Ear nose and throat notes

1. 10 HOURS
BLOCK
M17 CLASS
EAR, NOSE AND
THROAT
(ENT)
CONDITIONS
1

2. Objectives
 Review A & P of ear, nose and throat
 Ear, Nose and Throat examination
 Common diseases/conditions of Ear, Nose, and
Throat
 Perform ear irrigation
2

3. REVIEW OF A & P
The Ear
 Hearing and Balance
 Three parts outer, middle, and inner ear
 The outer & middle ear; hearing
 The inner ear; both hearing & equilibrium
 Receptors for hearing & balance
3

4. The Ear
4

5. The Ear
5

6. Cochlea:- Unrolled
6

7. ROUTE OF SOUND TO THE
EAR
7

8. AUDITORY PATHWAYS.
8

9. nebertppt
Nose and Throat
9

10. Paranasal Sinuses
 Lighten the skull.
 Warm and moisten the air.
 Resonance chambers for speech.
 Produce mucus that drains into the nasal
cavity
10

11. Examination of ENT
THE EAR
 Inspection: deformities, lesions, and discharge,
as well as size, symmetry, and angle of
attachment to the head
 Direct palpation: pain, tenderness
 Otoscopic Exam: ext. auditory canal & tympanic
membrane:- redness, perforation, exudate, blood,
masses
 Gross Auditory Acuity: one ear at a time;
Voice/Whisper, Weber and Rinne tests are done
11

12. Testing Gross Auditory Acuity
 Voice/Whisper Test: One ear occluded,
examiner whispers softly 1-2 feet away from the
unconcluded ear, out of pt’s sight.
 Normal: can correctly repeat word.
 Weber Test: Tests bone conduction.
Vibrating tuning fork placed on the pt’s mid-
forehead.
 Normal: sound heard equally in both ears or as
centered.
 Conductive hearing loss:- sound heard better in the
affected ear.
12

13.  Rinne Test: Distinguishes btwn conductive &
sensorineural hearing loss.
Examiner places stem of vibrating turning fork on
mastoid process & counts till pt. can no longer hear;
then immediately near the canal and counts till pt.
can no longer hear.
 Normal: air conduction > bone conduction.
 Conductive hearing loss:- bone conduction ≥ air
conduction.
 Sensorineural hearing loss:- air conduction > bone
conduction
13

14. Others
 Audiometry
 Pure-tone audiometry
 Speech audiometry
 Tympanography (impedance audiometry)
14

15. 15

16.  Other aspects NOSE and THROAT are
discussed in the video. D:AMREF-NCK e-
learningHead to toe video
assessmentpart2.flv
16

17. SINUSITIS &
RHINOSINUSITIS
DEFINITION
SINUSITIS:
 Inflammation of nasal mucosa; infectious or allergic
RHINOSINUSITIS:
 Inflammation of the mucosal lining of the nasal cavity
& paranasal sinuses.
 Can be Acute or Chronic/Recurrent
INCIDENCE
 Affects about 13% of adults; 2-3 episodes annually.
17

18. ETIOLOGY
 Allergens (mites, medications)
 Environmental irritants (smoke, fumes; humidity
changes)
 Mechanical obstruction/deformities (Hypertrophied
turbinates, Tumors, Foreign body)
 Infections
 Viruses (90-98%)
 Bacterial (<10%)
 Typical: Strep. pneumoniae, Haem. influenzae,
 Less common: Staph. aureus
 Fungi
18

19. PRESENTATION
Major Signs & Symptoms
 Purulent/ discolored nasal discharge
 Nasal congestion or obstruction
 Facial congestion or fullness
 Facial pain or pressure
 Hyposmia or anosmia
 Fever (for acute sinusitis)
Minor Signs & Symptoms
 Pruritus (itching nose, palate, throat, eyes, ears).
 Headache
 Ear pain or fullness
 Dental pain
 Cough
 Fatigue
19

