ANATOMY OF THE EAR and

ACUTE OTITIS MEDIA

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

Presented By:
Amiru Zachra
M. Aufaiq Akmal Noor
Mentari Nur Farida
 Outer Ear
• Auricle (Pinna)
• External Auditory Canal
• Tympanic Membrane
 Structures of the Auricle

Auricle (Pinna)
• Gathers sound waves
• Aids in localization
• Amplifies sound appr
ox. 5-6 dB
External Auditory Canal
• Approx. 1 inch long
• “S” shaped
• Outer 1/3  cartilaginou
s part
• Inner 2/3  bony part
• Allows air to warm befor
e reaching TM
• Isolates TM from physical
damage
• Cerumen glands moisten
/soften skin
• Presence of some cerume
n is normal
 External Auditory Canal

• Lateral third : cartilaginous portion —> contains cerumen-producing

glands & hair follicles.
• Medial two-thirds : bony portion —> epithelial lining over the
tympanic membrane.
Tympanic Membrane
• Thin membrane
• Forms boundary betwe
en outer and middle ear
• Vibrates in response to
sound waves
• Changes acoustical ene
rgy into mechanical ene
rgy
• Protects the middle ear
space from foreign mat
erial of the EAC
Tympanic Membrane (eardrum)

Tympanic
membrane
Pars tensa
(radial and
circular fibres)

Pars flaccida
(superior to the
lateral process
of malleus)
 Blood
Supply of
External Ear
Innervation
• N. Occipitalis minor (C2)
o upper part of cranial (medial) surface
• N. Auricularis magnus (C3)
o Including most of cranial (medial) surface
• N. Auriculotemporalis (CN V3) :
o Including tragus and anterior wall of external
auditory canal
• Auricular branch of N. Vagus (CN X)
• N. Facialis (CN VII)
Middle Ear
• Tympanic Cavity
• Ossicles
• Eustachian Tube
• Mastoid Air Cells
Boundaries of middle ear
Surfaces of the Middle Ear
Lateral Tympanic membrane
Anterior Eustachian tube
Posterior Aditus ad antrum
Superior Tegmen tympani
Inferior Jugular vein
 Surfaces of the Middle Ear
• Medial wall:
– A well marked rounded buldge: Promontary  produced by fi
rst turn of the cochlea
– Rounded Window: Lies below & behind the promontary
– Oval Window: above and behind the promontary  closed by
the foot of the stapes & leads to the vestibule of internal ear
– The horizontal part of facial canal: arching above the promon
tary & oval window
Tympanic Cavity
 Epitympanum

• Above the tympanic membrane.

• Small and contains little air.
• Contains the principal mass of the auditory ossic
les.
• Tympanic part of the facial nerve —> boundary b
etween the epitympanum & mesotympanum.
 Mesotympanum

• Mesotympanum : the portion

of the tympanic cavity at the l
evel of the tympanic membra
ne.
• Contains the round window, t
he oval window with the stap
es, and the promontory (bony
prominence overlying the bas
al turn of the cochlea).
 Hypotympanum

• Below the level of the tympanic membrane.

• Hypotympanum borders on the bulb of the jugular
vein.
• Contains cells (tympanic cells) that communicate wi
th the mastoid air cells.
 The Ossicles
 Ossicular chain = malleus, incus & sta
pes
 Malleus
• Attaches to TM at Umbo
 Incus
• Connector function
 Stapes
• Smallest bone in the body
• Footplate inserts in oval window
on medial wall
Focus/amplify vibration of TM to sma
ller area, enables vibration of cochlea
Eustachian Tube
• Mucous-lined, connects
middle ear cavity to naso
pharynx
• “Equalizes” air pressure in
middle ear
• Normally closed, opens u
nder certain conditions 
yawning, swallowing
• May allow a pathway for i
nfection
• Children “grow out of” m
ost middle ear problems
as this tube lengthens an
d becomes more vertical
Mastoid Process of Temporal Bone
• Bony ridge behind the auric
le
• protects cochlea and vestib
ular system
• Provides support to the ext
ernal ear and posterior wall
of the middle ear cavity
• Contains air cavities which
can be reservoir for infectio
n
 Surfaces of the Middle Ear
• Posterior Wall:
– The aditus  opening leading to the mastoid
antrum
– The pyramid  a hollow conical process conta
ining the stapedius muscle
– The verical part of the facial canal  medial t
o the aditus
 Stapedius Muscle

 Connects the stapes to the middle ear wall.

 Contracts in response to loud sounds (Acoustic Reflex).

