AUDITION  Overview of the Anatomy and Physiology


The ear is divided into three parts; External, Middle and Internal External Ear Auricle or pinna It collects sound waves and directs them toward the auditory meatus. External auditory meatus It directs sound waves to the tymapanic membrane; hairs and cerumen help cleanse the canal of foreign matter. Tymapanic membrane Protects the middle era and conducts sound vibration from the external ear to the ossicles.

as well as size and symmetry and angle of attachment to the head. which communicates with CSF via the cochlear duct. b. is bathed in a fluid called perilymph. cochlear duct and the organ of corti. lesions and discharge. This fluid also protects the end organ because it acts as a cushion against abrupt movements of the head. Ossicles 2. saccule.Middle Ear Consists of the middle ear cleft and contents: 1. Bony labyrinth Sussounds and protects the membranous labyrinth a. lying within but not completely filling the bony labyrinth. semicular canals. The external ear is examined by inspection and direct palpation. but it is often overlooked. c. .Contains the utricle and saccule which function in the sense of balance. The membranous labyrinth consists of the utricle. Mastoid bone Inner Ear The membranous labyrinth. If the maneuver is painful. Semicircular canals. the auricle and surrounding tissues should be inspected for deformities.Contains auditory receptors which function in hearing. Windows 3. Cochlea. Tenderness on palpation in the area of the mastoid may indicate acute mastoiditis or inflammation of the posterior auricular node.Function in the sense of balance.  Assessment Inspection of the External Ear Inspection of the external area is a simple procedure. Manipulation of the auricle does not normally elicit pain. acute external otitis is suspected. The membranous labyrinth contains a different fluid (endolymph). Eustachian tubes 4. Vestibule. A flaky scaliness on or behind the auricle usually indicates seborrhaic dermatitis and can be present on the scalp and facial structures as well.

Proper otoscopic examination of the external auditory canal and tympanic membrane requires that the canal be free of large amounts of cerumen. Because the distal portion of the canal is bony and covered by a sensitive layer of epithelium. with the examiner’s eye held close to the magnifying lens of the otoscope to visualize the canal and tympanic membrane. only light pressure can be used without causing pain. the cerumen may be removed by gently irrigating the external canal with warm water. testing one ear at a time. the otoscope should be held in the examiner’s right hand. This position prevents the examiner from inserting the otoscope too far into the external canal. The largest speculum that the canal and tympanic membrane. These tests are part of the usual screening physical examination and are useful if a more specific assessment is needed. Whisper test To exclude one ear from the testing. If the tympanic membrane cannot be visualized because of cerumen. The Weber and Rinne tests may be used to distinguish conductive loss from sensorineural loss when hearing is impaired. the tympanic membrane is more difficult to visualize because the canal obstructs the view. in a pencil hold position. Cerumen is normally present in the external ear and small amounts should not interfere with otoscopic examination. with the examiner’s hand braced against the patient’s face. Then the examiner whispers softly from a distance of 1 or 2 feet from the unoccluded ear and out of the patient’s sight. The external auditory canal is examined for discharge. The speculum is slowly inserted into the ear canal. The largest speculum that the canal can accommodate is guided gently down into the canal and slightly forward. inflammation or a foreign body. Evaluation of Gross Auditory Acuity A general estimate of hearing can be made by assessing the patient’s ability to hear a whispered phrase or a ticking watch. the auricle is grasped and gently pulled back to straighten the canal in the adult. Using the opposite hand. The patient with normal acuity can correctly repeat what was whispered.Otoscopic Examination The tympanic membrane is inspected with an otoscope and indirect palpation with a pneumatic otoscope. To examine the external auditory canal and tympanic membrane. . If the canal is not straightened with this technique. the examiners cover the untested ear with the palm of the hand.

