HANDLING IN otitis media

HANDLING IN otitis media

By:
Tutut SRIWILUDJENG T.
Dr. Wahidin Sudiro Husodo Mojokerto

INTRODUCTIONOtitis media is one that quite a lot of ear disease dijmpai. Patients with otitis media in general came for a treatment to a general practitioner. So the role of general practitioners is very important in this regard.Figures estimated prevalence in the world 65-3350 million people suffer from complaints otorrhoea, with 90% of this number there are in Southeast Asia, western Pacific and Africa. This paper will discuss the akuta otitis media, otitis media and otitis media effusion chronicle.
1. Otitis Media Akuta (OMA)Otitis media akuta here meant sapuratif akuta otitis media. OMA is an acute infection of the middle ear is usually caused by bacteria. Preceded by infection in the nose and / or throat. Often found in children - children than in adults. Actually more related to public health because of the era to do with socioeconomic conditions, in which case more often found in populations with poor economic statusPathogenesis of OMA are intimately associated with the condition of the fallopian Eustacius, both anatomically physiologically. In general, occur because nasofaringitis OMA Akuta rhinitis due and lead to failure of ventilation in the tympanic cavity. Henceforth occur cavity and transudation and exudation in the tympanic cavity.In the United Kingdom case of OMA are often found in children - children. At the age of less than 3 years are 30% of children had suffered from OMA. When in Indonesia as well as the patient is assumed to OMA will come of medication in a general practitioner or pediatrician. Thus there will be some possibilities in this patient. The first patient recovered the second one of the worst management or undiagnosed. When the two possibilities the latter case, the risk of suppurative otitis media chronicle and complications will be greater.Travel illness in OMA occurs in 4 stages: stage of inflammation (1), supurasi (II), perforation (III) and resolution (IV).Stadium inflammatory or also called aka kataral stage event of a complaint hearing ears feel full and decreases are preceded by the occurrence of rhinitis akuta. Clinical signs of tympanic membrane is the color began to hyperemia, retracted position or sometimes - sometimes appear water fluid level. When the patient arrived at this stage, the treatment given is antibiotic amoxicillin / co-trimoxazole and symptomatic medication.





Figure 1: The tympanic membrane during stage I.
If the disease continues to run will occur supurasi stage. The main complaint is otalgi great. In children - children who can not complain, then the child will be fussy sometimes vomiting, and anorexia. Other symptoms are fever, seizures occur in children dapt. Pendenganran tertap less. Clinical signs appear is the tympanic membrane and hipremi bombans. Same therapy in stage I, and parasintesis the tympanic membrane.





Figure 2: The tympanic membrane at the time of stage II.When Stage II passes without proper treatment it will be setting does stage perforation. Symptoms at this stage that stands out is otorrhoea which of course preceded by otalgi, permanent hearing decreased. Clinical signs of tympanic membrane perforation in pars Tensa is generally small and the toilet right ear. At this stage there was no otorrhoea sought after at the latest 2 weeks. It is better than 2 weeks are still going otorrhoea should be referred to the ENT doctor.






Figure 3: The tympanic membrane at stage III.
If stage III elapsed before 2 weeks there will be stage IV. At this stage the patient complained of hearing was still not back to normal. Clinical signs of perforation of the tympanic membrane is still visible but the color started to return to normal and not looked secret. Therapy at this stage does not exist. Patients are given ear hygiene education to maintain and control 2-4 weeks later to see if the tympanic membrane to close the closed spontaneously. If still no perforation could be referred to the ENT to be stimulating and epithelialization or Myryngoplasty.






Figure 4: The tympanic membrane at the time of stage IV.As a general practitioner, if the facility has a simple diagnostic and ENT devices, of course, be allowed to do therapy. Furthermore, when referring to people with OMA. Should be immediately referred if encountered complications. The most commonly encountered are acute mostoiditis, and facial nerve paresis, and complications such as meningitis intrakarnial, sebritis and brain abscess. Signs and symptoms to watch out for is the presence udim and pain in the area retroaurikula, fever, headache, stiff neck, facial paresis, ataxia, and a decrease in GCS. However, complications from this OMA after antibiotic era is rare.The reason for referring the case next OMA after 7 days if therapy fails, the effusion / perforation occurred OMA permanent and repeated 4 times in 6 months.At about - about 80% of OMA will occur spontaneous resolution. But if it does not happen then it will progress to otitis media or otitis media effusion chronicle. In the developing countries obtained the number 51 000 children aged less than 5 years old die because of complications.
 2. Chronic Otitis Media Sapuratif (Omsk)Chronic suppurative otitis media is the occurrence of chronic infections of the ear the hands. Symptoms that occurred was otorrhoea of ​​more than 2 weeks. But many scientists think after the 2 months. Otorrhoea can be recurrent or persistent. Clinical signs of perforation of the tympanic membrane, and found secret mukopurelen granulation polyp pathology and kolesteatom.Surveys by the health department in 1994 found the rate of 3.8% people suffer from middle ear infections. When referring to the criteria of WHO, the figure is considered high. The WHO classification is:> 4%: highest, 2-4%: high, 1-2%: low, <1%: the lowest.Omsk classification is as follows:1. Benign type, also called benign type, tubotimpanik, mucosa and safe.2. This type of danger, too type atikoantral disebutk, bone, and Malinga. Although the term malignant actually wrong.
3. Omsk benignPathogenesis of Omsk is still often a debate. But often found that the case was found in patients Omsk which childhood - kanaknya suffer recurrent Omsk. So in this case that has been agreed as the cause is the presence of several factors including: tubal dysfunction, viral infection / bacteria, allergies, immunity, environmental conditions and socio-economic conditions. Some other factors that support the occurrence of chronicity are: the existence of permanent perforation, irreversible pathology, obtruksi persistent in mastoid or tympanic cavity, and ostemielitus.The main complaint people in general are otorrhoea, then hearing decreased, or sometimes - sometimes otalgi. Clinical signs seen in central tympanic membrane is perforated at Tensa pars can be round or kidney, was secret at the tympanic cavity. Udim tympanic cavity mucosa, hypertrophy, or there is pathology granulation, or timpanosklerosis.






