Ear Infections

Frequently Asked Ear Questions

What does the ear look like?
The external ear that other people see is only the outer part of a complicated structure. The outer ear and ear canal are arbitrarily referred to as the external ear. The eardrum and the space beyond with the hearing bones, connected to the eustachian tube (which leads to the back of the nose), are referred to as the middle ear. A snail shell-like structure that contains fluid and nerve cells is called the cochlea. The cochlea and the nerve that leads to the brain are called the inner ear. There are also balance structures called semi-circular canals in the inner ear.

How does the ear work?
A sound wave is collected by the external ear and funneled through the ear canal. The sound wave strikes the eardrum. The eardrum vibrates and transmits the vibration through the three hearing bones, (malleus, incus and stapes) which are the smallest bones in the body. The stapes interfaces with the cochlea, which is fluid-filled. As the stapes moves, a fluid wave is set off through the cochlea and nerve cells move, depending on the type of sound force that is transmitted. The nerve cells, called hair cells, move perhaps like seaweed does underwater (as an example). When the hair cells move, the mechanical force is transferred to electrical activity that sets off the signals that are sent to the brain.

What is a perforation (or hole) in the eardrum?
The eardrum is a thin sheet of tissue that vibrates when a sound wave reaches it. Different mechanisms can cause a hole to occur in the thin eardrum. For example, an ear infection can cause an accumulation of pus behind the eardrum. As the pus builds up, the eardrum stretches like a water balloon, which can give the child significant ear pain. In some children, the pressure is sufficient that the eardrum "bursts," causing a hole in the eardrum, with a paradoxical relief of pain. This type of hole in the eardrum usually heals spontaneously, within a few days.

Mechanical trauma can also cause a hole in the eardrum. For example, sometimes the force of pressure from a dive into water by a young swimmer, can rupture the drum. Often the rupture will heal but occasionally, the perforation persists.

The most common reason for a hole in the eardrum is the result of a surgical procedure. This intentionally created perforation, allows ventilation to occur in the middle ear. Children who have had many ear infections and a subsequent problem of fluid remaining in the middle ear, usually can be helped by the placement of a ventilation tube. An incision is made in the eardrum and a hollow tube is placed in the eardrum to maintain the opening. The opening usually persists for a few months or years until the child has outgrown the problem. Usually the eardrum extrudes the tube on its own, and the perforation closes. Occasionally the perforation persists and needs further treatment.

Is a hole in the eardrum a "bad" thing?
A perforation created for the treatment of the consequences of ear infections, is an ally to your child's ear for the short run. However, after a period of time (usually years) if a hole in the eardrum has not closed spontaneously, and if the child is no longer having ear infections, the perforation presents some nuisance issues.

For example, water should not get into the ear because it can enter the eardrum through the hole and inoculate the ear with bacteria thus causing an ear infection. Also, the perforation must be checked periodically by a physician to make sure that the ear is not developing more chronic ear infections or more significant disease, such as cholesteatoma (see section below) or an ear polyp or a larger perforation.

About Eardrums

Can a hole in the eardrum be closed?
When the hole is probably no longer necessary, various techniques can be utilized to close the hole.

How does one close a hole in the eardrum?
Surgery is required to close a hole in the eardrum. Different techniques are available to the surgeon. If the hole is small, an operation can be done through the ear canal to the eardrum to place the patient's own tissue into the hole like one would place a cork into a bottle. Dr. Eavey has developed this technique which is now used by individuals in other parts of the world, such as Brazil. The procedure has even been used in remote areas of Australia by the Royal Flying Doctors, who assist the Aboriginal population.

The procedure described above is an outpatient procedure The patient is relatively comfortable during the process since no packing is required in either the middle ear or the ear canal. If a perforation is larger, it may be necessary to make an incision behind the ear. Cartilage and other tissues such as fascia (a thin type of tissue that coats muscles and is readily available) can be utilized to make the repair. Sometimes an eardrum operation (tympanoplasty) is combined with a mastoidectomy when more serious ear disease is present.(See below under cholesteatoma.)

Does the eardrum operation always work?
The procedure works 80-90% of the time. If the surgery is for closing a hole in the eardrum, usually hearing is spared or improved. If more serious disease exists in the middle ear, or there is a problem in the inner ear, hearing might not be normal even with the surgery.
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Ear Infections

How common are ear infections?
Ear infections account for approximately 25 million visits to physicians' offices annually. As many parents know, ear infections are often associated with a child who has pain and irritability or persistent hearing loss. Fortunately, antibiotics can provide significant relief. Also, many patients spontaneously improve. However, in a certain percentage of patients, medical therapy is insufficient. Sometimes surgical procedures such as insertion of ventilation tubes in the eardrums and/or adenoidectomy is necessary.

Are all ear infections alike?
The more common types of ear infections are acute infection, acute otitis media, or longer term fluid in the ear, otitis media with effusion. These conditions can exist separately but do in fact, frequently overlap. Other more significant infections can occur more rarely that have to do with more serious underlying ear disorders.

What general information might you share with parents in the office?
Below is the information sheet that is provided to patients in the office that explains different options and the treatment of ear infections. This is background information only and is not applicable to a specific patient. For more detailed information.(for patients of Dr. Eavey)
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The name, Cholesteatoma, is a misnomer. Previously it was thought that cholesterol was a major part of the condition. Actually, the condition consists of skin-like tissue growing in the middle ear where no skin belongs.

