Ch 16 - Ears

Whispered Voice Test

1.Test one ear at a time while masking hearing in other ear by placing one finger on tragus and rapidly pushing it in and out of auditory meatus 2.Shield your lips (or stand behind) so the person cannot compensate for a hearing loss (consciously or unconsciously) by lip reading or using the "good" ear 3.With your head 30 to 60 cm (1 to 2 ft) from person's ear, exhale and whisper slowly some two-syllable words 4.Normally, person repeats each word correctly after you say it

Hearing Continued

Brainstem •Signals are sent to the brainstem from each ear •Areas in the brainstem are sensitive to differences in intensity and timing of signals received, depending on the way the head is turned •This helps us determine the location and direction of a sound Cerebral cortex •Interprets meaning of sound •Elicits appropriate response

Assessments with an Otoscope

External canal: note any redness, swelling foreign bodies or discharge •If discharge is present note color and odor •Clean any discharge from speculum before moving to other ear •For individuals with hearing aids, note any irritation from ear molds Tympanic membrane: •Color and characteristics •Pearly grey •Light reflex- 5 oclock in R ear, 7 oclock in L ear •Sections of malleus •Position; flat and slightly pulled in at the center •Assess drum mobility (Valsalva maneuver or holding nose and swallowing) •Integrity of membrane: normal is fully intact •Note any abnormal perforations or scarring

Hearing

Function of hearing occurs through 3 levels: •Peripheral •Brainstem •Cerebral cortex Peripheral •Sound waves produce vibrations on TM, vibrations are carried through ossicles (tiny bones) to the oval window, then through the cochlea, then the round window. •Along the way, the basilar membrane vibrates based on frequency of sound •Frequency: pitch •Amplitude: loudness •Numerous fibers along the basilar membrane contain hair cells that are a part of the organ of Corti •As the hair cells bend, they transmit vibrations into electrical impulses •The impulses are conducted to the auditory portion of cranial nerve VIII and sent to brainstem

Developmental Competence: Infants and Young Children

Otoscope examination •Mandatory for any infant of child seeking treatment for illness or fever •Save for end of exam- young children may protest vigorously and refuse cooperation afterward •Parents may hold and comfort the child or you may enlist help of another staff member •Position child to get clear view of canal, avoid harsh restraint and sudden head movement •Position of eardrum is more horizontal in neonate, this makes it difficult to see completely and differentiate between TM and canal wall •By 1 month, TM is more vertical, exam is a bit easier Otoscope examination findings: •Not performed at birth due to canal being filled with amniotic fluid and vernix caseosa •During the first days of life, TM may look thick and opaque, may look "injected" and have mild redness from increase vascularity •TM may look injected after crying episode •May use a pneumatic bulb to instill a light puff of air to assess vibrality (mobility) •Note presence of tympanostomy tube for chronic otitis media •Although this is abnormal, it is not uncommon to find a foreign body in a child's canal

Pathways of Hearing

•Air conduction (most efficient, normal) •Bone conduction (transmission of vibrations directly to inner ear/cranial nerve VIII)

Subjective Data

•Any earache or other pain in ears? (Otalgia) •Location: Does it feel close to surface or deep in head? Does it hurt when you push on ear? •Character: Is it dull, aching or sharp, stabbing? Is it constant or does it come and go? Is it affected by changing position of head? •Any accompanying cold symptoms or sore throat? Any problems with sinuses or teeth? •Ever been hit on ear or on side of head or had any sport injury? Ever had any trauma from a foreign body? •What have you tried to relieve pain? •Infections •Any ear infections? As an adult or in childhood? •How frequent were they? How were they treated? •Discharge (otorrhea) •Any discharge from your ears? •Does it look like pus, or is it bloody? •Any odor to the discharge? •Any relationship between discharge and ear pain?

Environmental Noise Questions

•Any loud noises at home or on the job? For example, do you live in a noise-polluted area, near an airport or busy traffic area? Now or in the past? •Are you near other noises such as heavy machinery, loud persistent music, gunshots while hunting? •Coping strategies: Do you take any steps to protect your ears, such as headphones or ear plugs?

