Unit 3

Disorders of Ear

Foreign Body in the Ear

 Foreign body in the ear is something that enters the ear from outside the body that doesn’t
naturally belong there.
 It can interfere the auditory function and lead to infection, inflammation and hearing loss.
 It is the common reason for emergency visits, especially in children.
 The majority of these foreign objects are harmless.
 Some are extremely uncomfortable (insects or sharp objects) and some can rapidly
produce an infection (food or organic matter) requiring emerging treatment.

Causes
 Most objects that het stuck in the ear canal are placed there by the person themselves.
 Children who are curious about their bodies and interesting objects are the most common
group who has this problem (children aged 9 months to 8 years).
 Beans, food, paper, cotton swab, rubber erasers and small toys are the most common
foreign bodies.

Sign and Symptoms

 Pain, fullness or pressure
 Redness
 Decrease in hearing on affected side
 Swelling, Dizziness
 Nausea, Vomiting
 Tenderness

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Diagnosis
 History Taking
 Observing sign and symptoms
 Examination of ear: Objects in the ear usually can be seen by a qualified medical
profession by direct looking in the ear with otoscope.

Management
 Don’t attempt to remove foreign object by proving with a matchstick or any other tool.
To do so is to risk pushing the objects further into the ear and damaging the fragile
structure of middle ear.
 Remove the object if it is clearly visible and can be grasped easily with tweezers, gently
remove it.
 Modified tweezers or forceps can be used to reach in and grasp the object with the help of
an otoscope so that important structures are not damaged.
 Gentle suction can be used to suck out the object.
 Irrigation of the canal with warm water and a small catheter can flush certain material out
of the canal and clean debris.
 Small children do not tolerate painful interventions and may need to be sedated medically
to have objects removed from their ears.
 Try using gravity: Tilt the head to the affected side to try to dislodge the object.
 Try using oil for an insect:
 Try to float the insect out by passing mineral oil or baby oil into the ear. The oil
should be warm not hot.
 The insect would suffocate and may float out in the oil bath.
 Don’t use oil to remove any other object other than insect.
 If these method fail or the person continues to experience pain in the ear, reduced
hearing or a sensation of something lodged in the ear, seek medical assistance.

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  After the foreign body is removed the doctors may put the patients on antibiotics
drops from five days to a week to prevent infection from trauma to the ear canal.

Impacted Wax or Cerumen

 Wax is composed of secretions of sebaceous gland, ceruminous gland, hair, desquamated

epithelial debris, keratin and dirt.
 Wax has a protective function as it lubricates the ear canal and entraps any foreign
materials that enters the canal. Normally only a small amount of wax is secreted, which
dies up and is later expelled from the meatus.
 But sometimes it may dry up and form a hard impacted mass.

Etiology
 Blockage or impaction of ear wax occurs when the wax gets pushed deep within the ear
canal. Ear wax blockage affects 6% of people and is the most common ear problem.
 The most common cause of this is the use of Q-tips in the ear canal (and other objects
such as bobby pins and rolled napkin corners), which pushes the wax deeper into the ear
canal.
 Hearing aid and earplug users are also more prone to earwax blockage.

Risk Factors
 Narrow ear canal
 Hairy ear canal
 Hearing aids in ear
 Use of ear protection
 Drier cerumen production or over production

Sign and symptoms

 Impairment of hearing

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  Sense of blocked ear
 Tinnitus and giddiness
 Reflex cough due to stimulation of auricular branch of vagus.
 The onset of these symptoms may be sudden when water enters the ear canal during
bathing or swimming and wax swells up.
 Ear pain

Diagnosis
• By listening to the patient’s symptoms.

• Looking into the ear with an otoscope.

Management
1. Syringing
• Patient is seated with ear to be syringed towards examiner.
• Towel is placed around his/her neck.
• A kidney tray is placed over the shoulder.
• Pinna is pulled upwards and backwards and a stream of warm water from the ear syringe
is directed along the posterior-superior wall of meatus.
• Pressure of water is built up which expels the wax out.

2. Instrumental manipulation
• Cerumen hook, scoop or Jabson-Horne probe are used by skilled person to remove the
impacted wax.

