A:
|
CHRONIC EAR INFECTION
Chronic ear infection is the result of an ear infection that
has left a residual injury to the ear. This type of infection
has been established as the cause of your ear problem. Chronic
ear infection (the technical diagnosis is chronic otitis media)
symptoms depend upon whether or not there is involvement of
the mastoid bone and whether there is a hole in the eardrum.
In addition, the hearing level depends on whether or not there
has been injury to the middle ear bones as well as the eardrum.
There may be drainage, hearing impairment, tinnitus (head
noise), dizziness, pain, or rarely, weakness of the face.
Most often there is simply hearing loss, an uncomfortable
feeling and occasionally some discharge.
FUNCTION OF THE NORMAL EAR
The ear is divided into three parts: the external ear, the
middle ear, and the inner ear. Each part performs an important
function in the process of hearing.
Sound waves pass through the canal of the external ear and
vibrate the eardrum, which separate the external ear from
the middle ear. The three small; bones in the middle ear (hammer
or malleus, anvil or incus, and stirrup or stapes) act as
a transformer to transmit energy of the sound vibrations to
the fluids of the inner ear. Vibrations in this fluid stimulate
the delicate nerve fibers. The hearing nerve then transmits
impulses to the brain where they are interpreted as understandable
sound.
TYPES OF HEARING IMPAIRMENT
The external ear and the middle ear conduct sound; the inner
ear receives it. If there is some difficulty in the external
or middle ear, a conductive hearing loss occurs. If the trouble
lies in the inner ear, a sensorineural or hair cell loss is
the result. When there is difficulty in both the middle and
inner ear, a combination of conductive and sensorineural impairment
exists.
THE DISEASED MIDDLE EAR
Any disease affecting the eardrum or the three small ear bones
may cause a conductive hearing loss by interfering with the
transmission of sound to the inner ear. Such a hearing impairment
may be due to a perforation (hole) in the eardrum, partial
or total destruction of one or all of the three little ear
bones, or scar tissue.
When an acute infection develops in the middle ear (an abscessed
ear), the eardrum may rupture, resulting in a perforation.
This perforation usually heals. If it fails to do so a hearing
loss occurs, often associated with head noise (tinnitus) and
intermittent or constant ear drainage.
Occasionally after an infection in the healing process, skin
from the ear canal may be stimulated to grow through a perforated
eardrum, into the middle ear and into the mastoid. When this
occurs, a skin-lined cyst known as a cholesteatoma is formed.
This cyst will continue to expand over a period of time and
progressively destroy the surrounding bone. It usually destroys
the middle ear bones first, followed by the mastoid. Cholesteatoma
presents a grave danger to the inner and event to the brain
as meningitis may result. If a cholesteatoma is present, drainage
tends to be more constant and frequently has a foul odor.
TREATMENT OF CHRONIC OTITIS MEDIA
Home Care of the Ear
If a perforation is present, you should not allow water to
get into the ear canal. This may be avoided when showering
or washing by placing cotton in the external ear canal and
covering it with a layer of Vaseline. If you desire to swim,
a custom made mold is helpful in keeping water out of the
ear canal.
Avoid blowing your nose repeatedly in order to keep infection
in the nose from spreading to the ear through the eustachain
tube. If it is necessary to blow your nose, do not occlude
or compress one nostril while blowing the other.
In the event of ear drainage, keep the ear clean by using
a small cotton tipped applicator at the very outer portion
of the canal. Medication should be used if discharge is present
or when discharge occurs. Cotton may be placed in the outer
ear canal to catch discharge, but should not be allowed to
completely block the canal.
Medical Treatment
Medical treatment, including oral medications and ear drops,
will frequently stop the ear drainage. In addition, careful
cleaning of the canal and at times the application of antibiotic
powder may be necessary.
Different antibiotics by mouth may be necessary in some cases.
If the ear is safe, that is, if there is not continuing destruction
of the ear by scarring, infection, or by cholesteatoma, and
there is minimal hearing loss, medical treatment may be all
that is necessary for chronic otitis media. Otherwise, surgery
will be necessary.
SURGICAL TREATMENT
For many years surgical treatment was instituted in chronic
otitis media primarily to control infection and prevent serious
complications, that is, to make the ear safe and dry. In recent
years, it has often been possible with advances in surgical
techniques to reconstruct the diseased hearing mechanism.
Various tissue grafts may be used to repair the eardrum. These
include the covering of the muscle (fascia), vein, or the
covering of cartilage (perichondrium).
A diseased ear bone may be replaced by a synthetic prosthesis
and cartilage. Silastic may be used in the middle ear, behind
the eardrum to prevent scar tissue from forming, to promote
normal function of the ear and motion of the eardrum. When
the ear is filled with scar tissue or cholesteatoma or when
all the ear bones have been destroyed, it is usually necessary
to perform the operation in two stages. In the first stage,
the cholesteatoma is removed and silastic may be inserted
to allow more normal healing without scar tissue. In the second
operation, the silastic is removed and hearing may be reconstructed.
