best for students of nursing

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2. OTITIS MEDIA
 Middle ear infection is one of the most common early
childhood diseases particularly as a complication of
upper respiratory infection respiratory allergy,
adenoiditis, or unrepaired cleft palate
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3. Classification
 Acute or chronic otitis media—in which bacterial or
viral agents cause a purulent exudates to accumulate
behind the eardrum in the space of the middle ear.
 Serous otitis media—in which a nonpurulent sterile
mucoid effusion collects as a result of blocked –
Eustachian tubes
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4. Etiology
 Acute otitis media caused by the
 Hemophilus influenza
 Pneumococci
 Streptococci
 Moraxella catarrhalis.
 Chronic otitis media caused by inadequately treated the
acute otitis media, the recurrent adenoiditis or unrepaired
cleft palate.
 Allergic rhinitis or hypertrophic adenoids (URTIs).
 Recurrent episodes of acute otitis media or chronic otitis
media in young children increase the risk of hearing
impairment.
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5. Pathophysiology
 The middle ear cavity is normally a sterile, air-filled
space.
 During swallowing, air enters the middle ear through
the eustachian tube.
 If there is eustachian tube malfunction (due to
obstruction or abnormal mechanical factors), the
middle ear cavity does not ventilate normally and
negative pressure results as the air is absorbed.
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6.  Consequently, an effusion occurs in the middle ear
cavity, and bacteria from the nasopharynx may be
drawn into the cavity.
 The proliferation and subsequent infection by
microorganisms in the middle ear cavity results in the
suppuration found in acute otitis media
 Fluid obstruction of the eustachian tube can result
from inflammation of the tube itself, or from
hypertrophied nasopharyngeal lymphatic tissue.
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7.  Viral illnesses and allergies are also thought to
contribute to eustachian tube dysfunction.
 Mechanical factors associated with eustachian tube
malfunction include reduced patency and poor
muscular function
 Otitis media among infants and young children has a
developmental component.
 The eustachian tubes of this age group are more
horizontal than amongst older children and, therefore,
they do not have the potential benefit of gravity to
assist drainage.
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8. If the tube is blocked
Alteration in protective function
Drainage is impaired and the normal secretions are retained/ air cannot
escape the blocked tube so it is absorbed through the vascular circulation
causing a negative pressure within the middle ear
If the tube opens bacteria enters to the middle chamber
Organism proliferates and invades the mucosa
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9. History
 Classic symptoms include a preceding URTI, fever,
irritability, complaints of ear pain and diminished
appetite.
 There may also be vomiting, diarrhoea, disturbed sleep
and decreased hearing (older children).
 However, the overriding symptom in children with
AOM is pain.
 The pain is acute, severe and deep in the ear.
 If the child is young, there may be ear pulling, crying
and signs of infection (i.e. fever).
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10.  If the ear drum perforates, the pain is suddenly
relieved and a discharge will be observed.
 Onset, frequency and severity of symptoms.
 Rhinorrhoea, malaise, irritability, appetite and activity
levels.
 Presence of fever, ear discharge and past history of ear
infections.
 Additional symptoms (e.g. rashes, vomiting ,
diarrhoea, etc.).
 History of allergy to food or medication.
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11.  Family history of allergies.
 Feeding techniques and practices (e.g. supine feeding,
bottle to bed, bottle propping).
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12. Factors predisposing children to
development of otitis media
 The eustachian tubes are short, wide, and straight and lie
in a relatively horizontal plane
 The cartilage lining is undeveloped, making the tubes
more distensible and therefore more likely to open
inappropriately.
 The normally abundant pharyngeal lymphoid tissue readily
obstructs the eustachian tube openings in the
nasopharynx.
 Immature humoral defense mechanisms increase the risk
of infection.
 The usual lying-down position of infants favors the pooling
of fluid, such as formula or exudate, in the pharyngeal
cavity
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14. Physical examination
 General appearance and engagability of the child:
includes measurement of temperature
 Head and ENT: visualisation of the tympanic
membrane (TM) is the foundation upon which the
diagnosis of otitis media is made.
