pediatric eye and ear problems
TRANSCRIPT
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Pediatric Eye and Ear ProblemsAuthors/Editors: Nettina, Sandra M.; Mills, Elizabeth Jacqueline
Title: Lippincott Manual o Nursin! "ractice, #th Edition$op%ri!ht &'(() Lippincott *illia+s *il-ins
CONDITIONS OF THE EYE
INFECTIOUS PROCESSES
nectious processes o the e%e include conuncti0itis, orbital or periorbital cellulitis, andhordeolu+. The% are characterized b% inla++ation and tissue da+a!e caused b%
+icrobes, such as bacteria, 0iruses, or $hla+%dia tracho+atis. $onuncti0itis is a
co++on proble+, aectin! al+ost all children at so+e ti+e or another.
Pathophysioloy and Etioloy
Microbes are usuall% introduced into the e%e or surroundin! tissues b% direct
contact 1ith inected obects. "eriorbital cellulitis is usuall% associated 1ith
inection in nearb% tissues, such as sinusitis or dental abscess. This initiates an inla++ator% response that includes dilation o blood 0essels,
s1ellin!, antibod% production, and destruction o the oendin! a!ent b% 1hite
blood cells. $o++on bacterial a!ents include Staph%lococcus, Streptococcus pneu+oniae,
and 2ae+ophilus inluenzae. Adeno0irus and, less co++onl%, herpes 0irus +a%
occur.
3ecause the inectin! a!ents are easil% spread ro+ person to person,
conuncti0itis +a% occur in outbrea-s in 1hich se0eral children in the sa+e
a+il%, classroo+, or co++unit% are aected.
Clinical !ani"estationsThese depend on the part o the e%e that is inected. 4edness is characteristic, and +ust
be dierentiated ro+ the red e%e o noninectious processes
Common Causes of Eye Redness in Children
C#USE #SSOCI#TED SY!PTO!S !#N#$E!ENT
Con%&ncti'itis
5iral $o++onl% associated 1ith others%+pto+s o !eneralized 0iral
illness
2%!iene, rest
3acterial 6ello1, !reen, or 1hite dischar!e,
photophobia
Antibiotic e%edrops or oint+ent,
h%!iene$hla+%dial $ou!h, histor% o +aternal
inection
S%ste+ic antibiotic
2erpetic "ain, photophobia, s-in lesions E0aluation b% specialist, anti0irala!ents
Aller!ic tchin!, seasonal onset o Topical +ast cell stabilizer e%edrops,
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s%+pto+s, other aller!ic
s%+pto+s, 1ater% dischar!e
hista+ine78 anta!onist e%edrops,
a0oidance o aller!ens
$he+ical *ater% dischar!e, onset os%+pto+s 1hen e9posed to
ci!arettes or other irritants
A0oidance o irritatin! substances
Tra&ma "ain, photophobia, increased tear
production
E%e patch, reerral to specialist
Conenital
la&comancreased tear production,
cloudiness o cornea
4eerral to specialist
Con%&ncti'itis
4edness o the e%e caused b% dilation o the blood 0essels o the conuncti0a.
E9cessi0e tearin! or e9udate.
"hotophobia.
5ision +a% be cloud% because o e9udate, but is not i+paired.
Orbital or Periorbital Cell&litis
S1ellin! and inla++ation o sot tissues surroundin! the e%e.
Tenderness, pain.
ncreased te+perature o aected areas. 5ision not i+paired.
Hordeol&m (Stye)
"ustule in area o e%elash ollicle.
Tenderness, pain.
Localized s1ellin! and er%the+a.
Dianostic E'al&ation
$ulture o e9udate or bacteria or 0irus or anti!en testin! or Neisseria
!onorrhoeae or $. tracho+atis. ierent +edia are required or cultures o each,
but one s1ab +a% be sent or anti!en testin!. The +ost li-el% a!ents are tested,based on the histor% and ph%sical indin!s.
Screenin! 0ision e9a+ +a% be done; a thorou!h 0isual and ocular e9a+ +a% be
done i 0ision is i+paired or i internal in0ol0e+ent is suspected.
A dendritic ulcer caused b% herpes 0irus can be 0isualized b% instillin! luorescein
d%e and e9a+inin! the cornea 1ith a cobalt7iltered blue li!ht.
NURSIN$ #*ERT
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A child 1ho has a painul red e%e should be reerred i++ediatel% or +edical e0aluation
because this +a% indicate herpetic inection or da+a!e to the cornea.
