CLINICAL CASE REPORT

ENT POSTING YEAR 4

NAME :
MATRIX NO :
YEAR :
GROUP :
SUPERVISOR : DR. SANTOSH PATIL
 History Taking

Patient Identification data

1. Name : Rathod Narayan Dipleppa

2. IP number : 0592603
3. Age : 25 years
4. Nationality : Indian
5. Religion : Hindu
6. Address : Ramdurg, Belgaum
7. Occupation : Labour worker
8. Sex : Male
9. Marital status : Married
10. Date Of Admission : 24 April 2014
11. Date Of Clerking : 28 April 2014
12. Case type : ENT

Chief Complaints

1. Discharge from the both ears since 10 years

2. Hearing difficulty since 5 years
3. Headache since 1 month

History Of Presenting Illness

The patient was apparently alright 10 years back when he suddenly developed
discharge from the right and left ear. It was insidious in onset and on and off in nature. The
discharge was yellowish in colour, copious in amount, foul smelling without associated with
blood discharge. The discharge was aggravated by upper respiratory tract infection and
decrease when he took the medication. Unfortunately last month he noticed that the
discharge was associated with the blood stained discharge without earache.

He noticed that he got hearing difficulty on both ears since 5 years after he got the
discharge which right ear more decrease on hearing than left ear. He also said that he got
the headache since 1 month which right sided of head more than left sided. The headache
was insidious in onset, progressive in nature and throbbing in type. There is no aggravating
and relieving factor associated on his headache.
 The patient denied having any history of earache, facial pain, giddiness, loss of
balance, recurrent cold and sore throat, difficulty in breathing, difficulty in swallowing,
recurrent sneezing, running nose, vision difficulty, loss of appetite and loss of weight.

Past Medical And Surgical History

He was underwent fracture on right lower limb last 8 years back and was treated in
orthopaedic department with uneventful and without any complication. There is no history
suggestive of hypertension, diabetes mellitus, cardiac illness, any infection of tuberculosis,
renal failure, epilepsy, peripheral vascular disease, malignancy and syphilis. He also denied
having blood transfusion prior to admission.

Family History

On review of family history, he is first of four siblings in the family. Both of his parents and his
siblings live in healthy. There was no other chronic disease in the family such as
tuberculosis, cardiac disease, diabetes mellitus, hypertension, malignancy and bronchial
asthma.

Personal and Social History

He is non-vegetarian with good in appetite. His sleep is adequate. His bowel movement and
habit is regular and normal. His micturation habit is regular and normal. He is non-smoker
and non-consuming of any tobacco products and non-alcoholic also. He is non-allergies to
any food and no drug allergies prior to admission.

Drug History

There is no significant regarding his complaints. He is non drug abuse prior to the
admission.
Summary

Mr Narayan, a 25 years old, working as a labour worker and live in the Ramdurg, Belgaum
was admitted due to complaints of discharge from both ears since 10 years which last 1
month the discharge also associated with blood discharge stained, difficulty in hearing since
5 years which decrease hearing on right ear more than left ear and headache since 1 month
which more on right sided of head than left sided of head.

Physical Examination
General Inspection
The 25 year old male patient is lying comfortably in supine position. He does not look ill. He
is conscious and alert to time, place and person. He is not in pain or respiratory distress and
his hydrational and nutritional status are adequate. There is no muscle wasting, no gross
deformity and no abnormal movement. There is intravenous line attached to his left arm.

BODY MASS INDEX

1. Weight: 65kg
2. Height: 167cm
3. Body mass index: 23.31 kg/m2 (ideal BMI)

General Systemic Examination

A. Vital signs

1. Pulse rate:

86 beat per minutes on right radial artery, right forearm, in lying supine position,
volume is good, regular rhythm, character is good, blood vessel wall not palpable, no
radio-radial delay and no radio-femoral delay.

2. Blood pressure :

122/84 mmHg on right brachial artery, lying supine position

3. Respiratory rate:

18 breath cycle per minute on lying supine position

 4. Body temperature:

Clinically afebrile

B. Head

1. Eyes

 No yellowish discolouration of sclera.

