2.1 Anatomi dan Fisiologi Telinga Tengah

Telinga tengah merupakan rongga berisi udara yang terbagi atas kavum

timpani dan air cell mastoid (Probst dkk., 2006). Telinga tengah terdiri dari

membran timpani dan 3 tulang kecil yaitu maleus, inkus dan stapes. Di dalam

telinga tengah juga terdapat dua otot kecil yaitu m. tensor timpani yang melekat

pada manubrium maleus dan m. stapedius yang melekat pada stapes. M. tensor

timpani dipersarafi oleh n. trigeminus sedangkan m. stapedius dipersarafi oleh n.

fasialis. Korda timpani adalah cabang n. fasialis yang berjalan menyeberangi

rongga telinga tengah. Tuba Eustachius menghubungkan rongga telinga tengah

dengan faring (Moller, 2006). Membran timpani berbentuk agak oval dan

merupakan selaput tipis pada ujung liang telinga. Gendang telinga berbentuk

kerucut dan agak cekung bila dilihat dari liang telinga. Bagian utama dari gendang

telinga disebut pars tensa dan bagian kecilnya disebut pars flasida yang lebih tipis

dan terletak di atas manubrium maleus. Gendang telinga ditutupi oleh selapis sel

epidermis yang berlanjut dari kulit liang telinga. Tuba Eustachius terdiri dari

bagian tulang atau protimpanum yang berlokasi dekat rongga telinga tengah dan

bagian tulang rawan yang membentuk celah tertutup saat berakhir di nasofaring

(Moller, 2006).

The Eustachian tube consists of a bony part (the protympanum) that is

located close to the middle ear cavity, and a cartilaginous part that forms a closed

slit where it terminates in the nasopharynx.

(A) Cross-section of the human middle ear to show

the Eustachian tube.

(B) Orientation of the Eustachian tube in the adult. The tensor veli palatini

is shown (both reprinted from Hughes, 1985, with permission from Thieme

Medical Publishers).

The optimal function of the middle ear depends on keeping the air pressure

in the middle-ear cavity close to the ambient pressure. That is accomplished by

briefly opening the Eustachian tube. In the adult, the Eustachian tube is 3.5–3.9

cm long and it follows an inferior (caudal) – medially – anterior (ventral)

direction in the head, tilting downwards (caudally) by approximately 45 degrees

to the horizontal plane. The Eustachian tube is shorter in young children and it is

directed nearly horizontally. The cartilaginous part of the Eustachian tube forms a

valve that closes the middle ear off from pressure fluctuations in the pharynx such

as occurs during breathing and it decreases transmission of a person’s voice to the

middle-ear cavity. The mucosa inside the Eustachian tube (which really is not a

tube except for the bony part) is rich in cells that produce mucus and it has cilia

that propel mucus from the middle ear to the nasopharynx. The slit shaped

cartilaginous part of the Eustachian tube allows transport of material from the

middle-ear cavity to the nasopharynx but not the other way. The most common

way the Eustachian tube opens is by contraction of a muscle, the tensor veli

palatini muscle. The tensor veli palatini muscle is located in the pharynx and

innervated by the motor portion of the fifth cranial nerve. This muscle contracts

naturally when swallowing and yawning, and some individuals have learned to

contract their tensor veli palatine muscle voluntarily. The Eustachian tube can also

be opened by positive air pressure in the middle ear cavity but not by negative

pressure, which in fact may close it harder.

The middle-ear cavities consist of the tympanum (the main cavity) that lies

between the tympanic membrane and the wall of the inner ear (the

promontorium), a smaller part (the epitympanum) that is located above the

tympanum, and a system of mastoid air cells. The head of the malleus is located in

the epitympanum. The middle-ear cavity and the Eustachian tube are covered with

mucosa. The total volume of the middle-ear cavities is often given to be

approximately 2 cm3, but the size of the middle-ear cavities varies considerably

from person to person and if the volume of the mastoid air cells is included, the

total volume can be as large as 10 cm3.

