R. SYAMSUDIN,S.

H PUBLIC HOSPITAL
Ear-Nose-Throat, Head and Neck Department
Advisor : dr. H. Oscar Djauhari, Sp. THT
1. A 7 years old boy came to the ENT clinic with chief complain fullness
sensation of the both ears and pain since 3 days ago. He had upper
tract respiration infection as the prior disease.
Identity
Name
Age
Address
Chief complaint

: Ch. R
: 7 years old
: Pelabuhan Ratu
: fullness sensation of the both ears and pain since 3 days
ago
Additional complaint
: cannot hear clearly, fever.

Present Medical History

A 7 years old boy has been complaining fullness sensation of the both ears and
pain since 3 days ago. Before that, patient suffer fever, running nose, sore
throat and cough since 1 week ago. The patient also say that he cannot hear
voice clearly.
Past Medical History
Physical Examination
Ear :
External ear : There are no deformities
External acoustic canal
o Right : normal mucosa, cerumen (-), discharge (-), laceration(-)
o Left : normal mucosa, cerumen (-), discharge (-), laceration(-)
Tympanic membrane
o Right : Hyperemic, intact
o Left : Hyperemic, intact
Retroauricular
: Normal both side
Preauricular : Normal both side
Nose :
External nose
: no deformity, normal shape
Mucosa
: hiperemic (-)
Nasal septum
: No deviation
Choncha inferior
: Slightly hypertrophy both side, no discharge
Nasopharynx, Oropharynx :
Uvula at the middle, arcus pharynx symmetric.
Mucosa: normal, hyperemic (+)

Tonsil : T2-T2 slightly hyperemic, kripta +/+, detritus -/-

Face :
Simertri
Neck:
Lymph nodes enlargement (-)
Working Diagnosis
Acute Otitis Media stadium Hyperemic
Differential Diagnosis
Otitis Media Effusion
Further Examination

Tone Fork with 512 Hz : Rinne Test, Weber Test, Swabach Test, Bing
Test, Stenger Test
Treatment
Systemic antibiotics (amoxicillin 25mg/kg/day-clavulanat acid 5mg/kg/day,
PO)
Pseudoephedrin (max in children 75mg/day, in adults 150mg/day, PO)
Mefenamic acid 20-30mg/kg/day
Explanations
There are five stages of AOM : occlusion, hyperemic, suppurative,
perforation, and resolution.
In hyperemic stage, the tympanic membrane is swelling and there is
vasodilatation of the blood vessel.
Clinical manifestations of AOM are otalgia, fever, hearing loss, fullness
sensation of the ear, with a history of upper respiratory infection.
Effusion Otitis Media (EOM) is a condition with a non-purulent discharge in
the middle ear, intact tympanic membrane without any sign of infection. It
is divided to Acute EOM and Chronic EOM.
Sensory neural deafness is a hearing loss condition which is caused by
pathologic condition in cochlear or retro-cochlear.

2. A 20 years old female patient came to the ENT clinic with chief
complain severe headache with unconscious condition that come and
go.
Identity
Name
Age

: Ms. A
: 20 years old

Address
Chief complaint

: Selabintana
: Severe headache with unconscious condition that come
and go.
Additional complaint
: Suddenly has difficulty to smile and open the right
eye.
Purulent discharge from the ear periodically since 2 months
ago
Present Medical History
A 20 years old female patient has been complaining a severe headache with
unconscious condition that come and go . Before that, patient also noticed that
her mouth deviate to the right and she cant open her right eye. She also had
purulent otorhea of the right ear periodically since 2 months ago. A week ago
the discharge from the ear became massive.
Past Medical History
Allergy history denied.
Frequent common cold since child.
Physical Examination
Ear :
External ear : There are no deformities
External acoustic canal
o Right : Normal mucosa, Purulent discharge, smelly odor, yellowish
o Left : Normal mucosa, Cerumen (+)
Tympanic membrane
o Right : Marginal perforation, round shape
o Left : Difficult to examine
Retroauricular
: Normal both side
Preauricular : Normal both side
Nose :
External nose
: no deformity, normal shape
Mucosa
: hiperemic (-)
Nasal septum
: No deviation
Choncha inferior
: Slightly hypertrophy and hyperemic both side, no
discharge
Nasopharynx, Oropharynx :
Uvula at the middle, arcus pharynx symmetric.
Mucosa : normal
Tonsil : T0-T0
Face :
Deviation of the angle of the mouth to the right side
Ptosis at her right eye
Neck:
Lymph nodes enlargement (-)

Working Diagnosis
Right chronic suppurative otitis media(CSOM) with facial nerve palsy
complication and suspect Central Nervous System Complication : Meningitis and
Brain Abscess.
Differential Diagnosis
Primary brain tumor

