KABALE UNIVERSITY SCHOOL OF MEDICINE

ATUHAIRWE RITAH
I6/A/MBCHB/0739/F
ENT DEPARTMENT
DR NYANZI DANIEL
DEMOGRAPHICS

PATIENT’S DEMOGRAPHICS

NAME: Ainembabazi desire

AGE: 3 years

SEX: female

RELIGION: catholic

OCCUPATION: NONE

ADDRESS: Muyumbu

NEXT OF KIN: Naturinda Sharon (mother)

DATE OF CLERKSHIP: 30TH JANUARY 2020

PRESENTING COMPLAINT:

Pus discharge from the left ear for a month

HISTORY OF PRESENTING COMPLAINT:

Mother reports that child was well till a month ago when the mother saw some pus discharge
from the left ear, she cleaned it but continued appearing like three days in the week. She reported
that child would be in severe pain by holding to that ear while crying which would be aggravated
when she coughs

Mother reports child to have intermittent episodes of non productive cough and runny nose but
not being treated, however no difficulty in breathing, or chest pain, no haemoptysis

Mother reports no history of trauma, hearing loss, no dizziness, no loss of consciousness, no

headache

REVIEW OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM
She had no history of chest pain, palpitations, easy fatigability, difficult breathing at night and
chest tightness.

MUSCULOSKELETAL SYSTEM

There was no history of muscle pains, swollen limbs or loss of limb function.

ABDOMINAL SYSTEM

No history of abdominal pain, no loss of appetite, no nausea and vomiting, no history of melena
stool, no dysphagia

PAST MEDICAL HISTORY

She reports no history of any past admission, chronic illnesses such as diabetes mellitus,
hypertension, asthma, sickle cell disease or HIV/AIDS.

She had no history of any known food or drug allergy.

PAST SURGICAL HISTORY

She reports no history of any past major surgery, blood transfusion or trauma

FAMILY HISTORY

She is the first born out of two. Lives with her parents

She reported no history of any familial illnesses such as diabetes mellitus, sickle cell disease,
hypertension and asthma.

SOCIAL HISTORY

Lives in a permanent house.

She sleeps under a treated mosquito net, doesn’t drink boiled water

She doesn’t drink alcohol, smoke cigarette or chew tobacco.

SUMMARY OF HISTORY

Ainembabazi 3 year old girl presented with pus discharge from the left ear for a month. She
reported to have severe pain aggravated by coughing. She also has a history of intermittent non
productive cough and runny nose that was not being treated.

GENERAL EXAM INATION

Patient is lying supine in bed and is in a state of extreme dizziness.

Her capillary refill was less than 1 second, radial pulse 112beats per minute. She had no palmar
pallor, no finger clubbing or splinter hemorrhage. No lymphadenopathy

She had no conjunctiva pallor, no yellowing of the sclera.

She had a good oral hygiene; her tongue was moist with no bluish coloration under the tongue
and no cracked lips.

She had no pedal edema.

SYSTEMIC EXAMINATION

ENT EXAMINATION

Ear

Left ear: Normal auricle with no swelling or deformity, no skin tags, its in the normal position.
No lymphadenopathy, no surgical scars. No tenderness of the auricle and mastoid area

The ear canal was visible, there was pus discharge. The tympanic membrane was inflamed and
bulging

Right ear: Normal auricle with no swelling or deformity, no skin tags, its in the normal position.
No lymphadenopathy, no surgical scars. No tenderness of the auricle and mastoid area

Canal was clear. Normal tympanic membrane

Nose

The skin of the nose had its normal colour, was asymmetrical .no visible scars. Normal position
of nasal septum, no perforation. No swelling in the vestibule.

Mouth and throat

No wounds or lesions on the lips, good dental hygiene, normal gums. The tongue is mobility is
normal. Normal tonsils. The soft palate and uvula are normal.

Neck exam

No enlarged lymph nodes. No masses and lesions visible

ABDOMINAL EXAMINATION

Her abdomen was not distended, moving with respiration. There were no visible scars.

She had no organomegally. Was tympanic on palpation. Normal bowel sound heard on
auscultation

RESPIRATORY EXAMINATION

There were no surgical scars visible. The chest was symmetrical. Her respiratory rate was 11
cycles per minute.

She had a normal tactile vocal fremitus and chest expansion.

The chest was resonant on percussion.

There was equal air entry and no abnormal sounds heard.

CENTRAL NERVOUS SYSTEM.

The patient was conscious and well oriented to person, place and time. She had no neck stiffness.
There were no craniopathies.

She had normal muscle power and tone.

All the reflexes were normal.

