Middle Ear

Where is the Middle Ear: The ear is analytically divided into three parts: External, Middle, and Internal. At the end of the external auditory canal, there is the tympanum. The tympanum separates the external ear from the middle ear. In other words, the middle ear is located closer to the tympanum and comprised of a cavity. Inside this cavity, there are small ossicles called anvil, malleus, and stapes. These ossicles’ task is to transmit the voice coming from the external ear to the internal ear. The middle ear is connected to the nasal cavity through a canal (Eustachian tube). This canal sets the pressure inside the middle ear.

How many types of Middle Ear Inflammation are there? : Middle ear inflammation develops depending on bacteria. If this inflammation is newly emerged, it is called acute middle ear inflammation; but if it is present for a long time and appears as a hole on the tympanum, it is called chronic middle ear inflammation. However, sometimes middle ear inflammation is caused by blockage of the Eustachian tube (depending on allergy or adenoid). In this case, it is called serous middle ear inflammation.

How does the inflammation emerge? : When bacteria enter the middle ear and reproduce enough to cause diseases, middle ear inflammation occur. Microbes usually reach the middle ear through the Eustachian tube from the throat or the nasal passage. Since the Eustachian tube is shorter and flatter in children’s bodies, middle ear inflammation is more commonly seen with children. As long as the tympanum remains intact, inflammatory bacteria cannot pass from the external ear to the middle ear. Sometimes, the middle ear may have inflammations that are not caused by bacteria. This case is usually due to the pressure problems and accumulation of sticky liquid in the middle ear, which are caused by the blockage of the Eustachian tube because of allergy or adenoids. This case, which is referred as serous middle ear inflammation, has different symptoms than the middle ear inflammation caused by bacteria. Thus, they require different treatments. While the inflammation caused by bacteria is treated with medicines, serous middle ear inflammation may require surgeries such as scratching the tympanum or implanting tubes.

What are the symptoms? : The most common symptom of middle ear inflammation is pain. Especially children feel the pain more acutely. There are also complaints such as hearing loss, fever, restlessness in babies, and repletion. If the inflammation penetrates the tympanum, bloody or inflammatory drainage emerges. In serous middle ear inflammation, hearing loss without pain occurs. Also, in chronic middle ear inflammation, there are symptoms such as hearing loss, discontinuous or continuous drainage, and fetid odor.

What is observed during examination? : Examination findings vary according to the type of middle ear inflammation. In the inflammation caused by bacteria, the tympanum appears very red and convex. In serous otitis media, the most significant finding regarding the tympanum is its rupture. Reddening can also be seen. In chronic inflammations, holes in the tympanum and drainage, if exists, can be observed.

Which tests are performed? : Since diagnosis for a newly emerged middle ear inflammation is made during the examination, there is usually no need for tests. However, hearing tests are necessary for serous and chronic middle ear inflammations. These tests help to identify the level of hearing loss and to evaluate the examination results. In serous inflammations, a test called tympanometry is performed to determine middle ear pressure. In chronic middle ear inflammations, having x-ray or computerized tomography may be required, especially when the surgical operation is being considered.

How is it treated? : Acute middle ear inflammation is usually treated with antibiotics and painkiller medicines in a proper way. In rare cases when the body does not respond antibiotics, scratching the tympanum may be required. Medicine treatment is primarily applied in serous otitis media as well. Particularly the serous middle ear inflammations caused by allergy respond well to the medicine treatment. However, surgical operation such as scratching the tympanum and implanting tubes can be necessary for more than once. In chronic middle ear inflammations, medicine treatment is seldom sufficient for healing. Surgery is often required to heal chronic middle ear inflammations.

Middle Ear Inflammation is repeating very frequently: To name it a repeating middle ear inflammation, the patient must undergo 3 or more middle ear inflammations in a period of 6 months. For children with repeating middle ear inflammation, diseases such as cleft palate, nasal or sinus allergy, adenoid, and sinusitis are researched. If one of these diseases is identified, it is treated. If no such disease is present in the body, preventive treatment is applied according to following procedure: 1- Injection of low dose antibiotics when there is no middle ear inflammation. 2 – Scratching the tympanum or implanting a tube on the tympanum. 3- Removing adenoids. 4- Some vaccines.

