Disorders of the Ear

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

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

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

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

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

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 7

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

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

Loss of Hearing (Deafness) Nursing Interventions: Instruct in insertion and care of hearing aid p. 634 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

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

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 12

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 13

Figure 52-6 14

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.

Figure 52-7 16

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 17

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

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 Telephones can be adapted to send and receive written messages Earphones for radios, stereos, and televisions 19

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

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 21

Nursing Care Nursing diagnoses: (r/t, AEB) Impaired Verbal Communication Social Isolation Ineffective Coping Deficient Knowledge 22

Inflammatory and Infectious Disorders of the Ear

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

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

External Otitis 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

External Otitis 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

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

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 29

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

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 31

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

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/sx: earache, headache, fever, large amts of purulent exudate, malaise

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 34

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 35

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 36

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

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. 38

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)

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 40

Obstructions of the Ear

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

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

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 44

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

Noninfectious Disorders of the Ear

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

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

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

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. 644 “After Ear Surgery”

Figure 52-8 51

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

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

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 54

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 55

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

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

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

Ménière’s Disease Nursing Diagnosis: (r/t, AEB) Risk for Injury Risk for Deficient Fluid Volume Anxiety Ineffective Therapeutic Regimen Management 59

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 60

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

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 62

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

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 64

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

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

Nursing Considerations/Care for Post op Ear Surgeries

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) 68

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 69

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 70

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 71

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)