4. eye and ear disorders for ENT dis .pptx

ENT For nursing students lecturing in class & practice in real world

1. CHAPTER TWO 2. EYE DISORDER 2.1. OVERVIEW OF EYE ANATOMY

2. Content outlines • Anatomy of the eye • Diagnostic procedures of the eye • Refractive errors of the eye • Diseases of the eye lid • Diseases of the conjunctivitis • Diseases of the cornea • Disorder of the lens • Diseases of the uveal tract • Injuries of the eye • Other conditions of the eye(glaucoma, diabetic retinopathy ,retinal ditachment ) • Muscular disorders of the eye • Vitamin A deficiency • Onchocerciasis

3. The Eye

4. Basic Anatomy of the Eye Ocular appendages - Eyebrows - Eyelids - conjunctiva - Lacrimal Apparatus The eye ball - cornea - Lens - sclera - vitreous - uveal tract - Retina - Nerve & blood supply of the eye

5. ORBITAL CAVITY The orbital cavities are a pair of large bony sockets that contain eyeball, EOMs, nerves, vessels & orbital fat, and most of the lacrimal apparatus. Each cavity is pear-shaped and its apex is directed posteriorly, medially, and slightly upward; the stalk of pear lying within optic canal. The medial wall runs anteroposteriorly parallel to sagittal plane. The lateral wall diverges at angle of 45. 5

6. Seven bones make up the bony orbit: - Frontal -Sphenoid - Zygomatic - Lacrimal -maxillary - Palatine - Ethmoidal Orbital roof - made up of 2 bones: 1. orbital plate of frontal bone 2. lesser wing of sphenoid Medial wall -----  very thin wall 1.Frontal process of maxilla 2.Lacrimal bone 3.orbital plate of ethmoid 4.Lesser wing of sphenoid

7. Orbital floor 1.maxillary 2.palatine 3.orbital plate of zygomatic Lateral wall 1. zygomatic bone 2. greater wing of sphenoid

8. THE EYE BALL The normal adult AP diameter of the globe is b/n 21 & 26mm (average=24mm ) Consists of 3 layers of tissues: 1. Outer ( protective) layer : cornea, sclera 2. Middle vascular layer : iris, ciliary body, choroid 3. I nner (light sensitive) layer: Retina 8

9. The eyeball is the organ of sight. It is almost spherical in shape & has a diameter of about 2.5cm. The eyeball consists of three coats:- The fibrous coat Sclera & cornea The vascular pigmented coat ( uveal tract) The choroid, the cilliary body & the iris. The nervous coat The retina

10. Movements of the Eyeball All movements of the eye are then related to the direction of the movement of the anterior pole as it rotates on any one of the three axes ( horizontal, vertical, and sagittal). The terminology then becomes as follows: Elevation The rotation of the eye upward Depression The rotation of the eye downward Abduction The rotation of the eye laterally Adduction The rotation of the eye medially. Rotatory movements of the eyeball use the upper rim of the cornea (or pupil) as the marker. The eye rotates either medially or laterally.

11. The fibrous coat is made up of a posterior opaque part called the sclera, and an anterior transparent part called the cornea . The Sclera The sclera is opaque & forms the posterior five-sixth of the eyeball. It is composed of dense fibrous tissue and is white in colour . The sclera is thickest near the entrance of optic nerve but is thinnest about 6mm behind the sclerocorneal junction where the recti muscles are inserted. The sclera is directly continuous anteriorly with the cornea at the corneoscleral junction or limbus . The deep part of the limbus contains a circular canal known as the sinus venosus sclerae or the canal of schlemn Fibrous Coat Or Outer Coat

12. The Cornea The cornea is transparent & is largely responsible for the refraction of the light entering the eye. It replaces the sclera over the anterior 1/6 th of the eye ball. Posteriorly, the cornea is in contact with the aqueous humor. It is separated from the iris by a space called the anterior chamber. The cornea is avascular and devoid of lymphatic drainage. It is nourished by diffusion from the aqueous humor and from the capillaries at its edge. Nerve supply to the cornea is by the long ciliary nerves from the ophthalmic division of the trigeminal nerve.

13. The Iris and Pupil The iris is a thin, contractile, pigmented diaphragm with a central aperture called the pupil. By adjusting the size of pupil it controls the amount of light entering the eye. It is suspended in the aqueous humor between the cornea and the lens. The periphery of the iris is attached to the anterior surface of the ciliary body. It divides the space between the lens and the cornea into an anterior and a posterior chamber.

14. The Lens The lens is a transparent, biconvex structure enclosed in a transparent capsule. It is situated behind the iris and in front of the vitreous body and is encircled by the ciliary processes. The lens consists of An elastic capsule – Which envelops the lens. A cuboidal epithelium – Which is confined to the anterior surface of the lens deep to the capsule. Lens fibers Which are formed from the cuboidal epithelium at the equator of the lens. The lens fibers make up the bulk of the lens.

15. External structures of the eye

16. Inner layer The retina: is the visual receptive layer of the eye. The retinal structures are the optic disc, the retinal vessels, and the macula. The optic disc: is the area in which fibers from the retina converge to form the optic nerve. Is creamy yellow-orange to pink in color and a round or oval shape. M argins that are distinct and sharply demarcated, and a physiologic cup , the smaller circular area inside the disc where the blood vessels exit and enter. 17

17. Inner layer…cont’d The retinal vessels: include a paired artery and vein extending to each quadrant, growing progressively smaller in caliber as they reach the periphery. The arteries appear brighter red and narrower than the veins, and they have a thin sliver of light on them. The macula: is located on the temporal side of the fundus. It is a slightly darker pigmented region surrounding the fovea centralis , that is the area of sharpest and keenest vision. 18

18. Eye Lids The eyelids (palpebrae) are two folds of modified skin which cover the anterior surface of the eye. By their reflex closure, achieved by contraction of orbicularis oculi , they protect the eye from injury and shield the eyes from excessive light. Periodic blinking maintains a thin film of tears over the cornea which prevents desiccation & also movement of the eyelid during blinking helps ensure the even distribution of the tear film. The upper eyelid is larger and more mobile than the lower eyelid, and contains an elevator muscle called the levator palpebrae superioris.

19. Structure of eyelid Each eyelid is made up of the following layers from without inwards:- Skin, Subcutaneous connective tissue, Fibres of the palpebral part of orbicularis oculi Submuscular connective tissue, The tarsal plate (tarsus) with its tarsal glands and orbital septum, Palpebral conjunctiva The framework of the eyelids is formed by a fibrous sheet called the orbital septum. This is attached to the periosteum at the orbital margins

20. The superficial surface of the eyelids is covered by skin, and the deep surface is covered by a mucous membrane called the conjunctiva. The eye lashes are the short, curved hairs on the free edges of the eyelids. They are arranged in double or triple rows at the mucocutaneous junction. The sebaceous glands called as the glands of Zeis open directly into the eyelash follicles. The ciliary glands or glands of Moll are modified sweat glands that open separately between adjacent lashes. The tarsal glands are long, modified sebaceous glands that pour their oily secretion onto the margin of the lid; their openings lie behind the eyelashes. This oily material prevents the over-flow of tears and helps make the closed eyelids airtight.

21. Cont’d The conjunctiva is a thin mucous membrane that lines the eyelids and is reflected at the superior and inferior fornices onto the anterior surface of the eyeball. Its epithelium is continuous with that of the cornea. The upper lateral part of the superior fornix is pierced by the ducts of the lacrimal gland

22. Lacrimal Apparatus The structures concerned with secretion & drainage of the lacrimal fluid or tear fluid is termed as the lacrimal apparatus. It is made up of:- The lacrimal gland and its ducts, The conjunctival sac, The lacrimal canaliculi , The lacrimal sac The nasolacrimal duct .

