Chronic disease of the middle ear, the space between the ear drum and the inner ear organs of hearing, is a common problem. There is a wide range of causes for middle ear problems. It may result from a long lasting infection, or from an injury to your ear. The injury may be as mild as irritation from a Q-tip or as severe as a skull fracture, a major explosion near your ear, or acid entering your ear. However, there are common symptoms to all of these problems of the ear:
- hearing loss
- sensation of fluid or fullness in your ear
- ear pain
- ear drainage
If you have seen your primary care doctor, he/she may have told you that there is a problem in your middle ear and has treated you with various medications. If the problem has continued, more serious symptoms would be:
- continued hearing loss in one or both ears
- sensation of fluid or fullness and smelly drainage
- continued pain, pressure or discomfort in the ear area
- new onset of ringing or dizziness
Our office has four board certified ear, nose and throat doctors (otolaryngologists) who will take your history, examine you and explain their findings. Our certified audiologists will do hearing tests. Other recommendations may require x-rays or additional testing at a medical facility. Hopefully, this article will give you a nice overview of hearing loss and possible treatments for different ear problems.
HOW YOUR EAR WORKS
There are three main parts to your ear:
- Outer ear-auricle and ear canal down to the tympanic membrane (ear drum)
- Middle ear-air filled space with three small bones
- malleus (hammer)
- incus (anvil)
- stapes (stirrup)
- Inner ear-nerve portion of the ear
When sound travels and hits the eardrum, it moves the three small bones causing them to vibrate which transfers energy into the inner ear. Tiny hairs in the inner ear are stimulated and change sound energy to nerve signals. From the inner ear, the sound signals travel along the auditory (hearing) nerve to the brain for interpretation of sound and words.
There are two types of hearing loss, conductive and sensorineural. Both of these can result from injury, infections, and certain types of growths in your ear.
Conductive hearing loss results from problems occurring anywhere from the outer ear to the middle ear. This can be an outer ear problem, such as the ear canal being swollen from infection, wax blocking the ear canal, or a growth or foreign body in the ear canal. It can be an eardrum problem, like a large perforation or hole in the drum. Other causes include fluid or infection in the middle ear, or damage of the middle ear bones.
Anything that prevents normal conduction of vibration to the eardrum and the three small bones causes decreased hearing.
Sensorineural hearing loss occurs when the nerve cells of the inner ear or the nerve going to the brain have decreased in their function. The sound waves that enter the inner ear are not transmitted to the brain as well as desired. Common causes include:
- congenital hearing loss (hearing loss from birth)
- loud noises
- inherited hearing loss
- bacterial or viral infection
After an evaluation, treatment would be discussed with the patient or parent(s) of a child. Depending on the cause of hearing loss and the type of disease, options include medications, the use of a hearing aid, or surgery.
Surgical Treatment of Middle Ear Problems
There are many different surgical procedures for ear problems, but the most common ones include:
Tympanoplasty – repairing a hole in the tympanic membrane
Mastoidectomy – removing infected tissue & abnormal bone
Ossicular reconstruction – to repair some or all of the middle ear bones
Stapedectomy – for stiff or deteriorated bones
The benefits of surgery and the possible risks would be discussed prior to the surgery in relationship to the problem that exists. While each type of ear surgery has specific benefits and risks, the common benefits include creating a safe, closed eardrum, improved hearing, and less probability of ear drainage or infections. Possible risks include:
- failure of the tympanic membrane to heal
- decreased hearing
- weakness of the facial nerve
- numbness around the outer ear
- change of taste or decreased taste
- need for second surgery
- anesthesia problems
Description of Ear Surgeries
Tympanoplasty – repairing a damaged eardrum or one with a hole in it.
A hole in the ear drum can result from injury or infection, and often will heal by itself. However, when the hole does not heal, there is often hearing loss and chance of infection and drainage. The surgical repair prevents future infections from outside contamination such as water getting into the middle ear. It also prevents skin from the outside of your eardrum from growing into the middle ear causing a cholesteatoma. (Cholesteatoma will be discussed later.)
