Otitis Media is one of the common ear problems.

1. Case Scenario
22 year old boy was brought to the E.N.T. clinic with recurrent
nasal symptom of cold, stuffiness and rhinorrhoea since 1/2
months.
• He complained of 2 weeks back of an episode of left earache
followed by discharge which was profuse and mucoid. Pain was
severe at the middle of the night due to which he couldn’t sleep.

2. Diagnosis- Acute OTITIS
MEDIA

3. by-
Syanthika Dutta
B. Sc Nursing 3rd year
CON, MCH
Presentation on
Care of a patient with OTITIS MEDIA

4. Anatomy of EAR

5. Definition
Otitis Media is the inflammation of part or all of the lining
mucosa of the middle ear cleft i.e the eustachian tube,
tympanic cavity, attic, aditus, antrum and mastoid air cells

7. Acute
OTITIS
MEDIA
Acute OTITIS MEDIA without
effusion
Acute OTITIS MEDIA with
effusion
Aero OTITIS MEDIA
Chronic
OTITIS
MEDIA
Chronic Suppurative Otitis
media
Tubercular otitis media
Syphilitic otitis media
CLASSIFICATION OF OTITIS MEDIA

8. ACUTE OTITIS MEDIA
(without effusion)
• It is the acute inflammation of the mucosal lining of the middle ear
cleft.
• Basically affects the infants and the younger age group.
Normal AOM

9. Predisposing factors
• Younger age group
• Recurrent attacks of common cold.
• URI
• Tonsillitis
• Adenoids
• Chronic exposure to secondhand smoking.
• Chronic rhinitis & sinusitis
• Nasal Allergy
• Tumours of nasopharynx
• Cleft palate
• Eustachian tube dysfunction
• Medical conditions like Down syndrome, cystic fibrosis.

10. Aetiology
• Extension of Infection from nasopharynx (upper respiratory tract
infections)via eustachion tube
• Through Perforation or Grommet
• Often starts with Viral infection
• (RSV,Rhinovirus,Parainfluenza virus, Influenza virus) followed by
• Bacterial infection
• (Strep.Pneumoniae, H.Influenza,M.catarrhalis & Staph. Aureus)
• Inflammation of surrounding structures (rhinosinusitis)
• Allergic reaction ( allergic rhinitis)

11. Pathogenesis
Tubal occlusion-
hyperemia
Presuppuration/
Exudation
Suppuration
Resolution or
Complication

12. 1. Tubal Occlusion
2. Pre- suppuration
3. Suppuration 4. Resolution
STAGES

13. Clinical Manifestations
1. Pain
2. Decrease in hearing
3. Discharge
4. Fever
5. Malaise
6. Headache
7. Tympanic membrane bulging out, appears
erythematous.

14. Acute OTITIS MEDIA
(with effusion)
Accumulation of non-purulent/ sterile fluild in the
middle ear cleft resulting in hearing impairment.

15. Aetiology
1. Allergy
2. Eustachian tube dysfunction
3. Palatal abnormalities
4. Viral infections
5. Nasopharyngeal tumors
6. Environmental factors-. Bottle feeding, passive
smoking.

16. Pathogenesis
Eustachian tube
dysfunction
Negative
Middle ear
pressure
Goblet cell
hyplasia and
hypersecretion
Decrease in
mobility of
tympanic
membrane
Hearing
impairment

17. Clinical Presentations
1. Conductive deafness
2. Otalgia
3. Delayed and defective speech
4. Nasal Obstruction
5. Tympanic membrane appears bulging with
erythema.
6. Fever.

18. Aero OTITIS MEDIA
• Also known as Otitis Barotrauma
• It is a non-suppurative condition owning to the failure of
eustachian tube to maintain middle ear pressure at ambient
atmospheric level.

19. Clinical features
1. Severe Ear ache
2. Tinnitus
3. Tymphanic membrane retracted and
congested
4. Hearing loss

20. Chronic Suppurative Otitis Media
It is the chronic (>3 months) inflammation of the periosteal lining of the
middle ear cleft.

