SUPERVISOR:

dr. Sally Mahdiani., Sp.THT-KL (K)

Presenter:
Aryo Mandraguna Wibowo, dr.

Middle Ear
Inflammation
Otorhinolaryngology
Head and Neck Surgery Department
Medical Faculty Padjadjaran
University
Hasan Sadikin Hospital
2018
 2

INTRODUCTION
• Part or whole inflammation of middle ear mucous,
Definition tuba Eustachius, anthrum mastoid and mastoid cells

• Suppurative Otitis Media

Based on
symptoms
• Non suppurative Otitis Media

• Acute Otitis Media

Based On
Time
• Chronic Otitis Media

• Tuberculosa Otitis Media

Specific • Syphilitica Otitis Media

Modul telinga –radang telinga tengah, edisi I, Kolegium Ilmu kesehatan Telinga hidung tenggorok
Bedah Kepala dan Leher, 2008
EPIDEMIOLOGY
3 years old children : Almost
50-85% ever experience one
episode of otitis media

Acute Otitis Media Recurrent  Almost 20%

happen to < 1 years old , and increased until
40 % in children with 6 or more AOM episodes

USA : 60-80% baby experience 1st episodes

of AOM at age 1 and increased until 80-90%
experienced 1st episode of AOM at age 2-3

Highest incidence
AOM in USA 6-24
months of age

THT-KL RSHS
(2012-2014) :
11,3% with CSOM
 4

RISK FACTOR
Age

Genetic Kindergarten

Asthma and Milk bottle

atopy usage

Breastfeeding
Family history less than 3
months

Not adequate
Cigarretes
medication

Teether
Race
usage

Modul telinga –radang telinga tengah, edisi I, Kolegium Ilmu kesehatan Telinga hidung tenggorok
Bedah Kepala dan Leher, 2008
ANATOMY
 6

MIDDLE EAR ANATOMY

Probst R,Grevers G, Iro H.Basic Otorhinolaryngology. Thieme.2006. p.229

 7

TYMPANIC MEMBRANE
 Divide CAE and middle ear
 Angle:
 Kids : almost vertical
 Adults : 55o
 Diameter 9-10 mm x 8-9 mm
 Importance structure:
 umbo
 Cone of light
 pars flaccida
 pars tensa

Dhingra, PL. Diseases of ear, nose and throat.Elsevier.2007 p.6

 8

PRUSSAK SPACE
Prussak's space is important because it
is a site for pars flaccida acquired
cholesteatoma formation.

A cholesteatoma forms when there is a

deep retraction pocket in the tympanic
membrane.

The debris collects and enlarges and

ultimately forms a cholesteatoma.

Gulya AJ. Gulya and Schuknecht’s anatomy of the temporal bone with surgical implication Informa Health care SA 2007.
 9

MUSCLES
There are two muscles which serve a
protective function in the middle ear; the
tensor tympani and stapedius.

They contract in response to loud noise,

inhibiting the vibrations of the malleus,
incus and stapes, and reducing the
transmission of sound to the inner ear. This
action is known as the acoustic reflex.

Gulya AJ. Gulya and Schuknecht’s anatomy of the temporal bone with surgical implication Informa Health care SA 2007.
 10

EUSTACHIAN TUBE

The auditory tube (eustachian

tube) is a cartilaginous and bony
tube that connects the middle
ear to the nasopharynx. It acts
to equalise the pressure of the
middle ear to that of the
external auditory meatus.

Dhingra, PL. Diseases of ear, nose and throat.Elsevier.2007 p.6

MIDDLE EAR BLOOD SUPPLY

• The two largest branches are the tympanic

branch of the maxillary artery and the
mastoid branch of the occipital of posterior
auricular arteries

• Smaller branches come from the middle

meningeal artery, the ascending
pharyngeal artery, the artery of the
pterygoid canal and tympanic branches
from the internal carotid artery
Physiology of the Middle Ear
 The tympanic membrane receives sound waves (in the form of pressure
waves) from the auditory ear canal and converts the waves into
mechanical vibrations by way of the auditory ossicles. The mechanical
vibrations are then transmitted to the inner ear.

