RLE 101

HEALTH
ASSESSMENT
Assessing the Ears and Hearing

SAIDA LYN G. DATUSAPADAS, RN

Clinical Instructor
 LEARNING OUTCOMES
At the end of the discussion, Student Nurses will be able to:
 Identify the importance of assessing ears & hearing.
 Identify common conditions affecting different areas of the ear &
interventions.
 Perform a clinical ear and hearing assessment.
 Explain the significance of selected physical findings.
 Demonstrate properly the different techniques appropriate for
clients of different ages.
 Identify 10 common drugs that affect hearing.
 Demonstrate the correct use of an otoscope.
 Correctly instill eardrops.
 Assessing the Ears and Hearing

 The ears are important for hearing and balance.

 Ear examination is a thorough check of the ears. It is done to screen
for ear problems, such as hearing loss, ear pain, discharge, lumps, or
objects in the ear.
 Ear disorders may lead to hearing difficulty, balance problems, and
impaired general function.
 Hearing problems reduce the ability of patients to fully communicate
with the world around them. They can lead to confusion, mistrust,
social isolation, and the inability to give and receive accurate
information.
 Hearing disorders are often easily managed, early recognition and
intervention are necessary to prevent additional damage and to
promote a maximum level of wellness.
 Assessing the Ears and Hearing
 Assessment of external ear includes direct inspection & palpation.
Inspection of the remaining parts of the ear esp. eardrum &
determination of auditory acuity by the use of an OTOSCOPE.
 Approach the examination in a systematic way, starting from the
outer parts of the ear before moving to the inner parts of the ear.
 Inspect the pinna and the mastoid:
• Obvious deformities
• Scars or skin changes
• Signs of inflammation
 Palpate the lymph nodes and pinna, specifically:
• Pre- and post-auricular lymph nodes
• Tragus - Tragal tenderness is a sign of otitis externa
Otoscope
Anatomy of the Ear
 Assessing the Ears and Hearing

 Inspect the outer aspect of the external ear canal using the otoscope as a light source
 Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly
 Look for signs of:
• Wax or a foreign body
• Skin changes or erythema
• Discharge
 Inspect Tympanic Membrane by gently straighten out the ear canal by pulling the external ear
superiorly and posteriorly
 For an abnormal tympanic membrane, common signs may include:
• Perforations
• Tympanosclerosis
• Red and bulging membrane
• Retraction of the membrane
 Conditions Affecting the External Ear

 The external ear is the outermost part of the ear structures

 Disorders of the external ear include congenital malformation (birth defects),
trauma, and infectious or noninfectious lesions of the pinna, auricle, or auditory
canal.
 Trauma can damage or destroy the pinna and external canal. Surgical
reconstruction can re-form the pinna with skin grafts and plastic prostheses.
 Trauma to the auricle resulting in a hematoma requires the removal of blood
via needle aspiration to prevent calcification and hardening, which is often
referred to as a cauliflower or boxer’s ear.
 Benign cysts or polyps of the pinna or external canal are surgically removed if
they block the canal and affect hearing.
 Cancer cells, usually basal cell carcinoma, can occur on the pinna. Usually,
treatment consists of simple excision. When the lesion becomes larger, its
location near the skull and facial nerve makes treatment more difficult.
 Conditions Affecting the External Ear

 External otitis is a painful condition caused when irritating or infective agents

come into contact with the skin of the external ear. The result is either an allergic
response or inflammation with or without infection. Affected skin becomes red,
swollen, and tender to touch or movement. Swelling of the ear canal can lead to
temporary hearing loss due to obstruction.
 External otitis occurs more often in hot, humid environments, especially in the
summer, and is known as swimmer’s ear because it occurs most often in people
involved in water sports.
 Necrotizing or malignant otitis is the most virulent form of external otitis.
Organisms spread beyond the external ear canal into the ear and skull.
 The high mortality rate seen with malignant external otitis results from
complications such as meningitis, brain abscess, and destruction of cranial nerve
VII.
 Conditions Affecting the External Ear

1. External Otitis
 Use caution during otoscopic examination to avoid pressing on the walls of the
external canal, which causes pain.
 To prevent cross-contamination, examine the unaffected ear first.
 Hearing loss in the affected ear can be severe when inflammation obstructs the
ear canal and prevents sounds from reaching the eardrum (tympanic membrane).
 Management focuses on reducing inflammation, edema, and pain.
 Nursing priorities include comfort measures, such as applying heat to the ear for
20 minutes three times a day. This can be accomplished by using towels warmed
with water and then wrapped in a plastic bag or by using a heating pad placed on
a low setting.
 Teach the patient that minimizing head movements reduces pain.
 Topical antibiotic and steroid therapies are most effective in decreasing
inflammation and pain.
 Conditions Affecting the External Ear

