A CASE STUDY ON

INTRODUCTION
Acute Otitis Media is defined as the first 3 weeks of a process in which the middle ear shows the signs and
symptoms of acute inflammation. Otitis Media Effusion is defined as the presence of fluid in the middle ear with
accompanying conductive hearing loss and without concomitant symptoms or signs of acuity. OME is classified as
subacute when it persists from 3 weeks to 3 months after the onset of Acute Otitis Media and is classified as chronic
thereafter. 
Obstruction of the eustachian tube appears to be the most important antecedent event associated with AOM.
Most episodes are triggered by an upper respiratory tract infection (URTI) involving the nasopharynx. The infection is
usually of viral origin, but allergic and other inflammatory conditions involving the eustachian tube may create a
similar outcome. Inflammation in the nasopharynx extends to the medial end of the eustachian tube, creating stasis
and inflammation, which, in turn, alter the pressure within the middle ear. These changes may be either negative
(most common) or positive, relative to ambient pressure. Stasis also permits pathogenic bacteria to colonize the
normally sterile middle ear space through direct extension from the nasopharynx by reflux, aspiration, or active
insufflation. The response is the establishment of an acute inflammatory reaction characterized by typical
vasodilatation, exudation, leukocyte invasion, phagocytosis, and local immunologic responses within the middle ear
cleft, which yields the clinical pattern of AOM. In a minority of otitis-prone children, the eustachian tube is patulous or
hypotonic.
Viral infection in the nasopharynx with subsequent inflammation of the orifice and mucosa of the eustachian tube
has long been understood as part of the pathogenesis of AOM, although the complete role of the virus is not fully
understood. Concurrent or antecedent URTIs are identified in at least a quarter of all attacks of AOM in children, but
the virus itself seldom appears as the pathogen in the middle ear. Administration of trivalent influenza A vaccine has
been shown to reduce the frequency of AOM during the influenza season. 
 The presence of viruses in the middle ear effusion may influence the outcome of therapy for otitis media.
Results of outcome studies have been mixed, ranging from no effect to evidence of prolongation of acuity and
effusion when viruses are present in persons with AOM.
Immunologic activity may play a significant role in the frequency of AOM and its outcome. Although most
research has focused on the immunologic aspects of OME, certain relations between AOM and the patient’s
immune status have been demonstrated, as follows:
• Production of antibodies may promote clearance of a middle ear effusion after an acute attack
• Previous exposure or immunization may have a preventative role by suppressing colonization of the
nasopharynx by pathogens
• The formation of antibodies during an attack may prevent or modify future attacks; unfortunately, antibodies
to both Streptococcus pneumoniae and Haemophilus influenzae are of the polysaccharide type and the ability to
produce them develops late unless conjugated to proteins
• Minor or transient immunologic defects may give rise to recurrent otitis media
Pathogenic bacteria are recovered from the middle ear effusion in at least half the children with AOM, and
bacterial DNA or cell wall debris is found in another quarter to a third of specimens previously classified as sterile.
Four bacteria—namely, S pneumoniae, H influenzae, Moraxella catarrhalis,  and Streptococcus pyogenes —are
responsible for most episodes of AOM in persons older than 6 weeks. Other bacteria recovered and implicated in
AOM include Staphylococcus aureus, viridians streptococci, and Pseudomonas aeruginosa. The emergence of
resistance to antimicrobial agents is of increasing importance in the management of AOM and other bacterial
illnesses.  The various mechanisms used by bacteria to confer this resistance will be delineated as the common
pathologic agents linked to AOM are described.
 S pneumoniae is the most common etiologic agent responsible for AOM and for invasive bacterial infections in children of all age
groups. It is a gram-positive diplococcus with 90 identified serotypes (classified based on the polysaccharide antigen), the frequency of
which varies between age groups and geography.
Moraxella catarrhalis, in the mid-1970s, M catarrhalis was classified as nonpathogenic in middle ear infections, even though under
its previous name, Neisseria catarrhalis, it constituted approximately 10% of all isolates from middle ear aspirates. M catarrhalis is a gram-
negative diplococcus and is considered part of the normal flora of the human upper respiratory tract.
Streptococcus pyogenes although S pyogenes (a gram-positive coccus that constitutes the group A streptococci [GAS] in the
Lancefield classification), is still the fourth most isolated bacterial pathogen from ears with AOM, it has shown a steady decline in
frequency of recovery from the ear and in virulence over the past half-century. Similarly, a substantial decline in the major complications
of streptococcal infection, rheumatic fever, glomerulonephritis, and scarlet fever has occurred.
Pathologically, the ear showed a marked paucity of the normal vascular proliferation associated with an inflammatory
reaction. Instead, a complete loss of the vascularity normally associated with vasculitis or toxin exposure occurred. Healing was
never normal; tissue was replaced by epithelial invasion or scar tissue formation.
In industrialized societies, acute necrotic otitis media is now primarily of historic interest. The disease is still reported in
aboriginal populations living in areas where modern medicine has not yet penetrated. Anaerobic bacteria have been recovered
from the middle ears of children with AOM, but the data do not support a prominent role for these microorganisms in persons with
otitis media, at least in the acute form. They may, however, play a greater role in chronic inflammation of the adenoid bed and
biofilm formation. When recovered from ears of children with AOM, the anaerobic pathogen most often is not the sole pathogen
cultured. In the perinatal period, the Escherichia coli, Enterococcus species, and group B streptococci are the etiologic agents most
commonly responsible for sepsis and meningitis. These agents are often recovered from the middle ear, though the total
percentage is probably less than 10% of neonates with AOM
S pneumoniae remains the most common pathogen responsible for AOM in all age groups, including neonates. The
nonencapsulated H influenzae and nontypeable varieties may be invasive in these infants and constitute the second most common
pathogens recovered from the ear.
 The following are proven risk factors for otitis media; prematurity and low birth weight, young age, early onset, family
history, race - Native American, Inuit, Australian aborigine, altered immunity, craniofacial abnormalities, neuromuscular
disease, allergy, day care, crowded living conditions, low socioeconomic status, tobacco and pollutant exposure, use of
pacifier, prone sleeping position, fall or winter season, absence of breastfeeding, and prolonged bottle use
Children aged 6-11 months appear particularly susceptible to AOM, with frequency declining around age 18-20
months. The incidence is slightly higher in boys than in girls. A small percentage of children develop this disease later in
life, often in the fourth and early fifth year. After the eruption of permanent teeth, incidence drops dramatically, although
some otitis-prone individuals continue to have acute episodes into adulthood. Occasionally, an adult with an acute viral
URTI but no previous history of ear disease presents with AOM. Definite racial differences exist in the incidence of AOM.
Native Americans and Inuits have very high rates of acute and chronic ear infection, whereas African Americans appear to
have a slightly lower rate than white children living in the same communities.
Although the history of AOM varies with age, several constant features manifest during the otitis-prone years,
including the following:
• Neonates: Irritability or feeding difficulties may be the only indication of a septic focus
• Older children: This age group begins to demonstrate a consistent presence of fever and otalgia, or ear tugging
• Older children and adults: Hearing loss becomes a constant feature of AOM and otitis media with effusion (OME); ear
stuffiness is noted before the detection of middle ear fluid

