EAR DISORDERS

BY
VIRGINIAH NJAUINI
THE EAR
ANATOMY OF THE EAR
 Housed by the petrous temporal bone
 The ear has three parts: outer, middle & inner ear
 Outer ear
 Pinna
 External auditory meatus
 Collect sound waves
 Converged to the eardrum
 Sound changed to vibration
Contd….
 The middle ear:
 The tympanic cavity-contains ear ossicles which amplifies
vibrations
 Eustachian tube which connects the inner ear to the
pharynx
 Helps in equalizing pressure
Contd….
 The inner ear
 Bony labyrinth
 Cochlear
 Semicircular canals
 The vestibule
 Membranous labyrinth
 Cochlear duct, extends from the saccule
 3 semicircular ducts, extend from the utricle
INNER EAR

e
 OTITIS EXTERNA(O E)
 Description
 Inflammation or infection of the external auditory canal, the
auricle or both.
 The condition can be found in all age groups
 The condition can be acute or chronic
 The EAC is lined with squamous epithelium and is approximately
2.5 cm long in adults.
 Its function is to transmit sound to the middle ear while
protecting more proximal structures from foreign bodies and any
changes in environmental conditions
 .
Epidemiology
 OE is found in all regions of the United States, occurring in
4 of every 1000 people annually.
 The incidence is increased in tropical countries.
 Although the infection can affect all age groups, OE
appears to be most prevalent in the older pediatric and
young adult population, with a peak incidence in children
aged 7-12 years.
 OE affects both sexes equally. No racial inclination has been
established, though people in some racial groups have small
ear canals, which may predispose them to obstruction and
infection
ACUTE OTITIS EXTERNA
 Classification
 Acute diffuse OE - Most common form of OE, mostly seen in
swimmers.
 Acute localized OE (furunculosis) - Associated with infection
of a hair follicle
 Chronic otitis externa- similar to acute OE but with a during
longer than 6 weeks.
 Eczematous (eczematoid) OE - Encompasses various
dermatologic conditions (e.g. atopic dermatitis, psoriasis,
systemic lupus erythematosus, and eczema) that may infect
the EAC and cause OE
Contd…..
 Necrotizing (malignant) OE - Infection that extends into
the deeper tissues adjacent to the external auditory meatus;
occurs primarily in immunocompromised adults (eg,
diabetics, patients with AIDS)
 Otomycosis - Infection of the ear canal from a fungal
species (eg, Candida, Aspergillus
Risk Factors
 Swimming
 Warm/humid climates
 Underlying skin conditions e.g. eczema
 Immunosuppression e.g. diabetes
 Trauma e.g. excessive cleaning or scratching
 Hearing aids that reduce ventilation or introduce infection
into the canal
CAUSES
 Mostly bacterial: Pseudomonas aeruginosa, S. Epidermidis
and S. Aureus.
 Otitis externa can be fungal. There is an increased risk
after prolonged antibiotic courses.
Signs and symptoms
 Otalgia (ear pain) - especially on movement of the pinna
or jaw.
 Pruritus (itching) especially in fungal OE or chronic OE.
 Discharge-Initially clear, quickly becomes purulent and
foul smelling.
 Hearing loss- this can be due to stenosis of the auditory
canal.
 External auditory meatus swelling, erythema and
narrowing.
 Contd…
 Ear fullness and pressure
 Tinnitus
 Fever-occasionally
 Severe deep pain mostly in immunocompromised patients
which can be a sign of necrotizing(malignant) Otitis Externa
 History of exposure to activities in water e.g. swimming,
surfing
 History of preceding ear trauma (usually) (eg, forceful ear
cleaning, use of cotton swabs, or water in the ear canal
 Diagnosis
 History taking
 Physical examination
 In diabetic or immunocompromised patients with severe
pain in the ear necrotizing OE should be ruled out. Urgent
CT scan is required
 Blood glucose levels.
 Urine dipstick.
 Swab from the external ear canal for Microscopy, culture
and sensitivity.
 Treatment
 Patients with OE are treated objectively. Initial treatment
entails;-
 Pain management
 Removal of debris from the External auditory canal
 Administration of topical medications to control edema and
infection
 Avoidance of contributing factors
 Pharmacotherapy
 Topical medications e.g. hydrocortisone and acetic acid otic
solution
 Analgesic agents eg, acetaminophen, acetaminophen and
codeine
 Antibiotics e.g. hydrocortisone/neomycin/polymyxin B,
ciprofloxacin and hydrocortisone suspension
 Oral antibiotics (eg, ciprofloxacin
 Antifungal agents (eg, otic clotrimazole 1% solution, nystatin
powder
 Surgery
 Surgical debridement of the ear canal - Usually reserved for
necrotizing OE or for complications of OE (eg, external canal
stenosis)
 Often necessary in more severe cases of OE or in cases where
a significant amount of discharge is present in the ear.
 Very central in treatment of fungal infections
 Incision and drainage of the abscess.
 complications
 Necrotizing OE (the most significant complication)
 Mastoiditis
 Chondritis of the auricle (from spread of acute OE to the pinna,
particularly in patients with newly pierced ears)
 Bony erosion of the base of the skull (skull base
osteomyelitis [15] )
 Central nervous system (CNS) infection
 Cellulitis or lymphadenitis
Patient education
 Keeping the ear dry.
 Preventive use of acidifying drops is encouraged in
patients with recurrent OE.
 Avoid the use of cotton-tipped swabs to remove ear
cerumen.
 Educate on causes of OE and its prevention.
 References

