OTITIS MEDIA - Nursing and Midwifery - Flinders University · PDF fileBACKGROUND ·...
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BACKGROUND · Otitis Media is the infection of the inner ear and effects up to 50% of Aboriginal children in Australia. · Aboriginal children living in rural and remote areas of Australia often receive compromised health care due to their location and access to health services. · Guidelines for children with acute otitis media (AOM) and Otitis Media with Effusion (OME) living in urban areas have been developed over the past few years (1) . · Children living in urban areas are generally treated by general practitioners whereas those living in rural and remote areas are often treated by the Clinical Nurse, therefore guidelines are required to enable the latest evidence based practice to be possible in the rural and remote areas. Anatomy of the Ear Picture From: Reynolds: Nurs Stand, Volume 18(26).March 10, 2004.47-53, 55 Copyright Ovid technologies inc 2000-2004 DEFINITIONS Rural and Remote Nurse – Clinical nurse who works in remote clinics in Australia. Otitis Media (OM) – infection of the inner ear. Acute Otitis Media (AOM) – fluid build up behind the tympanic membrane with rapid onset of symptoms including bulging and/or signs of inflammation on the tympanic membrane. Mild Acute Otitis Media – little or no otalgia and fever under 39˚C. Severe Acute Otitis Media – moderate to severe otalgia as indicated by pain scale and fever over 39˚C. Acute Otitis Media with Perforation (AOMP) – As described above, but with discharge from at least one ear. Otitis Media with Effusion (OME) – fluid build up behind the tympanic membrane without the signs of AOM. Chronic Suppurative Otitis Media (CSOM) – Presence of fluid from within the inner ear discharging through a perforation in the tympanic membrane present for more than 6 weeks despite standard treatment. Otalgia – pain originating in the inner ear. Otorrhea – discharge from the inner ear. Ototoxic – relating to substances that are potentially toxic to the cranial nerves (cochlea) present in the inner ear. AIM To produce clinical practice guidelines for the rural and remote Clinical Nurse to improve the outcome of Aboriginal paediatric patients with Otitis media. Picture From: www.gccommune.com/kozy/images METHOD Using the latest guidelines and protocols from Australia and America regarding the treatment of AOM and OME, as well as incorporating cultural influences from two major Aboriginal treatment guidelines. Additionally, electronic databases were used as well as manual searching and interviews to access recent and relevant information required to create the recommendations for clinical practice in rural and remote areas of Australia. Evidence was classified according to the policy document “Recommendations for clinical practice guidelines” American Academy of Paediatrics 1 as either strong recommendations, recommendations or options depending on the quality of the evidence and the preponderance and balance of benefit and harm. RESULTS Diagnosis Diagnosis of AOM can be made with the following are present: Rapid onset of symptoms Presence of middle ear effusion (MEE) Visual signs of middle ear inflammation Strong Recommendation The only accurate way to diagnose Acute Otitis Media is a medical history indicating rapid onset of ear pain (otalgia), followed by inspection of the tympanic membrane with a pneumatic otoscope with adequate light power for accurate visual signs of inflammation including bulging, redness and limited mobility of the tympanic membrane (1, 2, 3 & 4) . Recommendation A diagnosis for OME can be made using a pneumatic otoscope to visualise fluid behind the tympanic membrane also OME occurs without the rapid onset of signs and symptoms and without signs of inflammation. Recommendation A history of ear tugging may be present in small children and used as a diagnostic tool. However, inspection of the tympanic membrane is still required to eliminate the presence of foreign body or a retracted tympanic membrane indicating reduced air space in the Eustachian tube, a negative diagnosis for acute otitis media (2) . Recommendation As Aboriginal children are especially susceptible to otitis media, it is important to inspect the ears at regular intervals (approx every 3 months) even when the child appears to be well (3,4) . Consult with a Doctor before administering treatment if any of the following are present: Signs for AOM above are negative or unclear Blood is present in the ear canal Signs of mastoiditis as evidenced by swelling around and/or behind the ear Otalgia accompanied by severe dizziness (4) . Oral Antibiotics Strong