PNP: Ear d/o

Before leaving the hospital after birth and follow up before 3mo.

3, 4, 5, 10, 12, 15 & 18 y/o.

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.

• 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

• Transmit sound
• Aid in balance

Auditory nerve - cranial nerve VIII

• 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

Superior portion of the pinna

• Startles (Moro reflex) to loud noise
• Awakens to sounds
• Blinks or widens eyes to noises

• Quiets to parents voice
• Stops activity to listen to new sound
• Looks for source of sound
• Reciprocates vocally and initiates sounds

• Coos and gurgles to inflexions
• Responds to simple phrases
• Turns to localize sounds in any plane
• Responds to own name

• 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

• Points to body parts when asked
• Has expressive vocabulary of 20 - 50 words
• 50% of speech intelligible to strangers

Pulling the ear downward, outward and backward

upward, and backward, slightly away from the head

• pneumatic otoscopy
• typanometry
• acoustic reflectometry

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).

• 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

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.

Audiometry assesses hearing loss in children by measuring hearing threasholds via bone and air conduction or both.

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

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

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.

It is the aspiration of middle ear fluid and is helpful for pain relief and ID of persistent infecting organisms. RARELY used in Pedi

Recessive - so check genetics

-10 to +15. Hearing loss starts at 16 - 25 (slight) profound is >90.

OME

• 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.

• 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

• 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

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.

• 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.

• 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

• 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

• 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

This occurs when a child w/ PE tubes has an upper respiratory infection (moxifloxacin - use in those > 1y/o) treat for 5 - 7 days

• 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

• Suction w/ Schuknecht FB catheter w/ umbrella
• Irrigation - Do not irrigate if TM perferated
• Bayonet forcepts
• Refer to ENT

• 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

• URI
• bottle propping
• ETS
• asthma and allergies
• cleft palate
• Down's syndrome

• S. pneumoniae
• H influenzae
• M. catarrhalis

Should be eval for fever not just AOM

• >102.2 (39C)= augmmgentin (Amoxicillin 90mg/kg/d & clavulanate 6.4mg/kg/d)
• <102.2 (39C) = amoxicillin 80 - 90mg/kg/d

• 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

• 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

• >6y/o: 5 - 7 days
• <6y/o: 10 days

3 distincts and well document episodes of AOM that have occurred w/i 6 mo or 4 or more episodes in 12 mo period

• Myringotomy
• PET

True

• Antimicrobial ototopical gtt: ofloxacin, ciprofloxacin, or cortisporin
• Ophthalmic gtt: Tobramycin or gentamycin
• Oral Abx is NOT indicated for functioning PETs

• Xylitol: Chew 3 - 5 sticks of gum a day
• S.E.: excessive gas and diarrhea

• 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

Nasopharyngeal carcinoma

• 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

• 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

• 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

• 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

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.

• Chronic OM with maloforous purlent otorrhea
• Vertigo
• Hearing loss

• 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

• Accurate Dx
• Immediate ENT referral for surgical excision

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.

• 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

• 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

• Urgent ENT referral
• Hospitalization,
• IV Abx
• Mastoidectomy

Pneumococcal conjugate vaccine

Bilateral pure tone hearing loss of 40 dB

• 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

• 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.

• 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

• 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

• 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

• 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

• 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

• 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