Pemicu 3 Pengindraan Yoko

Blok Pengindraan
Pemicu 2
Yoko Septian Jaya
405140090
ANATOMI
Anatomi
OTITIS EKSTERNA
Definition
• Otitis externa is a generalized condition of the skin
of the external auditory canal that is characterized
by general oedema and erythema associated with
itchy discomfort and usually an ear discharge.
Sumber : Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th ed, Vol.3, Chap.236h
Sumber : Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery,
7th ed, Vol.3, Chap.236h
Aetiology and Epidemiology
• A prevalence of 0.4% per year, affecting approximately
10% of the population during their lifetime.
• Any condition or situation that disturbs the lipid/acid
balance of the ear will predispose an individual to otitis
externa.
• Water and moisture are thought to cause a change
from a predominantly Gram-positive skin flora to a
Gram-negative one.
• As the ear becomes inflamed, healthy cerumen (with
its bactericidal properties) is rapidly removed from the
ear and is no longer produced.
Pathology
• The clinical course of otitis externa has been
divided into the following stages:
1. pre-inflammatory;
2. acute inflammatory (mild, moderate or severe);
3. chronic inflammatory.
• In the pre-inflammatory stage 1, the protective
lipid/acid balance (normal pH 4–5) of the ear is lost
and the stratum corneum becomes oedematous,
blocking off the sebaceous and apocrine glands
producing aural fullness and itching.
• With further oedema and scratching, there is
disruption of the epithelial layer and invasion of
resident or introduced organisms.
• This results in the acute inflammatory stage 2, with
a progressively thickening exudate, further
oedema, obliteration of the lumen and increasing
pain.
• In the severe stages, auricular changes and cervical
lymphadenopathy are often seen.
• By definition, chronic otitis externa occurs after six
months, although most clinicians probably regard a
resistant inflammation lasting longer than three
weeks as entering the chronic phase.
• There is some evidence that individuals whose skin
has a tendency to remain at a low pH are more
prone to develop a chronic problem.
• Stage 3 otitis externa is characterized by thickening
of the external canal skin and fibrous canal
stenosis.
Diagnosis
• Otitis externa is a clinical diagnosis based on the
following symptoms and signs: pain, itch, oedema
and erythema of the external auditory canal with
purulent otorrhoea and debris in the meatus.
Outcomes
• If untreated, mild attacks of otitis externa can
spontaneously resolve as the epithelial barrier
becomes re-established, the piloapocrine units
produce normal secretions and the pH of the canal
returns to normal.
• If the inflammation progresses faster than repair,
increasing pain, otorrhoea and oedema of the canal
occurs.
Management options
• Aural toilet
• remains the most effective single treatment for otitis
externa
• as microscopic toilet is not readily available to most GP,
patients are often treated with steroid antibiotic
medication in the form of drops or sprays without prior
toilet.
• Topical medication
• the sensitivity of the bacteria to the antibiotic in topical
medication does not seem to influence outcomes.
• it has proven dehydrating and antiinflammatory
properties and antibacterial activity against Streptoccoci
and Staphylococci, but poor activity against
Pseudomonas
• the dehydrating effect reduces canal oedema and also
helps reduce pain, but oral analgesia is usually necessary
in moderate or severe cases.
• NSAID if not contraindicated, are excellent analgesics for
otitis externa.
• Systemic antibiotics
• a consensus panel of the American Academy of
Otolaryngology – Head and Neck Surgery found no
evidence for the use of systemic medical treatment in
the absence of known risk factors or systemic signs
and/or symptoms
Prevention of recurrence
• Avoidance of water penetration into the ear is a major
management issue.
• Cotton wool with petroleum jelly (e.g. vaseline) will
work well in the bath or shower and custom-made ear
moulds can be made.
• Neoprene head bandages are a useful adjunct with the
above for children in swimming pools.
• The use of alcohol or proprietary preparations (e.g.
Aqua-ear or Ear-calm) after swimming will help remove
any water that has penetrated into the canal.
• Blow-driers (not on hot setting) can also help remove
moisture from the external auditory canal
INFLAMASI PADA
AURIKULAR
Definition
• The term correctly refers to infection or
inflammation involving the perichondrium of the
external ear: auricle and external auditory canal.
• However, it is commonly used to describe a
continuum of conditions of the external ear, from
erysipelas, through cellulitis, and true
perichondritis to chondritis.
Sumber : Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th ed, Vol.3, Chap.236i
Classification
• A useful practical classification might be:
• erysipelas of external ear;
• cellulitis of external ear;
• perichondritis;
• chondritis.
Aetiology
• The thin skin, minimal subcutaneous tissue and
vulnerable anatomical position make conchal
cartilage particularly susceptible to trauma with
subsequent infection.
• Such trauma may include laceration of the auricle,
surgery to the external ear, frostbite, burns,
chemical injury, infection of a haematoma of the
