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5: EYE GUIDELINES
C. Photophobia.
D. Diplopia.
OTHER SIGNS AND SYMPTOMS
A. The client’s head or chin tilts or the client closes one eye to
focus on objects.
SUBJECTIVE DATA
A. Describe the onset, duration, and progression of symptoms.
B. Review any history of eye problems. Ask how they were
corrected.
C. Determine whether the client, if a child, has reached the
age-appropriate milestones in development.
D. Does the client make faces or move their head to see bet-
ter (tilting the head or chin to improve acuity or to correct
diplopia)?
E. Rule out any eye damage or surgery.
F. Ask about family history of strabismus or other eye
disorders.
PHYSICAL EXAMINATION
A. Inspect:
1. Observe alignment of lids, sclera, conjunctiva, and
cornea.
2. Check pupillary response to light, size, shape, and
equality.
3. Check the red reex.
DIAGNOSTIC TESTS
A. Test visual acuity.
B. Perform the cover–uncover test: In this test, the “lazy eye”
drifts out of position and snaps back quickly when uncovered.
C. Perform the corneal light reex (Hirschberg) test: This tests
for symmetry of the pupillary light reexes to help detect strabismus. Normally, the light reexes are in the same position
on each pupil, but not with strabismus (positive Hirschberg
test).
D. Test extraocular movements: If a nerve supplying an extra-
ocular muscle has been interrupted or the muscle itself has
become weakened, the eye fails to move in the direction of the
damaged muscle. If the right sixth nerve is damaged, the right
eye does not move temporally. This is paralytic strabismus.
FOLLOW-UP
A. Monitor progress with eye patch.
B. Surgical intervention depends on the degree of deviation.
CONSULTATION/REFERRAL
A. Additional testing should be done by an ophthalmologist.
B. Pseudostrabismus (a false appearance of strabismus when
visual axes are really in alignment) is one of the most common
reasons a pediatric ophthalmologist is asked to evaluate an
infant.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Use the tumbling or illiterate E to test children; for pre-
schoolers, use the Allen picture cards.
2. In very young children, test visual acuity by assessing
developmental milestones: looking at the mother’s face,
responsive smile, and reaching for objects. By 3 to 5 years
of age, most children can cooperate with performance of
accurate visual acuity screening tests.
3. The eyes of the newborn are rarely aligned during the
rst few weeks of life. By the age of 3 months, normal oculomotor behavior is usually established and an experienced examiner may be able to document the existence of
abnormal alignment by this time.
4. Adolescents and young adults with strabismus often
have a predisposition to anxiety and depression disorders.
It is recommended that clinicians consider psychiatric
evaluation and management.
BIBLIOGRAPHY
American Academy of Ophthalmology. (2020, December). Pediatric
ophthalmology strabismus summary benchmarks 2020. https://www
.aao.org/summary-benchmark-detail/pediatric-ophthalmologystrabismus-summary-benchma
Gunton, W. B., Wasserman, B. N., & DeBenedictis, C. (2015). Strabismus.
Primary Care: Clinics in Ofce Practice, 2(3), 393–407.
Kanukollu, V. M., & Sood, G. (2021). Strabismus. StatPearls NCBI Resources.
https://www.ncbi.nlm.nih.gov/books/NBK560782/
Ozates, S., Ozates, M., Can, C., Polat, S., Yasar, H., Taskale, B., & Gogus,
A. (2018). Improvement in psychiatric symptoms after strabismus surgery in adolescent patients in long-term follow-up [Abstract]. British
Journal of Ophthalmology, 102(8), 1e–5e. https://doi.org/10.1136/
bjophthalmol-2018-312510
DIFFERENTIAL DIAGNOSES
A. Pseudostrabismus.
B. Ocular trauma.
C. Congenital defect.
PLAN
A. General interventions:
1. When poor xation is present, patch the stronger, dom-
inant eye to promote vision and muscle strengthening in
the weaker eye.
2. Corrective eyeglasses/contacts promote less focusing
efforts and help the eyes to look straight.
3. Prism lenses bend the light entering the eye, which
assists with reducing the amount of eye movement in
order to see an object.