In which cases surgery is performed? : In serous middle ear inflammation, if the patient has hearing loss untreatable with medicine, then surgery is required. In chronic middle ear inflammation, a surgery is required if the inflammation starts to dissolve the ossicles in the middle ear and to spread into the tissues around.
What are the risks? : There is usually no risk if acute middle ear inflammations are treated with a right dose and for an appropriate time period. In serous middle ear inflammations, there can be hearing loss due to the severe ruptures on the tympanum and dissolving of the middle ear ossicles. In case of severe tympanum ruptures, sometimes there emerges a tissue called cholesteatoma, which causes dissolution of bones and spreading of inflammation to surrounding tissues. Chronic middle ear inflammation can result in most dangerous effects, as compared to other inflammations. Cholesteatoma often comes into existence in case of chronic inflammations. Surgery may not be required if cholesteatoma is absent and if the level of hearing loss is tolerable. However, particularly cholesteatoma may trigger spreading of the inflammation and cause the complications listed below:
– Complete hearing loss and dizziness due to the inflammation’s spread into the internal ear.
– Brain abscess due to the inflammation’s spread into the brain.
– Facial paralysis
– Meningitis

How is surgery performed? :  The operation for serous otitis media can be either scratching the tympanum or implanting a tube. The liquid piled up in the middle ear is discharged by scratching (perforating) the tympanum. There is no need to implant a tube if amount of the liquid is low and if the liquid is not viscous. However, a tube is implanted in the perforated spot of the tympanum if the liquid does not flow due to its viscosity. These tubes, which are called ventilation tubes and which connect the external ear with the middle ear, enable air intake to the middle ear. While they can be applied with local anesthesia, usually general anesthesia is required, especially for children. Surgeries for chronic middle ear inflammations are often larger-sized operations. If there is no complication during the surgery, inflammation in the middle ear is discharged, breaking of the ossicles due to dissolving is fixed (this may sometimes require implanting prosthesis), and the hole in the tympanum is repaired. Usually the membrane of the muscle behind the ear is extracted and utilized for repairing the hole. In case of complications during the treatment of chronic middle ear inflammations, removing the inflammation is usually the primary and sometimes the only purpose of the surgery. To do so, the bones around the ear are expanded, and sustaining hearing function becomes a secondary objective. Sometimes hearing may even be sacrificed. In chronic inflammation surgeries, usually an incision behind the ear is made.

What happens if I do not have operation : In serous middle ear inflammations, rupture in the tympanum expands and liquid accumulation advances if the patient does not choose surgery. Hearing loss reaches to a level that hinders daily life conducts, and the chances of success in forthcoming operations diminish. In chronic middle ear inflammations, if hearing loss is tolerable, the inflammation is passive, and drainage is seldom, then the patient can carry on his/her life without an operation. In this case, the patient should avoid getting water into his/her ears and having upper respiratory tract infections. However, if the inflammation becomes active frequently, drainage emerges, hearing loss advances, dissolving of ear ossicles gains speed, and complications caused by middle ear inflammation arise, then the treatment method must surely be surgery.

What are risks of having surgery? : As it is with all surgeries, there are some risks and complications of middle ear surgeries as well. For instance, there are risks related to anesthesia since general anesthesia is commonly preferred for these operations. Also, perforating the tympanum may harm the internal ear, albeit very seldom. Some problems may emerge during tube implementation. The tympanum may be damaged while implementing the tube and the tube may enter the middle ear. After the tube is inserted, there can be permanent punctures, calcification, and infection in the tympanum, leading to drainage.  The surgeries for chronic middle ear inflammations are larger-scale operations, and they include some complications. Complete hearing loss due to damaging the internal ear, facial paralysis, injuring surrounding vessels and nerves are amongst the important complications.

What should I be careful about after surgery? : Patients with tubes implanted in their ears should be careful to prevent water from getting into their ears. Aside from this, check-up for once in a month would be sufficient. The most important issues in case of chronic middle ear inflammations are applying the dressings as proscribed by the doctor and taking the medicines in the way the doctor recommended. For patients who undergo surgeries for middle ear inflammations, there is no significant proscription regarding drink and food consumption. For those patients whose bone around the ear is deeply carved due to chronic middle ear inflammation, there can be earwax accumulation inside the carved spot. These earwax should be cleaned periodically.
Is surgery the ultimate solution? : In middle ear inflammation surgeries, there can be no promises for completely eliminating this problem forever. Patients with tubes implanted in their ears may experience pressure and liquid problems after the tube is removed. There are patients who continuously experience problems despite having several tube implementation operations. After chronic middle ear surgeries, problems such as instability of the implanted membrane, dislocation of the implanted prosthesis, and continuation of inflammation may emerge.