PEMICU 3

BLOK PENGINDERAAN

Michell
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.
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

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.
 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
– Pre-inflammatory
• Protective acid balance (pH 4-5) is lost  stratum corneum become
oedematous  blocking off the sebaceous & apocrine glands  aural
fullness & itching
• Further oedema & sctratching  disruption of epithelial layer  invasion
of resident/introduced organisms
– Acute inflammatory
• Progressive thickening exudate, further oedema, obliteration of the
lumen, pain >>
• Auricular change & cervical lymphadenopathy (severe)
– Chronic inflammatory
• Remain of low pH + > 3 weeks  thickening of external canal & fibrous
canal stenosis (acquired atresia of the external ear)
• Diagnosis (signs & • Complications
symptoms) – Perichondritis
– Pain, itch, oedema, – Chondritis
erythema of the external – Cellulitis
auditory canal – Parotitis
– With purulent otorrhoea & – Erysipelas
debris in meatus
• Managements
– Aural toilet
• With/-out microscopic assistance
– Topical medication
• Glycerol & ichthammol (90:10%) with aural wick (moderate & severe)
– Dehydrating effects  < pain, oedema
• NSAID (if not contraindicated)
• Combination drop of neomycin, polymyxin-B, hydrocortisone
– AE  filmy debris (mistaken for fungal overgrowth
– Neomycin & gentamycin  Staphyllocooccus
– Polymyxin-B  Pseudomonas & Staphyllococcus
• Quinolone (for no known risk of ototoxicity & it is sensitive to
Pseudomonas)
– Prevention of reccurence
• Avoidance of water penetration
• Cotton wool + petroleum jelly in bath / shower
• Alcohol / proprietary preparations (aqua-ear/ear-calm) after
swimming
• Blow driers (not on hot setting)  remove moisture
• Reccurent otitis externa with ear-mould hearing aid patient 
bone-anchored hearing aid
OTOMIKOSIS
 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
• Most commonly: cotton wool,
insects, beads, paper, small toys and
erasers
• Foreign bodies in the external
auditory meatus are most commonly
seen in children who have inserted
them into their own ears
• Adults are often seen with cotton
wool or broken matchsticks which
have been used to clean or scratch
the ear canal
Symptoms
• Children may present
asymptomatically, or pain or a
discharge caused by otitis
externa
• Live insects in the ear,
commonly small cockroaches,
are annoying due to discomfort
created by loud noise and
movement
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
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, 7 th ed.
 Otitis Media Akut
Anamnesa PF
• Gejala lokal • Inspeksi membran timpani di
– Sakit telinga, pendengaran kedua telinga dan
menurun, otorrhea, tinnitus membandingkannya
• Gejala umum • Keluarkan serumen dg Q-tips,
– Demam, iritabel, agitasi nokturnal, serumen loop, atau vacuum
ggg GIT
aspirator
• Tanyakan mengenai ISPA

Gleeson M, Browning GG, Burtin MJ, Clarke R, Hibbert J, Jones NS et al, editors. Scott-Brown’s Otolaryngology, 7 th ed.
 Otitis Media Akut
Diagnosa Tatalaksana
• Injeksi timpani • Antibiotik  tidak
• Hiperemis pd membran direkomendasikan pd 48 jam
• Bulging pertama
• Ada perforasi & otorrhea • Analgesik

Komplikasi
• Mastoiditis akut
• Facial palsy

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

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

Indication of surgical
treatment:
• Severe cases Myringotom
(complication is present/ y
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. 7 th ed vol: 1
 Acute otitis media in children
• ~ acute suppurative otitis media
•  inflammation of the middle ear cleft of rapid onset & infective origin,
associated with a middle ear effusion

