CHRONIC EAR DISEASE

Chronic otitis media (an infection involving the middle ear mastoid) is the cause of your ear problem. Symptoms depend upon whether the condition is active or inactive, where there is involvement of the middle ear bones or mastoid bone, and whether or not there is a hole in the eardrum. There may be drainage from the ear, hearing impairment, tinnitus (head noise), dizziness, pain, or rarely, weakness of the face.

FUNCTION OF THE NORMAL EAR:

The ear is divided into three parts: an external ear, a middle ear and an inner ear. Each part performs an important function in the process of hearing. The external ear consists of the auricle and ear canal. These structures gather the sound and direct it toward the eardrum membrane. The middle ear chamber lies between the external and the inner ear and consist of an eardrum membrane and the three small ear bones (ossicles): malleus (hammer), incus (anvil) and stapes (stirrup).

These structures transmit sound vibrations to the inner ear. In so doing they act as a transformer, converting sound vibrations in the external ear canal into fluid waves in the inner ear. The inner ear chamber contains the microscopic hearing nerve endings bathed in fluid. Fluid waves stimulate the delicate nerve end, which in turn transmit sound energy to the brain where it is interpreted.

Types of hearing impairment:

The external ear and the middle ear conduct and transform sound; the inner ear receives it. Where there is some difficulty in the external or middle ear, a conductive hearing impairment occurs. When the trouble lies in the inner ear, a sensorineural or nerve hearing impairment is the result. Difficulty in both the middle and inner ear results in a mixed impairment.

THE DISEASED MIDDLE EAR

Chronic otitis medial may result in a perforation (hole) in the eardrum, destruction of the middle ear bones, middle ear fluid and inflammations or scar tissue. This results in a conductive hearing loss.

During an acute infection of the middle ear (an abscessed ear) the eardrum may rupture, resulting in a perforation. Often the perforation will heal. If it fails to do so, a hearing loss occurs, often associated with head noise (tinnitus) and intermittent or constant ear drainage.

Occasionally, skin form the ear canal may grow through a perforated or retracted eardrum into the middle ear or mastoid. When this occurs, a skin-lined cyst known as a cholesteatoma is formed. A cholesteatoma may persist for many years without difficulty except for the annoying drainage and hearing loss. This cyst will continue to expand over time and gradually destroys the surrounding bone. It usually destroys the middle ear bones first, followed by the mastoid and eventually the inner ear. If left untreated, cholesteatoma may result in a loss of hearing and balance, facial paralysis, and even meningitis (brain infection).

Patients with cholesteatomas usually have persistent foul smelling drainage. The patient may have fullness or discomfort in the ear. Dizziness and facial weakness may develop in more advanced cases. If any of these symptoms occur, it is imperative that one seek immediate medical care. Surgery is usually necessary to eradicate the cholesteatoma, prevent serious complications, and obtain a dry, safe ear.

TREATMENT OF CHRONIC EAR DISEASE

Home Care of the Ear

If a perforation is present, you should not allow water to get into your ear canal. This may be avoided when showering or washing the hair by using an ear plug or placing cotton in the external ear canal and covering it with a layer or Vaseline.

Swimming is permissible only if you use a well-fitted, water tight ear plug. We can advise you in regard to this.

You should avoid vigorous blowing of your nose in order to prevent any infection in your nose from spreading to the ear through the eustachian tube. If it is absolutely necessary to blow your nose, do not occlude or compress both nostrils. Any nasal secretion preferably should be gently drawn backward and expectorated.

In the event of ear drainage, the drainage should be removed using a wash cloth, and NOT a cotton-tipped applicator. In cases of excessive discharge, cotton can be placed in the outer ear to catch any drainage.

Medical Treatment

Medical treatment frequently will stop ear drainage. Treatment consists of careful cleaning of the ear by an otologist and, at times, the application of antibiotic powder or ear drops. Antibiotics by mouth may be helpful in certain cases.

If antibiotic ear drops have been prescribed, the ear should be positioned to allow the drops to enter the ear canal and remain for approximately 5 minutes. If antibiotics powders have been prescribed, excessive drainage should be removed prior to their application. When using antibiotic powders (unlike ear drops) there is no need for special ear positioning.

Surgical Treatment

For many years, surgical treatment of chronic ear disease was primarily aimed at controlling infections and preventing serious complications. Hearing restoration was not a consideration. Earlier diagnosis and improved surgical techniques now have made it possible to reconstruct the diseased hearing mechanism in most cases.

Various tissue grafts may be used to replace or repair the eardrum. These grafts include fascia (the covering of the muscle located above the ear) and perichondrium (the covering of ear cartilage). A diseased ear bone may be repositioned or replaced by cartilage or a prosthesis (an artificial ear bone). The prosthesis may replave all fo the ear bones, a total ossicular prosthesis (TOP), or only a portion of the ear bones, a partial ossicular prosthesis (POP).

