Ear

Surgical Procedures


SOM: Serous Otitis Media:

Serous otitis media, better known as middle ear fluid, is the most common condition causing hearing loss in children. Normally, the space behind the eardrum which contains the bones of hearing is filled with air. This allows the normal transmission of sound. This space can become filled with fluid during colds or upper respiratory infections. Once the cold clears, the fluid will generally drain out of the ear through a tube that connects the middle ear to the nose, the Eustachian tube. The Eustachian tube does not drain well in children. Fluid that has accumulated in the middle ear space often remains blocked.

Because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay. Children begin to speak some words by 18 months. Children with fluid in both ears can show significant delay in their use of language. In addition, young children learn to pronounce words by hearing them spoken. When there is a hearing loss, even a mild one, the spoken words of parents and siblings are distorted to the child with fluid in the ears.

Identification of fluid in the middle ear is important, not only to prevent future speech problems, but to avoid permanent damage to the eardrum and the middle ear. Most children will have at least one ear infection before the age of four. With treatment, the ear infections clear up promptly. Without the follow-up visit, fluid may still be present, even though the child has no complaints or symptoms. Therefore, it is essential that ear infections be rechecked after initial treatment. Usually, the presence of fluid results in a "mild conductive hearing loss." This could be as much as 30% hearing loss overall. After the specialist confirms that fluid is present behind both eardrums, further medical treatment is often advised. This may consist of additional antibiotics, decongestants, and in some cases, nasal sprays.

If fluid has been present for over 12 weeks, surgical drainage of the fluid is often indicated. The decision to perform surgery should be based on the response to medical treatment, the degree of hearing loss and the appearance of the eardrum itself under the surgical microscope. Surgery which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted. The procedure, medically termed a myringotomy and tubes, or tympanostomy and tube, (BMT if Bilateral) or PET (Pressure Equalizing Tubes), is performed on children under general anesthesia.

OME: Otitis Media with Effusion:

Mucoid (thick mucous)

OE: Otitis External:

This is when the ear canal becomes inflamed and usually treated with antibiotic drops.

Tympanic Membrane:

Anatomy. a technical name for the eardrum. Tympanotomy or Myringotomy Hole cut into the ear drum to aerate the inner ear. Usually closes within 12 hours to one week.
 

BMT: Bilateral Myringotomy Tubes Surgery:

Which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted. The procedure, medically termed a myringotomy and tubes, or tympanostomy and tubes, is performed on children under general anesthesia. Surgery is performed on an ambulatory or same day surgery basis. Within an hour or two after surgery, the child can be discharged home, to be followed up by a visit to the specialist in approximately one week.

Parents often ask why the fluid cannot be drained without inserting a tube. The need for the tube insertion is because the eardrum incision generally heals very rapidly (within a few days), which is not long enough for the swollen membranes in the middle ear to return to normal. As soon as the eardrum heals, fluid will reaccumulate. Tubes were first introduced because of this very problem.

There are many types of tubes, but all tubes serve the same function. They keep the eardrum open, allow air to enter the middle ear space, and permit fluid in the middle ear to drain. Most tubes will gradually be rejected by the ear and work their way out of the eardrum. As they come out, the eardrum seals behind the tube. Tubes will last four to six months in the eardrum before they come out. Occasionally, the eardrum does not heal completely when the tube comes out. The majority of children treated with tubes do not require further surgery. They may have ear infections in the future, but most will clear up with medical treatment. Some children are very prone to ear infections and have a tendency to accumulate fluid after each infection. Children tend to outgrow this cycle by age 7 or 8. In an ear, nose and throat specialty practice, this group comprises 10 to 15% of all children who have required tubes. Occasionally the physician has to physically remove the tube from the eardrum. (PE Tube Removal ) PO Restrictions: No water in ears while tubes are in place. Patient needs to wear earplugs when swimming or cotton ball with Vaseline on it while in tub.

TM Perforation:

A perforation of the ear drum will generally heal without surgery. In some cases, however, instead of normally healing, the skin of the ear drum can grow through the hole into the middle ear. If infection is present, the skin will continue to grow into the middle ear and will become a tumor of the ear termed a cholesteatoma. Childhood perforations most commonly occur from infections. Fortunately, these are generally self-healing.

