Hearing Acuity
with sensorineural hearing loss.
Gross Assessment
Should be performed in a quiet room
-test the patient’s ability to hear your
whispered or spoken voice or the ticking
of a watch
Precise Assessment
-Audioscopy- uses an audioscope
• 40 dB intensity
• Frequency: 510, 1000,2000,4000
cycles per second (Hz)
-done with special equipment
(audiometer)
• Test one ear at a time while masking
the hearing in the other ear
• To “mask” an ear, have the patient
place a finger on the ear’s tragus &
push it quickly in and out of the
auditory meatus.
 WATCH TICKING TEST
- Hold a watch a few inches away from
the patient’s ear
- Move the watch slowly away from the
ear and ask the patient to say “now”
when ticking can no longer be heard
- Document the distance from the watch
to the ear from the point where ticking
stopped being heard.
 WHISPERED WORD TEST
- Stand 1-2 feet behind the client so they
can read your lips
- Instruct client to place one finger on
tragus of left ear to obscure sound
- Whisper word with 2 distinct syllables
towards client’s right ear.
- Ask client to repeat word back
- Repeat test for left ear
- Client should correctly repeat two
syllable word
• Whispered words & watch ticking test
consist mainly of high-frequency sound
& so are not easily heard by people
HEARING ASSESSMENT
• Tuning Fork Test
- Measure the air conduction (AC) and
bone conduction (BC) of sound
o AC- when sound waves are
transmitted through the air into the
auditory canal and so to the
eardrum, middle ear and inner ear
o BC- transmission of sound waves
through the cranial bones and inner
ear.
* AC is normally more sensitive than BC
2 types
1. Weber
2. Rinne test
 WEBER TEST
1. Distinguishes between conductive
and sensorineural hearing. Strikes a
512 Hz tuning fork softly
2. Place the vibrating fork on the
middle of the client’s head
3. Ask client if the sound is heard
better in one ear or the same in
both ears.
4. If hearing is normal, the sound is
symmetrical with no lateralization
• Sound localizes toward the poor ear
with a conductive loss
• Sound localizes toward the good ear
with a sensorineural hearing loss.
 RINNE TEST
1. Test compares air and bone
conduction on hearing , Strike 512
Hz tuning for softly
2. Place vibrating fork on the base fo
the mastoid bone
3. Ask the client to tell you when the
sound is no longer heard.
 4. Note the time interval and
immediately move the tuning fork
to the auditory meatus
5. Ask the client to tell you when the
sound is no longer heard.
6. Note the time interval and findings.
-N or (+) Rinne AC >BC
-AbN or (-) Rinne AC<BC
TUNING FORK TEST
 SCHWABACH TEST
- Examiner’s ear is assumed to be
normal
- Tuning fork placed near pinna of
subject
- Confirmed by the examiner when
sound is no longer heard
- Results:
o Prolonged: conductive loss
o Diminished: sensorineural loss
 ROMBERG TEST
- Done to test client equilibrium
- Have client stand with arms at side and
feet together
- Have client perform initially with eyes
open and then with eyes closed
- Client should maintain position for 20
seconds with only minimal swaying
• AUDIOMETRY
- Measure of hearing acuity
- Frequency
o Highness or lowness of sound
o The higher the frequency, the higher
the pitch
- Intensity
o Expressed in decibels (dB)
o Normal threshold -0 dB (51% of the
time)
o Painful for persons with normal
hearing-100dB
• PURE TONE AUDIOMETRY
- Pure tones presented at frequencies for
hearing, speech, music and other
common sounds
- Tested both for AC (earphones) and BC
(bone oscillator)
- Result is recorded as an audiogram
o Instruct the client
o Objective of the test is to determine
the softest sound that will elicit a
response (threshold)
o Tones will be presented that will
sound like bells or tuning forks
o Upon hearing- client should raise
hand or press button on presenting
side.
o When sound is no longer heard –
client lowers hand or releases button
o Test better ear first
• SPEECH AUDIOMETRY
- Speech reception threshold- minimum
loudness to repeat simple words.
- Uses a series of simple recorded words
spoken at various volumes into
headphones worn by the patient being
tested
- The patient repeats each word back to
the audiologist as it is heard.
- And adult with normal hearing will be
able to recognize and repeat 90-100%
of the words.
