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Case of the Month

A 37-year-old male diver reports to the clinic complaining of decreased hearing in his right ear, jaw pain that is worse with chewing, and right-sided facial pressure for 3 days. He states that when he is at depth, the pain increases and he is having a difficult time equalizing the pressure. He has been taking pseudoephedrine (Sudafed) and oxymetazoline hydrochloride (Afrin) for the last 5 days with minimal relief.

He denies fever, chills, body aches, cough, chest pain, SOB, wheezing, headache, vision changes, or dizziness.

  • Past Medical History: Allergic rhinitis
  • Past Surgical History: None
  • Current Medications: Cetirizine (Zyrtec; 10mg/day)
  • Allergies: Shellfish
  • Immunization Status: Up to date including annual flu vaccine
  • Social History: Social drinker, smokes one pack/day
  • Family History:
    • Mother- Diabetes, Schwannoma
    • Father- Hypertension, Lung Cancer
    • Sibling(s)- Depression

Vitals

  • Temp: 98.5
  • Pulse: 66
  • Respirations: 14
  • BP: 116/72
  • POx: 96% on Room Air
  • Weight: 189 lb, BMI 26.4
  • Height: 5’11”

Physical Exam

  • General: A&Ox3, sitting on the exam table, appears uncomfortable
  • HEENT: ATNC
    • Eyes: PERRL, EOMI
    • Left Ear: normal shape, external auditory meatus (EAM) is clear, TM normal with good light reflex, no post aricular or mastoid tenderness appreciated
    • Right Ear: normal shape; EAM clear; TM erythematous, bulging, absent light reflex; no post aricular or mastoid tenderness appreciated
    • Nose: Turbinates appear edematous with yellow discharge on right, clear on left
    • Throat: mucus membranes moist, no erythema or lesions appreciated
  • Neck: Soft supple, shoddy lymph nodes appreciated on right posterior cervical chain; trachea midline; painless ROM
  • Cardio: Regular rate & rhythm, no murmurs appreciated
  • Lung: Clear to auscultation bilaterally
  • Abdomen: flat, soft, non-tender, non-distended, normal bowel sounds
  • Extremities: no clubbing, cyanosis or edema, good peripheral pulses, muscle strength 5/5 bilaterally, 1+pedal pulses bilaterally,
  • Skin: warm, dry, no rashes

OM

http://mbahdukunbagong.blogspot.com/2011/07/acute-otitis-media.html

Lab Work

  • None

How would you approach this patient?

Differential Diagnosis

  • Otitis Media
  • Otitis Externa
  • TMJ Syndrome
  • Mastoiditis

Diagnosis: Otitis Media

Treatment

  • Amoxicillin Clavulanate (Augmentin) 875mg 2x daily for 10 days
  • Betamethasone (Celestone) 6mg IM
  • Salt water nasal rinse 3-4 times daily
  • Restricted Duty: no diving until resolved

Discussion:

Otitis Media can be straightforward to diagnose and treat. When considering treatment options amoxicillin is certainly the drug of choice in mild to moderate cases. Because the patient is a diver, a more aggressive approach was used. For patients who are penicillin resistant other drug choices include cefdinir (Omnicef), ceftriaxone (Rocephin), azithromycin (Z-Pak), clarithromycin (Biaxin), or trimethoprim-sulfamethoxazole (Bactrim).

In addition to antibiotics, you may consider several OTC adjuvants including pseudoephedrine (Sudafed), guaifenesin (Mucinex), and oxymetazoline (Afrin) in order to relieve congestion. You must remember that products such as oxymetazoline should be used for a very short duration and do have significant side effects such as rebound congestion.

Left untreated Otitis Media can lead to significant problems including mastoiditis, ruptured TM, and hearing loss. In a diver’s case complications could potentially result in job loss.

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