5. External ear

External ear: deformities otalgia, foreign bodies, and tumours

Otalgia

Foreign Bodies

Some objects are inserted intentionally into the ear by adults who may have been trying to clean the external canal or relieve itching or by children who introduce peas, beans, pebbles, toys, and beads. Insects may also enter the ear canal. In either case, the effects may range from no

symptoms to profound pain and decreased hearing.

Management

Removing a foreign body from the external auditory canal can be quite challenging. The three standard methods for removing foreign bodies are the same as those for removing cerumen: irrigation, suction, and instrumentation. The contraindications for irrigation are also the same. Foreign vegetable bodies and insects tend to swell; thus, irrigation is contraindicated. Usually, an insect can be dislodged by instilling mineral oil, which will kill the insect and allow it to be removed. Attempts to remove a foreign body from the external canal may be dangerous in unskilled hands. The object may be pushed completely into the bony portion of the canal, lacerating the skin and perforating the tympanic membrane. In rare circumstances, the foreign body may have to be extracted in the operating room with the patient under general anesthesia.

TUMOR

PATHOPHYSIOLOGY AND ETIOLOGY.

Benign masses of the external ear are usually cysts resulting from sebaceous glands. Other benign masses are lipomas, warts, keloids, and infectious polyps. Infectious polyps usually arise from the middle ear and enter the external ear through a hole in the tympanic membrane. Actinic keratosis is a precancerous lesion that can be found on the auricle and may be seen in the elderly. Malignant tumors such as basal cell carcinoma on the pinna and squamous cell in the ear canal may develop. These tumors can spread to surrounding tissue and bones if not treated.

SIGNS AND SYMPTOMS.

Changes in the appearance of the skin can occur with benign or malignant masses. Usually, impaired conductive or sensorineural hearing loss occurs with masses. Pain is another symptom and is usually described as deep pain radiating inward on the affected side. Ear drainage may be present. As the condition progresses, facial paralysis occurs. Visualization of the mass may be observed during otoscopic examination.

DIAGNOSTIC STUDIES.

A biopsy may be obtained to determine if the mass is benign or malignant. Imaging studies are also used to diagnose tumors. Audiometric studies reveal any hearing impairment.

Middle Ear- Impacted wax, Tympanic membrane perforation, otitis media, otosclerosis,  mastoiditis, tumours

IMPACTED WAX AND FOREIGN BODIES

Accumulated cerumen (earwax) may become impacted due to use of cotton swabs to clean ears and may be a problem for some people. Cerumen becomes drier in elderly people, making impaction more likely. Foreign bodies may be lodged in the ear canal intentionally or accidentally by the patient or other person (usually in children), or the patient may be completely unaware, as in insect obstruction.

Etiology and Clinical Manifestations

• • Cerumen usually builds up over period of time, causing slightly decreased hearing acuity and feeling that ears is plugged.

    • • May be underlying seborrhea or other dermatologic condition that causes flaking of skin that mixes with cerumen and becomes obstructive.

      • Cerumen may be pushed back over tympanic membrane by action of cotton swab.

      • Patient may instill ceruminolytic, which actually makes condition worse by softening cerumen and causing it to coalesce into larger clump.

  • Insect may fly or crawl into ear, causing initial low rumbling sound; later, feeling that ear is plugged and decreased hearing acuity.

  • Pain, fever, and drainage may occur as otitis externa develops.

Management

• • Accumulated cerumen (earwax) does not have to be removed unless it becomes impacted and interferes with hearing; may be removed by irrigating ear canal

  • Foreign bodies may be removed by instrumentation or irrigation.

    • • Insects - treat by instilling oil drops to smother insect, which then can be removed with ear spatula or irrigation.

      • Vegetable foreign bodies (eg, peas)- ”irrigation is contraindicated because vegetable matter absorbs water, which would further wedge it in the canal.

      • Only a skilled person should attempt to remove foreign body, to prevent tympanic membrane perforation and trauma to canal.

      • General anesthesia may be required for young children.

Nursing Interventions and Patient Education

• • Teach proper ear hygiene, especially not putting anything in ears.

  • Explain the normal protective function of cerumen.

  • If patient has problem with cerumen buildup and has been advised by health care provider to use a ceruminolytic periodically, make sure that patient is getting cerumen out of ear before more medication is instilled. A bulb syringe may be used by the patient at home to help remove softened cerumen.

  • Advise patient to report persistent fever, pain, drainage, or hearing impairment.

Tympanic membrane perforation

Perforation of the tympanic membrane is usually caused by infection or trauma. Sources of trauma include skull fracture, explosive injury, or a severe blow to the ear. Less frequently,

perforation is caused by foreign objects (eg, cottontipped applicators, bobby pins, keys) that have been pushed too far into the external auditory canal. In addition to tympanic membrane perforation, injury to the ossicles and even the inner ear may result from this type of trauma. Attempts by patients to clear the external auditory canal should be discouraged. During infection, the tympanic membrane can rupture if the pressure in the middle ear exceeds the atmospheric

pressure in the external auditory canal.

