Diagnosis & Treatment

Ears

Explain Earaches 
Dizziness and Motion Sickness
Ears and Altitude
About Swimmer’s Ear
About Earwax
Cholesteatoma: A Serious Ear Condition 
Ménière’s Disease
Explain Tinnitus
About Ear Tubes
Microsurgery of the Ear    



Explain Earaches
     

What is otitis media?
Otitis media means inflammation of the middle ear. The inflammation occurs as a result of a middle ear infection. It can occur in one or both ears. Otitis media is the most frequent diagnosis recorded for children who visit physicians for illness. It is also the most common cause of hearing loss in children.      

Although otitis media is most common in young children, it also affects adults occasionally. It occurs most commonly in the winter and early spring months.      

Is it serious?
Yes, it is serious because of the severe earache and hearing loss it can create. Hearing loss, especially in children, may impair learning capacity and even delay speech development. However, if it is treated promptly and effectively, hearing can almost always be restored to normal.      

Otitis media is also serious because the infection can spread to nearby structures in the head, especially the mastoid. Thus, it is very important to recognize the symptoms (see list) of otitis media and to get immediate attention from your doctor.      

How does the ear work?
The outer ear collects sounds. The middle ear is a pea sized, air-filled cavity separated from the outer ear by the paper-thin eardrum. Attached to the eardrum are three tiny ear bones. When sound waves strike the eardrum, it vibrates and sets the bones in motion that transmit to the inner ear. The inner ear converts vibrations to electrical signals and sends these signals to the brain. It also helps maintain balance.      

A healthy middle ear contains air at the same atmospheric pressure as outside of the ear, allowing free vibration. Air enters the middle ear through the narrow eustachian tube that connects the back of the nose to the ear. When you yawn and hear a pop, your eustachian tube has just sent a tiny air bubble to your middle ear to equalize the air pressure.     

 — Causes and types of hearing loss
Visit: http://www.youtube.com/watch

What causes otitis media?
Blockage of the eustachian tube during a cold, allergy, or upper respiratory infection and the presence of bacteria or viruses lead to the accumulation of fluid (a build-up of pus and mucus) behind the eardrum. This is the infection called acute otitis media. The build up of pressurized pus in the middle ear causes earache, swelling, and edness. Since the eardrum cannot vibrate properly, hearing problems may occur.      

Sometimes the eardrum ruptures, and pus drains out of the ear. But more commonly, the pus and mucus remain in the middle ear due to the swollen and inflamed eustachian tube. This is called middle ear effusion or serous otitis media. Often after the acute infection has passed, the effusion remains and becomes chronic, lasting for weeks, months, or even years. This condition makes one subject to frequent recurrences of the acute infection and may cause difficulty in hearing.      

What will happen at the doctor’s office?
During an examination, the doctor will use an instrument called an otoscope to assess the ear’s condition. With it, the doctor will perform an examination to check for redness in the ear and/or fluid behind the eardrum. With the gentle use of air pressure, the doctor can also see if the eardrum moves. If the eardrum doesn’t move and/or is red, an ear infection is probably present.      

    Two other tests may also be performed:

  • Audiogram – This tests if hearing loss has occurred by presenting tones at various pitches.
  • Tympanogram – This measures the air pressure in the middle ear to see how well the eustachian tube is working and how well the eardrum can move.


The importance of medication
      
The doctor may prescribe one or more medications. It is important that all the medication(s) be taken as directed and that any follow-up visits be kept. Often, antibiotics to fight the infection will make the earache go away rapidly, but the infection may need more time to clear up. So, be sure that the medication is taken for the full time your doctor has indicated. Other medications that your doctor may prescribe include an antihistamine (for allergies), a decongestant (especially with a cold), or both.      

Sometimes the doctor may recommend a medication to reduce fever and/or pain. Analgesic ear drops can ease the pain of an earache. Call your doctor if you have any questions about you or your child’s medication or if symptoms do not clear.      

What other treatment may be necessary?
Most of the time, otitis media clears up with proper medication and home treatment. In many cases, however, further treatment may be recommended by your physician. An operation, called a myringotomy may be recommended. This involves a small surgical incision (opening) into the eardrum to promote drainage of fluid and to relieve pain. The incision heals within a few days with practically no scarring or injury to the eardrum. In fact, the surgical opening can heal so fast that it often closes before the infection and the fluid are gone. A ventilation tube can be placed in the incision, preventing fluid accumulation and thus improving hearing.      

The surgeon selects a ventilation tube for your child that will remain in place for as long as required for the middle ear infection to improve and for the eustachian tube to return to normal. This may require several weeks or months. During this time, you must keep water out of the ears because it could start an infection. Otherwise, the tube causes no trouble, and you will probably notice a remarkable improvement in hearing and a decrease in the frequency of ear infections.      

Otitis media may recur as a result of chronically infected adenoids and tonsils. If this becomes a problem, your doctor may recommend removal of one or both. This can be done at the same time as ventilation tubes are inserted.      

Allergies may also require treatment.      

So, remember…
Otitis media is generally not serious if it is promptly and properly treated. With the help of your physician, you and/or your child can feel and hear better very soon. Be sure to follow the treatment plan, and see your physician until he/she tells you that the condition is fully cured.      

What are the symptoms?      

In infants and toddlers look for:
  • Pulling or scratching at the ear, especially if accompanied by other symptoms
  • Hearing problems, crying, irritability, fever, vomiting, ear drainage

Remember, without proper treatment, damage from an ear infection can cause chronic or permanent hearing loss.   


 

Explain Dizziness and Motion Sickness  
 Insight into causes and treatment options 

What is the difference between dizziness, vertigo, and motion sickness?
How does the body maintain its equilibrium?
How can I reduce dizzy spells?  

Early more than two million people visit a doctor for dizziness, and an untold number suffer from motion sickness. Although patients complain of similar symptoms, there are different treatments available. An otolaryngologist will explore the causes behind the balance discomfort by examining the ears, nose, and throat to make a diagnosis. Often times, cases of dizziness and motion sickness are mild and self-treatable disorders, but severe cases deserve medical attention. 

