It is one of the sensory organ which is responsible for hearing and balancing.

  • There are 2 ear situated on the lateral sides on cranium.
  • Ear consist of 3 parts.

External ear

Middle ear

Inner ear

External ear

  • Auricle
  • External ear canal
  • Tympanic membrane
  • Mastoid process

Middle ear

  • Inner side of the tympanic membrane
  • Boney ossicles
  • Eustachian tube
  • Round and oval window

Inner ear

  • Cochlea ( organ of corti)
  • Semicircular canal
  • 8th nerve

Mastoid process

Boney ridge located over the temporal bone.

Tympanic membrane

Is a thick transparent sheet of tissue that provide a barrier between external and middle ear. It is intact transparent, pearly gray colored concave in shape and should be free from lesion.


Eustachian tube

Open into the middle ear allow for equalization of pressure of both sides of the tympanic membrane.

Round and oval window

Middle ear is separated from the inner ear by this membrane.

Bony ossicles

  • Malleus
  • Incus
  • Stapes

Semicircular canal

Containing fluids and hair cells connecting to sensory nerve fiber of the 8th cranial nerve , it maintain balance.


Spiral shaped organ of hearing.

Organ of corti

Hearing receptors are present in this part.

8th cranial nerve (Vestibular cochlear nerve)

  • Cochlear branch: Transmit neural impulses from cochlea to the brain.
  • Vestibular branch: Transmit neural impulses from semicircular canal, utricle and sacule to the brain.

Diagnostic procedure

Otoscopic examination

The speculum is never blindly introduce in to the external canal to avoid injury in tympanic membrane.

  • Tilt the client head slightly away and hold the otoscope properly to permit the examiners hand to lie against the client head for support.
  • Pull the pinna back and up to straighten the external auditory canal.
  • Visualize external canal while slowly inserting the speculum.

Auditory test

  • Sound is transmitted by air conduction and bone conduction.
  • This test is used to access problem with air or bone conduction.

Screening test

  • Voice test
  • Ask the client to block one external canal.
  • Examiner stands one to two feet away and quietly whisper a statement.
  • Client is asked to repeat the whispered statement.
  • Each ear should be tested.
  • Watch test
  • A ticking watch is used to test for high frequency sound.
  • Examiner hold the ticking watch about 5 inch away from each ear and ask the client if ticking is heard.
  • Tuning fork test
  • Weber test
  • Rinne test

Weber test

  • Place the vibrant tuning fork stem in the middle of the client head at the midline of the forehead or above the upper lip over the teeth.
  • Hold the fork by the stem only.
  • The client is asked whether the sound is heard from midline of the head or from any side.
  • Normal: sound from midline or equally from both ears.
  • Conductive hearing loss: Sound from poorer ear.
  • Sensory neural hearing loss: Sound from better ear.

Rinne test

    • Test compares the client hearing by air conduction and bone conduction.
    • Examiner will place tuning fork in front of pinna and mastoid bone, and ask client to compare the sound (Which is louder).
    • If client is hearing better from in front of pinna it called + rinne.
    • If the client is hearing better from mastoid bone it called – rinne.
    • Normal and sensory neural hearing loss patient will be having + rinne.
    • Conductive hearing loss patient will have – rinne.

Vestibular assessment

Test for falling

  • The examiner ask the client to stand with the feet together and the arms hanging loosely at the sides with eyes closed.
  • The client normally remains erect with only slight swaying.
  • A significant sway is a positive Romberg sign.

Test for past pointing

  • Client sits in front of the examiner.
  • Client close the eyes and extent the arms in front by pointing both index finger at the examiner.
  • The examiner holds and touches his or her own extended index finger of the client to give the client a point of reference.
  • The client is instructed raise both arms and then lower them by attempting to return to the examiner index finger.
  • If the client can return to the point of reference means normal.
  • If the client with a vestibular function problem lacks a normal sense of position and is unable to return the extended finger to the point of reference. Instead the fingers deviate either to the right or to the left of the reference point.

Gaze nystagmus evaluation

  • Examine the client eye as they look straight ahead 30degree to each sides upward and downward and spontaneous nystagmus in any direction represent a problem with the vestibular system.

Diagnostic evaluation

  • Tomography
  • May be performed with or without contract medium.
  • Multiple X ray of the head are done to access the mastoid process, middle ear structures and inner ear structures to diagnosis acoustic neuroma .
  • Audiometry
  • Pure tone audiometry
  • Speech audiometry

Pure tone audiometry

  • It is used for identifying problem with hearing.
  • Pure tone is used for assessing hearing.

Speech audiometry

  • Client ability to hear spoken words is measured.

