ASSESSMENT AND MANAGEMENT OF PATIENTS WITH HEARING AND BALANCE DISORDER
FUNCTIONS OF THE MIDDLE EAR
ANATOMY AND PHYSIOLOGY OF THE EAR
FUNCTIONS
• Hearing
• Maintenance
EXTERNAL EAR (PINNA)
• The external ear is embedded in the
temporal bone bilaterally at the level
of the eyes.
• The external ear extends from the
auricle through the external canal to
the tympanic membrane or eardrum.
• The external ear includes the mastoid
process, the bony ridge located over
the temporal bone.
MIDDLE EAR
• The middle ear consists of the medial
side of the tympanic membrane.
• The middle ear contains three bony
ossicles.
o Malleus
o Incus
o Stapes
• Conduct sound vibrations from outer
ear to the central hearing apparatus
in the inner ear
• Protect the inner ear by reducing
the amplitude of loud sounds
• The eustachian tube allows
equalization of air pressure on each
side of the tympanic membrane so
that the membrane does not rupture.
INNER EAR
• The inner ear contains the
semicircular canals, cochlea, and
distal end of the eighth cranial
nerve.
• The semicircular canals contain fluid
and hair cells connected to sensory
nerve fibers of the vestibular
portion of the eighth cranial nerve.
• The inner ear maintains sense of
balance or equilibrium.
• The cochlea is the spiral-shaped
organ of hearing.
• The organ of Corti (within the
cochlea) is the receptor and organ
of hearing.
• Eighth cranial nerve
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o The cochlear branch of the
nerve transmits neuroimpulses
from the cochlea to the brain,
where they are interpreted as
sound.
o The vestibular branch
maintains balance and
equilibrium.
HEARING AND EQUILIBRIUM
• The external ear conducts sound
waves to the middle ear.
• The middle ear, also called the
tympanic cavity, conducts sound
waves to the inner ear.
• The middle ear is filled with air,
which is kept at atmospheric
pressure by the opening of the
eustachian tube.
• The inner ear contains sensory
receptors for sound and for
equilibrium.
• The receptors in the inner ear
transmit sound waves and changes in
body position to the nerve impulses.
ASSESSMENT OF THE EAR
OTOSCOPIC EXAMINATION
1. The speculum is never introduced
blindly into the external canal
because of the risk of perforating
the tympanic membrane.
2. The client's head is tilted slightly
away and the otoscope is held upside
down as if it were a large pen; this
permits the examiner's hand to lay
against the client's head for
support.
3. Pull the pinna up and back to
straighten the external canal in an
adult.
4. Visualize the external canal while
slowly inserting the speculum
5. The normal external canal is pink
and intact, without lesions and with
varying amounts of cerumen and
fine little hairs.
6. Assess the tympanic membrane for
intactness; the normal tympanic
membrane is intact, without
perforations, and should be free
from lesions.
7. The tympanic membrane is
transparent, opaque, pearly gray,
and slightly concave.
AUDITORY ASSESSMENT
1. Sound is transmitted by air
conduction and bone conduction.
2. Air conduction takes two or three
times longer than bone conduction.
3. Hearing loss is categorized as
conductive, sensorineura l, and
mixed conductive and sensorineural.
4. Conductive hearing loss is caused by
any physical obstruction to the
transmission of sound waves.
5. Sensorineural hearing loss is caused
by a defect in the cochlea, eighth
cranial nerve, or the brain itself.
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 6. A mixed conductive-sensorineural
hearing loss results in profound
hearing loss.
VOICE TEST
1. Ask the client to block one external
canal.
2. The examiner stands 1 to 2 feet
away and whispers a statement.
3. Client is asked to repeat the
whispered statement.
4. Each ear is tested separately.
WATCH TEST
1. A ticking watch is used to test for
high-frequency sounds.
2. The examiner holds a ticking watch
about 5 inches from each ear and
asks the client if the ticking is
heard.
TUNING FORK TEST (WEBER’S TUNING
FORK TEST)
1. Place the vibrating tuning fork stem
in the middle of the client's head, at
the midline of the forehead, or
above the upper lip over the teeth.
