Otitis Media Nursing Care Planning and Management: Study Guide

What is Otitis Media?

Otitis media is inflammation of the middle ear, named without reference to etiology or pathogenesis. It splits into several variants based on cause, duration, symptoms, and physical findings.

Pathophysiology

Eustachian tube dysfunction is the central problem. The mucosa at the pharyngeal end of the ET is part of the mucociliary system of the middle ear, and in children three things stack the deck: developmental differences in the eustachian tube, an immature immune system, and frequent upper respiratory infections.

In an infant the eustachian tube is shorter, wider, and straighter than in an older child or adult, so nasopharyngeal secretions reach the middle ear easily. Anything that interferes with the mucosa (edema, tumor, negative intratympanic pressure) lets infection extend directly from the nasopharynx into the middle ear.

Statistics and Incidences

Ear infections are extremely common in early childhood: five out of six children have at least one ear infection by their third birthday, according to the National Institute on Deafness and Other Communication Disorders (NIDCD). Otitis media is the most common reason children are prescribed antibiotics. Incidence peaks between 6 and 18 months of age, and many children go on to have repeated episodes.

Causes

Host, infectious, allergic, and environmental factors all contribute.

• Immature immune system. Otitis media thrives where immune defenses are down.
• Genetic predisposition. Familial clustering shows up in studies, though separating genetics from shared environment is hard.
• Anatomic abnormality. Children with palate and associated muscle abnormalities carry higher risk.
• Physiologic dysfunction. Abnormal ET mucosa function raises the risk of bacterial invasion of the middle ear.
• Bacterial pathogens. The most common is Streptococcus pneumoniae, followed by Haemophilus influenzae and Moraxella catarrhalis.
• Infant feeding methods. Breastfeeding is protective.

Clinical Manifestations

Suspect otitis media in a child with the classic head, neck, and general symptoms.

• Otalgia. Young children pull at the affected ear or their hair; ear pain is often worse lying down.
• Otorrhea. Discharge drains from the middle ear through a recent or existing perforation.
• Headache. Older children may report it.
• Upper respiratory symptoms. Cough, rhinorrhea, or sinus congestion is common, concurrent or recent.
• Fever. Two-thirds have a fever history, though temperatures above 40°C are uncommon.
• Irritability. May be the only early sign in an infant or toddler.

Assessment and Diagnostic Findings

• Laboratory tests. Usually unnecessary, though many experts recommend a full sepsis workup in infants younger than 12 weeks who present with fever and otitis media.
• Tympanocentesis. The criterion standard. Tap the middle ear to confirm fluid, then culture it to identify the pathogen.

Medical Management

In 2013 the American Academy of Pediatrics (AAP) published its updated clinical practice guideline on acute otitis media, a revision of the 2004 AAP and American Academy of Family Physicians guideline. It covers otherwise healthy children 6 months through 12 years.

• Antibiotic therapy. The guideline recommends antibiotics for bilateral or unilateral acute otitis media in children at least 6 months old with severe signs or symptoms, and for nonsevere bilateral disease in children younger than 24 months. Amoxicillin is first-line when the child has not had it recently, with amoxicillin-clavulanate used when amoxicillin was taken in the past 30 days, with purulent conjunctivitis, or when amoxicillin has previously failed. Observation with close followup is an option for some older children with nonsevere disease.

Pharmacologic Management

The FDA has approved more than a dozen antibiotics for otitis media. Antimicrobial agents clear pathogenic bacteria from the middle ear fluid.

Surgical Management

Integrate surgery with medical treatment from the start.

• Myringotomy and TT placement. Incise the eardrum to establish drainage and insert tympanostomy tubes to keep the middle ear draining.
• Adenoidectomy. Used in some patients, though the benefit is debated.

Nursing Management

Most children with otitis media are cared for at home, so your main job is teaching the family about prevention and care.

Nursing Assessment

• Physical examination. Examine the ear with an otoscope, pulling the ear down and back to straighten the canal.
• History. Ask about ear trauma, affected siblings, cranial or facial defects, and family history of otitis media.

Nursing Diagnoses

• Acute pain related to middle ear inflammation.
• Anxiety related to health status.
• Impaired verbal communication related to hearing loss.
• Disturbed sensory perception related to obstruction, middle ear infection, or auditory nerve damage.
• Risk for injury related to hearing loss and decreased visual acuity.
• Infection related to presence of pathogens.

Nursing Care Planning and Goals

• The child or parent reports absence of pain.
• The child is free of infection.
• The parents understand preventive measures.
• The child has normal hearing.

Nursing Interventions

• Positioning. Have the child sit up, raise the head on pillows, or lie on the unaffected ear.
• Heat application. Apply a heating pad or warm water bottle.
• Diet. Encourage breastfeeding (it confers natural immunity); position bottle-fed infants upright to feed.
• Hygiene. Teach the family to cover mouth and nose when sneezing or coughing and to wash hands often.
• Monitoring hearing loss. Check hearing ability frequently.

Evaluation

Goals are met when the child or parent reports no pain, the child is free of infection, the parents understand prevention, and the child has normal hearing.

Documentation Guidelines

• Individual findings: affecting factors, interactions, nature of social exchanges, specifics of behavior.
• Cultural and religious beliefs and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment of or progress toward desired outcomes.

Frequently Asked Questions

What causes ear infections in young children? The central problem is eustachian tube dysfunction. In infants the eustachian tube is shorter, wider, and straighter than in older children, so nasopharyngeal secretions reach the middle ear easily. An immature immune system and frequent upper respiratory infections add to the risk. The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

How common are ear infections? Very common. Five out of six children have at least one ear infection by their third birthday, according to NIDCD, and otitis media is the most common reason children are prescribed antibiotics. Incidence peaks between 6 and 18 months of age.

Do all ear infections need antibiotics? No. The 2013 AAP guideline recommends antibiotics for children with severe signs or symptoms and for younger children with bilateral disease, while observation with close followup is an option for some older children with nonsevere infection. When an antibiotic is needed, amoxicillin is usually first-line.

What are the symptoms of otitis media? Common signs are ear pain (a young child may pull at the ear), fever, fussiness or irritability, trouble sleeping, drainage from the ear, and reduced hearing. Pain is often worse when lying down. Irritability may be the only early sign in an infant.

Can ear infections affect a child's hearing? Fluid behind the eardrum can cause temporary hearing loss during and after an infection. Most hearing returns once the fluid clears. Repeated or persistent infections with fluid are monitored, and tympanostomy (ear) tubes may be placed to keep the middle ear draining.

How can ear infections be prevented? Breastfeeding offers some protection, as does keeping a bottle-fed infant upright during feeds. Avoiding secondhand smoke, good handwashing, and staying current on recommended vaccinations also lower the risk.