NCM116 LEC
MEDICAL SURGICAL NURSING
Second Semester – PRELIM
EAR
EAR
•
is a delicate sensory organ with the dual
functions of hearing & balance.
•
The sense of hearing is essential for normal
development & maintenance of speech as well as the
ability to communicate w/ others.
A.Y. 2023-2024
protects the middle ear & conducts sound
vibrations from the external ear to the ossicles
* Ossicles - contains the 3 smallest bones of the body
( malleus, incus, stapes)
are held in place by joints, muscles &
ligaments, assist in the transmission of sound
2 .small fenestrae (oval & round windows), located in
the medial wall of the middle ear, separates the
middle ear from the inner ear
•
Balance/equilibrium is essential for
maintaining
body
movement,
position
&coordination.
Anatomy of the Inner ear
ANATOMIC & PHYSIOLOGIC OVERVIEW
•
The organs for hearing (cochlea) & balance
(semicircular canals, as well the cranial nerves VII
(facial nerve) & VIII (vestibulocochlear nerve) are all
part of this complex anatomy
The ears are located on either side of the cranium at
approximately eye level.
Anatomy of the external ear
Auricle - attached to the side of the
head by skin, is composed mainly of cartilage, except
for the fat & subcutaneous tissue in the earlobe.
Function: Collects the sound waves & direct
vibration into the external auditory canal.
External auditory canal - is approximately 2-3 cm
long.
•
Is housed deep w/in the temporal bone.
Membranous Labyrinth - composed of the utricle,
saccule, cohclear duct, semicircular canals & the
organ of Corti, all of w/c are surrounded by a fluid
( endolymph).
the 3 semicircular canals ( posterior,
superior & lateral contain sensory receptor organs
that are arranged to detect rotational movements.
Organ of Corti
The lateral third is an elastic cartilaginous &
dense framework to w/c thin skin
is attached
-
medial 2/3 is bone lined w/ thin skin
-
ends at the tympanic membrane
located on the basilar membrane that
stretches from the base to the apex of the cochlea.
also referred to as the end organ for hearing,
transforms mechanical energy into neural activity &
separates sounds into different frequencies.
Anatomy of the middle ear
•
middle ear is connected to the nasopharynx
by the eustachian tube ( 1 mm wide & 35 mm long)
•
eustachian tube drains normal & abnormal
secretions of the middle ear & equalizes pressure in
the middle ear w/ that of the atmosphere
1.
Tympanic membrane/ eardrum - about 1 cm
in diameter, very thin, normally pearly gray &
translucent
ASSESSMENT OF THE EAR
-
Inspection of the external ear
-
Examined by inspection & direct palpation
Auricle & surrounding tissues is inspected
for deformities, lesions, & discharge as well as size,
symmetry, & angle of attachment.
1 –RM. AGUILAR, SN
NCM116 LEC
MEDICAL SURGICAL NURSING
Second Semester – PRELIM
A.Y. 2023-2024
Otoscopic Examination
hearing loss
Otoscope is NEVER blindly introduced into
the external canal- to avoid perforating the tympanic
membrane.
person w/ NORMAL HEARING-airconducted sound is longer than bone conducted
sound.
•
CONDUCTIVE
conducted sound is
Normal external canal is PINK and INTACT
•
Normal
tympanic
membrane
TRANSPARENT, OPAQUE, PEARLY GRAY,
SLIGHTLY CONCAVE
•
Evaluation of Gross Auditory Acuity
A.
WHISPER TEST
is
&
•
Normal test result is hearing the sound
equally in both ears.
•
If client hears the sound louder in one ear,
the term LATERALIZATION is applied to the side
hearing the loudest.
RINNE TEST
•
Compares the client’s hearing by air
conduction and bone conduction
•
Place the vibrating tuning fork stem on the
client’s mastoid process & ask the client to indicate
when he or she no longer hears the sound.
•
The examiner quickly brings the tuning fork
in front of the pinna without touching the client and
asks the client to indicate if he or she still hears the
sound
-Client normally continues to hear the sound 2x
louder in front of the pinna (Positive Rinne Test)
•
If client is unable to hear the sound through
the ear in front of the pinna, the client may have a
CONDUCTIVE HEARING LOSS.
useful in distinguishing
sensorineural
-bone
longer than air conducted sound.
Comparison of weber & rinne test
Diagnostic Evaluation:
Ear AUDIOMETRY - Measures hearing acuity • Uses
two types:
WEBER TEST
Place the vibrating tuning fork in the middle
of the client’s head at the midline of the forehead
C.
