Anatomy and Functioning of the Ear.

A) The outer or external ear

It includes three parts:

• Pinna (cartilage covered by skin placed on opposite sides of the head)
• Ear canal
• Ear drum outer layer (also called the Tympanic Membrane)

What is the Tympanic Membrane made up of?

The ear drum (also known as the Tympanic Membrane) is composed of three layers. The outer layer consists of a thin layer of skin, the middle layer is made of fibrous tissue and the inner layer is mucosa (similar to the tissue in the mouth and nose). The Tympanic Membrane is secured to the sidewalls of the end of the outer ear canal by a thick band of tissue called the Tympanic ring or annulus. This ring helps in the overall structural integrity and stability of the ear drum. The integrity of the Tympanic Membrane and associated structures is important for proper sound conduction.

How big is your ear drum?

The ear drum is an oval shaped pearly white membrane, with an average size of 8 x 10 mm.

B) The middle ear includes:

• Ear Drum
• Middle Ear Cavity (also called the Tympanic Cavity)
• Ossicles (3 tiny hearing bones connected like a chain; Malleus (or hammer) – long handle attached to the ear drum; Incus (or anvil) – the bridge bone between the malleus and the stapes; Stapes (or stirrup) – the footplate; the smallest bone in the body

C) Inner Ear

Inner Ear is the part of the ear that contains organs of the special sense of hearing and sense of equilibrium.The bony labyrinth in the temporal bone is divided into three parts the vestibule, the semicircular canals and the cochlea. Within the bony labyrinth is a membranous labyrinth, which is divided into three parts

• The semicircular ducts
• Two saclike structures, the saccule and utricle, located in the vestibule
• The cochlear duct, which is the only part of the inner ear involved in hearing. The entire inner ear is bathed in a cushioning fluid called the endolymph and the perilymph.

Mechanism of hearing: How sound vibrations transmitted in the Ear

The outer part of the ear collects sound and the sound travels through the pinna and the auditory canal, a short tube that ends at the ear drum. Ear drum function is to transmit the sound from the air to the ossicles (hearing bones) inside the middle ear and then to the inner ear through a window. Sound entering the outer ear travels through the middle ear and causes the ear drum and ossicles in the middle ear to vibrate and as it travels, sound amplifies (becomes louder) and changes from vibration in air to vibration in fluid. The sound vibrations then converted into electroneural signal and then reach the hearing centre in the brain, thus we perceive the sound as hearing sensation or as an understandable sound.

Mechanism of Balance or Equilibrium:

Motions of the head cause stimulation of another auditory nerve branch, the vestibular nerve, which signals the position of the head with respect to the rest of the body.

The three semi-circular canals are arranged at right angles to each other, so that they measure motions in all three planes and they transmit signals indicating changes of position through the vestibular nerve.

Ear Conditions.

What is an ear drum rupture or perforated ear drum?

An ear drum rupture is a small hole or tears in your ear drum. The ear drum or Tympanic Membrane is a thin membrane that divides your middle ear and outer ear canal and it vibrates when sound waves enter your ear leading to vibration of hearing bones which then passes vibrations to the hearing nerve. So, if your ear drum is ruptured your hearing can be affected.

What are causes of ear drum rupture or holes?

The common causes for Tympanic Membrane perforations (ear drum holes) are:

• Infection When you have an ear infection, fluids like pus accumulate behind the ear drum causing pressure to build up which then ruptures your ear drum.
• Trauma like slapping over the ear with an open hand, ear bud use.
• Barotrauma like sudden changes in air pressure per example scuba diving, flight journey, driving at high altitudes.
• Acoustic trauma due to extremely loud noises.

Can a ruptured ear drum heal?

Ear drum holes usually heal spontaneously. This spontaneous healing largely depends upon two factors: the size of the hole and the presence of infection. Holes or perforations greater than 40 – 50% of the size if the ear drums rarely heal by themselves. Infected perforations rarely close spontaneously. Holes of ear drum from blunt trauma like slapping over the ear is most likely heal spontaneously. This is true only for ear drum holes from blunt trauma that does not become infected.

How long does it take for a perforated ear drum to heal?

Usually, ear drums holes which are due to injury heal in one two months period, if not healed that must be closed with operation.

Precautions to promote healing of ear drum holes

Keeps your ear dry to prevent further infection Preventing water from entering the ear canal by stuffing your ears with cotton with Vaseline helps to avoid infections in the ear and better healing
Don’t blow the nose note more than absolutely necessary. Blowing your nose causes pressure to rise in your middle ears which can be painful and can also slow your ear drum’s healing.

What are treatments for ear drum holes or rupture?

Antibiotics and pain killers

The immediate problem, you may feel is the pain. To get relief from pain, you may be given anti-inflammatory medicines. And the next problem is chance of infection of your middle ear in case of traumatic ear drum holes. To prevent the infection, you may be given antibiotics which are also given in already infected cases.

Observation

Ear drum holes often heal without any invasive treatment. You may experience a temporary hearing loss, but usually you can expect a full recovery within eight weeks.

Surgery or ear drum hole operation

In cases where your ear drum hole is not healed, surgery is required patch the hole in the ear drum. A surgical repair of a perforated ear drum is called tympanoplasty where your ENT micro surgeon takes grafts from another area of your body and places it onto the hole of your ear drum.

Ear Pus or Discharge

What is ear infection with discharge?

