Ear and Hearing Disorders

Ear and Hearing Disorders
Chapter 54 Ear and Hearing Disorders Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Copyright © 2016 by Saunders, an imprint of Elsevier Inc.
Anatomy of the Ear External ear Auricle Innervation Lymph drainage External auditory canal Tympanic membrane What is the tympanic membrane commonly called? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Anatomy of the Ear (cont.)
Middle ear Bones: malleus, incus, and stapes Eustachian tube Mastoid process Inner ear Membranous labyrinth Bony labyrinth What fluid is contained in the membranous labyrinth? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Physiology of Hearing Perception and interpretation of sound depend on a complex series of steps A malfunction at any step can result in some type of hearing impairment Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Age-Related Changes Skin of the auricle may become dry and wrinkled Cerumen production declines; protective wax is drier Hairs in canal coarser/longer, especially in men Eardrum thickens; bony joints in middle ear degenerate Degenerative changes: atrophy of the cochlea, the cochlear nerve cells, and the organ of Corti Type of hearing loss associated with age: presbycusis Dryness of the external canal causes itching. What may cause hearing loss and balance problems in the older adult? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Health History History of present illness Changes in hearing acuity, pain, tinnitus, dizziness, vertigo, nausea, vomiting, and problems with balance Medical history Acute conditions: sinus infections, dental problems, allergies, upper respiratory infections Chronic conditions: hypertension, DM, hypothyroidism Surgical procedures on ear or throat or recent head injury It should be noted whether female patients have had rubella or have been immunized for the infection Medication history identifies drugs taken that might be ototoxic What is otalgia? The patient is asked to describe the nature of the pain (e.g., sharp, throbbing, dull) and when it occurs. Hearing impairments are often congenital (present at birth). One cause of hearing loss in an infant is rubella during the mother’s pregnancy. What does ototoxic mean? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Health History (cont.) Functional assessment Exposure to excessively loud noise, such as amplified music, firearms, or noisy machinery The use of any assistive hearing devices Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Physical Examination Observe how patient responds to a normal voice Note presence of a visible hearing aid Patient’s posture and balance while walking and sitting alert the examiner to possible inner ear problems Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Physical Examination (cont.)
External ear Position of the auricles is significant Auricles examined for shape, lesions, nodules Palpate auricles and mastoid process for tenderness Palpation in front of, below, and behind the ear may locate enlarged lymph nodes Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Physical Examination (cont.)
External auditory canal Inspect outer portion of the external auditory canal for any obvious obstructions or drainage If drainage, the color, amount, and odor recorded Inspect the external canal and the tympanic membrane What is the only normal secretion in the canal? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Diagnostic Tests and Procedures
Otoscopic examination Audiometry Caloric test Electronystagmography Hearing acuity tests Tuning fork tests Rinne test Weber test Posturography Rotary chair testing Other auditory tests Auditory evoked potential, auditory brainstem response, and electrocochleography Radiographic examinations, especially the computed tomographic (CT) scan, may be used to study the mastoid bone, middle ear, and inner ear. What is the difference between an otologist and audiologist? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Therapeutic Measures Ear drops Irrigation Hearing aids Cochlear implants Temporal bone stimulators Surgery Medications intended to be placed directly into the external ear canal are called otic drops, or simply ear drops. What points should be kept in mind when administering ear drops? Irrigation is the use of a solution to cleanse the external ear canal or to remove something from the canal. A hearing aid is a device that amplifies sound; that is, it makes sound louder. A cochlear implant may be recommended for people who cannot benefit from regular hearing aids. Patients with conductive hearing loss may benefit from a temporal bone stimulator. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Nursing Care of the Patient Having Ear Surgery
Preoperative Deficient Knowledge: Supply needed information about the procedure and surgical routine Anxiety: Address specific concerns, patient teaching and reassurance; notify provider if very anxious Notify operating staff of hearing impairment; ask if patient can wear the hearing aid to the surgical suite Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Nursing Care of the Patient Having Ear Surgery (cont.)
