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Chapter 13 • Dyspnea 171
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The lessening or absence of wheezes in a person
with asthma can indicate mucus plugging and an
impending episode of status asthmaticus.
Pneumonia
Pneumonia is usually associated with dyspnea, pleuritic
chest pain, cough with greenish or rust-colored sputum,
fever, and chills. In children, irritability, feeding problems, and lack of playfulness can also be seen. Objective manifestations of pneumonia include fever, tachycardia, tachypnea, inspiratory crackles, asynchronous
breathing, vocal fremitus, dull percussion sound over
area of consolidation, and bronchophony. Pneumonia
can be conrmed by chest radiography and sputum
cultures.
Hyperventilation Syndrome
Hyperventilation syndrome is a common cause of recurrent faintness without actual loss of consciousness.
Dyspnea, lightheadedness, palpitations, and paresthesias (perioral and extremities) occur. Restlessness,
anxiety, and a normal cardiovascular examination are
present. Recumbency does not relieve the symptoms.
Chest radiography is normal.
Laryngomalacia
Laryngomalacia is the most common cause of persistent stridor in infancy. Onset of the stridor is almost
always within the rst 4 weeks of life, commonly in
the rst week (with preterm neonates who were on
ventilation at high risk). Occasionally parents become
aware of the condition when a respiratory tract infection is present. Stridor is predominantly inspiratory,
and the sound can change with change in position of
the infant. The cry and cough are normal. Direct visualization of the larynx is performed for diagnosis.
Vascular Ring
Tracheal compression from vascular anomalies can
cause stridor and dyspnea in infants. The main symptom is soft inspiratory stridor with expiratory wheeze.
Frequently a brassy cough and difculty swallowing
may be present. Barium swallow followed by echocardiography is done to establish the diagnosis.
DIFFERENTIAL DIAGNOSIS OF Emergent Conditions Manifested by Dyspnea
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pulmonary
embolus
Foreign body
aspiration
Anaphylaxis Acute-onset dyspnea; history of
Pneumothorax Acute-onset dyspnea; sharp,
Croup History of upper respiratory tract
Acute-onset dyspnea, cough,
mild to severe chest pain, sense
of impending doom; hemoptysis; history of DVT, recent
surgery, oral contraceptive,
smoker, hypercoagulability
states
Acute-onset dyspnea; history
of drinking large amounts of
alcohol; in children, history of
putting small objects in mouth;
possible cough
insect sting, ingestion of drug,
or allergen
tearing chest pain; pain can
radiate to ipsilateral shoulder
infection
Restlessness, fever,
tachycardia, tachypnea,
diminished breath sounds,
crackles, wheezing, pleural
friction rub
Apnea or tachypnea,
restlessness, suprasternal
retractions, intoxication,
inspiratory stridor, localized
wheeze
Angioedema, tachypnea,
clammy skin, hypotension,
bilateral wheezes,
tachycardia
Tachycardia, diminished
breath sounds, decreased
tactile fremitus, hyperresonance of lung area affected;
possible hypertension and
tracheal shift
Hoarse, seal-bark cough,
fever (variable)
ABGs, chest radiograph,
ECG, ventilation/
perfusion scans,
d-dimer, CTPA
Lateral neck radiograph,
chest radiograph,
bronchoscopy
None; emergency
measures necessary
Chest radiograph, ABGs
None initially; if respiratory
distress increases, pulse
oximeter and referral
172 Chapter 13 • Dyspnea
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DIFFERENTIAL DIAGNOSIS OF Emergent Conditions Manifested by Dyspnea—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Acute epiglottitis Positional sitting forward; sore
throat, anxious, toxic child
Bacterial tracheitis Recent viral infection Fever, stridor, purulent sputum Radiography of airway,
Status asthmaticus Recent URI, exposure to
allergens, breathlessness
Botulism Honey ingestion in infant,
contaminated food ingestion
High fever, drooling, stridor,
muffled voice
Wheezing, coughing,
tachycardia, tachypnea
Hypoventilation, drooling,
