GROUP 2

OTITIS MEDIA

DISEASE Definition
INTRODUCTION In most cases, tympanic membrane perforation is caused by an illness or trauma. Trauma can be caused by a skull fracture, an
explosion, or a violent blow to the ear. Perforation is induced less commonly by foreign items that have been pushed too far into the
external auditory canal. If the pressure in the middle ear surpasses the atmospheric pressure in the external auditory canal during an
infection, the tympanic membrane might rupture. In most cases, tympanic membrane perforation is caused by an illness or trauma.
Trauma can be caused by a skull fracture, an explosion, or a violent blow to the ear. Bacteria can enter the eustachian tube by
contaminated secretions in the nasopharynx and through a tympanic membrane rupture in the middle ear. In most cases, a purulent
discharge is present in the middle ear, resulting in conductive hearing loss. In principle, the fluid is created by a decrease in middle ear
pressure induced by eustachian tube blockage. Although ear infections are more frequent in children, they can develop at any age. Otitis
Media is classified into three types: acute, serous, and chronic.

Acute Otitis media

- is a short-term infection of the middle ear that lasts less than 6 weeks.
- Pathogens that cause AOM are mostly bacterial or viral in nature, and they enter the eustachian tube via blockage caused by
upper respiratory infections, inflammation of surrounding tissues, or allergic responses, and move to the middle ear.

Serous Otitis Media

- commonly known as middle ear effusion, is characterized by the presence of fluid in the middle ear without evidence of active
infection.
- commonly encountered in clients following radiation therapy or barotrauma, as well as in patients with eustachian tube
dysfunction due to a concomitant upper respiratory infection or allergies.

Chronic Otitis Media

- recurring form of Serous Otitis Media that results in permanent tissue damage.
- Chronic middle ear infections weaken the tympanic membrane, destroy the ossicles, and affect the mastoid.

Etiology
- Viral infections
- Gram-negative enteric bacilli such as:
1. Escherichia coli
2. Staphylococcus aureus
- Most Common
1. S. aureus
2. H. influenzae.
- In children <14 years old
1. Streptococcus pneumoniae,
2. Moraxella (Branhamella) catarrhalis

Risk factors
Acute Otitis Media
- Younger Age
- Chronic Upper Respiratory infection
GROUP 2

- Medical Conditions:
● Down syndrome
● cystic fibrosis
● Cleft palate
- Chronic exposure to secondhand cigarette smoke.

Prevalence
- International statistics
● Incidence and prevalence in other industrialized nations are similar to US rates. In less-developed nations, OM is
extremely common and remains a major contributor to childhood mortality resulting from late-presenting intracranial
complications. International studies show an increased prevalence of AOM and chronic OM (COM) among Micronesian
and Australian aboriginal children.
- Age-related demographics
● Peak prevalence of OM in both sexes occurs in children aged 6-18 months. Some studies show bimodal prevalence
peaks; a second, lower peak occurs at age 4-5 years and corresponds with school entry. Although OM can occur at any
age, 80-90% of cases occur in children younger than 6 years. Children who are diagnosed with AOM during the first year
of life are much more likely to develop recurrent OM and chronic OME than children in whom the first middle ear infection
occurs after age 1 year.
- Sex-related demographics
● Several studies have now shown equal AOM prevalence in males and females; many previous studies had shown
increased incidence in boys.
- Race-related demographics
● For some time, the prevalence of OM in the United States was reported to be higher in black and Hispanic children than
in white children. However, a study that controlled for socioeconomic and other confounding factors showed equal
incidence in blacks and whites. Hispanic children and Alaskan Inuit and other American Indian children have a higher
prevalence of AOM than white and black children in the United States.

Morbidity and Mortality

- Indigenous Filipino population was identified to have a 48.7% prevalence of otitis media
- 50% of prevalence in young ages

SIGNS & 1. Acute Otitis Media

SYMPTOMS - *varies with the severity of the infection.
- Unilateral, accompanied by otalgia (ear pain)
● Pain is relieved after spontaneous perforation or therapeutic incision of the tympanic membrane.
- Other symptoms: drainage from the ear, fever, and hearing loss.

2. Serous Otitis Media

- Hearing loss
- Fullness in the ear or sensation of congestion
- Popping and crackling noises happen when the eustachian tube attempts to open such as when yawning or opening the mouth
- During Otoscopy
● Air bubbles may be visualized in the middle ear
GROUP 2

3. Chronic Otitis Media

- *vary depending on the degrees of hearing loss and a persistent or intermittent foul-smelling otorrhea
- No pain
● Except when the patient has acute mastoiditis
- Perforation
- Cholesteatoma - tumor of the external layer of the eardrum into the middle ear.

