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