What is the difference between dizziness, vertigo, and motion sickness? 
Some people describe a balance problem by saying they feel dizzy, lightheaded, unsteady, or giddy. This feeling of imbalance or disequilibrium is sometimes caused by an inner ear problem. Others describe their balance problem by using the word vertigo, which comes from the Latin verb “to turn”. They often say that they or their surroundings are turning or spinning. Vertigo can also be triggered by problems in the inner ear. 

Motion sickness is a common medical problem associated with travel. Some people experience nausea and even vomiting when riding in an airplane, automobile, boat, or amusement park ride. Motion sickness is usually just a minor annoyance and does not signify any serious medical illness, but some travelers are incapacitated by it. A few even suffer symptoms for a few days after the trip. 

 How does the body maintain its equilibrium? 

 Dizziness, vertigo, and motion sickness all relate to the sense of balance and equilibrium. Researchers in space and aeronautical medicine call this sense spatial orientation, because it tells the brain where the body is “in space:” what direction it is pointing, what direction it is moving, and if it is turning or standing still. Your sense of balance is maintained by a complex interaction of the following parts of the nervous system: 

  • The inner ears (also called the labyrinth), which monitor the directions of motion, such as turning, or forward-backward, side-to-side, and up-and-down motions.
  • The eyes, which monitor where the body is in space (i.e. upside down,rightside up, etc.) and also directions of motion.
  • The skin pressure receptors such as in the joints and spine, which tell what part of the body is down and touching the ground.
  • The muscle and joint sensory receptors, which tell what parts of the body are moving.
  • The central nervous system (the brain and spinal cord), which processes all the bits of information from the four other systems to make some coordinated sense out of it all.

 
The symptoms of motion sickness and dizziness appear when the central nervous system receives conflicting messages from the other four systems. For example, suppose you are riding through a storm, and your airplane is being tossed about by air turbulence. But your eyes do not detect all this motion because all you see is the inside of the airplane. Then your brain receives messages that do not match with each other. You might become “air sick.” Or, to use a true medical condition as an example, suppose you suffer inner ear damage on only one side from a head injury or an infection. The damaged inner ear does not send the same signals as the healthy ear. This gives conflicting signals to the brain about the sensation of rotation, and you could suffer a sense of spinning, vertigo, and nausea. 

 What medical conditions cause dizziness? 

 Circulation— If your brain does not get enough blood flow, you feel light headed. Almost everyone has experienced this on occasion when standing up quickly from a lying down position. But some people have light headedness from poor circulation on a frequent or chronic basis. This could be caused by arteriosclerosis or hardening of the arteries, and it is commonly seen in patients who have high blood pressure, diabetes, or high levels of blood fats (cholesterol). It is sometimes seen in patients with inadequate cardiac (heart) function or with anemia. 

 Certain drugs also decrease the blood flow to the brain, especially stimulants such as nicotine and caffeine. Excess salt in the diet also leads to poor circulation. Sometimes circulation is impaired by spasms in the arteries caused by emotional stress, anxiety, and tension. 

 If the inner ear falls to receive enough blood flow, the more specific type of dizziness that occurs is vertigo. The inner ear is very sensitive to minor alterations of blood flow and all of the causes mentioned for poor circulation to the brain also apply specifically to the inner ear. 

 Injury— A skull fracture that damages the inner ear produces a profound and incapacitating vertigo with nausea and hearing loss. The dizziness will last for several weeks, then slowly improve as the normal (other) side takes over 

Infection: Viruses, such as those causing the common “cold” or “flu,” can attack the inner ear and its nerve connections to the brain. This can result in severe vertigo, but hearing is usually spared. However, a bacterial infection such as mastoiditis that extends into the inner ear will completely destroy both the hearing and the equilibrium function of that ear. The severity of dizziness and recovery time will be similar to that of skull fracture. 

 Allergy— Some people experience dizziness and/or vertigo attacks when they are exposed to foods or airborne particles (such as dust, molds, pollens, danders, etc.) to which they are allergic. 

 Neurological diseases— A number of diseases of the nerves can affect balance, such as multiple sclerosis, syphilis, tumors, etc. These are uncommon causes, but your physician will think about them during the examination. 

 What kind of a medical examination can I expect? 
The doctor will ask you to describe your symptoms, whether it is light headedness or a sensation of motion, how long and how often the dizziness has troubled you, how long a dizzy episode lasts, and whether it is associated with hearing loss or nausea and vomiting. You might be asked to cite specific circumstances that induce a dizzy spell. You will also be questioned about your general health, medicines you are taking, head injuries, recent infections, etc. 

The physician will examine your ears, nose, and throat and do tests of nerve and balance function. Because the inner ear controls both balance and hearing, disorders of balance often affect hearing and vice versa. Therefore, your physician might recommend hearing tests or audiograms. Depending on your diagnosis, the physician might order skull X rays, a CT or MRI scan of your head, or special tests of eye motion after warm or cold water is used to stimulate the inner ear (ENG – electronystagmography). In some cases, blood tests or a heart evaluation might be recommended. 

    Tips to reduce dizzy spells

  • Avoid rapid changes in position, especially from lying down to standing up or turning around from one side to the other.
  • Avoid extremes of head motion (especially looking up) or rapid head motion (especially turning or twisting).
  • Eliminate or decrease use of products that impair circulation, e.g. nicotine, caffeine, and salt.
  • Minimize your exposure to circumstances that precipitate your dizziness, such as stress and anxiety or substances to which you are allergic.
  • Avoid hazardous activities when you are dizzy, such as driving an automobile, operating dangerous equipment, or climbing a step ladder, etc.

