Exam 24 - Ear Disorders

• The ear is responsible for the interpretation of sound and maintaining equilibrium.
• Anatomically, the ear contains three divisions: the external, middle, and inner ear.

External Ear

• The pinna (auricle) is part of the complex hearing organ.

Middle Ear

• Also known as the tympanic cavity
• It Features a small, air-filled chamber located within the temporal bone
• The Eustachian (auditory) tube is lined with a mucous membrane that joins the nasopharynx and middle-ear cavity

Inner Ear

• The labyrinth is a series of canals making up the structure
• The bony labyrinth is filled with perilymph

Nursing Assessment of the Ear

• Includes occurrence of:
  • Ear drainage
  • Tinnitus
  • Vertigo
  • Cerumen buildup
  • Pressure
  • Pain
  • Pruritus
• Consider other medical diagnoses, family history, and exposure to loud noises that may affect hearing
• Consider behavioral clues suggesting hearing loss
• Note history of ototoxic medications, current medications for ear disorders including side effects, and speech pattern abnormalities
• Determine if assistive hearing devices are used or if home remedies are used to treat ear trauma
• Communicate findings to personnel and document in patient records to prepare for otoscopic evaluation

Behavioral Clues of Hearing Loss

• Irritability, hostility, and hypersensitivity during interpersonal interactions
• Difficulty hearing upper-frequency consonants or hearing people mumbling
• Increasing the volume on the TV or radio
• Inappropriately answering questions or frequently asking for repetition
• Grim disposition and loss of humor
• Leaning forward to hear better
• Avoiding large gatherings or appearing aloof
• Ringing in the ears
• Unusually soft or loud voice and repeatedly asking others to repeat themselves

Laboratory and Diagnostic Examinations

• Otoscopy is used to visualize the external auditory canal and tympanic membrane, is the initial examination and takes 1-2 minutes.
• A whispered voice assesses the general hearing ability with the examiner standing 12-24 inches away and whispering one or two-syllable words
• Tuning fork tests (Weber and Rinne) are used to determine the type of hearing loss
  • The Weber test assesses auditory acuity, useful to determine conductive loss from middle-ear problems or sensorineural loss from inner ear disorders
  • The Rinne test distinguishes conductive from sensorineural hearing loss, performed with tuning forks placed 1/2 inch from the external auditory meatus
• Audiometry tests hearing acuity
• Vestibular testing assesses the auditory and vestibular systems for balance and equilibrium
• Nystagmus and vertigo may signal vestibular system problems

Nystagmus and Vertigo

• Nystagmus involves involuntary, rhythmic eye movements that can be horizontal, vertical, rotary, or mixed
• Vertigo describes a sensation of movement or spinning that is heightened when moving the head
• Romberg and past-point tests are performed for patients that report dizziness or disequilibrium to assess balance

Hearing Disorders

• Hearing impairment/deafness occurs along a spectrum of decreased auditory acuity
• Loss of hearing can affect speech/conceptual ability, personality development in congenital cases, and socialization potentially leading to depression and isolation.

Facilitating Communication for Individuals with Impaired Hearing

• If applicable, ensure hearing aid is in place and functioning
• Get the person's attention by raising an arm or hand, ask to turn off/down the TV or radio
• Ensure adequate lighting for the ability to lip-read
• Face the person when speaking and speak clearly without over accentuating words in a normal tone
• Re-phrase communication as needed and move closer to the person
• Write out proper names, and avoid eating, drinking, or covering the mouth during conversation
• Look for indicators of inattention
• Use phrases instead of one-word answers, and avoid annoyance in facial expression
• Encourage use of a hearing aid and allow adjustments and avoid asides when communicating in a group
• Always include the person in the conversation

Types of Hearing Loss

• There are six: Conductive, sensorineural, mixed, congenital, functional (psychogenic), and central.
• Conductive hearing loss occurs when sound is not adequately conducted through the external/middle ear to the inner ear's sensorineural apparatus
  • Common causes: Cerumen buildup and otitis media with effusion including foreign bodies, otosclerosis, and stenosis of the external auditory canal
  • Sensitivity to sound declines, clarity to sound is not changed and a hearing aids may be helpful
• Sensorineural hearing loss occurs even with normal delivery through the external and middle ear
  • Can be caused by Rh incompatibility, mother's exposure to syphilis/rubella during pregnancy, or ototoxic drugs
• Functional hearing loss has no organic cause, also known as psychogenic/nonorganic hearing loss
  • Caused by an emotional/psychological factor
• Central hearing loss occurs when auditory pathways are damaged, in the case of stroke/tumor

Clinical Manifestation and Assessment of Hearing Loss

• Manifestations depend on the degree of hearing loss
  • Subtle clues: Requesting to repeat information. More obvious signs: Non-responsiveness
• Subjective data includes the onset and progression, deficit in one or both ears, head trauma history, mental status changes, noise exposure/current meds, visual/speech disorders, other ear symptoms
• Objective data must include an assessment of behavioral clues that indicate a hearing difficulty

