DIAKNOSIS AND MANAGEMENT Otitis media effusion in CHILDREN

DIAKNOSIS AND MANAGEMENT
Otitis media effusion IN CHILDREN
By:
Tutut SRIWILUDJENG T.
Dr. Wahidin Sudiro Husodo Mojokerto

INTRODUCTIONOtitis media effusion (Ome) is a disease often suffered by babies and children. Outside the country, particularly in countries that have 4 seasons of this disease were found with the incidence and prevalence rates are high. From some literature can be concluded Ome average incidence by 14% - 62%, while other researchers have reported an average prevalence rate Ome 2% - 52% .1In Indonesia, are still rarely found in the literature that reported the incidence of this disease, this is caused because there has been no specific research on this disease, or not detected due to minimal complaints in children who suffer OME.1Ome is an inflammation of the middle ear of the mark in the presence of fluid in the pleural cavity of the middle ear with intact tympanic membrane without the signs of acute ifeksi. Ome included in the class of non-suppurative otitis media. There are many synonyms of this Ome. But the most widely accepted terminology is otitis media based efusi.4The presence of fluid in the middle ear resulting in hearing loss. Parents complain their children listen to television with the volume too loud, often re asking for the answers given his parents and did not immediately ignored when on call. Some children may not get complaints. The fluid in the middle ear in children can be many months and only recently recognized when the examination was held rutin.5The children need the ability to hear to learn to speak. The presence of hearing loss because of fluid in the middle ear resulted in delays bicara.6-8 diagnosis and early treatment can prevent children from hearing barriers Ome. This paper will be delivered the diagnosis and management of Ome.
1. DefinitionOtitis media effusion is middle ear inflammation characterized by the accumulation of fluid in the middle ear effusion with intact tympanic membrane without the signs and symptoms of inflammation akut.2, 9.102. Anatomy and physiologyTo understand the occurrence of Ome, anatomy and function of the fallopian Eustachius plays an important role. Tuba Eustachius is part of the system which best corresponds including the nose, nasopharynx, middle ear, and the cavity mastoid.2, 4 Tuba Eustachius not just a tube but an organ that contains lume with mucosa, cartilage, surrounded by soft tissue, such as Veli Palatine muskulus peritubular , Levator Veli Palatine, salpingofaringeus, and tensor tympanic and bone in the superior support. Differences tuba Eustachius in children and adults who cause increased incidence of otitis media in children anak.4The length of half the length of the fallopian tubes in young adults, making it easier reflux of nasopharyngeal secretions into the middle ear through the tube is short. The direction of the tube varies in children, the angle between the tubes with a horizontal plane is 100. While in adults 450. The angle between the tensor Veli Palatine with cartilage varies in children but relatively stable in adults. These differences may help explain the opening of the tubal lumen (contraction tensor Veli palatini) which are not efficient in children. Period of cartilage to grow from infancy to adulthood. Density of elastin in cartilage in infants less but greater density of cartilage. Ostmann fat pad is smaller by volume in infants. In children many Mucosal folds in the lumen of the fallopian Eustachius, this may explain the increased tubal compliance in children-anak.2, 4






Figure 1. The difference degree angle in children and tuba Eustachius dewasa.2
3. Etiology and PathogenesisEtiology and pathogenesis is multifactorial Ome include viral or bacterial infections, tubal dysfunction Eustachius, immunologic status, allergy, environmental and social factors. However a negative middle ear pressure, immunological abnormalities, or a combination of both factors is estimated to be a major factor in the pathogenesis of Ome. Other factors including adenoid hypertrophy, chronic adenoiditis, palatoskisis, nasopharyngeal tumors, barotrauma, radiation therapy, and inflamed comorbidities such as sinusitis or rhinitis. Smoking can induce lymphoid hiperplasi nasopharynx and adenoid hypertrophy is also an emergence pathogenesis OME.2
3.1 Impaired function of the fallopianTubal dysfunction causing aeration mechanism into the middle ear cavity is interrupted, the drainage from the ear cavity into the nasopharynx cavity disturbed and impaired middle ear cavity protection mechanisms against reflux of nasopharyngeal cavity. Due to the disorder of the middle ear cavity will experience a negative pressure. Negative pressure in the middle ear causes increased capillary and subsequently occurs permaebilitas transudation. In addition, populations occur infiltration of inflammatory cells and glandular secretion. As a result there is accumulation of secretions in the middle ear cavity. Chronic inflammation in the middle ear will cause the formation of granulation tissue, fibrosis and bone destruction.Tubal obstruction Eustachius ytang lead to a negative pressure in the middle ear tympanic membrane retraction will be followed. Adults will usually complain of discomfort, a feeling of fullness or feeling depressed and consequently incurred a mild hearing loss and tinnitus. Children may not show symptoms like this. If this situation lasts for a long time the liquid will be drawn out of the mucous membrane of the middle ear, causing a state which we call the serous otitis media. These events often occur in children associated with upper respiratory tract infections and some hearing loss mengikutinya.7, 12