Medical Management

Although most tympanic membrane perforations heal spontaneously within weeks after rupture, some may take several months to heal. Some perforations persist because scar tissue grows over the edges of the perforation, preventing extension of the epithelial cells across the margins and final healing. In the case of a head injury or temporal bone fracture, a patient is observed for evidence of cerebrospinal fluid otorrhea or rhinorrhea—a clear, watery drainage from the ear or nose, respectively. While healing, the ear must be protected from water.

Surgical Management

Perforations that do not heal on their own may require surgery. The decision to perform a tympanoplasty (surgical repair of the tympanic membrane) is usually based on the need to prevent potential infection from water entering the ear or the desire to improve the patient’s hearing. Performed on an outpatient basis, tympanoplasty may involve a variety of surgical techniques. In all techniques, tissue (commonly from the temporalis fascia) is placed across the perforation to allow healing. Surgery is usually successful in closing the perforation permanently and improving hearing.

OTITIS EXTERNA

Otitis externa is an inflammation of the tissue in the outer ear.

Pathophysiology and Etiology

Inflammation usually is caused by an overgrowth of pathogens. The microorganisms tend to follow trauma to the lining of the ear, or their growth is supported by retained moisture from swimming. Another possibility is that a hair follicle becomes infected, causing a furuncle or an abscess to develop.

Assessment Findings

The tissue in the external ear looks red. Sometimes it is difficult to see the tympanic membrane because of swelling. Clients describe discomfort that increases with manipulation during the examination. Hearing is reduced because of swelling. In severe infections, a fever develops and the lymph nodes behind the ear enlarge. Otoscopic examination reveals diffuse or confined

inflammation, swelling, and pus. A culture of drainage identifies the specific pathogen.

Medical Management

Treatment includes warm soaks, analgesics, and antibiotic ear medication, often with corticosteroid medication, such as neomycin/polymyxin/hydrocortisone otic solution (Cortisporin,

Otocort).

Nursing Management

The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, he or she advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. If chewing produces or potentiates discomfort, the nurse encourages the client to temporarily eat soft foods or consume nourishing liquids. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been

approved by the physician and to contact the physician if symptoms are not relieved in a few days.

ACUTE OTITIS MEDIA

Acute otitis media is an inflammation and infection of the middle ear caused by the entrance of pathogenic organisms, with rapid onset of signs and symptoms. It is a major problem in children but may occur at any age.

Pathophysiology and Etiology

• • Pathogenic organisms gain entry into the normally sterile middle ear, usually through a dysfunctional eustachian tube (suppurative otitis media).

  • Organisms include Streptococcus pneumoniae, H. influenzae, M. catarrhalis, and S. aureus.

  • In serous (secretory) otitis media, no purulent infection occurs, but blockage of the eustachian tube causes negative pressure and transudation of fluid from blood vessels and development of effusion in the middle ear.

Clinical Manifestations

• • Pain is usually the first symptom.

  • Fever may rise to 104° F to 105° F (40° C to 40.6° C).

  • Purulent drainage (otorrhea) is present if tympanic membrane is perforated.

  • Irritability may be noted in the young person.

  • Headache, hearing loss, anorexia, nausea, and vomiting may be present.

  • Purulent effusion may be visible behind tympanic membrane, or tympanic membrane may be reddened on otoscopic examination.

  • History may reveal previous upper respiratory infection, allergic rhinitis, or smoking in household and sibling otitis media in children.

Diagnostic Evaluation

• • Pneumatic otoscopy shows a tympanic membrane that is full, bulging, and opaque with impaired mobility (or retracted with impaired mobility).

  • Cultures of discharge through ruptured tympanic membrane may suggest causative organism.

Management

• • Antibiotic treatment—amoxicillin (Amoxil) is first-line treatment; cephalosporins, macrolides, or co-trimoxazole (Bactrim) may be used in penicillin allergy.

  • Amoxicillin/clavulanate (Augmentin) and cephalosporins are used for treatment failure due to increasing rate of beta-lactamase-producing bacteria that inactivate penicillin and other antibiotics.

  • Usual treatment course is 10 days.

  • Follow-up is indicated to determine effectiveness of therapy.

  • Nasal or topical decongestants and antihistamines have a limited role in promoting eustachian tube drainage.

  • Surgery—myringotomy.

    • • An incision is made into the posterior inferior aspect of the tympanic membrane for relief of persistent effusion.

      • Performed on selected patients to prevent recurrent episodes.

      • May be done because of failure of patient to respond to antimicrobial therapy; for severe, persistent pain; and for persistent conductive hearing loss.

Complications

• • Perforation of tympanic membrane

  • Chronic otitis media and mastoiditis

  • Conductive hearing loss

  • Meningitis, brain abscess

Otosclerosis

Otosclerosis is a pathologic condition in which there is formation of new spongy bone in the labyrinth, fixation of the stapes, and prevention of sound transmission through the ossicles to the inner fluids, resulting in deafness.

The cause is unknown, but there is a familial tendency and more women are affected than men.

Clinical Manifestations

• • Young adult presents with a history of slow, progressive hearing loss of soft, spoken tones, with no middle ear infection.

  • A frequent complaint is tinnitus; both ears may be affected equally.

  • History reveals gradual hearing loss.

  • Audiometry findings substantiate conductive or mixed hearing loss.

  • Bone conduction is much better than air conduction.

Management

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

  • Surgery—stapedectomy.

