KEPANITRAAN KLINIK ILMU PENYAKIT

THT
RSPAD GATOT SOEBROTO DITKESAD
JAKARTA
Periode 16 maret s/d 17 april 2015

DRUG THERAPY FOR

OTITIS MEDIA
Dokter pembimbing:
Dr. Khairan Irmansyah, SpTHT-KL, M.Kes

Disusun oleh:
Nova Geby Barika (UKRIDA) 11.2013.055
Olivia Papilaya (UKRIDA) 11.2013.186
Kevin William Hutomo B (UPN) 131.0221.019

OTITIS MEDIA

Otitis media (OM) is inflammation or infection of the middle

ear.

It occurs in the area between the ear drum (the end of the
outer ear) and the inner ear, including a duct known as the
Eustachian tube (ET).

http://www.indianjotol.org on Monday, March 16, 2015.

Acute bacterial OM can cause pain that leads to sleepless

nights for both children and parents, can cause eardrum
perforations, not all of which heal, and can spread to cause
mastoiditis and/or meningitis, brain abscess, and even death
if a severe infection goes untreated long enough.

Eardrum perforations

http://www.indianjotol.org on Monday, March 16, 2015.

High fever can occur and can cause febrile seizures.

OM is very common in childhood, with the average toddler

having 2-3 episodes a year, almost always accompanied by a
viral upper respiratory infection, mostly the common cold.

http://www.indianjotol.org on Monday, March 16, 2015.

The rhinoviruses that cause the common cold it promotes the

production of inflammatory mediators, reduced ciliary
clearance, altered bacterial adherence leading to ET
dysfunction, causing swelling and compromise the pressure
equalization, which is one of the physiological functions of the
tube.

http://www.indianjotol.org on Monday, March 16, 2015.

It has to be remembered that the ET dimension also changes

along with its anatomical and physiological appearance during
the early growth period of the child.

In the newborn, the tube is more slanting making it more

difficult to drain naturally and simultaneously milk may go
into the middle ear on feeding in lying down position.

http://www.indianjotol.org on Monday, March 16, 2015.

As the early years pass by the superior (upper) part of the tube
ossifies to bone, but the lower remains the same.

Progressions to chronic OM and cholosteatoma are much

more common in this group of people and often have a family
history of middle ear disease.

http://www.indianjotol.org on Monday, March 16, 2015.

ACUTE OTITIS MEDIA

Acute otitis media (AOM) is most often purely viral and

selflimiting, as is its usually accompanying viral upper respiratory
infection (URI) usually caused by respiratory syncytial virus,
rhinovirus influenza, parainfluenza and adenovirus.

http://www.indianjotol.org on Monday, March 16, 2015.

If the middle ear, which is normally sterile, becomes

contaminated with bacteria, pus and pressure in the middle ear
may result, and this is termed as acute bacterial otitis media
(OM).

It is necessary to establish whether it is viral or bacterial in

nature.

http://www.indianjotol.org on Monday, March 16, 2015.

Viral AOM usually presents as congestion and middle ear fluid

accumulation.

The

principle

bacteriological

organism

in

AOM

are

Haemophilus influenzae (42.8%), Streptococcus pneumonia

(35.71%) and Streptococcus pyogenus (7.14%), Moraxella
catarrhalis (21.42).

http://www.indianjotol.org on Monday, March 16, 2015.

FEATURES

1st phase - exudative inflammation lasting 1-2 days, fever, rigors,

meningism (occasionally in children), severe pain (worse at night),
muffled noise in ear (tinnitus), deafness, sensitive mastoid process.

2nd phase - resistance and demarcation lasting 3-8 days. Pus and
middle ear exudates, discharges spontaneously through the tympanic
membrane, afterwards pain and fever begin to subside. This phase can
be shortened with therapy.

http://www.indianjotol.org on Monday, March 16, 2015.

3rd phase - healing phase lasting 2-4 weeks. Aural

discharge dries up and hearing improves.

4th phase of complication - If the virulence of an organism is

high, infection may spread to surrounding structures leading to
intra temporal or/and intra cranial complications.

http://www.indianjotol.org on Monday, March 16, 2015.

OTITIS MEDIA WITH EFFUSION

Otitis media with effusion (OME), also called serous or

secretory otitis media (SOM), is a collection of fluid within the
middle ear space as a result of the negative pressure due to
altered Eustachian tube (ET) function.

http://www.indianjotol.org on Monday, March 16, 2015.

The diagnosis is confirmed by tympanometry which shows B

type curve and absent reflex. Myringotomy finally confirms it.
Pneumatic otoscopy and acoustic reflexometry are important
diagnostic tool.

http://www.indianjotol.org on Monday, March 16, 2015.

Fluid in the middle ear may cause conductive hearing

impairment, but only when it interferes with the normal
vibration of the eardrum by sound waves.

Over weeks and months, middle ear fluid can become thick
and glue-like (thus the name glue ear), which increases the
likelihood of conductive hearing impairment.

http://www.indianjotol.org on Monday, March 16, 2015.

