EAR
Conditions and surgery of the ear
Disclaimer:
The details in this section are for general information only. Always check with your own surgeon.
General information on ear surgery
A surgeon will take different approaches to the various parts of the ear in order to obtain access to the disease.
Some operations can be carried out via the ear canal without the need for any other incision around the ear. This route is known as a permeatal or transmeatal approach.
It is used for such conditions as otosclerosis or the insertion of grommets as well as some newer techniques of administering drugs to the inner ear in vertigo.
However, more frequently an incision around the ear is required to allow greater access to the middle ear, mastoid or inner ear. Sometimes this may be carried out through an incision just in front of the ear (endaural incision).
A common alternative to this route, which gives even greater exposure, is a post-aural incision which means an incision through the skin behind the ear.
Potential complications and results
All ear surgery carries potential dangers or complications. While these risks are usually very low, in certain types of surgery the risk is increased. You should be informed of these risks before embarking upon surgery so that you are clear on the implications of any operation.
The main risks are those of total hearing loss in the operated ear. Dizziness and tinnitus may result from surgery and paralysis or weakness of the muscles of the face may also occur as may disturbance of taste to one side of the tongue.
These complications may be either temporary or permanent. With modern techniques of surgery the risks are very low. Many ear diseases, if left untreated, can result in the same complications, though in such a scenario the chances of complications are comparatively higher.
The results or success of surgery on the ear may in certain instances be known instantly, for example following the insertion of grommets. However in many other cases the results do not become apparent until several weeks following surgery due to the healing process that is taking place. This is particularly true following the reconstruction of hearing.
After the operation
Following ear surgery the patient will have a head bandage in order to compress the area of the operation and prevent the collection of blood underneath the wound.
Normally the head bandage will remain in place for 24 or 48 hours, but in cases such as in the correction of the external ear, or bat ear, they may be left in place for up to two weeks.
Once the head bandage has been removed, usually there will be ‘packing’ in the ear canal which will also need to be removed. It is often thought that this is a painful process but generally speaking it is easily accomplished without any significant discomfort.
Stitches from the incisions are generally removed between one and two weeks postoperatively at the same time as removal of the packing if the stitches are not dissolvable.
Hearing and deafness
TOP
Disclaimer: The details in this section are for general information only. Always check with your own doctor.
Hearing loss is common and can affect people of any age. About 16% of adults in the UK have some degree of hearing loss. It is thought that half the general population above the age of 75 have some hearing loss. Children are the next most common group to be affected, usually due to fluid or infection in the middle ear but also due to congenital problems or viral illness during early childhood. Hearing loss can interfere with normal communication with others on a daily basis.
How your ear works
We are able to hear because sounds enter the ear canal and pass along it to the eardrum. The sounds cause vibrations first of the eardrum and then of the little bones, called ossicles, which bridge the gap between the drum and the cochlea (part of the inner ear).
In the cochlea the vibrations are translated into electrical signals which are passed on to the brain along the acoustic, or auditory, nerve.
Types of deafness
The causes of deafness can be broadly grouped according to where in the ear they occur. A problem of transmission (or conduction) of soundwaves through the ear canal and middle ear is referred to as a conductive hearing loss. A problem with the translation of the soundwaves into an electrical signal by the inner ear or the onward passage of those electrical impulses via the nerves to the brain is referred to as a sensorineural hearing loss.
A conductive hearing loss occurs when there is a failure of the conversion of soundwaves into movements by the eardrum and the little bones of the middle ear. This can occur either because the soundwaves are not reaching the eardrum, for example because of wax blocking the ear canal, or because the vibrating mechanisms of the eardrum or ossicles are not working properly, for example because of current or previous infections.
There are a great number of causes of conductive hearing loss including blockage by wax, infection, a collection of fluid, trauma or fixation of the ossicles in the middle ear (which is called otosclerosis). Fortunately, they can often be treated and hearing in the infected ear can be corrected or improved.
A sensorineural hearing loss is due to a problem of the inner ear or of the nerve that carries the signal from the inner ear to the hearing centres in the brain. Again there are many causes, the most common being that of hearing loss in old age (presbyacusis), which usually affects both ears to a similar degree and can be associated with noises in the ear (tinnitus). Other common conditions which affect the inner ear are infections (particularly by viruses), trauma, the side effects from certain medication and congenital causes. While some inner ear problems are reversible, generally speaking the hearing loss is irreversible (ie permanent). Extremely rarely, but more seriously, the hearing loss may be due to a growth, otherwise known as a tumour, on the hearing nerve in the brain.
The main difficulty with sensorineural hearing loss is an inability to hear adequately in conversations, especially when there is background noise. Many people complain that they can hear the sounds of a conversation, but cannot discriminate exactly what is being said. It can lead to immense frustration and feelings of isolation.
Although frequent in older people, it is not uncommon for people to notice problems with speech discrimination whilst they are in their 30s or even earlier, especially if they have had regular exposure to loud noise, for example by going clubbing.
Whilst there is no absolute cure for a sensorineural hearing loss, hearing aids help to amplify or increase the sounds that are transmitted to the inner ear and so partially overcome the hearing loss. The technology in hearing aids is continuing to improve and they can work very well for many people.
When to seek advice
You should always see your doctor urgently if you have a sudden hearing loss, as sometimes treatment for sudden deafness should be started within 48 hours of its onset.
