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Care of the Clients with Common Ear Problems

Medical Surgical Nursing

12/21/2017

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Jhon Willie S. Ybanez, SN

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ANATOMY AND PHYSIOLOGY *Weber Test – the rounded tip of the handle of the vibrating tuning fork is
placed on the client’s head or teeth. It uses bone conduction to test
The Ear lateralization of sound. A tuning fork is set in motion by tapping it on the
The Ear is divided into 3 parts: External, Middle and Internal Ear. examiner’s knee or hand, and placed on the pt’s head of forehead. This test is
(1) External Ear useful in cases of unilateral loss. It is more accurate in diagnosing sensorineural
a. Auricle or Pinna – it collects sound waves and directs vibrations toward the auditory hearing loss like in Meniere’s Disease.
meatus.
b. External auditory meatus (External auditory canal) Interpretation of results:
– Approximately 2.5cm long, the skin of the canal contains hair, sebaceous glands, and 1. Normal – Negative. Tone is heard in center of head or equally in both ears.
ceruminous glands, which secrete a brown, wax like, substance called Cerumen or Ear Wax. 2. Conductive hearing loss – tone is heard in poorer area, e.g. Otosclerosis. Hears
- It directs sound waves to the tymphanic membrane; hairs and cerumen help cleanse the the sound in the affected area.
canal of foreign matter. 3. Sensorineural hearing loss – hears the sound in the better-hearing hear.
c. Tymphanic Membrane (Eardrum) – protects the middle ear and conducts sound
vibrations from the external ear to the ossicles. (2 )Whisper Voice Test – the examiner covers one ear with palm of the hand, then whispers
- it is about 1cm in diameter and very thin softly 2-syllable words from a distance of 1 or 2 feet from the occluded ear, and out of the
- it is normally pearly gray and translucent pt’s sight (e.g. thirteen, fourteen, fifteen). The person with normal hearing acuity can
correctly repeat what was whispered.
(2) Middle Ear (Tympanic Cavity)
(3) Audiometry – it is the single most important diagnostic instrument in detecting hearing
a. Ossicles – contains the smallest bones of the body: Malleus, Incus, Stapes decrease the loss
magnitude of the sound
- mechanically transmit sound waves from the tympanic membrane through the oval Types:
window to the inner ear.
b. Windows: a. Pure-Tone Audiometry – the louder the tone before the client perceives it, the
b.1. Oval Window – transmits sound vibrations from the stapes to the fluids in the inner greater the hearing loss.
ear b. Speech Audiometry – spoken word is used to determine the ability to hear and
b.2. Round Window – relieves pressure as vibration exit the inner ear discriminate sounds and words. The louder the sound before the client
c. Eustachian Tube (Auditory Tube) – provides air passage from the nasopharynx to the perceives it, the greater the hearing loss.
middle ear. During yawning, sneezing and swallowing, the tensor veli palatine muscle
opens the tube to equalize the pressure on both sides of the tympanic membrane (4) Typanogram and Impedance Audiometry – it measures middle ear muscle reflex to
d. Mastoid – these air-filled spaces that aid the middle ear in adjusting to changes in sound stimulation and compliance of the tympanic membrane, by changing the air pressure
pressure in a sealed ear canal. Compliance is impaired with middle ear diseases.