NURSING 1. Anxiety related to surgical procedure, potential loss of hearing, potential taste disturbance, and potential loss of facial movement
DIAGNOSIS 2. Acute pain related to mastoid surgery
3. Risk for infection related to mastoidectomy; placement of grafts, prostheses, and electrodes; and surgical trauma to surrounding
tissues and structures
4. Impaired verbal communication related to ear disorder, surgery, or packing
5. Risk for injury related to impaired balance or vertigo during the immediate postoperative period, dislodgement of the graft or
prosthesis, or injury to the facial nerve (cranial nerve VII) and chorda tympani nerve

MANAGEMENT Medical Management

1. Ear irrigations
- The ear, especially the canal and eardrum, is very sensitive. Earwax buildup can cause damage to these structures over
time. This can affect your hearing.
- Removing excess earwax with ear irrigation is a safe way to minimize the risk of damage to the ear.
- Common Side effects:
a. Temporary dizziness
b. Ear canal discomfort
c. Tinnitus (ringing in the ears)

Surgical Management
1. Tympanoplasty
- a surgical technique to repair a defect in the tympanic membrane with the placement of a graft, either medial or lateral to
the tympanic membrane annulus.
- The goal of this surgical procedure is not only to close the perforation but also to improve hearing.
- There are five types of tympanoplasties.
● The simplest surgical procedure, type I (myringoplasty), is designed to close a perforation in the tympanic
membrane.
● The other procedures, types II through V, involve more extensive repair of middle ear structures.
- Surgery is usually performed in an outpatient facility under moderate sedation or general anesthesia

2. Grafting Technique
- True temporalis fascia is the most common graft because of its ease of harvest and its abundant availability, even in
revision cases.
- Some surgeons prefer loose areolar fascia (also known as “fool’s fascia”) and prefer to save the true fascia for revision
cases.
- Also, the “fool’s fascia” is considered by some to be more pliable, have less donor site morbidity, and be more
transparent after healing.
GROUP 2

- It is available via the same postauricular incision that can be used for tympanoplasty.
- Procedure in Grafting technique
a. The postauricular incision is marked and injected with lidocaine with epinephrine.
b. Dissection is carried down onto the fascia (loose areolar /true temporalis).
c. The graft is harvested.
d. Muscle is removed from the fascia graft, and the graft is then pressed and dried on the back table for later use.
e. Cartilage is available to be harvested easily from either the tragus or the conchal bowl if a post-auricular
approach is being used. Tragal cartilage is harvested with perichondrium attached via a small incision on the
medial surface of the tragus.

3. Ossiculoplasty
- surgical reconstruction of the middle ear bones to restore hearing.
- Prostheses made of materials such as Teflon, stainless steel, and hydroxyapatite are used to reconnect the ossicles, thereby
reestablishing the sound conduction mechanism.
- However, the greater the damage, the lower the success rate for restoring normal hearing.

4. Mastoidectomy
- Objective: remove the cholesteatoma, gain access to diseased structures, and create a dry (non infected) and healthy ear.
- Usually performed through a postauricular incision. Infection is eliminated by removing the mastoid air cells.
- A second mastoidectomy may be necessary to check for recurrent or residual cholesteatoma.
- Success rate: 75%
- Mastoid pressure dressing can be removed 24 to 48 hours after surgery.
- Any evidence of facial paresis should be reported.

Pharmacologic Management
- Acetaminophen and ibuprofen are effective analgesic agents
● commonly used for the treatment of pain in infants and children due to AOM and other conditions.
- Topical otic analgesics
● used to effectively treat pain due to AOM.
● A combination topical product (antipyrine, benzocaine, glycerin) has been shown in a controlled trial of children aged 5
years and older to effectively reduce pain due to AOM when given with acetaminophen.

Nursing Management
● Reducing Anxiety
- reinforces the information discussed by the otologic surgeon including anesthesia, the location of the incision
(postauricular), and expected surgical results (e.g., hearing, balance, taste, facial movement).
- Encouraged to discuss any anxieties and concerns about the surgery
● Relieving Pain
- complain very little about incisional pain after mastoid surgery, they do have some ear discomfort.
- Aural fullness or pressure after surgery is caused by residual blood or fluid in the middle ear.
➢ The prescribed analgesic medication may be taken for the first 24 hours after surgery and then only as needed.
- A wick or external auditory canal packing → if tympanoplasty was performed at the time of the mastoidectomy.
- For the next 2 to 3 weeks after surgery, the patient may experience sharp, shooting pains intermittently → eustachian
tube opens and allows air to enter the middle ear.
GROUP 2

