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OTITIS MEDIA
Definition: Presence of a middle ear infection or inflammation.
Acute Otitis Media: occurrence of bacterial infection within the middle ear cavity.
Otitis Media with Effusion: presence of nonpurulent fluid within the middle ear cavity (viral)
OM is the second most common clinical problem in childhood after upper respiratory infection.
EPIDEMIOLOGY Peak incidence in the first two years of life (esp. 6-12
months) Boys more affected girls 50% of children 1 yr of age will have at least 1
episode. 1/3 of children will have 3 or more infections by age 3 90% of children will have at least one infection by age
6. Occurs more frequently in the winter months
MICROBES AT FAULT!!!
Streptococcus pneumoniae Haemophilus influenzae(non-typeable) Moraxella catarrhalis Group A Streptococcus Staph aureus Pseudomonas aeruginosa RSV assoc. with Acute Otitis Media
Classification of Otitis Media
Acute Otitis Media: presents with fever, otalgia, and hearing loss
Otitis Media with Effusion: evidence of middle ear effusion on pneumatic otoscopy
Recurrent Otitis Media: inability to clear middle ear effusions
Chronic Serous Otitis Media: presents as ‘fullness in the ear’, tinnitus, or another acute disease.
RISK FACTORS Upper Respiratory Infections. Allergies. Craniofacial abnormalities. (cleft palate) Down’s Syndrome. Passive smoking. Eustachain tube, short, wide & straight.
PATHOGENESIS
This problem mainly deals with eustacian tube dysfunction. Otitis Media usually follows an URI in which there is edema of the eustacian tube, leading to blockage. Stasis of these middle ear secretions lead to infection and irritation
Other factors: allergic rhinitis, nasal polyps, adenoidal hypertrophy
SIGNS & SYMPTOMS
Neonates/Infants: change in behavior, irritability, tugging at ears, decreased appetite, vomiting.
Children(2-4): otalgia, fever, noises in ears, cannot hear properly, changes in personality.
Children (>4): complain of ear pain, changes in personality.
On Physical exam…
The classic description for Otitis Media is an erythematic, opaque, bulging tympanic membrane with loss of anatomic landmarks including a dull/absent light reflex.
Pneumatic Otoscopy: decreased tympanic membrane mobility
DIAGNOSIS
Pneumatic Otoscopy: standard tool for diagnosis
Impedance Tympanometry: useful for MEE. Measures the resonance of the ear canal for a fixed sound as the air pressure is varied.
Spectral Gradient Acoustic Reflectometry: measures the condition of the middle ear by assessing the response of the TM to a sound stimulus. Equivalent to tympanometry for dx of middle
ear effusions
Diagnosis cont.
Diagnostic tympanocentesis & myringotomy: involves puncturing the tympanic membrane and aspirating middle ear fluid to relieve pressure. Only used if the primary and secondary line treatment fail.
With the increasing incidence of drug resistant strains of S. pneumoniae, CDC recommends the capacity of clinicians to be efficient in using tympanocentesis.
INDICATIONS FOR TYMPANOCENTESIS
Toxic appearing child Failed treatment regimen with
antibiotics Suppurative complications Immunosuppressed pt. Newborn infant in which the usual
pathogens may not be the case.
DIFFERENTIAL DIAGNOSIS
Otitis externa Bullous myringitis Cerumen impaction Dental abscess Foreign body in ear canal Referred pain (parotid/tooth/lymphadenitis)
Tonsilitis
TREATMENT
Amoxicillin: 20-40 mg/kg/day tid for 10-14 days or,
Augmentin: 45 mg/kg/day po bid for 10-14 days
Auralgan: analgesic/adjunct for ear pain 2-4 drops tid
2nd Line Treatment Regimen
Cefzil Pediazole ( erythromycin/sulfisoxazole) Bactrim (trimethoprim/sulfamethoxazole These medications are used as
secondary agents if the primary antibiotic has failed after 10 days and the symptoms persists.
COMPLICATIONS
Hearing loss: conductive, sensoneural, mixed) Acute mastoiditis: before the advent of antibiotics Chronic perforation of the TM Tympanosclerosis Cholesteatoma Chronic suppurative OM Cholesterol granuloma: ‘Blue drum syndrome’ Facial nerve paralysis
Complications cont…
Intracranial complications Bacterial meningitis Epidural abscess Subdural empyema Brain abscess Otitic hydrocephalus Lateral sinus thrombosis
Nursing Intervention
Parent teaching about prophylactic care
Position infants as upright as possible during feeding
to avoid reflux of formula into eustachian tube.
Avoid smoking around infants and children.
Administer analgesics as ordered to provide pain
relief.
Heat pack application over the ear may relieve pain
for some children.
Position child on the affected side to promote
drainage (if draining, or postoperatively after
myringotomy).
Assist in removal of drainage, when possible
Postoperative support may include wicks inserted
loosely in the ear to promote drainage but prevent
infection transfer to middle ear.
Frequent cleansing of outer ear and moisture barrier
on ear to protect from purulent drainage.
Family-centered care Educating the family in care of child
Analgesia for pain management
• Postoperative care to prevent spread of infection
and promote healing
Providing emotional support to the child and family
• Explain the process for management of drainage.
• Encourage follow-up evaluation of hearing to detect
any loss of hearing.