21. Risk factors for CSOM
1. History of multiple episodes of acute OTITIS MEDIA
2. Living in crowded places
3. Member of a large family

22. Etiology for CSOM
1. Traumatic injury
2. Iatrogenic causes
3. Pathogens- Pseudomonas aeuroginosa,
Staphylococcus aureus, Aspergillus, Candida etc

23. Chronic Suppurative
OTITIS MEDIA
Classification of CSOM
Tubotymphanic
(Mucosal disease)
Atticoantral
(Cholesteatoma)
Active Inactive

24. Profuse, Mucoid,
Odourless
Scanty, Purulent, Foul
smelling
Central Attic or marginal
Pale Red and fleshy
Absent Present
Rare Common
Audiogram Mild to moderate
conductive deafness
Conductive or mixed
deafness
Criterion Tubotymphanic Atticoantral
Common
Discharge
Perforation
Granulation
Polyp
Cholesteatoma
Complications
Uncommon

25. Chronic Suppurative OTITIS MEDIA-
Tubotymphanic
Types-
1.Active- when the ear is discharging.
2. Inactive- when the ear is dry.
Characteristics-
1. Perforation is almost always central.
2.Mucosa is inflamed and edematous.
3. Polyps are seen.
4. Ossicular chain is usually intact.

26. Chronic Suppurative OTITIS MEDIA-
Atticoantral
This type of C.S.O.M. is considered as dangerous / unsafe type.
This type of CSOM is associated with formation of Cholesteatoma,
granulation tissues & occasionally cholesterol granulomas.
If left untreated, it leads to serious complications involving the temporal
bone and cranial cavity & brain.

27. What is Cholesteatoma?
Cholesteatoma
is simply “skin in wrong place”.
Aural cholesteatoma is a bag of stratifiedsquamous epithelium
within the middle ear which contains desquamated epithelial debris
(mainly keratin) and germs.
(This term is a misnomer: it is neither a tumor nor it contains
cholesterol crystals)
The correct term: Keratoma

28. Cholesteatoma

29. Pathophysiology of CSOM
Irritation and
inflammation
of the middle
ear mucosa
Mucosal edema Mucosal ulceration
Breakdown
of the
mucosal
epithelium
Granulation
tissue
formation
Destruction of
the margins of
the bone
margins
CSOM

30. Clinical features of CSOM
1. Otorrhoea
2. Otalgia
3. Fever
4. Malaise
5. Vertigo
6. Hearing loss in the affected ear
7. Perforation of tympanic membrane
8. Facial paralysis
9. Headache

31. Tubercular otitis media
Secondary to pulmonary Tb
Clinical features :-
Slow onset of disease-
--Painless condition
--Discharge is thin, scanty and odourless
--Tympanic membrane is pale yellow to rosy pink in colour.
--Perforations in the membrane are usually multiple and
may be associated with pale granulations.
--Hearing loss is disproportionate to other symptoms.

32. Tubercular otitis media

33. Syphylitic OTITIS MEDIA
Rare condition caused by Spirochetes reaching
middle ear cleft through eustachian tube or blood
borne.
Clinical features-
--Sensorineural hearing loss
--Tinnitus
--Vertigo
--Bone necrosis
--Sequestrum formation

34. Diagnostics and Investigations
1. Medical history of previous Otitis Media
2. Otoscopic Examination
3. CT scan –
Temporal bone CT scanning may reveal osseous
erosion of the scutum, ossicles, ear canal, mastoid, otic
capsule, fallopian canal, or tegmen, which typically
suggests cholesteatoma.
Also includes subperiosteal abscess or intracranial
abscess, and, in some cases, lateral sinus thrombosis.
4.MRI scan-
reveal dural inflammation, sigmoid sinus
thrombosis, labyrinthitis, and extradural and intracranial
abscesses.

35. Diagnostics and Investigations… .contd
5. Audiometry and Audiogram-
Conductive hearing loss is expected, but mixed or sensorineural
hearing loss may indicate more extensive disease and should alert the
treating physician of impending complications, including labyrinthitis.
6. Mastoid X-ray
7. Tympanogram
8. Middle ear Endoscopy

36. Otoscopic findings

37. X-ray view of Otitis
Media

38. CT scan image of Otitis
Media

39. MRI scan for Otitis Media

40. Endoscopic view of Acute
OTITIS MEDIA of right
middle ear

41. Treatment and Management
Patients with OTITIS MEDIA are frequently subjected to topical therapy as
compared to systemic therapy.