Fisiologinya belum lengkap

2.2 Otitis Media Serosa

OME is associated with ear discomfort and recurrences of acute otitis media

(AOM) and often follows an episode of AOM. Transient hearing loss is frequently

associated with OME. Spontaneous resolution of OME occurs in 90 per cent of

patients within three months of infection (otitis)

Otitis media with effusion (OME) is defined as middle-ear effusion (MEE) in the

absence of acute signs of infection. In children, OME—also referred to as “glue

ear”—most often arises after acute otitis media (AOM). In adults, it often occurs in

association with eustachian tube dysfunction, although OME is a separate

diagnosis. (jfp 06212)

(Rezes slizard)

Otitis media with effusion (OME) is a common condition of early

childhood in which an accumulation of fluid within the middle ear space causes

hearing impairment. The hearing loss is usually transient and self-limiting over

several weeks, but may be more persistent and lead to educational, language and

behavioural problems. OME may be overlooked because of the insidious nature of

the condition, and suspicion of hearing loss in children must be acted upon

effectively. In most instances of uncomplicated OME, no intervention is required

because the fluid clears spontaneously and the hearing recovers (pdf).

Otitis media with effusion (OME) is a middle eardisease characterized by presence of mucoid effusionin the middle ear without any signs of acute infection.1

This is a common clinical entity among the children.Since the disease is benign with an insidious onset,the diagnosis is usually delayed. The presence of fluidin the middle ear results in the impaired mobility oftympanic membrane and a conductive type of hearingloss. The complications and sequels of OME are animportant public health problem. The patients willhave impaired development of speech and language,poor school performance, tympanosclerosis, retractionpockets and psychosocial problems.2, 3, 4

The pathogenesis of otitis media with effusion isstill controversial. The causes such as Eustachiantube dysfunction, insufficient pneumatization ofmastoid, craniofacial abnormalities, infections,immunodeficiency, and allergic agents are widelydiscussed. Various risk factors are implicated suchas sex, race, premature delivery, passive smoking,allergy, asthma, family size, bottle feeding,socioeconomic status, cleft palate, adenoid hypertrophy,

have been studied and are still controversial(IMJM)

2.2.1 Epidemiologi Otitis Media Serosa

Experts have found it difficult to determine the exact incidenceof OME because it is often asymptomatic. In addition,many cases quickly resolve on their own, making it challengingto diagnose. A 2-year prospective study of 2- to 6-year-old preschoolersrevealed that MEE, diagnosed via monthly otoscopyand tympanometry, occurred at least once in 53% of the children

in the first year and in 61% of the children in the secondyear.3 A second study followed 7-year-olds monthly for one yearand found a 31% incidence of MEE using tympanometry.4 In the25% of children found to have persistent MEE, the researchersnoted spontaneous recovery after an average of 2 months. (jfp-06212)

We believe that nearly all children haveexperienced one episode of OME by the ageof 3 years, but the prevalence of OME varieswith age and the time of year. It is more prevalentin the winter than the summer months.5

OME is more common in Caucasian childrenthan in African American or Asian children. (jfp 06212)

The prevalence of OME in Malaysian children betweenthree months to twelve years old is 18.3%. Thosechildren suffering from frequent episodes of AOMhave increased risk of development of OME later on.Other factors such as gender, race, household size,daycare center attendance, breastfeeding, exposure tosmoking, allergy, asthma were not statisticallysignificant. (IMJM)

2.2.2 Etiologi dan Faktor Resiko Otitis Media Serosa

Risk factors for children include a familyhistory of OME, bottle-feeding, day care attendance,exposure to tobacco smoke, anda personal history of allergies.7,8 One studyconducted on mice suggested that inheritedstructural abnormalities of the middle earand eustachian tube may play a role as well.9

Some have suggested that effusions of OMEin children result from chronic inflammation,for example, after AOM, and that theeffusions are sterile; however, recent studieshave demonstrated that a biofilm is formedby bacterial otopathogens in the effusion.10-12

