Presentation Outline: Presentation Outline Review the anatomy of the ear Hearing loss Conductive hearing loss Sensorineural hearing loss Mixed hearing loss Use & care of hearing Aids Nursing management


Slide4: Can you imagine what your life would be like if you could not hear sound at all?


The Ear: The Ear Sensory organ with dual function: Hearing Assists with speech and the ability to communicate Equalibrium /Balance Essential for maintaining body movement,position and coodination


http://www.wisc-online.com/objects/index_tj.asp?objid=AP1502: http://www.wisc-online.com/objects/index_tj.asp?objid=AP1502 A learning activity that is animated & interactive


Normal eardrum: Normal eardrum


Slide8: Normal eardrum as seen through an otoscope                                                                                                                                                        Photograph courtesy of Hamid R. Djalilian, MD, University of Illinois at Chicago, adapted with permission. All rights reserved. http://www.otol.uic.edu


Causes of Hearing Loss: Causes of Hearing Loss 33.7% -- Overexposure to noise 28% --Aging - we begin to lose our hearing in our 30's and 40's by 65 years, more than half of us will have a hearing loss. Most people will still be in their working years when they realize they have a hearing loss 17.1% --infection or injury 4.4% -- genetics 16.8% -- other


Additional causes of hearing loss…: Additional causes of hearing loss… Congenital hearing loss Ototoxic medication Chemicals Meniere’s disease Meningitis Trauma from physical injuries Aging process Exposure to excessive noise Otosclerosis


Ototoxicity : Ototoxicity Salicylates - Salicylates cause a reversible hearing loss. As well, they are well known to cause tinnitus. As the salicylate is metabolized, hearing returns to normal (48-72 hours). Aminoglycoside Antibiotics - Ototoxicity occurs due to hair cell destruction. They usually affect the sensory cells in the basal turn of the cochlea producing a high frequency sensorineural hearing loss


Cont’d: Cont’d Diuretics - Both furosemide and ethacrynic acid are ototoxic. The damage they produce can be permanent or temporary. It is possibly due to altered electrolyte composition of the endolymph of the inner ear. Thiazide diuretics are not known to have ototoxic effects and may be a safer choice. **Beware of the septic patient in heart failure. They tend to be on ASA, Lasix and an aminoglycoside; all potentially ototoxic medications.


Cont’d: Cont’d Antineoplastic medications - Cisplatinum, bleomycin and nitrogen mustard all are ototoxic. They produce a permanent loss of hearing. Vancomycin - Antibiotic that can cause permanent hearing loss if used in high doses More pronounced if is given with a loop diuretic (Lasix)


Cont’d: Cont’d Erythromycin - when given in high doses, can produce ototoxicity. It is usually transient in nature. REF: http://meds.queensu.ca/medicine/otolaryngology/edu/ungrad/hl.htm


Varying degrees of hearing loss:: Varying degrees of hearing loss: Mild: People with a mild hearing loss cannot hear soft sounds. Sometimes they have to ask other people to repeat what they've said. It is hard for them to hear in noisy places. Moderate: A moderate hearing loss means that sounds must be fairly loud before a person can hear them. People with a moderate loss have trouble hearing others talk unless they talk loudly. Speech may not sound clear to them.


Slide17: Severe: People with a severe hearing loss can hear only very loud sounds. They cannot hear others talk. Many speech sounds are not clear to them. People with a severe loss hear vowels better than consonants. Profound: Even very loud sounds are not heard by people with a profound hearing loss. They cannot hear speech even if someone shouts. Low sounds, such as vowels, may be the only sounds they can hear. People with a profound loss may hear sounds only by feeling them through the body.


In adults, the most common causes : In adults, the most common causes Noise. Noise-induced hearing loss can affect people of all ages and most often develops gradually over many years. Age. presbycusis, changes in the nerve tissue and cells of the inner ear that occur as you grow older cause a gradual but steady hearing loss.


