Chronic Ear Infections

 

Chronic ear infections are medically referred to as chronic otitis media, which means “infection of the middle ear.” They may also be called middle ear infections.

Infection or inflammation of the middle ear occurs when the eustachian tube to that ear is blocked. The eustachian tube is the passage from the back of the throat to the middle ear. Chronic ear infection occurs when the eustachian tube becomes blocked repeatedly or remains blocked for extended periods of time.

SYMPTOMS OF CHRONIC EAR INFECTIONS
Symptoms of chronic ear infections depend upon whether the condition is active or inactive, whether or not there is involvement of the mastoid bone (the bone directly behind the ear) and whether or not there is a hole in the eardrum.

Pain and fullness in the ear are typical symptoms of an ear infection and are often accompanied by fever. A build-up of puss causes pain and dampens the vibrations of the ear drum, which usually results in temporary hearing loss. Severe infections may cause the eardrum to rupture. There may be discharge, hearing impairment, tinnitus (head noise), dizziness, pain or, rarely, weakness of the face.

Any disease affecting the eardrum or the three small ear bones may cause a conductive hearing loss by interfering with the transmission of sound to the inner ear. Such a hearing impairment may be due to a perforation (hole) in the eardrum, partial or total destruction of one or all of the three little ear bones, or scar tissue.

When an acute infection develops in the middle ear (an abscessed ear), the eardrum may rupture, resulting in a perforation. This perforation usually heals. If it fails to do so a hearing loss occurs, often associated with head noise (tinnitus) and intermittent or constant ear drainage.

CAUSES OF CHRONIC EAR INFECTIONS
Middle ear infections often begin with an upper respiratory infection such as a cold or with allergies, which may cause inflammation of the sinuses and auditory tubes. When the auditory tubes swell, fluid can become trapped in the middle ear behind the eardrum. When this trapped fluid becomes infected with bacteria, a middle ear infection is the result.

The small size of children’s auditory tubes, which are shorter and more narrow than those of adults, increases the chance that inflammation will block the tube completely, trapping fluid in the middle ear. This is why children are more susceptible to recurrent ear infections.

TREATMENT OF CHRONIC EAR INFECTIONS
Home Ear Care
Treatment of ear infection is best left in the hands of your physician. These tips are to be used in conjunction with medical treatment.

You should avoid blowing your nose in order to prevent any infection in your nose from spreading to the ear through the eustacian tube. Any nasal secretion preferably should be drawn backward and expectorated. If it is absolutely necessary to blow your nose, do not occlude or compress one nostril while blowing the other.

In the event of ear drainage, the ear canal should be kept clean by means of a small cotton tipped applicator. 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 but should not be allowed to block the ear canal.

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 using an ear plug or placing cotton swabs or lambs wool in the external ear canal and covering it with a layer of vaseline.

Swimming is permissible if you use a small ear plug. Your otologist can advise you in regard to this.

Medical Treatment
Medical treatment of chronic ear infections frequently will stop ear drainage. Treatment consists of careful cleaning of the ear and, at times, the application of antibiotic powder or eardrops. Antibiotics by mouth may be helpful in certain cases.

Surgical Treatment
For many years surgical treatment was instituted in chronic otitis media primarily to control infection and prevent serious complications. Changes in surgical techniques now have made it possible to reconstruct the diseased hearing mechanism in most cases.

Various tissue grafts may be used to replace or repair the eardrum. These include covering the muscle from above the ear (fascia) and covering of ear cartilage (perichondrium). A diseased ear bone may be replaced by a plastic prosthesis (TORP or PORP), cartilage, or may be repositioned (relocated).

A thin piece of plastic frequently is used behind the eardrum to prevent scar tissue from forming and to promote normal function of the middle ear and motion of the eardrum. When the ear is filled with scar tissue or when all ear bones have been destroyed, it may be necessary to perform the operation in two stages. At the first stage, a piece of stiff plastic is inserted to allow more normal healing without scar tissue. At the second operation, this plastic is removed and we attempt to restore hearing. A decision in regard to staging the operation is made at the time of the first surgery.

TYPES OF SURGERIES FOR CHRONIC EAR INFECTION
Myringoplasty
Most ear infections subside and the structures of the middle ear heal completely. In some cases, however, the eardrum may not heal and a permanent perforation (hole) in the eardrum results.

