CASE REPORT

ACUTE OTITIS MEDIA PERFORATION STAGE

Presentator:

Eko Nugroho 11/31218/KU/14338

Fariz Afristya 10/304567/KU/14086

Raymond Win 11/317739/KU/14701

Ruli Aulia 11/311641/KU/14244

Stacy Gabriella 11/317281/KU/14518

Moderator:

Dr. Camelia Herdini, M.Kes.,Sp.THT-KL

Otorhinolaringology–Head and Neck Surgery Department

Faculty of Medicine UGM, Dr.Sardjito Hospital Yogyakarta

Yogyakarta

2016
Introduction lesser extent Staphylococcus aureus, and
Acute Otitis Media can be defined as Streptococcus pyogenes.1
the rapid onset of signs and symptoms of Risk factors can be host related (age,
inflammation in the middle ear. It is thought gender, race, prematurity, allergy,
that between 50% and 85% of children immunocompetence, cleft palate and
experience at least one episode of AOM by 3 craniofacial abnormalities, genetic
years of age with the peak incidence being predisposition) as well as environmental
between 6 and 15 months. Young children (upper respiratory infections [URis],
are more prone to AOM due to an anatomical seasonality, day care, siblings, tobacco
predisposition; the eustachian tube is shorter, smoke exposure, breast-feeding,
more flexible, and horizontal which allows socioeconomic status, pacifier use, and
nasopharyngeal pathogens to enter the obesity) and are considered important in the
middle ear with relative ease. In fact occurrence, recurrence, and persistence of
nasopharyngeal dimensions have been shown middle-ear disease.1
to be smaller in children suffering from AOM is a purulent middle ear
repeated attacks of AOM. The eustachian process, therefore the signs and symptoms
tube matures by 7 years old; this may explain consistent with acute inflammation are
the relative decline in the incidence of OM present. AOM typically has a short history,
after this age. 1 and is commonly associated with fever,
otalgia, irritability, otorrhea, lethargy,
The etiology of OM is multifactorial anorexia, and vomiting; the symptoms alone
and relates to anatomical variations, lack sensitivity and specificity for diagnosis.
pathophysiology including the interaction Signs of inflammation include bulging or
between microbial agents and host immune fullness of the tympanic membrane (TM ),
response, and cell biology of the middle ear erythema of the TM, and acute perforation of
cleft (mastoid, middle ear cavity, eustachian the TM with otorrhea.2 On Otoscopy
tube) and nasopharynx. The bacteria examination , in stage of tubal occlusion,
commonly implicated in These are there is tympanic membrane retraction,
Streptococcus pneumoniae, Haemophilus tympanic membrane looks gloomy and the
influenzae, Moraxella catarrhalis, and to a light reflex can’t be seen. In stage of
hyperaemic, tympanic membrane looks
hyperemic with edema. In stage of
suppurative, tympanic membrane bulges
outside with yellow colour. In stage of
perforation, there is rupture of tympanic
membrane and pus drain out from the middle
ear to the external canal. 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.3
An AOM diagnosis requires
moderate to severe bulging of the tympanic
membrane, new onset of otorrhea not caused
by otitis externa, or mild bulging of the
tympanic membrane associated with recent
onset of ear pain (less than 48 hours) or
erythema. AOM should not be diagnosed in
children who do not have objective evidence
of middle ear effusion. An inaccurate
diagnosis can lead to unnecessary treatment
with antibiotics and contribute to the
4
development of antibiotic resistance.
Analgesics are recommended for
symptoms of ear pain, fever, and irritability..
Ibuprofen and acetaminophen have been
shown to be effective. Ibuprofen is preferred,
given its longer duration of action and its
lower toxicity in the event of overdose.
Topical analgesics, such as benzocaine, can
4
also be helpful.
Antibiotics should be routinely
prescribed for 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
102.2°F [39°C] or higher), and for children
younger than two years with bilateral AOM
regardless of additional signs or symptoms.
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 uni-
lateral AOM. A large prospective study of
this strategy found that two out of three
children will recover without antibiotics.
Recently, the American Academy of Family
Physicians recommended not prescribing
antibiotics for otitis media in children two to
12 years of age with nonsevere symptoms if
observation is a reasonable optio.
A meta-analysis of six RCTs of
children six months to 12 years of age with
acute otitis media examined the effectiveness
of amoxicillin or amoxicillin/clavulanic acid
versus placebo or delayed treatment in
reducing pain, fever, or both at three to seven
days. The authors concluded that antibiotics
were more effective than placebo or delayed
treatment in children with acute otitis media
and otorrhea (relative risk [RR] = 0.52; 95%
confidence interval [CI], 0.37 to 0.73;
number needed to treat [NNT] = 3) versus
children with acute otitis media without
otorrhea (RR = 0.80; 95% CI, 0.70 to 0.92;
NNT = 8) 5
The recent US guidelines recommend
the standard 10-day course of therapy for
younger children and for children with severe
disease, while for those 6 years of age and
older with mild to moderate disease. a 5- to
7-day course may be used.3
Clinicians should advise patient’s
family to prevent upper respiratory tract
infection (URTI) in the infant and children
and treat the URTI adequately. Clinicians
also can recommend the family to give
exclusive breast milk for at least six months
untill 2 years. Avoiding exposure to
environtmental risk factor such as tobacco
smoke and the others are also important. 4
Case Report
A 5 years old boy on August 2nd,2016
came to ENT clinic of Soeradji Tirtonegoro
Klaten Hospital with chief complaint of
discharge from the left ear. The discharge is
yellowish with foul odor. A week before, the
patient had flue (cough and rinorrhea)
followed with pain ear gripe two days after.
His mother report that the discharge from the
left ear was started 3 days ago concomitant
with diminish pain. There were no complain
of hearing loss and itch. During history
taking, the patient’s parents stated that he
never had similar condition before. They also
stated that the complaint never been treated
and their son never took any medications
before. Her mother routinely cleaned up her
