16.17 Otitis Media

Otitis media is a common pediatric disorder that refers to acute infection of the middle ear, although chronic forms of this disorder also exist. Otitis media with effusion is a subtype of this disorder in which there is no infection, but rather fluid buildup in the middle ear. This condition can be caused due to an episode of otitis media, an upper respiratory infection, or enlarged adenoids. Otitis media with effusion will be touched on briefly, but the focus of this section is otitis media.^[1],[2]

The infectious agent in otitis media can be a virus, bacteria, or a combination of the two. It can occur at any age but is most commonly seen in clients 6 to 24 months of age, with males being affected more frequently. Risk factors for developing otitis media include family history, enlarged adenoids, pacifier use, formula feeding instead of breastfeeding, allergies, exposure to cigarette smoke, attending daycare, and cochlear implants.^[3],[4]

Pathophysiology

Otitis media is caused by inflammation resulting from a recent upper respiratory tract infection. The edema in the small space of the ear leads to obstruction of the eustachian tube and the buildup of secretions. Bacterial or viral organisms can then flourish in this environment, leading to the development of discharge, which may be purulent. This buildup of discharge leads to the tympanic membrane appearing red and bulging.^[5] See Figure 16.23^[6] for an image depicting otitis media.

Assessment (Recognizing Cues)

Physical Exam

The most common presenting symptom of otitis media is ear pain, but some children may present with nonspecific symptoms such as ear pulling, irritability, decreased oral intake, poor sleep, gastrointestinal symptoms, or a low-grade fever. Examination of the ear with an otoscope may show the tympanic membrane being red with fluid present behind it. The fluid may be clear or purulent. Edema may also be present in the external ear canal.^[7],[8]

Potential complications of otitis media are perforation of the tympanic membrane, scarring of the tympanic membrane, or the spread of infection to nearby structures. Hearing loss can also occur with chronic or recurrent cases of otitis media. When hearing loss occurs in the age range of 6-24 months, speech problems can also result.^[9],[10]

In clients with otitis media with effusion, the most common symptom is hearing loss. Due to hearing loss, language may also be impaired. In some, hearing loss may become permanent. These clients may also have ear pain, but it is not a consistent symptom. Other symptoms may be a sensation of fullness in the ear or ear popping. Upon visualization with an otoscope, the tympanic membrane will be opaque and have decreased mobility.^[11],[12]

Common Laboratory and Diagnostic Tests

Otitis media is diagnosed clinically. Laboratory and imaging tests are not routinely performed unless complications are suspected or the client younger than 12 weeks old presents with a fever. A tympanocentesis, or fluid removal from the middle ear, may be performed in extreme cases or for those who are resistant to treatment. The fluid removed can then be cultured to identify the presence of pathogens. Otitis media with effusion is diagnosed with tympanometry, a test that measures how well the tympanic membrane moves. The results are displayed on a tympanogram, and its shape can help determine if abnormalities are present. In clients with otitis media with effusion, the shape of the tympanogram is flat. Hearing tests may also be performed to determine hearing loss.^{[13],[14],[15]}

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with otitis media include symptom management and the prevention of complications. Nursing diagnoses for clients with otitis media are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment. Possible nursing diagnoses for clients with otitis media are as follows^[16]:

• Acute pain r/t disease process
• Disturbed sensory perception r/t disease process
• Risk for injury r/t complication development

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions. Sample expected outcomes for clients with otitis media include the following^[17]:

• The client will exhibit a reduction in pain using a numeric scale, FACES, or FLACC, within one hour of treatment.
• The client will demonstrate normal hearing after the course of the illness.
• The client will demonstrate normal speech for developmental level after the course of the illness.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Medical interventions for otitis media consist of pain management and controlling the infection. Pain can be managed with the use of acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Antibiotics are often used to treat the infectious process, but their use is controversial. Some health care providers advise watchful waiting before prescribing antibiotics to determine if the infection clears on its own. However, oral antibiotics are prescribed if purulent discharge is present. If the tympanic membrane is perforated, antibiotic ear drops are prescribed. Otitis media with effusion will usually resolve on its own.

In clients with recurrent ear infections or chronic otitis media with effusion, placement of tympanostomy tubes by an ear, nose, and throat provider should be considered. During this procedure, an incision is made in the tympanic membrane, and a small tube is inserted to allow for drainage of fluid. This procedure can prevent future ear infections and the development of complications such as hearing loss. If enlarged adenoids are a causative factor in recurrent ear infections or effusions, adenoids can be removed at the same time the tympanostomy tubes are placed. Adenoids may be removed through ablation or excised and extracted through the mouth.^{[18],[19],[20],[21],[22]}

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client. When caring for a client with otitis media, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching, as described in the following subsections.^{[23],[24],[25],[26],[27],[28]}

Nursing Assessments

• Assess the ear of an infant by pulling the ear back and down to straighten the ear canal and permit better visualization.
• Assess for potential hearing loss.
• Assess the client for worsening symptoms such as increased pain or discharge, as this can indicate a complication is occurring.

Nursing Actions

• In the client with recurrent otitis media, ensure referrals to an audiologist and speech therapist if there is suspicion of hearing loss and resulting speech delays.
• Administer antibiotics and ear drops as prescribed by the provider.

Client Teaching

• Teach caregivers about the link between cigarette smoke exposure and the development of otitis media.
• Teach caregivers to feed infants in an upright position, as this can potentially reduce occurrences of otitis media and otitis media with effusion.
• Encourage influenza and pneumococcal vaccinations to prevent upper respiratory tract infections that can lead to otitis media.
• If a client had a tympanostomy tube insertion, teach the parents/caregivers about postoperative care. Anticipate the client may sleep most of the day after receiving general anesthesia. Pain can be managed with acetaminophen or NSAIDs. Full water submersion of the ears should be avoided. After the procedure, it is normal to observe a small amount of yellowish drainage or blood, but this should disappear after one to two days. Monitor for odorous or thick drainage from the ears, as this could indicate an infection. Antibiotic ear drops will be prescribed and should be administered based on the provider’s directions.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.