If you notice a hearing loss only in one ear, you should see your doctor, who will probably refer you on to an ENT specialist or an audiological physician.
If you (or people around you) notice a gradual deterioration of your hearing you should seek advice from your doctor who will advise you of the appropriate action to be taken, and will be able to organise a hearing test and specialist referral if necessary.
Links
Hearing aids and how to get one TOP
Disclaimer:
The details in this section are for general information only. Always check with your own doctor.
A hearing aid is a device that is used to increase the loudness of the sound reaching the ear of a person with a hearing difficulty. Modern hearing aids consist of three basic electronic components: a microphone, an amplifier and a loudspeaker.
The most common types of hearing aids are those that are worn in or behind the ear, but there are others, such as implantable hearing aids, which can be used in certain situations (see below).
Externally worn hearing aids
The most commonly used type of aid is the behind-the-ear hearing aid, where all the electronic components are contained in a skin-coloured plastic case that sits behind the ear.
Cosmetically more popular is the in-the-ear hearing aid, which is a smaller, more compact device worn in the ear canal, but it is inappropriate for people with severe deafness because it is not powerful enough to compensate for their hearing loss. It is not suitable for those with some loss of manual dexterity, because the control switches are quite small.
Even smaller is the completely-in-the-canal hearing aid, which is virtually invisible when worn. Again, because of its small size, its casing is too small to be able to hold a very powerful amplifier and so it is only useful for mild hearing losses.
For people with very severe deafness, the electronic components needed to amplify sounds can become too bulky to fit into small hearing aids and a separate body-worn hearing aid with larger switches would be most sui and controls is useful. However, with the advances in hearing aid technology this type of hearing aid is now much less common.
People with a conductive hearing loss may benefit from a device which is held in place behind the ear with a headband or 'alice band'. This is known as a bone conduction hearing aid.
People tend to benefit from this type of hearing aid if they have problems in the ear canal or middle ear, for example because of recurrent ear infections, previous surgery, or anatomical abnormalities such that they are unable to wear conventional hearing aids. Bone conduction aids can work very well, but can be quite bulky and obvious, and a more sophisticated type of bone conduction aid has been developed. This is the bone anchored hearing aid (see below).
Analogue or digital hearing aids?
There has been a lot written in the media recently about digital hearing aids. The ‘digital’ part of the hearing aid implies that these types of aids are more sensitive and better at restoring hearing than the older type of aids, and this is often, but not always, the case.
Digital hearing aids process sound in a fundamentally different way to analogue aids, by dividing up the sound into 'packets' and then processing them. This means that it is possible for digital aids to be more selective in filtering out irritating background noise.
Implantable hearing devices
Cochlear implant
People who have such a severe deafness that they hardly derive any benefit from conventional hearing aids (i.e. those people with a profound sensorineural hearing loss) may benefit from a cochlear implant.
In this type of implantable hearing aid a wire electrode is surgically inserted into the inner ear (the cochlea). Intense speech and hearing therapy is required often for several years following this operation. Cochlear implants can be used for children and adults.
Who can benefit from a hearing aid?
In theory, anybody with a hearing loss, whatever their age, who is having difficulty in following a normal conversation or listening to the TV or radio will benefit. However, you must have some residual hearing, however little, in order to benefit from a hearing aid. If no sound whatsoever is being heard, a cochlear implant may be indicated.
How can you obtain a hearing aid?
You can consult your ENT practitioner regarding the hearing aids, who will guide you further on this.
Tinnitus (ringing in the ears) TOP
Disclaimer:
The details in this section are for general information only. Always check with your own doctor.
Tinnitus is a word used by doctors to describe a condition when patients hear noises in their ears or in their heads.
Tinnitus has sometimes been described as ‘the sound of silence’ because all people, if they are seated in a completely quiet soundproofed room, will hear a type of rushing or hissing sound. Usually this noise is masked by environmental sounds. Hearing words, songs or voices is not included in the definition of tinnitus.
It is when this type of noise becomes intrusive into everyday life that it can become immensely irritating and becomes known as ‘tinnitus’. The noises of tinnitus may vary in pitch from low frequency to high frequency, they maybe intermittent or permanent and they usually vary in the intensity of sound. Some people spend a long time looking around the house for whatever it is that must be making the noise, other people fear that they may be developing a brain tumour.
Sometimes people notice that the intensity of the noises can alter according to various activities such as exercise, the drinking of coffee or wine and other stimuli.
Children can suffer from tinnitus as well as adults, which can be frightening for them when they do not understand what is happening. When tinnitus is first noticed, it can be very worrying.
Types of tinnitus
Tinnitus is generally divided into two types:
• noises that can be heard by somebody examining the patient (objective tinnitus)
• noises that can only be heard by the patient (subjective tinnitus)
Objective tinnitus
This type of tinnitus is uncommon. Noises may be caused by spasms of small muscles in the middle ear (often heard as a clicking sound) or by abnormalities of the blood vessels in and around the ear.
It is the turbulent bloodflow that is heard directly by the inner ear, and it usually occurs in time with the heart beat (pulsatile tinnitus). Pulsatile tinnitus can occur when there is an increased bloodflow to the ear, such as during an infection and inflammation, but also because of anatomical abnormalities of the blood vessels.
