Comprehensive Nursing Notes on Disturbed Sensory Perception: Hearing

Anatomy and Physiology of the Auditory System

• The Ear: A major sensory organ involved in hearing and equilibrium.

• Collaborative Care Team: Includes Otolaryngologists, Internal Medicine providers, and Audiologists.

• Inner Ear Structures:

  • Semicircular Canals: Responsible for detecting movement and maintaining balance. They are filled with fluid; movement of this fluid allows the detection of motion.

  • The Cochlea: Houses the Organ of Corti, which is the primary structure responsible for hearing.

    • Sound vibrations moving through the cochlea vibrate microscopic hair cells in the Organ of Corti.

    • Hair cell vibrations trigger electrical impulses sent to the brain via the auditory nerve.

• Pediatric Anatomy Specifics:

  • Eustachian tubes are smaller and more horizontal than in adults, which results in less effective drainage.

  • The external canal is curved upward in infants and toddlers. Around the age of $3$ years old, the canal assumes a more downward curvature, facilitating fluid flow.

Pediatric Considerations

• Critical Nature: Hearing loss in children is critical due to its impact on speech, language, and social skills development. Early intervention is essential for the child to reach their full potential.

• Causes of Hearing Loss:

  • Genetics: Accounts for $1/2$ of child hearing loss cases in the United States.

  • Acquired: These causes are often avoidable with proper recognition and intervention.

  • Maternal Infections (TORCH): Occur during pregnancy. TORCH includes Toxoplasmosis, Rubella, Cytomegalovirus (CMV), and Herpes Simplex.

  • Cytomegalovirus (CMV): The most common infection among the TORCH group that leads to infant hearing loss.

  • Other Causes: Head trauma and chronic ear infections.

Clinical Assessment and Physical Examination

• Health History Questions:

  • History of earaches with or without infection? Discharge from ears?

  • Any hearing loss (past or current)? Observed by family members?

  • Presence of Upper Respiratory Infection (URI)?

  • Does hearing loss occur after swimming or showering? (May indicate wax/cerumen swelling).

  • Impact on work, activities, daily life, or social isolation?

  • History of Tinnitus (ringing)? Check for ototoxic medications: Furosemide, Aminoglycosides (Gentamycin, Vancomycin), and Aspirin (ASA).

  • History of Vertigo? (May indicate labyrinth involvement).

  • Environmental noise exposure: Heavy machinery, music, earbuds, firearms, jackhammers, or aviation noise.

  • Ear cleaning habits (e.g., use of Q-tips).

  • Hearing aid use and care.

  • Date of last hearing evaluation.

• Inspection and Palpation (External Ear):

  • Assess the Auricle and surrounding tissue for deformities, lesions, discharge, size, and symmetry.

  • Manipulation of the ear should not cause pain.

• Otoscopic Exam:

  • The Pinna is pulled back gently to straighten the canal for viewing. For children under $3$ years old, pull the pinna straight down.

  • Inspect the external auditory canal for discharge, inflammation, or foreign bodies (FB).

  • Tympanic Membrane (TM): A healthy TM is pearly gray and sits at the base of the canal. Chart findings including color, position, fluid, blood, masses, and cerumen.

  • Cerumen: Normal in the canal. If the TM is obscured, cerumen may need removal via warm water irrigation or disimpaction by an Advanced Practice Registered Nurse (APRN).

Types of Hearing Loss

• Conductive Hearing Loss: Occurs when sound waves cannot pass through the outer and middle ear. Air transmission is impaired. Causes include cerumen impaction, middle ear infection, or otosclerosis.

  • Air Conduction: Sound enters the ear canal through the air.

  • Bone Conduction: Sound is transmitted when skull bones are stimulated (e.g., with a tuning fork) and sent to the inner ear.

• Sensorineural Hearing Loss: Results from an alteration in the inner ear, the auditory nerve, or the hearing center of the brain.

• Mixed Hearing Loss: A combination of conductive and sensorineural loss.

• Psychogenic Hearing Loss: Usually an emotional reaction; it is nonorganic with no structural cause.

