INSTALLATION PIPE GROMMET ON PATIENT OTITIS MEDIA EFFUSION

Anatomy Ear Outside

The outer ear consists of the auricle, ear canal and tympanic membrane. part lateral. Leaf the ear consists of from bone vulnerable elastin And The skin functions to collect sound waves, while the ear canal transmits them voice going to membrane timpani. Liang ear shaped S with a length of 2.5-3 cm. The outer third consists of cartilage containing many cerumen glands and hair, while the inner two-thirds consist of bone with little cerumen. ¹¹

Anatomy Middle Ear

The middle ear is a cavity that contains air and keeps air pressure balanced. The middle ear is cube-shaped which functions to conduct sound sound from ear outside to ear in. Part front room The ear is limited by the tympanic membrane, while the inside is limited by the foramen ovale and foramen rotundum. In the middle ear space there are the following parts: ¹¹

1. Membrane Timpani

Membrane timpani shared become two part, that is pars flaccida which is located at the top and pars tensa which is located at the bottom. Pars tensa is the part most big consists of from three layer. Layer outside called layer consists of from a smooth pseudostratified epithelial layer that normally reflects light. The inner layer called the mucosal layer, is a layer bordering with tympanic cavity and the layer between them. This layer consists of two layers of fibrous connective tissue that unite with a fibrocartilage ring that surrounds the tympanic membrane. The pars flaccida does not have a fibrous layer, so this is the first part to experience retraction when there is negative pressure in the ear. The tympanic membrane functions as a receiver of sound waves sound. Every There is wave sound Which enter hallway ear will be received by the tympanic membrane, then the tympanic membrane will bulge inward towards the middle ear and will touch the auditory ossicles, namely the malleus, incus and stapes. The auditory ossicles will transmit the sound waves to the inner ear . ¹¹

2. The bones hearing

The auditory ossicles consist of the malleus, incus and stapes. The long process of the malleus is attached to the tympanic membrane, the malleus is attached to the incus, and the incus attached to stapes. Stapes located on window oval Which associated with cochlea. Third bone the to form series bone Which across the middle ear and merges with the tympanic membrane. ¹¹

3. Cavity Timpani

The tympanic cavity is divided into three parts that are connected to the tympanic membrane plate, namely the epitympanum, mesotympanum and hypotympanum. The epitympanum is limited by a thin protrusion, namely tegmen tympani. The anterior part of the epitympanum contains the ampulla of the superior canal. In the anterior part of the ampulla of the superior canal there is the geniculate ganglion which is sign end front room Atik. Atik on part posterior narrows into the entrance to the mastoid antrum, namely the aditus ad antrum. Mesotympanum, in part medial restricted by capsule otic Which located more low than

n. Facialist pars tympani. The hypotympanum is a shallow space located lower than the tympanic membrane. The hypotympanum extends from the lateral semicircular canal to the posterior semicircular canal anteromedially.  sine  sigmoid. Corner  This  will found with throw away as clean as possible the mastoid pneumatization cells between the lateral semicircular canal and the sinodural angle. Trautman's triangle is the area located behind the antrum which restricted by the sigmoid sinus, lateral sinus And bone labyrinth. Limit medial is plate Dura posterior fossa. ¹¹

1. Anatomy Inner Ear

The inner ear consists of two parts, namely the bony labyrinth and the membranous labyrinth. The bony labyrinth consists of the cochlea, vestibule, and semicircular canals, while the membranous labyrinth consists of the utricle, saccule, cochlear duct, and semicircular ducts. The cavity of the bony labyrinth is lined by a thin layer of internal periosteum or endosteum, and is mostly filled with trabeculae (its arrangement resembles a sponge). The cochlea (snail house) is shaped like two and a half circles. End or peak cochlea called helicotrema, connect

On the superior part or roof of the mastoid antrum is bordered by the tegmen tympani, wall medial And floor from cavity mastoid This restricted by pars petrous and mastoid part of the temporal bone, the lateral part of the mastoid cavity is bordered by squama part outside from pars mastoid, on part medial from mastoid cavity there is aditus ad antrum which connects the mastoid cavity with the middle ear. At the time of birth the thickness of the antrum wall is only 1-2mm but when adults the thickness can reach 9-10mm. As previously stated that the mastoid cavity is shaped like a triangle whose apex will point caudally, and this part is the mastoid process. ¹²

Cavity mastoid is mastoid water cell the biggest Which is at in the petrous part of the temporal bone. The mastoid air cells themselves have many sizes, from the small one to the big one. In the section above and front from The shape of the mastoid air cell in the temporal bone tends to be irregular and large and contains air, but if we look towards the bottom, the size of the mastoid air cell tends to be irregular and large and contains air. mastoid cell This will the more shrink, And even on part apex water mastoid cell Which is at there size very small or even rather contains bone marrow. ¹²

