Ear Disorders Clinical Presentation PDF

Patient Presentation of ENT Ears Cerumen impaction: ​ Subjective ○​ HPI: ​ A 75-year-old male presents with a two-week history of decreased hearing in the left ear. He reports a sensation of...

Patient Presentation of ENT Ears Cerumen impaction: ​ Subjective ○​ HPI: ​ A 75-year-old male presents with a two-week history of decreased hearing in the left ear. He reports a sensation of fullness and occasional mild discomfort but denies any significant pain, fever, or drainage. The symptoms began gradually after he used cotton swabs for ear cleaning. He denies recent illness, swimming, or trauma to the ear. No history of similar symptoms in the past. ○​ Pertinent social: ​ None pertinent; frequently uses earbuds ​ Objective ○​ Pertinent PE: ​ AS: EAC occluded w hard, dark cerumen plug. T.M. not visible. No erythema, swelling, signs of infection ​ Weber: lateralizes to AS ​ Rinne: B>A on AS ​ Plan ○​ Attempted removal (because pt is symptomatic) w cerumenolytic, irrigation, or manually ○​ Educate to avoid Q-tips ○​ Refer to ENT if impaction cannot be removed ○​ Routine cleanings by healthcare professional q6-12 months Otitis externa (swimmer’s ear): ​ Subjective ○​ HPI: ​ A 7-year-old female presents with a five-day history of progressive ear pain in the right ear. She describes the pain as sharp and worse with touching or pulling on the ear. There is associated pruritus and a feeling of fullness in the ear. She reports mild clear discharge from the ear but denies hearing loss, fever, or recent trauma. Symptoms began after swimming during a recent beach vacation. She has tried over-the-counter pain relievers with limited relief. ○​ Pertinent PMH: ​ Hx of seasonal allergies ○​ Pertinent social: ​ Swims recreationally ​ Objective ○​ Pertinent PE: ​ AD: EAC edema and erythema. Purulent discharge. Pain w manipulation of tragus & auricle. T.M. difficult to visualize, but no obvious perforation. ​ Assessment ○​ OE due to pseudomonas aeruginosa, staphylococcus epidermis, or staphylococcus aureus ○​ Differentials: Fungal otitis externa (aspergillus, candida species) ​ Plan ○​ If mild: topical acidifying agent + glucocorticoid x 7 days ○​ If moderate: topical antibiotic + glucocorticoid x 7 days ○​ If severe: topical antibiotic + glucocorticoid x 7 days (less: levofloxacin; more: vancomycin) ○​ Counsel to protect ear while recovering; refrain from water sports x 7-10 days Malignant external otitis: ​ Subjective ○​ HPI: ​ A 72-year-old male with a history of poorly controlled diabetes mellitus presents with a three-week history of severe right ear pain and drainage. The pain is described as deep and throbbing, radiating to the jaw and neck. He also reports difficulty chewing due to pain. Symptoms began gradually and have worsened, despite using over-the-counter ear drops. The patient has noted intermittent fevers and night sweats but denies dizziness or hearing loss. He reports previous episodes of swimmer's ear, but this feels "much worse." ○​ Pertinent PMH: ​ DM II, HTN ​ Objective ○​ Pertinent PE: ​ Vitals: 100.8ºF temp, BP 140/85 ​ Edema & tenderness to R preauricular area, trismus ​ AD erythema, edema, granulation in EAC. Purulent discharge. Manipulation of auricle elicits severe pain. T.M. not visualized ​ Assessment ○​ MOE due to pseudomonas aeruginosa ​ Plan ○​ Culture of drainage, biopsy of granulations, CT/MRI/bone scan to determine severity ○​ 1-6 months PO/IV antibiotics FB in EAC: ​ Subjective ○​ HPI: ​ A 6-year-old boy is brought to the clinic by his mother, who reports that the child inserted a small bead into his right ear while playing two days ago. He initially complained of mild discomfort and said he could feel "something in his ear." Over the past day, he has become increasingly irritable, and his mother noticed a foul-smelling discharge from the affected ear. He