A 9-year-old girl is brought to the office due to "ringing in her right ear" over the past week. She also has noticed a popping sensation in the ear when she swallows and difficulty hearing soft sounds. The patient has had nasal congestion during this time but is otherwise well. She and her family flew home from a ski trip in Colorado a few days before her symptoms began. Vital signs are normal. Otoscopic examination shows a retracted right tympanic membrane with surrounding dilated blood vessels; the left side is unremarkable. Pupils are equal, round, and reactive to light and accommodation. Coordination and balance are normal. Cranial nerve testing demonstrates a mild reduction in hearing on the right side. Which of the following is the most likely diagnosis in this patient?

Question

A 9-year-old girl is brought to the office due to "ringing in her right ear" over the past week.  She also has noticed a popping sensation in the ear when she swallows and difficulty hearing soft sounds.  The patient has had nasal congestion during this time but is otherwise well.  She and her family flew home from a ski trip in Colorado a few days before her symptoms began.  Vital signs are normal.  Otoscopic examination shows a retracted right tympanic membrane with surrounding dilated blood vessels; the left side is unremarkable.  Pupils are equal, round, and reactive to light and accommodation.  Coordination and balance are normal.  Cranial nerve testing demonstrates a mild reduction in hearing on the right side.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d253_b235_bc81_2f7bdcb34efa_MD0003_00 This patient has tinnitus, hearing loss, and a retracted tympanic membrane (TM), findings consistent with eustachian tube dysfunction. The eustachian tubes connect the middle ear to the nasopharynx. Through physiologic opening and closing, they equalize middle ear pressure, drain middle ear fluid, and prevent reflux of nasopharyngeal secretions into the middle ear. Inflammation caused by infection (eg, rhinosinusitis), allergies, or environmental irritants (eg, cigarette smoke) can obstruct the eustachian tubes, leading to pressure dysregulation and lack of middle ear ventilation. Patients typically have ear discomfort or fullness, tinnitus, and hearing loss (often described as muffled hearing). In addition, eustachian tube dysfunction can cause an intermittent popping sensation, particularly during changes in pressure (eg, yawning, swallowing) as the eustachian tube temporarily opens. Otoscopic examination reveals a retracted TM due to negative pressure within the middle ear. Dilated blood vessels surrounding the TM reflect inflammation. Eustachian tube dysfunction is a predisposing factor for acute otitis media (AOM), particularly in children because they have short, narrow, floppy tubes. Other complications include permanent hearing loss, TM rupture, and cholesteatoma. Diagnosis is clinical, with treatment aimed at relieving the underlying cause (eg, antibiotics for acute bacterial rhinosinusitis, antihistamines for allergic rhinitis). children (Choice A) Symptoms of AOM may include fever, otalgia, and hearing loss. Although recurrent AOM may lead to TM retraction, acute examination findings include TM bulging or the presence of a middle ear effusion with TM erythema, which are not seen here. examination findings (Choice C) Ménière disease causes vertigo, tinnitus, and hearing loss due to inner ear dysfunction. Adults are most commonly affected, and otoscopic examination is normal. (Choice D) Otosclerosis causes conductive hearing loss in older adults due to bony overgrowth in the middle ear. Tinnitus may also be present, but the TM appears normal on examination. (Choice E) TM rupture due to barotrauma (eg, flying) can cause hearing loss and tinnitus. Symptoms develop at the time of inadequate pressure equalization (eg, ascent, descent), not days later, as in this case. In addition, a perforated TM on examination with or without a history of otorrhea would be expected. Educational objective: The eustachian tubes serve to equalize pressure and drain the middle ear through physiologic opening and closing. Inflammation can cause obstruction and symptoms of eustachian tube dysfunction, including ear fullness/discomfort, hearing loss, and tinnitus. Examination reveals tympanic membrane retraction. References: Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/26347263)

A 9-Year-Old Girl Is Brought to the Office Due to "Ringing