1. Vascularization, Flow Lymph And Innervation Ear

Artery auricularis posterior And branch auriculotemporal from artery The superficial temporal artery originates from the external carotid artery and supplies blood to the auricle and the cranial cavity. ear lateral. Branch auricularis deep from artery maxillary give

blood supply to the more medial aspect of the ear canal and the outer surface of the tympanic membrane. ¹¹ The vascularization of the middle ear is served by 6 arteries, namely the anterior branch of the maxillary artery which serves the tympanic membrane, the stylomastoid branch a. auricularis posterior Which serve ear middle And cells mastoid airway, petrosal branch of the internal meningeal artery, superior tympanic branch of the internal meningeal artery, pterygoid branch and tympanic branch of the internal carotid artery. ¹¹

The inner ear receives its vascular supply from the labyrinthine artery, which is a branch of the antero-inferior artery cerebellar. auricular vein posterior and superficial temporalis flowing hole ear. Veins auricularis posterior continued with the sigmoid sinus. The middle ear drains venous blood through the pterygoid venous plexus And sine petrosus superior. Flow blood vein ear in through

v. internal auditory, v. cochlear aqueduct and v. vestibular aqueduct. ¹² Streams lymph from ear middle flow to retropharyngeal And gland parotid,

while the Eustachian tube lymph flows to the retropharyngeal group. ⁵ The auricle and external acoustic canal are innervated by the auricular temporal branch of the mandibular division of the trigeminal nerve, the greater auricular nerve from the cervical plexus, the auricular branch of the vagus nerve, namely the Arnold nerve, and branches of the facial nerve. And glossopharyngeus. Part lateral, medial And posterior ear innervated by nerves auricularis major. Nerve Arnold to innervate pars osseous hole lower ear, the cartilaginous part of the posterior superior ear canal and the corresponding segment of the membrane timpani And simba concha. Liang ear part posterior superioris innervated by branches of the facial nerve. The contribution of the trigeminal and glossopharyngeal nerves is not well described. ^11,12

Nerves main ear middle served by plexus tympanicus And nerve of Jacobson, which receives its main supply from the glossopharyngeal n. The tympanic plexus provides innervation on surface medial membrane timpani, cavity tympani, mastoid air cells and bony part of the Eustachian tube. The chordatympanic nerve is a branch of the facial nerve that enters the middle ear through the posterior canaliculus and runs to the medial surface of the tympanic membrane between the arm of the malleus and the long process of the incus above the attachment of the tensortympanic tendon. The chorda tympani also supplies taste to the anterior two-thirds of the tongue and supplies secretomotor fibers to the submaxillary and sublingual salivary glands. ^11,12

Pathophysiology

Pathophysiology Ome nature multifactorial between other infection virus or bacteria, Eustachian tube dysfunction, immunological status, allergies, environmental and social factors.1 ¹⁶ There is a number of theory Which be the cause the occurrence disease otitis media with effusion, The first is Eustachian tube dysfunction. The Eustachian tube has three functions, namely regulatory function, protection function, and secretion. Conditions that can causes tubal dysfunction classified into two, namely functional factors and mechanics. Mechanical factors are caused pressure enlarged adenoids or neoplasm, process inflammation Which caused by infection, allergies, or trauma. Disruption of the tube function causes the aeration mechanism to the middle ear cavity. disturbed, drainage from cavity ear middle to cavity nasopharynx disturbed And disturbance mechanism protection cavity ear middle against reflux from the cavity nasopharynx. Consequence the disturbance cavity ear the middle will experience negative pressure. Negative pressure in middle ear causes an increase permeability capillary And furthermore happen transudation. Besides there is infiltration of the inflammatory cell population and glandular secretions. As a result of the accumulation Secret in middle ear cavity. Inflammation chronic in the middle ear will cause formation network granulation, fibrosis, And destruction bones. ^14,15,16 Theory both of which cause occurrence of otitis media with effusion is there is a condition And syndrome Which influence form one third middle face and the base of the throat such as Down syndrome and cleft lip. Children with lips chippy can experience insertion tensor veli palatine Which abnormal in the sky - sky soft Which cause inability For open tube eustachius adequately during swallowing and opening the mouth. This condition greatly influences the increased risk of otitis media with effusion. ^15,16

The third theory that causes otitis media with effusion is as a residual symptom of acute otitis media, where in children with acute otitis media, 45% were found to suffer from Otitis media with effusion in 1 month after that and 10% on 3 months after that. Things This Can happen estimated that pepsin on 60% of middle ear effusions cause upregulation of mucin genes which leads to increased secretion season Which Can become place develop breed for upper respiratory tract bacteria. ¹⁶

