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Chronic Ear Infections Chronic ear infection is the result of an ear infection that has left a residual injury to the ear. This type of infection has been established as the cause of your ear problem. Chronic ear infection (the technical diagnosis is chronic otitis media) symptoms depend upon whether or not there is involvement of the mastoid bone and whether there is a hole in the eardrum. In addition, the hearing level depends on whether or not there has been injury to the middle ear bones as well as the eardrum. There may be drainage, hearing impairment, tinnitus (head noise), dizziness, pain, or rarely, weakness of the face. Most often there is simply hearing loss, an uncomfortable feeling and occasionally some discharge. FUNCTION OF THE NORMAL EAR The ear is divided into three parts: the external ear, the middle ear, and the inner ear. Each part performs an important function in the process of hearing. Sound waves pass through the canal of the external ear and vibrate the eardrum, which separate the external ear from the middle ear. The three small; bones in the middle ear (hammer or malleus, anvil or incus, and stirrup or stapes) act as a transformer to transmit energy of the sound vibrations to the fluids of the inner ear. Vibrations in this fluid stimulate the delicate nerve fibers. The hearing nerve then transmits impulses to the brain where they are interpreted as understandable sound. TYPES OF HEARING IMPAIRMENT The external ear and the middle ear conduct sound; the inner ear receives it. If there is some difficulty in the external or middle ear, a conductive hearing loss occurs. If the trouble lies in the inner ear, a sensorineural or hair cell loss is the result. When there is difficulty in both the middle and inner ear, a combination of conductive and sensorineural impairment exists. THE DISEASED MIDDLE EAR Any disease affecting the eardrum or the three small ear bones may cause a conductive hearing loss by interfering with the transmission of sound to the inner ear. Such a hearing impairment may be due to a perforation (hole) in the eardrum, partial or total destruction of one or all of the three little ear bones, or scar tissue. When an acute infection develops in the middle ear (an abscessed ear), the eardrum may rupture, resulting in a perforation. This perforation usually heals. If it fails to do so a hearing loss occurs, often associated with head noise (tinnitus) and intermittent or constant ear drainage. Occasionally after an infection in the healing process, skin from the ear canal may be stimulated to grow through a perforated eardrum, into the middle ear and into the mastoid. When this occurs, a skin-lined cyst known as a cholesteatoma is formed. This cyst will continue to expand over a period of time and progressively destroy the surrounding bone. It usually destroys the middle ear bones first, followed by the mastoid. Cholesteatoma presents a grave danger to the inner and event to the brain as meningitis may result. If a cholesteatoma is present, drainage tends to be more constant and frequently has a foul odor. TREATMENT OF CHRONIC OTITIS MEDIA Home Care of the Ear If a perforation is present, you should not allow water to get into the ear canal. This may be avoided when showering or washing by placing cotton in the external ear canal and covering it with a layer of Vaseline. If you desire to swim, a custom made mold is helpful in keeping water out of the ear canal. Avoid blowing your nose repeatedly in order to keep infection in the nose from spreading to the ear through the eustachain tube. If it is necessary to blow your nose, do not occlude or compress one nostril while blowing the other. In the event of ear drainage, keep the ear clean by using a small cotton tipped applicator at the very outer portion of the canal. Medication should be used if discharge is present or when discharge occurs. Cotton may be placed in the outer ear canal to catch discharge, but should not be allowed to completely block the canal. Medical Treatment Medical treatment, including oral medications and ear drops, will frequently stop the ear drainage. In addition, careful cleaning of the canal and at times the application of antibiotic powder may be necessary. Different antibiotics by mouth may be necessary in some cases. If the ear is safe, that is, if there is not continuing destruction of the ear by scarring, infection, or by cholesteatoma, and there is minimal hearing loss, medical treatment may be all that is necessary for chronic otitis media. Otherwise, surgery will be necessary. SURGICAL TREATMENT For many years surgical treatment was instituted in chronic otitis media primarily to control infection and prevent serious complications, that is, to make the ear safe and dry. In recent years, it has often been possible with advances in surgical techniques to reconstruct the diseased hearing mechanism. Various tissue grafts may be used to repair the eardrum. These include the covering of the muscle (fascia), vein, or the covering of cartilage (perichondrium). A diseased ear bone may be replaced by a synthetic prosthesis and cartilage. Silastic may be used in the middle ear, behind the eardrum to prevent scar tissue from forming, to promote normal function of the ear and motion of the eardrum. When the ear is filled with scar tissue or cholesteatoma or when all the ear bones have been destroyed, it is usually necessary to perform the operation in two