The common pathogens found include nontypeableHaemophilus influenza, Streptococcuspneumoniae, and Moraxella catarrhalis.Inflammatory exudate or neutrophil infiltrationis rare in the fluid, however.The contribution of allergies to OME inchildren remains somewhat controversial. Aretrospective review from the United Kingdomof 209 children with OME found a historyof allergic rhinitis, asthma, and eczema in89%, 36%, and 24%, respectively.13 However,this study was done at an allergy clinic, andit is possible that the data from the clinic’s

specialized patient population are not generalizable.Gastroesophageal reflux may also beassociated with OME in children. However,studies measuring the concentration of pepsinand pepsinogen in middle-ear fluid haveprovided conflicting results (jfp 06212)

Eustachian tube dysfunction is considered the major etiologic factor resulting in

the development of middle ear disease. Blocked Eustachian tubes can cause

several symptoms, including ears that hurt and feel full, ringing or popping noises,

hearing problems, feeling a little dizzy [1]. Dizziness or vertigo from Eustachian

tube obstruction can be explained by increase of inner pressure of vestibular

organ. It is because negative middle ear pressure gives rise to the retraction of

tympanic membrane, and it makes the stapes push the oval window. Improvement

of tinnitus after Eustachian tube catheterization can mean that the tinnitus is from

the hypersensitivity of cochlear nucleus following decrease of afferent nerve

stimuli owing to air-bone gap [2]. When I need to explain the cause of headache

from negative middle ear pressure, I support the theory of ‘Sinus headache’ [3].

Middle ear cavity and mastoid cavity are named on the basis of anatomy.

However, if we view things from a different angle, we can regard them as one of

‘paranasal sinuses’ like maxillary sinus or frontal sinus in a view of physiology

and function. Mechanical obstruction of the Eustachian tube may be either

intrinsic or extrinsic. Intrinsic mechanical obstruction is usually caused by

inflammation of the mucous membrane lining of the Eustachian tube or an allergic

diathesis causing edema of the tubal mucosa. Extrinsic mechanical obstruction is

caused by obstructing masses such as hypertrophic adenoid tissue or

nasopharyngeal tumors [4]. In these cases, some process should be performed to

rule out possible mechanical causes for such as middle ear effusion or/and

Eustachian tube obstruction before all. Furthermore, ideally normal middle ear

cavity pressure with balance between both ears is the essential prerequisite to be

checked before any other tests for vestibular function, tinnitus, ear fullness,

sensorineural hearing loss, headache, earaches, itching sensation of ear,

migrainous vertigo, etc. What is first, necessary and sufficient for it? Eustachian

tube catheterization (so-called ‘Rosenmuller method’) (JOENTR 01).

Otitis media with effusion (OME) is common amongchildren with cleft palate with or without cleft lip (CP6L);approximately 90% will develop this problem(Grant et al.,1988; Sheahan et al., 2003). Research suggests that healthrelatedquality of life for those with OME can be affecteddue to sleeping problems, irritability, and emotionaldistress, as well as hearing loss (Brouwer et al., 2005). (13-139)

Of thevarious otologic complications, postirradiation otitis mediawith

effusion (OME) is the most common problem,2 and thissignificantly impairs the quality of life of postirradiated NPCpatients with symptoms such as conductive hearing loss, eardiscomfort, and muffling. (329)

Risk factors for Developmental Difficulties • Hearing loss independent of OME • Suspected or diagnosed speech and language delay • Autism spectrum disorder • Syndromes (i.e. Down Syndrome) or craniofacial abnormalities that include cognitive, speech, or language delays • Blindness or uncorrectable visual impairment • Cleft palate with or without an associated syndrome • Developmental delay • Known or suspected exposure to environmental disorganization, lack of linguistic stimulation, or neglect (OM)

2.2.3 Patofisiologi Otitis Media Serosa

2.2.4 Tanda dan Gejala Klinis Otitis Media Serosa

Look for these signs and symptomsOME is often asymptomatic. If a patient hasclinical signs of an acute illness, includingfever and an erythematous tympanic membrane,it’s important to evaluate for anothercause. OME can present with hearing loss ora sense of fullness in the ear. While an infantcannot express the hearing loss, the parentmay detect it when observing and interactingwith the child. Parents are also likely toreport that the child is experiencing sleepdisturbances.16

z Vertigo may occur with OME, althoughnot often. It may manifest itself if thechild stumbles or falls. An older child or adultwith vertigo may say that it feels like the roomis spinning. (jfp 06212)

