Assessment and Management of Patients with Hearing and Balance Disorders

Otoscopic Examination

The tympanic membrane is inspected with an otoscope and indirect palpation with a pneumatic ostoscope.

To examine the external auditory canal and tympanic membrane, the otoscope should be held in the examiner’s right hand, in a pencil-hold postion with the examiner’s hand braced against the patient’s face.

o This position prevents the examiner from inserting the otoscope too far into the

external canal. Using the opposite hand, the auricle is grasped and gently pulled back to straighten the

canal in the adult. PICTURE The speculum is slowly inserted into the ear canal.

o Largest speculum that the canal can accommodate: 5 mm in adult

The external auditory canal is examined for:o Discharge;

o Inflammation; or

o Foreign body

The healthy tympanic membrane is pearly gray and is positioned obliquely at the base of the canal.

Proper otoscopic examination of the external auditory canal and tympanic membrane requires that the canal be free of large amounts of cerumen.

Evaluation of Gross Auditory Acuity

Whisper Test

To exclude one ear from the testing, the examiner covers the untested ear with the palm of the hand.

Then the examiner whispers softly from a distance of 1 or 2 feet from the occluded ear and out of the patient’s sight.

Weber Test

This test uses bone conduction to test lateralization of sound. A tuning fork, set in motion by grasping it firmly by its stem and tapping it on the

examiner’s knee or hand, is placed on the patient’s head or forehead.

PICTURE This test is useful for detecting unilateral hearing loss.

Rinne Test

The examiner shifts the stem of a vibrating tuning fork between two positions:o For air conduction: 2 inches from the opening of the ear canal

o For bone conduction: against the mastoid bone

This test is useful for distinguishing between conductive and sensorineural hearing loss.

Comparison of Weber and Rinne Tests

Hearing Status Weber RinneNormal hearing Sound is heard equally in both

ears.Air conduction is audible

longer than bone conduction.Conductive hearing loss Sound heard best in affected

ear.Sound heard as long or longer

in affected ear.Sensorineural hearing loss Sound heard best in normal

hearing ear.Air conduction is audible

longer than bone conduction in affected ear.

Diagnostic Evaluation

A. Audiometry

2 kinds:

Pure-tone audiometry The sound stimulus consists of a pure or musical tone.

Speech audiometry The spoken word is used to determine the ability to hear and discriminate sounds

and words.

3 important characteristics when evaluating hearing:

1. Frequency Refers to the number of sound waves emanating from a source per second, measured

as cycles per second, or Hertz (Hz). The normal human ear perceives sounds ranging in frequency from 20 t0 20, 000 Hz.

2. Pitch Used to describe frequency

A tone with 100 Hz is considered of low pitch A tone of 10, 000 Hz is considered high pitch

3. Intensity The unit for measuring loudness is decibel (dB) The critical level of loudness is approximately 30 dB. Sound louder than 80 dB is perceived by the human ear to be harsh and can be

damaging to the inner ear.

Goal: The aim is to improve the hearing level of patients with hearing loss to 30 dB or better within the speech frequencies.

Severity of Hearing Loss

Loss in Decibels Interpretation0-15 Normal hearing>15-25 Slight hearing loss>25-40 Mild hearing loss>40-55 Moderate hearing loss>55-70 Moderate to severe hearing loss>70-90 Severe hearing loss>90 Profound hearing loss

B. Tympanogram/Impedance audiometry Measures middle ear reflex to sound stimulation and compliance of the tympanic

membrane by changing the air pressure in a sealed ear canal. Compliance is impaired with middle ear disease.

C. Auditory Brain Stem Response It is a detectable electrical potential from CN VIII and the ascending auditory pathways

of the brain stem in response to sound stimulation. Electrodes are placed on the patient’s forehead. Acoustic stimuli (e.g clicks) are made in the ear. The resulting electrophysiologic measurements can determine at which decibel level a

patient hears and whether there are any impairments along the nerve pathways (e.g tumor on CN VIII)

D. Electronystagmography

It is the measurement and graphic recording of the changes in electrical potentials created by eye movements during spontaneous, positional, or calorically evoked nystagmus.

