AUDITION Overview of the Anatomy and Physiology

EAR

The ear is divided into three parts; External, Middle and Internal External Ear Auricle or pinna It collects sound waves and directs them toward the auditory meatus. External auditory meatus It directs sound waves to the tymapanic membrane; hairs and cerumen help cleanse the canal of foreign matter. Tymapanic membrane Protects the middle era and conducts sound vibration from the external ear to the ossicles.

Middle Ear Consists of the middle ear cleft and contents: 1. Ossicles 2. Windows 3. Eustachian tubes 4. Mastoid bone Inner Ear The membranous labyrinth, lying within but not completely filling the bony labyrinth, is bathed in a fluid called perilymph, which communicates with CSF via the cochlear duct. The membranous labyrinth consists of the utricle, saccule, semicular canals, cochlear duct and the organ of corti. The membranous labyrinth contains a different fluid (endolymph). This fluid also protects the end organ because it acts as a cushion against abrupt movements of the head. Bony labyrinth Sussounds and protects the membranous labyrinth a. Vestibule- Contains the utricle and saccule which function in the sense of balance. b. Cochlea- Contains auditory receptors which function in hearing. c. Semicircular canals- Function in the sense of balance.

Assessment
Inspection of the External Ear Inspection of the external area is a simple procedure, but it is often overlooked. The external ear is examined by inspection and direct palpation; the auricle and surrounding tissues should be inspected for deformities, lesions and discharge, as well as size and symmetry and angle of attachment to the head. Manipulation of the auricle does not normally elicit pain. If the maneuver is painful, acute external otitis is suspected. Tenderness on palpation in the area of the mastoid may indicate acute mastoiditis or inflammation of the posterior auricular node. A flaky scaliness on or behind the auricle usually indicates seborrhaic dermatitis and can be present on the scalp and facial structures as well.

Otoscopic Examination The tympanic membrane is inspected with an otoscope and indirect palpation with a pneumatic otoscope. To examine the external auditory canal and tympanic membrane, the otoscope should be held in the examiners right hand, in a pencil hold position, with the examiners hand braced against the patients face. This position prevents the examiner from inserting the otoscope too far into the external canal. Using the opposite hand, the auricle is grasped and gently pulled back to straighten the canal in the adult. If the canal is not straightened with this technique, the tympanic membrane is more difficult to visualize because the canal obstructs the view. The speculum is slowly inserted into the ear canal, with the examiners eye held close to the magnifying lens of the otoscope to visualize the canal and tympanic membrane. The largest speculum that the canal and tympanic membrane. The largest speculum that the canal can accommodate is guided gently down into the canal and slightly forward. Because the distal portion of the canal is bony and covered by a sensitive layer of epithelium, only light pressure can be used without causing pain. The external auditory canal is examined for discharge, inflammation or a foreign body. Proper otoscopic examination of the external auditory canal and tympanic membrane requires that the canal be free of large amounts of cerumen. Cerumen is normally present in the external ear and small amounts should not interfere with otoscopic examination. If the tympanic membrane cannot be visualized because of cerumen, the cerumen may be removed by gently irrigating the external canal with warm water. Evaluation of Gross Auditory Acuity A general estimate of hearing can be made by assessing the patients ability to hear a whispered phrase or a ticking watch, testing one ear at a time. The Weber and Rinne tests may be used to distinguish conductive loss from sensorineural loss when hearing is impaired. These tests are part of the usual screening physical examination and are useful if a more specific assessment is needed. Whisper test To exclude one ear from the testing, the examiners cover the untested ear with the palm of the hand. Then the examiner whispers softly from a distance of 1 or 2 feet from the unoccluded ear and out of the patients sight. The patient with normal acuity can correctly repeat what was whispered.

Weber Test The Weber test uses bone conduction to test lateralization of sound. A tuning fork (ideally 512 Hz), set in motion by grasping it firmly by its stem and tapping it on the examiners knee or hand, is placed on the patients head or forehead. A person with normal hearing hears the sound equally in both ears or describes the sound as centered in the middle of the head. A person with conductive hearing loss, such as from otosclerosis or otitis media, hears the better in the affected ear. A person with sensorineural loss, resulting from damage to the cochlear or vestibulocochlear nerve, hears the sound in the better-hearing ear. The Weber test is useful for detecting unilateral hearing loss. Rinne Test In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions; 2 inches from the opening of the ear canal (for air conduction) and against the mastoid bone (for bone conduction). As the position changes, the patient is asked to indicate which tone is no longer audible. The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. A person with normal hearing reports that air-conducted sound is louder than bone conducted sound. A person with a conductive hearing loss hears bone-conducted sound as long as or longer than air-conducted sound. A person with a sensorineural hearing loss hears air conducted sound longer than bone-conducted sound. Assessment in client with hearing loss Irritable, hostile or hypersensitive I interpersonal relations Has difficulty in following directions Complains about people mumbling Turns up volume on TV Asks for frequent repetition Answers questions inappropriately Leans forward to hear better; face looks serious and strained Loses sense of humor; becomes grim and lonely Experiences social isolation Develops suspicious attitude Has abnormal articulation Complains of ringing in the ear Has unusually soft or loud voice Dominates conversation

