EAR NOSE AND THROAT CONDITIONS notes.pptx

EAR NOSE AND THROAT
CONDITIONS
BY KIM I.S

EAR CONDITIONS
ANATOMY REVIEW IN SUMMARY
• Hearing and Equilibrium
• 1. The external (outer) ear consists of the auricle,
external auditory canal, and tympanic membrane
(eardrum).
• 2. The middle ear consists of the auditory tube,
ossicles, oval window, and round window.
• 3. The internal (inner) ear consists of the bony labyrinth
and membranous labyrinth. The internal ear contains
the spiral organ (organ of Corti), the organ of hearing.

• 4. Sound waves enter the external auditory canal, strike
the tympanic membrane, pass through the ossicles, strike
the oval window, set up waves in the perilymph, strike
the vestibular membrane and scala tympani, increase
pressure in the endolymph, vibrate the basilar
membrane, and stimulate hair bundles on the spiral
organ (organ of Corti).
• 5. Hair cells convert mechanical vibrations into a receptor
potential, which releases neurotransmitter that can
initiate nerve impulses in first-order sensory neurons.

• 6. Sensory axons in the cochlear branch of the
vestibulocochlear (VIII) nerve terminate in the medulla
oblongata. Auditory signals then pass to the inferior
colliculus, thalamus, and temporal lobes of the cerebral
cortex.
• 7. Static equilibrium is the orientation of the body relative
to the pull of gravity. The maculae of the utricle and
saccule are the sense organs of static equilibrium. Body
movements that stimulate the receptors for static
equilibrium include tilting the head and linear
acceleration or deceleration.

• 8. Dynamic equilibrium is the maintenance of
body position in response to rotational
acceleration or deceleration. The cristae in the
semicircular ducts are the main sense organs
of dynamic equilibrium.
• 9. Most vestibular branch axons of the
vestibulocochlear nerve enter the brain stem
and terminate in the medulla and pons; other
axons enter the cerebellum.

Development of the Eyes and Ears
• 1. The eyes begin their development about 22 days after
fertilization from ectoderm of the lateral walls of the
prosencephalon (forebrain).
• 2. The ears begin their development about 22 days after
fertilization from a thickening of ectoderm on either side of
the rhombencephalon (hindbrain). The sequence of
development of the ear is internal ear, middle ear, and
external ear.
• 4. With age there is a progressive loss of hearing, and
tinnitus occurs more frequently.
•

ASSESSMENT OF THE EAR
Inspection of the External Ear
• The external ear is examined by inspection and direct
palpation.
• Inspect the auricle and surrounding tissues for
deformities, lesions, and discharge, as well as size,
symmetry, and angle of attachment to the head.
• Manipulation of the auricle does not normally elicit
pain.
• If this maneuver is painful, acute external otitis is
suspected.

• Tenderness on palpation in the area of the mastoid
may indicate acute mastoiditis or inflammation of
• the posterior auricular node.
• Occasionally, sebaceous cysts and tophi
(subcutaneous mineral deposits) are present on
• the pinna.
• A flaky scaliness on or behind the auricle usually
indicates seborrheic dermatitis and can be present
on the scalp and facial structures as well.

Otoscopic Examination
• The tympanic membrane is inspected with an
otoscope.
• The external auditory canal is examined for discharge,
inflammation, or a foreign body.
• The healthy tympanic membrane is pearly gray and is
positioned obliquely at the base of the canal. The
position and color of the membrane and any unusual
markings or deviations from normal are documented.

Otologic examination cont.....
• The presence of fluid, air bubbles, blood, or
masses in the middle ear also should be noted.
• For proper otoscopic examination of the
external auditory canal and tympanic
membrane requires that the canal be free of
large amounts of cerumen.
• Cerumen buildup is a common cause of hearing
loss and local irritation.

Evaluation of Gross Auditory Acuity
1.)Whisper Test
• To exclude one ear from the testing, the
examiner covers the untested ear with the
palm of the hand. Then the examiner whispers
softly from a distance of 1 or 2 feet from the
unoccluded ear and out of the patient’s sight.
• The patient with normal acuity can correctly
repeat what was whispered.

2.) Weber Test
• The Weber test uses bone conduction to test
lateralization of sound.
• A tuning fork , set in motion by grasping it
firmly by its stem and tapping it on the
examiner’s
• knee or hand, is placed on the patient’s head
or forehead.

Weber test cont....
• Results
• A person with normal hearing hears the sound equally in
both ears or describes the sound as centered in the middle of
the head.
• A person with conductive hearing loss, such as from
otosclerosis or otitis media, hears the sound better in the
affected ear.
• A person with sensorineural hearing loss, resulting from
damage to the cochlear or vestibulocochlear nerve, hears the
sound in the better-hearing ear.
• The Weber test is useful for detecting unilateral hearing loss

3.)Rinne Test
• In the Rinne test ,the examiner shifts the stem of
a vibrating tuning fork between two positions:
• 2 inches from the opening of the ear canal (for
air conduction) and against the mastoid bone
(for bone conduction) .
• As the position changes, the patient is asked to
indicate which tone is louder or when the tone is
no longer audible.

Rinne test cont...
• Results
• A person with normal hearing reports that air-
conducted sound is louder than bone-conducted
sound. A person with a conductive hearing loss hears
bone-conducted sound as long as or longer than air-
conducted sound.
• A person with a sensorineural hearing loss hears air-
conducted sound longer than bone-conducted sound.
• The Rinne test is useful for distinguishing between
conductive and sensorineural hearing loss.

3. Schwabach`s test
• Procedure: A turning fork is sounded and
placed on the mastoid process of the patient.
Whenever the patient ceases to hear the
tuning fork, it is transferred to the mastoid
process of the examiner, and if the examiner
can hear the tuning fork the scwabach test on
the patient is shortened. This test presupposes
perfect hearing on the part of the examiner.

