Assessment and Management of Patients with Hearing and Balance Disorders

1. Assessment and Management of Patients with Hearing and Balance Disorders Chapter 59

2. Assessment Inspection of external ear Otoscopic examination Gross auditory acuity Whispered word test Weber test Rinne test

3. Question Tell whether the following statement is true or false. A patient with sensorneural hearing loss is being assessed using the Rinne�s test. The nurse would expect air condution to be audible longer than bone conduction in the affected ear.

4. Answer True Rationale: In sensorineural hearing loss, the Rinne�s test would show that air conduction is audible longer than bone conduction in the affected ear.

5. Diagnostic Evaluation Audiometry Tympanogram Auditory brain stem response Electronystagmography Platform posturography Sinusoidal harmonic acceleration Middle ear endoscopy

6. Hearing Loss Affects more than 28 million people in the U.S. Increased incidence with age: presbycusis Key risk factor: exposure to excessive noise Types: Conductive Sensorineural Mixed functional

7. Manifestations Early symptoms: Tinnitus Increased inability to hear in a group Turning up the volume of TV Impairment may be gradual over time With advancing hearing loss patients may experience: Deterioration of speech, fatigue, indifference, social isolation or withdrawal

8. Prevention Environmental factors can diminish hearing Noise induced hearing loss Acoustic trauma In general today�s environment is louder Ear protection is the most effective preventive measure OSHA mandates hearing protection in the workplace

9. Guidelines for Communicating with the Hearing Impaired Use a low-tone, normal voice Speak slowly and distinctly Reduce background noise and distractions Face the person and get his attention Speak into the less-impaired ear Use gestures and facial expressions If necessary, write out the information or use sign language translator

10. Question Which of the following would be included as a guideline for communicating with a hearing-impaired patient who speech reads: Speak slowly Face the person Make sure face is clearly visible All of the above

11. Answer All of the above Rationale: When speaking, always face the person as directly as possible. Speak slowly and distinctly, pausing more frequently than you would normally. Make sure your face is as clearly visible as possible. Reference: Chart 59-4

12. Conditions of the External Ear Cerumen impaction Removal may be done by irrigation, suction, or instrumentation Gentle irrigation using lowest pressure Direct stream behind the obstruction Glycerin, mineral oil, half-strength H2O2 or peroxide in glyceryl may help soften cerumen

13. Conditions of External Ear (cont.) Foreign bodies Removal by irrigation, suction or instrumentation Do not irrigate if object could swell Removal can be dangerous May require extraction in surgery

14. Conditions of the External Ear (cont.) External otitis Inflammation most often due to staphylococcus, pseudomonas, or Aspergillus Manifestations: pain and tenderness, discharge, edema, erythema, pruritus, hearing loss, feeling of fullness in the ear Goal of therapy: reduce discomfort and edema, treat infection Wick may be inserted to keep canal open and facillitate medication administration

15. Conditions of the External Ear (cont.) Malignant external otitis AKA: temporal bone osteomyelitis Rare, progressive infection that effects the external auditory canal, surrounding tissues, and base of the skull Most often caused by Pseudomonas aeruginosa

16. Nursing Management Do not clean with cotton tipped applicator Avoid scratching or any activities that traumatize external canal Do not get canal wet (swimming, shampooing) Antiseptic otic drops after swimming Contraindicated if current ear infection or history of tympanic rupture

17. Conditions of the Middle Ear Tympanic membrane performation Acute otitis media More common in children Invading pathogens often Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis Manifestations: otalgia, fever, hearing loss Treatment: Antibiotic therapy Myringotomy or tympanotomy

18. Conditions of the Middle Ear (cont.) Serous otitis media Fluid in middle ear without evidence of infection Chronic otitis media Result of recurrent acute otitis media Chronic infection damages tympanic membrane and ossicle Involves mastoid Treatment Prevent by treatment of acute otitis media Surgical procedures

