Family Practice Guidelines 2017
Ear Guidelines

 Acute Otitis Media

Jill C. Cash and Moya Cook

 

Definition

1. Acute otitis media (AOM) is inflammation of the middle ear associated with an acute bacterial infection of the middle ear.

 

Incidence

1. AOM may occur at any age. It is most commonly seen in
2. Over two thirds of children have had at least one episode of otitis media by 3 years of age.
3. One third of children have had three or more episodes by 3 years of
4. One third of all pediatric visits are for otitis

 

Pathogenesis

1. Obstruction of the Eustachian tube can lead to a middle-ear effusion and infection. Contamination of this middle-ear fluid often results from a backup of nasopharyngeal secretions. The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

 

Predisposing Factors

1. Age less than 12 months
2. Recurrent otitis media (three or more episodes in the last 6 months)
3. Previous episode of otitis media within the last month

 

1. Medical condition that predisposes to otitis media (i.e., Down syndrome, AIDS, cystic fibrosis, cleft palate, and craniofacial abnormalities)
2. Native American heritage
3. Exposure to tobacco smoke and air pollution
4. Day-care attendance
5. Bottle propping
6. Family history of allergies
7. Pacifier use

 

Common Complaints

1. Ear pain
2. Pulling ears
3. Fever may or may not be present

 

Other Signs and Symptoms

1. Sleeplessness within past 48 hours
2. Decreased appetite
3. Increased fussiness
4. Acute hearing loss
5. Upper respiratory infection (URI) symptoms
6. Mastoiditis presenting with a swollen and red mastoid
7. Perforated tympanic   membrane   (sudden   severe   pain   followed   by immediate relief of pain with fluid drainage from the ear)
8. Cholesteatoma (saclike structure in the middle ear accompanied by white, shiny, greasy debris)

 

Subjective Data

1. Elicit onset and duration of
2. Inquire whether the patient recently had (or has concurrently) a
3. Determine whether the patient has any change in
4. Assess the patient for any drainage from the ear(s).
5. Question the patient or his or her caregiver regarding risk
6. Identify the patient’s history of otitis

 

Physical Examination

1. Check temperature, pulse, respirations, and blood

 

1. Inspect
   1. Observe the canal and auricle for redness, deformity, drainage, or foreign
   2. Inspect the tympanic membrane position to determine if it is neutral and whether landmarks are visible, retracted, full, or
   3. Observe ears for decreased or absent tympanic membrane
   4. Inspect nose, mouth, and
2. Auscultate heart and

 

Diagnostic Tests

1. Tympanogram shows flat or type B
2. Hearing test should be done in patients with persistent otitis media (greater or equal to 3 months’ duration).
3. Consider complete blood count if the patient appears toxic with a high fever.

 

Differential Diagnoses

1. AOM
2. Otitis media with effusion (OME)
3. Red tympanic membrane secondary to crying (differentiated from AOM by mobility with pneumatic otoscopy)
4. URI
5. Mastoiditis
6. Foreign body in the ear
7. Otitis externa

 

Plan

1. General intervention:  Pain   relief  with   acetaminophen  or   Auralgan may be used for a topical pain relief in children older than 3 years.
2. Patient teaching
   1. See Section III: Patient Teaching Guide for this chapter, “Acute Otitis Media.”
   2. Educate parents and care providers that children should avoid smoke exposure. Smoke-filled rooms increase the risk of frequent ear infections in
   3. For young children who use a bottle for feeding, stress the importance

 

of NOT propping bottles at any time for feeding. Propping bottles increases the risk of ear infections.