•
• Audiometry
• In detecting hearing loss, audiometry is the single most
important diagnostic instrument.
• Audiometric testing is of two kinds:-
• 1. pure-tone audiometry, in which the sound stimulus
consists of a pure or musical tone (the louder the tone before
the patient perceives it, the greater the hearing loss).
• 2. speech audiometry, in which the spoken word is used to
determine the ability to hear and discriminate sounds and
words.

• With audiometry, the patient wears earphones and signals
to the audiologist when a tone is heard. When the tone is
applied directly over the external auditory canal, air
conduction is measured.
• When the stimulus is applied to the mastoid bone,
bypassing the conductive mechanism (ie, the ossicles),
nerve conduction is tested.
• For accuracy, testing is performed in a soundproof room.
• Responses are plotted on a graph known as an audiogram,
which differentiates conductive from sensorineural hearing
loss.

• When evaluating hearing, three characteristics
are important:
1. frequency
2. pitch
3. intensity

• 1.) Frequency- refers to the number of sound
waves emanating from a source per second,
measured as cycles per second, or Hertz (Hz).
• The normal human ear perceives sounds
ranging in frequency from 20 to 20,000 Hz.
• The frequencies from 500 to 2000 Hz are
important in understanding everyday speech
and are referred to as the speech range or
speech frequencies.

• 2.) Pitch is the term used to describe frequency; a
tone with 100 Hz is considered of low pitch, and a
tone of 10,000 Hz is considered of high pitch.
• The unit for measuring loudness (intensity of
sound) is the decibel (dB), the pressure exerted
by sound.
• Hearing loss is measured in decibels.
• The critical level of loudness is approximately 30
dB.

Pitch cont...
• The shuffling of papers in quiet surroundings is about
15 dB.
• Low conversation, 40 dB.
• Jet plane 100 feet away, about 150 dB.
• Sound louder than 80 dB is perceived by the human
ear to be harsh and can be damaging to the inner ear.
• In surgical treatment of patients with hearing loss,
the aim is to improve the hearing level to 30 dB or
better within the speech frequencies.

• HEARING LOSS
• Hearing impairment has been reported to occur in 3 of every
1000 births, and approximately one half of the time it is
related to genetic factors.
• Ideally all hospitals or birthing centers should have universal
hearing screenings for all newborns after birth and prior to
discharge.
• Hearing loss is greater in men than in women.
• Hearing loss risk increases with age.(>55yrs .)
• Occupations such as carpentry, plumbing, and coal mining
have the highest risk of noise-induced hearing loss.

• CONDUCTIVE HEARING LOSS- usually results from an
external ear disorder, such as impacted cerumen, or a
middle ear disorder, such as otitis media or otosclerosis.
• In such instances, the efficient transmission of sound by
air to the inner ear is interrupted.
• A SENSORINEURAL LOSS- involves damage to the
cochlea or vestibulocochlear nerve.
• Mixed hearing loss and functional hearing loss also may
occur.
•

• Patients with mixed hearing loss have
conductive loss and sensorineural loss,
resulting from dysfunction of air and bone
conduction.
• A functional (or psychogenic) hearing loss is
nonorganic and unrelated to detectable
structural changes in the hearing mechanisms;
it is usually a manifestation of an emotional
disturbance.

Risk Factors for Hearing Loss
1. • Family history of sensorineural impairment
2. • Congenital malformations of the cranial structure (ear)
3. • Low birth weight (_1500 g)
4. • Use of ototoxic medications (eg, gentamycin, loop diuretics)
5. • Recurrent ear infections
6. • Bacterial meningitis
7. • Chronic exposure to loud noises
8. • Perforation of the tympanic membrane
9. Diabetes is partially responsible for sensorineural hearing
loss.

• Clinical Manifestations
• Early manifestations of hearing impairment
and loss may include:-
tinnitus
increasing inability to hear when in a group
a need to turn up the volume of the television.

• A person at home may feel isolated because of
an inability to hear the clock chime or to hear
the telephone.
• A pedestrian who is hearing-impaired may
attempt to cross the street and fail to hear an
approaching car.
• People with impaired hearing may miss parts
of a conversation.

• Hearing impairment can also trigger changes in
attitude, the ability to communicate, the awareness of
surroundings, and even the ability to protect oneself,
affecting a person’s quality of life.
• In a classroom, a student with impaired hearing may
be uninterested and inattentive and have failing
grades.
• Often, it is not the person with the hearing loss but
the people with whom he or she is communicating
who recognizes the impairment first.

• Prevention
• For prevention target the above risk factors (refer-
and note).
• Many environmental factors have an adverse effect
on the auditory system and, with time, result in
permanent sensorineural hearing loss.
• The most common is noise.
• Noise (unwanted and unavoidable sound) has been
identified as one of today’s environmental hazards.

Prevention cont...
• The volume of noise that surrounds us daily has increased into a
potentially dangerous source of physical and psychological damage.
• Loud, persistent noise has been found to cause constriction of
peripheral blood vessels, increased blood pressure and heart rate
(because of increased secretion of adrenalin), and increased
gastrointestinal activity.
• Although research is needed to address the overall effects of noise
on the human body, a quiet environment is more conducive to
peace of mind.
• A person who is ill feels more at ease when noise is kept to a
minimum.
• Numerous factors contribute to hearing loss.

Prevention cont...
• Noise-induced hearing loss -refers to hearing
loss that follows a long period of exposure to
loud noise (eg, heavy machinery, engines,
artillery, rock-band music).
• Acoustic trauma -refers to hearing loss caused
by a single exposure to an extremely intense
noise, such as an explosion.
• Usually, noise-induced hearing loss occurs at a
high frequency (about 4000 Hz).

