Anatomy of the Ear

Auditory System

• Composed of the Peripheral Auditory System and the Central Auditory System

Peripheral Auditory System

• Consists of the external, middle, and inner ear
• Responsible for the reception and perception of sound, as well as hearing and balance

Central Auditory System

• Includes CN VIII and the auditory cortex of the brain
• Functions to transmit and process sound and maintain equilibrium

External Ear

• Auricle is made of cartilage and connective tissue
• Includes external auditory canal and tympanic membrane (TM)
• Collects and transmits sound waves to the tympanic membrane

Middle Ear

• Cavity/air space within the temporal bone
• Connects middle ear to nasal pharynx via the Eustachian tube, which equalizes atmospheric pressure, allowing for free TM movement
• Contains malleus, incus, and stapes: the three smallest bones in the body
• Vibrations from TM cause ossicle movement which transmits sound waves to the oval window

Inner Ear

• Bony labyrinth containing functional organs for hearing and balance
• The cochlea (organ of Corti) transforms fluid vibrations from sounds into electrical impulses
• These impulses are then transmitted to acoustic portion of CN VIII
• Interpreted by the temporal lobe
• Organ of balance: three semicircular canals and vestibule
• Nerve impulses in vestibule are generated from movement
• Vestibular nerve joins cochlear nerve to form vestibulocochlear nerve (CN VIII)

Assessment of Auditory System

• Includes evaluation of both hearing and equilibrium, which are closely related

Vertigo

• Sensation of person or objects moving or spinning
• Stimulated by head movement

Nystagmus

• Abnormal eye movements or blurred vision

Subjective Data: Health History

• Includes childhood ear problems, systemic conditions, head injury, allergies, and current symptoms
• Questions about family history, medications which may be ototoxic, and satisfaction with hearing aids
• Examine impacted earwax

Functional Health Patterns

• Examines how hearing and balance problems can affect all aspects of life

Health Perception-Health Management Pattern

• Assess gradual vs. sudden hearing loss and discuss hearing preservation measures

Nutritional-Metabolic Pattern

• Inquire about otalgia (ear pain), referred pain, and discomfort with chewing or swallowing
• Note pt alcohol, sodium, and diet supplements intake

Elimination Pattern

• Note Straining increases pressure

Activity-Exercise Pattern

• Ask about balance problems, including their onset, duration, and frequency

Sleep-Rest Pattern

• Tinnitus and snoring habits

Cognitive-Perceptual Pattern

• Assess for pain, drainage (otorrhea), and hearing loss
• Note if they are attentive; able to follow directions, or perception by significant others

Self-Perception-Self-Concept Pattern

• Assess personal life, self-image, and social life

Role-Relationship Pattern

• Inquire about family, work, and social life

Sexuality-Reproductive Pattern

• Ask about Sex life & Relationships

Coping-Stress Tolerance Pattern

• Note presence of denial

Value-Belief Pattern

• Inquire about conflicts/stress and home remedies

Objective Data

• Inspect and palpate the external ear
• Use an otoscope for external auditory canal and TM for assessment -Color, fluid, landmarks, contour, and intactness
• Middle and inner ear can not be assessed
• Note abnormal findings

Diagnostic Studies: Audiometry

• Hearing acuity screening to diagnose degree and type of hearing loss
• With an audiometer (most common test), pure tones are produced at varying intensities
• Observe patient responses to determine specific patterns on audiogram
• Assesses sound frequencies and pure tone thresholds

Management of Auditory Problems: External Ear Canal

• Includes external otitis, cerumen and foreign bodies, trauma, and malignancy

Middle Ear and Mastoid

• Focuses on otitis media and otosclerosis

Inner Ear Problems

• Includes Meniere's Disease, Benign Paroxysmal Positional Vertigo (BPPV), Acoustic Neuroma, Hearing Loss and Deafness

Auditory Problems: External Otitis

• Inflammation or infection
• Bacterial or fungal causes
• From Swimming; Trauma; Piercing; Infections

Signs and Symptoms of External Otitis

• Ear pain (otalgia)
• Swelling of the ear canal resulting in muffled hearing
• Drainage that is serosanguinous or purulent
• Fever

Diagnosis and Treatments of External Otitis

• Otoscopic exam and culture and sensitivity tests (for drainage)
• Treatments: 7 to 14 days with moist heat, mild analgesia, and topical (otic drops)

