Chapter 59 Otitis Media
PATHOPHYSIOLOGY
Acute otitis media (AOM) is an inflammation of the middle ear. Children 6 years of age and younger are at particular risk for acute otitis media because their eustachian tubes are shorter and more horizontal, and lack the cartilaginous support found in older children and adults. This allows the eustachian tubes to collapse, which causes negative pressure in the middle ear. In turn, there is impaired drainage of middle ear fluid and possible reflux of pharyngeal secretions into this normally sterile area. The eustachian tubes of infants and children with cleft palate or Down syndrome are also wider, so they remain open; this allows bacteria to travel easily from the nasopharynx into the middle ear, and this further predisposes such children to infection. Acute otitis media is the most common infection for which antibacterial agents are prescribed for children in the United States. Among childhood diseases, it is second in prevalence only to the common cold, accounting for 1 in 3 pediatric sick visits in this country and over 13 million annual prescriptions. Growing concerns about the rising rates of antibacterial resistance have prompted changes in the medical management of uncomplicated AOM. Two types of otitis media are common in clinical pediatrics: acute otitis media and otitis media with effusion.
Acute Otitis Media
Acute otitis media is characterized by fluid in the middle ear with signs and symptoms of ear infection (bulging eardrum usually accompanied by pain, or perforated eardrum, often with drainage of purulent matter). The pathogens most commonly associated with otitis media include Streptococcus pneumoniae (25% to 50% of cases), nontypeable Haemophilus influenzae (15% to 30% of cases), Moraxella catarrhalis (3% to 20% of cases), viruses, and certain anaerobes. In the neonate, gram-negative enteric organisms or Staphylococcus aureus may also be the causative organisms. Group A Streptococcus and S. aureus (2% to 3% combined) were less common causes of acute otitis media in the pediatric population during the 1990s. Chlamydia pneumoniae infections may also be seen, most frequently in children aged 8 to 16 months.
Otitis Media with Effusion
Otitis media with effusion is characterized by fluid in the middle ear without signs and symptoms of ear infection. No definitive causative agent has been identified, although otitis media with effusion is seen more commonly in children with allergies or viral upper respiratory infections, and in those recovering from acute otitis media.
INCIDENCE
1. Otitis media occurs most often in children between 3 months and 3 years of age; age ranges of peak incidence are 5 to 24 months and 4 to 6 years.
2. Of affected children, 70% have one episode by age 3 years, with one third having more than three episodes. The younger the child at the time of the first infection, the greater the chance of recurrent infections.
3. Boys have more ear infections than girls.
4. Children are more likely to experience repeated episodes if a parent and/or sibling also had ear infections.
5. Children with craniofacial conditions such as a cleft lip and/or palate and Down syndrome are also at greater risk. Of children with cleft palate, 50% have chronic otitis media before surgical correction.
6. Children placed in large group day care settings from an early age have greater exposure to all causative bacteria and viruses from other children.
7. Exposure to an area with high pollution and/or allergens and to winter or spring weather conditions presents risk and increases the incidence of ear infections.
8. Children exposed to passive (secondhand) cigarette smoke have a significantly higher rate of otitis media.
9. Infants who are bottle-fed, especially while lying down, experience more ear infections than breast-fed infants.
CLINICAL MANIFESTATIONS
Acute Otitis Media
1. Red tympanic membrane, often bulging with no visible bony landmarks, immobile to pneumatic otoscopy (application of positive or negative pressure pulse to middle ear using bulb insufflator attachment on otoscope)
2. Rapid onset of signs and symptoms such as complaint of ear pain (otalgia), excessive crying or fussiness, and ear pulling in preverbal child
3. Fever, ranging from 100° to 104° F (present in about one half of children)
5. Anterior cervical lymphadenopathy
6. Transient conductive hearing loss lasting at least 2 to 4 weeks after acute infection
LABORATORY AND DIAGNOSTIC TESTS
1. Pneumatic otoscopy—to visualize tympanic membrane and test tympanic membrane mobility
2. Tympanogram—to measure tympanic membrane compliance and stiffness
3. Culture and sensitivity testing—only available if tympanocentesis (needle aspiration of middle ear via tympanic membrane) is performed
4. Hearing evaluation—recommended for child who has had bilateral otitis media with effusion 3 months or longer
MEDICAL MANAGEMENT
Because of concerns about drug resistance, observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up. This option refers to deferring antibacterial treatment for 48 to 72 hours and limiting management to symptom relief; it is limited to otherwise healthy children 6 months to 2 years of age with nonsevere illness and to older children without severe symptoms. Children less than 6 months of age should be treated with antibacterial therapy regardless of diagnostic certainty.
