Chronic Ear Disease

Chronic Ear Disease

Chronic Ear Infection

The diagnosis with chronic otitis media (an infection of the middle ear).  Our response to this condition depends on several factors: whether the condition is active or inactive, whether or not the mastoid bone is involved, or if there is a hole in the ear drum.  You may be experiencing discharge from the ear, hearing loss, tinnitus (ringing), dizziness, pain, and other less common problems. 

Function of the Normal Ear

There are three parts to the ear: the external ear, the middle ear, and the inner ear.  Each part plays a role, and each may be affected.  Normally, sound waves pass through the ear canal (external ear) and cause the ear drum to vibrate.  The ear drum (tympanic membrane) separates the external ear from the middle ear.  The middle ear contains three hearing bones (known as ossicles and are the smallest bones in the body) and air.  Vibration of the ear drum causes movement of the hearing bones (the malleus or hammer, incus or anvil, and stapes or stirrup).  The stapes interfaces with the fluid that fills the inner ear (or cochlea), and its movement causes a fluid wave to pass through the inner ear.  This fluid wave causes movement of tiny hair cells within the cochlea.  When those hair cells are displaced they generate an electrical signal that is transmitted by the hearing nerve to the brain where it processed.  The middle ear space “breathes” through the eustachian tube, which connects to the back of the nose.

Types of Hearing Loss

Since the external and middle ear conduct sound.  If there is a problem with external or middle ear it was cause a conductive hearing loss.  The inner ear creates the electrical signal and transmits it through the nerve.  If there is a problem in the inner ear, a sensorineural hearing loss results.  When the problem effects both systems it creates a mixed hearing loss.

The Diseased Middle Ear

Any condition which affects the ear drum or any of the three small hearing bones may cause a conductive hearing loss.  This may be due a perforation (hole) in the ear drum, partial or total destruction of one or all of the hearing bones, or skin debris which gets trapped behind the ear drum (cholesteatoma). 

Perforations may be the result of trauma to the ear drum, acute infection of the middle ear, or other less common causes.  Often, as the infection resolves the ear drum with heal itself.  If it fails to heal it may cause tinnitus (ringing), hearing loss, and intermittent drainage.

Since they are the smallest bones in the body, the hearing bones are susceptible to damage.  This can occur simply from the pressure of the ear drum retracting against them. 

The skin that lines the ear canal is the same skin that covers the rest of our body.  It is called squamous epithelium, and it is constantly shedding cells.  If the ear drum becomes retracted it may create a pocket.  If that pocket is deep enough the shedding cells will accumulate and create something called a cholesteatoma.  The accumulation will continue and the cholesteatoma will grow.  It can erode bone and typically will extend into the bone behind the ear called the mastoid.  As it expands it can erode into the inner and other surrounding structures.

Care of the Ear

If a perforation is present, you should protect the ear canal from water.  When showering or washing your hair this can be accomplished by using an ear plug or placing a cotton balls coated with a thin layer of vasaline in the ear canal.  Swimming may be possible with an ear plug.

Medical Treatment

Medical treatment will often stop the drainage. Medical treatment consists of careful cleaning of the ear and application of antibiotic powder or drops.  Occasionally, antibiotics by mouth may be required. 

Surgical Treatment

The primary intent of surgical treatment is to remove the trapped skin or infection and reconstruct the hearing mechanism.  The ear drum is typically rebuilt using fascia, the connective tissue that covers a muscle.  Occasionally, cartilage or the tissue that covers the cartilage (perichondrium) is used.  The hearing bones are replaced used a titanium prosthesis and cartilage.

Oftentimes, the hearing bones are replaced at a second surgery – typically 6-12 months after the initial surgery.  When this is planned, a thin piece of plastic is left behind in the middle ear space to prevent scar tissue from forming and to promote healing.  This has two advantages.  First, it allows any remnant of skin (squamous epithelium) that was missed to begin to accumulate debris.  This debris appears as a “pearl” and helps unsure that all the skin is removed.  Secondly, it allows the reconstructed ear drum to heal into position and ensures a more precise fit for the prosthesis.  The prothesis are measure in ¼ millimeter lengths, so accurate fit is important.  The decision to “stage” the surgery is made at the time of the first surgery.

Tympanoplasty

In the case of a perforation of the ear drum or damage to the hearing bones a surgery may be performed to repair the ear drum and hearing bones.  The surgery to reconstruct the ear drum is known as a tympanoplasty.  The procedure seals the ear drum and improves the hearing in many cases.  Depending on the size and position of the perforation, and the condition of the remaining ear drum, the procedure may be accomplished through the ear canal.  If a more extensive reconstruction is needed an incision may be made behind the ear.  Depending on involvement of the hearing bones, a second surgery may be required to place the prosthesis.  (See Planned Second Stage).

The patient is able to go home following surgery.  The ear will be packed to hold the grafts in place.  Three weeks following surgery the patient will place ear drops on the packing, helping it dissolve.  The patient may return to week in 3-7 days.  Healing may take 6-8 weeks.  Hearing improvement may not be noted for 2-3 months. 

Tympanoplasty with Mastoidectomy

If a cholesteatoma is present, or if the infection has settled into the mastoid bone, it becomes impossible to eliminate the infection by medical treatment.  Antibiotics may temporarily stop the drainage, but it will recur after antibiotics are discontinued.  A cholesteatoma or chronic ear infection may be present for many years without difficulty, except for the annoying drainage and hearing loss.  However, the disease may expand and cause damage to surrounding structures.  Dizziness, weakness of the face, and pain may develop.  Surgery may be necessary to prevent serious complications. 

