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Course: Pediatric Nursing

Topic: Nursing Care of Child With Eye and Ear Disorders

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the anatomy and physiology of the ears in children.
Identify factors associated with disorders of the ears in children.
Identify common disorders of the ears in children including their signs and symptoms.
Identify common diagnostic procedures for ear disorders in children and nursing implications.
Identify common medications and other treatment interventions for ear disorders in children and nursing implications.
Discuss the nursing management of a child with an ear disorder.

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Human Ear

The human ear is the organ of hearing and equilibrium.
Detects and analyzes sound by the mechanism of transduction, which is the process of converting sound waves into electrochemical impulses.
Audition cannot take place adequately if the anatomy is abnormal.

University of Rochester Medical Center Rochester, n.d.

Sánchez López de Nava & Lasrado, 2021

Contact info: info@nursesinternational.org

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Anatomy of Ear

The human ear is a rudimentary shell-like structure that lies on the lateral aspect of the head
It is a cartilaginous structure
Subdivides into three fundamental substructures:

The external ear
Middle ear
Inner ear

University of Rochester Medical Center Rochester, n.d.

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Anatomy of Ear (Continued)

The Outer Ear: (Auricle)

Composed of cartilage and is contact with the external world
Anatomical demarcations

helix
antihelix
tragus
antitragus

these demarcations lead to a depression called acoustic meatus

At the end of the outer ear, lies the middle ear, which is limited externally by the tympanic membrane and internally by the oval window.

University of Rochester Medical Center Rochester, n.d.

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Anatomy of Ear (Continued)

The middle ear is a rectangular shaped air-filled space
Consists of

ossicles; the
malleus, the
incus and the
stapes

Divides into an upper and a lower chamber

Epitympanic chamber (attic)
Tympanic chamber (atrium)

Has anatomical relations with jugular vein, carotid artery, inner ear, eustachian tube, and mastoid

University of Rochester Medical Center Rochester, n.d.

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Anatomy of Ear (Continued)

The inner ear is composed

the bony labyrinth
membranous labyrinth (one inside the other)

The bony labyrinth has a cavity filled with semicircular canals in charge of sensing equilibrium
The cochlea is the organ of hearing

University of Rochester Medical Center Rochester, n.d.

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Physiology of Ear

University of Rochester Medical Center Rochester, n.d.

Sánchez López de Nava & Lasrado, 2021

Outer ear- directs sound waves into the tympanic membrane.
Auricle- concentrates and directs the majority of the sound waves into the funnel-shaped canal.
Vibrations arrive at the tympanic membrane, triggering additional vibrations.

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The system by which humans detect sounds is comprised of the external auditory canal and its microstructures (pinna, tragus, anti-tragus, namely), the tympanic membrane, the ossicles, the cochlear structure, and its contents (endolymph, organ of Corti) and the nerve fibers that give birth to the vestibular and cochlear divisions of the VIII cranial nerve

The outer ear serves the function of directing sound waves into the tympanic membrane. The auricle concentrates the majority of the sound waves and directs it into the funnel-shaped canal. Because the human auricle is almost immobile and not that large, it is less effective with sound gathering than the ears of other mammals. This resonance mechanism only works with short wavelength sound waves (frequencies between 2000 to 7000 Hz) thus determining the sensitivity of the human ear to some frequencies that help us distinguish vowels from consonants. Then, vibrations arrive at the tympanic membrane, triggering vibration there as well. This vibration stimulates a chain of ossicular structures that will transmit the energy to the cochlea, a spiral structure in the inner ear. In the cochlea, the energy is no longer in the form of vibrations, but in the form of hydraulic energy.

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Physiology of Ear

This vibration stimulates a chain of ossicular structures that transmit the energy to the cochlea.
In the cochlea, the energy changes from vibrations to the form of hydraulic energy.
Once sound waves reach to inner ear, it converts into electrical impulses.
The auditory nerve transmits the impulses to the brain.
Brain translates the impulses as sound.

University of Rochester Medical Center Rochester, n.d.