Further Examination
Complete blood count (Hb, Ht, Trombocyte, Leukocyte, Differential count)
Head and neck CT-scan
Discharge culture
Treatment
Aural toilet with hydrogen peroxide 5% or alcohol
Local antibiotics (ofloxacin 3mg/ml, 2x10 drops, AD)
Systemic antibiotics (amoxicillin 25mg/kg/day-clavulanat acid 5mg/kg/day,
PO)
Pro-tympanoplasty if the infection is resolve.
Explanations
Purulent otorhea for 2 months with tympanic membrane central
perforation shows a CSOM history and physical finding, the most
commonly isolated bacteria responsible for CSOM are P. aeruginosa, S.
aureus, and the Proteus species
There are two type of CMOS. First Silent type and risk type. Silent type
usually occurs with the perforation at the central of tympanic membrane.
The risk type have a marginal or atic perforation.
Massive-blood-stained ear discharge is an indication that formed
granulation tissue bleed or the cholesteatomahas eroded the bony walls of
the middle ear and mastoid and is approaching a vascular structure as the
lateral sinus
Fever and rigors due to increasing infection process that might develop
into bacteremia
Difficulty to smile with a deviation of the angle of the mouth to the left
side and ptosis at her right eye are due to lower motor neuron facial nerve
paralysis caused by locally produced bacterial toxins or from direct
pressure applied to the nerve by cholesteatoma or granulation tissue.
Most meningeal pathogens are transmitted through the respiratory route,
as exemplified by the nasopharyngeal carriage of Neisseria meningitides
(meningococcus) and nasopharyngeal colonization with S pneumoniae
(pneumococcus). The cycle of inflammation, ulceration, infection, and
granulation tissue formation may continue, destroying surrounding bony
margins and ultimately leading to the various complications of CSOM,
include :

A brain abscess may occur in the temporal lobe or cerebellum, typically

from chronic otitis media.
An epidural abscess may occur as a result of bony destruction and
extension from coalescent mastoiditis or cholesteatoma.

Meningitis may be associated with acute or subacute/chronic infection.

Acute otitis media is the most common cause of meningitis. Extradural
granulation tissue or frank pus may be found.

In both adults and children, meningitis in the setting of chronic

suppurative otitis media may be secondary to the direct extension of
infection through the dura, through a previous stapedectomy site, or
through a cholesteatoma-induced labyrinthine fistula.

Otitic hydrocephalus may occur as a result of increased intracranial

pressure secondary to middle ear infection and complicated by sigmoid
sinus thrombosis with total occlusion.

A sigmoid sinus thrombosis or subdural abscess/empyema may be

associated with otitis media

3. A 8 years old boy came to the ENT clinic with chief complain pain
and itch of the left ear since 3 days ago. He had fever as the additional
complain.
Identity
Name
: Ch. D
Age
: 8 years old
Address
: Siliwangi
Chief complaint
: pain and itch of the left ear since 3 days ago
Additional complaint
: fever.
Present Medical History
A 8 years old boy has been complaining pain and itch of the left ear since 3 days
ago. Before that, patient suffers fever since 5 days ago.
s
Past Medical History
Physical Examination
Ear :
External ear : There are no deformities
External acoustic canal
o Right : Hyperemic mucosa (-), cerumen (-), discharge (-),
laceration(-)
o Left : Hyperemic mucosa at 2/3 inner segment (+), cerumen (-),
discharge (+), laceration(-)
Tympanic membrane
o Right : normal, intact, cone of light (+)

o Left : normal, intact, cone of light (+)

Retroauricular
: Normal both side

Nose :
External nose
: no deformity, normal shape
Mucous
: hiperemic (-)
Nasal septum
: No deviation
Choncha inferior
: normal at the both side, no discharge
Nasopharynx, Oropharynx :
Uvula at the middle, arcus pharynx symmetric.
Mucous
: wet, hyperemic (-)
Tonsil : T1/T1, not hyperemic mucosa
Face :
No Deviation
Neck:
Lymph nodes enlargement (-)
Working Diagnosis
Diffuse Otitis Externa
Differential Diagnosis
Furunculosis
Treatment
Local antibiotics (ofloxacin 3mg/ml, 2x10 drops, AD)
Mefenamic acid 20-30mg/kg/day
Decongestant
Explanations
Otitis externa is an inflammation or infection of the external auditory canal
and/or auricle. This condition is one of the most common medical conditions that
affect aquatic athletes. Individuals with allergic conditions, such as eczema,
allergic rhinitis, or asthma, also have a significantly higher risk of developing this
condition. Several factors can contribute to the development of otitis externa.
Absence of cerumen, high humidity, increased temperature, and local trauma
(eg, use of cotton swabs or hearing aids) can result in infection of the canal.
Aquatic athletes are particularly prone to the development of otitis externa
because repeated exposure to water results in removal of cerumen and drying of
the external auditory canal. Otitis externa occurs more often in the summer
months when swimming is more common,and this condition is also common in
tropical areas.8 The most common bacterial causes of otitis externa are
Pseudomonas aeruginosa and Staphylococcus aureus.
Otitis externa can be classified as follows:

Acute diffuse otitis externa is the most common form of otitis externa and
is most commonly seen in swimmers. Acute diffuse otitis externa is usually

caused by bacteria, but it can be occasionally caused by a fungus.