CHRONIC SUPPURATIVE OTITIS MEDIA

Chronic suppurative OM presents as a central, marginal or

attic perforation (hole) in the tympanic membrane and active
bacterial infection within the middle ear space for more than
4-6 weeks with pus that drains to the outside of the ear
(otorrhea), The purulence may be minimal enough to only be
seen on examination using an otoscope (cholesteatoma).

http://www.indianjotol.org on Monday, March 16, 2015.

Etiologically Staphylococcus aureus 30.7%, betahemolytic

streptococci 26%, Pseudomonas aeruginosa 16%, Escherichia
coli 10.6% and Klebsiella species 7% and has been observed by
the author as a causative organism.

http://www.indianjotol.org on Monday, March 16, 2015.

MANAGEMENT AND TREATMENT OF OTITIS MEDIA

Medical management of OM is actively debated in the medical

literature, primarily because of a dramatic increase in AOM
prevalence over the past 10 years caused by drug resistant S.
pneumonia and beta-lactamaseproducing H. Influenzae or M.
Catarrhalis, S. pneumonia.

http://www.indianjotol.org on Monday, March 16, 2015.

Beta-lactamases are enzymes that hydrolyze amoxicillin and

some, but not all, oral cephalosporins, leading to in vitro
resistance to these drugs.

As a result, empiric antibiotic therapy for this disease has

become more complex.

Many opinions have been expressed regarding which drugs are

best for first and secondline therapy or whether antibiotics
should be prescribed in all patients with AOM.
http://www.indianjotol.org on Monday, March 16, 2015.

GUIDELINES FOR MANAGEMENT OF ACUTE OTITIS MEDIA

Amoxicillin is the drug of choice which may be prescribed for:

unilateral AOM with symptoms, moderate to severe otalgia

with pyrexia

In bilateral cases even without pyrexia.

http://www.indianjotol.org on Monday, March 16, 2015.

Dosage: Amoxicillin 80-90 mg/kg/day along with 6.4

mg/kg/day potassium clavunate/clavulanic.

The Authors choice is cefuroxime axetil 30 mg/day with

potassium clavunate 6.4 mg/kg/day.

http://www.indianjotol.org on Monday, March 16, 2015.

Supportive therapy

Nasal decongestants, analgesics tincture benzoin steam

inhalations enhances the recovery.

Severe case Analgesic Narcotic

Steroids use controversial

Methyl prednisolone and deflazacort has been used with

some success

http://www.indianjotol.org on Monday, March 16, 2015.

MEDICAL THERAPY FOR OTITIS MEDIA WITH EFFUSION

Most cases of OME occur after an episode of AOM, and good

number of patients develops a SOM middle ear effusion (MEE).

OME are associated with conductive hearing loss, averaging

approximately 25 dB.

Most cases of OME resolve spontaneously

http://www.indianjotol.org on Monday, March 16, 2015.

Medical

management:

Antimicrobials,

antihistaminedecongestants, intranasal and systemic steroids,

nonsteroidal

anti-inflammatory

drugs,

mucolytics

and

aggressive management of allergic symptom

If OME is unresponsive to medical therapy and with an

MEE that persists more than 12 weeks tympanocentesis

http://www.indianjotol.org on Monday, March 16, 2015.

SURGICAL INTERVENTION

Integrate surgical management of AOM and OME with medical

treatment may be a modality for prompt relief and to avoid
complications.

Indications:

Severe Otalgia

Unresponsive antimicrobial therapy

OM associated with supurative complication

OM in newborn, sick neonate, immunologically deficient

http://www.indianjotol.org on Monday, March 16, 2015.

SPECIAL CASES: CLEFT PALATE

In cleft palate patients because of inherent ETD and increased

risk of OM, the TT may be placed with initial lip repair or may be
prior to palate repair.

http://www.indianjotol.org on Monday, March 16, 2015.

SPECIAL CASE: DOWNS SYNDROME

Children

with

DS

often

exhibit

ETD,

conductive

and

sensorineural hearing loss, external auditory canal (EAC)

stenosis, and subtle immunologic deficiencies high risk of
personality and child development.

Hence myringotomy/TT may be required at an early stage.

To prevent recurrent otitis externa, wax impaction or

cholesteatoma of EAC, canaloplasty should be performed.

http://www.indianjotol.org on Monday, March 16, 2015.

The incidence of OM and deafness could be prevented by

maternal education. Spesifically:

Contributing factors

Early management modalities of ear involvement

Public health efforts should be made to promote breast

feeding:

Inc. breastfeeding position

Avoid digital sucking and pacifiers

http://www.indianjotol.org on Monday, March 16, 2015.

Dairy products discouraged and abandoned.

Smoking should be discouraged and no smoking around the

children.

Harsh climate, crowded housing, poor sanitary

conditions, and lack of personal hygiene should be
adequately dealt with.

Exposure to cold to avoided in winter months which may

lead to silent OME.
http://www.indianjotol.org on Monday, March 16, 2015.