23. Diagnostic procedures of the eye 1/ HX 2/ P/E • Inspection • Visual acuity • Visual field ( perimetry testing) • Color vision • Palpation • Ophthalmoscope exam • Gonioscopy (visualizes the angle of the anterior chamber)

24. Perimetry testing Perimetry testing evaluates the field of vision A visual field is the area or extent of physical space visible to an eye in a given position Its average extent is 60 o superior, 75 o inferior, 60 o nasal, and 100 o temporal when the eye is in the primary gaze ( ie , looking directly forward ) Visual acuity is sharpest at the very top of the field and declines progressively toward the periphery It is most helpful in detecting central vision ( scotomas = blind areas in the visual field) in macular degeneration and the peripheral field defects in glaucoma and retinitis pigmentosa

25. Visual acuity Visual acuity is defined as the clarity or sharpness of vision , which is the ability of the eye to see and distinguish fine details The measurement of visual acuity records the acuteness of central vision for distance, and near or reading vision Visual acuity is an important factor for a variety of everyday tasks, including reading text, recognizing symbols, and performing assembly work It is tested at 6 meter as rays of light from this distance are nearly parallel

26. Factors which affect visual acuity Environmental factors  Lighting, crowding, position of chart  Color, brightness, and contrast Visual behaviors 1. Central, eccentric 2. Stable, wandering, nystagmus , unsteady 3. Head or body movement 4. Squinting or shutting one eye 5. Use of glasses (peeking over glasses, viewing through bifocal segment) Patient factors ( Fatigue, fear, nervousness, eye movements, motivation) Chart observation 1. Missing or skipping letters, & confusion of similar letters 2. Reading speed 3. Note any observation made by the patient (i.e. distortion, hallucination, blurred areas)

27. Visual acuity

28. Visual acuity …. Example : - If the 8th line is read at a distance of 6m this is VA 6/6. If same letters in the line are read but not all, it is expressed as, for example, OD: 6/6 OD (Right eye) , OS (Left eye) & OU(Both eyes) 20/20 does not necessarily mean perfect vision 20/20 vision only indicates the sharpness or clarity of vision at a distance Visual acuity refers to smallest letter size that patient gets half or more correct on line

29. Visual acuity ….

30. Ophthalmoscope Ophthalmoscope is a hand-held instrument that projects light through a prism & bends the light at 90 degrees, allowing the observer to view the retina The direct ophthalmoscope has several lenses arranged on a wheel. A lens may be chosen by rotating the wheel with the index finger with out interrupting the inspection

31. Tonometry • Tonometry measures IOP by determining the amount of force necessary to indent or flatten ( applanate ) a small anterior area of the globe of the eye Methods of measuring IOP • Digital • Golmann applanation tonometer • Schiotz ( perkins applanation ) tonometer • Pneumotonometer • Ton open Corneal reflecti

32. Corneal reflections Method - A pen torch is held at 1/3 m directly in front of both eyes - The position of the reflection on each eye is then compared Results • Normal corneal reflections – Symmetrical • Asymmetrical corneal reflections- Reflex loss in coma and lesions affecting CN V or CN VII

33. Ocular movements – The examiner sits in front of the patient & using a pen torch, observes both eyes moving in all eight positions of gaze. – This will include up, down, both sides & in all four corners, always returning to the straight a head or primary position. The patient’s head must be held still – Any muscle imbalance, over action & under actions are then noted 1/ Superior rectus 2/ Inferior rectus 3/ Lateral rectus 4/ Medial rectus 5/ Superior oblique 6/ Inferior oblique 7/ Levator palpebrae superior Color vision test • Indicative of conditions of the optic nerve (Ishihara polychromatic plates) Ex. Red/green/blue --- Blind • Acquired color vision losses may be caused by medications ( eg , digitalis toxicity) or pathology such as cataracts

34. Refractive errors Emmetropia (Normal refraction) Adequate correlation between axial length and refractive power Parallel light rays fall on the retina ( no accommodation Ametropia (Refractive error) include : Mismatch between axial length and refractive power Parallel light rays don’t fall on the retina ( no accommodation) – Nearsightedness (Myopia) – Farsightedness (Hyperopia or hypermetropia ) – Astigmatism (Asymmetric focus) – Presbyopia – Anisometropia

35. 1. Myopia or Short sight A short – sighted person has a long eyeball. The light rays therefore come to a focus in front of the retina Etiology Idiopatic , genetic link, long globe (axial myopia ), diabetes , & excessive refractive power S&Sxs Blurred distance vision, eye rubbing, Headache (not common) decreased distant vision – Squinting in an attempt to improve uncorrected visual acuity when gazing into the distance – Amblyopia – uncorrected myopia > 10 D

36. Myopia… Diagnosis Snellen’s visual acuity test & Ophthalmoscope Mild myopia = < - 5 Diopter Moderate myopia = - 5, - 8D Severe myopia = > - 8 D Treatment * Concave lens (Minus lens) = diverging lens * Bifocal glasses (for both distant & close objects) * Radical keratotomy(Laser) - shallow incision in the cornea causing it to flatten in desired area (could have significant complications) = Clear lens extraction

37. FIGURE (C) Myopia (nearsighted). A long eyeball causes the image to focus in front of the retina. 40 (D) Corrected myopia. Refractive Errors Cont’d…

38. Myopia …

39. 2. Hyperopia or Long sight The rays of light entering the eye are focused behind the retina – Impairment of near vision Etiology Genetic link, short globe, elderly, young children S & Sxs Blurred vision, Squinting, Eye rubbing, Headache, eye strain Diagnosis : Snellen chart visual acuity test & Ophthalmoscope Treatment * Convex lens (Plus lens) * Kerato refractive surgery * Lensectomy with IO implant Mild = + 2 - 3 Diopter Moderate = + 3 - 5 D Severe = > + 5 D

40. Figure (A) Hyperopia (farsighted). The eyeball is too short, causing the image to focus beyond the retina. 43 Figure (B) Corrected hyperopia . Refractive Errors Cont’d…

41. 3. Astigmatism is an error of refraction in which a ray of light is not sharply focused on the retina but is spread over a diffuse area. It results from unequal culvature of cornea. • Parallel rays come to focus in 2 focal lines rather than a single focal point Etiology : Genetic link, not completely round eye S&Sxs : Blurred vision to all distances , Squinting, Eye rubbing, head tilting and turning , headache , eye pain after reading Diagnosis : Snellen’s visual acuity test & ophthalmoscope RX : Radial keratotomy , Artificial lens transplant *Spherical lens with either concave or convex lenses Amblyopia – Uncorrected astigmatism -Either hyperopia or myopia may co-exist with astigmatism

42. 4. Presbyopia Presbyopia is   a  condition in which the lenses lose their elasticity because of aging, resulting in a decrease in ability to focus on close objects (rigidity of the lens ). • From the age of about 45 years, the lens in the eye no longer has the ability to accommodate for near vision (deposit of insoluble proteins in lens) • The light rays therefore fall behind the retina before coming to a focus. S/ Sx : Able to read at 40-50 cm, H/A, visual fatigue,difficult to read fine print

43. Presbyopia … Treatment - Lens transplant - Bifocal/trifocal glasses ( for reading) – Convex lens or ‘Plus’ lens 1. Hard contact lens 2. Soft contact lens - Progressive power glasses

44. 5.Anisometropia Means  vision in one eye is worse than the vision in the other due to a difference in refractive error. Refractive correction often leads to different image sizes on the retinas of both ( aniseikonia ) aniseikonia is the difference in the perceived size or shape of images between eyes Aniseikonia depend on degree of refractive anomaly and type of correction.

