CASE REPORT

ACUTE OTITIS MEDIA

Presented by:
Audiza Luthffia 13/350442/KU/16009
Ayu Larasati Sukarno 13/346237/KU/15698
Dian Rahmawati 13/346688/KU/15860
Joshepine Debora Uli 13/352456/KU/16058
Joshua Andrew 13/348775/KU/15922
Patria Aditya Arimukti 13/346366/KU/15761
Stephani Novia Wijaya 13/349279/KU/15945

Moderated by:
dr. Ashadi Prasetyo, M.Sc, Sp.THT-KL

Departement of Otorhinolaryngology, Head and Neck Surgery

Faculty of Medicine Universitas Gadjah Mada
Dr Sarjito Hospital
2017
INTRODUCTION of all culture-positive cases),
Haemophylus influenzae (40–45%),
Acute otitis media (AOM) is one
Streptococcus pyogenes (1–5%) and
of the most commonly occurring
Moraxella catarrhalis (1–5%).6
inflammatory diseases of infancy and
childhood and the third most frequent The pathogenesis of AOM
reason for prescription of antibiotics in begins with eustachian tube
this age group.1 More than 50% of the dysfunction. The Eustachian tube
children will have at least one episode preserves normal middle ear
of AOM by the age of one year. The conditions through three primary
disease is most frequent between 6 functions: clearance of middle ear
and 13 months of age.2 fluid, ventilation, and protection from
nasopharyngeal reflux. The
Acute otitis media is
mucociliary wave transports middle
inflammatory diseases of the middle
ear secretions toward the
ear with particular involvement of the
nasopharing. When a precipitating
tympanic cavity.3 The risk factor of
event, such as viral URTI or allergic
AOM are genetic predisposition,
rhinitis, triggers nasal mucosal
premature birth, male gender, family
inflammation, obstruction of the tubal
history of recurrent otitis media,
orifice leads to fluid stasis. Individuals
presence of siblings in the household,
with narrower and horizontally
young age, day care attendance,
oriented anatomy, cleft palate, or
exposure to smoking, lack of breast
tensor veli palatini deficiency have
feeding, supine feeding position, use
impaired drainage and are at higher
of pacifiers, family history of recurrent
risk for tubal dysfunction. Tubal
AOM, craniofacial abnormalities and
dysfunction induces a negative
low socioeconomic status.4 AOM is
pressure in middle ear resulting in
related to upper respiratory infection
tympanic membrane retraction and
(URTI); in 94% of patient URTI
transudation into tympanic cavity.
proceeds AOM, one in three children
Middle ear effusion caused by
will develop AOM after URTI.5
transudation becomes a favorable
The most frequent bacterial media for bacterial growth resulting in
pathogens causing AOM are infection of bacteria in timpanic cavity.
Streptococcus pneumoniae (40–45% The pus formation in the middle ear
push the tympanic membrane (bulging The 2013 U.S. AOM Guidelines
appearance of tympanic membrane) . recommended features for the
Continuous pus formation increase definition of AOM which is the
tension in tympanic membrane results presence of moderate to severe
in ischemia and necrosis of tympanic bulging of the tympanic membrane or
membrane. Necrosis in tympanic new onset of otorrhea not due to acute
membrane appears as tympanic otitis externa, presence of mild bulging
membrane perforation, this of the tympanic membrane and an
perforation allows passage of pus to acute (within 48 hours) onset of
outer ear canal. Resolutions of earache (holding, tugging, rubbing of
perforation will occur if patient is the ear in a nonverbal child) or intense
immunocompetent and the bacterial erythema of the tympanic membran,
virulence is low.7 and presence of medial ear efussion
based on pneumatic otoscopy and/or
The clinical practice guideline for
tympanometry.9
diagnosis and management of AOM
reported by the American Academy of Clinical manifestations of acute
Pediatrics provides that a diagnosis of otitis media are different based on its
AOM requires signs and symptoms stage. The first stage is tubal
such as recent, usually abrupt, onset occlusion which manifests as
of signs and symptoms of middle-ear retracted tympanic membrane, dull or
inflammation and effusion; presence normal tympanic membrane,
of middle ear effusion, indicated by symptom of deafness may pass
