Comprehensive clinical notes: CSOM history taking.

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CSOM is a crucial clinical case for 3rd-year medical students. It is also essential for medical students to learn about CSOM and its complications. I have tried to consolidate information on csom from various sources – the ENT book by Dhingra, the White army clinical case presentation videos, and the knowledge I gained during my clinical postings. You will receive a pdf of the same notes upon subscription to med-dose. It’s a med-ed newsletter that I write, which comprises all the exciting things that I have come across in medicine in the past one or two weeks.

I tried to explain various parts of history taking with an example case of CSOM. If you come across any mistakes, please drop in a message.

Before you begin, it is essential to introduce yourself to the patient and explain what you are going to do.

Demographic Details

Demographic details are essential in any history taking. They help you identify the patient, look for any occupational diseases, understand the social-economic condition of the patient.

Chief Complaints

  • Ear discharge x 6 months
  • Hearing Loss (hard of hearing) x 6 months
  • with + or – earache

All the patient’s chief complaints must be arranged in chronological order according to the appearance of symptoms as experienced by the patient.

HOPI

Ear Discharge

  • Onset: insidious
  • Progression: gradually progressing
  • Amount of discharge
    • Scanty: The tip of the swab stick is stained by discharge. E.g., Atticoantral
    • Moderate: Discharge remains in the external auditory canal
    • Profuse: Discharge comes out of EAC and stains the pillow during sleep Tubotympanic
  • color
    • Yellow: Streptococcus, Staphylococcus
    • Green: pseudomonas
    • Brown: Normal wax, Due to particular fungal infection such as Aspergillus fumigatus, A. flavus
    • Black: Aspergillus niger
    • Curdy White: candida
  • consistency of discharge
    • Mucoid ear discharge is seen in the tubotympanic type of CSOM. E.g., Usually, mucoid discharge indicates some middle ear pathology because of goblet cells in the middle ear. The middle ear contains different types of epithelium: (Dhingra page 10)
      • pseudostratified ciliated columnar: anterior and inferior part.
      • cuboidal epithelium: posterior part
      • flat, non-ciliated epithelium: epitympanum and mastoid air cells
    • The external ear does not have any mucous secreting cells. So a nonmucoid discharge can be furunculosis or rarely from a parotid abscess.
    • Clear watery discharge can occur in the case of CSF otorrhea
  • periodicity of discharge
  • Is it foul-smelling?
    • foul-smelling type of discharge is present in of CSOM unsafe  type or atticoantral  type Due to Bone necrosis or destruction (osteitis)
    • safe  type or tubotympanic kind usually does not have a foul-smelling discharge, but it can also present with foul-smelling discharge if it is secondarily infected
    • Otomycosis has a musty odor
    • Keratosis Obturens: Build-up of keratin in the ear canal. It presents ith whitish foul-smelling discharge. late stage of
    • malignant otitis external is also seen with foul-smelling discharge.
  • Is it blood-stained discharge?
    • Blood-stained discharge
      • External ear
        • Trauma: laceration of EAC skin,
        • Instruments
        • Inflammation: Ruptured furuncle, Malignant otitis externa A furuncle is a tiny boil, an infection of a hair follicle in the outer ear. It begins as a small pimple and then develops into a prominent local infection.
        • Malignancy
      • Middle ear
        • Trauma: Traumatic perforation.
        • indicates the presence of granulation tissue in the middle ear, which is seen in the case of atticoantral or unsafe CSOM. (In Suppurative stage)
        • Bloodstained discharge is also seen in malignancy.
        • Glomus tumor
        • Tubotympanic CSOM is not blood-stained.
  • aggravating and relieving factors: Aggravated by URTI /head bath/swimming, when is the last discharge

Hearing Loss

History to be elicited:

