PNP: Ear d/o

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MBitting
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90308
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PNP: Ear d/o
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2011-06-14 00:42:47
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Ear disorders Burns
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Ear disorders
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  1. Screening for Hearing should be done by
    Before leaving the hospital after birth and follow up before 3mo.
  2. AAP, Joint Commission on Infant Hearing, and Bright Futures recommend pure tone audiometry hearing screenings at what ages?
    3, 4, 5, 10, 12, 15 & 18 y/o.
  3. When does the ear began developing in utero? When is it completed? IF something is wrong with the ears, what other system should someone look at?
    Ear development in utero begans during the 3rd week of gestation and is completed by the third month of embryonic life. One should look at the kidneys.
  4. What are the 3 functions of the eustachian tube?
    • Ventilation of the middle ear to equalize air pressure in the middle ear w/ atmospheric pressure and to replace O2 that has been absorbed
    • Protect from nasopharyngeal sound, pressure, and secretions
    • Drainage of secretions from the middle ear into the nasopharynx
  5. The inner ear aids to:
    • Transmit sound
    • Aid in balance
  6. What cranial nerve is responsible for transmitting stimuli to the auditory cortx of the temporal lobe in the brain?
    Auditory nerve - cranial nerve VIII
  7. What are the defense mechanisms of the ear?
    • Debris is lubricated and extruded by the cilia in EAC
    • The canal maintains an acid pH in ear canal to prevent the growth of pathogenic bacteria.
    • Surface lining of the EAC is water resistant and has ample blood and lymph supply
    • Cerumen has antibacterial properties
  8. The inner and outer canthi of the eye should form a straight line with what?
    Superior portion of the pinna
  9. Development milestones to assess hearing:
    Birth to one month?
    • Startles (Moro reflex) to loud noise
    • Awakens to sounds
    • Blinks or widens eyes to noises
  10. Development milestones to assess hearing:
    3 - 6 mo?
    • Quiets to parents voice
    • Stops activity to listen to new sound
    • Looks for source of sound
    • Reciprocates vocally and initiates sounds
  11. Development milestones to assess hearing:
    6 - 12 mos?
    • Coos and gurgles to inflexions
    • Responds to simple phrases
    • Turns to localize sounds in any plane
    • Responds to own name
  12. Development milestones to assess hearing:
    12 - 18 mos?
    • Points to unexpected sound or familiea objects when asked
    • Follows simple direction w/o cues
    • Imitates some sounds, first words by 12 to 15 mo old
  13. Development milestones to assess hearing:
    18 - 24 mo?
    • Points to body parts when asked
    • Has expressive vocabulary of 20 - 50 words
    • 50% of speech intelligible to strangers
  14. Which way does one pull the ear to visualize the EAC better in young children?
    Pulling the ear downward, outward and backward
  15. Which way does one pull the ear to visualize the EAC better in older children and adolescents?
    upward, and backward, slightly away from the head
  16. Decrease TM mobility secondary to effusion can be noted how?
    • pneumatic otoscopy
    • typanometry
    • acoustic reflectometry
  17. What is EOAE?
    Evoked otoacoustic emision testing is a hearing screening used for universal screening of the newborn. Easy to perform on a quiet newborn. Normal hearing emits 20 dB (Spontaneous otoacoustic emissions).
  18. What does an EOAE not do?
    • EOAE does not quantify hearing deficit and may not identify auditory nerve dysfunction
    • Ambient room noise or an uncooperative child may interfere with the test or provide unreliable results
  19. What is ABR?
    ABR is Auditory Brainstem Response measures the initiation of sound-induced electrical signals in the cochlea. The ABR measures the functioning of the peripheral auditory system and neurological pathways related to hearing. Occasionally sedation is required. Neurologic abnormalities make interpretation of ABR impossible to interpret.
  20. What is Audiometry?
    Audiometry assesses hearing loss in children by measuring hearing threasholds via bone and air conduction or both.
