ANATOMY OF THE INNER EAR

 Oval window- The oval window, also known as the fenestra ovalis, is a connective tissue
membrane that sits at the end of the middle ear and the beginning of the inner ear. It links the
middle ear's small bones to the top region of the cochlea, known as the scala vestibuli.

Healthline. (2018, January 22). Oval window. https://www.healthline.com/human-body-maps/oval-

window

 Stapes- The stapes bone is the smallest one in the human body. It is the innermost ossicles in the
middle ear. The stapes bone is vital for hearing. Sound vibrates through the tympanic membrane
and travels through all three middle ear bones: the malleus, incus, and stapes.

Hayes, K. (2023, October 23). The Anatomy of the Stapes Bone. Verywell Health.
https://www.verywellhealth.com/stapes-anatomy-5092604

 Incus- The incus is an anvil-shaped central auditory ossicle that joins the malleus with the stapes.
It has two limbs and a cube-shaped body. The body of the incus is located in the epitympanic
recess and articulates with the head of the malleus via a facet to create the incudomalleolar joint.

Kenhub. (2024, February 27). Incus. https://www.kenhub.com/en/library/anatomy/incus#:~:text=The

%20incus%20is%20the%20anvilshaped%20central%20auditory%20ossicle,malleus%20via%20a
%20facet%2C%20forming%20the%20incudomalleolar%20joint.

 Malleus - The malleus is the largest and outermost bone in the auditory system. The ossicle
bones' sensory function is hearing. They do this by passing vibrational pressure from the eardrum
to the malleus, then the incus, the stapes, and ultimately the cochlea.

Valeii, K. (2023, August 22). Anatomy of the Malleus. Verywell Health.

https://www.verywellhealth.com/malleus-anatomy-5095984

 Tympanic Membrane - It is a thin layer of tissue in the human ear that picks up sound vibrations
from the surrounding air and sends them to the auditory ossicles, which are small bones in the
tympanic cavity at the middle ear.

Encyclopedia Britannica. (1998, July 20). Tympanic membrane | Definition, Anatomy, Function, &
Perforation. https://www.britannica.com/science/tympanic-membrane

 External auditory canal - It is the section of the ear that begins with the eardrum and extends to
the cartilage outside the ear. The fundamental function of the ear canal is to increase the volume
of sound collected by the pinna as it travels to the eardrum. It also functions as a filter, preventing
dangerous substances from reaching the eardrum.
Mph, A. O. P. (2024, March 25). A Look Inside the Ear Canal. Verywell Health.
https://www.verywellhealth.com/ear-canal-8610869

 Round window- The round window connects to the internal ear and is sealed by the secondary
tympanic membrane. The vibrations of this membrane enable the cochlear fluid to move.

Kenhub. (2023, November 3). Ear. https://www.kenhub.com/en/library/anatomy/the-ear

 Auditory tube- also called eustachian tubes, link the middle ears to the upper region of the throat
behind the nose. Eustachian tubes help keep the middle ear healthy by keeping the air pressure on
both sides of the eardrum constant. It drains fluids from the middle ear and protects it from
diseases such as germs and viruses.

Hayes, K. (2023, March 5). The Anatomy of the Eustachian Tube. Verywell Health.
https://www.verywellhealth.com/what-is-the-eustachian-tube-1192115

 Cochlear nerve - The cochlear nerve, also known as the acoustic nerve, is a sensory nerve that
transmits auditory information from the cochlea into the brain. It is one of many components that
comprise the auditory system, allowing for effective hearing.

Healthline. (2023, July 17). Cochlear nerve. https://www.healthline.com/human-body-maps/cochlear-

nerve#:~:text=The%20cochlear%20nerve%2C%20also%20known%20as%20the%20acoustic,up
%20the%20auditory%20system%2C%20which%20enables%20effective%20hearing.