42. Dimensions of
management
Pharmacological Management
Non-pharmacological management
Surgical
management
Nursing
management

43. Pharmacological Management
Ciprofloxacin
Tobramycin
Piperacilin
Ceftazidine
Antibiotic therapy

44. Dexamethasone
Analgesics
Corticosteroids
Paracetamol, Acetaminophen

45. Antipyretics
Nasal Decongestant
Contd..
Ephedrine

46. Non-pharmacological management
1. Application of hot compression
2. Aural toilet
3. Drainage suction from the ear

47. Surgical management
General indications for surgery-
1. Patients who donot respond to topical therapy
2. Perforation that persists beyond 6 weeks
3. Otorrhea that persists for longer than 6 weeks
despite antibiotic use
4. Cholesteatoma formation
5. Radiographic evidence of chronic mastoiditis, such
as coalescent mastoiditis
6. Conductive hearing loss.

48. A. Myringoplasty
It is the operation specifically designed to close tympanic membrane
defects.
The approach to the ear can be transcanal, endaural, or retroauricular.
-The transcanal approach requires less surgical exposure and leads to
faster healing.
-The endaural approach can improve exposure in ears with a lateral soft
tissue or cartilage overgrowth, but again, it tends to limit the surgical view.
-The retroauricular approach allows for maximal exposure but requires an
external skin incision.

50. B. Tympanoplasty
This surgical approach contains tow techniques-
1.Underlay technique involves placing the graft material underneath (or
medial to) the eardrum.
2. Overlay technique involves grafting lateral to the eardrum.

51. C. Ossiculoplasty
Ossiculoplasty refers to the surgical process of restoring the hearing
system between the tympanic membrane and oval window.
It involves the use of grafts and prosthesis.

53. D. Mastoidectomy
It consists of the removal of the outer wall of the
mastoid cortex and the exteriorization of all the
mastoid air cells.

54. Surgical complications
The complications of myringoplasty and tympanoplasty are-
- Infection
- Hematoma
- Taste disturbance owning to damage of chordae tympani nerve
- Ear numbess
- Conductive hearing loss
- Senironeural hearing loss
- Vertigo
- Facial paralysis

55. Surgical complications… contd
The complications of mastoidectomy are-
1. CNS leakage
2. Intracranial complications-. abscess, meningitis.

56. Nursing management
Nursing Assessment
Assessment of patient with otitis media include the following:
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.
Physical examination
The patient’s ear is examined with an otoscope by pulling the ear upwards and
back to straighten the ear canal.
If the patient is suffering from hearing loss, the nurse should be alert for the
following- Speech deterioration, Fatigue, Insecurity, Loneliness, Social
Withdrawal.

57. Subjective Data Objective data
1. Pain in the ear
2. Ear discharge
3. Nasal congestion
4. Sleepless night due
to ear pain.
5. Fever for 2 weeks.
1. Facial grimacing, irritable
2. Pain rate -7/10
3. Vital signs-
-Pulse rate- 120beats/min
-Temperature-100 °F
-Respiratory rate- 26breaths/min
4.Tymphanic membrane appears red
with bilateral bulge.
5. Pharynx slightly red without exudate.
6. Discharge appears mucoid and
purulent.

58. Nursing Diagnoses
1.Acute pain related to the inflammation of the middle ear as evidenced
by facial grimacing and verbalisation of the patient.
Interventions-
* Assess the intensity, duration of the pain.
* Assess the possible causes responsible for pain.
* To rate the intensity of pain according to scale.
* To record and monitor vital signs closely.
* To assist with divertional therapy.
* To administer with hot compression, as per order.
* To administer analgesics, as per order.
Pre-operative Nursing management

59. 2.Impaired verbal communication related to effects of
hearing loss as evidenced by neurological assessment.
Interventions-
* Assess reasons for impaired verbal communication.
* To make atmosphere conducive to communication.
* To assist with pen and paper to enable patient with communication.
* To observe for non-verbal communication and gestures.
* To speak in low and attentive manner.
* To maintain a specific routine for speech practice sessions.
* To arrange for speech and audio rehabilitation measures.

