otitis media akut
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OMAOTITIS MEDIA AKUT
Pembimbing :Dr. Daniel Widjaja, Sp. THT-KL
Presentan :Bernardus Mario Vito 2013-061-144Anastasia Michelle 2014-061-155
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Anatomi Telinga
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Telinga Tengah
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Embriologi Kavum Timpani• Kavum timpani berasal dari endoderm yaitu kantong
faringeal pertama.• Kantong melebar ke arah lateral dan bersentuhan dengan
dasar faringeal cleft pertama• Bagian distal dari kantong yaitu resesus tubotimpani
melebar dan membentuk kavitas timpani primitif dan bagian proksimal membentuk tuba eustachius.
Sumber : Langman’s Embriology 12th Ed.
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Embriologi Ossicles• Malleus dan incus berasal dari kartilago arcus faringeal
pertama.• Stapes berasal dari kartilago arcus yang ke dua.• Ossicles muncul di awal perkembangan janin namun
tetap tertananam dalam jaringan mesenkim selama 8 bulan menunggu luruhnya jaringan saat kavum melebar.
Sumber : Langman’s Embriology 12th Ed.
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Embriologi ossicles• Saat ossicles terbebas dari mesenkim maka epitel
endoderm membentuk jaringan pengikat mirip mesenterika. Jaringan ini lalu menjadi ligamen.
• Maleus berasal dari arkus faringeal pertama maka ototnya tensor timpani di persyarafi oleh nervus trigeminal sedangkan otot stapedius dipersyarafi oleh nervus facial/
Sumber : Langman’s Embriology 12th Ed.
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Embriologi • Pada masa akhir janin, kavum timpani melebar ke dorsal
dan membentuk tympanic antrum. Setelah lahir, epitel dari kavum timpani masuk ke tulang yang sedang berkembang yaitu prosesus mastoid dan membentuk mastoid air sacs.
• Hal inilah yang menghubungkan jika terjadi otitis media maka antrum dan sel mastoid air ikut terkena
Sumber : Langman’s Embriology 12th Ed.
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DEFINISI• Otitis Media Akut (OMA)
inflamasi pada membran mukosa telinga tengah, termasuk cavum timpani, antrum mastoid, dan tuba Eustachius
• Akut = 0 – 3 minggu
Sumber : Ballenger’s Othorhinolaryngology Head and Neck Surgery 16th Ed.
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DEFINISI• Inflamasi pada telinga tengah dengan tanda dan gejala akut
Gejala TandaDemam Otoskop untuk menilai membran
timpani dan cairan efusi
Otalgia MT ( warna, posisi, dan mobilitas) : gangguan mobilitas, MT keruh warnanya bisa juga kemerahan, bulging.
GelisahMenggaruk atau menarik telingaDisertai gejala infeksi saluran pernapasanMuntah dan diare
Sumber : Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media (AAP)
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Epidemiologi• 80% anak mengalami 1x episode OMA sebelum usia
sekolah• Survei kesehatan Indera Pendengaran 1994-1996 pada 7
provinsi di Indonesia didapatkan pervalensi seluruh usia sebesar 3,9%
• Laki-laki lebih sering daripada perempuan
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ETIOLOGI & PATOFISIOLOGI1. Disfungsi tuba Eustachius • Fungsi Tuba Eustachius :
• Ventilasi telinga• Proteksi• Drainage sekresi telinga tengah ke nasofaring
• Obstruksi tuba :• Mekanikal : intrinsik (infeksi, alergi) & ekstrinsik (massa)• Fungsional : penurunan tubal stiffness, gangguan sistem
pembukaan aktif
Sumber : Ballenger’s Othorhinolaryngology Head and Neck Surgery 16th Ed.
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Sumber : Bailey BJ, Johnson JT, Newlands SD. Head & Neck Surgery - Otolaryngology, 4th Edition
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ETIOLOGI & PATOFISIOLOGI2. Infeksi• Bakteri
• 60 % : Streptococcus pneumoniae, Haemophilis influenzae• 40 % : Group A Streptococcus, Moraxella catarrhalis,
Staphylococcus aureus, Streptococcus pyogenes• Virus : RSV
Sumber : Ballenger’s Othorhinolaryngology Head and Neck Surgery 16th Ed. Emedicine.medscape.com : Acute Otitis Media
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FAKTOR RESIKO• Prematuritas, BLR• Usia muda ( peak : 6 – 36 minggu)• Riwayat keluarga• Riwayat ISPA, alergi• Gastroesophageal reflux• Gangguan sistem imun• Abnormalitas kraniofasial : Cleft palate, Down’s synd• Eksposure polutan, lingkungan padat, sosioekonomi
rendah• Kurang breastfeeding, menggunakan dot
Sumber : Clinical Practice Guideline : The Diagnosis and Management of Acute Otitis Media (AAP)
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Faktor Risiko
Ramakrishnan K, Sparks RA, Berryhil W. Diagnosis and treatment of otitis media. Am Fam Physician 2007;76:1650-8, 1659-60.