1. Pharmaceutical therapy
   1. Drug of choice: Amoxicillin 90 mg/kg/d divided into two daily doses for 10 days, up to a maximum of 3 g/d.
   2. For concerns of amoxicillin resistance, treatment failure, recent use of antibiotic in the previous 30 days, and/or concurrent other infections, use an antibiotic with beta-lactamase activity such as amoxicillin-clavulanate (Augmentin). Other alternatives include cefdinir, cefpodoxime, cefuroxime, and
   3. For penicillin allergy: Cefdinir 14 mg/kg/d in one to two doses, maximum dose 600 mg/d. Cefpodoxime 10 mg/kg/d, once daily, maximum dose 800 mg/d. Cefuroxime susp, 30 mg/kg/d in two divided doses, maximum dose 1 g/d. Capsules: 250 mg every 12
   4. Alternative: One dose of ceftriaxone 50 mg/kg intramuscularly (IM). If clinically improved in 48 hours, no further treatment is recommended. If signs/symptoms continue, administer the second dose of ceftriaxone in 48 hours.
   5. Other alternatives: Macrolides
      1. Erythromycin plus sulfisoxazole (Pediazole): 50 to 150 mg/kg/d of erythromycin divided into four doses/d for 10 days; maximum dose 2 g erythromycin or 6 g sulfisoxazole/d. Do not use in children younger than 2
      2. Azithromycin 10 mg/kg/d, maximum dose 500 mg/d as single dose on day 1, then 5 mg/kg/d, maximum dose of 250 mg/d on days 2 to 5 for 10 days
      3. Clarithromycin 15 mg/kg/d divided into two doses, maximum dose 1 g/d.
      4. Trimethoprim with sulfamethoxazole 8 mg/kg/d of trimethoprim (40 mg/kg/d of sulfamethoxazole) divided into two daily doses for 10 days
   6. Children younger than 2 years should be treated with antibiotic therapy for 10 days. Children older than 2 years, without a previous history of otitis media, may be treated for 5 to 7 days. Erythromycin with sulfisoxazole 40 mg/kg/d (150 mg/kg/d of sulfisoxazole [Pediazole]) divided into four daily doses for 10 Do not use in children

 

younger than 2 months.

7. If the patient is asymptomatic and AOM is found on examination, consider observation without antibiotics only if child is older than 2 years. Recommend follow-up examination in 48
8. Other antibiotics (if first-line antibiotic fails): Amoxicillin and clavulanic acid (Augmentin), cefixime (Suprax), azithromycin (Zithromax), and cefprozil (Cefzil).
9. For persistent otitis media (3 months or longer), consider using an antibiotic for 21 days. Residual otitis media may need treatment with additional amoxicillin or beta-lactamase-resistant

 

Follow-Up

1. Check the patient in 2 to 4 weeks or if fever and complaints persist for more than 48 hours after the antibiotic is begun. Documentation of the resolution of the ear infection is valuable information if recurrent infections occur.

 

Consultation/Referral

1. Consult or refer the patient to a physician if he or she is less than 6 weeks of age, appears septic, or has
2. A patient with persistent otitis media with a hearing loss of 20 dB or more should be referred to an

 

Individual Considerations

1. Pregnancy: Do not use sulfa medications (sulfonamides) in pregnant patients, clients at
2. Pediatrics
   1. Children 6 weeks old or younger: Consider a blood culture and lumbar puncture if septicemia is The patient may need intravenous

(IV) antibiotics depending on culture results. Do not use sulfa medications (sulfonamides) in children younger than 2 months.

2. The American Academy of Pediatrics does not recommend the use of over-the-counter (OTC) cough and cold medications for children younger than 6 years. In older children, consider decongestants for nasal congestion. Antihistamines are not

1. Geriatrics: Elderly patients may present with OME and/or otitis media

 

secondary to a blocked Eustachian tube and/or URI.

 

 Cerumen Impaction (Earwax)

Jill C. Cash and Moya Cook

 

Definition

1. Cerumen impaction, or earwax buildup, can cause conductive hearing loss or discomfort.

 

Incidence

1. Cerumen impaction occurs in patients of all ages. It is commonly seen in the elderly. The incidence in nursing home patients is 40%.

 

Pathogenesis

1. Wax builds up in the external canal. With age, the normal self-cleaning mechanisms of the ear fail. Cilia, which have become stiff, cannot remove cerumen and dirt from the ear canal. The pushing of cotton swabs, paper clips, bobby pins, and so forth, into the ear canal may also impact cerumen.

