EAR

Otitis media with effusion

Otitis media with effusion (OME) is thick or sticky fluid behind the eardrum in the middle ear.

Causes

• The Eustachian tube connects the inside of the ear to the back of the nose. This tube helps drain fluid to prevent it from building up in the ear. The fluid drains from the tube and is swallowed. When the Eustachian tube is partially blocked, fluid builds up in the middle ear. Bacteria inside the ear become trapped and begin to grow. This may lead to an ear infection.
• The following can cause Eustachian tube dysfunction :
  • Allergies
  • Adenoid tissue hypertrophy behind nose which blocks behind nose opening of eustachean tube (most commonest in children)
  • Irritants (particularly cigarette smoke)
  • Respiratory infections
  • Sudden increases in air pressure (such as descending in an airplane or on a mountain road)

Getting water in a baby’s ears will not lead to a blocked tube.

OME is most common in winter or early spring, but it can occur at any time of year. It can affect people of any age. It occurs most often in children under age 2, but is rare in newborns.

Younger children get OME more often than older children or adults for several reasons:

• The tube is shorter, more horizontal, and straighter, making it easier for bacteria to enter.
• The tube is floppier, with a tinier opening that’s easy to block.
• Young children get more colds because it takes time for the immune system to be able to recognize and ward off cold viruses.

The fluid in OME is often thin and watery or gluey.

Symptoms

Older children and adults often complain of muffled hearing or a sense of fullness in the ear. Younger children may turn up the television volume because of hearing loss. When fluid or glue starts contracting infection due to longer accumulation patient starts complaining of ear pain.

Exams and Tests

Your doctor will examine the eardrum with an otoscope and look for certain changes, such as:

• Air bubbles on the surface of the eardrum
• Dullness of the eardrum when a light is used
• Eardrum that does not seem to move when little puffs of air are blown at it
• Fluid behind the eardrum

A test called tympanometry is an accurate tool for diagnosing OME. The results of this test can help tell the amount and thickness of the fluid.

An audiometer or other type of formal hearing test may be done. This can help the provider decide on treatment.

Treatment

Initial treatment will be medical. If infection or glue doesn’t subside we do a grommet insertion which is a ventilatory tube to drain middle fluid out and rid patient of symptoms. This tube stays in the ear drum for few months and extrudes by itself once middle ear lining dries up and becomes healthy.

• Avoid cigarette smoke
• Encourage infants to breastfeed
• Treat allergies by staying away from triggers (such as dust). Adults and older children may be given allergy medicines.
• In kids most of the time its associated with adenoids –which must be taken out for the Eustachian tube to work properly.

If there is a delay in clearance of fluid-there will be hearing loss and ear drum may slowly thins out which leads to formation of an ear perforation. Its always better to clear this problem as early as possible.

Alternative Names

OME; Secretory otitis media; Serous otitis media; Silent otitis media; Silent ear infection; Glue ear

Otosclerosis is a condition that causes gradual and progressive hearing loss. It happens when smallest hearing ossicle/bone in the middle ear stapes gets fixed in place. Most of the time, this happens when bone tissue in your middle ear grows around the stapes and impedes its vibration conduction to inner ear.

Etiology may be due to genetic, autoimmune, measles virus or hormonal.

2/3 have a significant family history.

After ear examination. other Tests include audiological and radiological evaluation are done to know extent of disease and prognosis of surgery.

Surgical procedure involves making a fenestra in foot plate region of stapes(3^rd bone\smallest middle ear bone)and removing diseased region of stapes along with complete suprastructure.  An artificial piston is kept in the fenestra made over foot plate with a perforator or skeeter drill. This piston other end is attached to second bone in ear that is incus. So principle of surgery is to replace a vibrating piston with that of diseased stapes bone. On table we can find improvement in hearing in most of cases are done under local anesthesia with IV sedation.

Above image white piston is the Teflon piston bypassing stapes bone and conducting vibrations into inner ear

The improvement in hearing is based on extent of disease progression, functioning of auditory (hearing) nerve during the time of surgery.

