GlossExtractor

67.

Mandac, Christian Paul 3/M Mandac, Christian Paul 3/M

 This is the case of

 This is the case of C.M., a 3 year old male who C.M., a 3 year old male who sought consult for left ear pain Patientsought consult for left ear pain Patient was diagnosed with

was diagnosed with acute otitis media left ear and otitis externa on rightacute otitis media left ear and otitis externa on right. Patient was. Patient was prescribed with Amoxicil

prescribed with Amoxicillin to complete for lin to complete for 10 days and Paracetamol 6.5ml every 4 hours.10 days and Paracetamol 6.5ml every 4 hours.

He was prescribed with Aplosyn otic drops 3 drops three times a

He was prescribed with Aplosyn otic drops 3 drops three times a day. Patient was instructedday. Patient was instructed to keep her ear dry and

to keep her ear dry and to have warm compress 15 minutes every 6 hours.to have warm compress 15 minutes every 6 hours.

Acute otitis media is

Acute otitis media is a bacterial infection of the a bacterial infection of the mucosally lined air-containinmucosally lined air-containing spacesg spaces of the temporal bone. Purulent material forms not only within the

of the temporal bone. Purulent material forms not only within the middle ear cleft but alsomiddle ear cleft but also within the pneumatized mastoid air cells and

within the pneumatized mastoid air cells and petrous apex. Acute otitis media petrous apex. Acute otitis media is usuallyis usually

precipitated by a viral upper respiratory tract infection that

precipitated by a viral upper respiratory tract infection that causes eustachiacauses eustachian tuben tube obstruction. This results in accumulation of

obstruction. This results in accumulation of fluid and mucus, which fluid and mucus, which becomes secondarilybecomes secondarily infected by bacteria. The most common pathogens both in

infected by bacteria. The most common pathogens both in adults and in childrenadults and in children are

are Streptococcus pneumoniae, Haemophilus Streptococcus pneumoniae, Haemophilus influenzae,influenzae, andandStreptococcus pyogenes.Streptococcus pyogenes.

Acute otitis media is most common

Acute otitis media is most common in infants and children, although it may occur at anyin infants and children, although it may occur at any age. Presenting symptoms and

age. Presenting symptoms and signs include otalgia, aural signs include otalgia, aural pressure, decreaspressure, decreased hearing, anded hearing, and often fever. The typical

often fever. The typical physical findings are erythema and decreased mobility of thephysical findings are erythema and decreased mobility of the tympanic membrane. Occasionally, bullae will be seen on the tympanic membrane.

tympanic membrane. Occasionally, bullae will be seen on the tympanic membrane.

 The treatment of acute otitis media is specific antibiotic therapy, often combined with  The treatment of acute otitis media is specific antibiotic therapy, often combined with nasal decongestants

nasal decongestants. The . The first-choice oral antibiotic treatment isfirst-choice oral antibiotic treatment is amoxicillinamoxicillin (20–40 mg/kg/d)(20–40 mg/kg/d) or

orerythromycinerythromycin (50 mg/kg/d) plus sulfonamide (150 mg/kg/d) for 10 (50 mg/kg/d) plus sulfonamide (150 mg/kg/d) for 10 days. Alternativesdays. Alternatives useful in resistant cases are

useful in resistant cases are cefaclorcefaclor (20–40 mg/kg/d) (20–40 mg/kg/d) or amoxicillin-clavulaor amoxicillin-clavulanate (20–40nate (20–40 mg/kg/d) combinations.

mg/kg/d) combinations.

Surgical drainage of the middle ear

Surgical drainage of the middle ear (myringotomy) is reserved for patients with(myringotomy) is reserved for patients with severe otalgia or when complications of

severe otalgia or when complications of otitis (eg, mastoiditis, meningitis) have occurred.otitis (eg, mastoiditis, meningitis) have occurred.

