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Normal Ear Function
Acoustic Neuroma
Chronic Otitis Media
Cochlear Implants
Eustachian Tube Problems
Facial Nerve Paralysis
Hearing Aids
Hearing Loss
Meniere's Syndrome
Positional Vertigo
Tinnitus/Head Noise
Ear Drum Perforation

Chronic otitis media is a chronic or recurring infection in the middle ear or subsequent problems from such an infection. The infection can be active or inactive. It is usual that there is a hole in the eardrum or has been one in the past. Often there has been drainage of pus and infection from the ear and some hearing loss. Most of the time, this condition is not painful, although it can be at times. The long-term complications from this type of infection can result in damage to the ear bones and result in hearing loss in addition to formation of a cyst, called a cholesteatoma, which destroys the ear bones and other parts of the ear as it grows beneath the remaining eardrum. Cholesteatomas are benign growths that occur in the ear usually as a consequence of poor Eustachian tube function and a vacuum effect that pulls the eardrum in. The outer layer of the eardrum is lined with skin. Skin sheds and normally the shed skin falls out of the ear canal. However, when the skin forms a pouch, the dead skin accumulates and builds up into a cyst. As this cyst expands from the continued building of layers of dead skin, it can cause destruction of parts of the inner ear including the three ear bones, the inner ear or balance canals, the facial nerve, and even the brain. Often the cyst will get infected and start draining pus. These cysts can be serious if left untreated. In the early part of the last century, cholesteatomas were a leading cause of in-hospital death. Fortunately through the methods of modern surgery described in subsequent sections, we can take care of these cysts. Most of the time we can remove the cholesteatoma and repair any damage as one operation. Occasionally we have to stage the surgery and come back in six to twelve months to make sure no projection of the cyst was hidden from view.

In addition to understanding the function of the normal ear, in this discussion, it is also helpful to explain the mastoid cavity. The mastoid is a series of air spaces in the bone just behind the ear. If one feels right behind the ear and just behind the jawbone, you can feel a small pyramid-shaped bony projection that points down toward the feet. This is the mastoid bone and it is connected to the middle ear. It is helpful to consider the mastoid as the sinus to the middle ear, much as the sinuses connect to the nose in the front part of the face. Often, disease and problems in the middle ear, or that space between the eardrum and the inner ear that contains the three ear bones, travels back into the mastoid cavity. In most cases, disease involving the middle ear of a chronic nature as we are discussing, stems from an original problem with the Eustachian tube, or the tube between the back of the nose and the ear. Poor function of this tube leads to vacuum in the ear and a retraction of the eardrum inward. Infections occur and perforations of the eardrum result, and eventual formation of a cyst occurs and extends back into the mastoid cavity.

Most of the time, the hearing loss from this type of problem is of a conductive nature, meaning a problem with conduction of the sound from the eardrum to the inner ear. Usually, the nerve endings still work quite well. For this reason, it is often possible to restore hearing surgically in this type of hearing loss.

Medical Treatment for Chronic Otitis Media
If there is a hole in the eardrum, it is useful to try and prevent water from entering the ear canal and getting through the hole in the eardrum. Water coming in through that hole will often introduce infection from the outside and lead to recurrent drainage. The use of the ear plugs provided at the clinic is usually quite effective in preventing this. These are highly recommended when showering or swimming.

Usually, it is prudent to surgically repair the hole in the eardrum to prevent these recurrent infections and complications that follow from them. In cases in which this is not recommended, there are medical treatments that are useful in curbing these infections and keeping them in check. Also, these medical treatments are used to decrease inflammation and swelling in the ear prior to surgical intervention.

Often, you will be given a card that explains how to cleanse the ear with a dilute vinegar solution. The vinegar is a weak acid that will cleanse debris from the infection out of the ear and the acid content will discourage infection. In addition to this treatment, it is often necessary to place various antibiotic drops or antibiotic powders in the ear after washing it out. When placing the drops in the ear, it is useful to first dry the outer ear canal with a small Q-tip. Make sure you do not place the Q-tip deeply. Next, lay down on your side and pull the ear back and out. This will help open up the ear canal. Then place the drops in the ear canal. After the drops are in the ear canal, press the front flap over the ear canal in and out in a pumping motion to pump the drops down into the ear. It is usually better to have someone else do this for you as they can manipulate it with both hands. 

