CSOM Long Case

 

Case 1; A 26-year-old male, Name – Sanju Kumar presented to ENT OPD with complaints of right ear discharge for the last 5 years and Rt side decreased hearing for the last 1 year.

 

HOW TO PRESENT YOUR CASE

 

Good Morning sir/ Madam. I am presenting the case of Mr. Sanju Kumar, 26 year old male resident of Kasna, Greater Noida, Hindu by religion and labourer by occupation. Presented to the ENT OPD with the

Chief complaints of :

• Right ear discharge since 5 years
• Decreased hearing since 1 year  

(Chief complaints should be in chronological order i.e. the complaints that came first will be written first)

 

• Significance of Name: To identify the patient, maintain the patient record, and to form a rapport with the patient.
• Significance of Age: Certain diseases are more commonly found in certain age groups, therefore useful to make a differential diagnosis. (Younger age: AOM, Foreign Bodies, Epistaxis due to nose picking. Adolescent: JNA; Older age: Presbycusis, carcinomas.)
• Significance of Sex: Certain diseases are more commonly found in particular gender, therefore useful to make a differential diagnosis. (Males: Juvenile nasal angiofibroma, Females: Otosclerosis).
• Significance of Religion: Congenital SNHL is more in consanguineous marriages.
• Significance of Occupation: Certain diseases are more commonly found in certain occupations. Noise-induced hearing loss is found more commonly in construction workers or workplaces with loud noises, Vocal nodules due to voice abuse are more commonly found in professions like teachers, singers and hawkers.
• Significance of Address: Certain diseases are more commonly found in certain areas. Rhinosporidiosis is more common in Jharkhand, Chhattisgarh, Madhya Pradesh and West Bengal.

History of presenting illness:

My patient was apparently well 5 years back when he developed discharge from right ear which was gradual in onset (D/D: sudden in onset: AOM, gradual in onset: CSOM), discharge was aggravated during URTI (Write any preceding events causing onset and treatment taken), relived with medication. (D/D: safe CSOM usually gets relived with medication, while Unsafe CSOM is usually not relived with medication), the discharge is progressive in nature (D/D: progressive in CSOM, non-progressive in ASOM), discharge is intermittent (D/D: continuous/intermittent), discharge is mucopurulent type (D/D: watery in CSF otorrhoea, otitis externa; mucoid in CSOM safe type; mucopurulent in ASOM, CSOM with secondary infection; purulent in unsafe CSOM, malignant otitis externa), discharge is yellow in colour (D/D: white in mucoid/fungal infection; yellow in bacterial infection; green in pseudomonas infection), discharge is profuse in amount (D/D: profuse in safe type, scanty in unsafe type), discharge is non-foul smelling (D/D: non foul smelling in safe type, foul smelling in unsafe type) and discharge is not blood stained (D/D: non blood stained in CSOM safe type, blood stained in unsafe type usually because of the granulations present in the middle ear). Write aggravating/relieving factors, other accompanying complaints, and the treatment taken.

Note:

• Continuous/ Intermittent discharge – Continuous is when discharge is not stopping. Intermittent is when discharge stops then again recurs.
• Mucoid discharge is described by the patient as stick white type of discharge, Mucopurulent is described as sticky yellowish type of discharge, and purulent is described as yellow non-sticky frank discharge.
• Profuse discharge is when it is coming out of the ear and Scanty when it is not coming out of the ear and seen only when patient is cleaning the ear.
• Foul smelling discharge is seen in unsafe CSOM (cholesteatoma) and it is due to the bone erosion and later on putrifaction of the bone.

Along with the discharge, patient also have complaints of decreased hearing from last 1 year which was gradual in onset (D/D: sudden in viral infections, ototoxic drugs, temporal bone fracture), more from right ear (D/D: unilateral in CSOM, Acoustic neuroma, herpes zoster oticus; bilateral in presbycusis, meniere’s disease, otosclerosis), progressive in nature (D/D: presbycusis, CSOM, meniere’s disease), first noticed while talking on the phone, not associated with discharge (imp : increase in hearing loss with discharge in active stage or flaring up of disease, decrease in hearing loss with discharge suggests ossicular disruption), no change in hearing in noisy environment (imp : otosclerosis patient hears better in noisy environment k/a paracusis willisi). Write aggravating/relieving factors, other accompanying complaints, and the treatment taken.

Negative History:

There is no history of earache (Otitis externa, ASOM, mastoiditis), pain behind the ear (mastoiditis), vertigo (labyrinthitis), nausea (labyrinthitis), blurred vision, diplopia (petrositis), Fever (meningitis, mastoiditis, brain abscess, lateral sinus thrombophlebitis), headache (meningitis, brain abscess, lateral sinus thrombophlebitis), facial asymmetry (facial palsy).

(Negative history is taken to rule out any complications):

• Earache, swelling behind the ear, fever: To rule out Mastoiditis.
• Nausea, vomiting, vertigo: To rule out Labyrinthitis.
• Blurred vision, diplopia, retro orbital pain, headache: To rule out Petrositis.
• Facial asymmetry: To rule out Facial palsy.
• Headache, Fever. To rule out Extradural abscess.
• Headache, Fever. To rule out Subdural abscess.
• Headache, high grade fever, neck rigidity: To rule out Meningitis.
• Headache, fever, delirium, convulsions, projectile vomiting: To rule out Brain abscess.
• Headache, fever, neck rigidity, projectile vomiting: To rule out Lateral sinus thrombophlebitis.

