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Chronic Suppurative Otitis Media

Ivan Wudexi


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Identitas Pasien

Nama: Ny. P

Umur: 42 tahun

Jenis Kelamin: Perempuan Alamat: Balingasal, Padureso, Kesumen

Pekerjaan: Pegawai Negeri

Tanggal Masuk: 19-07-2013 No. RM: 280109


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Keluhan utama

Pengeluaran cairan dari telinga kanan


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Riwayat Penyakit Sekarang (RPS)

Keluhan pengeluaran cairan tersebuttelah dirasakan olehpasien sejak kurang lebih 2 bulan yang lalu. Selama kurun2 bulan, pasien mengkonsumsi antibiotik oral namunkeluhan masih menetap.

Pasien mendeskripsikan bahwa cairannya berwarnakekuningan dan sedikit berbau tanpa disertai darah.Selain itu, pasien juga mengeluhkan adanya penurunanpendengaran di telinga kanan yang bertambah parah bilatelinga kanan terpapar air. Rasa nyeri di telinga tidakdirasakan. Keluhan di kepala, leher, tenggorokan danhidung disangkal.


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Riwayat Penyakit Dahulu (RPD)

Pasien mempunyai riwayat infeksi telinga

berulang yang disertai dengan pengeluaran

cairan (otorrhea)

Tidak ada riwayat allergi.


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Pemeriksaan THT

Telinga

Dextra Sinistra

Pinna Ukuran dan bentuk dbn,

massa(-), hiperemis(-)

Ukuran dan bentuk dbn ,

massa(-), hiperemis(-)

Tragus and/orpinna pain

(-) (-)

Canalis

auditorius

externus

massa(-), hyperemis (-),

bengkak(-)

massa(-), hyperemis (-),

bengkak(-)

Membran

timpani

Terlihat perforasi central

subtotal, discharge (+),

granulasi (-)

Dalam batas normal, cone of

light positive(+), hyperemis (-)

Mastoid Normal, nyeri (-) Normal, nyeri(-)

Lymp. node Tidak ada perbersaran


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Pemeriksaan THT

HidungNose

Paranasal

Sinus

Kanan Kiri

Inspeksi hidung Normal Normal

Palpasi hidung

dan sinusNormal, nyeri(-) Normal, nyeri (-)

Anterior

Rhinoscopy

Discharge(-), concha terlihat

normal, septum tidak

terdeviasi, massa(-)

Discharge(-), concha terlihatnormal, septum tidak

terdeviasi, massa(-)

Posterior

Rhinoscopy

Tidak dilakukan


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Pemeriksaan THT

Mulut dan tenggorokanLips Normal

Tooth Ginggiva Normal

Tongue Normal

Palate Normal

Uvula Normal

Tonsil Normal

Posterior Oropharynx Normal


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Diagnosis

Otitis Media Kronis Type Benign Active pada

Auris Dextra


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Manajemen

Aural Toilet

Aldisa tab (pseudoephredine + loratadine)

Alkilen tab (ofloxacin)


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Pembahasan


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Anatomy of middle ear


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Chronic Otitis Media

Definition

A recurrent infection of the middle ear and/or

mastoid air cell tract in the presence of a

tympanic membrane perforation

(Lustig LR et al., 2013)


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Chronic Otitis Media- Classification

Benign (inactive) COM

Characterized by a dry tympanic membraneperforation, not associated with active infection

Chronic Serous Otitis MediaCharacterized by continuous serous drainage(typically straw-colored)

Chronic Suppurative otitis media (CSOM)Diagnosed when there is persistent purulentdrainage through a perforated tympanic membrane



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CSOM

Definition

WHO defines CSOM as a chronic inflammation

of the middle ear and mastoid cavity, which

presents with recurrent ear discharges or

otorrhea through a tympanic perforation

WHO,2004


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CSOM

The point in time when AOM becomes CSOM

is still controversial

The WHO definition requires only 2 weeks of

otorrhea, but otolaryngologists tend to adopt

a longer duration varying from 6 weeks up to

3 months



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Types of CSOM

There are two major types of CSOM:

1. Mucosal type (tubo-tympanic disease,relatively safe)

2. Bony type (attico-antral disease)

According to the discharge activity, it can be

divided into active CSOM dan inactive CSOM.

(buku ajar THT UI)


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Types of TM Perforation

(buku ajar THT UI)

1. Central perforation annulus

is preserved

2. Marginal perforation

portion or the entire annulus

is involved


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Risk factor

Lower socioeconomic areas

Delay in tx for AOM

Poorer hygienic condition

Increased smoking

Poorer nutrition History of recurrent ear infections in childhood, with

longstanding (months or years) of otorrhea

Race predisposition (Australian Aborigines, Alaskaneskimos, american indians)

WHO,2004


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Pathogenesis

Occurs as a consequence of an episode ofAOM with perforation, with subsequentfailure of the perforation to heal.

Multiple episodes of acute infection outerepithelial layer of TM grows over the

perforation edges, covering middle fibrousand inner mucosal layer non-closing(chronic perforation) TM.



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Microbiology

Most common recovered organism are P.aeruginosaand S.aureus

In CSOM, typical pathogens reach the middle earthrough:

Insufflation of respiratory pathogens through theeustachian tube from the nasopharnyx intomiddle ear

Spread from the external canal inward through anon-intact tympanic membrane



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Diagnosis

Clinical features and otoscopic findings

WHO,2004


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Clinical features

Otorrhea (either intermittent or continuous)

Absence of pain and fever

Hearing loss (made worse by water exposure)

WHO,2004


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Otoscopic findings

Discharging tympanic perforation

Mucoid otorrhea


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Management

The goals of the tx of CSOM:

Stop otorrhea

Heal the tympanic membrane Eradicate current infection

Prevent complications

Prevent recurrence



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Management

Medical Management

Surgical Management


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Medical Management

Aural Toilet

Topical antibiotics (ex. Ciprofloxacin or

ofloxacin)

Systemic antibiotics only considered in

patients at risk for complicated or invasive ear

infections or in those who have received

several courses of empiric topical therapy and

are at higher risk for resistant organisms.



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Surgical Management

Indication: patients who develop complication

of chronic otitis, to remove infected tissue in

the middle ear or mastoid and to repair ear

damage that results in hearing loss andpresence of cholesteatoma.

Example: mastoidectomy, tympanoplasty,

ossicular bone reconstruction(Lustig LR et al., 2013)


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Complication of CSOM

Mastoiditis

Facial nerve paralysis

Petrositis Labyrinthitis

Intracranial complications (ex. Lateral sinus

thrombosis, meningitis, brain abscess)



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Follow Up and Education

Patient must be educated on how to apply

topical antibiotic

Patients should be advised to keep their ears

dry to prevent future complications, even

after medical tx results in a safe and dry ear.

During bath, the affected ears may be

occluded with petrolatum cotton



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Maturnuwun

Mohon asupan


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