 Scala vestibuli - The scala vestibuli begins with the oval window, which is an aperture at the base
of the cochlea that connects to the middle ear. It is filled with perilymph, a fluid similar in
composition to CSF fluid but distinct from the potassium-rich endolymph found in the scala
media. This is where vibrations from the middle ear's stapes bone enter the cochlea.

K., & K. (2024, March 4). Scala vestibuli - Structure, Location, Function, Diagram. Anatomy.co.uk |
Learn Human Anatomy From Experts. https://anatomy.co.uk/scala-vestibuli/

 Scala tympani- The scala tympani is one of the cochlea's three fluid-filled chambers, or scalae,
that play an important role in hearing. The flow of perilymph inside the scala tympani causes
vibrations in the basilar membrane, which activates hair cells in the organ of Corti situated in the
scala medium.

K., & K. (2024, March 4). Scala tympani - Structure, Function, Diagram. Anatomy.co.uk | Learn
Human Anatomy From Experts. https://anatomy.co.uk/scala-tympani/

 Cochlear duct- The cochlea is a fluid-filled, snail-like organ located inside the inner ear. It is
more than just another skeletal system component; it is essential to the function of hearing. The
cochlea includes hair cells that convert sound waves into electrical impulses that go via the
auditory nerve to the brain.

Hayes, K. (2024, May 10). The Anatomy of the Cochlea. Verywell Health.
https://www.verywellhealth.com/cochlea-anatomy-5069393

 Vestibular membrane- The vestibule of the ear is best defined as the region of the inner ear
between the tympanic cavity. The vestibule of the ear and the otolith organs, known as the utricle
and saccule, are components of the vestibular system, which regulates our equilibrium and
balance.
Hayes, K. (2023, August 14). Vestibule of the Ear. Verywell Health.
https://www.verywellhealth.com/vestibule-of-the-ear-anatomy-5096174

 Basilar membrane- The basilar membrane is an essential component of the inner ear and is
found inside the cochlea, which is moved by sound waves that strike the ear. The movement of
the basilar membrane causes the cilia of the hair cells to lightly brush against the surface of the
tectorial membrane. This kind of bending action causes the hair cells to generate a neural impulse,
signaling the brain that a sound wave has been recognized.
A. (2023, October 19). Basilar Membrane: What Is It? What Are Its Functions? Science ABC.
https://www.scienceabc.com/humans/basilar-membrane-what-is-it-and-what-does-it-do.html

Tectorial membrane- The tectorial membrane is a gelatinous membrane where sound entering the
inner ear activates various parts of the basilar membrane according on its frequency. The shearing
action between the stereocilia and the tectorial membrane excites hair cells in the stimulated areas.

Tectorial membrane | anatomy. (n.d.). Encyclopedia Britannica.

https://www.britannica.com/science/tectorial-membrane

 Spiral organ- The organ of Corti is a highly specialized and complex sensory epithelium that
comprises a variety of cells and structures that convert sound vibrations into electrical impulses,
which are ultimately conveyed to the brain via the auditory nerve. The organ of Corti's major role
is to transform mechanical sound waves into electrical impulses that can be processed by the
brain.

K., & K. (2024, March 4). Spiral organ - Structure, Function, Location (with Pictures). Anatomy.co.uk
| Learn Human Anatomy From Experts. https://anatomy.co.uk/spiral-organ/

ANATOMY OF THE BRAIN CIRCULATION

 Middle cerebral artery- The middle cerebral artery (MCA) is the primary blood channel that
transports oxygen and nutrients to key parts of your brain. These sections largely include the
frontal, parietal, and temporal lobes. The MCA provides structures such as Broca's region
(expressive speech) and Wernicke's area (receptive speech).

