The diagnosis of chronic otitis media (infection of the middle ear) has been established as the cause of your hearing impairment. This condition may be active or inactive.

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 that separates the external 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 carries the sound 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 nerve hearing 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 around the ear bones or the eardrum.

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.

CARE OF THE EAR

If a perforation is present, you should not allow water to get into your ear canal. This may be avoided when showering or washing the hair by placing cotton or lambs wool in the external canal and covering it with a layer of Vaseline. If you desire to swim, apply the cotton covered with Vaseline and use a tight fitting swimming cap. You should avoid blowing your nose if you have an active upper respiratory infection (cold). However, trying to blow air through the eustachian tube into the ear is very important. This is done by pinching your nostrils completely shut and blowing hard against the closed nostrils. If done properly, air should come through your ear.

Medication as prescribed, should be used if discharge is present or when discharge occurs. Cotton is placed in the outer ear to catch any discharge.

MEDICAL TREATMENT

Medical treatment will frequently stop ear drainage. Treatment consists of careful cleaning of the ear by the ear doctor and at times, application of antibiotic powder or ear drops. Antibiotics by mouth may be helpful in certain cases. Keep Q-Tips (cotton tip applicators) out of the ear. Keep fingers, bobby pins, and other objects away from your ear.

SURGICAL TREATMENT

For many years surgical treatment was instituted in chronic otitis media primarily to control infection and prevent serious complications. ln recent years changes in microsurgical techniques have made it possible to reconstruct the diseased hearing mechanism in most cases. The sound conducting mechanism is reconstructed with a variety of materials such as a plastic prosthesis, artificial bone, or the patient's own incus bone or . cartilage. Plastic sheeting is used in the middle ear to prevent scar tissue from forming. Patients usually leave the hospital in less than 24 hours (short stay). There is little pain or discomfort after surgery which is done under general anesthesia. The patient removes the head dressing the day after surgery and may return to work or school in several days. Hearing improvement may be noted after packing is removed at 2 weeks, and may improve over 6 months. Eardrops are used at night during the healing phase. Weekly visits are necessary until the ear is healed which usually occurs by 6 weeks. Depending on the status of the ear one of the following procedures is recommended. Patients usually can swim at three months after the operation. Yearly visits and hearing tests are necessary to check the operated ear.

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 the sound transmitting mechanism and/or the perforation in the eardrum if there is no drainage. This procedure seals the middle ear and improves hearing in many cases.

Outpatient surgery is usually performed through an incision made behind the ear. The perforation is repaired with the facial tissue taken from muscle above the ear and with skin flap from the ear canal making a two layer closure. If necessary the sound transmission to the inner ear is accomplished by reconstructing the ossicular chain with a variety of materials.

In some cases, if hearing does not improve, a minor secondary procedure which is per-formed through the ear canal may be necessary 8 to 12 months later.

TYMPANOPLASTY WITH MASTOIDECTOMY

Active infection may in some cases stimulate skin of the ear canal to grow through the eardrum perforation into the middle ear.

When this occurs, a skin-lined cyst known as a 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 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 has stopped is frequent.

A cholesteatoma or chronic ear infection may persist for many years without difficulty except for the 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 weak-ness of the face may develop. If any of these symptoms occur it is imperative that nine seek immediate medical care. Surgery may be necessary to eradicate the infection and prevent serious complications.

When the destruction by cholesteatoma or infection is widespread in the middle ear and mastoid bone the surgical elimination 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. The secondary objective is to improve hearing. The third objective is to maintain or reconstruct a normal appearing ear canal.

In 70% - 80% of cases the infection can be eliminated and the hearing restored in one operation. In adults cholesteatoma may re cur in 20% of cases while in children it recurs in 50% of cases. Patients with recurrent drainage from the ear and perforation of the drum usually require a mastoid tympanoplasty operation similar to patients with cholesteatoma. Since the incidence of recurrent disease is so high in children, a second operation is planned at one year to verify that there is no residual disease.

Occasionally a second minor operation may be considered at a later time to improve hearing, when the risk of residual disease is low.

TYMPANOPLASTY WITH REVISION MASTOIDECTOMY

The purpose of this operation is to eliminate drainage from the radical mastoid cavity, obliterate (fill in) the cavity, and attempt to obtain hearing improvement.

The operation is performed under general anesthesia through an incision made be-hind the ear. Muscle, fat, and cartilage from behind the ear are used to obliterate the mastoid area (cavity). If possible, the hearing mechanism is restored by using the normal ear bones, prosthesis, or cartilage.

MASTOID OBLITERATION OPERATION

The purpose of this operation is to eradicate any mastoid infection and to obliterate (fill in) a previously created radical mastoid cavity so the patient can swim and not need yearly cleaning of the ear. Hearing improvement is not considered.

The operation is performed under general anesthesia through an incision behind the ear. Muscle and fat grafts from behind the ear are used to fill in the mastoid space.

GENERAL COMMENTS AND COMPLICATIONS

Surgery may be successful in repair of the ear drum (95%) however, the hearing may remain the same as before surgery. In 1 % of the cases operated, the hearing may be further impaired. I infrequently there may be persistent drainage, head noise, and dizziness for some time following surgery. In less than .005% (1 in 500) percent of the cases, a facial weakness may develop. This is usually temporary. In 2% a post-op infection occurs which destroys the graft.

If you do not have surgery performed at this time, it is advisable to have annual examinations, especially if the ear is draining. Should you develop low grade pain in or about the ear, increased discharge, or dizziness, you should immediately consult: your physician.

In doing any type of ear surgery, the nerve of taste sometimes has to be sacrificed in order to remove all the disease. This will result: in a temporary taste disturbance in one area of the tongue for approximately three months. Patients complain of a metallic taste. The facial nerve is usually not in great jeopardy during most ear surgery, but under certain circumstances it may be out of place or involved with disease, and bruising of this nerve could result in a temporary facial paralysis.

POST OPERATIVE INSTRUCTIONS

For most ear surgery, two weeks post-op, packing must be removed from the ear. If there is some problem in returning for an appointment, please discuss this with the doctor. The doctor will order hearing tests after surgery.

Keep incisions dry when washing. Paper tape applied to wound, or plastic adhesives can be used. Cotton in the ear should be replaced at least daily when soaked with blood, and Vaseline coated when showering. Pain medication prescription will be given to you when leaving the hospital. We will attempt to call you after you have gone home

If there is any question, please call the office during office hours. Activity is a variable thing and is up to how the patient feels.

THE FACIAL NERVE DURING SURGERY

You will be pleased to learn that Dr. Silverstein has developed an instrument that helps prevent injury to the facial nerve during surgery of the ear. The way it works is simple. The facial nerve stimulator/ monitor has a bell that rings when the surgeon gets near the facial nerve, and also has a stimulator probe that allows for easier facial nerve location in bone, tumor, or soft tissue.

Although using the WR Silverstein nerve stimulator/monitor does not guarantee normal facial function after surgery, it does add an extra measure of safety, and allows the surgeon to test the facial nerve at the end of the procedure while the patient is still asleep. Immediately after surgery, the surgeon can inform the family that the facial function should be normal. Since 1985 there has not been a facial weakness in over 1500 surgeries related to chronic ear disease. This should help decrease your fears about facial nerve injury during surgery.

If you have any questions, need additional information, or would like to schedule an appointment, call TOLL FREE 1-888-418-9200