Right ear pain 3 weeks, thought it is malignant external earinflammation, it is a neurological disease!

Part A First, let's look at this case: an elderly woman, 85, who was treated for "3 weeks of pain in her right ear and 3 days for visual re-images", and the patient looked on to the right when re-sightedPhysical examination: Inflammation in the right outer ear canal, pain in the face of the right trigeminal nerve distribution region, right-hand neuroparalysis, and normal examination of the remaining craniofacial nerves and peripheral nervesThe patient had no elevated body temperature, normal blood pressure and a heart rate of 84 times/minThe patient suffered from Steven-Johnson syndrome more than 30 years ago with the use of "cephalosporine" antibiotics, and three years ago he suffered from early kidney cancer, a side-by-side surgical treatmentRecently perfected chest, abdomen, pelvic CT did not see metastasisPatients have no history of immunosuppressive use and deny a history of diabetesConsider the possibility of malignant external otitis (MOE) in the patient, and immediately give qingdamycin and hydrolycant pine therapy, while giving oral cyclopropyl saccharin therapyHowever, the patient developed right-hand nerve paralysis after 2 days and hearing loss after 2 weeksIs the patient's diagnosis wrong?Then look down..The patient's ear swab tested positive for pseudomonas, a condition that supports MOE diagnosisThus, it was treated and a CT examination of the tibia was improved to see if there was myelitisThe results showed no signs of myelitis, as imaging in early cases of MOE could be normal, but the patient's blood routine, kidney function, liver function and C-reactive protein were all normalThen look down..With further exacerbation of facial nerve paralysis, the Otolaryngology Department recommends neurologic consultations: the patient's external ear canal inflammation is light, and is inconsistent with the clinical manifestations of MOE, and a small blister can be seen in the patient's outer ear canalThe patient perfected the lumbar puncture and confirmed that the cerebrospinal fluid pressure was normal at 160mmH2O, lymphocyte syllaphmo (580 x 106/L), increased protein levels (0.96 g/L), and cerebrospinal fluid sugar levels were normal (2.7mmol/L, serum sugar levels 5.0mol/L) Cytology confirmed lymphocyte immersion, but there was no indication of the presence of tumor cells A diagnostic test of the virus PCR of cerebrospinal fluid, which indicates the shingles virus (VZV) ( In addition, head MRI enhancement (age-only brain changes only), anti-nuclear antibodies, anti-neutrophil cytoplasm antibodies, anticyclate peptides, serum protein electrophoresis, Lyme serology, HIV testing, syphilis serum testing, T-Spot testing are normal The patient's hearing threshold was normal at first, but after six months the test revealed a moderate hearing loss in the right ear (see Figure 1) Figure 1 Treatment For this patient, the initial treatment of MOE, oral cyclopropyma and local gingharycin, hydrogenated pine dropear drops drop the ear Second, pain control is the main, and can be installed on the lens prism to improve the double vision However, after diagnosis of VZV (6 days after admission), the patient was treated with intravenous Asilovir (10mg/kg three times a day for 14 days) and perisonol (60mg/day, lasting 5 days, and gradually reducing the amount of 10mg per day for the next 5 days) Results and follow-up The patient followed 2 times over the next 12 months Her ear and face pain, as well as the palsy of the nerves and the facial nerves, were completely relieved However, the patient's right ear hearing did not improve and hearing aids were installed Summary This article mainly talks about a case, for your reference, in the clinical work more attention This case is an 85-year-old woman who has ear pain and neuroparalysis after suffering from an external ear pseudomonasinfection infection The patient was eventually determined to have malignant external otitis However, although external earinflammation has been optimally treated and improved, patients develop editing of side nerve paralysis and sensory deafness After further investigation, it was found that the chickenpox-striped herpes virus is the cause of multiple cranial neuropathy Patients eventually were effective in antiviral combination hormone therapy, and in late follow-up, VI and VII were found to be completely relieved of cranial nerve paralysis, but the patient left hearing defects This case shows that when clinical development does not match expectations, it is important to consult with a multidisciplinary consultation and review and correct the diagnosis Part B shingles is caused by the activation of the shingles virus lurking in the sensory nerve section during the infection period Cell immunity prevents the virus from replicating, but when the virus is reactivated, VZV can spread along the sensory nerve and cause skin infections, which can occur in typical rashes distributed across the skin The most common example