FACULTY OF MEDICINE

TARUMANAGARA
UNIVERSITY

PEMICU 3
Agustus 14, 2017

SITI SURYANI 405140141

ANATOMY OF THE EAR

Copyright 2009, John Wiley & Sons, Inc.

THE EXTERNAL EAR
TYMPANIC
MEMBRANE
THE MIDDLE EAR

Copyright 2009, John Wiley & Sons,

Inc.
THE AUDITORY
OSSSICLE
(Malleus, Incus, Stapes)

Hole, Human Anatomy & Physiology, 10th ed

THE INTERNAL EAR

Copyright 2009, John Wiley &

Sons, Inc.
OSSEUS LABYRINTHS

Copyright 2009, John Wiley &

Sons, Inc.
MEMBRANACEOUS
LABYRINTHS

Copyright 2009, John Wiley &

Sons, Inc.
Copyright 2009, John Wiley &
Sons, Inc.
 LI 2

HISTOLOGI TELINGA
Junqueiras. Basic of histology text an
PART OF THE EAR

Junqueiras. Basic of histology text an

PART OF THE EAR

Junqueiras. Basic of histology text and a

PART OF THE EAR

Junqueiras. Basic of histology text an

Junqueiras. Basic of histology text an
Junqueiras. Basic of histology text an
Junqueiras. Basic of histology text a
Junqueiras. Basic of histology text an
 LI 3

FISIOLOGI PENDENGARAN
PROPERTIES OF SOUNDS
WAVE

Sherwood, Human Physiology From Cells to Systems, 6th ed

THE EAR

Sherwood, Human Physiology From Cells to Systems, 5th ed

Copyright 2009, John Wiley & Sons, Inc.
IONIC COMPOSITION
HAIR CELL
SOUNDS TRANSMISSION
OUTER EAR MIDDLE EAR INNER EAR

Auditory Ear- Hammer, Oval Cochlear canal

Pinna canal drum anvil, stirrup window
Upper and middle Lower
Pressure

Time

One Amplitude
vibration Amplification Organ of Corti
in middle ear stimulated
Sherwood, Human Physiology From Cells to Systems, 6th ed
 Malleus Incus Stapes vibrating Helicotrema Cochlea
in oval window

Sound waves
Perilymph

3 8 Scala
7 tympani
4
Scala
5 vestibuli
6 Basilar
1 2 9 membrane
External auditory 8
canal Spiral organ
(organ of Corti)
Tectorial membrane
Vestibular membrane
Cochlear duct
Tympanic (contains endolymph)
membrane
Secondary tympanic
membrane vibrating
Middle ear Auditory tube
in round window
Sherwood, Human Physiology From Cells to Systems, 6
 Sound waves

Vibration of
tympanic membrane

Vibration of
middle ear bones

Vibration of
oval window

Fluid movement Vibration of

within cochlea round window

In ear

Vibration of Dissipation of
basilar membrane energy (no
sound
(continue to next slide) perception) Fig. 6-36, p. 216
Bending of hairs of receptor
hair cells of organ of Corti
as basilar membrane move-
ment displaces these hairs
in relation to overlying
tectorial membrane in which
the hairs and embedded