Surgical Treatment
Surgical treatment varies based on the extent of the disease. These surgical treatments are classified according to the extent of the disease and the steps necessary to remedy the disease.

This involves reconstruction of the eardrum and/or the small bones in the middle ear after removal of disease.

A hole in the eardrum can be closed using tympanoplasty techniques. Most of the time, this involves making an incision in the crease behind the ear and using some of the covering of the chewing muscle located at the ear to reconstruct a new eardrum. This can be done using a general anesthetic (going to sleep) or a local anesthetic (using numbing medicine). This is usually done as an outpatient procedure and one would have a fluffy dressing over the ear that would stay on for one day.

This operation may involve replacement of one or more of the ear bones with a prosthetic or artificial device. The two most common types of prosthesis are partial ossicular prosthesis (POP) and total ossicular prosthesis (TOP). The POP connects the top of the third hearing bone, or stapes, to the eardrum. This is useful when the second bone, or incus, is diseased and has to be removed or when both the malleus and the incus (first and second bones) are diseased and need to be removed. The TOP is useful when the top part of the third bone is missing or diseased or if the entire stapes is missing. (Diagram I)

Sometimes there is extensive disease in the middle ear and it is necessary to put a piece of plastic in the middle ear after removal of disease so that the eardrum does not scar shut to the floor of the ear. We then come back in six to twelve months and remove the plastic and reconstruct the hearing with an artificial replacement. Often this cannot be determined until the time of surgery.

As mentioned previously, the mastoid is the cavity behind the ear that is connected to the middle ear. Often, a small skin cyst will develop in the eardrum and tract back through the middle ear into the mastoid cavity. This is called a cholesteatoma. In these cases and in cases in which there is severe disease in the middle ear, it is necessary to enter the mastoid cavity and remove this disease. The mastoid cavity is bounded at the top by the dura that covers the brain. The small honeycomb air cells in the bone of the mastoid are drilled away and the cholesteatoma is removed, and other diseased tissue is also removed to allow proper healing. Sometimes, the mastoidectomy has to be accomplished at the time of typmanoplasty even when this was not foreseen in the preoperative discussion. Nevertheless, most of the time we can tell if mastoidectomy will be needed at the time of tympanoplasty.

Mastoid Cavity
Sometimes, disease or previous surgery has destroyed the ear canal wall, separating the mastoid cavity from the ear canal. At this time, it may be feasible to reconstruct that ear canal wall. However, sometimes that is not possible. In this event, it is necessary to create a common cavity between the mastoid and the ear canal. The opening to the ear canal will be a good bit larger and this will be noticeable. The resultant cavity will generally not make any difference in the hearing compared to a normal ear canal. Sometimes, it is necessary to create this cavity when the cholesteatoma or cyst is very extensive and has resulted in complications that lend reconstruction unsuitable. Most of the time, it is known preoperatively if a cavity will need to be created. Sometimes, however, this cannot be determined until the time of surgery.

Goals of Surgery
The goals of surgery are first to eliminate the infection and create a dry, healed ear. The second goal is to improve the hearing. Sometimes, the disease is such that it precludes any attempts to reconstruct the hearing mechanism and the efforts are concentrated on just eliminating the infection. This is unusual today, but it does occur occasionally.

In some cases in which the disease is very extensive with widespread cholesteatoma or severe swelling of the lining of the middle ear and mastoid, it may be necessary to undergo two operations to restore the hearing. The first operation is to eliminate the disease. In this case, plastic will be placed in the mastoid cavity in the middle ear and the eardrum will be reconstructed. At the second procedure, the plastic will be removed, and the hearing will be reconstructed.

Postoperative Instructions
Usually, you will be given prescriptions for antibiotics and pain medicine. Take these as directed. It is not uncommon to experience a little dizziness in the first days after the operation. If this is severe and involves nausea and vomiting, or if it persists, please call Dr. House. You will also experience gurgling sounds in your ear for several weeks. This is not uncommon and nothing to be alarmed about. It is advisable to take the pain medicine regularly for the first twenty-four hours to prevent pain. It is easier to prevent pain than chase it once it has started. Nevertheless, these operations are not usually very painful.

