EAR FUNCTION DISORDERS

Transcribed by: John Cyril A. Roquete

ANATOMY AND PHYSIOLOGY

OF THE EARS
EXTERNAL EAR

• Auricle or pinna
• External auditory canal
• Tympanic membrane
• Acoustic antenna, focus sound waves HEARING AND THE COCHLEA
MIDDLE EAR • The cochlea as microphone
• When sound waves from the world outside strike
• The middle ear consists of:
the eardrum, it vibrates.
o The inner part of the ear drum
• These vibrations from the eardrum pass through
o The hammer (malleus)
the three bones of the middle ear and into the
o The anvil (incus)
inner ear through the oval window.
o The stirrup (stapes)
• Action of the oval window causes fluids in the
• Delivers sound to the inner ear where it is
cochlea to create waves where they disturb the
processed into a signal that the brain can
basilar membrane.
recognize
• Inner hairs attached to the basilar membrane
convert the waves into electrical impulses that
INNER EAR
are transmitted to the brain by the auditory
• The inner ear contains the most important parts nerve.
of the hearing mechanism - two chambers called • The hair cells are critical to hearing; it is the
the vestibular labyrinth and the cochlea. inner hairs that move in the Organ of Corti
fluids, and translate the fluid movements to
VESTIBULAR LABYRINTH chemical messengers that can in turn be
converted to electrical impulses that the brain
• The vestibular labyrinth consists of elaborately understands.
formed canals (3 semicircular tubes that connect
to one another), which are largely responsible
for the sense of balance.
ASSESSMENT OF THE EAR
HEARING:
COCHLEA
• Weber test
• The cochlea, which begins at the oval window, • Rinne test
curves into a shape that resembles a snail shell. • Whisper test
Tiny hairs line the curves of the cochlea. Both
the labyrinth and cochlea are filled with various INSPECTION:
fluids.
• Auricle and external canal
• Lesions, drainage, redness, pain.
• Tympanic membrane – color

EXTERNAL EAR

• Manipulation does not normally elicit pain

• Tenderness on palpation in the area of the
mastoid: Acute mastoiditis (inflammation of the
posterior auricular node)
• Flaky scaliness on or behind the auricle:
Seborrheic dermatitis

OTOSCOPIC EXAMINATION

• Tympanic membrane: Pearly gray

WHISPER TEST

• Whispers softly from a distance of 1 or 2 feet

from the un-occluded ear and out of the patient's
sight.
 WEBER TEST

• Uses bone conduction to test lateralization of

sound
• Conductive Hearing Loss: Hears the sound
better in the affected ear
• Sensorineural Hearing Loss: Better-hearing
ear TYPANOGRAM

RINNE TEST • Measures middle ear muscle reflex to sound

stimulation and compliance of the tympanic
• Two positions: 2 inches from the opening of the membrane by changing the air pressure in a
ear canal (for air conduction) and against the sealed ear canal.
mastoid bone (for bone conduction).
• Distinguishing between conductive and AUDITORY BRAIN STEM RESPONSE
sensorineural hearing loss
• Normal: Air-conducted sound louder than bone- • Detectable electrical potential from cranial
conducted sound nerve VIII and the ascending auditory
• Conductive Hearing Loss: Hears bone- pathways of the brain stem in response to
conducted sound longer sound stimulation.
• Sensorineural Hearing Loss: Hears air- • Electrodes placed on the forehead
conducted sound longer
ELECTRONYSTAGMOGRAPHY
AUDIOMETRY • Measurement and graphic recording of the
changes in electrical potentials created by eye
2 KINDS
movements during spontaneous, positional, or
calorically evoked nystagmus.
PURE-TONE AUDIOMETRY:
• Used to assess the oculomotor and vestibular
• Sound stimulus consists of a pure or musical systems.
tone. • Vestibular suppressants, such as sedatives,
tranquilizers, antihistamines, and alcohol,
SPEECH AUDIOMETRY:
withheld for 24 hours before testing.
• Spoken word used to determine the ability to
hear and discriminate sounds and words. PLATFORM POSTURAGRAPHY

3 CHARACTERISTICS • Investigate postural control capabilities such as

vertigo
FREQUENCY: • Integration of visual, vestibular, and
proprioceptive cues (sensory integration) with
• Number of sound waves emanating from a motor response output and coordination of the
source per second, measured as cycles per lower limbs tested.
second, or Hertz (Hz) (500 to 2,000 Hz: speech
range or speech frequencies) SINUSOIDAL HARMONIC ACCELERATION
PITCH: • Assess the vestibulo-ocular system by analyzing
• Describe frequency; 100 Hz: low pitch, 10,000 compensatory eye movements in response to
Hz: high pitch the clockwise and counterclockwise rotation of
the chair.
LOUDNESS:
MIDDLE EAR ENDOSCOPY
• Intensity of sound: Decibel (dB), pressure
exerted by sound • Tympanic membrane anesthetized topically for
• Critical level: Approximately 30 Db about 10 minutes before the procedure.
• Louder than 80 dB: Harsh and damaging to the • Irrigated with sterile normal saline solution
inner ear
• Wears earphones and signals to the audiologist EXTERNAL EAR DISORDERS
when a tone is heard
• Applied directly over the external auditory • The ear is a major sense organ. The ear is an
canal: Air conduction measured organ of both hearing and balance
• Applied to the mastoid bone: Nerve • It has three (3) parts:
conduction tested o The outer (external ear)
o Middle ear
o Inner ear
 CONDITIONS OF THE EXTERNAL EAR SIGNS AND SYMPTOMS