Graded potential changes

(receptor potential) in
receptor cells

Changes in rate of action

potentials generated in
auditory nerve

Propagation of action
potentials to auditory cortex
in temporal lobe of brain for
sound perception
Fig. 6-36, p. 216
ROLE OF STREOCILIA IN SOUND TRA
NSDUCTION
HAIR CELL ACTIVATION
Coding for the Qualities of Sound:
Frequency (Pitch) Coding
 LI GANGGUAN TELINGA
LI 4 LUAR
1) FISTULA PRE-AURIKULAR
2) OTITIS EXTERNA
3) HERPES ZOOSTER PADA
TELINGA
4) INFLAMASI PADA TULANG
5) BENDA ASING PADA TELINGA
6) SERUMEN PROP
7) TRAUMA AURIKULA
 OTITIS EXTERNA
DEFINITION
Otitis externa is a
generalized condition of the
skin of the external auditory
canal that is characterized
by general oedema and
erythema associated with
itchy discomfort and usually
an ear discharge.
EPIDEMIOLOGY ETIOLOGY
0.4% / year; 10% of – Secondary bacterial infection
population • Pseudomonas sp (50-65%);
gram (-) (25-35%); S.
Aureus (15-30%);
Streptococci (9-15%)
– Bathing
• The presence of bacteria in
bathing water doesn’t seem
to be a risk factor, although
bathing in freshwater lakes
contain Pseudomonas 
large outbreak in
Netherlands
– Irritant/allergic reactions
• Topical medications
(benzalkonium chloride &
steroids); neomycin
 PATHOLOGY
– Pre-inflammatory
• Protective acid balance (pH 4-5)
is lost  stratum corneum
become oedematous  blocking
off the sebaceous & apocrine
glands  aural fullness & itching
• Further oedema & sctratching 
disruption of epithelial layer 
invasion of resident/introduced
organisms
– Acute inflammatory
• Progressive thickening exudate,
further oedema, obliteration of
the lumen, pain >>
• Auricular change & cervical
lymphadenopathy (severe)
– Chronic inflammatory
• Remain of low pH + > 3 weeks
 thickening of external canal &
fibrous canal stenosis (acquired
atresia of the external ear)
DIAGNOSIS (SIGNS &
SYMPTOMS) COMPLICATIONS
– Pain, itch, oedema, erythema – Perichondritis
of the external auditory canal – Chondritis
– With purulent otorrhoea & – Cellulitis
debris in meatus – Parotitis
– Erysipelas
 MANAGEMENT
– Aural toilet
• With/-out microscopic assistance
– Topical medication
• Glycerol & ichthammol (90:10%) with aural wick (moderate & severe)
– Dehydrating effects  < pain, oedema
• NSAID (if not contraindicated)
• Combination drop of neomycin, polymyxin-B, hydrocortisone
– AE  filmy debris (mistaken for fungal overgrowth
– Neomycin & gentamycin  Staphyllocooccus
– Polymyxin-B  Pseudomonas & Staphyllococcus
• Quinolone (for no known risk of ototoxicity & it is sensitive to
Pseudomonas)
– Systemic antibiotics
• American Academy of otolaryngology  no evidence
PREVENTION OF RECCURENCE
• Avoidance of water penetration
• Cotton wool + petroleum jelly in bath / shower
• Alcohol / proprietary preparations (aqua-ear/ear-
calm) after swimming
• Blow driers (not on hot setting)  remove moisture
• Reccurent otitis externa with ear-mould hearing aid
patient  bone-anchored hearing aid
 HERPES ZOOSTER PADA TELINGA
DEFINITION
Herpes zoster oticus is
defined as a herpetic
vesicular rash on the
concha, external auditory
canal or pinna with a lower
motor neurone palsy of the
ipsilateral facial nerve.
PATHOLOGY
The disease is a reactivated varicella
zoster infection from dormant viral
particles resident in the geniculate
ganglion of the facial nerve and the spiral
and vestibular ganglia ofthe VIIIth nerve.
Recent work looking for varicella zoster in
the geniculate zone of the concha using
polymerase chain reaction (PCR) showed
the virus to be present in 100 percent of
patients with vesicles and in 71 percent of
individuals with no initial skin lesions, but
who developed vesicles within a week.
 DIAGNOSIS
 (MRI)
 Cerebrospinal fluid (CSF)
analysis having been shown
to have no role in
establishing either diagnosis
or prognosis
 TREATMENT
• Treat early with oral
acyclovir(800mg5/day) and
prednisolone(1mg/kg/day).
[Grade C]
• Treat before the vesicles
appear. [Grade D]
PERICHONDRITIS OF THE EXTERNAL EAR

