Oto-rhino-laryngological Nursing.pdf

NURS N312F Nursing Therapeutics (General Health Care) III Oto-rhino-laryngological Nursing (1) Learning Outcomes: After the lecture, students should be able to: 1. describe the anatomy and physiology of the ear; 2. describe the clinical features, nursing ass...

NURS N312F Nursing Therapeutics (General Health Care) III Oto-rhino-laryngological Nursing (1) Learning Outcomes: After the lecture, students should be able to: 1. describe the anatomy and physiology of the ear; 2. describe the clinical features, nursing assessment, investigations and procedures for common oto-rhino-laryngological conditions; 3. discuss the therapeutic and nursing management of common oto-rhino-laryngological disorders; 4. formulate and evaluate integrative nursing care plan for patients with oto-rhino- laryngological disorders. ANATOMY AND PHYSIOLOGY OF THE EAR (Chapter 64) ❖ External Ear ⚫ Auricle (pinna)  Composed mainly of cartilage, except for the fat and subcutaneous tissue in the earlobe  Collects sound waves and direct vibrations into the external auditory canal ⚫ External Auditory Canal  2 to 3 cm long, ends at the tympanic membrane  The skin of the canal contains hair, sebaceous glands and ceruminous glands which secret a brown, waxlike substance called cerumen (ear wax) ▪ Self-cleaning mechanism moves old skin cells and cerumen to the outer part of the ear ❖ Middle Ear ⚫ An air-filled cavity ⚫ Eustachian tube  Approximately 1 mm wide and 35 mm long  Connects the middle ear to the nasopharynx and allows passage of air between the throat and the tympanic cavity ▪ Equalizes pressure in the middle ear with that of the atmosphere  Normally closed, but it opens with swallowing or yawning 1  ⚫ Tympanic membrane (ear drum)  About 1 cm in diameter and very thin, pearly grey and translucent  Protects the middle ear and conducts sound vibrations from the external ear to the ossicles ⚫ Ossicles  The 3 smallest bones of the body, the malleus, the incus and the stapes ▪ Held in place by joints, muscles and ligaments ▪ The malleus attaches to the tympanic membrane ▪ The footplate of the stapes sits in the oval window, transmits sound to the inner ear ❖ Inner Ear (labyrinth): within the temporal bone behind the eye socket ⚫ Outer bony labyrinth ⚫ Inner membranous labyrinth ⚫ Bony labyrinth  Contains 3 regions: the semicircular canals, the vestibule, and the cochlea  Within the bony walls lies the membranous labyrinth, which conforms to the shape of the bony labyrinth, helps form the semicircular canals, the vestibule, and the cochlea  Surrounds and protects the membranous labyrinth, which is bathed in a fluid called perilymph ⚫ Membranous labyrinth  Composed of the utricle, the saccule, the cochlear duct, the semicircular canals and the organ of Corti  Endolymph: a fluid within the chambers of the membranous labyrinth ⚫ The 3 semicircular canals contain sensory receptor organs that are arranged to detect rotational movement ⚫ Cochlea  A snail-shaped, bony tube about 3.5cm with 2.5 spiral turns  Contains the organ of Corti ▪ Transform mechanical energy into neural activity and separate sounds into different frequencies ▪ The electromechanical impulse travels through the cochlear nerve to the temporal cortex of the brain to be interpreted as meaningful sound 2  FUNCTIONS OF THE EAR 1. Hearing ⚫ Conducted by 2 pathways  Air conduction and bone conduction  Normally, air conduction is the more efficient pathway ⚫ Sound Conduction and Transmission i. Air conduction Sound enters the ear through the external auditory canal and causes the tympanic membrane to vibrate The vibrations transmit sound through the lever action of the ossicles to the oval window as mechanical energy Transmitted through the inner ear fluids to the cochlea, stimulating the hair cells, and is subsequently converted to electrical energy The hair cells set up neural impulses that are encoded and then transferred to the auditory cortex in the brain, where they are decoded into sound message ii. Bone conduction Occurs by directly stimulating the bones of the skull that send sounds to the inner