Eye, Ear, and Throat Disorders

I. STRABISMUS
A. Description
1.Called “squint” or “lazyeye”
2.Condition in which the eyes are not aligned
because of lack of coordination of the
extraocular muscles
3.Most often results from muscle imbalanceor
paralysis of extraocular muscles but also may
result from conditions such as abrain
tumor, myasthenia gravis, or infection
4.Normal in the young infant but should not be
present after about age 4months
 B. Assessment
1.Amblyopia (reduced visual acuity) if not
treated early
2. Permanent loss of vision if not treated early
3. Loss of binocular vision
4. Impairment of depth perception
5. Frequent headaches
6. Squinting or tilting of the head to see
 C. Interventions
1. Corrective lenses may be indicated.
2. Instruct the parents regarding patching (occlusion therapy) ofthe
“good” eye to strengthen the weakeye.
3. Injection of botulinum toxin (Botox) may be prescribed (injectedinto
the eye muscle) as a nonsurgical intervention (treatment produces
temporary paralysis to allow the muscles opposite the paralyzed
muscle to
straighten the eye).
4. Inform the parents that the injection of botulinum toxin wears off in
about 2 months and, if successful, correction willoccur.
5. Prepare for surgery to realign the weak muscles as prescribed if
nonsurgical interventions are unsuccessful; this is performed before
the age of 2 years.
6. Instruct the parents about the need for follow-up visits.
 II. CONJUNCTIVITIS
A. Description
1.Also is known as “pinkeye”; is an inflammation
of the conjunctiva
2.Conjunctivitis usually is caused by
allergy, infection, or trauma.
3.Bacterial or viral conjunctivitis isextremely
contagious.
4.Chlamydial conjunctivitis is rare in older
children and, if diagnosed in a child who is not
sexually active, the child should be assessedfor
possible sexual abuse.
 B. Assessment
1. Itching, burning, or scratchyeyelids
2. Redness
3. Edema
4. Discharge
 C. Interventions
1. Instruct in infection control measures such as good hand washing andnot
sharing towels and washcloths.
2. Administer antibiotic or antiviral eye drops or ointmentas prescribed if
infection is present.
3. Administer antihistamines as prescribed if an allergy is present.
4. Instruct the child and parents about the administration of the prescribed
medications.
5. Instruct the parents that the child should be kept home from school or day
care until antibiotic eye drops have been administered for24 hours.
6. Instruct about the use of cool compresses to lessen irritation and wearing
dark glasses for photophobia.
7. Instruct the child to avoid rubbing the eye to prevent injury.
8. Instruct the child who is wearing contact lenses to discontinue wearing
them and to obtain new lenses to eliminate the chance of reinfection.
9. Instruct the adolescent that eye makeup should be discarded andreplaced.
 III. OTITISMEDIA
A. Description
1.Otitis media is an inflammatory disorder
usually caused by an infection of the middleear
occurring as a result of a blocked eustachian
tube, which prevents normal drainage.
2.Otitis media is a common complication of an
acute respiratory infection.
3.Infants and children are more prone to otitis
media because their eustachian tubes are
shorter, wider, and straighter.
 B. Assessment
1. Fever
2. Irritability and restlessness
3. Loss of appetite
4. Rolling of head from side to side
5. Pulling on or rubbing the ear
6. Earache or pain
7. Signs of hearing loss
8.Purulent ear drainage
9. Red, opaque, bulging, or retracting tympanic
membrane
 C. Interventions
1. Encourage fluid intake.
2. Teach the parents to feed infants in upright position, to prevent reflux.
3. Instruct the child to avoid chewing as much as possible during theacute
period because chewing increases pain.
4. Provide local heat and have the child lie with the affected ear down.
5. Instruct the parents in the appropriate procedure to clean drainage from
the ear with sterile cottonswabs.
6. Instruct the parents in the administration of analgesics or antipyretics such
as acetaminophen (Tylenol) to decrease fever and pain.
7. Instruct the parents in the administration of the prescribed
antibiotics, emphasizing that the 10- to 14-day periodis necessary to
eradicate infective organisms.
8. Instruct the parents that screening forhearing loss may be necessary.
9. Instruct the parents about the procedure for administering ear
medications.
 Administration of Medications

• In a child younger than age 3, pull the lobe down andback.

• In a child older than 3 years, pull thepinna up and back.
 D. Myringotomy
1. Description: Insertion of tympanoplastytubes
into the middle ear to equalize pressure and
keep the ear aerated
 2. Postoperative interventions

a. Instruct the parents and child to keep the ears dry.

b. The client should wear earplugswhile
bathing, shampooing, and swimming,
c. Diving and submerging under water are not allowed.
d. Instruct the parents that if the tubes fall out, it is not
an emergency, but the physician should benotified.
e. Parents can administer an analgesic such as
acetaminophen (Tylenol) to relievediscomfort
following insertion of tympanoplastytubes.
f. Parents should be taught that the child should not blow
his or her nose for 7 to 10 days after surgery.
