2.

Anatomi dan Fisiologi Telinga Tengah

Telinga tengah merupakan rongga berisi udara yang terbagi atas kavum

timpani dan air cell mastoid (Probst dkk., 2006). Telinga tengah terdiri dari
membran timpani dan 3 tulang kecil yaitu maleus, inkus dan stapes. Di dalam
telinga tengah juga terdapat dua otot kecil yaitu m. tensor timpani yang melekat
pada manubrium maleus dan m. stapedius yang melekat pada stapes. M. tensor
timpani dipersarafi oleh n. trigeminus sedangkan m. stapedius dipersarafi oleh n.
fasialis. Korda timpani adalah cabang n. fasialis yang berjalan menyeberangi
rongga telinga tengah. Tuba Eustachius menghubungkan rongga telinga tengah
dengan faring (Moller, 2006). Membran timpani berbentuk agak oval dan
merupakan selaput tipis pada ujung liang telinga. Gendang telinga berbentuk
kerucut dan agak cekung bila dilihat dari liang telinga. Bagian utama dari gendang
telinga disebut pars tensa dan bagian kecilnya disebut pars flasida yang lebih tipis
dan terletak di atas manubrium maleus. Gendang telinga ditutupi oleh selapis sel
epidermis yang berlanjut dari kulit liang telinga. Tuba Eustachius terdiri dari
bagian tulang atau protimpanum yang berlokasi dekat rongga telinga tengah dan
bagian tulang rawan yang membentuk celah tertutup saat berakhir di nasofaring
(Moller, 2006).
The Eustachian tube consists of a bony part (the protympanum) that is
located close to the middle ear cavity, and a cartilaginous part that forms a closed
slit where it terminates in the nasopharynx.

(A) Cross-section of the human middle ear to show

the Eustachian tube.

(B) Orientation of the Eustachian tube in the adult. The tensor veli palatini
is shown (both reprinted from Hughes, 1985, with permission from Thieme
Medical Publishers).
The optimal function of the middle ear depends on keeping the air pressure
in the middle-ear cavity close to the ambient pressure. That is accomplished by
briefly opening the Eustachian tube. In the adult, the Eustachian tube is 3.53.9
cm long and it follows an inferior (caudal) medially anterior (ventral)
direction in the head, tilting downwards (caudally) by approximately 45 degrees
to the horizontal plane. The Eustachian tube is shorter in young children and it is
directed nearly horizontally. The cartilaginous part of the Eustachian tube forms a
valve that closes the middle ear off from pressure fluctuations in the pharynx such

as occurs during breathing and it decreases transmission of a persons voice to the

middle-ear cavity. The mucosa inside the Eustachian tube (which really is not a
tube except for the bony part) is rich in cells that produce mucus and it has cilia
that propel mucus from the middle ear to the nasopharynx. The slit shaped
cartilaginous part of the Eustachian tube allows transport of material from the
middle-ear cavity to the nasopharynx but not the other way. The most common
way the Eustachian tube opens is by contraction of a muscle, the tensor veli
palatini muscle. The tensor veli palatini muscle is located in the pharynx and
innervated by the motor portion of the fifth cranial nerve. This muscle contracts
naturally when swallowing and yawning, and some individuals have learned to
contract their tensor veli palatine muscle voluntarily. The Eustachian tube can also
be opened by positive air pressure in the middle ear cavity but not by negative
pressure, which in fact may close it harder.
The middle-ear cavities consist of the tympanum (the main cavity) that lies
between the tympanic membrane and the wall of the inner ear (the
promontorium), a smaller part (the epitympanum) that is located above the
tympanum, and a system of mastoid air cells. The head of the malleus is located in
the epitympanum. The middle-ear cavity and the Eustachian tube are covered with
mucosa. The total volume of the middle-ear cavities is often given to be
approximately 2 cm3, but the size of the middle-ear cavities varies considerably
from person to person and if the volume of the mastoid air cells is included, the
total volume can be as large as 10 cm3.
Fisiologinya belum lengkap
2.2