After testing audiogram patterns are depicted on a graph to determine the type and level of the hearing loss.


  • Inform the client regarding the procedure.
  • Instruct the patient to identify the sound as they heard.

Electro nystagmography

  • This is vestibular tests that evaluate spontaneous and induced nystagmus.
  • It is used to distinguished between normal nystagmus and either medication induced or nystagmus caused by a lesion in the central or peripheral vestibular pathway.
  • Record changing electrical field with the movement of the eye as monitored by electrodes placed on the skin around the eye.


  • Keep patient NPO for 3hrs.
  • omit unnecessary medication before 24hrs.
  • Instruct the client that this is a long and tiring procedure. Client should bring prescribed eye glass for the exam.
  • The client sits and is instructed to gaze at light focus on a moving pattern, or a moving point and then sit with the eye close.
  • While sitting in a chair the client may be rotated to provide information about vestibular function, in addition the client ears are irrigated with both cool and warm water which may cause nausea and vomiting.
  • Provide clear liquid after procedure.
  • Provide assistance for ambulation.



Caloric test (bithermal test, occulo vestibular test)

Provide information about the function of the vestibular portion of the 8th cranial nerve and aids in the diseases of cerebellum and brain stem lesion.


  • Patency of the external canal is conformed.
  • Cool or warm water is introduced in to the external auditory canal.
  • Stimulation of the auditory canal with warm water produces a horizontal nystagmus towards the side of the irrigated ear when the vestibular nerve is normal. If nystagmus occur away from the irrigated ear indicate damage in the vestibular nerve or portion with the brain stem.
  • Stimulation of the auditory canal with cold water produce a horizontal nystagmus away from the side of the irrigated ear indicates normal vestibular nerve.
  • If nystagmus towards the side of the irrigated ear damage in the vestibular nerve or problem with brain stem.

Disorder of ear

Risk factors of ear disorders

  • Aging process
  • Infection
  • Medication or ototoxicity (salycilate, gentamicine, streptomycin)
  • Trauma
  • Tumors


Sound waves are blocked in to the inner ear because of external or middle ear disorders.


  • Inflammatory process.
  • Obstruction of external or middle ear.
  • Thick sermon or purulent discharge.
  • Build up of scar tissue on the tympanic membrane from previous middle ear surgery.


Pathological process of inner ear or of the sensory fibers that lead to the cerebral cortex.


    • Damage of inner ear structure.
    • Damage to the 8th cranial nerve.
    • Prolonged exposure to loud noise.
    • Inherited disorders.
    • Medication, trauma and infection.
    • Circulatory disorder.
    • Meniere’s disease.
    • Myxedema (hypothyroidism).
    • Brain tumor.

Signs and symptoms

  • Frequently asking people to repeat the statement.
  • Straining to hear.
  • Turning head or leading forward to favor one ear.
  • Shouting in conversation.
  • Raising volume of TV and radio
  • Failing to response when not looking in the direction of sound.
  • Answering questions incorrectly.
  • Withdrawing from social interaction.

Facilitating communication

  • Using written words if the client is able to read.
  • Provide plenty of light.
  • Get the attention of people before speaking.
  • Talk in a room without disruption of noise.
  • Move close to the client and speak slowly and loudly.
  • Validate client statement by asking to repeat what was said.
  • Correct vision problem to encourage lip reading.
  • Use sign language.
  • Specially trained dogs that help the client to alert from potential danger.
  • Use flash light as on phone and call bell system
  • Use hearing aids or cochlear implant.

Hearing aids

  • Used for conductive hearing loss.
  • Adjust the volume level to minimal hearing level to prevent feedback squeaking.
  • Teach the client to concentrate on the sounds that are to be heard and to filtered out background noise.
  • Instruct the client to clear the ear mold with mild soap and water.
  • Avoid excessive sweating of hearing aid and keep aid dry.
  • Clean hearing aid tube with a pipe cleaner.
  • Turn off the hearing aid and remove battery when not in use.
  • Keep extra battery on hand.
  • Avoid hair spray or other hair and face products from coming in contact with the receiver of the hearing aids.

Cochlear implant

  • Use for sensory neural hearing loss.
  • Small computer converts sounds in to electrical impulses.
  • Electrodes are placed in the inner ear with a computer device attached to the external ear.
  • Electrical impulses directly stimulate nerve fibers.


  • Disease of the labyrinthine capsule of the middle ear that result boney growth surrounding the ossicles.
  • It leads to fixation of bones.
  • Stapes fixation leads to conductive hearing loss.
  • If inner ear affected (cochlear Otosclerosis) leads to sensory neural hearing loss.


