CHAPTER 59: ASSESSMENT AND MANAGEMENT OF OSSICLES

PATIENTS WITH HEARING AND BALANCE DISORDERS

 assists in the transmission of sound
ANATOMY OF THE EAR  consists of three smallest bones of the body

EXTERNAL EAR 1. Malleus (hammer)

2. Incus (anvil)
 AURICLE (PINNA): 3. Stapes (stirrup)
o Composed mainly of cartilage.
o Collects sound waves and directs vibrations
into the external auditory canal.

 EXTERNAL AUDITORY CANAL:

o Skin contains hair, sebaceous glands, and
ceruminous glands, which secrete cerumen
(ear wax).
o Self-cleaning mechanism: Moves old skin
cells and cerumen to the outer part of the
ear.

MIDDLE EAR

 Air-filled cavity

EUSTACHIAN TUBE

 Connects the middle ear to the nasopharynx. Usually

closed; opens via the tensor veli palatini muscle
during yawning, swallowing, or a Valsalva maneuver.

TYMPANIC MEMBRANE (EARDRUM)

 Normal: Pearly gray and translucent.

 Protects the middle ear and conducts vibrations to the
ossicles.
 conducts sound vibrations from the external auditory
canal -> ossicles.
 Magnifies sound pressure 22 times by transmitting
from a large area to a smaller one.
INNER EAR FUNCTION OF THE EARS

CONTAINS: Hearing (conducted over two pathways: air and bone)

 organ for hearing (cochlea) AIR PATHWAY

 organ for balance (semicircular canals)
 cranial nerves VII (facial nerve) and VIII  Sounds transmitted by air conduction travel over the
(vestibulocochlear nerve) air-filled external and middle ear through vibration
of the tympanic membrane and ossicles.
LABYRINTH
BONE PATHWAY
 Bony Labyrinth: houses the cochlea and
semicircular canals  Sounds transmitted by bone conduction travel
 Membranous Labyrinth directly through bone to the inner ear, bypassing
o composed of the utricle, the saccule, the the tympanic membrane and ossicles.
cochlear duct, the semicircular canals, and
the organ of Corti, all of which are BALANCE AND EQUILIBRIUM
surrounded by a fluid called endolymph.
BODY BALANCE
THREE SEMICIRCULAR CANALS
 maintained by cooperation of:
 contain sensory receptor organs that are arranged to o muscles and joints of the body
detect rotational movement. (proprioceptive system)
 these receptor end organs are stimulated by changes o eyes (visual system)
in the rate or direction of a person’s movement. o labyrinth (vestibular system)
 utricle and saccule – involved with linear
movements. These areas send their information about equilibrium, or
balance, to the brain (cerebellar system) for coordination
and perception in the cerebral cortex.

---------ASSESSMENT OF HEARING AND BALANCE----------

INSPECTION OF THE EXTERNAL EAR

INSPECTION

 deformities, lesions, and discharge

 size, symmetry, and angle of attachment to the head
 Manipulation of the auricle $\rightarrow$ painful
(otitis media)

DIRECT PALPATION
ORGAN OF CORTI
 Tenderness on palpation (acute mastoiditis or
 housed in the cochlea (a snail-shaped, bony tube) inflammation of the posterior auricular node)
 also referred to as the end organ for hearing
 located on the basilar membrane that stretches from
OTOSCOPIC EXAMINATION
the base to the apex of the cochlea.
TYMPANIC MEMBRANE

 healthy color: pearly gray

 normal position: oblique at the base of the canal

EVALUATION OF GROSS AUDITORY ACUITY

WHISPER TEST

 cover the untested ear with the palm of the hand

 examiner then whispers softly from a distance of 1 or
2 feet from the unoccluded ear and out of the patient’s
sight.
patient with normal acuity – correctly repeats what was DIAGNOSTIC EVALUATION
whispered.
AUDIOMETRY
WEBER TEST
 The most basic and accurate testing to determine
 uses bone conduction to test lateralization of sound. and measure hearing ability.
 tuning fork (ideal: 512 Hertz [Hz])  Results are plotted on a graph known as an
 Done by grasping the tuning fork firmly by its stem audiogram.
and tapping it on the examiner’s knee or hand ->  Testing is performed by an audiologist.
place on patient’s head or forehead  Unit for measuring loudness (intensity of sound) is the
 useful for detecting unilateral hearing loss decibel (dB), the pressure exerted by sound