Most chronic ear disease can be corrected with only one operation. However, when the ear is filled with diseased tissue or when all ear bones have been destroyed, it may be necessary to perform the operation in two stages. At the first state, the diseased tissue is removed from the ear and the eardrum reconstructed. A special material is often placed in the middle ear to minimize scar tissue and allow more normal healing. At the second operation, the ear is inspected for any additional or recurrent disease and an attempt is made to reconstruct the middle ear bones.

SURGICAL PROCEDURES

Tympanic Membrane and Middle Ear Procedures:

Myringoplasty

Most middle ear infections subside with antibiotic therapy, and the eardrum and structures of the middle ear heal completely. However, in some cases, the eardrum ruptures and a permanent perforation (hole) in the eardrum may result. Myringoplasty is the operation performed for the purpose of repairing a very small perforation in the eardrum when there is no middle ear infection or disease of the ear bones. This procedure seals the middle ear and may improve the hearing.

Surgery is performed through the ear canal. A tissue graft is used to repair the defect in the eardrum. In most cases the eardrum is completely healed in 6 to 8 weeks, at which time any hearing improvement is usually noticeable. A decision is made at that time whether or not the patient can allow water to enter the ear canal.

Tympanoplasty

An ear infection may cause a perforation of the eardrum, damage the middle ear mucosa, and damage the three ear bones that transmit sound from the eardrum to the inner ear. Tympanoplasty is the operation performed to eliminate any infection and repair both the sound transmitting mechanism and any perforation of the eardrum. This procedure seals the middle ear and improves the hearing in many cases.

In cases limited to repair of the middle ear bones (ossiculoplasty), the operation may be performed through the earcanal under a local or general anesthetic. The patient is usually discharged from the hospital within twenty-four hours.

In cases where the eardrum needs to be repaired, an incision behind the ear may be necessary, depending on the extent of the perforation. This can be performed under local or general anesthesia. The perforation is repaired with a tissue graft. If necessary, the middle ear bones can be reconstructed during this operation. In some cases, it is not possible to repair the sound transmitting mechanism and the ear drum at the same time. In these cases, the eardrum is repaired first and, six months to twelve months later, the middle ear bones are reconstructed.

Healing is usually complete in eight weeks. A hearing improvement may not be noted for a few months.

MASTOID PROCEDURES

The mastoid is the bone located behind the ear that contains air cells arranged in a honeycomb pattern. The mastoid air cells connect to the space behind the eardrum (middle ear space). Diseases which involve the middle ear may spread through these air cell tracts to the mastoid, causing inflammation and infection.

Antibiotic therapy is usually sufficient to treat the infection/inflammation. However, in some cases surgical treatment of the mastoid (mastoidectomy) is required. A variety of mastoidectomy procedures have been developed to treat different disease processes involving the mastoid bone. These procedures include the following: simple mastoidectomy, intact canal wall mastoidectomy, canal wall down mastoidectomy, modified radical mastoidectomy. The patient usually returns to work in 3 to 5 days.

Simple (Complete) Mastoidectomy

A “simple” or “complete” mastoidectomy is performed through an incision behind the ear. The diseased mastoid air cells are opened and removed using a surgical drill. No attempt is made to reconstruct the air cells. The surgery is restricted to the mastoid bone and does not extend into the middle ear space.

Intact Canal Wall Mastoidectomy

Intact canal wall mastoidectomy is a more extensive surgical procedure than the simple mastoidectomy. It connects the mastoid air cell system with the middle ear space, without removing the back wall of the ear canal. This procedure is commonly used for the treatment of chronic ear infections due to cholesteatoma.

An incision is made behind the ear and the mastoid air cells are removed allowing visualization of the cholesteatoma. To access the middle ear space without removing the back wall of the ear canal, the facial recess cells (a tract of air cells overlying the facial nerve) are removed. The cholesteatoma is then removed from the mastoid and middle ear. Frequently, one or more of the middle ear bones are involved with cholesteatoma and must be removed. Cholesteatoma is an insidious disease and complete removal may be impaired by inflammation and hidden disease. Consequently, in most patients undergoing an intact canal wall mastoidectomy, the operation is performed in two stages. In the first operation, all apparent cholesteatoma is removed and the eardrum is rebuilt. Six to twelve months later the second operation is performed. During this operation the middle ear and mastoid are inspected for any residual cholesteatoma and the ossicular chain reconstructed.