Auditory Problems: Cerumen and Foreign Bodies in External Ear Canal

• Impacted cerumen causes discomfort, decreased hearing, tinnitus, and vertigo
• Irrigate with body-temperature solution to soften.
• Sitting position with aspectic technique
• Ensure proper positioning and draining of the syringe along with cerumen
• Foreign bodies require HCP removal to avoid pushing in farther
• Clean ear with washcloth and finger, avoid cotton-tip applicators

Auditory Problems: Trauma/injury

• Hematoma-Perichondritis
• Blows-conductive hearing loss
• Head trauma-injury to temporal lobe

Auditory Problems: Malignancy

• Skin cancer is most associated with sun exposure, treat with liquid nitrogen
• Teach patient education: hats and sunscreen

Auditory Problems: Otitis Media

• Acute otitis media-infection of TM, ossicles, and middle ear, usually a childhood disease
• Swelling of auditory tube traps bacteria; pressure on TM = redness, bulging, and pain
• Signs: fever, malaise, drainage, and reduced hearing
• Medical treatment: oral antibiotics and eardrops
• Surgery: myringotomy and tympanostomy tube-ventilate ear
• Allergy (etiology): antihistamines and nasal corticosteroid
• Otitis media with Effusion-inflammation of middle ear with fluid collection
• Causing fullness, plugged, popping, and decreased hearing
• Often follows acute otitis media and may last weeks to months resolves without treatment

Auditory Problems: Chronic Otitis Media and Mastoiditis

• Purulent exudate inflammation of ossicles, auditory tube, and mastoid bone
• May not have pain: hearing loss, nausea, dizziness
• Cholesteatoma may develop
• Diagnostics: otoscopic exam; culture and sensitivity; audiogram; x-rays, MRI, CT scan
• Goals: clear infection; repair perforation; preserve hearing
• Antibiotics: otic and systemic
• Evacuation of drainage
• Surgery: Tympanoplasty and/or mastoidectomy
• Postop: impaired hearing (temporary); drain/dressing care; keep suture line dry
• Patient education: change dressing/cotton ball

Auditory Problems: Otosclerosis

• Hereditary autosomal dominant disease; conductive (air) hearing loss in young adults
• Often unaware until severe
• Prevents movement of footplate in stapes, reducing transmission of vibration
• Diagnosis: Schwartz's sign; tuning fork (Rinne test) and audiogram
• Oral sodium fluoride, vitamin D, and calcium carbonate-slow progression
• Hearing aid
• Interprofessional care: stapedotomy or prosthesis
• Nursing: cotton ball/dressing; monitor for nausea, vomiting, dizziness
• Education: Avoid sudden movements and avoid increased inner ear pressure

Inner Ear Problems: Manifestations of Inner Ear Disease

• Affects Vestibular labyrinth, causing vertigo
• Affects the Auditory labyrinth, causing Sensorineural hearing loss and Tinnitus

Meniere's Disease

• Accumulation of endolymph in membranous labyrinth, usually in one ear
• Etiology often unknown; genetic, immune and environmental factors
• Onset in 40-60yo
• Excess fluid and pressure = hearing and balance problems
• Characterized by disability causing sudden, severe attacks of vertigo, nausea, vomiting, nystagmus, and unpredictable
• Prior to attack: fullness in ear, tinnitus, and muffled hearing
• Some experience feelings of being pulled to the ground ("drop attacks”) or whirling in space
• Lasts minutes □ hours; happens several times/year
• Diagnostic Tests: Audiogram with low frequency sensorineural hearing loss
• Spontaneous vertigo on two occasions with abnormal vestibular tests and use glycerol tests
• No cure; treatments to reduce frequency of vertigo attacks
• Management: acute attack medication, minimize vertigo and maintain safety
• Between attacks: antihistamines, low salt diet, limited caffeine and alcohol, and vestibular exercises
• Surgical intervention may be needed: Decompression, Vestibular nerve section or Ablation of labyrinth for unilateral disease
• Gentamicin injections can reduce production by damaging inner ear

Meniere's Disease: Teaching

• Protect from injury between attacks
• Lie or sit with onset of dizziness
• Avoid triggers like sudden movements and bright lights
• Follow home safety and not swim underwater, avoid high places
• Eat low sodium, limit caffeine and alcohol
• Practice balance therapy exercises.