Ear discharge is drainage of pus, blood, earwax or fluid from the ear. An infected ear produces pus discharge continuously, sometimes intermittently that can damage your hearing. That means you are having a hole in the ear drum as the fluid builds up behind the ear drum and tear the ear drum. Doctors call this as chronic otitis media

What are causes of Ear Pus or Discharge?

• Frequent cold is a common cause. The cold could result in the blockage of the eustachian tube, the connection between the throat and middle ear that equalizes air pressure.
• Living in overcrowded housing and eating a poor-quality diet.
• A ruptured ear drum.
• Skin irritations in the ear canal.
• Allergies.
• Enlarged adenoids.

What will happen to me?

It may lead to hearing loss, speech language problem in children. If untreated for long time, lead to infection of the large bone behind your ear (mastoiditis) and extra skin growing in your ear (cholesteatoma) and also a very slight risk of infection spreading into your brain and causing meningitis.

Is ear pus contagious?

No, it is not generally contagious.

What precautions help me from getting ear infection?

Do not use Cotton Buds to Clean Ears! These cotton buds tend to push earwax back into the canal causing wax to build up or can injure the ear drum. Ears are having self-cleaning mechanism to clean it selves. Allow the natural way to remove earwax by letting tiny hairs in the ear propel the wax outward as the canal moves with talking or chewing. Only you can use cloth or let the nature follow its course otherwise contact your ENT specialist.

Take treatment at the first sign of cold and sore throat. Otherwise it may cause ear infection

What treatments work for Ear Pus or Discharge?

Micro suction cleaning of your ears
Specialist ENT microsurgeon cleans your ears with micro suction. Cleaning your ears clears out pus and any debris in the canal so that the ear drsops can reach the point of infection.

Ear drops

Antibiotic ear drops help to dry up your ear as antibiotics kill the bacteria that cause infection. Some antibiotics might damage your hearing if you have a hole in your ear drum so, only specialist doctors prescribe these types of antibiotics.

Surgery

The operation called myringoplasty or tympanoplasty is done to repair hole in your ear drum. The specialist ENT microsurgeon puts a small patch of graft onto your ear drum hole. The Surgery is more likely to work if your surgeon is experienced in this kind of micro surgeries.

Common myths

Going in cold weather causes ear infections: No, ear infections are not caused by going in cold weather without your ears covered. The middle ear most often becomes infected from bacteria that travel up the eustachian tube which is opened behind the nose from the throat.

Ear infections run in families: No, there is no evidence that ear infections are inherited and runs in families. Ear infections are common in infants and young children because they have immature immune system and a shorter, less angled eustachian tube. Those who had frequent ear infections as a child may or may not continue to get ear infections them as adults.

Earwax

Earwax is made up of a slightly different mixture of substances in each individuals depending upon their environment, age, race, and diet.

Where does earwax come from?

Earwax is typically produced by glands in the skin of ear canal, only in your outer ear and NOT in the middle ear or inner ear.

Why do we have earwax?

The main purpose of the wax produced by your ears is to protect the ear from dust, foreign particles and microorganisms. It also protects ear canal skin from irritation due to water or pollutants. Earwax absorbs debris and dead skin cells preventing them from being pulled deeper into the ear canal. It prevents insects and bugs from creeping in. Earwax repels insects or traps insects that try to get into your ear. Your ears stay bug and insect-free. Essentially, it is your last line of defence in the ear.

How is earwax blocked in the ear canal?

Your ear canal produces oily secretions called earwax or cerumen. In normal circumstances, wax turns into dry flakes and falls on its own due to movements of jaw.

When your ear canal skin glands make more earwax than is necessary, it may get hard and block the ear. When you try to clean your ears with ear buds, bobby pins or other objects, the wax will be pushed deep inside more and more and causing a wax blockage. It may also cause a temporary hearing loss.

Earwax in children

Children just like adults produce earwax naturally. Don’t try to remove earwax in children with cotton buds that may push the wax deep inside and block it. If you suspect your child has earwax blockage, see you ENT surgeon, who will clean with special instruments without damaging ear drum.

Earwax in older adults

Earwax can also be problematic especially in old age people.

When to see a doctor

Most people don’t need frequent doctor visit for earwax removal. If you are unable to clear the way, you should seek attention of your ENT doctor. Your doctor may use irrigation, suction, or a curette to remove the wax blockage.

How to get rid of excess earwax

Softening Earwax

You can use wax softening drops to soften earwax and later visit your doctor to get removed of wax. You should never attempt to remove the earwax yourself. This can damage your ear drum and lead to infection or hearing loss. However, you will often be able to remove the excess earwax yourself but, use cotton buds on the outer portion of your ears only.

Ear Irrigation

You should never attempt to irrigate your ear yourself. Irrigation in case of a ruptured ear drum could cause infection or hearing loss.

Microsuction
Your specialist ENT doctor will do micro irrigation and suction to remove the blocked wax.

How to clean your ears yourself? What are best ways to remove earwax?

How to clean your ears at home?

You need to clean your ears properly when too much earwax is produced. Everyone has some myths about earwax. Many feel it is not normal. But the truth is it is the normal human body secretion, produced as a protective measure from keeping out dust, bacteria, and bugs from your ear. It helps to protect your sensitive and important middle and inner ear structures. Sometimes too much earwax is produced causing irritation or hearing loss. Then, you are having the only option of cleaning yourself or seeing your ENT doctor.

People tend to use cotton buds, hydrogen peroxide or bike keys to clean earwax.