 Diagnostics
AUDIOMETRY Pure-Tone Audiometry -sound stimulus consists of a pure or musical tone (the louder the tone before the patient perceives it the greater the hearing loss) Speech Audiometry -determines the ability to hear and discriminate sounds and words THREE IMPORTANT CHARACTERISTICS Frequency -number of sound waves emanating from a source per second, measured as cycles per second or Hertz (Hz) Pitch -term used to describe frequency, a tone with 100 Hz is low pitch, and a tone of 10,000 Hz is high pitch Intensity -the pressure exerted by sound/loudness -measured in decibels (dB) -30 dB is considered critical level

TYMPHANOGRAM impedance audiometry measures middle ear muscle reflex to sound stimulation and compliance of the tymphanic membrane by changing the air pressure in a sealed ear canal.

ELECTROCHLEOGRAPHY It is the recording of electrophysiologic potentials of the cochlea and cranial nerve VIII in response to acoustic stimuli. The active potentials responses to an auditory stimulus such as a click. The potentials measured include the action potential of the cranial nerve VIII (AP) and summating potential (SP). The resulting ratio is used to assist in diagnosing disorders of the inner ear fluid balance such as Menieres disease and perilymph fistula. Procedure The procedure is performed by placing an electrode as close as possible to the cochlea, either in the external auditory canal next to the tympanic

membrane or via a transtympanic electrode placed through the thympanic membrane near the round window membrane. Management Patients are asked not to take any diuretics for 48 hours before the test. Results Results are reported as an amplitude ratio between the action potential (AP) and the summating potential (SP). SP/AP ratios less than 0.33 are considered to be within the normal range. SP/AP ratios greater than 0.4 considered positive for endolympathic hydrops/ Meniere's disease.

ELECTRONYSTAGMOGRAPHY It is the measurement and graphic recording of the changes in electrical potentials created by eye movements during spontaneous, positional or calorically evoked nystagmus. It is used to assess the oculomotor and vestibular systems and their corresponding interaction. ENG helps in the diagnosis of conditions such as Menieres disease and tumors of the internal auditory canal or posterior fossa.

Procedure The patient is positioned in such a way that the lateral semicircular anal is parallel to the gravitational field and seated while electrodes are placed on the forehead and near the eyes. In the caloric portion of the testing, hot and cold air or water is placed in the external auditory canal and eye movements are then measured. Management - Patients are asked not to take any vestibular suppressants such as sedatives, tranquilizers, antihistamines or alcohol. - Patients are also asked not to take any vestibular stimulants such as caffeine for 24 hours before testing.

COMPUTERIZED DYNAMIC POSTUROGRAPHY also called test of balance (TOB). a non-invasive specialized clinical assessment technique used to quantify the central nervous system adaptive mechanisms (sensory, motor and central) involved in the control of posture and balance, both in normal and abnormal conditions. It has been proven effective in assessing vestibular as well as some neuromuscular disorders affecting balance.

Procedure During CDP testing, the patient stands on a movable, dual forceplate support surface within a moveable surround (enclosure). Under control of a computer, the force platform can either move in a horizontal plane (translate), or rotate out of the horizontal plane. Standardized test protocols expose the patient to support surface and visual surround motions, during which the patient's postural stability and motor reactions are recorded. These test protocols include: 1. Sensory Organization Test (SOT) Controlled spontaneous sway is eliminated without provoking motor reactions by moving the support surface and the visual enclosure in response to the patient's postural movements.

2. Motor Control Test (MCT) 3. Adaptation Test (ADT) During the motor control protocols (MCT and ADT), reactions are provoked by unexpected abrupt movements of the support surface.

Management - Secure the harness placed on the clients body to prevent falls. - Let the client rest for 5-10 minutes after the procedure in case dizziness occurs.

SINUSOIDAL HARMONIC ACCELERATION - also called as rotary chair testing - used for analyzing horizontal canal vestibuloocular reflex (VOR). - is typically ordered in addition to video nystagmography electronystagmography testing to evaluate your vestibular system.

