ENT Specialist

Repair of a Perforated Ear Drum (Myringoplasty)

A hole in the eardrum can be repaired effectively using a small piece of cartilage from the ear. This procedure can be performed by operating down the ear canal with a microscope (transcanal), or from behind the ear (postauricular) depending on the size and position of the hole in the eardrum. The eardrum is lifted and the middle ear structures are assessed. Then a graft of cartilage is harvested, and is placed under the lifted eardrum before it is returned back into the normal position.

If the small bones of hearing (ossicles) are not functioning properly, then a titanium implant may be required to reconstruct the hearing mechanism

Grommets

Grommet insertion is a surgical procedure in which a tiny ventilation pipe (grommet) is inserted into the eardrum to treat glue ear.

Glue ear is a condition in which glue-like fluid fills up in the middle ear and impairs hearing ability. Hearing loss may affect one or both ears. The common symptoms include mild ear pain, irritability, talking quietly, problems with communication and learning, and delayed development of speech and language in children.

The exact cause of fluid build-up in the middle ear is unclear, but it may be due to improper functioning of the Eustachian tube.

The Eustachian tube is a narrow tube that connects the middle ear to the back of nose. The tube helps in maintaining the balance of air pressure between the middle and outer ear. Opening of the tube while swallowing, chewing or yawning allows inflow of air into the middle ear and outflow of fluid thereby balancing air pressure on each side of the eardrum. If the Eustachian tube fails to open properly or gets blocked due to respiratory tract infections or allergies, an air pressure imbalance is created on either side of the eardrum thereby disrupting its function.  This imbalance causes the fluid to fill up the space of the middle ear thereby preventing its drainage.  Grommets help in maintaining equal air pressure by enabling drainage of this fluid from the middle ear.

Procedure

The aim of the procedure is to effectively restore hearing in individuals who are suffering from hearing loss due to middle ear fluid.

Grommet insertion is a short duration procedure carried out under general anaesthesia. Your surgeon will make a small incision of about 2-3 mm in the eardrum and drain out the fluid from the middle ear with the help of suction. A grommet is then inserted into the eardrum which allows immediate entry of air into the middle ear to keep it ventilated.

Post-operative Care

Following the surgery, sound will be heard at a much higher level than before the surgery. This is normal and you will get used to this normal level of hearing in a few days.

  • It is important to protect the ears from water while the grommets are in place. You may be advised to use cotton wool with Vaseline to plug the ear which prevents water entering into the ear.
  • You are allowed to swim as long as you have your doctor’s permission. Make sure to wear ear plugs while swimming.
  • Immediately consult your surgeon if you notice foul smelling ear discharge.
  • Your doctor may prescribe antibiotic drops to prevent ear infection.
  • Avoid inserting sharp objects into the ear.
  • Pain medications may be prescribed to relieve pain.

Risks and complications

Generally, grommet insertion is a safe procedure. But as with any surgery, grommet insertion involves certain risks and complications. They include:

  • Ear infection and discharge
  • Perforated (hole) eardrum
  • Minor eardrum damage and scarring

Grommets will allow entry of air into the middle ear for several months until it is naturally pushed out of the eardrum. Grommets will fall out after a period of 6 to 12 months which is usually enough time to resolve glue ear completely. However, if the fluid returns, or the problem of glue ear persists even after the grommet has fallen out, repeat grommet insertions may be required until the problem of glue ear is completely treated.

Repair of Ossicular Chain (Ossiculoplasty)

Surgical repair of the ossicular chain, also known as ossiculoplasty, is a procedure to repair or reconstruct the damaged or discontinued ossicles of the middle ear. The ossicles refer to the three tiny bones of the middle ear: malleus, incus, and stapes. These ossicles are located in the middle ear between the eardrum and inner ear. The ossicles function to transmit and amplify external sound to the inner ear.

Hearing impairment occurs when there’s damage to one or more ossicles of the middle ear. Any ear infections, tumours, or trauma can cause damage to the ossicles. The damaged ossicular chain is repaired with artificial grafts or the bones are reconstructed together to establish the normal connection between the eardrum and inner ear. The aim of the procedure is to improve hearing ability.

Procedure

The procedure is performed under general anaesthesia. You surgeon will either make a small cut in front or behind the ear to gain access to the ear canal. The eardrum or the tympanic membrane is lifted with care and the ossicles are thoroughly examined. Your surgeon then performs a repair of the damaged or dislocated ossicles. The bones are either reshaped so they function better, or removed and replaced with artificial ossicles (prostheses). Some cases of repair necessitate the use of grafts, which are usually derived from the cartilage of the ear canal. At the end of the procedure, the tympanic membrane is returned to its normal position and the incisions are sutured closed.

Post-operative Care

You may experience mild pain following the repair of the ossicular chain. Your hearing capacity is evaluated after a few weeks. If you notice drainage of blood or water from the ear, place a piece of gauze over the ear. Discharge for the first 7 to 10 days is normal, but if you notice discharge for a long time with pain, swelling or foul smelling odour, consult your doctor immediately.

