Acute Otitis Media by Nurul Astari Sembiring

1. ACUTE MEDIA OTITIS
(AMO)

2. 1
Introduction

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a common complication of upper respiratory tract
infection is highly prevalent among young children
Approximately 80% of children will have at least one
episode of acute otitis media (AOM), and between 80%
and 90% will have at least one episode of otitis media
with effusion (OME) before school age
Acute Otitis Media
(AOM)
Acute otitis media (AOM) is defined as an infection
of the middle ear and is the second most common
pediatric diagnosis in the emergency department
following upper respiratory infections. Although acute
otitis media can occur at any age,the most common age
range to get AOM is 3 to 24 months.

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Definition
Otitis media is inflammation of part or all of the mucosa of the
middle ear, eustachian tube, mastoid antrum and mastoid cells.
AOM defined by convention as the first 3 weeks of a process in
which the middle ear shows the signs and symptoms of acute
inflammation
AOM is the middle ear infection occurs abruptly causing
swelling and redness. Fluid and mucus become trapped inside the
ear, causing the child to have a fever, ear pain, and hearing loss.

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Etiology
1. Age
2. Gender
3. Socio-Economic Status
4. Breastfeeding
5. Tobacco and indoor smoke
exposure
6. Season
7. Another Factor
Etiology: Streptococcus pneumoniae, Haemophilus
influenzae dan Moraxella catarrhalis
Risk Factor
Eustachian tube (dysfunction) -> swollen, or
does not open or close properly -> tinnitus,
hearing loss and a feeling of fullness in the ear

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Pathogenesis
AOM episodes are
triggered by an
URTI
Congestion and edema of the upper
respiratory tract mucosa
congestion and edema of the mucosa of the upper
respiratory tract including the nasopharynx and
Eustachian tube
Eustachian tube narrows
There is a blockage of negative
pressure in the middle ear
Long term
Reflux occurs and aspiration of virus or bacteria from the nasopharynx to the middle
ear through the Eustachian tube
Infection and accumulation of
secretions in the middle ear
proliferation and secretion of
pathogenic microbes
Increase fluids accumulate behind
the eardrum -> The pressure from
the fluid buildup can cause the
tympanic membrane to break or
rupture.

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Diagnostic Action Statements
From The AAP Guidelines Include The Following
 AOM should be diagnosed when there is moderate to severe tympanic
membrane bulging or new-onset otorrhea not caused by acute otitis
externa
 AOM may be diagnosed from mild tympanic membrane bulging and
ear pain for less than 48 hours or from intense tympanic membrane
erythema; in a nonverbal child, ear holding, tugging, or rubbing
suggests ear pain
• AOM should not be diagnosed when pneumatic otoscopy
and/or tympanometry do not show middle ear effusion

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Diagnosis of AOM
History Taking
• Children:
• Usually fever (with or without) and
otalgia
• Symptoms of upper respiratory tract
infection and otorrhea, hearing loss,
and irritability.
• The most common symptom of AOM in
adults is sudden ear pain.
Clinical Symptoms
• Bouts of the common cold, upper
respiratory tract infections, urinary
tract infections, and recurrent
exanthematous fevers such as
measles, diphtheria, or whooping
cough.
• Infection of the tonsils and adenoids.
• Chronic rhinitis and sinusitis.
• Nasal allergies.
• Nasopharyngeal tumor
Predisposing Factors

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Physical Examination
 The tympanic membrane is pulled/retracted and
looks gloomy
 the light reflex disappears
 The tympanic membrane is reddish
 The tympanic membrane is bulging/There is a
yellowish area --> will rupture
 The tympanic membrane can be perforation -->
Starlight appearance

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Diagnosis
 The diagnosis of otitis media should always begin with a physical
exam and the use of an otoscope and hearing test with tuning fork.
 Laboratory Studies
Laboratory evaluation is rarely necessary. A full sepsis workup in infants
younger than 12 weeks with fever and no obvious source other than associated acute
otitis media may be necessary. Laboratory studies may be needed to confirm or
exclude possible related systemic or congenital diseases.
 Imaging Studies
Imaging studies are not indicated unless intra-temporal or intracranial
complications are a concern.

