Acute Otitis Media

(Perforation Stadium)
Presenters:

Eko Nugroho
Fariz Afristya
Raymond Win
Ruli Aulia
Stacy Gabriella

Moderator:
dr. Camelia Herdini M.Kes,
Sp.THT-KL, FICS
Introduction
• Defined as rapid onset of signs and symptoms of
inflammation in the middle ear.
• 50% and 85% of children experience at least one
episode of AOM by 3 years of age.
• Bacteria commonly implicated are Streptococcus
pneumoniae, Haemophilus influenzae,
Moraxella catarrhalis, Staphylococcus aureus,
and Streptococcus pyogenes.
(Quereishi et al, 2014)
Anatomy
Middle Ear
Tympanic membrane:
• 1 cm in diameter
• slightly concave on its outer surface
• Innervated by sensory branches of the vagus & trigeminal
nerves

Eustachian tube:
• Located posteriorly, a passageway to the nasopharynx.
• Allows throat infections to spread to the middle ear.

Three bones and two skeletal muscles:

• Connect the eardrum to the inner ear (malleus, incus and
stapes)
• Muscles are stapedius and tensor tympani
 Eustachian Tube Physiology
1. Ventilation or pressure regulation of the Increased/decreased
Excessive production
middle ear Tympanic pressure
of middle ear secretions
2. Protection of the middle ear from
nasopharyngeal secretions and sound
pressures Opening of
Closing of
3. Clearance or drainage of middle ear eustachian tube
secretions into the nasopharynx

Increase/decrease
external auditory
pressure

Drained into nasopharynx

Internal auditory
pressure balancing
Nasopharyngeal secretions
/ sound pressures
Eustachian Tube
Function
Histology of Middle Ear Tissue

• Epithel
pseudostatified
collumnar cilliated
type: sweeps material
from middle ear to
nasopharynx
• 20% epithel consists
of goblet cells
 Otitis Media
• Inflammation occurred on some or whole part of middle ear:
mucous, eustachian tube, mastoid anthrum, and mastoid cells.

Otitis
Media

Non
Suppurated
suppurated

Chronic Chronic
Acute otitis Acute
suppurated effusion
media barotrauma
otitis media otitis media
Acute Otitis Media
Rapid onset of signs and symptoms of
inflammation in the middle ear
Epidemiology
• 50% and 85% of children experience at least one
episode of AOM by 3 years of age.
• Peak incidence 6-15 months
• Young children more prone to AOM due to
anatomical predisposition: shorter, more flexible,
and horizontal
• Eustachian tube matures by 7 years old; decline in
the incidence of OM
Etiology

The bacteria :
• Streptococcus pneumoniae
• Haemophilus influenzae,
• Moraxella catarrhalis,
• Staphylococcus aureus
• Streptococcus pyogenes
Pathogenesis
• Obstruction of the eustachian: the most
important antecedent event associated with AOM.
Normal Tympanic Membrane
Eustachian tube occlusion stage
• Clinical manifestation
▫ Tympanic membrane
retraction
▫ Normal/cloudy
tympanic membrane
▫ Ear fullness
▫ Hearing loss
• Treatment
▫ Decongestant tympanic membrane retraction, gloomy,
▫ Antibiotic the light reflex can’t be seen.
Hyperemic (pre-suppuration) stage
• Clinical manifestation
▫ Hyperemic tympanic
membrane
▫ Edema tympanic
membrane
▫ Ear fullness
▫ Otalgia
▫ Hearing loss
• Treatment
▫ Decongestant
▫ Antibiotic tympanic hyperemic with edema.
▫ Analgesic
Suppuration stage
• Clinical manifestation
▫ Severe middle ear edema
▫ Purulent exudate secrete
▫ Bulging tympanic membrane
▫ Severe otalgia
▫ Fever
▫ Ear fullness
▫ Hearing loss
• Treatment
▫ Decongestant
▫ Antibiotic
▫ Analgesic
▫ Antipyretic
▫ Myringotomy tympanic membrane bulges outside with
yellow colour..
Perforation stage
• Clinical manifestation
▫ Tympanic membrane perforation
▫ Otorrhea
▫ No fever
• Treatment
▫ Ear toilet
▫ Antibiotic
there is rupture of tympanic membrane and pus drain out from the middle
ear to the external canal.
Perforation stage
Inactive perforation with
inflammation Active perforation
Resolution stage
• Clinical manifestation
▫ Decreased secrete → dry
▫ Perforation closure
• Treatment
▫ Antibiotic until 3 weeks if otorrhea continues

