R. SYAMSUDIN,S.H PUBLIC HOSPITALEar-Nose-Throat, Head and Neck Department

Advisor : dr. H. Oscar Djauhari, Sp. THT

1 . A 7 year s old boy came to the ENT clinic with chief complai n fullness sensation of the both ears and pain since 3 days ago. He had upper tract respiration infection as the prior disease.

IdentityName : Ch. RAge : 7 years oldAddress : Pelabuhan RatuChief complaint : fullness sensation of the both ears and pain since 3 days agoAdditional complaint : cannot hear clearly, fever.

Present Medical HistoryA 7 years old boy has been complaining fullness sensation of the both ears and pain since 3 days ago. Before that, patient suffer fever, running nose, sore throat and cough since 1 week ago. The patient also say that he cannot hear voice clearly.

Past Medical History-

Physical ExaminationEar :

External ear : There are no deformities External acoustic canal

o Right : normal mucosa, cerumen (-), discharge (-), laceration(-)o Left : normal mucosa, cerumen (-), discharge (-), laceration(-)

Tympanic membraneo Right : Hyperemic, intacto Left : Hyperemic, intact

Retroauricular : Normal both side Preauricular : Normal both side

Nose : External nose : no deformity, normal shape Mucosa : hiperemic (-) Nasal septum : No deviation Choncha inferior : Slightly hypertrophy both side, no discharge

Nasopharynx, Oropharynx : Uvula at the middle, arcus pharynx symmetric. Mucosa: normal, hyperemic (+) Tonsil : T2-T2 slightly hyperemic, kripta +/+, detritus -/-

Face :

SimertriNeck:

Lymph nodes enlargement (-)

Working Diagnosis Acute Otitis Media stadium Hyperemic

Differential Diagnosis Otitis Media Effusion

Further Examination Tone Fork with 512 Hz : Rinne Test, Weber Test, Swabach Test, Bing Test, Stenger

Test

Tre atment Systemic antibiotics (amoxicillin 25mg/kg/day-clavulanat acid 5mg/kg/day, PO) Pseudoephedrin (max in children 75mg/day, in adults 150mg/day, PO) Mefenamic acid 20-30mg/kg/day

Explanations There are five stages of AOM : occlusion, hyperemic, suppurative, perforation, and

resolution. In hyperemic stage, the tympanic membrane is swelling and there is vasodilatation of the

blood vessel. Clinical manifestations of AOM are otalgia, fever, hearing loss, fullness sensation of the ear,

with a history of upper respiratory infection. Effusion Otitis Media (EOM) is a condition with a non-purulent discharge in the middle ear,

intact tympanic membrane without any sign of infection. It is divided to Acute EOM and Chronic EOM.

Sensory neural deafness is a hearing loss condition which is caused by pathologic condition in cochlear or retro-cochlear.

2. A 20 year s old female patient came to the ENT clinic with chief complai n severe headache with unconscious condition that come and go .

IdentityName : Ms. AAge : 20 years oldAddress : SelabintanaChief complaint : Severe headache with unconscious condition that come and go.Additional complaint : Suddenly has difficulty to smile and open the right eye.

Purulent discharge from the ear periodically since 2 months agoPresent Medical History

A 20 years old female patient has been complaining a severe headache with unconscious condition that come and go . Before that, patient also noticed that her mouth deviate to the right and she can’t open her right eye. She also had purulent otorhea of the right ear periodically since 2 months ago. A week ago the discharge from the ear became massive.

Past Medical HistoryAllergy history denied.Frequent common cold since child.

Physical ExaminationEar :

External ear : There are no deformities External acoustic canal

o Right : Normal mucosa, Purulent discharge, smelly odor, yellowisho Left : Normal mucosa, Cerumen (+)

Tympanic membraneo Right : Marginal perforation, round shapeo Left : Difficult to examine

Retroauricular : Normal both side Preauricular : Normal both side

Nose : External nose : no deformity, normal shape Mucosa : hiperemic (-) Nasal septum : No deviation Choncha inferior : Slightly hypertrophy and hyperemic both side, no discharge

Nasopharynx, Oropharynx : Uvula at the middle, arcus pharynx symmetric. Mucosa : normal Tonsil : T0-T0

Face : Deviation of the angle of the mouth to the right side Ptosis at her right eye

Neck: Lymph nodes enlargement (-)

Working Diagnosis Right chronic suppurative otitis media(CSOM) with facial nerve palsy complication and suspect Central Nervous System Complication : Meningitis and Brain Abscess.