ear by using cotton buds. There are no
complaint of nose, throat, fever, hearing loss,
tinnitus, vertigo, cough, rhinorrhea, and
history of allergy. They suspected the ear
became wet while bathing. There is also no
history of similar complaint in patient’s
family.
The general status was good and
compos mentis, and vital sign’s result of the
patient was normal. The patient’s heart rate
was 84 x/minute, respiratory rate 22
x/minute, and body temperature 36,8OC.
There was discharge in the external auditory
canal of the left ear from the examination
with otoscope. There was a small perforation
on the center of the tympanic membrane. The
result of right ear, nose, and throat
examination was normal.
The diagnosis of this patient is acute
otitis media perforation stadium of the left
ear, based on the anamnesis and physical
examination. The medications given to the
patient were Amoxicillin syrup 3 times a day
and Rhinos junior 3 times a day. Patient was
told to keep both ear dry, take care both ear
hygiene, avoid predisposing factors such as
immediately seek medication when catching
a cough and rinorrhea, and return to the clinic
for a follow up after one week.
Discussion
The age of the patient is 5 years old
which make him suspectible of AOM. Young
children are more prone to AOM due to an
anatomical predisposition: the eustachian
tube is shorter, more flexible, and horizontal
which allows nasopharyngeal pathogens to
enter the middle ear with relative ease. The
eustachian tube matures by 7 years old; this
may explain the relative decline in the
incidence of OM after this age. 1
Risk factors can be host related (age,
gender, race, prematurity, allergy,
immunocompetence, cleft palate and
craniofacial abnormalities, genetic
predisposition) as well as environmental
(upper respiratory infections [URis],
seasonality, day care, siblings, tobacco
smoke exposure, breast-feeding,
socioeconomic status, pacifier use, and
obesity) and are considered important in the
occurrence, recurrence, and persistence of
middle-ear disease.1 The risk factors found in
the patient were environmental factors, and
immaturity of eustachian tube.
One of the diagnostic criteria is new
onset of otorrhea not caused by otitis externa4
which is veritable in this patient proven with
anamnesis result and physical.
AOM is divided into 5 stages. On
Otoscopy examination , in stage of tubal
occlusion, there is tympanic membrane
retraction, tympanic membrane looks gloomy
and the light reflex can’t be seen. In stage of
hyperaemic, tympanic membrane looks
hyperemic with edema. In stage of
suppurative, tympanic membrane bulges
outside with yellow colour. In stage of
perforation, there is rupture of tympanic
membrane and pus drain out from the middle
ear to the external canal. 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.3 In this patients,
findings of physical examination were
suitable with perforation stage.
Further discussion is about
management chosen by clinician on this case,
medication chosen was amoxicillin syrup and
rhinos junior which are antibiotics and
decongestans+antihistamins. Perhaps
clinicians decided to chose those regiment by
consideration of trying to quickly managing
the causal of acute otitis media, which
logically caused by excessive mucous that
can be managed with microbiologic spectrum. First-line treatment
decongestans+antihistamines. with amoxicillin is not recommended for
Antibiotics is the first drug chosen in these cases: in children with concurrent
this case, however previously when acute purulent conjunctivitis, after antibiotic
otitis media is not routinely trated with therapy within the preceding month, in
antibiotics, most children with acute otitis children taking amoxicillin as
media (70 to 90 percent) have spontaneous chemoprophylaxis for recurrent acute otitis
resolution within seven to 14 days; therefore, media or urinary tract infection, and in
antibiotics should not routinely be prescribed children with penicillin allergy.9
initially for all children.6 Delaying antibiotic Treatment goals in acute otitis media
therapy in selected patients reduces include symptom resolution and reduction of
treatment-related costs and side effects and recurrence. This is why analgetics should be
minimizes emergence of resistant strains.7 prescribed, as it’s known that acute otitis
But we must not forget that in this media causes major pain and discomfort on
acute otitis media case, it’s already ear and general head area. Pain management
progressed into perforated membrana is important in the first two days after
tympanic phase. According to a meta- diagnosis.10 Analgetic options include
analysis of six RCTs of children six months acetaminophen (15 mg per kg every four to
to 12 years of age with acute otitis media six hours) and ibuprofen (10 mg per kg every
examined the effectiveness of amoxicillin or six hours).14 Beside those systemic analgetics
amoxicillin/clavulanic acid versus placebo or and/or NSAIDs, Antipyrine/benzocaine otic
delayed treatment in reducing pain, fever, or suspension can be used for local analgesia on
both at three to seven days. The authors of worse cases with excrutiating pain shown by
these researches concluded that antibiotics patient.15
were more effective than placebo or delayed From this case, we see that several
treatment in children with acute otitis media clinician using antihistamines and/or
perforated tymphanic phase.8 decongestans for acute otitis media
Firstline antibiotics for acute otitis treatment. According to researches,
media is high dosage amoxicillin, as antihistamines only helps with nasal
amoxicillin is effective, safe, and relatively allergies, but they may prolong middle ear
inexpensive, and it has a narrow effusion16 and oral decongestants may only
be used to relieve nasal congestion. However,
neither antihistamines nor decongestants
improve healing or minimize complications
of acute otitis media, and they are not
17
routinely recommended. Corticosteroid use
has no benefit in acute otitis media.16
Conclussion
Patient 5 years old boy, based on
anamnesis and ENT examination was
diagnosed with Acute Otitis Media (AOM)
perforation stadium of the left ear. The
medications given to the patient were
antibiotics, decongestants and
antihistamines.
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