Assessment Test :

1. Voice Whisper test

2. Weber Test
3. Rinne Test
4. Audiometry
5. Electronystagmography- changes in electrical
potential
6. Tympanography ( impedance tomography )- air
pressure is manipulated in a sealed canal.
- measures middle ear muscle reflex to sound
stimulation,

CONDUCTIVE HEARING LOSS

A. Description

1. .Conductive Hearing Loss - occurs when auditory stimuli are not

adequately transmitted through the auditory canal, tympanic
membrane, middle ear, or ossicles to the inner ear.

B. ETIOLOGY

1. cerumen impaction- usually occurs in persons who naturally produce

large amounts of cerumen.
2. external otitis media- (bacterial and fungal), excessive moisture in the
auditory canal (swimmer’s ear), and trauma
3. serous otitis media- result from Eustachian-tube obstruction, sudden
changes in atmospheric pressure, allergy and viral disease
4. suppurative otitis media- may follow viral disease, tympanic
membrane perforation or prolonged forceful nose blowing.
 > common in infants and young children because of their immature
and relatively poorly draining Eustachian tubes.
5. otosclerosis- a hereditary condition; it affects women twice as often
as men and typically develops between ages 15 and 30.
6. trauma / tumors

C. PATHOPHYSIOLOGY

External Ear conditions Middle ear conditions

( impacted cerumen, otitis externa) trauma, otitis media, otosclerosis
tumors
Eustachian tube dysfunctions
↓↓↓

Disruptive conduction of vibration

↓↓↓

Impaired/interrupted mechanism /transmission of sound waves

↓↓↓

Hearing Loss

Symptoms : Diminished Hearing

Soft Spoken Voice

Clinical manifestations :

a. cerumen impaction- some degree of hearing loss

b. external otitis media- itching, pain and watery or purulent
discharge, crust, edema in the auditory canal
c. serous otitis media- sterile fluid accumulation, plugged feeling
in the ear, reverberation of the client’s own voice and hearing
loss.
d. Suppurative otitis media- pus accumulation, throbbing ear
pain, fever, hearing loss, nausea and vomiting, increased feeling
 of pressure in ear, possible tympanic ear membrane rupture,
bright red, bulging retracted membrane
Complication- tympanic membrane rupture
e. Otosclerosis- mixed hearing loss or sensorineural hearing loss
and tinnitus

Medical Management/Treatment:

a. HEARING AIDS

b. Other Aids : Alert and signal devices, assisted – listening devices from
telephone companies

D. NURSING MANAGEMENT:

1. Instruct the client about the correct way to remove impacted cerumen

a. soften cerumen with instilled peroxide or glycerol preparations

b. irrigate the ear in 2 or 3 days to remove the wax
c. instruct and keep otic solution in the ear for 15 min. by titling
the head sideways or by putting cotton in the ear
d. notify the health care provider if inflammation or irritation
occurs
e. not to use to solution for more than 4 consecutive days

2. Provide care to a client with tympanic-membrane perforation

a. maintain strict asepsis

b. do not irrigate the ear
c. protect water from contamination by having client wear ear
plugs & bathing cap
d. recognize that the client is at risk for labyrinthitis or meningitis
e. use a message board if necessary
f. insert a hearing aid if indicated
 3. Treat external otitis media with topical antibiotics and steroids, gentle
debridement, and acid-alcohol solutions to sterilize the auditory canal
as prescribed.
4. Discuss, prepare and assist a client with serous otitis media for
myringotomy which is an incision into the tympanic membrane to
relieve pressure and remove pus.

5. Provide nursing interventions for the client with suppurative otitis

media.
a. provide prescribed treatments for a client with suppurative otitis
media including systemic antibiotics, nasal decongestants,
analgesics
b. discuss, prepare and assist the client with suppurative otitis
media for surgery.
Mastiodectomy - removal of mastoid bone
myringoplasty - the repair of perforated tympanic membrane
tympanoplasty - a procedure involving the replacement or
rebuilding or middle ear structures

6. Discuss, prepare and assist the client with ostosclerosis for surgery, as
indicated

a. stapedectomy is the replacement of diseased ossicles with prothesis

b. fenestration is the creation of a new window into the labyrinth to
provide a new pathway for sound

7. Address Social Isolation and Depressive disorders

SENSORINEURAL HEARING LOSS

SENSORINEURAL- hearing loss resulting from damage to the inner ear or

to the neural pathways from the inner ear to the brain

PATHOPHYSIOLOGY- pf: genetic, congenital; damage to the hair cells in

the organ of Corti, VIIIth cranial nerve, or auditory portions of the brain;
trauma, infection; long-term exposure to environmental noise; ototoxic
agents; rapid infectious process
 |
lost or damaged receptor cells in the inner ear
changes in the cochlea apparatus
auditory nerve abnormalities
|
decreased or distorted ability to receive and interpret auditory stimuli

Diagnosis :

1. Tuning Forks
2. Audioscopes

Medical Management/ Treatment :

a. HEARING AIDS

b. Other Aids : Alert and signal devices, assisted – listening devices from
telephone companies

Surgery : implantable cochlear prosthesis ( direct stimulation of the auditory

nerve)

MIXED TYPE OF HEARING LOSS

MIXED- hearing problem involving BOTH conductive and sensorineural

impairment with a resultant reduction in sensitivity and sound discrimination
in varying degrees.