ear 2. Balance and Equilibrium ⚫ Body balance is maintained by the cooperation of the muscles and joints of the body (proprioceptive system), the eyes (visual system) and the labyrinth (vestibular system) ⚫ These areas send their information about equilibrium to the brain (cerebellar system) for coordination and perception in the cerebral cortex ⚫ The vestibular apparatus of the inner ear provides feedback regarding the movements and the position of the head and body in place ASSESSMENT ⚫ Health history  History of current problem, past medical history, history of hearing loss, ear problems or diseases  Family history of hearing loss, ear problems or diseases ⚫ Inspection of the external ear  Inspect the auricle and surrounding tissues ▪ size, symmetry and angle of attachment to the head ▪ deformities, lesions, and discharge ⚫ Palpate the area of the mastoid for tenderness 3  o indicate acute mastoiditis or inflammation of the posterior auricular node ⚫ Otoscopic examination  The auricle is grasped and gently pulled backward and upward to straighten the canal in the adult ▪ Examine the external auditory canal and tympanic membrane ▪ Check for any discharge, inflammation, or a foreign body  Healthy tympanic membrane is pearly grey and is positioned obliquely at the base of the canal  Cerumen is normally present in the external canal ▪ If the tympanic membrane cannot be visualized because of cerumen, the cerumen may be removed by gently irrigating the external canal with warm water Cerumen build-up is a common cause of hearing loss and local irritation ⚫ Evaluation of gross auditory acuity  Whispered voice test ▪ Assess the ability to hear a whispered phrase, testing one ear at a time  The Weber and Rinne tests ▪ To distinguish conductive loss from sensorineural loss when hearing is impaired DIAGNOSTIC EVALUATION ⚫ Audiometry  The single most important diagnostic instrument in detecting hearing loss  Performed by a certified audiologist in a soundproof room ▪ The patient wears earphones and signals to the audiologist when the tone is heard ▪ Measuring air conduction ✓ The tone is applied directly over the external auditory canal ▪ Measuring nerve conduction ✓ The stimulus is applied to the mastoid bone, bypassing the conductive mechanism (i.e. the ossicles) ▪ Responses are plotted on a graph known as an audiogram  2 types ▪ Pure-tone audiometry ✓ The sound stimulus consists of a pure or musical tone - The louder tone perceives it, the greater the hearing loss ▪ Speech audiometry 4   Spoken word is used to determine the ability to hear and discriminate sounds and words  Characteristics in evaluating hearing ▪ frequency, and intensity i. Frequency (tone) ✓ The number of sound waves emanating from a source per second - measured as cycles per second, or Hertz (Hz) ✓ Normal human ear perceives sounds ranging from 20 to 20,000 Hz ✓ The frequencies from 500 to 2000 Hz are important in understanding everyday speech - Referred to as the speech range or speech frequencies ii. Intensity (loudness) ✓ The unit for measuring loudness is the decibel (dB) - The pressure exerted by sound ✓ Sound louder than 80 dB - perceived by the human ear to be harsh and can be damaging to the inner ear ⚫ Tympanogram (Impedance audiometry)  Measures middle muscle reflex to sound stimulation and compliance of the tympanic membrane by changing the air pressure in a sealed ear canal  Compliance is impaired with middle ear disease ⚫ Electronystagmography (ENG) and video nystagmography (VNG)  Vestibular test  Detect eye movements in response to changes in head position or stimulation of balance sensors in the inner ear  Assess the oculomotor and vestibular system and their corresponding interaction  Diagnose causes of unilateral hearing loss of unknown origin, vertigo, or tinnitus 5 Hearing Loss ⚫ Deafness is the partial or complete loss of the ability to hear ⚫ Can be related to genetic factors or acquired causes ⚫ Classification  Conductive hearing loss ▪ Resulting from - an external ear disorder, such as impacted cerumen, or - a middle ear disorder, such as otitis media or otosclerosis ▪ The