Case presentation - CSOM

CASE PRESENTATION

Presented by: Dr Nitha George

Ajjaiah

14yrs

Male

Hindu

Student (9th grade)

Holakere, Chitradurga

CHIEF COMPLAINTS

Right ear discharge since 3 years

HISTORY OF PRESENTING ILLNESS

Right ear discharge

Since 3years

Insidious in onset

Intermittent ( one episode per month)

Each episode last for 5-7 days

Moderate amount, sticky white with yellow tinge, foul

smelling, not blood stained

Aggravated with episodes of common cold

Relieved with oral medications (details unavailable)

Last episode 1week back lasting for 3days

Relieved temporarily with oral medications

Decreased hearing in right ear

Since 3years

Following onset of right ear discharge

Insidious in onset

Gradually progressive

Was able to appreciate whispers well 3yrs back

At present can only perceive loud noises in right ear

Hearing worsens during episodes of active discharge

Ringing sensation of right ear since 3 years

Insidious in onset

Intermittent

Low pitched humming voice

Lasting throughout the episode of discharge

Aggravated during active discharge and relieved with its

resolution.

No h/o

Fever

Headache / vomiting

Unconsciousness / Neck stiffness

Earache

Visual disturbances

Speech problems

No h/o postaural swelling associated with fever

No h/o

Giddiness

Deviation of angle of mouth

No h/o trauma

Not h/o excessive sneezing/ excessive nasal discharge / postnasal drip/ bleeding from nose/ facial pain.

PAST HISTORY

Chronic adenotonsillitis for which he underwent

ADENOTONSILLECTOMY under general anaesthesia on

3/6/2013

No history of:

Prolonged hospital admissions

Juvenile DM / HTN

Allergy / Bronchial asthma / TB

Previous blood transfusions / drug allergies

Epilepsy

TREATMENT HISTORY

Used oral medications every month for one week during

episodes of ear discharge (Details not available)

One week of postop medications last week

T. Cefpodoxime 100mg BD for 5days

Analgesic Syrup (Aceclofenac 50mg and paracetamol 100mg)10ml

BD

FAMILY HISTORY

No similar complaints in the family

PERSONAL HISTORY

Appetite: Good

Diet: Mixed

Bowel and bladder : Regular

Sleep: Adequate

Habits -Nil

GENERAL EXAMINATION

14yr old male pt

Moderately built n nourished

Conscious, cooperative and well oriented to time, place

and person.

Vitals

Afebrile

BP : 100 / 70mm Hg

PR : 76 bpm

RR : 16/min

Pallor

Icterus

Cyanosis

Clubbing

Lymphadenopathy

Pedal edema

NIL

SYSTEMIC EXAMINATION

CVS : S1 S2 +

No murmers

RS: Bilateral NVBS

No added sounds

P/A: Soft, non tender

No organomegaly

CNS:

Normal

LOCAL EXAMINATION

EAR Right Left

Preauricular region Normal Normal

Pinna Normal Normal

Postauricular region Normal Normal

External auditory canal Scanty , green

foulsmelling discharge

Normal

TYMPANIC MEMBRANE

Seigelization : Right – No mobility

Left Tympanic membrane moving well

Cholesteatoma debris

in the anterior attic

•Moderate size central perforation

in the posterior quadrant

•Smooth regular anterior, superior and posterior margins

•Inferior margin not seen

•Active mucopurulent discharge in middle ear

Cone of light absent

Grade I retraction of pars tensa

Prominent lateral process of

malleus

•Anterior quadrant of TM hidden

behind anterior canal bulge

•Rest of tympanic membrane

congested

Foreshortening of handle

of malleus

CONTD…

Facial nerve Normal Normal

Fistula sign Negative Negative

Mastoid tenderness Absent Absent

Tuning fork tests ( 512 Hz)

Rinnes Negative Positive

Webers Lateralised to the right

Absolute bone conduction Equal to the examiner

NOSE

External appearance: Normal

Vestibule : Normal

Anterior rhinoscopic examination:

Mucosa normal

Septum normal with septal spur on left side

Lateral wall –HIT

Floor - Normal

Cold spatula test : Bilaterally equal fogging

Paranasal sinus : Non tender

PRE : Normal

ORAL CAVITY

Normal

OROPHARYNX

Posterior pharyngeal wall : Normal

Indirect laryngoscopy: Normal

NECK:

Bilateral jugulodigastric lymph nodes palpable

Right Left

Anterior pillar Normal Normal

Tonsil Healthy tonsillar fossae

Posterior pillar Normal Normal

Right Left

2 in number

2*1 cms each

2 in number

2*1 cms each

Non tender , firm , mobile

PROVISIONAL DIAGNOSIS

Right chronic otitis media, active squammous , with

conductive hearing loss without any complications

with bilateral hypertrophy of inferior turbinates.

INVESTIGATIONS

Otoscope

Otomicroscopy

PTA:

Right 66.6db (Moderately severe CHL)

Left 21.66 db

Xray B/L mastoid (Schullers view)

Xray PNS (Waters view)

Blood

Urine routine

ECG

Chest Xray PA view

FURTHER MANAGEMENT

Tympanoplasty with intact canal wall / canal wall

down mastoidectomy (intraop )

THANK YOU