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Paediatrics > Earache > Flashcards

Earache Flashcards

1
Q

What are the different anatomic landmarks of the ear? (TN)

A
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2
Q

What are 4 questions on history that should be asked of all patients presenting with earache?

A
  • Hearing loss
  • Tinnitus
  • Vertigo
  • Aural discharge
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3
Q

What are 2 sources of earache that should always be considered?

A
  • Local
  • Referred
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4
Q

What are 9 local causes of earache

A
  • Infection
    • Otitis Media
    • Otitis Externa
    • Malignant Otitis Externa
    • Mastoiditis
    • Herpes Zoster
  • Trauma
    • Barotrauma
    • Traumatic perforation
  • Cerumen impaction
  • Wegener’s granulomatosis
  • Cholesteatoma
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5
Q

What is mastoiditis? (TN)

A
  • Infection (usually subperiosteal) of mastoid air cells, most commonly seen approximately 2 weeks after onset of untreated or inadequately treated acute suppurative otitis media (same organisms)
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6
Q

What clinical triad is suggestive of mastoiditis? (TN)

A
  • Otorrhea
  • Tenderness to pressure over the mastoid
  • Retroauricular swelling with protruding ear
  • Can also see
    • Fever
    • Hearing loss
    • +/- TM perforation (late)
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7
Q

How is mastoiditis treated? (TN)

A
  • IV antibiotics
  • Surgical debridement
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8
Q

How can Herpes Zoster cause earache and what can it be associated with?

A
  • CN VII – can have concurrent Bell’s Palsy with pain and rash
  • Associated with vertigo, tinnitus and hearing loss
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9
Q

What are 2 risk factors for malignant otitis externa?

A
  • Diabetes
  • Immunocompromise
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10
Q

What are 3 findings associated with malignant otitis externa?

A
  • Refractory OE
  • Pain disproportionate
  • Granulation tissue on floor of external auditory canal
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11
Q

What is the cause of malignant otitis externa and how is it treated?

A
  • Pseudomonas (99%)
  • Admit for IV Cipro
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12
Q

What are 5 findings associated with Wegener’s Granulomatosis?

A
  • Arthralgia
  • Hearing loss
  • Oral/Nasal ulcers
  • Rhinorrhea
  • Myalgias
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13
Q

What is the presumed diagnosis for patients presenting with ear discharge (otorrhea) and (conductive) hearing loss?

A
  • Cholesteatoma
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14
Q

What are 5 findings that can be seen with a cholesteatoma?

A
  • Superior TM retraction (retraction pocket)
  • Pearly white spots on TM (granulation tissue)
  • Foul otorrhea
  • TM perforation
  • Conductive hearing loss
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15
Q

What are 11 causes of earache due to referred pain?

A
  • The 11 Ts
    • Teeth – cavities and abscess
    • Tongue
    • Trismus – spasm of mastication muscle, early sign of tetanus
    • TMJ dysfunction
    • Tonsillitis
    • Trigeminal neuralgia
    • Throat neoplasm
      • Risks: alcohol, smoking, age <50
      • Refer to ENT
    • Tracheitis
    • Thyroiditis
    • Thoracid aortic aneurysm and CAD
      • ECG, CXR, Trop
    • Temporal arteritis
      • Patient older than 50, PMR, constitutional symptoms, visual disturbances
      • Exam: tender artery/scalp, decreased temporal artery pulsation, eye exam
      • Get ESR
    • *Cervical arthritis
      • Referred from C2 and C3 nerve roots
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16
Q

What is the definition of AOM? (DFCM)

A
  • Presence of inflammation in the middle ear accompanied by rapid onset of signs and symptoms of an otalgia and decreased hearing
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17
Q

What is the definition of MEE? (DFCM)

A
  • Presence of fluid in the middle ear without signs and symptoms of an acute ear infection
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18
Q

What are 2 possible causes of MEE? (DFCM)

A
  • Inflammatory response following an episode of AOM
  • Spontaneously due to poor Eustachian tube function (post-URTI, seasonal allergies, airplane travel)
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19
Q

What symptoms may children experience with a MEE? (DFCM)

A
  • Transient hearing loss
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20
Q

How can a MEE be diagnosed on examination? (CPS)

A
  • Little or no mobility of the TM when both positive and negative pressure is applied using a pneumatic otoscope
  • Loss of bony landmarks
  • Presence of an air-fluid level
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21
Q