In addition, at this time total cholesteatoma removal is assured.
If it is not, it is removed at this time. Hearing improvement
is rarely noted at or immediately following surgery.
MYRINGOPLASTY
Most ear infections subside and the structures of the middle
ear heal completely. In some cases, however, the eardrum may
not heal and a permanent perforation (hole) in the eardrum
results.
Myringoplasty is the operation performed for the purpose of
repairing a perforation in the eardrum when there is no middle
ear infection or disease of the ear bones. This procedure
seals the middle ear and improves the hearing in many cases.
Surgery is usually performed under general anesthesia through
the ear canal or behind the ear. Fascia from muscle above
the ear is used to repair the defeat in the eardrum. The patient
is hospitalized for one night. Healing is complete in most
cases in six weeks, at which time any hearing improvement
is usually noticeable.
TYMPANOPLASTY
An ear infection may cause a perforation in the eardrum and
may also damage the three bones that transmit sound from the
eardrum to the inner ear and hearing nerve. Tympanoplasty
is the operation performed to repair both the sound transmitting
mechanism and any perforation in the eardrum. This procedure
seals the middle ear and improves the hearing in many cases.
Surgery may be performed through the ear canal or from behind
the ear, under a local or a general anesthetic. The perforation
is repaired with the fascia from muscle above the ear. Sound
transmission to the inner ear is accomplished by repositioning
or replacing diseased ear bones.
In some cases it is not possible to repair the sound transmitting
mechanism and the eardrum at the same time. In these cases
the eardrum is repaired first and, four months or more later,
the sound transmitting mechanism is reconstructed.
The patient is hospitalized for one night and may return to
work in several days to a week. Healing is usually complete
in six weeks. A hearing improvement may not be noted for a
few months.
TYMPANOPLASTY WITH MASTOIDECTOMY
Active infection may in some cases stimulate skin of the ear
canal to grow through the ear drum perforation into the middle
ear. When this occurs a skin-lined cyst known as cholesteatoma
is formed. This cyst may continue to expand over a period
of years and destroy the surrounding bone. If a cholesteatoma
is present, the drainage tends to be more constant and frequently
has a foul odor. In many cases, the persistent drainage is
only due to chronic infection in the bone and surrounding
the ear structures.
Once a cholesteatoma has developed or the bone has become
infected it is rarely possible to eliminate the infection
by medical treatment. Antibiotics placed in the ear and used
by mouth only result in a temporary improvement in most cases.
Recurrence after treatment has stopped is frequent.
A cholesteatoma or chronic ear infection may persist for many
years without difficulty except for annoying drainage and
hearing loss. It may, however, by local expansion and pressure
involve important surrounding structures. If this occurs,
the patient will often notice a fullness or a low- grade aching
discomfort in the ear region. Dizziness or weakness of the
face may develop. If any of these symptoms occur it is imperative
that one seek immediate medical care. Surgery may be necessary
to eradicate the infection and prevent more serious complications.
When the destruction by cholesteatoma or infection is widespread
in the ear structures (mastoid) the surgical elimination of
this may be difficult. Surgery is performed through an incision
behind the ear. The primary objective is to eliminate infection;
to obtain a dry, safe ear.
In some cases the infection cannot be eliminated and the hearing
restored in one operation. The infection is eliminated and
the ear drum rebuilt in the first operation. This requires
a general anesthetic with hospitalization. The patient may
usually return to work in one week.
A second operation may be performed months later to restore
the hearing mechanism and confirm infection control.
TYMPANOPLASTY WITH REVISION MASTOIDECTOMY
The purpose of this operation is to eliminate drainage from
the previously created mastoid cavity and attempt to obtain
hearing improvement.
The operation is performed under general anesthesia through
an incision behind the ear. The mastoidectomy is revised.
If possible, the hearing mechanism is restored by using implants
or cartilage.
The patient is usually hospitalized for two days following
surgery and may return to work after one week. Hearing improvement
may not be noted for a few months.
CANAL WALL DOWN-MASTOID OPERATION
The purpose of this operation is to eradicate the infection.
It is usually performed on those patients who may have very
resistant infections. Occasionally it may be necessary to
perform a canal wall down mastoid operation in some cases
that originally appeared suitable for tympanoplasty. This
decision must be reached at the time of the operation.
The CWD mastoid operation is performed under general anesthesia
and requires one night hospitalization. The patient may usually
return to work in one week. Hearing return to normal is rare
although improvement can often be expected. The ear canal
is larger than normal.