efficient transmission of sound by air to the inner ear is interrupted  Sensorineural hearing loss ▪ Damage to the cochlea or vestibulocochlear nerve ▪ e.g., Presbycusis  Mixed hearing loss ▪ Both conductive and sensorineural loss, resulting from dysfunction of air and bone conduction ⚫ Risk factor across the life span 1. Cerumen impaction 2. Trauma to the ear or head 3. Loud noise / loud sounds 4. Ototoxic medicines 5. Work related ototoxic chemicals 6. Nutritional deficiencies 7. Viral infections and other ear conditions ⚫ Delayed onset or progressive genetic hearing loss ⚫ Clinical Manifestations  Tinnitus (tinging in the ears)  Otalgia (earache)  Increasing inability to hear, e.g. need to turn up the volume of the television  Answering questions inappropriately  Showing irritability with others who do not speak up  Asking others to speak up  May have balance problems / dizziness 6 ⚫ Severity of Hearing loss Loss in Decibel (dB) Interpretation -10-15  Normal hearing 16-25  Slight hearing loss 26-40  Mild impairment 41-55  Moderate impairment 56-70  Moderately severe impairment 71-90  Severe impairment 91 +  Profound hearing loss ⚫ Investigations  Audiometry (type and pattern of hearing loss)  Speech audiometry (the intensity at which speech can be interpreted)  Tympanometry (the compliance and impedance of the middle ear to sound transmission) ⚫ Management  Prevention ▪ Prevent noise-induced hearing loss with ear protection ▪ Prevent acoustic trauma / physical trauma - Hearing loss by a single exposure to an extremely intense noise, such as an explosion  Surgical management ▪ To treat and improve a conductive hearing loss by eliminating the cause of the hearing loss ▪ Implantation of hearing aids for patients with sensorineural hearing loss  Hearing aids ▪ A device through which speech and environmental sounds are received by a microphone, converted to electrical signals, amplified, and reconverted to acoustic signals  Implanted hearing devices i. Bone conduction devices Transmit sound through the skull to the inner ear For patients with conductive hearing loss if a hearing aid is contraindicated (e.g. those with chronic infection) The device is implanted post-auricularly under the skin into the skull, and an external device worn above the ear, transmits the sound through the skin Two types ▪ Bone-anchored hearing aid - Implanted behind the ear in the mastoid area 7  - For conductive or mixed hearing loss ▪ Middle ear implantation - Implanted in the middle ear cavity - For sensorineural loss ii. Cochlear implant An auditory prosthesis for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids Provide stimulation directly to the auditory nerve, bypassing the nonfunctioning hair cells of the inner ear The microphone and signal processor, worn outside the body, transmit electrical stimuli to the implanted electrodes The electrical signals stimulate the auditory nerve fibres and then the brain, where they are interpreted 8 CONDITIONS OF THE EXTERNAL EAR Cerumen Impaction Foreign Bodies Otitis Externa 1. Cerumen Impaction ⚫ Cerumen accumulates in the external ear canal in various amounts and colours ⚫ Accumulation of cerumen as a cause of hearing loss is especially significant in older adult patients ⚫ Clinical manifestations  Sensation of fullness  Pain in the ear (otalgia)  Tinnitus  Itchiness  Chronic cough or hiccups (rare)  Hearing loss ⚫ Management  Remove cerumen by irrigation, suction or instrumentation  Manual removal ± suction ▪ Should be performed by clinicians with adequate experience and appropriate equipment  Irrigation ▪ Gentle irrigation with warm water usually helps remove impacted cerumen ▪ The water stream must flow behind the obstructing cerumen to move it first laterally and then out of the canal  Cerumenolytics ▪ Instil a few drops of warmed glycerin into the external auditory canal for 30 minutes prior to irrigation to soften cerumen ▪ Cerumenolytic agents: such as carbamide peroxide (Debrox) ▪ The use of any softening solution 2 to 3 times a day for several days is generally sufficient 2. Foreign Bodies ⚫ Small objects are inserted intentionally