Pathophysiology.

Otitis media (ot, “ear,” itis, “inflammation of,” and media, “middle”) is an inflammation of the middle ear. The middle ear is a tiny cavity in the temporal bone. Its entrance is guarded by the sensitive tympanic membrane, or eardrum, which transmits sound waves through the “oval window” to the inner ear, which contains the organs of hearing and balance. The middle ear opens into air spaces, or sinuses, in the mastoid process of the temporal bone. It is also connected to the throat by a channel called the eustachian tube. These structures—the mastoid sinuses, the middle ear, and the eustachian tube—are lined by mucous membranes. As a result, an infection of the throat can easily spread to the middle ear and lead to mastoiditis. The eustachian tube also protects the middle ear from nasopharyngeal secretions, provides drainage of middle ear secretions into the nasopharynx, and equalizes air pressure between the middle ear and the outside atmosphere. These protective functions are diminished when the tubes are blocked. Unequalized air pressure within the ear creates a negative pressure that allows organisms to be swept up into the eustachian tube.

Otitis media (OM) occurs most often after an upper respiratory tract infection and usually affects children between 6 and 24 months of age and in early childhood. It is caused by various organisms, of which Streptococcus pneumoniae and Haemophilus influenzae are the most common. Polyvalent pneumococcal polysaccharide vaccines have reduced the incidence of pneumococcal otitis media, but these vaccines are not effective in children under 2 years of age because they are not capable of producing an antibody response.

Manifestations.

The symptoms of OM are pain in the ear, which is often very severe; irritability; and diminished hearing. Fever, which may be as high as 40° C (104° F), headache, vomiting, diarrhea, and febrile seizures may also occur. Earaches in infants may be manifested by general irritability, frequent rubbing or pulling at the ear, and rolling of the head from side to side. The older child can point to the place that is tender. Visualization of the tympanic membrane via otoscope reveals a reddened and bulging membrane.

If an abscess forms, a rupture of the eardrum may result, and drainage from the ear may be evident. When this happens, the pressure is relieved and the child is more comfortable. Some amount of hearing loss may result from the rupture. OM is considered chronic if the condition persists for more than 3 months. Recurrent attacks can lead to serious complications. Chronic OM can lead to cholesteatoma (chole, “bile,” steato, “fat,” and oma, “tumor”), a cystlike sac filled with keratin debris. This may occlude the middle ear and erode adjacent ossicle bones, causing hearing loss. This condition is best treated by an otolaryngologist. Complications of repeated attacks of acute OM can include the development of chronic OM with effusion (fluid accumulation). Hearing loss can result. Treatment may be indicated because hearing loss may impair cognitive and language development that can hamper the education and communication abilities in developing children.

Treatment.

When an infection is evident, treatment is directed toward finding the causative organism and relieving the symptoms. A throat culture may be taken to determine the specific organism. Broad-spectrum antibiotics may be given orally and should be continued until the prescribed amount of medication has been taken. Analgesics are given to relieve pain. Antihistamines and decongestants are not effective in treating acute OM.

Surgical Treatment.

Surgical intervention may be necessary when medical treatment is unsuccessful. The physician may incise the tympanic membrane to relieve pressure and to prevent a tear by spontaneous rupture. This is called a myringotomy (myringa, “eardrum,” and otomy, “incision of”). A tympanic membrane (TM) button or tympanostomy ventilating tube (PE, pressure equalizer) may be inserted. This may fall out spontaneously within 6 to 12 months. In some children, the tubes may have to be reinserted to continue ventilation. Care is taken to avoid getting water in the ears while bathing or showering. All children should be followed up to make sure that the condition is resolved and to evaluate any hearing loss that may have occurred.

Comfort Measures.

Antipyretics may be given to reduce fever, and a warm compress may be applied locally for comfort. If the eardrum has ruptured, the child is placed on the affected side. Cold may also be beneficial. An ice pack may be prescribed to reduce edema and pressure. The skin around the ears must be kept clean and protected from any drainage to prevent tissue breakdown. Parents are instructed not to insert cotton swabs into the ears.

Pathophysiology.

Approximately 1 in 1000 newborns is born with some type of hearing impairment. This number may increase to 2 in 1000 for hearing loss occurring during childhood. Hearing-impaired children present special challenges to the health care team. Hearing loss can affect speech, language, social and emotional development, and behavior, as well as academic achievement. The nurse should have a basic understanding of how to approach and work with a hearing-impaired child.