20. PATHOPYSIOLOG
Y
20

21. PATHOPHYSIOLOGY Cont..
1. Sinuses in direct communication with
nasopharynx
2. Bacterial or viral infection of sinuses
3. Inflammation, (or tumors, polyps, trauma)
cause ostia obstruction
4. Ostia obstruction impede normal air & mucus
flow
5. Mucus stagnates, further growth of bacteria
causing eve further inflammation/ swelling
21

22. MANAGEMENT
DIAGNOSIS
 Mainly based on Hx. & Clinical Presentation
 X-ray, sinoscopy, ultrasound, CT, and MRI (chronic
cases)
 A confirmatory diagnosis is by obtaining cultures
by sinus puncture or endoscopy.
22

23. MEDICAL MANAGEMENT
 Depends on cause, from Hx & physical exam.
 Tx. focuses on symptom relief.
 Most common: Antihistamine/decongestant
 Leukotriene modifiers (Montelukast)]
 Mast cell stabilizer (Cromolyn)
 Tx. Goal is to shrink the nasal mucosa, relieve
pain, & treat infection (if present/ suspected)
 Observation without the use of antibiotics
 Antibiotic of choice: Amoxicillin OR Amoxicillin-
clavulanate
 For Penicillin allergy: Cotri-moxazole (Septrin)
 For Resistance: High dose Amoxicillin-clavulanate;
23

24. NURSING MANAGEMENT and PREVENTION
 Teaching on self-care is the basis of nursing
Mgt.:
 Avoid or reduce exposure to allergens/irritants
 Correct use/administration of meds/ following the
recommended antibiotic regimen
 Controlling the environment at home and at work
 Early Tx. & home remedies: saline nasal sprays/
drops.
 Hand hygiene
 Signs of complications: headache; neck stiffness;
persistent fevers
24

25. COMPLICATIONS
Local:
 Osteomyelitis
 Mucocele (cyst of the paranasal sinuses).
Intracranial:
 Cavernous sinus thrombosis,
 Meningitis
 Brain abscess
 Orbital cellulitis
25

26. VIRAL RHINITIS (COMMON
COLD)
DEFINITION
 Acute, infectious, viral inflammation of nasal mucosa
 Characterized by nasal congestion, rhinorrhea, sneezing,
sore throat, and general malaise.
AETIOLOGY
 Caused by approx. 200 different viruses
 Mostly Rhinoviruses.
 Other viruses
 Coronavirus,
 Adenovirus,
 Respiratory syncytial virus,
 Influenza virus,
 Parainfluenza virus.
26

27. CLINICAL MANIFESTATIONS
 nasal congestion
 rhinorrhea and nasal discharge
 sneezing
 tearing watery eyes
 sore throat
 low-grade fever
 chills
 general malaise
 headache
 muscle aches
 halitosis
 cough (later)
27

28. MANAGEMENT
COLABORATIVE MANAGEMENT
 Usually supportive; disease self-limiting
 Adequate fluid intake
 Rest
 Prevention of chilling
 Warm salt-water gargles soothe the sore throat
 NSAIDs e.g. Ibuprofen
 Antihistamines to relieve sneezing, rhinorrhea, & nasal
congestion.
 Expectorants e.g. Guaifenesin
 Topical nasal decongestants e.g. Phenylephrine
 Teach on hand hygiene; droplet prevention; & home
remedies
28

29. ADENOTOSILITIS *Covered in
Pediatrics
DEFINITION
 Inflammation of pharyngeal tonsils or adenoids.
AETIOLOGY
 Bacterial: GABHS (up to 30%)
 Viral: EBV (90%); others CMV
29

30. ADENOTOSILITIS
WALDEYER’S
30

31. CLINICAL PRESENTATION
 Sore throat
 Fever
 Foul-smelling breath
 Dysphagia
 Odynophagia
 Airway obstruction:
 Mouth-breathing
 Snoring
 Noisy respirations
 Sleep apnea
 Earache
 Draining ears
 Voice impairment
 Enlarged tonsils,
exudate
 Pyrexia
31

32. MANAGEMENT
DIAGNOSTICS
 History & clinical examination
 Intraoral ultrasound
 Throat/tonsilar swab for culture
 Audiometric assessment (with otitis)
32

