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Abstract: Otitis media is relatively common, and the cause may be related to adenoid hypertrophy or infection by pathogenic bacteria. The disease can usually be cured after treatment with surgery or medication depending on the specific cause. In this case, the patient came to our hospital with symptoms such as ear pain, hearing loss, and fever, and was diagnosed with otitis media. After active surgery and medication, the patient’s condition was basically stable, and the symptoms improved significantly, and he was discharged successfully.
Basic information】Male, 17 years old
Type of disease】Otitis media, adenoid hypertrophy
Hospital】Shanghai Changhai Hospital
Date of Consultation】May 2019
Treatment plan】Surgical treatment (nasoscopic adenoidectomy) + medication (cefazoxime sodium for injection, fluoxacin ear drops)
Treatment period】3 days of hospitalization and 1 week of regular postoperative review
Treatment effect】The condition is basically stable and the symptoms have improved significantly
I. Initial interview
When the patient first came to the clinic, he covered his right ear with his hand and had a painful expression, while using his hand to indicate that he had a sore throat and could not speak. He was diagnosed as having chronic tonsillitis after visiting the local hospital. After treatment with anti-inflammatory drugs, his symptoms were relieved, but he still had symptoms of nasal congestion, runny nose, occasional open-mouth breathing and snoring at night, which did not affect his daily life, so he was not given further treatment. However, two days ago, the patient developed fever and ear pain, so he came to our hospital. After examination, we found that the patient’s right eardrum was congested with fluid in the tympanic chamber, the mucous membrane of the pharynx and nose was congested, and the tonsils and adenoids were enlarged.
II. Treatment history
To further clarify the etiology, we gave the patient lung and nasopharyngeal X-ray examinations, which showed increased texture in the patient’s lungs bilaterally, and nasopharyngeal X-ray examination, which showed thickening of the soft tissue shadow in the posterior wall of the nasopharyngeal apex and narrowing of the nasopharyngeal cavity. After discussion with the patient and the patient’s family, it was recommended that the patient be given nasoscopic adenoidectomy. After the patient and his family agreed, we performed the operation under general anesthesia. During the operation, through the nasal endoscope, the adenoids could be clearly observed and treated by resection, and the operation went smoothly.
III. Treatment effect
After adenoidectomy, the patient’s symptoms improved and his hearing gradually recovered. The patient was given cefazoxime sodium for injection and fluoxacin ear drops to prevent infection. 3 days after the operation, the patient was observed to be recovering well, with no bleeding or oozing from the wound, and gradually recovered from symptoms such as earache, sore throat and hearing loss, and the nasopharyngeal wound also recovered well, so he was discharged from the hospital for recuperation.
One week after the operation, the patient came to the hospital for a follow-up examination and reported that the discomfort had completely disappeared, and that there was no congestion or fluid in the right ear, no redness or swelling in the pharynx, and the results of routine blood tests were normal, suggesting that the disease had been completely cured. However, the patient and his family were advised to closely monitor his condition and to seek medical attention in a timely manner if any uncomfortable symptoms appeared.
IV. Notes
We are glad that the patient was cured after a series of surgical treatments and postoperative medications, but since the patient’s condition had not fully recovered at the time of discharge, we need to pay attention to the following conditions.
1. Patients need to avoid touching their nose and ears with force during the recovery period after discharge to avoid affecting wound healing.
2. Patients should always pay attention to checking the nasal cavity after discharge to avoid inflammation of the nasal mucosa, which may affect breathing, and go to the hospital promptly if uncomfortable symptoms appear.
3, patients need to pay attention to avoid cold infection in daily life, pay attention to keep warm, and avoid smoking and drinking alcohol to avoid stimulating the respiratory mucosa.
4, in the daily diet, need to pay attention to ensure adequate nutrition, give high protein, high fiber food, such as eggs, milk, etc.. Physical exercise, such as running, should be carried out appropriately to enhance the body’s ability to resist diseases.
V. Personal insight
Under normal circumstances, human adenoids will degenerate at the age of about 10 years old, but if they do not degenerate, they can also cause other diseases. For otitis media diseases, they are often caused by factors such as adenoid hypertrophy. For example, the patient in this case has otitis media mainly due to adenoid hypertrophy, followed by symptoms such as ear pain, pus and hearing loss, which are typical symptoms of otitis media. In serious cases, they may suffer from respiratory distress, which may endanger their health. Therefore, otitis media is not a trivial problem, and children and adolescents who are in the process of growth and development should pay attention to the symptoms of otitis media and go to a regular hospital in time to identify the cause and provide regular treatment to prevent further development of the disease.