Postoperative Assessment: pain, nausea, dizziness, fever, wound drainage Interventions: Acute pain Risk for injury Risk for infection Disturbed sensory perception Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Question 1 Which of the following is not an age-related change in the ear? Cerumen production increases. The protective wax is drier. The eardrum thickens. Bony joints in the middle ear degenerate. Correct answer: A Rationale: Cerumen production declines and the protective wax is drier. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Question 2 Which is a contraindication to ear irrigation? Loose, waxy earwax Dried, hard earwax Ruptured tympanic membrane Impacted cerumen Correct answer: C Rationale: Irrigating a ruptured tympanic membrane could cause the fluid to be forced into the middle ear. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Types of Hearing Loss Conductive hearing loss Interference with the transmission of sound waves from the external or middle ear to the inner ear Sensorineural hearing loss Disturbance of the neural structures in the inner ear or the nerve pathways to the brain Mixed hearing loss A combination of conductive and sensorineural losses Central hearing loss Problem in the central nervous system Factors that may cause conductive hearing loss include obstruction of the external canal or eustachian tube and otosclerosis. Sensorineural hearing loss may be congenital, but it also can be caused by noise trauma, aging, Ménière disease, ototoxicity, diabetes, and syphilis. What is sensorineural hearing loss commonly called? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Signs and Symptoms Complaints that their hearing is good but others mumble Leaning or turning one ear toward the speaker May fail to follow directions, speak while others are speaking, or turn the radio/TV up very loud Irritability and even hostility not unusual Some become very suspicious of others because they cannot hear what is being said Otalgia (ear pain), dizziness, and tinnitus with certain types of disorders Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

The Impact of Hearing Impairment
Those who had impairments in early childhood usually have speech difficulties When a person refuses to admit to a hearing loss, family members and others may stop trying to communicate Hearing-impaired person may alienate those who would like to be close and supportive People with severe hearing impairment probably suffer the most severe social isolation of those with sensory disorders Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Adaptations to Hearing Loss
Hearing aids—some improvement in hearing Many patients read lips and observe body language Sign language uses a universal set of hand signals Telephones can be adapted to send and receive written messages Earphones for radios, stereos, and televisions Some television channels provide closed-captioned programming Handheld computers print out messages typed by the user Dogs are taught to recognize common sounds (doorbell, telephone, smoke alarm, crying baby) and to get the attention of the owner Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Care of the Patient with Impaired Hearing
Interventions Impaired verbal communication Social isolation Ineffective coping Deficient knowledge Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Foreign Bodies and Cerumen
Foreign bodies can get into the external ear canal Most small objects can be flushed by gentle irrigation Insects can be killed by instilling a small amount of mineral oil; they can then be flushed from the canal Alternative is to hold a flashlight near the auricle. Because insects are often attracted to light, they may move out of the canal Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Foreign Bodies and Cerumen (cont.)
Impacted cerumen is one of the most common causes of obstruction Provider may order ear drops to soften the cerumen before irrigation Provider can use ear forceps or a cerumen spoon to remove it Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Foreign Bodies and Cerumen (cont.)
Nursing care Inspect ear canal for impacted cerumen The primary nursing diagnosis is Disturbed sensory perception related to obstruction of the external auditory canal Educate patients to avoid trying to remove cerumen with cotton-tipped applicators or other tools such as hair pins The dry cerumen may be gold to dark brown. How is a foreign body or cerumen removed from the external auditory canal? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

External Otitis or Swimmer’s Ear
Infection/inflammation of lining of external canal Signs and symptoms Pain that increases when the auricle is pulled Dizziness, fever, and drainage Medical treatment Topical antibacterial or antifungal drugs Corticosteroid drops Interventions Acute pain Deficient knowledge What may cause external otitis? When infection is present, it often is caused by staphylococci or streptococci, but may also be fungal in origin. If the external canal is obstructed by edema, the provider may insert an ear wick through the blocked canal. Pain is treated with mild analgesics. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Acute Otitis Media Middle ear infection; usually develops with colds Edema: blockage of the eustachian tubes Fluid accumulates in the middle ear, causing painful pressure on tympanic membrane Membrane may rupture, resulting in scarring and subsequent hearing loss Patient often has a fever and headache More common in children than in adults Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Acute Otitis Media (cont.)
