DISORDERS OF

MIDDLE EAR
Prepared by ;
Malika Hirachan
Roll no. 12
Contents : • Introduction to Anatomy of Middle Ear

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 General Objectives :

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 Specific Objectives :

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 INTRODUCTION
Middle Ear (Tympanic Cavity):
o Middle ear is small, air filled cavity in temporal
bone
o It is lined by epithelium and is separated from
external ear by ear drum.
o It is separated from internal ear by oval window.
o The eardrum lies between the middle ear and outer
ear .

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• The structures of middle ear are;
• Auditory ossicles
• Oval window
• Eustachian tube

 Ossicles
• Three small bones that are connected and transmit the sound waves to the inner ear.
• The bones are called:
• Malleus; connects tympanic membrane to incus.
• Incus; connects malleus and stapes.
• Stapes; connects incus to oval window

 Oval window
• It is a membrane covered opening that leads from the middle ear to the vestibule of the inner ear and is
directly contacted by stapes .

 Eustachian tube
• A canal that links the middle ear with the back of the nose. The eustachian tube helps to equalize the
pressure in the middle ear. Equalized pressurePresentation
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is needed
title
for the proper transfer of sound waves. 6The
eustachian tube is lined with mucous, just like the inside of the nose and throat.
 Functions of Middle Ear
• The main function of the middle ear is to carry sound waves from the outer ear to the
inner ear, which contains the cochlea and where sound input can be communicated to
the brain. Sound waves are funneled into the outer ear and strike the tympanic
membrane, causing it to vibrate.
• These vibrations are carried through the three ossicles, and the stapes strike the oval
window, which separates the middle ear from the inner ear. When the oval window is
hit, it causes waves in the fluid inside the inner ear and sets into motion a chain of
events leading to the interpretation of sound as we know it.

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 Problems of the Middle Ear
Click icon to add picture

👂 Ear Infection (Otitis Media )

 Acute Otitis Media
 Otitis Media with Effusion
 Acute Necrotizing Otitis Media
 Chronic Suppurative Otitis Media
👂 Mastoiditis
OTITIS MEDIA
• “Otitis" means inflammation of the ear, and "media" means middle.
• Otitis media is a build-up of fluid in the middle ear, which is the space
between the eardrum and the inner ear.
• Usually, the middle ear is filled with air, but sometimes it gets filled with
fluid or mucus, for example during a cold. If the mucus gets infected
with bacteria it causes an ear infection.
• This inflammation often begins with infections that cause sore throats,
colds or other respiratory problems, and spreads to the middle ear.
• Infections can be caused by viruses or bacteria, and can be acute or
chronic.

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DEFINITION
Otitis media is an inflammation of the middle ear cleft i.e. the
Eustachian tube, middle ear cavity, mastoid antrum, mastoid air cells,
attic and aditus.
Inflammation of the middle ear characterized by the accumulation of
infected fluid in the middle ear, bulging of the eardrum, pain in the ear
and, if eardrum is perforated, drainage of purulent material (pus) into
the ear canal.

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INCIDENCE AND PREVALENCE
Although otitis media incidence and prevalence estimates from around the
world vary widely, it is clear that otitis media is a very common childhood
disease. It is especially prevalent in children younger than 2 years of age.
Approximately 80% of all children will experience a case of otitis media
during their lifetime .
In the Nepalese context, approximately 16% of the population above the age
of 5 years suffers from otitis media. More than 55% of these cases occur in
school going children, most of them belonging to the lower socio-economic
class .

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CLASSIFICATION OF OTITIS MEDIA
Otitis Media is a broad subject which could be classified into :
1. According to duration
a. Acute otitis media: up to 3 weeks
b. Subacute otitis media: 3 weeks-3 months
c. Chronic otitis media: >3 months
2. Nature of fluid/discharge
a. Otitis media with effusion
b. Otitis media without effusion
3. Causative organism
b. Bacterial otitis media (most common)
b. Tubercular otitis media
c. Syphilitic otitis media (less common)
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We are going to discuss the most common classification of otitis media :
1. Acute suppurative otitis media (ASOM)
2. Otitis media with effusion (OME)
3. Chronic suppurative otitis media (CSOM)

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🎐 ACUTE SUPPURATIVE OTITIS MEDIA

Acute Suppurative Otitis Media is a common bacterial infection affecting mucosa

of middle ear. Here, middle ear implies middle ear cleft i.e. eustachian tube,
middle ear attic, aditus, and mastoid ear cells.