weak cry, ptosis, ophthalmoplegia, loss of head control
Admit; life threatening
WBC increased,
tracheal culture
Peak flows, chest
radiograph, ABGs
Pulmonary function
testing, chest
radiograph, fluoroscopy, stool culture
DIFFERENTIAL DIAGNOSIS OF Nonemergent Conditions Manifested by Dyspnea
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pneumonia Dyspnea, cough, sputum
production (green, rust, or red),
pleuritic chest pain, chills; in
infants and children: irritability
and feeding problems
Hyperventilation
syndrome
Laryngomalacia Neonate, infant: history of stridor,
Vascular ring Infant: dyspnea, brassy cough,
Heart failure Chronic progressive dyspnea,
Anemia Dyspnea on exertion, fatigue,
Poor physical
conditioning
Asthma Dyspnea, paroxysmal cough,
Dyspnea, lightheadedness,
palpitations, paresthesias
(perioral and extremities)
history of URI
difficulty swallowing
cough, frothy sputum, fatigue,
lightheadedness, syncope,
weight gain, ankle swelling,
palpitations, PND, orthopnea,
history of heart disease; in
children: chronic progressive
dyspnea, sweating above lip and
forehead, especially while eating
palpitations, lightheadedness,
history of chronic disease
Dyspnea on exertion, weight gain,
palpitation on exertion, sedentary lifestyle, cigarette smoker
audible wheeze, history of
asthma or allergies
Fever, tachycardia, tachypnea,
inspiratory crackles,
asynchronous breathing, vocal
fremitus, percussion dull or flat
over area of consolidation,
bronchophony, egophony
Restlessness, anxiety, normal
CV examination
Inspiratory stridor; normal
cough, cry
Inspiratory stridor with expiratory
wheeze
Altered level of consciousness,
restlessness, jugular venous
distention, tachypnea, use of
accessory muscles to breathe,
rales, rhonchi, wheezes,
tachycardia, decreased
peripheral pulses, cool
extremities, displaced PMI, S3,
S4, ascites, liver enlargement
Pallor, tachypnea, cool dry skin
of extremities, possible orthostatic hypotension
Overweight, tachycardia Cardiac stress test
Restlessness, tachypnea, use
of accessory muscles to
breathe, intercostal retractions,
decreased vocal fremitus,
decreased breath sounds,
inspiratory and possibly
expiratory wheezes
Chest radiograph,
sputum cultures,
ABGs, WBC
Chest radiograph
Refer for visualization
of larynx
Barium swallow,
echocardiography
ECG, chest radiograph,
ABGs, echocardiogram
CBC, iron studies
Spirometry, chest
radiograph, ABGs
Chapter 13 • Dyspnea 173
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DIFFERENTIAL DIAGNOSIS OF Nonemergent Conditions Manifested
by Dyspnea—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
COPD Chronic progressive dyspnea,
dyspnea on exertion, persistent
cough, minimal sputum, easy
fatigue, history of smoking
Rapid shallow respirations, red-
dish complexion, increased
AP diameter of thorax, use of
accessory muscles to breathe,
pursed-lip breathing, decreased
tactile fremitus, decreased
respiratory excursion bilaterally,
lungs hyperresonant, distant
breath sounds, prolonged
expiration, occasional wheezes,
possible tachycardia, muffled
heart sounds
Chest radiograph,
pulmonary function
tests, exercise tests,
ABGs
REFERENCES AND READINGS
Bettmann MA, Lyders EM, Yucel EK, Khan A, Haramati LB, Ho
VB et al: Expert Panel on Cardiac Imaging. Acute chest pain—
suspected pulmonary embolism [online publication]. Reston
(VA): American College of Radiology (ACR); 2006.
Evans SE, Scanlon PD: Current practice in pulmonary function
testing, Mayo Clinic Proceedings 78:758, 2003.
Fedullo PF, Tapson VF: The evaluation of suspected pulmonary
embolism, N Engl J Med 349:1247, 2003.
Karnani NG, Reiseld GM, Wilson GR: Evaluation of chronic dyspnea,
Am Fam Physician 71:8, 2005.
Leung AKC, Kellner JD, Johnson DW: Viral croup: a current
perspective, J Pediatr Health Care 18:297, 2004.
Meek PM: Measurement of dyspnea in chronic obstructive pulmonary
disease: what is the tool telling you? Chron Respir Dis 1:1, 2004.
Owens S: Exercise intolerance, Pediatr Rev 21:6, 2000.
Schwartzstein RM: Evaluation of the patient with chronic dyspnea:
clinical application of pathophysiologic principles, Prim Care
Case Rev 3:201, 2000.