Vega, J. (2022, February 15). Anatomy of the Middle Cerebral Artery (MCA). Verywell Health.
https://www.verywellhealth.com/middle-cerebral-artery-3146149

 Posterior cerebral artery- The basilar artery has a terminal branch known as the posterior
cerebral artery. It primarily serves the occipital lobe, the inferomedial surface of the temporal
lobe, the midbrain, the thalamus, and the choroid plexus of the third and lateral ventricles. The
posterior cerebral artery contributes to the creation of the cerebral arterial circle (Willis), which
supplies the majority of the arterial blood flow to the brain.
Posterior cerebral artery. (2023, October 30). Kenhub.
https://www.kenhub.com/en/library/anatomy/posterior-cerebral-artery

 Basilar artery- The basilar artery is a rather big, strong blood vessel found in the posterior
cerebral fossa. It is the primary blood artery responsible for the brain's posterior circulation. This
is one of two arterial circuits that transports up to 15% of total cardiac output to brain tissue. The
increased demand for oxygenated blood is due to the several physiological activities that the brain
performs on a daily basis.

Basilar artery. (2023, October 30). Kenhub. https://www.kenhub.com/en/library/anatomy/basilar-artery

 Vertebral artery- The vertebral arteries are part of the circulatory system. They transport blood
to the brain and spinal cord, which are components of the nervous system. The vertebral artery
supplies 20% of the blood supply to your brain.

Professional, C. C. M. (n.d.). Vertebral Artery. Cleveland Clinic.

https://my.clevelandclinic.org/health/body/21689-vertebral-artery

 Anterior cerebral artery- The communicative segment (C7) of the internal carotid artery
terminates at the anterior cerebral artery. The anterior cerebral artery provides a significant
percentage of the medial cerebral hemisphere surfaces, including the corpus callosum, frontal,
parietal, and cingulate cortex.

 Anterior communicating artery- The anterior communicating artery is a small channel that links
the left and right anterior cerebral arteries and serves as the anterior boundary of Willis' cerebral
arterial circle. This artery nourishes the optic chiasma, lamina terminalis, preoptic and supraoptic
regions of the hypothalamus, parolfactory sections of the frontal cortex, anterior columns of
fornix, and the cingulate gyrus by its anteromedial central branches.

 Internal carotid artery- The internal carotid artery is a key branch of the common carotid artery
that supplies blood to numerous areas of the head, the most important of which is the brain. The
internal carotid arteries are part of the anterior circulation, which supplies the forebrain.

 Posterior communicating artery- the posterior communicating arteries connects the posterior
cerebral arteries to their ipsilateral internal carotid arteries.

 Posterior cerebral artery- The basilar artery has a terminal branch known as the posterior
cerebral artery. It primarily serves the occipital lobe, the inferomedial surface of the temporal
lobe, the midbrain, the thalamus, and the choroid plexus of the third and lateral ventricles.

Circle of Willis. (2023, October 30). Kenhub. https://www.kenhub.com/en/library/anatomy/circle-of-

willis
COURSE IN THE WARD (NARRATIVE)
MARCH 26,2023

The patient is admitted during night time to room of choice with the initial diagnosis of
Benign Paroxysmal Positional Vertigo (BPPV) to consider posterior circulation infarct. The patient is
under the service and care of Dr. Sebastian and Dr. Laurente during the following day (March 27,
2023). Upon physician’s order the patient is advised on a diet as tolerated (DAT) diet but the patient is
remained nothing per orem (NPO) for 8 hours. Then, 1 liter of plain NSS with 1 ampule of citicoline is
given to be administered for 12 hours. The patient is subjected for diagnostic exams including CT scan,
lipid profile, chest X-ray, and ECG monitoring. In addition, thyroid function test is carried out and the
test is noted done outside. All laboratory results are then carried out by the nurse on duty. The
physician orders medications which include: cinnarizine (Dizzinon) 75mg per tablet to be given three
times a day orally; betahistine 24 mg per tablet two times a day orally; Vitamin B complex (Vyclex) 1
tablet once a day orally; and metoprolol 50 mg per tablet once a day. The medication were given at
appropriate time and with the right dose to the patient. The vital signs is monitored every 4 hours as
advised, it must include proper monitoring of the blood pressure, temperature, pulse rate, and
respiration. Appropriately checking the intake and output of the patient is advised to be checked every
end of shift. The vital signs of the patient is promptly check with normal range as well as the intake and
voiding and bowel movement patterns.

