EARS OUTLINE: STUDENT ‘S HANDOUT

Pls. review your text book for more information. God bless you all.
PROPER COMMUNICATION HEARING IMPAIRED CLIENT

• APPROACH PATIENT FROM WITHIN LINE OF VISION

• YOU MAY TAP THE SHOULDER LIGHTLY BEFORE SPEAKING.

• REDUCE EXTERNAL NOISE BEFORE SPEAKING

• FACE THE CLIENT AND SPEAK SLOWLY AND CLEARLY

• SPEAK IN LOW PITCH AND NORMAL LOUDNESS

• USE NON-VERBAL CUES AND WRITTEN MESSAGE TO ENHANCE COMMUNICATION.

• IF WITH DIFFICULTY UNDERSTANDING, REPEAT WORDS.

• ASK CLIENT TO REPEAT DIRECTION/TEACHING THAT WAS DONE. TO ENSURE UNDERSTANDING.

AREAS TO CONSIDER IN PREVENTION OF EAR INFECTION:

• 1. Breastfeeding ( ENCOURAGE )
• 2. Daycare setting ( AVOID )
• 3. Control allergies ( Avoid allergens )
• 4. Feed baby upright ( proper way of bottle feeding )
• 5. Keep the nose clear ( during URTI )
• 6. Cigarette smoke ( avoid )
• 7. Echinacea
• 8. Chiropractic care
• 9. Eat more raw fruits and vegetables

COMMON MEDICATION
• ANTI – INFECTIVES
• kills or inhibit the growth of bacteria
• Examples: Amoxicillin (Amoxil)
Ampicillin trihydrate (Polycillin)
Chloramphenicol (Chloromycetin Otic)
• ANTIHISTAMINES and DECONGESTANTS
• produces vasoconstriction, reduces respiratory tissue hyperemia and edema to open obstructed Eustachian
tubes
• Examples: Aztemizole (Hismanal)
Cetirizine (Zyrtec)
Brompheniramine (Bromphen)
• LOCAL ANESTHETICS
• block nerve conduction at or near the application site to control pain
• Example: Benzocaine (Americaine Otic, Tympagesic)
• CERUMINOLYTIC MEDICATIONS
• emulsify and loosen cerumen deposits
• Examples: Boric Acid (Ear-Dry)
Carbamide Peroxide (Debrox)
Trolamine polypeptide oleate-condensate
(Cerumenex)
COMMON EAR PROBLEMS :
» External Otitis
» Otitis Media
» Mastoiditis
» Meniere’s Syndrome
» Otosclerosis
» Labyrinthitis
» Acoustic Neuroma
» Cerumen and Foreign Bodies
» Ear Trauma
Tests of vestibular (balance) function include: • Acoustic-reflex
• Electronystagmography (ENG, VNG) • Electrocochleography (ECoG)
• Rotation tests • Otoacoustic emissions (OAE)
• Computerized Dynamic Posturography (CDP) • Auditory brainstem response test
• Vestibular Evoked Myogenic Potential (VEMP) (ABR; also known as BER, BSER, or BAER)
Other diagnostic tests include:
Tests of auditory (hearing) function include: • Magnetic resonance imaging (MRI)
• Pure-tone audiometry • Computerized axial tomography (CAT, or CT)
• Speech audiometry

SYMPTOMS OF HEARING LOSS

• Irritable, hostile, hypersensitive in inter-cliental relations
• Complains about people mumbling
• Turns up volume on television
• Asks for frequent repetition and answers questions inappropriately
• Losses sense of humor
• Leans forward to hear better or turns head to the preferred side
 • Shuns large-group and small-group audience situations
• Shuns areas with increased background noise
• Might appear aloof and “stuck up”
• Complains or ringing in the ears
• Has an unusually soft or loud voice

KINDS OF HEARING LOSS:

1. Conductive Hearing Loss - sound waves are blocked to the inner ear fibers because of external or middle ear disorders
Causes:
 Inflammatory processes or obstruction of the external or middle ear
 Tumors
 Otosclerosis
 Scar tissue build-up in the ossicles due to previous surgery

2. Sensorineural Hearing Loss - Is a pathological process of the inner ear or of the sensory fibers that lead to the cerebral cortex*
Causes:
 Damage to the inner ear structure
 Damage to the cranial nerve
 Prolonged exposure to loud noise
 Medications
 Trauma
 Inherited disorders
 Infections
 Meniere’s Syndrome
 Surgery

