3. Bacterial Etiology
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.
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.
• Change of colour of the tympanic membrane to pink/red
• Bulging drum
• Loss of outline of drum and landmarks
• Discharge in meatus
• There may be tenderness over the mastoid.
– 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
• Occasionally tinnitus, voice resonance, giddiness and sickness
• Irritability may be the only indication in infants.
• Hearing loss occurs if accumulation of fluid has taken place.
Acute mastoiditis – infection of the mastoid process.
Cholesteatoma – cystic lesion within the middle ear.
Tympanic membrane perforation.
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
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
14. Types of Acute Otitis Media
Serous Otitis Media or Otitis Media with effusion
Inflammation of the TM with fluid in the middle
Caused by vacuum created by malfunction of the
Can cause hearing impairment and delayed
speech in children
Since infants cannot hear they cannot learn how
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
Impaired mobility of the TM
Loss of light reflex
Opacification of the TM
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)
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
31. NURSING DIAGNOSIS FOR ACUTE OTITIS MEDIA AND CHRONIC OTITIS
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 visualacuity.
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.
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 imagination,
•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.