Otitis Media

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Group 1 Abenojar, Bea Abinales, Jerome Adriano, Hannah Angeline Agbannawag, Jamie Agbayani, Rezzie Marie Aggabao, Ma. Concepcion Soccorro Agpalo, Vernice Eve Agustin, Lauren Paola

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Otitis Media
BACKGROUND Otitis media (OM) is the second most common disease of childhood, after upper respiratory infection (URI). OM is also the most common cause for childhood visits to a physician's office. Annually, an estimated 16 million office visits are attributed to OM; this does not include visits to the emergency department. OM is any inflammation of the middle ear without reference to etiology or pathogenesis. OM can be classified into many variants on the basis of etiology, duration, symptomatology, and physical findings.
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Acute Otitits Media (AOM) is a recurrent disease. More than one third of children experience 6 or more episodes of AOM by age 7 years. OM with effusion (OME), formerly termed serous OM or secretory OM, is MEE of any duration that lacks the associated signs and symptoms of infection (eg, fever, otalgia, irritability). OME usually follows an episode of AOM. Chronic suppurative OM is a chronic inflammation of the middle ear that persists at least 6 weeks and is associated with otorrhea through a perforated TM, an indwelling tympanostomy tube (TT; see image below), or a surgical 4/15/12 myringotomy

Otitis Media
Ear infection or inflammation (otitis media) facts:
Ear infection or inflammation causes fluid buildup in the

middle ear.
A cold orother respiratory infectioncan lead to ear

infections or inflammation.
Exposure to other children's colds, as in daycare, raises

the risk of ear infection or inflammation.

Bottle-feedingincreases the risk of ear infection or

inflammation in babies.

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Otitis Media
Ear infection or inflammation symptoms and signs are

fever, ear pain and fullness, as well as fussiness and feeding problems in young children.
Middle ear pus causes pain and temporary hearing loss. Rupture of the eardrum allows the pus to drain into the

ear canal.
Ear infection or inflammation is treated with observation,

antibiotics, orear tubes.

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Otitis Media
EPIDEMEOLOGY
Frequency

United States

OM, the most common specifically treated childhood disease, accounts for approximately 20 million annual physician visits. Various epidemiologic studies report the prevalence rate of AOM to be 17-20% within the first 2 years of life, and 90% of children have at least one documented MEE by age 2 years. OM is a recurrent disease. One third of children experience 6 or more episodes of AOM by age 7 years.

International

Incidence and prevalence in other industrialized nations are similar to US rates. In less developed nations, OM is extremely common and remains a major contributor to childhood mortality 4/15/12

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Mortality/Morbidity

US mortality rates are extremely low in this era of antimicrobial therapy (< 1 death per 100,000 cases). In developing nations with limited access to primary medical care and modern antibiotics, mortality rates are similar to US rates before antibiotic therapy. Morbidity from this disease remains significant, despite frequent use of systemic antibiotics to treat the illness and its complications. Several more recent studies have shown equal AOM prevalence in males and females; many previous studies had shown increased incidence in boys.
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Sex

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Age

Peak prevalence of OM in both sexes occurs in children aged 6-18 months. Some studies show bimodal prevalence peaks; a second, lower peak occurs at age 4-5 years and corresponds with school entry. Although OM can occur at any age, 80-90% of cases occur in children younger than 6 years. Children who are diagnosed with AOM during the first year of life are much more likely to develop recurrent OM and chronic OME than children in whom the first middle ear infection occurs after age 1 year 4/15/12

Otitis Media
What is otitis media? Otitis media is inflammation of the middle ear. "Otitis" means inflammation of the ear, and "media" means middle. This inflammation often begins with infections that causesore throats, colds or other respiratory problems, and spreads to the middle ear. These can be caused by viruses or bacteria, and can be acute or chronic. Acute otitis mediais usually of rapid onset and short duration. Acute otitis media is typically associated with fluid accumulation in the middle ear together with signs or symptoms of ear infection; a bulging eardrum usually accompanied by pain, or a perforated eardrum, often with drainage of purulent material (pus).Fevercan be 4/15/12 present.

Otitis Media
Chronic otitis mediais a persistent inflammation of the middle ear, typically for a minimum of a month. This is in distinction to an acute ear infection (acute otitis media) that usually lasts only several weeks. Following an acute infection, fluid (an effusion) may remain behind the ear drum (tympanic membrane) for up to three months before resolving. Chronic otitis media may develop after a prolonged period of time with fluid (effusion) or negative pressure behind the eardrum (tympanic membrane). Chronic otitis media can cause ongoing damage to the middle ear and eardrum and there may be continuing drainage through a hole in the eardrum. Chronic otitis media often starts painlessly without fever. Ear pressure or popping can be persistent for months. Sometimes a subtle loss4/15/12 of hearing can be due to chronic otitis media.

