CASE STUDY #1
Fawn Mumbulo 2013
Course 580
Sheila Gahan, FNP
D.B. is a 60 year old female
vitals: 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
PMH
 Dysfunction of right Eustachian
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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
SH/FH
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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
Medications
Allergies - Keflex
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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
ROS
 Constitutional: appears well groomed & appropriate for age, denies fever, chills or
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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
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.
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
 Rare, benign neoplasm originating
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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
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 thinwalled vascular channels
Diagnosis
 Eustachian tube dysfunction
 Hemotympanum
 Glomus tumor
 Sensorineural hearing loss, bilaterally
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.
Dx: Sensorineural Hearing Loss
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Epidemiology: age onset over 40 years
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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)
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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
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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
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Labs: CBC, ESR, TSH, UA, Serum glucose,
BUN/creatine, Lipid panel, Syphilis serology, Lyme
titer (is warranted)
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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
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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
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.
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
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.
References
Baradate, M., Bridger, A., & Somia, N. (2012). Entclinic. Retrieved from http://www.entsurgery.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