33. COLABORATIVE MANAGEMENT
 Treated through the use of supportive
measures:
 Rest
 Increased fluid intake
 Analgesics e.g. PCM
 Salt-water gargles
 For bacterial
 Penicillin (Augmentin, X-pen, benzathine)(first-line
therapy)
 Cephalosporins (ceftriaxone)
 Macrolides (clarithromycin)
 Clindamycin
 Consider corticosteroids e.g dexa
33

34. Indications for tonsillectomy and adenoidectomy.
1. Recurrent throat infections:
 ≥ 7 ep. in 1 yr
 5 ep./yr. for 2 yrs.
 3 ep. /yr. for 3yrs.
 ≥ 2 wks of lost school or work
2. Peritonsilar abscess
3. Associated airway obstruction or sleep apnea
4. Malignancy (or suspicion of)-biopsy
5. Repeated attacks of purulent otitis media
Adenoidectomy done if adenoids are concurrently
inflamed
34

35. COMPLICATIONS
 Post-op
 Postoperative bleeding
 Respiratory compromise
 Sore throat, otalgia, uvular swelling
 Dehydration
 Others
 Otitis media (commonest)
 Peritonsillar abscess (quinsy).
 Pneumonia
 Sepsis
 Meningitis
 Intracranial abscess
 Rheumatic fever
35

36. EPISTAXIS
 Bleeding from nostril, nasal cavity or nasopharynx
 Often self–limiting but may be severe & life-
threatening
 60% of population with at least one nosebleed
 6-10% will require medical treatment
 Bimodal age distribution
 High Incidence < 10 y/o
 Second peak: 45-65 y/o
36

37. Anatomic Considerations
 Bleeding usually arises from the nasal septum, which
is supplied by:
 Anterior ethmoidal artery
 Posterior ethmoidal artery
 Greater palatine
 Sphenopalatine artery
 Superior labial artery
 Anterior Nasal Cavity = Little’s Area
 Nose has abundant blood supply that permits it to bleed
easily
 Kesselbach’s Plexus
 Posterior Nasal Cavity
 Woodruff’s Plexus
Internal carotid
External carotid
37

38. Types
 Anterior = 90-95 % (from Kiesselbach’s plexus)
 Posterior = 5-10% (from sphenopalantine artery;
Woodruff’s Plexus)
38

39. Etiology
 85% of cases are idiopathic
 Traumatic Causes
 Nose picking
 Facial Trauma
 Mucosal Drying
 Foreign Body
 Barotrauma
 Substance, Environmental Irritants
39

40. Etiology
 Infections/ inflammation
 Rhinitis
 Sinusitis
 URTI
 Tumor’s/Lesions
 Nasopharyngeal neoplasms
 Sinus Neoplasms
 Benign nasal polyps
40

41. Etiology
 Coagulopathies
 Vit K deficiency
 Thrombocytopenia
 Bleeding disorders e.g Von-Willibrand’s disease
 Hormonal
 Vicarious menstruation
 Stystemic conditions
 Hypertension
 COPD
 Liver cirrhosis
 Drugs e.g Salicyclates, anticoagulants
41

42. Management
 Assessment
 Inspect the nose and back of the throat for obvious
bleeding and observe for frequent swallowing
 Level of consciousness and vital signs to detect signs
of hypovolemia
 Document allergies & major illnesses
 Anterior or posterior rhinoscopy
 Nasal endoscopy
 CBC-Hb, platelet count etc.
 Coagulation profile
 Radiology-X-ray, CT
42

43. Management
First aid
 ABC
Digital Pressure (Trotter’s Method)
1. Pt sits up
2. Head bent forward
3. Breath through open mouth
4. Pinch over Kiesselbach’s plexus for at least 15-20
min
43
Pinch here

44. Figure 16-7
44

45. Management
 Nasal Preparation
Vasoconstrictor sprays & anesthetics
 Cauterization
Silver Nitrate Sticks
Electocautery
 Anterior nasal packing balloon
tamponed
45

