Health Assessment Chapter 16- Ears

age-realted hearing loss

(presbycusis) is documented in of adults over 70 years of age and is associated with communication problems, a decrease in health-related quality of life, and a loss of physical and cognitive function, as well as depression, dementia, an increase in falls, an increase in hospitalizations, social isolation and loneliness, and even increased mortality1,3! It is a sensorineural loss that affects the middle ear structures or causes damage to nerve cells in the inner ear or to cranial nerve VIII. The person first notices a high-frequency tone loss, such as difficulty hearing a phone ringing or a microwave beeping. Also it is harder to hear consonants than vowels, and words sound garbled. The ability to localize sound is impaired. This hearing loss is accentuated with competing background noise (e.g., with music, with dishes clattering, or at a large, noisy party).

cone of light

- 5 o'clock in right ear 7 o'clock in left ear - reflection of light from otoscope

Otoscopic Exam: Adult

- An aging adult may have pendulous earlobes with linear wrinkling because of loss of elasticity of the pinna. Coarse, wiry hairs may be present at the opening of the ear canal. During otoscopy the eardrum normally may be whiter in color and more opaque, duller than in the younger adult. It also may look thickened. - A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. Note any difficulty hearing in the whispered voice test and hearing consonants during conversational speech. The aging adult thinks that "people are mumbling" and feels isolated in family or friendship groups.

