CASE STUDY #1

1. CASE STUDY #1 Fawn Mumbulo 2013 Course 580 Sheila Gahan, FNP

2. D.B. is a 60 year old femalevitals: BP 147/84, P 86, R 20, Temp 36 degrees, Ht 5’3”, Wt 180 lbs, BMI 31.96 • Edmeston/Burlington Health Center for follow up & reassurance 2/11/13 • CC: Right ear pain not resolving after 10 days of antibiotic treatment • HPI: Right ear pain 3/10. Onset of recurrent otitis media began after sinus surgery in 2005 with the last incident 1/28/13, which was treated with a ten day course of antibiotics. Symptoms tend to dissipate after infectious episode & treatment of antibiotics, pain has not resolved this time. There are no associations or alleviations to the pain. Denies history of injury or trauma. Unknown history of nasal steroid therapy short term or long term. • 1/15/13 Otitis Media right ear • 1/28/13 follow up after 10 days antibiotics • 2/11/13 follow up to recheck right ear, ENT referral • 2/12/13 ENT

3. PMH SH/FH • Dysfunction of right Eustachian tube • chronic sinusitis • Rhinitis • Fatigue • Hyperlipidemia • Melanoma of foot • Menopausal symptoms • Anxiety • Osteopenia • Epigastric pain • Surgical history: • Tubal ligation • Cesarean section • Excision of melanoma on foot • Sinus/nasal septum surgery 2005 • Never smoked • Drinks less than 0.6oz. ETOH/wk • Denies illicit drugs • Drinks caffeinated beverages once daily • Lives with husband, has two grown children married & living out of state • Grandparent on both sides deceased - unknown • Mother/father/brother/sister deceased - Cancer • Sister AW • Maternal/paternal Uncles - diabetes

4. MedicationsAllergies - Keflex • Acidophilus Probiotic once daily prn • Aspirin EC 81mg once daily • Wellbutrin XL 150mg once daily • Calcium 600mg 1 tab twice daily • Calcium-D once daily • Cymbalta 30mg 2 cap. Daily • Nasonex 50mcg nasal spray- 2 sprays ea. Nostril daily • MVI once daily • Omega 3 fatty acids/vit E 1,000-5mg once daily • Ambien 10mg one tab at bedtime • Lipitor 10mg once daily • Immunizations: Influenza, whole 10/12/12, Tdap 6/11/12, Zostavax 10/12/12

5. ROS • Constitutional: appears well groomed & appropriate for age, denies fever, chills or weakness • Head:Denies h/o trauma or injury that can be recalled, normocephalic. • Neck: Denies goiter, swelling, or enlarged lymphnodes. Denies inflammation, pain or drainage • Ears: Right ear pain 3/10, left ear no pain just dullness to sound, D.B. reports hearing loss bilaterally, recurrent infections since sinus surgery in 2005, denies mastoiditis • Nose/mouth/throat: chronic rhinitis, denies epistaxis, obstruction or swelling. Denies sores in mouth/tongue, last dental exam 1 yr. Denies h/o hoarseness, voice changes, sore throats or tonsillitis • Respiratory: Denies wheezing, dyspnea, cough, hemoptysis, pleurisy, TB, or asthma • Cardiovascular: Denies cardiac history, denies palpitations, tachycardia, heart murmur, irregular rhythm, chest pain, discomfort, exertional dyspnea, cyanosis, phlebitis, or skin color changes. Denies h/o HTN, rheumatic fever, cold extremities, edema or heart medications • Neurological: Reports dizziness on occasion when moving positions too fast. Denies sleeping disturbances (sleeps 7 hrs at night), denies twitching, convulsions, loss of consciousness or memory

6. Hemotympanum (symptom) The common causes of hemotympanum are therapeutic nasal packing, epistaxis, clotting disorders, blunt trauma to the head & skull base fracture. Characterized is idiopathic in the presence of chronic otitis media. Evidence shows that otitis media infections without symptoms and hemotympanum could be different stages of the same disease process. Rarely seen in anticoagulant or hematologic disorders such as leukemia. Vascular tumors of the middle ear such as glomus tumors should be considered with hemotympanum.

7. Differential Diagnosis-Chemodectoma: abnormal skin growth, believed to be an over response to a change in homeostasis Glomus tympanicum tumor Paraganglioma tumor Most common in 40-50 year old females, most common primary neoplasm's of the middle ear Pathophysiology: neuroendocrine vascular neoplasm arising from glomus bodies in the jugular bulb or middle ear neural plexus May involve CNVIII Symptoms: tinnitus, hearing loss, pain Signs: dark blue/purple or red/blue mass behind TM Diagnosis: CT with contrast of the temporal bone Management: surgical excision Rare, benign neoplasm originating from chemoreceptor tissue of the glomus tympanicum that arise from the glomus bodies that run with the tympanic branch of the glossopharyngeal nerve Hyistology consists of rounded or ovoid hyperchromatic cells grouped in an alveolus-like pattern within a fibrous stroma with large thin-walled vascular channels

8. Diagnosis • Eustachian tube dysfunction • Hemotympanum • Glomus tumor • Sensorineural hearing loss, bilaterally

9. Dx: Eustachian Tube (ETD) • Occurs when the tube fails to open properly preventing the normal flow of air to equalize. • Pathophysiology: related to mucosal disease and associated hypertrophy, precipitated by allergies. Viral infections resulting in decreased mucociliary clearance. Gastroesophageal reflux may play a role in ETD. • Symptoms: fullness, hearing loss, tinnitus, disequilibrium, intermittent sharp pain, sensation of fluid in ear, sustained pain, difficulty popping the ears that is usually relieved by swallowing, yawning, chewing. • Exam: shows retraction pockets of TM. • Treatment: mild, lasts only a few days, if longer then decongestants, steroids, antihistamines, or leukotriene antagonists may be given. Antibiotics if bacterial infection is suspected. • Diagnostic: CT scan to r/o tumors, tympanography to assess ET function.

