ACUTE OTITIS MEDIA PERFORATIVE STAGE

CASE REPORT

Presented by : Group 11.2

OVERVIEW

Anatomy of The Ear

(Marieb and Hoend, 2007)

The peripheral auditory system is divided into 3 parts :

The external earThe middle earThe inner ear

(Marieb and Hoend, 2007)

External Ear

(Lalwwani, 2006)

External Ear

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.

(Gray’s Anatomy for Student,2007)

Middle Ear

(Lalwwani, 2006)

Middle Ear

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.

(Gray’s Anatomy for Student,2007)

Middle Ear

Middle Ear

Tympanic Membrane

Oval shape 8 mm wide and 10 mm high consists of three layers:

1. The outer layer : from the ectoderm, consists of squamous epithelium.

2. The inner layer : from the endoderm, consists of cuboidal mucosal epithelium.

3. The middle layer : from the mesenchyme, called the middle fibrous layer

Tympanic Membrane

Pharyngotympanic Tube

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 45ºin relation to horizontal plane and in infants this inclination is 10º

Pharyngotympanic 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.

Vasculary Supply

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.

Vasculary Supply

. 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

Vasculary Supply

VeinsThese terminate in the pterygoid venous plexus and the superior petrosal sinus.

Innervation

- The nerves that innervate tympanic cavity is tympanic plexus.

- Derives from the tympanic branch of the glossopharyngeal nerve and the caroticotympanic nerves.

Innervation

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

OTITIS MEDIA

Introduction of Otitis Media

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)

Definition of Otitis Media= 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.

Incidence of Otitis Media

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,Ballenger’s,2002)

Incidence of Otitis Media

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)

Epidemiology of Otitis Media

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)

Etiology of Otitis Media

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

Risk Factors of Otitis Media

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

Risk Factors of Otitis Media

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

UMHS Otitis Media Guideline, 2002

Classification of Otitis Media 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

Classification of Otitis Media Acute Otitis Media   Suppurative  Nonsuppurative  Recurrent

Chronic Otitis Media   Suppurative    Tubotympanic     Cholesteatoma   Nonsuppurative    Otitis media with effusion 

Acute Otitis Media (AOM)

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.

Definition of AOM

- 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)

Pathogenesis of AOM

Acute Respiratory

Tract Infection

Eustachian tube

dysfunction

Inflammation process

Tube occlusion

decrease oxygen

concentration

mucocilliary defect

changes in pressure

sterile transudatio

n

infection accumulati

on of transudate

AOM

(Bailey,2006)

Signs & SymptomsCommon 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)

Clinical Features of AOMbased on stages of disease

Clinical Features of AOM

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.

(Sanna et al., 1999)

Clinical Features of AOM

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)

Clinical Features of AOM

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)

Clinical Features of AOM

Perforation stage- 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.(Sanna et al., 1999)

Clinical Features of AOM

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)

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Management of AOM

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

Management of AOM

(PERHATI-KL, 2007)

44

Management of AOM

1. Occlusion stage : Decongestant Antibiotic

2. Hyperemia stage: Antibiotic Decongestant Analgetic\

3. Suppurated Stage Antibiotic Analgesic, antipyretic If necessary Myringotomi

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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

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The Use of Antibiotic in AOM

First choice : Amoxicillin • Dose : 40 – 50 mg/kg BW/day• Effectiveness 85 -94 %• Cheap• Save

If resistance :Amoxyclav, cefuroxim, ceftriaxoneThird choice : clindamycin

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Prognosis of AOM

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.

Complication of AOM (Thieme, 2006)

CASE PRESENTATION

Patient’s Identity

Name : LAge : 4 years oldSex : MaleAddress :Banyumas

Anamnesis

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.

Patient’s History

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 (-)

Resume Anamnesis

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

Physical Examination

1. General status : well conscious, adequatly nourished.

2. Vital sign : Blood pressure : not measured Pulse : 100x/min Respiration : 22x/menit Temperature : afebrile

Otolaryngology Examination

(Refer to the whiteboard)

Ear Examination

Right Left

Auricula In normal limit In normal limit

CAE In normal limit Discharge (+)

Tympanic membrane Intact, anteroinferior cone of light (+)

Perforation, anteroinferior cone of light (-)

Otoscope Examination

Discharge mucopurulentNo abnormalities

ASAD

Otoscope Examination

Perforasi

ASAD

Palpation : no tenderness Rhinoscopy anterior :

Nasal Examination

Dextra Sinistra

Cavum Nasal

-Mass (-) Discharge (-)

-Mass (-) Discharge (-)

Septal Deviation

No

Choncae Media et Inferior :Edema (-)Hyperemic (-)

Media et Inferior :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 (-)

Oropharynx Examination

Laryngeal examination

(Not examined)

Diagnosis

Acute otitis media – perforative stage on Auris Sinistra

Differential Diagnosis

Acute Otitis MediaDiffuse External Otits

Treatment

Medication : Amoxicillin 80-90 mg/kg every 6 hours

for 5 days Acetaminophen 15 mg per kg every four

to six hours

Education

Avoid water exposureAvoid ear manipulationMaintain well nourished nutrition

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Problem

Recurrence of AOM

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Problem Discussion

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.

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)

Primary Prevention Strategies Modify Risk Factors

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

Early Antibitoc Therapy There is often parental pressure to prescribe

antibiotics at 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.

Vaccination

Secondary Prevention Strategies

Medical interventions Adherence issues Antibiotic treatment

Surgical interventionsScreening

Screening for hearing loss Screening for infection to implement

intensive treatment including prophylaxis.

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Case Discussion

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

Conclusion

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.

THANK YOUSUGGESTION PLEASE

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

AOM VS OME

Thank you