- Constant, throbbing pain accompanied by fever → infection and should be reported to the primary provider.
● Preventing Infection
- The external auditory canal wick, or packing →antibiotic solution before instillation. Prophylactic antibiotic agents are
given as prescribed, and the patient is instructed to prevent water from entering the external auditory canal for 6 weeks.
- A cotton ball or lamb’s wool covered with a water-insoluble substance (e.g., petrolatum jelly) and placed loosely in the
ear canal usually prevents water from entering the ear canal and should be used when the patient showers or washes
their hair, or in any situations in which water may enter the ear canal.
- The postauricular incision should be kept dry for the first 2 days.
- Signs of infection such as elevated temperature and purulent drainage should be reported.
- Some serosanguineous drainage from the external auditory canal is normal after surgery
● Improving Hearing and Communication
- Hearing in the operated ear may be reduced for several weeks because of edema, accumulation of blood and tissue fluid
in the middle ear, and dressings or packing.
- Improving hearing and communication, such as:
➢ reducing environmental noise
➢ facing the patient when speaking
➢ speaking clearly and distinctly without shouting
➢ providing good lighting if the patient relies on speech reading,
➢ using nonverbal clues (e.g., facial expression, pointing, gestures)
➢ And other forms of communication.
- Family members or significant others are instructed about effective ways to communicate with the patient.
- If the patient uses assistive hearing devices, one can be used in the unaffected ear
● Preventing Injury
- Vertigo may occur after mastoid surgery if the semicircular canals or other areas of the inner ear are traumatized.
- Antiemetic or antivertiginous medications (e.g., antihistamines) can be prescribed if a balance disturbance or vertigo
occurs.
- Safety measures such as assisted ambulation are implemented
➢ to prevent falls and injury.
- Avoid heavy lifting, straining, exertion, and nose blowing for 2 to 3 weeks after surgery
➢ to prevent dislodging the tympanic membrane graft or ossicular prosthesis.
- Facial nerve injury is a potential, although rare, complication of mastoid surgery.
➢ Instructed to report immediately any evidence of facial nerve (cranial nerve VII) weakness, such as drooping of
the mouth on the operated side, slurred speech, decreased sensation, and difficulty swallowing.
- A more frequent occurrence is a temporary disturbance in the chorda tympani nerve, which is a small branch of the facial
nerve that runs through the middle ear.
- Experiences taste disturbance and dry mouth on the side of surgery for several months until the nerve regenerates.

Patient Education
1. Sleep on your back or the unoperated ear for 1 week.
2. Avoid air travel and sun exposure for 6 weeks.
3. If you need to cough or sneeze, keep your mouth open.
4. Blow your nose gently, without blocking either nostril.
5. Do not shampoo your hair for 5 days. Wear a shower cap when bathing.
6. No swimming. Keep your ear dry for 6 weeks.
GROUP 2

7. You may resume strenuous activity and contact sports in 1 month.

8. Change your ear dressing daily as prescribed.
9. Report excess drainage or severe dizziness to the health care provider.

Home Care
HOME CARE ● Place a warm washcloth next to the affected ear. The client can also use a heating pad. They can even use cold compresses to
INSTRUCTIONS alleviate swelling and discomfort. Ask to keep an ice bag near the affected ear for some time.
● They can use colloidal silver, a natural antibiotic, to wash and clean their ears.
● Ask them to lie down, on their side, placing the infected ear on a dry pillow. After a short while, the fluid will probably drain out,
due to the force of gravity.
● Ask the client to dry up the excess water in the Eustachian tube, by using a blow dryer, placed about 12 to 15 inches away from
the ear.
● Recommend wiping the nose sniffling is nice.
○ In case the client needs to sneeze, sneeze with their mouth open to enable the air to escape, rather than be pressured to
the ears.
○ Avoid bending together with the head for two weeks. If they have to bend, bend in the knees and keep their head up as
far as they can.
○ They will sleep however they’re most comfortable. Maintaining the mind marginally elevated when sleeping can
decrease swelling through the initial week.
○ Patients may frequently have some dizziness or balance problems after surgery.
● The client must prevent airplane flights for the first fourteen days after surgery, ideally no flying for 1 month following the
operation. If they have any air travel plans, they have to start with at least a month’s gap from the surgery.
○ The head of the mattress may be raised by two or three inches. Following the first week, then the client might sleep with
no head of the bed elevated.
○ The client should avoid all actions that might raise the blood pressure in the face region. Therefore, the client shouldn’t
blow their nose for three weeks. Attempt to prevent coughing for their first few weeks post-operatively. If they must
sneeze, allow it to come from their mouth just like a cough.
○ Excessive coughing must likewise be avoided. The client should avoid gym courses or rigorous athletic activity for a
month following the operation.
○ Swimming, diving, and water skiing ought to be avoided for 2 months following the operation. In circumstances of a
stapedectomy operation, jet travel ought to be avoided for at least six weeks following the operation.
○ Scuba diving isn’t recommended after ear surgery. The client must not drive a vehicle for a week following the operation.
In case they’ve had a stapedectomy, wait fourteen days prior to driving.
○ Eyeglasses may be worn the moment the surgical dressing is removed. Contact lenses could be inserted daily following
an operation.
○ Tub bathrooms or showering may be resumed once the individual feels powerful enough to achieve that.

Medication
GROUP 2

● Take pain medicines exactly as directed.

○ If the doctor gave a prescription for pain, take it as prescribed.
○ If the client is not taking prescription pain medicine, recommend taking over-the-counter medications, such as
acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve). Educate them to read and follow all instructions
on the label.
○ Educate the client not to take two or more pain medicines at the same time unless the doctor told them to. Many pain
medicines have acetaminophen, which is Tylenol. Too much acetaminophen (Tylenol) can be harmful.
● Plan to take a full dose of pain reliever before bedtime. Getting enough sleep will help the client to get better.
● Recommend the client to try a warm, moist face cloth on the ear. It may help relieve pain.
● If the doctor prescribed antibiotics, let the client take them as directed. The client must not stop taking them just because they
feel better. They need to take the full course of antibiotics.