NORMAL (hears the sound equally in both ears) Loss in Decibels Interpretation
0–15 Normal hearing
SENSORINEURAL HEARING LOSS (from damage to the >15–25 Slight hearing loss
cochlear or vestibulocochlear nerve) >25–40 Mild hearing loss
>40–55 Moderate hearing loss
 hears the sound in the better-hearing ear. >55–70 Moderate to severe hearing loss
>70–90 Severe hearing loss
RINNE TEST (pronounced rin-ay) >90 Profound hearing loss

examiner shifts the stem of a vibrating tuning fork between two TYMPANOGRAM
positions:
 Also referred to as impedance audiometry
 2 inches from the opening of the ear canal (for air  Measures middle ear muscle reflex to sound
conduction), stimulation and compliance of the tympanic
 and against the mastoid bone (for bone membrane by changing the air pressure in a sealed
conduction) ear canal.
 Impaired compliance: middle air disease
As the position changes, the patient is asked to indicate which
tone is louder or when the tone is no longer audible. ELECTRONYSTAGMOGRAPHY

NORMAL HEARING:  is the recording of eye movements, specifically

nystagmus – during various oculomotor and
 patient reports that air-conducted sound is louder than vestibular testing.
bone-conducted sound (AC > BC)  Used to establish the diagnosis of:
 Conductive Hearing Loss (hears bone-conducted o Meniere’s disease
sound as long as or longer than air-conducted sound) o Vestibular neuronitis or labyrinthitis
 Sensorineural Hearing Loss (hears air-conducted o Benign paroxysmal positional vertigo (BPPV)
sound longer than bone-conducted sound)
PLATFORM POSTUROGRAPHY
Hearing Status Weber Rinne
Normal hearing Sound is heard Air conduction is  recommended for patients with dizziness and
equally in both audible longer than balance disorders
ears. bone conduction in  integration of visual, vestibular, and proprioceptive
both ears. cues (i.e., sensory integration) with motor response
Conductive Sound is heard Sound is heard as output and coordination of the lower limbs is tested.
hearing loss best in affected long or longer in
ear (hearing affected ear (hearing HEARING LOSS
loss). loss).
Sensorineural Sound is heard Air conduction is RISK FACTORS OF HL:
hearing loss best in normal audible longer than
hearing ear. bone conduction in  Congenital malformations of the cranial structure (ear)
affected ear.  Family history of sensorineural impairment
 Low birth weight (<1500 g)
 Rinne's: * Normal: AC > BC  Perforation of the tympanic membrane
o Conductive hearing loss: BC > AC  Recurrent ear infections
o Sensorineural hearing loss: AC > BC (false  Use of ototoxic medications (e.g., gentamycin, loop
negative) diuretics)
 Weber's:
o Normal: heard in midline
o Conductive hearing loss: heard in bad ear
o Sensorineural hearing loss: heard in good
ear
HEARING LOSS Clinical Manifestations

 Hearing loss occurs in men more often than in women DEAFNESS

(1) CONDUCTIVE HEARING LOSS  is the partial or complete loss of the ability to hear.

 usually results from an external ear disorder, such as Early manifestations may include:
impacted cerumen, or a middle ear disorder, such as
otitis media or otosclerosis.  tinnitus, increasing inability to hear when in a group,
 the efficient transmission of sound by air to the inner and a need to turn up the volume of the television.
ear is interrupted.
Management

AURAL REHABILITATION

 Hearing Aids
 Implanted Hearing Devices

CONDITIONS OF THE EXTERNAL EAR

 Cerumen Impaction
 Foreign Bodies
 External Otitis (Otitis Externa)
(2) SENSORINEURAL HEARING LOSS
(1) CERUMEN IMPACTION
 involves damage to the cochlea or vestibulocochlear
nerve.  Accumulation of cerumen $\rightarrow$ causing
otalgia (a sensation of fullness or pain in the ear) with
or without a hearing loss.

MANAGEMENT:

 removed by irrigation (gentle irrigation with warm

water)
 ceruminolytic agents
 instrumentation (cerumen curette, aural suction, and
binocular microscope)