into the ear  Cotton stick, peas, beans, toys ⚫ Insects may enter the ear canal and be unable to exit 9  ⚫ Clinical manifestations  No symptoms  Profound pain if the object injures the ear canal or the tympanic membrane, or causes an infection  Decreased hearing  Tinnitus  Chronic cough or hiccups (rare)  (if an insect enters the EAC) buzzing sound may hear or feel tickling sensation ⚫ Management  Three standard methods for removing foreign bodies  irrigation, suction and instrumentation  An insect can be dislodged by instilling mineral oil, which will kill the insect and allow it to be removed  Contraindication for irrigation include ▪ Tympanostomy tuber (grommet) / perforated tympanic membranes ▪ Vegetable matter (e.g., bean, matter swells as it absorbs water) ▪ Button batteries  The object may be pushed completely into the bony portion of the canal, lacerating the skin and perforating the tympanic membrane  In rare circumstances, the foreign body may have to be extracted in the operating room with patient under general anaesthesia 3. Otitis Externa ⚫ An inflammation of the external auditory canal ⚫ Causes  Water in the external auditory canal ▪ swimmer’s ear  Trauma to the skin of the ear canal ▪ permitting entrance of organisms into the tissues  Bacterial infection ▪ Staphylococcus aureus and Pseudomonas species  Fungal infection ▪ Aspergillus  Dermatosis such as psoriasis, eczema, or seborrheic dermatitis  Allergic reaction to hair spray, hair dye ⚫ Clinical Manifestations  Otalgia 10   Discharge from the external auditory canal  Pruritus  Hearing loss or a feeling of fullness in the ear  Fever  Cellulitis  Lymphadenopathy  Otoscopic examination ▪ External auditory canal is erythematous and oedematous ⚫ Management  Medical management ▪ Aims: ✓ Relieve the discomfort ✓ Reduce the swelling of the canal (corticosteroid) ✓ Eradicate the infection ▪ Analgesics for the first 48 to 96 hours ▪ Antimicrobial or antifungal otic medications ▪ For bacterial infection ✓ A combination of antibiotic and corticosteroid agent may be used to sooth the inflamed tissues  Nursing management ▪ Patient education on prevention ✓ Proper installation of otic topicals: - Correct application of topical agents (Time, site, dose, frequency) ✓ Ensure ear hygiene during acute episode - Protect the external auditory canal when showering, or washing hair - Use ear plugs or place a cotton ball coated with water- soluble jelly (petroleum jelly) in the ear canal during bathing or showering - With active otitis externa should not swim and refrain from water spots during treatment (7 – 10 days) ✓ Prevention of recurrence - Avoid events that traumatize the external auditory canal, such as scratching the canal with fingernail or other objects which may breaks the skin integrity may cause infection - The patient should be informed that the ear canal has 11  a natural self-cleaning mechanism and should avoid using cotton-tipped applicators or any other foreign objects to clean the auditory canal. - Refrain from wearing hearing aids, "ear buds," and similar devices until the pain and discharge have diminished. Additionally, these devices should be cleansed before using them again. CONDITIONS OF THE MIDDLE EAR Tympanic Membrane Perforation Acute Otitis Media (AOM) Serous Otitis Media Chronic Otitis Media Acute Mastoiditis Otosclerosis 1. Tympanic Membrane (TM) Perforation ⚫ Causes  Trauma or injury ▪ Any trauma to the ear or the head can cause a rupture of the TM ▪ Sources of trauma include skull fracture, injury from explosion (sudden explosive sounds and / or pressure), loud noise, or perforation by foreign objects (cotton-tipped applications that have been pushed too far into the external auditory canal)  Barotrauma (Pressure changes) ▪ Pressure outside the ear is drastically different from the pressure inside the ear can cause a rupture of the TM ▪ Activities that can cause barotrauma, e.g., scuba diving, flying in an airplane.  