A Discussion of Chronic Ear Infections
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, 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.
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.
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.
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 tests reveal your hearing level to be:
Left ear ______________________ decibels
Conversion to degree of handicap:
Examination of your ear reveals:
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:
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 (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.
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.
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, 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 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.
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.
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.