Definition and Anatomy Ear
Otitis media is an infection or inflammation (inflammation: inflammation) in the middle ear. The ear itself is divided into three parts: outer ear, middle ear and inner ear. Ears middle is the area bounded by the outside world by the ear drum. This area connects with the voice of the inner ear hearing instrument. Also in this area there are Eustachius channel that connects the middle ear to the back of the nasal cavity and upper throat. Use of this channel are:
§ maintain the balance of air pressure in the ear and adjust the air pressure in the outside world.
§ drain the small amount of mucus produced by the cells lining the middle ear to the back of the nose.
How is otitis media Happen
Otitis media is often preceded by respiratory infection such as strep throat or a cold that has spread to the middle ear through the canal Eustachius. Eustachius When the bacteria through the channel, they can cause infections in the channel, causing swelling around the channel, channel blockage, and the arrival of cell white blood cells to fight bacteria. White blood cells will kill the bacteria at the expense of themselves. As a result of pus formed in the middle ear. In addition, swelling of tissue surrounding the channel produced Eustachius cause mucous cells collected in the middle ear behind the eardrum.
If mucus and pus grew a lot, hearing can be subject to the eardrum and small bones connecting the ear drum to the hearing organ in the inner ear can not move freely. Experienced hearing loss is generally around 24 decibels (whisper soft) . However, more fluid can cause hearing loss to 45 decibels (the range of normal conversation). In addition, the ear also will feel painful. And the most weight, which is too much liquid can eventually tear the eardrum due to pressure.
As with the incidence of upper respiratory infections (ARI), otitis media is also one subscription disease of children. In the United States, an estimated 75% of children experience at least one episode of otitis media before the age of three years and nearly half of them experienced it three times or more. In the UK, at least 25% of children experience at least one episode before the age of ten years. otitis media in the country most often occurs at the age of 3-6 years.
The cause of acute otitis media (OMA) to a virus or bakteri. In 25% of patients, no cause is found microorganisms. The virus was found in 25% of cases da da and n sometimes infect the middle ear with bacteria. Common bacterial causes of otitis media are Streptococcus pneumoniae, followed by Haemophilus influenzae and Moraxella cattarhalis. To remember the OMA, although most cases are caused by bacteria, only a few cases requiring antibiotics. This is possible because no antibiotics were Eustachius channel will open again so that the bacteria will be eliminated with the flow of mucus.
Why Children Easier Esophageal OMA
Children are more susceptible to otitis media than adults because some things
§ child's immune system is still in development.
§ Eustachius tract in children is more straight and shorter horizontally so that the ARI is more easily spread to the middle ear.
§ adenoids (adenoids: one organ in the upper throat that play a role in the immune system) is relatively higher in children than adults. Adenoid position adjacent to the estuary channel Eustachius so large adenoids can interfere with the opening of the channel Eustachius. In addition, adenoids can become infected themselves where the infection can then spread to the middle ear through the canal Eustachius.
Diagnosis OMA should meet the following three things
1. The disease appeared suddenly (acute)
b. limited / no movement of the eardrum
c. the shadow of fluid behind the eardrum
d. discharge from the ear
3. The existence of signs / symptoms of middle ear inflammation, as evidenced by the existence of one
of the following signs:
a. redness in the ear drum
b. ear pain that disrupt sleep and normal activity
Children with OMA may experience ear pain or a history of pulling on the baby's ears, ear discharge, decreased hearing, fever, difficulty eating, nausea and vomiting, and irritability. but these symptoms (except discharge fluid from the ears) are not specific to OMA OMA so that diagnosis can not be based on history alone.
Middle ear effusion is checked by otoskop (tool to check the canal and eardrum clearly) . With otoskop can see the eardrum is bulging, discoloration eardrum becomes red or slightly yellow and gloomy, and the fluid in the ear canal.
If confirmation is required, generally done with pneumatic otoskopi (ear examination with otoskop to see the ear drum which is equipped with a small air pump to assess the eardrum response to changes in air pressure) eardrum movement is reduced or absent at all can be seen by examination this. This examination improve diagnostic sensitivity OMA. But generally the diagnosis of OMA can be enforced by ordinary otoskop.
Middle ear effusions can also be proved by timpanosentesis (pricking of the ear drum) . However timpanosentesis not done on any child. Indications include the need timpanosentesis OMA in infants under the age of six weeks with a history of intensive care in hospital, children with immune disorders, children who do not respond to several antibiotics, or with very severe symptoms and complications.
OMA to be distinguished from otitis media with effusion that can resemble OMA. To distinguish these it could consider the following things.
Symptoms and signs
Otitis media with effusion
Ear pain, fever, irritability
Middle ear effusion
A Bulging ear drum
|Eardrum movement is reduced|| |
OMA is a disease that will usually heal with OMA itself. About 80% recover within 3 days without antibiotics. The use of antibiotics does not reduce complications that can occur, including reduced auditory. Observations can be done in most cases. If symptoms do not improve within 48-72 hours or there is worsening of symptoms, antibiotics are given. American Academy of Pediatrics (AAP) categorize OMA which can be observed and which should be treated with antibiotics as follows:
Age Definitive diagnosis Diagnosis doubt
<6 months Antibiotics Antibiotics
6 months - 2 years Antibiotics Antibiotics if severe symptoms;
observation when mild symptoms
≥ 2 yrs Antibiotics if severe symptoms; observation
observation when mild symptoms
The definition of mild symptoms are mild ear pain and fever <39 ° C in the last 24 hours. While symptoms are ear pain is medium - heavy or fever ≥ 39 ° C.