3. Mixed Hearing Loss - both conductive and sensorineural hearing loss are present

PHYSICAL EXAMINATION
1. External ear canal by direct observation
2. Ear canal by Direct observation and with the use of:

Ex. OTOSCOPIC EXAMINATION

• The speculum is never introduced blindly into the external canal because of the risk of perforating the tympanic membrane
• Tilt head slightly away and the otoscope is held upside down as if it were a large pen to lay the examiner’s hand against the client’s head for
support.
• Pull the pinna up and back to straighten the external cannal in an adult
• Visualize the external canal while sllowly inserting the speculum

3. Internal Ear by:

Test for auditory acuity:
Voice Test
Watch Test
Weber’s Tuning Fork Test
Rinne’s Tuning Fork Test
Test for vestibular acuity:
Romberg Test for Falling
Test for Past Pointing
Gaze Nystagmus Evaluation
Hallpike’s Maneuver
OTOSCOPIC EXAMINATION
• speculum is never introduced blindly into the external canal because of the risk of perforating the tympanic membrane
• The client’s head is tilted slightly away and the otoscope is held upside down as if it were a large pen to lay the examiner’s hand
against the client’s head for support
• Pull the pinna up and back to straighten the external cannal in an adult
• Visualize the external canal while sllowly inserting the speculum

Test for auditory acuity:

Voice Test
• Ask the client to block one external canal
• The examiner stands 1 to 2 feet away and whispers a statement
• The client is asked to repeat the whispered statement

Watch Test
• A ticking watch is used to test for high-frequency sounds
• The examiner holds a ticking watch about 5 inches from each ear and asks the client if the ticking is heard
Tuning Fork Tests
Weber’s Tuning Fork Test
• Place the vibrating tuning fork stem in the middle of the client’s head, at the midline of the forehead or above the upper lip over the
teeth
• Hold the fork by the stem only
• Ask the client whether the sound is heard equally in both ears or whether the sound is louder in one ear
• Normal: sound is heard equally in both ears
• Abnormal: Lateralization of the sound (better heard in one ear)

Rinne’s Tuning Fork Test

• The vibrating tuning fork stem is placed on the client’s mastoid process
• Tell the client to indicate when he no longer hears the sound
• Quickly bring the tuning fork in front of the pinna without touching the client and asks the client to indicate whether he or she still
hears the sound
• Record the duration of both phases: bone conduction and air conduction
• Normal: the client continues to hear the sound two times longer in front of the pinna -by air conduction (+ Rinne Test)
• Abnormal: if client is unable to hear the sound through the ear in front of the pinna – CONDUCTIVE HEARING LOSS
(- Rinne Test)
Test for vestibular acuity:
Romberg Test for Falling
• The examiner asks the client to stand with the feet together, arms hanging loosely at the sides and eyes
closed.
• Normal: client remains erect with slight swaying
• Abnormal: Significant sway is present (+Romberg sign)
Gaze Nystagmus Evaluation
• The client’s eyes are examined as the client looks straight ahead, 30 degrees to each side, upward and
downward
• Any spontaneous nystagmus (involuntary, rhythmic, rapid twitching of the eyeballs) – represents a problem in
the vestibular system

Test for Past Pointing

• The client sits in front of the examiner
• The client closes the eyes and extends the arms in front, pointing both index fingers at the examiner
• The examiner holds and touches his or her own extended index fingers under the client’s extended index
fingers to give the client a point of reference
• Instruct the client to raise both arms and then lower them, attempting to return to the examiners’ extended
index fingers
• Normal: client can easily return to the point of reference
• Abnormal: lacks normal sense of position and cannot return the extended fingers to the point of reference,
instead, the fingers deviate to the right or left of the reference point
•
Hallpike’s Maneuver – assesses for positional vertigo and induced dizziness
• The client assumes a supine position
• The head is rotated to one side for 1 minute
• A positive test results in nystagmus after 5-10 seconds
Diagnostic Tests for the Ear
Tomography
• assess the mastoid, middle ear , and inner ear structures
• May be performed with or without contrast medium
• Multiple radiographs of the head are obtained
• Helpful in the diagnosis of acoustic tumors
Interventions:
1. All jewelry is removed
2. Lead eye shields are used to cover the cornea to diminish the radiation dose to the eyes
3. Client must remain still in a supine position
4. No follow-up care is required
Audiometry -Audiographic patterns are depicted on a graph to determine the type and level of hearing loss

• Measures hearing acuity

• Types:

