CASE PRESENTATION

ORL-HNS
PALTEP,RASHELL ANNE C.
QUILANG, SHEILA AYRA F.
GENERAL DATA
 Name: D. C.
 Age: 56 y.o.
 Gender: Female
 DOB: Sept. 25,
1962
 Address: Taytay,
Rizal
CHIEF COMPLAINT
 EAR PAIN, LEFT
HISTORY OF PRESENT ILLNESS
5 days PTC Interim

•Sudden onset of • Persistence of

left ear pain (9/10) symptoms
•Watery discharge • Yellow, watery, non
•Ear itchiness foul-smelling
•Tinnitus on left ear discharge
•Went swimming 1 • Decreased hearing
on left ear
week prior to onset
• Hence consult.
of symptoms
•No consult. No
medications taken.
Past Medical History
 (+) Hypertension, Losartan(50mg, OD) but
non compliant
 (+) Diabetes mellitus, diagnosed 15 years ago
 (-) PTB
 (-) Pneumonia
 (-) BA/ allergies
Family history
 (-) Asthma
 (-) Hypertension
 (-) Heart Disease
 (+) Diabetes mellitus, maternal and paternal
Personal and social history
 Housewife
 Non smoker
 Non alcoholic beverage drinker
 Denies illicit drug use
 Patient prefers to eat vegetables, fish and

sweets.
Review of Systems
General: (-)Weight Loss, (-)Weight gain

Integumentary: (-)Lumps, sores, itching, muscle pain

HEENT: (-) Blurring of vision, (+) Tinnitus, (+) decrease hearing on left ear, (+)
ear pain left ear, (+) itchiness on left ear, (-) epistaxis, (-) dry mouth,
(-)palpable lymph nodes, (-) hoarseness of voice

Respiratory: (-) Cough and colds, (-) Hemoptysis, Wheezing, Dyspnea

Cardiovascular: (-)Chest pain, palpitations, easy fatigability, syncope

Gastrointestinal: (-) Dyspaghia, (-) odynophagia, (-) nausea, (-) diarrhea,

constipation, melena, episgastric pain

Endocrine: (-)Excessive sweating, cold intolerance and thirst

Genitourinary: (-)Discharge, dysuria

Neurologic: (-) Seizure

Physical Examination
General Survey: Awake, conscious, coherent,
not in cardiorespiratory distress
Vital Signs:
 BP: 130/80
 HR: 79 bpm
 RR: 20 cpm
 Temp: 36.9⁰C
PHYSICAL EXAM
• RIGHT EAR  LEFT EAR
 Grossly normal
 Grossly normal Pinna
 Patent EAC
Pinna  (+) Tragal tenderness
 No tragal  (+) retained cerumen
tenderness on the left ear
 (+) yellow, watery and
 No discharge
non foul smelling
 Patent EAC  TM intact
 TM intact
PHYSICAL EXAM
NOSE ORAL CAVITY
 Septum Midline  No hyperemia
 No masses seen  Moist Buccal
 No discharge, no
Mucosa
epistaxis  Midline tongue and
 No congestion
uvula
 No
tonsillopharyngitis
 No post nasal drip
PHYSICAL EXAM
HEAD AND NECK
 No cervical Lymphadenopathies
 No mass

 No Facial asymmetry
Salient Features
• 56 years old/female  Decrease hearing
• Otalgia left ear sensation on left ear
 Tinnitus on left ear
• Yellowish, watery,
nonfoul-smelling
ear discharge, left
ear
• Tragal tenderness,
left ear
• Intact TM, both ears
Differentials
 Otitis media with/without perforation of the
TM
 Furunculosis
 Mastoiditis
 Contact dermatitis of the ear canal
Assessment
 ACUTE OTITIS EXTERNA, LEFT
Plan
DIAGNOSTICS
 Weber test- localized on the side of infection
 Rinne test- bone conduction greater than air

conduction
Plan
THERAPEUTICS
 Polymyxin + Neomycin + Dexamethasone

otic drops, 3 drops on the left ear 3 times/

day for 7 days
 Celecoxib 200mg/cap, 1 cap BID as needed

for pain
DISCUSSION
Anatomy
Anatomy
 Pinna: Single piece of
yellow elastic cartilage
covered with
Perichondrium and
skin(except lobule and
outer part of external
auditory canal)
External Auditory Canal
Cartilaginous: Bony:
 Outer 1/3rd & 8mm  Inner 2/3rd & 16mm
 Skin lining the bony
canal
 Continuation of canal in thin &
cartilage which forms continuous over the
the frame work of tympanic membrane
 Devoid of skin
pinna
Fissures of Santorini appendages(Hair and
 through them parotid
ceremonious Glands)
 About 6mm lateral to
or superficial mastoid
tympanic membrane ,
infection can appear in
bony meatus presents
the canal or vice versa
as narrowing called
ISTHMUS
Anatomy
 Innervation: cranial nerves V, VII, IX, X and
greater auricular nerve
 Arterial supply: superficial temporal,

posterior and deep auricular branches

 Venous drainage: Superficial temporal and

posterior auricular veins

 Lymphatics
CASE DISCUSSION OF ACUTE OTITIS
EXTERNAL
 OTITIS EXTERNA (SWIMMER’S EAR OR
TROPICAL EAR)
◦ Is a state of infection or inflammation of the
external auditory canal(EAC)
◦ It can range from mild inflammation to
osteomyelitis of the skull base
◦ Acute or chronic
ACUTE OTITIS EXTERNA
 Rapid onset (<48hours)
 Generally unilateral, associated with exposure

of the ear canal to water or local trauma

 Factors include:

◦ Congenital(narrow ear canal)

◦ Canal narrowed by exostoses
◦ Skin condition such as eczema, seborrhea or
psoriasis
◦ Trauma from ear plugs, hearing aids or wax
removal attempts
Signs and Symptoms
 Moderate to severe otalgia
 Pruritus
 Erythema
 Scant clear discharge
COMMON ISOLATES
Bacterial (>90%)
 Pseudomonas aeruginosa
 Staphylococcus epidermidis
 Staphylococcus aureus

Fungal (<2%)
 Aspergillus
 Candida
PATHOPHYSIOLOGY
 3 clinical stages
1. PREINFLAMMATORY STAGE
-consists of edema of the skin of the EAC and obstruction
of glands induce by local trauma or moisture

2. ACUTE INFLAMMATORY
• MILD- characterize by erythe and edematous EAC with
clear, odorless secretions
• MODERATE- increasing edema and pain and
mucopurulent secretions
• SEVERE- the EAC becomes obstructed with debris and
secretions, is intense painful often associated with
periauricular edema and adenopathy
PATHOPHYSIOLOGY
3. CHRONIC INFLAMMATION
-is a single episode lasting more than 4
weeks or 4 or more episodes within one ear
TREATMENT
1st line: prevention
 Occlusive earplugs when water exposure is

expected like in swimming

 Proper fitting of hearing aids
 Drying of EAC is encouraged
TREATMENT
 Topical therapy: treatment of choice for AOE
 Broad spectrum antibiotic coverage, acidic

vehicle, no potential ototoxicity, no allergic

potential, no precipitate in the canal, low
cost, and a steroid to reduce inflammation
◦ Fluoroquinolones
◦ Aminoglycoside combined with a secong antibiotic
for pseudomonal coverage
TREATMENT
 Aural toilet: important adjuvant to medical
therapy
◦ Clears the canal of debris and purulent drainage
◦ Better penetration of the ototopical agents
COMPLICATIONS
 Cellulitis
 Perichondritis
 Chrondritis