 https://emedicine.medscape.com/article/994550-overvie

 Paradis, J., & Messner, A. H. (2015). Ear, Nose, and

Throat Disorders. Pediatric Board Study Guide: A Last
Minute Review, 469–489. https://doi.org/10.1007/978-3-
319-10115-6_22
OTITIS MEDIA
OUTLINE
 Definition
 Anatomy ear
 Types of otitis media
 Etiology of otitis media
 Pathophysiology
 Clinical manifestation
 Diagnosis
 Management
 Complications
 Prevention
Definition

 Otitis Media is infection of the middle ear.

Types of otitis media
 Acute otitis media (AOM)-infection of the tympanum,
ossicles and space of the middle ear.
 Most common pathogens in in AOM are streptococcus
pneumonia, hemophilus influenza and Moraxella
catarrhlis.
 AOM is associated with ear pain, fever, irritability,
inflamed tympanic membrane.
Contd….
 Chronic suppurative otitis media(CSOM)- results from
repeated attacks of Otitis media especially in adults with
history of recurrent AOM in childhood.
 CSOM is characterized by a purulent discharge, and
inflammation involving the ossicles, auditory tube and
mastoid bone.
 Overtime, this can result in perforation of the eardrum.
 There is nausea, episodes of dizziness, hearing loss and it
is often painless.
Contd…

