CASE DISCUSSION -

CSOM

By: Kaushik R Bhat

17M3723
• NAME : X( Munib kumar)- Don't mention the name while
while presenting
• AGE : 21 YEARS
• SEX : MALE
• ADDRESS : KALGUNDI
• OCCUPATION : CARPENTER
• RELIGION: MUSLIM
• EDUCATION STATUS:
• SOCIOECONOMIC STATUS: Class II ,MODIFIED BG PRASAD
CLASSIFICATION
• DOA: 25/01 /2020
• DOE: 27/01/2020
• CHIEF COMPLAINTS :
1. Discharge from left ear since 1year
2. Pain in left ear since 2 months
3. Reduced hearing in left ear since 2 months
• HOPI:
Patient was apparently normal 1year back ,started
having discharge from his left ear , sudden in onset ,
gradually progressive, profuse(wet the pillow and
sheets) , intermittent, yellowish -white in colour ,
mucoid in consistency, non blood tinched , foul
smelling . No known aggrevating factors , but relieved
on medication.
Discharge is continuous in past 2 months and is not
relieved even on medication. No diurnal variation. No
seasonal variation. ( No posturnal variation).
 Patient also complaints of pain in left ear since 2
months, sudden in onset, Non progressive, mild, dull
aching continuous type of pain that aggravates on
hearing to loud noise (occupational exposure) and relieves
on medication. No diurnal , seasonal & postural variation.
Patient also complaints of reduced hearing in left
ear since 2 months , Insidious in onset, Non progressive
type , felt by difficulty in conversational speech.
Patient also gives the h/o tinnitus (subjective)
intermittent episodes lasting for 5-10 min after cleaning
the ear.
• H/o of itching present
• No h/o any ear Surgery
• No h/o pus discharge behind the ear
• No h/o giddiness (vertigo)
• No h/o double vision
• No h/o drooling of saliva, drying of eyes , drooping of face ( facial
palsy)
• No h/o headache and migraine,vomiting, convulsions
• No h/o high grade fever
• No h/o neck stiffness ,swelling
• No URTI ,nasal discharge ,sneezing ,disturbed smell ,nasal
blockadge, nasal bleed , swelling or injury, Sx
• No h/o sore throat , post nasal drip, cough with sputum , injury
• No h/o difficulty or pain during swallowing
• No h/o change in voice or nasal voice, stridor
• Snoring- cannot be commented
• No h/o any facial pain, swelling, deformity, injury or
lesions over the face
• No h/o any oral cavity ulcers, swelling, pain ,disturbed taste,
trismus, Ankyloglossia ,cleft palate or injury
• No h/o halitosis
• PAST HISTORY :
Patient came with similar complaints 1 year back
with reduced hearing which subsided completely after
medication. He was hospitalised for 3 days for the same.
Not k/c/o - syst HT /DM/TB/Epilepsy/Asthma/Syncope
No h/o surgery
No h/o Blood dyscrasias
• DRUG HISTORY:
Is on topical Antifungal since 1 year. (Not known)
Was on oral medication- drug not known.
Candid –B lotion(drops) for nail
Use of ototoxic drugs_______________
• PERSONAL HISTORY:
Diet : Mixed
Appetite : Normal
Sleep : Sound
B &B : N & R
Habits: Alcoholic since 2 years , once a week
90 ml whisky, Chewing tobacco since 1yr
FAMILY HISTORY:
Nothing significant
No h/o consanguineous marriage
H/o deafness in family- Not known
• SUMMARY:
21 yr old Male non comorbid patient, carpenter by
occupation with chronic ear pathology
Hence the probable diagnosis is Chronic otitis media with
Subacute exacerbation.
EXAMINATION
GENERAL PHYSICAL EXAMINATION:
Young male patient , Moderately built and poorly nourished
, consious (grade1) , co operative , well oriented to time, place , and
person.
• Pulse : 82 bpm , regular rhythm, normal volume , and character,
condition vessel wall normal , checked in right radial
artery.
• BP :
1. Palpatory method : 130 mm hg
2. Auscultatory method : 120/ 90 mm hg
3. Oscillatory method :
~Checked in left arm , supine position
• RR : 19 cpm, regular , abdomino thoracic type of breathing, equal
• Temperature : Afebrile
• Wt : 49kg
• Ht : 5’5
• BMI = wt/ sq ht = 17.976kg/ sqm
• O2 Saturation =__________
Pallor +ve , in lower palpaebral conjunctiva , nail beds look
Normal , palm crease present
Icterus –ve
Cyanosis –ve
Clubbing – ve
Generalized lympadenopathy –ve
Edema – ve
HEAD TO TOE EXAMINATION:
Multiple Hypo and Hyperpigmented vesicles over hand ,
abdomen and neck region .( Lichenification- Ankle)White discoloration
over proximal part of nail plate ,all fingers – not prominent in toes.
Face- Normal ( no adenoid facies)
SYSTEMIC EXAMINATION:
• RS : Bilateral normal vesicular breath sounds heard
No added sounds
• P/A : Soft , non tender, no palpable organomegaly
Bowel sounds heard
• CVS : S1 S2 heard , No murmurs
• CNS : Higher mental functions and Cranial nerve normal
No focal neurological defeciet
 • ENT & HEAD AND NECK EXAMINATION:
RIGHT LEFT
EAR: On Inspection,
Normal
• PINNA Normal
Normal
• PREAURICULAR Normal
Region Post auricular lymph nodes enlarged , non
Normal tender , pea sized , mobile firm .No previous
• POSTAURICULAR scars or sinus.
Region