 

Predisposing Factors

1. Aging (decreased function of ear cilia)
2. Use of hearing aids
3. Use of cotton swabs to clean ear canals

 

Common Complaints

1. Dryness and itching of ear canal
2. Dizziness
3. Ear pain
4. Hearing loss

 

Subjective Data

1. Elicit onset and duration of
2. Elicit history of cerumen
3. Question the patient regarding the method of cleaning

 

Physical Examination

1. Check temperature, pulse, respirations, and blood
2. Inspect
   1. Observe ears for thick, light- to dark-brown wax occluding the auditory
   2. Observe the tympanic membrane if possible. A perforated tympanic membrane is associated with otitis
   3. Inspect the nose and
3. Auscultation: Auscultate heart and

 

Diagnostic Tests

1. Conductive hearing loss of 35 to 40 dB
2. Perform Rinne and Weber
   1. The Rinne tuning-fork test reveals bone conduction greater than air conduction in the affected ear (abnormal). The Rinne test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction
   2. The Weber test reveals conductive hearing loss when sound travels toward the poor ear. Sensorineural hearing loss is present when sound travels toward the good ear. This is performed by striking a tuning fork and then placing it on the middle of the head. The patient should be asked where sound is being heard: from the left ear, the right ear, or equal in both ears. Normal results are reflected by sound being heard equally in both ears.

 

Differential Diagnoses

1. Cerumen impaction
2. Foreign body in the ear canal
3. Otitis externa: White, mucus-like ear discharge associated with otitis externa

 

Plan

 

1. General interventions
   1. Remove impaction by means of lavage or curettage. Be sure to inspect the canal and tympanic membrane after removal of the
   2. Document the patient’s hearing before and after removal of
2. Patient teaching
   1. See Section III: Patient Teaching Guide for this chapter, “Cerumen Impaction (Earwax).”
   2. Instruct the patient not to clean ears with cotton swabs, bobby pins, and so forth. Using these devices pushes the wax further into the ear canal and can worsen
3. Pharmaceutical therapy
   1. Drug of choice: Debrox, mineral oil, or olive oil two to three drops in the ear every day for 1 week to loosen the cerumen before lavage or curettage. Do not use Debrox if perforation of tympanic membrane is suspected.
   2. For prevention, have the patient use the aforementioned softeners for 2 to 3 days. Then have him or her use one capful of hydrogen peroxide in the ear twice daily, allow it to bubble for 5 to 10 minutes, then turn head to allow it to run

 

Follow-Up

1. No follow-up is needed unless indicated. Recurrence is common.

 

Consultation/Referral

1. Consult or refer the patient to a physician when cerumen cannot be cleared.

 

Individual Considerations

1. Geriatrics

1. Cerumen impaction is very common in the elderly due to atrophic cilia and dry epithelium in the ear
2. The use of hearing aids also can contribute to wax buildup and cause wax to be pushed further into the canal. Persons with hearing aids should be evaluated for wax buildup as

 

 Hearing Loss

Jill C. Cash and Moya Cook

 

Definition

Impaired hearing (complete or partial hearing loss) results from interference with the conduction of sound, its conversion to electrical impulses, or its transmission through the nervous system. There are three types of hearing loss:

1. Conductive hearing loss
2. Sensorineural hearing loss
3. Combined conductive and sensorineural loss

 

Incidence

1. Hearing loss is present in 10% to 15% of patients; approximately 30 million Americans have some degree of hearing impairment.

 

Pathogenesis

1. Conductive hearing   loss   presents   with   a   diminution   of   volume, particularly low tones and vowels. It may be caused by one of the following:
   1. Otosclerosis disorder of the architecture of the bony labyrinth fixes the footplate of the stapes in the oval
   2. Exostoses are bony excrescences of the external auditory
   3. Glomus tumors are benign, highly vascular tumors derived from normally occurring glomera of the middle ear and jugular
2. Sensorineural hearing loss characteristically produces impairment of the high-tone perception. Affected patients can hear people speaking, but they have difficulty deciphering words because discrimination is poor. It may be caused by one of the following:
   1. Presbycusis is hearing loss associated with aging and is the most common cause of diminished hearing in the elderly; onset is bilateral, symmetric, and
   2. Noise-induced hearing loss is due to chronic exposure to sound levels in excess of 85 to 90
   3. Drug-induced hearing loss can be caused by aminoglycoside antibiotics, furosemide, ethacrynic acid, quinidine, and

 