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    Tips to alleviate motion sickness

  • Always ride where your eyes will see the same motion that your body and inner ears feel, e.g. sit in the front seat of the car and look at the distant scenery; go up on the deck of the ship and watch the horizon; sit by the window of the airplane and look outside. In an airplane, choose a seat over the wings where the motion is the least.
  • Do not read while traveling if you are subject to motion sickness, and do not sit in a seat facing backward.
  • Do not watch or talk to another traveler who is having motion sickness.
  • Avoid strong odors and spicy or greasy foods immediately before and during your travel. Medical research has not yet investigated the effectiveness of popular folk remedies such as soda crackers and & Seven Up® or cola syrup over ice.
  • Take one of the varieties of motion sickness medicines before your travel begins, as recommended by your physician. Some of these medications can be purchased without a prescription (i.e., Dramamine®, Bonine®, Marezine®, etc.) Stronger medicines such as tranquilizers and nervous system depressants will require a prescription from your physician. Some are used in pill or suppository form.

Dizziness Questionnaire


 

Ears and Altitude —
Insight into air travel comfort and safety

 Have you ever wondered why your ears pop when you fly on an airplane? Or why, when they fail to pop, you get an earache? Have you ever wondered why the babies on an airplane fuss and cry so much during descent?

Ear problems are the most common medical complaint of airplane travelers, and while they are usually simple, minor annoyances, they occasionally result in temporary pain and hearing loss.

The ear and air pressure
It is middle ear that causes discomfort during air travel because it is an air pocket inside the head that is vulnerable to changes in air pressure.

Normally, each time (or each second an third time) you swallow, your ears make a little click or popping sound. This occurs because a small bubble of air has entered your middle ear, up from the back of your nose. It passes through the Eustachian tube, a membrane-lined tube about the size of a pencil lead that connects the back of the nose with the middle ear. The air in the middle ear is constantly being absorbed by its membranous lining and resupplied through the Eustachian tube. In this manner, air pressure on both sides of the eardrum stays about equal. If, and when, the air pressure is not equal the ear feels blocked.

Blocked ears and Eustachian tubes
The Eustachian tube can be blocked, or obstructed, for a variety of reasons. When that occurs, the middle ear pressure cannot be equalized. The air already there is absorbed and a vacuum occurs, sucking the eardrum inward and stretching it. Such an eardrum cannot vibrate naturally, so sounds are muffled or blocked, and the stretching can be painful. If the tube remains blocked, fluid (like blood serum) will seep into the area from the membranes in an attempt to overcome the vacuum. This is called “fluid in the ear,” serous otitis or aero-otitis.

The most common cause for a blocked Eustachian tube is the common cold. Sinus infections and nasal allergies are also causes. A stuffy nose leads to stuffy ears because the swollen membranes block the opening of the Eustachian tube.

How can air travel cause problems?
Air travel is sometimes associated with rapid changes in air pressure. To maintain comfort, the Eustachian tube must open frequently and wide enough to equalize the changes in pressure. This is especially true when the airplane is landing, going from low atmospheric pressure down closer to earth where the air pressure is higher.

Actually, any situation in which rapid altitude or pressure changes occur creates the problem. You may have experienced it when riding in elevators or when diving to the bottom of a swimming pool. Deep sea divers, as well as pilots, are taught how to equalize their ear pressure. You can learn the trick too.

How to unblock your ears
Swallowing activates the muscles that open the Eustachian tube. You swallow more often when you chew gum or when mints melt in your mouth. These are good air travel practices, especially just before take-off and during descent. Yawning is even better. Avoid sleeping during descent because you may not be swallowing often enough to keep up with the pressure changes.

If yawning and swallowing are not effective, pinch your nostrils shut, take a mouthful of air, and force the air into the back of your nose as if you were trying to blow your nose. When you hear a pop, you’ll know you have succeeded. You may have to repeat this several times during descent.

How can I help my baby unblock his ears?
Babies cannot intentionally pop their ears, but popping may occur if they are sucking on a bottle or pacifier. Feed your baby during the flight, and do not allow him or her to sleep during descent. Children are especially vulnerable to blockages because their Eustachian tubes are narrower than in adults.

Even after landing you can continue the pressure equalizing techniques, and you may find decongestants and nasal sprays to be helpful. If your ears fail to open or if pain persists, you will need to seek the help of a physician who has experience in the care of ear disorders. The ear specialist may need to release the pressure or fluid with a small incision in the ear drum.

Is the use of decongestants and nose sprays recommended?
Many experienced air travelers use a decongestant pill or nasal spray an hour or so before descent. This will shrink the membranes and help the ears pop more easily. Travelers with allergy problems should take their medication at the beginning of the flight for the same reason. However, avoid making a habit of nasal sprays. After a few days, they may cause more congestion than relief.

Decongestant tablets and sprays can be purchased without a prescription. However, they should be avoided by people with heart disease, high blood pressure, irregular heart rhythms, thyroid disease, or excessive nervousness. Such people should consult their physicians before using these medicines. Pregnant women should likewise consult their physicians first.


 

Swimmer’s Ear —
Insight into causes, prevention & when to see an ENT

Causes
Swimmer’s ear is an infection of the outer ear structures. It typically occurs in swimmers, but since the cause of the infection is water trapped in the ear canal, water from bathing or showering may also cause this common infection. When water is trapped in the ear canal, bacteria that normally inhabit the skin and ear canal multiply, causing infection and irritation of the ear canal. If the infection progresses it may involve the outer ear.


Treatment
Treatment for the early stages of swimmer’s ear includes careful cleaning of the ear canal and eardrops that inhibit bacterial growth. Mild acid solutions such as boric or acetic acid are effective for early infections.

For more severe infections, if you do not have a perforated eardrum, ear cleaning may be helped by antibiotics. If the ear canal is swollen shut, a sponge or wick may be placed in the ear canal so that the antibiotic drops will be effective. Pain medication may also be prescribed.

Follow-up appointments are very important to monitor progress of the infection, to repeat ear cleaning, and to replace the ear wick as needed.

Your otolaryngologist has specialized equipment and expertise to effectively clean the ear canal and treat swimmer’s ear.