B. Client teaching:
1. Reinforce the need to consistently wear an eye patch 2
to 6 hours per day, especially with children.
C. Pharmaceutical therapy:
1. In some cases, injections of botulinum toxin type A
(BOTOX) can weaken eye muscle and can be administered
by an ophthalmologist in place of surgery.
SUBCONJUNCTIVAL HEMORRHAGE
DEFINITION
A. Subconjunctival hemorrhage presents as blood patches in
the bulbar conjunctiva (see Figure 5.7).
FIGURE 5.7 Subconjunctival hemorrhage.
Source: Image courtesy of Daniel Flather.
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INCIDENCE
A. Although frequently seen in newborns, subconjunctival
hemorrhage may also be seen in adults after forceful exertion
(coughing, sneezing, childbirth, strenuous lifting).
B. Subconjunctival hemorrhages account for approximately
3% of emergent visits in the United States, and males have a
higher prevalence than females.
PATHOGENESIS
A. Subconjunctival hemorrhage occurs when the small blood
vessels in the conjunctiva rupture from force or injury. When
this occurs, the blood leaks out from the vessel, causing a red
staining of the sclera. This may appear as a dark red spot on
the white part of the eye. This disorder is believed to be secondary to increased intrathoracic pressure, which may occur
during labor and delivery or with physical exertion.
PREDISPOSING FACTORS
A. Local trauma.
B. Systemic hypertension.
C. Acute conjunctivitis.
D. Vaginal delivery (pushing during delivery).
E. Severe coughing.
F. Severe vomiting.
G. Long-term hemodialysis.
COMMON COMPLAINT
A. Red-eyed appearance without pain.
OTHER SIGNS AND SYMPTOMS
A. Bright red blood in plane between the conjunctiva and the
sclera.
B. Usually unilateral.
C. Normal vision.
SUBJECTIVE DATA
A. Identify onset and duration of symptoms.
B. Elicit information about trauma to the eye. Is it due to
severe coughing or vomiting?
C. Identify history of conjunctivitis or hypertension.
D. Review medications for anticoagulant or antiplatelet use,
including over-the-counter (OTC) herbal products.
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood pres-
sure (rule out hypertension).
B. Inspect:
1. Observe eyes.
2. Inspect ears, nose, and mouth.
3. Inspect skin for bruises or other trauma.
4. Assess for signs of trauma or abuse. Blood in the ante-
rior chamber (hyphema) can result from injury or abuse.
C. Other physical examination components are dependent on
etiology.
PLAN
A. General interventions:
1. Reassure the client. The hemorrhage is not damaging
to the eye or vision, and the blood reabsorbs on its own
over several weeks.
2. Teach safety to prevent trauma to the eye.
3. A slit-lamp exam may be performed to rule out any
ocular trauma.
B. Pharmaceutical therapy:
1. None.
FOLLOW-UP
A. If subconjunctival hemorrhage recurs, evaluate the client
further for systemic hypertension or blood dyscrasia.
CONSULTATION/REFERRAL
A. Consult or refer the client to a physician if hyphema is
noted, if glaucoma is suspected, or if the client has additional
eye injuries.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Hemorrhage is common in newborns after vaginal
delivery.
B. Adults:
1. Always measure blood pressure to rule out systemic
hypertension.
C. Geriatrics:
1. Always measure blood pressure to rule out systemic
hypertension.
2. Consider evaluation for blood dyscrasia.
3. Check clotting times if client is taking warfarin
(Coumadin).
BIBLIOGRAPHY
Channa, R., Zafar, S., Canner, J., Haring, S., Schneider, E., & Firedman,
D. (2016). Epidemiology of eye-related emergency department visits.
JAMA Ophthalmology, 134(3), 312–319. https://doi.org/10.1001/jamao
phthalmol.2015.5778
Doshi, R., & Noohani, T. (2021). Subconjunctival Hemorrhage. StatPearls
Resources. https://www.ncbi.nlm.nih.gov/books/NBK551666/
Makino, S. (2018). Massive subjunctive hemorrhage. Scholars Journal
of Medical Case Reports, 11 , 917–918. http://saspjournals.com/
wp-content/uploads/2018/12/SJMCR-611-917-918-c.pdf
UVEITIS
DEFINITION
A. Uveitis, also known as iritis, is inammation of the uveal
tract (iris, ciliary body, and choroid) and is usually accompanied by a dull ache and photophobia resulting from the irritative spasm of the pupillary sphincter (see Figure 5.8).