Recurrent acute otitis media may be

Recurrent acute otitis media may be managed with long-term antibiotic prophylaxis. Singlemanaged with long-term antibiotic prophylaxis. Single daily oral doses of sulfamethoxazole (500 mg) or

daily oral doses of sulfamethoxazole (500 mg) or amoxicillinamoxicillin (250 or 500 mg) are given over(250 or 500 mg) are given over a period of 1–3

a period of 1–3 months. Failure of this regimen to control infection is an indication formonths. Failure of this regimen to control infection is an indication for insertion of ventilating tubes.

insertion of ventilating tubes.

Otitis externa is an inflammatory and infectious process of the EAC.

Otitis externa is an inflammatory and infectious process of the EAC. PseudomonasPseudomonas aeruginosa

aeruginosa andand Staphylococcus aureusStaphylococcus aureus are the most are the most commonly isolated organisms. Lesscommonly isolated organisms. Less commonly isolated organisms include

commonly isolated organisms include ProteusProteus species,species, Staphylococcus epidermidisStaphylococcus epidermidis,, diphtheroids, and

diphtheroids, and Escherichia coliEscherichia coli..

In the

In the preinflammpreinflammatory stage, the atory stage, the ear is exposed to ear is exposed to predisposing factors, includinpredisposing factors, includingg heat, humidity, maceration, the absence of cerumen, and

heat, humidity, maceration, the absence of cerumen, and an alkaline PH. This can an alkaline PH. This can causecause edema of the stratum corneum and occlusion of

edema of the stratum corneum and occlusion of the apopilosebaceouthe apopilosebaceous units. In thes units. In the inflammatory stage, bacterial overgrowth ensues, with progressive edema

inflammatory stage, bacterial overgrowth ensues, with progressive edema and intensifiedand intensified pain. Incomplete resolution or persistent inflam

pain. Incomplete resolution or persistent inflammation for more than 3 mation for more than 3 months refers to themonths refers to the chronic inflammatory stage.

chronic inflammatory stage.

Symptoms of otitis externa may vary, depending on the

Symptoms of otitis externa may vary, depending on the stage and extent of disease.stage and extent of disease.

 The clinical diagnosis is suggested by

 The clinical diagnosis is suggested by the presence of otalgia, otorrhea, aural fullness,the presence of otalgia, otorrhea, aural fullness, pruritus, tenderne

pruritus, tenderness to palpation, and varying degrees of occlusion of the ss to palpation, and varying degrees of occlusion of the EAC. The patientEAC. The patient may also present with hearing loss that results from occlusion of the EAC

may also present with hearing loss that results from occlusion of the EAC by edema andby edema and debris. Signs of otitis externa include pain on distraction of the pinna, EAC

debris. Signs of otitis externa include pain on distraction of the pinna, EAC erythema,erythema, edema, otorrhea, crusting, and, in more advanced disease, lymphadenopathy of the edema, otorrhea, crusting, and, in more advanced disease, lymphadenopathy of the periauricu

periauricular and anterior cervical lymph nodes. Skin lar and anterior cervical lymph nodes. Skin changes of cellulitis may be changes of cellulitis may be present aspresent as well. In the chronic stage, the skin of

well. In the chronic stage, the skin of the EAC may be thickened.the EAC may be thickened.

 Treatment for otitis externa involves meticulous atraumatic debridement of the  Treatment for otitis externa involves meticulous atraumatic debridement of the EACEAC with the aid

with the aid of a of a microscope. Analgesia can be achieved with nonsteroidal anti-inflammatomicroscope. Analgesia can be achieved with nonsteroidal anti-inflammatoryry drugs (NSAIDs), opioids, or topical steroid

drugs (NSAIDs), opioids, or topical steroid preparatipreparations. After cleansing is ons. After cleansing is complete, oticcomplete, otic drop preparations that are antiseptic, acidifying, or antibiotic (or

drop preparations that are antiseptic, acidifying, or antibiotic (or any combination of any combination of these)these) should be used. If the

should be used. If the degree of stenosis of the canal is severe, a wick may degree of stenosis of the canal is severe, a wick may be carefullybe carefully placed in an effort to

placed in an effort to deliver the drops to the medial portion of deliver the drops to the medial portion of the canal.the canal.