CLINICAL MANIFESTATIONS

.Increased voice volume

.Client positions the head with the better ear toward the speaker
.Frequently asking people to repeat what they’ve said
.Responding inappropriately to questions or statements
.Questions may elicit a blank look if client has not heard or
understood its content
 .Complaining or ringing in the ear (tinnitus) in SNHL

MANAGEMENT

.Evaluation of type and degree of hearing impairment

Rinne and Weber tests compare air and bone sound conduction

-Auditory identifies the type and pattern of hearing loss

-Speech audiometry identifies the intensity at which speech can
be recognized and interpreted
-Tympanometry is an indirect measurement of the compliance
and impedance of the middle ear to sound transmission

.Use of hearing aids or other assistive devices can help many clients
with hearing deficits by amplifying the sound presented to the
hearing apparatus of the ear
.

For clients with conductive hearing loss:

-stapedectomy-removal and replacement of the stapes; when
hearing loss is related to otosclerosis
-tympanoplasty-reconstruction of the structures of the middle
ear. Chronic otitis media with necrosis and
scarring of the middle ear is a common indica-
tion for this type of surgery.

NURSING MANAGEMENT

.Encourage to talk about the loss of hearing and its effect on activities
of daily living
.Provide information about the type of hearing loss
.Encourage to interact with friends and family on a one-to-one basis in
quiet settings
.Treat with dignity and remind friends and family that a hearing
deficit
does not mean of mental faculties
 .Involve in activities that do not require acute hearing, such as
checkers and chess
.Refer client to an audiologist for evaluation and possible hearing-aid
fitting

.When conversing with client…

-wave the hand or tap the shoulder before beginning to speak
-when speaking, face the client and keep the hands away from
the face
-keep your face in full light
-reduce the noise in the environment before speaking
-use a low voice pitch with normal loudness
-use short sentences and pause at the end of each sentence
-speak at a normal rate, and do not over articulate
-use facial expressions or gestures
-provide a slate for written communication

.Teaching for primary prevention focuses on the following:

-care of the ears and ear canals; including cleaning and
treatment of infection

-no placing of any hard objects into the ear canal

-use of plugs to protect the ears during swimming or diving

-protecting the hearing by avoiding intermittent or frequent

exposure to loud noise

-monitoring for side effects with ototoxic medications

v -hearing evaluation when hearing difficulty is present

OTITIS EXTERNA

-An inflammation or infection of the external canal and/or auricle. It is

commonly known as swimmer’s ear.
PATHOPHYSIOLOGY

PF: Spending significant amount of time in the water

↓
Decreased cerumen production
↓
Drying of external auditory -------→ decreased acidity of
the
Canal & pruritus ear canal

Probing of the external auditory canal growth of

infec-
↓ tious agents
Skin breakdown |
|
↓ |
Entry of infectious agents < ----------------------------
↓
Inflammation & infection of an external ear

PF: increased humidity Pf: use of cotton swabs

Increased temperature use of hearing aids
(living in tropical areas) dermatologic conditions
(eczema, seborrhea,
contact
Dermatitis, psoriasis)
↓ ↓
Increased cerumen production
↓ ↓
Obstruction of the ear canal < -----------------
Local trauma
↓ ↓
Retention of moisture and debris Impaired skin integrity
(maceration)

↓ ↓
Entry and Growth of Infectious Agents
↓
 Inflammation and Infection of an External Ear

*Common Infectious Agents: P.aeruginosa, S.aureus, anacrobes & gram

negative organisms, fungi (aspergillus), yeast (candida)

Clinical Manifestations:
-otalgia
-aural fullness
-itching
-ear discharge initially clear and odorless, but quickly becomes
purulent and foul smelling)
-decreased hearing
-tinnitus
-tragal tenderness with manipulation
-erythematous and edematous external auditory canal
-presence of spores and hyphae if etiology is fungal
-fever (uncommon)

Complications:

-necrotizing otitis externa

-mastoiditis
-chonditis of an auricle
-bony erosion of a base of a skull
-CNS infection

Diagnostics : Ear Swab

NURSING MANAGEMENT:

-Gentle and thorough cleansing of debris and drainage from the

external auditory canal with irrigation
-Treatment of the infection with local antibiotics.
A tropical corticosteroid with antibiotic.
If cellulites is present, systemic antibiotics may be necessary

Preventive Measures :
 Stay out of the water until the acute inflammatory process
is completely resolved
Take precautions to keep the ear canal dry while in the water
immediately after swimming, dry the ear canal
Do not insert cotton swabs or other objects into the ear canal to
dry it. This removes the protective layer of cerumen and may
damage the skin of the canal, increasing the risk of bacterial
infection.