  • May be family history
  • Menopause
  • Excessive calcium deposition
  • Congenital

Signs and symptoms

  • Hearing loss may be unilateral or bilateral.
  • Tinnitus (ringing sound in the ear).
  • Discoloration of the ear drum. (Pinkish)
  • Negative rinne test
  • Hearing loud noise while chewing.
  • Hearing better in a noisy situation.


  • Fenestration ( Removal of stapes and replacement of prosthesis).


  • Hearing loss
  • Prolonged vertigo
  • Infection
  • Facial nerve damage


  • Instruct the patient to prevent any ear infection.
  • Avoid excessive noise blowing.
  • Not to clean external ear with cotton swab.
  • Remove hearing aid two week before surgery to ensure integrity of local tissue.

Post opp

  • Inform the client that hearing is initially worst after the surgical procedure because of swelling and noticeable improvement in hearing for as long as 6 weeks.
  • Gel foam ear packing also interferes hearing. It is used to decrease bleeding.
  • Ambulate the patient after 1 to 2 days, assist the patient during ambulation.
  • Provide side rails when the patient is in bed.
  • Administer antibiotics, anti vertiginous and analgesics.
  • Assist for complications like facial nerve damage, facial weakness, change in tactile sensation, vertigo, nausea, and vomiting.
  • Avoid showering and getting the head and wound wet.
  • Instruct the client refrain from using small object to clean the external ear canal.
  • Avoid quick head movement, sneezing nose blowing straining and changes in altitude to prevent dislodgement of the graft or prosthesis.


Inflammation of the labyrinthine capsule caused by acute or chronic otitis media.

Signs and symptoms

  • Hearing loss
  • Tinnitus
  • Spontaneous nystagmus
  • Vertigo
  • Nausea and vomiting


  • Monitor for signs of meningitis.
  • Administer systemic antibiotics.
  • Administer antiemetics and antivertiginous medication.
  • Instruct patient that vertigo subside as the inflammation resolves.


  • A chronic disease of the inner ear characterized by recurrent episodes of vertigo, progressive sensory neural hearing loss and tinnitus.
  • This is a syndrome, also called as endolymphatic hydrops, which refers to dilation of endolymphatic system by over production or decreased absorption of endolymphatic fluid.
  • Repeated damage to the cochlea cause by increased fluid pressure leads to permanent hearing loss.


  • Any cause that increase endolymphatic secretion in inner ear.
  • Viral and bacterial infection.
  • Allergic reaction.
  • Biochemical disturbance.
  • Decrease blood circulation leads to decrease absorption.

Signs and symptoms

  • Feeling of fullness in the ear.
  • Worsen hearing loss.
  • Tinnitus
  • Vertigo
  • Nausea, vomiting
  • Nystagmus


   Non surgical

  • Provide safety precaution.
  • Provide resting quit room.
  • Assist the patient while walking.
  • Move head slowly to prevent worsening of vertigo.
  • Restrict fluid water and sodium.
  • Avoid smoking.
  • Administer nicotinic acid (niacin) to dilate blood vessel and increase absorption.
  • Administer antihistamines to decrease production of histamine and to suppress inflammation.
  • Administer antiemetics as prescribed.
  • Administer sedative to calm down the patient.

Surgical management

  • Endolymphatic drainage with insertion of shunt.
  • Resection of vestibular nerve.
  • Labyrinthectomy (removal of semi circular canal)


  • Assess packing and dressing on the ear.
  • Speak from unaffected side.
  • Perform neurological assessment.
  • Maintain side rails.
  • Assist with ambulation.
  • Encourage use of bedside commode
  • Administer anti vertiginous, and antiemetic medication.


Inflammation of the middle ear occurring as a result of blocked eustachian tube tube which prevent normal discharge.


  • Respiratory infection

Signs and symptoms

  • Fever
  • Irritability
  • Restlessness
  • Loss of apatite
  • Rolling of head from side of side
  • Pulling or rubbing of ear
  • Ear ache
  • Hearing lose
  • Purulent discharge
  • Red opaque bulging tympanic membrane


  • Increased fluid intake
  • Feed infant in upright position
  • Avoid chewing
  • Apply hot compress to promote comfort
  • Clean the drainage with sterile cotton
  • Administer analgesic and antipyretics
  • Administer antibiotics up to 10 to 14 days to eradicate infection
  • Access for hearing loss

Surgical management

  • Myringotomy: insertion of tympanoplasty tube in to middle ear to equalize pressure and to keep ear aerated.