2.2.5 Penegakkan Diagnosis Otitis Media Serosa

Formal assessment of a child with suspected OME should include:

1. clinical history taking, focusing on:

- poor listening skills

- indistinct speech or delayed language development

- inattention and behaviour problems

- hearing fluctuation

- recurrent ear infections or upper respiratory tract infections

- balance problems and clumsiness

- poor educational progress

2. clinical examination, focusing on:

- otoscopy

- general upper respiratory health

- general developmental status

3. hearing testing, which should be carried out by trained staff using tests suitable

for the developmental stage of the child, and calibrated equipment

4. tympanometry.

Co-existing causes of hearing loss (for example, sensorineural, permanent

conductive and non-organic causes) should be considered when assessing a child

with OME and managed appropriately. (pdf)

Diagnosis relieson pneumatic otoscopyOn physical exam, the patient will likely appearwell. Otoscopic examination revealsfluid behind a normal or retracted tympanicmembrane; the fluid is often clear or yellowishin color.A subcommittee comprised of membersof the American Academy of Pediatrics,American Academy of Family Physicians, andthe American Academy of Otolaryngology-Head and Neck Surgery (AAP/AAFP/AAOHNS) published a clinical practiceguideline in 2004 that delineates the currentdiagnosis and management of childrenbetween 2 months and 12 years of age withOME.17

Pneumatic otoscopy, which can revealdecreased or absent movement of the tympanicmembrane (the result of fluid behindthe membrane), is the primary diagnosticmethod recommended by the guideline.Tympanometry and acoustic reflectometrymay also be used to make the diagnosis,especially when the presence of MEEis difficult to determine using pneumaticotoscopy.(jfp-06212)

2.2.5.2 Distinguish between OME and AOM

OMA OME

Children with AOM present with

combinations of ear pain (otalgia), loss

of landmarks, and an opaque, bulging,

inflamed tympanic membrane on direct

otoscopy. (otitome)

Diagnostic definition

Acute Otitis Media (AOM) (ICD-9-CM code 382.9) • Middle Ear Effusion (MEE) - demonstrated by pneumatic otoscopy, tympanometry, air fluid level, or a bulging tympanic membrane plus • Evidence of acute inflammation – opaque, white, yellow, or erythematous tympanic membrane or purulent effusion plus • Symptoms of otalgia, irritability, or fever

The diagnosis of OME is the presence of a

middle ear effusion in the absence of

symptoms. The effusion of OME can be serous,

mucoid, or purulent. (om)

Children with OME present with no evidence of acute inflammation despite visible fluid or reduced mobility on pneumatic otoscopy.1 The ear is not acutely painful, but the child may have ear discomfort and/or hearing loss (otitome).

Diagnostic definition

Otitis Media with Effusion (OME) (ICD-9-CM code 381.4) MEE without symptoms of AOM with or without evidence of inflammation

The diagnosis of AOM is based on the presence

of symptoms (ear pain, fever) in the context of

an inflamed middle ear effusion. (OM)

2.2.6 Penatalaksanaan Otitis Media Serosa

OMA OME

Therapy of OME • Children with middle ear effusions should be examined at 3 month intervals for clearance of the effusion [I, D*]. • Children with evidence of mucoid effusions or anatomic damage to the middle ear should be referred to otolaryngology if effusion or abnormal physical findings persist for 3 months [I, D*]. • Children with apparent serous effusions should be referred to otolaryngology if effusion persists for 6 months and there is evidence of hearing loss or language delay [I,

D*]. • Children with an asymptomatic middle ear effusion (no apparent developmental or behavioral problems) can be followed without referral [I, B*]. • Parents of all children with OME should be informed about approaches to maximize language development in a child with a possible hearing loss [I, C*]. • Decongestants and other nasal steroids have been shown not to decrease middle ear effusions [IIIA*]. (OM)