(3) Inner Ear – is housed deep within the temporal bone. The organs for hearing (Cochlea) (5) OculovestibularTest or Ice Water Caloric Test – irrigate the ear with cold water.
and balance (Semicircular Canal), as well as cranial nerves VII (Facial Nerves) and VIII
(Vestibulocochlear nerve), are all part of this complex anatomy. Normal result : lateral conjugate nystagmus of the eyes towards area of stimulation.
a. Bony Labyrinth – surrounds and protects the membranous labyrinth Abnormal result: dysconjugate nystagmus of the eyes.
a.1. Vestibule – contains the utricle and saccule, which function in the sense of balance. Then, irrigate the ear with warm water.
a.2. Cochlea – contains auditory receptors which functions in hearing Normal result: lateral conjugate nystagmus of the eyes away from the area of stimulation.
a.3. Semi-circular canals – function in the sense of balance. Abnormal result: dysconjugate nystagmus of the eyes.
b. Membranous labyrinth – contains receptor cells for hearing
b.1. Utricle and saccule – organ of static equilibrium (6) Otoscope – is used visually to examine the ears. Examines the external auditorycanal
b.2. Cochlear duct – contains Organ of Corti or The End Organ for Hearing, which is the and tympanic membrane. Otoscope should be held in the examiner’s right hand, in a pencil-
center for acute hearing and a snail-shaped, bony tube about 3.5cm long with 2 and a hald hold position, with the examiner’s hand braced against the patient’s face.
spiral turns. It contains the receptors for hearing.
b.3. Semi-circular canals – function in dynamic equilibrium (7) Schwabach Test – compares client hearing with that of the examiner (assuming that
examiner has normal hearing)
PHYSIOLOGIC CHANGES OF THE EAR WITH AGING
SYMPTOMS OF EAR DISEASES
1. Cerumen that accumulates in the external eat contribute to hearing loss
especially in low frequency range. DEAFNESS
2. Degeneration of the receptor cells in the Organ of Corti(Presbycussis) - means that the pt has a hearing loss which may be mild or severe
3. Ossicles may become less movable and interfere with transmission of sound - hearing loss may be conductive, sensorineural or mixed types
waves. - the most common causes of deafness in childhood is serious otitis media whereas in
4. Decrease in cochlear branch of thecranial nerve VII contributes to hearing loss; adults, presbycussis is the most common cause.
reduction in the vestibular branch interferes with balance and equilibrium. - Presbycussis means deafness of the elderly and it is a sensorineural hearing loss
5. Bacterial and viral infections in the temporal bone may cause sensorineural caused by the degeneration of the nervous tissue. It is more common among men,
hearing loss. over 50 years of age.
- Hearing loss in presbycussis is predominantly in the higher frequencies (high-pitched
sounds like women’s voice)

DIAGNOSTIC TESTS FOR AUDITORY ACUITY

(1) Tuning Fork Tests PAIN


- earache or otalgia is a very common complaint
*Rinne’s Test – compares air conduction form bone conduction; differentiates conductive - in children, the most common cause is acute otitis media whereas in adults is otitis
and sensorineural hearing loss. It is more accurate in diagnosing conductive hearing loss like externa
in Otosclerosis. The vibrating tuning fork is placed against the mastoid bone/ behind the - the pain may arise from the ear itself or from an adjacent site with a shared nerve
earlobe (bone conduction); then, it is placed 2 inches from the opening of the ear canal (air supply.
conduction) - the most common site for referred pain is the throat, hwere infections or, more
rarely, malignant tumors are responsible.
Interpretation of results:
1. Normal : Positive Rinne. Air conduction is better than bone conduction(the DISCHARGE
tone is louder in front of the ear). Air conduction is greater than bone - a discharge from the ear may be mucoid, purulent or bloody. It must be
conduction. Air conducted sound is louder than bone-conducted sound distinguished from the escape of wax which is a normal process.
2. Conductive hearing loss: bone conduction is better than air conduction (the - commonly the cause of a discharge it otitis externa or otitis media and in the latter
tone is louder behind the ear). Bone-conducted sound is longer than air- event, a perforation will be present in the tympanic membrane.
conducted sound. - iif perforation of the tympanic membrane is suspected or diagnosed, irrigation of
3. Sensorineural hearing loss: same as the normal finding. Air-conducted the ear should be avoided.
sound is longer than bone-conducted sound.
VERTIGO
- is a form of dizziness where the pt experiences a spinning sensation. It is a common
symptom when the balance or vestibular system of the inner ear is diseased. It is *Douce 2-3 days and then irrigate the ear to wash out the softened wax.
accompanied by nausea and vomiting Ear irrigation prescribed to:
*Clean the external auditory canal
TINNITUS *Remove the impacted cerumen
- or noise in the ear, is a very common complaint. *Apply heator cold to the ear as necessary
- its quality varies from a high-pitched whistle to the changing of belts or recognizable *Apply antiseptic solutions to the auditory canal
snatches of music. *Remove foreign bodies as prescribed
*To straighten ear canal of adUlt,pull pinna UP AND BACKWARDS
CLASSIFICATION OF HEARING LOSS *To straighten ear canal of a chilD, pull punna DOWN AND BACKWARDS
*Conductive Hearing Loss – involves interference with conduction of sound impulses
through the external auditory canal, the ear drum of the middle ear. It is validated by
Rinne’s Test.
*Sensorineural Hearing Loss – results from disease or trauma to the inner ear or acoustic EXTERNAL EAR PROBLEMS
nerve. It is validatedby Weber’s Test.
*Mixed hearing loss – involves both conductive and sensorineural hearing loss. o OTITIS EXTERNA
- refers to an inflammation of the external auditory cannal
ASSESSMENT IN A CLIENT WITH HEARING LOSS
Etiology
Irritable, hostile or hypersensitive in interpersonal relations.
Has difficulty in following directions  Bacterial causes, usually Psudomonas, and Staphylococcus aureus.
Complains about people mumbling  Fungal infection with Aspergillus and Candida albicans
Turns up volume on TV  Trauma to the ear canal, usually from cleaning the canal.
Asks for frequent repetition  Stagnant water in ear canal after swimming (Swimmer’s Ear)
Answers questions inappropriately
Leans forward to hear better; face looks serious and strained Clinical Manifestations
Loses sense of humor; becomes grim and lonely
Experiences social isolation  Pain and discharge from the external auditory canal
Develops suspicious attitude  Aural tenderness
Has abnormal articulation  Fever, cellulitis and lympadenopathy
Complains of ringing in the eras  Hearing loss or feeling of fullness
Has unusually soft or loud voice  Ear canal is erythematous and edematous
Dominates conversation  Discharge may be yellow or green and foul-smelling
 In fungal infections, hair-like black spores may even be visible
GUIDELINES FOR COMMUNICATING WITH THE CLIENT WITH HEARING
IMPAIREMENT Management

