Ear

Question 1

CONDUCTIVE HEARING LOSS

Answer 1

(Outer Ear and Middle Ear)

Any type of obstruction of sound waves will cause conductive hearing loss
Outer Ear
-Cerumen
-Otitis Externa

Middle Ear (fluid inside)
-Otitis Media
-Serous Otitis Media -Fluid filled

Question 2

SENSORINEURAL HEARING LOSS

Answer 2

Inner Ear
Damage or aging of the cochlea/vestibule
-Presbycusis, Meniere’s disease

  Damage to the nerve pathways (CNVIII or Acoustic Nerve)

  Otoxic drugs (oral aminoglycosides, erythromycin, tetracycline, high-dose aspirin

Question 3

Weber test

Answer 3

Place the tuning fork for midline on the forehead.
Normal finding is NO lateralization

Question 4

Tinne test

Answer 4

Place the tuning fork first on mastoid process, then at front of ear.
Normal finding : Air conduction (AC) lasts longer than bone conduction

Question 5

Hearing test tip

Answer 5

The Weber and Rinne test are complete opposites of each other.
In sensorineural hearing loss, Weber finds lateralization to “good” ear; Rinne test finds AC > BC
In conductive hearing loss, Weber finds lateralization to “bad” ear; Rinne test finds BC > AC

Question 6

Otitis Externa

Answer 6

Painful inflammation of the external auditory canal and auricle
Commonly known as “swimmer’s ear”
Does occur in the elderly, but more common in younger persons

Question 7

Otitis Media

Answer 7

Infectious or inflammatory process within the middle ear
May be acute or chronic, suppurative or serous in nature
Caused by bacteria or viruses

Question 8

Otitis Serous

Answer 8

Fluid trapped behind the tympanic membrane without an ear infection.
Often caused by URI or allergies

Question 9

OM etiology

Answer 9

Eustachian tubes dysfunction or congestion that prevents effective drainage of the middle ear

Infectious causative agents (typically respiratory bacteria):
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus

Question 10

OM sub and obj findings

Answer 10

Throbbing pain
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
Otorrhea
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
Bony landmarks are obscured
Hole in the tympanic membrane in serous cases if rupture occurs
Tympanic membrane retracted, opaque and dull with decreased movement (often in Otitis Media with effusion)

Question 11

mgmt OM

Answer 11

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)
Cefuroxime

If TM Perforation has occurred: Cortisporin Otic 4 ear drops topically, 3x/day 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

Question 12

Bell’s palsy

Answer 12

Sudden onset of unilateral facial paralysis or weakness
Generally self-limiting, with restoration of health in a matter of weeks

Etiology/ Incidence / Predisposing factors

Question 13

BP Etiology/ Incidence / Predisposing factors

Answer 13

Idiopathic
Probably involves inflammation of CN VII
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 disease

Question 14

BO obj and sub findings

Answer 14

Unilateral paralysis of face
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

Question 15

Bp lab and dx

Answer 15

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 involvement (not associated with Bell’s Palsy)

Question 16

BP mgmt

Answer 16

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

Question 17

Cholesteatoma

Answer 17

“Cauliflower-like” growth accompanied by foul-smelling ear discharge
Hearing loss on 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)
Treated with antibiotics and surgical debridement
Refer to Otolaryngologist

Question 18

Vertigo

Answer 18

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

Question 19

Vertigo Etiology / Incidence / Predisposing Factors

Answer 19

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

Question 20

Vertigo sub and ob finding

Answer 20

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

Question 21

Vertigo mgmt

Answer 21

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

Question 22

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?

Answer 22

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.

Question 23

Which of the following is Not considered an objective finding n patients who have a case of suppurative otitis media?

Answer 23

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.