Audio Visual Disturbances

8/9/2019 Audio Visual Disturbances

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Anatomy and Physiology

EXTERNAL EAR Auricle

Tympanic membrane

MIDDLE EAR Ossicles

Eustachian tube

INNER EAR Semilunar canals

Cochlea


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BALANCEBALANCE

HEARING

FUNCTIONS OF THE EARFUNCTIONS OF THE EAR


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HEARING

88thth CRANIAL NERVECRANIAL NERVE

1. COCHLEAR BRANCH1. COCHLEAR BRANCH

- transmits neuro-impulses from the cochlea to the brainwhere it is interpreted as sound

2. VESTIBULAR BRANCH2. VESTIBULAR BRANCH

- maintains balance & equilibrium


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Anatomy of the Inner Ear


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ASSESSMENT OF THE EAR

OTOSCOPIC EXAMOTOSCOPIC EXAM- visualize the external canal while slowly inserting the speculum

VOICE TESTVOICE TEST Ask the client to block one external canal

The examiner stands 1-2 ft away & quickly whispers a statement

The client is asked to repeat the whispered statement Each ear is tested separately

WATCH TESTWATCH TEST

A ticking watch is used to test the high-frequency sounds

The examiner holds a ticking watch about 5 inches from each

ear & asks the client if the ticking is heard


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TUNING FORK TESTSTUNING FORK TESTS

A. WEBER TUNING FORK TESTA. WEBER TUNING FORK TEST

Normal result: hearing the sound equally in both ears

FINDINGSFINDINGS

If the client hears the sound louder in 1 ear,- (+) LATERALIZATION(+) LATERALIZATION is present

where the sound is heard the loudest

INTERPRETATIONINTERPRETATION The finding may indicate the client has CONDUCTIVECONDUCTIVE

HEARING LOSSHEARING LOSS in the ear to which the ear is lateralized

The finding may indicate that there is a SENSORINEURALHEARING LOSS in the opposite ear


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WEBER TEST- is a quickscreening test for hearing. It

can detect unilateral (one-sided) conductive hearing lossand unilateralsensorineural hearing loss. The test is named

afterErnst Heinrich Weber

Normal:

Sound heard equally

CONDUCTIVE:

Louder

SENSORINEURAL:

Opposite


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TUNING FORK TESTSTUNING FORK TESTS

B. RINNE TUNING FORK TESTB. RINNE TUNING FORK TEST

Compares the clients hearing by air conduction & bone conductionAIR CONDUCTIONAIR CONDUCTION is 2is 2--3X longer than3X longer than BONE CONDUCTIONBONE CONDUCTION

NORMAL RESULT:NORMAL RESULT: (+) RINNE TEST(+) RINNE TEST

-- the client normally continues to hear the sound

2x louder in front of the pinna

The examiner records the duration of both phases, bone conductionfollowed by air conduction and compares the times


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A Rinne test should always be accompanied by a Weber

test to also detect sensorineural hearing loss and thus

confirm the nature of hearing loss. The Rinne test wasnamed after German otologist Heinrich Adolf Rinne

Normal:

Sound heard in front of

pinna

Findings:

(+) Rinne test Normal

(-) Rinne test

Conductive


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Otoscope Weber test


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Rinne Test


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VESTIBULAR ASSESSMENT OF

THE EARTEST FOR FALLINGTEST FOR FALLING

The examiner asks the client to stand with the feet together &arms hanging loosely at the sides & eyes closed

The client normally remains erect with slight swaying

TEST FOR PAST POINTINGTEST FOR PAST POINTING NORMAL TEST RESPONSE:NORMAL TEST RESPONSE:

- The client can easily return to the point of reference


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VESTIBULAR ASSESSMENT OFVESTIBULAR ASSESSMENT OF

THE EARTHE EAR

GAZE NYSTAGMUS EVALUATIONGAZE NYSTAGMUS EVALUATION Examine the clients eyes as they look straight ahead, 30

degrees to each side, upward & downward

HALLPIKE MANEUVERHALLPIKE MANEUVER Assesses for positional vertigo or induced dizziness

The client assumes a supine position

The head is rotated to one side for 1 minute


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DIAGNOSTIC TESTS FOR THE EAR

TOMOGRAPHYTOMOGRAPHY- may be performed with or without contract medium

- assesses the mastoid, middle ear & inner ear structures- multiple x-rays of the head are done