MARCH 27, 2023

The next day, in the supervision of Dr. Laurente, upon the physician’s order the patient was
given the following medication at 11:30 in the morning; stugerone forte 75mg per tablet to be given
two times a day orally; and serc 24 mg per tablet is given two times a day orally. At noon (12:00 PM),
the second bottle of 1 liter of plain NSS is given to be administered for 12 hours. The insertion site is
checked if patent and the flow rate is also adjusted adequately. Then, at 2:30 in the afternoon the
patient verbalize complaints of shortness of breath, dizziness, and headache. The patient is advised for
continuing administration of the drug indicated with administration of citicoline 500 mg per tablet to be
given two times a day orally, flunarizine (Flumig) 5mg 2 tablets once a day during bed time and shift
of metoprolol to nebivolol 5mg per tablet to be given once a day. Prompt monitoring of vital signs is
done every 4 hours and proper monitoring of intake and output is done at the end of the shift. The
blood pressure, temperature, respiration and pulse are all normal.

MARCH 28, 2023

At 7:30 in the morning the patient is under the care and service of Dr. Castillo. The third
bottle of 1 liter of plain NSS is given to be administered for 12 hours. The insertion site is checked if
patent and flow rate is adjusted appropriately. During 10:15 in the morning, the administration of
intravenous fluid is increased for 16 hours, flow rate is then adjusted. Then, at 12:25 in the afternoon,
under the supervision of Dr. Laurente and Dr. Sebastian the patient were advised to go home. The
patient is counseled for home medication for proper administration and advised for follow up check up
one week after with Dr. Sebastian. The patient verbalized understanding and express proper adherence
to plan of care. The vital signs were checked accordingly and result shows that the blood pressure,
temperature, pulse and respiration are normal.
 PATHOPHYSIOLOGY (PATIENT BASED)
BPPV

Idiopathic Female
Risk Factors: High blood glucose and low HDL 46 years old

Crystal otolithic organs dislodged from the

utricle in the vestibular membrane

Otolith crystal (otoconia) are trapped in semi-

circular canal

Sudden movement such as laying down and

standing up

Disrupt the normal movement of endolymph in

the semi-circular canals
Signals confusion to the brain

Vestibular nerves signals confusion to the brain

Legend:

 Non-modifiable Benign Paroxysmal Positional Vertigo (BPPV)

risk factors
 Modifiable risk
factors
 Diagnosis Dizziness
 Symptoms

The patient present symptoms of recurrent dizziness for 6 days prior to admission. It is commonly the
presented symptom of Benign Paroxysmal Positional Vertigo (BPPV). It arises from an unknown
cause and upon the laboratory results in lipid test patient has low HDL and upon glucose test patient
has high blood glucose levels which are common factors for disruption of crystals in the inner ear.
Vestibular membrane and semicircular canals are parts of the inner ear that aid balance. These canals
are filled with fluid called endolymph and has hair-like structure that sense changes. The vestibular
nerve is the one that signals the brain particularly the cerebellum for sudden shift in the endolypmh.
The otolith organs are part of the utricle and saccula in the vestibular canal. An injury or infection
causes these crystals to be dislodged in its original place. This causes the semi-circular canals sensitive
to movement like laying down and standing up signaling confusion to the brain. This causes spinning
sensation, dizziness, and nausea and vomiting.
 PATHOPHYSIOLOGY (PATIENT BASED)
POSTERIOR INFARCT

Elevated blood pressure Female

Low HDL 46 years old

Irritation in the endothelial lining of the blood

vessel

Inflammation on the endothelial cells

Atherosclerosis arises from damaged

endothelium

Build-up of fats, cholesterol, proteins, calcium

and immune cells are formed

Plaques are formed

Increase blood flow release the plaque from its

protective barrier

Plaques becomes inflamed

Proliferation of blood clot

Blood flow is blocked

Insufficient blood flow and oxygenation

Legend:
Infarction
 Non-modifiable
risk factors
 Modifiable risk
factors
 Diagnosis Severe headache
 Symptoms

