Pathophysiology

External otitis is a painful condition caused when irritating or infective agents come into contact with the skin of the external ear. The result is either an allergic response or inflammation with or without infection. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal can lead to temporary hearing loss due to obstruction. Allergic external otitis is often caused by contact with cosmetics, hair sprays, earphones, earrings, or hearing aids. The most common infectious organisms are Pseudomonas aeruginosa, Streptococcus, Staphylococcus, and Aspergillus.

External otitis occurs more often in hot, humid environments, especially in the summer, and is known as swimmer’s ear because it occurs most often in people involved in water sports. Patients who have traumatized their external ear canal with sharp or small objects (e.g., hairpins, cotton-tipped applicators) or with headphones also are more susceptible to external otitis.

Necrotizing or malignant otitis is the most virulent form of external otitis. Organisms spread beyond the external ear canal into the ear and skull. The high mortality rate seen with malignant external otitis results from complications such as meningitis, brain abscess, and destruction of cranial nerve VII.

Patient-Centered Collaborative Care

Manifestations of external otitis range from mild itching to pain with movement of the pinna or tragus, particularly when upward pressure is applied to the external canal. Patients report feeling as if the ear is plugged and hearing is reduced.

Use caution during otoscopic examination to avoid pressing on the walls of the external canal, which causes pain. Drainage from the ear is often greenish white. To prevent cross-contamination, examine the unaffected ear first. Hearing loss in the affected ear can be severe when inflammation obstructs the ear canal and prevents sounds from reaching the eardrum (tympanic membrane).

Management focuses on reducing inflammation, edema, and pain. Nursing priorities include comfort measures, such as applying heat to the ear for 20 minutes three times a day. This can be accomplished by using towels warmed with water and then wrapped in a plastic bag or by using a heating pad placed on a low setting. Teach the patient that minimizing head movements reduces pain.

Topical antibiotic and steroid therapies are most effective in decreasing inflammation and pain. Review best practices for instilling eardrops with the patient, as shown in Chart 51-1. Observe the patient self-administer the eardrops to make sure that proper technique is used. If edema obstructs the external canal, an earwick is inserted past the blockage, with drugs applied to the outside end (Fig. 51-1). A long piece of gauze dressing serves as an earwick, which the health care provider inserts using forceps to push carefully through the blocked external auditory canal to the eardrum. The earwick may be removed when eardrops can flow freely into the canal. Use handwashing whenever the infected ear is touched. Oral or IV antibiotics are used in severe cases, especially when infection spreads to surrounding tissue or area lymph nodes are enlarged.

FIG. 51-1 Earwick for instillation of antibiotics into the external canal. When edema occludes the external auditory canal, it is difficult for antibiotic solutions to enter the canal adequately. An earwick is placed through the meatus. Solutions placed on the external portion of the earwick are absorbed through the canal.

Analgesics, including opioids, may be needed for pain relief during the initial days of treatment. NSAIDs, such as acetylsalicylic acid (aspirin, Entrophen ) and ibuprofen (Advil), or acetaminophen (Tylenol, Abenol ) may relieve less-severe pain.

After the inflammation has subsided, a solution of 50% rubbing alcohol, 25% white vinegar, and 25% distilled water may be dropped into the ear to keep it clean and dry and to prevent recurrence. Teach the patient not to use cotton-tipped applicators to dry the ears, because this use could damage the canal and increase the risk for infection or inflammation. Teach him or her to use preventive measures for minimizing ear canal moisture, trauma, or exposure to materials that lead to local irritation or contact dermatitis. Recommend the use of earplugs when engaging in water sports to those patients with recurrent episodes of external otitis.

Pathophysiology

Cerumen (wax) is the most common cause of an impacted canal. A canal can also become impacted as a result of foreign bodies that can enter or be placed in the external ear canal, such as vegetables, beads, pencil erasers, and insects. Although uncomfortable, cerumen or foreign bodies are rarely true emergencies and can be carefully removed by a health care professional. Cerumen impaction in the older adult is common, and removal of the cerumen from older adults often improves hearing (Holcomb, 2009).

