Chronic Ear


(Information on ear intraoperative endoscopy can be found on the project website: www.otoendoscopy.pl)

In contrast to acute otitis media, which is a disease quite common, chronic otitis media is currently rare. This is due to early diagnosis and treatment of predisposing diseases and common use of antibiotics. Otherwise, as in acute inflammation, which, after conceding generally leaves no permanent changes in the construction of the ear, chronic inflammation is associated necessarily with pathological changes of clinical matter.

Smoldering inflammation leads to many changes in middle ear:

  • perforation of the tympanic membrane and leakage of discharge (pus, mucus, often with an unpleasant odor, pesky patients),
  • formation of granulation tissue, which can lead to further damage to the middle ear structures including the ossicles, labyrinth semicircular canals, facial nerve canal,
  • polyp formation ingrown into the lumen of the external ear canal,
  • tympanosclerosis plaque formation,
  • formation of adhesions of tympanic membrane with other structures of the tympanic cavity,
  • A particularly dangerous form of chronic inflammation of the middle ear is called. cholesteatoma, where ingrowing epidermis of the external auditory canal creates epidermoid cysts widespreading destructively deeper into the ear.

 

Main patients complaints are:

  • Hearing loss
  • Discharge from the ear, they might not be seen during the day, but leaving traces on the pillow at night,
  • Dizziness after getting water into the ear (associated with perforation of the tympanic membrane)
  • Dizziness and ear pain are rare in this pathology and are an alarm signals, demonstrating the occurrence of hazardous complications or other disease underlying this kind of symptoms (eg, recurrent acute otitis media, inflammation of the external ear canal).


The most common forms of active inflammation of the middle ear (with the leak) are:

Simple chronic otitis media.

Here there is a loss of the tympanic membrane in the pars tensa not including its edges, and the muco – purulent discharge. Accompanying symptom is hearing loss - it is usually caused by loss of the tympanic membrane and ossicular chain destruction. This disease is not at high risk of intracranial or intratemporal complications. Conservative treatment is sufficient. The aim is to dry the ear, which lead to the conceding of leakage. We need to cure the predisposing disease – which means a diseases primarily leading to obstruction of the Eustachian tube – which by its communication with the nasopharynx allows pressure equalization in the middle ear and to prevent the retraction of the tympanic membrane. It is mainly nasal septum, nasal polyps, adenoid hypertrophy (so-called "third tonsil"). It is very important to have regular ENT checks, which allow precise exoneration of ear, under control of microscope. After stabilization of the ear and disappearance of leakage, we carry out a planned operation to close the defect in the tympanic membrane, and possibly reconstruction of the ossicular chain if necessary and improve of hearing.

 

Cholesteatoma:

This type of inflammation is very important as it is associated with a high risk of complications during the course of the disease whose course is often oligosymptomatic and insidious. Cholesteatoma is epidermal cyst in the middle ear, resulting from disorders of migration of the epidermis of the skin of the external ear canal. It often grows in through the edge of a perforation of the tympanic membrane or from epitympanic retraction pocket (pouch of tympanic membrane ) which becomes so deep that the epidermal deposits can no longer be removed. Retraction pockets of low-grade therefore require constant microscopic monitoring of the ear in order to monitor the possible progression. In advanced pockets preventive tympanoplasty is performed.

 

Cholesteatoma is an insidious disease because it often for a long time is asymptomatic, even with wide destruction of the middle ear. Sometimes, even with wide ossicular chain damage, cholesteatoma mass acts as prothesis, leading the tones, which do not cause noticeable hearing loss.

In the case of epidermal mass infection appears smelly discharge from the ear, leading the patient to visit ENT. It should be noted that treatment of cholesteatoma is only surgical.


Chronic granulating otitis media:

It is characterized by muco – purulent discharge, loss of the tympanic membrane, the inability to dry the ear during conservative treatment, the possibility of bone destruction. Treatment of this condition is surgical with the collection of granulation tissue for histopathological examination.

