Adult and Pediatric Ear Disorders 2021 PDF

EAR DISORDERS D R. K I M B A L L O N E , D N P, A P R N - C N P  TYPES OF HEARING CONDUCTIVE HEARING LOSS of Outer Ear and Middle Ear (BC > AC) LOSS Any type of obstruction of sound waves will cause conductive hearing loss, lateralization to bad ear – Outer Ear Cerumen...

EAR DISORDERS D R. K I M B A L L O N E , D N P, A P R N - C N P  TYPES OF HEARING CONDUCTIVE HEARING LOSS of Outer Ear and Middle Ear (BC > AC) LOSS Any type of obstruction of sound waves will cause conductive hearing loss, lateralization to bad ear – Outer Ear Cerumen Known as Otitis Externa – Middle Ear (fluid inside) Known as Otitis Media Serous Otitis Media (effusion or fluid filled) SENSORINEURAL HEARING LOSS of Inner Ear (AC > BC) Damage or aging of the cochlea/vestibule, lateralization to good ear -From Presbycusis, Meniere's disease Damage to the nerve pathways (CNVIII or Acoustic Nerve) From Otoxic drugs (oral aminoglycosides, erythromycin, tetracycline, high-dose aspirin) Presbycusis: hypertension, smoking, diabetes, noise trauma can hasten. Treat with hearing aids and refer for audiometry per Joint Commission  TYPES OF HEARING TESTS Weber Test: Place the tuning fork for midline on the forehead. – Normal finding is NO lateralization – Ask where they hear a buzzing sound: Louder in left or right? Or both equally? Rinne Test: Place the tuning fork first on mastoid process, then at front of ear. – Normal finding : Air conduction (AC) lasts longer than bone conduction – Audiogram is more optimal, sensitive and specific than tuning fork CLINICAL TIP: The Weber and Rinne test are complete opposites of each other. In sensorineural hearing loss, Weber finds lateralization to “good” ear; Rinne test finds Air conduction > Bone conduction In conductive hearing loss, Weber finds lateralization to “bad” ear; Rinne test finds BC > AC  HEARING LOSS Gradual hearing loss can be found in: cholesteatoma, chronic renal failure, chronic otitis media, diabetes, hypothyroidism, noise exposure, otosclerosis, presbycusis, and retro cochlear neoplasm Fluctuating hearing loss can be found in: autoimmune disorders, Meniere’s disease, migraine headache, multiple sclerosis, otitis media peri lymphatic fistula, sarcoidosis, and syphilis Conductive hearing loss associated with cerumen: resolves with removal of the impaction Otolaryngology referral for: hard of hearing due to trauma, congenital hearing loss, tumors, obstruction of the external auditory canal, nonhealing TM rupture, and otosclerosis. – Sudden hearing loss warrants an evaluation to rule out conductive hearing loss or an identifiable cause. A thorough history and physical and in office visits can determine if urgent (within 1 week) referral is indicated  OTITIS DISORDERS Cerumen Wax- most common cause of impacted canal. Irrigate with body temp water and hydrogen peroxide for impacted cerumen. Carefully remove cerumen Otitis Externa – Painful inflammation of the external auditory canal and auricle, pruritic, discharge, and hearing loss within 48 hours – Commonly known as “swimmer’s ear” – Does occur in the elderly, but more common in younger persons – Otoscopy reveals an edematous and erythematous external ear canal, pain on palpating the tragus and repositioning auricle – Tylenol and codeine for pain, cotton wick for antibiotic eardrops (use of new gauzes as wick). With drops at room temp, lay on their side for two minutes and then remove wick, then replace with cotton ball. Topical antibiotics: Ofloxacin or Ciprofloxacin Otitis Media – Infectious or inflammatory process within the middle ear due to mucus entrapment, secondary to eustachian tube dysfunction – May be acute or chronic, suppurative or serous in nature – Caused by bacteria or viruses (Strep pnuemoniae or H. influenzae) Otitis Media with Effusion – Serous fluid trapped behind the tympanic membrane without an ear infection. – Often caused by URI or allergies – Moderate: ciprofloxacin-hydrocortisone  OTITIS MEDIA Etiology – Chronic OM: usually painless, always have discharge. Surgical intervention may be warranted because the TM is damaged and perforated (myringotomy) – Acute OM: Eustachian tubes dysfunction or congestion that prevents effective drainage of the middle ear – Hearing loss (muffled hearing), ear pain (otalgia), headache, fullness, foul drainage, bulging of TM with recent history of cold or allergic rhinitis flareup which precedes AOM onset – Infectious causative agents (typically respiratory bacteria): Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus SUBJECTIVE AND OBJECTIVE FINDINGS Otitis Media Rapid onset throbbing pain (otalgia) worse in prone position Conductive hearing loss Vertigo and nausea Severe ear pain with sudden relief usually indicates tympanic membrane rupture with immediate release of fluid into the middle ear cavity Tympanic membrane Otorrhea (ear drainage) rupture Red, dull, bulging tympanic membrane with serous or amber fluid in color A fine black line (fluid meniscus) indicates a partially-filled cavity Air bubbles may be visible beyond the tympanic membrane, middle ear effusion Bony landmarks are obscured Otitis Media with effusion Hole in the tympanic membrane in serous cases if rupture occurs Tympanic membrane normal or retracted, yellow fluid, opaque and dull with decreased movement (often in Otitis Media with effusion, middle ear fluid without infection). May follow AOM  MANAGEMENT OF OTITIS MEDIA Antibiotics (oral course for 10 days) – Amoxicillin (Amoxil) 500 po q12 hrs. or 250 mg q8 hrs. for mild to moderate AOM, 875 mg po q 12hrs or 500 mg q8hrs for severe AOM – Cefdinir (Omnicef) or Cefuroxime If TM Perforation has occurred: Cortisporin Otic 4 ear drops topically, TID for 7 days Analgesics PRN for pain : OTC acetaminophen or NSAIDS Refer to ENT – for recurrent Acute Otitis Media (3-4 infections in 6 months) – for Chronic Otitis Media ( 3 months or more bilaterally or 6 months or more unilaterally) – Perforation of TM – Hearing loss of 20 dB  ACUTE AND CHRONIC Acute or chronic disease of the mastoid process usually occurs secondary to otitis media. DISEASES Subjective: tenderness over mastoid bone, headache, ear pain, anorexia, vertigo, facial paralysis observation (report immediately as this may indicate damage to the facial nerve). Report headache or stiff neck immediately as it may indicate meningitis. Objective: draining from ear if perforated, fever, swelling over mastoid process, reddened TM with possible perforation. Treatment: systemic antibiotic eardrops, mastoidectomy – Continuous ringing or noise perception (tinnitus) is one of the most common ear disorders. Therapy focuses on masking tinnitus with background sounds, noise makers and music during sleeping hours – Acoustic neuroma- benign tumors evades CN. Surgical removal with craniotomy TM perforations usually heal within 24 hours Conductive hearing loss: interfering with air conduction (outer external and middle ear and impairs sound being conducted from outer to inner ear). Most common cause: Otitis media with effusion, Diagnose with otoscopic eval, audiogram, treat with hearing aid Sensorineural hearing loss: impairment of inner ear function. Causes: loud noise, drugs, presbycusis, atherosclerosis, hypertension, prolonged fever, Meniere's disease, diabetes, ear surgery. Affects CN 8. Treatment: hearing aids, cochlear implants, tympanoplasty  BELL ’ S PALSY Sudden onset of unilateral facial paralysis or weakness Generally self-limiting, with restoration of health in a matter of weeks It’s the most common cause of facial nerve injury. Etiology/ Incidence / Predisposing factors – Idiopathic – Probably involves inflammation of CN VII (7) – Affects individuals across the life span without gender preference – Clinical appearance often correlates with periods of stress, viral infection, or fatigue – Familial tendency – Increased incidence