Chronic suppurative otitis media (CSOM) is caused by recurrent ear infections resulting to tympanic membrane perforation characterized by persistent foul smelling otorrhea from the middle ear. Misconception on ear infection as related to poor hygiene and embarrassing foul smelling ear discharges, generates an erroneous notion of social stigma—which is one of the major causes of hearing loss in CSOM, since most of the cases are not reported and not diagnose earlier without immediate and appropriate treatment. Hearing loss is preventable, if only immediate treatment is taken (Smeltzer & Bare, 2004; Acuin, 2004; Bonin et al., 2003).

In the report of Acuin (2004), prevalence surveys confirmed that the global burden of illness from CSOM affects 65–330 million individuals with draining ears, 60% of whom (39–200 million) suffer from significant hearing impairment. CSOM accounts for 28, 000 deaths and a disease burden of over 2 million DALYs. Over 90% of the burden is borne by countries in the South-east Asia and Western Pacific regions, Africa and several ethnic minorities in the Pacific rim. Mastoidectomy with or without tympanoplasty eradicates mastoid infection in about 80% of patients and may be combined with surgical drainage of otogenic abscesses. However, such treatment is costly and does not always lead to satisfactory hearing improvement, and is inaccessible in many developing countries.

Smeltzer & Bare (2004), defines chronic suppurative otitis media as the result of repeated episodes of acute otitis media causing irreversible tissue pathology and persistent perforation of the tympanic membrane. Chronic infections of the middle ear damage the tympanic membrane, destroy the ossicles and involve the mastoid (Smeltzer & Bare, 2004, Acuin, 2004). CSOM may develop in elderly people who have had an asymptomatic or exacerbated chronic ear infection after URI or when water enters the middle ear during bathing or swimming. Chronic suppurative otitis media may be a complication of a retracted or perforated tympanic membrane. In elderly patients with otorrhea, squamous and basal cell carcinomas should be considered (Acuin, 2004). Tympanic membrane perforation may be permanent, and the middle ear mucosa may become hypertrophic. In some patients, the inflamed, polypoid hypertrophic mucosa protrudes through the perforation into the external auditory canal as an aural polyp. A cholesteatoma may be present. Some cases are complicated by abscess formation or erosion into bone (Smeltzer & Bare, 2004).

Anatomy and Physiology of Sense of Hearing (Hole’s Essentials of Human Anatomy & Physiology, 9th ed.)

The ear has external, middle and inner ear sections and provides the senses of hearing and equilibrium.

External Ear

The external ear consists of the auricle which collects the sound which then travels down the external auditory meatus.

Middle Ear

The middle ear begins with the tympanic membrane, and is an air-filled space (tympanic cavity) housing the auditory ossicles. Three auditory ossicles are the malleus, incus and stapes. The tympanic membrane vibrates the malleus, which vibrates the incus, then the stapes. The stapes vibrates the fluid inside the oval window of the inner ear. Auditory ossicles both transmit and amplify sound waves.

Auditory Tube

The auditory (eustachian) tube connects the middle ear to the throat to help maintain equal air pressure on both sides of the eardrum.

Inner Ear

The inner ear is made up of a membranouslabyrinth inside an osseous labyrinth. Between the two labyrinths is a fluid called perilymph. Endolymph is inside the membranous labyrinth. The cochlea houses the organ of hearing while semicircular canals function in equilibrium. Within the cochlea, the oval window leads to the upper compartment, called the scala vestibuli. A lower compartment, the scala tympani, leads to the round window. The cochlear duct lies between these two compartments and is separated from the scala vestibule by the vestibular membrane, and from the scala tympani by the basilar membrane. The organ of Corti, with its receptors called hair cells, lies on the basilar membrane. Hair cells possess hairs that extend into the endolymph of the cochlear duct. Above the hair cells lies the tectorial membrane, which touches the tips of the stereocilia. Vibrations in the fluid of the inner ear cause the hair cells to bend resulting in an influx of calcium ions. This causes the release of a neurotransmitter from vesicles which stimulate the ends of nearby sensory neurons.

