Ear Conditions

Ear Conitions Treated by Dr Jae Park

What is otitis externa?

Swimmer’s ear (also called acute otitis externa) is a painful condition that affects the outer ear and ear canal that is caused by infection, inflammation, or irritation.

These symptoms often occur after water gets trapped in your ear, especially if the water has bacteria or fungal organisms in it. Because this condition commonly affects swimmers, it is known as swimmer’s ear.

Swimmer’s ear often affects children and teenagers but can also affect those with eczema (a condition that causes the skin to itch), those with highly sensitive or allergic skin reactions, excess earwax, and who wear hearing aids or earbuds.

What Are the Symptoms of Swimmer’s Ear?

Signs and symptoms of swimmer’s ear may include:

• Itching inside the ear (common)

• Pain inside the ear that gets worse when you tug on the outer ear (common)

• Sensation that the ear is blocked or full

• Drainage from the ear

• Fever

• Decreased hearing

• Intense pain that may spread to the neck, face, or side of the head

• Swollen lymph nodes around the ear or in the upper neck

• Redness or swelling of the skin around the ear

If left untreated, a certain amount of hearing loss may occur. When the infection clears up, hearing usually returns to normal. Recurring ear infections (chronic otitis externa) are also possible. Without treatment, infections can continue to occur or persist.

Bone and cartilage damage (malignant otitis externa) are also possible due to untreated swimmer’s ear. If left untreated, ear infections can spread to the base of your skull, brain, or cranial nerves. Diabetics, older adults, and those with conditions that weaken the immune system are at higher risk for such dangerous complications.

What Are the Treatment Options?

Treatment for the early stages of swimmer’s ear includes careful cleaning of the ear canal and use of eardrops that inhibit bacterial or fungal growth and reduce inflammation. Mildly acidic solutions containing boric or acetic acid are often effective for early infections.

Before using any drops in the ear, it is important to be sure you do not have a perforated eardrum (an eardrum with a hole in it).

Drops are more easily administered if done by someone other than the patient, and the patient should lie down with the affected ear facing upwards. Prescription drops should be placed in the ear as directed on the label. After drops are administered, the patient should remain lying down for a few minutes, so the drops have time to work.

For more severe infections, your doctor may prescribe antibiotics to be applied directly to the ear. If the ear canal is swollen shut, your doctor may place a sponge or wick in the canal so the antibiotic drops will enter the swollen canal more effectively. Pain medication may also be prescribed. If you have tubes in your eardrum, a non-ototoxic (do not damage your hearing) topical treatment should be used. Topical antibiotics are effective for infection limited to the ear canal. Oral antibiotics may also be prescribed if the infection goes beyond the skin of the ear canal.

How Can Swimmer’s Ear be Prevented?

A dry ear is unlikely to become infected, so it is important to keep the ears free of moisture during swimming or bathing. Prevention tips include:

• Use ear plugs when swimming.

• Use a dry towel or hair dryer (from a distance) to dry your ears.

• Have your ears cleaned periodically by an ENT specialist if you have itchy, flaky or scaly ears, or extensive earwax.

• Do not use cotton swabs to remove ear wax. They may pack ear wax and dirt deeper into the ear canal, remove the layer of earwax that protects your ear, and irritate the thin skin of the ear canal. This creates an ideal environment for infection.

What is cholesteatoma?

Cholesteatoma is an abnormal skin growth or skin cyst trapped behind the eardrum, or the bone behind the ear.

Cholesteatomas begin as a build-up of skin, which causes either a lump on the eardrum or an eardrum retraction pocket. Over time, the skin collects and eventually causes problems like infection, drainage, and hearing loss. The skin may take a long time to accumulate and can spread to the area behind the eardrum (the middle ear space) or to the bone behind the ear, called the mastoid bone.

What Are the Symptoms of Cholesteatoma?

Cholesteatoma may cause these symptoms:

• Hearing loss

• Ear drainage, often with a bad smell

• Recurrent ear infections

• Sensation of ear fullness

• Dizziness

• Facial muscle weakness on the side of the infected ear

• Earache/pain

If you experience any of these symptoms, you should see an ENT (ear, nose, and throat) specialist, or otolaryngologist, as soon as possible.