ELECTRONYSTAGMOGRAPHYELECTRONYSTAGMOGRAPHY- records changing electrical fields with movement ofthe eye, as monitored by electrodes placed on theskin around the eye

AUDIOMETRYAUDIOMETRY- measures hearing acuity

- uses 2 types: PURE TONE AUDIOMETRY & SPEECH AUDIOMETRYPURE TONE AUDIOMETRY & SPEECH AUDIOMETRY- after testing, audiogram patterns are depicted on a graph to determinethe type & level of hearing loss


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DISORDERSDISORDERSOF THE EAROF THE EAR


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AGING PROCESSAGING PROCESS

INFECTIONINFECTIONMEDICATIONSMEDICATIONS

OTOTOXICITYOTOTOXICITY

TRAUMATRAUMA TUMORSTUMORS

Risk factors of ear disordersRisk factors of ear disorders


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CONDUCTIVE HEARING LOSSCONDUCTIVE HEARING LOSS- due to any physical obstruction to the transmission of soundwaves

SENSORINEURAL HEARING LOSSSENSORINEURAL HEARING LOSS

- due to a defect in the organ of hearing, in the 8th cranial

nerve, or in the brain itself

MIXED CONDUCTIVE, SENSORINEURALMIXED CONDUCTIVE, SENSORINEURALHEARING LOSSHEARING LOSS

- results in profound hearing loss


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CONDUCTIVE HEARING LOSSCONDUCTIVE HEARING LOSS

- sound waves are blocked to the inner ear fibersbecause of external ear or middle ear disorders

- disorders can often be corrected with no damage to hearing, orminimal permanent hearing loss

CAUSESCAUSESAny inflammatory process or obstruction of the external or middle

ear Tumors

Otosclerosis

A build-up of scar tissue on the ossicles from previous middle earsurgery


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SENSORINEURAL HEARING LOSSSENSORINEURAL HEARING LOSS

- a pathological process of the inner ear or of sensory fibers that

lead to the cerebral cortex

- often permanent- reduce further damage

- attempt to amplify sound as a means of improving hearing

CAUSESCAUSES Damage to the inner ear structures and nerves Prolonged exposure to loud noise

Medications, trauma, infections, surgery Inherited disorders

Metabolic & circulatory disorders Menieres syndrome Diabetes mellitus Myxedema


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MIXED HEARING LOSSMIXED HEARING LOSS-- also known as conductivealso known as conductive--sensorineuralsensorineural hearing losshearing loss

SIGNS OF HEARING LOSSSIGNS OF HEARING LOSS

Frequently asking people to repeat statementsFrequently asking people to repeat statements

Straining to hearStraining to hear

Turning head or leaning forward to favor one earTurning head or leaning forward to favor one ear

Shouting in conversationsShouting in conversations Ringing in the earsRinging in the ears Failing to respond when not looking in the direction of theFailing to respond when not looking in the direction of the

soundsoundAnswering questions incorrectlyAnswering questions incorrectly Raising the volume of the television or radioRaising the volume of the television or radioAvoiding large groupsAvoiding large groups Better understanding of speech when in small groupsBetter understanding of speech when in small groupsWithdrawing from social interactionsWithdrawing from social interactions


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HEARING AIDSHEARING AIDS- used for the client with conductive hearingloss

- can help the client with sensorineural loss,although it is not as effective

- a difficulty that exists in its use is the

amplification of background noise as wellas voices


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COCHLEAR IMPLANTATIONCOCHLEAR IMPLANTATION

- used for sensorineural hearing loss- a small computer converts sound waves intoelectrical impulses

- electrodes are placed by the internal ear with

a computer device attached to the externalear

- electronic impulses directly stimulate nervefibers


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Cochlearimplant


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- leads to degeneration or atrophy of the ganglionic cells inthe cochlea & a loss of elasticity of the basilar membranes

- leads to compromise of the vascular supply to the inner ear

with changes in several areas of the ear structure

ASSESSMENTASSESSMENTgradual & bilateral

no problem with hearing but cantunderstand what the words are

speaker is mumbling

PRESBYCUSISPRESBYCUSIS


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EXTERNAL OTITISEXTERNAL OTITIS

- an irritating or infective agent comes into contact withepithelial layer of the external ear