set in motion by grasping it firmly by its stem and tapping it on the examiner’s knee or hand. The Weber test is useful for detecting unilateral hearing loss. such as from otosclerosis or otitis media. A person with normal hearing reports that air-conducted sound is louder than bone conducted sound. 2 inches from the opening of the ear canal (for air conduction) and against the mastoid bone (for bone conduction). becomes grim and lonely Experiences social isolation Develops suspicious attitude Has abnormal articulation Complains of ringing in the ear Has unusually soft or loud voice Dominates conversation . A person with conductive hearing loss. hears the sound in the better-hearing ear. the examiner shifts the stem of a vibrating tuning fork between two positions. A person with a conductive hearing loss hears bone-conducted sound as long as or longer than air-conducted sound. Rinne Test In the Rinne test. hostile or hypersensitive I interpersonal relations Has difficulty in following directions Complains about people mumbling Turns up volume on TV Asks for frequent repetition Answers questions inappropriately Leans forward to hear better. hears the better in the affected ear. A person with a sensorineural hearing loss hears air conducted sound longer than bone-conducted sound. A tuning fork (ideally 512 Hz). is placed on the patient’s head or forehead. Assessment in client with hearing loss               Irritable. face looks serious and strained Loses sense of humor.Weber Test The Weber test uses bone conduction to test lateralization of sound. the patient is asked to indicate which tone is no longer audible. The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. A person with normal hearing hears the sound equally in both ears or describes the sound as centered in the middle of the head. A person with sensorineural loss. resulting from damage to the cochlear or vestibulocochlear nerve. As the position changes.

a tone with 100 Hz is low pitch. measured as cycles per second or Hertz (Hz) Pitch -term used to describe frequency. either in the external auditory canal next to the tympanic . Diagnostics AUDIOMETRY Pure-Tone Audiometry -sound stimulus consists of a pure or musical tone (the louder the tone before the patient perceives it the greater the hearing loss) Speech Audiometry -determines the ability to hear and discriminate sounds and words THREE IMPORTANT CHARACTERISTICS Frequency -number of sound waves emanating from a source per second.000 Hz is high pitch Intensity -the pressure exerted by sound/loudness -measured in decibels (dB) -30 dB is considered critical level - TYMPHANOGRAM impedance audiometry measures middle ear muscle reflex to sound stimulation and compliance of the tymphanic membrane by changing the air pressure in a sealed ear canal. The active potentials responses to an auditory stimulus such as a “click”. The resulting ratio is used to assist in diagnosing disorders of the inner ear fluid balance such as Meniere’s disease and perilymph fistula. and a tone of 10. The potentials measured include the action potential of the cranial nerve VIII (AP) and summating potential (SP). Procedure The procedure is performed by placing an electrode as close as possible to the cochlea. ELECTROCHLEOGRAPHY It is the recording of electrophysiologic potentials of the cochlea and cranial nerve VIII in response to acoustic stimuli.

Management Patients are asked not to take any diuretics for 48 hours before the test. Results Results are reported as an amplitude ratio between the action potential (AP) and the summating potential (SP).Patients are asked not to take any vestibular suppressants such as sedatives. It has been proven effective in assessing vestibular as well as some neuromuscular disorders affecting balance. ELECTRONYSTAGMOGRAPHY It is the measurement and graphic recording of the changes in electrical potentials created by eye movements during spontaneous. - . COMPUTERIZED DYNAMIC POSTUROGRAPHY also called test of balance (TOB). tranquilizers.Patients are also asked not to take any vestibular stimulants such as caffeine for 24 hours before testing. ENG helps in the diagnosis of conditions such as Meniere’s disease and tumors of the internal auditory canal or posterior fossa. a non-invasive specialized clinical assessment technique used to quantify the central nervous system adaptive mechanisms (sensory. In the caloric portion of the testing. It is used to assess the oculomotor and vestibular systems and their corresponding interaction. SP/AP ratios less than 0. positional or calorically evoked nystagmus. motor and central) involved in the control of posture and balance. Management . both in normal and abnormal conditions. SP/AP ratios greater than 0. .33 are considered to be within the normal range. hot and cold air or water is placed in the external auditory canal and eye movements are then measured. antihistamines or alcohol. Procedure The patient is positioned in such a way that the lateral semicircular anal is parallel to the gravitational field and seated while electrodes are placed on the forehead and near the eyes.membrane or via a transtympanic electrode placed through the thympanic membrane near the round window membrane.4 considered positive for endolympathic hydrops/ Meniere's disease.

