Otitis Media Protocol In 1-6 Year Old Patients - Essay Example

Evaluating the development of the protocol/algorithm and guidelines for otitis media in 6 y/o old patients University Date Otitis Media Protocol in 1-6 Year Old Patients This essay evaluates the development of protocol and guidelines for otitis media in 1-6 year old patients. After careful analysis an effort is made in proposing solutions and best possible protocol to manage otitis media. A protocol must adhere to guidelines. On a similar note the interpersonal relationships among the nursing team stand out as a factor of great importance. This relationship impacts the professional activities and offers assistance to the customers. The team bonding reflects in the work environment and influences the quality of service being provided. It goes without saying that wider health care team and relationship with each other positively impacts the protocol for otitis media. Otitis media is one of the most common conditions in young children (Bickley & Sizilagyi, 2012). Screening of all infants and toddlers for otitis media should be a priority (Johnson & Seaton, 2011). Otitis media or OM is only second to viral upper respiratory tract infection as the most common reason for a GP visit (Hughes & Pensak, 2011). Three common types of otitis media are; 1) typical acute media. It has a red distorted bulging tympanic membrane 2) acute otitis media, which has visible fluid behind the tympanic membrane 3) Otitis media with effusion, which has a yellowish fluid behind the retracted and thickened tympanic membrane. The middle ear spaces become filled with liquid that cause hearing impairment (NICE, 2008). In the case of otitis media with effusion usually the eardrum is dull and dilated blood vessels appear across its surface (Douglas et al., 2009). Other than pain and irritation in the ear otitis media can cause hearing impairment. Allergy is supposedly one of the pathogenic factors in otitis media (Bluestone, 2005). Protocol development One of the many problems with children with otitis media is the decision between pursuing a medical treatment or waiting (which is specially used in European countries). In the United States for example most of the children with acute otitis media are regularly treated with antimicrobial drugs (Hoberman et al. 2011). On the other hand in Europe, a watchful-waiting strategy, in which treatment is only reserved for patients whose condition does not improve without medication (Hoberman et al. 2011). In a study by (Hoberman et al. 2011) it was revealed that a group of children that received amoxicillin clavulanate 35%, which showed resolution of symptoms within 48 hours, and by day four it was 61% and by day seven it reached 80%. The waiting strategy is based on clinical trials that showed considerable improvement in children with acute otitis media (Hoberman et al. 2011). It is obvious that any protocol depends on the condition of patient. There can be no one-size-fits-all solution/treatment. However there are the general algorithms that can be followed. First and foremost is the identification of the problem. For instance ear infection is common in children but it can occur at any age. According to the website patient.co.uk the most common treatment is painkillers for a simple ear infection. Otitis media is a very common problem that the general practitioners treat in children. Both type of otitis media; acute otitis media (AOM) and otitis media with effusion (OME) mostly occurr during the childhood and the cause may be bacterial or viral infection (patient.co.uk). Most children have self-limiting illness that does not manifest itself to an extent where they would go see a general practitioner (patient.co.uk). By two years of age most children show at least one episode of AOM (Venekamp, 2013). A general risk factor regarding acute otitis media (AOM) is that white children are more prone to be affected compared to black children (Glasper et al. 2011). When children grow the angle between the Eustachian tube and pharynx, coughing or sneezing tends to close it (patient.co.uk). In small children the less acute angle helps infected material transmit down the tube towards the middle ear (patient.co.uk). The symptoms for acute otitis media include (patient.co.uk); Pain Malaise Irritability Fever Vomiting Upon further examination it may occur that the child may have a very high fever and reddish swollen eardrums (patient.co.uk). Children with fever must undergo extensive physical examination to rule out meningitis (Blijham, 2012). The irritation and pain usually subsides when the ear starts to discharge green pus (patient.co.uk). This happens when the eardrum bursts releasing the pressure (patient.co.uk). A differential diagnosis might reveal (patient.co.uk); Otitis