Advanced Practice Role in Nursing: Otitis Media and Externa

Advanced Practice Role in Nursing: Otitis Media and Externa

Ear pain (otalgia) is a common manifestation for most patients seeking services from ear specialists. A case in point of a condition contributing to this manifestation is otitis. Otitis is an ear condition in which there is inflammation of either the external ear (otitis externa) or the middle ear (otitis media). Other differential diagnoses for ear pain manifestation include foreign body obstruction and cerumen impactions (Ignatavicius, Workman, Blair, Rebar, & Winkelman, 2015). In essence, a look at the two types of otitis is the primary focus of this discussion. Central to the analysis are issues such as clinical manifestations, causative agents and physical assessment findings of the both otitis externa and media. Lastly, this paper will aim at identifying health history questions and age assessment considerations for patients presenting with ear pain in the clinical area.

An Overview of Otitis Externa

Otitis externa refers to an inflammation of the external auditory meatus/canal. It constitutes five classes, namely, acute, chronic, eczematous, necrotizing and hemorrhagic otitis externa. The risk factors are unique to the various types of otitis externa. For instance, the risk factors for acute and chronic otitis externa include ear scratching, swimming, and traumatization of external canal. On the other hand, a predisposing factor for eczematous otitis externa is primary skin disorder while diabetes and old age are factors associated with the necrotizing type (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).


Several causes are responsible for otitis externa. The following are the most common:

  1. A traumatized external canal
  2. Bacterial infection caused by Pseudomonas (accounts for 67% of all bacterial cases), staphylococcus, streptococcus, gram negative rods, Proteus vulgaris
  3. Fungal infection due to Aspergillus, (accounts for 90% cases), penicillium, Phycomycetes, Actinomyces, yeast, and Rhizopus
  4. Eczematous otitis externa is mainly due to pre-existing skin disorder such as eczema, seborrhea, neurodermatitis and contact dermatitis
  5. Sensitivity to topical medications (Ignatavicius, Workman, Blair, Rebar, & Winkelman, 2015)

Signs and Symptoms

Patients with otitis externa will manifest with several signs and symptoms that are worth noting. They include all the cardinal signs of inflammation, namely:

  • Pain (Characteristic to the pain is that it increases whenever there is manipulation of the pinna or the tragus)
  • Fever
  • Reddening of the inflamed part
  • Swollen ear canal

Other manifestations that otitis externa patients will present with include:

  • Foul smelling, and white to purulent ear discharge
  • An itchy sensation on the affected ear
  • Periauricular lymphadenopathy
  • Mild hearing loss due to blockage of the ear with a pimple like swelling (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013)

Physical Assessment Findings

On physical examination of the patient with otitis externa, a healthcare professional will observe several manifestations that are suggestive of this condition. Such assessment results include but not limited to:

  • Reddening of the tympanic membrane
  • Ear canal swelling
  • Otorrhea (Ignatavicius, Workman, Blair, Rebar, & Winkelman, 2015)

An Overview of Otitis Media

Otitis media refers to an inflammation of the middle ear. It entails three common types namely, acute otitis media, chronic otitis media and otitis media with effusion. The peak incidence of otitis media is in the age between 6-18 months. It significantly declines after age 7 years since before this age, the Eustachian tube anatomical structure (more horizontal and shorter) makes the children in this age bracket risk factors. As such, otitis media is rare in adults. Other risk factors include but not limited to male gender and family history of middle ear infection (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).

Primarily, acute suppurative otitis media occurs following the entry of pathogenic agents into the normally sterile middle ear through a dysfunctional Eustachian tube. On the contrary, acute secretory or serous otitis media does not result in purulent infection. Instead, the effusion in the middle ear is due to the blockage of the Eustachian tube, which leads to negative pressure and fluid shift from blood vessels (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).

In chronic otitis media, its occurrence is due to repeated bouts of acute otitis media following persistence invasion of an antibiotic-resistant organism or a virulent species of organisms. The last ramification of frequently recurring acute otitis media is the chronic inflammation of the middle ear, which comes with tissue damage. The commonly destroyed tissue is the mastoid bone tissue. The predisposing factors for the chronic otitis media are immunosuppression and chronic systemic disease (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).


Both acute and chronic otitis media predominantly occur following a primary bacterial infection that renders the Eustachian tube dysfunctional. Consequently, this allows bacteria entry into the middle ear. The common bacteria resulting in both types of otitis media are as follows:

  • Streptococcus pneumonia
  • Haemophilus influenza
  • Moraxella catarrhalis
  • Staphylococcus aureus

In chronic otitis media, other organisms such as Pseudomonas, Proteus, and Bacteroides species may be present (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).