2. .Procedure During CDP testing. reactions are provoked by unexpected abrupt movements of the support surface. you will sit in a rotational computerized chair positioned in the middle of a small. which are designed to help determine if your dizziness or imbalance is a result of a vestibular system or central nervous system problem. the patient stands on a movable. dual forceplate support surface within a moveable surround (enclosure). Management .is typically ordered in addition to video nystagmography electronystagmography testing to evaluate your vestibular system. Under control of a computer.Let the client rest for 5-10 minutes after the procedure in case dizziness occurs. . The client will be alone in the room.also called as rotary chair testing . the eye movements will be carefully monitored and recorded.used for analyzing horizontal canal vestibuloocular reflex (VOR). or rotate out of the horizontal plane. The test takes approximately 30 minutes and includes different sub-tests. during which the patient's postural stability and motor reactions are recorded. During these tasks. SINUSOIDAL HARMONIC ACCELERATION .Secure the harness placed on the client’s body to prevent falls. Sensory Organization Test (SOT) Controlled spontaneous sway is eliminated without provoking motor reactions by moving the support surface and the visual enclosure in response to the patient's postural movements. Adaptation Test (ADT) During the motor control protocols (MCT and ADT). The chair has a seatbelt and security head strap to keep your torso and head in place and will be given a pair of infrared video goggles. dark room. Standardized test protocols expose the patient to support surface and visual surround motions. but there is a microphone to speak to the audiologist operating the chair and conducting the test. / Procedure During rotary chair testing. specifically measuring the vestibulo-ocular reflex which occurs in response to movement of the chair. the force platform can either move in a horizontal plane (translate). which will record eye movements during the test. Motor Control Test (MCT) 3. These test protocols include: 1. .

suction or instrumentation. mechanical removal can be performed on a cooperative patient by a trained health care provider. The next part of the test is the chair test where the client will be turned at varying speeds in the rotary chair. To prevent injury. If irrigation is unsuccessful. Instrumentation . Instilling a few drops of warmed glycerin. which measures the eye movements in response to moving lights projected on the wall in front of the client. It’s important that you tell the audiologist if any symptoms such as dizziness. the water must stream behind the obstructing cerumen to move it first laterally and then out of the canal. mineral oil or half-strength hydrogen peroxide into the ear canal for 30 minutes can soften cerumen before its removal. Eye movement is recorded and analyzed again. particularly if it is not tightly packed in the external auditory canal. the lowest effective pressure should be used. Both types of tests are useful in diagnosing and localizing the source of dizziness or imbalance. Irrigation 2. direct visual. instruments such as cerumen curette. FOREIGN BODIES Removing a foreign body from the external auditory canal can be quite challenging. Suction 3. MANAGEMENT CERUMEN IMPACTION Cerumen can be removed by irrigation. If the cerumen cannot be dislodged by these methods. aural suction and a binocular microscope for magnification can be used. Using any softening solution two or three times a day for several days is generally sufficient. For successful removal. nausea or headache are experience during these tasks. gentle irrigation usually helps remove impacted cerumen. Unless the patient has a perforated eardrum or an inflamed external ear. Ceruminolytic agents.The first part of the test is called the oculomotor test. such as peroxide in glyceryl are available. The three standard methods for removing foreign bodies are the same as those for removing cerumen: 1.

