Disease of the Ear

DISEASE OF THE EAR
Overview of the ear
The ear is the organ of hearing. It is supplied by the 8th   cranial nerve i.e the cochlear part of the vestibulocochlear nerve which is stimulated by vibrations caused by sound waves.
With the exception of the auricle (pinna) the structure that forms the ear are encased within the petrous portion of the temporal bone.
STRUCTURE
The ear is divided into 3 dinstinct parts:
The outer ear
The middle ear (tympanic cavity)
The inner ear
Outer ear, consists of auricle (pinna) and the external acoustic meatus
Middle ear (tympanic cavity) is an irregular shaped air-filled cavity within the petrous portion of the temporal bone, the cavity, its contents and the air sacs, which open- out it.
Inner ear: or labyrinth meaning maze contains the organ of hearing and balance. It is described in two parts, the bony labyrinth and the membranous labyrinth.
GENERAL CAUSES OF EAR PROBLEMS
Trauma to the ear     - infections          - ear wax
Foreign bodies        - head trauma        - swimming
Exposure to very loud noise             - allergies
Air travel                    arteriousclerosis
Hypothyroidism.





MASTOIDTIS
It is an infection of the mastoid process. The portion of  the temporal bone of the skull that is behind the ear which contains open, air –containing spaces. It is usually caused by untreated acute otitis media (middle ear infection) and used to be a leading cause of child mortality. With development of antibiotics however, mastoiditis has become quiet rare in developed countries. It is treated with medications and / or surgery.
If untreated, the infections can spread to surrounding structures including the brain, causing serious complications.
PATHOPHYSIOLOGY
It is straight forward bacterial spread from the middle ear of the mastoid air cells, where the inflammation causes damage to the body structure.
Streptococcus pneumonia, streptococcus pyogenes haemophillus influenza, and moxaella catarrhalis are the most common organisms covered in acute mastoiditis.
The surgical treatment is mastoidectomy.
Pre-operative preparations/management
The hair is shaved over the side of side of the neck and temporal bone. This should be performed very gently because the pain is severe.
The external auditory meatus is cleaned with savlon 1:200. The routine preparations are similar to that of any operation performed under general anesthesia.

POST OPERATIVE MANAGEMENT
Should oozing of blood and pus occur, the outer dressing should be replaced.
The pack inserted into the wound is removed on the 2nd /3rd day and a general anaesthesia may be needed.
Its important maintains complete asepsis during the dressing. A new gauze pack is inserted into the depth of wound after mopping the mecrtus with hydrogen peroxide and wipping with methylated spirit.
Repetition of dressing is necessary until complete healing has occurred.
Pain must be relieved by administration of sedatives.
The diet in past operative stage should be rich in vitamin C and protein e.g.: milk, egg, meat and fruits should be given.
Since these patients are usually in poor general health, prolonged convalescence is desirable.
The nurse must observe the patient carefully during convalescence for any signs of meningitis/cerebral abcess.

EXCESSIVE EAR WAX
Earwax medically referred to as cerumen, is produced by glands in the outer ear canal. It purpose is to trap dust and other small particles and prevent them from reaching and potentially damaging the ear drum. Normally, the wax dries up and falls out of the ear along with any trapped dust or debris. Earwax serves to lubricate and protect the inside of the ear lubricate and protect the inside of the ear.
Excessive earwax occurs when the normal secretion of external auditory canal accumulates and become hard and dry.
CAUSES
 Dusty occupations e.g. Miners, dustmen etc.
Genetics
Tumour of the ear
Signs and symptoms
Deafness: where only a small aperture exists in the wax a sudden movement of wax ma completely occlude passage ways.
Irritation
Pain
Noises are not frequently heard.
Fullness of the ear.


DIAGNOSTIC INVESTIGATIONS
By signs and symptoms
Patient, family and occupational history
Ear examination with otoscope which reveals a firm yellow and dark mass.

