Lisa Gagnon, APRN Connecticut Pediatric Otolaryngology 7 th Annual Symposium October 4, 2012
11y/o female presents to ENT clinic…. Several years of otalgia associated with recurrent otorrhea (clear, then malodorous,yellow) Reported intermittent tinnitus, hearing loss R>L Multiple antibiotic drops, systemic Rx- no benefit Denied Vertigo/headache PMH- recurrent AOM as infant. Lead exposure requiring chelation, eczema. ?Allergies
Auricles- normal, no tenderness w/manipulation EAC’s with medial watery discharge, erythema TM’s intact/clear RX Vosol, then ½ strength vinegar/water Next month: ↑ scaling, erythema of canal- extending into conchal bowl. HT – Bilateral mixed mod-severe HL, nl tymps RX - 1/2str vinegar, external ear moisturization changed to steroid cream/moisturization & dermotic CT scan temporal bones ordered
6mo later (next visit) reported hx ear swelling unresponsive to prior treatments prescribed. Exam: minimal EAC wall changes ?fungal RX: Fluconazole-atomized →1 mo later – did not use fluconazole, reported use of steroid cream topically, felt hearing was nl Exam: normal ear exam- repeat audio wnl
Next few months…. would flare with erythema, itching, pain, dng, some swelling, primarily of distal canal, ears clogged ? Eczema vs. psoriasis component. Rx: repeated cleanouts, dermotic, aquaphor, steroid creams. Dermatology referral
Had Dermatology Evaluation completed- Looked good that day- “return when flares” ?Psoriasis vs. eczema Variety of creams prescribed (protopic, clobetasone, derma-smoothe) At that visit felt ears were clogged again…. Much of the same exam, findings. Rx steroid cream, return to dermatology, HT
Placed on clindamycin and prednisone by ED ENT Clinic next day – swelling of auricle without significant tenderness or erythema, lobule spared Canal walls with scaling and mild erythema, TM’s clear
Skin Biopsy (by Dermatology) showed superficial and deep perivascular and interstitial lymphohistiocytic infiltrate and mild spongiosis and parakeratosis, consistent with dermatitis, possibly allergic contact dermatitis Panel of 50 visiting dermatogists convened No identified etiology/allergen
Similar to last flare, seen in ENT clinic Now reporting headache preceeding episodes & ringing in ears EAC’s with similar findings- scaling/erythema, debris Bilateral SNHL (mod-severe) High dose steroid Rx Labs- CBC, ANA, ESR Rheumatology referral
Labs- CBC, Metabolic, LFT’s, ESR, Thyroid, muscle function, ANA, DNA, ENA screen, complement, IgG, IgA, rheumatoid factor, anti-CCP, CRP, ANCA CXR- Wnl Echo- Wnl
Relapsing Polychondritis Began Methotrexate 12.5mg weekly, Folic Acid Close weekly to monthly follow-ups Now increased to MTX 15mg weekly
Patient doing excellent! ABR completely normal (6/2012) No Flares Labs stable
Relapsing Polychondritis
Chronic otitis externa unresponsive to conventional therapies deserves further workup If external ear inflammation spares the lobule, consider diagnosis of relapsing polychondritis SNHL requires further workup and treatment Evaluate for further high risk associated manifestations