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TUBE HYPEREMIS STAGE
Presentator:Megawati Abubakar (12136)
Identity Nama Umur Alamat No MR
: Ny.A : 53 tahun : Srowot, Banyumas : 00494641
The main complaint was fulfilled ears History of present illness: Since 4 days ago, patient complained fulfilled ear both in the right and left side. The fulfilled was felt constantly and she felt discomfort inside the ears. Sometimes she heard buzzing inside her ear. The patien also got rhinorheae with waterry discharge along with fever until now. There was no discharge coming out from her ears, hearing loss, dizziness, or vertigo. She denied complaint in the throat.
History of the same complains (-) .History of alergy (-) History of illness in family members: . History of past illness: .History of the same complains (+) when she was 5 years old .History of alergy (-) .
Respiration : 25 x/min . Vital sign :. adequatly nourished.3 0C . Physical Examination General status : well conscious.Blood Pressure : not measured .Temperature : 38.Pulse : 92 x/min .
RESUME ANAMNESIS Fulfilled ear 4 days Discomfort inside ears Buzzing Rhinorheae Fever .
Pseudoefedrin 3x30 mg .Observation .Education .Paracetamol syrup 3x2 cth .TREATMENT .
2002) . (Bailey.INTRODUCTION Most common diseases of the middle ear are inflammations and infections play a major role Otitis media is the most common reason for an illness-related medical visit in preschool age children. 2006) second most common diagnosis made by pediatricians (Linsk R et al.
INTRODUCTION 70% of children will have had one or more episodes of acute otitis media by their third birthday. occurs mainly in children : newborn period .2002) .7 years occurs equally in males and females (Healy&Rosbe.Ballenger’s.
for both sexes.2006) .INTRODUCTION Bondy et al : the proportion of children with a diagnosis of otitis media was highest (42% to 60%) in the 7 to 36 months range Other studies have shown the highest incidence of acute otitis media. was in the 6 to 11 months (Bailey.
INTRODUCTION Epidemiologic studies at the University of Pittsburgh : 90% incidence of otitis media in urban children within the first 2 years of life. poor medical care increasing incidence of acute otitis media (Bailey.2007) Children who live in crowded households. (Clinical Otology.2006) .low socioeconomic conditions.
OVERVIEW ANATOMY .
mucous membrane-lined space in the temporal bone between the tympanic membrane laterally and the lateral wall of the internal ear medially.2007) .OVERVIEW The middle ear An air-filled. (Gray’s Anatomy for Student.
OVERVIEW MIDDLE EAR .
Middle Ear .
OVERVIEW AUDITORY OSSICLES .
3. 2. called the middle fibrous layer .OVERVIEW Tympanic Membrane Oval shape 8 mm wide and 10 mm high consists of three layers: 1. consists of squamous epithelium. consists of cuboidal mucosal epithelium. The inner layer : from the endoderm. The middle layer : from the mesenchyme. The outer layer : from the ectoderm.
the Eustachian tube lies at an angle 45ºin relation to horizontal plane and in infants this inclination is 10º .OVERVIEW Pharyngotympanic tube (Eustachian tube) The pharyngotympanic tube/Eustachian tube connects the middle ear .the nasopharynx Range of length : 31 to 38 mm In adults.
Ventilation of the middle ear associated with equalization.OVERVIEW Pharyngotympanic tube (Eustachian tube) The Eustachian Tube has three function : 1. 3.Drainage of middle ear secretions into the nasopharynxwith. 2. .Protection of the middle ear from sound and secretions.
stylomastoid branch of the occipital or posterior auricular arteries : the posterior tympanic cavity and mastoid air cells.anterior tympanic branch of the maxillary: tympanic membrane .OVERVIEW Vasculary Supply Great vessels . .
OVERVIEW .petrosal branch of the middle meningeal .the superior tympanic branch of the middle meningeal . The smallers arteries include: .a branch from the ascending pharyngeal .tympanic branch or branches from the internal carotid canal .
.OVERVIEW Veins These terminate in the pterygoid venous plexus and the superior petrosal sinus.