 The eustachian tube links the pharynx to the middle ear and while it is
normally closed, it can let a small amount of air though to equalize the
pressure between the middle ear and the atmosphere. It also drains
mucous from the middle ear.
 MYRINGITIS BULLOUS
• The vesicles in the superficial layer of
the TM.

• Aspirates from vesicles of the TM

contains influenza virus or
mycoplasma pneumonia.

• Bullous myringitis occurs in all age

groups but children , adolescents &
young adults are more frequently
affected.

Modul Utama Otologi. Inflamasi Telinga Tengah. edisi II. Kolegium Ilmu Kesehatan Telinga Hidung Tenggorok
Bedah Kepala dan Leher, 2015
 Sudden onset of severe usually unilateral , often throbbing pain in
the ear is the most common presentation. Usually blood staining
discharge can be present for a couple of hours. hearing
impairment is common( conductive and /or sensorineural).

 Analgesic & antibiotic can be used in the treatment of bullous

myringitis.Complete recovery of the sensorineural impairment
within three months occoured in between 60 to 100% treated
with amoxycilin.
 TYMPANOSCLEROSIS

• Tympanosclerosis is a condition in which there

is calcification of tissue in the eardrum and
middle ear, including the tympanic
membrane. If extensive, it may affect hearing

• The precise cause is not understood. It may

be an abnormal healing response.

• Tympanosclerosis commonly develops

secondary to acute and chronic otitis media

Modul Utama Otologi. Inflamasi Telinga Tengah. edisi II. Kolegium Ilmu Kesehatan Telinga Hidung Tenggorok
Bedah Kepala dan Leher, 2015
• Characteristic chalky white patches are seen on inspection
of the eardrum

• Treatment is only required if there is hearing loss.Hearing aids

can be beneficial, as with any form of conductive hearing
loss & Surgery
Otitis Media (OM)
OM is defined as inflammation in the middle ear without reference to
etiology. OM is one of the most common reasons for a Patient to visit
the ENT Specialist.

OM can be classified into four categories;

 Acute Otitis Media (AOM)
 Otitis Media with Effusion (OME)
 Recurrent AOM
 Chronic OME
ACUTE OTITIS MEDIA
 AOM is characterized by a short-lived infection (< 3 mo)
that may be initially viral and then bacterial in origin.

 Patients
generally experience pain and some hearing loss
and often develop a fever.

 Discharge from the ear usually accompanies this infection

in patients with acute suppurative otitis media.
Pathophysiology
of Acute Otitis Media (AOM)
The most important factor in the pathogenesis of AOM is abnormal
function of the eustachian tube.

 Reflux, aspiration, or insufflation of nasopharyngeal bacteria into the

middle ear via the dysfunctional eustachian tube may lead to
infection.

 Eustachian tube dysfunction occurs due to either abnormal

patency, or obstruction (either functional or mechanical).
Pathophysiology
of Acute Otitis Media (AOM)
Common causative microorganisms for AOM are:

 Streptococcus pnumoniae (30-50% of cases)

 Haemophilus influenzae (20-30% of cases)
 Moraxella catarrhalis (7-25% of cases)
Acute Otitis Media (AOM)
With and Without Perforation
When AOM is present and the TM is intact, it is referred to as
“AOM without perforation”.

