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Jawaban Brain Storming

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    Otitis Media

     Author: Muhammad Waseem, MD; Chief Editor: Glenn C Isaacson, MD, FACS, FAAP

    Background Otitis media OM! is the second most common disease of childhood, after u""er res"irator# infection $%I!& OM is also the most common cause for childhood 'isits to a "h#sician(s office& Annuall#, an estimated )* million office 'isits are attri+uted to OM; this does not include 'isits to the emerenc# de"artment& OM is an# inflammation of the middle ear -ithout reference to etiolo# or "athoenesis& OM can +e classified into man# 'ariants on the +asis of etiolo#, duration, s#m"tomatolo#, and "h#sical findins&

     Acute OM AOM! im"lies ra"id onset of disease associated -ith one or more of the follo-in s#m"toms: • Otalia

    • Fe'er 

    • Otorrhea

    • %ecent onset of anore.ia

    • Irrita+ilit#

    /omitin • Diarrhea

    0hese s#m"toms are accom"anied +# a+normal otosco"ic findins of the t#m"anic mem+rane 0M!, -hich ma# include the follo-in:

    • O"acit#

    • 1ulin

    • Er#thema

    • Middle ear effusion MEE!

    • Decreased mo+ilit# -ith "neumatic otosco"#  AOM is a recurrent disease& More than one third of children e."erience * or more e"isodes of AOM +# ae 2 #ears& OM -ith effusion OME!, formerl# termed serous OM or secretor# OM, is MEE of an# duration that lac3s the associated sins and s#m"toms of infection e, fe'er, otalia, irrita+ilit#!& OME usuall# follo-s an e"isode of AOM& Chronic su""urati'e OM is a chronic inflammation of the middle ear that "ersists at least * -ee3s and is associated -ith otorrhea throuh a "erforated 0M, an ind-ellin t#m"anostom# tu+e 00; see imae +elo-!, or a surical m#rinotom#&

    /arious t#m"anostom# tu+e st#les and si4es&

    Pathophysiology 0he most im"ortant factor in middle ear disease is eustachian tu+e E0! d#sfunction& In E0 d#sfunction

    E0D!, the mucosa at the "har#neal end of the E0 is "art of the mucociliar# s#stem of the middle ear& Interference -ith this mucosa +# edema, tumor, or neati'e intrat#m"anic "ressure facilitates direct e.tension of infectious "rocesses from the naso"har#n. to the middle ear, causin OM& Eso"haeal contents reuritated into the naso"har#n. and middle ear throuh the E0 can create a direct mechanical distur+ance of the middle ear mucosa and cause middle ear inflammation& In children, de'elo"mental alterations of the E0, an immature immune s#stem, and fre5uent infections of the u""er res"irator# mucosa all "la# ma6or roles in AOM de'elo"ment& Studies ha'e demonstrated ho- 'iral infection of the u""er res"irator# e"ithelium leads to increased E0D and increased +acterial coloni4ation and adherence in the naso"har#n.&7)8 Certain 'iral infections cause a+normal host immune and inflammator# res"onses in the E0 mucosa and su+se5uent micro+ial in'asion of the middle ear& 0he

    http://emedicine.medscape.com/article/928598-overview http://emedicine.medscape.com/article/928598-overview

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    host immune and inflammator# res"onse to +acterial in'asion of the middle ear "roduces fluid in the middle ear and the sins and s#m"toms of AOM&

     Althouh interactions +et-een the common "athoenic +acteria in AOM and certain 'iruses are not full# understood, stron e'idence indicates that these interactions often lead to more se'ere disease, lo-ered res"onse to antimicro+ial thera"#, and OME de'elo"ment follo-in AOM&

    Epidemiology Frequency United States OM, the most common s"ecificall# treated childhood disease, accounts for a""ro.imatel# 9 million annual "h#sician 'isits& /arious e"idemioloic studies re"ort the "re'alence rate of AOM to +e )29< -ithin the first 9 #ears of life, and =< of children ha'e at least one documented MEE +# ae 9 #ears& OM is a recurrent disease& One third of children e."erience * or more e"isodes of AOM +# ae 2 #ears& International Incidence and "re'alence in other industriali4ed nations are similar to $S rates& In less de'elo"ed nations, OM is e.tremel# common and remains a ma6or contri+utor to childhood mortalit# resultin from late"resentin intracranial com"lications&

    Mortality/Morbidity $S mortalit# rates are e.tremel# lo- in this era of antimicro+ial thera"# > ) death "er ), cases!& In de'elo"in nations -ith limited access to "rimar# medical care and modern anti+iotics, mortalit# rates are similar to $S rates +efore anti+iotic thera"#& A stud# that e.amined the causes of death in ?os Aneles Count# @os"ital from )=9)=BB, #ears "rior to the ad'ent of sulfa, sho-ed ) in  deaths -as caused +# intracranial com"lications of OM& Mor+idit# from this disease remains sinificant, des"ite fre5uent use of s#stemic anti+iotics to treat the illness and its com"lications& Intratem"oral and intracranial com"lications of OM are the 9 ma6or t#"es&

