After a cold and/or due to blockage of the Eustachian tube* fluid can be trapped in the middle ear. This is common in young children but can also occur in adults. Occasionally this can lead to a middle ear infection known as acute otitis media (AOM). AOM is very painful, causes earache, is usually associated with a high temperature and sometimes the ear drum will burst or perforate due to pressure build up. Acute otitis media usually settles without requiring antibiotics but if it persists for more than 48 hours or occurs frequently then a course of antibiotics may be necessary.
Persistent effusion is known as ‘glue’, it can fill the middle ear space reducing the ability of the middle ear to transmit sounds to the cochlea. This results in a conductive hearing loss. I therefore arrange a hearing test when this problem is suspected and also carry out a pressure test, which measures the movement of the eardrum. Usually the effusion resolves on it’s own as the mucous reabsorbs and the Eustachian tube clears. Obviously the hearing loss can be problematic and if it is persistent it can affect a child’s speech and language development. It can be very bothersome for adults too, affecting their ability to communicate at work and in social situations.
There are National Institute for Health and Care Excellence guidelines for treating this problem in children under 12. If the fluid (effusion) is persistent for longer than 3 months with an ongoing hearing loss at or beyond a certain level, then ventilation of the middle ears with Grommets may be necessary. Children with Cleft palate or Down’s syndrome are more susceptible to glue ear and there are specific guidelines for managing these children.
A grommet (or ventilation tube) is a tiny tube placed through the eardrum. One flange sits either side of the drum maintaining the middle ear pressure to prevent further build up of glue/mucous. Grommet insertion is usually done under a short general anaesthetic. A small hole is made in the eardrum, the fluid drained and the grommet inserted. As the drum heals it pushes the grommet out into the ear canal. Grommets usually stay in place for 9-12 months. In adults this can be longer as the drum tends to heal more slowly. Once they have fallen out and the drum has healed there is a chance that further middle ear effusions can occur. The grommet is therefore not a cure but in children they allow time for the Eustachian tube to develop and subsequently ventilate the middle ear naturally.
*The Eustachian tube is a small part of our anatomy that connects the middle ear to the back of the nasal cavity.
The ear canal has a bony portion (the inner 2/3rds) and a cartilaginous soft tissue portion (the outer 1/3rd). Wax is produced from glands located in the skin in the outer third of the ear canal. It provides a natural protective layer that helps to waterproof and has antibacterial properties. There is natural migration of skin from the centre of the eardrum down the sides of the ear canal to the waxy area and then out of the ear canal, hence the ears clean themselves. Using cotton buds can therefore push wax deeper into the ear canal and disturb/impair the natural self-cleaning process. If the canals are narrow or there is more wax production than ususal then blockage can occur. Eardrops, for example sodium bicarbonate may be able to breakdown the wax and help it to naturally fall out, sometimes however, removal by a specialist is necessary. This involves microsuction - looking into the ear canal with a microscope and using suction to carefully remove the wax.
Microsuction also forms an important part of the treatment if there is an outer ear canal infection - known as otitis externa (OE). The symptoms usually involve a combination of mucky discharge, pain, a feeling of blockage and occasionally hearing loss. This type of infection can occur after swimming or contamination from the outside with dirty water/debris. It is more likely to occur in people with an underlying skin condition. Some people have dry ear canal skin, which can be itchy. Sticking anything in the ear increases the risk of infection. The other part of the treatment for otitis externa is antibiotic eardrops targeted at the organisms causing the infection and sometimes, steroid eardrops to reduce inflammation. It is also important to keep the ear(s) dry when there is infection/discharge. The infection is less likely to clear if the ear keeps getting wet. Using cotton wool coated with Vaseline is a good way to prevent water getting in the ear when bathing or showering because Vaseline repels water.
When the Eustachian tube function is poor or the middle ear pressure struggles to equalise with atmospheric pressure* there is an increased likelihood of problems with middle ear infections. The middle ear cavity is lined with mucosa that produces mucous. If the mucosa is congested it thickens and produces more mucous - this is what happens during a cold or upper respiratory tract infection. If the inflammation persists then infection known as chronic otitis media can occur. There are a number of features of chronic middle ear infection but a hallmark of active disease is discharge, which we call otorrhoea. Surgery may be necessary for chronic infection. This involves a combination of clearing the inflamed tissue, potentially repairing or reinforcing the eardrum (tympanoplasty) and sometimes attempting to reconstruct the hearing mechanism (ossiculoplasty).
Disturbance of the natural skin clearing mechanism of the ear can lead to a build up of trapped skin. This can occur when there is chronic infection, or it can cause chronic infections. There may be an associated hole in the eardrum (see next section). The trapped skin is called cholesteatoma. Occasionally people are born with some trapped skin behind an intact eardrum - this is a congenital cholesteatoma. Cholesteatoma will slowly grow, expanding to fill available space; it will also erode surrounding bone. The erosion can damage important structures nearby including the little hearing bones (ossicles) causing hearing loss. In severe cases there can be erosion of the inner ear affecting the balance or hearing, there can also be erosion of bone causing pressure on the taste or facial nerves, which pass through the ear. The cholesteatoma can also spread upwards or inwards to the head cavity, which again is more serious. Cholesteatoma needs to be removed with surgery. There are a number of different operations (or surgical approaches) that can be carried out depending on the position and extent of the trapped skin. The aim of surgery is to remove all unhealthy tissue and attempt to improve the hearing by reconstructing the hearing mechanism. The relative complexity of this depends on the extent of the problem. More than one operation may be necessary because there is a chance of recurrent or residual disease.
We can now look for cholesteatoma by doing a specific type of MRI (magnetic resonance imaging) scan that has diffusion weighted sequences. This is particularly useful about a year after an initial operation to look for further trapped skin. Our radiologists can confidently detect cholesteatoma that is 3mm or greater in size.
*Atmospheric pressure is the pressure of the air that surrounds us on earth.
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