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5 Assessing Ears

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22 views18 pages

5 Assessing Ears

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© © All Rights Reserved
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You are on page 1/ 18

CHAPTER 17

Assessing Ears

Case Study • Cone of light—the reflection of the otoscope light seen as a


cone due to the concave nature of the membrane
Andrea Lopez, a 47-year-old elemen- • Pars flaccida—the top portion of the membrane that
tary school teacher, comes to the clinic appears to be less taut than the bottom portion
reporting fever and right earache for the • Pars tensa—the bottom of the membrane that appears to be
past 2 days. She states, “My students have taut
been sick a lot and I think I may have
caught something.” Middle Ear
The middle ear, or tympanic cavity, is a small, air-filled chamber
in the temporal bone. It is separated from the external ear by
the eardrum and from the inner ear by a bony partition contain-
ing two openings, the round and oval windows. The middle ear
Structure and Function contains three auditory ossicles: the malleus, the incus, and the
stapes (Fig. 17-1). These tiny bones are responsible for transmit-
The ear is the sense organ of hearing and equilibrium. It consists ting sound waves from the eardrum to the inner ear through the
of three distinct parts: the external ear, the middle ear, and the inner oval window. Air pressure is equalized on both sides of the tym-
ear. The tympanic membrane separates the external ear from the panic membrane by means of the eustachian tube, which con-
middle ear. Both the external ear and the tympanic membrane nects the middle ear to the nasopharynx (Fig. 17-1).
can be assessed by direct inspection and by using an otoscope.
The middle and inner ear cannot be directly inspected. Instead,
Inner Ear
testing hearing acuity and the conduction of sound assesses The inner ear, or labyrinth, is fluid filled and made up of the
these parts of the ear. Before learning assessment techniques, it is bony labyrinth and an inner membranous labyrinth. The bony
important to understand the anatomy and physiology of the ear. labyrinth has three parts: the cochlea, the vestibule, and the semi-
circular canals (Fig. 17-1). The inner cochlear duct contains the
STRUCTURES OF THE EAR spiral organ of Corti, which is the sensory organ for hearing.
Sensory receptors, located in the vestibule and in the membra-
External Ear nous semicircular canals, sense position and head movements
The external ear is composed of the auricle, or pinna, and the to help maintain both static and dynamic equilibrium. Nerve
external auditory canal (Fig. 17-1). The external auditory canal fibers from these areas form the vestibular nerve, which con-
is S-shaped in the adult. The outer part of the canal curves up nects with the cochlear nerve to form the eighth cranial nerve
and back; the inner part of the canal curves down and forward. (acoustic or vestibulocochlear nerve).
Modified sweat glands in the external ear canal secrete cerumen,
a wax-like substance that keeps the tympanic membrane soft.
Cerumen has bacteriostatic properties, and its sticky consis-
HEARING
tency serves as a defense against foreign bodies. The tympanic Sound vibrations traveling through air are collected by and
membrane, or eardrum, has a translucent, pearly gray appear- funneled through the external ear, causing the eardrum to
ance and serves as a partition stretched across the inner end of vibrate. Sound waves are then transmitted through auditory
the auditory canal, separating it from the middle ear. The mem- ossicles as the vibration of the eardrum causes the malleus, the
brane itself is concave and located at the end of the auditory incus, and then the stapes to vibrate. As the stapes vibrates at
canal in a tilted position such that the top of the membrane the oval window, the sound waves are passed to the fluid in the
is closer to the auditory meatus than the bottom. The distinct inner ear. The movement of this fluid stimulates the hair cells
landmarks (Fig. 17-2) of the tympanic membrane include: of the spiral organ of Corti and initiates the nerve impulses
• Handle and short process of the malleus—the nearest auditory that travel to the brain by way of the acoustic nerve.
ossicle that can be seen through the translucent membrane The transmission of sound waves through the external
• Umbo—the base of the malleus, also serving as a center and middle ear is referred to as “conductive hearing,” and the
point landmark transmission of sound waves in the inner ear is referred to as

328
17 • • • ASSESSING EARS 329

FIGURE 17-1 The ear. Structures


in the outer, middle, and inner
divisions are shown.

“perceptive” or “sensorineural hearing.” Therefore, a conductive are often gradual and go unrecognized by clients until a severe
hearing loss would be related to a dysfunction of the exter- problem develops. Therefore, asking the client specific ques-
nal or middle ear (e.g., impacted ear wax, otitis media, foreign tions about hearing may help in detecting disorders at an early
object, perforated eardrum, drainage in the middle ear, or oto- stage.
sclerosis). A sensorineural loss would be related to dysfunc-
tion of the inner ear (i.e., organ of Corti, cranial nerve VIII, or COLLECTING SUBJECTIVE DATA:
temporal lobe of brain).
THE NURSING HEALTH HISTORY
In addition to the usual pathway for sound vibrations
detailed previously, the bones of the skull also conduct sound First it is important to gather data from the client about the
waves. This bone conduction, though less efficient, serves to current level of hearing and ear health as well as past and fam-
augment the usual pathway of sound waves through air, bone, ily health history problems related to the ear. During data col-
and finally fluid (Fig. 17-3). lection, the examiner should be alert to signs of hearing loss
such as inappropriate answers, frequent requests for repetition,
etc. Collecting data concerning environmental influences on
Health Assessment hearing and how these problems affect the client’s usual activi-
ties of daily living (ADLs) is also important. Answers to these
Beginning when the nurse first meets the client, assessment types of questions help you to evaluate a client’s risk for hear-
of hearing provides important information about the client’s ing loss and, in turn, present ways that the client may modify
ability to interact with the environment. Changes in hearing or lower the risk of ear and hearing problems.

Pars flaccida
Incus

Short process
of malleus
Pars tensa

Handle
of malleus

Umbo

A Cone of light
B

FIGURE 17-2 (A) Right tympanic membrane. (B) Normal otoscopic view of the right tympanic membrane. (Moore, K.L. & Agur, A.
(2002). Essential clinical anatomy, 2nd ed. Philadelphia: Lippincott Williams & Wilkins.)
330 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

Conductive Phase:
Air conduction
Bone conduction
Sensorineural phase

FIGURE 17-3 Pathways of hearing.

