TATALAKSANA BEDAH

TERKINI PADA KASUS

OMSK
Aplikasi Anatomi, Fisiologi, Audiologi dan Pencitraan pada pilihan tatalaksana bedah
OMSK

FIKRI MIRZA PUTRANTO

FK UIN SYARIEF HIDAYATULLAH JAKARTA
 PENDAHULUAN
• Perkembangan penelitian pada telinga tengah melahirkan pemahaman baru dan
pendekatan baru pada tatalaksana OMSK

• Pemahaman anatomi dan fisiologi telinga tengah :

• Peran regulasi tekanan

• Amplifikasi vs gambaran audiologi

• Pencitraan dengan CT Scan resolusi tinggi

• Area tersembunyi di telinga tengah —> rekurensi infeksi

• Perkembangan teknik operasi dan instrumen —> endoscopic ear surgery

• Bagaimana menggunakan berbagai perkembangan diatas untuk memilih

tatalaksana yang paling efektif dan efisien yang di tujukan pada tiap
karakteristik pasien
 FISIOLOGI
TELINGA TENGAH
 FISIOLOGI TELINGA TENGAH DAN MASTOID
Morphofunctional partition of the middle ear cleft 7
AKTIF DAN GRADUAL —>
PERTUKARAN GAS OLEH MUKOSA
DI EPITIMPANUM DAN ANTRUM
MASTOID (KOMPARTEMEN
POSTEROSUPERIOR)

Fig. 2. Epithelium of the mucosa of the middle ear cleft. The two types of epithelium vary by
site. a: The antero-inferior compartment of the middle ear cleft has a pseudostratified epitheli-
al layer with numerous mucous and ciliated cells. The connective tissue is thick and relatively
dense. b: The postero-superior compartment has a monocellular epithelial layer composed of
only flat cells; there are no ciliated or mucous cells. The connective tissue is loose. The blood

PASIF DAN INTERMITTEN —>

vessel centers are considered the middle point of the longest axis of the vessels. In this study,
the measurements were based on the distance between the blood vessels’ center and the basal
membrane that is perpendicular to the long axis of the cross-sectioned vessel.
MEMBUKA / TUTUP TUBA
opening of small superficial submucosal vessels. In any case, this reduction in
EUSTACHIUS
distance OLEH M TENSOR
enables increased gas diffusion.

VELI
Clinical PALATINI
approach

Tympanosclerosis usually occurs in the antero-inferior part of the eardrum.

Tympanic membrane retraction pockets are more often located in the postero-
superior part of the tympanic membrane.

• Untuk dapat bekerja dengan efektif tekanan udara di telinga

book_Ars2008.indb 7 25-6-2008 13:59:31

tengah harus sedikit lebih negatif dari tekanan atmosfer

 Factors playing a role in middle ear ventilation

Eustachian
tube

Middle ear Transmucosal

Mastoid
pressure, gas exchange
buffer
homeostatic

Malleus handle
Acquired folds or other medialization
inflammatory tissue Middle ear
ventilation
route blockage
Bony limits
Congenital fold
(e.g epitympanum dimension)
 HISTOLOGI TELINGA TENGAH
KOMPARTEMEN ANTEROINFERIOR VS POS TEROSUPERIOR

Mukosa respiratori —>

gas exchange

P*V=C

SEMAKIN BESAR KOMPARTEMEN Mukosa silia —> proteksi

POSTERIOR SEMAKIN BERAT
EFEK PERUBAHAN TEKANAN
PADA KOMPARTEMEN ANTERIOR
 MIDDLE EAR
MICROVASCULARISATION
Normal
Ventilation Route

Ventilasi normal dimulai dari masuknya udara melalui daerah pro timpanum
menuju isthmus anterior dan posterior ke arah epitimpanum untuk mencapai
mukosa respiratori
 HIDDEN AREA

