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Chronic Ear Disease | Cholesteatoma Surgery | Otosclerosis Treatment Dallas

Chronic Ear Disease and Cholesteatoma

When a patient has long standing or recurrent problems with ear infection, or drainage from the ear, we term this chronic ear disease. Patients need to realize that having draining of pus and infection from the ear is an abnormal symptom. Chronic ear disease is a spectrum of problems which might include a hole in the eardrum, thickening of the mucosal lining of the middle ear space (mucosal hypertrophy), or ingrowth of skin from the outer surface of the eardrum to within the middle ear space, and formation of a skin cyst that we call a cholesteatoma.

Cholesteatoma

Cholesteatoma is an infected skin cyst that usually occurs as a result of chronic negative pressure in the middle ear space. The negative pressure generally arises from malfunction of the eustachian tube during childhood. The function of the eustachian tube is to allow air equalization between the upper throat and nose with the middle ear space. If it does not work well, negative pressure will develop in the middle ear space. Over time, this negative pressure can suck in the eardrum to a point to where it contacts structures of middle ear or the inside walls of the middle ear. At that point the skin will start to grow across those structures or within the middle ear space and eventually form a skin cyst as an invagination of the skin of the eardrum. The inside of this cyst contains dead skin and bacteria and is oftentimes infected. The leading edges of the cyst have been shown to secrete enzymes which can destroy bone on the wall on the surface of the middle ear or the small bones of hearing which transmit sound from the eardrum to the inner ear (ossicles). It is important to recognize that cholesteatomas are not cancer. However, they do have destructive qualities to local tissues, and if they are untreated they can cause permanent hearing loss, dizziness, facial paralysis, or brain abscesses and meningitis which could even result in death. It is not unusual for them to cause erosion of the ossicles and a conductive hearing loss. A very small subset of patients may be born with a small bit of skin tissue behind their eardrum. This is called a congenital cholesteatoma and most people who have this problem will present at a very young age with a very large cholesteatoma and possibly no real history of ear infections.

Diagnosis of Chronic Ear Disease and Cholesteatoma

In most cases, we can visualize the opening of a cholesteatoma using our surgical microscopes in the office. A patient who presents with a history of drainage from the ear might respond to antibiotic treatment, but if this drainage recurs over and over it may be a cholesteatoma. A CT scan may or may not be ordered. Sometimes a CT scan can be very helpful in predicting how much damage has been done, and at other times the CT scan does not give us a great deal of information. Rarely, an MRI scan could be indicated. It is very important to recognize that hearing tests are valuable in helping to diagnose and manage patients with chronic ear and cholesteatoma. Sometimes a hearing test may show subtle changes that a patient does not notice, which gives us information about the extent of the cholesteatoma. These hearing tests are particularly valuable in following a patient in the long run after they have had treatment. A specialized test called an ENG may be ordered to evaluate the balance function of the inner ear in a patient with cholesteatoma.

Treatment for Chronic Ear Disease and Cholesteatoma

In the vast majority of casessurgery is necessary to attempt to cure people of chronic ear disease, middle ear mucosal disease, and cholesteatoma. Antibiotics can help but generally will not solve the problem long term. The surgery to repair holes in the eardrum and address disease states of the middle ear including mucosal disease, and cholesteatoma is called tympanoplasty. If the disease process is spread to the mastoid bone air cells (which are behind the middle ear space), it may be necessary to perform a mastoidectomy in conjunction with tympanoplasty. This operation is typically a day surgery. It involves having an incision behind the ear. If the cholesteatoma is extensive it may be necessary to do the surgery in two stages. The first stage would be for removal of the cholesteatoma, repair of the eardrum, and to establish an air containing middle ear space. The second stage procedure to look for residual cholesteatoma and repair of the hearing may be necessary. Cholesteatoma may recur in about 20-30% of cases.

Summary

It is very important for patients who have chronic ear infections with or without cholesteatoma to recognize why their problem is termed (chronic). Once these processes start in the ear they can, in some cases, last to some degree for the rest of a patients life. Patients who have had successful surgery to control disease are termed “chronic ear disease patients with inactive disease”. In many cases we are able to greatly improve the condition of people’s ear and even hearing, but it is very important for patients to realize that it is truly a chronic process.

Dodd Twins Middle Ear Surgery

Watch the following video to see how middle ear surgery helped two young twin brothers.

