ADULT HEALTH NURSING II

UNIT VI: EYE AND ENT NURSING

Ms. Abida Razzaq MScN, BScN, RM, RN

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 ANATOMY AND PHYSIOLOGY OF
EXTERNAL AND MIDDLE EAR.

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 OTITIS EXTERNA

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 OTITIS MEDIA

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OTITIS MEDIA
Acute otitis media is an acute infection of
the middle ear, usually lasting less than 6
weeks.
The pathogens that cause acute otitis media
are
 Streptococcus pneumoniae,
 Haemophilus influenzae, and
 Moraxella catarrhalis,
Caused by upper respiratory infections,
inflammation of surrounding structures (e.g,
rhinosinusitis, adenoid hypertrophy), or
allergic reactions (e.g, allergic rhinitis).
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CLINICAL MANIFESTATIONS
Symptoms vary with the severity of the
infection; usually unilateral in adults.
Pain in and about the ear (otalgia) may be
intense and relieved only after spontaneous
perforation of the eardrum or after
myringotomy.
Fever;
Drainage From The Ear,
Hearing loss.

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 CONT…
Tympanic membrane is erythematous and
often bulging.
Conductive hearing loss due to exudate in
the middle ear.
Even if the condition becomes subacute (3
weeks to 3 months) with purulent discharge,
permanent hearing loss is rare.
Cholesteatoma (sac filled with degenerated
skin and sebaceous material) may be
present as a white mass behind the
tympanic membrane (Chronic OM)

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COMPLICATIONS
Perforation of the tympanic membrane may
persist and develop into chronic otitis
media.
Secondary complications involve the
mastoid (mastoiditis), meningitis, or brain
abscess (rare).

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MANAGEMENT
With early and appropriate broad-spectrum
antibiotic therapy, otitis media may clear
with no serious problem. If drainage occurs,
an antibiotic may be prescribed.
Outcome depends on efficacy of therapy
(the prescribed dose of an oral antibiotic
and the duration of therapy), the virulence
of the bacteria, and the physical status of the
patient.

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MEDICAL MANAGEMENT
(CHRONIC CONDITION)
 suctioning and cleansing of the ear
 Antibiotic drops are instilled or antibiotic
powder is applied
 Tympanoplasty procedures (myringoplasty and
more extensive types) may be performed to
prevent recurrent infection, reestablish middle
ear function, close the perforation, and improve
hearing.
 Ossiculoplasty may be done to reconstruct the
middle ear bones to restore hearing.
 Mastoidectomy may be done to remove
cholesteatoma, gain access to diseased
structures, and create a dry (noninfected) and
healthy ear.
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SURGICAL RX: MYRINGOTOMY
(TYMPANOTOMY)
an incision is made into the tympanic
membrane to relieve pressure and to drain
serous or purulent fluid from the middle ear.
This painless procedure
usually takes
less than 15 minutes.

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 MASTOIDITIS

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MASTOIDITIS
Mastoiditis is an inflammation of the mastoid
resulting from an infection of the middle ear
(otitis media).
Chronic mastoiditis can lead to the
formation of cholesteatoma
 (ingrowth of the skin of the external layer of the
eardrum into the middle ear).

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CLINICAL MANIFESTATIONS
Pain and tenderness behind the ear
(postauricular)
Discharge from the middle ear (otorrhea)
Fever,
Headache
Mastoid area that becomes erythematous
and edematous

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MEDICAL/SURGICAL MANAGEMENT
General symptoms are usually successfully
treated with
 antibiotics;
 occasionally, myringotomy is required.

Surgical Management
mastoidectomy may be necessary to
remove the cholesteatoma and gain access
to diseased structures.

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 MÉNIÈRE’S DISEASE

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MÉNIÈRE’S DISEASE
Ménière’s disease is an abnormal inner ear
fluid balance (too much circulatory fluid)
caused by malabsorption in the
endolymphatic sac or blockage in the duct.
 Endolymphatic hydrops, a dilation in the
endolymphatic space, develops.
 Either increased pressure in the system or rupture
of the inner ear membranes occurs, producing
symptoms

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Ménière’s disease is more common in adults,
with the average age of onset in the 40s

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TYPES
There are two possible subsets of the
disease:
1. Cochlear Disease: Cochlear disease is
recognized as a fluctuating, progressive
sensorineural hearing loss associated
with tinnitus and aural pressure in the
absence of vestibular symptoms or
findings.
2. Vestibular Disease: Vestibular disease is
characterized as the occurrence of
episodic vertigo associated with aural
pressure but no cochlear symptoms.
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SYMPTOMS
 In the early stage vertigo may be accompanied
by:
 Nausea;
 Dizziness;
 Vomiting;
 Temporary hearing loss;
 A feeling of pressure, ‘fullness’ and discomfort
in the ear;
 Palpitations and sweating;
 Tinnitus, which can vary in severity.
 Acute episodes of vertigo usually last 20
minutes to 24 hours.
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Hearing loss may eventually be permanent;
vertigo may then decrease, but balance
problems will remain, especially in the dark.
Other symptoms are depression, anxiety,
headaches and migraines.