Retrotimpanum

Protimpanum
Middle ear mechanics
Amplify sound
Different size of TM vs
stapes footplate
Different length of malleus
vs incus
Deliver sound from ear canal
to cochlea
System integrity
Pathology in chronic
otitis media
Timpanic membrane Myringoplasty
perforation

Ossicular fixation due to

tympanosclerosis or Middle ear and
hypertrophic mucosa ossicular
management
Ossicular discontinuity
Tympanic membrane
perforation
Patient without ossicular pathology

Size of tympanic membrane perforation is strongly

correlated with air bone gap in low frequency (< 2 KHz)

Mean air conduction in 500 Hz and 1 KHz < 60 dB

Perforation > 40 % and posterior perforation

deteriorates hearing more than anterior and central
perforation —> disruption in accoustic coupling
 described in detail the epitympanic diaphragm, which sepa-
rates the large epitympanic compartments from the Prussak
space and from the mesotympanum15 (Fig. 1.10). It consists,
in the direction anterior to posterior, of the tensor fold, the
anterior and lateral malleal ligamental folds (the latter forms
PATOLOGI TULANG PENDENGARAN AKIBAT OMSK
the roof of the Prussak space), the lateral incudomalleal fold,
and the posterior incudal folds. The tensor fold and the lat-
eral incudomalleal folds are thin duplicate folds, arising from
a fusion of two advancing, opposing air sacs. The ligamental
folds arise when the air sacs with the advancing epithelium,
deriving from the eustachian tube, passes the preexisting
• OMSK dengan kolesteatoma
umumnya berkembang di
atik atau mesotimpanum —
> destruksi oleh
kolesteatoma —> inkus,
maleus, stapes
OMSK tanpa kolesteatoma
• Fig. 1.12 Cholesteatoma that begins from the pars
—> jaringan granulasi di
telinga tengah
• Kekakuan gerak
• Hipoksi —> nekrosis
attic and to the superior mesotympanum. Extension superi-
orly can occur via a membrane defect or through the nonliga-
mental weak portion of the roof of the Prussak space, leading
to the lateral malleal space; from there the routes are open
to all compartments of the epitympanum. Cholesteatoma
municate with the antrum through the aditus.
The elegant publications of Palva’s group15,16 provide a
clear explanation of the potential paths of the spread of cho-
lesteatoma. Attic cholesteatoma that begins as a papillary
ingrowth from the pars flaccida into the Prussak space will
remain confined to this space if discovered early. Further ex-
tension occurs regularly via the posterior pouch, along the
medial wall of the tympanic membrane into the superior
mesotympanum (Fig. 1.11). Due to the relatively frequent
membrane defects in the posterior malleal ligamental fold
(36%) extension may also occur directly to the lower lateral
Fig. 1.11 Attic cholesteatomas that begin in
the pars flaccida (short orange arrow) will remain
confined to the Prussak space if discovered early. These
cholesteatomas can enlarge into the posterior epitym-
panic space, via the posterior pouch (red arrow), or
along the medial wall of the tympanic membrane into
the superior mesotympanum (green arrow). Extension
may also occur superiorly via a membrane defect (long
orange arrow) or through the nonligamental weak por-
tion of the roof of the Prussak space (yellow arrow), lead-
ing to the lateral malleal space; from there the routes
are open to all compartments of the epitympanum.
1 General Considerations in Cholesteatoma 7
tensa can extend into the lower lateral attic, and via
the tympanic isthmus, to all superior compartments
of the epitympanum.
These pathways of spread give rise to the patterns of
growth of cholesteatoma that are encountered at surgery
and have been classified as follows by Fraysse and others
(Fig. 1.14A–E):
Ossicular chain discontinuity
Ossicular chain discontinuity may be
resulted from bone resorption caused
by chronic inflammation and
cholesteatoma.