There are different reasons why a cholesteatoma may develop. The most common cause is poor ventilation of the middle ear space, which is called “eustachian tube dysfunction.” The eustachian tube is the natural tube that connects your middle ear space to your nose and sinuses and helps regulate the pressure behind your eardrum. If the eustachian tube is not working properly, the middle ear space does not get ventilated. This creates negative pressure and ultimately causes the weakened eardrum to retract. This retraction collects skin and earwax, which leads to a cholesteatoma. Seasonal allergies or sinusitis may contribute to eustachian tube dysfunction.

A cholesteatoma can develop when skin of the ear canal passes through a hole in the eardrum and into the middle ear space. Finally, another rare type of cholesteatoma is present at birth (congenital) and is related to how the ear develops.

Are There Potential Dangers?

Without proper treatment cholesteatoma will cause recurrent ear infections. Chronic infection of the ear can lead to progressive hearing loss and even deafness. Cholesteatoma can erode bone, including the three bones of hearing, which may cause infection to spread to the inner ear or brain. These infections can lead to meningitis, brain abscess, facial paralysis, dizziness (vertigo), and even death.

What Are the Treatment Options?

Cholesteatoma can be managed in a variety of ways, but definitive removal of the skin or cyst typically requires surgical intervention. Before surgery, your ENT specialist may need to carefully clean your ear and prescribe medications to help stop the drainage. These medications (oral antibiotics) may be taken by mouth, applied directly to the ear (topical antibiotics), or both. It is advised that you keep the ear dry while treating these infections.

The specific type of surgery depends on what part of the ear is involved with the cholesteatoma. Sometimes the extent of disease is clearly seen on the office exam. Other times imaging, often a CT scan, helps to define where the cholesteatoma is located. CT scans are a collection of X-rays that provide good detail on the bony anatomy of the ear. A hearing test, or audiogram, should be obtained. Other tests like an MRI or balance testing may be required.

The primary goal of cholesteatoma surgery is to remove the skin, clear the infection, and create a dry, safe ear. This may involve reconstructing the eardrum, removing bone behind the ear, or reconstructing the hearing bones. In some cases, a second surgery may be required to make sure all the cholesteatoma has been removed before the hearing bones can be rebuilt.

What is Otosclerosis?

Otosclerosis describes a condition of abnormal bone growth around one of the three small bones in the middle ear space called the stapes.

When bone around the stapes hardens, the bone cannot move freely, which limits the ability to properly transmit sound.

What Are the Symptoms of Otosclerosis?

The symptoms of otosclerosis include:

• Progressive/worsening hearing loss

• Difficulty hearing low-pitched sounds or whispers

• Ringing, roaring, buzzing, or hissing in the ears or head, known as tinnitus 

What Causes Otosclerosis?

An estimated 2.5 to 10 percent of adults have some otosclerosis in their middle ear. Hearing loss can happen anytime, but it often begins in young adults, those in their twenties or thirties. The condition can develop in both women and men, although it has a higher incidence in woman and has been linked to rapid onset during pregnancy. Otosclerosis affects both ears approximately 70 percent of the time, however, the amount of hearing loss may not be the same in each ear.

Approximately 60 percent of otosclerosis has an underlying genetic cause. Transmission of the gene that causes otosclerosis is complex and not everyone who has the gene will develop the condition.

What Are the Treatment Options?

The main options for otosclerosis include observation with repeated hearing tests, a hearing aid(s), or surgery. Observation is recommended only for mild hearing loss. Some medicines such as sodium fluoride or bisphosphonate supplements have been reported to limit the worsening of otosclerosis, but there is no definitive evidence of preventing its progression.

Hearing aids can help overcome a fixed stapes by increasing the sound volume.

Surgery for otosclerosis is called a stapedectomy or stapedotomy. It involves removing part (stapedotomy) or all (stapedectomy) of the fixed stapes bone and replacing it with a prosthetic device or implant. The prosthetic device allows the bones of the middle ear to move again, correcting the conductive hearing loss. This surgery will not address any inner ear (sensorineural) hearing loss. The stapes prostheses are very small and will not set off metal detectors. Modern prostheses are also MRI compatible.

