Sensory: Ears; Chapter 59 (Med-Surg Nursing) 

Susan Darby, RNC, MSN; Georgia College State University

Student Responsibility

·         Anatomic and physiologic overview (p.1790-1793).

·         Serous Otitis Media (p. 1802): Define middle ear effusion.

·         Labyrinthitis (p. 1808): Define disorder, explain how hearing is affected, and discuss medical management. 

Assessment: Inspection

1.       What size speculum do you use for the otoscope exam?

 

2.       For a child who is less than 3 years old, how do you grasp the auricle for an otoscopic exam?

 

3.       For an adult, how do you grasp the auricle for the otoscopic exam?

 

•      Otoscopic Exam: pars tensa, umbo, manubrium (handle), short process of malleus, and light reflex. 

1.       What color is a healthy tympanic membrane?

2.       How do you perform a whisper test? 

 

3.       How many inches from the ear should you hear a watch tick?

4.       What is the normal ratio for air to bone conduction for a Rinne test? 

Hearing loss

·         Most common disability in the U.S.

Sensorineural (perceptive) hearing loss

•      A form of hearing loss in which sound passes properly through the outer and middle ear but is distorted by a defect in the inner ear. Perceptive loss, usually progressive and bilateral. Damage to the cochlear or vestibulocochlear nerve (CN VIII).

•      You are performing a Weber test on a client with a sensorineural hearing loss in the right ear. Which ear would hear sound better?            

•      Etiology: Infections, ototoxic drugs, trauma, neuromas (tumor), noise, and aging process.

•      Clinical manifestations:  Difficulty distinguishing high-pitched sounds. Hearing aids have limited use for these clients because they can make sound louder but not necessary clearer.

Conductive hearing loss

·         Impairment of outer or middle ear or both. Hearing loss in which sound does not travel well to the sound organs of the inner ear. The volume of sound is less, but the sound remains clear. If the volume is raised, hearing is normal. A hearing aid may be helpful.

·         Etiology: Fluid or cerumen in the external canal. Otosclerosis (hardening) of the bones of the middle ear. Otitis media.

·         You are performing a Weber test on a client with a conductive hearing loss in the right ear. Which ear would hear sound better?

Functional (Psychogenic) hearing loss:

·         Usually a symptom of an emotional disturbance and unrelated to evident structural changes in the hearing mechanisms. Loss is often total, but without physical basis; the patient may suddenly recover.

Matching

a.       Sensorineural	Emotional disturbance resulting in a functional hearing loss. ___
b.       Conductive	Presence of fluid and cerumen in the external canal. ___
a.       Psychogenic	Damage to the cochlear or vestibulocochlear nerve. ___
	Sclerosis of the bones of the middle ear. ___

Clinical Manifestations:

·         Socially withdrawn:  Not being able to hear what is going on causes the hearing-impaired person to withdraw from situations that might prove embarrassing.

·         Suspiciousness: Often hears only part of what is being said, may suspect that others are talking about him or her.

·         Generally speaks both in loudness and pronunciation. Reluctant to ask for repeated statements and pretends to hear. Lose the ability to communicate. Changes in the awareness of environment and ability to protect oneself.

Which patient would you suspect may have a hearing impairment and loss?

a.       Mr. Ottenheimer who speaks very softly.

b.       Ms. Kelley who frequently asks for statements to be repeated.

c.       Mr. Flowers who asks a lot of questions.

d.       Ms. Brown who is very suspicious.

Gerontological Considerations 

·         A hearing loss occurs in about 25% of those between the ages of 65 and 75.

·         Atrophy (wasting) of the tympanic membrane. Increased hardness of the cerumen. Degeneration of cells at the base of the cochlea (the organ of hearing). 

·         The physician tells Mr. Brown that he has presbycusis. Mr. Brown asks, “What does this mean?” How would you respond?

 

·         Presbycusis: Hearing aids usually unnecessary and may confuse and upset the patient. Should be advised by an ear specialist (otologist) in collaboration with an audiology specialist (audiologist). Consider:  Phone amplifiers, TV and radio ear attachments. Buzzers instead of doorbells.

Match the hearing loss with the hearing aid

a.       Sensorineural	Not required. ___
b.       Conductive	Makes sounds louder but not clearer. ___
Psychogenic	May be helpful. ___
d.       Presbycusis	Unnecessary and may confuse and upset the patient. ___

Audiometry:

·         Pressure exerted by sound in decibels (dB). The critical level of loudness that most people (without a hearing loss) are comfortable with is 30 dB. Low conversation is 40 dB.