 Otitis Media with effusion(OME)-This is a condition in

which there is accumulation of fluid in the middle ear but
no signs of acute infection.
 Fluid builds up in the middle ear and Eustachian tube
placing pressure on the tympanic membrane.
 This pressure prevents the tympanic membrane from
vibrating properly.
 There is decrease in sound conduction by the membrane
and eventually decrease in hearing.
Contd…
 Middle ear effusion is frequently seen in patients after
radiation therapy.
 patients with Eustachian tube dysfunction from a
concurrent upper respiratory infection or allergy.
 Barotrauma-results from sudden pressure changes in the
middle ear caused by changes in barometric pressure, as in
scuba diving or airplane descent.
 A carcinoma (e.g., nasopharyngeal cancer) obstructing the
Eustachian tube should be ruled out in adults with
persistent unilateral serous otitis media(otitis media with
effusion).
Causes And Risk Factors
 Otitis media is a multifactorial disease. Infectious, allergic,
and environmental factors contribute to otitis media.
 Age – usually children between 6 months – 2 years are at
risk due to low immunity and shorter Eustachian tube
 Children in any day care – due to congestion therefore
prone to URTI.
 Bottle feeding usually in lying down posture is a common
risk for otitis media due to reflux of fluid into the ear.
Contd….
 Allergies
 URTI
 Previous history of acute otitis media
 Genetic predisposition
 Vitamin A deficiency
 Cochlear implants
 Lower socioeconomic status
 Decreased immunity due to human immunodeficiency
virus (HIV), diabetes, and other immuno-deficiencies
Contd…..
 Ethnicity-Native Americans and Hispanic children are
more prone to ear infections than other ethnic groups.
 Gender-more common in male than in female.
 Environmental smoke exposure
 parental history of recurrent childhood OM
 gastroesophageal reflux.
 Bacterial pathogens, Streptococcus
pneumoniae, Haemophilus
influenza, and Moraxella (Branhamella) catarrhalis are
responsible for more than 95%.
Pathophysiology
 Otitis media begins as an inflammatory process following
a viral upper respiratory tract infection involving the
mucosa of the nose, nasopharynx, middle ear mucosa, and
Eustachian tubes.
 Due to the reduced anatomical space of the middle ear, the
edema caused by the inflammatory process obstructs the
narrowest part of the Eustachian tube leading to a decrease
in ventilation.
Contd….
 There is increase in pressure in the middle ear, increasing
exudate from the inflamed mucosa, and buildup of
mucosal secretions, which allows for the colonization of
bacterial and viral organisms in the middle ear.
 The growth of these micro organisms in the middle ear
then leads to suppuration and eventually frank purulence
in the middle ear space.
 This is demonstrated clinically by a bulging or
erythematous tympanic membrane and purulent middle ear
fluid
Clinical Manifestation
 Unusual irritability
 Difficulty sleeping or staying asleep
 Tugging or pulling at one or both ears
 Fever, especially in infants and younger children
 Fluid draining from ear(s)
 Loss of balance
 Hearing difficulties
 Ear pain
 Poor feeding
 Inflammed tympanic membranes
Diagnosis
 History taking
 Physical examination e.g. use of an otoscope
 Tympanometry - test to examine the middle ear by
measuring the movement of the eardrum. Provides an
indirect measure of pressure within the eardrum.
 Acoustic reflectometry to detect fluid consistency in the
middle ear.
 Microscopic culture and sensitivity test.
 Differential Diagnosis
 Acute sinusitis
 Bacteremia
 Cholesteotoma
 Hearing impairment
 Pediatric Nasal polyps
 Nasal pharyngeal cancer
 Otitis externa
 Pediatric allergic rhinitis
 Mastoditis
Medical Management
 Once the diagnosis of acute otitis media is established, the
goal of treatment is to control pain and to treat the
infectious process with antibiotics
 Non-steroidal anti-inflammatory drugs (NSAIDs), such as
acetaminophen, can be used to achieve pain control.
 Oral antibiotics are indicated in treatment of otitis media.
High-dose amoxicillin or a second-generation
cephalosporin are first-line agents.
contd….
 If there is a TM perforation, treatment should proceed with
ototopical antibiotics safe for middle-ear use such as
ofloxacin, rather than systemic antibiotics, as this delivers
much higher concentrations of antibiotics without any
systemic side-effects
 Antibiotic of choice is high-dose amoxicillin for ten days
in both children and adult patients who are not allergic to
penicillin. Dosage 90 mg/kg/day divided into 3 doses
given after every 8 hrs x 10 days.
Contd…
 Amoxicillin has good efficacy in the treatment
of otitis media due to its high concentration in the middle
ear.
 for those with penicillin allergy alternatives;-
Azithromycin as a single dose 10 mg/kg or Clarithromycin
15 mg / kg/ day in 2 divide doses.
 Amoxicillin-clavulanate 90 mg/kg/per day for those who
don’t improve on amoxicillin.
Contd…
 In children who are vomiting or if there are situations in
which oral antibiotics cannot be administered, ceftriaxone
(50 mg/kg per day) for three consecutive days, either
intravenously or intramuscularly, is an alternative option.
Management of OME.
 Serous otitis media need not be treated medically unless infection
occurs.
 If the hearing loss associated with middle ear effusion is significant,
a myringotomy can be performed, and a tube may be placed to keep
the middle ear ventilated.
 Corticosteroids in small doses may decrease the edema of the
Eustachian tube in cases of barotrauma.
 A Valsalva maneuver which forcibly opens the Eustachian tube by
increasing nasopharyngeal pressure, may be performed with caution
since it can cause worsening in pain and perforation of the ear drum.
Nursing Diagnosis
 Acute pain related to inflammation and increased pressure in the
middle ear as evidenced by the patient verbalizing pain
 Disturbed sensory perception related to inflammation and edema of
the middle ear as evidenced by lack of response when spoken to.
 Deficient knowledge related to lack of information as evidenced by
the parent admitting that he smokes inside the house.
 Disturbed body image related to discharging ears as evidenced by
the patient covering her head including her ears and isolating
herself.
Management of CSOM
 Medical management
 Local treatment of chronic otitis media consists of careful
suctioning of the ear under otoscopic guidance.
 Instillation of antibiotic drops or application of antibiotic
powder is used to treat purulent discharge.
 Systemic antibiotics are prescribed only in cases of acute
infection.
Nursing care plan
Assessment Nursing Expected Intervention Rationale Evaluation
diagnosis outcome