Auditory Nerve Pathways

Nerve fibers carry impulses to the auditory cortices of the temporal lobes where they are interpreted.


pathophysiology2pathophysiology 1

Diagnostic Examination

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 (McFarland & Grant, 1988).

Culture and Sensitivity Testing of discharge reveals the presence of staphylococcus aureus – one of the most common bacterial pathogens of otitis media (Smeltzer & Bare, 2004).

Staphylococcus aureus is a respiratory pathogen that may have been insufflated from the nasopharynx into the middle ear through the Eustachian tube during bouts of upper respiratory infections. The bacteria is infrequently found in the skin of the external canal, but may proliferate in the presence of trauma, inflammation, lacerations or high humidity which may then gain entry to the middle ear through a chronic perforation (Acuin, 2004).

CT Scan revealed 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 or damaged.

The staphylococcus areus has infected and eroded the tympanic membrane causing perforation, ossicles and the mastoid bony partitions which may cause a conductive hearing loss. CSOM can cause chronic mastoiditis and lead to cholesteatoma formation. It can occur in the middle ear, mastoid cavity, or both. If untreated, cholesteatoma will continue to enlarge, possibly causing damage to the facial nerve and horizontal canal and destruction of other surrounding structures. Absence of cholesteatoma is a good indication that the condition is not malignant and not cancerous. Intactness of labyrinth and temporal bones are signs that there will be no sensori-neural defect (Smeltzer & Bare, 2004; Acuin, 2004).

Chronic Suppurative Otitis Media Assessment Tool and Treatment Model

Chronic Suppurative Otitis Media Assessment Tool and Treatment Model

Nursing Care Plan

            The two major problems of chronic suppurative otitis media are infection and pain (particularly, in the presence of mastoiditis). In case of fever, infection is the underlying cause of fever—if infection is treated, then fever will disappear.






History:> with history of recurrent childhood otitis media> reported non-compliance and incomplete antibiotic therapy for otitis media

> pt. is not taking any vitamins or any food supplements

> daily meals do not adhere with RDA and not enough source of protein and vitamin C

> reported that pt. lost weight since the symptoms and pain started because of anorexia and difficulty of eating related to facial swelling and pain

> secondhand-smoker since childhood

> complained of painful left ear radiating to temporal area and left side of the face


Infection, related to inadequate primary defenses secondary to injured tissue.Infection, related to presence of invading microorganism as revealed by the WBC differential count and culture and sensitivity.


Infection, related to inadequate secondary defenses due to malnutrition.

Short-term goals:> Infection is recognized early to allow for prompt treatment. Independent:

1. Assess for the presence, extent and severity and history of risk factors.Rationale: Malnutrition, any break in the continuity of the skin and tissue damage represents a break in the body’s normal line of defenses (Doenges et al., 2008; Gulanick & Myers, 2007).


2.  Monitor for the signs of infection such as redness, swelling, increased pain, injury, discharges and temperature.

Rationale: Temperature of up to 38°C for 48 hrs. after surgery is related to surgical stress; after 48 hrs. temperature greater than 37.7°C suggests infection; fever spikes that occur and subside are indicative of wound infection; very high temperature accompanied by sweating and chills may indicate septicemia (Doenges et al., 2008; Gulanick & Myers, 2007).


3. Assess nutritional status, including weight and history of weight loss.

Rationale: Patients with poor nutritional status may be anergic or unable to muster a cellular immune response to pathogens and are more susceptible to infection (Doenges et al., 2008; Gulanick & Myers, 2007).


4. Assess for exposure to individuals with active infections.

Rationale: This provides warning for potential infection e.g. nosocomial infection (Doenges et al., 2008; Gulanick & Myers, 2007).