Severity of Hearing Loss: 

·         0-15 = normal hearing. 15-25= slight. 25-40= mild. 40-55= moderate. 55-70= moderate to severe. 70-90= severe. >90= profound.

·         You are the nurse responsible for reviewing audiometry test results. How would you interpret the following findings?

o     Mr. Brown’s hearing loss is in dB of 40.

o     Ms. Hogan’s hearing loss is in dB of 12. 

Nursing Diagnosis

·         Sensory/perceptual alterations (auditory) RT; Impaired communication RT

Communicating

·         Prior to starting conversation, reduce distraction as much as possible. Name 3 examples:

a.

b.

c.

·         Stand in front of the client with the light source behind the client. Keep conversation short and direct – touch is important. Speak in a low-pitched voice, slowly, and distinctly. Do not shout. Use pencil and paper, boards, etc. If the client is a lip reader, face them directly. Do not obscure view of mouth (chew gum).

Prevention

·         Be aware of occupational hearing loss in industry. Wear protective earplugs and/or earmuffs where the noise level exceeds 80-85 db. Prevent excessive environmental noise levels in all settings.  Very loud electrical music can damage hearing. Persons of all ages should have periodic ear exams especially in school programs. Early detections can be followed up for treatment. Greater than 90 dB: Flushed skin. Stomach muscles constrict. Short tempers: In the hospital, patients are happier and less upset and anxious when noise is kept to a minimum.

Cerumen impaction

·         Mr. Brown is complaining of hearing loss and a sensation of fullness in both ears or pain in the ear (otalgia). What is the most common cause of hearing loss in older adults?

 

·         What is the best method to remove cerumen from Mr. Brown’s ears?

 

·         Does not need to be removed unless it becomes impacted and interferes with hearing. Nursing Alert:  Draining ears or perforation history – check with MD first.

·         After explaining the procedure to Mr. Brown, how would you position him?

 

·         Position protective toweling.

·         What type of irrigation solution should you use?

 

·         What temperature should the solution be?

 

·         Place emesis basin close to the patient’s head and under the ear. Adult: Up and back; Child: Down and back. Rationale: To straighten ear canal.

·         Where would you direct the stream?

 

 

·         If pain or dizziness occurs, discontinue treatment.  If an irrigating does not dislodge the wax, instill several drops of Debrox or NA HCO3 solution 2-3 times per day for 2-3 days.

·         Document: Time of irrigation. Kind and amount of solution used. Effect of treatment.

Foreign Bodies

•      Inserted by young or handicapped children. Insects: Instill oil drops to smother insect, which will then float out. Vegetable foreign bodies (peas): No irrigation because vegetable matter absorbs water, which could further wedge it in ear canal. Removal should be done by skilled person with instruments. For young children, general anesthesia is required.

•      The physician writes in Nancy’s chart that she has otalgia. What does this mean?

 

External otitis (otitis externa)

•             Maria is diagnosed with External Otitis (otitis externa). This is an infection of the ________ ear canal. May occur 2-3 days after swimming and diving (swimmer’s ear). Bacteria: Staphylococcus aureus. Pseudomonas. Fungus: Aspergillus. Name 4 clinical manifestations that Maria would have with otitis externa?

1.

·         Persistent, may awaken patient at night.

2.

·         Present on palpation of auricle. Medical Management: Prescription analgesics for 48 to 92 hours. Heat.

3.

·         Treatment: cortiocosteroid

4.

·         Treatment: Culture (antibiotic or antifungal).

·         Systemic symptoms absent.

·         Nursing management:  Do not use Q-tips. Cerumen may be forced against tympanic membrane. The canal lining may be roughen (abraded), making it more susceptible to infection. Cerumen that coats and protects the canal may be removed. Cleanse ear only with a wet washcloth over the tip of the finger. Avoidance of swimming. Do not allow water to enter the ear when shampooing or showering.

Exostoses

•      The surgeon will be removing exostoses from Tammy’s ears. What are exostoses?

 

•      Treatment:

Tympanic Membrane Perforation: Etiology

•      Infection (most frequent cause due to acute or otitis media). Trauma (next cause): Severe blow on the ear. Blast effect of high explosives. Foreign objects (bobby pins, matches, toothpicks, etc.). Force of a stream of water. Burns of face and head.