DEFINITION
 infection / inflammation
involving the perichondrium
of the external ear (auricle
& external auditory canal)
CLASSIFICATION
– Erysipelas (infection of the
overlying skin) of external ear
– Cellulitis (infection of the soft
tissue) of external ear
– Perichondritis
– Chondritis
 ETIOLOGY
– Thin skin  happens
secondary to trauma
– P. Aeruginosa (75-90%), S.
Aureus (50%)
– Gram (-) (Proteus & E. coli);
Streptococcus
PATHOLOGY
– Hyperplasia of dermal layers
– Thickened subcutaneous
tissue
– Intense infiltration with PMN
– Thickening of the
perichondrium
– Destruction of the cartilage by
phagocytes
 DIAGNOSIS

– Presentations
• Dull pain increasing in
severeity
• Inflammation involving the
cartilaginous pinna
• The lobule is spared (no
cartilage)
– Background history of
underlying trauma should be
sought
 DD
– Relapsing polychondritis
•  involvement of cartilages
at multiple sites, possibly
occular condition, vasculitis
– Extranodal non-Hodgkin’s
lymphoma
OUTCOMES
– Untreated  subperichondrial
abscess  avascular necrosis
of underlying cartilage 
marked deformity of pinna
– Fatal septicaemia
(streptococcal infection)
– Subacute bacterial
endocarditis
– Necrotizing fasciitis of the
neck
 MANAGEMENTS
– PREVENTION – Resistant cases
• Careful placement of ear piercing
away from the cartilaginous pinna • Aggressive excision of
• Surgery & in around the ear should necrosed cartilage + skin &
avoid trauma to the cartilage
• Hematomas of the auricles should subcutaneous tissue
be drained promptly + aseptic • Continuous drainage &
• Meticulous management of burn
injuries should include irrigation with antibiotics +
prophylactic antibiotics against steroid solution
gram (-) bacteria + removal of
crusts – Other forms
– FIRST-LINE MANAGEMENT • Ionthophoresis (effective
• Topical & oral antibiotics
• Discharge / abscess  draining +
local antibiotic delivery
culture & sensitivity without systemic absorption
– Pending the result  broad
spectrum antibiotics; high • Low-dose radiation
dose; IV
• UV radiation
FOREIGN BODIES IN THE EAR
Most common  cotton
wool, insects, beads, paper,
small toys & erasers
– 72%  failed attempts by
nonspecialists consist of firm,
rounded objects
CLINICAL PICTURE
– Children may present
asymptomatically / with pain
or discharge caused by otitis
externa
– Adult are often seen with
cotton wool / broken
matchsticks
– Live insects (ex. Small
cockroaches)  loud noise &
movement
 MANAGEMENT
– Nature of the foreign bodies
• Living insects
– be killed first by instilling oil
into the meatus into drown
before removal
• Irregular/soft graspable non-
living objects
– pair of crocodile forceps
• Organic objects: may absorb
water, swell & pain
– should NOT be syringed
• Button batteries
– Should NOT be syringed 
remove urgently
• Inorganic round/smooth non-
graspable
– Syringing is safe, often
successful, but may fail with
tightly impacted foreign
bodies
– Location of the foreign bodies
• Easier access, wider diameter, elastic nature, lesser
sensitivity  easier removal
• Space between the foreign body & the canal 
allows access for water / instrument through for
removal
• Firmly impacted of the foreign bodies medial to the
isthmus / failed removal attempts  trauma,
swelling  surgical removal
– Patient considerations
• Pay attention to younger, uncooperative children
– Watch for pain & trauma when the removal procedure
 COMPLICATION
– Introducing the foreign bodies
 laceration of the canal skin
& otitis externa
– Facial nerve palsy (leakage of
alkaline from button batteries)
– Damage & perforation of
tympanic membrane
– Ossicular chain
dislocation/fracture
 LI GANGGUAN TELINGA
LI 5 TENGAH