5. Maintain and demonstrate aseptic techniques for post-op wound cleaning and dressing.

Rationale: Use of aseptic techniques decreases the chances of transmitting or spreading pathogens (Doenges et al., 2008; Gulanick & Myers, 2007; Johnson et al., 2007).


6. Observe and instruct the patient and significant others to wash hands before, in between and after contact with the patient and the post-operative site.

Rationale: Handwashing effectively remove microorganisms from hands. Washing between the procedures reduces the risk of transmitting pathogens from one area of the body to another (Doenges et al., 2008; Gulanick & Myers, 2007; Johnson et al., 2007).


7.  Encourage increase intake of foods rich in vitamin C, protein and high caloric foods.

Rationale: To maintain optimal nutritional status (Gulanick & Myers, 2007). Protein is needed to replace body tissue and to produce antibodies to fight the infection; minerals are needed to help build and repair body tissue; extra calories are needed for increased metabolic rate; and vitamin C is necessary to fight infection (Roth, 2007).


8. Encourage increase fluid intake and maintain hydration.

Rationale: Extra fluid is needed to replace all the losses during perspiration and discharges accompanied by infection (Doenges et al., 2008; Roth, 2007; Johnson et al., 2007).


9. Render TSB for fever.

Rationale: Promotes evaporation thus decreasing body temperature.


1. Monitor WBC count.

Rationale: An increasing WBC ct. indicates the body’s efforts to combat pathogens. Very low WBC ct. indicates severe risk for infection because the patient does not have sufficient WBCs to fight infection (Doenges et al., 2008; Gulanick & Myers, 2007).


2. Administer and instruct the use and proper administration of antibiotic drugs (oral and otic). Emphasize the importance of adherence and compliance.

Rationale: Full compliance and proper administration helps for full recovery. Not completing the entire course of the prescribed antibiotic regimen can lead to drug resistance in the pathogens and reactivation of symptoms (Doenges et al., 2008; Gulanick & Myers, 2007).


>  Afebrile state; thermo-regulated.> With complete medications and taken on time; adherence reported.> Meals depend on what they can afford to buy but verbalized consciousness on the food the pt.  took and its vitamins content.

> complained of painful post-op site; pain scale of 7-8 out of 10.

> With dry and intact ear pack.

> Able to demonstrate proper handwashing techniques and verbalized its importance.

> Fluid intake of 2L/day.

> Observed aseptic techniques in handling ear packs during ear cleaning and post op site cleaning.

> good prognosis on the results of CBC with WBC diff. ct.

P.E.> S/P Mastoidectomy with tympanoplasty, type V> Swelling of left face and temporal area

> Normoset, asymmetrical, with tenderness and                 edema on the left ear, warm to touch

> Presence of dry and intact post-surgical incision on the left ear

> With left ear pack, dry and intact, no bleeding

> With foul smelling serous discharges on left ear

> With erythematous and edematous left ear canal

> With yellow bulging tympanic membrane

> Absence of hearing on left ear

> Bone conduction  is heard longer than air conduction

> With enlarged tender nodules at the left side of the neck

> With difficulty of moving the neck due to pain and edema

> (+) chilling and cold sensation

> skin warm to touch with profuse sweating

> T – 39.2°C; febrile


Long-term goals:> Patient remains free of infection, as evidenced by normal vital signs and absence of purulent aural discharges.> Absence of complications.
Diagnostic Results:> WBC differential count reveals an elevated white blood cells, neutrophils, lymphocytes and monocytes counts> Culture and sensitivity testing of discharge reveals the presence of staphylococcus aureus

> CT Scan revealed perforation of the tympanic membrane, ossicular abscess and erosions of the bony partitions of the mastoid air cells


NOC Outcomes:Knowledge on Infection Control (Gulanick & Myers, 2007; Johnson et al., 2007)

NIC Interventions:

Infection control and protection (Gulanick & Myers, 2007; Johnson et al., 2007)










Complaints:> complained of painful left ear radiating to temporal area and left side of the face> difficulty to move neck and its ROM, difficulty to masticate.

