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Etiologi OMSK :

Gangguan pada Tuba Eustachius yaitu terjadinya oklusi atau sumbatan pada saluran
tersebut yang menjadi faktor utama penyebab otitis media.
Faktor Predisposisi :
1. Infeksi saluran nafas atas, biasanya bakteri piogenik seperti
a. Staphylococcus aureus gram +, fakultatif anaerob (26%)
b. Pseudomonas Aeruginosa gram (-),
c. Streptokokus pneumokokus gram +, bakteri piogenik
d. Haemophilus influenza gram(-) fakultatif anaerob

Causes

A multitude of host, infectious, allergic, and environmental factors contribute to OM


development.

Host factors
Immune system: The immature immune systems of infants or the impaired immune
systems of patients with congenital immune deficiencies, HIV infection, or diabetes
may be involved in the development of OM. OM is an infectious disease that
prospers in an environment of decreased immune defenses. The interplay between
pathogens and host immune defense plays a role in disease progression. Patel et al
(2009) found higher interleukin (IL)6 levels in patients with OM who also had
influenza and adenoviral infections, whereas IL-1-beta (IL-1-beta) levels were higher
in patients who developed OM following URI.2 In another study, Skovbjerg et al
(2009) found that middle ear effusions with culturable pathogenic bacteria were
associated with higher levels of IL-1-beta, IL-8, and IL-10 than sterile effusions.3
Familial (genetic) predisposition: Although familial clustering of OM has been
demonstrated in studies that examined genetic associations of OM, separating
genetic factors from environmental influences has been difficult. No specific genes
have been linked to OM susceptibility. As with most disease processes, effects of
environmental exposures on genetic expression probably play an important role in
OM pathogenesis.
Mucins: The role of mucins in OME has been described. Mucins are responsible for
gel-like properties of mucus secretions. The middle ear mucin gene expression is
unique compared with the nasopharynx. Abnormalities of this gene expression,
especially upregulation of MUC5B in the ear, may have a predominant role in OME.
Anatomic abnormality: Children with anatomic abnormalities of the palate and
associated musculature, especially the tensor veli palantini, exhibit marked ETD and
have higher risk for OM. Specific anomalies that correlate with high prevalence of
OM include cleft palate, Crouzon syndrome or Apert syndrome, Down syndrome, and
Treacher Collins syndrome.
Physiologic dysfunction: Abnormalities in the physiologic function of the ET mucosa,
including ciliary dysfunction and edema, increase the risk of bacterial invasion of
the middle ear and the resultant OME. Children with cochlear implants have a high
incidence of OM, especially chronic OM and cholesteatoma formation. One study
described a relationship between laryngopharyngeal reflux and chronic OM (COM);
the authors concluded that reflux work-up should be performed as part of COM
investigations, and, if reflux is confirmed, reflux treatment should be initiated in
addition to treatment of primary disease.4
Vitamin A deficiency is associated with pediatric upper respiratory infections and
AOM.
Obesity has been linked to an increased incidence of OM, although the causal factor
is unknown. Speculations include alteration of intrinsic cytokine profile, increased
gastroesophageal reflux with alterations of the oral flora, and/or fat accumulation;
all of these have been linked with an increased incidence of OM. Conversely, OM
may increase the risk of obesity by altering the taste buds.5

Infectious factors
Bacterial pathogens
The most common bacterial pathogen in AOM is Streptococcus pneumoniae,
followed by nontypeable Haemophilus influenzae and Moraxella catarrhalis. These 3
organisms are responsible for more than 95% of all AOM cases with a bacterial
etiology.
In infants younger than 6 weeks, gram-negative bacilli (eg, Escherichia coli,
Klebsiella species, and Pseudomonas aeruginosa) play a much larger role in AOM,
causing 20% of cases. S pneumoniae and H influenzae are also the most common
pathogens in this age group. Staphylococcus aureus has also been found as a
pathogen in this age group in some studies, but more recent studies suggest that
the flora in these young infants may be that of usual AOM in children older than 6
weeks.
Many experts had proposed that the MEE associated with OME was sterile because
cultures of middle ear fluid obtained by tympanocentesis often did not grow
bacteria. This view is changing as newer studies show 30-50% incidence of positive
results in middle ear bacterial cultures in patients with chronic MEE. These cultures
grow a wide range of aerobic and anaerobic bacteria; S pneumoniae, H influenzae,
M catarrhalis, and group A streptococci are the most common.
M catarrhalis induced AOM differs from AOM caused by other bacterial pathogens
in several ways. It is characterized by higher a proportion of mixed infections,
younger age at the time of diagnosis, lower risk of spontaneous perforation of the
tympanic membrane, and an absence of mastoiditis.6
Further evidence for the presence of bacteria in the MEE of patients with OME was
provided by studies using polymerase chain reaction (PCR) assay to detect bacterial
DNA in MEE samples that were determined to be sterile using standard bacterial
culture techniques. In one such study using PCR assay, 77.3% of the MEE samples
had positive results for one or more common AOM pathogens (eg, S pneumoniae, H
influenzae, M catarrhalis).
In chronic suppurative OM, the most frequently isolated organisms include P
aeruginosa, S aureus, Corynebacterium species, and Klebsiella pneumoniae. An
unanswered question is whether these pathogens invade the middle ear from the
nasopharynx via the ET (as do the bacteria responsible for AOM) or whether they
enter through the perforated TM or a TT from the EAC.
The role of Helicobacter pylori in children with OME has been increasingly
recognized. Evidence that this agent might be responsible for OME comes from its
isolation from middle ear and tonsillar and adenoidal tissue in patients with OME.
Alloiococcus otitidis is a newly recognized species of gram-positive bacterium that
has been recently discovered as a pathogen associated with OME.7,8 This organism
is the most frequent bacterium in AOM, as well as in OME. It has also been detected
in patients who had been treated with antibiotics, such as beta-lactams or
erythromycin, suggesting that these agents may not be sufficiently effective to
eliminate this organism. Further investigation is needed to reveal the clinical role of
the organism in OM.