of VZV infection in the head and neck is Ramsay-Hunt syndrome (RHS) or ear band herpes, which usually causes facial nerve paralysis, ear aches, ear or upper palate and herpes triamcinolrate Usually multiple groups of cranial nerves are rarely affected RHS combinations with shingles meningitis (VZV) are even rarer Malignant otomy is an infection that extends from the outer ear canal to the base of the skull, which is mostly caused by copper-green pseudomonas Myelitis at the base of the skull can lead to cranial nerve paralysis, which is generally more common to infect the facial nerve alone, but can also affect other cranial nerves, such as VIII, IX, X, XI, XII and other cranial nerves at the outlet of the cranial nerve, such as the infection of the tip of the rock can lead to trigeminal nerves and palsy In clinical setting, the diagnosis of the disease is often overlooked, and early diagnosis and treatment can improve prognosis Here, in the cases we mentioned, patients were quickly diagnosed with MOE, but failed to improve and eventually developed into multiple groups of cranial nerve paralysis This was soon discovered as a result of shingles virus infection and its two rare complications (multi-group cranial neuropathy and meningitis) So for the case of earache, the disease continues to progress, we need to consider some other reasons? 1 Patients have a history of earpain, the disease continues to progress, 2 weeks after the emergence of cranial nerve paralysis, infection is the most likely cause When copper-green pseudomonas swabs are positive, antibiotics are treated with antibiotics, but because the treatment has no obvious effect and imaging is negative, it requires a multidisciplinary team to review and review the diagnosis Other pathogenic bacteria that can cause imaging negatives include staphylococcus and fungal infections, which can cause MOE, tuberculosis, which can cause granuloma meningitis, and pathogenic diseases including Listeria disease, Nisser disease, Lyme disease, syphilis, leptospirosis and HIV Although no rash appears during the onset period, the likelihood of considering VZV is low, but in clinical work still need to be considered 2 Based on the progress of the condition above, differential diagnosis also needs to be considered for other non-infectious diseases For example, malignant meningitis, especially with a history of kidney cancer or lymphoma needs attention In addition, inflammatory diseases that can cause cranial neuropathy include nervous system nodules, systemic lupus erythematosus and vasculitis (isolated central nervous system vasculitis, macrocellular arteritis, granules accompanied by multiple vasculitis and nodule polyarteryitis) Part C VZV has many different effects on the nervous system Facial nerves are most susceptible to fatigue in RHS, but multiple groups of cranial nerves such as VII, VIII, IX, V, X, VI and III are rarely affected When RHS is present, there can be no erythema blisters, which is very important to note, this is called a rash-free shingles In 1705 retrospective studies with side nerve paralysis not accompanied by ear canal and lip rash, 2.4% of patients were diagnosed with VZV DNA testing positive and elevated viral antibodies In addition, facial weakness may occur before the patient has vesicles, and a prospective study found that VZV infection occurred in 14% of cases In conventional RHS therapy, although there is no evidence of the use of antiviral drugs based on the hormones used, it is beneficial for the timely and accurate detection of RHS with multiple cranial neuropathy, and systematic antiviral therapy is even more important The cases mentioned in this article have these complications in the case of copper-green pseudomonasacytobacteria infection This raised initial concerns, considering that this could be MOE MoE diagnosis is notoriously difficult due to the lack of universally accepted diagnostic criteria Typical clinical manifestations of MOE are found mainly in cases of granulitis at the ineffective treatment of traditional treatments, granulated tissue at bone and cartilage connections, facial nerve sill or low cranial nerve paralysis, and more commonly in patients with diabetes dependent on insulin However, it does not exhibit so many characteristics, which makes it difficult to identify with other diseases such as otitis, chronic pustic otitis media and osteosarcoma This case reminds us of the importance of reviewing the diagnosis, especially in this case with improved ostothe, but the need to think about whether the diagnosis is correct when the clinical condition is still deteriorating It is also a reminder of the importance of multidisciplinary teams when diagnosis is called into question It is important to establish assumptions first when diagnosing a disease When it does not correspond to the expected clinical course, a review is required and, if necessary, multidisciplinary consultation is required Author: Eight Holes flute Source: Neurology 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