Otitis Media Serosa

OME is associated with ear discomfort and recurrences of acute otitis media
(AOM) and often follows an episode of AOM. Transient hearing loss is frequently
associated with OME. Spontaneous resolution of OME occurs in 90 per cent of
patients within three months of infection (otitis)
Otitis media with effusion (OME) is defined as middle-ear effusion (MEE) in the
absence of acute signs of infection. In children, OMEalso referred to as glue
earmost often arises after acute otitis media (AOM). In adults, it often occurs in
association

with eustachian tube dysfunction, although OME is a separate

diagnosis. (jfp 06212)

(Rezes slizard)

Otitis media with effusion (OME) is a common condition of early

childhood in which an accumulation of fluid within the middle ear space causes
hearing impairment. The hearing loss is usually transient and self-limiting over
several weeks, but may be more persistent and lead to educational, language and
behavioural problems. OME may be overlooked because of the insidious nature of
the condition, and suspicion of hearing loss in children must be acted upon
effectively. In most instances of uncomplicated OME, no intervention is required
because the fluid clears spontaneously and the hearing recovers (pdf).
Otitis media with effusion (OME) is a middle ear
disease characterized by presence of mucoid effusion
in the middle ear without any signs of acute infection. 1
This is a common clinical entity among the children.
Since the disease is benign with an insidious onset,
the diagnosis is usually delayed. The presence of fluid
in the middle ear results in the impaired mobility of
tympanic membrane and a conductive type of hearing
loss. The complications and sequels of OME are an
important public health problem. The patients will
have impaired development of speech and language,
poor school performance, tympanosclerosis, retraction
pockets and psychosocial problems.2, 3, 4
The pathogenesis of otitis media with effusion is
still controversial. The causes such as Eustachian
tube dysfunction, insufficient pneumatization of
mastoid, craniofacial abnormalities, infections,
immunodeficiency, and allergic agents are widely
discussed. Various risk factors are implicated such
as sex, race, premature delivery, passive smoking,
allergy, asthma, family size, bottle feeding,
socioeconomic status, cleft palate, adenoid hypertrophy,
have been studied and are still controversial(IMJM)

2.2.1

Epidemiologi Otitis Media Serosa

Experts have found it difficult to determine the exact incidence

of OME because it is often asymptomatic. In addition,
many cases quickly resolve on their own, making it challenging
to diagnose. A 2-year prospective study of 2- to 6-year-old preschoolers
revealed that MEE, diagnosed via monthly otoscopy
and tympanometry, occurred at least once in 53% of the children

in the first year and in 61% of the children in the second

year.3 A second study followed 7-year-olds monthly for one year
and found a 31% incidence of MEE using tympanometry.4 In the
25% of children found to have persistent MEE, the researchers
noted spontaneous recovery after an average of 2 months. (jfp-06212)
We believe that nearly all children have
experienced one episode of OME by the age
of 3 years, but the prevalence of OME varies
with age and the time of year. It is more prevalent
in the winter than the summer months.5
OME is more common in Caucasian children
than in African American or Asian children. (jfp 06212)

The prevalence of OME in Malaysian children between

three months to twelve years old is 18.3%. Those
children suffering from frequent episodes of AOM
have increased risk of development of OME later on.
Other factors such as gender, race, household size,
daycare center attendance, breastfeeding, exposure to
smoking, allergy, asthma were not statistically
significant. (IMJM)

2.2.2

Etiologi dan Faktor Resiko Otitis Media Serosa

Risk factors for children include a family

history of OME, bottle-feeding, day care attendance,
exposure to tobacco smoke, and
a personal history of allergies.7,8 One study
conducted on mice suggested that inherited
structural abnormalities of the middle ear
and eustachian tube may play a role as well.9
Some have suggested that effusions of OME
in children result from chronic inflammation,
for example, after AOM, and that the
effusions are sterile; however, recent studies
have demonstrated that a biofilm is formed
by bacterial otopathogens in the effusion.10-12
The common pathogens found include nontypeable
Haemophilus influenza, Streptococcus
pneumoniae, and Moraxella catarrhalis.
Inflammatory exudate or neutrophil infiltration
is rare in the fluid, however.
The contribution of allergies to OME in
children remains somewhat controversial. A
retrospective review from the United Kingdom
of 209 children with OME found a history
of allergic rhinitis, asthma, and eczema in
89%, 36%, and 24%, respectively.13 However,
this study was done at an allergy clinic, and
it is possible that the data from the clinics

specialized patient population are not generalizable.