3. If wax is too hard and impacted, it should be softened before removing by syringing or
instruments.
• 5% sodium bicarbonate in equal parts of glycerin, hydrogen peroxide, liquid paraffin,
olive oil or ceruminolytic agents like Para- dichlorobenzene 2% can be used for this
purpose.

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Nursing care of patient with Impacted Wax
• Teach proper ear hygiene, especially not putting anything in ears.

• Explain the normal protective function of cerumen.

• If the patient has a problem with cerumen buildup and has been advised by health care
provider to use ceruminolytic periodically, make sure that the patient is getting cerumen
out of ear before more medication is instilled. A bulb syringe may be used by the patient
at home to help remove softened cerumen.

• Advise patient to report persistent fever, pain, drainage, hearing impairment.

Otitis Media

Definition
• Otitis media is an inflammation of middle ear cleft i.e. the Eustachian tube, middle ear
cavity, antrum and mastoid ear cells.
• Otitis media is an inflammation located in the middle ear.
• It can occur as a result of a cold, sore throat or respiratory tract infection.
• It is one of the common diseases of early childhood.
• If the infection is sudden in onset and short in duration, it is called acute otitis media.
• If the infection is more than 3 months duration, it is chronic otitis media.

Types
a. Acute Suppurative Otitis Media

b. Chronic Suppurative Otitis Media

i. Tubotympanic (Safe type)
ii. Attico-antral type (Unsafe, Dangerous type)
c. Chronic Non-Suppurative Otitis Media

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 a. Acute Suppurative Otitis Media
•It is a common bacterial infection affecting mucosa of the middle ear.
•It usually follows acute upper respiratory tract infection.
•It is a common disorder occurring at all age and particularly in children because
their Eustachian tubes are shorter, wider and more horizontal than adult which makes
the organism pass easily.

Causative organism

• Streptococcus pneumonie

• Haemophilus influenza

Predisposing Factors

•Recurrent inflammation of surrounding structure like tonsillitis, rhinitis, sinusitis,

pharyngitis, adenitis.

•Naso-pharyngeal tumors
•Swimming and diving in contaminated water.
•Traumatic perforation of tympanic membrane.
•While feeding from bottle to infants in supine position, contaminated milk may enter the
Eustachian tube.

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Pathophysiology
Inflammation of Eustachian tube

Edema, congestion and occlusion of the tube and air cells in the middle ear

Exudates collects in the middle ear

Becomes purulent

Tympanic membrane stretches, bulges and rupture because of pressure

Pus is discharged into external auditory canal

Clinical Features

•Sudden acute pain in the ear (may even awake patient at night).
•Feeling of fullness of ear.
•Mild to moderate conductive hearing loss.
•Tinnitus, bubbling sounds are heard.
•Fever and malaise in children.
•Otoscopy reveals red, congested and bulging ear drum.
•Otorrhea and relief of pain after perforation of eardrum.

Diagnosis

•Otoscopy
•Tuning fork test
•Audiometry
•Pus for culture and sensitivity
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Treatment
i. Systemic:

• Analgesics

• Antibiotics – As soon as possible and for 7-10 days.

• Decongestants
ii. Local:

• Antibiotics ear drops- neomycin, chroramphenicol after the rupture of tympanic

membrane.

• Ear cleaning- The ear must be cleaned by cotton buds or may be sucked out.

• Water should be prevented from entering the ear.

iii. Surgical Management:

• Myringotomy may be rarely done (incision made in tympanic membrane to relieve

pressure caused by excessive build up of fluid or to drain pus from the middle ear).

b. Chronic Suppurative Otitis Media

• It is the chronic inflammation of the middle ear cleft characterized by ear discharge and
permanent perforation of the tympanic membrane leaving ear discharge that persists
beyond 3 months.

i. Tubo-tympanic or safer type

• Persistent and recurrent infection ascends from Eustachian tube to the tympanum hence
called tubo-tympanic.

• It is safe type as there is no danger to the life the patient.

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Etiology
•Age- occurs at all ages.
•Causative organism- Streptococci, Staphylococci, Pneumococci.
iv. Predisposing Factors

•Untreated acute otitis media.

•Chronic tonsillitis, sinusitis and enlarged adenoids (a mass of enlarged lymphatic tissue
between the back of the nose and the throat).

•Persistent and virulent type of inflammation.

