LMMU

ENT CONDTIONS

Conditions of the Ear

Sophai [Link] MSN BSN RN
 INTRODUCTION
• The ear is one of the special sense organs. It is the
organ of sense of hearing. It is divided into three
sections: the external ear, the middle and the inner
ear.
• The external and middle ear are primarily involved
with transmission of sound.
• The inner ear contains the organ of hearing as well as
structures concerned with body balance.
• Disorders of the middle and inner ear cause
problems, such as dizziness, vertigo and ataxia and
loss of balance. These can lead to falls and accidental
injuries.
 REVIEW OF ANATOMY AND PHYSIOLOGY OF THE
MIDDLE EAR
The middle ear is ventilated by the Eustachian tube,
which communicates with the nasopharynx. It
contains small bones called auditory ossicles (bones).
The auditory ossicles are:
• The malleus (hammer).
• The incus (anvile).
• The stapes (stirrup)
The first of these, the malleus is attached to the
tympanic membrane while the stapes attaches to the
oval window; the incus links the malleus and the
stapes.
 CONT’
• The tympanic membrane separates the
middle ear from the inner ear.
• The ossicles pass on sound vibrations received
by the tympanic membrane to the inner ear.
• The malleus transmits these vibrations to the
incus and the incus to the stapes.
• From the stapes, the sound vibrations are
transmitted to the oval window, finally to the
fluid in the middle ear.
Structure of the ear
 CONDITIONS OF THE EXTERNAL
EAR
TRAUMA
• Which can cause injury to the subcutaneous
tissue resulting into a hematoma. If
hematoma is not aspirated, it can result into
perichondritis -inflammation of the ear
cartilage.
• Blows to the external ear can result into
conductive hearing loss if there is perforation
of the tympanic membrane.
 EXTERNAL OTITIS MEDIA
• Inflammation of the auricle and external ear
canal. It is mostly caused by bacteria such as
staphylococcus aureas, pseudomonas,
Escherichia Coli.
Common presenting signs
• Otalgia (Pain)
• Purulent discharge in severe cases
• Impaired hearing due to swelling and obstruction
• Tinnitus, Vertigo
• Elevated temperature
 Diagnosis
• History and physical examination
• Otoscopic examination
• Culture and sensitivity
 Collaborative Care

• Administer analgesics depending on severity of pain

• Clean the ear canal three times a day
• Administer Otic drops (ear drops)- ege gentamycin,
chloramphenical ear drops, which should be at room
temperature, the tip should not touch the ear.
• During administration, position the ear so that the
drop can run down the canal. Patient should
maintain the same position for at least two minutes
to allow dispersion of the drops.
CONDITIONS OF THE MIDDLE EAR

PERFORATION TYMPANIC MEMBRANE

• DEFINITION
“This is the puncturing or tearing of the
eardrum usually caused by trauma or
infections.”(Berkow, 1997)
 CAUSES
Trauma
• Skull fracture
• Explosive injury
• Severe blow to the ear
• Foreign objects
Infection
• Otitis media
• Barotitis media-an inflammation of the ear caused by
changes in atmospheric pressure
 MEDICAL MANAGEMENT
Assessment
• History of Presenting-problem . Patient may
complain of impaired Hearing, or pain
• Then you conduct a symptom analysis
Physical examination
• Inspection/Observation
• Discharge/drainage
• Otoscopy
 Management
• Medical
• Eardrops- eg gentamycin ear drop for infection
• Antibiotics for prophylaxis
• Surgical
• Tympanoplasty
 OTITIS MEDIA
• Acute Otitis Media is a bacterial or viral infection of the
middle ear” (Berkow etal,1997)
• “Serous Otitis Media (middle ear effusion) is the
accumulation of serous fluid in the middle ear’ (Smeltzer etal,
2004)
• “Secretory Otitis Media is the accumulation of amber,or
grayish fluid in the middle ear, probably in response to an
allergy” (Luckmann et al, 1997)
• “Suppurative Otitis Media is an infection of the middle ear
caused by pus producing bacteria that are trapped in the
middle ear” (Luckmann et al, 1997)
 DEFINITION OT OTITIS MEDIA