Otoscopic Examination: Child

- In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination. Many young children protest vigorously during this procedure no matter how well you prepare, and it is difficult to re-establish cooperation afterward. Save the otoscopic examination until last. - Positioning of the child is important. You need a clear view of the canal. Avoid harsh restraint, but you must protect the eardrum from injury in case of sudden head movement (Fig. 16.12). Enlist the aid of a cooperative parent. Prop an infant upright against the parent's chest or shoulder, with the parent's arm around the upper part of the head. A toddler can be held in the parent's lap with his or her arms gently secured. As you pull down on the pinna, gently push in on the child's tragus as a lead-in to inserting the speculum tip. This sometimes helps avoid the startling poke of the speculum tip. - Remember to pull the pinna straight down on an infant or a child younger than 3 years. This method matches the slope of the ear canal (Fig. 16.13). - At birth the patency of the ear canal is determined, but the otoscopic examination is not performed because the canal is filled with amniotic fluid and vernix caseosa. After a few days the TM is examined. During the first few days it often looks thickened and opaque. It may look "injected," meaning having a mild redness from increased vascularity. The eardrum also looks injected in infants after crying. - The position of the eardrum is more horizontal in the neonate, making it more difficult to see completely and harder to differentiate from the canal wall. By 1 month of age the drum is in the oblique (more vertical) position as in the older child, and examination is a bit easier. - When examining an infant or young child, a pneumatic bulb attachment enables you to direct a light puff of air toward the drum to assess vibratility (Fig. 16.14). For a secure seal, choose the largest speculum that fits in the ear canal without causing pain. A rubber tip on the end of the speculum gives a better seal. Give a small pump to the bulb (positive pressure) and release the bulb (negative pressure). Normally the TM moves inward with a slight puff and outward with a slight release. - Inspect and Palpate the External EarSize and ShapeThe 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—ears smaller than 4 cm vertically; macrotia—ears larger than 10 cm. Edema with infection or trauma. Skin ConditionThe skin color is consistent with the person's facial skin color. The skin is intact, with no lumps or lesions. On some people you may note Darwin tubercle, a small, painless nodule at the helix. This is a congenital variation and is not significant (Fig. 16.6).16.6 Reddened, excessively warm skin with inflammation (see Table 16.2, External Ear Abnormalities, p. 335). Crusts and scaling occur with otitis externa, eczema, contact dermatitis, seborrhea. Enlarged, tender lymph nodes in the region indicate inflammation of the pinna or mastoid process. Red-blue discoloration with frostbite. Tophi, sebaceous cyst, chondrodermatitis, keloid, carcinoma (see Table 16.3, Lumps and Lesions on the Ear, p. 336). TendernessMove the pinna and push on the tragus. They should feel firm, and movement should produce no pain. Palpating the mastoid process should also produce no pain. Pain with movement occurs with otitis externa and furuncle. Pain at the mastoid process may indicate mastoiditis or enlarged posterior auricular node. The External Auditory MeatusNote the size of the opening to direct your choice of speculum for the otoscope. No swelling, redness, or discharge should be present.A sticky, yellow discharge accompanies otitis externa or may indicate OM if the drum has ruptured.Some cerumen is usually present. The color varies from gray-yellow to light brown and black, and the texture varies from moist and waxy to dry and desiccated. A large amount of cerumen obscures visualization of the canal and drum.Impacted cerumen is a common cause of conductive hearing loss.Inspect with the OtoscopeAs you inspect the external ear, note the size of the auditory meatus. Choose the largest speculum that fits comfortably in the ear canal, and attach it to the otoscope. Tilt the person's head slightly away from you toward the opposite shoulder. This method brings the obliquely sloping eardrum into better view.Pull the pinna up and back on an adult or older child; this helps straighten the S-shape of the canal (Fig. 16.7). (Pull the pinna down on an infant and a child younger than 3 years [see Fig. 16.13]). Hold the pinna gently but firmly. Do not release traction on the ear until you have finished the examination and the otoscope is removed.16.7Hold the otoscope "upside down" along your fingers and have the dorsa (back) of your hand touching the person's cheek braced to steady the otoscope (Fig. 16.8). This position feels awkward to you only at first. It soon will feel natural, and you will find it useful to prevent forceful insertion. Your stabilizing hand also acts as a protecting lever if the person suddenly moves the head.16.8Insert the speculum slowly and carefully along the axis of the canal. Watch the insertion; then put your eye up to the otoscope. Avoid touching the inner "bony" section of the canal wall, which is covered by a thin epithelial layer and is sensitive to pain. Sometimes you cannot see anything but canal wall. If so, try to reposition the person's head, apply more traction on the pinna, and re-angle the otoscope to look forward toward the person's nose.Once it is in place, you may need to rotate the otoscope slightly to visualize the entire eardrum; do this gently. A final note—perform the otoscopic examination before you test hearing; ear canals with impacted cerumen give the erroneous impression of pathologic hearing loss.The External CanalNote any redness and swelling, lesions, foreign bodies, or discharge. If any discharge is present, note the color and odor. (Clean any discharge from the speculum before examining the other ear to avoid contamination with possibly infectious material.) For a person with a hearing aid, note any irritation on the canal wall from poorly fitting ear molds. Redness and swelling occur with otitis externa; canal may be completely closed with swelling. Purulent otorrhea suggests otitis externa or OM if the drum has ruptured. Frank blood or clear, watery drainage (cerebrospinal fluid [CSF]) after head injury suggests basal skull fracture and warrants immediate referral. Foreign body, polyp, furuncle, exostosis (see Table 16.4, Ear Canal Abnormalities, p. 338). The Tympanic Membrane Color and Characteristics. Systematically explore its landmarks (Fig. 16.9). The normal eardrum is shiny and translucent, with a pearl gray color. The cone-shaped light reflex is prominent in the anteroinferior quadrant (at the 5 o'clock position in the right drum and the 7 o'clock position in the left drum). This is the reflection of your otoscope light. Sections of the malleus are visible through the translucent drum: the umbo, manubrium, and short process. (Infrequently you also may see the incus behind the drum; it shows as a whitish haze in the upper posterior area.) At the periphery the annulus looks whiter and denser. 