in hypertension, diabetes, viral infection such as Herpes Simplex, Herpes Zoster, Epstein-Barr virus, CMV, coxsackievirus, adenovirus, and influenza B – Lyme’s disease  SUBJECTIVE AND OBJECTIVE Unilateral paralysis of face FINDINGS Taste impairment Ipsilateral pain in ear, cheek, and face Weakness of upper and lower face Inability to close the eyelids Abnormal corneal reflex on the affected side Hyperacusis (increased hearing sensitivity) Normal facial sensation or may have pain in or behind the ear Taste disturbance Herpetic lesions around ear/face The corneal reflex (blink test) is abnormal in 100% of cases Excessive tearing or dry eye  LABORATORY / DIAGNOSTIC FINDINGS FOR BELL ’ S PALSY Diagnostic testing is non-specific Diagnosis is one of exclusion A Lumbar puncture typically is not needed but may reveal levels of CSF protein and cells Consider test to confirm other diagnoses such as: – CT, MRI, to rule out tumor – Lyme titer (if history of tick exposure is reported) – Audiogram to rule out CNVIII (8) involvement (not associated with Bell’s Palsy)  MANAGEMENT FOR BELL ’ S PALSY Eye Care - Artificial Tears PRN Eyelids may have to be taped closed to prevent external trauma Consider referral to Physical therapy for evaluation, exercise, stimulation Use of Steroids is indicated to decrease inflammation around CN VII – In the early stages of illness (before day 10 of onset) – Tapered regimen of Medrol Dosepak Explain to pt. this disorder is self-limiting; most resolve in 4-6 weeks with complete resolution in 6 months Differentiate between Bells Palsy and Stroke: Bells Palsy is temporary paralysis of the face from facial nerve damage. Stroke affects arm and leg as well as the face on that one side. If you cannot wiggle your eyebrow or smile, it is Bells Palsy (assuming you can move your arm and leg). If you can move your eyebrow and not smile, it’s more often a stroke.  CHOLESTEATOMA “Cauliflower-like” growth accompanied by foul-smelling ear discharge Hearing loss on the affected ear On exam, the tympanic membrane is NOT visible because of destruction by the tumor History of Chronic Otitis Media infection The mass is not cancerous but can erode into the bones of the face and damage the facial nerve (CN VII) Diagnostics: CT and audiogram Treated with antibiotics (Ofloxacin) and surgical debridement (definitive treatment). Remove debris from ear canal and avoid water entering external canal Refer to Otolaryngologist  VERTIGO False sensation of movement, usually associated with disequilibrium Disequilibrium is a sense of light-headedness or of being off-balance without movement Severe vertigo is also associated with nausea and vomiting, in addition to trouble standing or walking Etiology / Incidence / Predisposing Factors – Viral syndromes – Labyrinthitis – Meniere’s disease – Vascular disease/spasm – Damage to cranial nerve VIII – Meningitis, trauma, tumors – Damage to brain stem nuclei – Encephalitis, Brain abscess, Hemorrhage, Multiple Sclerosis – Other conditions – Tertiary syphilis, alcohol intoxication, drugs, cardiac arrythmia, hypoglycemia – Cerebellar (vertebrobasilar) - Transient ischemic attack, Cerebrovascular accident SUBJECTIVE & OBJECTIVE FINDINGS OF VERTIGO Sensation of movement/rotation Light-headedness/ “faint feeling” Sense of floating or swimming Tinnitus Hearing impairment Nausea, vomiting “Full” sensation in ear Nystagmus Carotid bruits Positional hypotension Conductive hearing loss Positive Romberg sign  MANAGEMENT OF VERTIGO Treat symptomatically Medication reconciliation and stopping unnecessary medications Bedrest during acute attacks Vestibular exercises to facilitate CNS compensation Vestibular suppressants – Meclizine (Antivert) 25-100 mg PO divided every 6 hours – Diazepam (Valium) 2.5-5 mg POS at bedtime – Scopolamine (Transderm Scope patch) apply 1 patch every 3 days Low salt diet with diuretics if Meniere disease is suspected Antiemetics – Ondansetron (Zofran) 4-8 mg PO every 12 hrs – Metoclopramide (Reglan) 10 mg every 6 hour – Promethazine (Phenergan) 12.5-25 mg PO or per rectum (Suppository) q4hr-caution for falls OTHER VERTIGO DISORDERS Vertigo: linked to ear issues. Dizziness can result from dehydration and hypotension. Advise to restrict head motions and move more slowly, maintain adequate hydration, antivertiginous drugs, prevent loss of balance accidents Labyrinthitis- infection of the labyrinth, meningitis is a common complication. Treat with systemic antibiotics, bedrest and darkened room, antiemetic, antivirtiginous meds, and psychosocial support Vestibular neuritis: often caused by viral inflammation of vestibular nerve or otitis media. Brief, severe vertigo, tinnitus, nausea, vomiting aggravated by head movement, and imbalance following unilateral loss of peripheral vestibular function. Hearing remains intact. Vertigo subsides within 48-72 hours, can last 5 days. Meniere's Disease- chronic disease of the inner ear causing vertigo and hearing loss, following infections of the middle ear/trauma. Subjective: vertigo that lasts 20 min on 2 occasions, nausea, headache, sensitivity to loud noises, unilateral sensory hearing loss, tinnitus. Diagnostics: audiogram and MRI, TSH, RPR testing for syphilis and Lyme's. - Assessment questions: Can you describe your symptoms, what makes it worse or better, history of allergies or infections, wretching or vomiting, diaphoresis, what makes you feel better, audiometry test to document unilateral hearing loss, nystagmus. - Treatment: diuretics, anticholinergics, antihistamines, vasodilators, neuroleptics, vitamins, restrict caffeine, low salt, alcohol, nicotine. Allow patient to move at own slow speed, promote safety, lie down if symptoms occur. AN OLDER MAN IS DIAGNOSED WITH CONDUCTIVE HEARING LOSS IN THE LEFT EAR BY THE NP. WHICH OF THE FOLLOWING IS EXPECTED WHEN PERFORMING A RINNE TEST? A. AC (air conduction) > BC (bone conduction) B. Lateralization to the bad ear C. BC > AC D. Lateralization to the good ear THE CORRECT ANSWER IS: C. BC>AC Rationale: The normal result in the Rinne test is air conduction (AC) greater than bone conduction (BC). When there is conductive hearing loss (i.e. Ceruminosis, Otitis media) the result will be BC greater than AC. The reason is that the sound waves are blocked (i.e. Cerumen, fluid in middle ear). Therefore, the patient cannot hear them as well as through bone conduction. A PATIENT PRESENTS WITH CONDUCTIVE HEARING LOSS SECONDARY TO OTITIS MEDIA. WHAT FINDINGS ARE EXPECTED WITH THE RINNE AND WEBER TESTS? A. Weber lateralizes to good ear B. Bone conduction > Air conduction C. No lateralization noted on the Weber test D. Air conduction > Bone conduction THE CORRECT ANSWER IS: B. Bone conduction > Air conduction An abnormal Rinne test (bone conduction > air conduction) is seen in patient with conductive hearing loss. The Weber test suggests sensorineural hearing loss if the sound lateralizes to the good side, conductive hearing loss is suggested if the sound lateralizes to the bad side WHICH OF THE FOLLOWING IS NOT CONSIDERED AN OBJECTIVE FINDING IN PATIENTS WHO HAVE A CASE OF SUPPURATIVE OTITIS MEDIA? A. Erythema of the tympanic membrane B. Visualize mobility of the tympanic membrane as measured by tympanogram C. Displacement of the light reflex D. Bulging of the tympanic membrane THE CORRECT ANSWER IS: B. Visualize mobility of the tympanic membrane as measured by tympanogram Rationale: Acute suppurative otitis media is an acute infection affecting the mucosal lining of the middle ear and the mastoid air system. Suppurative stage: the tympanic membrane bulges and ruptures spontaneously through a small perforation in the pars tensa. Ear discharge is usually present. Diagnosis is usually made simply by looking at the eardrum through an otoscope. The eardrum will appear red and swollen and may appear either abnormally drawn inward or bulging outward. Using