Acute Ear Proplem

1. SALALE UNIVERSITY
COLLEGAE OF HEALTH SCIENCE
DEPARTMENT OF ADULT HEALTH NURSING
Assignment Summation on : Acute Ear Problem
Summited To : Mr. Tadele K (Ass’t Professor)
Summited by: Dereje A ID:179/15& Shambel D ID:190/15
July,2023
Fitche, Ethiopia
10/4/2023 1

2. Outline
• Learning objectives
• Anatomy and Physiology of the Ear
• External ear problems
• Middle ear problems
• internal ear problems
• Hearing loss
• Reference
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3. Learning objectives
At the end of this session you will be able to:
• Review of anatomy and physiology of the ear
• List:-External ear problems
-Middle ear problems
-Internal ear problems
• Describe hearing loss
• Apply nursing knowledge in the management of
common ear problems
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4. Review of anatomy and physiology of the ear
 The ear is a sensory organ with dual functions
hearing and balance.
 The sense of hearing is essential for
maintenance of speech and the ability to
communicate with others.
 Balance, or equilibrium, is essential for
maintaining body movement, position, and
coordination.
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5. Review of anatomy and physiology of the ear
cont.…
• The ear is divided into three distinct parts
External Ear
• The external ear, housed in the temporal bone,
includes the auricle (i.e., pinna) and the external
auditory canal.
• The external ear is separated from the middle
ear by a disk like structure called the tympanic
membrane (i.e. eardrum).
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6. Review of anatomy and physiology of the ear
cont.…
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7. Review of anatomy and physiology of the ear
cont.…
• The auricle collects the sound waves and directs
vibrations into the external auditory canal.
• The external auditory canal is approximately 2.5
cm long.
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8. Review of anatomy and physiology of the ear
cont.…
• The skin of the canal contains hair, sebaceous
glands, and ceruminous glands, which secrete a
brown, wax like substance called cerumen (i.e.
ear wax).
• The ear’s self-cleaning mechanism moves old
skin cells and cerumen to the outer part of the
ear.
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9. Middle Ear
• The middle ear, an air-filled cavity, includes the
tympanic membrane laterally and the otic
capsule medially.
• The middle ear is connected by the Eustachian
tube to the nasopharynx and is continuous with
air-filled cells in the adjacent mastoid portion of
the temporal bone.
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10. Review of anatomy and physiology of the ear
cont.…
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11. Review of anatomy and physiology of the ear
cont.…
• The Eustachian tube serves as a drainage
channel for normal and abnormal secretions of
the middle ear and equalizes pressure in the
middle ear with that of the atmosphere.
• The tympanic membrane protects the middle ear
and conducts sound vibrations from the external
canal to the ossicles.
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12. Review of anatomy and physiology of the ear
cont.…
• The sound pressure is magnified 22 times as a
result of transmission from a larger area to a
smaller one.
• The middle ear contains the three smallest
bones (i.e. ossicles) of the body: malleus, incus,
and stapes.
• The ossicles, which are held in place by joints,
muscles, and ligaments, assist in the
transmission of sound.
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13. Review of anatomy and physiology of the ear
cont.…
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14. Review of anatomy and physiology of the ear
cont.…
Inner Ear
• The inner ear is housed deep within the
temporal bone. The organs for hearing i.e.
cochlea) and balance i.e. semicircular canals, as
well as cranial nerve VIII i.e. vestibulo cochlear
nerve, are all part of this complex anatomy.
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15. Review of anatomy and physiology of the ear
cont.…
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16. Review of anatomy and physiology of the ear
cont.…
• The cochlea and semicircular canals are housed
in the bony labyrinth. The bony labyrinth
surrounds and protects the membranous
labyrinth, which is bathed in a fluid called
perilymph.
• The membranous labyrinth contains a fluid
called endolymph.
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17. Review of anatomy and physiology of the ear
cont.…
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18. Review of anatomy and physiology of the ear
cont.…
• The membranous labyrinth is composed of the
utricle, the saccule, the cochlear duct, and the
organ of Corti.
• The three semicircular canals contain sensory
receptor organs stimulated by changes in the
rate or direction of an individual’s movement.
The utricle and saccule are involved with linear
movements.
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19. Review of anatomy and physiology of the
ear cont.…
• The organ of Corti also called the end organ for
hearing is located in the cochlea, a snail-
shaped, bony tube about 3.5 cm long transforms
mechanical energy into neural activity and
separates sounds into different frequencies.
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20. Common Ear Disorders
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21. Acute Ear Disorders
External ear problems
Impaction of Cerumen
• It is accumulate of large amounts of wax in the
external ear canal.
• Cerumen normally accumulates in the external
canal in various amounts and colors
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22. Impaction of Cerumen cont.…
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23. Impaction of Cerumen cont.…
 Clinical manifestation
• Otalgia ( earache or ear pain)
A sensation of fullness or pain in the ear, with or
without a hearing loss.
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24. Impaction of Cerumen cont.…
Management
• Cerumen can be removed by irrigation, suction,
or instrumentation.
• Unless the patient has a perforated eardrum or
an inflamed external ear (i.e. otitis externa),
gentle irrigation usually helps remove impacted
Cerumen, particularly if it is not tightly packed in
the external auditory canal.
10/4/2023 24