any bulging of the tympanic unnoticed especially in children, pain,
membrane, limited or absent mobility if occur, not so severe and may
of the tympanic membrane, air-fluid described as fullness. Second, stage
level behind the tympanic membrane, of pre-suppuration/hyperemic,
and otorrhea; and signs or symptoms manifests as hyperemic/injection of
of middle-ear inflammation as tympanic membrane due to vessels
indicated by either distinct erythema of engorgement, at this stage fever and
the tympanic membrane or distinct restlessness may start, increase of
earache (discomfort results in earache and deafness. Third, stage of
precludes normal activity or sleep). 8 suppuration manifests as edema,
bulging of tympanic membrane due to
presence of pus in the middle ear,
severe earache that can precludes
normal activity or sleep, and fever may
reach 39,50C.10
Fourth, stage of perforation, in
this stage spontaneous rupture of
tympanic membrane results in fall in
temperature, earache decreases, and
discharge could be purulent,
mucopurulent or bloody. Last, stage
of resolution, discharge may stop
within two days, most of the symptoms
resolve except for hearing impairment
due to residual effusion. The aim of
acute otitis media therapy are opening
tubal occlusion using decongestant,
decreasing earache and discomfort
using analgetic, and treating infection
using antibiotic. Acute otitis media
stage perforation also needs frequent
aural toilets/cleaning.10
CASE REPORT
A six year-old girl presented to
ENT clinic RSUD Banyumas on 25th
2017 with chief complain of pain in the
left ear since last night. Her parents
also complained of fever, irritable,
difficult to fall asleep, and frequently
waking up after falling asleep last
night. No history of ear discharge.
Other conditions such as dizzy, head
and face pain, buzzing sound
sensation, or hearing impairment were
denied. Her parents stated that 1 week
before the visit, the patient has history
of having upper respiratory tract
infection manifested as cough, sore
throat, runny nose, and nasal
congestion. The cough and nasal
symptoms has reduced by taking
some over the counter drugs, but the
parents forget the drugs name. There
were no similar complaints prior to the
visit. The girl has no history of allergy
or atopic history in the family. There
were no family history related to the
complaints as well as similar
complaints in the family.
Physical examination of the
right ear was within the normal limit.
While for the physical examination of
the left ear from inspection the
anatomy of the auricula was normal,
no redness and swelling of the
auricula were seen. There were no
pain when auricula was retracted as
well as when the tragus was palpated.
Inspection of the ear canal was not
hyperemic or edema. There were no
discharge seen in the ear canal. The
tympanic membrane was still intact
but hyperemic upon inspection. Cone
of light was not visible.
Physical examination of both
left and right nose showed no
anatomic abnormality, slight concha
edema, no hyperemic and minimal
discharge was seen. Physical
examination of the throat also within
the normal limit, the pharyng was not
hyperemic and no granule was seen.
The tonsil size was T1 in both right
and left tonsils, and also not
hyperemic.
Based on history-taking and
physical examination, patient was
then diagnosed with hyperemic stage
of acute otitis media. Patient was
prescribed with Amoxicilin forte syrup
2 teaspoon 3 times daily, Rhinos
Junior syurp 1 teaspoon 2 times daily,
Paracetamol syrup 1 ½ teaspoon 3
times daily as medications. Duration of
treatment is 7 days.
Patient was given education to
complete the antibiotic treatment
course and to take all medications
according to the recommendation.
Patient was also told to prevent
recurrency of the upper respiratory
infection, and avoid manipulating the
ear. The patient was advised to be
follow up in the following week, after 7
days of treatment.
DISCUSSION
In this case, the patient has
history of URTI. The patient suffered
from cough, runny nose, nasal
congestion, and mild fever a week