Weinberger M, Abu-Hasan M: Perceptions and pathophysiology
of dyspnea and exercise intolerance, Pediatr Clin N Am 56:33,
2009.
Werner HA: Status asthmaticus in children: a review, Chest 119:1913,
2001.
Zoorob R, Campbell J: Acute dyspnea in the ofce, Am Fam Physician
68:1803, 2003.
C H A P T E R
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14
Earache
talgia, or ear pain, is generally caused by an inammatory process. In children, inammation
O
more often have an earache from external ear conditions
or from referred pain from other head and neck structures. Acute otitis media (AOM) refers to any inammation of the middle ear and encompasses a variety of
clinical conditions. Otitis media with effusion is a collection of uid in the middle ear. This condition is also
known as serous otitis media, secretory otitis, or nonsuppurative otitis. External or middle ear disorders can often
be distinguished after a brief history and physical examination. If the physical ndings are normal, referred pain
is a likely cause. About 50% of referred pain is caused by
dental problems, although other causes may include temporomandibular joint (TMJ) disorder, parotitis, pharyngitis, or cervical, mouth, or facial disorders. The most
serious, although least common, cause of referred pain is
nasopharyngeal cancer, a condition more common in
Asians. Figure 14-1 illustrates the structures of the ear.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
most commonly occurs in the middle ear. Adults
Is this an acute infection?
Key Questions
n How old are you?
n Have you had a fever?
n Have you had an upper respiratory infection?
n Have you had ear infections before?
n Is there a family history of ear infections?
Age
The occurrence of AOM declines signicantly after
age 6. Increased age raises the likelihood of secondary otalgia caused by disorders of the head, face,
and neck; by sinus or periodontal disease; and by
malignancy.
Fever
Fever is present in 60% of all children with AOM. In
infants younger than 2 months, fever with AOM is
uncommon. A high fever accompanying otitis is more
likely to indicate a systemic illness, such as pneumonia
or meningitis.
Upper Respiratory Infection
A URI occurs when the mucous membranes of the nasopharynx and/or sinuses become infected and organisms
are forced up the lumen of the eustachian tube. Inammation of the mucosa or enlarged adenoids obstruct the
eustachian opening so that the air in the middle ear is
absorbed and replaced by mucus. This mucus creates a
mechanical obstruction and can serve as a medium for
bacterial growth.
Previous Infections
Infants younger than 3 months who have their rst
AOM run a high risk of recurrence. Seventy-one percent of children younger than age 3 years have had at
least one episode, and one third have had an average
of three episodes. Chronic otitis media can result in
anatomical changes to the tympanic membrane (TM)
and middle ear ossicles, which may predispose the
patient to additional ear infections.
Family History
Having a sibling or parent with chronic otitis media
makes it twice as likely for the illness to develop in the
child. The presence of chronic otitis media may also be
related to child-care practices, such as bottle propping,
or environmental exposures, such as second-hand cigarette smoke.
174
Chapter 14 • Earache 175
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Mastoid bone
Malleus
Cartilaginous
ear canal
FIGURE 14-1 External auditory canal, middle ear, inner ear. (From Barkauskas VH,
Baumann L, Darling-Fisher C: Health and physical assessment, ed 3, St Louis, 2002,
Mosby.)
Bony ear canal
Footplate of stapes
Incus
Tympanic
membrane
Oval window
What environmental conditions might
suggest increased risk?
Key Questions
n Does anyone around you smoke? Do you smoke?
n If a child: Does the child attend day care?
n If a child: Does the infant take a bottle lying
down?
n Have you been swimming recently?
n Have you recently been in an airplane or been scuba
diving?
Smoke Exposure
Second-hand cigarette smoke exposure has been associated with a two- to threefold increased risk of otitis
media. Cigarette smoking leads to functional eustachian tube obstruction and decreases the protective
ciliary action in the tube.
Attending Day Care
Attending a day care with other children is associated with an increased incidence rate of otitis media
because of exposure to organisms.
Three
semicircular
canals
Round
window
Eustachian
tube
Vestibular
branch (CN VIII)
Cochlear
branch (CN VIII)
Cochlea
Vestibule
Bottle Propping
In very young children, lying supine while drinking
from a bottle has been associated with AOM. It is
postulated that swallowing while lying down allows
nasopharyngeal uid to enter the middle ear, with
subsequent infection.