• The external ear can be divided functionally and • Discomfort (otalgia): Sensation of fullness or
structurally into two (2) parts, the auricle (pinna) pain in ear, with or without hearing loss
and the external acoustic meatus which ends • Hearing loss
at the tympanic membrane. • Tinnitus
• Dizziness
AURICLE • Chronic cough
• Auricle is a paired structure compound in either
DIAGNOSIS
side of the head. Functions to capture and direct
sound waves towards the external acoustic • Cerumen impaction is diagnosed by direct
meatus. visualization with an otoscope.
• Foreign bodies and a swollen canal from otitis
EXTERNAL ACOUSTIC MEATUS externa can impair tympanic membrane
visualization and should be ruled out before
• External acoustic meatus is a sigmoid shape
attempting cerumen removal.
tube that extends from the deep part of the
concha to the tympanic membrane.
MANAGEMENT
• The wall of the external 1/3 are formed by
cartilage whereas the inner 2/3 are formed by • Cerumen can be removed by irrigation, suction,
the temporal bone. or instrumentation. Unless the patient has a
• While the tympanic membrane lies at the distal perforated eardrum or an inflamed external ear
end of the external acoustic meatus. A (i.e., otitis externa), gentle irrigation with warm
connective tissue structure covered with skin on water usually helps remove impacted cerumen,
the outer and a mucous membrane on the particularly if it is not tightly packed in the
inside. The membrane is connected to the external auditory canal. For successful removal,
surrounding temporal bone by a the water stream must flow behind the
fibrocartilaginous ring. obstructing cerumen to move it first laterally and
then out of the canal. To prevent injury, the
CERUMEN IMPACTION lowest effective pressure should be used.
However, if the eardrum behind the impaction is
• Cerumen normally accumulates in the external perforated, water can enter the middle ear,
canal in various amounts and colors. Although producing acute vertigo and infection. If irrigation
wax does not usually need to be removed, is unsuccessful, direct visual, mechanical
impaction occasionally occurs, causing otalgia removal can be performed by a trained health
(a sensation of fullness or pain in the ear) with or care provider on a patient who is cooperative.
without a hearing loss.
• Accumulation of cerumen as a cause of hearing
loss is especially significant in older adult NOTE: Warm water (never cold or hot) and gentle
patients. Attempts to clear the external auditory (not forceful) irrigation should be used to remove
canal with matches, hairpins, and other cerumen. Irrigation that is too forceful can cause
implements are dangerous because trauma to perforation of the tympanic membrane, and ice water
the skin, infection, and damage to the tympanic causes vomiting.
membrane can occur.
• Accumulation of cerumen that causes symptoms • Instilling a few drops of warmed glycerin, mineral
and prevent assessment of the ear, or both. oil, or half-strength hydrogen peroxide into the
• Cerumen or ear wax – composed of secretion ear canal for 30 minutes prior to irrigation can
and slough epithelial cells and hair from the soften cerumen before its removal.
external auditory canal. Ceruminolytic agents, such as Peroxide in
• It protects the skin in the canal and is naturally Glyceryl (Debrox), are available. The use of
extruded. any softening solution two or three times a day
• Cerumen may accumulate and occlude the for several days is generally sufficient. If the
canal causing such signs and symptoms. cerumen cannot be dislodged by these methods,
• Can contribute to otitis externa because the instruments, such as a cerumen curette, aural
external auditory canal is innervated by the suction, and a binocular microscope for
auricle branch of the vagus nerve. magnification, can be used.
• Coughing and even cardiac depression can
accompany stimulation of the canal from SUMMARY:
cerumen impaction or removal attempts. • Manual removal using a curette
• Irrigation (not with perforated eardrum), suction,
or instrumentation
• Water stream flow behind the obstructing
cerumen to move it first laterally
• Lowest effective pressure used
• Instilling a few drops of warmed glycerin, mineral mineral oil, which will kill the insect and allow it
oil, or half-strength hydrogen peroxide into the to be removed.
ear canal for 30 mins to soften impacted • Attempts to remove a foreign body from the
cerumen external canal may be dangerous in unskilled
• Cerumenolytic Agents: Peroxide in glyceryl hands. The object may be pushed completely
(Debrox) cause an allergic dermatitis reaction into the bony portion of the canal, lacerating the
• Referral to an otolaryngologist skin and perforating the tympanic membrane. In
• The use of cotton swabs, hair pins, match sticks, rare circumstances, the foreign body may have
and ear candles should be avoided. to be extracted in the operating room with the
patient under general anesthesia.
FOREIGN BODIES IRRIGATION, SUCTION, AND
• Some objects are inserted intentionally into the INSTRUMENTATION:
ear by adults who may have been trying to clean • Modified tweezers or forceps to use and reach
the external canal or relieve itching, or by and grab the object with the help of otoscope
children who introduce peas, beans, pebbles, (lighted equipment).
toys, and beads. Insects may also enter the ear • Irrigation with warm water and small catheter
canal. In either case, the effects may range from can flush certain materials out of the canal and
no symptoms to profound pain and decreased clean out the debris.
hearing.
• Profound pain and decreased hearing FOREIGN VEGETABLE BODIES AND INSECTS:
• Common reason for emergency visits, esp. in • Irrigation contraindicated
children.
• The majority are harmless but it is extremely INSECT:
uncomfortable like insects or sharp objects in
• Instilling mineral oil (prior to going to doctor; to
ears.
kill insect and stop the buzzing or scraping
• Some can rapidly produce infection especially if
sensation in the eardrum).
the foreign body is a food or organic matter,
• Should be removed quickly as it causes
requiring emergency treatment.
distressing symptoms and great discomfort.
• Most objects stuck are placed by the person
They may crawl or bite the patient causing
himself, children that are curious about their
further damage.
bodies aging 9 months to 8 years (high risk).
• Common things: Beads, food (beans), paper,
cotton swabs, rubber eraser, small toys,
EXTERNAL OTITIS (OTITIS
marbles, small shells, etc. EXTERNA)
SYMPTOMS • External otitis (i.e., otitis externa), refers to an
inflammation of the external auditory canal.
• Pain • Bacterial or fungal infections are most
• Inflammation frequently encountered. The most common
• Irritation bacterial pathogens associated with external
• Skin in the ear canal and the eardrum is very otitis are Staphylococcus aureus and
sensitive; any inflammation or injury is usually Pseudomonas species. The most common
apparent due to pain or irritation. fungus isolated in both normal and infected ears
• Main signs of injury: Redness, swelling, bloody is Aspergillus (Grossman & Porth, 2014).
discharge, inflammatory fluid or pus • External otitis is often caused by a dermatosis
• Often scratch or rub ear repeatedly such as psoriasis, eczema, or seborrheic
dermatitis. Even allergic reactions to hair spray,
DIAGNOSIS hair dye, and permanent wave lotions can cause
dermatitis, which clears when the offending
• Can be challenging in young children because agent is removed.
they are not old enough to verbalize pain.
CAUSES
MANAGEMENT
• Water in the ear canal (swimmer’s ears)
• Removing a foreign body from the external
• Trauma to the skin of the ear canal
auditory canal can be quite challenging. The
• Permitting entrance of organisms into the tissues
three standard methods for removing foreign
• Systemic conditions, such as vitamin
bodies are the same as those for removing
deficiency and endocrine disorders
cerumen: irrigation, suction, and
instrumentation.
• The contraindications for irrigation are also the
same. Foreign vegetable bodies and insects
tend to swell; thus, irrigation is contraindicated.
Usually, an insect can be dislodged by instilling
 SYMPTOMS NURSING MANAGEMENT

• Patients usually report pain; discharge from

the external auditory canal; aural tenderness
(usually not present in middle ear infections);
and occasionally fever, cellulitis, and
lymphadenopathy.
• Other symptoms may include pruritus and
hearing loss or a feeling of fullness in the ear.
• On otoscopic examination, the ear canal is
erythematous and edematous.
• Discharge may be yellow or green and foul
smelling.
• In fungal infections, hairlike black spores may
be visible

