Posted in Pediatrics

One of the most common childhood ailments you’ll see is acute otitis media, otherwise known as a middle ear infection. The good news is, most infections clear on their own in a few days and don’t require anything beyond at-home treatment. The bad news is, they can be significantly painful and recurrent. Many children get repeated ear infections and it’s often due to malfunction of the eustachian tube. 

So let’s go through otitis media using the Straight A Nursing LATTE method. This is an acronym created to make learning about disease conditions systematic, straightforward and focused. Ready?

L: How will the patient LOOK? 

A child with otitis media will be exhibiting signs of pain, which most often includes crying and tugging or rubbing the affected ear. Infection is taxing to the system so children with otitis media could be lethargic as well. You may see drainage from the ear and the child could even display signs that he or she is not hearing you well, especially if the condition is chronic. Children with chronic, recurrent infections can even have speech delays secondary to severe hearing impairment.

A: How will you ASSESS the patient?

  • Assess temperature (could be significantly elevated up to 40-degrees C or 104F)
  • Feel the lymph nodes of the neck, assess for enlargement
  • Assess child’s hearing
  • Assess child’s speaking ability
  • Using an otoscope, visualize the tympanic membrane by pulling the pinna down and back if the child is younger than 3 years old; for older children, pull the pinna up and back. The tympanic membrane will be yellow or red with decreased movement.

T: What TESTS will be ordered?

WBC may be ordered, though the infection is typically diagnosed based off visualization of the membrane and presenting symptoms. 

An ENT (ear, nose and throat) specialist may examine the child for eustachian tube malfunction. Tympanometry (which measures movement of the eardrum), sonotubometry (which looks at the ability of the ET to open) and tubomanometry (which measures pressure and the ability of the ET to open) are diagnostic tests that show potential for assessing eustachian tube function, though more study is needed in this area.

T; WHAT TREATMENTS will be provided?

Therapies for acute otitis media are aimed at treating pain and reducing the fever, essentially acetaminophen and ibuprofen. If the child is younger than 6 months of age, the Centers for Disease Control and Prevention (CDC) recommends acetaminophen only. If the child is older, then they can be given either acetaminophen or ibuprofen. Ear drops can also be used to treat the pain of otitis media. 

NOTE: No child should be administered aspirin because of the risk for Reye’s syndrome. 

Antibiotics may be needed if the condition doesn’t clear on its own after about three days. 

If the child has an eustachian tube malfunction leading to chronic infections, then the MD may perform a procedure called a myringotomy with placement of tympanostomy tubes that equalize pressure in the eustachian tubes.  This is typically an outpatient procedure and the tubes come out on their own after 6-12 months so there’s no need for a follow-up procedure to remove them. 

E: How will you EDUCATE the family?

  • The eustachian tubes will come out on their own in 6-12 months. In most cases, the tubes do not need to be replaced, but the parents should let the MD know.
  • Keep water out of the tubes. Stanford Health recommends placing a cotton ball coated in petroleum jelly in the ear while bathing to keep any water (which contains bacteria) from entering and causing infection.
  • Keep the child in an upright position with feeding so that the head is higher than the stomach. If the baby is held in a horizontal position, the feeding can flow back into the child’s eustachian tubes and lead to infection. 
  • Things that can lead to acute otitis media are secondhand smoke and being around individuals who are infectious with bacterial or viral infections. Provide smoking cessation education and resources as needed.
  • If infections are persistent, make sure parents know the child could have speech delays. 
  • Make sure the parents know when to see their physician. The CDC recommends seeking medical care when the child has a fever above 39-degrees C (102.2F), drainage from the ear, symptoms that don’t improve after 2-3 days or get worse, or any signs of hearing loss.
  • Teach parents that mild infections will often clear on their own in a few days. Recurrent use of unnecessary antibiotics can lead to antibiotic resistance so they should only be used when needed. Typically antibiotics are started after three days of non-resolution.
  • Breastfed children are less likely to get ear infections due to the presence of antibodies in the breast milk. If possible, the CDC recommends exclusive breastfeeding until the baby is 6 months of age, with continued breastfeeding along with an expanded diet until at least 12 months of age. 
  • Parents should keep the child’s ears dry, especially after swimming as a way to prevent acute otitis media.
  • Children should stay current on all recommended vaccines. 
  • The ear tends to hurt more at night while the child is lying down. A warm compress on the outside of the ear may help relieve pain, but avoid using this in infants whose skin is especially sensitive.

As you can see, there’s a lot of information to know about acute otitis media. So if you’re pressed for time, the key information you absolutely need to know is: 

  • Signs of infection are fever and the child tugging at the ear.
  • Antibiotics are typically only given after three days; otherwise acetaminophen and ibuprofen are the mainstays of treatment to reduce pain and fever. 
  • Chronic infections are often due to eustachian tube malfunction and can lead to hearing loss and speech delays.
  • Chronic infections are treated surgically with a myringotomy and placement of tympanostomy tubes.

Want to study otitis media on the go? Get this in episode 128 on the Straight A Nursing podcast.

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References

CDC. (2020, April 30). Suffering from an earache? Centers for Disease Control and Prevention. https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/ear-infection.html

Cleveland Clinic. (n.d.). Ear infection (Otitis media) prevention. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8613-ear-infection-otitis-media/prevention

Smith, M. E., Bance, M. L., & Tysome, J. R. (2019). Advances in Eustachian tube function testing. World Journal of Otorhinolaryngology – Head and Neck Surgery, 5(3), 131–136. https://doi.org/10.1016/j.wjorl.2019.08.002Stanford Health Care. (n.d.). Treatments. https://stanfordhealthcare.org/medical-conditions/ear-nose-and-throat/eustachian-tube-dysfunction/treatments.html