 IV. TONSILLECTOMY AND
ADENOIDECTOMY
A. Description
1.Tonsillitis refers to
inflammation and infection of
the tonsils (Fig. 36-2).
2.Adenoiditis refers to
inflammation and infection of
the adenoids.
5.Fever
6. Cough
7.Enlarged adenoids may
cause nasal quality of
speech, mouth
breathing, hearing
difficulty, snoring, and/or
obstructive sleep apnea.
 C. Preoperativeinterventions
1. Assess for signs of active infection.
2. Assess bleeding and clotting studies because
the throat isvascular.
3.Prepare the child for a sore throat
postoperatively, and inform the child that he
or she will need to drinkliquids.
4. Assess for any loose teeth to decrease therisk
of aspiration during surgery.
 D. Interventions postoperatively
1. Position the child prone or side-lying tofacilitate drainage.
2. Have suction equipment available, but do not suction unless there is anairway
obstruction.
3. Monitor for signs of hemorrhage (frequent swallowing may indicate hemorrhage);if
hemorrhage occurs, turn the child to the side and notify the physician.
4. Discourage coughing or clearing the throat.
5. Provide clear, cool, noncitrus and noncarbonated fluids.
6. Avoid milk products initially because they will coat thethroat.
7. Avoid red liquids, which simulate the appearance of blood if the child vomits.
8. Do not give the child any straws, forks, or sharp objects that can be put into the
mouth.
9. Administer acetaminophen (Tylenol) for sore throat asprescribed.
10. Instruct the parents to notify the physician if bleeding, persistent earache, or fever
occurs.
11. Instruct the parents to keep the child away from crowds until healinghas occurred.
 V. EPISTAXIS(NOSEBLEEDS)
A. Description
1.The nose, especially the septum, is a highly
vascular structure, and bleeding usually
results from direct trauma, foreign bodies,and
nose picking, or from mucosalinflammation.
2.Recurrent epistaxis and severe bleeding
may indicate an underlying disease.
 B. Interventions
1. Have the child sit up and lean forward (not lying
down).
2. Apply continuous pressure to nose with the
thumb and forefinger forat least 10 minutes.
3.Insert cotton or wadded tissue intoeach
nostril, and apply ice or a cold cloth to the bridge
of the nose if bleeding persists.
4. Keep the child calm and quiet.
5.If bleeding cannot be controlled, packing or
cauterization of the bleeding vessel may be
prescribed.
 Refractive Errors
1.Description
a.Refraction is the bending of light rays; any problemassociated
with eye length or refraction can lead torefractive errors.
b.Myopia (nearsightedness): Refractive ability of the eye is too
strong for the eye length; images are bent and fall in front of, not
on, the retina.
c.Hyperopia (farsightedness): Refractive ability of the eye istoo
weak; images are focused behind the retina.
d.Presbyopia: Loss of lens elasticity because of aging; less able to
focus the eye for close work and images fall behind theretina.
e.Astigmatism: Occurs because of the irregular curvature of the
cornea; image does not focus on the retina.
 2. Assessment
a.Refractive errors are diagnosed through a
process called refraction.
b.The client views an eye chart while various
lenses ofdifferent strengths are systematically
placed in front of the eye and is asked
whether the lenses sharpen or worsen the
vision.
3.Nonsurgical interventions: Eyeglasses or
contact lenses
4.Surgical interventions
a.Radial keratotomy: Incisions are made
through the peripheral cornea to flatten the
cornea, which allows the image to befocused
closer to the retina; used to treat myopia.
 Surgical interventions cont…
b. Photorefractive keratotomy: A laser beam is used to
remove small portions of the corneal surface to
reshape the cornea tofocus an image properly on the
retina; used to treatmyopia and astigmatism.
c. Laser-assisted in-situ keratomileusis (LASIK): The
superficial layers of the cornea are lifted as a flap, a
laser reshapes the deeper corneal layers, and thenthe
corneal flap is replaced; used to treat
hyperopia, myopia, and astigmatism.
d. Intacs corneal ring: The shape of thecornea is changed
by placing a flexible ring in the outer edges of the
cornea; used to treat myopia.
 C. Legally blind
1. Description: The best visual acuity with
corrective lenses in the better eye of 20/200
or less or visual acuity of less than20 degrees
of the visual field in the better eye
 2. Interventions
a. When speaking to the client who has limited sight or is blind, the nurse
uses a normal tone of voice.
b. Alert the client whenapproaching.
c. Orient the client tothe environment.
d. Use a focal point and provide further orientation to the environment from
that focal point.
e. Allow the client to touch objects in the room.
f. Use the clock placement of foods on the meal tray to orient the client.
g. Promote independence as much as is possible.
h. Provide radios, televisions, and clocks that give the time orally, orprovide a
braille watch.
i. When ambulating, allow the client to grasp the nurse's arm at the elbow;
the nurse keeps his or her arm close to the body so that the client can
detect the direction ofMovement.
