Anatomy of the Ear: External : - It includes the ( pinna) and external auditory canal - it is separated from the middle

ear by a disklike structure the tympanic membrane ( eardrum). 1. Auricle it collects the soundwaves and directs vibrations into the external auditory canal.

2. External Auditory Canal it is approximately 2.5 cm long - it ends to the tympanic membrane with contains hair, sebaceous glands, and ceruminous glands, which secrete cerumen.

- it is connected to the nasopharynx by the eustachian tube and is continuous with air filled cells in the adjacent mastoid portion of the temporal bone. 1. Tympanic Membrane ( Eardrum) It is 1 cm in diameter and very thin Normally pearl gray and translucent It protects the middle ear and conducts sound vibrations from the external canal to the ossicles.

Three smallest bones: stapes, malleus and incus - It assist in the transmission of sound. - It separates the middle ear from the inner ear - It also provides an exit for sound and vibrations.

INNER EAR - It is located deep in the temporal bone

1. Cochlea - Organ for hearing 2. Semicircular canal balance - They are treated in the bony labyrinth 3. Organ of corti also called the end organ of hearing - it transforms mechanical energy into neural activity and separates sounds into different frequencies.

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sound conduction and transmission 3. balane and equilibrium

Assessment: 1. Inspection of External Ear - It is done by inspection and direct palpation, the auricle and surrounding tissues should be inspectedfor deformities,lesions and discharge.

size, symmetry and angle of attachment to the head - manipulation of the auricle does not normally elicit pain. - if it is painful ( acute external otitis is suspected) If there is tenderness upon palpation ( acute mastoiditis)
Otoscopic Examination It is done to examine the external auditory canal and tympanic membrane.

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External auditory canal examined for discharges Tympanic membrane- pearly gray and positioned obliquely at the base of the canals Proper tech: Hold the otoscope in the right or left hand, in a pencil-hold position. Steady the hand against the patients head to avoid inserting the otoscope too far in the external canal. - It requires that canal is free of large amount of cerumen.

- A general estimate of hearing can be made by assessing the patients ablity to hear and whispered phrase of a ticking watch, testing one ear at a time. 1. Whisper Test- cover the untested ear with palm then the examiner whispers softly from a distance of 1-2 feet from the unoccluded ear and oout of patients sight. 2. Rinnes Test the examiner shift the stem of a vibrating tunning fork between two positions, 2 inches from the opening of the ear canal( air conduction) and against the mastoid bone ( bone conduction)

As position changes, the patient is asked to indicate which tone is louder or when the tone is no longer audible. - It is useful for distinguishing between conductive and sensorial hearing loss a.Normal Hearing air conducted sounds is louder than the bone-conducted sound b. Conductive Hearing Loss- bone conducted sounds is longer than the airconducted sound c. Sensorineural hearing loss- air conducted sounds is longer than the boneconducted sound
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Audiometry it is the single most important diagnostic instruments in detecting hearing loss. - it is to assess ear conduction Kinds: 1. Pure-tone audiometry The sound stimulus consists of a pure or musical tone ( the louder the tone before the patient receives it, the greater the hearing loss) 2. Speech Audiometry - The spoken word is used to determine ability to hear and discriminate sounds and words.
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Decibel the unit of measuring loudness 20-20,000 Hz- normal human ear perceived 2. Tympanogram or impedence audiometry, measure middle ear muscle reflex to soound stimulation and compliance of the tympanic membrane by changing the air pressure in a sealed ear canal. - if compliance is impaired suspect for middle ear disease.

It is a detectable electrical potential from cranial nerve VIII and the ascending auditory pathways of the brain stem in response to sound stimulation. - - electrodes are placed on the patients forehead - - it will determine at which decibel level a patient hears and whether there are any impairements along the nerve pathways. 4. Platform Posturography - It is useful to investigate postural control capabilities as vertigo.
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It is done to safely and effectively as an office procedure to evaluate suspected perilymphatic fistula. Process:1.the tymphanic membrane is anesthesised topically for 10 mins before the procedure. 2. then the external auidtory canal is irrigated with sterile normal saline solution. 3. With the aid of a microscope, a tympanotomy is created with a laser beam or myringotomy knife, so that the endoscope can be inserted into the middle ear cavity.
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Hearing Loss Occur in 3 of every 100 births Greater in men than in women Causes: 1. Noise-induced hearing loss carpentry, plumbing and coal mining 2. Conductive hearing loss External ear disorder ( impacted cerumen) Middle ear disorder (Otitis media, otosclerosis)
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1. tinnitus 2.Increasing inability to hear when in a group 3. Unattended student or with failing grades 4. A person may feel isolated Assessment for Hearing Loss 1. Speech detorioration 2. Fatigue 3. Indifference 4. Social Withdrawal 5. Insecurity 6. Indecision and procrastination

7. Suspiciousness 8. False pride 9. Loneliness and unhappy Prevention: 1. Their should be a quiet enviroment 2. Use rehabilitation services and supplemental devices to improve communication with other people Nursing Management: 1. Trying to speak in a loud voice to a person who cannot hear 2. Providing interpretation for those who can communicate through sign language.