 Changes stapes mode of vibration; makes it less efficient and

reduce loudness perceived.
 Blood Supply of Middle Ear
• Anterior tympanic branch of maxillary artery  s
upplies tympanic membrane
• Stylomastoid branch of posterior auricular artery
 supplies middle ear and mastoid air cells
Inner Ear

• Bony Labyrinth
• Membranous Labyri
nth
 Inner Ear
• Consist of 2 part : bony labyrinth & memb
ranous labyrinth
• Sensory organ  hearing & balance
• Cochlea  hearing
• Semicircular canals and vestibule  balan
ce
 Bony Labyrinth

• Rigid, bony outer walls of inner

ear

• Cavities, lined by periosteum

• Contains clear fluid  perilymp

h
Bony Labyrinth

• Vestibule
• Semicircular canals
• Cochlea
 Membranous Labyrinth

• Collection of fluid filled tubes & chambers

• Contain receptors for hearing and balance
• Lodged within bony labyrinth
• Separated from bony labyrinth by perilymphati
c fluid
• Contains endolymph
Membranous Labyrinth
• Cochlear duct
• Utricle and saccule
• Semicircular ducts
• Endolymphatic duct and sac
 Cochlea
• Snail shaped
• Cochlear structures :
1 .3 chambers  scala vestibule, scala tympani, scala m
edia (cochlear duct)
2 .Hellicotrema
3 .Reissner’s membrane
4 .Basilar membrane
5 .Organ of corti  core component
6 .Hair cells
 Central Auditory System
• VIIIth Cranial Nerve or “Auditory Nerve”
– Bundle of nerve fibers
– Travels from cochlea through internal auditory meatu
s to skull cavity and brain stem
– Carry signals from cochlea to primary auditory cortex,
with continuous processing along the way
• Auditory Cortex
– Wernicke’s Area within Temporal Lobe of the brain
– Sounds interpreted based on experience/association
How Sound Travels Through The
Ear
• Acoustic energy, in the form of sound waves, is channeled into t
he ear canal by the pinna.
• Sound waves hit the tympanic membrane and cause it to vibrat
e, like a drum, changing it into mechanical energy.
• The malleus, which is attached to the tympanic membrane, start
s the ossicles into motion. The stapes moves in and out of the o
val window of the cochlea creating a fluid motion, or hydraulic
energy.
• The fluid movement causes membranes in the Organ of Corti to
shear against the hair cells.
• This creates an electrical signal which is sent up the Auditory Ne
rve to the brain. The brain interprets it as sound!
 CASE
Acute Otitis
Media
 Patient’s Identity

• Name : An.A
• Age : 7 years old
• Occupation : Elementary Student
• Address : Sukabumi
• Gender : Boy
• MR No : R000128xx
• Get in Hospital : August 26th 2019
• Examination date : August 26th 2019
• Information Source and Caretaker: Mother
 Main Symptom

 A 7-years old boys came to ENT clinic with with left

earache since 1 weeks ago, he had cough, runny
nose and fever, since 10 days before got hospital.
 Additional Symptoms
• Symptoms also with, hearing loss, and dizziness when head
suddenly moving. His semester report always decrease as lo
ng with severe of hearing loss.
• Fullness at the left ear, and hearing loss since 4 day prior to
admission.
• Had history of upper tract infection from 6 years old, which
is 10 day before got admission, he had cough, runny nose a
nd fever.
• Otalgia and fever reduce after the discharge was came out.
• Recently, he look withdrew from society.
 History of Present Illness
 A 7-years old boys came to ENT clinic with with l
eft earache, he had cough, runny nose and fever,
since 10 days before got hospital. It also felt earac
he (pain) continuously all day. The pain was incre
asing in severity, from mild pain at the beginning
until severe pain at the time of presentation.
 History of Present Illness
• The boy also felt a sensation of fullness at the left
ear, and hearing loss since 4 day prior to admissio
n.
• History of facial pain was denied.
• No symptom at right ear
• Sore throat, swallow pain, throatiness was denie
d
• Neck swollen was denied
 History of Present Illness

• 10 days before admission, he had cough, suffer

ed from runny nose, and fever. The nasal discha
rge was clear, watery, and massive in amount. T
he boy also had high-grade fever following this
earache
• History of previous treatment was denied.
 History of Past Illness

• He had history of upper tract infe

ction from 6 years old
 History of Family Illness

• History of family this illness or have

some symptom like this, was denie
d
Physical Examination (Generalized Statu
s)

• General condition : Appear ill

• Body weight : 20 kg
• Height : 120 cm
• Blood pressure : 90/70 mmHg
• Pulse : 92 beat/minute
• Respiratory rate : 21 times per minute
• Temperature : 38, 8oC
 Physical Examination (Ears)
Auris dextra :

• Auricle : normal
• External auditory canal:
– hyperemic (-), edema (-), mass (-), laceration (-) s
ecretion (-) , cerumen (+)
 Retroauricular : normal, no deformities
• Tymphanic membrane:
– Intact, hyperemic (-), bulging (-), light reflex (+)
 Physical Examination (Ears)
Auris sinistra:
• Auricle: normal
• External auditory canal:
– hyperemic (+), edema (-), mass (-), laceration (-) s
ecretion (+) , cerumen (+)
 Retroauricular: normal, no deformities
• Tymphanic membrane:
– Intact, hyperemic (+), bulging (-), light reflex ↓
• Rinne test (+), Webber lateralitation to the left (Cond
uctive Hearing Loss on left ear)
 Physical Examination (Nose)
Right Nose :
•Mucous membrane : hyperemic (+), edema (+), mass (-), lacer
ation (-), crust (-)
– Discharge : (+), mukoid, yellowish
– 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 Ne
ck)
• Oropharynx
– Posterior pharynx : hyperemic (-)
– Palatine tonsils : T1 / T1, hyperemic (-), detritus (-)
– Uvula : symmetrical
– Dental : no abnormatlities

