case dr. oscar 2 - omsk - facial palsy adriene enji

7/29/2019 Case Dr. Oscar 2 - OMSK - Facial Palsy Adriene Enji

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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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(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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(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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(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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(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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(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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(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

case dr. oscar 2 - omsk - facial palsy adriene enji

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