Question

A 73 YO WM with a history of hypertension (HTN) and type 2 diabetes mellitus (DM) presents to your office with excruciating left ear pain for the past 3 days. He also noticed that today his speech seems a bit slurred. His wife says that the left side of his face looks "droopy." He has had so much pain and swelling that he hasn't been able to put his hearing aid in for several days. He cleans his ears daily with cotton swabs prior to putting in his hearing aid. He denies having a fever, but says that his blood sugars have been higher than usual for the past 2 days. PMHx: The patient had "swimmer's ear" in the past, which responded to treatment with ear drops. He denies any ear problems in the last several years. Physical Exam (PE): VSS Afebrile WD WN WM in NAD He is in obvious pain and has a prominent left-sided facial droop. Ear = Left ear is diffusely swollen, and is tender on the pinna, the entire periauricular area, and the mastoid. There is purulent drainage from the ear canal. You are unable to insert a speculum into the canal because of the swelling and pain. Neuro = Evidence of facial nerve palsy on the left side. LAB = Blood tests show an elevated WBC count and a markedly elevated erythrocyte sedimentation rate (ESR). DEFINITIONS: Palsy: complete paralysis (neurology). Pinna = the outer projecting portion of the ear. Periauricular: Around the external ear. Erythrocyte sedimentation rate (ESR): A measure of the time it takes for red blood cells to settle (a nonspecific measure of inflammation) Ecthyma gangrenosum: Pustular skin lesions that later become necrotic ulcers and can lead to gangrene. Discussion Questions 1. What is your diagnosis? 2. What organism is the most likely etiology of this infection? 3. Which two toxins contribute to most of the systemic toxicity of this organism? 4. What is meant by NAD in the physical exam section?

Answer 1

The patient likely has advanced otitis externa caused by Pseudomonas aeruginosa. Exotoxin A and elastase are two toxins contributing to systemic toxicity. NAD indicates the patient is not in severe distress beyond the specific symptoms.

Step-by-step explanation:

Diagnosis and Etiology for Ear Pain with Facial Droop

The patient presents with excruciating ear pain, swelling, facial nerve palsy, and purulent drainage from the ear canal. These symptoms suggest an advanced infection known as otitis externa, complicated by facial nerve involvement. Given the patient's history, the most likely etiology of this infection is the bacterium Pseudomonas aeruginosa. This organism is commonly associated with otitis externa, particularly in cases where there has been frequent exposure to water, trauma or foreign objects in the ear canal, such as regular use of cotton swabs or hearing aids. Moreover, the patient's elevated white blood cell count and erythrocyte sedimentation rate indicate a significant systemic inflammatory response.

Considering the organism involved, exotoxin A and elastase are two toxins released by Pseudomonas aeruginosa that contribute to the systemic toxicity seen in infections caused by this bacterium. These toxins cause tissue damage and can impair immune response.

In the physical exam section, the term NAD stands for 'No Apparent Distress' or 'No Acute Distress,' meaning the patient does not appear to be in immediate or severe distress aside from the symptoms noted.

Answer 2

1. Malignant (Necrotizing) Otitis Externa

2. Pseudomonas aeruginosa

3. (1) Endotoxin

(2)Exotoxin A

4. No apparent distress

Step-by-step explanation:

1. Malignant (Necrotizing) Otitis Externa

Previous History of Otitis Externa (Swimmer's ear) and Diabetes Mellitus prompts towards this diagnosis.

Malignant (Necrotizing) Otitis Externa is an inflammatory condition. The causative agent is Pseudomonas aeruginosa.

It should be suspected in elderly diabetics and patients consuming immunosuppressants.

It bears resemblance with symptoms of otitis externa, presenting as otalgia (ear pain).

Paralysis of Cranial Nerve VII (Facial Nerve) is a common feature of this disease. Cranial VII palsy (paralysis) can present as facial droop as it does in this patient.

2. Pseudomonas aeruginosa

3. Pseudomonas produces an endotoxin which is mostly responsible for symptoms of sepsis and septic shock.

It produces a myriad of exotoxins. The most important is Exotoxin A responsible for tissue necrosis.

4. NAD stands for no apparent distress. It means that the patient is stable and his vital signs are not deteriorating.