• Maxillofacial : symmetrical

• Neck : mass (-), lymphadenopathy (-)

 Additional Examination

Usually no investigation is required

1 . Complete perifer blood : would be leukositosis if severe OM
2 . Ear swab : for know etiology
3 . Audiometry should be performed if chronic hearing loss is s
uspected; however, not during acute infection
 Working Diagnosis

• Acute otitis media sinistra, hyperemic

(presupurative) stage
 Treatment
– Antibiotic
Amoxicilin 50-100 mg/kgBB/day divide 3 dose  50 mg x 20
kg=1000 mg/day  per dose = 333 mg (± 3/4 tab) for 5-7 da
ys
– Antipyretic and analgetic
Paracetamol syr 10-15 mg/kgBB 10 mg x 20 kg = 200 mg
= ± 1,6 cth ≈2 cth (10 ml) for 3-5 days
– For cough
Ambroxol syr 1,2 mg/kgBB/days divide 3 dose  1,2 mg x 2
0 kg = 24 mg/3 dose =8 mg = 0,5 cth ≈ 1 cth (5 ml)
– Topical anticholinergic
Oxymetazoline HCL nasal spray 2 x 3 sprays per nostril for 3
days
 Acute Otitis Media

• Acute : rapid onset of signs and symptom less Acute t

han 3 weeks including otalgia with or without deafne
ss and changes in the normal otoscopic appearance o
f TM
• Otitis: inflammation of mucoperiostial lining of middl
e ear cleft. When it go beyond mucosa (ex: bone) the
complication start. It is otitis not osteitis.
• Media : not only middle ear cavity but the whole Med
ia cleft(middle earcavity+attic+aditus+antrum+ET)
 7 – 36 months
(42% - 60%)

Epidemiology

50.000 deaths per

year due to
complication
CSOM
 Etiology
 Streptococcus pneumoniae (most often)
 Haemophillus influenzae
 Branhamella catarrhalis
 Streptococcus β-hemoliticus group A
 Staphyllococcus aureus
 E. Coli
 RSV
 Main Risk Factor
Age
• Infants and toddlers are more severely affected  eust
achius tube smaller, wider and horizontal form
 Additional Risk Factors
• Exposure to group day care with subsequent increase in
respiratory infections
• Exposure to environmental smoke or other respiratory ir
ritants and allergens that interfere with Eustachian tube
function
• Lack of breast feeding
• Supine feeding position.
• Use of pacifiers by toddlers and older children
• Family history of recurrent AOM
• Craniofacial abnormalities
• Immune deficiency
 Pathophysiology

• Middle ear : sterile,there is a connection betwee

n cavum tympani by eustachius tube.
• There are barrier systems : cillia, muramidase (en
zym that products mucous), antibody and humo
ral factors, PMN, and phagocytic cells.
• The barrier impaired  invasion of microbes to t
he middle ear
 Stage
• Occlusion
• Hyperemic (presupurative)
• Suppurative
• Perforated
• Resolution
 Clinical Findings
• Child  Adults
– Upper tract infection  pain
– Pain inner ear  fullness in the ear
– Fever  hearing loss occured
– Restless
– Seizures
– Nausea and vomiting
– Diarrhea
– Holding the affected ear
An Endoscopic Findings at Its Early Stage (occlusion)
Established Acute Otitis Media: Pre-suppurative Stage
Established Acute Otitis Media: Suppurative Stage
Established Acute Otitis Media: Suppurative Stage
Established Acute Otitis Media: Suppurative Stage
Established Acute Otitis Media: Suppurative Stage
Established Acute Otitis Media: Suppurative Stage
Established Acute Otitis Media: Suppurative Stage
Clues to Underlying Eardrum Perforation if C
opious Ear Discharge Present
Responds to Treatment/Resolution
(Without Eardrum Perforation)
 Resolution of Infection
(With Small Central Perforation)
A Recently Perforated Eardrum: A Sequel of AOM
 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 ph
ysiologic solution, Child>12 th: HCl efedrine1% in physi
ologic solution)
– Antibiotics

• Hyperemic
– Antibiotic: amoxicillin 40 mg/kgBB/day in 3 doses, ampi
cillin 50-100 mg/kgBB/day in 3 doses, eritromicin 40 m
g/kgBB/day.
– Decongestan
 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.
– Decongestan
– 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 wil
l drained out by the perforation in tympanic
membrane. The antibiotics continued for 3 w
eeks. If 3 weeks pasts and secretes stills, mast
oiditis should be in differential diagnosis
 Prevention

• Modification of risk factors :repeated courses of antibio

tics for each new infection and antibiotic prophylaxis (s
hould be with specialist concern)
• Avoidance of exposure to environmental tobacco smok
e
• Ensure that children have had a complete course of pne
umococcal.
 Complication
• Mastoiditis, subperiosteal abscesses, meningiti
s, brain abscesses.
Rinne test
Weber’s test
Thank yo
u