2. Hold the fork by the stem only.
3. The client is asked whether the
sound is heard equally in both ears
or whether the sound is louder in
one ear.
4. Normal test result is hearing the
sound equally in both ears.
5. If the client hears the sound louder
in one ear, the term
6. lateralization is applied to the side
that hears the loudest.
7. Such a finding may indicate that the
client has a conductive hearing loss
in the ear to which the sound is
lateralized or that sensorineural
hearing loss has occurred in the
opposite ear.
TUNING FORK TEST (RINNE TUNING FORK
TEST)
1. The test compares the client's
hearing by air conduction and bone
conduction.
2. Air conduction is two or three times
longer than bone conduction.
3. The vibrating tuning fork stem is
placed on the client's mastoid
process and the client is asked to
indicate when he or she no longer
hears the sound.
4. The examiner quickly brings the
tuning fork in front of the pinna
without touching the client and asks
the client to indicate whether he or
she still hears the sound.
5. The client normally continues to hear
the sound two times longer in front
of the pinna; such results are a
positive Rinne test.
6. The examiner records the duration
of both phases, bone conduction
followed by air conduction, and
compares the times.
7. If the client is unable to hear the
sound through the ear in front of
the pinna, the client may have a
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 conductive hearing loss on the side
tested; in this situation, the bone
conduction is greater than the air
conduction (negative Rinne test).
8. Both the Rinne test and the Weber
tuning fork test are limited in
distinguishing between conductive
and sensorineural hearing losses.
VESTIBULAR ASSESSMENT (TEST FOR
FALLING)
1. The examiner asks the client to
stand with the feet together, arms
hanging loosely at the side, and eyes
closed.
2. The client normally remains erect
with only slight swaying.
3. A significant sway is a positive
Romberg sign.
VESTIBULAR ASSESSMENT (TEST FOR
FAST POINTING)
1. The client sits in front of the
examiner.
2. The client closes the eyes and
extends the arms in front, pointing
both index fingers at the examiner
3. The examiner holds and touches his
or her own extended index fingers
under the client's extended index
fingers to give the client a point of
reference.
4. The client is instructed to raise both
arms and then lower them, attempting
to return to the examiner's extended
index fingers.
5. The normal test response is that the
client can easily return to the point
of reference.
6. The client with a vestibular function
problem lacks a normal sense of
position and cannot return the
extended fingers to the point of
reference; instead, the fingers
deviate to the right or left of the
reference point.
VESTIBULAR ASSESSMENT (GAZE
NYSTAGMUS EVALUATION)
1. The client's eyes are examined as
the client looks straight ahead, 30
degrees to each side, upward and
downward.
2. Any spontaneous nystagmus—an
involuntary, rhythmic, rapid
twitching of the eyeballs—
represents a problem with the
vestibular system.
HALLPIKE'S MANEUVER
1. Assesses for positional vertigo or
induced dizziness.
2. The client assumes a supine position.
3. The head is rotated to one side for
1 minute.
4. A positive test results in nystagmus
after 5 to 10 second
DIAGNOSTIC TESTS FOR THE EAR
TOMOGRAPHY DESCRIPTION
• Tomography may be performed with
or without contrast medium.
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 • Tomography assesses the mastoid,
middle ear, and inner ear structures.
• Multiple radiographs of the head are
obtained.
• Tomography is especially helpful in
the diagnosis of acoustic tumors.
INTERVENTIONS
1. All jewelry is removed.
2. Lead eye shields are used to cover
the cornea to diminish the radiation
dose to the eyes.
3. The client must remain still in a
supine position.
4. No follow-up care is required.
AUDIOMETRY DESCRIPTION
• Audiometry measures hearing acuity.
• Audiometry uses two types, pure tone
audiometry and speech audiometry.
• Pure tone audiometry is used to
identify problems with hearing,
speech, music, and other sounds in
the environment.
• In speech audiometry, the client's
ability to hear spoken words is
measured.
• After testing, audiographic patterns
are depicted on a graph to
determine the type and level of the
hearing loss.
