Diseases of the Ear Otitis Media, Foreign Bodies in the Ears, Mastoiditis

8/13/2019 Diseases of the Ear Otitis Media, Foreign Bodies in the Ears, Mastoiditis

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Definition:

Inflammation of themiddle ear



Peak incidence in the first two years oflife (esp. 6-12 months)

Boys are more affected than girls 50% of children 1 yr of age will have at

least 1 episode.

1/3 of children will have 3 or moreinfections by age 3

90% of children will have at least oneinfection by age 6.







Protection from nasopharyngeal soundand secretions

clearance of middle ear secretions ventilation (pressure regulation) of

middle ear







AOM is an inflammation of the middle earassociated with a collection of fluid in themiddle ear space (effusion) or a discharge(otorrhea)

Acute otitis media is commonly definedas… 1. Presence of a middle ear effusion (MEE)

2. Tympanic Membrane inflammation3. Presenting with a rapid onset of

symptoms such as fever, irritability, orearache



Acute otitis media is often associated with anupper respiratory infection or cold.

Acute otitis media is characterized by

inflammation of the middle ear space whichpresents with the rapid onset of symptomssuch as otalgia, fever, irritability, anorexia, orvomiting.

Findings of middle ear inflammation include

middle ear fluid causing decreasedtympanic membrane mobility and bulgingwith impaired visibility of bony landmarks, ared or reddish yellow color, exudate on themembrane, or bullae





› Called chronic serous otitis in the past, this

pattern is usually defined as a middle-ear

effusion that has been present for at least

3 months.

› Some sort of eustachian tube dysfunction

is the principal predisposing factor.

› Persistent structural changes, such as apersistent eardrum perforation, imply past

otitis but not necessarily chronic infection.







As the fluid clears air fluid levels or bubbles may be seenthrough the membrane as seen in the images below.

Fluid present from 3 to 16 weeks following the diagnosis ofacute otitis media without otoscopic signs of inflammation is aresidual effusion. After 16 weeks the fluid can be classified as apersistent effusion.



Tympanosclerosis is a form of membrane thickeningproduced by hyalization.

It results from chronic inflammation or trauma; often in

association with the insertion of ventilating tubes.



Tympanic membrane perforations can occur in the pars tensaor pars flacida. (right)

Most perforations produced by acute otitis media heal withina few days when the tympanic membrane is otherwisenormal. The persistence of drainage, called otorrhea, for 6

weeks or longer is classified as chronic suppurative otitismedia. (left)



Gray Pink



Strep. pneumoniae - 30-35%

Haemophilus influenzae - 20-25%

Group A strep - 2-4% Infants with higher incidence of gram

negative bacilli



RSV - 74% of middle ear isolates

Rhinovirus

Parainfluenza virus Influenza virus



Upper Respiratory Infections

Allergies

Craniofacial abnormalities (cleft palate) Immunosuppressed Child



When the Eustachian tube becomesblocked, the air trapped in the middle ear isabsorbed into the surrounding tissues and is

replaced by thin fluid. In time, small glandsappear in the lining of the middle ear andthe mucus which they secrete, explain thepopular name of “glue ears” which is given

to this condition. It is seen most in thosechildren where an immature musculatureand repeated upper respiratory tractinfections, predispose to tubal obstruction.



Neonates/Infants: change in behavior,

irritability, tugging at ears, decreased appetite,vomiting.

Children(2-4): otalgia, fever, noises in ears,

cannot hear properly, changes in personality

Children (>4): complain of ear pain, changes

I personality



Pneumatic Otoscopy: standard tool fordiagnosis

Impedance Tympanometry: useful for MEE.

Measures the resonance of the ear canalfor a fixed sound as the air pressure isvaried.

Spectral Gradient Acoustic Reflectometry:measures the condition of the middle earby assessing the response of the TM to asound stimulus. Equivalent to tympanometryfor dx of middle ear effusions





› Bulging TM› Yellow, white,

or bright redcolor

› Opacificationof eardrum

› Impairedvisibility ofossicularlandmarks





Fluid level Bobbles



Perforation Cobble stoning



Diagnostic tympanocentesis &Myringotomy: involves puncturing thetympanic membrane and aspirating

middle ear fluid to relieve pressure. Onlyused if the primary and secondary linetreatment fail.

With the increasing incidence of drugresistant strains of S. pneumoniae, CDCrecommends the capacity of cliniciansto be efficient in using tympanocentesis.



Tympanocentesis

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Myringotomy

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Cefzil

Pediazole ( erythromycin/sulfisoxazole)

Bactrim (trimethoprim/sulfamethoxazole These medications are used as

secondary agents if the primary

antibiotic has failed after 10 days andthe symptoms persists.



Administer analgesics as ordered toprovide pain relief.

Apply heat pack application over the ear

may relieve pain for some children.

Position child on the affected side topromote drainage (if draining, or

postoperatively after myringotomy).







Acute pain related to inflammatory

processes

Nursing interventions:

1. Teach client to transfer the atmosphere byperforming relaxation methods as extreme painappears, like a sigh of relaxation.Rational: Methods of transfer of the atmospherewith the relaxation can reduce the pain sufferedby the client.

2. Cold compress around the ear area.Rational: Cold compresses aimed at reducingthe pain because the pain distracted by the

cold around the ear area.



3. Adjust the position of the client.

Rational: positions that suit will make theclient feel comfortable.

4. For collaboration, give analgesics asinstructed, give sedatives as indicated.Rational: Analgesics are effective painrelief in patients to reduce the sensation

of pain from within.



