Bilateral CSOM
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
A 35 year old female agricultural labourer by occupational from nalgonda district with chief complaints of decreased hearing loss on right side more than left side
HOPI: patient was apparently asymptomatic 33 years ago ,then she got right sided eardischarge ,insidious in onset ,intermittently for 2-3 episodes per year which is of profuse, mucoid in nature,non foulsmelling non blood stained aggravated on cold exposure ,urti temporarily relieved on medication .Each episode lasts for 3-4 days and last episode of discharge was 1 month back
H/o left year discharge insidious in nature intermittent from 1 year which is of profuse,mucoid in nature,non foulsmelling and non bloodstained aggravated on urti and temporarily relieved on medication
H/o b/ldecreased hearing loss,right more than left ear,progressive with no aggravating and relieving factors.
H/o ringing sensation in the ear , usually in right ear aggravated by stress ,each episode lasts for 2-3minutes.
No h/o trauma,no h/o earache,noh/o giddiness.
No h/o nausea ,vomiting, fever
No h/o nasal obstruction,recurrent bouts of sneezing,watering from eyes
No h/o nasal discharge,bleeding from nose ,trauma to nose and smell abnormalities
No h/o facial heaviness and post nasal discharge
No h/o throat pain,change in voice,halitosis,snoring.
Past history: NO H/o comorbidities such as hypertension, diabetes, asthma ,TB and thyroid diseases.No h/o exanthematous fevers.
Family history: Mother in law has same presentation
Personal History: Patient is agricultural labourer which consists mild to moderate work in fields such as picking out weeds and seeding and planting ,she does this work occasionally when she was allotted ,in remaining days she does house hold work,she has two children.she cant go to the work due to hearing loss.
She studied untill 10th class.
Nutritional history :24hr recall
She has normal appetite,sleep adequate,regular bowel and bladder movements, she drinks toddy occasionally 6 times a year
Treatment history:Used topical anti histamines when there is URTI
General examination: Patient is conscious coherent and cooperative oriented to time place and person
Moderately build and moderately nourished
VITALS : pulse rate :78 bpm,rhythm regular,lowvolume,
Blood pressure:
Temperature: afebrile
Respiratory rate : 18cpm
GENERAL EXAMINATION:
Pallor : present
Icterus : absent
Cyanosis,clubbing,lymphadenopathy and edema absent .
ENT EXAMINATION:
ON Examination of ear
Right ear left ear
Preauricular area normal normal
Post auricualar area normal normal
Mastoid tenderness negative negative
EAC CLEAR clear
Tympanic membrane:
Rt ear: single oval shaped central perforation in antero superior and inferior quadrant ,thick regular margins
Middle mucosa seen through perforation which is normal
Rest of Paris tense is dull and luster less
Pars flaccid- retracted.
Left ear: A single circular shaped central perforation involving posterosuperior and posteroinferior quadrants ,sharp regular margins ,middle mucosa,incudostapedial joint seen through perforation
Rest of parstensa is dull and luster less
Pars flaccid retracted
FACIAL NERVE EXAMINATION
Frontalis-normal drowning
Buccalis qnd orbicularis oris- normal blowing of cheeks
Orbicularis oculi- normal closure of eyelids
Zygomaticus major - normal smiling,no deviation
Platisma - normal
Nystagmus is negative on both sides
On valsalva no movement on both sides,hissing sound is present?
TUNING FORK TESTS
RINNES:
RT LT
256 BC>AC BC>AC
512 BC>AC BC>AC
1024 BC>AC BC >AC
WEBER : LATERALIZED TO RIGHT
ABC: SAME as mine on both sides
On examination ofnose
External framework: ROOT ,dorsum bridge ,tip normal
Tipraising test ,no causal dislocation
Vestibule,columella - normal
On ANTERIOR RHINOSCOPY: septum central,roof ,medial wall,floor ,lateral wall with turbinates and meatuses are normal
Functional tests: cold spatula- bilateral equal misting
Cotton wool test - bilateral equal movements
Posterior rhinoscopy
Posterior border of septum
Posterior end of turbinates
Eustachian tube opening
Torus tubaris
Fossa of rossenmuller are normal
On Examination of Para nasal sinuses:
On inspection:normal
On palpation : non tender sinuses
On examination of oral cavity:
No trismus
Lips normal
Teeth - dental caries on first molar
Gingivobuccal and gingivo lingual sulcus normal
Buccal mucosa,retromolar trigone, hardpalate,anterior 2/3red of tongue,floor of mouth normal
On examination of oropharynx:
Soft palate, uvula,bilateral anterior pillars,b/l tonsils pillar,b/l posterior pillar posterior pharyngeal wall normal
Indirect laryngoscopy
Base of tongue,vallecula,epiglottis ,aryepiglottic folds,carotenoids,truevocal cords- bilateral symmetrical movements ,false vocal cords,pyriform fosaa normal.
On examination of neck:
Laryngeal crepituss present
Laryngeal frame work intact
Trachea central
No palpable lymphnode
SYSTEMIC EXAMINATION:
CVS:apexbeat at 5th intercoastal space;S1 S2 heard in all spaces
RS: trachea central;bilateral vesicular breath sounds are heard; no added sounds
CNS:no focal neurological deficits
Abdomen: normal;nontender
Diagnosis:bilateral chronic suppurative otitis media safetype in right ear and unsafe type in left ear in quiet stage without any complications
MANAGEMENT
INVESTIGATIONS:
Examination under microscope
PURE TONE AUDIOMETRY
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