3.2 InfectionsBacterial infection is an important factor in the pathogenesis of Ome since reported the existence of bacteria in the middle ear. Streptococcus pneumonia, Haemophilus influenzae, Moraxella Catarrhalis known as the most pathogenic bacteria found in ear tengah.7, 13.14 Although the results obtained from a lower culture. The cause of the low figure is expected karena13: The use of long-term antibiotics prior to pemakian ventilation tube would reduce the proliferation of pathogenic bacteria, Secretion of immunoglobulins and lysozyme in middle ear effusions inhibits the proliferation of pathogens, Bacteria in middle ear effusion acts as a biofilm
3.3 Status of ImmunologyAdequate immunological factors play a role in Ome is secretory Ig A. immunoglobulin is produced by glands in the mucosa of the tympanic cavity. Secretory immunoglobulin A is mainly found in the effusion mukoid and is known as an active working surface immunoglobulin respiratory mucosa. It acts to block germ that is not to direct contact with the surface apitel, by forming the complex bond. Direct contact with the epithelial cell wall is the first stage of the penetration of bacteria to tissue infection. Thus, Ig A actively prevent infection kuman.14

3.4 AllergiesHow allergic factors play a role in causing Ome is still unclear. However, the clinical picture in believing that allergies play a role. The idea is embriologik analogy, where the tympanic mucosa were similar to the nasal mucosa. At least manifestation of the fallopian Eustachius lergi is a cause of chronic grafting and subsequently cause the effusion. However, IgE levels of research that became the criteria of atopic allergy, both levels in effusions and in serum does not fully support the allergy as penyebab.15Etiology and pathogenesis of otitis media because of allergies may be caused by one or more of the following mechanisms: 15 middle ear mucosa as the target organs (target organs) swelling due to inflammatory processes in the mucosa of the fallopian Eustachius nasopharyngeal obstruction due to inflammatory processes, and nasopharyngeal aspiration of bacteria contained in allergic secretions into the middle ear space.
4. Clinical symptomsOme Patients rarely give symptoms so that the children are often late known. Ome symptoms marked by a feeling of fullness in the ear, you hear a buzz that intermittent or continuous, hearing loss and mild pain. Dizziness also felt patients Ome-sufferers. Symptoms often are asymptomatic, so the Ome known by people close to the child such as parents or guru.2, 16Children with Ome also sometimes be seen pulling at their ear or feel like his ears tersumbat.17In advanced cases often found the existence of speech disorders and language development. Sometimes the situation is also encountered difficulties in communicating and backwardness in pelajaran.18, 19
5. DiagnosisOme diagnosis in children is not easy and there are significant differences in accordance with clinician skill, particularly at primary care level or pediatrician who diagnosed it. Symptoms no sensitive or specific, in fact many children without symptoms. Physical examination on children with Ome potentially inaccurate picture because the subjective impression of the tympanic membrane difficult to assess. Not to mention the children who are uncooperative during examination. However enamnesis and physical examination still plays an important role in diagnosing OME.6
5.1 AnamnesisIn diagnosing Ome required carefulness of the examiner. This is due to complaints that are not typical, especially in children. Parents usually complain of hearing loss in children, teachers reported that the child has hearing problems, setbacks in lessons at school, even in speech and language disorders. Ome often discovered accidentally during ear examination and hearing screening in school-sekolah.5, 11In children with Ome of history's most frequent complaints were hearing loss and sometimes felt ears feel full up with ear pain. And in children with Ome usually they are also often found with a history of cough, runny nose and sore throat berulang.3 In children greater difficulty they usually complain menengarkan lessons at school, or have to raise the volume while watching television in rumah.18 People Parents also often listened to his ears feel uncomfortable or often saw her son pulling the leaves telinganya.20
5.2 Physical examinationTo diagnose Ome on physical examination should be done otoskopi examination, timpanogram, audiogram and sometimes miringotomi action to ensure there is fluid in the ear tengah.5, 7,8,11,21
5.2.1 OtoskopiOtoskopi examination done for the condition, color, and translusensi tempani membrane. Various kinds of changes or abnormalities that occur in the tympanic membrane can be seen as berikut.21, 22:a) The tympanic membrane is dull and yellowish translucent menggati description other than that where the triangle of light reflex in the inferior quadrant Antero shortened, perhaps also showed that increased blood vessel kapier on the tympanic membrane. In the case with liquid mukoid or tympanic membrane mukupurulen younger colored (beige).b) retraction of the tympanic membrane when the manubrium malei look shorter and more horizontal, looked haggard and membrane retracts the light reflex. The color may change slightly yellowish.c) atelectasis, tympanic membrane is usually thin, atrophy and may stick to the incus, stapes and promontium, especially in cases that have been advanced, usually cases like this because of tubal dysfunction and otitis media effusion Eustachius longstanding.