 No pallor on conjunctivae
 No xanthelasma
 Arcus senilis was not present
 No cataract on both eyes

2. Oral Cavity/ mouth

 Tongue is well hydrated

 Oral mucosa no pallor
 Oral hygiene is fair
 Gums is healthy and teeth is normal
 No bleeding of the gums
 No cyanosis(central)
 No glossitis, no angular stomatitis
 No fetor hepaticus
 Purse lip is absent

C. Upper Limb

1. Palms
 The both palms were warm and dry
 The both of palms were no pallor
 The both of palms were no muscle wasting
 The both of palms were no palmar erythema

2. Fingers and Nails

 No pallor nails on both hands

 No clubbing on all fingers
 No nicotine stain on all fingers
  No peripheral cyanosis on all fingers
 No koilonychia on all fingers
 No platynychia on all nails
 The capillary filling on all nails are normal (less than 2 seconds)

3. Forearms and Arms

 No rashes on both arms

 No stratch marks on both forearms and arms
 No scars on both forearms and arms
 No bruises
 No flapping tremor
 No fine tremor
 No Osler's node
 No Janeway lesion

D. Neck

 No elevated Jugular Venous Pressure

 The Carotid pulse was good in volume and regular in rhythm
 No lymphadenopathy on both cervical lymph nodes and supraclavicular lymph nodes
 No thyroid enlargement and swelling

E. Lower Limbs
 No ankle oedema present
 No clubbing and no cyanosis
 No splinter haemorrhage
ENT EXAMINATION

A. Ear Examination
NO. FINDINGS RIGHT EAR LEFT EAR
1. Pinna  Normal (No congenital defects  Normal (No congenital
like microtia, macrotia, defects like microtia,
anotia) macrotia, anotia)
2. Pre auricular area  Normal (no swelling, no scars, • Normal (no swelling, no
no parotid sinus, no fistula) scars, no parotid sinus, no
fistula)
3. Post auricular area • Normal (no post auricular •Normal (no post auricular
groove swelling, no scars, no groove swelling, no scars,
parotid sinus, no fistula, no no parotid sinus, no fistula,
mastoid tenderness) no mastoid tenderness)
4. External auditory canal  Posterior canal wall bulge • Posterior canal wall bulge
(otoscope)  No patent, no atresia, no  No patent, no atresia, no
fistula present fistula present
 Discharge: copious amount,  Discharge: copious amount,
non-foul smelling with blood non-foul smelling with
discharge stained blood discharge stained
 Wax present, granulation  Wax present, no foreign
tissue present, no foreign bodies, no granulation, no
bodies, no polyp, no polyp, no otomycosis
otomycosis
5. Tympanic membrane  Large central perforation on  Large central perforation
(otoscopy) pars tensa on pars tensa
 Middle ear mucosa moist  Middle ear mucosa moist
present present
NO. FINDINGS RIGHT EAR LEFT EAR
5. Tympanic membrane
(otoscopy)

6. Hearing test
a) Rinne’s test  256 Hz: negative  256 Hz: negative
 512 Hz: negative  512 Hz: negative
 1024 Hz: negative  1024 Hz: positive

b) Weber’s test  Lateralized to the right ear

c) Absolute Bone  Normal (same as examiner)  Normal (same as examiner)
Conduction Test  No spontaneous nystagmus
d) Nystagmus
 Negative
e) Gelle’s test
f) Facial Nerve  Normal without any weakness on both sided of face
Examination
B. Nose Examination
NO. EXAMINATION FINDINGS
1. External appearance  Root of nose : normal
 Dorsum of nose: normal
 Nasal bridge: normal
 Ala nose: normal
 Tip of nose: normal
 Columella of nose: normal
 No nasal depression
 No nasal deformity such as hump nose, saddle nose
 No scar present
2. Cold spatula test  Adequate and bilateral equality
3. Compression of tip test  Caudal dislocation of right septum present
 Caudal dislocation of left septum absent
4. Vestibule  Skin appearance on both vestibule are normal
 No furuncle present
5. Anterior rhinoscopy  Right side: deviation of nasal septum present
 Nasal passage / cavity: normal on both sides
 Lateral wall:
- Turbinate: left inferior turbinate hypertrophied, right inferior
turbinate and middle turbinates on both sides are normal
- No polyp present
- Middle meatus: normal
- No presenting crust
 Colour of nasal mucosa: normal
 Floor of nose: normal, no discharge
 Roof of nose: normal
 No sensitivity, no bleeding present
NO. EXAMINATION FINDINGS
5. Anterior rhinoscopy

