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2:  Acute Otitis Media

Aimee Dassner; Jennifer E. Girotto

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Patient presentation.

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Chief Complaint

“Increased irritability and right ear pain.”

History of Present Illness

JL is a 22-month-old female who presents to her primary care provider (PCP) with a 2-day history of rhinorrhea and a 1-day history of increased irritability, fever (to 101.5°F per Mom), and right-ear tugging. Mom denies that JL has had any nausea, vomiting, or diarrhea.

Past Medical History

Full-term birth via spontaneous vaginal delivery. Hospitalized at 9 months of age for respiratory syncytial virus–associated bronchiolitis. Two episodes of acute otitis media (AOM), with last episode about 6 months earlier.

Surgical History

Social history.

Lives with mother, father, and her 5-year-old brother who attends kindergarten. JL attends daycare 2 d/wk, and stays at home with maternal grandmother 3 d/wk.

No known drug allergies

Immunizations

Home medications.

Vitamin D drops 600 IU/d

Physical Examination

Vital signs (while crying).

Temp 100.7°F, P 140 bpm, RR 35, BP 100/57 mm Hg, Ht 81 cm, Wt 23.7 kg

Fussy, but consolable by Mom; well-appearing

Normocephalic, atraumatic, moist mucous membranes, normal conjunctiva, clear rhinorrhea, moderate bulging and erythema of right tympanic membrane with middle-ear effusion

Good air movement throughout, clear breath sounds bilaterally

Cardiovascular

Normal rate and rhythm, no murmur, rub or gallop

Soft, non-distended, non-tender, active bowel sounds

Genitourinary

Normal female genitalia, no dysuria or hematuria

Alert and appropriate for age

Extremities

1. Which of the following clinical criteria is not part of the diagnostic evaluation or staging of acute otitis media (AOM) for this patient?

A. Rhinorrhea

D. Contour of the tympanic membrane

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Otitis Media

Case Presentation

JoAnn was at work when she received a call from the day care where Michael, her five month-old son, was being watched. The child care provider told JoAnn that Michael had been fussy that morning, napped only a short while, refused his bottle, and was running a temperature of 101°F. JoAnn told the day care provider that she would be right over to pick up Michael. She called her pediatrician’s office and scheduled an appointment for that afternoon.

The pediatrician inspected Michael's ears and informed JoAnn that Michael had a middle ear infection. She asked JoAnn if Michael had been coughing a lot and if he recently had a cold or runny nose. She also asked if Michael was breast-fed or bottle-fed and if there was anyone in their household who smoked. JoAnn told the doctor that Michael's nose had been draining quite a bit lately, that he was bottle-fed, and that neither she nor her husband smoked. The doctor wrote a prescription for antibiotics and instructed JoAnn to give Michael a non-prescription childrens' pain medication. An appointment was made for a recheck in two weeks.

Case Background

A middle ear infection, or otitis media, is most often of bacterial origin and commonly follows an upper respiratory infection. The bacteria usually enter the middle ear via the surface of the auditory tube mucus membrane. Inflammation of the tissues in the middle ear results from the infection. The auditory tube becomes swollen or clogged, and pus accumulates in the tympanic cavity of the middle ear as white blood cells rush to the site.

Otitis media can affect anyone, but is most common in young children, with 75% of children experiencing at least one episode by their third birthday. Children are more likely to suffer from otitis media than adults because their immune systems are immature, and their auditory tubes are shorter and straighter than those of adults. Children that attend large day cares, are bottle-fed, and are exposed to cigarette smoke are more likely to experience otitis media.

Symptoms in young children include severe earache, fever, nausea, vomiting, and diarrhea. Rupturing of the tympanic membrane, or eardrum, can also occur but is uncommon. If the condition is very persistent, generally seen as lasting for three months, an operation called a myringotomy can be performed. This operation involves the insertion of a ventilation tube in the tympanic membrane of an infected ear.

Describe the following middle ear structures, explain their functions, and explain how those functions may be impeded by otitis media.

Otitis Media

Otitis media is a common and frequently encountered ear infection that affects individuals of all ages, particularly young children. This condition involves inflammation and infection of the middle ear, often resulting from viral or bacterial pathogens. Otitis media can lead to various symptoms, including ear pain, fever , hearing difficulties, and fluid buildup behind the eardrum.

This article aims to serve as a comprehensive nursing guide to otitis media, diving into its causes, clinical manifestations, diagnostic methods, medical management, and nursing interventions.

Table of Contents

• What is Otitis Media? 

Pathophysiology

Statistics and incidences, clinical manifestations, assessment and diagnostic findings, pharmacologic management, surgical management, nursing assessment, nursing diagnoses, nursing care planning and goals, nursing interventions, documentation guidelines, what is otitis media.

Otitis media is very common among children.

• Otitis media is an inflammation of the middle ear without reference to etiology or pathogenesis.
• It can be classified into many variants based on etiology, duration, symptomatology, and physical findings.

In children, developmental alterations of the eustachian tube, an immature immune system, and frequent infections of the upper respiratory mucosa all play major roles in AOM development.

• The most important factor in middle ear diseases is eustachian tube dysfunction, in which the mucosa at the pharyngeal end of the ET is part of the mucociliary system of the middle ear.
• The eustachian tube in an infant is shorter and wider than in an older child or adult.
• The tube is also straighter, thereby allowing nasopharyngeal secretions to enter the middle ear more easily.
• Interference with the mucosa by edema, tumor , or negative intratympanic pressure facilitates the direct extension of infectious processes from the nasopharynx to the middle ear, causing otitis media.

Otitis media is one of the most common infectious diseases of childhood.