Available antibiotic preparations include

Available antibiotic preparations include ofloxacinofloxacin,, ciprofloxacin,ciprofloxacin, colistin,colistin, polymyxinpolymyxin B

B,, neomycinneomycin,, chloramphenicolchloramphenicol,, gentamicingentamicin, and, and tobramycintobramycin.. Polymyxin B andPolymyxin B and neomycin

neomycin preparatipreparations are often used in ons are often used in combination for the treatment of combination for the treatment of S aureusS aureus andand PP

aeruginosa

aeruginosa infections. Ofloxacin and ciprofloxacin are single-agent antibiotics with infections. Ofloxacin and ciprofloxacin are single-agent antibiotics with anan excellent spectrum of coverage for pathogens

excellent spectrum of coverage for pathogens encountered in otitis externa. Preparationsencountered in otitis externa. Preparations with steroids help to

with steroids help to reduce edema and otalgia. Systemic antibiotics are indicated forreduce edema and otalgia. Systemic antibiotics are indicated for infections that spread beyond the EAC. For chronic otitis externa, a canalplasty may be infections that spread beyond the EAC. For chronic otitis externa, a canalplasty may be indicated for thickened skin that

indicated for thickened skin that has caused canal obstruction. Patients must be has caused canal obstruction. Patients must be instructedinstructed to avoid EAC manipulation and water exposure if they have a

to avoid EAC manipulation and water exposure if they have a history of recurrent otitishistory of recurrent otitis externa.

externa.

68. Bejo, Bobby 38/M 68. Bejo, Bobby 38/M

 This is the case of

 This is the case of B.B., a 38 year old who B.B., a 38 year old who came in for follow up and came in for follow up and was last seenwas last seen Aug. 12, 2011. Patient had

Aug. 12, 2011. Patient had foreign body (dentures) and was status post foreign body (dentures) and was status post emergencyemergency esophagoscopy.

esophagoscopy.Extraction of foreign body via lateral pharyngotomy (8/5/11) was done.Extraction of foreign body via lateral pharyngotomy (8/5/11) was done.

During the follow-up, removal of suture was done. Patient was advised wound care two During the follow-up, removal of suture was done. Patient was advised wound care two times a day. Removal of NGT was also done. Patient was allowed to

times a day. Removal of NGT was also done. Patient was allowed to have general liquids forhave general liquids for 3 hours ; soft

3 hours ; soft diet for overnight then cereal diet.diet for overnight then cereal diet.

Most common objects that may cause foreign body

Most common objects that may cause foreign body ingestion in adults are fish bones,ingestion in adults are fish bones, dentures, and meat (most common

dentures, and meat (most common objects in pediatrics are coins). 95% of objects in pediatrics are coins). 95% of esophageaesophageall foreign bodies are located at

foreign bodies are located at the cricopharyngeus (other common sites are thethe cricopharyngeus (other common sites are the gastroesophag

gastroesophageal junction and the eal junction and the indentation from the aortic arch indentation from the aortic arch and left mainstemand left mainstem bronchus). Signs and symptoms include dysphagia, drooling, weight loss,

bronchus). Signs and symptoms include dysphagia, drooling, weight loss, chest pain andchest pain and fever. Chest x-ray is used

fever. Chest x-ray is used to identify the to identify the object, whereas barium swallow should be avoidedobject, whereas barium swallow should be avoided since it may obscure the field with endoscop

since it may obscure the field with endoscopy. y. Complications includComplications include esophageale esophageal perforation, mediastinitis, pneumomediastinum, pneumothorax, and

perforation, mediastinitis, pneumomediastinum, pneumothorax, and aspiration.aspiration.