Prevention cont...
• However, with continued noise exposure, the
hearing loss can become more severe and
include adjacent frequencies.
• The minimum noise level known to cause noise-
induced hearing loss, regardless of duration, is
about 85 to 90 dB.
• Hearing loss due to noise is permanent because
the hair cells in the organ of Corti are
destroyed.

MEDICAL MANAGEMENT
• AURAL REHABILITATION
• If hearing loss is permanent or cannot be treated by
medical or surgical means or if the patient elects not to
undergo surgery, aural rehabilitation may be beneficial.
• It is important to identify the type of hearing
impairment a person has so that rehabilitative efforts
can be directed at his or her particular need.
• The purpose of aural rehabilitation is to maximize the
communication skills of the person with hearing
impairment.

• Aural rehabilitation includes:-
auditory training
speech reading
speech training
use of hearing aids and hearing guide dogs.

• 1. AUDITORY TRAINING
• Auditory training emphasizes listening skills, so the
person who is hearing-impaired concentrates on the
speaker.
• 2. SPEECH READING
• The goals of speech training are to conserve, develop,
and prevent deterioration of current communication
skills.
• Speech reading (also known as lip reading) can help fill
the gaps left by missed or misheard words.

• 3. HEARING AIDS
• A hearing aid is a device through which speech and
environmental sounds are received by a microphone,
converted to electrical signals, amplified, and reconverted
to acoustic signals.
• With advances in hearing aid technology, amplification for
patients with sensorineural hearing loss is more helpful
than ever.
• A hearing aid makes sounds louder, but it does not improve
a patient’s ability to discriminate words or understand
speech.

4.HEARING GUIDE DOGS
• Specially trained dogs (service dogs) are available to assist the
person with a hearing loss.
• People who live alone are eligible to apply for a dog trained by
International Hearing Dog.
• The dog reacts to the sound of a telephone, a doorbell, an alarm
clock, a baby’s cry, a knock at the door, a smoke alarm, or an
intruder.
• The dog alerts its master by physical contact; the dog then runs to
the source of the noise.
• In public, the dog positions itself between the person with hearing
impairment and any potential hazard that the person cannot hear,
such as an oncoming vehicle or a loud, hostile person.

• SURGERY
• Surgical correction may be all that is necessary
to treat and improve a conductive hearing loss
by eliminating the cause of the hearing loss.

• COMPLICATION OF HEARING AIDS
• 1. external otitis
• 2. pressure ulcers.
• NB/Advice clients that ,If any of these
symptoms are present, notify your health care
provider for evaluation.May need medication
to treat infection, pain, or both.

CONDITIONS OF THE EXTERNAL EAR
• Cerumen Impaction
• Cerumen normally accumulates in the external canal in
various amounts and colors.
• Although wax does not usually need to be removed,
impaction occasionally occurs.
• Accumulation of cerumen as a cause of hearing loss is
especially significant in the elderly population.
• SIGNS AND SYMPTOMS
• 1.otalgia- a sensation of fullness or pain in the ear
• 2 a hearing loss.

• Management
• Attempts to clear the external auditory canal with
matches, hairpins, and other implements are
dangerous because trauma to the skin, infection,
and damage to the tympanic membrane can occur.
• Cerumen can be removed by:-
irrigation
suction
instrumentation.

Ear Irrigition
• -Contraindicated in perforated eardrum,(when water enter the
middle ear, it produces acute vertigo and infection) or an otitis
externa.
• -Gentle irrigation usually helps remove impacted cerumen.
• -For successful removal, the water stream must flow behind the
obstructing cerumen to move it first laterally and then out of
the canal.
• -To prevent injury, the lowest effective pressure should be used.
• -If irrigation is unsuccessful, direct visual, mechanical removal
can be performed on a cooperative patient by a trained health
care provider.

• Instilling a few drops of warmed glycerin, mineral oil,
or half-strength hydrogen peroxide into the ear canal
for 30 minutes can soften cerumen before its removal.
• Ceruminolytic agents, such as peroxide in glyceryl
(Debrox), are available; however, these compounds
may cause an allergic dermatitis reaction.
• If the cerumen cannot be dislodged by these
methods, instruments, such as a cerumen curette,
aural suction, and a binocular microscope for
magnification, can be used.

• FOREIGN BODIES
• Some objects are inserted intentionally into the
ear by adults who may have been trying to clean
the external canal or relieve itching or by children
who introduce peas, beans, pebbles, toys, and
beads. Insects may also enter the ear canal.
• S&S
• range from no symptoms to profound pain and
decreased hearing.

• Management
• Removing a foreign body from the external
auditory canal
• can be quite challenging.
• The three standard methods are used:-
Irrigation
Suction
Instrumentation.

• The contraindications for irrigation are:-
 Perforated eardrum
 Foreign vegetable bodies and insects ; this because they tend to
swell.
• Usually, an insect can be dislodged by instilling mineral oil, which
will kill the insect and allow it to be removed.
• This procedure should be done by skilled personnel , because the
object may be pushed completely into the bony portion of the
canal, lacerating the skin and perforating the tympanic membrane.
• In rare circumstances, the foreign body may have to be extracted
in the operating room with the patient under general anaesthesia.

EXTERNAL OTITIS (Otitis Externa)
• Def: It is the inflammation of the external auditory canal.
Etiological factors
• 1. water in the ear canal (swimmer’s ear)
• 2. trauma to the skin of the ear canal- permitting entrance
of organisms into the tissues.
• 3. systemic conditions, such as vitamin deficiency and
endocrine disorders (eg DM).
• 4. dermatosis eg psoriasis, eczema, or seborrheic dermatitis
• Bacterial eg S.aureus ,Pseudomonas) or fungal eg Aspergillus)
are the most common microorganisms respectively.