Gastroesophageal reflux may also be
associated with OME in children. However,
studies measuring the concentration of pepsin
and pepsinogen in middle-ear fluid have
provided conflicting results (jfp 06212)

Eustachian tube dysfunction is considered the major etiologic factor resulting in

the development of middle ear disease. Blocked Eustachian tubes can cause
several symptoms, including ears that hurt and feel full, ringing or popping noises,
hearing problems, feeling a little dizzy [1]. Dizziness or vertigo from Eustachian
tube obstruction can be explained by increase of inner pressure of vestibular
organ. It is because negative middle ear pressure gives rise to the retraction of
tympanic membrane, and it makes the stapes push the oval window. Improvement
of tinnitus after Eustachian tube catheterization can mean that the tinnitus is from
the hypersensitivity of cochlear nucleus following decrease of afferent nerve
stimuli owing to air-bone gap [2]. When I need to explain the cause of headache
from negative middle ear pressure, I support the theory of Sinus headache [3].
Middle ear cavity and mastoid cavity are named on the basis of anatomy.
However, if we view things from a different angle, we can regard them as one of
paranasal sinuses like maxillary sinus or frontal sinus in a view of physiology
and function. Mechanical obstruction of the Eustachian tube may be either
intrinsic or extrinsic. Intrinsic mechanical obstruction is usually caused by
inflammation of the mucous membrane lining of the Eustachian tube or an allergic
diathesis causing edema of the tubal mucosa. Extrinsic mechanical obstruction is
caused by obstructing masses such as hypertrophic adenoid tissue or
nasopharyngeal tumors [4]. In these cases, some process should be performed to
rule out possible mechanical causes for such as middle ear effusion or/and
Eustachian tube obstruction before all. Furthermore, ideally normal middle ear

cavity pressure with balance between both ears is the essential prerequisite to be
checked before any other tests for vestibular function, tinnitus, ear fullness,
sensorineural hearing loss, headache, earaches, itching sensation of ear,
migrainous vertigo, etc. What is first, necessary and sufficient for it? Eustachian
tube catheterization (so-called Rosenmuller method) (JOENTR 01).

Otitis media with effusion (OME) is common among

children with cleft palate with or without cleft lip (CP6L);
approximately 90% will develop this problem(Grant et al.,
1988; Sheahan et al., 2003). Research suggests that healthrelated
quality of life for those with OME can be affected
due to sleeping problems, irritability, and emotional
distress, as well as hearing loss (Brouwer et al., 2005). (13-139)
Of the
various otologic complications, postirradiation otitis mediawith
effusion (OME) is the most common problem,2 and this
significantly impairs the quality of life of postirradiated NPC
patients with symptoms such as conductive hearing loss, ear

discomfort, and muffling. (329)

Risk factors for Developmental Difficulties

Hearing loss independent of OME
Suspected or diagnosed speech and language delay
Autism spectrum disorder
Syndromes (i.e. Down Syndrome) or craniofacial abnormalities that include cognitive, speech, or
language delays
Blindness or uncorrectable visual impairment
Cleft palate with or without an associated syndrome
Developmental delay
Known or suspected exposure to environmental disorganization, lack of linguistic stimulation, or
neglect (OM)

2.2.3

Patofisiologi Otitis Media Serosa

2.2.4

Tanda dan Gejala Klinis Otitis Media Serosa

Look for these signs and symptoms

OME is often asymptomatic. If a patient has
clinical signs of an acute illness, including
fever and an erythematous tympanic membrane,
its important to evaluate for another
cause. OME can present with hearing loss or
a sense of fullness in the ear. While an infant
cannot express the hearing loss, the parent
may detect it when observing and interacting
with the child. Parents are also likely to
report that the child is experiencing sleep
disturbances.16
z Vertigo may occur with OME, although
not often. It may manifest itself if the
child stumbles or falls. An older child or adult
with vertigo may say that it feels like the room
is spinning. (jfp 06212)

