Otitis media

85 Otitis media




Overview/pathophysiology


Otitis media (OM) is the most common reason for visits to the pediatrician in the first 3 yr of life, the leading cause of antibiotic use, and the most common cause of hearing loss in children. It accounts for approximately 20 million health care provider visits each year. The highest incidence occurs between 6 mo and 18 mo with 80%-90% of cases occurring in children less than 6 yr. Many factors contribute to OM development, including host (i.e., immune system or anatomic abnormality), infectious (i.e., bacterial or viral pathogen), allergic, and environmental (i.e., feeding methods and group daycare) factors. Socioeconomic factors also affect the risk of developing OM, its diagnosis, and treatment. The most common bacterial pathogen for acute otitis media (AOM) is Streptococcus pneumoniae, and respiratory syncytial virus (RSV) is one of the most common viral pathogens (Waseem & Aslam, 2010). The American Academy of Pediatrics and the American Academy of Family Physicians (2004) recommended observation without antibiotic treatment for select children 2 mo to 12 yr of age with AOM for 48-72 hr. Unfortunately, management of AOM without antibiotics has not increased per a study by Coco et al. in the February 2010 issue of Pediatrics.


OM includes several conditions ranging from acute to chronic with or without symptoms:


• Otitis media (OM): inflammation of the middle ear.

• Acute otitis media (AOM): middle ear infection with symptoms of acute illness (fever, pain, irritability) and full or bulging tympanic membrane (TM) under positive pressure that lasts 3 wk or less.

• Otitis media with effusion (OME) or serous otitis media: inflammation of the middle ear without signs and symptoms of acute infection (other than reduced hearing), TM retracted or in neutral position under negative pressure or no pressure, and fluid in the middle ear space.

• Chronic OM with effusion: middle ear effusion lasting more than 3 mo.


Health care setting


Primary care; possible hospitalization if OM exacerbates a chronic condition or if surgical intervention is required



Assessment




Signs and symptoms:


Vary depending on type of OM and age of child.



AOM:


• Infant or young child: fever; possible ear drainage; crying; irritable and fussy; may tug, rub, or hold affected ear; sleep disturbances; decreased appetite; rolling head side to side; difficult to comfort; possible difficulty hearing.

• Older child: fever, possible ear drainage, complaints of ear hurting, crying, irritable, lethargic, decreased appetite (chewing causes increased ear pain), possible difficulty hearing.


OME:

Difficulty hearing, feeling of fullness/pressure in ear, tinnitus or popping sounds, mild balance disturbances.



Physical assessment:



Aom:

Pneumatic otoscopy reveals bulging, red, immobile TM (or decreased mobility of TM). Crying, removal of cerumen and thereby irritating the auditory canal, and fever can cause redness of the TM without infection being present. Postauricular and cervical lymph nodes may be enlarged.



Ome:

Pneumatic otoscopy may show a slightly injected, dull gray membrane; obscured landmarks; and fluid visible behind the TM. There is also decreased mobility of the TM.



Diagnostic tests




Pneumatic otoscopy:


A pneumatic attachment to the otoscope enables health care provider to introduce puffs of air into the ear. The TM does not move as well with fluid behind it. This device improves diagnostic accuracy by assessing mobility of TM, as well as visualizing it.



Tympanometry:


Method of providing information about possible presence of a middle ear effusion, including the actual pressures in the middle ear space. This is a quick and simple method of assessing TM mobility.



Acoustic reflectometry:


Rapid and easy way to measure reflected sound waves from TM; the louder the sound, the greater the likelihood of middle ear effusion. Advantages over tympanometry include that it is unaffected by crying or the presence of cerumen. It is not widely used, however, as there are no specific standards established to determine results.



Tympanocentesis:


“Gold standard” for diagnosis of AOM, although it is not routinely used because of cost, effort, and lack of availability. It involves removal of fluid from the middle ear to identify the bacteria causing the infection. It improves diagnostic accuracy, guides treatment by finding the causative pathogen, and avoids unnecessary medical or surgical intervention. It is especially useful in AOM unresponsive to antibiotics or recurrent AOM.



Culture and sensitivity:


Not routinely done, but if drainage is present or tympanocentesis is performed, it helps guide treatment in finding causative pathogen and antibiotics to which it is sensitive.





Nursing diagnosis:


Acute pain

related to increased pressure in the middle ear occurring with fluid and/or infection


Desired Outcome: Child is free from pain or has significantly decreased pain (e.g., less than 2 on FACES scale [0-5] or less than 4 on FLACC [face, legs, activity, cry, consolability] or a numeric scale [0-10]) within 1 hr after intervention/treatment.





















ASSESSMENT/INTERVENTIONS RATIONALES
Assess pain level at least q4h using developmentally appropriate pain scale for child (FLACC, FACES, or numeric scale). A pain scale developmentally appropriate for child will enable accurate assessment of pain level and help evaluate relief obtained.
Administer antipyretics/analgesics on a regular basis, for example, acetaminophen q4-6h for a maximum of 5 doses/day and/or ibuprofen q6-8h. This protocol provides better control of fever and pain than on a prn basis. Alternating acetaminophen and ibuprofen so that child receives pain medication q3h gives maximum pain/fever control.
Caution: Overdosage of acetaminophen can cause hepatic necrosis.
Reassess pain level and/or temperature 1 hr after administering medication. This evaluates effectiveness of pain relief/fever control measure.
Administer antibiotics, if prescribed. Instruct parents to: Many cases of AOM resolve in 2-3 days without antibiotics. This correlates with 2004 Clinical Practice Guidelines from the American Academy of Pediatrics.

– Administer correct dose of medication at correct time.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Otitis media

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