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6: EAR GUIDELINES
BIBLIOGRAPHY
National Institute on Deafness and Other Communication Disorders.
(2016). Quick statistics about hearing. https://www.nidcd.nih.gov/
health/statistics/quick-statistics-hearing
Rooth, M. A. (2017). The prevalence and impact of vision and hearing loss
in the elderly. North Carolina Medical Journal, 78(2), 118–120. https://
doi.org/10.18043/ncm.78.2.118
Weber, P. C. (2020). Etiology of hearing loss in adults. In D. G. Deschler
(Ed.), UpToDate
. Wolters Kluwer. https://www.uptodate.com/conte
nts/etiology-of-hearing-loss-in-adults?search=hearing%20loss&sour
ce=search_result&selectedTitle=1~150&usage_type=default&display
_rank=1
OTITIS
EXTERNA
DEFINITION
A.
Otitis externa is the generalized inammation of the exter-
nal auditory canal (EAC) with or without involvement of the
tympanic membrane (TM) and/or pinna. There is generally a
rapid onset (generally within 48 hours) of symptoms.
INCIDENCE
A.
Otitis externa is seen in clients of all ages. The incidence is
higher during summer months. All varieties (with the exception of necrotizing otitis externa) are common. It is one of the
most common infections treated by clinicians (the lifetime
incidence is up to 10%).
B.
Of otitis externa visits, 44% occur between the months of
June and August. Ambulatory visits for otitis externa are more
common in the South.
PATHOGENESIS
A.
Acute otitis externa (AOE) or swimmer’s ear: AOE is char-
acterized by rapid onset (1–2 days) of symptoms including
otalgia (often severe), EAC swelling, possible otorrhea, and/
or cellulitis of the pinna and the adjacent skin. It is uncommon before the age of 2 years. Pseudomonas is the most common bacterial infection (67%), followed by Staphylococcus and
Streptococcus. Infection can also be fungal (Aspergillus, 90%).
Bacterial or fungal invasion is usually preceded by trauma to
the ear canal, aggressive cleaning of the natural bactericidal
cerumen, or frequent submersion in water (swimming).
B.
Chronic otitis externa: This generally, results from a persis-
tent, low-grade infection and inammation with Pseudomonas.
C.
Eczematous otitis externa: This otitis externa is associated
with a primary coexistent skin disorder, such as atopic dermatitis, seborrheic dermatitis, and psoriasis.
D.
Necrotizing or malignant otitis externa: Invasive
Pseudomonas infection results in skull base osteomyelitis. It is
most commonly seen in the immunocompromised or diabetic
geriatric client.
PREDISPOSING
A.
Ear trauma from scratching with a foreign object or nger-
FACTORS
nail and overly vigorous cleaning of cerumen from the canal.
B.
Cerumen impaction.
C.
Frequent swimming.
D.
Use of a hearing aid.
E.
Eczema or other dermatologic conditions (eczematous oti-
tis externa).
F.
Debilitating disease (necrotizing otitis externa).
G.
Humid climates.
COMMON
A.
B.
COMPLAINTS
Otalgia.
Itching.
C.
Erythematous and swollen external canal.
D.
Purulent discharge.
E.
Hearing loss from edema and obstruction of the canal with
drainage.
OTHER
SIGNS AND SYMPTOMS
A.
Plugged ear sensation (aural fullness).
B.
Tenderness to palpation (tragus, pinna, or both) that is
disproportionate to what may be expected based on visual
inspection.
SUBJECTIVE
A.
Elicit the onset, duration, and intensity of ear discomfort.
B.
Inquire into the client’s history of ear infections.
C.
Determine whether the client notes any degree of hearing
DATA
loss.
D.
Question the client about recent exposure to immersion in
water (swimming).
E.
Question the client as to ear canal cleaning practices and
any recent trauma to the canal.
PHYSICAL
A.
Check temperature.
B.
Inspect:
EXAMINATION
1.
Carefully examine the ear with an otoscope for extreme
tenderness.
2.
Observe the ear for erythematous and edematous EAC;
look for otorrhea and debris.
3.
Attempt to visualize the TM, which may appear
normal.
4.
Inspect the nose and throat.
C.
Auscultate:
1.
Heart.
2.
Lungs.
D.
Palpate:
1.
Apply gentle pressure to the tragus and manipulate the
pinna to assess for tenderness.
2.
Palpate the cervical lymph nodes.
DIAGNOSTIC
A.
For persistent or chronic AOE, consider obtaining an otor-
TESTS
rhea specimen for culture and sensitivity testing and potassium hydroxide prep testing.
DIFFERENTIAL
A.
Otitis media.
B.
Foreign body.
C.
Mastoiditis.