Myringoplasty is the operation performed for the purpose of repairing a perforation in the eardrum when there is no middle ear infection or disease of the ear bones. This procedure seals the middle ear and may improve the hearing.

Surgery is performed under local anesthesia through the ear canal. Ear tissue is used to repair the defect in the eardrum. The patient is usually hospitalized as an outpatient and may return to work in a week. Healing is complete in most cases in six weeks, at which time any hearing improvement is usually noticeable.

Mastoid Surgery
There are two techniques of mastoid surgery: canal wall up and canal wall down. The decision on which technique is usually made at the time of surgery. Canal wall up mastoidectomy is preferred by members of the House Clinic because little, if any, precautions are necessary after the ear has healed (3 to 4 months).

Canal wall down surgery is necessary 30% of the time because of the extent of the disease or the development of the mastoid bone. Healing may be prolonged. Canal wall down surgery results in a larger ear opening (meatus) but little difference in the appearance of the ear. Periodic cleaning of the mastoid (ear) cavity is necessary indefinitely and it may be necessary to avoid water in the ear.

Tympanoplasty
An ear infection may cause a perforation of the eardrum, damage the mucosa and damage the three ear bones that transmit sound from the eardrum to the inner ear and hearing nerve. Tympanoplasty is the operation performed to eliminate any infection and repair both the sound transmitting mechanism and any perforation of the eardrum. This procedure seals the middle ear and improves the hearing in many cases.

In cases not requiring repair of the eardrum, the operation is usually performed under local anesthesia through the ear canal as an outpatient at the hospital.

Most tympanoplasties are performed through an incision behind the ear, under a local or general anesthesia. The perforation is repaired with ear tissue. 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, six months or more later, the sound transmitting mechanism is reconstructed.

The patient is usually hospitalized as an outpatient and may return to work in a week to ten days. Healing is usually complete in 8 weeks. A hearing improvement may not be noted for a few months.

Tympanoplasty with Mastoidectomy
Active infection may in some cases stimulate skin of the ear canal to grow through a perforated eardrum into the middle ear and mastoid. When this occurs, a skin-lined cyst known as cholesteatoma is formed. This cyst may continue to expand over a period of years and destroy the surrounding bone. If a cholesteatoma is present the drainage tends to be more constant and frequently has a foul odor. In many cases the persistent drainage is 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 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 serious complications.

When the destruction by cholesteatoma or infection is widespread in 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 infection, to obtain a dry, safe ear.

In most patients with cholesteatoma it is not possible to eliminate infection and restore hearing in one operation. The infection is eliminated and the eardrum rebuilt in the first operation. This requires a general anesthetic with hospitalization usually as an outpatient. The patient may usually return to work in one to two weeks.

When a second operation is necessary it will be performed six to twelve months later, to restore the hearing mechanism and to re-inspect the ear spaces for any residual (remaining) disease. See below.

On rare occasions a radical mastoid operation may be necessary to control infection in a case thought originally to be suitable for tympanoplasty.

Tympanoplasty: Planned Second Stage
The purpose of this operation is to re-inspect the ear spaces for disease and to improve the hearing.
Surgery may be performed through the ear canal under local anesthesia as an outpatient at the hospital.
More often than not, surgery is performed from behind the ear under general anesthesia. The ear is inspected for any residual (remaining) disease. Sound transmission to the inner ear is accomplished by replacing missing ear bones.
The patient is usually hospitalized as an outpatient and may return to work in four to seven days. Healing is usually complete in six weeks. Hearing improvement is frequently noted at that time.

Tympanoplasty with Revision Mastoidectomy
The purpose of this operation is to eliminate discharge from a previously created mastoid cavity defect and to improve the hearing.

The operation is performed under general anesthesia through an incision behind the ear. The mastoid cavity may be obliterated with fat from behind the ear or with bone. At times, the ear canal is rebuilt with cartilage or bone. The eardrum is repaired and, if possible, the hearing mechanism is restored. In most cases, however, a second operation is necessary to obtain hearing improvement (see Tympanoplasty: Planned Second Stage).

The patient is usually hospitalized as an outpatient and may return to work after one to two weeks. Complete healing of the inside of the ear may take four months.