(2) FOREIGN BODIES

(3) MIXED HEARING LOSS  some objects are inserted intentionally into the ear by
adults trying to clean the external canal or relieve
itching
 children who introduce peas, beans, pebbles, toys
PRESBYCUSIS and beads
 insects may enter the ear canal the effects may range
 used to describe this progressive hearing loss from no symptoms to profound pain and decreased
 age-related changes, occurs in the ear that may hearing
eventually lead to hearing deficits
Management
ACOUSTIC TRAUMA
 the three standard methods for removing foreign
 refers to hearing loss caused by a single exposure to bodies are the same as those for removing cerumen:
an extremely intense noise, such as an explosion. irrigation, suction and instrumentation
 Usually, noise-induced hearing loss occurs at a high  foreign vegetable bodies and insects tend to swell
frequency (about 4000 Hz). thus irrigation is contraindicated
 Hearing loss due to noise is permanent because the  an insect can be dislodged by instilling mineral oil,
hair cells in the organ of Corti are destroyed. which will kill the insect and allow it to be removed
 removal of foreign body by unskilled hands is
dangerous
 in rare circumstances, the foreign body may be
removed in the OR with patients under general
anesthesia
(3) EXTERNAL OTITIS (OTITIS EXTERNA)  be aware that if otitis externa is diagnosed, refrain
from any water sport activity for approximately 7 to 10
 inflammation of the external auditory canal days to allow the canal to heal completely.
Recurrence is highly likely unless you allow the
CAUSES external canal to heal completely.

 water in the ear canal (swimmer’s ear) CONDITIONS OF THE MIDDLE EAR
 trauma to the skin of the ear canal
 systemic conditions (vitamin deficiency and endocrine  Tympanic Membrane Perforation
disorders)  Acute Otitis Media (AOM)
 bacterial infection: Staphylococcus aureus and  Serous Otitis Media
Pseudomonas species  Chronic Otitis Media
 fungal infection: Aspergillus  Otosclerosis

Clinical Manifestations (1) TYMPANIC MEMBRANE PERFORATION

 pain & discharge — at external auditory canal  usually caused by infection or trauma
 fever, cellulitis, and lymphadenopathy  During infection, the tympanic membrane can
 pruritus and hearing loss or a feeling of fullness in the rupture if the pressure in the middle ear exceeds the
ear atmospheric pressure in the external auditory
canal.
OTOSCOPIC EXAMINATION
SOURCES OF TRAUMA
 ear canal is erythematous and edematous.
 skull fracture
Discharges  injury from explosion
 a severe blow to the ear
 may be yellow or green and foul smelling.
 In fungal infections, hairlike black spores may be Medical Management
visible.
 may heal spontaneously within weeks after rupture or
Medical Management months

 Analgesic medications – for the first 48-96 hours; Surgical Management

relieves discomfort
 Antimicrobial/antifungal otic medications – given by  TYMPANOPLASTY
dropper o tissue (commonly from the temporalis fascia)
 Corticosteroid – added to soothe inflamed tissues is placed across the perforation to allow
healing
Nursing Management
(2) ACUTE OTITIS MEDIA (AOM)
 avoid further external canal trauma (no using of
cotton-tipped applicators)  most commonly seen in children
 patients should also avoid getting the canal wet when  an acute infection of the middle ear, lasting less than
swimming or shampooing the hair – use cotton ball for 6 weeks
barrier  usually bacterial or viral $\rightarrow$ from eustachian
 use antiseptic otic preparations after swimming tube dysfunction caused by obstruction related to
URTIs
PREVENTION OF OTITIS EXTERNA  purulent exudate is usually present in the middle ear
$\rightarrow$ conductive hearing loss.
The nurse instructs the patient to:

 protect the external canal when swimming,

showering, or washing hair. Use ear plugs or place a
cotton ball covered in petrolatum jelly in the ear, and
wear a swim cap. The external canal may be dried
afterward with a hair dryer on low heat.
 place alcohol drops in the external canal to act as an
astringent to help prevent infection after water
exposure.
 prevent trauma to the external canal. Procedures,
foreign objects (e.g., bobby pin), scratching, or any
other trauma to the canal that breaks the skin integrity
may cause infection.
Clinical Manifestations Medical Management

Risk factors for AOM:  Corticosteroids (in small doses) – may decrease
the edema of the eustachian tube in cases of
 younger age, chronic URTIs barotrauma.
 medical conditions that predispose the patient to ear
infections (e.g., Down syndrome, cystic fibrosis, cleft Surgical Management
palate)
 chronic exposure to secondhand cigarette smoke  Myringotomy

Symptoms: (4) CHRONIC OTITIS MEDIA

 usually unilateral in adults, may be accompanied by  recurrent AOM that causes irreversible tissue
otalgia pathology.
 drainage from the ear, fever, and hearing loss.  Chronic infections of the middle ear -> damages the
 pain is relieved from a ruptured tympanic membrane tympanic membrane -> destroys the ossicles -> and
involves the mastoid
Medical Management
Clinical Manifestations
 If drainage occurs – antibiotic otic preparation
Otoscopic examination – may reveal a:
Surgical Management
 Perforation
 Myringotomy (tympanotomy) – an incision in the  Cholesteatoma (white mass behind the tympanic
tympanic membrane. membrane)
o procedure is painless
o takes less than 15 minutes. CHOLESTEATOMA
o under microscopic guidance, an incision is
made through the tympanic membrane  cystlike lesion of the external layer of the eardrum into
$\rightarrow$ to relieve pressure and to the middle ear
drain serous or purulent fluid from the  caused by a chronic retraction pocket of the tympanic
middle ear. membrane $\rightarrow$ creating a persistently high
negative pressure of the middle ear.
(3) SEROUS OTITIS MEDIA