 If canal is swollen and tender, an antibiotic solution containing a corticosteroid


1. Talk directly to the person facing him/her. So he/she can read/lip movements. is chosen to reduce inflammation and swelling. If acute inflammation and
2. Speak in clearly enunciated words, using normal tone of voice. Do not shout. closure of the ear canal prevent drops from saturating canal, a wick may need
High-pitched sound is used when shouting. This is more difficult to understand to be inserted so drops will gain access to walls of entire ear canal.
especially among older people.  Burrow’s solution (Aluminum Acetate solution) or topical corticosteroid cream
3. Use gestures with speech. or lotion is used in otitis externa caused by dermatitis.
4. Do not whisper to anybody in front of the hearing – impaired client.  Fungal infection may be treated with a topical antifungal such as nystatin.
5. Do not avoid conversation with a person who has hearing loss.  In chronic otitis externa, debris from ear canal may need to be removed
6. Do not show annoyance by careless facial expression. through irrigation or suction, after pain and analgesics may be needed.
7. Move closer to the person or toward the better ear of she/he does not hear
you. Nursing Interventions
8. Do not smile, do not chew gum or cover the mouth when talking to the person.  Instruct patients not to clean the external auditory canal with cotton-tipped
So, the person can read the lip movements. applicators.
9. Encourage the use of hearing aid if the client has one.  Avoid events that traumatize the external canal.
 Avoid getting the canal wet when swimming or shampooing the hair.
PLANNING FOR HEALTH PROMOTION  Infection can be prevented by using antiseptic otic preparations after
swimming.

Ear Protection

-the most common and important type of occupational hearing loss is caused by loud MIDDLE EAR PROBLEM
noise.
- a sound intensity is measured in decibel. Ordinary speechis about 50 db. Noise over 70 o ACUTE OTITIS MEDIA
db is potentially damanging to the ear. -an inflammation and infection of the middle ear caused by the entrance of
pathogenic organisms, with rapid onset of signs and symptoms. It is a major
General Ear Care problem in children but it may occur at any age.
- Pathogenic organisms gain entry into the normally sterile middle ear, usually
- Ear is generally self-cleaning. Cerumen (earwax) lubricates the skin in the through a dysfunctional Eustachian tube.
auditory canal and entraps foreign material entering the canal - Most common organisms include Streptococcus pneumoniae, Haemophilus
- Clean the auditory canal only with a wet soft cloth over the tip of the finger. influenza and Staphylococcus aureus.
Do not insert anything to the auditory canal beyond the extent of vision.
- It is best to keep the eyes and mouth both open while blowing the nose to Clinical Manifestations:
reduce pressure that may force contaminated material up the Eustachian  Pain and fever
tube and into the middle ear.  Purulent drainage (Otorrhea) is present if tympanic membrane is
perforated
COMMON NURSING INTERVENTIONS RELATED TO THE EARS  Irritability may be noted in the young person
 Headache, hearing loss, anorexia, nausea and vomiting may be
- Administration of ear drops present
- Medications ofr the ear should be warmed to prevent discomfort. Do not  Purulent effusion may be visible behind tympanic membrane may
overheat. be reddened on otoscopic examination.
- Instruct pt to turn head so that it is tilted away from the affected side. After  Hx may reveal previous upper respiratory infection, allergic rhinitis
drops are instilled, the head is kept tilted for a few minutesto prevent leakage or smoking in household and sibling otitis media in children
of drop from the ear.
- Softening and removing cerumen deposits: Management:
*Daily instilling a few drops of Hydrogen peroxide or warmed gkycerin
Carbamine (urea). Peroxide in glycerol (Oebrox) may be used.  Antibiotic tx – Amoxicillin is the 1st line of tx
 If drainage occurs, an antibiotic otic preparation is usually prescribed.
 Surgery: MYRINGOTOMY – an incision is made into the posterior inferior
aspect of the tympanic membrane for relief of persistent effusion. Surgery