!anaement
Antibiotic e%edrops or oint+ent, such as er%thro+%cin, tri+ethopri+ sulate and
pol%+%9in 3, sulaceta+ide, ciprolo9acin, or tobra+%cin, 1ill shorten the courseo bacterial conuncti0itis and 1ill +a-e the child +ore co+ortable.
S%ste+ic antibiotic treat+ent is indicated or orbital cellulitis. These children +a%
be ad+itted to the hospital or close obser0ation and a!!ressi0e +ana!e+ent.
A hordeolu+ 1ill usuall% resol0e 1ithout antibiotic treat+ent. *ar+ co+presses
are reco++ended, and incision and draina!e +a% be necessar%.
Complications
"er+anent scarrin! o the cornea and 0isual i+pair+ent 1ith herpetic inection.
Spread o orbital cellulitis to the central ner0ous s%ste+.
N&rsin #ssessment Assess nature and e9tent o s%+pto+s and their eect on childs acti0ities.
Assess 0isual acuit%.
eter+ine resources a0ailable to a+il% or treat+ent.
N&rsin Dianoses
4is- or nection
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o o not share 1ashcloths or to1els.
o A0oid s1i++in! until inection is resol0ed.
o The child can return to school ater ha0in! recei0ed antibiotic treat+ent
or 'B hours.
o ispose o conta+inated ite+s in proper receptacles.
#d'ise parents o" indications "or ree'al&ation by health care pro'ider+o Lac- o response to antibiotic treat+ent.
o ncrease in s1ellin! and tenderness.
o E%e pain.
o *orsenin! o 0isual acuit%.
o e0elop+ent o additional s%+pto+s such as e0er.
Encoura!e routine ollo17up 0isits.
E'al&ation. E/pected O&tcomes
"arents peror+ treat+ent correctl%; h%!iene procedures ollo1ed
"atient 0erbalizes less pain; tolerates bri!ht li!ht
CON$ENIT#* PRO0*E!S
$on!enital proble+s o the e%e include structural deects present at birth or de0elopin!soon thereater. These are usuall% !eneticall% trans+itted. The% include cataract,
dacr%ostenosis, !lauco+a, ptosis, and strabis+us.
Conenital Eye Problems
CONDITION #NDDESCRIPTION
C*INIC#*!#NIFEST#TIONS
!#N#$E!ENT
Conenital Cataract
?pacit% o the lens.
"ossible causes include
abnor+al e+br%onicde0elop+ent, inection
durin! pre!nanc%,
disturbance ocarboh%drate +etabolis+,
+etabolic disorders,retinopath% o pre+aturit%.
ncidence is 8 in '@(neonates.
Absence o red
rele9
5isible cloudin!
o lens
5ar%in!
i+pair+ent o
0ision, dependin!
on size, location,and densit% o
cataract
Ma% result in
a+bl%opia
Sur!ical re+o0al 1ith lens
i+plantation 1ithin irst
+onths to correct 0ision.
"ostoperati0e care:
sedation or irst 'B hours
to pre0ent cr%in!,
0o+itin!, and increasedintraocular pressure
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1hich pre0ents both e%es
ro+ ocusin! correctl% on
the sa+e i+a!e. ?ccurs inD o the population.
As%++etric
e9traocular
+o0e+ents iplopia, i+paired
depth
Tendenc% to closeone e%e or tilt head
durin! 0ision
testin!
A+bl%opia +a%
result 1ithouttreat+ent
strabis+us b% e9ercisin!
the +uscles o the 1ea-er
e%e.
Sur!ical repositionin! o
the e9traocular +uscles or
se0ere or i9ed cases.
"ostoperati0el%: antibiotic
oint+ent, no e%e patch.
N&rsin #ssessment
Assess or red li!ht rele9, especiall% in neonates. Absence or as%++etr% o the
red li!ht rele9 +a% indicate con!enital cataract or an intraocular tu+or.
nspect the e%es or redness o conuncti0a, cloudiness o the cornea, e9cessi0etearin!, e%elids that partiall% occlude the pupil, or ob0ious +isali!n+ent, 1hichpro0ide clues to con!enital e%e proble+s.
Assess 0isual acuit% routinel% in inants and children. $han!es in acuit% +a% be
the irst +aniestation o a proble+ or indication o eecti0eness o treat+ent.