denies hearing loss, dizziness, or fever. ​ Objective ○​ Pertinent PE: ​ AD reveals shiny, round object lodged in EAC. EAC erythematous w edema. Purulent discharge noted, no visible T.M. perforation ​ Plan ○​ ASSESS OTHER EAR & NOSE ○​ Irrigate (unless pt has T-tubes, perforated T.M., veggie matter, or button battery) ○​ Refer to ENT for button batteries, live insects, penetrating FBs, glass, etc. Acute otitis media (AOM): ​ Subjective ○​ HPI: ​ A 4-year-old girl is brought to the clinic by her father with complaints of right ear pain for the past two days. The child has been pulling at her right ear. Her symptoms began following three-day nasal congestion and low-grade fever, which started after exposure to a classmate with a cold. The father reports decreased appetite and difficulty sleeping but denies vomiting, diarrhea, or rash. ○​ Pertinent PMH: ​ Hx of seasonal allergies ​ Objective ○​ Pertinent PE: ​ 100.4ºF. AD T.M. bulging & erythematous. Painful mobility of T.M. ​ Assessment ○​ AOM due to streptococcus pneumonia (most commonly) ​ Plan ○​ W/O T.M. perforation ​ Child ​ Observation (48-72 hrs) and/or antibiotics + ibuprofen (or APAP) (at risk children & A AS ​ Assessment ○​ COM due to P. aeruginosa, proteus species, or S. aureus ​ Plan ○​ Remove infected debris (if necessary) ○​ Counsel to wear ear plugs at work ○​ Topical antibiotic drops (ciprofloxacin or oflaxacin) x 2-4 weeks Otitis media w effusion (OME): ​ Subjective ○​ HPI: ​ A 5-year-old boy is brought to the clinic by his mother, who is concerned about his reduced hearing over the past month. She has noticed that he often turns up the volume on the television and asks others to repeat themselves. The child denies pain, ear discharge, or fever. There is a history of nasal congestion and a cold about six weeks ago, but no recent ear infections. The mother reports the child occasionally complains of a "full feeling" in his ears but has no dizziness. ○​ Pertinent PMH: ​ Hx of recurrent URI ○​ Pertinent social: ​ Attends kindergarten ​ Objective ○​ Pertinent PE: ​ AU T.M. dull & retracted w loss of normal light reflex. Limited mobility of T.M. on pneumatic otoscopy. Visible bubbles in middle ear. Nasal mucosa congested w/o purulent discharge. ​ Whisper test: reduced response ​ Plan ○​ Child ​ Watchful waiting if not at risk for speech/learning problems (most resolve within 3-6 months) ​ T-tubes if at risk, T.M. changes, persistent HL ○​ Adult ​ Mild: no treatment ​ More: auto-insufflation ​ Moderate (due to seasonal allergies): short term antihistamines, PO decongestants, nasal steroids ​ Moderate (due to URI): short term nasal saline, PO decongestants, nasal steroids Cholesteatoma: ​ Subjective ○​ HPI: ​ A 42-year-old male presents with chronic foul-smelling discharge from his left ear for the past six months. He reports progressive hearing loss on the same side and occasional mild ear discomfort but denies acute pain, vertigo, or tinnitus. Symptoms began after a recurrent ear infection that resolved incompletely with over-the-counter treatments. He also notes a feeling of fullness in the left ear but denies systemic symptoms like fever or weight loss. ○​ Pertinent PMH: ​ Hx of recurrent otitis media during childhood ​ Hx of T-tube placement in childhood ○​ Pertinent social: ​ Works as a carpenter w frequent exposure to dust & loud noise ​ Objective ○​ Pertinent PE: ​ AS: foul-smelling discharge in EAC, T.M. retracted w visible white keratin debris, granulation tissue, no erythema/bulging ​ Weber: lateralizes AS ​ Rinne: B>A AS ​ Assessment ○​ Cholesteatoma due to ETD (or T.M. perforation in adults) ​ Plan ○​ Refer to ENT for potential surgery Eustachian tube dysfunction (ETD): ​ Subjective ○​ HPI: ​ A 28-year-old female presents with a three-week history of fullness and mild hearing loss in her right ear. She describes intermittent "popping" sensations