•Low resistance.
•Traumatic perforation of large size usually failing to heal.
•Acute necrotic otitis media.

Pathophysiology
Acute Otitis Media

Edema of mucous membrane of middle ear

Prolapse of mucous membrane through the perforation as a polyp

Clinical features
•Otorrhea
•Conductive deafness (mild to moderate)
•Central perforation
•Polyps may be present occasionally.

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Treatment
Conservative
•Elimination of all upper respiratory tract infection.
•Topical antibiotics and corticosteroids if discharge persists.
•Oral antibiotics
•Ear cleaning
•Nutrition of patient should be improved.

Surgical Management
•Polyps and granulations should be removed by Myringoplasty.
•Repair of ear drum and ossicular chain should be done.

ii. Attico-antral (Dangerous Type)

•It involves posterior superior part of middle ear cleft (Attic-antrum mastoid) associated with
cholesteatoma.

•This can give rise to serious complication like brain abscess, meningitis etc.

Etiology
•Due to the presence of cholesteatoma having eroding property i.e. gradually destroying.
•Usually choleasteatoma is infected by mixed bacterial flora.

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Pathophysiology
Formation of cholesteatoma leads to compression of middle ear and mastoid cells.

Necrosis and bone erosion

Extends to structure of middle ear

Complication (brain abscess, labyrinthitis)

Clinical Features
•Otorrhea (ear discharge)- scanty and foul smelling.
•Conductive hearing loss
•Bleeding or blood stained discharge may occur if granulation
•Polyps are present
•Tinnitus
•Perforation is marginal or attic
•Presence of cholesteatoma

Diagnosis
•Hearing test- tuning fork test, audiometry test.
•Pus culture and sensitivity test.
•X-ray of mastoid.

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Treatment
Conservative
•Keep ear dry.
•Treat precipitating factor like tonsillitis, sinusitis
•Analgesics
•Antibiotics ear drop locally and systemically.
•Treatment of complication.

Surgical Management
•Removal of granulation and polyps.
•Mastoidectomy.

c. Chronic non-Suppurative otitis media

•It is an accumulation of non-purulent effusion in the middle ear cleft which interferes with
hearing.

•The fluid may remain in the ear for long time.

Etiology
•Age- all age group.
•Predisposing factors:
 Obstruction of Eustachian tube which prevents normal ventilation of middle ear.
 Inappropriate use of antibiotics resulting in collection of sterile fluid.
 Upper respiratory tract infection.
 Allergic exudates of serous fluid into the middle ear.
 Excessive nose bleeding.

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Pathophysiology
Blockage of opening of Eustachian tube

Interference in entry of air in middle ear

Absorption of remaining air by mucous membrane lining

Creation of negative pressure that draws fluid from surrounding tissue

Effusion in the middle ear

Clinical Features
•Feeling of fullness and discomfort.
•Deafness
•Sensation of fluid in ear
•Tinnitus
•Otoscopy reveals fluid or air
•Bubble behind the ear drum
•Tympanic membrane is stretched

Treatment
•Treatment of underlying cause.
•Antibiotics
•Nasal decongestants

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Surgical Management
•Myringotomy – incision of tympanic membrane to release fluid from middle ear.
•Grommet- temporary ventilation of middle ear by inserting polyethylene tube called
Grommet through eardrum.

•The tube is left in position until potency of the auditory tube is re-established.

Nursing Management of Otitis Media

•Pre-operative and post-operative care of the patient undergoing surgery.
•Advise patient to prevent water from entering into ear during treatment.
•If ear wash is prescribed, teach the patient how to perform ear wash safely at home.
•Wash hands before and after procedure.
•Fill 2-3 ounce (59.15ml-88.7 ml) ear syringe with the solution at body temperature.
•Position the patient lying on the affected side.
•Place the tip of the syringe gently into ear canal and pump solution back and front into the
ear vigorously and repeatedly.

•Assist patient to lean over the side and let solution run out of end of procedure.
•Apply ear drop if instructed.
•Health teaching to the patient after surgery including sneezing or coughing with mouth
open for first few weeks after the surgery.

•Blow nose gently as needed one side at a time.