60. 3.Disturbed sensory perception related to obstruction, infection of the
middle ear, or auditory nerve damage as altered sensorium of patient.
Interventions-
* Assess for possible signs of obstruction in middle ear.
* Assess signs for auditory nerve damage.
* To assess with diagnostic procedures- Ctscan, MRI.
* To assess for hearing ability.
* To assess for any visible discharge from ear.
* To arrange for calm and quiet environment.
* To observe for non- verbal communication and gestures.

61. 4.Anxiety related to health status and impending surgery as
evidenced by increased apprehension of health deterioration.
Interventions-
* Assess the level and reasons for anxiety.
* Prepare the patient for surgery.
* Provide bed and sleep.
* Provide complete information such as possible outcome, side-effects of
the surgery.
* Encourage patient and family members to ventilate concerns about the
health status.
* To arrange discussion sessions to ventilate grievances.
* To introduce patients with the similar diagnosis and with better benefits
and outcomes.
* Reassessment.

62. 5. Risk for injury related to hearing loss and loss of balance.
Interventions-
* Maintain a safe environment.
* Assist the patient with ADLs.
* Assist with locomotion and movement.

63. 6. Risk of infection related to presence of pathogens.
Interventions-
* To monitor and record vital signs.
* To perform hand wash during patient handling.
* To avoid invasive procedures.
* To maintain aseptic measures during invasive procedures.
* To assess the discharge from ear and send for culture sensitivity.

64. Post-operative Nursing management
1. Acute pain related to surgical procedure as evidenced by
patient’s verbalisation.
Interventions-
* Assess duration, intensity and reason for pain.
* Rate the pain.
* Monitor vital signs, signs of inflammation.
* To elevate head at 30 to 45°.
* To administer hot compression, as per order.
* To assess the site of incision, any signs of discharge.
* To assist with divertional therapy.
* To administer analgesics, as per order.

65. 2. Impaired verbal communication related to hearing loss secondary
to surgery as evidenced by edema, accumulation of tissue fluid in the
middle ear.
Interventions-
* Assess the causes of impaired verbal communication.
* Elevation of head at 30-45° to relieve edema.
* To maintain a calm and quiet environment.
* To speak in clear and soft language with the patient.
* To observe for non-verbal clues.
* To educate family members about effective ways of communication.

66. 3. Impaired tissue integrity related to surgical incision as evidenced by
assessment of incision site.
Interventions-
* Assess the site of incision and the surrounding tissue.
* Assess any signs of edema and inflammation.
* Assess the discharge, the colour, amount of drainage.
* Elevation of head at 30-45°.
* Planning of diet rich in proteins, vitamins.
* Administration of antiseptics, as per order.

67. 4. Deficient knowledge about postoperative care as evidenced by
patient’s assessment of knowledge.
Interventions-
* Inform patient and family members about the expected effects and potential
side effects of medication.
* Instruct about aseptic measures during dressing.
* Avoid getting water in the operative ear for 2weeks after surgery.
* Any signs of increased drainage and inflammation should be immediately
brought into notice of the primary care giver.
* Follow up care.

68. 5.Risk for infection related to placement of grafts, prosthesis
secondary to ossiculoplasty.
Interventions-
* To monitor and record vital signs for every 2hrs.
* To perform hand hygiene while handling with patient.
* To maintain strict aseptic measures during dressing.
* To inspect the condition of wound.
* To observe for any signs of elevated temperature and purulent drainage.
* To maintain a clean environment.
* Administration of prophylactic antibiotics , as per order.

69. 6. Risk for injury related to vertigo due to dislodgment of prosthesis.
Interventions-
* Instruct patient to avoid heavy lifting, straining and nose blowing for 2-3weeks.
* Observe for any signs of difficulty in nerve injury such as – dropping of mouth,
slurred speech, decreased sensation and difficulty in swallowing.
* Administer antiemetics, as per order.

70. Prognosis
Death from AOM is rare in the era of modern medicine. With effective
antibiotic therapy, the systemic signs of fever and lethargy should begin to
dissipate, along with the localized pain, within 48 hours. Children with
fewer than 3 episodes are 3 times more likely to resolve with a single
course of antibiotics, as are children who develop AOM in nonwinter
months. Typically, patients eventually recover the conductive hearing loss
associated with AOM.

71. THANKYOU