    • • The removal of otosclerotic lesions at the footplate of stapes or complete removal of the stapes and the creation of a tissue implant with prosthesis to maintain suitable conduction.

      • To perform such delicate surgery, the otologic binocular microscope is used.

Cochlear Implant

A cochlear implant is a device that emits auditory signals for profoundly deaf people (see Figure 17-4). The single-electrode system bypasses the damaged cochlear system and stimulates the remaining auditory nerve fibers. This results in the perception of sound.

Description

• • Purpose is for patient to detect louder environmental sounds, but will not restore normal hearing.

  • The microphone and sound processor are positioned externally; the electrode is implanted internally and inserts into the cochlea.

  • Electrical stimuli converted from the sound processor are sent inside the body to the implanted electrode. These electrical signals stimulate the auditory nerve fibers, which are interpreted by the brain.

  • Success rate is highly variable, which has made the cochlear implant controversial.

About 25,000 cochlear implants have been inserted worldwide.

Patient Criteria

There are no standardized criteria for patient selection. Some data that are considered include:

• • Severe to profound sensorineural hearing loss in both ears

  • Little to no benefit with hearing aids

  • No medical contraindications

  • Physically healthy adult or child as young as age 18 months

  • No evidence of brain impairment, psychoses, or mental retardation

  • Reasonable expectations and optimism. Motivation must be present.

Nursing Interventions

• • Encourage the prospective patient to visit with someone who is currently using an implant to learn the positive and negative results of a cochlear implant.

  • Explain the rehabilitation process: usually begins 2 months after surgery. Included are:

    • • Adjustment of controls.

      • Operation and maintenance of stimulator unit.

      • Listening critically and learning lip reading.

      • Learning discrimination of sounds through cochlear implant. Understanding speech through cochlear implant is not possible with this device alone.

      • Many people trained with such an implant can lip read more easily and can distinguish voices and environmental sounds.

  • Pneumococcal vaccination is important for all cochlear implant candidates and recipients.

  • For care after surgery, see page 588.

Other Implantable Devices

• • Bone conduction devices transmit sound from an external device, worn above the ear, through the skin and into the skull to the inner ear. This device is indicated in those with conductive hearing loss when a hearing aid is contraindicated such as chronic ear infection.

  • Semi-implantable hearing aids are being tested for conductive and mixed hearing loss.

Maximizing Communication With the Person Who is Hearing Impaired

When hearing loss is permanent or not amenable to medical or surgical intervention, aural rehabilitation is necessary for the patient to maintain communication and prevent isolation. Aural rehabilitation is a multifaceted process that includes auditory training (listening skills), speech reading (formerly called lip reading), and the use of hearing aids. Nurses strive to maintain effective communication with patients. These suggestions promote better communication.

When the Person is Hearing Impaired and Able to Lip Read

• • Face the person as directly as possible when speaking.

  • Place yourself in good light so he can see your mouth.

  • Do not chew, smoke, or have anything in your mouth when speaking.

  • Speak slowly and enunciate distinctly.

  • Provide contextual clues that will assist the person in following your speech. For example, point to a tray if you are talking about the food on it.

  • To verify that patient understands your message, write it for him to read (ie, if you doubt that patient is understanding you).

When the Person is Hearing Impaired and Difficult to Understand

• • Pay attention when the person speaks; facial and physical gestures may help you understand what person is saying.

  • Exchange conversation with person when it is possible to anticipate replies. This is particularly helpful in your initial contact with person and may help you become familiar with speech peculiarities.

  • Anticipate context of speech to assist in interpreting what the person is saying.

  • If unable to understand person, resort to writing, or include in your conversation someone who does understand; request that person repeat that which is not understood.

Organizations That Help the Hearing Impaired

• • Alexander Graham Bell Association for the Deaf

    • http://www.agbell.org

  • American Speech-Language-Hearing Association

    • http://www.asha.org

  • National Association of the Deaf

    • http://www.nad.org

Community and Home Care Considerations

• • Prevention of hearing loss should be discussed in the community—in schools, the workplace, and community gatherings.

  • Preventable hearing loss includes:

    • • Noise-induced hearing loss—long periods of exposure to loud noise from machinery or engines.

      • Acoustic trauma—single exposure to intense noise such as an explosion or amplified music.

  • Prevention involves avoidance of both types of noise, generally noise above 85 or 90 decibels.

  • Teach people to be aware of their surroundings and avoid noisy places or turn off sources of noise in the environment whenever possible.

  • Teach proper use of ear protection including earplugs and headsets both in the workplace and elsewhere.

  • Advise people that the Occupational Safety and Health Administration requires ear protection when noise exposure is above the legal limits, so workers have a right to protective equipment.

Mastoiditis

Inner ear- Meniere’s Disease, labyrinthitis, ototoxicity, tumours

MENIERE DISEASE

Meniere's disease (endolymphatic hydrops) is a chronic disease that involves the inner ear and causes a triad of symptoms—vertigo, hearing loss, and tinnitus.

Pathophysiology and Etiology

• • Cause is unknown.

  • Fluid distention of the endolymphatic spaces of the labyrinth destroys cochlear hair cells.

  • Usually unilateral, later may become bilateral.

  • Occurs most frequently between ages 30 and 60.

  • Severity of attacks may diminish over the years, but hearing loss increases.

