OTITIS MEDIA

INTRODUCTION

An ear infection (sometimes called acute otitis media) is an infection of the

middle ear, the air-filled space behind the eardrum that contains the tiny vibrating
bones of the ear. Children are more likely than adults to get ear infections.Because
ear infections often clear up on their own, treatment may begin with managing
pain and monitoring the problem. Sometimes, antibiotics are used to clear the
infection. Some people are prone to having multiple ear infections. This can cause
hearing problems and other serious complications. Otitis media is a group of
inflammatory diseases of the middle ear. The two main types are acute otitis
media (AOM) and otitis media with effusion(OME). AOM is an infection of rapid
onset that usually presents with ear pain. In young children this may result in
pulling at the ear, increased crying, and poor sleep.[1] Decreased eating and
a fever may also be present. OME is typically not associated with
symptoms. Occasionally a feeling of fullness is described. It is defined as the
presence of non-infectious fluid in the middle ear for more than three
months. Chronic suppurative otitis media(CSOM) is middle ear inflammation that
results in discharge from the ear for more than three months.[7] It may be a
complication of acute otitis media. Pain is rarely present. All three may be
associated with hearing loss. The hearing loss in OME, due to its chronic nature,
may affect a child's ability to learn.

DEFINITION

Inflammation of the middle ear characterized by the accumulation of

infected fluid in the middle ear, bulging of the eardrum, pain in the ear and, if
eardrum is perforated, drainage of purulent material (pus) into the ear canal. Otitis
media is an inflammation of the middle ear without reference to etiology or
pathogenesis.

INCIDENCE

More than 80% of children have at least one episode of otitis media by the
time they are three years of age. Nearly half of these children have three or more
episode by the time they are three years of age. It occurs more often in the winter
and early spring. The peak incidence of AOM is in children aged 3-18 months.
Some infants may experience their first attack shortly after birth and are
considered otitis, prone (ie, at risk for recurrent otitis media). 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.
RISK FACTORS

Age.

Children between the ages of 6 months and 2 years are more susceptible to
ear infections because of the size and shape of their eustachian tubes and because
their immune systems are still developing.

Group child care.

Children cared for in group settings are more likely to get colds and ear
infections than are children who stay home. The children in group settings are
exposed to more infections, such as the common cold.

Infant feeding.

Babies who drink from a bottle, especially while lying down, tend to have
more ear infections than do babies who are breast-fed.

Seasonal factors.

Ear infections are most common during the fall and winter. People with
seasonal allergies may have a greater risk of ear infections when pollen counts
are high.

Poor air quality.

Exposure to tobacco smoke or high levels of air pollution can increase the
risk of ear infections.

Cleft palate.
 Differences in the bone structure and muscles in children who have cleft
palates may make it more difficult for the eustachian tube to drain.

Immature immune system.

Otitis media is an infectious disease that prospers in an environment of decreased

immune defenses.

Genetic predisposition.

Although familial clustering of otitis media has been demonstrated in studies that
examined genetic associations of otitis media, separating genetic factors from
environmental influences has been difficult.

Anatomic abnormality.

Children with anatomic abnormalities of the palate and associated musculature have a
higher risk for otitis media.

Physiologic dysfunction.

Abnormalities in the physiologic function of the ET mucosa increase the risk of

bacterial invasion of the middle ear and the resultant otitis media.

Bacterial pathogens.

The most common bacterial pathogen is Streptococcus pneumoniae, followed

by Haemophilus influenzae, and Moraxella catarrhalis.

Infant feeding methods.

Many studies report that breastfeeding protects infants against otitis media.

TYPES

a. Acute otitis media

This type of ear infection comes on quickly and is accompanied by swelling and
redness in the ear behind and around the ear drum. Fever, ear pain, and hearing
impairment often occur as a result of trapped fluid and/or mucous in the middle
ear.

b. Otitis media with effusion

Fluid (effusion) and mucous continue to accumulate in the middle ear after an
initial infection subsides. This can cause the feeling of the ear being “full” and
affect your ability to hear clearly.

PATHOPHYSIOLOGY

Due to etiological factors

Exudate and edema in the middle ear

Decrease retraction of tympanic membrane

Serous exudates in the middle ear

Pus formation
 Tympanic membrane rupture

Acute otitis media

CLINICAL FEATURES

Otitis media should be suspected in children with a history of characteristic head-

neck and general symptoms.

1.Otalgia.

Young children may exhibit signs of otalgia by pulling on the

affected ear or ears or pulling on the hair; otalgia apparently occurs more
often when the child is lying down.

2.Otorrhea.

Discharge may come from the middle ear through a recently

perforated tympanic membrane, or through another perforation.

3. Headache. An older child may complain of a headache.

4.Symptoms of upper respiratory infection.

Concurrent or recent symptoms of URI, such as cough, rhinorrhea or sinus

congestion is common.