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Cerumen Impaction It usually accumulates in the external canal Impaction usually occurs causing otalgia Attempts to clear the external auditory canal with matches, hairpins, and other implements are dangerous because trauma to the skin, infection, damage to the typanic membrane can occur.

Otalgia sensation of fullness or pain in the ear with or without hearing loss.

-instilling an ear drops (Ceruminolytic agents) Glycerly ( Debrox) instilled 30 mins before removal of the cerumen. 2. Foreign Bodies -inserted intentionally by adults to try cleaning the ear or to remove itchiness. -Introduction of pebbles, toys, peas by children -presence of small insects

Profound pain 2. Decrease hearing Management: irrigation,suction,instrumentation Foreign vegetable bodies or insects tend to swell- irrigation is contraindicated 3. External Otitis ( Otitis Externa) Refers to an inflammation of the external auditory canal. Causes: 1. Water in the ear canal (swimmers ear)
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2. Trauma to the skin of the ear canal 3.Bacterial or fungal condition - Staphylococcus and Pseudomonias species - Fungus Aspergillus 4. Dermatosis (psoriasis,eczema,seborrheic dermatitis) Clinical manifestation 1. Pain 2. Discharges from the external auditory canal 3. Aural tenderness 4. Occasional fever 5. Cellulitis

6. Pruritus 7.Hearing loss 8. Feeling of fullness Assessment 1. Ear canal is erythematous and edematous 2. Discharges maybe yellow or green and foul smelling
Medical Management: 1. Instruct the patient not to clean external auditory canal with cotton-tipped applications

2. Do not scratch the canal with fingernails or other subjects. 3. Avoid getting the canal wet when swimming or shampooing the hair. 4. Use antiseptic otic preparations after swimming.

Tympanic Membrane Perforation -it is usually caused by infection or trauma During infection, the tympanic membrane can rupture if the pressure in the middle ear. Causes trauma: 1. Skull fracture 2. Explosive injury, severe blow of the ear Medical Management: It will heal within weeks to month after rupture
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Tympanoplasty (surgical repair of tympanic membrane) 2. Acute Otitis Media ( AOM) - It is common in children - An acute infection in the middle ear that last for 6 weeks Causative agent: 1. Streptococcus pneumoniae, Haemophilus influenzae,Moraxella catarrhalis Clinical Manifestations: 1.Otalgia 2.Drainage from the ear

3. Fever 4. Hearing loss Risk Factors: 1. Chronic upper respiratory infections 2. Medical Conditions that predispose (Downs Syndrome,Cystic Fibrosis,Cleft palate, Secondhand cigarette smoke) Medical Management: 1. Broad Spectrum Antibiotic Therapy 2. Otic Antibiotic (drainage)

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Myringotomy Incision in the tympanic membrane Incision is made through tympanic membrane to relieve pressure and drain serous or purulent fluid from the middle ear.

Involves fluid, without evidence of active infection. Clinical Manifestation : 1. Hearing loss 2. Fullness in the ear or a sensation of congestion 3. Popping and crackling noises 4. Air bubbles Diagnostic Exam: 1. Otoscopy tympanic membrane appears dull
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it is not treated medically unless infection ocurred 2. Corticostteroids in small doses decrease edema of eustachian tube. 4. Chronic Otitis Media It is a result of recurrent Acute Otitis Media Chronic infection may cause drainage to tympanic membrane, destroy the ossicles, and involve mastoid. Clinical Manifestation: 1. Foul smelling otorrhea 2. Pain ( Acute Mastoiditis)
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3. Cholesteatoma in growth of the skin of the external layer eardrum into the middle ear. - common benign tumor in the middle ear Diagnostic Exam: 1. Visual examination 2. CT scan 3. MRI Medical Management: 1. Suctioning of the ear 2. Antibiotic drops/application of antibiotic