19. Middle Ear Surgical Procedures Tympanoplasty Reconstruction of the tympanic membrane Five types Type I: Simplest, closes perforation Types II-IV: Middle ear structures involve more extensive repair Ossiculosplasty Bone reconstruction Use of prostheses to reconnect ossicles

20. Middle Ear Surgical Procedures (cont.) Mastoidectomy Removal of diseased bone, mastoid air cells, and cholesteotoma to create a non-infected, healthy ear Cholesteatoma: Benign tumor Ingrowth of skin causing persistently high pressure in the middle ear Causes hearing loss, neurologic disorders, and destroys structures

21. Assessment of Patient Undergoing Mastoid Surgery Health history Includes present, past and family history Include data related to: Ear disorder Hearing loss Otalgia Otorrhea vertigo Medication

22. Nursing Diagnoses and Goals Identify nursing diagnoses you would expect to address in the patient undergoing mastoid surgery. What are the major goals associated with the nursing diagoses

23. Interventions Anxiety Reinforce information and patient teaching Provide support and allow patient to discuss concerns Relieve pain Analgesics Monitor pain characteristics Occasional sharp, shooting pain can occur as eustachian tube opens and allows air into middle ear Constant, throbbing pain and fever may indicate infection

24. Interventions (cont.) Prevent injury Implement safety measures Provide antiemetics or antivertigo medications Improve communication and hearing Reduced hearing can occur for several weeks Why? Use measures to improve hearing and communication previously discussed

25. Interventions (cont.) Preventing infection Monitor for signs and symptoms of infection Administer antibiotics as ordered Prevent contamination of ear with water from showering, shampooing, etc.

26. Patient Teaching Medication teaching Analgesics antivertigo Activity restrictions Gently blow nose Only one side at a time Sneeze and cough with mouth open Avoid Heavy lifting, exertion, and forceful nose blowing

27. Patient Teaching (cont.) Safety issues related to potential vertigo Instructions regarding potential complications and what and when to report Avoid getting water in ear Chart 59-6: Self-Care after Middle Ear or Mastoid Surgery, p. 2110

28. Question Which of the following medications is/are considered ototoxic substances? Gentamicin Aspirin Alcohol All of the above

29. Answer d) All of the above Rationale: Ototoxic substances include gentamycin, aspirin, alcohol, gold, quinine, and furosemide

30. Conditions of the Inner Ear Disorders of balance 8 million in U.S. with chronic problems of balance Additional 2.4 million with dizziness alone Contribute to falls and fractures in the elderly Terms: Dizziness Vertigo Nystagmus

31. Meniere�s Disease Abnormal inner ear fluid balance caused by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct. Manifestations: Fluctuating, progressive hearing loss Tinnitus Feeling of pressure or fullness Episodic, incapacitating vertigo that may be accompanied by nausea and vomiting

32. Meniere�s Disease (cont.) Treatment Low sodium diet 2000 mg/day Medication Meclizine (Antivert) Tranquilizers Antiemetics diuretics Surgery Endolymphatic sac decompression Middle and inner ear perfusion Intraotologic catheters Vestibular nerve sectioning

33. Nursing Management Refer to Chart 59-8: Plan of Nursing Care: Care of the Patient With Vertigo, pp. 2114 � 2118.

34. Additional Conditions of the Inner Ear Tinnitus Labyrinthitis Benign paroxysmal positional vertigo (BPPV) Ototoxicity Acoustic neuroma

35. Question Which surgical procedure for Meniere�s Disease provides the greatest success rate in eliminating the attacks of vertigo? Endolymphatic sac decompression Vestibular nerve sectioning Middle and inner ear perfusion Intra-otologic catheters

36. Answer b) Vestibular nerve sectioning Rationale: Vestibular nerve sectioning provides the greatest success rate (approximately 98%) in eliminating the attacks of vertigo associated with Meniere�s Disease.