11. Intepretation Tuning Fork

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Occlusion
Acute Otitis Media Stage
• Retraction of the tympanic membrane --> negative pressure in
the middle ear (air absorption).
• Maleus position --> more horizontal
• Light reflex can be reduced
• Edema that occurs in the eustachian tube --> blockage.
• The tympanic membrane may be normal (occasionally) or pale
cloudy in color.
• An effusion may have occurred, but could not be detected.
• Tympanic membrane: hyperemia and edema.
• Secretion --> exudate
• Hyperemia (prolonged tubal occlusion) --> invasion of
pyogenic microorganisms --> inflammation of the middle ear
and tympanic membrane --> congestion.
• Symptoms: otalgia, ear fullness and fever.
• Hearing: normal / loss hearing (there is an increase in air
pressure in the tympanic cavity)
Hyperemis

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Supuration
Stadium OMA
• Purulent exudate discharge from the tympanic
cavity -> Bulging of the tympanic membrane
• Symptoms: ear ->severe pain (getting worse),
tachycardia and fever
• The pressure of pus in the tympanic cavity does not
decrease -> ischemia (pressure in the capillaries) ->
thrombophlebitis in small veins -> mucosal and
submucosal necrosis.
• Tympanic membrane -> soft area (yellow
color/yellow spot -> this place will rupture)
b.
Acute Otitis Media Stage

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Perforation
• Delay in antibiotic administration
(high virulence and bacteria-->
tympanic membrane rupture--> pus
draining from the middle ear to the
outer ear (secretion out-->
pulsating).
• The child; previously restless ->
now calm, the body temperature is
drops and the child can sleep
soundly.
Acute Otitis Media Stage

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Resolution
• MT intact --> MT will return to normal
• Perforation --> the secret will decrease and eventually dry -->
MT will return to normal
• Hearing returned to normal.
• If the immune system is good or the virulence of the bacteria
is low, resolution can occur even without treatment.
• Acute otitis media can cause sequelae --> serous otitis media
if the secretions persist in the tympanic cavity (without
perforation).
Despite appropriate therapy, AOM can progress to chronic suppurative OM (CSOM) -> no
clinical improvement occurs (resolution stage failed). Failure of this stage is persistent
tympanic membrane perforation, with persistent or intermittent discharge.

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Algorithm
Therapy

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Acute Otitis Media Treatment
Occlusion
Hyperemis
Suppuration
Perforation
Resolution
Topical decongestants ->ephedrine HCl 0.5% for children <12 years or 1%
ephedrine HCl >12 years. With oral antibiotics (Ampicillin 50 mg/KgBW/day in 4
doses or amoxicillin 40 mg/KgBW/day in 3 doses)
Ampicillin 50-100 mg/kg/day in 4 divided doses or amoxicillin 40 mg/kg/day in 3
divided doses, or erythromycin 40 mg/kg/day given for 7 days and can be given
analgesics
Myryngotomy + oral AB
H2O2 3% for 3-5 days and oral administration of AB
if AOM cannot occur resolution phase, continue AB for 3
weeks

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First and Second Line Antybiotics Therapy

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Myryngotomy
Location of surgery --> posterior-inferior
Myryngotomy : incision in the pars tensa tympanic membrane
--> Fluid from the middle ear will then be
drained --> outer ear
Definition of myringotomy with paracentesis --> often equated
Myringotomy : A tiny incision will be made in the tympanic
membrane
Paracentesis : A minor surgical procedure that refers to puncture
of the tympanic membrane for microbiological
examination

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Prevention
Environmental Assessment and
Modification
Vaccination
• Approx. 60–80% of children
≤ 3 years old experience
AOM at least once. The
incidence of AOM has been
declining since the
introduction of the
pneumococcal and influenza
vaccinations
• Modification --> avoid cigarette
smoke
• Babies --> breastfeeding (exclusive
breastfeeding + up to 2 years of
age)
• Eating a healthy and variety of
foods

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Complication Acute Media Otitis
Ekstracranial Intracranial
Mastoiditis Meningitis
Bezold abscess Brain abscess
Labyrinthitis Lateral sinus thrombosis
Facial paralysis
Mastoiditis
with Bezold
Abscess

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Prognosis
Children who develop complications can be difficult to treat and have high
rates of recurrence. Intratemporal and intracranial complications, while very
rare, have significant mortality rates.
The prognosis for most of the patients with otitis media is excellent. Death
from AOM is rare With effective antibiotic therapy. The systemic signs of
fever, lethargy and localized pain should begin to dissipate, within 48 hours.
Patients is also recover the conductive hearing loss associated with AOM.
Effective antibiotic therapy is the mainstay of treatment.
Children with otitis media in the first 24 months of life often have difficulty
perceiving strident or high-frequency consonants, such as sibilants.

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Conclusion

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Oitis media is inflammation of part or all
of the mucosa of the middle ear,
eustachian tube, mastoid antrum and
mastoid cells. .
AOM episodes are triggered by an URTI. The etyology of
AOM are Streptococcus pneumoniae, Haemophilus influenzae
and Moraxella catarrhalis.
AOM's symptom are otalgia, otorrhoea, reduced hearing, ear
fullness, fever. AOM consists of 5 stages, they are occlusion,
hyperemia, suppuration, perforation, resolution. Therapy is
given according to the stage of the disease.
Complications of AOM include
mastoiditis, subperiosteal abscess, brain
abscess and meningitis.
AOM defined by convention as the first 3 weeks of a process
in which the middle ear shows the signs and symptoms of
acute inflammation

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