22.3 Ears

External Ear

The external ear is composed of the pinna (auricle) and the external auditory canal. The pinna (also, auricle) is the visible external part of the ear that is made up of cartilage and skin. It helps to collect sound waves from the environment and funnel them into the ear canal. The external auditory canal is a tubelike structure that connects the pinna to the eardrum. The canal is approximately an inch in length and is very sensitive to pain and pressure. The external auditory canal amplifies and directs sound waves toward the middle ear.

Middle Ear

The middle ear is a small, air-filled chamber located between the outer ear and the inner ear. It plays a crucial role in transmitting and amplifying sound vibrations from the eardrum to the inner ear. The middle ear is composed of the eardrum (tympanic membrane), ossicles, and eustachian tube. The tympanic membrane (also, eardrum) is a thin, cone-shaped membrane that separates the outer ear from the middle ear. It vibrates when struck by sound waves, transmitting these vibrations to the middle ear’s bones. The ossicles are the three tiny bones in the middle ear: the malleus (hammer), incus (anvil), and stapes (stirrup). The malleus (also, hammer) is attached to the inner surface of the eardrum and transmits vibrations from the eardrum to the incus. The incus (also, anvil), located between the malleus and the stapes, transmits vibrations from the malleus to the stapes. The stapes (also, stirrup), which is the smallest bone in the human body, transmits vibrations from the incus to the oval window of the cochlea. These bones amplify and transmit the vibrations from the eardrum to the fluid-filled inner ear. The eustachian tube connects the middle ear to the back of the nose. Its primary function is to equalize air pressure between the middle ear and the atmosphere, which is essential for maintaining proper hearing and preventing discomfort.

Inner Ear

The inner ear, composed of the cochlea and the vestibular system, is responsible for hearing and balance. The cochlea is a snail-shaped, fluid-filled structure responsible for converting sound vibrations into electrical signals that the brain can interpret as sound. It contains thousands of hair cells, which are specialized sensory cells that bend in response to fluid movement, initiating the hearing process. The vestibular system includes the semicircular canals and the vestibule, which are responsible for maintaining balance and spatial orientation. The semicircular canals detect rotational movements of the head, while the vestibule senses changes in linear acceleration and gravity.

Hearing

Hearing is a complex process that involves the conversion of sound waves in the environment into meaningful auditory perceptions in the brain. Sound waves are generated by vibrating objects, such as vocal cords, musical instruments, or any other source that creates vibrations in the air. These sound waves are essentially fluctuations in air pressure that propagate as waves of compressions and rarefactions through the air.

The sound waves are collected by the outer ear via the pinna. The pinna’s shape and orientation help to capture sound waves from various directions. The collected sound waves travel through the external auditory canal and strike the eardrum. The eardrum vibrates in response to the incoming sound waves. The vibration’s intensity and frequency are determined by the characteristics of the sound waves. The vibration of the eardrum is then transmitted to the three tiny bones in the middle ear: the ossicles (malleus, incus, and stapes). The ossicles amplify the vibrations, ensuring that the weak vibrations from the eardrum are transformed into stronger vibrations to the inner ear and cochlea. Once the sound waves reach the inner ear, they are converted into electrical impulses. The electrical signals generated by the activated hair cells are then transmitted to the auditory nerve fibers, which carry these electrical signals to the brain for further processing. The brain then translates these electrical impulses as sound.

Subjective Data

During an ear assessment, gathering subjective data through patient interviews is crucial to understanding one’s ear health history, concerns, and any symptoms they may be experiencing. Some key areas to explore when collecting subjective data related to ear assessment include the following:

1. Chief complaint and history of present illness:
   • Ask the patient to describe their primary concern or reason for seeking ear assessment.
   • Inquire about the onset, duration, and progression of any ear-related symptoms, such as pain, discomfort, hearing loss, tinnitus (ringing, buzzing, or hissing sounds in the ears), vertigo (sensation of spinning or dizziness), or balance problems.
2. Hearing changes:
   • Explore any recent changes in hearing, including difficulty hearing conversations, needing increased volume on devices, or missing certain sounds. Explain that any decrease in hearing is considered hearing loss.
   • Ask about exposure to loud noises, ear infections, or a family history of hearing loss.
3. Ear infections and discharge:
   • Inquire about any history of ear infections, including frequency and treatment.
   • Ask if there is any history of ear discharge, its color, consistency, and associated symptoms.
4. Pain and discomfort:
   • Assess the location, intensity, quality, and duration of any ear pain or discomfort.
   • Ask about factors that worsen or alleviate the pain, such as movement, pressure changes, or specific activities.
5. History of ear surgery or procedures:
   • Inquire about any previous surgeries or procedures related to the ears, such as ear tube insertion or ear surgery for hearing correction.
6. Medications:
   • Ask about any medications the patient is currently taking, including over-the-counter drugs, prescription medications, or herbal supplements.