Otitis Media
CAUSES A multitude of host, infectious, allergic, and environmental factors contribute to OM development. 1.) Host factors

Immune system - The immature immune systems of infants or the impaired immune systems of patients with congenital immune deficiencies, HIV infection, or diabetes may be involved in the development of OM. OM is an infectious disease that prospers in an environment of decreased immune defenses. The interplay between pathogens and host immune defense plays a role in disease progression.
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Familial

(genetic) predisposition - Although familial clustering of OM has been demonstrated in studies that examined genetic associations of OM, separating genetic factors from environmental influences has been difficult. No specific genes have been linked to OM susceptibility. As with most disease processes, effects of environmental exposures on genetic expression probably play an important role in OM pathogenesis. - The role of mucins in Otitits Media Effusion has been described. Mucins are responsible for gel-like properties of mucus secretions. The middle ear mucin gene expression is unique compared with the nasopharynx. Abnormalities of this gene expression, especially upregulation ofMUC5Bin the ear, may 4/15/12

Mucins

Otitis Media
Anatomic

abnormality - Children with anatomic abnormalities of the palate and associated musculature (e.g. cleft palate) pathogens - The most common bacterial pathogen in AOM is Streptococcus pneumoniae,followed by Haemophilus influenzaeandMoraxella catarrhalis. These 3 organisms are responsible for more than 95% of all AOM cases with a bacterial etiology.

2.) Infectious factors

Bacterial

**M catarrhalis-induced AOM differs from AOM caused by other bacterial pathogens in several ways. It is characterized by higher a proportion of mixed infections, younger age at the time of diagnosis, lower risk of 4/15/12

Otitis Media
** In chronic suppurative OM, the most frequently isolated organisms includeP aeruginosa, S aureus, Corynebacteriumspecies, andKlebsiella pneumoniae. An unanswered question is whether these pathogens invade the middle ear from the nasopharynx via the endotracheal (as do the bacteria responsible for AOM) or whether they enter through the perforated tympanic membrane. 3.) Viral pathogens
Because

acute viral URI is a prominent risk factor for AOM development, most investigators have suspected a role for respiratory viruses in AOM pathogenesis. The viruses most commonly associated with AOM arerespiratory syncytial virus(RSV), influenza viruses, parainfluenza viruses, rhinovirus, and 4/15/12 adenovirus

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4.) Factors related to allergies

The relationship between allergies and OM remains unclear. In children younger than 4 years, the immune system is still developing, and allergies are unlikely to play a role in recurrent AOM in this age group. following is a brief list of evidence for and against the etiologic role of allergy in OM:

The

Many patients with OM have concomitant allergic respiratory disease (eg, allergic rhinitis, asthma). patients with OM have positive results to skin testing or radioallergosorbent testing (RAST). is most common in the winter and early spring, yet most major allergens (eg, tree and grass 4/15/12 pollens) peak in the late spring and early fall.

Many

OM

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5.) Environmental factors Infant feeding methods - protects infants against OM. Passive smoke exposure Group daycare attendance - close contact among many children, which increases the risks of respiratory infection, nasopharyngeal colonization with pathogenic microbes, and OM. Socioeconomic factors - higher risk for environmental exposure to parental smoking, bottle-feeding, crowded group daycare, crowded living conditions, and viruses and bacterial 4/15/12 pathogens.

Otitis Media
CLINICAL MANIFESTATIONS Acute OM (AOM) implies rapid onset of disease associated with one or more of the following symptoms: Otalgia Recent onset of anorexia Fever May complain earache Otorrhea Irritability, difficulty sleeping Vomiting These symptoms are accompanied by abnormal otoscopic Opacity findings of the tympanic membrane (TM), which may includeBulging the following: Erythema

Middle ear effusion (MEE)

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ASSESSMENT
Persistent blockage of fullness of the ear Hearing loss Chronic ear drainage Development of balance problems Facial weakness Persistent deep ear pain or headache Fever Confusion or sleepiness Drainage or swelling behind the ear
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Normal

Acute OM

Chronic Suppurative Otitis Media

Serous Otitis Media

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PATHOPHYSIOLOGY
The patient has an antecedent event (viral URI or allergy)

results in Inflammation of the nasal passages and the Eustachian tube Inflammation of the mucosa in the Eustachian tube obstructs the narrowest portion of the tube, the Isthmus obstruction of the isthmus causes negative pressure followed by accumulation of secretions produced by the mucosa of the middle ear these secretions have no egress and accumulate in the middle ear space viruses and bacteria that colonize the upper respiratory tract can reach the middle ear via aspiration, reflux, or insufflations microbial growth in the middle ear secretions may result in suppuration with clinical signs of AOM the middle ear effusion may persist for weeks to months following sterilization of the4/15/12 ear middle