MANAGEMENT
Microsuation: using gently suction levels under a microscope to remove earwax. The procedure is uncomfortable and noisy and patient should be pre-informed.
Instrumentation: the use of instrument such as cerumen curette, binocular microscope for magnification and removing ear wax.
Aural toileting: use of instrument (home probe) to remove cerumen from the ear.

EAR IRRIGATION
It involves washing the external auditory canal of discharges to often and remove impacted cerumen or dislodge foreign body and to relieve localised inflammation and discomfort. Contraindication.
When a vegetable foreign body obstruct the canal because they are hydroscopic.
In patients with fever, cold ear infection, ruptured tympanic membrane.

INDICATIONS
To soften and remove cerumen
To clean the ear canal.
To dislodge a foreign body
To relieve localised inflammation and discomfort.


EQUIPMENT
Ear irrigation syringe        -     4x4 gause
Otoscope            -      cotton ball or trip applicator prescribed irrigants
Large basin
Linen saver pad
Ernesis bowl
Optional: adjustable lamp, container for irrigant tubering, clamp, catheter with ear tip

IMPLEMENTION
Explain the procedure to the patient, provide privacy wash your hands and put on gloves if necessary.
If you have not done so, use an otoscope to inspect the auditory canal to be irrigated
Help patient to a sitting position. To prevent solution from running down his neck, tilt his head slightly forward and toward the affected side. If he cannot sit, have him lie on his back to tilt his head slightly forward and towards the affected ear.
Make sure that you ensure adequate lightening.
If the patient is sitting, place the linen saver pad covered with a bath towel on his shoulder an dupper arm, under the affected ear.
Have  the patient hold the emesis basin close  to his head under the affected ear.
To avoid getting foreign matter into the ear canal, clean the auricle and the meatus of the auditory canal with a cotton ball or tip applicator moistened with normal saline or prescribed irrigant.
Draw the irrigant into the syringe and expel the air.
Straighten the auditory canal, the insert the syringe timp and start the flow.
During the irrigation, observe the patient for signs of pain and dizziness , stop the procedure and report if any.
Lf syringe is empty, remove it and inspect the return flow. Refill the syringe and continue until the return  flow  is clear. Never use more than  5OOmk during irrigation .
Remove the syringe, inspect the  canal for cleanliness with an otoscope.
Remove bath towel, linen saver and help patient  lie on the affected side with the 4x4 gauze pad under his ear to promote drainage from residual clebris and solution.
Note the irrigated ear
Note the volume and solutions used
Note the  appearance of the  canal before3 and after irrigstion.
Note the appearance of the flow return, patient tolerance to procedure and the comments made related to hearing activity.
complications:  lateral  sinus thrombosis, extradural abcess, meningitis, cerebral/crebellar abscess, facial palsy and rarely labyrinths, septicaemia and pyema, paralysis of the 7th cranial nerve.

FOREIGN BODY IN THE EAR
Getting an object stuck in the ear is a relatively common problem especially in toddlers. The vast majority of objects are lodged in the ear canal. Which is a small channel that ends at the eardrum. Because the ear canal is quite sensitive you can usually tell if there is something in the ear.
Common objects found in the ears include food material beads, toys and insects children usually place items in the ear out of curiosity.
Although earwax (cerumen) is not technically a foreign body, it does frequently accumulate in the ear canal and can cause discomfort/decrease hearing just like other foreign bodies.

CAUSES
The vast majority of objects found in the ears are placed there voluntarily usually by children for an endless variety of reason. A care giver should not threaten a child when asking about this possibility because the child may deny having put someting in the ear in other to avoid punishment.
This denial could result in a delay of its discovery and   increase the risk of complication.
Insects are well known to crawl into the ear usually when you are asleep. Sleeping on the floors, or out doors would increase the chance of unpleasant.

CLINICAL MANIFESTATION
Fortunately, most people can tell if there is something in the ear. The ear canal where most objects get stuck is sensitive. The symptoms of having a foreign body in the ear largely depend on the size, shape and substance involved.
Occasional, foreign body in the ear may go undetected and can cause an infection in the ear. This situation you may notice ongoing infectious drainage from the ear.
Pain is the most common symptom. If the object is blocking most of the ear canal.
Irritation of the ear canal can also make you nauseated the could cause you to vomit.
Bleeding is also common if the object is sharp.
Tinnitus (Ear buzzing as a result of  insert in the ear).
Fever
Difficulty comprehending
Decreased hearing
Ear discharge.