c/o pain Acute pain Patient Assess the This will help
restlessness related to should report client and in measuring
inflammation pain score the pain changes in
and increased reduction by the pain.
pressure in the end of 2 Monitor and Pain leads to
the middle hour record vital increase in
ear as signs 4 heart rate,
evidenced by hourly. respiratory
the patient rate and
verbalizing blood
pain Administer pressure.
prescribed These drugs
analgesics usually alter
(ibuprofen, response to
acetaminophe pain
n
 Nursing Management
 Monitor and record vital signs closely
 Ensuring the patient is comfortable by monitoring pain and
giving prescribed medication such as acetaminophen or
ibuprofen.
 Encourage patient to sit up, put a pillow behind or lie on the
unaffected ear. Elevation promotes drainage and reduces
pressure from the fluid.
 Reassuring the patients who may be experience hearing loss
that it is temporary and that will be resolved with treatment.
This will help reduce anxiety over hearing loss.
Contd….
 Assist parents to plan measures to decrease the chances of
recurrent OM;-
 completing the course of antibiotic,
 avoiding exposure to persons with URT infection,
 maintaining a smoke-free environment,
 and feeding the infant in a sitting position.
Surgical Management
 MYRINGOTOMY-This procedure is indicated for
patients who have experienced four episodes of otitis
media in 12 months.
 placement of the tympanostomy tube allows ventilation of
the middle ear space and maintenance of normal hearing.
 Tympanostomy tubes(ear tubes) are small hollow
cylinders made of plastic or metal that are inserted in the
tympanic membrane(eardrum).
 The tubes drain the fluid from the inner ear and also allow
the air in.
Contd…
 The procedure is conducted in he Doctors office and it
takes 15 minutes. Doesn’t require hospitalization.
 Antibiotics may be prescribed to prevent infection.
TYMPANOPLASTY
 The most common surgical procedure for chronic otitis media.
 surgical reconstruction of the tympanic membrane.
 Reconstruction of the ossicles may also be required.
 The purposes of a tympanoplasty are to reestablish middle ear
function, close the perforation, prevent recurrent infection, and
improve hearing.
 Tympanoplasty is performed through the external auditory
canal or through a post auricular incision.
 tympanoplasty procedures include restoring the continuity of
the sound conduction mechanism.
OSSICULOPLASTY
 is the surgical reconstruction of the middle ear bones to
restore hearing.
 Prostheses made of materials such as Teflon, stainless
steel, and hydroxyapatite are used to reconnect the
ossicles, thereby reestablishing the sound conduction
mechanism.
 greater the damage,the lower the success rate for restoring
normal hearing.
MASTOIDECTOMY
 The objectives of mastoid surgery are to remove the
cholesteatoma, gain access to diseased structures, and
create a dry (noninfected) and healthy ear.
 A mastoidectomy is usually performed through a post
auricular incision.
 Infection is eliminated by removing the mastoid air cells.
 Surgery is usually performed in an outpatient setting.
Contd..
 The patient has a mastoid pressure dressing, which can be
removed 24 to 48 hours after surgery.
 Facial nerve is at some risk of being injured during the
surgery hence the nurse should report to the physician any
evidence of paresis when the patient awakens from
anesthesia
Complications
 Ear drum perforation
 Mastoiditis
 Chronic suppurative otitis media
 Meningitis
 Neural thrombosis
 Facial nerve paralysis
 Hearing loss
 Can affect speech development
 Prevention of Otitis Media
 Don’t smoke or allow smokers near a child
 Control of allergies
 Prevention of colds
 Encourage breastfeeding-breast feeding reduces the rate of
ear infections
 Bottle feeding child should do it in an upright position to
avoid milk flowing back into the Eustachian tubes
 Watching for mouth breathing and snoring and seeking early
interventions.
Contd….
 Vaccination against flu(influenza vaccine)
 Maintain self care and good hygiene practices especially
of the ear.
 Keep the ear dry after taking shower or swimming/ can
also pad the ear to prevent contact with water.
Advise on discharge
 Take due medication as prescribed and indicated
 Advise on importance of a follow up care
 Report any underlying upper respiratory tract infection or
elevation in body temperature
 Avoid probing the ear with ear buds.
 References

