ACUTE OTITIS MEDIA CONGESTION STAGE

Presentator: 1. Megawati Abuabakar 2. Alfi Rizky Medikanto3. Yenni Listaria Lase4. Hanim Dzulbazlin D5. Hangga Harinawantara6. Lingga pradipta7. Rofi Rahmaning WidiModerator : dr. Lukman HakimACUTE OTITIS MEDIA Tube Occlusion Stage1INTRODUCTIONMost common diseases of the middle ear are inflammations and infections play a major role Otitis media is the most common reason for an illness-related medical visit in preschool age children. (Bailey, 2006)second most common diagnosis made by pediatricians(Linsk R et al,2002)INTRODUCTION70% of children will have had one or more episodes of acute otitis media by their third birthday.occurs mainly in children : newborn period - 7 yearsoccurs equally in males and females(Healy&Rosbe,Ballengers,2002)

INTRODUCTIONBondy et al : the proportion of children with a diagnosis of otitis media was highest (42% to 60%) in the 7 to 36 months rangeOther studies have shown the highest incidence of acute otitis media, for both sexes, was in the 6 to 11 months(Bailey,2006)

INTRODUCTIONEpidemiologic studies at the University of Pittsburgh : 90% incidence of otitis media in urban children within the first 2 years of life. (Clinical Otology,2007)Children who live in crowded households,low socioeconomic conditions, poor medical care increasing incidence of acute otitis media(Bailey,2006)

OVERVIEWANATOMY

OVERVIEWThe middle earAn air-filled, mucous membrane-lined space in the temporal bone between the tympanic membrane laterally and the lateral wall of the internal ear medially.(Grays Anatomy for Student,2007)OVERVIEWMIDDLE EAR

Middle Ear

OVERVIEWAUDITORY OSSICLES

OVERVIEWTympanic MembraneOval shape8 mm wide and 10 mm highconsists of three layers: The outer layer : from the ectoderm, consists of squamous epithelium. The inner layer : from the endoderm, consists of cuboidal mucosal epithelium. The middle layer : from the mesenchyme, called the middle fibrous layerTympanic Membrane

OVERVIEWPharyngotympanic tube (Eustachian tube)The pharyngotympanic tube/Eustachian tube connects the middle ear - the nasopharynxRange of length : 31 to 38 mmIn adults, the Eustachian tube lies at an angle 45in relation to horizontal plane and in infants this inclination is 10

OVERVIEWPharyngotympanic tube (Eustachian tube)The Eustachian Tube has three function :1.Ventilation of the middle ear associated with equalization.2.Protection of the middle ear from sound and secretions.3.Drainage of middle ear secretions into the nasopharynxwith.

OVERVIEWVasculary SupplyGreat vesselsanterior tympanic branch of the maxillary: tympanic membrane stylomastoid branch of the occipital or posterior auricular arteries : the posterior tympanic cavity and mastoid air cells. OVERVIEW. The smallers arteries include:petrosal branch of the middle meningealthe superior tympanic branch of the middle meningeal a branch from the ascending pharyngeal tympanic branch or branches from the internal carotid canalOVERVIEWVeinsThese terminate in the pterygoid venous plexus and the superior petrosal sinus.OVERVIEWInnervationThe nerves that innervate tympanic cavity is tympanic plexus.Derives from the tympanic branch of the glossopharyngeal nerve and the caroticotympanic nerves.

OVERVIEWTympanic Plexus supplies:Branches to the mucosa of the tympanic cavity, pharyngotympanic tube and mastoid air cells.A branch traversing an opening anterior to the fenestra vestibuli and joining the greater petrosal nerve.The lesser petrosal nerve, which may be regarded as continuation of the tympanic branch of the glossopharyngeal nerve travesing the tympanic plexusOVERVIEWDefinition-Acute otitis media (AOM) represents the rapid onset of an inflammatory process of the middle ear space associated with one or more symptoms or local or systemic signs(Healy and Rosbe,2002)Acute otitis media (AOM) is an infection that involves the middle ear. The tympanic membrane becomes inflamed and opaque. Blood vessels to the area dilate. Fluid accumulates in the middle ear space. AOM is usually associated with infection by viruses or bacteria.(http://www.utmb.edu/pedi_ed/AOM-Otitis/default.htm)