Cotton swabs are very popular ear cleaning method. These cottar buds are available everywhere in supermarkets, pharmacy and convenience stores and also give you feel of goodness as it is easy and used quickly and through it away. But the usage of cotton buds is not good for ears. Instead it harms your ears. It looks like cotton buds usage is a simple and effective cleaning method, but actually, it pushes the earwax deeper inside. Only little amount wax comes out with cotton buds. The more you push the earwax deeper into your ear, the more wax builds up eventually, it block the canal completely leading to hearing problem, infections by injuring the skin of the canal and also chance of injuring the ear drum which is a thin membrane.

So, it is recommended that Do NOT use cotton buds for ear cleaning. If you still want to use, you can use to clean the outer third of your ear canal where the earwax is produced.

Don’t use any tools like tip of a pen, car keys, and head of bobby pins.

Hydrogen Peroxide

Hydrogen peroxide is another method for cleaning earwax used by many people. It helps you to remove wax by softening and loosening the earwax, making it easier for you to remove with a cotton ball or make it easier for your ear to clean itself. But, it can cause irritation, dryness and an increased risk of infection. Sometimes unknowingly if you pour hydrogen peroxide in an ear with ear drum hole, it may lead to permanent hearing loss by damaging hearing nerves. So this is also NOT a choice for ear cleaning at home.

Ear Irrigation at home

People tend to use warm tap water which works as they soften and loosen the wax. But they can irritate your ear skin and any manipulation to remove oil may injure your ear drum. So this is also NOT a choice for ear cleaning at home.

Mineral Oil

Warm coconut oil, usually room temperature will soften and loosen the earwax, making it easier for your ear to drain itself. However, it cannot remove hardened wax or when used in perforated ear drum cases, lead to definite infection. So this is also NOT a choice for ear cleaning at home.

Professional Ear Syringing

Ear syringing is an effective method to clean earwax. This is an old method of cleaning.
It works by loosening up large chunks of wax when water is pushed towards the walls of the ear canal not to towards the ear drum. Once the wax is loosened, it can be removed with medical suction. It is a highly efficient ear cleaning method.

However, there are potential risks with this ear cleaning method like damage to the ear canal or ear drum and dizziness and nausea when the sudden pressure of water and its temperature affects your inner ear.

Those who like this “old school” solution can take Ear syringing NOT at home but BY professional ENT doctor of any local primary care physician.

The best method recommended for ear cleaning at home

The best way to clean your yars at home is not to clean your ears. Ears clean themselves, no need of cleaning by external methods. If you don’t do anything for cleaning, your ears will be clean on their own and will be healthy. Don’t try to disturb natural self-cleaning mechanism.

You can use cloth to remove wax in outer part of ear canal. More than this, nothing is required. Even if water enters your ear canal after bath, you can clean with cloth, otherwise leave it alone, it come out on its own. However when you have excess wax, you can see your ENT doctor who can remove the wax safely with Micro Suction method and special micro instruments.

How often should you clean your ears?

Wax cleaning is not at all required regularly.

Hearing Loss or Deafness

Hearing and understanding speech are essentials parts of everyday life. They facilitate the communication that connects you to the world.

What are the consequences of hearing impairment?

Hearing loss is an invisible condition. we cannot see hearing loss, only its effects can be felt. Hearing loss can affect people of all ages, from new born to elderly. Hearing loss may be a sudden or gradual loss, depending on the cause, it can be mild or severe, temporary or permanent. The degrees of hearing loss: mild, moderate, severe, profound.

Hearing impairment lead to inability to understand speech sound, decreased capability to communicate, delay in language development, economic and educational backwardness, social isolation and stigmatization.

Statistics of hearing disability in India

Hearing loss is a major public health issue and economic burden to the country and is the third most common physical condition after arthritis and heart disease.

Hearing impairment is the most frequent sensory deficit in human population, affecting more than 250 million people in the world.

In India, 63 million people (6.3%) suffer from significant hearing loss. The National Sample Survey (NSS) 58th round (2002) surveyed disability in Indian households and found that hearing disability was 2nd most common cause of disability and the most common cause of sensory deficit. It was estimated that the number of persons with hearing disability per 1, 00,000 persons was 291. Out of that, about 32% of the people had profound hearing disability (person could not hear at all) and 39% had severe hearing disability (Person could hear only shouted words). The survey also revealed that about 7% of people were born with a hearing disability and about 56% reported the onset of hearing disability at ≥ 60 years of age. The incidence of hearing disability during that year was reported to be 7 per 1, 00,000 population.

Deafness in Indian Constitution

The Rehabilitation Council of India Act, 1992 defined “hearing handicapped” as hearing impairment of 70dB and above, in better ear or total loss of hearing in both ears.
This law is applicable to only those persons with severe hearing impairment whose hearing loss is 70dB and above. Persons with hearing levels of 61 to 70dB, although suffering from severe hearing impairment, as per WHO classification, are automatically excluded from the hearing handicap category.

Section 2(i)(iv) of the persons with Disability Act, 1995(PWD) states that ‘hearing impairment’ is a disability and “hearing disability” has been redefined as – “a hearing disable person is one who has the hearing loss of 60dB or more in the better ear for conversational range of frequencies.” This is a step in the right direction, as all person with severe hearing impairment is now included in the hearing handicapped category.

Who will get affected with hearing loss?

