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PEMICU 3

BLOK
PENGINDERAAN
Agustina Cynthia C. S
405140066
Kelompok 15
LI 1. MMM ANATOMI TELINGA
Anatomi telinga
Telinga luar
TELINGA LUAR, terdiri dari :
1. Auricula
- Terdiri dari kartilago elastik berbentuk ireguler
yang dilapisi o/ kulit tipis
- Terdapat concha, helix, lobulus, tragus
- Suplai arteri  a. temporalis superfisialis dan
arteri2 auricularis post.
- Saraf utama yang ke kulit auricula  N.
auriculatemporalis dan auriculus magnus
- N. auriculus magnus  mmpersarafi
permukaan kranial (medial) atau belakang
telinga dan pars post dan perm. Lateral
(depan).
- N. auriculustemporalis  mmpersarafi
kulit di auricula anterior meatus acusticus
externus
- Drainase imfatik  perm lateral separuh
sup. : nl. Superficiales, perm. Crnial
separuh sup. Auricula bermuara ke nodi
mastoidei dan nl. Cervicales profundi, dan
lobulus ke nl. Cervicales superfisiales
2. Meatus acusticus externus
- Adalah suatu kanal yang mengarah ke dlm melalui
pars tympanica ossis temporalis dari auricula ke
membrana tympanica
- 1/3 lateral kanal adalah kartilaginosa dan 2/3
medialnya adalah tulang
- Glandula sebasea dan ceruminosa pada jaringan
subkutan pars kartilaginea meatus menghasilkan
serumen (earwax)
- Membran tympanica  terdpat pada ujung medial
MAE, perm. Externa di persarafi o/ n.
auriculotemporalis canag dari n.V 3, perm. Internal
di suplai o/ n. glossopharyngeus N. IX
Telinga tengah
TELINGA TENGAH
- Rongga telinga tengah atau cavitas timpani berisi udara yang sempit
pada pars petrosa ossis temporalis, cavitas memiliki dua bagian:
• Cavitas timpani propria: ruang yang mengarah ke sebelah dalam
membrna tympanica
• Recessus epitympanicus: ruang di supperior membrana.
1. Dinding cavitas tympani
- Memiliki enam dinding:
2. Tuba auditiva
- Mengubungkan cavitas timpani dengan nasopharynx, tempatnya bermuara ke
post meatus nasi inferior.
- Fungsinya ialah menyamakan tekanan dalam auris media dengan tekanan
atmosfer, sehingga memungkinkan gerakan membrana tymoanica, dengan
mmbiarkan udara masuk dan keluar cavitas tympani, tuba menyeimbangkan
tekanan pada kedua sisi membrana
- Arteri berasal : a. pharyngea ascendens (cabang arteri carotis externa), a.
meningea media dan a. canalis pterygoideus (cabang a. maxillaris)
- Vena : bermuara ke plexus venosus ptrygoideus
- Drainase limfatik : nl. Cervicales profundi
- Nervus : plexus tympanicus
3. Ossicula auditus
- Membntuk rantai mobil tulang keci yang menyilang cavits tympani dari
membrana tympanica ke fenestra vestibuli, suatu apertura oval pada dinding
labyrinthus cavitas timpani yang mengarah ke vesibulum labyrinthus osseus
- Malleus  nempel pada membrana tympanica, oleh krna itu malleus bergerak
bersama membrna. Berfungsi sebagai pengungkit
- Incus  terletak diantara malleus dan stapes
- Stapes  ossicula paling kecil, basis stapedis melekat pada fenestra vestibuli pda
dinding medial cavitas tympanis
- otot2 yang dihub. Dengan ossicula auditus  dua otot yang mengurangi atau menahan gerakan
ossicula auditus, dan satu otot yang mengurangi gerakan (vibrasi) membrana tympanica:
• M. tensor tympani: menrik manubrium ke medial, yang menegangkan membrana tympanica yang
mengurngi amplituido osilasinya  mencegah kerusakan aurisinterna bila dipajankan pasa suara
keras. Disuplai o/ N. mandbularis.
• Stapedius: menarik stapes ke post. Dan memiringkan basisnya pada fenestra vestibuli 
mmperkuat ligamentum anulare dan mengurangi kisaran osilasi, lig. Juga mencegah gerakan
berlebih stapes. Dan dipersarfi o/ n. fasialis.
Telinga dalam
TELINGA DALAM
- berisi organ vestibulocochlearis yang di hub. Dengan penerimaan suara dan mmpertahankan
keseimbangan.
1. Labyrinthus osseus
- Adalah suatu seri cavitas yang terdapat didalam capsula oticum pars petrosa ossis temporalis
- Cochlea  adalah bagian berbentuk selubung pada labyrinthus osseus yang berisi ductus
cochlearis, bagian auris interna yang berhub. Dengan pendengaran
- Vestibulum labyrinthus osseus  ruang oval yang berisi sacculus dan utriculus dan bag. Aparatus
keseimbangan
- Canalis semicircularis  terdiri dari 3, yaitu anterior, post, lateral. Berhub dengan labyrinthus
osseum.
2. Labyrinthus membranaceus
- Terdiri dari suatu rangkaian dan ductus yang saling berhub. Yang tergantung pada labyrinthus
osseus.
- Bag. Tersebut memilik endolimf,
- Memiliki dua divisi :
• Labyrinthus vestibularis  utriculus dan saculus dua kantong kecil yang berhub dalam vestibulum
labyrinthus osseus
• Labyrithus cochlearis  ductus cochlearis dalam cochlea.
- Ductus semicircularis  memiliki suatu ampulla pada satu ujung yang memiliki area sensorik,
crista ampullaris  u/ merekam gerakan endolimf dalam ampula yang disebabkan o/ rotasi
kepala bidang ductus.
- Ductus cochlears  berisi endolimf
3. Meatus acusticus externus
- Suatu kanal sempit yang berjalan secara lateral dengan panjang kira2 1 cm
dalam pars petrosa ossis temporalis
- Tertutup diseblah lateral o/ lamina tulang tipis perforata yang memisahkannya
dari auris interna
- Melalui lamina ini berjalanya n. facialis, n. vestibulocochlearis, dan pemb. Darah
lainya.
LI 2. MMM HISTOLOGI TELINGA
Histologi
◦ Sistem pendengaran berhubungan dengan pendengaran dan keseimbangan
◦ Sistem pendengaran terdiri dari tiga bagian utama: telinga luar, telinga tengah, dan telinga bagian dalam.
◦ Gelombang bunyi yang diterima oleh telinga luar  getaran mekanis oleh membran timpani  amplifikasi
oleh tulang telinga tengah  ke media cair telinga dalam melalui tingkap oval  transmisi ke otak oleh 2
bagian saraf vestibulokoklear
◦ Telinga dalam berisi perilimf, tergantung suatu labirin membranosa  atur pendengaran dan
mempertahankan keseimbangan
Telinga Luar