"eror+ 2irschber!s test or s%++etr% o the pupillar% li!ht rele9es to help
detect strabis+us. Nor+all%, the li!ht rele9es are in the sa+e position in each
pupil 1hen a li!ht is shone on the brid!e o the nose, but as%++etrical relection
1ill occur 1ith strabis+us
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o All children should be screened or 0isual acuit% and strabis+us. n %oun!
children, this is acco+plished b% ph%sical e9a+ination and assess+ent o
de0elop+ental +ilestones
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Teach about acti0it% restrictions ater !lauco+a sur!er%.
o 3ed rest +a% be required i++ediatel% postoperati0el%.
o ?lder children should not en!a!e in strenuous acti0it% or contact sports or
' 1ee-s.
Ad0ise that acti0it% is not usuall% restricted or sur!er% or strabis+us or ptosis.
Ater cataract sur!er%, encoura!e beha0iors to reduce the ris- o da+a!e tosutures ro+ increased intraocular pressure
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Blunt %rauma
This occurs 1hen the e%e or surroundin! tissues are struc- b% a blunt obect such
as a ball. The resultin! inur% includes tissue s1ellin! and seepa!e o blood into the
surroundin! tissues.
The bon% structures surroundin! the e%e +a% be ractured. The lens +a% beco+e dislod!ed or the retina +a% separate ro+ the bac- o the
e%e.
Perforating Inury
*hen an obect penetrates the e%eball, there +a% be loss o 0itreous +aterial
and/or da+a!e to the internal structures o the e%e.
3acteria +a% also be introduced into the interior o the e%e, causin! inection.
Chemical Inuries
$orrosi0e che+icals burn the delicate tissues o the cornea and +a% penetrate into
deeper la%ers o the e%e. 2ealin! +a% occur 1ith scarrin!.
Clinical !ani"estations
"ainGbecause the delicate tissues o the e%e contain +an% ner0e endin!s.
ncreased tear productionGone o the e%es deenses a!ainst inur% or irritation.
nection o the blood 0essels o the corneaGincrease o blood lo1 to the cornea
is another protecti0e +echanis+; +ost li-el% to be seen 1ith orei!n bodies,
abrasions, or che+ical burns that aect the cornea.
Impaired 'is&al ac&ity ca&sed by+
o S1ellin! o the cornea, reducin! its clarit%.
o S1ellin! o the sot tissues surroundin! the e%e, causin! the e%e topartiall% or co+pletel% close.
o E9cessi0e tear production, i+pairin! 0ision.
o a+a!e to internal structures o the e%e, alterin! or obstructin! 0isual
path1a%s.
5isible si!ns o inur%Gbruisin!, s1ellin!, or a orei!n obect 0isible in the e%e.
NURSIN$ #*ERT
At ti+es, pain +a% be useul in distin!uishin! a serious e%e proble+ ro+ a sel7li+itin!
condition.
Dianostic E'al&ation Thorou!h inspection o the e%e, includin! e0ersion o the upper lid to inspect or
a orei!n obect.
Hunduscopic e9a+ination +a% detect abnor+alities, such as a dislod!ed lens,
retinal he+orrha!e, retinal detach+ent, or papillede+a 1ith increased ?".
Stainin! 1ith luorescein d%e 1ill re0eal lesions o the cornea such as abrasions.
Assess+ent o e%e unction, includin! near and ar acuit%, e9traocular
+o0e+ents, and 0isual ield testin!.
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!anaement
Most childhood inuries are not se0ere and 1ill resol0e spontaneousl% 1ith no ad0erse
lon!7ter+ consequences. t is i+portant, ho1e0er, to identi% and obtain pro+pttreat+ent or si!niicant inuries.
Corneal 'brasion the abrasion 1as caused b% a contact lens or orei!n bod%, re+o0al o the
oendin! bod% is indicated.
"atchin! o the aected e%e, usuall% or 'B hours, 1ill control pain.
Antibiotic e%edrops or oint+ent pre0ent inection.
Blunt %rauma
Application o cold co+presses +a% help control pain and s1ellin!.
The head should be ele0ated ( de!rees to a0oid increased ?".
Sur!er% +a% be required because o da+a!e to underl%in! bones or e%e
structures.
Perforating Inury
Sur!er% is usuall% necessar% to re+o0e the obect and reconstruct da+a!ed
tissues.
NURSIN$ #*ERT
Ne0er re+o0e a penetratin! obect ro+ the e%e. t should be stabilized and the e%e
should be shielded 1ith no pressure applied. The other e%e should be patched and the
patient transported b% stretcher. The head should be ele0ated ( de!rees to a0oidincreased ?", and the child should be -ept on nothin!7b%7+outh orders in preparation
or sur!er%.
