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Ear and Hearing Problems Disorders

Dr Ibraheem Bashayreh, RN, PhD

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Anatomy of the Ear

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External Otitis• Painful condition caused when irritating or

infective agents come into contact with the skin of the external ear

• Commonly called swimmer’s ear• Two most common precipitants are

excessive mositure and trauma to ear canal. • 2 most common presenting symptoms are

“otalgia” (ear discomfort) and “otorrhea” (discharge from external ear canal). Common symptoms are pain, itching, tenderness, and temporary loss of hearing.

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External Otitis

• Treatment focused on reducing inflammation, edema, and pain with heat, bedrest, limited head movement, topical antibiotic and steroid therapy, and analgesics

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Furuncle

• Localized external otitis caused by bacterial infection of a hair follicle

• Hearing impaired if the lesion blocks the canal, most commonly cerumen (wax)

• Treatment with local and systemic antibiotics, heat application, earwick to relieve pain, and possible incision and drainage

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Cerumen or Foreign Bodies

• Cerumen (wax) is the most common cause of an impacted canal.

Function

• Lubrication,

• Trapping,

• Waterproof barrier,

• Antimicrobial,

• Inhibitory pH

Other blockages include vegetables, beads, pencil erasers, insects.

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Ear Wax• Content• Appearance

• Color

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Treatment

Rx: Irrigate canal with a mixture of water and hydrogen peroxide at body temperature for impacted cerumen; Cerumenex softens wax.

• Carefully remove foreign object.

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Water-clogged ear

• Not the same as Swimmer’s Ear (Otitis externa)

• Some people are more prone to retaining water

• Signs and symptoms include feeling of fullness, wetness, gradual hearing loss, itching, pain, inflammation, or infection. So can end up with otitis externa.

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Treatment

• Tilting the effected ear

• Use of blow dryer

• Isopropyl alcohol 95% in anhydrous glycerin 5%

• 50:50 mixture of acetic acid 5% (white vinegar) and isopropyl alcohol 95%

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Otitis Media

* One of the most common childhood

illnesses.

* Approximately $3 billion in

healthcare costs were attributed to >5

million cases in 1995

• Three out of 4 children experience ear infection (otitis media) by the time they are 3 years old.

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Otitis Media

• Three types of otitis media include:– Acute otitis media– Chronic otitis media– Serous otitis media

• Most commonly reported symptoms are cough, rhinitis, fever, and earache.

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Nonsurgical Management

• Quiet environment

• Bedrest with limited head movement

• Heat and cold applications

• Systemic and topical antibiotic therapy

• Analgesics

• Antihistamines

• Decongestants

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Surgical Management

• Myringotomy is a surgical opening of the pars tensa of the eardrum.

• Operative procedure includes grommet (polyethylene tube) placed through the tympanic membrane.

• Postoperative care: keep external ear and canal free of other substances while the incision is healing and keep head dry for several days.

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Mastoiditis

• Infection of the mastoid air cells caused by untreated or inadequately treated otitis media

• Nonsurgical management: antibiotics

(Continued)

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Mastoiditis (Continued)

• Surgical management: simple or modified radical mastoidectomy with tympanoplasty

• Complications: damage to cranial nerves, vertigo, meningitis, brain abscess, chronic purulent otitis media, and wound infection

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Trauma

• Trauma and damage to the eardrum and ossicles may occur by infection, by direct damage, or through rapid changes in the middle-ear cavity pressure.

• Eardrum perforations usually heal within 24 hours.

• Use preventive measures to protect the ear from trauma.

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Neoplasms

• Tumors are removed by surgery, which often destroys hearing in affected ear.

• Benign lesions are removed because, with continued growth of the neoplasm, other structures can be affected, damaging the facial or trigeminal nerve.

• When possible, reconstruction of the middle ear structures is performed.

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Tinnitus

• Continuous ringing or noise perception is one of the most common problems with ear or hearing disorders.

• Tinnitis cannot be observed or confirmed with diagnostic tests.

• When no cause is found, therapy focuses on masking the tinnitus with background sound, noisemakers, and music during sleeping hours.

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Vertigo and Dizziness

• Common manifestations of many ear disorders

• Advise client to:– Restrict head motions and move more

slowly.– Maintain adequate hydration.– Take antivertiginous drugs.– Prevent loss-of-balance accidents.

