Infeksi Telinga

Rizka Dany Afina

anatomi
• https://youtu.be/mptjEoHF2aI
• https://youtu.be/qYv9V2qna6I
• https://youtu.be/VRLm7cpmZSk
External Ear - Otitis externa, Malignant otitis
externaear – Acute otitis media, Chronic
Middle
suppurative otitis media
Inner ear – Labyrintitis, Vestibular neuronitis
Organis
m:
Viru
s
Bacteri
a
Funga
l
 Conductive hearing loss
• https://youtu.be/QE1AyH-uq9s
Otitis externa
Disease of
external ear
Otitis Externa

• Otitis Externa (OE) is refered to a spectrum of external

ear inflammation, which may also involve the pinna or
external ear canal.
Otitis Externa: Risk Factors
•Anatomic abnormalities o Dermatologic conditions
oCanal stenosis o Eczema
oExostoses o Psoriasis

oHairy ear canals

o Seborrhoea
o Other inflammatory dermatoses

•Canal obstruction o Water in ear canal

oCerumen obstruction o Humidity
oForeign body o Sweating
oSebaceous cyst o Swimming or other prolonged water
exposure

•Cerumen/epithelial integrity o Miscellaneous

oEarplugs o Purulent otorrhoea from otitis media
oHearing aids o Immunosuppression
oInstrumentation/itching o Stress
oTrauma
Etiolog
y:
• Bacteria(90 % of OE); pseudomonas aeruginosa,
pseudomonas vulgris, E.coli, S.aureus

Clinical
feature:
Acut
e:
• Pain aggrevated by movement of auricle (traction of
pinna or pressure over tragus
• Otorrhea (sticky yellow purulent
• discharge)
Conductive hearing loss +/- aural fullness secondary
to obstruction of ear canal by swelling and purulent
debris
• Post auricular
• lymphadenopathy
Pinna and/or periauricular soft tissue
erythematous and swollen
Chron
ic
• Pruritus of external ear +/- excoration
of ear canal
• Atrophic and scaly epidermal lining +/-
•otorrhea+/- hearing
No pain with loss of
movement
auricle
• Tympanic membrane appear
normal
Treatme
•nt:
Ear
toiletting
• Bacterial aetiology, send
for c+s
* antipseudomonal otic drop e.g gentamycin, ciprofloxacin
or combination of antibiotic and steroid (e.g Garasone or
* Cipro)
Do not use aminoglycoside if tympanic membrane (TM ) is
perforated - risk of ototoxicity
* Icthammol glycerine if external canal
edematous
* Sytemic antibiotic if either cervical lymphadenopathy
or cellulitis present
Otomycosis

Etiolog
y:
Candida albicans,
Aspergillus niger
Clinical
features :
•Malodorous
discharge
•Inflammat
ion
•Prurit
us
•Scali
ng
•Severe discomfort , suppuration can occur due to
superimposed bacterial infection commonly due to
pseudomonas species and proteus species
Treatme
nt :
•Meticulous ear toileting to remove fungal
•debris and hyphae Anti fungal – cotrimazole
ear drop
 Malignant Otitis Externa
Definiti