4. Ménière’s disease produces a fluctuating, unilateral, low-frequency impairment usually associated with tinnitus, a sensation of fullness in the ear, and intermittent episodes of
5. Acoustic neuroma is a benign tumor of the eighth cranial nerve (rare).
6. Sensorineural hearing loss is generally bilateral and symmetric, and it may be genetically
7. Sudden deafness can derive from head trauma, skull fracture, meningitis, otitis media, scarlet fever, mumps, congenital syphilis, multiple sclerosis, and perilymph leaks or

 

Predisposing Factors

1. Acoustic or physical trauma
2. Ototoxic medications (such as gentamicin and aspirin)
3. Changes in barometric pressures
4. Recent upper respiratory infection (URI)
5. Pregnancy
6. Otosclerosis
7. Nasopharyngeal cancer
8. Serous otitis media
9. Cerumen impaction
10. Foreign body in the ear

 

Common Complaints

1. Partial hearing loss
2. Total hearing loss
3. Difficulty understanding the television, phone conversations, and people talking

 

Other Signs and Symptoms

1. Unilateral or bilateral hearing loss
2. Hearing noises as “ringing,” “buzzing,” and so forth
3. Fullness in ear(s)

 

Subjective Data

1. Elicit the onset, duration, progression, and severity of symptoms. Note whether symptoms are bilateral or

 

1. Obtain the patient’s history of past or recent
2. Review the patient’s occupational and recreational exposure to risk factors.
3. Review the patient’s medical history and medications, including OTC drugs and
4. Review the patient’s history for recent URI or ear infections, especially for chronic ear
5. Elicit data about any previous hearing loss, how it was treated, and how it affected daily activities. There is often a history of previous ear disease with conductive hearing
6. Review the patient’s other symptoms such as dizziness, fullness or pressure in the ears, and
7. Review what causes difficulty with hearing, high tones versus low frequencies. Can the patient hear people talking, the television at normal volume, doorbells ringing, telephone ringing, and watch ticking?

 

Physical Examination

1. Temperature
2. Inspect
   1. Examine both ears for
   2. Externally inspect ears for discharge; note color and odor. Obstruction of the auditory canal by impacted cerumen, a foreign body, exostoses, external otitis, OME, or scarring or perforation of the eardrum due to chronic otitis may be
   3. Conduct otoscopic examination to observe the auditory canal for cerumen impaction or foreign
   4. Examine tympanic membrane for color, landmarks, contour, perforation, and acute otitis media (AOM). A reddish mass visible through the intact tympanic membrane may indicate a high-riding jugular bulb, an aberrant internal carotid artery, or a glomus
3. Palpate
   1. Palpate auricle and mastoid area for tenderness, swelling, or
   2. Check lymph nodes if infection is
4. Neurologic testing
   1. Weber test
   2. Perform a Weber screen. The Weber test reveals conductive

 

hearing loss when sound travels toward the poor ear. Sensorineural hearing loss is present when sound travels toward the good ear. This is performed by striking a tuning fork and then placing it on the middle of the head. The patient should be asked where sound is being heard from, the left ear, the right ear, or equal in both ears. Normal results are reflected by sound being heard equally in both ears.

2. Rinne screen
   1. The Rinne tuning-fork test reveals bone conduction greater than air conduction in the affected ear (abnormal). The Rinne test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction

 

Diagnostic Tests

1. Audiogram in primary setting
2. Air insufflation for tympanic membrane mobility
3. Tympanometry brainstem-evoked response audiogram
4. CT or MRI after consultation with an otolaryngologist

 

Differential Diagnoses

1. Congenital hearing loss
2. Traumatic hearing loss
3. Ototoxicity
4. Presbycusis
5. Ménière’s syndrome
6. Acoustic neuroma
7. Cholesteatoma
8. Infection
9. Cerumen impaction
10. Otitis externa
11. Foreign body in the ear
12. Tumors
13. Otosclerosis

 

1. Perforation of tympanic membrane
2. Serous otitis media
3. Hypothyroidism
4. Paget’s disease

 

Plan

1. General interventions
   1. Treat any primary cause (i.e., remove impacted cerumen).
   2. Inform the patient regarding results of screening and indications for further
2. Patient teaching
   1. Discuss avoiding loud noises, using earplugs, and so
   2. Instruct the patient not to insert small objects into the
3. Pharmaceutical therapy: Treat primary condition if

 

Follow-Up

1. If the primary cause of hearing loss is not identified, refer the patient to a physician.

 

Consultation/Referral

1. The patient should be referred to an otolaryngologist for an extensive workup when the primary cause cannot be
2. Referral should be made to a hearing aid specialist for hearing evaluation and treatment as indicated (i.e., hearing aids).