   Link to Learning

   Some medications can damage the ear, causing hearing loss, ringing in the ears, or balance problems. Medications that result in this side effect are known as ototoxic medications. There are over 200 known ototoxic medications on the market today. A list of ototoxic medications to be aware of as you conduct ear assessments is provided at this website.

7. Medical history:
   • Explore the patient’s medical history, including chronic conditions (e.g., diabetes, hypertension) that may impact ear health.
   • Inquire about autoimmune disorders, as some can affect hearing and ear health.
8. Personal habits:
   • Inquire about habits such as cleaning the ears with objects like cotton swabs or inserting foreign objects into the ears, which can cause harm.
9. Impact on daily life:
   • Discuss how ear-related symptoms impact the patient’s daily activities, communication, work, and overall quality of life.

Objective Data

When conducting an objective assessment of the ears, nurses gather physical information through inspection, palpation, and specialized tests. Key components of objective data collection during an ear assessment include the following:

1. Inspection of external ear:
   • Observe the external ear for any abnormalities, asymmetry, lesions, deformities, or signs of inflammation.
   • Note the condition of the skin, presence of scars, redness, swelling, or discharge around the ear.
2. Palpation of external ear:
   • Gently palpate the external ear for tenderness, warmth, or pain.
   • Palpate the mastoid process (bony prominence behind the ear) for tenderness or swelling.
3. Assessment of ear canal:
   • Using an otoscope (a medical instrument consisting of a light source and a magnifying lens to examine the external ear canal and the eardrum), visualize the ear canal for signs of obstruction, inflammation, discharge, or foreign bodies.
   • Note the color and condition of the ear canal skin.

   Life-Stage Context

   Variations in Assessing the Ear Canal

   Using an otoscope to examine the ears of adults and young children requires some differences in approach due to variations in anatomy, patient cooperation, and comfort. Here are some key differences:

   • Patient cooperation:
     • Adults: Adults can typically follow instructions, remain still, and cooperate during the examination, making it easier to use an otoscope.
     • Young children: Young children, especially infants and toddlers, may not understand or follow instructions, and they are more likely to move or cry during the examination. It may require the assistance of a parent or caregiver to hold the child still and keep them calm.
   • Positioning:
     • Adults: Adults can often sit upright, making it easier to examine their ears with a standard otoscope. They can tilt their head to facilitate access to the ear canal.
     • Young children: Children may need to be held in a specific position by a caregiver. For infants, this often involves holding them securely and gently tilting their head for ear examination. Toddlers may sit on a caregiver’s lap or lie down, depending on their age and comfort.
   • Size of ear canal:
     • Adults: Adult ear canals are typically larger and straighter, allowing for easier insertion of the otoscope.
     • Young children: The ear canal of a child is smaller, shorter, and may have a more acute angle. Care must be taken to avoid causing discomfort or injury during otoscopic examination.
   • Type of otoscope and speculum:
     • Adults: A standard otoscope with a larger speculum may be used for adults to visualize the ear canal effectively.
     • Young children: A smaller-sized otoscope with a pediatric speculum is often used for young children to accommodate their smaller ear canals.
4. Tympanic membrane examination:
   • Use an otoscope to examine the eardrum (tympanic membrane) for color, position, integrity, and landmarks.
   • Note the presence of perforations, fluid, bulging, or retraction of the tympanic membrane.
5. Weber and Rinne tests:
   • Use a tuning fork (a handheld, two-pronged metal instrument that emits a specific musical tone when struck) to perform the Weber and Rinne tests to assess hearing and identify potential conductive or sensorineural hearing loss (Figure 22.25).
   • The Weber test is used to determine whether hearing loss is present in one ear or if it is roughly equal in both ears. Strike the tuning fork to create vibrations. Place the base of the vibrating tuning fork on the patient’s forehead or midline of the skull, equidistant from both ears. Ask the patient if they hear the sound louder in one ear, both ears equally, or if they cannot tell. If the patient hears the sound equally in both ears, this suggests symmetrical hearing or normal hearing. If the patient hears the sound louder in one ear, this suggests hearing loss.
   • The Rinne test compares air conduction (AC) and bone conduction (BC) to assess whether hearing loss is due to conductive or sensorineural factors. Strike the tuning fork and place it gently on the patient’s mastoid bone behind one ear until the sound is no longer heard. Without delay, move the still-vibrating tuning fork next to the external auditory canal (AC) and ask the patient if they hear the sound again. Compare the time the patient hears the sound during BC (mastoid) and AC (auditory canal). If the patient hears the sound longer through AC than through BC (positive Rinne), this suggests normal or sensorineural hearing in that ear. If the patient hears the sound equally or longer through BC than through AC (negative Rinne), this suggests conductive hearing loss in that ear.

