Repair of a Perforated Ear Drum (Myringoplasty)

A hole in the eardrum can be repaired effectively using a small piece of cartilage from the ear. This procedure can be performed by operating down the ear canal with a microscope (transcanal), or from behind the ear (postauricular) depending on the size and position of the hole in the eardrum. The eardrum is lifted and the middle ear structures are assessed. Then a graft of cartilage is harvested, and is placed under the lifted eardrum before it is returned back into the normal position.

If the small bones of hearing (ossicles) are not functioning properly, then a titanium implant may be required to reconstruct the hearing mechanism

Exostoses Surgery (Swimmers Ear)

Swimmers and surfers who have spent a lot of time in the water can develop bony growths in their ear canal called exostoses. When these grow, they can completely occlude the lumen of the ear canal leading to water trapping, ear infections and hearing loss. Surgery can be an effective treatment to widen the ear canal, and resolve the ear problems. The surgery is performed under the microscope either from behind the ear (postauricular), or down the ear canal (endaural).

Removal of Cholesteatoma via Modified Radical Mastoidectomy

Modified radical mastoidectomy, also known as canal wall down (CWD) mastoidectomy, is a surgical procedure which involves removal of the posterior (back) wall of the ear canal to create a common cavity for the mastoid and ear canal. This single cavity also known as mastoid bowl opens up to the outside of the ear canal. The procedure allows easy and complete removal of cholesteatoma without touching the eardrum and ossicles.

Cholesteatoma is an abnormal growth of skin in the middle ear behind the eardrum. Layers of old skin build up inside the ear to form a pouch which overtime increases in size and damages the ossicles of the middle ear. The ossicles refer to the tiny bones which transmit and amplify external sound to the inner ear. Enlargement of this pouch may cause pressure or a feeling of fullness in the ear. You may experience symptoms such as foul smelling discharge, impaired hearing, and rarely, facial muscle weakness or paralysis.

Modified radical mastoidectomy is most often indicated when cholesteatoma extends to the mastoid air cells and cannot be removed with a combined approach tympanoplasty.

Procedure

Modified radical mastoidectomy is performed under general anaesthesia. Your surgeon will make a cut above or behind the ear and remove the bone covering the mastoid air spaces. A large cavity is created which gives good access for complete removal of the cholesteatoma. The cavity may be left open to allow for easy evaluation during follow-ups or may be closed with bone grafts or cartilage.

The cavity is generally not grafted in children as it reduces in size with increasing age. Your surgeon will pack the ear to promote wound healing. A second-look operation may be required if infection recurs.

Post-operative Care

Following the surgery, the operated ear and incision area should be kept clean and dry. Do not disturb the internal packing of the ear; you may trim the loose end of packing or change the external cotton wool packing if it gets soiled. The internal packing will be removed during your follow-up visit. Your surgeon may prescribe medications or ear drops to relieve pain and prevent infection. Avoid swimming, blowing the nose hard or strenuous exercises for a few weeks.

Risks and Complications

As with any surgery, modified radical mastoidectomy involves certain risks and complications. They include:

• Dizziness and ringing in ears (tinnitus)
• Loss of hearing
• Partial or complete facial nerve paralysis
• Taste alterations
• Ear infections

Advantage and Disadvantage

Advantages of a Modified radical mastoidectomy include infection removal and preventing its spread to other structures.

The main disadvantage of this procedure is frequent filling up of earwax into the created large cavity which requires periodic cleaning. Other disadvantages include:

• Water retention in the created cavity
• Alteration in hearing capacity due to structural change
• Scuba diving is contraindicated

Repair of Ossicular Chain (Ossiculoplasty)

Surgical repair of the ossicular chain, also known as ossiculoplasty, is a procedure to repair or reconstruct the damaged or discontinued ossicles of the middle ear. The ossicles refer to the three tiny bones of the middle ear: malleus, incus, and stapes. These ossicles are located in the middle ear between the eardrum and inner ear. The ossicles function to transmit and amplify external sound to the inner ear.