Clinical Manifestations

• • Sudden attacks occur, in which patient feels that the room is spinning (vertigo); may last 10 minutes to several hours.

  • Dizziness, tinnitus, and reduced hearing occur on involved side.

  • Headache, nausea, vomiting, and incoordination are present.

  • Sudden motion of the head may precipitate vomiting.

  • History usually reveals ear trouble, vasomotor rhinitis, and allergies.

  • The most comfortable position for the patient is lying down.

  • Irritability; other personality changes.

  • After multiple attacks, tinnitus and impaired hearing may be continuous.

Diagnostic Evaluation

• • Caloric test/ENG to differentiate Ménière's disease from intracranial lesion.

    • • Fluid, above or below body temperature, is instilled into the auditory canal.

      • Will precipitate an attack in patients with Ménière's disease.

      • Normal patient complains of dizziness; patient with acoustic neuroma has no reaction.

  • Audiogram shows sensorineural hearing loss.

  • CT scan, MRI to rule out acoustic neuroma.

Management

Medical

• • Patient can be asked to keep a diary noting presence of aural symptoms (eg, tinnitus, distorted hearing) when episodes of vertigo occur. This may help diagnose which ear is involved and whether surgery will be needed.

  • Administration of the vestibular suppressant to control symptoms.

    • • Meclizine (Antivert, Bonine) up to 25 mg qid

      • Diphenhydramine (Benadryl) 25 to 50 mg tid to qid

      • Diazepam (Valium) 2 mg tid or 5 to 10 mg I.M. or I.V. (addictive potential)

  • Streptomycin (I.M.) or gentamicin (transtympanic injection) may be given to selectively destroy vestibular apparatus if vertigo is uncontrollable.

  • Additional antiemetic, such as promethazine (Phenergan), may be needed to reduce nausea, vomiting, and resistant vertigo.

Surgical

• • Conservative—simple endolymphatic sac decompression or endolymphatic subarachnoid or mastoid shunt to relieve symptoms without destroying function.

  • Destructive surgery:

    • • Labyrinthectomy—recommended if the patient experiences progressive hearing loss and severe vertigo attacks so normal tasks cannot be performed; results in total deafness of affected ear.

      • Vestibular nerve section—neurosurgical suboccipital approach to the cerebellopontine angle for intracranial vestibular nerve neurectomy.

Complications

• • Irreversible hearing loss

  • Disability and social isolation due to vertigo and hearing loss

  • Injury due to falls

Nursing Assessment

• • Assess for frequency and severity of attacks.

  • Provide screening hearing tests.

  • Evaluate effect on patient's activities, potential for fall or injury.

Nursing Diagnoses

• • Risk for Injury related to sudden attacks of vertigo

  • Social Isolation related to fear of attack and hearing loss

Nursing Interventions

For care related to labyrinth surgery, see page 590.

Ensuring Safety

• • Help patient recognize aura so patient has time to prepare for an attack.

  • Encourage patient to lie down during attack, in safe place, and lie still.

  • Put side rails up on bed if in hospital.

  • Have patient close eyes if this lessens symptoms.

  • Inform patient that the dizziness may last for varying lengths of time. Maintain safety precautions until attack is complete.

Minimizing Feelings of Isolation

• • Provide encouragement and understanding. Show the patient that you understand the seriousness of this disorder, even though there is little that can be done to ease the discomfort:

  • Assist patient to identify specific triggers to control attacks.

    • • Remind the patient to move slowly, because jerking or making sudden movements may precipitate an attack.

      • Avoid noises and glaring, bright lights, which may initiate an attack.

      • Control environmental factors and personal habits that may cause stress or fatigue.

      • If there is a tendency to allergic reactions to foods, eliminate those foods from the diet.

  • Avoid oversedation of the patient through polypharmacy with sedatives, anticholinergics, and opioids that may increase risk of falling if attack occurs.

  • Teach patient to be aware of other sensory cues from the environment, visual, olfactory, and tactile, if hearing is affected.

Patient Education and Health Maintenance

• • Teach about medication therapy, including adverse effects of vestibular suppressants—drowsiness, dry mouth.

  • Advise sodium restriction as adjunct to vestibular suppressant therapy.

  • Advise patient to keep a log of attacks, triggers, and severity of symptoms.

  • Encourage follow-up hearing evaluations and provide information about surgical care if planned.

  • Teach patient hearing conservation methods—avoid loud noises, wear earplugs if necessary, avoid smoking, avoid use of ototoxic drugs, such as aspirin, quinine, and some antibiotics.

Evaluation: Expected Outcomes

• • Lays down with side rails up and eyes closed during attack; resolves without injury

  • Identifies caffeine, bright lights, and stress as triggering factors; verbalizes desire to eliminate these factors

LABYRINTHITIS

Labyrinthitis is an inflammation of the inner ear vestibular labyrinth system. It may be due to a viral or bacterial infection, occur as a symptom of a tumor or other pathology in the nervous system, or occur due to a physiologic response from external stimuli. The hallmark is vertigo.

See Box 17-1 for other causes of vertigo, including benign positional vertigo.

Pathophysiology and Etiology

• • Bacterial labyrinthitis is rare and usually a complication of bacterial meningitis, although it may rarely be seen with otitis media or cholesteatoma.