Chemical Inuries
Fentle lushin! o the aected e%es 1ith 1ater 1ill help re+o0e the oendin!
che+ical. This should be done ro+ the inner aspect o e%e to the outer to pre0ent
conta+inated 1ater ro+ lo1in! into the other e%e.
Antibiotics +a% be prescribed to pre0ent inection.
Hurther +ana!e+ent depends on the nature and e9tent o the inur%.
Complications
nection.
E9tensi0e tissue da+a!e +a% result in per+anent 0ision i+pair+ent.
isi!ure+ent +a% result ro+ se0ere or e9tensi0e tissue da+a!e.
N&rsin #ssessment
?btain histor% o inur%, includin! the childs account o ho1 the inur% occurred,
and a description o s%+pto+s e9perienced.
nspect or location and e9tent o s1ellin! and bruisin!, as%++etr%, or
abnor+alit% in appearance o an% part o the e%e.
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Assess 0isual acuit% and co+pare 1ith baseline. This should include near and ar
acuit% in each e%e. the patient cannot see 1ell enou!h to read a Snellen chart,
assess abilit% to count in!ers or percei0e li!ht.
N&rsin Dianoses
Acute "ain related to inla++ation, photophobia, or trau+a to e%e tissue 4is- or nur% related to i+paired 0ision and ad0erse eects o pain +edications
Heedin!, ressin!, and Froo+in! Sel7$are eicit related to i+paired 0ision and
ad0erse eects o pain +edications
N&rsin Inter'entions
Minimizing Pain
Appl% cold co+presses to the aected area to help reduce s1ellin! and
disco+ort.
Ieep the childs roo+ as dar- as possible to help reduce pain or photophobic
patients.
Ad+inister or teach parents to ad+inister anal!esics as prescribed.
Preventing Inury
En"orce sa"ety meas&res+
o >se o bed side rails.
o Assistance 1ith a+bulation.
o $lose obser0ation.
Maintaining 'DLs
"ro0ide assistance 1ith eatin!, bathin!, toiletin!, and other ALs, as needed.
Teach child location o sel7care ite+s and positionin! o ood on tra% to pro+ote
independence. Encoura!e child to atte+pt sel7care, and oer praise e0en i unsuccessul.
Family Ed&cation and Health !aintenance
Teach indications "or ree'al&ation by health care pro'ider+
o ncrease in s1ellin!, tenderness, discoloration, or pain.
o *orsenin! o 0isual acuit%.
o e0elop+ent o additional s%+pto+s, such as e0er, alteration in
sensoriu+, or other indications o neurolo!ic inur%.
"ro0ide saet% education to all a+ilies to pre0ent co++on causes o inur%. n
particular, encoura!e a+ilies to use protecti0e e%e1ear 1hen participatin! in
sports acti0ities. "ro0ide a+ilies 1ith inor+ation and support as the% cope 1ith ha0in! a 0isuall%
i+paired child in the ho+e. The A+erican Acade+% o ?phthal+olo!% has
patient inor+ation and a list o helpul resources at its *eb site,
http://111.aao.or!/aao/ne1s/e%enet/.
E'al&ation. E/pected O&tcomes
e+onstrates decreased pain
https://remote.smh.ca/aao/news/eyenet/,DanaInfo=www.aao.org+https://remote.smh.ca/aao/news/eyenet/,DanaInfo=www.aao.org+https://remote.smh.ca/aao/news/eyenet/,DanaInfo=www.aao.org+ -
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No inuries reported
ressin! and eedin! sel 1ith +ini+al assistance
H>N$T?NAL "4?3LEMS
Hunctional proble+s o the e%e in0ol0e i+pair+ent o the 0ision because o reracti0e
errors or disuse o 0isual path1a%s. Such proble+s requentl% result in a+bl%opiaGi+paired 0ision in one or both e%es due to poor 0isual sti+ulation rather than an or!anic
proble+. Abnor+al 0ision screenin! 1ith reerral occurs in 8.'D o @7%ear7old patientsand increases to C.8D b% the ti+e the child reaches a!e 8. A+bl%opia aects 8D to D
o the population.