Junqueiras Basic Histology Text and Atlas


Telinga
Luar

Junqueiras Basic Histology Text and Atlas


Telinga
Tengah

Junqueiras Basic Histology Text and Atlas


Telinga Dalam

Junqueiras Basic Histology Text and Atlas


Telinga Dalam

Junqueiras Basic Histology Text and Atlas


Telinga Dalam
◦ Terdiri atas :
◦ Labirin tulang
◦ Labirin membranosa
Labirin Tulang
◦ Dilapisi oleh endosteum dan terpisahkan dengan labirin membranosa oleh ruang perilimfatik
◦ Bagian tengah labirin tulang  vestibulum
KANAL SEMISIRKULAR
◦ Terdiri dari 3 kanal semisirkular : superior, posterior dan lateral  saling tegak lurus 1 sama lain
◦ Satu ujung pada setiap kanal melebar  ampula
◦ Di dalam kanal menggantung duktus semisirkular
VESTIBULUM
◦ Bagian tengah labirin tulang yang terletak antara koklea (anterior) dan kanal semirkular (posterior)
◦ Dinding lateral : punya tingkap oval (fenestra vestibuli) dan tingkap bundar (fenestra koklea)
◦ Berisi bagian khusus labirin membranosa : utrikulus dan sakulus
KOKLEA
◦ Berbentuk seperti suatu spiral tulang berongga mirip cangkang keong yang mengitari modiolus
◦ Dari modiolus keluar lempengan tulang yang berjalan spiral :
◦ Lamina spiralis tulang
◦ Ganglion spiralis
Telinga Dalam

Junqueiras Basic Histology Text and Atlas


Labirin Membranosa
◦ Terdiri dari epitel yang berasal dari ektoderm embrionik  masuk tulang temporal yang masih dalam
perkembangan  bentuk 2 kantong kecil : sakulus dan utrikulus, duktus semisirkular dan duktus koklear
◦ Endolimf  cairan kental yang mengalir di dalam lamina membranosa
Sakulus dan Utrikulus
Sakulus dan Utrikulus
◦ Memiliki 3 saluran :
◦ Duktus utrikulosakularis
◦ Duktus endolimfatik, ujung buntunya  sakus endolimfatik
◦ Duktus reuniens
◦ Dinding sakulus dan utrikulus terdiri atas lapisan jaringan ikat vaskular bagian luar yang tipis, lapisan dalam
terdiri atas epitel gepeng dan kuboid selapis
◦ Daerah khusus yang berperan sbg reseptor  makula sakuli dan makula utrikuli
◦ Ada 2 sel :
◦ Sel terang  absorpsi endolimf
◦ Sel gelap  mengatur komposisi endolimf
Sakulus dan Utrikulus