  • Viral labyrinthitis is more common, but poorly understood. It may be caused by a common upper respiratory virus or occur with mumps, rubella, rubeola, and influenza.

  • Conflicting visual, vestibular, and somatosensory signals may be caused by stimuli such as a roller coaster ride, a sudden stop, or a quick change in position. Elderly patients and those with cerebrovascular disease are at risk.

  • Hearing and balance may be affected by infectious or pathologic causes.

Clinical Manifestations

• • Sudden onset of incapacitating vertigo, with varying degrees of nausea and vomiting, hearing loss, and tinnitus.

  • The first attack is most severe; repeated attacks occur over 1 week to several months with infectious labyrinthitis.

  • Symptoms may remain steady or gradually increase with CNS pathology.

Diagnostic Evaluation

• • Characteristic infectious labyrinthitis may be monitored for improvement without diagnostic testing.

  • ENG with caloric and doll's eye testing to differentiate cause.

  • CT scan or MRI for suspected tumors of cranial nerve VIII.

  • Forced hyperventilation for 1 to 3 minutes to mimic symptoms—differentiates physiologic cause.

Vertigo

Vertigo is a type of dizziness characterized by the illusion of movement; either a perception that the surroundings are moving while the body remains still, or that one's body is moving while the surroundings remain still. It is caused by vestibular dysfunction—either in the peripheral vestibular system (inner ear) or the central vestibular system (brain stem and cerebellum).

• • Common causes of vertigo of peripheral origin include Meniere's disease, labyrinthitis, acoustic neuroma, and benign paroxysmal positional vertigo (BPPV).

  • Causes of central vertigo include multiple sclerosis, basilar migraine, transient ischemic attack or stroke of the basilar artery, brain tumor, trauma, and cerebral hemorrhage.

  • Other causes of dizziness are vaso-vagal syncope, hypovolemia, autonomic neuropathy of diabetes, severe anemia, aortic stenosis, hypoglycemia, hypoxia, hypocarbia, multiple sensory deficits, drug adverse effects, and emotional illness.

BPPV is the most common cause of vertigo. Its onset is sudden, it can be severe in intensity, and it is always related to change in position of the head. It can be diagnosed by thorough history and physical examination, including some provocative maneuvers such as the Dix-Hallpike maneuver. Diagnostic tests are required only to rule out central vestibular dysfunction and dizziness caused by other disorders. Patients with BPPV may be very concerned about their symptoms and at risk for injury due to imbalance.

NURSING CONSIDERATIONS

• • Ensure safety by creating an uncluttered environment, using side rails and handrails as necessary, using proper footwear, and encouraging the patient to call for help.

  • Teach patient to avoid sudden position changes, including simple head movements, such as looking up or turning over in bed.

  • Discourage use of alcohol and sedating drugs, which may further impair safe ambulation.

  • Most episodes of BPPV last seconds to minutes and completely resolve within 3 months; however, if severe or prolonged, suggest referral to a physical therapist for vestibular rehabilitation.

Management

• • The rare cases of bacterial labyrinthitis are treated with antibiotics, as with the suspected predisposing infection.

  • Viral and physiologic causes are treated with symptomatic support.

  • Prevention and management of attacks.

  • Vestibular suppressant and antiemetic medication as with Ménière's disease (meclizine, diazepam, promethazine).

  • Presumed pathologic causes are worked up, and the cause is treated with neurosurgery or another measure.

Complications

• • Permanent hearing loss

  • Injury from fall

Nursing Assessment

• • Assess frequency and severity of attacks and how patient handles them.

  • Assess for fever related to bacterial infection.

  • Assess for additional neurologic symptoms—visual changes, change in mental status, sensory and motor deficits—that may indicate CNS pathology.

  • Assess for effectiveness of vestibular stimulants and antiemetics.

  • If fall occurs, assess for injury.

Nursing Diagnoses

• • Risk for Injury related to gait disturbance secondary to vertigo

  • Anxiety related to sudden onset of symptoms

  • Risk for Deficient Fluid Volume related to vomiting and impaired intake

  • Bathing and Hygiene Self-Care Deficit related to vertigo

Nursing Interventions

Preventing Injury

• • At onset of attack, have patient lie still in darkened room with eyes closed or fixed on stationary object until the vertigo passes.

  • Make sure that patient can obtain help at all times through use of call system, close proximity to staff, or companion.

  • Remove obstacles in patient's environment.

  • Make sure that sensory aids are available—glasses, hearing aid, proper lighting.

  • Use side rails while patient is in bed.

  • Administer medications as directed; assess for and avoid oversedation.

Minimizing Anxiety

• • Explain the physiology behind vertigo and the possible triggers.

  • Support patient and family through the diagnostic process.

  • Assist patient to adjust activities to minimize the impact.

  • Teach stress reduction techniques, such as deep breathing, talking and asking questions, and distraction.

Ensuring Adequate Fluid

• • Keep diet light while vertigo is present.

  • Administer antiemetics as directed.

  • Assess intake and output as indicated.

  • Encourage fluids and small feedings while patient is feeling better.

Encouraging Safe Self-Care

• • Encourage activity while vertigo is minimal; rest during attacks.

  • Set up environment for patient's safety and convenience—chair near sink, walker to hold on to while walking if necessary, and so forth.