History of Present Health Concern


QUESTION RATIONALE

Changes in Hearing

Describe any recent changes in your A sudden decrease in ability to hear in one ear may be associated with otitis media. Sudden
hearing. sensorineural hearing loss (SSHL) or sudden deafness (up to a 3-day period) may be a medical
emergency and thus should be referred for immediate follow-up. Causes vary from unknown
etiology to infections, trauma, toxicity, and other neurologic or circulatory disorders (National
Institute on Deafness and Other Communication Disorders [NIDCD], 2010a; 2011b).
OLDER ADULT CONSIDERATIONS
Presbycusis, a gradual hearing loss, is common after the age of 50 years.

Are you ever concerned that you may be Have the client take the self-assessment “Ten Ways to Recognize Hearing Loss” provided by the
losing your ability to hear well? NIDCD (2011b) (Box 17-1, p. 333).

Are all sounds affected with this change Presbycusis often begins with a loss of high-frequency sounds (woman’s voice) followed later by
or just some sounds? the loss of low-frequency sounds.

Other Symptoms

Do you have any ear drainage? Describe Drainage (otorrhea) usually indicates infection. Purulent, bloody drainage suggests an infection of
the amount and any odor. the external ear (external otitis). Purulent drainage associated with pain and a popping sensation
is characteristic of otitis media with perforation of the tympanic membrane.

Do you have any ear pain? If the client Earache (otalgia) can occur with ear infections, cerumen blockage, sinus infections, or teeth and
answers yes, use COLDSPA to explore the gum problems.
symptom. Pain caused by “swimmer’s ear” differs from pain felt in middle ear infections. If wiggling the
Character: Describe the pain. outer ear without pain, the condition is most likely not swimmer’s ear (Centers for Disease Con-
Onset: When did it begin? trol and Prevention [CDC], 2011b).
Location: Where is it? Does it radiate? Clients with ear infections may experience nausea and dizziness.
Duration: How long does it last?
Severity: Rate your pain on a scale of
1–10 with 10 being the most severe.
Are you able to continue your usual
activities? Are you able to sleep?
Pattern: Have you taken any measures
to relieve it (medications, other)? Has it
helped?
Associated factors/How does it Affect
you? Do you have an accompanying sore
throat, sinus infection, or problems with
your teeth or gums?
17 • • • ASSESSING EARS 331

QUESTION RATIONALE

Do you experience any ringing, roaring or Ringing in the ears (tinnitus) may be associated with excessive earwax buildup, high blood pressure, or
crackling in your ears? certain ototoxic medications (such as streptomycin, gentamicin, kanamycin, neomycin, ethacrynic acid,
furosemide, indomethacin, or aspirin), loud noises, or other causes.
Approximately 10% of the population experiences tinnitus reactions that vary from mild awareness to
severe irritability, causing frustration, insomnia, or inability to concentrate. Some people adapt to this,
while it may impair up to 5% of these people in carrying out their ADLs (Holmes & Padgham, 2011).

Do you ever feel like you are spinning or Vertigo (true spinning motion) may be associated with an inner-ear problem. It is termed subjec-
that the room is spinning? Do you ever tive vertigo when clients feel that they are spinning around and objective vertigo when clients feel
feel dizzy or unbalanced? that the room is spinning around them. It is important to distinguish vertigo from dizziness.

Personal Health History


QUESTION RATIONALE

Have you ever had any problems with your A history of repeated infections can affect the tympanic membrane and hearing (Evidence-Based
ears such as infections, trauma, or earaches? Health Promotion and Disease Prevention 17-1, p. 333).

Describe any past treatments you have Client may be dissatisfied with past treatments for ear or hearing problems.
received for ear problems (medication,
OLDER ADULT CONSIDERATIONS
surgery, hearing aids). Were these suc-
The older client may have had a bad experience with certain hearing aids and may
cessful? Were you satisfied?
refuse to wear one. The client may also associate a negative self-image with a hearing aid.

Family History
QUESTION RATIONALE

Is there a history of hearing loss in your Age-related hearing loss tends to run in families (PubMed Health, 2010a).
family?

Lifestyle and Health Practices


QUESTION RATIONALE

Do you work or live in an area with fre- Continuous loud noises (e.g., machinery, music, explosives) can cause a hearing loss unless the
quent or continuous loud noise? How do ears are protected with ear guards. Farmers were found to have a high incidence of noise-induced
you protect your ears from the noise? hearing loss, yet many do not use hearing protective devices. Clients exposed to high noise levels
need to be informed of their options for using hearing protective devices (McCullagh & Robertson,
2009) (Evidence-based Health Promotion and Disease Prevention 17-1, p. 333).
Do you spend a lot of time swimming or Otitis externa, often referred to as swimmer’s ear, can occur when water stays in the ear canal for long
in water? How do you protect your ears periods of time, providing the perfect environment for germs to grow and infect the skin. Germs found
when you swim? in pools and at other recreational water venues are one of the most common causes of swimmer’s ear.
Symptoms include: itchiness inside ear, redness and swelling of the ear, pain in the ear when pressure
is applied to the ear or the ear is pulled on (pain may be severe), drainage of pus (CDC, 2011b). After
bathing or swimming, the external auditory canal should be dried using a hair dryer on the lowest heat
setting. People who swim frequently should use a barrier to protect their ears from water. However,
impermeable earplugs act as a local irritant and have been shown to predispose the ear canal to otitis
externa. A tight-fitting bathing cap offers better protection (Bereznicki & Peterson, 2008).
Has your hearing loss affected your Hearing loss or ear pain may interfere with the client’s ability to perform usual ADLs. Clients may
ability to care for yourself? To work? not be able to drive, talk on the telephone, or operate machinery safely because of decreased
hearing acuity. The ability to perform in occupations that rely heavily on hearing, such as a recep-
tionist or telephone operator, may be affected.
Has your hearing loss affected your Clients who have decreased hearing may withdraw, isolate themselves, or become depressed
socializing with others? because of the stress of verbal communication.
When was your last hearing examination? Annual hearing evaluations are recommended for clients who are exposed to loud noises for long
periods. Knowing the date of the examination helps to determine recent changes.
Do you wear a hearing aid? Some internal hearing aids may not visible to the interviewer. This will alert the nurse before doing
an ear exam. Sometimes hearing aids worn are not functioning well and need to be adjusted.
Clients may not be aware of this until someone indicates that they are not hearing well.
Continued on following page
332 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