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15. Normal TM
 The normal TM is
translucent with visible
bony landmarks and a
cone of reflected light
that is easily identifiable
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16.  Careful assessment of eyes, nose and throat is
required.
 Check for neck rigidity. Note that it is not uncommon
for auricular and cervical nodes to be enlarged.
 Cardiopulmonary: routine assessment with special
attention to the respiratory system.
 Abdomen: routine assessment.
 Skin: check for rashes.
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17. Clinical manifestations
 Infant
 Pain
 Infant becomes irritable and feels discomfort by
 holding or pulling their ears.
 rolling their head from side to side.
 Young children
 Complain of the pain.
 Temperature 40°C is common.
 Cervical or post auricular lymph gland enlargement
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18. Clinical manifestations
 Rhinorrhea.
 Vomiting and diarrhoea.
 Anorexia is common.
 Sucking or chewing—child has pain.
 Tympanic membrane may rupture. It relieves pain,
decreases temperature, there is purulent discharge in the
external auditory canal.
 Severe pain or fever is usually absent in serous otitis media.
l Feeling fullness in the ear.
 If chronic serous otitis media, conductive hearing loss in
young children.
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22. Treatment
 Suppuration otitis media—Administration of
antibiotics especially ampicillin for 10–14 days
 Prescribe antibiotics to children 6 months old and
older with severe signs or symptoms of AOM
(moderate or severe otalgia for at least 48 hours or
temperature ≥102.2°F [39°C]).
 Prescribe antibiotics for bilateral AOM in children
younger than 24 months without severe signs or
symptoms (moderate or severe otalgia for at least 48
hours or temperature
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23.  Either prescribe antibiotics or offer observation with
close follow-up (based on joint decision making with
parent or caregiver) for unilateral AOM in children 6
months to 23 months of age without severe signs or
symptoms (moderate or severe otalgia for at least 48
hours or temperature
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24.  Either prescribe antibiotics or offer observation with
close follow-up (based on joint decision making with
parent or caregiver) for unilateral or bilateral AOM in
children 24 months old or older without severe signs
and symptoms (moderate or severe otalgia for at least
48 hours or temperature
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25.  Myringotomy, a surgical
incision of the eardrum,
may be necessary to
alleviate the severe pain of
AOM.
 A myringotomy is also
performed to drain
infected middle ear fluid in
the presence of
complications (e.g.,
mastoiditis) or to allow
purulent middle ear fluid
to drain into the ear canal
for culture
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26.  Tympanostomy tube—
pressure-equalizing tubes
may be inserted to drain
fluid from the middle ear.
 Tympanostomy tube
placement may be
indicated with chronic OM
(three episodes in 6
months or four episodes in
1 year, with one episode
during the preceding 6
months)
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27.  Decongestant.
 Analgesic and antipyretic drugs.
 Ear drops to promote comfort and relieve pain
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28. Nursing management
1. Recognize Present
Signs and Symptom
 Older child
 Assess for evidence of
discomfort
 Crying
 Complaining pain
 Irritability
 Lethargy
 Anorexia
 Infant
 Crying
 Restless, irritable m
 Tendency to rub, hold
the ear
 Inspect external auditory
canal (drainage)
 Assess for learning
impairment
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29.  2. Eliminate Infective Agent
 Administration of antibiotics.
 Emphasize the patient importance of regular
administration of medication.
 3. Reduce Inflammation
 Administration of decongestants as prescribed.
 Apply cold compress.
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30.  4. Promote Comfort
 Positioning and comfort.
 Instil soothing substance into internal ear. m
Administration of analgesic.
 Apply external heat or cool compresses.
 Avoid chewing by offering liquid or soft food.
 5. Reduce Fever
 Administration of Antipyretic drugs.
 Provide tepid sponge bath.
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31.  6. Facilitate Drainage when Appropriate
 Position with affected ear.
 7. Prevent Skin Breakdown
 Keep skin around ear and pinna clean and dry.
 Change the cotton when soiled with drainage.
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32.  8. Prevent Complication
 Continue the medicine and ask the mother to come for
follow up.
 Avoid injuring ear or eardrum.
 9. Educate Parents
 Teach correct administration of medication.