DIAGNOSTIC TESTS
A. Perform visual screening.
B. Test extraocular movements and peripheral vision.
DIFFERENTIAL DIAGNOSES
A. Systemic hypertension.
B. Blood dyscrasia.
C. Trauma to eye.
D. Conjunctivitis.
E. Hyphema.
F. Abuse.
FIGURE 5.8 Uveitis.
Source: Image courtesy of Jonathan Trobe, MD.
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5: EYE GUIDELINES
INCIDENCE
A. The true incidence is unknown. Approximately 15% of cli-
ents with sarcoidosis present with uveitis. Of all cases, 48% to
70% are considered idiopathic.
B. Older adults, females, smokers, and those with gastro-
intestinal inammatory diseases have a higher prevalence of
uveitis.
PATHOGENESIS
A. The cause is unknown. Underlying causes include infec-
tions, viruses, and arthritis.
PREDISPOSING FACTORS
A. Collagen disorders.
B. Autoimmune disorders.
C. Ankylosing spondylitis.
D. Sarcoidosis.
E. Juvenile rheumatoid arthritis.
F. Lupus.
G. Reiter syndrome.
H. Behcet syndrome.
I. Syphilis.
J. Tuberculosis.
K. AIDS.
L. Crohn disease.
M. Tobacco use.
N. Undiagnosed or poorly controlled diabetes.
COMMON COMPLAINTS
A. Eye pain: painless to deep-seated ache.
B. Photophobia.
C. Blurred vision with decreased visual acuity.
D. Black spots.
E. Eye redness.
OTHER SIGNS AND SYMPTOMS
A. Unilateral or bilateral symptoms.
1. Unilateral: The pupil is smaller than that of the other
eye due to spasm.
B. Ciliary ush.
C. Pupillary contraction.
D. Nausea and vomiting with vagal stimulation.
E. Halos around lights.
F. Hypopyon (pus in anterior chamber).
G. Limbal ush with small pupil.
SUBJECTIVE DATA
A. Elicit the onset, course, duration, and frequency of symp-
toms. Are symptoms bilateral or unilateral?
B. Identify the possible causal activity or agent (chemical,
traumatic, or infectious etiologies).
C. Review the client’s history of uveitis and other ophthalmo-
logic disorders.
D. Review any associated fever, rash, weight loss, joint pain,
back pain, oral ulcers, or genital ulcers.
E. Review full medical history for comorbid conditions.
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood
pressure.
B. Inspect:
1. Assess both eyes for visual acuity and peripheral elds
of vision.
2. Check sclera and conjunctiva.
C. Other physical components need to be completed related
to comorbid conditions.
DIAGNOSTIC TESTS
A. Slit-lamp test: Examination reveals cells in the anterior
chamber and “are,” representing increased aqueous humor
protein. Inammatory cells, called keratic precipitates, can collect in clusters on the posterior cornea.
B. Penlight examination: Examination shows a slightly
cloudy anterior chamber in the uveitic eye.
DIFFERENTIAL DIAGNOSES
A. Acute angle-closure glaucoma.
B. Retinal detachment.
C. Central retinal artery occlusion.
D. Endophthalmitis.
PLAN
A. General interventions:
1. Treat underlying cause as indicated.
2. Provide immediate referral to an ophthalmologist due
to possible complications of cataracts and blindness.
B. Client teaching:
1. Inform the client that recurrent attacks are common
and also require immediate attention.
C. Pharmaceutical therapy:
1. Medications are given per ophthalmologist.
2. Uveitis and colitis often are simultaneously; oral ste-
roids are effective for both.
FOLLOW-UP
A. A client with uveitis needs follow-up with an
ophthalmologist.
CONSULTATION/REFERRAL
A. The client should be referred immediately to an ophthal-
mologist for evaluation and intervention.