Sánchez López de Nava & Lasrado, 2021

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Why Children are More at The Risk of Developing Ear Infections

Eustachian tubes are smaller and more level making it difficult for fluid to drain out of the ear.
The child’s immune system it’s still developing.
Sometimes bacteria gets trapped in the adenoids, causing a chronic infection that can then pass on to the eustachian tubes and the middle ear.

National Institute on Deafness and Other Communication Disorders, 2022

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True or False

Eustachian tubes are larger and more level so makes it easier for fluid to drain out of the ear, even under normal conditions.
The middle ear is composed of the bony labyrinth and the membranous labyrinth.
At the end of the outer ear, lies the middle ear, which is limited externally by the tympanic membrane and internally by the oval window.
The outer ear serves the function of directing sound waves into the tympanic membrane.
The inner ear concentrates the majority of the sound waves and directs it into the funnel-shaped canal.

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Acute Otitis Media (AOM)

An infection of the middle ear space

Second most common pediatric diagnosis in the emergency department (following upper respiratory infections)

Most common between the ages of 6 to 24 months

May be viral, bacterial, or co-infection

Danishyar & Ashurst, 2022

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Acute Otitis Media: Causes and Risk Factors

Infectious, allergic, and environmental factors contribute to otitis media

Decreased immunity due to HIV, and other immunodeficiencies
Genetic predisposition
Mucins which include abnormalities of this gene expression
Anatomic abnormalities of the palate and tensor veli palatini
Ciliary dysfunction
Cochlear implants
Vitamin A deficiency

Danishyar & Ashurst, 2022

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Acute Otitis Media: Causes and Risk Factors

Bacterial pathogens, Streptococcus pneumoniae, Haemophilus influenza, and Moraxella (Branhamella) catarrhalis
Viral pathogens such as respiratory syncytial virus, influenza virus, parainfluenza virus, rhinovirus, and adenovirus
Allergies
Lack of breastfeeding
Passive smoke exposure
Daycare attendance
Lower socioeconomic status
Family history of recurrent AOM in parents or siblings

Danishyar & Ashurst, 2022

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Acute Otitis Media: Signs and Symptoms

Otalgia (earache)
Pulling or tugging at the ears
irritability
Headache
Disturbed or restless sleep
Poor feeding
Anorexia
Vomiting
Diarrhea
Low grade fever

Danishyar & Ashurst, 2022

Contact info: info@nursesinternational.org

Although one of the best indicators for otitis media is otalgia, many children with otitis media can present with non-specific signs and symptoms, which can make the diagnosis challenging. These symptoms include pulling or tugging at the ears, irritability, headache, disturbed or restless sleep, poor feeding, anorexia, vomiting, or diarrhea. Approximately two-thirds of the clients present with fever, which is typically low grade.

The diagnosis of otitis media is primarily based on clinical findings combined with supporting signs and symptoms as described above. No lab test or imaging is needed. According to guidelines set forth by the American Academy of Pediatrics, evidence of moderate to severe bulging of the tympanic membrane or new onset of otorrhea not caused by otitis externa or mild tympanic membrane (TM) bulging with recent onset of ear pain or erythema is required for the diagnosis of acute otitis media. These criteria are intended only to aid primary care clinicians in the diagnosis and proper clinical decision making but not to replace clinical judgment.

Otoscopic examination should be the first and most convenient way of examining the ear and will yield the diagnosis to the experienced eye. In AOM, the TM may be erythematous or normal, and there may be fluid in the middle ear space. In suppurative OM, there will be obvious purulent fluid visible and a bulging

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Acute Otitis Media: Diagnosis

Clinically diagnosed by objective findings on physical exam (otoscopy) and presenting signs and symptoms

Diagnostic tools:

Pneumatic otoscope
Tympanometry
Acoustic reflectometry

Pneumatic otoscopy is the most reliable

**Note: Laboratory studies and imaging studies are rarely necessary for the diagnosis

Danishyar & Ashurst, 2022

Contact info: info@nursesinternational.org

Laboratory Studies

Laboratory evaluation is rarely necessary. A full sepsis workup in infants younger than 12 weeks with fever and no obvious source other than associated acute otitis media may be necessary. Laboratory studies may be needed to confirm or exclude possible related systemic or congenital diseases.