16.9 Normal tympanic membrane (right ear). (Courtesy Lemmi and Lemmi, 2011.) Yellow-amber drum color occurs with OM with effusion (serous). Red color with acute OM. Absent or distorted landmarks. Air/fluid level or air bubbles behind drum indicate OM with effusion (see Tables 16.5, Abnormal Views Seen on Otoscopy, and 16.6, Abnormal Tympanic Membranes, pp. 335 to 337). Position. The eardrum is flat and slightly pulled in at the center. Retracted drum due to vacuum in middle ear with obstructed eustachian tube. Bulging drum due to increased pressure in OM. Integrity of Membrane. Inspect the eardrum and the entire circumference of the annulus for perforations. The normal TM is intact. Some adults may show scarring, which is a dense white patch on the drum. This is a sequela of repeated ear infections. Examine the other ear but switch otoscope hands so the hand holding the otoscope braces against the person's cheek. Perforation shows as a dark oval area or as a larger opening on the drum. Vesicles on drum (see Table 16.6). Test Hearing AcuityYour screening for a hearing deficit begins during the history; "Do you have difficulty hearing now?" If the answer is yes, perform audiometric testing or refer for audiometric testing. If the answer is no, screen using the whispered voice test described as follows.This single question in people over 50 years has up to 90% agreement with hearing loss documented by audiometric testing.A pure tone audiometer gives a precise quantitative measure of hearing by assessing the person's ability to hear sounds of varying frequency. This is a battery-powered, lightweight, handheld instrument that is available in most outpatient settings. With the patient sitting, prop his or her elbow on the armrest of the chair with the hand making a gentle fist. Tell the patient, "You will hear faint tones of different pitches. Please raise your finger as soon as you hear the tone; then lower your finger as soon as you no longer hear the tone." Choose tones of random loudness in decibels on the audioscope. Each tone is on for 1.5 seconds and off for 1.5 seconds. Test each ear separately and record the results. An audiometer gives a precise quantitative measure of hearing by assessing the person's ability to hear sounds of varying frequency.Conductive and sensorineural loss (see Table 16.1, Hearing Loss, p. 335).Whispered Voice TestStand arm's length (2 feet) behind the person. Test one ear at a time while masking hearing in the other ear to prevent sound transmission around the head. This is done by placing one finger on the tragus and pushing it in and out of the auditory meatus. Move your head to 1 to 2 feet from the person's ear. Exhale fully and whisper slowly a set of 3 random numbers and letters, such as "5, B, 6." Normally the person repeats each number/letter correctly after you say it. If the response is not correct, repeat the whispered test using a different combination of 3 numbers and letters. A passing score is correct repetition of 4 of a possible 6 numbers/letters. Assess the other ear using yet another set of whispered items "4, K, 2."The person is unable to hear whispered items. A whisper is a high-frequency sound and is used to detect high-tone loss.Tuning Fork TestsTuning fork tests measure hearing by air conduction (AC) or bone conduction (BC), in which the sound vibrates through the cranial bones to the inner ear. The AC route through the ear canal and middle ear is usually the more sensitive route. If hearing loss is identified by history or whispered voice test, tuning fork tests traditionally were used to distinguish conductive loss from sensorineural loss. However, up to 40% of normal hearing people lateralize the Weber test, i.e., hear the tone louder in one ear. The Rinne (pronounced RIN-neh) test is more accurate in detecting conductive hearing loss. (Technique is described in Table 16.7.) Be aware that neither test can distinguish normal hearing from a sensorineural loss in both ears5a—you should rely on audiometry.With documented hearing loss, these tests may help distinguish conductive loss from sensorineural loss (see Table 16.7, Tuning Fork Tests, p. 342). But they cannot screen a conductive loss from a mixed conductive/sensorineural loss.5aThe Vestibular ApparatusThe Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. Because the Romberg test also assesses intactness of the cerebellum and proprioception, it is discussed in Chapter 24 (see Fig. 24.21). DEVELOPMENTAL COMPETENCEInfants and Young ChildrenExamination of the external ear is similar to that described for the adult, with the addition of examination of position and alignment on head. Note the ear position. The top of the pinna should match an imaginary line extending from the corner of the eye to the occiput. The ear should also be positioned within 10 degrees of vertical (Fig. 16.10).16.10 © Pat Thomas, 2006.Low-set ears are found with genetic disorders, including trisomy 21 (Down syndrome). Large prominent ears, misshapen ears, and creases on earlobes are nonspecific.Preauricular skin tags may occur alone or with other facial anomalies. Otoscopic Examination. In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination. Many young children protest vigorously during this procedure no matter how well you prepare, and it is difficult to re-establish cooperation afterward. Save the otoscopic examination until last. Ear pain and ear rubbing are associated with acute OM, as are a bulging red eardrum and middle ear effusion. Fever is usually present but not always (see Table 16.6).To help prepare the child, let him or her hold your funny-looking "flashlight." You may wish to have the child look in the parent's or a toy puppet's ear as you hold the otoscope (Fig. 16.11).16.11Positioning of the child is important. You need a clear view of the canal. Avoid harsh restraint, but you must protect the eardrum from injury in case of sudden head movement (Fig. 16.12). Enlist the aid of a cooperative parent. Prop an infant upright against the parent's chest or shoulder, with the parent's arm around the upper part of the head. A toddler can be held in the parent's lap with his or her arms gently secured. As you pull down on the pinna, gently push in on the child's tragus as a lead-in to inserting the speculum tip. This sometimes helps avoid the startling poke of the speculum tip.16.12Remember to pull the pinna straight down on an infant or a child younger than 3 years. This method matches the slope of the ear canal (Fig. 16.13).16.13At birth the patency of the ear canal is determined, but the otoscopic examination is not performed because the canal is filled with amniotic fluid and vernix caseosa. After a few days the TM is examined. During the first few days it often looks thickened and opaque. It may look "injected," meaning having a mild redness from increased vascularity. The eardrum also looks injected in infants after crying.Atresia—Absence or closure of the ear canal.The position of the eardrum is more horizontal in the neonate, making it more difficult to see completely and harder to differentiate from the canal wall. By 1 month of age the drum is in the oblique (more vertical) position as in the older child, and examination is a bit easier.When examining an infant or young child, a pneumatic bulb attachment enables you to direct a light puff of air toward the drum to assess vibratility (Fig. 16.14). For a secure seal, choose the largest speculum that fits in the ear canal without causing pain. A rubber tip on the end of the speculum gives a better seal. Give a small pump to the bulb (positive pressure) and release the bulb (negative pressure). Normally the TM moves inward with a slight puff and outward with a slight release.16.14An abnormal response is no movement. Drum hypomobility indicates effusion or a high vacuum in the middle ear. For the newborn's first 6 weeks, drum immobility is the best indicator of middle ear infection.Normally the tympanic membrane is intact. In a child being treated for chronic OM, you may note the presence of a tympanostomy tube in the central part of the eardrum. This is inserted surgically to equalize pressure and drain secretions. Finally, although the condition is not normal, it is not uncommon to note a foreign body in a child's canal such as a small stone or a bead.