Derives from the tympanic branch of the glossopharyngeal nerve and the caroticotympanic nerves.OVERVIEW - Innervation The nerves that innervate tympanic cavity is tympanic plexus. - .
The lesser petrosal nerve. pharyngotympanic tube and mastoid air cells. which may be regarded as continuation of the tympanic branch of the glossopharyngeal nerve travesing the tympanic plexus .OVERVIEW Tympanic Plexus supplies: Branches to the mucosa of the tympanic cavity. A branch traversing an opening anterior to the fenestra vestibuli and joining the greater petrosal nerve.
The tympanic membrane becomes inflamed and opaque.OVERVIEW Definition . AOM is usually associated with infection by viruses or bacteria.Acute otitis media (AOM) represents the rapid onset of an inflammatory process of the middle ear space associated with one or more symptoms or local or systemic signs (Healy and Rosbe. Blood vessels to the area dilate.2002) .Acute otitis media (AOM) is an infection that involves the middle ear.edu/pedi_ed/AOM-Otitis/default.utmb.htm) . Fluid accumulates in the middle ear space. - (http://www.
Moraxella catarrhalis .Haemophilis influenza (23%) Less Frequent .OVERVIEW ETIOLOGY most common bacterial pathogens: .Group A Streptococcus Branhamella catarrhalis Staphylococcus aureu .gram-negative enteric bacteria .Streptococcus pneumonia (35%) .
pressure Obstructed tuba influx bacteria Infection AOM (Bailey.2006) .PATHOPHYSIOLOGY Tuba dysfuction air resorbtion negatif.
Clinical Features - - Occlusion tube stage Performing tympanic membrane retraction due to negative pressure inside the middle ear due to air. . Sometimes the color of tympanic membrane normal or pale.
The perform Clinical Features Hyperemia stage or presupuration stage Dilated vessels in the tympanic membrane The tympanic membrane is hyperemia and edema.•Hyperemia stage or presupuration stage Hyperemia stage is characterized with dilated vessels in the tympanic membrane or the tympanic membrane is hyperemia and edema. The performing discharge may be serous so that difficult to assess. - - - .
OVERVIEW - - - Supuration stage All symptoms become more severe. The drum now starts bulging and convex. . The exudates exerts pressure on one spot of the ear drum. may be the point of perforation later and the point appears like yellow nipple.
usually in the anteroinferior quadrant with pulsatile discharge. - . pus starts flowing out.discharge can range from mucoid to frankly purulent. Pain and constitutional symptoms lessen with the escape of ear discharge.OVERVIEW - Perforation stage The drum perforates . Otorrhoea . Examination: ear drum reveals a small perforation.may be initially blood-stained.
In good immunity system .If perforation happens. resulotion will be performed eventhough without any medical treatment . the discharge will decrease and finally become dry. .OVERVIEW Resolution stage .If the tympanic membrane is still intact gradually back to normal condition.
fever) and physical examination will lead to the accurate diagnosis of acute otitis media The ultimate diagnostic test to confirm the presence of AOM involves aspiration of middle ear contents .OVERVIEW DIAGNOSIS Careful history (fulfilled/fullness ear.otalgia.
OVERVIEW - - - - TREATMENT Watchful waiting without antibiotic therapy healthy 2-year-olds or older children with nonsevere illness Antibiotic therapy First line therapy: Amoxicillin 80mg-90mg/kg/24 hours in three divided doses . Myringotomy . for 10 days The adjunctive therapy include analgesics and antipyretics.
CASE REPORT .
Both external auditory canals were within normal limit. Tympanic membranes were pale and retraction. Rhinoscopy anterior examination : hyperemia conchae & discharge serous-mucous Rhinoscopy posterior examination : within normal limit Orofarings examination : within normal limit Indirect laringoscopy examination : within normal limit . Otorhinolarygology examination: Otoscopy examination : the both auricles were within normal limit.
DIAGNOSIS acute otitis media in tube occlusion stage .
PROBLEM Recurrency .
. Planning Control again after 3 days of treatment to evaluate the disease.