Signs and Symptoms

Central to the acute otitis media are several clinical manifestations, which comprise the following:

  • Pain is the initial symptom noted
  • Fever
  • Purulent drainage in cases where there is tympanic membrane perforation
  • Irritability in young individuals
  • Headache, anorexia, nausea, and vomiting as well as hearing loss may also be present (Ignatavicius, Workman, Blair, Rebar, & Winkelman, 2015)

As for the chronic form of otitis media, the affected individuals will present with signs and symptoms such as:

  • Painless to dull ache with tenderness of mastoid
  • Foul smelling or odorless otorrhea
  • Vertigo and pain in cases where the CNS complications are present
  • Fever
  • Postauricular erythema and edema (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013)

Physical Assessment Findings

A medical professional examining a patient with otitis media will or may observe the following signs:

  • Reddening of the tympanic membrane
  • Postauricular edema
  • Otorrhea (Ignatavicius, Workman, Blair, Rebar, & Winkelman, 2015)

Health History Questions for a Patient with Ear Pain

During history taking for a patient with otalgia, the nurse should aim at establishing answers to several fundamental questions. A befitting example of such questions is the age of the patient. Dains, Baumann, and Scheibel, (2016) are of the opinion that age is important given that it will give a clue to the cause of the pain. Patients below the age of 7 are more likely to experience an earache following the development of acute otitis media. On the other hand, advanced age is an indicator of secondary otalgia caused by disorders affecting the head, face, and neck (Dains, Baumann, & Scheibel, 2016).

Another question that a nurse should seek to answer from the health history of the patient is the existence of fever in a patient. Fever accounts for almost 60% of all children with complaints of ear pain and ends up having acute otitis media. As such, it will enable one to establish the existence of acute otitis media (Dains, Baumann, & Scheibel, 2016).

Additionally, determining a history of upper respiratory infection is also a vital question in a health history for patients with ear pains. That is the case because a positive history of such infections is suggestive of a possibility of the entry of the causative agents to the middle ear via the Eustachian tube (Dains, Baumann, & Scheibel, 2016).

Furthermore, establishing if one has had previous episodes of ear infection is paramount in the health history of such patients. Such is the case given that recurrence of such infections especially in young children is more likely and may be the reason for the pain (Dains, Baumann, & Scheibel, 2016).

Determining a family history of ear infections for the patient is also central to this health history. That is a fact because the existence of two or more episodes of chronic ear infection in a sibling makes an individual a risk factor to the condition (Dains, Baumann, & Scheibel, 2016).

Lastly, a nurse must also establish whether the household environment of a patient exposes him/her to cigarette smoke. According to Dains, Baumann, and Scheibel, (2016) such information is necessary given that passive smokers are twice to thrice more likely to develop otitis media.

Assessment Considerations

During an examination of a patient with ear pain, certain considerations are of the essence so that one can attain valid findings. As such, highlighting these factors is also central to this discussion.

Primarily, when assessing children with otalgia, a nurse should pull the pinna downward and backward for the exposure of the external auditory canal to enhance the observation of the middle ear. Such an action is necessary given that children have a shorter Eustachian tube and an external auditory canal that is anatomically horizontal and is only observable with this kind of maneuver. On the contrary, when assessing adult patients, the nurse should pull the pinna upward and backward for the inspection of the external auditory canal (Ignatavicius, Workman, Blair, Rebar, & Winkelman, 2015).

Another examination consideration is the restraining of children and uncooperative adult patients before the procedure. Such a consideration is necessary for the prevention of injury to the external auditory canal because of lack of cooperation by an individual to assume one position. Restraining of a child is attainable through the parent holding the child firmly on his/her lap while a nurse examines the affected ear (Ignatavicius, Workman, Blair, Rebar, & Winkelman, 2015).


Concisely, this paper aimed at determining the practical details of both otitis externa and media as potential diagnoses for persons presenting with ear pain. Additionally, it targeted at identifying the health history questions for such patients and assessment considerations that a nurse must factor into his/her plan of care. Indeed, this discussion has largely achieved all these goals if not to their entirety. That said, going into the future, nurses and other healthcare professionals must rely on such information if the patients with otalgia are to benefit maximally from their interventions.


Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, Mo.: Elsevier Health Sciences.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care.

Ignatavicius, D. D., Workman, M. L., Blair, M., Rebar, C. R., & Winkelman, C. (2015). Medical-surgical nursing: Patient-centered collaborative care.




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