Assessment and Management of Patients with Hearing and Balance Disorders

Chapter 59

Assessment
Inspection of external ear Otoscopic examination Gross auditory acuity
Whispered word test

Weber test Rinne test

Question
Tell whether the following statement is true or false. A patient with sensorneural hearing loss is being assessed using the Rinne s test. The nurse would expect air condution to be audible longer than bone conduction in the affected ear.

Answer
True Rationale: In sensorineural hearing loss, the Rinne s test would show that air conduction is audible longer than bone conduction in the affected ear.

Diagnostic Evaluation
Audiometry Tympanogram Auditory brain stem response Electronystagmography Platform posturography Sinusoidal harmonic acceleration Middle ear endoscopy

Hearing Loss
Affects more than 28 million people in the U.S. Increased incidence with age: presbycusis Key risk factor: exposure to excessive noise Types:
Conductive Sensorineural Mixed functional

Manifestations
Early symptoms:
Tinnitus Increased inability to hear in a group Turning up the volume of TV

Impairment may be gradual over time With advancing hearing loss patients may experience:
Deterioration of speech, fatigue, indifference, social isolation or withdrawal

Prevention
Environmental factors can diminish hearing
Noise induced hearing loss Acoustic trauma

In general today s environment is louder Ear protection is the most effective preventive measure OSHA mandates hearing protection in the workplace

Guidelines for Communicating with the Hearing Impaired

Use a low-tone, normal voice Speak slowly and distinctly Reduce background noise and distractions Face the person and get his attention Speak into the less-impaired ear Use gestures and facial expressions If necessary, write out the information or use sign language translator

Question
Which of the following would be included as a guideline for communicating with a hearingimpaired patient who speech reads: a) Speak slowly b) Face the person c) Make sure face is clearly visible d) All of the above

Answer
d) All of the above Rationale: When speaking, always face the person as directly as possible. Speak slowly and distinctly, pausing more frequently than you would normally. Make sure your face is as clearly visible as possible. Reference: Chart 59-4

Conditions of the External Ear

Cerumen impaction
Removal may be done by irrigation, suction, or instrumentation Gentle irrigation using lowest pressure
Direct stream behind the obstruction Glycerin, mineral oil, half-strength H2O2 or peroxide in glyceryl may help soften cerumen

Conditions of External Ear (cont.)

Foreign bodies
Removal by irrigation, suction or instrumentation Do not irrigate if object could swell Removal can be dangerous
May require extraction in surgery

Conditions of the External Ear (cont.)

External otitis
Inflammation most often due to staphylococcus, pseudomonas, or Aspergillus Manifestations: pain and tenderness, discharge, edema, erythema, pruritus, hearing loss, feeling of fullness in the ear Goal of therapy: reduce discomfort and edema, treat infection Wick may be inserted to keep canal open and facillitate medication administration

Conditions of the External Ear (cont.)

Malignant external otitis
AKA: temporal bone osteomyelitis Rare, progressive infection that effects the external auditory canal, surrounding tissues, and base of the skull Most often caused by Pseudomonas aeruginosa

Nursing Management
Do not clean with cotton tipped applicator Avoid scratching or any activities that traumatize external canal Do not get canal wet (swimming, shampooing) Antiseptic otic drops after swimming
Contraindicated if current ear infection or history of tympanic rupture

Conditions of the Middle Ear

Tympanic membrane performation Acute otitis media
More common in children Invading pathogens often Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis Manifestations: otalgia, fever, hearing loss Treatment:
Antibiotic therapy Myringotomy or tympanotomy

Conditions of the Middle Ear (cont.)

Serous otitis media
Fluid in middle ear without evidence of infection

Chronic otitis media

Result of recurrent acute otitis media Chronic infection damages tympanic membrane and ossicle Involves mastoid Treatment
Prevent by treatment of acute otitis media Surgical procedures

Middle Ear Surgical Procedures

Tympanoplasty
Reconstruction of the tympanic membrane Five types
Type I:
Simplest, closes perforation

Types II-IV:
Middle ear structures involve more extensive repair

Ossiculosplasty
Bone reconstruction Use of prostheses to reconnect ossicles

Middle Ear Surgical Procedures (cont.)

