case presentation

1. CASE PRESENTATION
Presented by: Dr Nitha George

2.  Ajjaiah
 14yrs
 Male
 Hindu
 Student (9th grade)
 Holakere, Chitradurga

3. CHIEF COMPLAINTS
 Right ear discharge since 3 years

4. 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

5.  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

6.  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.

7.  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.

8. 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

9. 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

10. FAMILY HISTORY
 No similar complaints in the family

11. PERSONAL HISTORY
 Appetite: Good
 Diet: Mixed
 Bowel and bladder : Regular
 Sleep: Adequate
 Habits -Nil

12. 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

13. SYSTEMIC EXAMINATION
 CVS :
 S1 S2 +
 No murmers
 RS:
 Bilateral NVBS
 No added sounds
 P/A:
 Soft, non tender
 No organomegaly
 CNS:
 Normal

14. LOCAL EXAMINATION
EAR Right Left
Pre auricular region Normal Normal
Pina Normal Normal
Post auricular region Normal Normal
External auditory canal Scanty , green foul-
smelling discharge
Normal

15. 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

16. CONTD…
Facial nerve Normal Normal
Fistula sign Negative Negative
Mastoid tenderness Absent Absent
Tuning fork tests ( 512 Hz)
Rinnes Negative Positive
Weber's Lateralized to the right
Absolute bone conduction Equal to the examiner

17. 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
 Para nasal sinus : Non tender
 PRE : Normal

18. ORAL CAVITY
 Normal

19. 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

20. PROVISIONAL DIAGNOSIS
 Right chronic otitis media, active squammous , with
conductive hearing loss without any complications
with bilateral hypertrophy of inferior turbinates.

21. 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

22. FURTHER MANAGEMENT
 Tympanoplasty with intact canal wall / canal wall
down mastoidectomy (intraop )

23. THANK YOU