Recommendation Length of treatment by oral antibiotics should be not less than 7 days (1, 3, 4) . Strong Recommendation for Mild Acute Otitis Media Amoxicillin 50mg/kg/day in 2 or 3 doses for 7-10 days in populations where there is not a high rate of penicillin resistant pneumoniae (1,3,4) . Amoxicillin 80-90ml/kg/day in 2 or 3 doses for 7-10 days in populations where there is a high rate of penicillin resistant pneumoniae (1,3,4) . Recommendation for Severe Acute Otitis Media Amoxicillin/clavulanate 90mg/kg/day amoxicillin plus 6.4mg/kg/day clavulanate which is effective against _-lactamase-positive, Haemophilus influenzae and Moroxella catarrhalis (1) . Option for OME present for more than 3 months Low-dose amoxicillin 50mg/kg/day for 10-14 days 5 . Topical Therapy Option Ear cleansing using iodine solution to clear the ear from discharge and allow access to the tympanic membrane plus administration of antibiotic eardrops consisting of 0.2% ciprofloxacin 5 drops 2 doses daily for 9 days as this solution is not ototoxic. Other Treatment Methods Option Bush medicine regimes may be available for the treatment of pain, fever and ear discharge and should be explored for their efficiency and possible use for the treatment of ear infections. Cultural Issues And Increased Risk Factors Passive cigarette smoke in the home Sharing beds with other children Poor facial hygiene practices Lack of access to health care facilities Methods Of Prevention Encourage routine nose blowing from an early age to clear possible bacteria from the nasopharynx. Encourage facial hygiene such as routine face washing, including the external ear area. Encourage mothers to breast feed for as long as possible. Encourage older children and adults to smoke in well-ventilated areas away from children. Encourage parents and guardians to seek medical advice as soon as signs and symptoms arise of earache or hearing impairment. Encourage administration of the pneumococcal vaccine at the recommended age. Summary •Guidelines are required for Clinical Nurses working in rural and remote areas of Australia to enable the latest evidence based practice to occur. •Guidelines based on the latest evidence may encourage more Clinical Nurses to practice in rural and remote areas. •Guidelines based on the latest evidence allow Aboriginal people living in rural and remote communities the opportunity to equal treatment for illness. Acknowledgements Diane Chamberlain, Academic Mentor This work was supported by a SARNet grant, under the auspices of the Flinders University PHC RED program, funded by the Australian Government Department of Health and Ageing. References 1.Paediatrics Vol. 114 No. 3 September 2004 p874-877 2.American Academy of Pediatrics and American Academy of Family Physicians, 2004 ‘Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media’. Pediatrics, Vol 113 no 5, May 2004 p1451-1465. 3.Harrison, CJ, 2004 ‘Pediatric Practice: The new Guideline for managing otitis media’ Patient Care for the Nurse Practitioner: Practical Clinical and Professional Information. August 15, 2004 pp1-15. 4.Office for Aboriginal and Torres Strait Islander Health, 2001 ‘Recommendations for Clinical Care Guidelines on the Management of Otitis Media (Middle Ear Infection) in Aboriginal and Torres Strait Islander Populations’ March 2001. 5.Central Australian Rural Practitioners Association, 2003 ‘CARPA Standard Treatment Manual 4 th Edition’ Central Australian Rural Practitioners Association, Alice Springs, 2003. OTITIS MEDIA Diagnosis and Management of Acute Otitis Media and Otitis Media with Effusion in Aboriginal children aged 6 months to 18 years in Rural and Remote Australian Communities PAIN Strong Recommendation Use of pain assessment chart is recommended for assessing the level of discomfort of children presenting with AOM or OME. Children of varying age groups can be assessed using the following diagnostic tool for paediatric pain. Option When a child is experiencing mild pain paracetamol may be administered in the doses listed in the Table entitled Paediatric Analgesia Dosages. However, caution needs to be taken when administering paracetamol or ibuprofen to a child who is dehydrated, as there is an increased risk for liver toxicity (Joanna Briggs Institute, 2001). No Recommendation Use of complementary or alternative medicines such as herbal eardrops are not recommended for pain management as their efficacy is yet to be proven. http://www.ozoutback.com.au/postcards/postcards_forms/abor_kids_portr_1/index.htm By Allyson Chapple
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Transcript of OTITIS MEDIA - Nursing and Midwifery - Flinders University · PDF fileBACKGROUND ·...
