EAR DISORDERS

Brief Anatomy & physiology Middle ear: Ear drum laterally to otic capsule medially Connected to nasopharynx by eustachian tube which drains secretion from the middle ear and equalize pressure Tympanic membrane has 3 layers; outer continuous with skin of ear canal; fibrous middle layer; inner mucosal layer Ossicles: malleus, incus, stapes

Brief Anatomy & physiology Inner ear: Housed within temporal bone Cochlea for hearing Semicircular for balance Cranial nerves: VII-facial, VIII vestibulocochlear Both cochlea & semicircular are housed in bony labyrinth which is bathed by a fluid, perilymph Function of ear Hearing Balance & equilibrium; visual system, vestibular system, proprioceptive system corporate to balance

Clinical manifestations: Hearing loss Conductive hearing loss: result from external ear disorder, impacted cerumen; or middle ear disorder, otitis media—transmission of sound is interrupted Sensorineural hearing loss involves damage to chochlea or vestibulocochlear nerve Clinical manifestations: Tinnitus, increasing inability to hear in a group, Attitudes changes, reduced communication ability—reduced QoL May feel isolated ; loose a part of conversation May be unaware of their gradual impairment, surrounding Develop negative attitudes to hearing aids Read chart 59-2, P 1809

Noise-induced hearing loss: chronic exposure to loud noise prevention Noise-induced hearing loss: chronic exposure to loud noise Acoustic trauma: exposure to extremely intense noise, explosion Read chart 59-3, P1810 Wear ear protection Medical management--permanent or untreatable hearing loss-- aural rehabilitation Nursing management: effective communication; use interpreter, gestures-facial expression Having other health problems that may receive no attention

Middle ear acute otitis media Most commonly seen in children Is acute infection of middle ear; lasting less than 6 weeks Bacteria enter after eustacian tube dysfunction—URT infection-related obstruction / inflammation Enter from contaminated secretions in the nasopharynx or from tympanic membrane perforation A purulent exudate is usually present in the middle ear resulting in a conductive hearing loss

Clinical manifestations Symptoms vary with severity of infection Usually unilateral associated with Otalgia Pain is relieved after spontaneous perforation or therapeutic incision of the tympanic membrane Other symptoms: drainage, fever, hearing loss Otoscopic examination: tympanic membrane is erythematous and bulging Risk factors Age younger than 12 Chronic upper respiratory tract infection Chronic exposure to secondhand smoking Medical condition: cystic fibrossis, down syndrome, cleft palate

AOM Medical management May resolve with early, appropriate antibiotics If drainage, antibiotic otic preparation; The condition becomes subacute: lasting 3W.-3Ms with persistent purulent discharge Rarely does permanent hearing loss Complications: mastoid and intracranial complications, meningitis, brain abscess; rarely Surgical management Myringotomy (tympanotomy), an incision in the tympanic membrane to relieve pressure & drain purulent fluid, heals within 24-72 hours If AOM is recurrent, ventilating tube for 6-18 months to equalize pressure and drain fluid

Chronic otitis media Is the result of recurrent AOM causing irreversible tissue pathology and persistent perforation of the tympanic membrane; damage the ossicles Chronic infection destroys the ossicles, involve the mastoid Clinical manifestations: Varying degree of hearing loss, Persistent or intermittent foul-smelling otorrhea; Pain only in acute mastoiditis Otoscopic exam: perforation and chloesteatoma Chloesteatoma is an ingrowth of the skin of the external layer of eardrum into the middle ear Chronic otitis media can cause chronic mastoiditis

Chronic otitis media management Careful suctioning of the ear; instillation of antibiotics drops / powder Surgical: Tympanoplasty: surgical reconstruction of the tympanic membrane, reconstruction of ossicles may be required Purpose to re-establish the function of middle ear , improve hearing Is performed through external auditory canal or through a post-auricular incision Dramatic improvement of hearing Ossiculoplasty: is reconstruction of middle ear, bones, to restore hearing; prostheses are used to connect bones to reestablish sound conduction mechanism

Surgical management Mastoidectomy: the objectives, remove chloesteatoma, gain access to diseased structures, create a dry and healthy ear Performed through a post-auricular incision; under general anesthesia, Mastoid pressure dressing Immediately check for facial paresis Read nursing care plan for patients undergoing Mastoid surgery, P 1815-1816.

