LITERATURE REVIEW: ACUTE OTITIS MEDIA

Pembimbing : dr. Daniel Widjaja, Sp.THT-KL Penyaji : Regina Varani (2012-061-093) Mariani Devi (2013-061-027)

EMBRIOLOGI TELINGA
Pembentukan telinga dimulai pada usia 22 hari penebalan ectoderm invaginasi otic pit otocysts

Ventral (saculus dan duktus kokhlearis) dan Dorsal (utrikulus, kanalis semisirkularis dan duktus endolimfatik)

ANATOMI

Moore K. Clinically Oriented Anatomy 6th Edition. 2010. Lippincott William & Wilkins

TUBA EUSTACHIUS

ANATOMI MEMBRAN TIMPANI

LETAK PERFORASI
Sentral : pada pars tensa Marginal : sebagian tepi perforasi langsung berhubungan dengan anulus / sulkus timpanikum Atik : perforasi di pars flaksida

DEFINISI
Gejala dan tanda inflamasi pada telinga tengah dengan onset yang akut, disertai dengan efusi telinga tengah Inflamasi dan pus pada telinga tengah disertai dengan gejala dan tanda infeksi telinga.

EPIDEMIOLOGI
Usia puncak insidensi adalah 6 12 bulan pertama kehidupan Angka kejadian menurun seiring bertambahnya usia Mudah berulang pada usia muda Kurang lebih 80% anak anak mengalami OMA paling tidak satu kali sebelum usia 3 tahun

ETIOLOGI

FAKTOR RISIKO DAN PREDISPOSISI

PATOFISIOLOGI
INFEKSI

LINGKUNG AN

TUBA EUSTACHIUS

FAKTOR HOST

TELINGA TENGAH

REAKSI INFLAMASI

Edema mukosa, Penyumbatan kapiler, dan Infiltrasi leukosit PMN

STADIUM
Stadium oklusi tuba eustachius Stadium hiperemis Stadium supurasi Stadium perforasi Stadium resolusi

MANIFESTASI KLINIS

Nonspecific symptoms : Otalgia Irritability Fever Headache Cough Rhinitis Anorexia Vomiting Diarrhea Ear rubbing or pulling

Sign : Bulging membrane timpani Eritema membrane timpani Acute perforation, otorrhea

COMPLICATIONS

Intratemporal

Penurunan pendengaran (konduktif dan sensorineural) OMSK (dengan atau tanpa cholesteatoma) Mastoiditis Tympanosclerosis Facial paralysis
Meningitis Empiema subdural Abses otak Abses ekstradural

Intracranial

CDC

PNEUMATIC OTOSCOPY

MANAGEMENT OF AOM
Spontaneous resolution: 70-90% children within 7-14 days AB may be delayed in:

otherwise healthy children 6 months 2 yo with mild otitis in whom the diagnosis is uncertain children > 2 yo with mild symptoms or in whom the diagnosis is uncertain

Delaying AB therapy
treatment-related costs and side effects emergence of resistant strains.

INITIAL MANAGEMENT

OBSERVATIONS

Ensure follow-up and begin AB therapy if the child worsens or fails to improve within 48-72 hours of onset of symptoms wait-and-see prescription (WASP)

1/3 children rescue AB for persistent or worsening AOM AB use could potentially be reduced by 65% in eligible children.

MANAGEMENT: OBSERVATIONS

Symptomatic treatment PAIN management (in the first two days after diagnosis)
Acetaminophen (15 mg/kg/4-6 hours) and Ibuprofen (Motrin; 10 mg/kg/6 hours). Antipyrine/benzocaine otic suspension (Auralgan) local analgesia

NOT routinely recommended:

Antihistamines help with nasal allergies, may prolong MEE Oral decongestants may be used to relieve nasal congestion

Neither AH nor decongestants improve healing or minimize complications of AOM

Corticosteroid use has NO benefit in AOM.

AAP 2013

MANAGEMENT: ANTIBIOTICS
Most beneficial children < 2 years with bilateral AOM and in children with otorrhea. (AAP 2013, AFP 2007) AB is recommended for: (CDC, AAP 2013)

All children < 6 months Children > 6 months with severe infection (moderate or severe otalgia for at least 48 hours, or temperature > 39C). Children < 2 yo with bilateral AOM without severe signs or symptoms (mild otalgia <48 hours, temp < 39C).

AAP 2013

MANAGEMENT: ANTIBIOTIC SELECTION (AFP 2007)

FIRST LINE THERAPY: High-dosage amoxicillin (80 to 90 mg/kg/day, divided into two daily doses for 10 days) NOT recommended in children:

With concurrent purulent conjunctivitis, after AB therapy within the preceding month, taking amoxicillin as chemoprophylaxis for recurrent AOM or UTI, and with penicillin allergy.
Penicillin allergy with NO history of urticaria or anaphylaxis Cephalosporins. (AAP 2013) POSITIVE history Macrolides (azithromycin [Zithromax], clarithromycin [Biaxin]) or clindamycin [Cleocin].

MANAGEMENT OF PERSISTENT AOM

Persistent AOM NO CLINICAL IMPROVEMENT (within 48-72 hours)

REASSESS & EXCLUDE other causes of illness IF symptomatic treatment only Initiate AB therapy First line AB Second-line therapy

High-dose amoxicillin/clavulanate (Augmentin), cephalosporins, macrolides. Parenteral ceftriaxone administered daily over three days in children with emesis or resistance to amoxicillin/clavulanate.

For children who do not respond to second-line AB Clindamycin and Tympanocentesis. Levofloxacin (Levaquin) not approved by FDA

AAP 2013

MANAGEMENT: OPERATIVE (E-MEDICINE)

Tympanocentesis Myringotomy Myringotomy with ventilation tube (Tympanostomy) Mastoidectomy

http://emedicine.medscape.com/article/859316treatment#a1156

RECURRENT AOM

Occurrence of 3 or > episodes of AOM in 6-month period, or occurrence of 4 or > episodes of AOM in 12-month period that includes at least 1 episode in the preceding 6 months. Management
Watchful waiting. Minimizing risk factors exposure to cigarette smoke, pacifier use, bottle feeding, daycare attendance AB Prophylaxis (Long-term, low-dose AB) recurrence, but not widely accepted recommendations Surgery:

Tympanostomy tubes controversial Adenoidectomy, without myringotomy and/or tympanostomy tubes did not episodes of AOM when compared with chemoprophylaxis or placebo. Adenoidectomy + tympanostomy tubes may have benefit.

AOM MANAGEMENT AFP 2007

Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and Treatment of Otitis Media. Am Fam Physician. 2007

PREVENTIONS
Pneumococcal vaccines Annual influenza vaccines Exclusive breastfeeding Lifestyle changes Xylitol*