Lifestyle and Health Practices (Continued)


QUESTION RATIONALE

How do you care for your ears? Describe Earwax is a natural, self-cleaning agent that should not be regularly removed unless it is causing
how you clean your ears. a problem. A warm, moist washcloth should be used to clean the outside of the ears, but nothing
should be inserted into the ear canal.
A few drops of mineral oil, baby oil, glycerin, or commercial drops may be placed in the ear to
moisten the earwax to allow it to naturally work its way out of the ear.
It is important to see an otolaryngologist (ear, nose, and throat [ENT] doctor) when experiencing
ear discharge, fullness, ear pain, reduced hearing, or other persistent ear symptoms. The doctor
may recommend ways to remove excess earwax, such as irrigation (syringing), wax-dissolving
eardrops, and manual cleaning with a microscope and specialized instruments.
Never insert anything into your ear canal including cotton-tipped swabs,
pens, hairpins, and so on. Never use an “ear candle” to remove earwax.
These are ineffective and may cause burns, obstruction of the ear canal, or perfora-
tion of the tympanic membrane. Irrigation devices should only be used by health care
professionals.
(American Academy of Otolaryngology—Head and Neck Surgery [AAO-HNS], 2012).

Case Study
The case study introduced at the beginning of the chapter is now used to demonstrate how a nurse would use
the COLDSPA mnemonic to explore Ms. Lopez’s reported fever and earache.

Mnemonic Question Client Response


Character Describe the sign or symptom “I have an achy pressure sensation in my right ear that pulses with
(feeling, appearance, sound, every beat of my heart.”
smell, or taste if applicable).
Onset When did it begin? “Two days ago.”
Location Where is it? Does it radiate? “Inside my right ear.”
Does it occur anywhere else?
Duration How long does it last? Does it “The pressure is constant, but the pain varies depending on when
recur? I last took ibuprofen.”
Severity How bad is it? or How much “It kept me awake last night. On a scale of 1–10, I would rate the
does it bother you? pain as 7 right now. About an hour after I take ibuprofen the pain
decreases to a 3–4 out of 10.”
Pattern What makes it better or worse? “The pain never completely goes away. Ibuprofen makes the pain
tolerable. Coughing or increased activity makes the pain worse.”
Associated What other symptoms occur “Everything sounds muffled—I can hardly hear from my right ear.
factors/How it with it? How does it affect you? I had a cold about a week ago and it went away, but now I have
Affects the client this earache. I really don’t feel like working at school or at home.
I have also been running a fever of 100°F for two days.”

After investigating Ms. Lopez’s report of fever and earache, and denies the need for hearing protection. She reports
the nurse continues with the health history. Ms. Lopez that she swims infrequently in the summer months (1–2
remembers a couple of ear infections as a child but has times per month), and denies any ear issues associated with
never had an ear infection as an adult. She denies any pre- swimming. She has never had a formal hearing evaluation
vious treatments for ear problems. She denies ear trauma. and denies the use of a hearing aid. She does report the use
She denies a family history of hearing loss. She does not of cotton-tipped applicators to “clean out” her ears each
work in an area with frequent or continuous loud noises, morning after she showers.
17 • • • ASSESSING EARS 333

BOX 17-1 TEN WAYS TO RECOGNIZE HEARING LOSS

The following questions will help you determine if you need to have your hearing evaluated by a medical professional:
Do you have a problem hearing over the telephone?
Yes No
Do you have trouble following the conversation when two or more people are talking at the same time?
Yes No
Do people complain that you turn the TV volume up too high?
Yes No
Do you have to strain to understand conversation?
Yes No
Do you have trouble hearing in a noisy background?
Yes No
Do you find yourself asking people to repeat themselves?
Yes No
Do many people you talk to seem to mumble (or not speak clearly)?
Yes No
Do you misunderstand what others are saying and respond inappropriately?
Yes No
Do you have trouble understanding the speech of women and children?
Yes No
Do people get annoyed because you misunderstand what they say?
Yes No
If you answered “yes” to three or more of these questions, you may want to see an otolaryngologist (an ear, nose, and throat
specialist) or an audiologist for a hearing evaluation.
The material on this page is for general information only and is not intended for diagnostic or treatment purposes. A doctor or
other health care professional must be consulted for diagnostic information and advice regarding treatment.

Excerpt from NIH Publication No. 01-4913


For more information, contact the NIDCD Information Clearinghouse.

17-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION:


HEARING LOSS

INTRODUCTION According to the NIDCD (2011a), ear infections (otitis media)


According to Healthy People 2020 (2011), 1 in 6 Americans has cause an inflammation of the middle ear (often bacterial) and
a sensory or communication disorder, which can affect physical occur when fluid builds up behind the eardrum. Children get ear
and mental health. Hearing affects all interpersonal communica- infections more often than adults, especially before the third
tion. Personal relationships, academic and job performance, and birthday. Acute otitis media causes earache and often a fever.
even safety are affected when hearing is impaired, which can be When fluid stays trapped behind the eardrum after the infec-
frustrating or embarrassing. The National Institute on Deafness tion has seemed to resolve, otitis media with effusion (OME)
and Other Communication Disorders (NIDCD, 2011a) lists safety can be present. Only a professional examination can determine
areas as difficulty following a doctor’s orders, responding to this condition, as there are usually no symptoms. The NIDCD
warnings, and hearing doorbells or alarms. Uncorrected hearing notes that “chronic otitis media with effusion (COME) happens
impairment can affect childhood development as well. when fluid remains in the middle ear for a long time or returns
Hearing loss is determined as “the total or partial loss over and over again, even though there is no infection.”
of the ability to hear sound in one or both ears.” There are One in three people older than 60 and half of those older
two primary types: conductive hearing loss (CHL) related to a than 85 have hearing loss, and 3 in 4 children will have otitis
mechanical problem in the outer or middle ear (often revers- media before the third birthday.
ible); and sensorineural hearing loss (SNHL) resulting from HEALTHY PEOPLE 2020 GOAL
disease, injury, or decrease in the tiny hair-like nerve endings
in the inner ear (not reversible). OVERVIEW
Causes of hearing disorders are many and include genetics, The Healthy People 2020 objectives (2011) relate to a broad
infections, injuries to head or ear, ototoxic drugs, aging, and spectrum of disorders associated with communication, includ-
loud noises (especially if very loud or exposure is over a pro- ing hearing, balance, smell, taste, voice, speech, and lan-
longed time). Temporary hearing loss is associated with aller- guage. Specifically, these objectives concern newborn hearing
gies, blocked eustachian tubes, wax buildup in the ear canal, screening; ear infections (otitis media); hearing and assistive
ear infections, foreign bodies in the ear canal, injuries, scarred device use; tinnitus; balance and dizziness; smell and taste;
or perforated eardrum, and reactions to certain medications voice, speech, and language; and related Internet health care
(e.g., aminoglycosides, chloroquine, quinidine; UMMC, 2011). resource use.