It usually follows acute upper respiratory tract infection .

It is a common disorder occurring at all age and particularly in children because
their Eustachian tubes are shorter, wider and more horizontal than adult which
makes the organism pass easily.

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ETIOLOGY
 Most common organism in infants and young children are ;
- Streptococcus pneumoniae
- Hemophilus influenza
 Other organism include
- Streptococcus pyogenes
- Streptococcus aureus
- Pseudomonas aeruginosa
 It is usually followed by viral and bacterial upper respiratory tract infection.
 In adult, staphylococcus aureus, -hemolytic streptococcus pneumoniae is more
common.

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PREDESPOSING FACTORS
• Age;
- More common between the age of 3-7 years.
• Recurrent attacks of common cold, upper respiratory tract infection
• Tonsillitis and adenoids
• Chronic rhinitis and sinusitis.
• Nasal allergy.
• Tumors of nose and nasopharynx
• Nasal packing for epistaxis
• Cleft palate
• Poor socioeconomic status (due to poor sanitation and hygiene)
• Swimming and diving in contaminated water
• While feeding from bottle to infants in supine position, contaminated milk may enter the Eustachian
tube
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PATHOPHYSIOLOGY
Inflammation of Eustachian Tube

Edema, congestion and occlusion of the tube and airc ells in the middle ear

Exudates collects in the middle ear and becomes purulent

Tympanic membrane stretches, bulges and rupture because of pressure

Pus is discharged into external auditory canal

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CLINICAL FEATURES
Depends on the stage and age of patients.
• In children
• Pulling at ear
• Excessive crying
On Examination :
• High fever (1020 – 1030F ) and restless • Red, congested, bulged
• Vomiting and convulsion tympanic membrane
• Child feels better after ear discharge and fever comes • Discharge from ear
• Fever
• Conductive hearing loss
• In adult
• Clinical features of upper respiratory tract infection.
• Initially there is no fever
• Ear ache and deafness
• Ear ache becomes excruciating and disturbs in sleeping
• Tinnitus
• Ear discharge
• Pain is relieved after ear discharge
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DIAGNOSTIC EVALUATION
History taking; history of upper respiratory tract infection and trauma to the ear.
Observing clinical features
Otoscopy reveals congestion, redness and bulging of the ear drum.
Tuning fork test
Audiometry shows conductive deafness.
Pus for culture and sensitivity

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MANAGEMENT :
• Medical Management ;
i. Antibacterial therapy
• It should be started as soon as possible.
• Drugs effective in acute otitis media are ampicillin and amoxicillin for a minimum of 10 days, till
tympanic membrane regains normal appearance and hearing turns to normal.
ii. Decongestant nasal drops;
• Ephedrine nose drop or oxymetazoline (Navision) should be used to relieve eustachian tube edema and
promote ventilation of middle ear.
iii. Oral nasal decongestant and antihistaminic may be used.
iv. Analgesics and antipyretics.
• Paracetamol helps to relive pain and bring down temperature.
v. Ear toilet
• If there is discharge in the ear, it is dry mopped with sterile cotton buds and a wick moistened with
antibiotic may be inserted.
v. Dry local heat
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• It helps to relieve pain.
 • Surgical Management ;
Myringotomy may be rarely done (incision made in tympanic membrane to relieve
pressure caused by excessive build up of fluid or to drain pus from the middle ear).

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🎐 OTITIS MEDIA WITH EFFUSION
Otitis media with effusion is a build up of fluid in the middle ear
without signs and symptoms of acute infection (pain, redness of ear
drum and fever) .
This is insidious condition characterized by accumulation of non-
purulent effusion in the middle ear cleft. This is also called serous
otitis media.

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ETIOLOGY
Malfunctioning of Eustachian tube because of :
• Adenoid hyperplasia
• Chronic rhinitis and sinusitis
• Chronic tonsillitis
• Tumor of nasopharynx
• Cleft palate
Allergy
Untreated or inadequate antibiotic therapy in acute suppurative otitis media.
Viral infection of upper respiratory tract.

