A 10-year-old girl is brought to the office due to right ear pain that began yesterday. The patient's ear feels itchy and gives the sensation of something stuck inside. She recently returned from visiting her grandparents at their beach house for a family reunion; a few cousins also visiting were recovering from an upper respiratory infection. The patient had recurrent acute otitis media complicated by persistent effusion and required tympanostomy tube placement at age 2. The tympanostomy tubes have since fallen out, and she has had no ear infections since age 3. She is not up to date on vaccinations but has no chronic medical conditions. Her parents are smokers but usually do not smoke inside the house. Temperature is 37.1 C (98.8 F), blood pressure is 102/58 mm Hg, and pulse is 94/min. On examination of the right ear, there is exquisite tenderness to movement of the pinna during otoscopy. The canal is red and swollen. Most of the tympanic membrane can be seen, and it is clear with no fluid. The left ear is normal. Which of the following risk factors most likely contributed to this patient's condition?

Question

A 10-year-old girl is brought to the office due to right ear pain that began yesterday.  The patient's ear feels itchy and gives the sensation of something stuck inside.  She recently returned from visiting her grandparents at their beach house for a family reunion; a few cousins also visiting were recovering from an upper respiratory infection.  The patient had recurrent acute otitis media complicated by persistent effusion and required tympanostomy tube placement at age 2.  The tympanostomy tubes have since fallen out, and she has had no ear infections since age 3.  She is not up to date on vaccinations but has no chronic medical conditions.  Her parents are smokers but usually do not smoke inside the house.  Temperature is 37.1 C (98.8 F), blood pressure is 102/58 mm Hg, and pulse is 94/min.  On examination of the right ear, there is exquisite tenderness to movement of the pinna during otoscopy.  The canal is red and swollen.  Most of the tympanic membrane can be seen, and it is clear with no fluid.  The left ear is normal.  Which of the following risk factors most likely contributed to this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d656_7544_bc81_836123de200f_MD0003_00 This child with pinna tenderness, pruritus, and a painful, swollen external auditory canal has acute otitis externa (OE), also called "swimmer's ear" due to the most common risk factor: water exposure. Water exposure facilitates development of OE through several mechanisms. Cerumen typically coats the external auditory canal but can be displaced when exposed to flowing water. Cerumen has antibacterial properties; therefore, its loss can lead to increased bacterial growth. In addition, the ear canal is typically acidic, which inhibits bacterial growth, but significant water exposure can raise the pH. Frequent or excessive water exposure can also cause maceration of the skin of the canal, which disrupts the skin's protective barrier. Finally, water exposure introduces pathogenic bacteria into the external canal. Pseudomonas aeruginosa, which grows in water, is the most common pathogenic organism implicated in OE. Topical antipseudomonal antibiotics (eg, fluoroquinolones) are appropriate first-line therapy and would also cover Staphylococcus aureus (the second most common cause). Patients should be instructed to keep the ear dry until the infection resolves. (Choice A) Lack of vaccination against Haemophilus influenzae type b (Hib), an encapsulated bacterium, can increase the risk of acute otitis media (AOM), pneumonia, epiglottitis, and meningitis; lack of pneumococcal vaccination is a risk factor for AOM. However, neither Hib nor Streptococcus pneumoniae is a common cause of OE. (Choice B) Having multiple sick contacts increases the risk of upper respiratory infections, which can lead to AOM (as microbes in the upper respiratory tract enter the middle ear and multiply in mucosal secretions) but not to OE (as the tympanic membrane separates the external auditory canal from the middle ear). (Choice C) Recurrent AOM can lead to hearing loss, balance problems, tympanic membrane perforation, and cholesteatoma, but it does not increase the risk for OE. (Choice D) Tobacco smoke exposure is linked to an increased need for tympanostomy tubes for recurrent AOM, possibly related to smoke-induced dysfunction of the cilia in the upper respiratory tract. A link between OE and smoking has not been established. (Choice E) Tympanostomy tube placement can increase the risk of otorrhea, persistent tympanic membrane perforations, and cholesteatoma. It does not lead to increased risk of OE. Educational objective: Otitis externa ("swimmer's ear") is a painful infection of the external auditory canal. It often occurs after outdoor water exposure due to alterations in ear canal pH, loss of cerumen, skin maceration, and introduction of bacteria. Pseudomonas aeruginosa is the most common pathogen. References: Clinical practice guideline: acute otitis externa. (http://www.ncbi.nlm.nih.gov/pubmed/24491310)

A 10-Year-Old Girl Is Brought to the Office Due to Right