Clinical Manifestation
• 1.Pain
• 2.Pulurent discharge from the external auditory canal
• 3.Aural tenderness (Absent in middle ear infections)
• 4.occasionally fever, cellulitis, and lymphadenopathy.
• 5 Pruritus
• 6.Hearing loss or a feeling of fullness.
• 7.On otoscopic examination, the ear canal is
erythematous and oedematous.
• 8.In fungal infections, hair-like black spores visible.

• Medical Management
• The principles of therapy are aimed at:-
relieving the discomfort
reducing the swelling of the ear canal
eradicating the infection

• Pharmacologic mgt
• Analgesics- to relieve pain eg paracetamol, diclofenac
• Antibiotics ear drops, however in case of cellulitis and fever
systemic antibiotics are prescribed.
• Corticosteroids to soothe and relieve inflammation.
• If the tissues of the external canal are edematous, a wick
should be inserted to keep the canal open so that liquid
medications (eg, Burow’s solution, antibiotic otic preparations)
can be introduced.
•
•

Nursing Management
• -Instruct the patients not to clean the external auditory
canal with cotton-tipped applicators, and scratching the
canal with the fingernail or other objects (It traumatize the
external canal).
• -To avoid getting the canal wet when swimming or
shampooing the hair.
• - A cotton ball can be covered in a water-insoluble gel such
as petroleum jelly and placed in the ear as a barrier to
water contamination.
• -Infection can be prevented by using antiseptic otic
preparations after swimming.

• Prevention of Otitis Externa
• Protect the external canal when swimming,
showering, or washing hair. Ear plugs or a swim
cap should be worn.
Drying the external canal afterward with a hair
dryer on low heat may be suggested.
• Alcohol drops may be placed in the external
canal to act as an astringent to help prevent
infection after water exposure.

• Prevent trauma to the external canal.
Procedures, foreign objects (eg, bobby pin),
scratching, or any other trauma to the canal that
breaks the skin integrity may cause infection.
• If otitis externa is diagnosed, refrain from any
water sport activity for approximately 7 to 10
days to allow the canal to heal completely.
Recurrence is highly likely unless you allow the
external canal to heal completely.

• MALIGNANT EXTERNAL OTITIS
• Definition:- It is a progressive, debilitating, and
occasionally fatal infection of the external auditory
canal, surrounding tissue, and the base of the skull.
• It is a more serious, although rare, external ear
infection ( involves temporal bone- osteomyelitis).
• Pseudomonas aeruginosa is usually the infecting
organism in patients with low resistance to
infection (eg, patients with diabetes).

Malignant otitis externa cont...
• TREATMENT
• 1.Control of the diabetes
• 2.Administration of antibiotics (usually intravenously)- includes
the combination of an antipseudomonal agent and an
aminoglycoside, both of which have potentially serious side
effects. Because aminoglycosides are nephrotoxic and ototoxic,
serum aminoglycoside levels and renal and auditory function must
be monitored during therapy.
• 3. Analgesics
• 4.Aggressive local wound care - includes limited débridement of
the infected tissue, including
• bone and cartilage, depending on the extent of the infection.

MASSES OF THE EXTERNAL EAR
• EXOSTOSES
• -Are small, hard, bony protrusions found in the lower posterior
bony portion of the ear canal.
• -They usually occur bilaterally.
• -The skin covering the exostosis is normal.
• CAUSE
• It is believed that exostoses are caused by an exposure to cold
water, as in scuba diving or surfing.
• Management
• The usual treatment, if any, is surgical excision.
•

• OTHERS:-/ Malignant tumors also may occur in the
external ear.
• Most common are:-
• 1. basal cell carcinomas on the pinna
• 2.squamous cell carcinomas in the ear canal.
• NB/ If untreated, Malignant squamous cell
carcinoma may spread through the temporal bone,
causing facial nerve paralysis and hearing loss.
• -Carcinomas must be treated surgically.

Gapping Earring Puncture
• -This results from wearing heavy pierced
earrings for a long time or after an infection,
or as a reaction from the earring or impurities
in the earring.
• -This deformity can only be corrected
surgically.

CONDITIONS OF THE MIDDLE EAR
• 1.Tympanic Membrane Perforation
• CAUSE
• 1.infection - During infection, the tympanic
membrane can rupture if the pressure in the
middle ear exceeds the atmospheric pressure
in the external auditory canal.
• 2. trauma- Include skull fracture, explosive
injury, or a severe blow to the ear.

• 3.Less frequently, perforation is caused by
foreign objects (eg, cottontipped applicators,
bobby pins, keys) that have been pushed too far
into the external auditory canal.
• NB/ In addition to tympanic membrane
perforation, injury to the ossicles and even the
inner ear may result from this type of trauma.
• Attempts by patients to clean the external
auditory canal should be discouraged.

Medical Management
• -Most tympanic membrane perforations heal spontaneously
within weeks after rupture, or months.
• -Some perforations persist because scar tissue grows over the
edges of the perforation, preventing extension of the
epithelial cells across the margins and final healing.
• -If the cause is due to head injury or temporal bone fracture,
a patient is observed for evidence of cerebrospinal fluid ie:-
• Otorrhea a clear, watery drainage from the ear
• Rhinorrhea— a clear, watery drainage from the nose
• NB/ While healing, the ear must be protected from water.

Surgical Management
• -Perforations that do not heal on their own may
require surgery.
• The decision to perform surgery depend on:-
Prevent of potential infection from water entering
the ear
To improve the patient’s hearing.
• Tympanoplasty is done - which is surgical repair
of the tympanic membrane.
• Done in an outpatient basis.

Tympanoplasty cont...
• Tympanoplasty may involve a variety of
surgical techniques, whereby, 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.

2. ACUTE OTITIS MEDIA (AOM)
• Definition:- is an acute infection of the middle
ear, usually lasting less than 6 weeks.
• -Ear infections can occur at any age; however,
most common seen in children.
• -Is a fairly common result of a sore throat,
especially in children, whose pharyngotympanic
tubes are shorter and run more horizontally.
• -Otitis media is the most frequent cause of
hearing loss in children.

