Ear Diseases

• 2 Types of Meniere's Disease

  1. Cochlear Meniere’s - hearing loss 
  2. Vestibular Meniere's -  associated with vertigo
• Common causes of Meniere's Disease

  • Very common in middle aged person (40-60)
  • Idiopathic
  • Abnormal accumulation of fluid in membranous labyrinth (cochlea is affected)
  • Balance of ions

  1. Potassium
  2. Sodium 
  3. Chloride 
• Signs and Symptoms of Meniere's Disease

  Triad of symptoms

  1. Episodic vertigo - hallmark sign
  2. Tinnitus
  3. Fluctuating sensorineural hearing loss assessed through weber's test

  Other Signs

  1. Feeling of fullness or pressure in ears
  2. Incapacitating vertigo, accompanied by nausea and vomiting
  3. Endolymphatic hydrops
• Medications Administered for Meniere's Disease

  1. Diuretics to reduce fluid
  2. Diazepam to decrease pressure and alleviate vertigo
  3. Antinausetic medication
  4. Steroid + antibiotic injections gentamicin 
  5. Avoid aspirin containing medications (NSAIDs) causes tinnitus 
• Surgical Procedure for Meniere's Disease

  1. Endolymphatic Sac Decompression (shunting) - reduce pressure 
  2. Vestibular nerve sectioning - removal of vestibular nerve; under general anesthesia 
• Diet for Patient's with Meniere's Disease

  • Low salt low potassium and chloride diet 
  • Avoid canned, frozen or processed foods and monosodium glutamate (MSG)
  • Eat meals and snacks at regular intervals and stay hydrated
  • Eat fresh fruits, vegetables and whole grains
  • Limit coffee, tea, soft drinks and alcohol (because they are diuretic leading to fluid imbalance)
• Types of Otitis Media

  • Types:

  1. Acute Otitis Media (AOM) - has sudden and rapid onset
  2. Serous Otitis Media/Middle Ear Effusion - effusion from increased pressure; no infection
  3. Chronic Otitis Media - recurrent; damages the eardrum and mastoid cavity
• Involvement of Eustachian Tube:

  • Swelling and inflammation on the middle ear causes blockage
  • Pressure in the middle ear increases leading to discomfort, pain and difficulty hearing
• Involvement of Eardrum (Tympanic Membrane):

  • Swelling and bulging occurs from the build up in the back of the eardrum (seen through otoscopy)
  • If the pressure in the eardrum is too high, it can rupture and produce drainage (eventually turns to pus-like drainage). Accompanied with pressure and pain which can lead to temporary or permanent hearing loss
• Causes of Acute Otitis Media

  • URTI (bacterial and viral) 
  • Streptococcus pneumoniae, haemophilus influenzae, Moraxella catarrhalis
  • Higher incidence in children
  • Due to URTI susceptibility (has underdeveloped immune system)
  • Medical conditions such as Down Syndrome (shorter eustachian tube and narrow esopharyngeal airway)
  • Tendency to self inoculate (cross contamination)
  • Breastfeeding can lower the risk of acute otitis media because breast milk has antibody protection
  • Smoking (2nd hand smoking)
• Causes of Serous Otitis Media/Middle Ear Effusion

  • Allergic reaction (rhinitis)
  • Exposure to irritants (smoking)
  • Environmental factors (pollutants and allergens)
  • Radiation therapy and RAIU (px with cancer or thyroid problem); radiation does not only kill cancer cells but also healthy cells affecting eustachian tube
  • Barotrauma (high altitude places)
  • Eustachian tube dysfunction from a concurrent URTI or allergy
• Causes of Chronic Otitis Media

  1. Inadequate treatment of previous infections
  2. Anatomical problem of eustachian tube leading to poor ventilation
  3. Environmental factors (smoking)
• Signs and Symptoms of Acute Otitis Media

  1. Bulging of the eardrum due to fluid
  2. Otalgia
  3. Drainage from the ear
  4. Fever 
  5. Hearing loss due to build up of fluid from the eardrum (temporary only or conductive hearing loss) because the tympanic membrane  and the auditory ossicles or eardrum have poor movements due to negative pressure
  6. Noted irritability on children
  7. Poor appetite due to pain from chewing
• Signs and Symptoms of Serous Otitis Media

  1. Hearing loss (mild to moderate) from accumulation of fluid in inner ear
  2. Fullness in the ear from pressure 
  3. Sensation of congestion, popping & crackling noises (especially in high altitude places) due to movement of fluid and air
  4. Bulging of the eardrum from pressure seen in otoscope
• Signs and Symptoms of Chronic Otitis Media

  1. Cholesteatoma 
  2. Continuous drainage and pressure  seen through otoscope
• Pharmacologic Management for Acute Otitis Media

  Medication

  1. Antibiotic

  • Amoxicillin (if not effective, give azithromycin or cephalosporins)