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CINICAL FEATURES
• Most commonly affect the age of 5-8 years.
• Hearing loss is insidious and often unnoticed.
• No ear discharges
• Delayed and defective speech because of hearing loss.
• Mild earache
• Sign and symptoms of upper respiratory tract infection.
• Tinnitus
• Vertigo

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DIAGNOSTIC PROCEDURE
• History of upper respiratory tract infection.
• Dull and opaque tympanic membrane.
• Audiometry- conductive hearing loss
• X-rays mastoids

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MANAGEMENT
Medical management
• Oral and topical decongestants help to relief edema of eustachian tube.
• Antihistaminic and sometimes steroid may be used in case of allergy.
• Antibiotics are useful in case of upper respiratory tract infection.
• Teach the patient in chewing gum and repeated swallowing to open the tube.
Surgical management
• When medical treatment does not help, fluid must be removed surgically,
common surgical procedure.
• Myringotomy; an incision is made in tympanic membrane and fluid aspirated
with suction.
• Grommet insertion; grommet is inserted to provide continued aeration of middle
ear.
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• Surgical treatment of causative factors such as adenoidectomy tonsillectomy
🎐 CHRONIC SUPPURATIVE OTITIS MEDIA

Chronic suppurative otitis media is a long standing (>6 weeks)

infection of a part or whole of the middle ear cleft characterized
by painless ear discharge and a permanent perforation conductive
hearing loss. Chronic infection of the middle ear damages the
tympanic membrane, destroys the ossicles and involves the
mastoid.

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TYPES
• Tubo-tympanic; also called the safe or benign type. There is no risk
of serious complication.
• Attico-antral; also called unsafe or dangerous type and risk of
complication is high in this type.

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ETIOLOGY
• The most common bacteria are pseudomonas Aeruginosa, Staphylococcus, Klebsiella,
Pneumoniae.
• Chronic otitis media results from acute otitis media. Eustachian tube obstruction,
chemical and thermal burn, and blast injury.

PREDISPOSING FACTORS
• A history of multiple episodes of acute otitis media.
• Living in crowed condition.
• Passive smoking.
• Person with cleft palate, down syndrome, cleft lip and microcephaly are at risk of
chronic suppurative otitis media

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PATHOPHYSIOLOGY
Irritation and inflammation of the middle ear mucosa

Mucosal edema , ulceration and breakdown of epithelial lung

Resolving infection or inflammation by formation of

granulation of tissue

Formation of cholesteatoma

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CLINICAL FEATURES
• Usually manifested with conductive hearing loss and otorrhea.
• Pain is uncommon. Unless associated with osteitis of temporal bone occurs.
• Tympanic membrane is perforated and draining
• In patient with cholesteatoma, a mucopurulent granulation tissue appear in ear canal.

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DIAGNOSIS
o CBC with WBC differential count
• Hemoglobin, hematocrit and red blood cell counts may reveal normal. WBC
differential count reveals elevated white blood cells, neutrophils, lymphocytes and
monocytes counts that indicate severe inflammatory process and bacterial infections

o Culture and Sensitivity Testing

• Discharge reveals the presence of staphylococcus aureus – one of the most common
bacterial pathogens of otitis media

o CT Scan
• Reveals perforation of the tympanic membrane, ossicular abscess and erosions of the
bony partitions of the mastoid air cells. Absence or presence of cholesteatoma.
Labyrinth and temporal bones may be intact
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or damaged.
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Indication for surgery
• Perforation that persists beyond 6 weeks.
• Otorrhea that persist longer than 6 weeks despite antibiotic use
• Cholesteatoma formation
• Chronic mastoiditis

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NURSING INTERVENTION
1) Relieving pain
2) Preventing infection
3) Improving hearing and communication
4) Reducing anxiety
5) Preventing injury
6) Patient education
7) Promoting wound healing

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 Relieving pain;
• Assess the location, intensity and duration of pain, use of pain rating scale to know the severity of
pain.
• Heat application over ear may relieve pain as heat decreases pain through improved blood flow to the
area and though reduction of pain reflexes.
• Provide rest periods to promote relief, sleep, and relaxation as fatigue and over stimulants may result
exaggerated pain. a peaceful environment may facilitate rest.
• Patient with pain may be given analgesics medications NSAID, block the synthesis of prostaglandins,
which stimulate nociceptors. They are effective in managing mild to moderate pain.
• Medication should be given on time as prescribed by doctors.

