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Case Discussion

A 22 years old man came to clinic with a complaint osmilling since 4 days ago, and difficult swallowing since 2He had chronis suppurative otitis media 5 years ago.


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A. PATIENTS IDENTITY

Name : Mr. X Gender : Male

Age : 22 years old

Race : Sundanese

Occupation : student

Weight : 65 kg

Address : Ahmad Yani, Sukabumi


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B. HISTORY

Chief complaint : Drop of his right mouth cornerdifficulty with smiling

Additional complaint : difficult swallowing since 2 day

History of present illness : Patient had secretion coming out of htwice recently. First, 6 month ago and the latest was 3 month agperiod was 1 week. Secretion was yellowish green in color, slight

consistency and odorous. Patient went to general practitioner bewith no improvement. 1 week ago, patient noticed a drop of his mouth corner and difficulty in smiling. Patient felt this symptom worse along with time. Cough and cold was present too. Earacheabsent. Fever (-) and pain on other places were absent. History o).


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History of past illnes :5 years ago, patient had chronic suppurative otitis media ear

Hypertension (-)

Diabetes Mellitus (-)

History of Family Illnes : -


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C. PHYSICAL EXAMINATION

General appearance : mild illness Blood pressure : 120/90 mmhg

Pulse : 88x/minute

Respiratory rate : 25x/minute

Temperature : 37,2oC

ENT examination


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a. Ear

Right ear : Auricle : hyperemia (-), oedema (-)

Canalis Acousticus Externus:

hyperemic (-)

mass (-)

Secretion (+) minimal, yellowish green in color

Odorous smell

cholesteatoma (-)

Tymphanic membrane : central perforation

Cochlear Nerve examination :

Rinne test (-)

Weber lateralitation to the right

prolonged Schwabach.


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Throat : Uvula in the middle Pharynx : normal pharyngeal arch, hyperemic (-)

Tonsil : T1-T1, hyperemic (-)

Maxillofacial : asymmetrical

Neck : lymphadenopathy (-)


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Facial Nerve Examination (right / left) Facial expression : asymmetrical,right side of face slightly d

Raising eyebrow : difficult/ normal

Closing eyes : left behind/ normal

Smiling : left behind/ normal

Puff out the cheeks : left behind/ normal

Reveal the teeth : left behind /normal


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Working diagnosis Chronic suppurative otitis media of the right ear with a com

of right facial nerve paralysis.


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Work up

Lab : Complete Blood Count including differential count of wblood cells

Culture of secretion from the right ear and bacterial resistan

Audiometry test

Head CT Scan


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Therapy Topical Antibiotic : Gentamicin drops 0.3%, 3 x 4 drops per d

Oral Antibiotic : Ciprofloxacin, 2 X 500 mg p.o.

Steroid : Prednisone, 4 X 20 mg per day p.o.

Mecobalamin 3 x 500 mcg p.o


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Chronic suppurative otitis media (C


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Definition

Chronic suppurative otitis media (CSOM) inflammation of the middle ear and mastoidwhich presents with recurrent ear dischaotorrhoea through a tympanic perforation.


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Epidemiology

The larger the tympanic membrane perforation, the more lipatient is to develop CSOM

Some studies estimate the yearly incidence of CSOM to be 3per 100,000 persons in children and adolescents aged 15 yeyounger.


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Risk factors

Living in crowded conditions

Living in a large family

Poor nutrition and lower levels of zinc, selenium, calcium, a

Passive smoke exposure

Frequent upper respiratory tract infections and nasopharyn

Infectious and chronic diseases, such as measles, humanimmunodeficiency virus (HIV) infection, tuberculosis, diabetcancer


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Other comorbid conditions, such as cleft lip/palate, Down sycri du chat syndrome, choanal atresia, and microcephaly

Unhygienic practices, such as bathing in contaminated pondrivers, unsterile ear piercing, and cleaning ears with cotton b

Family history may also play a role in AOM and CSOM.


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Anatomy

The middle ear cleft can thought of as a 6-sided c

Its lateral boundary, the membrane, separates it outer ear

Its medial boundary is fothe promontory, which dbasal turn of the cochlea

Anteriorly, it is related totendon of tensor tympansuperiorly and the openeustachian tube inferior


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Posteriorly, it is relatedsuperiorly to the adituconnects the middle eawith the mastoid antruinferiorly to the facial r

The roof of the middleis formed by the tegmetympani.

The floor of the middlecavity lies in close relat

jugular foramen.


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Etiology

1. Could be a sequelae to inadeq

treated acute otitis media.

2.

Acute suppurative otitis mediapersistant perforation which cinfected from bacteria in the eauditory canal. This condition as persistant perforation syndr


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Pathophysiology

irritation and subsequent inflammation of the middle ear mucosa. Theinflammatory response creates mucosal edema.

mucosal ulceration and consequent breakdown of the epithelial lining.

The host's attempt at resolving the infection or inflammatory insultmanifests as granulation tissue, which can develop into polyps withinthe middle ear space

The cycle of inflammation, ulceration, infection, and granulation tissformation may continue, eventually destroying the surrounding bonmargins and ultimately leading to the various complications of CSOM


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Hearing loss is usually about 30 - 40 dB.

These patients have poorly pneumatised / sclerosed mastoisystem

Pain in the ear when present is always associated with otitis

Nonspecific symptoms of acute otitis media (e.g., fever, hea

irritability, cough, rhinitis, listlessness, anorexia, vomiting, dpulling at the ears) are common in infants and young childre


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Diagnosis

a. Physical examination

A large central perforation of the tympanic membrane (TM) is thcommon and perforation of the posterosuperior quadrant is thecommon

Discharge can range from purulent to fetid to cheese-like, and caear canal

typically not significant edema of the external auditory canal

There may be granulation tissue present, but it should be distingfrom retraction-pocket cholesteatoma in which the granulation toccupies the pars flaccida of the TM

Middle-ear mucosa, when it is seen, can be polypoid or edematoappear pale, red, or may be normal


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b. Imaging studies

A high-resolution temporal bone CT scan

c. Other test

A swab of the discharge : for culture and sensitivity test

An audiologic evaluation


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Complications

a. Sequele

Tympanosclerosis

b. Intratemporal Complications

Mastoiditis

Acute mastoiditis

Subacute mastoiditis Petrositis

Facial Nerve Paralysis

Suppurative Labyrinthitis

c.Intracranial Complicatio

Meningitis Intracranial Abscess

Lateral Sinus Thrombosis

Otic Hydrocephalus


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Facial Nerve

M C f F i l N


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Motor Component of Facial Nerve


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