EXTERNAL OTITIS (Otitis Externa) -inflammation of the external auditory canal Causes . is usually the infecting agent Management .fever . swimming and shampooing) . an insect can be dislodged by instilling mineral oil.The contraindications for irrigation are also the avoid infection use antiseptic otic preparations after swimming MALIGNANT EXTERNAL OTITIS (Temporal Bone Osteomyelitis) . the surrounding tissue and the base of the skull.hearing loss Management .Administration of antibiotics >antipseudomonal >aminoglycoside Local wound care >debridement of the infected tissue. .entrance of organisms into the tissues Clinical Manifestations . irrigation is contraindicated.a progressive. debilitating and occasionally fatal infection of the external auditory canal.discharge from external auditory canal >yellow/green >foul-smelling >hair-like black spores may be visible .pain .g. . which will kill the insect and allow it to be removed. including bone and cartilage.avoid getting the canal wet (e.water in the ear canal (swimmers’ ear) . depending on the extent of infection - .trauma to the skin of ear canal .aural tenderness .Pseudomonas Aeruginosa. Foreign vegetable bodies and insects tend to swell.pruritus . Usually. thus.instruct patients not clean external auditory canal with cotton-tipped applicators and to avoid scratching of the canal.

Ongoing researchmay offer new recommendations for treatment of acute otitis media. though they may be offered to individuals who havechronic middle ear fluid or chronic otitis media. Ear tubes are not the firstlinetreatment for acute otitis media. Management More than 80% of ear infections can resolve on their own. especially if there is no improvement with a few days of watchingan otherwise healthy child and providing pain relief with acetaminophen or ibuprofen. infection occurs behind the tympanicmembrane (eardrum). Since the vaccinefor Streptoccocus pneumoniae(PCV) was introduced.disturbance of equilibrium caused by constant motion Manifestations . meclizine hydrochloride) -provides relief from nausea and vomiting by blocking the conduction of vestibular pathway of the inner ear ACUTE OTITIS MEDIA Acute otitis media (middle ear infection) is extremelycommon in children and also occurs in adults.MOTION SICKNESS . should receive antibioticswithout delay. however. Acute otitis media is usually caused bybacteria. and this mayinfluence the choice of antibiotic treatment in the future. These conditions include congenital heart disease. TYMPANIC MEMBRANE PERFORATION A tympanic membrane perforation is a condition where your eardrum has a tear or hole in it. or inherited disorders ofthe immune system). Down syndrome.nausea and vomiting cause by vestibular overstimulation Management o OTC antihistamines (dimenhydrinate. Sometimes antibiotic treatment is necessary.Infants younger than 6 months with an infection. Some children with special circumstances should be more aggressivelytreated. Children who have an episode of acute otitis media within 30 daysof another episode usually require antibiotic treatment. other bacteria not covered by thisvaccine are now more common causes of acute otitis media. . other cancers. In acuteotitis media. Antibiotic resistance(whenbacteria are no longer killed by certain antibiotics) also changes with time.or immune system problems (such as leukemia.pallor . cleft palate.sweating . Children with repeated ear infections are often referred to anotolaryngologist (a doctor with specialized education in the management and surgery of head and neck problems) for evaluation.

You may also need surgery if your hearing loss or ear discharge does not get better with medicine. A tissue graft may be taken from your own body. Ask your caregiver for more information on the following: o Myringoplasty: This type of surgery uses a tissue graft to cover your torn eardrum. nothing needs to be done since most children outgrow the condition - . You may also need to have a mastoidectomy with your tympanoplasty surgery. A mastoidectomy is removal of infected bone from behind your ear. This is done when the hole in your eardrum is large. A procedure called a mastoidectomy may also be done with a myringoplasty. another person. You may also need the following: Surgery You may need surgery to repair your eardrum and prevent future ear infections. Tympanoplasty: This surgery repairs your torn eardrum and any damage to your inner ear. Your caregiver may clean your ear and put a bandage over it. You may be given antibiotic medicine to treat or prevent infection caused by bacteria (germs). predispose to tubal obstruction. A tympanoplasty also helps prevent chronic ear infections. A mastoidectomy may also help prevent your eardrum from breaking down. or is man-made. o SEROUS OTITIS MEDIA -Known as “glue ears” -Seen most in those children where an immature musculature and repeated upper respiratory tract infections.Management A mild eardrum perforation may heal on its own over time. -The child may develop hearing loss or earache -Examination of the ear will reveal the presence of fluid behind the tympanic membrane -A simple whisper test or an audiogram will confirm the presence of a hearing loss Management If the condition is temporary or intermittent. The medicine may be placed directly in your ear before it is covered with a bandage. an animal. Your eardrum may heal completely within a few weeks to a few months. The hole in your eardrum will be covered with a tissue graft. or does not heal on its own. He may also place a cotton ear plug in your ear to cover the tear.

