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NURSING MANAGEMENT OF PATIENT WITH DISORDERS OF

EAR NOSE AND THROAT

Review of anatomy and physiology of the Ear Nose and Throat-

 The ear is a sensory organ with dual functions—hearing and balance.


 The sense of hearing is essential for normal development and maintenance of speech as well
as the ability to communicate with others.
 The cranium encloses and protects the brain and surrounding structures, providing attachment
for various muscles that control head and jaw movements.
 Eight bones form the cranium: the occipital bone, the frontal bone, two parietal bones, two
temporal bones, the sphenoid bone, and the ethmoid bone.
 Some of these bones contain sinuses, which are cavities lined with mucous membranes and
connected to the nasal cavity.
 The ears are located on either side of the cranium at approximately eye level.

ANATOMY OF EXTERNAL EAR

 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.

ANATOMY OF THE INNER EAR

 The inner ear is housed deep within the temporal bone.


 The organs for hearing (cochlea) and balance (semicircular canals), as well as cranial nerves
VII (facial nerve) and VIII(vestibulocochlear nerve), are all part of these.
 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 is composed of the utricle, the saccule, the cochlear duct, the
semicircular canals, and the organ of Corti, all of which are surrounded by a fluid called
endolymph.
 The organ of Corti is housed in the cochlea, a snail-shaped, bony tube about 3.5 cm long with
two and a half spiral turns.
 The organ of Corti is located on the basilar membrane that stretches from the base to the apex
of the cochlea.
 The organ of Corti, also called the end organ for hearing, transforms mechanical energy into
neural activity and separates sounds into different frequencies.

Function of the Ears:

 Hearing is conducted over two pathways: air and bone.


 Sounds transmitted by air conduction travel over the airfilled external and middle ear through
vibration of the tympanic membrane and ossicles.
 Sounds transmitted by bone conduction travel directly through bone to the inner ear,
bypassing the tympanic membrane and ossicles.

Balance and Equilibrium

 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 EAR DISEASE CONDITION:

External otitis, or otitis externa:

 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:

 Water in the ear canal (swimmer’s ear);


 Trauma to the skin of the ear canal,
 Permitting entrance of organisms into the tissues; and systemic conditions, such as vitamin
deficiency and endocrine disorders.
 The most common bacterial pathogens associated with external otitis are Staphylococcus
aureus and Pseudomonas species.
 The most common fungus isolated in both normal and infected ears is Aspergillus.
 Even allergic reactions to hair spray, hair dye, and permanent wave lotions.

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).

MALIGNANT EXTERNAL OTITIS

 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.

CERUMEN OR FOREIGN BODIES

 Cerumen (wax) is the most common cause of an impacted canal.


 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.

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.

CONDITIONS OF MIDDLE EAR

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.

Chronic otitis media

 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

 Crowed living conditions


 Exposure to second hand smoke
 Respiratory illness
 Close contact with siblings those who have cold.
 Having Cleft Palate ( Abnormal Position of muscles and tendons )
 Premature birth
Clinical Manifestation of AOM

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.

Clinical Manisfestation of Chronic Otitis Media

 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:

 History, Physical Examination and Ear Examination.


 Otoscope to look at the ear drum for signs of an ear infection. (Ear ache sharp, sudden pain,
Warm drainage , fullness of ear, Nausea Muffled Hearing)
 Tympanometry: It measures how the ear drum responds to a change of air pressure inside ear.
(Tympanometry is an examination used to test the condition of the middle ear and mobility of
the eardrum (tympanic membrane) and the conduction bones by creating variations of air
pressure in the ear canal.)
 Hearing Test (Whisper Test, Weber Test,
 A tuning fork (ideally, 512 Hz), 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. 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.
 In the Rinne test (pronounced rin-ay), 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. A person with normal
hearing reports that air-conducted sound is louder than bone-conducted sound.
 Tympanocentesis (is the drainage of fluid from the middle ear usually caused by otitis media,
by using a small-gauge needle to puncture the tympanic membrane)
 Blood test

Complications

 Tympanic membrane Perforation


 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.)
 Facial Nerve Palsy
 Acute Labyrinthitis (Labyrinthitis is an inner ear disorder. The two vestibular nerves in your
inner ear send your brain information about your spatial navigation and balance control. When
one of these nerves becomes inflamed, it creates a condition known as labyrinthitis)
 Petrositis (most often refers to infection of the temporal bone, the bone in the skull that
surrounds the ear. This infection goes deep to the inner ear)

