The patient presented with ear pain, nasal congestion, and fever. Examination revealed a perforated eardrum, nasal discharge, and lymphadenitis. The initial diagnosis is acute otitis media with perforation and acute rhinosinusitis. Treatment includes ear drops, antibiotics, pain management, nasal irrigation, smoking/alcohol cessation counseling, and ENT referral.
The patient presented with ear pain, nasal congestion, and fever. Examination revealed a perforated eardrum, nasal discharge, and lymphadenitis. The initial diagnosis is acute otitis media with perforation and acute rhinosinusitis. Treatment includes ear drops, antibiotics, pain management, nasal irrigation, smoking/alcohol cessation counseling, and ENT referral.
The patient presented with ear pain, nasal congestion, and fever. Examination revealed a perforated eardrum, nasal discharge, and lymphadenitis. The initial diagnosis is acute otitis media with perforation and acute rhinosinusitis. Treatment includes ear drops, antibiotics, pain management, nasal irrigation, smoking/alcohol cessation counseling, and ENT referral.
The patient presented with ear pain, nasal congestion, and fever. Examination revealed a perforated eardrum, nasal discharge, and lymphadenitis. The initial diagnosis is acute otitis media with perforation and acute rhinosinusitis. Treatment includes ear drops, antibiotics, pain management, nasal irrigation, smoking/alcohol cessation counseling, and ENT referral.
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NAME: Purushothaman ,Deepika
COURSE: MD 3RD YEAR
Otolaryngology Head and Neck Surgery CASE
This is a case of B.S. a 32-year-old female who consulted in your clinic due to ear pain.
History:
2 weeks PTC: Patient experienced coughing with associated nasal congestion. She then selfmedicated with Paracetamol 500mg tablet taken 3 times a day. She also noted to be feverish No consult done.
7 days PTC: Patient noted to have right ear pain with sensation fullness and post nasal drip. She noted that her fever resolved hence no consult was done. She self-medicated with mefenamic acid affording slight relief and was able to sleep that night.
2 days PTC: Patient upon waking up noted to have right ear mucoid discharge & ear pain decreased at this time, hence consult
Upon interview, she noted that this is the first time she had an episode of ear discharge; past medical history noted S/P Rhinoplasty 2016. Works as a chemical engineer, occasional alcohol beverage, smoker for 10 pack years and denies use of illicit drugs.
The review of systems was unremarkable.
PHYSICAL EXAM:
General: Awake, coherent, not in distress, GCS 15
Vital Signs: BP: 110/90 HR: 76 RR: 17 Temp: 37.2 O2 saturation: 94 Eyes: Anicteric sclera, pale palpebral conjunctivae, Intact EOM Chest/Lungs: Symmetric chest expansion, no retractions, no rales Heart: Adynamic precordium, normal rate, regular rhythm, distinct heart sounds, no murmur Abdomen: Flat, normoactive bowel sounds, soft, nontender Extremities: Full equal pulses, no cyanosis, no edema, pallor Neurologic: Oriented to 3 spheres ENT PHYSICAL EXAM:
OTOSCOPY: Normal findings LEFT ear, Hyperemic TM with debris and with associated minimal mucoid discharge, on the RIGHT ear. Upon suctioning the ear discharge on the right ear you noted TM perforation.
ANTERIOR RHINOSCOPY: congested right and left nostril with associated whitish mucoid discharge
POSTERIOR RHINOSCOPY: Patient unable to tolerate the procedure
ORAL CAVITY: there was mucopurulent post nasal discharge, no exudates seen on both pharyngeal tonsils