Auditory Acuity Testing

• Whisper Test: A general hearing test performed one ear at a time. The nurse covers one ear with a palm and whispers softly from $1-2'$ away out of the patient's sight. Normal results: the patient repeats the phrase.

• Weber Test: Evaluates for unilateral hearing using bone conduction with a $512\,Hz$ tuning fork. The stem is placed on the top of the head or forehead.

  • Normal: Sound heard equally in both ears.

  • Conductive loss: Sound is heard better in the affected ear.

  • Sensorineural loss: Sound is heard better in the normal ear.

• Rinne Test: Evaluates conductive loss in each ear individually using a $512\,Hz$ fork.

  • Bone Conduction (BC): Stem held to the mastoid bone until no longer heard.

  • Air Conduction (AC): Fork moved $2"$ from the ear opening until no longer heard.

  • Positive (Normal) Rinne: AC is heard $2\times$ longer than BC.

  • Negative (Abnormal) Rinne: BC is equal to or longer than AC (BC > AC).

Diagnostic Procedures

• Audiometry: Measures frequency, pitch, and intensity in a soundproof room. Hearing is measured in decibels ($dB$). Values of $80\,dB$ are considered harsh.

• Tympanogram: Measures the functioning of the TM by changing air pressure in a sealed canal.

• Auditory Brain Stem Response (ABR): Measures inner ear (cochlea) and brain pathways using electrodes and computer recordings of brain wave activity. Typically used as a newborn screening tool.

• Electronystagmography (ENG): Measures electrical activity during eye movements to evaluate oculomotor and vestibular systems. Used for vertigo and tinnitus.

  • Pre-test: Caffeine held for $48\,hours$. Tranquilizers, stimulants, and antivertigo meds held for $5\,days$.

• Platform Posturography: Diagnoses balance disorders. The patient stands on a moving platform with a harness and closed eyes.

• Sinusoidal Harmonic Acceleration: A balance test looking at the vestibulo-ocular reflex. Diagnoses Meniere’s or tumors. The patient sits in a rotary chair in a closed booth.

• Middle Ear Endoscopy: Direct visualization of the middle ear using a scope through a cut in the TM. Requires local anesthesia and irrigation performed $10\,minutes$ prior.

Consequences and Manifestations of Hearing Loss

• Clinical Signs: Tinnitus, inability to hear in group settings, and increased TV volume.

• Pediatric Signs: Inattentiveness, lack of interest, and failing grades in school.

• Consequences:

  • Diminished quality of life regarding communication and anxiety.

  • Safety risks (e.g., missed fire alarms or inability to hear approaching cars).

  • Social isolation.

  • Body image disturbance (related to hearing aid use).

Prevention and Gerontologic Considerations

• Noise Exposure: Environmental hazards constrict peripheral blood vessels and increase Heart Rate (HR), Blood Pressure (BP), and GI activity.

  • Noise-Induced Hearing Loss: Caused by long-term exposure to loud noise.

  • Acoustic Trauma: Single exposure to intense noise (e.g., explosion at $4000\,Hz$).

  • Noise at $85-90\,dB$ causes damage regardless of duration.

• Gerontologic Changes:

  • Cerumen becomes harder and drier, increasing impaction risk.

  • TM may atrophy or become sclerosed.

  • Presbycusis: Progressive sensorineural hearing loss starting with high-frequency sounds, eventually affecting middle and lower frequencies.

  • Ototoxicity in Aging: Slower kidney filtration allows medications to build to toxic levels.

Nursing Management and Communication

• Recognize Reactions: Acknowledge emotional impact and ensure early detection through screening.

• Accommodations: It is illegal not to provide accommodations. Coordindate medical interpreters/sign language as needed.

• Communication Strategies:

  • Talk in the "better" ear; use gestures and non-verbal cues.

  • Show identification badge so the patient can read your name.

  • Write messages on paper; provide written resources at a 3rd-grade level.

  • Lip Reading (Speech Reading): Face the person directly, speak slowly and distinctly, and use clear masks if possible. Do not pretend to understand the patient if you do not.

