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 hearing-impaired patient who speech reads:

a)Speak slowlyb)Face the personc) Make sure face is clearly visibled)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)Gentamicinb)Aspirinc) Alcohold)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

– Surgery• Endolymphatic sac decompression• Middle and inner ear perfusion• Intraotologic catheters• Vestibular nerve sectioning

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 decompressionb)Vestibular nerve sectioningc) Middle and inner ear perfusiond)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.