Pain is usually minimal but can vary. Some patients may experience dizziness the first few days after surgery. Taste sensation may also be altered for several weeks or months following surgery, but usually returns to normal. Risks of injuring the ear drum or causing additional hearing loss are rare but should be discussed. The ear canal is generally packed at the time of surgery to allow the ear drum to heal properly. Hearing improvement may not be noticed until it is removed.

If otosclerosis affects both ears, typically the surgeon will choose to operate on the worst-hearing ear first and will not operate on both ears at the same time. The surgeon usually waits a minimum of six months before performing surgery on the second ear.

Following surgery, patients may be asked to refrain from nose blowing, swimming, or other activities that may get water in the operated ear or cause pressure within the middle ear space. Normal activities (including air travel) are usually resumed two to four weeks after surgery.

In advanced cases of otosclerosis, in which the disease has caused additional inner ear (sensorineural) hearing loss, a stapedectomy procedure may not be enough to restore useful hearing. In these situations, a cochlear implant may be considered.

What is tinnitus?

Tinnitus or ringing in ears is present in more than 90% of the population with around 30% of people becoming aware of their tinnitus. About one in five people with tinnitus have bothersome tinnitus, which negatively affects their quality of life and/or functional health. Tinnitus may be an intermittent or continuous sound in one or both ears. Its pitch can go from a low roar to a high squeal or whine, or it can have many sounds.

What Causes Tinnitus?

Most tinnitus is primary tinnitus, where no cause can be identified aside from hearing loss. Secondary tinnitus is associated with a specific underlying cause that may be treatable.

Tinnitus may be caused by different parts of the hearing system. The outer ear (pinna and ear canal) may be involved. Excessive ear wax, especially if the wax touches the ear drum, causing pressure and changing how the ear drum vibrates, can result in tinnitus.

Middle ear problems can also cause tinnitus, including middle ear infection (common) and otosclerosis (uncommon), which hardens the tiny ear bones or ossicles. Another rare cause of tinnitus from the middle ear that does not result in hearing loss is muscle spasms in one of the two tiny muscles in the ear. In this case, the tinnitus can be intermittent and sometimes your examiner may also be able to hear the sounds.

Most subjective tinnitus associated with the hearing system originates in the inner ear. Damage and loss of the tiny sensory hair cells in the inner ear (that can be caused by different factors such as noise damage, medications, and age) may also be associated with tinnitus.

Tinnitus may also originate from an abnormality in, or near, the hearing portion of the brain. These include a variety of uncommon disorders such as damage from head trauma, or a benign tumour called acoustic neuroma.

Tinnitus that sounds like your pulse or heartbeat is known as “pulsatile tinnitus.” Infrequently, pulsatile tinnitus may signal the presence of cardiovascular disease, narrowed arteries, or a vascular tumour in your head and neck, or ear. If you are experiencing this type of tinnitus, you should consult a physician as soon as possible for evaluation.

Finally, non-auditory conditions and lifestyle factors can exacerbate tinnitus. Medical conditions such as temporomandibular joint arthralgia (TMJ), depression, anxiety, insomnia, and muscular stress and fatigue may lead to, or exacerbate, tinnitus.

What Are the Treatment Options?

When you are evaluated for tinnitus, the first thing the doctor will do is obtain a complete history and perform a thorough, targeted physical examination. If your tinnitus is one-sided (unilateral), associated with hearing loss, or persistent, a hearing test, or audiogram, should be ordered. There is typically no need for radiologic testing (MRI scan) unless your tinnitus is pulsatile or associated with uneven, asymmetric hearing loss or neurological abnormalities.

Although there is no one “cure” for tinnitus, there are several options available that can help patients with tinnitus. Because tinnitus is relatively common and not always worrisome, not all patients need an evaluation. If your ENT specialist finds a specific cause for your tinnitus, they may be able to offer specific treatment to eliminate the noise. This may include removing wax or hair from your ear canal, treating middle ear fluid, treating arthritis in the jaw joint, etc. For many patients who have experienced tinnitus for less than six months, its natural course is to improve over time, and most people do not go on to have persistent, bothersome tinnitus.