• SPEECH DISCRIMINATION
- Tests ability to distinguish similar
sounds or words with similar sounds
- Assesses understanding of speech
- Uses 25-50 monosyllabic words
phonemically balanced with equal
difficulty
- 30-40 dB above speech reception
threshold
• TYMPHANOMETRY
- Test determines the functionality of the
tympanic membrane by observing its
response to waves of pressure, and
measuring the pressure.
- Assess mobility of eardrums
- Varies air pressure in the external
auditory canal
- For middle ear pathologic-conditions.
• AUDITORY BRAIN STERM EVOKED
RESPONSE (ABR)
- Represents the electrical response of
the CN VIII and some portion of the
brainstem which occurs 10-12 msec
after an auditory stimulus is sensed by
the inner ear
- Series of clicks are presented at 75 dB
or 80 dB above threshold
- Results is similar to EEG- waves are
interpreted
- Used in newborn hearing screening
Other Ancillary Tests
• CT Scan- structures of the ear
• MRI- greater sensitivity to soft tissue
changes
Precautions for Vestibular tests
• Performed last because may induce
nausea and vomiting
• Prior to test, patient should be advised
to come in with companion
• Limit food intake prior to test
• Advice against driving after the test;
arrange for transportation
• Have emesis basin, tissue/towel/drapes
ready
• Hold patient in examination room until
balance is regained
Vestibular tests
*Electronystamography or
Videonystagmography
- Patient should have adequate vision to
follow visual targets
- detects both central and peripheral
disease of the vestibular system
-Detects nystagmus or the vestibule-
ocular reflex
-May be contraindicated in patients with
history of previous seizures due to ocular
stimulation with lights.
CALORIC TESTING I-it is performed to
evaluate acoustic nerve which provides
hearing and balance.
 This test may be recommended
1. When someone is experiencing
dizziness or vertigo
2. When there is hearing loss with
suspected toxicity from certain
antibiotics
3. With some anemias
 Caloric stimulation is performed to
evaluate the acoustic nerve, which
provides hearing and helps with
balance.
4. When psychological causes or vertigo
are suspected
5. To determine the presence or extent
of brain damage in a comatose
person
LABORATORY TESTS
• Dix-Hallpike Test
- make sure that the patient has no neck
injury!
-Pull patient to a supine position form a
sitting position
-Induces vertigo in patients with BPV
-Nystagmus is evident within 5-10 sec
 BARANY CHAIR
-swivel 360 degrees to check for
stimulation of the vestibular system. At
right, an astronaut at NASA undergoes
a test on a Barany chair.
STRUCTURES OF NOSE AND SINUSES
-Nose is lined with respiratory mucosa,
except the vestibule (lined with skin
containing nasal hairs/ vibrissae)
-Mucus secreted from respiratory mucosa
is carried back into the nasopharynx by
ciliary movements
-nasal mucosa is normally redder than oral
mucosa because the lining of the nasal
cavities is very vascular
-Blood carries moisture and heat to the
mucosa
-Nasal blood supply comes from the
external and internal carotid systems.
-air enter the nose through 2 nostrils
(nares), separated by the nasal septum
(composed of cartilage and bone)
-Nasal cavities, located between the roof
of the mouth and the frontal ethmoid, and
sphenoid bones
-On the lateral walls of each nasalcavity
are three projections.
• Superior turbinate
• Middle turbinate
• Inferior turbinate
- The turbinate conchae increase the
area of mucus membrane over which
air passes
- Paranasal sinuses are airfilled cavities,
lined with mucous membrane
surrounding the nasal cavities
- Sinuses drain into the nasal cavities
through opening in the grooves
between the turbinates.
- Maxillary sinuses (antra)
• Largest and most accessible
• Located on either side of the nose in
the maxillary bones
-Frontal sinuses
• Lower forehead between and above
the eyes
- Sphenoid sinuses
• Rear of the nasal cavity
- Ethmoid sinuses
• Between the eyes and nose
- Olfactory cells
• Located in the olfactory membrane
covering the roof of the nose and the
floor of the anterior cranial fossa
- Nasolacrimal duct
• Small duct communicating indirectly
with the lacrimal glands and the nose
FUNCTION OF NOSE AND SINUSES
• Principal functions:
-olfaction (smelling)
-Air conditioning (controlling air temp
and humidity and removing particles
before air enters the trachea, bronchi,
and lungs).