Nursing Interventions 1. Endolymphatic Sac Decompression


-theoretically equalizes the pressure in the endolymphatic space
 Encourage the use of local warm compresses or heating pad to promote - a shunt or drain is inserted in the endolymphatic sac through a postauricular
comfort. incision
 Teach about medication thx
 Advise pt that sudden relief of pain may indicate tympanic membrane 2. Labyrinthectomy
rupture. Do not instill anything in ear and callhealth care provider. - recommended if the pt experiences progressive hearing loss and severe vertigo attacks so
 Encourage follow-up tx to ensure resolution. normal tasks cannot be performed; results in total deafness of affected ear.

3. Vestibular Nerve Section

o OTOSCLEROSIS -neurosurgical suboccipital approach to the cerebellopontine angle for intracranial


- Involves the stape and is thought to result from the formation of new, verstibular nerve neurectomy
abnormal spongy bone, around the oval window, which results in fixation of
the stape. Common Complications:
- The efficient transmission of sound is prevented because the staoes cannot
vibrate and carry the sound as conducted from the malleus and incus to the  Irreversible hearing loss
inner ear.  Disability and social isolation d/t vertigo and hearing loss
 Injury d/tfalls
Clinical Manifestations:
Nursing Management:
 May involve one or both ears
 Progressive conductive and mixed hearing loss  Help pt recognize aura so pt has time to prepare for an attack
 May or may not complain of tinnitus  Encourage pt to lie down during attack, in safe place, and lie still
 Normal tympanic membrane but may also reveals a pinkish orange tympanic  Limit foods high in salt or sugar. Be aware of foods with hidden salts and
membrane because of vascular and bony changes in the middle ear sugars.
 Bone conduction is better than air conduction on Rinne testing  Limit alcohol intake. Alcohol may change the volume and concentration of the
inner ear fluid and may worsen symptoms.
Surgical Management:  Avoid aspirin and aspirin-containing meds
 Teach about medication thx, including side effects
STAPEDECTOMY  Advise pt to keep a log of attacks, triggers, and severity of symptoms
- Involves removing the stapes superstructure and part of the footplate and  Encourage follow-up hearing evaluations and provide information about
inserting a tissue graft and a suitable prosthesis surgical care.
- Balance disturbance or true vertigo may occur during the postoperative period
for several days

o IMPACTED CERUMEN AND FOREIGN BODIES


-Accumulated cerumen (earwax) may become impacted d/t use of cotton
o MENIERE’S DISEASE swabs to clean ears and may be a problem for some people.
-an abnormal inner ear fluid balance by a malabsorption in the endolymphatic -cerumen becomes drier in elderly people, making impaction more likely
sac or a blockage in the endolymphatic duct. - foreign bodies may be dislodged in the ear canal intentionally or accidentally
by the pt or other person (usually in children), or the other pt may be
Clinical Manifestations: completely unaware, as in insect obstruction
 Fluctuating, progressive sensorineural hearing loss.
 Feeling of pressure of fullness in the ear Etiology:
 Meniere’s Triad:  May be underlying seborrhoea or other dermatologic condition
 Tinnitus or a roaring sound that causes flaking of skin that mixes with cerumen and becomes
 Vertigo, often accompanied by nausea and vomiting obstructive
 Sernsorineural hearing loss  Cerumen may be pushed back over tympanic membrane by action
of cotton swab
Diagnostic Evaluation:  Insect may fly or crawl into ear, causing initial low rumbling sound;
later, feeling that ear is plugged and decreased hearing acuity.
 Caloric Testing to differentiate meniere’s disease from intracranial lesion  Children who introduce peas, beans, pebbles, toys and beads.
 Fluid, above or below body temperature, is instilled into the
auditory canal Clinical Manifestations
 Will precipitate an attack in pts with meniere’s disease
 Normal pt complains of dizziness; pt with acoustic neuroma has no  Decreased hearing acuity
reaction  Feeling that ears is plugged
 Audiogram shows sensorineural hearing loss  Pain and fever
 CT scan, MRI to rule out acoustic neurons  Drainage may occur

