Visual and auditory conditions Flashcards
What is the prevalence of hearing loss in the UK (NHS England, 2017)?
11 million
1 in 6
The prevalence of hearing loss in England is estimated to increase to what figure by 2035 (NHS England, 2017)?
13 million
How many babies are born with some form of hearing loss every year (NHS England, 2017)?
840
How many children suffer with hearing loss (NHS England, 2017)?
50,000
What percentage of people over the age of 50 years suffer with hearing loss (NHS England, 2017)?
42%
What percentage of people over the age of 70 years suffer with hearing loss (NHS England, 2017)?
71%
What percentage of people retire early due to the impact of their hearing loss on communication at work (NHS England, 2017)?
41%
What percentage of those who identified “difficulty in hearing” as their main health problem were employed?
64% (compared with 77% of those with no long-term health issues or disability)
How much money is the UK economy estimated to lose per year in lost productivity and unemployment (NHS England, 2017)?
£25 billion
How many vision disorders are known to exist?
42
What is the main cause of sight loss in adults?
age-related macular degeneration
What percentage of adults in the UK have never had an eye examination (Eyecare Trust)?
10%
How many people in the UK fail to have regular sight tests (Eyecare Trust)?
20 million
What percentage of people in the UK admit to having problems with their vision (Eyecare Trust)?
85%
What proportion of children in the UK have an undetected problem with their vision (Eyecare Trust)?
1 in 5
What proportion of people in the UK are living with sight loss (Royal National Institute of Blind People, RNIB)?
1 in 30
What proportion of people aged 75 and over in the UK are living with sight loss (RNIB)?
1 in 5
How many people in the UK are forecast to be living with sight loss by 2050 (RNIB)?
4 million
What is the cost to the UK economy from sight loss (RNIB)?
£6.5 billion
How many people aged 65-84 in the UK are living with sight loss (RNIB)?
1.43 million
How many people in the UK are registered as blind or partially sighted (Access Economics)?
360,000
How many adults aged over 60 in the UK are living with a cataract (Public Health Action Support Team)?
570,000
What percentage of parents in the UK said their children have never had an eye test (College of Optometrists)?
25%
How many older people in the UK are living with late-stage age-related macular degeneration (RNIB)?
500,000
How many older people in the UK are living with glaucoma, either detected or undetected (EpiVision/RNIB)?
300,000
What percentage of people in the UK wear glasses (College of Optometrists)?
69%
What percentage of people in the UK wear contact lenses (College of Optometrists)?
13%
What six steps can help to keep your eyes and vision healthy (Vision Matters)?
healthy diet quit smoking maintain a healthy weight avoid exposure to UV light avoid digital eye strain using 20-20-20 rule book an eye test every two years
What foods are recommended for healthy eyes (Vision Matters)?
leafy greens (e.g. kale, spinach) brightly coloured fruit and vegetables (e.g. corn, carrots, orange sweet peppers, oranges) oily fish (e.g. salmon, tuna, mackerel) broccoli eggs
According to a study by the College of Optometrists, where are adults in the UK likely to turn to if they had an eye problem?
optometrist - 73% GP - 59% internet - 20% pharmacist/chemist - 11% walk-in clinic - 10% family member - 9% friend - 5% don't know - 2% none of these - 1%
According to the College of Optometrists, what treatments are used to correct vision in the UK?
glasses - 69%
contact lenses - 13%
laser eye surgery - 13%
none of these - 25%
How many people in the UK were registered as blind in 2017 (RNIB)?
350,000
How many people in the UK are registered as having a slight sight impairment (RNIB)?
176,125
How many people in the UK are registered as having severe sight impairment (RNIB)?
173,735
What proportion of people living with sight loss in the UK are women (RNIB)?
2 in 3
Which groups of people are at increased risk of sight loss (RNIB)?
