What Can You Do About Tinnitus?

Patient Presentation
An 8-year-old male came to clinic approximately 4 weeks after having left otitis media. His mother was concerned because he had said several times over the past week that he had sounds in his ears. He described the sounds as “popping” or sometimes “crunchy” like rice cereal. He said it wasn’t high pitched but was like a voice tone; it wasn’t too loud or soft. The sounds lasted only a few seconds but he wasn’t sure if it was associated with jaw movement or yawning. He denied ear pain, sore throat, or vertigo. He had normal balance and mentation. “It just sounds kind of weird for a few seconds and then goes away,” he described. He was not bothered by the sounds and denied having any similar problems in the past. He denied any trauma but did use headphones when he was playing videogames. The past medical history showed some upper respiratory tract infections including 2 otitis media infections in the past. He had not head trauma in the past. The family history was negative for any ear, nose or throat problems.

The pertinent physical exam showed a healthy boy with normal vital signs and growth parameters in the 75-90%. HEENT showed some clear fluid behind the left tympanic membrane with bubbles within the fluid. The tympanic membrane was in a normal position with normal landmarks. His right ear was normal. He had some very mild clear rhinorrhea. Yawning or other jaw movements did not reproduce the sounds. Neurological examination was normal including tests for balance. The diagnosis of a resolving middle ear effusion was made. The pediatrician counseled that it was most likely that the sounds were caused by the eustachian tube opening and closing causing air to move into the middle ear as the effusion was resolving. He recommended monitoring the problem and keeping a symptom diary with a followup appointment in 4 weeks if the problem was not resolving and sooner if it was becoming more frequent, painful or was affecting his activities including sleep or balance. He did not return for the followup appointment.

Discussion
Tinnitus is derived from the Latin word tinnire which means to ring but in general practice it means any perceived sound that is not generated externally. It is a common problem in adults. In children it is described as being commonly overlooked as children do not spontaneously report it. It is felt that children may consider the sound normal, or are easily distracted and therefore forget about it. Children can accurately describe the sounds they hear and use words such as buzz, ring, hum, swish, whish, blow or beep. Spontaneously reported tinnitus is ~6.5% and increases to 34% when children are specifically questioned in one study. Prevalence has been reported in up to 36% of children with normal hearing and rises to up to 66% in children with hearing loss. Constant tinnitus (43%) is reported more commonly than intermittent tinnitus (31.5%) and bilateral (69%) is more common than unilateral (31%). Tinnitus that affects quality of life is not reported in studies but studies in adults show ~33% will report tinnitus but only 0.4-1% report it affecting their quality of life. Reported problems in children with tinnitus include sensory perception problems, emotional/psychological problems, headache, dizziness and vertigo, fatigue, and sleep problems.

One study found no association between childhood hearing disorders and adult tinnitus after adjusting for adult hearing thresholds. Another study of adolescents found a high prevalence of tinnitus in those who had significant exposures to high sounds volume for long periods of time such as attending nightclubs or parties, headphone use for music or using cellphone headsets in the ear.

Learning Point
The cause of tinnitus is unclear but it has been associated with otitis media, myoclonus of the muscles of the palate or middle ear, acoustic trauma, arteriovenous malformations, and intracranial hypertension. Evaluation by an audiologist and otolaryngologist may uncover ear pathology. Treatment includes amplification if there is a hearing loss, sound generators (e.g. child who has increased problems in a quiet environment could listen to music while studying), and counseling. Counseling can validate the problem, discuss the natural history, identify aggravating and mitigating factors and help develop coping skills to address the tinnitus.

Questions for Further Discussion
1. What are indications for an audiogram?
2. How common is congenital hearing loss?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tinnitus

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Savastano M, Marioni G, de Filippis C. Tinnitus in children without hearing impairment. Int J Pediatr Otorhinolaryngol. 2009 Dec;73 Suppl 1:S13-5.

Shetye A, Kennedy V. Tinnitus in children: an uncommon symptom? Arch Dis Child. 2010 Aug;95(8):645-8.

Sanchez TG, Oliveira JC, Kii MA, Freire K, Cota J, Moraes FV. Tinnitus in adolescents: the start of the vulnerability of the auditory pathways. Codas. 2015 Jan-Feb;27(1):5-12.

Aarhus L, Engdahl B, Tambs K, Kvestad E, Hoffman HJ. Association Between Childhood Hearing Disorders and Tinnitus in Adulthood. JAMA Otolaryngol Head Neck Surg. 2015 Nov;141(11):983-9.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Common is Post Traumatic Stress Disorder in Children?