> unable to sleep and seen restless most of the times.

> complained of sharp, gradual and continuous left ear pain.



Acute pain related to presence of traumatized tissues secondary to surgical procedure done, S/P Mastoidectomy with tymphanoplasty, type V.Acute pain related to pressure on the nerve endings secondary to inflammatory process, Chronic suppurative otitis media. Short-term goals:> Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.> Follow prescribed pharmacological and non-pharmacological regimen.

> Verbalize non-pharmacologic  methods that provide relief.

> Demonstrate use of relaxation skills and diversional activities as indicated.




1. Assess pain characteristics.Rationale: Assessment of the pain experience is the first step in planning pain management strategies (Doenges et al., 2008; Gulanick & Myers, 2007).


2. Observe or monitor signs and symptoms associated with pain, such as BP, HR, temperature, color and moisture of skin, restlessness and ability to focus.

Rationale: Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating the pain (Gulanick & Myers, 2007).


3. Provide rest periods to facilitate comfort, sleep and relaxation.

Rationale: The patient’s experiences of pain may become exaggerated as the result of fatigue. In a cyclic fashion, pain may result in fatigue, which may result in exaggerated pain and exhaustion (Doenges et al., 2008; Gulanick & Myers, 2007).


4. Cognitive-behavioral strategies as follows:

a. Guided imagery

Rationale: The use of a mental picture or an imagined event involves use of the five senses to distract oneself from painful stimuli (Gulanick & Myers, 2007; Johnson et al., 2007).

b. Distraction techniques

Rationale: These heighten one’s concentration upon non-painful stimuli to decrease one’s awareness and experience of pain. Some methods are breathing modifications and nerve stimulation (Gulanick & Myers, 2007).

c. Relaxation exercises, biofeedback, breathing exercises and music therapy.

Rationale: Techniques are used to bring about a state of physical and mental awareness and tranquility. The goal of these techniques is to reduce tension, subsequently reducing pain (Doenges et al., 2008; Gulanick & Myers, 2007; Johnson et al., 2007).


5. Encourage deep breathing exercises.

Rationale: Promotes relaxation and reduces tension ( Doenges et al., 2008).


6. Provide anticipatory instruction on pain causes, appropriate prevention and relief measures.

Rationale: Knowledge about what to expect can help the patient develop effective coping strategies for pain management (Gulanick & Myers, 2007).


7. Instruct patient to report pain.

Rationale: Relief measures may be instituted (Gulanick & Myers, 2007).


8. Instruct the patient to evaluate and report effectiveness of measures used.

Rationale: Pain relief strategies can be modified to promote more satisfactory comfort levels (Gulanick & Myers, 2007).


9. Teach the patient effective timing of the medication dose in relation to potentially uncomfortable activities and prevention of peak pain periods.

Rationale: Patients need to learn to use pain relief strategies to minimize the pain experience (Gulanick & Myers, 2007; Johnson et al., 2007).




1. Administer analgesics or pain reliever as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects.

Rationale: Pain medications are absorbed and metabolized differently by patients, so their effectiveness must be evaluated individually by the patient. Analgesics may cause side effects that range from mild to life threatening (Gulanick & Myers, 2

> Reported pain relief with pain scale of 4 out of 10.> Rest and sleep provided as observed through no. of hrs. of sleep and nap during day time.> Reported of complete hours of sleep last night.

> Seen ambulating at bedside.

> Seen changing his clothes without any help.

> Able to take and finish his meals with good appetite (meaning he can move his jaw for mastication with ease).

> Neck movement and ROM ability.

> Seen smiling and chatting with significant others.

> Very interactive during the interview and speak with ease

> guarding behaviors

> Absence of pain related autonomic responses: no diaphoresis, BP-120/80 mmHg, PR-82 bpm, RR-22 cpm.

