Pemicu 3

“Mengapa telinga ini sakit?”

Adrian Pratama - 405100018
LO 2
 Menjelaskan kelainan telinga luar
Perichondritis of the external ear
  infection / inflammation involving the perichondrium of
the external ear (auricle & external auditory canal)

 Classification
 Erysipelas (infection of the overlying skin) of external ear
 Cellulitis (infection of the soft tissue) of external ear
 Perichondritis
 Chondritis

 Etiology
 Thin skin  happens secondary to trauma
 P. Aeruginosa (75-90%), S. Aureus (50%)
 Gram (-) (Proteus & E. coli); Streptococcus
Scott Brown’s otorhinolaryngology 7th
 Pathology  Diagnosis
 Hyperplasia of dermal  Presentations
layers  Dull pain increasing in
 Thickened subcutaneous severeity
tissue  Inflammation involving the
cartilaginous pinna
 Intense infiltration with  The lobule is spared (no
PMN
cartilage)
 Thickening of the  Background history of
perichondrium underlying trauma should
 Destruction of the cartilage be sought
by phagocytes
 DD
 Relapsing polychondritis
  involvement of cartilages
at multiple sites, possibly
occular condition, vasculitis
 Extranodal non-Hodgkin’s
lymphoma
 Outcomes
 Untreated 
subperichondrial abscess 
avascular necrosis of
underlying cartilage 
marked deformity of pinna
 Fatal septicaemia
(streptococcal infection)
 Subacute bacterial
endocarditis
 Necrotizing fasciitis of the
neck
 Managements
 Prevention
 Careful placement of ear piercing away from the cartilaginous pinna
 Surgery & in around the ear should avoid trauma to the cartilage
 Hematomas of the auricles should be drained promptly + aseptic
 Meticulous management of burn injuries should include prophylactic
antibiotics against gram (-) bacteria + removal of crusts
 First-line management
 Topical & oral antibiotics
 Discharge / abscess  draining + culture & sensitivity
 Pending the result  broad spectrum antibiotics; high dose; IV
 Resistant cases
 Aggressive excision of necrosed cartilage + skin & subcutaneous
tissue
 Continuous drainage & irrigation with antibiotics + steroid solution
 Other forms
 Ionthophoresis (effective local antibiotic delivery without systemic
absorption
 Low-dose radiation
 UV radiation
Foreign bodies in the ear
 Most common  cotton wool, insects, beads, paper, small
toys & erasers
 72%  failed attempts by nonspecialists consist of firm,
rounded objects

 Clinical picture
 Children may present asymptomatically / with pain or discharge
caused by otitis externa
 Adult are often seen with cotton wool / broken matchsticks
 Live insects (ex. Small cockroaches)  loud noise &
movement
 Management
 Nature of the foreign bodies
 Living insects
 be killed first by instilling oil into the meatus into drown before removal
 Irregular/soft graspable non-living objects
 pair of crocodile forceps
 Organic objects: may absorb water, swell & pain
 should NOT be syringed
 Button batteries
 Should NOT be syringed  remove urgently
 Inorganic round/smooth non-graspable
 Syringing is safe, often successful, but may fail with tightly impacted
foreign bodies
 Location of the foreign bodies
 Easier access, wider diameter, elastic nature, lesser sensitivity 
easier removal
 Space between the foreign body & the canal  allows access for
water / instrument through for removal
 Firmly impacted of the foreign bodies medial to the isthmus / failed
removal attempts  trauma, swelling  surgical removal
 Patient considerations
 Pay attention to younger, uncooperative children
 Watch for pain & trauma when the removal procedure
 Complication
 Introducing the foreign bodies  laceration of the canal skin &
otitis externa
 Facial nerve palsy (leakage of alkaline from button batteries)
 Damage & perforation of tympanic membrane
 Ossicular chain dislocation/fracture
Otitis externa
  generalized condition of the skin of the external auditory canal
that is characterized by general oedema & erythema associated with
itchy & discomfort & usually an ear discharge

 Classification
 Anatomical
  narrow meatus & obstruction of meatus
 Dermatological
  echzema, seborrhoic dermatitis
 Allergic
  atopy, non-atopic allergy, topical medication
 Traumatic
  skin maceration (bathing), ear probing, laceration
 Microbiological
  active chronic otitis media, P. Aeruginosa, fungi
 Epidemiology
 0.4% / year; 10% of population

