Problems of the Ear - Diseases and Disorders of the Ear
© 2004 Hearing Central LLC


There are two categories of hearing problems that cause hearing loss:

• Conductive hard of hearing - where sound cannot pass through the outer or middle ear.
   
• Sensorineural hard of hearing - where the cause of the hard of hearing is in the cochlea or in the hearing (auditory) nerve. Other names for this kind of hard of hearing include sensory, cochlea, neural, and inner ear hard of hearing. Sensorineural hard of hearing often reduces the quality of sound as well as its loudness.
  

Blockages
Otitis Externa
Swimmers Ear
Perforated ear Drum

Common Problems of the Middle Ear

Otitis Media
Glue Ear
Chronic Suppurative Otitis Media
Mastoid Infection
Otosclerosis
Damaged Ossicles

Sensorineral Hard of Hearing
Cochlear Implants

Blockages in the external ear canal  

Blockages in the external ear canal may affect your hearing. They are usually caused by wax. Your ear makes wax in order to clean itself. The wax normally falls out of the ear on its own. Occasionally, you may need to visit your doctor to have it removed.

Do not try to remove wax from your ears yourself. Never push cotton buds, fingers or anything else into your ears. You will push any wax there is onto your eardrum. This could cause pain, infection and hard of hearing. It is best to ask your doctor to check your ears if you think you have a wax build-up.


Otitis externa

Otitis externa is when the skin of the ear canal becomes inflamed. This may happen if you have:

• scratched the lining or your outer ear canal
• you have a skin condition such as eczema, or
• if you have picked up a fungal infection from swimming.

Symptoms
Initial symptoms may be itchiness and a watery discharge. The discharge may dry overnight around the outside of the ear. There is usually little or no hearing loss. See your doctor to get ear drops and keep the ear dry.

Treatments
If the cause is a bacterial infection, then a trip to the doctor is required to get a prescription for some type of anti-biotic. Over The Counter (OTC) topical antibiotics may do the job, but if the condition persists, see a doctor.

If the cause is a fungal infection, a trip to the doctor is also recommended.

Swimmers Ear
A known effective home remedy for "swimmer's ear" (the fungal infection kind) and if there is no perforation of the ear drum, is to obtain some powdered boric acid and a pint of ethyl alcohol (not methyl alcohol which is the more common kind) from your local pharmacy. Take a large pinch of the boric acid and drop into into the 1 pint of Ethyl alcohol. After shaking well, take an eyedropper full of the mixture and fill the ear with the mixture. Let sit for a minute, then turn the head to drain out. Do it one more time and wipe any excess liquid off. Do this three time a day for 5 days. In the mornings, you will notice the dries mixture will cake. Just wipe off with a damp cloth. UNDER NO CIRCUMSTANCES LET WATER OR SOAP INTO THE EAR WHEN YOU TAKE A SHOWER. After a week you should be fine.

Perforated eardrums

Perforated eardrums can also be caused by serious infections and head injuries. Most eardrums that are perforated however, are because of injury or trauma. Most will heal on their own within about three months. However, if a dirty item caused the injury, such as a stick, you might need antibiotics after the injury. If it fails to heal you may need a tympanoplasty to repair the eardrum. The perforated eardrum can also be treated by an operation called a myringoplasty, where a tissue graft is used to seal up the hole.

Common Problems of the middle ear   

Common terms for the bones of the middle ear (Ossicles) are: Stirrup (Stapes), Hammer (Malleus). Anvil (Incus)


Otitis media (Middle Ear Infection)

Otitis media is an infection or inflammation of the middle ear usually caused by a viral or bacterial infection.

Symptoms
Some of the symptoms of middle ear infection include:

• Earache
• Headache
• Fever
• Discharge from the ear
• Mild deafness
• Difficulties in sleeping
• Loss of appetite.

Causes: The causes of middle ear infection can be:

• A progressive head cold
• A viral sinus infection that spreads
• An otitis externa infection left too long that spreads to the inner ear
• Blowing your nose too hard, forcing sinal or eustachion material into the middle ear.
• An opportunistic infection entering through a perforated eardrum
• Treatment
  

Mild infections clear up by themselves in a matter of hours. Over-the-counter painkillers can help alleviate the pain. Warm olive oil dripped in the ear can also soothe the pain. repeat every few hours.

In more severe cases, antibiotics might be needed which usually includes an initial antibiotic shot, antibiotic pills and ear drops.

In many cases of middle ear infection, the eustachian tube is blocked and can cause or at least contributes to a middle ear infection. (See also Glue Ear, below). A eustachion tube can become blocked from any combination of the following:

• The body's inflammation reaction to an infection, swelling the tube to where it closes completely.