Pathophysioloy and Etioloy
Refractive errors are usually caused by a genetic $redis$osition to shortened or
elongated eyeballs or by individual variations in gro#th(
o n an elon!ated or shortened e%eball, the 0isual i+a!e is ocused either in
ront o or behind the retina, resultin! in unclear i+a!es.
o The nearsi!hted
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Standardi1ed 'ision screenin tests2 s&ch as the Snellen chart2 the Titm&s
machine2 or the H.O.T.3 matchin symbol test2 may be &sed "or distance
ac&ity screenin+
o Tests can be ad+inistered to children as %oun! as a!e .
o Each e%e should be tested separatel%.
Near 0ision +a% be tested b% ha0in! the child read or b% standardized 0isionscreenin! tests such as the Tit+us +achine. Each e%e should be tested separatel%.
Muscle balance can be tested usin! the cross co0er test and the Tit+us +achine.
!anaement
Most 0isual acuit% proble+s can be treated b% the use o correcti0e lenses or
reracti0e sur!er%. #mblyopia manaement "oc&ses on pre'ention thro&h early identi"ication
and treatment o" conditions that ca&se it+
o Strabis+us is treated 1ith !lasses and patchin! o the stron!er e%e. n
so+e cases, ho1e0er, sur!er% +a% be required.
o A ne1 phar+acolo!ic treat+ent, puriied botulis+ to9in, is beco+in!a0ailable or strabis+us but is not in 1idespread use. 3otulis+ to9in1or-s b% bloc-in! acet%lcholine release ro+ ner0e endin!s in the +uscle
that is contractin! e9cessi0el%.
o Sur!er% +a% also be required to correct ptosis.
o Acuit% proble+s due to reracti0e error are usuall% +ana!ed 1ith the use
o correcti0e lenses.
?pti+al outco+e is acco+plished 1hen treat+ent is be!un earl% in lie, 1hile
0isual path1a%s are still de0elopin!. 2o1e0er, so+e 0isual unction +a% bereco0ered e0en i the proble+ is treated in adolescence or adulthood. deall%, the
proble+ can be pre0ented b% earl% identiication and treat+ent o actors that +a%
cause it.
Complications
nuries caused b% 0isual i+pair+ent.
N&rsin #ssessment
3e!in 0isual acuit% screenin! earl%, in the preschool %ears, and 1hene0er a child
displa%s beha0iors su!!esti0e o acuit% proble+s.
Assess 2irschber!s test or s%++etr% o the pupillar% li!ht rele9es routinel%,
be!innin! at birth. "eror+ the cross co0er test as part o routine e%e assess+ent as soon as the child
can cooperate
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$hronic Lo1 Sel7Estee+ related to lo1ered peror+ance caused b% poor 0ision
N&rsin Inter'entions
Minimizing Effects of ,ensory Deficits
Encoura!e the consistent use o correcti0e lenses as prescribed.
Teach the parents -ays to help de'elop the child4s s5ills in interpretinin"ormation thro&h the senses o" hearin2 smell2 and to&ch+
o Ha+iliarize the child 1ith co++on sounds and s+ells in the en0iron+ent.
Also, orient the child to traic sounds and sounds associated 1ith dan!er,
such as ani+als and speedin! 0ehicles, and instruct the child ho1 to
respond.
o >se 0oice or touch, rather than acial e9pressions or !estures, to e9press
e+otion.
o Spea- to the child beore touchin! to reduce startlin!.
o Allo1 the child to touch and handle una+iliar obects to learn about
the+.
o 2a0e the child practice such thin!s as retellin! stories and !i0in! the ho+etelephone nu+ber and address.
o E9plain una+iliar sounds and s+ells to the hospitalized child.
Preventing Inury
4eco++end the use o shatterproo e%e!lasses 1ith le9ible ra+es.
4eco++end the use o e%e protection on a routine basis because e%e trau+a can
occur une9pectedl%. This is especiall% i+portant or children 1ho rel% on onl%
one e%e.
Su!!est e9tra protection, such as shatterproo !o!!les or shields, 1hen
participatin! in contact or ball sports and acti0ities.
Maintain a stable arran!e+ent o urniture in the ho+e, adequate li!htin!, and anuncluttered en0iron+ent to +ini+ize alls.
?rient hospitalized children to the hospital roo+ and oer assistance 1hen
1al-in!.
Promoting a Positive ,ense of ,elf-Esteem
"ro0ide opportunities or +aster% o de0elop+entall% appropriate acti0ities.
Encoura!e interactions 1ith si!hted children to decrease eelin!s o isolation.
Also, su!!est interactions 1ith children 1ith si+ilar alterations in 0ision.
Encoura!e the child to discuss eelin!s and strate!ies or copin! 1ith ne!ati0e
peer reactions such as teasin!.