External Ear

•Auricle and pinna: consists of movable cartilage and skin •Sound is funneled into the opening called the external auditory canal External auditory canal •2.5-3 cm long, stops at the eardrum or tympanic membrane •Outer 1/3 is cartilage •Inner 2/3 are bone covered by skin •Lined with glands that secrete cerumen: yellow waxy material for lubrication and protection of tympanic membrane •

Equilibrium

•Bony labyrinth in inner ear feeds information to brain about the body's position in space •Determined verticality or depth •Registers angle of your head in relation to gravity •If the labyrinth becomes inflamed, it feeds inaccurate information to brain •This causes staggering gait and/or a strong spinning/whirling sensation called vertigo

Lumps and Lesions on the Ear

•Chondrodermatitis Nodularis Helicus •Battle sign •Sebaceous Cyst •Tophi •Keloid •Carcinoma

Inspection with an Otoscope

•Choose largest speculum that will fit comfortably in ear canal •Tilt person's head slightly away from you to bring eardrum into view •Pull pinna up and back on an adult or older child/down and back on an infant or child under 3. •Hold pinna gently but firmly for entire otoscope exam •Hold otoscope "upside down", insert speculum slowly while bracing the back of your hand against head •You may need to rotate otoscope to visualize entire TM, do so gently •Avoid touching inner "bony" section of canal, it is sensitive •Always perform otoscope exam before you test haring to assess for impacted cerumen

Inner Ear

•Contains the bony labyrinth, which holds sensory organs for equilibrium and hearing •Bony labrynth contains •Vestibule and semicircular canals (equilibrium) •Cochlea (contains central hearing apparatus) •Cannot visually assess inner ear, but can assess functions

Subjective Data: Children and Infants

•Does child seem to be hearing well? •Have you noticed that infant startles with loud noise? Did infant babble around 6 months? Does he or she talk? At what age did talking start? Was speech intelligible? •Ever had child's hearing tested? If there was a hearing loss, did it follow any diseases in child or in mother during pregnancy? •Does child tend to put objects in ears? Is older child or adolescent active in contact sports? •Note: It is important to catch any problem early, because a child with hearing loss is at risk for delayed speech and social development and learning deficit

Cultural Considerations: Cerumen

•Dry cerumen: gray, flaky, and frequently forms thin mass in ear canal. •East Asians, American Indians •Wet cerumen: honey brown to dark brown and moist •Caucasions and African Americans •Presence and composition of cerumen are not related to poor hygiene; take caution to avoid mistaking flaky, dry cerumen for eczematous lesions

Subjective Data: Children and Infants

•Ear infections •At what age was child's first episode? How many ear infections in past 6 months? How many total? How were these treated? •A first episode within 3 months of life increases risk for recurrent OM •Has child had any surgery, such as insertion of ear tubes or removal of tonsils? •Are infections increasing in frequency, in severity, or staying same? •Does anyone in the home smoke cigarettes? •Does child receive care outside your home? In daycare center or someone else's home? How many children in group care?

Subjective Data: Hearing Loss

•Ever had any trouble hearing? •Onset: Did loss come on slowly or all at once? •Character: Has all your hearing decreased or just on hearing certain sounds? •In what situations do you notice loss: conversations, using telephone, listening to TV, at a party? •Do people seem to shout at you? •Do ordinary sounds seem hollow, as if you are hearing in a barrel or under water? •Have you recently traveled by airplane? •Do you have a family history of hearing loss? •Efforts to treat: Do you have any hearing aid or other device? Anything that helps hearing? •Coping strategies: How does loss affect your daily life? Any job problems? Feelings of embarrassment or frustration? How do your family and friends react?

Children at Risk for Hearing Deficit

•Exposure to maternal rubella •Exposure to maternal ototoxic drugs •Prematurity •Low birth weight •Trauma or hypoxia at birth •Congenital liver or kidney disease •Experiencing an illness with a persistently high fever

External Ear Abnormal Findings

•Frostbite •Branchial Remnant and Ear Deformity •Otitis Externa (swimmers ear) •Cellulitis

Hearing Loss

•Hearing loss •Anything obstructing transmission of sound impairs hearing •Conductive hearing loss: mechanical in nature, from changes in external or middle ear •Partial loss, person is able to hear if sound amplitude is strong enough to reach nerve elements in inner ear •Causes: impacted cerumen, foreign bodies, a perforated TM, pus or serum in middle ear, and otosclerosis, which is a decrease in mobility of ossicles •Sensorineural hearing loss: pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex •Increasing amplitude will not help •Causes: presbycusis (nerve degeneration), ototoxic drugs •Mixed hearing loss (conductive and sensorineural)

Self-Care Behavior Questions

•How do you clean your ears? •Last time you had your hearing checked? •If hearing loss was noted, did you obtain a hearing aid? How long have you had it? Do you wear it? How does it work? Any trouble with upkeep, cleaning, changing batteries?

