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The external ear includes the auricle (pinna) and the external auditory canal.
The external ear is separated from the middle ear by a disklike structure called the tympanic
membrane (eardrum).
Auricle: The auricle, attached to the side of the head by skin, is composed mainly of cartilage,
except for the fat and subcutaneous tissue in the earlobe.
It collects the sound waves and directs vibrations into the external auditory canal.
External Auditory Canal: It is approximately 2.5 cm long.
The lateral third is an elastic cartilaginous and dense fibrous framework to which thin skin is
attached.
The medial two thirds is bone lined with thin skin.
It ends at tympanic membrane.
The skin of the canal contains hair, sebaceous glands, and ceruminous glands, which secrete a
brown, waxlike substance called cerumen (ear wax).
ANATOMY OF THE MIDDLE EAR
The middle ear, an air-filled cavity, includes the tympanic membrane laterally and the otic
capsule medially.
The middle ear is connected to the nasopharynx by the eustachian tube and is continuous with
air-filled cells.
The eustachian tube, which is approximately 1 mm wide and 35 mm long, connects the
middle ear to the nasopharynx.
It drains normal and abnormal secretions of the middle ear and equalizes pressure that with
the atmosphere.
The tympanic membrane (eardrum), about 1 cm in diameter and very thin, is normally pearly
gray and translucent.
It consists of three layers of tissue: an outer layer, continuous with the skin of the ear canal; a
fibrous middle layer; and an inner mucosal layer, continuous with the lining of the middle ear
cavity.
The tympanic membrane protects the middle ear and conducts sound vibrations from the
external canal to the ossicles.
The middle ear contains the three smallest bones (the ossicles) of the body: the malleus, the
incus, and the stapes.
The ossicles assist in transmission of sound.
Body balance is maintained by the cooperation of the muscle and joints of the body
(proprioceptive system), the eyes (visual system), and the labyrinth (vestibular system).
These areas send their information about equilibrium, or balance, to the brain (cerebellar
system) for coordination and perception in the cerebral cortex.
External otitis, or otitis externa, refers to an inflammation of the external auditory canal.
It is a painful condition caused when irritating or infective agents come into contact with the
skin of the external ear.
Causes/Etiology:
Clinical Manifestation:
It includes pain, discharge from the external auditory canal, aural tenderness &
occasionally fever, cellulitis, and lymphadenopathy.
Other symptoms may include pruritus and hearing loss or a feeling of fullness.
On otoscopic examination, the ear canal is erythematous and edematous.
Discharge may be yellow or green and foul-smelling.
In fungal infections, hair like black spores may even be visible.
Medical Management:
The principles of therapy are aimed at relieving the discomfort, reducing the swelling of the
ear canal, and eradicating the infection.
Patients may require analgesic medications for the first 48 to 92 hours.
If the tissues of the external canal are edematous, a wick (piece of gauze soaked in treatment
drops) should be inserted to keep the canal open so that liquid medications (eg, Burow’s
solution, antibiotic otic preparations) can be introduced.
Antibiotic and corticosteroid agents to soothe the inflamed tissues.
Nursing Management:
Nurse should instruct patients not to clean the external auditory canal with cotton-tipped
applicators and to avoid events that traumatize the external canal such as scratching the canal
with the fingernail or other objects.
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 (eg, Swim
Ear, Ear Dry).
A more serious, although rare, external ear infection is malignant external otitis (temporal
bone osteomyelitis).
This is a progressive, debilitating, and occasionally fatal infection of the external auditory
canal, the surrounding tissue, and the base of the skull.
Pseudomonas aeruginosa is usually the infecting organism.
Successful treatment includes control of the diabetes, administration of antibiotics (usually
intravenously), and aggressive local wound care.
Local wound care includes limited débridement of the infected tissue, including bone and
cartilage, depending on the extent of the infection.
Exostoses are small, hard, bony protrusions found in the lower posterior bony portion of the
ear canal; they usually occur bilaterally.
It is believed that exostoses are caused by an exposure to cold water, as in scuba diving or
surfing. The usual treatment, if any, is surgical excision.
