Case Discussion

OTORRHEA
September 4, 2017
Case
A 42-year old male was, muro-ami diver, from
Camarines Norte, consulted due to ear discharge.
History of Present Illness
10 years prior to consult, patient started
experiencing ear discharge from his left ear. This
was described as yellowish, mucoid discharge
usually preceded by a bout of cough and colds.
No consult was done, and no medications were
taken during that time.
History of Present Illness
Interval history showed recurrent episodes of ear
discharge occurring almost once per month,
accompanied by gradually progressive hearing loss
in his left ear. No consult was done but patient
would usually insert cotton wick to dry the ear.
History of Present Illness
Patient consulted in a local health center due to
persistence of ear discharge, now described as
mucopurulent, and foul smelling. This was
accompanied by hearing loss in the left ear,
recurrent headache, and pain in the mastoid area.
Patient was given two-week duration of oral
antibiotics and otic drops with no relief of
symptoms noted.
Patient was referred to your clinic for further
evaluation.
Past Medical History
(+) history of ear discharge during childhood
(-) hypertension, (-) diabetes, (-) TB
(-) allergies (to food or medications)
(-) previous hospitalizations or surgeries
Family History
(-) Hypertension, (-) Diabetes
(-) Thyroid disorder, (-) Cancer
Personal/Social History
Smoker (10 pack years)
Alcoholic beverage drinker (2-3 long neck
brandy/week)
Physical Exam
OTOSCOPY
Physical Exam
Anterior rhinoscopy: septum midline, turbinates
not congested, no discharge
Oral cavity: no oral mucosal lesions, non hyperemic
posterior pharyngeal wall, tonsils not enlarged
No facial lesions, no facial asymmetry
No cervical lymphadenopathy
Normal neurologic exam
6-point Case Discussion
1. Salient history
2. Description of pertinent P.E. findings
3. Ancillary procedures
4. Diagnosis / Differential diagnosis
5. Management
6. Referral, prevention, surveillance, public health
awareness
Salient History
SUBJECTIVE OBJECTIVE
42-year old male (+) history of ear discharge
muro-ami diver during childhood
Yellowish, mucoid ear discharge from (-) allergies
left ear (10 years PTC; preceded by a Normal anterior rhinoscopy
bout of cough and colds)
Recurrent episodes of ear discharge Normal oral cavity findings
Gradually progressive hearing loss in (-) facial lesions, facial
his left ear asymmetry
Mucopurulent and foul smelling ear (-) cervical
discharge lymphadenopathy
Recurrent headache Normal neurologic
Pain in the mastoid area examination
Two-week duration of oral antibiotics
and otic drops with no relief of
symptoms
Pertinent P.E. Findings
Anterior rhinoscopy
Septum midline, turbinates not congested
No discharge
Pertinent P.E. Findings
Oral Cavity
no oral mucosal lesions, non hyperemic posterior
pharyngeal wall, tonsils not enlarged
Otoscopy
Left Ear: hyperemic, presence of white
translucent fluid,
Right Ear: Intact, normal TM position, pearly
white, translucent
Pertinent P.E. Findings
Inspection and Palpation of External Ear
Presence of mucopurulent and foul discharge
upon inspection
Tragal tenderness and pain elicited upon
palpation
Pertinent P.E. Findings
Hearing Acuity Test
Hearing loss in the left ear
Weber
Sound lateralized to L ear
Rinnes
L ear: BC>AC
R ear: AC>BC
Conductive hearing loss
Pertinent P.E. Findings
Pain in the mastoid area
Ancillary Procedures
Audiometry/Hearing Test
Pure Tone Audiometry

Pneumatic Otoscopy
For visualization and testing of mobility of TM

CT of temporal bone
Help diagnose complications of OM (mastoiditis,
meningitis, abscess)
 Ancillary Procedures
Tympanometry
Type A: normal middle
ear compliance
Type As: ossicular
fixation
Type Ad: ossicular
discontinuity
Type B: OME, cerumen
impaction, perforated
TM
Type C: negative
middle ear pressure,
eustachian tube
dysfunction
Diagnosis
Chronic Otitis Externa
Chronic Otitis Externa
Chronic inflammation of the skin lining the
external ear canal leading to the eardrum.
Can be caused by:
Bacterial infection
Chronic skin disorder (eczema, seborrhea)
Fungal infection
Chronic irritation (Q tips)
Habit of frequently scratching the ears
Differential Diagnosis
Condition Signs and Symptoms
Acute Otitis Both with ear pain and possible hearing loss.
Media Pneumatic otoscopy will show mobility of
tympanic membrane in Otitis Externa, as
compared to AOM. No tragal tenderness
Furunculosis Localized infected hair follicle in the
cartilaginous canal of the external ear. May
present the same as Otitis Externa but the
bony portion of the canal is usually normal.
Contact Allergic reactions to prior topical solution use.
Dermatitis
Differential Diagnosis
Condition Signs and Symptoms
Cancer of ear Bloody discharge with a visible lesion in the
canal ear canal
Cholesteatoma History of tympanic membrane perforation
with flaky debris in ear canal
Malignant Otitis High fever with granulation tissue in ear canal
Externa and may have cranial nerve involvement.
Otomycosis Extended use of topical steroids or
antibiotics. Will present as intense pruritus.
Differential Diagnosis
Condition Signs and Symptoms
Petrous Petrositis, infection of the petrous bone and
Apicitis air cells. It presents with retro-orbital pain,
cranial nerve six palsy, and ear drainage
Tuberculosis of Can present as painless otorrhea
the temporal
bone
Management
Topical antibiotics
Systemic antibiotics - for patients who have
received empiric topical antibiotics and at higher risk
for resistance
Aural toilet
Surgery - indicated for patients who developed
complications, to remove infected tissue in the middle
ear or mastoid and to repair the ear damage that
results in hearing loss
Acetic acid (can irritate middle ear)
Public Health Awareness
Experts recommend the following simple techniques for keeping water
out of the ears:
inserting a soft, malleable plug into the auricle to block entry to the
ear canal
or removing water from the ears after swimming (by positioning or
shaking the head, or by using a hair dryer on a low setting)
avoiding cotton swabs
they might impact cerumen
Daily prophylaxis with alcohol or acidic drops during at-risk
activities has also been suggested
Using hard earplugs should be avoided
can cause trauma, and the use of custom ear canal molds
Source: Hui, C. P., & Canadian Paediatric Society, Infectious Diseases and Immunization Committee. (2013). Acute otitis externa. Paediatrics
& Child Health, 18(2), 9698.
Prevention
Prevention:
Keep ears dry especially after diving/swimming
Tympanoplasty to seal the perforation and prevent bacterial
translocation
Symptoms of aural fullness, otalgia with or without fever, and
headache should be evaluated by an ENT
Because CSOM is preceded in most cases by AOM, the
most effective method of prevention is prompt and
appropriate treatment of AOM.
Children who are <2y/o and those who have language or
learning problems should have a follow-up ear exam 2-3 mos
after being treated for an ear infection.
Referral
Referral:
No improvement of symptoms despite
treatment
Unexplained treatment failure
Suspected malignant otitis
Pain and headache are more severe
Granulation tissue at the bone-cartilage
junction
Facial nerve paralysis (drooping of ipsilateral
face)