  21. What is pneumatic otoscopy?
    The pneumatic otoscopy assesses TM mobility. A good seal with the speculum and otoscope is required before insufflation of air into the canal. Altered mobility suggests MEE or possible perforation
  22. What is Tympanometry?
    Tympanometry evaluates the function of the middle ear by assessing the movement of the TM. It measures the movement in graph form. MINIMUM AGE - 7 mo due to ear canals are hypercompliant in response to pressures from the typmanometer
  23. What is Acoustic reflectometry?
    It is used to detect a MEE by directing a sound of varying frequency toward the TM and measuring the intensity of reflected sound. It can not distinguish if a MEE is serous or supurative. It is less accurate than pneumatic otoscopy.
  24. What is a tympanocentesis?
    It is the aspiration of middle ear fluid and is helpful for pain relief and ID of persistent infecting organisms. RARELY used in Pedi
  25. 80% of all ANHL is _____________
    Recessive - so check genetics
  26. Average threashold at 500 - 2000 Hz(dB) is
    -10 to +15. Hearing loss starts at 16 - 25 (slight) profound is >90.
  27. In the determination of Abx, Abx are NOT recommended for which OME or AOM?
    OME
  28. In inserting ototopicals, what advice should one give?
    • Rx should be warmed up before instilling
    • The tagus should be pumped a few times after instillation
    • The affected ear should be kept upright for at least 2 - 3 minutes after installation.
  29. What is the management of OE(Otitis Externa)?
    • Analgesics as needed
    • Remove FB
    • Lance any furuncles
    • Irrigate and debride w/ NaCl or Burow's solution
    • If impetigo: Cleanse, rinsem and apply Abx oint.
    • If mycotic: Cleanse w/ boric acid in ethanol solution followed by antifungal solution
  30. Prevention of OE consist of:
    • Avoid water in the ears
    • Use acidic eardrops in ear after swimming
    • Avoid scratching, cleaning and prolonged use of ceruminolytics.
    • Use blow dryer to dry the external auditory canal
  31. What otic solutions will be used to help OE?
    Steroid combination w antimicrobial provide a better cure rate & may help control the development of granulation tissue involving the TM and middle ear space. (Cipro HC Otic - >1 y/o or CiproDex - > 6mo for 7 - 10 days or Polymixim B & neomycin (Pediotic). Place in a wick soaked w/ Abx. Reapply drops every 2 - 3 hrs.
  32. Additional OE instructions:
    • If no improvements w/i 72 hrs (relief of otalgia, itching, and fullness), then recheck diagnosis
    • Lack of improvement may be due to obstructed ear canal, poor adherence, or contact sensititvity among other things
    • Oral or parental Abx is not needed unless except for systemic illness or failed topical Tx
    • Avoid cleaning, manipylating, or getting water in ear. NO SWIMMING during Txment
    • Administer analgesic for pain - narcotic might be needed for severe pain for short term use.
    • Lance furnuncle that is superficial and pointed (w/ 14G needle). If deep & diffused - utilize a heating pad or warm oil-based drops can speed resolution.
  33. What is the Txment for impetigo in OE?
    • If impetigo, clear canal w/ 1/2 strength H2O2 or other antiseptic sol w/ warm water rinse.
    • Apply Mupirocin 1 - 2 a day for 5 - 7 days.
    • Teach child not to place fingers in ear.
    • Keep finger nails short and hands cleans w/ antibacterial soap
    • Systemic Abx is not needed
  34. What is the Txment for fungal infection in OE?
    • Myotic OE is treated w/ solution of 5% boric acid in ethanol which is antiseptic and promotes drying.
    • Clotrimazole miconazole sol. can be used alone or w/ topical Abx cortisteroid solution for 5 -7 d.
    • F/u in 1 - 2 weeks for reeval. of OE and removal of debris.
    • Dermatology consultation if no improvement. w/i 1 week
  35. Prevention measures of OE are:
    • Avoid water in ear canals
    • Use well fitting earplugs when swimming in dirty water
    • Use acidic gtts (diluted vinegar or ETOH) 3 - 5 gtts p swimming.
