Ear infections are one of our most common ailments. 3 out of every 4 of children in America will have at least one ear infection before growing up.

Infections in adults are much less common. When they occur, they are often in people who've had many infections in childhood or who have other causes for ear congestion such as cigarettes, allergies or the common cold.

In fact, congestion of the ear is the cause of most infections. The ear ordinarily receives ventilation by the Eustachian tube which is a natural connection between the ear and the nose and throat.

Anatomy and Physiology

There are two parts of hearing: mechanical and nerve or electrical. The mechanical part picks up sound from the outer ear canal and then vibrates the ear drum and three tiny hearing bones in the middle ear.

The Eustachian tube is the natural connection between the ear and the nose and throat. It helps ventilate the middle ear as well as the mastoid which is an air-filled honeycomb behind the ear.

The inner ear looks a bit like a snail. It has two halves which are connected and are filled with fluid.

The coil or cochlea takes care of the nerve-part of hearing. Like a telephone, it takes the vibration and turns it into an electric signal that is relayed to the brain.

The other half of the inner ear is the balance or vestibular system. There are three balance canals, each set in a different direction.

In close association to the ear is the facial nerve. It helps move the face and also provides for some of the taste fibers to the tip of the tongue.

At the deepest level is the brain from where the hearing, balance and facial nerves originate.

CSOM

Most ear infections are simply treated with a course of antibiotics and decongestants. Recurring infections, however, may require a tiny tube placed into the ear drum to help it ventilate for weeks or months until the underlying congestion and infection can resolve. In some, infections will persist until smoking is discontinued or allergy treatments are undertaken.

Infections can sometimes lead to more serious ear problems such as permanent perforation of the ear drum, mastoiditis and cholesteatoma.

A cholesteastoma is an infected cyst made of dead, flaking skin and cholesterol. Although it is not a true tumor, with each infection it can create enzymes which can eat away at bone.

Common symptoms include hearing loss, ringing of the ear and foul drainage from the middle ear. If these warning signs are ignored, the surrounding bone can become progressively eaten away. This can result in erosion of the small hearing bones, loss of taste, deafness and dizziness. Rarely, the infection burrows in deep enough to paralyze the face or cause a life-threatening brain infection.

Chronic Ear Surgery

Surgery needs to be considered under four circumstances: ~ If infections recur despite medical therapy ~ If an ear drum perforation persists

~ If the hearing bones have been eroded ~ If a cholesteatoma is found

Similarly, there are three goals of ear surgery: ~ Clear out the infection and remove the cholesteatoma ~ Repair the perforated ear drum

~ Rebuild the hearing bones

The specifics of any particular ear operation may vary quite a bit because the surgeon can never be certain of the extent of disease until the ear is opened and examined under the microscope at the time of surgery. Not infrequently, a more minor second surgery may be required 9 to 12 months later in order to complete the reconstruction and check to see if there is any recurrent cholesteatoma.

Types of surgery

Tympanoplasty

Some patients only require repair of a perforated ear drum. Small holes towards the back of the ear drum have the highest chance for a successful graft. Chances for success are less with large perforations or with a poorly functioning Eustachian tube. Unfortunately, there is no known way to surgically rebuild or repair an abnormal Eustachian tube but its function can be improved if patients avoid smoke and treat any underlying allergies.

Most often, this surgery is done as an outpatient. An incision is made behind or in front of the ear for access and to harvest tissue to act as a new grafted ear drum.

Tympanomastoidectomy

For many decades, the only way to treat a badly infected ear was to open it widely and let it drain. Such procedures called radical mastoidectomies were often helpful in relieving the acute infection but in order to accomplish this, the ear drum and middle ear bones were sacrificed resulting in poor hearing and a large ear cavity that required frequent cleaning by a doctor. Even today, this operation is still occasionally needed for severely infected ears.

Over the last thirty years, a variety of other surgical options have been designed to help eliminate infection while minimizing hearing loss and cavity problems. Called tympanomastoidectomy, these procedures strive to spare or rebuild the ear drum and hearing bones. Because the ear drum is rebuilt, however, a second stage surgery is often needed to look beneath the new drum to check for any early signs of recurring cholesteatoma.

A modified radical mastoidectomy is a compromise between these two procedures.

The ear drum and hearing bones may be spared or rebuilt but the ear canal is widened. This technique may still leave a cavity which needs to be cleaned medically but has the advantage of often avoiding a second stage operation.

Ossicular chain reconstruction is the medical term for rebuilding the small hearing bones that have been affected by disease. Although it can occasionally be accomplished at the same time as a tympanomastoidectomy, the it is hard to predict the final position of the new ear drum. This makes determining the ideal size of any artificial bone (prosthesis) difficult. If it is a fraction of an inch too short, it will fall out of position. If it is too long, it will not be able to vibrate or will increase the chance of it being forced through the new ear drum.

Some of the newer materials today are suprisingly good at fooling the body into thinking that the implant is in fact the patients own natural tissue. As with any artificial implant, however, it is always possible that the prosthesis may become rejected. This may not occur until years after the surgery and would require replacement.

Deciding on a therapy

You and your doctor will need to decide on which therapy is best for you. This is always a matter of weighing the pro's and con's of each option whether it is medical or surgical.

Surgical risks vary according to the procedure and by a person's age and health. Most ear operations require a general anesthetic and an incision behind the ear after shaving a small amount of hair. Any surgery in or around the ear can put at risk many of the structures that reside in this area.

Therefore, risks typically include hearing loss, tinnitus, dizziness, infection and reperforation of the ear drum. Because of the close relationship of the facial nerve, face weakness or taste distubances are possible. As a rule, the more infected the ear, the greater the risks. At the Institute, however, our doctors do nothing except ear surgery. This experience and the use of lasers and facial nerve computers help to keep our complication rate extremely low.

Postop Expectations

After ear surgery, it is important to keep your ear canal dry for 4 weeks. Use a cotton ball for a day or two but change it frequently. After the first couple days try to leave the cotton out so that the ear can ventilate. For showers, waterproof the cotton ball by rubbing some vaseline jelly on it.

The incision behind the ear is often closed with absorbable stitches. Keep it dry for a week by covering it with a washcloth during showers. Pat it dry or use a hair dryer if it gets wet.

Avoid hard nose blowing which could cause shifting of the graft material.

Stuffiness and hearing loss can be expected for some time with any ear operation. This often improve slowly as your body absorbs the healing fluids.

In the meantime you can expect to hear inner ear noises and your own heartbeat.

You may have some dizziness after surgery. Ask your doctor how soon you may return to work or driving.

Conclusion

Fortunately, most types of ear infections can be treated. In many cases, a clean safer ear can be expected. Hearing can also be improved in many patients depending upon the severity of disease and the function of the Eustachian tube.