1. PN 141 – Day 3 Rebecca Maier, RN BSN
Disorders of the Ear
PN 141 – Day 3
Rebecca Maier, RN BSN
Steam coming out the ears:
Cartoon Dr looking into ear:
Light going right through the head on ear exam:
Caveman:

2. Objectives
Discuss major inflammatory, infectious and noninfectious disorders of the ear
Discuss med-surg management
Discuss nursing management
Client education

3. Hearing Impairment
A state of decreased auditory acuity that ranges from partial to complete hearing loss
Image:

4. Types of Hearing Loss Conductive hearing loss
Interference with the transmission of sound waves from the external or middle ear to the inner ear
Sensorineural hearing loss
Disturbance of the neural structures in the inner ear or the nerve pathways to the brain
Mixed hearing loss
A combination of conductive and sensorineural losses
Conductive Hearing Loss:
Common cause: cerumen build-up
Sensitivity to sound is diminished but clarity or interpretation of sound is not changed
Good candidate for hearing aid if cerumen is not the cause
Senorineural Hearing Loss
A defect in the inner ear results in distortion, making sound discrimination difficult
Usually caused by:
Trauma
Infectious process
Presbycusis
Exposure to ototoxic drugs
Destruction of the cochlear hair by intense noise
Hearing aid would amplify sound and would be useful if client not sensitive to loud noises 4

5. Types of Hearing Loss Congenital hearing loss Functional hearing loss
Can happen during pregnancy or delivery
Syphilis or Rubella exposure
Rh incompatibility
Anoxia or trauma during delivery
Ototoxic drugs
Functional hearing loss
No organic cause
Also called psychogenic or nonorganic hearing loss
Central hearing loss
Problem in the central nervous system
The brain’s auditory pathways are damaged as in a stroke
Ototoxic drugs - this is why you ask are you pregnant or planning to be pregnant before administering ototoxic drugs
Who can name 3 ototoxic drugs?
Anti-cancer drugs work by killing cancer cells. Unfortunately some can also damage or kill cells elsewhere in the body, including the ears. Cisplatin is well known to cause massive and permanent hearing loss. Carboplatin is also known to be ototoxic
Commonly used medicines that may cause hearing loss include:
Aspirin, when large doses (8 to 12 pills a day) are taken.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen.
Certain antibiotics, especially aminoglycosides (such as gentamicin, streptomycin, and neomycin). Hearing-related side effects from these antibiotics are most common in people who have kidney disease or who already have ear or hearing problems.
Loop diuretics used to treat high blood pressure and heart failure, such as furosemide (Lasix) or bumetanide.
Medicines used to treat cancer, including cyclophosphamide, cisplatin, and bleomycin.
Image:

6. Loss of Hearing (Deafness)
Clinical manifestations/assessment
Requests for repeating information
Non-response
Delayed speech development
Assessment
S: note onset and progression of the condition; deficit in one or both ears; family hx. or hx. of head trauma; exposure to noise, current medications, visual or speech disorders
O: behavioral clues that indicate hearing difficulty
P. 631 Box 13-2

7. Behavioral Clues Indicating Hearing Loss
Complaints that their hearing is good but others mumble
Leaning or turning one ear toward the speaker
May fail to follow directions, speak while others are speaking, or turn the radio/TV up very loud
Irritability and even hostility not unusual
Some become very suspicious of others because they cannot hear what is being said
Otalgia (ear pain), dizziness, and tinnitus with certain types of disorders
Old man Image:
Graphic image: 7

8. Loss of Hearing (Deafness)
Diagnostic Tests:
Weber’s Test
Rinne Test
Audiometric Testing
Nursing Responsibilities
Explain the purpose of and the procedure

9. Figure 13-13 Weber tuning fork test.
(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)
Weber tuning fork test.

10. Figure 13-14
Rinne tuning fork test.

11. Loss of Hearing (Deafness)
Medical management
According to the type of impairment
Hearing aids
Surgical procedures
Cochlear implant

12. Figure 13-15 Parts of a hearing aid.
(From Long, B., Phipps, W., & Cassmeyer, V. [1995]. Medical-surgical nursing: a nursing process approach. [3rd ed.]. St. Louis: Mosby.)
Parts of a hearing aid.

