The Ear

Nelson Self Assessments website 17th Edition

Question . 1. A 10-day-old infant develops irritability and rectal temperature of 38oC

on the day of planned discharge from the NICU after an uneventful recovery from
mild respiratory distress syndrome. Physical examination is unremarkable except for a
bulging, opaque left eardrum. A lumbar puncture reveals normal cerebrospinal fluid.
Diagnostic tympanocentesis is performed. Which of the following organisms is the
one most likely to be found?

A. Chlamydia trachomatis
B. Group A streptococci
C. Haemophilus influenzae type b
D. Escherichia coli
Explanation: E. coli and group B streptococci are common causative agents in
neonatal otitis media. The earlier in the first month of life plus the more
complicated the neonatal course, the more likely it is that these pathogens will
be found. (See Chapter 630 in Nelson Textbook of Pediatrics, 17th ed.)
E. Cytomegalovirus

Question . 2. A previously healthy 8-mo-old infant develops bronchiolitis. On the

fourth day of illness she is noted to have bulging, opaque, white eardrums bilaterally.
Which of the following treatment regimens is the most appropriate to institute?

A. High-dose oral amoxicillin

Explanation: Although respiratory syncytial virus (RSV) may cause otitis
media, it may be a co-pathogen with the typical bacterial causes of otitis
media; thus, RSV infection should be treated as for a bacterial otitis media. In
some European countries, answer D would be appropriate. (See Chapter 630)
B. Intramuscular ceftriaxone
C. Oral cefixime
D. No initial antibiotic treatment; watchful waiting
E. Oral azithromycin

Question . 3. A 2-yr-old boy presents with an upper respiratory tract infection and
axillary temperature of 38.5oC. He has not complained of ear pain. On pneumatic
otoscopy, his left eardrum is pink, translucent, and retracted, with 3+/4+ mobility; his
right eardrum is reddish, opaque, retracted, and immobile. Which of the following is
the likeliest ear-related diagnosis?

A. Bilateral acute otitis media

B. Normal left ear, right acute otitis media
C. Bilateral otitis media with effusion
D. Normal left ear, right otitis media with effusion
Explanation: The right ear has classic features on physical examination for an
otitis media with effusion. Not all children with otitis media complain of ear
pain, whereas all children who tug at their ears don't have otitis media. (See
Chapter 630 in Nelson Textbook of Pediatrics, 17th ed.)
E. Left otitis media with effusion, right acute otitis media

The Ear - Nelson Self Assessments website 17th Edition 1

Question . 4. All of the following statements regarding otitis media are correct
Except:

A. Otitis media is more prevalent among boys than among girls

B. Otitis media is equally prevalent in poor and in well-to-do children
Explanation: Medically underserved children have a higher risk of otitis media
than that documented for more affluent children. The reason for this is not
well established but could be related to frequent use of day care, the presence
of smoking, and other factors. (See Chapter 630 in Nelson Textbook of
Pediatrics, 17th ed.)
C. The peak prevalence of otitis media is in the first 2 years of life
D. Breast feeding provides protection against otitis media
E. Otitis media tends to run in families

Question . 5. A 12-mo-old infant in day care develops severe bilateral acute otitis
media. Her infection continues despite administration of a succession of antibiotics.
Tympanocentesis reveals the presence of penicillin-resistant Streptococcus
pneumoniae. Which of the following bacterial mechanisms is responsible for the
organism's resistance?

A. Production of -lactamase
B. Production of streptolysin toxin
C. Production of nitric oxide
D. Alteration in penicillin-binding proteins of the cell wall
Explanation: Antimicrobial resistance among pneumococci to penicillin is due
to alterations of penicillin- binding proteins. Treatment with -lactamase
competitors or -lactamase-resistant penicillins is not effective. (See Chapter
630 in Nelson Textbook of Pediatrics, 17th ed.)
E. Alteration of the nucleus

Question . 6. A 2-yr-old boy is seen for his routine check-up, 4 weeks after an
episode of bilateral acute otitis media that resolved uneventfully with antibiotic
treatment. He seems generally well, but his mother reports that he is not hearing as
well as usual. On pneumatic otoscopy, both his eardrums appear amber, opaque, and
retracted, and both are immobile. Otherwise his ENT examination is unremarkable.
Which of the following treatment regimens is the most appropriate to institute at this
time?

