Impacted Cerumen Patient is a5 year old, male complaining of ear pain. History started 3 days prior to consult when patient noticed ear pain accompanied by decreased hearing. Mother claims that he cleans the child’s ear almost everyday using cotton tips. No history of trauma, bleeding, ear discharge, tinnitus. Due to persistence of ear pain and decreased hearing, patient consulted. PMH: revealed no asthma, no allergies, no history of ear infections, normal developmental and auditory milestones FMH: non contributory PSH: not exposed in second hand smoke and leaves in a well lt, and well ventilated house (On PE: Anterior rhinoscopy showed turbinates not congested, no nasal discharge, no intranasal mass Posterior rhinosopy: no post nasal drip Oral cavity: (+) or (-} dental caries, no oral ulcers, non hyperemic posterior pharyngeal wall, tonsils not enlarged Face: no facial asymmetry, no neck masses, no cervical lymphadenopathy Otoscopy: non hyperemic external auditory canal both ears, tympanic membrane not visualized bilateral, with ceruminous debris obstructing the ear canal bilateral Weber's test showed no lateralization although this testis ideally done in a quiet or soundproof, environment because testing in the opd is not reliable Rinne’s test showed bone conduction is longer than air or equal ‘The rest of the physical exam findings were unremarkable My approach to diagnosis on this pediatric patient is based on the symptoms OR pathognomonic finding of a specific disease Based on the symptom of ear pain, my differential diagnosis would include the following: FATHER But after complete history and physical examination, which showed hearing loss and bilaterally obstructed ear canal, | have arrived with the diagnosis of Impacted Crumen, Bilateral, TFOBESERER: ‘Smratretion To discuss, ICis the complete blockage of the ear canal by accumulated ceruminous debris. itis ‘commonly caused by frequent manipulation of ear canal causing alteration of the normal centrifugal direction of the cerumen OR in other words disruption of the self cleansing mechanism of the ear canal. Ai Cerumen is composed of squamous epithelial debris produced,by thé ceruminous glands located in the cartilaginous part at the lateral 1/3 portion of the ear canal. And usually obstructs in the narrowestPortion of the ear canal called the isthmus which is formed by the junction of the cartilaginous and bony part of the canal, Just a question: do you think cerumen is important? (Our cerumen is important because it functions a 1. Protects ear from foreign body/debris 2. It moistens the ear canal thus frequent removal could cause dryness or pruritus 3. It produces enzymes that has antibacterial properties frequent removal could cause abrasion and eventual infection 4. and.. it maintains the normal pH of the canal so frequent removal of cerumen could cause proliferation of fungal microorganisms due to increase In pH causing otomycosis. For this patient, my management would include the following, First | plan to give the patient cerumenoiytics, example of which include sodium docusate otic drops, 3 Batts to both ears, TID for 5-7 days or cerumen softeners, example of which include baby oll and hydrogen peroxide for financially constrained patients Then after 5-7 days, if cerumen impaction persisted, on follow up | plan to perform aural irrigation to completely remove the Impacted cerumen. After | would advise the patient to avoid frequent ear manipulation, also advise parent regarding proper ear hygiene. Based on anticipatory guidelines, | would also advise the patient. Other guidelines: dewormning If infant: advise/update immunization schedule (holistic) If obese/or payat:. advised proper nutrition Thank you.AOM Patient is a 5 year old male complaining of ear pain, right. 5 days cough and colds, 3 days ear pain accompanied by decreased hearing. Persistence prompted consult. PMH: (+) allergic rhinitis, (-) asthma, (-) DM. FH: unremarkable PSH: unremarkable on PE: Anterior rhinoscopy showed turbinates not congested, no nasal discharge, no intranasal mass Posterior rhinosopy: no post nasal drip ral cavity: (+) or (-) dental caries, no oral ulcers, non hyperemic posterior pharyngeal wall, tonsils not enlarged Face: no facial asymmetry, no neck masses, no cervical lymphadenopathy (toscopy: non hyperemic external auditory canal both ears, tympanic membrane hyperemic and bulging Weber's test showed no lateralization although this test is ideally done in a quiet or soundproof environment therefore testing in the opd is not reliable Rinne’s test showed bone conduction is longer than air or equal The rest of the physical exam findings were unremarkable My approach to diagnosis on this pediatric patient is based on the symptoms OR pathognomonic finding of a specific disease Based on the symptom of ear pain, my differential diagnosis would Include the following: FATHER But after complete history and physical examination, which showed ear pain with bulging, hperemic tympanic membrane on PE I have arrived with the diagnosis AOM, AD-H-obese/sayatemalauteition Acute otitis media is the infection and subsequent inflammation of the middle ear. The middle ear is a space bordered laterally by the tympanic membrane, medially by the cochlea, posteriorly by the ‘mastoid, superiorly by the tegmen tympani or floor of the cranium and chronic middle ear infections ‘may cause complications due to invasion of these structures. ‘AOM is more common in children than adults. This Is due to the anatomic position of the Eustachian, tube which connects the nose to the middle ear. In children, Eustachian tube Is shorter and more horizontal causing a more accessible path for nasal secretions to go into the middle ear during episodes of colds or upper respiratory tract infections. Common bacterial pathogens that cause AOM include strep pneumonia, haemop! ‘Moraxella catarrhalis. s influenza, and‘AOM causes ear pain due to distension of the tympanic membrane and decrease in hearing due to ‘accumulation of fluid and exudates in the middle ear. if untreated, AOM could cause complications by Invading Its borders causing FLASS and ELMO’s BRAIN Management would include giving of systemic antibiotics, such as amoxicillin computed in 80-90 mkd, and antipyretic/analgesics such as paracetamol computed at 10-15 mkd. Preventive measures include avoidance of allergens since patient has allergic rhinitis and give antihistamines for mild intermittent rhinitis or sterold nasal spray for moderate persistent AR. Provide symptomatic treatment during episodes of colds such as nasal decongestants, Anticipatory guidelines. Thank you, CHRONIC OTITIS MEDIA (+) Hx of yellowish, foul-smelling ear discharge COM is chronic infection of the middle ear cavity manifested by tympanic membrane perforation and ear discharge. Usual bacteriologic agent is pseudornonas aeruginosa usually preceded by a bout of cough and colds or history of swimming which causes water to enter the middle ear cavity causing subsequent infection, funtreated, AOM could cause complications by invading the middle ear borders causing FLASS and ELMO’s brain ‘Treatment would include antibiotic otic drops. We usually give fluoroquinolones such as ofloxacin or ciprofloxacin otic drops due to the sensitivity of pseudomonas to it. Avoid manipulation and keep ears dry. Thank you.