Management: Management

Medical: For impacted cerumen:

 Pt can be asked to keep a diary noting presence of aural symptoms (e.g.tinnitus, 1. Cerumen can be removed by irrigation, suction or instrumentation unless the
distorted hearing) when episodes of vertigo occur. This may help diagnose pt has a perforated eardrum or an inflamed external ear
which ear is involved and whether surgery will be needed. 2. For successful removal, the water stream must flow behind the obstructing
 Administration of osmotic diuretics (Diamox) cerumen to move it first laterally and then out of the canal.
 Administration of the vestibular suppressant to control symptoms: 3. If irrigation is unsuccessful, direct visual, mechanical removal can be performed
 Meclizine (Antivert, Bonine) up to 25 mg qid 4. Instilling a few drops of warmed glycerine, mineral oil, or half-
 Diphenhydramine (Benadryl 25 to 50 mg tid to qid strengthhydrogen peroxide into theear canal for 30 minutes can soften
 Diazepam (Valium) 2 mg tid or 5 to 10 mg IM or IV (addictive cerumen before the its removal.
potential) 5. Use of cerumen curette, aural suction and a binocular microscope for
 Streptomycin (I.M.) or gentamicin may be given to selectively destroy magnifications.
vestibular apparatus if vertigo is uncontrollable
 Additional antiemetic, such as Promethazine (Phenergan), may be needed to
reduce nausea, vomiting and resistant vertigo.
For foreign objects
1. Irrigation for vegetable bodies and insects are contraindicated
2. Insect can be dislodged by instilling mineral oil
3. Mechanical removal and aural suction can be performed
4. Foreign bidy may have ti be extracted in the operating room with the pt under general
anesthesia.

o ACOUSTIC NEUROMA
- Is a benign tumor of the vestibular or acoustic nerve
- The tumor may cause damage to hearing and to facial movements and
sensations, Symptoms begin with tinnitus= and progress to gradual
sensorineural hearing loss.
- Tx includes surgical removal of the tumor via craniotomy
- Care is taken to preserve the function of the facial nerve
- Postop nursing care is similar to postoperative craniotomy care
- An acoustic neuroma expands out of the internal auditory canal, displacing the
cochlear, facial and trigeminal nerves located in the cerebellopontine angle.
- NOTE: After the surgery, the pt may experience asymmetry of the face d/t
affectation of the facial nerve. This will spontaneously be resolved in few
months.
- There will be dryness of the eye on the affected side and this eye will not be
able to produce tears for sometime. Artificial tears may be instilled into the eye
at regular basis to prevent corneal ulceration.
- There will be absent or diminished taste sensation d/t affectation of the facial
nerve.

DIFFERENT TYPES OF EAR SURGERIES

1. Myringoplasty – in involves closure of perforated tympanic membrane


2. Tympanoplasty – it onvolves closure of perforated tympanic membrane if the
middle ear is involved.
3. Myringotomy- in involves a simple incision in the tympanic membrane
4. Ossiculoplasty – it involves ossicular reconstruction
5. Stapedectomy – it involves use of laser to create a hole in the footplate of the
stapes and prosthesis is placed in the hole.
6. Labyrinthectomy – it involves surgical removal of the membranous labyrinth
through the oval window or through the mastoid bone

CARE OF THE CLIENT UNDERGOING EAR SURGERY

PREOPERATIVE CARE

1. Assess for upper respiratory infection


2. Shampoo the hair
3. Inform the client that he/she will be under local anesthesia but sedated during
surgery

POSTOPERATIVE CARE

1. Lie on the unoperated side


2. Blow nose genty one side at a time; sneeze or cough with mouth open for 1
week after surgery
3. Avoid strenuous physical activity like heavy lifting for 1 week and avoid
exercises or sports for 3 weeks postop.
4. Change cotton ballin ear daily
5. Keep ear dry for 6 weeks postop
 Do not shampoo hair for 1 week
 Protect ear with 2 pieces of cotton (outer piece saturated with
petrolatum)
6. Avoid airplane travel for 1 week postop. For sensation of ear pressure, hold
nose, close mouth and swallow to equalize pressure.
7. Report any drainage other than slight amount of bleeding to the physician
8. Avoid reading, watching TV or fast moving objects for 1 week posop. This is to
prevent vertigo.
9. Advise pt to seek for supervision when ambulating for the 1st time; dizziness or
lightheadedness may occur. This is to prevent falls.

REFERENCES:

UDAN, Medical-Surgical Nursing, 3rd Edition (*2017)

Brunner and Suddarth’s MS Nursing, 12th Edition