The diagnosis of chronic otitis media (long standing infection of the middle ear) has been determined as the cause of your ear problem. The reason that you have come to your doctor may be drainage from the ear, hearing impairment, tinnitus (head noise), dizziness, pain, or weakness of the face. What symptoms that you may have depend on the extent of disease present at its location.

1. Conductive hearing impairment is caused by either external ear or middle ear disease.
2. Nerve or sensorineural hearing impairment is due to inner ear disease or hearing nerve problems.
3. Mixed hearing loss is a combination of conductive and nerve hearing loss.

Hearing is measured in decibels (dB). The hearing level of 0 to 25 dB is considered normal hearing for conversational purposes.

Your hearing level is:

Right Ear { }decibels

Left Ear { }decibels

To facilitate an understanding of the normal function of the ear, we will divide it into three parts: an external ear, a middle ear and an inner ear. Each part performs an important function in the process of hearing.

The external ear is made up of an auricle (that part external to the head) and the ear canal. These structures gather the sound and direct it towards he ear drum membrane.

The middle ear chamber lies between the external ear and the inner ear. This chamber is connected to the back of the throat by the eustachian tube which serves as a pressure equalizing valve. The middle ear consists of the tympanic membrane (ear drum) and three small ear bones; malleus (hammer), incus (anvil) and stapes (stirrup). These structures transmit sound vibrations in the inner ear. The air space surrounding these little bones is known as the middle ear space. This is normally filled with air which passes through the eustachian tube from the back of the throat to the middle ear. Immediately behind and continuous with the middle ear space is a bony honeycomb of air pockets called the mastoid.

The inner ear has two chambers, the cochlea (hearing chamber) and the labyrinth (balance chamber). These are encased in bone and they have interconnecting fluids (endolymph and perilymph). The fluid bathes the delicate nerve endings of hearing and of balance. Fluid waves in the hearing chamber stimulate the hearing nerve endings which generate an electrical impulse. These impulses are transmitted to the brain for interpretation as sound. Movement of fluid in any of the balance chambers will result in electrical impulses which are interpreted in the brain as motion or movement.

Sound waves travel through the air and pass through the external ear. They strike the tympanic membrane causing it to vibrate. These vibrations are then transmitted through the chain of little ear bones to the fluid of the inner ear in a transformer method. A fluid wave is created and passes through the cochlear and stimulates the delicate endings of the hearing nerve. These nerve endings then enervate a nerve impulse which travels along the hearing nerve to the brain and there it is interpreted as sound.

Head movements forward and back or side to side cause movement of the fluid in the labyrinth. This fluid movement results in stimulation of the delicate nerve endings of the balance chambers causing electrical impulses which are carried to the brainstem producing the sensation of motion.

Problems affecting the external ear may be due to an infection, presence of too much ear wax, or an abnormal growth in the ear canal. The middle ear problem may be due to a hole in the eardrum, destruction of one or all of the three ear bones, a skin cyst (cholesteatoma) or scar tissue. These problems can usually be corrected with surgery.

A nerve hearing loss may be caused by disturbances of the inner ear, or from a breakdown in the hearing nerve transmission.

If a hole in the ear drum is present, you should not allow water to get in your ear canal. This may be avoided y placing cotton with Vaseline covering in the ear when showering or washing your hair. Swimming may be possible in certain cases if you use a small earplug and a swim cap pulled over the ears and precautions are used. Talk to your doctor.

You should not blow your nose as any infection your nose may spread to your ear through the eustachian tube. Any nasal secretions should be drawn backward through the nose into the back of the throat and then expectorated. If it is absolutely necessary to blow your nose, compress one nostril while blowing the other.

In the event of ear drainage, the ear canal should be kept clean by means of a small cotton tipped applicator. Medication, as prescribed, should be used if discharge is present or when it occurs. Cotton is placed in the outer ear to catch any discharge but should not be allowed to block the ear canal.

Your disease is caused by a perforation (hole) in the eardrum or a cholesteatoma (skin cyst). If a perforation is present, chronic drainage and infection may occur. This along will put the ossicles (bone of hearing), mastoid bone, inner ear, or facial nerve at a great risk. Surgery to close the hole is strongly recommended. Occasionally, it will be necessary; to stage the operation in order to clear the infection and then rebuild the hearing mechanism.

A cholesteatoma (skin cyst) is an abnormality of the eardrum. The cyst continues to grow slowly causing destruction of the ossicles (one of hearing), mastoid bone, inner ear canals, or facial nerve. Because of this cholesteatoma, chronic infection may occur. Usually it is necessary to stage the operation. The first stage is done to remove the cholesteatoma and any infection, and then to reconstruct the eardrum. Your hearing may occasionally be somewhat worse after the first operation. The second stage is to check for recurrent or residual cholesteatoma or infection (found in 5-15% of the operations) and then to attempt to rebuild the hearing mechanism. If your operation has been staged, it is imperative to have the second operation in 6-12 months following the first operation.