P.E.> S/P Mastoidectomy with tympanoplasty, type V> Swelling of left face and temporal area

> Normoset, asymmetrical, with tenderness and                 edema on the left ear, warm to touch

> Presence of dry and intact post-surgical incision on the left ear

> With left ear pack, dry and intact, no bleeding

> With foul smelling serous discharges on left ear

> With erythematous and edematous left ear canal

> With enlarged tender nodules at the left side of the neck

> With difficulty of moving the neck due to pain and edema

> Pain scale  >7.

> Guarding behavior protecting the affected site

> Pacing

> Seeking out other people for help in doing ADL’s

> Facial mask of pain

> Diaphoretic



Long-term goals:> Complete relief and absence of pain report without the need for pharmacologic and non-pharmacologic pain management.> Absence of complications.

> Able to perform ADLs without the help of other people.

Diagnostic Result:> CT Scan revealed perforation of the tympanic membrane, ossicular abscess and erosions of the bony partitions of the mastoid air cells  NOC Outcomes: Comfort level; Medication Response; Pain Control(Gulanick & Myers, 2007; Johnson et al., 2007)


NIC Interventions:

Analgesic Administration; Conscious Sedation; Pain Management

(Gulanick & Myers, 2007; Johnson et al., 2007)


(Doenges, M. E. et al, 2008; Gulanick, M. & Myers, J. L., 2007; Johnson, M. et al , 2007; Roth, R. A., 2007)

Other Nursing Concerns:

– Anxiety management

– Improving hearing and communication

– Promote wound healing and return of skin integrity

-Patient and significant other’s knowledge about the disease, treatment and prevention.

– Initiating self care and continuing care at home


Medications (Brener et al, 2007)

Anti-infective : Ofloxacin Otic

An antibiotic of Fluoroquinolone class, which inhibits bacterial DNA gyrase and prevents DNA replication in susceptible bacteria. Kills susceptible aerobic gram-positive and gram-negative organisms. Indication and dosage: for Chronic Suppurative Otitis Media –  twice daily on affected ear for 14 days.


Anti-infective :Amoxicillin Oral

An antibiotic of Aminopenicillin type that inhibits cell- wall synthesis during bacterial multiplication. Kills susceptible bacteria. Indication and dosage: for severe infections of the ear – 500 mg/capsule  1 capsule every 8 hrs. for 7 days.


Anti-pyretic / Analgesic : Paracetamol

Para-aminophenol derivative, which may produce analgesic effect by blocking pain impulses, by inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting in hypothalamic heat-regulating center. Relieves pain and reduces fever. Indication and dosage: mild pain or fever – 500 mg/tablet  1 tablet every 4 hrs., PRN.


Pain-reliever : Mefenamic Acid

The analgesic effect of NSAIDs may result from interference with the prostaglandins involved in pain. Prostaglandins appear to sensitize pain receptors to mechanical stimulation or to other chemical mediators. NSAIDs inhibit synthesis of prostaglandins peripherally and possibly centrally. Like salicylates, NSAIDs exert an anti-inflammatory effect that may result in part from inhibition of prostaglandin synthesis and release during inflammation. Indication and dosage: mild to moderate pain, inflammation, stiffness, swelling or tenderness caused by trauma or inflammatory process and surgical procedures – Mefenamic Acid 500mg/tablet  1 tablet every 8 hrs. PRN (if there is pain only) on full stomach.


Medical Management

Local treatment

Careful suctioning can be done on the affected ear under microscopic guidance performed by an experienced physician. Proper aural toilet habit and ear care. Instillation of antibiotic drops is used to treat purulent discharges. Also, systemic antibiotics may be prescribed as indicated (Smeltzer & Bare, 2004).

Surgical treatment

Surgical procedures include tympanoplasty, ossiculoplasty and mastoidectomy. Extent of damage and infection determines the type of procedure/s to be performed. Tympanoplasty is the surgical reconstruction of the tympanic membrane which requires ossicles reconstruction. This procedure restores middle ear function, close the perforation, prevent recurrent infection and improve hearing. Ossiculoplasty, surgical reconstruction of the middle ear bones to restore hearing by re-establishing the sound conduction mechanism. Mastoidectomy is done to remove the cholesteatoma, gain access to diseased structures, and create a dry and healthy ear (Smeltzer & Bare, 2004; Goldman, 1996).


