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History
A. General Data
J.G., 35 years old, Female, married, Roman Catholic, presently residing at Pasay City came in
our institution for OPD consult for the first time.
B. Chief Complaint: Ear pain, left
C. History of Present Pregnancy
Four days PTC, patient noted to have left ear pain, 5/10 pain scale, after an ear manipulation.
This was associated left ear discharge non-foul smelling and clear in character, tinnitus, colds and
cough. No medication taken and no consult done.
On the day of consult, persistence of symptoms prompted patient to sought consult.
D. Past Medical History
2003 Goiter, unrecalled medication but currently non-compliant to any medication.
She is non-hypertensive, non-diabetic and no history of pulmonary tuberculosis, asthma,
cancer, cardiovascular disease and kidney disease. She had no previous history of surgery and
hospitalizations. She had no history of allergy to any medications or any food.
E. Family History
There is a history of hypertension on paternal side and diabetes mellitus on the maternal side.
There were no history of asthma, cardiovascular disease, malignancies and kidney disease in her
family.
F. Obstetrical History: Gravida 2 Para 2 (2002)
G. Menstrual and Gynecological History
The patient had her menarche at the age of 11 occurring at regular intervals of 28 days lasting
for 3-4 days consuming 3 moderately soaked napkins per day and not associated with dysmenorrhea.
No pap smear done and no history of contraceptive use.
H. Sexual History
Patient had her first contact at the age 20 years old and had 3 sexual partners. She denies any
history of dyspareunia, postcoital bleeding, leukorrhea and exposure to sexually transmitted infection.
I. Personal and Social History
Patient is non-smoker, non-alcohol beverage drinker and denies illicit drug use. She is a high
school undergraduate and work as a maid. She lives at her boss house with their 5 children. Garbage is
collected every day and drinking water is distilled.
II. Review of Systems
General: (-) chills night sweats, fever, change in weight
Skin: (-) scars, lesions, rashes, ulcerations, excoriations
HEENT:
Head: (-) Headache, masses, bruises
Eyes: (-) eye pain, red eyes, eye itchiness, eye discharge
Nose: (-) colds, nasal discharge, epistaxis, trauma
Neck: (+) goiter, (-) neck pain, cervical lymphadenopathy
Throat: (-) throat pain, dysphagia
Respiratory: (-) difficulty of breathing dyspnea, hemoptysis, cough, colds
Heart: (-) cyanosis, edema, heart murmurs, chest pain, palpitations
Gastrointestinal: (-) nausea and vomiting, loss of appetite, abdominal pain, diarrhea, jaundice
Genitourinary: (-) dysuria, frequency, urgency, nocturia, enuresis, hematuria, vaginal discharge and
itchiness
Extremities: (-) swelling bilateral extremities , warmth/erythema, joint pain, muscle pain, cramps
Neurologic/Psychiatric: (-) mental status changes, agitation, disorientation, mood change, weakness
C. Skin and Appendages: The patients skin is fair, warm to touch and she has good skin turgor. No
raches, no edema, erythema, cyanosis, pallor, masses or lesions noted. The nail beds were not pale and
no clubbing or koilonychias were observed.
D. HEENT:
The patient has medium length, black hair with evenly distributed volume, pattern and
texture. Her head is symmetrical and normocephalic without lesions, masses, scars and tenderness. The
scalp has no lesions, non-edematous, no parasites nor scales.
Upon inspection, her eyes are symmetrical and not protruding. There were no ptosis or
strabismus noted. The eyebrows are also symmetrical and with equal hair distribution, eyelids were
non-edematous. Lacrimal glands were not swollen or tender. She has pink palpebral conjunctiva with
no inflammation, masses nor ulcerations noted. She has anicteric sclera with no corneal ulcers or
opacities. Her pupils are equally reactive to light, accommodation, consensual reflex. No visible
lesions, masses, ulcerations or serous drainage in the ears.