25. Impaction of Cerumen cont.…
• If the eardrum behind the impaction is
perforated, however, water can enter the middle
ear, producing acute vertigo and infection.
• If irrigation is unsuccessful, direct visual,
mechanical removal can be performed on a
cooperative patient by instruments, such as a
Cerumen curette, aural suction.
10/4/2023 25

26. Impaction of Cerumen cont.…
• 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.
• 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.
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27. Foreign bodies
• Some objects are inserted
• Intentionally into the ear
• Trying to clean the external canal or relieve
itching
• Children who introduce peas, beans, pebbles,
toys, and beads.
• Insects
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28. Management
• Removing a foreign body from the external
auditory canal is quite challenging.
• Three standard methods
• Irrigation:- Contraindications in vegetable
bodies and insects
• Suction
• Instrumentation
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29. Management cont.…
• Instilling mineral oil, which will kill the insect and
allow it to be removed.
• Drug treatment: Patient should be kept on
antibiotic if there is sign of infection on the ear
canal or purulent discharge
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30. Management cont.…
First line:
Amoxicillin, 500mg P.O. TID for 10 days for adults;
250mg P.O. TID for 10 days for children above 6 years of
age; 125mg/5ml OR 250mg/5ml P.O. TID 10 days for
children under 6 years of age.
OR
Amoxicillin/ clavulanate, 375mg P.O. TID for 10 days or
625mgP.O. BID 10 days for adults; 156mg/5ml P.O. TID
OR 312mg/5ml P.O. TID for 10 days for children.
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31. Management cont.…
• Cloxacillin, 500mg P.O. QID for 10 days for
adults; 50-100mg/kg/day P.O. divided into 4 doses
for10 days for children.
Alternatives
• Ox tetracycline hydrochloride + Polymyxin B
Sulphate + Hydrocortisone acetate, 2drops 2-3
times daily
OR
• Chloramphenicol, 2-3 drops 2-4 times daily
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32. Otitis Externa
• It is an inflammation of the external auditory
canal.
Cause
• Water in the ear canal i.e. swimmer’s ear
• Trauma to the skin of the ear canal. Bacterial
infection Staphylococcus aureus and
Pseudomonas species and fungal infection
Aspergillus are most frequently encountered.
• A dermatosis such as psoriasis, eczema, or
seborrheic dermatitis.
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33. FungalOtitis Externa/Otomycosis
• Fungal
• Most Common type.
• Most common organism: Aspergillus Niger
followed by Candida.
• Management: Ear toileting and topical
antifungal for at least 3 weeks.
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34. BacterialOtitisExterna/ Furunculosis
• Most Common organism is Staphylococcus aureus
• Severe pain – increases with jaw movement
• On pressing the tragus, patient complain pain-
tragal Sign.
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35. Bacterial Otitis Externa/ Furunculosis Cont...
• Management:- Antibacterial antibiotic- Amoxicillin
plus Clavulanic acid.
• 10% Ichthammol-glycerine pack in EAC to
reduce oedema.
• For pain management: -Tab Diclofenac for adult,
Syrup Ibuprofen for children.
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36. 10/4/2023 36