 also known as middle ear effusion

 involves the presence of fluid, without evidence of
active infection, in the middle ear.
 fluid results from a negative pressure in the middle
ear caused by:
o eustachian tube obstruction (from
URTIs/allergy)
o radiation therapy
o barotrauma (scuba diving or airplane
descent)

Clinical Manifestations

 hearing loss, fullness in the ear or a sensation of

congestion, or popping and crackling noises –
occurs as the eustachian tube attempts to open
 otoscopy – dull tympanic membrane with visible air
bubbles
 audiogram – shows a conductive hearing loss.
Medical Management DISORDERS OF BALANCE

 careful suctioning of the ear under otoscopic guidance DIZZINESS

 instillation of antibiotic drops or application of
antibiotic powder  altered sensation of orientation in space
 systemic antibiotic agents  more commonly referred to as lightheadedness

Surgical Management VERTIGO

 Tympanoplasty (most common)  is the misperception or illusion of motion of the

 Ossiculoplasty (surgical reconstruction of the middle person/surroundings.
ear)  a spinning sensation or say they feel as though
 Mastoidectomy (to remove the cholesteatoma) objects are moving around them.

(5) OTOSCLEROSIS (1) MOTION SICKNESS

 involves the stapes  a disturbance of equilibrium caused by a conflict in

 results from the formation of new, abnormal spongy motion receptor stimuli
bone, especially around the oval window
$\rightarrow$ fixated stapes $\rightarrow$ efficient Symptoms
transmission of sound is prevented $\rightarrow$ can
progress to complete deafness  sweating, pallor, nausea, and vomiting $\rightarrow$
 more common in women; a familial condition caused by vestibular overstimulation.
 manifestation will stop once stimulation stops
Clinical Manifestations
Management
 patient may or may not complain of tinnitus.
 Otoscopic examination – usually reveals normal  OTC antihistamines (dimenhydrinate or meclizine)
tympanic membrane. – provide some relief of nausea and vomiting by
 Rinne Test – bone conduction is better than air blocking the conduction of the vestibular pathway of
conduction (BC > AC) the inner ear.
 Audiogram – confirms conductive hearing loss or
mixed loss, especially in the low frequencies.

Medical Management

 Amplification with a hearing aid

Surgical Management
(2) MÉNIÈRE’S DISEASE
 Stapedectomy (stapedotomy) – removing the
stapes superstructure and part of the footplate and  an abnormality in inner ear fluid balance caused by a
inserting a tissue graft and a suitable prosthesis malabsorption in the endolymphatic sac or a blockage
in the endolymphatic duct.
 Endolymphatic hydrops (dilation of the
endolymphatic space) frequently occurs -> causing
either increased pressure in the system or rupture of
the inner ear membrane -> producing symptoms of
Ménière’s disease
 More common in adults, onset – 40s; appears to be
equally common in men and women, and is usually
bilateral.

CONDITIONS OF THE INNER EAR

 Motion Sickness
 Ménière’s Disease
 Benign Paroxysmal Positional Vertigo
 Tinnitus
 Labyrinthitis
 Acoustic Neuroma
TRIAD OF SYMPTOMS  first-line surgical approach to treat the vertigo of
Ménière’s disease
 Episodic vertigo  shunt or drain is inserted in the endolymphatic sac
 Tinnitus through a postauricular incision
 Fluctuating sensorineural hearing loss
Vestibular Nerve Sectioning
OTHER SYMPTOMS
 more effective; higher success rate
 feeling of pressure or fullness in the ear  can be performed by a translabyrinthine approach
 nausea and vomiting  cutting the nerve prevents the brain from receiving
input from the semicircular canals.
TWO SUBSETS

COCHLEAR MÉNIÈRE’S DISEASE

 fluctuating, progressive sensorineural hearing loss

associated with tinnitus and aural pressure in the
absence of vestibular symptoms or findings.