Signs and Symptoms
The most common symptoms of swimmer’s ear are mild to moderate pain that is aggravated by tugging on the outer ear and an itchy ear. Other symptoms may include any of the following:

  • Sensation that the ear is blocked or full
  • Drainage
  • Fever
  • Decreased hearing
  • Swollen lymph nodes
  • Intense pain that may radiate to the neck, face, or side of the head
  • The outer ear may appear to be pushed forward or away from the skull

 

Why Do Ears Itch?
An itchy ear is a maddening symptom. Sometimes it is caused by a fungus or allergy, but more often it is a chronic dermatitis (skin inflammation) of the ear canal. One type is seborrheia dermatitis, a condition similar to dandruff in the scalp; the wax is dry, flaky, and abundant. Some patients with this problem will do well to decrease their intake of foods that aggravate it, such as greasy foods, carbohydrates (sugar and starches), and chocolate. Doctors often prescribe a cortisone eardrop at bedtime when the ears itch. There is no long-term cure, but it can be kept controlled.

Prevention
A dry ear is unlikely to become infected, so it is important to keep the ears free of moisture after swimming or bathing. Q-tips should not be used for this purpose, because they may pack material deeper into the ear canal, remove protective earwax, and irritate the thin skin of the ear canal creating the perfect environment for an infection. The safest way to dry your ears is with a hair blow-dryer. If you do not have a perforated eardrum, rubbing alcohol or a 50:50 mixture alcohol and vinegar used as eardrops will evaporate excess water and keep your ears dry. Before using any drops in the ear, it is important to verify that you do not have a perforated eardrum. Check with your otolaryngologist if you have ever had a perforated, punctured, or injured eardrum, or if you have had ear surgery.

People with itchy ears, flaky or scaly ears, or extensive earwax are more likely to develop swimmer’s ear. If so, it may be helpful to have your ears cleaned periodically by an otolaryngologist.


 

About  Earwax

 Why does the body produce earwax?
Cerumen or earwax is healthy in normal amounts and serves to coat the skin of the ear canal where it acts as a temporary water repellent. The absence of earwax may result in dry, itchy ears. Most of the time the ear canals are self-cleaning; that is, there is a slow and orderly migration of ear canal skin from the eardrum to the ear opening. Old earwax is constantly being transported from the ear canal to the ear opening where it usually dries, flakes, and falls out.

 Earwax is not formed in the deep part of the ear canal near the eardrum, but in the outer part of the canal. So when a patient has wax blockage against the eardrum, it is often because he has been probing the ear with such things as cotton-tipped applicators, bobby pins, or twisted napkin corners. These objects only push the wax in deeper.

 What is the recommended method of ear cleaning?
Under ideal circumstances, the ear canals should never have to be cleaned. However, that isn’t always the case. To clean the ears, wash the external ear with a cloth, but do not insert anything into the ear canal.

Most cases of ear wax blockage respond to home treatments used to soften wax. Patients can try placing a few drops of mineral oil, baby oil, glycerin, or commercial drops, such as Debrox® or Murine® Ear Drops in the ear. These remedies are not as strong as the prescription wax softeners but are effective for many patients. Rarely, people have allergic reactions to commercial preparations.

Detergent drops such as hydrogen peroxide or carbamide peroxide may also aid in the removal of wax. Rinsing the ear canal with hydrogen peroxide (H2O2) results in oxygen bubbling off and water being left behind—wet, warm ear canals make good incubators for growth of bacteria. Flushing the ear canal with rubbing alcohol displaces the water and dries the canal skin. If alcohol causes severe pain, it suggests the presence of an eardrum perforation.

Why shouldn’t cotton swabs be used to clean earwax?
Wax blockage is one of the most common causes of hearing loss. This is often caused by attempts to clean the ear with cotton swabs. Most cleaning attempts merely push the wax deeper into the ear canal, causing a blockage.

The outer ear is the funnel-like part of the ear that can be seen on the side of the head, plus the ear canal (the hole which leads down to the eardrum). The ear canal is shaped somewhat like an hourglass—narrowing part way down. The skin of the outer part of the canal has special glands that produce earwax. this wax is supposed to trap dust and dirt particles to keep them from reaching the eardrum. Usually the wax accumulates a bit, dries out, and then comes tumbling out of the ear, carrying dirt and dust with it. Or it may slowly migrate to the outside where it can be wiped off.

 When should a doctor be consulted?
If the home treatments discussed in this leaflet are not satisfactory, or if wax has accumulated so much that it blocks the ear canal (and hearing), a physician may prescribe eardrops designed to soften wax, or he may wash or vacuum it out. Occasionally, an otolaryngologist (ear, nose, and throat specialist) may need to remove the wax using microscopic visualization.

If there is a possibility of a hole (perforation or puncture) in the eardrum, consult a physician prior to trying any over-the-counter remedies. Putting eardrops or other products in the ear with the presence of an eardrum perforation may cause an infection. Certainly, washing water through such a hole could start an infection.

What are the symptoms of wax buildup?
 — Partial hearing loss, may be progressive
 — Tinnitus, noises in the ear
 — Earache
 — Fullness in the ear or a sensation the ear is plugged Are ear candles an option for removing wax build up?

No, ear candles are not a safe option of wax removal as they may result in serious injury. Since users are instructed to insert the 10” to 15”-long, cone-shaped, hollow candles, typically made of wax-impregnated cloth, into the ear canal and light the exposed end, someof the most common injuries are burns, obstruction of the ear canal with wax, or perforation of the membrane that separates the ear canal and the middle ear.

Even though ear candling is an ancient practice with the intent to treat a wide variety of ear maladies including cerumen impactions, ear infections, hearing loss, tinnitus, Ménière’s disease, sinusitis, headaches, inhalant allergies, and many other conditions, the FDA has never cleared or approved marketing the products as a medical treatment.