46. Nasal Packing
 Nasal Tampon inserted horizontally after
lubrication of pack with bacitracin or KY-Jelly and
then allowed to expand after saturation with normal
saline.
46

47. Balloon tamponed
 Balloon Catheter coated with lubricant & platelet
aggregator.
 Soaked in water for 30 seconds then inserted into
the nose along the base of the nasopharynx.
 Cuff inflated with air/water until it provides
adequate tamponade.
47

48. Anterior Packing
 Pack the nasal cavity with xeroform ribbon
gauze from the floor upwards in an accordion
fashion using a bayonet forceps leaving a four
inch tail on each end out of nares
48

49. Posterior packing

49

50. Alternative Treatments
 Surgical Therapies
 Electrocautery
 Septal Surgery
 Arterial Ligation
 Alternative Treatments
 Angiographic Embolization
 Fibrin Glue
 Laser Therapy
 Hot Water Irrigation
50

51. Complications of Packing
 Failure to control bleeding
 Toxic Shock Syndrome
 Blockage of Duct drainage
 Nasovagal Reflex (Controversial)
 Obstructive Sleep Apnea
 Airway obstruction
 Removal can cause re-bleeding
 Pressure necrosis
51

52. Summary
 Epistaxis is common complaint affecting 60% of
population at some point in lifetime
 Key to evaluation is differentiation between anterior
and posterior bleeding source
 Anterior = 90-95 % (from Kiesselbach’s plexus)
 Posterior = 5-10% (from sphenopalantine artery)
 Consider possible causes for epistaxis with recurrent or
difficult to control nosebleeds
 Non-invasive techniques will stop the majority of
epistaxis (Trotter’s method, cautery, vasoconstrictive
compounds)
 Difficulty to control epistaxis may require nasal
packing
 Consider antibiotics while packing in place
 Posterior nasal bleeds should all be hospitalized
52

53. LARYNGITIS
 Inflammation of the larynx
 May be infectious or non-infectious;
 Acute:- sudden onset.
 Chronic:- persistent hoarseness.
ETIOLOGY
 Voice abuse
 Exposure to dust, chemicals, smoke, other pollutants
(allergic rhinitis)
 Descending URI. (pharyngitis): H. infuenzae; haemo lytic
streptococci or Staph. aureus.
 GERD (reflux laryngitis).
 Exposure to sudden temperature changes,
 Dietary deficiencies, malnutrition,
 Immunosuppressed state.
 NB: Most common cause is a virus. Bacteria are secondary.
53

54. CLINICAL PRESENTATION
 Hoarseness or aphonia
 Dry, irritating cough
 Discomfort or pain in throat
 Sore throat (worsens in the evening hours).
 Edematous uvula.
 Malaise and fever if laryngitis has followed
viral infection of upper respiratory tract.
54

55. COLLABORATIVE MANAGEMENT
 Vocal rest. This is the most important single
factor.
 Avoidance of smoking and alcohol.
 Steam inhalations e.g. oil of eucalyptus;
soothing and loosen viscid secretions.
 Cough sedative:- To suppress troublesome
irritating cough.
 Antibiotics:-with 2˚infection; Ampicillin, 3rd gen
cephalosporin
 Analgesics. To relieve local pain and discomfort.
 Steroids: laryngitis following thermal or chemical
burns,
55

56. DEVIATED NASAL SEPTUM
 Top of the nasal cartilaginous ridge leans to the
left or the right, usually causing passage
obstruction.
 Can result in poor drainage of the sinuses.
 Alone, can go undetected for years; no need for
correction.
 Many victims are unaware till some pain, or
complications arise.
56

57. Deviated Nasal
Septum
57

58. NASAL POLYPS
 Aetiology
 Not known
 Symptoms
 Nasal Obstruction
 Rhinorrhoea
 Treatment
 Topical steroid medication
 Surgery
58