Testing for Hearing Acuity

•If patient answers yes to hearing deficit during health history, immediately perform or refer for audiometric testing •Audiometry assesses a patients ability to hear sounds at varying frequencies •Battery powered, lightweight device found in most outpatient settings If patient answers no, test hearing acuity using whisper test or tuning fork tests

Developmental Competence: Aging Adults

•In aging persons, cilia lining ear canal become coarse and stiff •May cause cerumen to accumulate and oxidize, which greatly reduces hearing •Cerumen is drier with aging because of atrophy of apocrine glands •Impacted cerumen is a common but reversible cause of hearing loss in older people •Presbycusis: age related hearing loss •Gradual sensorineural loss caused by nerve degeneration in inner ear or auditory nerve •Onset usually occurs in 50s and slowly progresses •First notice a high-frequency tone loss •Ability to localize sound is impaired also •Accentuated when unfavorable background noise is present

Prevention of OM

•In the supine position effects of gravity and sucking tend to draw nasopharyngeal contents directly into middle ear •Urge parents to hold baby partly upright while feeding •Do not prop bottle or let baby take a bottle to bed •Encouraging breastfeeding helps prevent this problem •Most important side effect of otitis media is persistence of fluid in middle ear after treatment; this middle ear effusion can impair hearing, placing child at risk for delayed cognitive development

Developmental Competence

•Infants and young children •Examination of external ear is similar to that described for adult, with addition of examination of position and alignment on head •Note ear position •Top of pinna should match an imaginary line extending from corner of eye to the occiput

Children and Infants: Testing Hearing Acuity

•Infants and young children •Room should be silent and baby contented; make a loud sudden noise out of peripheral range of vision; you should note these responses: •Newborn: startle (Moro) reflex, acoustic blink reflex •3 to 4 months: acoustic blink reflex, infant stops movement and appears to listen, halts sucking, quiets if crying, cries if quiet •6 to 8 months: infant turns head to localize sound; responds to own name •Preschool and school-age child: child must be screened with audiometry Note behavioral manifestations of hearing loss: •Child is inattentive in casual conversation •Reacts more to movement and facial expression than to sound •Facial expression strained or puzzled •Frequently asks to have statements repeated •Confuses words that sound alike •Has accompanying speech problem •Appears shy and withdrawn and "lives in a world of his or her own" •Frequently complains of earaches •Hears better at times when environment more conducive

Developmental Competence: Infants and Children

•Inner ear starts to develop early in fifth week of gestation •In early development ear is posteriorly rotated and low set; later ascends to its normal placement around eye level •If maternal rubella infection occurs during first trimester, it can damage organ of Corti and impair hearing •Infant's anatomy •Eustachian tube is shorter, wider, more horizontal than adults (increased risk of infection) •Lumen surrounded by lymphoid tissue, easily occluded •External auditory canal is shorter, opposite slope of adults

Inspection and Palpation

•Inspect and palpate external ear •Size and shape •Ears are of equal size bilaterally with no swelling or thickening •Ears of unusual size and shape may be a normal familial trait with no clinical significance •Microtia and macrotia •Skin condition •Skin color consistent with person's facial skin color •Skin intact, with no lumps or lesions •On some people you may note Darwin's tubercle, a small painless nodule at the helix; this is a congenital variation and not significant Inspect and palpate external ear •Tenderness •Move pinna and push on tragus; they should feel firm, and movement should produce no pain •Palpating mastoid process should also produce no pain •External auditory meatus •Note size of opening to direct choice of speculum for otoscope •No swelling, redness, or discharge should be present •Some cerumen usually present