Differential Diagnosis Primary brain tumor

Further Examination Complete blood count (Hb, Ht, Trombocyte, Leukocyte, Differential count)

Head and neck CT-scan Discharge culture

Treatment Aural toilet with hydrogen peroxide 5% or alcohol Local antibiotics (ofloxacin 3mg/ml, 2x10 drops, AD) Systemic antibiotics (amoxicillin 25mg/kg/day-clavulanat acid 5mg/kg/day, PO) Pro-tympanoplasty if the infection is resolve.

Explanations Purulent otorhea for 2 months with tympanic membrane central perforation shows a CSOM

history and physical finding, the most commonly isolated bacteria responsible for CSOM are P. aeruginosa, S. aureus, and the Proteus species

There are two type of CMOS. First Silent type and risk type. Silent type usually occurs with the perforation at the central of tympanic membrane. The risk type have a marginal or atic perforation.

Massive-blood-stained ear discharge is an indication that formed granulation tissue bleed or the cholesteatomahas eroded the bony walls of the middle ear and mastoid and is approaching a vascular structure as the lateral sinus

Fever and rigors due to increasing infection process that might develop into bacteremia Difficulty to smile with a deviation of the angle of the mouth to the left side and ptosis at her

right eye are due to lower motor neuron facial nerve paralysis caused by locally produced bacterial toxins or from direct pressure applied to the nerve by cholesteatoma or granulation tissue.

Most meningeal pathogens are transmitted through the respiratory route, as exemplified by the nasopharyngeal carriage of Neisseria meningitides (meningococcus) and nasopharyngeal colonization with S pneumoniae (pneumococcus). The cycle of inflammation, ulceration, infection, and granulation tissue formation may continue, destroying surrounding bony margins and ultimately leading to the various complications of CSOM, include :- A brain abscess may occur in the temporal lobe or cerebellum, typically from chronic

otitis media.- An epidural abscess may occur as a result of bony destruction and extension from

coalescent mastoiditis or cholesteatoma.

- Meningitis may be associated with acute or subacute/chronic infection. Acute otitis media is the most common cause of meningitis. Extradural granulation tissue or frank pus may be found.

- In both adults and children, meningitis in the setting of chronic suppurative otitis media may be secondary to the direct extension of infection through the dura, through a previous stapedectomy site, or through a cholesteatoma-induced labyrinthine fistula.

- Otitic hydrocephalus may occur as a result of increased intracranial pressure secondary to middle ear infection and complicated by sigmoid sinus thrombosis with total occlusion.

- A sigmoid sinus thrombosis or subdural abscess/empyema may be associated with otitis media

3 . A 8 year s old boy came to the ENT clinic with chief complai n pain and itch of the left ear since 3 days ago. He had fever as the additional complain.

IdentityName : Ch. DAge : 8 years oldAddress : SiliwangiChief complaint : pain and itch of the left ear since 3 days agoAdditional complaint : fever.

Present Medical HistoryA 8 years old boy has been complaining pain and itch of the left ear since 3 days ago. Before that, patient suffers fever since 5 days ago. sPast Medical History-

Physical ExaminationEar :

External ear : There are no deformities External acoustic canal

o Right : Hyperemic mucosa (-), cerumen (-), discharge (-), laceration(-)o Left : Hyperemic mucosa at 2/3 inner segment (+), cerumen (-), discharge (+),

laceration(-) Tympanic membrane

o Right : normal, intact, cone of light (+)o Left : normal, intact, cone of light (+)

Retroauricular : Normal both sideNose :

External nose : no deformity, normal shape Mucous : hiperemic (-) Nasal septum : No deviation Choncha inferior : normal at the both side, no discharge

Nasopharynx, Oropharynx : Uvula at the middle, arcus pharynx symmetric. Mucous: wet, hyperemic (-) Tonsil : T1/T1, not hyperemic mucosa

Face : No Deviation

Neck: Lymph nodes enlargement (-)

Working Diagnosis Diffuse Otitis Externa

Differential Diagnosis Furunculosis

Treatment Local antibiotics (ofloxacin 3mg/ml, 2x10 drops, AD) Mefenamic acid 20-30mg/kg/day Decongestant

ExplanationsOtitis externa is an inflammation or infection of the external auditory canal and/or auricle. This condition is one of the most common medical conditions that affect aquatic athletes. Individuals with allergic conditions, such as eczema, allergic rhinitis, or asthma, also have a significantly higher risk of developing this condition. Several factors can contribute to the development of otitis externa. Absence of cerumen, high humidity, increased temperature, and local trauma (eg, use of cotton swabs or hearing aids) can result in infection of the canal. Aquatic athletes are particularly prone to the development of otitis externa because repeated exposure to water results in removal of cerumen and drying of the external auditory canal. Otitis externa occurs more often in the summer months when swimming is more common,and this condition is also common in tropical areas.8 The most common bacterial causes of otitis externa are Pseudomonas aeruginosa and Staphylococcus aureus.

