A 10-YEAR OLD KID WITH

EARACHE AND UPPER

RESPIRATORY TRACT INFECTION
a Case Presentation

Supervisor:
dr. H. Oscar Djauhari, Sp.THT-KL

Presented by:
Maria Emmanuelle (201706010125)
Sean Peter (201706010175)
 IDENTITY

• Name :A • Chief complaint:

• Age : 10 years old Earache on the left ear since 2
• Sex : Male days before admission

• Occupation : Student • Additional complaint:

• Address : Sukabumi Runny nose, cough, and fever

since 14 days before admission
 HISTORY OF PRESENT ILLNESS

•The boy suffered from runny nose, cold and cough.

•The nasal discharge was yellowish, mukoid, and massive in amount.
•The boy also suffered a low grade fever, but his parent did not take him to the
14 days ago doctor.

•He started to feel pain in his right ear, felt insidiously and continuously all day
•The pain was mild, but slowly the boy become more irritable
•There was a high-grade fever following this earache. History of ear
2 days ago discharge, foul-smell discharge, facial pain was denied.
 HISTORY OF PRESENT ILLNESS

•The boy become more irritable than a few days ago, so he

started to crying all day long
•The pain seems more severe than a few days ago

On the day •The boy still have a high grade fever

•His mother took him to the ENT clinic
of admission
 HISTORY OF PAST
FAMILY HISTORY
ILLNESS

• Previous illness with the same complaint
was denied
• Allergy was denied
• History of prematurity was denied
• History of family/his siblings with the
same complaint was denied
• History of tobacco exposure + 
father
 PHYSICAL EXAMINATION
(GENERALIZED STATUS)

• General condition : Appear ill

• Body weight : 25 kg
• Height : 130 cm
• Blood pressure : 90/60 mmHg
• Pulse : 125 beat per minute
• Respiratory rate : 24 times per minute
• Temperature : 38, 7oC
 PHYSICAL EXAMINATION
(EARS)

Auris dextra :
• Auricle : normal
• External auditory canal:
• hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen
(+)
• Tymphanic membrane:
• Intact, hyperemic (-), bulging (-), light reflex (+)
 PHYSICAL EXAMINATION
(EARS)

Auris sinistra :
• Auricle: normal
• External auditory canal:
• hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (+)
• Tymphanic membrane:
• Intact, hyperemic (+), bulging (-), light reflex ↓

Rinne test (+), Webber lateralitation to the left (Conductive Hearing Loss on
left ear)
 PHYSIC AL EXAMINATION
(NOSE)

Right Nose :
• Mucous membrane : hyperemic (+), edema (+), mass (-), laceration (-), crust (-)
• Inferior concha: eutrophy
• Discharge : (+), mukoid, yellowis
• Septum : normal, no deviation
• Air passage : normal

Left Nose :
• Mucous membrane : hyperemis (+), edema (+)
• Inferior concha : eutrophy
• Discharge : (+), mukoid
• Septum : normal
• Air passage : normal
 PHYSICAL EXAMINATION
(THROAT AND NECK)

• Oropharynx
• Posterior pharynx : hyperemic (-)
• Palatine tonsils : T1 / T1, hyperemic (-), detritus (-)
• Uvula : symmetrical
• Dental : no abnormatlities

• Maxillofacial : symmetrical
• Neck : mass (-), lymphadenopathy(-)
• Working Diagnosis
Acute otitis media dextra, hyperemic stage

• Workup
• tymphanometry

• Therapy
• Outpatient care
• Antibiotic
• Antipyretic and analgetic
• Topical anticholinergic
: Amoxicilin 3 x 500 mg PO for 7 days
: Paracetamol 3 x 125 mg PO for 3 – 5 days
: Oxymetazoline HCL nasal spray 2 x 3 sprays per nostril for 3 days
OTOLOGIC SYMPTOMS &
ACUTE OTITIS MEDIA
LITERATURE REVIEW
 Inflammatory

Primary Traumatic

Neoplastic
Earache

Head region
These regions are
Secondary innervated by the nerves
that also supply the ear
Neck region
CAUSES OF
OTALGIA
 OTITIS MEDIA
= MIDDLE EAR + MASTOID SPACE
INFLAMMATION

• 0 to 3 weeks in
ACUTE
duration

• 3 to 12 weeks in
SUBACUTE
duration

• longer than 12
CHRONIC
weeks in duration
 WHAT’S THE DIFFERENCE?