Pure Tone Audiometry – used to identify problems with hearing, speech music and other sounds in the environment
Speech Audiometry – measures client’s ability to hear spoken words

Interventions:
1. Inform the client regarding the procedure
2. Instruct the client to identify sounds as they are heard
Electronystagmography
• is a vestibular test that evaluates spontaneous and induced eye movements known as nystagmus
• Used to distinguish nystagmus caused by a lesion in the central or peripheral vestibular pathway
• Records changing electrical fields with the movement of the eyes, as monitored by electrodes placed on the skin around the eye
• The client sits and is instructed to gaze at lights, focus on a moving pattern, focus on a moving point and then close the eyes
• While sitting on a chair, the client may be rotated to provide information about vestibular function
• In addition, the client’s ear is irrigated with cool and warm water, which may cause nausea and vomiting

COMMON OTIC MEDICATIONS:

• ANTI – INFECTIVES
• kills or inhibit the growth of bacteria
Examples: Amoxicillin (Amoxil)
Ampicillin trihydrate (Polycillin)
Chloramphenicol (Chloromycetin Otic)
• ANTIHISTAMINES and DECONGESTANTS
• produces vasoconstriction, reduces respiratory tissue
• hyperemia and edema to open obstructed Eustachian tube

• Examples: Aztemizole (Hismanal)

Cetirizine (Zyrtec)
Brompheniramine (Bromphen)
• LOCAL ANESTHETICS
• block nerve conduction at or near the application site to control pain
• Example: Benzocaine (Americaine Otic, Tympagesic)
• CERUMINOLYTIC MEDICATIONS
• emulsify and loosen cerumen deposits
• Examples: Boric Acid (Ear-Dry)
Carbamide Peroxide (Debrox)
Trolamine polypeptide oleate-condensate
(Cerumenex)
COMMON EAR DISORDERS:
• External Otitis
• Otitis Media
• Mastoiditis
• Meniere’s Syndrome
• Otosclerosis
• Labyrinthitis
 • Acoustic Neuroma
• Cerumen and Foreign Bodies
• Ear Trauma

External Otitis -Is an infective inflammatory or allergic response involving the structure of external auditory canal or auricles
• may be acute or chronic *
• more common in children
• termed as “Swimmer’s Ear” occurs
more in hot and humid environments
• The skin becomes red, swollen and tender to touch on movement
Causes of External Otitis
(usually caused by bacteria or fungus)
 Water in the ear*
• Trauma to the skin of the ear canal*
• Bacterial infections
• Dermatologic conditions
• Exposure to dust and hair care products
• Regular use of earphones or earplugs
• Chronic drainage from a perforated tympanic membrane

Clinical Manifestations of Otitis Externa

• Moderate to severe ear pain (otalgia)
• Aural tenderness
• Discharges from the external auditory canal
• Lymphadenopathy
• Pruritus
• Hearing loss
• Feeling of fullness in the affected ear
Diagnostic Procedures:
• Otoscopic Examination
• Physical Examination (Inspection and Palpation)
• Microscopic Examination (Culture and Sensitivity)
MEDICAL MANGEMENT:
• Pain: Analgesic – Aspirin, Acetaminophen, Codeine
Heat therapy to the periauricular area
• Infection/Inflammation:
Antibacterial – Neomycin, Bactrim
Antifungal – keratolytic or contains 2%
salicylic acid

NURSING INTERVENTION:
• Observe and record the type and amount of aural drainage
• Apply heat locally for 20 mins, 3 times a day
• Encourage rest to assist in reducing pain
• Administer analgesics and instill ear drops as prescribed
• Instruct the client to keep ears clean and dry
• Instruct the client to use earplugs when swimming
• Instruct client that cotton- tipped applicators should not be used to clean ears
• Instruct client that the use of irritating agents should be discontinued
Acute Otitis Media - (usually occurs in children)
• Is an inflammatory disorder usually caused by an infection of the middle ear occurring as a result of a
blocked eustachian tube, which prevents normal drainage ARTI
• Children are more prone SWS

CLINICAL MANIFESTATIONS:
• Fever
• Irritability and restlessness (c)
• Loss of appetite (c)
• Rolling of head from side to side (c)
• Pulling on or rubbing the ear
• Earache or pain
• Signs of hearing loss
• Purulent ear drainage
• Red, opaque, bulging or retracting tympanic membrane

