Case presentation

1. CASE PRESENTATION ON
COM SQUAMOSAL TYPE,
WITH OTOGENIC BRAIN
ABSCESS.
DR. SANJAY MAHARJAN
1ST YR RESIDENT, ENT-HNS,
MTH.

2. PARTICULARS OF THE
PATIENT:
7yr/F
Firfire – 9, Tanahu
Hospital no. : 74012465
DOA : 07-9-2017

3. CHIEF COMPLAINTS :
• Right Ear discharge for 3yrs
• Headache for 15 days
• Fever and irritable for 3 days

4. HISTORY OF PRESENT ILLNESS:
Right ear discharge:
Since 3years
Insidious in onset
Continuous
Scanty, sticky white with yellow tinge, foul smelling, not
blood stained
Aggravated in cold and rainy seasons
Relieved with oral & topical medications
Last episode – 2 wks back as/w fever and headache

5. Fever:
Continuous
Max recorded 1030F
Not as/w chills and rigor
As/w irritability and few episodes of vomiting
Decreased hearing in Right Ear:
Since 3 yrs
Following onset of right ear discharge
Insidious in onset
Gradually progressive

6. No history of:
Tinnitus
Vertigo
Visual disturbances
Speech problems
Post-aural swelling
Giddiness
Deviation of angle of mouth
Trauma
Excessive sneezing, nasal discharge, postnasal drip or
epistaxis or facial pain.

7. • With these complains pt was taken to a local hospital
where some topical and oral antibiotics was prescribed.
• The symptoms worsened in following few days, high
grade fever, anorexia, nausea and vomiting.
• Pt became irritable
• Pt was then brought to emergency dept of MTH for
further Mx and Rx

8. PAST HISTORY:
• NVD term deliver, 2.5 kg in health post.
• Time and again visit to local hospital for ear ache
and discharge.
• No history of DM, HTN, TB

9. DRUG HISTORY:
• Not known to be allergic to any drugs
• Used oral & topical medications almost every month
for one week during episodes of ear discharge
(Details not available)

10. PERSONAL HISTORY:
 Appetite: decreased since onset of fever
 Diet: Mixed
 Bowel and bladder : Regular
 Sleep: Adequate
 Habits –Non smoker, non alcoholic

11. Family history:
No similar complains in family
Socio-economic history:
Poor

12. GENERAL
EXAMINATION:
GC : ill looking, irritable
Weight : 14 kg
BP : 110/80 mmHg
Temp : 100.5 F
RR : 16/min
Pulse : 89b/min

13. CNS examination :
GCS : E3V5M6 = 14/15
Plantar : B/l down going
Neck rigidity : +ve
Kernigs and Brudzinsky sign : -ve
CVS, Chest, P/A : within normal limits

14. LOCAL EXAMINATION:
Pre-auricular, pinna and post-
auricular region of b/l ear :
normal
Right ear:
EAC
• Scanty, greenish, foul smelling
discharge
• Red and fleshy polyp in
postero-superior quadrant of
bony EAC
• Granulations present along
with the polyp

15. Tympanic membrane:
• Medium sized perforation
in postero-superior
quadrant.
• Exposing whitish mass
and congested middle
ear mucosa
• Posterior margin of
perforation not visualized
• Rest of the TM
congested
• Prominent lateral process
of malleus

16. Facial nerve : intact
Mastoid tenderness :
absent
Tuning fork test and PTA :
inconclusive as pt was
irritable
Nose: NAD
Throat: NAD

17. INVESTIGATIONS:
WBC : 16000/cu.mm
Hb : 10.4 gm/dl
Platelets : 571,000/cu.mm
Urine R/E : WNL
RBS : 104 mg/dl
Urea : 28 mg/dl
Creatinine : 0.8 mg/dl
Sodium : 136 mEq/l
Potassium : 4.4 mEq/l
Serology : -ve
PT : 16.2s / INR : 1.2

18. IMAGING DATA:
CT head : a single hypodense lesion on Right occipital
lobe region. Dilated ventricles and prominent temporal
horns

19. DIAGNOSIS:
Right sided Active Chronic otitis
Media, squamosal type complicated
with otogenic brain abscess

20. DISCUSSION:
• Patient was prepared for undergoing emergency surgery
On 07-09-2017
Burr hole with evacuation of pus (by neurosurgery)
and mastoid exploration (by ENT-HNS) in same setting.
Findings :
• Findings from neurosurgery:
1. Thick, foul smelling, 4 ml of whitish pus from burr hole
and pus was sent for C/S

21. • Findings from Mastoid exploration surgery :
Surgery : Right MRM with type III tympanoplasty
Approach : Wilde’s post-auricular incision
Findings :
a) Polyp + granulations present in postero-superior
aspect of bony EAC
b) Bony defect in posterior EAC
c) Cholesteatoma present in attic, antrum and aditus
d) Middle ear mucosa inflammed and granulation
tissue present
e) Malleus head and stapes present but incus absent

22. CT SCAN AFTER SURGERY:

23. • Pus C/S report:
• Staph. Aureus isolated
• No resistance.

24. 7TH POST OPERATIVE DAY:
Suture from post auricular incision removed.
• Wound healthy and healed
Middle ear packing removed
• MRM cavity healing and healthy
• No discharge

25. HOSPITAL COURSE:
Patient admitted in neuro ICU under joint management of
dept of ENT-HNS and Neurosurgery and discharged on 01-10-
2017
Medication received:
• Inj. Ceftriaxone 1gm IV BD
• Inj. Ornidazole 500mg IV BD
• Inj. Gentamycin 40mg IV BD
• Inj. Ketorolac 15mg IV TDS
• Inj. Ranitidine 25mg IV BD
• Inj. Paracetamol 500mg IV TDS (alternate with ketorolac)
• Inj. Dexamethasone 4mg IV QID
• Ear drop Betnor 2drops TDS R-ear
• Alternate day dressing of post-auricual incision wound

26. Discharged date : 01-10-2017
Condition of patient on discharge was relatively better.
Following advice were given along with oral & topical
antibiotics, antihistamine and analgesics for 1 week
• Avoid water entry into operated ear, nose blowing,
flying/diving/swimming, lifting heavy objects/straining for
3 weeks.
• Mouth to be kept open during coughing & sneezing for 3
weeks.
• Review immediately in case of ear ache or discharge,
deviation of mouth, giddiness, sudden increase in
deafness and common cold and URTI
• f/up after 2 weeks

27. THANK YOU…