59. POST NASAL SPACE CARCINOMA
(NASOPHARYNGEAL CARCINOMA [NPC])
 Most common ca. originating from nasopharyngeal
epithelium
 Usually at level of eustachian tube
AETIOLOGY
 Viral infections –EBV
 Environmental influences e.g. carcinogens
 Salted fish with Carcinogenic volatile nitrosamines
 Hereditary; genetic susceptibility
 Smoking & alcohol consumption
59

60. 60

61. Clinical Presentation
 Neck Swelling (Cervical lymphadenopathy)
 Nasal Blockage
 Bloody Nasal Discharge/Epistaxis
 Ear Blockage
 Facial pains
 Facial pain
 Otitis media
 Nasal regurgitation --from soft palate paresis
 Unilateral hearing loss
 Cranial nerve palsies
 Trismus--lockjaw
 Bone pain or organ failure –in metastasis
61

62. MANAGEMENT
DIAGNOSTICS
For Dx; Typing; Staging
 Endoscopy with biopsy
 CT scan
 MRI
 PET Scan
STAGING
 Stage I: small; confined to nasopharynx
 Stage II: extending to local area; limited neck disease
 Stage III: large; with(out) neck disease
 Stage IV: large; involving intracranial regions, extensive
neck disease, and/or metastasis
62

63. TREATMENT
 Radiotherapy (mainstay)
 Chemotherapy
 Surgery- (rarely)
 Radio-chemotherapy recommended
63

64. CANCER OF THE LARYNX
 Approx ½ of all head & neck cancers.
 Almost all are classified as squamous cell carcinoma.
ETIOLOGY/RISK FACTORS
 Male gender (10:1)
 Age 60 to 70 years
 Tobacco use
 Alcohol use
 Vocal straining
 Chronic laryngitis
 Occupational exposure to carcinogens
 Nutritional deficiencies (riboflavin –B3)
 Family history
64

65. Subtypes
 Glottic Ca. : 59%
 Supraglottic Ca:
40%
 Subglottic Ca: 1%
65

66. CLINICAL MANIFESTATIONS
 Hoarse; harsh, raspy, low-pitched voice.
 Persistent cough; pain & burning in the throat
when drinking hot liquids & citrus juices.
 Lump felt in the neck.
 Late symptoms: dysphagia, dyspnea, unilateral
nasal obstruction or discharge, persistent
hoarseness or ulceration, & foul breath.
 Enlarged cervical nodes, weight loss, general
weight loss, & pain radiating to the ear may occur
with metastasis.
66

67. ASSESSMENT AND DIAGNOSIS
 Hx. of hoarseness
 Physical exam: every case of hoarseness
should be examined by in(direct) laryngoscopy;
 Biopsy (Dx, typing & staging)
 CT, MRI, & PET scan
Direct
67

68. Laryngoscopy
68

69. MED-SURG MANAGEMENT
 Goals:- cure, preserve effective swallowing,
voice, and avoidance of permanent
tracheostoma.
 Tx options:- surgery, radio, chemo, or
combinations.
Radiation ─excellent results in early-stage
69

70. MED-SURG MANAGEMENT
 Surgical:
 Vocal cord stripping—used to treat dysplasia
 Cordectomy—lesions limited to the middle 3rd of
the vocal cord
 Laser surgery—Tx of early glottic cancers
 Partial laryngectomy—early stages
 Total laryngectomy—stage IV tumor or recurrence
 Speech therapy: artificial larynx (electrolarynx)
70

71.  Partial laryngectomy
71

72.  Total Laryngectomy
72

73. Total Laryngectomy
73

74. NURSING MANAGEMENT
(LARYNGECTOMY)
Pre-op
 Educate abt. surgery; possible loss of natural
voice.
 Teach coughing & deep breathing exercises
74

75. NURSING MANAGEMENT (LARYNGECTOMY)
Post-op
 Maintain patent airway:
 Semi-fowler’s position.
 Observe for restlessness, labored breathing,
apprehension, & tachycardia
 Analgesics
 Encourage turning, coughing, deep breathing;
suction PRN.
 Early ambulation.
 Care laryngectomy tube e.g. cleaning stoma
75