2.2.5

Penegakkan Diagnosis Otitis Media Serosa

Formal assessment of a child with suspected OME should include:

1. clinical history taking, focusing on:
-

poor listening skills

indistinct speech or delayed language development
inattention and behaviour problems
hearing fluctuation
recurrent ear infections or upper respiratory tract infections
balance problems and clumsiness
poor educational progress

2. clinical examination, focusing on:

-

otoscopy
general upper respiratory health
general developmental status

3. hearing testing, which should be carried out by trained staff using tests suitable
for the developmental stage of the child, and calibrated equipment
4. tympanometry.
Co-existing causes of hearing loss (for example, sensorineural, permanent

conductive and non-organic causes) should be considered when assessing a child

with OME and managed appropriately. (pdf)

Diagnosis relies
on pneumatic otoscopy

On physical exam, the patient will likely appear

well. Otoscopic examination reveals
fluid behind a normal or retracted tympanic
membrane; the fluid is often clear or yellowish
in color.
A subcommittee comprised of members
of the American Academy of Pediatrics,
American Academy of Family Physicians, and
the American Academy of OtolaryngologyHead and Neck Surgery (AAP/AAFP/AAOHNS) published a clinical practice
guideline in 2004 that delineates the current
diagnosis and management of children
between 2 months and 12 years of age with
OME.17
Pneumatic otoscopy, which can reveal
decreased or absent movement of the tympanic
membrane (the result of fluid behind
the membrane), is the primary diagnostic
method recommended by the guideline.
Tympanometry and acoustic reflectometry
may also be used to make the diagnosis,
especially when the presence of MEE
is difficult to determine using pneumatic
otoscopy.(jfp-06212)

2.2.5.2 Distinguish between OME and AOM

OMA
OME
Children with AOM present with Children with OME present with no
evidence of acute inflammation despite
combinations of ear pain (otalgia), loss visible fluid or reduced mobility on
pneumatic otoscopy.1 The ear is not
of landmarks, and an opaque, bulging, acutely painful, but the child may have
ear discomfort and/or hearing loss
inflamed tympanic membrane on direct (otitome).
otoscopy. (otitome)

Diagnostic definition
Acute Otitis Media (AOM) (ICD-9CM code 382.9)
Middle Ear Effusion (MEE) demonstrated
by
pneumatic
otoscopy, tympanometry, air fluid
level,
or
a
bulging
tympanic
membrane plus
Evidence of acute inflammation
opaque,
white,
yellow,
or
erythematous tympanic membrane or
purulent effusion plus
Symptoms of otalgia, irritability, or
fever

middle

ear

effusion

in

the

absence of symptoms. The effusion of

OME

Otitis Media with Effusion (OME)

(ICD-9-CM code 381.4) MEE without
symptoms of AOM with or without
evidence of inflammation

The diagnosis of AOM is based on the

The diagnosis of OME is the presence

of

Diagnostic definition

can

be

serous,

mucoid,

presence

of

symptoms

(ear

pain,

fever) in the context of an inflamed

middle ear effusion. (OM)

or

purulent. (om)

2.2.6
OMA

Penatalaksanaan Otitis Media Serosa

OME
Therapy of OME
Children with middle ear effusions should
be examined at 3 month intervals for
clearance of the effusion [I, D*].
Children with evidence of mucoid effusions
or anatomic damage to the middle ear should
be referred to otolaryngology if effusion or
abnormal physical findings persist for 3
months [I, D*].
Children with apparent serous effusions
should be referred to otolaryngology if
effusion persists for 6 months and there is
evidence of hearing loss or language delay
[I, D*].

