1. Ear and Hearing Disorders
Chapter 52
Ear and Hearing Disorders 1

2. Learning Objectives
Identify the data to be collected for the assessment of
a patient with a disorder affecting the ear, hearing, or balance.
Describe the tests and procedures used to diagnose disorders
of the ear, hearing, or balance.
Explain the nursing considerations for each of the tests
and procedures.
Explain the nursing care for patients receiving common
therapeutic measures for disorders of the ear, hearing,
or balance.
Describe the pathophysiology, signs and symptoms,
complications, and medical or surgical treatment for selected
disorders.
Assist in the development of a nursing care plan for a patient
with a disorder of the ear, hearing, or balance.
Identify measures the nurse can take to reduce the risk
of hearing impairment and to detect problems early.

3. Anatomy of the Ear External ear Auricle Innervation Lymph drainage
External auditory canal
Tympanic membrane
What is the tympanic membrane commonly called? 3

4. Anatomy of the Ear Middle ear Inner ear
Bones: malleus, incus, and stapes
Eustachian tube
Mastoid process
Inner ear
Membranous labyrinth
Bony labyrinth
What fluid is contained in the membranous labyrinth? 4

5. Figure 52-1 5

6. Figure 52-2 6

7. 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
See Figure 52-3, p. 1189 7

8. Figure 52-3 8

9. 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? 9

10. Assessment of the External Ear, Hearing, and Balance10

11. Health History History of present illness Past medical history
Changes in hearing acuity, pain, tinnitus, dizziness, vertigo, nausea, vomiting, and problems with balance
Past medical history
Acute or chronic problems
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? 11

12. Health History Functional assessment
Exposure to excessively loud noise, such as amplified music, firearms, or noisy machinery
The use of any assistive hearing devices 12

13. 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 13

14. Physical Examination 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 14

15. Physical Examination 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? 15

16. Diagnostic Tests and Procedures
Otoscopic examination
Audiometry
Caloric test
Electronystagmography
Hearing acuity tests
Tuning fork tests
Rinne’s test
Weber’s test
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 and audiologist? 16

17. Figure 52-4 17

18. Figure 52-5 18

19. 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. 19

20. Figure 52-6 20

21. Figure 52-7 21

22. Care of the Patient Having Ear Surgery
Assessment
In postoperative period, pain, nausea, dizziness, fever
Inspect the wound dressing for drainage
Drainage color, odor, and amount
Interventions
Acute Pain
Risk for Injury
Risk for Infection
Disturbed Sensory Perception 22

23. 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’s disease, ototoxicity, diabetes, and syphilis.
What is sensorineural hearing loss commonly called? 23

24. 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 24

25. 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 25

26. 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 26

27. Care of the Patient with Impaired Hearing
Interventions
Impaired Verbal Communication
Social Isolation
Ineffective Coping
Deficient Knowledge 27

28. Disorders Affecting Hearing and Balance28

29. 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 29

30. Foreign Bodies and Cerumen
Impacted cerumen is one of the most common causes of obstruction
Physician may order ear drops to soften the cerumen before irrigation
Physician can use ear forceps or a cerumen spoon to remove it 30

31. Foreign Bodies and Cerumen
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? 31

32. 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 physician may insert an ear wick through the blocked canal.
Pain is treated with aspirin or codeine. 32

33. Furuncle
An inflamed area in the external auditory canal caused by infection of a hair follicle
The area is very painful to the touch
Hearing may be impaired if swelling blocks canal
Ruptured furuncle releases fluid that may drain
Treatment includes systemic and topical antibiotics (with an ear wick if needed)
If condition does not improve, physician may incise and drain it 33

34. 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 34

35. Acute Otitis Media 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? 35

36. 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? 36

37. Chronic Otitis Media 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 37

38. 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? 38

39. 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? 39

40. Otosclerosis Signs and symptoms Medical treatment
Slowly progressive hearing loss in the absence of infection
In the early stages, patient may report tinnitus
Rinne’s 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? 40

41. Figure 52-8 41

42. 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? 42

43. Care of the Patient Having a Stapedectomy
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? 43

44. 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 44

45. Labyrinthitis Signs and symptoms Medical treatment
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. 45

46. Labyrinthitis 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? 46

47. Ménière’s 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’s disease.
At what age does Ménière’s disease usually occur? 47

48. Ménière’s Disease 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? 48

49. Ménière’s Disease Medical diagnosis
Diagnosed by ruling out other conditions that can cause similar symptoms
Physician likely to order a number of radiographs and other tests to detect any neurologic, allergic, or endocrine disorders 49

50. Ménière’s Disease Medical treatment
Drugs: atropine, epinephrine, benzodiazepines such as diazepam (Valium), antihistamines, antiemetics, anticholinergics, vasodilators, and diuretics
Low-sodium diet
Vestibular rehabilitation
Caffeine, nicotine, and alcohol are discouraged.
How is vestibular rehabilitation performed? 50

51. Ménière’s Disease 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’s disease? 51

52. Ménière’s Disease 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 52

53. Ménière’s Disease Interventions Risk for Injury
Risk for Deficient Fluid Volume
Anxiety
Ineffective Therapeutic Regimen Management 53

54. Ménière’s Disease Postoperative care
Carefully check physician’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 patients 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? 54

55. 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 55

56. Presbycusis 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? 56

57. Presbycusis 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 57

58. 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? 58

59. Ototoxicity 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 physician
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 physician
Care plan should alert all staff to potential for ototoxicity 59