45. 5.Anisometropia… Symptoms : usually congenital and often asymptomatic Treatmen t – Anisometropia --> contact lens – Unilateral aphakia (absence of lens)--> contact lens or intraocular lens

46. Disease of the eye lid 1. Hordeolum (A Stye ) A Stye is an infection of sebaceous glands of Zeis or apocrine glands of Moll = Inflammatory infection of the hair follicle of the eye lid Cause: - Staphylococcus auerus &usually associated with blepharitis C/F: * Pain/swelling/redness/pus * patient feels something in the eye Mx : - Warm, moist compresses for 10 to 15 minutes,3- 4 times a day, hastens the healing process. - If the condition doesn't begin to resolve with in 48 hours, incision & drainage may be indicated. - Application of topical antibiotics - Analgesics

47. Hordeolaum ….

48. Disease of the eye lid… 2. Chalazion ( meibomian cyst, internal hordeolum ) Chalazion is a swelling of one of the meibomian glands(tarsal glands) due to blockage of its duct - It is chronic condition Cause : - Staphylococci are common causes if infected C/F : * Localized, painless swelling that develops over period of weeks * Pea size cyst * Painless slow swelling of the inner part of eye lid Mx : * Small ones usually disappear spontaneously after 1-2 month * Large ones usually need surgical removal ( Incision) - Warm compresses, massage & expression of the glandular secretions - Antibiotic(Doxycycline) therapy & corticosteroid drops * Chloramphenicol;3-4 x/d for 7-10 day, after the eye has been steamed Nursing care : - Apply steam to the eye - Instruct how to use drugs - Clean eye lids by using warm water

49. Chalazion …

50. Disease of the eye lid… 3. Blepharitis Is the inflammation of the eyelid margin It can be a cute or chronic inflammation of the eyelid margins -It is usually bilateral Causes * Ulcerative: staphy infection * Nonulcerative : allergies, smoke, dust, chemicals, seborrhea, stye , chalazion & acne rosacea C/M : - Irritation of eye lids margins and red rimmed eyes are chief - Burning Symptoms - Itching Mx : * Salt & water cleansing for 2 weeks * If unsuccessful - local antibiotics or sulfonamide - Warm compresses - Dandruff RX - Stop using make up or change the brand used - Improve hygiene Complications - Conjunctivitis _ Trichiasis - Entropion or ectropion of lower lid _Corneal ulcer

51. Trichiasis It is a condition in which the eye lashes grow in wards & rub on the cornea Cause: - Blepheritis - Trauma or surgery to the lids Rx: - Epilation Complications: - Corneal abrasions - Corneal ulceration - Corneal opacity - Vacularization of cornea

52. Entropion (inversion of eye lid into eye) - Turning inward of eyelids, usually lower eye lids Cause: - * Aging (course fibrous tissue) Symptoms and signs * Foreign body sensation * Tearing / itching / redness * Continuous rubbing causes conjunctivitis or corneal ulcers * Decreased visual acuity if not corrected Diagnosis * Visual examination Treatment * Clean up on its own * If not, minor surgery

53. Disease of the eye lid… Ectropion (Outturned eye lids) - It is turning outwards of the eye lids, usually the lower lids Cause: - Elderly (weakness of eye lid muscles) Symptoms and signs * Dryness of the exposed part of the eye, * Tears run down the cheeks * If not treated can cause ulcers and permanent damage to cornea Diagnosis * Visual examination Treatment * Minor surgery if doesn’t disappear

54. Ptosis ( Blepharoptosis ) - It is dropping of the upper eyelid -Weakness of eye muscle that raises eyelid (superior rectus, superior oblique) Etiology * Familial * Trauma * Diabetes mellitus * Muscular dystrophy * Myasthenia gravis * Brain tumors Symptoms and signs “Drooping eye” Blocks vision Diagnosis * Ophthalmic examination Treatment * Surgery (strengthen muscles) * Eye glasses with raised eyelid support * Treat underlying disease

55. Conjunctivitis Definition Conjunctivitis is an inflammation of the conjunctiva 58 Etiology Viral (more common) Bacterial Foreign bodies Allergens or chemical irritants It becomes inflamed & red. Conjunctivitis Often starts in one eye and spreads to the other eye. It is commonly transmitted among children & then among family members. Disorders of the Eye Lid Cont’d…

56. Classification of conjunctivitis Bacterial conjunctivitis Occurs in all age groups Epidemics commonly occur in children because of their poor hygienic habits The common causative microorganisms are: Staphylococcus aureus , Streptococcus pneumoniae , Haemophilus influenza 59 Disorders of the Eye Lid Cont’d…

57. Bacterial… C/ms Conjunctival redness Crusting exudate (pus) on the lids and in the corners of the eyes (lids may stick together in the morning on waking up). Irritation Tearing 60 Pt mg’t Self limiting usually Rx with antibiotics (TTC, CAF) will shorten the course Warm compress 3-4 times daily (10-15 min.) Careful hand washing and using individual towels will help prevent spreading the condition. Disorders of the Eye Lid Cont’d…

58. Classification of conjunctivitis… 2. Viral conjunctivitis Viral conjunctivitis occurs more commonly than bacterial conjunctivitis and is highly contagious . The virus is usually transmitted via contaminated eye secretions on the hand that then touches or rubs an eye, which infects the eye. The virus is hardy (strong) and may live on dry surfaces for 2 weeks or more. 61 Disorders of the Eye Lid Cont’d…

59. 2. Viral… C/ms Tearing / Watery discharge Foreign body sensation Redness Mild phtophobia Subconjunctival haemorrhage SXs resolve after about 1 week. 62 Pt mg’t It is not responsive to any Rx. Cold compresses 4-5 times daily (10min.) may alleviate some symptoms. Supportive measures such as eyewashes or eye irrigations Topical steroids ( Dexamethasone ) for temporary relief Good hygienic practices will decrease the spread Disorders of the Eye Lid Cont’d…

60. C/ms Itching ( the defining Sx ) Swelling of lids Tearing (watering) White or clear exudates Burning Redness 63 Pt mg’t Instruct to avoid the allergens. Wash out the allergens using eyewashes or eye irrigations . Cold compresses Topical antihistaminic or corticosteroid drops 3. Allergic conjunctivitis Allergic conjunctivitis is caused by exposure to some allergen (or irritants, chemicals, UV light) Disorders of the Eye Lid Cont’d…

61. Reading assignment Keratitis Diabetic Retinopathy Blindness 64

62. Cataracts Pathophysiology and Etiology Cataract is an opacity or clouding of the lens of the eye that leads to gradual painless blurring of vision and eventual loss of vision (loss of visual acuity). Vision is diminished because the light rays are unable to get to the retina through the clouded lens. Cataract can be compared to a window that is frosted or yellowed. It usually develops bilaterally but at different rates. 65 Disorders of the Globe Cont’d…

63. Cloudy or Opacity of the lens (loss of transparency) 66 Cataracts Cont’d…

64. Pathophysiology and Etiology… Cataracts are generally classified as Senile cataract - associated with aging Traumatic cataract - associated with injury Congenital cataract - inborn (present at birth) Secondary cataract - occurring after other eye or systemic diseases 67 Cataracts Cont’d…

65. Pathophysiology and Etiology… Factors that contribute to cataract development may include 68 Previous eye surgery, Familial, Nutritional deficiencies, Intraocular infections, Trauma, and Congenital defects. Age (most common type of cataract cause), lens becomes more compact and dense UV radiation (sunlight), Diabetes, Smoking, Drug toxicity (high level of steroids), Cataracts Cont’d…

66. Signs and Symptoms Gradual, painless , blurring of vision Double or hazy (cloudy or unclear) vision in the affected eye, Progressive loss of vision: The degree of vision loss depends on the location and extent of the opacity. Peripheral vision may be affected first & Near vision may initially improve 69 Cataracts Cont’d…

67. 70 Signs and Symptoms… Difficulty reading fine print or seeing in bright light, Needing brighter light to read fine print Increased sensitivity to glare (shine) such as when driving at night or Light sensitivity, Poor night vision Decreased color vision (or Loss of ability to discriminate b/n hues) Halos (circle of light) around lights Cataracts Cont’d…

68. Signs and Symptoms… Cloudy white opacity on pupil (or Pupil are yellowish, gray) The amount & pattern of cloudiness within the lens can vary. If the opacity is in the central portion of the lens => can generally see at dim light when the pupil is dilated 71 Cataracts Cont’d…

69. Diagnostic Tests Hx On visual inspection , the lens appears gray or milky. Blood work to uncover underlying cause Examine the lens (the presence of a cataract or cataract formation) and other internal structures through Direct ophthalmoscope and Slit-lamp microscope . Visual acuity is tested for near and far vision. Near vision may initially improve 72 Cataracts Cont’d…

70. Treatment Surgery is the Rx of choice. Medication has no role in the treatment of cataract. The only treatment for cataract formation is cataract surgery (surgical removal of the cloudy lens) . With the no-stitch cataract operation , there are no postoperative activity restrictions and vision is fine in about 2 days. 73 Cataracts Cont’d…