STAPEDECTOMY Instructions after Surgery

• Your surgery is done under local anesthesia you will go directly to the postoperative area and then to your allotted room where your family can remain with you for the rest of your stay.
• You will be on “strict” bed rest for 4 hours after surgery. During this time you may lie on your back or the un-operated ear.
• After 4 hours you can sit up and if there is no vertigo, dizziness, or nausea you will be allowed to walk to the restroom. If this is tolerated well you will be allowed to go home.
• After surgery: dressing will stay for one week.
• Avoid bumpy, loud rides on your way back home (ex:bus,auto) since it  may cause motion sickness, Vertigo  and nausea.
• Once dressing removed ,the ear will have only a cotton ball in the ear canal that should be changed as needed with a clean cotton ball for 2 week. The incision above the ear does not need any care. Stitches will be removed after 14^th
• Pain severity after ear surgery varies greatly from patient to patient but is usually at its worse the first few hours after surgery. While still at the hospital it is common for patients to need IM or IV pain medicines. Oral pain meds are usually all that is needed thereafter and will be prescribed for home use. These are usually needed for only a few days.
• Diet is “as tolerated” after surgery. Clear liquids will be given first and if tolerated a light food diet can be started that same day. The day after surgery the patient’s usual diet can be resumed.
• Nausea and even vomiting can occur the day of surgery and will be treated with medication as needed and patient will be prescribed nausea medicine for home use. In such cases clear liquids only should be given until all nausea has resolved.
• The hair may be washed 2 weeks after surgery, once ear drum and external incision area heals up and after consulting your surgeon.
• Place a firm cotton ball in the ear canal and place Vaseline on the outside of the cotton ball while taking bath during second and third week. Hold the cotton ball in place with the finger when rinsing the hair or face in the shower.
• For the first week attempt to sleep either on your back or the un-operated ear.
• Avoid blowing your nose or sniffing for 6 weeks after surgery. If sneezing occurs do so with the mouth open to avoid the build up of pressure in the ear.
• It is recommended that you remain home and rest for 1 week after a stapedectomy. Do not drive during this time. Going for an easy walk is acceptable.
• After your first postoperative visit on 8^th day you may resume non-strenuous activity and can attend your office, work. Exercising, sports, heavy lifting (that requires any degree of straining), and air travel should be avoided for 6 weeks after surgery. Driving to higher altitudes, swimming  should be avoided for 6 months . Avoid loud sounds like drilling, bombs or cracker sounds for 6 months. Avoid movie theatre for 3 months.
• Some dizziness and ringing in the ear is normal after surgery. Severe vertigo requires strict bed rest during the first week. If you still feel vertigo, dail bayya ent & cochlear implant centre at 0863-2225729 and get in touch with your surgeon
• You will not be able to hear well due to gel packing placed in the ear canal and due to dressing. Part of this packing will be removed at your postoperative visits by two weeks. The rest will dissolve naturally. Popping and crackling in the ear is normal and may occur for several weeks after surgery.
• The hearing will not be checked for at least 6 weeks after surgery. The final hearing result can take up to 3 months to obtain and may even continue to improve during the first year.
• Dark red, bloody drainage from the ear is normal. If anytime after surgery the drainage becomes “snotty” with a yellow mucous like appearance or develops a foul odor report this to doctor.

What is a cochlear implant?

A cochlear implant is a surgically implanted hearing device used in the rehabilitation of people with a significant hearing loss. Cochlear implant systems have both internal and external components. The external components include a speech processor, a transmitting coil, and a microphone. The surgically implanted internal components include a receiver and an electrode array.

How does a cochlear implant work?

1. Sounds are picked up by the microphone and sent to the speech processor.
2. The speech processor filters the sound into electrically coded signals.
3. The coded signals are sent to the transmitting coil and through the skin to the implanted receiver.
4. The receiver electrically activates the electrode array which in turn stimulates the fibers within the cochlea.
5. Nerve impulses are sent to the brain where they are interpreted as sound.

What happens during the surgery?

The nurses\ot staff  will take your child down to the operating room. The surgery takes about 1-2 hours for one cochlear implant . When your child is asleep under anaesthetic, A cut will be made in the crease behind the ear and a bony tunnel will be drilled to the middle ear where the entrance to the cochlea is found. A ‘bed’ for the implant is made by drilling away some bone on the surface of your child’s head. This is so that the implant lies flat on the head and does not leave a bump. The natural opening to the cochlea is opened and the implant electrode is very carefully threaded into the cochlea. Whilst your child is still asleep, the cochlear implant is tested by the audiologist to make sure that it is working well. Once this is done, the wound is closed with dissolvable stitches which do not need to be removed.

Will my child feel any pain?

Cochlear implant surgery causes little pain. If necessary, children can be given analgesic as pain relief.

What happens after the surgery?

Your child will go back to the ward once he/she has recovered from the anaesthetic. A pressure bandage will be around his/her head to help with healing. Your child may feel sleepy for the rest of the day. He/she might also feel sick in the tummy or vomit as a result of the general anaesthetic which is temporary.

Will my child hear immediately after implant surgery?