Imaging Studies

Imaging studies are not indicated unless intra-temporal or intracranial complications are a concern.

When an otitis media complication is suspected, computed tomography of the temporal bones may identify mastoiditis, epidural abscess, sigmoid sinus thrombophlebitis, meningitis, brain abscess, subdural abscess, ossicular disease, and cholesteatoma.
Magnetic resonance imaging may identify fluid collections, especially in the middle ear collections.

Tympanocentesis

Tympanocentesis may be used to determine the presence of middle ear fluid, followed by culture to identify pathogens.

Tympanocentesis can improve diagnostic accuracy and guide treatment decisions but is reserved for extreme or refractory cases.

Other Tests

Tympanometry and acoustic reflectometry may also be used to evaluate for middle ear effusion

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Treatment and Management

Mange pain: Non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen
Treat infection with antibiotics
ofloxacin for perforated tympanic membrane
If bacterial etiology: Amoxicillin, Azithromycin, Clarithromycin
Systemic steroids and antihistamines
Ototopical antibiotic drops
4 or more episodes of AOM within twelve months should be considered for myringotomy with tube (grommet) placement

Danishyar & Ashurst, 2022

Contact info: info@nursesinternational.org

Once the diagnosis of acute otitis media is established, the goal of treatment is to control pain and to treat the infectious process with antibiotics. Non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen can be used to achieve pain control. There are controversies about prescribing antibiotics in early otitis media, and the guidelines may vary by country, as discussed above. If there is clinical evidence of suppurative AOM, however, oral antibiotics are indicated to treat this bacterial infection, and high-dose amoxicillin or a second-generation cephalosporin are first-line agents. If there is a TM perforation, treatment should proceed with ototopical antibiotics safe for middle-ear use such as ofloxacin, rather than systemic antibiotics, as this delivers much higher concentrations of antibiotics without any systemic side effects.

When a bacterial etiology is suspected, the antibiotic of choice is high-dose amoxicillin for ten days in both children and adult clients who are not allergic to penicillin. Amoxicillin has good efficacy in the treatment of otitis media due to its high concentration in the middle ear. In cases of penicillin allergy, the American Academy of Pediatrics (AAP) recommends azithromycin as a single dose of 10 mg/kg or clarithromycin (15 mg/kg per day in 2 divided doses). Other options for penicillin-allergic clients are cefdinir (14 mg/kg per day in 1 or 2 doses), cefpodoxime (10 mg/kg per day, once daily), or cefuroxime (30 mg/kg per day in 2 divided doses).

For those clients whose symptoms do not improve after treatment with high dose amoxicillin, high-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin component, with 6.4 mg/kg per day of clavulanate in 2 divided doses) should be given. In children who are vomiting or if there are situations in which oral antibiotics cannot be administered, ceftriaxone (50 mg/kg per day) for three consecutive days, either intravenously or intramuscularly, is an alternative option. Systemic steroids and antihistamines have not been shown to have any significant benefits.

clients who have experienced four or more episodes of AOM in the past twelve months should be considered candidates for myringotomy with tube (grommet) placement, according to the American Academy of Pediatrics guidelines. Recurrent infections requiring antibiotics are clinical evidence of Eustachian tube dysfunction, and placement of the tympanostomy tube allows ventilation of the middle ear space and maintenance of normal hearing. Furthermore, should the client acquire otitis media while a functioning tube is in place, they can be treated with ototopical antibiotic drops rather than systemic antibiotics.

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Client Education

Pneumococcal and influenza vaccines to prevent upper respiratory tract infections (URTIs).
Avoidance of tobacco smoke can decrease the risk of URTI; Tobacco smoke is a respiratory stimulant that increases the risk of pneumonia in children.
Breastfeed whenever possible,as breast milk contains immunoglobulins that protect infants from foreign pathogens.

Danishyar & Ashurst, 2022

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What Would the Nurse Do?

