CMN 568 COMPREHENSIVE EXAM UPDATED QUESTIONS
AND ANSWERS RATED A+
✔✔Otitis External: signs and symptoms - ✔✔Edema and erythema of the external
canal, may be swollen shut.
Sever ear pain, made worse by movement of the pinna or tragus
Purulent discharge from the external canal, canal may be filled wih debris, making
visualization of the TM difficult or impossible
May have periauricular or cervical lymphadenopathy
✔✔Otitis externa: differential diagnosis - ✔✔AOM with TM rupture or patent PE tubes
Furunculosis(pimple/boil) of the ear canal, mastoidisis
✔✔Otitis Externa: Treatment - ✔✔Careful exam to see if the TM is intact, if you cannot
see TM you MUST assume perforation and manage accordingly.
Gentle removal of debris from canal if possible. If TM is intact, gently irrigate with NS
and bulb syringe. DO NOT irrigate if TM not visualized. Use warm water, not cold (will
cause vestibular response). Do not use "water pik"
Pain control: Tylenol or ibuprofen for mild pain, ma need narcotic analgesic for severe
pain.
✔✔Otitis externa: Antibiotics - ✔✔Topical eardrops are recommended unless there are
signs of systemic symptoms
Fluoroquinolone drops are first line- 4gtt BID x7d
Neomycin/Polymyxin B/Hydrocortisone - 3-4gtt QID for 7-10d (Do not use if TM is
perforated or PE tubes in place!)
✔✔Ear Wick use - ✔✔If canal is swolled, insert a pope ear wick to allow antibiotic drops
to get deep into the caancal
Insert dry wick, then moisten with ear drops to expand
Wick will fall out when swelling decreases
✔✔Otitis Externa - Prevention - ✔✔avoid vigorous ear cleaning
Avoid using q-Tips
Use drying agents after swimming - 2-3 gtt of 1:1 vinegar:alcohol or commercial ear
drops
✔✔Acute Otitis Media (AOM) - ✔✔Acute infection of the middle ear space with
inflammation and effusion
✔✔AOM Diagnosis - ✔✔2 things MUST be present: A bulging TM and Middle ear
effusion as demonstrated by pneumatic otoscopy or tympanometry
✔✔AOM Pathogens - ✔✔Streptococcus pneumoniae
Haemophilus influenzae
,Moraxella catarrhalis
Streptococcus pyogenes
✔✔AOM Risk factors #1 - ✔✔Eustachian tube dysfunction: meant to equalize pressure
and allow drainage from middle ear. Tubes in infants are shorter, wider, floppier and
horizontal than in adults making them more prone to dysfunction.
Bacterial colonization of the nasopharynx with AOM pathogens
Viral URI: inflammation of Eustachian tubes impairs function leading to middle ear
effusion
Smoke exposure: inflames Eustachian tubes, impedes drainage, and increases
pathogen colonization.
✔✔AOM Risk factors #2 - ✔✔Impaired immune defense: children with disorders that
cause immunocompromise are at increased risk.
Bottle feeding: Breastfeeding shown to reduce risk
Craniofacial disorders: T21 and cleft palate
Daycare attendance
Time of year: more prevalent in winter months along with viral URI
✔✔AOM: Clinical manifestations - ✔✔Symptoms: ear pain (tugging in young infant),
Fever
Signs: Bulging TM, red TM; Effusion (decreased mobility of TM), loss of bony landmarks
and light reflex, yellow or white effusion behind TM, Purulent otorrhea
✔✔AOM: Treatment - ✔✔Pain management
Observation option: 6Mo-2yr Unilateral w/o otorrhea or >2yr unilateral or bilateral w/o
otorrhea. (Must be able to be closely followed and antibiotics provided if worsens or no
improvement in 48-72 hours)
✔✔AOM: Treatment Antibiotics - ✔✔First line - Amoxicillin 80-90mg/gk/d divided BID
(Max 1000mg/dose, 2000mg/day) If child weighs >40kg 500-875mg PO Q12H which is
adult dose.
Duration:
<2yrs or any age with severe symptoms =10d
2-6yrs mild-mod symptoms = 7d
>6yrs mild-mod symptoms = 5d
Alternative (if PCN causes papular rash): Cephlosporin-cefdnir, cefuroxime,
cefpodoxime, or ceftriaxone 50mg/kg IM 1-3d if unable to take PO meds
Severe PCN allergy: Trimethoprim-sulfamethoxozole, Macrolides (azithromycin,
Erythromycin), clindamycin.