pinna, aspiration or incision of a haematoma and,
in recent years, ‘high’ piercing of the (cartilaginous)
portion of the auricle for the insertion of earrings.
• Superficial infections of the skin (erysipelas) or
subcutaneous tissue (cellulitis) of the external
auditory meatus or pinna may spread deeply to
involve the perichondium (perichondritis) or
cartilage (chondritis).
• The organisms most commonly isolated are
Pseudomonas aeruginosa and Staphylococcus
aureus.
• Other organisms cultured include Gram negatives
(proteus and Escherichia coli).
• Streptococcal infection has also been reported
Pathology
• Martin et al. describe hyperplasia of the dermal
layers, thickened subcutaneous tissue, intense
infiltration with PMN leukocytes, thickening of the
perichondium, and destruction of the cartilage by
phagocytes.
Diagnosis
• The presentation is with a dull pain increasing in
severity and the classical signs of inflammation
involving the cartilaginous pinna.
• The lobule, which contains no cartilage, is spared. The
severity of the pain and swelling of the pinna are
indicators for true perichondritis as opposed to the
more superficial conditions of erysipelas and cellulitis.
• The diagnosis is clinical and special investigations are
not routinely required.
• A background history of underlying trauma to the
external ear should be sought.
7th ed, Vol.3, Chap.236i
Outcomes
• If untreated, a subperichondrial abscess may
develop, leading to avascular necrosis of the
underlying cartilage and marked deformity of the
pinna.
• The infection may spread to the cartilage itself.
• Rare reported complications of perichondritis
include fatal septicaemia secondary to
streptococcal infection, subacute bacterial
endocarditis and necrotizing fasciitis of the neck.
Prevention
• Acute perichondritis should be prevented by careful
placement of ear piercings away from the cartilaginous
pinna.
• Surgery in and around the ear should avoid trauma to
cartilage and tight head bandages.
• Haematomas of the auricle should be drained promptly
and using careful aseptic techniques.
• The meticulous management of burn injuries to the
ears should include the use of prophylactic antibiotics
against Gram-negative bacteria and diligent local care
including daily dressings and the removal of eschars
and crusts.
First line management
• The mildest forms are adequately managed by the
use of topical and oral antibiotics.
• If there is a discharge or an abscess needs draining,
a pus swab should be sent for culture and
sensitivity; however, pending the result, antibiotic
treatment should not be delayed.
• Prompt treatment with a broad-spectrum antibiotic
at a high dose, possibly intravenously, should be
designed to cover common organisms and, in
particular, P. aeruginosa
HERPES ZOSTER
PADA TELINGA
Definition
• Herpes zoster oticus is defined as a herpetic
vesicular rash on the concha, external auditory
canal or pinna with a lower motor neurone palsy of
the ipsilateral facial nerve.
Sumber : Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th ed, Vol.3, Chap.236o
Nomenclature
• Herpes zoster oticus is commonly known as Ramsay
Hunt syndrome following the first description of 60
cases by John Ramsay Hunt in 1907.
• To be more accurate, herpes zoster oticus should
actually be called Ramsay Hunt syndrome type 1 as
Hunt actually described three neurological
syndromes – only one of which involved the facial
nerve and the ear.
Pathology
• The disease is a reactivated varicella zoster
infection from dormant viral particles resident in
the geniculate ganglion of the facial nerve and the
spiral and vestibular ganglia of the VIIIth nerve.
• Recent work looking for varicella zoster in the
geniculate zone of the concha using PCR showed
the virus to be present in 100% of patients with
vesicles and in 71% of individuals with no initial
skin lesions, but who developed vesicles within a
week.
7th ed, Vol.3, Chap.236o
Diagnosis
• The diagnosis is essentially still a clinical one, with
MRI and CSF analysis having been shown to have
no role in establishing either diagnosis or prognosis
• Detailed audiological studies have shown that
almost all patients with herpes zoster oticus have
abnormalities of the auditory pathway at several
different locations from the cochlea to the
brainstem, even though subjective hearing loss may
not be present
Diagnosis
• Auricular pain is often the first symptom and other
cranial nerves are frequently involved.
• In 14% of patients, the rash is not present initially
but develops several days after the onset of pain
and facial palsy.
• In some cases, the vesicular rash may in fact
present on the tongue or pharyngeal mucosa and
never present in the ear.
Outcomes
• In untreated patients, over 60% develop a complete
facial paralysis within a week and this figure is even
higher in individuals over the age of 50.
• If the palsy is complete, only 10% will get a full
return of normal function if facial nerve studies
reveal the absence of neural activity 10 days later.
• If the palsy is incomplete, 66% will recover
completely.
• Overall, approximately 50% of adults and 80% of
children will achieve full recovery.
Management options
• In a retrospective study of 80 patients, improved
outcomes were obtained if individuals were
commenced on acyclovir and prednisolone within 3
days of the onset of symptoms.
