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.
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.
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.
(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.