Hearing loss
Affecting nearly 16 million Americans, hearing loss may be temporary or permanent and partial or complete. This common symptom may involve reception of low-, middle-, or high-frequency tones. If the hearing loss doesn't affect speech frequencies, the patient may be unaware of it.
Normally, sound waves enter the external auditory canal, and then travel to the middle ear's tympanic membrane and ossicles (incus, malleus, and stapes) and into the inner ear's cochlea. The cochlear division of cranial nerve (CN) VIII (auditory nerve) carries the sound impulse to the brain. This type of sound transmission, called air conduction, is normally better than bone conduction—sound transmission through bone to the inner ear.
Hearing loss can be classified as conductive, sensorineural, mixed, or functional. Conductive hearing loss results from external- or middle-ear disorders that block sound transmission. This type of hearing loss usually responds to medical or surgical intervention (or in some cases, both). Sensorineural hearing loss results from disorders of the inner ear or of CN VIII. Mixed hearing loss combines aspects of conductive and sensorineural hearing loss. Functional hearing loss results from psychological factors rather than identifiable organic damage.
Hearing loss may also result from trauma, infection, allergy, tumors, certain systemic and hereditary disorders, and the effects of ototoxic drugs and treatments. In most cases, however, it results from presbycusis, a type of sensorineural hearing loss that usually affects people older than age 50. Other physiologic causes of hearing loss include cerumen (earwax) impaction; barotitis media (unequal pressure on the eardrum) associated with descent in an airplane or elevator, diving, or close proximity to an explosion; and chronic exposure to noise over 90 decibels, which can occur on the job, with certain hobbies, or from listening to live or recorded music.
History and physical examination
If the patient reports hearing loss, ask him to describe it. Is it unilateral or bilateral? Continuous or intermittent? Ask about a family history of hearing loss. Then obtain the patient's medical history, noting chronic ear infections, ear surgery, and ear or head trauma. Has the patient recently had an upper respiratory tract infection? After taking a drug history, have the patient describe his occupation and work environment.
Next, explore associated signs and symptoms. Does the patient have ear pain? If so, is it unilateral or bilateral, or continuous or intermittent? Ask the patient if he has noticed discharge from one or both ears. If so, have him describe its color and consistency, and note when it began. Does he hear ringing, buzzing, hissing, or other noises in one or both ears? If so, are the noises constant or intermittent? Does he experience dizziness? If so, when did he first notice it?
Begin the physical examination by inspecting the external ear for inflammation, boils, foreign bodies, and discharge. Then apply pressure to the tragus and mastoid to elicit tenderness. If you detect tenderness or external ear abnormalities, notify the physician to discuss whether an otoscopic examination should be done. (See Using an otoscope correctly, page 223.) During the otoscopic examination, note color change, perforation, bulging, or retraction of the tympanic membrane, which normally looks like a shiny, pearl gray cone.
Next, evaluate the patient's hearing acuity, using the ticking watch and whispered voice tests. Then perform Weber's and the Rinne tests to obtain a preliminary evaluation of the type and degree of hearing loss. (See Differentiating conductive from sensorineural hearing loss, page 304.)
Medical causes
Acoustic neuroma.Acoustic neuroma, which is a CN VIII tumor, causes unilateral, progressive, sensorineural hearing loss. The patient may also develop tinnitus, vertigo, and—with cranial nerve compression—facial paralysis.
Adenoid hypertrophy.Eustachian tube dysfunction causes gradual conductive hearing loss accompanied by intermittent ear discharge. The patient also tends to breathe through his mouth and may complain of a sensation of ear fullness.
Aural polyps.If a polyp occludes the external auditory canal, partial hearing loss may occur. The polyp typically bleeds easily and is covered by a purulent discharge.
Cholesteatoma.Gradual hearing loss is characteristic of cholesteatoma. It can be accompanied by vertigo and, at times, facial paralysis. Examination reveals eardrum perforation, pearly white balls in the ear canal, and possible discharge.
Cyst.Ear canal obstruction by a sebaceous or dermoid cyst causes progressive conductive hearing loss. On inspection, the cyst looks like a soft mass.
External ear canal tumor (malignant).Progressive conductive hearing loss is characteristic of an external ear canal tumor and is accompanied by deep, boring ear pain, purulent discharge and, eventually, facial paralysis. The patient may develop a rash in the external canal or pinna of the ear. Examination may detect the granular, bleeding tumor.
Glomus jugulare tumor.Initially, this benign tumor causes mild, unilateral conductive hearing loss that becomes progressively more severe. The patient may report tinnitus that sounds like his heartbeat. Associated signs and symptoms include gradual congestion in the affected ear, throbbing or pulsating discomfort, bloody otorrhea, facial nerve paralysis, and vertigo. Although the tympanic membrane is normal, a reddened mass appears behind it.
Head trauma.Sudden conductive or sensorineural hearing loss may result from ossicle disruption, ear canal fracture, tympanic membrane perforation, or cochlear fracture associated with head trauma. Typically, the patient reports a headache and exhibits bleeding from his ear. Neurologic features vary and may include impaired vision and an altered level of consciousness.
