Anatomy and Physiology

 EXTERNAL EAR
• Auricle
• Tympanic membrane
 
 MIDDLE EAR
• Ossicles
• Eustachian tube
 
 INNER EAR
• Semilunar canals
• Cochlea
FUNCTIONS OF THE EAR

HEARING

BALANCE
 HEARING
8th CRANIAL NERVE

1. COCHLEAR BRANCH
- transmits neuro-impulses from the cochlea to the brain
where it is interpreted as sound

2. VESTIBULAR BRANCH
- maintains balance & equilibrium
Anatomy of the Inner Ear
 ASSESSMENT OF THE EAR

OTOSCOPIC EXAM
- visualize the external canal while slowly inserting the speculum

VOICE TEST
• Ask the client to block one external canal
• The examiner stands 1-2 ft away & quickly whispers a statement
• The client is asked to repeat the whispered statement
• Each ear is tested separately

WATCH TEST
• A ticking watch is used to test the high-frequency sounds
• The examiner holds a ticking watch about 5 inches from each
ear & asks the client if the ticking is heard
 ASSESSMENT OF THE EAR
TUNING FORK TESTS
A. WEBER TUNING FORK TEST
• Normal result: hearing the sound equally in both ears

FINDINGS
• If the client hears the sound louder in 1 ear,
- (+) LATERALIZATION is present
where the sound is heard the loudest
INTERPRETATION
• The finding may indicate the client has CONDUCTIVE
HEARING LOSS in the ear to which the ear is lateralized
• The finding may indicate that there is a SENSORINEURAL
HEARING LOSS in the opposite ear
WEBER TEST- is a quick screening test for hearing. It
can detect unilateral (one-sided) conductive hearing loss
and unilateral sensorineural hearing loss. The test is named
after Ernst Heinrich Weber
Normal:
Sound heard equally

 CONDUCTIVE:
→ Louder

 SENSORINEURAL:
→ Opposite
 ASSESSMENT OF THE EAR
TUNING FORK TESTS
B. RINNE TUNING FORK TEST
• Compares the client’s hearing by air conduction & bone conduction
• AIR CONDUCTION is 2-3X longer than BONE CONDUCTION

• NORMAL RESULT: (+) RINNE TEST

- the client normally continues to hear the sound
2x louder in front of the pinna
• The examiner records the duration of both phases, bone conduction
followed by air conduction and compares the times
 A Rinne test should always be accompanied by a
Weber test to also detect sensorineural hearing loss and
thus confirm the nature of hearing loss. The Rinne test was
named after German otologist Heinrich Adolf Rinne

Normal:
Sound heard in front of
pinna

Findings:
(+) Rinne test →
Normal
(-) Rinne test →
Conductive
• Otoscope • Weber test
Rinne Test
 VESTIBULAR ASSESSMENT OF
THE EAR
TEST FOR FALLING
• The examiner asks the client to stand with the feet together &
arms hanging loosely at the sides & eyes closed
• The client normally remains erect with slight swaying

TEST FOR PAST POINTING

• NORMAL TEST RESPONSE:
- The client can easily return to the point of reference
 VESTIBULAR ASSESSMENT OF
THE EAR
GAZE NYSTAGMUS EVALUATION
• Examine the client’s eyes as they look straight ahead, 30
degrees to each side, upward & downward

HALLPIKE MANEUVER
• Assesses for positional vertigo or induced dizziness
• The client assumes a supine position
• The head is rotated to one side for 1 minute
DIAGNOSTIC TESTS FOR THE EAR
TOMOGRAPHY
- may be performed with or without contract medium
- assesses the mastoid, middle ear & inner ear structures
- multiple x-rays of the head are done

ELECTRONYSTAGMOGRAPHY
- records changing electrical fields with movement of
the eye, as monitored by electrodes placed on the
skin around the eye