Post opp management

  • Keep the ear dry
  • Keep the patient in supine position with operated ear upward.
  • Client education
  • Avoid strained activity
  • Avoid rapid head movement
  • Avoid bending
  • Avoid straining on bowel movement
  • Avoid travelling by air
  • Avoid forceful coughing
  • Avoid drinking threw a straw
  • Avoid contact with person with cold
  • Avoid washing hair, and showering for one week as prescribed
  • Instruct the client that not to blow the nose at a time, blow one side at a time with a mouth open.
  • Instruct the client to keep ear dry by keeping a ball of cotton, coated with petroleum jelly in the ear and change cotton ball daily.
  • Instruct the client to report to physician if there is excessive ear drainage.
  • Client should wear ear plug during bathing, shampooing and swimming.
  • Diving and submerging under water are not allowed.


            Inflammation of mastoid process.

Types:  Acute and Chronic

Cause : Untreated otitis media

Signs and symptoms

  • Swelling behind the ear
  • Pain with minimal head movement
  • Cellulites on the skin or external scalp over mastoid process
  • Red dull thick, immobile tympanic membrane with or without perforation
  • Tended or enlarged post auricular lymph node
  • Low grade fever
  • Malaise
  • Anorexia


Simple or modified radical mastoidectomy with tympanoplasty.


  • Damage to the facial and abducens cranial nerve
  • Meningitis
  • Brain abscess
  • Chronic otitis media
  • Wound infection

post operative nurses responsibility

  • Monitor for dizziness
  • Monitor complications
  • Change wound dressing after 24 hrs
  • Monitor the surgical incision for edema drainage and redness
  • Position the patient flat with operative side up
  • Provide bed rest with bedside commode privilege for 24
  • Assist with ambulation

Acoustic neuroma

A benign tumor of the vestibular or auditory nerve that lead to damage to hearing and facial nerve function like facial movement and sensation.

   Signs and symptoms

  • Tinnitus
  • Hearing loss
  • Dropping of facial muscle


Removal of tumor via craniotomy.


Injury to the tympanic membrane, due to any pressure. because tympanic membrane has a limited strutting capacity.


  • Foreign object placed in the external ear.
  • Any blunt injury to the basal skull or ear
  • Excessive noise blowing.

Signs and symptoms

  • Bleeding
  • Reduced hearing and pain



  • Spontaneous healing with in 24hrs.
  • Reconstruction of ossicles and tympanic membrane.

Cerumen and foreign body

  • Cerumen or wax is the most common cause of impacted ear
  • Foreign body can include vegetable, seeds, pencil, insects etc.

Signs and symptoms

  • Sensation of fullness in the ear
  • May or may not be hearing loss
  • Pain, itching or bleeding


  • Cerumen
  • For soft Cerumen add three drops of glycerin to the ear at bed time and three drops of hydrogenperoxide twice a day.
  • After several days given ear irrigation with 50-75 ml of solution.
  • Irrigation is contra indicated in client with a history of tympanic membrane perforation.
  • Foreign body
  • With foreign object of vegetable and seeds irrigation is used with care because these materials expand with hydration.
  • Insects are killed before removal so put mineral oil or alcohol to the ear to suffocate the insect which is then removed with ear forceps.
  • Insects can be coaxed out by flashlight or a humming noise
  • Use small ear forceps to remove the object and avoid pushing objects in to the ear



            Tonsillitis refers to the inflammation and infection of tonsil.

Adenoiditis refers to the inflammation and infection of adenoids.

  Signs and symptoms

  • Persistent and recurrent sour throat.
  • Enlarged bright red tonsil that may be covered with white excaudate.
  • Difficulty in swallowing (dysphagia)
  • Pain full swallowing (odinophagia)
  • Mouth breathing and unpleasant mouth odor.
  • Fever
  • Cough
  • Enlarged adenoids may cause nasal quality of speech, mouth breathing, hearing difficulty, snoring, and obstructive sleep apnea.


 pre operative

  • Access signs of active infection.
  • Access bleeding and clotting studies because of high vascularity of glands
  • Prepare the child for sour throat post operatively.
  • Access for any loose tooth to reduce the risk of aspiration during surgery.

post operative

  • Provide prone position or side line position to facilitate drainage.
  • Have suction equipment available, but do not suction unless there is an airway obstruction.
  • Monitor for sign of hemorrhage, if occur turn the child to the side and notify to the doctor.
  • Discourage coughing or clearing the throat.
  • Provide clear, cool, non citrus and non carbonated fluids.
  • Avoid milk product initially because they will coat the through.
  • Avoid red liquids which will stimulate the appearance of blood if the child vomits.
  • Do not give straw or sharp object that can be put in the mouth.
  • Administration of acetaminophen for sour throat.
  • Instruct the parent to notify the physician if bleeding persistent, persistent ear ache or fever occurs.
  • Instruct the parents to keep the child away from crowds until healing occurs.

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