Equilibrium

A state of balance

Tragus

Cartilaginous projection anterior to the external opening of the ear

Developmental Competence: The Aging Adult

In the older adult, cilia lining the ear canal become coarse and stiff. This may cause cerumen to accumulate and oxidize, which greatly reduces hearing. The cerumen itself is drier because of atrophy of the apocrine glands. A life history of frequent ear infections may result in scarring on the drum. Impacted cerumen is common in aging adults and other at-risk groups (e.g., institutionalized and mentally disabled), who may underreport the associated hearing loss. Cerumen impaction also blocks conduction in those wearing hearing aids. Cerumen should be removed when it leads to conductive hearing loss or interferes with full assessment of the ear. Ceruminolytics are wax-softening agents that expedite removal with electric or manual irrigators.

Developmental Competence: The Adult

Otosclerosis is a cause of conductive hearing loss in young adults between the ages of 20 and 40 years. It is a gradual bone formation that causes the footplate of the stapes to become fixed in the oval window, impeding the transmission of sound and causing progressive deafness.

tympanic membrane

The eardrum. A structure that separates the outer ear from the middle ear and vibrates in response to sound waves.

air conduction

The function of hearing involves the auditory system at three levels: peripheral, brainstem, and cerebral cortex. At the peripheral level the ear transmits sound and converts its vibrations into electrical impulses, which can be analyzed by the brain. For example, you hear an alarm bell ringing in the hall. Its sound waves travel instantly to your ears. The amplitude is how loud the alarm is; its frequency is the pitch (in this case, high) or the number of cycles per second. The sound waves produce vibrations on your tympanic membrane. These vibrations are carried by the middle ear ossicles to your oval window. Then the sound waves travel through your cochlea, which is coiled like a snail shell, and are dissipated against the round window. Along the way the basilar membrane vibrates at a point specific to the frequency of the sound. In this case the high frequency of the alarm stimulates the basilar membrane at its base near the stapes (Fig. 16.4). The numerous fibers along the basilar membrane are the receptor hair cells of the organ of Corti, the sensory organ of hearing. As the hair cells bend, they mediate the vibrations into electric impulses. The electrical impulses are conducted by the auditory portion of cranial nerve VIII to the brainstem. The function at the brainstem level is binaural interaction, which permits locating the direction of a sound in space and identifying the sound. How does this work? Each ear is actually one half of the total sensory organ. The ears are located on each side of a movable head. Cranial nerve VIII from each ear sends signals to both sides of the brainstem. Areas in the brainstem are sensitive to differences in intensity and timing of the messages from the two ears, depending on the way the head is turned.

inner ear

The inner ear is embedded in bone. It contains the bony labyrinth, which holds the sensory organs for equilibrium and hearing. Within the bony labyrinth, the vestibule and the semicircular canals comprise the vestibular apparatus, and the cochlea (Latin for "snail shell") contains the central hearing apparatus. Although the inner ear is not accessible to direct examination, you can assess its functions.