5.Fever. Two-thirds of children with otitis media have a history of fever, although
fevers greater than 40°C are uncommon.
 6.Irritability. Irritability may be the sole early symptom in a young infant or
toddler.

DIAGNOSTIC FINDINGS

1.Laboratory tests.

Laboratory evaluation is usually unnecessary, although many experts

recommend a full sepsis workup in infants younger than 12 weeks who present
with fever and otitis media.

2.Pneumatic otoscope
An instrument called a pneumatic otoscope is often the only specialized
tool a doctor needs to diagnose an ear infection. This instrument enables the doctor
to look in the ear and judge whether there is fluid behind the eardrum. With the
pneumatic otoscope, the doctor gently puffs air against the eardrum. Normally,
this puff of air would cause the eardrum to move. If the middle ear is filled with
fluid, your doctor will observe little to no movement of the eardrum.

3.Tympanometry.

This test measures the movement of the eardrum. The device, which seals
off the ear canal, adjusts air pressure in the canal, which causes the eardrum to
move. The device measures how well the eardrum moves and provides an indirect
measure of pressure within the middle ear.

4.Acoustic reflectometry.

This test measures how much sound is reflected back from the eardrum —
an indirect measure of fluids in the middle ear. Normally, the eardrum absorbs
most of the sound. However, the more pressure there is from fluid in the middle
ear, the more sound the eardrum will reflect.

5.Tympanocentesis.

Rarely, 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.

Other tests.

If the child has had multiple ear infections or fluid buildup in the middle
ear, the doctor may refer to a hearing specialist (audiologist), speech therapist or
developmental therapist for tests of hearing, speech skills, language
comprehension or developmental abilities.

COMPLICATIONS
Most ear infections don't cause long-term complications. Ear infections that
happen again and again can lead to serious complications:

1.Impaired hearing.

Mild hearing loss that comes and goes is fairly common with an ear
infection, but it usually gets better after the infection clears. Ear infections that
happen again and again, or fluid in the middle ear, may lead to more-significant
hearing loss. If there is some permanent damage to the eardrum or other middle
ear structures, permanent hearing loss may occur.

2.Speech or developmental delays.

 If hearing is temporarily or permanently impaired in infants and
toddlers, they may experience delays in speech, social and developmental skills.

3.Spread of infection. Untreated infections or infections that don't respond well to

treatment can spread to nearby tissues. Infection of the mastoid, the bony
protrusion behind the ear, is called mastoiditis. This infection can result in damage
to the bone and the formation of pus-filled cysts. Rarely, serious middle ear
infections spread to other tissues in the skull, including the brain or the membranes
surrounding the brain (meningitis).

4.Tearing of the eardrum.

Most eardrum tears heal within 72 hours. In some cases, surgical repair is
needed.

MANAGEMENT

Antibiotic therapy. Among other recommendations, the guidelines

recommended antibiotics for bilateral and unilateral otitis media in children aged
at least 6 months with severe signs and symptoms.

Pharmacologic Management

The FDA has approved more than a dozen antibiotics to treat otitis media.

1.Antimicrobial agents. These agents remove pathogenic bacteria from the

middle ear fluid.
SURGICAL MANAGEMENT
From the beginning, it is essential to integrate surgical management of otitis
media with medical treatment.

1.Myringotomy and TT placement.

Myringotomy or the incision of the eardrums may be performed to establish

drainage and to insert tiny tubes into the tympanic membrane to facilitate
drainage.

2.Adenoidectomy.

The performance of adenoidectomy to treat patients with otitis media has

generated extensive discussion and research, though potential benefits are
controversial.

Nursing Management

Most infants and children with otitis media are cared for at home; therefore, a
primary responsibility of the nurse is to teach the family caregivers about
prevention and the care of the child
.
Nursing Assessment

Assessment of a child with otitis media include the following:

1.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.

2.Physical examination. The infant’s ear is examined with an otoscope by

pulling he ear down and back to straighten the ear canal.
3.Positioning. Have the child sit up, raise head on pillows, or lie on unaffected
ear.

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

5.Diet. Encourage breastfeeding of infants as breastfeeding affords

natural immunityto infectious agents; position bole-fed infants upright when
feeding.

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

7.Monitoring hearing loss. Assess hearing ability frequently.

SURGICAL MANAGEMENT

1. Myringotomy and TT placement. Myringotomy or the incision of the

eardrums may be performed to establish drainage and to insert tiny tubes into the
tympanic membrane to facilitate drainage.

2. Adenoidectomy. The performance of adenoidectomy to treat patients with otitis

media has generated extensive discussion and research, though potential benefits
are controversial.

NURSING DIAGNOSIS

1. Acute pain related inflammation as evidenced by continuous crying episode.

2. Disturbed sensory perception related to inflammation of the middle ear as

evidenced by child compliants not being able to hear.

3.Risk for infection related to deficient knowledge regarding infection