When are you considered Legally Deaf ?: When are you considered Legally Deaf ? A person who cannot hear sounds of at least 90dB is considered legally deaf.


Decibel Ratings & Time Exposure: Decibel Ratings & Time Exposure 0dB- lowest sound audible to human ear. 30dB- Quiet library. 50dB- Refrigerator. 70dB- Busy traffic 90dB- Shop tools 120dB- Rock concert in front of speakers 140dB- Gunshot 180dB- Rocket launching pad


Four Degree’s of Hearing Loss: Four Degree’s of Hearing Loss Mild: 26-45 decibels, a little difficulty hearing speech. Even a mild hearing loss can serious for children learning to talk. Moderate: 45-55 decibels, more difficulty with speech Severe: 66-85 decibels, a lot of difficulty with speech. Profound: anything over 85 decibels


Illnesses that can cause deafness…: Illnesses that can cause deafness… Otitis media Jaundice CMV – Cytomegalovirus Mumps Measles Rubella


Slide23: http://library.thinkquest.org/10202/


Signs of Hearing Loss: Signs of Hearing Loss You miss parts of conversations and continually ask people to repeat themselves  The high and low tones disappear - you don't hear birds singing anymore Your family complains you have the TV up too loud You have to turn up the volume on the telephone to hear properly You can't distinguish speech from background noises - you can't follow dinnertime conversation with others are talking and music playing You find yourself straining to read lips and facial expressions to understand what someone is saying to you REF: http://www.thfc.ca/noise.html


Three types of hearing loss: Three types of hearing loss Conductive hearing loss Sensorineural hearing loss Mixed hearing loss


Conductive Hearing loss: Conductive Hearing loss Usually results from an external ear disorder. The efficient transmission of sound by air to the inner ear is interrupted.


Note the appearance of the ear canal including it's diameter and the presence of wax. It is usual to see some wax in almost every ear.: Note the appearance of the ear canal including it's diameter and the presence of wax. It is usual to see some wax in almost every ear.


Foreign body in the canal of a child (wax crayon) note the drum visible distal to the foreign body: Foreign body in the canal of a child (wax crayon) note the drum visible distal to the foreign body


Otosclerosis: Otosclerosis Genetic disorder where there is repeated reabsorption and redeposition of the bones in the ear Results in fixation of the footplate of the stapes in the oval window The hardening of the inner ear prevents transmission of sound vibration into the inner ear Autosommally dominant so only one parent needs to have the defected gene


Tympanosclerosis : Tympanosclerosis From repeated infections and trauma to the tympanic membrane A deposit of collagen and calcium within the middle ear that hardens around the ossicles The deposits can be in the middle ear, or as plaque in the tympanic membrane


Trauma to the Tympanic Membrane: Trauma to the Tympanic Membrane Can be caused by a slap to the face, falling in water, sports injuries, Q-tips, industrial accidents (ex welding sparks) A perforated eardrum can be cause from a very acute middle-ear infection or from a loud explosion. A blast or blunt injury can fracture of dislocate the ossicles and tear the tympanic membrane Basal skull fracture involves the temporal bone and can cause ossicular damage and facial nerve paralysis


Perferated Eardrum: Perferated Eardrum


Otitis Media:: Otitis Media: Most prevalent disorder of the middle ear. It is often related to gram negative organisms Chronic otitis media can lead to tympanic membrane retraction, adhesive otitis media, perforation of the tympanic membrane or ossicles.


Otitis externa, an infective / inflammatory condition, the canal may be so swollen that a view into the ear is impossible: Otitis externa, an infective / inflammatory condition, the canal may be so swollen that a view into the ear is impossible


This is chronic otitis externa. Although the canal wall is not swollen, the skin is excoriated and red. The drum is essentially normal.: This is chronic otitis externa. Although the canal wall is not swollen, the skin is excoriated and red. The drum is essentially normal.