13. Loss of Hearing (Deafness)
Nursing Interventions:
Instruct in insertion and care of hearing aid
p Box 13-3 Care of the Hearing Aid
Nursing Diagnoses include:
Disturbed Sensory Perception AEB frequently asking people to repeat themselves (auditory) related to new dx. of hearing impairment
Social isolation related to loss of hearing

14. Figure 52-6 14

15. Loss of Hearing (Deafness)
Prognosis:
Some restoration of hearing with surgical repair
Microtechnology has reduced size of hearing aids

16. Presbycusis Hearing loss associated with aging
Gradual atrophy of the sensory receptors and cochlear nerve fibers
Signs and symptoms
May hear well in quiet surroundings but poorly in noisy places
Ability to hear high pitched sounds is usually lost first 16

17. All of these change with age causing ARHL
Parts of the ear:
Cilia in the ear:
Cochlear implant:
ARHL- Age Related Hearing Loss

18. Presbycusis Medical Diagnosis and Treatment
Hearing evaluation for the older person whose hearing seems to be declining
Many with presbycusis benefit from hearing aids
Devices available to improve hearing: phone amplifiers and personal earphones for radios and televisions 18

19.
Figure 52-7 19

20. Impact of Hearing Impairment
Those who had impairments in early childhood usually have speech difficulties
When a person refuses to admit to hearing loss, family members and others may stop trying to communicate
Hearing-impaired person may alienate those who would like to be close and supportive 20

21. Impact of Hearing Impairment
People with severe hearing impairment probably suffer the most severe social isolation of those with sensory disorders

22. Adaptations to Hearing Loss
Hearing aids—some improvement in hearing
Many patients read lips and observe body language
Sign language uses a universal set of hand signals (wrong)
Telephones can be adapted to send and receive written messages
Earphones for radios, stereos, and televisions
This is a mistaken statement – sign language does NOT use universal hand signals; that’s why you have American sign language. If you went to many parts of South America they wouldn’t understand your signing anymore than they would understand your English. There are at least 300 recognized sign languages and that doesn’t begin to touch the dialects. 22

23. Adaptations to Hearing Loss
Some television channels provide closed-captioned programming
Handheld computers print out messages typed by the user
Dogs are taught to recognize common sounds (doorbell, telephone, smoke alarm, crying baby) and to get the attention of the owner

24. Nursing Care Educate pt. about hearing loss and aging
Work to overcome the resistance that many people have to admitting hearing loss
Once problem diagnosed, nurses can help the patient adapt and learn to use supportive devices
Old man Image: 24

25. Nursing Care Nursing diagnoses: (r/t, AEB)
Impaired Verbal Communication
Social Isolation
Ineffective Coping
Deficient Knowledge
Image: 25