BAME - increased risk of leading causes of sight loss
people with a learning disability - 10 times more at risk of blindness or partial sight loss than the general population
The causes of hearing loss can be divided into which two categories?
intrinsic factors (genetics) and extrinsic factors (environmental)
What is conductive hearing loss?
caused by impaired conduction of sound waves from the outer ear through the middle ear (tympanic membrane) to reach the inner ear
the inner ear cannot transduce sound waves into nerve impulses in the cochlea which pass to the auditory cortex
List some conditions that cause conductive hearing loss.
wax or foreign body otitis media (acute, serious, chronic) otitis externa otosclerosis damaged tympanic membrane ear barotrauma
What is sensorineural hearing loss?
caused by disease of the cochlea, the cochlear branch of the vestibular nerve (inner ear), or within the auditory cortex
sound waves are not processed correctly and they are hard to discriminate/distinguish
List some conditions that cause sensorineural hearing loss.
presbycusis noise pollution congenital Meniere's disease ototoxic drugs (e.g. aspirin, cisplatin, quinine, antibiotics, diuretics, chemotherapy) infections (e.g. mumps, syphilis)
Why is it important to complete a hearing assessment?
to eliminate other possible causes
to ensure appropriate onward referral
What signs involved with hearing loss would prompt further investigation, such as MRI?
if hearing loss is accompanied by any facial weakness or other symptoms
What is the first stage of an otoscopy?
wash hands
introduce yourself
explain procedure
obtain patient consent
What is the second stage of an otoscopy?
Which is your better hearing ear?
Have you got any pain or tenderness?
Can you give me a smile? - Look for facial weakness (1 of 5 cardinal symptoms of ear disease); facial nerve passes in the medial wall of the middle ear and may be affected by pathology in the ear)
What is the third stage of an otoscopy?
examine the better hearing ear
inspect external ear using light of otoscope
inspect skin colour and shape of pinna
look for other abnormalities (e.g. tophi, congenital defects)
look for surgical scars (endaural, postauricular)
What is the fourth stage of an otoscopy?
perform otoscopy to visualise the external auditory meatus and tympanic membrane
two sizes of speculum for the otoscope (choose the largest size speculum possible for the patient’s ear canal)
What is the fifth stage of an otoscopy?
when examining the right ear, hold the otoscope in the right hand
hold it like a pen, balanced between the thumb and index finger
extend the little finger and use this to rest against the patient’s face
What is the sixth stage of an otoscopy?
with the free left hand, pull the pinna gently upwards, outwards, and backwards to straighten the external ear canal and allow better view of the tympanic membrane
in children, pull the pinna down and back instead
What is the seventh stage of an otoscopy?
insert the otoscope into the external auditory meatus and inspect the canal for wax, discharge, inflammation, and other abnormalities
gently precede down the canal until the tympanic membrane is seen
What is the eighth stage of an otoscopy?
move the speculum around to examine the whole of the tympanic membrane and identify the normal landmarks (handle of the malleus, light reflex, pars tensa, pars flaccida)
What is the ninth stage of an otoscopy?
gently remove the otoscope, continuing to observe the ear canal for any pathology that may have been missed
repeat the examination on the other ear
What is the tenth stage of an otoscopy?
assess hearing using the tuning fork tests and audiometry
What causes should be excluded via assessment with adults presenting for the first time with hearing difficulties (NICE, 2018)?
impacted wax acute infections (e.g. otitis externa)
What are the signs of acute otitis media?
bulging tympanic membrane
dull or absent light reflex
What are the signs of attic cholesteatoma?
skin cyst visible behind tympanic membrane
What are the signs of otitis externa?
inflammation of external auditory meatus
What factors would prompt a referral for an audiological assessment?
if alternative causes are excluded
if there is a sudden or rapid onset of hearing loss and/or with specific additional signs/symptoms
Under what circumstances should you refer immediately (to be seen within 24 hrs) to an ENT service or A&E?
if the hearing loss developed suddenly (over a period of 3 days or less)
Under what circumstances should you refer urgently (to be seen within 2 weeks) to an ENT or audiovestibular medicine service?
if the hearing loss developed suddenly more than 30 days ago
if the hearing loss worsened rapidly (over a period of 4-90 days)
What is the first stage of a hearing test?
professional will ask questions relating to the patient’s hearing
How do you experience your hearing?
Have you been subjected to loud noise or other incidents?
Do people in your family suffer from hearing loss?
Do you hear better in one ear or the other?
