1. Disorders of the Ear

2. Objectives
Discuss major inflammatory, infectious and noninfectious disorders of the ear
Discuss med-surg management
Discuss nursing management
Client education

3. Hearing Impairment
A state of decreased auditory acuity that ranges from partial to complete hearing loss

4. 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
Conductive Hearing Loss:
Common cause: cerumen build-up
Sensitivity to sound is diminished but clarity or interpretation of sound is not changed
Good candidate for hearing aid if cerumen is not the cause
Senorineural Hearing Loss
A defect in the inner ear results in distortion, making sound discrimination difficult
Usually caused by:
Trauma
Infectious process
Presbycusis
Exposure to ototoxic drugs
Destruction of the cochlear hair by intense noise
Hearing aid would amplify sound and would be useful if client not sensitive to loud noises 4

5. Types of Hearing Loss Congenital hearing loss Functional hearing loss
Can happen during pregnancy or delivery
Syphilis or Rubella exposure
Rh incompatibility
Anoxia or trauma during delivery
Ototoxic drugs
Functional hearing loss
No organic cause
Also called psychogenic or nonorganic hearing loss
Central hearing loss
Problem in the central nervous system
The brain’s auditory pathways are damaged as in a stroke

6. Loss of Hearing (Deafness)
Clinical manifestations/assessment
Requests for repeating information
Non-response
Delayed speech development
Assessment
S: note onset and progression of the condition; deficit in one or both ears; family hx. or hx. of head trauma; exposure to noise, current medications, visual or speech disorders
O: behavioral clues that indicate hearing difficulty
P. 631 Box 13-2

7. Behavioral Clues Indicating Hearing Loss
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 7

8. Loss of Hearing (Deafness)
Diagnostic Tests:
Weber’s Test
Rinne Test
Audiometric Testing
Nursing Responsibilities
Explain the purpose of and the procedure

9. Loss of Hearing (Deafness)
Medical management
According to the type of impairment
Hearing aids
Surgical procedures
Cochlear implant

10. Loss of Hearing (Deafness)
Nursing Interventions:
Instruct in insertion and care of hearing aid
p Box 13-3 Care of the Hearing Aid
Nursing Diagnoses include:
Disturbed Sensory Perception AEB frequently asking people to repeat themselves (auditory) related to new dx. of hearing impairment
Social isolation related to loss of hearing

11. Loss of Hearing (Deafness)
Prognosis:
Some restoration of hearing with surgical repair
Microtechnology has reduced size of hearing aids

12. Presbycusis Hearing loss associated with aging
Gradual atrophy of the sensory receptors and cochlear nerve fibers
Signs and symptoms
May hear well in quiet surroundings but poorly in noisy places
Ability to hear high pitched sounds is usually lost first 12

13. 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 13

14. Figure 52-6 14

15. Figure 13-15 Parts of a hearing aid.
(From Long, B., Phipps, W., & Cassmeyer, V. [1995]. Medical-surgical nursing: a nursing process approach. [3rd ed.]. St. Louis: Mosby.)
Parts of a hearing aid.

16. Figure 52-7 16

17. Impact of Hearing Impairment
Those who had impairments in early childhood usually have speech difficulties
When a person refuses to admit to 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 17

18. Impact of Hearing Impairment
People with severe hearing impairment probably suffer the most severe social isolation of those with sensory disorders

19. 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 19

20. Adaptations to Hearing Loss
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

21. Nursing Care Educate pt. 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 21

22. Nursing Care Nursing diagnoses: (r/t, AEB)
Impaired Verbal Communication
Social Isolation
Ineffective Coping
Deficient Knowledge 22

23. Inflammatory and Infectious Disorders of the Ear

24. External Otitis Etiology/pathophysiology
Inflammation or infection of the external canal or the auricle of the external ear
Sometimes called “swimmer’s ear”
More present in hot, humid weather
Can be caused by allergy, bacteria, fungi, viruses, and trauma

25. External Otitis Etiology/Pathophysiology
Chemicals in hairsprays, cosmetics, hearing aids, and medications as well as from nickel or chromium in earrings can cause allergies  external otitis
Bacterial agents include: Staph Aureus, Pseudomonas A. and Streptococcus pyogenes

26. External Otitis Etiology / Pathophysiology
Viruses include herpes simplex and h. zoster
Fungi such as Aspergillus and Candida
Trauma from cleaning or scratching the ear canal with a foreign object
Dry hard cerumen  difficult removal  external otitis
Activities that allow moisture to become trapped in the ear creating a medium for bacteria to grow on:
Use of earphones, hearing aids, stethoscopes