 Teach to recognize signs of hearing impairment in the
infant or child.
 Avoid water in the ear
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33. Prognosis
 Most cases of OM resolve without any residual effects.
 However, varying degrees of hearing loss can occur.
 Although conductive hearing loss is most often
associated with OM, sensorineural hearing loss may
also be present, especially in severe forms of chronic or
recurrent OM, because of the passage of toxic
products from fluids into the cochlea through the
tympanic membrane
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34.  The longer the fluid is present, the greater the
sensorineural hearing loss.
 Children who are prone to OM should be referred to a
pediatric otolaryngologist and possibly a pediatric
allergist for identification and treatment of the cause
of their eustachian tube dysfunction.
 They should also be referred to a speech and language
pathologist for primary prevention counseling
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38. Croup
 Croup is a term applied to a broad classification of
upper airway illness that results from swelling of the
epiglottis and larynx.
 The swelling usually extends into the trachea and
bronchi; it causes severe inflammation and
obstruction of the upper airway
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39.  Causes
 Viral-induced edema
around the larynx.
 Parainfluenza viruses
(two-thirds of the
infections)
 Adenoviruses
 RSV
 Influenza
 Measles virus
 Bacterial
 Pertussis
 Diphtheria
 Mycoplasma.
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40. Pathophysiology
 In croup, inflammatory swelling and spasm constrict
the larynx, thereby reducing air flow.
 Inflammatory changes almost completely obstruct the
larynx and significantly narrow the trachea.
 Spasmodic laryngitis—typically involves
paroxysmal attacks of laryngeal obstruction generally
occurring at night
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41.  Acute obstructive laryngitis—a sudden narrowing
of the upper airway results from vocal cord edema.
 Acute laryngotracheobronchitis—inflammation
of the mucosal lining of the larynx and trachea results
in a constricted airway
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42. Clinical Manifestations
 Barking cough or hoarseness, sometimes described as a
“Seal bark” cough.
 Usually begins with cold like symptoms for 1 to 2 days.
 Worse at night and can last 5 to 6 days.
 Crackles and decreased breath sounds (indicates condition
has progressed to bronchi).
 Increased dyspnoea and chest retraction.
 Inspiratory stridor with varying degrees of respiratory
distress.
 Sudden or gradual onset.
 Muffled vocal sounds.
 Inability to swallow
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46.  https://www.youtube.com/watch?v=C1q6ATkMtm0
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47. Scale to identify the severity of
croup
Sign Severity score
0 1 2 3
Stridor None Mild Moderate at
rest
Severe, on
inspiration
Retractions None Mild Suprasternal,
intercostals
Severe, may
see sternal
retractions
Colour Dusky or
cyanotic
Breath Normal
sounds
Mild
decreased
Moderately
decreased
Markedly
decreased
Level of
consciousness
Normal Restless when
disturbed
Anxious Lethargic
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48.  Scoring: To quantify the severity of croup, add the
individual scores for each of the sign categories.
 A score between 0 and 15 is possible.
 The rating of mild, moderate, and severe is as follows:
4–5 is mild, 6–8 is moderate, >8 or any sign in the
severe category is severe.
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49. Medical Management
 Cool humidification during sleep with a cool mist tent or
room humidifier.
 Exposure of child to cool air.
 Oxygen administration, if necessary.
 Medications m Antipyretics such as acetaminophen
(Tylenol or paracetamol).
 Beta-agonist and beta-adrenergics (e.g., albuterol, racemic
epinephrine (Asthma Nefrin) aerosolized through face
mask.
 It is a rapid acting bronchodilator; it relieves bronchial
spasm and decreases the secretion.
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50.  Corticosteroids (e.g., dexamethasone); IM, PO,
Nebulized budeonide—It is an anti-inflammatory, it
reduces the oedema.
 Antibiotics if the infection is bacterial
 Administration of intravenous fluids to prevent
dehydration.
 Tracheostomy or ET intubation for impending airway
failure in very severe cases
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51. Nursing management
 Keep the child calm to ease respiratory effort and
conserve energy.
 Take the child into the bathroom, close the door, turn
on the shower’s hot-water spigot full-force, and sit
with the child as the room fills with steam; this should
decrease laryngeal spasm.
