Ear Disorders Past Papers PDF

Part 7 Evaluation and Management of Ear Disorders Auricular Disorders (Chapter 64, Slide 1 of 3) Conditions that affect the external ear Benign conditions associated with other disease processes Addison Cartilage calcification Hansen’s nodules Keloids Related to c...

Part 7 Evaluation and Management of Ear Disorders Auricular Disorders (Chapter 64, Slide 1 of 3) Conditions that affect the external ear Benign conditions associated with other disease processes Addison Cartilage calcification Hansen’s nodules Keloids Related to cultural practices Body piercing Serious illness that requires immediate referral and treatment Malignant otitis externa, basal cell cancer Auricle hematoma Auricular Disorders (Chapter 64, Slide 2 of 3) Symptoms Depend on the underlying cause of the disorder Malignant otitis externa may manifest as a sequela to an infection or a respiratory illness, and most often occurs in immunosuppressed or diabetic patients. Diagnostics Depend on the underlying disease process Biopsy Rheumatoid arthritis panel and autoimmune profiles Uric acid chemistry profile Auricular Disorders (Chapter 64, Slide 3 of 3) Management Topical alcohol and antibiotic ointment Oral cephalexin or dicloxacillin (mild infections) Hospitalization IV Abx intravenous cefazolin or nafcillin (severe infections) Aggressive treatment Perichondritis, malignant otitis externa, or signs of mastoiditis require immediate referral to an otolaryngologist, admission to a hospital, and aggressive antimicrobial therapy usually aimed against Pseudomonas and/or Staphylococcus aureus. Cerumen Impaction (Chapter 65, Slide 1 of 2) Occurs when thickened cerumen either partially or completely occlude the external ear canal Ear plugs, hearing aids, earbuds used to listen to music and talk on the phone, and probes such as cotton-tipped swabs used to clean the ear can cause cerumen impaction. Symptoms Complaint of unilateral or bilateral fullness or hearing loss, otalgia, itching, discomfort, tinnitus, cough, vertigo, and dizziness Cerumen Impaction (Chapter 65, Slide 2 of 2) Management Prior to ear lavage/removal of cerumen, inquire if patient has a history of a ruptured TM, tympanostomy tubes, or recent ear surgery. Removal with a cerumen spoon or curette Cerumenolytic or mineral oil, liquid docusate sodium, or hydrogen peroxide can be inserted in the affected ear daily for 3 to 5 days. Irrigation with water or normal saline at body temperature using an ear syringe, a device specifically designed for ear irrigation, or a regular syringe with a flexible catheter can be performed.  Discussion Question 1 Discuss management of cerumen impaction. What are the contraindications to the use of cerumenolytic agents?  Cholesteatoma (Chapter 66, Slide 1 of 2) An abnormal accumulation of squamous epithelial cells typically found within the middle ear, mastoid air spaces, or epitympanum Acquired (most common) Acquired lesions are associated with recurrent or persistent purulent ear infections and tinnitus. Congenital May slowly enlarge for years and be asymptomatic. Symptoms Impaired hearing may be the first sign of middle ear destruction from a cholesteatoma. Malodorous otorrhea, tinnitus, vertigo  Cholesteatoma (Chapter 66, Slide 2 of 2) Diagnostics Otoscopic exam Diagnostics Audiogram CT scan MRI Management Removal of debris from the ear canal Avoidance of water entering the canal Treatment with bacterial agents that cover the common bacterial organisms Reduce inner ear inflammation Surgery Definitive treatment  Impaired Hearing (Chapter 67, Slide 1 of 3) Impaired hearing is a defect in the detection and/or processing of sound waves. Impaired hearing affects both communication ability and personal safety and can be a socially isolating experience. Occurs at all ages, prevalence increases with advancing age. Hearing loss can reflect a wide variety of abnormalities and requires different considerations in children than in adults. Sudden hearing loss is associated with autoimmune diseases, chronic renal failure, infections, ischemia of the inner ear or retrocochlear structures, multiple sclerosis, sickle cell anemia, sudden idiopathic sensorineural hearing loss, and trauma. Factors associated with gradual hearing loss include cholesteatoma, chronic renal failure, chronic otitis media, diabetes hypothyroidism, noise exposure, otosclerosis, presbycusis, and retrocochlear neoplasm. Fluctuating hearing loss causes include autoimmune disorders, Meniere disease, migraine headache, multiple sclerosis, otitis media perilymphatic fistula, sarcoidosis, and syphilis.  