The nurse plans to provide teaching to the parents of a child diagnosed with acute otitis media.

Which instructions should the nurse include in the teaching plan? (Select all that apply).

Administer medications as prescribed
If a bacterial infection is present, do not administer antibiotics
Educate about pneumococcal and influenza vaccines to prevent upper respiratory tract infections
Use antibacterial soap for bathing the child
Encourage breastfeeding whenever possible

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Otitis Media With Effusion (OME)

A condition in which there is fluid in the middle ear, but no signs of acute infection.
The built up fluid places pressure on the tympanic membrane.
The pressure prevents the tympanic membrane from vibrating properly, decreases sound conduction, and therefore results in a decrease in client hearing.
Chronic OME-OME that persists for 3 or more months on examination or tympanometry.

Searight, 2022

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OME: Cause and Risk Factors

Passive smoking
Bottle feeding
Day-care nursery attendance
Atopy ·
Developmental anomalies: cleft palate
Downs Syndrome

Searight, 2022

Contact info: info@nursesinternational.org

Risk factors for OME include passive smoking, bottle feeding, day-care nursery, and atopy. Both children and adults can develop OME. However, the etiology of these populations are different. The Eustachian tube is positioned more horizontally in younger children. As the child develops into an adult, the tube elongates and angles caudally. Therefore, OME is more common in children, and the position of the head at this age can influence the development of OME. Children with development anomalies including the palate, palate muscles, decreased muscle tone for palate muscles, or bone development variations are at increased risk of development of OME, e.g., cleft palate, Down Syndrome. Beyond these anatomical variations, clients with Downs syndrome can have mucociliary function disorders that increase the risk of developing OME.

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OME: Signs and Symptoms

Often does not have obvious symptoms
Hearing loss (less common)
Communication difficulties
Withdrawal
Lack of attention
Impaired speech and language development
Intermittent earache
Sensation of ear popping
Opac tympanic membrane

Searight, 2022

Contact info: info@nursesinternational.org

Older children and adults often complain of muffled hearing or a sense of fullness in the ear. Younger children may turn up the television volume because of hearing loss. Hearing loss, although not always present, is the most common complaint in OME clients. Clients or parents of clients may complain of communication difficulties, withdrawal, and lack of attention. During an exam, a clinician may notice impaired speech and language development. Otalgia, earache, can be intermittent in these clients. In many instances, they will have the symptom of aural fullness or a sensation that the ear is popping. In adults, OME is more often unilateral. Adult clients may report tinnitus and the sensation of a foreign body in the external auditory canal. In either children or adults, OME commonly occurs concurrently with upper respiratory infections. Therefore, it is good to ask clients about prior or recurrent ear infections, nasal obstruction, and upper respiratory tract infections.

During a physical examination, signs of OME include opacification of the tympanic membrane and loss of the light reflex. There may also be a retraction of the tympanic membrane with decreased mobility. If gross retraction of the tympanic membrane is observed, intervention may be required to prevent the formation of a retraction pocket, such as modified cartilage augmentation tympanoplasty.

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OME: Diagnosis

Examination of ears and presence of:

Air bubbles on the surface of eardrum
Dullness of eardrum during light examination
Fluid behind eardrum
Tympanometry
Fluid in the middle ear can be accurately detected with acoustic otoscope Reflectometer

MedlinePlus, 2020

Searight, 2022

Contact info: info@nursesinternational.org

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OME: Treatment

Not treated unless there are signs of an infection
Follow up in 2 to 3 months
Advised

Avoid cigarette smoke
Encourage infants to breastfeed
Treat allergies by staying away from triggers (such as dust)
Adults and older children may be given allergy medicines
A single trial of antibiotics (if they were not given earlier)
If significant hearing loss, antibiotics or ear tubes may be needed

MedlinePlus, 2020

Searight, 2022

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

Which of the following interventions would a nurse expect in the treatment management of a child with otitis media with effusion? (Select all that apply)

Avoid cigarette smoke
Encourage infants to breastfeed
Treat allergies by staying away from triggers (such as dust)
Adults and older children may be given allergy medicines
A single trial of antibiotics (if they were not given earlier
If significant hearing loss, antibiotics or ear tubes might be needed

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Otitis Externa (OE) (Swimmer’s Ear)

Inflammation (either infectious or non-infectious), of the external auditory canal.
Sometimes inflammation may extend to the outer ear (pinna or tragus).
May be acute (lasting ＜6 weeks), or chronic (Lasts ＞3 months).
Repeated exposure to water may make the ear canal more vulnerable to inflammation.