•Change cotton ball dressing as prescribed.
•Report any drainage other than a slight amount of blood to the surgeon.
•Keep ear dry, 6 weeks after the surgery.
•Do not shampoo hair without barrier.
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 •Avoid loud noisy environment. Do not fly until approved by surgeon.

Labyrinthytis

• It is the infection and inflammation of the labyrinth of the inner ear which may give rise
the symptoms of vertigo, deafness and tinnitus.

• It may be caused by virus, bacteria and other condition.

Vertigo- dizziness
Tinnitus- ringing or buzzing in the ears

Etiology
• Staphylococcus aureus, Streptococcus pneumonia, Hemophilus influenza, Klebsilla.

• Acute and Chronic otitis media.

• Chronic otitis media with Cholesteatoma (an abnormal, noncancerous skin growth that
can develop in the middle section of your ear, behind the eardrum.

• Toxic drug ingestion.

• Excessive use of alcohol.

Clinical Features
• Sign of middle ear disease with severe bacterial infection.

• Progressive sensory-neural hearing loss.

• Severe Vertigo: Vertigo begins but peaks within 48 hours, causing loss of balance and
falling in the direction of the affected ear usually last within 3-6 weeks.

• Tinnitus

• Giddiness

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 • Nystagmus (rapid involuntary movements of the eyes) with jerking movement of the eye
towards the unaffected ear.

• Nausea and vomiting

Diagnostic Evaluation
• History of upper respiratory tract infection and recurrent otitis media

• Culture and sensitivity test of discharge if present

• Audiometric test shows sensory-neural hearing loss

• X-ray of Petrous bone

Medical Management
• Bed rest with immobilized head between pillows.

• Maintain proper functioning of side rails to prevent falling during vertigo.

• Antibiotic therapy according to culture and sensitivity of discharge if present. It should be

given in full dose.

• Analgesics and sedatives (prochlorperazine) are given for symptomatic relief of vertigo.

• Oral fluids to prevent dehydration due to vomiting and intravenous fluids in case of
severe vomiting.

• Recording and monitoring intake and output of patient.

• In severe cases, it should be treated by surgery.

Surgical Treatment
• Myringotomy (surgical incision into the eardrum, to relieve pressure or drain fluid): is
done if labyrinthitis is due to otitis media and tympanic membrane is bulging.

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 • Mastoidectomy (a procedure performed to remove the mastoid air cells) is done in acute
mastoiditis, chronic otitis media or Cholesteatoma.

• Labyrinthotomy (surgical incision into the labyrinth of the inner ear) for drainage of
pus from labyrinth.

Nursing Management
• Nurse should be advised to prevent upper respiratory tract infection.
• Maintain safe and healthy home environment.
• Prevention of otitis media.
• Early and complete treatment of ear disease.
• Monitor the side effect of ototoxic drugs.
• Monitor noise pollution and injuries.

Meniere’s Disease

• It is a disorder of inner ear in which the endolymphatic system is distended.

• It is also called endolymphatic hydrops.
• It is characterized by recurrent attack of severe vertigo, deafness, and tinnitus which
occur at irregular interval.
• It causes significant disability because of sudden, severe attacks of vertigo with nausea
and vomiting.

Etiology
The exact cause of Meniere’s disease is unknown.
Age: occurs mostly over the age of 40 years.
Predisposing factors:
• Over production or decreased absorption of endolymph results in endolymphatic hydrops.
• Reduced blood supply to the labyrinth due to vascular spasm.

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 • Retention of excessive amount fluid.
• Hypothyroidism
• Allergic reaction
• Viral infection
• Head trauma
• Autoimmune

Pathophysiology

Over production and defective absorption of endolymph

Increased pressure and volume within the membranous labyrinth

Distension of membranous labyrinth

Rupture of endolymphatic tissue

Mixing of endolymph and perilymph

Fluid and electrolyte imbalance within labyrinth

Exhibits sign and symptoms of Meniere’s Disease

Clinical Features
• Vertigo- It occurs in sudden attack of irregular intervals and duration (lasts from 10
minutes to several hours). It may range from mild dizziness or imbalance, loss of balance
and falling due to vertigo.
• Deafness: Sensory neural deafness.
• Tinnitus: it is low pitched roaring type aggravated during acute attack, change in intensity
and pitch of tinnitus may be learning symptoms of attack.

