EAR DISORDERS

Brief Anatomy & physiology

Middle ear: Ear drum laterally to otic capsule medially Connected to nasopharynx by eustachian tube which

drains secretion from the middle ear and equalize pressure

Tympanic membrane has 3 layers; outer continuous with skin of ear canal; fibrous middle layer; inner mucosal layer

Ossicles: malleus, incus, stapes

Brief Anatomy & physiology

Inner ear: Housed within temporal bone Cochlea for hearing Semicircular for balance Cranial nerves: VII-facial, VIII vestibulocochlear Both cochlea & semicircular are housed in bony

labyrinth which is bathed by a fluid, perilymph

Function of ear Hearing Balance & equilibrium; visual system, vestibular system,

proprioceptive system corporate to balance

Hearing loss

Conductive hearing loss: result from external ear disorder, impacted cerumen; or middle ear disorder, otitis media—transmission of sound is interrupted

Sensorineural hearing loss involves damage to chochlea or vestibulocochlear nerve

Clinical manifestations:

• Tinnitus, increasing inability to hear in a group,

• Attitudes changes, reduced communication ability—reduced QoL

• May feel isolated ; loose a part of conversation

• May be unaware of their gradual impairment, surrounding

• Develop negative attitudes to hearing aids Read chart 59-2, P 1809

prevention

• Noise-induced hearing loss: chronic exposure to loud noise• Acoustic trauma: exposure to extremely intense noise,

explosion Read chart 59-3, P1810 Wear ear protection

Medical management--permanent or untreatable hearing loss-- aural rehabilitation

Nursing management: effective communication; use interpreter, gestures-facial expression

Having other health problems that may receive no attention

Middle earacute otitis media

• Most commonly seen in children • Is acute infection of middle ear; lasting less than 6 weeks• Bacteria enter after eustacian tube dysfunction—URT infection-

related obstruction / inflammation• Enter from contaminated secretions in the nasopharynx or

from tympanic membrane perforation• A purulent exudate is usually present in the middle ear

resulting in a conductive hearing loss

Clinical manifestations

• Symptoms vary with severity of infection • Usually unilateral associated with Otalgia• Pain is relieved after spontaneous perforation or therapeutic

incision of the tympanic membrane • Other symptoms: drainage, fever, hearing loss• Otoscopic examination: tympanic membrane is erythematous

and bulging Risk factors Age younger than 12 Chronic upper respiratory tract infection Chronic exposure to secondhand smoking Medical condition: cystic fibrossis, down syndrome, cleft

palate

AOMMedical management

• May resolve with early, appropriate antibiotics• If drainage, antibiotic otic preparation;• The condition becomes subacute: lasting 3W.-3Ms with

persistent purulent discharge• Rarely does permanent hearing loss• Complications: mastoid and intracranial complications,

meningitis, brain abscess; rarely • Surgical management• Myringotomy (tympanotomy), an incision in the tympanic

membrane to relieve pressure & drain purulent fluid, heals within 24-72 hours

• If AOM is recurrent, ventilating tube for 6-18 months to equalize pressure and drain fluid

Chronic otitis media

• Is the result of recurrent AOM causing irreversible tissue pathology and persistent perforation of the tympanic membrane; damage the ossicles

• Chronic infection destroys the ossicles, involve the mastoid Clinical manifestations:• Varying degree of hearing loss,• Persistent or intermittent foul-smelling otorrhea; Pain only in

acute mastoiditis• Otoscopic exam: perforation and chloesteatoma • Chloesteatoma is an ingrowth of the skin of the external layer

of eardrum into the middle ear• Chronic otitis media can cause chronic mastoiditis

Chronic otitis mediamanagement

• Careful suctioning of the ear; instillation of antibiotics drops / powder

• Surgical: Tympanoplasty: surgical reconstruction of the tympanic

membrane, reconstruction of ossicles may be required Purpose to re-establish the function of middle ear , improve

hearing Is performed through external auditory canal or through a post-

auricular incision Dramatic improvement of hearing Ossiculoplasty: is reconstruction of middle ear, bones, to

restore hearing; prostheses are used to connect bones to reestablish sound conduction mechanism

Surgical management

- Mastoidectomy: the objectives, remove chloesteatoma, gain access to diseased structures, create a dry and healthy ear

- Performed through a post-auricular incision; under general anesthesia,

- Mastoid pressure dressing - Immediately check for facial paresis

- Read nursing care plan for patients undergoing Mastoid surgery, P 1815-1816.