Intact canal wall mastoidectomy is preferreed by surgeons of Pittsburgh Ear Associates because little, if any, water precautions are necessary after the ear has healed (3-4 months). Unfortunately, not all patients are suitable candidates for intact canal wall surgery due to extensive disease and anatomical constraints.

Canal Wall Down Mastoidectomy

Canal wall down mastoidectomy is also a more involved surgical procedure than the simple mastoidectomy. During this procedure the back wall of the ear canal is removed in conjunction with the mastoidectomy. This creates a common space (mastoid cavity) between the mastoid air cell system and the ear canal. This procedure is commonly used for the treatment of chronic ear infections due to cholesteatoma.

An incision is made behind the ear and the mastoid air cells are removed allowing visualization of the cholesteatoma. To maximize access to disease in the middle ear space, the back wall of the ear canal is removed. The cholesteatoma is then removed from the mastoid and middle ear. Frequently one or more of the middle ear bones are involved with cholesteatoma and must be removed. Usually, the cholesteatoma can be removed and the ear bones reconstructed in a single operation.

At the conclusion of this operation the opening to the ear canal is enlarged (meatoplasty) to facilitate postoperative cleaning and inspection of the mastoid cavity. Although the ear canal is larger, there is little difference in the appearance of the outer ear (auricle). Due to the creation of the meatus and the mastoid cavity, healing may be prolonged. In addition, periodic cleaning of the mastoid (ear) cavity is necessary indefinitely, and it may be necessary to avoid water in the ear.

Modified Radical Mastoidectomy

The modified radical mastoidectomy is a special type of mastoidectomy for cholesteatomas that do not involve the middle ear space and ear bones. the purpose of this operation is to eradicate the infection or cholesteatoma without the need to replace the middle ear bones. It is usually indicated in patients with cholesteatomas involving their only hearing ear.

The operation consists of removing the back wall of the ear canal in conjunction with the mastoidectomy. This creates a common space (mastoid cavity) between the mastoid air cell system and they ear canal. As opposed to the “canal wall down mastoidectomy” (see above), the middle ear bones and eardrum are left undisturbed.

An incision is made behind the ear. The mastoid air cells, as well as the back wall of the ear canal, are then removed allowing visualization of the cholesteatoma. The cholesteatoma is then removed from the mastoid and the middle ear space above the eardrum (epitympanum).

At the conclusion of this operation the opening to the ear canal is enlarged (meatoplasty) to facilitate postoperative cleaning and inspection of the mastoid cavity. Although the ear canal is larger, there is a little difference in the appearance of the outer ear (auricle). Due to the creation of the meatus and the mastoid cavity, healing may be prolonged. In addition, periodic cleaning of the mastoid (ear) cavity is necessary indefinitely, and it may be necessary to avoid water in the ear. Optimally, the hearing should be maintained at the preoperative level.

Radical Mastoidectomy

In patients with extensive cholesteatomas complete resection may not be possible. In these cases, a “radical mastoidectomy” is required. This operation creates a common cavity connecting the mastoid, middle ear space, and ear canal.

In this operation an incision is made behind the ear. The mastoid air cells and the back wall of the ear canal are resected. In addition, the eardrum and diseased ossicles are removed. All cholesteatoma is exteriorized or resected, and no attempt is made to reconstruct the eardrum and hearing bones. To decrease the likelihood of postoperative drainage from the ear, the eustachian tube is blocked.

The radical mastoid operation is performed under general anesthesia and may require one night of hospitalization following surgery. The patient may usually return to work in three to five days. Complete healing may require up to four months.

REVISION MASTOIDECTOMY PROCEDURES

Revision Mastoidectomy without Tympanoplasty

The purpose of this operation is to eradicate any mastoid infection and to obliterate (fill-in) a previously created mastoid cavity. Hearing improvement is not considered.

The operation is performed under general anesthesia through an incision behind the ear. Residual infection or cholesteatoma is removed from the mastoid and middle ear space. The mastoid cavity may be obliterated using a variety of materials including bone pate (collected mastoid bone particles) muscle, and fat. At times, the ear canal is rebuilt with cartilage or bone. Complete healing of the inside of the ear may take four months.

SPECIAL CONSIDERATIONS

Planned Second Stage Operations

Due to the unpredictable nature of chronic infections and cholesteatomas involving the middle ear and mastoid it may be necessary to perform two operations to adequately eradicate the disease. The first procedure (Stage I) is designed to control infection or cholesteatoma and then rebuild the eardrum. No effort is made to improve hearing by reconstructing the middle ear bones. In addition, a cartilage graft may be used to reinforce the eardrum and help prevent recurrence of the cholesteatoma.

The second operation (Stage II) is usually performed six to twelve months following the initial operation. During this procedure the mastoid and middle ear are inspected for residual cholesteatoma, and an attempt is made to improve the hearing by reconstructing the middle ear bones.

