Inner ear disorder

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Inner Ear Disorder INNER EAR DISORDERS Because the inner ear controls balance and hearing, disorders affecting it commonly produce loss of equilibrium, vertigo, nausea and vomiting, and hearing loss. Treatment varies with the disorder and may include drug therapy, surgery, and use of amplification devices. HEARING LOSS Hearing impairment is... the most common disability in the United States and the third most prevalent in those older than age 65. Mechanical or nervous impediment to the transmission of sound waves can produce hearing loss. The major forms are classified as conductive, sensorineural, or mixed. With conductive hearing loss, sound is interrupted as it travels from the external canal to the inner ear (the junction of the stapes and the oval window). With sensorineural hearing loss, sound wave transmission is interrupted between the inner ear and the brain. The most common type of sensorineural hearing loss, presbycusis, is prevalent in adults older than age 50 and can't be reversed or corrected. Mixed hearing loss combines dysfunction of conduction and sensorineural transmission. Congenital hearing loss can be conductive or sensorineural. Premature or low-birth-weight infants with congenital hearing loss are most likely to have structural or functional hearing impairments; infants with a serum bilirubin level greater than 20 mg/dl also risk hearing impairment from the toxic effects of such a high level on the brain. Because hearing loss is the most common birth defect, the National Institutes of Health as well as numerous other organizations recommend that every neonate be screened for hearing loss, preferably before discharge from the hospital. Early intervention, afforded by early detection, has been proven to help children with hearing loss perform better socially and cognitively as well as in language development than those without early intervention do. Sudden hearing loss, which can occur in a patient with no previous hearing loss, can be conductive, sensorineural, or mixed and usually affects only one ear. Depending on the cause, prompt treatment (within 48 hours) may restore hearing. Noise-induced hearing loss may be transient or permanent. Such hearing loss is common in workers subjected to constant industrial noise and in military personnel, hunters, and rock musicians. Hearing loss may be partial or total and is calculated using the American Medical Association formula: Hearing is 1.5% impaired for every decibel (dB) that the pure tone average exceeds 25 dB. Causes The most common cause of conductive hearing loss is cerumen (earwax) impaction, which occurs in patients with small or hairy ear canals. Conductive loss may be caused by anything that blocks the external ear (foreign body, edema, or drainage by infection) or by thickening, retraction, scarring, or perforation of the tympanic membrane. Other causes include otitis media, which is common in children and may accompany an upper respiratory tract infection; otitis externa, which results from a gram-negative bacterial infection of the external ear canal; and otosclerosis, which produces ossification of the stapediovestibular joint. Sensorineural hearing loss is caused by impairment of the vestibulocochlear nerve (eighth cranial nerve). The most common form of this type of hearing loss, presbycusis, results from loss of hair cells and nerve fibers in the cochlea or from drug toxicity. Other causes of nerve deafness are infectious diseases (measles, mumps, meningitis), arteriosclerosis, otospongiosis, injury to the head or ear, or degeneration of the organ of Corti. Sensorineural hearing loss may also follow prolonged exposure to loud noise (85 to 90 dB) or brief exposure to extremely loud noise (greater than 90 dB). Occasionally, sensorineural hearing loss results from an acoustic neuroma (a benign tumor that can be life-threatening). Congenital hearing loss, which may be sensorineural or conductive, may be transmitted as a dominant, autosomal dominant, autosomal recessive, or sex-linked recessive trait. Hearing loss in neonates may also result from trauma, toxicity, or infection during pregnancy or delivery. Predisposing factors include a family history of hearing loss or known hereditary disorders (for example, otosclerosis), maternal exposure to rubella or syphilis during pregnancy, use of ototoxic drugs during pregnancy, prolonged fetal anoxia during delivery, and congenital abnormalities of the ears, nose, or throat. In addition, trauma during delivery may cause intracranial hemorrhage and damage the cochlea or acoustic nerve. The cause of sudden hearing loss is unknown. However, the possibilities include occlusion of the internal auditory artery by spasm or thrombosis, subclinical mumps and other bacterial and viral infections, acoustic neuroma, or a single episode of Menie¨re's disease. Sudden hearing loss also may be caused by metabolic disorders, such as hypothyroidism, diabetes mellitus, and hyperlipoproteinemia; vascular disorders such as hypertensive arteriosclerosis; neurologic disorders, such as multiple sclerosis and neurosyphilis; blood dyscrasias, such as leukemia and hypercoagulation; and ototoxic drugs, such as tobramycin, streptomycin, quinine, gentamicin, furosemide, and ethacrynic acid. Complications If