Otitis Media

Question 1

Otitis media is an infection of which part of the ear?

1 - outer ear
2 - inner ear
3 - cochlea
4 - middle ear

Answer 1

4 - middle ear

Connects the middle ear with the eustachian tube which allowed air to ventilate middle ear and normalises pressure to atmospheric conditions

Question 2

3 of the following bones are contained within the middle ear. Which one of the following is NOT contained within the middle ear?

1 - malleus
2 - sesamoid
3 - incus
4 - stapes

Answer 2

2 - sesamoid
- helps ligaments move over bones and reduce friction

Stapes is the smallest bone.

Outer to inner order is malleus - incus - stapes (MIS)

Question 3

Which bone does the middle bone lie within?

1 - temporal bone
2 - occipital bone
3 - sphenoid bone
4 - nasal bone

Answer 3

1 - temporal bone

Contains mastoid air cells

Question 4

When looking at the tympanic membrane, the lateral malleolus can be used to identify which ear we are looking at. In the image below, are we looking at a left or right ear?

Answer 4

• right

If it points left then its the left ear

Question 5

What is the incidence of otitis media?

1 - 25 cases per 100,000
2 - 250 cases per 100,000
3 - 2500 cases per 100,000
4 - 25,000 cases per 100,000

Answer 5

2 - 250 cases per 100,000

Affects boy and girls equally

Question 6

Otitis media can affect any age, but which age is this most common in?

1 - <12 months
2 - <4 y/o
3 - <8 y/o
4 - <16 y/o

Answer 6

2 - <4 y/o

Typically aged 6-24 months

Question 7

Is otitis media more likely to cause conductive or sensorineural hearing loss?

Answer 7

• conductive hearing loss

Anything affecting the external ear, ear canal or middle ear can cause conductive hearing loss

Question 8

Which of the following is NOT an intrinsic risk factor for otitis media?

1 - gender
2 - atopic predisposition
3 - immunosuppression
4 - conditions affecting ciliary motility

Answer 8

1 - gender
- affects boys and girls equally

Conditions affecting ciliary motility include:
- Cystic fibrosis
- Primary ciliary dyskinesia
- Kartagener’s syndrome (autosomal recessive genetic ciliary disorder comprising of the triad of situs inversus, chronic sinusitis, and bronchiectasis.

Question 9

Which of the following is NOT an extrinsic risk factor for otitis media?

1 - Passive smoking
2 - No pneumococcal vaccination
3 - Daycare
4 - Breast fed
5 - Use of a dummy (pacifier)
6 - Low socioeconomic status

Answer 9

4 - Breast fed

Typically increased risk with bottle feeding as the strong swallow required to feed from a breast induces a sizeable negative pressure in the infants oral cavity allowing eustachian tube insufflation.

Question 10

Otitis media typically occurs due to which of the following?

1 - wide eustachian tube leading to ascending infection
2 - narrowing of outer ear causing infection of tympanic membrane that spreads to inner ear
3 - oedema and narrowing of eustachian tube, stops ear from draining
4 - all of the above

Answer 10

3 - oedema and narrowing of eustachian tube, stops ear from draining

Lack of drainage predisposes inner ear to colonisation of bacteria.

The earache patients typically have is because the blocked eustachian tube does not allow equalisation of pressure in the ear, which could lead to rupture of the tympanic membrane to try and equalise the pressure

Question 11

Children are more likely to develop otitis media for all of the following reasons, EXCEPT which one?

1 - narrower eustachian tubes
2 - increased fluid in eustachian tubes that can lead to infections
3 - eustachian tubes are more horizontal, inhibiting drainage
4 - more prone to respiratory infections

Answer 11

2 - increased fluid in eustachian tubes that can lead to infections

In ear examinations, the horizontal position of the eustachian tubes in children is why we pull the pinna down for paediatric examination, and up for adults

Question 12

Biofilms can occur in children with otitis media. Are treatments more of less effective in patients with biofilms in otitis media?

Answer 12

• less effective

Antibiotics have poor penetration of the biofilms

Question 13

3 of the following bacteria account for 95% of bacterial cultured from patients with otitis media. Which one is NOT one of these 3?

1 - Streptococcus pneumoniae
2 - Staphylococcus aureus
3 - Moraxella catarrhalis
4 - Haemophilus influenzae

Answer 13

2 - Staphylococcus aureus

Question 14

What is the cut off for acute otitis media?

1 - <72h
2 - <1 week
3 - <3 weeks
4 - <3 months

Answer 14

3 - <3 weeks

> 3 months to be chronic otitis media

Question 15

Chronic suppurative otitis media (CSOM) is defined as chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges (otorrhoea) through a tympanic perforation. How long must this typically last for to reach this diagnosis?

1 - >2 days
2 - >2 weeks
3 - >2 months
4 - >2 years

Answer 15

2 - >2 weeks

Question 16

All of the following are typical signs that can present in patients with variations of otitis media, EXCEPT which one?

1 - otalgia (ear pain)
2 - tugging or rubbing of the ear
3 - fever occurs in all patients
4 - viral URTI symptoms are common (e.g. coryza)
5 - ear discharge may occur if the tympanic membrane perforates
6 - hearing loss

Answer 16

3 - fever occurs in all patients

Fever can occur, but only in around 50% of cases

Question 17

Which of the following may be visible on otoscopy in a patient with otitis media?

1 - bulging tympanic membrane (loss of light reflex)
2 - opacification or erythema of the tympanic membrane
3 - perforation with purulent otorrhoea (discharge, can be red/ywllow)
4 - decreased mobility if using a pneumatic otoscope
5 - all of the above

Answer 17

5 - all of the above

Question 18

Which of the following is the most useful diagnostic tool to diagnose a patient with otitis media?

