FAR EASTERN UNIVERSITY

Department of Undergraduate Studies

INSTITUTE OF NURSING
Manila

Care of the Clients with Common Ear Disorders

DIAGNOSTIC TESTS FOR AUDITORY ACUITY

Tuning Fork Tests
A. Rinne’s Test
• Compares air conduction from bone conduction,
differentiates conductive and sensorineural hearing loss.
• The vibrating tuning fork is placed against the mastoid
bone/behind the ear lobe (bone conduction); then, it is placed
2 inches from the opening of the ear canal (air conduction)

• Interpretation of results is as follows:

o Normal: air conduction is better than bone conduction (the tone is louder in
front of the ear)
o Conductive hearing loss: bone conduction is better than air conduction (the
tone is louder behind the ear)
o Sensorineural hearing loss; same as the normal finding. It is more accurate in
diagnosing conductive hearing loss like in

B. Weber Test
• The rounded tip of the handle of the vibrating
tuning fork is placed on the client's head or teeth. It is
more accurate in diagnosing sensorineural hearing
loss like in Meniere's disease.
• Interpretation of results is as follows:
o Normal: tone is heard in center of head or equally
in both ears.
o Conductive hearing loss; tone is heard in poorer ear, e.g. otosclerosis
 o Sensorineural hearing loss: tone is heard in better ear.
o The test is useful in cases of unilateral loss.

C. Whisper Voice Test

• The examiner covers one ear with the palm of the hand,
then whispers softly 2- syllable words from a distance of 1
or 2 feet from the unoccluded ear, and out of the patient's
sight (e.g. thirteen, fourteen, fifteen).
• The person with normal hearing acuity can correctly
repeat what was whispered.

D. Audiometry

• It is the single most important diagnostic instrument in detecting hearing loss.

• Types of Audiometry
o Pure-tone Audiometry. The louder the tone
before the client perceives it, the greater the
hearing loss.

o Speech Audiometry. Spoken word is used to determine the

ability to hear and discriminate sounds and words. The louder
the sound before the client perceives it, the greater the hearing
loss.
 • Tympanogram or Impedance Audiometry. It
measures middle ear muscle reflex to sound
stimulation and compliance of the tympanic
membrane, by changing the air pressure in a
sealed ear canal.
• Compliance is impaired with middle ear disease

E. Oculovestibular Test/ Ice Water Caloric Test

• Irrigate the ear with cold water.
• Normal result: lateral conjugate nystagmus of
the eyes away area of stimulation.
• Abnormal result: dysconjugate nystagmus of the
eyes.
• Then, irrigate the ear with warm water.
• Normal result: lateral conjugate nystagmus of the eyes toward from the area of
stimulation.
• Abnormal result: dysconjugate nystagmus of the eyes

• Remember COWS: Cold Opposite Warm Same

SYMPTOMS OF EAR DISORDERS

• Deafness
o Means that the patient has a hearing loss, which may be mild or
severe.
o Hearing loss may be conductive, sensorineural or mixed types.
o The most common cause of deafness in childhood is serous
otitis media whereas in adults, presbycusis is most common
cause.
o Presbycusis means deafness of the elderly and it is a sensorineural hearing loss caused
by the degeneration of the nervous tissue. It is more common among men, over 50 years
of age.
o Hearing loss in presbycusis is predominantly in the higher frequencies (high-pitched
sounds like women's voice).
• Pain
o Earache or otalgia is a very common complaint.
o In children, the most common cause is acute
otitis media whereas in adults, it is otitis externs.
o The pain may arise from the ear itself or from
an adjacent site with a shared nerve supply.
o The most common site for referred pain is the throat, where infections more rarely,
malignant tumors are responsible.

• Discharge
o A discharge from the ear may be purulent or bloody. It
must be distinguished from the escape of which is a
normal process
o Commonly the cause of a discharge is otitis externa or
otitis media and in the latter event, a perforation will be
present in the tympanic membrane.
o If perforation of the tympanic membrane is suspected or
diagnosed, irrigation of the ear should be avoided.