Junqueiras Basic Histology Text and Atlas


Sel Rambut Sakulus dan Utrikulus

Junqueiras Basic Histology Text and Atlas


Duktus Semisirkular

Junqueiras Basic Histology Text and Atlas


Duktus
Koklear
dan Organ
Corti

Junqueiras Basic Histology Text and Atlas


LI 3. MMM FISIOLOGI PENDENGARAN
Pendengaran
◦ Pendengaran: persepsi energi suara oleh saraf
◦ Gelombang suara: getaran udara yang merambat yang tdd daerah-daerah bertekanan tinggi akibat kompresi
(pemadatan) molekul udara bergantian dengan daerah-daerah bertekanan rendah akibat penjarangan
(peregangan) molekul udara
◦ Suara ditandai oleh:
 Nada: ditentukan oleh frekuensi getaran
 Intensitas atau kekuatan: ditentukan oleh amplitudo gelombang suara
 Warna suara atau kualitas: bergantung pada overtone (frekuensi tambahan yang mengenai nada dasar)
Telinga
◦ Masing-masing telinga tdd:
 Telinga luar: aurikulus atau pinna,
meatus auditorius eksterna, membran
timpani
 Telinga tengah: osikulus auditorius, otot-
otot auditorius, Tuba Eustachii
 Telinga dalam: saluran labirin
Telinga luar
◦ Aurikulus atau pinna (daun telinga):
 Tdd lempeng fibrokartilaginus yang terbungkus oleh jaringan ikat dan kulit
 Kulit yang menutupinya tipis dan mengandung banyak rambut halus serta kelenjar sebasea
 Lekukan pada aurikulus yang membentuk orifisium meatus auditorius eksterna  konka
◦ Meatus auditorius eksterna:
 Berawal dari konka membentang ke dalam sebagai kanalis yang sedikit melengkung dgn panjang sekitar 55 mm
 Tdd bagian kartilaginous di sebelah luar dan bagian oseus (tulang) di sebelah dalam
 Kulit yang melapisi saluran mengandung kelenjar keringat modifikasi  serumen (sekresi lengket yang menjebak
partikel-partikel kecil asing)
◦ Membran timpani
 Membran tipisyang semi transparan dan memisahkan telinga tengah dengan meatus auditorius eksternus
 Bergetar ketika terkena gelombang suara
Telinga tengah / kavum timpani
◦ Osikulus auditorius
 Tiga buah tulang yang tersusun berbentuk rantai yang membentang melewati telinga tengah dari membran timpani
hingga foramen ovale: maleus, inkus, dan stapes
 Sewaktu membran timpani bergetar sebagai respons terhadap gelombang suara  rangkaian tulang ini ikut bergerak
dengan frekuensi yang sama  memindahkan frekuensi getaran ini dari membran timpani ke jendela oval
◦ Otot auditorius
 Terdapat 2 buah otot skeletal yang melekat pada osikulus: tensor timpani dan stapedius
 Fungsi M. Tensor Timpani: menarik membran timpani dan menjaganya agar selalu berada dalam keadaan teregang atau
terentang  penting untuk proses transmisi gelombang suara yang dapat mencapai setiap bagian dari membran timpani
 Fungsi M. Stapedius: mencegah gerakans tapes yang berlebihan. Saat kontraksi  menarik kolum stapes ke belakang
dan mengurangi gerakan footplate terhadap cairan dalam koklea
◦ Tuba Eustachii
 Saluran yang terbentang dari dinding anterior telinga tengah ke dalam nasofaring
 Menghubungakan telinga tengah dengan pars posterior rongga hidung  bentuk saluran udara antara telinga tengah
dan atmosfer  tekanan antara kedua sisi membran timpani akan sama besarnya
Refleks timpani
◦ Merupakan refleks atenuasi yang ditandai oleh kontraksi involunter muskulus tensor timpani dan stapedius
ketika merespon suara yang keras
◦ Kedua otot tsb kontraksi  manubrium maleus bergerak ke dalam sedangkan stapes tertarik keluar 
rigiditas osikulus auditorius  transmisi suara berkurang
◦ Makna relfeks timpani
 Melindungi membran timpani terhadap kemungkinan ruptur karena suara yang keras
 Mencegah terfiksasinya footplate os stapes pada foramen ovale ketika mendengar suara yang keras
 Membantu melindungi kokea terhadap kerusakan akibat suara yang keras
Telinga dalam / labirin
◦ Struktur membranous yan gterbungkus di dalam labirin tulang pada pars petrosus os temporalis
◦ Labirin tdd organ indera pendengaran (koklea) dan keseimbangan (aparatus vestibularis)
Koklea
◦ Sistem tubulus bergelung yang terletak jauh di dalam tulang temporal
◦ Tdd 3 kompartemen:
 Kompartemen atas: skala vestibuli
 Kompartemen tengah: duktus kokhlearis / skala media
 Kompartemen bawah: skala timpani
◦ Membran vestibularis yang tipis membentuk atap duktus koklearis, dan memisahkannya dari skala vestibuli
◦ Membran basilaris membentuk lantai duktus kokhlearis, memisahkannya dari skala timpani dan mengandung organ
corti
◦ Skala vestibuli dan skala timpani mengandung cairan perilimfe, sedangkan pada skala media mengandung endolimfe
◦ Skala vestibuli dipisahkan dari rongga telinga oleh jendela oval
◦ Lubang kecil lain yang ditutupi oleh membran (membran timpani sekunder), yaitu jendela bundar menutup skala
timpani dari telinga tengah
Organ corti
◦ Terletak di atas membran basilaris di seluruh panjangnya dan mengandung sel rambut (reseptor suara)
◦ Sel rambut tersusun menjadi 4 baris sejajar di seluruh panjangmembran basilaris:
 1 baris sel rambut dalam
 3 baris sel rambut luar
◦ Dari permukaan masing-masing sel rambut menonjol sekitar 100 rambut: stereosilia  berkontak dengan
membran tektorium
◦ Sel rambut dalam
 Sel yang mengubah gaya mekanis suara (getaran cairan koklea)  impuls listrik pendengaran
 Berhubungan melalui suatu sinaps kimiawi dengan ujung serat-sert saraf aferen  nervus auditorius (kokhlearis)
◦ Sel rambut luar
 Tidak memberi sinyal ke otak tentang suara yang datang
 Secara aktif dan cepat berubah panjang sebagai respon terhadap perubahan potensial membran (elektromotilitas)
 Sel rambut luar memendek pada depolarisasi dan memanjang pada hiperpolarisasi  menegaskan gerakanmembran
basilaris  meningkatkan respon sel rambut dalam  peka terhadap intensitas suara dan dapat membedakan berbagai
nada suara
Mekanisme
pendengaran
Lintasan auditorius
◦ Reseptor: sel rambut dalam organ Corti  diinervasi oleh serabut saraf aferen dan eferen, serabut saraf aferen
membentuk nervus auditorius
◦ Neuron urutan pertama:
 Sel bipolar  ganglion spiralis
 Dendrit sel bipolar tersebar di sekeliling sel rambut organ Corti (serabut aferen)
 Akson meninggalkan meatus auditorius interna sebagai nervus koklearis  medula oblongata  nukleus koklearis ventralis dan
dorsalis
◦ Neuron urutan kedua:
 Neuron pada nukleus koklearis ventralis dan dorsalis dalam medula oblongata
◦ Neuron urutan ketiga:
 Terletak dalam nukleus olivarius superior dan nukleus lemniskus lateralis
 Berakhir dalam korpus genikulatum medialis (pusat auditorius kortikal)  korteks temporalis sebagai radiasio auditorius
◦ Pusat auditorius kortikal
 Berada dalam lobus temporalis korteks serebri
 Berupa area 41, area 42 dan area Wernicke
LI 4. MMM GANGGUAN PADA
TELINGA LUAR
Pre-auricular sinus
◦ The outer ear is formed from cartilagenous tubercles of first arch origin which fuse to form the pinna
◦ A blind-ended sinus results from incomplete fusion and the inclusion of epithelial tissue forms a skin lining
to the sinus
◦ The barnchio-oto-renal syndrome: an autosomal dominant gene and includes external ear abnormality, pre-
auricular sinus and renal disorder
Presentation
◦ The opening of the sinus is apparent at birth and is often
bilateral
◦ There may be some sebaceous discharge from the punctum
◦ In some patients there is recurrent episodic infection which
may progress to abscess formation
Treatment
◦ Is the sinus is free of infection, it can be left alone
◦ Repeated episodes of infection  should be excised
OTITIS EKSTERNA
Otitis Externa
Definisi Faktor Predisposisi