Elements of acute diffuse otitis externa include rapid onset (generally
within 48 h); symptoms of ear canal inflammation that include otalgia,
itching, or fullness, with or without hearing loss or jaw pain; and
tenderness of the tragus or pinna, or diffuse ear edema or erythema or
both, with or without otorrhea, regional lymphadenitis, tympanic
membrane erythema, or cellulitis of the pinna.
Acute localized otitis externa, also known as furunculosis, is associated
with infection of a hair follicle.

Chronic otitis externa is the same as acute diffuse otitis externa, but it is
of longer duration (>6 wk).

Eczematous otitis externa encompasses various dermatologic conditions

(eg, atopic dermatitis, psoriasis, lupus erythematosus, eczema) that may
infect the external auditory canal and cause otitis externa.

Necrotizing "malignant" otitis externa is an infection that extends into the

deeper tissues adjacent to the auditory canal. This type of otitis externa
primarily occurs in adult patients who are immunocompromised (eg,
diabetes mellitus, acquired immunodeficiency syndrome [AIDS]) and is
rarely described in children. Necrotizing otitis externa may result in cases
of cellulitis and osteomyelitis.

4. A 17 years old girl came to the ENT clinic with chief complain
fullness sensation of the both ears since 5 days ago .
Identity
Name
: Ms. H
Age
: 17 years old
Address
: Cikole
Chief complaint
: fullness sensation of the both ears since 5 days ago
Additional complaint
: Runny nose, sneezing espesially in the dusty room
itchy nose, lacrimation
at the eyes, and clog nose since 3
years ago
Present Medical History
A 17 years old girl has been complaining fullness sensation of the both ears and
pain since 5 days ago. Before that, the patient had running nose and sneezing
since 3 years ago, espesially in the dusty room. These symptoms also followed
by itchy nose, lacrimation of the eyes and clog feeling nose. Patient has a lot of
discharge which is clear and watery-like. The symptoms occur along years about
four days a week, but dont disturb his daily activities. Patient also have a
sneezing at the morning but getting better at noon. There is no history of drug
abuse (nasal drop). Cough (-), fever (-).
Past Medical History
Asthma history denied.
Allergic to egg and seafood.
Physical Examination

Ear :
External ear : Normal both side
External acoustic canal
o Right : Hiperemis -, laceration -, discharge -, cerumen -, abnormal
mass -.
o Left : Hiperemis -, laceration -, discharge -, cerumen -, abnormal
mass -.
Tympanic membrane
o Right : Intact, normal cone of light.
o Left : Intact, normal cone of light.
Retroauricular : Normal both side
Preauricular : Normal both side
Nose :
Mucose : hiperemic both side, discharge +, watery-like.
Nasal septum : No deviation
Choncha inferior : Hipertrophy on both side, abnormal mass -.
Nasopharynx, Oropharynx :
Mucose : hiperemic -.
Tonsil : T1/T1, hiperemic -, smooth surface, normal crypt.
Uvula : No deviation.
Face :
Symmetric.
Neck :
No lymph nodes enlargement.
Working Diagnosis
Obstruction of the eustachius tube e.c. allergic rhinitis
Differential Diagnosis
- Acute Otitis Media
- Atopic Rhinitis
Further Examination
In vitro : Diffrential count, ELISA IgE.
In vivo : Skin end point titration
Intracutaneus Provocative Dillutional Food Test (IPDFT)
Treatment
Avoid the allergen.
Loratadine 5mg + Pseudoephedrine 120mg, twice a day for 7days.
Desensitization with inhalant allergen.
Decongestant

Complication

Sinusitis

Explanation
Obstructive disorders can be mechanical or functional. Mechanical obstruction
can be intrinsic due to intraluminal factors such as mucosal inflammation due to
allergy or infection, or extrinsic obstruction resulting in compromise of the
lumen. Extrinsic obstruction can be physiologic such as when the patient is
supine, or may be caused by a mass lesion such as a neoplasm or an adenoidal
mass. Functional obstruction results from persistent collapse of the eustachian
tube due to increased tubal compliance, an abnormal opening mechanism, or
both. Functional obstruction is more common in infants and young children, and
in many cases can be related to normal or abnormal developmental factors.