 Etiology
 Secondary bacterial infection
 Pseudomonas sp (50-65%); gram (-) (25-35%); S. Aureus (15-30%);
Streptococci (9-15%)
 Bathing
 The presence of bacteria in bathing water doesn’t seem to be a risk factor,
although bathing in freshwater lakes contain Pseudomonas  large
outbreak in Netherlands
 Irritant/allergic reactions
 Topical medications (benzalkonium chloride & steroids); neomycin
 Pathology
 Pre-inflammatory
 Protective acid balance (pH 4-5) is lost  stratum corneum become
oedematous  blocking off the sebaceous & apocrine glands  aural
fullness & itching
 Further oedema & sctratching  disruption of epithelial layer 
invasion of resident/introduced organisms
 Acute inflammatory
 Progressive thickening exudate, further oedema, obliteration of the
lumen, pain >>
 Auricular change & cervical lymphadenopathy (severe)
 Chronic inflammatory
 Remain of low pH + > 3 weeks  thickening of external canal &
fibrous canal stenosis (acquired atresia of the external ear)
 Diagnosis (signs &  Complications
symptoms)  Perichondritis
 Pain, itch, oedema,  Chondritis
erythema of the external  Cellulitis
auditory canal  Parotitis
 With purulent otorrhoea &  Erysipelas
debris in meatus
 Managements
 Aural toilet
 With/-out microscopic assistance
 Topical medication
 Glycerol & ichthammol (90:10%) with aural wick (moderate & severe)
 Dehydrating effects  < pain, oedema
 NSAID (if not contraindicated)
 Combination drop of neomycin, polymyxin-B, hydrocortisone
 AE  filmy debris (mistaken for fungal overgrowth
 Neomycin & gentamycin  Staphyllocooccus
 Polymyxin-B  Pseudomonas & Staphyllococcus
 Quinolone (for no known risk of ototoxicity & it is sensitive to Pseudomonas)
 Systemic antibiotics
 American Academy of otolaryngology  no evidence
 Prevention of reccurence
 Avoidance of water penetration
 Cotton wool + petroleum jelly in bath / shower
 Alcohol / proprietary preparations (aqua-ear/ear-calm) after swimming
 Blow driers (not on hot setting)  remove moisture
 Reccurent otitis externa with ear-mould hearing aid patient  bone-
anchored hearing aid
LO 3
 Menjelaskan kelainan telinga tengah
Bullous myringitis
 ~ myringitis bullosa haemorrhagica
 the findings of vesicles in the superficial layer of the tympanic
membranes
 Epidemiology
 Children, adolescents, young adults
 4% of 2028 children aged 7-24 mo

 Pathology
 Vesicles occur between the outer epithelium & the lamina propria of the
tympanic membrane

 Etiology
 Culture  similar to that in acute otitis media
 Influenza virus / Mycoplasma pneumoniae (suggested)
Scott Brown’s otorhinolaryngology 7th
 Symptoms
 Sudden onset of severe,
usually unilateral, often
throbbing pain in the ear
 Usually set in during /
following an upper
respiratory tract infection
 Bloodstained discharge
(couple of hours)
 Hearing impairment
 Signs
 Otoscopy
 Blood filled, serous blisters
in tympanic membrane
 Intact tympanic membrane
 Middle ear fluid (97%)
 Hearing impairment
 Other examination  DD
 Inspection of ear using  Acute otitis media
microscope  Herpes zoster oticus
 Pneumatic otoscopy &  Ramsay hunt sydnrome
tympanometry
  determine fluid in middle
ear
 Clinical evaluation of
cranial nerves (facial nerve)
 Pure tone audiogram
 Outcomes
 Complete recovery
(majority)
 Hearing impairment
 Sensorineural hearing
impairment (15-67%)
 Managements
 Without middle ear
affection & sensorineural
hearing loss  analgesic
 Middle ear affected 
acute otitis media’s
treatment
 Children < 2yo  acute
otitis media’s treatment
 Antibiotics
 Amoxicillin (60-100%
recovered)
Acute otitis media in children
 ~ acute suppurative otitis media
  inflammation of the middle ear cleft of rapid onset & infective
origin, associated with a middle ear effusion