37. 10/4/2023 37

38. Viral Otitis Externa / Herpes Zoster Oticus
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39. Otitis Externa cont.…
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40. Otitis externa cont.…
Clinical manifestations
• Pain
• Discharge from the external auditory canal
• Auditory tenderness
• Pruritus and hearing loss or a feeling of fullness.
• Fever and lymphadenopathy.
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41. Otitis externa cont.…
Assessment
• Otoscopic examination the ear canal is
erythematous and edematous.
• Discharge may be yellow or green and foul
smelling.
• In fungal infections, the hair like black spores
may even be visible.
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42. Otitis externa cont.…
Medical and nursing management
• Anti pain
• Antibiotic systemic and/or local.
• Antifungal agents
• Avoid swimming
• Advice to protect the ear when shampooing or
showering.
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43. Middle ear problems
• Tympanic Membrane Perforation
• Otitis media
• Otosclerosis
• Mastoiditis
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44. Perforation of the tympanic membrane
• Usually caused by:
• Infection or
• Trauma,
• Foreign objects (e.g. cotton tipped applicators,
bobby pins, keys
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45. Diagram which shows ear perforation
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46. Medical Management
• Most tympanic membrane perforations heal
spontaneously
• Some may take several months to heal.
• Some persist
• In the case of a head injury or temporal bone
fracture, a patient is observed for evidence of
cerebrospinal fluid
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47. Surgical Management
• Non healing on their own may require surgery.
• Tympanoplasty/surgical repair of the tympanic
membrane.
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48. Ear Ache (Otalgia)
Causes
• Primary otalgia: cause within the ear itself
• Secondary otalgia: Pain referred from another place
having same sensory innervation. (Referred
Otalgia)
Treatment
• Find the cause and treat accordingly.
• Analgesic.
10/4/2023 48

49. Middle ear problems
Otitis media
• It is inflammation of the middle ear, or middle ear
infection.
Types of otitis media
• Acute OM
• Chronic OM
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50. Acute otitis media
• It is an acute infection of the middle ear usually
lasting less than 6 weeks for adult but less than
2weeks for children
Cause
• The primary cause is usually Streptococcus
pneumoniae, Haemophilus influenza, and
Moraxella catarrhalis ( bacteria).
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51. Acute otitis media cont.…
• The microbes enter the middle ear after eustachian
tube dysfunction caused by obstruction related to
upper respiratory infections, inflammation of
surrounding structures
e.g:-sinusitis, adenoid hypertrophy, or allergic
reactions, allergic rhinitis.
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52. Acute otitis media cont.…
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53. Acute otitis media cont.…
Clinical manifestations
• A purulent exudate is usually present in the middle
ear, resulting in a conductive hearing loss
• Otalgia
• Fever
Assessment
• Otoscopic examination (the external auditory
canal appears normal. The patient reports no pain
with movement of the auricle. The tympanic
membrane is erythematous and often bulging).
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54. Clinical features of otitis
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55. Serous Otitis Media
• Serous otitis media or middle ear effusion
involves fluid, without evidence of active
infection, in the middle ear.
• In theory, this fluid results from a negative
pressure in the middle caused by eustachian tube
obstruction.
10/4/2023 55

56. Serous Otitis Media cont.…
• Frequently seen in patients after radiation
therapy or barotrauma and Eustachian tube
dysfunction.
• A carcinoma e.g. nasopharyngeal cancer
obstructing the Eustachian tube should be ruled
out in adults with persistent unilateral serous
otitis media.
10/4/2023 56

57. Clinical Manifestations
• Complain of hearing loss, fullness in the ear
• Sensation of congestion, or popping and
crackling noises
• Tympanic membrane appears dull on otoscopy,
and air bubbles may be visualized in the middle
ear.
• Usually, the audiogram shows a conductive
hearing loss.
10/4/2023 57

58. Management
• Serous otitis media need not be treated medically
unless infection i.e. AOM occurs.
• A myringotomy can be performed, and a tube
may be placed to keep the middle ear ventilated.
• Corticosteroids in small doses may decrease
edema of the Eustachian tube in cases of
barotrauma.
• Decongestants have not proved effective.
10/4/2023 58