Rigid Esophagoscopy is indicated for foreign bodies that remain in the esophagus for Rigid Esophagoscopy is indicated for foreign bodies that remain in the esophagus for

>24 hours, large object in the esophagus, any batteries; if possible may obtain similar object

>24 hours, large object in the esophagus, any batteries; if possible may obtain similar object in order to determine a strategy for instrumental removal. A second foreign body is always in order to determine a strategy for instrumental removal. A second foreign body is always checked. Fogarty catheters may be used for

checked. Fogarty catheters may be used for distal objects. If no distal objects. If no endoscopy indicated,endoscopy indicated, consider following with abdominal films and straining stool.

consider following with abdominal films and straining stool. Long-term Management icludesLong-term Management icludes oral corticosteroids for presence of edema and

oral corticosteroids for presence of edema and prophylactic antibioticsprophylactic antibiotics, as , as well as closewell as close follow-up.

follow-up.

69.

69.

Mazo, Christian Joy 6/MMazo, Christian Joy 6/M  This is the ca

 This is the case of C.M. a se of C.M. a 6 year old m6 year old male ale who came in who came in came in for in came in for in regardingregarding impacted cer

impacted cerumen. umen. Patient is dPatient is diagnosed withiagnosed with resolved impacted cerumenresolved impacted cerumen. Patient was. Patient was advised to come back once with problems.

advised to come back once with problems.

Cerumen is produced in the ear

Cerumen is produced in the ear canal by sebaceous and cerumen glands. canal by sebaceous and cerumen glands. AA

protective film is formed consisting of lysozymes, fatty acids, acid milleu which protects the protective film is formed consisting of lysozymes, fatty acids, acid milleu which protects the skin from various infections. The

skin from various infections. The ear canal is also cleansed via epithelial migration from ear canal is also cleansed via epithelial migration from thethe tympanic membrane towards the external meatus which effectively removes the cerumen.

tympanic membrane towards the external meatus which effectively removes the cerumen.

Disturbance of this normal self-cleansing mechanism or excessive cerumen secretion may Disturbance of this normal self-cleansing mechanism or excessive cerumen secretion may cause impacted cerumen. It is usually

cause impacted cerumen. It is usually precipitateprecipitated by d by excessive cleaninexcessive cleaning of g of the ears withthe ears with

cotton-tipped swabs. A cerumen plug may

cotton-tipped swabs. A cerumen plug may be formed which be formed which further hinders normal expulsionfurther hinders normal expulsion of the cerumen. Impaction may occur especially when there is contact with water. Drying of  of the cerumen. Impaction may occur especially when there is contact with water. Drying of  the meatal skin and

the meatal skin and decrease in secretions may cause hardening of the decrease in secretions may cause hardening of the cerumen whichcerumen which causes retention especially in narrow

causes retention especially in narrow ear canals.ear canals.

Although impacted cerumen may cause vertigo and

Although impacted cerumen may cause vertigo and tinnitus, ear pressure symptomstinnitus, ear pressure symptoms such as ear fullness and

such as ear fullness and hearing difficulty in the hearing difficulty in the affected ear are the usual encounteredaffected ear are the usual encountered symptoms. It is

symptoms. It is mainly diagnosed by visualization through an otoscope mainly diagnosed by visualization through an otoscope wherein a yellowish,wherein a yellowish, brownish to blackish material is observed to

brownish to blackish material is observed to obstruct the ear canal. Impacted cerumen alsoobstruct the ear canal. Impacted cerumen also sometimes lead to otitis externa. It may be removed via a

sometimes lead to otitis externa. It may be removed via a small instrument such as a hooksmall instrument such as a hook or curette or be flushed away by

or curette or be flushed away by aural cleaning with irrigaaural cleaning with irrigation jet or tion jet or a syringe.a syringe.

70.

70.