 Interventions cont…
j. Instruct the client to remain one step behind the
nurse when ambulating.
k. Instruct the client in the use of the cane for the
blind, which is differentiated from other canes by
its straight shape and white color with red tip.
l. Instruct the client that the cane is held in the
dominant hand several inches off the floor.
m.Instruct the client that the cane sweeps the
ground where the client's foot will be placed next
to determine the presence ofobstacles.
 D. Cataracts
1. Description
a.A cataract is an opacity of the
lens that distorts the image
projected onto the retina and
that can progress to blindness.
b.Causes include the aging
process (senile
cataracts), inherited (congenital
cataracts), and injury (traumatic
cataract s); cataract s also can
result from another eye disease
(secondary cataract s).
c.Intervention is indicated when
visual acuity has been reduced to
a level that the client finds to be
unacceptable or adverselyaffects
his or her lifestyle.
 2. Assessment
a.Blurred vision and decreased color
perception are early signs
b.Diplopia, reduced visual acuity, absence of
the red reflex, and the presence of a white
pupil are late signs. Pain or eye redness is
associated with age-related cataract
formation.
c. Loss of vision is gradual.
 3. Interventions
a.Surgical removal of the lens, one eye at a time, is
performed.
b.With extracapsular extraction the lens is lifted out
without removing the lens capsule; the proceduremay be
performed by phacoemulsification, in which the lens is
broken up by ultrasonic vibrations andextracted.
c.With intracapsular extraction, the lens and capsuleare
removed completely.
d.A partial iridectomy may be performed with the lens
extraction to prevent acute secondaryglaucoma.
e.A lens implantation may be performed at the time ofthe
surgical procedure.
 4. Preoperative interventions
a.Instruct the client regarding the
postoperative measures to prevent or
decrease intraocular pressure.
b.Stress to the client that care after surgery
requires instillation of different types of eye
drops several times a day for 2 to 4weeks
c.Administer eye medications
preoperatively, including mydriatics and
cycloplegics as prescribed.
 5. Postoperative interventions
a. Elevate the head of the bed 30 to 45 degrees.
b. Turn the client to the back or nonoperative side.
c. Maintain an eye patch as prescribed; orient the
client to theenvironment.
d. Position the client's personal belongings to the
nonoperative side.
e. Use side rails for safety.
f. Assist with ambulation.
 6. Client education
• Avoid eye straining.
• Avoid rubbing or placing pressure on
the eyes.
• Avoid rapid
movements, straining, sneezing, coug
hing,
• bending, vomiting, or lifting objects
heavier than 5 lb.
• Take measures to prevent
constipation.
• Follow instructions for dressing
changes and prescribed eye drops
and medications.
• Wipe excess drainage or tearing with
a sterile wet cotton ball from the
inner to the outercanthus.
• Use an eye shield at bedtime.
• If lens implantation is not
performed, the eye cannot
accommodate and glasses must be
worn at all times.
• Cataract glasses act as magnifying
glasses and replace central vision
only.
• Because cataract glasses
magnify, objects will appear closer;
therefore, the client needs to
accommodate, judge distance, and
climb stairs carefully.
• Contact lenses provide sharp visual
acuity but dexterity is needed to
insert them.
• Contact the physician about any
decrease in vision, severe eye
pain, or increase in eyedischarge
 E. Glaucoma
1. Description
a.A group of ocular diseases resulting in increased
intraocular pressure
b.Intraocular pressure is the fluid (aqueous humor)
pressure within the eye (normal intraocular pressure is10
to 21 mm Hg).
c.Increased intraocular pressure results from inadequate
drainage of aqueous humor from the canal of Schlemm or
overproduction of aqueoushumor.
d.The condition damages the optic nerve and can result in
blindness.
e.The gradual loss of visual fields may go unnoticed
because central vision is unaffected.
 2. Types
a.Acute closed-angle or narrow-angle glaucoma
results from obstruction to outflow of aqueous humor.
b.Chronic closed-angle glaucoma follows an untreated
attack of acute closed-angleglaucoma.
c.Chronic open-angle glaucoma results from
overproduction or obstruction to the outflow of
aqueous humor.
d.Acute glaucoma is a rapid onset of intraocular
pressure higher than 50 to 70 mmHg.
e.Chronic glaucoma is a slow, progressive, gradual
onset of intraocular pressure higher than 30 to 50 mm
Hg.