Viral pathogens
Because acute viral URI is a prominent risk factor for AOM development, most
investigators have suspected a role for respiratory viruses in AOM pathogenesis.
Many studies have substantiated this suspicion by showing how certain respiratory
viruses can cause inflammatory changes to the respiratory mucosa that lead to
ETD, increased bacterial colonization and adherence, and, eventually, AOM. Studies
have also shown that viruses can alter the host-immune response to AOM, thereby
contributing to prolonged middle ear fluid production and development of chronic
OME.
The viruses most commonly associated with AOM are respiratory syncytial virus
(RSV), influenza viruses, parainfluenza viruses, rhinovirus, and adenovirus.
Human parechovirus 1 (HPeV1) infection is associated with OM and cough in
pediatric patients.9 OM developed in 50% of 3-month follow-up periods that yielded
evidence of HPeV1 infection but in only 14% of the HPeV1-negative periods; in
recurring OM, the middle ear fluid samples were positive for HPeV in 15% of
episodes.
Factors related to allergies
The relationship between allergies and OM remains unclear. In children younger
than 4 years, the immune system is still developing, and allergies are unlikely to
play a role in recurrent AOM in this age group. Although much evidence suggests
that allergies contribute to the pathogenesis of OM in older children, extensive
evidence refutes the role of allergies in the etiology of middle ear disease.
The following is a brief list of evidence for and against the etiologic role of allergy in
OM:
Many patients with OM have concomitant allergic respiratory disease (eg, allergic
rhinitis, asthma).
Many patients with OM have positive results to skin testing or radioallergosorbent
testing (RAST).
Although mast cells are found in the middle ear mucosa, most studies fail to show
significant levels of immunoglobulin E (IgE) or eosinophils in the MEE of patients
with OM.
OM is most common in the winter and early spring, yet most major allergens (eg,
tree and grass pollens) peak in the late spring and early fall.
Most patients with concomitant OM and allergy show no marked improvement in
middle ear disease with aggressive allergy management, despite marked
improvements to nasal and other allergy-related symptoms.
Environmental factors
Infant feeding methods
Many studies report that breastfeeding protects infants against OM. The most
recent and best of these studies indicates that this benefit is evident only in children

who are breastfed exclusively for the first 3-6 months of life. Breastfeeding of this
duration reduces the incidence of OM by 13%.
The protective effects of breastfeeding for the first 3-6 months persist 4-12 months
after breastfeeding ceases, possibly because delaying onset of the first OM episode
reduces recurrence of OM in these children.
Passive smoke exposure
Many studies have shown a direct relationship between passive smoke exposure
and risk of middle ear disease.
A recent systematic review of 45 publications dealing with OM and parental smoking
showed pooled odds ratios of 1.48 (95% confidence interval [CI] of 1.08-2.04) for
recurrent OM, 1.38 (95% CI of 1.23-1.55) for MEE, and 1.3 (95% CI of 1.3-1.6) for
AOM.10
Group daycare attendance
Daycare centers create close contact among many children, which increases the
risks of respiratory infection, nasopharyngeal colonization with pathogenic
microbes, and OM.
Many researchers have used meta-analysis to confirm that exposure to other young
children (including siblings) in group daycare settings is a major risk factor for
OM.11 A meta-analysis reported that care outside the home conferred a 2.5-fold risk
for OM. Other critical reviews of studies on OM and group childcare show
heightened odds ratios of 1.6-4.0:1 for center care versus home care.
Children who attend daycare centers frequently acquire antibacterial-resistant
organisms in their nasopharynx, leading to AOM that may be refractory to
antibacterial treatment. American Academy of Pediatrics and American Academy of
Family Physicians' guidelines recommend high-dose amoxicillin/clavulanic acid as
the antibiotic of choice in the treatment of AOM in children who attend daycare.
Socioeconomic factors: Socioeconomic status encompasses many independent
factors that affect both the risk of OM and the likelihood that OM will be
diagnosed.12
In general, lower socioeconomic status confers higher risk for environmental
exposure to parental smoking, bottle-feeding, crowded group daycare, crowded
living conditions, and viruses and bacterial pathogens.
Compared with children from middle-income and high-income families, children
from lower socioeconomic groups use health care resources less frequently, which
decreases the likelihood that OM cases will be diagnosed.