Problems of Problems of the Earthe Ear

Ma. Tosca Cybil A. Torres, RN,MAN

Review: Anatomy and Physiology

The ear is divided into three parts:

• The external ear• The middle ear• The internal ear

The External/Outer Ear

External or Outer ear consists of the following:

• pinna or auricle - the outside part of the ear.

• external auditory canal or tube - the tube that connects the outer ear to the inside or middle ear.

• tympanic membrane - also called the eardrum. The tympanic membrane divides the external ear from the middle ear.

The Middle Ear

middle ear (tympanic cavity) consists of the following:

• ossicles - three small bones that are connected and transmit the sound waves to the inner ear. The bones are called:

☺malleus ☺ incus ☺ stapes

• eustachian tube - a canal that links the middle ear with the throat area. The eustachian tube helps to equalize the pressure between the outer ear and the middle ear. Having the same pressure allows for the proper transfer of sound waves. The eustachian tube is lined with mucous, just like the inside of the nose and throat.

The Inner Ear

inner ear consists of the following:

• Cochlea- contains the nerves for hearing

• Vestibule- contains receptors that respond to the position of the head as it relates to gravity

• semicircular canals- contains sensory organs of equilibrium

Acoustic Nerve {cranial nerve VIII}

• Connects the cochlea, semicircular canals, and

vestibular receptors with the brain

The Mechanism of HearingThe Mechanism of Hearing

Assessment

1. Health historya. elicit a description of the present illness

and CC.cardinal s/sx include:

• reports “trouble hearing”• ear pain or discharge from ear• ringing in the ears• dizziness or incoordination

b. Explore the client’s history for risk factors

• Age• Heredity• Allergies• Upper respiratory infection • Head trauma• Excessive environmental noise or

music • Certain ototoxic medications

2. Physical Examination

a. Inspection• inspect the auricle and surrounding tissues

for size, symmetry, and angle of attachment to head

• inspect external canal for lesions, dryness, cleanliness, and redness

• inspect for any bloody discharges, CSF, pus, or serous fluid

• Tympanic membrane inspection includes straightening the ext. auditory canal of an adult by pulling the auricle up and back while tilting the client’s head slightly; normal findings include an intact, shiny, pearly gray, and concave membrane that moves with swallowing

• Assessment of nose and throat should accompany ear assessment because infection in these areas may lead to ear problems

b. Palpation. Palate the area around the ear and palpate the auricle for pain or discomfort

3. Laboratory and diagnostic studies

a. An otoscopic examination is used to examine the external auditory canal and tympanic membrane

b. Hearing acuity screening is done by having the client identify the point near the ear at which he can hear a whispered voice or ticking watch; normally, the client should hear the sound at a distance of about 2 feet

c. The Weber test evaluates bone conduction with a tuning fork placed on the midline of the head ; normally the tone is heard equally in both ears by bone conduction

d. The Rinne test uses a tuning fork to evaluate air conduction and bone conduction; normally, air conduction is greater than the bone conduction {ie, positive Rinne result}

B. Nursing Diagnosis1. Sensory or perceptual

alteration: auditory2. Risk for injury 3. Impaired communication 4. Pain 5. Knowledge deficit 6. Anxiety 7. Social isolation

c. Planning and outcome identification

Major goals include:♥Adjustment to altered sensory

perception♥Absence of injury or vertigo ♥Ability to communicate effectively ♥Freedom form pain or discomfort ♥Knowledge of disease process and

treatment ♥Absence of social isolation and anxiety

d. Implementation

1. Promote measures that aide in maximizing the client’s auditory sensory or perceptual functioning

a. When hearing loss is permanent, encourage the client to participate in aural rehabilitation, which includes auditory training, speech reading, speech training, and use of hearing aids. b. Discuss the possibility of using hearing aidsc. Discuss the possibilty of obtaining a hearing guide dog to increase the client’s independence

2. Protect the client from injury a. protect the ears from loud noises with items

such as plugs or muffs

b. chew gum or suck hard candy when flying to open the eustacian tube and allow air into middle ear

c. NEVER insert any object into the auditory canal beyond the extent of vision

d. do not insert an object smaller than the finger into the ear

e. Instruct the client to blow the nose with the mouth open and both nostrils open to prevent forcing contaminated material into the middle ear

f. assist the client with vertigo by assisting with ambulation, keeping side rails up on the bed, and providing the client with a safe environment