- this leads to either an allergic response or S/S of infection

- the skin becomes red, swollen, & tender to touch on

movement- the excessive swelling of the canal lead to conductivehearing loss

- due to obstruction

- more common in children

- occurs more often in hot, humid environments

- prevention includes the elimination of irritating or infecting agents


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ASSESSMENTASSESSMENT

Pain

Itching

Plugged feeling in the ear

Redness & edema

Exudate

Hearing loss



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Otitis Externa


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NURSING CARENURSING CARE local heat application

Encourage rest

Administer analgesics such as aspirin or acetaminophen (Tylenol) forthe pain as prescribed

Instruct the client that the ears should be kept clean & dry

use earplugs for swimming

cotton-tipped applicators should not be used to dry ear becausetheir use can lead to trauma to the canal irritating agents such as hair products or

headphones should be discontinued


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OTITIS MEDIAOTITIS MEDIA

-a result of a blocked eustachian tube

- a common complication of an ARI- infants & children are more prone

ASSESSMENTASSESSMENT

Fever

Irritability, restlessness & loss of appetite

Rolling of head from side to side

Pulling on or rubbing the ear

Earache or pain Signs of hearing loss

Purulent ear drainage

Red, opaque, bulging or retracting tympanic membrane


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NURSING CARENURSING CARE Encourage oral fluids feed infants in an upright position

avoid chewing during the acute period

local heat

appropriate procedure to clean drainage from theear with sterile cotton swabs

analgesics or antipyretics such asAcetaminophen (Tylenol) to decrease fever & pain

administration of prescribed antibiotics

screening for hearing loss may be necessary

ear drops

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MYRINGOTOMYMYRINGOTOMY

- insertion of tympanoplasty tubes in the middle ear toequalize pressure & keep the ears dry

POSTPOST--OP NURSING CAREOP NURSING CARE Instruct the parents & child to keep the ears dry

Earplugs should be worn during bathing, shampooing &swimming

Diving & submerging under water are not allowed


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Clienteducation post myringotomyClienteducation post myringotomy

AvoidAvoidstrenuous exercisestrenuous exerciserapid head movements, bouncing or bendingrapid head movements, bouncing or bending

straining on bowel movementstraining on bowel movement

drinking through a strawdrinking through a straw

traveling by airtraveling by airforceful coughingforceful coughing

contact with persons with coldscontact with persons with colds

washing hair, showering or getting the head wet for a weekwashing hair, showering or getting the head wet for a week

InstructInstructblow one side at a time with wide mouth openblow one side at a time with wide mouth open

keep ears dry by keeping a ball of cotton coatedkeep ears dry by keeping a ball of cotton coatedwith petroleum jelly in the ear & to change cotton ball dailywith petroleum jelly in the ear & to change cotton ball daily

report excessive ear drainage to the physicianreport excessive ear drainage to the physician


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CHRONIC OTITIS MEDIACHRONIC OTITIS MEDIA- a chronicinfective, inflammatory, or allergic response

involving the structure of the middle ear

- surgical treatment is necessary to restore hearing

- the type ofsurgery can vary & include a simple

reconstruction of the tympanic membrane, a myringotomy, or

replacement of the ossicles within the middle ear

TYMPANOPLASTYTYMPANOPLASTY

- a reconstruction of the middle ear may be attempted to

improve conductive hearing loss


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- may be acute or chronic & results from untreated or inadequately

treated chronic or acute otitis media

- the pain is not relieved by myringotomy

ASSESSMENTASSESSMENT Swelling behind the ear & pain with minimal movement of the head

Cellulitis on the skin or external scalp over the mastoid process

A reddened, dull, thick, immobile tympanic membrane with or withoutperforation

Tender & enlarged post-auricular lymph nodes Low-grade feverAnorexia

MASTOIDITISMASTOIDITIS


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PREPRE--OP NURSING CAREOP NURSING CARE

Prepare the client for surgical removal of the infectedmaterial

Monitor for complications

SIMLPLE OR MODIFIED RADICAL MASTOIDECTOMYSIMLPLE OR MODIFIED RADICAL MASTOIDECTOMYWITH TYMPANOPLASTYWITH TYMPANOPLASTY is the common treatment

Once tissue that is infected is removed, tympanoplasty isperformed to reconstruct the ossicles & the tympanicmembranes, in an attempt to restore normal hearing



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COMPLICATIONSCOMPLICATIONS D

amage to the abducens & facial cranial nerves Damage exhibited by inability to look laterally (cranial nerve