Otitis externa can be classified as follows:

Acute diffuse otitis externa is the most common form of otitis externa and is most commonly seen in swimmers. Acute diffuse otitis externa is usually caused by bacteria, but it can be occasionally caused by a fungus. Elements of acute diffuse otitis externa include rapid onset (generally within 48 h); symptoms of ear canal inflammation that include otalgia, itching, or fullness, with or without hearing loss or jaw pain; and tenderness of the tragus or pinna, or diffuse ear edema or erythema or both, with or without otorrhea, regional lymphadenitis, tympanic membrane erythema, or cellulitis of the pinna.

Acute localized otitis externa, also known as furunculosis, is associated with infection of a hair follicle.

Chronic otitis externa is the same as acute diffuse otitis externa, but it is of longer duration (>6 wk).

Eczematous otitis externa encompasses various dermatologic conditions (eg, atopic dermatitis, psoriasis, lupus erythematosus, eczema) that may infect the external auditory canal and cause otitis externa.

Necrotizing "malignant" otitis externa is an infection that extends into the deeper tissues adjacent to the auditory canal. This type of otitis externa primarily occurs in adult patients who are immunocompromised (eg, diabetes mellitus, acquired immunodeficiency syndrome [AIDS]) and is rarely described in children. Necrotizing otitis externa may result in cases of cellulitis and osteomyelitis.

4 . A 17 year s old girl came to the ENT clinic with chief complai n fullness sensation of the both ears since 5 days ago .

IdentityName : Ms. HAge : 17 years oldAddress : CikoleChief complaint : fullness sensation of the both ears since 5 days agoAdditional complaint : Runny nose, sneezing espesially in the dusty room itchy nose, lacrimation

at the eyes, and clog nose since 3 years ago

Present Medical HistoryA 17 years old girl has been complaining fullness sensation of the both ears and pain since 5 days ago. Before that, the patient had running nose and sneezing since 3 years ago, espesially in the dusty room. These symptoms also followed by itchy nose, lacrimation of the eyes and clog feeling nose. Patient has a lot of discharge which is clear and watery-like. The symptoms occur along years about four days a week, but don’t disturb his daily activities. Patient also have a sneezing at the morning but getting better at noon. There is no history of drug abuse (nasal drop). Cough (-), fever (-).

Past Medical HistoryAsthma history denied.Allergic to egg and seafood.

Physical ExaminationEar :

External ear : Normal both side External acoustic canal

o Right : Hiperemis -, laceration -, discharge -, cerumen -, abnormal mass -.o Left : Hiperemis -, laceration -, discharge -, cerumen -, abnormal mass -.

Tympanic membraneo Right : Intact, normal cone of light.o Left : Intact, normal cone of light.

Retroauricular : Normal both side Preauricular : Normal both side

Nose : Mucose : hiperemic both side, discharge +, watery-like. Nasal septum : No deviation Choncha inferior : Hipertrophy on both side, abnormal mass -.

Nasopharynx, Oropharynx : Mucose : hiperemic -. Tonsil : T1/T1, hiperemic -, smooth surface, normal crypt. Uvula : No deviation.

Face : Symmetric.

Neck : No lymph nodes enlargement.

Working Diagnosis Obstruction of the eustachius tube e.c. allergic rhinitis

Differential Diagnosis - Acute Otitis Media - Atopic Rhinitis

Further Examination In vitro : Diffrential count, ELISA IgE. In vivo : Skin end point titration

Intracutaneus Provocative Dillutional Food Test (IPDFT)Treatment

Avoid the allergen. Loratadine 5mg + Pseudoephedrine 120mg, twice a day for 7days. Desensitization with inhalant allergen. Decongestant

Complication Sinusitis

ExplanationObstructive disorders can be mechanical or functional. Mechanical obstruction can be intrinsic due to intraluminal factors such as mucosal inflammation due to allergy or infection, or extrinsic obstruction resulting in compromise of the lumen. Extrinsic obstruction can be physiologic such as when the patient is supine, or may be caused by a mass lesion such as a neoplasm or an adenoidal mass. Functional obstruction results from persistent collapse of the eustachian tube due to increased tubal compliance, an abnormal opening mechanism, or both. Functional obstruction is more common in infants and young children, and in many cases can be related to normal or abnormal developmental factors.