Case Report Session

Otitis Eksterna Aricular Sinistra

Compiled By:

Darshini Sivanesan 1301-1213-2503
Kharte Ramachandran 1301-1212-3531
Subashini Periasamy 1301-1212-3553


Preceptor:
Prof Dr. Teti HS. Mandiadipoera,dr.,Sp. THT-KL(KAI), FAAAAI




DEPARTEMEN ILMU KESEHATAN TELINGA HIDUNG TENGGOROK BEDAH
KEPALA DAN LEHER (THT-KL)
FAKULTAS KEDOKTERAN UNIVERSITAS PADJADJARAN
RUMAH SAKIT DR. HASAN SADIKIN
BANDUNG
2014


PATIENT STATUS


I. PATIENT IDENTITY

Name : Mrs On
Age : 31 years
Gender : Female
Address : Bandung
Education : SD
Occupation : Housewife
Religion : Islam
Date of Examination : 30th April 2014

II. ANAMNESIS
Chief Complaint :
Painful left ear

Since 3 days ago, patient complained of pain in the left ear.The pain starts in the
morning when. The pain is continous in nature. Discharge from the left ear was
denied. Because of complaints, patient cleaned her ears with cotton buds, and
administered otollin (which she bought herself) 2 drops twice a day but felt no
improvement. Patient denied she had fever or headache. Ears did not feel itchy
Previous history of similar complaints was denied.Swimming denied. History of
trauma and a history of previous surgery denied. No history of diabetes mellitus.

III. PHYSICAL EXAMINATION
General Appearnce : Good, Compos Mentis
Nutritional Status : Kurang
Consciousness : Compos mentis
Vital Signs : Blood Pressure = 120/80 mmHg
Pulse = 80x/min
Respiration = 20 x/min
Temp = 36.7C
General Status
Head : Conjunctiva Anemic (-),
Icteric Sclera (-),
Others refer to local status
Neck : JVP normal
Enlargement of Lymph nodes(-)
Chest : symetrical shape and movement
Pulmo : sonor, VBS right = left
Heart : heart sound S1 and S2 normal, murmur(-)
Abdomen : Flat, Soft, bowel sound (+) normal
Liver and spleen not elarged
Extremities : warm, CRT <2sec
Deformity (-)

Local Status of The Ears
Part Abnormality
Auris
Dextra Sinistra
Preauricle
Congenital Abn
Tumor
Inflammation
Trauma
-
-
-
-
-
-
-
-
Auricle
Congenital Abn
Tumor
Inflammation
Trauma
-
-
-
-
-
-
-
-
Retroauricular
Edema
Hyperemis
Tenderness
Sikatriks
Fistula
Fluctuations
-
-
-
-
-
-
-
-
-
-
-
-
Canalis Acustikus
Externa
Congenital Abn
Skin
-
Tenang
-
Lacerated
Secretion
Cerumen
Edema
Granulation
Mass
Cholesteatoma
-
-
-
-
-
-

-
-
-
-
-
-
Tympanic
Membrane
Colour

Intact

Cone of Light
Greyish white

(+)

(+)


Greyish White

(+)

(+)











Nose
Examination
Nasal
Dextra Sinistra
External Exm. Shape and Size within normal limits within normal limits
Anterior
Rhinoscopy
Mucosa
Secretion
Crust
Inferior Chonca
Septum deviation
Polyp/tumor
Air flow
Normal
-
-
Eutropi
Normal
-
-
Eutropi
-
-
+




-
+








Posterior
Rhinoscopy
Mucosa
Coana
Secretions
Torus tubarius
Rosenmuller Fossa
Normal
Normal
-
Normal
Normal
-
Normal
Normal

Transiluminasi
4 | 4
4 | 4

Mouth and Oropharynx
Part Abnormality Description
Mouth
Mucosa of the mouth
Tongue
Palatum molle
Teeth

Uvula
Halitosis
Tenang
Normal, moist,normal movement to all direction
Normal, symmetrical
Carries (-)

Symmetrical , Deviation (-)
(-)
Tonsil
Mucosa
Size
Crypt :
Detritus :
Adhesion
Tenang
T
1
T
1

Tidak melebar
(-/-)
(-/-)





Pharynx
Mucosa
Granules
Post nasal drip
Normal
(-)
(-)

Maxilofacial
Shape : Symetrical
Parese N.Kranialis : N. Kranialis III, VI wnl
N. Kranialis VI wnl
N. Kranialis V wnl
N. Kranialis X wnl






Neck
Lymph Node : Lymph Node Enlargement (-)

Lump : (-)







Hearing Assesment
Tes pendengaran : Tes suara : normal / normal
Tes Rinne : + / +
Tes Weber : lateralisasi - / -

IV. RESUME
A 31 year old women came to the clinic with chief complaint pain of the left ear. Since 3
days ago, patient complained of pain in the left ear. The pain starts in the morning when. The
pain is continuous in nature. Discharge from the left ear was denied. Because of complaints,
patient cleaned her ears with cotton buds, and administered otollin (which she bought herself) 2
drops twice a day but felt no improvement. Patient denied she had fever or headache. Ears did
not feel itchy Previous history of similar complaints was denied. Swimming denied. History of
trauma and a history of previous surgery denied.
Local status revealed:-
ADS : CAE normal / Laserated, sekret -/-, serumen -/-
MT intak +/+, Cone of Light +/+, RA normal +/+