Swimming
Repeated or prolonged immersion in water results in
loss of protective cerumen and chronic irritation with
maceration from excessive moisture in the canal. This
leads to an increased occurrence of otitis externa, also
called swimmer’s ear.
Airplane Travelers, Divers
Barotrauma is a cause of acute serous otitis related to
pressure changes from ying or scuba diving. This is
often aggravated by recent upper respiratory tract infection or nasal congestion. Failure of the eustachian tube to
open and equilibrate during descent results in a collection
of serosanguineous uid in the middle ear. This may be
felt as ear pressure that can lead to pain, tinnitus, and
temporary deafness. Swallowing, chewing, or blowing
176 Chapter 14 • Earache
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out the nose with the mouth and nose occluded can
relieve symptoms.
Could this be related to a systemic disease?
Key Questions
n Do you have diabetes?
n Have you ever had dermatitis, eczema, or psoriasis?
n If a child: Does the child have a nonrepaired cleft
palate?
Diabetes Mellitus
Diabetes mellitus predisposes adults to malignant otitis
externa, which is cellulitis involving the ear and
surrounding tissue. Persons with diabetes are also at
increased risk for otitis media and mastoiditis.
History of Seborrheic Dermatitis or Psoriasis
Chronic inammatory dermatitis from overproduction
of sebum can occur in the external canal and cause
otitis externa.
Cleft Palate
Nonrepaired anomalies anatomically predispose a child
to otitis media because of functional obstruction of the
eustachian tubes.
What does the presence of pain tell me?
Key Questions
n Where specically is the pain felt?
n Is it in one ear or both?
n How severe is the pain?
n Does it interfere with sleeping, eating, or other
activities?
n How long have you had this pain?
n Is the pain constant or intermittent? If intermittent,
how long does it last?
n Does the pain travel (radiate) to other areas?
Location of the Pain
Pain of otitis externa is described as tenderness around
the outer ear or opening to the ear canal that worsens
with manipulation of the pinna. Mastoiditis is often associated with severe pain or tenderness over the mastoid
bone. If the pain is bilateral, suspect otitis externa. Referred pain or pain of AOM is usually unilateral. Infants
cannot assist in location of the ear pain; instead, they
exhibit behavioral changes that may indicate pain, such
as irritability, lethargy, poor appetite, vomiting, and diarrhea. Young children may pull or tug at their ears.
Quality of the Pain
The pain of AOM is often described as a deep pain or
a blockage of the ear. Serous otitis is often painless or
may be described as a bubbling, popping, or stuffy
sensation in the ear. Otitis externa involves a tenderness of the outer ear or ear canal that can be accompanied by itching. A cerumen impaction creates a milder
pain or vague discomfort of stuffed ears.
Quantity and Severity of the Pain
The pain of AOM is severe enough to interfere with
sleep and may be suddenly relieved if the eardrum
perforates. Chronic ear pain that is unresponsive to
treatment may indicate a tumor.
Onset, Timing, and Duration of the Pain
TMJ pain is often described as severe pain lasting a
few minutes and recurring three or four times per day,
sometimes associated with headache. It is worse in the
morning because nighttime teeth grinding is associated
with this condition. The pain is intermittent but can be
acute, and is related to trauma or overextension of the
mouth. Chronic pain may be related to dental malocclusion or rheumatoid arthritis.
Crying when sucking is often an infant’s only indica-
tion of pain with compression and increased pressure in
the ears. Nocturnal onset of otalgia from a developing
infection is caused by increased vascular pressure in the
reclined position, causing the TM to bulge and to stimulate pain sensation.
What does the presence of discharge or itching
tell me?
Key Questions
n Do you have any itching in the ear?
n Do you have any discharge from the ear?
Itching or Drainage
Itching or drainage from the ear usually indicates an
infection or inammation of the external canal. Itching
can also be a precursor to herpes zoster of the trigeminal nerve (CN V). Drainage may also be present after
the TM ruptures from increased middle ear pressure, or
it may be from exudate secondary to mastoiditis. Cholesteatoma is an epidermal inclusion cyst of the middle
Chapter 14 • Earache 177
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ear or mastoid. A perforation of the TM and associated
foul-smelling discharge may occur.
What does a history of trauma or injury
tell me?