• Interventions
INTERVENTION
1. Inform the client regarding the
procedure.
2. Instruct the client to identify the
sounds as they are heard.
ELECTRONYSTAGMOGRAPHY (ENG)
DESCRIPTION
• Electronystagmography is a
vestibular test that evaluates
spontaneous and induced eye
movements known as nystagmus.
• ENG is used to distinguish between
normal nystagmus and medication-
induced nystagmus, or nystagmus
caused by a lesion in the central or
peripheral vestibular pathway.
• ENG records changing electrical
fields with the movement of the eye,
as monitored by electrodes placed
on the skin around the eye.
INTERVENTIONS
1. The client is instructed to remain
NPO for 3 hours before testing,
avoiding caffeine-containing
beverages for 24 to 48 hours before
the test.
2. Unnecessary medications are
withheld for 24 hours before testing.
3. Instruct the client that this is a long
and tiring procedure.
4. The client should bring prescription
eyeglasses to the examination.
5. The client sits and is instructed to
gaze at lights, focus on a moving
pattern, focus on a moving point,
and then close the eyes.
6. While sitting in a chair, the client
may be rotated to provide
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 information about vestibular
function.
7. In addition, the client's ears are
irrigated with cool and warm water,
which may cause nausea and
vomiting.
8. Following the procedure, the client
begins taking clear fluids slowly and
cautiously because nausea and
vomiting may occur.
9. Assistance with ambulation may also
be necessary following the
procedure.
DISORDERS OF THE EAR
RISK FACTORS RELATED TO EAR DISORDERS
• Aging process
• Infection
• Medications
• Ototoxicity
• Trauma
CONDUCTIVE HEARING LOSS
• Conductive hearing loss occurs when
sound waves are blocked to the
inner ear fibers because of
external or middle ear disorders.
• Disorders often can be corrected
with no damage to hearing or minimal
permanent hearing loss.
CAUSES
1. Any inflammatory process or
obstruction of the external or middle
ear
2. Tumors
3. Otosclerosis
4. A buildup of scar tissue on the
ossicles from previous middle ear
surgery
SENSORINEURAL HEARING LOSS
• Sensorineural hearing loss is a
pathological process of the inner
ear or of the sensory fibers that
lead to the cerebral cortex.
• Sensorineural hearing loss is often
permanent, and measures must be
taken to reduce further damage or
to attempt to amplify sound as a
means of improving hearing to some
degree.
CAUSES
1. Damage to the inner ear structures
2. Damage to the eighth cranial nerve
3. Prolonged exposure to loud noise
4. Medications
5. Trauma
6. Inherited disorders
7. Metabolic and circulatory disorders
8. Infections
9. Surgery
10. Menière's syndrome
11. Diabetes mellitus
12. Myxedema
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 MIXED HEARING LOSS
• Mixed hearing loss also is known as
conductive-sensorineural hearing
loss.
• Client has sensorineural and
conductive hearing loss.
SIGNS OF HEARING LOSS
1. Frequently asking others to repeat
statements Straining to hear
2. Turning head or leaning forward to
favor one ear Shouting in
conversation
3. Ringing in the ears
4. Failing to respond when not looking
in the direction of the sound
Answering questions incorrectly
5. Raising the volume of the television
or radio Avoiding large groups
6. Better understanding of speech
when in small groups
7. Withdrawing from social interactions.
FACILITATION OF COMMUNICATION
1. Using written words if the client is
able to see, read, and write
Providing plenty of light in the room
2. Getting the attention of the client
before beginning to speak
3. Facing the client when speaking
4. Talking in a room without distracting
noises
5. Moving close to the client and
speaking slowly and clearly
6. Keeping hands and other objects
away from the mouth when talking to
the client
7. Talking in normal volume and at a
lower pitch because shouting is not
helpful and higher frequencies are
less easily heard
8. Rephrasing sentences and repeating
information
9. Validating with the client the
understanding of statements made by
asking the client to repeat what was
said
10. Reading lips
11. Encouraging the client to wear
glasses when talking to someone to
improve vision for lip reading
12. Using sign language, which combines
speech with hand movements that
signify letters, words, or phrases
13. Using telephone amplifiers
14. Flashing lights that are activated by
ringing of the telephone or doorbell
15. Specially trained dogs that help the
client be aware of sound and alert
the client to potential danger.
