Surgery: ENT

CASE PRESENTATION

GROUP C - Papellero, Patalinghug, Peñas, Perigo, Posa, Prado, Quirante

DATE AND TIME GATHERED: September 23, 2022 at
8:00am

SOURCE OF INFORMATION: Patient

% OF RELIABILITY: 96%
General Data

● P.J., 22 y.o, male,

● College student,
● Roman Catholic,
● Residing in Lahug, Cebu City
Chief Complaint: left ear Pain
HISTORY OF PRESENT ILLNESS:

● 6 weeks PTC, onset of yellowish nasal discharge associated with

fever, anosmia, headache, postnasal drip, and nasal congestion
alternately occurring on the both sides accompanied by halitosis.
● He took Co-Amoxiclav 625mg 1 tablet 2x a day for 7 days and
Neozep 1 tablet every 8 hours which afforded relief after 3 days.
● A week PTC, he had a decreased hearing acuity on the left ear.
Hearing loss was noted to be gradual however it is not associated
with pain, fever, headache, ear discharge, dizziness, vertigo, or
NAV
● 3 hours PTC, he develop otalgia, 6/10, while cleaning his left ear
and therefore opted for an ENT consult.
PERSONAL AND SOCIAL HISTORY: Patient is non-smoker, non-
alcoholic, no history of drug use.

PAST MEDICAL HISTORY: Patient is non-asthmatic and has

no allergies.

FAMILY HISTORY: Patient’s mother has a bronchial asthma

REVIEW OF SYSTEMS
 REVIEW OF SYSTEMS
General: recent weight change, clothes that fit more tightly or loosely than before, weakness, fatigue, fever

Skin: rashes, lumps, sores, itching, dryness, color change: darkening of lower extremities above the ankles since
changes in hair or nails

Head: Headache, head injury, dizziness,lightheadedness

Eyes: Wears prescription glasses, pain, redness, excessive tearing, double vision, blurred vision on the left eye, black
spots, specks, flashing lights, glaucoma, cataracts

Ears: Hearing loss on left ear, tinnitus, otalgia, vertigo, infection, otorrhea, otorrhagia, use or non-use of hearing aids

Nose and Sinuses: Frequent colds, nasal stuffiness, rhinorrhea or itching hay fever, nosebleeds, sinus trouble,
hyposmia, malar pain

Throat: Condition of teeth, gums, bleeding gums, dentures, if any and how they fit, sore tongue, dry tongue,
hypogeusia,frequent sore throats, hoarseness, dysphagia, last dental examination
 REVIEW OF SYSTEMS
Neck: Lumps, “swollen glands”, goiter, pain or stiffness in the neck

Breast: Lumps, pain or discomfort, nipple discharge, SBE

Respiratory: Cough, sputum (color, quantity), hemoptysis, dyspnea, bibasal rales, wheezing, pleurisy, last chest x-ray,
asthma, bronchitis, emphysema, pneumonia, TB

Cardiovascular: Heart trouble, high BP, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations,
dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema

Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, bowel movements, color and size of stools, change
in bowel habits, rectal bleeding or black/tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food
intolerance, excessive belching, or the passing of gas, jaundice,hepatitis

Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary
infections, kidney stones, incontinence, in males, reduced caliber or force of the urinary stream, hesitancy, dribbling
 REVIEW OF SYSTEMS
Genital (Male). hernias, discharge, from or sores on the penis, testicular pain or masses, history of STDs and their
treatments, sexual habits, interest, function, satisfaction, birth control methods, condom use, problems, exposure to
HIV infection

Peripheral Vascular: Intermittent claudication, leg cramps, varicose veins, past clots in the veins

Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe location of affected
joints, muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness or limitation in motion or
activity, duration & any history of trauma

Hematologic: Anemia, easy bruising or bleeding, past transfusions and or transfusion reactions

Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change
in glove or shoe size

Psychiatric: Nervousness, tension, mood, including depression, memory change, suicide attempts