The fourth theory that causes OME is secondary and subclinical bacterial infections such as pepsin which increases secretion season, cytokines, and also positive bacteria found in the examination of Otitis media effusion. The last theory that also causes the disease otitis media with effusion is related to gastroesophageal reflux disease where the pepsin in the middle ear effusion comes from reflux ^15,16

Factor immunological And factor allergy Also play a role in the occurrence O.M. In immunological factors that play a significant role in OME is secretory Ig A. This immunoglobulin is produced by glands in the mucosa of the tympanic cavity. Secretory Ig A is mainly found in mucoid effusions and is known as an immunoglobulin. Which active Work on the surface mucosa respiratory. His work namely blocking germs so as not to have direct contact with surface epithelium, by forming complex bonds. Direct contact with the epithelial cell wall is the first stage of germ penetration for tissue infection. Thus Ig A actively prevents infection germs. In allergic factors, the rationale used is the embryogenic analogy, where the tympanic mucosa originates from the same as the nasal mucosa. At least allergic manifestations in the Eustachian tube are the cause of chronic occlusion and subsequently cause effusion. However, from study level Ig E which become criteria allergy atopic, good the level in effusion and in serum does not fully support allergies as Cause. Etiology and the pathogenesis of otitis media due to allergies may be caused by one or more from mechanism like mucosa ear middle as organ target organ, swelling due to inflammatory processes in the Eustachian tube mucosa, nasal obstruction due to inflammatory processes, and aspiration of nasopharyngeal bacteria found in allergic secretions into the middle ear space ^15,16,17

Diagnosis

Diagnosis of otitis media with effusion is not easy and there are significant differences according to the clinician's skills. To establish the diagnosis of OME, anamnesis, otoscopy, tympanometry, and audiometry are carried out. ^19,20

Anamnesis

OME often occurs in children, although this disease rarely causes complaints. The history of this disease is usually known from the parents or teachers of the children. The complaints conveyed are an attitude of indifference towards voice surrounding, disturbance or delay talk, And Also learning achievement child Which the more decrease. On children Which more big or Adults usually feel an uncomfortable feeling in the ear (feeling full), ringing in the ears Which echo on ear, Possible Also obtained tinnitus. Anamnesis not in get complaint presence of signs of infection. ^15,16 The medical history needs to be explored completely and the risk factors for OME in patients should be sought. Immunological status, nutritional status, history of allergies in patients and their families, and abnormalities congenital that accompanies, for example palatoschisis is factors that should be considered in patients suspected of having OME. ^16,19

Otoscopy

Examination conducted to assess the condition, color, and translucency of the tympanic membrane. Various changes due to abnormalities that occur in the tympanic membrane can be seen as follows ^19,20 :

1. A dull, yellowish tympanic membrane changes the picture. translucent light besides That location triangle reflex light on 6 the anteroinferior quadrant is shortened, there may also be an increase in capillary blood vessels in the tympanic membrane. In cases with mucoid or mucopurulent fluid, the tympanic membrane is lighter in color.

2. Tympanic membrane retraction namely when the manubrium of the malleus appears shorter and more horizontal, the membrane appears more concave and the light reflex shortens. The color may turn slightly yellowish.

3. Atelectasis membrane timpani usually thinning, atrophy And Possible stick to incus, stapes And promontory, specifically on cases Which already continued, usually case This Because dysfunction tube eustachian tube And Ome Which Already walk in time that long.

4. Membrane timpani with cicatrix, gloomy until retraction heavy accompanied by with the atrophic part found in adhesive otitis media due to the occurrence of middle ear fibrotic tissue as a result of a previous inflammatory process that lasted a long time. This condition can be a complication of supurative otitis media or non-suppurative OME which causes damage to the middle ear mucosa. During healing, fibrotic tissue is formed which causes adhesions.

5. Fluid level water image or bubbles are usually found in OME with serous fluid.

6. A dark blue or purple tympanic membrane is seen in cases of hemotympanum. Which due to by fracture bone temporal, leukemia, vascular tumor of the middle ear. The lighter blue color may be due to barotrauma.