 

Individual Considerations

1. Pediatrics
   1. Most children are able to respond to a test of gross hearing using a small bell. To determine the patient’s hearing ability, note if the child stops moving when the bell is rung and if the child turns his or her head toward the
   2. When examining children, pull the pinna back and slightly upward to straighten the
2. Adults
   1. The external auditory canal in the adult can best be exposed by pulling the earlobe upward and

 

1. Geriatrics
   1. Impaired hearing among the elderly is common and can lower the quality of
   2. People with seriously impaired hearing often become withdrawn or appear confused.
   3. Subtle hearing loss may go
   4. Impacted cerumen is very common in the

 

 Otitis Externa

Jill C. Cash and Moya Cook

 

Definition

1. Otitis externa is a common, acute, self-limiting inflammation or infection of the external auditory canal and auricle.

 

Incidence

1. Otitis externa is seen in patients of all ages. Incidence is higher during summer months. All varieties (with exception of necrotizing otitis externa) are common.

 

Pathogenesis

1. Acute diffuse otitis externa (swimmer’s ear): Pseudomonas is the most common bacterial infection (67%), followed by Staphylococcus and Infection can also be fungal (Aspergillus, 90%). Bacterial or fungal invasion is usually preceded by trauma to the ear canal, aggressive cleaning of the naturally bactericidal cerumen, or frequent submersion in water (swimming).
2. Chronic otitis externa: Condition generally results from a persistent, low- grade infection and inflammation with
3. Eczematous otitis externa: Otitis externa associated with primary coexistent skin disorder such as atopic dermatitis, seborrheic dermatitis, and psoriasis.
4. Necrotizing or malignant otitis externa: Invasive Pseudomonas infection results in skull base osteomyelitis. It is most commonly seen in the

 

immunocompromised or diabetic geriatric patient.

 

Predisposing Factors

1. Ear trauma from scratching with a foreign object or fingernail, overly vigorous cleaning of cerumen from canal
2. Humid climate
3. Frequent swimming
4. Use of a hearing aid
5. Eczema (eczematous otitis externa)
6. Debilitating disease (necrotizing otitis externa)

 

Common Complaints

1. Otalgia
2. Itching
3. Erythematous and swollen external canal
4. Purulent discharge
5. Hearing loss from edema and obstruction of canal with drainage

 

Other Signs and Symptoms

1. Plugged ear sensation (aural fullness)
2. Tenderness to palpation (tragus)

 

Subjective Data

1. Elicit the onset, duration, and intensity of ear
2. Inquire into the patient’s history of previous ear
3. Determine whether the patient notes any degree of hearing
4. Question the patient about recent exposure to immersion in water (swimming).
5. Question the patient as to ear canal cleaning practices and any recent trauma to the

 

Physical Examination

1. Temperature
2. Inspect
   1. Carefully examine the ear with an otoscope for extreme
   2. Observe the ear for erythematous and edematous external canal; look

 

for otorrhea and debris.

3. Observe the tympanic membrane, which may appear
4. Inspect nose and

1. Auscultate heart and
2. Palpate
   1. Apply gentle pressure to tragus and manipulate pinna to assess for tenderness.
   2. Palpate cervical lymph

 

Diagnostic Tests

1. Examine ear canal scrapings and drainage under a microscope for hyphae (if fungal infection is suspected from previous history or ineffective topical therapy).
2. Culture vesicular lesions for

 

Differential Diagnoses

1. Otitis externa
2. Otitis media
3. Foreign body
4. Mastoiditis
5. Hearing loss
6. Wisdom tooth eruption
7. Herpetic otitis externa (vesicular eruptions in the ear canal are associated with herpetic otitis externa).
8. Necrotizing or malignant otitis externa (life-threatening condition that occurs in diabetic or immunocompromised patients). Cranial nerve palsies (of the seventh, ninth, and twelfth cranial nerves) and periostitis of the skull base have been associated with necrotizing otitis

 

Plan

1. General interventions
   1. When the patient’s ear canal is sufficiently blocked by edema or drainage, preventing passage of ear drops, cautiously irrigate the canal and insert a cotton wick (approximately 1 in. long for adults) to allow passage of drops.
   2. Insert the wick by gently rotating it while inserting it into the The

 

patient then places ear drops on the wick. The drops are absorbed through the wick, which allows medicine to reach the external canal. The provider may need to change the wick daily or several times per week.

