Running head: EAR PAIN CASE STUDY: UNIT 3 1
This case relates to a three year old preschool child who presents to the office with a complaint of left ear pain for two days. She is accompanied by her mother, Mary. The mother reports that the child has had an intermittent fever and her maximum temperature at home was 101 F (axillary). The pain is worse sometimes when she is lying down. The pain is occasional relieved with the use of over-the-counter pain relievers. Mother denies vomiting or diarrhea. The child has had a slight runny nose without cough. You may add more to this section depending on the presenting symptoms and what the subjective data was reported.
The purpose of this paper is to include differential diagnosis and a definitive diagnosis, address the psychosocial history, and any demographic characteristics that might affect the case, and develop a treatment plan to cure, or control the symptoms of the child’s condition so she could return to her previous state of health. Treatment modalities will be extracted from evidence-based standardizes guidelines provided by experts.
Past medical history: Julia was born vaginal delivery at 40 week’s gestation. She has not had any injuries or illnesses. Her developmental screening was within normal limits at last provider’s visit. Medication includes Tylenol for the fever and ear pain. She is allergic with penicillin which produces rash, itching and tongue swelling. Immunizations are up to date. Family history is unremarkable. Julia lives at home with both parents. Her mother works as a teacher and her father is a commercial fisherman. The family has a pet cat. Julia’s father smokes a pack of cigarettes a day.
Constitutional: Julia is alert and quiet, sitting on her mother’s lap. She appears well hydrated and well nourished. Vital signs: temp 100 (axillary), heart rate 100, respiration 26, and weight 14 kilograms.
Differential Diagnosis: Upper respiratory infection, otitis externa with effusion, transient middle ear effusion (MEE) related to barometric changes, mastoiditis, temporomandibular joint (TMJ) disorder, mumps, dental disorders, and tonsillitis. In addition, ear pain can result from a foreign body either in the nose or in the ear (more likely in young children) or from head or ear trauma (Buttaro et al., 2008).
Definitive Diagnosis: Acute otitis media (AOM), with bacterial or viral infection of the middle ear fluid, has a rapid onset and short duration. The actual cause is unknown, but it may be the sequelae of upper respiratory tract infections or allergies that result in edema of the eustachian tube. Some risk factors related to this case include tobacco and pollutant exposure, smoking, day care attendance, young age, altered immunity, allergy, and fall or winter season (Donaldson, 2014).
Clinical and physical manifestations: Patients with AOM may have an initial complaint of a painful ear that is worse in a prone position, throbbing, and painful earache with impaired hearing. Fever is often present. Orthoscopic findings specific for acute otitis media include a red, bulging, opaque, and inflamed tympanic membrane (TM), impaired visibility of ossicular landmarks, yellow or white effusion (pus) fluid behind the membrane. Decreased or absent mobility is one of the necessary criteria for accurate diagnosis of AOM (Klein & Pelton, 2014).
Diagnostic testing: Testing in the acute phase is generally unhelpful, because all children with acute otitis media have conductive hearing loss associated with the middle ear effusion. In addition, although tympanometry may assist in the diagnosis of middle ear effusion, this test is seldom necessary (Donaldson, 2014). Will perform Weber and Rinne test to determine whether conduction and sensorineural hearing have been affected (Hay et al., 2012).
Treatment: Klein & Pelton (2014) suggest initial antibiotic treatment for all chidren under six months old with a diagnosis of acute otitis media, and children older than two years who present with severe illness including moderate or severe otalgia, fever higher than 102.2 degrees Fahrenheit in the past 48 hours, and unilateral or bilateral acute otitis media or otorrhea.
When the decision is made to treat acute otitis media (AOM) with antimicrobial agents, the selection among available drugs is based upon clinical and microbiologic efficacy, acceptability (taste, texture) of the oral preparation, absence of side effects and toxicity, and convenience of the dosing schedule, and cost (Klein & Pelton, 2014). Since Julia is allergic to penicillin, a macrolide will be prescribed.