Past History : There is no past history of TB, Hypertension, thyroid disease, diabetes mellitus, coronary artery disease, liver or kidney disease, tuberculosis, HIV/AIDS any allergies or bleeding disorder.

Note: Past history includes similar complaints in the past and the treatment taken and history of surgeries accidents, radiations and complications. All the diseases suffered by the patient in past whether seemingly relevant/ irrelevant should be recorded in a chronological order.

Drug History : No significant drug history.

Note: Drug history includes all the drugs that the patient was/is taking such as steroids, chemotherapy, insulin, antihypertensive, diuretics, monoamine oxidase (MAO) inhibitors, contraceptives and hormone replacement therapy.

Personal history: Patient is a vegetarian by diet, with normal bladder and bowel habits. No history of smoking, tobacco chewing or alcohol intake.

Note: Personal history includes patient’s occupation, personal habits (smoking, alcohol and chewing of Paan, Supari and tobacco), food habits (vegetarian/non-vegetarian, regular/irregular, spicy food), lifestyle (exercise or sedentary), and marital status. In women menstrual history and number of pregnancies and miscarriages should be recorded.

Family history : There is no history of hearing loss in the family (otosclerosis), no history of consanguinity (congenital SNHL).

Note: It is important as many ENT diseases run in families and have genetic basis such as otospongiosis, certain types of sensorineural hearing loss, malignancies and autoimmune disorders. Infectious diseases such as STD, tuberculosis, mumps, pediculosis, scabies and diphtheria can affect other family members.

 

Examination :

General physical examination: Patient is sitting comfortably on chair and well oriented of time place and person. There is no pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, and oedema. Pulse : 88 beats per min, normal rhythm, volume, symmetrical, no radio radial or radio femoral delay. BP : 110/70 mm Hg taken in left hand sitting position Respiratory Rate : 18/min.

Facial Nerve Examination (motor function): Raising the eyebrows, Blowing whistle, Closing eyes, Blowing cheeks.

Local examination: Unless instructed otherwise, offer to examine the better ear first.

Ear : Right/Left

Tunning Fork Test: (D/D: Done to know the type and degree of hearing loss) done with 512 Hz tuning fork.

                                                Right                                       Left

Rinne’s test :               Negative                                  Positive

Weber’s test :            lateralised to right ear

Absolute Bone Conduction : same as examiner

Vestibular function tests:

• Romberg’s test – Negative (Note: standing with eyes closed)
• Unteberger test – Negative (Note: The patient is asked to step in place for about a minute (about 50–60 steps) with eyes closed and both arms raised at 90° in front of them. It is important they raise their legs adequately i.e. actually march on the spot)

Diagnosis:

Right ear chronic suppurative otitis media active safe type with mild/ moderate/ Severe conductive hearing loss without any complications. (Write the complication if it is there).

Investigations:

1. Examination under the microscope. (To confirm the diagnosis and to assess the ossicular chain mobility. We can also take a sample for culture sensitivity).
2. Ear discharge pus culture and sensitivity. (To avoid resistance against antibiotics)
3. Pure tone audiogram. (To know the type and degree of hearing loss)
4.  Xray mastoid. – Schuller’s and Towne’s view (Note: Usually done in Unsafe CSOM. But it can be done in safe also if the disease is long-standing) It is done to see the degree of mastoid pneumatisation, Sigmoid sinus position, Jugular bulb position, Tegmen position.
5. HRCT temporal bone. (Note: done in cases of unsafe CSOM, in cases of any complication). It provides good bony anatomy and demonstrates evidence of ossicular or bone erosion.
6. MRI. (Note: It can be done in unsafe CSOM having recurrent cholesteatoma, recidivism)
7. Basic routine investigations (Blood, Urine, Viral markers, ECG) for Pre Anaesthetic Check-up fitness if the patient is planned for surgery.

Management :

Tubotympanic (safe) type :

• Conservative / Medical : Aural toilet, Systemic and local antibiotics, Systemic antihistamines, Local decongestant nasal drops, Protection of ear from water.
• Surgical : Tympanoplasty (Goal is to achieve a safe, dry ear, with a secondary aim of hearing improvement)

Note: Management of Atticoantral (unsafe) type :Conservative treatment as the safe type but the main treatment of unsafe type remains to be surgery.

• Mastoidectomy
• Canal wall up mastoidectomy
• Canal wall down mastoidectomy

—— End of the chapter ——

Learning resources.

• Scott-Brown, Textbook of Otorhinolaryngology Head and Neck Surgery.
• Glasscock-Shambaugh, Textbook of  Surgery of the Ear.
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck surgery.

Author:

Dr. Rahul Kumar Bagla
MS & Fellow Rhinoplasty & Facial Plastic Surgery.
Associate Professor & Head
GIMS, Greater Noida, India
msrahulbagla@gmail.com

Please read. Glomus Tumour. https://www.entlecture.com/glomus-tumour/

Follow our Facebook page: https://www.facebook.com/Dr.Rahul.Bagla.UCMS

Join our Facebook group: https://www.facebook.com/groups/628414274439500