1. Patient teaching
   1. See Section III: Patient Teaching Guide for this chapter, “Otitis Externa.”
   2. The patient should be advised to keep water out of the ear for 4 to 6 weeks. The patient should not swim until symptoms are completely resolved and the wick is
   3. Bathing or showering is permitted with a cotton ball coated with petroleum jelly inserted into the ear to block water passage into the ear canal.
2. Pharmaceutical therapy
   1. For early, mild cases associated with swimming in which the primary symptom is pruritus, homemade preparations of 50% isopropyl alcohol and 50% vinegar can be used as a drying agent and to create an unsatisfactory environment for Pseudomonas
   2. Mild infection: Topical therapy—Use of acidifying agent such as Vosol or Vosol HC, which includes a glucocorticoid therapy: Instill five drops in the ear canal three to four times daily. (Vosol and Vosol HC are contraindicated with perforated eardrum; Vosol HC is contraindicated with viral otic )
   3. Moderate infection: Use of an acidifying agent, antibiotic and glucocorticoid therapy (Cipro HC), and Cortisporin is suggested. Other alternatives include Ciprofloxacin (Cipro HC), Ofloxacin (Floxin), Polymyxin B, Neomycin (Cortisporin Otic) suspension or solution. Adults should apply four drops to the canal four times daily for 7 days; children should apply three drops to the canal four times daily for 7 days. The suspension is recommended rather than the solution if the integrity of the tympanic membrane is in
   4. If fungal infection is suspected, Nystatin 100,000 units/mL or clotrimazole topical solutions may be used for candidal or yeast infections.
   5. Severe or resistant infections may require additional management with oral antibiotics and antifungals:
      1. Ciprofloxacin for pseudomonal infections; dicloxacillin or

 

cephalexin for staphylococcal infections.

1. Itraconazole (Sporanox) for treatment of otomycosis (fungal otitis externa).

5. For analgesia, use acetaminophen or ibuprofen. Short-term use of opiates may be necessary when acetaminophen and ibuprofen fail to control

 

Follow-Up

1. Usual follow-up is within 48 hours to assess improvement. Recheck in 1 to 2
2. In severe cases requiring antibiotic drops instilled by means of a wick, follow-up may be required daily or several times per week to remove and replace the

 

Consultation/Referral

1. Parenteral antibiotics are required for necrotizing otitis externa. These patients should be immediately referred to a
2. Consult or refer the patient to a physician if osteomyelitis is

 

Individual Considerations

1. Geriatrics
   1. Persistent otitis externa in the geriatric patient (especially those who are immunocompromised or diabetic) may evolve into osteomyelitis of the skull
   2. The external ear is painful and edematous, and a foul, green discharge is usually
   3. Treatment may require parenteral gentamicin with a beta-lactam agent. Surgery may be
   4. Oral fluoroquinolones may be useful if infection has not progressed to osteomyelitis.

 

 Otitis Media With Effusion

Jill C. Cash and Moya Cook

 

Definition

 

1. Otitis media with effusion (OME) is asymptomatic middle-ear fluid without signs of bacterial infection.

 

Incidence

1. OME is seen in patients of all
2. After the onset of acute otitis media (AOM), approximately 70% of children have fluid present at 2
   1. 40% have fluid present at 1
   2. 20% have fluid present at 2
   3. 10% have an effusion at 3

 

Pathogenesis

1. The effusion may be sterile fluid secondary to upper respiratory infection (URI) and Eustachian tube dysfunction. It may be residual fluid after an episode of AOM.