When AOM is present and the TM is NOT intact, it is referred to

as “AOM with perforation”.
AOM with Perforation
AOM with perforation has two categories;
 AOM complicated by perforation of the tympanic
membrane presenting as otorrhea. (Left)
 AOM in a patient with tympanostomy tubes. (Right)
OM with Effusion (OME)
OME occurs when thick fluid accumulates behind the
TM. OME typically occurs immediately following
treatment of AOM due to the resolution of acute
inflammation, allowing visualization of the middle ear
fluid behind the TM.
 AOM Therapy
Stadium Stadium Stadium Stadium
Occlusion Presupuration Supuration Perforation

antibiotics
HCL efedrin analgetic and
symptomatic H2O2 3%
Nose drops
drugs for 3-5 days
0,5%,
antibiotic
myringotomi If
ampicillin or Tympanic
penicilin) membrane
still intact and Adequate
antibiotic bulging to oral
prevent antibiotics
Nasal drops perforation

Modul Utama Otologi. Inflamasi Telinga Tengah. edisi II. Kolegium Ilmu kesehatan Telinga hidung tenggorok 2
4
Bedah Kepala dan Leher, 2015
 25

TREATMENT

OBSERVATION • Watchful waiting

• ANTIBIOTIK
MEDICATION • DEKONGESTAN
• MUKOLITIK

• Tympanostomi tubes
SURGERY • Myringotomy &
adenoidectomy
Modul Utama Otologi. Inflamasi Telinga Tengah. edisi II. Kolegium Ilmu Kesehatan Telinga Hidung Tenggorok
Bedah Kepala dan Leher, 2015
 CHRONIC SUPPURATIVE OTITIS MEDIA
 Chronic suppurative otitis media (CSOM) is a
perforated tympanic membrane with persistent
drainage from the middle ear (ie, lasting >6-12 wk).

 Chronic suppuration can occur with or without

cholesteatoma.

 The treatment plan for cholesteatoma always

includes tympanomastoid surgery with medical
treatment as an adjunct

Modul Utama Otologi. Inflamasi Telinga Tengah. edisi II. Kolegium Ilmu Kesehatan Telinga Hidung Tenggorok
26
Bedah Kepala dan Leher, 2015
 27

CSOM WITHOUT CHOLESTEATOMA

 Inflammation process limited at the
mucous, not hit the bone
 Central perforation
 Rarely causing dangerous
complication
 Cholesteatoma (-)

Modul Utama Otologi. Inflamasi Telinga Tengah. edisi II. Kolegium Ilmu Kesehatan Telinga Hidung Tenggorok
Bedah Kepala dan Leher, 2015
 28

CSOM WITH CHOLESTEATOMA

 Cholesteatoma +
 Perforation at marginal or
attic
 Typical ear odor
 Bone destruction
 Causing dangerous
complication:
 Extracranial : hearing impairment, N.
Facialis paralysis
 Intracranial : brain abscess,
meningitis, hidrocephalus

Modul Utama Otologi. Inflamasi Telinga Tengah. edisi II. Kolegium Ilmu kesehatan Telinga hidung tenggorok
Bedah Kepala dan Leher, 2015
SYMPTOMS
 draining ear of some duration
 hearing loss in the affected ear.
 Fever
 vertigo, and
 pain should raise concern about intratemporal or
intracranial complications
PHYSICAL EXAMINATION
 The external auditory canal may or may not be edematous and is not typically
tender.

 The discharge varies from fetid, purulent, and cheeselike to clear and serous.

 Granulation tissue is often seen in the medial canal or middle ear space.

 The middle ear mucosa visualized through the perforation may be edematous or
even polypoid, pale, or erythematous.

 A 512-Hz tuning fork examination is a critical part of the evaluation to establish if

hearing loss is present and whether it is conductive or sensorineural.
 Diagnosis

Schuller stenver X-Ray

CT-Scan

Ear pus culture

Modul Utama Otologi. Inflamasi Telinga Tengah. edisi II. Kolegium Ilmu Kesehatan Telinga Hidung Tenggorok
Bedah Kepala dan Leher, 2015
TREATMENT
 Topicaltherapy better than systemic therapy.
 Successful topical therapy consists of 3 important components:
 selection of an appropriate antibiotic drop
 regular aggressive aural toilet
 control of granulation tissue.
 Sometimes surgery may be necessary
 Mastoidectomy removes mastoid air cells, granulations & debris
 Tympanoplasty repairs eardrum; closes perforation of tympanic
membrane
Antibiotic drops

