1. EAR DISORDERS

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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 hours
If AOM is recurrent, ventilating tube for 6-18 months to equalize pressure and drain fluid

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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