Symptoms of a perforation include drainage from the ear and bloody discharge An adult with a perforation will generally notice a hearing loss in the ear. Water entering the ear when showering or swimming may be painful and can cause dizziness. Frequent summer ear infections related to swimming may be a symptom of an undetected perforation. Most adults with frequent ear infections, usually have had a history of ear infections in childhood. Flying with a severe cold can also perforate an eardrum due to changes in air pressure. This is especially true on landing. The sudden sensation of severe pain and a bloody discharge from the ear may signal a perforation. Self-inflicted damage with a cotton swab or other device inserted into the ear is another common cause of eardrum perforation in adults and children. The perforation must be protected from water entering the ear canal during bathing or showering. Plugs, cotton or lambs wool soaked in Vaseline can be used to protect the ear. Long standing perforations can be more severe due to infection and erosion of the bones of hearing, which disrupt the bony chain of the middle ear. An audiogram (hearing test) is taken to determine the degree of hearing loss.

TM Repair - patch:

(Can be done in office-local anesthesia)
If the eardrum does not heal on it's own, and the perforation is small, it can sometimes be closed by a simple office procedure. The ear surgeon can anesthetize the edges of the eardrum with a strong solution of Xylocaine or Phenol, or inject the ear canal skin with Xylocaine. Xylocaine will anesthetize on contact. Once the eardrum is anesthetized, the undersurface can be scratched with a sharp right angled hook. This stimulates the undersurface skin to heal and, in some instances, the drum will close. At the same time, the ear surgeon places a patch made of cigarette-type paper or other thin substance onto the outer surface of the eardrum. This will provide a matrix to allow the skin to heal underneath the drum. Perforations do not always heal with these techniques. Thus, in some cases, microsurgery may be necessary to close the perforation. This surgery is called tympanoplasty. It is often done on an ambulatory basis, going home on the same day of surgery.

Tympanoplasty:

Any of various surgical procedures performed on the eardrum or middle ear to restore or improve hearing in patients with conductive deafness. The repair can be done through the ear canal, but usually there is an incision made behind the ear, where a piece of facia or tissue is taken and used to rebuild the TM. (Tissue is sometimes taken from the ear lobe AKA the tragus.) The entire ear is pulled forward to gain access to the perforation. If the bones of hearing are eroded, then ossicular reconstruction (reconstruction of the bones of hearing) may be necessary at the time of tympanoplasty. In some cases, this can be determined before the surgery. In other cases, it only becomes obvious at the time that the ear is completely opened and examined under the microscope.

In over 90 percent of cases, the tympanoplasty procedure is successful. Tympanoplasty surgery is not always recommended. Chronic sinus or nasal problems such as severe allergies make the operation more difficult. They must be cleared up or controlled prior to tympanoplasty surgery. The ear and nose are connected by the eustachian tube. If there is active infection in the sinuses or nose, infected materials may block the eustachian tube or even back up into the tube itself. Severe allergies may cause swelling of the tube which is normally lined with mucous membranes. Unless allergies are controlled, swelling will block the eustachian tube and surgical attempts to repair the eardrum will fail. Tympanoplasty surgery may also not be recommended in very young children whose ears drain with every cold. However, this is a very controversial subject, because if perforations are neglected, they can form cholesteatomas.

PostOp (PO):

They will have an incision behind the ear with sutures. (The sutures are usually buried in the skin and do not have to be removed later.) Sterile foam gauze is placed into the ear canal and a big gauze bandage covers the ear. The external bandage can be removed 1days PO and the sterile packing is removed under the microscope in the office after 1 wk. Repeat hearing test in 4-6 wks. Most can return to work in 5-6 days PO, or 2-3 weeks if does heavy physical labor. (If hearing loss is mild and improves upon patching the hole, the ossicular chain is usually intact.)