AUDIOMETRY
- measures hearing acuity
- uses 2 types: PURE TONE AUDIOMETRY & SPEECH AUDIOMETRY
- after testing, audiogram patterns are depicted on a graph to determine
the type & level of hearing loss
DISORDERS
OF THE EAR
Risk factors of ear
disorders

 AGING PROCESS
 INFECTION
 MEDICATIONS
 OTOTOXICITY
 TRAUMA
 TUMORS
 ASSESSMENT OF THE EAR
CONDUCTIVE HEARING LOSS
- due to any physical obstruction to the transmission of sound
waves

SENSORINEURAL HEARING LOSS

- due to a defect in the organ of hearing, in the 8th cranial
nerve, or in the brain itself

MIXED CONDUCTIVE, SENSORINEURAL

HEARING LOSS
- results in profound hearing loss
 CONDUCTIVE HEARING LOSS
- sound waves are blocked to the inner ear fibers
because of external ear or middle ear disorders
- disorders can often be corrected with no damage to hearing, or
minimal permanent hearing loss

CAUSES
 Any inflammatory process or obstruction of the external or middle
ear
 Tumors
 Otosclerosis
 A build-up of scar tissue on the ossicles from previous middle ear
surgery
SENSORINEURAL HEARING LOSS
- a pathological process of the inner ear or of sensory fibers that
lead to the cerebral cortex
- often permanent
- reduce further damage
- attempt to amplify sound as a means of improving hearing

CAUSES
 Damage to the inner ear structures and nerves
 Prolonged exposure to loud noise
 Medications, trauma, infections, surgery
 Inherited disorders
 Metabolic & circulatory disorders
 Meniere’s syndrome
 Diabetes mellitus
 Myxedema
 MIXED HEARING LOSS
- also known as conductive-sensorineural hearing loss

SIGNS OF HEARING LOSS

 Frequently asking people to repeat statements
 Straining to hear
 Turning head or leaning forward to favor one ear
 Shouting in conversations
 Ringing in the ears
 Failing to respond when not looking in the direction of the
sound
 Answering questions incorrectly
 Raising the volume of the television or radio
 Avoiding large groups
 Better understanding of speech when in small groups
 Withdrawing from social interactions
HEARING AIDS
- used for the client with conductive hearing
loss
- can help the client with sensorineural loss,
although it is not as effective
- a difficulty that exists in its use is the
amplification of background noise as well
as voices
COCHLEAR IMPLANTATION

- used for sensorineural hearing loss

- a small computer converts sound waves into
electrical impulses
- electrodes are placed by the internal ear with
a computer device attached to the external
ear
- electronic impulses directly stimulate nerve
fibers
Cochlear implant
 PRESBYCUSIS
- leads to degeneration or atrophy of the ganglionic cells in
the cochlea & a loss of elasticity of the basilar membranes

- leads to compromise of the vascular supply to the inner ear

with changes in several areas of the ear structure

ASSESSMENT
gradual & bilateral
no problem with hearing but can’t
understand what the words are
speaker is mumbling
 EXTERNAL OTITIS
- an irritating or infective agent comes into contact with
epithelial layer of the external ear
- this leads to either an allergic response or S/S of infection
- the skin becomes red, swollen, & tender to touch on
movement
- the excessive swelling of the canal lead to conductive
hearing loss
- due to obstruction
- more common in children
- occurs more often in hot, humid environments
- prevention includes the elimination of irritating or infecting agents
EXTERNAL OTITIS
ASSESSMENT
 Pain
 Itching
 Plugged feeling in the ear
 Redness & edema
 Exudate
 Hearing loss
Otitis Externa
 EXTERNAL OTITIS
NURSING CARE
• local heat application
• Encourage rest
• Administer analgesics such as aspirin or acetaminophen (Tylenol) for
the pain as prescribed
• Instruct the client that
• the ears should be kept clean & dry
•use earplugs for swimming
•cotton-tipped applicators should not be used to dry ear because
their use can lead to trauma to the canal
• irritating agents such as hair products or
headphones should be discontinued
 OTITIS MEDIA
-a result of a blocked eustachian tube
- a common complication of an ARI
- infants & children are more prone

