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Case Discussion
A 22 years old man came to clinic with a complaint osmilling since 4 days ago, and difficult swallowing since 2He had chronis suppurative otitis media 5 years ago.
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A. PATIENTS IDENTITY
Name : Mr. X Gender : Male
Age : 22 years old
Race : Sundanese
Occupation : student
Weight : 65 kg
Address : Ahmad Yani, Sukabumi
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B. HISTORY
Chief complaint : Drop of his right mouth cornerdifficulty with smiling
Additional complaint : difficult swallowing since 2 day
History of present illness : Patient had secretion coming out of htwice recently. First, 6 month ago and the latest was 3 month agperiod was 1 week. Secretion was yellowish green in color, slight
consistency and odorous. Patient went to general practitioner bewith no improvement. 1 week ago, patient noticed a drop of his mouth corner and difficulty in smiling. Patient felt this symptom worse along with time. Cough and cold was present too. Earacheabsent. Fever (-) and pain on other places were absent. History o).
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History of past illnes :5 years ago, patient had chronic suppurative otitis media ear
Hypertension (-)
Diabetes Mellitus (-)
History of Family Illnes : -
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C. PHYSICAL EXAMINATION
General appearance : mild illness Blood pressure : 120/90 mmhg
Pulse : 88x/minute
Respiratory rate : 25x/minute
Temperature : 37,2oC
ENT examination
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a. Ear
Right ear : Auricle : hyperemia (-), oedema (-)
Canalis Acousticus Externus:
hyperemic (-)
mass (-)
Secretion (+) minimal, yellowish green in color
Odorous smell
cholesteatoma (-)
Tymphanic membrane : central perforation
Cochlear Nerve examination :
Rinne test (-)
Weber lateralitation to the right
prolonged Schwabach.
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Throat : Uvula in the middle Pharynx : normal pharyngeal arch, hyperemic (-)
Tonsil : T1-T1, hyperemic (-)
Maxillofacial : asymmetrical
Neck : lymphadenopathy (-)
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Facial Nerve Examination (right / left) Facial expression : asymmetrical,right side of face slightly d
Raising eyebrow : difficult/ normal
Closing eyes : left behind/ normal
Smiling : left behind/ normal
Puff out the cheeks : left behind/ normal
Reveal the teeth : left behind /normal
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Working diagnosis Chronic suppurative otitis media of the right ear with a com
of right facial nerve paralysis.
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Work up
Lab : Complete Blood Count including differential count of wblood cells
Culture of secretion from the right ear and bacterial resistan
Audiometry test
Head CT Scan
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Therapy Topical Antibiotic : Gentamicin drops 0.3%, 3 x 4 drops per d
Oral Antibiotic : Ciprofloxacin, 2 X 500 mg p.o.
Steroid : Prednisone, 4 X 20 mg per day p.o.
Mecobalamin 3 x 500 mcg p.o
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Chronic suppurative otitis media (C
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Definition
Chronic suppurative otitis media (CSOM) inflammation of the middle ear and mastoidwhich presents with recurrent ear dischaotorrhoea through a tympanic perforation.
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Epidemiology
The larger the tympanic membrane perforation, the more lipatient is to develop CSOM
Some studies estimate the yearly incidence of CSOM to be 3per 100,000 persons in children and adolescents aged 15 yeyounger.
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Risk factors
Living in crowded conditions
Living in a large family
Poor nutrition and lower levels of zinc, selenium, calcium, a
Passive smoke exposure
Frequent upper respiratory tract infections and nasopharyn
Infectious and chronic diseases, such as measles, humanimmunodeficiency virus (HIV) infection, tuberculosis, diabetcancer
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Other comorbid conditions, such as cleft lip/palate, Down sycri du chat syndrome, choanal atresia, and microcephaly
Unhygienic practices, such as bathing in contaminated pondrivers, unsterile ear piercing, and cleaning ears with cotton b
Family history may also play a role in AOM and CSOM.
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Anatomy
The middle ear cleft can thought of as a 6-sided c
Its lateral boundary, the membrane, separates it outer ear
Its medial boundary is fothe promontory, which dbasal turn of the cochlea
Anteriorly, it is related totendon of tensor tympansuperiorly and the openeustachian tube inferior
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Posteriorly, it is relatedsuperiorly to the adituconnects the middle eawith the mastoid antruinferiorly to the facial r
The roof of the middleis formed by the tegmetympani.
The floor of the middlecavity lies in close relat
jugular foramen.
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Etiology
1. Could be a sequelae to inadeq
treated acute otitis media.
2.
Acute suppurative otitis mediapersistant perforation which cinfected from bacteria in the eauditory canal. This condition as persistant perforation syndr
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Pathophysiology
irritation and subsequent inflammation of the middle ear mucosa. Theinflammatory response creates mucosal edema.
mucosal ulceration and consequent breakdown of the epithelial lining.
The host's attempt at resolving the infection or inflammatory insultmanifests as granulation tissue, which can develop into polyps withinthe middle ear space
The cycle of inflammation, ulceration, infection, and granulation tissformation may continue, eventually destroying the surrounding bonmargins and ultimately leading to the various complications of CSOM
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Hearing loss is usually about 30 - 40 dB.
These patients have poorly pneumatised / sclerosed mastoisystem
Pain in the ear when present is always associated with otitis
Nonspecific symptoms of acute otitis media (e.g., fever, hea
irritability, cough, rhinitis, listlessness, anorexia, vomiting, dpulling at the ears) are common in infants and young childre
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Diagnosis
a. Physical examination
A large central perforation of the tympanic membrane (TM) is thcommon and perforation of the posterosuperior quadrant is thecommon
Discharge can range from purulent to fetid to cheese-like, and caear canal
typically not significant edema of the external auditory canal
There may be granulation tissue present, but it should be distingfrom retraction-pocket cholesteatoma in which the granulation toccupies the pars flaccida of the TM
Middle-ear mucosa, when it is seen, can be polypoid or edematoappear pale, red, or may be normal
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b. Imaging studies
A high-resolution temporal bone CT scan
c. Other test
A swab of the discharge : for culture and sensitivity test
An audiologic evaluation
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Complications
a. Sequele
Tympanosclerosis
b. Intratemporal Complications
Mastoiditis
Acute mastoiditis
Subacute mastoiditis Petrositis
Facial Nerve Paralysis
Suppurative Labyrinthitis
c.Intracranial Complicatio
Meningitis Intracranial Abscess
Lateral Sinus Thrombosis
Otic Hydrocephalus
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Facial Nerve
M C f F i l N
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Motor Component of Facial Nerve
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