Exercise
● Balance retraining exercises (vestibular rehabilitation). Therapists trained in balance problems design a customized program of
balance retraining and exercises. Therapy can help the client to compensate for the imbalance, adapt to less balance, and
maintain physical activity. To prevent falls, their therapist might recommend a balance aid, such as a cane, and ways to reduce
their risk of falls in their home.
● Simple exercises to open the Eustachian tube and restore normal ear pressure include forcing themselves to yawn, holding their
nose while swallowing, gently blowing their nose into a tissue, or sucking on a sweet.
● Several yoga postures are good for the ears and may help to rebalance air pressure and restore hearing. One specific yoga
asana is Karnapidasana or the ear press.

Treatment and Education

● Educating Patients About Self-Care.
○ Patients require education about medication therapy, such as analgesic and antivertiginous agents (e.g., antihistamines)
prescribed for balance disturbance. Education includes information about the expected effects and potential side effects
of the medication. Patients also need instruction about any activity restrictions. Possible complications such as infection,
facial nerve weakness, or taste disturbances, including the signs and symptoms to report immediately, are included.

OPD Follow-up
● Continuing and Transitional Care.
○ Some patients, particularly older adult patients, who have had mastoid surgery may require the services of a home,
community-based, or transitional care nurse for a few days after returning home. However, most people find that
assistance from a family member or a friend is sufficient. The caregiver and patient are cautioned that the patient may
experience some vertigo and will therefore require help with ambulation to avoid falling. Any symptoms of complications
are to be reported promptly to the primary provider. The importance of scheduling and keeping follow-up appointments is
also stressed.

Diet
A proper diet also plays an essential role in reducing ear infection risk.
● Focus on fruits, vegetables, whole grains, and high-quality protein to strengthen their immune system.
● Consider eliminating milk and sugar, as they are common allergens.
GROUP 2

● It's also incredibly important to stay hydrated, as this can help thin mucus secretions.
● Essential fatty acids found in coldwater fish, flaxseeds, and flaxseed oil are useful for reducing inflammation.

Foods to be taken
● Recommend plenty of fruits, vegetables, whole grains, and healthful snacks, such as homemade smoothies and dried fruits.
● Vitamin C aids immune health by helping the white blood cells to destroy germs faster. Include vitamin c rich foods like peppers,
green leafy vegetables, berries, etc.
● Vitamins A and Zinc (carrots, tomatoes) also reduce ear infections due to their antioxidant properties.
● Let the client take only extra virgin olive oil, fish oils, and coconut oil as your only sources of dietary oil. Coconut oil is especially
healthy as an anti-infective. Increase raw foods and protein.
● The client must use only pure water for drinking and cooking (no well water or water containing fluoride or chlorine.)
● Make sure the client eats a healthy and balanced diet to includes vitamins A, C, and E, and zinc. A daily multivitamin is good if
you do not eat a healthy diet.

Foods to be avoided
● Eliminate all dairy products, gluten-containing grains, canned, processed, and frozen foods.
○ This includes milk, yogurt, cheese, lactose-free milk, and fortified soy milk and yogurt.

Self-Care After Middle Ear or Mastoid Surgery

Post Operative instructions for patients who have had a middle ear and mastoid surgery may vary among otolaryngologists. The nurse
instructs the patient in the following general guidelines:
● Take antibiotics and other medications as prescribed.
● Avoid nose blowing for 2–3 weeks after surgery.
● Sneeze and cough with the mouth open for a few weeks after surgery.
● Avoid heavy lifting (>10 pounds), straining, and bending over for a few weeks after surgery.
● Be aware that popping and crackling sensations in the operative ear are normal for approximately 3–5 weeks after surgery.
● Note that temporary hearing loss is normal in the operative ear due to fluid, blood, or packing in the ear.
● Report excessive or purulent ear drainage to the physician.
● Avoid getting water in the operative ear for 2 weeks after surgery.
● You may shampoo the hair 2–3 days postoperatively if the ear is protected from water by saturating a cotton ball with petrolatum
jelly (or some other water-insoluble substance) and loosely placing it in the ear. If the postauricular suture line becomes wet, pat
(not rub) the area and cover it with a thin layer of antibiotic ointment.

MASTOIDITIS

DISEASE Definition
INTRODUCTION Mastoiditis is a bacterial infection of the mastoid air cells surrounding the inner and middle ear. It is usually a result of an untreated
middle ear infection or otitis media and commonly occurs in children. Both acute and chronic bacterial infection in the mastoid air cell but
chronic mastoiditis occurs when acute mastoiditis remains undetected or untreated.

Etiology
● Middle ear infection (otitis media) - Bacteria from the middle ear can enter the mastoid bone's air cells.
● Cholesteatoma - a growing collection of skin cells that may block the drainage of the ear, resulting in mastoiditis
GROUP 2

Risk factors
● Recent middle ear infection.
● Weak immune system.
● Abnormal skin growth in the middle ear.
● Allergy
● Upper respiratory tract infection
● Snoring
● Low social status
● Infancy
● Elderly
● Passive smoker

Prevalence
The incidence of mastoiditis was approximately 4 cases per 100,000 children per year over 5 years. Rapid disease progression
appears to be more frequent in young children. The most common ages affected are 6–13 months because, during these ages, ear
infections are common. There is no racial predilection for mastoiditis and both females and male are affected by this disease. Most
prevalent in developing countries, specifically Sub-Saharan West Africa, Southeast Asia, and Oceania

Morbidity and Mortality

The mortality rate of mastoiditis in children remains 10 percent. In the pre-antibiotic era, 20% of cases of acute otitis media were
complicated by acute mastoiditis. Before the antibiotic era, 5 to 10% of children with acute otitis media developed mastoiditis with a
mortality rate of 2/100000 population but with the advent of antibiotics, mastoidectomy, and PCV-7 by 2008, the incidence has drastically
decreased.

