5: Ears Flashcards
Comparing the adult/child ear. A child has a smaller ______, which is more easily occluded during infection.
Nasopharynx
Comparing the adult/child ear. Lymph tissue (tonsils, adenoids) grows rapidly in early childhood. Atrophies after age _____.
12
Comparing the adult/child ear. In a child, small oral cavity and large tongue increase risk of _____.
Obstruction
Comparing the adult/child ear. In a child, smaller nares are more easily _____.
Occluded
Comparing the adult/child ear. In a child, the _____ is long and floppy, vulnerable to swelling with resultant obstruction.
Epiglottis
Comparing the adult/child ear. In a child, the larynx and glottis are _____ in the neck, increasing risk of aspiration.
Higher
Comparing the adult/child ear. In the child, the _____, _____, and _____ cartilages are immature and flexible, causing risk for collapse when the neck is flexed.
Thyroid, cricoid, and tracheal cartilages
Comparing the adult/child ear. In the child, _____ are functional in the airway. This allows for less compensation for edema, spasm, and trauma.
Fewer muscles
Comparing the adult/child ear. In the child, the large amounts of _____ and _____ lining the airway increase the risk for edema and obstruction.
Soft tissue and loosely anchored mucous membranes
_____ are masses of lymphatic tissue in the pharyngeal cavity.
Tonsils
What do tonsils do (2)?
- Filter and protect the respiratory and alimentary tract for pathogenic organisms.
- Play a role in the formation of antibodies protecting against URIs.
T/F Tonsils are larger in children than in adults.
True
The _____ is the tonsil on the posterior wall of the nasopharynx.
Adenoid
_____ primary teeth rest in their places at birth.
20
Primary teeth erupt beginning at _____ months of age.
6
Primary teeth are shed from approximately ages _____.
6-12
Permanent teeth erupt from approximately ages _____.
6-13
Wisdom teeth erupt from ages _____.
17-21
External ear.
Pinna
Contains glands secreting sweat, sebum, and cerumen.
Lubricates hair follicles aiding debris removal.
Functions properly only when patency is maintained.
Pinna/external auditory canal
Separates external from middle ear.
Tympanic membrane
Has a chamber containing ossicles.
Middle ear
Name the ear bones (3).
- Malleus
- Incus
- Stapes
Lies on tympanic membrane; vibrates with sound.
Malleus
Acts as a bridge for 2 bones.
Incus
Rests against oval window; stimulates fluids of inner ear.
Stapes
Ventilates middle ear.
Eustachian tubes
How does the Eustachian tube ventilate the middle ear (2)?
- Equalizes internal air pressure and atmospheric pressure.
2. Replaces absorbed oxygen.
What are the functions of the Eustachian tubes (3)?
- Ventilates middle ear.
- Protects from sound, pressure, and secretions.
- Drains secretions from middle ear into nasopharynx.
What are the functions of the inner ear (4)?
- Transmits sound.
- Aids balance.
- Responds to changes in direction of movement.
- Maintains equilibrium.
What are the steps to transmit sound (5)?
- Fluids move according to vibrations of TM, ossicles, and oval window.
- Fluid sound waves reach the cochlea.
- Sound is transduced by hairs in the organ of Corti.
- Impulses are sent by the hair cells to cranial nerve VIII.
- Impulses continue to the brain.
Where are equilibrium receptors located?
Semicircular canals and vestibule of inner ear
4 ways to restrain child for ear exam.
- On parent’s shoulder.
- On parent’s lap (belly to belly with child’s legs wrapping parent’s waist, head held to parental chest).
- Restrained on exam table.
- Papoose board.
What is the most comprehensive restraint for ear exams?
Papoose board
What age is the most difficult to restrain?
Toddlers 1-3
What is the preferred position for toddlers?
Parent’s lap. Allows for “hug” hold.
T/F If the parent isn’t helpful, you should use your body to lie over the child and restrain the top half of his body while you exam the ear.
True
Inflammatory reaction of external ear canal.
Otitis Externa
Simple infx involving edema, discharge, and erythema.
Otitis Externa
Otitis externa can involve _____, small abscesses of hair follicles.
Furuncles
If otitis externa is caused by staph, patient may exhibit _____.