Seek Consultation : any increase in pain, swelling, or redness

of surrounding tissues; fever, malaise or increased fatigue.

PHARMACOLOGIC MANAGEMENT:

ANALGESICS: acetaminophen, codcin

ANTIBIOTICS/CORTICOSTEROIDS: gentamicin, ofloxacin,
Betamethasone, hydrocortisone

CHRONIC OTITIS MEDIA

-is a chronic inflammation of the middle ear with tisse

damage, usually cause by repeated episodes of acute otitis
media. It may be caused by an antibiotic-resistant organism
or a particularly virulent strain of organism.

ETIOLOGY : repeated episodes of ACM,

Risk Factors : Chronic systemic disease ,immunosuppression

PATHOPHYSIOLOGY :
 Repeated episodes of ACM

1. The accumulation of pus inflammatory exudates

under pressure in the middle ear cavity may result in
necrosis of tissue, with damage to the tympanic
membrane and possibly the ossicles.
↓
2. Persistent rupture of the tympanic membrane and
damage to the ossicles
↓

INTERRUPED transmission of sound

↓
conductive hearing loss-mastoiditis
cholesteatoma

CLINICAL MANIFESTATIONS
1. Painless or dull ache and tenderness of mastoid.
2. Otorrhea may be odorless or foul smelling.
3. Vertigo and pain may be present if CNS complications
have occurred.
4. History will indicate several episodes of acute otitis
media, possible rupture or tympanic membrane.
5. Fever and postauricular erythema and edema.

DIAGNOSTIC EVALUATION

1. Air conductive hearing loss is present through

audiometric tests.
 2. X-rays may note mastoid pathology, for example,
cholesteatoma or haziness of mastoid cells.
3. Culture of exudates from middle ear (through ruptured
tympanic membrane or at time or surgery).

MANAGEMENT
Note: If advanced chronic ear disease is left untreated,
inner ear and life-threatening CNS complications may
develop because of erosion of surrounding structures.

Medical Therapy
1. Antibiotic and steroid eardrops may control middle ear
infection and inflammation, but once mastoiditis
develops, parenteral antibiotic therapy is necessary.
2. Eardrops containing neomycin, garamycin, tobramycin,
and quinolones such as Ciprofoxacin (cipro) are
instilled into the middle ear when the tympanic
membrane is ruptured.
3. IV antibiotics must cover beta-lactase-producing
organisms-ampicillin-sulbactam (Unasyn), cefuroxime
(Ceftin).
4. Frequent removal of epithelial debris and purulent
drainage may protect tissue from damage.

SURGICAL INTERVENTIONS
1. Indicated when cholesteatoma is present.
2. Indicated when there is pain, profound deafness,
dizziness, sudden facial paralysis, or stiff neck (may
lead to meningitis or brain abscess).
3. Types of procedures:
a. Simple mastoidectomy-removal of diseased bone
and insertion of a drain; indicated when there is
persistent infection and signs of intracranial
complications.
 b. Radical mastoidectomy-removal of posterior wall
of ear canal, remnants of the tympanic
membrane, and the malleous and incus.
c. Posteroanterior mastoidectomy-combines simple
mastoidectomy with tympanoplasty
(reconstruction of middle ear structures).

COMPLICATIONS

1. Acute and chronic mastoiditis

2. Cholesteatoma
3. CNS infection (meningitis, intracranial abscess)
4. Postoperatively-facial nerve paralysis, bleeding,
vertigo

NURSING ASSESSMENT
1. Assess for history of ear infection and treatment
compliance.
2. Assess for ear drainage, patency of tympanic
membrane
3. Assess for hearing loss
4. Palpitate for mastoid tenderness

PATIENT EDUCATION AND HEALTH MAINTENANCE

1. Teach patient to keep ear dry-avoid showers, washing

hair, swimming-to prevent any water from gaining
access to middle ear.
2. Encourage patient to follow up for frequent ear
cleaning.
3. Stress the importance of adhering to antibiotic
schedule
 4. Advise of complications and to report headache,
change in mental status or arousal, or increased ear
pain.
5. Stress the importance of follow-up hearing evaluations
and early intervention for any signs of ear infection in
the future.

MASTOIDITIS

Mastoiditis is an infection of the mastoid bone of the skull.

The mastoid is located just behind the outside ear.

