Ear and Hearing Disorders

Question 1

Appointments for hearing screening

Answer 1

• Newborns (by 1 month of age)
• F/U of abnormal NB screen by 3 months
• Puretone audiometry at 3, 4, 5, 6, 8, 10, 12, 15, and 18 years
  ** More frequent for children at risk

Question 2

Medical History Assessment of Ears

Answer 2

• hx of ear conditions
• hx or family history of ear abnormalities or kidney abnormalities
• itching/discharge
• prematurity
• URI
• tinnitus
• exposure to daycare, smoke, noise
• DM

Question 3

Physical Examination Assessment of Ears

Answer 3

• inspection of external ear structures
• developmental milestones of hearing/speech
• palpation/rotation for tenderness/inflammation
• otoscopic examination

Question 4

Pressure Equalizing Tubes

Answer 4

• refer if recurrent AOM 3 times/6 months or 4 times/year
• craniofacial abnormalities may warrant PET
• PET placement under general anesthesia
• No precautions if bathing, showering, or surface swimming
• Earplugs if driving or dunking

Question 5

Otitis Externa Causes

Answer 5

• protective barriers in EAC damaged
• P. aeruginosa, S. aureus most common
• otomycosis caused by Aspergillus or Candida
• chlorine kills normal ear flora
• regular cleaning removes the cerumen barrier

Question 6

Clinical Findings of Otitis Externa

Answer 6

• itching and irritation
• pain disproportionate to what is seen on exam
• pressure/fullness in ear
• hearing loss may occur
• sagging of superior canal, periauricular edema; pre- and postauricular lymphadenopathy
• swollen EAC with debris
• rare otorrhea
• red, crusty, or pustular lesions
• presence of PET or perforation of TM

Question 7

Diagnostic Studies for Otitis Externa

Answer 7

Not necessary to culture unless improvement not seen with treatment

Question 8

Management of Otitis Externa

Answer 8

• eardrops are mainstay (acetic acid or antibiotic with or without corticosteroid drops)
• no ototoxic drops if risk of perforation
• systemic antibiotics not used unless severe
• pt education about drops
• use a wick if significant swelling
• avoid cleaning, manipulating, getting warmer into ear = no swimming
• analgesics for pain
• debridement with cotton-tipped applicator
• clena canal with water or antiseptic solution if impetigo and apply antibiotic ointment
• treat fungal infections with clotrimazole-miconazole, or nystatin

Question 9

Complications of Otitis Externa

Answer 9

• infection of surrounding tissues with impetigo
• irritated furunculosis
• malignant OE with progression/necrosis

Question 10

Prevention of Otitis Externa

Answer 10

• avoid water in ear canals
• well fitting earplugs for swimming
• alcohol/vinegar/distilled water otic mix (2:1:1); 3-5 drops daily, especially after swimming
• blow dryer on warm setting to dry EAC
• avoid persistent scratching/cleaning of EAC
• avoid prolonged use of cerumenolytic agents

Question 11

Clinical Findings of Foreign Body in Ear Canal

Answer 11

• report of something in the ear
• itching, buzzing, fullness
• persistent cough or hiccups
• unilateral otalgia/otorrhea

Question 12

Management of Foreign Body in the Ear Canal

Answer 12

• adequate visualization
• refer to ENT if first attempt unsuccessful
• disk batteries must be removed emergently!!
• spherical objects most difficult
• suffocate insects with mineral oil and refer
• irrigate only if TM is intact

Question 13

Complications of Foreign Body in the Ear Canal

Answer 13

• infection
• perforation of TM
• damage to ossicles

Question 14

3 Components to Diagnose Otitis Media

Answer 14

1. recent, abrupt onset of middle ear inflammation and effusion
2. MEE confirmed by bulging TM, limited/absent mobility by pneumatic otoscopy, air-filled level behind TM, otorrhea
3. signs/symptoms of inflammation - distinct erythema of TM, pain

Question 15

Common Causes of Eustachian Tube Dysfunction

Answer 15

• URI
• allergies
• environmental tobacco smoke

Question 16

Causes of Acute Otitis Media

Answer 16

• ETD
• S. pneumoniae
• nontypeable H. infuenzae
• M. catarrhalis
• S. pyogenes
• viruses usually initial causative factor, but most AOM caused by bacteria or combination bacteria/virus

Question 17

Clinical Findings of AOM

Answer 17

• rapid onset of symptoms
• ear pain/pulling in infant
• irritability in infant/toddler
• otorrhea
• fever
• bulging TM
• decreased translucency of TM
• absent or decreased mobility of TM
• air fluid level behind TM
• erythema
• red, yellow, purple TM
• thin walled, sagging bullae filled with straw-colored fluid (bullous ,myringitis)

Question 18

Management of AOM

Answer 18

• amoxicillin BID (first line if no AOM in past 30 days, no conjunctivitis, no PCN allergy)
• bata lactam coverage if treated in the last 30 days
• ceftriaxone for vomiting child
• clindamycin for ceftriaxone failure; only if susceptibilities known
• no prophylactic antibiotics
• “watchful waiting”

Question 19

Watchful Waiting of AOM

Answer 19

• pain relief should be provided
• parent initiated visit/phone call for worsening
• scheduled F/U appt.
• Routine F/U phone call
• prescription to start if no improvement or worsening in 48-72 hours
• communication with parent, re-evaluation, ability to obtain medication must be in place

Question 20

Management of Persistent/Recurrent AOM

Answer 20

• if abx therapy complete with evidence of AOM still present, or recurrence within days - broad spectrum abx recommended
• persistent middle ear effusion common; abx not necessary
• recurrent AOM if > 3/6 months or > 4/year
• otolaryngology referral when therapy fails

Question 21

Prevention and Education for AOM

Answer 21

• pneumococcal vaccine
• flu vaccine
• xylitol gum/liquid if > 2 years
• exclusive breastfeeding to 6 months
• licensed daycare/fewer children
• avoid bottle propping, smoke exposure
• avoid use of pacifiers
• educate about drug resistant bacteria, antibiotic use

Question 22

Clinical Findings of Otitis Media with Effusion

Answer 22

• often asymptomatic/afebrile
• intermittent mild ear pain
• fullness in ear
• hearing loss in older children
• dizziness or impaired balance
• chronic vomiting, failure to thrive
• decreased TM mobility
• TM dull, bulging, opaque

Question 23

Prevention and Education for Otitis Media with Effusion

Answer 23

• F/U until TM/hearing normal
• remember important role of language development
• Maximize hearing by:
  
  1. facing child; get within 3 ft
  2. enunciating clearly
  3. using visual clues
  4. turning off competing background noise
  5. requesting preferential classroom seating

Question 24

Clinical Findings of Perforated TM

Answer 24

• may have no symptoms; may hear whistling sounds with sneezing, hearing loss
• profuse otorrhea may obscure TM

Question 25

Management of Perforated TM

Answer 25

• control otorrhea/watchful waiting while healing
• avoid ototoxic eardrops/treat with otic drops for ear infection if present
• no swimming
• most perforations will heal within 3 months