Ears

Tympanic membrane perforation

a hole in or rupture of the eardrum. Discharge from the ear is seen and often there is rapid relief of pain. Usually heals spontanously in a couple of weeks. Ototopical abx are recommended for a 10+-14 day course and referral to ENT should be made to assess hearing. Water activities should be limited.

Interventions and Teaching for Otitis Externa

1. when canal is sufficiently blocked by edema or drainage, preventing passage of ear drops, cautiously irrigate the canal and insert a cotton wick (approx. 1 in long for adults) to allow passage of drops 2. Insert the wick by gently rotating it while inserting it into ear. The patient then places ear drops on the wick. Provider may need to change wick daily or several times a week. Prevention: 1. Clean the outer ear only as needed. Do not place anything in the ear. 2. For swimmers, it may be helpful to dry ear canals out w/ hair dryer on a low setting after exposure. May also instill a solution of 50% isopropyl alcohol and 50% vinegar into the ear twice daily and after every submersion in water. OTC "swimmers ear" can be used. Teaching: 1. The patient should be advised to keep water out of the ear for 4-6 weeks. Should not swim until symptoms completely resolved and wick is removed. 2. Bathing or showering is permitted with a cotton ball coated in petroleum jelly inserted into the ear canal to block water passage.

Acute Otitus Media

Inflammation of the middle ear associated w/ acute bacterial infection. Usually caused by obstruction of the Eustachian tube which can lead to effusion and infection. Causes: S. pneumoniae, H influenzae, M. catarrhalis SS: Ear pain, pulling ears, fever may or may not be present Sleeplessness within past 48 hr, decreased appetite, increased fussiness, acute hearing loss, URI sx, mastoiditis presenting with a swollen or red mastoid, perforated tympanic membrane (sudden severe pain that is relieved when fluid drains), cholesteatoma (saclike structure in the middle ear accompanied by white, shiny, greasy debris) Tests: A. tympanogram shows flat or type B curve B. Hearing test should be done in patient w/ persistent media (greater than or equal to 3 mon) C. Consider CBC if patient looks toxic w/ fever.

Considerations for Otitis Media

-Consult the patient to an MD if they are less than 6 weeks -Hearing loss of 20 dB should get referred to an ear MD Prevention: 1. Wash child's hands often. 2. DO NOT SMOKE. should not be exposed to second hand smoke. 3. Do not prop the baby's bottle to feed. Increases ear infection 4. Do not allow to have bottle at bedtime. 5.Wean from bottle by 1st birthday. 6. Breastfeed for 1st 6 months-decreases chance of ear infection. Consideration: Preg: Do not use sulfa medications (sulfonamides) in pregnant patients. Kids: 1. <6 wks: consider blood culture and lumbar puncture if septicemia is suspected. May need IV antibiotics. Do not use sulfa drugs in children <2 mon 2. **The American Academy of Pediatrics does not recommend the use of OTC cough and cold medications for children younger than 6 yr.

Management of Hearing Loss

-Remove foreign body/ cerumen -Refer for audiogram -Refer for further eval/ hearing aid

Medications for Acute Otitis Media

1. **Drug of choice: Amoxicillin 90 mg/kg/d BID for 10 days --if there is concerns for resistance, recent antibiotic use in the last 30 days, or have other infections--use med w/ beta-lactamase activity such as Augmentin, or Cefdinir, Cefpodoxime, Cefuroxime, and Ceftraxone PCN Allergy: Cefdinir 14 mg/kg/d in 1-2 doses. Cefpodoxime 10 mg/kg/d, once daily Cefuroxime susp, 30 mg/kg/d BID-capsules: 250mg Q12H Macrolides: A. Erythromycin plus sulfisoxazole (Pediazole): 50-150 mg/kg/d of erythromycin divided into 4 doses/d for 10 days (NOT FOR <2 MON AGE) B Azithromycin 10 mg/kg/d on day 1, then 5 mg/kg/d on days 2-5 for 10 days Children younger than 2 should be treated w/ antibiotic tx for 10 days. Children older than 2 yr, w/o prev hx of otitus media may be tx for 5-7 days. (Pediazole). If asymptomatic and AOM is found on exam-may consider observation only if >2 yr. If first line antibiotics fail: use Augmentin, Suprax, Zithromax, Cefzil. For persistent otitis media (3 months or longer) consider using an antibiotic for 21 days. Residual otitis media may need tx w/ additional amoxicillin or beta-lactamase-resistant antibiotic. Important to follow up with patient and document the resolution of the infection.