and a feeling as if the ear is underwater. Symptoms began after a recent upper respiratory infection that resolved a week ago. She denies ear pain, discharge, fever, vertigo, or tinnitus. She reports that symptoms are worse with changes in altitude, such as during a recent flight. ○​ Pertinent PMH: ​ Seasonal allergic rhinitis ○​ Pertinent social: ​ Flew out of state recently ​ Objective ○​ Pertinent PE: ​ AD: T.M. mildly retracted w visible prominence of malleus. Dull appearance of T.M. w decreased mobility on insufflation. No perforation or erythema ​ Weber: lateralizes AD ​ Assessment ○​ ETD secondary to recent URI & allergic rhinitis (other causes: laryngopharyngeal reflux, lesion) ​ Plan ○​ Treat allergic rhinitis: trigger avoidance, PO/topical antihistamines, intranasal steroids ○​ Treat rhinosinusitis: nasal steroid, sinus rinse, nasal decongestant, antibiotics, pain meds Acoustic neuroma: ​ Subjective ○​ HPI: ​ A 45-year-old female presents with a six-month history of gradual hearing loss in her right ear. She describes difficulty understanding conversations in noisy environments and a persistent "ringing" sound in the affected ear. Over the past month, she has also noticed episodes of mild dizziness and unsteadiness but denies vertigo, nausea, or vomiting. She has no history of ear pain, discharge, or acute illness. The patient reports no significant headache, facial numbness, or weakness. ​ Objective ○​ Pertinent PE: AU EAC & T.M. normal ○​ Weber: lateralizes to AS ○​ Gait mildly unsteady. CNs intact. ○​ Negative Romberg sign ​ Plan ○​ MRI/CT ○​ Refer to ENT/neuro for observation, microsurgery, or radiotherapy Benign paroxysmal positional vertigo (BPPV): ​ Subjective ○​ HPI: ​ A 62-year-old female presents with a two-week history of brief episodes of dizziness triggered by positional changes, such as rolling over in bed, looking up, or bending down. She describes the dizziness as a spinning sensation lasting less than a minute, often accompanied by nausea but no vomiting. The episodes occur multiple times a day, and she has no associated headache, hearing loss, tinnitus, or ear fullness. She denies recent illness, trauma, or similar symptoms in the past. ○​ Pertinent PMH: ​ Controlled HTN ​ Objective ○​ Pertinent PE: ​ AU T.M. & EAC normal ​ CNs intact. Normal strength & sensation in extremities. Negative Romberg. ​ Positive R sided Dix-Hallpike; brief latency followed by vertical nystagmus lasting A on AS ​ Plan ○​ MRI/CT (if not obvious cause), glucose, CBS, TSH, serologic testing Sensorineural hearing loss (presbycusis): ​ Subjective ○​ HPI: ​ A 72-year-old male presents with gradually worsening hearing loss over the past two years. He describes difficulty understanding speech, particularly in noisy environments or when multiple people are talking. He often asks others to repeat themselves and finds that increasing the volume on the television or phone helps, though others complain it’s too loud. He denies ear pain, drainage, vertigo, or tinnitus. The patient reports that the problem affects both ears equally and has been progressively worsening. He has no history of ear infections, trauma, or exposure to loud noise. ○​ Pertinent PMH: ​ Controlled HTN ​ Controlled DM ○​ Pertinent social: ​ Former smoker (20 pack-years, quit 15 yrs ago) ​ Objective ○​ Pertinent PE: ​ All testing normal ​ Plan ○​ MRI/CT (if not obvious cause), glucose, CBS, TSH, serologic testing ○​ Refer to audiology for hearing aids External ear neoplasms: ​ Malignant (SCC) ○​ Biopsy ​ Benign (adenomatous tumor from ceruminous gland Middle ear neoplasms: ​ Rare, possible glomus tumor ○​ Pulsatile, tinnitus, HL ○​ Mass may be present behind T.M. ○​ May have CN neuropathies ○​ May warrant MRA & MRV to r/o vascular mass Inner ear neoplasms: ​ Acoustic neuroma (vestibular schwannoma) ○​ MRI ○​ Observe, surgery, and/or radiation