HARP.

Case Notes

CONDITION: Acute otitis media (AOM) in right ear Notes:

Otoscopy

Right

Left

Notes: The tympanic membrane may appear reddened and may also bulge due to pressure from mucus and blood cells in the middle ear space. The malleus may not be identifiable in the affected ear. The tympanic membrane may also become more opaque (Block & Harrison, !!"#. $roblems associated %ith testing: $atients commonly ha&e otalgia and so careful e'amination may be required. (oung children may be reluctant to allo% otoscopy to be performed and caution should be taken to not cause patient further discomfort or an'iety. )f a child has recently been crying or had a fe&er then this can cause a slight reddening of the tympanic membrane and should not be confused %ith a sign of *+, (-iagnosis and ,anagement of *cute +titis ,edia, !!.# Tuning for s Weber: Rinne: Negati&e /inne /ight ear $ositi&e /inne /ight 0eft

Notes: 1ound lateralisation to the right ear during the 2eber test indicates a conducti&e loss and this supports the negati&e /inne result for that ear, %hich also indicates a conducti&e loss. /eliability of test: *s young children are typically affected by *+, they may be unable to distinguish %hich ear sound lateralises to and by %hich method the sound is loudest in, so both tests may not be possible. There are also general limitations of these tests, including the unreliability of the tone as this &aries depending on the force used (3elfand, !!4#. 3elfand (5466, cited in 3elfand, !!4# also found that the /inne test may only correctly diagnose a conducti&e loss if the air7bone gap is up to 8!dB %hen using a "5 H9 tuning fork. Therefore these tests ha&e &ariable results and may e'plain %hy the British 1ociety of *udiology (B1*# states that they should only be used to :establish the probable presence or absence of a significant conducti&e; loss<. *lternati&e tests: +b=ecti&e tests that do not require a response may be more useful in children in order to determine the presence of *+,. 1uch tests

HARP. Case Notes

include tympanometry, %hich determine if fluid is behind the tympanic membrane. !ure tone audiometry and uncomforta"#e #oudness #e$e#s

Notes: ,asking %as required at "!!, 5!!!, !!! and .!!! H9 due to the presence of a >!dB or greater air7bone7gap. The audiorgram shape may appear to be flat or ?tented@, %ith a peak in the mid7frequencies (3elfand, !!4#, %ith a mild to moderate conducti&e loss (*lper et. *l, !!.#. 1ome patients may ha&e a sensorineural component to their loss (although not indicated in the audiogram abo&e# and this is thought to be caused by the transfer of to'ins to the inner ear (3elfand, !!4#. $roblems associated %ith testing: *s this test requires patient co7operation and understanding it is therefore not suitable for younger children. *lternati&e tests: )f a patient is too young to perform $ure Tone *udiometry ($T*# then tympanometry can be used to ascertain the condition of the tympanic membrane.

HARP. Case Notes

Tympanometry

Notes: /ight ear typmanometry results sho% a flat trace. The ear canal &olume is %ithin the normal range of !."75ml for children and so the results indicate that there is fluid behind the right tympanic membrane. The results from the left ear indicate a normal tympanogram shape, classed as a type ?*@ tympanogram (Aerger, 546!, cited in Bat9 et. *l, !!4#. -ifferent stages of acute otitis media are likely to produce &arying tympanogram morphology (Bat9 et. *l, !!4#. The tympanogram depicted abo&e is representati&e of a se&ere case of *+,. Notes on testing method: * screening mode %as used in order minimise the time that the young patient spent %ith the probe in their ear. This is a potential problem %hen dealing %ith paediatric patients but the faster mode does slightly help to o&ercome this. Acoustic ref#e%es Thresho#d /ight contralateral ipsilateral C" D C" C! 4! 6! D D D D .!!! H9 BBN "!! H9 5!!! H9 !!! H9 C" 6" D D ipsilateral 4" 4! 4! 0eft contralateral D D D