Slide38: Infected ear canal (otitis externa)                                                                                                                                                       


Slide39: Fluid in the middle ear                                                                                                                                                       


Sensorineural Hearing Loss: Sensorineural Hearing Loss Involves damage to the cochlea or vestibulocochlear nerve. Can be caused by congenital and hereditary factors, Meniere’s disease, ototoxicity, and aging and degenerative processes. Impairment of the function of the inner ear, the eighth cranial nerve or the brain.


Presbycusis: Presbycusis Progressive hearing loss, associated with aging population. Loss of ability to hear high frequency sounds. Degenerative changes in the labyrinthine structures.


Sudden Hearing Loss: Sudden Hearing Loss A condition where the person looses hearing in one ear suddenly Oral corticosteroids can restore hearing Cause is unknown, likely caused by viral diseases.


Congenital Hearing Loss: Congenital Hearing Loss Present at birth, develop during childhood or early adulthood and can worsen with time Often results in total deafness Occurs genetically and spontaneously Important to screen infants if there is a family history


Noise Induced Hearing Loss: Noise Induced Hearing Loss Hearing loss from prolonged exposure to loud noise (heavy machinery, engines, artillery). Usually occurs at the high frequency With continued exposure the hearing loss can become more severe and include adjacent frequencies. Can also occur with a traumatic injury, such as a loud blast.


Benign and Malignant Tumors: Benign and Malignant Tumors The first clinical sign is partial to complete hearing loss, followed by tinnitus and dizziness. The effect of the tumor depends on its location. It can cause symptoms such as an inability to interpret stimuli about position and movement, and tinnitus.


Glomus Tumor: Glomus Tumor


Meniere’s Disease: Meniere’s Disease An abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac. Can cause increased pressure in the inner ear or rupture of the inner ear membrane. Hearing loss is fluctuant Cause is unknown, could be viral, infection or stress.


Meniere’s Disease: Meniere’s Disease


Manifestations of Meniere’s Disease : Manifestations of Meniere’s Disease The three main symptoms are: Fluctuating progressive hearing loss (on the side involved) Tinnitus (roaring sound) Dizziness (vertigo)


Meniere’s Disease: Meniere’s Disease


Central Auditory Dysfuction: Central Auditory Dysfuction CNS cannot interpret the normal auditory signal Rare, but can be caused by CVA’s and tumors Known as central deafness


Mixed Hearing Loss: Mixed Hearing Loss Client has conductive and sensorineural hearing loss. Results from a dysfunction of air and bone conduction. This can include perforated ear drum and presbycusis.


Types of Hearing Loss: Types of Hearing Loss


Tinnitus: Tinnitus Subjective preception of sound with internal origin; unwanted noises in the head or ear. Characterized by a roaring sound, feeling of pressure or fullness in the ear, incapacitating vertigo, and nausea & vomiting. Referred to as “ringing in the ears”.


Tinnitus: Tinnitus


Tinnitus: Tinnitus Is not a disease, but a manifestation Subjective tinnitus - Ear noise that cannot be heard by an observer Objective tinnitus - Ear noise that can be heard by someone else than the client


Who gets Tinnitus?: Who gets Tinnitus? Very common in all age groups, especially following exposure to loud noise. Widely held misconception that it is confined to the elderly. Mild tinnitus is common – about 10 percent of the population have it all the time.


Assessment: Assessment Vertigo is the most common complaint, can accompany n&v. Diaphoresis, feelings of imbalance and disequilibrium. Aural pressure may occur only during or before attacks, or may be constant.


Medical Management of Tinnitus: Medical Management of Tinnitus Most can be treated with diet and medication therapy Adhering to a low sodium diet (2000 mg/day) Pharmacologic therapy Surgical management


Hearing Aids: Hearing Aids


Hearing Aids: Hearing Aids A Device through which speech and environmental sounds are received by a microphone, converted to electrical signals, amplified and reconverted to acoustic signals. Depress low frequencies or tones and enhance hearing for the high frequencies. Guidelines for assessment: Hearing loss > 30 dB


Hearing Aids: Hearing Aids Hearing aids make sounds louder, but do not improve a clients ability to discriminate words or understand speech. People who have low discrimination scores (ie. 20%) on audiograms will not benefit from a hearing aid. Hearing aids amplify all sounds including backround noise which can be bothersome. Computerized hearing aids


Hearing Aids: Hearing Aids Should be fitted according to the clients needs: Type of hearing loss Manual dexterity Should be dispensed by a certified audiologist


Hearing Aids con’t..: Hearing Aids con’t.. The FDA has established regulations to protect people with hearing impairments. Children must be evaluated by a physician Medical evaluation must be completed within 6 months before the purchase of a hearing aid.


