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OTITIS MEDIA WITH EFFUSION

Presented by :
dr. Solikin
Moderator :
dr. Danu Yudistira, MMR, Sp.T.H.T.K.L

Departemen Kesehatan Telinga Hidung Tenggorok Bedah Kepala Leher


Fakultas Kedokteran, Kesehatan Masyarakat dan Keperawatan UGM
RSUP Dr. Sardjito Yogyakarta
2019
Visi Program Studi Kesehatan
T.H.T.K.L
Menjadi program studi berstandar global yang
inovatif dan unggul, serta mengabdi kepada
kepentingan bangsa dan kemanusiaan dengan
dukungan sumber daya manusia yang profesional
dan dijiwai nilai-nilai Pancasila pada tahun 2020

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Misi Program Studi Kesehatan
T.H.T.K.L
1. Meningkatkan kegiatan pendidikan, penelitian dan
pengabdian masyarakat berlandaskan kearifan lokal.
2. Mengembangkan sistem tata kelola Program Studi
IK THT-KL yang mandiri dan berkualitas (Good
Governance).
3. Membangun kemitraan dan kerjasama dengan
rumah sakit dan seluruh pihak yang berkepentingan
dalam rangka mendukung kegiatan pendidikan,
penelitian dan pengabdian masyarakat.
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Introduction
 Otitis media with effusion (OME) is a condition in which there is
fluid in the middle ear, but no signs of acute infection.

 As fluid builds up in the middle ear and eustachian tube, it places


pressure on the tympanic membrane. The pressure prevents the
tympanic membrane from vibrating properly, decreases sound
conduction, and therefore results in a decrease in patient hearing.

 Chronic OME is defined as OME that persists for 3 or more


months

Bailey’s, 2014
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80% children

0.6% adults

will improve spontaneously within 3 months

30-40% experience recurrence

Roland et al, 2008


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Anatomy of The Ear
Anatomy of The Middle Ear 7
Middle ear 8

 Outer border : tympanic membrane


 Anterior border : eustachian tube
 Inferior border : bulbus jugularis
 Posterior border : aditus ad antrum, vertical facial canal,
 Medial border : horizontal semicircular canal, facial
canal, oval window, round window, promontorium
Anatomy of The Tympanic Membrane 9
Tympanic Membrane 10

 Pars flaksida (membrana Shrapnelli)


 Pars tensa
1. Epitel berlapis gepeng
2. Subepitel
jaringan penyambung 
p.d. & saraf >>, bula
3. Fibrosa (lamina propria)
radier & sirkuler
4. Submukosa
p.d. & saraf <<
5. Epitel kuboid simpleks

Kotikoski M, 2004
Anatomy of The Tympanic Cavum
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Anatomy of The Eustachian tube
Vascularitation 13

 Branch of the external carotid artery and basilaris artery.


 Inferior Tympanic (external carotid artery)  ascenden
faryngeal artery  tympanic cavum  inferior tympanic
kanalikulus with Jacobson nerve.
 Branch of the external carotid artery  anastomose 
anterior tympanic artery, profunda aurikularis artery,
mastoid artery, stilomastoid artery, superfisialis petrosus
artery, superior tympanic artery, & tubarius artery.
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Innervation
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Otitis media with effusion (OME)

a condition in which there is fluid in the middle ear,


but no signs of acute infection.
16

Host

Eustachian Environ
Tube
Dysfunction
Etiology mental

allergi
es
17
Pathogenesis
Tube Function
disturbed negative pressure

Tube obstruction
transudes

effusion

Infection (-) infection(+)

OME OMA

Bailey 2006
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Clinical Feature

Hearing Impairment
Flowing liquid sensation when changing head position

Slightly painful on early disease due to negative pressure

Balance related symptom on young children (chronic OME)


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Diagnostic test 20

 Tuning fork test


 Pneumatic otoscopy
 Tympanometry
 Audiometry
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Otoscopic finding on OME

dull tympanic membrane


• Distortion
• Loss of cone of light
Retraction of tympanic membrane
Air fluid level and air bubble
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Management

• Watchful Waiting
• Medication (such as local vasoconstrictor, antihistamine, steroids)
• Surgery
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CASE REPORT

 Name : Mrs. S
 Gender : Female
 Age : 41 yo
 Medical Record : 01.87.74.64
ANAMNESIS 24

► Chief complaint :
Deafness on her left ear since approximately 2 months ago

► She felt fullness on her ear, and she has a sensation of moving liquid every time she
changed the position of her head. She denied about dizziness, any ear discharge, pain on
the ear, facial palsy and fever. She also denied any trauma of the head and the ear, any
bloody discharge from the nose and there was no dual vision
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 Generally on good condition