• 75% had a complete recovery with early treatment,
compared to only 30 percent when treatment was
started on or after day 8.
FISTULA PRE-AURIKULAR
Fistula Pre-aurikular
• Telinga luar terbentuk dari arkus pertama tuberkel
kartilago yang mengalami fusi membentuk pinna.
• Sinus terbentuk krn fusi yang tidak lengkap dan masuknya
jaringan epitel membentuk lapisan kulit yang melapisi
sinus.
• Dapat terjadi karena keturunan.
• Temuan klinis :
• Sinus jelas saat lahir dan sering bilateral.
• Mungkina ada discharge sebasea.
• Jarang memberikan masalah.
• Dapat terjadi infeksi episodik berulang  abses.
• Resolusi spontan tidak terjadi krn sinus dilapisi dengan epitel
skuamosa.
Gleeson M, Browning GG, Burtin MJ, Clarke R, Hibbert J, Jones NS et al, editors. Scott-Brown’s Otolaryngology, 7th ed.
p.970, 1267-8.
Fistula Pre-aurikular
• Tatalaksana
• Tidak ada infeksi dapat
dibiarkan.
• Ada infeksi : eksisi.
• Operasi harus mengangkat
semua sisa epitel skuamosa.
• Sulit dieksisi dan sering
kambuh setelah ditangani.
• Dianjurkan memantau
secara aktif saraf wajah dan
menghindari infiltrasi
anestesi lokal.
p.970, 1267-8.
BENDA ASING TELINGA
Pathology
• The foreign bodies found most commonly in the
ear are, in order, cotton wool, insects, beads, paper,
small toys and erasers.
• An eclectic mix of more unusual foreign bodies has
been described in the literature.
• 72% of otolaryngology referrals from failed
attempts by nonspecialists consist of firm, rounded
objects such as beads or beans.
Sumber : Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th ed, Vol.3, Chap.236l
Clinical picture
• Foreign bodies in the external auditory meatus are
most commonly seen in children who have inserted
them into their own ears.
• Children may present asymptomatically, or with pain or
a discharge caused by otitis externa.
• Adults are often seen with cotton wool or broken
matchsticks which have been used to clean or scratch
the ear canal.
• Live insects in the ear, commonly small cockroaches,
are annoying due to discomfort created by loud noise
and movement.
7th ed, Vol.3, Chap.236l
Management options
• Removal can vary from being simple to being very
challenging and frustrating.
• Emergency or primary care physicians are
successful at removing about two-thirds of foreign
bodies under direct vision.
• In 82% of cases, these are irregularly shaped
objects with soft, graspable parts.
• As a result, ear, nose and throat (ENT) departments
see the problem cases these practitioners could not
solve.
The nature of the foreign body
• Living insects should first be killed by instilling oil
into the meatus to drown them before removal.
• Irregular/soft graspable non-living objects (dead
insects, cotton wool, paper, small toys) may be
removed with a pair of crocodile forceps.
• Organic objects (beans, etc.), which may absorb
water, swell and cause pain, should not be
syringed.
• Button batteries should not be syringed as they
may leak on exposure to water. They should be
removed urgently.
• Inorganic round/smooth non-graspable (beads,
erasers). Smooth, firm, rounded objects, such as
beads or toy gun pellets, are difficult to grasp and
can easily be wedged deeper into the meatus.
Syringe/remove with wax hook/removal under
anaesthetic.
Location of the foreign bodies
• The easier access, wider diameter, elastic nature and
lesser sensitivity of the lateral canal make the removal
of laterallying foreign bodies easier.
• Space between the foreign body and the canal wall
allows access for water or an instrument through for
removal.
• Firmly impacted foreign bodies medial to the isthmus,
particularly when failed removal attempts have caused
trauma and swelling of the canal skin, may require
surgical removal.
• A post-auricular approach and widening of the canal by
bone drilling is advised.
Patient considerations
• Younger, uncooperative children require special
handling.
• Prior unsuccessful attempts at removal may have
caused pain and trauma and the child may be unhappy
and uncooperative.
• Syringing is often useful in children as it is better
tolerated, and the risk of causing trauma is low.
• Once the foreign body has been removed it is advisable
to check the ears for underlying pathology as the child
may have put in the foreign body due to itch, pain or
otorrhoea.
Complications
• In general, these are limited to lacerations of the canal
skin and otitis externa.
• Rarely, facial nerve palsy may occur secondary to
leakage of alkaline material from a button battery and
necrosis of the surrounding tissue.
• Canal wall lacerations are present in 48% of cases
where prior attempts at removal by other health care
professionals have failed.
• Damage and perforation of the tympanic membrane,
and even ossicular chain dislocation or fracture may
occur.
• Multiple attempts at removal and the use of multiple
instruments are associated with complications.
SERUMEN PROP
Cerumen Props
• Cerumen : Kombinasi dri hasil sekresi dri sebacea &
apokrin yg tercampur dgn debris epitel
• Akumulasi cerumen  mengganggu clinical view
membran timpani, gangguan pendengaran,
ketidaknyamanan / sumber infeksi
• Pembersihan serumen dgn cotton swabs dpt
mendorong cerumen lbh dalam
• Cara pembersihan serumen  metode irigasi,
bekerja baik pda serumen yg lembek.
Ballenger’s Otorhinolaryngology Head & Neck Surgery Ed.6