    • Intratem"oral com"lications o @earin loss conducti'e and sensorineural! o 0M "erforation acute and chronic! o Chronic su""urati'e OM -ith or -ithout cholesteatoma! o Cholesteatoma o 0#m"anosclerosis o Mastoiditis o Petrositis o ?a+#rinthitis o Facial "aral#sis o Cholesterol ranuloma o Infectious ec4ematoid dermatitis

    • Intracranial com"lications o Meninitis o Su+dural em"#ema o 1rain a+scess o E.tradural a+scess o ?ateral sinus throm+osis o Otitic h#droce"halus

    ace $ntil recentl#, "re'alence of OM in the $nited States -as re"orted to +e hiher in +lac3 and @is"anic children than in -hite children& A stud# that controlled for socioeconomic and other confoundin factors sho-ed e5ual incidence in +lac3s and -hites& @is"anic children and Alas3an Inuit and other American Indian children ha'e hiher "re'alence of AOM than -hite and +lac3 children in the $nited States& International studies sho- increased "re'alence of AOM and chronic OM COM! amon Micronesian and

     Australian a+oriinal children&

    http://emedicine.medscape.com/article/994159-overview http://emedicine.medscape.com/article/993966-overview http://emedicine.medscape.com/article/966099-overview http://emedicine.medscape.com/article/994159-overview http://emedicine.medscape.com/article/993966-overview http://emedicine.medscape.com/article/966099-overview

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    Se! Se'eral more recent studies ha'e sho-n e5ual AOM "re'alence in males and females; man# "re'ious studies had sho-n increased incidence in +o#s&

    "ge

    • Pea3 "re'alence of OM in +oth se.es occurs in children aed *) months& • Some studies sho- +imodal "re'alence "ea3s; a second, lo-er "ea3 occurs at ae  #ears

    and corres"onds -ith school entr#& •  Althouh OM can occur at an# ae, =< of cases occur in children #ouner than * #ears&

    • Children -ho are dianosed -ith AOM durin the first #ear of life are much more li3el# to de'elo" recurrent OM and chronic OME than children in -hom the first middle ear infection occurs after ae ) #ear&

    #istory • Sus"ect acute otitis media AOM!, -ith or -ithout effusion, in children -ith a histor# of the

    follo-in s#m"toms: o @ead and nec3

     Otalia: oun children ma# e.hi+it sins of otalia +# "ullin on the affected ear or ears or "ullin on the hair& Otalia a""arentl# occurs more often -hen the child is l#in do-n e, durin the niht, durin na" time!, -hich ma# +e due to increased E0D -hen the child is in a recum+ent "osition&

     Otorrhea: Dischare ma# come from the middle ear throuh a recentl# "erforated 0M, throuh a "ree.istin 00, or throuh another "erforation& For trauma "atients, e.cludin a +asilar s3ull fracture -ith associated cere+ros"inal fluid CSF! otorrhea is im"ortant&

     @eadache  Concurrent or recent $%I s#m"toms e, couh, rhinorrhea, sinus conestion!

    o General  0-o thirds of children -ith AOM ha'e a histor# of fe'er, althouh fe'ers reater

    than C are uncommon and ma# re"resent +acteremia or other com"lications&  Irrita+ilit# ma# +e the sole earl# s#m"tom in a #oun infant or toddler&   A histor# of lethar#, althouh nons"ecific, is a sensiti'e mar3er for sic3 children

    and should not +e dismissed& o GI tract: S#m"toms include anore.ia, nausea, 'omitin, and diarrhea&

    • OME often follo-s an e"isode of AOM& Consider OME in "atients -ith recent AOM in -hom the histor# includes an# of the follo-in s#m"toms:

    o @earin loss: Most #oun children cannot "ro'ide an accurate histor#& Parents, carei'ers, or teachers ma# sus"ect a hearin loss or descri+e the child as inattenti'e&

    o 0innitus: 0his is "ossi+le, althouh it is an unusual com"laint from a child& o /ertio: Althouh true 'ertio ie, rooms"innin di44iness! is a rare com"laint in

    uncom"licated AOM or OME, "arents ma# re"ort some unsteadiness or clumsiness in a #oun child -ith AOM&

    o

    Otalia: Intermittent otalia tends to -orsen at niht& • OM treatment -idel# 'aries +ased on the duration of s#m"toms, "ast thera"eutic failures, and

    se'erit# of current s#m"toms& • E."osure to en'ironmental ris3 factors is another im"ortant as"ect of the histor# and includes the

    follo-in: o Passi'e e."osure

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