D.
Hearing loss.
E.
Wisdom tooth eruption.
F.
Herpes zoster oticus (vesicular eruptions in the ear canal
DIAGNOSES
are associated with herpetic otitis externa).
G.
Necrotizing or malignant otitis externa (life-threatening
condition that occurs in diabetic or immunocompromised
clients).
H.
Cranial nerve palsies (of cranial nerves VII, IX, and XII)
and periostitis of the skull base have been associated with necrotizing otitis externa.
PLAN
A.
General interventions:
1.
When the client’s earcanal is sufciently blocked by
edema or drainage, preventing passage of eardrops, gently insert a cotton ear wick (approximately 1 in. long for
adults) to allow passage of drops.
2.
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Insert the wick by gently rotating it while inserting it
into the ear. The client then places eardrops on the wick.
The drops are absorbed through the wick, which allows
themedicine to reach the entire EAC.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Acute Otitis Externa (Swimmer's Ear).”
1.
The client should be instructed on dry ear precautions
until the infection has resolved (usually 7–10 days). The
client should not swim until symptoms are completely
resolved and the wick is removed.
2.
Clients with appropriately treated uncomplicated AOE
generally show signs of symptom improvement within 48
to 72 hours.
3.
Bathing or showering is permitted with a cotton ball
coated with petroleum jelly inserted into the ear to block
water passage into the ear canal.
C.
Pharmaceutical therapy:
1.
For early, mild cases associated with swimming in
which the primary symptom is pruritus, acetic acid/aluminum acetate (Domeboro) can be used to create an unsatisfactory environment for Pseudomonas growth.
2.
For moderate to severe infection, use of ototopical anti-
biotics and ototopical glucocorticoid therapy (Ciprodex) is
suggested. Other alternatives include ciprooxacin (Cipro
HC) and ooxacin (Floxin). Potentially ototoxic ototopical aminoglycosides (neomycin and polymyxin) should be
avoided if the integrity of the TM is in question.
If fungal infection is suspected, clotrimazole and
a.
betamethasone dipropionate lotion (Lotrisone) can
also be used for fungal infection if the TM is intact.
Apply two drops in the affected ear BID for 10 days.
Nystatin 100,000 units/mL or clotrimazole topical
b.
solutions may be used for candidal or yeast infections.
3.
In general, oral antibiotics are not effective in treating
AOE and should not be prescribed. However, for a poorly
controlled diabetic client, an immunocompromised client,
or for severe infections, additional management with oral
antibiotics or oral antifungals may be indicated.
a.
Ciprooxacin for pseudomonal infections; dicloxa-
cillin or cephalexin for staphylococcal infections.
b.
Itraconazole (Sporanox) for treatment of otomycosis
(fungal otitis externa).
4.
For analgesia, use acetaminophen or ibuprofen.
Short-term use of opiates may be necessary when acetaminophen and ibuprofen fail to control pain.
OTITIS MEDIA
C.
For complications (abscess, mastoiditis, meningitis, etc.),
169
refer to the ED for emergent treatment.
INDIVIDUAL
A.
Geriatrics:
1.
CONSIDERATIONS
Persistent otitis externa in the geriatric client (espe-
cially those who are immunocompromised or diabetic)
may evolve into osteomyelitis of the skull base.
2.
The external ear is painful and edematous, and a foul,
green discharge is usually present.
3.
Treatment may require parenteral gentamicin with a
beta-lactam agent. Surgery may be necessary.
4.
Oral uoroquinolones may be useful if the infection
has not progressed to osteomyelitis.
BIBLIOGRAPHY
Goguen, L. A. (2019). External otitis: Treatment. In D. G. Deschler& M.
S. Edwards (Eds.), UpToDate . Wolters Kluwer. https://www.uptoda
te.com/contents/external-otitis-treatment?search=otitis%20externa
&source=search_result&selectedTitle=1~89&usage_type=default&
display_rank=1
Goguen, L. A. (2020). External otitis: Pathogenesis, clinical features, and
diagnosis. In D. G. Deschler& M. S. Edwards (Eds.), UpToDate
. Wolters
Kluwer.https://www.uptodate.com/contents/external-otitispathogenesis-clinical-features-and-diagnosis?search=otitis%20extern
a&source=search_result&selectedTitle=2~89&usage_type=default&d
isplay_rank=2
Rosenfeld, R. M., Schwartz, S. R., Cannon, C. R., Roland, P. S., Simon, G. R.,
Kumar, K. A., Huang, W. W., Haskell, H. W., & Robertson, P. J. (2014).
Clinical practice guideline: Acute otitis externa. Otolaryngology–Head
and Neck Surgery, 150(Suppl 1), S1–S24. https://doi.org/10.1177/019
4599813517083
OTITIS
MEDIA
DEFINITION
A.