• Jika serumen terlalu keras atau terlalu sakit saat
dibersihkan  penggunaan pelembek serumen
seperti kortikosteroid/antibiotik tetes telinga,
ceruminolytic solution (cerumenex). Pengunaan
dilakukan beberapa hari lalu dilakukan pemeriksaan
ulang  cerumen diangkat dgn irigasi atau suction
Ballenger’s Otorhinolaryngology Head & Neck Surgery Ed.6

OTITIS MEDIA AKUT
Definition
• The term ‘acute otitis media’ implies a viral or
bacterial infection of the mucosal lining of the
middle ear and mastoid air-cell system.
• It is characterized by an otoscopically abnormal
tympanic membrane.
• The clinical presentation is usually with otalgia and
systemic illness.
Sumber : Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th ed, Vol.3, Chap.237a
Diagnosis
• History
• Several symptoms suggest the diagnosis of acute otitis
media:
• local symptoms: ear ache, impaired hearing, otorrhea, tinnitus;
• general symptoms: fever, irritability, nocturnal agitation,
gastrointestinal signs (abdominal pain, diarrhea, vomiting,
anorexia).
• When confirmed with one or more of these complaints,
consider a diagnosis of acute otitis media.
• Obtain a clinical picture, ask in the case of a local
complaint, if the patient is experiencing any feeling of
general illness, and in the case of a general complaint, if
there are any local symptoms.
• Establish whether the patient has an upper airway
infection or has had one prior to the actual complaint.
The suspicion of acute otitis media will be strengthened
if this is the case.
• Physical examination
• Inspection of the eardrums is indicated to establish or
exclude the diagnosis of acute otitis media.
• Both eardrums should be inspected and compared.
• Cerumen or detritus can be removed with Q-tips soaked
in oil, a cerumen loop or, preferably, a vacuum aspirator.
The ear should not be rinsed by means of a syringe. For
patients with acute otitis media, the latter procedure is
very painful.
• Diagnosis
• The diagnosis is based on a combination of the history
and the image of the tympanum:
• a normal tympanum is pearl grey and transparent, with a clear
light reflex. This finding excludes acute otitis media.
• an injected tympanum can indicate early acute otitis media,
but can also be caused by crying or by a common cold. A clear
difference in redness between left and right tympanum
supports the diagnosis of acute otitis media;
• an intensely red tympanum.
• a bulging tympanum indicates the presence of liquid in the
middle ear under pressure.
• perforation of the tympanum with otorrhea (within an acute
clinical picture)
• Anamnestic data play an increasingly important role, the

more so when the image of the tympanum is unclear or
difficult to judge.
Natural history
• Around 10% of patients have a discharging ear at
presentation, presumed due to spontaneous
perforation of the tympanic membrane.
• In developed countries, acute otitis media in adults
is considerably more likely to be associated with
intra-temporal/cranial complications than chronic
otitis media
• Acute mastoiditis was the most common
complication at 83%; followed by facial palsies,
which can occur in association with or without
acute mastoiditis, account for 30%.
Management
• Though the majority of patients receive antibiotics
there is no evidence to support their efficacy.
• Indeed in a nonrandomized, international case
series of 386 adults, ‘recovery’ was more frequent
(92%) in those that did not receive antibiotics as
opposed to those that did (75%).
• Analgesis for otalgia would seem good practice,
though this is not supported by existing evidence.
OTITIS MEDIA SEROSA
Otitis Media dengan Efusi
• Aetiologi
• Carsinoma nasofaring
• Sinusitis
• Alergi
• Disfungsi tuba eustachius
• ISPA
Akumulasi mukus kronis di telinga tengah, kadang di sistem air-

cell mastoid (>12 minggu  kronik)
Bakteri & virus Gejala Klinis

• Streptococcus • Pe↓an pendengaran
pneumoniae ringan–sedang
• Haemophilus influenza • Telinga terasa penuh
• Moraxella catarrhalis • Tinitus
• Adenovirus • Sakit telinga
• Pusing
Diagnosis Tatalaksana
• MRI • Azelastine 2mg/hari
• Timpanometri selama 8 minggu
• Pembedahan
Komplikasi • Miringotomi
• Ateletaksis membran • Timpanosentesis
timpani • Pemasangan tube
ventilasi
• Meningitis
• Tuli Neurosensory
OTITIS MEDIA KRONIK
DEFINITION
• Chronic Otitis Media (COM) is an inflammatory process
in the middle-ear space that result in long-term, or
more often permanent changes in the tympanic
membrane including atelectasis, dimer formation,
perforation, tympanosclerosis, retraction pocket
development, or chloesteatoma
• COM result from long-term Eustachian tube

dysfunction with a poorly aerated middle-ear space,
multiple bouts of acute otitis media, persistent middle-
ear infection, or other chronic inflammatory stimulus.
Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Classification
• Chronic Active Otitis Media
• With Cholesteatoma
• Without Cholesteatoma
• Chronic Inactive Otitis Media
• With perforation
• With retraction pocket
• Adhesive otitis media
• With ossicular fixation or resorption
• Chronic inactive otitis media with frequent
reactivation

CLINICAL PRESENTATION
• Varies with the underlying severity of the infection,
the host response, and the time over course over
which it manifest
• Can be asymptomatic
• General symptom
• Conductive hearing loss (Primary symptom)
• Otalgia
• Otorrhea
• Aural fullness
• Pulsatile tinnitus
• otorrhagia

Chronic Active Otitis Media
With Cholesteatoma
• Cholesteatoma = an erosive process defined by
trapped squamous epithelium that produces and
accumulates desquamated keratin debris
• 2 general categories:
• Congenital
• Acquired

Congenital Chlolesteatoma
• Congenital cholesteatoma comprises squamous
epithelium retained in the middle-ear space during
embryologic migration of squamous cells
• Criteria diagnosis
• A normal tympanic membrane
• No history of prior ear infections
• No history of prior ear surgery including tympanostomy
• Commonly occurs in the anterosuperior quadrant of

the middle-ear space reflectiong the pathway of
embryologic cell migration
Clinical presentation
• Painless
• Whitish mass behind the tympanic membrane along with a
variably severe conductive hearing loss, depending on the
size of the cholestoma
• Imaging:
• Soft tissue mass in the middle-ear space that, as it enlarges, cause
varying degrees of bony erosion of tegmen, ossicular chain,
mastoid, and otic capsule
• Congenital cholesteatoma typically does not erode the
scutum
• Pathology:
• Kereatin cyst surround by epithelial cells that do not contact the
tympanic membrane
• Squamous epithelium surrounding the keratin debris can erode into
the ossicular chain