Infection ▪ Infection, specifically otitis media, results in necrosis and ischemia of the tympanic membrane, leading to its breakdown and rupture. ⚫ Management  Tympanic membrane perforations can heal spontaneously within weeks, or several months, after rupture  While healing, the ear must be protected from water getting into the ear canal  In case of head injury or temporal bone fracture ▪ observe for evidence of cerebrospinal fluid otorrhea or rhinorrhoea, a clear, watery drainage from the ear or nose respectively  Tympanoplasty 12  ▪ Surgical repair of tympanic membrane to prevent potential infection or to improve patient’s hearing ▪ Tissue (commonly from the temporalis fascia) is placed across the perforation to allow healing ▪ Surgery is usually successful in closing the perforation permanently and improve hearing 2. Acute Otitis Media (AOM) ⚫ Commonly seen in children ⚫ Acute infection of the middle ear lasting less than 6 weeks ⚫ Bacteria or virus enter the middle ear  after eustachian tube dysfunction caused by obstruction related to ▪ upper respiratory tract infection ▪ inflammation of surrounding structures (e.g., rhinosinusitis, adenoid hypertrophy), or ▪ allergic reactions (e.g., allergic rhinitis) ⚫ A purulent exudate is usually present in the middle ear, resulting in a conductive hearing loss ⚫ Risk factors  Children  Chronic upper respiratory tract infections  Medical conditions that predispose to ear infections ▪ e.g., Down syndrome, cystic fibrosis, cleft palate  Chronic exposure to second-hand cigarette smoke ⚫ Clinical manifestations  Fever  Upper respiratory tract infection  Rhinitis  Conductive hearing loss  Otalgia (relieved if tympanic membrane ruptures)  Drainage from the ear (if tympanic membrane perforates) ⚫ Management  With early and appropriate broad-spectrum antibiotics therapy, otitis media can resolve with no serious sequelae  If drainage occurs, an antibiotic otic preparation is usually prescribed  Myringotomy (i.e., tympanotomy) ▪ Performed if pain persisted 13  ▪ Under microscopic guidance, an incision is made through the tympanic membrane to relieve pressure and to drain serous or purulent fluid from the middle ear ✓ Analysed the drainage by culture and sensitivity test so that infecting organism can be identified, and appropriate antibiotic therapy prescribed ▪ The incision heals within 24 to 72 hours 3. Serous Otitis Media ⚫ Presence of fluid (without evidence of active infection) in the middle ear ⚫ In theory, this fluid results from a negative pressure in the middle ear caused by eustachian tube obstruction ⚫ In adults, an underlying cause for eustachian tube dysfunction must be sought ⚫ Risk factors  After radiation therapy or barotrauma  Barotrauma results from sudden pressure changes in the middle ear caused by changes in barometric pressure, as in scuba diving or airplane descent  Eustachian tube dysfunction from a concurrent upper respiratory infection  Nasopharyngeal carcinoma obstructing the eustachian tube ⚫ Clinical manifestations  Fullness in the ear or a sensation of congestion  Popping and crackling noises occur as the eustachian tube attempts to open  Audiogram ▪ Conductive hearing loss  Otoscopy ▪ Tympanic membrane appears dull, and air bubbles may be visualized in the middle ear ⚫ Management  Observe unless infection (e.g. AOM) occurs  Myringotomy ▪ If hearing loss associated with middle ear effusion is significant  Corticosteroids to decrease the edema of the eustachian tube in cases of barotrauma 14   Valsalva manoeuvre, which forcibly opens the eustachian tube by increasing nasopharyngeal pressure, may be cautiously performed ▪ May cause worsening pain or perforation of the tympanic membrane 4. Chronic Otitis Media ⚫ Chronic infections damage the tympanic membrane, destroy the ossicles and involve the mastoid ⚫ Chronic otitis media can cause chronic mastoiditis and lead to the formation of cholesteatoma  If untreated, cholesteatoma will continue to enlarge, possibly causing damage to the facial nerve and destruction of other surrounding structures ⚫ Rare in developed countries ⚫ Clinical manifestations  Different degrees of hearing loss  Persistent or intermittent foul-smelling otorrhea  Pain, in cases of acute mastoiditis, when the postauricular area is tender