 3. Assessment
a.Early signs include diminished
accommodation and increased intraocular
pressure.
b. Late signs include loss of peripheral
vision, decreased visual acuity not correctable
with glasses, halos around lights; headache or
eye pain occurs with acute closed-angle
glaucoma.
4. Interventions for acuteglaucoma
a.Treat acute glaucoma as a medical
emergency.
b.Administer medications as prescribed to
lower intraocular pressure.
c.Prepare the client for peripheral
iridectomy, which allows aqueous humor to
flow from the posterior to the anterior
chamber.
 5. Interventions for chronic glaucoma
a. Instruct the client on the importance
of medications (miotics) to constrict
the pupils, (carbonic anhydrase
inhibitors) to decrease the production
of aqueous humor, andb- blockers to
decrease the production of aqueous
humor and intraocular pressure.
b. Instruct the client of theneed for
lifelong medication use.
c. Instruct the client to weara Medic
Alert bracelet.
d. Instruct the client to avoid
anticholinergic medications.
e. Instruct the client to report eye
pain, halos around the eyes, and
changes in vision to the physician.
f. Instruct the client that when maximal
medical therapy has failed to halt the
progression of visual field loss and
optic nerve damage, surgery will be
recommended.
g. Prepare the client for trabeculoplasty
as prescribed to facilitate aqueous
humor drainage.
h. Prepare the client for trabeculectomy
as prescribed, which allows drainage
of aqueous humor into the
conjunctival spaces by the creation of
an opening.
 F.Retinaldetachment
1. Description
a.Detachment or separation of the retina from the
epithelium
b.Retinal detachment occurs when the layers of the
retina separate because of the accumulation of fluid
between them, or when both retinal layers elevate
away from the choroid as a result of atumor.
c. Partial detachment becomes complete if untreated.
d.When detachment becomes complete, blindness
occurs.
 2. Assessment
a. Flashes of light
b. Floaters or black spots (signs of bleeding)
c. Increase in blurred vision
d. Sense of a curtain being drawn over the eye
e. Loss of a portion of the visualfield
 3. Immediate interventions
a.Provide bed rest.
b.Cover both eyes with patches as prescribed to
prevent further detachment.
c. Speak to the client beforeapproaching.
d. Position the client's head asprescribed.
e. Protect the client from injury.
f. Avoid jerky head movements.
g. Minimize eye stress.
h.Prepare the client for a surgical procedureas
prescribed.
 4. Surgical procedures
a. Draining fluid from the subretinal space sothat
the retina can return to the normal position
b. Sealing retinal breaks by cryosurgery, a cold
probe applied to the sclera, to stimulate an
inflammatory response leading to adhesions
c. Diathermy, the use of an electrode needleand
heat through the sclera, to stimulate an
inflammatory response
d. Laser therapy, to stimulate an inflammatory
response and seal small retinal tearsbefore
the detachmentoccurs
e. Scleral buckling, tohold the choroid and retina
together with a splint until scar tissue
forms, closing the tear
f. Insertion of gas or silicone oil to promote
reattachment; these agents floatagainst the
retina to hold it in place until healing occurs.
 5. Postoperative interventions
a. Maintain eye patchesas
prescribed.
b. Monitor for hemorrhage.
c. Prevent nausea and vomiting and
monitor for restlessness, which
can cause hemorrhage
d. Monitor for sudden, sharpeye
pain (notify the physician).
e. Encourage deep breathing but
avoid coughing.
f. Provide bed rest for 1 to 2days as
prescribed.
g. Position the client asprescribed
(positioning depends on the
location of the detachment).
h. Administer eye medications asprescribed.
i. Assist the client with activities of daily living.
j. Avoid sudden head movements or anything
that increases intraocular pressure.
k. Instruct the client to limit reading for 3 to 5
weeks.
l. Instruct the client toavoid
squinting, straining and
constipation, lifting heavy objects,and
bending from the waist.
m. Instruct the client to wear dark glasses
during the day and an eye patch at night.
n. Encourage follow-up care because of the
danger of recurrence or occurrence in the
other eye.
 G. Macular degeneration
1. Adeterioration of the macula, the area of central vision
2. Can be atrophic (age-related or dry) or exudative(wet)
3. Age-related: Caused by gradual blocking of retinal
capillaries leading to an ischemic and necroticmacula;
rods and cones photoreceptors die.
4. Exudative: Serous detachment of pigment epithelium
in the macula occurs; fluid and blood collect under the
macula, resulting in scar formation and visual
distortion.
5. Interventions are aimed at maximizing theremaining
vision.
 6. Assessment
a. A decline in central vision
b. Blurred vision and distortion
 7. Interventions
a.Initiate strategies to assist in maximizing
remaining vision and maintaining
independence.
b. Provide referrals to communityorganizations.
c. Laser therapy or photodynamic therapy may
be prescribed to seal the leaking bloodvessels
in or near the macula.