INDIVIDUAL CONSIDERATIONS
A. Adults:
1. Recurrent uveitis may be a sign of another systemic
condition.
2. Other conditions to consider:
a. Infections (bacterial, spirochetal, viral, fungal, and
parasitic infections).
b. Inammatory diseases, including spondyloarthrop-
athies (ankylosing spondylitis, psoriatic arthritis, and
reactive arthritis) and inammatory bowel disease.
c. Multiple sclerosis.
d. Use of new medications.
RESOURCES
American Academy of Ophthalmology
P.O. Box 7424
San Francisco, CA 94120–7424
www.aao.org
Phone: 415-561-8500
Fax: +1 415-561-8533
American Council of the Blind
1703N. Beauregard St.
Suite 420
Arlington, VA 22201
www.acb.org
Phone: 202-467-5081, 1 800-424-8666
Fax: 703-465-5085
Email: infor@aph.org
American Foundation of the Blind
1401 South Clark Street
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161
Suite 730
Arlington, VA 22202
www.afb.org
Phone: 212-502-7600
Email: info@aph.org
American Printing House for the Blind
1839 Frankfort Avenue
P.O. Box 6085
Louisville, KY 40206–6085
www.aph.org
Phone: 800-223-1839; 502-895-2405
Fax: 502-899-2284
Email: info@aph.org
Books on Tape
www.booksontape.com
Email: libraryrep@penguinrandomhouse.com
Phone: 800-733-3000
Glaucoma Research Foundation
251 Post Street, Suite 600
San Francisco, CA 94198
www.glaucoma.org
Phone: 415-986-3162, 800-826-6693
Email: questions@glaucoma.org
Guide Dog Foundation for the Blind
371 E Jericho Turnpike
Smithtown, NY 11787
www.guidedog.org
Phone: 631-930-9000, 800-548-4337
Fax: 631-930-9009
9 a.m. to 5 p.m. (Eastern Standard Time),
Monday through Friday
Email: info@guidedog.org
National Service for the Blind and Physically Handicapped
National Library of Congress
1291 Taylor Street NW
Washington, DC 20542
www.loc.gov/nls/
Phone: 800-424-8567; 202-707-5100
TDD: 202-707-0744
Fax: 202-707-0712
Email: nls@loc.gov
National Society to Prevent Blindness
Prevent Blindness America
225 West Wacker Drive
Suite 400
Chicago, IL 60606
www.preventblindness.org/contact-us
Phone:800-331-2020
Email:info@preventblindness.org
BIBLIOGRAPHY
Duplechain, A., Conrady, C. D., Patel, B. C., & Baker, S. (2021). Uveitis.
StatPearls NCBI Resources. https://www.ncbi.nlm.nih.gov/books/NB
K540993/
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CLIENT TEACHING GUIDE
CONJUNCTIVITIS
PROBLEM You have an infection of the eye, or conjunctivitis, that causes redness, itching, drainage from the eye, and crusting
on the eyelids.
CAUSE Bacteria, viruses, or allergies can cause eye infections.
PREVENTION/CARE
A. Wash your hands frequently.
B. Avoid persons with conjunctivitis (pink eye).
C. Avoid known allergens.
TREATMENT PLAN
A. All types:
1. Wash your hands frequently, especially after touching the eyes, to avoid spread.
2. Use cool compress on the eyes as needed.
3. Wash crusting eyelids with baby shampoo daily.
4. Wipe the eyes from the inner to the outer corners.
B. Bacterial:
1. Bacterial conjunctivitis is contagious until 24 hours after starting medication.
C. Viral:
1. Viral conjunctivitis is contagious for 48 to 72 hours, but may last up to 2 weeks.
Activity: As tolerated.
Diet: As tolerated.
Medications: No medications are prescribed for viral infections. You will be given instructions on how to use eye drops or eye
ointment.
You Have Been Prescribed:
You Need to Take:
You Need to Notify the Office If You Have:
A. A reaction to your medication.
B. Trouble seeing.
C. New symptoms.
D. Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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CLIENT TEACHING GUIDE
EYE MEDICATION ADMINISTRATION
PROBLEM You have been prescribed a medication for your eye(s). It is very important that you know the correct way to use your
eye medication.