71. Treatment… After the lens is removed, there are several treatment options to correct the visual deficit that occurs when the eye is aphakic (absence of lens) and cannot accommodate or refract light properly. One Rx option is to provide the patient with eyeglasses or contact lenses that help correct the visual deficit. Another option is to replace the lens with a synthetic intraocular lens. Anesthetics, antibiotics, anti-inflammatory agents are used after surgery. 74 Cataracts Cont’d…

72. Glaucoma Definition Glaucoma is a group of diseases characterized by abnormal pressure within the eyeball. This pressure causes damage to the cells of the optic nerve, the structure responsible for transmitting visual information from the eye to the brain. The damage is silent, progressive, and irreversible until the end stages , when loss of peripheral vision occurs, followed by reductions in central vision and eventually blindness . 75 Disorders of the Globe Cont’d…

73. Definition… Glaucoma = Elevated intraocular pressure (NB: Normal accepted IOP range 10-22 mmHg by Tonometery ) + Damage to the optic nerve + Visual filed loss (loss of peripheral vision followed by reductions in central vision) + Blindness Glaucoma is the leading cause of blindness according to WHO 76 Glaucoma Cont’d…

74. Pathophysiology Although vision loss from glaucoma results from damage to the optic nerve and retina, the mechanism that causes  ed IOP involves the anterior part of the eye. The ciliary body secretes about 4-5 ml of aqueous humor a day. This bathes the lens with nutrients and then flows through the pupil into the anterior chamber, where it bathes the corneal endothelium. AH exits the eye through the trabecular meshwork & the canal of schlemm in the iridocorneal angle of the anterior chamber. 77 Glaucoma Cont’d…

75. 78 Figure Normal outflow of aqueous humor. A, Trabecular meshwork. B, Uveoscleral route. Glaucoma Cont’d…

76. Pathophysiology … Once glaucoma occurs, the patient will always have it and must follow a treatment regimen to maintain stable intraocular eye pressures. Increased IOP is the most important risk factor for developing glaucoma. Increased IOP results from a decrease in aqueous humor out flow & in some cases may also be related to an increased production (> 4-5 ml/day) of aqueous humor. 79 Glaucoma Cont’d…

77. Pathophysiology … Types of glaucoma The most common form of glaucoma, called primary glaucoma , consists of two types: Primary open-angle glaucoma (POAG) and Acute angle-closure glaucoma (AACG). A second form, secondary glaucoma may be caused by infections, tumors, or injuries. A third form, congenital glaucoma , primarily is due to developmental abnormalities. 80 Glaucoma Cont’d…

78. Pathophysiology … AACG ( Acute angle-closure glaucoma) OR Closed angle glaucoma Occurs in people who have an anatomically narrowed angle at the junction where the iris meets the cornea. When nearby eye structures such as the iris protrude into the anterior chamber, the angle is occluded , which blocks the flow of aqueous fluid. This is considered a medical emergency and results in partial or total blindness if not treated. Mechanism : Increased IOP due to a complete blockage of eyes AH drainage system - can lead to optic nerve damage 81 Glaucoma Cont’d…

79. Pathophysiology … In angle–closure glaucoma, the iris blocks the trabecular mesh-work & limits the flow of AH out of the A. chamber. Complete blockage of AH drainage system (the trabecular meshwork and Schlemm’s canal) Rare case Etiology: Trauma 82 Glaucoma Cont’d…

80. Pathophysiology … POAG (Primary open-angle glaucoma) Occurs when the drainage system of the eye, the trabecular meshwork and Schlemm’s canal, degenerate and subsequently block the flow of AH. The angle is normal size. Most common type (90%). Mechanism Increased IOP due to a malfunction in eyes AH drainage system - can lead to optic nerve damage Etiology: Trauma & Overuse of steroids 83 Glaucoma Cont’d…

81. Etiology and Prevention The incidence of AACG is highest among nearsighted individuals (Myopia). The incidence of POAG increases in those older than 40 years of age (older than age 50 for European Americans, older than age 35 for African Americans), in persons with diabetes , and in those with a family history of glaucoma. Those in high-risk groups should have yearly eye examinations for glaucoma detection. 84 Glaucoma Cont’d…

82. Signs and Symptoms 1. Acute angle closure glaucoma An ophthalmic emergency , AACG typically has a unilateral , rapid onset. Patient may complain of severe pain over the affected eye, blurred vision, rainbows around lights, eye redness, a steamy-appearing cornea, photophobia, & tearing. N/V may occur from the increased IOP. Dramatic increase in IOP may exceed 50 mmHg Permanent blindness if marked increase in IOP for 24-48 hrs 85 Glaucoma Cont’d…

83. Signs and Symptoms… 2. Primary open angle glaucoma POAG develops bilaterally . The onset is usually gradual and painless, so the patient may not experience noticeable symptoms (Often no S/S in early stages) Elevated IOP > 24 mmHg Slow loss of vision Peripheral vision lost before central vision Tunnel vision Headache Persistent dull eye pain Difficulty of adjusting to darkness Failure to detect colour changes 86 Glaucoma Cont’d…

84. Diagnostic Tests Tonometry – measurement of IOP In AACG, IOP may exceed 50 mm Hg. Visual field examination - looks for loss of peripheral vision. Ophthalmoscopy – examination of optic nerve or evaluation of the colour Gonioscopy - examination of the angle structures of the eye, where the iris, ciliary body, and cornea meet. 87 Glaucoma Cont’d…

85. Medical Management The goal of Rx is to lower the IOP & keep it at a level that prevents los of vision Miotics : Increase out flow of AH by constricting pupil --- opening the aqueous flow e.g. Pilocarpine hydrochloride Prostaglandin agonist: Increase out flow of AH by constricting ciliary muscle and iris sphincter. e.g. Latanoprost ( xalatan ) Beta–Adrenergic- se AH production and increase outflow, there by decreasing IOP e.g. Timolol Osmotic Agent: Moves water from intraocular structures resulting in a marked ocular hypotonic effect then decrease IOP e.g. Mannitol 88 Glaucoma Cont’d…

86. Surgical Management When medication is no longer able to control the flow of AH, surgical intervention may become necessary. Surgery focuses on creating an area for the AH to flow freely, thus preventing increased IOP. 89 FIGURE: Flow of aqueous humor after trabeculoplasty (arrows). Glaucoma Cont’d…

87. Nursing management Proper and regular administration of the ordered drugs Pt comforting like Darkening the room. Cold application on forehead. Administer analgesics. Maintain complete bed rest. Provide quiet and private space for the pt. Instructions about the surgery H. Education to avoid conditions that increase IOP, like, straining, heavy lifting etc 90 Glaucoma Cont’d…

88. Thank you!!! End for the Eye 91

89. EAR/ HEARING DISORDERS 92

90. The ear is a sensory organ with dual functions — hearing and balance. 93 Normal Anatomy & Physiology of the Ear The sense of hearing is essential for normal development and maintenance of speech as well as the ability to communicate with others. Balance, or equilibrium, is essential for maintaining body movement, position, and coordination.

91. The ear consists of three areas : the outer ear, the middle ear, and the inner ear. contains the receptors for the senses of hearing & equilibrium. The tympanic membrane (or eardrum) : separates the external and middle ear. It is stretched across the end of the ear canal & vibrates when sound waves strike it. 94 Normal Anatomy and Physiology of Ere Cont’d….

92. 95 Structures of the Ere Normal Anatomy and Physiology of Ere Cont’d….

93. Outer Ear The outer ear consists of Auricle ( pinna ) — visible portion composed of folds of cartilage covered with skin. External auditory canal (also called ear canal ) Ends at the tympanic membrane Is lined with skin that contains ceruminous glands which secrets cerumen or earwax. 96 Normal Anatomy and Physiology of Ere Cont’d….

94. Outer Ear… Function of Outer ear Sound conduction from auricle to tympanic memb . Production of cerumen , or earwax secreted by ceruminous glands used to. 97 Normal Anatomy and Physiology of Ere Cont’d….

95. Tympanic Membrane Normally pearly gray and translucent membrane Is held inward at its center by one of the ossicles , the malleus Protects the middle ear Conducts sound vibrations from the external canal to the ossicles . 98 Normal Anatomy and Physiology of Ere Cont’d….

