10/16/24, 10:29 100 cases
AM ENT
100 CASES IN EAR, NOSE & THROAT
by
Prof Dr Hassan Wahba
Professor of OtoRhinoLaryngology
Faculty of Medicine Ain Shams University
Case 1: A 10 year old child was having a right mucopurulent otorhea for the last 4
years. A week ago he became dizzy with a whirling sensation, nausea, vomiting and
nystagmus to the opposite side; his deafness became complete and his temperature
was normal. Three days later he became feverish, irritable and continuously crying
apparently from severe headache. Also he had some neck retraction. The child was
not managed properly and died by the end of the week.
CASE 1
Diagnosis &
Right chronic suppurative otitis media (mucopurulent otorhea of 4 years
reasons
duration) complicated by suppurative labyrinthitis (dizziness, nausea and
vomiting with nystagmus to the opposite side and complete loss of hearing)
and then complicated by meningitis (fever, severe headache and neck
retraction).
Explain the
Whirling sensation: vertigo due to inner ear inflammation
following
Nystagmus to the opposite side: suppurative labyrinthitis leading to fast
manifestations
phase of eye movement to the opposite ear and slow phase to the diseased
ear nystagmus direction is called according to the fast phase. In serous
labyrinthitis with no inner ear cell destruction the direction of nystagmus
is toward the diseased ear.
Severe headache: increased intracranial pressure due to meningitis
Neck retraction: due to meningeal inflammation
Further Otologic examination possible finding of a marginal perforation of
examination
atticoantral CSOM (cholesteatoma)
&/or Audiogram to reveal SNHL in the affected ear
investigations Kernig's and Brudzinski's signs
Fundus examination to show papilledema
about:blan 1/
k 100
,10/16/24, 10:29 100 cases
AM ENT
Lumbar puncture: turbid high pressure CSF with pus rich in
proteins
Complete blood picture
Treatment Antibiotics that cross the blood brain barrier
Analgesics
Repeated lumbar puncture to drain infected CSF and to relieve symptoms
and to inject antibiotics
Treaetment of the underlying otitis media appropriately according to its
type
Case 2: A 50 year old male patient complained of right earache of 2 days duration.
The pain was especially severe on chewing food and during speech. There was also
marked edema of the right side of the face. On examination, pressure on the tragus
was painful; and there was a small red swelling arising from the anterior external
auditory meatal wall. Rinne test was positive in the right ear. The patient gave a
history of 2 previous similar attacks in the same ear during the last six months but
less severe.
CASE 2
Diagnosis & Recurrent furunculosis of the right external auditory canal (pain in the ear
reasons with movements of the temporomandibular joint or pressure on the tragus,
edema of the face and a small red swelling in the anterior wall of the
external auditory canal)
Explain the Severe pain on chewing food: movements of the temporomandibular joint
following lead to movements of the cartilaginous external auditory canal that is
manifestations lined by skin containing hair follicles from which the furuncle arises.
Edema of the right side of the face: extension of the inflammatory edema
to the face in severe cases
Rinne positive: means normal hearing and NO conductive hearing loss
because when air conduction is better than bone conduction it is called
Rinne positive
Previous similar attacks: recurrence the most probable cause is
Diabetes mellitus
about:blan 2/
k 100
,10/16/24, 10:29 100 cases
AM ENT
Further Otoscopic examination of the tympanic membrane if
examination possible Blood glucose analysis to discover diabetes
&/or
investigations
Treatment Antibiotics
Analgesics
Never incise or excise for fear of perichondritis
Local antibiotic or glycerine icthyol ointment
Proper control of diabetes if discovered
Case 3: A 10 year old child complained of a right mucopurulent otorhea for the last 2
years. He suddenly became feverish and this was associated with diminution of the
ear discharge. There was also tenderness on pressure behind the auricle. The
retroauricular sulcus was preserved. There was no retroauricular fluctuation.
CASE 3
Diagnosis &
Right chronic suppurative otitis media (mucopurulent discharge of 2 years
reasons
duration) complicated by mastoiditis (fever with decreased ear discharge,
tenderness behind the auricle with preservation of retroauricular sulcus; it is
not an abscess because there is no retroauricular fluctuation).