Otalgia without hearing loss or fever is observed in adults with external otitis media, dental abscess, or pain referred
from the temporomandibular joint. Orthodontic appliances often elicit referred pain as the dental occlusion is altered.
 Diagnosis of AOM, Pneumatic otoscopy is the standard of care in the diagnosis of acute and chronic otitis media.
The following findings may be found on examination in patients with AOM:
•Signs of inflammation in the tympanic membrane
•Bulging in the posterior quadrants of the tympanic membrane may bulge, scalded appearance of the superficial
epithelial layer
•Perforated tympanic membrane (most frequently in posterior or inferior quadrants)
•Presence of an opaque serum like exudate oozing through the entire tympanic membrane
•Pain with/without pulsation of the otorrhea
•Fever
Other pharmacologic therapies have also been used to treat AOM. Analgesics and antipyretics have a definite
role in symptomatic management. Decongestants and antihistamines do not appear to have efficacy either early or
late in the acute process, although they may relieve coexistent nasal symptoms. Systemic steroids have no
demonstrated role in the acute phase.
Tympanocentesis and myringotomy are the procedures used to treat AOM. Certain patients require ventilation or
drainage of the middle ear cleft for an extended period or have a history of repetitive attacks; these patients benefit
from placement of a tympanostomy tube at the time of myringotomy.
Consultation is seldom necessary, although some otolaryngologists might be more comfortable having the
pediatrician provide all the primary care.
 At present, a chorus of advocates recommends withholding antibiotic therapy for patients with AOM and following a “watchful waiting” or “wait and
see” approach. As expected from long-known data, most children managed in this fashion do well, although a study from England observed an increase in
the rate of mastoiditis in children that was, essentially, the inverse of the rate of decrease in prescriptions for acute otitis.
A literature review by Thomas et al, which included scrutiny of evidence based AOM recommendations, particularly those found in current American
guidelines, concluded that the data used to compare the usefulness of prompt antibiotic therapy with 2-3 days of watchful waiting are not completely
consistent. The investigators stated that controlled trials with well-defined endpoints are still needed to better address the question. 
A randomized, double-blind, placebo-controlled study indicated that in children with AOM, antimicrobial treatment may prove most beneficial for those with
a severely bulging tympanic membrane, while initial observation may be the best course for children with a peaked tympanogram (A and C curves). The
study involved patients aged 6 to 35 months. 
Results from another randomized, placebo-controlled study indicated that antimicrobial treatment of AOM-related middle ear effusion is effective even
in older children. In the Finnish study, of 84 children aged 6 months to 15 years, 50% of the patients were treated with antibiotics, with middle ear effusion
resolving an average of 2 weeks earlier in these children than it did in patients who did not receive antibiotics. Reduction of mean duration of ear effusion
by age was as follows:
• < 2 years: 8 days
• Age 2-6 years: 20 days
• >6 years: 1 day
Some order has been brought to the discussions of antibiotic use under the auspices of the Centers for Disease Control and Prevention (CDC) and by
the Agency for Health Care Policy and Research (AHCPR), both agencies of the US government. The CDC published 6 principles of appropriate antibiotic use
to bring precepts of good public health and responsible therapy to the discussion while minimizing the selection of resistant strains of bacteria within the
community. These principles are as follows:
• Episodes of otitis media should be classified as AOM or otitis media with effusion (OME)
• Antimicrobials are indicated for treatment of AOM; however, diagnosis requires documented middle ear effusion and signs or symptoms of
acute local or systemic illness
• Uncomplicated AOM may be treated with a 5- to 7-day course of antimicrobials in certain patients older than 2 years
• Antimicrobials are not indicated for the initial treatment of OME; treatment may be indicated if effusions persist for longer than 3 months
 For the choice of regimen, in the absence of culture results obtained from tympanocentesis, selection of an
antibiotic should have the following 2 objectives: the antibiotic should cover most of the common bacterial
pathogens, and the antibiotic must be individualized for the child about allergy, tolerance, previous exposure to
antibiotics, cost, and community resistance levels. The duration of therapy is also empirically determined to some
degree, and data indicate that significant numbers of children do not receive prescribed antibiotics beyond relief of
acute symptoms. Traditionally, therapy is continued for 10-14 days; this is convenient for office scheduling, but it
may not necessarily be more efficacious than 5 or even 2 days of therapy.