Otitis media (OM) is dened as inammation of the space
between the eardrum and the inner ear due to any cause.
The two most common variants of OM are acute otitis media
(AOM) and otitis media with effusion (OME). It is important
for the clinician to understand the differences between these
two common middle ear conditions. A characteristic of AOM
is rapid onset of symptoms and inammation of the middle
ear. Middle ear effusion (MEE) may or may not be present.
OME is characterized by the presence of MEE without the
acute symptoms of AOM (Figures 6.1 and 6.2).
FOLLOW-UP
A.
Usual follow-up is within 3 to 5 days to assess improve-
ment. Recheck in 1 to 2 weeks.
B.
If an ear wick is inserted, the wick should be removed
within 3 to 5 days, once the swelling is reduced. It is common for the wick to spontaneously fall out as the swelling
improves. Upon reduction of swelling, ototopical drops can
then be directly instilled into the canal, without the need to
insert a new wick.
CONSULTATION/REFERRAL
A.
Parenteral antibiotics are required for necrotizing otitis
externa. Clients with this condition should be immediately
referred to an otolaryngologist or to theED.
B.
Consult or refer the client to an otolaryngologist or to
theED if osteomyelitis is suspected.
FIGURE
6.1 Otitis media.
Source:
Image courtesy of B. Welleschik.
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6: EAR GUIDELINES
4.
Ear fullness.
5.
Upper respiratory infection (URI) symptoms.
6.
Perforated tympanic membrane (TM): sudden severe
pain followed by immediate relief of pain with otorrhea.
B.
OME:
1.
New-onset hearing loss.
2.
Tinnitus.
3.
Unsteadiness.
4.
Ear pressure.
5.
Intermittent sharp otalgia.
6.
URI symptoms.
FIGURE
6.2 Otitis media with effusion.
Source:
Image courtesy of Michael Hawke, MD.
INCIDENCE
A.
AOM may occur at any age, but is most commonly seen in
children 12 months of age or younger. OME is seen in clients
of all ages. After the onset of AOM, approximately 70% of children have MEE present at 2 weeks, 40% have MEE present at
1 month, 20% have MEE at 2 months, and 10% have MEE at 3
months.
B.
Over two-thirds of children have had at least one episode
of OM by 3 years of age.
C.
One-third of children have had three or more episodes by
3 years of age.
D.
One-third of all pediatric visits are for OM.
E.
Approximately 2.2 million new cases of OME are diag-
nosed in the United States each year.
F.
Annual direct costs of OM in the United States are $3 bil-
lion to $5 billion.
PATHOGENESIS
A.
Obstruction of the eustachian tube can lead to an MEE
and infection. Contamination of this middle ear uid may
result from a backup of nasopharyngeal secretions. The most
common bacterial pathogens are Streptococcus pneumoniae,
Haemophilus inuenzae, and Moraxella catarrhalis. S. pneumoniae
and H. inuenzae combined cause 50% to 60% of pediatric
AOM. M. catarrhalis cause 3% to 14% of pediatric AOM.
PREDISPOSING
A.
Age younger than 12 months, although may occur at any age.
B.
Recurrent OM (three or more episodes in the last 6 months).
C.
Previous episode of OM within the last month.
D.
Medical condition that predisposes to OM (e.g., Down
FACTORS
syndrome, AIDS, cystic brosis, cleft palate, and craniofacial
abnormalities).
E.
Exposure to tobacco smoke and air pollution.
F.
Day-care attendance.
G.
Bottle propping.
H.
Nasal allergies.
I.
Pacier use.
COMMON
A.
COMPLAINTS
AOM:
1.
Otalgia.
2.
Pulling ears in children.
3.
Fever may or may not be present.
SUBJECTIVE
A.
Elicit the onset and duration of symptoms.
B.
Inquire whether the client recently had (or concurrently
DATA
has) a URI.
C.
Has the client/family noticed hearing loss in the affected ear?
D.
Elicit for otorrhea (ear drainage), with or without foul
odor.
E.
Review and inquire regarding risk factors.
F.
Identify the client’s history of OM.
G.
Inquire if the client has own recently.
PHYSICAL
A.
Check temperature, pulse, respirations, and blood
EXAMINATION
pressure.
B.
Inspect:
1.
Observe the canal and auricle for redness, deformity,
otorrhea, or foreign body.
2.
Inspect the TM position to determine whether land-
marks are visible and whether the TM is retracted, bulging, erythematous, or noted with MEE.
3.
Observe the ears for decreased or absent TM mobility.
4.
Inspect the nose, mouth, and throat.
C.