Causes of hearing loss

Congenital hearing loss: child born without hearing
Noise: when exposed to noises such as listening to very loud music, being in a noisy work environment can lead to hearing loss over many years. Sudden, noise-induced hearing loss from Deepawali crackers, gunfire and explosions is the number one disability caused by combat in current wars.
Aging: Age-related hearing loss is also known as Presbycusis.
Other causes of hearing loss: earwax build-up, injury to the ear or head, ear infection, a ruptured ear drum and other conditions that affect the middle or inner ear.
Medications: some antibiotics and chemotherapy drugs, aspirin, loop diuretics, anti-malaria drugs and several drugs for erectile dysfunction.
Diseases: heart disease, high blood pressure and diabetes; Otosclerosis, a bone disease of the middle ear and Meniere’s disease that affects the inner ear.

Diagnosing hearing loss

See Diagnosing hearing loss

Hearing Tests

See Hearing Tests

New born Hearing Screening programme

See New born Hearing Screening programme

Treatment for Hearing loss

How hearing loss is treated depends on the underlying cause of the hearing loss. If your hearing is impaired, treatment can improve your hearing and quality of life.

Hearing loss caused by damage to the middle ear:

Hearing loss that occurs when sounds are unable to pass through the middle ear into the inner ear (conductive hearing loss) is often temporary and treatable.

For example, earwax build-up can be removed by drops, a syringe or micro suction. Hearing loss caused by a bacterial infection can be treated conservatively with antibiotics. Micro Ear Surgery can be used to drain a fluid build-up, repair a perforated ear drum or correct problems with the hearing bones.

Hearing loss caused by damage to the inner ear:

Hearing loss due to the damage to the hearing nerves that transmit sound to brain (sensorineural hearing loss) is permanent.

You can use hearing aids suitable to you or cochlear implants if indicated to you.

See Hearing Aids
See Cochlear Implant Surgery

Preventing hearing loss

The risk of hearing loss loud noises depends on how loud the noises are and how long you are exposed to loud noise. Continuous exposure to the noise at or above 85dB (eg. loud traffic) can over time cause hearing loss.

However, you can reduce risk of noise-induced hearing loss by following the advice below.

Don’t put your television, radio or music too loud.

Use headphones that block more of outside noise (noise cancelling headphones) rather than turning up the volume.

Use ear plugs if you work in a noisy environment, such as a garage workshop, pub, nightclub or a building site or at loud concerts and at other events where there are high noise levels, such as motor races.

Don’t insert objects like cotton buds, fingers or sticks into your ears or into your children ears.

Be aware of the symptoms of common causes of hearing loss such as ear infections

Visit your ENT specialist if you or your child is experiencing hearing problems.Hearing and understanding speech are essentials parts of everyday life. They facilitate the communication that connects you to the world.

See Micro Ear Surgery

Tinnitus or Ringing in Ears

What is Tinnitus?

Tinnitus is a ringing, buzzing, hissing, clicking whistling or that seems to originate in the ear or head. Sometimes pulsatile Tinnitus may occur (the noise like your heartbeat). Usually you hear sound but it cannot be heard by others.

Tinnitus in many cases is not a serious problem, but rather constitutes a nuisance so severely that it interferes with their daily activities. Tinnitus can be extremely disturbing to people who are suffering from it. Many of times, Tinnitus is not a sign of something serious disease. Although bothersome, it can worsen with age in many people, sometimes it can improve with treatment. However, some people may require medical or surgical treatment for Tinnitus.

Tinnitus may start in any of the four parts of the hearing system: the outer ear, the middle ear, the inner ear and the brain.

Current theories suggest that as we age, the hearing cells called “hair cells” in the cochlea get damaged and when it is no longer sending the normal hearing signals to the brain, is confused and develops its own noise to make up for the lack of normal sound signals. This is then interpreted as Tinnitus.

What are symptoms of Tinnitus?

With Tinnitus, you hear a noise originating in your ears or head that no one around you hears. This noise is usually high-pitched ringing in the ears

• Ringing
• Buzzing
• Hissing
• Clicking
• Whistling

Tinnitus may be present all the time or it may be intermittent. Tinnitus may be more audible during night time when outside environmental noise is less. The Tinnitus is sometimes accompanied by hearing loss and giddiness in a condition called Meniere’s disease.

What conditions cause Tinnitus symptoms?

You may never find an exact cause in many cases. Tinnitus is not a disease itself. It is a symptom of an underlying condition, such as age-related hearing loss, ear injury or a circulatory system disorder or some other disease. Tinnitus caused by exposure to noise or drugs is usually noticed in both ears because; both ears are usually exposed to the same noise and drugs.

Age-related hearing loss: Probably the most common cause for Tinnitus is aging process associated with hearing loss. This Tinnitus becomes worse by anything that makes our hearing worse like ear infection or excess wax in the ear.

Exposure to loud noise: Loud noise exposure is a very common cause of hearing loss today and it often is the common cause of Tinnitus as well. Unfortunately, many people are unconcerned about the harmful effects of excessive loud noise from high intensity music, crackers, firearms or other sources.

Earwax blockage: When too much earwax accumulates in the ear canal, it becomes too hard to wash away naturally cause hearing loss and irritation of the ear drum which lead to Tinnitus.
Drugs such as aspirin, some antibiotics like polymyxin B, erythromycin, vancomycin and neomycin, quinine are also common cause of Tinnitus.

Meniere’s disease often presents with dizziness, Tinnitus and changing hearing loss that can last for hours but then goes away. This disease is actually caused by fluid imbalance that causes excessive pressure in the ear itself. The Tinnitus is merely a symptom of that.

Hearing bone changes: otosclerosis where thickening of hearing bones in your middle ear occurs may affect your hearing and cause Tinnitus. This condition tends to run in families.