•Vertigo
o A form of dizziness where the patient experiences a spinning
sensation. It is a common symptom when the balance or
vestibular system of the inner ear is diseased. It is accompanied
by nausea and vomiting.

• Tinnitus
o Noise in the ear is a very common
complaint.
o Its quality varies from a high-pitched
whistle to the clanging of bells or
recognizable snatches of music.
CLASSIFICATION OF HEARING LOSS
o Conductive hearing loss. It involves
interference with conduction of sound
impulses through the external auditory
canal, the eardrum or the middle ear. It
is validated by Rinne's Test

o Sensorineural hearing loss. It results

from disease or trauma to the inner ear or
acoustic nerve. It is validated by Weber's
Test.

o Mixed hearing loss. It involves both conductive and sensorineural hearing loss.

ASSESSMENT OF CLIENT WITH HEARING LOSS

o Irritable, hostile or hypersensitive in interpersonal relations.
o Has difficulty in following directions.
o Complains about people mumbling.
o Turns up volume on TV.
o Asks for frequent repetition.
o Answers questions inappropriately.
o Leans forward to hear better, face looks serious and strained.
o Loses sense of humor, becomes grim and lonely.
o Experiences social isolation.
o Develops suspicious attitude.
o Has abnormal articulation.
o Complains of ringing in the ears.
o Has unusually soft or loud voice.
o Dominates conversation.

GUIDELINES FOR COMMUNICATING WITH THE CLIENT WITH HEARING

IMPAIRMENT
o Use gestures with speech.
o Speak in clearly enunciated words, using normal tone of voice. Do not shout. High
pitched sound is used when shouting. This is more difficult to understand especially
among older people.
o Talk directly facing the person in order to allow reading of lip movements.
o Do not whisper to anybody in front of the hearing impaired client
 o Do not avoid conversation with a person who has hearing loss
o Do not show annoyance by careless facial expression.
o Move closer to the person or toward the better ear if he/she does not hear you.
o Do not smile, do not chew gum or cover the mouth when talking to the person. So the
person can read the lip movements.
o Encourage the use of hearing aid if the client has one.

COMMUNICATION WITH HEARING IMPAIRED PATIENT

A.Nonverbal Aids
a. Draw attention with hand movements.
b. Have speaker's face in good light.
c. Avoid covering face and mouth with hands.
d. Avoid chewing, eating, smoking while talking.
e. Maintain eye contact.
f. Avoid distracting environments.
g. Avoid careless expression that the patient may misinterpret
h. Use touch.
I. Move close to the better ear.
j. Avoid light behind speaker. The patient will not be able to see the speaker's face and
facial expressions that will help him understand what is being communicated.

B. Verbal Aids
a. Speak normally and slowly.
b. Do not over exaggerate facial expressions.
c. Do not over enunciate
d. Use simple sentences.
e. Rephrase sentence, use different words.
f. Write name or difficult words.
g. Avoid shouting.
h. Speak in normal voice directly into better ear.

DISEASES OF THE OUTER EAR

Bat Ear
o The pinna protrudes from the side of the head because the ridge of the antihelix has not
formed. The child maybe the object of mockery
o The antihelix can be reconstructed fairly easily through an incision on the back of the
pinna.
Wax (Impacted Cerumen)

Wax or cerumen is a normal substance produced in

the external ear canal. It is made up of epithelial
scales mixed with the secretions from special
glands in the skin of the outer ear.
o In most people, the wax escapes as it is formed
but in some, it remains in the ear canal, obstructing
it and causing deafness.
o Olive oil or liquid paraffin eardrops or hydrogen peroxide will soften the impact wax,
which is then removed by irrigation.
o It is important that the water in the syringe should be at body temperature so as not to
stimulate the inner ear and cause dizziness.
o The jet of water is directed at the wall of the ear canal and the wax is washed out. The
ear must be dried gently after the irrigation and it should be examined by a doctor to
exclude any damage to the tympanic membrane.
Foreign Bodies
o These are commonly found in the ears of children and the
variety is immense. Sometimes they can be removed by a
probe or irrigation with warm water but the child is often
frightened and uncooperative and a general anesthetic will
be necessary.
o The ear must always be checked to exclude any
underlying damage.
o An insect in the ear is treated similarly to the above-
mentioned intervention.
o If the foreign body is a vegetable seed, do not irrigate the ear. Vegetable seeds expand
when exposed to water.