Continued on following page


334 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

17-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION:


HEARING LOSS (Continued)

GOAL • Aging, especially due to many years of exposure to sounds


Reduce the prevalence and severity of disorders of hearing that can damage inner ear cells
and balance; smell and taste; and voice, speech, and language. • Heredity, with genetics that are related to susceptibility to
ear damage
OBJECTIVES • Occupational loud noises as regular part of the working
For newborns, the objectives include screening no later than environment (e.g., farming, construction, factory work)
age 1 month and follow-up audiologic examination no later • Recreational noises and exposure to explosive noises (fire-
than 3 months of age. arms and fireworks, which can cause both gradual or sud-
For otitis media in children and adolescents, the objective den permanent hearing loss; snowmobiling, motorcycling,
is to reduce the rate by 10%, and to reduce the proportion of listening to loud music or MP3s if volume is high).
adolescents who have noise-induced hearing loss. • Ototoxic medications (e.g., gentamicin, some chemother-
For hearing generally, the objective is to increase the propor- apy medications; or high-dose aspirin, some other pain
tion of persons with hearing impairments who have ever used relievers, antimalarial drugs, or loop diuretics can lead to
a hearing aid or assistive listening devices or who have cochlear tinnitus or hearing loss).
implants; increase the proportion of persons who have had a • Illnesses, especially with high fever (e.g., meningitis).
hearing evaluation on schedule or who have been referred by Argawal, Platz, and Niparko (2008) list risk factors as:
their primary care provider for hearing evaluation and treat- • Noise exposure
ment; increase the use of hearing protective devices; and reduce • Smoking
the proportion of adults who have noise-induced hearing loss. • Cardiovascular risk factors
WHO (2010) lists risk factors as:
SCREENING • Genetic and family susceptibility
The U.S. Preventive Services Task Force report on screen- • Premature birth
ing guidelines for hearing loss published in 1996 are being • Hypoxia during birth
revised (Fowler, 2011; USPSTF, 2011). Fowler reports that the • Rubella, syphilis, or certain other infections in pregnant
USPSTF recommendation to routinely assess hearing loss in mother
patients aged 50 years and older has been found to be effec- • Inappropriate use of ototoxic drugs (a group of more than
tive, according to a review by Chou et al. (2011). 130 drugs, such as the antibiotic gentamicin) during pregnancy
• Neonatal jaundice, which can damage the otic nerve in a
OTHER SCREENING RECOMMENDATIONS newborn baby
• Infectious diseases such as meningitis, measles, and mumps,
Healthy People 2020 (2011) and the U.S. Preventive Services
as well as chronic ear infections in childhood as well as in
Task Force (2011) recommend universal screening of all new-
later life
borns; the American Speech-Language-Hearing Association
• Head injury or injury to the ear
(2011e) recommends that all adults should be screening for
• Wax or foreign bodies blocking the ear canal
hearing loss at least every decade through age 50, and then
Mayo Clinic (2011a) lists risks for otitis media:
every 3 years; Agrawal, Platz, and Niparko (2008) recommend
• Age (between 6 months and 2 years especially, due to size
that screening should begin in young adulthood.
and shape of eustachian tubes)
Mayo Clinic lists some screening methods to diagnose hear-
• Group childcare
ing loss. These include general screening tests (asking clients to
• Babies fed from a bottle, especially lying down
cover one ear at a time to see how well they hear words spoken
• Seasons of fall and winter, due to exposure to colds, flu,
at various volumes and respond to other sounds); tuning fork
and increased allergens
tests (to differentiate types of hearing loss); and audiometer
• Poor air quality
tests (completed by an audiologist). Other simple assessments
• Family history
easily used to identify the need for further testing include ask-
• Ethnicity (Alaskan Indians and Inuits have higher incidence)
ing the person about any decreases in hearing persons’ voices
• Enlarged adenoids
or television, asking if others have said there may be a decrease
in hearing (for instance, as spouse); and observing the person’s CLIENT EDUCATION
behavior while completing the health assessment for evidence
Teach Clients
of diminished hearing. Chou et al. (2011) found that the “whis-
• Avoid sound exposure louder than a washing machine.
pered voice test at 2 feet and a single question regarding per-
• Avoid recreational risks that involve loud sounds or risks of
ceived hearing loss were comparable with a more detailed
head or ear injury.
screening questionnaire or a hand-held audiometric device for
• Avoid listening to extremely loud music for long periods of
identifying at least mild (>25 dB) hearing loss.”
time.
A personal hearing questionnaire for individuals is pro-
• Wear hearing protectors and take breaks from the noise in
vided by the NIDCD (2011b), called Ten Ways to Recognize
loud noise environments.
Hearing Loss. This quiz is recommended for anyone. It is avail-
• Have hearing checked periodically, especially after age 50.
able on the NIDCD website.
• If hearing loss is detected, obtain and use devices to im-
prove hearing.
RISK ASSESSMENT
• Immunize children against childhood diseases, including
The NIDCD (2011a) describes the damage noise does to hear- measles, meningitis, rubella, and mumps.
ing, noting that “regular exposure to more than 110 decibels • Be immunized against rubella before pregnancy if a wom-
for more than 1 minute risks permanent hearing loss and pro- an of child-bearing age.
longed exposure to any noise at or above 85 decibels can cause • If pregnant, get screening for syphilis and other STIs, ad-
gradual hearing loss.” Also ranking loud sound exposure high equate antenatal and prenatal care, and diagnosis and
on risks for hearing impairment, Mayo Clinic (2011c) lists: treatment for baby born with jaundice.
17 • • • ASSESSING EARS 335