59. Acute otitis media cont.…
 Management
• Antibiotic
• Surgical management. An incision in the TM (Myringotomy
or Tympanotomy – is a surgical incision to the ear drum to
drain exudate or serous fluid) to relieve pressure and to
drain serous or purulent fluid from the middle ear.
• Normally, this procedure is unnecessary for treating acute
otitis media, but it may be performed if pain persists.
10/4/2023 59

60. Otosclerosis
• Involves the stapes and result from the
formation of new, abnormal spongy bone,
especially around the oval window
• 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.
10/4/2023 60

61. Clinical Manifestations
• May involve one or both ears and manifests as
• A progressive conductive or mixed hearing loss.
• Patient may or may not complain of tinnitus.
• Otoscopic examination usually reveals a normal
tympanic membrane.
• Bone conduction is better than air conduction
on rinne testing.
10/4/2023 61

62. Medical Management
• There is no known nonsurgical treatment for
otosclerosis.
• However, some physicians believe the use of
sodium fluoride can mature the abnormal spongy
bone growth and prevent the breakdown of the
bone tissue.
• Amplification with a hearing aid also may help.
10/4/2023 62

63. Surgical Management
• Stapedectomy - removing the stapes
superstructure and part of the footplate and
inserting a tissue graft and a suitable prosthesis
• Stapedotomy- Involves the surgeon drills a
small hole into the footplate to hold a prosthesis.
10/4/2023 63

64. Mastoiditis
• The proximity of the mastoid to the middle ear
cleft suggests that most cases suppurative otitis
media are associated with inflammation of the
mastoid air cells.
• Hyperaemia,edema,serous then purulent
exudate collects in the cells
• Bone necrosis due to pressure of the exudate.
10/4/2023 64

65. Clinical manifestations
Acute mastoiditis:- is usually accompanied by
acute infection in the middle ear.
• Specific features of mastoiditis include swelling,
redness and tenderness over the mastoid bone
pinna is displaced outward and downward and a
purulent discharge may be seen after perforation
of the tympanum.
10/4/2023 65

66. Diagnosis
• Specimen- pus discharge from ear, freshly from
the tympanic membrane
• If the tympanic membrane is not perforated,
tympanocentesis should be performed to obtain
specimen from middle ear.
• Cultures for bacteria
10/4/2023 66

67. Treatment
• Antibiotics are similar as those used in otitis
media.
• If the disease in the mastoid has had a prolonged
cover for staph aureus and Gm neg enteric bacilli
for initial therapy until culture results ready.
• Mastoidectomy- when mastoid abscess forms
and sepsis has been controlled by antibiotics.
10/4/2023 67

68. Inner ear problems
 Labyrinthitis
•It is an inflammation of the inner ear, can be
bacterial or viral in origin.
•Bacterial labyrinthitis usually occurs as a
complication of otitis media.
•The infection can enter the inner ear by
penetrating the membranes of the oval or round
windows.
10/4/2023 68

69. Inner ear problems cont…
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70. Labyrinthitis cont.…
• Viral labyrinthitis is a common medical problem,
which affects hearing and balance.
• The most commonly identified viral causes are
mumps, rubella and influenza.
• Viral illnesses of the upper respiratory tract also
cause labyrinthitis.
10/4/2023 70

71. Clinical Manifestations
• A sudden onset of incapacitating vertigo,
usually with nausea and vomiting, various
degrees of hearing loss, and possibly tinnitus.
• The first episode is usually the worst;
subsequent attacks, which usually occur over a
period of several weeks to months, are less
severe.
10/4/2023 71

72. Management
• Treatment of bacterial labyrinthitis includes
intravenous antibiotic therapy, fluid replacement,
and administration of a vestibular suppressant,
such as meclizine, and antiemetic medications.
• Treatment of viral labyrinthitis is tailored to the
patient’s symptoms.
10/4/2023 72

73. Meniere’s syndrome
• It is an abnormal inner ear fluid balance caused
by mal absorption in the endolymphatic sac.
• The most prevalent opinion is that an acute
attack of Meniere's disease results from
fluctuating pressure of the fluid within the inner
ear.
10/4/2023 73