The antibiotic should have an appropriate spectrum

of activity that includes gram-negative organisms
(especially pseudomonads) and gram-positive
organisms (especially S aureus) . Aminoglycosides
and the fluoroquinolones are antibiotics that meet
this initial criterion.
Aural Toilet
• Aural toilet is a critical process in the treatment of CSOM.
• The external auditory canal and tissues lateral to the infected
middle ear are often covered with mucoid exudate or
desquamated epithelium.
• For best results, aural toilet should be performed 2-3 times per day
just before the administration of topical antimicrobial agents.
• Aural irrigation is an effective alternative that is often less
burdensome for patients and physicians. A solution of 50% acetic
acid and 50% sterile water is generally painless and effective.
Surgery indications
o Perforation that persists beyond 6 weeks

o Otorrhea that persists for longer than 6 weeks despite antibiotic

use

o Cholesteatoma formation

o Radiographic evidence of chronic mastoiditis, such as coalescent

mastoiditis

o Conductive hearing loss

 Chronic otorrhea

Otoscopy

TM
TM Intact
Perforation

Onset,
CSOM progresifitas,
predisposition,
systemic
disease, focus
infection,
treatment
history

-
Complication Complication +
- +
OE difus
Kolesteatom Kolesteatom
Otomikosis (CSOM
(CSOM
Dermatitis eksim Benigna) Bahaya)
OE maligna
Miringitis
Granulomatosa
Lihat Lihat Lihat
algoritma 1 algoritma 2 algoritma 3
 Algorit Kolesteatom
(CSOM
-
ma 1 Benigna)

OMSK CSOM
tenang active
Aural toilet, antibiotic
topical, antibiotic
systemic
Perforation Perforation Otore stays > 1
heal stays weeks

Antibiotic based
Ro. Mastoid on MO
(Schuller x-ray)
Conductive Conductiv Audiogram
HL - e HL +
Otorrhae Stays > 3
months

Ideal : timpanoplasti
with or without Ideal : mastoidectomy +
mastoidectomy tympanoplasty
 Algorit
ma 2 22Algoritma 2
Algoritma
Algoritma

+
+ Cholesteatoma
+kolesteatoma +
kolesteatoma
kolesteatoma
(OMSK bahaya)
(CSOM
(OMSK danger
bahaya)
(OMSK bahaya) type)