Are ear candles approved by the U.S. Food and Drug Administration?
The U.S. Food and Drug Administration (FDA) became concerned about the safety issues with ear candles after receiving reports of patient injury caused by the ear candling procedure. Although there are proponents who argue in favor of the use of ear candles, the FDA is unaware of any controlled studies or other scientific evidence that support the safety and effectiveness of these devices for any of the purported claims or intended uses as contained in the labeling.

Based on the growing concern associated with the manufacture, marketing, and use of ear candles, the FDA has undertaken several successful regulatory actions, including product seizures and injunctions, since 1996. These actions were based, in part, upon violations of the Food, Drug, and Cosmetic Act that pose an imminent danger to health.


 

Cholesteatoma: A Serious Ear Condition     

What is a cholesteatoma?
A cholesteatoma is a skin growth that occurs in an abnormal location, the middle ear behind the eardrum. It is usually due to repeated infection, which causes an ingrowth of the skin of the eardrum. Cholesteatomas often take the form of a cyst or pouch that sheds layers of old skin that builds up inside the ear. Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear. Hearing loss, dizziness, and facial muscle paralysis are rare but can result from continued cholesteatoma growth.    

How does it occur?
A cholesteatoma usually occurs because of poor eustachian tube function as well as infection in the middle ear. The eustachian tube conveys air from the back of the nose into the middle ear to equalize ear pressure (“clear the ears”). When the eustachian tubes work poorly perhaps due to allergy, a cold or sinusitis, the air in the middle ear is absorbed by the body, and a partial vacuum results in the ear. The vacuum pressure sucks in a pouch or sac by stretching the eardrum, especially areas weakened by previous infections. This sac often becomes a cholesteatoma. A rare congenital form of cholesteatoma (one present at birth) can occur in the middle ear and elsewhere, such as in the nearby skull bones. However, the type of cholesteatoma associated with ear infections is most common.    

What are the symptoms?
Initially, the ear may drain, sometimes with a foul odor. As the cholesteatoma pouch or sac enlarges, it can cause a full feeling or pressure in the ear, along with hearing loss. (An ache behind or in the ear, especially at night, may cause significant discomfort.) Dizziness, or muscle weakness on one side of the face (the side of the infected ear) can also occur. Any, or all, of these symptoms are good reasons to seek medical evaluation.    

Is it dangerous?
Ear cholesteatomas can be dangerous and should never be ignored. Bone erosion can cause the infection to spread into the surrounding areas, including the inner ear and brain. If untreated, deafness, brain abscess, meningitis, and rarely death can occur.    

What treatment can be provided?
An examination by an otolaryngologist-head and neck surgeon can confirm the presence of a cholesteatoma. Initial treatment may consist of a careful cleaning of the ear, antibiotics, and ear drops. Therapy aims to stop drainage in the ear by controlling the infection. The extent or growth characteristics of a cholesteatoma must also be evaluated.    

Large or complicated cholesteatomas usually require surgical treatment to protect the patient from serious complications. Hearing and balance tests, x-rays of the mastoid (the skull bone next to the ear), and CAT scans (3-D x-rays) of the mastoid may be necessary. These tests are performed to determine the hearing level remaining in the ear and the extent of destruction the cholesteatoma has caused.    

Surgery is performed under general anesthesia in most cases. The primary purpose of the surgery is to remove the cholesteatoma and infection and achieve an infection-free, dry ear. Hearing preservation or restoration is the second goal of surgery. In cases of severe ear destruction, reconstruction may not be possible. Facial nerve repair or procedures to control dizziness are rarely required. Reconstruction of the middle ear is not always possible in one operation; and therefore, a second operation may be performed six to twelve months later. The second operation will attempt to restore hearing and, at the same time, inspect the middle ear space and mastoid for residual cholesteatoma.    

Admission to the hospital is usually done the morning of surgery, and if the surgery is performed early in the morning, discharge maybe the same day. For some patients, an overnight stay is necessary. In rare cases of serious infection, prolonged hospitalization for antibiotic treatment may be necessary. Time off from work is typically one to two weeks.    

Follow-up office visits after surgical treatment are necessary and important, because cholesteatoma sometimes recurs. In cases where an open mastoidectomy cavity has been created, office visits every few months are needed in order to clean out the mastoid cavity and prevent new infections. In some patients, there must be lifelong periodic ear examinations.    

Summary
Cholesteatoma is a serious but treatable ear condition which can only be diagnosed by medical examination. Persisting earache, ear drainage, ear pressure, hearing loss, dizziness, or facial muscle weakness signals the need for evaluation by an otolaryngologist—head and neck surgeon   


 

Ménière’s Disease
Insight into the diagnosis and management

What are the symptoms?
How is a diagnosis made?
What treatments are available?
and more…

Ménière’s disease, also called idiopathic endolymphatic hydrops, is a disorder of the inner ear. Although the cause is unknown, it probably results from an abnormality in the fluids of the inner ear. In most cases only one ear is involved, but both ears may be affected in about 15 percent of patients. Ménière’s disease typically starts between the ages of 20 and 50 years. Men and women are affected in equal numbers.

 What are the symptoms?
The symptoms of Ménière’s disease may be only a minor nuisance, or can become disabling, especially if the attacks of vertigo are severe, frequent, and occur without warning. Among them are:

— Attacks of a spinning sensation or episodic rotational vertigo;
— Roaring, buzzing or ringing sound in the ear or tinnitus;
— Sensation of fullness in the affected ear;
— Intermittent hearing loss, especially in the low pitches during the early development stage;
— Fixed hearing loss involving all pitches in the advanced stage of the disease;
— Uncomfortable and distorted sounds.

From all the Ménière’s disease’s symptoms, vertigo is usually the most troublesome. It is commonly produced by disorders of the inner ear, but may also occur in central nervous system disorders. Vertigo may last for 20 minutes to two hours or longer. During attacks, patients are usually unable to perform activities normal to their work or home life. Sleepiness may follow for several hours, and the off-balance sensation may last for days.