LOSS
SENSORINEURAL HEARING LOSSair conducted sound longer than bone conducted
sound
The examiner stands 1 to 2 feet away &
quietly whispers a statement. The client w/ normal
hearing acuity can correctly repeat what was
whispered.
B.
HEARING
bet.
Conductive
&
a.
PURE TONE = the sound stimulus consists of
a pure or musical tone (the louder the tone before the
client perceives it, the greater the hearing loss)
b.
SPEECH AUDIOMETRY = the spoken word is
used to determine the ability to hear & discriminate
sounds & words
TYMPANOGRAM/ impedance audiometry
test of middle ear function muscle reflex to
sound stimulation & compliance of the tympanic
membrane by changing air pressure in the ear canal.
Compliance is impaired w/ middle ear
disease.
AUDITORY BRAIN STEM RESPONSE
uses a special computer to measure the way
the child’s hearing nerve responds to different
sounds.
hear.
helpful tool in determining a child’s ability to
PLATFORM POSTUROGRAPHY
recommended for clients w/ dizzinesss &
balance disorders.
used to determine if pts vertigo is worsening
or evaluate a pts response to treatment
2 –RM. AGUILAR, SN
NCM116 LEC
MEDICAL SURGICAL NURSING
Second Semester – PRELIM
A.Y. 2023-2024
pt stands on a platform, surrounded by a
screen, & diff conditions such as a moving platform
w/ a moving screen or a stationary platform w/ a
moving screen is presented.
1.
SINUSOIDAL HARMONIC ACCELERATION
A.
Talking into the less impaired ear & use
gestures & facial expression
-
a rotary chair is used to assess the vestibulo
-ocular system by analyzing compensatory eye
movements in response to the clockwise &
counterclockwise rotation of the chair
helps to identify dses such as Meniere dse,
tumors of the auditory canal &
Early detection of hearing loss.
2.
Use
of
rehabilitation
services
&
supplemental devices to improve communication.
B.
Provide interpreters for those who cannot
communicate.
C.
Nurses must work w/ pts who are deaf or
hearing impaired & their families to identify practical
& effective means of communication.
External Otitis/ Otitis externa
evaluate course of recovery
inflammation of the external auditory canal.
MIDDLE EAR ENDOSCOPY
Endoscope w/ very small diameters & acute
angles is used
to evaluate suspected perilymphatic fistula &
new onset conductive hearing loss
tympanic
membrane
is
anesthesized 10 mins prior to procedure.
topically
External auditory canal is irrigated w/ sterile saline.
•
Causes:
-
water in the ear canal (swimmer’s ear)
-
trauma to the skin of the ear canal
systemic conditions such
deficiency & endocrine disorders
as
vitamin
most common bacteria: Staphylococcus
aureus & Pseudomonas species
Tympanotomy is created w/ a laser beam or a
myringotomy knife.
most common fungus:
Endoscope is inserted in the middle ear. Video &
photos documentation is done thru the scope.
external otitis is often caused by dermatosis
such as psoriasis, eczema, or seborrheic dermatitis;
even allergy to hair spray, hair dye & permanent wave
lotions
EAR DISORDERS Hearing Loss
•
Clinical Manifestations:
Early Manifestations:
-
tinnitus
-
increasing inability to hear when in a group
-
a need to turn up the volume of the television
MEDICAL MANAGEMENT
if a hearing loss is permanent or untreatable
or if the pt elects not to be treated, AURAL
rehabilitation maybe beneficial.
NURSING MANAGEMENT
Aspergillus
CLINICAL MANIFESTATIONS:
in fungal infections- hair like black spores
may be visible
pain - yellow or green & foul smelling
discharge
-
ear tenderness
-
fever -cellulitis
-
lymphadenopathy
-
pruritus
-
hearing loss or a feeling of fullness in the ear
Objectives:
3 –RM. AGUILAR, SN
NCM116 LEC
MEDICAL SURGICAL NURSING
Second Semester – PRELIM
A.Y. 2023-2024
-
otoscopic exam
RISK FACTORS
-
ear canal is erythematous & edematous
1.
younger age
MEDICAL MANAGEMENT
2.
chronic upper respiratory infections
Analgesic medications for the 1st 48 to 96
hours.
3.
medical conditions that predispose the pt to
ear infections ( Down Syndrome, cystic fibrosis, cleft
palate)
Antimicrobial or antifungal otic medications
given by dropper at room temp
in bacterial infxn- a combination of antibiotic
& corticosteroid agent is used to soothe the inflamed
tissues.