How long do sterile MEE persist for typically? (DFCM)

A
  • 1 month in 50% of children
  • 3 months in 30% of children (10% in MUMS)
  • Most resolve over 12 weeks with no intervention necessary
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22
Q

Are decongestants, antihistamines or steroids recommended for MEE? (DFCM)

A
  • Not in children
  • Decongestants may offer symptomatic relief in adults
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23
Q

What is the single most effective modifiable risk factor for MEE? (DFCM)

A
  • Discontinue exposure to passive smoking
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24
Q

How should MEE be managed? (DFCM)

A
  • Follow-up recommended at 3 month intervals until the effusion has resolved
  • Refer to ENT in the presence of significant hearing loss or structure abnormalities of the tympanic membrane
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25
Q

At what ages do the majority of AOM occur? (DFCM)

A
  • <6 years
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26
Q

What is believed to have lowered the incidence of AOM in Canada? (CPS)

A
  • Pneumococcal vaccine
    • PCV7 decreased incidence by 13% to 19%
    • PCV13 introduced in 2011 reduced further
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27
Q

What are 11 risk factors for acute otitis media? (CPS)

A
  • Early age of first AOM
  • Male sex
  • Down’s syndrome
  • Orofacial abnormalities (clef palate)
  • Daycare attendance
  • Household crowding
  • Cigarette smoke exposure
  • Pacifier use
  • Shorter duration of breastfeeding
  • Prolonged bottle-feeding while lying down
  • Family history of AOM
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28
Q

Why is the incidence of AOM higher in children than adults? (CPS)

A
  • Children acquire viral infections more often
    • Can cause Eustachian tube dysfunction or obstruction which impairs the normal mechanism that allows drainage of fluid in the middle ear
    • Fluid stasis can be lead to colonization with bacteria
  • Children have shorter and more horizontal ETs than adults
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29
Q

What are 6 pathogens that can cause AOM and their relative proportion?

A
  • Steptococcus pneumoniae (40%)
  • Nontypeable Haemophilus influenza (25%) – less severe (more likely to resolve)
  • Moraxella catarrhalis (10%) – less severe (more likely to resolve)
  • Group A Streptococcus (2%)
  • Staphylococcus aureus (2%)
  • Viral (20-30%)
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30
Q

What are 6 nonspecific symptoms that can be found in AOM? (DFCM)

A
  • Irritability
  • Fever
  • Night-waking
  • Poor feeding
  • Cold symptoms
  • Conjunctivitis
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31
Q

What is the most sensitive and specific indicator on examination for acute inflammation consistent with AOM? (CPS)

A
  • Bulging TM
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32
Q

What finding on otoscopy also strongly supports a bacterial cause? (CPS)

A
  • Acute perforation with purulent discharge (otorrhea) in the setting of AOM
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33
Q

What are 2 causes of an erythematous TM on examination? (CPS)

A
  • Crying
  • Infection
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34
Q

What are 2 aspects required for the diagnosis of AOM on physical exam?

A
  • Diagnosis should NOT be made if there is no middle ear effusion (MEE)
  • Diagnosis requires full visualization of ear drum – i.e. no ear wax
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35
Q

What are the 3 diagnostic criteria required to diagnose AOM? (CPS)

A
  • Abrupt onset of symptoms (otalgia or suspected otalgia)
  • Middle Ear Effusion (MEE)
  • Middle Ear Inflammation (MEI) – doesn’t indicate AOM unless MEE
    • Erythema of TM
    • Distinct otalgia
    • If only fever and a red ear drum, look for another cause
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36
Q

What are 6 findings seen with a Middle Ear Effusion (MEE)?

A
  • Loss of landmarks
  • Bulging TM
  • Opacity of TM
  • Fluid behind TM
  • Otorrhea
  • Decreased mobility of eardrum on tympanography
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37
Q

For children >6 months of age with suspected AOM that have MEE present AND bulging tympanic membrane, how should they be managed? (CPS)

A
  • Moderately or severely ill = treat
    • Irritable, difficulty sleeping, poor response to antipyretics, severe otalgia OR
    • ≥39C in ABSENCE of antipyretics OR
    • >48h of symptoms
  • Mildly ill = observe 24h to 48 h
    • Alert, response, no rigors, responding to antipyretics, mild otalgia, able to sleep AND
    • <39C in absence of antipyretics AND
    • <48h of illness
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38
Q

What are 3 findings that are associated with a diagnosis of moderate-severe AOM?