 How is a diagnosis made?
The physician will take a history of the frequency, duration, severity, and character of your attacks, the duration of hearing loss or whether it has been changing, and whether you have had tinnitus or fullness in either or both ears. You may be asked whether there is history of syphilis, mumps, or other serious infections in the past, inflammations of the eye, an autoimmune disorder or allergy, or ear surgery in the past. You may be asked questions about your general health, such as whether you have diabetes, high blood pressure, high blood cholesterol, thyroid, neurologic or emotional disorders. Tests may be ordered to look for these problems in certain cases.

When the history has been completed, diagnostic tests will check your hearing and balance functions.
They may include:

    For hearing

  • An audiometric examination (hearing test) typically indicates a sensory type of hearing loss in the affected ear. Speech discrimination (the patient’s ability to distinguish between words like “sit” and “fit”) is often diminished in the affected ear.

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    For balance

  • An ENG (electronystagmograph) may be performed to evaluate balance function. In a dark room, recording electrodes are placed near the eyes. Warm and cool water or air is gently introduced into each ear canal. Since the eyes and ears work simultaneously through the nervous system, measurement of eye movements can be used to test the balance system. In about 50 percent of patients, the balance function is reduced in the affected ear.
  • Rotational testing or balance platform, may also be performed to evaluate the balance system.

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    Other tests

  • Electrocochleography (ECoG) may indicate increased inner ear fluid pressure in some cases of Ménière’s disease.
  • The auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computed tomography (CT) or, magnetic resonance imaging (MRI) may be needed to rule out a tumor occurring on the hearing and balance nerve. Such tumors are rare, but they can cause symptoms similar to Ménière’s disease.

 

How is Ménière’s Disease medically managed?
Aside from lifestyle changes, your doctor may advice you to take a diuretic (water pill) to reduce the frequency of attacks. Anti-nausea and anti-vertigo medications may also be prescribed to provide temporary relief. However, a side-effect of the medications may be drowsiness.

Another medication that may be used is gentamicin. It is an antibiotic, commonly administered in the form of drops or injections, which causes a partial loss of balance function in the treated ear, controlling vertigo in about three fourths of cases and usually preserving hearing. Apart from a period of disequilibrium that can occur as the patient adjusts to the new level of balance, this treatment is usually very well tolerated. It is also significantly simpler and less invasive than other surgical treatments.

 In addition, stress management counseling may be recommended, as stress tends to aggravate the symptoms of vertigo and tinnitus. If you have vertigo without warning, you should not drive, because failure to control the vehicle may be hazardous to yourself and others. Safety may require you to forego ladders, scaffolds, and swimming.

When is surgery recommended?
If vertigo attacks are not controlled by conservative measures and are disabling, one of the following surgical procedures might be recommended:

  • Intratympanic treatment, also known as chemical labyrinthotomy, is an office procedure in which a medicine, such as gentamicin, is injected into the middle ear. The endolymphatic shunt or decompression procedure is an ear operation that is usually preserves hearing. Attacks of vertigo are controlled in one-half to two-thirds of cases, but control is not permanent in all cases. Recovery time after this procedure is short compared to the other procedures.
  • Selective vestibular neurectomy is a procedure in which the balance nerve is cut as it leaves the inner ear and goes to the brain. Vertigo attacks are permanently cured in a high percentage of cases, and hearing is preserved in most cases.
  • Labryrinthectomy and eighth nerve section are procedures in which the balance and hearing mechanism in the inner ear are destroyed on one side. This is considered when the patient with Ménière’s disease has poor hearing in the affected ear. Labryrinthectomy and eighth nerve section result in the highest rates for control of vertigo attacks.


Tips to reduce the frequency of Ménière’s Disease episodes

  • Avoid caffeine, smoking, alcohol.
  • Restrict your salt intake.
  • Eat properly.
  • Get plenty of sleep.
  • Remain physically active, but avoid excessive fatigue.
  • Avert stress and anxiety, as it may aggravate vertigo and tinnitus.
  • Consider incorporating stress management techniques into your lifestyle.

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Tinnitus —
Insight into tinnitus-the noise in your ears

What causes tinnitus?
How is tinnitus treated?
What can help me cope?
and more…

Nearly 36 million Americans suffer from tinnitus or head noises. It may be an intermittent sound or an annoying continuous sound in one or both ears. Its pitch can go from a low roar to a high squeal or whine. Prior to any treatment, it is important to undergo a thorough examination and evaluation by your otolaryngologist. An essential part of the treatment will be your understanding of tinnitus and its causes.

 What causes tinnitus?
Most tinnitus comes from damage to the microscopic endings of the hearing nerve in the inner ear. The health of these nerve endings is important for acute hearing, and injury to them brings on hearing loss and often tinnitus. If you are older, advancing age is generally accompanied by a certain amount of hearing nerve impairment and tinnitus. If you are younger, exposure to loud noise is probably the leading cause of tinnitus, and often damages hearing as well.

There are many causes for “subjective tinnitus,” the noise only you can hear. Some causes are not serious (a small plug of wax in the ear canal might cause temporary tinnitus). Tinnitus can also be a symptom of stiffening of the middle ear bones (otosclerosis).

 Tinnitus may also be caused by allergy, high or low blood pressure (blood circulation problems), a tumor, diabetes, thyroid problems, injury to the head or neck, and a variety of other causes including medications such as anti-inflammatories, antibiotics, sedatives, antidepressants, and aspirin. If you take aspirin and your ears ring, talk to your doctor about dosage in relation to your size.

Treatment will be quite different in each case of tinnitus. It is important to see an otolaryngologist to investigate the cause of your tinnitus so that the best treatment can be determined.

 How is tinnitus treated?
In most cases, there is no specific treatment for ear and head noise. If your otolaryngologist finds a specific cause of your tinnitus, he or she may be able to eliminate the noise. But, this determination may require extensive testing including

X-rays, balance tests, and laboratory work. However, most causes cannot be identified. Occasionally, medicine may help the noise. The medications used are varied, and several may be tried to see if they help.