Short-duration therapy may not be appropriate in children younger than 2 years who appear prone to failure even
after 14 days of therapy. When antibiotics are used in this manner, marked variations are found in both the
effectiveness of individual agents and the susceptibility of individual pathogens. Generally, beta-lactam antibiotics
are most successful against gram-positive pathogens for both disruption of adhesion and post antibiotic effect.
Amoxicillin (or erythromycin-Sul isoxazole, in patients who are allergic to penicillin) remains the initial treatment of
choice in children with AOM. Surgical management of AOM can conveniently be divided into 3 related procedures:
• Tympanocentesis
• Myringotomy
• Myringotomy with insertion of a ventilating tube
 Indications for these 3 procedures may be diagnostic, therapeutic, or prophylactic. More than 1 indication for
a procedure may have to be considered on a case-by-case basis. Selection of the appropriate procedure results
from evaluation of patient factors, surgeon factors, available resources, and urgency. Each of these aspects must
be examined to select that procedure that gives the optimal predicted outcome. Tympanocentesis, in its purest
form, is a diagnostic procedure that gives the clinician access to acute or chronic middle ear effusions for culture
and other evaluations. However, it can also be employed in a therapeutic setting. Additionally, tympanocentesis
remains a valuable research tool in the evaluation of new antimicrobial agents for efficacy in AOM and for
identification of host defense mechanisms or flaws in the middle ear immunochemistry. Myringotomy is the
incision and drainage procedure for AOM. It is a product of technology that allows the illumination of the
tympanic membrane, with or without magnification. Some patients with AOM require ventilation or drainage of
the middle ear cleft for an extended period (eg, patients with mastoiditis), whereas others may have a history of
repetitive attacks. These patients benefit with the placement of a tympanostomy tube at the time of
myringotomy. In most instances, general anesthesia or sedation is necessary in older children because topical
anesthesia is relatively ineffective in acutely inflamed tympanic membranes. Numerous tube designs are now
available, each with its own weaknesses and strengths with respect to retention, reactivity, and complications.
Mastoidectomy predates the extensive use of tympanic membrane incision, primarily because of the severity of
the disease and the relatively frequent occurrence of spontaneous perforation in otitis-prone individuals. For
example, in Eskimo communities of northern Canada, native Inuit are often found with large central perforations
from chronic otitis.
 Children with recurrent AOM have no effusion within the middle ear cleft between attacks of acute disease.
Management of this condition is confined to either episodic management or preventive treatment.
In episodic management, each episode is considered a new attack and is treated with antibiotics; the patient is
monitored until the episode resolves. Preventative treatment involves the administration of a conjugated
heptavalent pneumococcal vaccine. Although the vaccine is intended to combat invasive effects in infants,
immunized children have a reduced incidence of AOM, a reduced need for antibiotic therapy or tympanostomy
tubes, and a reduced risk of invasion or hearing loss. Since the introduction of the heptavalent pneumococcal
vaccine in 2000, researchers have found that nearly two thirds of invasive pneumococcal disease cases in young
children have been caused by 6 serotypes that were not included in that vaccine
Re-examine patients within 48 hours if no evidence of decreasing acuity manifests, if symptoms become more
severe, or if a complication becomes evident. Otherwise, follow-up care is normally scheduled 10-14 days after the
acute event. Persistent middle ear effusion should be expected at the initial follow-up visit; statistically, only 30% of
patients show complete resolution. In the absence of acuity, further treatment is unwarranted, but the patient
should be scheduled to return at intervals until the effusion resolves. The author often gives parents an “emergency
prescription” to be filled if the child with fluid in the middle ear develops acute symptoms prior to the next scheduled
visit. In addition to decreasing off-hours calls, this provides the parent with a sense of security.
Hence, Acute otitis media (AOM) has been described as a self-limiting disease, provided that the patient does
not develop a complication. This is an old description that has a renewed relevance. In the new millennium,
practitioners are forced to learn the lessons of history because these may serve as our models of practice without
effective antimicrobial agents. Nevertheless, for the time being, antibiotics remain the initial therapy of choice for
AOM.
Objectives (CASE PRESENTATION)
 DEFINE ACUTE OTITIS MEDIA
 PRESENT AND UNDERSTAND THE CASE SCENARIO
 UNDERSTAND THE DISEASE PROCESS OF ACUTE OTITIS MEDIA
 DETERMINE TEST DONE AND TREATMENT MEDICATIONS
CASE SCENARIO
 