26. Inflammatory and Infectious Disorders of the Ear
Biofilms are densely packed communities of microbial cells that grow on living or inert surfaces and surround themselves with secreted polymers. Many bacterial species form biofilms, and their study has revealed them to be complex and diverse. The structural and physiological complexity of biofilms has led to the idea that they are coordinated and cooperative groups, analogous to multicellular organisms.1
Researchers have estimated that percent of microbial infections in the body are caused by bacteria growing as a biofilm – as opposed to planktonic (free-floating) bacteria.
According to a recent public statement from the National Institutes of Health, more than 65% of all microbial infections are caused by biofilms…. If one recalls that such common infections as urinary tract infections (caused by E. coli and other pathogens), catheter infections (caused by Staphylococcus aureus and other gram-positive pathogens), child middle-ear infections (caused by Haemophilus influenzae, for example), common dental plaque formation, and gingivitis, all of which are caused by biofilms, are hard to treat or frequently relapsing, this figure appears realistic.
Kim Lewis 4
inner ear infections – The majority of ear infections are caused by biofilm bacteria.13 These infections, which can be either acute or chronic, are referred to collectively as otitis media (OM). They are the most common illness for which children visit a physician, receive antibiotics, or undergo surgery in the United States.
It appears that in many cases recurrent disease stems not from re-infection as was previously thought and which forms the basis for conventional treatment, but from a persistent biofilm…. [The discovery of biofilms in the setting of chronic otitis media represents] a landmark evolution in the medical community’s understanding about a disease that afflicts millions of children world-wide each year and further endorses the emerging biofilm paradigm of chronic infectious disease.
Garth Ehrlich, PhD
Life cycle of biofilm communities
The biofilm life cycle in three steps: attachment, growth of colonies (development), and periodic detachment of planktonic cells.
Attachment/colonization
Biofilms form when bacteria adhere to surfaces in aqueous environments and begin to excrete a slimy, glue-like substance that can anchor them to a variety of materials including metals, plastics, soil particles, medical implant materials and, most significantly, human or animal tissue. The first bacterial colonists to adhere to a surface initially do so by inducing weak, reversible bonds called van der Waals forces. If the colonists are not immediately separated from the surface, they can anchor themselves more permanently using cell adhesion molecules, proteins on their surfaces that bind other cells in a process called cell adhesion.
These bacterial pioneers facilitate the arrival of other pathogens by providing more diverse adhesion sites. They also begin to build the matrix that holds the biofilm together. If there are species that are unable to attach to a surface on their own, they are often able to anchor themselves to the matrix or directly to earlier colonists. The expression of 800 genes have been shown to be altered when a single bacterial species joins a biofilm.24
According to Costerton, the genes that allow a biofilm to develop are activated after enough cells attach to a solid surface.
It appears that attachment itself is what stimulates synthesis of the extracellular matrix in which the sessile bacteria are embedded. This notion– that bacteria have a sense of touch that enables detection of a surface and the expression of specific genes– is in itself an exciting area of research.
William Costerton et al. 25
From :
Image: otitis :

27. External Otitis Etiology/pathophysiology
Inflammation or infection of the external canal or the auricle of the external ear
Sometimes called “swimmer’s ear”
More present in hot, humid weather
Can be caused by allergy, bacteria, fungi, viruses, and trauma

28. External Otitis Etiology/Pathophysiology
Chemicals in hairsprays, cosmetics, hearing aids, and medications as well as from nickel or chromium in earrings can cause allergies  external otitis
Bacterial agents include: Staph Aureus, Pseudomonas A. and Streptococcus pyogenes

29. External Otitis Herpes . Simplex
Etiology / Pathophysiology
Viruses include herpes simplex and h. zoster
Fungi such as Aspergillus and Candida
Trauma from cleaning or scratching the ear canal with a foreign object
Dry hard cerumen  difficult removal  external otitis
Activities that allow moisture to become trapped in the ear creating a medium for bacteria to grow on:
Use of earphones, hearing aids, stethoscopes
Herpes simplex image:
Aspergillus:

30. External Otitis Clinical manifestations/assessment
Fungal infection
Clinical manifestations/assessment
Pain with movement of auricle or chewing
Erythema, scaling, pruritus, edema, watery discharge, and crusting of the external ear
Drainage may be purulent or serosanquinous
Pseudomonas: green, musty-smelling drainage
Assessment: pain assessment; drainage assessment; home remedies used; presence of edema
Fungus :
Bacterial – reddened canal:

31. External Otitis Diagnostic Tests: Culture and Sensitivity of drainage
Medical Management
Oral analgesics; corticosteroids
Antibiotic or antifungal ear drops; oral antibiotics
Specific antibiotic will be based on the culture results
Nursing interventions: cleansing of ear canal; poss. heat for pain relief; instill ear drops; adequate method of communication

32. Acute Otitis Media Middle Ear Infection
Most often caused by: H. Influenza & Strep pneumoniae
Occurs frequently in children 6-36 mo. old and in the winter and early spring
Children’s shorter and straighter eustachian tubes provide easier access of microorganisms from the nasopharynx  middle ear.
Often post URI
Pussy inner ear: 32

33. Acute Otitis Media Clinical Manifestations: Assessment
Sense of fullness in the ear
Severe, deep throbbing pain behind the tympanic membrane (pain may disappear if TM ruptures)
Hearing loss, tinnitus (ringing, tinkling), and fever may develop
Assessment
See External Otitis
Diagnostic Tests: culture of purulent drainage
Infected fluid middle ear:
Acute Otitis Media :

