EAR DISORDERS

1. ANATOMY & PHYSIOLOGY

External Ear (if there is hearing loss in this area - it will be conductive)
1. Pinna or auricle
2. External auditory canal
Middle Ear (if there is hearing loss in this area - it will be conductive)
1. Tympanic Membrane
2. Ossicles – smallest bones of the body. The ossicles assist in transmission of sound.
a. malleus
b. incus
c. stapes
Inner Ear (if there is hearing loss in this area – it will be sensorineural)
1. Cochlea – the organ of hearing
2. Balance
3. Cranial Nerve VII – facial nerve
4. Vestibulocochlear nerve – Cranial Nerve VIII

2. FUNCTION
1. Hearing
2. Sound conduction & transmission
3. Balance & Equilibrium (VBC system)

There are two pathways:

• Air conduction – this is the most efficient
• Bone conduction

3. ASSESSMENT
a. Inspection of the External Ear
1. Auricle & surrounding tissues inspected for:
• Deformities
• Lesions
• Discharge – the color, the odor, the amount
• Size, symmetry, and angle of attachment to head
• Pain
• Dermatitis – excema, dermatitis
2. Manipulation of the auricle doesn’t normally elicit pain – if this maneuver is painful, it is
an external problem – probably Acute External Otitis
b. Otoscopic Exam
1. Held in right hand, bottom of scope pointing up
2. With left hand, grasp auricle
a. pull back & up for Adult
b. pull back & down for
Child <3
c. pull back & up for child
>3
3. Looking for position, discharge, inflammation, tympanic membrane
(normal=pearly gray), fluid, air bubbles, blood, masses, foreign bodies.
c. Evaluation of Gross Auditory Acuity – you are trying to determine if it is Conductive or
Sensorineural Hearing Loss:
 1. Whisper – stand 1-2’ away and whisper a phrase (have the patient cover one
ear at a time)
2. Weber – use a tuning fork on forehead – can they hear it on both sides
3. Rinne – use a tuning fork – once close to ear & once on mastoid bone – which
is louder – the ear should be
d. Sensorineural Hearing Loss – Inner
Ear
1. loss of hearing due to damage to the inner ear (hearing=Cochlear or Cranial
Nerve VIII=Vestibulocochlear)
e. Conductive Hearing Loss – External Ear &
Middle Ear
1. loss of transmission of sound
2. there is a problem from the external to the internal – remember your inner ear is
responsible for hearing
3. due to a disease process or obstruction
f. Functional Hearing Loss – see what you want to see, hear what you want to hear
(psychogenic) – there is no real organic cause for the hearing loss.
g. Mixed Hearing Loss – combination of conductive and senorineural

More than 26 million people are affected by hearing loss. Approximately 10 million have irreversible
hearing loss. Occupational exposure (coal miners, plumbers) is a major cause of hearing loss.

4. DIAGNOSTIC
a. Audiometry – have child raise hand when they hear the sound
b. Tympanogram
c. Auditory Brain Stem Response
d. Electronystagmography
e. Sinusoidal Harmonic Acceleration
f. Middle Ear Endoscopy

5. CONDITIONS OF THE EXTERNAL EAR - Conductive

A. Hearing Loss
1. Gerontologic Considerations
a. Age (65+ years)
b. cerumen becomes harder
c. Atrophy of the tympanic membrane
d. Cochlea degeneration
e. Familial – Presbycusis (losing hearing with age)
f. Life long exposure to loud noises – jets, guns, heavy machinery, saws
g. Meds – aspirin, quinine, aminoglycosides, loop diuretics
2. S&S
a. Tinnitus (ringing in the ears)
b. ↑ inability to hear in groups
c. a need to turn up the volume on TV
d. disinterested in the classroom – inattentive – failing grades
e. missing parts of the conversation
f. refusing to seek medical attention or wearing a hearing aid
3. Medical Management
a. Prevent
1. limit exposure to loud noises
2. wear ear plugs
b. Antibiotics
 c. Surgery – sometimes this is the only way to restore hearing
d. Aural Rehab – lip reading, hearing aids
4. Nursing Management (See chart in
Brunner)
a. know the different types of
hearing loss
b. facial expressions &
gestures
c. speak
louder