With Acquired Cholesteatoma
• Arises from squamous epithelium that has
migrated into the middle-ear space via retraction of
the tympanic membrane or through a perforation
of the tympanic membrane
• Trapped squamous epithelium  produces keratin
debris  desquamated and accumulate  bone
erosion with progressive enlargement

Classification
• Attic cholesteatomas
• Result from retraction of the pars flaccida of the
tympanic membrane (most common)
• Posterior-superior retractions  extend into the
posterior mesotympanum, facial recess, sinus tympani,
and can pass through aditus ad antrum into the mastoid
air cells
• Pars tensa chilesteatoma (least common)
• Result from retraction / perforation of the entire pars
tensa of the tympanic membrane
• Invariably involves the Eustachian tube orifice, the attic
and the mastoid

Clinical Presentation
• Retraction / perforation of the tympanic membrane
with trapped squamous debris (seen on otoscope)
• Conductive hearing loss  affect the ossicular chain
• Key diagnosis:
• CT scan: scutal erosion  present in acquired cholestoma,
absent in congenital cholestoma
• Pathologic examination  keratin cyst with a tympanic

membrane retraction / perforation in continuity with
the cyst

Without Cholesteatoma
• Definition:
• Chronic inflammatory process of the middle ear and mastoid
• Is an indolent process that can persist for years, or
indefinitely, in the absence of definitive management
• Clinical presentation:
• Presents with chronic otorrhea that varies in amount, color,
and consistency
• Otalgia is not severe and consists of a dull earache that waxes
and wanes
• Otorrhagia can occur, particularly with aural polyp formation
• Conductive hearing loss

Pathophysiology
• Early in the course of inflammation
• Mucosal edema along with submucosal fibrosis and hyperemia are
typical
• An inflammatory infiltrate is present and usually comprises
lymphocytes rather than polymorphonuclear cells
• Plasma cells, histocytes and macrophages are usually present
• As the condition progresses
• Soft, friable granulation tissue begins to form  consist of new
capillaries, connective tissue and inflammatory cells
• Variable amounts of mucoid and purulent otorrhea occur chronically
• When inflammation persists
• Aural polyps formed from the hyperemic, inflamed mucosa
• Mastoid air cell tracts can become blocked  occasionally causing the
formation of a cholesterol granuloma
• Ossicular erosion can occur

Chronic Inactive Otitis Media
With Perforation
• Definition:
• A permanent perforation of the tympanic membrane
without any ongoing inflammatory process or infection
in the middle ear or the mastoid
• Perforation can be in the pars flaccida or pars tensa of
the tympanic membrane
• Can be marginal, central, subtotal or total

Pathologically:
• The tympanic membrane is perforated but there is
no inflammation of the middle-ear space or
mucosa
• The perforation
• can be surrounded by healthy residual tympanic
membrane or by tympanosclerosis, a dimeric membrane
or a thick scar
• Can extend to the fibrous annulus and , rarely, involve it
• The lamina propria of the tympanic membrane can
thicken at the periphery of the perforation due to
fibrous tissue proliferation

With Retraction Pocket
• Definition:
• Any ongoing inflammation has resolved but a portion of
the tympanic membrane is retracted into the middle ear
or attic
• Can be result from several condition (e.g. Chronic
eustachian tube dysfunction)

Pathophysiology
• The ensuing negative middle-ear pressure pulls the
tympanic membrane medially, creating a retraction
pocket
• Negative pressure can occur from lack of ventilation
through the aditus ad antrum (attic block)
• Retraction pocket developed  subclinical
inflammatory state can evolve in the epithelial tissue 
adhesion that tether the tympanic membrane to the
ossicles, promontory mucosa, or medial aspect of the
scutum
• Ongoing inflammation can drive the retraction pocket
further into the middle ear or mastoid, despite
correction of the middle-ear pressure imbalance

With Adhesive Otitis Media
• Definition:
• Stable, near total, or total retraction of the tympanic
membrane onto the promontory, ossicles, and othe
middle ear structures
• Adhesion exist between the eardrum and these
structures such that negative insufflation or even
tympanostomy tube insertion cannot restore the drum
to normal anatomic position

Phatologically
• Tympanic membrane is retracted into the middle-ear
space and draped over the incus and stapes
• The tympanic membrane this and loses its lamina
propria
• Epidermization of the middle ear = extreme form of the
adhesive otitis media
• Transformation of the normal mucosal lining into a squamous
epithelial lining
• No keratin debris retained
• Epidermization can involve either portion / entire of the
middle ear
• can remain stable without evolving into cholesteatoma

With Ossicular Fixation or Resorption
• Complication of chronic otitis media
• Ossicular fixation typically is the result of
tympanosclerosis of the head of the malleus or the
body of the incus in the attic, or of the stapes
footplate around the annular ligament
• Adhesion can also form medial to the tympanic
membrane, impeding the normal mobility of the
ossicular chain

• Ossicular resorption is common with chronic otitis
media
• The incudostapedial joint is particularly vulnerable to
resorption given the tenuous blood supply to the
lenticular process of the incus
• However, resorption can occur at any part of the
ossicles and often involves the long process of the body
of incus and capitulum and crura of the stapes
• Involvement of the body of the incus and the
manubrium of the malleus can occur but are less
common