•      Surgical Management:  Most accidental perforations of the eardrum heal spontaneously. Tympanoplasty: Surgical repair of the ear drum.

Acute Otitis Media (AOM)

•      Acute infection of the ______ ear.

•      Caused by:  Streptococcus pneumoniae. Heamophilus influenzae. Moraxella catarrhalis.

•      Prevention: During acute Upper Respiratory Infection (URI), the nose should not be blown hard or blown with the mouth and nostrils closed. Rationale: Excessive pressure forces contaminated material back up into the middle ear. Occurs more often in children than adults because the child’s eustachian tube is more horizontal than the adults. Children should receive prompt medical attention when an URI develops or symptoms of an ear infection occurs.

•      Bobby is a 3 year old who comes to the clinic with a complaint of an earache. Name 7 symptoms that you will see in AOM.

1.        

·         Relieved if tympanic membrane ruptures. Assessment:  Examine the good ear first. Rate pain on a scale of 1 to 10.

2.        

·         A feeling that the environment is in motion. Move from one position to another slowly in order not to aggravate.

3.        

4.        

5.        

6.        

·         Fever caused by a virus (104-105 degrees). URI. Rhinitis (inflammation of the nasal mucosa). 

7.        

·         Anorexia. Nausea and vomiting.

·         Diagnostic Evaluation: Erythema, bulging, may be perforated. Otorrhea: Present if tympanic membrane ruptures; discharge is profuse. Culture of drainage may suggest causative organism.

What is the treatment for AOM (name 5)?

1.        

·         Promotes comfort and drainage.

2.        

·         Sedation avoided because it may interfere with early detection of intracranial complications.

3.

·         If the patient is allergic to PCN, E-mycin may be substituted.

·         Bobby’s mother, Sue, tells you, “Bobby was feeling better after a few days so I stopped giving him his antibiotics.” How would you respond?

 

4.

·         Instruct patient to try and to exhale forcefully while holding his nose and mouth tightly – this forces air along the auditory canal into middle ear. When successful, the patient will experience a “pop” and an immediate improvement. Perform 10-12 times a day.

5.

·         If the physician had to perform a tympanotomy or myringotomy, how would you explain this procedure to Bobby’s parents?

 

Purpose of tympanotomy or myringotomy:

•     Drain purulent (containing pus) fluid. Identify the infecting organism. Relieve tympanic membrane pressure. May be done because:  Failure to respond to antibiotics. Severe persistent pain. Conductive hearing loss.

•     Nursing alert:  Healing may take place, but the patient may be left with a residual deafness.

•     Secondary complications:  May involve the mastoid OR brain producing meningitis or brain abscess.

•     Pre and Postoperative care: Do not touch ear or drainage because it is infectious. Protect skin near draining orifice with petrolatum. Observe drainage and vital signs for possible evidence of bleeding. Avoid swimming, shampooing hair, and showering until tympanic membrane heals. To prevent reinfection no Q tips or ear picking to relieve itch.

Chronic Otitits Media (COM)

•           Repeated bouts of OM that cause inflammation May lead to perforation of the eardrum. Often begins in childhood into adult.

•           Etiology: A strain of organism that is resistant to the antibiotic used. A particularly virulent (infectious) strain of organism.

•           Clinical manifestations: Mild hearing loss. Foul smelling discharge (otorrhea). Pain frequently means a CNS complication has occurred. 

•           Medical Management: Antibiotics (infection). Steroid ear drops (control infection and inflammation). Analgesia. Frequent removal of debris and drainage.  If advanced chronic ear disease is left untreated, inner ear and life threatening CNS complications may develop because of erosion of surrounding structures.

•           Pre-operative Nursing Interventions:  Shaving depends on nature of the incision. Incision behind the ear (postaural) clip hair and shave scalp for 3-4 cm around ear (only if desired by surgeon). Incision through the ear canal (endaural) – shave is unnecessary.

Case Study

1.       Sam, a 26-year old client who has a history of COM and comes to the clinic with complaints of ear pain. What would you include in your assessment?

 

2.       The physician orders steroid eardrops. What is the best technique to evaluate Sam’s ability to administer the eardrops correctly (e.g., observe, verbal, read pamphlet)? 

3.       What is the most common surgical intervention for COM? _____________: Surgical reconstruction of the tympanic membrane is done to reestablish middle ear function, close perforations, and prevent recurrent infection.