on:
Severe infection due to Pseudomonas aeruginosa causing
osteomyelitis of the skull base
 Common in immunocompromised and
Life
elderly diabetics.
threatening.
Presentati
on:
• Severe
• pain
Involvement of the floor of the
• ear canal
Granulation
• tissue.
If untreated, it can involve the cranial
nervesnerve
• Facial and brain.
palsy occurs in 50% of patients, IX to XII may
also be involved.
Manageme
nt:
Medical
 Sugar
therapy
 Correction
control of
 immunosuppressive
Ciprofloxacin x state
6/52
Surgical
 Debridem
treatment
ent
Acute otitis media (AOM)
Disease of
middle ear
Definiti
on:
Acute inflammation of
middle ear
• https://youtu.be/TiSpjfuQxXM
Epidemiolo
gy:
• 60-70% of children have at least 1 episode of AOM
before 3 years old • 18 month to 6 years most common
age
• Onegroup
third have had >3 episodes
by age 3
Etiolo
gy
• VIRUSES : most episodes of AOM are preceded by
respiratory tract infection of viral origin
•
Rhinoviru
• Respiratory
s
syncytial virus
•
BACTERIA
• Streptococcus
: •pneumoniae
Haemophilus(30%)
Influenza
(20%)
• Moraxella catarrhalis
(12%)
Predisposing
factors:
• Eustachian tube
dysfunction/obstruction :
 Swelling of tubal mucosa-URTI,allergic
rhinitis,chronic sinusitis
 Obstruction/inflitration of eustachian tube ostium-
tumor(NPC), adenoid hyperthropy (not due to
obstruction but by maintaining source of infection),
barotrauma (sudden change in air pressure)
 Inadequate tensor palati function-
cleft palate
 Abnormal eustachian tube: Downs
syndrome
Predisposing factors:

• Distruption
action of :
 cilia in Katagener’s
syndrome
Immunosuppression/deficiency due to
chemotherapy, steroids, diabetes mellitus
RISK
FA C T O R S
• Host
Age/
factors
Genetic
Gender
Cleft palate/Down
predisposition
Allergy/
syndrome
Immunity
• Environmental
Daycare/
factors
Bottle (versus breast)
Siblings
feeding
Smokin
Pacifier Use
Low socioeconomic
g
Upper
status respiratory
infections
Clinical
feature:
• Triad- otalgia, fever, conductive
•hearing loss
Rarely tinnitus, vertigo or facial
nerve palsyif if tympanic membrane
• Otorrhea
perforated
• Infant/toddler- ear tugging, hearing loss, vomiting,

diarrhea, anorexia Otoscopy of TM

•
•Hyperemi
Bulging, pus seen
a
behind
• Loss ofTM
landmark: handle and long process of
malleus not visible
 S TA G E OF
• HYPERAEMIA
Hyperemia of the
mucus membrane of the
tympanic cavity, the
mastoid air cells &
ET
• Infection of the ET
ET becomes occluded by
oedema & hyperaemia
changes in middle ear
mucocilliary transport &
pressure,
like substance in ET
surfactant-
retraction of TM
S TA G E OF
EXUDATION/supuration
• Prolonged tubal occlusion  invasion of pyogenic
organisms  exudate in M.E.  TM congestion &
• bulges under pressure Symptoms:
• Marked earache (throbbing
• nature)
Deafness & tinnitus (only
• complained in adults) High fever &
• restlessness (in children)
Systemic symptoms: anorexia,
• Signvomiting, diarrhea
s • Congestion of pars
• tensa
Cartwheel appearance
• of TM whole of TM inc. pars flaccida
Later,
• becomes red Pneumatic otoscope 
reduce mobility
S TA G E OF SUPPURATION:
PERFORATIO
BEFORE
N
• Sympto
• Excruciating
ms:
• earache
Increasing
• High
deafness
fever
• Sign
s:• TM read & bulging with loss of
• Handle of malleus engulfed by the swollen
landmark
& protruding TM
• Yellow spot on TM
• rupture
Tenderness over mastoid
antrum
S TA G E S OF SUPPURATION :
AFTER PERFORATION
• Sympto
• Otalgia subsides
ms:
onset
with of
• discharge
Fever comes
down