NHS Inform, 2021

Medina-Blasini, Y., Sharman, 2022

Contact info: info@nursesinternational.org

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Otitis Externa: Causes

Bacterial infection: Pseudomonas aeruginosa or Staphylococcus aureus
Following condition are responsible for Otitis externa:

Irritation: Hair sprays, hair dyes
Fungal infections: Aspergillus variety and the Candida albicans variety
Allergies: Ear medication, ear plugs, shampoo or perspiration

NHS Inform, 2021

Medina-Blasini, Y., Sharman, 2022

Contact info: info@nursesinternational.org

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Otitis Externa: Risk Factors

Damage to the skin inside the ear
Frequently getting water in the ear:

May cause a child to scratch inside their ear
The moisture provides an ideal environment for bacteria to grow.

NHS Inform, 2021

Medina-Blasini, Y., Sharman, 2022

Contact info: info@nursesinternational.org

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Otitis Externa: Signs and Symptoms

Earache, itching and irritation in and around the ear canal
Redness and swelling of outer ear and ear canal
Feeling of pressure and fullness inside ear
Scaly skin in and around ear canal
Ear discharge
Tenderness when moving the ear or jaw
Swollen and sore glands in the throat
Some hearing loss

NHS Inform, 2021

Medina-Blasini, Y., Sharman, 2022

Contact info: info@nursesinternational.org

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Otitis Externa: Long Term Signs and Symptoms

Symptoms of chronic otitis externa:

Constant itch in and around ear canal
Discomfort and pain in ear worse with movement
Thin, watery discharge from ear
Lack of earwax
Stenosis (thick, dry skin build up in ear canal)

NHS Inform, 2021

Medina-Blasini, Y., Sharman, 2022

Contact info: info@nursesinternational.org

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Otitis Externa: Treatment

May resolve without treatment
Usually improves the symptoms with otic drop medication
Acetaminophen or NSAID for pain
Antibiotic otic drops like Polymyxin B, neomycin, and hydrocortisone (prescription)
May need specialist for further treatment if symptoms are severe or they fail to respond to treatment

NHS Inform, 2021

Medina-Blasini, Y., Sharman, 2022

Contact info: info@nursesinternational.org

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Otitis Media: Nurses’ Role

Ensure the optimum comfort and safety
Manage pain
Position child in fowler's or semi fowler's position
Encourage to lie on unaffected ear
Heating pad to affected ear
Encourage breastfeeding
Position bottle-fed infants upright when feeding to prevent aspiration
Ensure hygiene and infection control; teach coughing and sneezing etiquettes, encourage frequent hand hygiene Hygiene
Assess hearing ability frequently

Belleza, 2021

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Critical Thinking Questions

A nurse is caring for a 4-yr-old child diagnosed with otitis externa. Which further assessment finding requires immediate intervention?

Dry mucous membrane
A feeling of pressure and fullness inside the ear
Loss of balance
Ringing in the ears

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Hearing Loss

A hearing loss may occur when any part of the ear is not functioning properly.
May involve outer ear, middle ear, inner ear, hearing (acoustic) nerve, and auditory system.
May affect a child’s ability to develop speech, language, and social skills.
Early identification and treatment likely to achieve positive results.