• Pain
• Discharge from the external auditory canal
(yellow or green and foul-smelling) • Nurses should instruct patients not to clean the
• Aural tenderness external auditory canal with cotton-tipped
• Fever (since it is an infection) applicators and to avoid events that traumatize
the external canal, such as scratching the canal
• Cellulitis
with the fingernail or other objects.
• Lymphadenopathy
• Trauma may lead to infection of the canal.
• Pruritus
Patients should also avoid getting the canal wet
• Hearing loss or a feeling of fullness
when swimming or shampooing the hair.
• A cotton ball or lamb’s wool can be covered in
MEDICAL MANAGEMENT
a water-insoluble gel such as petrolatum jelly
• The principles of therapy are aimed at relieving and placed in the ear as a barrier to the canal
the discomfort, reducing the swelling of the ear getting wet.
canal, and eradicating the infection. Patients • Infection can be prevented by using antiseptic
may require analgesic medications for the first otic preparations after swimming (e.g., Swim
48 to 96 hours. Ear, Ear Dry), unless there is a history of
• Treatment most often includes antimicrobial or tympanic membrane perforation or a current ear
antifungal otic medications given by dropper infection.
at room temperature.
• In bacterial infection, a combination antibiotic PATIENT EDUCATION ON THE PREVENTION OF
OTITIS EXTERNA:
and corticosteroid agent may be used to
soothe the inflamed tissues. The nurse instructs the patient to:

• Protect the external canal when swimming,

showering, or washing hair. Use ear plugs or
• Analgesics for the first 48 to 92 hours. place a cotton ball covered in petrolatum
• Wick inserted to keep the canal open so that jelly in the ear, and wear a swim cap. The
liquid medications (Burrow’s solution, antibiotic external canal may be dried afterward with a hair
otic preparations) can be instilled. dryer on low heat.
• Instruct patients not to clean the external • Place alcohol drops in the external canal to act
auditory canal with cotton-tipped applicators as an astringent to help prevent infection after
(fiber of the cotton may get inside the ear). water exposure.
• Avoid getting the canal wet when swimming or • Prevent trauma to the external canal.
shampooing the hair. Procedures, foreign objects (e.g., bobby pin),
• Cotton ball in a water-insoluble gel such as scratching, or any other trauma to the canal that
petroleum jelly as a barrier. breaks the skin integrity may cause infection.
• Alcohol drops may be placed in the external • Be aware that if otitis externa is diagnosed,
canal. refrain from any water sport activity for
• Refrain from any water sport activity for approximately 7–10 days to allow the canal to
approximately 7 to 10 days to allow the canal heal completely. Recurrence is highly likely
to heal completely. unless you allow the external canal to heal
completely.
 MALIGNANT EXTERNAL
OTITIS (TEMPORAL BONE
OSTEOMYELITIS)
• A more serious, although rare, external ear
infection is malignant external otitis (temporal
bone osteomyelitis). This is a progressive,
debilitating, and occasionally fatal infection of
the external auditory canal, the surrounding
tissue, and the base of the skull.
MIDDLE EAR DISORDERS
• A complication of the external otitis externa that • The portion of the ear internal to the eardrum
occurs in an immunocompromised patient. and external to the oval window of the inner ear.
• Pseudomonas aeruginosa is usually the • The mammalian middle ear contains three
infecting organism in patients with low resistance ossicles (tiny bones):
to infection (e.g., patients with acquired immune o Malleus (hammer)
deficiency virus). o Incus
• Successful treatment includes administration of o Stapes (stirrup), which transfers the
antibiotics (usually intravenously [IV]), and vibration of the eardrum into waves in
aggressive local wound care. the fluid and membrane of the inner ear
• Standard parenteral antibiotic treatment includes
the combination of an antipseudomonal TYMPANIC MEMBRANE
agent and an aminoglycoside, both of which
have potentially serious side effects. Because PERFORATION (RUPTURED
aminoglycosides are nephrotoxic and ototoxic, EARDRUM)
serum aminoglycoside levels and kidney and
auditory function must be monitored during • Perforation of the tympanic membrane is usually
therapy. caused by infection or trauma.
• Local wound care includes limited • Sources of trauma include:
debridement of the infected tissue, including o Skull fracture
bone and cartilage, depending on the extent of o Injury from explosion
the infection. o Severe blow to the ear
• Isn’t commonly a complication of swimmer’s • Less frequently, perforation is caused by foreign
ears. objects (e.g., cotton-tipped applicators, hairpins,
• Usually occurs when you have other health keys) that have been pushed too far into the
conditions or is receiving treatment that can external auditory canal.
weaken the immune system (diabetes, • In addition to tympanic membrane perforation,
chemotherapy, HIV, and even AIDS). injury to the ossicles and even the inner ear
• Treatment usually involves antibiotic therapy. may result from this type of trauma.
• The condition can be difficult to treat requiring • During infection, the tympanic membrane can
the patient to take antibiotics for several months. rupture if the pressure in the middle ear exceeds
• You can receive antibiotics intravenously or the atmospheric pressure in the external
through a vein in the arm (if condition is severe). auditory canal.
• Treatment must be continued until tests show • A hole or tear in the thin tissue that separates
that the infection is gone. the inner canal from the eardrum.
• Surgery may be needed if significant tissue • This can result to hearing loss and can make the
damage occurs as a result of infection. It can middle ear vulnerable for infection.
remove damaged tissues and occurs after the • Caused by infection or trauma
infection has been cured. Only the doctor • Tympanic membrane can rupture if the pressure
decides if the client needs surgery or not. in the middle ear exceeds the atmospheric
pressure in the external auditory canal.
GAPPING EARRING PUNCTURE • It usually heals within a few weeks without
treatment but sometimes may require a patch or
• Results from wearing heavy pierced earrings for surgical repair to heal.
a long time or after an infection, or as a reaction
from the earring or other impurities in the
earring.
• Edges of the perforations are excised on the
lateral and medial surfaces of the earlobe.
• Usually requires surgery repair.
 SIGNS AND SYMPTOMS ASSESSMENT AND DIAGNOSTIC FINDINGS

• Ear pain that may subside quickly OTOSCOPE OR MICROSCOPE

• Mucus-like or pus-filled or bloody drainage from
the ear • Ear drum with a visual inspection use a lighted
• Hearing loss instrument.
• Ringing in the ear (Tinnitus)
LABORATORY TEST
• Spinning sensation (Vertigo)
• Nausea and Vomiting resulting from vertigo • If there are discharges from the ear, the doctor
may require laboratory for culture and sensitivity
COMMON CAUSES test to determine what bacterial infection has
caused the disorder.
MIDDLE EAR INFECTION (OTITIS MEDIA)