ASSESSMENT
 Fever
 Irritability, restlessness & loss of appetite
Rolling of head from side to side
 Pulling on or rubbing the ear
 Earache or pain
 Signs of hearing loss
 Purulent ear drainage
 Red, opaque, bulging or retracting tympanic membrane
 
NURSING CARE
• Encourage oral fluids

• feed infants in an upright position

• avoid chewing during the acute period

• local heat

• appropriate procedure to clean drainage from the

ear with sterile cotton swabs

• analgesics or antipyretics such as

Acetaminophen (Tylenol) to decrease fever & pain

• administration of prescribed antibiotics

• screening for hearing loss may be necessary

• ear drops
 MYRINGOTOM
Y
- insertion of tympanoplasty tubes in the middle ear to
equalize pressure & keep the ears dry

POST-OP NURSING CARE

• Instruct the parents & child to keep the ears dry
• Earplugs should be worn during bathing, shampooing &
swimming
• Diving & submerging under water are not allowed
 Client education post myringotomy
 Avoid
strenuous exercise
rapid head movements, bouncing or bending
straining on bowel movement
drinking through a straw
traveling by air
forceful coughing
contact with persons with colds
washing hair, showering or getting the head wet for a week
 Instruct
blow one side at a time with wide mouth open
keep ears dry by keeping a ball of cotton coated
with petroleum jelly in the ear & to change cotton ball daily
report excessive ear drainage to the physician
 CHRONIC OTITIS
MEDIA
- a chronic infective, inflammatory, or allergic response
involving the structure of the middle ear
- surgical treatment is necessary to restore hearing

- the type of surgery can vary & include a simple

reconstruction of the tympanic membrane, a myringotomy, or
replacement of the ossicles within the middle ear

TYMPANOPLASTY

- a reconstruction of the middle ear may be attempted to

improve conductive hearing loss
 MASTOIDITIS

- may be acute or chronic & results from untreated or inadequately

treated chronic or acute otitis media
- the pain is not relieved by myringotomy

ASSESSMENT
 Swelling behind the ear & pain with minimal movement of the head
 Cellulitis on the skin or external scalp over the mastoid process
 A reddened, dull, thick, immobile tympanic membrane with or without
perforation
 Tender & enlarged post-auricular lymph nodes
 Low-grade fever
 Anorexia
 MASTOIDITIS
PRE-OP NURSING CARE
• Prepare the client for surgical removal of the infected
material
• Monitor for complications
• SIMLPLE OR MODIFIED RADICAL MASTOIDECTOMY
WITH TYMPANOPLASTY is the common treatment
• Once tissue that is infected is removed, tympanoplasty is
performed to reconstruct the ossicles & the tympanic
membranes, in an attempt to restore normal hearing
 MASTOIDITIS
COMPLICATIONS
 Damage to the abducens & facial cranial nerves
 Damage exhibited by inability to look laterally (cranial nerve
VI) & a drooping of the mouth on the affected side (cranial
nerve VII)
 Meningitis
 Chronic purulent otitis media
 Wound infections
 Vertigo, if the infection spreads into the labyrinth
 OTOSCLEROSIS

- bony overgrowth of the tissue surrounding the ossicles

- causes the dev’t of irregular areas of new bone formation & causes
fixation of the bones
- stapes fixation leads to CONDUCTIVE HEARING LOSS
- if the disease involves the inner ear, SENSORINEURAL HEARING
LOSS is present
- common to have bilateral involvement, although hearing loss
may be worse in one ear
- cause is unknown, although has familial tendency
- nonsurgical intervention promotes the improvement of hearing through
amplification
- a PARTIAL STAPEDECTOMY or COMPLETE STAPEDECTOMY
WITH PROSTHESIS (FENESTRATION) may be surgically performed
 OTOSCLEROSIS