• Cause
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis
Risk factors for AOM
• age (younger than 12 months)
• chronic upper respiratory infections
• medical conditions that predispose to ear infections
(Down syndrome, cystic fibrosis, cleft palate)
• chronic exposure to secondhand cigarette smoke.

PATHOHPYSIOLOGY
• The causative organisms (refer), enter the middle ear after
eustachian tube dysfunction caused by obstruction related
to upper respiratory infections, inflammation of
surrounding structures (eg, rhinosinusitis, adenoid
hypertrophy), or allergic reactions (eg, allergic rhinitis).
• Bacteria can enter the eustachian tube from contaminated
secretions in the nasopharynx into the middle ear or/and
from the external ear through a perforated tympanic
membrane.
• A purulent exudate is usually present in the middle ear,
resulting in a conductive hearing loss.

• The symptoms of otitis media vary with the
severity of the infection.
• The condition, usually unilateral in adults.
1.Otalgia - pain is relieved after spontaneous
perforation or therapeutic incision of the
tympanic membrane.
2.Purulent discharge from the ear

S&s cont...
3.Fever
4.Hearing loss.
5.On otoscopic examination:-
the external auditory canal appears normal
The tympanic membrane is erythematous and
often bulging.
Patients report no pain with movement of the
auricle.

MEDICAL MANAGEMENT
• The outcome of AOM depends on:-
the efficacy of therapy- to include duration
the virulence of the bacteria
the physical health status of the patient.
• 1.Administer Early the appropriate broad-spectrum
antibiotic therapy.
• If drainage occurs, an antibiotic otic preparation is
prescribed eg gentamycin/ chloramphenical.
• 2.Analgesic to relieve pain and fever.

SURGICAL MANAGEMENT
• myringotomy (ie, tympanotomy) - Refers to an
incision in the tympanic membrane.
• Procedure
• -The procedure is painless and takes less than 15
minutes.
• -The tympanic membrane and ear canal is numbed
with a local anaesthetic agent such as phenol or
by iontophoresis (ie, electrical current flows
through a lidocaine- and-epinephrine solution).

SURGICAL MANAGEMENT cont...
• -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.
• -The drainage then is analyzed (by culture and
sensitivity testing) so that the infecting
organism can be identified and appropriate
antibiotic therapy prescribed.
• The incision heals within 24 to 72 hours.

SURGICAL MANAGEMENT cont...
• NB/Normally, this procedure is unnecessary
for treating AOM, but it may be performed if
pain persists
• Ventilating tubes are used to treat recurrent
episodes of AOM if no contraindication.
• The ventilating tube, which temporarily takes
the place of the eustachian tube in equalizing
pressure, is retained for 6 to 18 months.

• COMPLICATIONS
Chronic otitis media
Rarely does permanent hearing loss occur
Mastoiditis
Meningitis
Brain abscess

SEROUS OTITIS MEDIA (middle ear effusion)
• Def:-Refers to presence of fluid, without
evidence of active infection, in the middle ear.
• In theory, this fluid results from a negative
pressure in the middle ear caused by
eustachian tube obstruction.
• When this condition occurs in adults, an
underlying cause for the eustachian tube
dysfunction must be sought.

• Atielogy/ risk factors
 Frequently seen in patients after radiation therapy
 barotrauma
 patients with eustachian tube dysfunction from a concurrent
URI or allergy.
• Barotrauma results from sudden pressure changes in the
middle ear caused by changes in barometric pressure, as in
scuba diving or airplane descent.
• NB/ A carcinoma (eg, nasopharyngeal cancer) obstructing the
eustachian tube should be ruled out in adults with persistent
unilateral serous otitis media.

• Hearing loss
• Fullness in the ear or a sensation of congestion
• Popping and crackling noises- occur due to the
eustachian tube attempts to open.
• On otoscopic examination the tympanic membrane
appears dull, and air bubbles may be visualized in the
middle ear.
• 5. Usually, the audiogram shows a conductive hearing
loss.

Management
• -Serous otitis media need not be treated medically unless
infection occurs( ie AOM).
• -If the hearing loss associated with middle ear effusion is
significant, a myringotomy can be performed, and a tube may be
placed to keep the middle ear ventilated.
• -Corticosteroids in small doses to decrease the oedema of the
eustachian tube in cases of barotrauma.
• -Decongestants have not proved effective.
• - A Valsalva maneuver, which forcibly opens the eustachian tube
( by increasing nasopharyngeal pressure, may be cautiously
performed; this maneuver may cause worsening pain or
perforation of the tympanic membrane.)

• CHRONIC OTITIS MEDIA
• -Occurs as a result of recurrent AOM causing
irreversible tissue pathology and persistent perforation
of the tympanic membrane.
• -Chronic infections of the middle ear damage the
tympanic membrane, destroy the ossicles, and involve
the mastoid.
• -Before the discovery of antibiotics, infections of the
mastoid were life-threatening.
• -Today, acute mastoiditis is rare in developed countries.

Clinical Manifestations
• Symptoms may be minimal, with varying degrees.
 Hearing loss
 Persistent or intermittent, foul-smelling otorrhea.
 Pain is not usually experienced, except in cases of acute
mastoiditis (when the postauricular area is tender and
may be erythematous and edematous).
 Otoscopic examination may show a perforation
 Cholesteatoma - Identified as a white mass behind the
tympanic membrane or coming through to the external
canal from a perforation.- READ AHEAD

• Careful suctioning of the ear under otoscopic
guidance.
• Instillation of antibiotic drops or application of
antibiotic powder is used to treat purulent
discharge. Systemic antibiotics prescribed only
in cases of acute infection.
• Analgesic to relieve pain and fever

• Surgical Management
• Surgical procedures are used if medical
treatments are ineffective these include:-
• Tympanoplasty
• Ossiculoplasty
• Mastoidectomy

• 1.Tympanoplasty
• The most common surgical procedure for
chronic otitis media.
• It refers to the surgical reconstruction of the
tympanic membrane.
• Reconstruction of the ossicles may also be
required.