Her auricles were symmetrical. Tympanic membrane on left ear was not seen due to
retained cerumen, clear and non-foul smelling discharge was seen while tympanic membrane on
right is intact with no cerumen seen. There was left ear tragal tenderness noted.
Her nose is symmetrical and nasal septum is in midline. External nares are equal in size
and shape. Vestibule and nasal cavity has no masses, no serous/purulent/blood-tinged drainage. Both
nostrils are patent without watery/mucoid discharge. No nasal flaring was noted.
The lips are symmetrical, no masses or ulcerations. Gums and buccal areas are pinkish
free of lesions, masses or ulcerations. The tongue is pinkish and mobile, free of masses or ulcerations.
The palate is smooth and free of lesions. The floor of mouth is free of masses or ulcers. No
pharyngotonsilar congestion noted.
Anterior neck mass on the left, soft, non-movable, moves with deglutition and
approximately 3 cm x 2 cm x 3 cm in size was noted. Neck has no limitation of motion and any
nuchal spasm or rigidity. There was no lymphadenopathy, no enlargement of parotid and
submandibular glands and cervical lymph nodes noted. Thyroid gland moves with swallowing and
trachea is in midline position.
Anatomy1
The ear consists of three parts: the outer ear, middle ear and inner ear. The ear canal of the outer
ear is separated from the air-filled tympanic cavity of the middle ear by the eardrum. The middle ear contains the
Blood supply
The blood supply of the ear differs according to each part of the ear. The outer ear is supplied by a
number of arteries. The posterior auricular artery provides the majority of the blood supply. The anterior auricular
arteries provide some supply to the outer rim of the ear and scalp behind it. The posterior auricular artery is a
direct branch of the external carotid artery, and the anterior auricular arteries are branches from the superficial
temporal artery. The occipital artery also plays a role. The middle ear is supplied by the mastoid branch of either the
occipital or posterior auricular arteries or the deep auricular artery, a branch of the maxillary artery. Other
arteries which are present but play a smaller role include branches of the middle meningeal artery, ascending
pharyngeal artery, internal carotid artery, and the artery of the pterygoid canal. The inner ear is supplied by the
anterior tympanic branch of the maxillary artery; the stylomastoid branch of the posterior auricular artery; the
petrosal branch of middle meningeal artery; and the labyrinthine artery, arising from either the anterior inferior
cerebellar artery or the basilar artery.
Epidemiology
In the United States, 70% of all children experience one or more attacks of AOM before their
second birthday. A study from Pittsburgh that prospectively followed urban and rural children for the first 2 years of
life determined that the incidence of middle ear effusion episodes is approximately 48% at age 6 months, 79% at age
1 year, and 91% at age 2 years. The peak incidence of AOM is in children aged 3-18 months. Some infants may
experience their first attack shortly after birth and are considered otitis-prone (i.e., at risk for recurrent otitis media).
In the Pittsburgh study, the incidence was highest among poor urban children. Differences in incidence between
nations are influenced by racial, socioeconomic, and climatic factors. Children aged 6-11 months appear particularly
susceptible to AOM, with frequency declining around age 18-20 months. The incidence is slightly higher in boys
than in girls. A small percentage of children develop this disease later in life, often in the fourth and early fifth year.
After the eruption of permanent teeth, incidence drops dramatically, although some otitis-prone individuals continue
to have acute episodes into adulthood. Occasionally, an adult with an acute viral URTI but no previous history of ear
Pathophysiology
Obstruction of the Eustachian tube appears to be the most important antecedent event associated
with AOM. The vast majority of AOM episodes are triggered by an upper respiratory tract infection (URTI)
involving the nasopharynx.