76. Air flow with
Laryngectomy
tube
Voice prosthesis,
as part of speech
therapy
76

77. Post-op CONT…
 Alternative Communication Methods
 Speech therapist, involve family
 Call or hand bell; writing pad e.t.c
 Promote Adequate Nutrition & Hydration
 NPO for days, alternatives as ordered: IV fluids,
PN
 Start fluids; introduce solid foods as tolerated.
 Avoid sweet foods
 Rinse mouth, mouthwash, brush frequently.
 Observe for dysphagia
77

78. Post-op CONT…
 Monitor for potential complications:-
 Resp. distress & hypoxia, hemorrhage, infection,
wound breakdown, aspiration, & tracheostomal
stenosis.
 Promote Self-Home-Based Care
 Check!
78

79. COMPLICATIONS
1. Airway obstruction
2. Disfiguration: tumor removal; permanent
tracheotomy.
3. Infection
4. Voice alterations
5. Loss of taste & smell
6. Dysphagia
79

80. OTITIS MEDIA
 Inflammation of middle ear by pyogenic organisms.
AETIOLOGY
 Common esp. in infants & children of lower socio-
economic group.
 URTI; Chronic rhinitis and sinusitis
 Recurrent fevers i.e. measles, diphtheria, whooping
cough
 Nasal allergy
 Tumours of nasopharynx
 Packing of nose or nasopharynx for epistaxis.
 Cleft palate
80

81. AETIOLOGY
 Infection is:
Via eustachian tube
Via External ear
Blood-borne
 Most common organisms in infants & children
are Strep. pneumoniae (30%), Haem. influenzae
(20%) & Moraxella catarhalis (12%).
81

82. PATHOPHYSIOLOGY & CLINICAL
PRESENTATION
Runs through the following stages:
1. Tubal occlusion: Oedema & hyperaemia with
blockage of eustachian tube
 Deafness (conductive) and earache
2. Pre-suppuration: pyogenic organisms invade
tympanic cavity worsening hyperaemia with
exudate:
 Marked earache.
 Deafness & tinnitus (adults); high fever;
82

83. PATHOPHYSIOLOGY & CLINICAL PRESENTATION …
3. Suppuration: pus; bulging tympanic
membrane
 Deafness
 Excruciating pain, mastoid tenderness
 (vomiting, convulsions in children)
4. Resolution or Complication:
 Resolution: tympanic rupture, pus release &
subsidence of symptoms
 Complication: acute mastoiditis, abscess,
facial paralysis, labyrinthitis, extradural
abscess, meningitis, brain abscess or lateral
sinus thrombophlebitis.
83

84. Otitis Media
84

85. MANAGEMENT
 Antibacterial therapy:- ampicillin, amoxicillin
 Decongestant nasal drops:- Ephedrine drops; Oral
Pseudoephedrine
 Analgesics/antipyretics:- Paracetamol
 Ear toilet:- dry-mopping or a moistened wick
 Myringotomy:- Incising the bulging drum to
evacuate pus
Note: All cases should be carefully followed till
membrane returns to its normal appearance; conductive
deafness disappears
 Tympanostomy tube- for removal of loculated
thick fluid
85

86. 86

87. Nursing Care/Education
 Recurrent infections increase risk of permanent
hearing loss
 Take full-course of antibiotics
 Pain & fever management
 Control allergies & upper respiratory congestion.
 Avoid blowing or holding nose closed when
sneezing
 Prevent fluid pooling back to the eustachian tube;
-elevate infant’s head while feeding
-don’t allow infant to fall asleep with a bottle.
 Avoid swimming or water in the ears (use
87

88. Complications
88

89. MASTOIDITIS
 Inflammation of mucosal lining mastoid antrum and
bony walls of the mastoid air cell system.
ETIOLOGY
 Usually accompanies or follows acute otitis media.
 Associated with high virulence or lowered host
resistance
 Children are more affected
 Mostly caused Beta-haemolytic streptococci
89

