A 2 year old boy with Acute Otitis Media – Case Presentation

Nilanjana Basu, Homoeopathic Physician Lecturer, Department of Surgery

Sameer Rana E.N.T. Specialist, Professor, Department of Surgery

Bakson Homoeopathic Medical College, Greater NoidaCorrespondence to : niil2007@yahoo.co.in

Registration no. 4145/09Age/Sex – 2years/MaleResidence – Gamma 1,Greater

Noida

Chief Complaints

Recurrent nasal discharge and stuffiness since 1 ½ months

Itching in left ear since 10 days

History of presenting illness2 year old baby brought to the E.N.T.

clinic on 28.8.09 with recurrent nasal symptom of cold, stuffiness and rhinorrhoea since 11/2months.

His mother complained 2 weeks back of an episode of left earache followed by discharge which was profuse and mucoid. Pain was severe at the middle of the night due to which he couldn’t sleep.

History of hearing loss was not forthcoming. For the above complaints antibiotic and decongestant treatment was given by a local practitioner for 10days. At the time of case taking patient only had nasal complaints and itching in the left ear general irritability.

Past history

Patient had recurrent attacks of Upper respiratory tract infections

Family history

Mother – alive – Susceptibility to cold

Father - alive- Healthy

General physical examination

Mental state & conciousness-Well oriented & fully concious

Built & Nutrition – well builtFacies – normalPallor – absentIcterus – absent

Cyanosis – absentOedema – absentClubbing – absentTemperature – normalPulse – 100/minRespiration – 20/min

Examination of Head & NeckEAR –Bilaterally pinna normal, excoriation of

the skin and external canal on left side. External canal of Right side was normal. Left tympanic membrane congested with a small central perforation. Right tympanic membrane appeared normal. Patient did not respond to Tuning fork test. Facial nerve was normal bilaterally and there was no nystagmus.

NOSEBilaterally muco-purulent

discharge with pallor and oedema of turbinates.

THROAT – normal

EXAMINATION OF NECK – normal

Otoscopic examination

Left tympanic membrane congested with a small central perforation.

Summary of the case:A 2 year old boy presented with

itching of left ear since 10 days. He had h/o upper respiratory tract infection since 1 ½ months followed by an episode of left earache followed by discharge which was profuse and mucoid 2 weeks ago. Pain was severe at the middle of the night due to which he couldn’t sleep.

On examination the left tympanic membrane was congested with a small central perforation. The right ear was normal.

Diagnosis

Acute Otitis Media of left Ear

Rubric selectionThe patient was irritable, restless,

had itching in left ear at night. The rubrics selected likewise were from Kent Repertory.

Mind, restless, nervousness, nightMind, irritabilityEar, itching in, leftGeneralities, night

4145/09

Prescription

All the rubrics covered Rhustox, which was prescribed in 0/1 potency thrice a day.

Ear was regularly cleaned.

Follow up

After 7 days the baby’s nasal discharge decreased, irritability, restlessness and itching in ear were relieved. The medicine was continued for another 15 days.

Rhustox 0/2 was prescribed on 20.10.09. The ear was dry but the perforation started healing. The same medicine was continued for 7 more days. On 10.11.09 the ear was examined with an otoscope which revealed that the perforation was healed.

Discussions The importance of healing this

perforation is utmost as the recurrent attacks of cough and cold complicates the perforation and it becomes chronic otitis media with hearing loss and discharging ear.

This age also coincide with the development of speech. If the patient cannot hear there will be improper development of speech.

Rhustox was given on account of the restlessness of the baby at night which was very marked.

Fifty millesimal potency was prescribed as we required frequent repetition of the medicines in ever increasing dose.