Malignant tumors also may occur in the external ear.
Most common are basal cell carcinomas on the pinna and squamous cell carcinomas in the ear
canal.
Clinical Manifestation:
cerumen impaction or a foreign body in the ear may experience a sensation of fullness in the
ear, with or without hearing loss, and may have ear pain, itching, dizziness, or bleeding from
the ear.
Management
If the occluding material is cerumen, management options include watchful waiting, manual
removal, and the use of ceruminolytic agents followed by either manual irrigation or the use
of a low-pressure, electronic, oral irrigation device.
The canal can be irrigated with a mixture of water and hydrogen peroxide at body
temperature.
Insects are killed before removal unless they can be coaxed out by a flashlight or a humming
noise.
Lidocaine, a numbing agent, can be placed in the ear canal for pain relief.
Mineral oil or diluted alcohol instilled into the ear can suffocate the insect, which is then
removed with ear forceps.
If the patient has local irritation, an antibiotic or steroid ointment may be applied to prevent
infection and reduce local irritation.
Surgical removal of the foreign object may be required.
The object is removed through the ear canal (transcanal route) using a wire bent at a 90-degree
angle.
Otitis Media:
Acute otitis media (AOM) is an acute infection of the middle ear, usually lasting less than 6
weeks.
The pathogens that cause acute otitis media are usually Streptococcus pneumoniae,
Haemophilus influenzae, and Moraxella catarrhalis, which 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 and
the middle ear from a tympanic membrane perforation.
It is the 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.
Causes /Etiology
The condition, usually unilateral in adults, may be accompanied by otalgia. The pain is relieved after
spontaneous perforation or therapeutic incision of the tympanic membrane.
On otoscopic examination, the external auditory canal appears normal. The tympanic membrane is
erythematous and often bulging.
Pulling at ears
Excessive crying
Fluid draining from ear
Sleep disturbances
Fever
Headaches
Irritability
Difficulty Balancing.
Swimmer’s Ear (Itching, Watery discharge, Pain, tenderness on gently pulling of ear lobe,
Foul smelling, Yellowish discharge)
Trouble Hearing
Balance Problems and dizziness.
Minimal, with varying degrees of hearing loss and a persistent or intermittent, foul-smelling
otorrhea.
Otoscopic examination may show a perforation, and cholesteatoma can be identified as a
white mass behind the tympanic membrane or coming through to the external canal from a
perforation.
Diagnostic Evaluation:
Complications
Management:
Nursing Management
A ruptured eardrum is a tear in the thin membrane that separates outer ear from inner ear and when
there is abnormal opening or Perforation in tympanic membrane.
Causes
Ear Infection (When middle ear is infected the pressure is build up and pushed against the ear
drum, rise in pressure perforates the membrane)
Insertion of objects purposefully
Concussion (is a traumatic brain injury that affects your brain function) (Blast or Open handed
slap across ear)
Head Trauma
Barotrauma ( Pressure inside the ear and outside the ear are not equal)
Diagnostic Evaluation
Audiometry audiometry exam tests your ability to hear sounds. Sounds vary, based on their
loudness (intensity) and the speed of sound wave vibrations (tone). Hearing occurs when
sound waves stimulate the nerves of the inner ear. The sound then travels along nerve
pathways to the brain.
Otoscopy ( to visualize the eardrum)
Tunning Fork test
Management
Surgical Management
Otosclerosis
Clinical Manifestation:
It may involve one or both ears and manifests as a progressive conductive or mixed hearing
loss.
Bone conduction is better than air conduction on Rinne testing.
The audiogram confirms conductive hearing loss or mixed loss, especially in the low
frequencies.
Management
One of two surgical procedures may be performed, the stapedectomy or the stapedotomy. A
stapedectomy involve 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.
MASTOIDITIS
Mastoiditis is a bacterial infection of the mastoid air cells surrounding the inner and middle
ear.
The mastoid bone, which is full of these air cells, is part of the temporal bone of the skull.
The mastoid air cells are thought to protect the delicate structures of the ear, regulate ear
pressure and possibly protect the temporal bone during trauma.