Diagnostic Tests and Medical Management of Hearing Loss

• Conductive hearing loss causes lateralization of sound to the deaf ear during the Weber test
  • Rinne test: bone conduction > air conduction
• Sensorineural hearing loss causes lateralization of sound to the better ear during the Weber test
  • Rinne test: air conduction > bone conduction
• Audiometric testing determines the type of hearing loss and degree of impairment
• Medical management depends on the type of impairment.
• Surgical procedures, hearing aids, or cochlear implants used when appropriate with cochlear implantation is for individuals with profound bilateral sensorineural hearing loss

Hearing Aid Care

• Handle with care and wash daily with mild soap and water before drying completely
• Keep extra batteries and cord available and turn off aid or open the battery compartment when not in use
• Reinsert ear mold if whistling occurs. If aid fails to work:
  • Check the on-off switch and ear mold for cleanliness
  • Examine the battery for tightness of fit, replacing and checking for cracks in the tubing
  • Check position of mold with appropriate volume

What NOT to do with a Hearing Aid

• Do not put on heated surfaces, wash, or drop
• Do not wear in bath/shower or overnight and ignore whistling noises
• Avoid contact with cream, oil, or hair spray when on

Nursing Interventions and Pt Teaching for Hearing Aid Use

• Partial hearing loss may benefit from hearing aids, but it should only be worn if useful
• Factors leading to nonuse may include the perception of disability or discomfort
• Therefore, ensure that the hearing aid is used and works properly
• Key problems and interventions for hearing loss:
  • Impaired sensory awareness: Facilitate communication with patient and follow interventions for impaired hearing
  • Social seclusion: Assess/identify support systems, and establish effective communication
• Assist pt with learning to care for the aid and advise to have others speak slower and more clearer
• Surgical repair increases likelihood of partial/complete hearing with limited complications, and that advances in microtechnology have made smaller hearing aids

Inflammatory and Infectious Disorders of the Ear

• External otitis (swimmer's ear) is inflammation/infection of external canal/auricle of external ear and may be acute or chronic
• Causes include: allergies, bacteria, fungi, viruses, or trauma from nickel/chromium earrings, chemicals from hairspray/cosmetics/medications. Common bacteria include staph/pseudomonas/strep, as well as herpes viruses and aspergillus/candida fungi.
• More prevalent during hot/humid weather where excessive swimming washes out protective cerumen
• Cerumen in older adults can cause discomfort in the ear.
• Certain activities trap moisture contributing to infection, including use of earphones, earplugs/muffs, and stethoscopes

Clinical Manifestations and Assessment of Inflammatory Disorders

• Includes inflammatory or infectious process with movement of auricle/chewing as well as pain on the side.
• Includes erythema/scaling/pruritus/edema/watery discharge and crusting on the external ear, drainage may be purulent/serosanguineous
  • Drainage a green color with distinct Pseudomonas odor
• Edema may occlude the ear canal and dizziness/hearing loss
  • Chronic external otitis presents less pain but more pruritus and drainage with subjective and objective assessments evaluating the onset/color/severity of symptoms
• Patient may have partial loss of hearing or feeling of occluded ear if ear canal is edematous/obstructed by adenoids

Diagnostic Tests and Medical Management

• Obtain a culture of exudates and use oral analgesics if the pain severe
• Anti-microbial agents such as antibiotic or antifungal eardrops
• Clean ear canal and apply heat to external ear to relieve pain and instill prescribed eardrops
• Administer prescribed analgesics, warm compresses, and instill prescribed eardrops
• Provide patient with information to prevent infection at home
• Prognosis is favorable to topical antibiotic and corticosteroid eardrops, and that systemic antibiotics are rarely needed
• Untreated infections reaching the brain can be deadly.
  • Malignant external otitis media has high mortality rate unless treated.

Acute Otitis Media

• Inflammation of infection of the middle ear, common in children 6-36 months old during winter/early spring
• Shorter, straighter eustachian tubes provide easier access to microorganisms traveling to the middle ear.
• Buildup of sterile serous exudate causes tympanic membrane retraction, and that secondary bacterial infection causes purulent exudate with bulging

Clinical Manifestations and Assessment of Acute Otitis Media

• Manifestations include fullness in the ear and severe, throbbing pain with potential ruptures
• Other symptoms include hearing loss, tinnitus, and fever
• Similar to external otitis and pain on palpation/examination

Medical Management

• Antibiotic therapy is still the common form, analgesics / nasal decongestants are prescribed, and sedatives may be pre-scribed for children in conjunction with local heat
• Needle aspiration of secretions and incision of the tympanic membrane may relieve pressure, preventing spontaneous rupture
  • tympanostomy tubes may be used on short/long term use

Teaching patients about ear infections

• Ear canals during showers must be protected
• Swimming must be avoided during active infections or with perforated eardrums/contaminated water
• Antibiotics must be continued and URI & allergies must be treated
• Infected ears must be provided with eardrop insertion, proper use, and clean hands
• Medical providers must be notified of fevers/pain/discharge, and the success depends on antibiotic therapy
  • Untreated otitis media can lead to hearing loss
• Mastoiditis is more difficult to treat, and early decalcification may warrant intense therapy and myringotomy. Simple mastoidectomy may be required following destruction

