1. Hearing Loss
1.1. Conductive
1.1.1. Mechanical dysfunction of external or middle ear
1.1.2. Partial loss because a person is able to hear if sound amplitude is increased enough to reach normal nerve elements in inner ear
1.1.3. May be caused by impacted cerumen, foreign bodies, a perforated TM, pus or serum in middle ear, and otosclerosis
1.1.3.1. Otosclerosis-abnormal bone remodeling in the middle ear.
1.2. Sensorineural (perceptive)
1.2.1. signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex
1.2.2. Increase in amplitude may not enable a person to understand words.
1.2.3. May be caused by presbycusis and by ototoxic drugs, which affect hair cells in cochlea.
1.2.3.1. Presbycusis-hearing loss with aging
1.3. Mixed
1.3.1. Combination of conductive and sensorineural types in the same ear
2. Developmental Competence
2.1. Adults
2.1.1. Otosclerosis
2.1.2. Ages 20-40
2.1.3. Hardening that is progressive
2.2. Aging Adults
2.2.1. Cilia become stiff
2.2.2. Cerumen accumulates
2.2.3. Reduces hearing
2.2.4. Presbycusis:
2.2.4.1. Sensorineural hearing loss with aging (nerve breakdown)
2.2.5. Gradual sensorineural loss caused by nerve degeneration in inner ear or auditory nerve
2.2.6. Onset usually occurs in 50s and slowly progresses.
2.2.7. First notice a high-frequency tone loss.
2.2.8. Ability to localize sound is impaired also.
2.2.9. Accentuated when unfavorable background noise is present
2.2.10. Pendulous ear lobe
2.2.11. Tympanic membrane thicker and more opaque
3. Questions to Include in PQRST
3.1. Earache
3.2. Infections
3.3. Discharge
3.4. Hearing loss
3.5. Environmental noise
3.6. Tinnitus
3.6.1. Ringing in the ear
3.7. Vertigo
3.7.1. Sensation of being off balance
4. Otoscope Examination
4.1. Choose largest speculum that will fit comfortably in ear canal.
4.2. Tilt the person’s head slightly away from you to bring obliquely sloping eardrum into better view.
4.3. Pull pinna up and back on an adult or older child to straighten S-shape of canal.
4.4. Pull pinna down on an infant and a child under 3.
4.5. Hold pinna gently but firmly; do not release traction on ear until you have finished examination and removed otoscope
4.6. Insert speculum slowly and carefully along axis of canal.
4.7. Avoid touching inner “bony” section of canal wall covered by a thin epithelial layer because it is sensitive to pain.
4.8. Once in place, you may need to rotate otoscope slightly to visualize all the TM; do this gently.
4.9. Last, perform otoscopic examination before you test hearing.
4.10. Canals with impacted cerumen give the erroneous impression of pathologic hearing loss.
5. Hearing Acuity & Balance
5.1. Whisper Test
5.1.1. Test one ear at a time while covering the other ear to prevent sound transmission
5.1.1.1. Abnormal: the patient cannot repeat the words
5.2. Audiometry
5.2.1. Hear sounds through a headphone raises hands when sound is heard
5.2.1.1. Can detect whether there is sensorineural hearing loss or conductive hearing loss
5.3. Tuning Fork
5.3.1. Weber Test
5.3.1.1. Can detect unilateral conductive hearing loss
5.3.1.1.1. Place fork of bridge of forehead
5.4. Rinne Test
5.4.1. Strike tuning fork, place on the mastoid bone behind the ear
5.4.1.1. Patient will let the provider know when they no longer hear sound
5.4.1.1.1. Conductive loss: AC = BC or even longer (AC less than BC)
5.4.1.1.2. Sensorineural loss: Normal ratio intact but reduced, the person hears poorly both ways
5.5. Romberg Sign
5.5.1. Feet together, eyes closed
5.5.1.1. Abnormal: if patient sways or falls the results are positive(not good)
6. Tympanic Membrane
6.1. "The Eardrum"
6.1.1. Translucent membrane
6.1.1.1. Abnormal Findings: redness, swelling, otorrhea, bulging
6.1.1.1.1. Perforation: dark oval area
6.1.2. Pearly gray
6.1.3. Separates the outer ear from the middle ear
6.1.4. When sounds reach the tympanic membrane, they cause it to vibrate
6.1.5. The vibrations are then transmitted to the tiny bones of the ear
7. Hearing Pathways
7.1. Air conduction
7.1.1. Hearing occurs through air near the ears
7.2. Bone conduction
7.2.1. Bones of the skull vibrate and are transmitted directly to the inner ear to cranial nerve V111
7.3. Equillibrium
7.3.1. 3 semicircular canals, in the inner ear constantly feed information to the brain about the position of body space
7.3.1.1. Wrong information transmitted can lead to a staggering gait/vertigo
8. Objective Findings that may suggest Hearing Loss
8.1. Lip reading or watching your face and lips rather than your eyes
8.2. Frowning or straining forward to hear
8.3. Posturing of head to catch sounds with better ear
8.4. Misunderstands questions; frequently asks you to repeat
8.5. Irritable or shows startle reflex when you raise your voice
8.6. The person’s speech sounds garbled, vowel sounds distorted
8.7. inappropriately loud voice
8.8. Flat, monotonous tone of voice
9. Abnormal Findings
9.1. Redness, swelling, pain, excess cerumen
9.2. Tender, enlarged lymph nodes in the region of the pinna or mastoid process
9.3. Sticky yellow discharge may indicate that the ear drum has ruptured
9.4. Acute Otitis Media- occurs when middle ear fluid is infected
9.4.1. Redness, swelling, bulging, earache, fever
9.5. Otis Media with Effusion-fluid in the middle ear from a blocked eustachian tube
9.5.1. Feeling of fullness, popping sound while swallowing
9.6. Foreign body
9.6.1. Common in children
9.6.1.1. Toys, corn, beans, beads
9.6.2. Adults
9.6.2.1. Cotton tip applicator
9.7. Frostbite
9.7.1. Redish-blue discoloration from extreme cold, necrosis may occur
9.8. Otitis Externa
9.8.1. Infection of outer ear, with movement of the pinna and tragus
9.8.1.1. Purulent discharge, fever, enlarged, tender lymph nodes
9.9. Keloid
9.9.1. Overgrowth of scar tissue
9.9.1.1. Common with dark pigmentation
9.9.1.1.1. Most common cause: pierced ears
9.10. Battle sign
9.10.1. Ecchymotic discoloration from trauma to the side of the head
9.10.1.1. Basilar Skull Fracture including the temporal bone
9.11. Perforation
9.11.1. Acute otitis media is not treated the ear drum may rupture from increased pressure
9.11.1.1. Also occurs with trauma
9.12. Scarred drum
9.12.1. Dense white patches
9.12.1.1. Caused by repeated infections
9.12.1.1.1. Does not necessarily cause hearing loss
9.13. Blue drum
9.13.1. Trauma in middle ear due to skull fracture
9.14. Tympanostomy Tubes
9.14.1. Tubes inserted surgically through the eardrum to relieve middle ear pressure and promote drainage of chronic ear infections
9.14.1.1. Spontaneously come out in 12-18 months