96. Middle Ear The middle ear is an air-filled cavity in the temporal bone. It consists; Three tiny bones, called the ossicles (or Auditory bones), named for their shape Malleus (hammer) Incus (anvil) Stapes (stirrup) Eustachian (Auditory) tube; connects the middle ear to the nasopharynx . 99 Normal Anatomy and Physiology of Ere Cont’d….

97. Middle ear Ossicles Eustachian tube 3.04 Understand the functions and disorders of the sensory system 100 Normal Anatomy and Physiology of Ere Cont’d….

98. Middle Ear… Eustachian tube (or auditory tube) permits air to enter or leave the middle ear cavity. The air pressure in the middle ear must be the same as the external atmospheric pressure. Swallowing or yawning opens the eustachian tubes and permits equalization of these pressures. 101 Normal Anatomy and Physiology of Ere Cont’d….

99. Middle Ear… Function of Middle ear Conducts sound vibrations through ossicles Eustachian tube allows equalization of air pressure on each side of the TM to vibrate it properly and to prevent it from rupture. Protects the inner ear by reducing the amplitude of loud sounds. 102 Normal Anatomy and Physiology of Ere Cont’d….

100. Inner Ear Series of fluid-filled passages called the bony labyrinth, lined with membrane called the membranous labyrinth, which holds the sensory organs for hearing & equilibrium. The fluid between bone and membrane is called perilymph , and that within the membrane is called endolymph . The inner ear consists; Cochlea; which are concerned with hearing Organ of Corti (spiral organ), which contains tiny nerve endings called hair cells Vestibular apparatus; which are concerned with equilibrium. Vestibule & Semicircular canals 103 Normal Anatomy and Physiology of Ere Cont’d….

101. 104 Cochlea Semicircular canals Inner Ear… Normal Anatomy and Physiology of Ere Cont’d….

102. Physiology of Hearing The process of hearing involves the transmission (conduction) of vibrations and the generation of nerve impulses and A. Transmission of vibrations When sound waves enter the ear canal, vibrations are transmitted by the following structures: eardrum, malleus , incus , stapes, oval window of the inner ear, perilymph and endolymph within the cochlea, & hair cells of the organ of Corti . 105 Normal Anatomy and Physiology of Ere Cont’d….

103. Physiology of Hearing … B. Generation of nerve impulses When the hair cells bend , they generate impulses that are carried by the auditory nerve to the auditory cortex in the brain, where they are decoded into a sound message . The auditory areas , for both hearing & interpretation , are in the temporal lobes of the cerebral cortex . 106 Normal Anatomy and Physiology of Ere Cont’d….

104. Pathway of hearing 107 Normal Anatomy and Physiology of Ere Cont’d….

105. Pathway of hearing 108

106. Subjective Data To understand the patient’s ear disorder, perform a focused health history . Assessment of symptoms includes asking the WHAT’S UP? 109 Assessment of Ear and Hearing Status

107. Subjective Data… Symptoms and complaints related to the ear include Decreased or loss of hearing, Otalgia (sensation of fullness or pain in the ear), Otorrhea (ear discharge) Itching, Tinnitus (ringing, buzzing ) Vertigo (dizziness), or Deafness (partial or complete loss of the ability to hear). 110 Data Collection of the Ear & Hearing Status cont’d…

108. Objective data Inspection and palpation of the external ear Auditory acuity testing Weber test Rinne test Balance testing Otoscopic examination 111

109. Diagnostic Tests Culture. If there is exudate from any portion of the ear, a culture may be ordered. Diagnostic Evaluation a. Audiometry In detecting hearing loss, audiometry is the single most important diagnostic instrument. The unit for measuring loudness (intensity of sound) is the decibel (dB), the pressure exerted by sound. 112 Nursing Assessment…

110. Diagnostic Evaluation… Hearing loss is measured in decibels. Sound louder than 80 dB is perceived by the human ear to be harsh and can be damaging to the inner ear. Based on pure-tone audiometry , in which the sound stimulus consists of a pure or musical tone (the louder the tone before the pt perceives it, the greater the hearing loss), and Normal Hearing: PTAs < 25 dB Hearing Impairment: PTAs 25-92 dB Deaf: PTAs > 92 dB 113 Nursing Assessment…

111. Diagnostic Evaluation… b. Tympanogram A tympanogram , measures compliance of the tympanic membrane by changing the air pressure in a sealed ear canal. Compliance is impaired with middle ear disease. c. Middle Ear Endoscopy Evaluates middle ear and inner ear disorders. 114 Nursing Assessment…

112. 12/27/2022 115 Common Hearing (Ear) Disorders Hearing Loss Conductive hearing loss Sensory- Neural hearing loss Noise-induced hearing loss Disorders of external ear Otitis Externa (External Otitis ) Obstructions of the Ear Canal Impacted cerumen Foreign body Disorders of middle ear Otitis media Mastoditis Disorders of inner ear Labyrinthitis Ménière’s Disease Nursing Care of Patients with Ere Disorders

113. Definition & phatophysiology Hearing loss is an impairment or inability to apprehend (catch) or detect sound. Approximately one half of the time hearing impairment is related to genetic factors Hearing loss results from a mechanical or nervous impairment to the transmission of sound waves. Hearing loss can be temporary or permanent. 116 Hearing Loss

114. Definition & phatophysiology … Hearing loss of any significance nearly always involves problems of both sensitivity (the ability to hear) and acuity (the ability to resolve differences) – Hearing aids improve sensitivity to sound by amplifying it – but do not improve acuity. 117 Hearing Loss Cont’d…

115. Definition & phatophysiology …   The most common hearing disorders are those that affect hearing sensitivity, not acuity to sound . When a sound is presented to a listener with a hearing sensitivity disorder, one of 2 things may occur: The listener with a HS disorder may be unable to detect (sense) the sound. The sound will not be as loud to that listener as it would be to a listener with normal hearing. 118 Hearing Loss Cont’d…

116. Definition & phatophysiology … Hearing impairment ranges from partial deafness (difficulty hearing certain sounds or understanding words) to total deafness (complete loss of the ability to hear). . 119 Hearing Loss Cont’d…

117. Causes & predisposing factors for Hearing Loss Family history of sensorineural impairment Congenital malformations of the cranial structure (ear) Low birth weight (1500 g) Use of ototoxic medications ( eg , gentamycin, loop diuretics) Recurrent ear infections Chronic exposure to loud noises Perforation of the tympanic membrane 120 Hearing Loss Cont’d…

118. Causes & predisposing factors… Acute infections, e.g. mumps, (the most common cause of unilateral sensorineural hearing loss), Rubella, influenza, herpes zoster Neurologic disorders e.g. Bacterial meningitis, neurosphilis Metabolic disorders e.g. diabetes mellitus, hypothyroidism Vascular disorders e.g. arteriosclerosis, hypertension 121 Hearing Loss Cont’d…

119. Types of Hearing Loss The major forms of hearing loss are classified as Conductive hearing loss Sensory-neural hearing loss Other types of hearing loss Mixed hearing loss Noise-induced hearing loss Functional hearing loss Central hearing loss Congenital hearing loss 122 Hearing Loss Cont’d…

120. Pathways of Hearing Vibrations of sound  Air of the external ear  Eardrum  Ossicles  Cochlea  Cochlear nerve  Brain Conductive Phase Sensorineural Phase Conductive Hearing Loss Sensorineural Hearing Loss 123 Hearing Loss Cont’d…

121. Conductive Hearing Loss Conductive hearing loss is any interference with the conduction of sound vibrations through the external auditory canal, the eardrum, or the middle ear. OR It is an obstruction in outer or middle ear. The inner ear is not involved in a pure conductive hearing loss. It can be caused by anything that interferes with the ability of the sound wave to reach the inner ear. is a mechanical problem. 124 Hearing Loss Cont’d…

122. Conductive Hearing Loss… Causes & predisposing factors Impacted cerumen ( most common ), Ear infection (Otitis), Foreign bodies, Otosclerosis (ear hardening), Perforation of the tympanic membrane, Fluid in the middle ear, Trauma (ear) , Tumor (ear) . 125 Hearing Loss Cont’d…

