OTITIS MEDIA.pptx

otitis media

1. CHILDHOOD OTITIS MEDIA

2. Otitis Media definition Otitis Media is defined as an inflammation of the middle ear i.e., the area between the tympanic membrane and the inner ear.

3. Bacterial Etiology S. pneumonia. 1. Incidence: 38% 2. Beta Lactamase producing: 15-25% 3. Causes more severe cases with Otalgia and fever. Nontypeable H. influenzae . 1. Incidence: 27% 2. Beta Lactamase producing: 35% 3. More often associated with eye redness and discharge. Moraxella catarrhalis . 1. Incidence: 10% 2. Beta Lactamase producing: 85-100%

4. Viral Etiology 57% of RSV, 35% of influenza A, 33% of parainfluenza type 3, 30% of adenovirus, 28% of parainfluenza type 1, 18% of influenza B and 10% of parainfluenza type 2 virus infections.

5. Fungal Etiology Aspergillus or Candida

6. Incidence Approximately 40% of children suffer one or more episodes before the age of 10 years. More cases are seen in the winter months. Uncommon in adults.

7. PATHOPHYSIOLOGY

8. Signs Change of colour of the tympanic membrane to pink/red Bulging drum Loss of outline of drum and landmarks Discharge in meatus Perforation. There may be tenderness over the mastoid .

9. Symptoms Pain Usual onset at night and severe for 12 hrs, then settles and niggles for 3-5 days Discharge can occur (and often relieves pain) Fever, vomiting and loss of appetite may occur, especially in young children. Occasionally tinnitus, voice resonance, giddiness and sickness occur. Irritability may be the only indication in infants. Hearing loss occurs if accumulation of fluid has taken place.

10. Complications Acute mastoiditis – infection of the mastoid process. Cholesteatoma – cystic lesion within the middle ear. Meningitis. Hearing loss. Tympanic membrane perforation. Brain abscess.

11. Types of Otitis Media Acute Otitis Media Most common type seen in children Occurs when there is fluid in the middle ear Occurs with inflammation of the TM May be bacterial or viral

12. Phases of Acute Otitis Media 1st phase - exudative inflammation lasting 1–2 days, fever, rigors ,, severe pain (worse at night), muffled noise in ear, deafness, sensitive mastoid process, ringing in ears (tinnitus) 2nd phase - resistance and demarcation lasting 3–8 days. Pus and middle ear exudate discharge spontaneously and afterwards pain and fever begin to decrease. This phase can be shortened with topical therapy. 3rd phase - healing phase lasting 2–4 weeks. Aural discharge dries up and hearing becomes normal.

13. Types of Acute Otitis Media Otitis Media without effusion Inflammation of the TM with fluid in the middle ear May cause myringitis (cyst on TM) Present during the beginning stages of otitis media Formation of painful blisters on the eardrum (tympanum).

14. Types of Acute Otitis Media Serous Otitis Media or Otitis Media with effusion Inflammation of the TM with fluid in the middle ear Caused by vacuum created by malfunction of the Eustachian tube Can cause hearing impairment and delayed speech in children Since infants cannot hear they cannot learn how to talk

15. Chronic Otitis Media Occurs when the middle ear infection perists and causes significant hearing loss and damage to the middle ear May involve a perforation of the TM Pus may drain through the ear canal – a concept called otorrhea

16. Otitis Media Diagnosis Laboratory Studies – sepsis workup Imaging - study of choice is a contrast-enhanced CT scan of the temporal bones MRI is more helpful in depicting fluid collections Tympanometry may help with diagnosis in patients with OM with effusion

17. Diagnostic criteria for OM Bulging TM Retracted TM Impaired mobility of the TM Loss of light reflex Erythematous TM Purulent otorrhea Opacification of the TM

18. Normal Right TM

19. Acute Otitis Media-TM

20. Acute Otitis Media

21. Serous Otitis Media

22. Serous Otitis Media

23. Ruptured TM

24. Ruptured TM

25. Cholesteatoma

26. Cholesteatoma

27. MASTOIDITIS Mastoiditis is an inflammatory process of the mastoid air cells in the temporal bone.   Because the mastoid is contiguous to the middle ear cleft and an extension of it, virtually all children or adults with acute otitis media (AOM) and most individuals with chronic middle ear inflammatory disease have mastoiditis. In most cases, symptoms involving the middle ear ( eg , fever, pain,  conductive hearing loss )