VI) & a drooping of the mouth on the affected side (cranialnerve VII)

Meningitis

Chronic purulent otitis media Wound infections

Vertigo, if the infection spreads into the labyrinth


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OTOSCLEROSISOTOSCLEROSIS

- bony overgrowth of the tissue surrounding the ossicles

- causes the devt of irregular areas of new bone formation & causesfixation of the bones

- stapes fixation leads to CONDUCTIVE HEARING LOSSCONDUCTIVE HEARING LOSS

- if the disease involves the inner ear, SENSORINEURAL HEARINGSENSORINEURAL HEARINGLOSSLOSS is present

- common to have bilateral involvement, although hearing lossmay be worse in one ear

- cause is unknown, although has familial tendency- nonsurgical intervention promotes the improvement of hearing through

amplification- a PARTIAL STAPEDECTOMY or COMPLETE STAPEDECTOMYPARTIAL STAPEDECTOMY or COMPLETE STAPEDECTOMY

WITH PROSTHESIS (FENESTRATION)WITH PROSTHESIS (FENESTRATION) may be surgically performed


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OTOSCLEROSISOTOSCLEROSIS

ASSESSMENTASSESSMENT Slowly progressing conductive hearing loss

Bilateral hearing loss

A ringing or roaring type of constant tinnitus

Loud sounds heard in the ear when chewing

Pinkish discoloration (SCHWARTZES SIGN)(SCHWARTZES SIGN) of the tympanicmembrane

- indicates vascular changes in the ear

(-) Rinne test

Weber test shows lateralization of the sound to the ear withthe most conductive hearing loss


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Stapedectomy for Otosclerosis


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FENESTRATIONFENESTRATION-- removal of the stapes with a small hole drilled inremoval of the stapes with a small hole drilled inthe footplate & a prosthesis is connectedthe footplate & a prosthesis is connectedbetween thebetween the incusincus & footplate& footplate

-- sounds cause the prosthesis to vibrate in thesounds cause the prosthesis to vibrate in thesame manner as the stapessame manner as the stapes

COMPLICATIONSCOMPLICATIONS Complete hearing lossComplete hearing loss

Prolonged vertigoProlonged vertigo

InfectionInfection

Facial nerve damageFacial nerve damage


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LABYRINTHITISLABYRINTHITIS

- infection of the labyrinth that occurs as a

complication of acute or chronic otitis media

ASSESSMENTASSESSMENT Hearing loss that may be permanent on the

affected side

Tinnitus

Spontaneous nystagmus to the affected side

Vertigo

Nausea & vomiting


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LABYRINTHITISLABYRINTHITIS

PREPRE--OP NURSING CAREOP NURSING CARE

Monitor for signs of meningitis, the most commoncomplication

- evidenced by headache, stiff neck lethargy

Administer systemic antibiotics as Rx

Advise client to rest in bed in a darkened room

Administer antiemetics & antivertiginous medications as Rx

Instruct the client that the vertigo subsides as inflammationresolves

Instruct the client that balance problems that persist mayrequire gait training through physical therapy


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MENIERES SYNDROMEMENIERES SYNDROME- a syndrome also called ENDOLYMPHATICENDOLYMPHATICHYDROPSHYDROPS

- refers to dilation of the endolympathic system by eitheroverproduction or decreased reabsorption of endolymphatic

fluid- characterized by tinnitus, unilateral sensorineural hearing loss,& vertigo

- symptoms occur in attacks & last for several days, & the clientbecomes totally incapacitated

- initial hearing loss is reversible, but as the frequency of attackscontinues, hearing loss becomes permanent- repeated damage to the cochlea caused by increased fluidpressure leads to the permanent hearing loss


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MENIERES SYNDROMEMENIERES SYNDROME

CAUSESCAUSES

Any factor that increases endolymphatic secretion inthe labyrinth

Viral & bacterial infections

Allergic reactions

Biochemical disturbances

Vascular disturbances producing changes in themicrocirculation in the labyrinth


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ASSESSMENTASSESSMENT Feelings of fullness in the ear

Tinnitus, as a continuous low-pitched roar or humming sound- is present most of the time but worsens just before &

during severe attacks Hearing loss is worse during an attack

Vertigo- periods of whirling which might cause the client to fall to theground

- sometimes so intense that even when lying down, the clientholds the bed or ground in an attempt to prevent the whirling