AOM (Acute Otitis Media)

• Acute pyogenic inflammation of the middle ear cleft

ASOM (Acute Suppurative Otitis Media)

• AOM + formation of pus in the middle ear

EOM (Eosinophilic Otitis Media)

• Non purulent nearly sterile effusion in the middle ear cleft (without inflammation)
• Most often  the unresolved stage of AOM
• May also resulted from eustachian tube dysfunction/upper respiratory tract infection

CSOM (Chronic Suppurative Otitis Media)

• Persistence of purulent otorrhea through a tympanic membrane (TM) perforation or tympanostomy tube
(TT) that is unresponsive to medical therapy
Most common:
Streptococcus pneumoniae, H. influenza,
Moraxella catarhhalis
Following the upper respiratory tract
• Eustachian tube in infant  shorter, wider, more horizontal  accounts for the
high rate of otitis media in infants and children
• The majority of children with multiple recurrences of AOM have their first
episode before the age of 12 month
• By the age of 7  the tube has a more adult configuration
PATOPHYSIOLOGY

- Dysfunction ET Edema & Narrowing ET

- URI Congestion lumen

influx of
bacteria and ↑↑ negative
Inflammation viruses middle-ear
nasopharynx pressure
when ET opens

Mucosal edema,
capillary
engorgement,
infiltration PMN
 STAGING

• Edema and hyperemia of nasopharynx & ET occludes ET  negative middle ear pressure
• Symptoms: mild deafness, ear fullness, ear pain, no fever
• Sign: retracted tympanic membrane, conductive hearing loss
Occlusion

• Prolonged tubal occlusion  invasion of pyogenic organism  mucosal hyperemia

• Symptoms: throbbing ear pain, high degree of fever, bubbling sound in the ear, deafness
but does not get childs attention due to severe ear pain
• Signs: pars tensa bulging out tympanic membrane, pars flaccida congested and red later on,
Presuppuration conductive hearing loss, light reflex -
 STAGING

• Formation of pus in the middle ear and mastoid air cells

• Symptoms: excruciating ear pain, increasing deafness, constitutional symptoms
Suppuration • Signs:TM red and bulging, yellow spot (necrotic because of ischemia)

• Late in giving antibiotics therapy, tympanic membrane will be rupture and pus drains out from the middle
ear.
• Symptoms: Child will be calm now, reduce in body temperature, and sleep well.
Perforated • PE: Tympatic membrane is rupture and pus drains out

• If the tympanic membrane still intact, the condition of tympanic membrane slowly back to
normal. If there is a perforation, secretes will reduced and dried. Resolution will takes place
Resolution without medication if the immune system still in good performance
 Others:
Decongestants
Anaglesic, antipyretic
Ear drop and aural toilet
Dry local heat
 MANAGEMENT

• Occlusion
• To open the closed eustachius tube, so the pressure in middle ear can be reduced.
• Decongestan (Child < 12y.o: HCl ephedrine 0.5% in physiologic solution, Child>12 th: HCl efedrine1% in
physiologic solution)
• Antibiotics

• Hyperemic
• Antibiotic: amoxicillin 40 mg/kgBB/day in 3 doses, ampicillin 50-100 mg/kgBB/day in 4 doses, eritromicin
40 mg/kgBB/day.
• Decongestan
• Analgetics
• Antipiretics
 MANAGEMENT

• Suppurative
• Antibiotics: amoxicillin 40 mg/kgBB/day in 3 doses, ampicillin 50-100 mg/kgBB/day in 4
doses, eritromicin 40 mg/kgBB/day.
• Myringotmy
• Analgetics
• Antipiretics

• Perforated
• H2O2 3% 5 drops 3 dd 1 3-5 days
• Antibiotic local (ear drops)
 MANAGEMENT

• Resolution
• If the resolution didn’t take place, secretes will drained out by the
perforation in tympanic membrane. The antibiotics continued for 3
weeks. If 3 weeks pasts and secretes stills, mastoiditis should be in
differential diagnosis
 SURGICAL TREATMENT

TYMPANOCENTESIS MYRINGOTOMY

• Needle aspiration of fluid from middle • An incision is put in the TM to evacuate

ear middle ear fluid
• Indications:
• Indicated for:
• Bulging eardrum
• Premature newborns
• Acute excruciating pain
• Immunocompromised patients
• Unresponsive to antibiotics
• Failure of previous antibiotic therapy • Facial palsy
• Intracranial complications • Intracranial complications
COMPLICATIONS
 BIBLIOGRAPHY

• AAP Clinical Practice Guidelines: The Diagnosis and Management of Acute

Otitis Media, 2013
• Flint PW, Haughey BH, Lund VJ, Niparko JK, Robbins KT, Thomas JR, et al.
Cummings otolaryngology head and neck surgery. 6th edition, Elsevier,
Saunders: 2015
• Mohan Bansal, MS, PhD, FICS, FACS, Disease of ear, nose, and throat, Jaypee
Brothers Medical Publisher: 2013
THANK YOU 