OVERVIEWETIOLOGYmost common bacterial pathogens:Streptococcus pneumonia (35%) Haemophilis influenza (23%) Less FrequentMoraxella catarrhalisGroup A Streptococcus Branhamella catarrhalis Staphylococcus aureugram-negative enteric bacteriaPATHOPHYSIOLOGY

Infection Tuba dysfuction air resorbtion

negatif.pressure Obstructed tuba influx bacteria

AOM

(Bailey,2006)Clinical FeaturesOcclusion tube stagePerforming tympanic membrane retraction due to negative pressure inside the middle ear due to air.Sometimes the color of tympanic membrane normal or pale.

Clinical FeaturesHyperemia stage or presupuration stageDilated vessels in the tympanic membrane The tympanic membrane is hyperemia and edema. The performing discharge may be serous so that difficult to assess.

Hyperemia stage or presupuration stageHyperemia stage is characterized with dilated vessels in the tympanic membrane or the tympanic membrane is hyperemia and edema. The performing discharge may be serous so that difficult to assess.OVERVIEWSupuration stageAll symptoms become more severe. The drum now starts bulging and convex. The exudates exerts pressure on one spot of the ear drum, may be the point of perforation later and the point appears like yellow nipple.

OVERVIEWPerforation stageThe drum perforates , pus starts flowing out. Pain and constitutional symptoms lessen with the escape of ear discharge. Otorrhoea ,may be initially blood-stained,discharge can range from mucoid to frankly purulent. Examination: ear drum reveals a small perforation, usually in the anteroinferior quadrant with pulsatile discharge.

OVERVIEWResolution stage-If the tympanic membrane is still intact gradually back to normal condition.-If perforation happens, the discharge will decrease and finally become dry. In good immunity system , resulotion will be performed eventhough without any medical treatmentOVERVIEWDIAGNOSISCareful history (fulfilled/fullness ear,otalgia, fever) and physical examination will lead to the accurate diagnosis of acute otitis mediaThe ultimate diagnostic test to confirm the presence of AOM involves aspiration of middle ear contentsOVERVIEWTREATMENTWatchful waiting without antibiotic therapyhealthy 2-year-olds or older children with nonsevere illness Antibiotic therapyFirst line therapy: Amoxicillin 80mg-90mg/kg/24 hours in three divided doses , for 10 daysThe adjunctive therapy include analgesics and antipyretics.Myringotomy

CASE REPORTIdentityName : NSAge : 7 years oldGender : female Adress : srowot, BanyumasNo MR : 00494641Body weight : 21 kg

AnamnesisThe main complaint was fulfilled earsHistory of present illness:Since 4 days ago, patient complained fulfilled ear both in the right and left side. The fulfilled was felt constantly and she felt discomfort inside the ears. Sometimes she heard buzzing inside her ear. The patien also got rhinorheae with waterry discharge along with fever until now. There was no discharge coming out from her ears, hearing loss, dizziness, or vertigo. She denied complaint in the throat.

History of past illness: - History of the same complains (+) when she was 5 years old - History of alergy (-)History of illness in family members: - History of the same complains (-)- History of alergy (-)

Physical ExaminationGeneral status : well conscious, adequatly nourished.Vital sign :- Blood Pressure: not measured - Pulse: 92 x/min - Respiration: 25 x/min - Temperature: 38,3 0C

RESUME ANAMNESISFulfilled ear 4 daysDiscomfort inside earsBuzzingRhinorheaeFever

Otorhinolarygology examination: Otoscopy examination : the both auricles were within normal limit. Both external auditory canals were within normal limit. Tympanic membranes were pale and retraction. Rhinoscopy anterior examination: hyperemia conchae & discharge serous-mucousRhinoscopy posterior examination: within normal limitOrofarings examination: within normal limitIndirect laringoscopy examination: within normal limit

DIAGNOSISacute otitis media in tube occlusion stage

TREATMENT- Observation- Pseudoefedrin 3x30 mg- Paracetamol syrup 3x2 cth - EducationPROBLEMRecurrencyPlanningControl again after 3 days of treatment to evaluate the disease.