   Figure 22.25 Weber and Rinne tests assess hearing using a tuning fork. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
6. Assessment of balance and equilibrium:
   • Observe the patient’s posture, gait, and balance while standing, walking, or performing specific maneuvers (e.g., Romberg test) to assess equilibrium.
   • To perform the Romberg test (clinical assessment used to assess balance), instruct the patient remove their shoes and stand with their feet together, heels touching, and arms by their sides. Instruct the patient to stand still with their eyes open and maintain their balance for about twenty to thirty seconds. Observe the patient’s ability to maintain a steady posture during this time. After the eyes-open position, instruct the patient to close their eyes while maintaining the same stance. Observe the patient’s ability to maintain balance with their eyes closed for the same duration (20 to 30 seconds). If the patient can maintain balance in both positions without swaying significantly, the Romberg test is considered normal. If the patient sways, loses balance, or needs to step or move to prevent falling while their eyes are closed (but maintained balance with eyes open), the test is considered positive, which may indicate an inner ear problem, peripheral neuropathy, or other neurological conditions affecting balance. If the patient sways or loses balance regardless of whether their eyes are open or closed, the test result is negative, which might suggest more severe balance issues or issues unrelated to proprioception or the vestibular system.
7. Assessment of facial nerve function:
   • Observe for any facial asymmetry, weakness, or twitching that could indicate involvement of the facial nerve (cranial nerve VII).

Validating and Documenting Findings

Validating ear assessment findings involves ensuring the accuracy and reliability of the information gathered during the assessment process. This validation step is crucial for maintaining high-quality patient care, accurate medical records, and effective communication among healthcare professionals. If necessary, repeat certain aspects of the assessment to confirm the consistency of findings. This is especially important when dealing with subjective symptoms like hearing loss or vertigo. Ensure you use proper and calibrated equipment, such as an otoscope with a functioning light source, to accurately examine the external ear, ear canal, and tympanic membrane. If the patient has a history of ear assessments, compare your current findings to previous records to identify any changes or trends. This can be helpful in tracking the progression of conditions. If you have any doubts about your findings, consider seeking a second opinion from a colleague. Review your findings with the patient to ensure that their self-reported symptoms match your assessment, as patients may sometimes have additional information that can clarify certain findings. Relate your findings to the patient’s medical history, symptoms, and overall clinical presentation to ensure your findings are consistent and make sense in the context of the patient’s condition.

Documenting an ear assessment is an important aspect of healthcare practice as it ensures accurate communication of findings and helps with patient care continuity. Begin by noting the reason the patient is undergoing an ear assessment, such as complaints of pain, hearing loss, tinnitus, or other symptoms. Document relevant medical history, including any preexisting conditions, past ear infections, surgeries, or allergies. Detail the specific symptoms the patient is experiencing, such as ear pain, drainage, ringing in the ears, vertigo, or any discomfort. Describe the external ear’s appearance, noting any abnormalities, lesions, redness, swelling, or deformities. Document findings from the ear canal examination, including the presence of cerumen (earwax), signs of inflammation, foreign bodies, or discharge. Provide a thorough description of the tympanic membrane’s appearance, noting its color, position, integrity, landmarks (malleus, cone of light), and any abnormalities like perforations, scarring, or bulging. If applicable, include the results of any hearing tests performed during the assessment. Describe any observations related to balance or coordination, especially if the patient reported symptoms of dizziness or vertigo. Add any additional details that might be relevant, such as the patient’s response to treatment or any changes observed during the assessment.

Abnormalities of the External Ear and Canal

Abnormalities of the external ear and ear canal can vary widely and may affect appearance, hearing, and overall ear health. Some examples of abnormalities that can impact the external ear and ear canal include the following:

• Microtia: In the congenital condition microtia, the external ear is underdeveloped or absent. It can range from mild deformities to a complete absence of the ear.
• Macrotia: The condition macrotia involves having abnormally large ears compared to typical proportions.
• Stahl ear: Also known as “Spock ear,” Stahl ear involves a pointed or elflike appearance of the upper part of the ear due to an extra fold (Figure 22.26).

  Figure 22.26 Compare (a) an ear without Stahl condition to an (b) ear with Stahl condition. Stahl ear is caused by misshapen cartilage and is characterized by an extra horizontal fold of cartilage. (credit: “Stahl Ear” by National Human Genome Research Institute, Public Domain)
• Cauliflower ear: Often seen in individuals who participate in contact sports, cauliflower ear occurs when repeated trauma to the ear leads to a buildup of blood or other fluids in the cartilage, causing it to become deformed and resemble a cauliflower (Figure 22.27).