34. Acute Otitis Media Medical treatment Oral antibiotics Analgesics
Topical ear drops
Antihistamines
Myringotomy (small incision in the eardrum to drain fluid and relieve pressure)
Tympanostomy tube placement for long- or short-term use
Acute Otitis Media : 34

35. Acute Otitis Media Nursing Interventions Medication Instructions
If hearing loss, effective communication
Children are to be fed upright to prevent nasopharyngeal flora from entering the eustachian tube
Instruct to blow nose gently
If myringotomy performed, instruct parents to change the cotton in the outer ear 2x/day
Mastoiditis:
difficult to treat
iv tx. X several days
poss. myringotomy (surg incision of TM membrane to relieve pressure and release exudate)
if progressed, simple mastoidectomy

36. Acute Otitis Media
Mastoiditis: an infection of one of the mastoid bones.
Usually an extension of a middle-ear infection that was untreated or inadequately treated
S/S: earache, headache, fever, large amts of purulent exudate, malaise
Remember me telling you my daddy had a hole behind his ear? That’s because this is what happened to him in the 30’s before we had antibiotics.
Image red swollen pushing ear forward:
Image mastoidectomy – modern with a silicon block to fill the hole:

37. Fig. 3
Surgical procedures for mastoid obliteration with silicone blocks and bone pate. (A) After elevation of the anterior-based flap, a canal wall down mastoidectomy is performed. (B) The epitympanic cavity is obliterated with piecemeal cartilage. (C) Silicone blocks are used to fill the mastoid cavity. (D) Silicone blocks are fixed using fibrin glue and covered with bone pate. ★, piecemeal conchal cartilage; ◆, silicone block; ♣, bone pate
To get the bone out they have to remove all of the cartridge which are replaced with silicone blocks and then covered with bone to protect it. Do you know why they go to such lengths when they remove the mastoid? You have 2 very important nerves running through that area the facial nerve and the auditory nerve not to mention the internal carotid is in that area.

38. Chronic Otitis Media
Eardrum may be permanently perforated (ruptured) or shows signs of a healed perforation with chronic fluid trapped behind it
There may be intermittent drainage
Possible complications of chronic otitis media include mastoiditis, meningitis, labyrinthitis, cholesteatoma, and hearing impairment
Image: 38

39. Store suspension at room temperature
What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media? a.
Store suspension at room temperature b.
Discontinue drug when symptoms abate c.
Avoid alcoholic beverages d.
Take with meals only

40. c. Avoid alcoholic beverages
ANS: C
c. Avoid alcoholic beverages
Drinking alcohol is discouraged while on Ceclor. The drug should be taken in its entirety and stored in the refrigerator. The drug can be taken with or without meals.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 657, Table 13-5
OBJ: 16 TOP: Ceclor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

41. Chronic Otitis Media Medical treatment
Systemic antibiotics and, if the eardrum is intact, irrigations to remove debris
Tympanoplasty if tympanic membrane does not heal
Mastoidectomy if the infection has extended to the mastoid bone
Chronic ear infection image: 41

42. Labyrinthitis Inflammation of the labyrinthine canals of the inner ear
Acute labyrinthitis usually follows an acute upper respiratory infection, acute otitis media, pneumonia, or influenza
Also can be an adverse effect of drugs – e.g. Streptomycin can destroy the vestibular portion of the inner ear
Image: 42

43. Labyrinthitis Another type: suppurative (pus) labyrinthitis
Inner ear infection that usually follows an upper respiratory infection, ear infection, or ear surgery
The effects can destroy the labyrinth and cochlea, causing permanent deafness

44. Labyrinthitis Signs and symptoms
Sudden and severe vertigo, nausea, vomiting, headache, anorexia, nystagmus, photophobia, ataxic gait
Assessment: note frequency and duration of vertigo; safety measures taken; hearing ability, ringing in ears, nausea; jerking movements of eyes, color and moisture of skin.
Image: 44

45. Labyrinthitis Medical treatment
Anti-emetics and supportive care until it resolves
Antibiotics if infection is present
Dramamine or Meclizine for vertigo
Nursing Diagnosis:
Risk for injury r/t altered sensory perception (vertigo)
Fear r/t altered sensory perception (vertigo)
Image:

46. Labyrinthitis Nursing care Assess symptoms
Monitor intake and output, daily weights if possible, and food intake if persistent vomiting
Assist/supervise the patient when out of bed
Give antiemetics as prescribed
Instruct and monitor safety measures
Image:
Image of pitcher: 46

47. Obstructions of the Ear

48. Obstructions of the Ear
Etiology/pathophysiology
Impaction of cerumen in canal; foreign bodies
Clinical manifestations
Tinnitus and pain in the ear
Slight hearing loss; tugging at ear
Assessment
Pt. interview re: possibility of foreign body, home remedies used; note presence of foreign body
Diagnostic Tests: Otoscope exam
Image ear wax obstruction:

49. Obstructions of the Ear
Medical Management
Removal of cerumen by irrigation
Carbamide (Debrox) peroxide to soften cerumen
Foreign objects are removed with forceps
Insects are smothered with drops of oily substance and removed with forceps
Possible surgical removal of the foreign object
Image:

50. Foreign Bodies and Cerumen
Impacted cerumen is the most common causes of obstruction
Physician may order ear drops to soften the cerumen before irrigation
Physician can use ear forceps or a cerumen spoon to remove it
Ear full of wax: 50

51. Obstructions of the Ear
Nursing Interventions
During assessment – note the presence and amount of hearing impairment
Otoscope exam
Ear irrigations
Reassure pt. of return of hearing after obstruction removed
Nursing Diagnosis: Disturbed sensory perception (auditory) r/t presence of foreign body causing obstruction

52. Noninfectious Disorders of the Ear

53. Otosclerosis Etiology/pathophysiology
Chronic, progressive deafness due to formation of spongy bone, especially around the oval window with resulting immobility of joint of the stapes  tinnitus and then deafness
Fixed stapes cannot vibrate, so sound waves cannot be transmitted to inner ear
Effect is a conductive hearing loss
Most common in young Caucasian women

54. Otosclerosis Clinical manifestations/assessment
Slowly progressive conductive hearing loss
Low  medium pitched tinnitus
Deafness will first be noted between ages 11 and 20
Presence of mild dizziness  vertigo
Assess family hx of same

55. Otosclerosis Diagnostic Tests: Medical Management
Otoscope: Schwartz’ sign – a pink blush in the ear
Rinne’s Test, Weber’s test, Audiometric testing, tympanometry
Medical Management
Stapedectomy
Air conduction hearing aid

56. Otosclerosis Nursing Interventions
Post Stapedectomy Care per usual post ear surgery care
External ear packing – leave in place 5-6 days
Bedrest x 24 hrs
Keep flat with operative ear up (to maintain the placement of the prosthesis)
NO turning
Tx. Headache, dizziness
Review P “After Ear Surgery”

57. Figure 52-8 57

58. Meniere’s Disease Etiology/pathophysiology
Chronic disease of the inner ear
Recurrent episodes of vertigo  unilateral progressive nerve deafness, and tinnitus
Increase in endolymph fluid( increased pressure in the inner ear)
The cause is unknown
Attack triggers: alcohol, nicotine, stress, and certain stimuli such as bright lights and sudden movements of the head

59. Meniere’s Disease Clinical manifestations/assessment
Vertigo (recurrent) – often preceded by sense of fullness and pressure in the ear
Nausea and vomiting
Hearing loss – unilateral; repeated attacks can lead to permanent senorineural hearing loss
Tinnitus
Diaphoresis
Nystagmus

60. Ménière’s Disease Assessment Document pattern of acute attacks
Note substances/stimuli that trigger episodes
Specific symptoms including nausea, vomiting, vertigo, and tinnitus
Determine how the condition affects the patient’s life, what the patient knows about the disease, and coping mechanisms 60

61. Ménière’s Disease Medical Diagnosis
Diagnosed by ruling out other conditions that can cause similar symptoms – e.g. CNS disease
Physician likely to order a number of radiographs and other tests to detect any neurologic, allergic, or endocrine disorders
Audiogram, Vestibular testing, Glycerol test 61

62. Meniere’s Disease Medical management No specific treatment
Decrease fluid pressure
Fluid restriction; diuretics; low-salt diet
Avoid caffeine and nicotine
Dramamine, meclizine, and Benadryl – use between attacks
Meds may be given IV during acute attacks