Tympanoplasty -common surgical procedure -reconstruction of eardrum 2. Ossiculoplasty -reconstruction of the middle ear bones to restore hearing. 3.Mastoidectomy - To remove the cholesteatoma
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Anxiety related to surgical procedures Acute pain related to mastoid surgery Risk for infection Disturbed auditory sensory perception

Nursing Intervention: 1. Reducing Anxiety 2. Relieving Pain 3. Preventing Infection 4. Preventing Injury

Motion Sickness problem with balance it is a disturbance of equilibrium caused by constant motion. Ex. Aboard in a ship, riding a merry go around or swing Clinical Manifestation: 1. Sweating 2. Pallor 3. Nausea and vomiting Management: 1. OTC antihistamines for nausea and vomiting
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2. Menieres Disease - An abnormal inner ear fluid balance causedd by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic duct. Endolymphatic hydrops a dilation in the endolymphatic space, develops and increase pressure in the system or rupture of the inner ear causing Menieres disease. - it is common in adults - usually 40s, but begin from 20-40 years old - equally in men and women

Hearing loss 2. Tinnitus 3. Fullness of the ear 4. Vertigo with nausea and vomiting ( common) Assessment : 1. Vertigo frequency, duration, severity and character, nausea and vomiting Diagnostic Exam: 1. Physical Exam 2. Webers Test 3. Audiogram
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Medical Management: 1. Diet low sodium ( 1000-1100 mg/day or less) Sodium absorbs water and it disrupts the delicate balace between endolymph and perilymph in the inner ear. Pharmacologic Therapy 1. Antihistamine - suppress the vestibular system 2. Diazepam (Valium) control vertigo 3. Antiemetic agents- control vertigo because of antihistamine effect

4. Diuretic Therapy decrease pressure in endolymphatic system 5. Foods containing potassium - orange, tomatoes, banana - 6. Injection of gentamicin ( Garamycin)

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Limit foods high in salt and sugar. Be aware of foods with hidden salt and sugars. Eat meal and snacks at regular intervals to stay hydrated. Eat fresh fruits, vegetables, and whole grais. Limit the amount of canned, frozen or processed foods with high sodium content Drink plenty of fluids daily. Like, water, milk, and low-sugar fruit juices. Limit intake of coffee, tea, and softdrinks. Limit alcohol intake. It may change the

6. Avoid monosodium glutamate, which may increase symptoms. 7. Avoid aspirin and aspirin containing medications. It may increase tinnitus and dizziness. Surgical Management: - Aims to eliminate vertigo 1. Endolymphatic sac procedures 2. Vestibular nerve section

Is a brief period of incapacitating vertigo that occurs when the position of patients head changed with respect to gravity. - - onset is sudden and followed by predispostion for positional vertigo. - It is caused by disruption of debris within the semicircualr canal. Clinical manifestation: 1. Vertigo 2. Nausea and vomiting Management: 1. Bed rest
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4. Tinnitus is a symptoms of an underlying disorder of the ear that is associated with hearing loss - It is described as roaring, buzzing or hizzing sound in one or both ears. - It can be mild or severe. Risk Factors : 1. Thyroid disease 2. Hyperlipedemia 3. Vit B12 deficiency 4. Psychological disaorder 5. Fibromyalgia

6. Otologic disorder ( Menieres disease) 7. Neurologic disorders Diagnostic Exam: 1. Physical examination 2. Audiograph speech 3. Tympanogram 5. Labyrinthitis -inflammation of the inner ear, can be bacterial or viral. 1. Bacterial is rare because of antibiotic therapy

Mumps 2. Rubella 3. Rubeola 4. Influenza Clinical manifestation: 1. Incapacitating Vertigo 2. Hearing Loss 3. Tinnitus Management: Bacterial: 1. IV antibiotic
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2.Fluid replacement 3. Antihistamine 4. Antiemetic medications Viral: 1. Based on patients symptoms

Auditory training 2. Speech Reading ( Lip Reading) -goal of speech training are to conserve, develop and prevent deterioration of current communication skills. 3. Hearing Aids Is a device through which speech and environmental sounds are received by a microphone, converted to electrical glands. 4. Hearing Guide dogs -they are special trained dogs - It reacts to the sound of tel., doorbell, alarm
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Anxiety related to threat of or change in health status and disability effects of vertigo Risk for trauma related to impaired balance Self-care deficit related labyrinth dysfunction and episdodes of vertigo Powerlessness related to illness regimen and being helpless in certain situation due to vertigo/balance disturbance.