74. Meniere’s syndrome cont.…
Pathophysiology
• The membranous labyrinth, contains a fluid
called endolymph. The membranes can become
dilated like a balloon when pressure increases.
This is called "hydrops".
• One way for this to happen is when the drainage
system, called the endolymphatic duct or sac is
blocked.
10/4/2023 74

75. Meniere’s syndrome cont.…
• In some cases, the endolymphatic duct may be
obstructed by scar tissue, or may be narrow
from birth.
• In some cases there may be too much fluid
secreted by the stria vascularis.
10/4/2023 75

76. Clinical Manifestations
• Fluctuating, progressive sensorineural hearing loss;
• Tinnitus or a roaring sound;
• A feeling of pressure or fullness
• Incapacitating vertigo with nausea & vomiting.
• There are two subsets of the disease:
– Cochlear ménière’s disease - fluctuating, progressive
sensorineural hearing loss associated with tinnitus and
aural pressure
– Vestibular ménière’s disease - episodic vertigo
associated with aural pressure
10/4/2023 76

77. Ear Trauma
 Pinna laceration
•Trauma with sharp object: laceration of
• skin/cartilage.
•Management:
•Wash wound thoroughly
•Necrotic tissue debrided
•Repair/ skin flap
•Tetanus booster
10/4/2023 77

78. Cont.…
 Pinna hematoma
• Boxer’s ear or wrestler ear
• Sub perichondrial collection of blood b/w
perichondrium & cartilage.
• Shearing action on pinna.
Management
• Drainage:- Aspiration or incision
• Broad-spectrum antibiotics
10/4/2023 78

79. Hearing loss
• Hearing impairment has been reported to occur in 3 of
every 1000 births
• Hearing loss is greater in men than in women.
 Conductive hearing loss = results from an external
ear or a middle ear disorder
 A sensorineural loss = damage to the cochlea or
vestibulocochlear nerve.
 Mixed hearing loss
Conductive loss and sensorineural loss, resulting
from dysfunction of air and bone conduction.
10/4/2023 79

80. Risk Factors for Hearing Loss
• Family history of sensorineural impairment
• Congenital malformations of the cranial structure
(ear)
• Low birth weight (1500 g)
• Use of ototoxic medications (e.g. gentamycin, loop
diuretics)
• Recurrent ear infections
• Bacterial meningitis
• Chronic exposure to loud noises
10/4/2023 80

81. Clinical Manifestations
• Tinnitus
• Increasing inability to hear when in a group
• And a need to turn up the volume of the
television.
• Changes in attitude
• The ability to communicate, the awareness of
surroundings
10/4/2023 81

82. Clinical Manifestations….
Be alert the ff. points for hearing loss
• Speech deterioration- ears guide the voice, both
in loudness and in pronunciation.
• Fatigue: result of straining to hear
• Indifference: depressed and disinterested in life
• Social withdrawal
• Insecurity- lack of self-confidence and fear of
mistakes
10/4/2023 82

83. Nursing Management
• Adopting a communication style to fit the needs
and preferences of each patient.
• Cerumen can be removed by irrigation, suction,
or instrumentation.
• Gentle irrigation usually helps remove impacted
cerumen.
• Instilling a few drops of warmed glycerin, mineral
oil, or half-strength hydrogen peroxide into the
ear canal for 30 minutes can soften cerumen
10/4/2023 83

84. Reference
• Ibrahim SI, Cheang PP, Nunez DA. Incidence of meningitis
secondary to suppurative otitis media in adults. J Laryngol
Otol. 2010 Nov;124(11):1158-61.
• Laulajainen-Hongisto A, Lempinen L, Jero J. Complications
of acute otitis media. Duodecim. 2012;128(9):959-68.
• Lampikoski H, Aarnisalo AA, Jero J, Kinnari TJ. Mastoid
biofi lm in chronic otitis media. Otol Neurotol. 2012
Jul;33(5):785-8.
• Leskinen K, Jero J. Acute complications of otitis media in
adults. Clin Otolaryngol. 2005 Dec;30(6):511-6.
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