  • Reduce background noise.

Specific Ear Conditions and Management

Cerumen Impaction

• Waxy buildup that can cause Otalgia (ear pain) but may not always cause hearing loss.

• Management: Do not remove with implements (risk of TM perforation). Nursing management includes irrigation with warm water (lowest pressure) if the TM is intact. Debrox (OTC) can be used $2-3\times$ per day. Advanced providers may use aural suction or curettes.

Foreign Bodies (FB)

• Includes insects, toys, beans, etc.

• Management: Removal via irrigation, suction, or instrumentation.

• Contraindication: Irrigation is contraindicated for objects that swell (food/beans) or insects. Use mineral oil for insects to kill and dislodge them.

Otitis Externa (Swimmer's Ear)

• Inflammation of the external canal caused by water, trauma, or pathogens (Staphylococcus aureus, Pseudomonas, Aspergillus).

• Symptoms: Pain, discharge (yellow, green, foul), aural tenderness on manipulation, and pruritus (itching).

• Management: Relieve pain and swelling for $48-96\,hours$. Use antibiotic/corticosteroid drops or antifungals. No Q-tips or scratching with fingernails.

Tympanic Membrane Perforation

• Caused by trauma (skull fracture, Q-tips) or infection pressure.

• Management: May take weeks to months to heal. Surgical repair via Myringoplasty or Tympanoplasty if it fails to heal.

• Post-Op Care: Avoid nose blowing, sneezing, flying, and swimming. Maintain "operative ear up" for $12\,hours$; immediately post-op, lie on the unaffected side.

Acute Otitis Media (AOM)

• Middle ear infection common in children.

• Symptoms: Otorrhea (if TM ruptures), otalgia (stops if TM ruptures), fever, tugging at ear, and bulging red/yellow TM.

• Management: Broad-spectrum antibiotics (Amoxicillin). Surgical options include Myringotomy (painless, <15\,minutes to drain fluid) or placement of ventilating tubes for $6-18\,months$.

Vestibular Disorders

Motion Sickness

• Equilibrium disturbance from overstimulation.

• Management: Dimenhydrinate (Dramamine) or Meclizine (Antivert) taken $3\,hours$ before motion. Scopolamine patches (replaced every $3\,days$). side effects: dry mouth and drowsiness.

Ménière Disease

• Increased hydraulic pressure in inner ear lymphatics.

• Triad of Symptoms: Intermittent vertigo, tinnitus, and hearing loss.

• Dietary Management: Low sodium ($1000-1500\,mg/day$) to regulate fluid balance. Limit ASA and MSG. Plenty of fluids.

• Medications: Meclizine (vertigo), Diazepam (anxiety/vertigo), Antiemetics (Promethazine), and Diuretics (Furosemide).

Benign Paroxysmal Positional Vertigo (BPPV)

• Incapacitating vertigo triggered by head position changes due to "stuck" inner ear crystals (canaliths).

• Management: Bedrest, Meclizine, and the Epley Maneuver (fast movements to reposition crystals).

Labyrinthitis and Ototoxicity

• Labyrinthitis: Inflammation of the labyrinth causing vertigo and hearing loss. Bacterial forms require antibiotics.

• Ototoxicity: Permanent damage to the cochlea or CN VIII.

  • Common Drugs: Loop diuretics (Furosemide), chemotherapy (Cisplatin), Antimalarials (Quine), ASA, and Aminoglycosides (Gentamycin, Vancomycin).

  • Aspirin-related tinnitus usually stops when the drug is discontinued.

Aural Rehabilitation

• Hearing Aids: Amplify sound. Fitted by audiologists. Wash ear molds daily with soap and water (no alcohol). Whistling when uncupped or pain indicates a problem. Batteries changed weekly.

• Cochlear Implant: Auditory prosthetic for bilateral sensorineural loss. Stimulates the auditory nerve directly. Warning: MRI can inactivate the device.

• Hearing Guide Dogs: Service dogs trained by International Hearing Dog, Inc. to react to specific sounds (smoke alarms, intruders, etc.).