3 Types of Hearing Aids: 3 Types of Hearing Aids


In the Ear: In the Ear One piece. Fits directly into the ear. No external wires or cords Miniature microphone is in the ear This hearing aid is generally effective for very mild to severe hearing loss.


In The Ear Canal: In The Ear Canal Same as in the ear aids Is customized to fit the size and shape of the ear canal. Used for mild to moderately severe hearing loss. Can be damaged by earwax and ear drainage.


Behind the Ear: Behind the Ear Hearing aid which fits snugly behind the ear. The microphone, amplifier, and receiver are connected to a plastic ear-mold that fits inside the outer ear. Used for mild to profound hearing loss. Larger size permits use of larger components that enable the aid to provide more power and features.


Care of the hearing aid: Care of the hearing aid Cleaning Ear mold is the only part that can be washed frequently with soap and water. The cannula is cleaned with a small pipe cleaner Malfunctioning Is the switch on? Is the battery charged? Recognizing complications common medical problems include: external otitis and pressure ulcers in the external auditory canal or meatus.


Trouble shooting : Trouble shooting Whistling Noise Loose ear mold Improperly made Improperly worn Worn out Improper Aid Selection Too much power required Open mold used inappropriately


Trouble shooting con’t: Trouble shooting con’t Inadequate amplification Dead batteries Wax in ear Wax in mold Wires disconnected Aid turned off or vol. too low Improper mold Improper aid for defect Pain for mold Improperly fitted mold Ear skin or cartilage infection Middle ear infection Ear tumor Unrelated conditions


Implanted Hearing Devices: Implanted Hearing Devices Three types: The cochlear implant - for little or no hearing The bone conduction device -transmit sound through the skull to the middle ear -used in conductive hearing loss Semi implantable hearing device - not yet approved by FDA -still require an external device


Cochlear Implant: Cochlear Implant An auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids. The hearing loss may be congenital or acquired. An implant does not restore hearing but helps the person detect medium to loud environmental sounds and conversation.


Cochlear Implants Cont’d…: Cochlear Implants Cont’d… It is designed to provide stimulation directly to the auditory nerve, bypassing the hair cells of the inner ear which are not functioning. The microphone and signal processor are worn outside the body and transmit electrical stimuli inside the body to the implanted electrodes. The electrical signals stimulate the auditory nerve fibers and then the brain, where they are interpreted.


Cochlear Implants Con’t…: Cochlear Implants Con’t… Candidates who are at least 1 year old, are selected according to the following criteria: Profound sensioneural hearing loss in both ears Inability to hear and recognize speech well with hearing aids No medical contraindication to a cochlear implant or general anesthesia Indications that being able to hear would enhance the patient’s life.


Cochlear Implant Surgery: Cochlear Implant Surgery Involves implanting a small receiver in the temporal bone through a post auricular incision and placing electrodes into the inner ear. The microphone and transmitter are worn on an external unit. The patient undergoes extensive cochlear rehabilitation with the health care team (eg audiologist and speech pathologist). Several months may be needed to learn to interpret the sounds heard.


Hearing Guide Dogs: Hearing Guide Dogs


Hearing Guide Dogs: Hearing Guide Dogs People who live alone are eligible International hearing dog Inc. The dog reacts to the sound of a telephone, a doorbell, an alarm clock, a baby’s cry, a knock at the door, a smoke alarm, or an intruder. The dog alerts its master by physical contact. The dog then runs to the source of the noise. In public the dog positions itself b/t the hearing impaired person and potential hazard.Eg. Oncoming traffic or a hostile person.