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Surgery for Chronic Ear Disease/Cholesteatoma

Typically, surgery is required to control or attempt to cure chronic ear disease and cholesteatoma. Due to the chronic nature of these conditions, patients will often require more than one surgery. Cholesteatoma may recur in 20-30% of the cases after surgery. It is important for patients to recognize the chronic nature of their ear problem.

Tympanoplasty and Mastoidectomy

A tympanoplasty surgery is an operation to attempt to repair a tympanic membrane perforation while addressing problems in the middle ear including scarring, marked thickening of the mucosal lining of the middle ear, or formation of a skin cyst called cholesteatoma. The small bones of hearing in the middle ear space are called the ossicles. There are three ossicles and their function is to transfer sound from the eardrum to the inner ear. It is not unusual for these to be eroded by chronic ear disease or cholesteatoma. An ossiculoplasty is an additional procedure which would involve attempting to repair the chain of ossicles to where they would transfer sound to the inner ear. It may be performed in addition to a tympanoplasty. The mastoid cavity is the area of bone behind the middle ear space which contains air spaces. It is not unusual for this area to become involved with chronic ear infection, mucosal disease, or cholesteatoma. Additionally, looking through the mastoid into the middle ear space offers a surgeon added exposure and visualization of the middle ear contents and then proves surgery in the middle ear space. Also, diseased mastoid air cells can be opened to provide better ventilation for the middle ear space. A mastoidectomy is a surgical procedure where the bone of the mastoid is removed with a surgical drill. The tympanoplasty procedure and mastoidectomy procedure both require that an incision just behind the crease of the ear. It is through this incision that a graft of tissue of muscle lining tissue (fascia) is obtained to reconstruct the eardrum. It may be necessary during an ossiculoplasty or tympanoplasty operation to harvest a small piece of cartilage from the tragus, which is the small pointer cartilage just in front of the opening to the ear canal. Ossiculoplasty operations may utilize the patients own reshaped second ossicle (incus) or it may involve using a titanium implant with cartilage graft.

Goals of Chronic Ear Disease/ Cholesteatoma Surgery

There are four basic goals to this type of surgery. The first goal is to remove the infection, the mucosal disease, or cholesteatoma. The second goal is to reconstruct the tympanic membrane. The third goal is to recreate an air containing middle ear space behind the new eardrum. The fourth and final goal is to improve a patients hearing.

Many times it is necessary to perform surgery with the first three goals in mind, and perform a second stage operation at a different date to attempt to reconstruct hearing in people. It is important for patients to understand the reasoning behind a two-stage philosophy. For most patients, there is a high degree of inflammation and infection in their ear, which is addressed at the initial surgery. When a person’s ear is in this state it is much more likely to form significant scarring. This scarring would reduce the chances of obtaining a good hearing result. As mentioned earlier, the recurrence rate on cholesteatomas is as high as 20-30%. Due to these two factors, many times it is advisable that a patient have a second-stage operation several months removed from the primary surgery. The goals of this second-stage surgery are to ensure there is no recurrence and to attempt to reconstruct the pathway of sound from the eardrum to the inner ear in an inflammation and infection free environment.

What to Expect Post-Operatively

Patients will have been given prescriptions for pain medicine and antibiotics prior to surgery. You should go ahead and get these prescriptions filled so you will have them ready. We usually dispense a three-day supply of pain medicine and it is very rare that patients call for refills. Ear surgery can be painful but it is probably better described as tenderness rather than just simple pain. It is not unusual for patients to describe tenderness in the ear and behind the ear. Additionally it is not unusual for patients to have numbness of the ear in the upper ear and in the skin behind the ear. This will gradually resolve. Patients may or may not have vertigo after surgery; if they do they should notify our office for instructions. A great deal of packing is usually placed in the ear canal after surgery, and patients will feel fullness in this region and their hearing will be muffled. Do not be alarmed if some of the packing comes out, it is supposed to be a brownish rust color with a texture similar to gelatin. A patient may or may not have a head dressing on at the time of discharge. If you are sent home with a dressing, please remove it the following day, roughly 24 hours after surgery. It is not unusual to have some diffuse swelling in the region of the incision and even the side of the face slightly anterior to the ear. Any severe swelling or “goose egg swelling” should be reported to your doctor.

