Assessment and Management

of Patients with Hearing and

Balance Disorders
Anatomy of the Ear
Anatomy of the Inner Ear
Bone Conduction Compared to
Air Conduction
 Assessment

• Inspection of the external ear

• Otoscopic examination

• Gross auditory acuity

• Whisper test

• Weber test

• Rinne test
Technique for Using an Otoscope
Weber Test
Rinne Test
 Diagnostic Evaluation

• Audiometry
• Tympanogram
• Auditory brain stem response
• Electronystagmography
• Platform posturography
• Sinusoidal harmonic acceleration
• Middle ear endoscopy
 Hearing Loss
• Affects more than 28 million people in the U.S.

• Increased incidence with age: presbycusis

• Risk factors include exposure to excessive noise levels

Hearing Loss
 Hearing Loss
• Types
• Conductive: due to external middle ear problem

• Sensorineural: due to damage to the cochlea or

vestibulocochlear nerve

• Mixed: both conductive and sensorineural

• Functional (psychogenic): due to emotional problem

 Manifestations
• Early symptoms include:

• Tinnitus: perception of sound; often “ringing in the

ears”

• Increased inability to hear in a group

• Turning up the volume on the TV

 Manifestations
• Impairment may be gradual and
not recognized by the person
experiencing the loss

• As hearing loss increases, patients

may experience deterioration of
speech, fatigue, indifference,
social isolation, or withdrawal;
Guidelines for Communicating
With the Hearing Impaired
• Use a low-tone, normal voice

• Speak slowly and distinctly

• Reduce background noise and

distractions

• Face the person and get his

attention
Guidelines for Communicating
With the Hearing Impaired

• Speak into the less-impaired ear

• Use gestures and facial expressions

• If necessary, write out the

information or use a sign language
translator
EXTERNAL EAR CONDITIONS
CERUMEN IMPACTION
 Management
• Removal may be by irrigation,
suction, or instrumentation

• Gentle irrigation should be used

with lowest pressure, directing
stream behind the obstruction

§ Glycerin, mineral oil, half-

strength H2O2 or peroxide in
glyceryl may help soften
cerumen
FOREIGN BODIES
Conditions of the External Ear
• Foreign bodies
• Removal may be by irrigation,
suction, or instrumentation
• Objects that may swell (such
as vegetables or insects)
should not be irrigated
• Foreign-body removal can be
dangerous and may require
extraction in the operating
room
EXTERNAL OTITIS
• External otitis
• Inflammation is most
commonly due to the
bacteria staphylococcus or
pseudomonas, or to fungal
infection due to Aspergillus
Assessment Findings

• pain and tenderness,

• discharge,
• edema,
• erythema,
• pruritus,
• hearing loss,
• feelings of fullness in the
ear
 choleastoma

MANAGEMENT

• Therapy is aimed at
reducing discomfort,
reducing edema, and
treating the infection

• A wick may be inserted into

the canal to keep it open
and to facilitate medication
administration
Conditions of the External Ear

• Malignant external otitis:

• rare, progressive infection

• affects the external

auditory canal, surrounding
tissue, and the skull
MIDDLE EAR
CONDITIONS
TYMPANIC MEMBRANE
PERFORATION
• Rupture or perforation in the
eardrum
eardrum
• Function
• Receives vibration from
the outer ear and transmit
them to the small hearing
bones of the middle ear
CAUSES:
• Insertion of objects into the
ear canal purposely (eg,
cotton swabs) or accidentally
• Concussion caused by an
explosion or open-handed
slap across the ear
• Head trauma (with or without
basilar fracture)
CAUSES:
• Sudden negative pressure (eg,
strong suction applied to the ear
canal)

• Barotrauma (eg, during air travel or

scuba diving)

• Iatrogenic perforation during

irrigation or foreign body removal
Assessment Findings
• Ear pain
• may suddenly decrease right after
eardrum ruptures.