  • Assist patient with hygiene and other care as needed.

Patient Education and Health Maintenance

• • Teach patients with viral labyrinthitis that attacks are self-limiting, will become less severe, and should leave no permanent disability.

  • Teach safety measures during vertigo attacks.

  • Tell patient that vertigo is best tolerated while lying flat in bed in a darkened room, with eyes closed or looking at stable object.

  • Teach patients how to take medications, and to avoid other CNS depressants such as alcohol.

  • Encourage follow-up.

Evaluation: Expected Outcomes

• • Rests in bed during attack with side rails up

  • Verbalizes feelings and questions about treatment

  • Takes fluids, light diet every 4 hours, after medication administration

  • Performs appropriate hygiene and dressing by himself at bedside

Ototoxicity

A variety of medications may have adverse effects on the cochlea, vestibular apparatus, or cranial nerve VIII. All but a few, such as aspirin and quinine, cause irreversible hearing loss. At high doses, aspirin toxicity can produce bilateral tinnitus. IV medications, especially the aminoglycosides, are the most common cause of ototoxicity, and they destroy the hair cells in the organ of Corti.  To prevent loss of hearing or balance, patients receiving potentially ototoxic medications should be counseled about the side effects of these medications. These medications should be used with caution in patients who are at high risk for complications, such as children, the elderly, pregnant patients, patients with kidney or liver problems, and patients

with current hearing disorders. Blood levels of the medications should be monitored, and patients receiving long-term IV antibiotics should be monitored with an audiogram twice each week during therapy.

Neoplastic Disorders

Acoustic neuroma

Acoustic neuromas are slow-growing, benign tumors of cranial nerve VIII, usually arising from the Schwann cells of

the vestibular portion of the nerve. Most acoustic tumors arise within the internal auditory canal and extend into the

cerebellopontine angle to press on the brain stem, possibly destroying the vestibular nerve. Most acoustic neuromas are unilateral, except in von Recklinghausen’s disease (neurofibromatosis type 2), in which bilateral tumors occur.

Acoustic neuromas develop in 1 of every 10,000 people per year. These neuromas account for 5% to 10% of all intracranial tumors and seem to occur with equal frequency in men and women at any age, although most occur during middle age.

PATHOPHYSIOLOGY AND ETIOLOGY.

Inner ear tumors can be benign or malignant. Acoustic neuroma, a tumor of the eighth cranial nerve, is the most common benign tumor. It is slow growing, occurs at any age, and usually occurs unilaterally. As it spreads, it compresses the nerve and adjacent structures. Malignant tumors arising from the inner ear are rare. Squamous and basal carcinomas arise from the epidermal lining of the inner ear.

SIGNS AND SYMPTOMS.

Early symptoms of an acoustic neuroma include progressive unilateral sensorineural hearing loss of high-pitched sounds, unilateral tinnitus, and intermittent vertigo. Headache, pain, and balance disorders may also be present. Symptoms progress as the tumor spreads to other structures. Most malignant tumors grow quickly. The symptoms vary depending on the area of the ear that is involved.

DIAGNOSTIC TESTS.

Neurological, audiometric, and vestibular testing are used to diagnose neuroma. Auditory

brainstem evoked response (ABR) and electronystagmography (ENG) are completed. Examination of the cerebrospinal fluid shows increased protein. Computed tomography (CT) and magnetic resonance imaging (MRI) are used to determine size and location of the tumor.

THERAPEUTIC INTERVENTIONS.

The preferred method of treatment involves surgical removal of the tumor. The labyrinth is destroyed, with a resulting permanent hearing loss. Steroids and radiation may be used to decrease the size of the tumor or for inoperable tumors.

NURSING MANAGEMENT.

Nursing management focuses on preparing the patient for surgery and adjusting to the diagnosis and the resulting hearing loss

AURAL REHABILITATION

If hearing loss is permanent or cannot be treated by medical or surgical means or if the patient elects not to undergo surgery, aural rehabilitation may be beneficial. The purpose of aural rehabilitation is to maximize the communication skills of the person with hearing impairment. Aural rehabilitation includes auditory training, speech reading, speech training, and the use of hearing aids and hearing guide dogs. Auditory training emphasizes listening skills, so the person

who is hearing-impaired concentrates on the speaker. Speech reading (also known as lip reading) can help fill the gaps left by missed or misheard words. The goals of speech training are to conserve, develop, and prevent deterioration of current communication skills. It is important to identify the type of hearing impairment a person has so that rehabilitative efforts can be directed at his or her particular need. Surgical correction may be all that is necessary to treat and improve a conductive hearing loss by eliminating the cause of the hearing loss. With advances in hearing aid technology, amplification for patients with sensorineural hearing loss is more helpful than ever.

