Acute Otitis Mediaa Case Presentation

Supervisor:dr. H. Oscar Djauhari, Sp. THT

Presented by:Yulius Andi Ruslim (2010-061-049)Efrem Fridolin Suryadi (2010-061-144)Farrell Tanoto (2010-061-149)

The CasePart I

The Case A 7-years old boys came to hospital with an earache of his right ears. He had a history of upper tract infection.

Identity and ComplaintName : AAge: 7 years oldOccupation: StudentAddress: Jl. KoperasiChief complaint: earache on the right ear Additional complaint : runny nose, cough, fever since 7 days ago, and hearing loss since 4 days ago (gradually)

History of Present IllnessPatient, 7 year old, male, comes to the ENT clinic with complain of pain on his right ear.

Seven days ago he got fever (38,5 degree Celcius), cough, and runny nose. The colour of the secrete was clear and serous. He had taken medication for cold and flu but his symptoms did not improve.

After four days, it became green yellowish, mucoid. He becomes more irritable than usual, pulling his right ear. He had hearing loss gradually since 4 days ago. This complain occurs for the first time. Pain in the ear suddenly appeared, continuous all day and made him uncomfortable and irritable.

History of Past Illness Upper respiratory tract infection infrequently since he was infant.

Physical Examination(Generalized Status)General appearance: moderately illAwakeness: compos mentis (E4M6V5)Pulse rate: 115 bpmRespiration rate: 25 bpmTemperature: 38,7 oC

Physical Examination (Ears)Auris dextra :- Auricle : hyperemia (-), oedema (-) - Retroauricular: normal, no deformities- Canalis acusticus externus : skin: hyperemia (-), oedema (-) discharge: (-)serumen: (+) minimal- Tymphanic membrane : intact, bulging (+), light reflex reduced (+), hyperemis- Rinne test (-), Webber lateralitation to the right, prolonged Schwabach. (Conductive Hearing Loss on Right ear)

Physical Examination (Ears)Auris sinistra : Auricle : normal, no deformitiesCanalis acusticus externus: skin: hyperemia (-), edema (-) discharge: (-)serumen: (+) minimalTymphanic membrane : intact, bulging (-), light reflex (+), colour greyRetroauricular: normal, no deformitiesRinne test (+), Webber lateralitation to the right, Schwabach same with the examiner.

Physical Examination (Nose)Right Nose :Mucous membrane : hyperemis (+), edema (+)Inferior concha: eutrophyDischarge: (+), mukoid, green yellowishSeptum : normal, no deviation

Left Nose :Mucous membrane : hyperemis (+), edema (+) Inferior concha: eutrophyDischarge: (+), mukoidSeptum : normal

Physical Examination (Throat and Neck)Throat :Uvula: in the middlePharynx: anterior and posterior pharyngeal arcus normal, hyperemia (+)Tonsil : T2/T2, hyperemis (-), cripta dilatation (-), detritus (-)

Maxillofacial: symmetric

Neck : unpalpable lymph node / unpalpable lymph node

Working DiagnosisAcute Otitis Media supurative stage auris dextra

WorkupBlood count including differential count of white blood cellsCulture of pus of the middle ear

TherapyOutpatientParacetamol tab 6 x 250 mg per oral, if temperature > 37,8 CAmoxicillin tab 3 x 250 mg per-oral, for 7 daysMyringotomy

Acute Otitis MediaEtiologyStreptococcus pneumoniae (tersering)Haemophillus influenzaeStreptococcus -hemoliticus group AStaphyllococcus aureusStaphylllococcus epidermidisE. Coli

PathophysiologyMiddle ear : steril modeThere is a connection between cavum tympani by eustachius tube. There are barrier systems : cillia, muramidase (enzym that products mucous), antibody and humoral factors, PMN, and phagocytic cells.The barrier impaired invasion of microbes to the middle ear

STAGEOcclusionHyperemicSuppurativePerforatedResolution

Clinical FindingsChildUpper tract infectionPain inner earFeverRestlessSeizuresNausea and vomitingDiarrheaHolding the affected ear

Adultspainfullness in the earhearing loss occured

ManagementOcclusionTo open the closed eustachius tube, so the pressure in middle ear can be reduced.Decongestan (Child < 12y.o: HCl ephedrine 0.5% in physiologic solution, Child>12 th: HCl efedrine1% in physiologic solution)Antibiotics

HyperemicAntibiotic: amoxicillin 40 mg/kgBB/day in 3 doses, ampicillin 50-100 mg/kgBB/day in 4 doses, eritromicin 40 mg/kgBB/day.DecongestanAnalgeticsAntipiretics

ManagementSuppurativeAntibiotics: amoxicillin 40 mg/kgBB/day in 3 doses, ampicillin 50-100 mg/kgBB/day in 4 doses, eritromicin 40 mg/kgBB/day.DecongestanAnalgeticsAntipiretics

PerforatedH2O2 3% 5 drops 3 dd 1 3-5 daysAntibiotic local (ear drops)

ManagementResolutionIf the resolution didnt take place, secretes will drained out by the perforation in tympanic membrane. The antibiotics continued for 3 weeks. If 3 weeks pasts and secretes stills, mastoiditis should be in differential diagnosis

Complication Mastoiditis, subperiosteal abscesses, meningitis, brain abscesses.