VESTIBULAR MÉNIÈRE’S DISEASE

 is characterized as the occurrence of episodic vertigo

associated with aural pressure but no cochlear (3) BENIGN PAROXYSMAL POSITIONAL VERTIGO
symptoms.
 A brief period of incapacitating vertigo.
OTHER SYMPTOMS:  Occurs when the position of the patient’s head is
changed with respect to gravity, typically by placing
 Vertigo (may last minutes to hours, possibly the head back with the affected ear turned down.
accompanied by nausea or vomiting)
 Diaphoresis Management:
 Persistent feeling of imbalance or disequilibrium
 Bed rest, repositioning techniques.
ASSESSMENT AND DIAGNOSTIC FINDINGS  Canalith repositioning procedure (involves quick
movements of the body, rearranges the debris in the
Physical examination findings canal).
 Meclizine (1 to 2 weeks).
 Weber test – may lateralize to the ear opposite the  Vestibular rehabilitation.
affected ear.
 Audiogram – reveals a sensorineural hearing loss in (4) TINNITUS
the affected ear.
 Roaring, buzzing, or hissing sound in one or both
Medical Management ears.
 May be a symptom of an underlying disorder.
DIET: low-sodium (1000 to 1500 mg/day or less) diet.
Underlying Disorder/Factors:
PHARMACOLOGIC THERAPY
 Ototoxic substances
 Antihistamines (Meclizine) – shortens the attack  Cardiovascular/thyroid disease
 Tranquilizers (Diazepam) – assists in vertigo control  Hyperlipidemia
 Antiemetic agents (Promethazine suppositories) –  Vitamin B12 deficiency
for N/V & vertigo  Psychological disorders (depression, anxiety)
 Diuretic therapy (hydrochlorothiazide,  Fibromyalgia
spironolactone) – may relieve symptoms by lowering  Otologic disorders (Ménière’s disease, acoustic
the pressure in the endolymphatic system neuroma)
 Intratympanic injection of gentamicin – used to  Neurologic disorders (head injury, multiple sclerosis)
cause ablation of the vestibular hair cells; however,
the risk of significant hearing loss is high SELECT OTOTOXIC SUBSTANCES

Surgical Management  Aminoglycoside antibiotic agents: amikacin,

gentamicin, kanamycin, netilmicin, neomycin,
Endolymphatic Sac Decompression (shunting) streptomycin, tobramycin
 Anti-inflammatory agents: salicylates (aspirin),
 equalizes the pressure in the endolymphatic space. indomethacin
 Antimalarial agents: quinine, chloroquine
  Chemicals: alcohol, arsenic Management
 Chemotherapeutic (antineoplastic) agents:
cisplatin, nitrogen mustard, carboplatin Three options for managing an acoustic neuroma include:
 Loop diuretic agents: ethacrynic acid, furosemide,
acetazolamide, torsemide, azosemide, ozolinone, 1. Surgical removal
indacrinone, piretanide 2. Radiation
 Metals: gold, mercury, lead 3. Observation
 Other antibiotic agents: erythromycin, azithromycin,
clarithromycin, minocycline, polymyxin B, vancomycin  Tumors less than 1.5 cm: Conservative treatment &
routine monitoring.
(5) LABYRINTHITIS  Surgical removal: For patients who are at low risk.

 An inflammation of the labyrinth of the inner ear Potential Complications of Surgery

 Can be bacterial or viral in origin
 Occurs as a complication of otitis media  Facial nerve paralysis, cerebrospinal fluid leakage,
meningitis, and cerebral edema.
Clinical Manifestations  Death from acoustic neuroma surgery is rare.

 Sudden onset of incapacitating vertigo with N/V Surgical Management

(nausea/vomiting)
 Various degrees of hearing loss, possibly tinnitus Translabyrinthine Approach

Management  Indications: Significant hearing loss or when hearing

preservation is not possible.
 Bacterial labyrinthitis – IV antibiotic therapy; fluid  Procedure: Behind the ear, open the mastoid bone
replacement and the inner ear to access the tumor.
 Administration of an antihistamine/ antiemetic
(meclizine) Retrosigmoid Approach
 Viral labyrinthitis – symptomatic mgt.
 Indications: For smaller neuroma and hearing
preservation.
 Procedure: Approach is on the occipital bone; the
cerebellum is allowed to fall back out of the way, and
the bone over the internal canal is removed for
access of the tumor.

(6) ACOUSTIC NEUROMA

 Synonym: Also referred to as vestibular

schwannomas.
 Definition: Slow-growing, benign tumors of cranial
nerve VIII $\rightarrow$ usually arising from the
Schwann cells of the vestibular portion of the nerve.
 Risk Factors: A known risk factor for acoustic
neuroma is cell phone usage.

Manifestations

 Unilateral tinnitus and hearing loss (most

common).

Diagnostic Studies

 MRI scan with a contrast agent – the imaging study

of choice.