• After the rupture:

• Drainage from the ear (drainage

may be clear, pus, or bloody)

• Ear noise/buzzing – ringing

sensation
 Assessment Findings
• After the rupture:
• Earache or ear discomfort
• Fullness of ear

• Hearing loss in the involved ear

(hearing loss may not be total)

• vertigo

• Blood tinged discharge from the ear

Diagnostic Study

• Otoscopic
examination

• Tympanogram
• Notes the
pressure

• Audiogram
• Hearing test
Tympanogram
Management
• Antibiotics
• Decongestant
• Ear irrigation
• To remove debris
• Advise the client to clean ear and dry
• Analgesics
Surgical management
• Tympanoplasty
• Surgical correction of perforated
eardrum
• Graft is placed to restore the damaged
tympanic membrane
• Myringoplasty
• Closure of perforation
• Ossiculoplasty
• Ossicular reconstruction
Nursing Management
• Putting warmth on the ear may
help relieve discomfort.

• Painkillers such as ibuprofen or

acetaminophen to relieve pain.

• Keep the ear clean and dry while it

is healing.
Nursing Management
• Place cotton balls in the ear while
showering or shampooing to prevent
water from entering the ear.

• Advise client to avoid swimming or

putting head underneath the water.

• Antibiotics (oral or ear drops) to

prevent or treat an infection.

• Place a patch over the eardrum to

speed healing.
ACUTE OTITIS MEDIA
• Bacterial or viral infection of the middle ear
 INCIDENCE

• Most frequently seen in

children(infants and
preschoolers)
• Shorter ear canal and more
horizontal
• Blockage of eustachian tube
causes lymphedema and
accumulation of fluid in the
middle ear
 Causes:

• Pathogens are most

commonly Streptococcus
pneumonia, Haemophilus
influenzae, and Moraxella
catarrhalis
 Assessment Findings

• otalgia (ear pain)

• Infant pulls or touches ear
frequently
• fever,
• hearing loss
• Dysfunction of eustachian tube
• Ear infection –r/t respi infection
• Increased middle ear pressure
• Bulging tympanic membrane

• Irritability; cough; nasal

congestion
Diagnostic test
• C&S fluid
• Reveals causative
organism
Assessment Findings

• Treatment
§ Antibiotic therapy
§ Myringotomy or
tympanotomy
Nursing Intervention
• Administer antibiotics as ordered.
• Full 10 days course
• Proper positioning: older children:
pull earlobe up and back
• Infants
• Down and back
• Administer acetaminophen for
fever and discomfort
• Administer decongestants as
ordered.

• to relieve eustachian tube

obstruction

• Provide care for myringotomy

• Let child wear earplugs when
showering or having hair washed;
do not permit driving
 • Be aware that tubes may fall out
for no reason

• Provide client teaching

• Medication administration
• Post op care
• Serous otitis media:
• fluid in the middle ear without evidence of
infection

• Chronic otitis media

• Result of recurrent acute otitis media
• Chronic infection damages the tympanic
membrane and ossicle, and involves the
mastoid
• Treatment
§ Prevent by treatment of
acute otitis
§ Tympanoplasty,
ossiculoplasty, or
mastoidectomy
Middle Ear Surgical Procedures
• Tympanoplasty

• Reconstruction of the tympanic

membrane

• Ossiculoplasty

• Reconstruction of the bones of the

middle ear

• Prostheses are used to reconnect

the ossicles to reestablish sound
conduction
Middle Ear Surgical Procedures

• Mastoidectomy
• Removal of diseased bone,
mastoid air cells, and
cholesteatoma to create a
non-infected, healthy ear
• Cholesteatoma
OTOSCLEROSIS
• Formation of new spongy
bone in the labyrinth of the
ear causing fixation of the
stapes in the oval window