What is the second stage of a hearing test?
ear examination using otoscope
What is the third stage of a hearing test?
hearing test in a quiet room without background noise or in a special soundproof room
pure tone test - tests the ability to hear a number of different pure tones, using a pair of soundproof headphones
bone conduction test - place a small bone conductor behind the ear to measure the ability to hear pure tones; will reveal a problem in the middle ear cavity
What is the fourth stage of a hearing test?
test the ability to understand speech
performed to identify problems with auditory nerve by sending signals from the ear to the brain
performed to identify problems understanding speech and sounds in the brain itself
What is the fifth stage of a hearing test?
tympanometry - tests the condition of the middle ear and mobility of the tympanic membrane
performed to identify specific hearing conditions
What is the sixth stage of a hearing test?
test results are presented in an audiogram
this shows the degree of hearing loss and whether the patient could benefit from hearing aids
What methods are recommended for earwax removal?
electronic irrigator
microsuction
manual removal using a probe
What medication is prescribed for earwax removal?
olive oil or almond oil drops 3-4 times daily for 3-5 days (do not prescribe almond oil ear drops to anyone who is allergic to almonds)
Why are ear drops prescribed prior to ear irrigation?
to soften wax and aid removal
What are the contraindications for ear irrigation in relation to current or previous ear problems?
history of previous problem with irrigation (pain, perforation, severe vertigo)
current perforation of tympanic membrane
history of perforated tympanic membrane in the last 12 months (controversial)
history of ear surgery (except extruded grommets in the last 18 months, with subsequent discharge from an ENT department)
mucus discharge from the ear (may indicate an undiagnosed perforation) in the last 12 months
history of otitis media in the last 6 weeks
acute otitis externa with an oedematous ear canal and painful pinna
What are the contraindications for ear irrigation in relation to certain patient groups?
grommets in place
cleft palate, whether repaired or not
hearing in only one ear if it is the ear to be treated, as there is a remote chance that irrigation could cause permanent deafness
presence of a foreign body, including vegetable matter, in the ear (hygroscopic matter, e.g. peas or lentils, will expand on contact with water making removal more difficult)
confusion or agitation, as unable to sit still
inability to cooperate (e.g. young children, some people with LDs)
What is the first stage of ear irrigation?
sit at the same level as the patient
apply the waterproof shoulder cape around the patient’s neck to ensure they will be kept dry from water and debris
use a headlight to ensure full visibility of the ear canal during the procedure
What is the second stage of ear irrigation?
use tap water and ensure the temperature is at 40°C
after 20 secs of running the tap water, insert approx. 700 mls of warm water into the reservoir
pour water onto your finger to ensure the water is warm enough for the procedure to be performed
What is the third stage of ear irrigation?
remove a new single-use QrX tip from the packaging, push the collar back, and ensure the tip is securely held in place when the collar is released
turn on the machine and set the pressure control to minimum
What is the fourth stage of ear irrigation?
using the foot pedal to start the flow of water, you and the patient use your finger to ensure both are comfortable with the water temperature and noise of the machine
ask the patient to sit sideways on the chair so they can lean on the chair to be able to comfortably hold the newt tank in place under the earlobe
What is the fifth stage of ear irrigation?
using the headlight to aid the visibility of the ear canal, hold the irrigation handle across the palm of your hand and introduce it to the entrance of the ear canal
What is the sixth stage of ear irrigation?
after irrigating the ear for 10 secs, stop and question the patient that they remain comfortable and do not feel any water at the back of the nose or throat
as the patient is comfortable, continue the procedure and straighten the ear canal by holding the pinna up and out
What is the seventh stage of ear irrigation?
continue irrigation with the handle pressed against the tragus and water flowing along the posterior wall of the ear canal
What is the eighth stage of ear irrigation?
using the headlight, see that the wax is coming towards the entrance of the ear canal
you can now appropriately use the wax scoop to remove the wax
What is the ninth stage of ear irrigation?
using a tissue to dry the entrance of the ear canal, remove a new disposable scoop from the bag
straightening the ear canal, and with the headlight for visibility, insert the wax scoop into the ear canal and remove wax
this has reduced the length of the irrigation procedure and improves patient comfort
What is the tenth stage of ear irrigation?
drying the entrance of the ear canal, perform oral toilet to remove all the water from the ear canal
using cotton wool, tease the cotton wool apart and insert the serrated end of the wax scoop onto the cotton wool
What is the eleventh stage of ear irrigation?
