Otitis media effusion

Lina Lasminingrum
2014
BAGIAN I.Kes THT-KL
RSUP Dr.Hasan Sadikin Bandung

OTITIS MEDIA
Inflammation of the
middle ear without
referrence to a specific
etiology or pathogenesis
(Blue Stone,1994, Aria WHO, 2004)

Second health problem in children after

URTI
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OTITIS MEDIA EFFUSION

Inflammation of the
middle ear space
resulting in a
collection of fluid
behind an intact
tympanic
membrane

OME often follows episode

of Acute Otitis Media

Acute , sub acute,

chronic
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Otitis Media Efusion

The presence of
fluid in the middle
ear without signs or
symptoms of acute
ear inflammation

SYNONIMS
Serous otitis media
Secretory otitis
media
Allergic otitis
media
Catarrhal otitis
media
Non supurative
otitis media

Tubotympanic
catarrh
Hydrotubotympan
um
Exsudative
catarrh
Tubotympanitis
Tympanic hydrops
Glue ear
Fluid ear

OTITIS MEDIA EFFUSION

15-40% age < 5 th
The most frequent
cause of CHL in
children
Bacteria in middle ear
fluid same as AOM
Usually asymptomatic
Most episodes of OME
resolve
spontaneously
watchfull waiting?

Risk Factors for Otitis Media

Viral upper respiratory infection

Allergic Rhinitis
Eustachian tube dysfunction
Cigarette smoking (passive)
Bottle fed, not breast fed
Male sex
Immunologic deficiency
Cilia dysfunction
Cleft palate disease
Reflux (Crapko :Pepsin in 60% px OME)
Genetic predisposition
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Pathogenesis OME
MECHANICAL
OBSTRUCTION OF
Intraluminal:
Viral Rhinitis
THE TUBE
Allergic
Rhinitis
Extraluminal:
Negative pressure
Adenoid Hipertrophy
Nasopharyngeal tumour Of middle ear
Duration
Magnitude

AOM

Effusion:
Transudation
Exudation

OME

FUNCTIONAL
Poor
m. tensor Veli
Palatini function
Increased tubal
compliance

NATURAL HISTORY OF OMA

PAIN & FEVER SUBSIDE IN 24 HOUR 7
DAY
COMPLETE RESOLUTION EXCEPT MIDDLE
EAR EFFUSION 7-14 DAYS
ASYMPTOMATIC RESOLUTION IN MEE
AFTER OMA : 4-12 WEEKS
watchfull
waiting?
Natural history of OM , Laryngoscope 2003; 113: 1645-57

Diagnosis
HISTORY
Decreased hearing
Aural fullness and or
pressure
Plugged
URTI, plane trip, scuba
diving

CHILDREN
Pull at the ears
clogged sensation
Poor hearing
Speech & language
developmental delay
ADULTS
Aural pressure
Hearing loss
Tinnitus
Dizziness
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OME
DIAGNOSTIC
OTOSCOPY PNEUMATIC !!
MIDDLE EAR FLUID
TM RETRACTED / THICKENING / OPAQUE

TIMPANOGRAM : TYPE B

PHYSICAL EXAMINATION
Poorly mobile
tympanic membrane
in neutral position,
bulging, or retracted
Color of tympanic
membrane :
yellow serous
effusion
gray mucoid
efusion
Air bubble (+)
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DIAGNOSTIC WORKUP
Pneumatic otoscopy
Sensitivity & spesificity
Tympanometry
> 90 %
Diagnostic miringotomy
Audiometric evaluation
Flexible fiberoptic nasopharyngoscopy
CT scan
Acoustic reflectometry

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MANAGEMENT OME
GOALS :
1.RESTORATION NORMAL HEARING
2.AVOIDANCE MIDDLE EAR
SEQUELE

MANAGEMENT OME
Risk factors??
Watchfull waiting?
Effect to ME
Tympanic membrane,
ossicles

Effect development
speech, language, learning,
behaviour

Effect to quality of life

- Emotional, social

MANAGEMENT OME
TREATMENT
Antimicroba controversy, short
term benefit
Mucolytic, antihistamindecongestan, steroid no different
result compare to placebo
July/06 Cochrane Review supports
both oral and intranasal steroids for
short term benefit of OME

SURGICAL TREATMENT
Early surgical intervention to
prevent speech and language delay
& possible permanent structural
changes
Substantial hearing loss
Developmental delay or disabilities
Severe tympanic membran
retractions
Balance disorders
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SURGERY FOR OME

Initial
Myringotomy & ventilation tube
Adenoidectomy
Myringotomy alone is not effective

Pembedahan ulangan
Adenoidectomy and myringotomy + ventilation
tube

Tonsilectomy
Is not indicated in management OM
Rosenfeld et al. Otolaryngol head & neck surg 2004 : 130 : S 95- S 118

Ventilation tube
Drainage MEE
Bypass ET for ME
ventilation
Spesific therapy for
ME
drug consentration
in ME 1000x compare
to serum bact
biofilm?
Almost no systemic
absorption

Modifiable risk factors in OME

BREAST FEEDING
AVOID CIGARETTE
SMOKE
DAY CARE
ALLERGEN
AVOIDANCE
ADENOID?
REFLUX ?
GROWING UP
QUICKLY
Genetic?

AAP GUIDELINE
STRONG RECOMMENDATION
USE PNEUMATIC OTOSCOPY AS
PRIMARY DIAGNOSTIC METHOD AND
DISTINGUISH OME FROM OMA
RECOMMENDATION
DOCUMENT LATERALITY, DURATION OF
EFFUSION AND PRESENCE &SEVERITY
OF ASSOSIATED SYMPTOMS

AAP GUIDELINE
RECOMMENDATION
DISTINGUISH THE CHILD WITH OME
WHO IS AT RISK FOR SPEECH,
LANGUANGE OR LEARNING PROBLEM
MANAGE THE CHILD WHO IS NOT AT
RISK WITH WATCHFULL WAITING FOR 3
MONTHS
HEARING TESTING WHEN OME
PERSISTS FOR 3 MONTHS OR LONGER

AAP GUIDELINE
RECOMMENDATION
CHILDREN WITH PERSISTENT OME WHO
ARE NOT AT RISK SHOULD BE EXAMINED
INTERVAL 3-6 MONTHS
WHEN A CHILD BECOME SURGICAL
CANDIDATE (VENT TUBE), ADENOIDECTOMY
SHOULD NOT BE PERFORMED UNLESS
INDICATED. TONSILECTOMY OR
MYRINGOTOMY ALONE SHOULD NOT BE
USED TO TREAT OME

AAP GUIDELINE
NEGATIVE RECOMMENDATION
POPULATION-BASED SCREENING
PROGRAMS IN HEALTHY ASYMPTOMATIC
CHILDREN
ANTIHISTAMINES AND DECONGESTANS
FOR TREATMENT; ANTIMICROBIALS AND
CORTICOSTEROID DONT HAVE LONGTERM EFFICACY & SHOULD NOT USE
FOR ROUTINE MANAGEMENT

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THANK
YOU !!

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