Notes: /esults %ere obtained for the left ipsilateral refle' and the contralateral right refle'. Both of these thresholds %ere %ithin the normal threshold range of 6"7 4! dB Hearing 0e&el (H0# for pure tone sounds and "!76"dB H0 for broadband noise. Ho%e&er no results %ere obtained for the right ipsilateral and left contralateral refle'. The reason for this is because of the ?probe ear and stimiulus ear principles@ (Bat9 et. *l, !!4#. These state that if there is a conducti&e hearing loss in the probe ear, then the acoustic refle' %ill be absent. )n this case the absent refle' is the ipsilateral right. The stimulus ear principle suggests that a conducti&e loss in the stimulus ear %ill raise the acoustic refle' by the le&el of the air bone gap. )n this case the air bone gap is

HARP. Case Notes

appro'imately >!7>" dB in the left ear. 2ithout the presence of the *+, the indi&idual@s thresholds are likely to be %ithin " dB or their bone conduction thresholds. This means that their acoustic refle'es %ould be appro'imately C"74! dB, based on e&idence that suggests a refle' appro'imately C! dB abo&e $T* thresholds (reference#. Therefore the refle' in this case %ould be appro'imately 55" dB, as C" E >!F 55". This is abo&e the safe le&els that acoustic refle'es can be performed at, hence the absent contralateral left refle'. *lternati&e diagnosis: The results indicated abo&e are typical of a conducti&e loss and the diagnosis of *+, must be taken in con=unction %ith otoscopy and the history taking. )mportantly these results may also be &ery similar in patients %ho ha&e facial ner&e pathology of the right side. *gain in differentiating the diagnosis the patient@s history and symptoms are &ery important, as are the results of $T*. Otoacoustic emissions

Notes:

&enera# comments:

'ources of e$idence: *lper, G.,., Bluestone, G.-., Aohar, A.H., ,andel H.,. & Gasselbrant, ,.0., !!., Advanced therapy in Otitis Media, )llustrated edn, BG -ecker $ublishers, I1*, pp .547. !, /etrie&ed >rd Aanuary !5! from: http:JJbooks.google.co.ukJbooksKidFIL7 r+pB8o1cG&pgF$*.54&lpgF$*.54&dqFacuteEotitisEmediaEdegreeEofEloss &sourceFbl&otsFp*5)glk0bu&sigF=47 T>!Tn)iCr)MNmCB8uHko+L>*&hlFen&eiF%ON*1"mM+orC!%T%%Bm1BL&s aFD&oiFbookOresult&ctFresult&resnumF"&&edF!GB.L8*H%B*P&Fonepage &qFacuteQ !otitisQ !mediaQ !degreeQ !ofQ !loss&fFfalse Block, 1 & Harrison, G.A., !!8, Diagnosis and Management of Acute Otitis Media, >rd edn, $rofessional Gommunications )ncorporated, I1*, pp 5575 , retir&ed 5st Aanuary !5! from: http:JJbooks.google.co.ukJbooksK idFkH2 c%B168)G&printsecFfrontco&er&dqFrelated:)1BN!6CC5.C P&Fon epage&qF&fFfalse 3elfand, 1.*., !!4, Essentials of Audiology, Thieme ,edical $ublishers, Ne% (ork, I1*

HARP. Case Notes

1hanks, A & 1hohet, A, !!4 ?Tympanometry in clinical practice@ in Bat9, A, ,ed%etsky, 0, Burkard, / & Hood, 0, (eds#, Handbook of linical Audiology! 0ippincott 2illiams & 2ilkins, I1* pp 5"475C" -iagnosis and ,anagement of *cute +titis ,edia, !!., "ediatricsR 55>, pp 5."57 5.8", /etrie&ed 5st Aanuary !5! from: http:JJpediatrics.aappublications.orgJcgiJreprintJ55>J"J5."5