◦ Generalized condition of the skin of the external


auditory canal that is characterized by general
oedema and erythema associated with itchy
discomfort and usually an ear discharge.
Otitis Externa
Etiology
◦ Any condition or situation that disturbs the lipid/acid balance of the ear  predispose
◦ Water and moisture  change from a predominantly Gram-positive skin flora to a Gram-
negative one.
◦ Inflamed  healthy cerumen is rapidly removed from the ear and is no longer produced.
◦ Bathing  bathing in freshwater lakes containing pseudomonas
◦ Allergies reactions  treatment of otitis externa is often with topical medications and sensitivity
to these can actually exacerbate the condition (neomycin, steroid)
◦ Secondary bacterial infection
Pathology
STAGE 1 : PRE-INFLAMMATORY
◦ The protective lipid/acid balance lost and the stratum corneum becomes oedematous, blocking off the
sebaceous and apocrine glands producing aural fullness and itching  with further oedema and scratching 
disruption of the epithelial layer and invasion of resident or introduced organisms
STAGE 2 : ACUTE INFLAMMATORY
◦ Progressively thickening exudate, further oedema, obliteration of the lumen (mild, little or no obliteration;
moderate, subtotal obliteration; severe, complete obliteration) and increasing pain
◦ Severe stages  auricular changes and cervical lymphadenopathy
STAGE 3 : CHRONIC INFLAMMATORY
◦ lasting longer than three weeks
◦ Thickening of the external canal skin and fibrous canal stenosis
Otitis Externa
Diagnosis Prognosis dan Komplikasi