the tympanogram with the otoscope allows a puff of air to be blown lightly into the ear. Normally, this should cause movement of the eardrum, this movement may be decreased or absent. A PATIENT PRESENTS WITH UNILATERAL EAR PAIN, A SENSATION OF EAR FULLNESS, AND MUFFLED HEARING. THE PHYSICAL EXAM IS NOTABLE FOR A BULGING, ERYTHEMATOUS TYMPANIC MEMBRANE WITH REDUCED MOBILITY ON OTOSCOPY. THESE FINDINGS SUGGEST A. Otitis media with effusion WHICH DIAGNOSIS? B. Otitis Externa C. Acute otitis media D. Bullous myringitis  THE CORRECT ANSWER IS: C. Acute Otitis Media Clinical manifestations of otitis media are unilateral and include otalgia (ear pain), and decreased or muffled hearing. Diagnosis is by otoscopy, which reveals a bulging tympanic membrane with reduced mobility. WHICH OF THE FOLLOWING IS A COMMON BACTERIAL PATHOGEN FOUND IN OTITIS EXTERNA? A. Streptococcus pneumoniae B. Haemophilus influenzae C. Pseudomonas aeruginosa D. Moraxella catarrhalis THE CORRECT ANSWER IS: C. Pseudomonas aeruginosa A PATIENT PRESENTS WITH REDUCED HEARING, TINNITUS, AND FULLNESS IN THE AFFECTED EAR. THE PATIENT REPORTS FREQUENT SPONTANEOUS EPISODES OF VERTIGO, EACH LASTING 30-45 MINUTES. AUDIOMETRY CONFIRMS SENSORINEURAL HEARING LOSS IN THE AFFECTED EAR. WHICH OF THE FOLLOWING IS FIRST-LINE TREATMENT FOR THIS DIAGNOSIS BASED ON CLINICAL FINDINGS? A. Vestibular rehabilitation therapy B. Lifestyle modification including salt restriction C. Pharmacotherapy with diuretics D. Glucocorticoid therapy for symptom management THE CORRECT ANSWER IS: B. Lifestyle modification including salt restriction The patient is presenting with signs of Meniere’s disease. Patients experience progressive hearing loss with vestibular symptoms including spontaneous episodes of vertigo that last 20 minutes to 12 hours and occur two or more times, and fluctuating aural symptoms (reduced hearing, tinnitus, fullness). Audiometry confirms sensorineural hearing loss. Initial therapy includes lifestyle modifications such as salt restriction and limiting caffeine and alcohol consumption. A PATIENT PRESENTS WITH UNILATERAL EAR PAIN AND DECREASED HEARING. THE PATIENT REPORTS A RECENT UPPER RESPIRATORY INFECTION. AN OTOSCOPIC EXAM REVEALS A BULGING TYMPANIC MEMBRANE, WITH REDUCED MOBILITY. THERE IS PARTIAL OPACIFICATION OF THE TM. THE PATIENT DOES NOT A. Cefdinir REPORT A PENICILLIN ALLERGY. (Omnicef) BASED ON THESE SYMPTOMS, WHICH B. Amoxicillin- Clavulanate (Augmentin) MEDICATION IS INDICATED FOR FIRST-LINE C. Doxycycline (Adoxa) THERAPY? D. Clarithromycin (Biaxin) THE CORRECT ANSWER IS: B. Amoxicillin- Clavulanate (Augmentin) The patient is presenting with signs of acute otitis media (unilateral otalgia and decreased hearing). Otoscopic exam is required for diagnosis, often revealing a bulging, opacified, erythematous tympanic membrane. Antibiotics are recommended for treatment, Augmentin is recommended as first-line therapy in patients with no PCN allergy. Other three answers can be used for patients with a mild PCN allergy A MIDDLE AGED PATIENT PRESENTS WITH ANXIETY AND DIZZINESS. THEY COMPLAIN THAT UPON GETTING OUT OF BED THAT MORNING, THEY HAD S EVER E DIZ Z INES S AND ALMOS T F ELL BECAU S E “THE R OOM WAS S PINNING S O MUCH”. THE PATIENT’S GAIT IS UNSTABLE WITH SOME SWAYING NOTED. THEY REPORT BECOMING VERY DIZZY AND HAVING PROBLEMS WITH BALANCE WHEN MOVING THEIR HEAD QUICKLY. THE PATIENT DENIES TRAUMA, HYPERTENSION, TINNITUS, HEARING LOSS, AND FEVER. THE ROMBERG TEST IS POSITIVE. WHICH OF THE FOLLOWING CONDITIONS IS MOST LIKELY? A. Benign paroxysmal positional vertigo (BPPV) B. Meniere’s disease C. Acoustic neuroma D. CVA THE CORRECT ANSWER IS: A. Benign paroxysmal positional vertigo (BPPV) BPPV is the most common cause of vertigo in the US. It is caused by calcium carbonate crystals in the semicircular canals. An initial treatment is the Epley maneuver, in which the head is turned sequentially, which helps to move the crystals