Preventing injury from vertigo. Vertigo occurs if the semicircular canals or other areas of the inner ear are traumatized during the mastoid surgery (Smeltzer & Bare, 2004).

Preventing altered sensory perception. Facial nerve (cranial nerve VII) injury is potential but rare complication of mastoid surgery. Chorda tympani nerve disturbance may occur resulting to alteration in taste and dry mouth on the side of the surgery but soon will disappear until the nerve regenerates (Smeltzer & Bare, 2004).

 Health Teaching




Cognitive: Be able to identify the effects and actions of every medication.Psychomotor: Patient and significant others will be able to demonstrate the proper administration of drugs (oral and otic).Affective: Be able to understand the importance of adherence to medication regimen. 1. Administration of take home medications.a. proper time, dosage and route of administrationb. importance of adherence to medications

c. lay-man’s explanation on pharmacology and pharmacokinetics of medications

d. does and don’ts when taking the medications

e. proper instillation of otic drops


Able to identify that ofloxacin drops and amoxicillin are antibiotics that fights infection and dose should be completed to prevent recurrence. Identify that paracetamol should only be taken every four hours if there is fever and mefenamic acid, if there is pain–both should be taken on full stomach to prevent GI ulcer.Provide written instructions to memorize the schedule of medication intake.Confidence in performing the proper instillation of otic drops.

Understands the importance of full adherence to medical regimen.


Cognitive: Patient and significant others will be able to understand the procedures in aural toilet habit.Psychomotor: Patient and significant others will be able to demonstrate the procedures of aural toilet habit.Affective: Patient and significant others will be able to understand the importance of the procedures of aural toilet habit and the importance of compliance for the early recovery of the patient.


2. Aural toilet habita. Proper aural cleaningb. Proper cleaning of post-operative site

c. Aseptic techniques in cleaning post-operative site

d. Handwashing techniques


Confidence to perform proper ear cleaning, aural toilet interventions and instillation of otic drops.Patient and significant others verbalized the importance of handwashing and aseptic techniques when handling the post-operative site.Practice handwashing and applying alcohol most of the times.
Cognitive: Be able to identify the anatomy and physiology of the ear and relate it to instillation of otic drops, aural toilet habit, disease process, surgical procedures and the hearing process.Affective: Develop understanding about his present condition and promote the importance of compliance to medical regimen. 3. Anatomy and physiology of the ear. Verbalize awareness on the anatomy and physiology of the ear.Awareness about the importance of treatment in correlation to anatomy and physiology.Verbalize understanding about the disease process.

Able to identify the ear canal, ear drum and the ossicles and correlate it to the instillation of otic drops, aural toilet habit, disease process, surgical procedures done and the hearing process.


Cognitive: Patient and significant other will be informed and instructed properly about follow up care and check up to promote compliance.Psychomotor: Be able to include and prioritize check up in his schedule and plan the activities.Affective: Promote understanding the importance of compliance and adherence to early recovery and rehabilitation.


4. Follow up care and check up Able to include the follow up check up in his schedule and plan the activities.Seen noting the date of his check up on his calendar.Verbalized the importance of follow up check up.


Cognitive: Be able to identify foods that will aid in the early recovery.Psychomotor: Be cautious and promote awareness on the vitamins and mineral contents of the food that he take.Affective: Be able to understand the importance of dietary management in the early recovery.


5. Dietary Managementa. Foods rich in protein, iron, vitamin C and zinc.b. Foods to avoid

c. Foods to take

d. Importance of diet in the recovery

Able to identify foods of daily meals which are to be included and what to avoid in the dietary list to improve present condition.Meal serves adhere with recommended dietary allowance.Awareness on the importance of foods rich in protein and iron for wound healing; and vitamin C and zinc to boost immune system and aids infection.