Mastoid interventions (surgery)—nursing interventions Reducing anxiety Discuss any anxiety & concerns Provide information about surgery and expected results, hearing, taste, balance Relieving pain Residual blood or fluid in middle ear may cause discomfort Analgesics for 24 hours; then as needed Intermittent sharp shooting pain—eustachian tube is open & allows air to enter middle ear Constant throbbing pain with fever—infection & should be reported

Mastoid interventions—nursing interventions Preventing infection External auditory canal wick (packing) impregnated with antibiotic Prophylactic antibiotic Instruct patients to prevent water from entering the ear canal for 6 weeks Use a cotton ball covered with water-insoluble, petroleum jelly during showers Keep post-auricular wound dry Immediately report S &S of infection

Mastoid interventions—nursing interventions Improving hearing & communications Hearing may be reduced in the operated ear Measures include Reducing environmental noise Face the patient; speak clearly & distinctly without shouting Adequate lighting for speech reading non-verbal clues

Mastoid interventions—nursing interventions Preventing injury Vertigo may occur after surgery Antiemetic or antivertiginous, antihistamine, can be prescribed Safety measures: assisted ambulation to prevent fall Instruct to avoid heavy lifting, straining, exertion, nose blowing for 2-3 weeks after surgery to prevent dislodging the tympanic membrane graft

Meniere disease Abnormal fluid balance of inner ear Caused by Malabsorption in the endolymphatic sac Blockage in the endolymphatic duct Endolymphatic hydrops, a dilatation in the endolymphatic space develops Thus increasing pressure in the system Or, causing rupture in the inner ear membrane

Meniere disease—clinical manifestations Fluctuating progressive sensorineural hearing loss Tinnitus, a roaring sound A feeling of pressure or fullness in the ear Incapacitating vertigo associated by nausea & vomiting Cochlear Meniere: Fluctuating progressive sensorineural hearing loss associated with tinnitus & aural pressure Vestibular Meniere: episodic of vertigo associated with aural pressure but not cochlear symptoms

Meniere disease—health assessment Determine frequency, duration, severity of vertigo Assess diaphoresis & persistent feeling of imbalance—may weaken patients at night Feeling well between attacks Assess hearing loss; may fluctuate with tinnitus Audiogram Elecctronystagmogram Physical exam

Medical management Low sodium diet; to maintain adequate hydration Psychological evaluation Read dietary guidelines Chart 59-7,P. 1819 Pharmacologic therapy Antihistamines, Mclizine, to suppress the vestibular system Tranquilizers, Diazepam , in acute instances to control vertigo Antiemetic, Promethazine to control nausea/vomiting Diuretics to decrease the pressure in the endolymphatic system –intake of foods containing K

Surgical management To improve quality of life—relieve vertigo Hearing loss, tinnitus may remain Endolymphatic sac decompression or shunting—a shunt or drain is inserted in the endolymphatic sac to equalize the pressure in the endolymphatic spac through a postauricular incision; treat vertigo of Meniere’s disease Vestibular nerve sectioning—provides greatest success in eliminating vertigo Cutting the nerve prevents the brain from receiving inputs from semicircular canal Read Chart 59-8, P. 1821; care of the patient with vertigo

Meniere disease—nursing care for patients with vertigo Remains free of any injury associated with imbalance & fall Assess vertigo and extent of disability regarding ADLs Administer antivertiginous medications Encourage patients to sit down when dizzy Place pillows in each side of the head to restrict movement Assess to identify aura that suggests an impending vertigo Patients keep eye open & stare straight ahead when lying down & experience vertigo

Meniere disease—nursing care for patients with vertigo Maintain normal fluid & electrolytes balance Assess I & O, electrolytes, indicators of dehydration Encourage oral fluids as tolerated—restrict caffeine-containing beverages Administer antiemetic & antidiarrheal if needed Relieve anxiety Provide information about vertigo & its treatment Encourage exploring fears & concerns Teach stress management Avoid stress-producing activities

Meniere disease—nursing care for patients with vertigo Reduce the risk of trauma Assess for balance disturbances Assist with ambulation when indicated Assess for visual acuity & proprioceptive deficit Encourage increase in activities Help identify hazards at home READ CHART 59-8 p. 1821-1823.