Patient-Centered Collaborative Care

Patients with a cerumen impaction or a foreign body in the ear may experience a sensation of fullness in the ear, with or without hearing loss, and may have ear pain, itching, dizziness, or bleeding from the ear. The object may be visible with direct inspection.

When the occluding material is cerumen, management options include watchful waiting, manual removal, and the use of ceruminolytic agents followed by either manual irrigation or the use of a low-pressure, electronic, oral irrigation device (Holcomb, 2009). The canal can be irrigated with a mixture of water and hydrogen peroxide at body temperature (Fig. 51-2), following best practices for proper irrigation (Chart 51-2). Removal of a cerumen obstruction by irrigation is a slow process and may take more than one sitting. When it is the cause of hearing loss, cerumen removal may improve hearing. Between 50 and 70 ml of solution is the maximum amount that the patient with an impaction usually can tolerate at one sitting.

FIG. 51-2 Irrigation of the external canal. Cerumen and debris can be removed from the ear by irrigation with warm water. The stream of water is aimed above or below the impaction to allow back-pressure to push it out rather than further down the canal.

If the cerumen is thick and dry or cannot be removed easily, suggest an over-the-counter ceruminolytic product such as Cerumenex to soften the wax before trying to remove it. Another way to soften cerumen is to add 3 drops of glycerin or mineral oil to the ear at bedtime and 3 drops of hydrogen peroxide twice a day. After several days of this treatment, the cerumen is more easily removed by irrigation. In some cases, a small curette or cerumen spoon may be used by a health care professional to scoop out the wax. Care is taken with this method because damage to the canal or the eardrum can occur with improper technique.

Discourage the use of cotton swabs and ear candles (hollow tubes coated in wax inserted into the ear and then lighted at the far end) to clean the ears or remove cerumen. Chart 50-3 in Chapter 50 describes steps to teach patients regarding ear hygiene and self–ear irrigation. Refer to Chart 51-3 for nursing care considerations of older adult patients with cerumen impaction.

Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Lidocaine, a numbing agent, can be placed in the ear canal for pain relief. Mineral oil or diluted alcohol instilled into the ear can suffocate the insect, which is then removed with ear forceps.

If the patient has local irritation, an antibiotic or steroid ointment may be applied to prevent infection and reduce local irritation. Hearing acuity is tested if hearing loss is not resolved by removal of the object.

Surgical removal of the foreign object may be required. The object is removed through the ear canal (transcanal route) using a wire bent at a 90-degree angle. The wire is looped around the object, and the object is pulled out. Because this procedure is painful, general anesthesia is needed.

Pathophysiology

The three common forms of otitis media are acute otitis media, chronic otitis media, and serous otitis media. Each type affects the middle ear but has different causes and pathologic changes. If otitis progresses or is untreated, permanent conductive hearing loss may occur.

Acute otitis media and chronic otitis media, also known as suppurant or purulent otitis media, are similar. An infecting agent in the middle ear causes inflammation of the mucosa, leading to swelling and irritation of the small bones (ossicles) within the middle ear, followed by purulent inflammatory exudate. Acute disease has a sudden onset and lasts 3 weeks or less. Chronic otitis media often follows repeated acute episodes, has a longer duration, and causes greater middle ear injury. It may be a result of the continuing presence of a biofilm in the middle ear. A biofilm is a community of bacteria working together to overcome host defense mechanisms to continue to survive and proliferate (Lee et al., 2009). (See Chapter 25 for more information about biofilms.) Therapy for complications associated with chronic otitis media, unlike that of acute otitis media, usually involves surgical intervention.

The eustachian tube and mastoid, connected to the middle ear by a sheet of cells, are also affected by the infection. If the eardrum membrane perforates and infective materials spill into the external ear, external otitis develops that thickens and scars the middle ear if left untreated. Necrosis of the ossicles destroys middle ear structures and causes hearing loss.