• The purposes of a tympanoplasty
 To re-establish middle ear function
 To close the perforation
 To prevent recurrent infection
 To improve hearing.
• Tympanoplasty is performed through the external
auditory canal with a transcanal approach or through a
postauricular incision.
• Surgery is usually performed in an outpatient facility
under moderate sedation or general anesthesia.

• 2. Ossiculoplasty
• Refers to the surgical reconstruction of the
middle ear bones to restore hearing.
• Prostheses made of materials such as Teflon,
stainless steel, and hydroxyapatite are used to
reconnect the ossicles, thereby reestablishing
the sound conduction mechanism.
• However, the greater the damage, the lower the
success rate for restoring normal hearing.

• 3.Mastoidectomy
• The objectives of mastoid surgery are to:-
 Remove the cholesteatoma
 Gain access to diseased structures
 Create a dry (noninfected) and healthy ear.
• -If possible, the ossicles are reconstructed during the
initial surgical procedure.
• -A mastoidectomy is usually performed through a
postauricular incision.
• -Infection is eliminated by removing the mastoid air cells.

Mastoidectomy cont....
• -A second mastoidectomy may be necessary to check for
recurrent or residual cholesteatoma.
• -The success rate for correcting this conductive hearing loss is
approximately 75%. Surgery is usually performed in an
outpatient setting.
• -The patient has a mastoid pressure dressing, which can be
removed 24 to 48 hours after surgery. NB/ Although infrequently
injured, the facial nerve, which runs through the middle ear and
mastoid, is at some risk for injury during mastoid surgery.
• -As the patient awakens from anesthesia, any evidence of facial
paralysis should be reported to the physician

CHOLESTEATOMA
• Definition- is an ingrowth of the skin of the
external layer of the eardrum into the middle
ear.
• - It is generally caused by a chronic retraction
pocket of the tympanic membrane, creating a
persistently high negative pressure of the
middle ear.
• -The skin forms a sac that fills with degenerated
skin and sebaceous materials.

Cholesteatoma cont....
• -The sac can attach to the structures of the middle ear
or mastoid, or both.
• -Chronic otitis media can cause chronic mastoiditis and
lead to the formation of cholesteatoma.
• -It can occur in the middle ear, mastoid cavity, or both,
often dictating the type 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.

• INCIDENCE
• -Cholesteatomas are common benign tumors of the
inner ear .
• -Congenital cholesteatomas are usually found in
children and may cause severe bone loss of the incus.
• -Cholesteatomas found in elderly patients generally
develop in the external canal.
• -They usually do not cause severe sequelae such as
hearing loss or neurologic disorders.

• SIGNS AND SYMPTOMS OF CHOLESTEATOMA
• A times are asymptomatic.
• Hearing loss
• Facial pain and paralysis
• Tinnitus, or vertigo.
• Audiometric tests often show a conductive or
mixed hearing loss.

• DX AND TREATMENT
• History and physical examination based on
presenting symptoms(visual examination )
• Computed tomography (CT) or MRI.
• Therapy includes:-
• treatment of the acute infection
• Surgery for removal of the mass to restore
hearing.

NURSING MGT OF A PATIENT UNDERGOING MASTOID SURGERY
(Mastoidectomy)
• Although several otologic surgical procedures are
performed under moderate sedation, mastoid
surgery is performed using general anesthesia.
Assessment
• The health history includes:-
A complete description of the ear disorder,
including infection, otalgia, otorrhea, hearing
loss, and vertigo.

Duration and intensity of the disorder
Its causes, and previous treatments.
Obtain Information on health problems and all
medications that the patient is taking.
Medication allergies and family history of ear disease
should be obtained.
Physical assessment to address erythema, edema,
otorrhea, lesions, and characteristics such as odor and
color of discharge.
The results of the audiogram are reviewed.

• Planning and Goals
• The major goals of caring for a patient undergoing
mastoidectomy include :-
 reduction of anxiety
 freedom from pain and discomfort
 prevention of infection
 stablize or improved hearing and communication
 absence of vertigo and related injury
 absence of or adjustment to sensory or perceptual alterations
 increased knowledge regarding the disease, surgical procedure,
and postoperative care.

• Nursing Interventions
Reducing Anxiety
Reinforces the information discussed by the
otologic surgeon with the patient, including
anesthesia, the location of the incision
(postauricular), and expected surgical results (eg,
hearing, balance, taste, facial movement).
The patient also is encouraged to discuss any
anxieties and concerns about the surgery.

Relieving Pain
• Administer the prescribed analgesic medication.
• For the next 2 to 3 weeks after surgery, the
patient may experience sharp, shooting pains
intermittently as the eustachian tube opens and
allows air to enter the middle ear.
• Constant, throbbing pain accompanied by fever
may indicate infection and should be reported to
the physician.

Preventing Infection
• Measures include:-
The external auditory canal wick, or packing, may
be impregnated with an antibiotic solution before
instillation.
Prophylactic antibiotics are administered as
prescribed.
patient is instructed to prevent water from
entering the external auditory canal for 6 weeks.

Prevention of infection cont....
A cotton ball or lamb’s wool covered with a water-
insoluble substance (eg, petroleum
jelly) and placed loosely in the ear canal usually
prevents water contamination.(used during showers
or hair washes, or in any situations in which water
may enter the ear).
The postauricular incision should be kept dry for the
first 2 days.
Signs of infection such as an elevated temperature
and purulent drainage should be reported.