Options observation for 48-72 hours can only be performed on children aged six months - two years with mild symptoms during the examination, or diagnostic doubts in children over two years. To be able to choose observation, follow-up must be ensured to happen. Fixed analgesia given in the observation period.
British Medical Journal gave a slightly different criteria for applying the these observation. According to the BMJ, the choice of observation can be done, especially in children without general symptoms such as fever and vomiting.
If it was decided to give antibiotics, the first choice for most children is amoxicillin. § Sources such as AAFP (American Academy of Family Physicians) recommend giving 40 mg / kg body
weight / day in children with low risk and 80 mg / kg body weight / day for children with high risk.
High risk in question, among others is less than two years of age, was treated daily at the daycare,
and there is a history of giving antibiotics in the last three months.
§ WHO recommends 15 mg / kg body weight / gift with maximum 500 mg.5
§ AAP recommended dose of 80-90 mg / kg weight badan/hari.6 this dose is associated with increased
percentage of bacteria that can not be solved with standard doses in the United States. Until recently in
Indonesia, there are no data that suggests something similar, so the wise choice is to use a dose of
40 mg / kg / day. Documentation of bacteria that are resistant to standard doses should be based on
culture results and antibiotic resistance testing.
Antibiotics in the OMA will result in improvement of symptoms within 48-72 hours. In the first 24 hours occurred stabilization, was second in the 24 hours began repairs. If the patient does not improve within 48-72 hours, there may be other diseases or treatment provided is not adequate. In cases like this are considered second-line antibiotics. For example:
§ In patients with severe symptoms or OMA are likely to be caused Haemophilus influenzae and Moraxella catarrhalis, which are then selected antibiotics are amoxicillin-clavulanate. Another source states of amoxicillin-clavulanate do if symptoms do not improve within seven days or re-emerged in 14 days.
§ If the patient has a mild allergy to amoxicillin, can be given cephalosporins such as cefdinir, cefpodoxime, or cefuroxime.
§ In severe allergy to amoxicillin, which is given azithromycin or clarithromycin.
§ Another option is to erythromycin-sulfisoxazole or sulfamethoxazole-trimethoprim. However, both these combinations are not an option on the OMA that does not improve with amoxicillin. If the provision of amoxicillin-clavulanate did not give results, choices made are ceftriaxone for three days.
It should be noted that the cephalosporin used in OMA is generally a second generation or third generation with a broad spectrum. Likewise azythromycin or clarythromycin. Broad-spectrum antibiotic, although they could kill more types of bacteria, have a greater risk. Normal bacteria in the body will be killed so that the balance of flora in the body disturbed. In addition, the risk of the formation of antibiotic resistant bacteria will be greater. Therefore, this option is only used in cases with clear indications of second-line antibiotics.
Giving antibiotics in otitis media performed for ten days in children aged under two years old or children with symptoms berat.6 At the age of six years and over, giving antibiotics just 5-7 days. In the UK, the recommended antibiotic treatment is 3-7 days or five days. Cochrane reviews showed no significant differences between the antibiotics in less than seven days compared with the provision of more than seven days. And because of that giving antibiotics for five days is considered sufficient in otitis media. Giving antibiotics in a longer time increases the risk of side effects and bacterial resistance.
Analgesia / pain relief Besides antibiotics, treatment should be accompanied OMA pain relief (analgesia) . analgesia is commonly used simple analgesia such as paracetamol or ibuprofen. However, it should be noted that the use of ibuprofen, it must be ensured that the child did not experience gastrointestinal disturbances such as vomiting or diarrhea because ibuprofen can aggravate the digestive tract irritation.
§ Provision of other drugs such as antihistamines (allergy) or decongestants do not provide benefits to children
§ Provision of corticosteroids did not recommended
§ Myringotomy (myringotomy: hole in the eardrum to remove fluid that accumulates behind it) is also only
done in special cases where the symptoms are very severe or there are complications.
Some things that seem to reduce the risk of OMA are:
§ prevention of respiratory infection in infants and children,
§ breastfeeding for at least 6 months,
§ avoidance of milk in the bottle when the child lay,
§ and avoidance of exposure to cigarette smoke
Swimming likely not increase the risk OMA.
Chronic otitis media is characterized by a history of a chronic discharge from one or two ears. If the eardrum has been broken more than 2 weeks, the risk of infection is very common. Generally, the handling is done is to wash and dry ears for several weeks until the liquid is no longer exit.
Otitis media is not treated can spread to tissues surrounding the middle ear, including the brain.
Some circumstances that require referral to the ENT specialist is;
§ Children with frequent episodes of OMA. Definition of "often" is more than 4 episodes in 6 months.
Another source said "often" is more than 3 times in 6 months or more than 4 times in one year
§ Children with effusion for 3 months or more, discharge from the ear, or holes in the eardrum
§ Children with the possibility of serious complications such as mastoiditis or facial nerve paralysis
(mastoiditis: an inflammation of the bones of the skull, approximately located at the bony ridge
behind the ear)
§ children with craniofacial abnormalities (craniofacial: head and face), Down syndrome, cleft, or
with speech delay
§ OMA with moderate-severe symptoms that do not give a response to the two antibiotics
(Excerpted from various sources)