CASE REPORT

OTITIS MEDIA WITH EFFUSION

Presentator
dr. Muhammad Arif Darmawan

Moderator :
Dr. dr. Sagung Rai Indrasari., M.Kes., Sp.T.H.T.K.L(K)., FICS

Departemen Kesehatan Telinga Hidung Tenggorok – Kepala Leher

Fakultas Kedokteran, Kesehatan Masyarakat dan Keperawatan
Universitas Gadjah Mada
RSUP Dr. Sardjito
2018
Background
Otitis media with effusion is an
inflammatory process of the middle ear
mucosa that is characterized by the presence
of non-purulent fluid in the middle ear
without signs of acute infection.1,2 Another
name for this disease is glue ear, allergic otitis
media, mucoid ear, otitis media secretory,
non-suppurative otitis media, and serous
otitis media.1
About 2.2 million people in the
United States are diagnosed with effusion
otitis media each year which is estimated to
cost nearly 4 billion US dollars. About 90%
of children suffer from otitis media with
effusion at the age before school, where the
most common age is 6 months to 4 years.
Many episodes will improve spontaneously
within 3 months, but around 30-40% of
children will experience recurrence, and 5-
10% will end 1 year or more. The incidence
of EOM decreases in adulthood.2
Etiology Otitis media with effusion is
multiple. Otitis media with effusion occurs
because of the interaction of various host
factors, allergies, environmental factors, and
Eustachian tube dysfunction. Negative
middle ear pressure, immunological
abnormalities, or a combination of these two
factors are thought to be the main factors.
Other contributing factors are adenoid
hypertrophy, chronic adenoiditis,
palatoskisis, barotrauma, and accompanying
inflammation such as sinusitis or rhinitis.
Otitis media with effusion can also occur
during the OMA resolution phase. When the
acute inflammatory process is cured, 45% of
OMA patients experience persistent effusion
1
after 1 month, decreasing to 10% after 3
months.3
The pathogenesis of otitis media with
effusion is not well understood compared to
acute otitis media. Otitis media with effusion
can occur due to eustachian tube obstruction
or due to previous or ongoing middle ear
inflammation.3 The abnormal function of the
eustachian tube is the basis of otitis media,
where the eustacial tube in infants and
children is wider, horizontal and its function
is immature compared to adults. 3
According to the theory of hydrops ex
vacuo, tubal obstruction can change the
regulation of middle ear pressure and produce
negative pressure in the middle ear. When
negative pressure occurs, an effusion takes the
form of transudation or exudation.
Inflammation of nasal cavity, secondary
infection of the upper respiratory tract, allergic
rhinitis, adenoid hypertrophy or
nasopharyngeal tumor mass can have an
adverse effect on the normal function of the
eustachian tube which can lead to otitis media
with effusion.4,5
Otitis media with effusion is
characterized by a nonpurulent effusion of
the middle ear that may be either mucoid or
serous. Symptoms usually involve hearing
loss or aural fullness but typically do not
involve pain or fever. In children, hearing
loss is generally mild and is often detected
only with an audiogram. Serous otitis media
is a specific type of otitis media with effusion
caused by transudate formation as a result of
a rapid decrease in middle ear pressure
relative to the atmospheric pressure. The
fluid in this case is watery and clear.4
Physical examination using otoscopy
is still the main method in diagnosing otitis
media with effusion because it is available at
the practice site, is cheap and accurate in
experienced hands.2 On physical examination
using otoscopy shows limited movement of
the tympanic membrane in yellow (serous
effusion), gray color (mucoid effusion). The
position of the tympanic membrane can be
neutral, protruding or retracted. In the case of
serous effusion, the air bubble and air fluid
level can be seen. As stated earlier, a
thorough examination of the head and neck
including the nasopharynx is indicated to
evaluate the possibility of a nasopharyngeal
tumor that can clog the eusthacian tube
lumen.
Otitis media with effusion diagnosis
is based on history and physical examination.
If the diagnosis of otitis media with effusion
is still undecided, an otoendoscopy
examination, tympanometry, audiometry
should be considered as an additional
examination
Otitis media with effusion
management includes medical treatments
such as local vasoconstrictor (nose drops),
antihistamine, steroids, In otitis media with
effusion with a low risk, watchful waiting is
done for 3 months after the diagnosis is made.
A hearing test is recommended if otitis media
with effusion persists for more than 3 months.
In otitis media with effusion with a low risk
are re-examined intervals of 3-6 months until
the effusion no longer exists. If surgery in
otitis media with effusion is indicated,
Tympanostomy Tube (TT) is the initial
procedure.2,4
Case Report
An 8-year-old girl came to the ENT
clinic with chief complaint of fullness
sensation on the left ear accompanied with
2
hearing loss since 5 days ago. Other ear
complaints such as pain, itching, discharge,
ringing, and dizziness spinning were deniad.
Sleep snoring, nosebleeds, double vision,
headaches were denied. The patient does not
complain of fever. Patients also complained
sneezing six times in the morning and when
exposed the dust.
Vital signs examination revealed
blood pressure 114/68 mmhg, temperature
36.8 0C, respiration rate 20x/minute, heart
rate 76x/minute. On anthropometric
examination, body weight was 35 kg, height
140 cm.
From physical examination, the left
ear examination revealed the tympanic
membrane is intact, air bubbles appear and
cone of light in the tympanic membrane was
short, and limited movement from the
valsava maneuver. The right ear examination
revealed external auricle is normal, tympanic
membrane is intact, cone of light was short,
and the tympanic membrane was limited
movement from the valsava manuver.
Conductive hearing loss of the left ear was
obtained by tuning fork.
On examination of anterior
rhinoscopy was obtained both inferior chonca
were pale. There was no discharge.
Oropharyngeal examination was within
normal limit.
Patient refused to take nasoedoscopic
examination.
Based on the history and physical
examination, patients are diagnosed with
otitis media with effusion.
Patient was given antibiotic
amoxyllin 3 x 350 mg and combination with
pseudoephedrine 3 x 30 mg.