-Olfactory cells- neurons that divide
into numerous hairlike processes in the
olfactory membrane
- Axons form the cell bodies become the
olfactory nerve, which passes to the
olfactory center in the brain.
PHYSIOLOGY OF SMELL
-Turbulence from sniffing increases air
flow in supper turbinates near olfactory
mucosa
FUNCTION OF NOSE AND SINUSES
-temp. is controlled by the enlargement - (anteriorly) using a nasal sepeculum
and contraction of “blood spaces” or” and (posteriorly) with a
swell spaces” in the erectile tissues in the nasopharyngeal mirror
turbinate bones. • Causes of nasal obstruction

- When inspired air is cold and dry water Examination of Nasopharnyx

is absorbed by it from the nasal • Best examined with a mirror with the
mucosa tongue depressed with a tongue blade
- A blanket of serum and mucus covers or gauze
the nasal mucosa surface • Specialist may use a
- As much as 1L of moisture can be nasopharyngoscope to examine the
evaporated from the nose during 24 nasopharynx
hours of normal breathing
- Submucosal glands replenish the Examination of Paranasal Sinuses
moisture • Inspecting and plapating the soft
- Particle control is achieved by the overlying tissues
mucous throughout the nose, sinuses, • Observing any nasal secretions
pharynx, trachea, bronchi, and • Transillumination of the maxillary and
bronchioles frontal sinuses
- Airborne particles cling to this viscid • To more completely assess sinus
blanket conditions, sinus x-rays may be used
- The mucous blanket secretions contain
the enzyme lysozyme to combat Smell Assessment
microorganisms • Senses of taste and smell are closely
- The beating action of cilia carries the related
blanket back toward the pharynx, • Smell and Taste are affected by
where it is swallowed - Many conditions (viral infection, normal
- Any residual bacteria are then aging, head injury, local obstruction)
destroyed by gastric juice and HCL - Medications( metronidazole, local
- Sinus function is not definitely know anesthetics, some antibiotics,
- Lighten the weight of the skull allopurinol, codeine, morphine,
- Give vocal resonance and timbre carbamazepine, lithium)
- Produce mucus for the nasal cavity • Smell impairment
ASSESSMENT OF NOSE AND - Hyposomia (decrease in smell
SINUSES sensitivity)
• History - Anosmia (bilateral and complea
• Examination of Nose, Nasopharynx and absence of smell sensitivity)
Paranasal Sinuses
• Smell assessment  Have the patient identify various odors
• Diagnostic procedures  Test each nostril separately
 Have the patient sniff tubes (first with
Examination of Nose eyes open)
• External nose
 Document whether the patient can
-symmetry, swelling, redness, lumps
o Perceive each odor
• Nasal Chamber
o Identify each oder accurately
 Smell is perceived mainly via Olfactory temporary relief, the nose becomes
nerve (CN1) although some are more stuffy.
perceived via the trigeminal nerves • Vasoconstrictors can be systematically
(CN V) absorbed and should not be used by
 Trigeminal irritants are perceived even hypertensive patients unless
by patient with anosmia prescribed
• Some nasal medication may cause
Olfactory and Trigeminal Stimulants distressing symptom (restlessness,
• Olfactory heart palpitations and tension)
- Coffee (instant powder) • Oil-based solutions are of usually used
- Phenylethyl alcohol since they interfere with normal ciliary
- Almod oil action and may cause pneumonitis if
- Peppermint aspirated
- Musk
 Instilling Nose Drops
• Trigeminal • Direct nose drops toward the problem
- Ammonia area by positioning the patient in such
- Acetone a way that the drops flow toward the
- Menthol affected area
• Support the person’s head with one
DIAGNOSTIC PROCEDURES hand
- Nose and Throat cultures • Observe the person’s reaction to the
- X-ray medication
- CT scan • Ask the patient to remain still for at
- MRI least 5 mins after the drops are
instilled and to breathe through the
COMMON NASAL INTERVENTIONS mouth
• Solution can drain into the posterior
 Nasal Medications nose give the person a basin to
• Drops, spray, aerosol (nebulizer) expectorates solution running into the
• Most often instilled into the nose are oropharynx and motuh
vasoconstrictors (phenylephrine) used • Have tissues available to wipe excess
mainly to reduce nasal congestion solution from the external nares and
• Use only as prescribed to avoid face
rebound effect
• 0turbinate engorgement is controlled  Nasal Aerosol
by ANS • Also used to diffuse medication over
• Vasoconstrictors stimulates the nose’s inner surface
sympathetic nerves, hence, • Usually self-administered
compensatory relaxation of the turbinal • Shake aerosol before use
vesssels occur after the medication has • Tilt head back
stopped • Occlude one nostril and insert tip into
• This relaxation is accompanied by other nostril and administer one dose
nasal stuffiness, thus, after a period of of medication
 Nasal Irrigation - Breather through mouth
• Occasionally prescribed to clean the - Periodically assess nasal packings
nose - Elevate head
• Normal saline solution is most - Do not blow nose
commonely used - Patient’s mouth may become dry and
• Usually self-administered for chronic develop an unpleasant taste and odor
nasal conditions due to mouth breathing blood and post
• Aspiration is a potential hazard nasal discharges.