On Going Care When OME has been present for at least 12 weeks, observation is advised at 3

month intervals until the resolution of effusion. If there are concerns of

‘significant’ hearing loss or structural abnormalities of the tympanic

membrane, a formal hearing evaluation and referral to an otolaryngologist is

recommended (otitis)

Initial management of OME1,2If a child has OME, attempt to determine the length of time the effusion has been present. If the history obtained from the patient or parent suggests the effusion has been present for less than 12 weeks, re-examine the child on a six week basis. If the effusion has been present for 12 or more weeks, see Recommendation 3. Note: Decongestants, antihistamines, steroids, and antibiotics are not recommended in the treatment of OME. (otitome)

When OME has been present for 12 or more weeksA formal hearing evaluation and referral to an otolaryngologist should occur.

RationaleOtitis media with effusion (OME) is one of the most common illnesses of childhood and is often proceeded by an attack of AOM. OME is associated with ear discomfort, hearing loss and recurrences of acute otitis media (AOM). OME frequently is preceded by an episode of AOM and may take more than three months to clear. After an episode of AOM, fluid will be present in 50 per cent of patients after one month, in 25 per cent of patients after two months, and in 10 per cent of patients at three months.1

Monitoring and treatment of persistent OME has a number of goals. Language delay may be associated with OME and hearing loss. Treatment of this condition may promote age appropriate language development, although this treatment outcome has recently been challenged.3 Surgical treatment of chronic OME may prevent middle ear

complications, such as atelectatic tympanic membrane, permanent conductive hearing loss, cholesteatoma, etc.Medical treatment options for OME are generally ineffective. Antibiotics

may hasten the resolution of OME in only 14 per cent of cases.1,2 Other

interventions such as decongestants, antihistamines, steroids4 have

shown no benefit and should not regularly be used to treat this

condition. (otitome)

Rationale for OME RecommendationsAfter an episode of AOM, fluid will be present in 50 per cent of patients after one month, in 25 per cent of patients after two months, and in 10 per cent of patients at three months.28,30,31 Pneumatic otoscopy can be a useful clinical skill to help detect the presence of fluid behind the tympanic membrane.1 OME does not require antibiotic treatment. While OME has been linked to hearing loss and impaired development in

children, recent evidence indicates that persistent middle-ear effusion in

otherwise normal children does not cause long term developmental

impairments.8,10,30 Surgical treatment of chronic OME may prevent middle ear

complications, including: atelectatic tympanic membrane, permanent

conductive hearing loss, cholesteatoma, etc. If a child does become a

candidate for surgery, tympanostomy tube insertion is the preferred initial

procedure (otitis)

Appropriate time for intervention

1.3.1 The persistence of bilateral OME and hearing loss should be confirmed over

a period of 3 months before intervention is considered. The child's hearing should

be re-tested at the end of this time.

1.3.2 During the active observation period, advice on educational and behavioural

strategies to minimise the effects of the hearing loss should be offered. (pdf)

Children with persistent bilateral OME documented over a period of 3 months

with a hearing level in the better ear of 25–30 dBHL or worse averaged at 0.5, 1, 2

and 4 kHz (or equivalent dBA where dBHL not available) should be considered

for surgical intervention. (pdf)

Exceptionally, healthcare professionals should consider surgical intervention in

children with persistent bilateral OME with a hearing loss less than 25–30 dBHL

where the impact of the hearing loss on a child's developmental, social or

educational status is judged to be significant. (pdf)

Surgical interventions

Once a decision has been taken to offer surgical intervention for OME in children,

insertion of ventilation tubes is recommended. Adjuvant adenoidectomy is not

recommended in the absence of persistent and/or frequent upper respiratory tract

symptoms.

Children who have undergone insertion of ventilation tubes for OME should be

followed up and their hearing should be re-assessed. (pdf)

Non-surgical interventions

The following treatments are not recommended for the management of OME:

- antibiotics

- topical or systemic antihistamines

- topical or systemic decongestants

- topical or systemic steroids

- homeopathy

- cranial osteopathy

- acupuncture

- dietary modification, including probiotics

- immunostimulants

- massage.