Otitis Media:
• This is the inflammation of the middle ear
caused by various types of bacteria, (de Wit. S.
C, 1998)
• It is an inflammation of the middle ear that
most often occurs in infants and children but
can occur at any age, (Luckman etal, 1997).
 TYPES OF OTITIS MEDIA
1. Acute Otitis Media
• It is an cute infection of the middle ear, usually
lasting less than 6 weeks.
• The primary cause of acute Otitis Media is
Streptococcus pneumonie, Haemophilus
influenza and other viral infection which enter
the middle ear after eustachian tube
dysfunction caused by obstruction related to
upper respiratory infections, inflammation of
surrounding structures or allergic reactions.
There are two types of acute Otitis Media:
 cont
a) Suppurative Otitis Media
• The suppurative form is caused by conditions
that allow nasopharyngeal flora to reflux
through the Eustachian tube and colonize the
middle ear, such as respiratory tract infection
and allergic reaction.
• Suppurative Otitis media usually results from
infection with pneumococci, Haemophilus
influenza, and other microrganisms
organisms.
 cont
• Predisposing factors include the normally
wider, shorter, more horizontal Eustachian
tubes in children as well as anatomical
anomalies.
• Chronic suppurative Otitis media results from
inadequate treatment of acute otitis episodes
or from infection by resistant strains of
bacteria.
 cont
b) Secretory Otitis Media.
• Obstruction of the Eustachian tube causes
buildup of negative pressure in the middle ear,
promoting transudation of serous fluid from
blood vessels in the middle ear.
• Such effusion may result from Eustachian tube
dysfunction due to viral infection or allergy,
rapid aircraft descent in a person with an
upper respiratory tract infection, or rapid
underwater ascent in scuba diving.
 cont
• It is chraracterised by severe conductive
hearing loss, sensation of fullness in the ear
and popping, crackling or clicking sounds on
swallowing or with jaw movement.
• The patient may echo when he speaks and
may report a vague feeling of top heaviness.
 PATHOPHYSIOLOGY OF ACUTE OTITIS MEDIA
Following entry of micro- organisms into the
middle ear through the Eustachian tube from
the nasal area, there is an inflammatory
reaction of the mucous membranes of the
eustachian tube, characterized by redness and
swelling which lead to obstruction of the
auditory canal.
 cont
As the inflammatory process continues, pus
and exudates form creating unequal pressures
between the pharynx and the middle ear.
Eventually infection spreads to the entire
middle ear.
• The tympanic membrane become inflamed,
may bulge or retract. This can lead to partial,
reduced aeration, increase in pressure and
rupture of the tympanic membrane if
treatment is delayed(Bare B.G & Smeltzer S.C
2004).
 Summary of pathophysiology
• Organism enters middle ear through the
eustachian tube
• Inflamation of the [Link] causing oedema and
blockage
• Formation of pus and exudation with unequal
pressure
• Bulging/retraction of the tympanic membrane
with possible rapture
 Predisposing factors
• Some of the predisposing factors to this
condition are:
• Frequent episodes of upper respiratory tract
infection
• Nasal allergies
• Genetics, in some families children`s
Eustachian tubes tend to be floppy and close
easily
• Craniofacial abnormalities
• Exposure to cigarette smoke
 Clinical Manifestations of Acute Otitis Media
• Ear pain, which may be throbbing in nature in the
affected ear due to the inflammatory process and
pressure.
• Signs of infection such as elevated temperature,
irritability or decreased appetite.
• Hearing loss or decreased hearing, usually
resolves when tympanic membrane mobility is
restored.
• Sensation of fullness in the affected ear
• Lack of response to conversation due to hearing
loss.
• Purulent discharge due to fluid exudates
secondary to inflammatory process.
2. CHRONIC OTITIS MEDIA
• Chronic Otitis Media results from repeated
attacks of Acute Otitis Media which can cause
irreversible tissue pathology and persistent
perforation of the tympanic membrane.
• The infection damages the tympanic
membrane, destroy the ossicles and spread to
the mastoid bone cells.
 Clinical Manifestations of Chronic Otitis Media
• History of repeated ear infections
• Painless otorrhea with foul odour.
• Perforation of the tympanic membrane with
or without ossicular damage,
• Conductive hearing loss, which is more severe.
• Abnormal tympanogram showing a large
volume of perforation.
• Vertigo
 MANAGEMENT THE PATIENT WITH OTITIS MEDIA
HEALTH HISTORY
• When taking specific history of otitis media,
ask the patient the following questions: -
• Opening questions are; How is your hearing?
Have you had any trouble with ears? If any
• Does it involve one or both ears? Did it start
suddenly or gradually?
• What are the associated symptoms ,if any?
 cont
• Ask about complaints of earache or pain in the
ear and associated factors such as fever, sore
throat, cough and concurrent upper
respiratory infection
• Ask about discharge from the ear, especially if
associated with earache or trauma
 PHYSICAL EXAMINATION
• Physical examination includes: -
• Direct observation / inspection
• Check for drainage (otorrhea) as well as the
colour from the ear.
• Observe if the patient can hear i.e. leaning
forward to the communicator, frequent
requests for repetition or lack of response or
speaking louder.
• Observe the gait to detect any problem with
balance.
 INVESTIGATIONS
• To examine the ear canal, the following can be
done: -
• Otoscopy: To visualize the ear canal and
eardrum for integrity.
• Aural speculum with the head mirror: To
visualize the ear canal.
• Tympanogram: To measure the mobility of the
tympanic membrane.
• Ear swab: To isolate the causative
organism(s).
 MEDICAL TREATMENT
The following drugs can be administered as
prescribed:
Systemic antibiotics -according to culture results
e.g. Ampicillin or Amoxicillin.
Topical antibiotics e.g. Gentamycine or
Chloraphenicol eardrops .
Analgesia e.g. Paracetamol or Aspirin.
 SURGICAL INTERVENTION
Tympanoplasty:
• A small plastic tube is inserted into the
middle ear to create an artificial auditory
canal to equalize pressure on both sides of the
eardrum.
Myringotomy:
• Surgical incision of the tympanic membrane
to allow drainage and relieve pressure.
 NURSING PROBLEMS