• Avoid the use of ototoxic drugs unless prescribed by a • Get treatment for tonsil and adenoid infections and in-
qualified health care worker and properly monitored for flammation.
correct dosage. • Keep child home from day care if possible when there is an
• If you have a newborn, avoid feeding from bottle while outbreak of ear infections.
infant is lying on back. • Teach child to avoid putting foreign bodies in ears.
• Have newborn infant screened for hearing. • Avoid use of instruments to remove wax from ears due to
• Get treatment for ear infections as soon as they are noticed; chance of impacting it further. See professional care for
follow up with health care provider after symptoms seem wax removal.
to be gone to make sure there is no fluid left in the ear.

COLLECTING OBJECTIVE DATA: response? This initial observation provides you with clues as
PHYSICAL EXAMINATION to the status of the client’s hearing.

The purpose of the ear and hearing examination is to evaluate Equipment


the condition of the external ear, the condition and patency • Watch with a second hand for Romberg test
of the ear canal, the status of the tympanic membrane, bone • Tuning fork (512 or 1024 Hz)
and air conduction of sound vibrations, hearing acuity, and • Otoscope
equilibrium. The external ear structures and ear canal are rela-
tively easy to assess through inspection. Using the tuning fork
to evaluate bone and air conduction is also a fairly simple
procedure. However, more practice and expertise are needed
to use the otoscope correctly to examine the condition of the
structures of the tympanic membrane.

Preparing the Client


Make sure that the client is seated comfortably during the ear
examination. This helps to promote the client’s participation,
which is very important in this examination. In addition,
the test should be explained thoroughly to guarantee accu- Physical Assessment
rate results. To ease any client anxiety, explain in detail what Before performing the examination, make sure to:
you will be doing. Also, answer any questions the client may • Recognize the role of hearing in communication and adap-
have. As you prepare the client for the ear examination, care- tation to the environment, particularly in regard to aging.
fully note how the client responds to your explanations. Does • Know how to use the otoscope effectively when performing
the client appear to hear you well or seem to strain to catch the ear examination (Assessment Guide 17-1).
everything you say? Does the client respond to you verbally • Understand the usefulness and significance of basic hearing
or nonverbally or do you have to repeat what you say to get a tests.

ASSESSMENT GUIDE 17-1 Otoscope


The otoscope is a flashlight-type viewer 1. Ask the client to sit comfortably with to straighten the external auditory canal.
used to visualize the eardrum and external the back straight and the head tilted Do not alter this positioning at any time
ear canal. Some guidelines for using it slightly away from you toward his or her during the otoscope examination.
effectively follow. opposite shoulder. 4. Grasp the handle of the otoscope
2. Choose the largest speculum that fits between your thumb and fingers and
comfortably into the client’s ear canal hold the instrument up or down.
(usually 5 mm in the adult) and attach it 5. Position the hand holding the otoscope
to the otoscope. Holding the instrument against the client’s head or face. This
Speculum Body (contains in your dominant hand, turn the light on position prevents forceful insertion of
light source) the otoscope to “on.” the instrument and helps to steady your
3. Use the thumb and fingers of your hand throughout the examination, which
opposite hand to grasp the client’s auricle is especially helpful if the client makes
firmly but gently. Pull out, up, and back any unexpected movements.
6. Insert the speculum gently down and
forward into the ear canal (approximately
0.5 inch). As you insert the otoscope, be careful
not to touch either side of the inner portion
of the canal wall. This area is bony and cov-
ered by a thin, sensitive layer of epithelium.
Any pressure will cause the client pain.
7. Move your head in close to the otoscope
and position your eye to look through
the lens.
336 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

External Ear Structures


INSPECTION AND PALPATION

Inspect the auricle, tragus, and Ears are equal in size bilaterally (normally 4–10 cm). Ears are smaller than 4 cm or larger than
lobule. Note size, shape, and position The auricle aligns with the corner of each eye and 10 cm.
(Fig. 17-4). within a 10-degree angle of the vertical position.
Earlobes may be free, attached, or soldered Malaligned or low-set ears may be seen with
(tightly attached to adjacent skin with no apparent genitourinary disorders or chromosomal
lobe). defects.

CULTURAL CONSIDERATIONS
Most African Americans and Caucasians
have free lobes, whereas most Asians have
attached or soldered lobes, although any type
is possible in all cultural groups (McDonald,
2010; Overfield, 1995).
OLDER ADULT CONSIDERATIONS
The older client often has elongated
earlobes with linear wrinkles.

FIGURE 17-4 Inspecting the external ear.

Continue inspecting the auricle, tragus, The skin is smooth, with no lesions, lumps, or Some abnormal findings suggest various
and lobule. Observe for lesions, discol- nodules. Color is consistent with facial color. disorders, including:
orations, and discharge. Darwin’s tubercle, which is a clinically insignificant • Enlarged preauricular and postauricular
projection, may be seen on the auricle (Fig. 17-5). lymph nodes—infection
No discharge should be present. • Tophi (nontender, hard, cream-colored
nodules on the helix or antihelix, contain-
ing uric acid crystals)—gout
• Blocked sebaceous glands—postauricular
cysts
• Ulcerated, crusted nodules that bleed—
skin cancer (most often seen on the helix
due to skin exposure)
• Redness, swelling, scaling, or itching—otitis
externa
• Pale blue ear color—frostbite (see Abnor-
mal Findings 17-1 on page 342)

FIGURE 17-5 Darwin’s tubercle.


17 • • • ASSESSING EARS 337

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Palpate the auricle and mastoid Normally the auricle, tragus, and mastoid process A painful auricle or tragus is associated with
process. are not tender. otitis externa or a postauricular cyst.

Tenderness over the mastoid process


suggests mastoiditis.

Tenderness behind the ear may occur with


otitis media.