Causes : Acute Otitis Media, middle ear infections

Incidence : children

Mastoiditis is usually caused by a middle ear infection (acute otitis

media). ↓

The infection may spread from the ear to the mastoid bone of the
skull. ↓

The mastoid bone fills with infected materials and its honeycomb-
like structure may deteriorate.

Before antibiotics, mastoiditis was one of the leading causes of

death in children.

Symptoms

• Drainage from the ear

• Ear pain or discomfort
• Fever, may be high or suddenly increase
• Headache
• Hearing loss
 • Redness of the ear or behind the ear
• Swelling behind ear, may cause ear to stick out

Exams and Tests

• CTscan of the ear

• Head CT scan
• Skull x-ray

A culture of drainage from the ear may show bacteria.

Treatment Mastoiditis may be difficult to treat because

medications may not reach deep enough into the mastoid bone.

It may require repeated or long-term treatment. The infection is

treated with antibiotics by injection, then antibiotics by mouth.

SURGERY ;

(mastoidectomy) if antibiotic therapy is not successful.

(myringotomy ) ; drain the middle ear through the eardrum needed

to treat the middle ear infection.

Possible Complications : destruction of mastoid bone

• Dizziness or vertigo
• Epidural abscess
• Facial paralysis
• Meningitis
• Partial or complete hearing loss
• Spread of infection to the brain or throughout the body

Prevention
Promptly and completely treating ear infections reduces the risk of
mastoiditis.

LABYRINTHITIS

-is an inflammation of the inner ear vestibular labyrinth

system. The hallmark is vertigo.

ETIOLOGY : viral or bacterial infection, occur as a symptom

of a tumor or other pathology in the nervous system, or
occur due to a physiologic response from external stimuli.

PATHOPHYSIOLOGY

1. Upper respiratory virus, mumps, rubella, rubeolla,

and influenza, bacterial meningitis, complication,
otitis media and cholesteatoma, various stimuli
(such as roller coaster ride, sudden stop, quick
change in position

conflicting vestibular, somatosensory signals,

Sudden on set of incapacitating vertigo, nausea, and

vomiting, hearing loss and tinnitus
 ↓

Symptoms may remain steady or gradually increase

with CNS pathology

DIAGNOSTIC EVALUATION

1. Characteristic infectious labyrinthitis may be

Monitored for improvement without diagnostic
testing.

2. ENG with caloric and doll’s eye testing to differ-

entiate cause.

3. CT or MRI for suspected tumors of cranial nerve VIII

MANAGEMENT

1. bacterial labyrinthitis are treated with antibiotics

2. Viral and physiologic causes are treated with symptom-
atic support.
3. Prevention and management of attacks.
4. Vestibular suppressant and antiemetic medication
(meclizine, diazepam, promethazine).
5. Presumed pathologic causes are worked up, cause
is treated with neurosurgery

COMPLICATIONS

1. Permanent hearing loss

2. Injury from fall
NURSING ASSESSMENT

1. Assess frequency and severity of attacks and how patient

handles them.

2. Assess for fever related to bacterial infection.

3. Assess for additional neurologic symptoms—visual

changes, change in mental status, sensory and motor
deficits, - indicate CNS pathology

4. Assess for effectiveness of vestibular stimulants and

Antiemetics.

5. If fall occurs, assess for injury.

NURSING DIAGNOSIS

.High Risk for Injury related to gait disturbance secondary to

vertigo
.Anxiety related to sudden onset of symptoms
.Risk for Fluid Volume Deficit related to vomiting and
Impaired intake
.Self-Care Deficit (bathing, dressing, feeding, toileting)
related to vertigo

NURSING INTERVENTIONS:

Preventing Injury

1. At onset of attack, have patient lie still in darkened

room with eyes closed or fixed on stationary object,
until the vertigo passes.
 2. Ensure that patient can obtain help at all times
through use of call system, close proximity to staff, or
companion.
3. Remove any obstacles in patient’s environment.
4. Ensure that sensory aids are available—glasses,
hearing aid, proper lighting.
5. Use side rails while patient is in bed.
6. Administer medications as directed; assess for and
avoid oversedation.

MINIMIZING ANXIETY

1. Explain the physiology behind vertigo and the possible

triggers.
2. Support patient and family through the diagnostic
process.
3. Assist patient to adjust activities to minimize the
impact.
4. Teach stress reduction techniques such as deep
breathing, talking and asking questions, and
distraction.

ENSURING ADEQUATE FLUID

1. Keep diet light while vertigo is present.

2. Administer antiemetics as directed.
3. Assess intake and output as indicated.
4. Encourage fluids and small feedings while patient is
feeling better.

ENCOURAGING SELF-CARE

1. Encourage activity while vertigo is minimal; rest

during attacks.
 2. Set up environment for patient’s safety and
convenience—chair near sink, walker to hold on to
while walking if necessary, and so forth.
3. Assist patient with hygiene and other care as needed.