Hearing Aids A hearing aid is a device through which speech and environmental sounds are received by a microphone, converted to electrical signals, amplified, and reconverted to acoustic

signals. Many aids available for sensorineural hearing loss depress the low frequencies, or tones, and enhance hearing for the high frequencies. A general guideline for assessing the patient’s need for a hearing aid is a hearing loss exceeding 30 dB in the range of 500 to 2000 Hz in the better-hearing ear. A hearing aid makes sounds louder, but it does not improve a patient’s ability to discriminate words or understand speech. People who have low discrimination scores

(ie, 20%) on audiograms may derive little benefit from a hearing aid. Hearing aids amplify all sounds, including background noise, which may be disturbing to the wearer. Computerized hearing aids are available to compensate for background noise or allow amplification at certain programmed frequencies rather than at all frequencies. Occasionally, depending on the type of hearing loss, binaural aids (ie, one for each ear) may be indicated. Chart 59-11 provides tips for hearing aid care. A hearing aid should be fitted according to the patient’s needs (eg, type of hearing loss, manual dexterity, and preferences), rather than the brand name, by a certified audiologist licensed to dispense hearing aids. Many states have consumer protection laws that allow the hearing aid to be returned after a trial use if the patient is not completely satisfied. In addition, to protect the health and safety of people with hearing impairments, the U.S. Food and Drug Administration (FDA) has established certain regulations. A medical evaluation of the impairment by a physician must be obtained within 6 months before the purchase of a hearing

aid. However, the written statement from a physician may be waived if the patient (a fully informed adult 18 years of age or older) signs a document to this effect. Health care professionals who dispense hearing aids are required to refer prospective users to a physician if any of the following otologic conditions are evident:

• Visible congenital or traumatic deformity of the ear

• Active drainage from the ear within the previous 90 days

• Sudden or rapidly progressive hearing loss within the previous 90 days

• Complaints of dizziness or tinnitus

• Unilateral hearing loss that occurred suddenly or within the previous 90 days

• Audiometric air–bone gap of 15 dB or more at 500, 1000, and 2000 Hz

• Significant accumulation of cerumen or a foreign body in the external auditory canal

• Pain or discomfort in the ear A user instruction brochure is provided with every hearing aid device. In this brochure, the following information is presented:

• Notification that good health practice requires a medical evaluation before purchasing a hearing aid

• Notification that any of the eight otologic conditions previously listed should be investigated by a physician before purchase of a hearing aid

• Instructions for proper use, maintenance, and care of the hearing aid, as well as instructions for replacing or recharging the batteries

• Repair service information

• Description of avoidable conditions that could damage the hearing aid

• List of any known side effects that may warrant physician consultation (eg, skin irritation, accelerated cerumen accumulation) The evolution in technology has led to the availability of

many smaller and more effective hearing aids. It is estimated that 98% of all hearing aids sold today are behindthe- ear, in-the-ear, or in-the-canal types (Table 59-4). One of the newest in-the-ear models is the Lyric, and other new models are being developed. The Lyric is placed in the ear canal just 4 mm from the tympanic membrane. Its volume is controlled by a magnet, and when its batteries no longer function (1 to 4 months), a physician can remove it with the magnet and reinsert a new device. This device does not have many of the problems (eg, feedback noise, overamplification of background noise) associated with other hearing aids, and it does not involve the expense and uncertainty of surgical procedures. However, it is not an option for a

DISORDERS OF THE EXTERNAL EAR

Various disorders such as impacted cerumen, injury from foreign objects, or otitis externa affect the external acoustic meatus. If these disorders are not treated carefully and adequately, they may spread to the middle ear.

IMPACTED CERUMEN

Impacted cerumen is accumulated ear wax that obstructs the external acoustic meatus.

Pathophysiology and Etiology

Impacted cerumen is more common among people who have excessive thick or dry cerumen. Both qualities interfere with drainage toward the proximal end of the meatus, where cerumen normally leaves the ear during regular shampooing and showering. The trapped cerumen interferes with the transmission of sounds carried on air waves.

Assessment Findings The client reports having a sense of fullness or pain in the ears, referred to as otalgia, and diminished hearing. The client asks that words be repeated, misinterprets questions, or raises the volume on the television or radio. Visual inspection with an otoscope shows an orange-brown accumulation of cerumen in the distal end of the external acoustic meatus. Audiometric, Rinne, and Weber tests reveal conductive hearing

loss.

Medical Management

Dried cerumen is hydrated by instilling 1 or 2 drops of halfstrength peroxide, warm glycerin, or mineral oil, or it is

softened with commercial agents, such as carbamide peroxide (Debrox) and triethanolamine (Cerumenex). Cerumen is removed mechanically by irrigating the ear if the eardrum is intact or using an instrument called a cerumen spoon.

Nursing Management

The nurse inspects the ears and implements measures to remove excessive cerumen. Ear drops can be warmed by holding the container in the hand for a few moments or placing it in warm water. If irrigation or instillation of liquids is ordered, the nurse warms the liquid to body temperature. Cold or hot liquids cause dizziness, and the potential for injury exists if the liquid is hot. The nurse avoids inserting the irrigating syringe too deeply so as to close off the auditory canal. He or she directs the flow toward the roof of the canal rather than the eardrum.

FOREIGN OBJECTS

Pathophysiology and Etiology

Foreign objects find their way into the ear either by accident or by deliberate insertion. Sharp objects can scratch the skin or cause blunt penetration of the eardrum. Insect stings cause

local inflammation of the tissue.

Assessment Findings

The client describes discomfort, diminished hearing, feeling movement, or hearing a buzzing sound. On gross inspection, there is evidence of abrasion from trauma, or an insect or an

object is seen. Inspection with a penlight or otoscope reveals swelling and redness in the auditory canal.