A 2-year-old girl was seen by a pediatric nurse practitioner in the ambulatory clinic. The girl's
mother reported that her daughter had been fussing and pulling on her right ear for the past
2 days but had no fevers or lethargy. There were no recent sick contacts.
 
The patient had no history of ear surgery. She was not taking any medications and had no
known drug allergies.
 
The patient demonstrated normal vital signs. She appeared nontoxic and was breathing
comfortably. She was awake, active, and tugging on her right ear. There was no erythema or
edema of the right auricle or mastoid.
 
Otoscopic exam of the right ear demonstrated a normal-appearing external auditory canal and
an inflamed and bulging tympanic membrane. The tympanic membrane was immobile
on pneumatic insufflation. No otorrhea was seen in the canal. The remainder of the physical
exam, including left ear otoscopy, was unremarkable.
 
Diagnosis reveal an acute otitis media.
Pathophysiology of
Acute otitis media
 Table 1.1 Nursing Care Plan for acute pain
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute pain   INDEPENDENT: Pain scale measures the changes GOAL MET:
The girl's mother related to   Assess client’s description and in the level of pain by different  
reported that her inflamed middle After 8 hours of frequency of pain; Use a pain providers.  Preverbal infants After 8 hours of
daughter had been ear manifested comprehensive rating scale. Observe if the vigorously pull comprehensive
fussing and pulling on by the child nursing infant is tugging or rubbing an or rub the affected ear, roll the nursing intervention,
her right ear for the tugging her right intervention, child ear. head, and appear irritable. child experienced
past 2 days ear, inflamed and will experience     relief from pain as
  bulging tympanic relief from pain as Encourage and assist the Promotes physical comfort evidenced by sleeping
Objective: membrane evidenced by parent to hold and comfort and distraction for a child through the night, not
Normal appearing   sleeping through the client. experiencing illness. pulling the ear and
external auditory the night, not     decrease crying
canal pulling the ear and   Movement of the eustachian tube, episodes
  decrease crying Encourage the mother to such as with chewing, may further
Inflamed and bulging episodes provide and offer liquid to soft aggravate the pain.
tympanic membrane foods.  
    Provides information about the
Tympanic membrane   effectiveness of the
was immobile on Monitor child for relief of pain medication and prevents untoward
pneumatic insufflation and any side effects effects.
  of medication  
    DEPENDENT:
  Analgesic such as acetaminophen
DEPENDENT: and ibuprofen alter response to
Administer pain medication pain.
 such as acetaminophen or 
 Table 1.2 Nursing Care Plan for Disturbed sensory perception; Auditory
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Disturbed sensory After 8 hours of Independent   Goal met.
The girl's mother perception: Nursing     At the end of 8 hours
reported that her Auditory related interventions, Reduce unnecessary The child may be confused and Nursing interventions,
daughter had been to inflammation patient’s auditory environmental noise. startled by sounds he or she Patient’s auditory
fussing and pulling on of the middle ear sense will be   cannot hear properly. sense is restored.
her right ear for the as evidence by restored. Encourage parents to speak in  
past 2 days patient right ear   a loud and clear voice and Assist the client to hear what is
  examinations look at the child when talking being said.
Objective: show inflamed    
Child is and bulging Notify caregiver of changes in  
  tympanic hearing ability or drainage  
Patient is very membrane. from the affected ear. Complications of Otitis Media may
irritable, complains     include perforation of the
pain and tugging her   eardrum, mastoiditis, or
right ear   conductive hearing loss.
  Collaborative  
Patient right ear    
examination shows Administer Antibiotics as  
swollen, inflammed prescribed e.g., Amoxicillin  
and bulging   When indicated for bacterial
perforated tympanic   infection, a full 10- day course of
membrane   an antibiotic is given to resolve
  otitis media and regain hearing.
   