MEDICAL / SURGICAL MANAGEMENT of ACUTE OTITIS MED

• Antibiotic therapy
Amoxicillin (Amoxil)
Ampicillin trihydrate (Polycillin)
Chloramphenicol (Chloromycetin Otic)
• Analgesics and Antipyretics
Acetaminophen (Tylenol)
• Corticosteroids
Dexamethasone (Maxidex)
Prednisolone (Pred-G)
• Myringotomy – is the insertion of tympanoplasty tubes into the middle ear to
equalize pressure and keep the air aerated
Post – op Procedures: instruct the client (or parents for their child to)
 1. Keep ears clean and dry
2. Wear earplugs while bathing and shampooing
3. Diving and submerging underwater are not allowed
4. Do not blow the nose for 7-10 days after surgery
Myringotomy:
is a surgical procedure in which a tiny incision is created in the eardrum, so as to relieve pressure caused by the
excessive build-up of fluid, or to drain pus. Myringotomy is often performed as a treatment for otitis media.

CHRONIC OTITIS MEDIA

• Is a chronic infective, inflammatory, or allergic response involving the structure of the middle ear
• Requires surgical treatment to restore hearing
Clinical Manifestations
(some signs and symptoms in acute otitis media)
• Persistent intermittent, foul-smelling otorrhea
• Usually no pain except in the presence of Mastoiditis
• Tympanic perforation* (Tympanic membrane appears dull on otoscopy)
• Cholesteatoma –white mass behind the tympanic membrane filled with degenerated skin and sebaceous
materials
• Popping and crackling noises
Chronic Otitis Media
Medical and Surgical Management
(medications administered are the same in acute otitis media)
1. Tympanoplasty - Is the surgical repair of the tympanic membrane.
2. Ossiculoplasty – is the surgical repair of the ossicles

Pre-Operative Nursing Interventions:

1. Administer antibiotic drops as prescribed.
2. Clean the air of debris as prescribed; irrigate the ear with a solution of equal parts of vinegar and sterile water
as prescribed to restore the normal pH of the ear.
3. Instruct client to obtain adequate rest, eat a balanced diet, and drink adequate fluids
4. Instruct client to avoid forceful coughing since it increases pressure in the middle ear.
Post-Operative Nursing Interventions:
1. Instruct client that initial hearing after surgery is diminished because of the packing in the ear canal.
2. Keep the dressing clean and dry.
3. Keep the client flat with operative ear up for at least 12 hours
4. Administer antibiotics as prescribed
5. Instruct the client that he or she may return to work in about 3 weeks post-op as prescribed

MASTOIDITIS:
-characterized by a bacterial infection and inflammation of air cells of the mastoid bone.
-may be acute or chronic and results from untreated otitis media

Signs and Symptoms of MASTOIDITIS

• Swelling behind the ear and pain with minimal movement of the head
• Cellulitis on the skin or external scalp over the mastoid process
• A reddened, dull, thick immobile tympanic membrane, with or without perforation
• Tender and enlarged post-auricular lymph nodes
• X-ray of the mastoid area (reveal hazy mastoid air-cells and bony walls bet cells appear decalcified)
• Low-grade fever
• Malaise
• Anorexia
NURSING INTERVENTIONS:
Prepare the client for surgical removal of the infected material
Monitor for complications such as:
-Damage to the abducens and facial cranial nerve -inability to look laterally CN VI (abducens)
-drooping of the mouth on the affected side CN VII
(facial)
-Meningitis
-Brain abscess
-Chronic purulent otitis media
-Vertigo

Post-operative interventions:
• Monitor for dizziness
• Monitor for signs of meningitis (stiff neck and vomiting)
• Prepare a wound dressing change 24 hrs post-op
• Monitor the surgical incision for edema, drainage and redness
• Position the client flat with the operative side up
• Restrict the client to bed with bedside commode privileges for 24 hrs as prescribed
• Assist the client with getting out of bed to prevent falling or injuries from dizziness
 • With reconstruction of the ossicles via a graft, take precautions to prevent dislodging of the graft

MENIERE’S SYNDROME
• Also called ENDOLYMPHATIC HYDROPS
• refers to the dilatation of the endolymphatic system by overproduction or decreased reabsorption of
endolymphatic fluid
• the syndrome is characterized by: TINNITUS, UNILATERAL SENSORINEURAL HEARING LOSS and VERTIGO
• Symptoms occur in attacks and last for several days*
Initial hearing loss is reversible but as the frequency of attacks continues, hearing loss becomes permanent