B. Cerumen Impaction
1. cerumen normally accumulates in the external canal in various amounts and
colors
2. sometimes impaction does occur – requiring removal
3. Otalgia – a sensation of fullness or pain in the ear
4. more common in elderly
5. Management
a.Irrigation – warm water gently squirted into ear canal
b. Suction – aural suction – sometimes the cerumen will need to be softened with some
type of softening agent before being suctioned
c.Instrumentation – Cerumen Curette
d. Referral – if the above doesn’t work – ER

C. Foreign Bodies
1. Causes
a. some objects are inserted intentionally in the ear by adults who are
trying to clean the external canal or to relieve itching
b. by children sticking objects in the ear (beads, pebbles, peas, toys)
2. There may be no symptoms or profound pain
3. Management – 3 standard methods
a. Irrigation – Warning: if there is a vegetable or insects in there, don’t
irrigate – it will swell – mineral oil can be used to remove an insect
b. Suction
c. Instrumentation
d. Referral

D. External
Otitis (Otitis Externa)
1. Inflammation of the external auditory canal

2. Causes
a. water in the ear canal (Swimmer’s ear)
b. trauma
c. bacterial or fungal infections
d. dermatitis
e. allergic reactions – hair spray, hair dye, permanents

3.
S&S
a. pai
n
 b. discharge – yellow, green, foul
smelling
c. aural tenderness when touching the ears
d. fev
er
e. cellulitis &
lymphadenopathy
f. hearing loss – due to the canal starting to shut off from the
swelling
g. itc
hing
h. feeling of
fullness
i. erythematous and
edematous

4. Medical Management
a. GOAL: relieve discomfort, reduce swelling, ↓ infection
b. analgesics
c. antibiotics - usually something topical like ear drops (if you get into like
cellulites and it gets systemic, then the patient will be put on an oral antibiotic)
d. corticosteroids
e. antifungal

5. Nursing Management
a. Teach patients
1. not to clean the external canal w/cotton-tipped applicators
2. No swimming or use a barrier when swimming
3. do not allow water to enter the ear when shampooing or showering
4. a cotton ball can be covered in water –insoluble gel such as petroleum
jelly and placed in the ear as a barrier
5. Keep water out of the ear canal
b. Prevent infection by using antiseptic otic preparations after swimming
(Swim Ear or Dry Ear)
c. Usually on antibiotics or antifungals for 7 days.

E. Gapping Earring Puncture

1. Causes
a. wearing heavy pierced earrings for a long time
b. wearing them after an infection
c. reaction to earrings – some people just can’t wear certain types of earings
d. wearing more than one earring
2. Management – correct surgically
3. If you are prone to keloids, you may end up with them when you try to have this fixed.

6. CONDITIONS OF THE MIDDLE EAR - Conductive

A. Tympanic Membrane Perforation
1. Causes
a. Infection – puss and infection can put pressure on the eardrum which can
cause it to rupture
 b. trauma – skull fracture, explosive injury, severe blow to the ear, foreign objects
(bobby pins), a really loud noise
2. Medical Management
a. most heal spontaneously within weeks after rupture – some may take
months to heal
b. observe for evidence of CSF – Otorrhea or Rhinorrhea – clear watery
discharge from ear or nose
c. while healing – protect from water – we do not want any bacteria to get
into the ear and cause infection
3. Surgical Management
a. Tympanoplasty – involves putting some type of skin or tissue over the
perforation so that it can heal
4. Nursing Management
a. no cleaning ear w/bobby pins, cotton swabs, keys
b. while healing, protect from water