Figure 2. Otitis media adesiva (atelectasis) 23d) the tympanic membrane with sikatrik, bleak until severe retraction accompanied by the atrophy was found in otitis media due adesiva by fibrotic tissue middle ear as a result of previous inflammatory process that lasted long.e) The description of water or fluid level bubles usually found in liquid-filled Ome serus.






Figure 3. Serous fluid in the cavity Figure 4. Multiple water bubbletimpani23 on Ome 23
f) tympanic membrane dark blue or purple hematotimpanum shown in cases caused by temporal bone fractures, leukemia, tumor vascular middle ear. While the younger blue color may be caused by barotraumas.




Figure 5. Tympanic cavity with fluid which is mixed darah.23g) Another description is found sikatrik and spotting kalisifikasi.
On examination Ome otoskopi pointed suspicion if found mark-tanda21:a) There were no signs of acute inflammation.b) There is a change in color of the tympanic membrane due to reflection from the fluid in the tympanic cavity.c) tympanic membrane appear more prominent.d) tympanic membrane retraction or atelectasis.e) There were water or bubble fluid levels, orf) The mobility is reduced or modifying membrane.
5.2.2 Otoskop pneumatic / otoskop SieglePneumatic Otoskop was first introduced by Siegle, relatively unchanged since its first introduction in 1864. Examination otoskopi pneumatic but can see the type of perforation, tissue pathology, and to an intact tympanic membrane can also be viewed gerakanya (mobility) by giving positive pressure then the tympanic membrane will move to the medial and when given a negative pressure then will move to the tympanic membrane leteral. Examination otoskopi pneumatic is standard on OME.6 diagnostic physical, 21





Figure 6. Otoskop Siegle23
5.2.3 tympanometryTimpanometer is a tool to determine the condition of the middle ear system. This measurement gives an overview of tympanic membrane mobility, hearing bone stock condition, including circumstances in the middle ear air pressure in it, so useful in knowing conduction disorders and tubal function Eustachius.14, 21Graph the results of measurements or timpanogram timpanometeri can to find a picture in the middle ear abnormalities. Although found a huge variation in timpanogram but in principle there are only three types, namely type A, type B, and type C.6, 21In patients Ome timpanogram picture that is often found is type B. Type B is relatively flat shape, it shows the movement of the tympanic membrane is limited due to the fluid or adhesions in the tympanic cavity. The graph is very flat may occur due to perforation of tympanic membrane, a lot of wax on the outer ear canal or fault on the appliance that is clogged channels.







Figure 7. Overview timpanogram.25 type
Tympanometry examination can predict the existence of fluid in the tympanic cavity better than saja.6 otoskopi examination, 7,21,25