  • Wear a shower cap over your ears, or gently place a cotton wool ball in the operated ear while you shower. You should avoid water getting into the ear canal during the healing process.
  • Your doctor may prescribe ear drops or pain medications to relieve pain.
  • Avoid blowing your nose too hard for a few weeks and sneeze with your mouth open.
  • Strenuous exercises or air travel should be avoided for a few weeks.
  • Eating a healthy diet and quitting smoking will help with healing.

The risks and complications associated with the ossicular chain repair include

  • Same or diminished hearing
  • Perforated eardrum
  • Wound infection
  • Bleeding or discharge
  • Rarely, facial nerve damage
  • Dizziness which usually resolves
  • Altered taste

Balloon Dilatation of the Eustachian Tube

Balloon dilation of the Eustachian tube is a procedure in which the Eustachian tube is widened to improve its functions.

The Eustachian tube is a narrow tube that connects the middle ear to the back of nose. The tube helps in maintaining the balance of air pressure between the middle and outer ear. Opening of the tube while swallowing, chewing or yawning allows inflow of air into the middle ear and outflow of mucus thereby balancing air pressure on each side of the eardrum. This process maintains normal functioning of the eardrum.

If the Eustachian tube fails to open properly or gets blocked due to respiratory tract infections or allergies, an air pressure imbalance is created on either side of the eardrum thereby disrupting the functions of the tube. This may cause dulled hearing, ear fullness, tinnitus, and dizziness. Usually, this is a temporary condition which resolves on its own. But if this condition persists for a long time, it may permanently damage the middle ear and eardrum. If the symptoms do not respond to medical treatment your surgeon may advice either balloon dilation of the Eustachian tube , autoinflation (opening the tube by increasing nasal pressure) or insertion of grommets (ventilation tubes). 

Procedure

As a pre-operative measure, tubomanometry will be performed to assess the extent of Eustachian tube dysfunction. Tubomanometry evaluates the extent of the Eustachian tube opening and transfer of gas into the middle ear. Your surgeon will administer general anaesthesia and insert a small catheter with a balloon at its end into the Eustachian tube. A trans-nasal endoscope (flexible long tube attached to a video camera and lighted device) will guide the catheter through the nose into the Eustachian tube. After the balloon is properly placed into the Eustachian tube, your doctor will fill the balloon with saline solution up to a certain pressure. The pressure is maintained for about two minutes to stretch the Eustachian tube and the balloon deflated. The balloon is carefully removed along with the endoscope from the nose.

Risks

The risks associated with balloon dilation of the Eustachian tube include:

  • Damage of Eustachian tube
  • Permanent hearing loss
  • Ear infection and pain
  • Narrowing or scarring of the tube

Removal of Cholesteatoma via Combined Approach Tympanoplasty

Combined approach tympanoplasty (CAT) or canal wall up (CWU) mastoidectomy is a surgical procedure performed for the removal of a cholesteatoma in which the wall of the ear canal is left intact.

Cholesteatoma is an abnormal growth of skin in the middle ear behind the eardrum. Layers of old skin build up inside the ear to form a pouch which overtime increases in size and damages the ossicles of the middle ear. The ossicles refer to the tiny bones which transmit and amplify external sound to the inner ear. Enlargement of this pouch may cause pressure or a feeling of fullness in the ear. You may experience symptoms such as foul smelling discharge, impaired hearing, and rarely, facial muscle weakness or paralysis.

CAT is most often indicated in children for removal of a cholesteatoma and to overcome long-term complications from the mastoid cavity.

Procedure

The aim of this procedure is to remove the cholesteatoma, prevent future complications and spread of infection to other structures, and to leave the canal wall intact.

Combined approach tympanoplasty involves removal of the mastoid air-cells while retaining the bony walls of the ear canal intact. Surgery is performed under the effect of general anaesthesia or local anaesthesia with sedation.

The operative steps include:

A C-shaped hairline cut is made from above the pinna of the ear and a complete flap of skin from the mastoid bone is elevated.

Your surgeon carries out a mastoidectomy (removing the mastoid air-cells in the skull behind the ear) to expose the ossicles of middle ear. A tympanotomy (incision into the eardrum) is performed to identify the facial nerve and prevent it from damage.

Cholesteatoma with or without the damaged middle ear ossicles are removed based on the extent of injury present.
Your surgeon will examine the cavity endoscopically (flexible tube attached to a video camera and lighted device) and check for any residual cholesteatoma.

The bony canal wall is then reconstructed with bone graft or cartilage.

The tympanic membrane is repaired (tympanoplasty) with a graft. Your doctor will pack the middle ear and external ear with gel foam to support the grafts. The incised whole skin flap is closed and sutured.

A second look procedure may be required after 9 to 12 months to evaluate for residual or recurrent cholesteatoma and also for repair of the ossicular chain if needed.