B. Acute Otitis Media

1. acute infection of the middle ear
2. last < 6 wks
3. Causes
a. Streptococcus pneumoniae
b. Haemophilus influenzae
c. Moraxella catarrhalis
4. bacteria enters the ear through the eustachian tube from upper respiratory infections
5. bacteria can also enter the tube through a perforated tympanic membrane
6. S&S
a. vary w/severity of infection
b. unilateral in adults
c. may be accompanied by otalgia (sensation of fullness or pain around the
ear)
d. drainage from ears
e. fever
f. hearing loss
g. otorrhea
h. NO pain w/movement of auricle
i. tympanic membrane is erythematous and often bulging
7. Medical Management
a. PO antibiotics – if there has been no improvement in 3 days, the child
needs to be brought back to the doctor’s office because the type of antibiotic needs
to be changed. The main thing is to get the antibiotics into the system
b. antipyretics
c. analgesics
8. Surgical Management
a. myringotomy or tympanotomy - incision is made through tympanic
membrane and drains the fluid
b. PE tubes – usually stay in for 6-18 months
9. Preventative
a. Antibiotics should be taken the full 10 days – the fever and pain will go
away in 2 days, but teach the pt to continue w/meds
b. If pain doesn’t disappear, call DR
c. No smoking
d. Don’t prop the bottle to feed the baby
 C. Serous Otitis Media
1. fluid, with no infection, in the middle ear
2. fluid is from negative pressure – the eustachian tube is obstructed
3. seen mostly in children
4. Causes
a. seen after radiation therapy
b. barotrauma – sudden pressure changes (scuba diving, airplanes) – this is
why people chew gum whenever they fly
5. Carcinoma – obstructs the eustachian tube – this should be ruled out if the pt continues to
have Serous Otitis Media
6. S&S
a. hearing loss - conductive
b. fullness in the ear
c. sensation of congestion
d. popping and crackling noises
e. Tympanic membrane is dull
f. can see air bubbles in the middle ear
7. Management
a. doesn’t need to be treatment unless infection occurs (acute otitis media)
b. myringotomy for hearing loss and to release the fluid
c. PV tubes – to release the fluid – the fluid might actually be causing
pressure and the pressure may be causing some pain
d. Corticosteroids - ↓ edema/inflammation
e. Valsalva maneuver – opens eustachia tube – may cause worse pain and
perforation of tympanic membrane – use CAUTION – we do not teach children how
to do the Valsalva maneuver.

D. Chronic Otitis Media

1. Caused from repeated episodes of Acute Otitis Media – causes persistent perforation of
the tympanic membrane – chronic infections destroy the ossicles. The eardrum just does
not look normal any more
2. S&S
a. hearing loss
b. foul-smelling otorrhea
c. NO pain
d. may can see the perforation of the membrane
e. Cholesteatoma can be identified – a white mass behind the tympanic
membrane – this usually doesn’t cause pain
3. Medical Management
a. suctioning
b. antibiotic drops
c. No systemic antibiotics are not prescribed unless there is Acute Infection
(fever, cellulitis) (systemic antibiotics are antibiotics for the whole body)
4. Surgical Management – choice of surgery depends on severity
a. tympanoplasty
b. ossiculoplasty
c. mastoidectomy

E. Otosclerosis – involves the stapes

1. Caused by a formation of new, abnormal spongy bone – HARD BONE – prevents
transmission of sound
 2. more common in women
3. frequently hereditary
4. worsened by pregnancy
5. S&S
a. hearing loss – Conductive/Mixed – progressive conductive hearing loss
b. normal tympanic membrane – because this affects the stapes, not the
membrane
c. with this disorder bone conduction is better than air conduction on Rinne
test – that’s why it is a conductive hearing loss (in normal hearing air conduction is
better than bone conduction)
6. Medical Management
a. No NON-Surgical treatment
b. Florifcal sometimes helpful
c. hearing aid can help with hearing loss
d. amplification
7. Surgical Management
a. Stapedectomy

