The Ears

Dr. Zyad Saleh

Anatomy

Structure of the Ear:

The ear is organ of hearing. It comprises of three parts:

Outer earMiddle earInner ear

Structure of the outer Ear:

•It is composed of two parts; auricle and ear canal.•Auricle is cartilage cover by skin and has firm elastic consistency. •The auricle function is to gather sound waves.

•The ear canal is approximately 2.5 cm long. •The outer portion of the canal consists of cartilage and skin, that is hairy and contains glands that produce earwax (cerumen). •The inner portion consists of sensitive, thin, hairless skin, that is surrounded by bone. •The canal has slight S-curve in adults.•The canal ends with ear drum (tympanic membrane).

•Mastoid process (the lowest portion of mastoid part of the temporal bone) can be palpable behind the lobule. LANDMARK• The earwax is yellow, waxy material that lubricates and protects the ear; forms a sticky barrier that helps keep foreign bodies from entering and reaching tympanic membrane.

Tympanic membrane:

•Separates the external and middle ear.•Tilted obliquely to the ear canal

•Translucent membrane with a pearly gray color and a prominent cone of light (reflection of the otoscope light).•Cone shaped light prominent at 5 o’clock position in Rt ear and 7 o’clock position in Lt ear.

Tympanic membrane:

•Handle and short process of the malleus (ossicle)•Umbo—the base of the malleus, also serving as a center point landmark•Cone of light—the reflection of the otoscope light seen as a cone due to the concave nature of the membrane

Tympanic membrane:

• Pars flaccida—the top portion of the membrane that appears to be less taut than the bottom portion• Pars tensa—the bottom of the membrane that appears to be taut

Structure of the middle Ear:

•Is an air-filled cavity inside the temporal bone that transmits sound by three tiny bones (ossicles) namely malleus, incus, stapes. •It is connected with a nasopharynx.The Eustachian tube is normally closed but it opens with swallowing or yawning.•It is approximately 3.5 cm long and its function is pressure equalization (middle ear and atmosphere) and mucus drainage from the inner ear.

Function of the of middle Ear:

1. Conducts sound vibrations from outer ear to central hearing apparatus in the inner ear.

2. Protects inner ear by reducing the amplitude of loud sounds. 3. Its Eustachian tube allows equalization of air pressure on each side of tympanic membrane so membrane does not rupture with change in pressure.

• The inner ear is fluid filled contains bony labyrinth and membranous labyrinth.

Structure of the inner Ear:

•Consists of the vestibule and the semicircular canals and the cochlea (snail shell) that contains the central hearing apparatus.

•The inner ear is not accessible to examination, however, its function can be assessed.

•Holds the sensory organs for equilibrium and hearing.

Subjective Data

Concerning symptoms of the ear are:Hearing loss

Earache (otalgia)Discharge (otorrhea)

TinnitusVertigo

During data collection, the examiner should be alert to signs of hearing loss such as inappropriate answers, frequent requests for repetition, etc.The opening questions may be:How is your hearing?Have you had any troubles with your ears?

If the patient has any problem / symptom do further assessment to that symptom using OLD CART questions.

- Do you have any ear drainage? Describe the amount and any odor.

- Do you have any ear pain?

Earache

Otitis media: medical term for middle ear infectionOtitis externa: inflammation of the outer ear and ear canal.

Otitis externa

Tinnitus:Do you experience any ringing, roaring or crackling in your ears?Is a perceived sound that has no external stimulus and commonly is heard as musical ringing or roaring noise. Vertigo: refers to perception that the patient or the environment is rotating or spinning. (an inner-ear problem.) It is termed subjective vertigo when clients feel that they are spinning around and objective vertigo when clients feel that the room is spinning around them.. It is important to distinguish vertigo from dizziness

Past history:

Congenital hearing lossRemoval of cerumenEar surgeryTraumaInfectionExposed to hazardous noise levelsHistory of syphilis, rubella, meningitis. Describe any past treatments

Hearing loss

•Has your hearing loss affected your ability to care for yourself? To work?. •Do you wear a hearing aid?•How do you care for your ears? Describe how you clean your ears.

Family history:

Hearing lossOtitis mediaAllergiesSmoking

Lifestyle habits:

Objective Data

Inspect and palpate the external ear:•Size and shape and ear alignment: ears are equal size bilaterally with no swelling or thickening, (taking in consideration a normal familial trait).•Skin Condition: skin color is consistent with facial skin color, skin intact, with no lump or lesions. •Tenderness: move the auricle and push the tragus, should feel firm with no pain. otitis externa?•External auditory meatus: cerumen appearance-color varies from yellow to brown or black; may be moist and waxy to dry. Any other discharge? Inflammation?

Inspect the eardrum:

Color:shiny and translucent with a pearl-gray color.

Cone-shaped light reflex.

Section of malleus.

Integrity: intact eardrum.

Perforated eardrum

Inspect the eardrum:Red, bulging eardrum and distorted, diminished, or absent light reflex—acute otitis mediaYellowish,Bluish or dark red color—White spots—

Perforated eardrum

Auditory Acuity:•Whisper-Voice test.Test one ear at a time, ask pt to close her other ear, stand behind the pt, whisper softly toward unoccluded ear, increase intensity of sound if necessary. (Able to correctly repeat the two-syllable word as whispered.)

#testing of ear and bone conduction is done if the patient has problems in hearing… •Weber test: after making tuning fork Vibrating, ask about where the pt hear it. normally heard in the midline. In unilateral conductive hearing loss sound is heard in impared ear.• evaluate the conduction of sound waves

through bone to help distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear).

In unilateral sensorineural hearing loss it is heard in the good ear. conductive hearing loss the poor ear receives most of the sound conducted by bone vibration.

•Rinne’ test: compare air conduction (AC) with bone conduction (BC). Place vibrating tuning fork on the mastoid bone, when the pt can no longer hear the sound, quickly place the fork close to the ear, and ask if the sound can be heard again. •Air conduction sound is normally heard longer than bone conduction sound (AC > BC).•Conductive hearing loss: BC=AC, or BC>AC. •Sensorineural hearing loss: AC>BC.

Romberg test: Test-assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance.Ask patient to stand up with feet together. When stable have pt close eyes wait about 20 seconds; slight swaying may occur.Positive Romberg’s –loss of balance that occurs when closing eyes.