A
  • Moderate-severe pain
  • Pain persisting >48h
  • Fever >39
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39
Q

What are 2 considerations in the treatment of AOM?

A
  • Pain management
  • Antibiotics
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40
Q

How should pain be treated in patients with AOM?

A
  • Tylenol 15 mg/kg q6h (max 75 mg/kg/day)
  • Advil 10mg/kg q6h (max dose 400 mg, max daily dose 40 mg/kg/day)
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41
Q

How should adults with AOM be treated? (DFCM)

A
  • Start antibiotic therapy immediately
  • If no improvement in 48-72 hours, patient should be re-examined as there may be a new focus of infection or inadequate therapy
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42
Q

In which situations and ages should children with AOM be treated with antibiotics?

A

Age

Uncertain Dx

Unilateral AOM without Otorrhea

Bilateral AOM without Otorrhea

Severe Symptoms

Otorrhea (perforation)

<6 months

Antibiotics for 10d

Antibiotics for 10d

Antibiotics for 10d

Antibiotics for 10d

Antibiotics for 10d

6 to 23 months

Severe: Antibiotics 10d

Non-severe: Tylenol

Severe: Antibiotics 10d

Non-severe: Tylenol

Antibiotics for 10d

Antibiotics for 10d

Antibiotics for 10d

>2 years

Observe and Tylenol

Severe: Antibiotic 5d

Non-severe: Tylenol

Severe: Antibiotic 5d

Non-severe: Tylenol

Antibiotics for 5 days

Antibiotics for 5-10 days

43
Q

What % of untreated children have resolution of AOM at 7-14 days? (TFP)

A
  • 70%
    • 80-90% (DFCM/MUMS)
44
Q

In which children with suspected AOM can watchful waiting be used? (MUMS)

A
  • Children >2 years of age and previously healthy
  • Children 6 months to 2 years IF parents can observe for 48-72 hours
  • NOT recommended in children <6 months
45
Q

What should all parents of children being treated for AOM be told? (MUMS)

A
  • Seek immediate medical reassessment if symptoms worsen or new symptoms appear (e.g. rash, drowsiness, difficulty breathing, vomiting)
  • If symptoms do not improve after 48 hours (fever, ear pain, fussiness) then return for reassessment and likely start antibiotics
    • 24-48h (CPS)
46
Q

What is the recommended duration of antibiotic therapy for children with AOM? (MUMS/CPS)

A
  • 5 days = >2 years
  • 10 days = 6 months to 2 years
  • 10 days = <6 months
47
Q

What is the first-line antibiotic for the treatment of AOM in adults and children? (MUMS/CPS)

A
  • Adults: Amoxicillin 500 mg TID
  • Children: Amoxicillin 80 mg/kg/day divided BID or TID (max 3g per day) if no previous amoxicillin in the last 30 days
48
Q

What is the second-line antibiotic for the treatment of AOM and its indication? (MUMS)

A
  • Adults: Amoxicillin-Clavulin 500 mg TID or 875 mg TID
  • Adults: Cefprozil 250-500 mg BID
  • Children: Amoxicillin-Clavulin 40-80 mg/kg/day divided BID (max 3g per day)
    • Recent Amoxicillin
    • Concurrent purulent conjunctivitis – more likely H. influenza or M catarrhalis
    • Recurrent AOM unresponsive to Amoxicillin – may be H. influenza or M catarrhalis
  • Children: Cefprozil 30 mg/kg/day divided BID
    • History of hypersensitivity to penicillins UNLESS previous reaction was life-threatening (i.e. angioedema, bronchospasm or hypotension)
49
Q

How do the doses recommended by the CPS differ from MUMS for treating AOM? (CPS)

A
  • Amoxicillin 45-60 mg/kgday divided TID as capsules or suspension
50
Q

How can Amoxicillin-Clavulin be prescribed to increase tolerance? (MUMS)

A
  • BID – reduces total amount of Clavulin
51
Q

What is the preferred Amoxicllin-Clavulin suspension for treatment of AOM in children and why? (CPS)

A
  • 7:1 formulation (most amoxicillin combined with the least amount of clavulin)
    • Each 5 mL of suspension contains 400 mg amoxicillin and 57 mg clavulanate
    • <10 mg/kg/day dose of clavulanate associated with higher risk of diarrhea
  • For a child weight ≤35 kg, 45-60 mg/kg/day divided TID for 10 days
    • Specify 400 mg/5 mL suspension of 7:1 formulation
  • For a children weight >35 kg, 500 mg tablets TID a day for 10 days
52
Q

What are third-line antibiotics for the treatment of AOM and their indications?