V. DIFFERENTIAL DIAGNOSIS
- Otitis Eksterna Auris Sinistra

VI. WORKING DIAGNOSIS
Otitis Eksterna Auris Sinistra

VII. FURTHER EXAMINATION
-

VIII. MANAGEMENT
General
- Keep ears constanly dry and clean
- No swimming
- Avoid cleaning ears with cotton buds or sharp objects
Specific
- Ottopain ear drop 3xgtt
- Amoxicillin 3x500mg
- Acetomenophen

VIV. PROGNOSIS
Quo ad vitam : ad Bonam
Quo ad functionam : ad bonam


DISCUSSION

1. Is the diagnosis of this patient appropriate?
Otitis externa is an infection of the external ear canal. Most ear canal infections are
caused by excessive moisture carrying bacteria into the cerumen of the ear canal, leading to
maceration and inflammation. Another common cause is local trauma allowing bacteria to enter
compromised skin. The most common causative organism is Pseudomonas species.
Staphylococci, streptococci, and (in rare cases) fungi are other causative agents.
In general, the pH of the ear canal is normal or slightly acidic, the pH becomes alkaline
and this reduces the protection of the ear from infections. In the state of warm and humid air,
bacteria and fungi grow well. Minor trauma can occur due to scrapping of the ear or due to
swimming that causes changes in the skin due to contact with water.

Acute otitis externa can be divided further into , namely :
1 . Furunculosis / otitis externa sirkumskripta
Because the skin on the outer third of the ear canal hair follicles , sebaceous
glands and cerumen gland , this facilitates pilosebaseus infection , thus forming
furuncle. Infecting organism usually are Staphylococcus aureus or Staphylococcus albus .
Symptoms are severe pain ,may or may not be accompanied by large ulcers . In addition,
hearing loss may occur if large furuncles clog the ear canal . Treatment depends on the
state of furuncles . When it has become an abscess , sterile aspiration and prescribing
antibiotics in the form of an ointment , such as bacitracin and Polymixin B. Systemic
antibiotics are usually not needed ,symptomatic drugs such as analgesics can be given .

2 . Diffuse otitis externa
Usually involves about two- thirds of the skin in the ear canal . Ear canal skin is
hyperemic and swollen with no. Infecting organism are usually the Pseudomonas group,
Staphylococcus aureus or S. Albus , and Escherichia coli . The symptoms are the same as
otitis externa sirkumkripta , but sometimes there is discharge that has bad odour . In
some literature findings, there are :
1 . tenderness of the tragus
2 . Severe pain
3 . Swelling of the ear canal wall
4 . Secretions were slightly
5 . Hearing is normal or slightly reduced
6 . Absence of fungal particles
7 . Possible existence of regional lymphadenopathy with tenderness

Treatment is by inserting a tampon soaked with antibiotics into the ear canal so
that there is contact between the skin and the antibiotics . Sometimes systemic antibiotics
are necessary .

3 . Otomycosis
Fungal infections facilitated by the highly humid area . The most common is the
aspergillus . Also sometimes candida albicans.Symptoms commonly include itchyness
and fullness in the ear canal , but often without other complaint .It is treated by cleaning
the ear canal . with 2-5 % acetic acid solution in alcohol and is dripped into the ear canal
,antifungal drug can be administered topically topically .

4 . Perichondritis
This condition occurs when a trauma or inflammation causes effusion of serum or
pus in between layers perikondrium and cartilage of the outer ear . The diagnosis is when
a part of the auricle that are involved swells , becomes red , feels hot and painful . The
etiology could be due to trauma from a surgery , or infection of Staphylococcus spp ,
Streptococcus spp , Pseudomonas aeruginosa .Treatment in the form of parenteral
antibiotics and topical treatment for comorbid canal infections . Antibiotics according to
culture results should be given.

Chronic otitis externa include:
1. Necrotizing otitis externa
Necrotizing otitis externa is in addition, involves inflammation of the outer ear
parts, but sometimes also with seventh cranial nerve dysfunction. This condition is
usually found in elderly diabetics patients, and the most common etiologic agents is
Pseudomonas aeruginosa. This happens because of severe infections acquired in the
temporal bone and soft tissue ear. Treatment with anti-Pseudomonas beta-lactam
antibiotic with an aminoglycoside. Additionally local debridement of granulation tissue,
abscess drainage and removal sekuestra can be done.

2. Is the treatment appropriate for this patient?

Analgesics -- Otitis externa is quite painful for some, and patients frequently request analgesics.
Inexpensive simple NSAIDs and/or narcotics are appropriate. In some cases, systemic analgesics
are helpful before ear cleaning






Otic antibiotics -- These agents are commonly prescribed for treating otitis externa with cure
rates between 87-97%.






3. What is the prognosis of this patient?
Most patients with external otitis improve greatly within 48-72 hours and are well in 1
week to 10 days. With proper patien education the prognosis is good. Failure to improve within
several days should call the diagnosis intoquestion and prompt the physician to reevaluate the
patient