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COMPLICATIONS OF OTITIS MEDIA:
Chronic suppurative otitis media Postauricular abscess Facial nerve paresis Labyrinthitis Labyrinthine fistula Mastoiditis Temporal abscess
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MEDICAL MANAGEMENT
( source: BRUNNER) In ACUTE OTITIS MEDIA With early and appropriate broad spectrum antibiotic therapy, otitis media may resolve with no serous sequelae. If drainage occurs, an antibiotic otic preparation is usually prescribed. The condition may be subacute (lasting 3 weeks to 3 months), with persistent purulent discharge from the ear. In SEROUS OTITIS MEDIA Serous otitis media need not be treated medically unless infection occurs. If hearing loss associated with middle ear effusion is significant, a myringotomy can be performed, and a tube may be placed to keep the middle ear ventilated(SURGICAL MANAGEMENT) Corticosteroids in small doses may decrease edema of Eustachian tube in cases if barotrauma. In CHRONIC OTITIS MEDIA Local treatment of chronic otitis media consist of careful suctioning of the ear under otoscopic guidance. Instillation of antibiotic drops or application of antibiotic powder is used to treat purulent discharge. Systemic antibiotics are prescribed only in cases of acute infection.

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TREATMENT

SYMPTOMATIC

Analgesics - Effective to treat the pain caused by otitis media

**Decongestants - Not recommended, either nasal or oral, due to lack of benefit

ANTIBIOTICS - Used only when analgesics cannot control the pain - Course of antibiotics should be given as a trial prior to referral for ventilating tubes.

- If penicillin allergy is not a concern and if the patient has no recent exposure to antibiotics, a reasonable choice for initial therapy is amoxicillin, administered at the same high dose recommended by the CDC for AOM (ie, 8090 mg/kg/d). Reasons for using amoxicillin include safety, effectiveness, well tolerated and reasonably priced
- In cases in which second-line therapy is empirically chosen (a

common occurrence, because few primary care physicians routinely perform tympanocentesis in the office), the recommendations suggest administering the following 3 4/15/12

Otitis Media

High-dose oral amoxicillin/clavulanate: (80-90 mg/kg/d of amoxicillin component, 6.4 mg/kg/d of clavulanate component) Oral cefuroxime axetil: (suspension: 30 mg/mg/d; tablet 250 mg bid) Intramuscular (IM) ceftriaxone: (administered as a single IM injection of 50 mg/kg on 3 consecutive days)

** The choice of these 3 preparations from among the 16 antimicrobials currently approved by the US Food and Drug Administration (FDA) for OM therapy was based on studies that reported that these drugs achieve sufficient concentrations in middle ear fluid for bacteriocidal action against the common o STEROID THERAPY - steroid administration may have a role in patients pathogens in AOM who are not good surgical candidates. - The steroid regimen should be oral prednisone or prednisolone at a dose of 1 mg/kg/d for 5-7 days, administered in combination with a beta-lactam antibiotic. - contraindicated in patients with exposure to varicella who have not received the varicella vaccine because of the possibility of lifethreatening disseminated disease.

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MYRINGOTOMY
Used in chronic cases with effusions Also called myringocentesis, tympanotomy, tympanostomy, orparacentesisof the tympanic membrane. Ear tubes, or tympanostomy tubes, are small tubes open at both ends that are inserted into the incisions in the eardrums metal, or both. They are left in during myringotomy.fall out place until they They come by themselves or until they are removed by a doctor.and in various shapes and sizes are made of plastic, Recommended in those who have more than 3

episode of acute otitis in 6months that does not respond to drug treatment. An additional element ofpostoperative careis the recommendation of many doctors that the child use ear plugs to keep water out of the ear during bathing or swimming to reduce the risk of infection 4/15/12

ear is a three-layer structure. The outer and inner layers consist of epithelium cells. Perforations occur as a result of defects in the middle layer, which contains elastic collagen fibers. Small perforations usually heal spontaneously. However, if the defect is relatively large, or if there is a poor blood supply or an infection during the healing process, spontaneous repair may Eardrums may also be perforated as a result of trauma, such as an object in the ear, be hindered. a slap on the ear, or an explosion.

TYMPANOPLAS The tympanic membrane of the TY

There are five basic types of tympanoplasty procedures: Type I - tympanoplasty is called myringoplasty, and only involves the restoration of the perforated eardrum by grafting. Type II - tympanoplasty is used for tympanic membrane perforations with erosion of the malleus. It involves grafting onto the incus or the remains of the malleus. Type III - tympanoplasty is indicated for destruction of two ossicles, with the stapes still intact and mobile. It involves placing a graft onto the stapes, and providing protection for the assembly.

