OTITIS MEDIA

Reported by: Jhoanne G. Seda Mary Sheena Trinidad Amaina Charmaine Valencia

DEFINITION
Otitis media (Latin for "Inflammation of the Middle Ear") is inflammation of the middle ear, or middle ear infection. Otitis media occurs in the area between the tympanic membrane (the end of the outer ear) and the inner ear, including a duct known as the eustachian tube. It is one of the two categories of ear inflammation that can underlie what is commonly called an earache, the other being otitis externa. Diseases other than ear infections can also cause ear pain, including cancers of any structure that shares nerve supply with the ear and shingles which can lead to herpes zoster oticus. Though severely painful, otitis media is not threatening and usually heals on its own within 24 weeks.

CLASSIFICATION

Acute Serous

Otitis Media Otitis Media

Chronic

Suppurative Otitis Media

CLASSIFICATION
Otitis media has many degrees of severity, and various names are used to describe each. The terminology is sometimes confusing because of multiple terms being used to describe the same condition. A common misconception with ear infection is that sufferers think that a symptom is itchy ear. Although sufferers may feel discomfort, an itchy ear is not a symptom of ear infection.

ACUTE OTITIS MEDIA

Acute otitis media (AOM) is most often purely viral and self-limited, as is its usual accompanying viral URI (upper respiratory infection). There is congestion of the ears and perhaps mild discomfort and popping, but the symptoms resolve with the underlying URI. If the middle ear, which is normally sterile, becomes contaminated with bacteria, pus and pressure in the middle ear can result, and this is called acute bacterial otitis media.

ACUTE OTITIS MEDIA

Viral

acute otitis media can lead to bacterial otitis media in a very short time, especially in children, but it usually does not. The individual with bacterial acute otitis media has the classic "earache", pain that is more severe and continuous and is often accompanied by fever of 102 F (39 C) or more. Bacterial cases may result in perforation of the ear drum, infection of the mastoid space (mastoiditis) and in very rare cases further spread to cause meningitis.

ACUTE OTITIS MEDIA

Features:

1st phase
exudative fever

inflammation lasting 12 days

rigors meningism (occasionally in children) severe pain (worse at night) muffled noise in ear

ACUTE OTITIS MEDIA

deafness sensitive mastoid process ringing in ears (tinnitus)

ACUTE OTITIS MEDIA

2nd phase
resistance

and demarcation lasting 38

days. Pus and middle ear exudate discharge spontaneously and afterwards pain and fever begin to decrease. This phase can be shortened with topical therapy.

ACUTE OTITIS MEDIA

3rd phase
healing

phase lasting 24 weeks. Aural discharge dries up and hearing becomes normal.

SEROUS OTITIS MEDIA

Otitis media with effusion (OME), also called serous or secretory otitis media (SOM), is simply a collection of fluid that occurs within the middle ear space as a result of the negative pressure produced by altered Eustachian tube function. This can occur purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis media. Fluid in the middle ear sometimes causes conductive hearing impairment, but only when it interferes with the normal vibration of the eardrum by sound waves.

SEROUS OTITIS MEDIA

Over weeks and months, middle ear fluid can become very thick and glue-like (thus the name glue ear), which increases the likelihood of its causing conductive hearing impairment. Early-onset OME is associated with feeding while lying down and early entry into group child care, while parental smoking, too short a period of breastfeeding and greater amounts of time spent in group child care increased the duration of OME in the first two years of life.

CHRONIC SUPPURATIVE
Chronic suppurative otitis media involves a perforation (hole) in the tympanic membrane and active bacterial infection within the middle ear space for several weeks or more. There may be enough pus that it drains to the outside of the ear (otorrhea), or the purulence may be minimal enough to only be seen on examination using a binocular microscope. This disease is much more common in persons with poor Eustachian tube function. Hearing impairment often accompanies this disease.

SIGNS & SYMPTOMS

Accompanying

or precedent upper respiratory infection (URI) symptoms (very common) Earache/fullness Decreased hearing Fever Otorrhea Infants may be asymptomatic or irritable. Infants may present with pulling/tugging of the ear.

