23
Assessment and Management:
Auditory Problems
Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability Sensory Perception
Infection Stress and Coping
LEARNING OUTCOMES
1. Describe the structures and functions of the auditory 7. Explain the pathophysiology, clinical manifestations, and
system. nursing and interprofessional management of common
2. Obtain significant subjective and objective assessment ear problems.
data related to the auditory system from a patient. 8. Compare the common causes, management, and
3. Perform a physical assessment of the auditory system rehabilitative potential of conductive and sensorineural
using the appropriate techniques. hearing loss.
4. Distinguish normal from common abnormal findings of a 9. Explain the use, care, and patient teaching related to
physical assessment of the auditory system. assistive hearing devices.
5. Link the age-related changes in the auditory system to 10. Describe measures used to assist the patient in adapting to
differences in assessment findings. decreased hearing.
6. Describe the purpose, significance of results, and nursing
responsibilities related to diagnostic studies of the
auditory system.
KEY TERMS
acoustic neuroma otosclerosis
benign paroxysmal positional vertigo (BPPV) presbycusis
external otitis tinnitus
Ménière disease vertigo
nystagmus
AUDITORY SYSTEM STRUCTURES AND FUNCTIONS OF AUDITORY
Hearing is a complex process that allows us to interact with
SYSTEM
the environment. It is the basis for social interaction and com- The auditory system is composed of the peripheral auditory
munication. Having a hearing impairment can lead to major system and central auditory system. The peripheral auditory
challenges that can adversely affect well-being. Difficulties with system includes the structures of the ear itself: external, mid-
related concepts, including functional ability and cognition, dle, and inner ear (Fig. 23.1). This system is involved with the
may be present with hearing loss. Problems with equilibrium reception and perception of sound. The inner ear functions in
can impair coordination, balance, and orientation. This chapter hearing and balance.
presents an overview of auditory function and discusses care The central auditory system integrates and assigns meaning
when problems occur. to what you hear. This system includes the vestibulocochlear
436
, CHAPTER 23 Assessment and Management: Auditory Problems 437
External ear (not to scale) Middle ear Inner ear
Auricle External acoustic Temporal Tympanic
(pinna) meatus bone membrane
Semicircular canals
Oval window
Facial nerve
Vestibular nerve Vestibulocochlear
Cochlear nerve nerve (CN VIII)
Cochlea
Vestibule
Malleus Incus Stapes Round window
Auditory tube
Auditory
ossicles
Fig. 23.1 External, middle, and inner ear. (Modified from Patton KT, Thibodeau GA: Anatomy and physiology,
ed 8, St Louis, 2013, Mosby.)
nerve (cranial nerve [CN] VIII) and auditory cortex of the Middle Ear
brain. The brain and its pathways transmit and process sound The middle ear cavity is an air space in the temporal bone.
and sensations that maintain your equilibrium. Mucous membrane lines the middle ear and is continuous
The role of the external and middle part of the ear is to con- from the nasal pharynx via the eustachian (auditory) tube. The
duct and amplify sound waves from the environment. This part eustachian tube equalizes atmospheric air pressure between the
of sound conduction is termed air conduction. Problems in these middle ear and throat. This allows the TM to move freely. It is
parts of the ear may cause conductive hearing loss, resulting in a normally closed, opening only with yawning, swallowing, and
decrease in sound intensity and/or a distortion in sound. chewing. Blockage of the tube can occur with allergies, naso-
Damage to or a problem of the inner ear or along the nerve pharyngeal infections, or enlarged adenoids. A tube that stays
pathways results in sensorineural hearing loss. Besides causing open is patulous. When this occurs, autophony, or hearing your
distortion or faintness of sound, sensorineural hearing loss may own voice, may be present.
affect the ability to understand speech or cause complete hear- The middle ear contains the ossicles, the 3 smallest bones in
ing loss. Impairment within the auditory pathways of the brain the body: malleus, incus, and stapes. Vibrations of the TM cause
causes central hearing loss. Central hearing loss causes difficulty the ossicles to move and transmit sound waves to the oval win-
in understanding the meaning of words the person heard. Types dow. The superior part of the middle ear is the epitympanum, or
of hearing loss are discussed later in this chapter. the attic. It also communicates with air cells within the mastoid
bone. The mastoid is the posterior part of the temporal bone.