Management:

 Antiobiotic treatment is used to treat Otitis Media


 Antimicrobials (Amoxicillin, Azithromycin, Ceftriaxone, Clarithromycin)
 Topical Agents ( Ciprofloxacin, Ofloxacin)

Nursing Management

 Acute Pain r/t Inflammation of middle ear tissue


 Dsiturbed Sensory Perception r/t auditory conductive disorder

Tympanic Membrane Perforation

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)

Signs and Symptoms

 Not able to recognize at first


 Some may feel Air coming out of their ear when they blow nose.
 Sudden sharp pain
 Drainage from ear (Bloody, Clear, Pus)
 Ear Noise or buzzing
 Hearing loss (Partial or Complete)
 Facial Weakness or dizziness

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

 Keep Ear Dry


 Oral or Topical Antibiotics

Surgical Management

 It is required to repair eardrum and prevent future ear infections.


 Myringoplasty: it uses tissue graft to cover the torn eardrum.
 Tympanoplasty (Tympanoplasty, also called eardrum repair, refers to surgery performed to
reconstruct a perforated tympanic membrane (eardrum) or the small bones of the middle ear.
Eardrum perforation may result from chronic infection or, less commonly, from trauma to the
eardrum.)
 Type I tympanoplasty is called myringoplasty, and only involves the restoration of the
perforated eardrum by grafting.
 Type II tympanoplasty is used for tympanic membrane perforations with erosion of the
malleus. It involves grafting onto the incus or the remains of the malleus.
 Type III tympanoplasty is indicated for destruction of two ossicles, with the stapes still intact
and mobile. It involves placing a graft onto the stapes, and providing protection for the
assembly.
 Type IV tympanoplasty is used for ossicular destruction, which includes all or part of the
stapes arch. It involves placing a graft onto or around a mobile stapes footplate.
 Type V tympanoplasty is used when the footplate of the stapes is fixed.

Otosclerosis

 Oto means ear and Sclerosis is abnormal hardening of body tissue.


 It 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.

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

 Middle ear infection.


 Bacteria from the middle ear can travel into the air cells of the mastoid bone.
 Less commonly, a growing collection of skin cells called a cholesteatoma, may block
drainage of the ear, leading to mastoiditis.

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

 Disease affecting the hearing and balancing system.


 It characterized by recurrent and sudden episodes of dizziness, tinnitus, progressive hearing
loss usually in one ear.
 It is due abnormal increase in the amount of endolymph fluid in endolymphatic chamber in
inner ear.
 There is excessive build of fluid in endolymphatic chamber causing the vestibular membrane
to stretch.
 At some moment the wall of membrane ruptures and both the fluid endolymp and perilymph
and cause the symptoms of spinning dizziness also known as the vertigo.

Pathophysiology

 The exact pathophysiology of Ménière’s disease is debatable.


 The underlying mechanism is believed to be a distortion of the membranous labyrinth,
resulting from over accumulation of endolymph.
 The endolymph and perilymph (fluids that fill the chambers of the inner ear) are separated
by thin membranes housing the neural apparatus of hearing and balance.
 Variations in pressure stress these nerve‐rich membranes, resulting in hearing disturbance,
tinnitus, vertigo, imbalance and a pressure sensation in the ear.
 When hydrops occurs this is possibly due to an increase in endolymphatic pressure; in turn
this causes a break in the membrane that separates the perilymph from the endolymph.
 The sudden change in the rate of vestibular nerve firing creates an acute vestibular
imbalance.
 The actual distention caused by increased endolymphatic pressure also leads to a
mechanical disturbance of the auditory and otolithic organs.
 Irritation of the utricle and saccule may produce non‐rotational vestibular symptoms.
 This physical distention also results in mechanical disturbance of the organ of Corti.
 Distortion of the basilar membrane and the inner and outer hair cells can cause hearing
loss and/or tinnitus.

Causes

 The main cause is unknown.


 Head injury
 Middle ear infection
 Allergies
 Alcohol
 Smoking
 Respiratory infection

Clinical Manifestation:

Patient may experience following:

 Vertigo and Dizziness


 Tinnitus
 Hearing Loss
 Fullness in ear
 Photophobia

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:

Endolymphatic Sac Decompression

 Incision behind the involved ear exposing the Mastoid bone.


 Identification of Facial nerve.
 The endolymphatic sac opened and Valve is inserted to drain the fluid.