3. Promote measures that enhance effective communication

a. work with the client to develop means of communication that is effective and mutually satisfying [e.g.. Lip reading, writing]

b. avoid startling the client; get the attention of the client before speaking

c. when talking to the hearing-impaired client-devote full attention to what the person is

saying -speak slowly and distinctly in a low-pitched,

clear voice, but also not yell at the client-minimize background noise-do not try to appear as if you understand when

you do not -try to determine the essential meaning of what

is being said; use nonverbal cues

4. Promote measures that help prevent or decrease pain and discomfort

a. instruct the client on the correct way to administer prescription analgesics

b. explain that in may be necessary to insert a wick into ear canal to keep canal open so that liquid medication can be administered

c. instruct to avoid putting anything in ear and do not put the head under water until ear pain or infection is resolved.

d. instruct not to put heat or cold compress to the ear

5. Provide the client with self care instructions

a. instruct to avoid getting the ear wet to avoid infection b. instruct to avoid persons with URTIc. instruct to avoid bending, straining, anf flying until allowed in the post op period d. instruct to take full course of prescribed medications, even after symptoms are relievede. instruct to pull the top of the ear up and back when instilling the ear drops to straighten the ear canal f. instruct to prevent burns with a hair dyer when auricle is numb

6. Promote measures that prevent social isolation

- do not exclude the client from conversations in the room 7. Minimize anxiety

- assess level of anxiety by allowing the client to ventilate feelings, assisting to identify coping skills and stress management techniques

8. Prepare a client undergoing ears surgery for post op expectations and requirements

a. inform that hearing may not improve noticeably until swelling subsides and packs are removed b. explain expected post op restrictions on positioning and movement c. instruct not to sneeze, cough, blow his nose, or touch the ear or dressing until allowed

9. Take steps to prevent injury from post op complications

a. monitor s/sx of infection b. do not disturb the inner dressing c. avoid applying pressure to the ear or ear dressingm which could dislodge a graft or prosthesisd. observe for signs of facial nerve injury e. instruct to report tinnitus, fluctuating hearing, or vertigo

10. Promote mobility within post op restrictions

a. maintain bed rest for up to 48 hours b. position the client on her side with operative ear up to prevent displacement of graft; with the operative ear down to promote drainage; or on the unoperative side to minimize nausea and vomiting

11.Relieve post op discomfort and guard

against injury

a. Maintain the prescribed position b. Keep the bed rails up, and assist with ambulation c. Instruct to breath deeply through an open mouth d. Medicate for nausea and pain as indicated e. Provide a light or liquid diet to control nausea as

necessary

e. Outcome evaluationThe client:

♣Modifies his lifestyle to decrease disability and exert maximum control and independence within limits posed by impaired hearing

♣ Demonstrates understanding of effective ear care, hearing protection measures and remains free from injury

♣ Is able to effectively communicate with others

♣ Reposts relief of pain and discomfort♣ Verbalizes understanding of the

disorder, self care, and ways modify home and work to maintain safety

♣ Socializes with family, friends, and maintains an active social life

♣ Verbalizes a decrease in anxiety

Conductive hearing loss

Refers to various problems involving impaired passage of sound from the external ear and the inner ear. Specific conditions include:

A. Cerumen impactionB. External otitis media C. Serous otitis mediaD.Suppurative otitis media

Cerumen impaction

• Usually occurs in persons who naturally produce large amounts of cerumen

• Impacted cerumen in external ear can block sound from reaching the tympanic membrane

• Cerumen impaction is often visible; the client demonstrates some degree of hearing loss

External otitis media

• may be caused by infection [bacterial or fungal], excessive moisture in the auditory canal [swimmer’s ear], and trauma

• involves the inflammation of the external ear, with crust formation and edema in the auditory canal

• Results in itching, pain, and watery or purulent discharge

Serous otitis media

• May result from eustachian tube obstruction, sudden changes in atmospheric pressure, allergy, and viral disease

• Involves sterile fluid accumulation in the middle ear. It may be acute or chronic; frequent recurrences can threaten hearing

• Is manifested by plugged feeling in ear, reverberation of the client’s own voice, and hearing loss

Suppurative otitis media• May follow viral disease, tympanic membrane

perforation, or prolonged forceful nose blowing.• Most common in infants and young children because

of their immature and relatively poorly draining eustachian tubes

• Involves pus accumulation in the middle ear and possibly extending into adjacent structures. Chronic recurrence may lead to tympanic membrane perforation

• Typically produces:ּס Throbbing ear pain ּס Fever, hearing loss, nausea and vomitingּס Feeling of increased pressure in the ear ּס Bright red, bulging or retracted tympanic membraneּס Possible tympanic membrane rupture with discharge [otorrhea]

Laboratory and diagnostic findings

Otoscope findings depend on the stage of disease.

