Tympanoplasty with Mastoidectomy
Ossicular Chain Reconstruction
Middle Ear Exploration
Chronic otitis media, otherwise known as “chronic ear disease”, is a disorder that causes a range of problems, affects adults more than children, and is caused by chronic (lasting more than six months) middle ear infection. The problem usually stems from Eustachian tube dysfunction. The Eustachian tube is the narrow opening between the middle ear and the back of the nose. It normally acts like a valve, opening and closing with swallowing to equalize the air pressure between the nose and middle ear. The Eustachian tube may be small or inadequate from birth or the mucosal lining the tube may be inflamed or swollen from chronic infection in the sinuses or allergies. Children often have Eustachian tube dysfunction, leading to repeated episodes of acute otitis media (middle ear infection of shorter duration), and the necessity for ventilation tubes, tiny tubes surgically placed into the ear drum of children to provide temporary drainage and ventilation for the middle ear. This problem usually resolves by the time a child is 6-8 years of age, because at that point the skull and Eustachian tubes are normally near adult size. A small percentage of children will develop perforations from their ventilation tubes, requiring a tympanoplasty, or will go on to have chronic otitis media as adults.
In adults, Eustachian tube dysfunction and chronic otitis media are closely related and produce problems ranging from serous otitis media/otitis media with effusion (chronic middle ear fluid), adhesive otitis media (retracted or collapsed ear drum from decreased pressure inside the middle ear), tympanic membrane perforation (hole in the ear drum), conductive hearing loss (something interfering with sound reaching the inner ear), ossicular discontinuity or ossicular fixation (damage to the tiny bones in the middle ear between the ear drum and inner ear), mastoiditis (fluid or infection in the mastoid bone behind the ear), and cholesteatoma (locally destructive cyst of trapped skin debris in the middle ear or mastoid).
Perforations of the ear drum can occur for reasons besides chronic otitis media, including trauma and extreme pressure changes. Sometimes patients do not know how they got a perforation in their ear drum. If any of these conditions are present, your surgeon may recommend an operation to correct the problem, which may consist of one or more of the following procedures in combination:
Tympanoplasty – Operation to repair a perforation in the ear drum. Tissue from another area, typically fascia or perichondrium (connective tissue), is used to make a “graft” (patch) which is then used to repair the ear drum from the underside. The graft is held in place with dissolvable packing material placed under the graft and on top of the ear drum after it is put back into position. The repair takes several weeks to heal and during this time the patient is asked to avoid activities such as heavy lifting or hard blowing of the nose, which could dislodge the graft before it is healed. Cartilage is also frequently used to reinforce a graft in situations where the surgeon is concerned that the graft may become retracted again, or for large perforations.
Mastoidectomy – Operation to remove infection or disease (cholesteatoma) from the mastoid, the normally porous bone behind the ear. It is almost always performed in conjunction with tympanoplasty. An incision is made behind the ear and the diseased bone is drilled away down to the level of the opening into the middle ear, which is provides aeration (ventilation) to the mastoid. Mastoidectomy also provides access to the middle ear space and ossicles (middle ear bones) which may be necessary to eradicate disease from areas of the middle ear that could not be adequately accessed through the ear canal. In cases where there is extensive cholesteatoma extending from the middle ear into the mastoid or in an area of the middle ear that cannot be adequately accessed, it may be necessary to remove the bony posterior wall between the ear canal and mastoid, creating a “cavity”. Such a procedure is often called a “canal wall down mastoidectomy”. The advantage of such a procedure is that it allows convenient monitoring for recurrence of cholesteatoma and cleaning of the ear in clinic. The disadvantage is that the patient must visit their ear surgeon approximately once a year to have their ear and mastoid cavity cleaned, as well as the need to keep water out of the ear.
Ossicular Chain Reconstruction – This is a procedure to repair or replace one or more of the tiny bones in the middle ear, consisting of the malleus, incus, and stapes (hammer, anvil, and stirrup), when they have been damaged by infection, disease, or trauma. It is always performed as part of a tympanoplasty and sometimes with a mastoidectomy as well. The artificial bone used for this repair is called a prosthesis, and there are many different types and styles of prostheses which can replace one or more of the ossicles, depending on the situation. These prostheses are usually made of titanium, plastic, or ceramic of some type. It is often necessary to use a tiny piece of cartilage between a prothesis and the graft to reduce the chances of extrusion (prosthesis being rejected by the body and coming out through the ear drum). Ossicular chain reconstruction is done to improve conductive hearing loss, but the actual degree of hearing improvement that is achieved is often difficult to predict.
Middle Ear Exploration – There are situations where a patient has a conductive hearing loss, but it is not completely clear from the history, examination of the ear, or a CT scan exactly what is causing the loss. In this case, the surgeon may recommend a middle ear exploration. This is an operation in which the ear drum is folded back so that the middle ear and ossicles can be inspected. The surgeon will palpate (touch with an instrument) the ossicles to assess their degree of mobility. The bones must all be able to move easily in order to efficiently transmit sound to the inner ear. If it is found that they are damaged or defective, the surgeon will perform an ossicular chain reconstruction.
There are three objectives of all operations for chronic ear disease. They are, in order:
- Eradicate infection and disease (especially cholesteatoma)
- Produce a “safe” ear (an ear that is safe to get wet, without perforation in the ear drum)
- Restore or improve hearing (not always possible)
All the above operations are performed on an outpatient basis at the Shea Clinic Ambulatory Surgery Center with the patient under general anesthesia. If your operation requires an incision behind your ear, there will be slightly more pain and discomfort afterwards than if it is done through your ear canal. Healing takes several months to become complete, and the hearing improvement will usually not be apparent immediately after your operation. It is recommended that you avoid flying for several weeks following your operation, and you should not get your ear wet until your surgeon tells you that it is okay to do so. The sutures will dissolve on their own and will not have to be removed. You will be given a follow-up appointment several weeks after your operation to remove the packing material that is still in your ear. At this point your hearing will be tested to assess the degree of improvement.
All operations involve risks, which include but are not limited to bleeding, infection, further loss of hearing, dizziness, recurrent perforation, recurrent cholesteatoma, alteration in taste on the side of the tongue, facial nerve weakness (very rare and usually temporary), complications from anesthesia (also very rare), and the need for additional operations. Most of these issues are minor and will resolve over time. No guarantee of success can be given, however. Dr. Paul Shea is fellowship-trained in neuro-otology and has extensive training and experience in the surgical treatment of all forms of chronic ear disease. The ambulatory surgery center at the Shea Clinic was specifically designed for operations on the ear, nose, and throat, and the latest techniques and state of the art equipment are used to insure the best possible outcome for all patients, including facial nerve monitoring on all procedures.
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