Otitis Externa
o This is an inflammation of the outer ear that is
lined by skin. The condition is usually bilateral and
the symptoms start with itching.
 o The patient scratches the ear that becomes infected, painful and sometimes blocked by
a thin mucopurulent discharge.
o Allergy, stress and the presence of contaminated water may all play a part but the
treatment is the same.
o Any precipitating cause is removed and a swab is taken for culture and sensitivity. The
ear canal is cleaned gently, thoroughly and frequently using a wisp of cotton wool on the
tip of a suitable probe.
o Drops are then instilled directly or used to infuse a small wick of ribbon gauze which is
left in the ear for one or two days. The drops may be simple disinfectants or may be
combinations of topical antibiotics (to kill the bacteria) and steroids (to reduce
inflammation).
o The condition tends to recur.

Boils
A boil or furuncle is found in the outer hair-bearing skin of the ear canal. It is very
painful because the skin at this site is firmly tethered to the underlying cartilage. Like
boils elsewhere, it is caused by staphylococcus and the relevant antibiotic is only
necessary when the symptoms are severe. Analgesics are necessary and the possibility of
underlying diabetes must be excluded.

Tumors

Malignant tumors of the ear are most

common in the outer ear where both basal
cell carcinoma and squamous carcinoma are
found. The small lesion is treated with
radiotherapy but the larger will need surgical excision.
Serous (Secretory) Otitis Media

When the Eustachian tube becomes blocked, the air trapped in the middle
ear is absorbed into the surrounding tissues and is replaced by thin fluid.
In time, small glands appear in the lining of the middle ear and the mucus
which they secrete, explain the popular name of "glue ears" which is
given to this condition.
 It is seen most in those children where an immature musculature and repeated upper
respiratory tract infections, predispose to tubal obstruction.
• The child develops a hearing loss that may pass unnoticed.
• However, the parents may have noted that the child's schoolwork has deteriorated or
that he turns up the television.
• There may also be associated episodes of earache caused by a suppurative infection of
the fluid.
•An examination of the ear will reveal the presence of fluid behind the tympanic
membrane and a simple whisper test or an audiogram will confirm the presence of a
hearing loss.
• If the condition is temporary or intermittent, nothing needs to be done since most
children outgrow the condition.
• If it is more severe, an alternative means of allowing air into the middle ear, must be
found.
• A hole is made in the tympanic membrane (a myringotomy) and the hole is prevented
from healing by inserting a small plastic tube (grommet, dottle or stopple).
• At the same time, any underlying cause (sinusitis or enlarged adenoids) is treated.
• As long as the grommet remains in place and remains unblocked the hearing is normal.
• However, the grommet drops out after tubes may be the middle ear. The majority of
patients with grommets in place can be allowed to go swimming although earplugs are
advisable.
• It is hoped that the patient will have outgrown the problem by then, but a grommet may
need to be reinserted if fluid reaccumulates.

Acute Otitis Media

The middle ear is in continuity with the

nasopharynx and is therefore very prone
to infection from it. This is especially so
in the presence of serous otitis media
when a convenient culture medium is
available for the invading bacteria. The middle ear mucosa becomes inflamed and the
cavity fills with which escapes by bursting out through the tympanic membrane into the
external ear.
 • The patient, who is usually a child with a cold, develops an earache of increasing
severity that ceases when the membrane bursts.
• The perforation usually heals after 2 to 3 days but this should be checked after one
month and the presence of an underlying serous otitis media excluded.
• The patient should be confined to bed and given analgesics.
• A covered hot water bottle applied to the ear is helpful and warm olive oil drops will
soothe the inflamed membrane.
• If a patient is seen before the perforation occurs, penicillin should be given and should
be continued for at least 5 days and until the inflammation has settled.
• A swab should be taken from the discharging ear and sent for culture and sensitivity.
• Complications may arise but these are now rare.
• The most common is acute mastoiditis, a condition in which an abscess develops in the
mastoid bone and burst out behind the ear. It is now only seen in children whose natural
defense mechanisms are not functioning normally.

