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a Case Presentation
Supervisor:
dr. H. Oscar Djauhari, Sp. THT-KL
Presented by:
Adrienne Trinovia Sulistyo (2011-061-020)
Daniela Angeline (2012-061-001)
Chronic Suppurative Otitis Media
with Facial Nerve Palsy
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The Case
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The Case
Mr. Y, a 19-years old man came to hospital with
difficulty in smiling and dropping of his right
corner of his mouth since 5 days ago. He had a
history ofchronic suppurative otitis media of his
right ear.
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Identity and Complaint Name : Mr. Y
Age : 19 years old
Occupation : Student
Weight : 58 kg
Height : 167 cm Address : Jl. Koperasi, Sukabumi
Chief complaint : Drop of his right mouth corner and
difficulty in smiling
Additional complaint : -
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History of Present Illness Patient had secretion coming out of his right ear. It
comes out intermittently since 4 months ago and the
latest was 1 month ago. Secretion was yellowish in
color, slightly thick in consistency and has foul
smell. Patient went to general practitioner before butwith no improvement.
5 days ago, patient noticed a drop of his right
mouth cornerand difficulty in smiling. Patient feltthis symptom became worse along with time.
Earache was absent. Fever and pain on other places
were absent. Hearing loss (+). Tinnitus (+). History
oftrauma (-).
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History of Past Illness
Since 4 months ago, patient had secretioncoming out of his right ear intermittently.
2 months ago went to the community health
centre and was given oral medication but the
discharge still came out.
Allergic (-)
Hypertension (-)
Diabetes Mellitus (-)
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Physical Examination
(Generalized Status)
General appearance : moderately ill
Awakeness : compos mentis
Blood Pressure : 110/70 mmHg
Pulse rate : 80 beat per minute Respiration rate : 20 bet per minute
Temperature : 36,9oC
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Physical Examination
(Ears)
Right ear :
Auricle : hyperemic (-), oedema (-)
Canalis Acousticus Externa : hyperemic (-), mass (-),
Discharge (+) minimal, yellowish and purulent, cholesteatoma (-),
Odorous smell, laceration (-)
Tymphanic membrane : marginal perforation, light
reflex (-)
Rinne test (-), Weberlateralitation to the right, prolonged Schwabach.
Left ear :
Auricle : hyperemic (-), oedema (-)
Canalis Acousticus Externa : hyperemic (-), mass (-), discharge (-),
cholesteatoma (-), laceration (-)
Tymphanic membrane : intact, bulging (-), light reflex (+)
Rinne test (+), Schwabach test same with the examiner.
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Physical Examination
(Nose)
Right Nose : Mucous membrane : within normal range
Concha : eutrophy
Cavum : discharge(-),mass (-),crust (-
),bleeding (-)
Septum : normal
Left nose :
Mucous membrane : within normal range
Concha : eutrophy
Cavum : discharge(-),mass (-),crust (-
),bleeding (-)
Septum : normal
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Physical Examination
(Nasopharynx, Oropharynx, Maxilofascial, and Neck)
NPOP Mucous membrane : hyperemic -/-, oedem -/-
Arcus anterior : uvula in the middle, mass -/-
Pharynx : normal pharyngeal arch,
hyperemic (-)
Tonsil : T1-T1, hyperemic (-)
Neck : lymphadenopathy (-)
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Physical Examination
(Facial Nerve)
Facial Nerve Examination (right / left) Facial expression : asymmetrical, right
side of face slightly dropped
Raising eyebrow : difficult / normal
Closing eyes : left behind / normal
Smiling : left behind / normal
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Working Diagnosis Chronic suppurative otitis media auris dextra with
complication of dextra facial nerve paralysis.
Differential Diagnosis
Primary tumor in the middle of right ear.
Workup
Bacteria culture and sensitivity test from the eardischarge
Audiometry test
Head CT scan
Lab : Complete blood count including differentialcount of white blood cells
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Medication
Topical antibiotic : ofloxacin ear drops 3mg/ml, 2 x10 drops daily for 10 14 days in right ear
Oral antibiotic : Amoxicillin-clavulanic acid, 2 x
500 mg p.o. for 10 14 days
Steroid : Prednisone, 4 X 20 mg per day p.o.
Nerve decompression
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Literature review
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Chronic Suppurative Otitis Media
(CSOM)
Definition
a persistent or intermittent infected discharge
through a nonintact tympanic membrane (ie,
perforation or tympanostomy tube)
Chronic perforation of the tympanic membrane can
occur without suppurationinactive CSOM
Epidemiology prevalent in developing countries and is more
common in lower socioeconomic groups in the
developed world.
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Chronic Suppurative Otitis Media
(CSOM)
Pathogenesis
most cases: CSOM occurs as a consequence of an
episode of AOM with perforation, with subsequent
failure of the perforation to heal.
continued presence of a middle ear effusion
degeneration of the fibrous layer of the tympanic
membrane.
P aeruginosa, S aureus, and the Proteus species.
Two main mechanisms by which a chronic perforation
can lead to continuous or repeated middle ear
infections:
Direct contamination from external ear because the protective
physical barrier of the tympanic membrane is lost. The loss of as cushion in reventin reflux of naso har nx
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Clinical Findings SYMPTOMS AND SIGNS
History of otorrhea, intermittent or continuous Hearing loss Discharge mucopurulent or bloodstained otorrhea Edematous mucous membrane in the middle ear
Large perforation : identify the presence of ossiculardiscontinuity
SPECIAL TESTSA swab of the discharge : for culture and sensitivity test
An audiologic evaluation Computed tomographic (CT) scans : demonstrating
bony anatomy and are essential if an intracranialextension of the infection is suspected.
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Differential Diagnosis
cholesteatoma
chronic granulomatous conditions
Wegener granulomatosis
mycobacterial infection
histiocytosis X
sarcoidosis
necrotizing otitis externa or malignant neoplasm
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Treatment
NONSURGICAL MEASURESAural toilet
Topical antibiotics
Systemic antibiotics
SURGICAL MEASURES
Tympanoplasty
Tympanomastoid surgery (tympanoplasty + corticalmastoidectomy)
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Complications Sequelae
Tympanosclerosis (hyalinization of tympanic membrane)
Atelectasis of tympanic membrane (grossly retracted or collapsed
tympanic membrane)
Intratemporal Complications
Mastoiditis Petroisitis (close relationship with CN. V and CN. VI retroorbital
pain, lateral rectus palsy)
Facial Nerve Paralysis
Suppurative Labyrinthitis
Intracranial Complications Meningitis
Intracranial abscess
Lateral sinus thrombosis
Otic Hydrocephalus
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Facial Nerve
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Facial palsy
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Differential Diagnosis of Facial
Paralysis
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Thank You
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