Auscultate:
1.
Heart.
2.
Lungs.
DIAGNOSTIC
A.
Tympanometry is a test that measures how easily the TM
TESTS
vibrates. Type A tympanograms are normal, type B tympanograms indicate MEE, and type C tympanograms indicate negative middle ear pressure with or without MEE.
B.
A diagnostic audiogram should be done in clients with
persistent OM (greater or equal to 3 months’ duration), subjective hearing loss, speech delay, or possible cholesteatoma.
C.
Consider a complete blood count if the client appears toxic
with a high fever.
DIFFERENTIAL
A.
Red TM secondary to crying (differentiated from AOM by
DIAGNOSES
mobility with pneumatic otoscopy).
B.
URI.
C.
Acute mastoiditis and meningitis (rare but serious).
D.
Foreign body in the ear.
E.
Acute otitis externa.
F.
Eustachian tube dysfunction (ETD).
G.
Cholesteatoma (saclike structure in the middle ear usually
accompanied by chronic foul-smelling otorrhea and progressive hearing loss).
H.
Spontaneous TM rupture.
PLAN
A.
General intervention:
1.
Pain relief with acetaminophen or ibuprofen.
B.
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Client teaching: See Client Teaching Guides for this chapter,
“Acute Otitis Media” and “Otitis Media With Effusion.”
1.
Educate the parents and care providers that chil-
dren should avoid smoke exposure. Smoke-lled rooms
increase the risk of frequent ear infections in children.
2.
For young children who use a bottle for feeding, stress
the importance of NOT propping bottles at any time for
feeding. Propping bottles increases the risk of OM.
C.
Pharmaceutical therapy:
1.
Intranasal glucocorticoids and intranasal antihista-
mines (Astelin) used concomitantly are often helpful with
improving the underlying ETD, thus resolving the MEE.
2.
Oral antihistamines and decongestants are not recom-
mended for routine use for treating OME in children.
3.
Oral antibiotics may shorten the duration of symptoms
in clients with AOM.
4.
The drug of choice for AOM is amoxicillin 90 mg/kg/d
divided into two daily doses for 10 days, up to a maximum
of 3 g/d.
5.
For concerns of amoxicillin resistance, treatment fail-
ure, recent use of antibiotic in the previous 30 days, and/
or other concurrent infections, use an antibiotic with
beta-lactamase activity, such as amoxicillin- clavulanate
(Augmentin). Other alternatives include cefdinir, cefpodoxime, cefuroxime, and ceftriaxone.
6.
For penicillin allergy, alternatives are cefdinir 14 mg/
kg/d in one to two doses, maximum dose 600 mg/d; cefpodoxime 10 mg/kg/d, once daily, maximum dose 800
mg/d; or cefuroxime suspension, 30 mg/kg/d in two
divided doses, maximum dose 1 g/d, or capsules, 250 mg
Q12H.
7.
Alternatively, one dose of ceftriaxone 50 mg/kg intra-
muscularly (IM) may be given. If clinically improved in
48 hours, no further treatment is recommended. If signs/
symptoms continue, administer the second dose of ceftriaxone in 48 hours.
8.
Other alternativesinclude macrolides.
a.
Erythromycin plus sulsoxazole (Pediazole): 50
to 150 mg/kg/d of erythromycin divided into four
doses/d for 10 days; maximum dose 2 g erythromycin
or 6 g sulsoxazole/d (Do not use in children younger
than 2 months).
b.
Azithromycin 10 mg/kg/d, maximum dose 500
mg/d as a single dose on day 1, then 5 mg/kg/d, maximum dose of 250 mg/d on days 2 to 5 for 10 days.
c.
Clarithromycin 15 mg/kg/d divided into two
doses, maximum dose 1 g/d.
d.
Trimethoprim with sulfamethoxazole 8 mg/kg/d
of trimethoprim (40 mg/kg/d of sulfamethoxazole)
divided into two daily doses for 10 days.
9.
Children younger than 2 years should be treated with
antibiotic therapy for 10 days; children older than 2 years
without a history of OM may be treated for 5 to 7 days:
erythromycin with sulsoxazole 40 mg/kg/d (150 mg/
kg/d of sulsoxazole [Pediazole]) divided into four daily
doses for 10 days. Do not use in children younger than 2
months.
10.
If the client is asymptomatic and AOM is found on
examination, consider observation without antibiotics
only if the child is older than 2 years. Recommend a
follow-up examination in 48 hours.
11.
Other antibiotics (if rst-line antibiotic fails) include
amoxicillin and clavulanic acid (Augmentin), cexime
(Suprax), azithromycin (Zithromax), and cefprozil (Cefzil).