·         Ossiculoplasty:  Surgical reconstruction of the middle ear bones to restore hearing. Prostheses are used to reconnect the ossicles (malleus, incus, and stapes) thereby reestablishing the sound conduction mechanism.

·         Mastoidectomy: Performed to remove a cholesteatoma (a cyst like mass that can occur in the middle ear secondary to infection). Not as common as tympanoplasty. Simple: Removal of mastoid cells. Indicated when there is persistent tenderness, fever, discharge from ear, or headache. Radical: Removal of all diseased tissue from mastoid area and middle ear.

1.       Sam is scheduled to have a mastoidectomy, and he is asking you what the surgical procedure involves. How should you begin your conversation?

 

2.       Name 4 symptoms of facial paralysis (CN VII) that you need to monitor Sam for after mastoidectomy?

a.

b.

c.

d.

 

·         Post-operative Nursing Interventions: Cortisone preparation (assist in restoration of nerve function). Analgesia (pain and restlessness). It is common for the patient to experience a sense of ear fullness or pressure.  Other complications:  Observe for infection and purulent discharge.  Antibiotics. Postauricular incision should be kept dry for 2 days. 

·         Following radical mastoidectomy: The semicircular canals (senses movement and maintains balance) are manipulated.  Results in vertigo.

·         Spread of infection to brain: Unusually high temperature. Chills. Stiff neck. Nausea and vomiting. 

·         Note: Status of hearing:  If stapes (pronounced STAY-PEAZ) has been removed or dislodged, then hearing is lost. If stapes or cochlea have not been removed or disturbed, then hearing is regained; a hearing aid may be required.

·         Advised that it is normal to hear popping and crackling sounds in the affected ear for about 3 to 5 weeks.

·         Prevent 2 activities that increases ICP:

1.

2.

Otosclerosis

•      Debra, 30 years old age, mother of one, has had a progressive hearing loss for two years. The physician tells her that she otosclerosis. What does this mean?

 

Normal ear

•      Sounds waves vibrate the tympanic membrane and set the bones of the middle ear in motion (malleus, incus, and stapes).

Otosclerosis

•      Formation of new, abnormal spongy bone, especially around the oval window (base of the stapes). Malleus and incus are moving normally, but the stapes is motionless or “fixed.” Prevents sound transmission through the ossicles to the inner fluids. Cause unknown.

•      Clinical Manifestations: Presents with history of slow, progressive hearing loss without middle ear infection. A frequent complaint is buzzing or ringing noises in both ears.

•      Medical Management: No known medical treatment for this form of deafness, but amplification with a hearing aid may be helpful. Surgery. 

•      Preoperative: Observe for unusual symptoms:  Fever: infection, external otitis, and otitis media. Headache: infection. Vertigo: inner ear reaction. Ear pain: infection or irritation of auditory nerve.

•      Stapedectomy:  Removal of otosclerotic lesions at footplate of stapes and creation of tissue implant with prosthesis to maintain suitable conduction.  To perform delicate surgery, the otologic binocular microscope is used.

•      Post-operative: Position patient as desired by MD preference. Ear uppermost to maintain position of graft and stability. Lying on operated ear to permit drainage. Assume the most comfortable position.

•      Health education:  May be weeks before full effect of surgery is determined as far as hearing is concerned. At first, hearing may be impaired because of tissue edema, packing etc.

•      Debra is admitted for a stapectomy. Name 4 teaching points that you would include in your health education postoperatively?

1.

 

2.

 

3.

 

4.

 

Conditions of the inner ear

·         Disorders of the vestibular system or acoustic nerve (CN VIII). Falls secondary to these disorders account for more than 100,000 hip fractures in elderly people each year.

·         Mr. Saunders has a disorder of the vestibular branch of the acoustic nerve (CN VIII) name four clinical manifestations that he may experience? Remember: VANN

1.

·         Dizziness is the altered sensation of orientation in space. May be associated with inner ear disturbances. Management: Dramamine  (antihistamine).  Scopolamine (anticholingeric).

2.

·         Failure of muscular coordination.

3.

·         Involuntary rhythmic eye movement. Name 2 examples:

a.

b.

 

4.

·         Name 4 examples.

a.

b.

c.

d.

Meniere’s Disease (Endolymphatic Hydrops)

·         Stem’s from dysfunction of the labyrinth (inner ear). 

·         Case Study: David is a 40-year-old lawyer who travels internationally. He has recently been diagnosed with Meniere’s disease. Before an attack, what typical symptom would David experience?

 

•             What are the three classic triad of symptoms associated with this disease?