Procedure During rotary chair testing, you will sit in a rotational computerized chair positioned in the middle of a small, dark room. The chair has a seatbelt and security head strap to keep your torso and head in place and will be given a pair of infrared video goggles, which will record eye movements during the test. The client will be alone in the room, but there is a microphone to speak to the audiologist operating the chair and conducting the test. The test takes approximately 30 minutes and includes different sub-tests, which are designed to help determine if your dizziness or imbalance is a result of a vestibular system or central nervous system problem. During these tasks, the eye movements will be carefully monitored and recorded, specifically measuring the vestibulo-ocular reflex which occurs in response to movement of the chair.

The first part of the test is called the oculomotor test, which measures the eye movements in response to moving lights projected on the wall in front of the client. The next part of the test is the chair test where the client will be turned at varying speeds in the rotary chair. Eye movement is recorded and analyzed again. Both types of tests are useful in diagnosing and localizing the source of dizziness or imbalance. Its important that you tell the audiologist if any symptoms such as dizziness, nausea or headache are experience during these tasks.

MANAGEMENT
CERUMEN IMPACTION Cerumen can be removed by irrigation, suction or instrumentation. Unless the patient has a perforated eardrum or an inflamed external ear, gentle irrigation usually helps remove impacted cerumen, particularly if it is not tightly packed in the external auditory canal. For successful removal, the water must stream behind the obstructing cerumen to move it first laterally and then out of the canal. To prevent injury, the lowest effective pressure should be used. If irrigation is unsuccessful, direct visual, mechanical removal can be performed on a cooperative patient by a trained health care provider. Instilling a few drops of warmed glycerin, mineral oil or half-strength hydrogen peroxide into the ear canal for 30 minutes can soften cerumen before its removal. Ceruminolytic agents, such as peroxide in glyceryl are available. Using any softening solution two or three times a day for several days is generally sufficient. If the cerumen cannot be dislodged by these methods, instruments such as cerumen curette, aural suction and a binocular microscope for magnification can be used.

FOREIGN BODIES 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: 1. Irrigation 2. Suction 3. 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.

EXTERNAL OTITIS (Otitis Externa) -inflammation of the external auditory canal Causes - water in the ear canal (swimmers ear) - trauma to the skin of ear canal - entrance of organisms into the tissues Clinical Manifestations - pain - discharge from external auditory canal >yellow/green >foul-smelling >hair-like black spores may be visible - aural tenderness - fever - pruritus - hearing loss Management - instruct patients not clean external auditory canal with cotton-tipped applicators and to avoid scratching of the canal. - avoid getting the canal wet (e.g. swimming and shampooing) - to avoid infection use antiseptic otic preparations after swimming MALIGNANT EXTERNAL OTITIS (Temporal Bone Osteomyelitis) - a progressive, debilitating and occasionally fatal infection of the external auditory canal, the surrounding tissue and the base of the skull. - Pseudomonas Aeruginosa, is usually the infecting agent Management - Administration of antibiotics >antipseudomonal >aminoglycoside Local wound care >debridement of the infected tissue, including bone and cartilage; depending on the extent of infection -

MOTION SICKNESS - disturbance of equilibrium caused by constant motion Manifestations - sweating - pallor - nausea and vomiting cause by vestibular overstimulation Management o OTC antihistamines (dimenhydrinate, meclizine hydrochloride) -provides relief from nausea and vomiting by blocking the conduction of vestibular pathway of the inner ear ACUTE OTITIS MEDIA Acute otitis media (middle ear infection) is extremelycommon in children and also occurs in adults. In acuteotitis media, infection occurs behind the tympanicmembrane (eardrum). Acute otitis media is usually caused bybacteria. Management More than 80% of ear infections can resolve on their own. Sometimes antibiotic treatment is necessary, especially if there is no improvement with a few days of watchingan otherwise healthy child and providing pain relief with acetaminophen or ibuprofen.Infants younger than 6 months with an infection, however, should receive antibioticswithout delay. Some children with special circumstances should be more aggressivelytreated. These conditions include congenital heart disease, cleft palate, Down syndrome,or immune system problems (such as leukemia, other cancers, or inherited disorders ofthe immune system). Children who have an episode of acute otitis media within 30 daysof another episode usually require antibiotic treatment. Ear tubes are not the firstlinetreatment for acute otitis media, though they may be offered to individuals who havechronic middle ear fluid or chronic otitis media. Children with repeated ear infections are often referred to anotolaryngologist (a doctor with specialized education in the management and surgery of head and neck problems) for evaluation. Ongoing researchmay offer new recommendations for treatment of acute otitis media. Since the vaccinefor Streptoccocus pneumoniae(PCV) was introduced, other bacteria not covered by thisvaccine are now more common causes of acute otitis media. Antibiotic resistance(whenbacteria are no longer killed by certain antibiotics) also changes with time, and this mayinfluence the choice of antibiotic treatment in the future. TYMPANIC MEMBRANE PERFORATION A tympanic membrane perforation is a condition where your eardrum has a tear or hole in it.