• Sign
s:• EAC may contain
tinged
blood-
mucopurul
discharge
• ent
Pin-hole
perforation
S TA G E OF
RESOLUTION
• With drainage of the pus and host
defense/treatment  inflammation resolves
• Pin-hole perforation
heals
• Sympto
• Acute symptoms
ms:
subside
• Ear becomes
• dry
Eventually hearing
restored
• Sign
s • Dry pin-hole
perforation
• Later – healed
perforation
 MANAGEMENT
• Pain management
• Antibiotics:
• AOM (uni/bilateral) ped > 6 mo with severe symptoms
(moderate to severe pain min 48 hours or temp > 390)
• Bilateral AOM in 6 – 23 mo without severe symptoms
• Unilateral AOM ped 6 – 23 mo OR AOM ped > 24 mo:
conservative (48 – 72 hrs)
• Prophylaxis antibiotics not recommended for preventing AOM
• Ventilation tube in recurrent AOM (3 episodes in 6 mo OR 4
episodes in 1 year with 1 episode in following 6 mo)
Symptomatic
therapy:
• Antipyretics/
• analgesic
Decongestant- may relieve nasal congestion but
not treat AOM
Preventi
on:
• Parent education about
• risk factor
Antibiotic
• prophylaxis
Pneumococal and influeanza
vaccine
• Surgery-in recurrent AOM(depend on local factor
i.e eustachian tube factor or regional factor) e.g
adenoid hyperthropy
DISTINGUISHING OM WITH
OME
• Otitis media and otitis media with effusion(OME)
are two distinct entities and often are part of the
disease continuum
• OME is defined as the presence of middle ear fluid
without acute signs or symptoms.
• Acute signs and symptoms associated with OM
should be identified as absent by history taking and
• physical examination.
The presence of fluid in the middle ear can be
determined by physical examination using electric
otoscopy, pneumatic otoscopy, otoendoscopy, or
otomicroscopy with support of tympanometry
Serous Otitis Media
Otitis media+effusion-Glue ear

Featur
es
• Dull retracted
• TM show air-fluid
May
• level
Conductive
• hearing
Commonlossin children; often after AOM and can
• persist for weeks Reduced hearing noticed by
• parents/teacher
Unsteadin
ess
80% clear at 8
weeks
Hearing tests?

A hearing test is not appropriate at the initial

presentation if there is no evidence of significant
hearing loss or developmental delay. If signs and
symptoms of OME continue, hearing should be assessed
after 3 months, where OME can be regarded as
persistent.
 Management
Adults presentation - the nasopharynx is examined to
exclude tumour. Secretory otitis media is uncommon in
adults. It usually follows a cold and spontaneously
resolves; this may take up to 6 weeks
In Children- 50% of cases will resolve spontaneously
within 6 weeks
Persistence of bilateral Otitis media with effusion (OME)
and hearing loss in a child should be confirmed over a
period of 3 months before intervention is considered

Surgery: adenoidectomy or myringotomy and

grommet insertion.
COMPLICATIONS OF A C U T E
MEDI
OTITIS
A
 Mastoiditis
Definition: infection of mastoid air cells, most
commonly seen approximately 2 weeks after onset
of untreated or inadequateAO treat
M
Etiolo
gy
-same organisme as

in AOM Clinical
• Otorrh
feature:
•Tea
enderness to pressure over
• mastoid
Retroauricular swelling with
• protuding earloss +/- TM
Fever,hearing
perforation(late)
• CT scan: opacity of mastoid air cell by fluid and
interruption of normal trabeculation of cell
 MASTOIDITIS -
PRESENTATION

• Sign
s:• Abnormal-appearing
membrane
tympanic
• (88%)
Fever
• (83%)
Narrowed EAC
• (80%)
Post auricular edema
(76%)

Gliklich RE, Eavey RD, Iannuzzi RA, Ca ma cho AE. A contemporar y

analysis of acute mastoiditis. Arch Otolaryngol Head Neck Surg.
 IMAGIN
G

HRCT Temporal
Bony destruction with Coalescence of the
-bone
mastoid - Fluid in mastoid
Treatment

• IV
• antibiotic
Cortical
s
mastoidectomy
Indication of
Failure of medical treatment
surgery:
after 48H intracranial
Symptom
Aural
complication
discharge persistant for 4 wks and
resistant to antibiotics
Chronic suppurative otitis
media
Disease of
middle ear
CSOM without
cholesteatoma
CSOM with
cholesteatoma
Presentati
on:
ear
discharge
hearing
loss
pai
n
•AOM chronic suppurative OM if involve
3month duration
Unsafe attic perforation

Any defect or
apparent perforation
in the attic must be
considered unsafe
and should be
referred for ENT
assessment. This
crust in the attic
represents a large
underlying
cholesteatoma sac.

