OTITIS MEDIA

E. Phiri
 Broad objective
• At the end, learners should be able to
assess and manage a child with ear
infection
 Learning outcomes
 Review anatomy of the ear
 Define Otitis Media (OM)
 State the causes of OM
 Discuss the predisposing factors of OM
 Describe the pathophysiology of OM
 Describe the classification of OM
 Explain the management of OM
 State the complications of OM
 Definition
 Inflammation of the middle ear.
 Peak incidence is in the first three
years of life (esp. 6-12 months).
 1/3 of children will have 3 or more
infections by age 3. 90% will have at
least one infection by age 6.
 Occurs more frequently in the winter
months
Causative organisms
 Streptococcus
 Haemophilus influenzae
 Group A Streptococcus
 Staphylcoccus aureus
 Pneumococcus
 Virus
 Fungus
Predisposing factors
 Bottle feeding
 Upper Respiratory Tract Infections
 Allergies
 Craniofacial abnormalities (cleft palate)
 Down’s Syndrome
 Passive smoking
 Measles
 Moisture in the ear
 Trauma caused by foreign objection
 Pathophysiology
 The middle ear is a small space
behind the ear drum that is supposed
to be well ventilated by air that
normally passes up from behind the
nose, through the eustachian tube,
keeping the middle ear clean and dry.
 Normally the ear is ventilated 3-4
times/min as the eustachian tube
opens during swallowing & oxygen
….is absorbed by blood in the vessels of
the middle ear mucuos membranes

 When the eustachian tube is blocked,

there is poor ventilation in the middle
ear, and it becomes damp & warm,
perfect for developing infection
 The infection causes swelling or
edema causing pain. As the body tries
to fight the infection, exudates results
leading to pus accumulation
 The blockage also creates a relative
negative pressure within the middle
ear leading to fluid accumulation.
 The fluid, pus & oedema result in
poor conduction of sound waves
resulting in impaired hearing.
 The blocked eustachian tube
connecting the middle ear and nasal
pharyngeal results in poor balance.
 Theaccumulating pus causes the ear
drum to bulge externally. When it
spontaneously ruptures, pus drains
out
Diagnosis
• History of ear pain and draining pus.
• Pus seen draining
• Myringotomy to collect fluid sample. Done
for a bulging membrane if severe vomiting,
pain, diarrhoea is present
• Examination by
otoscope
CLASSIFICATION