OTITIS MEDIA
171
FOLLOW-UP
A.
Check the client with AOM in 2 to 4 weeks or if fever and
complaints persist for more than 48 hours if an antibiotic is
begun. Documentation of the resolution of the ear infection is
a valuable information if recurrent infections occur.
B.
Recheck the client with OME after 4 to 6 weeks.
CONSULTATION/REFERRAL
A.
Refer the client to an otolaryngologist if they are less than
6 weeks of age, appears septic, or has mastoiditis.
B.
For persistent OM (3 months or longer) and/or docu-
mented hearing loss due to MEE, refer to an otolaryngologist
for consideration of tympanostomy tube insertion. Also, refer
to otolaryngology for suspected speech or learning delay in
children with chronic MEE.
C.
For complications (abscess, mastoiditis, meningitis, etc.),
refer to the ED for emergent treatment.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Do not use sulfa medications (sulfonamides) in preg-
nant clients.
B.
Pediatrics:
1.
Antibiotic therapy should NOT be used to treat OME
due to the small benets that are offset by adverse reactions, bacterial resistance, and lack of impact in future ear
surgery. Most cases of OME will spontaneously resolve
within 3 months. Simply monitor closely. However, OME
may become chronic, requiring an otolaryngology consult.
2.
For children 6 weeks old or younger, consider a blood
culture and lumbar puncture if septicemia is suspected.
The client may need intravenous (IV) antibiotics depending on culture results.
3.
Do not use sulfa medications (sulfonamides) in chil-
dren younger than 2 months.
4.
The American Academy of Pediatrics does not rec-
ommend the use of over-the-counter cough and cold
medications in children younger than 6 years. In older
children, consider decongestants and/or intranasal steroids for nasal congestion.
5.
Antihistamines are not recommended.
C.
Adults:
1.
OME may be present in adults, usually unilaterally, and
usually associated with URI or allergies due to a blocked
eustachian tube.
2.
If there is no accompanying URI, a nasopharyn-
geal mass or adenoid hypertrophy must be ruled out.
Otolaryngology consult should be considered for nasopharyngeal endoscopic examination.
BIBLIOGRAPHY
Klein, J. O., & Pelton, S. (2015). Acute otitis media in children: Treatment. In
M. Edwards& G. Isaacson (Eds.), UptoDate . Wolters Kluwer. http://w
ww.uptodate.com/contents/acute-otitis-media-in-children-treatment
Limb, C. J., Lustig, L. R., & Durand, M. L. (2021). Acute otitis media in
adults. In D. Deschler (Ed.), UpToDate
.uptodate.com/contents/acute-otitis-media-in-adults?search=otitis%
20media&source=search_result&selectedTitle=1~150&usage_type=d
efault&display_rank=1
Pelton, S. I., & Marom, T. (2021). Management of otitis media with effu-
sion (serous otitis media) in children. In S. Kaplan& G. Isaacson (Eds.),
UpToDate. Wolters Kluwer. http://www.uptodate.com/contents/
management-of-otitis-media-with-effusion-serous-otitis-media-in-chi
ldren?source=search_result&search=otitis+meda+with+effusion&se
lectedTitle=1~48
Poe, D., & Bassem, M. (2019). Eustachian tube dysfunction. In D. Deschler
(Ed.), UpToDate. Wolters Kluwer. http://www.uptodate.com/contents/
. Wolters Kluwer. https://www
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6: EAR GUIDELINES
eustachian-tube-dysfunction?source=search_result&search=eustac
hian+tube+dysfunction&selectedTitle=1%7E39
Rosenfeld, R. M., Shin, J. J., Schwartz, S. R., Coggins, R., Gagnon, L.,
Hackell, J. M., Hoelting, D., Hunter, L. L., Kummer, A.W., Payne, S.
C., Poe, D. S., Veling, M., Vila, P. M., Walsh, S. A., & Corrigan, M. D.
(2016). Clinical practice guideline: Otitis media with effusion (Update.
Otolaryngology-Head and Neck Surgery, 154(Suppl. 1), S1–S41. https://
doi.org/10.1177/0194599815623467
,
TINNITUS
DEFINITION
A.
Tinnitus is the perception of sound heard in the ear and/or
head with no external source. It may be described by the client
as unilateral, bilateral, or centralized.
B.
Primary tinnitus is dened as tinnitus that is idiopathic
and may or may not be associated with sensorineural hearing
loss (SNHL). Secondary tinnitus is dened as tinnitus that is
associated with an underlying cause other than SNHL (e.g.,
cerumen impaction, middle ear disease, Eustachian tube dysfunction, Ménière disease, and vestibular schwannoma).
INCIDENCE
A.
