The Ear Sensory organ with dual function: hearing and balance (thanks to cranial nerve #8) Anatomy

of the ear: External ear: Pinna, external auditory canal, ear lobe Auricle (pinna): collects sound waves, directs vibrations into auditor canal External auditory canal: contains ceruminous glands (secretes cerumen), ends at tympanic membrane Middle ear: tympanic membrane, malleus, incus, stapes and footplate Tympanic membrane: protects middle ear, conducts sound vibrations from external canal to ossicles, should be pearly grey, shiny and translucent in color Ossicles: 3 bones (malleus, incus, stapes). The stapes bones actually vibrates and transmits sound Inner ear: semicircular canals, cochlea, oval window, round window Coclea: organ for hearing Semicircular canals: controls your balance

Cranial nerves V (facial) & VIII (vestibulocochlear): when assessing nerve #8, you assess balance and auditory Organ or Corti: separates sound into different frequencies, travels through acoustic nerve into temporal cortex of brain where meaningful sound interpreted Sound travels through the inner ear Question: Otalgia is a sensation of fullness or pain in the ear True: OT= ear algia=pain Sound Conduction and transmission: Enters auditory canal Tympanic membrane vibrates Transmit sound through ossicles and oval window to cochlea: stimulating hair cells Transmitter through inner ear fluids as mechanical energy Converted to electrical energy Travels through vestibulocochlear nerve to CNS ------------> to CNS, interpreted as SOUND. Cone conduction compared to air conduction: Bone conduction: straing to sound --> to bone --> to inner ear Air conduction: oval window --> to round window --> to CNS

Inspection of the External Ear: Inspection and direct palpation for deformities, lesions and discharge. Check for symmetry, size and attachment Auricle: elicits pain in external otitis Palpate Mastoid for tenderness, mastoiditis Otoscope Examination: to assess the inner ear. Allows you to visualize the tympanic membrane. Cannot be seen without the otoscope. Auricle grasped and pulled back gently to straighten canal (visualization of T M)

Looking for discharge, inflammation, and foreign bodies, fluid, air bubbles, blood and masses.

Weber Test Uses bone conduction to test for conductive issues and sensorineural issues. Normal Hearing: sound equally transferred to both ears Abnormal hearing: conductive (sound transferred to affected ear - otitis media; Sensorineural: sound transferred to unaffected ear, damage to cochlear nerve. Results are (+) or (-), patient will state they hear the sound on the affected ear the loudest

Rinne Test Vibrating tuning fork placed against mastoid, when sound no longer heard, fork then placed to external canal. Normal AC > BC, since Air conduction is through external canal and bone conduction is through mastoid bone Sensorineural loss: decreased in both AC and BC, then you want to do a weber test to confirm Test question: What assessment is completed with the Weber test? Bone Conduction of sound (remember Weber=bone, Rynne= air and bone) Diagnostic Evaluation Audiometry: detects hearing loss, using tone and speech (especially done with children in 7 th grade) Used to test hearing Tympanogram: measures middle ear muscle reflex by air pressure and fluid in the ears. Used to detect middle ear disease Auditory Brainstem response: uses electrodes to detect sound stimulation

Used to detect cranial nerve tumors Electronystagmography: Measures changes in electrical potentials evoked by spontaneous eye movement Used to detect Menieres disease and tumors Platform posturography: tests autonomic system in postural conditions Evaluates vertigo

Advise patients NOT TO take suppressants for 24 hours, will affect the results Hearing Loss Increased incidence with age, half of individuals with hearing loss > 65 y/o Greater incidence in men Risk factors: includes exposure to excessive noise levels (acoustic trauma) Types of hearing loss: Conductive: due to external or middle ear problem (impacted cerumen, otitis media, otosclerosis) Sensorineural: due to damage to the cochlea or vestibulocochlear nerve (loud noise, age (presbybusis), meds (ototoxicity) Mixed: both conductive and sensorineural Functional: (psychogenic) due to emotional problem Manifestations: early symptoms include tinnitus (ringing in the ears), turning up volume to TV Impairment may be gradual and not recognized by the person experiencing the loss As hearing loss increases, person may experience: deterioration of speech, fatigue, social isolation (dont wanna talk to others since they cannot hear themselves and others)

Test question: sensory deprivation is the most important thing to prevent in the elderly!!! Guidelines for communicating with the hearing impaired Use a low-tone, normal voice Speak slowly and distinctly Face the person and get his or her attention Use gestures and facial expressions Conditions of the external ear: Cerumen impaction: removal may be by irrigation, suction, or instrumentation Gentle irrigation should be used with lowest pressure Glycerin, mineral oil or peroxide may help soften.

Manifestations: pain and tenderness, discharge, edema, erythema, pruritus, hearing loss, feelings of fullness in the ear Therapy: aimed at reducing discomfort, reducing edema and treating infection A wick may be inserted int he canal to keep it open and facilitate medication administration Tympanic membrane perforation: can lead to hearing loss, most heal spontaneously Foreign bodies: removal may be by irrigation, suction, or instrumentation External otitis: inflammation of ear canal most commonly due to bacteria (staphylococcus or psudomonas, or fungal infection due to aspergillus Test question: What is the main culprit in external otitis?

Pseudomonas - found in pts w/ immunosuppression (diabetes, etc), treated with IV antibiotics Conditions of the middle ear: Acute otitis media See most frequently in children Pathogens are streptococcus, influenzae Manifestations include otalgia, fever, hearing loss Treatment: antibiotic therapy (if due to infection) Serous otitis media Fluid in the middle ear without evidence of infections Chronic otitis media: damages T M, ossicle and involves the mastoid Happens a lot in frequent plane travelers and in divers. Chronic otitis media Damages T M. Ossicle and involves the mastoid Complication: cholesteoma-ingrowth of skin, forms sac filled with sebaceous material and dead skin Can destroy temporal bone structures Otosclerosis: involves stapes Abnormal spongy bone, prevents stapes from vibrating Tx: stapendectomy Middle ear surgical procedures Tympanoplasty: reconstruction of the tympanic membrane Ossiculoplasty: reconstruction of the bones of the middle ear, especially the stapes Patient teaching: meds teaching, activity restrictions (ex: blow nose gently), safety issues related to potential vertigo, avoid getting water in ear, follow up care. Conditions of the inner ear: biggest risk factors is FALLS Dizziness: any altered sense of orientation in space Vertigo: the illusion of motion or a spinning sensation Nystagmus: involuntary rhythmic movement of the eyes, associated with vestibular dysfunction Tinnitus: symptom of underlying condition affecting hearing loss Contributing factors: ototoxicity r/t ASA, Quinine, Diuretics, Antibiotics, Vitamine B12 deficiency, thyroid disease, psychological disorders Tx: diagnostic testing, coping Labyrinthitis: inflammation of the labyrinth (inner ear) Bacterial or viral, affects hearing and balance Manifestation: sudden vertigo with N&V Treatment: based on symptoms Benign positional vertigo (BBPV): disruption of debris within semicircular canal Treatment: bedrest, Canalith repositioned procedure (quick movement of the head in the hopes that the debris will move so stopping the vertigo Menieres disease: abnormal inner ear fluid balance caused by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct Manifestations: episodic, incapacitating vertigo; fluctuating, progressive hearing loss, tinnitus, feeling of pressure or fullness Acoustic Neuroma: slow rowing benign tumors of cranial nerve VIII Symptom: unilateral tinnitus MRI or CT performed Management: surgical removal is best treatment Treatment: low-sodium diet (the less sodium, the less fluid) Meclizine (Antivert), also antiemetics and diuretics may be used