External Ear The facial nerve (CN VII) traverses above the oval window of
The external ear consists of the auricle (pinna), external auditory the middle ear. The thin, bony covering of the facial nerve can
canal, and tympanic membrane (TM), or eardrum. The auricle is become damaged by chronic ear infection, skull fracture, or
composed of cartilage and connective tissue covered with epi- trauma during ear surgery. Problems may occur with volun-
thelium, which also lines the external auditory canal (Fig. 23.1). tary facial movements, eyelid closure, and taste discrimination.
The external auditory canal is a slightly S-shaped tube about Permanent damage to the facial nerve can result.
1 inch (2.5 cm) in length in the adult. The lining of the first
one-third of the canal contains fine hairs (cilia), sebaceous (oil) Inner Ear
glands, and ceruminous (wax) glands. The oil and wax lubricate The inner ear consists of 3 spaces in the temporal bone, assem-
the ear canal, keep it free from debris, and kill bacteria. Thin bled in a system called the bony labyrinth. The space is filled
epithelium lines the distal two-thirds of the canal. It is over bone with watery fluid called perilymph. Within the perilymph is the
and very sensitive. membranous labyrinth. It follows the shape of the bony laby-
The function of the external ear and canal is to collect and rinth and holds a thicker fluid called endolymph.
transmit sound waves to the TM. The TM is a shiny, translucent, The inner ear holds the functional organs for hearing and
pearl-gray membrane. It is made up of epithelial cells, connective balance. The receptor organ for hearing is the organ of Corti.
tissue, and mucous membrane. It serves as a partition and trans- It lies on the basilar membrane in the cochlea. Its tiny hair cells
mits sounds between the external auditory canal and middle ear. transform fluid vibrations from sounds into electrical impulses.
, 438 SECTION 5 Problems Related to Altered Sensory Input
These are transmitted by the acoustic part of the vestibuloco- Age-related changes in the auditory system and differences
chlear nerve (CN VIII) to the temporal lobe of the brain to pro- in assessment findings are outlined in Table 23.1.
cess and interpret the sound.
Three semicircular canals and the vestibule make up the Case Study
organ of balance. The semicircular canals sit at right angles to Patient Introduction
each other. Structures in each canal and the vestibule generate
nerve impulses in response to our movements. The vestibule is R.S. is a 57-year-old woman who comes to the emergency
department with extreme dizziness. R.S. states that she is
beside the oval window between the semicircular canals and the
so dizzy she “can’t do anything but lie down.” She reports
cochlea. Nerves from receptors in the vestibule join those from
feeling like her right ear is “plugged” and is having ringing
the semicircular canals to form the vestibular nerve. It joins in that ear.
with the cochlear nerve to form the vestibulocochlear nerve, or
CN VIII. Discussion Questions
(© iStock.com/ 1. What are the possible causes of R.M.’s hearing and
Hearing Sound EyeMark.) balance problems?
Hearing depends on a series of complex steps that change sound 2. Is her condition stable or an emergency?
waves in the air into electrical signals. Sound waves travel by 3. What assessment questions will you ask?
You will learn more about R.S. and her condition as you read this chapter.
air (air conduction) and are picked up by the auricles and audi-
tory canal. Sound waves strike the TM, causing it to vibrate. Answers available at http://evolve.elsevier.com/Lewis/medsurg
The central part of the TM is connected to the malleus, which
then starts to vibrate. The malleus transmits the vibration to the
incus and then the stapes. As the stapes moves back and forth, it
ASSESSMENT OF AUDITORY SYSTEM
pushes the membrane of the oval window in and out. Assessment of the auditory system should include assessment
Movement of the oval window makes waves in the peri- of hearing and equilibrium because the auditory and vestibular
lymph. These vibrations are picked up by the tiny sensory (balance) systems are closely related. It is often hard to separate
hair cells of the cochlea, which initiate nerve impulses. These symptoms related to these 2 systems. Help the patient describe
impulses are carried by nerve fibers to the main branch of the symptoms and problems to determine the source of the prob-
acoustic portion of CN VIII and then to the brain. The bones lems. Health history questions to ask a patient with an auditory
of the skull can also transmit sound directly to the inner ear problem are listed in Table 23.2.
(bone conduction).