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 • Feeling of fullness or pressure
• Anxiety due to fear of treatment
• Severe nausea and vomiting
• Headache
• Nystagmus

Diagnosis
• Tuning fork Test
• Audiometry : to test the ability to hear sound
• ECG
• Otoscopy
• Electrocochleography: technique of recording electrical potential generated in the inner
ear and auditory nerve in response to sound using an electrodes placed in ear canal or
tympanic membrane to determine id cochlea has an excessive amount of fluid pressure.

Management
a. General Management
• Reassurance by psychological support.
• Cessation of smoking.
• Low salt diet.
• Avoid excessive intake of water.
• Lifestyle modification.

b. Management of Acute attack

• Reassurance
• Bed rest
• Vestibular sedatives: dimenhydrinate, prochlorperazine, diazepam
• Vasodilators: papaverine, isoxsuprine, adenosine triphosphate

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c. Management of chronic phase
• Vestibular sedatives: prochlorperazine
• Vasodilators: nicotinic acid, betahistine
• Diuretics: Frusemide
• Avoid allergen
• HRT (Hormone Replacement Therapy) for hypothyroidism
• Intratympanic Gentamycin therapy

d. Surgical Management
• Endolymphatic Decompression
• Sacculotomy : draining the sac that contains endolymph.
• Labyrinthectomy: Membranous labyrinth is destroyed. This gives relief from attack of
vertigo.
• Endolymphatic shunt operation

e. Nursing Management
Assessment
History taking, Hearing test

Nursing Diagnosis
Vertigo related to imbalance of endolymph and perilymph fluid.
Altered sensory perception: Hearing loss related to fullness of ear..

Nursing Intervention
• Prevent the patient from injuring during attack by placing him/her in bed with side rails.
• Give assurance and emotional support concerning the nature of disease.
• Give low sodium diet and low fluid intake to reduce edema and the production of
endolymphatic fluid.
• Avoid noise and bright light which may encourage attack.
• Advice patient to avoid intake of alcohol, caffeine, sugar and smoking.

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 • Before surgery, if patient is vomiting,
 Record fluid intake and output
 Give antiemetic as ordered
 Give small amount of fluid frequently
• Post operative care
 Carefully record intake and output
 Instruct patient that nausea and dizziness will be present for 1-2 days after surgery.
 Give prophylactic antibiotics and antiemetic as ordered.

Otosclerosis

• It is a disease of the labyrinth capsule of middle ear that results in a bony overgrowth of
the tissue surrounding the ossicles.
• It causes the development of irregular areas of a new bone formation and causes the
fixation of the bone.
• Stapes fixation leads to conductive hearing loss.
• If the disease involves inner ear, sensorineural hearing loss is present.
• Bilateral involvement is uncommon, although hearing loss may be worse in one ear.
• Formation of new spongy bone in the labyrinth of ear causing fixation of the stapes in the
oval window.
• This prevents transmission of auditory vibration to the inner ear.
• It is more common in female.

Causes
• The cause is unknown.
• Familial tendency may be one cause.

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Sign and symptoms
• Slow progressing conductive hearing loss.
• Bilateral hearing loss.
• A ringing or roaring type of constant tinnitus.
• Loud sounds heard in ear when chewing.
• Pinkish discoloration of tympanic membrane indicating vascular changes within the ear.
• Negative Rhinne’s test.
• Weber’s test shows lateralization of the sound to the ear with the most conductive hearing
loss.

Diagnosis
• Audiometry : reveals conductive hearing loss.
• Weber’s test and Rhinne’s test: show bone conduction is greater than air conduction.

Management
 Non surgical intervention: promote the improvement of hearing by amplification.
 Surgical intervention:
• Removal of bony growth that is causing the hearing loss.
• A partial stapedectomy or complete stapedectomy with prosthesis (fenestration) may be
performed.

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 Mastoiditis

•Mastoiditis is a bacterial infection of the mastoid bone.

•The mastoid bone has a honey-comb like structure which contains air spaces called mastoid
air cell which help maintain the air space and drain the middle ear.

•When the mastoid cells become infected or inflamed, often as a result of an unresolved
middle ear infection (otitis media), mastoiditis can develop.