Brain tumours like acoustic neuroma also cause Tinnitus. These tumours arise on the hearing nerve itself and cause Tinnitus. This type of Tinnitus is usually present in one ear that is affected and not present in the other normal ear.

Pulsatile Tinnitus is usually related to blood flow changes occur during pregnancy, anaemia overactive thyroid, or tumours involving blood vessels near the ear and also in a condition known as benign intracranial hypertension (an increase in the pressure of the fluid surrounding the brain).

Temperomandibular joint, joint between ear and mandible malalignment problems or “twitching” of muscles of the ear or throat causes clicking type Tinnitus.

Head injuries or neck injuries: Head or neck trauma which is affecting the inner ear, hearing nerves or brain function may cause Tinnitus usually in one ear.

When to see a doctor

You can visit your doctor if you have Tinnitus that bothers you. If you develop Tinnitus after an upper respiratory infection like cold and it is not improving within a week, then you need to visit your ENT surgeon.

If your Tinnitus started suddenly or without an apparent cause or if you have hearing loss or dizziness with the Tinnitus, take it as an emergency and meet your ENT surgeon immediately within hours. It helps your doctor to get time to treat before it is too late.

It is particularly important if the Tinnitus is only heard on one side as it is usually caused by nerve tumours.

What kind of a doctor treats Tinnitus?

The Tinnitus is best treated by ENT microsurgeon as many of conditions of Tinnitus are caused by ENT related conditions. But depending upon the underlying cause of the Tinnitus you may also see other specialists like Neurologist, Dentist for temporomandibular joint (TMJ) disorder, Cardiologist for heart disease, Psychologist to counsel you in dealing with your Tinnitus to treat this condition

How is the Tinnitus diagnosed?

ENT specialist will examine your ears, head and neck include a complete history and physical examination of the head and neck including the various nerves in the area to look for possible causes of Tinnitus. The cause of Tinnitus may never be found in many cases.

The complete hearing tests performed if required a special audiogram known as an Auditory Brainstem Response (ABR). Computerized Tomography (CT) scan or Magnetic Resonance Imaging (MRI) may also be required depending on the type of Tinnitus.

The Tinnitus sounds you hear also can help your ENT surgeon to identify possible underlying causes.

Heartbeat like sounds shows blood vessel problems such as high blood pressure, an aneurysm or a tumour that causes the blockage of the ear canal or eustachian tube which amplifies the sound of your heartbeat in your ears called pulsatile Tinnitus.

Clicking sounds show muscle contractions in and around your ear that can hear in bursts.
Humming sounds shows the Tinnitus is usually vascular in origin, sound fluctuations may occur when you exercise or change positions like when you lie down or stand up.

Low-pitched ringing in Meniere’s disease may become very loud before an attack of vertigo or giddiness. Otosclerosis also cause low pitched Tinnitus.

High-pitched ringing occurs usually to exposure to very loud noise or a blow to the ear that usually goes away after a few hours. If hearing loss occurs, Tinnitus becomes permanent. Long-term noise exposure, age-related hearing loss, drugs or acoustic neuroma may cause a continuous, high-pitched ringing Tinnitus in both ears.

Earwax, foreign bodies or hairs in the ear canal can rub against the ear drum and cause a variety of sounds.

Psychoacoustics
Several acoustic parameters of Tinnitus can be measured like pitch or frequency in cases of monotone Tinnitus or frequency range and bandwidth in cases of narrow band noise Tinnitus. And also loudness above hearing threshold at the indicated frequency in dB and minimum masking level are measured. In general, Tinnitus pitch or frequency range is between 5000 Hz and 8000 Hz and loudness less than 10 dB above the hearing threshold.

What is the treatment for Tinnitus?

Treatment of Tinnitus depends upon the cause. These include medications, stress management techniques, biofeedback and lifestyle changes. You will be discussed with steps you can take to reduce the severity of Tinnitus or to help you cope better with the Tinnitus.

Treating an underlying health condition

ENT specialist microsurgeons will first try to identify any underlying, treatable condition that is causing your Tinnitus. If there is an underlying cause, treating the cause may lead to improvement of your Tinnitus.

Earwax removal: Removing impacted earwax can decrease Tinnitus.

Treating blood vessel condition: Underlying vascular conditions may require medication or surgery to address the problem.

Changing the medication: If drugs are the cause of Tinnitus, you may be recommended to stop the drug and switch over to a different drug.

Noise suppression: Outside environmental sounds like fans, air conditioners or music help to suppress the internal Tinnitus at night so that it is less bothersome. Electronic devices like White noise machines which produce simulated environmental sounds such as falling rain or ocean waves are often an effective treatment for Tinnitus are used to suppress the noise.

Hearing aids: Hearing aids are especially helpful if you have hearing problem as well as Tinnitus.

Tinnitus Maskers: Worn just like hearing aids, these Tinnitus maskers produce a continuous, low-level white noise that suppresses Tinnitus symptoms. Tinnitus maskers will help the brain ignore the specific Tinnitus frequency.
How effective Tinnitus maskers? Following a period of masking, there will be residual inhibition, the temporary suppression and/or disappearance of Tinnitus accounts for effectiveness of Tinnitus maskers.

Tinnitus retraining: You are delivered individually programmed tonal music to mask the specific frequencies of the Tinnitus you experience. Tinnitus retraining technique over time may accustom you to the Tinnitus, helping you not to focus on it. Counselling is often a component of Tinnitus retraining technique.