Azythromycin 10mg/kg on day 1 and 5mg/kg on days 2 to 5, Ibuprofen for pain and fever, as directed, and external heat or cold (Burns et al., 2009). Macrolides are alternatives for patients who have had immediate hypersensitivity reactions (anaphylaxis, angioedema, bronchospasm, and urticaria) to penicillin. In addition increasing the dose of macrolide antibiotics does not overcome macrolide resistance among pneumococcal isolates as with beta-lactam drugs (Hay et al., 2012).
Normally, antibiotic would not be recommended for fever less than 102.2F. However, because of Julia’s psychosocial and demographic environment, she is at high risk of developing repeated episodes of otitis media. I believe that it would be safe to treat her with antibiotic to prevent complications. Despite the advocates of watchful waiting, the overwhelming consensus is still that antibiotics are the initial therapy of choice for acute otitis media for three valid reasons: After the institution of antibiotic therapy, a marked decline in the suppurative complications of AOM is noted; practitioners cannot predict with certainty which patients will develop complications; studies have demonstrated that the use of antibiotics improves patient outcomes in both early and late phases of AOM (Donaldson, 2014, p. 15).
Education/Health promotion: Prompt treatment of upper respiratory infection, pneumococcal vaccine as scheduled and yearly influenza vaccine, early treatment of influenza with oseltamivir to help reduce otitis media, complete course of antibiotic to prevent drug-resistance bacteria and recurrence, maintain follow up appointments, address side effects of antibiotics, stress out the importance of follow up appointments, and offer smoking cessation program to Julia’s father.
Referral: If the patient does not respond to initial or alternative therapy, referral to a physician or otolaryngologist is necessary (Hay et al., 2012).
Follow up: Julia will return in 72 hours to evaluate the effectiveness of antibiotic therapy. If she shows improvement, she will return to clinic in two to four weeks (Burns, 2009). If no improvement in symptomology despite initial antibiotic, she will be reevaluated for other causes of persistent symptoms, and determine whether a change in antibacterial therapy is warranted (Hay et al., 2012). The main reason for follow-up of children with resolved symptoms is to monitor the resolution of middle ear effusion which is associated with conductive hearing loss. Persistent middle ear effusion is common after the resolution of acute symptoms. In a large prospective study, middle ear effusion persisted for weeks to months after the onset of acute otitis media in children (Hay et al., 2012).
Does the patient’s psychosocial history affect how you might treat the case?
Day care attendance is a significant risk factor of acute otitis media. Among other factors number of cigarettes smoked in household, asthma, allergies are significant (Burns et al., 2009).
Tobacco smoke and air pollution – The patient’s father smokes a pack of cigarette a day. Exposure to tobacco smoke and ambient air pollution increases the risk of acute otitis media. Studies have proven that there is a relative risk of acute otitis media among children whose parents smoke. The mechanism for this association is not entirely clear but may be related to increased nasopharyngeal and oropharyngeal carriage of Streptococcus pneumonia (Klein & Pelton, 2014).
Day care – Apparently, Julia attends day care since both of her parents work. In fact, she may be attending the daycare at the same school where her mother works. Exposure to viral illness in congregate settings such as school or day care is a primary risk factor for otitis media (NHCHC, 2003). The transmission of bacterial and viral pathogens is common in day care centers. Multiple observational studies indicate that children attending day care centers, especially with four or more other children, have a higher incidence of acute otitis media than children who receive care at home (Klein & Pelton, 2014).
Allergies/Exposure to domestic pets – The objective assessment reveals that there is a cat living in Julia’s home. It has been suggested that the effect of dogs and cats is not related to the household allergen levels to which they contribute but instead to the bacterial products associated with their presence (Johnson et al., 2002, p. 12) Bacterial endotoxins activate a Th1-type immune response, suppressing the expression of a Th2-type, or allergic, immune response. Animals therefore may play a crucial role during early life by serving as the bacterial exposure vehicle necessary for the immune system’s deviation to a mature nonallergic Th1-type response (p. 12).
What if the patient lived in a rural setting?