  1. Steroids
• Preventive Measures for Acute Otitis Media

  1. Vaccination to avoid URTIs (pneumococcal and streptococcal vaccines)

  • Pneumococcal vaccines: PCV13
• Surgical Intervention for Acute Otitis Media

  1. Myringotomy or Tympanotomy

  • Relieves pressure and drain serous or purulent fluid 
  • Small incision is made, then a tube is inserted in the eardrum to drain fluid
  • The patient is under general anesthesia
  • The tube lasts up to weeks, months and years depending on the draining time
  • CX: if the tube is in the ear for too long, it can fall or granulation forms on the surroundings of the tube causing obstruction (cholesteatoma)
• Interventions for Serous Otitis Media

  • No treatment unless infected 
  • Corticosteroid - to reduce inflammation
  • Valsalva Maneuver, Autoinflation techniques, Toynbee maneuver 
• Interventions for Chronic Otitis Media

  1. Suctioning of ear
  2. Antibiotic drops and powder (liquid leads to maceration causes damage easily, so powder is preferred)
• Surgical Intervention for Chronic Otitis Media

  1. Tympanoplasty (Grafting)

  • For persistent infection despite medical treatment
  • Px has conductive hearing loss
  • Ruptured eardrum
  • Post op: Main goal - the site should not be infect and provide proper wound care

  1. Ossiculoplasty

  • Prostheses made of teflon, stainless steel, titanium or hydroxyapatite is inserted in eardrum which receives the vibrations and transmission of sounds

  1. Mastoidectomy

  • removal of mastoid to remove cholesteatoma
  • CX: facial nerve injury 
• Types of Otitis Externa: 

  1. Acute - less than 6 weeks
  2. Chronic - more than 3 months or recurrent 
• Otitis Externa has higher incidence in:

  1. Children (ages 7-14)
  2. Tropical country
• Infectious Causes of Otitis Externa:

  1. Bacteria: Staphylococcus Aureus, Pseudomonas 

  • Pseudomonas is a bacteria that is sensitive to acidic environment
  • Management: Acidic Acid (vinegar)

  1. Fungal: Candida, Aspergillus
• Non-infectious Causes of Otitis Externa

  1. Excessive Moisture and temperature of the environment (water in the canal - swimming)
  2. Changes and alteration in the acidity and pH in the ear
  3. Protective barriers of the ears (epithelial cells and cerumen) become thinner or damage

  • Cerumen or ear wax also provides acidic environment to the ear

  1. Trauma to the ear
  2. Allergic reaction to products (hair coloring products, jewelries, earbuds and earplugs)
  3. Obstructions (cotton swabs pushes ear wax back that may cause obstruction)
• Signs and Symptoms of Otitis Externa

  1. Inflammation and swelling of ear canal
  2. Macerated epithelial cells (dry skin)

  • From excessive cleaning, scratching or trauma

  1. Otalgia: ear pain 

  • Upon pulling of pinna or tragus 

  1. Redness and swelling visible on otoscope
  2. Discharge/drainage of fluid

  • Initially clear on early phase, then becomes pus-like/serous with foul smell

  1. Decrease in hearing 
  2. Feeling of fullness in the ear
  3. Tinnitus 
  4. Lymphadenopathy in the neck
  5. Fever 
• Medical Management for Otitis Externa

  1. Antimicrobial (antibiotic & antifungal)

  • For bacterial (antibiotic) and fungal (antifungal) infections only (not for trauma)
  • Perform culture and sensitivity testing first to identify microorganism prior to giving antibiotic to avoid antimicrobial resistance
  • Usually otic medications (by drops)

  1. Steroids (Corticosteroid)

  • For inflammation

  1. Combination of Antibiotic and Corticosteroid
  2. Acetic Acid Solutions

  • To create an acidic environment in the ear canal to prevent growth of fungal infection

  1. NSAIDs

  • For pain, discomfort and reduce inflammation
• Medications for Otitis Externa

  • Common Antibiotic: Neomycin, Gentamicin, Ciprofloxacin, Ofloxacin, Tobramycin
  • Common Antifungal: Clotrimazole, Miconazole, Ketoconazole
  • Common Medication: 
  • Hydrocortisone
  • Ciprofloxacin, Ofloxacin or Tobramycin + Dexamethasone
• Nursing Responsibilities for Otitis Externa

  1. Emphasize the importance of medication compliance to prevent antimicrobial resistance
  2. Demonstrate proper technique on how to administer ear drops
  3. Avoid cleaning external auditory canal with cotton tipped applicators
  4. Avoid getting the ear canal wet when swimming or shampooing the hair (use clean earplugs)
  5. Apply mineral oil if the earwax is hard to soften it
  6. Adequate rest and hydration
• How to Apply Ear Drops

  • Affected ear up
  • Gently pull your earlobe out and up to straighten auditory tube
  • Administer the medication, make sure it is close to the ear but is not touching the ear or exudate
  • The medication is inteded for single person use only
  • Gently push earflap to encourage liquid into ear
  • Stay for at least 2 minutes before moving