Signs and Symptoms of MENIERE’S SYNDROME

• Feeling of fullness in the ear
• Tinnitus ( a continuous low-pitched roar or humming sound)
• Hearing loss that is worse during an attack
• Vertigo that is so intense that even while lying down, the client holds the bed or ground in an attempt to
prevent the whirling
• Nausea and vomiting
• Nystagmus
• Severe headaches
NURSING INTERVENTION:
• Prevent injury during vertigo attacks
• Provide bed rest in a quiet environment
• Provide assistance with walking
• Instruct the client to move the head slowly to prevent worsening of the vertigo
• Initiate sodium and fluid restrictions as prescribed
• Administer nicotinic acid (niacin) as prescribed for its vasodilatory effect
• Administer antihistamines as prescribed to reduce inflammation
• Administer antiemetics as prescribed
• Administer tranquilizers and sedatives as prescribed to calm the client, allow the client to rest, and control
vertigo, nausea and vomiting
• Mild diuretics may be prescribed to decrease endolymph volume

Surgical Interventions for Meniere’s Syndrome

• Endolymphatic drainage and insertion of a shunt to assist the drainage of excess fluids
• Vestibular nerve resection or total removal of the labyrinth (labyrinthectomy)

Post – operative Interventions:

• Assess packing and dressing on the ear
• Speak to the client on the side of the unaffected ear
• Maintain side rails
• Assist with ambulating
• Administer antivertiginous and anti emetic medications as prescribed

OTOSCLEROSIS
• is a disease of the labyrinthine capsule of the middle ear that results in a bony overgrowth of the tissue
surrounding the ossicles and causes fixation of the bones
• Unknown cause, although it is thought to have a familial tendency
• S/s: bilateral hearing loss constant tinnitus
Schwartze’s sign-pinking discoloration of the tympanic membrane
Loud sounds heard in the ear when chewing
• Surgical intervention:
removal of bony overgrowth causing the hearing loss
Partial or complete stapedectomy with prosthesis (fenestration)
STAPEDECTOMY: A a surgical procedure of the middle ear performed to improve hearing.

• Removing the stapes bone and replacing it with a micro prosthesis

• The world's first stapedectomy is credited to Dr. John J. Shea, Jr., performed in May, 1956.
• PURPOSE:
• to improve the movement of sound to the inner ear.
• to treat progressive hearing loss caused by otosclerosis

LABYRINTHITIS
• Infection of the labyrinth that occurs as a complication of acute or chronic otitis media
• S/s: Hearing loss may be permanent on the affected side
Tinnitus
Spontaneous nystagmus on the affected side
Vertigo
Nausea and vomiting
• Nursing Interventions:
 Monitor for signs of meningitis
Administer systemic antibiotics as prescribed
Advise client to rest in bed in a darkened room
Administer anti-emetics and antivertiginous medications as prescribed

Acoustic Neuroma

 A vestibular schwannoma, often called an acoustic neuroma

 -is a benign primary intracranial tumor of the myelin-forming cells of the vestibulocochlear nerve (CN VIII).
 -The term "vestibular schwannoma" is the correct one because the tumor involves the vestibular portion
of the 8th cranial nerve
 -arises from Schwann cells, which are responsible for the myelin sheath in the peripheral nervous system.

CLINICAL MANIFESTATION:

 ipsilateral sensorineural hearing loss/deafness,

 disturbed sense of balance and altered gait,
 vertigo with associated nausea and vomiting,
 pressure in the ear, all of which can be attributed to the disruption of normal vestibulocochlear nerve
function.
 tinnitus (most often a unilateral high-pitched ringing, sometimes a machinery-like roaring or hissing
sound, like a steam kettle).
CERUMEN:
Earwax, also known by the medical term cerumen,
 is a yellowish waxy substance secreted in the ear canal of humans and many other mammals.
 It protects the skin of the human ear canal, assists in cleaning and lubrication,
 provides some protection from bacteria, fungi, insects and water.
 Excess or impacted cerumen can press against the eardrum and/or occlude the external auditory canal
and impair hearing.
 Can cause conductive hearing loss. It is also estimated to be the cause of 60–80% of hearing aid faults.
INTERVENTION
 Movement of the jaw helps the ears' natural cleaning process.
 Softening the earwax with olive oil or some other agent will usually encourage the wax to come out.
The most common method of cerumen removal
 syringing with warm water.
 A curette method is more likely to be used by otolaryngologists when the ear canal is partially occluded
and the material is not adhering to the skin of the ear canal.
 Cotton swabs, on the other hand, push most of the earwax further into the ear canal and remove only a
small portion of the top layer of wax that happens to adhere to the fibres of the swab.