1. ACUTE OTITIS MEDIA

• Inflammation of the middle ear cavity for
less than14 days.
• Mostly from bacteria or viral infection
accompanying a URI
Signs and symptoms
 Earache (pain) on the affected ear
- Aggravated by chewing and suckling.
- Identified by verbalisation, the talking age
- Rubbing or pulling of affected ear, rolling of
head from side to side, crying, difficult
sleeping in infants
 Fever (temperature as high as 40oC)
 Febrile convulsions in young infant, chills in
older children due to the high fever
 Irritability due to pain
 Refuse to breastfeed or eat due to the pain
 Decreased or impaired ( hearing loss)
hearing due to failure of the conduction of
sound waves through the middle ear.
 Nausea and vomiting due to increased
pressure in the middle ear from the infection.
 Imbalance due to blocked auditory tube
from the accumulating pus which
equalizes pressure
 Tenderness on pressure over mastoid
bone.
 Dehydration due to fever and vomiting.
 Otoscopic exam
– Red tympanic membrane, Bulging, Dull or
absent light reflex, Diminished movement,
Purulent material (air fluid level)
 Spontaneous perforation causes a
purulent discharge
Normal Acute otitis media
Treatment
• Treat infection with antibiotics
– Cotrimoxazole 18-30mg/kg/dose BD x
10 days or Amoxicillin 15mg/kg/dose
TDS x 5 days
• Fever & pain with paracetamol 10mg/kg
body weight TDS X 3 days
• Continue breastfeeding and give fluids to
prevent dehydration
• If spontaneous rupture of the tympanic
membrane, keep the ear clean by wicking
 Complications
 Impaired or loss of hearing
 Chronic perforation of the tympanic
membrane
 Chronic otitis media
 Pharyngitis
2. SECRETORY OTITIS MEDIA
• An effusion in the middle ear resulting
from incomplete resolution of acute otitis
media or obstruction of the eustachian
tube without infection.
Signs and symptoms
• Many children will be asymptomatic but
can show signs of
–Hearing loss
–Sense of pressure or fullness in the ear
Treatment
• Mostly its self limiting
• Antibiotic are of no value though they may
be prescribed
• If condition is due to allergy, give
antihistamines
• If no improvement occurs in 1-3 months,
myringotomy may be performed to
aspirate fluid and insert a tympanostomy
tube which allows ventilation of the
middle ear and temporarily relieves ET
obstruction.
3. OTITIS EXTERNA
• Otitis externa is an inflammation of the
skin lining the external auditory canal
• May be caused by a viral, bacterial or
fungal infection, a complication of a skin
condition (e.g. eczema) or a foreign body.
• Otitis externa may complicate chronic
suppurative otitis externa as the draining
pus irritates the skin of the external
canal.
Signs and symptoms
• Mild otitis externa
– The ear is itchy, external canal appears
normal.
• Moderate otitis externa
– The ear is painful with a purulent, smelly
discharge.
– Pain is worse if the pinna is pulled.
– External canal is red and contains debris.
– Mild deafness from partial obstruction of
the external ear canal cause mild.
• Severe otitis externa
–The ear is very painful with deafness
due to complete obstruction of the
canal.
–On examination, the external canal is
red and swollen.
Treatment
• Give analgesia
• Flucoxacillin
• Make a wick of ribbon gauze, add
hydrocortisone or Betamethasone cream and
gently insert in the ear for 2 to 3 days

Severe cases (diffuse otitis eternal)

• Dry mop the ear
• Give acetic acid ear drops 2% in alcohol QID
for 5 days
Severe otitis externa
• The canal should be packed with a
cotton wick soaked in ichthammol and
glycerine to reduce the swelling.
• Then the infection can be treated as in
moderate case
• A boil in the external canal can be very
painful and should be treated with oral
antibiotics
4. CHRONIC OTITIS MEDIA
• Persistent, chronically draining (6 wks or more),
suppurative perforation of the tympanic
membrane.
• Also referred to as chronic suppurative otitis
media (CSOM)
• Causes middle ear damage, damages the
tympanic membrane, destroy the ossicles, and
involve the mastoid. Common cause of deafness
in young children.
• May be worsen after an URI or when water enters
the middle ear during bathing or swimming
Causes
• Untreated or repeated episodes of acute
otitis media
• Eustachian tube obstruction
• Mechanical trauma
• Thermal or chemical burns, Blast injuries
Risks
• Down syndrome
• Microcephaly
• Cleft lip
• Craniofacial abnormalities
• Organisms involved include Streptococcal
aureus, streptococcus, Proteus mirabilis

Signs and symptoms

• Conductive hearing loss
• Otorrhoea which can be foul smelling
• Pain is uncommon unless there is infection of
the temporal bone
• Otoscopic exam may show perforation of the
tympanic membrane & growth on the middle
ear (cholesteatoma).
 Management
The aim is to treat the infection and keep the
ear dry so that the perforation in the eardrum
can heal.
• Amoxycillin 15mg/kg/body weight, 8 hourly,
orally x 7-10 days
• Clean the external canal at least twice a day
with a cotton bud to keep it dry or a cotton
wick to dry the external canal is very useful
(wicking).
• Avoid swimming or showering to prevent
water entering the ear
• Ear drops are of little help.
• Refer to an ENT specialist/clinic if the ear
continues to drain after 2 weeks of treatment,
if the condition recurs or if you suspect a
complication
• Reports of fever, vertigo, and pain should raise
concern about intra temporal or intracranial
complications.
 Assignment

Teach a mother on how to perform ear wicking

at home
• If no antibiotic response, then surgery is
recommended.