Encoura!e independence in sel7care acti0ities to pro+ote autono+%, such asdressin!, eedin!, and use o bathroo+.
Assist the patient and a+il% 1ith eecti0e copin! +echanis+s to pro+ote a+il%
stabilit%
Comm&nity and Home Care Considerations
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"eror+ a saet% inspection o the ho+e en0iron+ent and +a-e chan!es as
necessar% to help pre0ent alls and other inuries.
Assist a+il% access to inancial and social resources as needed.
Ma-e sure that the child is recei0in! specialized educational resources as needed.
Family Ed&cation and Health !aintenance Teach the i+portance o 1earin! correcti0e lenses as prescribed, and their proper
care.
4eer a+ilies o blind children to co++unit% resources that can help their child
learn special s-ills, such as readin! 3raille, usin! a cane, or de0elopin! sel7care
s-ills. nor+ation can be obtained ro+ a!encies such as the A+erican
Houndation or the 3lind, http://111.ab.or!.
E'al&ation. E/pected O&tcomes
dentiies co++on sounds
No inur% reported; 1ears protecti0e e%e!lasses
4eports !ood school peror+ance and participation in e9tracurricular acti0ities;can eat and dress independentl%
CONDITIONS OF THE E#R
EUST#CHI#N TU0E DYSFUNCTION
Eustachian tube d%sunction
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allo- the passae o" in"ected nasal secretions into the middle ear ca'ity+ Ris5
"actors incl&de+
o More requent episodes o upper respirator% inections in %oun!er
children.
o Nasal aller!ies.
o FeneticsGin so+e a+ilies, childrens eustachian tubes tend to be lopp%and to close easil%.
o Nati0e A+erican or Es-i+o herita!e.
o $ranioacial abnor+alities.
o o1n s%ndro+e.
o Lo1er socioecono+ic status.
o E9posure to ci!arette s+o-e.
!ost common bacterial aents incl&de+
o S. pneu+oniae.
o 2ae+ophilus inluenzae.
o Mora9ella catarrhalis.
3arotrau+a, caused b% rapid chan!es in at+ospheric pressure, +a% also lead toclosure o the eustachian tube and to de0elop+ent o serous otitis. This is lessli-el% to in0ol0e introduction o +icroor!anis+s throu!h inected nasal
secretions; de0elop+ent o A?M is less co++on.
Clinical !ani"estations
ecreased hearin!Gte+porar% conducti0e hearin! loss; usuall% resol0es 1hen
t%+panic +e+brane +obilit% is restored.
Sensation o ullness in the aected ears.
"oppin! sensations in the aected ears +a% be e9perienced as the eustachian tube
be!ins to open and ad+it air into the +iddle ear ca0it%.
Ear pain. Si!ns o inectionGe0er, irritabilit%, or decreased appetite.
Dianostic E'al&ation
Otoscopic e/amination+
o ?MEG%ello1ish eusion, pro+inent bon% land+ar-s, a diuse li!ht
rele9, and decreased +obilit% o t%+panic +e+brane.
o A?MGinla+ed t%+panic +e+brane 1ith decreased or absent +obilit%;
bul!in! o the t%+panic +e+brane +a% obscure the bon% land+ar-s and
li!ht rele9.
T%+pano+etr%Gquic- and si+ple 1a% to assess t%+panic +e+brane +obilit%
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(A) Type A tympanogram: This is the normal pattern showing mobility of the tympanic
membrane with a peak mobility at the 0 point (the point at which there is neither positivenor negative pressure in the external ear canal). (B) Type B tympanogram: This patternshows a low level of mobility with no peak. t is characteristic of impaire! mobility !ue to
the presence of flui! in the mi!!le ear. (") Type " tympanogram: This pattern shows a
!istinct peak in the mobility level of the tympanic membrane# but the peak occurs whenthere is negative pressure in the external ear canal. This in!icates eustachian tube
!ysfunction causing negative pressure in the mi!!le ear cavity. $egative pressure in the
external ear canal e%uali&es pressure on both si!es of the tympanic membrane an! allowsfor maximum mobility.
o A probe occludes the ear canal 1hile pressure is 0aried and a test sound is
e+itted. The test produces a !raphic displa% that sho1s the +obilit% o the
t%+panic +e+brane at 0arious air pressures.o A nor+al readin! has a distinct pea- in the +iddle o the !raph
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o A probe held at the openin! o the ear canal +easures relected sound
1a0es ro+ the +iddle ear.
o 4eduction in relected sound is an indication o +iddle ear eusion.