Follow upPatient came after 3 days treatmentComplaint: the fulfilled ears was getting relievedPhisycal examination : Otoscopy examination : Both external auditory canals are within normal limit. Tympanic membranes were not retraction anymorePlan: continued the treatment and educated the parents to come back to the doctor if the symptoms were more severe.

DISCUSSIONPatient is diagnosed as acute otits media based on the anamnesis and physical examinationBased on the symptoms and signs this patient comes in tube occlusion stageSautter and Hirose: otitis media may be associated with several inciting factors, most commonly upper respiratory tract infection and Eustachian tube dysfunctionDISCUSSIONAcute otitis media is usually characterized by rapid onset of otalgia and erythema of the tympanic membrane, otalgia and fever are more evident in younger children and maybe absent in older childrenusing pneumatic otoscopy alone has been shown to have 85% sensitivity and 75% specificity in the diagnosis of otitis mediaDISCUSSIONAccording to Guidelines & Protocols Advisory Commitee : If older than 24 months, most cases of AOM resolve with systemic analgesics alone and do not require antibiotics. If signs and symptoms of AOM persist in spite of systemic analgesics after 48 to 72 hours, treat with antibioticsDISCUSSIONLalwani AK: There is no role for oral decongestants or antihistamines in the treatment of Acute Otitis MediaBhargava: systemic decongestan like phenylephrine hydrochloride or pseudoephedrine decongest the mastoid, middle, ear cavity, and the Eustachian tube along with nasal cavity

DISCUSSIONAfter 3 days treatment, patient comes and shows better condition than before but we still plan to continue the observationCONCLUSIONHave been reported a patient, girl, 7 years old and is diagnosed as acute otitis media in tube occlusion stage. The initial treatment of this patient is by giving pseudoefedrine 3x30 mg, paracetamol syrup 3x2cth, observation of the disease, also education. After 3 days treatment, the patient comes and shows better conditions than before getting any treatmentsTHANK YOUSUGGESTION PLEASE

50UMHS Otitis Media Guideline, May, 2002Low Risk Factors:Exposure to group day care with subsequent increase in respiratory infections. Exposure to environmental smoke or other respiratory irritants and allergens that interfere withEustachian tube function. Lack of breast feeding & Supine feeding position

UMHS Otitis Media Guideline, May, 2002High Risk FactorsCraniofacial abnormalities. Immune deficiency. Gastro-esophageal reflux. ClasificationAcute stage is the short (less than 3 months) and rapid onset of signs and symptoms of middle ear disease.

Chronic stage is middle ear disease for 3 months or more(Bailey, 2006)

> 3 months : Ballanger,1996 > 2 months : Djaafar, 2001 > 6 weeks : Rolland, 2002SIGN and SYMPTOM

Common signs and symptoms Fever Otalgia OtorheaFullness in the earIrritability Crying/shouting (child)Eardrum : light reflect (-),hyperemia, bulging, perforation

Less common signs and symptoms Tinnitus Vertigo Facial paralysis Swelling behind the ear (Bailey, 2006)Bluestone CD, Klein JO Otitis Media in Infants and Children 1995

Bluestone CD, Klein JO Otitis Media in Infants and Children 1995

1. Stadium Oklusi TubaRadang mukosa hidung/nasofaring berlanjut ke tuba eustachii mukosa udem lumen tuba sempit fungsi (ventilasi dan drainage) terganggu O2 menurun tekanan udara menurun perubahan mukosa kavum timpani, sehingga :Perubahan permeabilitas vasa darah dan limfePeningkatan permeabilitas membran selProliferasi sel kelenjarTerjadi transudasi hydrops ex vacuo2. Stadium hiperemis (Presupurasi)Anamnesis : demam, otalgia, fullness, pendengaran berkurangOtoskopi : membran timpani kemerahan/hiperemiTerapi: pada stadium ini bertujuan untuk memperlancar fungsi tuba (dengan mukolitik) dan menghindari perforasi m.tympaniObat: antibiotik, analgetik, antipiretik, nasal decongestan, antiinflamasi