If the decision is made to treat with an antibacterial agent, the first-line antibiotic medication most often prescribed is amoxicillin, 80-90 mg/kg per day, for 10 days. Clinical response should occur within 48 to 72 hours. The second-line medication regimen (to be used when an amoxicillin-resistant organism is suspected) includes amoxicillin with clavulanate (Augmentin, a second-generation cephalosporin), cefaclor, or co-trimoxazole. In the penicillin-allergic child, azithromycin may be used.
Recurrent otitis media may be treated by myringotomy, a surgical procedure in which pressure-equalizing (PE) tubes are inserted into the tympanic membrane (refer to the Medical Management section in this chapter). This allows ventilation of the middle ear, relieves the negative pressure, and permits drainage of fluid. The tubes usually fall out after 6 to 12 months. Complications that may result include atrophy of the tympanic membrane, tympanosclerosis (scarring of the tympanic membrane), chronic perforation, and cholesteatoma.
Initial management of the child involves observation or treatment with antibiotic therapy (optional at this time). In most cases, otitis media with effusion resolves spontaneously within 3 months. Parents should be encouraged to avoid exposing their children to passive smoking as a means of controlling an environmental risk factor. Myringotomy is not recommended for initial management of otitis media with effusion in an otherwise healthy child.
After 3 months, if the child has hearing in the normal range, as indicated by a hearing threshold level of better than 20 dB in the better-hearing ear, the child is observed or treated with antibiotics (this remains optional at this time). In most cases, otitis media with effusion resolves spontaneously.
If the child has bilateral hearing deficits of 20 dB hearing threshold level or worse, the child is treated with antibiotic therapy or undergoes a bilateral myringotomy with tympanostomy tubes. Either one or both treatment approaches may be chosen to manage bilateral otitis media with effusion that has lasted a total of 3 months in an otherwise healthy child aged 1 to 3 years who has a bilateral hearing deficit.
Management strategies used after 4 to 6 months include a bilateral myringotomy with tympanostomy tubes to manage bilateral otitis media with effusion that has lasted a total of 4 to 6 months in an otherwise healthy child aged 1 to 3 years who has a bilateral hearing deficit.
NURSING INTERVENTIONS
Acute Otitis Media
1. Treat and instruct family to treat child with analgesics and/or antipyretics as needed for symptoms.
2. Offer small amounts of fluids frequently with cup or spoon if breast or bottle is refused, because sucking may cause increased ear pain in younger child.
3. Be aware that increased fluid intake is vital to any child with fever or illness to prevent dehydration and promote healing.
4. Instruct family about safe and effective use of prescribed antibiotic.
5. Monitor and instruct family to observe for (and report) common allergic or adverse reactions to antibiotic therapy (e.g., diarrhea, nausea and vomiting, skin rash or urticaria). Serious dermatologic, hematologic, renal, hepatic, neurologic, endocrine, and/or cardiorespiratory reactions are rare.
6. Monitor and instruct family to observe for signs of complications with acute otitis.
Otitis Media with Effusion
1. Educate family about course of disease and lack of definitive cause and treatment.
2. Support child and family if conductive hearing loss is present; reassure them that this is likely to resolve spontaneously.
3. If myringotomy is required, supply age-appropriate explanations of procedure to child and parents (see Appendix F).
Discharge Planning and Home Care
1. Instruct child and parents about maintaining patency of tympanostomy (e.g., when child is swimming or bathing, use ear plugs).
2. Instruct about limiting child’s activities until fully recovered.
3. Educate about importance of avoiding exposure of children to passive tobacco smoke; if household members or child care providers are unable to quit smoking, smoking should be done outdoors, away from child.
4. Inform parents there are no recommendations for complementary and alternative medicines such as acupuncture, herbal remedies, chiropractic treatments, and nutritional supplements in children.
CLIENT OUTCOMES
1. Child will be free of pain as demonstrated by verbal and nonverbal behaviors.
2. Child’s activity level and appetite will return to normal.
3. Child will demonstrate no hearing loss.
4. Child will demonstrate no speech delay.
5. Family will be referred to educational resources on otitis media (Box 59-1).
Box 59-1 Resources
• Agency for Healthcare Research and Quality (AHRQ)
Toll-free TDD service (hearing impaired only): 888-586-6340
• American Academy of Pediatrics: www.aap.org
• American Medical Association and Nemours Foundation: Childhood infections: otitis media, Kidshealth (website): www.kidshealth.org. Accessed June 10, 2003.
American Academy of Pediatrics and American Academy of Family Physicians. Diagnosis and management of acute otitis media. Pediatrics. 2004;113(5):1451.
Asch-Goodkin J. Acute otitis media: What the evidence says. Contemp Pediatr. 2002;19(suppl):4.
Takata GS, et al. Evidence assessment of management of acute otitis media: I. The role of antibiotics in treatment of uncomplicated acute otitis media. Pediatrics. 2001;108(2):239.