Neurologic: Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or “pins and
needles” , tremors or other involuntary movements
PHYSICAL EXAMINATION
General Survey
Patient is alert, coherent, cooperative and
oriented to the time and place. Patient is
mesomorphic, ambulatory, normal speech
and not in respiratory distress. No
involuntary movements not tremors noted.
Patient has a clean appearance and his face
is appropriate for his age.
VITALS
Blood Pressure: 120/90 mmHg, left arm, sitting
Temperature: 36.5 °C, left axilla
Heart Rate: 70 bpm Left radial, regular, bounding
Respiratory Rate: 18 cpm, normal depth.
regular
Height: 170.5 cm
Weight: 65 kg
BMI: 22.6, normal
Physical Examination
SKIN:
Inspection:
Patient has fair skin complexion. No signs of jaundice and cyanosis. No
lesions nor melasma
noted. Patient is in good hygiene with no foul odor.

Palpation:
The skin was dry, and warm to touch. The skin has a good mobility and
turgor. It was of smooth
texture, without excessive sweating nor oiliness.
Physical Examination
NAILS:
Inspection:
Fingers have no discoloration, no pitting, no clubbing, were well groomed
and uniform with no
deformities and lesions.

Palpation:
It was smooth, intact, and adhered to the nail bed, and the nail base angle
is 160 degrees, and
no lesions were noted. No clubbing of fingers with pinking nail plate.
Capillary refill test is less than two (2) seconds.
Physical Examination
HAIR:
Inspection:
The hair is evenly distributed. No alopecia was noted. There was no
scaling nor lesions
observed. The hair color is black.

Palpation:
Hair has a smooth texture and is straight.
Physical Examination
HEAD:
Inspection:
The head Is symmetrically round, with a normocephalic skull, and
symmetrical facial features.

Palpation:
The head is smooth without any deformities. Salivary glands are non-
tender. Temporal
arteries are elastic and non-tender.
Physical Examination
EYES
INSPECTION: Eyebrows are colored black, smooth with no hair loss or crusting or swelling.
Orbital rim has no bony deformities. Eyelids have smooth lid margin without scaling or crusting.
No swelling noted. Patient’s eyelashes have complete lid closure. A thin grayish white arc or
circle not quite at the edge of the cornea. Both eye lenses are clear, ellipsoid, biconcave, flexible
and intact. Both iris are black, flat, ring-shaped and intact. Both sclera are anicteric without
congestion, swelling nor thickening, hemorrhages nor exudates. Both pupils are isocoric without
congestion, round. No ptosis or proptosis. There was a positive direct and consensual light
reflex.
Fundoscopy revealed a positive red orange reflex. Round optic disc with distinct borders. CD
ratio is 0.4 and AV ratio is 2:3.
Extraocular movements: Normal range of motion in all 6 cardinal directions of gaze. No
nystagmus noted.
PALPATION: Tonometry of both eyes were soft like the tip of nose.
Physical Examination
EARS:
Inspection:
Both ears are symmetrical. No deformities, cerumen, lesions nor
discharges were observed.
The auricles are symmetrical. No lesions and tenderness were noted on
both
ears. The external auditory canal is Intact, pink and patent.

Palpation:
There was no tenderness on the auricles and tragus. Both ears are soft.
Physical Examination
Otoscopy: Unremarkable ear on the right; bulging tympanic membrane
on the left
Weber test: Lateralized on right ear
Rinne test: Conductive hearing loss of the left ear; BC>AC (left ear);
AC>BC (right ear)
Physical Examination
Nose and Paranasal Sinuses

Inspection:
The nose is symmetrical with distinct borders, and nostrils are with intact vestibules.
Nasal septum is in the midline and intact.

The nasal turbinates are intact on the right. No unremarkable changes noted on the
right nostril.

Minimal whitish discharge on the left nostril, pale to pinkish nasal cavity mucosa. No
mass noted.