Internal Ear: Otoscopic Examination


INSPECTION

Inspect the external auditory canal. A small amount of odorless cerumen (earwax) Abnormal findings associated with specific
Use the otoscope (see Assessment is the only discharge normally present. Cerumen disorders include:
Guide 17-1 on page 335). color may be yellow, orange, red, brown, gray, or • Foul-smelling, sticky, yellow discharge—
black. Consistency may be soft, moist, dry, flaky, otitis externa or impacted foreign body
Note any discharge along with the or even hard. • Bloody, purulent discharge—otitis media
color and consistency of cerumen with ruptured tympanic membrane
(earwax). CULTURAL CONSIDERATIONS
• Blood or watery drainage (cerebrospinal
Most Europeans and Africans, 97% or
fluid)—skull trauma (refer client to physi-
more, have wet earwax; Asians and Native
cian immediately)
Americans have dry earwax, with transition
• Impacted cerumen blocking the view
in southern Asia. The gene accounting for this
of the external ear canal—conductive
has been isolated and is associated with lower
hearing loss
sweat production of the apocrine glands, pos-
• Refer any client with presence of foreign
sibly an adaptation to cold (Wade, 2006).
bodies such as bugs, plants, or food to
OLDER ADULT CONSIDERATIONS the health care practitioner for prompt
In some older clients, harder, drier ceru- removal due to possible swelling and
men tends to build as cilia in the ear canal infection. If the object in the ear is a
become more rigid. Coarse, thick, wire-like button-type battery, medical attention is
hair may grow at the ear canal entrance as urgent as leaking chemicals can burn and
well. This is an abnormal finding only if it damage the ear canal even within 1 hour
impairs hearing. (Cunha, 2011).

Observe the color and consistency of The canal walls should be pink and smooth, Abnormal findings in the ear canal may
the ear canal walls and inspect the without nodules. include:
character of any nodules. • Reddened, swollen canals—otitis externa
• Exostoses (nonmalignant nodular swellings)
• Polyps may block the view of the eardrum
(see Abnormal Findings 17-2 on page 343).

Inspect the tympanic membrane The tympanic membrane should be pearly, gray, Abnormal findings in the tympanic mem-
(eardrum). Note color, shape, consis- shiny, and translucent, with no bulging or retrac- brane may include:
tency, and landmarks. tion. It is slightly concave, smooth, and intact. A • Red, bulging eardrum and distorted,
cone-shaped reflection of the otoscope light is diminished, or absent light reflex—acute
normally seen at 5 o’clock in the right ear and otitis media
7 o’clock in the left ear. The short process and • Yellowish, bulging membrane with
handle of the malleus and the umbo are clearly bubbles behind—serous otitis media
visible (see Fig. 17-2A and B, p. 329). • Bluish or dark red color—blood behind
the eardrum from skull trauma
OLDER ADULT CONSIDERATIONS
• White spots—scarring from infection
The older client’s eardrum may appear
• Perforations—trauma from infection
cloudy. The landmarks may be more promi-
• Prominent landmarks—eardrum retrac-
nent because of atrophy of the tympanic
tion from negative ear pressure resulting
membrane associated with the normal pro-
from an obstructed eustachian tube
cess of aging.
• Obscured or absent landmarks—eardrum
thickening from chronic otitis media (see
Abnormal Findings 17-2 on page 343).

Continued on following page


338 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Internal Ear: Otoscopic Examination (Continued)

To evaluate the mobility of the tym- The healthy membrane flutters when the bulb is With otitis media, the membrane does not
panic membrane, perform pneumatic inflated and returns to the resting position once move or flutter when the bulb is inflated.
otoscopy with a bulb insufflator the air released.
attached by using an otoscope with
bulb insufflators. Observe the position
of the tympanic membrane when the
bulb is inflated and again when the air
is released.

Hearing and Equilibrium Tests

Box 17-2 on p. 340 describes hearing CULTURAL CONSIDERATIONS More than 30% of people over age 65 have
loss and testing. In general, African Americans have some type of hearing loss; 14% of people
slightly better hearing at low and high between 45 and 64 years of age have hear-
frequencies (250 and 6000 Hz); Caucasians ing loss. In addition, close to 8 million people
have better hearing at middle frequencies between the ages of 18 and 44 have hearing
(2000 and 4000 Hz). African Americans are loss.
less susceptible to noise-induced hearing loss
(Helzner et al., 2005). Adults should be screened every 10 years
through age 50 and at 3-year intervals there-
after (American Speech-Language-Hearing
Association [ASHA], 2011b).

Perform the whisper test by asking Able to correctly repeat the two-syllable word as Unable to repeat the two-syllable word after
the client to gently occlude the ear not whispered. two tries indicates hearing loss and requires
being tested and rub the tragus with a follow-up testing by an audiologist.
finger in a circular motion. Start with
testing the better hearing ear and then
the poorer one. With your head 2 feet
behind the client (so that the client
cannot see your lips move), whisper a
two-syllable word such as “popcorn”
or “football.” Ask the client to repeat it
back to you. If the response is incorrect
the first time, whisper the word one
more time. Identifying three out of six
whispered words is considered passing
the test. The whisper test has been
studied in both pediatric and adult
clients to evaluate hearing acuity and
has been found to have a high sensitiv-
ity and specificity (Pirozzo, Papinczak,
& Glasziou, 2003).

Perform Weber’s test if the client Vibrations are heard equally well in both ears. No With conductive hearing loss, the client
reports diminished or lost hearing lateralization of sound to either ear. reports lateralization of sound to the poor
in one ear. The test helps to evalu- ear—that is, the client “hears” the sounds
ate the conduction of sound waves in the poor ear. The good ear is distracted
through bone to help distinguish by background noise and conducted air,
between conductive hearing (sound which the poor ear has trouble hearing. Thus
waves transmitted by the external and the poor ear receives most of the sound
middle ear) and sensorineural hearing conducted by bone vibration.
(sound waves transmitted by the inner
ear). Strike a tuning fork softly with the With sensorineural hearing loss, the client
back of your hand and place it at the reports lateralization of sound to the good
center of the client’s head or forehead ear. This is because of limited perception of
(Fig. 17-6). Centering is the important the sound due to nerve damage in the bad
part. Ask whether the client hears the ear, making sound seem louder in the unaf-
sound better in one ear or the same in fected ear.
both ears.
17 • • • ASSESSING EARS 339

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

With conductive hearing loss, bone conduc-


tion (BC) sound is heard longer than or
equally as long as air conduction (AC) sound
(BC ≥ AC).