 Subgroups
 Sporadic episodes
  infrequent isolated events; occurring with respiratory tract infection
 Resistant AOM
  persistence of symptoms & signs of middle ear infection beyond 3-5 days of
antibiotic treatment
 Persistent AOM
  persistence / recurrence of symptoms & signs of AOM > 6 days of finishing a
course of antibiotics
 Reccurent AOM
  >=3 episodes of AOM in 6 mo period/4-6 episodes in 12 mo
 Risk factors  Epidemiology
 Genetic factors  Commonest illness of
 Family members
childhood
 Maternal blood group A
 Atopy
 Highest incidence  first
 Immune factors year of life
 IgG2 deficiency
 Defective component-dependent
opsozination
 Aberrant expression of certain
cytokines
 Environmental factors
 Poor socioeconomic status
 Syndromic association
 Turner syndrome, down syndrome,
cleft palate
 Diagnosis
 Combination of often
nonspecific symptoms
 Evidence of inflammation of
the middle ear cleft
 Additional information of
middle ear effusion
 may well not be a clear
history of a crescendo of
otalgia in a coryzal child 
rapid symptomatic relief
associated with tympanic
membrane perforation
 Symptoms
 Apyrexial (2/3)
 Rapid onset of
 Otalgia, hearing loss, fever
 Otorrhoea (blood stained)
 Excessive crying, irritability
 Coryzal symptoms
 Vomiting, poor feeding
 Ear-pulling, clumsiness
 Commonly develop 3-4
days after coryzal
symptoms
 Signs
 Appear unwell, rubbing ear
 Otoscopic exam 
 Opaque tympanic membrane,
 Most commonly yellowish
pink, red in only 18-19%
 Bulging
 Hypomobility of the drum
 Perforated drum /
ventilation tube in situ 
mucopurulent ottorhoea
 Investigations
 DD
 Tympanometry  middle ear
effusion
 Tympanocentesis & culture
 Nasopharyngeal swabbing for
bacterial culture
 Iron deficiency anemia & white
blood cells disorder associated
with AOM
 Immunoglobulin assay
 Reccurrent infection of
ventilation tube  investigation
for primary ciliary dyskinesia
 Especially if nasal & pulmonary
symptoms coexist
 Pain  tonsilitis, teething,
temporomandibular joint disorder,
uncomplicated upper respiratory
tract infection
 Red tympanic membrane 
screaming child
 acute mastoiditis
 otitis media with effusion
 otitis extema
 trauma
 Ramsay hunt syndrome
 bullous myringitis
 first indication of serious
underlying disease
 Wegener's granulomatosis or
leukaemia
 Etiology
 Infective agents
 Viruses
 RSV, influenza A virus,
parainfluenza virus, human
rhinovirus, adenovirus
 Bacteria
 H. Infulenza 16-37%
 M. Catarrhalis 11-23%
 S. Pyogenes 13%
 S. Aureus 5%
 Routes of infections
 Eustachian tube
 negative middle ear pressure
 movement of bacteria up
the tube
 shorter, straighter and more
patulous tube
 Tympanic membrane
perforations / grommets
 Associated with water
exposure
 Haematogenous
 Managements
 Conservative
 Simple analgesic & anti-pyrexials (paracetamol & ibuprofen)
 Medical
 Antibiotics (after 2-3 days of watchful waiting  fail to improve)
 Amoxicillin (1st ) 80mg/kg/day
 Macrolide  penicillin-sensitive & drug-resistant pneumococci
 Amoxicillin-clavulonate / cefuroxime
 Ceftriaxone IM
 Antihistamines & decongestants
 Surgery
 Myringotomy
 Severe case (present of complication) & relieve pain / when microbiology is
strongly required
 Management of recurrent acute otitis media
 Alteration of risk factors
 Sitting a child semi-upright if bottle fed, avoiding passive smoke
inhalation
 Restricting use of pacifiers after infancy for otitis prone children
 Continue breastfeeding at least 6 mo + vitamin C & NO alcohol
 Medical prophylaxis
 Antibiotics, xylitol, vaccination (virus & bacterial), immunoglobulins,
benign commensals (alpha streptococci)
 Surgical prophylaxis
 Ventilation tube
 Adenoidectomy & adenotonsillectomy
 Complication
 Intracranial
 Meningitis
 Extradural abscess
 Subdural empyema
 Sigmoid sinus thrombosis
 Focal otitic encephalitis (cerebritis)
 Brain abscess
 Otitic hydrocephalus
 Extracranial
 Tympanic membrane
 Acute mastoiditis
 Petrositis
 Facial nerve palsy
 labyrinthitis
Mastoiditis
  inflammation with the mastoid air-cell system
 Extension of infection & inflammation during acute otitis media
 Traditional teaching  preceed by 10-14 days of middle ear symptoms

