1. C ASE PRESENTATION Presented by: Dr Nitha George

2. Ajjaiah 14yrs Male Hindu Student (9 th grade) Holakere, Chitradurga

3. C HIEF COMPLAINTS Right ear discharge since 3 years

4. H ISTORY OF PRESENTING ILLNESS Right ear discharge Since 3years Insidious in onset Intermittent ( one episode per month) Each episode last for 5-7 days Moderate amount, sticky white with yellow tinge, foul smelling, not blood stained Aggravated with episodes of common cold Relieved with oral medications (details unavailable) Last episode 1week back lasting for 3days Relieved temporarily with oral medications

5. Decreased hearing in right ear Since 3years Following onset of right ear discharge Insidious in onset Gradually progressive Was able to appreciate whispers well 3yrs back At present can only perceive loud noises in right ear Hearing worsens during episodes of active discharge

6. Ringing sensation of right ear since 3 years Insidious in onset Intermittent Low pitched humming voice Lasting throughout the episode of discharge Aggravated during active discharge and relieved with its resolution.

7. No h/o Fever Headache / vomiting Unconsciousness / Neck stiffness Earache Visual disturbances Speech problems No h/o postaural swelling associated with fever No h/o Giddiness Deviation of angle of mouth No h/o trauma Not h/o excessive sneezing/ excessive nasal discharge / postnasal drip/ bleeding from nose/ facial pain.

8. P AST HISTORY Chronic adenotonsillitis for which he underwent ADENOTONSILLECTOMY under general anaesthesia on 3/6/2013 No history of: Prolonged hospital admissions Juvenile DM / HTN Allergy / Bronchial asthma / TB Previous blood transfusions / drug allergies Epilepsy

9. T REATMENT HISTORY Used oral medications every month for one week during episodes of ear discharge (Details not available) One week of postop medications last week T. Cefpodoxime 100mg BD for 5days Analgesic Syrup (Aceclofenac 50mg and paracetamol 100mg)10ml BD

10. F AMILY HISTORY No similar complaints in the family

11. P ERSONAL HISTORY Appetite: Good Diet: Mixed Bowel and bladder : Regular Sleep: Adequate Habits -Nil

12. G ENERAL EXAMINATION 14yr old male pt Moderately built n nourished Conscious, cooperative and well oriented to time, place and person. Vitals Afebrile BP : 100 / 70mm Hg PR : 76 bpm RR : 16/min Pallor Icterus Cyanosis Clubbing Lymphadenopathy Pedal edema NIL

13. S YSTEMIC EXAMINATION CVS : S1 S2 + No murmers RS : Bilateral NVBS No added sounds P/A: Soft, non tender No organomegaly CNS: Normal

14. L OCAL EXAMINATION EARRightLeft Preauricular regionNormal PinnaNormal Postauricular regionNormal External auditory canalScanty, green foulsmelling discharge Normal

15. T YMPANIC MEMBRANE Seigelization : Right – No mobility Left Tympanic membrane moving well Cholesteatoma debris in the anterior attic Moderate size central perforation in the posterior quadrant Smooth regular anterior, superior and posterior margins Inferior margin not seen Active mucopurulent discharge in middle ear Cone of light absent Grade I retraction of pars tensa Prominent lateral process of malleus Anterior quadrant of TM hidden behind anterior canal bulge Rest of tympanic membrane congested Foreshortening of handle of malleus

16. C ONTD … Facial nerveNormal Fistula signNegative Mastoid tendernessAbsent Tuning fork tests ( 512 Hz) Rinnes NegativePositive WebersLateralised to the right Absolute bone conductionEqual to the examiner

17. N OSE External appearance: Normal Vestibule : Normal Anterior rhinoscopic examination: Mucosa normal Septum normal with septal spur on left side Lateral wall –HIT Floor - Normal Cold spatula test : Bilaterally equal fogging Paranasal sinus : Non tender PRE : Normal

18. O RAL CAVITY Normal

19. O ROPHARYNX Posterior pharyngeal wall : Normal Indirect laryngoscopy: Normal NECK: Bilateral jugulodigastric lymph nodes palpable RightLeft Anterior pillarNormal TonsilHealthy tonsillar fossae Posterior pillarNormal RightLeft 2 in number 2*1 cms each 2 in number 2*1 cms each Non tender, firm, mobile

20. P ROVISIONAL DIAGNOSIS Right chronic otitis media, active squammous, with conductive hearing loss without any complications with bilateral hypertrophy of inferior turbinates.

21. I NVESTIGATIONS Otoscope Otomicroscopy PTA: Right 66.6db (Moderately severe CHL) Left 21.66 db Xray B/L mastoid (Schullers view) Xray PNS (Waters view) Blood Urine routine ECG Chest Xray PA view

22. F URTHER MANAGEMENT Tympanoplasty with intact canal wall / canal wall down mastoidectomy (intraop )

23. THANK YOU