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患者,女,67岁。因左耳疼痛、流脓、伴耳鸣3d,在当地医院给予清耳及应用抗生素治疗。清耳时,不慎挖破外耳道壁。10d后,患者张口困难伴项背肌肉疼痛,来我院就诊,门诊以急性化脓性中耳炎收入院。当日夜间,患者出现颈项强直、张口受限、苦笑面容。急请传染科会诊,诊断为破伤风。经1个月的抗菌、抗毒、解疼、镇静等治疗,患者痊愈。详询病史,除外耳道有损伤史外,无其他外伤史。出院诊断为耳源性破伤风。
Patient, female, 67 years old. Due to left ear pain, pus, with tinnitus 3d, in the local hospital to give ear and the application of antibiotic therapy. Clear ear, accidentally dig the external auditory canal wall. After 10d, patients with mouth pain difficult to back muscle pain, to our hospital, outpatient hospital with acute suppurative otitis media income. Day and night, patients with neck stiffness, restricted mouth, smile face. Emergency infectious disease consultation, diagnosis of tetanus. After 1 month of antibacterial, anti-drug, pain relief, sedation and other treatment, the patient recovered. Detailed history, except for the history of injury to the ear canal, no history of other trauma. Discharged diagnosis of ototoxicity tetanus.