The infection is usually of viral origin, but allergic and other inflammatory conditions involving
the Eustachian tube may create a similar outcome. Inflammation in the nasopharynx extends to the medial end of the
Eustachian tube, creating stasis and inflammation, which, in turn, alter the pressure within the middle ear. These
changes may be either negative (most common) or positive, relative to ambient pressure. Stasis also permits
pathogenic bacteria to colonize the normally sterile middle ear space through direct extension from the nasopharynx
by reflux, aspiration, or active insufflation. The response is the establishment of an acute inflammatory reaction
characterized by typical vasodilatation, exudation, leukocyte invasion, phagocytosis, and local immunologic
responses within the middle ear cleft, which yields the clinical pattern of AOM. In a minority of otitis-prone
children, the Eustachian tube is patulous or hypotonic. Children with neuromuscular disorders or abnormalities of
the first or second arch are most likely too open and are therefore predisposed to reflux of nasopharyngeal
contents into the middle ear cleft. To become pathogenic in hollow organs, such as the ear or sinus, most bacteria
must adhere to the mucosal lining. Viral infections that attack and damage mucosal linings of respiratory tracts may
facilitate the ability of the bacteria to become pathogenic in the nasopharynx, Eustachian tube, and middle ear cleft.
Risk factors
The following are proven risk factors for otitis media:
Prematurity and low birth weight
Young age
Early onset
Family history
Race - Native American, Inuit, Australian aborigine
Altered immunity
Craniofacial abnormalities
Neuromuscular disease
Allergy
Day care
Crowded living conditions
Low socioeconomic status
Tobacco and pollutant exposure
Use of pacifier
Prone sleeping position
Fall or winter season
Absence of breastfeeding, prolonged bottle use
Staging
The disease runs through the following stages:
1. Stage of tubal occlusion
2. Stage of pre-suppuration
3. Stage of suppuration
4. Stage of resolution or complication
1. Stage of tubal occlusion
Edema and hyperemia of nasopharyngeal end of Eustachian tube blocks the tube, leading to
absorption of air and negative intratympanic pressure. There is retraction of tympanic membrane with some
degree of effusion in the middle ear but fluid may not be clinically appreciable. Deafness and earache are the
two symptoms but they are not marked. There is generally no fever. Tympanic membrane is retracted with
handle of malleus assuming a more horizontal position, prominence of lateral process of malleus and loss of
light reflex; and there is also conductive deafness.
2. Stage of pre-suppuration
If tubal occlusion is prolonged, pyogenic organisms invade tympanic cavity causing hyperemia of
its lining. Inflammatory exudate appears in the middle ear. Tympanic membrane becomes congested. There is
marked earache which my disturb sleep and is of throbbing nature. Deafness and tinnitus are present, but
complained only by adults.
Usually, child runs high degree of fever and is restless. To begin with, there is congestion of pars
tensa. Leash of blood vessels appear along the handle of malleus and at the periphery of tympanic membrane
imparting a cart-wheel appearance. Later, whole of tympanic membrane including pars flaccida becomes
uniformly red. There is a conductive type of hearing loss.
3. Stage of suppuration
This is marked by formation of pus in the middle ear and to some extent in mastoid air cells.
Tympanic membrane starts bulging to the point of rupture. Earache becomes excruciating. There is deafness and
fever of 102-103F. This may be accompanied by vomiting and even convulsions. Tympanic membrane appears
red and bulging with loss of landmarks. Handle of malleus may be engulfed by the swollen and protruding
tympanic membrane and may not he discernible. A yellow spot may be seen on the tympanic membrane where
Diagnosis
Pneumatic otoscopy is the standard of care in the diagnosis of acute and chronic otitis media. The
following findings may be found on examination in patients with AOM:
Signs of inflammation in the tympanic membrane
Bulging in the posterior quadrants of the tympanic membrane may bulge; scalded appearance of the superficial
epithelial layer
Perforated tympanic membrane (most frequently in posterior or inferior quadrants)
Presence of an opaque serum-like exudate oozing through the entire tympanic membrane
Pain with/without pulsation of the otorrhea
Fever
Tympanocentesis involves aspiration of the contents of the middle ear cleft by piercing the
tympanic membrane with a needle and collecting that material for diagnostic examination.