◦ Pain, itch, oedema, erythema of the external ◦ If untreated mild attacks of otitis externa can
auditory canal with purulent otorrhea and debris spontaneously resolve as the epithelial barrier
in the meatus becomes re-established
◦ If the inflammation progresses faster than repair,
increasing pain, otorrhoea and oedema of the
canal occurs
◦ Due to the rich lymphatic drainage of the area,
lymphadenopathy often occurs and soft tissue
infection progresses  perichondritis, chondritis,
cellulitis, parotitis and/or erysipelas
Management
AURAL TOILET
◦ Most effective single treatment
◦ Irrigation of the ear canal is effective for the removal of debris
TOPICAL MEDICATION
◦ Glycerol and ichthammol is commonly used with an aural wick for moderate and severe cases
◦ proven dehydrating and antiinflammatory properties and antibacterial activity against Streptoccoci and
Staphylococci, poor activity against Pseudomonas
◦ The dehydrating  reduces canal oedema and also helps reduce pain, oral analgesia  moderate or severe
cases
◦ Nonsteroidal antiinflammatories (not contraindicated)  excellent analgesics for otitis externa
PREVENTION OF RECCURENCE
◦ Prone to recurrent attacks, avoidance of water penetration into the ear
◦ Cotton wool with petroleum jelly  work well in the bath or shower and custom made ear moulds 
expensive
◦ Neoprene head bandages are a useful adjunct with the above for children in swimming pools.
◦ The use of alcohol or proprietary preparations after swimming
◦ Blow-driers  help remove moisture
Otomikosis
◦ Fungal otitis externa
◦ Hot, humid climates, secondary to prolonged treatment
with topical antibiotics.
◦ Predispose  diabetes and immunocompromised
◦ Etiology :
◦ Aspergillus  80 – 90%
◦ Candida  10 – 20%
◦ Clinical finding :
◦ Black, grey, green, yellow or white discharge with debris
◦ Sometimes debris is seen with visible fungal hyphae
Management
◦ Toilet and removal of the debris
◦ Topical antifungal drops (e.g. Locorten-Vioform)
◦ Resistant otomycosis  immunotherapy with dermatophyte (Trichophyton, Oidiomycetes and
Epidermophyton (TOE)) extracts and dust mite  TOC
◦ Fungi can cause invasive otitis externa especially in immunocompromised patients  systemic antifungal
SERUMEN PROP
Serumen prop
• Earwax is a beneficial substance and does not
routinely need to be cleaned or removed.
• In some persons, however, the earwax does
not extrude but becomes impacted in the canal
preventing the normal transmission of sound.
• Earwax is a beneficial substance and does not
routinely need to be cleaned or removed. In
some persons, however, the earwax does not
extrude but becomes impacted in the canal
preventing the normal transmission of sound.
- this is amenable to removal by either syringing, probe removal or removal
under microscopic control.
- Wax softening  Occlusive wax, especially if adherent to the canal wall, may
need to be softened prior to removal
- to soften the wax, the patient is asked to turn their head on the side to allow
the external canal to be filled with water and liquid soap (decreases surface
tension of water) or a wax softener. The tragus is then pushed in and out to aid
penetration into the wax. The patient should continue this for about 20 minutes
prior to syringing. If the wax remains adherent and resistant to syringing, the
patient should be sent home with instructions to repeat this manoeuvre
regularly for the rest of the day and the next morning before syringing is
attempted again.
- The syringe is filled with warm water at body
temperature. A headlight should be worn to
illuminate the external canal adequately, while the
canal is straightened by pulling the pinna
posterosuperiorly. If a gap is present between the
wax and the canal wall, the stream of water should
be bounced off the wall at that point. This allows
water pressure to be generated behind the wax
plug and will result in its extrusion (Figure 235.7).
If there is no gap, the stream of water should be
directed at the junction of the wax and the canal
and a gap created allowing the water to generate
pressure behind the wax plug. Depending on the
size of the wax plug, a number of syringefuls may
be required before extrusion occurs. Once
otoscopy confirms the clearance of the wax plug,
the canal needs to be dried with either a piece of
string placed down the ear canal or by mopping
the canal.
- Mopping the ear canal  A mop can be used to dry the ear canal after syringing
or to remove discharge or debris from the ear canal.
BENDA ASING
Foreign bodies in the ear
Etiology Symptoms

◦ Most commonly: cotton wool, insects, beads, ◦ Children may present asymptomatically, or pain
paper, small toys and erasers or a discharge caused by otitis externa
◦ Foreign bodies in the external auditory meatus ◦ Live insects in the ear, commonly small
are most commonly seen in children who have cockroaches, are annoying due to discomfort
inserted them into their own ears created by loud noise and movement
◦ Adults are often seen with cotton wool or broken
matchsticks which have been used to clean or
scratch the ear canal
Therapy
Complications
◦ Lacerations of the canal skin
◦ Otitis externa
◦ Facialnerve palsy secondary to leakage of alkaline materialfrom a button battery and necrosis of the
surrounding tissue (rare)
◦ Complications may occur during attempted removal: canal wall lacerations
◦ Damage and perforation of the tympanic membrane, and even ossicular chain dislocation or fracture may
occur
HERPES ZOSTER PADA TELINGA
Herpes zoster oticus (Ramsay Hunt
Syndrome)
◦ A herpetic vesicular rash on the concha, external auditory canal or pinna with a lower motor neuron palsy of
the ipsilateral facial nerve

ETIOLOGY
◦ The disease is a reactivated varicella zoster infection from dormant viral particles resident in the geniculate
ganglion of the facial nerve and the spiral and vestibular ganglia of the VIIIth nerve
Signs & symptoms
◦ The VIIIth nerve may be involved to a variable degree  heraing loss, tinnitus and/or vertigo
◦ Auricular pain
◦ Facial palsy
◦ 14% patients, the rash is not present initially but develops several days after the onset of pain and facial palsy.
In some cases, the vesicular rash may in fact present on the tongue or pharyngeal mucosa and never present
in the ear
◦ Zoster sine herpete: a facial palsy caused by the zoster virus, but with no rash
◦ This makes herpes zoster oticus the second commonest cause of unilateral facial pasly after idiopathic Bell’s
palsy
Diagnosis
◦ The diagnosis is essentially still a clinical one
◦ MRI and CSF analysis having been shown to have no role in establishing either diagnosis or prognosis
◦ Acute phase  MRI can actually be confusing as the inflammation of the nerve in the internal auditory canal
can occasionally be mistaken for a small vestibular schwannoma
Therapy
◦ Treat early with oral acyclovir (800 mg x 5/day) and prednisolone ( 1 mg/kg/day)
◦ Treat before the vesicles appear
LI 5. MMM GANGGUAN PADA
TELINGA TENGAH
OTITIS MEDIA AKUT
Otitis Media Akut Bakteri
Haemophilus
influenzae
Streptococcus
pneumoniae
Moraxella catarrhalis
Streptococcus aureus
Bakteri lain
Tidak tumbuh

Infeksi dari lapisan mukosa telinga bagian tengah dan sistem


mastoid air-cell disebabkan oleh bakteri atau virus.

