CASE REPORT

Presented by : Group 11.2

(Marieb and Hoend, 2007)

The peripheral auditory system is divided into 3 parts :

The external ear The middle ear The inner ear

(Marieb and Hoend, 2007)

(Lalwwani, 2006)

The external auditory canal consists of a

1/3 lateral cartilaginous portion and a 2/3 medial bony portion.

The tympanic membrane is the border

between middle and external ear, which consists of three layers: the outer, middle, and inner layers.
(Grays Anatomy for Student,2007)

(Lalwwani, 2006)

The middle ear cavity originates embryologically from the first branchial pouch There are three ossicles the malleus, the incus, and the stapes. An 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)

 1. 2. 3.

Oval shape 8 mm wide and 10 mm high consists 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 layer

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

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.

Great vessels - anterior tympanic branch of the maxillary: tympanic membrane - stylomastoid branch of the occipital or posterior auricular arteries : the posterior tympanic cavity and mastoid air cells.

. The smallers arteries include: - petrosal branch of the middle meningeal - the superior tympanic branch of the middle meningeal - a branch from the ascending pharyngeal - tympanic branch or branches from the internal carotid canal

Veins These terminate in the pterygoid venous plexus and the superior petrosal sinus.

The nerves that innervate tympanic cavity is tympanic plexus. Derives from the tympanic branch of the glossopharyngeal nerve and the caroticotympanic nerves.

Tympanic 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 plexus

Most common diseases of the middle ear are inflammations infections play a major role Otitis media - 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)

= inflammatory process within the middle ear cleft.

Otitis media can be either acute or chronic. There is no absolute time period that distinguishes between acute and chronic OM, but, in general, disease that persists for more than 3 months should be considered chronic.

70% of children will have had one or more episodes of acute otitis media by their third birthday. Occurs mainly in children : newborn period - 7 years Occurs equally in males and females

(Healy&Rosbe,Ballengers,2002)

Bondy et al : the proportion of children with a diagnosis of otitis media was highest (42% to 60%) in the 7 to 36 months range Other studies have shown the highest incidence of acute otitis media, for both sexes, was around the age of 6 to 11 months

(Bailey,2006)

Epidemiologic 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)

Most common bacterial pathogens:

- Streptococcus pneumonia (35%) - Haemophilis influenza (23%)

Less Frequent
- Moraxella catarrhalis - Group A Streptococcus - Branhamella catarrhalis

- Staphylococcus aureu
- gram-negative enteric bacteria

Low 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 with - Eustachian tube function. - Lack of breast feeding & Supine feeding position
UMHS Otitis Media Guideline, 2002

High Risk Factors : Craniofacial abnormalities. Immune deficiency. Gastro-esophageal reflux.

UMHS Otitis Media Guideline, 2002

Acute 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, 2002

Acute Otitis Media Suppurative Nonsuppurative Recurrent

Chronic Otitis Media Suppurative Tubotympanic Cholesteatoma Nonsuppurative Otitis media with effusion

 Acute otitis media (AOM) is one of the most

common infectious diseases seen in children, having its peak incidence in the first 2 years of life.

Acute otitis media (AOM) represents the rapid onset of an inflammatory process of the middle ear space associated with one or more symptoms of 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)

Acute Respiratory Tract Infection

Eustachian tube dysfunction

Inflammation process

Tube occlusion

sterile transudation

changes in pressure

mucocilliary defect

decrease oxygen concentration

infection

accumulation of transudate

AOM

(Bailey,2006)

Common signs and symptoms

Fever Otalgia Otorhea Fullness in the ear Irritability Crying/shouting (child) Eardrum : light reflect (-),hyperemia, bulging, perforation

Less common signs and symptoms

Tinnitus Vertigo Facial paralysis Swelling behind the ear

(Bailey, 2006)

(Sanna et al., 1999)

Occlusion tube stage Performing tympanic membrane retraction due to negative pressure inside the middle ear due to air. Sometimes the color of tympanic membrane normal or pale.

Hyperemia stage or presupuration stage

Dilated vessels in the tympanic membrane The tympanic membrane is hyperemia and edema. The performing discharge may be serous so that difficult to assess.

(Sanna et al., 1999)

Supuration stage
All 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.

(Sanna et al., 1999)

Perforation stage

(Sanna et al., 1999)

The 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.

Resolution 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 treatment

(Sanna et al., 1999)

Aim of Therapy To reduce the severity and duration of pain and other symptoms, To stop infection proses To prevent complications, To minimise adverse effects of treatment.