1) OTITIS MEDIA AKUT

2) OTITIS MEDIA KRONIK
3) OTITIS MEDIA SUPURATIF
4) PERFORASI MEMBRAN
TYMPANI
5) MIRINGITIS BULLOSA
6) MASTOIDITIS
7) KOLESTEATOMA
 ACUTE OTITIS MEDIA IN CHILDREN
DEFINITION
~ acute suppurative otitis
media
 inflammation of the middle
ear cleft of rapid onset &
infective origin, associated
with a middle ear effusion
SUBGROUPS
– Sporadic episodes
•  infrequent isolated events;
occurring with respiratory tract
infection
– Resistant AOM
•  persistence of symptoms & signs
of middle ear infection beyond 3-5
days of antibiotic treatment
– Persistent AOM
•  persistence / recurrence of
symptoms & signs of AOM > 6 days
of finishing a course of antibiotics
– Reccurent AOM
•  >=3 episodes of AOM in 6 mo
period/4-6 episodes in 12 mo
 RISK FACTORS EPIDEMIOLOGY
– Genetic factors – Commonest illness of
• Family members
childhood
• Maternal blood group A
• Atopy – Highest incidence  first year
– Immune factors of life
• IgG2 deficiency
• Defective component-
dependent opsozination
• Aberrant expression of certain
cytokines
– Environmental factors
• Poor socioeconomic status
– Syndromic association
• Turner syndrome, down
syndrome, cleft palate
 DIAGNOSIS
– Combination of often
nonspecific symptoms
– Evidence of inflammation of
the middle ear cleft
– Additional information of
middle ear effusion
– may well not be a clear history
of a crescendo of otalgia in a
coryzal child  rapid
symptomatic relief associated
with tympanic membrane
perforation
SYMPTOMS
– Apyrexial (2/3)
– Rapid onset of
• Otalgia, hearing loss, fever
• Otorrhoea (blood stained)
• Excessive crying, irritability
• Coryzal symptoms
• Vomiting, poor feeding
• Ear-pulling, clumsiness
– Commonly develop 3-4 days
after coryzal symptoms
 SIGNS
– Appear unwell, rubbing ear
– Otoscopic exam 
• Opaque tympanic membrane,
• Most commonly yellowish
pink, red in only 18-19%
• Bulging
– Hypomobility of the drum
– Perforated drum / ventilation
tube in situ  mucopurulent
ottorhoea
 INVESTIGATIONS
– Tympanometry  middle ear
effusion
– Tympanocentesis & culture
– Nasopharyngeal swabbing for
bacterial culture
– Iron deficiency anemia & white
blood cells disorder associated
with AOM
– Immunoglobulin assay
– Reccurrent infection of
ventilation tube  investigation
for primary ciliary dyskinesia
• Especially if nasal &
pulmonary symptoms coexist
DD
– Pain  tonsilitis, teething,
temporomandibular joint disorder,
uncomplicated upper respiratory
tract infection
– Red tympanic membrane 
screaming child
– acute mastoiditis
– otitis media with effusion
– otitis extema
– trauma
– Ramsay hunt syndrome
– bullous myringitis
– first indication of serious
underlying disease
• Wegener's granulomatosis or
leukaemia
 ETIOLOGY
– Infective agents
• Viruses
– RSV, influenza A virus,
parainfluenza virus, human
rhinovirus, adenovirus
• Bacteria
– H. Infulenza 16-37%
– M. Catarrhalis 11-23%
– S. Pyogenes 13%
– S. Aureus 5%
ROUTES OF INFECTIONS
– Eustachian tube
• negative middle ear pressure
 movement of bacteria up
the tube
• shorter, straighter and more
patulous tube
– Tympanic membrane
perforations / grommets
• Associated with water
exposure
– Haematogenous
 Managements Management of recurrent acute
otitis media
– Conservative
• Simple analgesic & anti- – Alteration of risk factors
pyrexials (paracetamol &
ibuprofen) • Sitting a child semi-upright if
– Medical bottle fed, avoiding passive
• Antibiotics (after 2-3 days of smoke inhalation
watchful waiting  fail to • Restricting use of pacifiers after
improve)
– Amoxicillin (1st )
infancy for otitis prone children
80mg/kg/day • Continue breastfeeding at least 6
– Macrolide  penicillin- mo + vitamin C & NO alcohol
sensitive & drug-resistant
pneumococci – Medical prophylaxis
– Amoxicillin-clavulonate /
cefuroxime • Antibiotics, xylitol, vaccination
– Ceftriaxone IM (virus & bacterial),
• Antihistamines & immunoglobulins, benign
decongestants
commensals (alpha streptococci)
– Surgery
• Myringotomy – Surgical prophylaxis
– Severe case (present of • Ventilation tube
complication) & relieve pain
/ when microbiology is • Adenoidectomy &
strongly required
adenotonsillectomy
 COMPLICATION
– Intracranial
• Meningitis
• Extradural abscess
• Subdural empyema
• Sigmoid sinus thrombosis
• Focal otitic encephalitis
(cerebritis)
• Brain abscess
• Otitic hydrocephalus
– Extracranial
• Tympanic membrane
• Acute mastoiditis
• Petrositis
• Facial nerve palsy
• labyrinthitis
ACUTE OTITIS MEDIA IN ADULTS

