Case Report: Acute

Otitis Media
Moderator :dr. Ashadi Prasetyo, M.Sc, Sp.THT-KL

Group 16103 Banyumas:

Ali Ariyono - Saskia Octariza R - Meydita Fauzia P.I.
Kevin Leonardo - Annisa Indah Saraswati

5 September 2017
INTRODUCTION
Acute Otitis Media (AOM) is defined by convention as the first 3
weeks of a process in which the middle ear shows the signs and
symptoms of acute inflammation.

Acute otitis media is common childhood disorder. It leads to

signifificant morbidity and leading cause of antibiotic prescription.
Between 50% and 85% of children experience at least one episode of
AOM by 3 years of age with peak incidence being between 6 and 15
months

(AAFP, 2013)
ANATOMY
Definition
Acute otitis media (AOM) represents the rapid onset of an
inflammatory process of the middle ear space associated with one or
more symptoms or local or systemic signs.
(Coker TR et al,2010)
 Risk Factor

(AAFP, 2013)

(Johnson, T, et.al., 2014)

Etiology
Bacteria :
Streptococcus pneumonia (40%)
Haemophilus influenzae (25-30%)
Streptococcus haemoliticus
Staphylococcus aureus

Virus :
Respiratory Synctial Virus
Mononucleousis

Others :
Chlamidia
Mycoplasma
(Ramakhrisnan, 2007)
Pathophysiology

Mechanical dysfunction
Tubal dysfunction
Functional dysfunction

Pressure in
middle ear (-)
Otitis Media
with effusion
Effusion
Acute otitis
media
Clinical Manifestation
Sudden onset of severe and pulsating earache. The child may cry
and scream inconsolably, he/she is ushed and ill; the temperature
may be as high as 40C. In children often unspecific side symptoms
such as irritability and stomach ache are present.
Hearing loss of conductive nature is always present in acute otitis
media and adults may report tinnitus sensation.
Otorrhea
Headache
Conccurent Upper Respiratory Infection : Cough, rhinorrhea, Nasal
congestion, sore throat, cough, runny nose.
Staging
Tubal occlusion stage
Hyperemic stage or pre-suppurative stage
Suppuration stage
Perforation stage
Resolution stage
 Sign of tubal occlusion stage is tympanic membrane retraction due
Tubal occlusion stage to negative pressure inside the middle ear. The tympanic
membrane might appear normal or pale.

Hyperemic stage is characterized with dilated vessels in the

Hyperemic stage or tympanic membrane, therefore the tympanic membrane appears
pre-suppurative stage hyperemic and edematous. Serous discharge that might present is
difficult to assess.
Suppuration All symptoms become more severe. The tympanic membrane starts
bulging. Later on, the exudates exert pressure on one spot of the

stage tympanic membrane. This may become the point of perforation

later and it appears as yellow poin

The drum perforates, pus starts flowing out. Pain and

Perforation constitutional symptoms lessen with the escape of ear discharge.
Otorrhoea, may be initially blood-stained, can range from mucoid

stage to purulent discharge. During examination, perforation can be

observed, usually in the anteroinferior quadrant with pulsatile
discharge.
Resolution If the tympanic membrane is still intact, it will be gradually back
to normal condition. If perforation accurs, the discharge will