• Subgroups
– Sporadic episodes
•  infrequent isolated events; occurring with respiratory tract infection
– Resistant AOM
•  persistence of symptoms & signs of middle ear infection beyond 3-5 days of antibiotic
treatment
– Persistent AOM
•  persistence / recurrence of symptoms & signs of AOM > 6 days of finishing a course of
antibiotics
– Reccurent AOM
•  >=3 episodes of AOM in 6 mo period/4-6 episodes in 12 mo
• Risk factors
– Genetic factors • Epidemiology
• Family members
– Commonest illness of
• Maternal blood group A
• Atopy childhood
– Immune factors – Highest incidence  first
• IgG2 deficiency year of life
• Defective component-dependent
opsozination
• Aberrant expression of certain
cytokines
– Environmental factors
• Poor socioeconomic status
– Syndromic association
• Turner syndrome, down syndrome,
cleft palate
• Diagnosis
– Combination of often nonspecific • Symptoms
symptoms – Apyrexial (2/3)
– Evidence of inflammation of the
– Rapid onset of
middle ear cleft
• Otalgia, hearing loss, fever
– Additional information of middle
• Otorrhoea (blood stained)
ear effusion
• Excessive crying, irritability
• Coryzal symptoms
– may well not be a clear history • Vomiting, poor feeding
of a crescendo of otalgia in a • Ear-pulling, clumsiness
coryzal child  rapid
– Commonly develop 3-4 days
symptomatic relief associated
with tympanic membrane after coryzal symptoms
perforation
• Signs
– Appear unwell, rubbing ear
– Otoscopic exam 
• Opaque tympanic membrane,
• Most commonly yellowish pink,
red in only 18-19%
• Bulging
– Hypomobility of the drum
– Perforated drum / ventilation
tube in situ  mucopurulent
ottorhoea
• Investigations
– Tympanometry  middle ear
effusion
– Tympanocentesis & culture
– Nasopharyngeal swabbing for
bacterial culture
– Iron deficiency anemia & white
blood cells disorder associated
with AOM
– Immunoglobulin assay
– Reccurrent infection of ventilation
tube  investigation for primary
ciliary dyskinesia
• Especially if nasal & pulmonary
symptoms coexist
• DD
– Pain  tonsilitis, teething,
temporomandibular joint disorder,
uncomplicated upper respiratory
tract infection
– Red tympanic membrane 
screaming child
– acute mastoiditis
– otitis media with effusion
– otitis extema
– trauma
– Ramsay hunt syndrome
– bullous myringitis
– first indication of serious underlying
disease
• Wegener's granulomatosis or leukaemia
• Etiology
– Infective agents
• Viruses
– RSV, influenza A virus,
parainfluenza virus, human
rhinovirus, adenovirus
• Bacteria
– H. Infulenza 16-37%
– M. Catarrhalis 11-23%
– S. Pyogenes 13%
– S. Aureus 5%
• Routes of infections
– Eustachian tube
• negative middle ear pressure
 movement of bacteria up
the tube
• shorter, straighter and more
patulous tube
– Tympanic membrane
perforations / grommets
• Associated with water exposure
– Haematogenous
• Managements
– Conservative
• Simple analgesic & anti-pyrexials (paracetamol & ibuprofen)
– Medical
• Antibiotics (after 2-3 days of watchful waiting  fail to improve)
– Amoxicillin (1st ) 80mg/kg/day
– Macrolide  penicillin-sensitive & drug-resistant pneumococci
– Amoxicillin-clavulonate / cefuroxime
– Ceftriaxone IM
• Antihistamines & decongestants
– Surgery
• Myringotomy
– Severe case (present of complication) & relieve pain / when microbiology is strongly required
• Management of recurrent acute otitis media
– Alteration of risk factors
• Sitting a child semi-upright if bottle fed, avoiding passive smoke inhalation
• Restricting use of pacifiers after infancy for otitis prone children
• Continue breastfeeding at least 6 mo + vitamin C & NO alcohol
– Medical prophylaxis
• Antibiotics, xylitol, vaccination (virus & bacterial), immunoglobulins,
benign commensals (alpha streptococci)
– Surgical prophylaxis
• Ventilation tube
• Adenoidectomy & adenotonsillectomy
• Complication
– Intracranial
• Meningitis
• Extradural abscess
• Subdural empyema
• Sigmoid sinus thrombosis
• Focal otitic encephalitis (cerebritis)
• Brain abscess
• Otitic hydrocephalus
– Extracranial
• Tympanic membrane
• Acute mastoiditis
• Petrositis
• Facial nerve palsy
• labyrinthitis
OTITIS MEDIA SEROSA
 Otitis media with effusion
• Akumulasi mukus di telinga bagian tengah
dan terkadang di sistem udara sel mastoid
yang bersifat kronik • Diagnosis
• Etiologi
– radiology
– infeksi : Streptococcus pneumoniae,
– Otoscopy
Haemophilus influenzae, Moraxella
catarrhalis dan adenovirus – tympanometry
– Patologi di nasofaringeal • Terapi
– Alergi
– Medikasi
– Obstruksi tuba eustasia
– Operasi
• Gejala Klinis
– Alat bantu pendengaran
– Kehilangan pendengaran
– Telinga terasa penuh • Komplikasi
– Tinnitus – Atelektasis dari membran
– nyeri di telinga dan pusing timpani
Scott-brown’s otorhinolaryngology, head and neck– surgery
Meningitis
volume 3
Otitis media with effusion in adults
Ch. 237 b page 3388-3393 – sensorineural hearing lose
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 • Red/buldging tympanic memb
& malaise) • Retro-auricular swelling
• Mastoid tenderness & localized
• Tenderness is typically sited
reactive lymphadenopathy
over MacEwen’s triangle
• In children
– On palpation through conchal
– Erythema &/ edema of everlying
bowl)
mastoid soft tissue
– Otalgia & irritability • Pinna protrusion
• In adult • Sagging of post wall of ext
– Local pain & tenderness auditory canal
• 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 • DD :
culture – AOM
• CT scan of mastoid – Otitis externa
– Reveal osteitis, abscesses, – Furunculosis
intracranial complications – Reactive lymphadenopathy
– Undiagnosed cholesteatoma
– Wegener’s granulomatosis