Otoscopic examination shows suspicion of OME if the following ¹⁹ signs are found :

1. No existence signs inflammation I

2. There is change color membrane timpani consequence reflex from existence fluid in the tympanic cavity

3. Membrane timpani looks more prominent

4. Membrane retraction or atelectasis

5. Got it water fluid levels or bubbles

6. Mobility membrane reduce or fixation

Sadness And Berco describe 4 stadium from retraction membrane timpani ²⁷ :

• stadium I : membrane timpani retraction light

• stadium II : membrane timpani retraction And contact with incus or stapes

• stadium III : atelectasis ear middle (  membrane timpani touch

  promontory)

• stadium IV : otitis media adhesive (membran timpani attached             to the promontory)

Hearing loss is more common in OME patients with fluid. Which thick (glue ears). Although thus a number of studies say there is no significant difference between serous and thick fluids on hearing loss, whereas volume fluid Which found on ear middle is more influential. Patients with OME on audiogram are often found to have hearing loss with mild conductive hearing loss (CHL). until currently so that No so affected with life a day-

days. Patients with severe conductive hearing loss may have had fixation or rupture of the ossicular chain . ²² The OME guidelines jointly developed by the AAFP and AAOHNS and AAP state that audiometry is one component of the examination of patients with OME. Audiometry is recommended on patient with Ome in 3 month or more or suspected to exist decline hearing meaningful. Based on statement in accordance with some studies, conductive deafness is often associated with OME and has an effect on process hear second ear, localization voice, perception talk in noise. ^22,23

1. Radiology

Effective radiological examinations for OME screening include plain mastoid radiographs, which will but this examination has long been abandoned. CT-scan is very sensitive For to uphold diagnosis especially For get rid of the presence of complications of otitis media such as mastoiditis, sigmoid sinus thrombosis, or cholesteatoma, but this examination is not really necessary in establishing the diagnosis of OME. CT-scan plays an important role in unilateral OME patients to rule out the possibility of a mass in the nasopharynx. ²²

Management

Generally OME resolves spontaneously within 3 months, conservative treatment in the form of steroid intranasal or steroid systemic, antibiotics, antihistamines, and decongestants are no longer recommended. So observation is carried out or watchful waiting for 3 months from the onset of effusion or since the diagnosis was made especially for children who are not at risk for speech and language disorders or learning disorders. Clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery do not recommend the use of oral or intranasal corticosteroids. ²⁷ This is also similar to Berkman et al. oral steroid administration during 2 months with results There is no benefit in using oral steroids as therapy for OME. Principi et al. said that giving decongestants is not recommended as a treatment for OME because it has not been proven to be effective and can increase risk of developing rhinitis medicamentosa. Treatment And control to allergy can reduce or cure OME. ^19,20 Barazi et al said Desloratadine is effective in treating children with OME especially with a history of allergies, because it can accelerate the resolution of effusion and hearing loss, reducing the number of ventilation tube requirements. ^10,24

Operative treatment is performed in cases where conservative treatment for more than 3 months does not heal. There are several indications for operative action in OME in the form of hearing loss associated with OME, suspicion of speech and language delay, autism spectrum disorder and other developmental disorders, Down syndrome or craniofacial disorder . To provide good results for drainage, myringotomy and installation of a tympanostomy tube or ventilation pipe are performed. ^24,25 The tympanostomy tube was first introduced by Beverley Armstrong in 1954 and is still used until now. This tube designed to remain within the tympanic membrane and prevent rapid closure of the myringotomy incision. These tympanostomy tubes are small and well tolerated by the tympanic membrane. Tympanostomy tubes can be maintained for 1-2 years depending on the type used. Tympanostomy tubes must be placed in a normal area. Areas that are myringosclerotic will result in tube tympanostomy more easy let go And No well fixed. Tympanostomy tubes placed in normal areas will be surrounded by sclerotic tissue that allows the tympanostomy tube to be installed longer. Tympanostomy tubes are placed in the antero inferior quadrant area or poster inferior. Tube tympanostomy will maintained until patent tube function. ^26,27 The purpose of installing a tympanostomy tube or ventilation tube is to eliminate fluid on ear middle, overcome disturbance hearing that occurs, preventing recurrence, preventing cognitive, speech development disorders, Language And psychosocial. There is Lots type tube tympanostomy, start from the shape, size, and basic materials used to make it. Based on size and shape, there are Which installed only For a number of month And There is Which maintained until some year. For example tube bobbin type installed For 6 until 18 month. This tube is removed when the tympanic membrane heals. While the T-type tube is installed for several years to prevent repeated installation. However, the disadvantage tube T-type This is cause perforation permanent And triggerthe occurrence of cholesteatoma. As with short-term tubes, long-term tubes also often become blocked by cell debris, requiring tube replacement. ^26,27,28 Examples of tympanostomy tubes like Paparella, Shepard, Armstrong Gommet, Reuters Bobbin, and T tube.

4  Complications

The further consequences of OME can result in hearing loss which will affect speech and intellectual development. Changes that occur in the middle ear can cause the disease to progress to atelectasis and adhesive otitis media. ^21,23

Atelectasis and adhesive otitis media usually occur together with OME, although OME can resolve allowing aeration of the attic and mastoid, but not all patients with chronic OME develop atelectasis. Permanent damage due to OME can cause partial or total hearing loss. ²³

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