The inner ear is fully formed during the early months of prenatal life. If an expectant mother contracts German measles or other viral infection during this period, the child may be born with a hearing loss; this is termed congenital deafness. Deafness can also be acquired. Infectious diseases such as measles, mumps, chickenpox, or meningitis can result in various degrees of hearing loss. The common cold, some medications, exposure to loud noise levels, certain allergies, and ear infections may also be responsible. Hearing problems can also be temporary if they are caused by cerumen (wax) accumulation. Some rattles and squeaky toys can emit sounds as loud as 110 decibels. (Sounds above 80 decibels can cause damage.) These types of toys should not be held close to the infant’s ear.

Early diagnosis and treatment of hearing-impaired children is important to prevent adverse physical and mental complications from developing. Members of the health care team concerned with the child who is hearing impaired include the physician, otologist (ear specialist), audiologist, speech therapist, specially trained teacher, social worker, psychologist, school nurse, and members of the child’s family.

The various degrees of hearing loss range from a complete bilateral loss (which affects both ears) to a loss so mild that the problem is never recognized. Hearing loss can result from defects in the transmission of sound to the middle ear, from damage to the auditory nerve or ear structures, or from a mixed hearing loss that involves both a defect in nerve pathways and interference with sound transmission. If hearing loss is complete, the child misses all the pleasures of sound and has difficulty in communication (children learn to talk by imitating what they hear). Behavior problems may arise because these children do not understand verbal directions. They may become aggressive with other children in their attempt to communicate. If they are ridiculed by playmates, personality development will be affected. Unless these children are helped early in life, they may become socially isolated.

Partial bilateral deafness may be responsible for behavior problems and poor progress in school. It is most commonly caused by chronic ear infections, such as OM, or by blockage of the eustachian tube. Children who have hearing losses in one ear are less affected if hearing in the other ear is normal.

Diagnosis and Treatment.

The American Academy of Pediatrics recommends a goal of universal detection of hearing impairment in infants before 3 months of age, with interventions started no later than 6 months of age to minimize problems with growth and development (Wolff et al., 2010). The evoked otoacoustic emissions (OAE) test is a preferred method for neonatal testing. The brainstem auditory evoked response (BAER) test records brain wave responses generated by the auditory system. These tests are easily administered to the newborn infant, and many hospitals routinely screen newborns for hearing ability before discharge. Lack of response by the infant to sounds or music or lack of the startle reflex in infants under 4 months of age are the first signs that may alert the parents or nurse to the possibility of hearing impairment. Early diagnosis and prompt treatment are primary requisites, regardless of the child’s age. Complete bilateral deafness is usually discovered during infancy. Partial deafness may be unrecognized until the child begins school. Many hearing problems are detected by the school nurse administering standard hearing tests.

Tympanometry measures ear pressure but is difficult to perform adequately on an active infant or small child. A tuning fork is used to evaluate for air conduction (Rinne test) or bone conduction (Weber test). This type of test requires the child to be cooperative and able to communicate what is heard or felt. Diagnosis of hearing loss can be confirmed by visual reinforcement audiometry (VRA), which identifies sensitivity to sounds in young infants.

Many hearing defects are amenable to medical or surgical treatment. Hearing aids can amplify sound waves. Surgically placed cochlear implants are used for some children with nerve damage. Children who suffer a severe loss of hearing need more extensive help from personnel at an auditory training center. These children must begin treatment as soon as the hearing loss is discovered.

Nursing Care.

Various methods are used to bring the child into the world of sound. Lip reading, sign language, writing, visual aids, and amplified sound are but a few examples. The parents are instructed in means of communication that correspond with those used by the teachers.

The nurse must be aware of the symptoms of deafness in the child. Newborns are observed for their response to auditory stimuli. The Brazelton Neonatal Behavioral Assessment Scale evaluates the infant’s orientation response to the sound of a voice. The persistence of the Moro reflex beyond 4 months of age may also be an indication of deafness. The infant who makes no verbal attempts by 18 months of age should undergo a complete physical examination. Indifference to sound, behavior problems, or poor school performance may also be signs of deafness. The nurse inquires into the facilities that are available in the community for such a child.