Unexpected Operative Findings

Despite an adequate preoperative evaluation, the surgeon may encounter unexpected changes in mastoid and middle ear anatomy due to the disease process. Some of these abnormalities include the following: (a) exposure of the facial nerve, (b) an opening (fistula) into the balance canals or cochlea (hearing organ), (c) extensive damage to the ossicular chain. These findings may necessitate a second stage procedure, or the conversion to a canal wall down mastoidectomy.

In addition, the surgeon may encounter structural variations in normal mastoid and middle ear anatomy, which can cause the surgeon to alter the planned surgical procedure. In some cases of chronic ear disease the mastoid is constricted requiring removal of the back wall of the ear canal to adequately visualize and exteriorize the cholesteatoma.

Intraoperative Monitoring

The facial nerve, which supplies movement to the muscles of the facial expression, courses through the middle ear and mastoid. To minimize any risk to the facial nerve during ear surgery, specialized electrical nerve monitoring equipment is frequently used.

WHAT TO EXPECT FOLLOWING SURGERY

The following are some symptoms that may follow any ear operation.

Taste Disturbance and Mouth Dryness

Taste disturbance and mouth dryness are not uncommon for a few weeks following surgery. In some patients, this disturbance is prolonged.

Tinnitus

Tinnitus (head noise), frequently present before surgery, is almost always present temporarily after surgery. It may persist for one to two months and then decrease in proportion to the hearing improvement. Should the hearing be unimproved or worse, the tinnitus may persist or be worse.

Numbness of Ear

Temporary loss of skin sensation in and about the ear is common following surgery. This numbness may involve the entire outer ear and may last for six months or more.

Jaw Symptoms

The jaw joint is in intimate contact with the ear canal. Some soreness or stiffness in jaw movement may occur after ear surgery. It usually subsides within one to two months.

Drainage Behind the Ear

Rarely, your surgeon may insert a drain tube behind the ear. The necessity for this is usually not apparent before surgery. Should a drain tube be necessary, it will protrude through the skin behind the ear about 1/4 of an inch and may be left in place for 1 to 10 days.

RISKS AND COMPLICATIONS OF SURGERY

Fortunately, major complications are rare following surgery for correction of chronic ear infection.

Ear Infection

Ear infection, with drainage, swelling and pain, may persist following surgery or, on rare occasions, may develop following surgery due to poor healing of the ear tissue. Were this the case, additional surgery might be necessary to control the infection.

Loss of Hearing

In one percent of the ears operated on, the nerve hearing is further impaired permanently due to the extent of the disease present or due to complications in the healing process; nothing further can be done in these instances. On occasions, there is a total loss of hearing in the operated ear.

In some cases, a two-stage operation is necessary to obtain satisfactory hearing and to eliminate the disease. The conductive hearing is usually worse after the first operation in these instances.

Dizziness

Dizziness may occur immediately following surgery due to irritation of the inner ear structures. Some unsteadiness may persist for a week postoperatively. On rare occasions, dizziness is prolonged.

One percent of the patients with chronic ear infection due to cholesteatoma have a labyrinthine fistula (abnormal opening into the balance canal). When this problem is encountered, dizziness may last for six months or more.

Facial Paralysis

The facial nerve travels through the ear bone in close association with the middle ear bones, eardrum and the mastoid. A rare postoperative 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 vary rare occasions, the nerve may be injured at the time of surgery or it may be necessary to excise it in order to eradicate disease. When this happens, a sensory nerve which supplies sensation to the skin in the upper part of the neck is removed to replace the facial nerve. Paralysis of the face under these circumstances might last six months to a year, and there would be a permanent residual weakness. Eye complications, requiring treatment by a specialist could develop.

Hematoma

A hematoma (collection of blood under the skin) develops in a small percentage of cases, prolonging hospitalization and healing. Re-operation to remove the clot may be necessary if this complication occurs.

Complications Related to Mastoidectomy

A cerebral spinal fluid leak (leak of fluid surrounding the brain) is a very rare complication. Re-operation may be necessary to stop the leak.

Intracranial (brain)complications such as meningitis or brain abscess, even paralysis, were common in cases of chronic otitis media prior to the antibiotic era. Fortunately, these now are extremely rare complications.

TRAVEL RESTRICTIONS FOLLOWING SURGERY

You should have someone drive you from the hospital. Air travel is permissible 48 hours after surgery.

GENERAL COMMENTS

If you decide NOT to have surgery performed at this time or if surgery is not advisable, you should have periodic examinations, especially if the ear is draining. Untreated chronic ear disease may result in serious complications. Should you develop dull pain in or about the ear, increased discharge, dizziness, or weakness of the face, you should immediately consult with us.