The Client With External Otitis External otitis is a common inflammation of the ear canal.

Commonly known as swimmers ear, it is most prevalent in people who spend significant time in the water. Competitive athlete, including swimmers, divers, and surfers, are particularly prone to external otitis. Wearing a hearing aid or ear plugs, which hold moisture in the ear canal, is an additional risk factor. Although pseudomonas aeruginosa or other bacterial infection is the most common cause. Pathophysiology Disruption of the normal environment within the external auditory canal typically precedes the inflammatory process. Retained moistur, cleaning, or drying of the ear canal remove the protective layer of cerumen, an acidic, water-repellent substance with antimicrobial properties. The client with external otitis often complains of a feeling of fullness in the ear. Ear pain typically is present and may be severe. The pain of otitis externa can be differentiated from that associated with otitis media by manipulation of the auricle or tragus. In externa otitis this maneuver increases the pain, whereas the client with otitis media experiences no change in pain perception. Collaborative Care For otitis externa, the following steps are recomended in treatment (Schelkun, 1991): Through cleansing of the ear canal, particularly if drainage or debris is present Tratment of the infection with local or, ifnecessary, systemic antibiotic agents Medication to relieve the pain and itching Teaching on the prevention of future episodes of swimmers ear

A topical corticosteroid may be ordered in combination with the antibiotic to provide immediate relief of the pain, swelling, and itching. Polymyxin B-neomycin-hydrocortisone (Cortisporin Otic) is a typical combination preparation used to treat external otitis; these antibiotics are effective against Pseudomonas, the most common infective organism. Clients who are sensitive to neomycin may develop dermatitis, which necessitates stopping the drug. Nursing Care External otitis can cause the client to experience severe pain and discomfort. Impaired Tissue Integrity Nursing interventions with rationales follow: Inform clients that ear canals rarely need cleansing beyond washing of the externa meatus with soap and water. Teach clients of all ages not to clean ear canals with any implement. Teach the client (and, if necessary a family member or friend) how to instill prescribed ear drops Teach the client to avoid getting water in the affected ear until it is fully healed.

Other Nursing Diagnoses Pain related to acute inflammatory process Sleep Pattern Disturbance related to ear discomfort Risk for Noncompliance with water activity restrictions related to desire to continue training

Client and Family Teaching Cellulitis of the surrounding tissue is a possible complication of external otitis. Instruct the client to report to the primary care provider any increase in pain, swelling, or redness of surrounding tissues; fever; or other manifestations of infection such as malaise or increased fatigue. The Client with Impacted Cerumen and Foreign Bodies The external auditory canal can be obstructed by cerumen or foreign bodies. As cerumen dries, it moves down and out of the ear canal. Aging is a risk factor for cerumen impaction, because less is produced and it is harder and drier. A variety of objects become foreign bodies in the ear canal. In adults, implements used to clean the ear canal may break and become lodged. Insect also may enter the ear canal and be unable to exit. The foreign body or impacted cerumen may be visualized on otoscopy. Impacted cerumen appears as a yellow brown, or black mass in the canal (Porth, 1994). Impacted wax, objects, or insects may require physical removal using an ear curret, forceps, or rightangel hook inserted via an otoscope and ear speculum. Inability to visualize the tympanic membrane or observation of a dark, shyni mass obstructing the canal may indicate a need for an irrigation or other procedure to clear the canal. Stress the risk of impacting cerumen against the tympanic membrane when using cotton-tipped swabs to clean the ear canal. The Client with Otitis Media Otitis media, inflammation or infection of the middle ear, primarily affects infants and young children but may also occur in adults. Pathophysiology There are two primary forms of otitis media: (1) serous and (2) acute or suppurative. Both forms are associated with upper respiratory infection and auditory tube dysfunction. Serous Otitis Media Serious otitis media occurs when the auditory tube is ibstructed for a prolonged time, impairing equalization of air pressure in the middle ear. The resulting negative pressure in the middle ear causes

sterile serous fluid to move from the capillaries into the space, forming a sterile effusion of the middle ear. Acute Otitis Media The auditory tube also provides a route for the entry of pathogens into the normally sterile middle ear, resulting in acute or suppurative otitis media. Acute otitis media typically follows an upper respiratory infection. Edema of the auditory tube impairs drainage of the middle ear, causing mucus and serous fluid to accumulate. Collaborative Care The diagnosis of otitis media is usually based on the clients history and the physical examination. The tympanic membrane may be visualized with a pneumatic otoscope. Generally, the tympanic membrane moves slightly when air is instilled. Less movement is seen in clients with auditory tube dysfunction. Laboratory and Diagnostic Tests Impedance audiometry, also known as tympanometry, is an accurate diagnostic test for otitis media with effusion. A CBC may be performed to assess for an elevated WBC indicative of acute bacterial infection.

Pharmacology Auditory tube dysfunction and serous otitis media are treated with decongestants and autoinflation of the middle ear. Acute otitis media is treated with antibiotic therapy often in combination with decongestants. Penicillin, erythromycin, amoxicillin, trymethoprim-sulfamethoxazole, or cefaclor are commonly prescribed and effective against most organisms infecting the middle ear.

Surgery A myringotomy or tympanocentesis may be performed to relieve excess pressure in the middle ear and prevent spontaneous rupture of the eardrum. Myringotomy, or surgical drainage of the middle ear, may be performed to relieve severe pain or when complications of acute otitis medi, such as mastoiditis, are present. Nursing Care Pain can be a significant problem for clients with otitis media, as well as the risk of damage to delicate tissues of the middle ear by the infectious and inflammatory processes. Pain Tissue edema, effusion of the middle ear, and the inflammatory response can affect the pain-sensitive tissues of the middle ear in otitis media.

Impaired Tissue Integrity In chronic otitis media, mucosal changes occur, granulation (scar) tissue may develop, and changes in the ossicular chain may result. Other Nursing Diagnoses Sensory/Perceptual Alteration: Auditory related to conductive hearing loss associated with middle ear effusion Risk for Noncompliance with prescribed therapeutic regimen related to lack of understanding Risk for Injury related to potentioal perforation of tympanic membrane.

Client and Family Teaching When antibiotic therapy is prescribed, teach the client about the drug, its effects, recommended administration, and possible side effects. The client also need to know about symtoms of allergic or adverse reactions that should be reported to the physician. If surgical intervention is necessary, teach the client and family members about the surgery and postoperative care.