The patient complaints severe headache prior to admission. The patient has elevated blood pressure 130/90
and lipid test results indicates low HDL. This are prior risk for posterior infarct which can lead to ischemic
stroke. It arises from developing plaques due to irritation of the endothelial cells. This are usually due to
teratogenic substances and changes in blood flow (hypertension) causes. The arteries are in the chronic
inflammatory state leading to damaged tissue. This becomes site for atherosclerosis wherein cholesterol
build-up arises. Formation of plaques are prominent causative of blood clots, it occurs when the protective
barrier of the plaques are worn of due to strong force of blood flow. This cause inflammation along the site
where the plaques resides. Blood clots form continuously until it blocks the artery resulting to insufficient
blood flow and oxygenation in the brain.
 PATHOPHYSIOLOGY (BOOK BASED)
INFARCT

Hypertension Female
High cholesterol Older age (50 years old and above)
Hyperglycemia Smoking and alcohol consumption

Irritation in the endothelial lining of the blood Atrial fibrillation and heart attacks
vessel

Inflammation on the endothelial cells Stagnation of blood

Atherosclerosis arises from damaged Formation of blood clots in the left atrium
endothelium

Build-up of fats, cholesterol, proteins, calcium Dislodged from the surface of the heart through
and immune cells are formed the aorta

Plaques are formed Travels through the upper blood circulation

Increase blood flow release the plaque from its Blockage to smaller arteries in the brain
protective barrier

Plaques becomes inflamed

Proliferation of blood clot

Blood flow is blocked

Legend:

 Non-modifiable
risk factors
Insufficient blood flow and oxygenation
 Modifiable risk
factors
 Diagnosis
 Symptoms Infarction

Severe headache Impaired speech and Muscle weakness Impaired sense of sight
cognition

The most common cause of cerebral insufficiency is the manifestation of high cholesterol,
hypertension, and hyperglycemia which induces chronic inflammation. Some irritants also irritates the
endothelial cells which lead to the severe damage. It potentiates the inflammation of the endothelium thus
leads to site for the atherosclerotic cell formation. It leads to development of plaques in the vessels. These
are build-up of cholesterol and immune cells. It has a protective barrier or cp which are then washed out by
the continuous flow of blood. The exposed plaques triggers the inflammation response thus it easily binds
with other substance producing a clot disrupting the blood flow in the cerebral circulation. These leads to
deprivation of oxygen leading to hypoxia. This process could lead to ischemic stroke, common symptoms
of stroke includes severe headaches, loss of consciousness and speech response, muscle weakness seen
mostly in drooping of face, and impaired vision.
 PATHOPHYSIOLOGY (BOOK BASED)
BPPV

Infection Female
Trauma/Injury Older age (50 years old and above)
Migraines

Crystal otolithic organs dislodged from the

utricle in the vestibular membrane

Otolith crystal (otoconia) are trapped in semi-

circular canal

Sudden movement such as laying down and

standing up

Disrupt the normal movement of endolymph in

Legend: the semi-circular canals
 Non-modifiable Signals confusion to the brain
risk factors Vestibular nerves signals confusion to the brain
 Modifiable risk
factors
 Diagnosis
 Symptoms Benign Paroxysmal Positional Vertigo (BPPV)

Dizziness Nausea/vomitting Double-vision

The most common cause of benign paroxysmal positional vertigo is when there is disruption in the
otolith organ crystals. These otolith organs also called otoconia are dislodged in the semi-circular canal due
to head trauma, previous injury, infections and migraines. It alters the endolymph fluid in the semi-circular
canal to sends signals to the brain. This cause confusion to the brain as the otoconia alters proper
functioning of the semi-circular canals essential for balance. This leads to severe dizziness, nausea and
vomiting and nystagmus or double vision to an individual experiencing BPPV.