Patient Presentation
A pediatrician was talking with a colleague who asked, “Maybe you know the answer to this question? I was evaluating a teenager yesterday and the problem list had PTSD also listed as one of his problems. I could see that there were several notes for counseling. I had another patient within the last month who also had PTSD listed as a problem. I know that adults certainly can get PTSD, but how common is it in kids?” The pediatrician said she wasn’t exactly sure but that kids like adults can have many traumatic experiences in their life and that usually, with a supportive environment, the kids work through the problem. “We’re recognizing these problems more and more, even in young children, because of the stressful environments that many kids live in. Even a single event could cause PTSD but most don’t thankfully. Suicide is also an increasing problem in the teen population with stress and trauma certainly playing a part,” he said.

Discussion
Exposure to traumatic stress events including physical abuse, sexual abuse, violence, witnessing violence in the home or community, severe family dysfunction/psychopathology, natural disasters, severe accidents and/or their own or their caregivers’ life-threatening illness are not uncommon in children and adolescents.” It is estimated that up to 60% of teens age 16-18 have experienced at least 1 traumatic event.

Some children, teens and adults may experience transient psychological problems or distress which may cause physical complaints including pain, behavioral changes such as irritation or regression, sleep problems, etc.. Some children, teens and adults go on to experience more difficulties immediately after the event or later on.

Risk factors for having significant problems include multiple traumatic exposures, multiple trauma types (physical, emotional, sexual, etc.), trauma intensity, personal mental health problems, high risk social situations including poverty, isolation, delinquent peer affiliation, multiple out-of-home placements and family members with physical or mental illness including substance abuse. Resiliency helps to moderate the effects including having problem-solving skills, self control, positive interpersonal relationships, safe home and school environments, religious faith, success with school and peers, socioeconomic advantage, and being older when trauma occurred.

To review a case about resiliency to the effects of war click here.

To review a case about the effects of bullying click here.

To review a case about gun violence click here.

Learning Point
Post traumatic stress disorder (PTSD) is a psychological disorder in a group that also includes reactive attachment disorder, adjustment disorder, acute stress reaction and acute stress disorder. The DSM-5® has criteria for children > 7 years, teens and adults. There must be:

  • An exposure to a traumatic event by direct self-exposure, direct witnessing of the exposure, learning of the personal exposure by a close friend or relative, or exposure by repeated discussions of the exposure by others
  • Intrusive experiencing of the traumatic events such as intrusive thoughts or memories, nightmares, flashbacks, intense distress with reminders of the trauma, etc..
  • Avoiding of the stimuli that brings on the intrusive experiences such as avoiding people, places, conversations, etc..
  • Negative cognition and mood associated with the trauma such as believing the world is not safe, distorted blame of the events, detachment from interpersonal relationship, anhedonia or persistent negative emotions including fear, guilt or confusion, etc..
  • Arousal and reactivity alterations such as anger and aggression, self-harm, recklessness, easily startled, hypervigilance, problems falling asleep, etc..
  • Duration of symptoms must be at least 30 days
  • Causes clinical impairment in important areas of functioning or significant distress

There are other criteria for children < 7 years old, but they are similar.

“The reported overall lifetime prevalence of PTSD in the general youth population is 3-9%. Some studies show gender differences with 4% of males having PTSD and 7% of females. A meta-analysis showed a highly significant association between PTSD and suicidality and “…was associated with elevated levels [of] suicidality in adolescents in a wide range of circumstances.” Suicide is the 3rd leading cause of death in the U.S. so recognition of traumatic stress, PTSD and potential suicidality is important.

There are several traumatic screening tools that can be used and PTSD is considered highly treatable. Although treatment plans are individualized “…[c]ommon treatment elements include (1) psychoeducation about PTSD, (2) relaxation and coping skills, (3) affect monitoring and emotion regulation skills, (4) cognitive processing of reactions to trauma, (5) helping the child construct a therapeutic trauma narrative, (6) in vivo exposure to trauma reminders and practicing of coping skills, (7) conjoint parent-child sessions, and (8) monitoring and enhanced individual safety.”

Questions for Further Discussion
1. What mental health services are available in your community for PTSD?
2. What role does the media and social media play in traumatic stress?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Post Traumatic Stress Disorder

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Stoddard FJ Jr. Outcomes of traumatic exposure. Child Adolesc Psychiatr Clin N Am. 2014 Apr;23(2):243-56, viii.