2. Furuncle is a localized external otitis caused by bacterial infection, usually Staphylococcus, of a hair

follicle. It includes intense local pain to light touch. The area is swollen and red. No drainage is seen
unless the furuncle has ruptured. Hearing is impaired if the lesion blocks the canal. The furuncle may
need to be incised and drained if it does not resolve with antibiotic therapy.
3. Perichondritis is an infection of the perichondrium, a tough, fibrous tissue layer that surrounds the
cartilage and shapes the pinna. Infection can be caused by opening an area of pus or localized infection,
insect bites, trauma, postoperative complication of tympanoplasty, and cartilage ear piercing. In addition
to systemic antibiotic therapy, a wide incision is made and suction drainage is used to remove pus and
other fluid.
4. Foreign Bodies
Cerumen (wax) is the most common cause of an impacted canal. A canal can also become impacted as a
result of foreign bodies that can enter or be placed in the external ear canal, such as vegetables, beads,
pencil erasers, and insects
 Patients with a cerumen impaction or a foreign body in the ear may experience a sensation of fullness
in the ear, with or without hearing loss, and may have ear pain, itching, dizziness, or bleeding from
the ear.
 Management options include watchful waiting, manual removal, and the use of cerumenolytic agents
followed by either manual irrigation or the use of a low-pressure, electronic, oral irrigation device The
canal can be irrigated with a mixture of water and hydrogen peroxide.
 Conditions Affecting the Middle Ear

1. Otitis Media
 The three common forms of otitis media are acute otitis media, chronic otitis
media, and serous otitis media. If otitis progresses or is untreated,
permanent conductive hearing loss may occur.
 Acute otitis media causes more intense pain. Hearing is reduced and
distorted. The patient may notice a sticking or cracking sound in the ear upon
yawning or swallowing. Headaches and systemic symptoms such as malaise,
fever, nausea, and vomiting can occur. As the pressure on the middle ear
pushes against the inner ear, the patient may have dizziness or vertigo.
 Otoscopic examination findings vary, depending on the stage of the condition.
 Cultures are taken only when previous treatment is ineffective. When the
eardrum is not perforated, a needle aspiration or myringotomy may be
performed by a physician or nurse practitioner to withdraw fluid for culture.
 Conditions Affecting the Middle Ear

Nonsurgical Management
 Put the patient in a quiet environment. Bedrest limits head movements that
intensify the pain. Heat may be applied by using a heating pad adjusted to a low
setting. Application of cold also may relieve pain.
 Topical antibiotics are not used to treat otitis media. Systemic antibiotic
therapy decreases pain by reducing inflammation. 
  Analgesics relieve pain and reduce fever.
 Antihistamines and decongestants are prescribed to decrease fluid in the middle
ear
Surgical Management
 If pain persists after antibiotic therapy and the eardrum continues to bulge,
a myringotomy (surgical opening of the pars tensa of the eardrum) is
performed. This procedure drains middle ear fluids and immediately relieves
pain.
 Conditions Affecting the Middle Ear

2. Mastoiditis is an infection of the mastoid air cells caused by untreated or inadequately treated otitis
media. This infection can be acute or chronic. Antibiotic therapy is used to treat the middle ear infection
before it progresses to mastoiditis.
 Otoscopic examination shows a red, dull, thick, immobile eardrum with or without perforation. Lymph
nodes behind the ear are tender and enlarged. Patients may have low-grade fever, malaise, ear drainage,
and loss of appetite. Hearing loss occurs, and computed tomography (CT) scans show fluid in the air
cells of the mastoid process.
Interventions focus on halting the infection before it spreads to other structures.
 IV antibiotics are used to prevent the spread of infection.
 Cultures of the ear drainage determine which antibiotics should be most effective.
 Surgical removal of the infected tissue is needed if the infection does not respond to antibiotic therapy
within a few days.
 Complications occur when infective material is not removed completely or when other structures are
contaminated. Complications include damage to cranial nerves VI and VII, decreasing the patient’s
ability to look sideways (cranial nerve VI) and causing a drooping of the mouth on the affected side
(cranial nerve VII). Other complications include vertigo, meningitis, brain abscess, chronic purulent otitis
media, and wound infection.
 Conditions Affecting the Middle Ear

3. Trauma
 Damage may occur to the eardrum and ossicles by infection, by direct damage, or through
rapid changes in the middle ear pressure.
 Foreign objects placed in the external canal exert pressure on the eardrum and cause
perforation. If the objects continue through the canal, the bones of the middle ear may be
damaged.
 Blunt injury to the skull and ears can also damage or fracture middle ear structures.
 Slapping the external ear increases the pressure in the ear canal and can tear the eardrum.
 Excessive nose blowing can increase pressure within the middle ear & can perforate the
eardrum.
 Most eardrum perforations heal within a week or two without treatment. Repeated
perforations, especially from chronic otitis media, heal more slowly, with scarring.
Depending on the amount of damage to the ossicles, hearing may or may not return. Hearing
aids can improve hearing in this type of hearing loss. Surgical reconstruction of the ossicles
and eardrum through a tympanoplasty or a myringoplasty may also improve hearing.
 Nursing care priorities focus on teaching about trauma prevention.
 Assessment of Hearing