Chronic Otitis Media

• When a middle ear infection becomes persistent it is

called chronic otitis media.
• Permanent damage is done to the tympanic membrane
and to the ossicles and the patient may be very deaf with
a large central perforation and a persistent discharge.
• The discharge is particularly likely to occur when the
patient has a cold because infected secretions pass up the
Eustachian tube.
• An attempt is made to remove any source of infection in the nose or and the local
discharge can be controlled by regular irrigation and the instillation of eardrops.
• When the ear has been dry for several months it is suitable for a surgical repair of
perforation.
• A piece of fascia is taken from the surface of the temporalis muscle and the thin tissue
is grafted over the perforation.
• The graft may be laid on the inner or the outer surface of the tympanic membrane and
the operation is known as a myringoplasty
 • Similarly, any loss of ossicular continuity can be corrected by repositioning a damaged
ossicle or by replacing it with a piece of bone or a prosthesis.
• This operation is called tympanoplasty. More recently it has become possible to remove
the tympanic membrane and its attached ossicles in one block from a cadaver.
• These homograft tissues can then be implanted into a suitable patient but the operation
is technically very difficult.

Cholesteatoma

• This cyst lined by squamous

epithelium and filled with layers of
epithelial scales. The cyst forms from an
in pouching of the upper segment of the
tympanic membrane, into the middle ear
cavity
• Initially, the epithelial scales escape
into external canal, but as the mouth of
the pouch narrow they are retained and
accumulate.
• The cholesteatoma is unique that it has the property of eroding most of the tissues that
encounters. The contents of the cyst becomes infected and the condition may be regarded
as a for of chronic otitis media
• The extent of the damage determined by the direction in which the cholesteatoma
enlarges.
• Usually the ossicles are damaged, but an upward extension will produce a brain abscess
or meningitis.
• Similarly, a downward extension may produce a facial paralysis or damage the inner ear
•The treatment will include surgical and some form of radical mastoidectomy, which is
necessary for its removal.
Otosclerosis

In otosclerosis, abnormal, spongy, highly

vascularized bone grows across the margins
of the oval window and to the footplate of
the stapes that longer vibrate condition is
more common in women.
• It begins in early adulthood and the
deafness progressively worsens.
• It causes conductive hearing loss.
• Rinne's test indicates that bone conduction is better than air conduction
• The treatment is a choice between a hearing aid and surgery and the operation is known
as stapedectomy.
• The mobile part of the stapes is removed and hole is made in the fixed footplate.
• A Piston (or a similar prosthesis) is placed in the hole and hooked around the incus to
reestablish sound transmission.
• The inner ear is at risk during the operation and this must be clearly explained to the
patient.
• Some dizziness almost always occur temporarily and this is countered by antivertigo
drugs.

DISEASES OF THE INNER EAR

• Any disease affecting the inner ear

causes damage to the delicate nerve
endings responding for hearing and
balance and the patient may
complain of vertigo, deafness or
tinnitus.
• Trauma, loud noises and some
drugs may damage the inner ear and
they should be avoided if possible,
 •In Meniere's disease, there is an accumulation of endolymph in the inner ear and the
patient suffers from episodes of severe vertigo.
• A tumor known as an acoustic neuroma may occur in the internal auditory canal and its
symptoms will mimic those of inner ear disease.
• The ear, nose and throat surgeon carries out many investigations to distinguish between
these in an attempt to diagnose a neuroma at an early age.

Meniere's Disease (Endolymphatic

Hydrops)
• It is characterized by accumulation of
endolymph in the inner ear.
• It is chronic, with remissions and
exacerbations.
Causes
o Unknown
o Virus
o Emotional Stress

•Assessment in Meniere's disease

• Vertigo (most characteristic manifestation)
• Unilateral or bilateral gradual hearing loss
• "Drop attacks" (the patient experiences the feeling of being pulled to the ground)
• Feeling of as if one is whirling in space
• Tinnitus (described as "roar" or "like the ocean")
• Nausea and vomiting
• Weber Test shows that tone lateralizes better in the good ear.