stage
decrease and finally become dry. In immunocompetent patient,
resolution will occur even without any medical treatment
Additional/Useful Diagnostic
Procedure
Endoscopy of the nose/nasopharynx (adenoids, nasopharyngeal
tumour)
Microbiology: culture taken from the nose/nasopharynx
Ultrasound of the paranasal sinuses
Schller X-ray, paranasal sinuses
Paediatric counselling
Treatment
Antibiotic Choice (for children)
 Analgesics/antiphlogistics: e. g. 75150 mg diclofenac
orally/suppository for adults, 2 mg/kg body weight
orally/suppository for children.
Mefanaminic acid: 7501,500 mg orally/suppository for adults; 6.5
mg/kg body weight orally or 12 mg/kg body weight suppository for
children. Avoid the use of aspirin in children.
Nasal vasoconstrictors: nose spray/nose drops, e. g. 0.1%
xylomethazoline for adults, 0.05% for children, several times per
day.
Surgical Treatment
The recommended European standard is:
Myringotomy (paracentesis): indicated when bulging of the
tympanic membrane persists, for immediate relief of pain.
Adenoidectomy: in recurrent acute otitis media, in most cases
accompanied by myringotomy and insertion of grommets.
Antrotomy/mastoidectomy: in cases of present or imminent
mastoiditis, labyrinthitis, thrombosis of the sigmoid sinus or
endocranial complications. Usually simultaneous insertion of
grommets.
Differential Diagnosis
1. Usually acute otitis media shows very characteristic
clinical features.
2. Earpain in normal otoscopic fndings: see also the algorithm for
Earache.
Neuralgia of the auricular branch of the vagus nerve, e. g. in acute
tonsillitis, neuralgia of the glossopharyngeal nerve following
tonsillectomy or in carcinoma of the lateral wall of oropharnyx and
hypopharynx
Eagle syndrome: irritation of the glossopharyngeal nerve by an
abnormally long processus styloideus
Irritation of the temporomandibular joint (temporomandibular joint
syndrome)
Cervicofacial syndrome (C4C5)
Complication
Acute otitis media must be managed with care to prevent
subsequent complications such as mastoiditis (inammation of the
mastoid cell system), acute labyrinthitis (dizziness, vertigo,
deafness), facial palsy, thrombosis of the sigmoid sinus, meningitis
and subdural-epidural abscess.
Case report
Patients Identity

Name : RK
Gender : Male
Age : 3 years 9 months old
Address : Jepara, Binangan
Religion : Islam
Medical Record : 00 69 14 XX
Chief complaint
Discharge from left ear
Current History
Left ear discharge occurs since 4 days ago, the color was yellowish
white and its consistency was thick, irritability (-) pulling on ear(-)
hearing loss (+), lack of appetite(-), fever (+), cough (-), nasal
congestion (-), nasal discharge (-) .
The patient suffered from common cold one week ago.
Past illnesses
Alergy (-)
Trauma (-)
Family History
Allergy (-)
Anamnesis summary
Otorrhea (+) thick, yellowish white discharge
Hearing loss (+)
Fever (+)
Physical Examination
General State: Compos mentis, active
HR : 94x/minute, regular
RR : 20 x/minute, regular, toracoabdominal
Temp : 37.8 0C , axilla

BW : 13 kg
BH : 115 cm
Physical Examination

Head : IC -/-

AC -/-

Neck : lymphadenopathy (-)

coli region mass (-)

pain in swallowing (-)

Ear Examination
Dextra Sinistra
Pinna Normal, mass(-), Normal, mass(-),
hiperemis(-) hiperemis(-)
Tragus pain (-) (-)
Canalis Hiperemis(-) Normal, discharge(+),
auditorius corpus alienum(-), hipermis(-) , edema (-)
externus discharge(-),
edema(-)

Tymphanic Hyperemis(-), Hyperemis(+), bulging (-

Membrane bulging (-), cone of ), cone of light (-),
light(+) perforation (+) pars
Mastoid Normal,pressure Normal, pressure pain(-)
pain(-)
 Discharge
(+)

Hiperemis (+)

Perforation (+)
Nose and paranasal sinus examination
Dextra Sinistra

Inspection Deformity (-), Discharge Deformitas (-),

(-), Hyperemic (-), Discharge (-),
Skin lession (-) Hyperemic (-),
Skin lession (-)
Palpation Tenderness (-), Tenderness (-),
Crepitation (-) Crepitation (-)
Percussion Facial pain (-) Facial Pain (-)

Rhinoskopy anterior Choncae : Choncae :

Hyperemic (-), Edema (-), Hyperemic (-), Edema
Discharge (-) viscous (-), Discharge (-)
discharge, Mass (-) viscous discharge,
Septum: Deviation (-) Mass(-)
Septum: Deviation (-)
 D S