Children with an asymptomatic middle ear

effusion (no apparent developmental or
behavioral problems) can be followed
without referral [I, B*].
Parents of all children with OME should be
informed about approaches to maximize
language development in a child with a
possible hearing loss [I, C*] .
Decongestants and other nasal steroids
have been shown not to decrease middle ear

effusions [IIIA*] . (OM)

On Going Care
When OME has been present for at least 12 weeks, observation is advised at 3
month intervals until the resolution of effusion. If there are concerns of
significant

hearing

loss

or

structural

abnormalities

of

the

tympanic

membrane, a formal hearing evaluation and referral to an otolaryngologist is

recommended (otitis)

Initial management of OME1,2

If a child has OME, attempt to determine the length of time the effusion has been
present. If the history obtained from the patient or parent suggests the effusion has
been present for less than 12 weeks, re-examine the child on a six week basis. If
the effusion has been present for 12 or more weeks, see Recommendation 3.
Note: Decongestants, antihistamines, steroids, and antibiotics are not
recommended in the
treatment of OME. (otitome)
When OME has been present for 12 or more weeks
A formal hearing evaluation and referral to an otolaryngologist should occur.

Rationale
Otitis media with effusion (OME) is one of the most common illnesses
of childhood and is often proceeded by an attack of AOM. OME is
associated with ear discomfort, hearing loss and recurrences of acute
otitis media (AOM). OME frequently is preceded by an episode of AOM
and may take more than three months to clear. After an episode of
AOM, fluid will be present in 50 per cent of patients after one month, in
25 per cent of patients after two months, and in 10 per cent of patients
at three months.1
Monitoring and treatment of persistent OME has a number of goals.
Language delay may be associated with OME and hearing loss.
Treatment of this condition may promote age appropriate language
development, although this treatment outcome has recently been
challenged.3 Surgical treatment of chronic OME may prevent middle ear
complications, such as atelectatic tympanic membrane, permanent
conductive hearing loss, cholesteatoma, etc.
Medical treatment options for OME are generally ineffective. Antibiotics
may hasten the resolution of OME in only 14 per cent of cases. 1,2 Other

interventions such as decongestants, antihistamines, steroids 4 have

shown no benefit and should not regularly be used to treat this
condition. (otitome)
Rationale for OME Recommendations
After an episode of AOM, fluid will be present in 50 per cent of patients after
one month, in 25 per cent of patients after two months, and in 10 per cent of
patients at three months.28,30,31 Pneumatic otoscopy can be a useful clinical skill
to help detect the presence of fluid behind the tympanic membrane. 1 OME
does not require antibiotic treatment.
While OME has been linked to hearing loss and impaired development in
children, recent evidence indicates that persistent middle-ear effusion in
otherwise

normal

children

does

not

cause

long

term

developmental

impairments.8,10,30 Surgical treatment of chronic OME may prevent middle ear

complications,

including:

atelectatic

tympanic

membrane,

permanent

conductive hearing loss, cholesteatoma, etc. If a child does become a

candidate for surgery, tympanostomy tube insertion is the preferred initial
procedure (otitis)

Appropriate time for intervention

1.3.1 The persistence of bilateral OME and hearing loss should be confirmed over
a period of 3 months before intervention is considered. The child's hearing should
be re-tested at the end of this time.
1.3.2 During the active observation period, advice on educational and behavioural
strategies to minimise the effects of the hearing loss should be offered. (pdf)

Children with persistent bilateral OME documented over a period of 3 months

with a hearing level in the better ear of 2530 dBHL or worse averaged at 0.5, 1, 2
and 4 kHz (or equivalent dBA where dBHL not available) should be considered
for surgical intervention. (pdf)
Exceptionally, healthcare professionals should consider surgical intervention in
children with persistent bilateral OME with a hearing loss less than 2530 dBHL
where the impact of the hearing loss on a child's developmental, social or
educational status is judged to be significant. (pdf)
Surgical interventions
Once a decision has been taken to offer surgical intervention for OME in children,
insertion of ventilation tubes is recommended. Adjuvant adenoidectomy is not
recommended in the absence of persistent and/or frequent upper respiratory tract
symptoms.
Children who have undergone insertion of ventilation tubes for OME should be
followed up and their hearing should be re-assessed. (pdf)
Non-surgical interventions
The following treatments are not recommended for the management of OME:
-

antibiotics
topical or systemic antihistamines
topical or systemic decongestants
topical or systemic steroids
homeopathy
cranial osteopathy
acupuncture
dietary modification, including probiotics
immunostimulants
massage.