We measure sound waves in 2 ways, intensity or strength
and frequency or pitch. We measure the intensity in terms of
decibels (dB). The lowest hearing decibel level is 0 dB, which TABLE 23.1 GERONTOLOGIC
is nearly total silence and the softest sound that we can hear. ASSESSMENT DIFFERENCES
Normal speech is around 40 to 65 dB; a soft whisper is 20 dB. Auditory System
Sounds above 90 dB can lead to hearing damage if people are
exposed to them every day or all the time. Hearing becomes Differences in Assessment
uncomfortable if the sound pressure level is above 110 dB. Changes Findings
Frequency is the measurement of the number of sound External Ear
vibrations in 1 second. We measure it in hertz (Hz). The higher Increased hair growth Visible hair, especially in men
the frequency is, the higher the pitch. Normally, a child and a Loss of elasticity in cartilage Collapsed ear canal
young adult can hear frequencies from about 16 to 20,000 Hz, Thicker, drier earwax Impacted earwax, potential hearing
loss
but hearing is most sensitive between 500 and 4000 Hz. This is
similar to normal speech frequencies. Middle Ear
Atrophy of TM Conductive hearing loss
Gerontologic Considerations: Effects of Aging on
Auditory System Inner Ear
Hair cell degeneration, neuron Presbycusis, diminished sensitivity
Presbycusis, or hearing loss due to aging, is the third most
degeneration in auditory nerve to high-pitched sounds, impaired
common health issue in older adults, after arthritis and heart
and central pathways, reduced speech reception, tinnitus
disease.1 Calcification of the ossicles diminishes sound trans- blood supply to cochlea, calcifica-
mission. Tinnitus, or ringing in the ears, may accompany the tion of ossicles
hearing loss that results from the aging process. Cerumen glands Less effective vestibular apparatus Alterations in balance and body
atrophy, causing cerumen (earwax) to be much drier. The hair in semicircular canals orientation
in the ear becomes thicker and coarser, trapping the hard, dry
earwax in the canal. Accumulation of dry earwax in the external Brain
Decline in ability to filter out Difficulty hearing in a noisy environ-
canal can interfere with the transmission of sound. Atrophy of
unwanted and unnecessary ment, heightened sensitivity to
vestibular structures in the inner ear causes a decline in balance,
sound loud sounds
slowing of motor responses, and musculoskeletal limitations.
Assessment and Management:
Auditory Problems
Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability Sensory Perception
Infection Stress and Coping
LEARNING OUTCOMES
1. Describe the structures and functions of the auditory 7. Explain the pathophysiology, clinical manifestations, and
system. nursing and interprofessional management of common
2. Obtain significant subjective and objective assessment ear problems.
data related to the auditory system from a patient. 8. Compare the common causes, management, and
3. Perform a physical assessment of the auditory system rehabilitative potential of conductive and sensorineural
using the appropriate techniques. hearing loss.
4. Distinguish normal from common abnormal findings of a 9. Explain the use, care, and patient teaching related to
physical assessment of the auditory system. assistive hearing devices.
5. Link the age-related changes in the auditory system to 10. Describe measures used to assist the patient in adapting to
differences in assessment findings. decreased hearing.
6. Describe the purpose, significance of results, and nursing
responsibilities related to diagnostic studies of the
auditory system.
KEY TERMS
acoustic neuroma otosclerosis
benign paroxysmal positional vertigo (BPPV) presbycusis
external otitis tinnitus
Ménière disease vertigo
nystagmus
AUDITORY SYSTEM STRUCTURES AND FUNCTIONS OF AUDITORY
Hearing is a complex process that allows us to interact with
SYSTEM
the environment. It is the basis for social interaction and com- The auditory system is composed of the peripheral auditory
munication. Having a hearing impairment can lead to major system and central auditory system. The peripheral auditory
challenges that can adversely affect well-being. Difficulties with system includes the structures of the ear itself: external, mid-
related concepts, including functional ability and cognition, dle, and inner ear (Fig. 23.1). This system is involved with the
may be present with hearing loss. Problems with equilibrium reception and perception of sound. The inner ear functions in
can impair coordination, balance, and orientation. This chapter hearing and balance.