Nausea & vomiting

Nystagmus

Severe headaches


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NONNON--SURGICAL MANAGEMENTSURGICAL MANAGEMENT Preventing injury during vertigo attacks Providing bed rest in a quiet environment

Provide assistance while walking

Instruct the client to move the head slowly Initiate Na & fluid restrictions as Rx

Instruct to avoid smoking Administer

Nicotinic acid (Niacin) as Rx

antihistamines as Rxantiemetics as Rxtranquilizers & sedatives as Rx


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SURGICAL MANAGEMENTSURGICAL MANAGEMENT-- performed when medical therapy is ineffective & the

functional level of the client has decreased significantly

ENDOLYMPHATIC DRAINAGEENDOLYMPHATIC DRAINAGE& INSERTION OF THE SHUNT& INSERTION OF THE SHUNT- may be performed early in the course of the disease to assistwith the drainage of excess fluids

RESECTION OF

THE VESTIBULAR NERVERESECTION OF

THE VESTIBULAR NERVE LABYRINTHECTOMYLABYRINTHECTOMY

- removal of the labyrinth may be performed


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MENIERESMENIERES

SYNDROMESYNDROMEPOSTPOST--OP NURSING CAREOP NURSING CARE

Assess packing & dressing on the ear Speak to the client on the side of the unaffected ear

Perform neurological assessments

Maintain side rails

Assist with ambulating

Encourage the use of bedside commode

Administer antivertiginous& antiemetic medications as Rx


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$FRXVWLF$FRXVWLF1HXURPD1HXURPD- a benign tumor of the vestibular or acoustic nerve- causes damage to hearing & to facial movements & sensations- treatment includes surgical removal of the tumor viacraniotomy

- care is taken to preserve the function of the facial nerve

- the tumor rarely recurs after surgical removal

ASSESSMENTASSESSMENT Symptoms usually begin with tinnitus & progress to gradual

sensorineural hearing lossAs tumors enlarges, damage to adjacent cranial nerves occurs


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- foreign objects placed in the external canal may exert pressureon the tympanic membrane & cause perforation

- if the object continues thorough the canal, the bony structuresof stapes, incus & malleus may be damaged

- a blunt injury to the basal skull & ear can damage the middleear structures through fractures extending to the middle ear

- excessive blowing & rapid changes of pressure that occur withnon-pressurized air flights can increase pressure in the middleear

- depending on the damage to the ossicles, hearing loss may ormay not return


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TRAUMATRAUMA

NURSING CARENURSING CARE Tympanic perforations usually heal within 24 hours

Surgical reconstruction of the ossicles & tympanicmembrane through tympanoplasty or myringotomymay be performed to improve hearing


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CERUMEN &CERUMEN &

FOREIGN BODIESFOREIGN BODIES

CERUMEN/EAR WAXCERUMEN/EAR WAX-- the most common cause of impacted canals

FOREIGN BODIESFOREIGN BODIES-- can include vegetables, beads, pencil erasers & insects

ASSESSMENTASSESSMENT Sensation of fullness in the ear with or without hearing loss Pain, itching or bleeding


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CERUMENCERUMEN

NURSING CARENURSING CARE Removal of the wax by irrigation is a slow process

Irrigation is C/I in clients with a hx of tympanic membraneperforation

To soften cerumen, add 3 gtts of glycerin to the ear @ hs& 3 gtts of hydrogen peroxide BID

After several days the ear is irrigated 50-70 ml of solution is the maximal amount a client can

tolerate during an irrigation sitting


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NURSING CARENURSING CARE If the foreign matter is vegetable, irrigation is used with care

- the material expends with hydration

Insects are killed before removal unless they can be coaxedout by flashlight or a humming noise

Mineral oil or alcohol is instilled to suffocate the insect whichis then removed with ear forceps

Use small ear forceps to remove the object & avoid pushingthe object farther into the canal & damaging the tympanicmembrane


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OTIC MEDICATIONSOTIC MEDICATIONS


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IRRIGATION OF THE EARIRRIGATION OF THE EAR Irrigation of the ear needs to be prescribed by MD

Ensure that there is direct visualization of the tympanic membrane

Warm irrigating solution to 100 F- solutions not close to the clients body temp will cause ear injury,nausea & vertigo