•In acute mastoiditis, infection may spread outside of the mastoid bone and cause serious
health complications.

•Honey-comb structure may deteriorate.

•Mastoiditis usually affects children.
•Before antibiotics, mastoiditis was one of the leading causes of death in children.
•Now it is a relatively uncommon and much less dangerous condition.

Causes
•As mentioned above, mastoiditis often develops as a result of a middle ear infection.
Bacteria from the middle ear can travel into the air cells of mastoid bone. In addition, a skin
cyst (Cholesteatoma) in the middle ear may block drainage of the ear, leading to mastoiditis.

•Organisms like:
 Streptococcus pneumonia- most frequently isolated pathogen in acute mastoiditis.
Prevalence of approximately 25%.
 Group A beta-hemolytic streptococcus
 Staphylococcus pyogens
 Staphylococcus aureus
 Moraxella catarrhalis

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  Hemophilus influenza

•Inadequate drainage
•Immunosuppressant patient

Types
•Acute Mastoiditis : sudden inflammation of mastoid due to causative organisms like
Streptococcus, Staphylococcus, etc.

•Chronic Mastoiditis: inflammation of mastoid that occurs due to CSOM in which the
Cholesteatoma erodes the mastoid bone.

Sign and symptoms

•Drainage from the ear
•Bulging and drooping of the ear
•Ear pain or discomfort
•Fever, may be high or suddenly increase
•Headache
•Hearing loss
•Redness of the ear or behind the ear
•Swelling behind ear, may cause ear to stick out.

Diagnosis
•Otoscopy
•Blood test
•X-ray

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 •Ear culture (removal of fluid or other substances from the ear to check for infection).
•CT Scan or MRI
•If patient may have developed meningitis as a result of mastoiditis, a lumbar puncture will
be performed to test spinal fluid for infection.

Management
Medical Management
•Chronic mastoiditis is treated with oral antibiotics, eardrops and regular ear cleaning ny a
doctor. If these treatment do not work, surgery may be necessary to prevent further
complications.

•Antibiotics will be given through an IV line to treat the infection.

Surgical Management
•Surgery may also be needed to drain the fluid from the middle ear, called Myringotomy.
During Myringotomy, a small hole in the eardrum is made to drain the fluid and relieve
pressure from the middle ear. A small tube may be inserted into the middle ear to ventilate
and prevent fluid getting into the middle ear. Typically, the tube will fall out on its own after
six to 12 months.

•Mastoidectomy, surgical removal of infected mastoid bone if the infection is severe.

Types of Mastoidectomy
a. Simple Mastoidectomy:

•This procedure is done for the purpose of draining in acute mastoiditis.

• This procedure involves postural drainage behind the ear.

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 •All the infected mastoid cells are removed and the small drain is inserted which does not
disturbs the structure and the function of the middle ear.

b. Radical Mastoidectomy

•Radical Mastoidectomy is performed for CSOM with Cholesteatoma having sensory neural
hearing loss.

•It involves the removal of all disease from the mastoid air cell system and tympanic cavity.
•The eardrum, malleus, incus are also removed.
•In this operation, the mastoid , the middle ear and the external auditory canal are converted
into single cavity and donot preserve hearing.

c. Modified Mastoidectomy

•Modified Mastoidectomy is performed in majority of the cases of CSOM with

Cholesteatoma.

•In this surgery, disease is eradicated from the middle ear cleft but the eardrum, malleus and
incus are preserved.

•The mastoiditis and the middle ear is converted into single cavity and then a separate
middle ear cavity is prepared which preserves hearing.

Nursing Management
Pre-operative Management
•Keep external ear clean and dry.
•Shave 2cm above the mastoid area.
•And general pre-operative care.

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Post-operative care
•Elevate the head of the bed at 30⁰.
•Lie with the operative side up after surgery.
•Monitor vitals and observe the sign of bleeding from the ear as well as operative site.
•Sedatives, analgesics and antibiotics according to the doctor’s order should be given.
•Start liquid to normal diet after 4 hours of surgery.
•Observe patient closely for any signs of facial palsy.
•Patient may have nausea, vomiting and vertigo so prevent patient from fall injury.

Discharge teaching
•Instruct patient to wash hand before touching the ear and administering the medication in
ear.

