Surgical Treatment of Ear Infection, Ear Drum Perforation & Cholesteatoma

Medical Treatment of Chronic Otitis Media/Infection

Medical treatment, principally consisting of eardrops, powders, and irrigators, will frequently stop ear drainage. In addition, careful cleaning of the canal in the office by a physician is usually 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 infection or by cholesteatoma, and there is minimal hearing loss, medical treatment may be all that is necessary for chronic otitis media. Otherwise, surgery may be necessary.

Surgical Treatment

For many years, surgical treatment was utilized 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, including the covering of a muscle above the ear (fascia), or the covering of ear cartilage (perichondrium). A diseased ear bone may be replaced by a synthetic prosthesis and cartilage. When the ear is filled with scar tissue or cholesteatoma, or when the ear bones have been destroyed, it is often necessary to perform the operation in two stages. In the first stage, the cholesteatoma is removed, holes in the eardrum are repaired 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 can be noted at or shortly following surgery.

Myringoplasty

Most middle ear infections subside and the structures of the middle ear heal completely without surgery. In some cases, however, the ear drum 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. Smaller perforations can frequently be repaired in the office with a paper patch on the eardrum or the fat taken from the earlobe. Surgery is sometimes performed under general anesthesia through the ear canal or behind the ear. Fascia from muscle above the ear can be used to repair the defeat in the eardrum. Surgery is usually performed as outpatient procedure. Healing is complete in most cases within six weeks, at which time any hearing improvement is usually noticeable.

Tympanoplasty and Ossiculoplasty

An ear infection or cholesteatoma 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 with the Ossiculoplasty 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 after, the sound transmitting mechanism is reconstructed.

Surgery is performed as an outpatient surgery and the patient may return to work within several days to a week. Healing is usually complete in six weeks. A hearing improvement may not be noted until the ear bones have been reconstructed.

Tympanoplasty and 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 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 only due to chronic infection in the bone and associated 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 ears and used by mouth only result in a temporary improvement in most cases. Recurrence after medical treatment has stopped is frequent.

Patients frequently experience persistent ear drainage and 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, including the mastoid, the surgical elimination of this may be difficult. Surgery is performed through an incision behind the ear. The primary objective is to eliminate the infection, and obtain a dry, safe ear.

In some cases the infection cannot be eliminated and the hearing restored in one operation. The infection is addressed and the eardrum rebuilt in the first operation. This requires a general anesthetic. The patient may usually return to work in one week. A second operation may be performed months later to restore the hearing mechanism and/or confirm infection and cholesteatoma 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 improvements. The operation is performed under general anesthesia through the incision behind the ear. The mastoidectomy is revised. If possible, the hearing mechanism is restored by using implants or cartilage. The patient usually 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 infection and cholesteatoma. 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 usually as an outpatient procedure. 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. The patient requires routine ear cleaning after this type of operation for the rest of his/her life.

Mastoid Obliteration Operation

The purpose of this operation is to eradicate any mastoid infection and to obliterate (fill-in) a previously created mastoid cavity after a canal wall down-mastoid operation. Hearing improvement is not a focus. 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 usually returns to work in several days to one week after surgery. Complete healing may require up to three months.

Risk and Complication of Surgery

Summary

Eardrum grafting is successful in over 90% of patients, resulting in a healed, dry ear. Hearing improvement following surgery depends upon many factors, among which are the extent of the ear bone damage and the ability of the ear to heal properly. It is uncommon to have total restoration of hearing when the ear bones are damaged. If surgery is not successful, the hearing usually remains the same as before surgery. In 2% of the cases operated, the hearing may be further impaired. Occasionally, there may be persistent drainage, head noise, and dizziness for some time following surgery. In less than 1% of the cases, a facial weakness may develop. This is usually a temporary complication. If you do not have surgery performed at this time, it is advisable to have regular 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.