untreated, conductive hearing loss resulting from otitis media can lead to tympanic membrane perforation, cholesteatoma, and permanent hearing loss. Assessment findings Although congenital hearing loss may produce no obvious signs of hearing impairment at birth, the infant generally demonstrates deficient response to auditory stimuli within 2 to 3 days. In an older child, the patient history may describe a hearing loss that impairs speech development. Rinne and Weber's tests may indicate if the hearing loss is conductive or sensorineural. In a patient with conductive hearing loss, the history may uncover a recent upper respiratory tract infection. Weber's test is positive, and the Rinne test also may be positive. A patient with sudden deafness may report recent exposure to loud noise or brief exposure to an extremely loud noise. The patient may complain of persistent tinnitus and transient vertigo. Audiometric tests indicate that the patient has a loss of perception of certain frequencies (around 4,000 Hz) or, if he has experienced lengthy exposure, loss of perception of all frequencies. Weber's and Rinne tests may indicate conductive or sensorineural hearing loss. In a patient with sensorineural hearing loss resulting from presbycusis, the patient history is probably the most valuable assessment tool because the patient may not have noticed the hearing loss or may deny it. The history also may expose the use of ototoxic substances. Hearing tests reveal a loss that's usually in the high-frequency tones. The patient may report a history of tinnitus. A positive Rinne test may indicate sensorineural hearing loss. Diagnostic tests Auditory brain response is used to measure activity in the auditory nerve and brain stem. If test results are positive or inconclusive, additional tests may be ordered. A computed tomography scan helps to evaluate vestibular and auditory pathways, and pure tone audiometry is used to assess the presence and degree of hearing loss. Magnetic resonance imaging is used to evaluate brain condition and helps detect acoustic tumors or lesions. Electronystagmography is used to evaluate vestibular function. Otoscopic or microscopic examination can be used to diagnose middle ear disorders or remove debris of infection. Treatment Treatment for patients with hearing loss varies with the type and cause of impairment and may include medication to treat infections and dissolve cerumen, surgery (stapedectomy, tympanoplasty, cochlear implant, and myringotomy), hearing aids or other effective means of aiding communication, and an antibiotic and a decongestant for hearing loss resulting from otitis media. An analgesic may be given for pain. An antipyretic may be given for fever. A sedative may be given to small children for comfort. Treatment for sudden deafness requires prompt identification of the underlying cause. For noise-induced hearing loss, overnight rest usually restores normal hearing in the patient exposed to noise levels greater than 90 dB for several hours but who hasn't been exposed to such noise repeatedly. As hearing deteriorates, treatment should include speech and hearing rehabilitation because hearing aids rarely help. A cochlear implant may be an option for a patient who's profoundly deaf or extremely hard of hearing. Children and adults can be candidates for insertion of this device. In the United States, 13,000 adults and 10,000 children have received a cochlear implant. This device, which is surgically placed in the skin behind the ear, can provide a sense of sound to help the patient understand auditory stimuli in his environment as well as speech. Whereas hearing aids simply amplify sound, a cochlear implant processes sounds from the environment, converting them to electrical impulses, which are then transmitted to the brain for interpretation. Presbycusis may necessitate a hearing aid. Dietary measures can help to prevent further hearing loss. Studies suggest that people with high cholesterol levels experience greater hearing loss as they age than those with low cholesterol levels do. Nursing diagnoses 1. Acute pain 2. Anxiety 3. Chronic low self-esteem 4. Deficient knowledge (diagnosis and treatment) 5. Disturbed sensory perception: Auditory 6. Fear 7. Impaired verbal communication 8. Ineffective coping 9. Risk for infection 10. Risk for injury Key outcomes The patient will express feelings of comfort. The patient will identify strategies to reduce anxiety. The patient will express positive feelings related to self-esteem. The patient and family will express an understanding of the condition and its treatment. The patient will regain hearing or develop other means of communication. The patient will express feelings and concerns. The patient will effectively communicate feelings and needs. The patient will express his feelings about the disorder and exhibit adequate coping mechanisms. The patient will exhibit no signs or symptoms of infection. The patient will avoid injury. Nursing interventions Answer the patient's questions, encourage him to discuss his concerns about hearing loss, and offer reassurance when appropriate. If the patient has difficulty understanding procedures because of hearing loss, give clear, concise explanations of treatments and procedures. Face him when speaking; enunciate words clearly, slowly, and in a normal tone; and allow