Objective Data: Hearing Loss

•Lip reading or watching your face and lips rather than your eyes •Frowning or straining forward to hear •Posturing of head to catch sounds with better ear •Misunderstands questions; frequently asks you to repeat •Irritable or shows startle reflex when you raise your voice •Person's speech sounds garbled, vowel sounds distorted •Inappropriately loud voice •Flat, monotonous tone of voice

Aging Adult

•May have pendulous earlobes with linear wrinkling because of loss of elasticity of pinna •Coarse, wiry hairs may be present at opening of canal •Eardrum normally may be whiter in color and more opaque, duller and thicker than in younger adult •High-tone frequency loss apparent for those affected with presbycusis, hearing loss that occurs with aging •Revealed in difficulty hearing whispered words in voice test and in difficulty hearing consonants during conversation •Aging adult feels that "people are mumbling" and feels isolated in family or friendship groups

Tuning Fork Tests

•Often used to differentiate between conductive and sensorineural loss •Measure hearing air conduction (AC) or by bone conduction (BC), in which sound vibrates through cranial bones to the inner ear •AC route through ear canal and middle ear usually the more sensitive route •May use Weber test or Rinne test, neither can distinguish normal hearing from a sensorineural loss in both ears •To activate tuning fork, hold it by stem and strike tines softly on back of your hand •A hard strike makes tone too loud, and it takes a long time to fade out

Developmental Competence: Adults

•Otosclerosis •Common cause of conductive hearing loss in young adults between ages of 20 and 40 years •Gradual hardening that causes foot plate of stapes to become fixed in oval window, impeding transmission of sound and causing progressive deafness

Objective Data Preparation

•Position sitting up straight with head at eye level •May need to irrigate ear canal to remove excess cerumen to allow visualization of middle ear structures •Ensure ear drum is intact, no current infection, and no previous contraindications •Irrigation is performed using warmed solution of mineral oil + hydrogen peroxide or warm water with bulb syringe or water pik •Direct fluid to posterior wall, leave space around irrigator tip Equipment •Otoscope •Pneumatic bulb attachment •Tuning forks in 512 and 1024 Hz

Otitis Media

•Risk factors are a combination of physiological (as previously discussed) and environmental Environmental risk factors: •Absense of breast feeding for first 3 months of life •Preterm birth •Secondhand smoke •Daycare •Male sex •Pacifier use •Seasonal changes •Bottle feeding

Vestibular Apparatus

•Romberg test: assesses ability of vestibular apparatus in inner ear to help maintain standing balance •Also assesses intactness of cerebellum and proprioception as it is part of the neurologic system •Will cover in Chapter 24

Tympanic Membrane

•Separates external and middle ear, also called eardrum •Translucent pearly grey in color •Oval and slightly concave •Prominent cone of light in the anteroinferior quadrant •Can visualize bones of middle ear through membrane: umbo, manubrium, short process •Other parts of TM: pars flaccida, pars tensa, annulus

Summary Checklist

•Subjective data collection •Inspect external ear •Size and shape of auricle, position and alignment on head •Note skin condition •Check auricle and tragus for tenderness •Evaluate external auditory meatus •Otoscopic examination •External canal - redness or swelling •Cerumen discharge, foreign bodies or lesions •Inspect tympanic membrane •Color, characteristics, position, and integrity •Test hearing acuity

Tinnitus and Vertigo Questions

•Tinnitus •Ever felt ringing, crackling, or buzzing in your ears? When did this occur? •Does it seem louder at night? •Are you taking any medications? •Vertigo (subjective or objective) •Ever felt vertigo, that the room is spinning around or feel that you are spinning? •Ever felt dizzy, like you are not quite steady, or falling or losing your balance? Giddy, lightheaded?

Middle Ear

•Tiny air-filled cavity inside temporal bone •Contains tiny ear bones, called auditory ossicles •Malleus, incus, stapes •The middle ear has 4 openings •Opening to outer ear (protected by TM) •Openings to inner ear: oval window and round window •Eustachian tube: connects middle ear with nasopharynx (opens with swallowing/yawning) •The middle ear has 3 functions 1.Conduct sound vibrations from outer ear to inner ear 2.Protect inner ear by reducing amplitude of loud sounds 3.Eustachian tube equalizes air pressure on each side of TM to prevent rupture