Vascular tumours of the middle ear are rare, but also can give a pulsatile tinnitus. Such objective tinnitus which can be heard by the examining doctor may require further investigation by an ear, nose and throat surgeon or audiological physician, and may in some instances have a surgical cure.
Subjective tinnitus
This is by far the most common type of tinnitus. Everyone, if sitting in a soundproof room, hears noises in their heads. Usually these noises are masked in everyday life by all the noise going on in the world around us. If you cannot hear sounds in the outside world so well, you tend to notice the natural noises inside your head much more because they are not being masked (drowned out) by the environmental noises.
Tinnitus is often, but not always, linked to a hearing loss. If the tiny hair cells of the cochlea are damaged, for example through certain drugs, noise exposure or as part of the aging process, the cochlea becomes less good at discriminating sounds, and your hearing is affected.
It is possible that these damaged hair cells also give rise to random noises which we hear as tinnitus. This is the reason that when you consult a specialist about tinnitus, you will have a hearing test.
Damaged hair cells in the inner ear may be a cause of tinnitus
Hearing loss is not the only cause of tinnitus, but it occurs in many people who do have some problem with their hearing, even if it is only mild, and perhaps unnoticed by the patient themselves.
The loudness of tinnitus is not linked to the degree of hearing loss, nor does the loudness of tinnitus always increase with time. Only about 20% of people with tinnitus perceive it as a great irritation; the majority are able to ignore it most of the time (see treatment below).
Certain types of diseases that affect the inner ear can also be associated with tinnitus (eg Menière's disease)
Further investigation
If tinnitus is only affecting one ear or if it is causing great distress, further investigation is warranted and is generally carried out by an ear nose and throat surgeon or audiological physician.
Investigations usually include hearing tests, and can also involve blood tests and radiological investigations (x-rays or scans). Not everyone with tinnitus will need every investigation. Sometimes no definite cause for the tinnitus is found. On other occasions a readily identifiable cause will be found such as a hearing loss.
Very rarely a more serious condition will be found, such as a tumour of the auditory nerve. Whilst specific causes such as this will be directly addressed, the majority of patients may benefit from other types of medical treatment.
Fortunately, the majority of patients who suffer from tinnitus will either find it gets better by itself, or that they will learn to tolerate the noises after a short period of time of only a few weeks or months.
Treatment
Generally the treatment of tinnitus falls into two main areas: tinnitus counselling or the use of mechanical devices such as hearing aids or white noise generators to control the symptoms.
Some simple measures can be very effective. If you find that the tinnitus is loudest when you are trying to get to sleep, try putting a small radio next to your bed, turning the tuning dial to a frequency in between two stations so that you hear ‘white noise’, and turn the volume down low so that you can only just hear the noise.
This will give your ears something else to listen to and many people find it a very useful method of getting to sleep. Other people use relaxation tapes, again with the volume down so that you can only just hear it.
Tinnitus counselling
This is a system whereby the cause of the tinnitus is clearly explained and the approach to understanding and controlling its significance in the patient’s daily life is clarified.
Mechanical devices
The use of hearing aids or tinnitus maskers amplify surrounding noises so that the tinnitus is no longer heard. Hearing aids are ideal if there is an associated hearing loss with the tinnitus. Tinnitus maskers are not so commonly used any more, but worked on the idea that a continuous noise, generated in the ear canal by the masker, would mask the tinnitus and would also provide an effect for several hours after it had been switched off.
White noise generators
These are sometimes used during tinnitus counselling and as a part of tinnitus retraining. Again, they can provide a less threatening, more controllable type of noise than the tinnitus, but need to be used as part of the retraining - they are not a solution in themselves.
Other types of treatment
Multiple types of treatment have been tried for tinnitus, and although they can be helpful for some patients, none of them will help all patients. Hypnosis and acupuncture can occasionally help.
Extracts of Gingko biloba (the maidenhair tree) is another method, but no properly controlled study has shown a positive effect. In general, drug treatments are not very helpful. Some types of sedatives have been used, but they are not good for long-term use and do not solve the problem.
It is estimated that about 30% to 40% of the population will suffer from tinnitus at one point in their life, particularly if they have hearing loss. The vast majority will either have intermittent tinnitus which is manageable, or more persistent tinnitus which is can be controlled without any significant treatment.
A small minority will require further management and it is these patients who will require referral to an ear nose and throat surgeon or an audiological physician.
Dizziness and vertigo
Disclaimer:
The details in this section are for general information only. Always check with your own doctor.
There are a multitude of causes of dizziness which may have nothing to do with the balance organ in the inner ear. Fainting attacks, heart problems, thyroid problems and brain problems can all give rise to feelings of light-headedness, giddiness and general imbalance.
One form of dizziness is vertigo which is the specific complaint of either the environment moving in relation to the patient or the patient moving in relation to the environment. It is usually a spinning or rotatory sensation. Vertigo is specifically linked to problems with the inner ear. Of the people who suffer from vertigo due to inner ear problems, 99% will recover with time and without any treatment.
Normal Balance
Balance and the ability to remain upright is dependent upon three systems:
• Eyes
• Feet, Legs & Neck
• Inner Ear
All three of these systems give information to the brain about the position of the body in space. Generally people can keep their balance if two of the three systems are working, but they cannot cope with only one system working. This is why most people tend to become more unsteady as they get older, because they may have arthritis in their legs and their neck or poor eyesight.