123. Sensorineural Hearing Loss Sensorineural hearing loss results from disease or trauma to the sensory or neural components of the inner ear (involves damage to the cochlea or vestibulocochlear nerve). Sensory hearing loss originates in the cochlea (results from deterioration of the cochlea) and involves the hair cells and nerve endings. Neural hearing loss originates in the auditory nerve or brainstem (from lesions involving 8 th CN, auditory nuclei). 126 Hearing Loss Cont’d…

124. Sensorineural Hearing Loss… Causes Sensorineural hearing loss ( nerve deafness ) is failure of inner ear nerves to transmit sound impulses properly to the brain Sensory hearing loss occurs with Old age ( presbycusis ) Repeated Noise damage Medications ( ototoxic ) Inner ear disorders Neural hearing loss occurs with lesions involving eighth cranial nerve (Auditory nerve damage). It is the least comm on clinically recognized cause of hearing loss. 127 Hearing Loss Cont’d…

125. Other Types of Hearing Loss Mixed hearing loss Mixed hearing loss occurs when an individual has both conductive and sensorineural hearing loss. This can be caused by a combination of any of the disorders previously mentioned. 128 Hearing Loss Cont’d…

126. Signs and symptoms Early S/Ss of hearing impairment and loss may include Tinnitus (complains of ringing, buzzing or roaring noise in ears) Increasing inability to hear when in a group, and A need to turn up the volume of the television. Difficulty understanding words or certain sounds Frequent requests for repetition (asks “What did you say?”) Avoidance of social situations ( changes in social and work activities ) 129 Hearing Loss Cont’d…

127. Signs and symptoms… complains of people talking softly, speaks in a quiet or loud voice, answers questions inappropriately, avoids group activities, loss of sense of humor, appears aloof (detached), and Total deafness (complete loss of the ability to hear). 130 Hearing Loss Cont’d…

128. Diagnostic Tests and Findings Rinne’s and Weber’s tests, audiometric testing Abnormal Rinne’s and Weber’s tests, audiometric testing indicates hearing loss 131 Hearing Loss Cont’d…

129. 132

130. Therapeutic Interventions Goal: improving the patient’s hearing. Varied with type and cause of impairment Possibly medication to treat infections Dissolve cerumen using Ceruminolytics or Ear irrigation Hearing aids: are most effective with conductive hearing loss when no inner ear and nerve damage are present. Hearing Loss Cont’d…

131. FIGURE: Hearing aids. (A) Behind-the-ear hearing aid. (B) In-the-ear hearing aid. 134 Intervention… Hearing Loss Cont’d…

132. The most common disorders of the external ear Infections of the ear canal Obstructions of the ear canal because of Impacted Cerumen FB 135 External Ear Disorders

133. It is a condition commonly referred to as an “earache.” Usually unilateral 136 Otitis Externa (External Otitis , Swimmer's Ear) Definition EO is an inflammation or infection of the skin of the external auditory canal or the auricle. External Ear Disorders Cont’d…

134. One common name for Otitis Externa is “ Mediterranean ear/S wimmer’s ear” b/se it frequently develops in people who have been swimming & people who have had water trapped in their ears. Local trauma such as picking the ear cause contamination, or on going exposure to moisture produces an environment conductive to the overgrowth of normal flora. 137 External Otitis Cont’d…

135.   Ethiology Infecting organisms Bacteria (Staph. aureus & Pseudomonas species) Fungi ( Aspergillus niger & Candida albicans ) Immunosuppression 138 External Otitis Cont’d…

136. Predisposing factors Swimming in contaminated water; cerumen creates a culture medium for the water born organisms Cleaning the ear canal with pin, finger or other foreign objects; this irritates the ear canal & possibly introduces the infection microorganisms. Exposure to dust, hair care products, or other irritants, which causes the patient to scratch his ear, excoriating (attacking) the auricle & canal External Otitis Cont’d….

137. Predisposing factors… Regular use of earphones, which trap moisture in the ear canal, creating a culture medium for infection Chronic drainage from a perforated tympanic membrane Contribution of the structure External Otitis Cont’d….

138. Contribution of the Structure External Otitis Cont’d….

139.  Clinical manifestation Ear pain, conductive hearing loss, ear discharge which varies in consistency and colour, and Gradual onset of pruritis (itching) are common S/Ss. Moderate to severe pain that is exacerbated by : Manipulation of the auricle (gently pulling on the pinna or putting pressure on the tragus), Clenching the teeth, Opening the mouth, or Chewing Partial conductive hearing loss (or a feeling of fullness). Discharge (may be yellow or green & foul smelling) In chronic otitis external, pruritis (or itching) which may lead to scaling & skin thickening Fever, Periauricular lymphadenopathy & Regional cellultitis (Occasionally) 142 External Otitis Cont’d….

140. Acute Otitis Externa In Acute OE the canal is often reddened, swollen, narrowed, moist (ear discharge), and tender. 143 In chronic OE the skin of the canal is dry, itchy, & dark yellow-brown hair like black spores may even be visualized in fungal infections On otoscopic examination CMs of OE….

141. Diagnosis History History of ear pain. P/E Pain on palpation of the auricle Periauricular lymphadenopathy & Regional cellulites Otoscopy : Redness & swelling of the ear canal Culture & sensitivity tests If Rx fails or otitis externa recurs frequently consider sending an ear swab for bacterial & fungal microscopy and culture   External Otitis Cont’d….

142. Management The principles of therapy are aimed at : remove or treat any precipitating or aggravating factors, relieving the discomfort (pain), reducing the swelling of the ear canal, and eradicating the infection. To relieve pain & reduce swelling: Heat therapy to the periauricular region Analgesics 145 External Otitis Cont’d….

143. Management... To eradicate the infection; Antibiotics/Antifungal If fever or regional cellulites - Instillation of antibiotic ear drops Corticosteroids In chronic otitis externa , primary treatment consists of cleansing the ear & removing debris. Provide appropriate self-care (Ear care) advice- see below 146 External Otitis Cont’d….

144. 147 External Otitis Cont’d….

145. Obstructions of the Ear Canal Any obstructions of the ear canal may interfere with auditory function Lead to infection, inflammation, or conductive hearing loss. Causes:- 1 - Impacted cerumen 2 - Foreign body External Ear Disorders Cont’d….

146. 1. Impacted Cerumen It is an accumulation of cerumen (Ear wax) in to the auditory canal in various amounts and colors. It can cause temporary conductive hearing losses in clients of all ages. 149 Obstructions of the Ear Canal…

147. Pathophysiology and Etiology Cerumen is a normal byproduct of a healthy ear. It lubricates the ear canal and protects the canal & TM. Normally, the ear is self-cleaning. As cerumen is produced by the subcutaneous glands of the ear canal, it migrates out of the ear canal by way of the tiny hairs lining the outer layer of the external ear canal. However, cerumen may become impacted , blocking the ear canal. At times, wax must be mechanically removed. 150 Impacted Cerumen…

148. Pathophysiology and Etiology…. Most common factors to cerumen impaction are narrowed ear canal, excess production of ear wax, and poor ear hygiene Large amounts of hair in the ear canal Work in dusty or dirty areas Improper cleaning ( Inappropriate instrumentation ), Disturb the natural cerumen excretion process by inserting Q-tips and other foreign objects into ear canal Hearing aids Bony growths secondary to an osteoma 151 Impacted Cerumen Cont’d….

149. Signs and Symptoms. If cerumen has become impacted, the patient may experience a feeling of fullness in the ear , or blocked ear, with or without a hearing loss. It can cause otalgia , a sensation of fullness or pain in the ear. Otoscopic examination reveals cerumen blocking the ear canal. Once the cerumen is removed by a qualified professional, hearing returns to preimpact levels. 152 Impacted Cerumen Cont’d….

150. Diagnostic Studies. Hearing acuity can be decreased. Whisper voice, Rinne’s, and Weber’s tests also indicate conductive hearing loss in the affected ear. 153 Impacted Cerumen Cont’d….

151. Management Cerumen can be removed by irrigation (with water), suction, or instrumentation ( Gentle scraping the ear canal with a cerumen spoon ) Generally ear irrigation is performed:- To remove impacted cerumen To apply heat To remove foreign body To remove discomfort To clean ear canal before surgery 154 Impacted Cerumen Cont’d….