Disturbed Sensory Perception: auditoryconductive disorder related to the sound

of the organ.

Intervention:

Looking at the client when speaking.

Reduce noise in the client environment.

Speaking clearly and firmly on the clientwithout the need to shout.

Provide good lighting when the clientrelies on the lips.



Using the signs of non-verbal (Ex. facial

expressions, pointing, or bodymovement) and other communications.

Instruct family or the people closest to

the client on how techniques of effectivecommunication so that they can interactwith clients.

If the client wants, the client can use

hearing aids.



Sensory perception alteration related toloss of hearing/impaired hearing

Risk injury/trauma related to accident Altered growth and development for

infant.





One of the most important structures inyour inner ear is the mastoid bone.

Although it’s called a bone, the mastoiddoes not have the typical structureassociated with bones in the humanbody. Rather than being solid and rigid

like most bones, the mastoid bone ismade out of air sacs and resembles asponge.



To function properly, the mastoid must

receive air from other parts of the ear,

including the Eustachian tube. Your

Eustachian tube connects your middle earto the back of your throat. If an infection

develops in your middle ear and your

Eustachian tube is blocked, it may causean infection in the mastoid bone. This

serious infection is known as mastoid bone

infection of the skull, or mastoiditis.



Mastoiditis is the most common intratemporalcomplication of acute otitis media.

Mastoiditis occurs when the aditus ad antrumbecomes obstructed by inflammation.

The pressure thus generated by the purulentsecretions within the mastoid, or the antrumin young infants, is relieved by egress throughthe cribiform area or the tympanomastoidfissure, resulting in inflammation and

tenderness in the postauricular sulcus. The pressure also causes necrosis and erosion

of the bony trabeculae of the mastoid.





Suspicion of mastoiditis should be raisedwhen certain findings are present.

Pain was the most common presenting

symptom. Physical signs included anabnormal-appearing tympanicmembrane (88%), fever (83%), anarrowed external auditory canal (80%),

and postauricular edema with proptosis.(76%). (2)



Abnormal-appearing tympanic membrane



Postauricular edema with proptosis.



Even without clear evidence of mastoiditis, a“masked” mastoiditis should be suspected ifthere is persistent pain or otorrhea despite 2weeks of antibiotic treatment.

Acute mastoiditis is defined not by fluid in themastoid air cells, but by bony destruction withcoalescence of the mastoid cavity.

This can be seen on a CT scan of the temporal

bones, which is usually ordered when there ishigh clinical suspicion for mastoiditis.



Mastoiditis should be initially treated atleast with IV antibiotics.

Culture and gram-stain directed therapy

is optimal. The most common pathogen recovered

from culture is Streptococcuspneumoniae. Streptococcus pyogenes,

Staphylococcus aureus, and coagulase-negative Staphylococcus species arealso common.



Symptoms

› Symptoms may follow AOM, with or without

a symptom-free interval of a few days toseveral weeks or more.

Otalgia

Aural discharge

Conductive hearing loss fever



Physical findings› Fever, from a slight elevation to 39

› Otorrhea may be absent

› Pulsatile may be observed

› Tympanic perforation is present, but itmay be obscured by intense edema

› Swelling of the superior TM andposterosuperior wall of EAC

› Postauricular area erythema and tenderness

Pitting edema

Obliteration of the postauricular crease



Antibiotic

Intravenous antibiotic therapy

should be maintained for at least24-48 h after the resolution ofsymptoms

Then followed with oral antibioticfor 2 weeks



The indications for asurgical treatment

The timing of surgery

(immediate versusdelayed)

The choice ofsurgical procedure.

mastoidectomy

Mastoidectomy +ventilation tubeplacement



Myringotomy, tympanocentesis, or a

mastoidectomy is performed becausethe goals of surgery are to drain theinfection and to obtain pus for culture.



Pre-Op Care

Assess for upper respiratory tract

infection. Shampoo the hair

Inform the client that he/she will be

under local anesthesia but sedatedduring surgery.



Post Op Care:

Assist the patient to lie on the

unoperated side. Instruct patient to blow nose gently one

side at a time; sneeze or cough withmouth open for 1 week after surgery.

Avoid physical activity for 1 week andexercises or sports for 3 weeks post op.





For sensation of ear pressure instruct thepatient to hold nose, close mouth andswallow to equalize pressure.

Assess the patient to report any drainageother than slight amount of bleeding tothe physician.

Instruct the patient to avoid reading.Watching TV or fast moving objects for 1week post op.





Risk for Infection related to post opsurgery.

Sensory perception alteration related toimpaired hearing.

Pain/Discomfort related to post opsurgery.

Impaired swallowing

Sleep pattern disturbance related topositioning of the affected site.





Usually put in by

patient, some bugs fly

in

kill bugs with mineral oil,

or lidocaine

remove with forceps,

suction or tissueadhesive



These are commonly found in the ears ofchildren.

Sometimes they can be removed by aprobe or irrigation with warm water butthe child is often frightened anduncooperative and a gen. anesthetic

will be necessary. The ear must always be checked to

exclude any underlying damaged.



An insect in the ear is treated similarly.

If foreign body is vegetable seed, do not

irrigate the ear because vegetableseeds expand when exposed to water.



Assess for any signs of infection andreport it to the physician.

Asses for pain and/or discomfort. Instruct the parents to check his/her child

to avoid this kind of problem.

For adult patient instruct them not to putanything in their ears when theircleansing it.



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Diseases of the Ear Otitis Media, Foreign Bodies in the Ears, Mastoiditis