Tympanoplasty
• This is surgical reconstruction of the tympanic
membrane. Reconstruction of the ossicles may
also be required.
• Purpose is to re-establish middle ear function,
close the perforation, prevent recurrent
infection, and improve hearing
Ossiculoplasty.
• Surgical reconstruction of the middle ear
bones to restore hearing by re-establishing the
sound conduction mechanism. However, the
greater the damage, the lower the success
rate for restoring normal hearing.
Mastoidectomy.
• The objectives are to remove the
cholesteatoma, gain access to diseased
structures, and create a dry and healthy ear. If
possible, the ossicles are reconstructed during
 Nursing diagnoses
• Pain related to inflammation of the middle ear
evidenced by ear rubbing, crying
• Impaired verbal communication related to
hearing loss secondary to the infection
• Risk for injury related to altered balance
secondary to middle ear infection
• Social isolation related to foul-smelling
discharge
Complications
• Mastoditis
• Chronic otitis media can progress to a variety
of mild to life-threatening complications
• Complications are separated into 2 subgroups:
 Intratemporal
 Intracranial
Intratemporal complications
• Petrositis occurs when the infection extends
beyond the confines of the middle ear and
mastoid into the petrous apex.
• Facial paralysis may occur in the setting of
CSOM with or without cholesteatoma.
• Labyrinthitis occurs when the infection
spreads to the inner ear. The infection gains
access to the inner ear through the round and
oval windows or through one of the
semicircular canals exposed by bony erosion.
Intracranial complications
• Lateral sinus thrombophlebitis occurs as the
infection extends through the mastoid bone
into the sigmoid sinus.
• Meningitis develops as a consequence of
direct or hematogenous spread of the
infection.
• Various intracranial abscesses that may occur
can be extradural, subdural, or parenchymal.
MASTODITIS
 Specific objectives
By the end of this presentation students should
be able to:
• Define mastoditis
• Desribe the pathophysiology of mastoditis
• Outline the diagnostic measures of mastoditis
• Outline the clinical manifestation of mastoditis
• Manage mastoditis
 Definition
• Mastoiditis is a bacterial infection of the
mastoid air cells surrounding the inner
and middle ear. The mastoid bone, which
is full of these air cells, is part of the
temporal bone of the skull.
• The mastoid air cells are thought to
protect the delicate structures of the ear,
regulate ear pressure and possibly
protect the temporal bone during
trauma.

• When the mastoid cells become infected

or inflamed, often as a result of an
unresolved middle ear infection (otitis
media), mastoiditis can develop.
 Causes
• Bacteria from the middle ear can travel
into the air cells of the mastoid bone
(from acute or chronic otitis media).
• Less commonly, a growing collection of
skin cells called a cholesteatoma, may
block drainage of the ear, leading to
mastoiditis.
 Clinical manifestations
• Ear pain (otalgia
• Fever, irritability, and lethargy
• Swelling behind or above the ear
• Redness and tenderness behind the ear
• Drainage from the ear
• Bulging and drooping of the ear (pinna pushed
forward)
• Infants usually show nonspecific symptoms, like
anorexia, diarrhea, irritability.
 Classification
Acute
• There is persistent purulent ear discharge
• Tenderness in the affected ear
• A painful swelling behind the ear
• Enlarged lymph nodes in the neck region
• Redness of the affected ear
Chronic
• There is persistent purulent ear discharge
• The child has a swelling behind the ear
for a long time
• Hearing is a problem
• Meningitis can be the presenting
symptom
 Diagnosis

• History taking and physical examination

• Magnetic Resonance Imaging (MRI) scan

• White blood cell count to confirm infection

• Computerized tomography (CT) scan

• Culture in case of drainage

• Exploratory surgery as a last resort

 Management
• Antibiotics
– Ampicillin 25-50mg/kg IM or IV TDS for 5 days
– If not available, Cholamphenical 15mg/kg TDS
IV for 5 days then orally for 10 days
– Or Benzylpenicillin 50, 000iu/kg every 6 hours
IV and Gentamycin 7.5mg OD for 5 days then
chloromphenical orally for ten days
• Surgical drainage may be necessary
Nursing interventions