 Improving hearing and communication;

• some measures are initiated to improve hearing and communication, such as ;
• reducing environmental noise
• facing patient when speaking
• speaking clearly and distinctly without shouting
• providing good lightening, if patient can read lips
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use nonverbal clues e.g. facial expression, pointing, gestures,
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 Reducing anxiety ;
• Assess the patient anxiety level
- mild anxiety; no physiological symptoms, normal vitals, calm but reports nervousness.
- moderate anxiety; appear energized, slightly elevated vitals, reports feeling of tense.
- severe anxiety; elevated vitals, urinary urgency, reports agitated, experiences poor muscle coordination.
• Use presence, touch, verbalization, and demeanor to remind patients that they are not alone and to
encourage expression or clarification of needs, concerns, unknowns and questions as a nurse being
supportive and approachable promotes communication.
• Explain all activities, procedures, and issues that involve the patient; Use nonmedical terms and calm
slow speech as patient experience less anxiety and less emotional distress because they know what to
expect further.

 Educating patients ;
• Assess the ability to learn, perform or willingness related to desired health care as appropriate teaching
plan can be outlined.
• Patient requires education about medication therapy, such as analgesics e.g. Ibuprofen , antipyretic e.g.
paracetamol,
•20XXInstruct patient to avoid traumatize the external canal,
Presentation title such as scratching the canal with finger nail
36 or
Preventing infection ;
• Encourage intake of protein rich and calorie rich foods as it helps supports the
immune system responsiveness.
• Limit visitors as restricting visitation reduces the transmission of pathogens.
• Patient should be instructed to avoid swimming in polluted water as polluted water
aggravate the infection.
• Preventing ascending and descending infection by applying ascetic technique during
dressing or changing ear packs.

Preventing injury ;
• Assess for balance disturbance or vertigo by taking history and by examination for
nystagmus.
• Transfer patient to a room near the nurse station as nearby location provides more
constant observation and quick response.
• Ask family to stay with patients, this is to prevent the patient from accidentally
falling
 Promoting wound healing ;
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COMPLICATION
Complications of acute otitis media consists of :
 perforation of the ear drum
 infection of the mastoid space behind the ear (mastoiditis)
 rarely intracranial complications can occur, such as bacterial meningitis, brain
abscess, or Dural sinus thrombosis.

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MASTOIDITIS
MASTOID : The mastoid process is the portion of the temporal bone of
the skull that is behind ear which contains open, air-containing spaces.
DEFINITION :
• Mastoiditis is an inflammation of the mastoid antrum and air cells. It is a
complication of otitis media in which infection spreads from the
tympanic antrum to invade bony walls of the cells of the mastoid process.
• Inflammation of mucosal lining of antrum and mastoid air cell system is
called mastoiditis. Generally, infection is spread from mucosal lining of
mastoid cells to the adjacent bony walls of mastoid air cell system.
• Infection can spread to surrounding structures, including the brain,
causing serious complications.
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EPIDEMIOLOGY
In the United States and other developed countries, the incidence of
mastoiditis is quite low, around 0.004%, although it is higher in developing
countries.
The condition most commonly affects children aged from two to thirteen
months, when ear infections most commonly occur. Males and females are
equally affected.

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TYPES

ACUTE LATENT
MASTOIDITIS MASTOIDITIS

CHRONIC
MASTOIDITIS

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ETIOLOGY
• Usually develops as the complication of acute otitis media.
• Commonly seen in children.
• The most common causative organisms are Pneumococcus, Hemophilus influenzas,
beta hemolytic streptococci and staphylococci

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PATHOPHYSIOLOGY
Otitis media / Cholesteatoma

➙
Inadequate drainage of exudate

➙
Spread of exudate into mastoid air cells

➙ ➙
Extension of infection to mastoid air cells

Congestion of mucosa of mastoid bone

➙ ➙
Pus collection in mastoid air cells

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CLINICAL FEATURES
i. Severe pain in the mastoid region .
ii.Redness , swelling and tenderness in the mastoid region
iii.
Persistent of recurrent fever
iv.Profuse otorrhea and become creamy yellow in color, later may
become foul smelling and decrease in amount due to obstruction to the
drainage.
v. Deafness may increase further (conductive type )

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DIAGNOSTIC INTERVENTION
• History of pain and tenderness over the mastoid area
• Examination by otoscope shows; a dull, thickened and edematous
tympanic membrane.
• Culture and sensitivity of ear discharge
• X-rays of mastoid bone shows cloudiness in the mastoid air cells.
• CT scan or MRI
• Audiometry and tuning fork test indicate conductive hearing loss.