Medications for Otitis Externa

1. 50% isopropyl alcohol and 50% vinegar in early, mild cases. 2. Mild Infection: -Topical tx: Use of Vosol or Vosol HC, which has glucocorticoid-5 drops in the ear 3-4 times a day (CONTRAINDICATED W/ PERFORATED EAR DRUM) Vosol HC cant be used in viral infections 3.Moderate: -Cipro HC and Cortisporin, along w/ other options. Adults should apply 4 gtt QID for 7 days; children should apply 3 gtt to canal QID for 7 days. -If fungus suspected, Nystatin may be used for candidal or yeast infections. 4.Severe or resistant -Ciprofloxacin for psuedomonal infectionsl dicoloxacillin or cephalexin for staph infection -Itraconazole (Sporanox) for tx of otomycosis (fungal otitis externa)

Interventions/Teaching of Acute Otitus Media

1. Pain relief w/ tylenol or advil. Auralgan may be used for a topical pain relief in children older than 3 yr 2. Teach parents that children should avoid smoke exposure. Smoke-filled rooms increase the risk of frequent ear infections in children. 3. Teach parents who use a bottle for feeding, TO NOT prop the bottle at any time for feeding because in increases the risk of infection.

Interventions/Plan for OME

1. Should be monitored closely for resolution of effusion w/o tx in several weeks. 2. Those that are persistent are at risk for hearing loss, speech, language, and learning disorders. 3. Children with persistent OME should be referred to ENT for hearing evaluation and possible tubes. 4. Speech and language evaluation or documentation of hearing loss is recommended for children with OME older than 3 months. Teaching: 1. Educate patients that OME is not treated with antibiotics since no infection is present. 2. If symptoms change, infection should be suspected and the primary care provider should be notified of new symptoms. 3. Teach about the routine use of antihistamines and decongestations are not recommended. Meds: 1. ABX are not recommended for OME. However in certain situations (Amoxil) for 10-14 days is recommended. 2. Intranasal glucocorticoid is not recommended for OME in children

Conditioned Play Audiometry

2.5-5 yrs The child responds to sound stimulus by performing an activity, such as putting a peg into a board

Grades of hearing loss in children

20-40 dB mild 41-55 dB moderate 56-70 dB moderately severe 71-90 dB severe 91+ dB profound

Conventional Audiometry

5 yr and up The child indicates when he or she hears a sound.

Congenital Hearing Loss

50% are nonhereditary (prenatal infections, teratogenic drugs, and perinatal injuries). The most common known mutation associated with nonsyndromic hearing loss is in the GJB2 gene, which encodes the protein Connexin 26.

Otitits Media w/ Effusion

Effusion (OME) is a asymptomatic middle-ear fluid without signs of bacterial infection. SS: ear pain, increased pressure sensation in the ears, recent hearing loss, the patient may have a sense of fullness in the ears. Tests: A. Pneumatic otoscopy reveals decreased mobility (Assessment w/ pneumatic otoscopy is strongly recommended) B. Negative pressure on tympanogram

Visual Reinforcement Audiometry

6 months to 2.5 yrs Auditory stimulus is pared with positive reinforcement. Ex: child turns to sound and a toy will light up. After a brief conditioning period, the child localizes toward the tone, if audible, in anticipation of the lighted toy

Behavioral Observational Audiometry

Behavioral Observational Audiometry (birth-6 months). Sounds are presented at different levels, and the audiologist watches for a reaction, such as a change in respiratory rate, starting or stopping of a activity, startle, head turn, or muscle tensing. The method is highly tester dependent and error-prone

Ear canal Foreign Body

Cerumen can be obstructive like a foreign body. If the cerumen or object is large or difficult to remove with available instruments, otolaryngology referral is recommended. Veggie matter should never be irrigated because it can swell and become more difficult to remove. An emergency situation exists if it is a disk-type battery. An electric current is generated in the moist canal and a severe burn can occur in less than 4 hours. If the TM cannot be visualized, assume a perforation and avoid irrigation or ototoxic medications.