. Tympanic membranes were not retraction anymore Plan : continued the treatment and educated the parents to come back to the doctor if the symptoms were more severe. Follow up Patient came after 3 days treatment Complaint: the fulfilled ears was getting relieved Phisycal examination : Otoscopy examination : Both external auditory canals are within normal limit.
DISCUSSION Patient is diagnosed as acute otits media based on the anamnesis and physical examination Based on the symptoms and signs this patient comes in tube occlusion stage Sautter and Hirose: otitis media may be associated with several inciting factors. most commonly upper respiratory tract infection and Eustachian tube dysfunction .
DISCUSSION Acute otitis media is usually characterized by rapid onset of otalgia and erythema of the tympanic membrane. otalgia and fever are more evident in younger children and maybe absent in older children using pneumatic otoscopy alone has been shown to have 85% sensitivity and 75% specificity in the diagnosis of otitis media .
If signs and symptoms of AOM persist in spite of systemic analgesics after 48 to 72 hours. treat with antibiotics .DISCUSSION According to Guidelines & Protocols Advisory Commitee : If older than 24 months. most cases of AOM resolve with systemic analgesics alone and do not require antibiotics.
middle.DISCUSSION Lalwani AK: There is no role for oral decongestants or antihistamines in the treatment of Acute Otitis Media Bhargava: systemic decongestan like phenylephrine hydrochloride or pseudoephedrine decongest the mastoid. ear cavity. and the Eustachian tube along with nasal cavity .
patient comes and shows better condition than before but we still plan to continue the observation .DISCUSSION After 3 days treatment.
7 years old and is diagnosed as acute otitis media in tube occlusion stage. girl. also education. the patient comes and shows better conditions than before getting any treatments . paracetamol syrup 3x2cth. The initial treatment of this patient is by giving pseudoefedrine 3x30 mg. After 3 days treatment. observation of the disease.CONCLUSION Have been reported a patient.
UMHS Otitis Media Guideline, May, 2002
Low Risk Factors: Exposure to group day care with subsequent increase in respiratory infections. Exposure to environmental smoke or other respiratory irritants and allergens that interfere with Eustachian tube function. Lack of breast feeding & Supine feeding position
Gastro-esophageal reflux. Immune deficiency. . 2002 High Risk Factors Craniofacial abnormalities. May.UMHS Otitis Media Guideline.
Clasification Acute stage is the short (less than 3 months) and rapid onset of signs and symptoms of middle ear disease. 2002 . 2001 : Rolland. Chronic stage is middle ear disease for 3 months or more (Bailey.1996 : Djaafar. 2006) > 3 months > 2 months > 6 weeks : Ballanger.
bulging.SIGN and SYMPTOM Common signs and symptoms Fever Otalgia Otorhea Fullness in the ear Irritability Crying/shouting (child) Eardrum : light reflect (-).hyperemia. 2006) . perforation Less common signs and symptoms Tinnitus Vertigo Facial paralysis Swelling behind the ear (Bailey.
Bluestone CD. pneumoniae H. influenzae Amoxicillin Amoxicillin (80-100 mg/kg/d) Amoxicillin/ Clavulanate +++ ++++ +++ +++ +++ ++++ . Klein JO Otitis Media in Infants and Children 1995 S.
pnuemoniae H. influenzae Cefaclor ++ +++ Cefixime ++ ++++ Cefuroxime ++++ ++++ Cefprozil ++++ +++ Ceftibuten ++ ++++ Ceftriaxone ++++ ++++ Cefpodoxime ++++ ++++ Loracarbef +++ ++++ . Klein JO Otitis Media in Infants and Children 1995 S.Bluestone CD.
Stadium Oklusi Tuba Radang mukosa hidung/nasofaring berlanjut ke tuba eustachii mukosa udem lumen tuba sempit fungsi (ventilasi dan drainage) terganggu O2 menurun tekanan udara menurun perubahan mukosa kavum timpani. sehingga : Perubahan permeabilitas vasa darah dan limfe Peningkatan permeabilitas membran sel Proliferasi sel kelenjar Terjadi transudasi hydrops ex vacuo .1.
antipiretik. fullness. nasal decongestan.2. otalgia. Stadium hiperemis (Presupurasi) Anamnesis : demam. antiinflamasi . analgetik.tympani Obat: antibiotik. pendengaran berkurang Otoskopi : membran timpani kemerahan/hiperemi Terapi: pada stadium ini bertujuan untuk memperlancar fungsi tuba (dengan mukolitik) dan menghindari perforasi m.