Tinnitus is a very common medical problem that affects an
estimated 50 million people in the United States.
PATHOGENESIS
A.
Tinnitus is poorly understood and there is wide disagree-
ment on the pathophysiology. It is best described as a nonspecic manifestation of pathology of the inner ear, cranial
nerve VIII, and/or the central auditory mechanism. There
is a strong association between tinnitus, stress, anxiety, and
depression.
PREDISPOSING
A.
Cerumen impaction.
B.
Anxiety, depression, or “high stress” (common).
C.
Tympanic membrane (TM) perforation.
D.
Middle ear effusion (MEE).
E.
Eustachian tube dysfunction.
F.
Acoustic trauma.
G.
Ototoxic drugs.
H.
Vascular aneurysm.
I.
Jugular bulb anomaly. Compression of the ipsilateral jugu-
lar vein abolishes the objective tinnitus of a jugular megabulb
anomaly.
J.
Anemia.
K.
Temporomandibular joint syndrome.
L.
Hypertension.
COMMON
A.
Ringing.
B.
Roaring.
C.
Buzzing.
D.
Clicking.
E.
Hissing.
F.
Hearing loss.
G.
Pulsing.
OTHER
SIGNS AND SYMPTOMS
A.
“Mufed” hearing or ear pressure.
B.
Change in own voice quality.
SUBJECTIVE
A.
Review the onset, duration, course, and type of symptoms;
note whether the tinnitus is unilateral, bilateral, or centralized.
FACTORS
COMPLAINTS
DATA
B.
Determine the frequency and quality of the sound. Is the
ringing constant, intermittent, or pulsing?
C.
Review all medications, including over-the-counter drugs
and prescriptions.
D.
Determine whether the client has experienced trauma
(domestic violence, motor vehicle accident, etc.).
E.
Rule out a recent sinus, oral, or ear infection.
F.
Review any previous occurrences.
G.
Review work, hobbies, and music habits for noise levels
(potential noise-induced SNHL).
H.
Assess the date of thelast hearing examination and deter-
mine whether there was any known hearing loss.
I.
Review whether the client uses cotton-tipped swabs or
other small objects for ear cleaning.
J.
Inquire about current stressors the client is experiencing. Is
there an active history of depression, anxiety, fatigue, chronic
pain, high stress (emotional and physical), worrying, and so
on?
PHYSICAL
A.
Take temperature if an infectious cause is suspected.
B.
Inspect:
EXAMINATION
1.
Observe the external ear for discharge; note color and
odor.
2.
Conduct otoscopic examination of the auditory canal
for cerumen impaction or foreign body.
3.
Inspect the TM for color, landmarks, contour, perfora-
tion, and acute otitis media (AOM).
C.
Auscultate:
1.
The skull should be auscultated for a bruit if the origin
of the problem remains obscure.
D.
Palpate:
1.
Palpate the auricle and the mastoid area for tender-
ness, swelling, or nodules.
2.
Check the lymph nodes if infection is suspected.
E.
Perform neurologic examination:
1.
Cranial nerve VIII is tested by evaluating hearing.
2.
First evaluate how the client responds to your
questions.
3.
Clients who speak in a monotone or with erratic vol-
ume may have hearing loss.
4.
Check the client’s response to a soft whisper (should
respond at least 50% of the time).
5.
Perform the Rinne test.
6.
Perform the Weber test.
DIAGNOSTIC
A.
Hearing screening is performed in the primary care set-
TESTS
ting; other more precise audiologic tests are performed by an
audiologist and/or an otolaryngologist.
B.
Obtain CT scan or MRI after consultation with an
otolaryngologist.
DIFFERENTIAL
A.
Cerumen impaction.
B.
Foreign body in the ear.
C.
AOM.
D.
Acute otitis externa.
E.
Acoustic traumas.
F.
Vascular aneurysm.
G.
Temporomandibular joint syndrome.
H.
Otosclerosis.
I.
Ototoxicity.
J.
Ménière disease.
K.
Presbycusis.
DIAGNOSES
L.
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Central nervous system lesion.
M.
Depression and anxiety.
PLAN
A.
General interventions:
1.
Stress the importance of not placing small objects in the
ear and using cotton-tipped applicators to clean the external ear only.
2.
Suggest masking techniques. For example, keeping a
radio or sound machine on for background noise often
facilitates sleep or work.
3.
Consider hearing aid use in clients with hearing loss
and tinnitus.
4.
Address the underlying conditions if present (depres-
sion, anxiety insomnia, hearing loss, drug toxicity, etc.).
5.
Consider behavioral therapy, such as biofeedback,
mindfulness meditation, or cognitive behavioral therapy,
to teach client coping strategies and to treat underlying
emotional issues.
6.