CAUSE You have been diagnosed with:
PREVENTION/CARE The health of your eyes is important.
A. Use good handwashing and try not to rub your eyes with your ngers.
B. Clean your contacts regularly with contact cleaning solution. Do not put your contacts in your mouth to moisten.
C. Wear sunglasses in bright sunshine.
D. Use eye goggles when working and playing sports to ensure extra protection.
E. Replace your eye makeup often. Mascara, eye shadow, and eyeliner grow bacteria. Do not share makeup.
TREATMENT PLAN
A. Correct use of your medication is important.
B. You may or may not require an eye patch or shield.
How to Apply Eye Ointment
A. Always wash your hands before placing medication in your eyes.
B. Gently pull down the lower eyelid.
C. Make a small pocket between the eyeball and the eyelid.
D. If you have someone helping to put eye ointment in the lower lid pocket, look up and away while they put in the medicine.
E. Do not let the tube of medicine touch the eye or eyelid.
F. Squeeze a thin ribbon of the medication into the pocket of the eyelid.
G. Start at the inner fold of the eye going from the nose to the outer eye.
H. Let go of the eyelid and blink to spread the medication.
How to Instill Eye Drops
A. Always wash your hands before placing medication in your eyes.
B. Gently pull down the lower eyelid.
C. Make a small pocket between the eyelid and the eyeball.
D. If you have someone helping to put eye drops in the lower lid pocket, look up and away while they put in the medicine.
E. Do not let the bottle of medication touch the eye or the eyelid.
F. Squeeze the prescribed number of drops of the medicine into the pocket of the eyelid.
G. Let go of the eyelid and blink (or tell the client to blink) to spread the medication.
Activity: No restrictions are required unless you require eye surgery; then you will be given specic instructions about the amount
of activity allowed.
Diet: No restrictions.
Medications:
You Have Been Prescribed:
You Need to Take:
You Need to Notify the Office If:
A. You are unable to put in the medication yourself or get help from others.
B. You are not better 24 to 48 hours after starting the medication.
C. Your vision is worse after using the medication.
D. You have an allergic reaction to the medicine.
E. Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
C H A P T E R
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EAR
Jill
C. Cash and Emily Y. Brignola
CERUMEN
GUIDELINES
IMPACTION (EARWAX)
DEFINITION
A.
Cerumen is dened as a mixture of ear secretions and dead
epithelial cells which migrate laterally and often mix with
hair. Cerumen occurs naturally in the external auditory canal
(EAC) and cleans, lubricates, and protects the EAC. Excessive
accumulation of cerumen can cause a partial or complete
obstruction of the EAC.
INCIDENCE
A.
Cerumen impaction is one of the most common reasons for
seeking medical care. Impacted cerumen occurs in 1 in 10 children, 1 in 20 adults, and at least one-third of geriatric clients.
It is also common in developmentally delayed populations.
B.
Approximately 12 million ofce visits per year occur for
cerumen extraction in the United States.
PATHOGENESIS
A.
Accumulation of cerumen can be due to failure of the
self-cleaning mechanism of the EAC. Cilia that have become
stiff cannot remove cerumen and dirt from the ear canal. The
pushing of cotton swabs, paper clips, bobby pins, and other
objects into the EAC may also impact cerumen.
PREDISPOSING
A.
Aging.
B.
Use of hearing aids or earbuds.
C.
Use of cotton swabs or other objects to clean the EAC.
COMMON
A.
Dryness and itching of EAC.
B.
Unsteadiness.
C.
Otalgia.
D.
Hearing loss.
E.
Tinnitus.
F.
Fullness.
G.
Hearing aid feedback or malfunction.
H.
Itching.
SUBJECTIVE
A.
Elicit the onset, duration, and laterality of symptoms.
B.
Elicit history of cerumen impaction.
C.
Question the client regarding the method of cleaning their
FACTORS
COMPLAINTS
DATA
ears.
PHYSICAL
A.
Check temperature, pulse, respirations, and blood pressure.
B.
Inspect:
EXAMINATION
1.