 
 Table 1.3 Nursing Care Plan for Risk for infection
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Risk for infection After 4 hours of nursing     Goal met
The girl's mother reported related to bulging of intervention the child INDEPENDENT    
that her daughter had tympanic membrane will remain free from   After 4 hours of nursing
been fussing and pulling as manifested by the further infection and Advice family members on Proper hygiene prevents spread of intervention the child
on her right ear for the child frequently complications from handwashing techniques and the Pathogens. remained free from
past 2 days pulling her right ear otitis media. importance of covering their   further infection and
  mouths and noses when sneezing   complications from otitis
Objective: or coughing.   media.
Normal appearing    
external auditory canal Encourage increased fluid intake,  
  good nutrition, and adequate rest.  
Inflamed and bulging    
tympanic membrane Eliminate allergens and airway Decreases susceptibility to infection.
  irritants such as tobacco, smoke,  
Tympanic membrane was and dust.  
immobile on pneumatic    
insufflation   Passive smoking contributes to increase
    the incidence of otitis media.
  Place the infant in an upright  
position when feeding. Do not prop  
bottles. Elevated position prevents injection of
  milk and pathogens into the eustachian
  tube
DEPENDENT:  
If infection occurs, teach the patient  
to take antibiotics as prescribed. Completing the duration of the
Instruct patient to take the full prescribed antibiotics lessens the chance
course of antibiotics even if for growth
symptoms improve or disappear Of a microorganism. Not completing the
  prescribed antibiotic regimen can lead to
 Table 2.1 DRUG STUDY OF AMOXICILLIN
NAME OF DRUG MODE OF INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES
ADMINISTRATION
Brand Name: Child: PO 25–50 Infections of ear, Hypersensitivity to Body as a Whole: As Assessment & Drug Effects
Amoxil/Amoxil Forte mg/kg/d (max: 60–80 nose, throat, GU tract, penicillin; infectious with other penicillins.
 Determine previous hypersensitivity reactions to
mg/kg/d) divided q8h skin, and soft tissue mononucleosis. Hypersensitivity
Generic Name: penicillin, cephalosporins, and other allergens prior
or 200–400 mg q12h caused by susceptible (rash, anaphylaxis),
amoxicillin to therapy.
bacteria. superinfections. 
 Lab tests: Baseline C&S tests prior to initiation of
GI: Diarrhea, nausea,
therapy, start drug pending results; periodic
Classification: vomiting, pseudo-
assessments of renal, hepatic, and hematologic
membranous
ANTIINFECTIVE; ANTI functions should be made during prolonged
colitis (rare). 
BIOTIC; AMINOPENIC therapy.
ILLIN Hematologic: Hemolytic
 Monitor for S&S of an urticarial rash (usually
anemia,
Prototype: Ampicillin occurring within a few days after start of drug)
eosinophilia, agranulocyt
suggestive of a hypersensitivity reaction. If it
Availability osis (rare). 
occurs, look for other signs of hypersensitivity
125 mg, 250 mg, 500 Skin: Pruritus, urticaria, (fever, wheezing, generalized itching, dyspnea),
mg tablets; 250 mg, or other skin eruptions.  and report to physician immediately
500 mg capsules; 50
Special  Report onset of generalized erythematous,
mg/mL, 125 mg/5 mL,
Senses: Conjunctival maculopapular rash (ampicillin rash) to physician.
250 mg/5 mL powder
ecchymosis. Ampicillin rash is not due to hypersensitivity;
for suspension; 200
however, hypersensitivity should be ruled out.
mg, 400 mg, 600 mg
dispersible.  Closely monitor diarrhea to rule out
pseudomembranous colitis.
 
  Patient & Family Education

   Take drug around the clock, do not miss a dose,

and continue therapy until all medication is taken,
unless otherwise directed by physician.
 Table 2.2 DRUG STUDY OF ANTIPYRINE/BENZOCAINE OTIC
NAME OF DRUG MODE OF INDICATION CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES
ADMINISTRATI EFFECTS
ON
Brand Name: Acute otitis media Temporary Hypersensitivity to Body as a Assessment & Drug Effects
Dolotic, A/B Otic, relief of pain benzocaine or other Whole: Low
Child: With  Assess swallowing when used on oral
Otic Care, OtiLam and discomfort PABA derivatives (e.g., toxicity;
tympanostomy mucosa, as benzocaine may interfere
in pruritic skin sunscreen sensitization in
Generic Name: tubes: 1-12 with second (pharyngeal) stage of
problems, preparations), or to any susceptible
antipyrine years as 0.3% swallowing; hold food and liquids
minor burns of the components in individuals; allergic
/benzocaine otic otic solution: accordingly.
and sunburn, the formulation; use of reactions, anaphyla
Instill 5 drops
Classification: minor wounds, ear preparation in xis.  Assess for sensitivity. Local
(0.75 mg) into
and insect patients with perforated Methemoglobinemi anesthetics are potentially sensitizing
otic anesthetics the canal of the
bites. Otic eardrum or ear a reported in to susceptible individuals when
Prototype: Procai affected ear(s)
preparations discharge; applications infants. applied repeatedly or over extensive
ne bid for 10 days.
are used to to large areas; use in areas.
Availability relieve pain children <2 y.  Patient & Family Education
and itching in
5% spray, cream,  Use specific benzocaine
acute
ointment; 6% preparation ONLY as prescribed or
congestive
cream; 8% recommended by manufacturer.
and serous
lotion, 20%
otitis media,  Discontinue medication if the
spray, ointment,
swimmer's ear, condition persists, worsens, or if
gel, liquid
and otitis signs of sensitivity, irritation, or
externa. infection occur.

NAME OF DRUG
Brand Name:
Augmentin, Augmentin-
ES600, Augmentin XR, Clavulin
Generic Name: AMOXICILLIN
AND CLAVULANATE
POTASSIUM
 
Classification:
ANTIINFECTIVE; BETA-
LACTAM
ANTIBIOTIC; AMINOPENICILLI
N and report to physician immediately.
Prototype: Ampicillin
Availability:
250 mg, 500 mg, 875 mg
tablets; 125 mg, 200 mg, 400
mg chewable tablets; 125
mg/5 mL, 200 mg/5 mL, 250
mg/5 mL, 400 mg/5 mL, 600
mg/5 mL oral suspension;
1000 mg amoxicillin/62.5 mg
clavulanate sustained-release
tablets
Actions
 