• Often results from the accumulation of fluids in TUNING FORK EVALUATION

the middle ear. • Two prong metal instruments that produces
• Pressure from these fluids can cause the sounds when struck.
eardrum to rupture. • Helps the doctor detect hearing loss.
• A tympanometer uses a device inserted into the
BARRON’S TRAUMA
ear canal that measures the response of the
• A stress exerted on the eardrum when the air eardrum to slight changes in air pressure.
pressure in the middle ear and the air pressure Certain patterns of response can indicate a
from the environment are out of balance. perforated ear drum.
• If the pressure is severe, the eardrum can
rupture. AUDIOLOGY EXAM
• Often caused by air pressure changes • A series of strict, calibrated test that measures
associated with travel (higher altitudes). how well you hear sound at different volumes
• Other events that can cause certain changes in and pitches.
pressure like scuba diving, an indirect blow to • Conducted in a soundproof booth
the ear such as an impact of an automobile
airbag. MEDICAL MANAGEMENT

LOUD SOUNDS OR BLASTS • Although most tympanic membrane perforations

heal spontaneously within weeks after rupture,
• A loud sound/blast from an explosion or gunshot some may take several months to heal. Some
is essentially overpowering soundwave, can perforations persist because scar tissue grows
really cause a tear in your eardrum. over the edges of the perforation, preventing
extension of the epithelial cells across the
FOREIGN OBJECTS IN THE EAR margins and final healing.
• Small objects such as cotton swabs or hair pin • In the case of a head injury or temporal bone
can puncture or tear the ear drum. fracture, a patient is observed for evidence of
cerebrospinal fluid otorrhea or rhinorrhea—a
SEVERE INJURIES clear, watery drainage from the ear or nose,
respectively. While healing, the ear must be
• Skull-based fractures may cause the protected from water getting into the ear canal.
dislocation or damage to the middle ear and • Heal spontaneously within weeks after rupture
inner ear structure including the ear drum. • Head injury or temporal bone fracture:
Otorrhea
COMPLICATIONS • Tympanoplasty (surgical repair of the tympanic
membrane)
HEARING LOSS

• Usually it is temporary, lasting only until the tear SURGICAL MANAGEMENT

or hole in the eardrum has healed.
• Perforations that do not heal on their own may
require surgery. The decision to perform a
MIDDLE EAR CYSTS OR CHOLESTEATOMA
tympanoplasty is usually based on the need to
• Very rare prevent potential infection from water entering
• This cyst, which is composed of skin cells and the ear or the desire to improve the patient’s
other debris, can develop in the middle ear as hearing.
long-term result of ear drum rupture. • Performed on an outpatient basis,
tympanoplasty may involve a variety of surgical
techniques. In all techniques, tissue (commonly
from the temporalis fascia) is placed across the
perforation to allow healing.
• Surgery is usually successful in closing the
perforation permanently and improving hearing.

ACUTE OTITIS MEDIA

• Ear infections can occur at any age; however,
they are most commonly seen in children. Acute
otitis media (AOM) is an acute infection of the
middle ear, lasting less than 6 weeks.
Pathogens that cause AOM are usually bacterial
or viral and enter the middle ear after eustachian
tube dysfunction caused by obstruction related
to upper respiratory infections, inflammation of
surrounding structures (e.g., rhinosinusitis,
MEDICAL MANAGEMENT
adenoid hypertrophy), or allergic reactions
(e.g., allergic rhinitis). • The outcome of AOM depends on the efficacy of
• Bacteria can enter the eustachian tube from therapy (the prescribed dose of an oral antibiotic
contaminated secretions in the nasopharynx and and the duration of therapy), the virulence of the
the middle ear from a tympanic membrane bacteria, and the physical status of the patient.
perforation. A purulent exudate is usually • With early and appropriate broad-spectrum
present in the middle ear, resulting in a antibiotic therapy, otitis media may resolve with
conductive hearing loss. no serious sequelae. If drainage occurs, an
• Acute infection of the middle ear, usually lasting antibiotic otic preparation is usually prescribed.
less than weeks. • The condition may become subacute (lasting 2
• Causes: weeks to 3 months), with persistent purulent
o Streptococcus pneumonia discharge from the ear. Rarely does permanent
o Haemophilus influenza hearing loss occur.
o Moraxella catarrhalis • Secondary complications involving the mastoid
and other serious intracranial complications,
SYMPTOMS such as meningitis or brain abscess, although
rare, can occur.
• Symptoms of otitis media vary with the severity
of the infection. The condition, usually unilateral
BROAD-SPECTRUM ANTIBIOTIC THERAPY
in adults, may be accompanied by otalgia. The
pain is relieved after spontaneous perforation or • Since it is an infection
therapeutic incision of the tympanic membrane.
Other symptoms may include drainage from the MYRINGOTOMY OR TYMPANOTOMY
ear, fever, and hearing loss.
• Incision in the tympanic membrane to relieve
pain and prevent pressure.
• Painless and takes less than 15 minutes
• Otalgia: Relieved after spontaneous perforation • Allows the drainage to be analyzed (by culture
or therapeutic incision and sensitivity testing)
• Drainage from the ear • Incision heals within 24 to 72 hours
• Fever
• Hearing loss SURGICAL MANAGEMENT
• Absent aural tenderness
MYRINGOTOMY
RISK FACTORS
• A myringotomy (i.e., tympanotomy) is an
• Younger age incision in the tympanic membrane. The
• Chronic upper respiratory infections tympanic membrane is numbed with a local
• Medical conditions that predispose the patient to anesthetic agent such as phenol or by
iontophoresis (i.e., in which electrical current
ear infections (e.g., Down syndrome, cystic
flows through a lidocaine and epinephrine
fibrosis, cleft palate),
solution to numb the ear canal and tympanic
• Chronic exposure to secondhand cigarette
membrane).
smoke
• The procedure is painless and takes less than
15 minutes. Under microscopic guidance, an
incision is made through the tympanic
membrane to relieve pressure and to drain
serous or purulent fluid from the middle ear.
Normally, this procedure is unnecessary for
treating AOM, but it may be performed if pain
persists.
• Myringotomy also allows the drainage to be MANAGEMENT
analyzed (by culture and sensitivity testing) so
that the infecting organism can be identified and • Serous otitis media need not be treated
appropriate antibiotic therapy prescribed. The medically unless infection (i.e., AOM) occurs.
incision heals within 24 to 72 hours.
• If AOM recurs and there is no contraindication, a MYRINGOTOMY
ventilating, or pressure-equalizing, tube may be
• If the hearing loss associated with middle ear
inserted. The ventilating tube, which temporarily
effusion is significant, a myringotomy can be
takes the place of the eustachian tube in
performed, and a tube may be placed to keep
equalizing pressure, is retained for 6 to 18
the middle ear ventilated.
months. The ventilating tube is then extruded
with normal skin migration of the tympanic
CORTICOSTEROIDS
membrane, with the hole healing in nearly every
case. Ventilating tubes are used to treat • Corticosteroids in small doses may decrease
recurrent episodes of AOM. the edema of the eustachian tube in cases of
barotrauma. Decongestants have not proved to
SEROUS OTITIS MEDIA be effective.