Sometimes removal of granulation changes can be difficult due to the pulling important structures in the process – for example, the facial nerve.

 

The inactive forms of otitis media include:

 

Tympanosclerosis

In this disease in the lining of the middle ear appear collagen – calcium deposits.

Often dry perforation is present, sometimes tympanic membrane is thickened with calcium deposits, reducing its mobility. Ossicles also tend to be immobilized.

The diagnosis can often be made in policlinic, but sometimes diagnosed is made only after diagnostic typanotomy due to conductive hearing loss.

Extensive changes do not indicate satisfactory improvement after surgery. In these cases  hearing aids are recommended.

 

Atelektazja

 

It involves pulling the tympanic membrane in to the tympanic cavity. When only part of tympanic membrane is involved we are talking about retraction pockets. They are very important because of the risk of transmitting in to the cholesteatoma.

Pockets are a form of hernia in which the sac is formed of the epidermal layer of the tympanic membrane pulling through a aperture in the fibrous layer. Specific risk (called the precholesteatoma state) are pockets with discharge, filled with epidermis or polyps. As already mentioned, retraction pockets require periodic inspection and consideration of treatment that improves the ventilation of the middle ear as the removal of adenoid, deviated nasal septum correction or insertion of tympanostomy tube.

Surgery

In the case of otitis surgery has two main objectives. The first is the removal of the causes of inflammation - infected granulation tissue or cholesteatoma matrix, the second is to restore sound conduction system – the tympanic membrane and ossicular chain to improve the hearing.

The different types of ear surgery include:

  • radical ear surgery – now rarely performed, especially in the case of complications of otitis, which is aimed at creating a common cavity and good conditions for the purification of the ear. We do not perform  here the reconstruction of the conduction sound system.
  • lateral petrosectomy – also aims to clean the ear from pathological changes. It is used in case of deafness of occupied ear or severe sensorineural hearing loss. With this technique, you have to ensure complete removal of inflammation, because after cleaning the postoperative cavity is filled with fat taken from the abdominal wall, locked down tight, including suturing the external auditory canal.


Tympanoplastic surgeries

While operating the diseased ear we face two problems (especially when it comes to choesteatoma) at first – the most radical removal of the disease, giving no chance of recurrence and the second issue is the ability to restore the best possible hearing.

Genaral operations to remove inflammation and simultaneously reconstruct the ossiculo-tympanic system are called tympanoplasty. They are divided into open and closed type.

The closed type save posterior wall of the ear canal, resulting in good ability to reproduce the sound conduction system, however, gives worse conditions for complete removal of changes from the ear, which in the case of cholesteatoma requires a second operation, in English called "second -look " about 9 months after first treatment, which means the re-opening of the middle ear, during this stage we assess that there is no recurrence of the disease and then we implant the ossicles prothesis under the reconstructed tympanic membrane. After healing of the ear it can be soaked.

Open type operation – here the operation is performed in one step, elimination of the posterior wall of the external ear canal gives a very good view of the operative ear – therefore the small cholesteatoma recurrence rate. Ear after open surgery can not, unfortunately, be soaked in water, hearing results are worse and every six months it is necessary to clean ear cavity from collected wax and exfoliated epidermis.

Currently, we bring in into the ear operation endoscopes that can be used inside the ear during the procedure and allow to visualize the recesses difficult to visualize in the operative microscope. Hopefully we will be able more effectively remove completely inflammation of the middle ear, reducing the number of recurrence. Intraoperative use of endoscopy also gives hope to increase the efficiency of the reconstruction of the ossicular chain, thus improving hearing.

Currently, the Department of Otolaryngology, Medical University of Warsaw carries out development project funded by the National Research and Development Centre "The development of the principles of endoscopic surgery of the middle ear" under the direction of prof. Kazimierz Niemczyk.