adequate time for him to grasp what's expected. Provide a pencil and paper to aid communication, and alert the staff to his communication problem. To speak to a patient who can read lips, approach within his visual range and attract his attention by raising your arm or waving. (Touching him may be unnecessarily startling.) Then stand directly in front of him in a well-lit area, and speak slowly and distinctly. Place the patient with hearing loss in a place where he can observe activities and approach people because such a patient depends totally on visual clues. Encourage the patient who's learning to use a hearing aid because he may experience periods of self-doubt and apprehension about wearing the aid. Refer children with suspected hearing loss to an audiologist or otolaryngologist for further evaluation. Provide the patient and family with opportunities to express their concerns and expectations about the hearing loss. Help them select another mode of communication. Patient teaching Teach the patient and his family about hearing loss, its causes, and its treatments. Explain tests and procedures. For the patient who requires surgery, give preoperative and postoperative instructions. For the patient receiving a hearing aid, demonstrate how to operate and maintain the device, and suggest carrying extra batteries at all times. Remind him that the aid won't restore hearing to a normal level and that it makes speech louder but not necessarily clearer. Encourage him to experiment with the controls for best results. Advise him that lessons in lipreading may increase the effectiveness of the aid. Tell him that if the hearing aid requires repair, he may be able to borrow a substitute from the repair agency. For the patient with temporary hearing loss, emphasize the danger of excessive exposure to noise and encourage the use of protective devices in a noisy environment. If the patient is pregnant, stress the danger of exposure to drugs, chemicals, and infection (especially rubella). Encourage the patient to maintain a low-cholesterol diet, and teach him about foods that are low in cholesterol. If the patient's hearing loss stems from cerumen buildup and the physician has advised ear cleaning or irrigation, demonstrate the proper technique for this and for instilling medication. If the patient has hearing loss resulting from otitis media, discuss the prescribed antibiotic and decongestant and tell him to report any adverse reactions. Review the prescribed medication as well as its proper dosage, administration, and adverse effects. Encourage the patient to tell the physician if he develops a significant earache. LABYRINTHITIS is an inflammation of the labyrinth of the inner ear (which controls both hearing and balance). Labyrinthitis typically produces severe vertigo with head movement and sensorineural hearing loss. Vertigo begins gradually but peaks within 48 hours. Because it may last 3 to 5 days, causing loss of balance and falling in the direction of the affected ear, it may incapacitate the patient. Symptoms gradually subside over 3 to 6 weeks. Prevention is possible through early and vigorous treatment of predisposing conditions, such as otitis media and any local or systemic infection. Causes Labyrinthitis results from the same organisms (viral or bacterial infections) that cause acute febrile diseases, such as pneumonia, influenza and, especially, chronic otitis media. Viral labyrinthitis the most prevalent form may result from viral illnesses of the respiratory tract, measles, mumps, rubella, or encephalitis. Bacterial labyrinthitis may be caused by otitis media infection or bacterial meningitis. In patients with chronic otitis media, cholesteatoma formation erodes the labyrinth bone, allowing bacteria to enter from the middle ear. Drug toxicity also may cause labyrinthitis. Complications Meningitis, partial or total hearing loss on the affected side, trauma from falling, permanent balance disability, and decreased quality of life may develop. Assessment findings The patient with labyrinthitis may complain of severe vertigo from any movement of the head, nausea and vomiting, and a unilateral or bilateral hearing loss. Questioning may uncover a recent upper respiratory tract infection. Tinnitus may not be present. On inspection, note spontaneous nystagmus, with jerking movements of the eyes toward the unaffected ear. The patient may also demonstrate excessive giddiness. To minimize these symptoms, he may assume a characteristic posture lying on the side of the unaffected ear and looking in the direction of the affected ear. Examination of the affected ear may reveal purulent drainage. Diagnostic tests Evaluation of labyrinthitis relies on culture and sensitivity tests to identify the infecting organism if purulent drainage is present, audiometric testing to reveal any sensorineural hearing loss, computed tomography scanning to rule out a brain lesion, and tympanometry and electronystagmography. Treatment measures are based on relieving the patient's symptoms and include bed rest with the head immobilized between pillows, oral meclizine to relieve vertigo, and massive doses of an antibiotic to combat diffuse purulent labyrinthitis. Oral fluids can prevent dehydration from vomiting; I.V. fluids may be needed for severe nausea and vomiting. When conservative management