!anaement
&titis Media #ith Effusion >suall% resol0es spontaneousl%.
Treat+ent o underl%in! predisposin! actors
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o Ad0erse eects.
Ad+inister aceta+inophen as directed or pain or e0er.
Appl% 1ar+ co+presses to the e9ternal ear.
Ad+inister anal!esic otic drops, i prescribed; usuall% indicated 1hen no
peroration o the t%+panic +e+brane e9ists.
Ad0ise ele0ation o head to acilitate draina!e o luid ro+ the +iddle ear intothe phar%n9.
Teach older children to sti+ulate openin! o their eustachian tubes b% %a1nin! or
peror+in! 5alsal0as +aneu0er.
Minimizing 0earing Loss
Teach parents to reco!nize earl% si!ns o otitis and to see- pro+pt treat+ent.
"ro0ide preoperati0e and postoperati0e teachin! i 0entilation tubes are indicated
sin! speciall% desi!ned bottles to allo1 upri!ht eedin!.
o denti%in! and eli+inatin! aller!ens, such as particular oods, +olds, anddust.
o Not e9posin! the child to ci!arette s+o-e.
Teach the i+portance o ta-in! antibiotic at prescribed ti+es or the indicated
len!th o therap% to pre0ent partial treat+ent and the de0elop+ent o resistance.
Teach all parents the dierence bet1een 0iral and bacterial inections and that
o0eruse o antibiotics or 0iral inections contributes to the de0elop+ent o
resistant bacteria. Encoura!e all parents to consult 1ith health care pro0ider
beore startin! antibiotic therap% or presu+ed inection.
I" 'entilatin t&bes are placed2 instr&ct parents to do the "ollo-in+
o "re0ent 1ater or other luids ro+ enterin! the ear canal. Encoura!e use o
earplu!s 1hen the child is bathin! or s1i++in!.o iscoura!e instillation o eardrops or other +edications in the e9ternal ear
unless the% ha0e been prescribed b% the health care pro0ider.
o Tubes 1ill all out o the ear spontaneousl%, usuall% in ) to 8' +onths.
Enco&rae "amilies to disc&ss herbal therapy -ith health care pro'ider i"
interested+
o Echinacea is used b% so+e to enhance i++une unction.
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o Eardrops 1ith +ullein, St. Johns 1ort, and !arlic are a0ailable to alle0iate
pressure in the +iddle ear durin! acute ear inections.
o Folden seal is said to ha0e anti+icrobial acti0it%. 2i!h a+ounts +a%
cause F disco+ort and possibl% ner0ous s%ste+ eects.
E'al&ation. E/pected O&tcomes e+onstrates i+pro0ed co+ort; a+il% states proper treat+ent re!i+en
Maintains ollo17up 0isits; eusion resol0ed
Speech and lan!ua!e de0elop+ent appropriate or a!e; reports re!ular
assess+ent; recei0es therap% ro+ specialist, i indicated
E?TERN#* OTITIS
E9ternal otitis is inla++ation in the e9ternal ear canal. t is requentl% unilateral but +a%
be bilateral.
Pathophysioloy and Etioloy
Ca&sed by bacteria or "&ni+ Common pathoens incl&de+o "seudo+onas aeru!inosa.
o Enterobacter aero!enes.
o "roteus +irabilis.
o Staph%lococcus epider+idis.
o Hun!i
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$ultures usuall% not necessar%.
!anaement
Acetic acid solution
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Hunctional hearin! disorders arise ro+ proble+s in the unction o the ear. n a quiet
en0iron+ent, the health% child can hear tones bet1een ( and '@ decibels. $ate!ories o
hearin! i+pair+ent include sli!ht, 8@ to '@ decibels; +ild, '@ to B( decibels; +oderate,B( to )@ decibels; se0ere, )@ to C@ decibels; and proound, C@ or +ore decibels. n the
>nited States, appro9i+atel% @,((( inants are born 1ith +oderate to proound bilateral
sensorineural hearin! loss each %ear. Hactors that place an inant at hi!h ris- or hearin!loss include lo1 birth 1ei!ht, a+il% histor% o hereditar% childhood hearin! loss, and
certain inections, such as rubella or bacterial +enin!itis.
Pathophysioloy and Etioloy
2earin! loss +a% be conducti0e or sensorineural.
