Case studies

In this section you will find case histories. Read and answer the questions that are set at the bottom of each case. The cases have been selected because they represent both common problems and serious complications of common disease that must not be missed.

Where relevant you will find links to other pages that will help you to understand the cases.

Case 1  "The deaf child"

A five-year-old boy was referred to a paediatric otolaryngology clinic by his General Practitioner, the mother being concerned that the child could not hear satisfactorily. Closer questioning suggested that the problem had been present for at least six months but that before this he had been well.

Apart from some occasional otalgia and a tendency towards clumsiness there were no other significant symptoms. The boy had suffered from mumps and had spent a short period on the Special Baby Care Unit at birth due to some neonatal jaundice but had not required more than UV therapy. Otherwise his medical history was unremarkable but his progress in school was starting to slow.

Examination of the ears found bilateral dull drums that were retracted. His nose was clean and his throat and neck healthy for his age.

Questions 

1. What is the most likely diagnosis?

2. Why do children suffer this when adults do not?

3. Apart from the most likely diagnosis the history suggests the possibility of two other causes of deafness.

    What are these?

4. What are the long-term consequences for this child if he is not treated?

    (ear related and non-ear related).

5. What treatments can be offered? (surgical and non-surgical)

 

Case 2 - A case of an orbital complication of sino-nasal disease

Questions 

1. How are patients examined for proptosis?

2.How do we test for loss of red saturation and what is the relevance of this sign?

3. What other complications might have arisen from the orbital abscess?

4. The patient presents with a subperiosteal abscess of the orbit. This is a complication of another disease process.

    What is that process?

5. What other complications might have arisen from the underlying condition?

A 6-year-old child presents to the Accident Department with a two-day history of swelling and redness around his right eye. For the four days prior to this he had been a little unwell with an upper respiratory infection and had been off school.

On admission to the unit he was mildly febrile but his pulse, BP and respirations were normal and he was well oxygenated in air. The examining F1 found that, in addition to the redness and minor periorbital swelling (which made seeing the eye difficult), there was a restriction in the left eye movements. She thought that there was a slight degree of proptosis as well. Examining for vision was difficult as the child was a little uncooperative and she was not sure whether the child had loss perception of red saturation or not.

Following departmental protocol she started the patient on IV ceftriaxone and flucloxacillin and made a referral to the Ophthalmology department and to the on-call ENT surgeon. The patient was admitted to the paediatric ward.

The ENT SpR confirmed the F1’s findings and asked for a CT scan to be arranged showing the orbit and sinuses. They also recommended that, in addition to the antibiotics, nasal decongestant drops should be added.

With light sedation the child was scanned (see image) and this confirmed the presence of a subperiosteal orbital abscess, proptosis and opacification of the ethmoid sinuses. He continued his IV antibiotics overnight and was reviewed in the morning.

At review the swelling had not subsided and it was felt that the proptosis was worse. Accordingly a decision was made to offer drainage of the abscess under general anaesthesia. This was done later that day (see image).

In theatre the nose was examined and this revealed pus draining into the middle meatus on the right. The surgeon placed a curved, interrupted incision between the nasion and the medial canthus. They then cut down onto bone and through periosteum. The periosteum was elevated backwards into the orbit until pus started to flow from the wound. The pus was sampled for C&S and a drain placed and secured.

Over the next two days the fever settled along with the erythema and swelling. The drain was removed after the second post op day as it had ceased to discharge. The patient was sent home and made a good and full recovery.

 

Case 3 - Chronic otitis media with facial paralysis

A 9 year old girl presents to the Accident and Emergency department with a one day history of right facial weakness. On questioning it appears that she had had some hearing difficulties at school over the preceding three years and had also had a foul smelling right ear at times. This had been taken to her family doctor and had been treated with short courses of ear drops. The drops seemed to improve the smell but her hearing difficulty persisted. Generaly she had been keeping up with her work at school. In addition to her facial weakness she complained of a watering right eye which felt gritty.

In addition to the eye signs the F1 found an abnormal looking eardrum on the right. It appeared to be covered in pus and dead skin and it smelt fetid. Tuning fork testing was done with Weber lateralising to the affected ear. Rinne testing found bone conduction to be better than air conduction on the right side but was normal on the left side. oral examination and examination of the parotid glands found no abnormalities.

She was referred to the ENT department were a diagnosis of xxx was made. CT scanning was performed and showed opacification of the right mastoid air cells with erosion of the attic bone and soft tissue density material in the middle ear.

Later that day she underwent surgery to the ear in the form of a mastoid exploration to remove disease. She had an uneventful postop course with eventual recovery of full facial function. There were no eye sequelae.

The examining F1 made note of a Grade 5 House and Brackman lower motor neurone facial weakness on the right side. There was some redness of the ipsilateral eye but a full range of movement of the eye and no ptosis or proptosis. Full examination of the eye was not possible at the time but it later appeared that she had a corneal abrasion on that side.

Questions 

1. Given the history, examination and CT findings above what is the most likely diagnosis?

2. What type of hearing loss does she have? Conductive or sensorineural?

3. What is the relevance of the corneal abrasion? How did it occur and what are the implications for management of this

    patient?

4. What other complications might this child have presented with given your diagnosis?