Medications: Medications can sometimes cure Tinnitus or at least may help to reduce the severity of symptoms. Antidepressants like amitriptyline and nortriptyline in cases of severe Tinnitus have been used with some success. Beware of troublesome side effects like dry mouth, blurred vision, constipation and heart problems. Alprazolam may help to reduce Tinnitus symptoms. Side effects are drowsiness, nausea and also can become habit-forming.

Alternative medicine: Alternative therapies that have been used for Tinnitus include:

• Acupuncture
• Hypnosis.
• Ginkgo Biloba.
• Zinc Supplements.
• B Vitamins.

Transcranial Magnetic Stimulation (TMS) - Neuromodulation technique has been successful in reducing Tinnitus symptoms. It is a painless, non-invasive therapy currently under trials in Europe and U.S.
Cognitive Behavioural Therapy (CBT) - This is a type of psychological counselling which can be delivered via the internet or in person. It benefits by decreasing the amount of stress those with Tinnitus feel.

Acceptance and Commitment Therapy (ACT)

Relaxation techniques may also be useful

What home remedies and lifestyle changes soothe Tinnitus symptoms?

Self-management techniques some tips may help your Tinnitus less bothersome. Simple adjustments make you feel better although the Tinnitus can’t be cured.

Avoid possible aggravants: Reduce exposure to things that may aggravate your Tinnitus like loud noises, caffeine and nicotine.

Mask the Tinnitus: during nights, a noisy fan, air conditioner, soft music may help mask the noise from Tinnitus.

Stress management: Stress can make the Tinnitus worse. So, relaxation therapy, biofeedback or exercise alleviate stress and provide some relief.

Reduce alcohol consumption: Alcohol increases blood flow to the inner ear by dilating your blood vessels and increases the Tinnitus. So avoid alcohol intake.

Psychological Counselling: Tinnitus does not always go away completely with the treatment. Psychologist can help you learn coping techniques to make Tinnitus symptoms less bothersome. Psychological Counselling can also help problems like anxiety and depression often associated with Tinnitus.

Support groups: There are Tinnitus support groups that meet in person or in Internet forums that share your Tinnitus experience with others who have Tinnitus. This may be helpful.
Education. Learning as much as you can about Tinnitus and ways to alleviate symptoms can make it less bothersome for some people.

Can Tinnitus be prevented?

Some precautions can help prevent certain types of Tinnitus though in many cases, Tinnitus is the result of unknown cause that cannot be prevented.

Use protection from loud noises: If you are working in noisy environment like industries that uses loud machinery or use firearms or listening to music at very high volume through headphones, always wear ear plugs to protect your hearing as continuous exposure to loud noise can damage hearing nerves and cause hearing loss and Tinnitus.

Take care of your cardiovascular health: Eating healthy food and regular exercise to keep you healthy and fit to keep your blood vessels healthy can help prevent Tinnitus linked to blood vessel disorders.

Do many people suffer from Tinnitus?

Yes, millions around the world suffer from Tinnitus. Many people with Tinnitus from developed countries like UK, US, Germany, Canada, New Zealand, Australia form self-help groups to support each other. Given professional help and commitment, Tinnitus symptoms can be reduced for many people.

Does Tinnitus mean that one is going deaf?

Tinnitus is a symptom of some unknown problem in the hearing system. It is usually associated with hearing loss, though sometimes may present with normal hearing. Tinnitus is a warning signal that you may have some problem in the hearing system or may have conditions that affect blood supply of inner ear so, get evaluated for the underlying causes and protect against excessive noise to further prevent damage to hearing nerves.

Giddiness or Vertigo

What is vertigo?

Vertigo is a sense of rotation or the world spinning, experienced even when someone is perfectly still.

Dizziness is a term that is used to explain different sensations like light-headedness and spinning (vertigo) accompanied by an involuntary, rapid, rhythmic eye movements (nystagmus); giddiness; or feeling as if one is going to faint (syncope).

Vertigo when not associated with other symptoms is not serious.

What are causes of vertigo?

There are many causes for giddiness.

A) Disorders involving the balance organs in ears:

Balance organs in inner ears get affected from infection of the inner ear (labyrinthitis), inner ear fluid imbalance (Meniere’s disease), viral infection of the vestibular nerve (vestibular neuronitis) and inner ear fluid leaking into the middle ear. These conditions cause giddiness and also ringing in the ears (Tinnitus). Prevalence of dizziness caused by fluid disturbances in the inner ear (e.g., Meniere’s disease) is 1,000 per 100,000 populations.

Ear diseases like mastoiditis, otitis media, cholesteatoma, vestibular neuronitis also causes giddiness when affects inner ear.

B) Disorders involving decrease in blood circulation and oxygen to the brain:

Any decrease in blood circulation and oxygen to the brain can cause dizziness and fainting.

Irregular heart rhythm (dysrhythmia) can result in a sudden reduction in the amount of blood pumped to the brain and can cause dizziness.
Cerebral Transient Ischemic Attack or TIA: Temporary deficiency of blood in the brain secondary to narrowing of the arteries in the brain also can result in dizziness.
Orthostatic or postural hypotension: Sudden change in position from sitting or lying to standing can cause a drop in blood pressure and dizziness.
Medications: Dizziness can result from taking medications such as antihypertensives, antidepressants, , antihistamines or diuretics.
Anaemia: Due to blood loss.
Trauma or sweating (dehydration):

• From decreased blood volume or fluid loss.
• Diabetes mellitus, multiple sclerosis, and Parkinson’s disease.
• Double vision (diplopia) is a more serious symptom that may indicate a disease affecting the brainstem and is a warning of a serious stroke or other disease processes.
• Slurred speech (dysarthria) that accompanies dizziness and vertigo point to a disease process that is affecting the brain itself (e.g. a stroke, brain tumour).