Discussion
Otitis media with effusion is the
presence of fluid in the middle ear without
any signs and symptoms of acute
inflammation with a complete tympanic
membrane. The presence of fluid in the
middle ear causes a decrease in the function
of the tympanic membrane and the middle ear
causing a decrease in hearing function.1 Otitis
media with effusion is characterized by a non
purulent effusion of the middle ear that may
be either mucoid or serous. Symptoms
usually involve hearing loss or aural fullness
but typically do not involve pain or fever. In
children, hearing loss is generally mild and is
often detected only with an audiogram.
Serous otitis media is a specific type of otitis
media with effusion caused by transudate
formation as a result of a rapid decrease in
middle ear pressure relative to the
atmospheric pressure. The fluid in this case is
watery and clear.4
From the history of patients with
complaints of feel ears full, and decreased
hearing, other complaints do not exist. On an
otoscopy examination, the left ear tympanic
membrane air bubbles, the light reflex
shortens, the retraction on the tympanic
membrane. On the otoscopy examination the
right ear gets retraction of the tympanic
membrane. Based on the results of the history
and physical examination, patients were
diagnosed with Otitis media with effusion.
The risk factors for otitis media with
effusion in these patients are the possibility of
suspecting a history of allergies which is
characterized by a history of frequent
3
sneezing in the morning and sneezing when
exposed to dust. This is in accordance with
the theoretical basis which says the risk
factors involved in the pathogenesis of Otitis
media with effusion include a history of
allergies, asthma, socioeconomic status, and
adenoid hypertrophy.6
One possible mechanism for the
development of otitis media with effusion is
an in situ reaction of the middle ear mucosa
for antigens inhaled through the nose or
nasopharynx. Although most clinical studies
suggest that there is no increase in IgE levels
in the middle ear, about 23% of patients
allergic to otitis media with effusion may
have a local allergic reaction in their middle
ear. In addition, several experimental studies
have shown that the middle ear mucosa can
react immunologically to antigen-IgE
interactions and that this mechanism may
occur in some allergic patients.7
Otitis media with effusion diagnosis
is based on history and physical examination.
If the diagnosis of otitis media with effusion
is still undecided, an otoendoscopy
examination, tympanometry, audiometry
should be considered as an additional
examination.3,4
The investigation is done is
tympanometry. Tympanometry is
examination or measurement of middle ear
function, including tympanic membrane
mobility, eustachian tube function, and
tympanic cavity condition. Tympanomteri
presents a tympanogram, a graph of the
relative flexibility of the osicular tympanic
system while the air pressure in the ear canal
is altered. Maximum flexibility is obtained at
normal air pressure, and decreases if the air
pressure is increased or lowered. Type A
indicates that the condition of the middle ear
is normal. Type B has fluid in the middle ear.
Type C has an eustachian tube function
disorder. Type AD has stiffness in the
auditory bone or otosclerosis.8
Type B tympanogram with a flat
curve and normal canal volume shows a
diagnostic direction to effusion otitis media.
Compared to all other forms of
tympanogram, type B has a sensitivity
between 56 and 73 percent and a specificity
between 50 and 98 percent in detecting otitis
media with effusion which is confirmed
