THE EAR

EXTERNAL EAR
• Auricle or pinna
• Tube leading through temporal bone = ear canal
o 1¼ inches long
o Modified sweat glands secrete cerumen
o Tympanic membrane across auditory canal - Protects middle ear

MIDDLE EAR
• Malleus, incus, stapes (spec. bones to ear)
o All are attached and play a role in the hearing process
• Several openings into middle ear canal
o Eustachian Tube - Opens into middle ear which allows for more routes of infection
o E-Tube purpose is to equalize pressure against the tympanic membrane

INNER EAR – LABYRINTH

• Vestibule – Connects CN VIII – aids in balance
• Cochlear – Hearing ability
• Semicircular Canal – Sense of equilibrium – Balance
o Inner ear trouble – will have problems with balance, coordination, and hearing.

Ear problems affecting balance are the cause of 100,000 people breaking their hips every year
An elderly person with an inner ear infection will lose their balance then possible fall
GENERAL TERMS AND INFORMATION
• Dizziness
o Altered sensation of orientation and space – nonspecific term
• Vertigo
o Hallucination or illusion of motion.
o Spinning sensation; objects moving around them – inner ear
• Ataxia
o Not truly R/T ear but can be present with inner ear but more associated with
musculoskeletal
o Cerebral palsy.
• Syncope
o Not characteristic of ear; “Fainting or LOC” not ear clarify with description

HEARING LOSS
• Conductive Loss
o External Ear Disorders
 You cannot get the sound to the inner part to be processed. Problem with
transmission of sound
• Wax build up
• Otitis Media – The fluid buildup is blocking the sound getting to the inner ear
• Sensorineural
o Inner ear and the nerves and the actual hearing process itself
o Problems with the cochlear or vestibular nerve
o Cranial nerve and function inner ear
• Mixed
o Combination of both
 • Function Psychogenic
o Somatoform
o When you lose your hearing for no physical reason
GERONTOLOGIC CONSIDERATION
• Cerumen
o Become harder and drier (natural with aging)
o Increases chances of Impaction within ear
• Middle Ear
o Atrophy and become sclerotic (don’t know why)– decrease in function
o The tympanic membrane can atrophy
• Inner Ear
o Degenerative changes: family history important (natural process as get older)
• Presbycusis
o Progressive hearing loss associated with aging

EARLY SIGNS OF LOSS OF HEARING

• Tinitus
• Speak louder to be heard ( volume to TV / Radio)
• At risk if life long exposure to loud noises - degenerative loss
o 25% of people 65-74 will have hearing problems
o 50% from 75 y/o and up
o Diabetes can result in Sensoryneural hearing loss

MEDICATIONS THAT CAN CAUSE OTOTOXCISITY

• Aminoglycides and ASA

PSYCHOSOCIAL CONSIDERATIONS
• People don’t like to admit they have problems hearing
• Adults
o Communication with  volume, change in personality, change in surroundings. May
walk out in front of a car
• Children
o Inattention;  schoolwork and loud speech
• Not eager to seek med attention because of fear of hearing aid

ASSESSMENT
• Ear examination of external ear
o Inspect and palpate, looking for anything unusual or any nodules (gout-tophi)
o It should not hurt to touch the ear
• Middle Ear OTOSCOPIC EXAM
Child – Down and back
o Otoscope visualize canal and tympanic membrane Adult – Up and back
• Inner Ear Child must be restrained to
perform an examination
o Problem with coordination
• Placement of ear in reference to head
o  placement with Down’s syndrome, Mental retardation, renal abnormalities
• Position: Pinna out from skull not greatly enlarged
 o Note any Swelling that occurs along back of ear – May be infection
o Skin tags or anything unusual about the ear (tophi)
o Flat ear with infant on side too long especially premature

AUDITORY ASSESSMENT
• Reflexes – Newborn should be startled when a loud noise is present
• Response to noise
o Clapping or ringing bell
o Should grimace or blinking
• Crib-O-Gram
o May not be used as much – Omits noise and records infants response
• Tympanometry
o Measure middle ear air pressure assess for middle ear disease
• Audiometry
o Tones and loudness
• Brainstem – Auditory Evoked Response
o Used neonatal nursery - Electrodes attached to head look at electrical waves
o Used routinely in premature infants; may do other babies

ADULT AUDITORY ASSESSMENT

• Whisper test – General
• Weber test – Conductive loss
• Rhinne test – Conductive loss
• Audiometry – Loss of tone, loudness
 EAR DISORDERS
CONDITIONS OF EXTERNAL EAR
• Foreign body could progress to deafness
o Foods, rocks, insects
• Treatment: Irrigation, suction, instrumentation
o Need to know if swells with water (vegetables, pasta, beans, insects)
o Bloody discharge – not common with ear infection but can be a foreign body
o May have no symptoms or may have pain and hearing is affected

MASTOIDITIS
• Inflammation of mastoid R/T middle ear infection
• Major Complication of otitis media invasion – a Hematogonous infection

SIGNS AND SYMPTOMS

• Pain and Tenderness behind ear
• Edema / swelling (ear-face)
• Headache
• Ear discharge
TREATMENT
• Medication : Analgesic and antibiotics
• Surgery
o Mastoidectomy – may require part of mastoid process with possible.
o Complication of paralysis of the fact, meningitis, brain abscess