6. Posterior rhinoscopy

7. Paranasal sinuses  Frontal sinuses: no tenderness

 Ethmoidal sinuses: no tenderness
 Maxillary sinuses: no tenderness
C. Throat Examination
NO. EXAMINATION FINDINGS
1. Oral cavity  Lips : normal
 Labial mucosa : normal
 Vestibule: normal
 Buccal mucosa : pink in colour, no mass present
 Gingivo labial sulci: normal
 Gingivo buccal sulci: normal
 Gums: normal
 Teeth: normal
 Floor of mouth: normal, no foul smelling
 Anterior 2/3 tounge: normal
 Hard palate: normal
 Soft palate: normal
 Uvula: normal

2. Oropharynx  Anterior faucial pillar: normal

 Palatine tonsils: normal
 Posterior faucial pillar: normal
 Base of tongue: normal
 Posterior pharyngeal wall: congested
 Lateral pharyngeal wall: congested
NO. EXAMINATION FINDINGS
3. Indirect laryngoscopy

4. Neck  External appearance: all normal within limit

 No lymph nodes enlargement
 Laryngeal framework: normal
 Crepitus: absent
 Thyroid gland: no enlargement
 Cricovertebral click: present
 Engorged veins: absent
 Fistula/ sinuses: absent
SYSTEMIC EXAMINATION

1. Respiratory system
Inspection No obvious gross deformity of chest. The chest expands symmetrically
on each respiration. No scars noted. No visible vein dilatation and visible
pulsation. No pectus excavatum, no pectus carniatum, no prominent
accessory muscle of respiration
Palpation Trachea is central and tracheal tug is absent. Apex beat was at 5th
intercostal space, 1 cm lateral to midclavicular line. Chest expand
normal both sides. Vocal fremitus is normal and equal on both sides.
Percussion The percussion is resonance equally at all lung zones. Area of liver
dullness is in right 5th intercostals space in midclavicular line. Area of
cardiac dullness is normal.
Auscultation The vesicular breath sound is heard most at the area of lung with normal
intensity. The vocal resonance is normal and equal on both sides. No
added sounds present such as crepitation and rhonchi. On posterior
examination, both lung areas are noted normal.

2. Abdominal examination
Inspection The abdomen is not distended. Flank not full. The umbilicus is centrally
located. The abdomen is noted to move with each respiration. No
surgical scar noted. No obvious visible dilated vein and no visible
pulsation.
Palpation On superficial palpation, abdomen is soft and non tender. On deep
palpation, abdomen is soft and non tender. No masses can be felt. The
liver is not palpable. Liver span is 12cm. Spleen is not palpable. Kidney
is not ballotable.
Percussion No presence of shifting dullness.
Auscultation Presence of bowel sound with normal intensity.
No renal bruits heard, nor others bruits heard.
3. Examination Of Nervous System

Cranial Nerves Examination

Cranial Nerve Test Right Left

Olfactory Smell sensation Intact Intact

Optic Visual acuity Intact intact

Visual field Intact Intact

Color vision Intact Intact

Light reflex – direct Intact Intact

- indirect Intact Intact

Occulomotor, Ptosis, Fixation No No

Trochlear,
Abducen Squint

Accommodation Intact Intact

Trigeminal Motor Intact Intact

Sensory Intact Intact

Corneal reflex Intact Intact

Jaw jerk Intact

Facial muscles

 Forehead wrinkling Intact Intact

 Eye closure
 Blowing Intact Intact
 Nasolabial fold
 Angle of mouth Intact Intact

Intact Intact

Intact Intact

Taste anterior 2/3 Unable to assess

Vestibulocochlear Whispering Not intact Not intact

Glassopharyngeal Uvula Not deviated

Vagus

Gag reflex Present

Accessory Sternocleidomastoid Intact Intact
muscle

Trapezius muscle Intact Intact

Hypoglossal Tongue’s inspection No wasting, abnormal movement

No deviation

Muscle power of tongue Intact Intact

Motor System (upper and lower limb)

Right Left

Inspection No hypertrophy No hypertrophy

No muscle wasting No muscle wasting

No involuntary and No involuntary and

abnormal movements abnormal movements

Tone Normal Normal

Power

- Neck flexion/extension 5/5 5/5

- Shoulder 5/5 5/5

abduction/adduction
5/5 5/5
- Elbow flexion/extension
5/5 5/5
- Wrist flexion/extension
5/5 5/5
- Grip
5/5 5/5
- Hip flexion/extension/
abduction/adduction

