Sensory System & Neurological System Part D: Sensory: Care of the Ears

Care of the Ears

External Ear

• Sound waves travel via air conduction.
• The auricles and auditory canal pick up sound waves.
• Sound waves strike the tympanic membrane, causing it to vibrate.
• The vibration is transmitted to the liquid medium of the inner ear.
• Tiny hair cells of the cochlea pick up the vibration and initiate nerve impulses.
• These nerve impulses are carried by nerve fibers to the main branch of CN VIII (acoustic) and then to the brain.

Assessment of the Auditory System

• Subjective assessment.
• Objective assessment:
  • Physical Assessment
    • Inspection
    • Palpation
  • Otoscopic Examination
    • External canal.
    • Internal canal.
  • Using an Otoscope

Hearing Assessment

• Audiometry
  • An audiometer produces tones at varying intensities to which the client can respond.
• Tuning fork tests
  • Weber (test for conductive hearing loss)
    • Tuning fork on middle of head.
    • Normal: Hear sound equally.
    • Lateralization: Hear sound louder in one ear.
  • Rinne (test for sensorineural hearing loss)
    • Comparison of hearing by air conduction and bone conduction.
    • Sound heard 2x-3x longer by air conduction.
    • Place tuning fork on mastoid process until no longer heard; then move fork in front of pinna (air conduction).

Disorders of the External Ear

External Otitis

• Inflammation or infection of the epithelium of the auricle and ear canal, involving the external ear.
• Painful condition caused by irritating or infective agents.
• Affected area red, swollen, tender; pain increased by movement.
• Swelling/inflammation of auditory canal leads to decreased hearing.
• Commonly caused by cosmetics, hair spray, earphones, earrings, hearing aids.
• Infectious organisms: Pseudomonas/Streptococcus/Staphylococcus/Aspergillus
• Swimmer's ear is a common cause.
• Assessment:
  • Pain, increased by manipulation of auricle or tragus.
  • Feeling of fullness.
  • Foul-smelling white to purulent drainage.
  • Red, swollen ear canal with discharge on otoscopic exam.
  • Otoscopic exam: Cerumen looks yellow, brown, or black.
• Diagnosis: Physical exam.
• Treatment: analgesics, antibiotics (otic drops), warm compresses.
• Avoid cotton tip applicators.
• Older adults are more susceptible to cerumen impaction.

Cerumen Impaction

• Cerumen in ear canal can cause discomfort and decrease hearing.

Foreign Body in the External Ear

• Objects that become foreign bodies in ear canal: cleaning objects, insects, beans.

Irrigation of Ear Canal

• Nursing Interventions: Irrigation for cerumen removal.

Otitis Media (OM)

• Infection of the middle ear, affects primarily young children and infants.
• Organisms of OM: Streptococcus pneumoniae, H. influenzae, Moraxella catarrhalis.
• Contributing factors for development of OM: Age, attendance in daycare, viral infections, positioning with feeding, allergies.

Acute Otitis Media (AOM)

• Infection of tympanum, ossicles, and middle ear space.
• Usually follows URI and appears suddenly.
• Associated with other signs of illness.
• Parts of middle ear are infected and swollen.
• Fluid is trapped behind eardrum.
• Clinical manifestations: pain, fever, malaise, decreased hearing.
• Symptoms: Tugging or pulling at ear, fussiness and crying, trouble sleeping, fluid draining from ear (yellowish green, purulent, foul smelling may indicate ruptured eardrum), clumsiness or problems with balance, trouble hearing or responding to quiet sounds.
• Diagnosis: physical exam.
• Treatment: antibiotics; last resort: surgery.

Chronic Otitis Media

• Untreated or repeated OM.
• OM with effusion: inflammation with fluid in middle ear.
• Clinical manifestations: Patient may report tinnitus, headache, malaise, fever, nausea, vomiting, dizziness.
• Diagnosis: otoscopic findings will vary depending on condition’s stage; eardrum may be spontaneously perforated.
• Treatment: Eliminating infection while reducing pain, nonsurgical and surgical management.
  • Nursing diagnosis: Infection due to otitis media, pain due to ear infection.

Otitis Media with Effusion

• Presence of fluid behind TM without signs of infection.
• Often follows AOM.
• Resolves usually in 1-3 months.
• Assessment: Decreased hearing (popping or snapping sound), TM-Decreased mobility/retracted or bulging, hearing loss (Conductive).
• Otitis Media persistent: symptoms while being treated or within 1 month after treatment.
• Otitis Media Recurrent: More than 3 episodes over 6-month period.

Surgical Management of Otitis Media

• Myringotomy (surgical opening of pars tensa)
  • An incision is made into posterior inferior aspect of tympanic membrane for relief of persistent effusion.
• Myringotomy with tympanostomy tubes (grommet)
  • Post Op: Small amt reddish drainage normal first few days. Report any fever, Discuss water in ears with physician.
  • Usual: ear plugs or cotton balls covered with petroleum jelly for baths and shampoos.
  • Swimming allowed only with ear plugs and approval from physician.
  • Diving and swimming in deep water prohibited.
  • Tubes fall out: Not an emergency but notify physician.
• NON-SURGICAL MANAGEMENT: Watchful waiting: 80% resolve without meds
• SURGICAL MANAGEMENT - for pain persisting after antibiotic treatment:

Tinnitus

• Ringing in the ear(s).
• Common ear or hearing disorder.
• Symptoms range from mild ringing to loud roaring in ear.
• Diagnostic testing cannot confirm, but is used to assess hearing and rule out other disorders.
• An MRI scan may reveal a growth or tumor near the ear or the eighth cranial nerve that could be causing tinnitus. Imaging tests can also help doctors evaluate pulsatile tinnitus. They can show changes in the blood vessels near the ears and determine whether an underlying medical condition is causing symptoms.
• Tinnitus can have disturbing emotional consequences.
• Factors that can cause tinnitus: Presbycusis, Otosclerosis, Meniere’s Disease, Certain drugs, Exposure to loud noise.
• Treatment: If no cause is identified therapy focuses on masking tinnitus.
  • Use of background sound, noisemakers, music during sleep.
  • Ear mold hearing aids can amplify sounds to drown out tinnitus during day.
• American Tinnitus Association assists clients in coping

Meniere's Disease

• A progressive disorder leading to an accumulation of endolymph in the membranous labyrinth.
• The excess fluid and resulting pressure lead to hearing and balance problems (including episodic vertigo, tinnitus, and ear pressure/fullness).
• Usually occurs in men between 20 and 50 years old.
• Includes tinnitus, one-sided sensorineural auditory.
• May also include headache, fullness of ear, hearing loss, vertigo.
• Teach to move head slowly; reduce sodium; stop smoking; comply with drug therapy.
• Pressure pulse treatment; labyrinthectomy
• Nursing Assessment:
  • Sudden or gradual.
  • Recurrent attacks of vertigo.
  • Gradual loss of hearing.
  • Tinnitus.
  • Attacks may be preceded by: Feeling of fullness in ears, Roaring or ringing sensation.
  • Attacks of severe rotary vertigo occur abruptly and often unpredictably-Lasts minutes to hours.
  • Attacks may be linked to: Inc. Sodium intake, Stress, Vasoconstriction, Progression of Disease
• Assessment: Profound hearing loss, Vertigo can be severe enough to cause immobility, nausea and vomiting.
• Salt restriction and diuretics:
  • Limiting dietary salt 1-2 gm Na/d and taking diuretics help some people control dizziness.
  • Other dietary and behavioral changes:
    • Caffeine, chocolate, alcohol seems to worsen attacks in some people so should be avoided-Vasoconstriction.
    • Smoking causes vasoconstriction and can worsen symptoms or precipitate an attack!
  • Cognitive therapy:
    • Helps people focus on how they interpret and react to life experiences and cope better with unexpected nature of attacks
• Injections
  • Antibiotic gentamicin into middle ear helps control vertigo but can significantly raises risk of hearing loss
  • Corticosteroids to reduce dizziness
• Pressure pulse treatment
  • Recently approved by FDA this device fits into outer ear and delivers intermittent air pressure pulses to middle ear. Air pressure pulses appear to act on endolymph fluid to prevent dizziness.
• Surgery: Labyrinthectomy
  • Only recommended when all other treatments have failed
  • Surgery on endolymphatic sac to decompress it or cut vestibular nerve

Hearing Loss

Conductive Hearing Loss

• Due to any physical obstruction, inflammation to transmission of sound waves to nerve fibers.
• Chronic OM, Otosclerosis (chronic progressive hearing loss caused by formation of spongy bone), cerumen.
• Occurs when there is a problem conducting sound waves anywhere along the route through the outer ear, tympanic membrane (eardrum), or middle ear (ossicles). Related to external-ear or middle-ear disorders
• Minimal damage
• Causes:
  • Cerumen (ear wax) impacted.
  • Foreign Body in the ear canal.
  • Inflammatory process or obstruction (TUMORS).
  • Changes in tympanic membrane: bulges/retractions/perforations.
  • Otosclerosis – most common cause of hearing loss in young adults. Decreased transmission of vibration to the inner ear fluids due to spongy bone preventing development.

Sensorineural Hearing Loss

• Due to damage to inner ear, in 8th CN. (vestibulocochlear).
• Noise exposure
• Genetic
• Age (presbycusis) Hair cells of cochlea degenerate-progressive hearing loss, Begins in early adulthood, Hearing aids are useful.
• Ototoxic drugs: antibiotics, some diuretics (furosemide), NSAIDs, chemo
• History – client may report that they can hear sound, but not comprehend the speech
  • How long has patient noticed change in hearing?
  • Sudden or gradual onset?
  • Exposure to noises
  • Use of ototoxic drugs
  • Ear infections, eardrum perforation, trauma
  • Genetic connection
  • Pain

Ototoxic Drugs

• Antibiotics: Amikacin, Chloramphenicol, Erythromycin, Gentamycin, Streptomycin sulfate, Tobramycin sulfate, Vancomycin
• Diuretics: Furosemide(Lasix)
• Nonsteroidal anti-inflammatory: Ibuprofen, Indomethacin, Naproxen, Salicylates (Aspirin)
• Chemotherapy Drugs: Cisplatin

Hearing Aids

• Encourage to begin using hearing aid slowly to adjust to device.
• Adjust volume to minimal hearing level to prevent feedback squeaking.
• Teach to concentrate on sounds to be heard/filter out background noises.
• Instruct to clean ear mold with mild soap/water.
• Avoid excessive wetting of hearing aid.
• Clean ear cannula of hearing aid with toothpick or pipe cleaner.