Hinkle Ch. 60 Assessment & Management of Patients with Ear & Hearing Disorders

Diagnostic Evaluation

• Audiometry – evaluates hearing through frequency, pitch and intensity

• Tympanogram

• Auditory brainstem response

  • detectable electrical potential from CN VIII

• Electronystagmography – changes in electrical potentials created by eye movement -> vertigo

• Platform posturography -> dizziness, balance disorders, vertigo

• Sinusoidal harmonic acceleration: -> Meniere’s dz

• Middle ear endoscopy

Hearing Loss

• Prevalence increases with age; 50% over the age of 70 (Table 59- 2)

• Increased incidence with age—presbycusis

• Risk factors: exposure to excessive noise levels, family hx, genetics, infection, ototoxic medications

• Types

  • Conductive; caused by external of middle ear problem

  • Sensorineural; caused by damage to the cochlea or vestibulocochlear nerve

  • Mixed; both conductive and sensorineural resulting from dysfunction of air and bone conduction.

  • Functional (psychogenic); caused by emotional problem

Manifestations of Hearing Loss

• Early symptoms

  • Tinnitus: perception of sound; often “ringing in the ears”

  • Increased inability to hear in a group

  • Turning up the volume on the TV

  • Family notices hearing loss first

• Impairment may be gradual and not recognized by the person experiencing the loss

• Prevention –> loud persistent noise can cause vasoconstriction of peripheral blood vessels, increased BP and HR and increase GI activity.

Guidelines for Communicating with Hearing Impaired Persons

• Determine how the person prefers to communicate

• Use a low-tone, normal voice

• Speak slowly and distinctly

• Reduce background noise and distractions

• Face the person and get their attention

• Speak into the less impaired ear

• Use gestures and facial expressions

• If necessary, write out information or obtain a sign language translator

Cerumen impaction

• May cause otalgia

• Removal may be by irrigation, suction, or instrumentation

• Avoid cotton swabs (Qtips)

• external ear condition

External otitis

• Inflammation most commonly caused by bacteria, Staphylococcus or Pseudomonas, or fungal infection from Aspergillus spp

• Manifestations include pain (with movement of auricle or tragus) and tenderness, discharge, edema, erythema, pruritus, hearing loss, and feelings of fullness in the ear

• Treated w/ analgesics, antimicrobial/antifungals/abx/corticosteroids

• external ear condi

Tympanic membrane perforation

• usually caused by infection or trauma.

• Keep ear dry

• middle ear condition

Acute otitis media

• an acute infection of the middle ear, lasting less than 6 weeks.

• Most frequently seen in children

• Pathogens are most commonly bacterial or viral

• Manifestations include otalgia (ear pain), fever, and hearing loss.

  • Purulent drainage if TM ruptures

• Treatment

  • Antibiotic therapy – broad spectrum

  • Myringotomy or tympanotomy

• middle ear condition

Serous otitis media

• fluid in the middle ear without evidence of infection

  • No infection -> no abx

• middle ear condition

Chronic otitis media

• Result of recurrent acute otitis media

  • Conductive hearing loss

• Chronic infection damages the tympanic membrane, ossicle, and involves the mastoid

• Treatment

  • Prevent by treatment of acute otitis

  • Tympanoplasty, ossiculoplasty, or mastoidectomy

• middle ear condition

Middle Ear Surgical Procedures

• Tympanoplasty

  • Reconstruction of the tympanic membrane

• Ossiculoplasty

  • Reconstruction of the bones of the middle ear

  • Prostheses are used to reconnect the ossicles to reestablish sound conduction

• Mastoidectomy

  • Removal of diseased bone, mastoid air cells, and cholesteatoma to create a noninfected, healthy ear

  • Cholesteatoma is a benign tumor or an ingrowth of skin that causes persistently high pressure in the middle ear, which causes hearing loss and neurologic disorders and destroys structures

    • Risk for facial nerve damage

Conditions of the Inner Ear

• Disorders of the vestibular system may increase the risk of falls

• Dizziness: any altered sense of orientation in space

• Vertigo: the illusion of motion or a spinning sensation

  • Meclizine

• Nystagmus: involuntary rhythmic movement of the eyes associated with vestibular dysfunction

• Tinnitus: roaring/buzzing/hissing sound in one or both

• Benign positional vertigo (BPPV): brief period of incapacitating vertigo that occurs when the position of the patient’s head is changed with respect to gravity

  • Eply maneuver

• Ototoxicity

  • Aminoglycosides, Antiinflammatory agents, Antimalarial agents, Chemicals, antineoplastic, Loop diuretic agents, Metals

• Motion sickness: disturbance of equilibrium caused by a sensory conflict in motion receptor stimuli

• Ménière Disease

Ototoxic substances

• Aminoglycoside antibiotic agents: amikacin, gentamicin, kanamycin, netilmicin, neomycin, streptomycin, tobramycin

• Antiinflammatory agents: salicylates (aspirin), indomethacin

• Antimalarial agents: quinine, chloroquine

• Chemicals: alcohol, arsenic

• Chemotherapeutic (antineoplastic) agents: cisplatin, nitrogen mustard, carboplatin

• Loop diuretic agents: ethacrynic acid, furosemide, acetazolamide, torsemide, azosemide, ozolinone, indacrinone, piretanide

• Metals: gold, mercury, lead

• Other antibiotic agents: erythromycin, azithromycin, clarithromycin, minocycline, polymyxin B, vancomycin

Ménière Disease

• Abnormal inner ear fluid balance cause by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct

• Manifestations triad of symptoms: episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss. Feeling of pressure, nausea and vomiting

  • Sounds from a tuning fork (Weber test) may lateralize to the ear opposite the hearing loss, the one affected with Ménière’s disease

• Cochlear Ménière’s disease

• Vestibular Ménière’s disease

Ménière Disease - treatment

• Low-sodium diet; 1000 to 1500 mg/day

  • Regulate balance of fluids in body

• Meclizine (Antivert); tranquilizers—valium, antiemetics—promethazine, and diuretics may also be used – What medications should be avoided? Why? How do diuretics relieve symptoms?

• Surgical management to eliminate attacks of vertigo; endolymphatic sac decompression, middle and inner ear perfusion, and vestibular nerve sectioning

  • Surgical tx is to eliminate vertigo -> so may still have tennitis, hearing loss and aural fullness

Aural rehabilitation

• maximize the communication skills

  • Auditory training, speech reading, speech training, use of hearing aids and hearing guide dogs

Hearing aids

• amplify sound (include background noise)but do not improve ability to discriminate words or understand speech.

  • Remove at night

  • Implanted hearing devices

  • Cochlear implant – used with sensorineural hearing loss

    • MRI precaution

Safety Measures & Patient Education

• Communication

  • Face patient when speaking

  • Reduce background noise

  • Speak slowly and clearly

  • Use written communication if needed

• Hearing Aids

  • Remove at night

  • Keep clean and dry

  • Change batteries as needed

• Vertigo / Balance Safety

  • Risk for falls

  • Assist with ambulation

  • Avoid sudden head movements

  • Sit or lie down during vertigo

• Middle / Inner Ear Care

  • Keep ear dry

  • Avoid the Valsalva maneuver

  • Low-sodium diet (Ménière)