ASSESSMENT
 Slowly progressing conductive hearing loss
 Bilateral hearing loss
 A ringing or roaring type of constant tinnitus
 Loud sounds heard in the ear when chewing
 Pinkish discoloration (SCHWARTZE’S SIGN) of the tympanic
membrane
- indicates vascular changes in the ear
 (-) Rinne test
 Weber test shows lateralization of the sound to the ear with
the most conductive hearing loss
Stapedectomy for Otosclerosis
FENESTRATION
- removal of the stapes with a small hole drilled in
the footplate & a prosthesis is connected
between the incus & footplate
- sounds cause the prosthesis to vibrate in the
same manner as the stapes

COMPLICATIONS
 Complete hearing loss
 Prolonged vertigo
 Infection
 Facial nerve damage
LABYRINTHITIS
- infection of the labyrinth that occurs as a
complication of acute or chronic otitis media

ASSESSMENT
 Hearing loss that may be permanent on the
affected side
 Tinnitus
 Spontaneous nystagmus to the affected side
 Vertigo
 Nausea & vomiting
 LABYRINTHITIS
PRE-OP NURSING CARE
• Monitor for signs of meningitis, the most common
complication
- evidenced by headache, stiff neck lethargy
• Administer systemic antibiotics as Rx
• Advise client to rest in bed in a darkened room
• Administer antiemetics & antivertiginous medications as Rx
• Instruct the client that the vertigo subsides as inflammation
resolves
• Instruct the client that balance problems that persist may
require gait training through physical therapy
MENIERE’S SYNDROME
- a syndrome also called ENDOLYMPHATIC
HYDROPS
- refers to dilation of the endolympathic system by either
overproduction or decreased reabsorption of endolymphatic
fluid
- characterized by tinnitus, unilateral sensorineural hearing loss,
& vertigo
- symptoms occur in attacks & last for several days, & the client
becomes totally incapacitated
- initial hearing loss is reversible, but as the frequency of attacks
continues, hearing loss becomes permanent
- repeated damage to the cochlea caused by increased fluid
pressure leads to the permanent hearing loss
MENIERE’S SYNDROME
CAUSES
 Any factor that increases endolymphatic secretion in
the labyrinth
 Viral & bacterial infections
 Allergic reactions
 Biochemical disturbances
 Vascular disturbances producing changes in the
microcirculation in the labyrinth
MENIERE’S SYNDROME
ASSESSMENT
 Feelings of fullness in the ear
 Tinnitus, as a continuous low-pitched roar or humming sound
- is present most of the time but worsens just before &
during severe attacks
 Hearing loss is worse during an attack
 Vertigo
- periods of whirling which might cause the client to fall to the
ground
- sometimes so intense that even when lying down, the client
holds the bed or ground in an attempt to prevent the whirling
 Nausea & vomiting
 Nystagmus
 Severe headaches
MENIERE’S SYNDROME
NON-SURGICAL MANAGEMENT
• Preventing injury during vertigo attacks
• Providing bed rest in a quiet environment
• Provide assistance while walking
• Instruct the client to move the head slowly
• Initiate Na & fluid restrictions as Rx
• Instruct to avoid smoking
• Administer
•Nicotinic acid (Niacin) as Rx
•antihistamines as Rx
•antiemetics as Rx
•tranquilizers & sedatives as Rx
MENIERE’S SYNDROME
SURGICAL MANAGEMENT
- performed when medical therapy is ineffective & the
functional level of the client has decreased significantly

• ENDOLYMPHATIC DRAINAGE
& INSERTION OF THE SHUNT
- may be performed early in the course of the disease to assist
with the drainage of excess fluids

• RESECTION OF THE VESTIBULAR NERVE

• LABYRINTHECTOMY
- removal of the labyrinth may be performed
 MENIERE’S
SYNDROME
POST-OP NURSING CARE
• Assess packing & dressing on the ear
• Speak to the client on the side of the unaffected ear
• Perform neurological assessments
• Maintain side rails
• Assist with ambulating
• Encourage the use of bedside commode
• Administer antivertiginous& antiemetic medications as Rx
 