Autoinflation may be considered during the active observation period for children
with OME who are likely to cooperate with the procedure.

Hearing aids should be offered to children with persistent bilateral OME and
hearing loss as an alternative to surgical intervention where surgery is
contraindicated or not acceptable. (pdf)
Management of OME in children with Down's syndrome
The care of children with Down's syndrome who are suspected of having OME
should be undertaken by a multidisciplinary team with expertise in assessing and
treating these children.
Hearing aids should normally be offered to children with Down's syndrome and
OME with hearing loss.
Before ventilation tubes are offered as an alternative to hearing aids for treating
OME in children with Down's syndrome, the following factors should be
considered:
-

the severity of hearing loss

the age of the child
the practicality of ventilation tube insertion
the risks associated with ventilation tubes
the likelihood of early extrusion of ventilation tubes.

Management of OME in children with cleft palate

The care of children with cleft palate who are suspected of having OME should be
undertaken by the local otological and audiological services with expertise in
assessing and treating these children in liaison with the regional multidisciplinary
cleft lip and palate team.
Insertion of ventilation tubes at primary closure of the cleft palate should be
performed only after careful otological and audiological assessment.
Insertion of ventilation tubes should be offered as an alternative to hearing aids in
children with cleft palate who have OME and persistent hearing loss. (pdf)

Information for children, parents and carers

1.9.1 Parents/carers and children should be given information on the nature and
effects of OME, including its usual natural resolution.
1.9.2 Parents/carers and children should be given the opportunity to discuss
options
for treatment of OME, including their benefits and risks.
1.9.3 Verbal information about OME should be supplemented by written
information
appropriate to the stage of the child's management.
Effectiveness of surgical procedures for treating OME
There is a need for good-quality randomised controlled trials documenting the
effect of adjuvant
adenoidectomy with ventilation tubes compared to ventilation tubes alone in the
management of
persistent bilateral OME in children. Trials should be sufficiently powered (large)
to accurately
document a probably small but continuing difference due to adjuvant
adenoidectomy, and to
identify subgroups that would particularly benefit from surgical intervention.
Why this is important
Despite a lack of robust scientific evidence, adjuvant adenoidectomy with
ventilation tube
insertion is routinely performed for recurrent or chronic persistent OME. There is,
therefore, a
need for good quality, randomised controlled trials with large samples which
address the power
deficit in measuring any additional difference derived from adjuvant
adenoidectomy. In particular,
the proportion of time spent with middle ear fluid and any corresponding benefit
to hearing
should be investigated. The trials need to follow up study participants beyond 6
12 months after
ventilation tube insertion. This is because a high proportion of tubes would have
fallen out during
this period, and therefore any advantage that may exist for adjuvant
adenoidectomy would
become, in principle, demonstrable. Up to 2 years is a feasible follow-up period
without high
sample attrition. Further trials should also evaluate benefit to children's respiratory
and general
health, and additional benefits (for example, re-insertion of ventilation tubes)
which would add
precision to cost-effectiveness or costutility comparisons.

(JFP-06212)
How best to approach treatment

There are several management options to

choose from, including watchful waiting,
medication, and/or surgery. (Another option,
autoinflation, which has shown some shortterm
benefits, is described in Should you
recommend autoinflation?17-19 at left.)
The goals of management are to resolve
the effusion, restore normal hearing (if diminished
secondary to the effusion), and
prevent future episodes or sequelae. The
most significant complication of OME is permanent
conductive hearing loss, but tinnitus,
cholesteatoma, or tympanosclerosis may also
occur.
In most patients, OME resolves without
medical intervention. If additional action is
required, however, the following options may
be explored.
z Medication. While the AAP/AAFP/