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Labyrinthitis

• Infection of the labyrinth

• Meningitis a common complication of labyrinthitis

• Treatment with systemic antibiotics, bedrest in a darkened room, antiemetics, antivertiginous medications, psychosocial support

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Meniere’s Disease

• Affects 200/100,000 people• Inner chronic ear Disorder• A typical Acute Attack causes vertigo,

tinnitus, feeling of fullness and pressure in ear, fluctuating hearing loss, nausea and vomiting.

• Average acute attack lasts 2-4 hours and leaves patient exhausted. Patient tends to sleep for hours after acute attacks

• Is there a Cure??

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Ménière's Disease Rx

• Nonsurgical management includes slow head movements, salt and fluid restrictions, cessation of smoking, mild diuretics, nicotinic acid, antihistamines, antiemetics, diazepam.

• Surgical management is a last resort and consists of labyrinthectomy (Excision of the labyrinth of the ear) or endolymphatic decompression with drainage and shunt.

• Hearing in the affected ear is often sacrificed.

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Acoustic Neuroma

• Benign tumor of eighth cranial nerve

• Surgical removal via craniotomy

• Extreme care taken to preserve the function of the facial nerve

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Hearing Loss

• One of the most common physical handicaps in North America.

• Common causes of conductive hearing loss: any inflammation process or obstruction of the external or middle ear by cerumen or foreign objects.

(Continued)

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Hearing Loss (Continued)

• Common causes of sensorineural hearing loss: loud noise, drugs, atherosclerosis, hypertension, prolonged fever, Ménière's disease, diabetes mellitus, and ear surgery.

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Assessments • Tuning fork tests

• Otoscopic examination

• Psychosocial assessment

• Laboratory tests

• Radiographic assessment

• Other diagnostic assessments such as audiogram

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Treatment of Hearing Loss

• Drug therapy

• Assistive devices

• Hearing aids

• Cochlear implants

(Continued)

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Treatment of Hearing Loss

(Continued)

• Tympanoplasty– Postoperative care includes antiseptic-

soaked gauze packed in the ear canal, clean dressing, client flat with head turned to the side and the operative ear facing up for at least 12 hours after surgery, prescribed antibiotics, activity restrictions.

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Stapedectomy

• A partial or complete stapedectomy with a prosthesis corrects hearing loss and is most effective for hearing loss related to otosclerosis.

• Hearing improvement may not occur until 6 weeks after surgery.

(Continued)

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Stapedectomy (Continued)

• Damage to cranial nerves, vertigo, and nausea and vomiting are common after surgery.

• Pain medications and antibiotics are often used.

• Safety measures and antivertiginous drugs should be applied.

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Nose & Sinus Disorders

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Epistaxsis•Precipitating factors

–Trauma•Picking

–Blunt contact–Drying of nasal mucous membranes–Infection–Substance abuse–Arteriosclerosis–Hypertension–Bleeding disorders–Anticoagulant therapy

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Epistaxsis

•Clinical Manifestations–90% anterior nasal septum

•Trauma •Drying•Infection

–Posterior secondary to•Blood dyscrasias•Hypertension•Diabetes •Tends to be more severe•Occurs more frequently in older adult

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Epistaxsis

•Management–Anterior

•Simple first aid–Apply pressure for 5-10 minutes–Apply ice packs to nose & forehead–Sitting position leaning forward–Discourage swallowing blood

•Medications–Topical vasoconstrictors

»Cocaine»Neo-Synephrine»Adrenaline

–Nasal spray or on cotton swab held against bleeding site

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Epistaxsis

• Medications cont’d

– Chemical cauterization• Silver nitrate• Gelfoam

– Topical anesthetic (pre packing)• Tetracaine• Lidocaine• Cocaine

• Nasal Packing ~ Anterior– Petroleum gauze– 24-72 hours commonly

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Epistaxsis

• Nasal Packing ~ Posterior– Pack both anterior & posterior– 2-5 days

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Epistaxsis

• Posterior Packing cont’d

– Monitor for hypoxemia– Administer oxygen as ordered– Frequent oral hygiene– Administer narcotic analgesics as

ordered– Monitor for complications

• Toxic shock syndrome• Otitis media• Sinusitis

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Epistaxsis

• Endoscopic Surgery– Cauterizing bleeding vessel– Ligation of internal maxillary artery