In stage of resolution, if the tympanic membrane is still intact, it will

improve slowly. If there is a perforation, then discharge will slowly
decrease and dry out
Resolution stage
Inactive perforation with inflamation Cicatrix
Risk factor
Host related Environmental
- age, - upper respiratory
- gender, infections [URis],
- race, - seasonality,
- prematurity, - day care,
- allergy, - siblings,
- tobacco smoke exposure,
- immunocompetence,
- breast-feeding,
- cleft palate and
craniofacial - socioeconomic status,
abnormalities, - pacifier use,
- genetic - obesity
predisposition
Differential Diagnosis
AOE
• mimic the appearance of AOM because of erythema
involving the tympanic membrane.
• Distinguishing AOE-AOM: the latter may require
systemic antimicrobials.
• Pneumatic otoscopy: good tympanic membrane
mobility with AOE but will show absent or limited
mobility with AOM and associated middle-ear
effusion.
• Tympanometry: normal peaked curve (type A) with
AOE but a flat tracing (type B) with AOM.
Treatment
• Analgesics
Ibuprofen and acetaminophen:effective.
Ibuprofen is preferred: longer duration of action
and its lower toxicity in the event of overdose.
Antibiotics
• Observation VS Antibiotic Therapy
Among children with mild symptoms, observation may
be an option in those six to 23 months of age with
unilateral AOM, or in those two years or older with
bilateral or unilateral AOM.

Antibiotics should be routinely prescribed :

- Children with AOM who are six months or older with
severe signs or symptoms (i.e., moderate or severe
otalgia, otalgia for at least 48 hours, or temperature of
39°C or higher)
- Children younger than two years with bilateral AOM
regardless of additional signs or symptoms.
Antibiotics
High-dose amoxicillin should be the initial
treatment in the absence of a known
allergy. The advantages of amoxicillin include
low cost, acceptable taste, safety, effectiveness,
and a narrow microbiologic spectrum

Oral cephalosporins, such as cefuroxime

(Ceftin), may be used in children who are
allergic to penicillin
1st line and alternative AOM antibiotic
Education
• Prevent upper respiratory tract infection (URTI)
and treat the URTI adequately.
• Exclusive breast milk
• Avoiding exposure to environtmental risk factor
Case Report
Identity
• Date of visit : August 2nd 2016
• Name : IS
• Age : 5 years
• MR : 72-71-xx
• Sex : Male
• Address : Klaten
History taking
• Chief complaint: discharge from the left ear
History taking
• History of present illness:
▫ The discharge is yellowish with foul odor.
▫ Flu started a week ago, followed by ear pain two
days later.
▫ Three days ago, pain diminished and discharge
from left ear came out.
▫ No medications were taken before.
▫ His ears are routinely cleaned up using cotton
buds.
▫ There are no complaint of nose, throat, fever,
hearing loss, tinnitus, and vertigo.
History taking
• Past illness history
▫ Allergic history (-), asthma history (-)
• Family illness history
▫ Similar disease history (-), allergic history (-)
History resume
• Flu since 7 days, and pain since 5 days
• Yellowish and foul odor discharge since 3 days
ago, pain diminished.
• No medications was taken
Physical examination
• General status: good, CM.
• Vital sign:
▫ Heart rate : 84 bpm
▫ Respiratory rate : 22 x/minute
▫ Body temperature : 36,8 °C
▫ Body Weight : 17 kilograms
Ear examination
Right ear Left ear
Auricle Normal shape & size Normal shape & size
(normotia), mass (-), (normotia), mass (-),
hyperemic (-) hyperemic (-)
Auricular pain (-) (-)
External auditory canal Mass (-), hyperemic (-), Mass (-), hyperemic (-),
edema (-), discharge (-) edema (-), yellowish
discharge with foul odor
(+)
Tympanic membrane Intac, cone of light (+) Perforated, central
located, irregular margin
Mastoid Normal, pain (-) Normal, pain (-)
Lymph nodes No enlargement No enlargement
Ear Examination
• Ear: There was discharge in the external
auditory canal of left ear. A small perforation on
the center of the tympanic membrane with
irreguler margin was found.