insert cotton wool to the entrance of the ear canal and
using a gentle rotary motion of the scoop, water left pooling within the ear canal will be absorbed back by the cotton wool
What is the twelth stage of ear irrigation?
once the cotton wool is wet, it should be discarded from the scoop
re-examine the ear to ensure all the water has been removed from the ear canal, there is no wax or debris left in the ear canal, and the patient has a normal tympanic membrane
What is the final stage of ear irrigation?
advise patient to keep ears dry from the entry of water for a minimum of five days after irrigation (a small amount of cotton wool coated in petroleum jelly)
advise patient not to insert any implement in their ear which could damage ear canal or tympanic membrane
advised to return for ear care and examination in one year
document the results of procedure according to local policy
What is Meniere’s disease?
a long-term vestibular condition caused by an accumulation of endolymph within the membranous labyrinth
this leads to increased pressure and distension, and the destruction of sensory cells within the ampulla/cochlea
can start unilaterally and progress to bilateral
both sexes are equally affected and it can occur at any age
What is the incidence of Meniere’s disease?
1:1000-1:2000 of the population (depends on the source)
What percentage of Meniere’s disease sufferers have a family history of the disease?
7-10%
List some of the common signs and symptoms of Meniere’s disease.
acute attacks of vertigo (severe dizziness)
fluctuating tinnitus
increasing deafness
feeling of pressure in the ear
What happens in Meniere’s disease stage one (early)?
unpredictable attacks of vertigo which can last from a few minutes to hours
this can accompany hearing loss with a sensation of fullness in the affected ear and tinnitus
the hearing and sensation in the ear return to normal between attacks
What happens in Meniere’s disease stage two (intermediate)?
attacks of vertigo; tinnitus; hearing loss
attacks of vertigo continue with variable remissions, though may be less severe
before/after the attack the person may experience a period of imbalance and movement-induced giddiness
tinnitus becomes more prominent and often fluctuates or increases with the attacks
What happens in Meniere’s disease stage three (late)?
hearing loss; balance difficulties; tinnitus
hearing loss increases and often the attacks of vertigo diminish/stop
hearing loss can be severe and distortion
loudness, discomfort and recruitment can occur
permanent damage to the balance organ in the ear and significant general balance problems are common, especially in the dark
What is the pharmacological treatment for Meniere’s disease?
(nausea and vomiting) - buccal prochlorperazine or cyclizine (examples)
What is the non-pharmacological treatment for Meniere’s disease?
complementary therapy
vestibular rehabilitation
surgery
What is complementary therapy?
this may include acupuncture or counselling
What is vestibular rehabilitation?
a programme of head, eye and neck movements, usually led by a physiotherapist, to assess balance function and re-educate the balance system so the person becomes more stable
What surgeries can be used to treat Meniere’s disease?
intratympanic steroids (injection into the inner ear) intratympanic gentamicin (injected through the tympanic membrane) endolymphatic sac surgery (bone removed around the sac) labyrinthectomy (95-98% success rate) vestibular neurectomy (cuts the nerve), grommets (tympanstomy)
What is age-related macular degeneration (AMD)?
ageing changes without any other obvious cause that affects the central area of the retina (macula)
painless condition that generally leads to the gradual impairment of vision, but it can sometimes cause a rapid reduction in vision
it mainly affects the central vision, which is responsible for reading and recognising faces.
What percentage of those 50 years or over suffer with AMD in the UK?
2.4%
What percentage of those 65 years or over suffer with AMD in the UK?
4.5%
What percentage of those 80 years or over suffer with AMD in the UK?
12.2%
List some of the common risk factors for AMD.
older age presence of AMD in the other eye family history of AMD smoking hypertension BMI of 30 kg/m2 or higher diet low in omega 3 and 6, vitamins, carotenoid and minerals diet high in fat lack of exercise
What is dry (non-neovascular) AMD?
accounts for 90% of all AMD cases
layers of the macula (including photoreceptors and retinal pigment epithelium) get progressively thinner, and lead to reduced function, due to atrophy
What happens in the early stage of dry AMD?
causes pigment discolouration within the macula tiny drusen (waste products) appear on the retina, and may lead to deterioration and atrophy of the retinad dry AMD often does not progress further than pigment discoloration and the presence of drusen
What happens in the late stage of dry AMD?