BACKGROUND· Otitis Media is the infection of the inner ear and effects up to 50% of Aboriginal children in Australia.
· Aboriginal children living in rural and remote areas of Australia often receive compromised health caredue to their location and access to health services.
· Guidelines for children with acute otitis media (AOM) and Otitis Media with Effusion (OME) living in urbanareas have been developed over the past few years (1).
· Children living in urban areas are generally treated by general practitioners whereas those living in ruraland remote areas are often treated by the Clinical Nurse, therefore guidelines are required to enable thelatest evidence based practice to be possible in the rural and remote areas.
Anatomy of the Ear
Picture From: Reynolds: Nurs Stand, Volume 18(26).March 10, 2004.47-53, 55 Copyright Ovidtechnologies inc 2000-2004
DEFINITIONSRural and Remote Nurse – Clinical nurse who works in remote clinics in Australia.
Otitis Media (OM) – infection of the inner ear.
Acute Otitis Media (AOM) – fluid build up behind the tympanic membrane with rapid onset of symptomsincluding bulging and/or signs of inflammation on the tympanic membrane.
Mild Acute Otitis Media – little or no otalgia and fever under 39˚C.
Severe Acute Otitis Media – moderate to severe otalgia as indicated by pain scale and fever over 39˚C.
Acute Otitis Media with Perforation (AOMP) – As described above, but with discharge from at least one ear.
Otitis Media with Effusion (OME) – fluid build up behind the tympanic membrane without the signs of AOM.
Chronic Suppurative Otitis Media (CSOM) – Presence of fluid from within the inner ear discharging through aperforation in the tympanic membrane present for more than 6 weeks despite standard treatment.
Otalgia – pain originating in the inner ear.
Otorrhea – discharge from the inner ear.
Ototoxic – relating to substances that are potentially toxic to the cranial nerves (cochlea) present in the innerear.
AIMTo produce clinical practice guidelines for the rural and remote Clinical Nurse to improve the outcome ofAboriginal paediatric patients with Otitis media.
Picture From: www.gccommune.com/kozy/images
METHODUsing the latest guidelines and protocols from Australia and America regarding thetreatment of AOM and OME, as well as incorporating cultural influences from two majorAboriginal treatment guidelines. Additionally, electronic databases were used as well asmanual searching and interviews to access recent and relevant information required tocreate the recommendations for clinical practice in rural and remote areas of Australia.
Evidence was classified according to the policy document “Recommendations for clinicalpractice guidelines” American Academy of Paediatrics1 as either strong recommendations,recommendations or options depending on the quality of the evidence and thepreponderance and balance of benefit and harm.
RESULTSDiagnosisDiagnosis of AOM can be made with the following are present:
Rapid onset of symptoms
Presence of middle ear effusion (MEE)
Visual signs of middle ear inflammation
Strong RecommendationThe only accurate way to diagnose Acute Otitis Media is a medical history indicatingrapid onset of ear pain (otalgia), followed by inspection of the tympanic membrane with apneumatic otoscope with adequate light power for accurate visual signs of inflammationincluding bulging, redness and limited mobility of the tympanic membrane (1, 2, 3 & 4).
RecommendationA diagnosis for OME can be made using a pneumatic otoscope to visualise fluid behindthe tympanic membrane also OME occurs without the rapid onset of signs and symptomsand without signs of inflammation.
RecommendationA history of ear tugging may be present in small children and used as a diagnostic tool.However, inspection of the tympanic membrane is still required to eliminate the presenceof foreign body or a retracted tympanic membrane indicating reduced air space in theEustachian tube, a negative diagnosis for acute otitis media (2).
RecommendationAs Aboriginal children are especially susceptible to otitis media, it is important to inspectthe ears at regular intervals (approx every 3 months) even when the child appears to bewell (3,4).
Consult with a Doctor before administering treatment if any of the following are present:
Signs for AOM above are negative or unclear
Blood is present in the ear canal
Signs of mastoiditis as evidenced by swelling around and/or behind the ear
Otalgia accompanied by severe dizziness (4).
Oral AntibioticsStrong RecommendationLength of treatment by oral antibiotics should be not less than 7 days (1, 3, 4).
Strong Recommendation for Mild Acute Otitis MediaAmoxicillin 50mg/kg/day in 2 or 3 doses for 7-10 days in populations where there is not a highrate of penicillin resistant pneumoniae (1,3,4).