CAUSES
CLINICAL MANIFESTATION
Fever, irritability, and lethargy
Swelling of the ear lobe
Redness and tenderness behind the ear
Drainage from the ear
Bulging and drooping of the ear
MENIER’S DISEASE
Pathophysiology
Causes
Clinical Manifestation:
Diagnostic Evaluation
Neurological examination
Caloric stimulation tests the eye reflexes by warming and cooling the inner ear.
CT Scan
MRI Scan
Electronystagmography (is a diagnostic test to record involuntary movements of the eye
caused by a condition known as nystagmus.)
Audiogram
Health History
Medical Management:
No cure to disease.
Treatment aimed to relieve the pressure in inner ear by drugs such as:
Antihistamines, Anticholinergic, Steriods, Diuretics.
Meclizine may responds to vertigo and dizziness.
Diazepam has effect on nerve controlling balance.
Streptomycin given intramuscularly cure vertigo.
Salt Restriction is essential.( decrease accumulation fluid in the inner ear.)
Diet management.
Stop Smoking.
Surgical Management:
Labyrinthectomy
Vestibular Neurectomy:
Chemical Labyrinthectomy
With the help of medication such as Streptomycin the nerve endings of only balance are
destroyed.
VERTIGO
Pathophysiology
Causes
Clinical Manifestation:
Nausea,
Vomiting,
falling,
Nystagmus,
Hearing loss, and tinnitus.
Labyrinthitis,
Causes
Clinical Manifestation
Hearing loss,
Tinnitus,
Nystagmus.
Vertigo with nausea and vomiting.
Management
ACOSUTIC NEUROMA
An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear
nerve (cranial nerve [CN] VIII) enters the internal auditory canal.
The tumor can compress the trigeminal and facial nerves and arteries within the internal
auditory canal.
Pathophysiology
The vast majority of acoustic neuromas develop from the Schwann cell investment of the
vestibular portion of the vestibulocochlear nerve.
Less than 5% arise from the cochlear nerve.
The superior and inferior vestibular nerves appear to be the nerves of origin with about
equal frequency.
Overall, 3 separate growth patterns can be distinguished within acoustic tumors, as
follows: (1) no growth or very slow growth, (2) slow growth (ie, 0.2 cm/y on imaging
studies), and (3) fast growth (ie, ≥ 1.0 cm/y on imaging studies).
Although most acoustic neuromas grow slowly, some grow quite quickly and can double
in volume within 6 months to a year.
Although some tumors adhere to one or another of these growth patterns, others appear to
alternate between periods of no or slow growth and rapid growth.
Tumors that have undergone cystic degeneration (presumably because they have outgrown
their blood supply) are sometimes capable of relatively rapid expansion because of
enlargement of their cystic component.
Clinical Manifestation
unilateral, progressive, sensorineural hearing loss; reduced touch sensation in the posterior
ear canal; unilateral tinnitus; and mild, intermittent vertigo.
Diagnostic tests
Management
Stereotactic radiosurgery may slow tumor growth and preserve the facial nerve.
Hearing Loss
Conductive hearing loss occurs when conditions in the outer or middle ear impair the
transmission of sound through air to the inner ear.
Causes otitis media with effusion, impacted cerumen, perforation of the TM, otosclerosis,
and narrowing of the external auditory canal.
The patient often speaks softly because hearing his or her own voice (which is conducted
by bone) seems loud.
This patient hears better in a noisy environment.
Sensorineural hearing loss is caused by impairment of function of the inner ear or the
vestibulocochlear nerve (CN VIII).
Congenital and hereditary factors, noise trauma over time, aging (presbycusis), Ménière’s
disease, and ototoxicity can cause sensorineural hearing loss.
Ototoxic drugs include aspirin, nonsteroidal anti-inflammatory drugs, antibiotics
(aminoglycosides, erythromycin, vancomycin), loop diuretics, and chemotherapy drugs.
The main problems are the ability to hear sound but not to understand speech, and the lack of
understanding of the problem by others.
The ability to hear high-pitched sounds, including consonants, diminishes. Sounds become
muffled and difficult to understand.
