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Abstract: The patient in this case is a middle-aged woman who developed symptoms of upper respiratory tract infection with right ear discomfort 10 days ago. After local treatment, the symptoms of upper respiratory tract infection improved, but the right ear discomfort did not ease, so she came to our hospital and was diagnosed with secretory otitis media and underwent surgical treatment and medication. The patient’s discomfort disappeared and the results of the review were normal, and she recovered from secretory otitis media.
Basic information】Female, 44 years old
Disease Type】Otitis media
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】June 2021
Treatment plan】Surgical treatment (tympanoplasty) + oral medication (cefaclor capsules, prednisone acetate tablets, standard myrtle oil enteric capsules) + topical medication (budesonide nasal spray)
Treatment period】2 weeks of inpatient treatment, 6 months of outpatient follow-up
Treatment effect】Cured, no discomfort in the right ear
I. Initial consultation
The patient, a 44-year-old female, reported that she developed tinnitus, dullness and dullness in her right ear 10 days ago, and felt no hearing loss or ear pain, but had nasal congestion, runny nose, cough and sputum. The outpatient physical examination showed that the right tympanic membrane was cloudy, invaginated and congested with normal activity; the left tympanic membrane was mildly invaginated with normal activity and poor light cone reflection; the bilateral nasal cavity was crowded with poor ventilation and the bilateral inferior turbinates were enlarged; the mucosa of the pharynx was not congested and the bilateral tonsils were Ⅰ° enlarged; no abnormality was found in the larynx. The diagnosis of secretory otitis media was made by combining the relevant symptoms and signs, and further treatment was given after perfecting the examination.
II. Treatment history
Routine blood tests were completed and no significant abnormalities were found. After communicating with the patient and his family, considering the short onset of the disease, pharmacological treatment was taken first. Considering the presence of nasal congestion, runny nose, cough, cough and other uncomfortable symptoms, the patient was first given cefaclor capsules for anti-infection, standard myrtle oil enteric capsules to promote sputum discharge, and budesonide nasal spray to improve nasal ventilation, as well as prednisone acetate tablets to control upper respiratory tract infection while actively treatment of secretory otitis media. After one week of drug treatment, the patient’s symptoms improved, but the symptoms of ear stuffiness still existed. After otoscopic examination, it was determined that there was fluid in the middle ear cavity, so tympanocentesis was performed.
III. Treatment effect
After medication, the patient’s symptoms of nasal congestion, runny nose, cough and sputum disappeared, but he still had ear congestion and ear sink, so he underwent surgery. One week after surgery, the puncture site crusted off and the endoscopic examination was repeated. The tympanic membrane had no abnormal symptoms such as congestion, invagination and turbidity, and the tympanic chamber conductance map was type A. The patient reported the disappearance of tinnitus, ear congestion and other uncomfortable symptoms, and the comprehensive assessment showed that the patient was cured, indicating that the treatment was effective.
IV. Notes
The patient was very happy that her condition improved after treatment and her sad face due to ear discomfort disappeared. I also reminded the patient that he still needs to continue taking medication for 1 week after the puncture surgery, and that he should visit the hospital outpatient clinic after 1 week to check his postoperative condition. During this period, care should be taken to protect the right ear. Showering is not recommended, and you can take a soft cloth ball or cotton ball to block the external ear canal when washing your hair or face to avoid water in the ear canal, which can lead to post-operative complications of infection and make treatment more difficult; also, you should not dig your ear with your fingers or buckling spoon until you have fully recovered from the surgery, so as not to stimulate the piercing and cause bleeding and infection.
V. Personal insight
Most patients with secretory otitis media have symptoms similar to those in this article, such as nasal congestion, runny nose, cough and other upper respiratory tract infections. Therefore, an important point in preventing this disease is to prevent upper respiratory tract infections, add clothing according to the weather changes in a timely manner to avoid catching cold, and avoid blowing on air conditioners when the weather is hot to prevent the recurrence or occurrence of secretory otitis media. In addition, if symptoms of upper respiratory tract infection occur with ear discomfort, you should be alert to otitis media and seek medical attention promptly for a clear diagnosis and symptomatic treatment.