Tympanomastoidectomy:

Mastoid infection, if present, may require that tympanoplasty surgery include mastoidectomy. The mastoid cavity may contain a reservoir of infection. If this material is not cleaned out, the new eardrum will break down after initial success. Thus, it is advisable to obtain a CT scan to visualize the mastoid cavity, if there is a history of prolonged and resistant infection. If the mastoid cavity appears diseased, the tympanoplasty with combined mastoidectomy is often recommended. This operation, termed tympanomastoidectomy, not only involves repairing the eardrum, but during the same operation, the mastoid bone is opened with a drill and all diseased tissue is removed. This procedure may lengthen the operation by 45 minutes or more, but it will improve the chance of a successful result.

OCR: Ossicular Chain Reconstruction:

If the bones of hearing are eroded, then ossicular reconstruction (reconstruction of the bones of hearing) may be necessary at the time of tympanoplasty. Infection can gradually wear away the connection to the point where the bone is no longer in contact with the stapes bone. One can think of the incus as the player arm of a phonograph and the stapes as the needle. If the player arm is not in contact with the needle, sound will not be transmitted with the same force as it would with a good connection.

In some cases, this can be determined before the surgery. In other cases, it only becomes obvious at the time that the ear is completely opened and examined under the microscope. The ear surgeon must decide whether the bones of hearing can be reconstructed at the time of the reconstruction of the ear drum. In most cases, this is possible if the ear is dry and not infected. There are several options. If the gap is small, it can be bridged by inserting a small piece of bone or cartilage taken from the patient at another site (behind the ear or from the lobe of tissue called the tragus in front of the ear). If there is a larger gap, then the incus bone is removed and modeled into a tooth-like prosthesis, using the operating microscope. This is then reinserted between the stapes and the malleus in order to reestablish continuity of the ossicular chain.

Otosclerosis:

The immobilization of the stapes bone occurs slowly. Perception of hearing loss is so slow that many people with otosclerosis only become aware of their hearing loss when friends or relatives call it to their attention. Many individuals with otosclerosis compensate for their hearing loss by inadvertantly learning to read lips. Hearing loss in otosclerosis may be in one, or both ears. When the hearing loss is in both ears, its effects on daily communication are significant. Noises in the ear usually accompany otosclerosis. The sensation of background noises in the ear, even in the quiet, is called, tinnitus. In otosclerosis, tinnitus may be a broad band hissing sound, discreet tones or pulses. Also, the nerve of hearing is sometimes effected by otosclerosis. The tinnitus may be worse in this case.

Tinnitus will go away in about half the cases of otosclerosis, when treated surgically. It is uncommon for the tinnitus to worsen after surgery. The individual with otosclerosis has several options. If the degree of hearing loss is minimal and only affects one ear, no intervention can be considered. However, hearing in both ears is necessary to localize where sounds are coming from. This enhances our ability to hear. Individuals with good hearing in one ear only, generally adapt, but it is still distressing when a sudden blockage of one ear is experienced by an infection or wax. Hearing aids can be fitted in cases of otosclerosis.

Some individuals with otosclerosis purchase a hearing aid because of health problems, age, or concerns regarding surgery. However, most people in good health will generally elect surgery to correct their hearing loss. This surgery is called stapedectomy, meaning removal of the stapes bone. After removal of the stapes bone (which is not properly vibrating), a small window is made to the inner ear. An artificial replacement made out of teflon and platinum or other material is then substituted for the non-functioning stapes bone. The artificial replacement (prosthesis) is very tiny, since the stapes bone, which it is replacing, is only about 3.5 mm in height, less than 1/8 of an inch.

Stapedectomy:

The operation can be done through the ear canal. Anaesthesia can be either general (completely asleep), or local (the ear being anaesthesized with an injection). An incision is made in the ear canal near the ear drum. The ear drum is then carefully raised and the ear surgeon uses the operating microscope to see the structures in detail. The middle ear is now opened. The bones of hearing are evaluated, confirming the surgeon's diagnosis of otosclerosis. The calcium deposit is usually visible, and the stapes bone is tested. It does not move when pressed. The stapes bone is now separated from the incus (anvil.) Freed from the stapes, the incus and malleus (hammer) bones can now move when pressed. A laser or other micro instrument vaporizes the tendon and the arch of the stapes bone, and the stapes bone remnant is removed from the middle ear. The ear drum is then folded back into its normal position and held down with a small gelatin sponge.