 Alteration in comfort due to pain and
 Nasal Packs anxiety
• Made of small petroleum gauze or - Nasal surgery is not usually painful but
small cotton ball soaked in epinephrine may be uncomfortable because of the
• Inserted by a physician packing
• Explain procedure to patient - Ice packs or cold compress may be
• Take and document the patient’s VS prescribed to reduce pain and edema
periodically through the procedure - Pain may be reduced by promoting
• Assist the physician while inserting the drainage
packing - Help the person to relax
• Help the patient into a comfortable
sitting position  Alteration in nutrition, less than body
• Encourage patient to breath through requirements due to difficulty
the mouth swallowing
• Tell the patient to expectorate any - Give fluids as prescribed (usually liquid
blood accumulating in the nasopharynx diet)
and not to swallow it - Be sure that gag reflex has returned
• Airway obstruction can occur if a before giving oral liquids
posterior nasal pack accidentally slips - Oral hygiene before meals may
out of place improve the person’s appetite
• When packing is removed, tell patient - Encourage fluid intake
not to blow the nose for 48 hrs.
because of danger of bleeding COMMON NASAL AND SINUS
DISORDER
Nursing intervention for Post- • Rhinitis
Nasal Surgery patients • Common cold
 Remind the patient to • Allergic rhinitis
- Breathe through the moth (because of • Non-allergic vasomotor rhinitis
nasal packing) • Nasal polyps
- Do not blow the nose • Hypertrophied turbinates
- Spit out drainage accumulating in the • Foreign bodies
nasopharynx • Nosebleed (epistaxis)
 After sinus surgery, If GA is given, turn • Deviated nasal septum
the patient on to the side to prevent • Nasal Fx
aspiration of bloody drainage before • Infected an Hypertrophied adenoids
consciousness returns. • Sinusitis
 Ineffective airway clearance
 Epistaxis
- Nosebleed
- May occur spontaneously or result form
diease or trauma
- Minor trauma is the most common
cause
- More severe causes
o Severe trauma
o Deviated or perforated nasal septum
o Acute sinusitis
o Local cancer
o HPN, sclerotic blood vessels, acute
rheumatic fever, leukemia
Emergency care for Anterior Nosebleed
- Position client upright and leaning
forward
- Reassure and reduce anxiety
- Apply direct lateral pressure to the
nose for 5 minutes
- Apply ice or cold compress to the nose
if possible
- To prevent re-bleeding, instruct to
avoid blowing the nose
- Seek medical assistance if persistent
 Nasal Polyp
- Benign, grapelike clusters of mucous
membrane and connective tissue
- Gradually form from recurrent,,
localized swellings of the nasal sinus
mucosa
- Once fully developed, they appear as
smooth pale tumors with pedunculated
bases
- Usually multiple and insensitive to
touch
- Most common site in the nose is the
middle meatus
- Most frequently develop in people who
have allergic rhinitis
- Symptoms of nasal obstruction occur
when the polyps become large enough
to obstruct the airways
- Large persistent polyps are surgically
removed (polypectomy)
 Nasal Fx
- Nasal & nasopharyngeal bleeding
- Disfiguring soft tissue edema around
the nose after the injury
- Apply ice bag and tightly hold the nose
- Once edema occurs, wait for 2 or 3
days for the edema to subside before
setting the Fx
- Skull x-rays to rule out possible skull Fx
- And identify the location of Fx and
bone fragments
- Reduced under anesthesia, displaced
bone fragment are pushed into proper
alignment and held in place with
intranasal packing or external
dressings or nasal splints
 Common Cold
- Simple acute viral rhinitis (coryza)
- Most common problem of the nose and
sinuses
- Inflammation of the nasal mucosa
- Caused by filterable virus and is spread
by droplet contact from sneezing
- Contagious for the first two or three
days
- Causes
o Rhinovirus, adenovirus, influenza,
virus, parainfluenza virus,