The balance organ (or labyrinth) is made up of three semicircular canals and the vestibule, which are all filled with liquid. The semicircular canals sense rotational movement and the vestibule senses acceleration and deceleration.
Inner ear disease and vertigo
Many different factors can affect the inner ear and cause vertigo. One way to distinguish them is by the duration of the dizziness.
Short-lived episodes of dizziness (few seconds to minutes)
An extremely common type of vertigo is benign positional vertigo. This is typically a very sudden onset of dizziness, which settles rapidly after a few seconds or at most a couple of minutes.
It is often started off by the person suddenly looking upwards or sideways, and some people get it when they turn over in bed. In between attacks, the sufferer feels entirely normal. It is probably caused by a little piece of lining coming loose in the inner ear and floating into the balance receptor, causing a sudden increase in nerve stimulus to the brain.
Sometimes the attacks start following a whiplash injury or other head injury, but often there appears to be no reason that they should have started. The attacks usually disappear with time.
Medicines do not help, but a manoeuvre known as Epley's Manoeuvre can be extremely effective in some patients. This can be carried out either by the ear nose and throat surgeon or physiotherapy department, depending on the hospital.
Medium length episodes of dizziness (half-hour to several hours)
These types of vertigo are rarer and are thought to be due to an increase in pressure of the fluid in the inner ear, although nobody really knows for sure.
Menière's disease or endolymphatic hydrops result in episodes of severe vertigo that can last up to several hours. The dizzy episodes are usually linked with vomiting, and the sufferer can often tell an episode is about to start because he or she notices a drop in their hearing, a feeling of fullness in the ear and some tinnitus. The hearing recovers once the vertigo has settled, but may gradually deteriorate with time.
Treatment of Menière's disease can involve medicines and, more rarely, surgery, but this will be organised by your local ear nose and throat department once the diagnosis of Menière's disease has been made.
Longer episodes of dizziness: (days to weeks)
An infection of the inner ear (labyrinthitis) or an inflammation of the balance nerve (vestibular neuronitis) can give rise to severe rotatory dizziness for up to two to three weeks, with a slow return to normal balance which can take a further few weeks.
Again, the initial episode is often associated with vomiting and the patient can be bed-bound because the dizziness is so severe. This is best treated at first with a vestibular sedative medication, but any treatment should be stopped quite quickly to allow the brain to compensate and recover from the dizziness. Recovery is much quicker in the long run if treatment with anti-dizziness medicines is not prolonged.
Investigations
The majority of patients who experience episodes of vertigo will recover without any long-term ill effects and usually within a few weeks or month of the onset of the symptoms.
In the majority, specialist investigations do not help with the diagnosis but they can be helpful in certain circumstances. If they are thought necessary, investigations of vertigo will generally be carried out in a hospital by a neurologist, general physician or ear nose and throat surgeon or a audiological physician. Types of test that may be requested include: audiological (hearing) tests, tests of balance, blood tests (rarely), and radiological examinations such as an MRI scan or CT scan.
Treatment
In general the treatment of vertigo is symptomatic, i.e. treatment is given to control the symptoms without regard to the specific cause of the vertigo. The body is very good at overcoming the imbalance experienced during inner ear disease, and so symptomatic treatment should be short because it can delay this natural compensation.
Rehabilitation (including Cawthorne Cooksey Exercises)
There are specifically targeted exercises to speed up the brain’s natural compensation after inner ear disease. Recovery can be hastened by these exercises which can be organised by your local ear nose and throat or physiotherapy department.
Vestibular sedatives
The inner ear may be ‘suppressed’ (or made sleepy) by the use of drugs such as Stemetil or Stugeron. These drugs reduce the overactivity of the balance organ and so reduce the dizziness and vomiting that can occur in inner ear problems.
However, they are not a long-term solution and should be used for as short a time as possible because they prolong the time taken for the body to readjust after the vertigo.
Menière's disease
This is a longer term disease and there are two aims of treatment. One is to treat the acute episodes of dizziness with vestibular sedatives (see above), and the other is to try to reduce the frequency of the dizzy episodes.
Frequently advice will be given to restrict intake of salt, caffeine and alcohol, which can help some patients with Menière's disease. Increasing the bloodflow of the inner ear may help and so drugs like Betahistine (Vertin) are often prescribed.
Some people with Menière's disease may benefit from surgery if the episodes of vertigo are frequent and disabling and not responding to medical treatment.
When surgery is needed
Surgery may be advised if medical treatment proves ineffective and the episodes of vertigo are disabling. The options range from those such as the simple insertion of a grommet through to operations which completely destroy the inner ear, or divide the nerves leading from the inner ear to the brain.
Unfortunately, many (although not all) effective surgical operations also destroy the hearing of that ear and so the vertigo is usually severe before a patient opts to undergo such treatment.
Because there are so many different causes of vertigo, there are several different operations and so it would take too much space to detail them all here, but your ear nose and throat consultant will go through them with you.
New treatments
There are always new treatments being developed and there is very encouraging progress being made using drugs delivered directly into the ear which selectively destroy the inner ear balance mechanisms without affecting hearing.
