A 50yr-old Chinese man presents with 'fullness' and 'muffled' hearing of the left ear, associated with tinnitus (humming sound) for the past 3 months. He also has blood-stained nasal discharge and a neck swelling on the same side.
What is the name of this common ear condition?
How many signs of this ear condition can you spot on this otoscopic picture of the left tympanic membrane? (What are the others that are not present? There should be at least 10 in all).
What treatment would you offer to this man for his ear condition?
What is the most important underlying condition you must rule out?
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4 comments:
Mr Yap.. I'm gonna have a go at this question..
Hopefully I'm right la..
This common ear condition is otitis media with effusion ( glue ear / secretory otitis media )
IN this otoscopic picture,
- the tympanic membane is dull, yellowish
- it looks retracted
- there is some yellowish substance seen behind the tympanic membrane ( the air-fluid level cannot be visualize )
- there is horizontalization of the handle of malleus
- there are radial vessels seen surrouding the perifiries of the tympanic membrane.
What are the others that are not present
- the loss of cone of light
- lateral process of malleus becoming more prominent.
- bulging in the initial stage
- immobile tympanic membrane
Btw, i only got 9 la. :(
Treatment: myringotomy and grommet insertion
Since the man presented with only unilateral symptoms, examination of hte nasopharyx is essential to rule out nasopharyngeal carcinoma
Excellent jo. Well done. 9/10 is a distinction.
The 10th, which may or may not be present, is the presence of bubbles!
Yes, you are absolutely right in wanting to rule out NPC.
Reasons for that:
1) Age - 30-60 is the high risk group for NPC
2) Sex - Male:Female ratio in NPC is 2.8 to 1
3) Race - Chinese in Malaysia have the highest incidence of NPC
4) Unexplained OME of recent onset should always alert one to the possibility of NPC in our community
5) The other obvious tell-tale symptoms - neck swelling, blood-stained discharge - make the diagnosis a give-away!
This otoscopic picture, is in fact from one such patient.
i think it's NPC.
There is a strong history that suggest NPC. An middle age to elderly, male, Chinese, presented with tinnitus and neck swelling (a far more common presentation for NPC). Knowing that it's unilateral lesion, NPC should be rule out.
The otoscopic examination releaved tympanic membrane retractions, with some yellowish substances behind it (probably pus?), eroded handle of malleus, and some prominent vessels around the tympanic membranes. The cone of light is present. I cant really appreciate the air fluid level and "bubble apperance" of this tympanic membrane. nevertheless, taking history into accounts, I think this patient probably has Otitis Media with Effusion secondary to Eustachia tube blockage by enlarged NPC. The neck nodes, being the most common presentation in NPC, usually signify poorer prognosis because they are often the second stage or even third stage of metastatic spread. Ths first LN involved in NPC is retropharyngeal nodes, but unfortunately, it's non palpable.
My treatment will divide into 2 parts, namely for the OME and NPC.
As for the OME, I think myringectomy with gromet insertion can be done.
As for the NPC, the mainstay of treatment is radiotherapy. CT scan should be done to determine the staging and further management shall be determined by the staging.
Thank you.
Eugene
Of course Grommet insertion should not be done.
THis patient will require radiotherapy and it will create a chronically discharging ear!!
Very silly suggestion
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