Palpation:
Neither frontal and maxillary tenderness nor nasopharyngeal congestion was noted.
Physical Examination
Mouth

Inspection:
Both upper and lower lips are reddish, symmetrical, and dry without any
lesions. Oral mucosa is pink, unremarkable.
Tongue is normal in shape and size, pink in color with rough papilla, in the
midline, and is mobile.

Both hard and soft palates are pink. Uvula is pink in color, and in the
midline. Tonsils are not enlarged and have neither exudates nor
tonsilloliths.

Whitish discharge noted on Nasopharynx and Oropharynx posterior wall

Pharyngeal wall is pink in color, has no lesions and exudates nor congestions. The buccal mucosa has
neither lesions nor ulcerations.

Gingiva is not inflamed, coral pink in color, pyramidal in shape, follows a curve line around the
tooth, and is not bleeding.

Pharynx: Whitish discharge noted on nasopharynx and oropharynx posterior wall.

Physical Examination
NECK

Inspection: Trachea is in the midline. Neck is symmetric. Thyroid gland is

not enlarged. The cartilage moves upward upon swallowing.

Palpation: Thyroid isthmus is palpable, and lobes were not felt. Neither
masses nor venous distention were noted. Neither preauricular, posterior
auricular, occipital, tonsillar, submandibular, submental, superficial
cervical, posterior cervical and supraclavicular lymphadenopathies were
noted.
Physical Examination
CHEST AND LUNGS
Inspection: No gross deformities, equal chest expansion, no
intercostals retractions
Palpation: No tenderness, normal tactile fremitus noted.
Percussion: Dullness over the right posterior mid to basal lung
fields
Auscultation: No wheezing or abnormalities noted.
Physical Examination
HEART
Inspection: No cyanosis noted and point of maximal impulse (PMI) is not visible.

Palpation: Carotid upstrokes are brisk, no thrills. Point of maximal impulse is palpable at the
left 5th intercostal space approximately 8 cm from midsternal line with no thrills nor heaves,
and its diameter is 2 cm and its amplitude is like a gentle tap with brief duration.

Percussion: Left cardiac border:

Third Intercostal Space (ICS): 3 cm from MSL (Midsternal Line)

Fourth Intercostal Space (ICS): 7 cm from MSL (Midsternal Line)

Fifth Intercostal Space (ICS): 7 cm from MSL (Midsternal Line)

Right cardiac border: No dullness beyond right edge of the sternum in the third, fourth,
and fifth intercostal space

Auscultation: Neither murmur, nor extra sounds were heard. Distinct S1 which is loud at the
apex and S2 which is loud at the base.
Physical Examination
BREAST AND AXILLAE

Inspection: Both axilla has no lesions, swelling nor signs of

inflammation. Both breasts were symmetrical. No dimpling,
retractions, lesions nor masses noted on both breasts. No peau d'
orange noted. Nipples had no scaliness, ulceration, inversion,
retraction and discharge. Areola are light brown in color, circular in
shape, raised, and with no eczema changes.