COCHLEAR IMPLANTATION
• Cochlear implants are used for
sensorineural hearing loss.
• A small computer converts sound
waves into electrical impulses.
• Electrodes are placed by the
internal ear with a computer device
attached to the external ear.
• Electronic impulses directly stimulate
nerve fibers.
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HEARING AIDS
• Hearing aids are used for the client
with conductive hearing loss.
• Hearing aids can help the client with
sensorineural hearing loss, although
they are not as effective.
• A difficulty that exists in the use of
hearing aids is the amplification of
background noise and voices.
• Client education
CLIENT EDUCATION REGARDING A HEARING
AID
1. Encourage the client to begin
using the hearing aid slowly to
adjust to the device.
2. Adjust the volume to the minimal
hearing level to prevent feedback
ASSESSMENT
squeaking.
3. Teach the client to concentrate on
the sounds that are to be heard and
to filter out background noise.
4. Instruct the client to clean the ear
mold with mild soap and water.
5. Avoid excessive wetting of the
hearing aid and try to keep the
hearing aid dry.
6. Clean the ear cannula of the
hearing aid with a toothpick or pipe
cleaner. Turn off the hearing aid
and remove the battery when not in
use.
7. Keep extra batteries on hand.
8. Keep the hearing aid in a safe
place.
9. Prevent hair sprays, oils, or other
hair and face products from coming
into contact with the receiver of the
hearing aid.
PRESBYCUSIS
• Presbycusis is a sensorineural
hearing loss associated with aging.
• Presbycusis leads to degeneration or
atrophy of the ganglion cells in the
cochlea and a loss of elasticity of
the basilar membranes.
• Presbycusis leads to compromise of
the vascular supply to the inner ear,
with changes in several areas of the
ear structure.
1. Hearing loss is gradual and bilateral.
2. Client states that he or she has no
problem with hearing but cannot
understand what the words are.
3. Client thinks that the speaker is
mumbling.
EXTERNAL OTITIS
• External otitis is an infective
inflammatory or allergic response
involving the structure of the
external auditory canal or auricles.
• An irritating or infective agent
comes into contact with the epithelial
layer of the external ear.
• Contact leads to an allergic
8
 response or signs and symptoms of
an infection.
• The skin becomes red, swollen, and
tender to touch on movement.
• The extensive swelling of the canal
can lead to conductive hearing loss
because of obstruction.
• External otitis is more common in
children; it is termed swimmer's ear
and occurs more often in hot, humid
environments.
• Prevention includes the elimination
of irritating or infecting agents.
ASSESSMENT
1. Pain
2. Itching
3. Plugged feeling in the ear
4. Redness and edema
5. Exudate
6. Hearing loss
INTERVENTIONS
1. Apply heat locally for 20 minutes
three times a day.
2. Encourage rest to assist in reducing
pain.
3. Administer antibiotics or
corticosteroids as prescribed.
4. Administer analgesics such as aspirin
or acetaminophen (Tylenol) for the
pain as prescribed.
5. Instruct the client that the ears
should be kept clean and dry.
6. Instruct the client to use earplugs
for swimming.
7. Instruct the client that cotton-tipped
applicators should not be used in
dry ears because their use can lead
to trauma to the canal.
8. Instruct the client that irritating
agents such as hair products or
headphones should be discontinued.
OTITIS MEDIA
• Otitis media is an inflammatory
disorder usually caused by an
infection of the middle ear
occurring as a result of a blocked
eustachian tube, which prevents
normal drainage.
• Otitis media is a common complication
of an acute respiratory infection.
• Infants and children are more prone
to otitis media because their
eustachian tubes are shorter, wider,
and straighter.