fails, treatment necessitates surgical excision of the cholesteatoma and drainage of the infected areas of the middle and inner ear. A labyrinthectomy or vestibular nerve section may be done in some patients. Nursing diagnoses 1. Activity intolerance 2. Anxiety 3. Deficient knowledge (diagnosis and treatment) 4. Disturbed sensory perception: Auditory 5. Fear 6. Risk for deficient fluid volume 7. Risk for falls 8. Risk for infection 9. Risk for injury Key outcomes The patient will perform activities of daily living to the fullest extent possible. The patient will identify strategies to reduce anxiety. The patient will verbalize an understanding of the condition and its treatment. The patient will regain hearing or develop other means of communication. The patient will express fear and concerns. The patient will maintain normal fluid volume. The patient will identify methods to safeguard his home environment to prevent falls. The patient will remain free from signs and symptoms of infection. The patient will avoid injury. Nursing interventions Answer the patient's questions, encourage him to express his concerns about hearing loss, and offer reassurance when appropriate. If the patient has difficulty understanding procedures because of hearing loss, give clear, concise explanations of treatments and procedures. Face him when speaking; enunciate words clearly, slowly, and in a normal tone; and allow adequate time for him to grasp what's expected. Provide a pencil and paper to aid communication, and alert the staff to his communication challenges. Keep the side rails of the bed up to ensure the patient's safety. Assist with ambulation, as needed, to prevent falls. Maintain the patient on bed rest in a darkened room with his head immobile to reduce symptoms. Give an antiemetic, as ordered, and monitor the patient's response. Monitor blood pressure, turgor, mucous membranes, and pulse for symptoms of dehydration. Provide the patient with oral fluids to prevent dehydration from vomiting. If vomiting precludes oral intake, administer I.V. fluids, as ordered, and monitor intake and output. Patient teaching Teach the patient about the disease and what can be done to treat it and prevent its occurrence. Caution the patient to limit activities, such as driving a motor vehicle or operating machinery, to avoid danger from vertigo. Reassure the patient that recovery is certain but may take as long as 6 weeks. Review the home care checklist. Encourage the patient to seek prompt treatment for upper respiratory tract and systemic infections, particularly for otitis media. Stress the importance of controlling the use of salicylates and other potentially toxic substances. Instruct the patient to complete the prescribed drug regimen. Warn him to discontinue the drug and notify the physician if adverse effects occur. If surgery is required, give the patient preoperative and postoperative instructions. MENIERE'S DISEASE (or endolymphatic hydrops) is an inner-ear problem stemming from a labyrinthine dysfunction. It's associated with increased fluid pressure in the labyrinth. Although it usually affects adults between ages 30 and 60, it may begin at any age. It occurs in both sexes. The disease involves only one ear at first, but about 20% of patients eventually develop problems in both ears. Even with proper treatment, this chronic disease can cause hearing loss. Causes Menie¨re's disease may result from an overproduction or decreased absorption of endolymph, the fluid within the cochlea and semicircular canals. Pressure from this excess fluid disturbs and damages the sensory cells that transmit hearing and balance perception to the brain. The cause of this overproduction (or underabsorption) is unknown. Various theories attribute the problem to excess sodium retention, an allergic reaction to certain foods, vascular spasms that constrict blood vessels supplying the inner ear, or metabolic, toxic, and emotional factors. These factors may influence the interval of an attack or precipitate an attack. Complications Menie¨re's disease leads to residual tinnitus and partial to total hearing loss on the affected side, permanent balance disability, trauma from falling, dehydration, and reduced quality of life. Assessment findings Menie¨re's disease produces three characteristic effects: severe vertigo, tinnitus, and sensorineural hearing loss. Fullness or a blocked feeling in the ear is also quite common. Violent paroxysmal attacks last from 10 minutes to several hours. During an acute attack, other signs and symptoms include severe nausea, vomiting, sweating, giddiness, and nystagmus. Also, vertigo may cause loss of balance and falling to the affected side. To lessen these signs and symptoms, the patient may assume a characteristic posture of lying on the unaffected ear and looking in the direction of the affected ear. Between attacks, the patient may be free of vertigo. The patient may experience imbalance, unsteady gait, history of falls, inability to maintain an upright position or posture, inability to walk heel to toe on examination, visual changes (blurred vision, diplopia), altered taste or smell, and altered communication. In addition, findings may include hypotension, vomiting or diarrhea, changes in lifestyle, withdrawal, depression, fear, anxiety, and panic. Because these signs can mimic other