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Abstract: This case patient is a middle-aged male, more than half a year ago, right ear discomfort, in the local consultation after taking medication, but the effect is not good, today came to our hospital, after the relevant physical examination, confirmed the diagnosis of secretory otitis media, and according to the patient’s condition, given to the operating room treatment after the patient’s discomfort disappeared, and in 5 months after the surgery to pull out the tube.
Basic information】Male, 53 years old
Type of disease】Otitis media
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】June 2021
Treatment plan】Surgical treatment (endoscopic tympanoplasty) + injectable medication (dexamethasone sodium phosphate injection) + intravenous (cefuroxime sodium for injection) + topical medication (furosemide nasal drops)
Treatment period】3 days of hospitalization and 5 months of tube placement
Effectiveness】Cured
I. Initial consultation
The patient, 53 years old, reported that 7-8 months ago, he had a blocked feeling in his right ear and felt stuffy in his ear without hearing loss and occasional ear pain. He was treated with oral medication and ear drops (specific name and dosage unknown) at a local clinic, but the effect was not good and the blockage and stuffiness did not decrease. He then came to our hospital and underwent an outpatient physical examination, which showed that the right tympanic membrane was sunken in, with poor activity and significant turbidity in the lower 1/2 of the tympanic membrane and poor light cone reflection. The right inferior turbinate of the nose was enlarged, and the tonsils were enlarged bilaterally. A swelling was seen in the upper pole of the left tonsil.
II. Treatment history
After communicating with the patient and his family about the patient’s condition, the patient agreed to undergo surgical treatment. According to the patient’s condition, an endoscopic tympanoplasty was selected as more suitable for the patient. Since the fluid was viscous, a tympanic membrane puncture was performed to inject an appropriate amount of dexamethasone sodium phosphate injection, and then the fluid in the right ear was aspirated, and a silicone tympanic ventilation tube was placed to the edge of the tympanic incision, and the external auditory canal opening was blocked with a canceled toxic cotton ball. The operation went smoothly, and the patient returned to the ward after the operation. The patient complained of nasal congestion during the operation, so nasal drops of furosemide were used to ensure the nasal cavity and the eustachian tube were unobstructed.
III. Treatment effect
The patient’s condition gradually improved after the surgical treatment. The patient was discharged from the hospital 3 days after surgery due to his previous good health and proper postoperative care. 7 days after surgery, he was reexamined by endoscopy, and there was no blockage or detachment of the ventilation tube; the pure tone hearing test showed normal hearing level, and the patient reported that the blockage and stuffiness in the right ear disappeared, and the ear pain also basically disappeared. Five months after the operation, the patient came back for a follow-up examination. The electro-otolaryngoscopy showed that the area around the ventilation tube was clean and the patient had no abnormal symptoms, indicating that the treatment plan was effective and the tube was removed.
IV. Notes
The patient’s discomfort in the right ear improved after surgery, and he was discharged after 3 days of hospitalization, very happy, and I felt very pleased. I also reminded the patient to rinse his mouth in time after meals to ensure the cleanliness in his mouth before he was discharged. Swimming and diving are forbidden before full recovery after surgery. Usually, you can wash your hair with the assistance of your family and plug the ear canal with cotton balls to avoid getting water in the right ear canal and causing infection. In addition, you should follow up with the hospital 2 weeks after surgery to check the recovery of the right ear. Finally, if the patient recovers well after surgery and the results of the post-operative review are normal, the tube can be removed 3-6 months after surgery.
V. Personal insight
Chronic secretory otitis media is one of the more common types of otitis media. Although it is more common in children, it can develop from acute to chronic in adults like the patient in this article due to the prolonged course of the disease, so once the symptoms of ear pain, ear congestion, tinnitus and other uncomfortable symptoms occur and cannot be relieved, you should seek medical attention in a timely manner to avoid delaying treatment. In addition, the primary treatment for this type of disease is the use of drugs such as Ambroxol Hydrochloride tablets, but if the effect of drug treatment is not good, surgery can be taken according to the patient’s condition.