Palpation: No masses and lymph node tenderness noted on both

axilla. Both breasts were finely granular during the examination.
masses upon doing vertical strip pattern of palpation. No discharge,
pus or blood noted upon careful and gentle squeezing on both
nipples. Areola had no lesions, swellings, or masses noted.
Physical Examination
Abdominal Examination:
Inspection
Abdomen is flat, with no discolorations, stretch marks, dilated veins,
rashes, or bruises noted.
Auscultation
Normoactive bowel sounds.
Percussion
Negative splenic percussion sign and CVA tenderness.
Palpation
No rigidity or guarding noted. No masses palpated. Negative
Murphy’s sign.
Others:
Negative ascites in fluid wave test and shifting dullness exam
Digital Rectal exam:
No hernia, no hemorrhoids, no rectal prolapse. Tight external sphincter
tone, empty rectal vault, and the prostate size is normal. The feces has no
blood on the examining finger.
Back and Extremities:
Full range of motion in all joints of the upper and lower extremities. No
evidence of atrophy, swelling, weaknesses, or deformities. No curvature
abnormalities of the spine noted.
Physical Examination
CN 1 (Olfactory): can recognize the smell of coffee on both nostrils
CN 2 (Optic): Visual acuity OD 20/20, OS 20/20
: Visual field OD/OS intact
: Fundus NAD
CN 2, 3 (Optic, Oculomotor): Pupils reactive to direct and
consensual light, size 4mm
CN 3, 4, 6, (Oculomotor, Trochlear, Abducens): Full extraocular
movements noted in both eyes, no proptosis noted
CN 5 (Trigeminal):
Motor - able to clench teeth (normal contraction of masseter
and temporal muscles)
Sensory: able to discern light touch, pain, and temperature on
3 all 3 divisions/areas
Physical Examination
CN 7 (Facial): Symmetrical facial movements on both
sides. No weakness noted.
CN 8 (Vestibulocochlear): Whispered voice test normal,
Weber lateralized on Right Ear, Rinne: Left AC < BC,
Right AC > BC
CN 9, 10 (Glossopharyngeal, Vagus): voice is normal
(no hoarseness notes), symmetrical swallowing
movements and rising of soft palate
CN 11 (Spinal Accessory):
Trapezius: able to shrug both shoulders against
examiner’s hands
Sternocleidomastoid: able to move head to each
side against examiner’s hands
CN 12 (Hypoglossal): tongue midline, no asymmetry or
deviation noted
 CLINICAL IMPRESSION

left acute unilateral Otitis

media
secondary to acute rhinosinusitis
BASIS OF IMPRESSION
● Bilateral yellowish nasal discharge
● Fever
● Anosmia
● Headache
● Post nasal drip
● Bilateral nasal congestion with halitosis
● Left ear otalgia with hearing loss
● Otoscopy: Bulging tympanic membrane on the left ear
● Weber’s test: lateralizes to the right
● Rinne test: (R) - AC>BC ; (L) - AC<BC; Conductive Hearing Loss
● Nose: (+) whitish discharge on left meatus, pale to pinkish nasal mucosa
● Pharynx: (+) whitish discharge in the posterior wall of Nasopharynx and Oropharynx
DIFFERENTIAL DIAGNOSIS
 Rule In Rule Out

Acute Otitis Externa (+) Otalgia (-) Pain in the Tragus and
(+) Hearing Loss Pinna
(-) Erythema and edema of
External Ear
(-) No history of infection of
external ear or swimming

Allergic Rhinitis (+) Nasal Congestion (-) No history of allergy

(+) Rhinorrhea (-) Sneezing Episode
(+) Anosmia (-) No conjunctivitis
(-) Nasal Itchiness
Bullous myringitis (+) Fever (-) No bullae over tympanic
(+) Otalgia membrane
(+) Hearing loss (-) Serous/serosanguinous fluid

Cholesteatoma (+) Otalgia (-) Granulation tissue on middle

(+) Hearing loss ear
(-) Headache
(-) Facial palsy
Upper Respiratory Tract Infection (+) Fever (-) Cough
(+) Nasal Congestion (-) Body Malaise
(+) Rhinorrhea (-) Sputum Production

COVID-19 (+) Fever (-) Cough

(+) Anosmia (-) Body Malaise
(-) Sputum Production
(-) No History of Exposure
DIAGNOSTIC MANAGEMENT
Otoscopy- to visualize the structures and integrity of
tympanic membrane

Tympanometry: assess abnormalities consistent with

perforation, although confirmation still requires
examination. Type B or Type C tympanograms indicate
middle ear effusion.