DEFINITION AETIOPATHOLOGY
The term ‘acute otitis media’
implies a viral or bacterial
infection of the mucosal lining of
the middle ear and mastoid air-
cell system. It is characterized by
an otoscopically abnormal
tympanic membrane. The clinical
presentation is usually with
otalgia and systemic illness.
 HISTORY
 Several symptoms suggest
the diagnosis of acute otitis
media:
 local symptoms: ear ache,
impaired hearing, otorrhea,
tinnitus
 general symptoms: fever,
irritability, nocturnal
agitation, gastrointestinal
signs (abdominal pain,
diarrhea, vomiting,
anorexia).
PHYSICAL EXAMINATION
– Inspection of the eardrums is indicated
to establish or exclude the diagnosis of
acute otitis media. Inspection of the
eardrum will help the general
practitioner estimate the gravity of the
illness.
– Both eardrums should be inspected and
compared.
– Cerumen or detritus can be removed
with Q-tips soaked in oil, a cerumen
loop or, preferably, a vacuum
aspirator. The ear should not be rinsed
by means of a syringe. For patients
with acute otitis media, the latter
procedure is very painful.
 DIAGNOSIS
– The diagnosis is based on a
combination of the history and the
image of the tympanum:
• a normal tympanum is pearl grey
and transparent, with a clear light
reflex. This finding excludes acute
otitis media;
• an injected tympanum can
indicate early acute otitis media,
but can also be caused by crying
or by a common cold. A clear
difference in redness between left
and right tympanum supports the
diagnosis of acute otitis media;
DIAGNOSIS
• an intensely red tympanum
confirms the diagnosis of
acute otitis media;
• a bulging tympanum
indicates the presence of
liquid in the middle ear
under pressure. This feature
also confirms the diagnosis
of acute otitis media;
• perforation of the tympanum
with otorrhea (within an
acute clinical picture) also
confirms the diagnosis of
acute otitis media.
 BULLOUS MYRINGITIS
DEFINITION EPIDEMIOLOGY
~ myringitis bullosa haemorrhagica – Children, adolescents, young
 the findings of vesicles in the adults
superficial layer of the tympanic
membranes • 4% of 2028 children aged 7-
24 mo
PATHOLOGY
– Vesicles occur between the outer
epithelium & the lamina propria of
the tympanic membrane