and may be erythematous and oedematous  Cholesteatoma ▪ Abnormal collection of skin cells behind the TM / the bone behind the ear ▪ A white mass behind the tympanic membrane or coming through to the external canal from a perforation ⚫ Management  Local treatment ▪ Suction of the ear under otoscopic guidance ▪ Instillation of antibiotic drops or application of antibiotic powder to treat purulent discharge ▪ Systemic antibiotic agents for acute infection  Surgical management ▪ If medical treatments are ineffective ▪ Tympanoplasty ✓ Most common ✓ To reestablish middle ear function, close the perforation, prevent recurrent infection and improve hearing ✓ Performed through the external auditory canal with a trans- canal approach or through a postauricular incision - To close a perforation in the tympanic membrane - Extensive repair of middle ear structures 15  ▪ Ossiculoplasty ✓ Reconstruction of the middle ear bones to restore hearing ✓ Prostheses are used to reconnect the ossicles, thereby reestablishing the sound conduction mechanism - materials include Teflon, stainless steel, and hydroxyapatite ▪ Mastoidectomy ✓ Removal some or all the air cells in the mastoid process of the temporal bone - When they have become infected or invaded by cholesteatoma ✓ To remove the cholesteatoma, gain access to diseased structures, and create a dry (noninfected) and healthy ear ✓ Performed through a postauricular incision under general anaesthesia - Infection is eliminated by removing the mastoid air cells ✓ A second mastoidectomy may be necessary to check for recurrent or residual cholesteatoma. The hearing mechanism may be reconstructed at this time ✓ The patient has a mastoid pressure dressing, which can be removed 24 to 48 hours after surgery  Complications: facial nerve injury 5. Acute Mastoiditis ⚫ Inflammation of the mastoid process behind the ear and of the air space connecting it to the cavity of the middle ear ⚫ Usually caused by bacterial infection that spread from middle ear ⚫ Usually respond to antibiotics  Mastoidectomy may be required in severe cases ❖ Clinical Manifestations ⚫ Otalgia ⚫ Irritability in young children ⚫ Protrusion of the auricle ⚫ Postauricular tenderness, erythema, swelling ⚫ Lethargy ⚫ Narrowing of the external auditory canal ⚫ Otorrhoea ❖ Caring of patient undergoing Mastoid Surgery ⚫ Assessment  Health history ▪ infection, otalgia, otorrhea, hearing loss, and vertigo 16   Duration and intensity of the disorder, its causes, and previous treatments  Past medical history, current medications, allergic history and family history of ear disease  Physical assessment ▪ erythema, oedema, lesions, otorrhea, and characteristics such as odour and colour of the discharge  Audiometry ⚫ Nursing Interventions  Relieve Pain ▪ Administer analgesic medication for the first 24 hours ▪ Assess for any pain related to disease / external auditory canal packing  Prevent infection ▪ Prevent water from entering the external auditory canal for 6 weeks ▪ Place a cotton ball covered with a water-insoluble substance in the ear canal loosely to prevent water from entering the ear canal during shower and hair washing ▪ The postauricular incision should be kept dry for the first 2 days ▪ Administer prophylactic antibiotic agents as prescribed ▪ Report signs and symptoms of infection such as an elevated temperature, purulent drainage  Prevent injury ▪ Vertigo may occur after mastoid surgery if the semicircular canals or other areas of the inner ear are traumatized ✓ Administer antiemetic or anti-vertiginous medications as prescribed if a balance disturbance or vertigo occurs ✓ Safety measures such as assisted ambulation are implemented to prevent falls and injury ▪ Avoid heavy lifting, straining and nose blowing for 2 to 3 weeks after surgery to prevent dislodging the tympanic membrane graft or ossicular prosthesis ▪ Report immediately for evidence of facial nerve injury such as drooping of the mouth on the operated side, slurred speech, decreased sensation, and difficulty swallowing  Patient education ▪ Take antibiotics & other medications, such as analgesics and anti-vertiginous