  • Side
  • Onset: Sudden/ Gradual. (insidious)
    • Sudden Hearing Loss: viral diseases, trauma, fracture of temporal bone Gradual Hearing Loss: CSOM
  • Progression: static or progressive
    • Static: Tubotympanic
    • progressive: Degeneration of ear ossicles
  • Degree of hearing loss: mild/moderate/severe by the daily activities affected
  • Fluctuating/Non-fluctuating hearing loss
    • fluctuating hearing loss occurs in CSOM: Sometimes, hearing improves in patients when there is discharge due to the round window shielding effect.
    • serous otitis media: Hearing is usually better in the supine position
    • Perilymph fistula: A perilymphatic fistula (PLF) is an abnormal communication between the perilymph-filled inner ear and outside the inner ear that can allow perilymph to leak from the cochlea or vestibule, usually an oval or round window. It can present with fluctuating hearing loss.
    • Meniere’s disease
    • Autoimmune inner ear disorders

Round window shielding effect: The ear discharge helps to maintain phase difference between round and oval window. If there is no discharge, i.e in case of dry perforation sound waves strike oval and round window simultaneously, thus cancelling out each other’s effect.

In Serous otitis media there is no ear discharge as the tympanic membrane is intact.

  • Deafness increases/ decreases at the time of discharge
    • usually, the time of discharge deafness should increase as it means flare-up of the disease but hearing can sometimes improve at the time of release: Round window shielding effect
    • in case of an ossicular disruption, discharging fluid inside the middle ear acts as a suitable medium for the sound transmission, and the patient may find improvement of hearing at the time of discharge
  • Alteration of sound with vertigo
    • In Meniere’s disease, deafness increases before the onset of vertigo and usually improves after an episode of vertigo. But the hearing loss gets worse with every episode of vertigo.
  • Ask for any H/o of improvement in hearing in noisy conditions. This is called paracusis. In otosclerosis, paracusis is present, i.e., hearing improves in a noisy environment. Paracusis occurs because the person speaking talks loudly in a noisy environment.
  • Ask for any aggravating and relieving factors

Ear Ache: SOCRATES

  • Site
  • Onset
  • Character
  • Radiation
  • Associations
  • Time course: Does it follow any time pattern, how long did it last?
  • Exacerbating / relieving factors
  • Severity

Note: Ear ache is an important symptom and it is essential to know nerve supply of ear to understand various causes of ear ache.

Other History

  • Ask for H/o fever
    • To rule out Intracranial Complications – these are associated with nausea/vomiting acute necrotizing otitis media can occur following exanthematous fever. It has a profuse discharge. Immunity is decreased. beta-streptococci causing marginal perforation leading to secondary acquired cholesteatoma
  • Ask for H/o Pain
    • CSOM is a painless condition. However, Pain can occur if there are any complications like Mastoiditis Acute exacerbation of CSOM associated with otitis externa Otomycosis
  • Ask for H/o vertigo :
    • To rule out inner ear infections: CSOM can cause dizziness if the inner ear is involved. The most common cause of vertigo is BPPV
  • Ask for H/o tinnitus
  • No H/O Trauma preceding the onset
    • Trauma – tympanic membrane perforation – not healed – ear infection causing ear discharge
  • Ask for H/o swelling: Rule out Mastoid abscess
  • Ask for H/o facial weakness: Rule out facial palsy
  • Ask for H/o visual disturbances: gradenigo syndrome It is a triad of 1) Discharge 2) Diplopia (6th nerve palsy) 3) Retro – orbital pain (involvement of 5th nerve)

It is advisable to add, ‘No nasal and throat complaints at the end of HOPI’

Past History

  • MEDICAL: DM/Htn/TB/asthma
  • SURGICAL: No prev ENT surgeries (esp failed myringoplasty, grommet insertion)

Personal History

H/o smoking: smoking hampers mucociliary clearance thus predisposes to csom. Cessate smoking 2 week prior and 2-3 weeks post surgery.

Family History

  • Ask for overcrowding
  • Ask for H/o deafness in family: congenital causes of hearing loss Michael Aplasia Syndromes

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