27. External Otitis Clinical manifestations/assessment
Pain with movement of auricle or chewing
Erythema, scaling, pruritus, edema, watery discharge, and crusting of the external ear
Drainage may be purulent or serosanquinous
Pseudomonas: green, musty-smelling drainage
Assessment: pain assessment; drainage assessment; home remedies used; presence of edema

28. External Otitis Diagnostic Tests: Culture and Sensitivity of drainage
Medical Management
Oral analgesics; corticosteroids
Antibiotic or antifungal ear drops; oral antibiotics
Specific antibiotic will be based on the culture results
Nursing interventions: cleansing of ear canal; poss. heat for pain relief; instill ear drops; adequate method of communication

29. Acute Otitis Media Middle Ear Infection
Most often caused by: H. Influenza & Strep pneumoniae
Occurs frequently in children 6-36 mo. old and in the winter and early spring
Children’s shorter and straighter eustachian tubes provide easier access of microorganisms from the nasopharynx  middle ear.
Often post URI 29

30. Acute Otitis Media Clinical Manifestations: Assessment
Sense of fullness in the ear
Severe, deep throbbing pain behind the tympanic membrane (pain may disappear if TM ruptures)
Hearing loss, tinnitus (ringing, tinkling), and fever may develop
Assessment
See External Otitis
Diagnostic Tests: culture of purulent drainage

31. Acute Otitis Media Medical treatment Oral antibiotics Analgesics
Topical ear drops
Antihistamines
Myringotomy (small incision in the eardrum to drain fluid and relieve pressure)
Tympanostomy tube placement for long- or short-term use 31

32. Acute Otitis Media Nursing Interventions Medication Instructions
If hearing loss, effective communication
Children are to be fed upright to prevent nasopharyngeal flora from entering the eustachian tube
Instruct to blow nose gently
If myringotomy performed, instruct parents to change the cotton in the outer ear 2x/day
Mastoiditis:
difficult to treat
iv tx. X several days
poss. myringotomy (surg incision of TM membrane to relieve pressure and release exudate)
if progressed, simple mastoidectomy

33. Acute Otitis Media
Mastoiditis: an infection of one of the mastoid bones.
Usually an extension of a middle-ear infection that was untreated or inadequately treated
S/sx: earache, headache, fever, large amts of purulent exudate, malaise

34. Chronic Otitis Media
Eardrum may be permanently perforated (ruptured) or shows signs of a healed perforation with chronic fluid trapped behind it
There may be intermittent drainage
Possible complications of chronic otitis media include mastoiditis, meningitis, labyrinthitis, cholesteatoma, and hearing impairment 34

35. 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 35

36. Labyrinthitis Inflammation of the labyrinthine canals of the inner ear
Acute labyrinthitis usually follows an acute upper respiratory infection, acute otitis media, pneumonia, or influenza
Also can be an adverse effect of drugs – e.g. Streptomycin can destroy the vestibular portion of the inner ear 36

37. Labyrinthitis Another type: suppurative (pus) 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

38. Labyrinthitis Signs and symptoms
Sudden and severe vertigo, nausea, vomiting, headache, anorexia, nystagmus, photophobia, ataxic gait
Assessment: note frequency and duration of vertigo; safety measures taken; hearing ability, ringing in ears, nausea; jerking movements of eyes, color and moisture of skin. 38

39. Labyrinthitis Medical treatment
Anti-emetics and supportive care until it resolves
Antibiotics if infection is present
Dramamine or Meclizine for vertigo
Nursing Diagnosis:
Risk for injury r/t altered sensory perception (vertigo)
Fear r/t altered sensory perception (vertigo)

40. 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
Instruct and monitor safety measures 40

41. Obstructions of the Ear

42. Obstructions of the Ear
Etiology/pathophysiology
Impaction of cerumen in canal; foreign bodies
Clinical manifestations
Tinnitus and pain in the ear
Slight hearing loss; tugging at ear
Assessment
Pt. interview re: possibility of foreign body, home remedies used; note presence of foreign body
Diagnostic Tests: Otoscope exam

43. Obstructions of the Ear
Medical Management
Removal of cerumen by irrigation
Carbamide (Debrox) peroxide to soften cerumen
Foreign objects are removed with forceps
Insects are smothered with drops of oily substance and removed with forceps
Possible surgical removal of the foreign object