Mixed hearing loss occurs due to a combination of conductive and sensorineural causes.
Central hearing loss involves an inability to interpret sound, including speech, because of
a problem in the brain (CNS).
Functional hearing loss may be caused by an emotional or a psychologic factor.
The patient does not seem to hear or respond to pure-tone subjective hearing tests, but no
physical reason for hearing loss can be identified.
Clinical Manifestation
Hearing loss are answering questions inappropriately, not responding when not looking at the
speaker, asking others to speak up, and showing irritability with others who do not speak up.
Other behaviors that suggest hearing loss include straining to hear, cupping the hand around
the ear, reading lips, and an increased sensitivity to slight increases in noise level.
Tinnitus.
Aural Rehabilitation
Aural rehabilitation includes auditory training, speech reading, speech training, and the use of
hearing aids and hearing guide dogs.
Auditory training emphasizes listening skills, so the person who is hearing-impaired
concentrates on the speaker.
Speech reading (also known as lip reading) can help fill the gaps left by missed or misheard
words.
The goals of speech training are to conserve, develop, and prevent deterioration of current
communication skills.
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.
A hearing aid makes sounds louder, but it does not improve a patient’s ability to discriminate
words or understand speech.
Three types of implanted hearing devices are commercially available or in the investigational
stage: the cochlear implant, the bone conduction device, and the semi-implantable hearing
device.
Cochlear implants are for patients with little or no hearing. Bone conduction devices, which
transmit sound through the skull to the inner ear, are used in patients with a conductive
hearing loss if a hearing aid is contraindicated (eg, those with chronic infection).
The device is implanted postauricularly under the skin into the skull, and an external device—
worn above the ear, not in the canal— transmits the sound through the skin.
There are two types of implantable hearing aids.
The bone anchored hearing aid (BAHA) is implanted behind the ear in the mastoid area.
The middle ear implantation (MEI) is implanted in the middle ear cavity.
The BAHA is used for conductive or mixed hearing loss, while the MEI is used for
sensorineural hearing loss.
A cochlear implant is an auditory prosthesis used for people with profound sensorineural
hearing loss bilaterally who do not benefit from conventional hearing aids.
An implant does not restore normal hearing; rather, it helps the person detect medium to loud
environmental sounds and conversation.
The implant provides stimulation directly to the auditory nerve, bypassing the nonfunctioning
hair cells of the inner ear.
The microphone and signal processor, worn outside the body, transmit electrical stimuli to the
implanted electrodes.
The electrical signals stimulate the auditory nerve fibers and then the brain, where they are
interpreted.
The surgery involves implanting a small receiver in the temporal bone through a postauricular
incision and placing electrodes into the inner ear (Fig. 59-7).
The microphone and transmitter are worn on an external unit.
The patient undergoes extensive cochlear rehabilitation with the multidisciplinary team, which
includes an audiologist and speech pathologist.
Specially trained dogs (service dogs) are available to assist the person with a hearing loss.
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.
Presbycusis
Presbycusis, hearing loss associated with aging, includes the loss of peripheral auditory
sensitivity, a decline in word recognition ability, and associated psychologic and
communication issues.
It is related to degenerative changes in the inner ear.
Benign Paroxysmal Positional Vertigo
It is a brief period of incapacitating vertigo that occurs when the position of the patient’s head
is changed with respect to gravity, typically by placing the head back with the affected ear
turned down.
It is thought to be due to the disruption of debris within the semicircular canal.
This debris is formed from small crystals of calcium carbonate from the inner ear structure,
the utricle.
This is frequently stimulated by head trauma, infection, or other events.
Vestibular rehabilitation can be used in the management of vestibular disorders.
This strategy promotes active use of the vestibular system through an interdisciplinary team
approach, including medical and nursing care, stress management, biofeedback, vocational
rehabilitation, and physical therapy.
Pathophysiology
MANAGEMENT
The cells of the body need energy for all their metabolic activities. Most of this energy is
derived from chemical reactions, which can only take place in the presence of oxygen (O2).
The respiratory system provides the route by which the supply of oxygen present in the
atmospheric air enters the body, and it provides the route of excretion for carbon dioxide.