Radiography or CT scan :to visualize sinuses, not routinely

done unless there is the presence of complications

Tympanocentesis: the gold standard for bacteriologic

diagnosis but it is not usually indicated in the diagnosis of
acute otitis media
RT-PCR: To rule out COVID-19 infection
THERAPEUTIC MANAGEMENT
Treatment for Acute Otitis Media
ANTIBIOTIC THERAPY:
Amoxicillin + Clavulanic Acid

- 1st line of treatment for penicillin resistant organism

B. Cephalosporins

C. Sulfisoxazole + Erythromycin

ADJUNCTIVE THERAPY
A. Dry Heat Application

B. Anesthetic Ear Drops

Treatment for Acute Otitis Media
PAIN MANAGEMENT:
A. Analgesics (Paracetamol)

- Slight relief of otalgia and fever.

SURGICAL INTERVENTION
A. Tympanocentesis
Treatment for Acute Rhinosinusitis
ANTIBIOTIC THERAPY:
Amoxicillin + Clavulanic Acid

- 1st line of treatment for penicillin resistant organism

B. Doxycycline or respiratory fluoroquinolone

ADJUNCTIVE THERAPY
A. Intranasal Steroid Spray

B. Saline Irrigation

C. Nasal Decongestants
Vaccination
PNEUMOCOCCAL VACCINE ( Pneumovax and Prevnar 13)

- Used for preventing S. pneumoniae conditions such as rhinosinusitis and

otitis media.

INFLUENZA VACCINE
DISCUSSION
Anatomy
Physiology
Physiology
Etiology
RHINOSINUSITIS
● Usually viral
● Bacterial pathogens: Strep. Pneumoniae, H. influenzae, M. catarrhalis
● Fungi
● NONINFECTIOUS
○ allergic rhinitis (with either mucosal edema or polyp obstruction)
○ Barotrauma (deep sea diving / air travel)
○ Exposure to chemical irritants
○ Tumors
○ Granulomatous diseases (granulomatosis with polyangiitis, rhinoscleroma)
○ Conditions leading to altered mucus content (CF)
Pathophysiology
Rhinosinusitis
● Inflammation of the nose and the paranasal sinuses
● results from interactions between a predisposing condition
○ allergic rhinitis
○ immune deficiency
○ inflammatory response from a viral infection
● Viruses account for the majority of cases (rhinovirus, coronavirus, influenza, respiratory syncytial virus
(RSV), and parainfluenza)

● IMPAIRED
● EDEMA AND
VENTILATION AND ● SECONDARY
● INFLAMMATION OBSTRUCTION OF THE
DRAINAGE OF THE BACTERIAL INFECTION
SINUS OSTIUM
SINUS
Pathophysiology
Otitis Media
● Inflammation of the middle ear

● Negative pressure
● Immune and ● Colonization of
in the middle ear,
● Upper respiratory inflammatory ● Eustachian tube organisms and
increase exudate,
tract infection responses in the obstruction accumulation of
build up of mucosal
ET mucosa fluid
secretions
Clinical Manifestation
Clinical Manifestation
Prognosis
● Prognosis for most of the patients with otitis
media is excellent.
● Early diagnosis and treatment have resulted in a
better prognosis of this disease.
● Tympanic membrane perforations typically heal on
their own, leading to a favorable prognosis.
● For rhinosinusitis the large majority of cases will
either resolve spontaneously or can be effectively
treated with antibiotics.
● Adults with recurrent AOM should undergo further
evaluation for Eustachian tube obstruction
Patient Education
1. Children:
a. Clinicians should recommend pneumococcal conjugate vaccine to all
children
b. Clinicians may recommend an annual influenza vaccine to all children
c. Clinicians should encourage exclusive breastfeeding for at least 6
months
d. Clinicians should encourage prevention of OM by reduction of risk
factors and education of parents/caregivers
2. Patients should seek help if:
a. A new or increasing ear pain
b. New or increasing pus or blood draining from the ear
c. Fever with a stiff neck or a severe headache
d. Have new or worse symptoms
e. Not getting better after taking antibiotics for 2 days
References
Cummings Otolaryngology Head and
Neck Surgery 6th Ed

Philippine Society of Otolaryngology-

Head and Neck Surgery, Clinical Practice
Guidelines, 2016