Medical treatment Oral antibiotics Topical ear drops Antihistamines Myringotomy Prior to administering the drops, the canal should be cleared of debris. Antihistamines may be ordered if allergies are thought to be contributing to the problem. Myringotomy is the creation of a small opening in the tympanic membrane. What is the purpose of a myringotomy? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Chronic Otitis Media Hearing loss and continuous or intermittent drainage Eardrum usually perforated (ruptured) or shows signs of a healed perforation Possible complications of chronic otitis media include mastoiditis, meningitis, labyrinthitis, cholesteatoma, and hearing impairment An audiogram may detect some conductive hearing loss if the bones in the middle ear have been damaged by the chronic infection. Does the patient with chronic otitis media usually experience pain? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Chronic Otitis Media (cont.)
Medical treatment Systemic antibiotics and, if the eardrum is intact, irrigations to remove debris Tympanoplasty if tympanic membrane does not heal Mastoidectomy if the infection has extended to the mastoid bone Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Care of the Patient Having a Mastoidectomy
After surgery on the middle ear: comfort, safety, prevention of infection, and prevention of pressure on the tympanic membrane Nausea common Inspect the dressing and describe drainage but do not disturb or remove the dressing Assist patient first time out of bed, in case of dizziness Patient should avoid activity that creates pressure on the tympanic membrane (blowing the nose, coughing, sneezing, straining) If the patient does have to cough or sneeze, what advice should be given to prevent injury? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Otosclerosis A hereditary condition in which an abnormal growth causes the footplate of the stapes to become fixed Fixed stapes cannot vibrate, so sound waves cannot be transmitted to inner ear Effect is a conductive hearing loss Most common in young white women If the disease also involves the inner ear, the patient has sensorineural hearing loss as well. What population is otosclerosis most common in? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Otosclerosis (cont.) Signs and symptoms Slowly progressive hearing loss in the absence of infection In the early stages, patient may report tinnitus Rinne test reveals bone conduction to be greater than air conduction Medical treatment Stapedectomy Surgical risks include complete hearing loss, infection, prolonged vertigo, and damage to the facial nerve. Why is bedrest usually ordered for several days after a stapedectomy? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Care of the Patient Having a Stapedectomy
After surgery, pain relief, safety, prevention of infection, and avoidance of pressure in the ear Especially important that the patient not do anything that increases pressure in the ear Nausea, vomiting, and vertigo are common The packing in the ear should not be disturbed When is the packing commonly removed? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Care of the Patient Having a Stapedectomy (cont.)
After dressing and packing removed, patient advised to keep the ear dry for at least 2 weeks Swimming and showering not permitted for 6 weeks The patient should avoid contact with people who have colds. A balanced diet and adequate rest are needed for tissue healing and resistance to infection Vertigo may persist after discharge and you must help the patient plan for assistance with activities of daily living. How soon will hearing improvement occur? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Labyrinthitis Inflammation of the labyrinth Acute labyrinthitis usually follows an acute upper respiratory infection, acute otitis media, pneumonia, or influenza Also can be an adverse effect of drugs One type is suppurative labyrinthitis Inner ear infection that usually follows an upper respiratory infection, ear infection, or ear surgery The effects can destroy the labyrinth and cochlea, causing permanent deafness Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Labyrinthitis (cont.) Signs and symptoms Vertigo, nausea, vomiting, headache, anorexia, nystagmus, and sensorineural hearing loss on the affected side Medical treatment Antiemetics and supportive care until it resolves Antibiotics if infection is present A typical episode lasts 3 to 6 weeks. What is nystagmus? Additional symptoms of suppurative labyrinthitis are tinnitus and hearing loss. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Labyrinthitis (cont.) Nursing care Assess symptoms Monitor intake and output, daily weights if possible, and food intake if persistent vomiting Assist/supervise the patient when out of bed Give antiemetics as prescribed If vomiting persists, the patient is at risk for development of fluid and electrolyte imbalances (hypokalemia, fluid volume deficit). How is fluid and electrolyte imbalance treated? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Labyrinthitis (cont.) Nursing care Interventions Risk for injury Imbalanced nutrition: Less than body requirements Risk for deficient fluid volume Anxiety How can the nurse provide for patient safety when a patient is experiencing labyrinthitis? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Ménière Disease A disorder of the labyrinth The cause is unknown Symptoms related to an accumulation of fluid in the inner ear Attack triggers: alcohol, nicotine, stress, and certain stimuli such as bright lights and sudden movements of the head More than 2 million Americans are thought to have attacks of Ménière disease. At what age does Ménière disease usually occur? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Ménière Disease (cont.)