7. CONDITIONS OF THE INNER EAR – Sensorineural

A. Motion Sickness – disturbance of equilibrium
1. Caused by constant motion – ship, merry-go-round, swing, back seat of a car
2. S&S
a. Sweating
b. Pallor
c. Nausea &Vomiting
3. Management
a. OTC antihistamines (Dramamine, Bonine)
b. Anticholinergics – drying is a side effect
c. Treat the signs and symptoms
4. No driving car or operating heavy machinery if drowsiness occurs

B. Meniere’s Disease (sensorineural)

1. an abnormal inner ear fluid balance
2. common in adults
3. starts in the 40’s
4. both ears are affected equally, bilaterally
5. S&S
a. fluctuating, progressive sensorineural hearing loss –– may fluctuate
b. tinnitus – may fluctuate – or may occur during or after attacks – or
may be constant – this is the second most reason that the patient will seek
treatment
c. roaring sound
d. feeling of pressure
e. feeling of fullness in the ear
f. episodic incapacitating vertigo
g. Nausea &Vomiting
h. diaphoresis
i. Vertigo – the most troublesome complaint
 6. Treatment and Diagnostics
a. Vertigo
b. Diaphoresis
c. Feeling of imbalance or disequilibrium because of the inner ear problems
d. These attacks can awaken them at night – they’ll feel well between attacks
e. Hearing loss fluctuating
f. Tinnitis
g. Aurel pressure
h. No absolute Diagnostic test – physical exam will be normal
i. Head lateralizes to the ear opposite the hearing loss
j. There will be a sensorineural hearing loss in the affected ear
7. Management
a. Diet - ↓ NA diet (2000mg/day) – these patient’s have a fluid problem
b. Meds
1. antihistamines (Antivert)
2. Tranquilizers (Valium)
3. Antiemetics (Phenergan)
4. Diuretics (Lasix)
c. Psychological counseling
d. Surgery is done to eliminate attacks of vertigo – may still have hearing
loss, tinnitus, fullness feeling

9. OTOTOXICITY
a. A variety of meds can cause this
1. aspirin at high doses
2. quinine
3. aminoglycosides (Vancomycin)
b. Teach patients receiving these meds about their side effects
c. Monitor blood levels - the physician will order the blood work
d. Audiograms 2/week during therapy

11. AURAL REHAB

a. hearing aids
b. hearing guide dogs
c. auditory training
d. speech reading – lip reading
e. speech training

12. RF Injury RT altered mobility because of gait disturbance and vertigo

a. assess for vertigo, hearing loss, tinnitus, aural fullness
b. assess extent of disability in RT activities of daily living
c. teach or reinforce balance therapy
d. administer or teach administration of antivertiginous meds
e. teach about med s/e
f. encourage pt to sit down when dizzy
g. place pillow on each side of head to restrict movement
h. assist pt in identifying aura that suggests an impending attack
i. recommend that the pt keep eyes open and stare straight ahead when lying down and
experiencing vertigo

13. Impaired adjustment RT disability requiring change in lifestyle due to unpredictability of vertigo
 a. encourage pt to identify personal strengths and roles that can still be fulfilled
b. provide info about vertigo and what to expect
c. include family and significant others in rehab process
d. encourage pt to maintain sense of control by making decisions and assuming more
responsibility for care

14. RF Deficient fluid volume RT ↑ fluid output, altered intake, and meds
a. assess, or have pt assess, I&O (including emesis, liquid stools, urine, diaphoresis)
b. monitor lab values
c. assess for dehydration, including BP(orthostasis), pulse, skin turgor, mucous membranes,
and LOC
d. encourage oral fluids as tolerated – discourage beverages containing caffeine
e. administer, or teach administration of, antiemetics, and anti-diarrheal meds
f. teach med s/e

15. Anxiety RT threat of, or change in , health status and disability effects of vertigo
a. assess level of anxiety – help pt identify coping skills used successfully in the past
b. provide information about vertigo and its treatment
c. encourage pt to discuss anxieties and explore concerns about vertigo attacks
d. teach pt stress mgmt techniques or make appropriate referrals
e. provide comfort measures and avoid stress-producing activities
f. instruct pt in aspects of tx regimen