SIGNS & SYMPTOMS

Visualization of the tympanic membrane with identification of a middle ear effusion (MEE) and inflammatory changes is necessary to establish the diagnosis of acute otitis media (AOM).

Bulging of the tympanic membrane is the most sensitive sign of MEE. Other findings that indicate the presence of MEE include limited mobility of the tympanic membrane with pneumatic otoscopy and fluid visualized behind the tympanic membrane. If difficult to determine, acoustic reflectometry or tympanometry may be helpful.

SIGNS & SYMPTOMS

of the tympanic membrane is common in crying infants and with fever, this must be distinguished from the injection due to inflammation associated with AOM. A history suggestive of AOM and an ear canal full of purulent exudate is generally considered sufficient to diagnosis AOM with perforation. Blisters on the tympanic membrane may be present (bullous myringitis).
Injection

SIGNS & SYMPTOMS

Movement

of the tragus should be painless in AOM. If pain is present, suspect that a foreign body is in the ear canal or that the patient has otitis externa. The association between bacterial conjunctivitis and AOM is well described, thus any patient with purulent conjunctival exudate should receive thorough examination of the tympanic membranes. Sinusitis and purulent rhinitis frequently accompany AOM in children and infants.

CAUSES
Blockage of the eustachian tubes may be caused by: Respiratory infection (cold) Allergies Exposure to cigarette smoke Infected or overgrown adenoids (tonsils) For infants, being fed lying down (drinking a bottle while lying on the back) Ear infections occur most often in the winter. They are not contagious, but a cold may spread among a group of children and cause some of them to get ear infections.

RISK FACTORS
Age (children between 6 - 36 months are most likely to get ear infections) Recent illness (such as a cold or sinus infection) History of allergies (like hay fever, also called allergic rhinitis, or sinusitis) Exposure to secondhand smoke Day care Having family members who are prone to ear infections Multiple episodes of acute otitis media (AOM). Living in crowded conditions.

RISK FACTORS
Being a member of a large family. Studies of parental education, passive smoking, breast-feeding, socioeconomic status, and the annual number of upper respiratory infections (URTIs) show inconclusive associations only. Craniofacial anomalies increase risk: cleft lip or palate, Down's syndrome, cri du chat syndrome, choanal atresia, and microcephaly all increase the risk of CSOM.

ANATOMY & PHYSIOLOGY

ANATOMY & PHYSIOLOGY

The ear has three parts:

The

outer ear The middle ear The inner ear.

ANATOMY & PHYSIOLOGY

The outer ear is made up of the following: The pinna is the part of the ear that you can see.It is the skin and the cartilage that sticks out from the side of the head. The external auditory canal leads from the pinna to the eardrum. The canal is not completely straight. It has bends in it. To examine the canal, gently pull The pinna upwards and backwards. This makes the canal straight, and easier To look at with an otoscope (auroscope). The walls of the canal are covered by skin. This skin produces wax, which Helps to protect the ear against dust and insects. Usually the wax gathers in

ANATOMY & PHYSIOLOGY

The

canal. The wax dries out and falls out of the canal. Wax can become hard and compacted - this can cause discomfort and hearing problems. The skin inside the canal is fixed tightly to the cartilage and bone. This meansthat even slight inflammation and swelling can cause quite severe pain. People with infection of the outer ear often present at clinics complaining of pain inside the ear.

ANATOMY & PHYSIOLOGY

ANATOMY & PHYSIOLOGY

The eardrum is also called the tympanic membrane. It divides the outer ear and the middle ear. The eardrum can be seen with an otoscope. It is usually a shiny grey-white colour. If you shine a light on the membrane with an otoscope, you will see that the eardrum reflects some of the light. This is called the light reflex.

ANATOMY & PHYSIOLOGY

The middle ear

Lies behind the eardrum. It is a space inside the skull. This space is filled with air.

ANATOMY & PHYSIOLOGY

The middle ear contains : The osicles. Inside the middle ear are three tiny bones or osicles. They are the smallest bones in the body. Sound travels to the inner ear along these bones. If these bones get damaged in any way, then the patient will suffer a loss of hearing. One of these bones is call the hammer or malleus. You can see the handle of the hammer if you look at the eardrum with an otoscope. The handle is attached to the top part of the eardrum.

