reply to this discussion 20

This 21-year-old patient presenting with right ear pain for 2 days which started shortly after scuba lessons. Pain is described as pressure, crackling, and dizziness. Further questioning should include:

  • What part of the ear hurts?
  • Is it constant or intermittent?
  • What makes it worse?
  • How have you treated it?
  • What makes it better?
  • Any other symptoms, fever, discharge from ear, runny nose?
  • Rate the pain on a scale of 1-10
  • Have you had this before?
  • Have you been sick recently?
  • Do you smoke, use alcohol or rec drugs?
  • What is your medical hx?
  • Do you have “tubes” in your ears?
  • Any pain when you chew?
  • Does the pain prevent you from sleeping?
  • Any difficulty hearing?
  • Have you had recent dental work?
  • Do you have TMJ?

Time Course

In this case, since the patient was just scuba diving and the symptoms occurred “shortly after”, this could be middle ear barotrauma (MEB) since the pain and symptoms start within the first 24 hours after diving. Acute otitis media develops most often in children and the elderly following a cold or respiratory infection. Meniere’s usually occurs in those over age 50. Otitis externa usually develops in people age 30-60 (Dunphy et al., 2015).

Patient age

Children are more likely to develop acute otitis media, swimmers are more likely to develop otitis externa, barotrauma is caused by scuba diving, and temporal arteritis and neoplasms would be more likely for older adults with comorbidities (Earwood, 2018).

Diagnostic tests

For this patient, history and exam with otoscope would be appropriate. If hearing loss is involved, referral to a neurologist for further testing would be warranted.

DDx

Dx testing

Pharm

Rationale

Middle Ear Barotrauma

History/otoscope/neuro

Decongestants

This can be caused by blocked Eustachian tubes due to too rapid descent in diving. Chewing gum or yawning may help (Harvard Health Publishing, 2018).

Otitis Externa (swimmer’s ear)

History/exam/neuro

Topical corticosteroids, antibiotics

This is external ear inflammation, usually fungal (Balch, 2019)

Otitis media

History/otoscope/neuro

Tylenol/ibuprofen/amoxicillin

Management of pain if there is no fever; fever would indicate infection, necessitating the use of antibiotics (Dunphy, 2015).

Meniere’s disease

History/exam/neuro/ abnormal Weber/Rinne

Bedrest, low sodium diet, diuretics

This is caused by allergies/stress, excess sodium imbalance in the ear (Dunphy, 2015)

Balch, Graeme, et al. “Oral Corticosteroids for Painful Acute Otitis Externa (Swimmer’s Ear): A Triple-Blind Randomized Controlled Trial.” Australian Journal of General Practice, vol. 48, no. 8, Jan. 2019, pp. 565–572., doi:10.31128/ajgp-12-18-4795.

Dunphy, L., Winland-Brown, J., Porter, B., Thomas, D. (2015). Primary care: The art and science of advanced practice nursing. F.A. Davis Company.

Earwood, J. S., Rogers, T. S., & Rathjen, N. A. (2018). Ear Pain: Diagnosing Common and Uncommon Causes. American Family Physician, 97(1), 20–27. Retrieved from https://search-ebscohost-com.libauth.purdueglobal….

https://www.health.harvard.edu/a_to_z/barotrauma-a-to-z