A
  • Azithromycin 10 mg/kg/day x1 and 5 mg/kg/day x4
    • Penicillin allergy
  • Septra 5-10 mg/kg/day divided BID
    • Penicillin allergy
  • Use for 10 days if first-line failure
53
Q

How fast should symptoms improve and resolve after starting antimicrobials for AOM? (CPS)

A
  • Improve within 24h
    • RTC if no improvement within 24-48h
  • Resolve within 2-3 days
54
Q

What should all children with a perforated TM who present with symptoms of AM be treated with? (CPS)

A
  • Systemic antimicrobials
  • Examine for associated complications
55
Q

What is the preferred treatment for uncomplicated AOM in the presence of a chronic TM perforation or ventilation tubes? (MUMS)

A
  • Ciprodex 4 drops BID for 5 days
    • Superior to oral AM/CL in the median time to cessation of otorrhea (4 days vs 7 days), clinical cure rates (85% vs 59%) and adverse effects profile
56
Q

In which situations could Ciprodex be prescribed for AOM and what is the dose?

A
  • Ciprodex 4 drops BID for 5-10 days
    • Perforation
    • Venting tubes
57
Q

What should patients with otitis media with tympanic membrane perforation try to avoid? (DFCM)

A
  • Prevention of water entry into canal
58
Q

What is the NNT for antibiotics for AOM in children? (TFP)

A
  • NNT = 3 to 10
59
Q

What are the risks (NNH) for antibiotics prescribed for AOM in children? (TFP)

A
  • Diarrhea NNH = 5
  • Diaper rash NNH = 7
  • Eczema NNH = 19
60
Q

What is the evidence for delayed prescription of antibiotics for AOM in children? (TFP)

A
  • 4 studies
    • 2 studies found no difference
    • 2 studies found immediate prescriptions superior (NNT=6-7)
    • Delayed prescriptions may increase patient dissatisfaction
61
Q

Are prophylactic antibiotics for recurrent AOM appropriate? (MUMS)

A
  • No
  • Decrease ~1 episode per year vs Antibiotic Resistance
62
Q

What is the most common complication of AOM? (CPS)

A
  • Acute mastoiditis
63
Q

What are 6 potential complications of AOM? (CPS)

A
  • Meningitis
  • Facial weakness or paralysis (CN VII palsy)
  • Failure of ipsilateral eye abduction due to petrous bone inflammation or infection (CN VI palsy) = Gradenigo’s syndrome
  • Labyrinthitis or Vertigo (infection spreads to the cochlear space)
  • Hearing loss
  • Venous sinus thrombosis of the transverse, lateral or sigmoid venous sinuses
64
Q

What are 3 indications for tympanostomy tubes?

A
  • 3 episodes of AOM in 6 months
  • 4 episodes of AOM in 12 months, with 1 episode in the last 6 months
  • OME for ≥3 months with bilateral hearing loss ≥20 dB
65
Q

What are indications (2) to refer a patient to ENT with a history of AOM?

A
  • Retracted tympanic membrane
    • Need to rule out cholesteatoma
  • Clef palate or craniofacial malformations or Down syndrome
  • Recurrent infections (4 in 1 year, 3 in 6 months)
  • Severe signs and symptoms (high fever, intractable pain) despite adequate antibiotic therapy
  • Recurrent infections with colonization of multi-drug resistant bacteria
  • Persistent TM perforation (>6 weeks) with or without suppurative drainage
  • Chronically draining (chronic suppurative otitis media)
    • May consider swabbing for possible candida and aspergillus species
66
Q

How should recurrent AOM be treated?

A
  • Treat with first-line agents if no previous antibiotics in 30 days and previously achieved good effect
  • Treat all ages for 10 days
67
Q

How does chronic perforation or tube ventilation with AOM present and how should it be treated?