ETIOLOGY
– Culture  similar to that in acute
otitis media
– Influenza virus / Mycoplasma
pneumoniae (suggested)
 SYMPTOMS
– Sudden onset of severe,
usually unilateral, often
throbbing pain in the ear
– Usually set in during /
following an upper respiratory
tract infection
– Bloodstained discharge
(couple of hours)
– Hearing impairment
SIGNS
– Otoscopy
• Blood filled, serous blisters
in tympanic membrane
• Intact tympanic membrane
• Middle ear fluid (97%)
– Hearing impairment
OTHER EXAMINATION
– Inspection of ear using
microscope
– Pneumatic otoscopy &
tympanometry
•  determine fluid in middle
ear
– Clinical evaluation of cranial
nerves (facial nerve) DD
– Pure tone audiogram Acute otitis media
Herpes zoster oticus
Ramsay hunt sydnrome
 OUTCOMES MANAGEMENTS
– Complete recovery (majority) – Without middle ear affection
– Hearing impairment & sensorineural hearing loss
• Sensorineural hearing  analgesic
impairment (15-67%) – Middle ear affected  acute
otitis media’s treatment
– Children < 2yo  acute otitis
media’s treatment
– Antibiotics
• Amoxicillin (60-100%
recovered)
 MASTOIDITIS
DEFINITION
 inflammation with the
mastoid air-cell system
– Extension of infection &
inflammation during acute
otitis media
• Traditional teaching 
preceed by 10-14 days of
middle ear symptoms
Etiology
– 20% dont grow bacteria
– S. Pneumoniae, S. Pyogenes,
P. Aeruginosa, S. Aureus
(common)
– H. Influenza (< common); M.
Catarrhalis, P. Mirabilis
(rare)
Epidemiology
– Disease of childhood
• 28 % < 1yo; 38%  4yo; 8%
 8-18yo; 4%  > 18 yo
– US  1..2 – 2% per 100,000
 SYMPTOMS
– Systemic signs of infection
(fever & malaise)
– Mastoid tenderness &
localized reactive
lymphadenopathy
– In children
• Erythema &/ edema of
everlying mastoid soft tissue
• Otalgia & irritability
– In adult
• Local pain & tenderness
– Otorrhea (30%)
SIGNS
– Red/buldging tympanic memb
– Retro-auricular swelling
– Tenderness is typically sited
over MacEwen’s triangle
• On palpation through
conchal bowl)
– Pinna protrusion
– Sagging of post wall of ext
auditory canal
 CLINICAL COURSE
– Infection may spread to mastoid periost
via emissary veins  acute mastoiditis
& periostitis  no abscess; symptoms
(+)
– Destruction of mastoid bone’s air cells

• Subperiosteal abscess (post auricular
region)
• Zygomatic abscess (above & in front of
pinna)
• Bezold’s abscess
• Retropharyngeal / parapharyngeal
abscess
– Pus tracking down peritubal cells
– Subacute (masked) mastoiditis in
incompletely treated AOM after 10-14
days of infection
• Sign (-); otalgia & fever persist 
serious complication
 EXAMINATION
– Full blood count, CRP, blood
culture
– CT scan of mastoid
• Reveal osteitis, abscesses,
intracranial complications
DD
– AOM
– Otitis externa
– Furunculosis
– Reactive lymphadenopathy
– Undiagnosed cholesteatoma
– Wegener’s granulomatosis
 TREATMENT COMPLICATIONS
– Intracranial complications (6-
– Modern antimicrobials + 17%)
radiographic monitoring
– Early performance of
myringotomy
– Mastoid surgery
(mastoidectomy)
• Indication  failure of
improvement despite aggressive
medical management,
development of other
intracranial complications
• Goal of surgery  drainage of
mastoid, removal of granulation
tissue, restoration of normal
ventilatory pathways
• + continuation of antibiotic
theraoy postoperatively for
weeks
Bellanger's otorhinolaryngology 17th
 TREATMENT
– Myringotomy with/-out
ventilation tube placement
– Culture of aspirate & high-
dose IV antibiotics
– Abscess drainage with/-out
cortical mastiodectomy
• If failure to improve,
subperiosteal abscess
formation, complication
developments

Scott-Brown’s otorhinolaryingology, head & neck surgery