Medical Management

Mineral oil is instilled into the ear to smother an insect. Solid objects are removed with small forceps.

Nursing Management

The nurse instructs clients to clean the ears with a face cloth rather than inserting objects into the ears. A hat with earflaps or a scarf is recommended when venturing into the woods or other areas with a high insect population

DISORDERS OF THE MIDDLE EAR

OTITIS MEDIA

Otitis media is an acute inflammation or infection in the middle ear. Clients may have acute or chronic forms of either serous otitis media, also known as secretory or nonsuppurative otitis media, or the purulent or suppurative type. Although otitis media is more common among young children, adults can and do develop middle ear infections.

Pathophysiology and Etiology

Serous otitis media, a collection of pathogen-free fluid behind the tympanic membrane, results from irritation associated with respiratory allergies and enlarged adenoids. Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear

during upper respiratory infections. When fluid or pus collects in the middle ear, pressure

increases, which causes the eardrum to bulge and spontaneously rupture in some cases. Rupture results in a jagged tear of tissue that heals slowly and sometimes incompletely.

Scarring interferes with the vibration of the eardrum, causing diminished hearing. Clients with perforated eardrums are prone to repeated infections.

Other potentially serious complications can occur. Because the middle ear connects with the mastoid process, a part of the temporal bone, pathogens that are unresponsive to antibiotic therapy can spread, causing mastoiditis, or they can travel deeper in the inner ear, causing labyrinthitis. Infection also may extend to the meninges, causing meningitis, or brain abscess may result from its extension to the brain. If septicemia occurs, the infection can spread to the

large veins at the base of the brain and cause lateral sinus thrombosis. Facial nerve damage and facial paralysis may result from the infection. With prompt and adequate treatment, complications are rare.

Assessment Findings

The client often describes a history of having had a recent upper respiratory infection or seasonal allergies. Signs and symptoms vary widely depending on the type and severity of the inflammation but may include a fever, tinnitus, malaise, severe earache, and diminished hearing. Tenderness behind the ear indicates mastoiditis. The eardrum looks red and bulging. Pressure in the middle ear or dysfunction of inner ear structures can cause nausea, vomiting, and dizziness. If

the tympanic membrane perforates, fluid drains into the external acoustic canal and pain is relieved. The white blood cell count shows an elevated number of neutrophils and eosinophils. If the eardrum has ruptured and drainage is present, the cultured drainage reveals a specific

infectious microorganism.

Medical and Surgical Management

Prompt treatment usually prevents rupture of the eardrum. In some cases, the fluid is aspirated by needle. Antibiotics are given to control the infection. The overuse of antibiotics, however, has created another problem: microorganisms are becoming resistant and, for some infections, the available antibiotics are of limited benefit. To reduce the consequences of spontaneous rupture of the eardrum, subsequent scarring, and hearing loss, the physician performs a myringotomy or tympanotomy, an incisional opening of the tympanic membrane. The incised opening facilitates drainage of the purulent material, eases the pressure, and relieves the throbbing pain. The incision heals readily, with little scarring. Plastic surgery (myringoplasty) usually is successful in

repairing the perforated eardrum. In one technique, the edges of the perforation are cauterized and a patch of blood-soaked absorbable gelatin sponge (Gelfoam) is used as a scaffolding

over which new tissue grows until it has filled in the defect. Chronic infections are prevented if the eardrum is repaired. In the case of mastoiditis, a mastoidectomy is performed to remove the diseased tissue. With early and effective antibiotic therapy, mastoiditis is rare.

Nursing Management After myringotomy, the discharge from the ear is bloody and then purulent. To remove the drainage, the nurse wipes the external ear repeatedly with a dry sterile cotton applicator. An alternative is to insert a loose (not tightly packed) cotton pledget in the external ear to collect drainage. The nurse changes the cotton when it becomes moist.

OTOSCLEROSIS

Otosclerosis is the result of a bony overgrowth of the stapes and a common cause of hearing impairment among adults. Fixation of the stapes occurs gradually over many years.

Pathophysiology and Etiology

The underlying cause of otosclerosis is unknown. The condition, which is more common in women than in men, usually becomes apparent in the second and third decades of life. It seems to be accelerated during pregnancy. Most clients have a family history of the disease, which indicates a possible hereditary relationship. Otosclerosis interferes with the vibration of the stapes and the transmission of sound to the inner ear. Although hearing loss in otosclerosis is of the conductive type, when and if progression of the disease involving the cochlea of the inner ear occurs, a mixed type of hearing loss develops.

Assessment Findings

Signs and Symptoms

A progressive, bilateral loss of hearing is the most characteristic symptom. The client notices the hearing loss when it begins to interfere with the ability to follow conversation. There is particular difficulty hearing others when they speak in soft, low tones, but hearing is adequate when the sound is loud enough. Tinnitus appears as the loss of hearing progresses. It is especially noticeable at night, when surroundings are quiet, and can be quite distressing to the client.

The eardrum appears pinkish-orange from structural changes in the middle ear. When the Rinne test is performed, the sound is heard best when the tuning fork is applied behind the ear. The sound lateralizes to the more affected ear when the Weber test is performed.

person whose ear canal is too narrow to accommodate it.