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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 ( impacted cerumen, otitis externa) ↓↓↓ 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 Middle ear conditions trauma, otitis media, otosclerosis tumors Eustachian tube dysfunctions
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 indication 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 Canal & pruritus Probing of the external auditory canal infec↓ Skin breakdown tious agents | | ↓ | Entry of infectious agents < ---------------------------↓ Inflammation & infection of an external ear PF: increased humidity Increased temperature (living in tropical areas) contact ↓ 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 ↓ Dermatitis, psoriasis) ↓ Pf: use of cotton swabs use of hearing aids dermatologic conditions (eczema, seborrhea, ear canal growth of
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. 2. 3. 4. Acute and chronic mastoiditis Cholesteatoma CNS infection (meningitis, intracranial abscess) 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 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 honeycomblike 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
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.
ENG with caloric and doll’s eye testing to differentiate 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 symptomatic 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. 2. 3. 4. Keep diet light while vertigo is present. Administer antiemetics as directed. Assess intake and output as indicated. 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 (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
5. 6. 7. 8.
Headache, nausea, vomiting and incoordination are present. Sudden motion of the head may precipitate vomiting. History often reveals ear trouble, vasomotor rhinitis, and allergies. Irritability;other personality changes. 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 cellsorgan 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.
- 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.
viral upper respiratory infection / nasal allergy ↓
↓ 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, nonallergic 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 Allergic rhinitis-IgE-mediated response causing release of vasoactive substances from mast cells Non-allergic rhinitis Infectious-viral (common cold) and bacterial (purulent) Drug-induced (rebound rhinitis; rhinitis medicamentosa)-caused by excessive use of topical nasal decongestants Vasomotor rhinitis-unexplained automatic nasal dysfunction as a result of overactivity of the parasympathetic nerve supply to the mucous membranes of the nose and paranasal sinuses Rhinitis of pregnancy-nasal congestion resulting from estrogen-mediated mucosal engorgement.
2. 3. 4. 5.
CLINICAL MANIFESTATIONS 1. Hypersecretion-wet, running/dripping nose or postnasal 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.
-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 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 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 hypertrophied Turbinates (Infection/Allergens) (Chronic rhinitis) ↓ ↓ swelling of nasal hypertrophy of mucous membrane nasal concha Nasal polyps
(congenital) ↓ Deflection from the midline in the 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 xrays 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