SIGNS & PHYSIOLOGICAL ALTERATIONS

SYMPTOMS Skin
● Erythema and Edema of the periauricular area

Ear
● Otorrhea
● Sagging External Ear Canal
● Nipplelike protrusion of the central tympanic membrane, indicating the presence of pus

CLINICAL FEATURES
● Fever, Irritability, and lethargy
● Swelling of the ear lobe
● Redness and tenderness behind the ear
● Drainage from the ear
● Conductive type hearing loss
GROUP 2

LABORATORY FINDINGS
There are no definitive laboratory tests associated with mastoiditis. But patients will have Elevated WBC in blood tests and ear culture
will be done for the presence of bacteria in the ear

DIAGNOSTIC FINDINGS
Otoscope
● Nipplelike protrusion of the central tympanic membrane, indicating the presence of pus
● Sagging ear canal

CT scan
CT scan shows the localization and enlargement of middle ear spaces (double arrow), indicative of
mastoiditis. CT scan can also show otitis media (single arrow), and pus formation (triple arrow) in
some patients.

NURSING CONSIDERATIONS
● Offer liquid to soft diet
● Have the patient sit up or elevate the patient’s bed
● Provide warm compress on the ear
● Speak to the patient with a loud and clear voice
● Educate the patient to take the antibiotics as directed by the physician

NURSING 1. Pain related to inflammatory process

DIAGNOSIS 2. Impaired auditory sensory perception related to perforation of tympanic membrane
3. Impaired verbal communication related to hearing deficit
4. Risk for trauma related to balance difficulty
5. Disturbed sensory perception related to auditory nerve damage.

MANAGEMENT Medical Management

1. Antibiotic therapy - is the mainstay treatment for both acute and chronic mastoiditis
2. Ear-irrigation - for removing purulent discharge.

Surgical Management
1. Mastoidectomy - Mastoid surgery, also known as mastoidectomy, involves drilling a hole in the mastoid bone and removing
infected mastoid air cells, and air bubbles in the skull, near the inner ears. General anesthesia is used for this surgery.
a. Simple mastoidectomy - the incision is made behind the ear to remove the infected air cells by approaching through
the ear.
GROUP 2

b. Radical mastoidectomy - removes the tympanic membrane and is indicated for extensive spread of cholesteatoma.
The eardrum and middle ear structures may be completely removed. Usually, the stapes are spared if possible to help
preserve some hearing.
c. Cortical mastoidectomy - removal of mastoid air cells without disturbing the middle ear.
2. Myringotomy - a tiny incision created in the eardrum relieves pressure caused by excessive buildup of fluid or pus.
3. Tympanoplasty - also called eardrum repair. It is the surgical reconstruction of the perforated eardrum or the small bones of the
middle ear.

Pharmacologic Management
1. Antibiotics - IV antibiotic treatment is initiated immediately with a drug that provides central nervous system penetration, such as
ceftriaxone 1 to 2 g (children, 50 to 75 mg/kg) once a day continued for ≥ 2 weeks; vancomycin or linezolid are alternatives. Oral
treatment with a quinolone may be acceptable.
2. NSAIDs - Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) assist to reduce swelling, pain, and fever. This
medication is available with or without a prescription from a doctor. NSAIDs might cause gastrointestinal bleeding or renal
difficulties.
3. Acetaminophen - helps decrease fever and pain.

Nursing Management
- Assess pain for location, intensity, etc.
- Administer analgesics as prescribed to relieve pain.
- Administer medications as ordered.
- Provide plenty of fluids.
- Use cool water sponging to reduce body temperature.
- Encourage patient and family to use signs of non-verbal communication such as facial expression, pointing, and body movement
in case of hearing difficulties.

● Post-operative care
○ Place the patient on bed rest for 24 hours post-operation.
○ Provide a comfortable position i.e. the patient lies with the operated ear up.
○ Elevate the head of the bed to reduce swelling and pressure on the operated ear.
○ Administer antibiotics, analgesics, and antihistamines as ordered.
○ Assess hearing acuity by using the whisper test, Rinne’s test, and Weber test postoperatively.

Patient Education
1. Instruct the patient to keep the ear dry 4-6 weeks after surgery
2. Avoid heavy lifting, straining, and exertion.
3. Do not blow your nose for 2-3 weeks after surgery to prevent dislodging of the tympanic membrane graft.

HOME CARE Medication

INSTRUCTIONS - Educate them to take the prescribed medication depending on how the doctor instructs them to.
GROUP 2

- Do not abruptly stop taking the medication even if the symptoms subside.

Exercise
- Avoid activities that involve heavy lifting and straining.