(MIDDLE EAR EFFUSION) VALSAVA MANEUVER

• Middle ear effusion, or serous otitis media, • A Valsalva maneuver, which forcibly opens the
involves the presence of fluid, without evidence eustachian tube by increasing nasopharyngeal
of active infection, in the middle ear. In theory, pressure, may be cautiously performed; this
this fluid results from a negative pressure in the maneuver may cause worsening pain or
middle ear caused by eustachian tube perforation of the tympanic membrane.
obstruction.
• When this condition occurs in adults, an
underlying cause for the eustachian tube
CHRONIC OTITIS MEDIA
dysfunction must be sought. Middle ear effusion • Chronic otitis media is recurrent AOM that
is frequently seen in patients after radiation causes irreversible tissue pathology. Chronic
therapy or barotrauma and in patients with infections of the middle ear damage the
eustachian tube dysfunction from a concurrent tympanic membrane, destroy the ossicles, and
upper respiratory infection or allergy. involve the mastoid but are rare in developed
• Barotrauma results from sudden pressure countries.
changes in the middle ear caused by changes in • A long-term infection of the middle ear
barometric pressure, as in scuba diving or
airplane descent. SYMPTOMS
• A carcinoma (e.g., nasopharyngeal cancer)
• Symptoms may be minimal, with varying
obstructing the eustachian tube should be ruled
out in adults with persistent unilateral serous degrees of hearing loss and a persistent or
otitis media. intermittent, foul-smelling otorrhea. Pain is not
usually experienced, except in cases of acute
• Fluid, without evidence of active infection, in the
mastoiditis, when the postauricular area is
middle ear.
tender and may be erythematous and
• Results from a negative pressure in the middle
edematous. Otoscopic examination may show a
ear caused by Eustachian tube obstruction
perforation, and cholesteatoma can be identified
as a white mass behind the tympanic membrane
SYMPTOMS
or coming through to the external canal from a
• Patients may complain of hearing loss, perforation.
fullness in the ear or a sensation of • Cholesteatoma is a tumor of the external layer
congestion, or popping and crackling noises of the eardrum into the middle ear. It is generally
that occur as the eustachian tube attempts to caused by a chronic retraction pocket of the
open. The tympanic membrane appears dull on tympanic membrane, creating a persistently high
otoscopy, and air bubbles may be visualized in negative pressure of the middle ear. The skin
the middle ear. Usually, the audiogram shows a forms a sac that fills with degenerated skin and
conductive hearing loss. sebaceous materials. The sac can attach to the
structures of the middle ear, mastoid, or both.
• Chronic otitis media can cause chronic
mastoiditis and lead to the formation of
• Hearing loss cholesteatoma. It can occur in the middle ear,
• Fullness in the ear or a sensation of congestion mastoid cavity, or both, often dictating the type
• Popping or crackling noises of surgery to be performed. If untreated,
cholesteatoma will continue to enlarge, possibly
causing damage to the facial nerve and
horizontal canal and destruction of other
surrounding structures.
• Cholesteatomas are cystlike lesions of the inner OSSICULOPLASTY
ear. They usually do not cause pain; however, if
treatment or surgery is delayed, they may burst • Surgical reconstruction of the middle ear bones
or destroy the mastoid bone. These fast-growing • Prostheses (Teflon, stainless steel, and
lesions may cause severe sequelae such as hydroxyapatite) reconnect the ossicles
hearing loss. Cholesteatomas found in older
adult patients generally develop in the external MASTOIDECTOMY
canal.
• Performed through a postauricular incision
• Cholesteatomas may be asymptomatic, or they
• Mastoid pressure dressing removed 24 to 48
may cause hearing loss, facial pain and
hours after surgery
paralysis, tinnitus, or vertigo. Audiometric tests
• Evidence of facial paresis reported to the
often show a conductive or mixed hearing loss.
physician
Based on presenting symptoms, diagnosis may
• Analgesic taken for the first 24 hours after
be made by visual examination or by computed
tomography (CT) or MRI scan. Therapy includes surgery
treatment of the acute infection and surgical • Constant, throbbing pain accompanied by fever
removal of the mass to restore hearing. report to the physician.
• Prophylactic antibiotics; prevents water
contamination
• Reduce environmental noise, facing the patient
• Intermittent, foul-smelling otorrhea when speaking, speaking clearly and distinctly
• Pain is not usually experienced: May be due without shouting, and providing good lighting.
to the distraction of the ear drum
• Cholesteatoma: Ingrowth of the skin of the SURGICAL MANAGEMENT
external layer of the eardrum into the middle ear
• Asymptomatic TYMPANOPLASTY
• Hearing loss • The most common surgical procedure for
• Facial pain and paralysis chronic otitis media is tympanoplasty, or surgical
• Tinnitus reconstruction of the tympanic membrane.
• Vertigo Reconstruction of the ossicles may also be
required. The purposes of a tympanoplasty are
MEDICAL MANAGEMENT to reestablish middle ear function, close the
perforation, prevent recurrent infection, and
• Local treatment for chronic otitis media consists
improve hearing.
of careful suctioning of the ear under otoscopic
• There are five types of tympanoplasties. The
guidance. Instillation of antibiotic drops or
simplest surgical procedure, type I
application of antibiotic powder is used to treat
(myringoplasty), is designed to close a
purulent discharge. Systemic antibiotic agents
perforation in the tympanic membrane. The
are prescribed only in cases of acute infection.
other procedures, types II through V, involve
more extensive repair of middle ear structures.
CAREFUL SUCTIONING
The structures and the degree of involvement
can differ, but all tympanoplasty procedures
include restoring the continuity of the sound
INSTILLATION OF ANTIBIOTIC DROPS conduction mechanism.
• Tympanoplasty is performed through the
external auditory canal with a transcanal
approach or through a postauricular incision.
APPLICATION OF ANTIBIOTIC POWDER
The contents of the middle ear are carefully
inspected, and the ossicular chain (malleus and
incus unit) is evaluated. Ossicular interruption is
TYMPANOPLASTY most frequent in chronic otitis media, but
problems of reconstruction can also occur with
• A surgical reconstruction of the tympanic malformations of the middle ear and ossicular
membrane dislocations due to head injuries. Dramatic
improvement in hearing can result from closure
MYRINGOPLASTY of a perforation and reestablishment of the
ossicles. Surgery is usually performed in an
• Simplest surgical procedure
outpatient facility under moderate sedation or
• Performed through the external auditory canal
general anesthesia.
with a transcanal approach or through a
postauricular incision.
• Wick or external auditory canal packing used
 OSSICULOPLASTY women, is a familial condition, and can progress
to complete deafness.
• Ossiculoplasty is the surgical reconstruction of • Results from the formation of new, abnormal
the middle ear bones to restore hearing. spongy bone.
Prostheses made of materials such as Teflon, • Efficient transmission of sound prevented
stainless steel, and hydroxyapatite are used to because the stapes cannot vibrate and carry the
reconnect the ossicles, thereby reestablishing sound more common in women and frequently
the sound conduction mechanism. However, the hereditary.
greater the damage, the lower the success rate
for restoring normal hearing. SYMPTOMS