Patient-Centered Collaborative Care

Assessment

The patient with acute or chronic otitis media has ear pain with and without movement of the external ear. Acute otitis media causes more intense pain. As the pressure in the middle ear increases, there is a sensation of fullness in the ear. Hearing is reduced and distorted. The patient may notice a sticking or cracking sound in the ear upon yawning or swallowing or may have tinnitus in the form of a low hum or a low-pitched sound. Conductive hearing loss may occur as sound wave transmission is obstructed. Headaches and systemic symptoms such as malaise, fever, nausea, and vomiting can occur. As the pressure on the middle ear pushes against the inner ear, the patient may have dizziness or vertigo.

Otoscopic examination findings vary, depending on the stage of the condition. The eardrum is initially retracted, which allows landmarks of the ear to be seen clearly. At this early stage, the patient has only vague ear discomfort. As the condition progresses, the eardrum’s blood vessels dilate and appear red (Fig. 51-3). In the third stage, the eardrum becomes red, thickened, and bulging, with loss of landmarks. Decreased eardrum mobility is evident on inspection with a pneumatic otoscope. Pus may be seen behind the membrane.

FIG. 51-3 Otoscopic view of otitis media.

If the condition progresses, the eardrum spontaneously perforates (ruptures) and pus or blood drains from the ear (Fig. 51-4). When the membrane ruptures, the patient notices a marked decrease in pain as the pressure on middle ear structures is relieved (Fig. 51-5). Eardrum perforations from any cause may heal if the underlying problem is controlled. Initially, the eardrum membrane is thinner over the healed perforation. A simple central perforation does not interfere with hearing unless the small bones of the middle ear are damaged or the perforation is large. Repeated perforations with extensive scarring can cause hearing loss.

FIG. 51-4 Otoscopic view of a perforated tympanic membrane.

FIG. 51-5 Perforations of the tympanic membrane. Central perforations heal more quickly than marginal perforations. Marginal perforations that do not heal allow cholesteatoma formation.

Cultures of drainage after a perforation from uncontrolled otitis media may reveal the infecting agent. Cultures are taken only when previous treatment is ineffective. When the eardrum is not perforated, a needle aspiration or myringotomy may be performed by a physician or nurse practitioner to withdraw fluid for culture.

Interventions

Surgical Management

If pain persists after antibiotic therapy and the eardrum continues to bulge, a myringotomy (surgical opening of the pars tensa of the eardrum) is performed. This procedure drains middle ear fluids and immediately relieves pain.

Preoperative care includes reassuring the patient that the myringotomy will relieve pain and is usually performed without anesthesia. Many people are concerned about a perforation and its effect on hearing. To relieve some of this anxiety, discuss the reasons for the procedure and encourage the patient to use techniques such as deep breathing before and during the procedure. Systemic antibiotic therapy continues before and after this procedure. Clean the external canal with a bacteriostatic solution such as povidone-iodine (Betadine) before the myringotomy.

The operative procedure is a small surgical incision often performed in an office or clinic setting and heals rapidly. Another approach is the removal of fluid from the middle ear with a needle. For relief of pressure caused by serous otitis media and for those patients who have repeated episodes of otitis media, a small grommet (polyethylene tube) may be surgically placed through the eardrum to allow continuous drainage of middle ear fluids (Fig. 51-6).

FIG. 51-6 Grommet through the tympanic membrane. A small grommet is placed through the tympanic membrane away from the margins, which allows prolonged drainage of fluids from the middle ear. The grommet can be removed later and the tympanic membrane allowed to heal naturally or patched with a small piece of homogenous tissue.

Postoperative care priorities include teaching the patient to keep the external ear and canal free of other substances while the incision is healing. Instruct him or her to keep the head dry by not washing the hair or showering for several days. Other instructions after surgery are listed in Chart 51-4.

Chart 51-4 Patient and Family Education

Preparing for Self-Management: Recovery from Ear Surgery

• Avoid straining when you have a bowel movement.

• Do not drink through a straw for 2 to 3 weeks.

• Avoid air travel for 2 to 3 weeks.