 Contusions
1. Description
a.Bleeding into the soft tissue as a result ofan
injury.
b.A contusion causes a black eye; the
discoloration disappears in about 10days.
c.Pain, photophobia, edema, and diplopia
may occur.
 2. Interventions
a.Place ice on the eyeimmediately.
b.Instruct the client to receive a thorougheye
examination.
 Foreign bodies
1. Description: An object such as dust or dirt
that enters the eye and causesirritation
 2. Interventions
a. Have the client look upward, expose the lower
lid, wet a cotton-tipped applicator with sterile
normal saline, gently twist the swab over the
particle, and remove it.
b.If the particle cannot be seen, have the client
look downward, place a cotton applicator
horizontally on the outer surface of the upper eye
lid, grasp the lashes, and pull the upper lid
outward and over the cotton applicator; if the
particle is seen, gently twist a swab over it to
remove.
 Penetrating objects
1. Description: An eye injury in which anobject
penetrates the eye
 2. Interventions
a. Never remove the object because it may be holding
ocular structures in place; theobject must be removed
by the physician.
b. Cover the object with acup.
c. Do not allow the client to bend over.
d. Do not place pressure on the eye.
e. Client is to be seen by a physicianimmediately.
f. X-rays and CTscans of the orbit are usually obtained.
g. Magnetic resonance imaging (MRI) is contraindicated
because of the possibility of metal-containing projectile
movement during the procedure.
 Chemical burns
1. Description: An eye injury in which acaustic
substance enters the eye
 2. Interventions
a. Treatment should begin immediately.
b. Flush the eyes at the scene of the injury with water for at least 15 to
20 minutes.
c. At the scene of the injury, obtain a sample ofthe chemical involved.
d. At the emergency room, the eye is irrigated with normal saline
solution or an ophthalmic irrigation solution for at least 10 minutes.
e. The solution is directed across the cornea and toward the lateral
canthus.
f. Prepare for visual acuity assessment.
g. Apply an antibiotic ointment asprescribed.
h. Cover the eye with a patch asprescribed.
DISORDERSOFTHEEAR
A. Risk factors related to eardisorders
• Aging process
• Infection
• Medications
• Ototoxicity
• Trauma
• Tumors
 B. Conductive hearing loss
1. Description
a.Conductive hearing loss occurs whensound
waves are blocked to the inner ear fibers
because of external or middle eardisorders.
b.Disorders often can be corrected with no
damage to hearingor minimal permanent
hearing loss.
 2. Causes
a.Any inflammatory process or obstruction of
the external or middleear
b. Tumors
c.Otosclerosis
d.A buildup of scar tissue on the ossiclesfrom
previous middle ear surgery
 C. Sensorineural hearing loss
1. Description
a.Sensorineural hearing loss is apathological
process of the inner ear or of the sensory
fibers that lead tothe cerebral cortex.
b.Sensorineural hearing loss is often
permanent, and measures must be taken to
reduce further damage or to attempt to
amplify sound as a means of improving
hearing to somedegree.
 2. Causes
a. Damage to the inner f. Inherited disorders
ear structures g. Metabolic and
b. Damage to the eighth circulatory disorders
cranial nerve h. Infections
c. Prolonged exposure to i. Surgery
loud noise j.Menière's syndrome
d. Medications
k. Diabetes mellitus
e. Trauma
l. Myxedema
 D. Mixed hearing loss
1.Mixed hearing loss also is known as
conductive-sensorineural hearing loss.
2.Client has sensorineural and conductive
hearing loss.
E. Signs of hearing loss and facilitating
communication
• Signs of Hearing Loss
• Frequently asking others to repeat statements
• Straining to hear
• Turning head or leaning forward tofavor one ear
• Shouting in conversation
• Ringing in the ears
• Failing to respond when not looking in the direction of the sound
• Answering questions incorrectly
• Raising the volume of the television orradio
• Avoiding large groups
• Better understanding of speech when in smallgroups
• Withdrawing from socialinteractions
 Facilitation of Communication
• Using written words if the client is able to
see, read, and write
• Providing plenty of light in the room
• Getting the attention of the client before
beginning to speak
• Facing the client when speaking
• Talking in a room without distractingnoises
• Moving close to the clientand speaking
slowly and clearly
• Keeping hands and other objects awayfrom
the mouth when talking to the client
• Talking in normal volume and at a lowerpitch
because shouting is not
• helpful and higher frequencies are lesseasily
heard
• Rephrasing sentences and repeating
information
• Validating withthe client the understanding
of statements made by asking the client to
repeat what wassaid
• Reading lips
• Encouraging the client to wearglasses when
talking to someone to improve vision for lip
reading
• Using sign language, which combinesspeech
with hand movements thatsignify
letters, words, or phrases
• Using telephone amplifiers
• Flashing lights that are activated by ringing of
the telephone or doorbell
• Specially trained dogs that help theclient be
aware of sound and alert the client to
potential danger
 H. Presbycusis
1.Description
a.Presbycusis is a sensorineural hearing loss
associated with aging.
b.Presbycusis leads to degeneration or atrophy
of the ganglion cells in the cochlea and a loss of
elasticity of the basilarmembranes.
c.Presbycusis leads to compromise of the
vascular supply to the inner ear, withchanges in
several areas of the earstructure.