mycoplasma
• Symptoms
- Burning or irritation in the nasopharynx
- Sneezing, chillness, copious nasal
discharge, muscular aching, malaise,
mild fever
- Headache for the first 2 days
- Nasal discharge becomes purulent and
increasing nasal obstruction occurs
- A sore throat does not usually occur
with a common cold
- Self-limited
- Treatment is symptomatic
- No specific cure
- Antibiotics aer not indicated
- Secondary invasion of bacteria may
complicate a common cold causing
symptoms to persist and become
worse
 Allergic Rhinitis
- Hay fever
- Triggered by hypersensitivity reactions
to airborne allergens
- May be seasonal and acute or
perennial and chronic
• S/sx
- Sneezing, nasal obstruction, tearing,
recurrent thin nasal discharge, frontal
headache, itchiness of eyes and nose
- Turbinates are typically hyperemic and
edematous
- Nasal mucosa appear smooth and
glistening
• Treatment
- Eliminate or limit intake of chocolate,
milk, and eggs
- Cover mattress and pillow with plastic
- Do not touch domestic animals
- Use non-allergenic cosmetics
- Cover overstuffed furniture
- Use antihistamines as prescribed
- Install air condition in the house avoid
wool bedding.
 Seasonal Allergic Rhinitis
- Acute episodes lasting for several
weeks and then disappears and recurs
the same time the next year.
- Usually caused by grass pollens,
flowers or trees
 Chronic Rhinitis
- Constantly present or may occur
intermittently w/o any seasonal pattern
over a period of many years
- Often associated with allergic sinusitis
- Sensitivity to contacts constantly
present in our environment (domestic
animal hair, dandruff, newspaper, wool,
house dust, foods, tobacco)
- Less severe than seasonal allergic
rhinitis but treatment is more difficult
since it us usually hard to identify the
allergen
 Non-allergic Vasomoto rhinitis
- Chronic, intermittent nasal obstruction
or stuffiness often accompanied by
nasal discharge
- May result from stress, nervousness,
tension, or some endocrine problems
- Symptoms may be aggravated by
changes in environmental changes in
environmenta temp
- Treatment
o Sympathomimetics
-RHINITIS OF PREGNANCY
- Nasal congestion resulting from
estrogen-mediated mucosal engorgement
-May occur with oral contraception
> Rhinitis Medicamentosa/Drug-
induced
-“Rebound: nasl congestion from overuse
of nose drops or sprays
 SINUSITIS
- Inflammation of sinus producing an
inflammatory mucosal change
- Head pain and mucoid nsal discharge
are often attributed to sinusitis
- Causes:
o Infection spread from the nasal
passages to the sinuses
o Blocked routes of normal sinus
drainage
- Purulent or non-purulent
- Acute or chronic
- Types (ethmoid, frontal, maxillary or
sphenoid)
 ACUTE SINUSITIS
- Caused by infection (pneumonia, Anatomy of the Pharynx
influenza, rhinitis) passing into the • Nasopharynx
sinuses via the nasal passages -Located behind the nose, above the soft
- Assessment palate
o Malaise, lack of appetite, nausea, - Contains adenoids (pharyngeal tonsils)
nasal obstruction, congestion and openings of the Eustachian tube
o Purulent nasal discharge, fever
pressure over the involved sinuses, • Oropharynx
pain - Extends from the soft palate to the
-Tx base of the tongue
o Relieve pain with analagesics - With palatin tonsils (faucial tonsils)
o Promotes sinus drainage by adequate
fluid intake, moist steam inhalation, • Laryngopharynx
mucolytics - Extends from the base of the tongue to
o Control infection the esophagus
o Increase resistance with rest, well- - Critical dividing point between
balanced diet and reduced stress respiratory and digestive passages

 SINUSITIS Physiolgy of Pharynx

-Surgery • Respiration
- Maxillary antral puncture and • Deglutition
lavage • Voice resonance
- Caldwell-Luc procedure • Articulation
-FESS
 CHRONIC SINUSITIS  Deglutition
- Repeated or sustained sinus infections 3 stages
