HARP. Case NotesCONDITION:Acute otitis media (AOM) in right earNotes:

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, 2005). Problems associated with testing: Patients commonly have otalgia and so careful examination may be required. Young children may be reluctant to allow otoscopy to be performed and caution should be taken to not cause patient further discomfort or anxiety. If a child has recently been crying or had a fever then this can cause a slight reddening of the tympanic membrane and should not be confused with a sign of AOM (Diagnosis and Management of Acute Otitis Media, 2004)

Tuning forks Right LeftWeber:

Right earRinne: Negative

RinnePositive Rinne

Notes: Sound lateralisation to the right ear during the Weber test indicates a conductive loss and this supports the negative Rinne result for that ear, which also indicates a conductive loss. Reliability of test: As young children are typically affected by AOM they may be unable to distinguish which ear sound lateralises to and by which 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 varies depending on the force used (Gelfand, 2009). Gelfand (1977, cited in Gelfand, 2009) also found that the Rinne test may only correctly diagnose a conductive loss if the air-bone gap is up to 60dB when using a 512 Hz tuning fork. Therefore these tests have variable results and may explain why the British Society of Audiology (BSA) states that they should only be used to “establish the probable presence or absence of a significant conductive… loss”. Alternative tests: Objective tests that do not require a response may be more useful in children in order to determine the presence of AOM. Such tests

HARP. Case Notesinclude tympanometry, which determine if fluid is behind the tympanic membrane.

Pure tone audiometry and uncomfortable loudness levels

Notes: Masking was required at 500, 1000, 2000 and 4000 Hz due to the presence of a 30dB or greater air-bone-gap.

The audiorgram shape may appear to be flat or ‘tented’, with a peak in the mid-frequencies (Gelfand, 2009), with a mild to moderate conductive loss (Alper et. Al, 2004). Some patients may have a sensorineural component to their loss (although not indicated in the audiogram above) and this is thought to be caused by the transfer of toxins to the inner ear (Gelfand, 2009). Problems associated with testing: As this test requires patient co-operation and understanding it is therefore not suitable for younger children. Alternative tests: If a patient is too young to perform Pure Tone Audiometry (PTA) then tympanometry can be used to ascertain the condition of the tympanic membrane.

HARP. Case NotesTympanometry

Notes:Right ear typmanometry results show a flat trace. The ear canal volume is within the normal range of 0.5-1ml 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 ‘A’ tympanogram (Jerger, 1970, cited in Katz et. Al, 2009). Different stages of acute otitis media are likely to produce varying tympanogram morphology (Katz et. Al, 2009). The tympanogram depicted above is representative of a severe case of AOM.

Notes on testing method: A screening mode was used in order minimise the time that the young patient spent with the probe in their ear. This is a potential problem when dealing with paediatric patients but the faster mode does slightly help to overcome this.

Acoustic reflexes

ThresholdRight Left

contralateral ipsilateral ipsilateral contralateral85 X 500 Hz 95 X

85 X 1000 Hz 90 X

80X

2000 Hz90 X

90 X4000 Hz

85 X

70 X BBN 75 X

Notes:Results were obtained for the left ipsilateral reflex and the contralateral right reflex. Both of these thresholds were within the normal threshold range of 75-90 dB Hearing Level (HL) for pure tone sounds and 50-75dB HL for broadband noise. However no results were obtained for the right ipsilateral and left contralateral reflex. The reason for this is because of the ‘probe ear and stimiulus ear principles’ (Katz et. Al, 2009). These state that if there is a conductive hearing loss in the probe ear, then the acoustic reflex will be absent. In this case the absent reflex is the ipsilateral right. The stimulus ear principle suggests that a conductive loss in the stimulus ear will raise the acoustic reflex by the level of the air bone gap. In this case the air bone gap is

HARP. Case Notesapproximately 30-35 dB in the left ear. Without the presence of the AOM the individual’s thresholds are likely to be within 5 dB or their bone conduction thresholds. This means that their acoustic reflexes would be approximately 85-90 dB, based on evidence that suggests a reflex approximately 80 dB above PTA thresholds (reference). Therefore the reflex in this case would be approximately 115 dB, as 85 + 30= 115. This is above the safe levels that acoustic reflexes can be performed at, hence the absent contralateral left reflex.

Alternative diagnosis: The results indicated above are typical of a conductive loss and the diagnosis of AOM must be taken in conjunction with otoscopy and the history taking. Importantly these results may also be very similar in patients who have facial nerve pathology of the right side. Again in differentiating the diagnosis the patient’s history and symptoms are very important, as are the results of PTA.

Otoacoustic emissions

Notes:

General comments:

Sources of evidence:Alper, C.M., Bluestone, C.D., Johar, J.E., Mandel E.M. & Casselbrant, M.L., 2004, Advanced therapy in Otitis Media, Illustrated edn, BC Decker Publishers, USA, pp 419-420, Retrieved 3rd January 2010 from: http://books.google.co.uk/books?id=UQ-rOpK6oScC&pg=PA419&lpg=PA419&dq=acute+otitis+media+degree+of+loss&source=bl&ots=pA1IglkLbu&sig=j9-T30TnIi8rIZFm8B6uEkoOQ3A&hl=en&ei=w_FAS5mZOor80wTwwKmSBQ&sa=X&oi=book_result&ct=result&resnum=5&ved=0CB4Q6AEwBA#v=onepage&q=acute%20otitis%20media%20degree%20of%20loss&f=false

Block, S & Harrison, C.J., 2006, Diagnosis and Management of Acute Otitis Media, 3rd edn, Professional Communications Incorporated, USA, pp 11-12, retirved 1st January 2010 from: http://books.google.co.uk/books?id=kEW2cwKS76IC&printsec=frontcover&dq=related:ISBN0788148222#v=onepage&q=&f=false

Gelfand, S.A., 2009, Essentials of Audiology, Thieme Medical Publishers, New York, USA

HARP. Case Notes Shanks, J & Shohet, J, 2009 ‘Tympanometry in clinical practice’ in Katz, J, Medwetsky, L, Burkard, R & Hood, L, (eds), Handbook of Clinical Audiology, Lippincott Williams & Wilkins, USA pp 159-185

Diagnosis and Management of Acute Otitis Media, 2004, Pediatrics; 113, pp 1451- 1465, Retrieved 1st January 2010 from: http://pediatrics.aappublications.org/cgi/reprint/113/5/1451