16. RF Trauma RT Impaired balance

a. assess for balance disturbance and/or vertigo by taking hx and examination for nystagmus,
+ Romberg, and inability
to perform tandem Romberg (pt stands w/feet together and arms at side, close eyes for
20-30 sec, examiner stands
close to pt in case he loses his balance. Slight swaying is normal, but loss of balance is
abnormal and is
considered +Romberg)
b. Assist w/ambulation when indicated
c. Assess for visual acuity and proprioceptive deficits
d. encourage increased activity level with or without use of assistive devices
e. help identify hazards in home environment

17. Ineffective coping RT personal vulnerability and disabling effects of vertigo

a. assess cognitive appraisal of illness and factors that my contribute to inability to cope
b. provide factual information about treatment and future health status
c. encourage and help pt to participate in decision making about adjustments in lifestyle
d. encourage pt to maintain diversional or recreational activities, exercise, and social events
e. help to identify personal strengths and develop coping strategies based on previous
positive experiences in dealing w/
stress, and situational supports
f. Refer pt to support groups or counseling as indicated

18. Self-Care Deficit: feeding, bathing/hygiene, dressing/grooming, toileting

a. Administer, or teach administrations of, antiemetics and other prescribed meds to relieve
N&V associated w/vertigo
b. encourage pt to perform self-care when free of vertigo
c. review diet w/ pt and caregivers
d. offer fluids as necessary
19. Powerlessness RT illness regimen and being helpless in certain situations due to vertigo/balance
disturbance
a. assess pt’s needs, values, attitudes, and readiness to initiate activities
b. provide opportunities for pt to express feelings and self and illness
c. help ot identify previous coping behaviors that were successful
20. Deficient diversional activity RT environmental lack of such activity
a. assess level and type of diversional activity to plan appropriate activities
b. discuss usual pattern of diversional activities w/pt – suggest opportunities to continue
meaningful diversional activities

21. CHILDREN - OTITIS MEDIA – OM

a. most prevalent disease in early childhood
b. highest 6mos – 2 years
c. more boys are affected
d. Acute Otitis Media is highest in winter
e. Children living w/smokers will have ↑ risk
f. RF
1. living with a smoker
2. day care attendance
g. Breast fed children have lower incidences
h. Acute S&S
1. follows an upper respiratory infection
2. otalgia – earache
3. fever
4. purulent d/c (otorrhea) may or may not be present
i. Infant S&S
1. crying
2. fussy, restless, irritable
3. tendency to rub, hold, or pull at affected ear
4. rolls head from side to side
5. difficulty comforting the child
6. loss of appetite
j. Older Child S&S
1. crying and or verbalizes feelings of discomfort
2. irritable
3. lethargy
4. loss of appetite
k. Chronic S&S
1. hearing loss
2. difficulty communicating
3. feeling of fullness, tinnitus, vertigo may be present
l. Management
1. PO Antibiotics – 5-10 day course of oral antibiotics (amoxicillin,
amoxicillinclavulanate, sulfonamides,
erythromycin, azithromycin, cephalosporins) – will see an improvement in about
2 days
2. IM Ceftriaxone
3. surgery if meds don’t work
4. antipyretics to relieve fever
5. No steroids, decongestants, or antihistamines
6. analgesics to relieve pain
 7. heating pad on low heat and wrapped in a towel may reduce discomfort – place over
the ear with the child
lying on the affected ear
8. ice compress may also relieve pain and reduce edema and pressure
m. Prevention
1. sitting or holding an infant upright during bottle-feeding and breast-feeding
2. Propping bottles is discouraged to avoid the supine position and to encourage
human contact during
feeding
3. teach parents the initial signs of OM – irritability and pulling at the ear
4. Eliminate tobacco smoke and known allergens

FYI: Air conduction is supposed to be better than bone conduction in normal hearing. in some
disorders, you may have it where air conduction is better than bone conduction. With otosclerosis,
this will not be true, the bone conduction is better than the air conduction.