externa Post-auriculur adentis Tooth pain Herpetic infection of the ear Trauma Management of Acute Otitis Media The 2004 AAFP guidelines specifically ask for historical and physical exam findings necessary for diagnosing AOM (Albert & Skolnik, 2008). The majority cases of this type of otitis media resolve on their own without any specific treatment (patient.co.uk). Recently published guidelines on the subject stated that adequate analgesia should be prescribed in severe cases however; antibiotics should be avoided in mild cases (patient.co.uk). The last three decades have seen an increase of using antibiotics for treating children with AOM (Schlossberg, 2008). The guidelines specifically state that it is highly recommended not to use antibiotics when there is a diagnostic uncertainty in children under two years of age (patient.co.uk). There are cases where patient should be considered for antibiotic treatments (patient.co.uk); Patients with symptoms escalating to over three days Children under two years of age with bilateral AOM or swollen eardrums Children with Otorrhea An increased risk of complications like significant part long liver, immunosuppression or cystic fibrosis, even premature babies can also be considered for antibiotic treatments Patient can be considered for hospital admission when the child is younger than three months with a probable chance of having AOM (patient.co.uk). A child (aged between 3 to 6 months) spiking a temperature of over 38°C should be considered for hospital admittance (patient.co.uk). Meningitis, mastoiditis or facial paralyses are the suspected complications that should not be ignored and hospital admission should be made at an appropriate time (patient.co.uk). However, only 25% of younger children show symptoms like fever and otalgia (Block & Harrison, 2005). Approximately 75-90% of cases of OME occurring after an episode of AOM, resolve within three months (Ars, 2008). To prevent and manage AOM the caretaker must assess and modify risk factors whenever possible (patient.co.uk). For instance, repeated courses of antibiotics for every new infection acquired as well as antibiotic prophylaxis (patient.co.uk). The latter should never be started without specialist advice. There is limited evidence suggesting that inserting regulation tubes, also known as grommets, can result in a mean reduction of 1.5 episodes of AOM in the first six months (patient.co.uk). This arrangement can be made with parental permission. Scope For a general step-by-step algorithm for otitis media in children please refer to the index given at the end of the report. In case of complications such as otitis media with effusion OME (in children) the following symptoms could present (patient.co.uk); Ear ache Loss in hearing or behavioural problems A significant hearing loss (20 to 30 dB) No hearing loss In diagnosing OME otosocopy be can be useful however, normal looking eardrum does not exclude OME (patient.co.uk). The caretaker must look for the following signs if OME (glue ear ) is present (patient.co.uk): Opacification of the eardrum Loss off light reflex or it diffused light reflex A concave, retracted or indrawn drum Absent or decreased mobility of the eardrum Traces of bubbles or fluid Amber or yellowish change in colour to the eardrum Swelling or bulging of the eardrum Antibiotics are not recommended for treating otitis media with effusion (NICE, 2008). The correct protocol for managing a patient with otitis media, consider this example. The caretaker should focus on the duration of child symptoms and the impact on the patient’s life as well as schooling (Farboud et al. 2011). History of ear infections or upper respiratory tract infections, are crucial to understanding how the symptoms manifest themselves. The caretaker or physician should ask about the aural discharge (specifically persistent foul-smelling discharge) (Farboud et al. 2011). These primary procedures adhere to the guidelines of specifically diagnosing the problem. Listing the key elements of a disability like poor listening skills can be crucial in diagnosing the problem at an early stage. The poor listening skills manifest themselves especially in noisy environments like classrooms (Farboud et al. 2011). Parents that bring their children OME complain about repeating themselves or the child watching television on high volume. The caretaker should also watch out for delayed language development. In-attention or behavioural problems can also indicate OME, especially accompanied with slow educational progress (Farboud et al. 2011). The hearing impairment does not remain persistent, it can fluctuate (Farboud et al. 2011). When the child acts clumsy or shows poor balance it can also indicate the same problem (Farboud et al. 2011). For developing the clinical practice