ANATOMY & PHYSIOLOGY

The Eustachian tube. There is a very thin tube which connects the middle ear to the throat. This is called the Eustachian tube. Air can move through these tubes between the throat and the middle ear. The middle ear is connected to the throat by the Eustachian tube.

ANATOMY & PHYSIOLOGY

If air can travel between the throat and the middle ear so can infection. Infection can move up and down the tubes from the throat to the ear, and from the ear to the throat. For this reason it is important to examine the ear and the throat. Always examine the throat when treating an ear infection. The middle ear lies inside the skull. There is only a very thin layer of bone between the middle ear and the brain. Infection can spread from the middle ear to the lining of the brain. The membranes lining the brain are also called the meninges. If this happens, the patient gets inflammation of the meninges or meningitis.

ANATOMY & PHYSIOLOGY

The mastoid bones
lie

at the base of the skull,directly behind the ears. They are not required for hearing. The mastoid bones are full of air spaces. These air mastoid area spaces are connected to the middle ear. This means that it is possible for infection to spread from the middle ear to the mastoid area.

ANATOMY & PHYSIOLOGY

ANATOMY & PHYSIOLOGY

The inner ear. The inner ear lies deep inside the skull. There are nerves in the inner ear that carry the sound to the brain. If the nerves get damaged, then the patient will suffer from loss of hearing or loss of balance. It is not possible to look at the inner ear during clinical examination. The function of the inner ear can be tested by testing hearing and balance.

PATHOPHYSIOLOGY
Modifiable * Recent illness (such as a cold or sinus infection) * Day care * Living in crowded conditions. * Being a member of a large Non - modifiable * Age (children between 6 36 months are most likely to get ear infections) * History of allergies (like hay fever, also called allergic rhinitis, or sinusitis)

VIRAL UPPER RESPIRATORY INFECTION (URI) OBSTRUCTION OF THE EUSTACHIAN TUBES NEGATIVE PRESSURE

PATHOPHYSIOLOGY
SEROUS EFFUSION

FERTILE MEDIA FOR MICROBIAL GROWTH OTITIS MEDIA

SURGICAL MANAGEMENT
Tympanocentesis,

myringotomy, or both may be appropriate to delineate the etiology of acute otitis media in an immunocompromised patient, a patient with mastoiditis, a patient with persistent fever in the face of antibiotic therapy, or a patient with intractable pain. y If acute otitis media is present in infants younger than 2-3 months, some authors recommend tympanocentesis. y These procedures often are performed by the ear, nose, and throat (ENT) consultant.

SURGICAL MANAGEMENT

Drainage tubes (myringotomy) -- If your child has recurring ear infections that don't respond to antibiotics or if the fluid in the child's ear affects his hearing, your doctor may suggest putting in drainage tubes. During this surgery, which requires general anesthesia, the surgeon inserts a small drainage tube through the eardrum. Fluid behind the eardrum can drain out, equalizing the pressure between the middle and outer ear, which should improve your child's hearing. The tubes usually come out on their own as your child grows and the drainage holes heal.

SURGICAL MANAGEMENT
If

ear infections persist after age 4, your doctor may suggest having your child's adenoids (tonsils) removed.

MEDICAL MANAGEMENT
Antibiotics

-- The antibiotic most often prescribed for an ear infection is amoxicillin, unless the patient is allergic to penicillin. If that's the case, there are several options. Children who are treated with antibiotics are more likely to develop vomiting, diarrhea, or a rash.

MEDICAL MANAGEMENT
Ear

drops -- If the patient has recurring ear infections, a perforated eardrum, or develops infection after ear tubes have been placed, the doctor may prescribe antibiotic ear drops instead of oral antibiotics, to be used over a period of time (like a few months). If the patient doesn't have ear tubes in place and doesn't have any drainage from the ear, the doctor may also prescribe anesthetic ear drops to relieve pain.

MEDICAL MANAGEMENT
Ibuprofen,

acetaminophen For pain or fever. Children under 18 should not take aspirin, due to the risk of developing a rare but serious illness called Reye's syndrome.