Management A mild eardrum perforation may heal on its own over time. Your caregiver may clean your ear and put a bandage over it. He may also place a cotton ear plug in your ear to cover the tear. You may be given antibiotic medicine to treat or prevent infection caused by bacteria (germs). The medicine may be placed directly in your ear before it is covered with a bandage. Your eardrum may heal completely within a few weeks to a few months. You may also need the following: Surgery You may need surgery to repair your eardrum and prevent future ear infections. This is done when the hole in your eardrum is large, or does not heal on its own. You may also need surgery if your hearing loss or ear discharge does not get better with medicine. Ask your caregiver for more information on the following:
o

Myringoplasty: This type of surgery uses a tissue graft to cover your torn eardrum. A tissue graft may be taken from your own body, another person, an animal, or is man-made. A procedure called a mastoidectomy may also be done with a myringoplasty. A mastoidectomy is removal of infected bone from behind your ear. A mastoidectomy may also help prevent your eardrum from breaking down. Tympanoplasty: This surgery repairs your torn eardrum and any damage to your inner ear. A tympanoplasty also helps prevent chronic ear infections. The hole in your eardrum will be covered with a tissue graft. You may also need to have a mastoidectomy with your tympanoplasty surgery.

SEROUS OTITIS MEDIA -Known as glue ears -Seen most in those children where an immature musculature and repeated upper respiratory tract infections, predispose to tubal obstruction. -The child may develop hearing loss or earache -Examination of the ear will reveal the presence of fluid behind the tympanic membrane -A simple whisper test or an audiogram will confirm the presence of a hearing loss Management If the condition is temporary or intermittent, nothing needs to be done since most children outgrow the condition

If severe, a hole is made in the tympanic membrane (myringotomy) and the hole is prevented from healing by inserting a small plastic tube (grommet dottle or stopple) o If the grommet remains unblocked, the hearing is normal. When the condition is recurrent, large tubes is inserted to aerate the middle ear. Any underlying cause(sinusitis or enlarged adenoids is treated)

CHRONIC OTITIS MEDIA -A condition when a middle ear infection becomes persistent. -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 persistent discharge. Management - An attempt is made to remove any source of infection in the nose or nasopharynx and the local discharge can be controlled by regular irrigation and instillation of ear drops. - Myringoplasty- Surgical operation involves taking a piece of fascia from the surface temporalis muscle and the thin tissue is grafted over the perforation, the graft may be laid on the inner or outer surface of the tympanic membrane. - Tympanoplasty- Any loss of ossicular continuity can be corrected by repositioning a damaged ossicle or by replacing it with a piece of bone or prosthesis

ORTOSCLEROSIS Involves the stapes and is thought to result from the formation of new, abnormally spongy bone especially around the oval window, with resulting fixation of the stapes. The efficient transmission of sound is prevented because the stapes cannot vibrate and carry the sound as conducted from the malleus and incus to the inner ear.

Management There is no known nonsurgical treatment for otosclerosis. However, some physicians believe the use of sodium fluoride can mature the abnormal spongy bone growth and prevent the breakdown of the bone tissue. Amplification with a hearing aid also may help Surgical Management

One of two surgical procedures may be performed, the stapedectomy or the stapedotomy. A stapedectomy involves removing the stapes superstructure and part of the footplate and inserting a tissue graft and a suitable prosthesis. The surgeon drills a small hole into the footplate to hold a prosthesis. The prosthesis bridges the gap between the incus and the inner ear, providing better sound conduction. Stapes surgery is very successful approximately 95% of patients experience resolution of conductive hearing loss. Balance disturbance or true vertigo, which rarely occurs in other middle ear surgical procedures, may occur during the postoperative period for several days. MENIEREs DISEASE - An abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolympathic duct. Management Most patients with Menieres Disease can be successfully treated with diet and medication. Many patients can control their symptoms by adhering to a lowsodium (2000mg/day) diet. The ampunt of sodium is one of many factors that regulate the balance of fluid within the body. Sodium and fluid retention disrupts the delicate balance between endolymph and perilymph in the inner ear. Pharmacologic Therapy Pharmacologic Therapy for Menieres Disease consists of antihistamines such as meclizine (Antivert), which suppress the vestibular system. Tranquilizers such as diazepam may be used in acute instances to help control vertigo. Antiemetics such as promethazine suppositories help control the nausea and vomiting and the vertigo because of their antihistamine effect. Diuretic therapy may relieve symptoms by lowering the pressure in the endolymphatic system. Intake of foods containing potassium is necessary if the patient takes a diuretic that causes potassium loss. Surgical Management o Endolympathic Decompression This procedure is favoured by many otolaryngologists as a first line surgical approach to treat the vertigo of Menieres disease because it is relatively simple and safe and can be performed on an outpatient basis.

