Chapter 36: Ear and Hearing Disorders

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. The parent of a 4-month-old infant is concerned that the infant cannot hear. Which test will
the primary care pediatric nurse practitioner order to evaluate potential hearing loss in this
infant?
a. Acoustic reflectometry
b. Audiometry
c. Auditory brainstem response (ABR)
d. Evoked otoacoustic emission (EOAE) testing
ANS: C
ABR is not a direct measure of hearing but allows for inferences to be made about hearing
thresholds and is useful for identifying hearing loss in a young infant. Although sedation is
occasionally required, this test is useful in infants and young children unable to cooperate with
EOAE or audiometry. Acoustic reflectometry is used to detect middle ear effusion.
Audiometry requires a cooperative child. EOAE is used for universal screening in newborns.
The American Academy of Pediatrics (AAP) Bright Futures guidelines (AAP, 2014)
recommends pure-tone audiometry at 3, 4, 5, 6, 8, 10, 12, 15, and 18 years of age.

2. The primary care pediatric nurse practitioner obtains a tympanogram on a child that reveals a
sharp peak of -180 mm H O. What does this value indicate?
a. A normal tympanic membrane
b. Middle ear effusion
c. Negative ear pressure
d. Tympanic membrane perforation
ANS: C
The type C tympanogram has a sharp peak between -100 and -200 mm H O and reflects
negative ear pressure. A normal tympanogram has a sharp positive peak or a type A
tympanogram. Middle ear effusion and a TM perforation both cause a type B tympanogram
with either no peak or a flattened wave.

3. An 18-month-old child with no previous history of otitis media awoke during the night with
right ear pain. The primary care pediatric nurse practitioner notes an axillary temperature of
100.5°F and an erythematous, bulging tympanic membrane. A tympanogram reveals of peak
of +150 mm H O. What is the recommended treatment for this child?
a. Amoxicillin 80 to 90 mg/kg/day in two divided doses
b. An analgesic medication and watchful waiting
c. Ceftriaxone 50 to 75 mg/kg/dose IM given once
d. Ototopical antibiotic drops twice daily for 5 days
ANS: B
 This child has no previous history and only has a mild fever and can be managed by watchful
waiting, with parents given instructions about when and why to notify the provider. Analgesia
is essential so that the child can be comfortable. If antibiotics are indicated as a result of no
improvement after 48 to 72 hours, amoxicillin is the first-line drug. Ceftriaxone is given if the
child is vomiting. Topical antibiotics are given when there is a perforation in the tympanic
membrane.

4. A 7-month-old infant has had two prior acute ear infections and is currently on the 10th day of
therapy with amoxicillin-clavulanate after a failed course of amoxicillin. The primary care
pediatric nurse practitioner notes marked middle ear effusion and erythema of the TM. The
child is irritable and has a temperature of 99.8°F. What is the next step in management of this
child’s ear infection?
a. Order a second course of amoxicillin-clavulanate.
b. Perform tympanocentesis for culture.
c. Prescribe clindamycin twice daily.
d. Refer the child to an otolaryngologist.
ANS: D
Children who have persistent infection who have failed appropriate therapy and those who
have had three or more episodes of AOM in 6 months should be referred to an
otolaryngologist. Ceftriaxone is ordered when Augmentin fails. The PNP does not perform
tympanocentesis. Clindamycin is used for ceftriaxone failure but only if the susceptibilities
are known.

5. A 3-year-old child with pressure-equalizing tubes (PET) in both ears has otalgia in one ear.
The primary care pediatric nurse practitioner is able to visualize the tube and does not see
exudate in the ear canal and obtains a type A tympanogram. What will the nurse practitioner
do?
a. Order ototopical antibiotic/corticosteroid drops.
b. Prescribe a prophylactic antibiotic medication.
c. Reassure the parent that this is a normal exam.
d. Refer the child to an otolaryngologist for follow-up
ANS: A
A normal, or type A, tympanogram in a child with PET may indicate a clogged tube.
Ototopical antibiotic/corticosteroid drops can occasionally clear a clogged PET. Prophylactic
antibiotics are not recommended to prevent otitis media. It is not necessary to refer unless the
pain continues in spite of standard measures.

6. What will the primary care pediatric nurse practitioner teach the parents of a child who has
new pressure-equalizing tubes (PET) in both ears?
a. Parents should notice improved hearing in their child.
b. PET will help by reducing the number of ear infections the child has.
c. The child should use earplugs when showering or bathing.
d. The tubes will most likely remain in place for 3 to 4 years.
ANS: A
 By reducing middle ear fluid, the child with hearing loss from this condition should show
improvement in hearing. Children may still have infections but without persistent effusion.
Earplugs are not necessary unless the child’s head is submerged. PETs usually fall out on their
own; if they are still in place 2 to 3 years after placement, they should be removed by the
otolaryngology surgeon.