 

Predisposing Factors

1. Recent otitis media
2. Concurrent URI

 

Common Complaints

1. Ear pain
2. Increased pressure sensation in the ears
3. Recent hearing loss

 

Other Signs and Symptoms

1. The patient has a sense of fullness in the ears.

 

Subjective Data

1. Elicit the onset and duration of
2. Question the patient about recent history of otitis media or
3. Question the patient about hearing
4. Determine if the patient has a past history of frequent otitis

 

Physical Examination

1. Check temperature, pulse, respirations, and blood

 

1. Inspect
   1. Ears, noting fluid level, serous middle fluid, and a translucent, amber, gray membrane with decreased
   2. Nose, mouth, and
2. Auscultate heart and
3. Palpate head, neck, and lymph
4. Neurologic examination
   1. Perform the Rinne test. This test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction
   2. Perform the Weber

 

Diagnostic Tests

1. Pneumatic otoscopy   reveals   decreased      Assessment   with pneumatic otoscopy is strongly recommended.
2. Negative pressure on

 

Differential Diagnoses

1. OME
2. Cerumen impaction
3. AOM
4. Foreign body in the ear

 

Plan

1. General interventions
   1. Patient should be monitored closely for resolution of effusion without treatment within several
   2. Patients who have persistent effusion are at risk for hearing loss, speech, language, and learning
   3. Children with persistent OME should be referred to an otolaryngologist for a hearing evaluation and possible tympanostomy tubes as
   4. Speech and language evaluation or documentation of hearing loss is

 

recommended for children with OME older than 3 months.

1. Patient teaching
   1. See Section III: Patient Teaching Guide for this chapter, “Otitis Media With Effusion.”
   2. Educate parents that OME is not treated with antibiotics since no infection is
   3. If symptoms change, infection should be suspected and the primary care provider should be notified of new symptoms and that reevaluation is needed.
   4. Teach the parents/care provider that routine use of antihistamines and decongestants is not
2. Pharmaceutical therapy
   1. The American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Otolaryngology-Head Neck Surgery do not recommend routine use of antibiotic therapy for OME. However, in certain situations, a course of antibiotics (Amoxil) for 10 to 14 days is
   2. Intranasal glucocorticoids are not recommended for routine use for OME in
   3. Antihistamines and decongestants are not recommended for routine use for OME in

 

Follow-Up

1. Recheck the patient’s ears after 4 to 6 weeks to evaluate effectiveness of treatment.

 

Consultation/Referral

1. Consult or refer the patient to a physician if treatment is not effective or if the patient has a persistent effusion (at least 3 months) along with a hearing loss of 20 dB or
2. Consider referring the patient to an

 

Individual Considerations

1. Geriatrics
2. OME may be present in the elderly, usually unilaterally, and usually associated with a URI or allergies due to a blocked Eustachian

 

2. If there is no accompanying URI, a nasopharyngeal mass must be ruled out.

 

 Tinnitus

Jill C. Cash and Moya Cook

 

Definition

1. The word tinnitus comes from the Latin tinnire, which means “to ring.” It refers to any sound heard in the ears or head.

 

Incidence

6. It is estimated that 6.4% of the adult population has experienced tinnitus at some point. More than 7 million people in the United States are thought to experience tinnitus.

 

Pathogenesis

1. Tinnitus is poorly understood. It is best described as a nonspecific manifestation of pathology of the inner ear, eighth cranial nerve, or the central auditory mechanism.

 

Predisposing Factors

1. Cerumen impaction
2. Tympanic membrane perforation
3. Fluid in the middle ear
4. Acute otitis media (AOM)
5. Acoustic trauma
6. Ototoxic drugs
   1. Sulfas
   2. Aminoglycosides
   3. Salicylate
   4. Indomethacin
   5. Propranolol
   6. Levodopa
   7. Carbamazepine

 

1. Vascular aneurysm
2. Jugular bulb      Compression  of   the   ipsilateral  jugular  vein abolishes the objective tinnitus of a jugular megabulb anomaly
3. Anemia
4. Temporomandibular joint syndrome
5. Hypertension

 

Common Complaints

1. Ringing
2. Roaring
3. Buzzing
4. Clicking
5. Hissing
6. Hearing loss

 

Other Signs and Symptoms

1. “Muffled” hearing
2. Change in own voice, lower pitch

 