SNAP-safety net antibiotic prescription
✔✔AOM: First line treatment failure - ✔✔If patient has taken amoxicillin in the past 30
days or who fail to improve in 48-72hrs on amoxicillin or have otitis-conjunctivitis
syndrome:
,Amoxicllin-clavulanate, use formulation with 90mg/kg/day divided BID or Ceftriazone
50mg/kg/day x3d
Alternatives: Clindamycin w or w/o 3rd generation cephalosprin, tympanocentisis by
ENT, Refer
✔✔AOM: Treatment in presence of PE tubes - ✔✔Treatment of child with PE tubes and
otorrhea but no systemic syptoms such as pain or fever: flouroquinolone drops.
✔✔AOM: recurrence >4 weeks - ✔✔Likely a new pathogen, start over with amoxicillin
or other first line treatment.
✔✔AOM: Reasons for antibiotic failure - ✔✔Do not use macrolides such as
azithromycin or clarithromycin after failure of amoxicillin due to high resistance of H flu
and S. pneumoniae
Non-compliance, may need IM ceftriaxone
Vomiting of medication/medication refusal
✔✔AOM: Prevention - ✔✔Avoid second hand smoke
Encourage breastfeeding
Discourage bottle propping
Discourage pacifier use after 6Mo
Find child care with fewer children
Antibiotic prophalxysis is NOT recommended
Vaccines!
✔✔Otitis Media with effusion - ✔✔Presence of middle ear effusion without signs of
acute inflammation
Usually painless
May precede or follow episode of AOM
✔✔Otitis Media with effusion: Clinical manifestations - ✔✔Symptoms: usually painless
but patients will report fullness or pressure, decreased hearing
Signs: TM is either neutral or retracted, decreased motion of TM, TM whitish or amber
color, hearing impairment on audiometry
✔✔Otitis Media with effusion: risk factors - ✔✔After AOM, fluid remains in middle ear for
several weeks - up to three months
✔✔Otitis Media with effusion: Treatment - ✔✔Antibiotics not recommended
Have child return at 4 week intervals to check progress
Refer for audiology evalutaiton after 3 months of continuous effusion in children < 3yrs
or at risk of language delay
Children with hearing loss or speech delay should be referred to ENT for PE tubes
, ✔✔Tympanostomy tubes (PE tubes) - ✔✔Fall out on their own, document if the tubes
are still three.
✔✔AOM: complications - ✔✔Tympanoslerosis: scarring of the TM and middle ear
structures resulting in conductive hearing loss
Tympanic membrane rutpure
Cholesteatoma - granulation tissue develops causing a greasy looking mass near a
retraction pocket or perforation. Refer to ENT.
✔✔Acute Viral rhinitis - ✔✔Most common pediatric infectious disease.
Known as the common cold.
Sudden onset of clear or mucoid rhinorrhea, nasal congestion, and fever. May also
have sore throat and cough with erythematous nose, throat, and TM.
✔✔Name the four sinuses - ✔✔frontal, ethmoid, sphenoid, maxillary
✔✔Acute Bacterial Rhinosinusistis: Common pathogens - ✔✔Strep pneumoniae
H influenzae
M Catarrhalis
B hemolytic strep
✔✔Acute Bacterial Rhinosinusistis: symptoms - ✔✔nasal congestion, purulent nasal
discharge, facial pain/pressure, cough, headache, fever
✔✔Acute Bacterial Rhinosinusistis: Course - ✔✔Onset may be gradual or sudden.
Lasts <30 days and symptoms resolve completely
✔✔Acute Bacterial Rhinosinusistis: diagnosis - ✔✔Should not be made until symptoms
last longer than 10 days without improvement or worsening of symptoms within 10 days
after initial improvement.
If patient presents with focal signs such as periorbital edema, severe sinus tenderness,
or severe headache - DO NOT wait 10 days to treat with antibioitics.
Routine sinus xrays are not recommended.
✔✔Acute Bacterial Rhinosinusistis: Treatment - ✔✔Pediatrics: Mild symptoms first line
Amoxicillin or Augmentin. Non type 1 PCN allergy = cephalosporin. Poor response after
3 or more days second line ABX. Severe symptoms = Beta lactamase stable abx.
Adults: Younger than 65, first line augmentin 500/125 or 800/125 x5-7d. (5-10). With
severe symptoms high dose augmentin 200/125 BID 7-10d.
Type I PCN allergy or hepatic imparment = doxycycline or clindamycin
✔✔Recurrent sinusitis - ✔✔defines as successive episodes of bacterial sinusitis
infection of the sinuses each lasting less than 30 days and separated by intervals of at
lease 10 days
AND ANSWERS RATED A+
✔✔Otitis External: signs and symptoms - ✔✔Edema and erythema of the external
canal, may be swollen shut.