Key Questions
n Have you had any recent trauma to the ear?
n Have you had any head trauma?
n How do you clean your ears? Do you use cotton-
tipped swabs?
n Do you have a history of excessive earwax?
n If a child: Does the child have a history of putting
objects in the ears?
n Have you had any recent insect bites around the ear?
n Have you been exposed to any loud noise?
Ear Trauma
Perforation of the eardrum can be caused by blunt
or penetrating trauma. Blunt trauma might include a
slap to the ear or barotrauma. Penetrating trauma to the
canal or TM may be self-induced with cotton-tipped
swabs or other sharp objects used to remove cerumen
or to scratch the canal.
Head Trauma
Direct injury to the inner ear by fracture of the petrous
temporal bone located at the base of the skull also
destroys the inner ear.
Cerumen Impaction
Cerumen is a naturally wet, sticky, honey-colored wax
that serves as a lubricant to protect the external ear canal.
In some individuals it occurs in a dark, scaly form and
accumulates in the ear canal. This accumulation may
cause hearing loss, tinnitus, pressure sensation, vertigo,
and infection. Self-cleaning practices can produce trauma
to the canal, and cerumen-softening solutions can cause
chemical irritation to the canal tissue.
Foreign Bodies
Foreign bodies, such as feathers, beads, and insects
(especially cockroaches), can produce ear pain and
inammation. Children often self-insert objects.
Insect Bites
Insect bites can lead to acute pain and tenderness of
the external canal and may develop into a secondary
infection.
Loud Noise
Exposure to high-pitched and loud noise for a prolonged period of time destroys the cochlear hair cells.
Exposure to noisy work environments, to the operation
of heavy machinery, and to loud music increases the
risk of injury and eventual hearing loss.
Is hearing loss a clue?
Key Questions
n Do you have any difculty in hearing?
n Do you have any dizziness?
n Do you have any ringing in the ear?
n If a child: Do you think the child can hear normally?
n If a child: Does the child turn his or her head to listen?
Difficulty in Hearing
Reports of hearing loss or “difculty hearing” can indicate blockage of the ear canal by cerumen or a foreign
body, inammation of the middle or inner ear, or a neoplasm. The most frequent cause is conductive hearing
loss caused by blockage of the external canal, usually by
cerumen. Chronic otitis media is usually a condition of
adults who have a chronic infection that may destroy the
ossicles and spread to the mastoid, labyrinth, and intracranial structures, causing hearing loss. Chronic ear pain
is often associated with hearing loss and ear discharge
secondary to a perforated nonhealing TM.
Hearing Loss in Children
Chronic otitis media with effusion causes a conductive
hearing loss in children. This loss may be caused by
negative middle ear pressure, the presence of an effusion in the middle ear, or structural damage to the TM
or ossicles.
Dizziness, Ringing in Ear
Hearing loss associated with dizziness, vertigo, or tinnitus may indicate a serious inner ear condition. Abnormal middle ear ventilation and middle ear effusion are
the most common causes of balance disturbance in children. These symptoms are caused by reestablishment of
aeration in the middle ear cavity as the effusion clears.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
A correct diagnosis of ear pain requires a good view of
the TM and external ear canal. Cerumen obstruction
should be removed through lavage or by separating an
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impaction with an ear curette so that irrigation uid
can penetrate behind the impaction. The curette must
be manipulated cautiously because trauma to or inammation of the sensitive perichondrium, which lies
immediately below a thin layer of epithelium in the ear
canal, elicits excruciating pain and easy bleeding.
Lavage should not be performed if the medical history
suggests perforation of the TM. Without visualization
of the TM, however, otitis media cannot be ruled out.
Lavage solution helps to soften the cerumen and can be
purchased commercially in kits or a solution can be made
of hydrogen peroxide and water (1:1).
Note Behaviors in Children
Otitis media is the most common childhood disorder.
Young infants may exhibit nonspecic signs of irritability, poor feeding, congestion, and fever. Older infants
and young toddlers are irritable, pull on the painful ear,
or bang their head on the affected side. Older children
will report an earache.
Inspect External Ears
General inspection should begin with the pinna and
condition of the skin around the ear, face, and scalp.
Hemorrhage over the mastoid bone (Battle sign) may
occur with a basal skull fracture. Eczematous seborrhea or psoriasis manifests as redness and scaling of
the skin that can extend into the external ear canal.