CARDIOVASCULAR EXAMINATION

No oslers node, no splinter hemorrhages, pulse rate 94, blood pressure 100/98 mmHg. No radial-
radial delay, no radial femoral delay. The apex beat was in the 5thintercoastal space. Heart sound
1 and 2 heard

INVESTIGATIONS

 CBC to check for increased neutrophils incase of bacterial infection

 Pus swab can be for culture and sensitivity. Can also be for gram stain to identify the
organism whether its gram positive or gram negative and this guides on what
antibacterial to give
 audiometry to know if there is any hearing loss and its level
 HIV
 ESR
 CT scan to check for any complications

DIFFERENTIAL DIAGNOSIS

Acute suppurative otitis media

Otitis media with effusion

Otitis externa

choleostoma

Contact dermatitis

DIAGNOSIS

LEFT EAR ACUTE SUPPURATIVE OTITIS MEDIA

TREATMENT

Pharmacological
Amoxylin tablets as antibiotic

Iburophen tablets as analgesic

Chloramphenicol ear drops

Non pharmacological

Ear wicking to remove the discharge

Advise patient to avoid pouring water into her ears

DISCUSSION

ACUTE SUPPURATIVE OTITIS MEDIA

It is an acute inflammation of middle ear by pyogenic organisms. Here, middle ear implies middle ear
cleft, i.e. eustachian tube, middle ear, attic, aditus, antrum and mastoid air cells.
Aetiology
 It is more common especially in infants and children because these children are prone to
recurrent viral infections. It can also be because of lower socio-economic group.
 Typically, the disease follows viral infection of upper respiratory tract but soon the pyogenic
organisms invade the middle ear.
Routes of Infection
1. Through Eustachian tube.
 It is the most common route.
 Infection travels via the lumen of the tube or along subepithelial peritubal lymphatics.
 Eustachian tube in infants and young children is shorter, wider and more horizontal and thus
may account for higher incidence of infections in this age group.
 Breast or bottle feeding in a young infant in horizontal position may force fluids through the
tube into the middle ear and hence the need to keep the infant propped up with head a little
higher. Swimming and diving can also force water through the tube into the middle ear.
2. Through external ear.
 Traumatic perforations of tympanic membrane due to any cause open a route to middle ill
infection.
Predisposing Factors
Anything that interferes with normal functioning of eustasian tube predisposes to middle ear infection.
It could be:
 Recurrent attacks of common cold, upper respiratory tract infections, and exanthematous fevers
like measles, diphtheria and whooping cough.
 Infections of tonsils and adenoids.
 Chronic rhinitis and sinusitis.
 Nasal allergy.
 Tumors of nasopharynx, packing of nose or nasopharynx for epistaxis.
 Cleft palate.
Causative agents
 Most common organisms in infants and young children are Streptococcus pneumoniae ,
Haemophilus influenza and Moraxella cawrrhalis. Other organisms include Streptococcus
pyogenes, Lococcus aureus and sometimes Pseudomonas aerugnosa.

Pathology and Clinical Features

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. Oedema 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.

Symptoms. Deafness and earache are the two symptoms but they are not marked. There is generally no
fever.
Signs. Tympanic membrane is retracted with handle of malleus assuming a more horizontal position,
prominence of lateral process of malleus and loss of light reflex.
Tuning fork tests show 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.

Symptoms. There is marked earache which disturbs sleep and is of throbbing nature. Deafness and
tinnitus are also present, but complained only by adults.
Usually, child runs high degree of fever and is restless.
Signs. 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 It a cart-wheel appearance. Later, whole of tympanic membrane including pars flaccida
becomes uniformly red.
Tuning fork tests will again show 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.

Symptoms. Earache becomes excruciating. Deafness increases, child may run fever of 102-103°F. This
may be accompanied by vomiting and even convulsions.
Signs. 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 rupture is imminent. In preantibiotic era, one could see
a nipple-like protrusion of tympanic membrane with a yellow spot on its summit.
Tenderness may be elicited over the mastoid annum.
X-rays of mastoid will show clouding of air cells because of exudate.

4. Stage of resolution. The tympanic membrane ruptures, with release of pus and subsidence of
symptoms.
Inflammatory process begins to resolve. If proper treatment is started early or if the infection was mild,
resolution may start even without rupture of tympanic membrane.

Symptoms. With evacuation of pus, earache is relieved, fever comes down and child feels better.
Signs. External auditory canal may contain blood tinged discharge which later becomes mucopurulent.
Usually, a small perforation is seen in antero-inferior quadrant of pars tensa. Hyperaemia of tympanic
membrane begins to subside with return to normal colour and landmarks.
5. Stage of complication. If virulence of organism is high or resistance of patient poor, resolution may
not take place and disease spreads beyond the confines of middle ear.
It may lead to acute mastoiditis, subperiosteal abscess, facial paralysis, labyrinthitis, petrositis,
extradural abscess, meningitis, brain abscess or lateral sinus thrombophlebitis.