Cond&cti'e loss occ&rs -hen so&nd transmission thro&h the o&ter and>or
middle ear is impaired2 ca&sed by impaction o" cer&men in the e/ternal ear
canal2 "l&id in the middle ear ca'ity2 or scarrin o" the tympanic membrane+
o A +echanical obstruction, such as ceru+en or a orei!n obect bloc-in!
the e9ternal ear canal, +a% bloc- the passa!e o sound 1a0es to the
t%+panic +e+brane.o *ith otitis +edia or ?ME, luid in the +iddle ear ca0it% does not trans+it
sound as 1ell as air.
o A scarred or perorated t%+panic +e+brane has lost its nor+al +obilit%
and does not trans+it sound as 1ell as a nor+al one.
o Most cases o conducti0e hearin! loss in children are re0ersible and
produce no per+anent eect.
Sensorine&ral hearin loss res<s "rom damae to the cochlea or a&ditory
ner'e and conenital de"ects o" the cochlea+ E/amples incl&de damae ca&sed
by ototo/ic dr&s2 damae res<in "rom prenatal in"ections2 and damae
ca&sed by proloned e/pos&re to lo&d noise+
o a+a!e to the auditor% ner0e pre0ents trans+ission o sound i+pulses tothe brain or interpretation.
o a+a!e to hair cells o the cochlea +a% be caused b% prolon!ed e9posure
to loud noise, resultin! in hearin! loss, especiall% pronounced or hi!h7
pitched sounds.o Sensorineural proble+s are usuall% irre0ersible.
Clinical !ani"estations
nants +a% be noted to be unresponsi0e to sound. 4esponse to sound, ho1e0er, is
not suicientl% reliable as a screenin! +ethod, especiall% or hi!h7ris- inants.
Children &s&ally do not complain that they cannot hear -ell+ They may
e/hibit other sins o" hearin problems2 incl&din+o "oor acade+ic peror+ance or beha0ior proble+s in school.
o Lac- o response to sounds.
o ela%ed lan!ua!e de0elop+ent.
o Listenin! to the tele0ision or radio at a loud 0olu+e.
o Spea-in! loudl%.
Dianostic E'al&ation
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$hronic Lo1 Sel7Estee+ related to social and acade+ic diiculties
N&rsin Inter'entions
Minimizing Effects of 0earing Loss
Hace the child, use appropriate acial e9pressions, and +a-e sure the child can see
%our ace clearl% 1hen co++unicatin!. Approach the child so that %ou can be seen; touch the dea child on the shoulder
to !et attention.
Assist the child in utilizin! hearin! aid as prescribed.
Promoting Effective Communication
eter+ine usual +ethod o co++unication: abilit% to 1rite, usin! 0erbal cues, or
readin! lips. o not depend on !estures to co++unicate 1ith child or 1ith a thirdpart% 1ho does not -no1 si!n lan!ua!e.
?btain an interpreter, 1hen necessar%, or children 1ho co++unicate usin! si!n
lan!ua!e. Adequate co++unication is especiall% i+portant 1hen pro0idin! health
education or 1hen treatin! children 1ho +a% ha0e been abused. Help the parents o" a yo&n child to stim&late and comm&nicate -ith him or
her+
o Teach the+ to use !estures, +i+e, and non0erbal co++unication.
o Teach the+ to help the inant to de0elop 1atchin! beha0ior b% re1ardin!
hi+ 1ith pleasure and praise.
o Teach the+ to tal- to the child 1hile loo-in! directl% into his e%es and
usin! appropriate acial e9pressions.
Preventing Inury
Ad0ise parents that ho+e saet% de0ices, such as s+o-e detectors, +a% require
0isual or tactile alar+s
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Family Ed&cation and Health !aintenance
Encoura!e a+ilies to learn si!n lan!ua!e and alternati0e +ethods o
co++unication 1ith the child. Ad0ise on proper hearin! aid cleanin! and +aintenance.
Encoura!e attention to health +aintenance needs, such as i++unizations and
1ell7child 0isits. Hor additional support and inor+ation, reer to a!encies such as the A+erican
Speech72earin! Association, http://111.asha.or!.
E'al&ation. E/pected O&tcomes
4esponds appropriatel% to en0iron+ental sti+uli
$o++unicates eecti0el% throu!h si!n lan!ua!e, interpreter, and 0isual cues
4eports no inuries
4eports adequate pro!ress in school and participation in e9tracurricular acti0ities
,ELEC%ED RE1ERE!CE,
Al1ard, *.L.M.
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Marc%, F., et al.