• Pain in the ear

• Inadequate food intake
• Altered auditory sensory perception
• Impaired verbal communication
• Low self-esteem
 NURSING CARE PLAN
PROBLEM/NEED
• 1. pain in the ear
NURSING DIAGNOSIS
• Pain in the ear related to auditory nerve
disturbances due to infection evidenced by
complaints of pain within the ear.
OBJECTIVE
• To relieve the patient of ear pain and
discomfort within the first 6 hours of
intervention.
 cont
INTERVENTION
• Assess the level of pain and aggravating
factors for baseline data.
• Offer divisional therapy e.g. watching TV at
low volume.
• Apply cold/warm compresses around the
affected ear to soothe and relieve pressure
from the affected area.
 cont
• Encourage bed rest to limit movements which
can induce pain.
• Avoid stooping and lifting heavy things which
increases pressure on the ear,
• Administer prescribed analgesics and
antibiotics
• Monitor and document the patient’s response
to treatment for continuity of care
 cont
EVALUATION
• The patient is relieved of ear pain within the
first 6 hours evidenced by calmness and
peaceful rest
PROBLEM
2. Inadequate food intake
NURSING DIAGNOSIS
• Inability to take adequate food due to fear of
pain when chewing and on swallowing
radiating from the middle ear.
 cont
OBJECTIVE
• To promote good nutrition status and
hydration while in the hospital
INTERVENTION
• Avoid foods that require a lot of chewing
• feed the patient with balanced diet to aid
healing
• Encourage soft foods and swallow gently
slowly to avoid inducing ear pain
 cont
EVALUATION
• The patient is able to take adequate food and
is well hydrated through out treatment period
PROBLEM
3. Impaired verbal communication
NURSING DIAGNOSIS
• Impaired verbal communication related to
hearing problem due to inflammation in the
middle ear.
 cont
OBJECTIVE
• To promote adequate communication and
improved hearing within 3 days.
INTERVENTION
• Assess the degree of hearing impairment
• Use alternative method of communication like
use of gestures, sign language, writing notes
or use of a bell.
• Speak clearly without shouting and minimize
background noise which may confuse sound
perception
 cont
EVALUATION
• The patient is able to hear verbal commands
clearly within 3 days evidenced by obeying
verbal instructions.
 POSSIBLE COMPLICATIONS FOLLOWING OTITIS
MEDIA
• Perforation of the tympanic membrane
• Permanent hearing loss
• Scaring of the middle ear due to healing
process or damage to the ossciles
• Delayed speech and language development in
children
• Mastoiditis, meningitis, lateral sinus
thrombosis, or intracranial abscess due to
spread of bacterial infection.
 DISCHARGE PLAN
• Advise the patient to avoid swimming or
getting water in the ears.
• Teach the patient how to use eardrops
• Teach the patient the causes, signs and
symptoms Otitis Media.
• Explain to the patient the dosages,
administration and side effects of any
prescribed medications.
 cont
• Advise the patient to come for follow up care
on the appointment date or to come back
when the problem becomes worse.
• Inform patient that surgery may be needed to
remove the fluid from the ear if infection does
not resolve and restore some degree of
hearing.
• Advise the family members and friends to
speak to the patient audibly without shouting.
 Mastoiditis
It is an inflammation of the Air cells of the mastoid
bones cause by mainly by staphylocucus aureu and
Escherichia Coli.
It is usually a complication of repeated untreated otitis
media. (Lewis, etal, 2004)
Clinical manifestations
• Tenderness or Pain behind the ear
• Swelling over the mastoid
• Impaired Hearing
• Ear Discharge in case of accompanying Middle ear
infection
 Diagnosis
• History may reveal repeated episodes of
middle ear infection
• Otoscopic examination may reveal perforated