90. PATHOPHYSIOLOGY
1. Infection + inflammation of periosteal lining.
2. Pus cannot be effectively drained
3. Pus accumulates under tension.
4. Hyperaemia & engorgement causes dissolution of
Ca2+ (hyperaemic decalcification).
5. Destruction of mastoid air cells & cavity; pus-filled.
6. Pus may break through mastoid cortex & on to
surface
90

91. CLINICAL MANIFESTATION
 Retro-aural pain
 Fever; persistent or recurrent
 Ear discharge; profuse & increases in
purulence.
 Mastoid tenderness
 Sagging of poster superior meatal wall.
 Tympanic perforation. dull & opaque
 Swelling over the mastoid.
 Conductive hearing loss always present.
91

92. Mastoiditi
s
92

93. DIAGNOSIS
 CBC:- Leucocytosis
 ESR:- Raised
 Ear swab for culture & sensitivity
 Mastoid X-ray:- mastoid cavity or
clouding:-exudate
 CT scan (gold standard)
93

94. MANAGEMENT
Difficult to treat!
 Antibiotics. Amoxiclav or Ampicillin.
 Myringotomy
 Cortical mastoidectomy:- with sub-
periosteal abscess; no improvement.
94

95. COMPLICATIONS
 Subperiosteal abscess
 Labyrinthitis
 Facial paralysis
 Extradural abscess
 Subdural abscess
 Meningitis
 Brain abscess
 Lateral sinus thrombophlebitis
 Otitic hydrocephalous
95

96. HEARING LOSS AND
DEAFNESS
Hearing impairment is common among older
adults.
TYPES OF HEARING LOSS
1. CONDUCTIVE
 Occurs in the middle ear
 Sound cannot be conducted from outer to inner
ear.
Aetiology
 Impacted cerumen; foreign bodies.
 Middle ear disease (otitis media)
96

97. 2. SENSORINEURAL
 Impaired inner ear or vestibulocochlear nerve
function.
Etiology
 Congenital & hereditary factors
 Noise trauma during a period of time
 Aging (presbycusis)
 Meniere’s disease*assignment
 Ototoxicity
 Syphylis, Cytomegalovirus
 Tuberculosis
 DM
97

98. 3. MIXED HEARING LOSS
 Both conductive & sensorineural losses.
 Surgery can correct conductive loss but
sensorineural loss remains.
 Able to hear sound but not to understand
speech
98

99. 4. CENTRAL & FUNCTIONAL HEARING
LOSS
 Problem along the pathway from the inner ear
to the auditory region or in the brain itself.
Note
 Unable to understand or put meaning to incoming
sound.
 Positive family Hx of deafness.
 Functional may be from emotional/psychologic
factors.
 No organic cause can be identified.
 Psychologic counseling may help.
99

100. CAUSES
CONDUCTIVE SENSIRONEURAL
External Ear Congenital Bilateral Noise Induced
Foreign Body Presbycusis
Tumour Autoimmune
Infection Drug Mediated
Middle Ear Trauma Unilateral Trauma
Infection Perilymphatic
Fistula
Cholesteatoma Acoustic
Neuroma
Otosclerosis Meniere’s Disease
Glomus Tumour Idiopathic
100

101. TEST YOUR KNOWLWDGE!
Conductive hearing loss is initially detected by:
a) A negative Rinne test
b) A positive Rinne test
ANSWER: B
Test Normal Conductive loos SN loss
Rinne AC> BC
Rinne positive
BC > AC
Rinne positive
AC> BC
Weber Equal Lateralised to the
poor ear
Lateralised to the
better ear
101

102. RISK FACTORS FOR HEARING
LOSS
a) Prolonged exposure to high-intensity sound
waves.
b) Repeated, chronic ear infections
c) Prenatal problems of rubella & eclampsia
d) Premature birth
e) Ototoxic medications: aminoglycosides,
diuretics
f) Female with family history of otosclerosis
102