Improving Hearing and Communication
• Hearing in the operated ear may be reduced for
several weeks because of edema, accumulation
of blood and tissue fluid in the middle ear, and
dressings or packing.
• Measures are initiated to improve hearing and
communication include:-
Reducing environmental noise
facing the patient when speaking

Improving Hearing and Communication cont.......
 speaking clearly and distinctly without shouting
 providing good lighting if the patient relies on speech
reading
 using nonverbal clues (eg, facial expression, pointing,
gestures) and other forms of communication.
 Family members or significant others are instructed
about effective ways to communicate with the patient.
 If the patient uses assistive hearing devices, one can be
used in the unaffected ear.

Preventing Injury
 Vertigo may occur after mastoid surgery if the semicircular
canals or other areas of the inner ear are traumatized.
 Antiemetic or antivertiginous medications (eg, antihistamines)
to relieve balance disturbance or vertigo if it occurs.
 Safety measures such as assisted ambulation are
implemented to prevent falls and injury.
 The patient is instructed to avoid heavy lifting, straining,
exertion, and nose blowing for 2 to 3 weeks after surgery to
prevent dislodging the tympanic membrane graft or ossicular
prosthesis.

Preventing Altered Sensory Perception
• Facial nerve injury is a potential, although rare,
complication of mastoid surgery.
• The patient is instructed to report immediately any
evidence of facial nerve (cranial nerve VII) weakness that
is:-
 drooping of the mouth on the operated side
slurred speech
decreased sensation
difficulty swallowing.

Preventing Altered Sensory Perception cont....
• A more frequent occurrence is a temporary
disturbance in the chorda tympani nerve, ( a
small branch of the facial nerve that runs
through the middle ear.) Patients experience
a taste disturbance and dry mouth on the side
of surgery for several months until the nerve
regenerates.

Promoting Home and Community-Based Care
• TEACHING PATIENTS SELF-CARE.
 Instruct patients on medication therapy ie analgesic
and antivertiginous agents (eg, antihistamines)
prescribed for balance disturbance.
 Teaching includes information about the expected
effects and potential side effects of the medication.
 Possible complications such as infection, facial nerve
weakness, or taste disturbances, including the signs
and symptoms to report immediately.

Teaching patient self-care cont....
 Elderly patients particularly, who have had mastoid surgery
may require home care nurse for a few days after returning
home.
 However, most people find that assistance from a family
member or a friend is sufficient.
 The importance of scheduling and keeping follow-up
appointments is also stressed.
• Take antibiotics and other medications as prescribed.
• • Avoid nose blowing for 2 to 3 weeks after surgery.
• • Sneeze and cough with the mouth open for a few weeks
after surgery.

Teaching patient self-care cont....
• • Avoid heavy lifting , straining, and bending over for a
few weeks after surgery.
• • Popping and crackling sensations in the operative ear
are normal for approximately 3 to 5 weeks after surgery.
• • Temporary hearing loss is normal in the operative ear
due to fluid, blood, or packing in the ear.
• • Report excessive or purulent ear drainage to the
physician.
• • Avoid getting water in the operative ear for 2 weeks
after surgery.

• OTOSCLEROSIS
• -Involves the stapes and is thought to result from the
formation of new, abnormal spongy bone, especially
around the oval window, with resulting fixation of the
stapes.
• -The efficient transmission of sound is prevented
because the stapes cannot vibrate and carry the
sound as conducted from the malleus and incus to the
inner ear.
• .

INCIDENCE
 -More common in women
 -hereditary
 -pregnancy may worsen it.
Clinical Manifestations
• Otosclerosis may involve one or both ears.
 progressive conductive or mixed hearing loss.
 patient may or may not complain of tinnitus.
 Otoscopic examination usually reveals a normal tympanic
membrane.
 On rinne testing Bone conduction is better than air conduction

• No known nonsurgical treatment for
otosclerosis.
Use of sodium fluoride may mature the
abnormal spongy bone growth and prevent
the breakdown of the bone tissue.
Amplification with a hearing aid also may help.

• Surgical Management
• Stapedectomy or the stapedotomy surgery is done..
• -A stapedectomy involves removing the stapes superstructure
and part of the footplate and inserting a tissue graft and a
suitable prosthesis.
• -The surgeon drills a small hole into the footplate to hold a
prosthesis.
• -The prosthesis bridges the gap between the incus and the
inner ear, providing better sound conduction.
• - Approximately 95% of patients experience resolution of
conductive hearing loss following stapes surgery.

CONDITIONS OF THE INNER EAR
• INCIDENCE
• -In USA Almost 8 million American adults
suffer chronic problem with balance,Whereas
and an additional 2.4 million are affected by
dizziness alone.
• Disorders of balance are a major cause of falls
of elderly people.

DEFINITION OF TERMS
• DIZZINESS is used frequently by patients and health
care providers to describe any altered sensation of
orientation in space.
• VERTIGO is the misperception or illusion of motion of
the person or the surroundings.
• -Most people with vertigo describe a spinning
sensation or say they feel as though objects are
moving around them.
• ATAXIA is a failure of muscular coordination and may
be present in patients with vestibular disease.

DEFINITION OF TERMS cont...
• NOTE:- Syncope, fainting, and loss of consciousness are not
forms of vertigo and usually indicate disease in the
cardiovascular system.
• Nystagmus : Is an involuntary rhythmic movement of the eyes.
• Nystagmus occurs normally when a person watches a rapidly
moving object (eg, through the side window of a moving car or
train).
• Pathologically it is an ocular disorder associated with vestibular
dysfunction.
• Nystagmus can be horizontal, vertical, or rotary and can be
caused by a disorder in the central or peripheral nervous system.