Amoxicillin 80-90ml/kg/day in 2 or 3 doses for 7-10 days in populations where there is a highrate of penicillin resistant pneumoniae (1,3,4).
Recommendation for Severe Acute Otitis MediaAmoxicillin/clavulanate 90mg/kg/day amoxicillin plus 6.4mg/kg/day clavulanate which iseffective against _-lactamase-positive, Haemophilus influenzae and Moroxella catarrhalis (1).
Option for OME present for more than 3 monthsLow-dose amoxicillin 50mg/kg/day for 10-14 days 5.
Topical TherapyOptionEar cleansing using iodine solution to clear the ear from discharge and allow access to thetympanic membrane plus administration of antibiotic eardrops consisting of 0.2% ciprofloxacin5 drops 2 doses daily for 9 days as this solution is not ototoxic.
Other Treatment MethodsOptionBush medicine regimes may be available for the treatment of pain, fever and ear dischargeand should be explored for their efficiency and possible use for the treatment of ear infections.
Cultural Issues And IncreasedRisk Factors
Passive cigarette smoke in the home
Sharing beds with other children
Poor facial hygiene practices
Lack of access to health care facilities
Methods Of PreventionEncourage routine nose blowing from an early age to clear possiblebacteria from the nasopharynx.
Encourage facial hygiene such as routine face washing, including theexternal ear area.
Encourage mothers to breast feed for as long as possible.
Encourage older children and adults to smoke in well-ventilated areasaway from children.
Encourage parents and guardians to seek medical advice as soon assigns and symptoms arise of earache or hearing impairment.
Encourage administration of the pneumococcal vaccine at therecommended age.
Summary•Guidelines are required for Clinical Nurses working in rural andremote areas of Australia to enable the latest evidence based practiceto occur.
•Guidelines based on the latest evidence may encourage more ClinicalNurses to practice in rural and remote areas.
•Guidelines based on the latest evidence allow Aboriginal people livingin rural and remote communities the opportunity to equal treatment forillness.
AcknowledgementsDiane Chamberlain, Academic Mentor
This work was supported by a SARNet grant, under the auspices of the Flinders University PHC RED program, funded by theAustralian Government Department of Health and Ageing.
References1.Paediatrics Vol. 114 No. 3 September 2004 p874-877
2.American Academy of Pediatrics and American Academy of Family Physicians, 2004 ‘Clinical Practice Guideline: Diagnosis andManagement of Acute Otitis Media’. Pediatrics, Vol 113 no 5, May 2004 p1451-1465.
3.Harrison, CJ, 2004 ‘Pediatric Practice: The new Guideline for managing otitis media’ Patient Care for the Nurse Practitioner:Practical Clinical and Professional Information. August 15, 2004 pp1-15.
4.Office for Aboriginal and Torres Strait Islander Health, 2001 ‘Recommendations for Clinical Care Guidelines on the Management ofOtitis Media (Middle Ear Infection) in Aboriginal and Torres Strait Islander Populations’ March 2001.
5.Central Australian Rural Practitioners Association, 2003 ‘CARPA Standard Treatment Manual 4th Edition’ Central Australian RuralPractitioners Association, Alice Springs, 2003.
OTITIS MEDIADiagnosis and Management of Acute Otitis Media
and Otitis Media with Effusion in Aboriginal children aged 6 months to 18 years in Rural
and Remote Australian Communities
PAINStrong RecommendationUse of pain assessment chart is recommended for assessing the level of discomfortof children presenting with AOM or OME. Children of varying age groups can beassessed using the following diagnostic tool for paediatric pain.
OptionWhen a child is experiencing mild pain paracetamol may be administered in thedoses listed in the Table entitled Paediatric Analgesia Dosages. However, cautionneeds to be taken when administering paracetamol or ibuprofen to a child who isdehydrated, as there is an increased risk for liver toxicity (Joanna Briggs Institute,2001).
No RecommendationUse of complementary or alternative medicines such as herbal eardrops are notrecommended for pain management as their efficacy is yet to be proven.
http://www.ozoutback.com.au/postcards/postcards_forms/abor_kids_portr_1/index.htm
By Allyson Chapple