Pain in the opening of the ear canal and inamed skin
may suggest a bacterial infection. Fungal and yeast
infections appear as white or dark patches. Furuncles
or lesions secondary to trauma or irritation appear as
localized areas of tenderness or swelling. A hot,
swollen, and erythematous ear and surrounding skin
indicate cellulitis. Redness and painful swelling over
the mastoid process is a sign of infection in the mastoid air cells.
Palpate External Ears
Palpate the pinna and tragus for tenderness. In mastoiditis, the pinna is displaced forward and swelling may be
present behind the ear. Palpation of the mastoid process
elicits severe tenderness. Otitis externa is associated
with pain on manipulation of the pinna. With referred
pain, the structures will appear normal, although palpation over the TMJ may elicit tenderness, and movement
of the jaw may create a clicking sound.
Palpate the preauricular and postauricular areas
on the right and left simultaneously to elicit pain.
Palpate anterior and posterior cervical lymph nodes
and over the mastoid process. Preauricular nodes
may be enlarged in AOM and otitis externa. Postauricular swelling may indicate extension of infection
into the mastoid cavity.
Inspect Ear Canals
With the otoscope, observe for the patency of the
canal, the condition of the skin of the ear canal, and
the presence of cerumen. With cerumen impaction,
no structures can be visualized. A foreign body is
easily visualized. Vesicles on the external ear canal
and auricle may indicate herpes zoster (Ramsay Hunt
syndrome).
Visualize any discharge, noting color, consistency,
and odor. Discharge is usually indicative of an active
infection. However, cranial trauma with cerebrospinal
uid leakage must be kept in mind. Cheesy, green-blue,
or gray discharge can be seen with otitis externa.
Inspect Tympanic Membranes
Visualize the TM, noting light reex and anatomical
structures. A normal TM is translucent and pearly gray
in color. Mild diffuse redness can occur from crying or
coughing. Mild vascularity is sometimes seen in the
normal eardrum, especially on the handle of the malleus. Localized redness is a sign of inammation.
Scarring and effusion can cause whitening and opacication of the TM.
The contour of the normal TM is somewhat concave. Fullness or bulging indicates either increased
air pressure or, more commonly, increased hydrostatic pressure within the middle ear. Fullness of
the eardrum is seen rst around the periphery of the
TM. As pressure increases, central fullness becomes
visible. Concavity or retraction of the eardrum is associated with negative middle ear pressure or postinammatory adhesions. As the eardrum retracts, the
handle of the malleus short process becomes more
visible.
Myringitis is a red, inamed eardrum without effusion. Bullous myringitis describes an extremely
painful condition of small blisters on the TM caused
by bacterial otitis media. Figure 14-2 illustrates the
usual landmarks of a normal right TM. Chronic otitis
media can lead to cholesteatoma, or a cyst-like mass
behind the eardrum, caused by the proliferation of
squamous epithelium. The mass can grow to cause
necrosis of the ossicles. Examination will reveal a
Incus
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Pars
tensa
Chapter 14 • Earache 179
12
Short
process
of malleus
Handle of
malleus
9
6
3
Umbo
Cone of
light
FIGURE 14-2 Usual landmarks of the right tympanic
membrane with a “clock” superimposed. (Modified from
Potter PA, Perry AG: Basic nursing: essentials for practice,
ed 6, St Louis, 2006, Mosby.)
collection of white granulation tissue with perforation of the TM.
Perform Pneumatic Otoscopy
(Insufflation)
The normal eardrum is suspended from its margins and
responds to slight pressure changes. Insufation tests
the mobility of the TM. It can be an insensitive test for
otitis media if poor technique fails to create a seal.
Properly performed, however, it is more reliable than
visualization alone.
To perform insufation, a large speculum is needed
to create a seal. A normal nding elicits a slight motion
of the TM when air is insufated. This movement is
compared with the opposite ear. A TM that has been
retracted as a result of negative middle ear pressure or
adhesions does not move with ination, but rebound
mobility is seen when the bulb is released. Any accumulation of liquid in the middle ear (e.g., effusion) or
scarring of the TM inhibits movement when air is
insufated.
Test Hearing Acuity
Hearing acuity is tested using the whisper test and the
tuning fork for the Rinne and Weber tests. The sensory
function of the acoustic nerve (CN VIII) should be
tested to determine whether air or bone conduction loss
is present with ear pain.
