Ear Infections and Allergic Rhinitis

Question 1

etiology of otitis externa

Answer 1

bacterial: gm - E. coli, pseudomonas aeruginosa, proteus vulgaris; gm + staph. aureas
fungal: Asperigillis or Candida albicans

Aka “swimmers ear” brought on by heat + moisture, may be secondary to trauma or associated with skin diseases.

Question 2

presentation of otitis externa

Answer 2

external ear pain and tender tragus; pruritis; discharge (yellow =pseudomonas, green =staph, white/black “fluffy”=fungus); EAC erythematous, edematous; may have conductive hearing loss

Note if TM is intact or not

Question 3

treatment of otitis externa

Answer 3

Bacterial: Cortisporin Otic Suspension (do NOT use if perforated TM), Ofloxacin Otic Solution (for perforated TM); 3-4 gtts QID, resolves in 5-7 days

Fungal: Clotrimazole 1% Solution 3 gtts BID x 14d

Prevention/Prophylaxis: keep canal dry, 2% Acetic Acid (VoSol) or 50/50 white vinegar/water solution

Question 4

etiology of malignant otitis externa

Answer 4

Pseudomonas infection of ear with involvement of underlying bone.

diabetic and immunocompromized patients at higher risk

Question 5

presentation of malignant otitis externa

Answer 5

fever, increasing ear pain; red, granulation tissue in EAC; discharge; ear/EAC erythematous, edematous; may have conductive hearing loss

watch for cranial nerve 7 & 8 involvement

Question 6

treatment of malignant otitis externa

Answer 6

need to admit, IV antibiotics, and debride

Question 7

etiology of acute otitis media

Answer 7

Strep. pneumoniae, H. flu; Moraxella catarrhalis;
many other bacteria & viruses

risk factors: children’s straight eustachian tube, enlarged adenoids; 2nd hand smoke; seasonal; day care

Question 8

presentation of acute otitis media

Answer 8

irritability; decreased appetite; +/- fever; ear pain (tugging on ear); hearing loss; conjunctivitis; rhinorrhea; ear discharge; vomiting and diarrhea; erythematous TM with decreased mobility, loss of landmarks

Question 9

treatment of acute otitis media

Answer 9

antibiotics:if less than 6 mo - antibiotics
If 6 mo to 2y - antibiotics if Dx is certain or illness is severe
if 2y - antibiotics if diagnosis is certain AND illness is severe; use augmentin or other if kids are high risk for amoxicillin resistant bacterial infection

care for pain/fever: acetaminophen, ibuprofen (esp if fever >101F)

fluids, decongestants (not antihistamines)

Question 10

etiology & diagnosis of chronic otitis media

Answer 10

> 3 cases of acute otitis media in 6 months; or >4 cases in 12 months

may be brough on by trauma, cholesteatoma

pseudomonas, proteus, S. aureus, mixed

Question 11

presentation of chronic otitis media

Answer 11

recurrant acute otitis media symptoms, TM perforaton w/purulent discharge; conductive hearing loss

Question 12

treatment of chronic otitis media

Answer 12

refer to ENT, myringtomy

Question 13

etiology of TM perforations

Answer 13

associated with acute/chronic otitis media; trauma

Question 14

presentation of TM perforations

Answer 14

+/- pain; otorrhea (discharge/drainage); vertigo(indicative of inner ear injury); conductive hearing loss; no TM movement; visualize perforation

Question 15

treatment of TM perforations

Answer 15

most heal spontaneously

Question 16

etiology of mastoiditis

Answer 16

extension of otitis externa or acute otitis media to the mastoid process (suspect if these conditions are slow to resolve)

Question 17

presentation of mastoiditis

Answer 17

mastoid tenderness, edema, erythema; deep temporal pain

Question 18

treatment of mastoiditis

Answer 18

IV antibiotics, refer to ENT

Question 19

etiology of serous otitis media

Answer 19

middle ear effusion secondary to inflammation/dysfunction of the eustachian tube; may be seen foling URI, acute otitis media, or with allergic rhinitis

Question 20

presentation of serous otitis media

Answer 20

“ear fullness,” decreased or “tunnel” hearing; usually painless; amber colored fluid or bubbles behind immobile TM; retraction of TM; Tympanogram is type B

Question 21

treatment of serous otitis media

Answer 21

topical nasal decongestants (to open eustachian tube, no more than 3 days)
antibiotics: amoxicillin, augmentin, bactrim

refer to ENT for persistant fluid and/or hearing loss, or if unilatera.

Question 22

etiology of labyrinthitis

Answer 22

benign, acute inflammation/infection of the vestibular system; usually associated with viral infections

AKA “vestibular neuronitis”

Question 23

presentation of labyrinthitis

Answer 23

acute onset of severe rotational vertigo, not related to head position; horizontal nystagmus; ataxia (unstable gait); nausea and vomiting

NO tinnitus, NO hearing loss

Question 24

treatment of labyrinthitis

Answer 24

symptomatic:bedrest, hydration

benzodiazepines (Diazepam); anti-cholinergics (prochlorperazine); antihistamines

Question 25

etiology of allergic rhinitis

Answer 25

hyper-responsiveness to allergen, increased production of IgE antibiodies leads to an inflammatory response

may be seasonal or perennial

Question 26

presentation of allergic rhinitis

Answer 26

rhinorrhea, sneezing, itchy eyes, itchy nose, nasal congestion, clear post nasal drainage, cough, “allergic salute”; bluish mucosa w/ clear discharge on nasal speculum exam; swollen, red or pale conjunctiva; allergic shriners, Denie Morgan lines

Question 27

diagnosis of allergic rhinitis

Answer 27

Skin tests (can produce false - & +): scratch and prick or "wheal-and-flare" 
Blood tests (non specific): IgE (not really useful) radioallergosorbent test(RAST)

Question 28

treatment of allergic rhinitis

Answer 28

identify and avoid allergens; antihistamines (first generation - Benadryl is sedating); decongesttants(caution with HTN), topical corticosteroids (risk of growth hormone decrease in kids); immunotherapy (hyposensitization - last resort).

Question 29

vasomotor rhinitis

Answer 29

abnormal autoimune responsiveness triggered by stress, arousal, perfumes, smoke, or anti-hypertension meds

AKA Perennial Non-Allergic Rhinitis

Question 30

presentation of vasomotor rhinitis

Answer 30

nasal congestion, rhinorrhea

NO itching or sneezing; nasal mucosa appears normal

Question 31

treatment of vasomotor rhinitis

Answer 31

avoid triggers; antihistamines; decongestants; topical anticholinergics (Atrovent)

Question 32

background of nasal polyps

Answer 32

associated with ‘asthma triad’: asthma, nasal polyps, aspirin hypersensitivity
seen with allergic rhinitis and vasomotor rhinitis

Question 33

presentation of nasal polyps

Answer 33

nasal conjestion; pedunculated, non tender, soft grey tissues growths in nose

Question 34

treatment of nasal polyps

Answer 34

refer to ENT for surgery

Question 35

etiology of rhinitis medicamentosa

Answer 35

tachyphylaxis/overuse of topical decongestants - if they stop the medication they get severe rebound congestion

Question 36

presentation of rhinitis medicamentosa

Answer 36

rebound conngestion when topical decongestants are discontinued; erythematous mucosa

Question 37

treatment of rhinitis medicamentosa

Answer 37

discontinue / taper off of topical decongestants (may use a nasal steroid to help with taper)

sypmtoms resolve 2-3 weeks after discontinuation