Labyrinthectomy

 With same approach the labyrinth is exposed.


 Also exposing & drilling semicircular canals , the nerve of balance is completely removed.

Vestibular Neurectomy:

 It involves the resection of vestibular nerve to alleviate vertigo.

Chemical Labyrinthectomy

 With the help of medication such as Streptomycin the nerve endings of only balance are
destroyed.
VERTIGO

 Sensation of Moving (Self and Surrounding)


 Horizontal Spinning(As if in Swing)
 Also has Nausea, Vomiting, Sweating.

Pathophysiology

 Mismatch in sensory inputs from:


 Eyes
 Proprioception from Joints.
 Signals from Vestibular Systems.

Causes

 Peripheral Problem affecting the Vestibular System


 Central Problem affecting the Brain stem or cerebellum

Peripheral Problem affecting the Vestibular System

 Benign Paraoxysmal Positional Vertigo ( Crystals of Calcium Carbonate Otoconia)


 Meniere disease
 Vestibular Neuronitis (Inflammation of Vestibular Nerve)

Central Problem affecting the Brain stem or cerebellum

 Posterior Circulation Infraction (Stroke)


 Tumors
 Multiple Sclerosis
 Vestibular Migrane.

Clinical Manifestation:

 Nausea,
 Vomiting,
 falling,
 Nystagmus,
 Hearing loss, and tinnitus.
Labyrinthitis,

 It’s an inflammation of the inner ear, can be bacterial or viral in origin.


 It affects the hearing and balancing system.

Causes

 Infection in another part of body (Otitis Media)


 Viral Infection.
 Head injury.
 Neoplasm.
 Stress
 Alcohol Consumption
 Upper respiratory tract infection.
 Cholesteatoma.

Clinical Manifestation

 Hearing loss,
 Tinnitus,
 Nystagmus.
 Vertigo with nausea and vomiting.

Management

 Treatment of bacterial labyrinthitis includes IV antibiotic therapy, fluid replacement, and


administration of an antihistamine (eg, meclizine [Antivert]) and antiemetic medications.
 Treatment of viral labyrinthitis is based on the patient’s symptoms

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

 It include neurologic, audiometric, and vestibular tests; CT scans; and MRI.

Management

 Stereotactic radiosurgery may slow tumor growth and preserve the facial nerve.

Hearing Loss

 Hearing disorders are a common cause of disability.

Conductive 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

 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.

 Mixed hearing loss occurs due to a combination of conductive and sensorineural causes.

Central and Functional Hearing Loss.

 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

 BPPV is a mechanical problem in the inner ear.


 It occurs when some of the calcium carbonate crystals (otoconia) that are normally
embedded in gel in the utricle become dislodged and migrate into one or more of the 3
fluid-filled semicircular canals, where they are not supposed to be.
 When enough of these particles accumulate in one of the canals they interfere with the
normal fluid movement that these canals use to sense head motion, causing the inner ear to
send false signals to the brain.
 Fluid in the semi-circular canals does not normally react to gravity. However, the crystals
do move with gravity, thereby moving the fluid when it normally would be still.
 When the fluid moves, nerve endings in the canal are excited and send a message to the
brain that the head is moving, even though it isn’t.
 This false information does not match with what the other ear is sensing, with what the
eyes are seeing, or with what the muscles and joints are doing, and this mismatched
information is perceived by the brain as a spinning sensation, or vertigo, which normally
lasts less than one minute.
 Between vertigo spells some people feel symptom-free, while others feel a mild sense of
imbalance or disequilibrium.

MANAGEMENT

 The canalith repositioning procedure is commonly used.


 This noninvasive procedure, which involves quick movements of the body, rearranges the
debris in the canal.
 The procedure is performed by placing the patient in a sitting position, turning the head to a
45-degree angle on the affected side, and then quickly moving the patient to the supine
position.
 Patients with acute vertigo may be treated with meclizine for 1 to 2 weeks. After this time, the
meclizine is stopped, and the patient is reassessed.
 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.
 A physical therapist prescribes balance exercises that help the brain compensate for the
impairment to the balance system.
 The Epley maneuver or repositioning maneuver is a maneuver used by medical professionals
to treat one common cause of vertigo, benign paroxysmal positional vertigo (BPPV) of the
posterior or anterior canals of the ear.

ANATOMY AND & PHYSIOLOGY OF NOSE

 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.

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