large sections of the retina that are well demarcated (geographies) stop functioning
this is called geographic atrophy (GA)
What is wet (neovascular/exudative) AMD?
accounts for 10% of all AMD cases
new blood vessels grow in the choroid layer behind the retina - choroidal neovascularization (CNV)
the new vessels are weak, and leak fluid, lipids and blood
the leaking gets into the layers of the retina (including the layers of the macula) and can cause scar tissue to form and retinal cells to stop functioning
According to NICE (2018), what classifies as ‘normal eyes’?
no signs of age-related macular degeneration (AMD)
small (‘hard’) drusen (less than 63 micrometres) only
According to NICE (2018), what classifies as early AMD - low risk of progression?
medium drusen (63 micrometres or more and less than
125 micrometres) or
pigmentary abnormalities
According to NICE (2018), what classifies as early AMD - medium risk of progression?
large drusen (125 micrometres or more) or
reticular drusen or
medium drusen with pigmentary abnormalities
According to NICE (2018), what classifies as early AMD - high risk of progression?
large drusen (125 micrometres or more) with pigmentary abnormalities or
reticular drusen with pigmentary abnormalities or vitelliform lesion without significant visual loss (best-corrected acuity better than 6/18) or
atrophy smaller than 175 micrometres and not involving the fovea
According to NICE (2018), what classifies as late AMD (indeterminate)?
retinal pigment epithelial (RPE) degeneration and dysfunction (presence of degenerative AMD changes with subretinal or intraretinal fluid in the
absence of neovascularisation)
serous pigment epithelial detachment (PED) without neovascularisation
According to NICE (2018), what classifies as late AMD (wet active)?
classic choroidal neovascularisation (CNV)
occult (fibrovascular PED and serous PED with neovascularisation)
mixed (predominantly or minimally classic CNV with occult CNV)
retinal angiomatous proliferation (RAP)
polypoidal choroidal vasculopathy (PCV)
According to NICE (2018), what classifies as late AMD (dry)?
geographic atrophy (in the absence of neovascular AMD)
significant visual loss (6/18 or worse) associated with: dense or confluent drusen or
advanced pigmentary changes and/or atrophy or
vitelliform lesion
According to NICE (2018), what classifies as late AMD (wet inactive)?
fibrous scar
sub-foveal atrophy or fibrosis secondary to an RPE tear
atrophy (absence or thinning of RPE and/or retina)
cystic degeneration (persistent intraretinal fluid or tubulations unresponsive to treatment)
NB eyes may still develop or have a recurrence of late AMD (wet active)
What is the purpose of an AMD assessment?
to determine the cause of the visual disturbance and what type of treatment, if any are available
in terms of AMD dry or wet, there are options available to reduce the impact of the condition
What are the differences in treatment options between dry and wet AMD?
dry AMD - limited treatment options, or ability to reduce visual loss (despite making up 90% of cases) most treatments are aimed at patients with wet AMD or late-stage wet AMD
What is the pharmacological treatment for wet AMD?
antiangiogenic therapies - a group of medication that was traditionally used to treat metastatic kidney cancer
the medication slows down tumour growth by preventing the formation of new blood vessels
this is beneficial in wet AMD, due the formation of new and fragile vessels
ranibizumab
What is the pharmacological treatment for late AMD (wet active)?
intravitreal anti-vascular endothelial growth factor (VEGF) treatment
photodynamic therapy is offered as an adjunct to anti-VEGF in second-line treatment for late wet AMD only
monitoring is only seen as beneficial in those with late AMD (wet active)
What are some of the non-pharmacological treatments for AMD?
certification of visual impairment to enable people to access necessary benefits and services
group-based rehabilitation programme in addition to a low-vision service to promote independent living for people with AMD
counselling - as needed to support individuals and significant others
What percentage of people experiencing sight loss are offered emotional support in response to their deteriorating vision?
17%
What percentage of blind and partially sighted people of working age are in employment?
27% (33% in 2006)
What percentage of blind and partially sighted people of working age say they have some or great difficulty in making ends meet?
39%
What percentage of blind and partially sighted people say that they sometimes, frequently or always experience negative attitudes from the public in relation to their sight loss?
35%
What percentage of blind and partially sighted people are rarely or never optimistic about the future?
31%