Further work is still to be undertaken in this area and will no doubt result in improved techniques for the control of vertigo in patients who are long-term sufferers. Anyone suffering from persistent recurrence of vertigo should consult their doctor in order to find the cause and to arrange effective treatment.
Infections of the ear TOP
Disclaimer:
The details in this section are for general information only. Always check with your own doctor.
Ear infections are common and represent a significant proportion of a family doctor’s work. Fortunately, the majority of infections settle without ill effects whether the problem is in the outer, middle or inner ear, although sometimes longer term problems can arise.
The ear is divided into three parts: outer, middle and inner (see diagram). Infection in each part will give rise to certain patterns of symptoms and the type of symptoms which may occur with ear infections include:
• pain or earache
• discharge which may be blood-stained or smelly
• deafness
• dizziness
• noises (tinnitus)
The only sign of an ear infection in young children may simply be a fever and some tugging of the ear by the child.
Dependent on which features are predominant, it is possible to identify the infection as arising within one of the three parts of the ear.
Outer ear infections (otitis externa)
This is an infection of the skin of the ear canal and very common. It can be extremely painful so that sleep may be impossible. Generally, outer ear infections are caused by a bacterial infection of the skin of the canal, although occasionally it may be due to a fungus or yeast.
The skin can become so swollen that the ear canal closes, causing temporary deafness, and there can be a scanty discharge from the ear. It occurs commonly in people who suffer from skin problems such as eczema, psoriasis or dermatitis but also in people with narrow ear canals or who swim a great deal.
It can affect both ears and often keeps recurring, especially if you are otherwise rundown or stressed. Not surprisingly, such symptoms usually mean that you will need to consult your doctor in order to receive effective treatment.
Treatment for outer ear infections is generally in the form of antibiotic ear drops which are instilled into the ear canal for at least a week. Sometimes antibiotics by mouth will also be necessary. In severe cases referral to an ear nose and throat specialist is both necessary and appropriate for cleaning of the ear canal and more intensive treatment.
Middle ear infections (otitis media)
Middle ear infections are also extremely common, particularly in children. The most common is acute otitis media which is characterised by a severe earache and high temperature, generally in a child, with associated deafness.
Like an abscess, once the eardrum bursts and the pus comes out of the ear the pain eases. The eardrum mostly heals once the infection settles and the hearing also returns to normal.
Longer term problems can occur when such infections are frequent, because there can be damage to the eardrum, or perhaps persistent deafness due to fluid remaining behind the eardrum (glue ear). In such cases referral to a specialist is appropriate.
A second but more serious form of middle ear infection is when it becomes chronic or long-lasting. Generally, chronic middle ear disease is associated with a smelly ear discharge and deafness, but rarely with pain.
Other significant symptoms such as tinnitus, weakness of the face or dizziness can occasionally occur. In these cases referral to an ear nose and throat surgeon is very important as the treatment usually involves surgery to remove the infection from the middle ear and mastoid bone. To ignore such disease can be potentially dangerous.
Mastoiditis is an acute infection of the mastoid bone which surrounds the ear. It is much less common than in previous decades, but certainly still occurs, especially in toddlers, and it needs urgent treatment with antibiotics once the child is admitted to hospital.
Infections of the inner ear are fortunately less common and are generally caused by viruses, although occasionally by secondary bacterial infection. They tend to cause problems with sudden hearing loss or dizziness.
The common cold virus is perhaps the most common cause of inner ear infections but many other viruses have also been associated with sudden deafness such as mumps, measles and herpes.
Treatment
Infections of the ears that do not settle within a couple of days should precipitate a visit to your ENT practitioner.
Most ear infections will initially be treated with either antibiotic ear drops or antibiotics taken by mouth. When the infection is severe, admission to hospital may be necessary for antibiotics via a drip. In some complicated cases surgery may be the best form of treatment.
Glue ear TOP
Disclaimer:
The details in this section are for general information only. Always check with your own doctor.
Glue ear is a condition in which fluid accumulates in the middle ear behind the ear drum. It is the commonest cause of partial deafness in children and it is estimated that one in four children are affected with glue ear at some stage of their lives.
The build up of fluid in the middle ear is due to a problem of blockage of the tube that connects the middle ear to the back of the nose (Eustachian tube)
The Eustachian tube normally plays an important role in maintaining equal air pressure between the outside and inside of the middle ear. When the tube becomes obstructed, the air in the middle ear becomes absorbed and the resulting vacuum draws fluid into the middle ear cavity from the lining of the ear (the mucosa).
Initially the fluid is thin and watery but eventually it becomes thick and tenacious, hence the name ‘glue ear’. Because the middle ear is now filled with fluid rather than air, the hearing is muffled. Obstruction of the tube may be due to repeated bacterial and viral upper respiratory tract infections, enlarged adenoids or nasal allergy.
It is important to note that in children the Eustachian tube is more horizontal and smaller than in adults and this is one of the reasons why glue ear is relatively common in children.
Because of the change in size of the Eustachian tube as you get older, and becaue you tend to be less prone to infections as you get older, children usually grow out of glue ear. However, it can take a long time, although it usually resolves by the age of 12. Glue ear may lead to delayed speech development, behavioural or educational problems.
Treatment
There is some debate about how effective medical treatments are and the mainstay of treating children with glue ear is with ventilation tubes (grommets).