Medical treatment will often control ear drainage. The ear is usually cleaned by your physician in the office. Ear drops or cream may be used to correct the infection. Antibiotics by mouth may be helpful in certain cases.

Your surgeon believes that you are a satisfactory surgical candidate at this time for:

If you do not have surgery, it is important to have frequent hearing exams, especially if your ear is draining. If you have pain in or around the ear, increased drainage or dizziness, twitching or numbness in your face, call us immediately.

1. If this is your first operation, eardrum grafting is successful in over ninety percent (90%) of the patients resulting in a healed and dry ear.
2. Hearing improvement following surgery depends on many factors discussed in the text. It is uncommon to have total restoration of hearing, you have approximately Out of ten chances that surgery will be effective improving your hearing,
3. In your case, two operations will be necessary in all likelihood in order to improve the hearing. On this case, your hearing may be worse in the operated ear between operations. It is imperative that the second stage operation be performed to rule out the possibility of recurrent or residual disease in the ear in addition to an attempt at hearing improvement.

For many years, surgical treatment was used for chronic otitis media primarily to control infection and prevent serious complications. Advancements of surgical techniques have now made it possible to rebuild the diseased hearing mechanism in most cases.

Various tissue rafts may be used to replace the eardrum. These include the covering of the muscle from above the ear (fascia) and covering of ear cartilage (perichondrium), or covering from the skull (pericranium). A diseased ear bone may be replaced by a plastic part, cartilage, transplant or it may actually be reshaped or repositioned.

A thin piece of plastic frequently is used behind the eardrum to prevent scar tissue from forming and to promote normal function of the middle ear and motion of the eardrum. When the ear is filled with scar tissue or when or when all ear bones have been destroyed, it may be necessary to perform the operation in two stages. At the first stage, a piece of stiff plastic is inserted to allow more normal hearing without scar tissue. At the second operation, this plastic may be removed, recurrent or residual disease is looked for, and an attempt for restoring hearing is performed. A decision in regards to staging the operation is made at the time of the first surgery.

MYRINGOPLASTY

This operation is performed to repair a hole in the eardrum when there is no middle ear infection or disease of the ear bones. This procedure closes the middle ear in a natural way and may improve hearing. Surgery is performed under local or general anesthesia. Tissue grafts are used to repair the defect in the ear drum. The patient may be hospitalized for one night and may return to work within a week. Healing is complete, in most cases, in eight weeks at which time any hearing improvement is usually noticed.

TYMPANOPLASTY

Tympanoplasty is the operation performed to eliminate any infection and repair both the sound transmitting mechanism and any hole in the eardrum. This may improve hearing.

Most tympanoplasties are performed through an incision behind the ear, under a local or general anesthetic. The perforation is repaired with fascia or perichondrium. Sound transmission is accomplished by repositioning or replacing diseased ear bones. Occasionally, a piece of cartilage is used to stiffen the eardrum and attempt to stop recurrent retraction pockets or cholesteatoma.

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 six to twelve months later the sound transmitting mechanism is reconstructed. (See planned second stage on a following page)

The patient may be hospitalized for one night following surgery, and may return to work in a week to ten days. Healing is usually complete in eight weeks. 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 a hole in the eardrum into the middle ear and mastoid bone. When this occurs, a skin-lined cyst known as a cholesteatoma is formed. This cyst may continue to grow over a period of years and destroy the surrounding bone. If a cholesteatoma is present, the drainage tends to be more constant and frequent and has a foul odor. In many cases, the persistent drainage is due only to chronic infection in the bone 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 is 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 localized growth and pressure, involve more important surrounding structures in Figure 1. If this occurs, the patient will notice a fullness or a low grade aching discomfort in the ear region. Dizziness or weakness of the face may develop. Some patients will develop meningitis or a brain abscess because of this condition. If any of these symptoms develop, it is critical that you seek immediate medical care. Surgery may be necessary to eliminate the infection and prevent these serious complications.

When destruction by cholesteatoma or infection is widespread in the mastoid, the surgical treatment of this may be difficult. Surgery is performed through an incision behind the ear. The primary objective is to eliminate infection, and to obtain a dry, safe ear.

In most patients, it is not possible to eliminate infection and restore hearing in one operation. The infection is eliminated, the mastoid bone removed, and the ear drum rebuilt in the first operation. This requires a general anesthetic. The patient may be hospitalized for one night or so following surgery. The patient may usually return to work in one to two weeks.

When a second operation is necessary it will be performed six to twelve months later. At that time, your surgeon will check for recurrent disease, residual disease, and attempt to restore the hearing mechanism.

On rare occasions, it is necessary to do a radical mastoid operation (see below) to control infection in a case thought at first to be suitable for a tympanoplasty.

TYMPANOPLASTY: PLANNED SECOND STAGE

The purpose of this operation is to reinspect the ear spaces for disease and to attempt to improve the hearing. Surgery may be performed through the ear canal or from behind the ear, under a local or general anesthetic. The ear is inspected for any remaining or recurrent disease. Sound transmission to the inner ear is accomplished by replacing missing ear bones.