surgical procedure.9
Management of otitis media with
effusion is divided into three, which are:
watchful waiting, medical therapy, and
surgical intervention. According to systemic
review that observes the course of the disease
with spontaneous resolution Otitis media
with effusion. The high rate of spontaneous
resolution Otitis media with effusion, so
observations can be given to Otitis media
with effusion sufferers who do not cause
interference. Hearing tests must be performed
if Otitis media with effusion lasts up to 3
months or more or causes significant hearing
loss. If the average hearing threshold is less
than 20 dB, watchful waiting is
recommended, but if it's more than 40 dB
compared to healthy ones, surgical
intervention is recommended. Between 21
and 39 dB, management is based on duration
of effusion and severity of symptoms.10
Mandel et al. report from 518 children
with Otitis media with effusion found
resolution with antibiotics faster. Giving
direct intranasal corticosteroids as an anti-
inflammatory in the eustachian tube and the
middle ear prevents release inflammatory
4
mediator, increasing surfactant on the
eusthacius tube so it will improve eustachian
tube function. Corticosteroids also play a role
in reduce fluid viscosity in the ear center and
manage sodium transport transepithelium in
the middle ear epithelium so that fluid in the
middle ear will reduced.10
Surgical intervention is a last one
choice. Myringotomy alone are less effective
for long term management and not
recommended for otitis media with effusion.
Myringotomy with installation
tympanostomy tube is based on status
patient's hearing and risk of complications
disease. Several randomized clinical trials
indicates of installation tympanostomy tube
for chronic ottis media with effusion. Mandel
et al. report otitis media with effusion with
duration of 2 months or more that is not
respond to therapy shows myringotomy alone
has numbers high therapy failure compared to
tympanostomy tube is installed. Gates et al.
reported similar things where the installation
of tympanostomy tube yielded better results
than that Myringotomy only.10
Resume
A female patient aged 8 years with a
diagnosis of Auris Sinistra Otitis Media with
effusion that has been given antibiotic
amoxyllin 3 x 350 mg. Given combination
with pseudoephedrine 3 x 30 mg. Patients are
planned to control for 5 days and planning
for an allergy test.
Refference
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Hammadi YA. Diagnostic accuracy of
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Brooklyn,New York.2016: volume
154(S1).S1.
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AHS, Saleh ADA, Awadh AM.
Prevalence and risk factors of otitis media
with effusion in school children in Qassim
Region of SaudiArabia. Int J Health Sci
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Media Wth Effusion. Departement of
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Hidung Tenggorokan . Edisi Ketujuh,
Jakarta FKUI, 2015, hal 57 – 70.
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Chong AW, Prepageran N. 2012.
Prevalence and Risk Factors Associated
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Eustachian Tube Blockage and Otitis
Media With Effusion : A Riview.
Otolayngologi, Head and Neck Surgery
2006 : 563-568.
8. Simpson SA, Lewis, Voort J, Butler. 2011.
Oral or topical nasal steroids for hearing
loss associated with otitis media with
effusion in children (Review). The
Cochrane Libarary. (5):1-59
9. GLee KJ. Infection of the ear. In: Essential
Otolaryngology Head & Neck Surgery 8th