MASTOID OBLITERATION OPERATION
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. The mastoid space is filled with
bone, a temporalis muscle flap or a combination. The patient
is usually hospitalized for one night and may return to work
in several days to one week. Complete healing may require
up to three months.
THE FINDINGS IN YOUR CASE
Hearing is measured in decibels (dB). The hearing of 0 to
25 dB is considered normal hearing for conversational purposes.
Our hearing evaluations reveal your hearing level to be:
Right ear______________________decibels
Left ear ______________________ decibels
Conversion to degree of handicap:
25dB............................0% 55dB......(moderate).......45%
30dB........(mild).............8% 65dB........(severe).........60%
35dB........(mild)............15% 75dB........(severe)........75%
45dB......(moderate)......30% 85dB........(severe)........90%
Examination of your ear reveals:
Right: Left:
Scarring of the eardrum and middle ear
A perforation in the eardrum
A Cholesteatoma (skin-lined cyst) in the middle ear or mastoid
bone
Partial or total destruction of one or more of the middle
ear bones. The extent of this destruction can be determined
accurately only at the time of surgery
A mastoid cavity
You are a satisfactory candidate at this time for:
Right: Left:
Myringoplasty operation (repair of the eardrum)
Tympanoplasty operation (eradication of infection, if present,
and repair of the eardrum and middle ear bones)
Tympanoplasty with mastoidectomy (eradication of mastoid and
middle ear infection with repair, if possible, of the eardrum
and middle ear bones)
Tympanoplasty with revision mastoidectomy
Canal wall down mastoid operation
Mastoid obliteration operation
In some cases a two stage operation is necessary to obtain
satisfactory hearing and to eliminate the disease. The hearing
is usually worse after the first operation in these instances.
YOUR OUTLOOK WITH SURGERY
Drainage: Eardrum grafting is successful
in over 90% of patients, resulting in a healed, dry ear.
Hearing: Hearing improvement following surgery
depends upon many factors, among which are the extent of the
ear bone damage and the ability of the ear to heal properly.
It is uncommon to have total restoration of hearing.
You have approximately _________out of ten chances that surgery
will be effective in improving your hearing.
In your case two operations will be necessary, in all likelihood,
in order to improve the hearing. In this case your hearing
may be worse in the operated ear between operations, because
there would be no connection between the inner ear and reconsructed
ear drum.
WHAT TO EXPECT FOLLOWING SURGERY
There are some symptoms which may follow any ear operation.
There will almost always be unusual sounds in the ear. There
may be popping, gurgling, squishing, or echoing. These are
very common and may last as long as several months. They are
not, however, cause for concern.
Taste Disturbance and Mouth Dryness
Taste disturbance and mouth dryness are not uncommon for a
few weeks following surgery. In 5% of the patients this disturbance
may last as long as several months.
Tinnitus
Tinnitus (constant 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 is very common after
ear surgery. It usually subsides within one to two months.
Ear Fullness
The ear is packed with dissolvable packing following surgery.
For this reason your hearing will seem diminished for 4-6
weeks.
RISKS AND COMPLICATIONS OF SURGERY
Fortunately, complications are uncommon 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. If this is
the case, additional surgery might be necessary to control
the infection.
Loss of Hearing
In 3% of the ears operated, the 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 instance. Rarely, there is a total loss of
hearing in the operated ear.
Dizziness
Dizziness may occur immediately following surgery due to swelling
in the ear and irritation of the inner ear structures. Some
unsteadiness may persist for a week postoperatively. On rare
occasions dizziness is prolonged. Ten percent of the patients
with chronic ear infections 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 from swelling of the nerve and usually subsides
spontaneously. On very 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 skin sensation
nerve is removed from the upper part of the neck to replace
the facial nerve. Paralysis of the face under these circumstances
might last six months to a year and there would be permanent
residual weakness. Eye complications, requiring treatment
by a specialist, could develop.
A hematoma (collection of blood under the skin) develops in
a very small percentage of cases, prolonging hospitalization
and healing. Reoperation 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. Reoperation 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 ear. Fortunately, these now
are extremely rare complications.
TRAVEL RESTRICTIONS FOLLOWING SURGERY
You should have someone drive you home from the hospital.
Air travel is permissible 48 hours after surgery and is preferred
to automobile or train travel for trips of over 200 miles.
GENERAL COMMENTS
If surgery is not successful, the hearing usually remains
the same as before surgery. In 2% of the cases operated, the
hearing may be further impaired.
Occasionally there may be persistent drainage, head noise,
and dizziness for some time following surgery. In less than
1% of the cases, a facial weakness may develop. This is usually
a temporary complication.
If you do not have surgery performed at this time, it is advisable
to have regular examinations, especially if the ear is draining.
Should you develop low-grade pain in or about the ear, increased
discharge, or dizziness, you should immediately consult your
physician.
Should any questions arise regarding your ear difficulty,
feel free to call or write at any time.
|