HEAD AND NECK: cervicalymphadenitis right upper jugular
GUIDE QUESTIONS
1. WHAT ARE THE SALIENT FEATURES OF THE CASE?
The salient features of the case include:
1. General Physical Examination:
- Awake, coherent, and not in distress - Glasgow Coma Scale (GCS) score of 15 - Vital signs within normal limits with slightly decreased O2 saturation (94%)
2. Eye Examination: - Anicteric sclera - Pale palpebral conjunctivae - Intact extraocular movements 3. Chest/Lung Examination: - Symmetric chest expansion - Absence of retractions and rales
4. Cardiac Examination: - Adynamic precordium - Normal heart rate and regular rhythm - No murmurs detected
6. Extremities Examination: - Full and equal pulses - No evidence of cyanosis, edema, or pallor
7. Neurologic Examination: - Oriented to 3 spheres
8. ENT Physical Examination:
- Otoscopy revealed a normal left ear and a hyperemic tympanic membrane ™ with associated minimal mucoid discharge and a TM perforation in the right ear after suctioning the discharge - Anterior rhinoscopy showed congestion in both nostrils with whitish mucoid discharge - The patient was unable to tolerate the posterior rhinoscopy - Oral cavity examination showed mucopurulent post nasal discharge with no exudates seen on the pharyngeal tonsils - Presence of cervical lymphadenitis in the right upper jugular region
Given these findings, it seems there is a focus on ear and sinus-related issues, in addition to the lymphadenitis in the head and neck region. Addressing the ear perforation and the nasal discharge would likely be key aspects of the patient’s management.
2. WHAT IS YOUR INITIAL DIAGNOSIS?
Considering the symptoms and findings you’ve described, it seems that the most likely initial diagnosis for B.S. could be acute otitis media with perforation, along with acute rhinosinusitis, and associated lymphadenitis. Let’s break it down:
Acute Otitis Media with Perforation:
- B.S. presented with a history of coughing, nasal congestion, and subsequent ear pain with a sensation of fullness. This development progressed to mucoid discharge from the right ear and a documented tympanic membrane ™ perforation during the otoscopic examination. These findings are suggestive of acute otitis media with the ruptured tympanic membrane, leading to the discharge and decreased ear pain.
3. WHAT IS THE TREATMENT/PLAN OF MANAGEMENT FOR THIS CASE
Based on the symptoms and physical examination findings you’ve provided, here’s a proposed treatment/management plan for B.S.’s case:
1. Medical Therapy: - Ear Discharge and Perforated Tympanic Membrane: Consider topical eardrops that contain antibiotics and/or corticosteroids to address the ear infection and promote healing of the perforated tympanic membrane. Pain management may also be necessary. - Acute Rhinosinusitis: If bacterial infection is suspected due to persistent symptoms, a short course of antibiotics might be considered. Be mindful of the selection of antibiotics to address potential resistant organisms, especially given the patient’s self-medication history.
2. Symptomatic Relief: - Pain management: Consider appropriate analgesics, and avoid mefenamic acid due to its potential adverse effects on the gastrointestinal system. - Nasal decongestants: If appropriate, nasal decongestants may offer relief for nasal congestion. - Saline nasal irrigation: This can help in clearing mucus and reducing nasal congestion, considering that the patient has associated nasal symptoms.
3. Environmental and Behavioral Modification:
- Counseling: Advise the patient to cease smoking and limit alcohol consumption, both of which can exacerbate sinus and ear inflammation. - Professional Assessment: Considering her work as a chemical engineer, a review of her workplace environment might be necessary to identify potential irritants or allergens contributing to her symptoms and to ensure a safe work environment.
4. Referral to Specialist: - Given her past medical history, including rhinoplasty, and the complexity of her symptoms, referral to an otolaryngologist (ear, nose, and throat specialist) is crucial. They can provide a more specialized evaluation, including further assessment of the nasal and sinus cavities, as well as the perforated eardrum. The ENT specialist can also assess the need for any surgical intervention, especially if there are concerns about the tympanic membrane perforation.
5. Monitoring and Follow-up:
- Schedule a follow-up appointment to monitor the patient’s response to treatment and ensure proper healing of the ear and resolution of sinus symptoms. This is essential to facilitate further management decisions and to assess for complications.
6. Health Education: - Patient education is crucial regarding the dangers of self-medication, impact of lifestyle choices like smoking and alcohol consumption on health, and the importance of seeking timely medical care.