It helps diagnose conditions such as Meniere’s disease and tumors of internal auditory canal or posterior fossa.

Any vestibular suppressants, such as sedatives, tranquilizers, antihistamines, and alcohol are withheld for 24 hours before testing.

E. Platform Posturography It is used to investigate postural control capabilities such as vertigo. It can be used to evaluate if a person’s vertigo is becoming worse or to evaluate the

person’s response to treatment.

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External Otitis

Refers to the inflammation of the external auditory canal. Causes:

o water in the ear canal (swimmer’s ear)

o trauma to the skin of ear canal, permitting entrance of organisms into the tissues

o systemic conditions such as vitamin deficiency and endocrine disorders

Staphylococcus aureus and Pseudomonas species are the most common bacterial pathogens associated with external otitis.

Aspergillus is the most common fungus isolated in both normal and infected ears. Clinical manifestations:

o Pain and discharge from the external auditory canal

o Aural tenderness

o Occasionally: fever, cellulitis, and lymphadenopathy.

o Other symptoms: pruritus and hearing loss or a feeling of fullness.

o On otoscopic examination: the ear canal is erythematous and edematous.

Discharge may be yellow or green and foul-smelling.o In fungal infections: hair-like black spores may even be visible.

Medical Management:o Analgesic for the first 48 to 92 hours.

o If the tissues of the external canal are edematous, a wick should be inserted to

keep the canal open so that liquid medications can be introduced,

o Medications usually combine antibiotic and corticosteroid agents to soothe the

inflamed tissues.o For cellulitis or fever: systemic antibiotics may be prescribed.

o For fungal disorders: antifungal agents are prescribed.

Nursing Management:o Instruct patients to avoid events that traumatize the external canal such as

scratching the canal with the fingernail or other objects.o Patients should also avoid getting the canal wet when swimming or shampooing

the hair.o A cotton ball can be covered in a water-insoluble gel such as petroleum jelly and

placed in the ear as a barrier to water contamination.

Malignant External Otitis (Temporal bone osteomyelitis)

Rare and more serious external ear infection. This is a progressive, debilitating, and occasionally fatal infection of the external auditory

canal, the surrounding tissue, and the base of the skull. Pseudomonas aeruginosa is usually the infecting organism in patients with low resistance

to infection (e.g patients with diabetes). Treatment: control of the diabetes, administration of antibiotics, and aggressive local

wound care.

Masses of the External Ear

Exostoseso Are small, hard, bony protrusions found in the lower posterior bony portion of the

ear canal; they usually occur bilaterally.o Caused by an exposure to cold water, as in scuba diving or surfing.

o Treatment: surgical excision.

Gapping Earring Puncture

Results from wearing heavy pierced earrings for a long time or after an infection, or as a reaction from the earring or other impurities in the earring.

This deformity can only be corrected surgically.

Conditions of the Middle Ear

a) Tympanic Membrane Perforation Usually caused by infection or trauma.

o Sources of trauma include skull fracture, explosive injury, or a severe blow to the

ear. Less frequently, perforation is caused by foreign objects (e.g cotton-tipped applicators,

bobby pins, or keys) that have been pushed too far into the external auditory canal. Medical Management:

o Most tympanic membrane perforations heal spontaneously within weeks after

rupture, and some may take several months to heal. o In the case of a head injury or temporal bone fracture, a patient is observed for

evidence of cerebrospinal fluid otorrhea or rhinorrhea. o While healing, the ear must be protected from water.

Surgical Management:o Tympanoplasty – surgical repair of the tympanic membrane.

b) Acute Otitis Media (AOM) It is an acute infection of the middle ear, usually lasting less than 6 weeks. Pathogens that cause AOM:

o Streptococcus pneumoniae

o Haemophilus influenza

o Moraxella catarrhalis

Bacteria can enter the Eustachian tube from contaminated secretions in the nasopharynx and the middle ear from a tympanic membrane perforation.