•Prevent entry of water inside ear for at least 6 weeks.

•Never put oil or scratch ear.
•Blow nose gently and one side at a time.
•Avoid flying in place for at least 2 months.
•Discharge and pus may be present for about 2 months after surgery.

Complications
•Hearing loss
•Blood clot
•Meningitis
•Facial nerve palsy

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 •Brain abscess

Deafness/hearing impairment

Definition
•Deafness, or hearing impairment is a partial or total inability to hear.

Types
• Conductive hearing loss

• Sensory Neural hearing loss

• Mixed hearing loss

a. Conductive hearing loss

•An interruption of passage of sound from external ear to the middle ear is considered as
conductive hearing loss.

•Generally, conductive hearing loss does not cause total inability to hear, and a loss of
clarity.

•In other words, sounds are heard but they are weak and muffled and distorted.

Causes
•External ear- wax and foreign body.
•Middle ear- traumatic rupture of the tympanic membrane.
•Abnormal growth
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 •Inflammatory condition like ASOM, CSOM
•Blockage of Eustachian tube.
b. Sensory Neural hearing loss
•Sensory neural deafness is the hearing loss that occurs from the damage of the inner ear and
the 8th cranial nerve that runs from ear to the brain.

•This causes interruption in the passage of the message from the ear to the brain.

Causes
•Hereditary disorder
•Use of ototoxic drugs during pregnancy like streptomycin, tetracycline
•Age related hearing losses
•Disease of blood vessels
•Infections like measles, mumps, meningitis, scarlet fever
•Injury
•Loud noise or sounds

c. Mixed Hearing Loss

•In this type of deafness, both conductive and sensory neural deafness are present.

Causes
•Trauma: blast injury, head injury, acoustic trauma
•CSOM with labyrinthitis
•Otosclerosis

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Causes of Deafness
•Age: the progressive loss of hearing as the advancement of age.
•Long term exposure to loud environmental noise.
•Any sound above 85dB can cause hearing loss is related both to the power of the sound as
well as the length of exposure.

•8 hours of 90dB can cause damage to ears, any exposure to 140 dB sound causes immediate
damage (causes actual pain).

•Hereditary
•Injury to ear
•Disease or illness
•Use of medications like amino glycosides (gentamycin), diuretics, aspirin and NSAIDs.

Sign and Symptoms

•In children
 Delayed in learning to talk, or they are not clear when they speak.
 Often asks you to repeat yourself.
 Often talks very loudly.
 Often turns up the volume of the TV so that it is very loud.

• In adult
 Muffling of speech and other sounds.
 Difficulty in understanding words, especially against background noise or in a crowd of
people.
 Frequently asking others to speak more slowly, clearly and loudly.
 Needing to turn up the volume of TV and radio.
 Withdrawal from conversations.

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  Avoidance of some social settings.

Diagnostic Tests
•History taking and physical examination.
•Otoscopy
•Tuning fork tests: allow differentiation between conductive and sensory neural hearing loss.
•Audiometry

Management
Medical Management
•Conductive Hearing Loss
 If impacted wax or foreign body- is removed by syringing.

 Perforated eardrum is treated by tympanoplasty or myringoplasty.

 If CSOM, mastoidectomy is done.

 Ventilation tube is inserted for blocked Eustachian tube.

•Specific therapy
 Specific diseases like syphilis, diabetes mellitus should be treated.
 Steroids therapy is useful in sudden perceptive deafness.
 Vasodilator drugs are useful in Meniere’s disease.
 Tranquilizer and antidepressant may be needed for depressed patient due to deafness
and tinnitus.
 Speech therapy : It is developed by special therapist or a teacher for deaf.
 Lip reading: Lip reading is taught so that they may understand the speech.
 Hearing aids: It provides assistance to many individuals with hearing impairment. It
makes sound louder but don’t improve the ability to hear.

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 •Surgical Management
 Children with persistent chronic or recurrent otitis media with resultant effusions may
benefit from placement of Myringotomy tubes to ventilate the middle ear space to
prevent negative pressure in this area.
 If otitis results in the destruction or fixation of the ossicles, surgery may improve
ossicular function.
 Sensory neural deafness cannot be treated with surgical means other than cochlear
implantation.