Encourage reduction in dietary caffeine, sodium, alco-
hol, and nicotine as these substances may exacerbate
tinnitus.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Tinnitus.”
1.
Educate the client regarding techniques/therapies to
improve symptoms of tinnitus.
2.
Encourage the client to attend therapy sessions and/or
support groups as indicated.
C.
Pharmaceutical therapy:
1.
No medication “cures” tinnitus.
2.
Low-dosage benzodiazepines and insomnia medica-
tions may be benecial for short-term relief of debilitating tinnitus. These medications are generally not advised
for long-term management of tinnitus. The client’s risk of
drug dependency should be carefully evaluated prior to
prescribing these medications.
TINNITUS
173
FOLLOW-UP
A.
No specic follow-up is required for tinnitus unless a
treatable problem is identied.
CONSULTATION/REFERRAL
A.
Consult with an otolaryngologist in most cases of tinnitus.
B.
Referral of an anxious client to the otolaryngologist may
be necessary to assure the client that everything has been
explored and that there is no serious or correctable underlying condition.
C.
Any client with a history of head trauma should be referred
to an otolaryngologist because in rare cases tinnitus may be
associated with an acoustic neuroma, arteriovenous stula, or
an aneurysm of the intrapetrous portion of the internal carotid
artery.
BIBLIOGRAPHY
Bhatt, J. M., Bhattacharyya, N., & Harrison, W. L. (2017). Relationship
between tinnitus and the prevalence of anxiety and depression.
Laryngoscope, 127(2), 466–469. https://doi.org/10.1002/lary.26107
Kallogjeri, D., Piccirillo, J. F., Spitznagel, E., Hale, S., Nicklaus, J. E.,
Hardin, F. M., Shimony, J. S., Coalson, R. S., & Schlaggar, B. L. (2017).
Cognitive training for adults with bothersome tinnitus: A randomized
clinical trial. JAMA Otolaryngology–Head and Neck Surgery, 143(5), 443–
451. https://doi.org/10.1001/jamaoto.2016.3779
Tunkel, D. E., Bauer, C. A., Sun, G. H., Rosenfeld, R. M., Chandrasekhar,
S. S., Cunningham, E. R., Archer, S. M., Blakley, B. W., Carter, J. M.,
Granieri, E. C., Henry, J. A., Hollingsworth, D., Khan, F. A., Mitchell,
S., Monfared, A., Newman, C. W., Omole, F. S., Phillips, C. D.,
Robinson, S. K., & Whamond, E. J. (2014). Clinical guidelines: Tinnitus.
Otolaryngology Head Neck Surgery, 151(Suppl. 2), S1–40. https://doi.org/
10.1177/0194599814545325
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CLIENT
TEACHING GUIDE
ACUTE OTITIS EXTERNA (SWIMMER’S EAR)
PROBLEM
ear.” This is a common condition characterized by itching in the ear, sometimes followed by severe ear pain, swelling, and drainage of the ear canal. Difculty hearing may also occur. The eardrum is rarely affected.
CAUSE
long exposure to water in the ear canal after frequent swimming and self-cleaning of the earwax. It may involve either a bacterial
or a fungal infection.
PREVENTION/CARE
The
following measures may prevent future problems with otitis externa:
A.
Clean the outer ear only as needed. Do NOT attempt to clean the internal ear canal. Do not use cotton-tipped swabs or any
other device to clean down into the ear canal. Usually, wax is just pushed deeper into the canal with this method and the canal
may be traumatized by the instrument used.
B.
For swimmers or others susceptible to frequent recurrences of otitis externa, it may be helpful to dry the ear canals with a blow
dryer on a low setting after exposure to water. Also, isopropyl alcohol (rubbing alcohol) may be instilled into the ear canal after
showering, bathing, or swimming. Do not instill rubbing alcohol into the ear if the ear is already infected or if there is a hole in the
eardrum. Ear plugs may be benecial to swimmers with recurrences of otitis externa.
TREATMENT
A.
For the most common bacterial infections associated with otitis externa, antibiotic/steroid eardrops are usually prescribed. For
fungal infections associated with otitis externa, antifungal/steroid eardrops are usually prescribed. Frequent cleanings by an otolaryngologist may be required to remove infection. For both bacterial and fungal infections associated with otitis externa, the ear
should be kept dry until it is healed. This means no swimming until symptoms are totally resolved. To bathe or shower, rst coat
cotton balls with petroleum jelly and use them to plug the ears.
Your
practitioner has diagnosed a condition known as acute otitis externa, sometimes also referred to as “swimmer’s
Acute
otitis externa occurs from irritation to the external canal of the ear. The most common causes of otitis externa are
PLAN
Activity:
The only activity restrictions are those involving submersion in water. Bathing and hair washing are permitted as described
previously.