ASSESSMENT
1. Fever
2. Irritability and restlessness
3. Loss of appetite
4. Rolling of head from side to side
5. Pulling on or rubbing the ear
6. Earache or pain
7. Signs of hearing loss
8. Purulent ear drainage
9. Red, opaque, bulging, or retracting
tympanic membrane
9
INTERVETIONS
1. Encourage fluid intake.
2. Teach the parents to feed infants in
upright position, to prevent reflux.
3. Instruct the child to avoid chewing
as much as possible during the acute
period because chewing increases
pain.
4. Provide local heat and have the
child lie with the affected ear down.
5. Instruct the parents in the
appropriate procedure to clean
drainage from the ear with sterile
cotton swabs.
6. Instruct the parents in the
administration of analgesics or
antipyretics such as acetaminophen
(Tylenol) to decrease fever and
pain.
7. Instruct the parents in the
administration of the prescribed
antibiotics, emphasizing that the 10-
to 14-day period is necessary to
eradicate infective organisms.
8. Instruct the parents that screening
for hearing loss may be necessary.
9. Instruct the parents about the
procedure for administering ear
medications.
MYRINGONTOMY
• Insertion of tympanoplasty tubes into
the middle ear to equalize pressure
and keep the ear aerated
POSTOPERATIVE INTERVENTIONS
1. Instruct the parents and child to
keep the ears dry
2. The client should wear earplugs
while bathing, shampooing, and
swimming,
3. Diving and submerging under water
are not allowed.
4. Instruct the parents that if the tubes
fall out, it is not an emergency, but
the physician should be notified.
5. Parents can administer an analgesic
such as acetaminophen (Tylenol) to
relieve discomfort following
insertion of tympanoplasty tubes.
6. Parents should be taught that the
child should not blow his or her nose
for 7 to 10 days after surgery.
CLIENT EDUCATION FOLLOWING
MYRINGOTOMY
1. Avoid strenuous activities.
2. Avoid rapid head movements,
bouncing, or bending. Avoid
straining on bowel movement.
3. Avoid drinking through a straw.
Avoid traveling by air.
4. Avoid forceful coughing.
5. Avoid contact with persons with
colds.
6. Avoid washing hair, showering, or
getting the head wet for 1 week as
prescribed.
7. Instruct the client that if he or she
needs to blow the nose, to blow one
side at a time with the mouth open.
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 8. Instruct the client to keep ears dry
by keeping a ball of cotton coated
with petroleum jelly in the ear and to
change the cotton ball daily.
9. Instruct the client to report
excessive ear drainage to the
physician.
CHRONIC OTITIS MEDIA
• Chronic otitis media is a chronic
infective, inflammatory, or allergic
response involving the structure of
the middle ear.
• Surgical treatment is necessary to
restore hearing.
• The type of surgery can vary; it
includes a simple reconstruction of
the tympanic membrane, a
myringoplasty, or replacement of the
ossicles within the middle ear.
• A tympanoplasty, reconstruction of
the middle ear, may be attempted to
improve conductive hearing loss.
PREOPERATIVE INTERVENTIONS
1. Administer antibiotic drops as
prescribed.
2. Clean the ear of debris as
prescribed; irrigate the ear with a
solution of equal parts of vinegar
and sterile water as prescribed to
restore the normal pH of the ear.
3. Instruct the client to avoid persons
with upper respiratory infections.
4. Instruct the client to obtain adequate
rest, eat a balanced diet, and drink
adequate fluids.
5. Instruct the client in deep breathing
and coughing; forceful coughing,
which increases pressure in the
middle ear, is to be avoided
postoperatively.
POSTOPERATIVE INTERVENTIONS
1. Inform the client that initial hearing
after surgery is diminished because
of the packing in the ear canal;
hearing improvement will occur after
the ear canal packing is removed.
2. Keep the dressing clean and dry.
3. Keep the client flat, with the
operative ear up for at least 12
hours.
4. Administer antibiotics as prescribed.
5. Instruct the client that he or she
may return to work in about 3 weeks
postoperatively as prescribed.
MASTOIDIS
• Mastoiditis may be acute or chronic
and results from untreated or
inadequately treated chronic or
acute otitis media.
• The pain is not relieved by
myringotomy.