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ASSESSMENT AND DIAGNOSTIC METHODS
Disease is not diagnosed until the four
major symptoms are present;
 vertigo and nausea and vomiting contributes to
diagnosis.
There is no absolute diagnostic test for this
disease.
Audio vestibular diagnostic procedures,
including Weber’s test, are used with finding
of sensorineural hearing loss in the affected
ear.
Electronystagmogram may be normal or
may show reduced vestibular response.
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MEDICAL MANAGEMENT
 Goals of treatment may include
recommendations for changes in lifestyle and
habits or surgical treatment.
 The treatment is designed to eliminate vertigo or to
stop the progression of or stabilize the disease.
 Psychological evaluation may be indicated if patient is
anxious, uncertain, fearful, or depressed.
Dietary Management
 Low sodium (1,000 to 1,500 mg/day or less)
 Avoidance of alcohol, monosodium glutamate
(MSG), aspirin and aspirin-containing
medications

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PHARMACOLOGIC THERAPY
Antihistamines, such as meclizine (Antivert),
to suppress the vestibular system;
Tranquilizers such as diazepam (Valium)to
help control vertigo;
Antiemetics such as promethazine
(Phenergan) suppositories to control the
nausea, vomiting, and vertigo.
Diuretics to lower pressure in the
endolymphatic system.
Vasodilators are often used in conjunction
with other therapies.

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SURGICAL MANAGEMENT
Surgical procedures include endolymphatic
sac procedures and vestibular nerve
section.
However,

Hearing loss, tinnitus, and aural fullness may

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NURSING MANAGEMENT
Assessment
During the health history, collect data about
the ear problem
 Infection,
 Otalgia,
 Otorrhea,
 Hearing loss and vertigo,
 Duration and intensity,
 Causation,
 Prior treatments, health problems, current
medications, family history, and
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 CONT…
 Drug allergies.
 Observe For Erythema,
 Edema,
 Otorrhea,
 Lesions, And
 Odor And Color Of Discharge.
 Review Results of audiogram.

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NURSING DIAGNOSES
1. Anxiety related to surgical procedure,
potential loss of hearing, potential taste
disturbance, and potential loss of facial
movement
2. Acute pain related to mastoid surgery
3. Risk for infection related to
mastoidectomy, placement of grafts,
prostheses, or electrodes; surgical trauma
to surrounding tissues and structures

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4. Disturbed auditory sensory perception
related to ear disorder, surgery, or packing
5. Risk for trauma related to impaired balance
or vertigo during the immediate
postoperative period or from dislodgment of
the graft or prosthesis
6. Disturbed sensory perception related to
potential damage to facial nerve (cranial
nerve VII) and chorda tympani nerve
7. Deficient knowledge about mastoid disease,
surgical procedure, and postoperative care
and expectations

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NURSING INTERVENTIONS
Reducing Anxiety
1. Reinforce information the otologic
surgeon has discussed anesthesia, the
location of the incision (postauricular),
and expected surgical results (hearing,
balance, taste, and facial movement).
2. Encourage patient to discuss any anxiety
or concerns.

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NURSING INTERVENTIONS
Relieving Pain
1. Administer prescribed analgesic agent for
the first 24 hours postoperatively and then
only as needed.
2. If a tympanoplasty is also performed, inform
patient that he or she may have packing or a
wick in the external auditory canal and may
experience sharp shooting pains in the ear
for 2 to 3 weeks postoperatively.
3. Inform patient that throbbing pain
accompanied by fever may indicate infection
and should be reported to the physician.

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NURSING INTERVENTIONS
Preventing Infection
1. Explain prescribed prophylactic antibiotic
regimen.
2. Instruct patient to avoid water from entering
the ear for 6 weeks and to kee postauricular
incision dry for 2 days; a cotton ball or
lamb’s wool covered with a water-insoluble
substance (eg, petroleum jelly) and placed
loosely in the ear canal usually prevents
water contamination.
3. Observe for and report signs of infection
(fever, purulent drainage).
4. Inform patient that some serous drainage is
normal postoperatively.
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NURSING INTERVENTIONS
Improving Hearing and Communication
1. Initiate measures to improve hearing and
communication:
A. Reduce environmental noise, face patient when
speaking, speak clearly and distinctly without
shouting.
B. Provide good lighting if patient must speech-read
and use nonverbal clues.
2. Instruct family that patient will have
temporarily reduced hearing from surgery
as a result of edema, packing, and fluid in
middle ear; instruct family in ways to
improve communication with patient.

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NURSING INTERVENTIONS
Preventing Injury (Vertigo)
1. Administer antiemetics or antivertiginous
medications (eg, antihistamines) as
prescribed if a balance disturbance or
vertigo occurs.
2. Assist patient with ambulation to prevent falls
and injury.
3. Instruct patient to avoid heavy lifting,
straining, exertion, and nose blowing for 2 to
3 weeks after surgery to prevent dislodging
the tympanic membrane graft or ossicular
prosthesis.

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NURSING INTERVENTIONS
Preventing Altered Sensory Perception
1. Reinforce to patient that a taste
disturbance and dry mouth may be
experienced on the operated side for
several months until the nerve
regenerates.
2. Instruct patient to report immediately any
evidence of facial nerve (cranial nerve
VII) weakness, such as drooping of the
mouth on the operated side.

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NURSING INTERVENTIONS
Promoting Home- and Community-Based Care
1. Provide instructions about prescribed
medications: analgesics, antivertiginous
agents, and antihistamines for balance
disturbance.
2. Inform patient about the expected effects
and potential side effects of the medications.
3. Instruct patient about any activity
restrictions.
4. Teach patient to monitor for possible
complications, such as infection, facial nerve
weakness, or taste disturbances, including
signs and symptoms to report immediately.
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5. Caution caregiver and patient that patient
may experience some vertigo and will
therefore require help with ambulation to
avoid falling.
6. Instruct patient to report promptly any
symptoms of complications to the
surgeon.
7. Stress the importance of scheduling and
keeping follow-up appointments.

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REFERENCES
Chapter 59 in Smeltzer, S. C., Bare, B. G.,
Hinkle, J. L., & Cheever, K. H. (2010). Brunner
and Suddarth’s textbook of medical-surgical
nursing (12th ed.). Philadelphia: Lippincott
Williams & Wilkins.

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