Benign Paroxysmal Positional Vertigo (BPPV)

• Vertigo caused by free-floating debris (“ear rocks") in semicircular canal with head movements
• Symptoms: nystagmus, loss of balance, nausea
• Diagnosis: auditory and vestibular tests
• Treatment: Epley maneuver

Differences: BPPV vs. Meniere's disease

BPPV

• Short spurts of vertigo that depend on gravity and position
• Should not impact hearing
• Little to no long term complications
• Treated with a canalith repositioning maneuver

Meniere’s Disease

• Long and intense bouts of vertigo (at least 20 mins)
• Paired with hearing loss and/or roaring tinnitus
• Can lead to long term hearing complications
• Treatment varies from person to person.

Acoustic Neuroma

• Unilateral benign tumor where vestibulocochlear nerve (CN VIII) enters the internal auditory canal, on the nerve that connects the inner ear to the brain
• Thought to develop from Schwann cells, that support and insulate nerve fibers
• Slow Growing in age 40-60 years
• Diagnosed early to avoid compression of trigeminal and facial nerves and arteries

Acoustic Neuroma Symptoms and Diagnostics

• Unilateral, progressive sensorineural hearing loss
• Reduced touch sensation in posterior ear canal
• Unilateral tinnitus with mild intermittent vertigo
• Neurologic and audiometric tests or MRI

Acoustic Neuroma Treatments

• Treatment depends on tumor size and growth rate, severity of symptoms, along with patient's overall health
• Options include Radiation for small tumors and Surgical treatment effective for all tumors via Stereotactic radiosurgery

Patient Education

• Follow up to monitor hearing and tumor recurrence
• Report clear, colorless discharge from nose; possibly cerebrospinal fluid (CSF)

Hearing Loss and Deafness: Issues

• External Ear: from Impacted cerumen, Foreign bodies, External otitis
• Middle Ear: from Otitis media, Serous otitis, Otosclerosis, Tympanic membrane trauma, Cholesteatoma or Acoustic neuroma
• Inner ear: from Ménière's disease, Noise-induced hearing loss, Presbycusis, or Ototoxicity

Hearing Loss and Deafness: Clinical Manifestations

• Inappropriate response with Straining to hear
• Cupping hand at ear & Reading lips
• Increased sensitivity to slightly increased noise
• Sudden hearing loss is a medical emergency

Types of Hearing Loss

• Conductive – external and middle ear
• Sensorineural – inner ear
• Mixed hearing loss
• Central hearing loss
• Functional hearing loss
• Syndromic hearing impairment

Conductive Hearing Loss

• Occurs when sound waves are blocked or obstructed in the outer (external) or middle ear, preventing them from reaching the inner ear (cochlea)
• Causes: Earwax buildup, Otitis media with effusion, TM perforation, Otosclerosis, Allergies, and tumors
• Patient speaks softly
• Bone conduction makes own voice seem loud and they may hear better in noisy environment
• Identify cause and treat accordingly
• If cannot treat or correct the cause – hearing aids

Sensorineural Hearing Loss

• Caused by damage in inner ear or vestibulocochlear nerve (CN VIII)
• Causes: Congenital and hereditary factors & Aging (presbycusis)
• Noise exposure from Ménière's disease, Infections, Trauma and Ototoxicity
• Can hear sound, but they are muffled and difficult to understand, especially speech
• Decreased ability to hear high-pitched sounds
• Ototics used (aspirin, abx, loop diuretics, NSAIDS, and chemo drugs)
• Others do not understand the problem and it is diagnosed by audiogram (loss of decibel levels)
• Hearing aid makes sounds louder but not clearer

Mixed Hearing Loss

• Combination of Conductive damage in outer or middle ear and Sensorineural damage in inner ear or auditory nerve
• Conductive loss treated surgically and Sensorineural loss is treated with hearing aids

Central Hearing Loss

• Type of hearing impairment that occurs due to damage or dysfunction in the central nervous system (CNS)
• Causes includes: Stroke or Brain injury, Tumors, Multiple Sclerosis and Infections. As well as Aging or Genetics