 Take the child outside into cool air
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52.  Use a cool-mist vaporizer
near the child’s bed after
an acute episode (after a
crisis, mucus production
increases, and the child
may vomit in large
amounts; this vomiting
doesn’t require medical
treatment).
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53.  Encourage clear fluid intake to promote liquification
of secretions and provide calories for energy.
 Provide steam tent bed to reduce the edema and
lubricate the secretion in the throat.
 Anticipate that the child may need hospitalization for
tracheotomy, oxygen, or mist if the crisis doesn’t
resolve
 Assess respiratory and cardiovascular status to detect
any indication that the obstruction is becoming worse.
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54.  l Monitor vital signs and pulse oximetry to detect early
signs of respiratory compromise.
 Administer medications, as ordered, and note
effectiveness to maintain or improve the child’s
condition.
 Provide emotional support for the parents to decrease
anxiety
 Monitor for rebound obstruction when administering
racemic epinephrine; the drug’s effects are short-term
and may result in rebound obstruction
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55. ACUTE EPIGLOTTITIS
 Acute epiglottitis, or acute supraglottitis, is a medical
emergency.
 It is a serious obstructive inflammatory process that
occurs principally in children between 2 and 5 years of
age but can occur from infancy to adulthood.
 The disorder is a medical emergency and requires
immediate medical attention.
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56.  The obstruction is supraglottic, as opposed to the
subglottic obstruction of laryngitis.
 The causative agent is usually H. influenzae.
 LTB and epiglottitis do not occur together.
 Epiglottitis (noninfectious) may also be caused by
ingestion of caustic agents or hot foods or liquids,
smoke inhalation, foreign bodies.
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57. Clinical Manifestations
 The onset of epiglottitis is abrupt, less often preceded
by cold symptoms and more often by a sore throat.
 It can rapidly progress to severe respiratory distress.
 The child usually goes to bed asymptomatic to awaken
later complaining of sore throat and pain on
swallowing.
 The child has a fever and appears sicker than clinical
findings suggest.
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58.  The child insists on sitting upright and leaning
forward (tripod position), with the chin thrust out,
mouth open, and tongue protruding.
 Drooling of saliva is common because of the difficulty
or pain on swallowing and excessive secretions.
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60. Note
 Three clinical observations that are predictive of
epiglottitis are absence of spontaneous cough,
presence of drooling, and agitation
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61. Management
 Epiglottitis may develop suddenly, with respiratory
obstruction appearing rapidly.
 Progressive obstruction leads to hypoxia, hypercapnia,
and acidosis, followed by decreased muscular tone,
reduced level of consciousness, and, when obstruction
becomes more or less complete, sudden death.
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62.  Nasotracheal intubation or tracheostomy is usually
considered for the child with severe respiratory
distress.
 Humidified oxygen is administered as necessary either
via mask in older children or as blow-by in younger
children to avoid further agitation.
 Whether or not there is an artificial airway, the child
requires intensive observation by experienced
personnel.
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63.  The epiglottal swelling usually decreases after 24 hours
of antibiotic therapy, and the epiglottis is near normal
by the third day.
 It is recommended that diagnostic tests and invasive
procedures be postponed on the child with suspected
epiglottitis until an airway has been established
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64.  Children with suspected bacterial epiglottitis are given
antibiotics intravenously, followed by oral
administration to complete a 7- to 10-day course.
 The use of corticosteroids for reducing edema may be
beneficial during the early hours of treatment.
 Most intubated children have a course of
corticosteroids for 24 hours before extubation.
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65. Nursing Care Management
 Epiglottitis is a serious and frightening disease for the
child, family, and health professionals.
 It is important to act quickly but calmly and provide
support without unduly increasing anxiety.
 The child is allowed to remain in the position that
provides the most comfort and security, and parents
are reassured that everything possible is being done to
obtain relief for their child.
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66.  Droplet isolation precautions are indicated for 24
hours after initiation of effective antibiotic therapy to
control spread of respiratory organisms.