Impaired Hearing (Chapter 67, Slide 2 of 3) Immediate specialist referral to an otolaryngologist or neurologist is indicated for patients with sudden hearing loss. May present as sudden, progressive, or fluctuating in nature Assess whether unilateral or bilateral Associated symptoms: Otalgia, ear fullness, vertigo, tinnitus, or cranial neuropathies should be documented. Patients medical and family history, and medication use should incorporate current and past treatments with oral and IV meds, and OTC.  Impaired Hearing (Chapter 67, Slide 3 of 3) Diagnostics Rinne and Weber test Screening audiogram Tympanometric screening MRI/CT scan Management Remove cerumen impaction. Results in spontaneous improvement in hearing Treat underlying infection, other etiologies Otolaryngology referral is indicated for patients with hearing deficit associated with trauma, congenital hearing loss, tumors, obstructions of the external auditory canal, nonhealing tympanic membrane rupture, and otosclerosis. Treatment for otosclerosis may be stapedectomy or sound amplification. Tympanic membrane perforation may heal spontaneously or require a surgical patch or graft.  Discussion Question 2 Discuss possible causes of impaired hearing. What are possible causes of intermittent hearing loss? Inner Ear Disorders (Chapter 68, Slide 1 of 3) Vestibular Neuritis Acute unilateral labyrinthine dysfunction, severe vertigo, nausea, vomiting; imbalance lasting a few days followed by vertigo and disequilibrium with rapid head movement; last for weeks to months Presenting symptoms Severe vertigo, nausea, and vomiting aggravated by head movement. Tinnitus may be present, but hearing remains intact. Management Treat the underlying cause and provide symptomatic relief. Pharmacotherapy: Anticholinergics, antihistamines, long-acting benzodiazepines, or antiemetics Vestibular exercises Inner Ear Disorders (Chapter 68, Slide 2 of 3) Meniere Disease Chronic condition of the inner ear characterized by recurrent vertigo and hearing loss; Four symptoms, may or may not occur simultaneously: dizziness described as spinning vertigo, low- frequency sensorineural hearing loss, tinnitus, and a feeling of fullness in the affected ear Presentation Early phase: Have intermittent attacks of vertigo that last from minutes to hours, often associated with nausea and vomiting. These episodes are commonly accompanied by pressure in the ear, low-pitched tinnitus fluctuating in intensity, and unilateral hearing loss. Management Refer to an otolaryngologist for testing and management. There is no cure for the disease, and treatment can be difficult. Goals of therapy include managing the episodes of vertigo and arresting the disease process. Inner Ear Disorders (Chapter 68, Slide 3 of 3) Tinnitus The perception of a sound when there is no sound in the environment. Usually chronic, benign, but annoying ringing, buzzing, hissing, high-pitched screeching, whistling, or other noise in one or both ears that can be constant or intermittent. Presentation Sounds associated with the tinnitus are helpful in identifying the etiology. Management Hearing aids, sound masking, and cognitive-behavioral therapy may be indicated. If vascular related, steroids may be effective. Sound maskers alone, such as electronic noise-generating devices, mood tapes, and radio static (if there is no hearing loss) Antidepressants  Otitis Externa (Chapter 69) Otitis externa is a cellulitis of the external auditory canal that may extend to the auricle. Often referred to as “swimmer’s ear” Acute otitis externa Pain of the affected ear and auricle developing over 48 hours or less Classic presentation: Pain and tenderness on palpation of the tragus and on repositioning of the auricle to allow inspection of the canal Chief symptoms: Pain, feeling of fullness, itching Other signs and symptoms: drainage from the affected ear and hearing loss Chronic otitis externa Canal is dry without cerumen. Primarily one of intense pruritus Management Clear debris from the canal Manage pain NSAIDs, opioids, topical anesthetics Treat the infection and inflammation. Topical antibiotics  Otitis Media (Chapter 70, Slide 1 of 2) Fluid in the middle ear is associated with varied inflammatory or infective processes that may be bacterial, fungal, or viral in origin, and is most often associated with upper respiratory tract infections or allergies. Types Acute otitis media (AOM)—A rapid onset and short duration Otitis media with effusion (OME)—Accumulation of serous fluid in the middle ear without acute inflammation Middle ear effusion (MEE)—Accumulation of serous fluid in the middle ear and can be associated with AOM Severity of symptoms (otalgia and fever) aligns with type of AOM. AOM—Rapid onset otalgia, worse in a prone position, remains the common initial complaint of patients.  