- a benign tumor of the vestibular or acoustic nerve
- causes damage to hearing & to facial movements &
sensations
- treatment includes surgical removal of the tumor via
craniotomy
- care is taken to preserve the function of the facial nerve
- the tumor rarely recurs after surgical removal

ASSESSMENT
 Symptoms usually begin with tinnitus & progress to gradual
sensorineural hearing loss
 As tumors enlarges, damage to adjacent cranial nerves occurs
 
- foreign objects placed in the external canal may exert pressure
on the tympanic membrane & cause perforation
- if the object continues thorough the canal, the bony structures
of stapes, incus & malleus may be damaged
- a blunt injury to the basal skull & ear can damage the middle
ear structures through fractures extending to the middle ear
- excessive blowing & rapid changes of pressure that occur with
non-pressurized air flights can increase pressure in the middle
ear
- depending on the damage to the ossicles, hearing loss may or
may not return
 TRAUMA

NURSING CARE
• Tympanic perforations usually heal within 24 hours
• Surgical reconstruction of the ossicles & tympanic
membrane through tympanoplasty or myringotomy
may be performed to improve hearing
 CERUMEN &
FOREIGN BODIES
CERUMEN/EAR WAX
- the most common cause of impacted canals

FOREIGN BODIES
- can include vegetables, beads, pencil erasers & insects

ASSESSMENT
 Sensation of fullness in the ear with or without hearing loss
 Pain, itching or bleeding
 CERUMEN
NURSING CARE
• Removal of the wax by irrigation is a slow process
• Irrigation is C/I in clients with a hx of tympanic membrane
perforation
• To soften cerumen, add 3 gtts of glycerin to the ear @ hs
& 3 gtts of hydrogen peroxide BID
• After several days the ear is irrigated
• 50-70 ml of solution is the maximal amount a client can
tolerate during an irrigation sitting
 
NURSING CARE
• If the foreign matter is vegetable, irrigation is used with care
- the material expends with hydration
• Insects are killed before removal unless they can be coaxed
out by flashlight or a humming noise
• Mineral oil or alcohol is instilled to suffocate the insect which
is then removed with ear forceps
• Use small ear forceps to remove the object & avoid pushing
the object farther into the canal & damaging the tympanic
membrane
 OTIC
MEDICATIONS
 OTIC
OTIC MEDICATION
MEDICATION
ADMINISTRATION
ADMINISTRATION

ADMINISTERING EAR DROPS

ADULT
• Pull the pinna up & back to straighten the external canal to instill
ear drops

CHILD
• Pull the pinna down & back for infants & children younger than 3
years of age
• Pull the pinna up & back for children for children more than 3 years
IRRIGATION OF THE EAR
• Irrigation of the ear needs to be prescribed by MD
• Ensure that there is direct visualization of the tympanic membrane
• Warm irrigating solution to 100° F
- solutions not close to the client’s body temp will cause ear injury,
nausea & vertigo
• Irrigation must be done gently to avoid damage to the eardrum
• When irrigating, don’t direct irrigating solution directly toward the
eardrum
• If perforation of the eardrum is suspected, irrigation is not done
 MEDICATIONS
MEDICATIONSTHAT
THATAFFECT
AFFECTHEARING
HEARING

ANTIBIOTICS
• Amikacin (Amikin)
DIURETICS
• Chloramphenicol
• Acetazolamide (Diamox)
- Chloromycetin • Furosemide (Lasix)
- Chloroptic • Ethacrynic acid (Edecrine)
- Ophthoclor
• Erythromycin
- E-Mycin
- ERYC OTHERS
- Ery-Tab • Cisplatin (Platinol, Platinol-AQ)
- PCE Dispertabs • Nitrogen mustard
- Ilotycin • Quinine (Quinamn)
• Gentamicin (Garamycin) • Quinidine
• Streptomycin sulfate - Cardioquin
(Streptomycin) - Quinaglute
• Tobramycin sulfate (Nebcin) - Quindex
• Vancomycin (Vancocin)
 ANTI-INFECTIVE
ANTI-INFECTIVE
MEDICATIONS
MEDICATIONS
- Kill or inhibit the growth of bacteria
- Used for otitis media or otitis externa
- C/I if a prior hypersensitivity exists