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Type IV - tympanoplasty is used for ossicular destruction, which includes all or part of the stapes arch. It involves placing a graft onto or around a mobile stapes footplate. Type V - tympanoplasty is used when the footplate of the stapes is fixed.

The purpose of tympanoplasty is to repair the perforated eardrum, and sometimes the middle ear bones (ossicles) that consist of the incus, malleus, and stapes. Tympanic membrane grafting may be required. If needed, grafts are usually taken from a vein or fascia (muscle sheath) tissue on the lobe of the ear. Synthetic materials may be used if patients have had previous surgeries and have limited graft availability.

Generally, the patient can return home within two to three hours.Antibioticsare given, along with a mild pain reliever.

After 10 days, the packing is removed and the ear is evaluated to see if the graft was successful. Water is kept away from the ear, and nose blowing is discouraged.

Most patients can return to work after five or six days, or two to three weeks if they perform heavy physical labor. After three weeks, all packing is completely removed under the operating microscope. It is then determined whether or not the graft has fully taken.

Activities that change the tympanic pressure are forbidden, such as sneezing with the mouth shut, using a straw to drink, or heavy nose blowing. A complete hearing test is performed four to six weeks after the operation.

Tympanoplasty is successful in over 90% of cases. In most cases, the operation 4/15/12 relieves pain and infection symptoms completely. Hearing loss is minor.

Otitis Media
NURSING MANAGEMENT ( 11 CORE COMPETENCIES )
I.

Safety and Quality Nursing Care

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Otitis Media
II.

Management of Resources and Environment Instruct the client the use of earplugs while in water, but as much as possible avoid swimming. Protect ears during shower. infants against OM.

o Ensure immunizations are up-to-date. It protects the o Maintains a safe environment Encourage family members to keep childs
environment smoke-free.

Avoid crowded areas such as daycares wherein

close contact among many children increases the risks of respiratory infection, nasopharyngeal colonization with pathogenic microbes, and OM. 4/15/12

Otitis Media
III.

Health Education may have a conductive hearing loss Maintain adequate diet and fluid intake Provide education and support if myringotomy is necessary for chronic infection and infection.

*Post-op: a. call the physician if the following symptoms occur : ear pain, fever, myringotomy misplaced, drainage from the ear b. instruct the client the use of earplugs while in water. c. warm moist compress d. Avoid swimming, protect during shower, avoid nose
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Otitis Media

If the client is infant, advise the parents that infants should never be put in a lying position when feeding to prevent reflux of nasopharyngeal flora Encourage family members to keep childs environment smoke free Encourage the client to complete the prescribed course of antibiotic treatment to prevent infection Encourage client to perform valsalvas maneuver several times daily to promote Eustachian tube patency Avoid blowing the nose or getting the ear wet when bathing Encourage client for follow up check up after completion of antibiotic treatment Recognize early symptoms of upper respiratory tract
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IV. Ethico Moral Responsibility

Respect the rights of individual

The nurse must maintain confidentiality of information health teaching must be done, the client has rights to education privacy to the client

Adequate Provide

Accepts responsibility and accountability for own decisions and actions

The A

nurse must know that he/she is answerable to others for his or her own actions/decisions nurse must know the rationale for each nursing responsibility that is carried out to 4/15/12 the patient

Otitis Media
The

nurse must know how to act on questionable orders from the Doctors

Adheres to the national and international code of ethics for nurses

Every

nursing action performed must be in accordance to the code of ethics, the institution rules and guidelines , the guidelines set by the PNA and the World health organizations unethical and immoral incidents to proper authorities
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Reports

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V.

Legal Responsibilities Documentation of the nursing actions done and procedures done to client. Have the client or guardian sign the consent before any invasive procedures.

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VI. Personal and Professional

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VII. Research

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VIII. Record Management

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IX. Communication

Speak slowly and clearly Eliminate distracting noises when talking to the patient Get the attention of the patient before beginning to speak

Talk in lover tone Face patient when talking Validate the understanding of the statements made by asking to repeat what was said
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X.

Collaboration and Teamwork Surgeon - a physician who specializes in the placement of the tubes. Anesthesiologist - a medical physician with specialized training in anesthesia. He/she will perform a history and physical examination and formulate a plan of anesthesia for your child. The plan will be discussed with you (nurse) together with the patients and the patients questions will be answered. Insertion of myringotomy tubes requires general anesthesia in children. Collaboration with the physician, pharma, labs, 4/15/12

Otitis Media
XI. Quality Improvement

Encourage fluid intake Teach parent to feed infants in upright position Teach parent about administering ear medication. In a child younger than age 3, pull the pinna down and back, while in a child older than 3 years, pull the pinna up and back Instruct child not to chew during acute episode since it increases pain Provide local heat and have the child lie with the affected ear down Instruct and teach the parent how to clean drainage 4/15/12 from the ear with sterile cotton swabs