AAOHNS guideline recommends against

routine antibiotics for OME,17 it does note
that a short course may provide shortterm
benefit to some patients (eg, those for
whom a specialist referral or surgery is being
considered).
A separate meta-analysis found that antibiotics
improve clearance of the effusion
within the first month after treatment (rate
difference [RD]=0.16; 95% confidence interval
[CI], 0.03-0.29 in 12 studies analyzed),
but effusion relapses were common, and no
significant benefit was noted past the first
month (RD=0.06; 95% CI, -0.03 to 0.14 in
8 studies).20
If you do use antibiotics, a 10- to 14-day
course is preferred.17 Amoxicillin, amoxicillinclavulanate and ceftibuten have been
evaluated in separate clinical trials, but none
has been clearly shown to have significant
advantage over any other. 21,22
Antihistamines, decongestants, and oral
and intranasal corticosteroids have little effect
on OME in children and are not recommended.
17 A Cochrane review including 16
studies found that children receiving antihistamines
and decongestants are unlikely
to see their symptoms improve significantly and many patients experience
adverse effects
from the medications23 (number needed
to harm=9).
A randomized, double-blind trial involving
144 children <9 years of age with OME
for at least 2 months evaluated 4 regimens
involving amoxicillin alone or in combination
with prednisolone. Children in the
amoxicillin+prednisolone arms were significantly
more likely to clear their effusions at 2
weeks (number needed to treat=6; P=.03), but
not at 4 weeks (P=.12). At 4-month follow-up,
effusions had recurred in 68.4% and 69.2%
of those receiving amoxicillin+prednisolone
and those receiving amoxicillin alone, respectively
(P= .94).24
z Surgeryor not? The AAP/AAFP/
AAOHNS guideline recommends physicians
perform hearing testing when OME is present
for 3 months or longer, or at any time if
language delay, learning problems, or a significant
hearing loss is suspected in a child
with OME. The results of the hearing test can
help determine how to proceed, based on
the hearing level noted for the better hearing
ear.
You can manage children with hearing
loss 20 dB and without speech, language,
or developmental problems with watchful
waiting. Children with hearing loss of 21 to
39 dB can be managed with watchful waiting
or referred for surgery. If watchful waiting is

pursued, there are interventions at home and

at school that can help. These include speaking
near the child, facing the child when
speaking, and providing accommodations in
school so the child sits closer to the teacher.
Consider re-examination and repeat hearing tests every 3 to 6 months until the
effusion
has resolved or the child develops symptoms
indicating surgical referral.
When hearing loss is 40 dB, the AAP/
AAFP/AAOHNS guideline recommends that
you make a referral for surgical evaluation
(ALGORI THM).17
Other indications for referral to a surgeon
for evaluation of tympanostomy tube
placement include situations in which there
is:
structural damage to the tympanic membrane
or middle ear (prompt referral is
recommended)
OME of 4 months duration with persistent
hearing loss (40 dB) or other signs or
symptoms related to the effusion
bilateral OME for 3 months, unilateral
OME 6 months, or total duration of any
degree of OME 12 months.17
Any decision regarding surgery should
involve an otolaryngologist, the primary care
provider, and the patient and/or family. The
AAP/AAFP/AAOHNS guideline recommends
against adenoidectomy in children with persistent
OME without an indication for the
procedure other than OME (eg, chronic sinusitis
or nasal obstruction).17
Keep in mind that evidence of lasting
benefit (>12 months) is limited for surgery in
most patients, and the surgical and anesthetic
risks must be considered before moving
forward.17 (For more on the evidence regarding
surgery, see Cochrane weighs in on tympanostomy
tubes above.25) Tonsillectomy
also does not appear to affect outcomes and
is not advised.17
z When a referral is always needed.

Regardless of hearing status, promptly refer

children with recurrent or persistent OME
who are at risk of speech, language, or learning
problems (including those with autism
spectrum disorder, developmental delay,
Downs syndrome, diagnosed speech or language
delay, or craniofacial disorders such as
cleft palate) to a specialist (jfp 06212).17

2.2.7

Komplikasi Otitis Media Serosa

The two major complications of OME are:

1) a transient hearing loss, potentially associated with language development or behavioral
problems, and

2) chronic anatomic injury to the tympanic membrane leading to the need for reconstructive
surgery.

2.2.8

Prognosis Otitis Media Serosa