Impetigo
Chronic OE is often found in patients with _____ and _____.
Hearing aids and skin conditions
What 2 skin conditions are related to chronic OE?
- Seborrhea
2. Eczema
OE is usually caused by _____ in the external ear. Changes the acidic environment, promoting bacterial or fungal growth.
Retained moisture
How do swimming pools cause OE?
Chlorine kills normal flora, allowing pathogens to grow.
Most common culprits of OE (2).
- Pseudomonas
2. Staph
T/F Discharge from a perforated AOM can cause secondary OE.
True
What causes furunculosis (2)?
- Staph
2. Strep pyogenes by self-inoculation
T/F OE and furunculosis are treated the same.
False. Furunculosis is treated differently than when the entire ear canal is swollen.
Causes of otomycosis (2)?
- Candida
2. Aspergillus
When is otomycosis most common (2)?
- After ABX use.
2. After systemic steroid use.
Most common patient populations for otomycosis (2)?
- DM
2. Immunocompromised
Presentation of OE (9)?
- Itching and irritation that progresses to pain.
- Pressure or fullness in ear.
- Hearing loss.
- Otorrhea (discharge).
- Systemic complaints uncommon (usually localized to ear canal).
- Pain with manipulation of tragus or pinna.
- Pain with ear exam.
- Swollen external canal with debris.
- Local lymphadenopathy.
On the ear exam, a red indurated point can indicate _____ or _____.
Furunculosis or Folliculitis
Black lesion on TM with _____.
Fungal infx.
_____ OE can present as a dry, flaky, thinning canal.
Chronic
What are the DDx for OE (7)?
- Otitis media with perforation
- Chronic suppurative otitis media
- Mastoiditis
- Cholesteatoma
- Posterior auricular lymphadenopathy
- Dental infection
- Eczema
Management of OE (5)?
- Remove any foreign body.
- Irrigate with saline or Burrow’s solution.
- Antibiotic ear drops +/- steroid.
- No water in ear canal/avoid cleaning.
- No swimming.
- Analgesics for pain.
- Antifungals for mycotic infx.
- Preventive therapy
T/F FNPs can lance existing furuncles.
False. ENTs can.
What is preventive therapy for OE?
Acidic eardrops prior to swimming. Can be vinegar or Vosol (acetic acid solution).
What is first-line therapy for OE (3)?
Fluoroquinolone eardrops
- Cipro
- Ofloxacin
- Neomycin
What might indicate contact dermatitis in OE?
Lessened pain with increased itching.
When can otic drops not be used for OE?
Perforated TM. Use systemic.
Suppurative effusion of the TM, infection with pus formation behind the TM.
Acute Otitis Media (AOM)
Bullae form between the layers of the TM, pressing outward into the ear canal.
Bullous myringitis (type of AOM)
The treated acute OM never gets better or returns within 1 to 2 days after finishing antibiotics.
Persistent AOM
What qualifies as recurrent AOM?
3 separate cases of AOM within 6 months or 6 cases within 12 months.
Irritable, ear pain (pulling on ear), occasional discharge from ear, fever, symptoms of URI.
AOM
T/F Hx is a good predictor of AOM.
False. Hx is a poor predictor of an ear infection.
What will you find on examination with AOM (5)?
- Bulging or retraction of TM.
- Limited or absent mobility.
- Abnormal air fluid level.
- Otorrhea (perforated TM).
- Major erythema of TM.
T/F Major erythema of TM indicates AOM.
True
Eardrum is yellow or amber in color.
Serous OM. Precursor to AOM.
TM color when infected.
Bright red.
T/F Landmarks are absent or distorted in AOM.
True
T/F Bubble may form behind the TM in AOM.
True. Also indicates otitis media with effusion.
T/F Eardrums may retract or bulge in AOM.
True. Vacuum sucks it. Or bulges from buildup of too much fluid.
Inability of the eardrum to react to air flow.
Hypomotility
_____ is an early sign of AOM.
Hypomotility
An _____ is found when the tympanic membrane appears translucent above and opaque below a line demarcating the separation.
Air-fluid level
Round, darkened oval in the TM.
Perforated TM
Where does central perforation occur?