10. Dx: Sensorineural Hearing Loss • Epidemiology: age onset over 40 years • Pathophysiology: Presbycusis (related to aging), environmental induced, CNVIII disease (Meniere’s, Acoustic Neuroma), viral (mumps), Hematologic (polycythemia vera, sickle cell anemia, leukemia, hypercoagulable), Microvascular disease (DM, hyperlipidemia), Ototoxic medication induced, Infectious (Tertiary Syphilis, Lyme disease), Endocrine disease (Hypothyroidism), Autoimmune, Congenital deafness, Trauma (temporal bone fx involving Cochlea/vestibule, perilymph fistula) • Symptoms: Tinnitus that occurs early in hearing loss, pain with loud noise exposure, frequency of repeating what others say, impaired word understanding, patient’s voice is loud, hearing difficulty in noisy environments, unable to hear high frequency sounds • Signs: Otoscopy exam is normal, Weber test is abnormal, sound radiates to ear with less sensorineural loss, Rinne test is abnormal, both air conduction/bone conduction is reduced • Labs: CBC, ESR, TSH, UA, Serum glucose, BUN/creatine, Lipid panel, Syphilis serology, Lyme titer (is warranted) • Imaging: MRI head at the internal auditory canal (gold standard to r/o acoustic neuroma), detects herpes zoster oticus, vascular lesions • MRA head if vascular lesion suspected • CT temporal bone r/o mastoiditis, cholesteatoma, views bone anatomy, identify acoustic neuroma & vascular lesions • Management: • Audiology test • Acute hearing loss is an emergency (high dose of steroids needed) • Otolaryngology evaluation • Chronic hearing loss, hearing aid, often no etiology identified, can resolve spontaneously

11. Refining list of diagnoses • Physical findings of the right ear are consistent with a vascular etiology of unknown cause • CT scan of temporal bone will determine tumor vs. vascular related diagnosis • Sensorineural hearing loss is not consistent with findings of right ear at this time it is a separate diagnosis that is likely caused from Presbycusis. A Weber test demonstrated right lateralization. A Rinne’s test showed no abnormalities. Whisper test had to be repeated in left ear.

12. Analysis • Diagnosis: Eustachian tube dysfunction & Sensorineural hearing loss • Etiology: Sensorineural hearing loss determined by audiologist that it is likely to be caused from Presbycusis • The literature suggests that there is no way to determine incidence due to the fact that sensorineural hearing loss is the normal aging process & Eustachian tube dysfunction has multiple pathophysiology’s • Pathophysiology: Hearing loss d/t Presbycusis, Hemotympanum, otalgia of middle ear of unknown cause

13. Management • Interventions: Simple acts of yawning, swallowing or chewing can open ET. Another maneuver to inflate the ET would be to perform the valsalva maneuver to break the negative pressure. As for sensorineural hearing loss, preventing & treating otitis media, control environmental noise, & treating allergies. Focus on patient acceptance, resources for hearing devices, communication techniques (speech pathology), & coping mechanisms. • Appropriate follow up: Depending on the diagnostic testing. Infectious disease after a 14-28 day course of antibiotics (Augmentin, Ceclor, Bactrim for therapeutic tx) if effusion persists. Addition of prednisone 1mg/kg once daily for 7 days. Reevaluate 4-6 wks post treatment with an otoscopic exam. Myringotomy may need to be done to relieve effusion. For sudden sensorineural hearing loss immediate referral to ENT. For non resolving hemotympanum referral to ENT. • Family/patient education: Keep ear canal dry, do not use Q-tips, use of peroxide if cerumen built up.

14. References Baradate, M., Bridger, A., & Somia, N. (2012). Entclinic. Retrieved from http://www.ent-surgery.com.au Dean, A., & Hughes, W. (2012). Ear anatomy. Retrieved from http://www.virtualmedicalcentre.com Dunphy, L.M., Winland-Brown, J.E., Porter, B.O., & Thomas, D.J. (2011). Primary care: The art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis Company. Echejoh, G.O., Silas, O.A., Manasseh, A.N, Mandong, B.M., & Adoga, A.S. (2011). Chemodectoma: Three case-series with review of literature. Journal Of Medicine and Medical Science, 2(5), 849-853 Fidan, V., Ozcan, K., & Karaca, F. (2011). Bilateral hemotympanum as a result of spontaneous epistaxis. International Journal of Emergency Medicine, 4(3), 1-3. doi: 10.1186/1865-1380-4-3 Isaacson, J.E., & Vora, N.M. (2003). Differential diagnosis and treatment of hearing loss. American Family Physician, 68(6), 1125-1132. Moses, S. (2008). Family practice notebook: Sensorineural hearing loss. Retrieved from http://www.fpnotebook.com Valentino, R.L. (2009). Chronic dysfunction of the eustachian tube. The Clinical Advisor. Retrieved from http://www.clinicaladvisor.com