Acute Otitis Media
Anatomy & Physiology
Tympanic Membrane – eardrum, protects the middle ear. Separates the
external from the middle ear.
Middle ear – tympanic cavity, a small air-filled, mucosa-lined cavity within
the temporal bone.
Oval Window – the stapes bone transmits movement to the oval window.
Anatomy & Physiology
Round Window – as the stapes footplate moves into the oval window, the
round window, covered by a thin membrane, provides an exit for sound
vibrations.
Pharyngotympanic or Eustachian Tube – normally, the tube is flattened and
closed, but swallowing or yawning can open it briefly to equalize the pressure
in the middle ear cavity with the external, or atmospheric, pressure.
Ossicles – transmit the vibratory motion of the eardrum to the fluids of the
inner ear.
Hammer, or Malleus
Anvil, or Incus
Stirrup, or Stapes
Overview of the Disease
Ear infections can occur at any age
Most commonly seen in children
3 out of 4 children experience an ear infection by the time they are 3 years of
age.
Acute Otitis Media (AOM)
An acute infection of the middle ear, usually lasting less than 6 weeks.
Pathogens
Streptococcus Pneumoniae, Haemophilus Influenzae, & Moraxella Catarrhalis
The specific pathogen which enter the middle ear after eustachian tube
dysfunction caused by obstruction related to URIs, inflammation of
surrounding structures, or allergic reactions.
A purulent exudate is usually present in the middle ear, resulting in a
conductive hearing loss.
Assessment
Predisposing Factors (Down Syndrome, Cystic Fibrosis, Cleft Palate)
Health History (age, hx of URTIs, allergies)
Physical Head to Toe Assessment (Esp. Ears, Mouth, Nose, & Neck)
Pathophysiology
Obstruction of the Eustachian tube appears to be the most important
antecedent event associated with AOM. The vast majority of AOM episodes
are triggered by an URTI involving the nasopharynx.
Viral & Bacterial Infection
The infection is usually of viral origin, but allergic and other inflammatory
conditions involving the Eustachian tube may create a similar outcome.
Inflammation in the nasopharynx extends to the medial end of the Eustachian
tube, creating stasis and inflammation, which, in turn, alter the pressure within
the middle ear.
These changes maybe either negative (most common) or positive, relative to
ambient pressure.
Stasis also permits pathogenic bacteria to colonize the normally sterile middle
ear space through direct extension from the nasopharynx by reflux, aspiration,
or active insufflation.
The response is the establishment of an acute inflammatory reaction
characterized by typical vasodilatation, exudation, leukocyte invasion,
phagocytosis, and local immunologic responses within the middle ear cleft,
which yields the clinical pattern of AOM.
To become pathogenic in hollow organs, such as the ear or sinus, most
bacteria must adhere to the mucosal lining. Viral infections that attack and
damage mucosal linings of respiratory tracts may facilitate the ability of the
bacteria to become pathogenic in the nasopharynx, eustachian tube, & middle
ear cleft.
Medical Management
In the infant’s ear, it examined with an otoscope by pulling the ear down and
back to straighten the ear canal.
In the adult, the ear is pulled up and back.
The exam reveals a bright-red, bulging eardrum in otitis media.
Spontaneous rupture of the eardrum may occur, in which case there will be
purulent drainage, and the pain caused by the pressure build-up in the ear will
be relieved.
If present, purulent drainage is cultured to determine the causative organism
and appropriate antibiotic.
If drainage occurs, antibiotic otic preparation is usually prescribed.
The condition may be come subacute (lasting 3 weeks to 3 months), with
persistent purulent discharge from the ear.
Rarely does permanent hearing loss occur.
Mastoiditis, infection of the mastoid sinus, is a possible complication of
untreated acute otitis media.
Mastoiditis was much more common before the advent of antibiotics.
Currently it is seen only in children who have an untreated ruptured eardrum
or inadequate treatment (through noncompliance of caregivers or improper
care) of an acute episode.
Surgical Management
Myringotomy or Tympanotomy. An incision in the tympanic membrane.
tympanic membrane is numbed with a local anesthetic (phenol or by
iontophoresis)
Iontophoresis is a process in which ionized chemical substances are applied to
the surface of the body and introduced into the tissue using electrical current.
The anesthetic will act in tissue along the path of least resistance.
Iontophoresis can be used to safely and easily anesthetize the TM.
Iontophoresis does not involve any injection, is nearly painless, and is well
tolerated by children.
Iontophoresis may be useful for placement of a myringotomy with or without
tympanostomy tube or for use children to facilitate foreign body removal.
Anesthesia of the TM should last about 1.5 hours.
The procedure is painless and takes less than 15 minutes.
An incision is made through the tympanic membrane to relieve pressure and to
drain serous or purulent fluid from the middle ear.
The procedure may be performed if pain persists.
Myringotomy also allows the drainage to be analyzed (CST)
The incision heals within 24 – 72 hrs.
If AOM recurs & no contraindication, a ventilating or pressure equalizing tube
may be inserted.
Temporarily takes the place of the eustachian tube in equalizing pressure, is
retained for 6 to 18 months.
Treat recurrent episodes of AOM.
Nursing Diagnosis
1. Risk for Infection related to knowledge deficit about infection
2. Disturbed Sensory Perception: Auditory related to inflammation and presence
of discharge in the middle ear
3. Acute Pain related to inflammation and increased pressure in the middle ear
Nursing Management
Mostly, patients with AOM are cared for at home.
Therefore, a primary responsibility of the nurse is to teach the family
caregivers about prevention and the care of the patient with AOM.
Prevention
Hold infant in an upright position or with head slightly elevated while feeding
to prevent formula from draining into the middle ear through the wide
eustachian tube.
Never prop a bottle.
Do not give infant a bottle in bed. This allows fluid to pool in the middle ear,
encouraging organisms to grow.
Protect child or self from exposure to others with upper respiratory infections.
Protect child or self from passive smoke; don’t permit smoking in child’s
presence.
Remove sources of allergies from the home.
Observe for clues to ear infection: shaking head, rubbing or pulling at ears,
fever, combined with restlessness or screaming and crying.
Be alert to signs of hearing difficulty in toddlers and preschoolers. This may
be the first sign of an ear infection.
Teach gentle nose blowing.
Care of Client with AOM
Have child or self with upper respiratory infection who shows symptoms of
ear discomfort checked by a health care professional.
Complete the entire amount of antibiotic prescribed.
Use heat (such as a heating pad on low setting) to provide comfort.
Soothe, rock, and comfort child to help relieve discomfort. The child is more
comfortable sleeping on side of infected ear.
Give pain medications (such as acetaminophen) as directed. Never give
aspirin.
Provide liquid or soft foods; chewing causes pain.
Know that hearing loss may last up to 6 months after infection.
Schedule follow-up with hearing test as advised.
Sources:
Brunner & Suddarth’s Textbook of Medical Surgical Nursing, 12th Edition,
Volume 2, pg. 2106 – 2107
Broadribb’s Introductory Pediatic Nursing, Nancy T. Hatfield, 7th Edition, pg.
352 – 354
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