before the ear symptoms appear.
As mention before, upper
respiratory infection has a relation with
incidence of otitis media (OM). A
research conducted by Chonmaitree
et al show relation between URTI
caused by virus infection with
incidence of OM. Rhinovirus and
adenovirus were among the most
frequently detected causative agent
found in patients with URI. The overall
incidence of OM following was 61%,
including a 37% incidence of AOM and
a 24% incidence of otitis media
effusion (OME). AOM occurred in
approximately one-half of children
with URTI due to adenovirus,
respiratory syncytial virus, or
coronavirus and in approximately one-
third of those with URI due to influenza
virus, parainfluenza virus, enterovirus,
or rhinovirus. AOM and OME was
diagnosed on days 1–24 in the course
of URI, with the peak occurring on
days 3–5, the median time was day 4
for AOM and day 3 for OME.11
While for the bacterial studies,
Revai et al published a research that
show nasopharyngeal cultures were
85.6% positive for pathogenic bacteria
in URTI. S. Pneumoniae was isolated
alone or combination with another
bacterial in 34% of the cases, H.
influenzae was isolated in 34%, and
M. catarrhalis was isolated in 69%.12
Thirty five percent of URTI
episodes were complicated by AOM.
AOM diagnosis peaked on day 3, and
85% of AOM episodes
diagnosed within 7 days after URTI
onset. The Odd Ratio showed
increased risk of AOM when the
nasopharynx was colonized
pathogenic bacteria (S. pneumoniae,
NT H. influenzae, or M. catarrhalis),
compared with no pathogen. The 3
pathogenic bacteria, either alone or in
combination, were more likely to be
isolated from samples from children
with AOM than from samples from
children without AOM. Compared with
a child with no bacteria in the
nasopharynx, a child with 2 types of
bacteria in the nasopharynx was 2.6
times as likely to have AOM.12
Bacteria colonized in
nasopharing enter the middle ear via
the eustachian tube. Normally,
bacteria are prevented from entering
the middle ear by the ciliated
epithelium that lines the eustachian
tube. Respiratory virus infection
disrupts the mucociliary system and
impairs the ear’s primary mechanical
barrier from bacterial invasion. In
addition, eustachian-tube dysfunction
can lead to reduced middle-ear
pressure, which forces mucus,
nasopharyngeal secretions, and
bacteria into the middle ear; this
creates an ideal milieu for bacterial
superinfection.13
were
The highest incidence of AOM
after URTI to be between 6 and 11
months of age.13 The increased
with susceptibility to AOM in younger
children has been postulated to be
secondary to inadequate immunologic
response and a shorter, straighter,
and narrower Eustachian tube. The
anatomical features of eustachian
tube in pediatrics makes the
progession of the infection at upper
respiratory tract to the middle ear
more possible than those in adults.
The horizontal direction of drainage
into throat in pediatrics makes the
migration of pathogen to the middle
ear easier than the gravity assisted
the
vertical direction of drainage in adults.
The shorter tube length in pediatrics
also gives the pathogen a shorter
pathway to reach the middle ear. It
stands to reason that the taller
children are protected from exposure
to known avoidable otitis media risk effective for moderate or severe pain.
factors, the later the onset of AOM and But the use of narcotics requires
the lower their lifetime incidence.14 prescription, and consideration of the
side effects, such as risk of respiratory
In this case, the patient
depression, altered mental status,
recieved amoxicilin forte syrup,
gastrointestinal upset, and
Rhinos Junior syrup, and Paracetamol
constipation.15 The route of
syrup as medications.
administration is more preferred in oral
Based on American Academy route rather than ear drop because the
of Family Physicians (AAFP), there administration analgesic ear drops
are three recommendations for AOM should be delayed until examination
treatment which are the use of the whole tympanic membrane is
analgesics, observational protocol, performed. Administration of
and antibiotics. analgesic ear drops is not

