Case Report

Day/Date : Monday/March 27th 2023

Doctors on duty : Redza/If-Zazi-Nissa/Stevy-Ahmad
Senior clerkship : Puji-Siti-Muthia
Consultant : AL Hafiz, MD, ORL-HNS (C)
Department of Otorhinolaryngology Head and Neck Surgery
Faculty of Medicine Andalas University/Dr. M. Djamil Hospital
Padang
 Identity of Patient
Female, 44 years old

Chief Complaint

Pain at the left ear since 3 hours before admission

 Medical History
Previously, patient was scratching his left ear canal
using cotton bud 1 week ago. After that he felt pain
at the left ear, then she went to private hospital and
got medication. Patient forgot the name of the
medicines. Because the pain was getting worse the
patient went to emergency room of Dr. M. Djamil
Hospital Padang
There was fullness sensation of the left ear since 1
day ago
 Medical History
There were no blood or discharge came out from the
ear
There was no history of discharge or blood came out
from the ear
There was no decrease of hearing
There was habit cleaning the ear canal using a cotton
bud
There were no history of traveling to high land or by
airplane in last few days
 Medical History
There were no history of swimming or diving
There were no fever, cold and cough
 General Examination
General condition was good, composmentis cooperative

BP : 122/68 mmHg
PR : 98 x/minutes
RR : 20 x/minutes
T : 37.6 oC
 ENT Examination
Ear
Right
Auricle : pain on pressing the tragus (-)
pain on pulling the pinna (-)

Ear canal was wide, tympanic membrane was intact,

cone of light (+)
 ENT Examination
Ear
Left
Auricle : pain on pressing the
tragus (+), pain on pulling the
pinna (+), Ear canal was
narrow, edema (+) at 1/3
lateral of ear canal, hyperemic
(+), fluctuative (+), tympanic
membrane couldn’t be
evaluated, discharge (-)
 ENT Examination
Nose
Right nasal cavity
Nasal cavity was wide, inferior and middle turbinate
were eutrophy, discharge (-), septal deviation (-)

Left nasal cavity

Nasal cavity was wide, inferior and middle turbinate
were eutrophy, discharge (-), septal deviation (-)
 ENT Examination
Throat
Pharyngeal arch was symmetric, uvula in the
midline, tonsil T1-T1 not hyperemic, posterior
pharyngeal wall was not hyperemic
 Working Diagnosis
Working • Otitis externa circumscripta at the left
Diagnosis ear
ICD X • Unspecified otitis external left ear
(H60.91)
 Management
Ear toilet
Informed consent to do incision and drainage the
furuncle  patient agreed
Incision and drainage the furuncle  succeeded, pus
(+) ± 1 cc
 Management
Evaluation
Left Ear : Ear canal was
narrow, edema (+) at 1/3
lateral of ear canal,
hyperemic (+), tympanic
membrane couldn’t be
evaluated, discharge (-)
 Management
Informed consent to do ear packing  patient
agreed
Ear packing + betamethasone 0,1% + neomycin
sulphate 0,5%  succeeded
Therapy :
- Ofloxacin 0,3% ear drops 2x5 drops at left ear
- Ibuprofen 3x400 mg (Orally)
- Ciprofloxacin 2x500mg (Orally)
Control to ORL-HNS Outpatient Clinic 2 days later for
evaluation and removal ear packing
THANK YOU
References