NURSING MANAGEMENT
1.
Instruct pt not to clean the external auditory
canal w/ cotton-tipped applicators & to avoid events
that traumatize the external ear
2.
Instruct to avoid getting the canal wet when
swimming or shampooing hair.
3.
Infection can be prevented by using
antiseptic otic preparations after swimming
Acute Otitis Media
an acute infection of the middle ear, lasting
less than 6 wks •
Cause by Bacterial or viral
pathogens>> enter the middle ear after eustachian
tube dysfunction caused by obstruction r/t URI,
inflammation of surrounding structures (
rhinosinusitis, adenoid hypertrophy) or allergic
reactions
4.
chronic exposure to second hand smoke
SURGICAL MANAGEMENT
tympanotomy)
Myringotomy
(i.e.
- an incision in the tympanic membrane •
Local anesthetic(i.e. phenol) is used to numbed the
tympanic membrane.
Incision is made thru the tympanic membrane (under
microscopic guidance) to relieve pressure & to drain
serous/purulent fluid. •
ventilating tubes- used to treat recurrent
AOM
Avoid strenuous activity, rapid head movements,
bouncing, or bending, straining on bowel movement,
drinking by straw, traveling by air, forceful coughing
Chronic Otitis Media • is recurrent AOM that causes
irreversible tissue pathology. •
Chronic infections of the middle ear
damage the tympanic membrane, destroy the
ossicles, & involve the mastoid
CLINICAL MANIFESTATIONS
Bacteria can enter the eustachian tube fr
contaminated secretions in the nasopharynx & the
middle ear from a tympanic membrane perforation •
-
a purulent exudate present in the
middle ear results in conductive hearing loss
if mastoid is involve: pain, postauricular area
tenderness, edematous & erythematous
CLINICAL MANIFESTATIONS
otoscopic exam- show perforation &
cholesteatoma ( white mass behind the tympanic
membrane or coming thru the external canal from a
perforation.
1.
otalgia/pain
2.
drainage
3.
fever
4.
hearing loss
varying degrees of hearing loss
persistent or intermittent foul smelling
otorrhea
CHOLESTEATOMA - is a tumor of the external layer of
the eardrum into the middle ear
4 –RM. AGUILAR, SN
NCM116 LEC
MEDICAL SURGICAL NURSING
Second Semester – PRELIM
cause hearing loss, facial pain & paralysis,
tinnitus, or vertigo
diagnosis may be made by visual exam or CT
or MRI scan
Therapy: treatment of infection & surgical
removal of mass
A.Y. 2023-2024
4.
Improving hearing & communicationreducing environmental noise; face the pt when
speaking, speak clearly & distinctly w/o shouting
5.
Preventing injury-assist in ambulation to
prevent falls & injury; instruct pt to avoid heavy
lifting, straining, exertion, & nose blowing.
Otosclerosis
MEDICAL MANAGEMENT
careful suctioning of the ear under otoscopic
guidance
instillation of antibiotic drops or application
of antibiotic powder to treat purulent discharge
systemic antibiotic agents are prescribed
only in cases of acute infection
SURGICAL MANAGEMENT
A. Tympanoplasty - surgical reconstruction of the
tympanic membrane to reestablish middle ear
function, close the perforation, prevent recurrent
infection, & improve hearing
b. Ossiculoplasty - surgical reconstruction of the
middle ear bones to restore hearing
Prostheses made of materials such as teflon
& stainless steel are used to reconnect the ossicles,
thus reestablishing sound conduction mechanism
C. Mastoidectomy - usually performed thru a
postauricular incision to remove the cholesteatoma,
gain access to diseased structures, & create a non
infected & healthy ear
NURSINGINTERVENTIONS:
mastoid ectomy
1.
Reducing anxiety- reinforce information
discussed by the otologic surgeon.
2.
Relieving pain- prescribed analgesic for the
1st 24 hrs then PRN
3.
Preventing infectionprophylactic antibiotics
are given as prescribed; packing is impregnated w/
antibiotic sol’n; cotton ball covered w/petroleum
jelly is placed in the ear canal to prevent water from
entering.
involves the stapes and is a result of the formation
of new, abnormal spongy bone w/c results to fixation
of the stapes.
Efficient transmission of sound is prevented bec the
stapes cannot vibrate & carry the sound fr the malleus
& incus to the inner ear.
more common in women; is a familial condition &
can progress to
deafness
CLINICAL MANIFESTATIONS:
1.
loss
Progressive conductive or mixed hearing
2.