 BP : 110/60 mmHg
 HR : 76 bpm
 RR : 20 /minute
 Temp: 36.8O C
E N T S TAT U S 26

Right ear Left ear

Outer ear Normal Normal

Ear canal Normal Normal

Tympanic membrane tympanic membrane was Air bubbles appear,


intact, cone of light was cone of light was short
normal
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TUNING FORK TEST


AD AS

Rinne + -

Weber Lateralization to the Left Ear

Schwabach
Same as examiner Extended

Conclussion AS CHL
Otoendoscopy 28

Dextra Sinistra
Nasoendoscopy 29

Dextra Sinistra
DIAGNOSIS 30

Otitis Media with Effusion

• Amoxycillin-
Clavulanate 3 x 625 mg
PLAN • Pseudoephedrine 3 x 60
mg
• Evaluate 1 months
PROBLEM TO DISSCUSS 31

 The problem with this case is diagnosis


DISCUSSION
Anamnesis

Deafness on her left ear o Hearing Impairment


since approximately 2 o Flowing liquid sensation
months ago. She felt when changing head
fullness on her ear, and position
she has a sensation of
o Slightly painful on early
moving liquid every
disease due to negative
time she changed the
pressure
position of her head.

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Initially the effusion is serous as a transudate

The histological changes of the middle ear


mucosa
(by an increase of goblet cell metaplasia
and mucus glands)

The liquid becomes seromucous, then


mucoid and finally
the effusion becomes thick and stringy, like
a glue (gummy ear)
The resultant
congestion prevents ETD also caused by
ciliary dysmotility,
normal eustachian nasopharynx
tube function and carcinoma, cleft
pressure regulation palate,
is altered within the gastroesophageal
middle ear reflux, and adenoid
hypertrophy.

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Physical Examination
Left Ear o Presence of fluid behind the
o Tympanic membrane tympanic membrane (an air fluid
is intact, air bubbles level or bubble may be visible in
appear and cone of the middle ear), without acute
light in the tympanic onset or signs of infection
membrane was short o Pneumatic otoscopy is the best
diagnostic tool for OME because
one can observe and identify the
lack of movement of the
tympanic membrane
o Audiometry
o Tympanometry
36

 Appropriate diagnostic tools to diagnose


OME include pneumatic otoscopy,
tympanometry and pure tone audiometry
 Active observation for 3 months is needed
for newly diagnosed OME prior to surgical
intervention
37

• The range of frequencies that an


individual can perceive is plotted
on an audiogram. The decibel (dB)
Audiometry range of individuals with OME is
decreased in the audiogram.
Audiometry will demonstrate a
variable air bone-gap
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Tympanometry is examination or
measurement of middle ear function,
including tympanic membrane mobility,
eustachian tube function, and tympanic
cavity condition
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Management
The patient was given  watchful waiting
antibiotic amoxicillin-
clavulanate 3 x 625  medical therapy
mg and combination
 And surgical intervention
with pseudoephedrine
3 x 60 mg
41

 Otitis Media With Effusion is a fluctuating condition with


symptom that vary with time and age
 It is often under diagnosed
 Untreated OME may lead to hearing impairment
 Long term complication include adhesive otitis media,
ossicular chain disruption, retraction pocket and
cholesteatoma
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Summary

A 41 years old female came to the ENT clinic with complaint of


deafness on her left ear since approximately 2 months ago. She felt
fullness on her ear, and she has a sensation of moving liquid every
time she changed the position of her head. The patients was diagnosed
with otitis media with effusion. Patient was given antibiotic
amoxicillin-clavulanate 3 x 625 mg and combination with
pseudoephedrine 3 x 60 mg. The patient was educated to came 1
month again for control.

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Thank You
Suggestion Please
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Otot sistem tuba eustachius

- 4 otot : - m. tensor veli palatini


- m. levator veli palatini
- m. salpingopharyngeus
- m. tensor tympani
- ET tertutup saat istirahat
terbuka saat mengunyah, menelan dan menguap
- m. tensor veli palatini  dilatator
(m. levator veli palatini)

Mekanisme pembukaan tuba :


- aktif konstraksi m.tensor velli palatini .
- pasif beda tekanan kavum tympani
dengan nasofaring (reflektoris)  20-40 mmHg
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Vaskularisasi TE
 A. Pharyngeal Asending
 A. Meningeal

 V. Pharyngeal
 V. plexus Pterygoid
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Persarafan TE
 Cab Pharyngeal dari ganglion
Sphenopalatina dari N. Maksilaris ostium
TE
 N. Mandibula  pars kartilago
 N.IX  pars osseus
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Fungsi Tuba
 Pengatur tekanan / ventilasi
 Fungsi clearence / drainase
 Fungsi proteksi
Gangguan fungsi tuba 50