Mastoidectomy
Removal of diseased bone, mastoid air cells, and cholesteotoma to create a non-infected, healthy ear Cholesteatoma:
Benign tumor
Ingrowth of skin causing persistently high pressure in the middle ear Causes hearing loss, neurologic disorders, and destroys structures

Assessment of Patient Undergoing Mastoid Surgery

Health history
Includes present, past and family history

Include data related to:

Ear disorder Hearing loss Otalgia Otorrhea vertigo

Medication

Nursing Diagnoses and Goals

Identify nursing diagnoses you would expect to address in the patient undergoing mastoid surgery. What are the major goals associated with the nursing diagoses

Interventions
Anxiety
Reinforce information and patient teaching Provide support and allow patient to discuss concerns

Relieve pain
Analgesics Monitor pain characteristics
Occasional sharp, shooting pain can occur as eustachian tube opens and allows air into middle ear Constant, throbbing pain and fever may indicate infection

Interventions (cont.)
Prevent injury
Implement safety measures Provide antiemetics or antivertigo medications

Improve communication and hearing

Reduced hearing can occur for several weeks
Why?

Use measures to improve hearing and communication previously discussed

Interventions (cont.)
Preventing infection
Monitor for signs and symptoms of infection Administer antibiotics as ordered Prevent contamination of ear with water from showering, shampooing, etc.

Patient Teaching
Medication teaching
Analgesics antivertigo

Activity restrictions Gently blow nose

Only one side at a time Sneeze and cough with mouth open

Avoid
Heavy lifting, exertion, and forceful nose blowing

Patient Teaching (cont.)

Safety issues related to potential vertigo Instructions regarding potential complications and what and when to report Avoid getting water in ear Chart 59-6: Self-Care after Middle Ear or Mastoid Surgery, p. 2110

Question
Which of the following medications is/are considered ototoxic substances? a) Gentamicin b) Aspirin c) Alcohol d) All of the above

Answer
d) All of the above Rationale: Ototoxic substances include gentamycin, aspirin, alcohol, gold, quinine, and furosemide

Conditions of the Inner Ear

Disorders of balance
8 million in U.S. with chronic problems of balance Additional 2.4 million with dizziness alone Contribute to falls and fractures in the elderly

Terms:
Dizziness Vertigo Nystagmus

Meniere s Disease
Abnormal inner ear fluid balance caused by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct. Manifestations:
Fluctuating, progressive hearing loss Tinnitus Feeling of pressure or fullness Episodic, incapacitating vertigo that may be accompanied by nausea and vomiting

Meniere s Disease (cont.)

Treatment
Low sodium diet
2000 mg/day

Medication
Meclizine (Antivert) Tranquilizers Antiemetics diuretics Endolymphatic sac decompression Middle and inner ear perfusion Intraotologic catheters Vestibular nerve sectioning

Surgery

Nursing Management
Refer to Chart 59-8: Plan of Nursing Care: Care of the Patient With Vertigo, pp. 2114 2118.

Additional Conditions of the Inner Ear

Tinnitus Labyrinthitis Benign paroxysmal positional vertigo (BPPV) Ototoxicity Acoustic neuroma

Question
Which surgical procedure for Meniere s Disease provides the greatest success rate in eliminating the attacks of vertigo? a) Endolymphatic sac decompression b) Vestibular nerve sectioning c) Middle and inner ear perfusion d) Intra-otologic catheters

Answer
b) Vestibular nerve sectioning Rationale: Vestibular nerve sectioning provides the greatest success rate (approximately 98%) in eliminating the attacks of vertigo associated with Meniere s Disease.