Gleeson M, Browning GG, Burtin MJ, Clarke R, Hibbert J, Jones NS et al, editors. Scott-Brown’s Otolaryngology, 7th ed.
Otitis Media Akut
Anamnesa PF

◦ Gejala lokal ◦ Inspeksi membran timpani di kedua telinga dan


◦ Sakit telinga, pendengaran menurun, otorrhea, membandingkannya
tinnitus
◦ Keluarkan serumen dg Q-tips, serumen loop,
◦ Gejala umum atau vacuum aspirator
◦ Demam, iritabel, agitasi nokturnal, ggg GIT
◦ Tanyakan mengenai ISPA

Gleeson M, Browning GG, Burtin MJ, Clarke R, Hibbert J, Jones NS et al, editors. Scott-Brown’s Otolaryngology, 7th ed.
Otitis Media Akut
Diagnosa Tatalaksana

◦ Injeksi timpani ◦ Antibiotik  tidak direkomendasikan pd 48 jam


◦ Hiperemis pd membran pertama

◦ Bulging ◦ Analgesik

◦ Ada perforasi & otorrhea

Komplikasi
◦ Mastoiditis akut
◦ Facial palsy

Gleeson M, Browning GG, Burtin MJ, Clarke R, Hibbert J, Jones NS et al, editors. Scott-Brown’s Otolaryngology, 7th ed.
Management of Acute
Conservative treatment
(analgesics and anti-
Episodes
• Ibuprofen
pyrexials)
• Paracetamol

Indication Antibiotic : Antibiotic


• Who fails improve after 2-3 • Amoxicillin-
days of watchful waiting clavulonate
• An iregular illness course • Cefuroxime axetil
• High risk :
orally
immunodeficiencies
• Ceftriaxone IM

Indication of surgical treatment:


• Severe cases (complication is Myringotomy
present/ suspected)
• To relieve severe pain

Gleeson M, Browning G, Burton M,Clarke R, Hibbert J, Jones N S,etc. Scott-brown’ s


Otorhinolaryngology, Head and Neck Surgery. 7th ed vol: 1
OTITIS MEDIA SEROSA
Otitis media with effusion
◦ Akumulasi mukus di telinga bagian tengah dan ◦ Diagnosis
terkadang di sistem udara sel mastoid yang bersifat
kronik ◦ radiology
◦ Etiologi ◦ Otoscopy
◦ infeksi : Streptococcus pneumoniae, Haemophilus
influenzae, Moraxella catarrhalis dan adenovirus ◦ tympanometry
◦ Patologi di nasofaringeal ◦ Terapi
◦ Alergi
◦ Medikasi
◦ Obstruksi tuba eustasia
◦ Gejala Klinis
◦ Operasi
◦ Kehilangan pendengaran ◦ Alat bantu pendengaran
◦ Telinga terasa penuh
◦ Komplikasi
◦ Tinnitus
◦ nyeri di telinga dan pusing ◦ Atelektasis dari membran timpani
◦ Meningitis
◦ sensorineural hearing lose
Scott-brown’s otorhinolaryngology, head and neck surgery volume 3
Otitis media with effusion in adults
Ch. 237 b page 3388-3393
OTITIS MEDIA KRONIK
Definisi Abnormalitas permanen pada pars tenda dan flasida
Klasifikasi • Active (ada inflamasi dan produksi pus)
• Mucosal (perforasi dengan otorhea)
• Squamous (kolesteatoma)
• Inactive (ada potensi menjadi aktif)
• Mucosal (dry perforation)
• Squamous (retraksi, atelektasis epidermizartion)
• Healed (permanen abnormalitas, tidak potensi menjadi aktif lagi karena hasil
akhir dari pembedahan)
• Tympanosclerosis, healed perforation
INACTIVE MUCOSAL (dry perforation)
- Perforasi permanen pada pars tensa, dapat meluas ke annulus/terkepung
oleh pars tensa
- Tidak inflamasi
- Tympanoplasti (eksisi epitel skuamosa yang masih tumbuh)
INACTIVE SQUAMOUS EPITHELIAL
- Tekanan negatif statis pada telinga tengah  retraksi (atelektasis) membran
timpani  retraction pocket
- Epidermisasi (pergantian mukosa telinga tengah dgn keratin tanpa retensi
debris keratin)
ACTIVE MUCOSAL (perforasi dengan otorrhea)
- Terdapat inflamasi kronik pada telinga tengah
- Perubahan mukosa membentuk “aural polyps” (menonjol melalui defek pada
membran timpani)
Scott's Brown 7th Edition
Klasifikasi ACTIVE SQUAMOUS EPITHELIAL
- Ada retensi debris keratin (keratoma)
- Koleostoma dapat kering (tertutup keratin) atau disertai infeksi bakteri 
otorrhea yg berbau busuk
- Koleostatoma dapat berbahaya karena memicu resorpsi tulang
HEALED
- Healed perforation (akibat proses penyembuhan yg gagal  membentuk
“dimeric membrane” (terdiri dari epidermis dan mukosa saja), cenderung
retraksi akibat tekanan negatif)
- Tympanosclerosis (terdapat deposit hyalin (white plaques di timpani
membran atau white nodular di lapisan submukosa), hasil akhir dari
proses penyembuhan, dapat menyebabkan imobilitas tulang
pendengaran)
- Fibrosistik dan fibro-oseus sklerosis (penyembuhan  formasi fibrosis
dan kista  fibrooseus sklerosis  neoosteogenesis  conductive
hearing loss), bersifat non progresif, kontraindikasi terhadap
tympanoplasty
Etiologi Otitis media akut, otitis media akut efusi, genetik, ras, lingkungan, disfungsi
tuba eustachius, refluks gastroesophageal, penyakit autoimun
Tatalaksana Pembedahan, alat bantu dengar (bagi yang ada gangguan pendengaran), atau
tanpa tatalaksana
Scott's Brown 7th Edition
OTITIS MEDIA KRONIK