in the semicircular canals by gravity. There is no tinnitus or hearing loss, so Meniere's disease and acoustic neuroma can be ruled out. W HIC H O F T H E FO LLO W IN G C O N D IT IO NS IS C LA S S IFIE D A S SE NSO R IN E U R A L H E A R ING LO S S ? A. Presbycusis B. Otitis media C. Ceruminous D. Otitis externa THE CORRECT ANSWER IS: A. Presbycusis Presbycusis is a type of sensorineural hearing loss that is caused by normal aging of the auditory system. It initially affects the ability to hear high pitched sounds (speaking). Conductive hearing loss examples include otitis media, otitis externa, vestibular schwannoma, and ceruminosis A PATIENT PRESENTS WITH A SENSATION OF AURAL FULLNESS AND DECREASED HEARING. THE PATIENT DENIES SIGNIFICANT PAIN BUT REPORTS A VIRAL INFECTION. OTOSCOPIC EXAM REVEALS AN INTACT TM WITH CLEAR YELLOW FLUID BEHIND THE TM. TREATMENT FOR THIS CONDITION INCLUDES WHICH OF THE FOLLOWING INTERVENTIONS? A. Observation and supportive therapy with oral decongestants B. Treatment with Amoxicillin-clauvanate (Augmentin) C. Topical antibiotic ear drops D. Immediate referral for ENT evaluation THE CORRECT ANSWER IS: A. Observation and supportive therapy with oral decongestants This patient is presenting with otitis media with effusion, which is characterized by hearing loss and a sense of aural fullness. Otoscopic exam reveals the presence of middle ear fluid and an intact TM without active infection evidence. Management involves supportive care because most effusions resolve within 12 weeks. Treatment for symptoms includes antihistamines, oral decongestants, and/or nasal corticosteroids. Acute otitis media requires antibiotic therapy (Augmentin) or second-third gen cephalosporins with mild PCN allergy. For those with ruptured TM in acute otitis media, topical antibiotics. An ENT referral is indicated for chronic perforated TM or persistent hearing loss in acute otitis media A C HILD HA S R E C U R R E N T IM P A C T IO N O F C E R U M E N IN B O T H E A R S A N D T H E P A R E NT A S KS W H A T C A N BE D O N E T O H E LP P R E V E N T T H IS. W H A T S U G G E S T IO N W ILL T H E P R O V ID E R P R O V ID E ? a. Cleaning the outer ear and canal with a soft cloth b. Removing cerumen with a cotton-tipped swab c. Trying thermal-auricular therapy when needed d. Using an oral irrigation tool to remove cerumen THE CORRECT ANSWER IS: A. Parents should be instructed to use a soft cloth to clean the outer ear and canal only. Use of a cotton-tipped swab or any other implement may push cerumen deeper into the canal and risk damaging the tympanic membrane. Thermal-auricular therapy is not recommended. Oral irrigation tools have high pressure and a risk of damage to the tympanic membrane. A YOUNG CHILD HAS A PALE, WHITISH DISCOLORATION BEHIND THE TYMPANIC MEMBRANE. THE PROVIDER NOTES NO SCARRING ON THE TYMPANIC MEMBRANE (TM) AND NO RETRACTION OF THE PARS FLACCIDA. THE PARENT STATES THAT THE CHILD HAS NEVER HAD AN EAR INFECTION. WHAT DO a. Chronic cholesteatoma THESE FINDINGS b. Congenital cholesteatoma MOST LIKELY REPRESENT? c. Primary acquired cholesteatoma d. Secondary acquired cholesteatoma THE CORRECT ANSWER IS: ANS: B Patients without history of otitis media or perforation of the TM most likely have congenital cholesteatoma. Primary acquired cholesteatoma will include retraction of the pars flaccida and a prior ear infection. Secondary acquired cholesteatoma has findings associated with the underlying etiology. A CHILD IS DIAGNOSED AS HAVING A CONGENITAL CHOLESTEATOMA. WHAT IS INCLUDED IN MANAGEMENT OF THIS CONDITION? a. Antibacterial treatment (SELECT ALL b. Insertion of pressure equalizing tubes (PETs) THAT APPLY.) c. Irrigation of the ear canal d. Removal of debris from the ear canal e. surgery to remove the lesion THE CORRECT ANSWER IS: ANS: A, D, E Cholesteatoma is treated with antibiotics, removal of debris from the ear canal, and possibly surgery. PETs and irrigation