Martinez W, Polo AJ, Zelic KJ. Symptom variation on the trauma symptom checklist for children: a within-scale meta-analytic review. J Trauma Stress. 2014 Dec;27(6):655-63.

Panagioti M, Gooding PA, Triantafyllou K, Tarrier N. Suicidality and posttraumatic stress disorder (PTSD) in adolescents: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2015 Apr;50(4):525-37.

Connor DF, Ford JD, Arnsten AF, Greene CA. An Update on Posttraumatic Stress Disorder in Children and Adolescents. Clin Pediatr (Phila). 2015 Jun;54(6):517-28.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How is Swimmer’s Itch Diagnosed?

Patient Presentation
A 4-year-old male came to clinic with a pruritic rash for 24 hours. He had been swimming in the local freshwater lake over the weekend. His mother had tried calamine lotion and over-the-counter strength hydrocortisone cream but said that “he just can’t stop itching.” The rash started on his legs but soon involved the area where his swimsuit had been. She denied any new soap, lotions, sunscreens, insect repellents or other new products. They were frequent users of this lake which was known to have swimmer’s itch and she said, “he just lives in the lake when we are there.” The mother said that she was also starting to itch around her ankles that morning. The past medical history was non-contributory.

The pertinent physical exam showed a healthy male who was rubbing his legs and groin. His vital signs were normal with growth parameters in the 50-90%. The rash was 2-3 mm macules with most having a papular component but no vesicles. The lesions were grouped especially in flexural areas of the ankles, knees, groin and buttocks. He had some distinct excoriations and some generalized erythema of the groups but it was difficult to tell if there was real erythema or it was secondary to rubbing. The mother’s ankles did not have any distinct lesions but did have general erythema because of her rubbing them.

The diagnosis of swimmer’s itch was made. The pediatrician recommended using an antihistamine and prescription strength topical hydrocortisone to help with the pruritis. “This usually takes a few days to go away but I think the medicines should help him be more comfortable. Swimmer’s itch often gets worse with more exposure so I would try to keep away from the lake if you can and swim elsewhere. If you go there, it helps to wash off right away and change clothes, so the bugs that cause this have less chance to get into his skin,” the pediatrician advised.

Discussion
Cercarial Dermatitis (CD) is known by many names throughout the world, but is commonly known as swimmer’s itch. It is a water-borne, non-communicable infectious disease that is caused by the larval stage (cercariae) of parasitic schistosomatid flukes. The cercariae causes an allergic maculopapular skin rash in humans that is usually self-limited (usually 4-10 days) but can cause problems for up to 20 days.

CD parasites are considered an emerging disease because of the increased distribution of the problem across the globe. Different parasite species cause the problem. In a normal life cycle that occurs mainly in fresh water but also brackish water, schistosome eggs invade various species of aquatic snails that act as an intermediary hosts. Within the snails, the schistosome eggs develop into schistosome cercariae. The schistosome cercariae migrate from the snail back into the water. In the water the schistosome cercariae encounters birds or mammals which are their definitive host. The cercariae penetrate the skin of the bird or mammal and travel within the host to a definitive organ (which depends on the species) where they develop into schistosome flukes. The schistosome flukes produces eggs which leave the definitive host usually through the intestinal tract usually, but occasionally through the bladder and urinary system. The schistosome eggs then start the cycle all over.

The usual intended definitive hosts are avian, especially waterfowl. Many different varieties of aquatic snails act as the intermediary host and of the more than 100 different schistosome species, 70% can cause CD. One of the most common species which causes CD is Trichobilharzia. Humans are incompatible species and are simply affected bystanders.

CD occurs in the warm weather when snails and bathers have their height of activity. Slow moving water, water near the edge of the water body, and being in the exposed water for longer increases the risk of acquiring CD. Children, especially 5-9 year olds, who play near the water’s edge for long periods of time have increased risk. It also appears that the children’s skin is more sensitive. The risk can be decreased by swimming in places where definitive hosts are not present or are present in fewer numbers, swimming farther out from the water’s edge especially in faster moving water, not swimming for long periods of time, and washing off and changing clothes after the potential exposure. Environmental mitigation includes drug treatment of definitive hosts, drug treatment of snails or manual removal of snails from the water. Use of waders, impermeable gloves and other protective clothing is a must for some recreational or professional uses.