DIAGNOSIS
The

doctor will ask questions about the patient if have had ear infections in the past and ask to describe the current symptoms. He or she will use an otoscope to look inside the ear. If infected, there may be areas of dullness or redness or there may be air bubbles or fluid behind the eardrum. The fluid may be bloody or filled with pus. The doctor will also check for any sign of perforation (hole or holes) in the eardrum.

DIAGNOSIS
The doctor may also do other tests: Tympanometry, which uses a small handheld instrument to measure changes in air pressure in the ear and can indicate if the eardrum is ruptured Reflectometry, in which a small instrument is placed near the ear and makes a sound, allowing the doctor to see if fluid is present behind the eardrum. A hearing test may be recommended if the child has had persistent ear infections.

WORK - UP

Laboratory Studies definitive laboratory examination exists for acute otitis media. In the event that a tympanocentesis is performed, a sample of the effusion should be sent for culture and sensitivity.
No

WORK - UP

Imaging Studies studies are not valuable for diagnosis of acute otitis media. Radiography and/or CT scanning of the mastoid air cells may be helpful in select cases of suspected mastoiditis.
Imaging

WORK - UP
Other Tests Insufflation, tympanometry, and acoustic reflexometry are helpful to identify the presence or absence of middle ear effusion (MEE). y Of these, insufflation is the only one commonly used. y Tympanometry and acoustic reflexometry cannot be recommended as a routine screening test for acute otitis media. However, in a patient in whom examination is difficult, normal tympanometric results may help rule out acute otitis media.

WORK - UP
Hearing

tests are not helpful in diagnosing acute otitis media. Nasopharyngoscopy may reveal anatomic factors involved in acute otitis media and show purulent matter at the nasal opening of the eustachian tube, but the findings are of no acute diagnostic value.

NURSING MANAGEMENT
1. Determine the presence of pain with swallowing, neck rotation, palpation of the face and head (over the sinuses), palpation of the mastoid process and manipulation of the pinna. 2. Assess the TMJ by inserting the index fingers ino the external auditory canals and applying pressure anteriorly while the client opens and closes the mouth.

NURSING MANAGEMENT
3. Monitor for clinical manifestations of infection, and administer antibiotics as prescribed. 4. Teach the client to complete the entire prescription of the antibiotic even though manifestations may have cleared. 5. Instruct the client to avoid getting water in the ear while bathing or showering by using earplugs or placing cotton balls coated with petroleum jelly in the ear canal.

COMPLICATIONS
Serous

otitis media with effusion (OME) is the most common complication. y It may cause mild discomfort in some patients; however, if it is bilateral, hearing loss with resultant speech delay may occur in infants.

COMPLICATIONS
Perforation

of the tympanic membrane is a frequent but usually not serious complication. Treatment is not changed from that described above, but follow-up care is more important. With proper treatment, most perforations heal within a couple of weeks, with no residual complications.

COMPLICATIONS
Mastoiditis

Intracranial

complications, such as epidural abscess or cavernous sinus thrombosis, are rare and should be treated with admission to a critical care unit. They usually present primarily rather than as a late complication of treated otitis.

COMPLICATIONS
Cholesteatoma

(secondary acquired): This is an epithelial growth that occurs behind the eardrum and is a serious possible sequela of injury to the tympanic membrane. y This injury can be a perforation (mostly, a posterior marginal perforation) resulting as a complication from chronic otitis media or trauma, or it may be due to surgical manipulation of the drum.

COMPLICATIONS
y

The hallmark symptom of a cholesteatoma is painless otorrhea, either unremitting or frequently recurrent. Overtime, the cholesteatoma increases in size and destroys the delicate middle ear bones. The resulting ossicular problems due to fixation, discontinuity, or absorption can cause a further conductive hearing loss.

COMPLICATIONS
y

Cholesteatoma may also grow to involve the facial nerve causing facial paralysis. In some instances, they can expand up into the brain. Cholesteatoma is a serious condition and, when diagnosed, requires prompt treatment. Computed tomography (CT scan) may be helpful in defining the extent of the disease and can act as a roadmap for surgery.