pediatric eye and ear problems

8/13/2019 Pediatric Eye and Ear Problems

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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+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.


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


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!.


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.


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.


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.


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


23/27

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.


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&lts "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&ltin "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.


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%.



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25/27

$hronic Lo1 Sel7Estee+ related to social and acade+ic diiculties


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!.


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.

pediatric eye and ear problems

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