Tympanocentesis should be performed in the following patients with AOM:
Neonates who are younger than 6 weeks (and therefore are more likely to have an unusual or more invasive
pathogen)
Immunosuppressed or immunocompromised patients
Management
1. Pharmacotherapy
Antibiotics are the only medications with demonstrated efficacy in the management of AOM;
therefore, these agents are the initial therapy of choice. The antibiotic chosen should cover most of the common
bacterial pathogens and be individualized for the child with regard to allergy, tolerance, previous exposure to
antibiotics, cost, and community resistance levels. Duration of treatment may also be a consideration in the
choice of antibiotic. Antibiotics used in the management of AOM include the following:
Amoxicillin
Amoxicillin/clavulanate
Erythromycin base/Sulfisoxazole
Trimethoprim-sulfamethoxazole
Cefixime
Cefuroxime axetil
Cefprozil
Cefpodoxime
Cefdinir
Clindamycin
Clarithromycin
Azithromycin
Ceftriaxone
Some order has been brought to the discussions of antibiotic use under the auspices of the Centers
for Disease Control and Prevention (CDC) and by the Agency for Health Care Policy and Research (AHCPR), both
agencies of the US government. The CDC published 6 principles of appropriate antibiotic use in an attempt to bring
precepts of good public health and responsible therapy to the discussion while minimizing the selection of resistant
strains of bacteria within the community. These principles are as follows:
Episodes of otitis media should be classified as AOM or otitis media with effusion (OME)
Antimicrobials are indicated for treatment of AOM; however, diagnosis requires documented middle ear
effusion and signs or symptoms of acute local or systemic illness
Uncomplicated AOM may be treated with a 5- to 7-day course of antimicrobials in certain patients older than 2
years
Antimicrobials are not indicated for the initial treatment of OME; treatment may be indicated if effusions persist
for longer than 3 months
Persistent OME after therapy for AOM is expected and does not require repeat treatment with antimicrobials
Antimicrobial prophylaxis should be reserved for controlling recurrent AOM, defined as 3 or more distinct,
well-documented episodes in 6 months or 4 or more episodes in 12 months
2. Surgery
Surgical management of AOM can be divided into the following 3 related procedures:
Tympanocentesis
Myringotomy
Complications
The complications of AOM are classified by location as the disease spreads beyond the mucosal
structures of the middle ear cleft. They may be categorized as follows:
a) Intratemporal - Perforation of the tympanic membrane, acute coalescent mastoiditis, facial nerve palsy,
acute labyrinthitis, petrositis, acute necrotic otitis, or development of chronic otitis media
b) Intracranial - Meningitis, encephalitis, brain abscess, otitis hydrocephalus, subarachnoid abscess, subdural
abscess, or sigmoid sinus thrombosis
c) Systemic - Bacteremia, septic arthritis, or bacterial endocarditis
Danger signs of possible impending complications include (1) sagging of the posterior canal wall,
(2) puckering of the attic, and (3) swelling of post-auricular areas with loss of the skin crease.
Prognosis
Death from AOM is rare in the era of modern medicine. With effective antibiotic therapy, the
systemic signs of fever and lethargy should begin to dissipate, along with the localized pain, within 48 hours.
Children with fewer than 3 episodes are 3 times more likely to resolve with a single course of antibiotics, as are
children who develop AOM in non-winter months. Typically, patients eventually recover the conductive hearing loss
associated with AOM. Middle ear effusion and conductive hearing loss can be expected to persist well beyond the
duration of therapy, with up to 70% of children expected to have middle ear effusion after 14 days, 50% at 1 month,
20% at 2 months, and 10% after 3 months, irrespective of therapy. In most instances, persistent middle ear effusion
can merely be observed without antimicrobial therapy; however, a second course of either the same antibiotic or a
drug of a different mechanism of action may be warranted to prevent a relapse before resolution.
Source:
1. https://en.wikipedia.org/wiki/Ear
2. Grays Anatomy 3rd Edition
3. Medscape: Otitis Media. http://emedicine.medscape.com