• Nursing Management
 Keeping the objects out of ear:
 Instruct the patient to keep objects out of the ear.
 Avoid cleaning ear with wash cloth and finger.
 Avoid inserting hand object into the ear canal.
 Avoid pins to clean. It might penetrate middle ear leading to serious injury.

•Hearing impairment can be caused by acute loud noise, so control the environmental noise.
•Immunization: promote childhood and adulthood immunization including measles, mumps
and rubella.

•Ototoxic drugs can cause damage to hearing. Monitor patient’s reaction to drugs known for
ototoxicity.

• Identify the person who has risk for potential hearing loss.

•Communication
 While communicating with the person with hearing impairment, follow the following
guidelines:
 Get the patient’s attention by touching him/her lightly.
 Stand facing the patient with the light on your face, this will help the patient on
speech.

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  Speak slowly and clearly.
 Speak in normal tone, don’t shout.
 If person does not seem to understand, express it differently.
 Don’t smile, chew gum or cover the mouth when talking to a person with limited
hearing.
 Don’t show careless facial expression.
 Encourage the use of hearing aid if the person has one, allow him/her to adjust it
before speaking.

• Care of hearing aids:

 Turn the hearing aid off when not in use.
 Open the battery compartment at night to avoid accidental drainage of the battery.

• Keep an extra battery available at all times.

• Wash the ear, mould frequently/daily, if necessary with mild soap and warm water.

• Do not use hearing aid if an ear is infected.

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 Tumours of Ear
Definition

• A tumour is an abnormal growth of body tissue.

• Tumours can be cancerous (malignant) or non-cancerous (benign).

• They can occur on the externa l ear, or in the ear canal, the middle ear or inner ear.

• Tumours in different areas of the ear behave differently.

a. Benign Tumour
• May develop anywhere in the ear canal.

• These tumours rarely become malignant and with proper treatment.

• Prognosis is good.

Types

i. Osteoma
• It arises from cancellous bone and present as a single, smooth, bony, hard pedunculated
tumour often rising from the posterior wall of the osseous meatus near the outer end.

• Treatment is surgical removal by fracturing through its pedicle or removing with drill.

ii.Ceruminous adenoma

• It is a tumor of modif ied sebaceous gland which secretes cerumen.

iii. Papilloma
• Papilloma may be present as a tufted (hair like) growth or flat gray plague and is rough to
full. It is viral in origin.

• Treatment is surgical excision or curettage with cauterisation of its base.

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 iv. Adenoma
• It arises from sebaceous gland of the meatus and presents as a smooth,skin covered
swelling in the outer meatus. Treatment is surgical excision.

v. Exostosis
• They are the most common benign tumours of the bony canal. It may be:

a. Single pedunculated: rare and usually unilatera l form of cancellous bone and rega rded
as true osteoma.

b. Multiple exostosis: this type is more frequently seen and usually bilatera l. They are
formed of dense ivory bone covered w ith a thin layer of meatal skin in the deeper bony
meatus.

Clinical features

• Usually asymptomatic when small.

• When the tumour is large, it obstructs the ear canal by itself or through accumulated
cerumen and debris. It may cause irritation, deafness.

Diagnosis

• History Taking

• Otoscopy

• Biopsy

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Treatment
• Aural irrigation is done to keep the canal free of collected debris as often as necessary.

• Surgical excision of tumour

• Mastoidectomy is necessary when chronic suppuration of the middle ear cleft is

complicated by the obstructive exostosis.

b. Malignant Tumour
• Squamous cell carcinoma is common malignant tumour.

• Most often squamous cell carcinoma is seen in all cases of long standing ear
discharge.

Clinical Features
• Blood stained discharge from the ear.

• Granulation and polyp may bleed readily to touch.

• Pain may be absent at first but deep ear pain later.

• Deafness is conductive type.

• Ulcerated area or mass in the meatus or auricle can be seen.

Diagnosis
• Biopsy of the mass or ulcer.

• Plain radiograph y of the temporal bone and CT scan to see bony erosion and spread of
tumour.

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 Treatment
• Irradiation- Failure requires excision.

• Surgery- Total auricuectomy if cancer is limited to auricle.

• Radical Mastoidectomy- Wide excision of the auricle canal and bone.

• Radiotherapy may have to be given later,

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