 Tuba terbuka abnormal  hilangnya jaringan lemak disekitar


mulut tuba  penurunan BB hebat, penyakit kronis ( rinitis atrofi
dan faringitis), ggn f/ otot (myastenia gravis).
 Obstruksi tuba  peradangan mukosa atau adenoid, tumor,
sikatriks post op adenoidektomi.
 Barotrauma  perubahan tekanan yang tiba2  tuba gagal
membuka  beda tek > 90 mmHg otot tdk mampu membuka 
tek. Negatif  eksudasi  OME
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Alat untuk mengukur kekakuan membran timpani


Kita dapat memperkirakan adanya disfungsi tuba
eustachius bila tercatat puncak negatif
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Macam cairan pada efusi telinga tengah 57

1. Cairan serosa ( OMSA / OMSK )


- steril, viscositas rendah, kuning, tidak lengket .
2. Cairan mukoid ( glue ear )
- prod gl. Mukosa c. tympani, viscositas tinggi,
lengket, steril, kuning-keabuan , biasanya krn
disfungsi kronis tuba.
3. Cairan purulenta (oma)
- nanah krn proses infeksi, tidak steril, viscositas
tinggi.
4. Cairan berdarah (barotrauma )
- ada proses diskontinuitas jaringan pada telinga
tengah/dalam => perdarahan.
5. Cairan liquor ( LCS )
- Fraktur Os temporale.
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Drugs Dosage 66
AMOKSISILIN-POTASIUM KLAVULANAT
67
Amoxicillin and clavulanate potassium is a fixed
combination of amoxicillin trihydrate (an aminopenicillin
antibiotic) and the potassium salt of clavulanic acid (a β-
lactamase inhibitor); clavulanic acid synergistically
expands amoxicillin’s spectrum of activity against many
strains of β-lactamase-producing bacteria.
Amoxicillin and clavulanate potassium is used principally
for the treatment of infections caused by susceptible β-
lactamase-producing strains of Moraxella catarrhalis
(formerly Branhamella catarrhalis), Escherichia coli,
Haemophilus influenzae, Klebsiella, and Staphylococcus
aureus.
Adapted from: drugs info at www.emedicine-medscape.com
AMOKSISILIN-POTASIUM KLAVULANAT
68

Amoxicillin and clavulanate potassium has been effective


when used orally in adults and children for the treatment
of abscesses, cellulitis, and impetigo caused by
susceptible penicillinase-producing and nonpenicillinase-
producing Staphylococcus aureus and S. epidermidis,
Streptococcus pyogenes (group A β-hemolytic
streptococci), or Corynebacterium.

Adapted from: drugs info at www.emedicine-medscape.com


Augmentin ES 69
AMOKSISILIN-POTASIUM KLAVULANAT
Augmentin is an oral antimicrobial agent that combines
amoxicillin with the β-lactamase inhibitor clavulanate
potassium. Amoxicillin is a semisynthetic antibiotic that is an
analog of ampicillin.
Clavulanate potassium, the potassium salt of clavulanic acid,
is a β-lactamase inhibitor capable of inactivating a wide
variety of β-lactamases by blocking the active sites of these
enzymes. It is particularly active against the plasmid-mediated
β-lactamase commonly responsible for transferring resistance
to penicillins, but has no appreciable antibiotic activity itself
2003 by the American Pharmaceutical Association
ventilation tube 70

 Recurrent AOM unresponsive to medical therapy


 Chronic OM with bilateral persistent effusion
greater than 3 months and conductive hearing
loss
 Negative middle ear pressure with impending
cholesteatoma
(Bailey,2014)
MIRINGOTOMI 71

 Tindakan insisi pada pars tensa membran tympani


pada kuadran posterior-inferior agar tejadi
drainase sekret dari telinga tengah ke liang
telinga luar
 Dapat menimbulkan komplikasi berupa
perdarahan akibat trauma liang telinga luar,
dislokasi tulang pendengaran, trauma pada
fenestra rotundum, trauma nervus facialis
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 Otitis media akut berulang yang tidak


respon terhadap terapi medikamentosa
 Otitis media efusi persisten >3 bulan &
disertai CHL
 Indikasi absolut jika terjadi OME dng
penurunan pendengaran ≥ 40dB
 Indikasi relatif jika penurunan pendengaran
21-40dB
 Tujuan :
 Mengurangi frekuensi dan keparahan OMA
 Secara umum memperbaiki CHL yang
disebabkan oleh OME
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 Komplikasi :
 Persistenperforasi MT pada waktu TT
diambil(pipa yg dipertahankan selama
36 bulan)
 Timpanosklerosis atau scarring
 Pipa tersumbat
 Pembentukan jaringan granulasi
disekitar pipa
 Penipisan atau atrofi disekitar pipa
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 Follow up 3 minggu setelah


pemasangan tube & kemudian
kontrol setiap 6 bulan sampai tube
diambil
 Jika terjadi 2x episode otore sebelum
jadwal follow up 6 bulan, harus kontrol
ke THT
 Tube biasanya lepas pada bulan 9-12
bulan
 Pengambilan tube setelah 18-24
bulan
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