A
  • Presents as painless otorrhea
  • If no systemic signs – Ciprodex 4 drops BID for 5 days
  • Otherwise regular antibiotics for 10 days (All Ages)
68
Q

What are 5 recommendations that can be may for prevention of AOM?

A
  • Pneumococcal vaccine to all children
  • Influenza vaccine to all children
  • Encourage breast feeding for 6 months – avoid bottle feeding in supine position
  • Avoid pacifiers after 6 months
  • Avoid tobacco smoke
69
Q

What should children with recurrent AOM be tested for?

A
  • Hearing loss
70
Q

How should children with middle ear effusion (MEE) be followed?

A
  • Reassessed in 3 months for effusion resolution
    • 10% will still have effusion – send for hearing test
      • Refer if hearing loss
    • Avoiding smoke is most effective intervention
    • Antihistamines and decongestants cause harm
71
Q

What is acute otitis externa also called? (CPS)

A
  • Swimmer’s ear
72
Q

What is the definition of AOE? (DFCM)

A
  • Presence of inflammation in the external auditory canal
73
Q

At what age is AOE less commonly seen? (CPS)

A
  • Children < 2 years
74
Q

How can swimming lead to AOE? (CPS)

A
  • Skin desquamation leads to microscopic fissures that provide a portal of entry for infecting organisms
75
Q

What are 8 risk factors for AOE? (CPS)

A
  • Swimming
  • Trauma
  • Foreign body
  • Hearing aid
  • Certain dermatological conditions
  • Chronic otorrhea
  • Wearing tight head scarves
  • Immunocompromised
  • Ear piercing à infection of the pinna
76
Q

What findings are AOE most commonly associated with? (DFCM/CPS)

A
  • Otalgia (70%)
  • Pruritus/scaling (60%)
  • Aural fullness (22%)
  • Hearing loss (32%)
  • Ear canal pain with chewing
  • Otorrhea
  • Diffuse ear canal edema, erythema or both
  • Regional lymphadenitis
  • Pain with stretching of pinna
  • Pain with pushing of tragus
77
Q

What are 2 signs suggestive of AOE instead of AOM? (CPS)

A
  • Tenderness (out of proportion to visible inflammation) with:
    • Tragus push
    • Pinna pull
78
Q

What are 2 precipitants of AOE? (DFCM)

A
  • Excessive moisture
    • Moisture removes cerumen and increases the pH of the external canal, providing an ideal environment for pathogen growth and proliferation
  • Trauma
    • Q-tip use may cause abrasions and allow entry of pathogens to deeper tissue
79
Q

What are 4 possible causes of AOE? (DFCM)

A
  • Bacterial infection
  • Fungal
  • Allergic
  • Dermatitis
80
Q

What are the most common bacterial pathogens causing AOE? (DFCM)

A
  • Pseudomonas auruginosa
  • Staphylococcus aureus
  • 1/3 of cases polymicrobial
81
Q

How common is fungal AOE and what are the possible causes of it? (DFCM)

A
  • 2-10% of cases
  • Occurs after treatment with antibiotics
  • Superficial candida can occur in those who use hearing aids due to the moisture
82
Q

What complication of AOE should be examined for in patients presenting with signs of OE and how should they be managed? (DFCM)

A
  • Necrotizing (Malignant) AOE
    • Invasive infection of the external auditory canal with cartilage and bone involvement
    • May present with facial nerve palsy and pain as a prominent symptom
  • Immediate referral to ENT
83
Q

What should be done for the management of AOE if there is debris in the ear? (MUMS/CPS)

A
  • Aural toilet
    • If severely swollen, Merocel wick is recommended (expandable wick to decrease canal edema and facilitate topical medication delivery
    • NO evidence for effectiveness of aural toilet (CPS)
84
Q

What should be done in a patient with AOE if a defect in the TM cannot be ruled out? (MUMS)

A
  • Proceed as if there is a defect in the TM
85
Q

How can the external ear canal be cleaned of any debris or cerumen to examine the TM in patients presenting with AOE? (DFCM)

A
  • AVOID using a curette (inflammation can make the canal vulnerable to trauma)
  • AVOID flushing unless the TM can be clearly visualized
  • Best done with low suction or by using a fluffed-out cotton swab
  • Antibiotic drops or hydrogen peroxide may be used to moisten/soften any debris
86
Q