Labyrinthitis

• Characterized by inflammation of labyrinthine canals of the inner ear and is a top cause of vertigo
• Can be caused by viral URIs or drugs/foods, as well as destruction via Streptomycin and tobacco/alcohol use related to middle-ear/mastoid infections
• Characterized by severe and sudden onset vertigo that may present with nausea and photophobia/ataxia/nystagmus
• Evaluation includes the frequency, duration, safety measures, and potential autonomic responses.
• Diagnostics include diminishing electro- /audiometry, as well as no specific medical management as antibiotics and antiemetics can address

Labyrinthitis interventions

• Interventions focus on fluids and side rails
• Focus on patient feelings, actions/orders, nature of disorder, and use of low-salt diets with diuretics
• It takes patience, precaution, and assistance. It may require rest and prescribed medications

Obstructions of the ear

• Ear canal obstruction is caused typically by impaction or foreign bodies, especially in children
• Excessive cerumen can emerge from narrower ear canals by causing occlusion/tinnitus/loss of hearing, which is assessed through subjective and objective data
• Assessment includes observation and otoscopic examinations
• Medical management addresses irrig/cerumen removal, as well as use of medications, drops, surgical procedures to fix any unsuccessfulness

Obstruction interventions

• Interventions focus on sensation, meds, proper techniques, and preventing additional damage
• Prognosis depends on the obstruction and the use of correct treatment for resolution/healing
• Patient can be prevented by informing them the objects and their appropriate uses

Noninfectious Disorders of the Ear

• Otosclerosis is a condition characterized by chronic progressive deafness caused by the formation of spongy bone - especially around the oval window
• Ankylosis causes further bone formation during adolescence with spongy, replacing bone in the otic capsule causes tinnitus and deafness via autosomal dominance
• It occurs frequently in women with an onset around pregnancy with potential otosclerosis
• Objective data comes from assessments and family history for proper treatment, potentially yielding otoscleroic tissue
• The tympanometry shows stiffness with variable hearing loss
• Management follows fluoride, D & carbonate vitamins to stabilize hearing and potentially slow bone absorption with hearing aids

Otosclerosis: Next Steps

• Post- stapedectomy care follows other ear surgery teaching and interventions. Some options may include hearing aids to maintain sound conduction.

Meniere's Disease

• Meniere's disease is driven by recurring vertigo, progressive nerve issues, and tinnitus, often striking around 30-60 years of age in women
• Etiologies follow several risk factors/lack specific treatment based on potential increases of endolymph fluids causing pressure and related ailments.
• S&S (sign and symptoms)include nystagmus, nausea and fullness
• Notes should be recorded of a patient's history and knowledge of their disorders for reference, assessing actions and degrees.

Meniere's Disease Management

• Medical management is done by first confirming positive findings and then determining a plan of action for MRI/CT and checking audiology.
• Tuning fork tests can be used and combined to manage fluid in the ear. There are also other pharmaceuticals like Dimenhydrinate, etc.

Otic-specific Surgeries

• In the context of certain ear surgeries, the surgery will destroy the affected region or drain it/correct internal pathways to promote balance over the long term.
• Side rails in the patient's area are crucial for them and in teaching new/upcoming patients.

Surgery Patient Interventions

• Care should be scheduled to have limited stimulation in quite, comforting environments
• The implementation of low-salt options can influence long-term balance for the ear, potentially improving balance with proper care.

Outer/Middle Ear Surgeries

• Removal and replacement of ear structures is possible with proper care for those structures to preserve hearing After surgery, you should:
• Keep the area dry and use protection + change cotton weekly/daily as well as avoiding physical contact + consulting medicine or physician

Ear surgeries

• tympanoplasty /Myringotomy surgeries function to relieve pressure on the affected/inner-middle ear by assisting the flow of liquids, removing excess fluid with cotton as needed
• Care should be taken not to aggravate and continue checking any incisions
• Cochlear Implants serve a hearing purpose and stimulate cortexes to assist people who had previously had no option or low abilities

Senses

• The tongue features over 10,000+ taste buds with several identified taste sensations
• Other senses, like smell, are related but can vary wildly
• Sensory information is then sent as messages to the brain

Tactile receptors

• Location of receptors is based on their intent
• Proprioception functions to maintain the position of the body
• Together these senses help coordination, but can be affected over time

Sensory Aging

• Sensory aging reduces the size and functionality when exposed over a long period. Aging can result in loss of sensations or abilities from damage. The result may be physical loss or sensation.
• For someone with a disorder, you should: Determine if those needs lead to a problem and then create a plan to address it which can then be tested for an effect.
• You must be sure to assist based on patients that are safe and stable over whatever period is appropriate, but consider patient culture and needs, adjusting as needed.