PATIENT EDUCATION AND HEALTH MAINTENANCE

1. Teach patients with viral labyrinthitis that attacks are

self-limiting, will become less severe, and should leave
no permanent disability.
2. Teach safety measures during vertigo attacks.
3. Tell patient that vertigo is best tolerated while lying
flat in bed in a darkened room with eyes closed or
looking at stable object.
4. Teach patients how to take medications, and to avoid
other CNS depressants such as alcohol.
5. Encourage follow-up.

OUTCOME-BASED EVALUATION

.Resting in bed during attack with side rails up

.Patient verbalizing feelings and questions about
treatment
.Taking fluids, light diet every 4 hours, after medication
administration
.Performing appropriate hygiene and dressing by self
at bedside

MENIERE’S DISEASE
 Meniere’s disease (endolymphatic hydrops) is a chronic
disease that involves the inner ear and causes a triad of
symptoms—vertigo, hearing loss, and tinnitus.

ETIOLOGY : exact cause unknown

Incidence :

1. Usually unilateral, later may become bilateral.

2. Occurs most frequently between age 30 and 60.
Severity of attacks may diminish over the years, but hearing
loss increases

PATHOPHYSIOLOGY :

PF : middle ear infection, head trauma or an upper respiratory

tract infection, or by using aspirin, smoking cigarettes or
drinking alcohol, narrowed endolymphatic duct, too much
fluid secreted by stria vascularis
↓
swelling of the endolymphatic sac or other tissues in the
vestibular system of the inner ear
↓
endolymphatic fluid bursts from its normal channels in the ear and
flows into other areas causing damage
↓
“HYDROPS”
↓
Fluid distention of the endolymphatic spaces of the labyrinth
destroys cochlear hair cells

CLINICAL MANIFESTATIONS

1. Sudden attacks occur, in which patient feels that

the room is spinning (vertigo); may last 10 minutes
to several hours.
3. Dizziness, tinnitus, and reduced hearing occur on
involved side.

4. Headache, nausea, vomiting and incoordination

are present.
5. Sudden motion of the head may precipitate vomiting.
6. History often reveals ear trouble, vasomotor rhinitis,
and allergies.
7. Irritability;other personality changes.
8. tinnitus and impaired hearing may be continuous.

DIAGNOSTIC EVALUATION

1. Caloric test/ENG to differentiate Meniere’s disease

from intracranial lesion.
a. Fluid, above or below body temperature, is
instilled into the auditory canal.
b. Will precipitate an attack in patients with
Meniere’s disease.
c. Normal patient complains of dizziness; patient
with acoustic neuroma has no reaction.
2. Audiogram shows sensorineural hearing loss.
3. CT, MRI to rule out acoustic neuroma.

MEDICAL MANAGEMENT

1. Patient can be asked to keep a diary noting presence

of aural symptoms (eg, tinnitus, distorted hearing)
when episodes of vertigo occur. This may help
diagnose which ear is involved and whether surgery
will be needed.
2. Administration of the vestibular suppressant to control
symptoms.
a. Meclizine (Antivert,Bonine) up to 25 mg qid
 b. Diphenhydramine (Benadryl) 25 to 50 mg tid to
qid
c. Diazepam (Valium) 2 mg tid or 5 to 10 mg IM or
IV (addictive potential)
3. Streptomycin (IM) or gentamycin (transtympanic
injection) may be given to selectively destroy
vestibular apparatus if vertigo is uncontrollable.
4. Additional antiemetic such as promethazine
(Phenergan) may be needed to reduce nausea,
vomiting and resistant vertigo.

SURGICAL

1. Conservative-simple endolymphatic sa
decompression or endolymphatic subarachnoid or
mastoid shunt to relieve symptoms without
destroying function.
2. Destructive surgery;
a. Labyrinthectomy-recommended if the patient
experiences progressive hearing loss and severe
vertigo attacks so normal tasks cannot be
performed; results in total deafness of affected
ear.
b. Vestibular nerve section-neurosurgical
suboccipital approach to the cerebellopontine
angle for intracranial vestibular nerve
neurectomy.

COMPLICATIONS

1. Irreversible hearing loss.

2. Disability and social isolation due to vertigo and
hearing loss.
3. Injury due to falls.

NURSING ASSESSMENT
 1. Assess for frequency and severity of attacks.
2. Provide screening hearing tests.
3. Evaluate effect on patient’s activities, potential for
fall or injury.

NURSING DIAGNOSIS

1. Risk for Injury related to sudden attacks of vertigo

2. Social Isolation related to fear of attack and hearing
loss.

NURSING INTERVENTIONS
Ensuring Safety

1. Help patient recognize aura so patient has time to

prepare for an attack.
2. Encourage patient to lie down during attack, in safe
place and lie still.
3. Put side rails up on bed if in hospital.
4. Have patient close eyes if this lessens symptoms.
5. Inform patient that the dizziness may last for varying
lengths of time.