103. CLINICAL MANIFESTATIONS
i. Asking others to speak up
ii. Answering questions inappropriately
iii. Not responding when not looking at the
speaker
iv. Straining to hear
v. Cupping hand around ear
vi. Showing irritability with others who do not
speak up
vii. Increasing sensitivity to slight increases in
noise level
viii. Tinnitus
ix. Speech problems: deterioration of present speech
or delayed speech development.
103

104. DIAGNOSTICS
History
 Onset/ime Course – Acute vs Chronic, Bilateral vs
Unilateral
 Aggravating/Relieving Factors
 Associated Symptoms – Tinnitus, Vertigo, Pain,
Discharge
 Trauma – Physical, Barotrauma, Noise Induced
 Medications
Exam & Tests
 Weber & Rinnes tests (conductive vs sensorineural
loss).
 Audiometry (hearing & comprehension)
104

105. MANAGEMENT
 Hearing aids: most effective with conductive loss.
 Speech therapy
 Sign language
 Stapedectomy: for otosclerotic lesions
 Cochlear implants: for profound sensorineural hearing
loss.
105

106. NURSING MANAGEMENT
1. Teach client how to care for hearing aid
 Keep the hearing aid dry
 Avoid using hair spray, cosmetics, or oils around
the ear.
 Always have extra batteries
 At night, turn off & open the battery compartment
 Avoid exposing it to extreme temperatures
 Clean ear mold part with a mild soap & water
 Clean any debris or cerumen
 Have it professionally cleaned every 3 to 6
months.
106

107. 2. To prevent complications after stapedectomy
 Appropriate pre-op teaching about post-op
activities.
 Dressing change as appropriate.
 Assess client for dizziness; maintain safety
measures
 Position Pt. on side with head of bed slightly
elevated.
 Instruct client not to blow nose
 Administer analgesics, antibiotics
 Instruct that hearing may not improve till edema
subsides.
107

108. 3. Advice on discharge:
 Keep the ear dry for 4 to 6 week after surgery.
 Avoid flying for at least a month after surgery
 Report unusual sensations or feelings in the ear
& any ear drainage.
 Notify health care provider if vertigo occurs
108

109. ASSISTIVE DEVICES & TECHNIQUES
 Hearing Aids. Fitted by an audiologist or
speech/hearing specialist. Many types.
 Speech/lip Reading. Pt. uses speech-associated
visual cues like gestures & facial expression to
help clarify the spoken message.
 Sign language. It is a visual-spatial language that
involves facial features such as eyebrow motion &
lip-mouth movements.
109

110. ASSISTIVE DEVICES & TECHNIQUES
 Cochlear Implant. Electronic hearing device that
stimulates inner ear nerves. Used incase of
hearing aids-failure.
 Assisted Listening Devices. Direct amplification
devices, amplified telephone receivers, alerting
flash systems, infrared amplifying systems, & a
combination of FM receiver & hearing aid.
110

111. Hearing Aids
111

112. Cochlear Implant
112

113. Questions?
For your own knowledge READ ON:
1. Hearing aids.
2. Stapedectomy
3. Cochlear implants
113

114. EAR IRRIGATION
 A routine procedure to remove excess ear wax
(cerumen) or foreign materials from the ear.
 Too much wax can cause blockage, resulting in
earaches, ringing in the ears, or temporary
hearing loss.
 Usually painless.
 Lukewarm water is squirted into the ear canal, by
a machine that squirts water at the right
pressure.
 This dislodges the softened plug which then falls
out with the water.
114

115. INDICATIONS
 Foreign body
 Impacted cerumen; Often works if the plug has been
softened e.g olive oil ear drops.
CONTRAINDICATIONS
 Previous complications following irrigation.
 Hx of ear surgery
 Cleft palate (even if repaired).
 Current ear infection or within six weeks.
 Recurrent otitis externa.
 Current or previous perforated eardrum
115

116. Impacted Cerumen
116

117. 117

118. Critical Thinking
A 20-year-old man, a member of a college
swim team, has recurrent external otitis—his
third
episode in the past 6 weeks. He is being
treated at an ENT clinic.
Devise an evidence-based practice teaching
plan for this patient.
118

119. END
119