Learning Issues

Learning Issues - Learning Issues Monday, August 23, 2010...

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Learning Issues Monday, August 23, 2010 6:12 PM Learning Issue: Immobility of the Tympanic Membrane Name: Michael Holmes Definition Tympanic membrane is immobile to positive and negative pressure during physical exam using a pneumatic attachment of the otoscope. Causes -Bulging with no mobility: middle ear effusion due to pus or fluid -Retracted with no mobility: obstruction of the Eustachian tube with or without middle ear effusion -Mobility with negative pressure only: obstruction of Eustachian tube with or without ear effusion -Excess mobility: Healed perforation, atrophic tympanic membrane Risk Factors -Serous otitis media -Acute otitis media -Trauma to the TM Pathophysiology - Perforation of TM -Acute otitis media or otitis media with effusion Signs and Symptoms -Bulging with no mobility: middle ear effusion due to pus or fluid -Retracted with no mobility: obstruction of the Eustachian tube with or without middle ear effusion -Mobility with negative pressure only: obstruction of Eustachian tube with or without ear effusion -Excess mobility: Healed perforation, atrophic tympanic membrane What to look for in physical exam Observe the TM with a pneumatic attachment on an otoscope. When applying positive pressure to the TM it should move towards the middle ear. When negative pressure is applied the TM should move towards the clinicians eye. Movement with positive and negative pressure is expected and is indicated by a change in the cone of light appearance. No movement is expected when the TM is perforated or a pressure equilibrium tube is in place. In addition, the clinician should be observing the TM for bulging, retraction, and effusion in the middle ear. Diagnostic Testing Using an otoscope with a pneumatic attachment the TM is observed while applying positive and negative pressure, while looking at the light reflex of the TM. Medications/ Treatment plan First Line therapy 1. (ADULT) The first choice of oral treatment is amoxicillin, 20-40 mg/kg/d, or erythromycin, 50 mg/kg/d plus sulfonamide 150 mg/kg/d for 10 days. In resistant cases cefaclor 20-40 mg/kg/d, or amoxicillin-clavulanate 20-40 mg/kg/d
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combinations can be used. (Child) The first choice of oral treatment is amoxicillin, 90 mg/kg/d, up to 4 g/d. For children over 2 y, give 5 d; under 2 y, for 10 d. 1. If amoxicillin gives a rash, give cefuroxine (ceftin), cefdinir (omincef), or cefpodoxine (vantin). 2. If uticaria or other Ige-mediated events have occurred, give Trimeethoprim-sulfamethoxazole or arithromycin (zithromax) 3. If child is unable to take oral medications, give single dose of ceftriaxone (rocephin). Second line therapy 1. amoxicillin-clavulanate (augmentin ES-600), given so that patient recieves amoxicillin at 90 mg/kg/d.
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Learning Issues - Learning Issues Monday, August 23, 2010...

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