Is cholesteatoma common?
It is not common. But it is very commonly seen In the office of someone who does a considerable amount of ear care. In our hospital it is very commonly seen.

What damage does cholesteatoma do in the ear?
The disease can significantly destroy the hearing bones of the ear. Over time, the cholesteatoma can cause considerable problems. The significant time frame is years and decades, usually not weeks and months . Not only are the hearing bones being destroyed, but other tissues can become involved such as the facial nerve (which can cause paralysis), the inner ear(which can cause deafness and/or dizziness), the brain (as a cause of brain abscess or meningitis), or the neck (the site of an abscess).

What is the treatment for cholesteatoma?
Cholesteatoma can only be treated with surgery. It is important to know that the surgery might not be a one-stage treatment since cholesteatoma is a condition that requires long-term monitoring.

What type of surgery is needed?
The traditional surgical approach to cholesteatoma is to open up the small spaces among the middle ear, the ear canal and the mastoid (the bump in the skull that you feel behind the ear). This amount of surgery is needed because of the extensive destruction of tissue from the disease. This is called a canal wall down mastoidectomy.

Another procedure attempts to maintain more normal anatomy. With this surgery, the ear canal wall is maintained (canal wall up mastoidectomy). This operation is not applicable for all patients however. 

A third procedure makes a window between the mastoid and the ear canal wall to allow visualization but then reconstruction of the wall at the end of the operation recreates an intact ear canal wall (canal wall window mastoidectomy). It should be noted that cholesteatoma frequently recurs. Sometimes a second surgery is even planned, before the first operation occurs.

What are the goals of the surgery?
We attempt to eliminate the disease and to reconstruct the ear in a way to try to prevent re-accumulation of disease. Additionally, we work to gain the maximum hearing possible under the circumstances, depending on the location of the disease and the destruction that has already occurred. It is also our goal to provide an ear repair for the patient, that will not be problematic with water exposure and to provide as much of a normal appearance to the ear as is possible. Accomplishing those tasks is not always possible. But often, many of the objectives can be accomplished. We are particularly sensitive to hearing needs in children because the ear must serve them for decades.

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Sensorineural Hearing Loss

What is sensorineural hearing loss?
This type of hearing loss refers to a malfunction in the cochlea (sensory) and/or in the nerve (neural) to the brain.

What causes sensorineural hearing loss?
There are many causes of sensorineural hearing loss. In children, genetic causes are common. Sometimes infectious diseases, mechanical trauma or other conditions can create this type of hearing loss.

Is this why my baby was tested for hearing at birth?
Most states now have universal hearing screening for newborns. This type of hearing test screens to check the ears of normal babies. The test was first performed on babies who had been critically ill and had graduated from Neonatal Intensive Care Units where there is a high incidence of sensorineural hearing loss. Now, hearing loss can be detected in many babies near the time of their birth. It is usually necessary to follow up with more advanced hearing testing if there is a failure measured by screening.

Will sensorineural hearing loss get worse over time?
In some children, hearing remains stable. In other children, the loss progresses. For example, a condition known as "the enlarged vestibular aqueduct syndrome" progressively fluctuates and worsens in many patients. There are genetic conditions involved with progressive sensorineural hearing loss. Fortunately, many children with sensorineural hearing loss do have stable hearing that does not fluctuate.

Is this the type of hearing loss that requires hearing aids?
Hearing aids may be necessary for this type of hearing loss, depending on whether one or both ears are involved, as well as on the degree of hearing loss.

Is there any simple treatment for sensorineural hearing loss?
On occasion, we can try medications such as steroids with some success. There is no "simple operation" for sensorineural hearing loss although there are certain circumstances that warrant an operation, for example, to explore the ear for an inner ear fluid leak. For patients who have so little hearing that they cannot respond to hearing aids, there is an operative procedure called a cochlear implant. The implant procedure, however, is reserved for the very few patients who have a profound sensorineural loss in both ears.

Are x-rays usually done to look for a cause of sensorineural hearing loss?
X-rays are frequently obtained to look for an inner ear malformation.

Does blood work ever get performed?
In cases where the hearing loss could be familial, lab work can be obtained. It is a long process and not all families can be selected. However, we have had success in locating the gene in select families. 

There is another condition that involves a gene for a protein called connexin 26. There are times when we draw blood if this condition is suspected. The results, however, are not always clear at this time.

Will my child need special education?
Quite possibly. Besides hearing aids, in a classroom setting, sometimes an instrument called an FM trainer is used that helps to broadcast sound from the teacher. Other classroom maneuvers can be adopted as necessary. There are times when being educated in a mainstream school is appropriate for the child but other children may need to go to a school that specializes in education for the hearing impaired.

The Draining Ear

Should I panic if I see drainage from the ear? 
Many parents see earwax or other material that comes out of the ear and confuse it with something more significant.

What if blood or pus comes out of the ear?
Unless there is a condition like a skull fracture in which one would have some concern about the integrity of the ear, blood is usually present when an ear infection ruptures the eardrum. At other times, there will be blood mixed with pus, should an infection occur when a child has a hole in the eardrum or a tube in the eardrum. Usually these conditions can be treated with antibiotics either in drop form or in oral antibiotic form.