Table 2.3 DRUG STUDY OF AMOXICILLIN AND CLAVULANATE
POTASSIUM
MODE OF INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES
ADMINISTRATION
Child:  Infections caused by Combination shares toxic GI: Diarrhea, nausea, Assessment & Drug Effects
susceptible beta- potential of ampicillin. vomiting. 
PO <40 kg, 20–40  Determine previous hypersensitivity
lactamase-producing Hypersensitivity to penicillins;
mg/kg/d (based on Skin: Rash, urticaria. reactions to penicillin, cephalosporins, and
organisms: lower infectious mononucleosis.
amoxicillin component) other allergens prior to therapy.
respiratory tract  Other: Candidal vaginitis;
divided q8–12h; >3
infections, acute moderate increases in serum  Lab tests: Baseline C&S tests prior to
mo, 90 mg/kg/d of 600
bacterial sinusitis, ALT, AST; initiation of therapy; start drug pending
ES divided q12h x 10 d
community acquired glomerulonephritis; agranulo results.
pneumonia, otitis cytosis (rare).
media, sinusitis, skin  Monitor for S&S of an urticarial rash
and skin structure (usually occurring within a few days after
infections, and UTI. start of drug) suggestive of a
hypersensitivity reaction. If it occurs, look
for other signs of hypersensitivity (fever,
wheezing, generalized itching, dyspnea),
 Note: Generalized, erythematous,
maculopapular rash (ampicillin rash) is not
due to hypersensitivity. It is usually mild
but can be severe. Report onset of rash to
physician, since hypersensitivity should be
ruled out.
Patient & Family Education
 Female patients should report onset of
symptoms of Candidal vaginitis (e.g.,
moderate amount of white, cheesy, non-
odorous
 vaginal discharge; vaginal inflammation
and itching; vulvar excoriation,
inflammation, burning, itching). Therapy
may have to be discontinued.
Pneumatic otoscopy
Pneumatic otoscopy is the primary diagnostic tool to evaluate the status of the middle ear, because it allows assessment of the TM and
its mobility. The normal TM is translucent and concave and moves briskly with application of positive and negative pressure. A visible
landmark is the handle (manubrium) of the malleus, which is attached to the TM, with the umbo in the center of the TM. To
adequately visualize the TM, the external ear canal must be cleared of cerumen and debris. The assessment of the TM should note
position, color, degree of translucency.
Pneumatic otoscopy is an examination that allows determination of the mobility of a patient’s tympanic membrane (TM) in response to
pressure changes. The normal tympanic membrane moves in response to pressure. Immobility may be due to fluid in the middle ear, a
perforation, or tympanosclerosis, among other reasons. [1
Therefore, pneumatic otoscopy is important, as it can indicate the presence of effusion even when the appearance of the eardrum
otherwise gives no indication of middle ear pathology
 
The physical examination of a normal TM reveals a pale gray and usually translucent eardrum. The middle ear landmarks include the
short process and manubrium (or handle) of the malleus, which are in contact with the eardrum, and the chorda tympani nerve and
incudostapedial joint posterosuperiorly, which are deep or medial to the TM but are usually visible through the eardrum
In AOM, the TM is thickened and edematous and sometimes pale-yellow pus can be seen through the TM (Fig. 5-4). In the early
phases of AOM (myringitis), the TM may be reddened, but diagnosis of ear disease cannot be confirmed unless a middle ear effusion is
present. The strongest positive predictor of AOM is a bulging tympanic membrane that obliterates normal landmarks, followed by the
finding of reduced mobility and then an opaque tympanic membrane. 50 Redness alone is the least predictive because of the potential
for false-positive results that can occur when the child cries. Occasionally, there may be a red effusion when hemorrhage has occurred
in an inflamed middle ear.
NURSING RESPONSIBILITY
BEFORE
Prior to the start of the procedure, remove any wax that may obscure the view
Obtain consent.
Clear the external ear canal of any wax that might obscure the view.
 
DURING
doctor gently pulls the ear downward and backward to straighten the ear canal and get a better view of the eardrum.
 
The tip of an otoscope is then inserted into the ear canal, ensuring that a strong seal is made with the canal.
 
The eardrum is assessed for color, translucency, and position. A normal ear canal is convex, translucent, and intact.
The bulb on the otoscope is squeezed and released alternately create positive and negative pressure on the eardrum
and assess its mobility.
 