Ménière's disease.Initially, Ménière's disease, an inner ear disorder, produces intermittent, unilateral sensorineural hearing loss that involves only low tones. Later, hearing loss becomes constant and affects other tones. Associated signs and symptoms include intermittent severe vertigo, nausea and vomiting, a feeling of fullness in the ear, a roaring or hollow-seashell tinnitus, diaphoresis, and nystagmus.
Nasopharyngeal cancer.Nasopharyngeal cancer causes mild unilateral conductive hearing loss when it compresses the eustachian tube. Bone conduction is normal, and inspection reveals a retracted tympanic membrane backed by fluid. When this tumor obstructs the nasal airway, the patient may exhibit nasal speech and a bloody nasal and postnasal discharge. Cranial nerve involvement produces other findings, such as diplopia and rectus muscle paralysis.
Otitis externa.Conductive hearing loss resulting from debris in the ear canal characterizes acute and malignant otitis externa. With acute otitis externa, ear canal inflammation produces pain, itching, and a foul-smelling, sticky yellow discharge. Severe tenderness is typically elicited by chewing, opening the mouth, and pressing on the tragus or mastoid. The patient may also develop a low-grade fever, regional lymphadenopathy, a headache on the affected side, and mild to moderate pain around the ear that may later intensify. Examination may reveal greenish white debris or edema in the canal.
With malignant otitis externa, debris is also visible in the canal. This life-threatening disorder, which most commonly occurs in the patient with diabetes, causes sensorineural hearing loss, pruritus, tinnitus, and severe ear pain.
Otitis media.Otitis media is a middle ear inflammation that typically produces unilateral conductive hearing loss. In patients with acute suppurative otitis media, the hearing loss develops gradually over a few hours and is usually accompanied by an upper respiratory tract infection with a sore throat, cough, nasal discharge, and headache. Related signs and symptoms include dizziness, a sensation of fullness in the ear, intermittent or constant ear pain, a fever, nausea, and vomiting. Rupture of the bulging, swollen tympanic membrane relieves the pain and produces a brief, bloody, purulent discharge. Hearing returns after the infection subsides.
Hearing loss also develops gradually in patients with chronic otitis media. Assessment may reveal a perforated tympanic membrane, purulent ear drainage, an earache, nausea, and vertigo.
Commonly associated with an upper respiratory tract infection or nasopharyngeal cancer, serous otitis media commonly produces a stuffy feeling in the ear and pain that worsens at night. Examination reveals a retracted—and perhaps discolored—tympanic membrane and possibly air bubbles behind the membrane.
Otosclerosis.Otosclerosis is a hereditary disorder in which unilateral conductive hearing loss usually begins when the patient is in his early twenties and may gradually progress to bilateral mixed loss. The patient may report tinnitus and an ability to hear better in a noisy environment. The deafness is usually noticed between ages 11 and 30.
Skull fracture.With a skull fracture, auditory nerve injury causes sudden unilateral sensorineural hearing loss. Accompanying signs and symptoms include ringing tinnitus, blood behind the tympanic membrane, scalp wounds, and other findings.
Temporal bone fracture.Temporal bone fracture can cause sudden unilateral sensorineural hearing loss accompanied by hissing tinnitus. The tympanic membrane may be perforated, depending on the fracture's location. Loss of consciousness, Battle's sign, and facial paralysis may also occur.
Tympanic membrane perforation.Commonly caused by trauma from sharp objects or rapid pressure changes, perforation of the tympanic membrane causes abrupt hearing loss along with ear pain, tinnitus, vertigo, and a sensation of fullness in the ear.
Other causes
Drugs.Ototoxic drugs typically produce ringing or buzzing tinnitus and a feeling of fullness in the ear. Chloroquine, cisplatin, vancomycin, and aminoglycosides (especially neomycin, kanamycin, and amikacin) may cause irreversible hearing loss. Loop diuretics, such as furosemide, ethacrynic acid, and bumetanide, usually produce a brief, reversible hearing loss. Quinine, quinidine, and high doses of erythromycin or salicylates (such as aspirin) may also cause reversible hearing loss.
Radiation therapy.Irradiation of the middle ear, thyroid, face, skull, or nasopharynx may cause eustachian tube dysfunction, resulting in hearing loss.
Surgery.Myringotomy, myringoplasty, simple or radical mastoidectomy, or fenestrations may cause scarring that interferes with hearing.
Nursing considerations
▪ When talking with the patient, remember to face him and speak slowly.
▪ Don't shout, smoke, eat, or chew gum when talking.
▪ Prepare the patient for audiometry and auditory evoked-response testing.
▪ Provide an alternate means of communication, if necessary.
Patient teaching
▪ Explain interventions to the patient, such as a hearing aid or cochlear implant to improve his hearing.
▪ Discuss the importance of ear protection and avoidance of loud noise.
▪ Stress the importance of following instructions for taking prescribed antibiotics.
▪ Explain the underlying cause of the hearing loss and its treatment.
Pictures
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Ear symptoms
Read excerpts from these other book chapters related to Ear symptoms:
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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- EARACHE
- "Differential Diagnosis in Primary Care" (2007)
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Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Ear symptoms
» Next page: Otorrhea (Nursing: Interpreting Signs and Symptoms)
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