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CHRONIC SUPPURATIVE OTITIS MEDIA

Presenter : chok chun hung

Name : Bapak Amat Soekoni Alamat: purworejo Umur : 73 thn Pekerjaan : tidak bekerja Agama : islam Nikah : sudah bernikah

KU : Patient mengeluh sejak beberapa ini pendengaran telinga kirinya menurun dan tidak dapat mendengar dengan baik

RPS: 1 minggu sebelum masuk poliklinik THT, patient mengeluh telinga kirinya suka keluar cairan berwarna kuning ,bau tetapi tidak sakit, telinga kirinya juga sering suka berdengung dan kepalanya juga sering suka pusing. Patient juga suka menusuk nusuk telinganya dengan kayu kelapa ketika telinganya gatal.

RPD : patient mengeluh telinga kanannya sudah tidak bisa mendengar sejak patient kecil lagi. Patient tidak mempunyai riwayat hypertensi atau allergy.

RPK : keluarganya tidak pernah ada yang seperti ini

Test garpu tala


Test rinne : AD positive SNHL/ normal Test weber : Lateralisasi ke kiri Test schwabach AD pemendekan pendengaran

AS negative CHL

AS pemanjangan pendengaran

Pemeriksaan fisik : AD I : x merah, inflamasi, x anatomy kelainan x pus P : tragus helix antehelix tidak nyeri

AS sama sama

Pemeriksaan otoscope AD -Dinding telinga bersih, x cerumen, -Tympani membran buram, telinga -cone of light Dan tulang incus x kelihatan

AS - tampak lecet , luka pada dinding disertai pus -perforasi luas pada bagian tengah

Dx : Otitis media supurative chronic auris sinistra Tx : Trifed ( pseudo ephedrin 60mg Tripolidine 2.5 mg ) S3dd1 ambroxol ( mucolytic ) 30mg S3dd1 tarivid ( ofloxacin drops ) S2ddI

Education : Jgn sampai kena air dulu, jika mandi dibalut Jgn ditusuk tusuk lagi, jika gatal kembali kontrol lagi Kontrol lagi setelah obat selesai

Introduction
CSOM is a long-standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation.

Epidemiology
Higher in developing countries because of poor socioeconomic standards, poor nutrition and lack of health education. Both sexes and all age groups.

TYPES
Tubotympanic or safe Profuse, mucoid, odourless discharge Central perforation Granulations uncommon Pale polyp Cholesteatoma absent Complications rare Mild to moderate conductive deafness Atticoantral or unsafe Scanty, purulent, foul-smelling discharge Attic or marginal perforation Granulations common Red and fleshy polyp Cholesteatoma present Complications common Conductive or mixed deafness

Tubotympanic type
Aetiology It is the sequelae of acute otitis media usually following exanthematous fever and leaving behind a large central perforation. Ascending infections via the eustachian tube. Persistent mucoid otorrhea is sometimes the result of allergy to ingestants such as milk, eggs, fish, etc.

Central perforation

Pathology
Perforation of pars tensa Middle ear mucosa- normal when disease is quiscent or inactive. Oedematous and velvety when disease is active. Polyp Ossicular chain Tympanosclerosis Fibrosis and adhesions

Bacteriology
Pus culture in both types of aerobic and anaerobic CSOM may show multiple organisms. Common aerobic organisms are Ps. Aeruginosa, Proteus, E. coli and Staph. Aureus, while anaerobes include Bacteroides fragilis and anaerobic Streptococci.

Alternative classification
Tubotympanic Active- perforation of pars tensa, inflammation of mucosa and mucopurulent discharge. Inactive- permanent perforation of pars tensa but middle ear mucosa is not inflamed and there is no discharge. Atticoantral Active- presence of cholesteatoma of posterosuperior region of pars tensa or in pars flaccida. Inactive- retraction pockets in pars tensa or pars flaccida.

Clinical features
Ear discharge- non-offensive, mucoid or mucopurulent, constant or intermittent. Hearing loss- conductive type Round window phenomenon Perforation Middle ear mucosa- normally, it is pale pink and moist; when inflamed it looks red, oedematous and swollen.

Investigations
Examination under otoscope Audiogram Culture and sensitivity of ear discharge Mastoid X- rays/ CT scan temporal bone

Treatment
Aural toilet Ear drops (decongestant, mucolytics and such) Systemic antibiotics Precautions Treatment of contributory causes- tonsils, adenoids, maxillary antra and nasal allergy Surgical treatment Reconstructive surgery

Atticoantral type
Aetiology- cholesteatoma ,a cystlike mass lined with stratified squamous epithelium filled with desquamating debris, often including cholesterol, usually in the middle ear and mastoid region.(usually associated with chronic inflammation and infection of the middle ear, but some people acquire it at birth or because of perforations to the tympanic membrane (eardrum)) Patology Cholesteatoma Osteitis and granulation tissue Ossicular necrosis Cholesterol granuloma

1. 2. 3. 4.

Cholesteatoma

Symptoms and signs


Symptoms Ear discharge- usually scanty, but always foul smelling due to bone destruction Hearing loss Bleeding Signs Perforation Retraction pocket Cholesteatoma

Investigations
Examination under otoscope Tuning fork tests and audiogram X- ray mastoids/ CT scan temporal bone Culture and sensitivity of ear discharge

Features indicating complications of CSOM


Pain Vertigo Persistent headache Facial weakness A listless child refusing to take feeds and easily going to sleep Fever, nausea and vomiting Irritability and neck rigidity Diplopia Ataxia Abscess around ear

Treatment
1. 2. Surgical treatment Canal wall down procedure Canal wall up procedure Reconstructive surgery Conservative treatment

Comparison of procedures
Canal wall up procedure Canal wall down procedure

Meatus

Normal appearance

Widely open meatus communicating with mastoid Dependence on doctor for cleaning mastoid cavity once or twice a year Low rate of recurrence or residual disease and thus a safe procedure Not required

Dependence

Does not require routine cleaning

Recurrence or residual disease

High rate of recurrent or residual cholesteatoma Requires second look surgery after 6 months or so to rule out cholesteatoma No limitation. Patient allowed swimming. Easy to wear a hearing aid if needed

Second look surgery

Patients limitations

Swimming can lead to infection of mastoid cavity and it is thus curtailed Problems in fitting a hearing aid due to large meatus and mastoid cavity which sometimes gets infected

Auditory rehabilitation