Subjective Data

1. Review the onset, duration, course, and type of symptoms; note whether they are bilateral or
2. Determine the frequency and quality of sound; is the ringing constant, intermittent, or pulsating?
3. Review all medications, including over-the-counter (OTC) drugs and prescriptions.
4. Determine whether   the   patient   has   experienced   trauma   (domestic violence, motor vehicle accident, and so forth).
5. Rule out a recent sinus, oral, or ear
6. Review any previous occurrences. Ask: How was it treated?
7. Review work, hobbies, and music habits for noise levels (potential damage).
8. Assess the date of last hearing examination and determine whether there was any known hearing
9. Review whether the patient uses cotton-tipped swabs or other small objects for ear

 

Physical Examination

1. Take temperature if infectious cause is
2. Inspect
   1. Observe the external ear for discharge; note color and
   2. Conduct otoscopic examination of the auditory canal for cerumen impaction or foreign
   3. Inspect tympanic membrane for color, landmarks, contour, perforation, and
      1. The landmarks (umbo, handle of malleus, and the light reflex) should be visible on a normal
      2. The tympanic membrane should be pearly gray in color and translucent.
      3. A bulging tympanic membrane is more conical, usually with a loss of bony landmarks and a distorted light
      4. A retracted tympanic membrane is more concave, usually with accentuated bony landmarks and a distorted light reflex (pathologic conditions in the middle ear may be reflected by characteristics of the tympanic membrane).
   4. Auscultation
      1. The skull should be auscultated for a bruit if the origin of the problem remains
   5. Palpate
      1. Palpate auricle and mastoid area for tenderness, swelling, or
      2. Check lymph nodes if infection is
   6. Visual examination
      1. Check for nystagmus if vertigo is
   7. Neurologic examination
      1. The eighth cranial nerve is tested by evaluating
      2. First evaluate how the patient responds to your
      3. Patients who speak in a monotone or with erratic volume may have hearing
      4. Check the patient’s response to a soft whisper (should respond at least 50% of the time).
      5. Perform the Rinne test: The Rinne test is performed by placing the struck tuning fork against the mastoid Begin counting or timing the

 

interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction stops.

6. Perform the Weber

 

Diagnostic Tests

1. Audiogram is performed in the primary care setting; other testing is performed by an otolaryngologist. Any association of the sound with respiration, drug use, vertigo, noise trauma, or ear infection should be checked. When the problem is present only at night, it suggests increased awareness of normal head
2. CT scan or MRI after referral to an otolaryngologist
3. Posterior fossa myelography

 

Differential Diagnoses

1. Tinnitus
2. Cerumen impaction
3. Foreign body in the ear
4. AOM
5. Otitis externa
6. Acoustic traumas
7. Vascular aneurysm
8. Temporomandibular joint syndrome
9. Otosclerosis
10. Ototoxicity
11. Ménière’s syndrome
12. Presbycusis
13. Central nervous system lesion

 

Plan

1. General interventions
   1. Stress the importance of not placing small objects in the ear and using cotton-tipped applicators to clean external ear
   2. Suggest to the patient that keeping a radio on for background noise often facilitates sleep or

 

3. Address underlying   conditions   if   present   (depression,   insomnia, hearing loss, drug toxicity).
4. Consider behavioral   therapy,   such   as   biofeedback   or   cognitive behavioral therapy, to teach patient coping

1. Patient teaching
   1. Educate the   patient   regarding   techniques/therapies   to    improve symptoms of
   2. Encourage the patient to attend therapy sessions as
2. Pharmaceutical therapy
   1. No medication “cures”
   2. Vasodilators, tranquilizers, antidepressants, and seizure medications have been shown to reduce
   3. Placebos are also of therapeutic

 

Follow-Up

1. No specific follow-up is required for tinnitus unless a treatable problem is identified.

 

Consultation/Referral

1. Consult with an otolaryngologist as
2. Referral of an anxious patient to the otolaryngologist may be necessary to satisfy the patient that everything has been explored and that there is no serious or correctable underlying
3. Any patient with a history of head trauma should be referred to a physician because tinnitus may be associated with an arteriovenous fistula or an aneurysm of the intrapetrous portion of the internal carotid