I.

Introduction
Overview Otitis media (OM) is the second most common disease of childhood, after upper respiratory infection (URI). Inflammation of the middle ear characterized by the accumulation of fluid in the middle ear, bulging of the eardrum, pain in the ear and, if eardrum is perforated, drainage of purulent material (pus) into the ear canal. It is a fairly common result of sore throat, whose pharyngotympanic tube run more horizontally. In O.M, the eardrum bulges and often becomes inflamed. Statistical Data About 50 percent of infants have at least one ear infection by their first birthday. Peak incidence of otitis media occurs in the first 3 years of life, especially between 6 and 24 months of age. http://www.uptodate.com/contents/patient-information-ear-infections-otitis-media-inchildren Anatomy and Physiology

y y y y y y y

Pinna: the cartilage and skin of the external ear Ear canal: passageway that leads to the eardrum Tympanic membrane: the eardrum Ossicles: three tiny bones that vibrate when sound waves strike the eardrum Inner ear, or labyrinth: includes the cochlea and semi-circular canals Cochlea: contains fluid and hair cells Semi-circular canals: contains fluid and hair cells

Pathophysiology
Cause: Bacteria Virus

Acute Inflammation of the middle ear

Eustachian tube obstruction

Middle ear air absorption

Engorgement of the middle ear cleft lining.

Hyperemia of tympanic membrane

Serous oxidation

Bulging tympanic membrane

Exudation become purulent

Further congestion and bulging of tympanic

Tympanic membrane may be rupture

Discharge of pus

III. History
Age. Infants and young children are more prone as discussed earlier. Also, the younger a child is at the time of the first ear infection, the greater the chance he or she will have repeated infections http://www.pediatriconcall.com/fordoctor/diseasesandcondition/infectious_diseases/otitis _mediadoc.asp Allergy. Studies have shown that food and airborne allergies can cause otitis media. The most common offending foods are milk products (from cows), wheat, egg white, peanut products, soy, corn, oranges, tomatoes and chicken. The most common airborne allergens are cigarette smoke, pollen, animal dander, house dust, mold, fungi, sulfur dioxide, bacteria and volatile organic compounds such as formaldehyde, pesticides and herbicides. Nutritional deficiency. Researchers have found that children with vitamin A, zinc and iron deficiencies are more susceptible to upper respiratory and ear infections. Additionally, large amounts of prostaglandins (fatty acids found naturally in all people) and leukotrienes may also play a part. Infection. Otitis media infections are caused by viruses or bacteria that infect the cells lining the eustachian tube, throat and middle ear. When infected, these cells become swollen and secrete a thick mucus that may clog the eustachian tube and cause fluid and pressure to build behind the eardrum. Some of the most common bacteria to cause this infection are Streptococcus pneumoniae, Haemophilus influenzae and moraxella catarrhalis. http://www.healthscout.com/ency/68/611/main.html

Obesity. One 2001 study found a link between ear infections and childhood obesity. Eardrum abnormalities increased the more the child weighed, which might explain the association. Parental Behavior. Pregnant women who drink alcohol put their babies at risk for birth defects that can cause a number of problems, among them hearing loss and OME.
y

Babies who are bottle-fed may have a higher risk for otitis media than do breastfed babies. The American Academy of Pediatrics recommends breastfeeding for at least six months. Several studies have found that the use of pacifiers place children at even higher risk for ear infections. Sucking increases production of saliva, which is a vehicle for bacteria that can travel up the Eustachian tubes to the middle ear.

http://adam.about.com/reports/000078_5.html .

IV. Assessment
y y y y y y y pulling or scratching at the ear drainage from the ear irritability, vomiting fullness or pressure in the ear dizziness loss of balance

V. Diagnostic Test
Test Significance

Pneumatic otoscopy, Normal in patients with AOE, but abnormal in patients with otitis media alone or in combination with AOE.

Examination that allows determination of the mobility of a patients tympanic membrane (TM) in response to pressure changes.

Tympanometry, Normal in patients with Tympanometry is a test used to detect AOE, but abnormal in patients with otitis disorders of the middle ear, This test media alone or in combination with AOE. measures your ear's responses to the sound and different pressures.

Ear culture, Ear cultures are recommended in patients who fail to respond to conventional therapy, and results will direct the choice of systemic antibiotics

An ear drainage culture is a laboratory test to check for infection-causing substances in a sample of fluid, pus, wax, or blood from the ear.

Microscopy of exudate/debris from ear White filamentous hyphae are seen on canal, microscopic exam of exudate/debris from the ear canal in cases of fungal otitis externa (otomycosis).The presence of black spores indicates Aspergillus niger as the causative organism in fungal otitis externa (otomycosis).

VI. Medical and surgical management

Medication Mechanism of action

Antibiotic (amoxicillin) This is usually prescribed for 10 days. About 10% of children do not respond within the first 4872 hours of treatment, and antibiotic therapy may have to be changed. Even after antibiotic treatment, 40% of children are left with some fluid in the middle ear which can cause temporary hearing loss lasting for up to 3 to 6 weeks. In most children, this fluid eventually disappears spontaneously (on its own).