The decision to operate and insert a grommet in the eardrum is dependent on many factors such as the patient’s age, whether there are recurrent middle ear infections, pain, speech delay, learning or behavioral difficulties.
It can also depend on the appearance of the eardrum (for instance whether there is a retraction pocket, which is a localised area of scarring that may lead to problems).
Young children with poor language development, pain or recurrent ear infections should have grommets inserted as soon as possible. Older children with few symptoms can be treated conservatively with regular follow-up visits in the outpatient clinic, to monitor their hearing and the appearance of the ear drum.
The main objective of grommet insertion is to get rid of the fluid in the middle ear by allowing air to enter through the grommet, so temporarily bypassing the problem. Normal hearing is restored once this objective is accomplished.
Grommets are available in many different shapes and sizes. On average, a grommet will stay in place between six to 12 months and will then fall out as the healing eardrum pushes it out into the ear canal.
If the child redevelops glue ear, it may be necessary to re-insert another grommet. The operation to insert a grommet is usually performed as day-case surgery under general anaesthesia and it is one of the most common ear nose and throat procedures.
The main complication associated with grommets is infection, but this can be treated with oral antibiotics or ear drops. In order to prevent infection, children with grommets are usually advised to use ear plugs and a bathing cap when going swimming and also to avoid diving, although opinions among surgeons do vary. This is particularly important in children with sinusitis or rhinitis.
However, infection can also arise from the nose via the Eustachian tube, even when the ears are well protected.
Grommets TOP
Disclaimer:
The details in this section are for general information only. Always check with your own surgeon
What are grommets and why are they used?
Grommets are very small plastic tubes, which sit in a hole in the eardrum. They let air get in and out of the ear.
Some people get fluid behind the eardrum. This is sometimes called ‘glue ear’. It is very common in young children, but it can happen in adults too. We don’t know exactly what causes glue ear.
Most young children will have glue ear at some time, but it doesn’t always cause problems. We only need to treat it if it is causing problems with hearing or speech, or if it is causing lots of ear infections.
Grommets usually fall out by themselves as the eardrum grows. They may stay in for six months, or a year, or sometimes even longer. You may not notice when they drop out.
Does my child have to have grommets?
Glue ear tends to get better by itself, but this can take a while. We like to leave children alone for the first three months, because about half of them will get better in this time. After three months, we see the child again and decide whether we need to operate. If the glue ear is not causing any problems, we can just wait for it to settle by itself.
If glue ear is causing problems with poor hearing, poor speech or lots of infections, it may be better to put grommets in. If we do put in grommets, the glue ear may come back when the grommet falls out. This happens to one child out of every three who has grommets put in. We may need to put more grommets in to last until your child grows out of the problem.
What are the alternatives to grommets?
Some doctors may use nose drops or nasal sprays to see if they help. Steroid nasal sprays may help some children if they are able to use them. Antibiotics too are prescribed in the initial period although at half the usual dose.
Antihistamines do not seem to help this type of ear problem. Taking out the adenoids may help the glue ear get better, and your surgeon may want to do this at the same time as putting grommets in. A hearing aid can sometimes be used to treat the poor hearing and speech problems that are caused by glue ear. This would mean that your child would not need an operation.
Can I do anything to help my child?
Speak clearly, and wait for your child to answer. Make sure he or she can see your face when you speak. Call your child’s name to get them to look at you before you speak. Let nursery and school teachers know that your child has a hearing problem. It may help for your child to sit at the front of the class.
After the operation
Grommets are not usually sore at all. You can give your child painkillers if you need to.
Grommets should improve your child’s hearing straight away. Some children think everything sounds too loud until they get used to having normal hearing again. This usually takes only a few days.
Your child should usually be able to go back to school or nursery the day after the operation.
What about ear infections?
Most people with grommets do not get any ear infections. If you see yellow fluid coming out of the ear, it may be an infection. It will not be as sore as a normal infection, and your child won’t be as ill. If you get some ear drops from your doctor, the problem will quickly settle. Some doctors may give antibiotics by mouth instead of antibiotic ear drops.
Can my child swim with grommets in?
Your child can start swimming a couple of weeks after the operation, as long as they don’t dive under the water. You do not need to use earplugs - the hole in the grommet is too small to let water through. You do need to avoid getting dirty or soapy water into the ear, so in the bath or shower plug your child's ears with a cotton-wool ball covered in Vaseline.
What else should I know about grommets?
It is OK to fly in an aeroplane with grommets. The pain from the change in pressure in the aeroplane cannot happen when the grommets are working. We need to check your child’s hearing after grommets have been put in, to make sure their hearing is better. Sometimes when a grommet comes out, a small hole is left behind. This usually heals up with time, and we rarely need to operate to close the hole. The grommet can leave some scarring in the eardrum. This does not affect the hearing.
Perforated ear drum TOP
Disclaimer:
The details in this section are for general information only. Always check with your own surgeon
What is a perforated eardrum?
A perforated eardrum means there is a hole in the eardrum, which may have been caused by infection or injury. Quite often a hole in the eardrum may heal itself. Sometimes it does not cause any problems. However it may cause recurrent infections with a discharge from the ear. If you have an infection you should avoid getting water in the ear. If the hole is large then you may experience some hearing loss.
A hole in the eardrum can be identified by an ENT specialist using an instrument called an otoscope.