A. A 10-day course of amoxicillin

B. A 10-day course of amoxicillin-clavulanate
C. Short-course treatment with azithromycin
D. Observation without treatment for at least 2 more mo
Explanation: The finding of a retracted opaque immobile eardrum after
successful treatment of otitis media is not uncommon and warrants close
observation. In most cases the abnormalities resolve spontaneously. (See
Chapter 630 in Nelson Textbook of Pediatrics, 17th ed.)
E. Referral for consideration of myringotomy and tube insertion

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Question . 7. A 4-yr-old girl has had repeated bouts of acute otitis media since early
infancy. At age 10 mo she underwent bilateral myringotomy with tube insertion. She
remained well for 6 months but then experienced several episodes of tube otorrhea.
The tubes were extruded at age 2 yr, and since then she has averaged 6 episodes of
recurrent acute otitis media each year. At present her eardrums are normal in
appearance except for some atrophic scarring. She breathes easily through her nose
and does not snore. Her internist father is inquiring about the advisability of
adenoidectomy, which was recommended on the golf course by an ENT colleague.
Which of the following statements will best help the parents decide about surgery?

A. Adenoidectomy has shown greater efficacy in preventing recurrent otitis

media in children who have previously received tympanostomy tubes than in
those who have not.
Explanation: Adenoidectomy is one important approach to management of a
child with recurrent otitis media after failure of tympanostomy tubes. This is
true despite the absence of obstruction or significant enlargement of adenoidal
tissue (for age). (See Chapter 630 in Nelson Textbook of Pediatrics, 17th ed.)
B. Adenoidectomy has shown efficacy only during the first 2 yr of life
C. Adenoidectomy has shown efficacy only in children with enlarged adenoids
D. Adenoidectomy has shown greater efficacy in boys than in girls
E. Adenoidectomy has failed to show efficacy in preventing recurrent otitis media

Question . 8. An otherwise healthy 12-mo-old boy develops bilateral otitis media

with effusion in September that persists for 3 mo. An audiogram performed in
December shows a pure-tone average threshold of 30 dB. The parents do not accept a
recommendation for myringotomy and insertion of tympanostomy tubes. The effusion
persists, and a repeat audiogram the following April shows the same results as
previously. The parents again decline surgery. The effusion is still present at a check-
up in July, but in September, 1 yr after onset, the effusion has cleared. Without further
intervention, which of the following outcomes should the parents anticipate as most
likely at the time the child enters school?

A. The child's cognitive development will be unaffected but his speech and
language development will be impaired
B. Both his cognitive and his speech and language development will be impaired
C. Neither his cognitive nor his speech and language development will be
impaired
Explanation: This is an important observation that has been confirmed by
many studies. (See Chapter 630 in Nelson Textbook of Pediatrics, 17th ed.)
D. His cognitive and language development will be unaffected, but his speech
development will be impaired
E. His cognitive and speech development will be unaffected but his language
development will be impaired

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Question . 9. Vertigo in children is:

A. Frequently associated with otitis media

B. Usually related to motion sickness
C. Most likely to be related to Meniere disease
D. An uncommon symptom in children
Explanation: Vertigo, a sense of motion, should not be confused with
dizziness. Vertigo may be associated with nystagmus and may be due to
labyrinthitis, congenital ear defects, trauma, cholesteatoma, neuronitis, benign
paroxysmal vertigo, Mnire disease, or CNS diseases. (See Chapter 626 in
Nelson Textbook of Pediatrics, 17th ed.)
E. Always associated with a hearing loss

Question . 10. Otorrhea (purulent ear drainage) may be associated with all of the
following Except:

A. Presence of a tube in the ear

B. Perforated eardrum
C. Cholesteatoma
D. Lyme disease
Explanation: Lyme disease may cause cranial neuropathies (most often cranial
nerve VII) but should not cause otorrhea. The most common causes of
otorrhea may be otitis externa and perforation of the tympanic membrane in
children with otitis media. (See Chapter 626 in Nelson Textbook of Pediatrics,
17th ed.)
E. Acute otitis media

Question . 11. Conductive hearing loss is:

A. Common in children with chronic ear fluid

Explanation: Otitis media is the most common form of acquired conductive
hearing loss. Any pathologic condition of the pinna, external ear canal,
tympanic membrane, or ossicles can produce congenital or acquired
conductive hearing loss. (See Chapter 627 in Nelson Textbook of Pediatrics,
17th ed.)
B. A permanent condition related to nerve damage
C. Always associated with ossicular abnormalities
D. An uncommon complication of otitis media
E. Unlikely when an intact tympanic membrane is present

Question . 12. Down syndrome (trisomy 21) is commonly associated with:

A. Narrow ear canals

B. Conductive hearing loss
C. Chronic ear fluid
D. Speech delay
E. All of the above
Explanation: Down syndrome may be associated with conductive or sensorineural
hearing loss. (See Chapter 627 in Nelson Textbook of Pediatrics, 17th ed.)