1.

•             Most common symptom.

2.

•             Subjective perception of sound with internal origin.

3.

·         Clinical signs: Nausea and vomiting (due to vertigo). Incoordination.

·         Since the danger of a serious fall is real, what immediate action should David take when experiencing vertigo?

 

·         Darken and quiet room. Avoid sudden position changes. Vertigo attacks last several hours or all day. Client may curtail social activities out of fear of embarrassment from having a dizzy spell in public.

·         Nursing Diagnosis: Risk for injury RT vertigo; Social isolation related to attacks of vertigo and hearing loss.

·         Pathophysiology: An over-abundance of circulating fluid causes the triad of symptoms.

·         Theories:  Increase in pressure of lymph. Emotional or endocrine disturbance.  Vasomotor changes (nerves that have muscular control of the blood vessel walls)  - cause a spasm of the internal auditory artery. Allergic reaction. Adrenal pituitary insufficiency. Congenital or acquired syphilis. Regardless of the cause:  Endolymphatic hydrops (dilation in the endolymphatic space) develops.

·         Diagnostic Evaluation:  Audiometry.

·         Caloric test: Fluid, which is above or below body temp instilled into canal. Normal patient: Complains of dizziness. Acoustic neuroma: (a benign tumor of the 8^th cranial nerve). No reaction. Meniere’s syndrome: Severe attack.

·         What is David’s prognosis for Meniere’s disease?

 

·         Medical management: Psychotherapy. Allergic hyposensitization.

·         David is instructed to modify his diet. What is the most frequently recommended diet modification for this disease? 

 

·         What drugs are used to treat this disease? What drug would you anticipate to administer during an acute attack? Remember DATA 

1.

·         (hydrochlorothiazide). Relieve fluids in the ear, vertigo, and tinnitus. 

2.

 

3.

·         (Valium) Controls vertigo.

4.

·         (Phenergan). Reduces nausea, vomiting, and vertigo. 

·         Other: Thyroid function tests. Glucose tolerance test.  Allergy history.

·         Health Education: No smoking, caffeine, and stimulating drugs. Reduce stress and fatigue.

·         Eliminate allergies (name 6)

1.

2.

3.

4.

5.

6.

·         David finds the chronic tinnitus extremely irritating. What type of strategy would you suggest?

 

·         Endolymphatic Sac Decompression: The most popular surgical procedure. One-way valve into the sac to allow for equilibriation of the inner ear fluid. 

Ototoxic drugs

·         You need to give a presentation in your nursing class about ototoxic drugs. What drugs will you include in your presentation?

1.

·         Instruct the client to report hearing loss, dizziness, or tinnitus, to help prevent permanent ear damage.

2.

·         Contains salicylate, which can induce reversible hearing loss. Instruct client to report signs of tinnitus.

3.

·         (used for leg cramps)

4.

·         (amikacin, gentamycin, tobramycin). Side effect: Tinnitus.

Hearing Aids

·         Check batteries by turning volume all the way up until it whistles. If it does not whistle, new batteries should be inserted. 

·         Mr. Saunders wears hearing aids in both of his ears and they are making a whistling noise. What does this indicate?

 

Cochlear Implant

·         A device that emits auditory signals for profoundly deaf persons. Composed of: External parts (worn outside the body). Internal parts (surgically implanted).

·         Name 3 suggestions that you could give a client to prevent sensory deprivation.

1.

2.

3.

Sensory Grading Criteria 

Instructions 

1.      Select a disability involving sensation or perception (blindness, deafness, etc.). Alter your environment so that you experienced this disability for at least one hour. 

2.      At the completion of your experience, write a paper describing your reactions. 

Grading criteria 

1. Student experienced the disability for at least one hour (25 points). 

2. Paper was approximately two pages long and typed according to the American Psychological Association (APA) format. 

·        Double spaced (5 points) 

·        12 font (5 points) 

·        One inch margins (5 points) 

·        Free of spelling errors (5 points) 

·        Free of grammar errors (5 points) 

3.  Paper included: 

•  Disability that was selected, how you altered your environment, and type of activities experienced (20 points).
•  How did you feel experiencing this disability (10 points)? 
•  How did this experience change how you will take care of client who is blind or deaf (10 points)?
• In your nursing practice, how will you assist clients to preserve their eyesight and hearing (10 points)?  

Papers are due at 8:00 am on the designated day. Papers that are received late will have 5 points deducted for each day late.