A person’s ear may protrude slightly after surgery but it will gradually pull back into a more natural position over the course of approximately two months. It is important to avoid allowing water to get into the ear canal after surgery. A patient may wash their hair five-days after surgery. The ear canal should be protected from water at all times by saturating a piece of cotton with Vaseline and placing it in the ear near the opening of the ear. This will repel water while in the shower. It is extremely rare that a patient would have facial weakness after surgery, but should it occur it should be reported immediately to our office. We typically see patients who have this type of surgery one week after surgery to evaluate their wound and four to five weeks after surgery to clean their ear and check on the healing process and possibly evaluate the hearing.

Expectations

A person who has a cholesteatoma can expect that we can remove the cholesteatoma with no residual cholesteatoma present in 70-80% of cases. If it is a very small cholesteatoma those numbers are even greater. If a person was to have a small cholesteatoma residual found at the time of the second-stage surgery the chances of it coming back are extremely low (less than 5%). It may be necessary for a patient to undergo allergy treatment and go on allergy shots to help prevent this. With regard to repairing perforated eardrums, our success rate for tympanoplasty is greater than 95%. In the vast majority of patients who have ossiculoplasty we are able to improve their hearing, but it is rare that we are able to repair a person hearing to a perfect or near perfect level. It is very difficult to recreate the normal anatomy that is necessary to conduct sound perfectly from the eardrum to the inner ear. We strive and train continually to give our patients the best hearing reconstruction possible, and that is the best that we can do.

Summary

In summary, chronic ear disease and cholesteatoma is a very complicated and rare subject that very few people know about. If you want to discuss any of these topics in greater depth or have any questions about them please ask our surgery counselor and/or doctors prior to your surgery to make sure that you understand your condition, its prognosis, and treatment.

Otosclerosis

Otosclerosis is a condition which can involve a person’s ossicles (small bones of hearing) and create conductive hearing loss. This condition arises when abnormal, immature bone grows and “fixes” one of the small ossicles-typically the stapes. The stapes is the third bone in the chain of three ossicles. It receives sound from the eardrum and first two bones and transfers the vibration into the inner ear. Once the otosclerotic bone has grown around the footplate of the stapes, it will not vibrate and therefore does not conduct sound well into the inner ear. This is the cause of the conductive hearing loss. It is unknown what causes otosclerosis, but it tends to be more commonly seen in women and it can be familial. If a person is diagnosed with otosclerosis there is approximately a 40% chance they will develop it in the other ear.

Stapedectomy Surgery

Watch the following video for a story of how Stapedectomy surgery helped a woman with Otosclerosis.

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Diagnosis of Otosclerosis

There are no imaging studies or blood tests to diagnose otosclerosis. The diagnosis is made through the analysis of a patient’s history and hearing test results. The most typical presentation of otosclerosis would be a slowly progressive conductive hearing loss that is present in the low frequencies. Sometimes patients will have a mixed hearing loss which means that the otosclerosis has also involved the cochlea and caused sensorineural hearing loss in addition to the conductive hearing loss. There is no confirmed treatment for cochlear otosclerosis.

Otosclerosis Treatment Options

Otosclerosis is not a dangerous condition. Patients who have otosclerosis can elect to have no treatment, they may choose to purchase a hearing aid, or they may elect to undergo surgery. The surgery for otosclerosis is called a stapedectomy or stapedotomy. It is a day surgery which requires a general anesthetic. The surgery itself generally lasts only 30 minutes or so. Many patients choose to undergo surgery in order to avoid having to maintain a hearing aid.

Otosclerosis Surgery

If you have been diagnosed with otosclerosis it is important that you recognize that this condition can be treated with an elective outpatient surgery called a stapedectomy or stapedotomy.

The History of Otosclerosis Surgery

In the late 1950s a young surgeon in Tennessee determined that an operation could be done to help patients with otosclerosis. The operation involved removing the third little bone of hearing (stapes) and replacing it with a prosthesis that would transfer sound from the second bone (incus) to the inner ear. Once this operation was proven to be safe and effective many long time suffering patients with otosclerosis underwent the surgery. At this time, the instance of otosclerosis is approximately 1 in 40,000 patients; therefore many patients are referred to sub-specialists because of the rarity of this problem.