Autoinflation may be considered during the active observation period for children

with OME who are likely to cooperate with the procedure.

Hearing aids should be offered to children with persistent bilateral OME and

hearing loss as an alternative to surgical intervention where surgery is

contraindicated or not acceptable. (pdf)

Management of OME in children with Down's syndrome

The care of children with Down's syndrome who are suspected of having OME

should be undertaken by a multidisciplinary team with expertise in assessing and

treating these children.

Hearing aids should normally be offered to children with Down's syndrome and

OME with hearing loss.

Before ventilation tubes are offered as an alternative to hearing aids for treating

OME in children with Down's syndrome, the following factors should be

considered:

- the severity of hearing loss

- the age of the child

- the practicality of ventilation tube insertion

- the risks associated with ventilation tubes

- the likelihood of early extrusion of ventilation tubes.

Management of OME in children with cleft palate

The care of children with cleft palate who are suspected of having OME should be

undertaken by the local otological and audiological services with expertise in

assessing and treating these children in liaison with the regional multidisciplinary

cleft lip and palate team.

Insertion of ventilation tubes at primary closure of the cleft palate should be

performed only after careful otological and audiological assessment.

Insertion of ventilation tubes should be offered as an alternative to hearing aids in

children with cleft palate who have OME and persistent hearing loss. (pdf)

Information for children, parents and carers1.9.1 Parents/carers and children should be given information on the nature andeffects of OME, including its usual natural resolution.1.9.2 Parents/carers and children should be given the opportunity to discuss optionsfor treatment of OME, including their benefits and risks.1.9.3 Verbal information about OME should be supplemented by written informationappropriate to the stage of the child's management.

Effectiveness of surgical procedures for treating OMEThere is a need for good-quality randomised controlled trials documenting the effect of adjuvantadenoidectomy with ventilation tubes compared to ventilation tubes alone in the management ofpersistent bilateral OME in children. Trials should be sufficiently powered (large) to accuratelydocument a probably small but continuing difference due to adjuvant adenoidectomy, and toidentify subgroups that would particularly benefit from surgical intervention.Why this is important

Despite a lack of robust scientific evidence, adjuvant adenoidectomy with ventilation tubeinsertion is routinely performed for recurrent or chronic persistent OME. There is, therefore, aneed for good quality, randomised controlled trials with large samples which address the powerdeficit in measuring any additional difference derived from adjuvant adenoidectomy. In particular,the proportion of time spent with middle ear fluid and any corresponding benefit to hearingshould be investigated. The trials need to follow up study participants beyond 6–12 months afterventilation tube insertion. This is because a high proportion of tubes would have fallen out duringthis period, and therefore any advantage that may exist for adjuvant adenoidectomy wouldbecome, in principle, demonstrable. Up to 2 years is a feasible follow-up period without highsample attrition. Further trials should also evaluate benefit to children's respiratory and generalhealth, and additional benefits (for example, re-insertion of ventilation tubes) which would addprecision to cost-effectiveness or cost–utility comparisons.

(JFP-06212)

How best to approach treatmentThere are several management options tochoose from, including watchful waiting,medication, and/or surgery. (Another option,autoinflation, which has shown some shorttermbenefits, is described in “Should yourecommend autoinflation?”17-19 at left.)The goals of management are to resolvethe effusion, restore normal hearing (if diminishedsecondary to the effusion), andprevent future episodes or sequelae. Themost significant complication of OME is permanentconductive hearing loss, but tinnitus,cholesteatoma, or tympanosclerosis may alsooccur.In most patients, OME resolves withoutmedical intervention. If additional action isrequired, however, the following options maybe explored.z Medication. While the AAP/AAFP/

AAOHNS guideline recommends againstroutine antibiotics for OME,17 it does notethat a short course may provide shorttermbenefit to some patients (eg, those forwhom a specialist referral or surgery is beingconsidered).A separate meta-analysis found that antibioticsimprove clearance of the effusionwithin the first month after treatment (ratedifference [RD]=0.16; 95% confidence interval[CI], 0.03-0.29 in 12 studies analyzed),but effusion relapses were common, and nosignificant benefit was noted past the firstmonth (RD=0.06; 95% CI, -0.03 to 0.14 in8 studies).20