agents, as prescribed ▪ Provide information on the expected effects and potential side effects of the medication 17  ▪ Avoid nose blowing for 2 to 3 weeks after surgery ▪ Sneeze and cough with the mouth open for a few weeks after surgery ▪ Avoid getting water in the operative ear for 2 weeks ▪ Instruction of activity restriction ✓ Avoid heavy lifting, straining, & bending over for a few weeks after surgery ▪ Be aware that popping & crackling sensations in the operative ear are normal for approximately 3 to 5 weeks after surgery ▪ Note the temporary hearing loss is normal in the operative ear due to fluid, blood or packing in the ear ▪ Observe for complications and seek medical advice immediately ✓ Infection, facial nerve weakness or taste disturbances 6. Otosclerosis ⚫ Results from the formation of new, abnormal spongy bone, especially around the oval window, with resulting fixation of the staples ⚫ The efficient transmission of sound is prevented because the stapes cannot vibrate and carry the sound to the inner ear ⚫ Can progress to complete deafness ⚫ May involve one or both ears ⚫ Clinical manifestations  Progressive conductive or mixed hearing loss  Tinnitus ⚫ Management Surgical interventions ▪ Stapedectomy ✓ Remove the stapes superstructure and part of footplate, and insert a suitable prosthesis ▪ Stapedotomy ✓ The surgeon drills a small hole into the stapes, instead of removing it, to hold a prosthesis ❖ Caring of patient undergoing Ear Surgery 18  ⚫ Postoperative care  Assess for bleeding or drainage from the operated ear → may indicate complications  Administer anti-emetics → prevent vomiting (increase the pressure in the middle ear)  Assess for vertigo or dizziness → ensure safety during ambulation  Remind the activities restrictions ⚫ Health education  Prevent contamination of the ear canal  Do not remove inner ear dressing until physician’s instruction  Avoid blowing the nose (keep mouth open when coughing or sneezing)  Do not swim without approval  Administer antiemetic/antihistamine medication  Notify complications (e.g. fever, bleeding, increased drainage and dizziness) CONDITIONS OF THE INNER EAR Motion Sickness Meniere’s Disease Benign Paroxysmal Positional Vertigo Acoustic Neuroma 1. Motion Sickness ⚫ A disturbance of equilibrium caused by constant motion ⚫ Risk factors  Sex: females are generally more susceptible to motion sickness than meles  Age: Children less than two years old are typically resistant to motion sickness, and then decreases throughout adulthood  Migraine  Hormonal factors: individuals are particularly susceptible to motion sickness during pregnancy; may also affected by the menstrual cycles and by use of oral contraceptives  Expectations ⚫ Clinical manifestations  Sweating  Pallor  Nausea and vomiting  Malaise ⚫ Management 19   Environment modifications ▪ Looking at the horizon or a faraway, immobile object ▪ Avoid reading or looking at a screen while in motion, as this can increase conflict between vestibular and visual cues ▪ Seat selection: e.g., choosing the front seat in a car when you are a passenger or opting for forward-facing seats when travelling by train or bus  Antihistamines ▪ May provide some relief of nausea and vomiting by blocking the conduction of the vestibular pathway of the inner ear ▪ Sedation effect ▪ Nonsedating antihistamines do not appear to be effective ▪ Example: Dimenhydrinate or Meclizine  Anticholinergic medication ▪ Treat nausea and vomiting ▪ Less sedation effect than antihistamines ▪ Example: Scopolamine patches (Transderm Scop) 2. Meniere’s Disease ⚫ Abnormality in inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic duct ⚫ Clinical manifestations  Triad of symptoms ▪ episodic vertigo ▪ tinnitus ▪ fluctuating sensorineural hearing loss  A feeling pressure or fullness in the ear  Incapacitating vertigo, often accompanied by nausea and vomiting ⚫ Assessment and diagnostic findings  History taking ▪ frequency, duration, severity, and characteristics of the vertigo attacks ▪ nausea and vomiting ▪ hearing loss with tinnitus  Audiogram: reveals a sensorineural hearing loss in the affected