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MANAGEMENT :
In acute condition, mastoiditis can be treated by symptomatic treatment and adequate
anti-bacterial therapy but chronic condition with cholesteatoma should be treated with
surgical procedure.

➥Medical management
• Hospitalization of patient in acute condition.
• Aural toilet for cleaning of auditory canal by suctioning or syringing.
• Analgesics (ibuprofen, tramadol) for pain and antipyretics (paracetamol) for fever.
• Antibiotics according to culture of discharge, e.g. amoxicillin or ampicillin.
Chloramphenicol or metronidazole need to be added for anaerobic organism.
• Treatment of predisposing factor of otitis media.
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➥ Surgical management
• Surgical management includes removal of affected mastoid bone. This is
done by mastoidectomy.

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MASTOIDECTOMY
• Mastoidectomy is the incision, drainage and removal of diseased mucosa and
bone from mastoid process of the temporal bone. Three types of mastoidectomy
done according to condition of disease :

RADICAL
• The incision is MASTOIDECTOMY • Removal of
made behind the • It involves removal of mastoid ear cells
ear to remove the all disease from the without disturbing
infected ear cells mastoid ear cell the middle ear
system and tympanic
cavity .
SIMPLE CORTICAL
MASTOIDECTOMY MASTOIDECTOMY

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NURSING MANAGEMENT
➺Nursing assessment
• Assess pain for location , intensity etc
• Hearing test
• Culture and sensitivity test of discharge if present

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➺Nursing diagnosis

• Actual diagnosis
• Acute pain related to inflammation and infection on middle ear / related to surgical
incision
• Disturbed sensory perception related to obstruction, infection of the middle ear, or
auditory nerve damage.
• Risk for infection related to presence of pathogens

• Potential diagnosis
• Anxiety related to surgical procedure
• Impaired verbal communication related to effects of hearing loss

• Risk diagnosis
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Risk for trauma related to balance difficulties or title
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➺Nursing intervention
1. Relieving pain;

• Assess the location, intensity and duration of pain, use of pain rating
scale to know the severity of pain.
• Heat application over ear may relieve pain.
• Provide rest periods to promote relief, sleep, and relaxation as fatigue
and over stimulants may result exaggerated pain. a peaceful environment
may facilitate rest.
• Patient with pain may be given analgesics medications NSAID .They are
effective in managing mild to moderate pain.
• Medication should be given on time as prescribed by doctors.
• Distraction therapy
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2. Improving hearing and communication;

• Some measures are initiated to improve hearing and communication,

such as ;
• Reducing environmental noise
• Facing patient when speaking
• Speaking clearly and distinctly without shouting
• Providing good lighting , if patient can read lips
• Use nonverbal clues e.g. Facial expression, pointing, gestures, and others
form of communication.
• Use of hearing aids if hearing loss is decreased

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3. Reducing anxiety ;

• Assess the patient anxiety level :

- mild anxiety; no physiological symptoms, normal vitals, calm but reports
nervousness.
- moderate anxiety; appear energized, slightly elevated vitals, reports feeling of
tense.
- severe anxiety; elevated vitals, urinary urgency, reports agitated, experiences poor
muscle coordination.
• Use presence, touch, verbalization to remind patients that they are not alone
• Explain all activities, procedures, and issues that involve the patient; Use nonmedical
terms and calm slow speech as patient experience less anxiety and less emotional
distress because they know what to expect further.

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4. Preventing infection ;

• Encourage intake of protein rich and calorie rich foods as it helps supports the immune
system responsiveness.
• Limit visitors as restricting visitation reduces the transmission of pathogens.
• Patient should be instructed to avoid swimming in polluted water.
• Preventing infection by applying aseptic technique during dressing or changing ear packs.