Note the bulging

eardrum too.
Marginal perforation plus cholesteatoma formation

Unsafe because it is a
perforation involving the
drum margin
 Cholesteatoma
Disease of
middle ear
Definiti
on:
A cyst compose of keratinizing squamous epithelium
ear,mastoid and
occuring in middle
temporal bone
• 2 type: congenital &
acquired
Congeni
tal
• Present of small white pearl behind intact TM or as
conductive hearing loss
• Believe due to aberrant migration of external canal
ectoderm during development
• Not ass with OM/Eustachian tube
dysfunction
Acquire
d:
• Consequence of OM & chronic Eustachian
• dysfunction
Frequently ass with retraction pocket in pars
flaccida and marginal perforation of TM
• Ass with chronic inflammatory process cause
progessive distruction of surrounding bony structures
Clinical
feature:
• Sympto
m:Hx of OM ventilation
 tube,ear surgery Progessively
 hearing
Otalgia, loss(conductive)
aural
fullness, fever
• Sig
n:Retraction pocket in TM,may contain
 keratin debris TM perforation
 Granulation tissue, polyp visible
 on otoscopy Maladorous otorrhea
Complication

Loca Intracrani
l• Ossicular al
• Meningi
hearing
erosion:conductive • tis
Sigmoid sinus
loss ear
• Inner thrombosis
• Intracra
Sensoryneural
erosion: abcess(subdural,epidural,
nial
loss,dizziness,labyri
hearing llar
cerebe
• nthitis
Temporal )
infection:mastoiditis,p
bone
arositis
• Facial
paralysis
Investigati
on:
• Audiogram and CT
scan
Treatme
nt:
• No conservative therapy for
cholesteatoma
• Surgical: mastoidectomy+/-tympanoplasty+/-ossicular
reconstruction
Cholesteotoma
 Labyrintitis
Disease of
inner ear
Labyrinthitis (inflammation of the labyrinth) occurs
when an infection affects both branches of the
hearing changes
vestibulo-cochlear nerve,asresulting
well as dizziness
in
or vertigo.
Organis
m:
•Virus: herpes, influenza, measles, rubella, mumps,
polio, hepatitis, and Epstein-Barr.
•Bacter
ial
Presentati
on:
•dizzine
ss
•verti
go
•nausea and
vomiting
•tinnitus, which is characterized by a ringing or
buzzing in your ear •loss of hearing
Manageme
nt:
•Hearing
test
•Blood test – FBC,
sugar level
Treatme
nt:
•Medication to control
nausea
•Antihistamines: desloratadine (Clarinex),
loratadine (Claritin) •Steroid
•Anti-
viral
•Antibiotic if suspect
bacterial
•Bed
rest
 Vestibular neuritis

Disease of
Neuritis (inflammationinner earnerve) affects the branch
of the
associated with balance, resulting in dizziness or
vertigo
The termbut no change
neuronitis in hearing.
(damage to the sensory neurons
of the vestibular ganglion) is also
used.
Organis
m:
•Virus: herpes, influenza, measles, rubella, mumps,
polio, hepatitis, and Epstein-Barr.
•Bacter
ial
Presentati
on:
•dizzine
ss
•verti
go
•nausea and
vomiting
•tinnitus, which is characterized by a ringing or
buzzing in your ear •NO loss of hearing
Manageme
nt:
•Hearing
test
•Blood test – FBC,
sugar level
Treatme
nt:
•Medication to control
nausea
•Antihistamines: desloratadine (Clarinex),
loratadine (Claritin) •Steroid
•Anti-
viral
•Antibiotic if suspect
bacterial
•Bed
rest
THANK
YOU