- Knee flexion/extension 5/5 5/5

- Ankle 5/5 5/5

dorsiflexion/plantarflexion

- Toes flexion/extension
5/5 5/5
Co ordination

- Finger nose test Intact

- Heel knee test Intact

Gait Normal

Reflexes (upper limb; lower limb already mention above on local examination)

Right Left

Deep Tendon Jerks

- Biceps jerk Normal Normal

- Supinator jerk Normal Normal

- Triceps jerk Normal Normal

Sensory System (upper and lower limb)

Upper limbs Right Left

Superficial Sensations

- Touch, pain, Intact Intact

temperature

Deep Sensations

- Vibration Intact Intact

Lower limbs Right Left

Superficial Sensations

- Touch, pain, Intact Intact

temperature

Deep Sensations

- Vibration Intact Intact

Cerebellar Signs
 Dysarthia – nil
 Titubation – nil
 Nystagmus – nil
 Intention tremor – nil
 Disdiadokokinesia – nil
 Rebound phenomenon – nil
 Pendular knee jerk – nil
 Ataxia – nil

Meningeal Signs
 Neck stiffness – nil
 Kernig’s sign – negative

Summary
Patient was conscious and alert and not in ill condition. On Ear, Nose and Throat
Examination, the ear revealed discharge on bilateral ear with copious amount, non-foul
smelling with blood discharge stained, granulation tissue present on right ear, posterior canal
bulge on bilateral tympanic membrane of ears with large central perforation on pars tensa
and middle ear mucosa moist present. Hearing test for Rinne’s test revealed negative
indicate conductive deafness, Weber’s test revealed lateralized on right ear and Absolute
Bone Conduction test revealed normal which was same with examiner. On nose
examination, there was right caudal dislocation septum, presenting of right deviation nasal
septum with left inferior turbinate hypertrophied on anterior rhinoscopy. On throat
examination, there were presenting of granular and congested on posterior pharyngeal wall
and lateral pharyngeal wall. On systemic examination, all were in normal limits.
Provisional diagnosis

Provisional diagnosis Positive findings Negative findings

Bilateral chronic suppurative  Prolong history of ear  Discharge was foul-
otitis media tubotympanic discharge and deafness smelling
type with active phase with  No history of earache  No presenting of polyp
conductive hearing loss,  Discharge was profuse,
without any complication of mucoid
otitis media and presenting  Perforation was large
of right deviation nasal central on pars tensa
septum and left inferior  On hearing test: present of
turbinate hypertrophied conductive deafness

Differential diagnosis
Differential diagnosis Positive findings Negative findings
Bilateral chronic suppurative  History of prolong of ear  Discharge is profuse,
otitis media atticoantral type discharge and hearing mucoid
loss  Perforation was large
 No history of earache central on pars tensa
 Discharge was foul-  Polyp absent
smelling  No complication of otitis
 On hearing test: present media present
of conductive deafness  No retraction pocket
present

Tubercular otitis media  Painless ear discharge with  No history suggestive

foul smelling pulmonary tubercular
 Large central perforation  No history of loss of
on pars tensa weight, loss of appetite
 Hearing loss present  Facial paralysis absent

Syphilitic otitis media  Prolong ear discharge with  No history of suggestive

foul smelling syphilis infection
 Hearing loss present  No history of vertigo and
tinnitus
Investigations
Investigations Expected Result

Full Blood count  Leucocytosis with increase ESR Hb 14.3g/dL

count indicate infection / inflammation TWBC 8.4X109/L
 Low haemoglobin levels indicate Hematocrit 46.4%
anemia Platelet 2.77X109/L
Neutrophil 54%
Lymphocytes 40%
Eosinophils 2%
Monocytes 4%
Basophils 1%
Reticulocyte 0.8%
count
ESR 02 mm in
1st hr
Red cell 5.12
count millions/
cmm
 All in normal limits
 Peripheral blood smear
revealed normal

Urea and  To detect any changes in urea and creatinine levels

Creatinine test Components Results Interpretations
Serum Urea 14 mg/dL Urea slightly low while
Serum Creatinine 0.9 mg/dL serum creatinine
reveal in normal limits
 Investigations Expected and Result
Microbiology test  To confirm the type of infection organism
(culture and  To know the organism sensitive towards antibiotic that later to treat on
sensitivity test) that antibiotic (specific antibiotic)