First recommendation, the use recommended in children under 3

of analgesics. The goal of analgesic years old without a previous tympanic

administration is to relieve pain in membrane visualization because

patients with AOM since pain is one of there is not a solid evidence of

the most troublesome complain in efficacy, it is not safe in case of

AOM. Ramakrishnan et al stated that spontaneous perforation, and may

acetaminophen or ibuprofen are alter the otoscopic assessment

effective analgesics to treat mild to because of cerumen fluidification.17

moderate pain.15 Bertin et al conduct The second recommendation is

a multicenter randomized double-blind the observational treatment. This
controlled study and conclude that the protocol has been proved to reduce
analgesics effect of ibuprofen was the use of antibiotics in 56% 6 months-
significant compared to a placebo, but 12 years old patient.18 Observation
no significant analgesic effect of without use of antibacterial agents in a
acetaminophen was observed.16 But child with uncomplicated AOM is an
recent study stated that option for selected children based on
acetaminophen can be used for diagnostic certainty, age, illness
treating pain in AOM. Narcotic severity, and assurance of follow-up.
analgesia with codeine or analogs is This option should be limited to
otherwise healthy children 6 months to >39oC).15 If antibiotics is indicated, the
2 years of age with non-severe illness first line is amoxicillin 80-
at presentation and an uncertain 90mg/kg/day. In patient with severe
diagnosis, and to children 2 years of infection and if the patient is infected
age and older without severe beta lactamase producing
symptoms at presentation or with an Haemophillus influenza and Moraxella
uncertain diagnosis. In these catarrhalis, the regimen should start
situations observation provides an with high dose Amoxicillin clavulanat
opportunity for the patient to improve (90mg/kg/day Amoxicillin dan
without antibacterial treatment. The 6,4mg/kg/day clavulanat divided in 2
indications of observational protocol doses). If the patient is allergic to
are absent of fever or vomit, parents penicillin, and the reaction is not type I
and patient agreed to delay antibiotics hypersensitivity (urticarial or
administration. While the relative anaphylactic reaction), the patient can
contraindications are history of be given cefdinir (14 mg/kg/day in 1 or
antibiotic treatment within the last 2 2 doses), cefpodoxime (10 mg/kg/day
weeks and present of otorrhea. The once daily), or cefuroxime (30
use of this protocol refer to delay in mg/kg/day in 2 divided doses) can be
antibiotic treatment for selected used. In cases of Type I reactions,
patients with no complications for 72 azithromycin (10 mg/kg/day on day 1,
hours or more. During the followed by 5 mg/kg/day x 4 days as a
observational period, the patients only single daily dose) or clarithromycin (15
receive symptomatic treatment mg/kg/day in 2 divided doses) can be
including analgesics. Antibiotic used in an effort to select an
treatment should be initiate if antibacterial agent of an entirely
symptoms of AOM persist until the different class. Other possibilities
third day.19 include erythromycin-sulfisoxazole
(50 mg/kg/day of erythromycin) or
Antibiotics are recommended
sulfamethoxazole-trimethoprim (6–10
for all children under 6 months, 6
mg/kg/day trimethoprim). Alternative
months – 2 years with certain
therapy in the penicillin-allergic patient
diagnosis, and for children above 2
who is being treated for infection that
years old with severe infection
is known or presumed to be caused by
(moderate to severe otalgia or fever
penicillin-resistant S pneumoniae is
clindamycin at 30 to 40 mg/kg/day in 3 Histamine interacts with
divided doses. In the patient who is histamin receptors such as H1, H2,
vomiting or cannot otherwise tolerate H3, H4. H1 receptor is responsible for
oral medication, a single dose of allergic reaction. Interaction of
parenteral ceftriaxone (50 mg/kg) has histamine with H1 receptor causes
been shown to be effective for the vasodilatation, thus increasing
initial treatment of AOM.15 vascular permeability. This condition
could lead to congestion.
If the patient fails to respond to
Antihistamine works by binding to H1
the initial management option within
receptor competitively. It will prevent
48 to 72 hours, the clinician must
the interaction between histamine and
reassess the patient to confirm AOM
H1 receptor.20
and exclude other causes of illness. If
AOM is confirmed in the patient Decongestan stimulates alpha-
initially managed with observation, the adrenergic receptor resulting in
clinician should begin antibacterial vasoconstriction of dilated arteries,
therapy. If the patient was initially decreasing the edema and mucus
managed with an antibacterial agents, formation.21
the clinician should change the
However, the use of
antibacterial agents.
antihistamine and/or decongestant
Since the patient is already 6 only have a little clinical effect, thus
years old (more than 2 years old) and are not recommended for routine in
the diagnosis of AOM is already AOM treatment.22 In this case, the
established, the patient fulfil the patient was given antihistamine and
criteria for antibiotic therapy. decongestant to relieve the nasal
symptom.
As for the symptomatic
treatment for this case, the patient CONCLUSION
were given Rhinos Junior syrup
A 6-year-old girl patient was
containing 15 mg pseudoefedrin and 1
diagnosed with hyperemic stage of
mg chlorpheniramine maleate / 5ml
acute otitis media. Patient was
and Paracetamol (acetaminophen
prescribed with Amoxicilin forte syrup,
class which act as analgetic as well as
Rhinos Junior syurp, Paracetamol
antipyretic).
syrup as medications for 7 days.
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