MINIMIZING FEELINGS OF ISOLATION

1. Provide encouragement and understanding. Show the

patient that you understand the seriousness of this
disorder.
2. Assist patient to identify specific triggers to control
attacks.
a. Remind the patient to move slowly;
b. Avoid noises and glaring, bright lights,-may
initiate an attack
c. Control environmental factors and personal habits
that may cause stress or fatigue
 d. If there is a tendency to allergic reactions to
foods, eliminate those foods from the diet.

OTOSCLEROSIS
-is a pathologic condition in which there is formation of
new spongy bone in the labyrinth, fixation of the stapes, and
prevention of sound transmission through the ossicles to the
inner fluids, resulting in deafness.

ETIOLOGY : The cause is unknown but, there is a

familial tendency and more women are affected than men.
Conenital/autosomal patterns.

PATHOPHYSIOLOGY :

BEGINS WITH RESORPTION OF BONE IN ONE OR MORE

FOCI
↓
BONE APPEARS SPONGY THAN NORMAL
↓
RESORBED BONE THEN REPLACED BY AN OVERGROWTH OF
NEW, SCLEROTIC BONE
↓
PROCESS IS SLOWLY PROGRESSIVE, INVADING MORE
AREAS OF THE TEMPORAL BONE,( STAPES OF FOOTPLATE)
↓
PATHOLOGIC BONE IMMOBILIZES THE STAPES
↓
REDUCE TRANSMISSION OF SOUND, PRESSURE ON INNER
STRUCTURES, VESTIBULOCOCHLEAR NERVE
↓
S/SX
Tinnitus, conductive / mixed hearing loss, vertigo
Progressive loss of soft spoken tones

Diagnostics : Audiometry findings substantiate conductive

or mixed hearing loss.
 Bone conduction is much better than air conduction.

MANAGEMENT

1. No known medical treatment exists for this form of

deafness, but amplification with a hearing aid may be
helpful.
2. Surgery—stapedectomy.
a. That removal of otosclerotic lesions at the
footplate of stapes or complete removal of the
stapes and the creation of a tissue implant with
prosthesis to maintain suitable conduction.
b. To perform such delicate surgery, the otologic
binocular microscope is used.

PSYCHOGENIC HEARING LOSS- usually a manifestation of

an emotional disturbance and unrelated to evident structural
changes in the hearing mechanisms. Loss is often total, but
without physical basis, the patient may suddenly recover.

PRESBYCUSIS

-a progressive, bilaterally perceptive hearing loss of older

people, usually involving high frequencies, that occurs with
the aging process.

INCIDENCE : 65-75 YEARS OF AGE, 40% OF population

older than 75 yrs. Old, men more than women

ETIOLOGY : Degenerative changes in the ear ( hair cells-

organ of corti )

PATHOPHYSIOLOGY :

OLD AGE ( 65-75 YRS. OLD )

↓
PF : CHRONIC NOISE EXPOSURE, VASCULAR DISORDERS
↓
DEGENERATIVE CHANGES ( LOSS OF NEUROEPITHELIAL
HAIR CELLS, NEURONS, STRIA VASCULARIS
↓
(SNHL) HEARING LOSS
MANIFESTATIONS :

1. DIFF. IN UNDERSTANDING WORDS IN A NOISY

ENVIRONMENT
2. REPORTS HEARING SOFT WHISPERED, NORMALLY
SPOKEN OR SHOUTED WORDS
3. LOSS OF HIGH FREQUENCY SOUND DESCRIMINATION
FIRST

MANAGEMENT :

1. All other possibly treatable hearing disorders should be

ruled out before this diagnosis. There is no effective
medical or surgical treatment.
2. The patient should be counseled by an otologist
(physician who specializes in the ear) in collaboration
with an audiologist (nonphysician provider who can
suggest non-medical treatment).
3. Helpful aids should be considered, such as a telephone
amplifier, radio and television earphone attachments,
buzzers instead of doorbell.
4. Understanding and help from family members are
important.

ACOUSTIC NEUROMA
 - slow growing benign, tumor of CN VIII, arise from
Schwann cells of vestibular portion of the nerve

Assessment

- unilateral tinnitus, hearing loss, with or without

vertigo or balance disorder

Diagnostic Exams

MRI
CT scan

Management

1. surgery

complications : facial nerve paralysis, CSF leak, meningitis,

cerebral edema.

SINUSITIS

-is an inflammation of the mucous membranes of one

or more paranasal sinuses. It is usually precipitated by
congestion from viral upper respiratory infection and/or
nasal allergy. Chronic sinusitis is a suppurative inflammation
of the sinuses with chronic irreversible change in the mucosa
and sinus bony area.

