Chapter 59
Assessment and
Management of Patients
with Hearing and
Balance Disorders
Anatomy of the Ear
Anatomy of the Inner Ear
Bone Conduction Compared With Air
Conduction
Assessment of Hearing and Balance
Inspection of the external ear
Otoscopic examination
Gross auditory acuity
Whisper test
Weber test
Rinne test
Weber Test and Rinne Test
Question #1
What assessment is completed with the Weber test?
A. Air conduction of sound
B. Bone conduction of sound
C. Air and bone conduction of sound
D. Neither air or bone conduction of sound
Answer to Question #1
B. Bone conduction of sound
Rationale: The Weber test assesses bone conduction
of sound. The Rinne test assesses both air and bone
conduction of sound.
Diagnostic Evaluation
Audiometry
Tympanogram
Auditory brainstem response
Electronystagmography
Platform posturography
Sinusoidal harmonic acceleration
Middle ear endoscopy
Hearing Loss
Prevalence increases with age; 50% over the age of 70
(Table 59-2)
Increased incidence with age—presbycusis
Risk factors include exposure to excessive noise levels
Types
o Conductive; caused by external of middle ear
problem
o Sensorineural; caused by damage to the cochlea or
vestibulocochlear nerve
o Mixed; both conductive and sensorineural
o Functional (psychogenic); caused by emotional
problem
Manifestations of Hearing Loss
Early symptoms
o Tinnitus: perception of sound; often “ringing in
the ears”
o Increased inability to hear in a group
o Turning up the volume on the TV
Impairment may be gradual and not recognized by
the person experiencing the loss
As hearing loss increases, person may experience
deterioration of speech, fatigue, indifference, social
isolation or withdrawal, and other symptoms
Guidelines for Communicating with
Hearing Impaired Persons
Determine how the person prefers to communicate
Use a low-tone, normal voice
Speak slowly and distinctly
Reduce background noise and distractions
Face the person and get their attention
Speak into the less impaired ear
Use gestures and facial expressions
If necessary, write out information or obtain a sign
language translator
Conditions of the External Ear #1
Cerumen impaction
o Removal may be by irrigation, suction, or instrumentation
o Gentle irrigation should be used with lowest pressure,
directing stream behind the obstruction. Glycerin, mineral
oil, half-strength H2O2, or peroxide in glyceryl may help
soften cerumen
Foreign bodies
o Removal may be by irrigation, suction, or instrumentation
o Objects that may swell (e.g., vegetables or insects) should
not be irrigated
o Foreign body removal can be dangerous and may require
extraction in the operating room
Conditions of the External Ear #2
External otitis
o Inflammation most commonly caused by bacteria
Staphylococcus or Pseudomonas, or fungal infection from
Aspergillus spp
o Manifestations include pain and tenderness, discharge,
edema, erythema, pruritus, hearing loss, feelings of
fullness in the ear
o Therapy is aimed at reducing discomfort, reducing edema,
and treating the infection
o A wick may be inserted in the canal to keep it open and
facilitate medication administration
Malignant external otitis: rare, progressive infection that affects
the external auditory canal, surrounding tissues, and skull
Question #2
Is the following statement true or false?
Otalgia is a sensation of fullness or pain in the ear.
Answer to Question #2
True
Rationale: Otalgia is a sensation of fullness or pain in
the ear and can occur with or without hearing loss.
When occurring with acute otitis externa the pain may
be persistent and awaken the patient at night. When
occurring with acute otitis media the pain may be
relieved if the tympanic membrane ruptures.