The hearing-impaired child in the hospital needs the same opportunities to communicate as the child who does not have this disability. The nurse smiles when approaching the child. Body language communicates a lot, especially if there is a severe communication problem. The nurse faces the child when speaking and is positioned at eye level with the child. The nurse must ensure that the child sees him or her before touching to avoid startling the child. Sign language is the use of hand signals that correspond to words and assist in communication with a deaf child. Previously developed speech patterns may regress during hospitalization. Visual aids, writing, or drawing can be used to enhance communication.

If a hearing aid is indicated, the child is equipped with one and taught how to use it. Regular checkups ensure that the hearing aid is working properly. A hearing aid is expensive and invaluable to the child. It is put in a safe place when not in use. When the child goes to surgery, it is given to the parents or placed in the hospital safe. The pockets of hospital gowns are checked before the gowns are placed in the laundry.

The National Hearing Center provides information about hearing aids. Hearing aids are designed to fit in the ear, behind the ear, on eyeglass frames, or on the body with wires to the ear. The nurse should check ear hygiene and be sure hairs are not caught on the end of the hearing aid to ensure a proper fit and to minimize noise and whistling problems. Teaching safe battery handling and storage and promoting self-care are important nursing responsibilities.

Home care of the hearing-impaired child should include speech therapy. Flashing lights should be installed in the home to alert the child to doorbells and other sound-based devices.

Telecommunication devices for the deaf (TDD) are available to enable telephone communication. Closed captioning devices for television are available to the child who can read.

The school nurse can help the family nurture socialization skills. Some hearing-impaired children attend special schools for the deaf, and some are mainstreamed into the general school population. Each hearing-impaired child and each family unit should be followed by the multidisciplinary health care team.

Pathophysiology.

Reye’s syndrome is an acute noninflammatory encephalopathy (pathology of the brain) and hepatopathy (pathology of the liver) that follows a viral infection in children. There may be a relationship between the use of aspirin (acetylsalicylic acid) during a viral flu or illness such as chickenpox (varicella) and the development of Reye’s syndrome. For this reason, aspirin use is generally contraindicated for the pediatric population. Some studies show that a genetic metabolic defect triggers Reye’s syndrome.

Manifestations.

Liver cell pathology causes an accumulation of ammonia in the blood. Toxic levels of ammonia cause cerebral manifestations (e.g., cerebral edema, increased intracranial pressure [ICP]), which results in neurological changes such as altered behavior, altered level of consciousness, seizures, and coma.

In children, the sudden onset of effortless vomiting and altered behavior (e.g., lethargy, combativeness) or altered level of consciousness after a viral illness is characteristic of Reye’s syndrome. The results of blood tests assessing liver function will be abnormal. In infants, diarrhea, hypoglycemia, tachypnea with apneic episodes, and seizures may occur approximately 1 week after a respiratory illness.

Prevention.

The education of the public concerning the dangers of using salicylate-containing medications during viral illnesses such as varicella in children may have contributed to the decline in the occurrence of Reye’s syndrome. The availability of the varicella vaccine may also have an impact on the reduced incidence of Reye’s syndrome.

Treatment.

Early treatment can result in recovery with some neuropsychological deficits. However, progression to the acute stage is often rapid and unpredictable. The goals of treatment include reducing ICP and maintaining a patent airway, cerebral oxygenation, and fluid and electrolyte balance.

Frequent assessment of vital signs and a careful assessment of neurological status are essential. Observation for signs of bleeding is important because liver dysfunction causes blood-clotting abnormalities. Parental education and support are necessary. Encouraging parents to participate in their child’s care helps to reduce the parents’ and child’s level of anxiety.

Manifestations.

Pathophysiology.

Meningitis is an inflammation of the meninges (the covering of the brain and spinal cord). Various organisms can cause bacterial meningitis. Organisms may invade the meninges indirectly by way of the bloodstream (sepsis) from centers of infection such as the teeth, sinuses, tonsils, and lungs, or directly through the ear (otitis media), or from a fracture of the skull.

Bacterial meningitis is often referred to as purulent, that is, pus forming, because a thick exudate surrounds the meninges and adjacent structures. This can lead to certain sequelae such as subdural effusion and, less frequently, hydrocephalus. The peak incidence for bacterial meningitis is between 6 and 12 months of age. Meningococcal meningitis is readily transmitted to others. Meningitis is less common in children older than 4 years of age. H. influenzae is the most common causative agent. H. influenzae type B vaccine and PCV have decreased the incidence of bacterial meningitis. The approaches to nursing care for all types of meningitis are similar.

Manifestations.