Otitis media, the most common cause of antibiotic prescription in the United States, is an infection of the middle ear that can occur in several forms. Acute otitis media (AOM) is a suppurative (pus-forming) effusion of the middle ear with acute onset, presence of middle ear effusion (MEE), and signs of middle ear inflammation. Bullous myringitis is AOM that leads to bullae formation between the middle and the inner layers of the tympanic membrane. Persistent otitis media occurs when an acute infection does not resolve after 4 weeks of treatment. Recurrent otitis media occurs in children with three separate bouts of AOM within a 6-month period, six within a 12-month period, or six episodes by 6 years of age. Ostitis media is common, and at least half of children have their first epidose prior to their first birthday.
The eustachian tube protects the middle ear from secretions and allows for drainage of secretions into the nasopharynx. It also permits equalization of air pressure with atmospheric pressure in the middle ear. A mechanical obstruction of the eustachian tube can result in infection and middle ear effusion. A functional obstruction can occur with persistent collapse of the eustachian tubes, particularly in infants and young children, because the amount and stiffness of their cartilage is less than that of older children and adults. Eustachian tube obstruction leads to negative middle ear pressure and a sterile MEE. Drainage of the effusion is inhibited by impaired mucociliary action and sustained negative pressure. Contamination of the middle ear may occur from nasopharyngeal secretions and lead to infection. Because infants and young children have a shorter eustachian tube than older children, it makes them more susceptible to reflux of nasopharyngeal secretions into the middle ear and development of infection. Other predisposing factors include upper respiratory infections, allergies, Down syndrome, bottle propping during feedings, daycare attendance, and parental smoking. Complications include persistent AOM, tympanic membrane perforation, mastoiditis, hearing loss for several months, speech delay, and cerebral thrombophlebitis.
Bacteria pulled into the eustachian tube leads to the accumulation of purulent fluid in the middle ear. Common bacteria include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. S. pneumoniae is the most common type of infection (40% to 50% of all cases) and is the least likely to resolve without antibiotic treatment.
Nursing care plan assessment and physical examination
Determine the presence of risk factors by observing the child and asking the parents questions. If the child is not able to speak, ask the parents if the child has had evidence of ear pain (otalgia). In infants and young children, ear pain is often manifested by irritability, inability to sleep, and ear pulling. Ask if the child has demonstrated lethargy, dizziness, tinnitus, and unsteady gait. Other symptoms include diarrhea, vomiting, fever, sudden hearing loss, stuffy nose, rhinorrhea, and sneezing.
During an examination with an otoscope, the clinician can see a reddened, bulging tympanic membrane with poor mobility and obscured or absent landmarks. The tympanic membrane is often hypervascular and red, yellow, or purple in color. Note that redness alone should not be used to diagnose AOM, particularly in a crying child. The tympanic membrane may demonstrate thin-walled, sagging bullae filled with yellow fluid if the child has bullous myringitis. Differential diagnosis includes mastoiditis, dental abscesses, sinusitis, parotitis, peritonsillar abscess, trauma, impact teeth, and immune deficiency. It is important for practitioners to distinguish between AOM and otitis media with effusion (OME); OME is more common than AOM. Antibiotics may be prescribed unnecessarily for OME, which is fluid in the middle ear without signs or symptoms of infection and is usually caused when the eustachian tube is blocked. When infection follows, the child develops signs and symptoms of AOM.
Evaluate the parental-child interaction to determine how well the parent follows up on the child’s cues. Determine the extent of the parent’s knowledge about risk factors. Determine the parent’s feeding practices.
Nursing care plan primary nursing diagnosis: Risk for infection related to invasion or proliferation of microorganisms
Nursing care plan intervention and treatment plan
Once AOM is diagnosed, the primary treatment is pharmacologic. However, a current debate exists as to whether antibiotics are appropriate because of growing rates of antibiotic-resistant bacteria. Many physicians support the idea that because 60% to 90% of the infections resolve without antibiotics, treatment for all AOM may not be necessary. Antibiotics are recommended for children with clear local signs (bulging membrane with cloudy or yellow fluid, very red membrane, or otorrhea), if systemic signs (fever in particular) are present, if more than three attacks have occurred in the past 18 months, or if OME is present. Decongestants and antihistamines are not considered helpful unless the child has allergies.
In patients with severe pain, therapeutic drainage (myringotomy) may be necessary to provide immediate relief. An incision is made that is large enough to allow for adequate drainage of the middle ear. Children who undergo this procedure need to be evaluated after approximately 14 days to determine that the infection and otoscopic signs are resolving.
Explain to the parents that the symptoms should begin to resolve in 24 to 48 hours as the antibiotics take effect. If the acute signs increase in the first 24 hours despite antibiotics, the parents need to bring the child back for a return examination to rule out severe infections such as meningitis or suppurative complications. Make sure that the parents understand that the child needs to receive the entire course of therapy to prevent recurrent infections. Teach the parents that supportive therapy with relief of pain and fever will increase the child’s comfort. Application of heat may provide pain relief.
Instruct the parents about bottle propping, feeding infants while they are recumbent, and passive smoke exposure, all of which are risk factors for developing AOM. Breastfeeding until at least 4 to 6 months has a protective effect against AOM. Encourage patients to attend followup appointments and to avoid requesting antibiotics unless it is absolutely necessary. If repeated infections occur and the child attends daycare, parents may want to consider another
situation.
Nursing care plan discharge and home health care guidelines
Make sure that the parents understand all aspects of the treatment regimen, with particular attention to taking the full course of medication therapy. Make sure the parents understand the necessity of any follow-up visits.
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