Cholesteatoma:

A perforation of the ear drum will generally heal without surgery. In some cases, however, instead of normally healing, the skin of the ear drum can grow through the hole into the middle ear. If infection is present, the skin will continue to grow into the middle ear and will become a tumor of the ear termed a cholesteatoma. Cholesteatomas are NOT a form of cancer. They are benign tumors. As they grow, they can look like an onion peel of white skin formed into a ball. They can destroy the bones of hearing as they grow, especially when the ear is infected or if water gets into the middle ear with other infections.

Symptoms of cholesteatoma include hearing loss and recurring discharge from the ear. Pus or unpleasant smelling fluids coming from the ear are common. A surgical microscope is necessary to make a proper inspection and cleansing of the condition, especially when there is infection. Cholesteatomas actively erode bone because they contain enzymes which are activated by moisture. In time, cholesteatomas will eventually erode the bone leading into the inner ear. This can cause nerve loss and deafness as well as severe imbalance and dizziness. The thin plate of bone that separates the roof of the ear from the brain can also be eroded by cholesteatomas. This exposes the covering of the brain. In extreme situations, it can lead to brain infection and other severe complications.

Cholesteatoma is a serious condition and, when diagnosed, requires prompt treatment. Medical treatment concentrates on drying the infection within the ear. Antibiotics, given both by mouth and drops in the ear, combined with weekly cleaning of the ear under the surgical microscope, can clear up the infection. Polyps (growth of inflamed tissue) are often present in the ear with cholesteatoma. The bone behind the ear is called the mastoid bone. It connects to the middle ear. In a healthy ear, it is filled with air. In most cases of cholesteatoma, the mastoid bone is filled with irritated mucous membranes and cholesteatoma itself often grows into this bone. The CAT scan will guide the ear surgeon as to how far the cholesteatoma has grown and whether it has eroded into the inner ear or brain. The CAT scan will also indicate the degree to which bones of hearing have been eroded. Once infection is cleared up and the ear is dry, a decision regarding surgery to remove the cholesteatoma can be made.

Some cholesteatomas which are very small can be removed through the ear canal. Most cholesteatomas require that an incision be made behind the ear to expose the tumor adequately. The cholesteatoma is completely removed microscopically.Hearing reconstruction is often delayed because it is necessary to rebuild the bones of hearing at a future date. In more extensive cholesteatomas, the tumor may have eroded through the bony wall which separates the middle ear from the mastoid. This may require a more radical operation, removing the wall separating the middle ear from the mastoid. The result is a so-called open cavity which requires life-long follow-up. In the past, ear surgeons believed that this operation had to be performed in all cholesteatomas involving the mastoid. However, today, most ear surgeons agree that the open cavity, or radical mastoid operation should be reserved for only the most invasive and destructive cholesteatomas. In less extensive cholesteatomas, especially when infection is well controlled before surgery, an intact canal wall operation is the favored procedure. This operation preserves the wall between the middle ear and mastoid.

The principal advantages of the intact canal wall operation are a more normal canal and ear drum, and a greater possibility of hearing restoration. In addition, most patients with the intact canal wall operation can allow water in the ear. The chief disadvantage of the intact canal wall operation is that a regrowth of cholesteatoma may not be evident. With an intact canal wall, regrowth of cholesteatoma may be completely unnoticed until it becomes very large. The ear drum is opened at the second operation and the bones of hearing are then reconstructed. If a regrowth of cholesteatoma is found, the tumor is again removed and reconstruction may be delayed for another 6 months or a year. Repeat CAT scans may also be performed in some cases to avoid further surgery. Even with careful microscopic surgical removal of cholesteatoma, 10% to 20% of cholesteatomas can recur. In children, some ear surgeons report up to 50% recurrence rates with the intact canal wall procedure.

As acquired or congential cholesteatomas increase in size, they can also affect the nerve that moves the face, the facial nerve. This nerve extends from the brain to the face by going through the inner ear, the middle ear, exiting near the forward tip of the mastoid bone, rising up to the front of the ear, and finally branching into the upper and lower face. Infected cholesteatomas may erode the bone covering this nerve. Pressure or irritation by the cholesteatoma on the facial nerve may then result in facial weakness or actual paralysis of the face on the side of the involved ear. In this case, ear surgery may be necessary on an emergency basis to prevent permanent facial paralysis.