Discharge Plan

Medications : Pain-reliever, anti-pyretic and antibiotic medications as prescribed, with proper instructions on intake, administration and compliance.

Environmental : Avoidance of noise-pollution and other hearing hazards. Provide sounds soothing to ears.

Treatment : Proper aural toilet habit and aseptic daily post-op wound care with proper instructions on how to perform the procedures.

Health Teaching : Improving hearing and communication techniques. Health promotion and prevention on the possible recurrence and occurrence of complications.

Out-patient : Follow up consultation after 1 week, as indicated, and or as advised. Importance of compliance to continuous care at home.

Diet : Dietary management of foods rich in protein, iron, vitamin C and zinc. Avoid foods rich in sodium and cholesterol as it may impairs tissue healing; sugar control for diabetic clients. Emphasize importance of diet for rehabilitation and fast recovery.

Health promotion and prevention are the functions of the primary health care system. Mass awareness and education about CSOM can avert social stigma thus, promoting acceptance. This will play a vital role for screening and early detection. A history of at least 2 weeks of persistent ear discharge should alert primary health workers to the problem. Hearing loss can be prevented if people will listen and learn the ways on how it can be avoided.

CSOM may lead to hearing loss or deafness. The antibiotics and surgeries are very expensive. Its effects are not only centered on the social stigma moreover, its burden is on the permanent damage of deafness. But it can be prevented, early detection and management will save thousands of patients from deafness. Early management will save you from expensive cost of medications, surgery and hospitalization.


  • Acuin, J. (2004). Chronic Suppurative Otitis Media: Burden of Illness and Management Options. Geneva, Switzerland: World Health Organization Publication, 7–10, 20. Bonin, E. et al. (2003).
  • Adapting Your Practice: Treatment and Recommendations for Homeless Children with Otitis Media. Nashville: Health Care for the Homeless Clinician’s Network, 1–3. Brener T. et al. (2007).
  • Springhouse Nurse’s Drug Guide 2007, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 1175, 934–937, 149–151, 99–101, 75–76. Doenges, M. E. et al. (2008).
  • Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales, 11th ed. Philadelphia: F.A. Davis Company, 409–413, 498–503.
  • Goldman, M. A. (1996). Pocket Guide to the Operating Room, 2nd ed. Philadelphia: F.A. Davis Company, 437–440. Gulanick, M. & Myers, J. L. (2007). Nursing Care Plans: Nursing Diagnosis and Intervention, 6th ed. Singapore: Mosby Elsevier, 108–112, 144–149. Johnson, M. et al. (2007). NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, & Interventions, 2nd ed. Singapore: Mosby Elsevier, 557–561, 303–305. McFarland, M. B. & Grant, M. M. (1988).
  • Nursing Implications of Laboratory Tests, 2nd ed. New York: Delmar Publishers, Inc., 19–30. Roth, R. A. (2007). Nutrition & Diet Therapy, 9th ed. Singapore: Delmar and Thomson Asia Pte Ltd., 382. Smeltzer, S.C. & Bare, B.G. (2004).
  • Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 10th ed. PA: Lippincott Williams & Wilkins, 1802–1805. Sheir, D.N. et al (2006). Hole’s Essentials of Human Anatomy & Physiology, 9th ed. New York: McGraw-Hill Companies, Inc. 


  1. Thank you so much mam.. You r doing a gr8 job. Plz show me the path of knowledge..i m a 3rd year nursing student..uor biadata have inspired a lot.. I want to become like you .. Plzz plzz plzz show me the path.. And help me to become like you..

    • Sohini chandra : Thank you so much. I believe you can do better than I did. You are still young … and for sure you will be better than me in the near future. Just study hard and focus on your dreams … strive harder beyond what you can do. We always have that adrenaline power… it will be released the more you aspire … have a great day!