Hearing impairment occurs when there’s damage to one or more ossicles of the middle ear. Any ear infections, tumours, or trauma can cause damage to the ossicles. The damaged ossicular chain is repaired with artificial grafts or the bones are reconstructed together to establish the normal connection between the eardrum and inner ear. The aim of the procedure is to improve hearing ability.

Procedure

The procedure is performed under general anaesthesia. You surgeon will either make a small cut in front or behind the ear to gain access to the ear canal. The eardrum or the tympanic membrane is lifted with care and the ossicles are thoroughly examined. Your surgeon then performs a repair of the damaged or dislocated ossicles. The bonesareeither reshaped so they function better, or removed and replaced with artificial ossicles (prostheses). Some cases of repair necessitate the use of grafts, which are usually derived from the cartilage of the ear canal. At the end of the procedure, the tympanic membrane is returned to its normal position and the incisions are sutured closed.

Post-operative Care

You may experience mild pain following the repair of the ossicular chain. Your hearing capacity is evaluated after a few weeks. If you notice drainage of blood or water from the ear, place a piece of gauze over the ear. Discharge for the first 7 to 10 days is normal, but if you notice discharge for a long time with pain, swelling or foul smelling odour, consult your doctor immediately.

• Wear a shower cap over your ears, or gently place a cotton wool ball in the operated ear while you shower. You should avoid water getting into the ear canal during the healing process.
• Your doctor may prescribe ear drops or pain medications to relieve pain.
• Avoid blowing your nose too hard for a few weeks and sneeze with your mouth open.
• Strenuous exercises or air travel should be avoided for a few weeks.

• Eating a healthy diet and quitting smoking will help with healing.

The risks and complications associated with the ossicular chain repair include

• Same or diminished hearing
• Perforated eardrum
• Wound infection
• Bleeding or discharge
• Rarely, facial nerve damage
• Dizziness which usually resolves
• Altered taste

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Stapes Surgery

Stapes surgery is a procedure to treat loss of hearing caused by otosclerosis, a condition that affects the normal functioning of the stapes bone (one of the middle ear bones forming the ossicular chain that conducts sound). Bony overgrowthcauses the stapes joint to become rigid or fixed in place thereby preventing sound waves from reaching the inner ear. This condition hampers the process of nerve stimulation inside the inner ear and causes hearing impairment. Stapedectomy surgery involves replacing the damaged stapes with a prosthesis (artificial stapes)so that sound is effectively transmitted from the eardrum to the inner ear. This resolves the problem of impaired hearing.

Procedure

Stapes surgery is performed under the effect of general anaesthesia or local anaesthesia with sedative. The procedure will be performed using an operating microscope. Steps of the procedure include:

• Your surgeon will first make an incision in the ear canal and lift the eardrum.
• A small drill or laser will be used to remove a part or the whole of the damaged stapes bone.
• An artificial piston (metal or plastic prosthesis) will be placed in the gap to reconnect the middle ear bones and the inner ear.
• The eardrum will be placed back into its original position and will be supported with packing material in the ear canal.

Post-operative Care

Afterthe procedure, you may be able to hear on and off during the first few weeks with a temporary muffled sound. The dressing will be left inside the ear canal for 1 or 2 weeks. Avoid air travel, vigorous blowing of noseand entry of water into the ear. Keep the ear clean and dry; change the cotton wool if it gets soiled, but do not pull the dressing out. A hearing test may be conducted after 1 to 2 months. Regular activities can be resumed after consulting your doctor.

Risks and Complications

As with any surgery, stapes surgery involves certain risks and complications. They include:

• Infection or bleeding
• Damage to eardrum
• Slipped artificial stapes
• Diminished hearing
• Altered taste
• Rarely, facial weakness

After the stapes surgery, you are advised to have regular hearing tests to keep track of the surgical outcome and condition of the other unoperated ear.