152. Management…. Ear irrigation Soften cerumen before its removal; Instilling a few drops of warmed glycerin , mineral oil, or half strength hydrogen peroxide into the ear canal for 30 minutes then the ear can be irrigated by irrigation solution , usually water, warmed to a bogy To. OR cerumen can be removed with a cerumen spoon, or forceps. Use softening solution two or three times a day for several days if cerumen is to hard to remove at once. If irrigation is unsuccessful, direct visual, mechanical removal can be performed by a trained HCP. 155 Impacted Cerumen Cont’d….

153. Removing Cerumen… 156 FIGURE Ear irrigation. (A) Child. (B) Adult. Impacted Cerumen Cont’d….

154. Removing Cerumen… 157 FIGURE Ear irrigation. (C) Irrigation. Impacted Cerumen Cont’d….

155. Contra indications for Ear irrigation External ear infection Tympanic membrane perforation Tubes in the ear NB: Ear irrigation should be stopped immediately if it causes pain, nausea or dizziness Impacted Cerumen Cont’d….

156. 2. Foreign body Some objects may enter or be introduced into the ear canal. E.g. insects, peas, beans, paper, etc The effects may range from no symptoms to profound pain & decreased hearing Sensation of movement- if insect Obstructions of the Ear Canal…

157. Management The three standard methods for removing foreign bodies are the same as those for removing cerumen : irrigation (with water) , suction, and instrumentation. NB: Foreign vegetable bodies and insects tend to swell ; thus, irrigation is contraindicated. 160 Foreign body Cont’d….

158. Management… Usually, an insect can be dislodged by instilling a few drops of mineral oil in to the ear canal , which will kill the insect and allow it to be removed. OR quickly killed by instillation of 70% alcohol solution; then it can then be removed with a cerumen spoon, or forceps. Vegetables Require preliminary irrigation with 70% alcohol solution OR dislodged by instilling a few drops of mineral oil in to the ear canal; it can then be removed with a cerumen spoon, or forceps. 161 Foreign body Cont’d….

159. Otitis media Pathophysiology and Etiology. Otitis media is the most common disease of the middle ear. Otitis media is a general term for inflammation of the middle ear, mastoid, and eustachian tube. 162 Middle Ear Disorders

160. Pathophysiology and Etiology. .. Inflammation of the nasopharynx causes most cases of otitis media. As inflammation occurs, the nasopharyngeal mucosa becomes edematous and discharge is produced. The eustachian tube becomes blocked when fluid, pus, or air builds up in the middle ear, and this impairs middle ear ventilation. 163 Otitis media Cont’d…

161. Pathophysiology and Etiology. .. Otitis media is common disorder among infants & young children because of their short eustachian tube , which provides a pathway for bacteria to enter from the nasopharynx OM is the most common cause of transient conductive hearing loss in children Caused by eustachian tube failure 164 Otitis media Cont’d…

162. Pathophysiology and Etiology. .. There are several types of otitis media in which inflammation can occur alone (without drainage), inflammation can occur with infective drainage, or inflammation can occur with non-infective drainage. 1. Otitis media without effusion The first type of OM is otitis media without effusion. This is an inflammation of the middle ear mucosa without drainage. 165 Otitis media Cont’d…

163. Pathophysiology and Etiology. .. 2. Otitis media with infective drainage Occurs when there is a bacterial infection of the middle ear mucosa. This is called acute OM, suppurative OM, or purulent OM. The infected fluid becomes trapped in the middle ear. If the infection continues longer than 3 months, chronic otitis media results. 166 Otitis media Cont’d…

164. Pathophysiology and Etiology. .. 3. Otitis media with effusion (non-infective drainage) The third type of otitis media is otitis media with effusion. Other names include serous OM, nonsuppurative OM, or glue ear. With this type of otitis media, non-infective fluid accumulates within the middle ear. 167 Otitis media Cont’d…

165. Serous Otitis Media Otitis media Cont’d…

166. Acute Otitis Media AOM usually lasts less than 6 weeks It is common in children . Causes Mostly viral but can be bacterial Primary causes Haemophilus influenzae , and Streptococcus pneumoniae , 169 Otitis media Cont’d…

167. Pathophysiology Primary causes which enter the middle ear after eustachian tube dysfunction caused by obstruction related to URT infections or inflammations . Bacteria can enter the eustachian tube from contaminated secretions in the nasopharynx and the middle ear from a TM perforation. 170 Acute Otitis media Cont’d…

168. Clinical Manifestations Acute otitis media commonly follows an URI. Usually unilateral in adults Otalgia (ear pain or earache), But it relieved after spontaneous perforation or therapeutic incision of the TM Fever, and Conductive hearing loss or fullness in the affected ear. Acute Otitis media Cont’d…

169. On otoscopic examination The external auditory canal appears normal Red, bulging TM indicates acute purulent OM. 172 If the TM is perforated, Yellow or green discharge from the ear & No pain Acute Otitis media Cont’d…

170. Diagnosis: History: Hx of upper respiratory tract infection & ear pain. PE The patient reports no pain with movement of the auricle but reports mastoid tenderness with palpation of the mastoid process. On otoscopic examination The external auditory canal appears normal. The TM is erythematous and often bulging. Lab. Analysis of ear discharges Acute Otitis media Cont’d…

171. Medical Management Analgesia: For most children helps most. Antibiotics should not be routinely prescribed for uncomplicated AOM. For children under age 6 may significantly benefit from Abs – ill. Ampicillin 50-100mg/kg/day in four divided doses for 10days or Amoxicillin 30 mg/kg/day in three divided doses for10days Surgical Management: myringotomy or tympanotomy 174 Acute Otitis media Cont’d…

172. Chronic Otitis Media It is the result of repeated episodes of acute otitis media causing irreversible tissue pathology and persistent perforation of the TM. Characterized by chronic pus draining from the ear for about 2wks or above OR Recurrent ear discharge. 175 Otitis media Cont’d…

173. Perforation of the TM Chronic Otitis media Cont’d…

174. Clinical Manifestations Symptoms may be minimal, Varying degrees of conductive hearing loss , persistent or intermittent, & Foul-smelling otorrhea (purulent discharge with offensive odor) Painless ( Pain not usually experienced except in cases of acute mastoiditis ) Otoscopic evaluation: Perforation of the TM 177 Chronic Otitis media Cont’d…

175. Medical Management Ear weeping (dry the ear by wicking) Treat fever & pain if present Instillation of antibiotic drops Systemic Abs usually not effective but a single antibiotic dose is tried Surgical Management Tympanoplasty and mastoidectomy 178 Chronic Otitis media Cont’d…

176. Common Signs and Symptoms of OM History of URT infection and ear pain or earache (most common) Examination of the ears shows Red, bulging TM or Pus discharging ears after the TM is perforated. Presence of pyogenic microorganisms (in suppurative otitis media) 179 Otitis media Cont’d…

177. Signs and Symptoms… Acute otitis media commonly follows an URI. Fever, earache, & feeling of fullness in the affected ear are common symptoms. As purulent drainage forms, There is pain & conductive hearing loss. Nausea and vomiting may also be present. Otoscopic examination reveals a reddened, bulging TM. Purulent drainage (Yellow or green discharge) may be evident in the external ear canal if the TM ruptures. 180 Otitis media Cont’d…

178. Signs and Symptoms… Chronic otitis media Symptoms may be minimal Varying degrees of conductive hearing loss, persistent or intermittent, & Otoscopic evaluation reveals : Perforation of the TM & No pain Foul-smelling otorrhea (Purulent discharge with offensive odor) In both cases mastoid tenderness indicates that the infection may have spread to the mastoid area. 181 Otitis media Cont’d…

179. Common Diagnostic Studies Laboratory studies may indicate an elevated WBC count. Ear cultures may be obtained on any drainage to identify the specific infective organism. Conductive hearing loss is usually present on Rinne’s, Weber’s, and whisper voice tests. Imaging studies may be done to diagnose infection. 182 Otitis media Cont’d…

180. Complications. A perforation may occur with an acute or chronic infection. Build-up of fluid and pressure in the middle ear can cause a spontaneous perforation of the tympanic membrane. The patient usually experiences pain before the rupture and relief of pain after the rupture. The fluid in the middle ear moves through the perforation into the ear canal, relieving the pressure and pain. A tympanic membrane perforation causes hearing loss . The location & size of the perforation determine the extent of hearing loss. Damage to the ossicles can also occur with perforation. 183 Otitis media Cont’d…