44. Foreign Bodies and Cerumen
Impacted cerumen is 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 44

45. Obstructions of the Ear
Nursing Interventions
During assessment – note the presence and amount of hearing impairment
Otoscope exam
Ear irrigations
Reassure pt. of return of hearing after obstruction removed
Nursing Diagnosis: Disturbed sensory perception (auditory) r/t presence of foreign body causing obstruction

46. Noninfectious Disorders of the Ear

47. Otosclerosis Etiology/pathophysiology
Chronic, progressive deafness due to formation of spongy bone, especially around the oval window with resulting immobility of joint of the stapes  tinnitus and then deafness
Fixed stapes cannot vibrate, so sound waves cannot be transmitted to inner ear
Effect is a conductive hearing loss
Most common in young Caucasian women

48. Otosclerosis Clinical manifestations/assessment
Slowly progressive conductive hearing loss
Low  medium pitched tinnitus
Deafness will first be noted between ages 11 and 20
Presence of mild dizziness  vertigo
Assess family hx of same

49. Otosclerosis Diagnostic Tests: Medical Management
Otoscope: Schwartz’ sign – a pink blush in the ear
Rinne’s Test, Weber’s test, Audiometric testing, tympanometry
Medical Management
Stapedectomy
Air conduction hearing aid

50. Otosclerosis Nursing Interventions
Post Stapedectomy Care per usual post ear surgery care
External ear packing – leave in place 5-6 days
Bedrest x 24 hrs
Keep flat with operative ear up (to maintain the placement of the prosthesis)
NO turning
Tx. Headache, dizziness
Review P “After Ear Surgery”

51. Figure 52-8 51

52. Meniere’s Disease Etiology/pathophysiology
Chronic disease of the inner ear
Recurrent episodes of vertigo  unilateral progressive nerve deafness, and tinnitus
Increase in endolymph fluid( increased pressure in the inner ear)
The cause is unknown
Attack triggers: alcohol, nicotine, stress, and certain stimuli such as bright lights and sudden movements of the head

53. Meniere’s Disease Clinical manifestations/assessment
Vertigo (recurrent) – often preceded by sense of fullness and pressure in the ear
Nausea and vomiting
Hearing loss – unilateral; repeated attacks can lead to permanent senorineural hearing loss
Tinnitus
Diaphoresis
Nystagmus

54. 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 54

55. Ménière’s Disease Medical Diagnosis
Diagnosed by ruling out other conditions that can cause similar symptoms – e.g. CNS disease
Physician likely to order a number of radiographs and other tests to detect any neurologic, allergic, or endocrine disorders
Audiogram, Vestibular testing, Glycerol test 55

56. Meniere’s Disease Medical management No specific treatment
Decrease fluid pressure
Fluid restriction; diuretics; low-salt diet
Avoid caffeine and nicotine
Dramamine, meclizine, and Benadryl – use between attacks
Meds may be given IV during acute attacks

57. Meniere’s Disease Medical Management cont.
Surgical Procedures are for preservation of hearing
See Table 13-7 p. 644 AHN for surgeries and post op nursing interventions

58. Meniere’s Disease Nursing Interventions
Maintain the prescribed low-salt diet
Administer diuretics
Acute vertigo: bedrest, sedation, antiemetics
Provide effective means of communication
Safety
Patient Education
Review: Patient Teaching “Vertigo” p.640

59. Ménière’s Disease Nursing Diagnosis: (r/t, AEB) Risk for Injury
Risk for Deficient Fluid Volume
Anxiety
Ineffective Therapeutic Regimen Management 59

60. 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 60

61. Ménière’s Disease Post Operative Care cont.
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

62. 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 62

63. Ototoxicity
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

64. 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 64

65. Ototoxicity Nursing Care
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

66. Surgeries of the Ear Stapedectomy Tympanoplasty Myringotomy
Removal of the stapes of the middle ear
To restore hearing in the treatment of otosclerosis
Tympanoplasty
Operative procedures on the eardrum or ossicles of the middle ear to restore hearing
Myringotomy
Surgical incision of the eardrum
To relieve pressure and release purulent exudate fron the middle ear

67. Nursing Considerations/Care for Post op Ear Surgeries

68. Post Op 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) 68

69. Post Op 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 69

70. Post Op 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 70

71. General: 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
Nsg. Interventions:
Pain management
Safety
Reduce risk for Infection
Disturbed Sensory Perception 71

72. Nursing Diagnoses – r/t, AEB
Health Mainentance, ineffective
Anxiety
Self-care deficit
Fear
Impaired environmental interpretation syndrome
Impaired social interaction
Impaired home maintenance
Risk for injury
Risk for loneliness
Sensory perception, disturbed (auditory or visual)