    • Use blow dryer on warm setting to ear canal areas
    • Avoid ceruminolytic agents
  36. What is the treatment for TTO (Tympanostomy tube otorhea?
    This occurs when a child w/ PE tubes has an upper respiratory infection (moxifloxacin - use in those > 1y/o) treat for 5 - 7 days
  37. What type of Hx leads to increase suspicion of FB to ear?
    • Child reports something in the ear or something thrown at them
    • c/o of buzzing, fullness, or object in the ear canal
    • persistent cough or hiccups
    • Unilateral otalgia or otorrhea
  38. Management of FB to ear:
    • Suction w/ Schuknecht FB catheter w/ umbrella
    • Irrigation - Do not irrigate if TM perferated
    • Bayonet forcepts
    • Refer to ENT
  39. What are the 3 cardinal signs/Sx of AOM?
    • Recent, abrupt onset of inflammation& effusion (ear pain, irritability, otorrhea, and/or fever)
    • MEE confirmed by buldging TM; limited mobility of TM; air-fluid level behind TM; otorrhea
    • S/sx of ME inflammation w/ erthema of TM, or distint otalgia interfering w/ normal sleep or activity
  40. Predisposing factors for AOM:
    • URI
    • bottle propping
    • ETS
    • asthma and allergies
    • cleft palate
    • Down's syndrome
  41. Most common organisms for AOM?
    • S. pneumoniae
    • H influenzae
    • M. catarrhalis
  42. What is imp when a child has a fever at 2 mo old?
    Should be eval for fever not just AOM
  43. What is the differential Txment for AOM w/ and w/o a fever?
    • >102.2 (39C)= augmmgentin (Amoxicillin 90mg/kg/d & clavulanate 6.4mg/kg/d)
    • <102.2 (39C) = amoxicillin 80 - 90mg/kg/d
  44. Pain management for AOM?
    • Tylenol or Motrin
    • Auralgen (topical analgesic agent) for pt >5y/oand no TM perforation or PET
    • Distraction, oil application or external use of heat or cold
  45. Who should be treated for AOM?
    • Age less than 6 mo: TREAT whether certain of diagnosis or not
    • Age 6 mo - 2 y/o and certain of Dx: Treat
    • Age 6mo - 2 y/o and uncertain of Dx: Treat if severe illness; IF NOT severe observe
    • Age >2y/o: Abx if severe. Observe if not severe
  46. How long do you treat a child with Abx for AOM?
    • >6y/o: 5 - 7 days
    • <6y/o: 10 days
  47. When is AOM cosidered recurrent?
    3 distincts and well document episodes of AOM that have occurred w/i 6 mo or 4 or more episodes in 12 mo period
  48. When OM has failed refer to ENT - what has can be done?
    • Myringotomy
    • PET
  49. T/F Decongestants and antihistamines are not helpful in the Txment of AOM
    True
  50. What is the Txment for perforated TMs or patent, draining PETs?
    • Antimicrobial ototopical gtt: ofloxacin, ciprofloxacin, or cortisporin
    • Ophthalmic gtt: Tobramycin or gentamycin
    • Oral Abx is NOT indicated for functioning PETs
  51. Alternative to help prevent AOM:
    • Xylitol: Chew 3 - 5 sticks of gum a day
    • S.E.: excessive gas and diarrhea
  52. Prevention of AOM?
    • PCV 7 decreases incidents of pneumococcal AOM
    • Annual influenza vaccine, esp in high risk infants that attend day care
    • Early Txment of influenza w antiviral oseltamivir (H.influenza type b vaccine is not helpful to prevent AOM - even though it is recommended)