Treatment and Education

- Place a warm compress over the ear as it may help ease the pain
- Wear earplugs while swimming or showering.
- Avoid air travel if possible or places with high altitudes.
- Keep your head slightly elevated for the first 24 hours after going home.
- Sneeze with your mouth open.
- Get your doctor’s permission before flying in a plane, or swimming.

OPD Follow up
- Note and attend all the scheduled follow-ups such as blood test, culture test, and imaging test to monitor the progress
- Attend scheduled return for wound check and removal of bandages, and stitches
- Notify the physician if the patient experienced adverse effects to the medication such as rashes, diarrhea, and abdominal pain

Diet
- Educate the patient to avoid eating solid diet foods that require strenuous chewing such as meats and breads. Chewing may
aggravate the pain

LABYRINTHITIS

DISEASE Definition
INTRODUCTION - Labyrinthitis, an inflammation of the labyrinth of the inner ear, can be bacterial or viral in origin.
- It causes inflammation that can affect the structures of this part of the ear and disrupt the flow of sensory information from the ear
to the brain.

Etiology
- Bacterial labyrinthitis - occurs as a complication of otitis media, spreading to the inner ear by penetrating the membranes of the
oval or round windows.
- Viral labyrinthitis - most common viral causes are mumps, rubella, rubeola, and influenza.

Risk Factors
- Viral illnesses of the upper respiratory tract such as common cold and flu
- Herpetiform disorders of the facial and acoustic nerves (i.e., Ramsay Hunt syndrome)
- Long-lasting, untreated, middle-ear infections
- Meningitis and head injury
- Respiratory illnesses, such as bronchitis
- Viral infections, including herpes and measles
- Autoimmune conditions (Wegener granulomatosis or polyarteritis nodosa)
GROUP 2

Prevalence
- Viral labyrinthitis - more common than bacterial labyrinthitis, 1 case in 10,000 persons, with up to 40% of these patients
complaining of vertigo or dysequilibrium.

Morbidity and Mortality

- Mortality: Deaths associated with labyrinthitis are not reported except in cases of meningitis or overwhelming sepsis.
- Morbidity of bacterial labyrinthitis is significant:
● Regardless of etiology, this accounts for one third of all cases of acquired hearing loss.
● In the pediatric population, the risk of hearing loss secondary to meningitis is estimated to be 10-20%.
● Permanent hearing loss occurs in 10-20% of children with meningitis.
● Permanent sensorineural hearing loss (SNHL) occurs in approximately 6% of patients with herpes zoster oticus who
present with hearing loss.

SIGNS & Physiological Alterations

SYMPTOMS - The infection of the labyrinth in the inner ear is known as labyrinthitis. The labyrinth is a network of fluid-filled passages that
provide information to the brain about the position of your head and variations in movement. As a result, the labyrinth is
necessary for healthy balance and hearing.
- The message conveyed to the brain is interrupted if the labyrinth becomes diseased and inflamed, and it transmits messages to
the brain even when the body and head are still. This causes dizziness, nausea, and spinning feelings, which are all signs of
vertigo.

Clinical Features
- Sudden onset
1. Incapacitating vertigo
2. Nausea and vomiting
3. Various degrees of hearing loss
4. Tinnitus (Possible)

- Lack of balance when walking

- Periods of uncontrolled, back-and-forth eye movements (nystagmus)
- Inability to concentrate

Laboratory Findings
- No specific laboratory findings are usually indicated for labyrinthitis. However, there are certain lab tests needed which are
dependent upon the suspected cause:
1. If systemic infection is suspected
a. Complete blood count
b. Blood culture and sensitivity

2. Perform culture and sensitivity testing of middle ear effusions, if present.

Diagnostic Findings
GROUP 2

- MRI: This is done to rule out stroke.

- Electrocardiogram (ECG) or other cardiovascular tests: These can rule out cardiovascular causes.

- Electronystagmography (ENG) or videonystagmography (VNG): These record your eye movement. This helps to find the
exact area of the problem in your vestibular system and evaluate the cause of your balance disorder.

Nursing Considerations
1. Conservative management
a. Advise the patient to rest in a comfortable position.
b. Reduce the salt and sugar intake of the patient.
c. Increase fluid intake to 2-3L/day.
d. Educate the patient to avoid alcohol and quit smoking.
e. Remain stress-free

2. Preventing injury due to risk for fall

a. Assess conditions that can increase the patient’s level of fall risk such as a change in mental status, medications, etc.
b. Keep the patient’s bedside free from anything that can hit his head on.
c. Make sure that the patient’s bed is at its lowest position.
d. Keep it as adjacent to the floor as possible.
e. Use side rails on the bed whenever needed and avoid using restraints.
f. Move the patient to a room that is near the nurse’s station.
g. Teach the patient to move slowly.
h. Encourage family members and relatives to remain with the patient at all times.

3. For impaired ability to transfer

a. Assess the degree of impairment using the 0-4 functional level classification.
b. Provide a safe environment by keeping bed rails up, maintaining the bed in a low position.
c. Allow the patient to perform tasks at his or her own pace.
d. Encourage the patient to move slowly.
e. Give medications as ordered.

NURSING 1. Risk for injury related to gait disturbance and vertigo.