 2. Assessment
a.Hearing loss is gradual andbilateral.
b.Client states that he or she has no problem
with hearing but cannot understand whatthe
words are.
c. Client thinks that the speaker ismumbling.
 I. External otitis
1.Description
a.External otitis is an infective inflammatory or allergic responseinvolving
the structure of the external auditory canal or auricles.
b.An irritating or infective agent comes into contact with the epithelial
layer of the externalear.
c.Contact leads to an allergic response or signs and symptoms ofan
infection.
d. The skin becomes red, swollen, and tender to touch onmovement.
e.The extensive swelling of the canal can lead to conductive hearingloss
because of obstruction.
f.External otitis is more common in children; it is termed swimmer's ear
and occurs more often in hot, humidenvironments.
g. Prevention includes the elimination of irritating or infecting agents
 2. Assessment
a. Pain
b. Itching
c. Plugged feeling in the ear
d. Redness and edema
e. Exudate
f. Hearing loss
 3. Interventions
a. Apply heat locally for 20 minutes three times aday.
b. Encourage rest to assist in reducingpain.
c. Administer antibiotics or corticosteroids asprescribed.
d. Administer analgesics such as aspirin or acetaminophen (Tylenol) for
the pain asprescribed.
e. Instruct the client thatthe ears should be kept clean and dry.
f. Instruct the client to use earplugs forswimming.
g. Instruct the client that cotton-tipped applicators should not be used
in dry ears because their use can lead to trauma tothe canal.
h. Instruct the client that irritating agents such as hair productsor
headphones should be discontinued.
 K. Chronic otitis media
1. Description
a.Chronic otitis media is a chronic infective,
inflammatory,
or allergic response involving the structure of the
middle ear.
b. Surgical treatment is necessary to restorehearing.
c.The type of surgery can vary; it includes a simple
reconstruction of the tympanic membrane, a
myringoplasty, or replacement of theossicles within
the middle ear.
d.A tympanoplasty, reconstruction of the middle ear,
may be attempted to improve conductive hearingloss.
 2. Preoperative interventions
a.Administer antibiotic drops asprescribed.
b.Clean the ear of debris as prescribed; irrigate theear
with a solution of equal parts of vinegar and sterile
water as prescribed to restore the normal pH of the
ear.
c.Instruct the client to avoid persons with upper
respiratory infections.
d.Instruct the client to obtain adequate rest, eat a
balanced diet, and drink adequatefluids.
e.Instruct the client in deep breathing and coughing;
forceful coughing, which increases pressure in the
middle ear, is to be avoidedpostoperatively.
 3. Postoperative interventions
a.Inform the client that initial hearing after surgery
is diminished because of the packing in the ear
canal; hearing improvement will occur after the
ear canal packing is removed.
b. Keep the dressing clean and dry.
c. Keep the client flat, with the operative ear up for
at least 12 hours.
d. Administer antibiotics asprescribed.
e.Instruct the client that he or she may return to
work in about 3 weeks postoperatively as
prescribed.
 L. Mastoiditis
1. Description
a.Mastoiditis may be acute or chronic and
results from untreated or inadequately
treated chronic or acute otitis media.
b. The pain is not relieved bymyringotomy.
 2. Assessment
a. Swelling behind the ear and pain with minimal
movement of the head
b.Cellulitis on the skin or external scalp overthe
mastoid process
c. A reddened, dull, thick, immobile tympanic
membrane, with or without perforation
d. Tender and enlarged postauricular lymph nodes
e. Low-grade fever
f. Malaise
g. Anorexia
 3. Interventions
a. Prepare the client for surgical removal of infected
material.
b. Monitor for complications.
c. Simple or modified radical mastoidectomy with
tympanoplasty is the most commontreatment.
d. Once tissue that is infected is removed, the
tympanoplasty is performed to reconstruct the
ossicles and tympanic membranes in anattempt
to restore normal hearing.