Tanda dan Gejala OMK
• Hearing loss
• Otorrhea 
• OMSK : cairan kental, banyak, intermiten.
• Cholesteatoma : cairan sedikit, bau, purulent
• Pada keadaan lebih parah  bloody otorrhea
• Otalgia  otitis eksterna sekunder/ sequela
intrakranial dari cholesteatoma
• Nasal obstruction
• Tinnitus
• Keadaan lebih parah : Vertigo  labyrinthine fistula,
Paralisi N.VII, gejala neurologis
Ballenger's Otorhinolaryngology Head and Neck Surgery

Pemeriksaan
• Otomicroscopic examination
• Evaluasi nasofaring (disfungsi tuba eustachius)
• Audiometri
• Tes Weber dan Rinne
• Bila terdapat gejala vestibular  pneumatic
otoscopy
• Imaging: CT & MRI tulang temporal
• Kultur

Tatalaksana
• AB topikal (kuinolon topicalotorrhea pada ps dgn
OMSK uncomplicated)
• Antiseptik topical  boric acid, aluminum acetate,
povidone-iodine
• Regular aural toilet
• Rekuren /infeksi kronik  AB sistemik, irigasi dgn
solusio asam asetat (half strength) sebelum
diberikan AB tetes
• Bedah

Mastoiditis
Mastoiditis
• Infeksi dan peradangan yang meluas ke rongga
mastoid selama otitis media akut.
• Epidemiologi:
• Anak-anak  28% <1 tahun, 38% 1-4 tahun, 21% 4-8
tahun, 8% 8-18 tahun, 4% >18 tahun.
• Infeksi dapat menyebar ke periosteum mastoid
melalui vena  mastoiditis akut dengan periostitis.
• Tidak ada abses, lipatan post-aurikular mungkin
terasa penuh, pina mungkin terdorong ke depan
dan ada bengkak ringan, eritema dan tenderness di
daerah post-aurikular.
Mastoiditis
• Osteitis mastoid akut  infeksi terjadi  merusak
os mastoid  abses subperiosteal (daerah post-
aurikular)
• Abses zigomatikus dpt berkembang diatas dan
didepan pinna
• Perforasi korteks medial mastoid, berjalan dari
sternomastoid ke posterior triangle  abses bezold
Mastoiditis
• Etiologi:
• Sekitar 20% tidak ada bakteri
• Streptococcus pneumoniae
• Streptococcus pyogenes
• Pseudomonas aeruginosa
• Staphylococcus aureus are the most commonly reported
• Haemophilus influenzae, Moraxella catarrhalis, Proteus
mirabilis and Gram-negative anaerobes rarely.
Mastoiditis
• Tanda & gejala:
• Otalgia • Diagnosis
• Iritabilitas pada anak • Full blood count
• Bulging membran • CRP
timpani • Kultur darah
• Bengkak retro-aurikular • CT-scan / MRI
• Eritema retro-aurikular
• Pireksia
• Protrusion pinna
• Penurunan dinding
posterior kanal auditori
eksternal (karena abses
subperiosteal)
Mastoiditis
• Diagnosa banding
• AOM, otitis externa, furunculosis dan reactive
lymphadenopathy.
• Undiagnosed cholesteatoma, Wegener's granulomatosis,
leukaemia dan histiocytosis
• Tatalaksana:
• Myringotomy (dengan atau tanpa ventilation tube
placement
• IV AB dosis tinggi
• Drainase dengan atau tanpa mastoidektomi kortikal
Mastoiditis
S Otalgia, iritabel pd anak
O • Bulging membran timpani
• Bengkak & eritema retro-aurikular
• Pe↓an dinding posterior kanal auditori eksternal
• Protrusion pinna
A • Full blood count
• CRP
• Kultur darah
• CT-scan / MRI
P • Miringotomi
• IV AB dosis tinggi
• Drainase dengan atau tanpa mastoidektomi kortikal
MIRINGITIS BULLOSA
Bullous Myringitis
• Bullous myringitis (myringitis bullosa
haemorrhagica) is the finding of vesicles in the
superficial layer of the tympanic membrane.
• The vesicles occur between the outer epithelium
and the lamina propria of the tympanic membrane.
• More detailed histology has not been described.
Sumber : Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th ed, Vol.3, Chap.236b
Aetiology
• Cultures from aspirates of the vesicles and middle
ear fluid are similar to that in acute otitis media.
• An infection by influenza virus or by Mycoplasma
pneumoniae has been suggested as the aetiological
agent but no evidence for this.
• Occurs in all age groups but children, adolescents
and young adults are more frequently affected.
Symptoms
• Sudden onset of severe, usually unilateral, often
throbbing pain in the ear is the most common
presentation.
• The symptoms usually set in during or following an
upper respiratory tract infection.
• A hearing impairment (conductive and/or
sensorineural) is common in the affected ear.
Signs
• Otoscopy reveals blood-filled, serous or
serosanginous blisters involving the tympanic
membrane and sometimes the medial aspect of the
ear canal
• A serosanginous secretion can be seen if the
blisters rupture
• Tympanic membrane is intact.
• In young children, middle ear fluid was present in
the majority (97%) but is an uncommon finding in
other age groups.
Signs
• In an older population, a hearing impairment was
seen in 17 of 20 ears.
• Six of these impairments were pure sensorineural,
seven mixed and four conductive.
• The site of the sensorineural hearing loss is the
cochlea.
7th ed, Vol.3, Chap.236b
Diagnosis
• Diagnosis is based on physical examination.
• Vesicles in the superficial layer of the tympanic
membrane are present.
• The main differential diagnoses are acute otitis
media, herpes zoster oticus or Ramsay Hunt
syndrome.
Investigation
• Pneumatic otoscopy and tympanometry help