5.2.4 audiogramFrom examination audiometrik obtained pure tone threshold value of bone and air.Hearing loss is more frequently found in patients Ome with a viscous fluid (glue ear). Nevertheless some studies say there is no significant difference between the liquid and viscous serus against hearing loss, while the volume of fluid found in the middle ear is more berpengaruh.21Patients with Ome found deafness conductive hearing loss with mild to moderate so as not very influential in everyday life. Persistent bilateral deafness more than 25 dB can interfere with intellectual development and ability to speak anak21. If this could be allowed to gain weight deafness is bad for patients. Ill-effects may include local disorders of the ear as well as the more common disorders, such as disorders of language development and decline in school lessons. Patients with more severe conduction deafness may have been obtained fixation or break the chain osikel.26Ome guidelines prepared jointly by the AAFP, and AAP AAOHNS states that audiology is one component of patient examination Ome. Audiometrik examination is recommended in patients with Ome for 3 months or more, language delay, learning disorders or suspicion of significant hearing impairment. Based on several studies, conduction deafness is often associated with Ome and influential in the process of hearing both ears, sound localization, speech perception in noise. Hearing loss caused by Ome will start blocking the ability of language that didapat.7, 27
5.2.5 RadiologyMastoid radiology examination images previously used for screening effective Ome, but now rarely done. Anamnesis of disease history and physical examination to help diagnose disease much month.7CT scans are very sensitive and is not required for diagnosis. Although CT scan is important to get rid of the complications of otitis media eg mastoiditis, sigmoid sinus thrombosis or any kolesteatoma. CT scan is important especially in patients with unilateral Ome which must be ensured that the mass in the nasopharynx has disingkirkan.7
6. ManagementThe diagnosis and treatment as early as possible play an important role. The success of treatment is determined by finding the causes and overcome in order to prevent further due to the disease. Tubal blockage and infection of upper respiratory tract of chronic and recurrent is one important factor diperhatikan.16But Ome own management is still a debate, is caused by either conservative treatment or surgery, each has advantages and disadvantages. Ome conservative treatment is not yet proven to cure patients with Ome, but in principle can reduce morbidity when conservative therapy fails or is not considered memuaskan.28Treatment of Ome include conservative treatment and surgery. Conservative treatment locally (nose drops or spray) and systemic broad spectrum antibiotics among others, an antihistamine, decongestant, with or without corticosteroids. Treatment and control of allergies can reduce or cure otitis media efusi.16Operative treatment be done in cases where conservative treatment after diving more than 3 months did not recover. To give good results against the drainage done miringotomi and vent pipe installation. Ventilation pipes installed in the area quadrant Antero Antero inferior or superior. Vent pipe will be maintained until this paten.16 tubal function in the operative management include mirigotomi with or without ventilation pipe installation and adenoidektomi with or without tonsilektomi.2, 4The objective is to eliminate the ventilation pipe installation in the middle ear fluid, hearing loss happens, preventing recurrence, preventing disruption of cognitive development, speech, language and psikososial.2, 4






Figure 8. Figure 9 Installation of vent pipe. Ome with a hole(Grommet) .23 ex parasitesis.23
Otitis media effusionOme (otitis media effusion)Full flavor ears / hearing loss / otofoni








Figure 10. Scheme of the diagnosis and management OME297. ComplicationDue to continued Ome may result in loss of auditory function that will affect the development of speech and intellectual. Changes that occur in the middle ear can lead to disease progression to otitis media and chronic otitis media adesiva maligna.2, 4.30
8. SummaryOme often occurs in infants and children so it is quite difficult in diagnosing illness. Nearest and many interact with the child would be a good source of information. Attention parents and teachers are very helpful in making the diagnosis.Etiology and pathophysiology is multifactorial Ome, mutual support and inter-related. In infants and children, immunological status is very important to maintain resistance to infection.History and physical examination is necessary in the diagnosis Ome. The use of pneumatic tools otoskopi, tympanometry, audiometric for physical examination is helpful in establishing the diagnosis.Treatment of Ome include conservative treatment and surgery. Conservative treatment includes antibiotics, antihistamines, dekogestan, with or without corticosteroids. Treatment is operative include mirigotomi with or without ventilation pipe installation and adenoidektomi with or without tonsillectomy.Piñatalaksanaan a fast, accurate and adequate essential role in inhibiting the process of hearing loss and other complications.REFERENCES1. Tamim S, Djafar ZA, Soetirto I. The prevalence of otitis media effusion in children nursery school - and elementary school children in kindergarten and elementary school of Al-Azhar Jakarta. Manuscript collection of PIT attention. Batu Malang 27 to 29 October 1996; 215.2. Bluestone CD, Client JO Otitis media in infants and children In bluestone et al eds. Otolaryngology Pediatrics 2nd ed Philadelphia, WB Saunders Co., 1995.3. Paparella MM, Jung TTK, MV Goycoolea Otitis media with effusion In Paparella MM, eds DA Shumrick Neurootology Otolaryngology and Otolaryngology 3rd ed, WB Saunders Co, 1991: 1325-1330.4. Rosenfeld RM and bluestone CD. Evidence-based media Stephen Berman, MD eds. Canada BC Decker Inc. 1999.5. 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