7. The parents of a child with a history of otitis externa asks about ways to prevent this
condition. What will the primary care pediatric nurse practitioner recommend?
a. Cleaning ear canals well after swimming
b. Drying the ear canal with a hair dryer
c. Swimming only in chlorinated pools
d. Using cerumenolytic agents daily
ANS: B
Otitis externa is most frequently caused by retained moisture in the ear canal after swimming
and when the protective barriers on the skin break down. Drying the ear canals with a hair
dryer on a low setting helps to remove the moisture. Cleaning the ear canals, swimming in
chlorinated water, and using a cerumenolytic remove the wax that protects the ear canal from
superficial infection.

8. A child reports itching in both ears and is having trouble hearing. The primary care pediatric
nurse practitioner notes periauricular edema and marked swelling of the external auditory
canal and elicits severe pain when manipulating the external ear structures. Which is an
appropriate intervention?
a. Obtain a culture of the external auditory canal.
b. Order ototopical antibiotic/corticosteroid drops.
c. Prescribe oral amoxicillin-clavulanate.
d. Refer the child to an otolaryngologist.
ANS: B
Ototopical antibiotic/corticosteroid drops are the mainstay of therapy for OE. It is not
necessary to obtain a culture unless the infection does not respond to treatment. Oral
antibiotics are not indicated unless impetigo occurs and is severe. A referral to a specialist is
not recommended.

9. The primary care pediatric nurse practitioner notes a small, round object in a child’s external
auditory canal, near the tympanic membrane. The child’s parent thinks it is probably a dried
pea. What will the nurse practitioner do to remove this object?
a. Irrigate the external auditory canal to flush out the object.
b. Refer the child to an otolaryngologist for removal.
c. Remove the object with a wire loop curette.
d. Use a bayonet forceps to grasp and remove the object.
ANS: B
Spherical objects are the most difficult to remove and should be referred. Irrigation is not
recommended for objects made of organic material and also increases the risk of pushing the
object farther down.
10. A 3-year-old child has had one episode of acute otitis media (AOM) 3 weeks prior with a
normal tympanogram just after treatment with amoxicillin. In the clinic today, the child has a
type B tympanogram, a temperature of 102.5°F, and a bulging tympanic membrane. What will
the primary care pediatric nurse practitioner order?
a. A referral for tympanocentesis
b. Amoxicillin twice daily
c. Amoxicillin-clavulanate twice daily
d. Intramuscular ceftriaxone
ANS: C
Amoxicillin-clavulanate should be given for failed therapy with amoxicillin or when the child
has had AOM treated with amoxicillin within the past month.

11. The primary care pediatric nurse practitioner diagnoses acute otitis media (OTM) in a 2-year-
old child who has a history of three ear infections in the first 6 months of life. The child’s
tympanic membrane is intact and the child has a temperature of 101.5°F. What will the nurse
practitioner prescribe for this child?
a. Amoxicillin twice daily for 10 days
b. An analgesic medication and watchful waiting
c. Antibiotic ear drops and ibuprofen
d. Ceftriaxone given once intramuscularly
ANS: B
This child has no recent history, is over 24 months, and has relatively mild symptoms, so can
be treated by watchful waiting with adequate follow-up and analgesic medication. Antibiotics
are not indicated unless the child worsens or does not improve in 48 to 72 hours.

12. A child who was treated with amoxicillin and then amoxicillin-clavulanate for acute otitis
media (OTM) is seen for follow-up. The primary care pediatric nurse practitioner notes dull-
gray tympanic membranes with a visible air-fluid level. The child is afebrile and without pain.
What is the next course of action?
a. Administering ceftriaxone IM
b. Giving clindamycin orally
c. Monitoring ear fluid levels for 3 months
d. Watchful waiting for 48 to 72 hours
ANS: C
Children with AOM may have effusion up to 3 months after the acute infection. The child
should be monitored to ensure that this resolves. Antibiotics are not indicated. There is no
acute infection, so watchful waiting for worsening of symptoms is not indicated.

13. A school-age child has a history of chronic otitis media and is seen in the clinic with vertigo.
The primary care pediatric nurse practitioner notes profuse purulent otorrhea from both
pressure-equalizing tubes and a pearly-white lesion on one tympanic membrane ™. Which
condition is most likely?
a. Cholesteatoma
b. Mastoiditis
c. Otitis externa
d. Otitis media with effusion
ANS: A
This child has symptoms of cholesteatoma, especially with a pearly white lesion on the TM.
Mastoiditis involves the mastoid bone behind the ear. The description provided would not
indicate either otitis externa or otitis media with effusion.