CDC, 2021

Dimitrov & Gossman, 2022

Contact info: info@nursesinternational.org

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Hearing Loss: Causes and Risk factors

May happen any time during life cycle

May have unknown cause

Possible genetic cause

Risk factors: Down syndrome or Usher syndrome

CDC, 2021

Dimitrov & Gossman, 2022

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Hearing Loss: Causes and Risk factors (Continued)

Exposure to infection before birth
NICU stay or complications while in the NICU
Blood transfusion
Abnormal head, face or ear shape
Meningitis
Head trauma that required hospital stay

CDC, 2021

Dimitrov & Gossman, 2022

Contact info: info@nursesinternational.org

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Hearing Loss: Signs and Symptoms (Infant)

Loss of startle reflex
Does not turn to the source of a sound after 6 months of age
Does not say single words, such as “dada” or “mama” by 1 year of age
Responds do some sounds but not others

CDC, 2021

Dimitrov & Gossman, 2022

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Hearing Loss: Signs and (in Children)

Delayed speech
Speech is not clear
Does not follow directions.
Often says, “Huh?”
Turns the TV or computer volume to high

CDC, 2021

Dimitrov & Gossman, 2022

Contact info: info@nursesinternational.org

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Hearing Loss: Screening and Diagnosis

Infants

All newborns should have a hearing screening no later than 1 month of age.

Children

Children should have their hearing tested before they enter school and any time when there is a concern about the child’s hearing.

CDC, 2021

Dimitrov & Gossman, 2022

Contact info: info@nursesinternational.org

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Hearing Loss: Treatment and Management

Good treatment plans will include close monitoring, follow-up

Assistive communication options:

Learning other ways to communicate, (sign language)
Technology to help with communication (hearing aids and cochlear implants)
Medicine and surgery to correct hearing loss
Family support services

CDC, 2021

Dimitrov & Gossman, 2022

Contact info: info@nursesinternational.org

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Hearing Loss: Nurse’s Role

Create optimal listening environment; minimize noises by closing door and windows
Turn off the TV and other sound devices before talking to the child
Provide comfort and safety
Observe for the signs of frustration
Attention to visual cues
Be familiar with the child’s hearing aids

My Health Alberta.ca, 2021

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References

Andrews, M.M., Boyle, J.S. & Collings, J. W. (2020). Transcultural Concepts in Nursing Care (8th Ed.). Wolters Kluwer, Philadelphia, PA.

Belleza, M. (2021,February 11). Nurses lab: Otitis Media. https://nurseslabs.com/otitis-media/

CDC- Center for Disease Control and Prevention. (2021, June 21). What is Hearing Loss in Children? https://www.cdc.gov/ncbddd/hearingloss/facts.html

Danishyar, A., Ashurst, J.V. (2022, January 21). Acute Otitis Media. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470332/#!po=7.14286

Contact info: info@nursesinternational.org

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References

Dimitrov, L., Gossman, W. (2022, January 15). Pediatric Hearing Loss. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538285/

Medina-Blasini, Y., Sharman, T. (2022, April 30). Otitis Externa. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556055/

MedlinePlus. (2020, July 22). Otitis media with effusion. https://medlineplus.gov/ency/article/007010.htm

My Health Alberta.ca. (2021, February 1). Hearing: Helping children with hearing loss to listen and learn. https://myhealth.alberta.ca/speech-language-hearing/hearing/for-children/helping-children-with-hearing-loss-listen-learn

Contact info: info@nursesinternational.org

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References

National Institute on Deafness and Other Communication Disorders. (2022, March 16). Health Information: Ear Infections in Children. https://www.nidcd.nih.gov/health/ear-infections-children

NHS Inform. (2021, July 06). Otitis externa. https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/otitis-externa#symptoms-of-otitis-externa

Sánchez, L. d. N. A., Lasrado, S. (2021, August 30). Physiology, Ear. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540992/#:~:text=The%20ear%20is%20a%20cartilaginous,contact%20with%20the%20external%20world

Contact info: info@nursesinternational.org

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References

Searight, F.T., Singh, R., Peterson, D.C. ( 2022, May 1). Otitis Media With Effusion. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538293/

University of Rochester Medical Center Rochester. (n.d.). Anatomy and Physiology of the Ear. https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02025#:~:text=Hearing%20starts%20with%20the%20outer,middle%20ear%20called%20the%20ossicles.

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