  Figure 22.27 Cauliflower ear is a deformity to the auricle caused by blunt force trauma. (credit: “Cauliflower ear” by “MartialArtsNomad.com”/Wikimedia Commons, CC BY 2.0)
• Otitis externa: Also known as “swimmer’s ear,” otitis externa is an infection or inflammation of the external ear canal, usually caused by water exposure or bacterial/fungal infections (Figure 22.28). Otitis externa causes the ear canal to be erythematous and edematous with associated yellow, white, or gray debris. Patients often report itching in the ear canal with pain that is worsened by pulling upward and outward on the auricle. Otitis externa is treated with antibiotic drops placed in the ear canals.

  Figure 22.28 Swimmer’s ear is characterized by redness or swelling (inflammation), irritation, or infection to the outer ear canal. (credit: “Otitis externa” by Klaus D. Peter/Wikimedia Commons, CC BY 3.0)
• Earwax impaction: An earwax impaction is a buildup of earwax (cerumen) that can lead to discomfort and hearing loss and even contribute to ear infections. Cerumen can be removed via irrigation of the ear canal, eardrops to dissolve the wax, or manually.

  Real RN Stories

  Earwax Impaction

  Nurse: Jackson, RN
  Clinical setting: Pediatric primary care clinic
  Years in practice: 22
  Facility location: Birmingham, Alabama

  One time, we had an 8-year-old child come in with symptoms of a cold. Upon looking in the child’s ears, the provider noticed the ear was impacted with earwax. The child reported the ear had been hurting a bit (resembling pain associated with an ear infection). We performed irrigation in the office, and you could not believe the earwax that came out of the child’s ear. It looked like a tree trunk of earwax. In all of my twenty-two years in practice, I have never seen so much wax in a child’s ear, particularly that came out of the ear in one piece. After irrigating the ear, the child reported they could hear much better, and the provider was able to visualize the eardrum, noting the child’s eardrum was red, swollen, and infected. The child was prescribed antibiotics for the ear infection; however, there is no doubt the child could hear better after getting all of that wax out.

• Foreign body in the ear canal: Any foreign body in the ear canal that becomes lodged in the canal can cause pain, discomfort, and potential damage to the ear canal or tympanic membrane.
• Congenital ear tags and pits: Small pieces of extra tissue (a congenital ear tag) or small depressions (a congenital ear pit) near the external ear can be present at birth.

Abnormalities of the Tympanic Membrane

Abnormalities of the tympanic membrane can impact hearing and overall ear health. The following are some examples of abnormalities that can affect the tympanic membrane:

• Perforated eardrum: A perforated eardrum is a condition where there is a hole or tear in the tympanic membrane. It can result from infections, trauma, or sudden changes in pressure (such as from a loud noise). A perforated eardrum can cause hearing loss, ear pain, and susceptibility to infections.
• Tympanosclerosis: The condition called tympanosclerosis involves the formation of thickened or scarred areas on the eardrum due to repeated infections or inflammation. Tympanosclerosis can affect hearing if it covers a significant portion of the eardrum.
• Tympanic membrane retraction: In tympanic membrane retraction, the eardrum is pulled or retracted into the middle ear. This can occur due to negative pressure in the middle ear and can lead to chronic ear infections and hearing problems.
• Myringitis: An inflammation of the eardrum termed myringitis can cause pain, discomfort, and sometimes even small blisters on the surface of the eardrum.
• Otitis media (middle ear infection): Acute otitis media typically occurs after an upper respiratory infection when the eustachian tube becomes inflamed and the middle ear fills with fluid, causing ear pain and irritability. This fluid can become infected, causing purulent fluid and low-grade fever. Acute otitis media is diagnosed by a healthcare provider using an otoscope to examine the tympanic membrane for bulging and purulent fluid. Chronic or recurrent ear infections can lead to repeated inflammation of the tympanic membrane, potentially causing scarring or functional issues. Individuals with chronic ear infections may have “tubes” placed in the tympanic membrane to drain the fluid from the middle ear and prevent infection from developing.

Abnormalities of the Inner Ear

Abnormalities of the inner ear can lead to various hearing and balance disorders, as the inner ear plays a crucial role in both auditory and vestibular (balance) functions. The following are some examples of abnormalities that can affect the inner ear:

• Sensorineural hearing loss: One of the most common types of hearing loss, sensorineural hearing loss results from damage to the hair cells in the inner ear or the auditory nerve. It can be congenital or acquired due to factors such as aging, noise exposure, genetics, infections, or certain medications.
• Ménière disease: Ménière disease is a disorder of the inner ear characterized by episodes of vertigo (spinning sensation), fluctuating hearing loss, tinnitus (ringing in the ears), and a feeling of fullness or pressure in the ear.
• Labyrinthitis: An inflammation of the inner ear is termed labyrinthitis, often caused by viral infections. It can lead to sudden onset of vertigo, hearing loss, and imbalance.
• Inner ear trauma: Trauma to the head or ears can result in inner ear trauma, damage that leads to hearing loss, dizziness, and other symptoms.