DIAGNOSIS 2. Anxiety related to threat of, or change in health status and disability effects of vertigo as evidenced by fear and tremors.
3. Disturbed auditory sensory perception related to altered sensory transmission and reception as evidenced by vertigo.
4. Self-care deficit related to labyrinth dysfunction and episodes of vertigo as evidenced by an inability to access the bathroom,
complete toilet hygiene, and prepare food.
5. Powerlessness related to illness regimen and being helpless in certain situations due to vertigo/balance disturbances as
evidenced by an insufficient sense of control and inability to perform ADLs.

MANAGEMENT Medical Management

- Symptom relief and management
GROUP 2

Surgical Management
- Surgical Management
● Myringotomy
○ Creating a hole in the tympanic membrane to allow fluid that is trapped in the middle ear to drain out blood, pus, or
water.
○ Purpose: to evacuate the effusion.
○ Indication: suppurative labyrinthitis, cases of labyrinthitis resulting from otitis media

Pharmacologic Management
- Bacterial Labyrinthitis - symptom relief
1. IV antibiotic therapy - based on culture and sensitivity results
2. Fluid replacement
3. Antihistamine - meclizine or promethazine
4. Antiemetic medications - serotonin antagonists (ondansetron, granisetron and tropisetron), dexamethasone, droperidol,
and cyclizine
5. Corticosteroid medicines (to help reduce nerve inflammation) - prednisone

- Viral Labyrinthitis
● Symptom management

Nursing Management
A. Bed rest - to prevent falls from losing balance

B. Hydration
- Intravenous (IV) fluid for severe nausea and vomiting

C. Treating Infection
- Note for signs of infection such as an elevated temperature and purulent drainage
- Administer antibiotics based on culture and sensitivity

D. Improving Hearing And Communication

- Reducing environmental noise, facing the patient when speaking
- Speaking clearly and distinctly without shouting
- Providing good lighting if the patient relies on speech reading, and using nonverbal clues (e.g., facial expression,
pointing, gestures)
- Provide other forms of communication such as pen and paper.

E. Preventing Injury
- Safety measures such as assisted ambulation are implemented to prevent falls and injury.
- Instruct to avoid heavy lifting, straining, exertion, and nose blowing to prevent dislodging the tympanic membrane graft
after drainage and putting pressure to inflamed membrane

F. Outpatient basis.
GROUP 2

- Caution patients to seek further medical care for worsening symptoms, especially neurologic symptoms (eg, diplopia,
slurred speech, gait disturbances, localized weakness or numbness).

Patient Education
1. While recovering from labyrinthitis, rest and avoid any sudden movements of the head.
2. Avoid driving and operating potentially dangerous machinery.
3. During a vertigo attack, try to remain calm and avoid unnecessary movement.
4. Avoid bright lights and television or computer screens during an attack and find a quiet place to sit down and wait for it to pass.
5. Get up slowly from a lying down or seated position.
6. Wear ear protection during recreational and work activities involving high noise levels.
7. Avoid heavy lifting, straining, exertion, and nose blowing.
8. Note that temporary hearing loss is normal in the operative ear due to fluid, blood, or packing in the ear.
9. Report excessive or purulent ear drainage to the physician.

HOME CARE Medication

INSTRUCTIONS - Instruct the patient to take medications exactly as prescribed.
- If the Physician orders antibiotics, take this medication as directed, and complete the full course of the therapy. Do not stop
taking the medications just because you feel better.

Exercise
- Try balance exercises for vertigo if suggested by the Physician. Instruct the patient to stand with both feet together, arms on the
side, and hold this position for 30 seconds.
- Instruct the patient to perform Brandt-Daroff exercise as ordered by the Physician. This may help the brain adapt to the
occurrence of vertigo. When doing this exercise, instruct the client to sit on the edge of the bed, quickly lie down on one side,
stay in this position for at least 30 seconds until vertigo subsides, sit upright again, and if vertigo persists, wait for it to subside,
and do it on the other side. Usually, this exercise must be done repetitively at least 10 times twice each day.

Treatment and Education

- Educate the patient on the importance of bed rest and keeping the head still for at least the first few days when vertigo persists.
- Instruct the patient to return to normal activities if vertigo hasn’t subsided for more than a few days. As the brain slowly adapts to
the occurrence of vertigo, it will slowly go away.
- Instruct the patient to avoid environments with high stress and noise.

OPD Follow-up
- It is important to adhere to regular follow-up visits and laboratory workups with your Physician.
- Follow up with your Physician whenever you experience (1) recurring vertigo, (2) new symptoms arising, (3) worsening of
symptoms, (4) hearing loss, (5) Severe symptoms such as convulsions, double vision, fainting, weakness or paralysis.
- Consult your physician regarding the appropriate medication you have to take during the course of the treatment
- Consult your Dietitian with regards to the appropriate diet and meal plan that you need to follow.

Diet
- Instruct the client to evenly distribute food and fluid intake throughout the day to help with the inner-ear fluid stability and prevent
migraine attacks caused by hypoglycemia.
- Avoid foods and beverages that have a high salt or sugar content.
- A diet high in fresh fruits and vegetables, whole grains, low in canned, processed frozen food, and other processed foods are
GROUP 2

highly recommended as this controls salt and sugar intake.