 Manage the pain, fever

 Assess for signs of dehydration
 Treat the infection by administering
prescribed antibiotics
 Watch for signs of brain involvement
(meningitis or brain abscess)
• If there is no improvement with
antibiotics, then mastoidectomy can be
done.
• The aim is to remove the cholesteatoma,
gain access to diseased structures, and
create a dry and healthy ear.
• The hearing mechanism may be
reconstructed at this time.
 Complications
•Destruction of the mastoid bone
•Facial paralysis
•Nausea, vomiting, vertigo (labyrinthitis)
•Hearing loss
•Brain abscess or meningitis
•Vision changes or headaches (blood clots
in the brain)
MASTOIDECTOMY
 Definition

• A mastoidectomy is a procedure
performed to remove parts of the
bone or diseased mastoid air cells.

• Parts of the bone are removed when

the infection spreads onto the
temporal bone.
• Done if
• antibiotic treatment fails clear
the chronic otitis media
• cholesteatoma (skin cyst)
develops which may gradually
lead to serious complications
such as bscess in the brain,
deafness, damage to the facial
nerve, meningitis etc
• done to put in a cochlear
implant.
 Cont’d…
• A second mastoidectomy may be
necessary to check for recurrent or
residual cholesteatoma
 Types

Simple mastoidectomy
• The surgeon opens the mastoid bone,
removes the infected air cells, and
drains the middle ear

Radical mastoidectomy
• The surgeon may remove the
eardrum and middle ear structures.
Sometimes a skin graft is placed in
the middle ear
Modified radical mastoidectomy
• This is a less severe form of radical
mastoidectomy. Not all middle ear
bones are removed and the eardrum
is rebuilt
 Goals for patient care
• The major goals of caring for a patient
undergoing mastoidectomy include:

• Reduction of anxiety
• Freedom from pain and discomfort
• Prevention of infection
• Stable or improved hearing and
communication
• Absence of injury from vertigo
• Absence of or adjustment to sensory
or perceptual alterations
• Return of skin integrity
 Pre-operative care

• Anxiety related to surgical procedure/

potential loss of hearing/potential taste
disturbance/potential loss of facial
movement evidenced by patient
verbalization.
• Deficient knowledge about mastoid
disease, surgical procedure, and
postoperative care and expectations
 Cont’d..
Subjective data
• Collect subjective data including -
health history includes a complete
description of the ear problem,
including infection, duration and
intensity of the problem, its causes,
and previous treatments.
• Obtain information about medication
patient is taking, medication allergies.
 Post-operative care
• Acute pain related to mastoid surgery
• Disturbed auditory sensory perception
related to ear disorder, surgery
• Risk for infection related to mastoidectomy,
placement of grafts, prostheses, electrodes,
and surgical trauma to surrounding tissues
and structures
• Disturbed auditory sensory perception
related to ear disorder, surgery
 Cont’d..
• Disturbed sensory perception related to
potential damage to facial nerve (cranial
nerve VII) and chorda tympani nerve

• Impaired skin integrity related to ear

surgery, incisions, and graft sites

• Risk for trauma related to balance

difficulties or vertigo during the
immediate postoperative period
 Complications

• Facial nerve paralysis or weakness (a

rare complication caused by facial
nerve injury)
• Sensorineural hearing loss (a type of
inner ear hearing loss that may occur
in up to six percent of patients)
• vertigo (dizziness; it may persist for
several days)
• Change in taste (food may taste
metallic, sour, or otherwise “off”; this
often resolves after a few months)
• Tinnitus (abnormal noises in the ear
such as ringing, popping, and hissing)

**reasure that all this goes away after

some weeks or months***