cause the mucous membrane lining to • Voluntary movement of food from the
become thickened mouth into the pharynx
- Difficult to treat and is directed at • Transport of the food through the
correcting underlying cause (remove pharynx
polyp, eradicate dental infections, • Passage of the bolus through the
straighten deviated nasal septum and esophagus
treat allergy) • After mastication, food is positioned on
- S/sx the middle 3rd of the tongue
o Lethargy, difficulty sleeping, chronic • Elevation of tongue and soft palate
sough, chronic purulent nasal forces the bolus into the oropharynx
discharge, inability to smell, chronic • Suprahyoid muscles contract, elevating
sinus headache. the hyoid bone and larynx thus the
opening the hypopharynx
The Pharynx • Intrinsic laryngeal muscles contract in
• Common passageway between the a sphincter-like fashion to prevent
respiratory and digestive tracts aspiration
• Located behind the oral and nasal • A strong motion of tongue posterior,rly
cavities plunges the food inferiorly through the
 oropharynx , a movement aided by the • Procedures
contraction of the superior and middle - Indirect Laryngoscopy
pharyngeal constrictors - Endoscopy
• Peristalsis, assisted by gravity, moves • Radiographic
the food down the esophagus and into - X-ray
the stomach - CT scan
- MRI
Anatomy of the Larynx
Composed of 9 cartilages: 3 single, 3  HISTORY
paired - Drug use
• Thyroid- Adam’s apple - Allergies
• Cricoid-below the thyroid cartilage; - Frequent URTI
contains vocal cords
• Arytenoid- attach at the back end of • Occupational history
the vocal cords, for vocal cord - Teachers
movement - Salesman
• Epiglottis- lead-shaped elastic cartilage - TV and radio anchor
guarding the glottis
• Corniculate • Demographic Data
• Cuneiform • Family History and Genetic Risk
- Cancers
Two pairs of vocal cords - Maternal exposure to teratogenous or
• False disease
• True • Personal History
- Smoking history
Physiology of the Larynx
• Protection of the airway Current Health Problems
• Respiration • Common complaints
• Phonation - Sore throat
- Adducted true vocal cords serve as a - Discharge in the throat
passive reed that vibrates when air is - Sense of lump, fullness or swelling
forced through them - Difficulty in swallowing
- Changes in shape, mass and tension of
the true vocal cords produces different
pitches
- Loudness of voice proportional to the Physical examination
pressure in the subglottic airstream -Perform PE in an adequately lighted
- Whispering due to escape of air area
between the abduction sphenoid -have patient sit upright and leaning
without vibration of the tru vocal cords Slightly forward as if pushing the chin
towards the examiner
Assessment of the Throat
• History -Equipment
• Physical Examination Lights
- Inspection
- Palpation
 Inspection -Pharyngitis is an inflammation of the
Observe for palate and uvula Pharynx that frequently results in a sore
- Color throat
- Symmetry - It may be caused by a variety of
- Evidence of discharge (postnasal) microorganisms.
- Edema or ulceration
- Tonsil enlargement and inflammation
Observe neck
- Symmetry
- Alignment
- Masses

 Palpation
Gently palpate the neck
- Position of the trachea
- Massess
- Lymph nodes

 Indirect Laryngoscopy
• Requires a mirror to view the larynx
and hypopharynx
• Assess function of vocal cords or to
obtain tissue for biopsy
• The mirror is placed against the soft
palate
• May make patient anxious and
uncontrollable

Nursing Interventions
- NPO several hours before procedure
- Assess client for allergies to iodine,
contrast media, or local anesthetics
- Administer pretest medications
(sedation)
- Assess client for fear
- After the procedure NPO until gag
reflex
- Encourage coughing
- Assess VS q 15 min atleast 2 hr
- After procedure and then q2 x 24 h
- Assess client for bleeding
- After procedure, administer lozenges
or gargles as prescribed.

Pharyngitis