Exam 2: Ears and Sinuses [6] Flashcards
Patient reports symptoms of otalgia and difficulty hearing in one ear. The NP performs an exam and notes a dark brown mass in the lower portion of the external canal blocking the patient’s TM. What is the initial action?
A. Ask patient about previous problems with that ear
B. Irrigate the canal with normal saline
C. Prescribe a cerumenolytic agent for that ear
D. Use a curette to attempt to dislodge the mass
Answer:
Before attempting to remove the cerumen, the NP must determine if the TM is intact and should ask:
- If pressure equalizing tubes
- If a history of ruptured TM
- Any previous ear surgeries
Once the TM is determined to be intact, the NP can attempt to remove the ear wax
- Irrigate with saline
- Prescribe a cerumenolytic agent for that ear
- Use a curette to attempt to dislodge the mass but only if it is in the outer 3rd section of the canal
If a patient complains of clicking and popping of the ear while chewing, what could be causing the problem?
Cerumen (ear wax) buildup
A young child has a pale, whitish discoloration behind the TM. The NP notes no scarring on the TM and no retraction of the pars flaccida. The parent states the child has never had otitis media. What do these findings most likely represent?
A. Chronic cholesteatoma
B. Congenital cholesteatoma
C. Primary acquired cholesteatoma
D. Secondary acquired cholesteatoma
Answer: B (congenital cholesteatoma) Patients without history of otitis media or perforation of TM most likely have congenital cholesteatoma
Primary acquired cholesteatoma will include retraction of the pars flaccida
Secondary acquired cholesteatoma has findings associated with the underlying etiology
A patient reports a feeling of fullness and pain in both ears and the NP elicits exquisite pain when manipulating the external ear structures. What do you think is going on?
A. Acute otitis externa
B. Acute otitis media
C. Chronic otitis externa
D. Otitis media with effusion
Answer: (A) Symptoms are classic for acute otitis externa
Chronic otitis externa more commonly presents with itching
Acute otitis media presents with fever and TM inflammation and without external canal inflammation
Otitis media with effusion causes a sense of fullness but not pain
What are the classic symptoms of acute otitis externa?
Acute otitis externa:
Fullness in ears Pain elicited with manipulation of external structures Swelling Discharge Pruritus
Which chronic ear condition typically presents with itching?
Chronic otitis externa
Which ear condition can cause a sense of fullness but not pain?
Which ear condition can cause a sense of fullness but not pain?
Otitis media with effusion
A patient has an initial episode of otitis external associated with swimming. The patient’s ear canal is mildly inflamed and the tympanic membrane is not involved. Which medication should be ordered?
A. Cipro HC
B. Fluconazole
C. Neomycin
D. Vinegar and alcohol
With no culture, the NP should choose a medication that is effective against both P. aeruginosa and S. aureus
Cipro HC covers both organisms and also contains a corticosteroid for inflammation
Fluconazole is an oral antifungal med used when fungal infection present
Neomycin alone does not cover these organisms
Vinegar and alcohol are used to treat mild fungal infections
A pediatric patient’s assessment confirms otalgia, fever of 38.8 C, and a recent history of URI. The NP is unable to visualize the TM in the right ear because of the presence of cerumen in the ear canal. The left TM is dull gray with fluid levels present. What is the correct action?
A. Perform a tympanogram on the right ear
B. Recommend symptomatic treatment for fever and pain
C. Remove the cerumen and visualize the tympanic membrane
D. Treat empirically with amoxicillin 80-90 mg/kg/day
The AAP 2013 guidelines strongly recommends visualization of the TM to accurately diagnose otitis media and not to treat based on symptoms alone; therefore, the NP should attempt to remove the cerumen to visualize the TM.
If the TM doesn’t look bad then watchful waiting
A tympanogram cannot be performed when cerumen is blocking the canal
Which patient may be given symptomatic treatment with 24-hour follow-up assessment without initial antibiotic therapy?
A. 36-month-old with fever of 38.5 C, mild otalgia, and red, non-bulging TM
B. 4-year-old, afebrile child with bilateral otorrhea
C. 5-year-old with fever of 38.0 C, severe otalgia, and red, bulging TM
D. 6-month-old with fever of 39.2 C, poor sleep and appetite and bulging TM
Which patient may be given symptomatic treatment with 24-hour follow-up assessment without initial antibiotic therapy?
Answer: (A) 36-month-old with fever of 38.5 C, mild otalgia, and red, non-bulging TM
Note:
Children > 24-months-old with fever < 39 C and non-severe symptoms may be watched for 24 hours with symptomatic treatment
Children with otorrhea, severe AOM, and fever > 39 C should be given antibiotics
A patient reports ear pain and difficulty hearing. An otoscope exam reveals a small tear in the TM of the affected ear with purulent discharge. What is the initial treatment?
A. Insert a wick into the ear canal
B. Irrigate the ear canal to remove the discharge
C. Prescribe antibiotic ear drops
D. Refer the patient to an otolaryngologist
A patient reports ear pain and difficulty hearing. An otoscope exam reveals a small tear in the TM of the affected ear with purulent discharge. What is the initial treatment?
Answer: C; This perforation is most likely due to infection and should be treated with antibiotic ear drops
Wicks are used for otitis externa
The ear canal should not be irrigated to avoid introducing fluid into the middle ear
It is not necessary to refer unless the perforation does not heal
A 7-month-old infant has had 2 prior acute ear infections and is currently on the 10th day of therapy with amoxicillin-clavulanate after a failed course of amoxicillin. The NP notes marked middle ear effusion and erythema of the TM. The child is irritable and has a temp of 99.8 F. What is the next step?
A. Order a second course of amoxicillin-clavulanate
B. Perform tympanocentesis for culture
C. Prescribe clindamycin BID
D. Refer child to otolaryngologist
A 7-month-old infant has had 2 prior acute ear infections and is currently on the 10th day of therapy with amoxicillin-clavulanate after a failed course of amoxicillin. The NP notes marked middle ear effusion and erythema of the TM. The child is irritable and has a temp of 99.8 F. What is the next step?
A. Order a second course of amoxicillin-clavulanate
B. Perform tympanocentesis for culture
C. Prescribe clindamycin BID
D. Refer child to otolaryngologist
Answer: D; Children who have persistent infection who have failed appropriate therapy and those who have had 3 or more episodes of AOM in 6 months should be referred to an otolaryngologist
Ceftriaxone is ordered when Augmentin fails
The NP doesn’t perform tympanocentesis
Clindamycin is used for ceftriaxone failure but only if susceptibilities are known
When do the sinuses develop?
Maxillary: radiographically at birth
Ethmoid: radiographically present at birth
Frontal: anatomically present by 1 year, radiographically present by 3-7 years
Sphenoid: anatomically present by 4-5 years, radiographically present by 9 years
What is the youngest age to diagnose sinusitis?
Age 7 or older
Under age 7 used to be called “adenoiditis”
What are the signs and symptoms of sinusitis?
Signs/symptoms of sinusitis:
A cold that abates and returns (a “second sickening”)
Purulent nasal discharge
Morning or nocturnal cough (cough can be worse at night d/t post-nasal drip)
Periorbital edema (more common in children)
Fever (without cause)
Malodorous breath