determine whether the middle ear contains fluid.
• Clinical evaluation of the cranial nerves and, in
particular, the facial nerve must be carried out for
to distinguish from herpes zoster oticus or Ramsey
Hunt syndrome.
• Pure-tone audiogram including bone conduction
thresholds is essential for detection of
sensorineural hearing impairment.
Outcomes
• In the vast majority of cases a complete recovery is
seen within days.
• In a prospective study a sensorineural hearing
impariment of > 15 dB in two frequencies was
reported in 65% of 18 patients.
• In other reports, the frequency of sensorineural
hearing impairment was between 15 and 67 %
Management options
• In cases without middle ear affection & without
sensorineural hearing loss, only analgesics are
recommended.
• When the middle ear is affected, antibiotics can be
used as in the treatment of acute otitis media.
• In children < 2 years, acute bullous myringitis
should be treated as acute otitis media.
• Antibiotics have also been recommended in cases
with sensorineural hearing impairment
Effect of management
• Spontaneous resolution of the blisters and middle
eareffusion, if present, is the norm.
• Complete recovery of the sensorineural impairment
within three months occurred in between 60 and
100 % of affected patients treated with amoxicillin.
PERFORASI MEMBRAN
TIMPANI
Perforasi Membran Timpani
• Dapat terjadi karena
• Penyakit (terutama infeksi) : OM, mastoiditis
• Trauma
• Perawatan medis : irigasi telinga
• Gejala : suara bersiul terdengar ketika bersin, pe↓an
pendengaran, biasanya tidak sakit.
• Tanda : sekret purulen.
• Px : otoskopi, tes impedansi telinga tengah, timpanometri,
audiometri, otomikroskopi, radiografi atau MRI (jika ada
kolesteatoma atau destruksi tulang pendengaran).
• Tatalaksana :
• Mengontrol otorea : AB sistemik (cotrimoxazole, amoksisilin)
• Timpanoplasti http://emedicine.medscape.com/article/858684-overview
https://www.med.unc.edu/ent/adunka/for-patients/symptoms-
disorders/tympanic-membrane-perforations
Perforasi Membran Timpani
S O A P
• Suara bersiul • Sekret • Otoskopi • Mengontrol
terdengar purulen. • Tes impedansi telinga tengah otorea : AB
ketika bersin. • Audiometri • Timpanometri sistemik
• Pe↓an umumnya (cotrimoxazole,
• Audiometri
pendengaran. normal. amoksisilin)
• Otomikroskopi
• Timpanoplasti
• Radiografi / MRI
http://emedicine.medsca
pe.com/article/858684-
overview
https://www.med.unc.ed
u/ent/adunka/for-
patients/symptoms-
disorders/tympanic-
membrane-perforations
TIMPANOSKLEROSIS
Timpanosklerosis
• Merupakan deposit hialin bahan aseluler yg terlihat
sebagai plak putih di membran timpani dan deposit
nodula putih di lapisan submukosa telinga tengah
pada otoskopi.
• Secara patologis adalah hasil akhir proses
penyembuhan : kolagen di jaringan fibrosa mengalami
hyalinisasi, kehilangan struktur dan menyatu menjadi
massa yg homogen.
• Patogenesis :
• Hipersensitivitas imunologi lokal.
• Pe↑ kadar O2 pd telinga tengah dgn paparan thdp radikal
O2.
• Inflamasi lokal.
Timpanosklerosis
• Menyebabkan :
• Gangguan transmisi suara.
• Imobilitas penghubung tulang pendengaran.
• Gejala : umumnya asimtomatik.
• Pemeriksaan (otoskopi) :
• Penipisan dan atau kekeruhan lokal atau umum pars
tensa
• Plak berbentuk bulan sabit atau tapal kuda
• Tatalaksana :
• Timpanoplasti
• Rekonstruksi tulang pendengaran
Timpanosklerosis
S O A P
• Asimtomatik • Pars tensa menipis • Otoskopi • Timpanoplasti
• Bisa merupakan hasil dr dan atau keruh • Rekonstruksi
proses penyembuhan • Tampak plak tulang
• Dpt terjadi ggn brbentuk spt bulan pendengaran
pendengaran sabit atau tapal kuda
KOLESTEATOMA
Kolesteatoma
• Definisi :
Kolesteatoma terdiri dari epitel skuamosa berkeratin
yang terperangkap di dalam dasar tengkorak, dimana
dapat mengikis dan menghancurkan struktur penting
dalam tulang temporal . Kondisi ini dapat menyebabkan
komplikasi pada sistem saraf pusat ( seperti abses otak,
dan meningitis.
• Klasifikasi :
• Kolesteatoma kongenital
• Primary acquired cholesteatoma
• Secondary acquired cholesteatoma
Ballenger’s Otorhinolaryngology 17 Head

and Neck Surgery 2009
Kolesteatoma
• Kolesteatoma kongenital : • Staging kolesteatoma kongenital :
• Kolesteatoma yang tumbuh di blkg • Stage I  kolesteatoma terbatas
MT yg intak tanpa ada riwayat pada 1 kuadran
otorrhea
• Stage II  mengenai banyak
• Berasal dari metaplasia skuamosa kuadran tanpa mengenai tulang
mukosa telinga tengah atau migrasi pendengaran (meatus, incus,stapes)
dari epitel skuamosa celah
eksternal melalui MT yg mengalami • Stage III  mengenai tulang2
mikroperforasi pendengaran tanpa perluasan ke
mastoid
• Normalnya : tumpukan epitel
skuamosa (formasi epidermoid) • Stage IV  mengenai mastoid
di anterosuperior celah telinga
tengah (10-33 minggu masa
gestasi) mengalami transisi
membentuk mukosa telinga tengah
• Kolesteatoma  ketika formasi
dermoid gagal mengalami involusi
• Kolesteatoma  anterosuperior 
posterosuperior  antrum dan
mastoid

