 x 250 mg PO for 7 days Antipyretic and analgetic : Paracetamol 3 x 250

mg PO for 3 – 5 days Topical anticholinergic : Oxymetazoline HCL nasal

spray 2 x 3 sprays per nostril for 3 days Miringotomy

Definition and Terminology

Otitis media represents an inflammatory condition of the middle ear and mastoid space.

The presence or absence of middle-ear effusion (MEE) and its duration help further to define the process.

Effusion is the liquid resulting from infection and mucosal inflammation ,can be serous (thin, watery), mucoid (thick, viscous), or purulent (pus).

Definition and Terminology

Otitis media with effusion (OME) can occur as a post inflammatory response to Acute Otitis Media (AOM) from a viral infection, or because of Eustachian-tube dysfunction.

Chronic suppurative otitis media (CSOM) is characterized by persistence of purulent otorrhea through a tympanic membrane (TM) perforation or tympanostomy tube (TT) that is unresponsive to medical therapy

Duration

• 0 to 3 weeks in durationACUTE

• 3 to 12 weeks in duration

SUBACUTE

• longer than 12 weeks in duration

CHRONIC

Epidemiology

The onset of AOM during the first year of life is important because the majority of children with multiple recurrences of AOM have their first episode before the age of 12 month

Associated with upper respiratory infections (URIs). Prevalence is similar between boys and girls. Children who live in crowded households or low

socioeconomic conditions or who have poor medical care or both also have been found to have an increased incidence in both acute and chronic OM

Etiology

AOM is a complication of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection Streptococcus pneumoniae (most often) Haemophillus influenzae Branhamella catarrhalis Streptococcus β-hemoliticus group A Staphyllococcus aureus E. Coli RSV

Risk Factor Age (younger), ET in infants and children is shorter, more

horizontal, and functionally less mature compared with that in adults.

Allergies Nasal obstruction (sinusitis, adenoid hypertrophy, nasal or

nasopharyngeal tumors) Craniofacial abnormalities (ex. Cleft palate, deformity of the

midface, skull base, nose/ paranasal sinus, Down syndr, etc) Exposure to enviromental smoke or irritants Exposure to group day care Family history of recurrent acute otitis media Immunodeficiency No breastfeeding Upper respiratory tract Infection

Patophysiology

- Dysfunction ET- URI

Edema &

Congestion

Narrowing ET lumen

Inflammation

influx of bacteria

and viruses nasopharynx when ET

opens

↑↑ negative middle-

ear pressure

Mucosal edema, capillary

engorgement, infiltration PMN

Staging

Occlusion

• Retraction of tympanic membrane because of negative pressure in middle ear, created by air absorbtion.

• Chief complaint : tinnitus, sensation of fullness• PE : normal tympanic membrane or in livid color. Maybe

the effusion has been occured, but can’t be recognized. This stage is hard to be distinguish with serous otitis media which caused by virus or allergic reaction.

Hyperemic

• Vascular dilatation in tympanic membrane so the tympanic membrane in reddish/hyperemic looks or oedema. Secretes may hard to be noticed.

• Chief Complaint : painful perception • PE: tympanic membrane is reddish, edema

Suppurative

• The mucous in middle ear in edema state and the epithelium destroyed, so the middle ear now filled by purulent exudate. This can cause tympanic membrane bulging to the outside.

• Chief Complaint : Pain at ear, heart rate, temperature of the body raise. PE: Tympanic membrane is bulging. If the pressure in the middle ear can’t be reduced, can caused iscemic condition of the tympanic membrane because of pressure to the capillaries. Necrotic at tympanic membrane cause the tympanic membrane looked as flabby and yellowish color. This is the site where rupture could take place.

Perforated

• Late in giving antibiotics therapy, tympanic membrane will be rupture and pus drains out from the middle ear.

• Chief Complaint : Child will be calm now, reduce in body temperature, and sleep well.

• PE: Tympatic membrane is rupture and pus drains out

Resolution

• If the tympanic membrane still intact, the condition of tympanic membrane slowly back to normal. If there is a perforation, secretes will reduced and dried. Resolution will takes place without medication if the immune system still in good performance

Clinical Findings

Child Upper tract infection Pain inner ear Fever Restless Fullness in the ear Hearing loss

Adults pain fullness in the ear hearing loss occured

Management Occlusion

Decongestan (Child < 12y.o: HCl ephedrine 0.5% in physiologic solution, Child>12 th: HCl efedrine1% in physiologic solution)

Antibiotics

Hyperemic Antibiotic: amoxicillin 40 mg/kgBB/day in 3 doses, ampicillin

50-100 mg/kgBB/day in 4 doses, eritromicin 40 mg/kgBB/day.

Decongestan Analgetics Antipiretics

Management

Suppurative Antibiotics: amoxicillin 40 mg/kgBB/day in 3 doses,

ampicillin 50-100 mg/kgBB/day in 4 doses, eritromicin 40 mg/kgBB/day.

Myringotomy Analgetics Antipiretics

Perforated H2O2 3% 5 drops 3 dd 1 3-5 days Antibiotic local (ear drops)

Management

Resolution If the resolution didn’t take place, secretes will drained

out by the perforation in tympanic membrane. The antibiotics continued for 3 weeks. If 3 weeks pasts and secretes stills, mastoiditis should be in differential diagnosis

Complications

References

Anatomy and Physiology of the Nose and Paranasal Sinuses : Snow JB, Ballanger JJ. Ballenger’s Otorhinolaryngology Head and Neck Surgery 6th. Ontario; 2003.

Effendi H, editor. Boies: Buku Ajar Penyakit THT. Ed ke-6. Jakarta: Penerbit Buku Kedokteran EGC; 1997.

Lalwani AK, editor.Current Diagnosis & Treatment in Otolaryngology - Head & Neck Surgery. USA: McGraw-Hill; 2008.

Cummings et al, editor. Otolaryngology - Head and Neck Surgery. Ed ke-3. USA: Mosby-Year Book; 1998.