Modified Radical Mastoidectomy
The purpose of this operation is to eradicate the infection without consideration of hearing improvement. It is usually performed in those patients who may have very resistant infections or have infection in an only hearing ear. Occasionally it may be necessary to perform a radical mastoid operation in some cases that originally appeared suitable for a tympanoplasty. This decision is made at the time of surgery. A fat or bone graft from the ear is necessary at times to help the ear heal properly.

The radical mastoid operation is usually performed under general anesthesia as an outpatient. The patient may usually return to work in one or two weeks. Complete healing may require up to four months.

Mastoid Obliteration Operation
The purpose of this operation is to eradicate any mastoid infection and to reduce the size of a previously created mastoid cavity. Hearing improvement is not considered.

The operation is performed under general anesthesia through an incision behind the ear. The mastoid space is filled with fat (from the ear or abdomen) or bone or both of these. The patient is usually hospitalized as an outpatient and may return to work in one to two weeks. Complete healing may require up to three months.

WHAT TO EXPECT FOLLOWING SURGERY
There are some symptoms which may follow any ear operation.

Taste Disturbance and Mouth Dryness
Taste disturbance and mouth dryness are not uncommon for a few weeks following surgery. In some patients this disturbance is prolonged.
Tinnitus
Tinnitus (head noise), frequently present before surgery, is almost always present temporarily after surgery. It may persist for one to two months and then decrease in proportion to the hearing improvement. Should the hearing be unimproved or worse, the tinnitus may persist or be worse.

Numbness of Ear
Temporary loss of skin sensation in and about the ear is common following surgery. This numbness may involve the entire outer ear and may last for six months or more.

Jaw Symptoms
The jaw joint is in intimate contact with the ear canal. Some soreness or stiffness in jaw movement is very common after ear surgery. It usually subsides within one to two months. Drainage Behind the Ear At times your surgeon may insert a drain tube behind the ear. The necessity for this is usually not apparent before surgery. Should a drain tube be necessary, it will protrude through the skin behind the ear about 1/4 of an inch and may be left in place for 1 to 10 days.

RISKS AND COMPLICATIONS OF SURGERY
Fortunately major complications are rare following surgery for correction of chronic ear infection.

Ear Infection
Ear infection, with drainage, swelling and pain, may persist following surgery or, on rare occasions, may develop following surgery due to poor healing of the ear tissue. Were this the case, additional surgery might be necessary to control the infection.

Loss of Hearing
In 3% of the ears operated the hearing is further impaired permanently due to the extent of the disease present or due to complications in the healing process; nothing further can be done in these instances. On occasion there is a total loss of hearing in the operated ear.

In some cases a two stage operation is necessary to obtain satisfactory hearing and to eliminate the disease. The hearing is usually worse after the first operation in these instances.

Dizziness
Dizziness may occur immediately following surgery due to swelling in the ear and irritation of the inner ear structures. Some unsteadiness may persist for a week postoperatively. On rare occasions dizziness is prolonged.

10% of the patients with chronic ear infection due to cholesteatoma have a labyrinthine fistula (abnormal opening into the balance canal). When this problem is encountered, dizziness may last for six months or more.

Facial Paralysis
The facial nerve travels through the ear bone in close association with the middle ear bones, eardrum and the mastoid. A rare postoperative complication of ear surgery is temporary paralysis of one side of the face. This may occur as the result of an abnormality or a swelling of the nerve and usually subsides spontaneously.

On very rare occasions the nerve may be injured at the time of surgery or it may be necessary to excise it in order to eradicate disease. When this happens a skin sensation nerve is removed from the upper part of the neck to replace the facial nerve. Paralysis of the face under these circumstances might last six months to a year and there would be a permanent residual weakness. Eye complications, requiring treatment by a specialist, could develop.

Hematoma
A hematoma (collection of blood under the skin) develops in a small percentage of cases, prolonging hospitalization and healing. Re-operation to remove the clot may be necessary if this complication occurs.

Complications Related to Mastoidectomy
A cerebral spinal fluid leak (leak of fluid surrounding the brain) is a very rare complication. Re-operation may be necessary to stop the leak.

Intracranial (brain) complications such as meningitis or brain abscess, even paralysis, were common in cases of chronic otitis media prior to the antibiotic era. Fortunately these now are extremely rare complications.

GENERAL COMMENTS
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 dull pain in or about the ear, increased discharge, dizziness, or twitching or weakness of the face, you should immediately consult your physician.