PATHOPHYSIOLOGY :
 viral upper respiratory infection / nasal allergy
↓
Allergic reaction
↓

Congestion of the sinuses

↓

Obstruct sinus drainage

↓

Inflammation of sinuses

CLINICAL MANIFESTATIONS

Acute Sinusitis
1. Pain—stabbing or aching, over the infected sinus and
referred to face and head.
2. Nasal congestion and discharge; may or may not be
present
3. Anosmia (lack of smell); inspired or expired air cannot
reach the olfactory groove
4. Red and edematous nasal mucosa
5. May have fever

CHRONIC SINUSITIS

1. Persistent nasal obstructions; chronic nasal discharge,

clear or purulent when infected
2. Cough-produced by constant dripping of discharge
back into nasopharynx
3. Feeling of facial fullness/pressure
4. Headache-may be vague or in same pattern as acute
sinusitis, more noticeable in the morning; fatigue

DIAGNOSTIC EVALUATION
 1. Sinus x-rays and CT Scan show air-fluid level in acute
sinusitis; thickening of sinus mucous membranes,
opacification,and anatomic obstruction patterns in
chronic sinusitis.
2. Antral puncture and lavage-provides culture material
to identify infectious organism; also a therapeutic
modality to clear of bacteria, fluid, and inflammatory
cells.
3. Nasal and sinus endoscopy (the sinuses can be easily
accessed after the patient has had an antrostomy).

MANAGEMENT

1. Topical decongestant spray or drops or systemic

decongestants for mucosal shrinkage to encourage
drainage from sinus. Topical therapy should be limited
to no more than three successive days of use.
2. Topical nasal corticosteroids are frequently used in
chronic sinusitis, and may be used in acute cases.
3. Antibiotic, usually trimethoprim-sulfamethoxazole
(Bactrim), penicillinase-resistant penicillins,
cephalosporins, or macrolide antibiotics.
4. Usually 10 to 14 day course for acute sinusitis.
5. Prolonged therapy for chronic sinusitis
6. Analgesic-pain may be significant
7. Warm compresses; cool vapor humidity for comfort
and to promote drainage.
8. Surgical interventions (for chronic sinusitis when
conservative treatment is unsuccessful)

a. Endoscopic sinus surgery-endoscopic removal of

diseased tissue from affected sinus, used to treat
chronic sinusitis of maxillary, ethmoid, and frontal
sinuses.
b. Nasal antrostomy (nasal-antral window)-surgical
placement of an opening under inferior turbinate
 to provide aeration to the antrum to permit exit
for purulent materials

COMPLICATIONS
Depend on anatomic location of sinus involved.
1. Extension of infection to the orbital contents and
eyelids.
2. Bone infection (osteomyelitis) may spread by direct
extension or through blood vessels. Frontal bone
commonly affected.

3. CNS complications include meningitis, subdural and

epidural purulent drainage, brain abscess, cavernous
sinus thrombosis (acute thrombophlebitis originating
from an infection in an area having venous drainage to
cavernous sinus).

RHINITIS

-are disorders of the nose that interrupt its normal

functions of olfaction, and warming, filtering, and
humidifying inspired air. These include allergic rhinitis, non-
allergic rhinitis, vasomotor rhinitis, and other conditions.
ETIOLOGY : Allergens, viruses, bacteria, drug-induced,
automatic nasal dysfunction

PATHOPHYSIOLOGY

Allergic type

Allergen inhaled
↓
Triggers antibody production
↓
Antibodies bind to mast cells,
↓
Mast cells stimulated
 ↓
Allergic reaction
↓
Histamine and other chemicals released
↓
Itching, swelling and mucus production

1. Allergic rhinitis-IgE-mediated response causing release

of vasoactive substances from mast cells
2. Non-allergic rhinitis
3. Infectious-viral (common cold) and bacterial
(purulent)
4. Drug-induced (rebound rhinitis; rhinitis
medicamentosa)-caused by excessive use of topical
nasal decongestants
5. Vasomotor rhinitis-unexplained automatic nasal
dysfunction as a result of overactivity of the para-
sympathetic nerve supply to the mucous membranes
of the nose and paranasal sinuses
6. Rhinitis of pregnancy-nasal congestion resulting from
estrogen-mediated mucosal engorgement.