Scott's Brown 7th Edition


OTITIS MEDIA KRONIK PADA ANAK
Definsi Inflamasi kronik pada telinga tengah
Gejala Otorrhea dan hearing loss
Komplikasi Kantung retraksi, perforasi membran timpani, kelainan tulang
pendengaran, kolesteatoma
MASTOIDITIS
Mastoiditis
◦ inflammation with the mastoid air-cell system
◦ Extension of infection & inflammation during acute otitis media
◦ Traditional teaching  preceed by 10-14 days of middle ear symptoms

◦ Etiology
◦ 20% dont grow bacteria
◦ S. Pneumoniae, S. Pyogenes, P. Aeruginosa, S. Aureus (common)
◦ H. Influenza (< common); M. Catarrhalis, P. Mirabilis (rare)

◦ Epidemiology
◦ Disease of childhood
◦ 28 % < 1yo; 38%  4yo; 8%  8-18yo; 4%  > 18 yo
◦ US  1..2 – 2% per 100,000
Mastoiditis
Symptoms Signs

◦ Systemic signs of infection (fever & malaise) ◦ Red/buldging tympanic memb


◦ Mastoid tenderness & localized reactive ◦ Retro-auricular swelling
lymphadenopathy
◦ Tenderness is typically sited over MacEwen’s
◦ In children triangle
◦ Erythema &/ edema of everlying mastoid soft
tissue ◦ On palpation through conchal bowl)
◦ Otalgia & irritability ◦ Pinna protrusion
◦ In adult ◦ Sagging of post wall of ext auditory canal
◦ Local pain & tenderness
◦ Otorrhea (30%)
Clinical course
◦ Infection may spread to mastoid periost via emissary veins  acute mastoiditis & periostitis  no abscess;
symptoms (+)
◦ Destruction of mastoid bone’s air cells 
◦ Subperiosteal abscess (post auricular region)
◦ Zygomatic abscess (above & in front of pinna)
◦ Bezold’s abscess
◦ Retropharyngeal / parapharyngeal abscess
◦ Pus tracking down peritubal cells

◦ Subacute (masked) mastoiditis in incompletely treated AOM after 10-14 days of infection
◦ Sign (-); otalgia & fever persist  serious complication
Mastoiditis
Examination DD and Complication

◦ Full blood count, CRP, blood culture ◦ DD :


◦ AOM
◦ CT scan of mastoid
◦ Otitis externa
◦ Reveal osteitis, abscesses, intracranial complications
◦ Furunculosis
◦ Reactive lymphadenopathy
◦ Undiagnosed cholesteatoma
◦ Wegener’s granulomatosis

◦ Complications
◦ Intracranial complications (6-17%)
Treatment
◦ Modern antimicrobials + radiographic ◦ Myringotomy with/-out ventilation tube
monitoring placement
◦ Early performance of myringotomy ◦ Culture of aspirate & high-dose IV antibiotics
◦ Mastoid surgery (mastoidectomy) ◦ Abscess drainage with/-out cortical
◦ Indication  failure of improvement despite mastiodectomy
aggressive medical management, development of ◦ If failure to improve, subperiosteal abscess
other intracranial complications formation, complication developments
◦ Goal of surgery  drainage of mastoid, removal
of granulation tissue, restoration of normal
ventilatory pathways
◦ + continuation of antibiotic theraoy postoperatively
for weeks
PERFORASI MEMBRAN TIMPANI
Perforasi Membran Timpani
Biasanya timbul sekunder terhadap otitis media akut

Tubotimpanik Sentral
(anterior dan inferior)
Perforasi membran
timpani

Atticoantral
Marginal
(posterior dan superior)

Manifestasi Klinis
• Tidak ada inflamasi → asimtomatik
• Hilang pendengaran minimal (kecuali ada
discharging/penyakit-penyakit osikular)
• Discharge pada telinga → pucat dan opak
Pemeriksaan
• Inspeksi → lumen saluran telinga terisi cairan
mukoid
• Otoskopi
• Membran timpani → menebal, opak, perforasi;
dapat terlihat mengalami inflamasi, pembuluh
darah yang lebih jelas
• Dari perforasi dapat terlihat → derajat
inflamasi mukosa telinga tengah, integritas
rantai osikular
• Audiologi (mulai usia 4 tahun)

Tatalaksana
• Farmakologi : antibiotik topikal / sistemik, steroid
topikal, antiseptik topikal
• Nonfarmakologi : aural toilet, bedah penutupan
perforasi membran timpani / timpanoplasti
TIMPANOSKLEROSIS
Tympanosklerosis
◦ Merupakan hasil akhir dari proses penyembuhan COM (chronic otitis media) dimana kolagen dan jaringan
fibrosa mengalami proses hyalinisasi, kehilangan strukturnya dan bergabung menjadi satu masa homogen.
Tympanosklerosis
MIRINGITIS BULLOSA
Bullous myringitis
◦ Bullous myringitis (myringitis bullosa haemorrhagica): the finding of vesicles in the superficial layer of the
tympanic membrane
◦ The vesicles occur between the outer epithelium and the lamina propia of the tympanic membrane
Etiology
◦ Cultures from aspirates of the vesicles and middle ear fuid  similar to that in acute otitis media
◦ Infection by influenza virus or by Mycoplasma pneumoniae has been suggested as the aetological agent but no
evident for this
Signs & symptoms
Symptoms Signs