Kolesteatoma
• Primary acquired cholesteatoma
• Kolesteatoma yang timbul dari retraksi pars flaccida
• Secondary acquire cholesteatoma :
• Berasal dari perforasi membran timpani, biasanya
tumbuh di kuadran posterosuperior telinga tengah
• Etiopatogenesis :
• MT invaginasi
• Epithelial invasion
• Hiperplasia sel basal
• Metaplasia skuamosa

Kolesteatoma
• Tanda dan Gejala : • Diagnosis : dengan PF dan
• Hilang pendengaran radiologi.
kondukftif • CT Scan  utk melihat letak
• Painless otorrhea lesi dan defek pada tulang
• Dizziness (jarang) • Histopatologi 
• Jaringan granulasi pada ditemukannya epitel
saluran telinga dan telinga skuamosa, namun tdk dapat
bagian tengah  tdk membenakan antara kista
merespon pd antibiotik sebasea dan keratoma
• MRI  Digunakan terutama
• Kolesteatoma juga dapat bila terdapat suspek :
timbul dengan gejala CNS : • Invasi ke lapisan duramater
• Trombosis sinus Sigmoideus • Subdural atau epidural abses
• Abses epidural • Herniasi otak ke cavitas
mastoidea
• Meningitis • Inflamasi membran labyrinth
atau N.fasialis
• Trombosis sinus sigmoideus
• Meningitis
Ballenger’s Otorhinolaryngology 17 Head and Neck Surgery 2009

http://emedicine.medscape.com/article/860080-overview
Kolesteatoma
• Tatalaksana :
• Canal wall-down tympanomastoidectomy
• In the canal wall–down (open) procedure, the posterior
canal wall is removed. A large meatoplasty is created to
allow adequate air circulation into the cavity that arises
from the operation. Canal wall–down operations have the
highest probability of permanently ridding patients of
cholesteatomas.
• Canal wall-up tympanomastoidectomy
• In the canal wall–up (closed) procedure, the canal wall is
preserved. Canal wall–up procedures have the advantage
of maintaining a normal appearance, but the risk of
persistent or recurrent cholesteatomas is higher than in the
canal wall–down operation.
Kolesteatoma
• Komplikasi :
• Destruksi tulang yg terkena dan struktur lain yg
berhubungan (ossicles, canal N.VII, tegmen timpani,
tegmen mastoideum)
• Purulen otorrhea
• Hilang pendengaran konduktif
• Erosi capsula otic  fistula labyrinthine, vertigo, atau
supuratif labirintin
• Fistula, labirintitis, erosi koklea  hilang pendengaran
sensorineural
• Paralisis N.facialis
Scott-Brown’s Otorhinolaryngology, Head and

Neck Surgery 7th Ed
Kolesteatoma
Kongenital Kolesteatoma Primary Acquired Cholesteatoma
Secondary Acquired Cholesteatoma
ABSES BEZOLD
ABSES BEZOLD
• Abses Bezold  komplikasi yg jarang terjadi dri
mastoiditis
• Disebabkan oleh perforasi di bony plate forming
pada bagian dlm ujung mastoid. Terjadi dimana tip
cells yg besar & piringan tulang yg membentuk
dinding bag dlam mastoid sangat tipis & korteks
luar yg tebal  akibat perforasi pus akan keluar
turun ke bawah sternomastoid taw di antara
lapisan dalam cervical fascia
• Infeksi cervical berkembang menjadi abses di leher
bag dlm ke otor sternocleidomastoideus
• Diagnosis :
• CT-scan
• Terapi :
• Eksisi, drainase abses, & pengangkatan jaringan
granulasi yg terkait

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Ballenger’s Otorhinolaryngology Head & Neck Surgery Ed.6

Ballenger’s Otorhinolaryngology Head & Neck Surgery Ed.6

• Anamnestic data play an increasingly important role, the

Akumulasi mukus kronis di telinga tengah, kadang di sistem air-

Bakteri & virus Gejala Klinis

• COM result from long-term Eustachian tube

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

• Commonly occurs in the anterosuperior quadrant of

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

• Pathologic examination  keratin cyst with a tympanic

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Glasscock – Shambaugh, Surgery of The Ear, 6th ed

Ballenger's Otorhinolaryngology Head and Neck Surgery

Ballenger's Otorhinolaryngology Head and Neck Surgery

Ballenger's Otorhinolaryngology Head and Neck Surgery

Ballenger’s Otorhinolaryngology 17 Head

Ballenger’s Otorhinolaryngology 17 Head

Ballenger’s Otorhinolaryngology 17 Head

Ballenger’s Otorhinolaryngology 17 Head and Neck Surgery 2009

Scott-Brown’s Otorhinolaryngology, Head and

Kongenital Kolesteatoma Primary Acquired Cholesteatoma

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