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Nasal Polyps

• Benign grapelike growth of mucous membrane

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Nasal Polyps

• Form in areas of dependent mucous membrane

• Usually bilateral

• Stem-like base makes them moveable

• May enlarge nasal obstruction

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Nasal Polyps• Management

– Topical corticosteroid nasal spray– Low-dose oral corticosteroids– Surgery

• Polypectomy under local anesthesia– Nasal packing to control bleeding– Avoid blowing nose 24-48 hours post removal of

packing– Avoid straining at stool, vigorous coughing,

strenuous exercise– Monitor for bleeding

» Frequent swallowing» Visible blood at back of throat

• Laser surgery to remove polyps• May require multiple surgeries as polyps tend to

recur

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Deviated Septum

•May result from trauma•Causes nasal obstruction

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Deviated Septum

• Surgery– Septoplasty or submucous resection

• Manipulation of septal cartilage

– Post operatively• Bilateral nasal packing

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Rhinoplasty

• Surgical reconstruction of the nose

• Relief of airway obstruction

• Repair visible deformity

• Reshaping of nose by– Moving– Rearranging– Augmenting

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Rhinoplasty

• Post operatively– Nasal packing for 72 hours– Temporary plastic splint for 3-5 days– Swelling subsides within 10-14 days– Normal sensation returns within

several months

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Sinusitis

• Inflammation of mucous membranes of sinuses

• Acute or chronic

• Follows upper respiratory infection

• Organisms – Streptococci– Streptococcus pneumoniae– Haemophilus influenzae– Staphylococci

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Sinusitis•Sinuses are air-filled cavities in facial bones•Lined with ciliated mucous membranes•Help move fluid & microorganisms out of sinuses into nasal cavity•Normally sterile environment

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Sinusitis•Pathophysiology

–Inflammation of mucous membranes

•Obstruction •Impaired drainage •Mucus secretions collect in sinus cavity

–Medium for bacterial growth

•Inflammatory response

–Serum & leukocytes invade area to combat infection–Increase in swelling & pressure

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Sinusitis

• Obstruction– Nasal polyps– Deviated septum– Rhinitis– Tooth abscess– Swimming or diving trauma– Prolonged nasotracheal intubation

• Frontal and maxillary sinuses commonly involved in adults

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Sinusitis

• Complications– Periorbital abscess– Cellulitis– Cavernous sinus thrombosis– Meningitis– Brain abscess– Sepsis– Hearing loss due to eustachian tube

edema

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Sinusitis

• Clinical Manifestations– Looks sick– Pain & tenderness

• Increases when leaning forward• Worse during first 3-4 hours in

morning

– Headache– Fever – Malaise

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Sinusitis

• Clinical Manifestations cont’d

– Nasal congestion– Purulent nasal discharge– Bad breath– Swallowed nasal secretions

• Irritate & inflame the throat• Nausea or vomiting

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Sinusitis• Diagnonstics

– Sinus X-rays– CT scan– Magnetic resonance imaging (MRI)

• Rule out malignancy of sinus

• Medications– Antibiotics (orally) for two weeks

• Longer if needed to prevent relapse

– Antibiotics IV in hospital if no response to oral treatment

– Decongestants• Oral• Nasal spray

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Sinusitis

• Surgery– Endoscopic sinus surgery

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Endoscopic Sinus Surgery•Nursing care

–Generally no packing required–Frequent nasal cleaning & irrigation

•Sterile normal saline

–Teach•Open mouth sneezing •Avoid blowing nose•Avoid lifting or straining

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Sinusitis

• Surgery cont’d

– Antral irrigation• Saline solution instilled via 16-gauge

needle• Patient seated with head forward &

mouth open to allow drainage of purulent irrigating solution

– Caldwell-Luc procedure• If endoscopic surgery unsuccessful• Creates an opening between maxillary

sinus & lateral nasal wall

– External sphenoethmoidectomy

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Sinusitis

• Post-op Nursing Care– Gauze packing 24-48 hours post-op– Upper lip & teeth numbness for

several months– Impaired chewing on affected side– Liquids only first 24 hours post-op

• Followed by soft diet

– Avoid for 2 weeks after removal of packing

• Dentures• Valsalva maneuver

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Infectious Disorders

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Rhinitis {Common Cold}

• Highly contagious

• Peaks during September and late January– When schools open/resume

• 200+ strains of viruses

• Spread by aerosolized droplet nuclei or direct contact

• Local respiratory inflammatory response due to antigen-antibody defense

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Rhinitis

• Clinical Manifestations– Erythematous & boggy nasal

mucous membranes– Nasal congestion– Rhinorrhea – Sneezing & coughing– Sore throat– Fever– Malaise– Achy