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MANIFESTASI KLINIS• McCornick et al (2005) 2 sistem skoring
• OM-3 : • Physical suffering : otalgia, demam• Emotional distress : iritabel, nafsu makan ↓• Limitation of activity
• ETG-5 (Ear Treatment Group Symptom Questionnaire, 5 items) : demam, otalgia, iritabilitas, nafsu makan ↓, gangguan tidur
Sumber : Clinical Practice Guideline : The Diagnosis and Management of Acute Otitis Media (AAP)
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MANIFESTASI KLINIS• Shaikh et al (2009)
• AOM-SOS (Acute Otitis Media Severity of Symptom Scale): • Ear tugging/rubbing/holding• Excessive crying• Irritability• Difficulty sleeping• Decreased activity / appetite• Fever
Sumber : Clinical Practice Guideline : The Diagnosis and Management of Acute Otitis Media (AAP)
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DIAGNOSIS• Anamnesis :
• Akut : 0 – 3 minggu• Gejala : otalgia, demam, iritabel, vomitus, diare
Gejala lainnya : otorea, vertigo, facial paralysis• Faktor resiko
• PF (Otoscopy)• Otalgia • Membran timpani : hiperemis, dapat bulging, mobilitas ↓• Dapat terjadi perforasi, purulent otorrea
Sumber : Ballenger’s Othorhinolaryngology Head and Neck Surgery 16th Ed.
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DIAGNOSIS• PP :
• kultur (aspirasi) pada pasien dengan komplikasi supuratif yang berat
• Tympanocentesis :• OM pada pasien dengan otalgia berat atau toksik• Tidak merespon dengan terapi antimikroba• Onset OM pada pasien yang sudah dapat terapi antibiotik• OM yang diduga / pasti berhubungan dengan komplikasi supuratif• Newborn, neonatus, immunosupresi
Sumber : Ballenger’s Othorhinolaryngology Head and Neck Surgery 16th Ed.
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Evaluasi1,4 . . .
Anamnesa demam
nyeri dalam telinga riw. batuk pilek sebelumnya gg.pendengaran anak gelisah & susah tidur tiba2 menjerit waktu tidur memegang telinga yang
sakit
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Strategi Terapi6
Presentasi pertama• Menegakkan diagnosis melalui gejala dan pemeriksaan fisik
yang didapat.• Pemilihan observasi atau pemberian antibiotik• Atasi Nyeri
Gejala Persisten (48-72 jam)• Ulangi pemeriksaan telinga untuk tanda dan gejala otitis
media• Jika otitis media masih tampak mulai/ ganti terapi
antibiotik• Jika masih persisten setelah terapi antibiotik
pertimbangkan ceftriaxone, clindamycin IM atau tympanocentesis.
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TATALAKSANA
AGE Otorrea with AOM
Unilateral / Bilateral AOM with Severe Symptoms
Bilateral AOM Without Otorrhea
Unilateral AOM Without Otorrhea
6 mo to 2 y
Antibiotic therapy (10h)
Antibiotic therapy (10h)
Antibiotic therapy (10h)
Antibiotic therapy or additional observation
> 2 y Antibiotic therapy Antibiotic therapy
Antibiotic therapy or additional observation
Antibiotic therapy or additional observation
Sumber : Clinical Practice Guideline : The Diagnosis and Management of Acute Otitis Media (AAP)
Recommendation for Initial Management for Uncomplicated AOM
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TATALAKSANAInitial Immediate or Delayed
Antibiotic TreatmentAntibiotic Treatment After 48 – 72 h of Failure of Initial Antibiotic Treatment
Recommended First Line Therapy
Alternative treatment (if Penicillin Allergy)
Recommended First Line Therapy
Alternative Treatment
• Amoxicilin (80-90 mg/kg/day in 2 divided dose)
• Amoxicilin Clavulanate (90 mg/kg/day of amoxicilin, with 6.4 mg/kg/day of clavulanate [amoxicilin to clavulanate ratio 14 : 1] in 2 divided doses)
• Cefdinir (14 mg/kg/day in 1 or 2 dose)
• Cefuroxime (30 mg/kg/day in 2 divided doses)
Cefpodoxime (10 mg/kg/day in 2 divided doses)
• Ceftriaxone (50 mg IM or IV per day for 1 or 3 day)
• Amoxicilin-Clavulanat (90 mg/kg/day of amoxilin, with 6.4 mg/kg/day of clavulanate in 2 divided dose)
• Ceftriaxone (50 mg IM or IV for 3 day)
• Ceftriaxone, 3 d Clindamycin (30-40 mg/kg/day in 3 divided dose) with/ without 3rd generation cephalosporin
• Clindamycin (30-40 mg/kg/day in 3 divided doses) plus 3rd generation cephalosporin
• Tympanocentesis• Consult specialist
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Durasi Terapi Antibiotik5
• Durasi terapi optimal untuk pasien OMA : 10 hari• Rekomendasi untuk anak usia < 2 tahun : 10 hari• Usia 2 – 5 tahun dengan OMA ringan- sedang : 7 hari
• Usia ≥ 6 tahun : dengan OMA ringan – sedang : 5 -7 hari
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TATALAKSANA
Sumber : Clinical Practice Guideline : The Diagnosis and Management of Acute Otitis Media (AAP)
Treatment Modality of Otalgia Comments
• Acetaminophen, Ibuprofen
• Home remediesDistractionExternal application of heat / coldOil drops in external auditory canal
• Topical AgentBenzocaine, procaine, lidocaineNaturopathic agents
• Homeopathic agents• Narcotic analgesia with codein or analogs
• Tympanostomy / myringotomy
For mild – moderate pain
May have limited effectiveness
Benefit over acetaminophen in patient > 5 yo≈ amethocaine/phenazone drops in > 6 yo
Moderate-severe pain
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TATALAKSANA• Terapi bedah : tympanostomy tube (pada pasien dengan
efusi)• Vaksin
• Pneumococcal vaccine• Influenza vaccine
• Breastfeeding • Perubahan pola hidup• Xylitol
Sumber : Clinical Practice Guideline : The Diagnosis and Management of Acute Otitis Media (AAP)
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Komplikasi• Mastoiditis• Otitis media supuratif kronik• Abses post auricular• Paresis nervus kranial• Meningitis• Labyrinthitis• Petrositis• Abses Intrakranial