5. HISTORY OF PRESENT ILLNESS
• One year ago had an episode of upper respiratory tract
infection with pain right ear
• Subsequently patient developed intermittent ear discharge
• Discharge:
• Profuse
• Mucopurulent
• Odourless
• Not blood stained
• Decreased hearing right ear
11. • EAR
• RIGHT EAR : Medium sized central perforation in
the pars tensa
• No discharge
• No cholesteatoma
• LEFT EAR : normal
• Whispered voice not appreciated in right ear
12. Tuning fork test
RINNE TEST
• NEGATIVE ON RIGHT SIDE
• POSITIVE ON LEFT SIDE
WEBER TEST
. LATERALIZED TO RIGHT SIDE
19. TREATMENT
( during active episode )
• REGULAR AURAL TOILET
• EAR DROPS ( 0.6% ofloxacin 3 drops two times a day for 7
days , steroids -- betamethasone )
• SYSTEMIC ANTIBIOTICS ( Capsule ampicillin 625mg three times
a day for 7 days )
• NASAL DECONGESTANTS ( XYLOMETAZOLINE nasal spray three
times a day for 7 days )
• Systemic anti-histamines ( tab. loratidine 10mg once daily )
Presented with complains of ear discharge and decreased hearing in right ear for 1 year
My patient was asymptomatic 1 year ago when he had an episode of urti followed by severe pain in rt ear, which resulted in pus discharge from rt ear, The episode settled with medication prescribed at local Garrison medical center. Since then he IS HAVING intermittent discharge from his right ear. It usually follows an upper resp tract inf. It is copious and mucprlnt. He described it as odourless and has never been blood stained. Most of the time it stops with the resolution of urti. It is never accompanied by pain. He also complains of decreased hearing in his rt ear for last 1 year. It is constant and he feels difficulty in hearing normal conv. Voice. There is no history of pain in the ear, accompanied head ache, dizziness or facial weakness.
He was operated for ac appendicitis 3 years ago
On gpe he is young male of average built concious , coopertive well orirnted in time place and person, sitting comfortably in bed with stable vital signs
His systemic examination was unremarkable
A detailed ear nose and throat examination was carried out
On aural examination the pinna and eac appeared normal on both sides and there was no tendernes on either side. Speculem examination of Rt ear revealed medium sized central perforation in the pars tensa. There was no discharge orcholesteatomaHisLeft ear did not reveal any abnormality, more over he could hear conversational voice in both ears where as whispered voice could only be heard in lft ear
His tunning fork tests revealed a conductive type of decreased hearing in rt ear
Rest of the nose throat and neck examination was normal
ON THE BASIS OF HISTORY AND EXAMINATION….
Pure tone audiogram shows a conductive HEARING loss inrt ear with 20-30 decibel air bone gap
X ray mastoids did not reveal any abnormality
Based on history, clinical examination and investigations a final diagnosis of was made ……. Inactive withCONDUCTIVE HEARING LOSS
Patient was managed with aural toilet , local antibiotic drops and oral antibiotic drops
Patient was counseled to keep his ear dry by avoiding water entry in the ear, and prompt treatment of urti to be carried out if such an episode occur. He was ADVISED TO keep his ear dry for about 3 months, so that the surgical procedure can be carried out, for repair of the tympanic membrane that is myringoplasty.