• -ve
TRAGAL & MASTOID -ve
TENDERNESS Congestion present , no discharge
• EAC Normal
• TYMPANIC MEMBRANE
• MIDDLE EAR
• -NA-
FACIAL NERVE -NA-
• TYMPANIC MEMBRANE
RIGHT LEFT
• Intact and is mobile • Pars tensa: Small central
• Pearly white in colour perforation in posterior
superior quadrant
• Cone of light Normal
~ slightly congested and
slightly bulging out
• Pars flaccida looks Normal
• Discharge present on TM
OTOSCOPE
• TUNING FORK TESTS :

RINNES TEST WEBER‘S TEST ABSOLUTE BONE

CONDUCTION TEST

Left : +ve 512 Hz, Heard better Same as examiner

+ve 1024 hz

Right: +ve for all 3 Lateralized to the Same as examiner

left
• VESTIBULAR FUNCTION TESTS :
Normal, ( nystagmus – absent ; fistula test –ve)
• CEREBELLAR FUNCTION TEST:
1. Gait – Normal
2. Romberg’s test – normal(-ve)
3. Tremors – Absent
4. Dysdiadochokinesia – N
5. Finger to nose test – N
6. Finger to finger test – N
7. Heal to shin test – N
(cerebellar signs are normal)
 • NOSE & PARANASAL SINUS EXAMINATION:
• External framework of nose – Normal
• Skin over the nose – Hyperpigmented macules seen
• Tip raising test- Normal ( not painful)
Ala and columella normal
Vestibule of nose – Normal b/L
Nasal passage – Normal
No caudal dislocation
• Anteror Rhinoscopy
Septum – Normal & Central ( no deviation )
No growth or swelling
Nasal cavity proper – B/L normal
Floor - Normal
Lateral wall- normal b/L
(pale pink mucosa , No inflammation)
Turbinate size – Normal
No discharge or any mass
• Posterior Rhinoscopy -
Adenoid Hypertrophy seen
No hypertrophy of post end of inf turbinate
No discharge in middle meatus
• Functional tests of nose –
1) COLD SPATULA TEST- B/L equal fogging
2) COTTON –WOOL TEST – Whisp of cotton moves both on
inspiration and expiration
3) Sense of smell – Normal
• PARANASAL SINUS :
- No swelling and redness over the region

of sinuses
- No tenderness over the region
- Transillumination for frontal sinus - +ve
 • ORAL CAVITY
• Lips and angle of mouth – Normal inner and outer border
Normal Vermillion Border
• Oral cavity opening - Normal( oral sub mucosal fibrosis -beteln)
• Buccal mucosa- White patches present and scrapable
• Teeth and gingiva – Nicotin stains present
No bleeding on touch
• Anterior 2/3rd of tongue- Normal ( No fissure ,ulcer or deviation )
White patch present
• Floor and hard palate – Normal
• Opening of Submandibular duct – Normal
• Opening of sublingual and Parotid duct – Normal
• Gingivobuccal sulcus & Gingivolabial sulcus – Normal
• Retromolar Trigone- Normal , no inflammation
(hidden area)
 • OROPHARYNX
• Anterior pillar – Normal , no ulceration or growths seen b/l
• Tonsils – Normal ( no inflammation and swelling)
• Uvula and soft palate – Uvula central
No congestion
• Posterior pharyngeal wall – Normal b/l
• INDIRECT LARYNGOSCOPY- Base of tongue and vallecula Normal
 • EXAMINATION OF NECK AND NECK LYMPH NODES:
• No swelling ,sinus ,fistula or scar
• B/l carotids palpable
• No palpable lymph node(mass or
swelling ) in neck
• Laryngeal framework- Normal
• Thyroid- Central in position
Normal size
• Laryngeal crepitus – Heard
 PROVISIONAL DIAGNOSIS

☆Left Chronic Otitis Media Mucosal active Mild degree of

CHL with no impending complications.
 MANAGEMENT:
☆INVESTIGATIONS:
• ROUTINE :
Blood - CBC and DLC ,TLC ,Hb level,ESR
Bleeding time & Clotting time,HbA1c
Urine- Sugar, Albumin , Microscopy
Skin prick test – Allergy
HIV Antibody testing –ELISA /EIA
Chest XRAY
• SPECIFIC:
-Microscopy -Bonsins test
- Culture and Sensitivity
- Antibiotic sensitivity
- AUDIOMETRY – Pure tone audiometry + Patch test
- X –Ray of mastoid – SCHULLER’S VIEW
X-RAY Lateral view
• TREATMENT :
- Aural toileting /Dry mopping
- Suction clearance or wet mopping
Note: Syringing is contraindicated =>Perforation
- Topical Antibiotics Ear drops (from sensitivity report)
~Gentamycin /Neomycin/Tobramycin
~ Ciprofloxacin/Ofloxacin/Moxifloxacin
~ Chloramphenicol
~ Polymyxin –B
- Systemic Antibiotics
- Steroids
- Rx of contributory factors +take precautionary measures.
TYMPANOPLASTY
MYRINGOPLASTY

1) Underlay technique

2) Overlay Technique
ADENOIDECTOMY

St Clair Thomson Adenoid Curette

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