• MOTION SICKNESS
• Refers to a disturbance of equilibrium caused by constant
motion.
• For example, it can occur aboard a ship, while riding on a
merry-go-round or swing, or in a car.
• The syndrome manifests itself in:- sweating, pallor, nausea,
and vomiting caused by vestibular overstimulation.
• These manifestations may persist for several hours after the
stimulation stops.

Motion sickness cont.....
• Management
 Antihistamines such as dimenhydrinate (Dramamine) or
meclizine hydrochloride.
• May provide some relief of nausea and vomiting by blocking
the conduction of the vestibular pathway of the inner ear.
 Anticholinergic medications Eg scopolamine.
• Side effects such as dry mouth and drowsiness may occur.
• Potentially hazardous activities such as driving a car or
operating heavy machinery should be avoided if drowsiness
occurs.

TINNITUS
• Tinnitus is a symptom of an underlying disorder of the ear
that is associated with hearing loss.
• Patients describe tinnitus as a roaring, buzzing, or hissing
sound in one or both ears
• INCIDENCE
• -This condition affects approximately 37 million people in
the United States.
• -Most prevalent between 40 and 70 years of age
• -The severity of tinnitus may range from mild to severe.

Risk factors
• -several ototoxic substances.
• Underlying disorders such as; thyroid disease,
hyperlipidemia, vitamin B12 deficiency
• psychological disorders (eg, depression, anxiety)
• fibromyalgia
• otologic disorders (Ménière’s disease, acoustic
neuroma)
• neurologic disorders (head injury, multiple sclerosis).

DX AND RX
• Do a physical examination to determine the cause of
tinnitus.
• An audiograph speech discrimination test or a
tympanogram may be used to help determine the
cause.
• NB/Some forms of tinnitus are irreversible; therefore,
patients may need teaching and counseling about
ways of adjusting to their treatment and dealing with
tinnitus in the future.

Labyrinthitis
• -It is an inflammation of the inner ear ,can be bacterial or viral in
origin.
• -Bacterial labyrinthitis is rare because of antibiotic therapy, but a
times occurs as a complication of otitis media.
• -The infection can spread to the inner ear by penetrating the
membranes of the oval or round windows.
• -Viral labyrinthitis is a common diagnosis
• -The most common viral causes are mumps, rubella, rubeola, and
influenza.
• -Viral illnesses of the upper respiratory tract and herpetiform
disorders of the facial and acoustic nerves also cause labyrinthitis.

Labyrinthitis cont..
sudden onset of incapacitating vertigo
nausea and vomiting
various degrees of hearing loss
tinnitus may occur.

Labyrinthitis cont..
• Management
For bacterial labyrinthitis administer IV antibiotic
fluid replacement- because of the nausea and vomiting
administration of an antihistamine Eg, meclizine ,
promethazine
antiemetic medications.
Treatment of viral labyrinthitis is based on the patient’s
symptoms.
•

• RHINITIS
• Definition:- Is a group of disorders characterized
by inflammation and irritation of the mucous
membranes of the nose.
• These conditions can have a significant impact on
quality of life and contribute to sinus, ear, and
sleep problems and learning disorders.
• Rhinitis often coexists with other respiratory
disorders, such as asthma.

• Rhinitis may be:-
acute
chronic
nonallergic
allergic.
• Allergic rhinitis is further classified as seasonal
or perennial

Rhinitis cont.....
• rhinitis is commonly associated with exposure
to airborne particles such as dust, dander, or
plant pollens in people who are allergic to
these substances.
• Seasonal rhinitis occurs during pollen seasons,
and perennial rhinitis occurs throughout the
year.

• Factor that trigger/ cause rhinitis
• Rhinitis may be caused by a variety of factors, including:-
• changes in temperature or humidity
• odors
• infection
• age
• systemic disease
• use of over-the-counter (OTC) and prescribed nasal
decongestants

Factor cont....
• presence of a foreign body.
• foods Eg, peanuts, walnuts, brazil nuts, wheat,
shellfish, soy, cow’s milk, and eggs.
• medications Eg, penicillin, sulfa medications, aspirin,
antihypertensive agents such as angiotensin-
converting enzyme (ACE) inhibitors and beta-blockers.
• particles in the indoor and outdoor environment.
Note: The most common cause of nonallergic rhinitis is
the common cold.

• The signs and symptoms of rhinitis include:-
 rhinorrhea (excessive nasal drainage/ runny nose)
 nasal congestion
 nasal discharge (purulent with bacterial rhinitis)
 sneezing
 pruritus –(of nose ,roof of the mouth, throat, eyes, and
ears.
 Headache ( if rhinosinusitis is also present).
• NOTE/Nonallergic rhinitis can occur throughout the year.

• The management of rhinitis depends on the cause.
• If viral rhinitis is the cause, medications may be prescribed to
relieve the symptoms.
• In allergic rhinitis, allergy tests may be performed to identify
possible allergens.
• Use of desensitizing immunizations and corticosteroids may be
required.
• For bacterial infection antibiotics are prescribed.
• Patients with nasal septal deformities or nasal polyps are ENT
Specialist.

• Pharmacologic Therapy
• For allergic and nonallergic rhinitis the focus is on
symptom relief.
• 1.Antihistamines
• Most common treatment and are administered
for sneezing, pruritus, and rhinorrhea.
• Eg. Brompheniramine/pseudoephedrine (is an
combination antihistamine/decongestant).
piriton, cetrizine

• PHARMACOLOGY CONT,
• 2.Corticosteroid
• intranasal corticosteroids as sprays or instillation may be used
for severe congestion.
• 3.Cromolyn (NasalCrom)- a mast cell stabilizer that inhibits
the release of histamine.
• 4.Oral decongestant agents.
• 5.Saline nasal spray - act as a mild decongestant and can
liquefy mucus to prevent crusting.
• Note/Ophthalmic solution may be used to relieve irritation,
itching, and redness of the eyes.

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