During surgery, the patient is usually asleep with a general anesthetic. The operation will be performed through your ear canal or through an incision made behind your ear. The eardrum is repaired with your own tissue, known as the graft. This graft tissue could be:
- fascia-taken from above the ear
- perichondrium-the lining of the cartilage at the little prominence at the front to your ear
- fat-from your ear lobe
- skin-depending on the situation
The graft is held in place with a soft absorbing material called Gelfoam. Gelfoam is a cellulose product used since the 1960’s which is well tolerated in patients. This prevents the graft from slipping and helps heal the perforation.
The whole procedure usually takes 1½ -3 hours, and generally patients can go home the same day.
Mastoidectomy – removing tissue growth, infection, diseased tissue lining, and infected bone from an area above and behind the middle ear.
The mastoid bone is made up of small cells, which are called air cells. Infection may spread through these areas and go into several small areas. The growth of skin, called cholesteatoma, may grow in several of these irregular areas. The cholesteatoma will often destroy the middle ear bones, invade into the facial nerve, the inner ear and even progress toward the brain-making it very necessary to remove this.
During mastoid surgery, the patient always has general anesthesia. The operation is performed through an incision behind your ear although there are times that it may be done with incisions along the ear canal. The procedure takes 1½ -3 hours and is often done with a tympanoplasty and
ossicular reconstruction. Depending on the amount of disease, the operation could take 4-5 hours. Patients may need to stay overnight after surgery, but often can go home the same day.
Ossicular reconstruction – repair of some or all of the middle ear bones.
If the middle ear bones have been destroyed or are completely surrounded by infection, diseased tissue or cholesteatoma, one or more of them may need to be removed to get at the disease. The bones are replaced with synthetic bones. The most common bone that needs to be replaced is the incus. With each additional bone that needs replacing, the chance for improved hearing worsens. More specific percentages will be discussed in the office by the doctor depending on the overall condition of your ear.
The patient usually has general anesthesia or possibly a local anesthetic with sedation. The operation takes about 2 hours depending on whether it is combined with other ear procedures.
GENERAL INFORMATION CONCERNING SURGERY
Once a surgery date has been scheduled, the proper preoperative scheduling will be done. The hospital will contact you about any anesthetic issues, and any heart, blood pressure or diabetic medications that you need to continue.
You will need a ride home after surgery.
There will be NO eating or drinking after midnight the day before surgery.
The hospital or our office will tell you exactly when and where to arrive prior to surgery. Written information will also be given to you at our office concerning this.
Once you arrive, the hospital nurses will be taking your history and the anesthesiologist will be talking to you during the preoperative time.
Immediately after surgery, you will wake up in the recovery room, where you are watched very closely. From there you will be going to a unit that treats patients for day surgical procedures.
Once you are sent to this hospital unit, your family & friends are allowed to be with you.
You will probably have some type of dressing/bandage over your ear or possibly completely around your head. Your ear will feel full because there is packing in your ear.
Once you are awake enough and are able to drink fluids and eat food, the nurses will allow you to be discharged from the hospital. With ear surgery, this is usually 3-4 hours after your procedure.
The nurses will check you for the following things prior to allowing you to go home:
- that you are awake enough to travel comfortably
- that there is little or no bleeding
- that you have minimal or no pain
- that you do not have significant nausea, vertigo or dizziness
- that your overall health (heart rate, blood pressure, breathing) is stable
- that you do not have a fever
What you can do at home:
- visit your doctor about one week after ear surgery
- off from work usually one week, possibly two weeks
- do light activity at home
- avoid getting your ear wet-you may wash your hair if you protect your ear from water. One way is to put a plastic cup over your ear while washing your hair.
- take your pain medication and possible antibiotics, as directed, resume all your other previous medications
- Sneeze or cough with your mouth open to protect from building up pressure in your ear. (Do NOT try to pop your ears).