When dizziness leads to syncope or loss of consciousness, problems with blood circulation (heart, blood vessels and problems that affect their function) must be checked.

Other causes of dizziness include severe pain, anxiety, stress, fatigue, high fever, pressure on the neck (e.g. tight collar), strenuous coughing, straining with defecation or urination, , spinning rapidly around in a circle (as during carnival rides), injury, fright, low blood pressure (hypotension), standing rigidly at attention for an extended period, alcohol intoxication, use of illicit drugs, hyperventilation, low blood glucose (hypoglycaemia), and hysterical seizures.

Treatment

Treatment for giddiness is based on its underlying cause and may consist of bed rest and taking medication like vestibular suppressants, antihistamines, medications to lessen nausea, corticosteroids or medications affecting the GABA (Gamma Amino Butyric Acid) receptors.

Dietary changes like reducing the salt content and reducing alcohol, caffeine and nicotine intake may be helpful in the treatment of giddiness.

Regular physical exercise and improving general health are also important in treating giddiness.

Vestibular Rehabilitation Therapy

Vertigo is also treated with individualized head, neck, and body movements that assist brain compensation.

Benign Paroxysmal Positional Vertigo (BPPV) is treated with canalith repositioning maneuvers (Epley maneuver) to move canaliths within the semicircular canals of the inner ear to a position where giddiness is reduced.

Surgical procedures

When medical management is not working, surgery may be done. A variety of surgical procedures are done which include the removal of the labyrinth that constitute the inner ear (labyrinthectomy), cutting the balance nerve (selective vestibular neurectomy) or placing a shunt within the labyrinth (endolymphatic shunt).

Diagnosis of Ear Conditions

Hearing Clinic: Computerized Cochleo Vestibular Lab

One Stop Clinic

MicroCare ENT Hospital and Research Institute, an international super speciality ENT hospital at Hyderabad, India which provides you best hearing services for your hearing problems, all the services are under one roof.

State of Art Hearing Diagnostic Equipment

MicroCare hearing clinic is equipped with state of art, modern equipment to help you getting correct diagnosis and treatment for your hearing problems.

Treatment options.

We at MicroCare ENT Hospital and Research Institute provide you all treatment options for all ear conditions. We assess many factors, including your age, the severity of symptoms and other health conditions and provide you best treatment possible.

Wait-and-see approach

Some ear infections resolve even without treatment with antibiotics. Symptoms of ear infections usually improve within few days and most infections clear up on their own within one to two weeks without any treatment.

Antibiotic therapy.

Treatment with antibiotics might be beneficial for ear infections. You should weigh the benefits of antibiotics against the potential side effects and concern about overuse of antibiotics creating strains of resistant disease.

Managing pain

Warm compress: Placing a moist, warm cloth over the affected ear may lessen the pain.
Pain medication: use of over-the-counter acetaminophen or ibuprofen to relieve pain.

Ear ventilation tubes.

If your child has recurrent infection of ear or Glue ear, you may be recommended a procedure to drain fluid from the middle ear called Grommet insertion. Some ventilation tubes are intended to stay in place for three to six months and then fall out on their own. Other tubes are designed to stay in longer even up to two years and may need to be surgically removed. The ear drum usually closes up again after the tube falls out.

Treatment for chronic ear infection

Chronic ear infection that results in perforation of the ear drum is often treated with antibiotics administered as drops. You will be recommended regular hearing tests and in case of children speech and language tests.

For persistent ear infections not responding to the medication, you will be advised surgical intervention in the form of Tympanoplasty with or without mastoidectomy.

For hearing loss, depending upon the cause, you will be advised the latest treatment. Treatment for severe hearing loss usually means using different hearing technology to improve your hearing. There is no single therapy that is best for every person with the condition. You will be recommended based on how much hearing you lost, how healthy you are, your lifestyle and how your ears were damaged.

Diagnosis of Ear Conditions

Latest advancements MicroCare ENT Hospital and Research Institute, ENT Super Speciality International Hospital in Hyderabad strives to provide the best research outputs in the field of ENT and micro ear surgery to patients who require those advancements. Recent Advances and Future Directions in Hearing Research.

Stem Cell Therapy for the inner ear.

Hearing in humans is mediated through mechanosensory hair cells located within the inner ear. Hair cells are generated only during a short period of embryonic development. As a result, loss of hair cells as a consequence of disease, injury or genetic mutation, leads to permanent hearing loss. At present, cochlear implantation which bypasses hair cells is the only option for profound hearing loss. However, outcomes with cochlear implantation are still variable and even the best implant cannot provide the acuity of a biological ear.

The recent emergence of stem cell technology has the potential for new therapy for profound hearing loss through hair cell regeneration.

Identification of molecular components of stereocilin7, prestin has advanced the understanding of hair cell transduction; at which hair cells convert sound vibrations into an electrical signal. Dozens of new gene defects in hereditary hearing loss have been identified in recent years to better predict the course of hearing loss and develop stem cell therapeutic interventions like possible use of endogenous inner ear stem cells to induce repair as well as the transplanting stem cells into the ear.

Recent advances and future directions in balance disorders research.

Advancements in understanding of comorbid relationships among balance disorders, migraine and anxiety will lead to better treatments.