Some patients with hearing loss and tinnitus have improvement with the use of hearing aids, with or without built-in ear-level maskers. Sound therapies that involve simple things like background music or noise or specialized ear-level maskers may be a reasonable treatment option. The effects of tinnitus on quality of life may also be improved by cognitive behavioural therapy (CBT) counselling, which usually involves a series of weekly sessions led by a trained professional.

Acupuncture may or may not be help your tinnitus; there are not enough quality studies of this type of treatment to make a recommendation. Transcranial magnetic stimulation is a new modality, or therapeutic agent, but its long-term benefits are unproven and cannot be recommended for treating tinnitus at this time.

What is Ménière’s disease?

Ménière’s disease (also called idiopathic endolymphatic hydrops) is one of the most common causes of dizziness originating in the inner ear. In most cases only one ear (unilateral) is involved, but both ears (bilateral) may be affected.

Ménière’s disease typically affects people between the ages of 40- and 60-years-old and can impact anyone. Occasional symptoms include vertigo (attacks of a spinning sensation), hearing loss, tinnitus (a roaring, buzzing, or ringing sound in the ear), and a sensation of fullness in the affected ear. These episodes typically last from 20 minutes up to eight to 12 hours.

What Are the Symptoms of Ménière's Disease?

Ménière’s disease symptoms may include:

• Dizziness or vertigo (attacks of a spinning sensation)

• Hearing loss

• Tinnitus (a roaring, buzzing, or ringing sound in the ear)

• Sensation of fullness in the affected ear

• Symptoms tend to come and go together

What Causes Ménière's Disease?

Although the cause is unknown, Ménière’s disease symptoms are due to increased volume of fluid in the inner ear. Too much fluid may accumulate either due to excess production or inadequate absorption. In some individuals, especially those with involvement of both ears, allergies or autoimmune disorders may play a role in producing Ménière’s disease. In some cases, other conditions may cause symptoms similar to those of Ménière’s disease.

People with Ménière’s disease have a “sick” inner ear and are more sensitive to factors such as fatigue and stress that may influence the frequency of attacks.

To find out how to help and what is causing this condition, your physician will take a history of the frequency, duration, severity, and character of your attacks, the duration of hearing loss, or whether it has been changing, and whether you have had tinnitus or fullness in either or both ears. When the history has been completed, diagnostic tests to assess your hearing and balance may be performed. They may include:

Hearing tests—An audiometric examination (hearing test) typically shows a sensory type of hearing loss in the affected ear. Speech discrimination (the patient’s ability to tell one word from another) is tested as well.

Balance tests—An electronystagmogram (ENG) test may be performed to measure balance by following eye movement when warm and cool water, or air, are inserted into the ear. Often this shows that the balance function is reduced in the affected ear. Rotational or balance platform testing may also be used to evaluate balance.

What Are the Treatment Options?

Although there is no cure for Ménière’s disease, the attacks of vertigo can be controlled in nearly all cases. Treatment options include:

• A low salt diet and a diuretic (water pill)

• Anti-vertigo medications (used to stop acute attacks)

• Intratympanic injection with either dexamethasone or gentamicin

• Surgery

In many people, careful control of salt in the diet and the use of medication to help release extra fluid can control symptoms well.

Intratympanic injections inject medication through the eardrum into the middle ear space where the ear bones reside. This treatment is done in your ENT specialist’s office one or more times. One type of medication, Gentamicin, eases dizziness but may increase hearing loss and worsen overall balance. Corticosteroids do not cause hearing loss but are less helpful for dizzy spells.

Surgery

Surgery is needed in only a small minority of patients with Ménière’s disease. If vertigo attacks are not controlled by conservative measures and are disabling, a surgical procedure might be recommended.

Labryrinthectomy and eighth nerve section are procedures in which the balance and hearing mechanism in the inner ear are destroyed on one side. This is considered when the patient with Ménière’s disease has poor hearing in the affected ear. Labryrinthectomy and eighth nerve section result in the highest rates for control of vertigo attacks.