Conditions of the Middle Ear #1
Tympanic membrane perforation
Acute otitis media
o Most frequently seen in children
o Pathogens are most commonly bacterial or viral
o Manifestations include otalgia (ear pain), fever,
and hearing loss
o Treatment
Antibiotic therapy
Myringotomy or tympanotomy
Conditions of the Middle Ear #2
Serous otitis media: fluid in the middle ear without
evidence of infection
Chronic otitis media
o Result of recurrent acute otitis media
o Chronic infection damages the tympanic
membrane, ossicle, and involves the mastoid
o Treatment
Prevent by treatment of acute otitis
Tympanoplasty, ossiculoplasty, or
mastoidectomy
Middle Ear Surgical Procedures
Tympanoplasty
o Reconstruction of the tympanic membrane
Ossiculoplasty
o Reconstruction of the bones of the middle ear
o Prostheses are used to reconnect the ossicles to
reestablish sound conduction
Mastoidectomy
o Removal of diseased bone, mastoid air cells, and
cholesteatoma to create a noninfected, healthy ear
o Cholesteatoma: benign tumor, an ingrowth of skin that
causes persistently high pressure in the middle ear, which
causes hearing loss and neurologic disorders and destroys
structures
Stapedectomy for Otosclerosis
Otosclerosis is most often caused when one of the bones in the middle ear, the stapes,
becomes stuck in place. When this bone is unable to vibrate, sound is unable to travel
Assessment of the Patient Undergoing
Mastoid Surgery
Health history
Include data related to the ear disorder, hearing
loss, otalgia, otorrhea, and vertigo
Duration and intensity, causes, and previous
treatments
Medications
Physical assessment
o Erythema, edema, lesions
o Discharge; color and odor
o Review audiogram results
Planning and Goals for the Patient
Undergoing Mastoid Surgery
Major goals include:
o Reduction of anxiety
o Freedom from pain and discomfort
o Prevention of infection
o Stable or improved hearing and communication
o Absence of vertigo and injury
o Increased knowledge of disease, surgical
procedure and postop care
Nursing Interventions for the Patient
Undergoing Mastoid Surgery #1
Reduction of anxiety
o Reinforce information and patient education
o Provide support and allow to discuss anxieties
Relieving pain
o Medicate with analgesics for ear discomfort
o Note: Occasional sharp, shooting pans may occur as the
eustachian tube opens and allows air into the middle ear.
Constant throbbing pain and fever may indicate infection
Preventing injury
o Safety measures such as assisting with ambulation
o Provide antiemetics or antivertigo medications
Nursing Interventions for the Patient
Undergoing Mastoid Surgery #2
Improving communication and hearing
o Note: Hearing may reduce for several weeks after surgery
because of edema, accumulation of blood and fluid in the
middle ear, and dressings and packings
o Use measures to improve hearing and communication as
discussed in “Communicating with Hearing Impaired
Persons.”
Preventing infection
o Monitor for signs and symptoms of infection
o Administer antibiotics as ordered
o Prevent contamination of ear with water from showers,
washing hair, and so on
Patient Education for the Patient
Undergoing Mastoid Surgery
Medication education: analgesics, antivertigo
medications
Activity restrictions
Safety issues related to potential vertigo
Instruction regarding potential complications and
reporting of problems
Follow-up care
Question #3
What patient education for post mastoid surgery
would be incorrect?
A. Avoid getting water in the ear
B. Constant throbbing pain may be a sign of infection
C. Call for assistance to ambulate to prevent injury
D. There are no activity restrictions after this
procedure
Answer to Question #3
D. There are no activity restrictions after this
procedure
Rationale: Patients should be taught to avoid getting
water in the ear to prevent injury and potential
infection. A constant throbbing pain may be a sign of
infection. Patients should call for assistance to get up
to prevent injury in case the patient experiences
vertigo. There are activity restrictions after this
procedure. Patients should be taught to only blow one
side of nose at a time and avoid lifting and straining to
prevent pressure changes within the ear that might
damage the surgical intervention.
Conditions of the Inner Ear #1
Disorders of the vestibular system may increase the
risk of falls
Dizziness: any altered sense of orientation in space
Vertigo: the illusion of motion or a spinning
sensation
Nystagmus: involuntary rhythmic movement of the
eyes associated with vestibular dysfunction
Conditions of the Inner Ear #2
Tinnitus
Labyrinthitis
Benign positional vertigo (BBPV)
Ototoxicity
Acoustic neuroma: tumor of the VIII cranial nerve
Ménière Disease
Abnormal inner ear fluid balance cause by malabsorption of the
endolymphatic sac or blockage of the endolymphatic duct
Manifestations include triad of symptoms: episodic vertigo,
tinnitus, and fluctuating sensorineural hearing loss. Feeling of
pressure, nausea and vomiting
Treatment
o Low-sodium diet; 1000 to 1500 mg/day
o Meclizine (Antivert); tranquilizers—valium, antiemetics—
promethazine, and diuretics may also be used
o Surgical management to eliminate attacks of vertigo;
endolymphatic sac decompression, middle and inner ear
perfusion, and vestibular nerve sectioning
Question #4
Is the following statement true or false?
A cochlear implant is an auditory prosthesis used for
people with profound sensorineural hearing loss
bilaterally who do not benefit from conventional
hearing aids.
Answer to Question #4
True
Rationale: A cochlear implant is an auditory prosthesis
used for people with profound sensorineural hearing
loss bilaterally who do not benefit from conventional
hearing aids.