Over pars tensa near the TM
Where does marginal perforation occur?
Annulus in the upper region of the TM
T/F Perforation can occur from inside out pressure or outside in pressure.
True
T/F A slap or blow to the ear can cause a sudden perforation in the TM.
True
T/F Ruptured TM should be followed up but will heal on its own.
True
Mainly used for children who have recurrent otitis media.
Tympanostomy Tubes
Why is it important to prevent recurrent otitis media?
Can cause difficulty with language development and hearing.
T/F FNPs place tympanostomy tubes in the office.
False. Refer to ENT for evaluation.
What is the purpose of tympanostomy tubes?
To create channel from outside the ear to the middle ear, allowing for release of pressure. This allows for drainage, possibly decreasing need for ABX.
T/F The likelihood of otitis media decreases immediately after tubes are placed.
True
When do tubes usually extrude?
12-18 months after placement (TM grows to fill in hole).
Overgrowth of epidermal tissue in the middle ear.
Cholesteatoma
Pearl white, cheese-like lesion embedded in the TM.
Cholesteatoma
Why should a cholesteatoma be removed?
Can erode bone and cause hearing loss.
What are signs of cholesteatoma (3)?
- Discharge (early sign)
- Unilateral conductive hearing loss
- Ringing in ears (tinnitus)
Refer patient to ENT if found.
Dense white patches on the TM.
Scarring
T/F Scarring can affect hearing or cause long-term effects.
False
Diagnose AOM when these are present (8).
- Middle ear effusion.
- Bulging.
- Poor mobility.
- Air fluid level.
- Discharge.
- Cloudiness of TM.
- Erythema.
- Otalgia
T/F AOM with effusion can occur with a respiratory infx, and before/after AOM.
True
T/F AOM with effusion needs ABX treatment.
False. Supportive care for pain control. Decongestant can help move fluid out of the Eustachian tubes.
Which of these patients with AOM should be treated with ABX?
- Down’s syndrome
- Immunodeficiency
- < 6 months old
- Chronic otitis media with effusion
All of them. Chronic otitis media with effusion may respond better to topical ABX.
Pain control for AOM (5)?
- Tylenol (under 6 months)
- Ibuprofen (over 6 months)
- Warm/cold oil
- Distraction
- Auralgan
T/F Ear drum must be intact to use auralgan.
True
When is observation treatment permitted?
- Child otherwise healthy.
- Age 6 months - 2 years with non-severe or uncertain diagnosis.
- 2 years or older with non-severe or uncertain diagnosis.
T/F It is ok to prescribe ABX in AOM and ask the parents to not fill for 2-3 days.
True. If symptoms improve, don’t fill. If symptoms persist, start treatment. In these 2-3 days, treat symptoms only.
T/F Supportive care is considered treatment for AOM.
False. It is only to see if infx resolves spontaneously. It is not treatment.
Should ABX be used in AOM?
<6 months. Certain diagnosis.
Yes
Should ABX be used in AOM?
<6 months. Uncertain diagnosis.
Yes
Should ABX be used in AOM?
6 months - 2 years. Certain diagnosis.
Yes
Should ABX be used in AOM?
6 months - 2 years. Uncertain diagnosis.
Yes if severe. No if not severe.
Should ABX be used in AOM?
2 years +. Severe illness.
Yes
Should ABX be used in AOM?
2 years +. Mild to moderate AOM.
No
Should ABX be used in AOM?
2 years +. Uncertain diagnosis.
No
What organisms cause AOM (5)?
- Strep pneumoniae (25-50%)
- Nontypeable H. influenzae (15-30%)
- Moraxella catarrhalis (3-20%)
- Viruses (40-75%)
- No pathogens found (16-25%)
Factors that increase drug resistance (4).
- Hx of ear infx.
- Day care attendance.
- ABX within past 30 days.
- Under 2 years old.
What is the first choice of ABX for AOM?
Amoxicillin
80-90 mg/kg/day
If allergic to PCN, but not type 1, what is the drug choice for AOM (3)?
Cephalosporin:
- Cefdinir 14 mg/kg/day
- Cefpodoxime 10 mg/kg/day
- Cefuroxime 30 mg/kg/day
For those with type 1 allergy to PCN, what is treatment for AOM (5)?