DIAGNOSTIC INVESTIGTIONS
Otoscopic test, observe the tympanic membrane and the lining for foreign bodies.
Auditory test, this assesses hearing acuity conduction is by 2 ways.
Air conduction test (acts)

Voice test-client standing about 30 – 60 cm away from the nurse and is asked to repeat whatever nurse whispers.
Each ear is tested separately.
Bone conduction test (BCT)
Weber Tunning fork test, a vibrated fork is placed on the middle of the forehead the client to report in which ear sound is loudest.
Tomographic test (x-ray)
C.T. scan
M  R I
Swab for c/s



TREATMENT
Treatment will largely depend on the location and the object / objects involved.
Years of experience often provide innovative techniques that are safe and effective.
If the object is metallic, a long instrument may be magnetized to assist in gently pulling the object from the ear.
Another common technique involves irrigating the ear. If the ear drums appear intact warm water can be gently squirted pas the object using a small catheter.
EAR GROWTH
Tumors of the ear can be benign or maligiant. They can occur on the external ear or in the ear canal, the middle ear or ear. Tumor in different areas of the ear behave differently thus it is necessary to describe tumours based on their site of occurance as well as their behaviour and treatment.
TUMORS OF THE EXTERNAL CANAL
The  external ear canal begins at the opening got the  cup shaped portion (conccha) of the ear and extends down ward to the eardrum. Immediate biopsy of any suspicious lesion in the external ear canal should be performed immediately in most common malignant tumors are basel cell or squamous cell cancers.

BENIGN EAR CYST (EXOSTOSES)
 The exact course is unknown but cyst may, occur when oils are produced in a skin gland faster than they can be released from gland.
Benign bony tumors of the ear canal (exostoses and oesteomas) may be caused by exess  growth of bone. Repeated exposure to cold water’s may increase the risk benign tumors of the ear canal.

SYMPTOMS
The symptoms of cyst’s include:
Pain – if cysts are in the outside ear canal or getinted
Small soft skin lamps on, behind or infront of the ear.
Ear discomfort gradual hearing loss in ear
There may be no symptoms presented (asymptomatic)


DIAGNOSTIC TEST
Benign cyst and tumors are usually discovered during a routine ear examination which can include hearing tests (audiometry)
CT scan can be done

TREATMENT
Surgical excision of squamous cell carcinoma
When squamous cell cancers become large, surgery combined with radiation therapy is necessary for a complete cure.
If the cyst or tumor is not painful and does not interfere with hearing, treatment is not necessary.

CHOLESTEATOMA
Cholesteatoma is a growth of skin cells occurring behind the drum that causes damage to the ear drum itself the middle ear bones and in some instances the inner ear, the facial nerve, the barrier between the brain and the ear and even the blood vessels supplying brain structures, it can lead to more serious problems including chronic ear infectious, permanent hearing less and relentless process for years before symptoms advance. The tissue is destructive to normal structure but is not malignant in nature.
TYPES
Congenital cholesteatoma
Acquired cholesteatoma – it grows over time in a previously healthy ear. It starts with a hole in the ear drum or  a retraction in the ear drum as a result of ear infections, trauma.
After the hole is created the opportunity exists for healthy skin cells to move from the ear canal and begin growing behind the eardrum.
Intermittent continuous drainage from the ear
Build – up of dried crusts in the ear
Acute and chronic intections
Pain
Diagnostic test
Direct examination of the ear using a high powered  microscope
CT scan
MR.

TREATMENT
Antibiotics can decrease associated infections
Surgery – tympanomastoidectomy.

NURSING MANAGEMENT
It is a day case so the patient goes home after the surgery the client is educated to avoid wetting the dressing when bathing
Cover the ear with  a cotton bal with a small amount of petroleum jelly on it.