1 - clinical diagnosis
2 - vital signs
3 - head X-ray
4 - biochemistry and blood cultures

Answer 18

1 - clinical diagnosis

Examination and history taking

Question 19

All of the following can be complications of otitis media, except which one?

1 - Mastoiditis
2 - Papilledema
3 - Meningitis
4 - Intracranial abscesses
5 - tympanic membrane rupture

Answer 19

2 - Papilledema

Question 20

Tympanic Membrane Perforation (Hole)can occur in otitis media. What is important to exclude as a potential cause?

1 - otosclerosis
2 - cholesteatoma
3 - presbyacusis
4 - necrotising otitis externa

Answer 20

2 - cholesteatoma

Keratinising squamous epithelium that be locally aggressive through mass effect and secreting enzymes to resorb surrounding structures.

Question 21

Tympanic Membrane Perforation (Hole)can occur in otitis media. The vast majority heal within what time period?

1 - <2 weeks
2 - <4 weeks
3 - <8 weeks
4 - >12 weeks

Answer 21

3 - <8 weeks

MUST AVOID WATER IN THE EAR

Otherwise try:

• topical antibiotics
• myringoplasty

Question 22

Which of the following should be considered as likely diagnoses in otitis media?

1 - impacted cerumen
2 - Otitis externa
3 - Foreign body
4 - Cholesteatoma
5 - Bullous myringitis
6 - Mastoiditis
7 - Labyrinthitis
8 - all of the above

Answer 22

8 - all of the above

Question 23

Does otitis media always require the use of antibiotics?

Answer 23

• no

The majority of cases will resolve without treatment in <3 days

In first 3 days give analgesia, antipyretics and fluids

Question 24

A mum presents to the GP with her daughter who has had pain in her ear for the last 24h that has kept her awake. Following inspected, you diagnose otitis media, but she is otherwise well. What would the initial management be as the GP?

1 - prescribe amoxicillin for 5-7 days
2 - advise to take analgesia, antipyretics and fluids for the first 3days
3 - refer to ENT on standard pathway and in meantime give oral amoxicillin for 5-7 days
4 - urgent referral to ENT

Answer 24

2 - advise to take analgesia, antipyretics and fluids for the first 3days

Patients typically get better in the first 3 days

Question 25

In otitis media, how long should patients receive conservative management before they are prescribed antibiotics? 1 - 24h 2 - 3 days 3 - 1 week 4 - 2 weeks

Answer 25

2 - 3 days

Question 26

Antibiotics should be considered in otitis media in all of the following circumstances, EXCEPT which one? 1 - systemically unwell 2 - aged >65 3 - high risk of complications 4 - signs of more serious illness

Answer 26

2 - aged >65

Question 27

Antibiotics are not always required in otitis media (OM), except in all of the following groups, EXCEPT which one? 1 - Children <2 y/o with bilateral OM 2 - Children <3 months with a temperature >38ºC 3 - Children <5 y/o with previous OM 4 - OM with ear discharge 5 - Systemically unwell patient with OM that persists with positive ear swab 6 - patients at high risk of complication

Answer 27

3 - Children <5 y/o with previous OM

Question 28

Which of the following is typically the 1st line treatment for otitis media? 1 - Amoxicillin (5-7 day course) 2 - Erythromycin or clarithromycin 3 - Gentamycin 4 - all of the above

Answer 28

1 - Amoxicillin (5-7 day course) Given orally 2 - Erythromycin or clarithromycin

Question 29

1st line treatment for otitis media is oral amoxicillin for 5-7 days. If patients are allergic to penicillin, what should they be given instead? 1 - Co-amoxiclav 2 - Erythromycin or clarithromycin 3 - Gentamycin 4 - all of the above

Answer 29

2 - Erythromycin or clarithromycin

Question 30

Which of the following should be performed if amoxicillin antibiotics do not begin to improve the symptoms of the patient with otitis media? 1 - referral to ENT 2 - consider alternative diagnosis 3 - add co-amoxiclav to current antibiotic 4 - all of the above

Answer 30

3 - add co-amoxiclav to current antibiotic Refer to hospital if severe systemic infection or complications

Question 32

Which of the following is NOT a common complications for otitis media (OM)? 1 - Chronic OM 2 - Hearing loss 3 - Tympanic membrane perforation 4 - Tinnitus 5 - Mastoiditis 6 - Seborrheic dermatitis

Answer 32

6 - Seborrheic dermatitis Associated with otitis externa Image has indications for which patients to admit

Question 33

Which of the following is NOT an uncommon complications for otitis media (OM)? 1 - Mastoiditis 2 - Bacterial meningitis 3 - Tinnitus 4 - Extradural abscess 5 - Subdural abscess 6 - Labyrinthitis 7 - Facial paralysis

Answer 33

3 - Tinnitus This is a common complication of OM

Question 34

All of the following viruses can cause otitis media, but which is the most common? 1 - Respiratory syncytial virus 2 - Coronavirus 3 - Adenovirus 4 - Rhinovirus 5 - Influenza (all types) 6 - Enterovirus 7 - Parainfluenza (all types)

Answer 34

1 - Respiratory syncytial virus Accounts for 41-56% of cases

Question 35

All of the following can occur in otitis media, but which is most common? 1 - viral only cause 2 - bacterial only cause 3 - bacteria + viral cause 4 - fungal and viral

Answer 35

1 - viral only cause All others can also occur