The patient may be hospitalized for one night and may return to work in about one week. Healing is usually complete in six to eight weeks. Hearing improvement is frequently noted at that time.

TYMPANOPLASTY WITH
REVISION MASTOIDECTOMY

The purpose of this operation is to eliminate discharge from a previously created mastoid cavity defect and if possible to improve the hearing. The operation is performed under general anesthesia through an incision behind the ear. At times, the ear canal is rebuilt with cartilage or bone. The eardrum is repaired and, if possible, the hearing mechanism is restored. In most cases, a second operation is necessary to obtain hearing improvement.

The patient may be hospitalized for one or two nights and may return to work after one or two weeks. The hearing of the inside of the ear may take three or four months.

MODIFIED RADICAL MASTOIDECTOMY

The purpose of this operation is to eliminate the infection without consideration of hearing improvement. It is usually performed on those patients who have very resistant infection or have infections in an only hearing ear. Occasionally, it may be necessary to perform a radical mastoid operation in some cases that originally appeared suitable for a tympanoplasty. The decision is made at the time of surgery. A fat, muscle or bone graft to the ear is necessary, at times, to help the ear heal properly.

It is usually necessary to enlarge the ear opening in these situations. The canal is enlarged and part of the ear cartilage is removed. This is performed so that proper ear cleaning will be possible. This is called a meatoplasty.

The radical mastoid operation is performed under general anesthesia and may require one night of hospitalization. The patient may usually return to work in one to two weeks. Complete healing may require up to four months.

MASTOID OBLITERATION OPERATION

The purpose of this operation is to eliminate any mastoid infection and to obliterate or fill any previously created mastoid cavity. Hearing improvement is usually not considered.

The operation is performed under general anesthesia through an incision behind the ear. The mastoid space is filled with fat, muscle or bone. The patient may be hospitalized for one night and may return to work in one to two weeks. Complete healing may require three or four months.

There are some symptoms that may follow any ear operation.

1. Taste disturbance and mouth dryness. Taste disturbance and mouth dryness are not uncommon for a few weeks following surgery. In some patients, the disturbance is prolonged and permanent. This would be due to involvement of a nerve that goes through the middle ear with the disease process. It supplies taste sensation to only one part of the tongue.
2. Tinnitus. Tinnitus (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, or it may persist. Should the hearing not improve or worsen, the tinnitus may persist or be worse.
3. Ear Numbness. Temporary loss of skin sensation in and about the ear is common following surgery. This numbness may involve the entire outer ear and may persist for six months or permanently.
4. Jaw Symptoms. The jaw joint is the front of the ear canal. Some soreness or stiffness in the jaw movement is very common after ear surgery. It usually goes away within one to two months.
5. Drainage behind the Ear. At times, the surgeon may need to insert a drain tube behind the ear. The need for this is usually not apparent before surgery. Should a drain tube be necessary, it will be removed in the post-operative course.
6. Ear Pressure Ear "popping" sensation or a mild equilibrium disturbance may occur from packing in the middle ear.

Fortunately, complications are uncommon following surgery for correction of chronic ear infection but rarely some occur and are described below.

1. Loss of Hearing In three percent (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 circumstances. On very rare occasions, there is total loss of hearing in the operated ear. 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.
2. Dizziness 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. Some patients with chronic ear infection due to cholesteatoma have a labyrinthe fistula (abnormal opening into the balance canal). When this problem is encountered, dizziness may last for six months or more.
3. Facial Paralysis The facial nerve travels through the ear bone and is in close association with the middle ear bones, eardrum, and mastoid. A rare post-operative complication of ear surgery is paralysis of one side of the face. This may occur as a result of an abnormality or a swelling of the nerve and usually improves spontaneously. On rare occasions, the nerve may be injured at the time of surgery or it may be necessary to remove it in order to eliminate the disease.
   
   When this happens, a skin sensation nerve is removed from the upper part of the neck to replace the nerve. Paralysis of the face under these circumstances might last six months to a year and there would be a permanent residual weakness. Eye complications, requiring treatment by a specialist could develop.
4. Hematoma A hematoma (a collection of blood under the skin) develops in a small percentage of cases, prolonging hospitalization and healing. Re-operation to remove the clot may be necessary if this complication occurs.
5. Complication related to Mastoidectomy A cerebral spinal fluid leak (leak of fluid surrounding the brain) is a very rare complication. Re-operation may be necessary to stop the leak.
6. Brain Complications Intracranial complications such as meningitis or rain abscess, even paralysis were common in cases of chronic otitis media prior to the antibiotic era. Fortunately these are now extremely rare complications.
7. Anesthetic Complications These are very rare but can be serious. You may discuss these with your anesthesiologist.

Great advancements have been made in the prevention, diagnosis and treatment of hearing, balance and facial nerve disorders. This has been done through the years by dedicated doctors, largely financed by their private practices. Much research still remains to be done so that more patients may benefit. Special recognition is given to two great centers who have trained hundreds of doctors world wide been active in critical research advancements and have organized sections of this booklet for patients’ benefits.