SIDE EFFECTS
 Overgrowth of non-susceptible organisms

NURSING CARE
• Assess V/S
• Assess for allergies & pain
• Monitor for nephrotoxicity
• Instruct the client to report dizziness, fatigue, fever, or sore throat
- indicative of superimposed infection
• Instruct to complete the entire course of medication
• Instruct to keep the ear canals dry
ANTI-INFECTIVE
ANTI-INFECTIVE MEDICATIONS
MEDICATIONS
EXAMPLES
• Amoxicillin (Amoxil)
• Ampicillin trihydrate (Polycillin)
• Cefaclor (Ceclor)
• Clindamycin HCl (Cleocin)
• Trimethoprim (TMP) & Sulfamethaxazole (SMZ)
- Bactrim, Cotrim, Septra
• Erythromycin (Ilotycin, E-Mycin)
• Penicillin V potassium (Pen V)
• Loracarbef (Lorabid)
• Clarithromycin (Biaxin)
• Polymyxin B sulfate (Aerosporin)
• Tetracycline HCl (Achromycin)
• Acetic acid and Aluminum acetate (Otic Domeboro)
 ANTI-HISTAMINES
ANTI-HISTAMINES &
&
DECONGESTANTS
DECONGESTANTS
- Produce vasoconstriction
- Stimulate the receptors of the respiratory mucosa
- Reduce respiratory tissue hyperemia & edema to open obstructed
eustachian tubes
- Used for acute otitis media

SIDE EFFECTS
 Drowsiness
 Blurred vision
 Dry mucous membranes

NURSING CARE
• Inform the client that drowsiness, blurred vision, & dry mouth may occur
• Instruct the client to increase fluid intake unless C/I & to suck on hard
candy to alleviate dry mouth
• Instruct the client to avoid hazardous activities if drowsiness occurs
 EXAMPLES
• Tripolidine & pseudoephedrine (Actifed)

• Naphazoline HCl (Allerest, Albalon)

• Chlorpheniramine (Chlor-Trimeton, Teldrin)

• Brompheniramine (Bromphen, Dimetane)

• Terfenadine (Seldane)

• Clemastine (Tavist)

• Cetirizine (Zyrtec)

• Astemizole (Hismanal)
 LOCAL
LOCAL
ANESTHETICS
ANESTHETICS
- Block nerve conduction at or near the application site to control pain
- Used for pain associated with ear infections

MEDICATION : Benzocaine (Americaine Otic; Tympagesic)

SIDE EFFECTS
 Allergic reaction
 Irritation

NURSING CARE
• Monitor for effectiveness if used for pain relief
• Assess for irritation or allergic reaction
 

- Emulsify & loosen cerumen deposits
- Used to loosen & remove impacted ear wax from the ear canal

SIDE EFFECTS
 Irritation
 Redness or swelling of the ear canal

NURSING CARE
• Instruct the client not to use drops more often than prescribed
• Moisten a cotton plug with medication before insertion
• Keep the container tightly closed & away from moisture
• Avoid touching the ear with the dropper
• 30 minutes after installation, gently irrigate the ear as Rx with warm
water using a rubber bulb ear syringe
• Irrigation may be done with hydrogen peroxide sol’n as Rx
- to flush cerumen deposits out of the ear canal
• For chromic cerumen impaction, 1-2 gtts of mineral oil will soften the wax
• Instruct the client to notify MD if redness, pain or swelling persists
CERUMINOLYTIC
CERUMINOLYTIC
MEDICATIONS
MEDICATIONS
EXAMPLES
• Carbamide peroxide (Debrox)
• Boric acid (Ear-Dry)
• Trolamine polypeptide oleate-condensate
- Cerumenex