Irrigation must be done gently to avoid damage to the eardrum

When irrigating, dont direct irrigating solution directly toward theeardrum

If perforation of the eardrum is suspected, irrigation is not done

MEDICATIONS THAT AFFECTMEDICATIONS THAT AFFECT


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ANTIBIOTICSANTIBIOTICS Amikacin (Amikin)

Chloramphenicol

- Chloromycetin- Chloroptic- Ophthoclor

Erythromycin- E-Mycin- ERYC- Ery-Tab- PCE Dispertabs

- Ilotycin Gentamicin (Garamycin)

Streptomycin sulfate(Streptomycin)

Tobramycin sulfate (Nebcin)

Vancomycin (Vancocin)

MEDICATIONS THAT AFFECTMEDICATIONS THAT AFFECT

HEARINGHEARING

DIURETICSDIURETICS Acetazolamide (Diamox) Furosemide (Lasix) Ethacrynic acid (Edecrine)

OTHERSOTHERS Cisplatin (Platinol, Platinol-AQ) Nitrogen mustard

Quinine (Quinamn) Quinidine

- Cardioquin- Quinaglute- Quindex


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ANTIANTI--INFECTIVEMEDICATIONSINFECTIVEMEDICATIONS

- Kill or inhibit the growth of bacteria- Used for otitis media or otitis externa

- C/I if a prior hypersensitivity exists

SIDE EFFECTSSIDE EFFECTS

Overgrowth of non-susceptible organisms

NURSING CARENURSING CARE Assess V/S

Assess for allergies & pain

Monitor for nephrotoxicity Instruct the client to report dizziness, fatigue, fever, or sore throat

- indicative of superimposed infection

Instruct to complete the entire course of medication

Instruct to keep the ear canals dry


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ANTIANTI--INFECTIVE MEDICATIONSINFECTIVE MEDICATIONS

EXAMPLESEXAMPLES Amoxicillin (Amoxil)

Ampicillin trihydrate (Polycillin)

Cefaclor (Ceclor)

Clindamycin HCl (Cleocin)

Trimethoprim (TMP) & Sulfamethaxazole (SMZ)- Bactrim, Cotrim, Septra

Erythromycin (Ilotycin, E-Mycin)

Penicillin V potassium (Pen V)

Loracarbef (Lorabid) Clarithromycin (Biaxin)

Polymyxin B sulfate (Aerosporin)

Tetracycline HCl (Achromycin)

Acetic acid and Aluminum acetate (Otic Domeboro)


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ANTIANTI--HISTAMINES &HISTAMINES &

DECONGESTANTSDECONGESTANTS

- Produce vasoconstriction- Stimulate the receptors of the respiratory mucosa- Reduce respiratory tissue hyperemia & edema to open obstructedeustachian tubes

- Used for acute otitis media

SIDE EFFECTSSIDE EFFECTS Drowsiness Blurred vision Dry mucous membranes

NURSING CARENURSING CARE Inform the client that drowsiness, blurred vision, & dry mouth may occur

Instruct the client to increase fluid intake unless C/I & to suck on hardcandy to alleviate dry mouth

Instruct the client to avoid hazardous activities if drowsiness occurs


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EXAMPLESEXAMPLES

Tripolidine & pseudoephedrine (Actifed)

Naphazoline HCl (Allerest, Albalon)

Chlorpheniramine (Chlor-Trimeton, Teldrin)

Brompheniramine (Bromphen, Dimetane)

Terfenadine (Seldane)

Clemastine (Tavist)

Cetirizine (Zyrtec)

Astemizole (Hismanal)

LOCALLOCAL


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LOCALLOCAL

ANESTHETICSANESTHETICS- Block nerve conduction at or near the application site to control pain

- Used for pain associated with ear infections

MEDICATIONMEDICATION :: Benzocaine (Americaine Otic; Tympagesic)Benzocaine (Americaine Otic; Tympagesic)

SIDE EFFECTSSIDE EFFECTSAllergic reaction Irritation

NURSING CARENURSING CARE Monitor for effectiveness if used for pain relief

Assess for irritation or allergic reaction

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CERUMINOLYTICCERUMINOLYTIC

MEDICATIONSMEDICATIONS

EXAMPLESEXAMPLES Carbamide peroxide (Debrox)

Boric acid (Ear-Dry)

Trolamine polypeptide oleate-condensate- Cerumenex

Audio Visual Disturbances

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