Developmental Competence: Infants and Children

The inner ear starts to develop early in the 5th week of gestation. In early development the ear is posteriorly rotated and low set; later it ascends to its normal placement around eye level. If maternal rubella infection occurs during the 1st trimester, it can damage the organ of Corti and impair hearing. The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's; thus it is easier for pathogens from the nasopharynx to migrate through to the middle ear (Fig. 16.5). The lumen is surrounded by lymphoid tissue, which increases during childhood; thus the lumen is easily occluded. These factors place the infant at greater risk for middle ear infections than the adult. The infant's and the young child's external ear canals are shorter and have a slope opposite to that of the adult's.

middle ear

The middle ear is a tiny air-filled cavity inside the temporal bone (see Fig. 16.1). It contains tiny ear bones, or auditory ossicles: the malleus, incus, and stapes. It has several openings. Its opening to the outer ear is covered by the tympanic membrane. The openings to the inner ear are the oval window at the end of the stapes and the round window. Another opening is the eustachian tube, which connects the middle ear with the nasopharynx and allows passage of air. The tube is normally closed, but it opens with swallowing or yawning. The middle ear has three functions: (1) it conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear; (2) it protects the inner ear by reducing the amplitude of loud sounds; and (3) its eustachian tube allows equalization of air pressure on each side of the tympanic membrane so the membrane does not rupture (e.g., during altitude changes in an airplane).

bone conduction

The normal pathway of hearing is air conduction (AC), described earlier; it is the most efficient. An alternate route of hearing is by bone conduction (BC). Here the bones of the skull vibrate. These vibrations are transmitted directly to the inner ear and to cranial nerve VIII

presbycusis

age related hearing loss

otorrhea

any discharge from the ear

vertigo

dizziness

cerumen

ear wax

lobule

earlobe

otosclerosis

hardening of the bony tissue in the ear

otoscope

instrument used for visual examination of the ear

conductive hearing loss

involves a mechanical dysfunction of the external or middle ear. It is a partial loss because the person is able to hear if the sound amplitude is increased enough to reach normal nerve elements in the inner ear. Conductive hearing loss may be caused by impacted cerumen, foreign bodies, a perforated tympanic membrane, pus or serum in the middle ear, and otosclerosis (a decrease in mobility of the ossicles)

Umbo

knob of the malleus that shows through the tympanic membrane

Otitis media

or OM (middle ear infection), occurs because of obstruction of the eustachian tube or passage of nasopharyngeal secretions into the middle ear. This creates a ripe environment for bacteria to grow. Acute OM is so common that up to 60% of children experience an episode during the 1st year of life, and by age 3 years up to 83% have suffered an episode.9 Besides the anatomy of the infant eustachian tube, the following risk factors predispose to acute OM: absence of breastfeeding in the first 3 months of age, preterm birth, exposure to secondhand tobacco smoke (SHS), daycare attendance, male sex, pacifier use, seasonality (fall and winter), and bottle-feeding.9 Ambulatory visits for acute OM have decreased in the past 20 years, a decrease best explained by a concurrent increase in the number of smoke-free households. Public awareness of the dangers of SHS on child health together with the surge in no-smoking rules in households and vehicles may be responsible. Also, hospital admissions for acute OM have decreased since the addition of pneumococcal and influenza vaccinations to the early childhood immunization schedule.10 The most important side effect of acute OM is the persistence of fluid in the middle ear after treatment. This middle ear effusion can impair hearing, placing the child at risk for delayed cognitive development.

otalgia

pain in the ear

external ear

pinna/auricle - Its characteristic shape serves to funnel sound waves into its opening, the external auditory canal. The canal is a cul-de-sac 2.5 to 3 cm long in the adult and terminates at the eardrum, or tympanic membrane (TM). The canal is lined with glands that secrete cerumen, a yellow, waxy material that lubricates and protects the ear. The wax forms a sticky barrier that helps keep foreign bodies from entering and reaching the sensitive tympanic membrane. Cerumen migrates out to the meatus by the movements of chewing and talking. The outer one third of the canal is cartilage; the inner two thirds tunnels through the temporal bone and is covered by thin, sensitive skin. The canal has a slight S-curve in the adult. The outer one third curves up and toward the back of the head, whereas the inner two thirds angles down and forward toward the nose. The TM separates the external and middle ear and is tilted obliquely to the ear canal, facing downward and somewhat forward. It is translucent with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light (Fig. 16.2). The drum is oval and slightly concave, pulled in at its center by one of the middle ear ossicles, the malleus. The parts of the malleus show through the translucent drum; these are the umbo, the manubrium (handle), and the short process. The small, slack, superior section of the TM is called the pars flaccida. The remainder of the drum, which is thicker and more taut, is the pars tensa. The annulus is the outer fibrous rim of the drum. - Lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes.

tinnitus

ringing or buzzing in the ears

mastoid process

round projection on the temporal bone behind the ear

Sensorineural (perceptive) hearing loss

signifies pathology of the inner ear, cranial nerve VIII, or the auditory areas of the cerebral cortex.4 A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, a gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect the hair cells in the cochlea.

Pinna/auricle

the visible part of the ear