Risks and Complications:

Most patients who undergo surgery for cholesteatoma are able to maintain or improve their hearing at a subsequent operation for reconstruction of the bones of hearing. However, individuals may not be candidates for further reconstructive surgery if irreversible changes took place in the ear due to the disease. A hearing aid fitting will usually be considered in this situation. In some instances (less than 1% of operations for cholesteatomas), complete hearing can be lost at the time of surgery or during the healing process. The facial nerve is potentially at risk in all cases of ear surgery, but especially when removing a cholesteatoma. Special care must always be taken to identify the facial nerve. Sometimes, the normal structures may be severely distorted and the nerve very difficult to identify, especially in an infected ear. To counter this difficulty, a facial nerve monitor is often used to identify the facial nerve in cholesteatoma surgery.

Meniere's Disease:

Meniere's Disease is a very disturbing illness, presenting patients with hearing loss, pressure in the ear, tinnitus, severe imbalance and vertigo. Meniere's Disease rarely occurs in children. In most cases, it begins in both men and women in the thirties or early middle age. Also, Meniere's is rarely noted for the first time in older people.

Symptoms:

Symptoms of Meniere's Disease come in cycles. The patient suffers multiple episodes lasting several months at a time; then, it generally subsides. In some individuals, the symptoms seem to be more severe in spring, fall or when under extra emotional stress. Ten to 15 percent of cases resembling Meniere's Disease may be the result of an immune disorder of the body, the system producing antibodies which attack the inner ear. Cholesteatomas (cystic growths) and other infections of the middle ear can also produce symptoms similar to Menieres. Initial evaluation is based on a very careful history given to the ear surgeon, as well as an examination of the ears under the operating microscope to rule out obvious infections or visible growths. Then, a comprehensive hearing test (audiogram) is taken. A low frequency up sloping hearing loss of the neural type noted on the hearing test is typical of Meniere's.

Additional testing is performed:
  1. Electronystagmography, or balance test (ENG)
  2. Electrocochleography (ECOG)
  3. Brainstem evoked response audiometry (BSER)
  4. Magnetic Resonance Imaging (MRI) with a contrast dye called Gadolinium can rule out an acoustic neuroma or other brain tumor as a possible source of symptoms
  5. Lab tests should include examination for inner ear immune related infections or conditions.

Once testing is completed, the ear surgeon can evaluate the results, rule out extraneous conditions and confirm the diagnosis of Meniere's Disease. Even after this extensive testing, the test results may not be conclusive. When the diagnosis of Meniere's Disease is eventually confirmed, treatment is directed at ending or markedly reducing the frequency and severity of attacks.

Treatment includes modification of personal habits, diet, stress reduction and regular exercise -- all extremely important in the overall treatment of Meniere's Disease. Medications will be recommended; evaluation of all treatments must be carefully annotated. Over time, salt restriction results in decreased fluid accumulation in the inner ear, reducing excess pressure on the nerve endings of balance and hearing. A daily diuretic, typically Hydrochlorthiazide (combined with Triamterene to retain potassium) help the body to further reduce fluid retention. Use of medications such as Antivert (Meclizine) is usually of no benefit in true Meniere's Disease, even if it helps in other balance disorders. However, Valium (Diazepam) and other Benzodiazepines have a direct effect on the nerve controlling balance and its central connections to the brain. When Valium is given at the onset of a vertigo attack, it can prevent the attack from continuing. (N.B. Valium and similar medications should not be taken daily, because they may be habit forming.) Combining Cortisone-type medications with diuretics should be tried once again. Dyazide, combined with oral Decadron or Prednisone (cortisone) given over a period of 2 to 3 weeks will be helpful in gauging some form of medical response. If combined cortisone and diuretics plus diet are not effective in improving clinical symptoms, then surgery is advised.