tympanic membrane
• X ray, MRI and CT scan of the temporal bone
Medical Treatment
• Systemic antibiotic therapy eg Cefotaxine or
ampicillin
 Surgical Therapy
Mastoidectomy
• Surgical operation that aims at removing
diseased tissue from the mastoid process
usually accompanied by tympanoplasty
(eradication of middle disorder and
reconstruction of the hearing mechanism)
 NURSING CARE OF PATIENTS
UNDERGOING SURGERY OF THE EAR
Preoperative Care
• Ensure that any active infection is eradicated
by administering prescribed antibiotics
• Measure Vital signs during the period prior to
surgery to act as baseline data and determine
presence or absence of infection
• Ensure adequate head and ear hygiene
through ear cleaning and head wash
 Cont’
• Perform immediate pre-operative care –
– Obtain an informed consent
– Measure Vital Signs as baseline data
– Label patient by putting an identification band, with
patient’s name, age, sex, type of surgery and surgical site
(Left or right ear)
– Give pre operative instruction ( Avoid any activities that
can cause pressure on the surgical incision or cause
increased middle ear pressure thus disrupting the repair
eg coughing, sneezing, blowing the nose). If the patient
coughs, he she should leave the mouth open to avoid
increased middle ear pressure
 Cont’
– Instruct the patient on what is expected in theatre
and immediately after surgery that they will have
a bandage around the head and vital signs will be
measured at frequent intervals more than usual
• Address any question from the patient
 Post Operative Care for Ear
surgery
• Immediate post op, you measure the vital
signs and compare with pre-op baseline
• Check for amount and type of drainage on the
cotton ball dressing for an endaural incision
• Check the mastoid dressing for any bleeding
• Monitor the tightness of the circular head
bandage and ensure it does not cause excess
pressure on the auricle
 Cont’
• Instruct patient to avoid any activities that can cause
pressure on the surgical incision or cause increased
middle ear pressure thus disrupting the repair eg
coughing, sneezing, blowing the nose. If the patient
coughs, he she should leave the mouth open to avoid
increased middle ear pressure.
• Assist the patient when getting up for the first time
as dizziness and loss of balance may result into falls
• The first mastoid dressing is removed by the surgeon
72 hours after surgery and similarly the first dressing
is done by the surgeon
• Avoid sudden movements that can trigger ear pain
 Cont’
• Patient can take small sips of oral fluids once bowel sounds
return, followed by adequate fluids and usually meal as tolerated,
while avoiding foods that require excessive mastication
• Give IEC on discharge
– Come back for review-Provide written document to remind
patient
– Report any sudden pain, severe drainage of fever which can be
a sign of infection
– Avoid sudden movements at home
– Avoid touching the incision sight to prevent infection
– Take a diet rich in proteins and vitamins to promote healing
– When bathing avoid water from entering the ears
– Avoid cleaning the ears with materials that can cause injury or
infection
 REFERENCES
1. Bare B.G & Smeltzer S.C (2004). Medical-Surgical Nursing,
10th edition, Lippincott Williams & Wilkins, Philadelphia.
2. Bickley S.L & Szilagyi P.G (2009. Guide to Physical
Examination and History Taking, 10th edition, Lippincott
Williams & Wilkins, New Delhi.
3. DeWit, S.C. (1998), Essentials of Medical-Surgical Nursing,
4th Edition, W. B Saunders Company, Philadelphia.
4. Luckman, J. (1997), Saunders manual of Nursing Care, W.B
Saunders Company, Philadelphia.
5. Margaret F.A , Fawcett J. N, Runciman P.J, (2001). Nursing
Practice Hospital and Home, 2rd edit, ChurchHill Livingstone,
Edinburgh.