guideline on managing acute otitis media the American Academy of paediatrics and American Academy of family physicians gathered the subcommittee on management of acute otitis media, which was a group of primary care and subspecialty physicians (Subcommittee on Management of Acute Otitis Media, n.d.). Here are the few excerpts of the guidelines issued by the AAP. The general guiding principle is that a strong recommendation in favour of particular action is arranged when the benefits of the intervention exceed its drawbacks. For instance a strong recommendation against an action is only made when the anticipated harm exceeds the good it does (Subcommittee on Management of Acute Otitis Media, n.d.). In certain circumstances strong recommendations may be made when high-quality evidence is absent (Subcommittee on Management of Acute Otitis Media, n.d.). The general summarization is that clinicians are supposed to follow a strong recommendation unless there is a compelling reason for an alternative (Subcommittee on Management of Acute Otitis Media, n.d.). Management of presenting problem There are certain problems that need to be considered in order to cope with otitis media in children. There are certain risk factors (patient.co.uk) for otitis media with effusion in children such as; a) It is more common in Boys than in girls Children in day care centres Children with older siblings Children that parents who smoke During the winter season b) There is a study that discovered a link between gastro-oesophageal reflux and otitis media with effusion in children c) The current upper respiratory tract infections can be a cause for acquiring OME The reason could also be genetic because a family history of chronic otitis media with effusion is a significant reason for this disease in small children (Bluestone & Klein, 2007). University of Minnesota Minneapolis issued a study in which it was discovered that a region of chromosome 19 was a harbouring susceptibility locus for chronic otitis media (Acton, 2012). Spontaneous resolution is usually the case but it is worth observing the child for three months. This is known as active observation. A study suggested that 50% of children with 20 dB hearing loss recover within three months without any treatment (patient.co.uk). Children that show persistent symptoms should be referred to a hearing assessment or should be taken to an ENT specialist if the general practitioner does not have audiometry (patient.co.uk). Pure tone audiometric is probably the best process for hearing assessment (patient.co.uk). However, it is only suitable for children that are over four years old (patient.co.uk). There is no medical danger in using this test for younger children but the problem is it is very hard for children under the age of four to cooperate. The McCormick toy test and the effective distraction tests are also suitable for children that are under the age of four years (patient.co.uk). The National Institute for Health and Clinical Excellence suggests a second hearing test right after three months (patient.co.uk). By following the guidelines and protocol AOM and OME can be effectively managed. Regardless of the kind of otitis media a wider healthcare team is beneficial for its effective management. Otitis media in young children can be effectively managed using a team approach. When there is hearing impairment involved, the multidisciplinary teamwork becomes all the more important. Many researchers have argued that the first generation of team skills in medical practice was narrowly focused on CRM (subdomain of team training) (Salas & Frush, 2012). The modern form of medical team training is based on core skills. It is customized to the teamwork outcomes. For instance four team training outcomes are identified by Salas & Frush (2012); mutual trust, adaptability, shared mental models and team orientations. All these outcomes refer to a wider healthcare team. Mutual trust is necessary, where team members trust each other’s judgements and information. In managing children with OM one team member will have to rely on the other’s information about patient history. The recommended protocol (shown in the index) seeks information from children and parents before diagnosing. A wider healthcare team will focus on their specific tasks and trust will make them bond in managing the patient. The scope of managing OM depends on the severity and the qualification of the clinicians. The majority of OM cases are well within the scope of management by primary care providers (Shah et al. 2013). Complications like hearing loss or perforation must be dealt with medical management (Shah et al. 2013). Antibiotics and surgery are treatment only in severe cases and can only be recommended (and/or managed) by a qualified doctor. Healthcare