In which patients should systemic treatments be considered for AOE? (DFCM)

A
  • Diabetes
  • History of radiation to ear
  • Inflammation extending beyond ear canal
  • Significant edema preventing the application of topical therapy
  • Immunodeficiency
87
Q

What would recurrent AOE infections or infections resistant to topical treatment be concerning for? (DFCM)

A
  • Diabetes
  • Leukemia
  • DiGeorge Syndrome
88
Q

When would a culture be performed for a patient with suspected AOE? (DFCM)

A
  • Severe OE with fever and lymphadenopathy
89
Q

What is first-line treatment for AOE with intact TM? (DFCM)

A
  • Buro-Sol 2-3 drops TID or QID ($ cheapest $)
    • Contains aluminum acetate and benzethonium chloride
    • Less toxic, avoids resistance, lower cost
90
Q

How effective is Buro-Sol for treating AOE? (CPS)

A
  • Equally effective as topical antimicrobials in clinical cure rates at one week (Cochrane Review)
  • Inferior in clinical and microbiological cure at 2-3 weeks (Cochrane Review)
91
Q

If a patient with suspected AOE has no evidence of dermatitis and only infection, what can be used? (MUMS)

A
  • Polysporin or Polysporin/Lidocaine 1-2 drops QID
92
Q

What is second-line treatment for AOE with intact TM? (DFCM/MUMS)

A
  • Cortisporin 3 drops TID or QID (4 drops in adults)
    • Contains 10,000 U polymyxin, 5 mg neomycin and 10 mg hydrocortisone per mL (ototoxicity)
    • Neomycin can be sensitizing when used topically
  • Sofracort 2-3 drops TID or QID
    • Contains 5 mg framycetin and 0.05 mg gramicidin and 0.5 mg dexamethasone per mL (ototoxicity)
  • Garasone 3-4 drops TID
    • Contains 3 mg gentamicin and 1 mg betamethasone per mL
    • Beware risk of OTOTOXICITY
  • Ciprodex 4 drops BID ($$$)
    • Contains 3 mg ciprofloxacin and 1 mg dexamethasone per mL
93
Q

What is first-line treatment for AOE withOUT intact TM? (DFCM/MUMS)

A
  • Ciprodex 4 drops BID ($$$)
94
Q

For how long should treatment be for mild-to-moderate AOE with topical antibiotics? (CPS)

A
  • 7-10 days
95
Q

What is the cure rates for topical antimicrobials compared to placebo in the treatment of AOE? (CPS)

A
  • +46% absolute clinical cure rate compared to placebo (Cochrane Review)
  • +61% bacteriological cure rate compared to placebo (Cochrane Review)
96
Q

How soon should patients notice a response with topical antimicrobials for AOE and how long can full response take? (CPS)

A
  • 48-72 hours for clinical response
  • 6 days for full response
97
Q

What should be considered in patients that do not respond to topical antimicrobials? (CPS)

A
  • Obstruction
  • Foreign body
  • Non-adherence to therapy
  • Alternative diagnosis
    • Dermatitis from contact with nickel
    • Viral infection
    • Fungal infection
    • Antimicrobial resistance
98
Q

What are 3 reasons to discontinue treatment for AOE? (DFCM/MUMS)

A
  • Tinnitus
  • Hearing loss
  • Vertigo or Imbalance
99
Q

What is the risk associated with prolonged use of combination antibiotics for AOE? (DFCM)

A
  • Alter normal flora and result in a fungal infection
100
Q

What is first-line treatment for otomycosis? (DFCM/MUMS)

A
  • Clotrimazole 1% cream apply BID (am and qhs)
  • Tolnaftate 1% cream apply BID (am and qhs)
  • Locacorten Vioform drops 2-3 drops BID
101
Q

What is second-line treatment for otomycosis? (DFCM)

A
  • Keto-derm apply BID (am and qhs)
102
Q

When is Keto-derm used for otomycosis as second-line and what does it do? (DFCM)

A
  • Used if no response to above after 1 week
  • Contains ketoconazole, which covers for Aspergillus niger
103
Q

How can AOE be prevented after swimming? (DFCM)

A
  • Remove moisture
    • Warm air from a blow dryer
    • Tilting the head to allow drainage
    • Adding a few drops of vinegar to the ear
      • ONLY in the presence of an intact TM

Paediatrics (2 decks)

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