Cholesteatoma and CSOM with

granulation tissue —> consider for
ossicular damage

Discontinuity : complete and

incomplete

Most common site incudostapedial

joint
 PATOGENESIS MASTOID
KONGENITAL VS AKUISITAL

• Tulang mastoid saat lahir hanya terdiri atas antrum

• Pada perkembangannya osteoblast yang membelah akan berubah

menjadi osteoklas —> membentuk sel - sel mastoid

• 2 teori gangguan pneumatisasi :

• Infeksi berulang : mekanisme pertahanan tubuh melokalisir

peradangan, osteoblas tidak berubah menjadi osteoklas

• Lokasi dura dan sinus sigmoid normal

• Kelainan genetik : sel mastoid tidak terbentuk sempurna

• Lokasi dura dan sinus sigmoid tertarik ke inferior dan anterior

 MASTOIDECTOMY ?
• Non cholesteatoma :

• RCT Ramakrishnan (2011) : tidak ada perbedaan perbaikan

pendengaran dan rekurensi mastoidektomi vs trans kanal anterior
attikotomi

• Systematic review, Trinidade (2016); mastoidectomy bermanfaat pada

OMSK yang basah

• Cohort, Dundar (2015), mastoidektomi tidak membedakan hasil

operasi pada pasien dengan mastoid sklerotik

• Cholesteatoma :

• Limited : anterior atticotomy

• Luas : CWD + obliterasi + kanaloplasti —> self cleansing cavity

ENDOSCOPIC
EAR SURGERY
 EES VS MES

Microscope Endoscope
 Terminology
Endoscopic Ear Surgery (EES)

Use of the endoscope for simultaneous visualisation

and dissection of outer ear, middle ear, and or mastoid

The endoscope is in one hand, dissection instruments

in the other hand

Transcanal, transmeatal, transmastoid, or transcranial

lateral skull base approach
 Terminology

Transcanal Endoscopic Ear Surgery (TEES)

Endosopic ear surgery techniques in which the

external auditory canal is used as the primary surgical
portal to access the tympanic membrane, middle ear,
inner ear or fundus of internal auditory canal.
 EQUIPMENTS
High Definition (HD) monitor

3 charge-couple device (3CCD) camera system

1 CCD : all red out !!

Light source : Xenon & LED are more recommended

No higher than 50% - heat injury

 ENDOSCOPE
Sinus

0, 30/45 degree, 4 mm in diameter, 18 cm long

0, 30/45 degree, 2.7 mm in diameter, 18 cm long

Ear

0, 30/45 degree, 3 mm in diameter, 15 cm long

3 mm in diameter
15 cm long
 Instruments
Standard Ear Microsurgery Set
 Curved Forceps Ear Curattes

EES dissectors Otologic drill

Instruments with suction system

Kasus lanjut
 SET UP OF EES
MONITOR/
MICROSCOPE ENDOSCOPIC
STAND BY CAMERA SYSTEM Drill
system ANESTHESIA

PATIENT

INSTRUMENT/ Suction
NURSE

SURGEON
 Cost analysis

• Komponen
• Barang habis pakai : + mata bor untuk mikroskop
• Sewa alat operasi (KSO)
• Sewa endoskop/mikroskop : 150 rb vs 600 rb
• Biaya pembiusan : lama operasi
• Lama rawat dan obat : 1 hari vs 2-3 hari post op
• Di luar sewa kamar operasi dan jasa medik operator
• Endoskopi : 50 - 60 % pagu BPJS kelas 3 (40 min - 2,5
jam)
• Mikroskop : 70 - >100 % pagu BPJS kelas 3 (maks 3 jam)
Upaya adaptasi di Klinis dengan evaluasi
era JKN mikroskop / endoskop:
- Aktif vs tenang
- Aman vs kolesteatoma

• Algoritma operasi Telinga Audiologi :

—> membagi pasien Ambang dengar < 50 dB
tindakan endoskopi vs Gap pada 2 KHz < 15 dB
mikroskopi
CT Scan :
• Mengadakan set Perluasan penyakit
pemeriksaan endoskopi
sederhana di poli klinik
BPJS —> meningkatkan Endoskopi Mikroskop
pemasukan
MEMILIH KASUS BEDAH
ENDOSKOPI TELINGA