 Can other people hear the noise in my ears?
Not usually, but sometimes they are able to hear a certain type of tinnitus. This is called “objective tinnitus,” and it caused either by abnormalities in blood vessels around the outside of the ear or by muscle spasms, which may sound like clicks or crackling inside the middle ear.

 The following list of DOs and DON’Ts can help lessen the severity of tinnitus:

—Avoid exposure to loud sounds and noises.
—Get your blood pressure checked. If it is high, get your doctor’s help to control it.
—Decrease your intake of salt. Salt impairs blood circulation.
—Avoid stimulants such as coffee, tea, cola, and tobacco.
—Exercise daily to improve your circulation.
—Get adequate rest and avoid fatigue.
—Stop worrying about the noise. Recognize your head noise as an annoyance and learn to ignore it as much as possible.

 What can help me cope?
Concentration and relaxation exercises can help to control muscle groups and circulation throughout the body. The increased relaxation and circulation achieved by these exercises can reduce the intensity of tinnitus in some patients.

 Masking out the head noise with a competing sound at a constant low level, such as a ticking clock or radio static (white noise), may make it less noticeable. Tinnitus is usually more bothersome in quiet surroundings. Products that generate white noise are available through catalogs and specialty stores.

 Hearing Aids may reduce head noise while you are wearing it and sometimes cause it to go away temporarily, if you have a hearing loss It is important not to set the hearing aid at excessively loud levels, as this can worsen the tinnitus in some cases. However, a thorough trial before purchase of a hearing aid is advisable if your primary purpose is the relief of tinnitus.

 Tinnitus maskers can be combined within hearing aids. They emit a competitive but pleasant sound that can distract you from head noise. Some people find that a tinnitus masker may even suppress the head noise for several hours after it is used, but this is not true for all users.


 

Microsurgery of the Ear   

Microsurgery of the ear (Tympanoplasty) is a surgical procedure to reconstruct a perforated tympanic membrane (ear drum) or the small bones of the middle ear. Eardrum perforation may result from chronic infection or, less commonly, from trauma to the eardrum. Mastoid exploration may or may not be combined with this operation.    

Ear Drum
The tympanic membrane (ear drum) of the ear is a three-layer structure. The outer and inner layers consist of epithelium cells. Perforations occur as a result of defects in the middle layer, which contains elastic collagen fibers. Small perforations usually heal spontaneously. However, if the defect is relatively large, or if there is a poor blood supply or an infection during the healing process, spontaneous repair may be hindered. Eardrums may also be perforated as a result of trauma, such as an object in the ear, a slap on the ear, or an explosion.    

The purpose of Tympanoplasty is to repair the perforated ear drum, and sometimes the middle ear bones (ossicles) that consist of the incus, malleus, and stapes. Tympanic membrane grafting may be required. If needed, grafts are usually taken from tragus or temporalis fascia    

Types
There are five basic types of tympanoplasty procedures:
• Type I tympanoplasty is called myringoplasty, and only involves the restoration of the perforated eardrum by grafting.
• Type II tympanoplasty is used for tympanic membrane perforations with erosion of the malleus. It involves grafting onto the incus or the remains of the malleus.
• Type III tympanoplasty is indicated for destruction of two ossicles, with the stapes still intact and mobile. It involves placing a graft onto the stapes, and providing protection for the assembly.
• Type IV tympanoplasty is used for ossicular destruction, which includes all or part of the stapes arch. It involves placing a graft onto or around a mobile stapes footplate.
• Type V tympanoplasty is used when the footplate of the stapes is fixed.    

Depending on its type, Tympanoplasty can be performed under local or general anesthesia. In small perforations of the eardrum, Type I tympanoplasty can be easily performed under local anesthesia with intravenous sedation. An incision is made into the ear canal and the remaining eardrum is elevated away from the bony ear canal, and lifted forward. The surgeon uses an operating microscope to enlarge the view of the ear structures. If the perforation is very large or the hole is far forward and away from the view of the surgeon, it may be necessary to perform an incision behind the ear. This elevates the entire outer ear forward, providing access to the perforation. Once the hole is fully exposed, the perforated remnant is rotated forward, and the bones of hearing are inspected. If scar tissue is present, it is removed either with micro hooks or laser.    

Tissue is then taken either from the back of the ear-Temporalis fascia graft, the tragus (small cartilaginous lobe of skin in front the ear). The tissues are thinned and dried. An absorbable gelfoam sponge is placed under the eardrum to support the graft. The graft is then inserted underneath the remaining eardrum remnant, which is folded back onto the perforation to provide closure. Very thin sheeting is usually placed against the top of the graft to prevent it from sliding out of the ear when the patient sneezes.    

Diagnosis
The examining physician performs a complete physical with diagnostic testing of the ear, which includes an audiogram and history of the hearing loss, as well as any vertigo or facial weakness. A microscopic exam is also performed. Otoscopy is used to assess the mobility of the tympanic membrane and the malleus. CT Scan is routinely performed before tympaoplasty.    

Postoperative care
Once the mastoid bandage is and drain, if any removed, the neat day, patient can go home. Antibiotics are given, along with a mild pain reliever. After 10 days, the packing is removed and the ear is evaluated to see if the graft was successful. Water is kept away from the ear, and nose blowing is discouraged. If there are allegies or a cold, antibiotics and a decongestant are usually prescribed. Most patients can return to work after five or six days, or two to three weeks if they perform heavy physical labor. After three weeks, all packing is completely removed under the operating microscope. It is then determined whether or not the graft has fully taken.    

Complications
Possible complications include failure of the graft to heal, causing recurrent eardrum perforation; narrowing (stenosis) of the ear canal; scarring or adhesions in the middle ear; perilymph fistula and hearing loss; erosion or extrusion of the prosthesis; dislocation of the prosthesis; and facial nerve injury. Other problems such as recurrence of cholesteatoma, may or may not result from the surgery. Tinnitus (noises in the ear), particularly echo-type noises, may be present as a result of the perforation itself. Usually, with improvement in hearing and closure of the eardrum, the tinnitus resolves. In some cases, however, it may worsen after the operation. It is rare for the tinnitus to be permanent after surgery.    