If you do use antibiotics, a 10- to 14-daycourse is preferred.17 Amoxicillin, amoxicillin-clavulanate and ceftibuten have beenevaluated in separate clinical trials, but nonehas been clearly shown to have significantadvantage over any other. 21,22

Antihistamines, decongestants, and oraland intranasal corticosteroids have little effecton OME in children and are not recommended.17 A Cochrane review including 16studies found that children receiving antihistaminesand decongestants are unlikelyto see their symptoms improve significantly and many patients experience adverse effectsfrom the medications23 (number neededto harm=9).A randomized, double-blind trial involving144 children <9 years of age with OMEfor at least 2 months evaluated 4 regimensinvolving amoxicillin alone or in combinationwith prednisolone. Children in theamoxicillin+prednisolone arms were significantlymore likely to clear their effusions at 2weeks (number needed to treat=6; P=.03), butnot at 4 weeks (P=.12). At 4-month follow-up,effusions had recurred in 68.4% and 69.2%of those receiving amoxicillin+prednisoloneand those receiving amoxicillin alone, respectively(P= .94).24

z Surgery—or not? The AAP/AAFP/AAOHNS guideline recommends physiciansperform hearing testing when OME is presentfor 3 months or longer, or at any time iflanguage delay, learning problems, or a significanthearing loss is suspected in a childwith OME. The results of the hearing test canhelp determine how to proceed, based onthe hearing level noted for the better hearingear.You can manage children with hearingloss ≤20 dB and without speech, language,or developmental problems with watchfulwaiting. Children with hearing loss of 21 to39 dB can be managed with watchful waitingor referred for surgery. If watchful waiting is

pursued, there are interventions at home andat school that can help. These include speakingnear the child, facing the child whenspeaking, and providing accommodations inschool so the child sits closer to the teacher.Consider re-examination and repeat hearing tests every 3 to 6 months until the effusionhas resolved or the child develops symptomsindicating surgical referral.When hearing loss is ≥40 dB, the AAP/AAFP/AAOHNS guideline recommends thatyou make a referral for surgical evaluation(ALGORI THM).17

Other indications for referral to a surgeonfor evaluation of tympanostomy tubeplacement include situations in which thereis:• structural damage to the tympanic membraneor middle ear (prompt referral isrecommended)• OME of ≥4 months’ duration with persistenthearing loss (≥40 dB) or other signs orsymptoms related to the effusion• bilateral OME for ≥3 months, unilateralOME ≥6 months, or total duration of anydegree of OME ≥12 months.17

Any decision regarding surgery shouldinvolve an otolaryngologist, the primary careprovider, and the patient and/or family. TheAAP/AAFP/AAOHNS guideline recommendsagainst adenoidectomy in children with persistentOME without an indication for theprocedure other than OME (eg, chronic sinusitisor nasal obstruction).17

Keep in mind that evidence of lastingbenefit (>12 months) is limited for surgery inmost patients, and the surgical and anestheticrisks must be considered before movingforward.17 (For more on the evidence regardingsurgery, see “Cochrane weighs in on tympanostomytubes” above.25) Tonsillectomyalso does not appear to affect outcomes andis not advised.17

z When a referral is always needed.Regardless of hearing status, promptly referchildren with recurrent or persistent OMEwho are at risk of speech, language, or learningproblems (including those with autismspectrum disorder, developmental delay,Down’s syndrome, diagnosed speech or languagedelay, or craniofacial disorders such ascleft palate) to a specialist (jfp 06212).17

2.2.7 Komplikasi Otitis Media Serosa

The two major complications of OME are: 1) a transient hearing loss, potentially associated with language development or behavioral problems, and

2) chronic anatomic injury to the tympanic membrane leading to the need for reconstructive

surgery.

2.2.8 Prognosis Otitis Media Serosa