MASTOIDECTOMY • Otosclerosis may involve one or both ears and

manifests as a progressive conductive or
• The objectives of mastoid surgery are to remove mixed hearing loss. The patient may or may
the cholesteatoma, gain access to diseased not complain of tinnitus.
structures, and create a dry (noninfected) and • Otoscopic examination usually reveals a normal
healthy ear. If possible, the ossicles are tympanic membrane.
reconstructed during the initial surgical • Bone conduction is better than air conduction on
procedure. Occasionally, extensive disease or Rinne testing.
damage dictates that this be performed as part • The audiogram confirms conductive hearing loss
of a two-stage operation. or mixed loss, especially in the low frequencies.
• A mastoidectomy is usually performed through a
postauricular incision. Infection is eliminated by
removing the mastoid air cells. A second
mastoidectomy may be necessary to check for • Conductive or mixed hearing loss
recurrent or residual cholesteatoma. The hearing • Tinnitus
mechanism may be reconstructed at this time.
The success rate for correcting this conductive MEDICAL MANAGEMENT
hearing loss is approximately 75%. Surgery is
usually performed in an outpatient setting. The • The management of otosclerosis can be surgical
patient has a mastoid pressure dressing, which or medical. Amplification with a hearing aid may
can be removed 24 to 48 hours after surgery. help (Grossman & Porth, 2014).
Although infrequently injured, the facial nerve,
which runs through the middle ear and mastoid,
is at some risk for injury during mastoid surgery.
• Use of sodium fluoride, hearing aid also may
As the patient awakens from anesthesia, any
help
evidence of facial paresis should be reported to
• Stapedectomy: Removing the stapes
the primary provider.
superstructure and part of the footplate and
inserting a tissue graft and a suitable prosthesis.
NURSING MANAGEMENT

• Antiemetics or antivertiginous medications DISORDERS OF THE INNER

(antihistamines)
• Avoid heavy lifting, straining, exertion, and nose EAR
blowing for 2 to 3 weeks after surgery • The inner ear is known as the labyrinth of the
(increases ear pressure; rupture of suture lines). ear
• Blow nose gently one side at a time for 1 week • Part of the ear that contains organs of the
after surgery. senses of hearing and equilibrium
• Sneeze and cough with the mouth open. • The bony labyrinth, a cavity in the temporal
• Popping and crackling sensations in the bone, is divided into three sections:
operative ear are normal for approximately 3 to 5 o Vestibule
weeks after surgery. o Semicircular canals
• Shampoo the hair 2 to 3 days postoperatively o Cochlea
if the ear is protected from water by saturating a • Within the bony labyrinth, is a membranous
cotton ball with petroleum jelly. labyrinth, which is also divided into three parts:
o Semicircular ducts
OSTOSCLEROSIS o Two saclike structures, the saccule and
utricle, located in the vestibule
• Otosclerosis involves the stapes and is thought
o Cochlear duct, which is the only part of
to result from the formation of new, abnormal
the inner ear involved in hearing. The
spongy bone, especially around the oval
cochlear duct forms a shelf across the
window, with resulting fixation of the stapes. The
cochlea dividing it into two sections -
efficient transmission of sound is prevented
scala vestibule and scala tympani.
because the stapes cannot vibrate and carry the
• Endolymph: A cushioning fluid that bathes the
sound as conducted from the malleus and incus
entire inner ear
to the inner ear. Otosclerosis is more common in
• Perilymph: Separates the bony and MEDICAL MANAGEMENT
membranous labryrinths
• Disorders of balance are common, and dizziness • Over-the-counter antihistamines such as
may increase the risk of falls. Dimenhydrinate (Dramamine) or Meclizine
(Antivert) may provide some relief of nausea
DIZZINESS and vomiting by blocking the conduction of the
vestibular pathway of the inner ear.
• The term dizziness is used frequently by • Anticholinergic medications, such as
patients and health care providers to describe Scopolamine patches (Transderm Scop), may
any altered sensation of orientation in space also be effective because they antagonize the
and is more commonly referred to as histamine response.
lightheadedness. • These must be applied several hours before
exposure to motion and replaced every 3
VERTIGO days.
• Vertigo is the misperception or illusion of • Side effects such as dry mouth and
motion of the person or the surroundings. drowsiness may occur.
Most patients with vertigo describe a spinning • Potentially hazardous activities such as driving a
sensation or say they feel as though objects are car or operating heavy machinery should be
moving around them. avoided if drowsiness occurs.