181. TM perforation Otitis media Cont’d… Complications…

182. Complications… Tympanosclerosis is another complication of repeated middle ear infections. Tympanosclerosis consists of deposits of collagen and calcium on the TM. Mastoiditis can occur if AOM is not treated. The infection spreads to the mastoid area, causing pain. Since the use of antibiotics, acute mastoiditis is relatively uncommon. Chronic mastoiditis is still seen with repeated middle ear infections (COM). 185 Otitis media Cont’d…

183. Therapeutic Interventions. Medical interventions of OM For most children o ral analgesics such as aspirin, acetaminophen, or codeine or ear drops are given to control pain. Bacterial infections are treated with antibiotics such as Amoxicillin, penicillin V, erythromycin, and cotrimoxazole 186 Otitis media Cont’d…

184. Medical interventions… Acute Otitis Media Non-drug treatment: Dry the ear by wicking Drug treatment: First line: Co- trimoxazole , 4 mg/kg trimethoprim 20mg/kg sulphamethaxozole BID for 05 days. Alternative Amoxicillin, 20-40 mg/kg/24 hours divided into 3 doses p.o . for 05 days 187 Otitis media Cont’d…

185. Medical interventions… Chronic otitis media: discharging ear for more than 2wks. Treatment is usually non-drug, such as Ear weeping ( dry the ears with frequent wicking ) 188 Chronic Otitis media Cont’d…

186. Therapeutic Interventions… Surgical intervention: includes several techniques. Paracentesis may be performed with a needle and syringe. The TM is punctured with the needle, and the fluid is drained from the middle ear. A myringotomy : During this procedure, an incision is made in the tympanic membrane and fluid is allowed to drain out or is suctioned out of the middle ear. Various types of transtympanic tubes may be inserted to keep the incision open. Reconstructive repair of a perforated tympanic membrane is called a myringoplasty . A mastoidectomy involves incision, drainage, and surgical removal of the mastoid process if the infection has spread to the mastoid area. 189 Otitis media Cont’d…

187. Mastoditis Definition : it is an inflammation of mastoid bone & cells Cause : as a complication of acute & chronic OM. C/ms : Tenderness, swelling behind the ear, mastoid process or tender on palpation Fever, pain etc 190 Middle Ear Disorders Cont’d…

188. Dx : Hx PE X-ray shows inflammation of the mastoid hole. Mgt Abs Anti-pain Surgery: Mastoidectomy 191 Mastoditis Cont’d…

189. Labyrinthitis Pathophysiology and Etiology. Labyrinthitis is an inflammation or infection of the inner ear. It can be caused by either viral or bacterial pathogens. The bacterium or virus enters the inner ear from the middle ear, meninges , or bloodstream. Destruction of soft tissue structures from the infection can cause permanent hearing loss. 192 Inner Ear Disorders

190. Pathophysiology and Etiology… a. Bacterial labyrinthitis : Usually occurs as a complication of otitis media. The infection can enter the inner ear by penetrating the membranes of the oval or round windows OR after middle ear or mastoid surgery. 193 Labrinthitis Cont’d…

191. Pathophysiology and Etiology… b. Viral labyrinthitis : It may be caused after URT infection. The most commonly identified viral causes are mumps, rubella, and influenza. It is also a common medical diagnosis w/c affects hearing and balance. 194 Labrinthitis Cont’d…

192. Signs and Symptoms. Vertigo, tinnitus, and sensori -neural hearing loss are the most common symptoms. Vertigo, or dizziness , occurs when the vestibular structures are involved. Tinnitus, or ringing in the ear, occurs when the infection is located in the cochlea . Sensorineural hearing loss can be caused by infections in the cochlea or vestibular structure s. 195 Labrinthitis Cont’d…

193. Signs and Symptoms… Other signs and symptoms include pain, fever, nausea, vomiting, and beginning nerve deafness. 196 Labrinthitis Cont’d…

194. Diagnostic Tests. Laboratory tests such as a CBC may be completed to diagnose infection . Thorough hearing evaluation may reveal mild to complete hearing loss. Rinne’s and Weber’s tests can indicate conductive or sensorineural hearing loss. 197 Labrinthitis Cont’d…

195. Therapeutic Interventions. Bacterial inner ear infections: IV Antibiotics are used. Viral infections: usually run their course in about 1wk. Symptomatic treatment Mild sedation may help the patient relax . Although there is no specific medicine to relieve dizziness, antihistamines can be used if they prove helpful on an individual basis. Patients may be placed on bed rest. 198 Labrinthitis Cont’d…

196. Ménière’s Disease Pathophysiology and Etiology. Ménière’s disease is a balance disorder . Its cause is unknown . but it is associated with factors, that increase fluid disturbances ( hypersecretion , hypoabsorption , deficit membrane permeability, hormonal imbalance), such as Viral or Bacterial infections Allergic reactions Bio-chemical disturbances Long term mental stress 199 Inner Ear Disorders Cont’d…

197. Pathophysiology and Etiology… The pathologic changes of minieres syndrome are either over production or decreased re-absorption of endolymphatic fluid, causing a distortion of the entire system of the inner ear canal. This distortion leads to decreased hearing from dilation of the cochlear duct, vertigo because of damage to the vestibular system, & tinnitus with an unknown cause. 200 Ménière’s disease Cont’d…

198. Pathophysiology and Etiology… The initial hearing loss is reversible , but repeated damage to the cochlea, caused by increased fluid pressure , leads to permanent hearing loss. Involvement The disease is generally unilateral . Incidence The disease usually develops between 40 and 60 years of age. 201 Ménière’s disease Cont’d…

199. Signs and Symptoms. A triad of symptoms of vertigo, unilateral sensor-neural hearing loss, and tinnitus characterizes Ménière’s disease. The attacks may occur suddenly , or The patient may experience warning signs such as headache or fullness in the ears. Recurring episodic bouts of the disease occur with the incapacitating triad of symptoms and nausea and vomiting . 202 Ménière’s disease Cont’d…

200. Signs And Symptoms… During an acute episode ; The patient experiences vertigo that lasts 2 to 4 hours. The vertigo is usually accompanied by N/V , followed by unsteadiness. The pt is uncoordinated & has gait changes when walking. Hearing loss is often described as a fluctuating fullness in the ears Tinnitus is present. The vital signs usually remain normal. Irritability, depression, & withdrawal are common behavioral changes 203 Ménière’s disease Cont’d…

201. Diagnostic Tests. They include audiometric studies, neurological testing, and radiographs of the internal ear . Audiometric studies identify the type and magnitude of the hearing loss. Neurological testing and radiographic studies rule out other pathological conditions. 204 Ménière’s disease Cont’d…

202. Therapeutic Interventions. Medical Treatment Goals: to preserve hearing and reduce symptoms. Medical Rx consists of symptomatic treatment for acute attacks & prophylactic treatment b/n attacks. Tranquilizers and vagal blockers as well as bed rest may be needed during acute attacks. Salt restricted diet, diuretics, antihistamines, and vasodilators are used as prophylactic treatment. The pt should avoid alcohol, caffeine, and tobacco use. 205 Ménière’s disease Cont’d…

203. Surgical treatment Surgical Rx is used only when medical mg’t has failed . When involvement is unilateral, a labyrinthectomy (Surgical destruction of labyrinth or vestibular nerve) is performed. This causes complete loss of hearing (deafness) in that ear. Another surgical intervention is establishing a shunt from the inner ear to the subarachnoid space. This procedure helps drain the fluid & prevent future hearing loss. Another surgical Rx is intratympanic gentamicin injection . 206 Ménière’s disease Cont’d…

204. Nursing Management. Nursing management focuses on managing the patient’s symptoms and providing safety during the acute attacks. Administer medication, monitor fluid and nutritional status, and ensure safety. Protect from injury during attack, use side rails; encourage patient to lie down during attack Instruct patient to pull of road if driving when an attack occurs Post operative care for patient with total labyrinthectomy Bed rest for 2 days due to severe vertigo Instruct patient to avoid sudden movements 207 Ménière’s disease Cont’d…

205. Thank you 208