 4. Complications
a. Damage to the abducens and facial cranialnerves
b. Damage is exhibited by inability to looklaterally
(cranial nerve VI, abducens) and a drooping of
the mouth on the affected side (cranial nerve
VII, facial).
c. Meningitis
d. Brain abscess
e. Chronic purulent otitis media
f. Wound infections
g. Vertigo, if the infection spreads into the labyrinth
 5. Postoperative interventions
a. Monitor for dizziness.
b. Monitor for signs of meningitis, as evidenced by a stiff neckand
vomiting.
c. Prepare for a wound dressing change 24 hours postoperatively.
d. Monitor the surgical incision for edema, drainage, andredness.
e. Position the client flat with the operative side up.
f. Restrict the client to bed with bedside commode privileges for24
hours as prescribed.
g. Assist the client with getting out of bed to prevent falling or injuries
from dizziness.
h. With reconstruction of the ossicles via a graft, take precautionsto
prevent dislodging of the graft.
 M. Otosclerosis
1. Description
a. Otosclerosis is a disease of the labyrinthine capsule of the middle ear that results
in a bony overgrowth of the tissue surrounding the ossicles.
b. Otosclerosis causes the development of irregular areas of new bone formation and
causes the fixation of the bones.
c. Stapes fixation leads to a conductive hearing loss.
d. If the disease involves the inner ear, sensorineural hearing loss is present.
e. Tohave bilateral involvement is not uncommon, although hearing loss may be
worse in one ear.
f. The cause is unknown, although it is thought to have a familialtendency.
g. Nonsurgical intervention promotes the improvement of hearingthrough
amplification.
h. Surgical intervention involves removal of the bony growth causing the hearingloss.
i. A partial stapedectomy or complete stapedectomy with prosthesis (fenestration)
may be performed surgically.
 2. Assessment
a. Slowly progressing conductive hearing loss
b. Bilateral hearing loss
c. A ringing or roaring type of constanttinnitus
d. Loud sounds heard in the ear whenchewing
e. Pinkish discoloration (Schwartze's sign) of the
tympanic membrane, which indicates vascular
changes within the ear.
f. Negative Rinne test
g. Weber's test shows lateralization of sound tothe
ear with the most conductive hearingloss.
 N. Fenestration
1. Description
a.Fenestration is removal of the stapes, with a
small hole drilled in the footplate;a prosthesis
is connected between the incus andfootplate.
b.Sounds cause the prosthesis to vibrate in the
same manner as the stapes.
c. Complications include complete hearing
loss, prolonged vertigo, infection, or facial
nerve damage.
 2. Preoperative interventions
a.Instruct the client in measures toprevent
middle ear or external earinfections.
b.Instruct the client to avoidexcessive nose
blowing.
c.Instruct the client not to clean the ear canal
with cotton-tipped applicators and to avoid
trauma or injury to the ear canal.
 3. Postoperative interventions
a. Inform the client that hearing is initially worse after the surgical procedure
because of swelling and that no noticeable improvement in hearing may
occur for as long as 6 weeks.
b. Inform the client that the Gelfoam ear packing interferes with hearing but
is used to decreasebleeding.
c. Assist with ambulating during the first 1 to 2 days after surgery.
d. Provide side rails when the client is in bed.
e. Administer antibiotic, antivertiginous, and pain medications asprescribed.
f. Assess for facial nerve damage, weakness, changes in tactile sensation and
taste sensation, vertigo, nausea, and vomiting.
g. Instruct the client to move the head slowly when changing positions to
prevent vertigo.
h. Instruct the client to avoid persons with upper respiratory tract infections.
i. Instruct the client to avoid showering and getting the
head and wound wet.
j. Instruct the client to avoid using small objects (cotton-
tipped applicators) to clean the external ear canal.
k. Instruct the client to avoid rapid extreme changes
inpressure caused by quick head
movements, sneezing, nose blowing, straining, and
changes in altitude.
l. Instruct the client to avoid changes in middle ear
pressure because they could dislodge the graftor
prosthesis.
 O. Labyrinthitis
1.Description: Infection of the labyrinth that
occurs as a complication of acute or chronic
otitis media
2.May result from growth of a cholesteatoma—
benign overgrowth of squamous cell
epithelium
 3. Assessment
a.Hearing loss that may be permanent on the
affected side
b. Tinnitus
c. Spontaneous nystagmus to the affected side
d. Vertigo
e. Nausea and vomiting
 4. Interventions
a. Monitor for signs of meningitis, the most common
complication, as evidenced by headache, stiff neck,and
lethargy.
b. Administer systemic antibiotics asprescribed.
c. Advise the client to rest in bed in a darkened room.
d. Administer antiemetics and antivertiginous
medications asprescribed.
e. Instruct the client that the vertigo subsides as the
inflammation resolves.
f. Instruct the client that balance problems that persist
may require gait training through physicaltherapy.