• Prevents transmission of
auditory vibration to the inner
ear
 Pathophysiology

Decreased Diminished
vibration of transmission of
stapes sound to inner ear
Assessment Findings
• Progressive, bilateral hearing
loss
• Nighttime tinnitus
• Pinkish orange eardrum
 Diagnostic Test
• Audiometry
• Reveals conductive hearing loss

• Weber’s and Rinne’s test

• Show bone conduction is greater than
air conduction
Stapedectomy for Otosclerosis

q removal of diseased portion of

stapes and replacement with a
prosthesis to conduct vibrations from
the middle ear to inner ear
q Usually performed under local
anesthesia
Nursing Intervention
• Preoperative
• Provide general pre-
operative nursing care,
including an explanation of
post-op expectations
• Explain to the client that
hearing may improve
during surgery and then
decrease due to edema
and packing.
• Postoperative
• Position the client according
to the surgeon’s orders
• Possibly with operative
ear uppermost to prevent
displacement of the graft)
• Postoperative
• Have client deep breathe
every 2 hrs while in bed, but
no coughing
• Elevate side rails; assist the
client with ambulation and
move slowly (may have some
vertigo)
• Administer medications as
ordered: analgesics, antibiotics,
antiemetics, anti-motion-sickness
drugs.

• Check dressings frequently for

excessive drainage or bleeding

• Assess facial nerve function,i.e.,

wrinkling forehead, closing
eyelids, puffing out cheeks; check
for asymmetry.
• Question client about pain,
headache, vertigo, and unusual
sensations in the ear; report
existence to physician

• Provide client teaching and

discharge planning
• Warnings against blowing nose
or coughing; sneeze with
mouth open
• Need to keep ear dry in the
shower; no shampooing until
allowed

• No flying for 6 months; esp if

with URTI

• Placement of cotton ball in

auditory meatus after packing
is removed; change twice a
day.
Nursing Process—Assessment of the Patient
Undergoing Mastoid Surgery

• Health history

• Include data related to the

ear disorder, hearing loss,
otalgia, otorrhea, and vertigo

• Medications
Nursing Process—Diagnosis of the Patient
Undergoing Mastoid Surgery
• Anxiety
• Acute pain
• Risk for infection
• Disturbed auditory sensory perception
• Risk for trauma related to imbalance or
vertigo
• Disturbed sensory perception related to
damage to facial nerve
• Impaired skin integrity
• Deficient knowledge
Nursing Process—Planning the Care of the
Patient Undergoing Mastoid Surgery
• Major goals include:
• Reduction of anxiety
• Freedom from pain and
discomfort
• Prevention of infection
• Stable or improved
hearing and
communication
Nursing Process—Planning the Care of the
Patient Undergoing Mastoid Surgery
• Major goals include:
• Absence of vertigo and injury
• Absence of or adjustment to
altered sensory perception, return
of skin integrity
• Increased knowledge of disease
• Surgical procedure and
postoperative care
 Interventions
• Reduce anxiety
• Reinforce information and
patient teaching
• Provide support and allow
patient to discuss anxieties
 Interventions
• Relieve pain

• Medicate with analgesics for ear

discomfort
• Occasional sharp, shooting
pains
• occur as the eustachian tube
opens and allows air into the
middle ear; constant throbbing
pain and fever may indicate
infection
Interventions (cont.)
• Prevent injury
• Implement safety measures
such as assisting with
ambulation

• Provide antiemetics or
antivertigo medications
Interventions (cont.)
• Improve communication and
hearing
• Hearing may be reduced for
several weeks following surgery
due to edema, accumulation of
blood and fluid in the middle ear,
and dressings and packings

• Use measures to improve

hearing and communication as
discussed in “Communicating
With the Hearing Impaired”
 Interventions
• Preventing infection

• Monitor for signs and symptoms

of infection

• Administer antibiotics as
ordered

• Prevent contamination of ear

with water from showers,
washing hair, etc.
 Patient Teaching
• Medications teaching; analgesics and
antivertigo medications