Surgery to repair the perforation
An operation to repair the perforation is called a 'myringoplasty'. The benefits of closing a perforation include prevention of water entering the middle ear, which could cause ear infection. Repairing the hole means that you should get fewer ear infections. It may result in improved hearing, but repairing the eardrum alone seldom leads to great improvement in hearing.
If the hole in the eardrum has only just occurred, no treatment may be required. You should discuss with your surgeon whether to wait and see, or have surgery now.
The myringoplasty operation
The operation can be done under local or general anesthesia.
We perform the surgery usually through the ear opening itself. Many surgeons howe4ver may prefer to make a cut behind the ear or above the ear opening. Occasionally, your surgeon may need to widen the ear canal with a drill to get to the perforation. The material used to patch the eardrum is taken from under the skin. This eardrum 'graft' is placed against the eardrum. Dressings are placed in the ear canal. You may have an external dressing and a head bandage for a few hours.
The operation can successfully close a small hole eight to ninety percent of times. The success rate is not quite so good if the hole is large.
Possible complications
There are some risks that you must be aware of before giving consent to this treatment. These potential complications are rare. You should consult your surgeon about the likelihood of problems in your case.
• Taste disturbance: The taste nerve runs close to the eardrum and may occasionally be damaged. This can cause an abnormal taste on one side of the tongue. This is usually temporary but occasionally it can be permanent.
• Dizziness: Dizziness is common for a few hours following surgery. On rare occasions, dizziness is prolonged.
• Hearing loss: In a very small number of patients, severe deafness can happen if the inner ear is damaged.
• Tinnitus: Sometimes the patient may notice noise in the ear, in particular if the hearing loss worsens.
• Facial Paralysis: The nerve for the muscle of the face runs through the ear. The facial paralysis affects the movement of the facial muscles for closing of the eye, making a smile and raising the forehead. It is almost never seen as a complication of this surgery.
• Reaction to ear dressings: Occasionally the ear may develop an allergic reaction to the dressings in the ear canal. If this happens, the pinna (outer ear) may become swollen and red. You should consult your surgeon so that he can remove the dressing from your ear. The allergic reaction should settle down after a few days.
Cholesteatoma/mastoid operations TOP
Disclaimer:
The details in this section are for general information only. Always check with your own surgeon
What is this?
A cholesteatoma is a cyst or sac of skin that is growing backwards behind your eardrum into the middle ear and mastoid. It results in a chronic, smelly discharge, and the longer it remains the more damage it can do to the delicate structures of the ear.
Why have an operation?
If left untreated, after many years it could destroy your hearing, destroy your balance organ and damage your facial nerve which would give you a paralysed side of your face. It can also cause brain infections, because the ear is so close to the brain. It is therefore necessary to remove it, before it is able to cause such damage.
By removing the cholesteatoma, you should no longer be at risk of these complications. It may also be possible to improve your hearing in that ear.
What does the operation involve?
It is almost always done under general anaesthetic. You will have a cut either behind your ear, or just in front and above your ear. The extent of the operation depends on the extent of the disease. The aim is to remove all the disease but preserve as much of the workings of your ear as possible.
The mastoid bone is like a bony sponge, full of little pockets that can harbour the cholesteatoma, so these will need to be removed and smoothed out. If the disease is surrounding the ossicles, these little bones will also have to be removed.
The facial nerve, which supplies the muscles in your face, runs in a bony canal through your ear. Sometimes the bone overlying the nerve has been destroyed by the disease, but at all care is taken to avoid damaging this nerve (see risks).
After the disease has been removed, a graft will be used to seal up any hole in the eardrum, and packing placed in the ear canal.
There are multiple variations of the mastoid operation, so your surgeon will explain the details which apply to you.
What happens after the operation?
You will stay in hospital at least one night after the operation. If the stitches are not dissolvable, they will be removed after one or two weeks. The packing will be removed from your ear after 2 weeks.
If you have a mastoid cavity after the operation, it will need regular care in the ear nose and throat outpatients department until it is entirely healed.
What are the risks of the operation?
The risks of the operation are similar to those of leaving the cholesteatoma in your ear, only more controlled and much rarer. There is a risk of reduced hearing after the operation but this is often able to be improved by an operation at a later date once the cholesteatoma has been controlled.
There is a rare risk to the facial nerve resulting in a weakness of the side of the face.
Sometimes a second operation is planned about one year after the original operation to check for recurrence of the cholesteatoma. There is also a risk of taste disturbance on one side of your tongue.
When can I wash my hair/swim/fly?
If you are careful about keeping water away from your operated ear, you can wash your hair after a week.
You should be able to swim about four to six weeks after the operation, depending on how well the operation has healed, and so you should ask your surgeon at your postoperative outpatients appointment.
You should be able to fly at any time after the operation unless you have also had an operation to improve your hearing at the same time as the mastoid operation - again, check with your surgeon.
Otosclerosis TOP
Disclaimer:
The details in this section are for general information only. Always check with your own surgeon
The Ear
The ear consists of the outer, middle and inner ear. Sound travels through the outer ear and reach the eardrum, causing it to vibrate. The vibration is then transmitted through three tiny bones in the middle ear called the ossicles. These three ossicles are called malleus, incus and stapes, sometimes known as hammer, anvil and stirrup. The vibration then enters the inner ear which is a snail-shaped bony structure filled with fluid. The nerve cells within the inner ear are stimulated to produce nerve signals. These nerve signals are carried to the brain, where they are interpreted as sound.