The Weber test is performed with a 512-hertz (Hz)
or higher frequency tuning fork. To perform the test,
rmly place the vibrating tuning fork on a midline point
of the skull. If there is unilateral conductive hearing
loss, sound will lateralize to the ear with loss because
the better ear is being distracted by ambient noise.
Alternately, if the patient has unilateral sensorineural
loss, the sound will lateralize to the better ear because
the neural pathway is interrupted on the affected side.
Equal perception of vibration can indicate normal hearing or bilateral hearing loss. The Rinne test compares
air conduction with bone conduction; the ratio should
be 2:1. A 20- to 30-decibel (dB) conductive loss would
result in better sound transmission through bone than
through air. Conductive hearing loss results when sound
transmission is impaired through the external or middle
ear. Sensorineural hearing loss results from a defect in
the inner ear.
Examine Related Body Systems
Examine other regional body systems of the head
and neck, including inspection of the conjunctivae,
examination of the mucosa and patency of the nose,
percussion and palpation of the frontal and maxillary
sinuses for tenderness, and inspection of the posterior pharynx for lymphedema, color, and presence
of exudate. Inspection of the condition of the oral
mucosa—teeth and gums—will provide information
about possible causes of referred pain. A focused
physical examination for head and neck symptoms
should include palpation of cervicofacial lymph
nodes, especially the preauricular and postauricular
nodes.
Perform an Intraotic Manipulation
If referred pain is suspected, conduct a more extensive
neurological examination and assess for TMJ disorder.
TMJ pain can be replicated by instructing the patient to
180 Chapter 14 • Earache
https://t.me/med1917
open the mouth wide. Face the patient, insert a single
ngertip in each ear, and pull the patient toward you
as the patient is instructed to open and close the mouth.
Pain will be elicited in 90% of patients with TMJ
disorder.
Evaluate Cranial Nerves V, VII, and IX
Observe jaw and facial muscle movement for symmetry and strength by palpating over the masseter
muscles and asking the patient to bite and clench the
teeth (CN V). Assess intactness of sensation to pain
and light touch using a sharp/dull stimulus over
the three branches of CN V. Both CN VII (anterior
two thirds) and CN IX (posterior one third) innervate
taste sensation to the tongue as well as sensation
to the external ear. Test taste sensation by having
the patient protrude the tongue and apply sweet and
salty substances separately to each half of the tongue
to test CN VII and bitter and sour substances to
test CN IX.
Pneumatic otoscopy
Middle
ear
External canal
pressure
Pos
Neg
3+
2+
Tympanic
membrane position
1. Neutral
Ext.
canal
LABORATORY AND DIAGNOSTIC
STUDIES
Tympanometry
Tympanometry involves inserting a probe into the external ear canal while continually changing pressure
against the eardrum to assess the mobility of the TM.
The tympanogram provides an indirect measure of
pressure in the middle ear. Under normal middle ear
pressure, the TM absorbs the sound energy waves and
produces a bell-shaped pattern that peaks when sound
pressure is introduced. With positive or negative middle ear pressure, the tympanogram results in a at pattern or an early peak pre ssure. Figure 14-3 illustrates
examples of various tympanogram results.
Audiometry
Audiometry assesses both the frequency and the intensity of sound that can be perceived. An air conduction
audiometer transmits via earphones a pure tone that has
Middle ear
Content
Air
status
Pressure
Normal
Tympanograms
Jerger's
classification
Type A
Peaked
Gradual
Gradual
Type A
Type A
Type C
Type C
Type B
Type C
Type A+
Type B
Type B
2. Neutral
monometric
3. Neutral
4. Retracted
slightly
5. Retracted
markedly
6. Retracted
7. Full
8. Bulging
Liquid
4+
Air
liquid
Air
Air
Normal
Normal
Low
negative
High
negative
Indeter-
minate
Positive
or inde-
terminate
Indeter-
minate
Peaked
400 0 +200200
3+
Air
1+
1+
0
0
0
0
1+
0
Air and
2+
3+
Air and
2+
liquid
2+
Air and
1+
liquid
0
Liquid
Liquid
0
and air
0
Liquid
FIGURE 14-3 Middle ear evaluation with pneumatic otoscopy and imped-
ance tympanograms. (From Daeschner CW Jr: Pediatrics: an approach to independent learning, New York, 1983, John Wiley & Sons.)
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