5. Preventing injury ;

• Assess for balance disturbance or vertigo by taking history and by examination for
nystagmus.
• Transfer patient to a room near the nurse station as nearby location provides more constant
observation and quick response.
• Ask family to stay with patients, this is to prevent the patient from accidentally falling.
• Anti-emetics and anti-vertiginous medications can be prescribed if there is balance
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disturbance.
6. Promoting wound healing ;

• The patient is advised to avoid heavy lifting, straining, exertion and

nose blowing.
• Encourage intake of protein rich and calorie rich foods as it helps
supports the immune system responsiveness.

7. Educating patients ;

• Patient requires education about medication therapy, such as analgesics

e.g. ibuprofen, antipyretic e.g. paracetamol,
• Instruct patient to avoid traumatize the external canal, such as
scratching
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•
Pre Operative Nursing Management
• Maintain cleanliness of the patient to minimize infection post-operatively.
• Skin preparation around the mastoid area. The scalp is shaved 2cm around the
affected ear and cleansed thoroughly.
• Patient informed consent to be taken after explanation of surgical procedure,
time, post-operative care, prognosis etc.
• Psychological support should be provided to the patient and family member to
alleviate anxiety by open communication.
• Check and collect investigation;
• Collect all the investigation necessary to confirm if the patient is fit for general
anesthesia or not.

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Post Operative Nursing Management
• Receive patient from OT nurse with all patient documents, observe surgical site for
bleeding, drainage or drainage tube if placed.
• Maintain the head of bed at 30o to promote the drainage of secretion .
• Monitor vital sign and document it.
• Monitor intravenous fluid infusion, check iv site.
• Post-operative medication should be given in time, antibiotics to prevent secondary
infection, sedatives and analgesics to control pain and restlessness.
• Patient is observed closely for signs of facial paralysis such as dropping of mouth,
inability to close eye lids and who have injury to the nerve are informed immediately
and taken back to OT for nerve repair.
• Nausea, vomiting and vertigo may be present after surgery, so assist the patient in
getting out of bed.
• Remove mastoid (head) dressing after 24 hours.
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Discharge Teaching
• Hand washing before and after touching the ear and changing dressing.
• External dressing should be changed daily for 3-5 days.
• Avoid heaving lifting, straining and bending.
• Popping and crackling sensation and normal in the ear after 3-5 weeks after the surgery.
• Change the cotton ball in your ear after 2-3 days and then daily use bacitracin ointment on the
cotton ball.
• After 10-14 days of surgery the drainage is normal. Each day it will be less in amount. The color
of the drainage will change from red to yellow to clear, and then stop, report any change in color
of drainage such as bright red, purulent.
• Don’t take bath until pack is inside the ear.
• Prevent water entering in the ear by putting a Vaseline layer over the outside of the cotton ball
for about 6 weeks.
• Never put the oil and never scratch the ear.
• Blow nose gently one side at a time and sneeze or cough with mouth open
• Avoid flying for 2 month following operation.
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• Take medication as prescription and follow up regular
PROGNOSIS
With prompt treatment, it is possible to cure mastoiditis.
Seeking medical care early is important. However, it is difficult for
antibiotics to penetrate to the interior of the mastoid process and so it may
not be easy to cure the infection; it also may recur.

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COMPLICATIONS
The complication of mastoiditis are as follows;
• Extracranial complication
• Facial nerve palsy
• Labyrinthitis
• Intracranial complication
• Extradural abscess
• Subdural abscess
• Meningitis
• Brain abscess
• Sigmoid sinus thrombophlebitis

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 REFERENCES
🌱 https://www.stanfordchildrens.org/en/topic/default?id=anatomy-and-physiology-of-the-ear-90-P02025
🌱 https://www.verywellhealth.com/middle-ear-anatomy-5105085
🌱 https://www.sun.ac.za/english/faculty/healthsciences/surgical-sciences/Documents/Lectures/Middle%20Ear%
20Diseases.pdf
🌱 http://www.kumj.com.np/issue/16/479-482.pdf
🌱 https://www.slideshare.net/binuenchappanal/mastoiditis-238218726?fbclid=IwAR3FlAv_Rqzd-ujjWDmjSKU
lMWzNn6lBHyL-MRj7UmctfVoAmpBMK3Dof-E

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