What is otosclerosis?
Otosclerosis is a disease of the bone surrounding the inner ear. It can cause hearing loss when abnormal bone forms around the stapes, reducing the sound that reaches the inner ear. This is called conductive hearing loss. Less frequently, otosclerosis can interfere with the inner ear nerve cells and affect the production of the nerve signal. This is called sensorineural hearing loss.
The cause of otosclerosis is not fully understood, although it tends to run in families and can be hereditary. People who have a family history of otosclerosis are more likely to develop the disorder.
Otosclerosis affects the ears only and not other parts of the body. Both ears are usually involved to some extent. However, in some individuals, only one ear is affected. It usually begins in the teens or early twenties. Some research suggests a relationship between otosclerosis and the hormonal changes associated with pregnancy.
Symtoms & diagnosis of otosclerosis
The commonest symptom is hearing loss that may take many years to become obvious. The degree of hearing loss may range from slight to severe. It can be conductive, sensorineural or both.
In addition to hearing loss, some people with otosclerosis may experience tinnitus or noise in the ear. The intensity of the tinnitus is not necessarily related to the degree or type of hearing loss. Very rarely, otosclerosis may also cause dizziness.
An examination by an otolaryngologist is needed to rule out other diseases or health problems that may cause these same symptoms. The amount of hearing loss and whether it is conductive or sensorineural can be determined only by careful hearing tests.
How can otosclerosis be treated?
There is no known cure for otosclerosis. The individual with otosclerosis has several options: do nothing, be fitted with hearing aids, or surgery. No treatment is needed if the hearing impairment is mild.
Hearing aids amplify sounds so that the user can hear better. The advantage of hearing aids is that they carry no risk to the patient. An audiologist can discuss the various types of hearing aids available and make a recommendation based on the specific needs of an individual.
The stapedotomy operation
If one ear is affected, the operation may help to locate the direction of sound and hear better in noisy background. If both ears are affected, the operation is usually done on the poorer ear. The patient may still need a hearing aid in the opposite ear.
The operation usually takes about an hour. You might be asleep although some surgeons prefer to do the operation with only your ear anaesthetised. A cut is made above the ear opening or inside the ear canal. The top part of the stapes is removed with fine instruments. A small opening is then made at the base, or “footplate”, of the stapes into the inner ear. Some surgeons use laser to perform this procedure. A small piece of vein may be taken from the back of the hand to use as a graft inside the ear. A plastic or metal prosthesis is then put into the ear to conduct sound from the remaining ossicles into the inner ear. You will have packing placed in the ear canal.
How successful is the operation?
The chances of obtaining a good result from this operation by experienced surgeons are over 80 percent. This means that eight out of ten patients will get an improvement of hearing up to the level at which their inner ear is capable of hearing. You should enquire from your surgeon his personal success rate of stapedotomy.
Possible complications
There are some risks that you must consider before giving consent to this treatment. These potential complications are rare. You should consult your surgeon about his complication rate.
• Loss of hearing: In a small number of patients the hearing may be further impaired due to damage to the inner ear. It can even result in a severe loss of hearing in the operated ear. This may be to the extent that one cannot obtain benefit from a hearing aid in that ear. For experienced surgeons, this complication happens in around one in 100 patients. Therefore the poorer hearing ear is normally selected for surgery first.
• Dizziness:Dizziness is common for a few hours following stapedotomy and may result in nausea and vomiting. Some unsteadiness can occur during the first few days following surgery; dizziness on quick head movement may persist for several weeks. On rare occasions, dizziness is prolonged.
• Taste disturbance: The taste nerve runs close to the eardrum and may occasionally be damaged. This can cause an abnormal taste on one side of the tongue. This is usually temporary but it can be permanent in one in ten patients.
• Tinnitus: Sometimes the patient may notice noise in the ear, in particular if the hearing loss worsens.
• Other complications: The uncommon risk of total loss of hearing, disturbance of balance or taste could have a serious implication to certain employments. You should discuss with your specialist about these concerns.
• Reaction to ear dressings: Occasionally the ear may develop an allergic reaction to the dressings in the ear canal. If this happens, the pinna (outer ear) may become swollen and red. You should consult your surgeon so that he can remove the dressing from your ear. The allergic reaction should settle down after a few days.
What happens after the operation?
You will usually go home the day after the operation or sometimes the same day.
The ear may ache a little but this can be controlled with painkillers provided by the hospital.
A slight amount of dizziness is normal after the operation.
There may be a small amount of discharge from the ear canal. This usually comes from the ear dressings. The packing in the ear canal will be removed after two or three weeks
You may need to take two to three weeks off work.
You should keep the ear dry for the first few weeks. Plug the ear with a cotton wool ball coated with Vaseline when you are having a shower or washing your hair.
Avoid straining for the first few weeks after surgery, that is, no heavy lifting. Only blow the nose gently. Avoid air travel until cleared by your surgeon.
Hearing may not return to normal for up to three months. You should consult the surgeon if there is a sudden onset of deafness, dizziness or severe pain after you are discharged from the hospital. You are advised to avoid diving or flying when you have a cold if possible.
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