Nursing Management: Nursing Management The nurse who u/s can better adopt communication style Talking into healthy ear Use gestures and facial expressions Devote full attention to what the person is saying. Look and listen-do not try to attend to another task while listening. Engage the speaker in conversation when it is possible for you to anticipate the replies. The enables you to become accustomed to any peculiarities in speech patterns. Try to determine the essential context of what is being said; you can often fill in the details from the context.


Nsg Management Con’t: Nsg Management Con’t Do not try to appear as if you understand if you do not. If you cannot understand at all or have serious doubt about your ability to understand what is being said have the person write the message rather than risk misunderstanding. Having the person repeat the message in speech, after you know its content, also aids you in becoming accustomed to the person’s pattern of speech. When speaking, always face the person as directly as possible


Nsg Management Con’t: Nsg Management Con’t Make sure your face is as clearly visible as possible. Locate yourself so that your face is well lighted Do not obscure the person’s view of your mouth in any way No gum or candy in mouth Be sure that the patient knows the topic or subject before going ahead with what you plan to say. Speak slowly and distinctly, pausing more frequently than you would normally If for any reason your mouth must be covered (eg. mask) and you must direct or instruct the patient, write the message.


Prevention : Prevention Noise is the most common environmental factor! The sheer volume of noise that surrounds us daily has increased from simple annoyance into a potentially dangerous source of physical and psychological damage. In terms of physical impact, loud persistent noise has been found to cause constriction of peripheral blood vessels, increase BP and HR, (increase secretion of adrenaline), and increase GI activity Quiet environment = more conducive to peace of mind.


Prevention: Prevention Occupational health and safety & health administration requires that workers wear ear protection to prevent noise-induced hearing loss when exposed to noise over the legal limits. Ear protection is the most effective preventable measure. Noise induced hearing loss = loss that follows a long period of exposure to loud noise (eg. Heavy machinery, engines, etc.) Acoustic trauma = loss caused by a single exposure to an extremely intense noise such as an explosion


Diagnostic Tests: Diagnostic Tests 1. Audiometry: Pure-Tone audiometry Speech audiometry 3 important characteristics: Frequency (sound waves per second- Hz) Pitch (describes the frequency) Intensity (unit for measuring loudness-dB)


Diagnostic Tests con’t….: Diagnostic Tests con’t…. 2. Tympanogram: measures middle ear muscle reflex 3. Auditory brain stem response: measurement of electric responses recorded from the hearing nerves and brain by means of small, disk-like electrodes taped behind each ear and on the forehead. 4.Middle ear endoscopy:


Nursing Diagnosis: Nursing Diagnosis Risk for impaired adjustment R/T hearing loss Anxiety R/T sensory losses Impaired communication R/T hearing impairment Ineffective individual coping R/T hearing impairment Fear R/T perceived immediate and long-term effects of sensory impairment Risk for injury R/T impaired sensory function Powerlessness R/T inability to communicate Sensory-Perceptual Alterations R/T misinterpretation secondary to auditory alterations Impaired social interaction R/T communication barriers secondary to hearing deficits


Case Study: Case Study Charlie is a 70 year old war veteran who lives alone. He has recently been diagnosed as having moderate hearing loss. What are Charlie’s risk factors for hearing loss? What are some potential nursing diagnoses? What interventions would be appropriate for Charlie? What is the best treatment option for Charlie’s hearing loss?


References: References Smeltzer, S.C., Bare, B.G. (2004) Brunner & Suddarth’s textbook of medical surgical nursing. Philadelphia: Lippincott. http://meds.queensu.ca/medicine/otolaryngology/edu/ungrad/hl.htm http://library.thinkquest.org/10202/ www.apsea.ca Rosdahl, C. (1999) The textbook of Basic Nursing 7th ed. Philadelphia: Lippincott. P.228-230