 Prophylactic antibiotic treatment of household and
other contacts may be indicatED
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67. Tonsillitis
 Tonsillitis is an inflammation of the tonsils that is also
included in upper respiratory tract infections
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68. Etiology
 Mostly viral and bacterial.
 Group a beta-haemolytic streptococcus is the most
common and the most important bacterial agent after
2 year of age.
 Oral anaerobes
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69. Pathophysiology
 The tonsils are involved in immunity and antibody
production.
 Because of their location, tonsils are exposed to
pathogens on a regular basis.
 This can lead to micro abscesses with chronic or
recurring infections.
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70.  Waldeyer’s tonsillar
ring—a mass of
lymphoid tissues around
the nasal and oral
pharynx that consists of
three pairs of tonsils
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71.  Palatine tonsils, also
known as faucial tonsils:
 Located on both sides of
the oropharynx, behind
and below the opening
of the mouth.
 Surface is visible on oral
examination.
 Removed during
tonsillectomy
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72.  Pharyngeal tonsils, also
known as the adenoids:
 Located on the back wall
of the nasopharynx
above the palatine
tonsils.
 Close to the nares and
eustachian tubes, which
causes problems when
they become inflamed.
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73.  l Lingual at the base of
the tongue:
 Located at the base of
the tongue.
 Rarely removed.
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74. Complications
 Obstruction from tonsillar hypertrophy.

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76. Complications
 Otitis media,
Retropharyngeal and
Peritonsillar abscess.
 Non-supportive—Acute
glomerulonephritis,
Rheumatic fever.
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78. Clinical Manifestations
 Acute Tonsillitis
 Mild to severe sore throat.
 Decreased food intake
 Dysphagia.
 Abdominal pain.
 Vomiting.
 High grade fever.
 Headache.
 Other signs of URTI (runny
nose, sneezing, coryza, etc.).
 Tenderness in the lymph
glands in the submandibular
area
 Muscular and joint pain.
 Chills, Malaise.
 Pain that commonly refers to
ears.
 Excess secretions that cause a
constant urge to swallow.
 A feeling of constriction in
the back of the throat
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79.  Chronic Tonsillitis
 Recurrent sore throat.
 Purulent drainage in the tonsillar crypts.
 Diffuse redness and exudates, petechiae over palates,
and, tender cervical lympho adenopathy
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81. Medical management
 Treatment of viral tonsillitis consists of supportive care
such as, salt water gargles.
 Antibiotics for bacterial infections:
 Benzathine penicillin or another broadspectrum
antibiotics are the drugs of choice for a group A beta-
haemolytic streptococcus infection.
 Most oral anaerobes also respond to penicillin
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82.  Antipyretics—syrup or tablet paracetamol.
 Analgesics to relieve pain and inflammation.
 To prevent complication, antibiotic therapy should
continue for 10 to 14 days.
 Chronic tonsillitis or the development of
complications may require tonsillectomy; but only
after the patient has been free from tonsillar or
respiratory tract infection for 3 to 4 weeks
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83. Surgical Management
 Tonsillectomy or adenoidectomy, or both, may be
indicated in chronic enlargement that interferes with
swallowing or breathing, or in recurrent streptococcal
infections, peritosillar abscess, or retropharyngeal
abscess
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84. Tonsillectomy
 Tonsillectomy (surgical removal of the palatine
tonsils) may be indicated for massive hypertrophy that
results in difficulty breathing or eating.
 Absolute indications are:
 peritonsillar abscess
 airway obstruction
 tonsillitis resulting in febrile seizures
 tonsils requiring tissue pathology
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85. Adenoidectomy
 Adenoidectomy (the surgical removal of the adenoids)
is recommended for children:
 who have hypertrophied adenoids that obstruct nasal
breathing
 recurrent adenoiditis and sinusitis
 OM with effusion
 airway obstruction
 sleep-disordered breathing
 recurrent rhinorrhea
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87. Criteria for tonsillectomy
 Criteria for consideration of tonsillectomy:
 at least seven episodes in the previous year
 at least five episodes in each of the previous 2 years
 at least three episodes in each of the previous 3 years.