• A contributing factor can be the discharge of the dead bacteria and dead lymphocytes in the lymphatic fluid from the middle ear. The lymphatic system contains the white blood cells or lymphocytes which are the body's defense against foreign objects such as bacteria. When the white blood cells kill bacteria, the lymphatic fluid becomes pus-like. Pus is made up of dead white blood cells and dead bacteria. This discharge from the middle ear can irritate the eustachion tube causing it to close.

A blocked eustachion tube is what causes the pain of a middle ear infection. Pus builds up in the inner ear cavity with no where to go, putting pressure on the inner ear and the ear drum. If left without treatment, pressure in the middle ear cavity can be so great that it bursts the ear drum. The initial excruciating pain of a burst eardrum is immediately compensated for by pain reduction from the release of pressure. Whereas, prior to the burst eardrum, sleep was impossible, the pain relief from the pressure reduction allows the sufferer to finally sleep. If the middle ear infection is cured, the ruptured ear drum usually heals on its own, although sometimes surgery (tympanoplasty) is indicated if the rupture is extremely large.

Otitis Media Complications -Glue Ear

There is a natural flow of fluids from the middle ear (the fluids keep the middle ear cavity moist) that migrate through the eustachion tube to the back of the throat. A blocked eustachion tube prevents air from reaching the middle ear. When this happens the middle ear can fill up with the fluid that can becomes thick, like glue over time. This problem is called glue ear or otitis media with effusion. The buildup of fluid in the middle ear reduces the movement of the eardrum and ossicles, and hearing is reduced. More information


Otitis Media Variants

Chronic Suppurative Otitis Media (CSOM)
CSOM is the name given to a condition when you get an infection of the middle ear which fails to heal and is draining all the time. There are two forms of this condition:

• Tubo-tympanic. The tubo-tympanic form usually involves a perforation of the central part of your eardrum. This can be caused by infection, injury or surgery.
  
  Symptoms
  You may have a hearing loss and a discharge, which may come and go, and will become noticeable particularly if you get a cold or your ear gets wet. You might also get tinnitus.
  
  Treatment
  If the opening is not too large, it may close and heal on its own. Failing that, an ENT (Ear, Nose, and Throat specialist) may close it with surgery or by covering it with a special material to keep the opening closed while it heals,.
  
  You can usually help your symptoms by taking simple steps - for example, by wearing an ear plug or keeping your ear dry when you are having a bath or swimming. A hearing aid can improve your hearing. However, you may need an operation to repair the hole in the eardrum. This is called a tympanoplasty or myringoplasty.
   
• Attico-antral. The attico-antral form of CSOM might also involve a hole in your eardrum - usually in the upper part. This form of CSOM can be more of a problem than the tubo-tympanic form because your eardrum sheds dead skin which can build up and enter your middle ear. This skin can then mix with wax and other debris to form a cyst-like mass. This is known as a cholesteatoma. This type of CSOM can be quite serious, because the cholesteatoma can get bigger and cause damage to nearby parts of your ear, such as the eardrum and ossicles.

Symptoms
The attico-antral form of the condition causes a smelly discharge to leak from the ear. You may also have a hearing loss and sometimes tinnitus. You can get vertigo - dizziness - if your semicircular canals, which form part of the balance system, are damaged. Occasionally the cholesteatoma can damage the bone covering the nerve that supplies your face, which can weaken your facial muscles. In very severe cases it may even wear through your skull, causing meningitis or brain infections.

Signs that damage is taking place include extreme pain, vertigo, weakness of the facial muscles and bad headaches.

Treatment
It is important to remove the cholesteatoma and all traces of infection. For this, it is usually necessary to have a procedure known as mastoid surgery (see below), usually performed by an Ear, Nose, Throat (ENT) specialist.

Attico-antral Complications - Mastoid Infection

The mastoid is an area of bone just behind the ear. In fact the cochlea part of the inner ear is actually embedded in it. The mastoid contains lots of small air pockets like a sponge. Because it is made mainly of bone, the mastoid does not have a large blood supply going to it, thus minimizing the effect of any antibiotics - if the antibiotic can't get to the site, it can't destroy any bacteria. Surgery may be required to remove the infection.

Mastoid Surgery

An operation on the mastoid bone is done under general surgery.  It involves drilling away the infected bone. This aims to remove all the infected tissue and cholesteatoma. There are a few different types of mastoid surgery depending on how bad your condition is. Some of these leave a cavity (hole) in the mastoid bone, which may require regular cleaning. Your surgeon should discuss with you exactly which operation is suitable.

Otosclerosis

 The last bone in the vibration chain in the middle ear is the stapes. It is attached to the cochlea at the oval window. Otosclerosis is a metabolic imbalance condition that causes new bone to grow over the end of the stapes, where it connects to the cochlea. This leads to a reduction in movement and eventually the bone becomes fixed as no vibration occurs, causing the elimination of transfer of sound to your inner ear and permanent hearing loss.

Very occasionally, otosclerosis can also affect your inner ear. The condition can affect either one, or more commonly, both ears. If left untreated, otosclerosis will cause your hearing to steadily get worse and can lead to profound deafness.