ASSESSMENT
1. Swelling behind the ear and pain
with minimal movement of the head
2. Cellulitis on the skin or external
scalp over the mastoid process
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 3. A reddened, dull, thick, immobile
tympanic membrane, with or without
perforation
POSTOPERTIVE INTERVENTIONS
4. Tender and enlarged postauricular
lymph nodes
5. Low-grade fever
6. Malaise
7. Anorexia
INTERVENTIONS
1. Prepare the client for surgical
removal of infected material.
2. Monitor for complications.
3. Simple or modified radical
mastoidectomy with tympanoplasty is
the most common treatment.
4. Once tissue that is infected is
removed, the tympanoplasty is
performed to reconstruct the
ossicles and tympanic membranes in
an attempt to restore normal
hearing.
COMPLICATIONS
1. Damage to the abducens and facial
cranial nerves
2. Damage is exhibited by inability to look
laterally (cranial nerve VI, abducens)
and a drooping of the mouth on the
affected side (cranial nerve VII, facial).
3. Meningitis
4. Brain abscess
5. Chronic purulent otitis media
6. Wound infections
7. Vertigo, if the infection spreads into the
labyrinth
1. Monitor for dizziness.
2. Monitor for signs of meningitis, as
evidenced by a stiff neck and
vomiting.
3. Prepare for a wound dressing
change 24 hours postoperatively.
4. Monitor the surgical incision for
edema, drainage, and redness.
5. Position the client flat with the
operative side up.
6. Restrict the client to bed with
bedside commode privileges for 24
hours as prescribed.
7. Assist the client with getting out of
bed to prevent falling or injuries
from dizziness.
8. With reconstruction of the ossicles
via a graft, take precautions to
prevent dislodging of the graft.
OTOSCLEROSIS
• Otosclerosis is a disease of the
labyrinthine capsule of the middle
ear that results in a bony
overgrowth of the tissue
surrounding the ossicles.
• Otosclerosis causes the development
of irregular areas of new bone
formation and causes the fixation of
the bones.
• Stapes fixation leads to a
conductive hearing loss.
• If the disease involves the inner ear,
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 sensorineural hearing loss is
present.
• To have bilateral involvement is not
uncommon, although hearing loss may
be worse in one ear.
• The cause is unknown, although it is
thought to have a familial tendency.
• Nonsurgical intervention promotes
the improvement of hearing through
amplification.
• Surgical intervention involves
removal of the bony growth causing
the hearing loss.
• A partial stapedectomy or complete
stapedectomy with prosthesis
(fenestration) may be performed
surgically.
ASSESSMENT
1. Slowly progressing conductive
hearing loss
2. Bilateral hearing loss
3. A ringing or roaring type of
constant tinnitus
4. Loud sounds heard in the ear when
chewing
5. Pinkish discoloration (Schwartze's
sign) of the tympanic membrane,
which indicates vascular changes
within the ear.
6. Negative Rinne test
7. Weber's test shows lateralization of
sound to the ear with the most
conductive hearing loss.
FENESTRATION
• Fenestration is removal of the
stapes, with a small hole drilled in
the footplate; a prosthesis is
connected between the incus and
footplate.
• Sounds cause the prosthesis to
vibrate in the same manner as the
stapes.
PREOPERATIVE INTERVENTIONS
1. Instruct the client in measures to
prevent middle ear or external ear
infections.
2. Instruct the client to avoid excessive
nose blowing.
3. Instruct the client not to clean the
ear canal with cotton-tipped
applicators and to avoid trauma or
injury to the ear canal.
POSTOPERATIVE INTERVENTIONS
1. Inform the client that hearing is
initially worse after the surgical
procedure because of swelling and
that no noticeable improvement in
hearing may occur for as long as 6
weeks.
2. Inform the client that the Gelfoam
ear packing interferes with hearing
but is used to decrease bleeding.
3. Assist with ambulating during the
first 1 to 2 days after surgery.
4. Provide side rails when the client is
in bed.
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5. Administer antibiotic, antivertiginous,
and pain medications as prescribed.