When you take a history: (Ask all listed questions)
  1. When did this dizziness begin?
  2. What was it like?
  3. How long did the spinning last?
  4. Had she had previous episodes?
  5. Does she have any other ear symptoms such as tinnitus, ear fullness or hearing loss?
  6. Does she have any other neurologic symptoms?
  7. Does she have a headache?
  8. Did she awaken with dizziness or did she become dizzy after she awakened?
  9. Does she have any idea what seemed to have triggered it?

Dizziness, vertigo, and motion sickness all relate to the sense of balance and equilibrium. Researchers in space and aeronautical medicine call this sense spatial orientation, because it tells the brain where the body is "in space:" what direction it is pointing, what direction it is moving, and if it is turning or standing still. Your sense of balance is maintained by a complex interaction of the following parts of the nervous system:

  • The inner ears (also called the labyrinth), which monitor the directions of motion, such as turning, or forward-backward, side-to-side, and up-and-down motions.
  • The eyes, which monitor where the body is in space (i.e. upside down, right side up, etc.) and also directions of motion.
  • The skin pressure receptors such as in the joints and spine, which tell what part of the body is down and touching the ground.
  • The muscle and joint sensory receptors, which tell what parts of the body are moving.
  • The central nervous system (the brain and spinal cord), which processes all the bits of information from the four other systems to make some coordinated sense out of it all.

The symptoms of motion sickness and dizziness appear when the central nervous system receives conflicting messages from the other four systems.

Circulation:
If your brain does not get enough blood flow, you feel light headed. Almost everyone has experienced this on occasion when standing up quickly from a lying down position. But some people have light headedness from poor circulation on a frequent or chronic basis. This could be caused by arteriosclerosis or hardening of the arteries, and it is commonly seen in patients who have high blood pressure, diabetes, or high levels of blood fats (cholesterol). It is sometimes seen in patients with inadequate cardiac (heart) function or with anemia.

Certain drugs also decrease the blood flow to the brain, especially stimulants such as nicotine and caffeine. Excess salt in the diet also leads to poor circulation. Sometimes circulation is impaired by spasms in the arteries caused by emotional stress, anxiety, and tension. If the inner ear fails to receive enough blood flow, the more specific type of dizziness occurs, that is-vertigo. The inner ear is very sensitive to minor alterations of blood flow and all of the causes mentioned for poor circulation to the brain also apply specifically to the inner ear.

Injury: A skull fracture that damages the inner ear produces a profound and incapacitating vertigo with nausea and hearing loss. The dizziness will last for several weeks, then slowly improve as the normal (other) side takes over.

Infection: Viruses, such as those causing the common "cold" or "flu," can attack the inner ear and its nerve connections to the brain. This can result in severe vertigo, but hearing is usually spared. However, a bacterial infection such as mastoiditis that extends into the inner ear will completely destroy both the hearing equilibrium function of that ear. The severity of dizziness and recovery time will be similar to that of a skull fracture.

Allergy: Some people experience dizziness and/or vertigo attacks when they are exposed to foods or airborne particles (such as dust, molds, pollens, danders, etc).

Neurological diseases: A number of diseases of the nerves can affect balance, such as multiple sclerosis, syphilis, tumors, etc. These are uncommon causes, but your physician will think about them during the examination.

Otoplasty (Ear Pinning):

Deformity of the ears is among the commonest visible birth defects in children. This problem varies in complexity and often remains unrepaired into adulthood, especially with the current reluctance of "managed-care" plans to underwrite the cost of appropriate surgery. Often typified by failure of the outer rim of the ear to fold back toward the scalp during fetal development, this defect results in outward protrusion of the ears, and thus undue prominence. This ear deformity often results in taunts by other children, and is thus thought to best be repaired before a child enters school. The surgical procedure to repair protruding ears is best done under general anesthesia in young children, but can be easily be carried out under local anesthesia, with or without sedation, in teen and adult patients. Surgical repair involves exposing and reshaping the deformed ear cartilages, creating the missing ear folds, and positioning the ears in proper location adjacent to the mastoid bones of the skull. A special contour-conforming ear-dressing is used for about 5-7 days post-op to prevent disruption of the repair, and a protective head-band is recommended for six weeks to protect the repair and allow it to stabilize.