Conductive hearing loss occurs when sound


is not conducted through the outer ear canal
to the eardrum and ossicles of the middle
ear. Possible causes include: fluid in middle
ear, middle-ear infection (otitis media), aller-
gies (serous otitis media), eustachian tube
dysfunction, perforated eardrum, benign
tumors, impacted cerumen, infection in the
ear canal (external otitis) or presence of a
foreign body (ASHA, 2011a).

FIGURE 17-6 The Weber test assesses sound conducted via bone.

Perform the Rinne test. The Rinne Air conduction sound is normally heard longer With sensorineural hearing loss, air conduction
test compares air and bone conduction than bone conduction sound (AC > BC). sound is heard longer than bone conduction
sounds. Strike a tuning fork and place sound (AC > BC) if anything is heard at all.
the base of the fork on the client’s
mastoid process (Fig. 17-7A). Sensorineural hearing loss occurs with
damage to the inner ear (cochlea), or to
Ask the client to tell you when the the nerve pathways between the inner ear
sound is no longer heard. and brain. This is the most common type
of permanent hearing loss. It decreases
Move the prongs of the tuning fork to one’s ability to hear faint sounds. Even loud
the front of the external auditory canal speech may be muffled. Causes include:
(Fig. 17-7B). Ask the client to tell you ototoxic drugs, genetic hearing loss, aging,
if the sound is audible after the fork is head trauma, malformation of the inner ear,
moved. and loud noise exposure (ASHA, 2011c).

FIGURE 17-7 For the Rinne test, the tun-


ing fork base is placed first on the mastoid
process (A), after which the prongs are
moved to the front of the external audi-
A B
tory canal (B).
Continued on following page
340 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Hearing and Equilibrium Tests (Continued)

Perform the Romberg test. This Client maintains position for 20 seconds without Client moves feet apart to prevent falls or
tests the client’s equilibrium. Ask the swaying or with minimal swaying. starts to fall from loss of balance. This may
client to stand with feet together, arms indicate a vestibular disorder.
at sides, and eyes open, then with the
eyes closed.
When performing this
test, put your arms
around the client without touching
him or her to prevent falls.

BOX 17-2 HEARING LOSS AND TESTING

SENSORINEURAL HEARING AND HEARING LOSS inner ear. While a number of causes exist, cerumen buildup
Actual hearing takes place when sound waves are channeled and fluid in the middle ear are the most common barriers to
through the auditory canal, causing the tympanic membrane “vibration” transmission.
to vibrate. These vibrations are transmitted through the mid-
dle ear by the auditory ossicles to the inner ear, where they OLDER ADULT CONSIDERATIONS
are converted into nerve impulses that travel to the brain for Conductive hearing impairment is not uncommon in
interpretation. the older client due to greater incidence of cerumen buildup
A sensorineural hearing loss results when damage is and/or atrophy or sclerosis of the tympanic membrane. A
located in the inner ear. Conduction of sound waves is occur-
condition called otosclerosis often occurs with aging as the
ring through normal pathways, but the impaired inner ear
cannot make the conversion into nerve impulses. Possible
auditory ossicles develop a spongy consistency that results
causes of sensorineural hearing loss are prolonged exposure in conductive hearing loss.
to loud noises or using ototoxic medications.
HEARING TESTS
OLDER ADULT CONSIDERATIONS
The tests discussed in this chapter are performed to give the
Presbycusis, a gradual sensorineural hearing loss due examiner a basic idea of whether the client has hearing loss,
to degeneration of the cochlea or vestibulocochlear nerve, what type (conduction or sensorineural) of hearing loss it
is common in older (over age 50) clients. The client with might be, and whether there is a problem with equilibrium.
presbycusis has difficulty hearing consonants and whispered These tests present an opportunity to educate clients about
words; this difficulty increases over time. risk factors for hearing loss. These tests are not completely
accurate and do not provide the examiner with an exact
CONDUCTIVE HEARING AND LOSS percentage of hearing loss. Therefore, the client should be
Bone conduction occurs when the temporal bone vibrates referred to a hearing specialist for more accurate testing if a
with sound waves and the vibrations are picked up by the problem is suspected.
tympanic membrane and/or auditory ossicles. This type of Auditory testing performed with a tuning fork is meant
conduction results in the perception of sound but is virtually for screening only and should not be used for diagnostic pur-
ineffective for interpretation of sounds. poses. Variations from expected findings in any tests using
A conductive hearing loss occurs when something blocks a tuning fork are simply an indication of the need for more
or impairs the passage of vibrations from getting to the elaborate testing and referral.

Case Study
The chapter case study is now used to palpation bilaterally. Scant amount of brown cerumen lines
demonstrate the physical examination of the external auditory canals bilaterally. Bilateral canals with-
Andrea’s ears. out redness, edema, or discharge. Left tympanic membrane
The client’s auricle, tragus, and lobule are pearly gray, shiny, translucent, without bulging or retrac-
present and symmetric bilaterally. The auri- tion. Cone of light present at 7 o’clock. Handle of malleus
cle aligns with the lateral canthus of each and umbo visible. Right tympanic membrane red and bulg-
eye and has a 10-degree angle of vertical position bilaterally. ing with absent light reflex. No bony landmarks visible.
Earlobes are free. The skin on the ears is smooth, without Whisper test: Able to distinguish 2-syllable words from
lesions, lumps, or nodules; color is consistent with that of 2 feet bilaterally. Weber’s test: Sound lateralizes to the right
the face. Auricle, tragus, and mastoid process nontender to ear. Rinne test: AC > BC bilaterally. Romberg test negative.
17 • • • ASSESSING EARS 341

VALIDATING AND
bony landmarks visible. Whisper test: Able to distin-
DOCUMENTING FINDINGS guish 2-syllable words from 2 feet bilaterally. Weber’s
Validate the ear assessment data that you have collected. This test: Sound lateralizes to the right ear. Rinne test:
is necessary to verify that the data are reliable and accurate. AC > BC bilaterally. Romberg test negative.
Document the assessment data following the health care facil-
ity or agency policy.