Observe the EAC for occluding cerumen.
2.
Observe the tympanic membrane (TM) if possible. A
perforated TM can be associated with otitis mediaor use
of objects by the client to clean their own ears.
3.
Inspect the nose and throat.
C.
Auscultate:
1.
Heart.
2.
Lungs.
DIAGNOSTIC
A.
None required.
DIFFERENTIAL
A.
Foreign body in the ear canal.
B.
Otitis externa.
TESTS
DIAGNOSES
PLAN
A.
General interventions:
1.
If experienced in removal of cerumen impaction and
chooses to proceed with cerumenectomy, the clinician
may elect to obtain written informed consent prior to performing this procedure. Remove impaction by means of
lavage or curettage. Be sure to inspect the canal and TM
after removal of the cerumen. Document the client’s hearing before and after removal of cerumen.
2.
If initial management is unsuccessful or for severe
cerumen impaction, consider otolaryngology consult for
microscopic cerumenectomy.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Cerumen Impaction (Earwax).”
1.
Instruct the client to avoid cleaning their own ears.
Advise not to clean their ears with cotton swabs, bobby
pins, and so forth. Using these devices pushes the wax further into the ear canal and can worsen symptoms.
2.
Instruct the client to avoid ear candling.
C.
Pharmaceutical therapy:
1.
None indicated.
FOLLOW-UP
A.
No follow-up is needed unless indicated. Recurrence is
common.
The
contributions of Ken Watford to this chapter in prior editions are acknowledged here.
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6: EAR GUIDELINES
CONSULTATION/REFERRAL
A.
Refer the client to an otolaryngologist when cerumen can-
not be safely removed.
INDIVIDUAL
A.
Geriatrics:
1.
CONSIDERATIONS
Cerumen impaction is very common in the older adults
due to atrophic cilia and dry epithelium in the ear canal.
2.
The use of hearing aids and earbuds can also contrib-
ute to wax buildup and cause thewax to be pushed further into the canal. Persons using hearing aids or earbuds
should be evaluated for wax buildup as indicated.
BIBLIOGRAPHY
Dinces, E. (20121). Cerumen. D. Deschler (Ed.), UpToDate. Wolters Kluwer.
https://www.uptodate.com/contents/cerumen?source=machineLea
rning&search=ear+lavage&selectedTitle=1%7E150§ionRank=1&
anchor=H9#H9
Krouse, H. J., Magit, A. E., O’Connor, S., Schwarz, S. R., & Walsh, S.
A. (2017). Plain language summary: Earwax (Cerumen impaction). Otolaryngology–Head and Neck Surgery, 156(1), 30–37. https://
doi.org/10.1177/0194599816680327
Schwartz, S. R., Magit, A. E., Rosenfeld, R. M., Ballachanda, B. B., Hackell,
J. M., Krouse, H. J., Lawlor, C. M., Lin, K., Parham, K., Stutz, D. R.,
Walsh, S., Woodson, E. A., Yanagisawa, K., & Cunningham, E. R.
(2017). Clinical practice guideline (Update): Earwax (Cerumen impaction. Otolaryngology–Head and Neck Surgery, 156(Suppl. 1), S1–S29.
https://doi.org/10.1177/0194599816671491
HEARING
LOSS
DEFINITION
A.
Impaired hearing (complete or partial hearing loss) results
from interference with the conduction of sound, its conversion to electrical impulses, or its transmission through the nervous system. It is important to distinguish the type of hearing
loss because the treatment options are signicantly different
based on the type. There are three types of hearing loss:
1.
Conductive hearing loss (CHL; defect in the conduc-
tive pathway of the ear).
2.
Sensorineural hearing loss (SNHL; defect in the inner
ear, cochlea, or the auditory nerve (cranial nerve VIII).
3.
Mixed hearing loss (combined conductive and sensori-
neural loss).
INCIDENCE
A.
Hearing loss is the most prevalent sensory decit in the
United States. Approximately 30 million (12.7%) individuals
in the United States have bilateral hearing loss and 48 million
(20.3%) have hearing loss in at least one ear.
B.