Stadium Supurasi Adanya perubahan mukosa cavum timpani pertahanan mukosa setempat menurun kuman hidung/nasofaring penetrasi ke cavum timpani pembentukan eksudat purulen tekanan cavum meninggi bulging .3.
3. Stadium Supurasi Adanya perubahan mukosa cavum timpani pertahanan mukosa setempat menurun kuman hidung/nasofaring penetrasi ke cavum timpani pembentukan eksudat purulen tekanan cavum meninggi bulging .
4. Stadium perforasi Tekanan tinggi cavum timpani iskemia nekrosis mukosa dan submukosa perforasi .
5. terjadi resolusi pada perforasi membran timpani . Stadium Resolusi Pada stadium ini proses penyakit menyembuh Oedem mukosa berkurang. sekret berkurang/mengering Membrana tympani kembali normal. fungsi tuba membaik.
trauma pada fenestra rotundum.1990) Tindakan insisi pada pars tensa membran tympani pada kuadran posterior-inferior agar tejadi drainase sekret dari telinga tengah ke liang telinga luar Dapat menimbulkan komplikasi berupa perdarahan akibat trauma liang telinga luar. trauma nervus facialis .MIRINGOTOMI (Efiaty. dislokasi tulang pendengaran.
AOM with acute complications (mastoiditis. Patient is in neonatal periode 5.VII. AOM with severe otalgia 3. Child with low immune system 6.Indication 1. paresis n. Culture . fever still (+) even antibiotic had been given 4. meningitis) 2. Recurrent ear-ache or steady earache.
m.pasif beda tekanan kavum tympani dengan nasofaring (reflektoris) 20-40 mmHg .aktif konstraksi m. tensor veli palatini . tensor tympani .m. levator veli palatini . salpingopharyngeus .Otot sistem tuba eustachius . tensor veli palatini dilatator Mekanisme pembukaan tuba : .4 otot : . .tensor velli palatini .m.m. menelan dan menguap -M.ET tertutup saat istirahat terbuka saat mengunyah.
Acute Otitis Media Clinical Guideline from the American Academy of Pediatrics and American Academy of Family Physicians 2004) .
The drug also has been used for self-medication in the symptomatic prevention of otitic barotrauma The usual dosage of pseudoephedrine hydrochloride for adults and children 12 years of age or older is 60 mg every 4–6 hours with a maximum of 240 mg daily.PSEUDOEPHEDRINE Pseudoephedrine is a sympathomimetic agent that occurs naturally in plants of the genus Ephedra. Pseudoephedrine is used as a nasal decongestant for self-medication for the temporary relief of nasal congestion associated with upper respiratory allergy and to provide temporary relief of sinus congestion and pressure. some pediatricians recommend 4 mg/kg or 125 mg/m2 daily.4 divided doses. Adapted from: drugs info at www.and. β-adrenergic receptors.emedicine-medscape.com . Alternatively. the drug acts directly on both α. to a lesser degree. given in 3.
Sympathomimetic effects of pseudoephedrine presumably also may occur in other areas of the respiratory tract.PSEUDOEPHEDRINE Pseudoephedrine acts directly on α-adrenergic receptors in the mucosa of the respiratory tract producing vasoconstriction that results in shrinkage of swollen nasal mucous membranes. including the eustachian tube. edema. and nasal congestion.. and an increase in nasal airway patency. these effects may improve or maintain eustachian tube patency and allow equilibration of middle ear pressure during external atmospheric pressure changes (e.emedicine-medscape. Adapted from: drugs info at www. hyperbaric oxygenation).com . drainage of sinus secretions is increased. during descent of an aircraft. reduction of tissue hyperemia. underwater diving.g.
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