Hi. My name is Michael Seidman, I am an Otorhinolaryngologist (also known as an ENT Surgeon). I received my BS degree in nutrition and MD degree both from the University of Michigan. I did a residency training in Otolaryngology and then did a fellowship in hearing, balance, facial nerve, skull base, acoustic neuroma and cochlear implant surgery at the Ear Research Foundation in Florida. I am the primary surgeon at HFHS who performs sophisticated ear surgery.
By definition, you have a chronic ear infection, which implies a hole in the ear and usually but not always, you will have experienced some drainage ranging from once to all the time. Typically, the hole in the ear and the chronic low-grade infection causes a hearing loss, sometimes from the hole itself or from erosion of the three tiny bones of hearing. I would like to show you some specific anatomy as this will help you understand the nature of your problem.
Sometimes people also have what is called cholesteatoma. Cholesteatoma is the medical term for skin in the middle ear. Skin is okay and normal in the external ear, but if it gets into the middle ear it is considered a potentially dangerous situation. I see this all the time, and the majority of people do just fine with routine ear surgery. Cholesteatoma is considered dangerous because it slowly erodes important structures. If it erodes upward, it can enter the brain and cause a brain abscess. If it erodes into the inner ear it can cause permanent hearing loss/deafness, tinnitus (ringing in the ear) and balance problems including vertigo (spinning). It can erode into the facial nerve and cause paralysis of the face. Thus, this is a problem that requires surgical attention.
The primary goals of surgery are to:
- Eradicate any long term infection or cholesteatoma
- Fix the hole in the ear, if present
- Improve hearing if possible
- Create a "safe" ear
There are several operations that we do, depending upon the nature of your problem. Most people can be treated with either of the following operations: Tympanoplasty, Tympanoplasty with mastoidectomy, Radical mastoidectomy with meatoplasty +/- tympanoplasty, revision of any of these surgeries.
Tympanoplasty: this means to explore the middle ear, remove disease and rebuild the eardrum. This is an outpatient procedure that takes approximately 1.5 hours if it is straight forward or 2.5 hours if it is more difficult. You will typically have a preoperative appointment with a nurse from the anesthesia team who will determine your needs and discuss some of what to expect. On the day of surgery we will re-discuss the ear that we are operating on and I will answer any further questions that you might have. An intravenous line is typically started, unless you are a child (in which case they start the line after you are asleep this is at the discretion of the anesthesia team). You are then taken into the operating room, and appropriate monitors are attached to check your heart oxygen saturation, temperature, blood pressure, etc. The anesthesiologist then gives you medicines and maybe a mask over your face to help you fall asleep. Once you are asleep, I place special monitors with regard to your facial function. This allows me to monitor your facial nerve (which is always in close proximity when doing ear surgery). The facial nerve monitor reduces, but does not guarantee, the risk of facial nerve injury. Next I shave about 2 inches of hair behind your ear and then we sterilize your skin with betadine or some other agent if you have a known allergy to this compound. The incision is made behind the ear, so it is relatively hidden. To rebuild your eardrum I use something called temporalis fascia, which is the covering of the muscle used for chewing. This really has no bearing on the muscle and is not something that you will miss or feel after surgery. I remove any disease from your middle ear and then assess your bones of hearing to make sure they are connected and working appropriately. If not, I may do what is called an ossiculoplasty or ossicular chain reconstruction (which means to re-connect your hearing mechanism). Sometimes I am able to use your second bone of hearing (incus) and do what is called an incus interposition graft, other times I use a sterile man made prosthesis often called a POP or TOP. I also place gel foam (a sponge like material) in your ear to help stabilize the prosthesis and to support the fascia graft, this keeps it from falling away from the hole in the ear and helps in healing. This gel foam takes about 6-8 weeks to fully dissolve, so most people have more hearing loss immediately after surgery and this may gradually improve as the gel foam dissolves. Sometimes I need to put silastic sheeting in, which is a plastic like material that reduces scarring/adhesion, this can stay inside the ear or mastoid forever, rarely, we remove it with a second procedure.