Analysis of Data: Diagnostic


Case Study Reasoning
Think back to the case study. The nurse After collecting subjective and objective data pertaining to the
completed the following documentation ears, identify abnormal findings and client strengths. Then
of her assessment of Andrea Lopez. cluster the data to reveal any significant patterns or abnormali-
Biographic Data: AL, 47-year-old, His- ties. These data will then be used to make clinical judgments
panic elementary education teacher. (nursing diagnoses: health promotion risk, or actual) about
Alert and oriented. Asks and answers the status of the client’s ears. Following are some possible con-
questions appropriately. clusions that the nurse may make after assessing a client’s ears.

Reason for Seeking Health Care: “I have an achy pressure


sensation in my right ear that pulses with every beat of SELECTED NURSING DIAGNOSES
my heart and have had fever for 2 days.” The following is a list of selected nursing diagnoses that may
History of Present Health Concern: Ms. Lopez reports that be identified when analyzing data from ear assessment.
she developed right ear pain 2 days ago. The ear pain
is described as a constant pressure sensation that var- Health Promotion Diagnoses
ies with intensity based on last dose of ibuprofen. She • Readiness for enhanced communication related to expressed
reports that the pain kept her awake last evening. Has desire for hearing aid
had fever of 100°F for last 2 days. Denies having been
swimming. Currently rates right ear pain as 7 out of 10. Risk Diagnoses
Reports that ibuprofen reduces pain to 3–4 out of 10. • Risk for Injury related to hearing impairment
• Risk for Loneliness related to hearing loss
Personal Health History: Ms. Lopez remembers a couple
of ear infections as a child but has never had an ear infec- Actual Diagnoses
tion as an adult. She denies any previous treatments for
• Risk for Injury related to hearing loss
ear problems. She denies ear trauma.
• Acute Pain related to infection of external or middle ear
Family History: She denies a family history of hearing loss. • Impaired Social Interaction related to inability to interact
effectively with others secondary to hearing loss
Lifestyle and Health Practices: She does not work in
an area with frequent or continuous loud noises, and
denies the need for hearing protection. She reports that SELECTED COLLABORATIVE PROBLEMS
she swims infrequently in the summer months (1–2
After grouping the data, it may become apparent that certain
times per month), and denies any ear issues associated
collaborative problems emerge. Remember that collaborative
with swimming. She has never had a formal hearing
problems differ from nursing diagnoses in that nursing inter-
evaluation and denies the use of a hearing aid. She does
ventions cannot prevent them. However, these physiologic
report the use of cotton-tipped applicators to “clean
complications of medical conditions can be detected and mon-
out” her ears each morning after she showers.
itored by the nurse. In addition, the nurse can use physician-
Physical Exam Findings: The client’s auricle, tragus, and and nurse-prescribed interventions to minimize the complica-
lobule are present and symmetric bilaterally. The auricle tions of these problems. The nurse may also have to refer the
aligns with the lateral canthus of each eye and has a client in such situations for further treatment of the problem.
10-degree angle of vertical position bilaterally. Earlobes The following is a list of collaborative problems that may be
are free. The skin on the ears is smooth, without lesions, identified when assessing the ear. These problems are worded
lumps, or nodules; color is consistent with that of the Risk for Complications (RC), followed by the problem.
face. Auricle, tragus, and mastoid process nontender to • RC: Otitis media (acute, chronic, or serous)
palpation bilaterally. Scant amount of brown cerumen • RC: Otitis externa
lines the external auditory canals bilaterally. Bilateral • RC: Perforated tympanic membrane
canals without redness, edema, or discharge. Left tym-
panic membrane pearly gray, shiny, translucent, without
bulging or retraction. Cone of light present at 7 o’clock.
MEDICAL PROBLEMS
Handle of malleus and umbo visible. Right tympanic If after grouping the data it becomes apparent that the client
membrane red and bulging with absent light reflex. No has signs and symptoms that may require medical diagnosis
and treatment, referral to a primary care provider is necessary.
342 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS
ABNORMAL FINDINGS

Case Study
After collecting and analyzing the data for Potential Collaborative Problems
Andrea Lopez, the nurse determines that • RC: Ear infection
the following conclusions are appropriate: • RC: Ruptured tympanic membrane
Refer to primary care provider to diagnose and treat her
Nursing Diagnoses ear condition. To view an algorithm depicting the process
• Acute Pain r/t physical evidence of tym- of diagnostic reasoning for this case, go to .
panic membrane inflammation
• Ineffective Health Maintenance r/t lack of knowledge
about potential tympanic membrane damage from
cotton-tipped applicator use in ears

ABNORMAL FINDINGS 17-1 Abnormalities of the External Ear and Ear Canal
Many abnormalities may affect the external ear and ear canal; among them are infections and abnormal growths. Some are
pictured below.

Malignant lesion. Buildup of cerumen in ear canal.

Polyp.

Otitis externa. (© 1992 Science Photo Library/Custom


Medical Science Photography)

Exostosis.
17 • • • ASSESSING EARS 343

ABNORMAL FINDINGS
ABNORMAL FINDINGS 17-2 Abnormalities of the Tympanic Membrane
The thin, drum-like structure of the tympanic membrane is essential for hearing. It is also essential for promoting equilib-
rium and barring infection. Damage to the membrane may have grave and serious consequences.

Acute Otitis Media Blue/Dark Red Tympanic Perforated Tympanic Membrane


Note the red, bulging membrane; Membrane Perforation results from rupture
decreased or absent light reflex. Indicates blood behind eardrum due caused by increased pressure, usually
to trauma. from untreated infection or trauma.

(© 1992 Science Photo Library/Custom Medical


Science Photography)

Serous Otitis Media Scarred Tympanic Membrane Retracted Tympanic Membrane


Note the yellowish, bulging membrane White spots and streaks indicate scar- Prominent landmarks are caused by
with bubbles behind it. ring from infections. negative ear pressure due to obstructed
eustachian tube or chronic otitis media.

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344 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS

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