Functional Hearing Loss

• Type of hearing loss where there is no identifiable organic cause for the hearing impairment
• Probable Causes include emotional or psychologic causes due to Lack of hearing or response to pure-tone subjective hearing tests; no physical reason identified
• Psychologic counseling may help

Genetic Link: Hearing Loss

Non-syndromic hearing impairment

• Common and Alters cochlear function
• Increase risk of ototoxicity
• Structural malformations, with a GJB2 gene mutations

- Syndromic hearing impairment

• Syndrome of problems involves eyes, kidneys and musculoskeletal, nervous systems
• More than 400 syndromes that include hearing loss as a symptom

Tinnitus

• Perception of sound that originates in the head, “ringing in ears” or “head noise"
• Bilateral tinnitus may be first symptom of hearing loss, especially in older
• May be soft or loud, high pitched or low pitched due to Noise exposure
• More than 200 drugs cause tinnitus
• Related to TMJ, stroke, head and neck injuries

Nursing and Interprofessional Management of Hearing Loss and Deafness:

• Invisible disability that is hard to see. Can't "see” the disability.
• Is Typically noticed when communicating can be frustrating for the patient, due to Loneliness, depression, cognitive decline and Denial of impairment or unaware
• Effective teaching-learning where patient can understand
• Confirming understanding of health Education with Visual aids
• Turn off TV or radio during teaching
• Patients may require an interpreter when Patient uses sign language, where ADA requires Interpreter with significant information for Discharge instruction and Consent

Nursing and Interprofessional Management of Hearing Loss and Deafness:Health promotion for Enviornmental Noise Control

• Noise is most preventable cause of hearing loss, treat with noise limits
• Acoustic trauma destroys hair cells of organ of Corti
• Noise-induced hearing loss is affected by How loud, how close you are, and how long you listen

Hearing Conservation

• Follow OSHA standards as well as noise analysis and hearing protection with Periodic hearing screening & Patient education
• Immunizations, such as Regularly scheduled immunizations for children and adults promote for the fetus because Fetal damage can be caused by viruses
• Women of childbearing age need special consideration, especially with Ototoxic substances (drugs or agents) which lead to toxcity and causes Tinnitus, diminished hearing, or balance problems
• Stopping the drug may prevent further damage; allow symptoms to disappear

Assistive Devices

• Hearing aids: Initial use in a quiet ambient, storage is cool, dry place, remove battery and Clean weekly
• Amplified telephone
• Send sound directly to hearing aid and use Direct amplification devices, FM systems, TV listeners
• Notification systems use amplified sounds, visual light cues, vibration as alarms, such as Smoke detector and doorbells
• profound deafness needs Text-telephone alert (flashing lights), closed captioning, specially trained dog
• Lip reading or Speech Reading that uses visual cues with speech facilitates understanding for 40% of spoken words and uses Verbal and nonverbal communication techniques.
• Sign Langue that has Specific hand gestures with facial &shoulder movement, such as the American Sign Language (ASL)

Nursing and Interprofessional Management of Hearing Loss and Deafness:Implantable Devices

• Cochlear Implant for severe to profound sensorineural hearing loss in one or both ears. Bypass damaged portions of ear & directly activates CN VIII
• Ideal patient is deaf after they acquired speech & language
• external portion that had microphone to picks up sounds in the environment. Which goes toSound Processor that converts the sound into electronic signals and is sent to the transformer
• The Transmitter forwards the signal to the Receiver and the electrodes stimulate the auditory nerve and carries the information directly to the brain to interupt as sound

Bone-anchored hearing aid (BAHA)

• helps withConductive hearing loss and single-sided deafness. Bypasses the outer and middle ear and Transmits sound vibrations directly to the inner ear via bone conduction Stimulate Implants that are Stimulate the ossicles (bones) in the middle ear to improve sound transmission (middle-ear)

Gerontological Considerations

• Presbycusis—age-related hearing loss due to Loss of peripheral auditory sensitivity where can hear vowels, not consonants or decreased ability to understand speech.
• Can lead to confusion, embarrassment, and isolation that is caused by degeneration of inner ear with noise exposure.
• Pt will rely on hearing device with amplification when treated.
• Pt may refuse due to cost, appearance, lack of knowledge, competing sounds, unrealistic expectations, dexterity, accepted part of aging