Results
Tympanoplasty is successful in over 90% of cases. In most cases, the operation relieves pain and infection symptoms completely. Hearing loss is minor.   


 

About  Ear Tubes Insight into causes and treatment options   

— Who needs ear tubes and why?
— What to expect after surgery and more   

Painful ear infections are a rite of passage for children – by the age of five, nearly every child has experienced at least one episode. Most ear infections either resolve on their own (viral) or are effectively treated by antibiotics (bacterial). But sometimes, ear infections and/or fluid in the middle ear may become a chronic problem leading to other issues such as hearing loss, behavior, and speech problems. In these cases, insertion of an ear tube by an otolaryngologist (ear, nose, and throat surgeon) may be considered.   

What are ear tubes?   
Ear tubes are tiny cylinders placed through the ear drum (tympanic membrane) to allow air into the middle ear. They also may be called tympanostomy tubes, myringotomy tubes, ventilation tubes, or PE (pressure equalization) tubes.   

These tubes can be made out of plastic, metal, or Teflon and may have a coating intended to reduce the possibility of infection. There are two basic types of ear tubes: short-term and long-term. Short- term tubes are smaller and typically stay in place for six months to a year before falling out on their own. Long-term tubes are larger and have flanges that secure them in place for a longer period of time. Long term tubes may fall out on their own, but removal by an otolaryngologist is often necessary.   

Who needs ear tubes and why?   
Ear tubes are often recommended when a person experiences repeated middle ear infection (acute otitis media) or has hearing loss caused by the persistent presence of middle ear fluid (otitis media with effusion). These conditions most commonly occur in children, but can also be present in teens and adults and can lead to speech and balance problems, hearing loss, or changes in the structure of the ear drum. Other less common conditions that may warrant the placement of ear tubes are malformation of the ear drum or Eustachian tube, Down Syndrome, cleft palate, and barotrauma (injury to the middle ear caused by a reduction of air pressure), usually seen with altitude changes such as flying and scuba diving.   

Each year, more than half a million ear tube surgeries are performed on children, making it the most common childhood surgery performed with anesthesia. The average age of ear tube insertion is one to three years old. Inserting ear tubes may:   

reduce the risk of future ear infection,
restore hearing loss caused by middle ear fluid,
improve speech problems and balance problems, and
improve behavior and sleep problems caused by chronic ear infections.  

How are ear tubes inserted in the ear?   
Ear tubes are inserted through an outpatient surgical procedure called a myringotomy. A myringotomy refers to an incision (a hole) in the ear drum or tympanic membrane. This is most often done under a surgical microscope with a small scalpel (tiny knife), but it can also be accomplished with a laser. If an ear tube is not inserted, the hole would heal and close within a few days. To prevent this, an ear tube is placed in the hole to keep it open and allow air to reach the middle ear space (ventilation).   

What happens during surgery?   
A light general anesthetic (laughing gas) is administered for young children. Some older children and adults may be able to tolerate the procedure without anesthetic. A myringotomy is performed and the fluid behind the ear drum (in the middle ear space) is suctioned out. The ear tube is then placed in the hole. Ear drops may be administered after the ear tube is placed and may be necessary for a few days. The procedure usually lasts less than 15 minutes and patients awaken quickly.   

Sometimes the otolaryngologist will recommend removal of the adenoid tissue (lymph tissue located in the upper airway behind the nose) when ear tubes are placed. This is often considered when a repeat tube insertion is necessary. Current research indicates that removing adenoid tissue concurrent with placement of ear tubes can reduce the risk of recurrent ear infection and the need for repeat surgery.   

What to expect after surgery?   
After surgery, the patient is monitored in the recovery room and will usually go home within an hour if no complications are present. Patients usually experience little or no postoperative pain but grogginess, irritability, and/or nausea from the anesthesia can occur temporarily.   

Hearing loss caused by the presence of middle ear fluid is immediately resolved by surgery. Sometimes children can hear so much better that they complain that normal sounds seem too loud.   

The otolaryngologist will provide specific postoperative instructions for each patient including when to seek immediate attention and follow-up appointments. He or she may also prescribe antibiotic ear drops for a few days.   

To avoid the possibility of bacteria entering the middle ear through the ventilation tube, physicians may recommend keeping ears dry by using ear plugs or other water­tight devices during bathing, swimming, and water activities. However, recent research suggests that protecting the ear may not be necessary, except when diving or engaging in water activities in unclean water such as lakes and rivers. Parents should consult with the treating physician about ear protection after surgery.   

Consultation with an otolaryngologist (ear, nose, and throat surgeon) may be warranted if you or your child has experienced repeated or severe ear infections, ear infections that are not resolved with antibiotics, hearing loss due to fluid in the middle ear, barotrauma, or have an anatomic abnormality that inhibits drainage of the middle ear.   

Possible complications   
Myringotomy with insertion of ear tubes is an extremely common and safe procedure with minimal complications. When complications do occur, they may include:   

— Perforation – This can happen when a tube comes out or a long-term tube is removed and the hole in the tympanic membrane (ear drum) does not close. The hole can be patched through a minor surgical procedure called a tympanoplasty or myringoplasty.   

— Scarring – Any irritation of the ear drum (recurrent ear infections), including repeated insertion of ear tubes, can cause scarring called tympanosclerosis or myringosclerosis. In most cases, this causes no problems with hearing.   

— Infection – Ear infections can still occur in the middle ear or around the ear tube. However, these infections are usually less frequent, result in less hearing loss, and are easier to treat – often only with ear drops. Sometimes an oral antibiotic is still needed.   

Ear tubes come out too early or stay in too long – If an ear tube expels from the ear drum too soon (which is unpredictable), fluid may return and repeat surgery may be needed. Ear tubes that remain too long may result in perforation or may require removal by the otolaryngologist.