Otitis Media (Chapter 70, Slide 2 of 2) Diagnostics Otoscopic exam Tympanometry Acoustic reflectometry Rinne and Weber tests Sinus X-ray study or a computed tomography (CT) scan of the sinuses Allergy testing CBC with diff Tympanocentesis Management Immediate referral for children under 6 months of age or a child who appears toxic The need for antibiotic therapy is determined on an individual basis based on history and presentation. Current recommendations are for “watchful waiting.” Generally, amoxicillin is the preferred first-line medication. Analgesics: Acetaminophen or ibuprofen is preferred.  Discussion Question 3 Describe management for acute otitis media. When is immediate referral indicated?  Tympanic Membrane Perforation (Chapter 71, Slide 1 of 2) Opening in the membrane that, as a mechanical component of hearing, separates the external ear from the middle ear. Results from a variety of conditions Is a cause of conductive hearing loss Most perforations heal spontaneously without incident. Some TM perforations may need referral to a specialist. Symptoms Hearing loss, a sensation of fullness or popping in the effected ear, tinnitus, and vertigo are common symptoms associated with tympanic perforation.  Tympanic Membrane Perforation (Chapter 71, Slide 2 of 2) Diagnostics Otoscopic exam Patients with trauma-associated presentations should be assessed for possible skull fracture, facial nerve injury, and evidence of cerebrospinal fluid leakage from ear or nose. Audiogram Management Most perforations heal spontaneously unless there is infection. Some will require repair with a patch or graft. Patients should keep water out of the ear until the perforation has healed. Antibiotic drops or systemic antibiotics are often necessary when infection is evident.  Part 7: Evaluation and Management of Ear Disorders Case Study 1 Dennis, a 58-year-old male, presents with complaints of decreased hearing and fullness in his ears. On examination you note impacted cerumen.  Case Study 1 Discussion Question 1 Dennis would like to know what caused this. He states that he regularly cleans his ears. You tell him that there are many possible reasons including A. His age B. Men are more susceptible. C. Use of earbuds and cotton swabs D. Talking on the phone for long periods of time  Case Study 1 Discussion Question 2 Which options for removal do you provide to Dennis? A. Irrigation B. Manual removal with curette C. Cerumenolytic or mineral oil, liquid docusate sodium, or hydrogen peroxide daily for 3–5 days D. All of the above  Case Study 1 Discussion Question 3 What important questions do you need to ask Dennis to determine the appropriate removal method? A. If he has had any recent surgical procedures B. If he is currently taking any medications C. If he has a history of a ruptured TM, tympanostomy tubes, or recent ear surgery D. If he has ever had impacted cerumen before  Part 7: Evaluation and Management of Ear Disorders Case Study 2 Brandon, a 2-year-old boy, presents with his father. His father states that Brandon has been having fevers and is intermittently crying and keeps touching his right ear. He states that symptoms started last night.  Case Study 2 Discussion Question 1 Which examination and diagnostics are indicated? A. CT scan B. Viral respiratory nasal swab C. Otoscopic exam D. CBC and chemistry panel  Case Study 2 Discussion Question 2 You explain to Brandon's father that he has acute otitis media, and the recommended treatment is A. Antibiotics B. Analgesics and watchful waiting; they usually resolve on their own. C. An immediate referral to otolaryngology D. Antihistamines  Case Study 2 Discussion Question 3 When antibiotics are indicated for otitis media, which is the preferred first line antibiotic? A. Cephalosporins B. Augmentin C. Amoxicillin D. Doxycycline