Diet:
No changes are required in your diet.
You
Have Been Prescribed:
Medications:
A.
Prescription eardrops are used to treat otitis externa.
B.
The drops should be applied down the ear canal’s opening.
C.
In severe cases, oral antibiotics may be given.
You
Need to Instill ___________________ Drops Into the Affected Ear ___________________ Times Per Day.
You
Need to Notify the Office or Go to the Emergency Department If You:
A.
Have symptoms that have not cleared up in 3 days.
B.
Have a fever over 100°F.
C.
Have severe ear pain or new symptoms present.
D.
Are unable to instill eardrops into the ear due to swelling of the ear canal.
E.
Other:
Phone:
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CLIENT
TEACHING GUIDE
ACUTE OTITIS MEDIA
PROBLEM
of ear pain and possible hearing loss.
CAUSE
PREVENTION/CARE
A.
Wash your child’s hands often. Always wash hands before eating and after playing, especially when playing with other children.
B.
Do not smoke. Children should not be exposed to secondhand smoke. Secondhand smoke increases the risk of ear
infections in children.
C.
Avoid exposure to other children/people as much as possible, especially during the rst year of life. Exposure to others
increases the risk of contracting a virus that may lead to getting a cold. Many ear infections occur after having a cold or upper
respiratory infection.
D.
If your child is bottle-fed, do not “prop” the bottle. Always hold your baby when bottle feeding.
E.
Do not allow your child to have a bottle at bedtime.
F.
Wean your child from the bottle by their rst birthday.
G.
Breastfeeding your baby for the rst 6 to 12 months of life is highly recommended. Breastfeeding reduces the risk of ear infec-
tions because breast milk contains antibodies that ght against ear infections.
H.
Childhood immunizations are encouraged to be given at the recommended ages. Some immunizations, such as the u vaccine
and pneumococcal vaccine, may protect your child from getting ear infections.
Acute
Usually
otitis media inammation of the space between the eardrum and the inner ear is characterized by a rapid onset
caused by bacteria or viruses.
TREATMENT
A.
Follow up with a healthcare provider as instructed to avoid complications of otitis media or permanent hearing loss.
Activity:
Diet:
PLAN
Your child may not play as much when they are sick. Activity is encouraged as tolerated.
Your child may not eat well when they are sick. No change in diet is recommended. Encourage uids for hydration.
Medications:
A.
Children’s Tylenol and/or ibuprofen may be used for fever or pain.
B.
Do not use aspirin in children.
C.
Antibiotics may be prescribed. Give as prescribed.
You
Have Been Prescribed:
You
Need to Take:
Your
child needs to nish all the antibiotics, even though they may start to feel better.
You
Need to Notify the Office If You Have:
A.
Continued fever or no improvement in symptoms in 48 hours.
B.
A child who acts as if they have a stiff neck, headache, or other new symptoms.
C.
Continual crying or not being able to console your child.
D.
Rash while taking medicine.
E.
Other:
Phone:
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CLIENT
TEACHING GUIDE
OTITIS MEDIA WITH EFFUSION
PROBLEM
CAUSE
treated. The eustachian tube can be blocked, preventing proper ventilation of the middle ear. Symptoms may include difculty
hearing and a feeling of fullness and/or pain in the ear.
TREATMENT
A.
Determine if there is difculty with hearing.
B.
Make accommodations for the hearing loss, such as sitting in the front of the classroom at school and speaking clearly and
loudly. Reduce or eliminate external noises while having a conversation.
C.
If the buildup of uid in the middle ear lasts for longer than 3 months, a hearing evaluation should be completed. A referral to
an ear specialist may be required for further care.
D.
Follow up with a healthcare provider as instructed to avoid complications and/or permanent hearing loss.
Activity:
Diet:
Medications:
mines (Astelin) are sometimes prescribed and can improve the time that is taken for resolution of the middle ear uid. These medications should be taken exactly as directed. Antibiotics are likely not needed.
There
is inammation of the middle ear with effusion, which is the presence of uid in the middle ear without infection.
The
middle ear uid can remain behind the tympanic membrane after a middle ear infection (acute otitis media) has been
PLAN
There is no activity restriction.
There is no special diet.
Middle ear uid often resolves without treatment within 3 months. Nasal spray steroids and nasal spray antihista-
Have Been Prescribed:
You
You
Need to Take:
You
Need to Notify the Office if You Have:
A.
Fever.
B.
Decreased appetite.
C.
Decreased activity level.
D.
Ear pain.
E.
Noticed a change in hearing loss or speech development.
F.
Any other new symptoms that occur.
G.
Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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