presents an overview of auditory function and discusses care The central auditory system integrates and assigns meaning
when problems occur. to what you hear. This system includes the vestibulocochlear
436
, CHAPTER 23 Assessment and Management: Auditory Problems 437
External ear (not to scale) Middle ear Inner ear
Auricle External acoustic Temporal Tympanic
(pinna) meatus bone membrane
Semicircular canals
Oval window
Facial nerve
Vestibular nerve Vestibulocochlear
Cochlear nerve nerve (CN VIII)
Cochlea
Vestibule
Malleus Incus Stapes Round window
Auditory tube
Auditory
ossicles
Fig. 23.1 External, middle, and inner ear. (Modified from Patton KT, Thibodeau GA: Anatomy and physiology,
ed 8, St Louis, 2013, Mosby.)
nerve (cranial nerve [CN] VIII) and auditory cortex of the Middle Ear
brain. The brain and its pathways transmit and process sound The middle ear cavity is an air space in the temporal bone.
and sensations that maintain your equilibrium. Mucous membrane lines the middle ear and is continuous
The role of the external and middle part of the ear is to con- from the nasal pharynx via the eustachian (auditory) tube. The
duct and amplify sound waves from the environment. This part eustachian tube equalizes atmospheric air pressure between the
of sound conduction is termed air conduction. Problems in these middle ear and throat. This allows the TM to move freely. It is
parts of the ear may cause conductive hearing loss, resulting in a normally closed, opening only with yawning, swallowing, and
decrease in sound intensity and/or a distortion in sound. chewing. Blockage of the tube can occur with allergies, naso-
Damage to or a problem of the inner ear or along the nerve pharyngeal infections, or enlarged adenoids. A tube that stays
pathways results in sensorineural hearing loss. Besides causing open is patulous. When this occurs, autophony, or hearing your
distortion or faintness of sound, sensorineural hearing loss may own voice, may be present.
affect the ability to understand speech or cause complete hear- The middle ear contains the ossicles, the 3 smallest bones in
ing loss. Impairment within the auditory pathways of the brain the body: malleus, incus, and stapes. Vibrations of the TM cause
causes central hearing loss. Central hearing loss causes difficulty the ossicles to move and transmit sound waves to the oval win-
in understanding the meaning of words the person heard. Types dow. The superior part of the middle ear is the epitympanum, or
of hearing loss are discussed later in this chapter. the attic. It also communicates with air cells within the mastoid
bone. The mastoid is the posterior part of the temporal bone.
External Ear The facial nerve (CN VII) traverses above the oval window of
The external ear consists of the auricle (pinna), external auditory the middle ear. The thin, bony covering of the facial nerve can
canal, and tympanic membrane (TM), or eardrum. The auricle is become damaged by chronic ear infection, skull fracture, or
composed of cartilage and connective tissue covered with epi- trauma during ear surgery. Problems may occur with volun-
thelium, which also lines the external auditory canal (Fig. 23.1). tary facial movements, eyelid closure, and taste discrimination.
The external auditory canal is a slightly S-shaped tube about Permanent damage to the facial nerve can result.
1 inch (2.5 cm) in length in the adult. The lining of the first
one-third of the canal contains fine hairs (cilia), sebaceous (oil) Inner Ear
glands, and ceruminous (wax) glands. The oil and wax lubricate The inner ear consists of 3 spaces in the temporal bone, assem-
the ear canal, keep it free from debris, and kill bacteria. Thin bled in a system called the bony labyrinth. The space is filled
epithelium lines the distal two-thirds of the canal. It is over bone with watery fluid called perilymph. Within the perilymph is the
and very sensitive. membranous labyrinth. It follows the shape of the bony laby-
The function of the external ear and canal is to collect and rinth and holds a thicker fluid called endolymph.
transmit sound waves to the TM. The TM is a shiny, translucent, The inner ear holds the functional organs for hearing and
pearl-gray membrane. It is made up of epithelial cells, connective balance. The receptor organ for hearing is the organ of Corti.
tissue, and mucous membrane. It serves as a partition and trans- It lies on the basilar membrane in the cochlea. Its tiny hair cells
mits sounds between the external auditory canal and middle ear. transform fluid vibrations from sounds into electrical impulses.
, 438 SECTION 5 Problems Related to Altered Sensory Input
These are transmitted by the acoustic part of the vestibuloco- Age-related changes in the auditory system and differences
chlear nerve (CN VIII) to the temporal lobe of the brain to pro- in assessment findings are outlined in Table 23.1.
cess and interpret the sound.