CLINICAL MANIFESTATIONS

1. Hypersecretion-wet, running/dripping nose or post-

nasal drip
2. Nasal obstruction symptoms-nasal congestion,
pressure, or stuffiness
3. Headache

MANAGEMENT

1. Treatment of underlying cause

a. Allergy-antihistamines
 b. Infection-supportive care for viral; antibiotics for
bacterial
2. Topical decongestants
3. Intranasal corticosteroids-preferred treatment in
vasomotor rhinitis, may also be used in other types

NURSING INTERVENTIONS AND PATIENT EDUCATION

1. Avoid irritating inhalants, especially smoke, aerosols,

noxious fumes.
2. Do not overuse topical nasal sprays/drops.
3. Do not blow nose too frequently or too hard; doing so
may cause infection to spread, sinuses to become
infected, and an eardrum to be perforated.
4. Blow through both nostrils at the same time to
equalize pressure.
5. Side effect of systemic decongestants is stimulation of
sympathetic nervous system-insomnia, nervousness,
palpitations.

6. Intranasal corticosteroids do not cause significant

systemic absorption in usual doses, but occasionally
may cause pharyngeal fungal infections and rarely
cause nasal septal perforation.
7. Be aware that many people use a variety of herbal
products to prevent and treat nasal and sinus
infections. Echinacea, zinc, and vitamin C are
generally safe, but should not be taken in greater
amounts than recommended.

EPISTAXIS
 -refers to nosebleed or hemorrhage from the nose.

PATHOPHYSIOLOGY

PF : local causes, trauma, systemic causes

↓
Rupture of tiny, distended vessels in the mucous membranes
of the nose

1. Local Causes:
a. Dryness leading to crust formation-bleeding
occurs with removal of crusts by nose picking,
rubbing or blowing.
b. Trauma-direct blows

2. Systemic causes are less common-hypertension,

arteriorsclerosis, renal disease, bleeding disorders
(most common systemic cause).
3. Majority of nosebleeds are anterior, posterior bleeds
are more difficult to control

DIAGNOSTIC EVALUATION

1. Inspection with nasal speculum to determine site of

bleeding.
2. Laboratory evaluation to exclude blood dyscrasias.
3. CT scan/ nasopharyngiography ( IF TUMOR suspected )

MANAGEMENT

Depends on severity and source of bleeding in nasal

cavity.
 1. Patient is placed in an upright posture, leaning forward
to reduce venous pressure and instructed to breathe
gently through the mouth to prevent swallowing of
blood.
2. With anterior bleeds, patient is instructed to compress
the soft part of nose with index finger and thumb for 5
to ten minutes.
3. A cotton pledget soaked with a vasoconstricting agent
may be inserted into each nostril, and pressure is
applied if bleeding is not controlled by compression
alone.
4. The blood vessel may be cauterized.
5. If bleeding continues or posterior bleeding is initially
identified, packing may be layered into nasal cavity
and nasopharynx or balloon tamponade maybe
required to apply pressure over a larger area.
6. Surgical ligation of vessels may be required.

COMPLICATIONS

1. Rhinitis, maxillary and frontal sinusitis.

2. Hemotympanum, otitis media

NASAL OBSTRUCTION

-is the blockage of the nasal passages usually due to

membranes lining the nose becoming swollen from inflamed
blood vessels.
- allergic, inflammatory, neoplastic, endocrine, or
metabolic disorder, a structural abnormality; a traumatic
injury; or a mechanical obstruction (foreign objects).

PATHOPHYSIOLOGY
PF:

.Allergic reaction
.Common cold or influenza
.Hay fever, allergic reaction to pollen or grass
.Sinusitis or sinus infection

Deviated septum Nasal polyps hypertrophied

Turbinates
(congenital) (Infection/Allergens) (Chronic rhinitis)
↓ ↓ ↓
Deflection from swelling of nasal hypertrophy of
the midline in the mucous membrane nasal concha
form of lumps
↓ ↓ ↓
Complete obstruct- obstruct nasal breath- interferes air
ion of one nostril ing and sinus drainage passage
↓ ↓ ↓
Interference of Sinusitis Sinusitis
sinus drainage

S/SX

-Breathing difficulty
-Blocked nose
-Runny nose
-Decreased sense of smell
-Postnasal drip
DRUGS

Topical nasal vasoconstrictors may cause rebound rhinorrhea

and nasal obstruction if used longer than 5 days.
Antihypertensives may cause nasal congestion as well.

SURGERY

-Nasal obstruction may occur after sinus or cranial surgery

or even after rhinoplasty.
-Hypertrophied turbinates treated with application of
aerosolized corticosteroid to shrink
-Polypectomy removal of polyps

DIAGNOSTICS

-fiberoptic endoscopy in the diagnosis of adenoid

hypertrophy in children
-CT Scan for chronic nasal obstruction
-a nasal smear and culture for bacterial and fungi, and x-
rays of the sinuses.

NSG MGMT

-Apply ice pack to reduce pain and swelling

-Place clint in semi fowlers position to promote drainage,
reduce edema and enhance breathing
-Inspect nasal dressing for bleeding
-Provide oral hygiene
-Advise patient not to blow nose
-Avoid heavy lifting