• Initially the tympanic membrane is retracted• In the second stage, the tympanic

membrane’s blood vessels dilate and appear red

• During the third stage, the tympanic membrane becomes red, thickened, and bulging, with a lost of landmarks

• If the tympanic membrane spontaneously perforates, pus and blood drain from the ear

Nursing management

1. instruct the client about the correct way to remove impacted cerumen

a. Soften the cerumen with distilled peroxide or glycerol preparations, such as Debrox

b. Instruct the client to irrigate the ear in 2 or 3 days to remove the wax

c. Instrcut the client to keep otic solution in the ear for 15 minutes by tilting head sideways or by putting cotton in the ear

d. Instruct the client to notify the physician if inflammation or irritation occurs

e. Instruct the client not to use the solution for more than 4 consecutive days

2. Provide care to a client with tympanic membrane perforation

a. Maintain strict asepsisb. Do not irrigate the ear c. Protect from water contamination by having

the client wear ear plugs and a bathing cap d. Recognize that the client is at risk for

labyrinthitis or miningitis e. Use a message board if necessary f. Insert a hearing aid if indicated

3. Treat external otitis media with a topical antibiotic and steroids, gentle debridement, and acid- alcohol solutions to sterilize the auditory canal as prescribed

4. Discuss, prepare, and assist patient with serous otitis media for myringotomy, which is an incision into the typanic membrane to relieve pressure and remove pus

5. Provide nursing interventions for the client with suppurative otits media.a. Provide prescribed treatments which may

include systemic antibiotics for at least 7 days, nasal decongestants, and analgesics

b. Discuss, prepare, and assist the client for surgery 1. mastoidectomy- removal of the mastoid bone 2. myringoplasty- repair of perforated tympanic membrane3. tympanoplasty- involves the replacement or rebuilding of middle ear structures.

Ménière's Disease

• is an inner ear disorder that brings spontaneous episodes of vertigo that can last minutes to hours.

• Along with the vertigo, there may be some hearing loss in the affected ear that comes and goes, as well as an increase in tinnitus and a sense of fullness in the Ménière's affected ear.

• Between episodes, client may have a persistent hearing loss and tinnitus in the affected ear.

• The vertigo associated with Ménière's Disease may happen suddenly, or may build in intensity over several hours and the client may begin to experience nausea or vomiting.

• The underlying cause of Ménière's Disease is unknown.

• Ménière's Disease is felt to be due to an abnormality in the fluid balance of the inner ear.

Clinical manifestations

• Sudden episodes of severe whirling vertigo, with an inability to stand or walk, an episode may last up to several hours

• Buzzing tinnitus worsens before and during an episode

• Nausea, vomiting, and diaphoresis • Possibly, brief loss of consciousness with

nystagmus

Possible Treatments for Ménière's Disease

The treatment of Ménière's Disease is two fold.

• The first is to treat the symptoms of vertigo with anti-vertigo medication. Often an anti-nausea agent is necessary to combat the sick feeling that comes with vertigo. During and following a vertigo attack, the affected patient should avoid movements as they may increase the severity of the symptoms. 

• The second form of treatment is prevention of further vertigo attacks. Certain medications are effective in reducing the frequency and severity of vertigo attacks.

Nursing management 1. Provide nursing during an acute attack a. Provide a safe, quiet, dimly lit environment, and enforce bed

restb. Provide emotional support and reassurance to alleviate

anxiety c. Administer prescribed medications, which may include

antivertigo agents, antihistamines, and antiemetics

2. Instruct the client on self care instructions to control the number of acute attacks

a. Discuss the nature of the disorder b. Discuss the need for a low salt diet c. Explain the importance of avoiding stimulants and

vasoconstrictorsd. Discuss medications which may be prescribed to prevent

attacks or self-administration of appropriate medications during attack whick may include anticholinergic medications, vasodilators, and antihistamines

3. Discuss, prepare, and assist the client with surgical options

a. labyrinthectomy- most radical procedure and involves resection of the vestibular nerve or total removal of the labyrinth performed by the transcanal route, which results in deafness in that ear

b. Endolymphatic decompression consists of draining the endolymphatic sac and inserting a shunt to enhance the fluid drainage

• End of discussion