 P.Menière's syndrome
1. Description
a.Menière's syndrome is also called endolymphatic
hydrops; it refers to dilation of the endolymphatic system
by overproduction or decreased reabsorption of
endolymphatic fluid.
b. The syndrome is characterized by tinnitus, unilateral
sensorineural hearing loss, and vertigo.
c.Symptoms occur in attacks and last for several days, and
the client becomes totally incapacitated during the attacks.
d.Initial hearing loss is reversible but as the frequencyof
attacks continues, hearing loss becomes permanent.
e.Repeated damage to the cochlea caused by increased
fluid pressure leads to permanent hearingloss.
 2. Causes
a.Any factor that increasesendolymphatic
secretion in the labyrinth
b. Viral and bacterial infections
c. Allergic reactions
d. Biochemical disturbances
e.Vascular disturbance, producing changes in the
microcirculation in the labyrinth
f. Long-term stress may be a contributing factor.
 3. Assessment
a. Feelings of fullness in the ear
b. Tinnitus, as a continuous low-pitched roar or humming sound, that
is present much of the time but worsens just before and during
severe attacks
c. Hearing loss that is worse during anattack
d. Vertigo, as periods of whirling, that might cause the client to fall to
the ground
e. Vertigo that is so intense that even while lying down, theclient
holds the bed or ground in an attempt to prevent the whirling
f. Nausea and vomiting
g. Nystagmus
h. Severe headaches
 4. Nonsurgical interventions
a. Prevent injury during vertigo attacks.
b. Provide bed rest in a quiet environment.
c. Provide assistance with walking.
d. Instruct the client to move the head slowly to prevent worsening of the
vertigo.
e. Initiate sodium and fluid restrictions asprescribed.
f. Instruct the client to stop smoking.
g. Administer nicotinic acid (niacin) as prescribed for its vasodilatory effect.
h. Administer antihistamines as prescribed to reduce the productionof
histamine and the inflammation.
i. Administer antiemetics as prescribed.
j. Administer tranquilizers and sedatives as prescribed to calm the
client, allow the client to rest, and control vertigo, nausea, and vomiting.
k. Mild diuretics may be prescribed to decrease endolymphvolume
 5. Surgical interventions
a. Surgery is performed when medical therapy is
ineffective and the functional level of the client
has decreased significantly.
b. Endolymphatic drainage and insertion of ashunt
may be performed early in the course of the
disease to assist with the drainage of excess
fluids.
c. A resection of the vestibular nerve or total
removal of the labyrinth ora labyrinthectomy
may be performed.
 6. Postoperative interventions
a. Assess packing and dressing on the ear.
b. Speak to the client on the side of the unaffected
ear.
c. Perform neurological assessments.
d. Maintain side rails.
e. Assist with ambulating.
f. Encourage the client to use a bedsidecommode
rather than ambulating tothe bathroom.
g.Administer antivertiginous and antiemetic
medications asprescribed.
 Trauma
1. Description
a.The tympanic membrane has a limited stretching ability and gives
way under high pressure.
b.Foreign objects placed in the external canal may exertpressure
on the tympanic membrane and causeperforation.
c.If the object continues through the canal, the bony structure of
the stapes, incus, and malleus may be damaged.
d. A blunt injury to the basal skull and ear can damage themiddle
ear structures through fractures extending tothe middle ear.
e.Excessive nose blowing and rapid changes of pressure that occur
with nonpressurized air flights can increase pressure in the middle
ear.
f. Depending on the damage to the ossicles, hearing loss mayor
may not return.
 2. Interventions
a.Tympanic membrane perforations usually heal
within 24 hours.
b.Surgical reconstruction of the ossicles and
tympanic membrane through tympanoplasty
or myringoplasty may be performed to
improve hearing.
 S. Cerumen and foreignbodies
1. Description
a.Cerumen, or wax, is the mostcommon
cause of impacted canals.
b. Foreign bodies can include
vegetables, beads, pencil erasers, insects, and
other objects.
 2. Assessment
a.Sensation of fullness in the ear withor
without hearing loss
b. Pain, itching, or bleeding
 3. Cerumen
a. Removal of wax by irrigation is a slow process.
b.Irrigation is contraindicated in clients with a
history of tympanic membrane perforationor
otitis media.
c. To soften cerumen, add three drops of glycerin or
mineral oil to the ear at bedtime, and three drops
of hydrogen peroxide twice daily asprescribed.
d. After several days, irrigate the ear.
e. The maximum amount of solution thatshould be
used for irrigation is 50 to 70mL.
 4. Foreign bodies
a.With a foreign object of vegetable
matter, irrigation is used with care becausethis
material expands with hydration.
b. Insects are killed before removal, unless they can
be coaxed out by flashlight or a hummingnoise.
c. Mineral oil or diluted alcohol is instilled to
suffocate the insect, which then is removedusing
ear forceps.
d. Use a small ear forceps to remove the objectand
avoid pushing the object farther into the canal
and damaging the tympanic membrane.