Clinical Manifestations:o Otalgia

o Drainage from the ear

o Fever

o Hearing loss

o The tympanic membrane is erythematous and often bulging

Risk factors:o Age (younger than 12 months)

o Chronic upper respiratory infections

o Medical conditions that predispose to ear infections

Down syndrome, cystic fibrosis cleft palateo Chronic exposure to secondhand cigarette smoke

Medical Management:

o If drainage occurs, an antibiotic otic preparation is usually prescribed.

Surgical Management:o Myringotomy or tympanotomy

The tympanic membrane is numbed with a local anesthetic such as phenol The procedure is painless and takes less than 15 mins. Under microscopic guidance, an incision is made through the tympanic

membrane to relieve pressure and to drain serous or purulent fluid from the middle ear.

Normally, this procedure is unnecessary for treating AOM, but it may be performed if pain persists.

Myringotomy also allows the drainage to be analyzed (by C&S testing) so that the infecting organism can be identified and appropriate antibiotic therapy can be prescribed.

o If AOM recurs and there is no contraindication, a ventilating, or pressure-

equalizing tube may be inserted. The ventilating tube, which temporarily takes the place of the Eustachian

tube in equalizing pressure, is retained for 6 to 18 months. This tube is used to treat recurrent episodes of AOM.

c) Serous Otitis Media (middle ear effusion) It involves fluid, without evidence of active infection in the middle ear. In theory, this fluid results from a negative pressure in the middle ear caused by

Eustachian tube obstruction. It is frequently seen in patients after radiation therapy or barotrauma and in patients with

Eustachian tube dysfunction from a concurrent upper respiratory infection or allergy. Clinical Manifestations:

o Hearing loss

o Fullness in the ear

o Sensation of congestion

o Popping and crackling noises

o The tympanic membrane appears dull on otoscopy, and air bubbles may be

visualized in the middle ear.o Usually, the audiogram shows a conductive hearing loss.

Management:o Serous otitis media need not be treated medically unless infection (ie, AOM)

occurs.o Myringotomy can be performed, and a tube may be placed to keep the middle ear

ventilated.

o Corticosteroids in small doses may decrease the edema of the Eustachian tube in

cases of barotrauma.

d) Chronic Otitis Media It is the result of recurrent AOM causing irreversible tissue pathology and persistent

perforation of the tympanic membrane. Chronic infections of the middle ear damage the tympanic membrane, destroy the

ossicles, and involve the mastoid. Clinical Manifestations:

o Hearing loss

o Foul-smelling otorrhea

o Pain is not usually experienced, except in cases of acute mastoiditis

o Postauricular area is tender and may be erythematous and edematous.

o Otoscopic examination may show a perforation and cholesteatoma can be

identified as a white mass behind the tympanic membrane or coming through to the external canal from a perforation.

Cholesteatoma is an ingrowth of the skin of the external layer of the eardrum into the middle ear.

If untreated, cholesteatoma will continue to enlarge, possibly causing damage to the facial nerve and horizontal canal and destruction of other surrounding structures.

Congenital cholesteatomas are usually found in children and may cause severe bone loss of the incus.

Cholesteatomas found in elderly patients generally develop in the external canal.

Medical Management:o Careful suctioning of the ear under otoscopic guidance

o Instillation of antibiotic drops or application of antibiotic powder is used to treat

purulent discharge. o Systemic antibiotics are prescribed only in cases of acute infection.

Surgical Management:o Tympanoplasty

Purposes: reestablish middle ear function; close the perforation; prevent recurrent infection; and improve hearing.

o Ossiculoplasty

It is the surgical reconstruction of the middle ear bones to restore hearing.o Mastoidectomy

Objectives: to remove the cholesteatoma; gain access to diseased structures; and create a dry (noninfected) and healthy ear.