The efficient transmission of sound is prevented because the stapes cannot vibrate and carry the sound as conducted from the malleus and incus to the inner ear. When the condition is recurrent. a hole is made in the tympanic membrane (myringotomy) and the hole is prevented from healing by inserting a small plastic tube (grommet dottle or stopple) o If the grommet remains unblocked. .Myringoplasty. Management There is no known nonsurgical treatment for otosclerosis.Surgical operation involves taking a piece of fascia from the surface temporalis muscle and the thin tissue is grafted over the perforation. abnormally spongy bone especially around the oval window.- - If severe. the graft may be laid on the inner or outer surface of the tympanic membrane. Amplification with a hearing aid also may help Surgical Management . -Permanent damage is done to the tympanic membrane and to the ossicles and the patient may be very deaf with a large central perforation and persistent discharge. some physicians believe the use of sodium fluoride can mature the abnormal spongy bone growth and prevent the breakdown of the bone tissue. with resulting fixation of the stapes.An attempt is made to remove any source of infection in the nose or nasopharynx and the local discharge can be controlled by regular irrigation and instillation of ear drops.Tympanoplasty. the hearing is normal.Any loss of ossicular continuity can be corrected by repositioning a damaged ossicle or by replacing it with a piece of bone or prosthesis ORTOSCLEROSIS Involves the stapes and is thought to result from the formation of new. Management . However. . large tubes is inserted to aerate the middle ear. Any underlying cause(sinusitis or enlarged adenoids is treated) CHRONIC OTITIS MEDIA -A condition when a middle ear infection becomes persistent.

Sodium and fluid retention disrupts the delicate balance between endolymph and perilymph in the inner ear. . Antiemetics such as promethazine suppositories help control the nausea and vomiting and the vertigo because of their antihistamine effect. The prosthesis bridges the gap between the incus and the inner ear. MENIERE’s DISEASE . the stapedectomy or the stapedotomy. Pharmacologic Therapy Pharmacologic Therapy for Meniere’s Disease consists of antihistamines such as meclizine (Antivert). The surgeon drills a small hole into the footplate to hold a prosthesis. providing better sound conduction. Management Most patients with Meniere’s Disease can be successfully treated with diet and medication. The ampunt of sodium is one of many factors that regulate the balance of fluid within the body. Balance disturbance or true vertigo. Stapes surgery is very successful approximately 95% of patients experience resolution of conductive hearing loss. A stapedectomy involves removing the stapes superstructure and part of the footplate and inserting a tissue graft and a suitable prosthesis. Surgical Management o Endolympathic Decompression This procedure is favoured by many otolaryngologists as a first line surgical approach to treat the vertigo of Meniere’s disease because it is relatively simple and safe and can be performed on an outpatient basis. Diuretic therapy may relieve symptoms by lowering the pressure in the endolymphatic system. Intake of foods containing potassium is necessary if the patient takes a diuretic that causes potassium loss. which rarely occurs in other middle ear surgical procedures. Tranquilizers such as diazepam may be used in acute instances to help control vertigo.An abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolympathic duct.One of two surgical procedures may be performed. may occur during the postoperative period for several days. Many patients can control their symptoms by adhering to a lowsodium (2000mg/day) diet. which suppress the vestibular system.