3. Stadium SupurasiAdanya perubahan mukosa cavum timpani pertahanan mukosa setempat menurun kuman hidung/nasofaring penetrasi ke cavum timpani pembentukan eksudat purulen tekanan cavum meninggi bulging3. Stadium SupurasiAdanya perubahan mukosa cavum timpani pertahanan mukosa setempat menurun kuman hidung/nasofaring penetrasi ke cavum timpani pembentukan eksudat purulen tekanan cavum meninggi bulging4. Stadium perforasiTekanan tinggi cavum timpani iskemia nekrosis mukosa dan submukosa perforasi5. Stadium ResolusiPada stadium ini proses penyakit menyembuhOedem mukosa berkurang, fungsi tuba membaik, sekret berkurang/mengeringMembrana tympani kembali normal, terjadi resolusi pada perforasi membran timpaniMIRINGOTOMI(Efiaty,1990)Tindakan insisi pada pars tensa membran tympani pada kuadran posterior-inferior agar tejadi drainase sekret dari telinga tengah ke liang telinga luarDapat menimbulkan komplikasi berupa perdarahan akibat trauma liang telinga luar, dislokasi tulang pendengaran, trauma pada fenestra rotundum, trauma nervus facialis

Indication 1. AOM with acute complications (mastoiditis, paresis n.VII, meningitis)2. AOM with severe otalgia3. Recurrent ear-ache or steady ear-ache, fever still (+) even antibiotic had been given4. Patient is in neonatal periode5. Child with low immune system6. Culture

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 menguapM. tensor veli palatini dilatator

Mekanisme pembukaan tuba : - aktif konstraksi m.tensor velli palatini . - pasif beda tekanan kavum tympani dengan nasofaring (reflektoris) 20-40 mmHgAcute Otitis Media Clinical Guideline from the American Academy of Pediatrics and American Academy of Family Physicians 2004)

Pseudoephedrine is a sympathomimetic agent that occurs naturally in plants of the genus Ephedra; the drug acts directly on both - and, to a lesser degree, -adrenergic receptors.Pseudoephedrine is used as a nasal decongestant for self-medication for the temporary relief of nasal congestion associated with upper respiratory allergy and to provide temporary relief of sinus congestion and pressure. The drug also has been used for self-medication in the symptomatic prevention of otitic barotraumaThe usual dosage of pseudoephedrine hydrochloride for adults and children 12 years of age or older is 60 mg every 46 hours with a maximum of 240 mg daily.Alternatively, some pediatricians recommend 4 mg/kg or 125 mg/m2 daily, given in 3- 4 divided doses. Adapted from: drugs info at www.emedicine-medscape.comPSEUDOEPHEDRINE68Pseudoephedrine acts directly on -adrenergic receptors in the mucosa of the respiratory tract producing vasoconstriction that results in shrinkage of swollen nasal mucous membranes, reduction of tissue hyperemia, edema, and nasal congestion, and an increase in nasal airway patency; drainage of sinus secretions is increased. Sympathomimetic effects of pseudoephedrine presumably also may occur in other areas of the respiratory tract, including the eustachian tube; these effects may improve or maintain eustachian tube patency and allow equilibration of middle ear pressure during external atmospheric pressure changes (e.g., during descent of an aircraft, underwater diving, hyperbaric oxygenation).Adapted from: drugs info at www.emedicine-medscape.comPSEUDOEPHEDRINEKOMPLIKASI (Thieme, 2006)

KOMPLIKASI INTRAKRANIAL (Dhillon,1999)

S. pneumoniaeH. influenzae

Amoxicillin++++++

Amoxicillin

(80-100 mg/kg/d)+++++++

Amoxicillin/

Clavulanate+++++++

S.pnuemoniaeH. influenzae

Cefaclor+++++

Cefixime++++++

Cefuroxime++++++++

Cefprozil+++++++

Ceftibuten++++++

Ceftriaxone ++++++++

Cefpodoxime++++++++

Loracarbef+++++++