Three semicircular canals and the vestibule make up the Case Study
organ of balance. The semicircular canals sit at right angles to Patient Introduction
each other. Structures in each canal and the vestibule generate
nerve impulses in response to our movements. The vestibule is R.S. is a 57-year-old woman who comes to the emergency
department with extreme dizziness. R.S. states that she is
beside the oval window between the semicircular canals and the
so dizzy she “can’t do anything but lie down.” She reports
cochlea. Nerves from receptors in the vestibule join those from
feeling like her right ear is “plugged” and is having ringing
the semicircular canals to form the vestibular nerve. It joins in that ear.
with the cochlear nerve to form the vestibulocochlear nerve, or
CN VIII. Discussion Questions
(© iStock.com/ 1. What are the possible causes of R.M.’s hearing and
Hearing Sound EyeMark.) balance problems?
Hearing depends on a series of complex steps that change sound 2. Is her condition stable or an emergency?
waves in the air into electrical signals. Sound waves travel by 3. What assessment questions will you ask?
You will learn more about R.S. and her condition as you read this chapter.
air (air conduction) and are picked up by the auricles and audi-
tory canal. Sound waves strike the TM, causing it to vibrate. Answers available at http://evolve.elsevier.com/Lewis/medsurg
The central part of the TM is connected to the malleus, which
then starts to vibrate. The malleus transmits the vibration to the
incus and then the stapes. As the stapes moves back and forth, it
ASSESSMENT OF AUDITORY SYSTEM
pushes the membrane of the oval window in and out. Assessment of the auditory system should include assessment
Movement of the oval window makes waves in the peri- of hearing and equilibrium because the auditory and vestibular
lymph. These vibrations are picked up by the tiny sensory (balance) systems are closely related. It is often hard to separate
hair cells of the cochlea, which initiate nerve impulses. These symptoms related to these 2 systems. Help the patient describe
impulses are carried by nerve fibers to the main branch of the symptoms and problems to determine the source of the prob-
acoustic portion of CN VIII and then to the brain. The bones lems. Health history questions to ask a patient with an auditory
of the skull can also transmit sound directly to the inner ear problem are listed in Table 23.2.
(bone conduction).
We measure sound waves in 2 ways, intensity or strength
and frequency or pitch. We measure the intensity in terms of
decibels (dB). The lowest hearing decibel level is 0 dB, which TABLE 23.1 GERONTOLOGIC
is nearly total silence and the softest sound that we can hear. ASSESSMENT DIFFERENCES
Normal speech is around 40 to 65 dB; a soft whisper is 20 dB. Auditory System
Sounds above 90 dB can lead to hearing damage if people are
exposed to them every day or all the time. Hearing becomes Differences in Assessment
uncomfortable if the sound pressure level is above 110 dB. Changes Findings
Frequency is the measurement of the number of sound External Ear
vibrations in 1 second. We measure it in hertz (Hz). The higher Increased hair growth Visible hair, especially in men
the frequency is, the higher the pitch. Normally, a child and a Loss of elasticity in cartilage Collapsed ear canal
young adult can hear frequencies from about 16 to 20,000 Hz, Thicker, drier earwax Impacted earwax, potential hearing
loss
but hearing is most sensitive between 500 and 4000 Hz. This is
similar to normal speech frequencies. Middle Ear
Atrophy of TM Conductive hearing loss
Gerontologic Considerations: Effects of Aging on
Auditory System Inner Ear
Hair cell degeneration, neuron Presbycusis, diminished sensitivity
Presbycusis, or hearing loss due to aging, is the third most
degeneration in auditory nerve to high-pitched sounds, impaired
common health issue in older adults, after arthritis and heart
and central pathways, reduced speech reception, tinnitus
disease.1 Calcification of the ossicles diminishes sound trans- blood supply to cochlea, calcifica-
mission. Tinnitus, or ringing in the ears, may accompany the tion of ossicles
hearing loss that results from the aging process. Cerumen glands Less effective vestibular apparatus Alterations in balance and body
atrophy, causing cerumen (earwax) to be much drier. The hair in semicircular canals orientation
in the ear becomes thicker and coarser, trapping the hard, dry
earwax in the canal. Accumulation of dry earwax in the external Brain
Decline in ability to filter out Difficulty hearing in a noisy environ-
canal can interfere with the transmission of sound. Atrophy of
unwanted and unnecessary ment, heightened sensitivity to
vestibular structures in the inner ear causes a decline in balance,
sound loud sounds
slowing of motor responses, and musculoskeletal limitations.