professionals are accountable for their duties and practice. They should be well aware of the issues of working with children under 16 years of age and they must strictly follow the guidelines of seeking consent (NICE, 2008). Such guidelines fall under the best practice advice. The governance system should be built based on these guidelines. The governance structure should be such as it makes sure that a good communication exists between healthcare professionals and patients’ parents, as this communication is “essential” (NICE, 2008). Evidence based written information based on patient’s specific needs should be the base for this communication (NICE, 2008). Only putting a system like that is not enough. Regular auditing is imperative to ensure that healthcare practitioners are properly following the guidelines. ‘Standards for better health’ issued by the department of health in July 2004 is an example of such guidelines that should govern the auditing of clinical practice. Implementing the clinical guidelines forms part of the developmental standard D2 (NICE, 2008). It is through teamwork, wider healthcare team, effective log information, medical expertise, remaining within the scope of practitioner’s skill, following the guidelines and the presence of accountability/auditing entity that can significantly improve the management of patients under the age of six suffering from otitis media. References 1. Acton, A. 2012. Otitis media with effusion: new insights for the healthcare professional. Atlanta: Scholarly Editions. 2. Albert R. H. & Skolnik, N. S. 2008. Essential infectious disease topics for primary care. PA: Humana Press. 3. Ars, B. 2008. Chronic otitis media: Pathogenesis oriented therapeutic management. Amsterdam: Kugler Publications. 4. Bickley, Lynn & Szilagyi, Peter. G. 2012. Bate’s guide to physical examination and history taking. Lippincott Williams & Wilkins. 5. Blanco et al. 2007. The importance nursing leadership in managing interpersonal relationship amongst health team -Journal of research fundamental care online. , NMC. 6. Blijham, J. 2012. NHG clinical practice guidelines M09/acute otitis media - feverish illness in children. Springer Science & Business Media. 7. Block, S. L. & Harrison, C. J. 2005. Diagnosis and management of acute otitis media. NY: Professional Communications Inc. 8. Bluestone, C. D. 2005. Eustachian tube: Structure, function, role in otitis media. PMPH-USA. 9. Bluestone, C. D. & Klein, J. O. 2007. Otitis media in infants and children. PMPH-USA. 10. Douglas et al. 2009. Macleod clinical exam. Elsevier Health Sciences. 11. Glasper et al. 2011. Emergencies in children’s and young people’s nursing. Oxford University Press. 12. Hoberman et al. 2011. Treatment of acute otitis media in children under 2 years of age. NEJM. 364: 105-115. [Accessed online] http://www.nejm.org/doi/full/10.1056/Nejmoa0912254 13. Hughes, G. B. & Pensak, M. L. 2011. Clinical otology. NY: Thieme. 14. Johnson, C. & Seaton, J. 2011. Educational audiology handbook. Cengage Learning. 15. N.d. Ear infection (otitis media). Patient.co.uk. [Accessed online] http://www.patient.co.uk/health/ear-infection-otitis-media 16. NICE. 2013. Surgical management of otitis media with effusion in children overview. [Accessed online] http://pathways.nice.org.uk/pathways/surgical-management-of-otitis-media-with-effusion-in-children?fno=1# 17. NICE Guidelines [CG60]. 2008. Surgical management of otitis media with effusion in children. [Accessed online] https://www.nice.org.uk/guidance/CG60/chapter/introduction 18. NICE. 2008. Do not do recommendation. [Accessed online] https://www.nice.org.uk/savingsAndProductivityAndLocalPracticeResource?ci=http%3A%2F%2Fsearch.nice.org.uk%2Fusingguidance%2Fdonotdorecommendations%2Fdetail.jsp%3Faction%3Ddetails%26dndid%3D117 19. Farboud et al. 2011. Otitis media with effusion (“glue ear”). BMJ. 343:d3770 [Accessed online] http://www.bmj.com/content/343/bmj.d3770 20. Sales, E. & Frush, K. 2012. Improving patient safety through teamwork and team training. Oxford University Press. 21. Schlossberg, D. 2008. Clinical infectious disease. Cambridge University Press. 22. Shah et al. 2013. Otolaryngology for the paediatrician. Bentham Science Publishers. 23. Subcommittee on Management of Acute Otitis Media. N.d. Diagnosis and management of acute otitis media. AAFP. [Accessed online] 24. http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/final_aom.pdf 25. Venekamp et al. 2013. Antibiotics for acute otitis media in children. The Cochrane Library (John Wiley & Sons). [Accessed online] http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000219.pub3/abstract Index Algorithm for Development and Treatment of Otitis Media in Children Flow Chart Continues on the next page* Surgical Management of Otitis Media1 Read More