The destruction by cholesteatoma or infection may need to be eliminated by opening the mastoid bone (mastoidectomy) and eradicating the disease.  This is done through an incision behind the ear.  It is done in conjunction with a tympanoplasty (reconstruction of the ear drum).

In most patients, it is not possible to eliminate the cholesteatoma or infection and reconstruct the hearing bones at the same time.  The infection and/or cholesteatoma are removed in the first operation.  This is done under general anesthesia and the patient is able to go home the same day.  The ear canal will be full of packing.  The patient will place ear drops on the packing starting three weeks after surgery.  The patient will typically return to work 3-7 days following surgery. 

When a second operation is required, it will be performed 6-12 months later. (See Planned Second Stage).

On rare occasions a more involved mastoidectomy may be required to control the infection.  (See Modified Radical Mastoidectomy).

Tympanoplasty: Planned Second Stage

The surgery is intended to accomplish two goals: ensure that all the infection or cholesteatoma has been removed and to improve the hearing.  It is occasionally accomplished through the ear canal, but more often than not it is done through an incision behind the ear.  The ear is inspected carefully for any residual (remaining) disease and a titanium prothesis is positioned to transmit sound waves from the reconstructed ear drum to the inner ear.

The patient goes home the day of surgery and may return to work in 3-7 days.  The ear is packed and the patient places ear drops on the packing starting 3 weeks after surgery.  Healing is usually complete in 6 weeks, and the hearing may continue to improve for 2-3 months.

Modified Radical Mastoidectomy

The extent of the infection or cholesteatoma may necessitate this procedure.  It is less desirable because hearing outcomes are not as good.  In addition, it creates a situation that requires periodic maintenance.  In this procedure, a portion of the ear canal is removed creating a “bowl” instead of the normal cylindrical ear canal.  This bowl may be filled in (obliterated) with fat or other bone.  The opening of the ear canal is enlarged during the procedure to facilitate post-operative care and cleaning.

The surgery is performed under general anesthesia through an incision behind the ear.  The patient may go home following surgery.  There is a large pack placed to stabilize the newly enlarged ear canal.  That pack is removed 7-10 days after surgery.  The healing takes longer – often 8-12 weeks.  The patient may return to work 3-7 days following surgery.

What to Expect Following Surgery

There are some symptoms which may follow any ear operation.

Taste Disturbances and Mouth Dryness

The nerve that supplies taste and sensation to a portion of the tongue is called the chorda tympani.  It runs through the middle ear and may be affected by surgery.  This may cause a taste disturbance and/or dry mouth for a few weeks following surgery.

Tinnitus

Ringing in the ears, frequently present before surgery, is almost always present temporarily after surgery.  It may persist for one to two months and then decrease as hearing improves.  Should the hearing not improve, or get worse, the tinnitus may persist.

Numbness of the Ear

Temporary loss of skin sensation in and around the ear is common following surgery. It may involve the entire outer ear and may persist for up to 6 months.

Jaw Symptoms

The back wall of the jaw joint is the front wall of the ear canal.  Some soreness or stiffness of jaw movement is common after ear surgery.  It usually resolves within one to two months.

Risks and Complications of Surgery

Fortunately, major complications are rare following ear surgery.

Ear Infection

Ear infection, with drainage, swelling and pain my persist (or on rare occasions develop) following ear surgery.  Were this the case, oral antibiotics or additional surgery may required to control the infection.

Loss of Hearing

It is possible that the ear undergoing surgery may have some sensorineural (nerve) hearing loss following surgery.  This happens in approximately 3% of ears.  On very rare occasions, a total loss of hearing may occur in the operated ear. 

In those cases that require a second surgery to obtain satisfactory hearing and eliminate disease, the hearing is usually worse between the first and second surgery.

Dizziness

Dizziness may occur immediately following surgery due to swelling or irritation of the inner ear.  Some unsteadiness may persist for a week post-operatively.  On rare occasions it may last longer.

In patient with cholesteatoma, it is possible that the cholesteatoma will have eroded into the balance canal.  When this problem is encountered the dizziness may last  for 6 months or more.

Facial Paralysis

The facial nerve, which is the nerve that is responsible for movement of the muscles of the face, travels through the mastoid.  It is in close association with eh middle ear bones.  A rare complication of ear surgery is temporary paralysis of one side of the face.  This may occur as the result of an abnormality or a swelling of the nerve and usually subsides spontaneously.

On very rare occasions the nerve may be injured at the time of surgery.  In this situation the paralysis may last 6 months to a year and there would be permanent residual weakness.  Eye complications could develop and secondary procedures may be required.

Hematoma

A hematoma (or collection of blood under the skin) develops in a small percentage of cases.  It may lead to some discoloration or bruising around the eye.  If significant, it may require a re-operation to remove the clot.

Complications Related to Mastoidectomy

On very, very rare occasions the dura may be violated during mastoid surgery.  If this happens, it may lead to intracranial complications, such as abscess formation or cerebrospinal fluid leak.  If these extremely rare complications were to occur, it would require a re-operation.

Restrictions Following Surgery

Until cleared by your surgeon, you should not:

  1. Allow water into the ear.  A cotton ball with a thin layer of vasaline or very careful positioning of the head while showering will be sufficient.
  2. Do not blow your nose.  If you must sneeze, sneeze with your mouth open.
  3. Do not greater than 20 pounds.

You will need a ride home following surgery.  Air travel is permissible 48 hours following surgery.

General Comments

If you elect not to have the surgery performed, it is recommended that you have annual examinations, especially if the ear is draining.  If you develop persistent dull ear pain, increased drainage, dizziness, or facial weakness you should immediately consult a physician. 

Cholesteatoma is a type of skin cyst that is located in the middle ear and mastoid bone in the skull.

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