 Lewis Dirksen, Heitkemper Bucher (2012) Medical- Surgical

Nursing, Assessment and management of clinical problems.
9th Edition. Elsevier, Canada.
 Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry
H. Cheever (2010) Brunner &Saddarth’s text book of medical
–Surgical Nursing. 9th Edition. Lippincott, China.
MASTODITIS
Skull and facial bones
Definition

 Suppurative infection of the middle ear that spreads to

mastoid cavity resulting in osteitis of the mastoid bone.
 May become purulent and lead to bony breakdown within
the mastoid bone (acute coalescent mastoiditis)
 All inflammatory processes of the mastoid air cells of the
temporal bone.
Contd…

 As the mastoid is contiguous to and an extension of the

middle ear, virtually every child or adult with
acute otitis media (AOM) or chronic middle ear
inflammatory disease has mastoiditis.
 Disease within the mastoid is not considered a separate
entity.
Mastoditis
Pathophysiology
 Acute mastoiditis is associated with AOM.
 In some patients, the infection spreads beyond the mucosa
of the middle ear cleft, and they develop osteitis within the
mastoid air-cell system or periosteitis of the mastoid
process, either directly by bone erosion through the cortex
or indirectly via the emissary vein of the mastoid
Risk factors &causes

 Children younger than 2 years are prone to mastoditis

 microbial factors include;-streptococcal pneumoniae,
Haemophilus influenzae, group A Streptococcus
pyogenes (GAS).
 Persistent middle ear infections.
 Cholesteotoma-Abnormal collections of skin cells inside
the ear which may prevent the ear from draining properly.
Signs & symptoms
 Persistent otorrhea more than 3 weeks.
 High fever that persist even when the patient is on
antibiotics.
 Pain that is localized deep in or behind the ear and it is
typically worse at night.
 Hearing loss is common
 Infants will feed poorly, irritability and diarrhoea
 Protuberant ear.
 Erythema, tenderness and oedema (post auricular region)
over the mastoid bone
 Adenopathy
Diagnosis
 CT-Scan of the temporal bone
 Microscopic, culture and sensitivity of samples obtained
from the ear through tympanocentesis
 Spinal fluid is also evaluated if intracranial extension is
suspected.
 Complete blood count-high wbc on admission is
suggestive of a complicated case.
 Audiometry test-test ones ability to hear sounds. Usually
done after recovery.
Differential diagnosis

 Cellulitis,
 Otitis externa,
 Lymphadenopathy,
 Trauma,
 Tumor
Management and treatment
 Systemic antibiotics( usually intravenous)
 High doses of intravenous steroids
 Analgesics, antipyretics
 Surgical interventions includes myringotomy and
Mastoidectomy.
 Mastoidectomy is contraindicated in persons with general
systemic diseases that must be controlled e.g diabetes,
hypertension, poor cardiac condition, bleeding disorders
with prolonged bleeding and clotting time
complication
 Hearing loss
 Facial palsy
 Cranial nerve involvement
 Osteomyelitis
 Petrositis-infection of the temporal bone
 Labyrinthiasis-inflammation of the inner ear or nerves that
connect the inner ear to the brain.
 Gradenigo syndrome-otitis media, retro-orbital pain,
abducens palsy
 Mastoidectomy
 Mastoidectomy is surgery to remove cells in the hollow, air-
filled spaces in the skull behind the ear within the mastoid
bone. These cells are called mastoid air cells.
prevention

 Timely diagnosis and treatment of ear infections

 Vaccination
 3
Josée Paradis and Anna H. Messner 2

Author information Copyright and License information Disclaimer

References

 https://nurseslabs.com/otitis-media-nursing-care-plans/3/
 Danishyar, A., & Ashurst, J. V. (2020). Acute Otitis
Media. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/
NBK470332/
 Lewis Dirksen, Heitkemper Bucher (2012).Medical surgical
nursing, Assessment and Management of Clinical Problems. 9th
Edition, Elsevier. Canada.
 Paradis, J., & Messner, A. H. (2015). Ear, Nose, and Throat
Disorders. Pediatric Board Study Guide: A Last Minute Review,
469–489. https://doi.org/10.1007/978-3-319-10115-6_22
THE END