Mastoid interventions (surgery)—nursing interventions

Reducing anxiety Discuss any anxiety & concerns Provide information about surgery and expected results,

hearing, taste, balance Relieving pain Residual blood or fluid in middle ear may cause discomfort Analgesics for 24 hours; then as needed Intermittent sharp shooting pain—eustachian tube is open &

allows air to enter middle ear Constant throbbing pain with fever—infection & should be

reported

Mastoid interventions—nursing interventions

Preventing infection External auditory canal wick (packing) impregnated with

antibiotic Prophylactic antibiotic Instruct patients to prevent water from entering the ear canal

for 6 weeks Use a cotton ball covered with water-insoluble, petroleum jelly

during showers Keep post-auricular wound dry Immediately report S &S of infection

Mastoid interventions—nursing interventions

Improving hearing & communications Hearing may be reduced in the operated ear Measures include Reducing environmental noise Face the patient; speak clearly & distinctly without shouting Adequate lighting for speech reading non-verbal clues

Mastoid interventions—nursing interventions

Preventing injury Vertigo may occur after surgery Antiemetic or antivertiginous, antihistamine, can be prescribed Safety measures: assisted ambulation to prevent fall Instruct to avoid heavy lifting, straining, exertion, nose blowing

for 2-3 weeks after surgery to prevent dislodging the tympanic membrane graft

Meniere disease

Abnormal fluid balance of inner ear Caused by Malabsorption in the endolymphatic sac Blockage in the endolymphatic duct Endolymphatic hydrops, a dilatation in the endolymphatic

space develops Thus increasing pressure in the system Or, causing rupture in the inner ear membrane

Meniere disease—clinical manifestations

• Fluctuating progressive sensorineural hearing loss• Tinnitus, a roaring sound• A feeling of pressure or fullness in the ear• Incapacitating vertigo associated by nausea & vomiting Cochlear Meniere: Fluctuating progressive sensorineural

hearing loss associated with tinnitus & aural pressure Vestibular Meniere: episodic of vertigo associated with aural

pressure but not cochlear symptoms

Meniere disease—health assessment

• Determine frequency, duration, severity of vertigo• Assess diaphoresis & persistent feeling of imbalance—may

weaken patients at night• Feeling well between attacks • Assess hearing loss; may fluctuate with tinnitus• Audiogram• Elecctronystagmogram• Physical exam

Medical management

• Low sodium diet; to maintain adequate hydration• Psychological evaluation • Read dietary guidelines Chart 59-7,P. 1819 Pharmacologic therapy• Antihistamines, Mclizine, to suppress the vestibular system• Tranquilizers, Diazepam , in acute instances to control vertigo• Antiemetic, Promethazine to control nausea/vomiting • Diuretics to decrease the pressure in the endolymphatic

system –intake of foods containing K

Surgical management

• To improve quality of life—relieve vertigo• Hearing loss, tinnitus may remain

Endolymphatic sac decompression or shunting—a shunt or drain is inserted in the endolymphatic sac to equalize the pressure in the endolymphatic spac through a postauricular incision; treat vertigo of Meniere’s disease

Vestibular nerve sectioning—provides greatest success in eliminating vertigo

Cutting the nerve prevents the brain from receiving inputs from semicircular canal

Read Chart 59-8, P. 1821; care of the patient with vertigo

Meniere disease—nursing care for patients with vertigo

Remains free of any injury associated with imbalance & fall• Assess vertigo and extent of disability regarding ADLs• Administer antivertiginous medications • Encourage patients to sit down when dizzy• Place pillows in each side of the head to restrict movement • Assess to identify aura that suggests an impending vertigo• Patients keep eye open & stare straight ahead when lying down

& experience vertigo

Meniere disease—nursing care for patients with vertigo

Maintain normal fluid & electrolytes balance• Assess I & O, electrolytes, indicators of dehydration • Encourage oral fluids as tolerated—restrict caffeine-containing

beverages• Administer antiemetic & antidiarrheal if needed

Relieve anxiety• Provide information about vertigo & its treatment• Encourage exploring fears & concerns• Teach stress management• Avoid stress-producing activities

Meniere disease—nursing care for patients with vertigo

Reduce the risk of trauma• Assess for balance disturbances• Assist with ambulation when indicated• Assess for visual acuity & proprioceptive deficit• Encourage increase in activities• Help identify hazards at home

• READ CHART 59-8 p. 1821-1823.