AFTER
Provide comfort. If test is facilitated at the bedside, reposition the client properly
TYMPANOCENTESIS
A doctor may use a tiny tube that pierces the eardrum to drain fluid from the middle ear — a procedure called
tympanocentesis. The fluid is tested for viruses and bacteria. This can be helpful if an infection hasn't responded
well to previous treatments. A minor surgical procedure that refers to puncture of the tympanic membrane with a
small gauge needle to aspirate fluid from the middle ear cleft or to provide a route for administration of
intratympanic medications.
Tympanocentesis is a diagnostic and therapeutic procedure used in the treatment of a wide range of otological
disorders, including acute otitis media, chronic otitis media with effusion, tympanic membrane retraction,
sensorineural hearing loss, and Ménière disease.
In most cases, doing a culture and sensitivity test on fluid collected by tympanocentesis can identify the bacteria
causing the infection. This helps the doctor prescribe an antibiotic that is more likely to work.
For a culture, a sample of body fluid or tissue is added to a substance that promotes the growth of germs. If no
germs grow, the culture is negative. If germs that can cause infection grow, the culture is positive. The type of
germ may be identified using a microscope or chemical tests. Bacteria usually grow quickly in a culture (2 days),
while other types of organisms, such as a fungus, can take longer.
A culture and sensitivity test may be done on many different body fluids, such as urine, mucus, blood, pus, saliva,
breast milk, spinal fluid, or discharge from the vagina or penis.
Nursing responsibilities
BEFORE
Prior to the start of the procedure, remove any wax that may obscure the view
Obtain informed consent.
Clear the external ear canal of any wax that might obscure the view.
Administer a local anesthetic agent in one of the methods described above in Anesthesia.
DURING
Position the patient supine, with the head rotated away from the operator, to allow visualization of the tympanic
membrane using an appropriately sized aural speculum.
*Optimal visualization is of prime importance. Take care to use the largest aural speculum that fits the external ear canal,
and do not proceed beyond the hair-bearing skin. Use a low magnification on the operating microscope to ensure
orientation, and clearly identify the handle of the malleus and the inferior half of the tympanic membrane. Then increase
the magnification of the microscope to allow precise placement of the needle.
Carefully advance the needle to the tympanic membrane, taking care not to damage the ear canal skin.
Once on the tympanic membrane, advance the needle through it and aspirate the syringe. In children with acute otitis
media, the perforation of the tympanic membrane is done quickly; in those with topical or no analgesia, the advance is
often best done slowly to minimize the pain of passing through the sensitive middle ear mucosa.
 

AFTER
Provide comfort. If test is facilitated at the bedside, reposition the client properly
MYRINGOTOMY
Myringotomy is a surgical procedure of the eardrum or tympanic membrane. The procedure is performed by making a
small incision with a myringotomy knife through the layers of tympanic membrane This surgical procedure permits direct
access to the middle ear space and allows the release of middle-ear fluid, which is the end product of
otitis media with effusion (OME), whether acute or chronic. The fluid is suctioned from the middle ear through the
incision and, if indicated, sent for bacterial or viral cultures. Currently, bilateral myringotomy is often used in conjunction
with placement of middle-ear ventilation tubes, which permits the incised drum to remain open and allows better drainage
of middle-ear fluid. OME may spontaneously occur because of inadequate ventilation of the middle-ear space related to
poor eustachian tube function or a persistent inflammatory response to acute otitis media (AOM). a 3-mm, 5-mm, or 7-
mm tube is inserted and used to release the serous or mucoid effusion
Myringotomy may be indicated in cases of AOM, recurrent AOM with effusion (RAOME), and chronic otitis media with
effusion (COME). Patients with AOM that is refractory to medical therapy or associated with signs of toxicity require
myringotomy with or without middle-ear culture. Children with recurrent acute episodes of otitis media (usually
understood as more than 4-5 infections in 6 months) benefit from myringotomy.
Reasons to Have a Myringotomy
A myringotomy may be done:
To restore hearing loss caused by chronic fluid build-up and to prevent delayed speech development caused by hearing
loss in children
To place tympanostomy tubes — these tubes help to equalize pressure. It may also help prevent recurring ear infections
and the accumulation of fluid behind the ear drum.
To help treat an ear infection that is not responding to medical treatment
To take sample fluid from the middle ear to examine in the lab for the presence of bacteria or other infections
NURSING RESPONSIBILITY
BEFORE
Prior to the start of the procedure, remove any wax that may obscure the view
Obtain informed consent.
Clear the external ear canal of any wax that might obscure the view.
Administer a local anesthetic agent in one of the methods described above in Anesthesia.
AFTER
Instruct the parent that it is important for your child to rest for the remainder of the day and be
under adult supervision. The child should not ride his/her bike or perform such activities that require
coordination.
Instruct the parent that child will need to stay in the recovery room to be watched until he or she is
alert and his or her vital signs are stable. The length of time your child will spend in the recovery
room may be different from other patients because some children take longer than others to wake
up after anesthesia
IMMITTANCE TESTING (TYMPANOMETRY)
Immittance testing is an excellent adjunct to the assessment of middle ear status and the management of otitis media. When otoscopic
evaluation is inconclusive or difficult to perform, tympanometry can be very useful in evaluating ear disease in children older than 6 months
of age. It is easy to perform and most often is well accepted by the patient. It has been used for school screening as well as in pediatricians’
offices. It also is valuable for documentation of middle ear status over time with repeat testing.
Tympanometry can help diagnose disorders that can lead to hearing loss, especially in children. The test measures the movement of your
tympanic membrane in response to changes in pressure. The tympanic membrane is a thin tissue that separates the middle and outer
segments of the ear. The results of tympanometry are recorded on a graph called a tympanogram.
The test can help your doctor determine if you have:
fluid in your middle ear
otitis media (a middle ear infection)
a perforation (tear) in the tympanic membrane
a problem with the eustachian tube, which links the upper part of the throat and nose with the middle ear
Normal tympanometry test results mean. There’s no fluid in the middle ear. The eardrum moves normally. There’s normal pressure in the
middle ear. There’s normal movement of the ossicles (the small bones of the middle ear that conduct sound and aid in hearing) and the
eardrum. Normal pressure inside the middle ear can vary between +50 to -200 decapascals (daPa) for both children and adults and the
abnormal tympanometry test results may suggest. Fluid in the middle ear, perforation of the eardrum (tympanic membrane), scarring of the
eardrum, which usually results from frequent infections, middle ear pressure beyond the normal range