 Etiology
 20% dont grow bacteria
 S. Pneumoniae, S. Pyogenes, P. Aeruginosa, S. Aureus (common)
 H. Influenza (< common); M. Catarrhalis, P. Mirabilis (rare)

 Epidemiology
 Disease of childhood
 28 % < 1yo; 38%  4yo; 8%  8-18yo; 4%  > 18 yo
 US  1..2 – 2% per 100,000
 Symptoms  Signs
 Systemic signs of infection  Red/buldging tympanic
(fever & malaise) memb
 Mastoid tenderness &  Retro-auricular swelling
localized reactive  Tenderness is typically sited
lymphadenopathy over MacEwen’s triangle
 In children  On palpation through
 Erythema &/ edema of conchal bowl)
everlying mastoid soft tissue  Pinna protrusion
 Otalgia & irritability  Sagging of post wall of ext
 In adult auditory canal
 Local pain & tenderness
 Otorrhea (30%)
 Clinical course
 Infection may spread to mastoid periost via emissary veins 
acute mastoiditis & periostitis  no abscess; symptoms (+)
 Destruction of mastoid bone’s air cells 
 Subperiosteal abscess (post auricular region)
 Zygomatic abscess (above & in front of pinna)
 Bezold’s abscess
 Retropharyngeal / parapharyngeal abscess
 Pus tracking down peritubal cells
 Subacute (masked) mastoiditis in incompletely treated AOM
after 10-14 days of infection
 Sign (-); otalgia & fever persist  serious complication
 Examination  DD
 Full blood count, CRP,  AOM
blood culture  Otitis externa
 CT scan of mastoid  Furunculosis
 Reveal osteitis, abscesses,  Reactive lymphadenopathy
intracranial complications
 Undiagnosed cholesteatoma
 Wegener’s granulomatosis

 Complications
 Intracranial complications
(6-17%)
 Treatment
 Modern antimicrobials + radiographic monitoring
 Early performance of myringotomy
 Mastoid surgery (mastoidectomy)
 Indication  failure of improvement despite aggressive medical
management, development of other intracranial complications
 Goal of surgery  drainage of mastoid, removal of granulation tissue,
restoration of normal ventilatory pathways
 + continuation of antibiotic theraoy postoperatively for weeks

Bellanger's otorhinolaryngology 17th

 Treatment
 Myringotomy with/-out ventilation tube placement
 Culture of aspirate & high-dose IV antibiotics
 Abscess drainage with/-out cortical mastiodectomy
 If failure to improve, subperiosteal abscess formation, complication
developments

Scott-Brown’s otorhinolaryingology, head &

neck surgery
Bezold’s abscess
  abscess that result from perforation of the medial mastoid cortex
 tracking down the sternomastoid to the posterior triangle

 Epidemiology
 predominantly in adults (13 of 15, 87%) who were male (12 of 15, 80%

 Etiology
 complicated by
 a suboccipital epidural abscess, hearing deficit, and thromboses of the sigmoid and
transverse sinuses, mastoiditis
 gram-positive aerobes
(Streptococcus species, Staphylococcusspecies, Enterococcus),
 gram-negative aerobes (Klebsiella, Pseudomonas, Proteus),
 anaerobes (Peptostreptococcus and Fusobacterium species)
Medscape.com
 Pathophysiology
 lateral aspect of the mastoid process is composed of thicker bone
than that of the medial wall
 insertion point for the digastric, sternocleidomastoid, splenius capitis, and
longissimus capitis muscles
 Thicker lateral mastoid process & confluence of the neck muscles 
strong barrier against pus laterally  pus in the mastoid erodes
through the area of least resistance, the mastoid tip, which is inferior
and media
 abscesses are formed deep in the neck musculature
 evade early detection
 Larger abscess  disease in the suprascapular, suprasternal,
parapharyngeal, paralaryngeal, and even contralateral axilla/ neck
 Extension to vertebrae or base of the skull  death
 Symptoms  Diagnosis
 neck pain,  Plain films of the mastoid 
 opacification of the mastoid air
 neck mass,
cells
 post auricular pain,  contrast-enhanced CT
 otalgia, imaging of the temporal bone
 otorrhea, and neck provides the most
useful information
 CT scan of the chest 
 Less common  suspicion of deeper thoracic/
 fever, headache, hearing loss, vertebral abscess spread
facial paralysis, or cervical  MRI & magnetic resonance
lymphadenopathy angio gram of the head
 brain involvement is present
 Treatment
 antibiotics directed at the causative organisms + mastoidectomy

 Complications
 Hearing loss