Hearing loss is a common condition, affecting about 9 million people in England. It usually happens gradually as people get older and is most common in people over 65. Hearing difficulties can happen at any age and have several causes. People often put off getting help for hearing loss, yet it can have a major impact on their quality of life, causing them to lose confidence and feel isolated from family and friends. It can also lead to depression and anxiety (National Institute for Health and Care Excellence (NICE), 2018).
Consequently, monitoring and maintenance of hearing are fundamental parts of nursing assessment (Dougherty et al, 2015). Apart from hearing, ears are crucial for balance, and poor hygiene can contribute to poor hearing and cerumen impaction (also known as earwax impaction) (Millward, 2017).
Anatomy and physiology
It is important that health professionals understand the anatomy and physiology of the ear to enable them to assess and diagnose ear conditions. The ear has three main parts (Figure 1):
Abnormalities
Cerumen excess
Cerumen build-up, which is common, can prevent adequate clinical examination of the ear and sometimes delay investigations and management. Each year, an estimated 2.3 million people have issues with cerumen that are sufficient to need intervention (NICE, 2018). Some of the most common causes of build-up and ear damage is due to the use of hearing aids or earbud-type headphones, and the use of cotton buds (Castella, 2018). Other reasons for build-up or impaction include working in very dusty or dirty environments, patients having excessive hair in or around their ears, or having ears with narrow ear canals (O'Brien, 2012).
Symptoms of cerumen build-up include tinnitus, vertigo, discharge, pain, hearing loss, and otitis externa. Treatment of cerumen impaction includes using pre-treatment wax softeners either immediately before or up to 5 days before ear irrigation or syringing is carried out by an appropriately qualified health professional (Castella, 2018). Common types of softeners recommended by NICE (2018) guidelines and the Institute for Quality and Efficiency in Health Care (2017) include warm olive oil, almond oil, water or cerumenolytics such as urea hydrogen peroxide 5.0% w/w.
Ear irrigation is an invasive procedure. Wax softeners are advised as a first line of treatment and the procedure should be carried out by a qualified practitioner (Dougherty et al, 2015).
Otitis externa
Otitis externa is caused by inflammation of the external ear, which may be caused by infection or allergy.
It may also be due to excess wax trapping water in the EAM or to scratching the ear with sharp objects or contaminated fingernails (Brooker et al, 2015). A procedure called ‘aural toilet’ may be carried out by specialist practitioners to treat this condition (Rotherham NHS Foundation Trust, 2017).
Tinnitus
According to the British Tinnitus Association (BTA) (2017) 10–15% of the population experiences tinnitus. It affects both sexes and is more common in older people; however, it can occur at any age. It is associated with the perception of hearing buzzing, ringing or whistling in one or both ears, or noises for which there is no external source. It can also be associated with a heightened awareness of spontaneous electrical activity in the auditory system (BTA, 2017). Those with tinnitus also describe a ‘blocked sensation’, despite having normal middle ear pressure and eardrum mobility.
Assessment and pre-procedural considerations
Examine the ear for any discharge, swelling, tenderness, redness, and then the amount and texture of any cerumen present to determine the current health of the ear. Inspection of the inner ear is carried out using an otoscope (Marieb and Hoehn, 2013). At this point in the assessment, the nurse must establish the patient's current level of hearing; although hearing tests are carried out by audiologists, it is also the nurse's responsibility to assess hearing (Berman and Snyder, 2012). It is important to ensure that the patient understands the need to lie still in order to avoid injury with the dropper due to sudden movement (Dougherty et al, 2015).
Nursing assessment for hearing
It is important to establish the type of hearing loss the patient is experiencing, particularly if it is due to wax impaction or infection, such as otitis externa. Referral to an audiology specialist for diagnostic treatment may be required, especially if the hearing loss has developed suddenly or has specific additional symptoms (NICE, 2018).
The guidelines also state that, if the hearing loss occurred suddenly (over 3 days or less), the person should be seen immediately (within 24 hours) by an ear, nose and throat (ENT) specialist or in an emergency department to establish the cause. If the hearing loss has occurred over more than 30 days, then the individual should be seen within 2 weeks by either an ENT specialist or the audiovestibular medicine service. Finally, if the hearing loss lasts between 4 and 90 days, the individual should be referred to these services within 2 weeks.
NICE (2018) guidance states that stroke guidelines may need to be followed if a patient presents with symptoms that include facial droop or unilateral hearing loss to the affected side. Similarly, those with otorrhoea (ear discharge) and otalgia (earache) who have not responded to treatment within 72 hours may need to be referred to specialist services.
The NICE guidance includes further information on associated ear disorders (NICE, 2018).
There are several ways to assess hearing, including the whispered voice test, and tuning fork tests such as the Weber and Rinne tests (Table 1 and Figure 2). These can help identify conductive and sensorineural hearing loss (Epstein et al, 2008; Douglas et al, 2013; Rawles et al, 2015; British Society of Audiology, 2016). The British Society of Audiology (2016) recommends a 512 Hz tuning fork because the tone does not fade too quickly.
| Whispered voice test |
Procedure
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| Weber test (tests for lateralisation) |
Procedure
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| Rinne test (tests for comparison of loudness of perceived air conduction with bone conduction) |
Procedure
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Ear cleaning
Speaking and regular jaw movement make the ear canal self-cleaning, allowing the cerumen to make its way up to the EAM, where it emerges onto the skin (Oladeji et al, 2015.). However, if there are issues with the ear canal's natural cleaning, then this may become impacted (Burton et al, 2016).
Dougherty et al (2015) suggest that ear cleaning should take place after bathing and showering, and cotton buds or similar should not be inserted in the ear. Recommendations on cleaning the outside of the ear are to use a dry tissue or alcohol-free baby wipe to clean behind and around the ear.
Administering ear drops
Indications for ear drops vary, but may include infection; to reduce discomfort and inflammation; or to treat infection. However, in cases of a perforated ear drum, the instillation of ear drops is contraindicated. In specific cases where this is advisable, the drops should be administered with caution while maintaining asepsis (Hogston and Marjoram, 2011) (Table 1 and Table 2).
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Types of ear drops
Medication for the ear can be in the form of drops, sprays, ointments and solutions. Absorption of the medication may be affected by the presence of cerumen or the acidic environment around the ear skin surface (Dougherty et al, 2015). Ear drops are single-person use only, and it must be noted when the medication was opened. Special instructions should be followed, for example if the drops need to be stored at a specific temperature or used within a certain timeframe.
Drops tend to absorb rapidly into the system providing a more sustained drug release (Baillie, 2014).
Conclusion
This article has outlined the anatomy and physiology of the ear, alongside identifying some common abnormalities of the ear. The role of the nurse in providing ear care and assessing for hearing has also been discussed, together with some considerations that need to be taken into account when undertaking assessment and care of the ear within clinical practice.