Globally, approximately 538 million individuals experi-
ence hearing loss that is considered to be disabling.
PATHOGENESIS
A.
CHL presents with a decrease in hearing volume and/or
clarity due to failure of one or more of the conductive components of the external or middle ear. It may be caused by one of
the following:
1.
Cerumen impaction.
2.
Otitis media with effusion (OME).
3.
Eustachian tube dysfunction (ETD).
4.
Tympanic membrane (TM) perforation.
5.
Cholesteatoma: growth of squamous epithelium within
the middle ear space.
6.
Otosclerosis: hereditary middle ear disease that
involves xation of the ossicular chain with resulting progressive CHL.
7.
Tympanosclerosis: scarring and thickening on the TM
after TM injury or surgery.
8.
Exostoses of the external auditory canal (EAC): bony
excrescences of the EAC.
9.
Glomus tumors: benign, highly vascular tumors
derived from normally occurring glomera of the middle
ear and jugular bulb.
10.
Congenital malformations such as microtia and/or
atresia.
B.
SNHL results from injury to the hair cells in the cochlea
and/or the nerves innervating the hair cells. It is usually bilateral and symmetrical. The following are the most common
causes:
1.
Noise-induced hearing loss: due to chronic exposure to
loud noises.
2.
Presbycusis: age-related damage to cranial nerve VIII;
usually bilateral, gradually progressive, and symmetrical.
3.
Genetic factors.
4.
Infectious, autoimmune, or postinammatory processes.
5.
Drug-induced hearing loss: may be caused by amino-
glycoside antibiotics, furosemide, ethacrynic acid, quinidine, chemotherapeutic agents such as cisplatin, and
high-dose aspirin.
6.
Ménière disease: an inner ear syndrome consisting of
uctuating, unilateral, low-frequency SNHL associated
with tinnitus, a sensation of fullness in the ear, and recurring andoften severe episodes of vertigo lasting at least 20
minutes and up to 12 hours.
7.
Acoustic neuroma: benign tumor of cranial nerveVIII
(rare).
8.
Sudden SNHL can derive from head trauma, viral or
microvascular events, skull fractures, meningitis, otitis
media (OM), scarlet fever, mumps, congenital syphilis,
multiple sclerosis, and perilymph leaks or stulas. Sudden
SNHL can be bilateral or unilateral.
PREDISPOSING
A.
Acoustic or physical trauma.
B.
Ototoxic medications (e.g., aminoglycosides, aspirin, radi-
FACTORS
ation therapy, and chemotherapy).
C.
Recent upper respiratory infection (URI).
D.
Barotrauma.
E.
Otosclerosis.
F.
Nasopharyngeal cancer.
G.
Cerumen impaction.
H.
ETD with middle ear effusion (MEE).
I.
Foreign body in the EAC.
J.
Developmental delays.
COMMON
A.
COMPLAINTS
Difculty understanding words (poor word recognition),
especially with background noise present.
B.
Associated tinnitus.
C.
Ear pressure, fullness, and/or otalgia.
SUBJECTIVE
A.
Elicit the onset, duration, progression, and sever-
DATA
ity of symptoms. Note whether symptoms are bilateral or
unilateral.
B.
Obtain the client’s past or recent trauma.
C.
Review the client’s occupational and recreational exposure
to loud noise.
D.
Review the client’s medical history and medications,
including over-the-counterdrugs and prescriptions.
E.
Review the client’s family medical history.
F.
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Review the client’s history for recent URI or ear infections,
especially for chronic ear infections.
G.
Elicit data about any previous hearing loss, how it was
treated, and how it affected daily activities. There may be a
history of ear disease with CHL.
H.
Review the client’s other symptoms, such as dizziness,
fullness or pressure in the ears, and noises.
I.
Review what causes difculty with hearing, high tones
versus low frequencies. Can the client hear people talking,
the television at normal volume, doorbells ringing, telephone
ringing, and watch ticking?
PHYSICAL
A.
Check temperature.
B.
Inspect:
EXAMINATION
1.
Examine both ears for comparison.
2.
Externally inspect the ears for discharge; note color
and odor. Check for obstruction of the auditory canal by
impacted cerumen, a foreign body, exostoses, acute otitis
externa, OME, or scarring or perforation of the TM.