63. Meniere’s Disease Medical Management cont.
Surgical Procedures are for preservation of hearing
See Table 13-7 p. 644 AHN for surgeries and post op nursing interventions

64. Meniere’s Disease Nursing Interventions
Maintain the prescribed low-salt diet
Administer diuretics
Acute vertigo: bedrest, sedation, antiemetics
Provide effective means of communication
Safety
Patient Education
Review: Patient Teaching “Vertigo” p.640

65. Ménière’s Disease Nursing Diagnosis: (r/t, AEB) Risk for Injury
Risk for Deficient Fluid Volume
Anxiety
Ineffective Therapeutic Regimen Management 65

66. Ménière’s Disease Postoperative care
Carefully check physician’s orders for position and activity limitations
Safety, comfort, and detection of complications
Antiemetics to control nausea and vomiting
No nonessential care until patient tolerates movement 66

67. Ménière’s Disease Post Operative Care cont.
Assist patients when getting up and walking
Call button should always be within reach; patients may be dizzy for several days, unsteady for several weeks
Assess for facial nerve damage

68. Ototoxicity
Damage to the ear or eighth cranial nerve caused by specific chemicals, including some drugs
Common ototoxic drugs are salicylates (aspirin) and aminoglycoside antibiotics
From reversible tinnitus to permanent hearing loss 68

69. Ototoxicity
The primary symptom of ototoxicity with salicylates is tinnitus, which disappears when the drug is discontinued
Extent depends on dosage and how long it was given
Patients who have poor renal function are at special risk for ototoxicity because drugs are excreted more slowly

70. Ototoxicity Nursing care
Primary are early detection and prevention of progressive hearing loss caused by ototoxic drugs
To reduce risk of ototoxicity, be familiar with these drugs. Instruct patients to report hearing loss, tinnitus, or problems with balance
Promptly report such symptoms to the physician
Teach patients that aspirin is not a harmless drug 70

71. Ototoxicity Nursing Care
Monitor urine output of patients on ototoxic drugs: low output may mean the drug is excreted slowly, increasing risk of toxicity
Report low urine output to the physician
Care plan should alert all staff to potential for ototoxicity

72. Surgeries of the Ear Stapedectomy Tympanoplasty Myringotomy
Removal of the stapes of the middle ear
To restore hearing in the treatment of otosclerosis
Tympanoplasty
Operative procedures on the eardrum or ossicles of the middle ear to restore hearing
Myringotomy
Surgical incision of the eardrum
To relieve pressure and release purulent exudate fron the middle ear

73. Nursing Considerations/Care for Post op Ear Surgeries

74. Post Op Mastoidectomy
After surgery on the middle ear: comfort, safety, prevention of infection, and prevention of pressure on the tympanic membrane
Nausea common
Inspect the dressing and describe drainage but do not disturb or remove the dressing
Assist patient first time out of bed, in case of dizziness
Patient should avoid activity that creates pressure on the tympanic membrane (blowing the nose, coughing, sneezing, straining) 74

75. Post Op Stapedectomy
After surgery, pain relief, safety, prevention of infection, and avoidance of pressure in the ear
Especially important that the patient not do anything that increases pressure in the ear
Nausea, vomiting, and vertigo are common
The packing in the ear should not be disturbed 75

76. Post Op Stapedectomy
After dressing and packing removed, patient advised to keep the ear dry for at least 2 weeks
Swimming and showering not permitted for 6 weeks
The patient should avoid contact with people who have colds. A balanced diet and adequate rest are needed for tissue healing and resistance to infection 76

77. General: Care of the Patient Having Ear Surgery
Assessment
In postoperative period, pain, nausea, dizziness, fever
Inspect the wound dressing for drainage
Drainage color, odor, and amount
Nsg. Interventions:
Pain management
Safety
Reduce risk for Infection
Disturbed Sensory Perception 77

78. Nursing Diagnoses – r/t, AEB
Health Mainentance, ineffective
Anxiety
Self-care deficit
Fear
Impaired environmental interpretation syndrome
Impaired social interaction
Impaired home maintenance
Risk for injury
Risk for loneliness
Sensory perception, disturbed (auditory or visual)