• Avoid excessive coughing for 2 to 3 weeks.

• Stay away from people with respiratory infections.

• If you need to blow your nose, blow gently, without occluding either nostril, with your mouth open.

• Avoid getting your head wet, washing your hair, and showering for 1 week.

• Keep your ear dry for 6 weeks by placing a ball of cotton coated with petroleum jelly (e.g., Vaseline) in your ear. Change the cotton ball daily.

• Avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

• Change your ear dressing every 24 hours or as directed.

• Report excessive drainage immediately to your physician.

Pathophysiology

The lining of the middle ear is continuous with the lining of the mastoid air cells, which are embedded in the temporal bone. Mastoiditis is an infection of the mastoid air cells caused by untreated or inadequately treated otitis media. This infection can be acute or chronic. Antibiotic therapy is used to treat the middle ear infection before it progresses to mastoiditis.

Patient-Centered Collaborative Care

The manifestations of mastoiditis include swelling behind the ear and pain with minimal movement of the tragus, the pinna, or the head. Pain is not relieved by myringotomy. Cellulitis (infection spreading sideways through the tissues of the skin) develops on the skin or external scalp over the mastoid process. The ear is pushed sideways and down. Otoscopic examination shows a red, dull, thick, immobile eardrum with or without perforation. Lymph nodes behind the ear are tender and enlarged. Patients may have low-grade fever, malaise, ear drainage, and loss of appetite. Hearing loss occurs, and computed tomography (CT) scans show fluid in the air cells of the mastoid process.

Interventions focus on halting the infection before it spreads to other structures. IV antibiotics are used to prevent the spread of infection. These drugs have limited use in actual mastoiditis treatment because they do not easily penetrate the infected bony structure of the mastoid. Cultures of the ear drainage determine which antibiotics should be most effective. Surgical removal of the infected tissue is needed if the infection does not respond to antibiotic therapy within a few days. A simple or modified radical mastoidectomy with tympanoplasty is the most common treatment. All infected tissue must be removed so that the infection does not spread to other structures. A tympanoplasty is then performed to reconstruct the ossicles and the eardrum to restore hearing. Patient preparation, the operative procedure, and follow-up care for tympanoplasty are discussed on pp. 1101 and 1102.

Complications occur when infective material is not removed completely or when other structures are contaminated. Complications include damage to cranial nerves VI and VII, decreasing the patient’s ability to look sideways (cranial nerve VI) and causing a drooping of the mouth on the affected side (cranial nerve VII). Other complications include vertigo, meningitis, brain abscess, chronic purulent otitis media, and wound infection.

Pathophysiology

Trauma and damage may occur to the eardrum and ossicles by infection, by direct damage, or through rapid changes in the middle ear pressure. Foreign objects placed in the external canal exert pressure on the eardrum and cause perforation. If the objects continue through the canal, the bones of the middle ear may be damaged. Blunt injury to the skull and ears can also damage or fracture middle ear structures. Slapping the external ear increases the pressure in the ear canal and can tear the eardrum. The eardrum has a limited stretching ability and gives way under high pressure. Excessive nose blowing and rapid changes of pressure that occur with nonpressurized air flight (barotrauma) can increase pressure within the middle ear. High pressure damages the ossicles and can perforate the eardrum.

Patient-Centered Collaborative Care

Most eardrum perforations heal within a week or two without treatment. Repeated perforations, especially from chronic otitis media, heal more slowly, with scarring. Depending on the amount of damage to the ossicles, hearing may or may not return. Hearing aids can improve hearing in this type of hearing loss. Surgical reconstruction of the ossicles and eardrum through a tympanoplasty or a myringoplasty may also improve hearing. (See later discussion of nursing care on p. 1102 in the Tympanoplasty section.)

Nursing care priorities focus on teaching about trauma prevention. Caution patients to avoid inserting objects into the external canal and to follow the steps in Chart 50-3 in Chapter 50 for ear hygiene. Stress the importance of using ear protectors when blunt trauma is likely, especially in sports such as boxing and wrestling.