• COLLABORATIVE MANAGEMENT FOR THE CLIENT WITH MENIERE'S

DISEASE
• Bed rest during exacerbation.
• Low sodium diet. To prevent retention of water.
• Avoid drinking large volumes of fluids.
• Avoid reading during vertigo.
• Provide quiet, darkened room
• Provide soft, mellow music during tinnitus to dived the patient's attention.
• Avoid alcohol, caffeine, tobacco. These cause exacerbation of symptoms.
• Stress therapy.

•Medications:
• tranquilizers, vagal blockers (atropine), antihistamines, vasodilators, diuretics
 • To reduce vertigo, the following medications may be prescribed:
• Diazepam (Valium) o Meclizine (Antivert/ Bonamine plus nicotinic acid)
• Fentanyl with Droperidol (lnnovar)

Acoustic neuroma•
A benign tumor of the vestibular
or acoustic nerve.
• The tumor may cause damage to
hearing and to facial movements
and sensations.
• Symptoms begin with tinnitus
and progress to gradual
sensorineural hearing loss.
• Treatment includes surgical removal of the tumor via craniotomy.
• Care is taken to preserve the function of the facial nerve.
• Postop nursing care is similar to post operative craniotomy care.
• “An acoustic neuroma expands out of the internal auditory canal, displacing the
cochlear, facial, and trigeminal nerves located in the cerebellopontine angle.

*Note: After surgery, the patient may experience asymmetry of the face due to
affectation of the facial nerve. This will spontaneously be resolved in few months.
• There will be dryness of the eye on the affected side and this eye will not be able to
produce tears for sometime. Artificial tears may be instilled into the eye at regular basis
to prevent corneal ulceration.
• *There will be absent or diminished taste sensation due to affectation of the facial
nerve.
Different Types of Ear Surgeries
 • Myringoplasty. It involves closure of perforated tympanic membrane.
• Tympanoplasty. It involves closure of perforated tympanic membrane, if the middle
ear is involved.
• Myringotomy. It involves a simple incision in the tympanic membrane.
• Ossiculoplasty. It involves ossicular reconstruction.
• Stapedectomy. It involves surgical removal of the stape followed by replacement with
prosthesis
• Stapedotomy. It involves use of laser to create a hole in the footplate of the stapes and
prosthesis is placed in the hole.
• Labyrinthectomy. It involves surgical removal of the membranous labyrinth through
the oval window or through the mastoid bone.

• Care of the Client Undergoing Ear Surgery

Preoperative Care
• Assess for upper respiratory tract infection.
• Shampoo the hair.
• Inform the client that he/she will be under local anesthesia but sedated during surgery.

Post-operative Care
• Instructions include the following:
• Lie on the unoperated side.
• Blow nose gently one side at a time, sneeze or cough with mouth open for 1 week after
surgery.
• Avoid strenuous physical activity like heavy lifting for 1 week and avoid exercises or
sports for three weeks postop.
-Change cotton ball in ear daily.
-Keep ear dry for6 weeks postop.
-Do not shampoo hair for 1 week
-Protect ear with 2 pieces of cotton (outer piece saturated with petrolatum)
• Avoid airplane travel for 1 week postop. For sensation of ear pressure hold nose, close
mouth and swallow to equalize pressure
• Report any drainage other than slight amount of bleeding to the physician.
• Avoid reading, watching TV or fast moving objects for 1 week postop. This is to
prevent vertigo
• Advise patient to seek for supervision when ambulating for the first time, dizziness or
lightheadedness may occur. This is to prevent falls.
REFERENCES
Brunner & Suddarth Textbook of Medical-Surgical Nursing, 14th edition Phildelphia,
Wolters Kluwer

Special thanks to
Neugene Rowan S. Cu, MAN, RN, RM, CNN, CSSYB, Faculty FEU-IN