The primary risks of any ear surgery include but are not limited to bleeding, infection, change or loss of sense of taste (about 1/2 of patients experience this and usually this resolves in days to 6 months but can be permanent in some people -this is really unusual), this is because the taste nerve (chorda tympani) runs right thru the middle ear, in some people with cholesteatoma this may already be eroded and most people don't or didn't notice the change in taste as it was so gradual. There is also a risk to the facial nerve as this runs right through the middle ear and mastoid. I have done 1000's of ear surgeries and have never injured a facial nerve from routine ear surgery, I have operated on a child who had 8 previous MT operations and I was asked to do his 9th operation, after surgery he had facial weakness which resolved after 1 week. The use of the facial nerve monitor reduces the risk of facial paralysis but does not guarantee against it. Other risks include recurrence of cholesteatoma (if you had it in the first place), this is a common occurrence and is usually secondary to the disease process itself. Cholesteatoma is said to recur in 20-50% of the cases. In my experience it recurs in about 20-25% of patients. Some surgeons automatically recommend a "2nd look" procedure, where we come back to the OR and re-operate 6-12 months after the initial surgery. I base this decision on the extent of the cholesteatoma. If there is only a small cholesteatoma, I will not routinely recommend a 2nd look, however, if there is a significant amount of cholesteatoma it is advised to go back and re-explore the ear in 6-12 months. Typically, in children, cholesteatoma tends to be a bit more aggressive than in adults. Other risks include complete hearing loss, tinnitus (ringing in the ear) and permanent balance disturbances but these are few and far in-between. Nonetheless, they can occur.
Most surgeons will tell you that they have an 80-85% success rate at closing the hole in the eardrum and eliminating drainage. In my hands the success rate approaches 95%, we are very good, but not perfect. Another very possible occurrence is slipping of the incus interposition or the TOP or POP (whichever is used). In most routine tympanoplasty surgery, the bones of the hearing are intact, but when they are not we attempt to re-attach them. They are the smallest bones in the body and if they slip off from where I place them, but even 1/10th of a millimeter, the hearing will be down. Options include doing nothing, wearing a hearing aid or attempting a revision ossiculoplasty. When using your own incus to reconstruct, I will sometimes (with your permission) use cyanoacrylate glue (super glue), I have found that my success rate (of bones staying where they belong) to increase to about 80%, this is not an FDA approved use, but I have found that in medicine, there are many things that are routinely used that are not FDA approved, nonetheless, if you would rather I did not use the glue please tell me and I will abide by your wishes. Most people who are honest with you about their results will tell you that about ½ have improvement in their hearing (when you have to work on the ear bones). Since using the super glue our results have improved to about 80%, and there appear to be no risks from using the glue, we use only a tiny drop. After surgery you will experience some pain, this is typically well controlled with Tylenol with codeine or Darvocet (if you are allergic to codeine). Everyone's pain tolerance is different some are back to work the next day while other require up to a week off.
24 hours after surgery you need to remove the head bandage. Start by washing your hands thoroughly then cut the gauze bandage down the middle of your forehead. Carefully remove the entire dressing. There will be a cotton ball which you should change daily or as often as it is saturated. If it requires changing more than every hour, I need to be called. You must be careful because there is a 1-2 inch piece of gauze (outside packing-within the ear canal), if this comes out a little, just tuck it back in gently, if it is all the way out just leave it out, there is more packing in deeper. You should remove the steri-strips (band-aid like material behind the ear) 7 days after surgery. I will remove the inside packing in the office in 7-14 days. Then you will use drops in the ear usually 1-2 times per day for 7-14 days. You will need to be seen every 2-4 weeks until the ear is completely healed which is typically 3 weeks if you are fast and 3 months if you are slow. Just so you are not surprised, it is normal for the ear to stick out, this will gradually go down over weeks to months, sometimes it sticks out permanently, but this is usually subtle. Many people complain of numbness of the ear and occasionally there will be shooting pains, this goes away with time.
Some restrictions include:
- No forceful nose blowing
- If you sneeze, be sure your mouth is open
- No lifting of more than 5-10 lbs until further notice (usually 4-6 weeks)
- No straining
- Keep ear dry until further notice
Copyrighted to Michael Seidman,MD., FA