    • Xylitol
    • Attend less populated day care
    • Breast feeding exclusively for 6 mo
    • No propping of bottle, feeding infant lying down, or passive smoke exposure
    • Avoid use of pacifier
  53. Unilateral OME can indicate:
    Nasopharyngeal carcinoma
  54. What is the management of OME?
    • Document in med records the presence and duration of effusion and whether unilateral or bilateral
    • Identify those at risk for speech, language, or learning problems
    • Children not at risk should be be watched for 3 mo...usually resolves in this time
    • Hearing and language testing should be done for OME lasting >3mo
  55. Referral to ENT for OME?
    • Documented bil effusion that persist 4 months or longer
    • An identified persistent hearing loss
    • Sensory, physical, cognitive, or behavior factors that make a child more susceptible for development delay or disorder
    • Recurrent or persistent OME regardless of hearing status
    • Structural damage to the TM or middle ear
  56. Recommendations for OME?
    • No E-B for using antihistamines or decongestants
    • Limited E-B for using antihistamines for allergies
    • Antimicrobial therapy or cortisteroids have no long term efficacy and not recommended
    • Tonsilectomy or adenoidectomy alone should not be used to treat OME
    • CAM has no EB
  57. Education & prevention for OME
    • Imp of f/u until TM and hearing are normal (Advise parents that OME can last weeks to months)
    • Remind parents of the importance to interact w/ kids for language development
  58. What is a cholesteatoma?
    It is a epidermal inclusion cyst of the middle ear or mastoid consisting of desquamated debris from the keratinizing squamous epithelial lining of hte middle ear. It can be congenital or acquired. It can be from an inflammatory process, perforation of the TM, and failure of desquamated tissue to clear from the middle ear. Incident rate is unknown.
  59. What is the Hx of Cholesteatoma?
    • Chronic OM with maloforous purlent otorrhea
    • Vertigo
    • Hearing loss
  60. What is the PE of a Cholesteatoma?
    • Pearly white lesion present on or behind the TM
    • Aural polyps are considered cholesteatomas unless proven otherwise.
    • Congenital cholesteatomas are often in the most anterior, inferior position of the TM
  61. What is the management of cholesteatoma?
    • Accurate Dx
    • Immediate ENT referral for surgical excision
  62. What is mastoiditis?
    Mastoiditis is a supurative infection of the mastoid cells. The mucoperiosteal lining of the mastoid air cells become inflamed and subsequent swelling and obstruction of drainage from the mastoid.
  63. What are the Hx and PE of Mastoiditis?
    • Concurrent or recurrent AOM
    • Fever and otalgia
    • Persistent OM unresponsive to Abx therapy
    • Postauricular swelling
    • In infants, swelling above the ear, displacing the pinna inferiorly or laterally.
    • In older children, the swelling pushes the earlobe superiorly and laterally
  64. What will the diagnositc studies show for a patient that has mastoiditis?
    • XRay: coalescence of mastoid air cells and loss of bony trabeculation
    • CT can provide definitive anatomic information
    • Tympanocentesis w/ culture and gram stainhelp ID offending organism
  65. What is the management of Mastoiditis?
    • Urgent ENT referral
    • Hospitalization,
    • IV Abx
    • Mastoidectomy
  66. Prevention for mastoiditis?
    Pneumococcal conjugate vaccine
  67. Definition of Hearing loss?
    Bilateral pure tone hearing loss of 40 dB
  68. 3 types of Hearing loss?
    • Sensorineural hearing loss: most commonly associated w/ dysfunction of or damage to the cochlea (inner ear) and less often associated w damage to to the auditory nerve (8th cranial nerve). (Labeled auditory neropathy or dyssynchrony - not helped by hearing aids, but may respond to cochlear implants. SNHL can be congenital or acquired, mild or severe and is permanent).
    • Conductive: Can be congenital or acquired, results from blocked transmission of sound waves from the EAC to the inner ear (AOM or OME) the cochlear functions normally. Bone conduction is usually normal w decreased air conduction. HL is in hte range of 20 - 60 dB. MEE results in an average HL of 27 to 31 dB.
    • Central HL: occurs when the nerves or nuclei of the central nervous system, either in the pathways to the brain or the brain itself, are damaged or impaired
  69. What are some of the causes of SNHL & conductive HL?
    • Craniofacial anomalies: aural atresia, cleft lip or cleft palate, external ear deformity w/o atresia, dysmorphic facies w/o external ear deformity
    • Generic aberrations or congenital deformities: white forelock, cafe au lait spots, family Hx of SNHL, metabolic abn.