They do not kill bacteria, but they stop bacteria from multiplying by preventing bacteria from forming the walls that surround them. The walls are necessary to protect bacteria from their environment and to keep the contents of the bacterial cell together. Bacteria cannot survive without a cell wall

Treatment Guidelines for Acute Otitis Media (AOM)

y y y y

Accurate diagnosis of AOM including differentiation from OME. Children less than 6 months of age should receive immediate antibiotic treatment. Children 6 months or older should be treated for pain within the first 24 hours with either acetaminophen or ibuprofen. An initial observation period of 48 to 72 hours is recommended for select children to determine if the infection will resolve on its own without antibiotic treatment. (Most children do improve within 72 hours.) For children aged 6 months to 2 years, criteria for recommending an observation period are an uncertain diagnosis of AOM and a determination that the AOM is not severe. For children older than 2 years, the observation period criteria are nonsevere symptoms or uncertain diagnosis. Severe AOM symptoms include moderate to severe pain and a fever of at least 102.2 degrees (39 degrees Celsius). If antibiotics are needed, amoxicillin is recommended as first-line treatment (except in children who are allergic to penicillins).

Treatment Guidelines for Otitis Media with Effusion (OME) Watchful Waiting. The child is typically monitored for the first three months. Antibiotics are not helpful for most patients with OME. For one, the condition resolves without treatment in nearly all children, especially those whose OME followed an acute ear infection. Approximately 75 to 90 percent of OME cases that result from AOM resolve within three months. If OME last longer than 3 months, a hearing test should be conducted. Even if OME lasts for longer than 3 months, the condition may resolve on its own and intervention may not be necessary. The physician will re-evaluate the child at periodic intervals to determine if there is risk for hearing loss. Drug Treatment. Antibiotics and corticosteroids have not proven to be of long-term benefit and are not recommended for routine management of OME. Antihistamines and decongestants are not effective for OME, either used alone or in combination. At present, there is no compelling evidence to indicate that allergy treatment can not assist with OME management nor has a causal relationship between allergies and OME been established.

Surgery Myringotomy

Significance This kind of surgery offers relief to children and some adults who suffer recurrent ear infections or persistent fluid in the middle ear, which can lead to hearing loss. In a short and simple outpatient procedure, an otolaryngologist makes a small incision in the eardrum and inserts a tiny ventilation tube called a tympanostomy tube. The tube promotes drainage of fluid from the middle ear and keeps it from recurring. The procedure also usually results in a marked reduction in the number and severity of ear infections. The tube will fall out on its own within 3 to 18 months. Additional myringotomies may be necessary.

Adenoidectomy.

This procedure is only recommended for children 4 years of age or older, if the serous otitis media has lasted three months or more and the adenoids are repeatedly inflamed. This procedure is only recommended for children 4 years of age or older, if the serous otitis media has lasted three months or more and the tonsils are repeatedly inflamed. a plastic operative procedure to repair a damaged eardrum

Tonsillectomy

Tympanoplasty

Myringoplasty

Surgical closure of a perforation in the eardrum by means of a tissue graft

Nursing responsibility
1 Explain all diagnostic tests and procedures. After myringotomy, maintain drainage flow. Don't place cotton or plugs deep in the ear canal; however, sterile cotton may be placed loosely in the external ear to absorb drainage. 2 To prevent infection, change the cotton whenever it gets damp, and wash hands before and after giving ear care. Watch for headache, fever, severe pain, or disorientation. 3 After tympanoplasty, reinforce dressings, and observe for excessive bleeding from the ear canal. Administer analgesics as needed. Warn the patient against blowing his nose or getting the ear wet when bathing. 4 Encourage the patient to complete the prescribed course of antibiotic treatment. If nasopharyngeal decongestants are ordered, teach correct instillation. 5 Suggest application of heat to the ear to relieve pain. 6 Advise the patient with acute secretory otitis media to watch for and immediately report pain and fever-signs of secondary infection. VII. Nursing diagnosis Risk for altered growth and development related to hearing loss Pain related to inflammation and pressure on tympanic membrane Risk for infection related to invasion or proliferation of microorganisms

Reference: Essentials of human Anatomy and Physiology eight edition by Elaine Marieb page 285286 http://emedicine.medscape.com/article/994656-overview http://en.wikipedia.org/wiki/Otitis_media http://en.wikipedia.org/wiki/Myringotomy http://www.medi-info.com/otitis-media/

Laguna State Polytechnic University Santa Cruz, Campus Santa Cruz, Laguna COLLEGE OF NURSING

OTITIS MEDIA IN CHILDREN

Submitted to: Ms. Janice Bernardo RN Clinical Instructor Submitted by: Group 2 Baysa, Josiephine Nolasco, Mariz Ethell Palcunan, Veejay