Ear Disease (chronic)

Surgeries for Chronic Ear Disease

It is sometimes difficult to define exactly what a chronic ear disease is. A group of physicians once tried to establish a common definition and were unsuccessful. Recently, the Agency for Health Care Policy review suggested that the best way to define it would be disorders where there is a hearing problem for more than four months. Many different disease processes make up this group of disorders called chronic ear disease. This may include chronic otitis externa or chronic otitis media, tympanic membrane perforation, retraction pockets, cholesteatoma, chronic mastoiditis or recurring otorrhea. There are many operations which are suggested for chronic ear disease.

Pressure-equalization tubes (P.E. tube or tube)

The most commonly performed operation in America is the placement of a P.E. tube. The modern P.E. tube was invented by Dr. Armstrong in 1951. More than one million tubes are inserted in America alone. P.E. tubes may be indicated if a person has a significant hearing loss, chronic otitis media, middle ear effusions, atelectasis or retraction pockets. The idea of a P.E. tube is to allow air to enter the middle ear through a different route than the eustachian tube. Such a pathway will reduce the need for air to enter the middle ear through the eustachian tube and therefore allow fluids to drain more easily.

There are many different kinds of P.E. tubes. Each surgeon has a preference about the type of P.E. tube used. The type used may also depend on the patient?s diagnosis. All P.E. tubes have a life span. From the date that they are inserted they will usually fall out of the eardrum into the ear canal within six months to 1/2 years, but some are meant to stay in the eardrum forever.
ENT PE Tube in Eardrum

This operation is extremely quick. Once the procedure begins, the entire operation may last less than 10 minutes. Adults usually have the procedure performed under local anesthesia, often in the clinic on the same day. Children are usually are sedated and given a brief general anesthetic in order place the P.E. tubes. An incision is made in the lower forward quadrant of the eardrum. If fluid is present in the ear, the fluid will be suctioned out. A small plastic or metal tube is guided into position. Small flanges on the tube hold it in place. Most patients cannot feel the tube when it is in the appropriate position. It relieves pressure in the middle ear and therefore often provides almost immediate comfort. When the tube finally is extruded it will not create a permanent hearing problem. It will create a scar in the tympanic membrane. No study has shown that hearing is impaired by this type of scar.

Some physicians feel that while the tube is in place, patients should try to keep the ear canal dry. Many studies have shown that routine use of water such as bathing and swimming in chlorinated water does not increase the chance of infection or drainage. The largest single potential complication from a P.E. tube is the risk of infection. Some studies have shown rates of infection as high as 20 percent. Most infections can be treated with topical ear drops. Patients who have a P.E. tube can fly and carry on most other activities without danger.

Exploratory tympanotomy
If a physician identifies an abnormality in the middle ear, the surgeon may elect to explore the middle ear. The exploration may be done to better define a problem, correct a problem or to plan for later procedures. Most patients have this procedure either with local or general anesthesia in an operating room. The ear canal is washed with an antimicrobial soap and medicine is injected into the ear canal to help numb the skin as well as to reduce bleeding. An incision is made in the skin of the ear canal wall. The skin and tympanic membrane is lifted from the bone and the middle ear is entered. Most procedures are brief in duration and recovery is quick. The surgeon may elect to place absorbable material in the middle ear and may pack material in the ear canal to secure the skin in a normal position. Antibiotic ointments may be applied to minimize recurrence of drainage or to lower the chance of postoperative infection. As with all ear procedures, it is possible to have a complication. Complications include alteration in taste, a worsening in hearing or dizziness. Some patients can also have other complications including facial weakness. These are very uncommon.

A tympanoplasty is an operation which is performed on the tympanic membrane and the middle ear. It is done to repair a hole in the tympanic membrane. The operation is usually done under general anesthesia but it is possible to perform it under local anesthesia with sedation. It is typically performed in the operating room. The ear canal is washed with an antimicrobial soap. The ear canal is washed with an antimicrobial soap and medicine is injected into the ear canal to help numb the skin as well as to reduce bleeding. While some operations are performed through the ear canal, many involve an incision directly behind the ear. The incision is made in the skin crease behind the ear. The ear canal skin is lifted up and the eardrum remnant is lifted from its normal position. An exploratory tympanotomy is often done once the eardrum is lifted up. Work can be done on the hearing bones connecting the ear drum to the inner ear. It is common to obtain a graft from the muscle directly behind and above the ear. This graft is used to repair the eardrum. Other graft materials include cartilage from the ear. The middle ear space is usually packed with absorbable material. Following the operation the ear canal is often filled with antibiotic ointment or absorbable packing. The skin incision is closed. After the operation, a plastic ear cup dressing is usually placed over the ear.

The operation has a relatively low risk. The major risk is failure of the eardrum graft. Other complications such as infection, bleeding or anesthetic risks are uncommon. Hearing loss can occur from the operation. Dizziness and vertigo can happen immediately following the procedure but are not generally debilitating. A few patients will experience taste change. Most patients do not experience facial weakness but it is possible.

Tympanoplasty and canal wall up mastoidectomy
When middle ear disease extends into the mastoid, it is necessary to remove the disease from both locations. This often means that the mastoid bone will need to be explored and removed in order to identify and remove the disease. This operation is called a mastoidectomy. The operation is completed in the same way that a tympanoplasty is performed. The mastoid bone immediately behind the ear canal is removed. This bone is removed in such a way to expose the structures of the inner ear and surrounding structures without damaging them. The eardrum is repaired or recreated. This operation increases the time of the surgery but does not change the risks from a tympanoplasty alone substantially.

Tympanoplasty and canal wall down mastoidectomy
If the middle ear and mastoid disease are extensive, it may be necessary to remove the posterior ear canal wall. This means that the opening to the ear will include the space of the old ear canal and mastoid. The opening to the ear will be substantially larger. This may change the appearance of the ear. It usually results in the outer ear settling into the side of the head. The part of the operation to widen the ear opening is referred to as a meatoplasty. This type of procedure is more likely to result in some element of hearing loss. It is usually performed when patients have an existing hearing problem. The goal of the operation is to obtain a dry and clean ear. This is used to eliminate long-standing disease or in those cases where other operations have failed. The risks of this operation are similar to that of a tympanoplasty and canal wall up mastoidectomy. There are some small risks associated with abnormal healing of the meatoplasty.

Radical mastoidectomy
This operation is performed as a last effort to obtain a dry clean ear. It will result in a maximum conductive (60 dB) hearing loss. It is almost always used for very extensive disease or for cases where other operations have failed. From the outside, the operation looks the same as a tympanoplasty and canal wall down mastoidectomy but no ear drum is created. The eustachian tube is blocked and the middle ear space is filled with a muscle graft. In cases where revision surgery is performed the risks of the operation are greater, but still small.


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