Otosclerosis can run in families and often begins around the age of 30. The condition is also more common in women and often gets worse in pregnancy. It is thought that this is due to the release of high levels of the hormone estrogen during pregnancy. If you have otosclerosis and are worried that your pregnancy may affect your hearing, see your doctor. You may have to have a hearing test from time to time in order to monitor your hearing.

Symptoms
Symptoms include tinnitus and hearing loss, often at lower frequencies - deeper sounds - to begin with. You may also find that your hearing is better in noisy surroundings. People with otosclerosis tend to speak quietly.

Treatment
In the early stages of otosclerosis, or when the condition is mild, you might not need any treatment. Hearing aids are very useful initially. However, as the calcium buildup on the stapes progresses you will gradually lose your hearing. Sodium fluoride tablets have been shown to help prevent the progression of otosclerosis, but only if the condition has also affected the inner ear.

At some point, most people usually have an operation - a stapedectomy or stapedotomy - where a tiny piston replaces the stapes so that sound can travel to the inner ear. This operation has a high success rate.

Stapedectomy
This operation aims to improve your hearing by replacing the stapes - one of the ossicles - with a piston. The piston helps to restore the movement of the ossicles, so transmitting sound into the inner ear.

Photo courtesy American Academy of Family Physicians

Most of the stapes bone is removed, leaving just the portion called the footplate, which sits in contact with the oval window. The oval window is the link between the middle and inner ear. A small hole is then drilled in the footplate and the piston is inserted so that it sits in contact with the oval window. At its other end, the piston is attached to the incus (anvil), the middle of the three ossicles.

About 85% of people find the operation a success and report a good improvement in hearing. However, there is a very small risk - about 1% - that fluid will leak from the inner ear and cause a complete loss of hearing in that ear. There is also a small risk of fluid loss in the years following surgery - for example, if you have a sudden blow to the head or sudden pressure change that causes the piston to penetrate the membrane of the oval window.

Occasionally the piston may move slightly and you will need a second operation to put it back into place. If you have this second operation there is a higher risk - about 5% - that you will lose your hearing completely in the ear that has been operated on.

Damaged Ossicles (Ossicular chain disruption)

Serious infections and head injuries can damage one or all three of the bones that make up the ossicles. Babies are sometimes born with malformed ossicles. They can be repaired or replaced by having an operation called an ossiculoplasty.

Ossiculoplasty
An ossiculoplasty operation repairs damage that has occurred as a result of infection or injury to more than one of the three bones of the ossicles. The damaged ossicles are replaced with either artificial bone, called prostheses, or small pieces of bone taken from somewhere else in your body. The prostheses can be made from man-made bone material, plastic or ceramic. The ossicles are very small and this makes the surgery very delicate. This means that although the operation can improve your hearing, it may not completely return.

This damage may happen from the following causes:

• Naturally, as you grow older (Presbyacusis). Hearing aids will be helpful in this situation.
• If you have a disease such as mumps or meningitis.
• If you have to take certain strong drugs - in particular aspirin in very high doses, or antibiotics called aminoglycosides (i.e. streptomycin and gentamicin)
• If you are exposed to loud noise for a long time. (By law, if you work somewhere very noisy you must be provided with earplugs or muffs to protect your hearing.)
• If you have a serious head injury with a skull fracture.
• Before a baby is born - for example, if the mother has rubella (German measles) while she is pregnant.
• If a baby is born prematurely or if the mother has a difficult labor.
• Sensorineural hard of hearing from birth may also be genetic. It is common for people in one family to have the same pattern of hearing loss as they get older.

Treatment

Other than for the gradual destruction of the hairs that line the cochlea, the only good treatment for disease of genetic causes is a cochlear implant. A cochlear implant may be an option for people who have become profoundly deaf through sensorineural hard of hearing, or for children who were born deaf.

Cochlea implants

If you were born hearing but have lost nearly all your hearing through sensorineural hard of hearing, and hearing aids are not powerful enough to help, a cochlea implant may be an option for you.

A cochlea implant is a small electronic device consisting of:

• An external battery worn somewhere on the body or clothes
• A microphone/ sound processor usually placed behind the ear which translates sounds into electrical signals and then sends these to the internal part.
• A connecting system which is surgically implanted in the ear. It passes through the ear drum and the middle ear, bypassing the ossicles.
• A thin receptive wire that is threaded into the full length "snail shell" of the cochlea to transmit electrical impulses from the sound processor to the auditory nerves. The brain doesn't care where the signals originate, just that it can hear them and interpret them
  
  

A cochlea implant does not provide perfect hearing, but many people who have cochlea implants can understand speech and recognize different sounds around them. Some can even use the telephone.

Children who are born deaf can also sometimes have cochlea implants. Better results are likely if this is done while they are still very young.

© 2004 Hearing Central LLC