stages. In the first stage, the cholesteatoma is removed and silastic may be inserted to allow more normal healing without scar tissue. In the second operation, the silastic is removed and hearing may be reconstructed. In addition, at this time total cholesteatoma removal is assured. If it is not, it is removed at this time. Hearing improvement is rarely noted at or immediately following surgery. MYRINGOPLASTY Most ear infections subside and the structures of the middle ear heal completely. In some cases, however, the eardrum may not heal and a permanent perforation (hole) in the eardrum results. Myringoplasty is the operation performed for the purpose of repairing a perforation in the eardrum when there is no middle ear infection or disease of the ear bones. This procedure seals the middle ear and improves the hearing in many cases. Surgery is usually performed under general anesthesia through the ear canal or behind the ear. Fascia from muscle above the ear is used to repair the defeat in the eardrum. The patient is hospitalized for one night. Healing is complete in most cases in six weeks, at which time any hearing improvement is usually noticeable. TYMPANOPLASTY An ear infection may cause a perforation in the eardrum and may also damage the three bones that transmit sound from the eardrum to the inner ear and hearing nerve. Tympanoplasty is the operation performed to repair both the sound transmitting mechanism and any perforation in the eardrum. This procedure seals the middle ear and improves the hearing in many cases. Surgery may be performed through the ear canal or from behind the ear, under a local or a general anesthetic. The perforation is repaired with the fascia from muscle above the ear. Sound transmission to the inner ear is accomplished by repositioning or replacing diseased ear bones. 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, four months or more later, the sound transmitting mechanism is reconstructed. The patient is hospitalized for one night and may return to work in several days to a week. Healing is usually complete in six weeks. A 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 the ear drum perforation into the middle ear. When this occurs a skin-lined cyst known as cholesteatoma is formed. This cyst may continue to expand over a period of years and destroy the surrounding bone. If a cholesteatoma is present, the drainage tends to be more constant and frequently has a foul odor. In many cases, the persistent drainage is only due to chronic infection in the bone and 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 has 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 local expansion and pressure involve important surrounding structures. If this occurs, the patient will often notice a fullness or a low- grade aching discomfort in the ear region. Dizziness or weakness of the face may develop. If any of these symptoms occur it is imperative that one seek immediate medical care. Surgery may be necessary to eradicate the infection and prevent more serious complications. When the destruction by cholesteatoma or infection is widespread in the ear structures (mastoid) the surgical elimination of this may be difficult. Surgery is performed through an incision behind the ear. The primary objective is to eliminate infection; to obtain a dry, safe ear. In some cases the infection cannot be eliminated and the hearing restored in one operation. The infection is eliminated and the ear drum rebuilt in the first operation. This requires a general anesthetic with hospitalization. The patient may usually return to work in one week. A second operation may be performed months later to restore the hearing mechanism and confirm infection control. TYMPANOPLASTY WITH REVISION MASTOIDECTOMY The purpose of this operation is to eliminate drainage from the previously created mastoid cavity and attempt to obtain hearing improvement. The operation is performed under general anesthesia through an incision behind the ear. The mastoidectomy is revised. If possible, the hearing mechanism is restored by using implants or cartilage. The patient is usually hospitalized for two days following surgery and may return to work after one week. Hearing improvement may not be noted for a few months. CANAL WALL DOWN-MASTOID OPERATION The purpose of this operation is to eradicate the infection. It is usually performed on those patients who may have very resistant infections. Occasionally it may be necessary to perform a canal wall down mastoid operation in some cases that originally appeared suitable for tympanoplasty. This decision must be reached at the time of the operation. The CWD mastoid operation is performed under general anesthesia and requires one night hospitalization. The patient may usually return to work in one week. Hearing return to normal is rare although improvement can often be expected. The ear canal is larger than normal. MASTOID OBLITERATION OPERATION The purpose of this operation is to eradicate any mastoid infection and to obliterate (fill-in) a previously created mastoid cavity. Hearing improvement is not considered. The operation is performed under general anesthesia through an incision behind the ear. The mastoid space is filled with bone, a temporalis muscle flap or a combination. The patient is usually hospitalized for one night and may return to work in several days to one week. Complete healing may require up to three months.
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