Explain the
Diminution of ear discharge: reservoir sign dischrge decreases but is still
following
there and whenever discharge decreases fever and other constitutional
manifestations
symptoms increase in intensity
Tenderness behind the auricle: due to inflammation of the bone of the
mastoid process and its overlying periosteum
Retroauricular sulcus preserve: as the inflammatory process is
subperioteal No retroauricular fluctuation: it is mastoiditis and so is not a
mastoid abscess yet
Further Otoscopic examination of the ear possible finding of a
examination
cholesteatoma
&/or Look for the rest of the manifestations of mastoiditis as sagging of
investigations
the posterosuperior wall of the bony external auditory canal
CT scan of the ear to show opacity in the mastoid bone
about:blan 3/
k 100
, 10/16/24, 10:29 100 cases
AM ENT
Complete blood picture
Treatment Medical treatment in the form of antibiotics and
Drainage of the ear through myringotomy and
Mastoidectomy is essential to remove all disease from the ear
Case 4: A 9 year old child has been complaining of right continuous offensive ear
discharge for the last 3 years. A month ago he began to suffer from headache, fever
and some vomiting for which he received symptomatic treatment. The patient’s
condition was stable for a while, then after 2 weeks he started to suffer from severe
headache and drowsiness. The patient also noticed difficulty going up and down the
stairs. A week later, he developed weakness in the left arm and left leg, and became
markedly drowsy. He became comatose the next day.
CASE 4
Diagnosis &
Right atticoantral (cholesteatoma) chronic suppurative otitis media
reasons
(continuous offensive ear discharge for 3 years) complicated by right
temporal lobe abscess (manifestations of increased intracranial tension with
weakness in the opposite side of the body on the left arm and leg)
Explain the
Initial headache fever and vomiting: indicates the initial stage of a brain
following
abscess formation in the stage of encephalitis
manifestations
Stable condition of 2 weeks: latent phase of brain abscess with decreased
symptoms
Severe headache and vomiting after 2 weeks: manifestations of a formed
brain abscess leading to increased intracranial tension
Difficulty going up and down the stairs: due to hemipareisis (weakness) in
the opposite left leg to the diseased ear
Comatose: final stage of brain abscess
Further Otoscopic examination of the ear
examination CT scan with contrast to locate the brain abscess
&/or Complete blood picture to show leucocytosis very good to know
investigations
prognosis with treatment
Fundus examination to show papilledema
Treatment Antibiotics that cross the blood brain barrier
about:blan 4/
k 100
AM ENT
100 CASES IN EAR, NOSE & THROAT
by
Prof Dr Hassan Wahba
Professor of OtoRhinoLaryngology
Faculty of Medicine Ain Shams University
Case 1: A 10 year old child was having a right mucopurulent otorhea for the last 4
years. A week ago he became dizzy with a whirling sensation, nausea, vomiting and
nystagmus to the opposite side; his deafness became complete and his temperature
was normal. Three days later he became feverish, irritable and continuously crying
apparently from severe headache. Also he had some neck retraction. The child was
not managed properly and died by the end of the week.
CASE 1
Diagnosis &
Right chronic suppurative otitis media (mucopurulent otorhea of 4 years
reasons
duration) complicated by suppurative labyrinthitis (dizziness, nausea and
vomiting with nystagmus to the opposite side and complete loss of hearing)
and then complicated by meningitis (fever, severe headache and neck
retraction).
Explain the
Whirling sensation: vertigo due to inner ear inflammation
following
Nystagmus to the opposite side: suppurative labyrinthitis leading to fast
manifestations
phase of eye movement to the opposite ear and slow phase to the diseased
ear nystagmus direction is called according to the fast phase. In serous
labyrinthitis with no inner ear cell destruction the direction of nystagmus
is toward the diseased ear.
Severe headache: increased intracranial pressure due to meningitis
Neck retraction: due to meningeal inflammation
Further Otologic examination possible finding of a marginal perforation of
examination
atticoantral CSOM (cholesteatoma)
&/or Audiogram to reveal SNHL in the affected ear
investigations Kernig's and Brudzinski's signs
Fundus examination to show papilledema
about:blan 1/
k 100
,10/16/24, 10:29 100 cases
AM ENT
Lumbar puncture: turbid high pressure CSF with pus rich in
proteins
Complete blood picture
Treatment Antibiotics that cross the blood brain barrier
Analgesics
Repeated lumbar puncture to drain infected CSF and to relieve symptoms
and to inject antibiotics
Treaetment of the underlying otitis media appropriately according to its
type
Case 2: A 50 year old male patient complained of right earache of 2 days duration.