Learning Point
The cercariae penetrate into human skin. If it is the initial contact, the cercariae may not cause a rash but can cause allergic sensitization. With subsequent exposure, there can be a prickling feeling with entry of the cercariae and then the rash becomes extremely pruritic. With recontact, a small macular-papular rash (1-2 mm initially) centered around the entry point of the cercariae happens within 12-48 hours. The macules can remit or become larger and vesicles can form on top of the papules. There can be surrounding erythema of the rash area. Pustules can occur if there is bacterial superinfection and pigmented spots can persist after resolution of the papules. The rash usually resolves within 4-10 days but can last for up to 20 days. Acute systemic reactions such as generalized limb swelling, nausea, diarrhea and fever can occur with subsequent exposure. The diagnosis is usually clinical-based but if needed, the organism can be identified on skin biopsy. Criteria include contact with water, rash appearance within 12-48 hours of exposure, and lesions on the body only where the water was in contact. Treatment of the rash is usually with antihistamines and/or topical steroids. The differential diagnosis includes insect bites, contact dermatitis, bacterial dermatitis, and skin reactions to larval cnidarians such as sea anemones or thimble jellyfish (if in appropriate location).

Questions for Further Discussion
1. What other parasites affecting humans are water-bourne?
2. What do you recommend for summer safety?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Parasitic Diseases and Water Safety (Recreational).

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Cercarial Dermatitis or Cercariosis: What’s in a Name?
Morley NJ. Trends Parasitol. 2016 Feb;32(2):92-3.

Pinto HA. Cercarial Dermatitis’ and ‘Cercariosis’: Very Broad Terms.
Trends Parasitol. 2016 May;32(5):351-2.

Horak P, Mikes L, Lichtenbergova L, Skala V, Soldanova M, Brant SV. Avian schistosomes and outbreaks of cercarial dermatitis.
Clin Microbiol Rev. 2015 Jan;28(1):165-90.

Kolarova L, Horak P, Skírnisson K, Mareckova H, Doenhoff M.
Cercarial dermatitis, a neglected allergic disease.
Clin Rev Allergy Immunol. 2013 Aug;45(1):63-74.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Long Do Concussive Symptoms Last?

Patient Presentation
An 11-year-old male came to clinic approximately 20 hours after falling off some school playground equipment. The fall was witnessed by adults but not the parent. The parent was told the child fell approximately 4 feet onto a wood-chip covered surface but hit his head more than once. The adults got to him quickly and did not report loss of consciousness. He says he remembers playing and being picked up by the adults, but not actually hitting his head. His mother took him home and said that during the evening he seemed quieter, tired and ate less. He complained of a headache and she gave him some acetaminophen. In the morning, his mother had to awaken him but he woke up easily. He complained of continued top of his head and frontal headache without radiation. He held his left eye closed because “otherwise I see 2 of things and I don’t like it.” He also complained of light and noise sensitivity. He also had some problems walking but his mother wasn’t sure if it was his balance or because of his eyes. She reported that he seemed to have his normal personality but was tired and wanted to rest throughout the day. The review of systems was negative for any memory loss, or emesis/nausea.

The pertinent physical exam showed a healthy appearing male who answered questions easily and without delay. His vital signs were normal including a blood pressure of 98/56. Visual acuity was 20/30 with each eye and was 20/20 with both eyes. He had a small contusion along his forehead hairline and he reported that his headache was centered around this spot without much radiation. He consistently would close his left eye throughout the examination. His pupils were 3 mm, symmetric and responded appropriately to light and accommodation. He complained of light sensitivity but when visual fields were checked with decreased ambient lighting they were normal for individual eyes and when tested together. He complained of seeing 2 of everything. His retina exam was brief, but discs appeared sharp on partial exam. Neurologically his cranial nerves were intact with normal DTRs bilaterally. He was slower with rapid alternative movements of his hands, and had some past pointing with finger to nose test. Romberg was positive when he closed his eyes and he was not able to do a tandem gait. His gait was normal but slower with his eyes open. He had no balance issues when sitting.

The diagnosis of a concussion was made, but because of the onset after the event of the visual symptoms and the consistent closing of one eye, the pediatrician contacted the neurologist. The neurologist felt that this was consistent with concussion symptoms but felt that he should be seen by ophthalmology and themselves the following day. He was sent home with head injury and strict brain rest instructions.