Dextra Sinistra Dextra Sinistra

Throat Examination
Components D S
Dextra Sinistra
Lip Hyperemic (-), stomatitis (-)

Teeth-gum Caries (-), edema (-), hyperemic (-)

Palate Pink, shiny mucosal , mass (-), wound (-), white

spots (-), symmetric

Uvula One peak, central, deviation (-)

Palatine tonsil hyperemic (-), T1, hyperemic (-), T1,

criptae widening (-) criptae widening (-)

Lingua l tonsil unseen unseen

Posterior Wall of granulae (-), post-nasal drip (-)

pharynx
 Nose Examination
Dextra Sinistra Components D S

Discharge Fluid (-), blood (-), Fluid (-), blood (-),

pus (-) pus (-)
Nasal concha Edema (-) Edema (-)

Septum Deviation (-), Deviation (-),

laceration (-) laceration (-)
Tumor - -

Paranasal sinuses Pain (-) Pain (-)

Diagnosis
Acute otitis media perforation stadium of the left
ear
Management
• Pharmacotherapy
▫ Amoxicillin syrup 3 times a day
▫ Rhinos junior 3 times a day
• Education
▫ Keep both ear dry and clean
▫ Avoid predisposing factors such as cold and cough
▫ Immediately seek medication when catching a
cough and or rhinorrhea
• Plan: follow up after one week
Discussion
Risk Factors
Theory Patient’s case
 Age
Host Environment
 Infection
• Age • Season  Socioeconomic
• Race • Infection
 Season
• Gender • Siblings
• Prematurity • Day care
• Allergy • Passive smoker
• Immunocompetence • Breast feeding
• Craniofacial • Socio economic
abnormalities • Pacifier use
• Genetic • Obesity
Physical exam findings
Theory Patient’s case
• None of these were found
Tubal occlusion
• Cone of light (-)
• Tympanic membrane retraction
Hyperemic
• Edema (+)
• Hyperemic (+)
Suppurative
• Membrane bulging out
• Yellow color
Physical exam findings
Theory Patient’s case
• Membrane is centrally
Perforation perforated in the left ear.
• Suits with perforation stadium
• Rupture of membrane of acute otitis media otoscopic
• Pus drain out findings.
Resolution
• Intact tympanic membrane
• Dried discharge
Medications
Theory Patient’s case
Patient was given
• Recommended, adjusted to
Antibiotics patient condition • Amoxycillin syrup (antibiotic)
• High dose amoxycilin • Rhinos junior (decongestant +
antihistamines)
• Reducing symptoms and Consideration:
increase QoL • Quickly manages the cause of
Analgetics
• Choices: acetaminophen
and ibuprofen acute otitis media (excessive
mucous) with decongestants +
antihistamines
Decongestant • Helps with nasal allergies
& • May prolong middle ear
Antihistamines effusion
Conclusion
• 5 years old boy diagnosed with Acute Otitis
Media perforation stadium of left ear.
• Medications given were antibiotics,
decongestants and antihistamines.
Thank you,
Please give input