Otitis media

Otitis media is a common early childhood infection. Anatomic features that make young children
particularly susceptible to ear infections include shorter, more horizontal and compliant eustachian
tubes and bacterial carriage in the adenoids. Other risk factors include exposure to cigarette smoke,
overcrowding, bottle feeding, cleft palate, Down syndrome, allergy and immune dysfunction. These risk
factors contribute to the pathophysiology of the two common varieties of otitis media, acute otitis
media and otitis media with effusion.

Acute Otitis Media

Acute otitis media (AOM) in children tends to have a bimodal age distribution, with children between
ages 6 and 24 months and 5 to 6 yr at greatest risk.

Otitis media is one of the most common infectious diseases of childhood.

 Two of every three children have at least one episode of otitis media by the time they are 1 year
old.

 Otitis media accounts for approximately 20 million annual physician visits.

 Various epidemiologic studies report the prevalence rate of acute otitis media to be 17-20%
within the first two years of life.

 One-third of children experience six or more episodes of otitis media by age 7 years.

 Peak prevalence of otitis media in both sexes occurs in children aged 6 to 18 months.

Etiology

The most common organisms causing AOM are Streptococcus pneumoniae and Haemophilus influenzae,
accounting for approximately 65% cases; 15% are caused by Moraxella catarrhalis, Streptococcus
pyogenes and Staphylococcus aureus. Respiratory viruses play an important role in initiating otitis media
and may be the only pathogens in some cases, since 20% of middle ear aspirates are sterile.

Diagnosis

 AOM is characterized by the rapid onset of symptoms, which may be local, e.g. otalgia or ear
tugging, and/or systemic, e.g. fever or crying.
 Older children may report impaired hearing.
 History of recent upper respiratory tract infection is common.
  Otoscopic examination reveals a red and bulging tympanic membrane with reduced mobility as
measured by either tympanometry or insufflation through the otoscope (pneumatic otoscopy).

 Rupture of the drum with ear discharge (suppuration) may have already occurred, in which case
the ear canal contains an opaque yellow-green or reddish-brown fluid. Cleaning of this fluid
usually reveals an intact drum, as the rupture is small and closes promptly after spontaneous
perforation.
 The diagnosis of AOM is considered certain if all of the following criteria are met: (i) rapid onset;
(ii) signs of middle ear effusion; and (iii) signs and symptoms of middle ear inflammation.

Management

 Antimicrobial therapy is recommended. However, in some cases children may qualify for a trial
of observation
 Amoxicillin should be the first line therapy for AOM. Higher doses (80-90 mg/kg/day)
may be considered where streptococcal resistance is endemic. Agents with-lactamase resistance
(e.g.amoxicillin-clavulanic acid, cefaclor, cefuroxime or newer cephalosporins) are useful
second-line drugs. Initial antibiotic therapy should last at least 7 days. Reexamination is
indicated after 3-4 days and at 3 weeks.
 Adjuvant treatment with oral and topical decongestant drugs is not necessary.
 Antihistaminic agents, which contribute little to the resolution of otitis media and may
precipitate sinus infections due to their drying effect on mucosal secretions, are also not
recommended.
 Tympanocentesis (aspiration of the middle ear fluid) with a bent 18-gauge spinal needle on a
syringe may provide specimen for culture in patients with complicated AOM who cannot
tolerate tympanostomy tube insertion.
 Tympanocentesis improves otalgia but does not shorten the course of the illness.
 Many children present with recurrent episodes of AOM. A child that has 4 episodes of AOM in 6
months or 6 episodes in 12 months should be considered for tympanostomy tube insertion. If a
child requires a second set of tympanostomy tubes, concurrent adenoidectomy is considered.
No benefit from concurrent tonsillectomy has been demonstrated in patients with recurrent
AOM.

Otitis Media with Effusion (OME)

Following an episode of AOM, serous or mucoid middle ear effusions may be seen. Effusions are found
to persist in up to 40% of children 1 month after AOM and in 10% after 3 months. Many children with
OME do not have a history of previous acute middle ear infections. Most children are asymptomatic or
complain of hearing loss and ear fullness. Otalgiais not normally present.

Otoscopy reveals a dull tympanic membrane with middle ear effusion frequently with air fluid levels or
bubbles. Reduced tympanic membrane mobility on either pneumatic otoscopy or type B pattern on
tympanometry confirms the diagnosis.

Since over 65% of serous middle ear effusions resolve spontaneously within 3 months, newly diagnosed
effusions should be observed for this period. Antibiotic administration is not shown to resolve OME. Use
of antihistamines and decongestants is not recommended. The benefit of corticosteroid administration
has not been proven but a brief trial of steroids is commonly used.

If effusion persists beyond 3 months, tympanostomy tube insertion may be considered for any hearing
loss>25 dB. Other indications of tube placement in OME are speech delay, altered behavior,major
sequelae such as otitic meningitis or impending cholesteatoma formation from tympanic membrane
retraction. Improvement in hearing and ear discomfort is immediate. Mean time before extrusion is
usually between 12 and 18 months.
Insertion of long term tubes (of T-tube design) or adenoidectomy may be considered in patients with
recurrent or persistent symptomatic effusion. T-tubes have been associated with tympanic membrane
perforation. Earplugs are recommended while the tubes are in place to avoid entry of water into the
middle ear space.

Chronic Suppurative Otitis Media (CSOM)

Ear drainage that persists for longer than 6 weeks is generally due to chronic inflammation of the middle
ear space or mastoid air cells. Chronic suppurative otitis media (CSOM) invariably presents with
tympanic membrane perforation, which allows otorrhea. CSOM most often results from neglected
episodes of AOM and is therefore more common in children with inadequate access to health care. It
most often occurs in the first five years of life as Eustachian tube dysfunction plays a central
role in the pathophysiology.
Etiology:

The most commonly isolated organism is Pseudomonas aeruginosa; other organisms include
Staphylococcus aureus, Proteus spp, E. coli and anerobes. Fungi, especially Aspergillus and Candida spp.,
may be important.