SAMPLE RESULT
Ear swab  Methiciline sensitive
Staphylococcus aureus
isolated
 Amoxycillin: resistant
 Gentamycin: resistant
 Erythromycin: sensitive
 Ciplofloxacin: sensitive

Provisional diagnosis
Bilateral chronic suppurative otitis media tubotympanic type with active phase with
conductive hearing loss, without any complication of otitis media and presenting of right
deviation nasal septum and left inferior turbinate hypertrophied

Management
1. General management for chronic suppurative otitis media tubotympanic type
i. Investigation
 Examination of ear under microscope
 Audiogram
 Culture and sensitivity of ear discharge
 Mastoid X-rays or CT scan temporal bone

ii. Treatment
 Aim is to control infection and eliminate ear discharge and at a later stage to
correct the hearing loss by surgical means.
 Aural toilet: remove all discharge and debris from the ear
  Ear drops: antibiotic ear drops containing neomycin, polymyxin, chloromycetin
or gentamicin
 Systemic antibiotics: in acute exacerbation of chronically infected ear
 Precautions towards patient activities: such as to keep water out of ear during
bathing, swimming and hair wash.
 Treatment of contributory causes
 Surgical treatment
 Reconstructive surgery: myringoplasty with or without ossicular reconstruction

2. General management for deviation nasal septum

 Minor degrees of septal deviation with no symptoms are commonly seen in patients
and require no treatment.
 It is only when deviated septum produces mechanical nasal obstruction or the
symptoms that an operation is indicated.
 Submucous resection (SMR) operation
 Septoplasty

3. Management in patient (ward)

 The body temperature, blood pressure, respiratory rate and pulse rate were
monitored every 6 hourly daily.
 Investigation ordered: ear swab for culture and sensitivity, X-rays bilateral mastoid-
Schuller’s view, routine blood investigation (full blood count)
 Paracetamol 500mg (tablet) –only administrated if indicate fever.
 Injection of Ciplox 100ml (I.V) (1-0-1)
 Injection of Mezol 100ml (I.V) (1-1-1)
 Injection Rantec 2cc (I.V) (1-0-1)
DISCUSSION

Chronic suppurative otitis media is a long-standing infection of a part or whole of the

middle ear cleft characterized by ear discharge and a permanent perforation. A perforation
becomes permanent when its edges are covered by squamous epithelium and it does not
heal spontaneously. A permanent perforationcan be likened to an epithelium-lined fistulous
track. Chronic suppurative otitis media tubotympanic type is safe which it involves
anteroinferior part of middle ear cleft and is associated with a central perforation. There is no
risk of serious complication. While the chronic suppurative otitis media atticoantral type is
unsafe with involves posterosuperior part of cleft and associated with an attic and marginal
perforation. The risk of complication is high in this variety.

CSOM TUBOTYMPANIC CSOM ATTICOANTRAL

DISCHARGE Profuse, mucoid, odourless Scanty, purulent, foul smelling
PERFORATION Central Attic / marginal
GRANULATIONS Uncommon Common
POLYP Pale Red and fleshy
CHOLESTEATOMA Absent Present
COMPLICATIONS Rare Common
Mild to moderate conductive
AUDIOGRAM Conductive / mixed deafness
deafness

Features indicating of complication of chronic suppurative otitis media:

 Pain
 Vertigo
 Persistent headache
 Facial weakness
 A listless child refusing to take feeds
 Fever and neck rigidity
 Diplopia
 Ataxia
 Abscess round the ear- mastoiditis
Complicatios of suppurative otitis media:

GROUPS TYPES
 Mastoiditis
Intratemporal (within the  Petrositis
confines of temporal bone)  Facial paralysis
 Labyrinthitis
 Extradural abscess
 Subdural abscess
 Meningitis
Intracranial
 Brain abscess
 Lateral sinus thrombophlebitis
 Otitic hydrocephalus

Sequalae of otitis media:

 Perforation of tympanic membrane

 Ossicular erosion
 Atelectasis and adhesive otitis media
 Tympanosclerosis
 Cholesteatoma formation
 Conductive hearing loss due to ossicular erosion or fixation
 Sensorineural hearing loss
 Speech impairment
 Learning disabilities