• Activity restrictions

• Gently blow nose on only one side at a

time; sneeze and cough with mouth open

• Patient may need instruction to avoid

heavy lifting, exertion, and nose blowing
to prevent dislodgement of grafts or
prostheses
 Patient Teaching
• Safety issues related to potential
vertigo

• Instruction regarding potential

complications and reporting of
problems

• Avoid getting water in ear

• Follow-up care
INNER EAR CONDITIONS
• Disorders of the vestibular
system affect more than 30
million in the U.S.; falls
resulting from these disorders
result in 100,000 hip fractures a
year

• Dizziness: any altered sense of

orientation in space
• Vertigo: the illusion of motion or
a spinning sensation

• Nystagmus: involuntary
rhythmic movement of the eyes
associated with vestibular
dysfunction
MENIERE’S DISEASE
Ménière’s Disease

• Abnormal inner ear fluid

balance caused by
malabsorption of the
endolymphatic sac or
blockage of the
endolymphatic duct
• Also known as idiopathic
endolymphatic hydrops

• Dramatic variability is the

hall mark of the disease
Incidence
• Highest between ages 30 and
60
Cause
• Unknown
• Allergy
• Toxicity
• Localized ischemia
• Hemorrhage
• Viral infection
• edema
• obstruction of endolymphatic
outflow at the endolymphatic
duct level

• increased production of
endolymph

• reduced absorption of
endolymph caused by a
dysfunctional endolymphatic
sac
 Assesment Findings
• Progressive triad of symptoms

• fluctuating, progressive hearing loss;

• tinnitus;

• episodic, incapacitating vertigo that

may be accompanied by nausea and
vomiting

• Lasting hours or days/attacks occur

several times a year

• feeling of pressure or fullness

DIAGNOSTIC TESTS
• Audiometry
• Reveals
sensorineural hearing
loss

• Vestibular tests
• Reveal decreased
function
• Weber test
• Sound from a tuning
fork (may lateralize
to the ear opposite
the hearing loss, the
one affected with
meniere’s disease)
 Ménière’s Disease

• Treatment
• Low-sodium diet,
2000 mg a day:
Pharmacologic Therapy
• Antihistamine meclizane
(Antivert)
• Suppreses the vestibular
system
• Tranquilizer (Diazepam) Valium
• Used in acute instances to
help control vertigo
Pharmacologic Therapy
• Antiemetic(Promethazine
/ Phenergan)

• Suppositiories help
control n/v and vertigo
because of
antihistamine effect
• Diuretic Therapy)
Hydrochlorothiazide

• Reduce symptoms by
lowering the pressure in
the endolymphatic
system
• Surgical Treatment
• Surgical management to eliminate attacks
of vertigo
• endolymphatic sac decompression
• middle and inner ear perfusion
• vestibular nerve sectioning
• process of cutting the vestibular part
of the cochleovestibular cranial nerve
• Endolymphatic sac decompression(shunting)
• Equalizes the pressure in the endolymphatic
space
• A shunt or drain is inserted in the
endolymphatic sac through a postauricular
incision
• Middle ear perfusion
• Ototoxic medication
(Streptomycin or
Gentamicin) can be
given to pt by infusion
into the middle and inner
ear
• Meds to decrease
vestibular function and
decrease vertigo
Nursing Intervention
• Maintain bed rest in a quiet,
darkened room in position of
choice, elevate side rails as
needed

• Only move the client for

essential case
• (bath may not be essential)

• Provide an emesis basin for

vomiting
• Monitor IV therapy; maintain accurate I &
O

• Assist with ambulation when the attack is

over

• Administer medications as ordered

• Prepare the client for surgery as indicated

• Post op care includes using above
measures
• Provide client teaching and
discharge planning concerning
• Use of medication and side
effects
• Low sodium diet and decreased
fluid intake
• Importance of eliminating
smoking
• END-

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