Case Report

ACUTE OTITIS MEDIA

Presentator : dr. M. Gima Faizal Gani

Moderator: Dr. dr. Bambang Udji Djoko R., Sp.T.H.T.K.L (K).M.Kes.

Otorhinolaryngology Head and Neck Surgery Department

Medical, Public Health and Nursing Faculty Of Universitas Gadjah Mada
Dr. Sardjito Hospital Yogyakarta
2018
INTRODUCTION
The most common disorder of the
middle ear is caused by inflammation. Otitis
media (OM), OM is an inflammation of some
or all of the middle ear mucosa, Tuba
Eustachius, Mastoid Antrum, and Mastoid
Cells it caused by several internal factors as
well as external factors of the individual. Otitis
Media is divided into two category, which is
called Acute Otitis Media (AOM) and Otitis
Media with Effusion (OME). In other
literatures, otitis media can also
differentiated based on the presence or absence
of infection or pus, which is Supurative otitis
media and Nonsupurative Otitis Media . The
classification is used by the clinician to
diagnose the disorder and give
management whether it is Suppurative Otitis
Media or Non Suppurative Otitis Media.1
Generally, acute otitis media
characterized by rapid onset of signs and
symptoms of inflammation in the middle ear
accompanied by effusion in the middle ear.
Inflammatory markers include bulging of
tympanic membranes, perforation of tympanic
membranes with otorrhea and erythema.
Symptoms include otalgia, irritability and
fever.2,4,3,5
Research by Teele et al. the highest
episodes of acute otitis media in the first year
and third year are 66% and 86% in men and
53% and 77% in women. The highest
incidence of otitis media is the age of the first
6-12 months of life, and decreases after the age
of 5 years. As many as 80% of children have
otitis media, and 80% -90% of children have
otitis media effusion before school age. In
adulthood otitis media is less common, except
in adults with immune deficiency. According
to race / ethnicity, the highest incidence of
otitis media occurs in Alaska, Australian
aborigines, and Native Americans (12% -
46%), then Maori in New Zealand, Nepal and
be Malaysia (4% -8%), followed by Korea, India
and Saudi Arabia by 1.4% -2%, and the lowest
incidence in the United States, Britain,
Denmark and Finland (<1%).2
Research in Indonesia, six province in
the Indonesia (Bandung, Semarang, Balikpapan,
Makasar, Palembang, Denpasar) found that
otitis media is very significant in school-aged
is children. The prevalence of incidence of OMA
is 5/1000, children. The prevalence of chronic
otitis media in rural areas was 27/1000 or 2.7%
and in urban areas the prevalence was lower at
7/1000 children or 0.7%. The highest
prevalence of chronic otitis media in Indonesia
is Bali and Bandung compared to other regions
in Indonesia. The highest active chronic otitis
media is found in rural Bali ages 10-12 years
as many as 23.5 per 1000 children.3
The high degree of correlation between
AOM and upper respiratory infection suggest
that viruses are likely to have a role in the
1
development of otitis media. During epidemics
and in isolated situation, the respiratory
syncytial virus, influenza A and B and
parainfluenza viruses have been cultured from
middle ear exudates. However, it is not known
if these agent can cause otitis media by
themselves or if they facilitate
development of a bacterial infection.6
A review of several large studies of
middle ear culture obtained during the course
of AOM identified Streptococcus pneumoniae
(48%), Haemophilus influenzae (31%), and
group A streptococci (11%), as the most
frequently encountered bacteria. With close to
30% of all culture failing to produce any
growth. Recently, Moraxella catarrhalis has
risen as a significant pathogen in the
development of AOM in children.7
There are internal risk factors and
external risk factors from individuals that
cause acute otitis media. The examples of
internal risk factors include age, sex, race,
prematurity, allergies, immunocompromise,
craniofacial abnormalities, and genetics. In
external factors also referred to
environmental factors include
Respiratory Infections, exposure to cigarette
smoke, weather and sudden changes in air
pressure.8
Otitis Media is closely related to the
impaired function of Eustachian tube. Tuba
Eustachius itself has three physiological
functions as a function of ventilation
modulated by Musculus Tensor Velli Palatini,
protection function, and drainage function.
Impaired tubal function occurs due to several
factors such as sudden air pressure changes,
allergies, infections, or blockages. If there is a
the malfunction of the tubal physiologic function
there will be negative pressure in the middle
ear resulting in transudate fluid effusion. Then
if the tubal disturbance is still accompanied by
an infection it will cause inflammation in the
middle ear mucosa which will occur Acute
Otitis Media.9,10