•OMSK tipe bahaya bersifat progresif,

Pilihan
• •CSOM
kolesteatom Dangerous
yang semakin
•OMSK luas type,
akan
tipe progresif,
bahaya bersifat•Atikotomi
progresif,anterior
•OMSK tipe bahaya bersifat
progressive
mendestruksi tulang yang dilewatinya.
•Timpanoplasti Pilihan
dinding utuh (Canal wall up
Bigger
• • kolesteatom
•Infeksi sekunder
yang• kolesteatom
Kolesteatom
akan yang
menyebabkan
semakin luas akan semakin luas Pilihan
akan
will tympanoplasty)
mendestruksi tulang yang •Atikotomi
dilewatinya. •Atikotomi anterior
anterior
destruct
keadaan
mendestruksi septik
tulangbone
lokal dan
structure down tympanoplasty) •Timpanoplasti
yang dilewatinya. •Timpanoplasti dinding
Choices:
runtuh (canal wall
dinding
Secondary
•nekrosis
• •Infeksi septik •Infeksi infection
di jaringan lunak yangakanwill •Timpanoplasti dinding utuh (Canal wallutuh
up (Canal wall up
tympanoplasty) • Atikotomi anterior
sekunder menyebabkan
•Atticoantroplasti tympanoplasty)
dilalui sekunder
kolesteatom akan
dan dimenyebabkan
jaringan
causing
keadaan septik local
keadaan
jugalokal dan septic
septik lokal and •Dan sebagainya
dan • Canal
•Timpanoplasti wall
dinding up tympanoplasty
runtuh (canal wall
sekitarnya menyebabkan destruksi •Timpanoplasti dinding runtuh (canal wall
septic
jaringan soft
lunak yang tissue
•nekrosis
mengancam necrosis
septik akan jaringan lunakdown
diyang
down
yangtympanoplasty)
tympanoplasty)
• Canal wall down tympanoplasty
•nekrosis septik di jaringan lunak
whichkomplikasi-komplikasi.
terjadinya passed by
dilalui kolesteatom
dilalui •Atticoantroplasti
•Atticoantroplasti • Atticoantroplasti
dan di jaringan
dilalui kolesteatom dankolesteatom
di jaringan dan di jaringan
cholesteatom
•Satu-satunya sekitarnya
cara and
juga
pengobatan the tissue
menyebabkan
adalah •Dan sebagainya•Dan sebagainya
destruksi
sekitarnya juga menyebabkan destruksi
around
bedah
jaringan itjaringan
lunak yang too will
lunakcause
mengancam yang
akanmengancam akan
destruction
terjadinya in the
terjadinya end
komplikasi-komplikasi.
komplikasi-komplikasi.
complication will cara
•Satu-satunya happen
pengobatan adalah
• •Satu-satunya
Other way to resolve
cara pengobatan
bedah
adalahit by
bedah
surgery
Algorit
ma 3 CSOM +
COMPLICATION

INTRA INTRA
CRANIAL TEMPORAL

• ekstradura Abscess • Subperiosteal

• Subdura Abscess abscess
• Tromboflebitis sinus • Paresis fasial
lateral • Labirinitis
• Meningitis • petrositis
• Brain Abscess
• Meningitis otikus

algoritma 4 algoritma 5
 PROTOKOL PENATALAKSANAAN PASIEN OMSK
DENGAN KECURIGAAN KOMPLIKASI INTRA
Algorit KRANIAL
ma 4 Rawat inap
Periksa sekret telinga
Antibiotik dosis tinggi intravena 7-15 hari, obat ajuvan
Konsul spesialis saraf/saraf anak
CT scan +
kontras

Abses intrakranial - Abses intrakranial+ CT scan tidak dapat

dilakukan
Hidrosefalus otitik Hidrosefalus otitik Pengobatan
medikamentosa bersama
spesialis bedah saraf
Keadaan Keadaan Konsul
umum umum bedah
buruk saraf KU Mastoidekt KU Mastoidekt
baik baik omi dalam buruk omi dalam
bius umum bius lokal
Pertimbangkan
Mastoidekt
mastoidektomi
omi dalam Bedah saraf : Bedah saraf
dalam bius
bius umum
lokal operasi tidak operasi
Medikamentosa 1-2 bulan, monitor
perkembangan komplikasi dengan
CT scan tiap 1-2 minggu

Mastoidekto Mastoidekto Mastoidekt Pertimbangkan

KU KU
mi bersama mi kemudian omi dalam mastoidektomi
baik buruk dalam bius
bedah saraf bius umum
lokal
Algoritm
Komplikasi Intra Temporal
a5

Abses N. VII Labirinitis Petrositis Tromboflebiti

Subperiosteal Fistel labirin s sinus lateral

CT Scan CT Scan

Antibiotik Antibiotik dosis Antibiotik Antibiotik

tinggi +
dosis tinggi + dosis tinggi + dosis tinggi + Antibiotik
mastoidektom
mastoidekto i + Dekompresi mastoidekto mastoidekto dosis tinggi +
mi saraf mi mi + mastoidekto
petrosektom mi
i

Pemilihan antibiotik idealnya

berdasarkan pemeriksaan
mikrobiologik dan tes sensitivitas
kuman
THANK YOU…