    • Environmental exposure: ototoxic Rx, bacterial or viral meningitism other infectious diseases, loud noises, head trauma.
  70. Hearing loss risk factors:
    • Birth weight: less than 1500g
    • Severe depression at birth (APGAR 0 - 3 at 5 min; failure to initiate a response by 10 min; hypotonia at up to 2 hours old)
    • NICU admission for 2 days or longer
    • Prolonged mecanical ventilation for greater than 10 days
    • Persistent pulmonary hypertension
    • Long Q-T syndrome: profound HL
    • Congenital infections: TORCH
    • Metabolic d/o: PKU and galactosemia
    • Endocrine d/o: adrenal hyperplasia & hypothyroidism
    • Craniofacial anomalies: morphologic abn of the pinna and ear canal
    • Genetic syndromes: sickle cell, sher syndrome, NF1, Waardenburg syn, osteopetrosis
    • Hyperbiliruninemia: requiring exchange transfusion or causing kernicterus
    • Family Hx of hereditary childhood SNHL
    • Ototoxic Rx exposure
  71. Risk factors for HL in kids 1 mo to 3 y/o:
    • Parental concerns
    • Kidney malformation
    • Family Hx of permanent childhood HL
    • Syndromes associated w/ progressive HL: NF1 and osteopetrosis
    • Neurodegenerative d/o: Hunters syndeome or sensorimotor neuropathiesm Friedreich ataxia and Charcot- Marie- Tooth disease
    • Head trauma w/ LOC or skull Fx
    • Bacterial meningitis
    • Ototoxic Rx exposure
    • DM
    • Recurrent or persistent OME for at least 3 mo
    • Failure to learn to speak at appropriate age; baby talk; monotone or difficult to understand; avoidance of speaking
    • Failure of school audiograml decrease note taking; seeming to misunderstand, ignore, confuse or miss what is being said
    • Aggression, increased physical c/o;
    • Environmental exposure to firecracker, toy cap pistols, firearms, loud music
    • Hx of head or neck irradiation
  72. If HL:
    • Abn Hearing screens during routine WCV or other office visits
    • Kids younger than 6 mo obtain an ABR
    • Complete PE with special attention to the eyes, skin, and skeletal and nervous system is need
    • Ears: ck for preauricular pits, auricular malformation or appendage, abn TM integrity, impaired mobility w pneumatic otoscopy
    • Eyes: cataracts, corneal opacities, coloboma, blindness nystagmus, exophthalmos, night blindness, heterochromia iridis or blue sclerae
    • Craniofacial anomalies or genetic stigmata
  73. What diagnostic studies need to be ordered when a child has HL?
    • UA, serum BUN, & creatinine: r/o renal disease
    • CBC, TFT, sickle cell screen
    • TORCH (Toxoplasmosis, other agents, rubella, Cytomeglovirus, herpes simplex screens for newborns
    • Genetic testing
    • ECG: Long Q-T interval syndrome
    • Ophthalmologic exam: TORCH, retinitis pigmentosa assoc w Usher Syndrome
    • CT as indicated to r/o inner ear malformation
  74. Management for HL?
    • Refer to ENT and audiologist
    • Refer for surgical intervention if indicated
    • Tx medical condition
    • Genetic counseling
    • Hearing aids if possible or cochlear implants (make sure proper immunization)
    • Recommend special school & teaching strategies
    • Eval & Tx for AOM & OME
    • Screen for HL if bil MEE is present for 3 mo or longer
    • Ensure family center approach in decision
  75. Prevention for HL?
    • Good prenatal care
    • Provide Rh (D) immune globulin to prevent erythroblastosis fetalis in susceptible women
    • Treat prenatal and perinatal infections promptly
    • Avoid ototoxic Rx use
    • Immunize against MMR, varicella, H. influenzae
    • Avoid environmental factors assoc. w HL

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