A stapedectomy operation involves removal of a portion, or the entire, stapes bone and usually involves placement of a tissue graft between the prosthesis and the inner ear. As surgeons performed more and more surgeries for otosclerosis, the small fenestra stapedotomy technique was developed. This operation involves using a laser and a micro-drill to create a very small opening through the stapes footplate into the inner ear. A prosthesis is then put in this region and a blood clot is used for tissue seal. It is generally felt that a stapedotomy procedure is slightly safer than a stapedectomy, and that patients may have slightly less postoperative dizziness. Our operation of choice is a stapedotomy but we are willing and able to do a stapedectomy as the need may arise (for example, in revision surgeries).

Surgery - What to Expect

A stapedotomy surgery is performed as a day surgery procedure under general anesthetic. We perform surgery at Harris Methodist of Southlake and Methodist Hospital for Surgery in Addison. On the day of surgery a patient will be admitted to the day-surgery unit and have an IV started in the holding area. The patient will be taken back to the operating room where they will breathe inhalation anesthetic and go to sleep. In addition to general anesthetic a patient will have their airway protected by being intubated. The surgery involves looking through the ear canal with a microscope and making an incision in the skin of the ear canal. This skin is reflected along with the ear drum to allow for visualization of the middle ear contents. We verify that a patient does indeed have otosclerosis. When we suspect a patient has otosclerosis, there is a 97% chance that we will be correct. 3% of the time it will be a different problem which almost always involves the second bone of hearing and can be dealt with at the time of surgery. The laser is used to remove the top of the stapes bone, and a laser and small micro-drill are used to create the small fenestra (hole) in the stapes footplate. Measurements are obtained and a very small platinum and surgical grade plastic prosthesis is placed into the fenestra and attached to the second bone, the incus. Blood typically is drawn from a separate mini-puncture site by the anesthesiologist (usually near the ankle). This blood is used to generate the blood clot which is used as a tissue seal. The eardrum is reflected back in place and the ear canal is packed off with dissolvable packing material.

The Early Postoperative Period

After surgery, in the recovery room a stapedotomy patient may or may not be slightly dizzy. There are medications which can control this dizziness well, most notably Valium in a very low dose. Most patients would agree that there is some postoperative pain but it is only moderate. The ear will feel stuffy because of the dissolvable packing, which is in the ear canal. Patients are discharged from the day surgery unit with prescriptions for pain medicine, antibiotics, and anti-vertigo medicine (Valium). It is helpful that these prescriptions would have been filled prior to surgery.

It is not unusual for a patient to also notice some burning or tingling on the side of the tongue, because there is a nerve which controls taste through parts of the tongue behind the eardrum which we generally have to move out of the way to do the surgery. This symptom may or may not be present, and if it is present it may persist for several weeks but will gradually disappear. The patient may notice an improvement of hearing in the first few days or week after surgery or not, depending on the degree of hearing loss present prior to surgery. If you are not noticing a big improvement in your hearing, do not be concerned because the packing will muffle hearing as well as swelling of the eardrum. As you have been informed before, approximately one patient out of every one hundred and fifty may lose their hearing to a point to which there would be no benefit from a hearing aid as a result of surgery. If you have severe vertigo or extremely loud roaring in the ear you should contact our office and alert us.

Long Term Expectations

In over 95% of patients, we are able to close the “air-bone gap” (the difference between your true hearing and your nerve hearing potential). Your hearing result largely depends how much hearing loss is present and how much of the hearing loss is due to nerve hearing loss. Your hearing test will be explained to you in depth prior to surgery, and should you have any questions make sure to ask them. Patients who have stapedectomies can expect their prosthesis to remain in place with no long term problems in at least 95% of cases. It is extremely rare that a prosthesis will shift. A symptom of a shift of the prosthesis would be renewed hearing loss. Patients who have a displaced prosthesis can have surgery to regain their hearing (revision stapedotomy), and this surgery is very similar to the original surgery.

Summary

Surgery for otosclerosis is very helpful in that it can allow patients to avoid having to use a hearing aid or enhance their use of hearing aids should they be necessary. Patients who have the surgery, by and far, are very happy with their result and would recommend it to other people diagnosed with otosclerosis. It is a safe and highly effective procedure which we are specialized in performing. I hope that this document answers many of the questions you may have, make sure and ask the surgery scheduling counselor or doctor should you have any questions which have not been addressed prior to or after surgery.

 
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