 One episode of tonsillitis is a sore throat plus at least
one of the following: temperature greater than 100.9° F
(38.3° C), cervical adenopathy (>2 cm or tender
nodes), exudate on the tonsils, or positive culture for
GABHS
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88. Contraindications
 Contraindications to either tonsillectomy or
adenoidectomy are
 cleft palate, since both tonsils help minimize escape of
air during speech
 acute infections at the time of surgery because the
locally inflamed tissues increase the risk of bleeding
 uncontrolled systemic diseases or blood dyscrasias
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89.  Generally, removal of the tonsils should not occur until
after 3 or 4 years of age because of the problem of
excessive blood loss in young children and the
possibility of regrowth or hypertrophy of lymphoid
tissue.
 The tubal and lingual tonsils often enlarge to
compensate for the lost lymphoid tissue, resulting in
continued pharyngeal and eustachian tube
obstruction
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90. Nursing Management
 Preoperative Care
 Explain why the child is coming to the hospital.
 Encourage the parents to stay with the child until
surgery.
 Prepare the child for the sights and sounds of surgery;
explain that the child will be sleeping during surgery.
 Allow the child to play with the equipment.
 Provide reassurance that the child will never be alone
and won’t feel the procedure
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91.  Put a transitional object in the recovery room for the
child.
 Prepare the child for throat surgery.
 Maintain a soft to liquid diet.
 The child may breathe through his mouth; a vaporizer
(cool mist) may help to keep mucous membranes from
drying out.
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92. Postoperative Care
 Place the child in a prone or side-lying position to facilitate
drainage.
 Don’t do suction except to remove an obstruction; this will
prevent trauma to the site.
 Check for signs of haemorrhage, which require immediate
attention:
 Frequent swallowing
 Restlessness
 Fast, thready pulse
 Vomiting bright red blood; however, be aware that
vomiting dried blood is common.
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93.  Provide an ice collar for comfort and for reducing
edema
 Most children experience moderate pain after a T&A
and need pain medication at regular intervals for at
least the first 24 to 48 hours.
 Analgesics may need to be given intravenously to avoid
the oral route, however liquid analgesics may be given
as tolerated.
 Local anesthetics, such as tetracaine lollipops or ice
pops, and antiemetics, such as ondansetron (Zofran),
may be administered postoperatively.
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94.  Food and fluid are restricted until children are able to
swallow them and are alert with no signs of
hemorrhage.
 Cool water, crushed ice, flavored ice pops, or diluted
fruit juice is given; fluids with a red or brown color are
generally avoided to distinguish fresh or old blood in
emesis from the ingested liquid.
 Straws should be avoided, since these may damage the
surgical site and cause subsequent bleeding.
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95.  Citrus juice may cause discomfort and is usually poorly
tolerated.
 Milk, ice cream, or pudding is not usually offered until
clear fluids are retained because milk products coat
the mouth and throat, causing the child to clear the
throat, which may initiate bleeding.
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96.  Postoperative hemorrhage is unusual but can occur.
 The nurse observes the throat directly for evidence of
bleeding, using a good source of light and, if necessary,
carefully inserting a tongue depressor.
 Other signs of hemorrhage are tachycardia, pallor,
frequent clearing of the throat or swallowing by a
younger child, and vomiting of bright red blood.
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97.  Restlessness, an indication of hemorrhage, may be
difficult to differentiate from general discomfort after
surgery.
 Decreasing blood pressure is a much later sign of
shock.
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98. Discharge instructions
 Should include:
 Avoiding foods that are irritating or highly seasoned,
 Avoiding the use of gargles or vigorous toothbrushing,
 Discouraging the child from coughing or clearing the
throat or putting objects in the mouth
 Using analgesics and opioids for pain
 Limiting activity to decrease the potential for bleeding.
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99.  Hemorrhage may occur up to 10 days after surgery as a
result of tissue sloughing from the healing process.
 Any sign of bleeding warrants immediate medical
attention.
 Objectionable mouth odor and slight ear pain with a
low-grade fever are common for a few days
postoperatively.
 However, persistent severe earache, fever, or cough
requires medical evaluation.
 Most children are ready to resume normal activity
within 1 to 2 weeks after the operation
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100.  QUESTIONS
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