◦ Sudden onsetof severe, usually unilateral, often ◦ Otoscopy: blood-filled, serous or serosangious
throbbing pain in the ear blisters involving the tympanic membrane &
◦ The symptoms usually set in during or following sometimes the medial aspect of the ear canal
an upper respiratory tract infection ◦ A serosanginous secretion can be seen if the
◦ A bloodstained discharge can be present for a blisters rupture
couple of hours ◦ Tympanic membrane is intact
◦ Hearing impairment (conductive and/or
sensorineural)is common in the affected ear
Examination
◦ Inspection of the ear
◦ Pneumatic otoscopy and tympanometry  help determine whether the middle ear contains fluid
◦ Clinical evaluation of the crainal nerves and, in particular, the facial nerve  to distinguish from herpes
zoster oticus
◦ Pure-tone audiogram including bone conduction thresholds is essential for detection of sensorineural hearing
impairment
Diagnosis
Diagnosis Differential diagnosis

◦ Based on physical examination: vesicles in the ◦ Acute otitis media


superficial layer of the tympanic membrane are
◦ Herpes zoster oticus /Ramsay Hunt Syndrome
present
Therapy
◦ Without middle ear affection and without sensorineural hearing loss analgesics
◦ When the middle ear is affected  antibiotics can be used as in the treatment of acute otitis media
◦ In children <2 yrs  acute bullous myringitis should be trated as acute otitis media
KOLESTEATOMA
Kolesteatoma
◦ The stratified squamous epithelium of the tympanic
membrane and external ear canal can migrate prior to
being shed at the entrance to the external meatus  the
ear canal protects itself from filling with shed
keratinocytes.
◦ Under some circumstances, squamous epithelium
accumulates within the temporal bone  if the squamous
epithelium and accumulating keratinocytes are within the
middle ear space  cholesteatoma
Klasifikasi
Congenital Cholesteatoma Acquired Cholesteatoma

◦ Keratin cysts may accumulate because the ◦ Keratin accumulates within a diverticulum of
tympanic membrane squamous epithelium which
epithelium from which they arise is closed  as a extends into the middle ear  keratin accumulates
result of developmental abnormality or may be as a result of inadequate epithelial migration
iatrogenic. ◦ Proses :
◦ Criteria of Derlaki and Clemis: ◦ Immigration  migration of squamous epithelium
into the middle ear through a defect in the tympanic
◦ white mass medial to an intact tympanic membrane membrane
◦ normal pars tensa and flaccida ◦ Retraction  progressive retraction of the tympanic
membrane, either in the pars flaccida or associated with
◦ no previous history of ear discharge, atrophy of the pars tensa
perforation or previous otological procedures ◦ Basal cell hyperplasia  proliferation of the basal
layers of the keratinizing epithelium of pars flaccida
Klasifikasi : Iatrogenic Cholesteatoma
◦ Implantation of squamous epithelium as a result of blunt or sharp trauma to the tympanic membrane
Symptoms
Cholesteatoma
Diagnosis Treatment

• Audiology : kemampuan mendengar mungkin ◦ Surgical removal  tujuannya :


bisa berubah (baik/buruk) ◦ Membuang semua cholesteatoma
• Pemeriksaan dengan anestesi : untuk periksa ◦ Mencegah cholesteatoma yang akan datang
bagian atap membran tympani ◦ Untuk mendapat telinga yang tahan dari air
◦ Pengembalian pendengaran
ABSES BENZOLD
Bezold’s abscess
◦  abscess that result from perforation of the medial mastoid cortex  tracking down the sternomastoid to
the posterior triangle

◦ Epidemiology
◦ predominantly in adults (13 of 15, 87%) who were male (12 of 15, 80%

◦ Etiology
◦ complicated by
◦ a suboccipital epidural abscess, hearing deficit, and thromboses of the sigmoid and transverse sinuses, mastoiditis
◦ gram-positive aerobes (Streptococcus species, Staphylococcusspecies, Enterococcus),
◦ gram-negative aerobes (Klebsiella, Pseudomonas, Proteus),
◦ anaerobes (Peptostreptococcus and Fusobacterium species)

Medscape.com
Pathophysiology
◦ lateral aspect of the mastoid process is composed of thicker bone than that of the medial wall
◦ insertion point for the digastric, sternocleidomastoid, splenius capitis, and longissimus capitis muscles

◦ Thicker lateral mastoid process & confluence of the neck muscles  strong barrier against pus laterally 
pus in the mastoid erodes through the area of least resistance, the mastoid tip, which is inferior and media
◦ abscesses are formed deep in the neck musculature
◦ evade early detection

◦ Larger abscess  disease in the suprascapular, suprasternal, parapharyngeal, paralaryngeal, and even
contralateral axilla/ neck
◦ Extension to vertebrae or base of the skull  death
Diagnosis
Symptoms Diagnosis

◦ neck pain, ◦ Plain films of the mastoid


◦ opacification of the mastoid air cells
◦ neck mass,
◦ contrast-enhanced CT imaging of the temporal
◦ post auricular pain,
bone and neck provides the most useful
◦ otalgia, information
◦ otorrhea, ◦ CT scan of the chest
◦ suspicion of deeper thoracic/ vertebral abscess spread
◦ Less common: fever, headache, hearing loss,
facial paralysis, or cervical lymphadenopathy ◦ MRI & magnetic resonance angio gram of the head
◦ brain involvement is present
Treatment & complication
Treatment Complication

◦ Antibiotics directed at the causative organisms + ◦ Hearing loss


mastoidectomy
RESEP