of the ear canal are not part of treatment for cholesteatoma A CHILD WHO HAS RECURRENT OTITIS MEDIA FAILS A HEARING SCREEN AT SCHOOL. THE PROVIDER SUSPECTS WHICH TYPE OF HEARING LOSS IN THIS a. Central CHILD? b. Conductive c. Mixed type d. Sensorineural THE CORRECT ANSWER IS: ANS: B A common cause of conductive loss is fluid in the middle ear as a result of chronic otitis media with effusion. Central hearing loss is related to CNS disorders. Mixed-type hearing loss is related to causes of both conductive and sensorineural hearing loss. Sensorineural hearing loss is caused by damage to the structures in the inner ear, usually caused by infection, barotrauma, or trauma A P A T IENT IS S US P E C T E D O F H A V IN G V E S T IB U LA R N E UR ITIS. W H IC H FIND IN G O N P HY S IC A L E XA MINA T IO N IS C O NSIST E N T W IT H T HIS D IA G N O S IS ? a. Facial palsy and vertigo b. Fluctuating hearing loss and tinnitus c. Spontaneous horizontal nystagmus d. Vertigo with changes in head position THE CORRECT ANSWER IS: ANS: C Many patients with vestibular neuritis will exhibit spontaneous horizontal or rotary nystagmus, away from the affected ear. Facial palsy with vertigo occurs with Ramsay Hunt syndrome, caused by herpes zoster. Fluctuating hearing loss with tinnitus is common in Meniere’s disease. Tinnitus may occur with vestibular neuritis but hearing loss does not occur. Patients with benign paroxysmal positional vertigo will exhibit vertigo associated with changes in head position A P A T IENT R E P O R T S S E V E R A L E P IS O D E S O F A C U T E V E R T IG O , S O M E LA S T IN G UP T O A N HO U R , A S S O C IA T E D W IT H N A USE A A ND V O M IT IN G. W HA T IS P A R T O F T H E INIT IA L D IA G NO ST IC W O R KU P FO R T HIS P A T IE N T ? a. Audiogram b. Auditory brainstem testing c. Electrocochleography d. Vestibular testing THE CORRECT ANSWER IS: ANS: A An audiogram and magnetic resonance imaging (MRI) are part of basic testing for Meniere’s disease. The other testing may be performed by an otolaryngologist after referral WHICH SYMPTOMS MAY OCCUR WITH VESTIBULAR NEURITIS? (SELECT ALL THAT APPLY.) a. Disequilibrium b. Fever c. Hearing loss d. Nausea and vomiting e. Tinnitus THE CORRECT ANSWER IS: ANS: A, D, E Vestibular neuritis can cause severe vertigo, disequilibrium, nausea, vomiting, and tinnitus, but not fever or hearing loss. A P A T IENT R E P O R T S A FE E LIN G O F FU LLN E S S A N D P A IN IN BO T H E A R S A N D T H E P R A C T IT IO N E R E LIC IT S E XQUIS ITE P A IN W HEN M A N IP U LA T ING T H E E X T E R NA L E A R S T R UC T UR E S. W H A T IS T H E LIKE LY D IA G N O S IS ? a. Acute otitis externa b. Acute otitis media c. Chronic otitis externa d. Otitis media with effusion THE CORRECT ANSWER IS: ANS: A This patient’s symptoms are classic for acute otitis externa. Chronic otitis externa more commonly presents with itching. Acute otitis media is accompanied by fever and tympanic membrane inflammation, but not external canal inflammation. Otitis media with effusion causes a sense of fullness but not pain. A P A T IENT HA S A N IN IT IA L E P IS O D E O T IT IS E X T E R N A L A SSO C IA TE D W IT H S W IM M ING. T H E P A T IE N T ’ S E A R C A NA L IS MILD LY INFLA M E D , A N D T H E T YM P A NIC M E M BR A NE IS N O T INV O LV E D. W H IC H M E D IC A T IO N W ILL BE O R D E R ED ? a. Cipro HC b. Fluconazole c. Neomycin d. Vinegar and alcohol THE CORRECT ANSWER IS: ANS: A In the absence of a culture, the provider should choose a medication that is effective against both P. aeruginosa and S. aureus. Cipro HC covers both organisms and also contains a corticosteroid for inflammation. Fluconazole is an oral antifungal medication used when fungal infection is present. Neomycin alone does not cover these organisms. Vinegar and alcohol are used to treat mild fungal infections WHICH ARE RISK FACTORS FOR DEVELOPING OTITIS EXTERNA? (SELECT ALL THAT