The pain was especially severe on chewing food and during speech. There was also
marked edema of the right side of the face. On examination, pressure on the tragus
was painful; and there was a small red swelling arising from the anterior external
auditory meatal wall. Rinne test was positive in the right ear. The patient gave a
history of 2 previous similar attacks in the same ear during the last six months but
less severe.
CASE 2
Diagnosis & Recurrent furunculosis of the right external auditory canal (pain in the ear
reasons with movements of the temporomandibular joint or pressure on the tragus,
edema of the face and a small red swelling in the anterior wall of the
external auditory canal)
Explain the Severe pain on chewing food: movements of the temporomandibular joint
following lead to movements of the cartilaginous external auditory canal that is
manifestations lined by skin containing hair follicles from which the furuncle arises.
Edema of the right side of the face: extension of the inflammatory edema
to the face in severe cases
Rinne positive: means normal hearing and NO conductive hearing loss
because when air conduction is better than bone conduction it is called
Rinne positive
Previous similar attacks: recurrence the most probable cause is
Diabetes mellitus
about:blan 2/
k 100
,10/16/24, 10:29 100 cases
AM ENT
Further Otoscopic examination of the tympanic membrane if
examination possible Blood glucose analysis to discover diabetes
&/or
investigations
Treatment Antibiotics
Analgesics
Never incise or excise for fear of perichondritis
Local antibiotic or glycerine icthyol ointment
Proper control of diabetes if discovered
Case 3: A 10 year old child complained of a right mucopurulent otorhea for the last 2
years. He suddenly became feverish and this was associated with diminution of the
ear discharge. There was also tenderness on pressure behind the auricle. The
retroauricular sulcus was preserved. There was no retroauricular fluctuation.
CASE 3
Diagnosis &
Right chronic suppurative otitis media (mucopurulent discharge of 2 years
reasons
duration) complicated by mastoiditis (fever with decreased ear discharge,
tenderness behind the auricle with preservation of retroauricular sulcus; it is
not an abscess because there is no retroauricular fluctuation).
Explain the
Diminution of ear discharge: reservoir sign dischrge decreases but is still
following
there and whenever discharge decreases fever and other constitutional
manifestations
symptoms increase in intensity
Tenderness behind the auricle: due to inflammation of the bone of the
mastoid process and its overlying periosteum
Retroauricular sulcus preserve: as the inflammatory process is
subperioteal No retroauricular fluctuation: it is mastoiditis and so is not a
mastoid abscess yet
Further Otoscopic examination of the ear possible finding of a
examination
cholesteatoma
&/or Look for the rest of the manifestations of mastoiditis as sagging of
investigations
the posterosuperior wall of the bony external auditory canal
CT scan of the ear to show opacity in the mastoid bone
about:blan 3/
k 100
, 10/16/24, 10:29 100 cases
AM ENT
Complete blood picture
Treatment Medical treatment in the form of antibiotics and
Drainage of the ear through myringotomy and
Mastoidectomy is essential to remove all disease from the ear
Case 4: A 9 year old child has been complaining of right continuous offensive ear
discharge for the last 3 years. A month ago he began to suffer from headache, fever
and some vomiting for which he received symptomatic treatment. The patient’s
condition was stable for a while, then after 2 weeks he started to suffer from severe
headache and drowsiness. The patient also noticed difficulty going up and down the
stairs. A week later, he developed weakness in the left arm and left leg, and became
markedly drowsy. He became comatose the next day.
CASE 4
Diagnosis &
Right atticoantral (cholesteatoma) chronic suppurative otitis media
reasons
(continuous offensive ear discharge for 3 years) complicated by right
temporal lobe abscess (manifestations of increased intracranial tension with
weakness in the opposite side of the body on the left arm and leg)
Explain the
Initial headache fever and vomiting: indicates the initial stage of a brain
following
abscess formation in the stage of encephalitis
manifestations
Stable condition of 2 weeks: latent phase of brain abscess with decreased
symptoms
Severe headache and vomiting after 2 weeks: manifestations of a formed
brain abscess leading to increased intracranial tension
Difficulty going up and down the stairs: due to hemipareisis (weakness) in
the opposite left leg to the diseased ear
Comatose: final stage of brain abscess
Further Otoscopic examination of the ear
examination CT scan with contrast to locate the brain abscess
&/or Complete blood picture to show leucocytosis very good to know
investigations
prognosis with treatment
Fundus examination to show papilledema
Treatment Antibiotics that cross the blood brain barrier
about:blan 4/
k 100