Normal
Normal
Throat examination

Structure Result
lips pink
Teeth and gum Caries (-) hyperemic (-)
tongue Leukoplakia (-) wound (-)
hyperemic (-)
Oropharynx Tonsil size : T1/T1

T1
T1

D S
Diagnosis
Acute Otitis Media std perforasi Auricula
sinistra
treatment
Clanexi forte (250mg/5ml) 3 d.d 5 ml
Rhinos Junior 2 x 5 ml
Paracetamol 3 x 0,5 cth
follow up patient after 1 week
DISCUSSION
Problems
How to differentiate Acute otitis media
from Otitis media with effusion?
Antibiotic use in children with Acute
Otitis Media ?
AOM and OME
AOM is an infection that involves the middle ear which the
tympanic membrane becomes inflamed and opaque
AOM represents the rapid onset of an inflammatory process of the
middle ear space associated with one or more symptoms or local
or systemic signs
OME is fluid in the middle ear without signs or symptoms of
inflammation that can occur just prior to or persist after an
infection for a few days or up to many weeks
In OME, the tympanic membrane will not be red or bulging as it is if
the child has AOM
 Signs and Symptoms OME AOM

Impaired hearing Mild-to- Mild-to-moderate

moderate
Pain (otalgia) No Moderate-to-severe

Tenderness No No

Purulent drainage No Only after perforation of

(otorrhea) tympanic membrane

Bacterial infection No Yes

Systemic symptoms No Yes

(ie, fever, malaise)
Antibiotic use
AOM (bilateral or unilateral) in children 6 months and older with
severe signs or symptoms (moderate or severe otalgia or otalgia for
at least 48 hours or temperature 39C or higher) antibiotic
therapy
Bilateral AOM in children 6 months through 23 months of age
without severe signs or symptoms antibiotic therapy
Unilateral AOM in children 6 months to 23 months of age without
severe signs or symptoms antibiotic therapy or close
observation
Nonsevere AOM in older children antibiotic therapy or offer
observation with close follow-up
Observation a mechanism must be in place to ensure follow-up
and begin antibiotic therapy if the child worsens or fails to improve
within 48 to 72 hours of onset of symptoms.
 Initial watchful waiting without antibiotic therapy for healthy
children 6 months to 2 years of age with nonsevere illness (mild
otalgia, fever < 39 C) at presentation and an uncertain diagnosis
and to children 2 years of age and older without severe symptoms
at presentation or with an uncertain diagnosis.7 It is because AOM
symptoms improve in most within 13 days. If observation is
chosen, a mechanism must be in place to ensure appropriate
treatment if symptoms persist for more than 48 to 72 hours.
 Spiro et al had proved that management of AOM by intial watchful
waiting is significantly reduce antibiotics usage in the population.
McCormick et all also proved that parents satisfaction in group that
was treat by observation and was treated by antibiotics are the
same. Antibiotics use can reduce treatment failure and control the
symptoms but also can increase the side effects of antibiotics and
increase the percentage of multidrug resistant S. pneumonia in
nasopharynx.
Indication for observation protocol are (helmi, 2003) :
No fever
No vomiting
Patient or parents agree delay antibiotic use
Clanexi forte -> amoxicilin and clavulanic acid
Amoxicilin-clavulanic acid :
Second-line drug. For patients with recurrent or persistent acute
otitis media, those taking prophylactic amoxicillin, those who have
used antibiotics within the previous month, and those with
concurrent purulent conjunctivitis

(AAFP,2013)
rhinos : pseudoephredine HCl and loratadine
Antihistamine can help reduce the symptoms for the patient with
Rhinitis alergy. While oral decongestant can be used to reduce nasal
congestion. But, antihistamine and decongestant are not routinely
recommended due to its lack ability topromote healing or reduce
the complication of AOM.

(Bluestone, 2003)
CONCLUSION
We have reported a 3 years old female with chief complaint left ear
discharge since 4 days ago came to ENT clinic in RSUD Banyumas.
She was diagnosed with acute otitis media AS. The patient was
treated with Clanexi forte (250mg/5ml) 3 times daily ,Rhinos Junior
2 x 5 ml and Paracetamol 3 x 0,5 cth
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