6. Assess for facial nerve damage,
weakness, changes in tactile
sensation and taste sensation,
vertigo, nausea, and vomiting.
7. Instruct the client to move the head
slowly when changing positions to
prevent vertigo.
8. Instruct the client to avoid persons
with upper respiratory tract
infections.
9. Instruct the client to avoid showering
and getting the head and wound wet.
10. Instruct the client to avoid using
small objects (cotton-tipped
applicators) to clean the external
ear canal.
11. Instruct the client to avoid rapid
extreme changes in pressure caused
by quick head movements, sneezing,
nose blowing, straining, and changes
in altitude.
12. Instruct the client to avoid changes
in middle ear pressure because they
could dislodge the graft or
prosthesis.
LABYRINTHITIS
• Infection of the labyrinth that
occurs as a complication of acute or
chronic otitis media
• May result from growth of a
cholesteatoma—benign overgrowth
of squamous cell epithelium
ASSESSMENT
1. Hearing loss that may be permanent
on the affected side
2. Tinnitus
3. Spontaneous nystagmus to the
affected side
4. Vertigo
5. Nausea and vomiting
INTERVENTIONS
1. Monitor for signs of meningitis, the
most common complication, as
evidenced by headache, stiff neck,
and lethargy.
2. Administer systemic antibiotics as
prescribed.
3. Advise the client to rest in bed in a
darkened room.
4. Administer antiemetics and
antivertiginous medications as
prescribed.
5. Instruct the client that the vertigo
subsides as the inflammation
resolves.
6. Instruct the client that balance
problems that persist may require
gait training through physical
therapy
MENIÈRE'S SYNDROME
• Menière's syndrome is also called
endolymphatic hydrops; it refers to
dilation of the endolymphatic system
by overproduction or decreased
reabsorption of endolymphatic fluid.
• The syndrome is characterized by
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 tinnitus, unilateral sensorineural
hearing loss, and vertigo.
• Symptoms occur in attacks and last
for several days, and the client
becomes totally incapacitated during
the attacks.
• Initial hearing loss is reversible but
as the frequency of attacks
continues, hearing loss becomes
permanent.
• Repeated damage to the cochlea
caused by increased fluid pressure
leads to permanent hearing loss.
CAUSES
1. Any factor that increases
endolymphatic secretion in the
labyrinth
2. Viral and bacterial infections
3. Allergic reactions
4. Biochemical disturbances
5. Vascular disturbance, producing
changes in the microcirculation in
the labyrinth
6. Long-term stress may be a
contributing factor.
ASSESSMENT
1. Feelings of fullness in the ear
2. Tinnitus, as a continuous low-pitched
roar or humming sound, that is
present much of the time but worsens
just before and during severe
attacks
3. Hearing loss that is worse during an
attack
4. Vertigo, as periods of whirling, that
might cause the client to fall to the
ground
5. Vertigo that is so intense that even
while lying down, the client holds the
bed or ground in an attempt to
prevent the whirling
6. Nausea and vomiting
7. Nystagmus
8. Severe headaches
NONSURGICAL INTERVENTIONS
1. Prevent injury during vertigo
attacks.
2. Provide bed rest in a quiet
environment.
3. Provide assistance with walking.
4. Instruct the client to move the head
slowly to prevent worsening of the
vertigo.
5. Initiate sodium and fluid restrictions
as prescribed.
6. Instruct the client to stop smoking.
7. Administer nicotinic acid (niacin) as
prescribed for its vasodilatory
effect.
8. Administer antihistamines as
prescribed to reduce the production
of histamine and the inflammation.
9. Administer antiemetics as prescribed.
10. Administer tranquilizers and
sedatives as prescribed to calm the
client, allow the client to rest, and
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 control vertigo, nausea, and
vomiting.
11. Mild diuretics may be prescribed to
decrease endolymph volume
SURGICAL INTERVENTIONS
1. Surgery is performed when medical
therapy is ineffective and the
functional level of the client has
decreased significantly.
2. Endolymphatic drainage and
insertion of a shunt may be
performed early in the course of
the disease to assist with the
drainage of excess fluids.
