A CASE IN EAR
By: Roll No 37,38,39
DEMOGRAPHIC DATA
NAME: Mrs. Kala
AGE: 54 Years
SEX: Female
OCCUPATION: Housewife
ADDRESS: Porur, Chennai
SOCIOECONOMIC STATUS: Middle Class
CHIEF COMPLAINTS
EAR DISCHARGE in the RIGHT EAR x 7 MONTHS
PAIN in the RIGHT EAR x 7 MONTHS
HEARING LOSS in the RIGHT EAR x 2 MONTHS
HISTORY OF
PRESENTING ILLNESS
EAR DISCHARGE
Side- Right Ear
Onset- Insidious
Duration- 7 Months, Intermittent
Progression- Progressive
Nature/Consistency- Mucopurulent
Quantity- Profuse
Smell- Non foul smelling
Colour- Yellowish and Not blood stained
Aggravating and Relieving Factors- N/A
EAR PAIN
Side- Right Ear
Onset- Insidious
Duration- 7 Months
Progression- Progressive
Type- Intermittent
Character- Pricking type
Aggravating Factors- After bath
Relieving Factors- Medication
Radiation- To face and neck- For the past month
HARD OF HEARING
Side- Right Ear; Unilateral
Onset- Insidious
Duration- 2 Months
Progression- Progressive
Type- Continuous
• The patient also complains of Ear Block since the past 1 month
which was progressive in nature.
• She complains of ringing in the ear for past 1 month.
• Giddiness for the past 1 month which was insidious in onset and
was aggravated by loud noise.
No history of nasal block, bleeding, discharge, sneezing, smell
disturbance, snoring, change in voice.
No history of throat pain, difficulty in swallow, disturb of taste, sore
throat, bad odour of breath
PAST HISTORY
PAST MEDICAL HISTORY:
Patient is not known Diabetic or Hypertensive. No history of
Tuberculosis or Trauma or Allergies.
PAST SURGICAL HISTORY:
No significant surgical history
PERSONAL HISTORY
Normal sleep, appetite, bowel & bladder movements
No history of smoking or substance abuse
FAMILY HISTORY
No significant family history
EXAMINATION
GENERAL EXAMINATION:
Conscious- Oriented to place, person & time
Moderately built and nourished
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy
VITALS:
BP: 130/80 mmhg; RR: 17 breaths per minute; Pulse: 79 BPM;
Temperature: Afebrile
SYSTEMIC EXAMINATION:
CVS- S1 & S2 heard; RS- Normal vesicular breath sounds heard on both
sides; CNS- Normal Sensory/Motor reflex and actions; PER ABDOMEN-
No palpable mass, tenderness or organomegaly was noted.
LOCAL EXAMINATION
INSPECTION:
RIGHT EAR LEFT EAR
Normal Normal
PREAURICULAR REGION
(Free of scars, swelling, tenderness) (Free of scars, swelling, tenderness)
Normal Normal
POST AURICULAR REGION
(Free of scars, swelling, tenderness) (Free of scars, swelling, tenderness)
Normal pinna Normal pinna
EXTERNAL EAR
(Size, shape, location) (Size, shape, location)
EXTERNAL AUDITORY Mucopurulent discarge; Not blood
No discharge
CANAL stained
PALPATION:
RIGHT LEFT
TRAGAL TENDERNESS Negative Negative
MASTOID TENDERNESS Negative Negative
3 FINGER TEST Negative Negative
With aural speculum, Discharge present
EXTERNAL AUDITORY Mucopurulent, not blood stained No discharge
CANAL & Non foul smelling
TYMPANIC MEMBRANE
TUNING FORK TEST:
RIGHT LEFT
RINNE’S TEST Negative; BC>AC Positive; AC>BC
WEBER’S TEST Lateralized
ABSOLUTE BONE
Not reduced Not reduced
CONDUCTION
VESTIBULAR FUNCTION TEST:
Fistula Test- Negative in both right and left ears
NOSE:
Ext nose- No scars, sinus, swelling and deformity
Normal osteocartilage framework
Paranasal sinus- No tenderness
THROAT:
Normal oral cavity, oropharynx, tonsil
Indirect laryngoscopy was not done.
PROVISIONAL
DIAGNOSIS
Right ear Chronic suppurative otitis media, Tubotympanic type,
Active stage, with Conductive Hearing loss with a extra cranial
complications.
INVESTIGATION:
• Cultural sensitivity of the discharge to know the organism.
• X ray of mastoid to know the extent of CSOM.
• Pure tone audiometry to check the degree of hearing.
• CT Scan to assess the extent of the disease and to aid in surgical
planning.
TREATMENT:
• Aural toilet
• Suction clearance
• Topical antibiotics in the form of ear drops.
• Systemic antibiotics to be used according to cultural sensitivity.