Clinical manifestations:

 Cholesteatoma, a sac of squamous epithelium extending from the tympanic membrane into the
middle ear, also preset with a chronically draining ear. Most cholesteatoma is acquired. Rarely,
it may be congenital, arising through the eustachian tube by passage of neonatal epithelim.
 Though not malignant, cholesteatoma may cause serious complications by slow expansion and
local destruction.

Diagnosis :

 Chronic ear discharge is the hallmark of CSOM.

 Otoscopy reveals perforation of the tympanic membrane. A chronically draining ear may also be
seen with cholesteatoma

Management:

 Medical therapy consists primarily of topical antibiotics and aural toilet.

 Topical quinolones appear to be effective and safe. Complicated infections and/or any
signs of systemic involvement require the use of systemic antibiotic therapy. Parents should be
instructed to avoid water exposure. Secondary fungal otitis externa is a complication of topical
antibiotic treatment. Otolaryngology referral is necessary to rule out cholesteatoma.
 Surgery is usually indicated for cases of CSOM that do not respond to conservative treatment.
Surgical therapy involves repair of the tympanic membrane perforation (tympanoplasty) with or
 without mastoidectomy. If cholesteatoma is suspected, ear exploration via mastoidectomy and
cholesteatoma removal is mandatory. The primary goal of surgical therapy for cholesteatoma is
to create a 'safe ear' by removal of all cholesteatoma. Hearing preservation is a secondary goal.

Otitis Externa
Acute otitis externa (swimmer's ear) presents with itching,pain and fullness. Erythema and edema of
the ear canal and tenderness on moving the pinnae or tragus are diagnostic features. Otorrhea is
common.

Risk factors include swimming, impacted cerumen, hearing aid use, eczema or trauma from foreign
objects (hairpins or cotton swabs).

The etiologic agents of otitis extern include P. aeruginosa, Staphylococcus, Proteus, E. coli,
Aspergillus and Candida spp.

Treatment consists of ear canal culture, cleaning and topical antibiotic drops. Topical antibiotics
have clinical cure rates up to 80%. If edema is significant, ribbon gauze or a 'wick' may be placed in
the external auditory canal to stent it open for drop delivery. Oral antibiotics are reserved for failure
to improve and complications. Otomycosis or fungal otitis externa is most common in humid
weather and presents with pain and pruritus. These opportunistic infections are frequently seen
subsequent to treatment of a bacterial infection. Examination reveals fungal spores and filaments.
Aspergillus and Candida is the most common pathogens. Aural toilet and a topical antifungal (e.g.
clotrimazole) are curative.

Otic furunculosis is an exquisitely painful, superficial abscess in the outer portion of the ear canal,
typically from S. aureus. Oral antistaphylococcal antibiotics and analgesics bring about prompt relief.
Incision and drainage may be necessary.

Eczematous or psoriatic otitis externa describes a group of inflammatory conditions in which there is
drainage, pruritis and/or scaling of the ear canal skin. Underlying causes include contact dermatitis,
atopic dermatitis and seborrheic dermatitis.

Malignant otitis externa is a rare invasive infection of the external auditory canal cartilage and bone.
Immunocompromised children (acquired immunodeficiency syndrome, leukemia, diabetes mellitus,
immunosuppression after organ transplant) are at risk. Pseudomonas aeruginosa is the most
common etiology. Invasive fungal species, especially Aspergillus, are also seen. The external auditory
canal is tender and facial or scalp necrosis may arise, with or without cranial nerve abnormalities.
Diagnosis is confirmed with CT and MRI scan and/or scintigraphy for osteomyelitis of the temporal
 bone. Aggressive surgical debridement and parenteral antibiotics and/or antifungals for 4 6eeks are
required. Treatment response may be monitored with serial Gallium67 bone scans.

Complications of otitis media

lntracranial

 Meningitis
 Epidural abscess
 Dural venous (sigmoid sinus) thrombosis
 Brain abscess
 Otitic hydrocephalus
 Subdural abscess

Extracranial

 Acute coalescent mastoiditis

 Subperiosteal abscess
 Facial nerve paralysis
 Labyrinthinitis or labyrinthine fistula

Nursing management

Nursing Assessment

Assessment of a child with otitis media includes the following:

Physical examination.The infant’s ear is examined with an otoscope by pulling he ear down and back to
straighten the ear canal.

History.Assess if there is a history of trauma to the ears, affected siblings, a history of cranial/facial
defects or any familial history of otitis media.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:

 Acute pain related to the inflammation of the middle ear.

 Anxiety related to health status.

 Impaired verbal communication related to effects of hearing loss.

 Disturbed sensory perception related to obstruction, infection of the middle ear, or auditory
nerve damage.

 Risk for injury related to hearing loss, decreased visual acuity.

  Infection related to presence of pathogens.

Nursing Interventions

Nursing care for the child with otitis media include:

 Positioning: Have the child sit up, raise head on pillows, or lie on unaffected ear.

 Heat application: Apply heating pad or a warm hot water bottle.

 Diet: Encourage breastfeeding of infants as breastfeeding affords natural immunity to infectious

agents; position bole-fed infants upright when feeding.

 Hygiene: Teach family members to cover mouths and noses when sneezing or coughing and to
wash hands frequently.

 Monitoring hearing loss: Assess hearing ability frequently.

Evaluation

Goals are met as evidenced by:

 The child or parent indicated absence of pain.

 The child is free of infection.

 The parents stated understanding of preventive measures.

 The child has normal hearing.