During surgery implant will be switched on and nerve stimulation and electrode impedances will be checked and then device will be switched off. After switch on ie 14 day after suture removal-device will be switched on and external processor will be attached. From this point child starts to hear sound. In elderly hearing will be spontaneous after switch on. But for infants or kids will have to undergo frequent mapping and AVT therapy sessions to get optimal hearing and speech

Auditory-Verbal therapy is a specialized type of therapy designed to teach a child to use the hearing provided by a hearing aid or a cochlear implant for understanding speeach and learning to talk. The child is taught to develop hearing as an active sense so that listening becomes automatic and the child seeks out sounds in life.

Hearing and active listening become an integral part of communication, recreation, socialization, education and work.

Auditory-verbal therapy is a family-centered approach.

Auditory-verbal therapist provides guidance to the parents, teaching them how to utilize and integrate the principles of auditory-verbal therapy into their lives.

There are nine principles of auditory-verbal practice which are integrated into the lives of auditory-verbal families. The principles are as follows:

• early detection, identification, and management of hearing loss
• appropriate amplification
• a parent partnership with the auditory-verbal therapist
• total integration of listening into the child’s personality
• one-on-one therapy
• acoustic feedback
• the following of an auditory hierarchy
• teaching which is continually diagnostic
• the implementation of mainstreaming as appropriate (Auditory-Verbal International)

The goal of all of the communication approaches is to give children with hearing loss the skills and abilities to communicate with their peers. This, however, is not the only goal — these individuals, as adults, must become contributing members of society. That is, they must find employment and actively participate in their communities.

Sudden Sensorineural hearing loss
Sudden deafness can occur within no time in an otherwise normal hearing patient. It also comes with ear fullness, ringing sensation and sometimes giddiness. If patient comes within 24 hours, hearing tests has to be done. We also suggest MRI of brain and with special emphasis on hearing nerve to rule out any etiology in brain and other lesions compressing  auditory nerve . If MRI is normal (in most cases) with profound (ie severe) hearing loss is confirmed in Pure tone audiogram -intravenous and intra tympanic steroids have to be started immediately. Most of the cases show minimum improvement of 50% or more, if treatment was started within 24hours. If severe or profound hearing loss sets in permanently – patient has got only one option i.e hearing aid and if doesn’t help in worse cases a cochlear implant.

Pure tone audiometry showing left ear sensori neural hearing loss

Tinnitus

Tinnitus  is the perception of noise or ringing in the ears. Tinnitus effects 1 out of 5 people. It is not a symptom actually but it’s a sign of underlying condition. It can be seen in hearing loss( age related, sudden deafness), fluid in middle ear( SOM), injury to ear(physical trauma, noise induced). Patients coming to us with tinnitus will be tested and based on the etiology we advice necessary treatment . Treatment can include oral as well as intratympanic injections. Its prognosis is solely based on its duration of onset and how early a patient gets treatment. If medical management doesn’t completely reduce or nil response-we suggest tinnitus masker devices.

Facial nerve palsy

Facial nerve is the nerve which controls muscles of face. Facial nerve paralysis is characterized by unilateral facial weakness, with other symptoms including loss of taste, hyperacusis and decreased salivation and tear secretion. Other signs may be linked to the cause of the paralysis, such as vesicles in the ear, which may occur if the facial palsy is due to shingles. Most commonly it is idiopathic ( no reason) also known as Bells palsy. Other causes are trauma, infection, paralysis, tumors. Treatment of facial nerve palsy depends on the cause.  It is usually treated with steroids. If medical treatment fails- we suggest facial nerve decompression surgery as early as possible.

Decompressed nerve -white arrow area showing location of compressed nerve

Otitis externa

Otitis externa is infection of external ear. It can be localized(boil) or diffuse. It is usually caused by local bacteria when the patient tries to clean his ears on his own. Patient complains of severe pain with ear discharge. It has to treated with antibiotics and anti-inflammatory drugs. In diabetic patients extra care has to be taken as they are more prone to infection and delayed wound healing. If it gets infected with pseudomonas in diabetics it is known as malignant otitis externa which has to be treated aggressively as it can cause facial nerve paralysis.

Otomycosis

It is a type of external otitis but caused by fungal organisms. Most common organisms causing fungal otitis externa are Aspergillus niger and candidal sp.  In aspergillus cases black fungal spores can be seen on otoscopy and in candidal infection whitish discharge can be seen. It has to be treated with antibiotics, anti histamines and local antifungal cream or drops.

Preauricular sinus

A preauricular sinus is a common congenital malformation characterized by small pit infront of the ear. It is formed due to failure of fusion of membranes(hillocks of his) during development of baby. It is usually asymptomatic but once it gets infected it is better to excise. During surgery sinus tract has to be excised fully including part of cartilage where the sinus tract is attached.