Signs and symptoms Hearing loss and vertigo accompanied by pallor, sweating, nausea, and vomiting Hearing loss is unilateral Tinnitus accompanies acute attacks Patients who have had many attacks may eventually have permanent sensorineural hearing loss A feeling of fullness and pressure in the ear often precedes a vertigo attack Acute attacks occur at intervals and last for hours to days. Hearing usually improves between attacks, but some loss of low-frequency sounds may remain. What may occur if sudden movements are made during a vertigo attack? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Medical diagnosis Diagnosed by ruling out other conditions that can cause similar symptoms Provider likely to order a number of radiographs and other tests to detect any neurologic, allergic, or endocrine disorders Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Medical treatment Drugs: atropine, epinephrine, benzodiazepines such as diazepam (Valium), antihistamines, antiemetics, anticholinergics, vasodilators, and diuretics Low-sodium diet Vestibular rehabilitation Pressure pulse treatment Caffeine, nicotine, and alcohol are discouraged. How is vestibular rehabilitation performed? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Surgical treatment Surgical procedures work by draining excess fluid from the inner ear (endolymphatic shunt) or by cutting the part of the acoustic nerve that controls balance (vestibular nerve section) More destructive surgical procedures are labyrinthotomy and labyrinthectomy Surgery is usually advised only when all other measures have failed. What are potential complications of surgery for Ménière disease? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Assessment Document pattern of acute attacks Note substances/stimuli that trigger episodes Specific symptoms including nausea, vomiting, vertigo, and tinnitus Determine how the condition affects the patient’s life, what the patient knows about the disease, and coping mechanisms Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Postoperative care Carefully check provider’s orders for position and activity limitations Safety, comfort, and detection of complications Antiemetics to control nausea and vomiting No nonessential care until patient tolerates movement Assist patient when getting up and walking Call button should always be within reach; patients may be dizzy for several days, unsteady for several weeks Assess for facial nerve damage The first few days after surgery, the patient’s symptoms are usually severe. How can the nurse assess for facial nerve damage? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Presbycusis Hearing loss associated with aging Result of changes in one or more parts of the cochlea Signs and symptoms May hear well in quiet surroundings but poorly in noisy places Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Presbycusis (cont.) Medical diagnosis and treatment Hearing evaluation for the older person whose hearing seems to be declining Many with presbycusis benefit from hearing aids Devices available to improve hearing: phone amplifiers and personal earphones for radios and televisions Many people have the mistaken idea that hearing loss in older adults is inevitable and not treatable. How can a patient improve communication? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Presbycusis (cont.) Nursing care Educate about hearing loss and aging Work to overcome the resistance that many people have to admitting hearing loss Once problem diagnosed, nurses can help the patient adapt and learn to use supportive devices Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Ototoxicity Damage to the ear or eighth cranial nerve caused by specific chemicals, including some drugs Common ototoxic drugs are salicylates (aspirin) and aminoglycoside antibiotics From reversible tinnitus to permanent hearing loss The primary symptom of ototoxicity with salicylates is tinnitus, which disappears when the drug is discontinued Extent depends on dosage and how long it was given Patients who have poor renal function are at special risk for ototoxicity because drugs are excreted more slowly Aminoglycosides can cause permanent hearing loss. Besides hearing, what else may be affected by ototoxicity? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Ototoxicity (cont.) Nursing care Primary are early detection and prevention of progressive hearing loss caused by ototoxic drugs To reduce risk of ototoxicity, be familiar with these drugs. Instruct patients to report hearing loss, tinnitus, or problems with balance Promptly report such symptoms to the provider Teach patients that aspirin is not a harmless drug Monitor urine output of patients on ototoxic drugs: low output may mean the drug is excreted slowly, increasing risk of toxicity Report low urine output to the provider Care plan should alert all staff to potential for ototoxicity Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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