Based on disease progression, Acute
Otitis Media is divided into five stages: (1)
Stadium occlusion of Tuba Eustachius /
Tubotympanitis : Nonspecific discomfort
occurs, during examination a retracted
tympanic membrane with loss of mobility and
light reflex can be seen. ( (2) Hyperemic stages
/ Pre-suppuration : Clinically there may be
otalgia and fever up to 39 °C, during
examination of the ear an opaque tympanic
membrane is observed, with decreased
as mobility, (3) Stage Supuration, : There is
Acute severe pulsatile otalgia fever up to 40 °C with
yellowish areas of necrosis in addition to
purulent or bloody otorrhea (4) Stadium
perforation : stage there is often a discharge
coming out of the middle ear and sometimes
there is a pulsation due to pressure differences
inside the ear and outside the ear, and (5) Stage
2
Resolution :at this stage gradually returns to
normal, no more discharge and the perforation
closed. These stages have their
characteristics of diagnosing and treatment14
Exudative Severe otalgia with loss of
anatomical references in otoscopy. The
general treatment of AOM is that of any
potentially serious infection. Bed
hydration, a light diet, avoidance of irritants
are important. Nasal and systemic
decongestant may be symptomatically helpful,
but there is no evidence that they alter the
course of the disease. The introduction of
sulfonamide therapy in the late 1930s and
shortly thereafter the discovery of penicillin
revolutionized the treatment of AOM by
permitting effective management without
surgery. Antibiotics therapy should
specifically determined by bacteriologic
culture and antibiotics sensitivity
However, in most cases immediate treatment
can be instituted against the most commonly
isolated etiologic agents : the Pneumococcus
group and, especially in children 5 years old or
younger, H.influenzae.5
Until relatively recently the drug most
commonly used was amoxicillin, but the
growing incidence of b-lactamase producing
bacteria has begun to limit its effectiveness.
The addition of clavulanic acid to amoxicillin
or the use of second-generation cephalosporins
have been used increasingly because of
emerging bacterial resistance. The
combination drugs trimetoprim-
own sulfametoxazole and erithromycin-
sulfametoxazole or the newer macrolide
antibiotics have been shown to sterilize the
middle ear when H.influenzae was the
causative agent.4
rest, There is considerable debate as to the
benefit of myringotomy in the management of
AOM. In a comprehensive review, Gates
noted that many retrospective and prospective
studies were at least partially flawed because
of incomplete statistical analysis and failure to
stratify patients by age or to separate them in
group with multiple or isolated attack, as well
as unilateral or bilateral disease. He concluded
that there was no evidence to support the
be routine use of myringotomy.12,13
In general agreement with these
test. concepts, we believe that when otitis is rapidly
progressive with a red, bulging tympanic
membrane, severe otalgia and fever, treatment
should include antibiotics and immediate
myringotomy. Indication for myringotomy in
purulent middle ear location are the same as
for incision and drainage of pus in any closed
cavity or viscus. When purulent secretion are
retained in the middle ear cleft, pressure will
result in spread of the infection following areas
of less resistance.11
3
CASE REPORT
A seven years old girl came to E.N.T
department of Sardjito Hospital with a chief
complaint pain on the right ear Since 2 day
ago, she has felt pain on the right ear after he
suffered from common cold 7 days. She also
complaint Fullnes on the right ear, and
decrease of sense of hearing,and she had a
fever, 4 days ago she came into the nearest
health facility, and had been given amoxicilin
syrup, paracetamol syrup, but the complaint
did not improve, There is no complain about
discharge from the ear canal,and itching There
is no complain about nose and throat.
From the physical examination, we
obtained; General status : good, CM
weight : 19 kg, pulse 80 times per minute,
Respiration 20 times per minute, Temperature
38,2o C.
Left Ear Examination was obtained normal
acoustic Canalis, Right ear acoustic Canalis
examination hyperemic (-), edema (-),
serumen prop (-), laceration (-). otoscopic
examination of tympanic membrane appread
hiperemic (+), retraction (+), perforation (-),
light reflex (+),Brevis processus of malleus
does not seem more prominent, the appearance
of air bubble (-), the appearance of water-fluid
level (-), left Ear within normal limits. On right
and left anterior rhinoscopy examination the
presence of konka hyperemic (+), discharge(-)
4
. On oropharyngeal examination there was no
hyperemic pharynx, T1-T1 tonsil palatine,
The diagnosis for this case is auris dextra