Rinne Test
 Strike the tuning fork against your elbow and place against the mastoid process (bone
conduction), then once patient stops hearing it, hold it near the external ear canal (air
conduction)
• For normal hearing or sensorineural hearing loss, air conduction is heard better than bone
conduction (Rinne positive)
• For conductive hearing loss, bone conduction is heard better than air conduction (Rinne
negative)
Weber Test
 Strike the tuning fork against your elbow and place on the patient’s forehead in the midline.
Ask the patient whether the sound is heard in the midline or has lateralized
• For normal hearing, the sound is heard in the midline
• For conductive hearing loss, the sound is loudest on the ipsilateral side to the hearing deficit
• For sensorineural hearing loss, the sound is loudest on the contralateral side to the hearing
deficit
 Assessment of Hearing

 Medicines that damage the ear and cause hearing loss are known as
ototoxic medicines. They are a common cause of hearing loss,
especially in older adults who have to take medicine on a regular basis.
 Hearing loss caused by these types of medicine tends to happen
quickly. The first symptoms usually are ringing in the ears (tinnitus)
and vertigo. Hearing usually returns to normal after you stop taking the
medicine. But some medicines can cause permanent hearing loss even
if you stop taking them.
 Commonly used medicines that may cause hearing loss include:
• Aspirin, when large doses (8 to 12 pills a day) are taken.
• Non-steroidal anti-inflammatory drugs (NSAIDs).
• Certain antibiotics.
• Loop diuretics. They're used to treat high blood pressure and heart failure.
• Certain medicines used to treat cancer.
 Assessment of Hearing

Correctly instill eardrops

Usage in Adults and Teens
 These instructions apply whether you're alone or helping someone:
1. Fold a towel in half and lay it on a kitchen or bathroom counter.
2. Lay your head on the towel with the affected ear up.
3. Gently pull the earlobe out and up to straighten the ear canal.
4. Carefully put the recommended number of drops into the ear canal.
5. Gently push on the ear flap to help move the liquid in deeper.
6. Keep the head down for at least a minute or two so the medication can fully coat
the canal.
7. Repeat with the other ear if needed.
 Assessment of Hearing

Usage in Children
 The process can be harder for children, especially if they're young or squeamish. If possible, try to have two
adults present: one to keep the child still and one to put the drops in.
 The procedure is slightly different because children's ear canals are shorter and have a more horizontal angle.
 To safely give them drops:
1. Fold a clean towel in half and place it on the floor or bed.
2. Have the child lay their head on the towel, affected ear up.
3. One of you should hold the child's head still. If the child is especially fidgety, try lying down and cradling them
while restraining the head.
4. Gently pull the earlobe out and down (rather than out and up) to straighten the canal.
5. Put in the prescribed number of drops.
6. Gently push on the flap of the ear or plug the ear with a cotton ball.
7. Keep the child in this position for several minutes.
8. Repeat on the other ear if needed.
 For an infant, try swaddling them to keep them still. Toddlers may need to be cradled with their arms and legs
fully restrained.
 Assessment of Hearing

PROCEDURE
7.A. AURICLES (a structure resembling an ear or earlobe.)
1. Assemble equipment and supplies
 Otoscope with several sizes or ear specula
2. Inspect the auricles for color, symmetry of the size and position
3. Palpate the auricles for textures, elasticity and areas of tenderness
B. EXTERNAL EAR CANAL AND TYMPANIC MEMBRANE
4. Using ana otoscope, inspect the external ear canal for cerumen, skin lesions, pus and
blood.
5. Inspect the tympanic membrane got color and gloss.
C. GROSS HEARING ACUITY TEST
6. Assess clients response to normal voice tones. If client has difficulty hearing the
normal voice, proceed in the following test.
 Assessment of Hearing

7. Have the client occlude one ear, out of the client’s sight, place a ticking
watch 2-3 cm (1-2inches) from the unoccluded ear (watch tick test)
8. Ask what the client can hear. Repeat with the other ear.
D. TUNING FORK TEST
9. Perform Weber test
10. Perform Rinne test
11. Document pertinent findings.
8.A. NOSE
2. Inspect the external nose for any deviation in shape size or color and
flaring or discharges from the nares.
3. Lightly palpate the external nose to determine any areas to tenderness,
masses, and displacements of bone and cartilage.
 Assessment of Hearing

4. Determine patency of both nasal cavities. ( ask the client to close the
mouth, exert pressure on one nares and breath through the opposite nares.
Repeat the procedure to assess the patency of the opposite nares)
5. Inspect nasal cavities using flashlight.
6. Observe the presence of tenderness, swelling, growth and discharge.
7. Inspect the nasal septum between the nasal chambers.
8. Palpate the maxillary and frontal sinuses for tenderness.