Sinco, Zosimo Sr. 70/MSinco, Zosimo Sr. 70/M  This is the ca

 This is the case of Z.S. a se of Z.S. a 70 year old 70 year old male male who came in who came in came in rcame in regarding ear egarding ear painpain on both ears. Patient is diagnosed with

on both ears. Patient is diagnosed with conductive hearing loss on the right and conductive hearing loss on the right and withwith aural polyp.

aural polyp. Ear wick was placed. PND otic drops 2-3 drops three times Ear wick was placed. PND otic drops 2-3 drops three times a day fro 7 a day fro 7 days,days, Cloxacillin 500 mg/cap 1 cap every 6 hours for

Cloxacillin 500 mg/cap 1 cap every 6 hours for 7days and Mefenamic Acid 500 mg/ cap, 17days and Mefenamic Acid 500 mg/ cap, 1 cap every 6 hours for pain were prescrive

cap every 6 hours for pain were prescrive In CHL, the

In CHL, the pathology lies in the pathology lies in the external ear canal, ear drum (tympanic membrane),external ear canal, ear drum (tympanic membrane), ossicles or middle ear. Because of the pathology, impaired conduction of sound occur;

ossicles or middle ear. Because of the pathology, impaired conduction of sound occur;

hence, there is decreased intensity of sound

hence, there is decreased intensity of sound reaching the cochlea. Unlike SNHL, there is reaching the cochlea. Unlike SNHL, there is nono distortion of sound

distortion of sound hence understanding speech is no problem hence understanding speech is no problem with adequate intensity.with adequate intensity.

Persons with CHL tends to speak softly because they hear the speech louder (bone>air Persons with CHL tends to speak softly because they hear the speech louder (bone>air conduction), hence they lower their voices

conduction), hence they lower their voices since they perceive that they since they perceive that they are speaking loudly.are speaking loudly.

Hearing loss is mild to moderate around 30-40 dB. The

Hearing loss is mild to moderate around 30-40 dB. The most common etiology is Impactedmost common etiology is Impacted cerumen and other foreign bodies.

cerumen and other foreign bodies. Other possible etiology include: ear canal atresia, otitisOther possible etiology include: ear canal atresia, otitis externa/medi

externa/media, otosclerosis, ear canal a, otosclerosis, ear canal tumors, and myringitis. Diagnosis of tumors, and myringitis. Diagnosis of CHL includesCHL includes otoscopic findings of the ear canal and ear drum; Weber’s test that lateralizes to the otoscopic findings of the ear canal and ear drum; Weber’s test that lateralizes to the affected ear; a negative Rinne test

affected ear; a negative Rinne test (bone>air conduction); a higher air conduction (bone>air conduction); a higher air conduction thresholdthreshold on PTA. Treatment is directed at the specific etiology. For instance, in cases of impacted on PTA. Treatment is directed at the specific etiology. For instance, in cases of impacted cerumen, the cerumen is flushed out; or in AOM, the

cerumen, the cerumen is flushed out; or in AOM, the infection is relieved by antimicrobialinfection is relieved by antimicrobial agents.

agents.

An aural polyp is a growth

An aural polyp is a growth in the outside (external) ear canal. It may be attached toin the outside (external) ear canal. It may be attached to the eardrum (tympanic membrane), or it may grow from the middle ear space. Aural polyps the eardrum (tympanic membrane), or it may grow from the middle ear space. Aural polyps may be caused by:

may be caused by: cholesteatomacholesteatoma, foreign object, , foreign object, inflammation and tumor. Bloody drainageinflammation and tumor. Bloody drainage from the ear is the

from the ear is the most common symptom. Hearing loss can also occur. An aural polyp ismost common symptom. Hearing loss can also occur. An aural polyp is diagnosed through an examination of the ear canal and middle ear using an otoscope diagnosed through an examination of the ear canal and middle ear using an otoscope oror microscope. Treatment depends on the underlying cause. Avoiding water in

microscope. Treatment depends on the underlying cause. Avoiding water in the ear, steroidthe ear, steroid

microscope. Treatment depends on the underlying cause. Avoiding water in the ear, steroidthe ear, steroid

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