disorders, diagnostic tests must be performed to confirm the diagnosis. Diagnostic tests Electronystagmography is used to measure the electropotential of eye movements when nystagmus is produced and provides a graphic recording of labyrinthine function. Audiometric tests reveal sensorineural loss and loss of discrimination and recruitment. An auditory brain stem response test helps determine if a cochlear or retrocochlear lesion is causing hearing loss. Magnetic resonance imaging is used to evaluate the structure of the brain and rules out brain lesions or tumors. Laboratory testing must be done to rule out metabolic problems (hypoglycemia or thyroid, lipid, or autoimmune disorders). Treatment Management of Menie¨re's disease aims to eliminate vertigo and prevent further hearing loss. For an acute attack, the patient may assume whatever position is comfortable. Atropine may stop the attack in 20 to 30 minutes. Dimenhydrinate, meclizine, diphenhydramine, or diazepam may relieve a mild attack. A severe attack may respond to epinephrine or diphenhydramine. Long-term management includes the use of a diuretic or a vasodilator, a vestibular suppressant, labyrinthine exercises, and restricted sodium intake. A prophylactic antihistamine or a mild sedative may also help. Some 75% of patients respond to a salt-free diet and the use of a diuretic. However, diuretic efficacy hasn't been proved. Avoiding tobacco, alcohol, and caffeine may be recommended. For the anxious and fearful or depressed patient, a psychological evaluation is indicated. If the disease persists after more than 2 years of treatment or produces incapacitating vertigo, the patient may require surgery. Some patients benefit from endolymphatic sac decompression (endolymphatic shunt). This procedure creates an opening in the labyrinth to drain excess fluid from the ear. A more complex procedure resects the vestibular nerve, which carries impulses from the mechanisms involved with position sense in the inner ear to the brain. If the patient has severe hearing loss in one ear, radical labyrinthectomy may be helpful. Systemic streptomycin is reserved for patients in whom the disease is bilateral and no other treatment can be considered. Nursing diagnoses 1. Acute pain 2. Anxiety 3. Deficient fluid volume 4. Disturbed sensory perception: Auditory 5. Fear 6. Hopelessness 7. Imbalanced nutrition: More than body requirements 8. Ineffective coping 9. Powerlessness 10. Risk for falls 11. Risk for injury Key outcomes The patient will express feelings of comfort. The patient will identify strategies to reduce anxiety. The patient will maintain adequate fluid balance. The patient will regain hearing or develop other means of communication. The patient will express fears and concerns. The patient will participate in decisions about care. The patient will identify appropriate food choices according to his prescribed diet. The patient and his family will seek appropriate support groups to assist with coping. The patient will express feelings of control over well-being. The patient will identify strategies to safeguard his home environment to prevent falls. The patient will avoid injury. Nursing interventions If the patient experiences an attack in the facility, keep the bed rails up to prevent falls. Don't let the patient rise or walk without help. Answer the patient's questions, encourage him to express his concerns about hearing loss, and offer reassurance when appropriate. If the patient has difficulty understanding procedures because of hearing loss, give clear, concise explanations of treatments and procedures. Face him when speaking; enunciate words clearly, slowly, and in a normal tone; and allow adequate time for him to grasp what's expected. Provide a pencil and paper to aid communication, and alert the staff to his communication challenges. Before surgery, if the patient is vomiting, record fluid intake and output and characteristics of vomitus. Administer an antiemetic, as ordered, and frequently give small amounts of fluid. After surgery, carefully record intake and output. Give a prophylactic antibiotic and antiemetic, as ordered, and monitor the patient's response. Help the patient to identify successful coping behaviors. Teach the patient about his diagnosis and treatment. Stress the importance of maintaining his activity level and exercising regularly. Patient teaching Review a low-sodium diet with the patient. Discuss foods and nonprescription drugs that contain sodium. Instruct the patient about the prescribed diuretic and vasodilator. Tell him to report any adverse reactions. Advise against reading and exposure to glaring lights to reduce dizziness. Instruct the patient to avoid sudden position changes and any tasks that vertigo makes hazardous, because an attack can begin rapidly. Because stress and fatigue can trigger attacks, teach the patient relaxation and stress management techniques. Review ways to modify the patient's lifestyle, including making adequate time for rest and relaxation. After surgery Tell the patient to expect dizziness and nausea for 1 to 2 days. Because Bell's palsy is a complication of surgery, instruct the patient to be alert for possible signs and symptoms, such as facial numbness and tingling and incomplete eye closure.

Inner ear disorder

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