The organs of the respiratory system are:
Nose
pharynx
larynx
Trachea
Two bronchi (one bronchus to each lung)
Bronchioles and smaller air passages
Two lungs and their coverings, the pleura
Muscles of breathing – the intercostal muscles and the diaphragm.
The nasal cavity is the main route of air entry, and consists of a large irregular cavity divided
into two equal passages by a septum.
The posterior bony part of the septum is formed by the perpendicular plate of the ethmoid
bone and the vomer. Anteriorly, it consists of hyaline cartilage.
The roof is formed by the cribriform plate of the ethmoid bone and the sphenoid bone, frontal
bone and nasal bones.
The floor is formed by the roof of the mouth and consists of the hard palate in front and the
soft palate behind.
The medial wall is formed by the septum.
The lateral walls are formed by the maxilla, the ethmoid bone and the inferior conchae.
The posterior wall is formed by the posterior wall of the pharynx.
The nasal cavity is lined with very vascular ciliated columnar epithelium (ciliated mucous
membrane, respiratory mucosa) which contains mucus-secreting goblet cells (p. 249).
The anterior nares, or nostrils, are the openings from the exterior into the nasal cavity. Nasal
hairs are found here, coated in sticky mucus.
The posterior nares are the openings from the nasal cavity into the pharynx.
The paranasal sinuses are cavities in the bones of the face and the cranium, containing air.
The sinuses are involved in speech and also lighten the skull. The nasolacrimal ducts extend
from the lateral walls of the nose to the conjunctival sacs of the eye. They drain tears from the
eyes.
In the nasal cavity, air isvwarmed, moistened and filtered.
The three projecting conchae increase the surface area and cause turbulence, spreading
inspired air over the whole nasal surface. The large surface area maximises warming,
humidification and filtering.
The nose is the organ of the sense of smell (olfaction).
Specialised receptors that detect smell are located in the roof of the nose in the area of the
cribriform plate of the ethmoid bones and the superior conchae
These receptors are stimulated by airborne odours.
The resultant nerve signals are carried by the olfactory nerves to the brain where the sensation
of smell is perceived.
The pharynx (throat) is a passageway about 12–14 cm long.
It extends from the posterior nares, and runs behind the mouth and the larynx to the level of
the 6th thoracic vertebra, where it becomes the oesophagus.
the pharynx is divided into three parts: nasopharynx, oropharynx and laryngopharynx.
The nasopharynx :The nasal part of the pharynx lies behind the nose above the level of the
soft palate.
On its lateral walls are the two openings of the auditory tubes (p. 193), one leading to each
middle ear.
On the posterior wall are the pharyngeal tonsils (adenoids), consisting of lymphoid tissue.
The oral part of the pharynx lies behind the mouth, extending from below the level of the soft
palate to the level of the upper part of the body of the 3rd cervical vertebra.
The lateral walls of the pharynx blend with the soft palate to form two folds on each side.
Between each pair of folds is a collection of lymphoid tissue called the palatine tonsil.
The laryngeal part of the pharynx extends from the oropharynx above and continues as the
oesophagus below, with the larynx lying anteriorly.
Passageway for air and food
The pharynx is involved in both the respiratory and the digestive systems: air passes through
the nasal and oral sections, and food through the oral and laryngeal sections.
Warming and humidifying
By the same methods as in the nose, the air is further warmed and moistened as it passes
towards the lungs.
Hearing
The auditory tube, extending from the nasopharynx to each middle ear, allows air to enter the
middle ear.
This leads to air in the middle ear being at the same pressure as the outer ear, protecting the
tympanic membrane (eardrum, p. 193) from any changes in atmospheric pressure.
Protection
The lymphatic tissue of the pharyngeal and laryngeal tonsils produces antibodies in response
to swallowed or inhaled antigens (Ch. 15).
The tonsils are larger in children and tend to atrophy in adults.
Speech
The pharynx functions in speech; by acting as a resonating chamber for sound ascending from
the larynx, helps (together with the sinuses) to give the voice its individual characteristics.