Post-operative Care

Following the surgery, the operated ear and incision area should be kept clean and dry. Do not disturb the internal packing of the ear; you may trim the loose end of packing or change the external cotton wool packing if it gets soiled. The internal packing will be removed during your follow-up visit. Your surgeon may prescribe medications or ear drops to relieve pain and prevent infection. Avoid swimming, blowing the nose hard or strenuous exercises for a few weeks.

Risks and Complications

As with any surgery, modified radical mastoidectomy involves certain risks and complications. They include:

  • Dizziness and ringing in ears (tinnitus)
  • Loss of hearing
  • Partial or complete facial nerve paralysis
  • Taste alterations
  • Ear infections

Removal of Cholesteatoma via Modified Radical Mastoidectomy

Modified radical mastoidectomy, also known as canal wall down (CWD) mastoidectomy, is a surgical procedure which involves removal of the posterior (back) wall of the ear canal to create a common cavity for the mastoid and ear canal. This single cavity also known as mastoid bowl opens up to the outside of the ear canal. The procedure allows easy and complete removal of cholesteatoma without touching the eardrum and ossicles.

Cholesteatoma is an abnormal growth of skin in the middle ear behind the eardrum. Layers of old skin build up inside the ear to form a pouch which overtime increases in size and damages the ossicles of the middle ear. The ossicles refer to the tiny bones which transmit and amplify external sound to the inner ear. Enlargement of this pouch may cause pressure or a feeling of fullness in the ear. You may experience symptoms such as foul smelling discharge, impaired hearing, and rarely, facial muscle weakness or paralysis.

Modified radical mastoidectomy is most often indicated when cholesteatoma extends to the mastoid air cells and cannot be removed with a combined approach tympanoplasty.

Procedure

Modified radical mastoidectomy is performed under general anaesthesia. Your surgeon will make a cut above or behind the ear and remove the bone covering the mastoid air spaces. A large cavity is created which gives good access for complete removal of the cholesteatoma. The cavity may be left open to allow for easy evaluation during follow-ups or may be closed with bone grafts or cartilage.

The cavity is generally not grafted in children as it reduces in size with increasing age. Your surgeon will pack the ear to promote wound healing. A second-look operation may be required if infection recurs.

Post-operative Care

Following the surgery, the operated ear and incision area should be kept clean and dry. Do not disturb the internal packing of the ear; you may trim the loose end of packing or change the external cotton wool packing if it gets soiled. The internal packing will be removed during your follow-up visit. Your surgeon may prescribe medications or ear drops to relieve pain and prevent infection. Avoid swimming, blowing the nose hard or strenuous exercises for a few weeks.

Risks and Complications

As with any surgery, modified radical mastoidectomy involves certain risks and complications. They include:

  • Dizziness and ringing in ears (tinnitus)
  • Loss of hearing
  • Partial or complete facial nerve paralysis
  • Taste alterations
  • Ear infections

Advantage and Disadvantage

Advantages of a Modified radical mastoidectomy include infection removal and preventing its spread to other structures.

The main disadvantage of this procedure is frequent filling up of earwax into the created large cavity which requires periodic cleaning. Other disadvantages include:

  • Water retention in the created cavity
  • Alteration in hearing capacity due to structural change
  • Scuba diving is contraindicated

Stapes Surgery

Stapes surgery is a procedure to treat loss of hearing caused by otosclerosis, a condition that affects the normal functioning of the stapes bone (one of the middle ear bones forming the ossicular chain that conducts sound). Bony overgrowth causes the stapes joint to become rigid or fixed in place thereby preventing sound waves from reaching the inner ear. This condition hampers the process of nerve stimulation inside the inner ear and causes hearing impairment. Stapedectomy surgery involves replacing the damaged stapes with prosthesis (artificial stapes) so that sound is effectively transmitted from the eardrum to the inner ear. This resolves the problem of impaired hearing.

Procedure

Stapes surgery is performed under the effect of general anaesthesia or local anaesthesia with sedative. The procedure will be performed using an operating microscope. Steps of the procedure include:

  • Your surgeon will first make an incision in the ear canal and lift the eardrum.
  • A small drill or laser will be used to remove a part or the whole of the damaged stapes bone.
  • An artificial piston (metal or plastic prosthesis) will be placed in the gap to reconnect the middle ear bones and the inner ear.
  • The eardrum will be placed back into its original position and will be supported with packing material in the ear canal.

Post-operative Care

After the procedure, you may be able to hear on and off during the first few weeks with a temporary muffled sound. The dressing will be left inside the ear canal for 1 or 2 weeks. Avoid air travel, vigorous blowing of nose and entry of water into the ear. Keep the ear clean and dry; change the cotton wool if it gets soiled, but do not pull the dressing out. A hearing test may be conducted after 1 to 2 months. Regular activities can be resumed after consulting your doctor.

Risks and Complications

As with any surgery, stapes surgery involves certain risks and complications. They include:

  • Infection or bleeding
  • Damage to eardrum
  • Slipped artificial stapes
  • Diminished hearing
  • Altered taste
  • Rarely, facial weakness

After the stapes surgery, you are advised to have regular hearing tests to keep track of the surgical outcome and condition of the other unoperated ear.

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