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(PERHATI-KL, 2007)

1. Occlusion stage : Decongestant Antibiotic 2. Hyperemia stage: Antibiotic Decongestant Analgetic\ 3. Suppurated Stage Antibiotic Analgesic, antipyretic If necessary Myringotomi
44

4. Perforation stadium H2O2 3 % for 3-5 days Antibiotic 5. Resolution Stadium Antibiotic is continued until 3 weeks if discharge seen in canal ear via perforation TM

45

First choice : Amoxicillin Dose : 40 50 mg/kg BW/day Effectiveness 85 -94 % Cheap Save If resistance : Amoxyclav, cefuroxim, ceftriaxone Third choice : clindamycin

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The prognosis of patients with acute otitis media is excellent. However, patients and/or their parents still should be encouraged to finish the prescribed medication and to keep their follow-up appointments. Symptoms usually improve within 24 hours and almost always within 48-72 hours.

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Name Age Sex Address

:L : 4 years old : Male :Banyumas

Chief complaint : left ear discharge History of present illness:

A week before coming to the hospital, patient suffered from cough and flu, which subsided. 2 days before coming to the hospital, patient complaint of pain the left ear and feeling of fullness in the left ear . There was also fever . At the day of visit, the patient complained about purulent discharge coming out from the left ear since 2 days before, whitish in colour, moderate in amount. Hearing loss (-), itchiness (-), pain in the left ear (+) but less than before. No complaint about nose, mouth and throat.

History of past illness:

Same symptoms before (+) when patient was around 2

years old History of ear operations (-) History of playing with foreign bodies (-) History of allergy (-) History of trauma (-)

History of illness in family members: - History of the similar complaints (-) - History of alergy (-)

A 4 year old patient with a history of cough and flu, now presenting with purulent discharge from the left ear. Pain (+) and deafness (+) but lessened

1. General status : well conscious, adequatly nourished. 2. Vital sign :

Blood pressure Pulse : 100x/min Respiration

: not measured

: 22x/menit Temperature : afebrile

(Refer to the whiteboard)

Right Auricula In normal limit

Left In normal limit

CAE

In normal limit

Discharge (+)

Tympanic membrane

Intact, anteroinferior cone of light (+)

Perforation, anteroinferior cone of light (-)

No abnormalities
AD

Discharge mucopurulent
AS

AD

AS

Perforasi

Palpation : no tenderness Rhinoscopy anterior :

Dextra Cavum Nasal Septal Deviation Choncae -Mass (-) Discharge (-) Sinistra -Mass (-) Discharge (-) No Media et Inferior : Media et Edema (-) Inferior : Hyperemic (-) Edema (-) Hyperemic (-)

Rhinoscopy Posterior (not examined)

Buccal mucous : hiperemis (-), inflamation(-), massa (-) Tongue : hiperemis (-), inflamation(-), deformity (-) Palatum : hiperemis (-), inflamation(-), deformity (-) Gum : edeme (-), inflamation (-), deformity (-) Tooth : caries (-), not fully developed, deformity (-) Pharyng, uvula, and tonsil : normal Post Nasal drip (-) Discharge purulent (-)

(Not examined)

Acute otitis media perforative stage on Auris Sinistra

Acute Otitis Media Diffuse External Otits

Medication :
Amoxicillin 80-90 mg/kg every 6 hours for 5 days Acetaminophen 15 mg per kg every four to six

hours

Avoid water exposure Avoid ear manipulation Maintain well nourished nutrition

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Recurrence of AOM

 Recurrent AOM is defined as 3 episodes of

acute suppurative OM in a 6-month period, or 4 episodes in a 12-month period, with complete resolution of symptoms and signs between episodes of infection.

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The main prevention stratergies required for the control of otitis media are environmental, and include the alleviation of houseing and overcrowding problems and access to good nutrition. The effectiveness of prevention stratergies depends on the degree to which:
Primary prevention strategies can prevent the early

development or recurrence of otitis media The prevention and management of chronic otitis media can prevent subsequent hearing loss (secondary infection) The hearing loss can be treated effectively to minimize disability (tertiary infection)

Modify Risk Factors

Early Antibitoc Therapy

Environmental and nutritional improvements Breast feeding Swimming Nose blowing, chewing and other stratergies

There is often parental pressure to prescribe antibiotics at

Vaccination

the first presentation of an upper respiratory tract infection However there is little evidennce that otitis media can be prevented if treatment is commenced at the first sign of upper respiratory symptoms.

Medical interventions
Adherence issues Antibiotic treatment

Surgical interventions Screening

Screening for hearing loss Screening for infection to implement intensive

treatment including prophylaxis.

In children the canal between nose and Eustachian tube is shorter and more flat so that nasal discharge can enter the middle ear easily and induce Otitis Media
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Have been reported a patient, boy, 4 years old and is diagnosed as acute otitis media in perforation stage. The initial treatment of this patient is by giving antibiotics and pain reliever, along with education.

Acute Otitis Media Clinical Guideline from the American Academy of Pediatrics and American Academy of Family Physicians 2004)

AOM VS OME