hearing and balance disorders ch 64

SMeltzer Textbook of MEdical Surgical NursingChapter 59
Balance Disorders
Objectives
On completion of this chapter, the learner will be able to:
1 Describe the anatomy and physiology of the ear.
2 Describe methods used to assess hearing and to diagnose hearing and balance disorders.
3 List the manifestations that may be exhibited by a person with a hearing disorder.
4 Identify ways to communicate effectively with a person with a hearing disorder.
5 Differentiate problems of the external ear from those of the middle ear and inner ear.
6 Compare the various types of surgical procedures used for managing middle ear disorders and appropriate nursing care.
7 Use the nursing process as a framework of care for patients undergoing mastoid surgery.
8 Use the nursing process as a framework of care for patients with vertigo.
9 Describe the different types of inner ear disorders, including the clinical manifestations, diagnosis, and management.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy of the Ear
Anatomy of the Inner Ear
Assessment
Otoscopic examination
Geriatric Considerations
Loss of sensory “hair” cells in the organ of Corti
Otosclerosis of the bones (incus, stapes, malleus)
Cerumen becomes harder and drier
Familiar predisposition to sensorineural hearing loss
Presbycusis-manifested by loss of hearing for high-frequency sounds followed by middle and lower frequencies
Life long exposure to loud noise, certain medications
Weber and Rinne Test
Diagnostic Evaluation
Tympanogram-measures the mobility of the tympanic membrane and middle ear structures relative to sound
Otoscopy-used to examine the external auditory canal, the tympanic membrane, and malleus bone visible through the TM
Which ear is this?
Hearing Loss
Increased incidence with age—presbycussis
Types
Conductive; due to external or middle ear problem
Sensorineural; due to damage to the cochlea or vestibulocochlear (VIII) nerve
Mixed; both conductive and sensorineural
Functional (psychogenic); due to emotional problem
PRESBYCUSSIS-progressive hearing loss particular to high-pitched sounds
*
Manifestations of hearing loss
Speaks softly
Sensorineural
Speaks loudly
Dizziness
Manifestation & Risk Factors
Impairment may be gradual and not recognized by the person experiencing the loss
As hearing loss increases, person may experience deterioration of speech, fatigue, indifference, social isolation or withdrawal, and other symptoms
Conductive-hx of middle ear infections, old age (otosclerosis)
Sensorineural-prolonged exposure to loud noises, ototoxic meds, infectious processes, age (presbycusis)
* Chart 64-2 & 64-3 *
Guidelines for Communicating with the Hearing-Impaired
Use a low-tone, normal voice
Speak slowly and distinctly
Face the person and get his or her attention
Speak into the less-impaired ear
Use gestures and facial expressions
If necessary, write out information or obtain a sign language translator
Chart 64-4
Conditions of the External Ear
Cerumen impaction
Removal may be by irrigation, suction, or instrumentation
Gentle irrigation should be used with lowest pressure, directing stream behind the obstruction. Glycerin, mineral oil, ½ strength H2O2, or peroxide in glyceryl may help soften cerumen
Foreign bodies
Removal may be by irrigation, suction, or instrumentation
Objects that may swell (such as vegetables or insects) should not be irrigated
Foreign body removal can be dangerous and may require extraction in the operating room
Conditions of the External Ear (cont’d)
External otitis
Inflammation most commonly caused by bacteria Staphylococcus or Pseudomonas, or fungal infection from Aspergillus spp.
Manifestations include pain and tenderness, discharge, edema, erythema, pruritus, hearing loss, feelings of fullness in the ear
Therapy is aimed at reducing discomfort, reducing edema, and treating the infection.
A wick may be inserted in the canal to keep it open and facilitate medication administration.
Malignant external otitis: rare, progressive infection that effects the external auditory canal, surrounding tissue, and skull
Conditions of the Middle Ear
Tympanic membrane perforation
Acute otitis media
Pathogens are most commonly Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis
Manifestations include otalgia (ear pain), fever, and hearing loss
Treatment
Conditions of the Middle Ear (cont’d)
Serous otitis media: fluid in the middle ear without evidence of infection
Chronic otitis media