- Drink adequate amounts of fluid every day. It is recommended to drink at least 5 or more glasses of water every day.
- Avoid foods and beverages that contain caffeine.
- Limit or eliminate alcohol consumption
- Do not smoke.
- Ask your Physician or a Dietitian before taking extra herbs, vitamins, and supplements.

References:
Brunner, L. S., Suddarth, D. S., Smeltzer, S. C. O., & Bare, B. G. (2004). Brunner & Suddarth's textbook of medical-surgical nursing (10th ed.). Philadelphia:
Lippincott Williams & Wilkins.

Boston, M. (2020, September 2). LABYRINTHITIS workup: Approach considerations, Imaging Studies, Audiography. Labyrinthitis Workup: Approach
Considerations, Imaging Studies, Audiography. Retrieved April 29, 2022, from https://emedicine.medscape.com/article/856215-workup

Care24. (2022, April 7). Home Nursing For Pre & Post Operative Care for Tympanoplasty | Tympanoplasty Post Op.
https://care24.co.in/nursing/post-operative-care/tympanoplasty

Devan, P. M. (2022, January 15). Mastoiditis: Practice Essentials, Etiology, Epidemiology. Medsape.
https://emedicine.medscape.com/article/2056657-overview#showall

Discharge Instructions for Mastoidectomy. (n.d.). Saint Luke’s Health System. https://www.saintlukeskc.org/health-library/discharge-instructions-mastoidectomy

Cedars. (n.d.). Retrieved April 29, 2022, from

https://www.cedars-sinai.org/health-library/diseases-and-conditions/l/labyrinthitis.html#:~:text=Labyrinthitis%20is%20the%20inflammation%20of,symptom
s%20go%20away%20over%20time

Gabbey, A. E. (2019, March 8). Ear Irrigation. Healthline. https://www.healthline.com/health/ear-irrigation#_noHeaderPrefixedContent

Gibson, M. (2020, July 29). Mastoiditis epidemiology and demographics - wikidoc. WikiDoc.
https://www.wikidoc.org/index.php/Mastoiditis_epidemiology_and_demographics

National Library of Medicine. (2021). Medline Plus: Labyrinthitis - aftercare. Retrieved April 29, 2022 from
https://medlineplus.gov/ency/patientinstructions/000716.htm

Marks, H. (2010, August 6). Mastoiditis. WebMD. https://www.webmd.com/cold-and-flu/ear-infection/mastoiditis-symptoms-causes-treatments

Mastoidities: Care Instructions. (2020, December 2). Myhealth.Alberta.

https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=abo9094
GROUP 2
Mastoid Surgery. (2019, June 14). ENT of Athens.
https://www.entofathens.com/ent/ear/mastoid-surgery/#:%7E:text=Mastoid%20surgery%2C%20or%20mastoidectomy%2C%20involves,and%20there%20
may%20be%20stitches

Mastoiditis-Symptoms, Causes, Risk Factors and Prevention | KayaWell. (2020, July 14). Kayawell Health Care.
https://www.kayawell.com/blog/mastoiditis-symptoms-causes-risk-factors-and-prevention

MyHealth.Alberta.ca. (2020). Labyrinthitis: Care Instructions. Retrieved April 29, 2022 from
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=ug6290

PennMedicine. (2021). Labyrynthitis. Retrieved April 29, 2022 from

https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/labyrinthitis

Labyrinthitis. Labyrinthitis - Vestibular - What We Treat - Physio.co.uk. (n.d.). Retrieved April 29, 2022, from
https://www.physio.co.uk/what-we-treat/vestibular/labyrinthitis.php

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th
ed.). St. Louis: Elsevier.

Ranjan, R. (2017, May 19). Otitis Media: Treatment, Diet and Home Remedies. mTatva Health-PIE.
https://www.mtatva.com/en/disease/otitis-media-treatment-diet-and-home-remedies/

Reilly, B. K., MD. (2021, December 23). Tympanoplasty: Background, Pathology, Indications.
https://emedicine.medscape.com/article/2051819-overview#:%7E:text=Tympanoplasty%20is%20a%20surgical%20technique,but%20also%20to%20impro
ve%20hearing

Waseem, M. M. (2022, April 7). Otitis Media: Practice Essentials, Background, Pathophysiology.
https://emedicine.medscape.com/article/994656-overview#:%7E:text=Various%20epidemiologic%20studies%20report%20the,AOM%20by%20age%207
%20years

Vaishnav, N. (n.d.). Labyrinthis. SlideShare a Scribd company. Retrieved April 29, 2022, from https://www.slideshare.net/NikhilVaishnav3/labyrinthis

VEDA. (2022). Scientific Study: Dietary Considerations. Retrieved April 29, 2022 from
https://vestibular.org/article/coping-support/living-with-a-vestibular-disorder/dietary-considerations/

Zhang, Y., Xu, M., Zhang, J., Zheng, L., Wang, Y., & Yin Zheng, Q. (2014, January 23). Risk Factors for Chronic and Recurrent Otitis Media–A Meta-Analysis.
NCBI. Retrieved April 29, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900534