APPLY.) a. Cooler, low-humidity environments b. Exposure to someone with otitis externa c. Having underlying diabetes mellitus d. Use of ear plugs and hearing aids e. Vigorous external canal hygiene THE CORRECT ANSWER IS: ANS: C, D, E Otitis externa is a cellulitis of the external canal that develops when the integrity of the skin is compromised. Diabetes mellitus predisposes patients to skin disorders. Using devices that cause moisture retention and irritation will increase the risk. Vigorous cleansing removes protective cerumen. Warm, high-humidity environments increase risk. The disease is not contagious A P E D IA T R IC P A T IE N T ’ S A S S E S S M E N T C O NFIR M S T H E P A T IE NT H A S O T A LG IA , A FE V E R O F 3 8. 8 ° C , A ND A R E C E NT H IST O R Y O F U P P E R R E S P IR A T O R Y E X A M IN A T IO N. T HE E XA MINE R IS UN A B LE T O V IS U A LIZ E T H E T Y M P A N IC M E M BR A NE S IN T H E R IG HT E A R BE C A U S E O F T H E P R E SE NC E O F C E R U M E N IN T HE E A R C A NA L. T H E LE FT T YMP A NIC M E M B R A N E IS D U LL G R A Y W IT H FLU ID LE V E LS P R E SE NT. W H A T IS T H E C O R R E C T A C T IO N ? a. Perform a tympanogram on the right ear. b. Recommend symptomatic treatment for fever and pain. c. Remove the cerumen and visualize the tympanic membrane. d. Treat empirically with amoxicillin 80 to 90 mg/kg/day. THE CORRECT ANSWER IS: ANS: C The AAP 2013 guidelines strongly recommend visualization of the tympanic membrane to accurately diagnose otitis media and not to treat based on symptoms alone. The practitioner should attempt to remove the cerumen to visualize the tympanic membrane. A tympanogram cannot be performed when cerumen is blocking the canal. Because the child may have an acute ear infection, antibiotics may be necessary. WHICH PATIENT MAY BE GIVEN SYMPTOMATIC TREATMENT WITH 24 HOURS FOLLOW-UP ASSESSMENT WITHOUT INITIAL ANTIBIOTIC THERAPY? a. A 36-month-old with fever of 38.5°C, mild otalgia, and red, non-bulging TM b. A 4-year-old, afebrile child with bilateral otorrhea c. A 5-year-old with fever of 38.0°C, severe otalgia, and red, bulging TM d. A 6-month-old with fever of 39.2°C, poor sleep and appetite and bulging TM THE CORRECT ANSWER IS: ANS: A Children older than 24 months with fever less than 39°C and nonsevere symptoms may be watched for 24 hours with symptomatic treatment. Children with otorrhea, those with severe AOM, and any children with fever greater than 39°C should be given antibiotics A PATIENT REPORTS EAR PAIN AND DIFFICULTY HEARING. AN OTOSCOPIC EXAMINATION REVEALS A SMALL TEAR IN THE TYMPANIC MEMBRANE OF THE AFFECTED EAR WITH PURULENT DISCHARGE. WHAT IS THE INITIAL TREATMENT FOR THIS PATIENT? a. Insert a wick into the ear canal. b. Irrigate the ear canal to remove the discharge. c. Prescribe antibiotic ear drops. d. Refer the patient to an otolaryngologist THE CORRECT ANSWER IS: ANS C. This perforation is most likely due to infection and should be treated with antibiotic ear drops. Wicks are used for otitis externa. The ear canal should not be irrigated to avoid introducing fluid into the middle ear. It is not necessary to refer unless the perforation does not heal. A P A T IENT R E P O R T S E A R P A IN A FT E R BE IN G HIT IN T H E H E A D W IT H A BA S E B A LL. T HE P R O V ID E R N O T E S A P E R FO R A TE D T Y M P A NIC M E M BR A N E. W HA T IS T HE R E C O M ME ND E D T R E A T M E NT ? A. Order antibiotic ear drops if signs of infection occur. b. Prescribe analgesics and follow up in 1 to 2 days. c. Reassure the patient that this will heal without problems. d. Refer the patient to an otolaryngologist for evaluation THE CORRECT ANSWER IS: ANS: D Patients with traumatic or blast injuries causing perforations of the tympanic membranes should be referred to specialists to determine whether damage to inner ear structures has occurred. For an uncomplicated perforation, the other interventions are all appropriate