Sever ear pain, made worse by movement of the pinna or tragus
Purulent discharge from the external canal, canal may be filled wih debris, making
visualization of the TM difficult or impossible
May have periauricular or cervical lymphadenopathy
✔✔Otitis externa: differential diagnosis - ✔✔AOM with TM rupture or patent PE tubes
Furunculosis(pimple/boil) of the ear canal, mastoidisis
✔✔Otitis Externa: Treatment - ✔✔Careful exam to see if the TM is intact, if you cannot
see TM you MUST assume perforation and manage accordingly.
Gentle removal of debris from canal if possible. If TM is intact, gently irrigate with NS
and bulb syringe. DO NOT irrigate if TM not visualized. Use warm water, not cold (will
cause vestibular response). Do not use "water pik"
Pain control: Tylenol or ibuprofen for mild pain, ma need narcotic analgesic for severe
pain.
✔✔Otitis externa: Antibiotics - ✔✔Topical eardrops are recommended unless there are
signs of systemic symptoms
Fluoroquinolone drops are first line- 4gtt BID x7d
Neomycin/Polymyxin B/Hydrocortisone - 3-4gtt QID for 7-10d (Do not use if TM is
perforated or PE tubes in place!)
✔✔Ear Wick use - ✔✔If canal is swolled, insert a pope ear wick to allow antibiotic drops
to get deep into the caancal
Insert dry wick, then moisten with ear drops to expand
Wick will fall out when swelling decreases
✔✔Otitis Externa - Prevention - ✔✔avoid vigorous ear cleaning
Avoid using q-Tips
Use drying agents after swimming - 2-3 gtt of 1:1 vinegar:alcohol or commercial ear
drops
✔✔Acute Otitis Media (AOM) - ✔✔Acute infection of the middle ear space with
inflammation and effusion
✔✔AOM Diagnosis - ✔✔2 things MUST be present: A bulging TM and Middle ear
effusion as demonstrated by pneumatic otoscopy or tympanometry
✔✔AOM Pathogens - ✔✔Streptococcus pneumoniae
Haemophilus influenzae
,Moraxella catarrhalis
Streptococcus pyogenes
✔✔AOM Risk factors #1 - ✔✔Eustachian tube dysfunction: meant to equalize pressure
and allow drainage from middle ear. Tubes in infants are shorter, wider, floppier and
horizontal than in adults making them more prone to dysfunction.
Bacterial colonization of the nasopharynx with AOM pathogens
Viral URI: inflammation of Eustachian tubes impairs function leading to middle ear
effusion
Smoke exposure: inflames Eustachian tubes, impedes drainage, and increases
pathogen colonization.
✔✔AOM Risk factors #2 - ✔✔Impaired immune defense: children with disorders that
cause immunocompromise are at increased risk.
Bottle feeding: Breastfeeding shown to reduce risk
Craniofacial disorders: T21 and cleft palate
Daycare attendance
Time of year: more prevalent in winter months along with viral URI
✔✔AOM: Clinical manifestations - ✔✔Symptoms: ear pain (tugging in young infant),
Fever
Signs: Bulging TM, red TM; Effusion (decreased mobility of TM), loss of bony landmarks
and light reflex, yellow or white effusion behind TM, Purulent otorrhea
✔✔AOM: Treatment - ✔✔Pain management
Observation option: 6Mo-2yr Unilateral w/o otorrhea or >2yr unilateral or bilateral w/o
otorrhea. (Must be able to be closely followed and antibiotics provided if worsens or no
improvement in 48-72 hours)
✔✔AOM: Treatment Antibiotics - ✔✔First line - Amoxicillin 80-90mg/gk/d divided BID
(Max 1000mg/dose, 2000mg/day) If child weighs >40kg 500-875mg PO Q12H which is
adult dose.
Duration:
<2yrs or any age with severe symptoms =10d
2-6yrs mild-mod symptoms = 7d
>6yrs mild-mod symptoms = 5d
Alternative (if PCN causes papular rash): Cephlosporin-cefdnir, cefuroxime,
cefpodoxime, or ceftriaxone 50mg/kg IM 1-3d if unable to take PO meds
Severe PCN allergy: Trimethoprim-sulfamethoxozole, Macrolides (azithromycin,
Erythromycin), clindamycin.