28. Treatment with penicillin 1. Antibiotic duration 1. Age under 6 years a. First Line 1. Amoxicillin 80-90 mg/kg/day PO divided twice daily for 10 days (7 days if age>6) 2. If Penicillin Allergy, use Macrolide (e.g. Azithromycin) b. Second Line (10 day course) 1. Amoxicillin with clavulanate (Augmentin) 90 mg/kg/day divided twice daily for 10 days 2. Cefuroxime ( Zinacef , Ceftin ) 30 mg/kg/day divided twice daily for 10 days 3. Cefprozil ( Cefzil ) 30 mg/kg/day divided twice daily for 10 days 4. Cefdinir ( Omnicef ) 14 mg/kg/day divided one to two times daily fo 10 days 5. Cefpodoxime ( Vantin ) 30 mg/kg once daily for 10 days c. Third Line 1. Strongly consider Tympanocentesis for bacterial culture 2. Ceftriaxone ( Rocephin ) 50 mg/kg IM daily for 3 days 3. Clindamycin 30-40 mg/kg/day divided four times daily for 10 days.

29. 1. Consider Tympanocentesis 2. Clindamycin ( Cleocin ) 30-40 mg/kg/day (max 1800 mg) divided four times daily for 10 days 3. Macrolide antibiotics (High bacterial resistance rate) 1. Erythromycin 2. Clarithromycin (Biaxin) 15 mg/kg/day divided twice daily for 10 days 3. Azithromycin (Zithromax) 1. One dose of Azithromycin XR ( Zmax ) at 30 mg/kg (up to 1500 mg) or 2. Three days of Azithromycin at 20 mg/kg/day once daily (up to 500 mg/day) or a. This high dose approached Augmentin efficacy in one study b. Arrieta (2003) Antimicrob Agents Chemother 47:3179 3. Azithromycin 10 mg/kg (max: 500 mg) day 1, then 5 mg/kg/day (max 250 mg) for 5 days 4. Fluoroquinolones (avoid under age 16 years) 1. Gatifloxacin ( Tequin ) 2. Levofloxacin (Levaquin) 3. Moxifloxacin ( Avelox ) Treatment if allergic to penicillin

30. Simple analgesi a Paracetamol Ibuprofen (some evidence superior) There are no published controlled trials to support the use of antihistamine and decongestant preparations.

31. NURSING DIAGNOSIS FOR ACUTE OTITIS MEDIA AND CHRONIC OTITIS MEDIA 1.  Acute Pain  /  Chronic Pain  related to the inflammatory process. 2. Impaired verbal communication related to the effects of hearing loss. 3. Disturbed Sensory perception: hearing related to obstruction, infection of the middle ear or auditory nerve damage. 4. Risk for injury related to hearing loss, decreased visual acuity . 5.  Anxiety  related to surgical procedure, diagnosis, prognosis, anesthesia, pain, loss of function, the possibility of a greater hearing loss after surgery. 6. Social isolation related to pain, foul-smelling otorrhoea . 7. Knowledge  Deficit  regarding treatment, and prevention of relapse of the disease process.

32. INTERVENTION: Reduce noise in the client environment. Look at the client when speaking. Speak clearly and firmly on the client without the need to shout. Provide good lighting when the client relies on the lips. Using the signs of non-verbal ( eg facial expressions, pointing, or body movement) and other communications. Instruct family or the people closest to the client on how techniques of effective communication so that they can  interact  with clients. If the client wants, the client can use hearing aids.

33. Assess the level of intensity of the client and client's coping mechanisms. Give analgesics as indicated. Distract the patient by using relaxation techniques: distraction, guided  i magination, touching, etc.. Encourage breastfeeding of infants. Instruct the parents to administer antibiotics exactly as directed and to complete prescribed course of medication. Telephone the parents 2–3 days after initial examination. Examine ear 3–4 days after completion of antibiotic treatment, or if symptoms worsen in child on symptomatic treatment. Assess motor and language development at each health care visit.