Chronic infection damages the tympanic membrane, ossicle, and involves the mastoid
Treatment
Tympanoplasty, ossiculoplasty, or mastoidectomy
Middle Ear Surgical Procedures
Ossiculoplasty
Reconstruction of the bones of the middle ear
Prostheses are used to reconnect the ossicles to reestablish sound conduction
Mastoidectomy
Removal of diseased bone, mastoid air cells, and cholesteatoma to create a noninfected, healthy ear
Cholesteatoma: benign tumor, an ingrowth of skin that causes persistently high pressure in the middle ear, which causes hearing loss and neurologic disorders and destroys structures
Stapedectomy for Otosclerosis
Patient Teaching After Middle Ear or Mastoid surgery Chart 64-6
Medications teaching; analgesics, antivertigo medications
Activity restrictions
Gently blow nose only one side at a time, and sneeze and cough with mouth open
Note: patient may need instruction to avoid heavy lifting, exertion, and nose blowing to prevent dislodgement of grafts or prostheses
Safety issues related to potential vertigo
Instruction regarding potential complications and reporting of problems
Avoid getting water in ear
Follow-up care
Conditions of the Inner Ear
Disorders of the vestibular system affect more than 30 million in the U.S. and falls resulting from these disorders result in 100,000 hip fractures a year.
Dizziness: any altered sense of orientation in space
Vertigo: the illusion of motion or a spinning sensation
Nystagmus: involuntary rhythmic movement of the eyes. This is associated with vestibular dysfunction.
Conditions of the Inner Ear
Meniere’s disease
Ototoxicity
Visual, vestibular, and proprioceptive systems provide the brain with input regarding balance. Problems within any of these systems pose a risk for loss of balance.
Inner ear problems are characterized by tinnitus, vertigo, and dizziness.
Ménière’s Disease
Abnormal inner ear fluid balance cause by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct
Manifestations include fluctuating, progressive hearing loss; tinnitus; feeling of pressure or fullness; and episodic, incapacitating vertigo that may be accompanied by nausea and vomiting
Treatment
Meclizine (Antivert); also tranquilizers, antiemetics, and diuretics may be used
Surgical management to eliminate attacks of vertigo; endolymphatic sac decompression, middle and inner ear perfusion, and vestibular nerve sectioning
Labyrinthitis
Diagnostic Testing
Electronystagmography (ENG)
Electrodes are placed around the eyes and movements of the eyes are recorded when the ear canal is stimulated with cold water instillation or injection of air.
Bed rest and NPO until vertigo subsides
Restrict caffeine, alcohol, sedatives and antihistamines 24 hr prior to test.
Caloric testing
Warm or cool water is instilled in the ear to induce nystagmus
The eyes’ response to the instillation of water is diagnostic of vestibular disorders
COWS
Medications
Vertigo Reducing Activities
Decrease intake of salt
Avoid caffeine and alcohol
Take a diuretic to decrease the amt of fluid in semicircular canals
Take precautions when vertigo is present, use assistive devices, rest in quiet, dark room
Maintain safe environment that is free of clutter
Interdisciplinary Care for Vertigo
A combination of biofeedback, physical therapy, and stress management may be used
Postural education can teach the client positions to avoid as well as positional exercises that can terminate an attack of vertigo
Question
Is the following statement True or False?
A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids.
Answer
True
A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids.
Discussion Topics
1. A patient has been diagnosed with Meniere’s disease.
What medication therapy and surgical management are utilized in Ménière's disease?
2. A patient has been admitted for severe vertigo.
What is the proper technique for performing an otoscopic examination?
3. A patient’s physical exam uncovered the need for a more specific hearing assessment.
What is the difference between the Weber and Rinne test as evaluators of gross auditory acuity?
NCLEX
The nurse collects a history from a client suspected of a sensorineural hearing loss. Which of the following findings supports the diagnosis and should be reported?
The ability to hear high-pitched sounds
Frequent ear irrigations for dry, hard cerumen
A history of exposure to excessive noise over a period of time
The client speaks softly
Answer
3

hearing and balance disorders ch 64

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