This data has not been reported but Klein & Pelton (2014) report that there is an increased risk of otitis media in children living in low-social economic areas. This association results from lack of access to medical care, poverty, household crowding, and local environmental factors. Several studies have shown that rural children are much more affected by acute suppurative otitis media because they swim in polluted water in the pond for longer time than usual. They frequently jump in the pond. Often water enters nose and nasopharynx and thus middle ear gets infected through the eustachian tube. Many of these cases are not attended properly and treated adequately and results in post-perforative stage of acute supportive otitis media due to unwarnesses about otitis media and its treatment. Possibly, these cases persist as chronic suppurative otitis media (Biswas et al., 2002, p. 6). One can conclude that swimming in polluted water is the most important factor for the prevalence of chronic suppurative otitis media (CSOM) to be more in rural children. Low living standard, poor socioeconomic condition, lack of education, unawareness about and inadequate knowledge of getting the treatment are also responsible for occurrence and persistence of the disease. As a result chronic suppurative otitis media is more prevalent in the rural children (p. 6).
Are there any demographic characteristics that might affect this case?
Age – Julia is three years old and according to Klein & Preston (2014) between 60 and 80 percent of children have at least one episode of AOM by one year of age, and 80 to 90 percent by two to three years. Also, there is a small increase between five to six years (the time of school entry). Immunologic naiveté. Some of these factors are identifiable as the change in skull configuration and vectors of the eustachian tube, development of antibodies following exposure to bacterial pathogens (Klein & Pelton, 2014). Julia’s immune system is surely affected by daily exposure to passive smoking from her father. Exposure to passive cigarette smoking acts in several ways to increase the individual’s risk for otitis media. It increases the risk of persistent middle ear effusion by enhancing colonization, prolonging the inflammatory response, and impeding drainage of the middle ear through the eustachian tube. Passive smoking puts Julia at higher risk for upper respiratory tract infections by decreasing the mucociliary functioning in her eustachian tube (Buttaro et al., 2008).
Season (increased incidence during the fall and winter months) (Klein & Pelton, 2014). Julia’s mother works as a teacher, and as such she is exposed to the school environment for both seasons. Julia also goes to day care during the fall and winter months, which also increases her risk of exposure to the pathogens causing upper respiratory infection and otitis media.
Are there any standardized guidelines that you should use to assess or treat the case?
The plan of care that I use to assess or treat Julia is based on the guidelines for the management of uncomplicated acute otitis media in children six months through 12 years, recommended by the by American Association of Pediatrics and the American Association of Family Practice (AAP/AAFP), and reported by Donaldson (2014, pp. 12-14). These guidelines include:
· Acute otitis media should be diagnosed when there is moderate to severe tympanic membrane bulging or new-onset otorrhea not caused by acute otitis externa.
· Acute otitis media may be diagnosed for mild tympanic membrane bulging and ear pain for less than 48 hours or for intense tympanic membrane erythema; in a nonverbal child, ear holding, tugging, or rubbing suggests ear pain.
· Acute otitis media should not be diagnosed when pneumatic otoscopy and/or tympanometry do not show middle ear effusion.
· Antibiotics should be prescribed for bilateral or unilateral acute otitis media in children aged at least 6 months with severe signs or symptoms (moderate or severe otalgia or otalgia for 48 hours or longer or temperature 39°C or higher) and for non-severe, bilateral acute otitis media in children aged six to 23 months.
· Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases, clinicians should prescribe an antibiotic with additional β-lactamase coverage.
· Clinicians should reevaluate a child whose symptoms have worsened or not responded to the initial antibiotic treatment within 48-72 hours and change treatment if indicated.
· In children with recurrent AOM, tympanostomy tubes, but not prophylactic antibiotics, may be indicated to reduce the frequency of acute otitis media episodes.
· Clinicians should recommend pneumococcal conjugate vaccine and annual influenza vaccine to all children according to updated schedules.
Acute otitis media is a common occurrence in children younger than five years. Despite research into prevention and therapy, the costs of this disease continue to escalate while the incidence remains relentless. In the United States, the total annual cost to for acute otitis media otitis media with effusion runs into billions of dollars (Donaldson, 2014). With early identification of the disease, or accurate diagnosis, prompt treatment with careful use of antibiotics, and education, the astute nurse practitioner can help prevent complications associated with the disease, thus, decreasing its cost.
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