The patient’s clinical course showed that he still had some double vision and light sensitivity the next day but it was improving and ophthalmology did not see any structural problems. The family reported to neurology that his headache was improving and he was less fatigued but still was sleeping more. On examination they found similar balance problems but his mother said they were improved from the previous day.

After one week of brain rest, followup with the pediatrician showed resolution of all symptoms but he still was fatigued and sleeping more. His mother said that he seemed to take longer to do some activities. The pediatrician recommended slow reintroduction to activities and school and followup in another week which he did not come for. At his well child appointment 3 months later, his mother said that he got better so she didn’t bring him to that appointment.

Discussion
Concussion as defined by the International Conference on Concussion in Sport in 2012 is “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.” It results in quick onset of signs and symptoms of physical and cognitive impairment. Concussion is sometimes referred to as mild traumatic brain injury (TBI) as mild TBI refers to “…concussions that are generally not life threatening despite the potential for short-term disability and serious ongoing sequelae.” Concussion symptoms are usually categorized as:

  • Cognitive – confusion, difficulty remembering, difficulty thinking or concentrating, mentally foggy, delayed motor or verbal responses or “feeling slow”
  • Emotional – irritability, volatility, nervous, depression or sadness
  • Physical/somatic – headache, dizziness, balance problems, nausea/emesis, blurry vision, light sensitivity, sound sensitivity
  • Sleep disturbance – increased sleep duration, prolonged sleep latency, drowsiness

Headache is the most commonly reported initial symptom (93%) followed by dizziness and confusion.

Concussion is a clinical diagnosis based on reported symptoms, mental status examination and physical examination.

Learning Point
The duration of concussive symptoms are very individual. A 2015 systemic review and meta-analysis of high school and collegiate athletes found that in general high school athletes report more physical symptoms and cognitive problems than collegiate athletes. High school athletes compared to college athletes report slower recovery for physical symptoms (15 days vs 6 days) and for cognitive recovery (7 days vs 5 days). Especially as the cognitive recovery seems to be about the same for both groups, collegiate athletes may be underreporting their physical symptoms deliberately (because wanting to return to play or pressure to return to play) or are not attributing the symptoms to the concussion.

A 2014 study of the post-concussion symptom duration of 280 teenagers and young adults ages 11-22 years (median 14 years), who came to the emergency room within 72 hours of the concussion, found that initially patients presented with headache, dizziness, fatigue and taking longer to think, but in the followup period new symptoms developed especially cognitive and emotional symptoms including sleep problems, fatigue, forgetfulness and frustration. Visual symptoms were initially reported and occurred after initial assessment included blurry vision (32% and 5.4%), double vision (13.2% and 2.1%) and light sensitivity (42.5% and 10.7%). For all symptoms, 77% had some symptoms on day 7, 32% on day 28 and 15% on day 90. The median days for all symptom duration was 13 days. For all symptoms evaluated the median days of symptoms duration was 14 or less with the exception of sleep disturbance and irritability which was 16 days.

So, many patients have resolution of all symptoms by 2 weeks, but there will be some patients who continue to have some symptoms even several weeks later. Cognitive symptoms were often present initially, developed later in other patients and were more likely to last longer.

Some risk factors for prolonged concussion recovery time include age < 18 years, prior history of concussions, duration of symptoms with those concussions, timing of the concussions relative to each other and the current incident, having migraine headache, depression, attention deficit disorder, learning disabilities and sleep disorders.

Questions for Further Discussion
1. How is acute concussion managed? When can an athlete return to play? When can a child return to learning? For a review click here.
3. How are prolonged concussive symptoms managed?
4. What screening tools can be used to help screen for concussion?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Concussion

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Consensus statement, SCAT3. Br J Sports Med 2013;47:5 259.

Consensus statement, Child SCAT3, Br J Sports Med 2013;47:5 263.

Eisenberg MA, Meehan WP 3rd, Mannix R. Duration and course of post-concussive symptoms. Pediatrics. 2014 Jun;133(6):999-1006.

Williams RM, Puetz TW, Giza CC, Broglio SP. Concussion recovery time among high school and collegiate athletes: a systematic review and meta-analysis. Sports Med. 2015 Jun;45(6):893-903.

McGinley AD, Master CL, Zonfrillo MR. Sports-Related Head Injuries in Adolescents: A Comprehensive Update. Adolesc Med State Art Rev. 2015 Dec;26(3):491-506.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital