Download Case Scenario - Connecticut Pediatric Otolaryngology

Lisa Gagnon, APRN
Connecticut Pediatric Otolaryngology
7th Annual Symposium
October 4, 2012
11y/o female presents to ENT clinic….
 Several years of otalgia associated with recurrent
otorrhea (clear, then malodorous,yellow)
 Reported intermittent tinnitus, hearing loss R>L
 Multiple antibiotic drops, systemic Rx- no benefit
 Denied Vertigo/headache

PMH- recurrent AOM as infant. Lead exposure
requiring chelation, eczema. ?Allergies
Auricles- normal, no tenderness w/manipulation
EAC’s with medial watery discharge, erythema
TM’s intact/clear
RX Vosol, then ½ strength vinegar/water
Next month: ↑ scaling, erythema of canal- extending into
conchal bowl.
HT – Bilateral mixed mod-severe HL, nl tymps
RX - 1/2str vinegar, external ear moisturization
changed to steroid cream/moisturization & dermotic
CT scan temporal bones ordered
6mo later (next visit)
reported hx ear swelling
unresponsive to prior
treatments prescribed.
Exam: minimal EAC wall
changes ?fungal
RX: Fluconazole-atomized
→1 mo later – did not use
fluconazole, reported use
of steroid cream topically,
felt hearing was nl
Exam: normal ear examrepeat audio wnl
Next few months…. would flare with
erythema, itching, pain, dng, some swelling,
primarily of distal canal, ears clogged
? Eczema vs. psoriasis component.
Rx: repeated cleanouts, dermotic, aquaphor,
steroid creams.
 Dermatology referral

Had Dermatology Evaluation completedLooked good that day- “return when flares”
?Psoriasis vs. eczema
Variety of creams prescribed
(protopic, clobetasone, derma-smoothe)
At that visit felt ears were clogged again…. Much
of the same exam, findings .
Rx steroid cream, return to dermatology, HT
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Placed on clindamycin and
prednisone by ED
ENT Clinic next day –
swelling of auricle without
significant tenderness or
erythema, lobule spared
Canal walls with scaling
and mild erythema, TM’s
clear

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Skin Biopsy (by
Dermatology) showed
superficial and deep
perivascular and interstitial
lymphohistiocytic infiltrate
and mild spongiosis and
parakeratosis, consistent with
dermatitis, possibly allergic
contact dermatitis
Panel of 50 visiting
dermatogists convened
No identified
etiology/allergen
Similar to last flare, seen in ENT
clinic
 Now reporting headache
preceeding episodes & ringing in
ears
 EAC’s with similar findingsscaling/erythema, debris
 Bilateral SNHL
(mod-severe)
 High dose steroid Rx
 Labs- CBC, ANA, ESR


Rheumatology referral

Labs- CBC, Metabolic, LFT’s,
ESR, Thyroid, muscle function,
ANA, DNA, ENA screen,
complement, IgG, IgA,
rheumatoid factor, anti-CCP,
CRP, ANCA


CXR- Wnl
Echo- Wnl
Relapsing Polychondritis
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Began Methotrexate 12.5mg weekly, Folic Acid
Close weekly to monthly follow-ups
Now increased to MTX 15mg weekly

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Patient doing excellent!
ABR completely normal (6/2012)
No Flares
Labs stable
Relapsing Polychondritis

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Chronic otitis externa unresponsive to
conventional therapies deserves further
workup
If external ear inflammation spares the lobule,
consider diagnosis of relapsing polychondritis
SNHL requires further workup and treatment
Evaluate for further high risk associated
manifestations