Figure 5: The tympanic membrane in Omsk benign.
Management of benign Omsk can be seen in the algorithm below.
 Omsk B (active)

• CT / toilet• Systemic AB• AB ATopikal

Rujuik otorrhoea remained ≥ 1 mg

AB + culture

Otorrhoea settled> 3 bl

MastoiddektomiTimpanoplastiOmsk quiet (dry perforation)• Conservative• Operative
In the standard implementation guide Omsk in Indonesia, chronic suppurative otitis media include the active phase and quiet phases are also commonly referred to as dry perforations.When the diagnosis of active Omsk has been an upright, then the edge is the toilet routine ear, systemic antibiotics, topical antibiotics for a week. If it still otorrhoea after the examination is necessary kulturn and germs and antibiotic sensitivity are given in the parental, or patients can be directly referred to the ENT. After therapy is appropriate given the sensitivity of the bacteria while still otorrhoea for more than 3 months, then performed surgery, and timpanoplasti mastoidektomi.The important thing to understand in the use of ear drops are an indication of the true and the effect will be to exacerbate ototoksik patient complaints. Group of ear drops until recently considered safe are ofloxacin, whereas chloramphenicol, gentamicin and neomycin has been shown to be ototoksis 13. Also is the correct way of ear toilet. OMK patient abroad must come every day to clean, if not then have to clean it yourself at least 3 times a day by way of aspirated with a syringe or absorbed with tissue paper.





Figure 6: Paper for toilet tissue and cotton.
4. Omsk Hazard TypeReferred to as a type of danger because of the pathology kolesteatom are progressive and destructive so that potential complications resulting in a dangerous and life-threatening.Clinical symptoms similar to those seen in OMK benign, but it will be very different if there have been complications. Clinical sign is the presence of perforation tweaking, marginal or large central (total) in the presence kolesteatom. Mukopurulen secretions accompanied by a distinctive odor.




Figure 7: tympanic membrane in OMK Hazard TypeOMK complications from this type of hazard can occur intratemporal, ekstratemporal and intracranial. Intratemporal complication is paresis, and labirintitis. Ekstratemporal is subperiosteal mastoid abscess, Bezold abscess and abscess Mouret. Intrakarnial is meningitis, serebritis, brain abscess, abscess perisinus, ekstradural abscess and lateral sinus thrombophlebitis.Therapy for Omsk type of hazard is mastoidektomi surgery. Mastoidektomi may be accompanied by hearing bone reconstruction depending on the case.Below is an algorithm Omsk management scenarios for general practitioners.Otorrhoea ≤ 2 mg. New, never Tx blmSK I: - Anamnesis thorough
 - MT hrs seems difficult to reconcile
 - How to toilet ear
 - AB topical2 mg

Otorrhoea + New, Tx blm has recovered otorrhoea -
SK: - Resistance AB- Check the compliance of patient- Consider topical AB- Beware the dangers- Refer

SK: - AB Fever, otalgi, sefalgi SK IV: - AB high dose- Toilet ear Vertigo, udim retroaurkuler - Refer- Refer
- Without otorrhoea hearing decline +- ReferSK V: - Reconstruction - Eradication- ABD - Reconstruction







5. Otitis media effusion (Ome)Serous otitis media is an inflammation of the middle ear with accumulation of secretions without signs and symptoms of infection. There are some common synonyms of serous otitis media, secretory otitis media and glue ear. Ome incidence in developed countries is 80% in children - children younger than 4 years had suffered from Ome.Ome pathophysiological occurrence is due to the occurrence of chronic blockade of the fallopian Eustachius from the disease - a chronic disease as well as allergic rhinitis, adenoid hypertrophy and nasopharyngeal tumors. Blockade of the fallopian Eustachius will husband's dance in the tympanic cavity pressure becomes negative and then going transudation. If the blockade of the fallopian continue to run the transudation process will continue.Symptoms that arise are fully felt in the ear, hearing less, tinnitus, sometimes - sometimes otalgi. In the child - children rarely complain about the above symptoms, especially among children under five, but because his hearing is less then there will be symptoms - symptoms of speech and language disorders sometimes occur until school developmental disorder. Because symptoms are not too annoying in general the patient came for a treatment already in the stage of complications.Local clinical signs were found in the retraction of the tympanic membrane bleak colors, bubble water, hair line, or membrane, such as would be found somewhat bombans conduction deafness.Treatment of this Ome generated a lot of uncertainty in the physician and patient. Parasintesis tympanic membrane with the installation of gromet still the main therapy, beside the treatment on the etiology factor.Complications can occur because of delayed treatment. The complications that occurred are OMK type of hazard, adhesive otitis media and atelectasis. This situation will cause severe deafness.Prognosis in children - children are generally better, and can heal spontaneously within a few months. Because the children - children are usually caused by allergies that would improve the child's age line.The next question for a general practitioner is when referring. If the diagnosis is difficult to enforce then immediately refer. When given after three months of treatment does not improve then need to be referred.
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