ATAXIA MENIERE DISEASE

• Ataxia is a failure of muscular coordination and • Ménière disease is an abnormality in inner ear
may be present in patients with vestibular fluid balance caused by a malabsorption in the
disease. endolymphatic sac or a blockage in the
• Syncope, fainting, and loss of consciousness endolymphatic duct. Endolymphatic hydrops
are not forms of vertigo and usually indicate (dilation of the endolymphatic space) develops,
disease in the cardiovascular system. and either increased pressure in the system or
rupture of the inner ear membrane occurs,
NYSTAGMUS producing symptoms of Ménière disease.
• Ménière disease affects 10 to 12 of 1000 people
• Nystagmus is the involuntary rhythmic in the United States. It is estimated that there
movement of the eyes. It occurs normally when are 615,000 cases in the United States, with
a person watches a rapidly moving object (e.g., approximately 45,500 new cases diagnosed
through the side window of a moving car or annually. More common in adults, onset is
train). generally seen when adults reach their 40s, with
• However, pathologically, it is an ocular disorder symptoms usually beginning between the ages
associated with vestibular dysfunction. of 20 and 60 years. Ménière disease appears to
• Nystagmus can be horizontal, vertical, or rotary be equally common in men and women, and is
and can be caused by a disorder in the central usually bilateral.
or peripheral nervous system. • Abnormal inner ear fluid balance caused by a
malabsorption in the endolymphatic sac or a
MOTION SICKNESS blockage in the endolymphatic duct.
o Cochlear: Absence of vestibular
• Motion sickness is a disturbance of equilibrium
symptoms (dizziness or balance) or
caused by constant motion. findings
• For example, it can occur aboard a ship, while o Vestibular: No cochlear symptoms
riding on a merrygo-round or swing, or in a car. (hearing loss)
• Common in travelers
• “Byahilo” SYMPTOMS
• Disturbance of equilibrium caused by constant
motion • Ménière disease is characterized by a triad of
symptoms: episodic vertigo, tinnitus (unwanted
SYMPTOMS noises in the head or ear), and fluctuating
sensorineural hearing loss. It may also include a
• The syndrome manifests itself in sweating, feeling of pressure or fullness in the ear and
pallor, nausea, and vomiting caused by incapacitating vertigo, often accompanied by
vestibular overstimulation. These nausea and vomiting (Hansson & Brattmo, 2013;
manifestations may persist for several hours NIDCD, 2015b). These symptoms range in
after the stimulation stops. severity from a minor nuisance to extreme
disability, especially if the attacks of vertigo are
severe. At the onset of the disease, usually only
one or two of the symptoms are manifested.
• Sweating
• Some characterize the disease into two subsets:
• Pallor
cochlear and vestibular.
• Nausea and Vomiting
 COCHLEAR MENIERE disrupts the delicate balance between endolymph and
perilymph in the inner ear. Psychological evaluation and
• Cochlear Ménière disease is recognized as a cognitive therapy may be indicated if a patient is
fluctuating, progressive sensorineural hearing anxious, uncertain, fearful, or depressed.
loss associated with tinnitus and aural pressure
in the absence of vestibular symptoms or • Low-sodium or sugar (2000 mg/day) diet
findings. • Antihistamines: Meclizine (Antivert);
suppresses the vestibular system
VESTIBULAR MENIERE • Tranquilizers: Diazepam (Valium); controls
vertigo
• Vestibular Ménière disease is characterized as
• Antiemetics: Promethazine (Phenergan);
the occurrence of episodic vertigo associated
suppositories control the nausea & vomiting
with aural pressure but no cochlear symptoms.
• Diuretic Therapy: Hydrochlorothiazide; Foods
Patients may experience either cochlear or
containing potassium (bananas, tomatoes,
vestibular disease symptoms; however,
oranges)
eventually all of these symptoms develop.
• Meals and snacks at regular intervals
• Eat fresh fruits, vegetables, and whole grains
• Drink plenty of fluids daily: Water, milk, and
• Fluctuating, progressive sensorineural hearing low sugar fruit juices
loss • Avoid caffeine because of its diuretic effect
• Tinnitus or a roaring sound • Avoid monosodium glutamate (MSG), aspirin
• A feeling of pressure or fullness in the ear and aspirin containing medications
• Vertigo accompanied by nausea and vomiting • Middle and Inner Ear Perfusion: Ototoxic
medications, such as Streptomycin or
ASSESSMENT AND DIAGNOSTIC FINDINGS Gentamicin administered by infusion into the
middle ear and inner ear.
VERTIGO • Intra-otologic Catheters: Catheters developed
to provide a conduit from the outer ear to the
• Vertigo is usually the most troublesome
inner ear.
complaint related to Ménière disease. A careful
• Vestibular Nerve Sectioning: Performed by a
history is taken to determine the frequency,
trans-labyrinthine approach, cutting the nerve
duration, severity, and character of the vertigo
prevents the brain from receiving input from the
attacks. Vertigo may last minutes to hours,
semicircular canals.
possibly accompanied by nausea or vomiting.
Diaphoresis and a persistent feeling of
DIETARY GUIDELINES
imbalance or disequilibrium may awaken
patients at night. Some patients report that these
THE NURSE INSTRUCTS THE PATIENT TO:
feelings last for days. However, they usually feel
well between attacks. Hearing loss may • Limit foods high in salt or sugar. Be aware of
fluctuate, with tinnitus and aural pressure waxing foods with hidden salts and sugars.
and waning with changes in hearing. These • Eat meals and snacks at regular intervals to stay
feelings may occur during or before attacks, or hydrated. Missing meals or snacks may alter the
they may be constant. fluid level in the inner ear.
• Physical examination findings are usually • Eat fresh fruits, vegetables, and whole grains.
normal, with the exception of those of cranial Limit the amount of canned, frozen, or
nerve VIII. Sounds from a tuning fork (Weber processed foods with high sodium content.
test) may lateralize to the ear opposite the • Drink plenty of fluids daily. Water, milk, and low-
hearing loss, the one affected with Ménière sugar fruit juices are recommended. Limit intake
disease. An audiogram typically reveals a of coffee, tea, and soft drinks. Avoid caffeine
sensorineural hearing loss in the affected ear. because of its diuretic effect.
This can be in the form of a “Pike’s Peak” • Limit alcohol intake. Alcohol may change the
pattern, which looks like a hill or mountain. A volume and concentration of the inner ear fluid
sensorineural loss in the low frequencies occurs and may worsen symptoms.
as the disease progresses. The • Avoid monosodium glutamate (MSG), which
electronystagmogram may be normal or may may increase symptoms.
show reduced vestibular response. • Pay attention to the intake of foods containing
potassium (e.g., bananas, tomatoes, oranges) if
MEDICAL MANAGEMENT taking a diuretic that causes potassium loss.
• Avoid aspirin and aspirin-containing
Most patients with Ménière disease can be successfully
medications. Aspirin may increase tinnitus and
treated with diet and medication. Many patients can
dizziness.
control their symptoms by adhering to a low-sodium
(1000 to 1500 mg/day or less) diet. The amount of
sodium is one of many factors that regulate the balance
of fluid within the body. Sodium and fluid retention
 • Benign paroxysmal positional vertigo is a brief
LABYRINTHITIS
period of incapacitating vertigo that occurs
• Labyrinthitis, an inflammation of the labyrinth of when the position of the patient’s head is
the inner ear, can be bacterial or viral in origin. changed with respect to gravity, typically by
• Bacterial labyrinthitis is rare because of antibiotic placing the head back with the affected ear