SNAP-safety net antibiotic prescription
✔✔AOM: First line treatment failure - ✔✔If patient has taken amoxicillin in the past 30
days or who fail to improve in 48-72hrs on amoxicillin or have otitis-conjunctivitis
syndrome:
,Amoxicllin-clavulanate, use formulation with 90mg/kg/day divided BID or Ceftriazone
50mg/kg/day x3d
Alternatives: Clindamycin w or w/o 3rd generation cephalosprin, tympanocentisis by
ENT, Refer
✔✔AOM: Treatment in presence of PE tubes - ✔✔Treatment of child with PE tubes and
otorrhea but no systemic syptoms such as pain or fever: flouroquinolone drops.
✔✔AOM: recurrence >4 weeks - ✔✔Likely a new pathogen, start over with amoxicillin
or other first line treatment.
✔✔AOM: Reasons for antibiotic failure - ✔✔Do not use macrolides such as
azithromycin or clarithromycin after failure of amoxicillin due to high resistance of H flu
and S. pneumoniae
Non-compliance, may need IM ceftriaxone
Vomiting of medication/medication refusal
✔✔AOM: Prevention - ✔✔Avoid second hand smoke
Encourage breastfeeding
Discourage bottle propping
Discourage pacifier use after 6Mo
Find child care with fewer children
Antibiotic prophalxysis is NOT recommended
Vaccines!
✔✔Otitis Media with effusion - ✔✔Presence of middle ear effusion without signs of
acute inflammation
Usually painless
May precede or follow episode of AOM
✔✔Otitis Media with effusion: Clinical manifestations - ✔✔Symptoms: usually painless
but patients will report fullness or pressure, decreased hearing
Signs: TM is either neutral or retracted, decreased motion of TM, TM whitish or amber
color, hearing impairment on audiometry
✔✔Otitis Media with effusion: risk factors - ✔✔After AOM, fluid remains in middle ear for
several weeks - up to three months
✔✔Otitis Media with effusion: Treatment - ✔✔Antibiotics not recommended
Have child return at 4 week intervals to check progress
Refer for audiology evalutaiton after 3 months of continuous effusion in children < 3yrs
or at risk of language delay
Children with hearing loss or speech delay should be referred to ENT for PE tubes
, ✔✔Tympanostomy tubes (PE tubes) - ✔✔Fall out on their own, document if the tubes
are still three.
✔✔AOM: complications - ✔✔Tympanoslerosis: scarring of the TM and middle ear
structures resulting in conductive hearing loss
Tympanic membrane rutpure
Cholesteatoma - granulation tissue develops causing a greasy looking mass near a
retraction pocket or perforation. Refer to ENT.
✔✔Acute Viral rhinitis - ✔✔Most common pediatric infectious disease.
Known as the common cold.
Sudden onset of clear or mucoid rhinorrhea, nasal congestion, and fever. May also
have sore throat and cough with erythematous nose, throat, and TM.
✔✔Name the four sinuses - ✔✔frontal, ethmoid, sphenoid, maxillary
✔✔Acute Bacterial Rhinosinusistis: Common pathogens - ✔✔Strep pneumoniae
H influenzae
M Catarrhalis
B hemolytic strep
✔✔Acute Bacterial Rhinosinusistis: symptoms - ✔✔nasal congestion, purulent nasal
discharge, facial pain/pressure, cough, headache, fever
✔✔Acute Bacterial Rhinosinusistis: Course - ✔✔Onset may be gradual or sudden.
Lasts <30 days and symptoms resolve completely
✔✔Acute Bacterial Rhinosinusistis: diagnosis - ✔✔Should not be made until symptoms
last longer than 10 days without improvement or worsening of symptoms within 10 days
after initial improvement.
If patient presents with focal signs such as periorbital edema, severe sinus tenderness,
or severe headache - DO NOT wait 10 days to treat with antibioitics.
Routine sinus xrays are not recommended.
✔✔Acute Bacterial Rhinosinusistis: Treatment - ✔✔Pediatrics: Mild symptoms first line
Amoxicillin or Augmentin. Non type 1 PCN allergy = cephalosporin. Poor response after
3 or more days second line ABX. Severe symptoms = Beta lactamase stable abx.
Adults: Younger than 65, first line augmentin 500/125 or 800/125 x5-7d. (5-10). With
severe symptoms high dose augmentin 200/125 BID 7-10d.
Type I PCN allergy or hepatic imparment = doxycycline or clindamycin
✔✔Recurrent sinusitis - ✔✔defines as successive episodes of bacterial sinusitis
infection of the sinuses each lasting less than 30 days and separated by intervals of at
lease 10 days