o Intraotologic Catheters Potential uses of these catheters include treatment for sudden hearing loss and various disorders causing intractable vertigo. Future applications may include tinnitus and slowly progressing sensorineural hearing loss. Intratympanic injections of ototoxic medications for round window membrane diffusion can be used to decrease vestibular function. Established surgical techniques can be used for the patient with vertigo who has not responded to medical or physical therapeutic modalities. o Vestibular Nerve Sectioning Vestibular nerve sectioning provides the greatest success rate in eliminating the attacks of vertigo. It can be performed by a translabyrintharine approach or in a manner that can conserve hearing, depending on the degree of hearing loss. Most patients with incapacitating Menieres disease have little or no effective hearing. Cutting the nerve prevents the brain from receiving input form the semicircular canals.

LABYRINTHISTIS - Is an ear disorder that involves irritation and swelling (inflammation) of the inner ear. Causes Although rare because of antibiotic therapy, bacterial labyrinthitis usually occurs as a complication of otitis media. The infection can enter the inner ear by penetrating the membranes of the oval or round windows. Viral labyrinthitis is a common medical diagnosis, but little is known about this disorder, which affects hearing and balance. The most commonly identified viral causes are mumps, rubella, rubeola, and influenza. Viral illnesses of the upper respiratory tract and herpetiform disorders of the facial and acoustic nerves (ie, Ramsay Hunt syndrome) also cause labyrinthitis. Manifestations Labyrinthitis is characterized by a sudden onset of incapacitating vertigo, usually with nausea and vomiting, various degrees of hearing loss, and possibly tinnitus. The first episode is usually the worst; subsequent attacks, which usually occur over a period of several weeks to months, are less severe.

Management Treatment of bacterial labyrinthitis includes intravenous antibiotic therapy, fluid replacement, and administration of a vestibular suppressant, such as meclizine, and antiemetic medications. Treatment of viral labyrinthitis is tailored to the patients symptoms.

OTOTOXICITY Is damage to the ear (oto-), specifically the cochlea or auditory nerve and sometimes the vestibular system, by a toxin. - It is commonly medication-induced; ototoxic drugs o Antibiotics - aminoglycoside and gentamicin o Loop Diuretics - furosemide o Chemotherapeutic agents cisplatin o NSAIDs o Others quinine, aspirin Manifestations - Hearing loss - Vertigo - Tinnitus Management No specific treatment is available, but immediate withdrawal of the drug may be warranted in cases where the consequences of doing so are less severe than the consequences of the ototoxicity.

ACOUSTIC NEUROMA An acoustic neuroma is a slow-growing, benign tumor of cranial nerve VIII, usually arousing from the Schwann cells of the vestibular portion of the nerve. Most acoustic tumors arise within the internal auditory canal and extend into the cerebellpontine angle to press upon the brainstem. The most common presenting symptoms in patients with an acoustic neuroma are unilateral tinnitus and hearing loss with or without vertigo or balance disturbance. Magnetic resonance imaging with a paramagnetic contrast agent is the imaging study of choice. Computed tomography scan with contrast dye maybe also performed. An MRI with contrast should identify a 2- to 3mm tumor whereas a CT scan with contrat may miss tumors of 2 cm in diameter. Surgical removal of acoustic tumors is the treatment of choice.

HEARING AIDS A hearing aid is an instrument through which sounds, both speech and environment, are received by a microphone, converted to electrical signals, amplified and reconverted to acoustic signals. A hearing aid makes sounds louder, but it does not faithfully reproduce the sounds nor does it improve a patients ability to discriminate words or understand speech. Caring of the Hearing Aid A hearing aid must be cared for carefully, and the wearer should know how to do so as well as what to do it the aid fails. The ear mold, the only part of the instrument that may be washed, is washed frequently (daily, if necessary) in soap and water and the cannula is cleansed with a small applicator or pipe cleaner. The ear mold must be dry before it is snapped into the receiver. The transmitter is usually worn behind the ear of in the frame of the eyeglasses. Spare parts should also be available. Common medical problems among wearers of hearing aids are otitis externa and pressure ulcers in the external auditory canal or meatus.