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Rhinitis

• Diagnostics – History & physical

• Treat symptoms– Adequate rest– Increased fluids– Avoid chills

• Medications– Decongestants– Warm saltwater gargles– Throat lozenges

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Rhinitis

• Complimentary Therapies– Herbal remedies

• Echinacea• Garlic

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Rhinitis

• Prevention– Avoid crowds– Maintain good general health– Stress reduction– HANDWASHING

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Pharyngitis & Tonsillitis

• Viral or bacterial– Group A beta-hemolytic

streptococcus

• Contagious– Spread by droplet nuclei

• Complications– Abscess– Scarlet fever– Toxic shock syndrome– Rheumatic fever– Post-strept glomerulonephritis

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Pharyngitis & Tonsillitis

• Clinical Manifestations– Pain– Fever– Enlarged & tender lymph

nodes

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Pharyngitis & Tonsillitis

• Usually self-limiting

• Diagnostics– Throat swab– Complete blood count

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Pharyngitis & Tonsillitis

• Medications– Antipyretics– Mild analgesics

• Acetaminophen

– Antibiotics for 10 days• Penicillin drug of choice• Erythromycin• Amoxicillin• Cefuroxime

• Surgery– Tonsillectomy with adnoidectomy

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Pharyngitis & Tonsillitis• Post-op Nursing Care

– Monitor for bleeding• Delayed hemorrhage up to 1 week post• Avoid use of aspirin• Observe for excessive swallowing

– Ensure patent airway• Semi-Fowler’s• Head turned to side• Artificial airway until return of gag & swallow

reflexes

– Ice collar– Ice chips or sips as desired– Warm saline mouthwashes– Liquid or semi-liquid diet for several days

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Laryngitis

• Inflammation of larynx• Commonly in conjunction with

URI• Other causes

– Excessive use of voice– Sudden change in temperature– Exposure to irritants

• Dust• Fumes• Smoke• Pollutants

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Laryngitis

• Clinical Manifestations– Change in voice

• Hoarseness• Complete loss of voice (aphonia)

– Sore throat– Dry cough

• Treatment– Rest voice– Avoid irritants– Impaired verbal communication

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Influenza

• AKA: Flu

• Highly contagious

• Viral

• Occurs in epidemics or pandemics

• Local outbreaks every 1-3 years

• Global epidemics every 10-15 years

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Global Epidemics• Influenza outbreak 2009

– “Swine flu” (H1N1)

• Influenza outbreak 1968– “Hong Kong flu”– About 34,000 deaths in U.S.

• Influenza outbreak 1957– “Asian flu”– About 70,000 deaths in U.S.

• Influenza outbreak 1918– “Spanish flu”– More than 500,000 deaths in U.S.– Possibly 50 million deaths worldwide– ½ of deaths were in young, healthy adults

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Influenza

• Pathophysiology– Transmitted by airborne droplet &

direct contact– Three major strains

• Influenza A virus– Responsible for most infections– Responsible for most severe outbreaks– Able to alter its surface antigens– Each strain named for strain, geographic

origin, and year» A/Taiwan/89

• Influenza B virus• Influenza C virus

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Influenza

• Complications– Sinusitis– Otitis media– Tracheobronchitis– Pneumonia

• Especially in elderly or immune suppressed populations

• Progresses rapidly• Results in hypoxemia• Ending in death within a few days

– Reye’s syndrome• Associated with influenza B virus• Fatal hepatic failure & encephalopathy develop

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Influenza

• Clinical Manifestations– Syndromes

• Uncomplicated nasopharyngeal inflammation

• Viral URI followed by bacterial infection• Viral pneumonia

– Rapid onset– Chills and fever– Malaise, fatigue, weakness– Muscle aches

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Influenza• Prevention

– Immunization

• Treatment– Establish diagnosis

• History & physical• Knowledge of outbreak in community

– Symptomatic relief• Amantadine (Symmetrel) or rimantadine

(Flumadine) for prophylaxis if exposed• Other antivirals may reduce duration & severity

of symptoms– Zanamivir (Relenza)– Oseltamivir (Tamiflu)– Ribavirin (Virazole)

– Prevent complications

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Older Adult•Respiratory muscles weaken•Large bronchi & alveoli enlarge•Available surface area of lungs decreases

–Reduced ventilation & gas exchange–Functional cilia decrease in number & action

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Older Adult

•Cough reflex decreased•Chest wall compliance decreased

–Osteoporosis–Calcification of costal cartilage

•Increased risk for aspiration•Increased risk for infection•Poor nutrition