3.
Conduct otoscopic examination to observe the EAC for
cerumen impaction or foreign body.
4.
Examine the TM for color, landmarks, contour, per-
foration, and acute otitis media. A reddish mass visible
through the intact TM may indicate a high-riding jugular bulb, an aberrant internal carotid artery, or a glomus
tumor.
C.
Palpate:
1.
Palpate the auricle and the mastoid area for tender-
ness, swelling, or nodules.
2.
Check thelymph nodes if infection is suspected.
D.
Perform neurologic examination:
1.
Weber test:
a.
The Weber test reveals CHL when thesound travels
toward the poor ear. SNHL is present when thesound
travels toward the good ear. This screening test is performed by striking a tuning fork and then placing it on
the middle of the head. The client is then asked where
thesound is being heard from—the left ear, the right
ear, or equal in both ears. Normal results are reected
by thesound being heard equally in both ears.
2.
Rinne screen:
a.
The Rinne tuning fork test reveals bone conduction
greater than air conduction in the affected ear (abnormal).
The Rinne test is performed by placing the struck tuning
fork against the mastoid bone. Begin counting or timing
the interval from the start to when the client can no longer
hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction.
Air-conducted sound should be heard twice as long as
bone-conducted sound after bone conduction stops.
DIAGNOSTIC
A.
Audiologic screening in primary setting.
B.
Air insufation for TM mobility.
C.
Diagnostic pure-tone audiometry (hearing test) with tym-
TESTS
panometry (used to evaluate the TM and the middle ear status) performed by an audiologist.
D.
CT of the temporal bones or MRI of the internal auditory
canals after consultation with an otolaryngologist.
DIFFERENTIAL
A.
Congenital hearing loss.
B.
Traumatic hearing loss.
DIAGNOSES
167
C.
Ototoxicity.
D.
Presbycusis.
E.
Ménière syndrome.
F.
Acoustic neuroma.
G.
Cholesteatoma.
H.
Infection.
I.
Cerumen impaction.
J.
Otitis externa.
K.
Foreign body in the ear.
L.
Tumors.
M.
Otosclerosis.
N.
Perforation of TM.
O.
Serous OM.
P.
Hypothyroidism.
Q.
Paget disease.
HEARING LOSS
PLAN
A.
General interventions:
1.
Treat any primary cause (e.g., remove impacted ceru-
men, treat ETD, etc.).
2.
Inform the client regarding the results of screening and
indications for further testing.
B.
Client teaching:
1.
Discuss avoiding loud noises, use of hearing protec-
tion, and so forth.
2.
Instruct the client not to insert small objects into the ear
or to attempt to clean their ears.
C.
Pharmaceutical therapy:
1.
Treat the primary condition if applicable.
FOLLOW-UP
A.
If the primary cause of hearing loss is not identied, refer
the client to an otolaryngologist.
CONSULTATION/REFERRAL
A.
The client should be referred to an otolaryngologist for an
extensive workup when the primary cause cannot be identied. Most types of CHL can be medically or surgically corrected. Both unilateral and bilateral deafness can usually be
surgically improved by cochlear implantation.
B.
Referral should be made to a hearing aid specialist for
hearing evaluation and treatment as indicated (e.g., hearing
aids). Both CHL and SNHL can often be improved with hearing aids.
INDIVIDUAL
A.
Pediatrics:
1.
CONSIDERATIONS
Most children are able to respond to a test of gross
hearing using a small bell. To determine the client’s hearing ability, note if the child stops moving when the bell is
rung and if the child turns their head toward the sound.
2.
When examining children, pull the pinna back and
slightly upward to straighten the canal.
B.
Adults:
1.
The EAC in the adult can best be exposed by pulling
the earlobe upward and backward.
C.
Geriatrics:
1.
Impaired hearing among the elderly is common and
can lower their quality of life.
2.
Individuals with signicantly impaired hearing may
become withdrawn or appear confused.
3.
Hearing loss can be a contributing cause of depression
in the older population.
4.
Impacted cerumen is common in the elderly.
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