3. A resection of the vestibular nerve
or total removal of the labyrinth or
a labyrinthectomy may be
performed.
POSTOPERATIVE INTERVENTIONS
1. Assess packing and dressing on the
ear.
2. Speak to the client on the side of
the unaffected ear.
3. Perform neurological assessments.
4. Maintain side rails.
5. Assist with ambulating.
6. Encourage the client to use a
bedside commode rather than
ambulating to the bathroom.
7. Administer antivertiginous and
antiemetic medications as prescribed.
ACOUSTIC NEUROMA
• Acoustic neuroma is a benign tumor
of the vestibular or acoustic nerve.
• The tumor may cause damage to
hearing and to facial movements and
sensations.
• Treatment includes surgical removal
of the tumor via craniotomy.
• Care is taken to preserve the
function of the facial nerve.
• The tumor rarely recurs after
surgical removal.
• Postoperative nursing care is similar
to postoperative craniotomy care.
ASSESSMENT
1. Symptoms usually begin with tinnitus
and progress to gradual
sensorineural hearing loss.
2. As the tumor enlarges, damage to
adjacent cranial nerves occurs.
TRAUMA
• The tympanic membrane has a limited
stretching ability and gives way
under high pressure.
• Foreign objects placed in the
external canal may exert pressure
on the tympanic membrane and cause
perforation.
• If the object continues through the
canal, the bony structure of the
stapes, incus, and malleus may be
damaged.
• A blunt injury to the basal skull and
ear can damage the middle ear
16
 structures through fractures
extending to the middle ear.
• Excessive nose blowing and rapid
changes of pressure that occur with
nonpressurized air flights can
increase pressure in the middle ear.
• Depending on the damage to the
ossicles, hearing loss may or may not
return.
INTERVENTIONS
1. Tympanic membrane perforations
usually heal within 24 hours.
2. Surgical reconstruction of the
ossicles and tympanic membrane
through tympanoplasty or
myringoplasty may be performed to
improve hearing.
CERUMEN AND FOREIGN BODIES
• Cerumen, or wax, is the most common
cause of impacted canals.
• Foreign bodies can include
vegetables, beads, pencil erasers,
insects, and other objects.
ASSESSMENT
1. Sensation of fullness in
the ear with or without
hearing loss
2. Pain, itching, or bleeding
CERUMEN
• Removal of wax by irrigation is a
slow process.
• Irrigation is contraindicated in
clients with a history of tympanic
membrane perforation or otitis
media.
• To soften cerumen, add three drops
of glycerin or mineral oil to the ear
at bedtime, and three drops of
hydrogen peroxide twice daily as
prescribed.
• After several days, irrigate the ear.
• The maximum amount of solution that
should be used for irrigation is 50 to
70 mL.
FOREIGN BODIES
• With a foreign object of vegetable
matter, irrigation is used with care
because this material expands with
hydration.
• Insects are killed before removal,
unless they can be coaxed out by
flashlight or a humming noise.
• Mineral oil or diluted alcohol is
instilled to suffocate the insect,
which then is removed using ear
forceps.
• Use a small ear forceps to remove
the object and avoid pushing the
object farther into the canal and
damaging the tympanic membrane
17
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care. 5th ed., 2006, W.B. Saunders, Philadelphia

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of clinical problems. 6th ed., 2004, Mosby, St. Louis.

Mosby: In Mosby's expert 10-minute physical examinations. 2nd ed., 2005, Mosby, St. Louis.

1. A 44 year old man has recently been diagnosed with Meniere’s disease. Develop a
teaching plan that focuses on control of the patient’s symptoms. Provide rationale for
each component of the teaching plan.

2. Discuss the strength of evidence that supports specific dietary strategies for
controlling the symptoms of Meniere’s disease.

3. Make a nursing care plan on a patient having ear disorder. Choose at least three
visual disorders as your concept and related problem.

4. A 20 year old man, a member of a college swim team, has recurrent external otitis- his
third episode in the past 6 weeks. He is being treated at an ear-nose- throat clinic.
Devise an evidence- based practice teaching plan for this patient.

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