Unit 4B hearing & balance

external & middle ear

-they can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum
-nothing smaller than the patient's own fingertip should be inserted into the canal

-uniformly shaped without skin tags or deformity
-attached to the side of the head at a posterior angle of 10 degrees or less.

-dry, clean, free from lesions, and not reddened.

-gently tap with one finger over the
mastoid process, compress the tragus with one finger, & gently move the pinna forward & backward
-Any tenderness suggests an inflammation of the external ear or the mastoid.

-Select the largest speculum
that most comfortably fits the patient's external canal
-Do not examine the ears of
a confused patient with an otoscope.
-tilt the patient's head slightly away, hold otoscope upside down
-observe the ear canal as you insert the speculum into the external canal.
-Never blindly insert because of the risk of perforating the eardrum

-always intact
-shiny, transparent
-opaque or pearly gray
-without lesions

-Hold a ticking watch 5 inches from each ear, ask if ticking is heard
-The patient with normal hearing should be able to hear it.

-ask the patient to block one external ear canal while standing 1 to 2 feet away.
-Quietly whisper a statement,ask to repeat it
-Test each ear separately
-If the patient does not respond correctly, use a louder whisper.

-painful
-caused by irritating or infective agents
-the external ear canal or auricle has either an allergic response or inflammation with or without infection

-watchful waiting, manual removal, and the use of ceruminolytic agents followed by irrigation

-most virulent form of external otitis.
-Organisms spread beyond the external ear canal into the ear and skull
-complications: meningitis, brain abscess, and destruction of cranial nerve VII.

-mild itching
-pain with movement of the pinna or tragus or when upward pressure is applied to the external canal.
-ear feels plugged and hearing reduced.

-comfort measures: application of heat to the ear for 20 minutes three times a day
-Teach that bedrest limits head movements,thereby reducing pain.
-mesh for drops
-analgesics for pain

Topical antibiotic and steroid therapies are most effective in decreasing
inflammation and pain

-use mixture of water and hydrogen peroxide at body temp
-Do not irrigate an ear with an eardrum perforation or otitis media- this may spread the infection to the inner ear.

-Irrigation is not used if vegetable matter - material expands when wet, making the impaction worse.
-Insects are killed before removal unless coaxed out by a flashlight or a humming noise.
-Lidocaine, a numbing agent, can be placed in the ear canal
for immediate pain relief.
-Mineral oil or diluted alcohol can
suffocate insect, which is then removed with ear forceps.

-sensation of fullness in the ear
-with or without hearing loss
-ear pain, itching, dizziness, or bleeding from the ear
-object may be visible with direct inspection.

-acute otitis media
-chronic otitis media
-serous otitis media

permanent conductive hearing loss

-infecting agent introduced into the middle ear causes inflammation of the mucosa, swelling&irritation of the small bones (ossicles) within middle ear
-purulent exudate follows
-sudden onset,lasts 3 weeks or less

-pain with or without movement of external ear
-sensation of fullness in the ear.
-reduced/distorted hearing
-sticking/cracking sound in
the ear on yawning/swallowing
-tinnitus
-Headaches
-malaise, fever, nausea, vomiting
-dizziness or vertigo

-repeated acute episodes
-has a longer duration then acute
-causes greater middle ear injury

-after infection, fluid filled but not infected anymore

-trauma
-sticking things in the ear
-infection with rupture

-the eardrum spontaneously perforates (breaks open)
-pus or blood drains from the ear
-when the membrane ruptures, pt notices a marked decrease in pain as the pressure is relieved
-perforations from any cause may
heal if underlying problem is controlled
-repeated perforations can cause hearing loss.

-smoking in house
-daycare
-allergies
-long term use of pacifier

-infection
-direct damage
-rapid changes in the middle-ear cavity pressure

-within a week or two without treatment

-teach preventive measure to protect ear
-avoid inserting objects into external canal
-stress importance of using ear protectors when blunt trauma is likely

-continuous ringing or noise perception in the ear
-diagnostic testing cannot confirm
-can have disturbing emotional consequences

-exact course of problem & Tx vary with underlying cause
-If no cause can be found/treated, therapy focuses on ways to mask ringing

-background sound
-noisemakers
-music during sleeping hours
-support groups to help with coping

-common manifestations of many ear disorders

-nausea, vomiting, falling, nystagmus, hearing loss, tinnitus
-unless cause can be treated, each manifestation is treated

-restrict head motions, move more slowly
-maintain adequate hydration, especially after vomiting
-maintain safe, uncluttered environ.
-use cane/walker

-dimenhydrinate (Dramamine), diazepam (Valium), scopolamine
- often dissatisfied b/c side effects (especially drowsiness) can be worse than vertigo
-do not drive while taking these

-tinnitus, one-sided sensorineural hearing loss, vertigo, N/V
-long term
-attacks that can last several days, are almost fully incapacitating, and full recovery often takes several days

-unknown
-abnormal inner ear fluid balance (excess of endolymphatic fluid)
-often occurs with infections, allergic reactions, fluid imbalance
-long-term stress may have role

-move head slowly to prevent worsening vertigo
-nutrition can reduce amount of endolymphatic fluid (see p.1128 Iggie)
-advise pt to stop smoking

-mild diuretics to decrease endolymph volume
-antihistamines to reduce severity or stop acute attack
-nicotinic acid for vasodilation
-antiemetics for N/V
-benzos for calming

-infection of labyrinth (inner ear)
-may be related to viral/bacterial infection, complication of otitis media

-vertigo, N/V, hearing loss, tinnitus

-systemic antibiotics
-stay in bed in a darkened room
-antiemetics/antivertiginous drugs (Dramamine)
-psychosocial support: hearing loss may be permanent, persistent balance may improve with gait training & PT

-disturbance of equilibrium
-N/V, pallor, sweating
-antiemetics: must take before getting on board, in car, etc

-benign tumor of CN VIII (acoustic nerve in inner ear)
-slow-growing, often damages other structures in the process
-tinnitus, hearing loss, vertigo
-treat with surgery

-speech deterioration, fatigue, indifference, social withdrawal, insecurity, indecision & procrastination, suspiciousness, false pride, loneliness & unhappiness, tendency to dominate conversation

sensorineural hearing loss that occurs as result of aging

-longstanding environmental noise (work/hobby related)
-ototoxic side effects of medications such as aspirin & aminoglycoside antibiotics

-speak straight to person, let them see your lips
-make sure there is good lighting
-make sure you have their attention before speaking
-direct your voice to the 'good' ear
-decrease/eliminate background noises
-utilize other forms of communication as necessary
-DON'T shout
-rephrase when you are not understood

-reconstructs middle ear to improve conductive hearing loss
-procedures vary from simple reconstruction of the eardrum to replacement of ossicles