Otitis Externa

Common, acute, self-limiting inflammation or infection of the external auditory canal and auricle. Patho: A. acute diffuse otitis externa (swimmer's ear): Pseudomonas is the most common bacterial infection, followed by Staphylococcus and Streptococcus. Infection can also be fungal (Aspergillus 90%) B. Chronic otitis externa: condition generally results from a persistent, low grade infection and inflammation with Pseudomonas. C. Eczematous otitis externa: Otitis externa associated with primary coexistent skin disorder such as atopic dermatitis, seborrheic dermatitis, and psoriasis D. Necrotizing or malignant otitis externa: Invasive Pseudomonas infection results in skull base osteomyelitis. (most common in immunocompromised or geriatric DM patients) SS: Otalgia, itching, erythematous and swollen external ear canal, purulent drainage, hearing loss from edema and obstruction of canal with drainage. plugged ear sensation (aural fullness), tenderness to palpation (tragus) Test: a. Examin ear canal scrapping and drainage under a microscope for hyphae (if fungal infection suspected) b. Culture vesicular lesions for viruses. F/U: Usual follow up within 48 hr to assess improvement. Recheck in 1-2 weeks. Consult: Parenteral antibiotics required for necrotizing otitis externa. Considerations: Geratrics: 1. Persistent infections may evolve into osteomyelitis of the skull base 2. The external ear is painful and edematous, and a foul, green dc is usually present 3. Tx may require parenteral gentamycin w/ a beta-lactam agent. Surgery may be needed 4. Oral fluoroquinolones may be useful if infection has not progressed to osteomyelitis.

What is the normal hearing decibel?

Considered normal if it is within 20 dB of normal.

Acquired Hearing Loss

Exposure to ototoxic medications, meningitis, autoimmune or neoplastic conditions, noise exposure, and trauma. Infections such as syphilis or Lyme disease. Hearing loss associated with CMV may be present at birth or may have a delayed onset. The loss is progressive in approximately half of all patients with congenital CMV-associated hearing loss.

Newborn Hearing Screen

Goal of hearing loss identification by 3 months of age, and appropriate intervention by 6 months. Auditory brainstem response and otoacoustic emission testing are the two commonly employed screening modalities. (these can also be used if a child can not be reliably tested using other methods)

Mastoiditis

Occurs when infection spreads from the middle ear space to the mastoid portion of the temporal bone, which lies behind the ear and contains air filled spaces. -Can occur at any age but commonly <2 yr. S/S: Postauricular pain, fever, and an outwardly displaced pinna. On exam, mastoid area often appears indurated and red and, with disease progression, swollen and fluctuant. Earliest finding is severe tenderness on mastoid palpation. AOM is almost always present. Tests: CT to check progression Complications: Meningitis can be a complication of acute mastoiditis. Lumbar puncture should be performed in these cases. Tx: IV antibiotics as long as no abcesses are noticed on CT. If there is no improvement in 24-48 hr-surgical intervention is needed.

Conductive Hearing Loss

Occurs when the sound transmission is blocked somewhere between the opening of the external ear and the cochlear receptor cells. *Most common cause in kids is fluid in the middle ear caused by otitis media and related conditions such as ear effusion and Eustachian tube dysfunction. Other causes: auditory canal atresia or stenosis, TM perforation, cerumen impaction, cholesteatoma, and middle ear abnormalities. *Recommends hearing and language skills be assessed in children who have recurrent acute otitis media or MEE lasting longer than 3 months.

Audiologic Evaluation of Infants/Children

Signs of hearing loss include inconsistent response to sounds, not following directions, speech and language delays, and turning the volume up on tv or radios. If suspected, refer the patient to formal testing with a audiologist.

cholesteatoma

cystlike mass composed of epithelial cells and cholesterol occurring in the middle ear; may be associated with chronic otitis media If infection is superimposed, serous or purulent drainage will be seen, and the middle ear cavity may contain granulation tissue or even polyps. Persistent, recurrent or foul-smelling otorrhea following appropriate medical management should make one suspect a cholesteatoma.

Sensorineural Hearing Loss

hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness. Loss may be present at birth (congenital) or acquired. Risk Factors: + family hx, birth weight less than 1500 g, low Apgar scores, craniofacial abnormalities, hypoxia, in-utero infections (eg, TORCH syndrome), hyperbilirubinema requiring exchange, and mechanical ventilation for more than 5 days