NURSING RSPONSIBILITIES
BEFORE
doctor may look inside your ear canal with a special instrument called an otoscope. This is to make sure there’s no earwax or a
foreign object obstructing your ear canal.
DURING
Instruct the client not to move, speak, or swallow during the test. If you do, it may give an incorrect result.
The test takes about two minutes or less for both ears
 DISCHARGE CARE PLAN
MEDICATION
 Ensure that the patient’s caregiver is able to follow the medication instructions

Rationale: To achieve the therapeutic effect of the medication prevent further complications and risks
 Instruct the significant other to notice and report any unfavourable or unpleasant responses that may develop while taking the drug.

Rationale: To prevent further complications

 Instruct the significant other not to give any other medicine to her child without first asking the healthcare provider.

Rationale: To prevent any complications 

EXERCISE/ACTIVITY
 Instruct the significant other to place a warm washcloth on the outer ear for 20 minutes to help with pain until the pain medicine starts to work.

Rationale: to alleviate discomfort and may help ease pain.

 Advise significant other to let the child rest and sleep as much as possible.

Rationale: resting will help the child’s body fight the infection
 Instruct the mother to have assist her child in an upright position

Rationale: This is to alleviate pressure

 Instruct the significant other to watch for ear discharge

Rationale: Pus discharge can be normal with an ear infection. Most often, this heals after the ear infection is treated. Wipe the discharge away. Careful not to plug the ear
withcotton as retained pus can cause an infection of the lining of the ear canal.
 Advise the significant other to avoid using cotton swabs to her child

Rationale: Cotton swabs pack wax into the ear canal.

 Instruct the mother not to bottle-feed the child while lying on her back. It should be at thirty-degree or more.

Rationale: This is to prevent fluid accumulation in the Eustachian tube.

TREATMENT
 Emphasize to the mother the importance of regular follow up check-up and as instructed by the
physician
Rationale: To make sure that the patient and significant other has full awareness and knowledge
about the condition. This will also promote recovering well from the illness.
 Ensure that the significant other will give the child’s medication at the right time as directed by the
physician
Rationale: Medications should be taken regularly to make sure that it has an effective amount of
drug in the body.

HYGIENE
 Advise the mother to wash her child’s hands often to prevent infection
Rationale: Hand washing lessens the contamination to microorganism that may cause infection.
 Instruct the significant other to keep her child away from cigarette smoke
Rationale:   To prevent future ear infections and their potential risks. Exposure to secondhand
smoke can make ear infections more severe and frequent.
OUTPATIENT
Encourage significant other to follow scheduled check-ups for her child.
Rationale:  The child’s ear will need to have the ear rechecked to make sure the infection has gone away.
Ensure that patients know who to call if they are having problems
Advise the family members to seek medical advice if any abnormality arises
Rationale: To prevent further complications and have the client monitored until full recovery is attained.

DIET
Instruct the significant other to keep the child well hydrated
Rationale: To help flush the bacteria and viruses out of the body
Instruct the significant other to follow a healthy diet centered around fresh fruits, vegetables, whole grains, and
high-quality protein
Rationale: This will make the child’s immune system stronger.
Instruct the significant other to avoid dairy products
Rationale: Dairy is the number one contributor to childhood ear problems. 
Advise the significant other to let the child eat carrots and tomatoes which are a good source of vitamin A and C.
Rationale: It also reduce ear infections due to their antioxidant properties.

SPIRITUAL
Assist the patient and the significant other with their spiritual needs.
Encourage the client to continue to seek God’s guidance and enlightenment

 
REFERENCES:

INTRODUCTION

https://emedicine.medscape.com/article/859316-overview#a1

PATHOPHYSIOLOGY

https://www.grepmed.com/images/8313/pediatrics-peds-pathophysiology-symptoms-signs

DRUG STUDY
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/A054.html

http://robholland.com/Nursing/Drug_Guide/data/monographframes/A053.html

http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/B013.html

DIAGNOSTIC EXAM

https://emedicine.medscape.com/article/1413525-overview#a10

https://emedicine.medscape.com/article/1348950-overview

https://www.healthline.com/health/tympanometry

https://emedicine.medscape.com/article/1413525-overview#a2

https://www.medicinenet.com/how_do_you_perform_a_pneumatic_otoscopy/article.htm

https://www.nwh.org/surgery/surgical-discharge-instructions/myringotomy-and-tubes-instructions

https://www.uofmhealth.org/health-library/hw184017

https://childrensnational.org/visit/conditions-and-treatments/ear-nose-throat/myringotomy-tubes

DISCHARGE CARE PLAN

 
https://www.healthychild.com/ear-infections-alternative-solutions/

https://www.mtatva.com/en/disease/otitis-media-treatment-diet-and-home-remedies/

https://my.clevelandclinic.org/health/diseases/8613-ear-infection-otitis-media

https://www.bootshearingcare.ie/hearing-health/ear-infections/