Do not blow your nose for the first two to three weeks after surgery. If you need to, sniff gently. If you sneeze, make sure your mouth is open as when you cough.

You will have a fluffy bandage on your ear in most cases. Take scissors and cut the band just over the eye and unwrap the bandage. Allow all the fluffy material to fall off, and remove it. Behind the ear, there will be some pieces of tape on the skin. Leave these alone. In most cases, you would have to work hard to remove these pieces of tape, to don't worry about it. There will be some cotton in the ear canal. Remove this cotton. Place a clean piece of cotton in the outer ear, just below the ear canal to catch any drip. Do not place it in the canal and stop the canal up. There will be some drainage for a few days after the operation. After the drainage stops, it is not necessary to keep any cotton in the ear at all. When the tape behind the ear is removed at one week, it will then be permissible to wash the area behind the ear, but not until that time. After one week, when taking a shower or washing hair, place a piece of cotton in the ear canal and place some Vaseline or tape over the edge of the cotton to keep water from going in the ear canal. Do this until examination by Dr. House in the weeks to come indicates it is okay to discontinue this. Do not use an earplug in the ear canal after surgery as this will push the packing too deep and may dislodge the new eardrum. Make sure to avoid putting anything else in the ear, including finger tip or Q-tip, etc. Usually, two or three weeks after surgery, you will be given a prescription for some ear drops to place in the ear canal. Continue to do this twice a day until you return. This will help loosen the packing in the ear canal and help some of it come out. Do not be alarmed when this packing comes out. Often, it looks like flesh. This is normal and should not be of concern.

Other things that one can expect after surgery include an occasional metal taste in the mouth or dryness in the mouth. This usually goes away within a month or two.

Often, there is some numbness of the outer ear. This numbness may last for several months. Very rarely this numbness persists indefinitely.

The jaw joint is located just in front of the ear canal and sometimes there is some stiffness in the jaw due to surgery on the chewing muscle and the ear canal, and this usually goes away within a few weeks.

Occasionally, it is necessary to insert a small drain behind the ear that can be sewn in place. In this case, there will be some drainage through that drain until such time as it is deemed prudent to remove the drain.

Risks and Complications of Surgery
Ninety-five percent of the time, the new eardrum heals very well. Occasionally, it does not heal well and the graft does not "take." In this case, it may be necessary to perform the operation again. However, this is very rare.

Occasionally, the hearing is slightly worse following surgery in which there is severe scarring in the ear. This is usually in cases in which reconstruction of the hearing is not possible. In less than 1% of the cases, total hearing loss occurs. This usually occurs when a cyst has eroded into the inner ear and has destroyed part of the inner ear. In removing the cyst, the fluid of the inner ear comes out and the hearing is lost. Usually, this complication cannot be foreseen before surgery. Fortunately, it is indeed a very rare occurrence.

Frequently one experiences a metal taste in the mouth for a few weeks after surgery. This rarely persists. In cases of cholesteatoma, it is not uncommon to lose some taste sensation in the front part on the tongue on the affected side. Because of the abundance of taste buds in the mouth, this is rarely problematic.

It is not unusual to be dizzy right after ear surgery. This usually goes away within a day or two. Occasionally, however, dizziness persists. Persistent dizziness that does not resolve occurs in less than 1% of the cases. This is also usually due to invasion of the inner ear by a cyst. Very rarely, an additional operation is necessary to help this.

The nerve that moves the face travels through the ear. Any time there is an operation on the ear, this nerve is at risk for injury. However, this is extremely rare, occurring much less than 1% of the time. This usually occurs only when there is extensive disease that has eaten away the bone from around this nerve. In the extremely rare event in which this complication does occur, it may be necessary to have further surgery to repair the nerve and procedures on the eyelid to help it close.

Occasionally the infection has eroded into the brain. This is rare but could result in a leak of spinal fluid or infection of that fluid. Special measures might be necessary to remedy this unforeseen happening if it arises.

General Anesthesia
Going to sleep for an operation these days is extremely safe; however, there are some complications that can occur that can be serious. Please ask your anesthesiologist about these risks.

Chronic otitis media can cause a lot of problems with the ear. Fortunately, we can prevent most of the problems or correct them with micro-surgical techniques. We can take care of any problems you may have with this condition at the Jackson Ear Clinic. If you have any questions, please let us know.

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