- Azithromycin 10 mg/kg/day on day 1, then 5 mg/kg/day for 4 days
- Clarithromycin 15 mg/kg/day
- Pediazole 50 mg/kg/day of erythro
- Bactrim 6–10 mg/kg/day
- Clindamycin 30–40 mg/kg/day
What is the last choice ABX in AOM?
Bactrim
For a sick or vomiting child, what is the AOM treatment (3)?
- 1 dose of Ceftriaxone 50 mg/kg.
- Second dose may be necessary next day.
- Oral treatment at home.
When do you assess for ABX failure?
Within 48-72 hours of end of course or development of symptoms.
If ABX failure occurs, what ABX is used?
Augmentin 90 mg/kg/day (Not just clavulanic acid)
What is the treatment for persistent AOM infx?
Ceftriaxone 50 mg/kg/day x 3 days IV or IM. Refer to ENT for persistent or chronic infx.
T/F If Amoxicillin fails, move to Augmentin. If that fails, move to Cefdinir. If that fails, move to Macrolide/Fluroquinolone.
True. Not a fixed guideline, but you broaden spectrum with each step, avoiding resistance to any 1 ABX.
T/F Children of smokers have higher risks of AOM.
True
Follow-up for AOM (2).
- Treated - RTO 2-4 weeks.
2. Untreated - RTO 2-3 days.
T/F Follow-up for AOM is acceptable with a phone call.
True. If parents are reliable and child seems well.
High fever. No appetite. Requires inpatient treatment.
Bacteremia or Septicemia
Name supperative infx other than AOM (4)?
- Tonsillitis
- Conjunctivitis
- Pharyngitis
- Lymphadenitis (can be managed outpatient if not severe)
Evidence of middle ear effusion (MEE) without signs or symptoms of acute bacterial ear infection.
Otitis Media with Effusion (OME)
OME can occur spontaneously with Eustachian tube dysfunction caused by an inflammatory process with which conditions (6)?
- AOM
- Viral illness
- Anatomic abnormalities
- Barotrauma
- Allergies
- Combination of the above
Eustachian tube dysfunction changes the middle ear mucosa in the following sequence (3).
- Mucosa becomes secretory with increased mucus production.
- Mucus becomes viscous as the mucosa absorbs water.
- Fluid becomes stuck behind the TM.
T/F Eustachian tube dysfunction can cause OME which can then become AOM.
True
Often asymptomatic and afebrile. Intermittent complaints of mild ear pain. Fullness in the ear (“popping” or the feeling of “talking in a barrel”). Hearing loss in older children/adults. Dizziness or impaired balance.
OME
T/F Chronic vomiting with FTT can be related to chronic OME.
True, but only in extreme cases.
TM has decreased mobility. Dull, bulging, and/or opaque TM. Range of no visible to barely visible landmarks. Translucent with visible landmarks. Air-fluid level or air bubbles.
OME
Persistent unilateral OME may indicate _____.
Nasopharyngeal carcinoma.
Persistent unilateral OME is often seen with a hx of _____.
Smoking
OME hearing loss risk factors (10)?
- Bilateral OME for 4 months or longer.
Plus TWO of the following: - OME on either side for longer than 8 weeks.
- Speech development slower than peers.
- Speech that becomes less clear.
- Decreased amount of talking.
- Less responsive to name/familiar sounds.
- Says “huh?” or “what?” frequently.
- Sits close to TV or wants volume louder.
- Difficulty learning, esp with reading and spelling.
- Hyperactive or inattentive.
Management of OME (3)?
- Document each instance and duration (unilateral, bilateral, associated symptoms).
- Identify children at risk for speech, language, or learning problems (d/t OME or otherwise).
- Watchful waiting in children who are not at risk (spontaneous resolution).
How long can you watch children not at risk with OME?
3 months from onset or diagnosis. 75% resolves. F/U during the 3 months with pneumatic otoscopy and/or tympanogram at clinician discretion. Re-examine at 3-6 month intervals.
T/F Hearing and language testing is recommended if OME lasts for 3 months or longer.
True. Also if there is any language delay, learning problems, or significant hearing loss is suspected.