Tinnitus
3.
Otoscopic
membrane
exam-
normal
•
MEDICAL MANAGEMENT:
1.
Amplication w/ a hearing aid
tympanic
Surgical management:
1.
Stapedectomy - removing the stapes
superstructure & part of the footplate & inserting a
tissue graft & a suitable prosthesis.
2.
Stapedotomy- the surgeon drills a small hole
into the stapes to hold a prosthesis * In both
procedure, the prosthesis bridges the gap bet the
incus & the inner ear, providing better sound
conduction.
Labyrinthitis
inflammation of the labyrinth of the
inner ear, can be bacterial or viral in origin.
5 –RM. AGUILAR, SN
NCM116 LEC
MEDICAL SURGICAL NURSING
Second Semester – PRELIM
the infection can spread to the inner ear by
penetrating the membranes of the oval or round
windows
affects hearing & balance
CLINICAL MANIFESTATIONS:
1.
Sudden onset of incapacitatingvertgigo
2.
Nausea & vomiting
A.Y. 2023-2024
3.
Electronystagmogramnormal or may show
reduced vestibular response
MEDICAL MANAGEMENT:
1.
Diet & medication- low sodium diet (1000 to
1500 mg/day or less)
2.
Psychological evaluation & cognitive therapy
may be indicated if a pt is anxios, uncertain, fearful or
depressed
PHARMACOLOGIC THERAPY:
3.
Various degrees of hearing loss
4.
tinnitus
MANAGEMENT:
1.
IV antibiotic therapy
2.
Fluid replacement
3.
Antihistamine & antiemetic medications
4.
Viral labyrinthitissymptomatic treatment
1.
Antihistamine
shortens the attack
such
as
meclizine
w/c
2.
Tranquilizers such as diazepam (Valium) to
help control vertigo
3.
Antiemetic drugspromethazine (Phenergan)
suppository
4.
Diuretic therapy-relieve symptoms by
lowering the pressure in the endolymphatic system
SURGICAL MANAGEMENT:
Meniere disease
an abnormality in inner ear fluid
balance caused by malabsorption in the
endolymphatic sac or a blockage in the
endolymphatic duct
•
Endolymhatic hydrops (dilation of the
endolymphatic space) develops & either increased
pressure in the system or rupture of the inner ear
membrane resulting to s/s of MD
1.
Endolymphatic
Sac
Decompression/Shunting - Shunt/Drain is inserted in
the endolymphatic sac thru a postauricular incision it equalizes the pressure in the endolymphatic space
2.
Vestibular Nerve Sectioning - performed by a
translabyrinthine approach or in a manner that can
conserve hearing. - Cutting the nerve prevents the
brain from receiving input from the semicircular
canals. - greatest success rate (98%) in eliminating
vertigo attacks.
Aural Rehabilitation
CLINICAL MANIFESTATIONS:
If hearing loss is permanent; cannot be
treated aural rehab is beneficial
1.
Triad symptoms: episodic vertigo; tinnitus;
fluctuating sensorineural hearing loss
includes:
2.
Feeling of fullness/pressure in the ear
1.
auditory training- listening skills
3.
Incapacitating vertigo w/ nausea & vomiting
2.
speech reading/ lip reading,
ASSESSMENT & DIAGNOSTIC FINDINGS:
1.
3.
speech training- to conserve, develop &
prevent deterioration of communication skills
PE findings are usually normal
4.
the use of hearing aids & hearing guide dogs
2.
Audiogram reveals sensorineural hearing
loss in the affected ear
6 –RM. AGUILAR, SN
NCM116 LEC
Second Semester – PRELIM
MEDICAL SURGICAL NURSING
A.Y. 2023-2024
Medications that affect hearing loss
Amikacin
Chloramphenicol •Gentamicin Streptomycin
Tobramycin
Furosemide
Ethacrynic acid Acetazolamide
Anti-infective Ear Medications
Amoxicillin • Ampicillin • Cefaclor •
Clindamycin •
Co-trimoxazole • Erythromycin •
Chloramphenicol
ANTIHISTAMINES and DECONGESTANTS
Terfendaine Ceterizine
CERUMINOLYTIC MEDICATIONS
Emulsify and loosen cerumen deposits
Used to loosen and remove impacted wax from the
ear canal
Carbamide peroxide
Boric acid
Trolamine polypeptide oleate-condensate
7 –RM. AGUILAR, SN