Chronic Suppurative Otitis Media

Ivan Wudexi

Identitas Pasien
Nama: Ny. P Umur: 42 tahun Jenis Kelamin: Perempuan Alamat: Balingasal, Padureso, Kesumen Pekerjaan: Pegawai Negeri Tanggal Masuk: 19-07-2013 No. RM: 280109

Keluhan utama
Pengeluaran cairan dari telinga kanan

Riwayat Penyakit Sekarang (RPS)

Keluhan pengeluaran cairan tersebut telah dirasakan oleh pasien sejak kurang lebih 2 bulan yang lalu. Selama kurun 2 bulan, pasien mengkonsumsi antibiotik oral namun keluhan masih menetap.

Pasien mendeskripsikan bahwa cairannya berwarna kekuningan dan sedikit berbau tanpa disertai darah. Selain itu, pasien juga mengeluhkan adanya penurunan pendengaran di telinga kanan yang bertambah parah bila telinga kanan terpapar air. Rasa nyeri di telinga tidak dirasakan. Keluhan di kepala, leher, tenggorokan dan hidung disangkal.

Riwayat Penyakit Dahulu (RPD)

Pasien mempunyai riwayat infeksi telinga berulang yang disertai dengan pengeluaran cairan (otorrhea) Tidak ada riwayat allergi.

Pemeriksaan THT
Telinga
Dextra
Pinna Ukuran dan bentuk dbn, massa(-), hiperemis(-)

Sinistra
Ukuran dan bentuk dbn , massa(-), hiperemis(-)

Tragus and/or pinna pain Canalis auditorius externus

(-)
massa(-), hyperemis (-), bengkak(-)

(-)
massa(-), hyperemis (-), bengkak(-)

Membran timpani
Mastoid

Terlihat perforasi central subtotal, discharge (+), granulasi (-)

Normal, nyeri (-)

Dalam batas normal, cone of light positive(+), hyperemis (-)

Normal, nyeri(-)

Lymp. node

Tidak ada perbersaran

Pemeriksaan THT
Hidung
Nose Paranasal Sinus
Inspeksi hidung Normal Normal, nyeri(-)
Discharge(-), concha terlihat normal, septum tidak terdeviasi, massa(-)

Kanan

Kiri
Normal Normal, nyeri (-)
Discharge(-), concha terlihat normal, septum tidak terdeviasi, massa(-)

Palpasi hidung
dan sinus Anterior Rhinoscopy Posterior Rhinoscopy

Tidak dilakukan

Pemeriksaan THT
Mulut dan tenggorokan
Lips Tooth Ginggiva Tongue Palate Uvula Tonsil Posterior Oropharynx Normal Normal Normal Normal Normal Normal Normal

Diagnosis
Otitis Media Kronis Type Benign Active pada Auris Dextra

Manajemen
Aural Toilet Aldisa tab (pseudoephredine + loratadine) Alkilen tab (ofloxacin)

Pembahasan

Anatomy of middle ear

Chronic Otitis Media

Definition A recurrent infection of the middle ear and/or mastoid air cell tract in the presence of a tympanic membrane perforation

(Lustig LR et al., 2013)

Chronic Otitis Media- Classification

Benign (inactive) COM Characterized by a dry tympanic membrane perforation, not associated with active infection Chronic Serous Otitis Media Characterized by continuous serous drainage (typically straw-colored) Chronic Suppurative otitis media (CSOM) Diagnosed when there is persistent purulent drainage through a perforated tympanic membrane
(Lustig LR et al., 2013)

CSOM
Definition WHO defines CSOM as a chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges or otorrhea through a tympanic perforation
WHO,2004

CSOM
The point in time when AOM becomes CSOM is still controversial The WHO definition requires only 2 weeks of otorrhea, but otolaryngologists tend to adopt a longer duration varying from 6 weeks up to 3 months
(Lustig LR et al., 2013)

Types of CSOM
There are two major types of CSOM: 1. Mucosal type (tubo-tympanic disease, relatively safe) 2. Bony type (attico-antral disease) According to the discharge activity, it can be divided into active CSOM dan inactive CSOM.
(buku ajar THT UI)

Types of TM Perforation
1. Central perforation annulus is preserved 2. Marginal perforation portion or the entire annulus is involved

(buku ajar THT UI)

Risk factor
Lower socioeconomic areas Delay in tx for AOM Poorer hygienic condition Increased smoking Poorer nutrition History of recurrent ear infections in childhood, with longstanding (months or years) of otorrhea Race predisposition (Australian Aborigines, Alaskan eskimos, american indians)

WHO,2004

Pathogenesis
Occurs as a consequence of an episode of AOM with perforation, with subsequent failure of the perforation to heal.

Multiple episodes of acute infection outer epithelial layer of TM grows over the perforation edges, covering middle fibrous and inner mucosal layer non-closing (chronic perforation) TM.
(Lustig LR et al., 2013)

Microbiology
Most common recovered organism are P.aeruginosa and S.aureus In CSOM, typical pathogens reach the middle ear through: Insufflation of respiratory pathogens through the eustachian tube from the nasopharnyx into middle ear Spread from the external canal inward through a non-intact tympanic membrane
(Lustig LR et al., 2013)

Diagnosis
Clinical features and otoscopic findings

WHO,2004

Clinical features
Otorrhea (either intermittent or continuous) Absence of pain and fever Hearing loss (made worse by water exposure)

WHO,2004

Otoscopic findings
Discharging tympanic perforation Mucoid otorrhea

Management
The goals of the tx of CSOM: Stop otorrhea Heal the tympanic membrane Eradicate current infection Prevent complications Prevent recurrence
(Lustig LR et al., 2013)

Management
Medical Management Surgical Management

Medical Management
Aural Toilet Topical antibiotics (ex. Ciprofloxacin or ofloxacin) Systemic antibiotics only considered in patients at risk for complicated or invasive ear infections or in those who have received several courses of empiric topical therapy and are at higher risk for resistant organisms.
(Lustig LR et al., 2013)

Surgical Management
Indication: patients who develop complication of chronic otitis, to remove infected tissue in the middle ear or mastoid and to repair ear damage that results in hearing loss and presence of cholesteatoma. Example: mastoidectomy, tympanoplasty, ossicular bone reconstruction
(Lustig LR et al., 2013)

Complication of CSOM
Mastoiditis Facial nerve paralysis Petrositis Labyrinthitis Intracranial complications (ex. Lateral sinus thrombosis, meningitis, brain abscess)
(Lustig LR et al., 2013)

Follow Up and Education

Patient must be educated on how to apply topical antibiotic Patients should be advised to keep their ears dry to prevent future complications, even after medical tx results in a safe and dry ear. During bath, the affected ears may be occluded with petrolatum cotton
(Lustig LR et al., 2013)

Maturnuwun
Mohon asupan