• Complications
– Intracranial complications (6-17%)
 Treatment
• Modern antimicrobials + • Myringotomy with/-out
radiographic monitoring
ventilation tube placement
• Early performance of myringotomy
• Mastoid surgery (mastoidectomy) • Culture of aspirate & high-
– Indication  failure of improvement dose IV antibiotics
despite aggressive medical
management, development of other • Abscess drainage with/-out
intracranial complications cortical mastiodectomy
– Goal of surgery  drainage of mastoid,
removal of granulation tissue, – If failure to improve,
restoration of normal ventilatory subperiosteal abscess
pathways formation, complication
– + continuation of antibiotic theraoy
developments
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
• Sudden onsetof severe, usually
unilateral, often throbbing pain in
the ear
• The symptoms usually set in
during or following an upper
respiratory tract infection
• A bloodstained discharge can be
present for a couple of hours
• Hearing impairment (conductive
and/or sensorineural)is common in
the affected ear
Signs
• Otoscopy: blood-filled, serous
or serosangious blisters
involving the tympanic
membrane & sometimes the
medial aspect of the ear canal
• A serosanginous secretion can
be seen if the blisters rupture
• Tympanic membrane is intact
 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
• Based on physical examination:
vesicles in the superficial layer
of the tympanic membrane are
present
Differential diagnosis
• Acute otitis media
• Herpes zoster oticus /Ramsay
Hunt Syndrome
 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
• Keratin cysts may accumulate
because the epithelium from
which they arise is closed  as a
result of developmental
abnormality or may be iatrogenic.
• Criteria of Derlaki and Clemis:
– white mass medial to an intact
tympanic membrane
– normal pars tensa and flaccida
– no previous history of ear discharge,
perforation or previous otological
procedures
Acquired Cholesteatoma
• Keratin accumulates within a diverticulum
of tympanic membrane squamous
epithelium which extends into the middle
ear  keratin accumulates as a result of
inadequate epithelial migration
• Proses :
– Immigration  migration of squamous epithelium
into the middle ear through a defect in the
tympanic membrane
– Retraction  progressive retraction of the
tympanic membrane, either in the pars flaccida
or associated with atrophy of the pars tensa  
– 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
• Audiology : kemampuan
mendengar mungkin bisa
berubah (baik/buruk)
• Pemeriksaan dengan anestesi :
untuk periksa bagian atap
membran tympani
Treatment
• Surgical removal  tujuannya :
– Membuang semua cholesteatoma
– Mencegah cholesteatoma yang
akan datang
– 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)

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 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
• post auricular pain, the temporal bone and neck
• otalgia, provides the most useful information
• otorrhea, • CT scan of the chest 
– suspicion of deeper thoracic/ vertebral
• Less common: fever, abscess spread
headache, hearing loss, facial • MRI & magnetic resonance angio
paralysis, or cervical gram of the head
lymphadenopathy – brain involvement is present
 Treatment & complication
Treatment Complication
• Antibiotics directed at the • Hearing loss
causative organisms +
mastoidectomy