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Question . 13. Pneumatic otoscopy is:

A. Used only to assist in diagnosis of infection

B. Reserved for the operating room to assist in ear tube placement
C. An important office tool for diagnosis of ear fluid and negative middle ear
pressure
Explanation: This is a valuable method that all pediatricians should learn
during residency. It facilitates excellent assessment of the mobility of the
tympanic membrane and any pain associated with the applied pressure. (See
Chapter 630 in Nelson Textbook of Pediatrics, 17th ed.)
D. Performed by an audiologist to assess hearing
E. Not recommended for acute otitis media

Question . 14. Hearing screening in infants is:

A. An elective procedure for diagnosing the presence of middle ear fluid

B. Performed only in healthy infants without risk factors for hearing loss
C. Performed in all hospitals in the first week of life
D. Most commonly performed using otoacoustic emissions (OAE) and/or
auditory brainstem evoked response (ABR)
Explanation: These are the most accurate and reliable tests. Whether all infants
should be screened in the first week of life or before nursery discharge
remains controversial. (See Chapter 627 in Nelson Pediatrics, 17th ed.)
E. Unlikely to detect severe or profound hearing loss

Question . 15. Sensorineural hearing loss in the United States is:

A. Most likely to be inherited in autosomal dominant fashion

B. Most likely to be inherited as an autosomal recessive disorder when
genetically transmitted
Explanation: In about 40% of the cases, sensorineural hearing loss is due to an
autosomal recessive disorder. Mutations of the connexin gene and other
genetic syndromes (long Q-T syndrome), are responsible for many genetic
causes of hearing loss. (See Chapter 627 in Nelson Pediatrics, 17th ed.)
C. Caused by a genetic abnormality in less than 20% of cases
D. Most commonly caused by bacterial meningitis
E. Usually related to chronic ear infections

Question . 16. In moderate to severe SNHL, hearing aids are:

A. Usually placed when the child starts kindergarten

B. Difficult for parents to deal with and require skilled nursing care
C. Not well tolerated and require surgical placement over the mastoid bone
D. Placed as early as age 2-3 mo when the deficit is diagnosed early
Explanation: These are very well tolerated and helpful, especially if started
before age 6 mo. (See Chapter 627 in Nelson Textbook of Pediatrics, 17th ed.)
E. Used only if cochlear implantation cannot be performed

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Question . 17. Otitis externa is:

A. Commonly related to swimming

B. Most commonly caused by Pseudomonas aeruginosa
C. Best treated with topical antibiotic drops
D. Treated with wick placement and drops if severe canal swelling is present
E. All of the above
Explanation: This is the classic swimmer's ear and is due to wetness with
tissue maceration and secondary infection. It can occur without swimming.
(See Chapter 629 in Nelson Textbook of Pediatrics, 17th ed.)

Question . 18. Cochlear implants may be associated with:

A. Pneumococcal meningitis
Explanation: Pneumococcal meningitis may be a complication of cochlear
implants. All patients should be immunized with the currently available
vaccines. (See Chapter 627 in Nelson Textbook of Pediatrics, 17th ed.)
B. Sinusitis
C. Facial cellulitis
D. Septic jugular vein thrombosis
E. Brain abscess

Question . 19. A hearing deficit of moderate loss is associated with an average sound
threshold of 30-50 dB in combination with:

A. Most speech sounds missed at normal conversational levels

B. Language retardation
C. Unvoiced consonant sounds missed
D. Inattention
E. All of the above
Explanation: Unvoiced consonant sounds are missed even with slight hearing
loss. (See Chapter 627 in Nelson Textbook of Pediatrics, 17th ed.)

Question . 20. All of the following indicate the need for referral for audiologic
assessment Except:

A. No differentiated babbling or vocal imitation at age 12 mo

B. No use of single words at age 18 mo
C. Single-word vocabulary of 10 words or fewer at age 24 mo
D. Less than a 100-word vocabulary, or no evidence of two-word combinations,
at age 30 mo
E. All of these indicate the need for referral for audiologic assessment
Explanation: All of these indicate the need for audiologic assessment. (See
Chapter 627 in Nelson Textbook of Pediatrics, 17th ed.)

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Question . 21. A 4-yr-old child who is new to your clinic has a small pitlike
depression anterior to the helix and above the tragus. There are no symptoms. Which
of the following is the recommended initial management?

A. Observation only
Explanation: A pitlike depression just anterior to the helix and above the
tragus may represent a cyst or an epidermis-lined fistulous tract. These are
common, with an incidence of approximately 8 cases in 10,000 children but do
not require surgical removal unless there is recurrent infection. (See Chapter
628 in Nelson Textbook of Pediatrics, 17th ed.)
B. Exploration by probing
C. Computed tomography (CT) or magnetic resonance imaging (MRI) to
evaluate for possible branchial cleft cyst
D. Referral for surgical excision
E. Referral for chromosome analysis

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