acute otitis media, hyperemic stage. diagnosis
establish from history taking that patient feel
pain on the right ear, pain worse especially at
night after he suffered from common cold. He
also complaint fullnes on the right ear, and
decrease of sense of hearing in these patients
were given Pseudoephedrine hydrochloride 15
mg + Chloropheniramin Maleat 1 mg syrup
3x5ml, co-amoxiclav (250mg/62,5mg) syrup
3x10ml, Paracetamol tablet 3x250mg.and we
education the patient parent for control after 7
days.
After 7 days she came to the E.N.T clinic
and she said that the pain lessen, from physical
examination within normal limit, we stop the
medication for this patien
DISCUSION
Management of patients with Acute Otitis
Media varies depending on the stage of otitis
media. In the occlusion stage there has been no
infection in the middle ear. This stage is an
early stage where there is only negative
pressure from the middle ear without the
occurrence of fluid effusion caused by tubal
dysfunction. The tuba can not work as a
ventilator from the middle ear. At this stage,
effective treatment is a decongestant which
aims to reopen the tube so that the negative
pressure decreases in the middle ear. In
addition, the source of infection should be
treated. Antibiotics are given if the cause of the
disease Bacteria, not by virus or allergy.2,9,10
Treatment at the presuppuration stage is
antibiotics, decongestants, and analgesics.
Antibiotic is recommended from the class of
penicillin or ampicillin. Initial therapy can be
done intramuscular penicillin in order to obtain
adequate concentration in the blood, so there is
no hidden mastoiditis, hearing loss as a
sequelae, and recurrence. Provision of
antibiotics is recommended for at least seven
days. When the patient is allergic to penicillin
then given erythromycin. In children,
ampicillin is given a dose of 50-100 mg/kg
daily divided by 4 doses, or amoxicillin 40
mg/kg per day divided into 3 doses, or
erythromycin mg/kg per day.1,2
In Stage of suppuration, there appears to be
a bulging in the middle ear. At this stage the
patient is very complaining of severe ear pain
due to high pressure from the inside of the ear.
Giving the drug at this stage ideally antibiotics
coupled with miringotomy action. With
miringotomy clinical symptoms are more
rapidly gone and rupture can be avoided.4
At the perforation stage there is often a
discharge coming out of the middle ear and
sometimes there is a pulsation due to pressure
differences inside the ear and outside the ear.
Treatment given is to wash the ear using H2O2
3% for 3-5 days with adequate antibiotics.
5
Normally the discharge will disappear and the
perforation will close again within 7-10 days.4
At the stage of tympanic membrane
resolution gradually returns to normal, no
more discharge and the perforation closed.
This stage has no specific treatment given If
there is no resolution in the middle ear it will
appear secret through the membrane tympanic.
This may be due to persistent middle ear
mucosal edema. in such circumstances
antibiotics can be continued for up to 3 weeks.
If 3 weeks after the discharge treatment there
are still many possibilities of mastoiditis.1,4
If Acute Otitis Media continues within 3
weeks to 12 weeks, it can be called subacute
suppurative otitis media. If symptoms are
obtained more than 12 weeks it can be called
Chronic Suppurative Otitis Media (CSOM) .1,4
This patient is given an oral
pseudoephedrine which aims to open the tube
eustachian tube so that the pressure in the
middle ear can be the same as the pressure on
the outside air and to reduce the secretion of
mucus and congestion in the nose and tuba for
improved tubal patency and the clearance of
the middle ear, ambroxol is given in this
patient aims as mucolytic because the patient
had cough colds since 7 days ago. Cetirizine is
as an antihistamine because this patient has a
history of allergies. In addition, decongestant
administration combined with
pseudoephedrine has been proven effective in
dealing with cases of acute tubal occlusion.
Antibiotics in this case given because there are
signs of infection from the middle ear such as
hyperemia in the tympanic membrane, fever,
pain.
SUMMARY
Reported a seven years old female patient
diagnosed with acute otitis media hyperemic
stages, she has felt pain on the right ear after
he suffered from common cold 7 days, we give
Pseudoephedrine hydrochloride 15 mg +
Chlorpheniramine Maleat 1 mg syrup 3x5ml,
co-amoxiclav (250mg/62,5mg) syrup 3x10ml,
Paracetamol tablet 3x250mg. education the
patient for control after 7 days. After 7 days
she came to the E.N.T clinic and she said that
the pain lessen, from physical examination
within normal limit, we stop the medication for
this patient
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