ear  Electronystagmogram may be normal or may show reduced vestibular response ⚫ Management  Low-sodium diet (1500 to 2000 mg/day or less) to control symptoms ▪ Amount of sodium regulate the balance of fluid within the body. Sodium and fluid retention disrupt the delicate balance between endolymph and 20  perilymph in the inner ear  Pharmacologic therapy ▪ Antihistamines → shorten the attack ✓ Example: Meclizine ▪ Tranquilizers → control vertigo in acute phase ✓ Example: Diazepam (Valium) ▪ Antiemetic → control the nausea and vomiting, and vertigo ✓ Example: Promethazine (Phenergan) ▪ Diuretic agent → lower the pressure in the endolymphatic system ✓ Example: Hydrochlorothiazide (Dyazide), spironolactone  Surgical intervention ▪ Endolymphatic sac decompression ✓ A shunt or drain is inserted in the endolymphatic sac through a postauricular incision to equalize the pressure in the endolymphatic space to treat vertigo of Meniere disease ▪ Vestibular nerve sectioning ✓ Provides the greatest success rate in eliminating the attacks of vertigo ✓ Trans-labyrinthine approach, or suboccipital or cranial approach ✓ Cutting the nerve prevents the brain from receiving input from the semicircular canals 3. Benign Paroxysmal Positional Vertigo (BPPV) ⚫ A brief positional vertigo that occurs when the position of the patient’s head is changed with respect to gravity, typically by placing the head back with the affected ear turned down ⚫ Thought to be due to the disruption of debris within the semicircular canal  This debris is formed from small crystals of calcium carbonate from the inner ear structure (the utricle) ⚫ Clinical manifestations  Vertigo  Nystagmus  Light-headedness  Loss of balance  Nausea and vomiting ⚫ Diagnose  Hallpike-Dix Manoeuvre 21  ⚫ Management  Bed rest is recommended with acute symptoms  Repositioning technique ▪ Epley manoeuvre ▪ Non-invasive procedure, which involves quick movements of the body, rearrange the debris in the canal ▪ Safe, inexpensive, and easy to perform ▪ Premedicated with prochlorperazine (Compazine) 1 hour before the procedure ▪ Placing the patient in a sitting position, turning the head to 45-degree angle on the affected side, and then quickly moving the patient to the supine position  Pharmacological therapy ▪ Vestibular suppressants ✓ e.g. Meclizine for 1-2 weeks 4. Acoustic Neuroma ⚫ Also referred to as vestibular schwannomas ⚫ Slow-growing, benign tumours of cranial nerve VIII usually arising from the Schwan cells of the vestibular portion of the nerve ⚫ Most acoustic tumours arise within the internal auditory canal and extend to cerebellopontine angle to press on the brain stem, possibly destroying the vestibular nerve ⚫ Clinical manifestations  Unilateral tinnitus and hearing loss  Vertigo or balance disturbance ⚫ Diagnosed by MRI or CT scan with contrast ⚫ Management  Conservative treatment with routine monitoring  Surgical removal of acoustic tumours ▪ Objective is to remove the tumour while preserving facial nerve function ▪ If acoustic tumour has damaged the cochlear portion of the cranial nerve VIII, and hearing is impaired ✓ Surgery is performed using a trans labyrinthine approach, and the hearing mechanism is destroyed ▪ If hearing is still good before the surgery ✓ A suboccipital or middle cranial fossa approach to remove the tumour, and preserve hearing ✓ Potential complications: Facial nerve paralysis, cerebrospinal fluid leakage, meningitis, and cerebral oedema 22 Textbook Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical- surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. References LeMone, P., Burke, K., & Bauldoff, G. (2011). Medical-surgical nursing: critical thinking in client care (5th ed.). Upper Saddle River NJ: Pearson. LeMone, P., Burke, K., Bauldoff, G., & Gubrud, P. (2015). Medical-surgical nursing: Clinical Reasoning in Patient Care (6th ed.). Boston: Pearson. Lewis, S. (2017). Medical-surgical nursing: assessment and management of clinical problems (10th ed.). St. Louis: Elsevier. Linton, A. D. (2016). Introduction to Medical-Surgical Nursing (6th ed.). St. Louis: Elsevier Saunders. 23