rubella. Manifestations Labyrinthitis is characterized by a sudden onset of incapacitating vertigo. The infection can enter the inner ear by penetrating the membranes of the oval or round windows. Ramsay Hunt syndrome) also cause labyrinthitis. bacterial labyrinthitis usually occurs as a complication of otitis media. various degrees of hearing loss. LABYRINTHISTIS . subsequent attacks. The first episode is usually the worst. Future applications may include tinnitus and slowly progressing sensorineural hearing loss. which affects hearing and balance. are less severe. Intratympanic injections of ototoxic medications for round window membrane diffusion can be used to decrease vestibular function. Established surgical techniques can be used for the patient with vertigo who has not responded to medical or physical therapeutic modalities.Is an ear disorder that involves irritation and swelling (inflammation) of the inner ear. usually with nausea and vomiting. and possibly tinnitus. depending on the degree of hearing loss. Viral labyrinthitis is a common medical diagnosis. Viral illnesses of the upper respiratory tract and herpetiform disorders of the facial and acoustic nerves (ie. Causes Although rare because of antibiotic therapy. It can be performed by a translabyrintharine approach or in a manner that can conserve hearing.o Intraotologic Catheters Potential uses of these catheters include treatment for sudden hearing loss and various disorders causing intractable vertigo. . rubeola. The most commonly identified viral causes are mumps. Most patients with incapacitating Meniere’s disease have little or no effective hearing. and influenza. which usually occur over a period of several weeks to months. but little is known about this disorder. o Vestibular Nerve Sectioning Vestibular nerve sectioning provides the greatest success rate in eliminating the attacks of vertigo. Cutting the nerve prevents the brain from receiving input form the semicircular canals.

by a toxin.aminoglycoside and gentamicin o Loop Diuretics . OTOTOXICITY Is damage to the ear (oto-). - - - . fluid replacement. such as meclizine. Treatment of viral labyrinthitis is tailored to the patient’s symptoms.Vertigo .furosemide o Chemotherapeutic agents – cisplatin o NSAIDs – o Others – quinine. and antiemetic medications. ototoxic drugs o Antibiotics . .Tinnitus Management No specific treatment is available. usually arousing from the Schwann cells of the vestibular portion of the 3mm tumor whereas a CT scan with contrat may miss tumors of 2 cm in diameter.Management Treatment of bacterial labyrinthitis includes intravenous antibiotic therapy. ACOUSTIC NEUROMA An acoustic neuroma is a slow-growing. Magnetic resonance imaging with a paramagnetic contrast agent is the imaging study of choice.Hearing loss . but immediate withdrawal of the drug may be warranted in cases where the consequences of doing so are less severe than the consequences of the ototoxicity. Most acoustic tumors arise within the internal auditory canal and extend into the cerebellpontine angle to press upon the brainstem. The most common presenting symptoms in patients with an acoustic neuroma are unilateral tinnitus and hearing loss with or without vertigo or balance disturbance. specifically the cochlea or auditory nerve and sometimes the vestibular system. and administration of a vestibular suppressant. aspirin Manifestations . benign tumor of cranial nerve VIII. Surgical removal of acoustic tumors is the treatment of choice. Computed tomography scan with contrast dye maybe also performed.It is commonly medication-induced. An MRI with contrast should identify a 2.

Spare parts should also be available. amplified and reconverted to acoustic signals. The transmitter is usually worn behind the ear of in the frame of the eyeglasses. are received by a microphone. - . both speech and environment. if necessary) in soap and water and the cannula is cleansed with a small applicator or pipe cleaner. A hearing aid makes sounds louder. The ear mold.HEARING AIDS A hearing aid is an instrument through which sounds. Common medical problems among wearers of hearing aids are otitis externa and pressure ulcers in the external auditory canal or meatus. but it does not faithfully reproduce the sounds nor does it improve a patient’s ability to discriminate words or understand speech. the only part of the instrument that may be washed. is washed frequently (daily. Caring of the Hearing Aid A hearing aid must be cared for carefully. converted to electrical signals. and the wearer should know how to do so as well as what to do it the aid fails. The ear mold must be dry before it is snapped into the receiver.

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