MENIERE’S DISEASE
• Thought was brain disease
• Condition of inner ear characterized by triad of symptoms (Classic)
o Episodic Incapacitating Vertigo
 Severe loss of function
 Extremely serious vertigo
 It comes and goes
o Tinnitus
 Severe extreme ringing in the ears
o Fluctuating Sensorineural Hearing Loss
 Loss of hearing
• Etiology is unknown
• Theories
o Abnormal hormonal and neurochemical influence on blood flow to labyrinth
o Electrolyte disturbance within labyrinth fluids
o Allergic reaction
o Autoimmune disorders
o Too much circulating fluid
• Endolymphatic hydrops: Dilation (swelling) in endolymphatic space develops and produces
symptoms
• Either  pressure in system or rupture of inner ear membrane
• Incidence: More common in adults with onset in 40’s
• Reported in children as young as 4 y/o and adults all ages  to 90’s
 • Gender, ear affected equally - Genetic disposition

CLINICAL MANIFESTATIONS
• *Fluctuating, progressive sensorineural hearing loss – it gets worse
• *Tinnitus or a roaring sound
• *Feeling of pressure or fullness in ear
• *Episodic, incapacitating vertigo often accompanied by nausea and/or vomiting
At onset of the disease perhaps only one to two symptoms will manifest

ASSESSMENT AND DIAGNOSTIC FINDINGS

• Not easy to diagnose
• History to determine frequency, duration, severity, and character of vertigo attacks
• Physical exam – Normal with exception of cranial nerve VIII
• Weber test – Lateralize to the opposite ear
• Audiogram reveals sensorineural hearing loss of the affected ear
• Electronystagmogram
• NO absolute diagnostic test

MEDICAL MANAGEMENT
• No cure for this disease
• Successful treatment with diet and medication therapy
o Low Na
 2000 mg/day
o Avoid caffeine
o Avoid nicotine
o Avoid alcohol
o Avoid any stimulant
o Lifestyle, habits

• Pharmacologic Therapy
o Antihistamines
 Antivert – Medizine
• For vertigo and dizziness
o Tranquilizers
 Diazepam – Valium
• Cannot be used long term - Short term therapy
o Antiemetics
 Promethazine – Phenergan for nausea and vomiting
o Diuretic Therapy
 Hydrochlorothiazide – Dyazide
• Decreases pressure
• Intake of the following – bananas, tomatoes, oranges
o Vasodilators
 Used in conjunction with other therapy
• Nicotinic Acid
• Papaveine Hydrochloride – Pavabid
• Methantheline Bromide – Bauthine
 • Surgical Management

o Vertigo attacks reduce quality of life

• Endolymphatic Sac Decompression

o 1st line surgical approach to treat vertigo because relatively simple and safe and
performed on outpatient basis
o The sac dilates for some reason so this procedure drains the sac to relieve vertigo
o Shunt or drain inserted in endolymphatic sac via postauricular incision (relieve, shunt
fluid buildup)
o 75% success rate
o Does not cure or keep the disease from occurring it only cuts down on the vertigo

• Labrynthectomy
o Remove part of the labrynth
o Destroy auditory function of inner ear – Loss of some hearing
o Complications
 Facial nerve injury
 Cerebrospinal fluid leak – meningitis
 Total hearing loss

• Vestibular Nerve Section

o Conserve hearing
o Greatest success rate (98%) eliminating vertigo
o Performed by: Translabyrinthine (through hearing mech) conserve hearing
(suboccipital or middle cranial fossa)
o Cutting nerve prevents brain from receiving input form semicircular canals
o Requires brief hospital stay

NURSING DIAGNOSIS
• High R/F injury R/T Vertigo
• Impaired adjustment
• R/F Fluid volume deficit – meds
• Anxiety – change in health status
• R/F Trauma – balance
• Ineffective individual coping R/T dz process,  function
• Diversion activity deficit
• Self care deficit R/T vertigo
• Powerlessness – Loss of all control
OTOSCLEROSIS
• Seen in adults
• Aggressive deafness
• Involves stapes
o Is thought to result from a formation of new, abnormal spongy bone (middle ear),
especially around oval window with resulting fixation of stapes
• Efficient transmission of sound prevented because stapes cannot vibrate and carry sound
as conducted from malleus and incus to inner ear
• More common in females and is frequently hereditary
• One or both ears
• May be worsened by pregnancy
• DO in fact have hearing loss

CLINICAL MANIFESTATIONS
• Involve one or both ears
• Presents as progressive conductive or mixed hearing loss
• May or may not C/O tinnitus
• Normal tympanic membrane with otoscopic exam

DIAGNOSTIC TESTS
• Otoscopic exam
o Will be normal
• Look at symptoms
• Rhinne test (bone conduction) will be better than air
• Audiogram confirms conductive hearing loss or mixed loss especially low frequency
o Conductive because the sound cannot get to inner ear due to hardened stapes

MEDICAL MANAGEMENT
• No know non surgical treatment
• Auditory rehab: hearing aids or surgery

• Surgical Management

o Stapedectomy
 Performed through canal
 Removing the entire stapes superstructure and part of foot plate and inserting
tissue graft and suitable prosthesis
 Balance disturbance or true vertigo can occur for short time after
stapedectomy

o Stapendotomy
 Some elect to remove only small part of stapes foot plate
 Prosthesis bridges gap between incus and inner ear providing better sound
conduction
 Very successful in improving hearing

The tube leading from the auricle to the temporal bone is the ear canal.
REVIEW