• Two of every three children have at least one episode of otitis media by the time they are 1 year old.
• Otitis media accounts for approximately 20 million annual physician visits.
• Various epidemiologic studies report the prevalence rate of acute otitis media to be 17-20% within the first two years of life.
• One-third of children experience six or more episodes of otitis media by age 7 years.
• Peak prevalence of otitis media in both sexes occurs in children aged 6 to 18 months.

A multitude of host, infectious, allergic, and environmental factors contribute to the development of otitis media.

• Immature immune system. Otitis media is an infectious disease that prospers in an environment of decreased immune defenses.
• Genetic predisposition. Although familial clustering of otitis media has been demonstrated in studies that examined genetic associations of otitis media, separating genetic factors from environmental influences has been difficult.
• Anatomic abnormality. Children with anatomic abnormalities of the palate and associated musculature have a higher risk for otitis media.
• Physiologic dysfunction. Abnormalities in the physiologic function of the ET mucosa increase the risk of bacterial invasion of the middle ear and the resultant otitis media.
• Bacterial pathogens. The most common bacterial pathogen is Streptococcus pneumoniae, followed by Haemophilus influenzae , and Moraxella catarrhalis .
• Infant feeding methods. Many studies report that breastfeeding protects infants against otitis media.

Otitis media should be suspected in children with a history of characteristic head-neck and general symptoms.

• Otalgia. Young children may exhibit signs of otalgia by pulling on the affected ear or ears or pulling on the hair ; otalgia apparently occurs more often when the child is lying down.
• Otorrhea. Discharge may come from the middle ear through a recently perforated tympanic membrane, or through another perforation.
• Headache. An older child may complain of a headache.
• Symptoms of upper respiratory infection. Concurrent or recent symptoms of URI, such as cough , rhinorrhea or sinus congestion is common.
• Fever. Two-thirds of children with otitis media have a history of fever, although fevers greater than 40°C are uncommon.
• Irritability. Irritability may be the sole early symptom in a young infant or toddler.

Otitis media may be revealed through the following:

• Laboratory tests. Laboratory evaluation is usually unnecessary, although many experts recommend a full sepsis workup in infants younger than 12 weeks who present with fever and otitis media.
• Tympanocentesis. The criterion standard in the diagnosis of otitis media is tympanocentesis to determine middle ear fluid, followed by culture of fluid to identify causative pathogens.

Medical Management

In 2013, the American Academy of Pediatrics (AAP) and the American Academy of Family Practice published updated guidelines on the medical management of otitis media.

• Antibiotic therapy. Among other recommendations, the guidelines recommended antibiotics for bilateral and unilateral otitis media in children aged at least 6 months with severe signs and symptoms.

The FDA has approved more than a dozen antibiotics to treat otitis media.

• Antimicrobial agents. These agents remove pathogenic bacteria from the middle ear fluid.

From the beginning, it is essential to integrate surgical management of otitis media with medical treatment.

• Myringotomy and TT placement. Myringotomy or the incision of the eardrums may be performed to establish drainage and to insert tiny tubes into the tympanic membrane to facilitate drainage.
• Adenoidectomy. The performance of adenoidectomy to treat patients with otitis media has generated extensive discussion and research, though potential benefits are controversial.

Nursing Management

Most infants and children with otitis media 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 child.

Assessment of a child with otitis media include the following:

• Physical examination. The infant’s ear is examined with an otoscope by pulling he ear down and back to straighten the ear canal.
• History. Assess if there is a history of trauma to the ears, affected siblings, a history of cranial/facial defects or any familial history of otitis media.

Based on the assessment data, the major nursing diagnoses are:

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

Main Article: 4 Otitis Media Nursing Care Plans 

The major goals for the child with otitis media are:

• The child or parent will indicate absence of pain.
• The child will be free of infection.
• The parents will state understanding of preventive measures.
• The child will have normal hearing.

Nursing care for the child with otitis media include:

• Positioning . Have the child sit up, raise head on pillows, or lie on unaffected ear.
• Heat application. Apply heating pad or a  warm hot water bottle.
• Diet. Encourage breastfeeding of infants as breastfeeding affords natural immunity to infectious agents; position bole-fed infants upright when feeding .
• Hygiene. Teach family members to cover mouths and noses when sneezing or coughing and to wash hands frequently.
• Monitoring hearing loss. Assess hearing ability frequently.

Goals are met as evidenced by:

• The child or parent indicated absence of pain.
• The child is free of infection.
• The parents stated understanding of preventive measures.
• The child has normal hearing.

Documentation in a child with otitis media include the following:

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

5 thoughts on “Otitis Media”

This was very useful..thank you

One tip I always share with parents is to make sure their child is up to date on their pneumococcal vaccinations, as pneumococcal bacteria are a common cause of ear infections. Another important tip is to encourage frequent hand washing, especially after being in crowded or public places, to help prevent the spread of infections. It’s also important to monitor for signs of an ear infection, such as pain, redness, or discharge, and to seek prompt medical attention if these symptoms occur. Thank you for bringing attention to this important topic!

I have this and It absolutely sucks! I started getting Eustachian tubes put in when I was 18months old, and still to this day I am having Estuation tubes put in every other year or so. I am currently, 24. I got my first set of hearing aids when I turned 17, bilateral. I hope one day in the future we can have an answer to permanently treat this instead of creating more and more scar tissue on my eardrums every single surgery I get. Scar tissue gets worse and worse every surgery I have. It’s building up on my eardrum, so it’s just decreasing my hearing every single time.

Hello Skyler M,

I’m really sorry to hear about your ongoing struggle with otitis meida and hearing loss. It sounds incredibly tough, especially with the impact on your hearing. It’s totally understandable to hope for a better, more lasting solution.

Have you explored any new treatment options lately? Sometimes specialists in audiology or advanced otology might have different approaches worth considering.

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