therapy, but it sometimes occurs as a turned down. The onset is sudden and followed
complication of otitis media. by a predisposition for positional vertigo, usually
• The infection can spread to the inner ear by for hours to weeks but occasionally for months
penetrating the membranes of the oval or round or years.
windows. • Benign paroxysmal positional vertigo is thought
• Viral labyrinthitis is a common diagnosis, but to be due to the disruption of debris within the
little is known about this disorder, which affects semicircular canal. This debris is formed from
hearing and balance. The most common viral small crystals of calcium carbonate from the
causes are mumps, rubella, rubeola, and inner ear structure (the utricle). This is frequently
influenza. stimulated by head trauma, infection, or other
• Viral illnesses of the upper respiratory tract and events. In severe cases, vertigo may easily be
herpetiform disorders of the facial and acoustic induced by any head movement. The vertigo is
nerves (i.e., Ramsay Hunt syndrome) also usually accompanied by nausea and vomiting;
cause labyrinthitis. however, hearing impairment does not generally
occur.
SYMPTOMS
CAUSES
• Labyrinthitis is characterized by a sudden onset
of incapacitating vertigo, usually with nausea • Frequently stimulated by head trauma
and vomiting, various degrees of hearing • Infection
loss, and possibly tinnitus. The first episode is • Other events
usually the worst; subsequent attacks, which
usually occur over a period of several weeks to MANAGEMENT
months, are less severe.
• Bed rest is recommended for patients with
acute symptoms.
• Repositioning techniques can be used to treat
• Incapacitating vertigo vertigo. The canalith repositioning procedure,
• Nausea and vomiting also known as the Epley maneuver, is
• Hearing loss commonly used. noninvasive This procedure,
• Tinnitus: 1st episode is worst; subsequent which involves quick movements of the body,
attacks rearranges the debris in the canal. The
procedure is performed by placing the patient in
MEDICAL MANAGEMENT a sitting position, turning the head to a 45-
degree angle on the affected side, and then
• Treatment of bacterial labyrinthitis includes IV quickly moving the patient to the supine position.
antibiotic therapy, fluid replacement, and The procedure is safe, inexpensive, and easy to
administration of an antihistamine (e.g., perform. Patients with acute vertigo may be
meclizine) and antiemetic medications. treated with Meclizine for 1 to 2 weeks. After
• Treatment of viral labyrinthitis is based on the this time, the Meclizine is stopped and the
patient’s symptoms. patient is reassessed.
• Patients who continue to have severe positional
vertigo may be premedicated with
Prochlorperazine (Compazine) 1 hour before
• IV antibiotic therapy the canalith repositioning procedure is
• Fluid replacement performed.
• Administration of an antihistamine (Meclizine) • Vestibular rehabilitation can be used in the
• Antiemetic medications management of vestibular disorders. This
strategy promotes active use of the vestibular
BENIGN PAROXYSMAL system through an interdisciplinary team
approach, including medical and nursing care,
POSITIONAL VERTIGO (BPPV) stress management, biofeedback, vocational
• Brief period of incapacitating vertigo occurs rehabilitation, and physical therapy. A physical
when the position of head is changed with therapist prescribes balance exercises that help
respect to gravity. the brain compensate for the impairment to the
• Due to the disruption of debris within the balance system.
semicircular canal
• Debris formed from small crystals of calcium
carbonate from the inner ear structure, the
utricle.
 • An MRI scan with a contrast agent (i.e.,
OTOTOXICITY
Gadolinium or Gadopentetate [Magnevist]) is
• A variety of medications may have adverse the imaging study of choice. If the patient is
effects on the cochlea, vestibular apparatus, or claustrophobic or cannot undergo an MRI scan
cranial nerve VIII. All but a few, such as aspirin for other reasons, or if the scan is unavailable, a
and quinine, cause irreversible hearing loss. CT scan with contrast dye is performed.
Aspirin toxicity can produce bilateral tinnitus. However, MRI is more sensitive than CT in
IV medications, especially the delineating a small tumor.
aminoglycosides, are a common cause of
ototoxicity, because they destroy the hair cells in MEDICAL MANAGEMENT
the organ of Corti.
• Conservative treatment is recommended for
• Antineoplastic agents also cause hair cell death
patients with tumors less than 1.5 cm and in
in the cochlea, which can lead to hearing loss.
those who are older. In addition, routine
These medications can be found in the body
monitoring is recommended for these patients.
several months later; side effects are dose
dependent, with higher doses causing increased • For patients who are at low risk, surgical
ototoxicity. Therefore, hearing loss may occur at removal of the acoustic tumor is the treatment of
any time, even several months after the last choice because these tumors do not respond
dose of the medication was given. well to radiation or chemotherapy. Because
treatment of acoustic tumors crosses several
• To prevent loss of hearing or balance, patients
specialties, the interdisciplinary treatment
receiving potentially ototoxic medications should
approach involves a neurologist and a
be counseled about their side effects. These
neurosurgeon.
medications should be used with caution in
patients who are at high risk for complications, • The objective of the surgery is to remove the
such as children, older adults, patients who are tumor while preserving facial nerve function.
pregnant, patients with kidney or liver problems, • Most acoustic tumors have damaged the
and patients with current hearing disorders. cochlear portion of cranial nerve VIII, and
Blood levels of the medications should be hearing is impaired. In these patients, the
monitored, and patients receiving long-term IV surgery is performed using a translabyrinthine
antibiotics should be monitored with an approach, and the hearing mechanism is
audiogram twice each week during therapy. destroyed.
• If hearing is still good before surgery, a
suboccipital or middle cranial fossa approach to
ACOUSTIC NEUROMA removing the tumor may be used. This
• Acoustic neuromas, also referred to as procedure exposes the lateral third of the
vestibular schwannomas, are slow-growing, internal auditory canal and preserves hearing
benign tumors of cranial nerve VIII, usually (Park et al., 2015).
arising from the Schwan cells of the vestibular • Potential complications of surgery include
portion of the nerve. Most acoustic tumors arise facial nerve paralysis, cerebrospinal fluid
within the internal auditory canal and extend into leakage, meningitis, and cerebral edema.
the cerebellopontine angle to press on the brain • Death from acoustic neuroma surgery is rare
stem, possibly destroying the vestibular nerve. (Park et al., 2015)
Most acoustic neuromas are unilateral, except in
von Recklinghausen disease
(neurofibromatosis type 2), in which bilateral
tumors occur.
• Acoustic neuromas develop in 1 of every
100,000 people per year. These neuromas
account for 6% of all intracranial tumors and
seem to occur with equal frequency in men and
women at any age, although most occur during
middle age.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• The most common assessment findings of

patients with acoustic neuromas are unilateral
tinnitus and hearing loss with or without
vertigo or balance disturbance. It is important
to identify asymmetry in audiovestibular test
results so that further workup can be performed
to rule out an acoustic neuroma.
• Although conflicting data exist, the only known
risk factor for acoustic neuroma is cell phone
usage.