The effectiveness of canal repositioning manoeuvres for the treatment of positional vertigo (BPPV) offering clinicians’ wide range of possibilities in the development of new technologies.

The development of a vestibular prosthesis from a re-engineered commercial cochlear implant provides a means of stimulating the semicircular canals, part of the balancing system of the ear. This vestibular prosthesis could be a treatment for Meniere’s disease and other balance disorders.

Hearing aid's and implantable hearing devices

Advancements in the digital technology of hearing aids provide noise reduction, directional hearing and feedback cancellation. Binaural hearing aids further improve sound direction localization.

Combined use of a hearing aid and a cochlear implant in opposite ears or the same ear helps hearing communication more than either device alone. The use of binaural cochlear implants has improved further directionality and performance in noise.

Experimental cochlear implant designs with Infrared cochlear nerve stimulation and intra-nerve electrodes offer more precise stimulation of specific nerve sites.

The auditory brainstem implant (ABI) is now the more advanced version of cochlear implant, typically used in cases where the auditory nerve has been surgically removed due to tumor growth, such as in people with neurofibromatosis 2 (NF2). It stimulates the part of the brain that processes sound.

Tinnitus

Tinnitus is the abnormal brain activity of auditory and non-auditory areas involved in the perception of sound. Newer therapies will use brain stimulation to treat Tinnitus. The use of vagus nerve stimulation paired with a variety of tones over an extended period has been effective in the treatment of noise-induced Tinnitus in experimental models.

Auditory processing

Advances in brain imaging along with behavioural studies of auditory perception about the integration of auditory activity with other sensory systems (balance, movement and body position, vision) and cognitive function (learning, memory, attention) have increased understanding of real-world auditory processing and of various auditory neuropathies.

Micro Ear Surgery

What is a Tympanoplasty Surgery?

Tympanoplasty is the repair of ear drum holes

When the ear drum is unable to heal itself, our ear specialist microsurgeons perform a microsurgery to repair ear drum holes. Over years of experience in the past, ENT surgeons tried many materials to close ear drum holes like synthetic films, paper, skin, vein, ear lobe fat, fascia (thin tissue that covers muscle) and perichondrium (thin tissue that covers around cartilage). Fascia is now recognised as the best material to repair Tympanic Membrane perforations.

Can the ear drum be replaced?

Ear drum can be replaced by helping it naturally to heal by placing a graft in the ear drum hole area.

Ear drum hole closure techniques

Myringoplasty means microsurgery confined to the ear drum itself. The middle ear hearing bones (ossicles) are not touched. It is most often performed for small ear drum holes. The ear drum uses the fascia graft as a scaffold over which a new ear drum can grow. Myringoplasty method is effective in small perforations of ear drum.

Tympanoplasty is commonly performed for ear drum holes greater than 10 – 20% of the size of the entire ear drum. There are different types of Tympanoplasty.

Tympanoplasty: the micro ear surgery is confined to the ear drum alone and no manipulation of the middle ear hearing bones is done. Tympanoplasty which includes manipulation of the middle ear hearing bones is called tympanoossiculoplasty (Tympanoplasty with ossicular reconstruction). Surgery which includes manipulation of the mastoid bone behind the ear is called Tympanoplasty with Mastoidectomy.

Same day discharge:

All patients who underwent any type of tympanoplasty procedure are discharged home the same day of surgery as no rest is required unless there are complicating factors.

Success rate:

We at MicroCare ENT Hospital and Research institute gives you the best result possible with 100 % success rate in primary cases and overall, there is approximately 99% success rate in closing Tympanic Membrane perforations with tympanoplasty in secondary cases where severe complications occur as a result of previous surgeries done elsewhere. MicroCare has become one of the best ENT hospitals in the world for ear micro surgeries.

What is a Mastoidectomy?

Mastoidectomy is a micro surgical procedure of the ear that removes damaged mastoid air cells which are air cells present behind your ear in your skull. The damaged mastoid air cells are often the result of an ear infection that has spread into your mastoid bone behind the ear and also because of persistence of the infection for a long time.

What are types of Mastoidectomy?

Simple Mastoidectomy: Your ENT microsurgeon opens your mastoid bone, removes the infected and diseased air cells and opens drainage pathways in your middle ear.

Modified Radical Mastoidectomy: Your ENT microsurgeon removes some part of your mastoid bone which is diseased and rebuilding your ear drum.

Radical Mastoidectomy: Your ENT microsurgeon removes your ear drum, remove your middle ear structures and possibly place a skin graft in your middle ear. It is done in completely dead ear which is not at all useful to you.

Why do I need a Mastoidectomy?

Proper antibiotics at proper dose and duration usually treat ear infections, but surgery is an option if antibiotics fail.

The main purpose of the Mastoidectomy operation is to treat complications of chronic ear infection (Chronic Otitis Media, COM) which is a long term ear infection in your middle ear causing serious complications like Cholesteatoma, which is a skin pouch, if left untreated, destroys everything on its way including bone. Cholesteatoma or chronic infection may in turn leas to further complications like Brain Abscess, Deafness, Facial Nerve Paralysis which causes you the facial paralysis, Meningitis also called inflammation of the membranes of your brain, Labyrinthitis or Dizziness or Vertigo.

Your ENT doctor may also perform a Mastoidectomy in a cochlear implant surgery.

This Mastoidectomy surgery can also be done to remove abnormal growths or tumours at the base of your skull.

How is a Mastoidectomy performed?

The Mastoidectomy is usually performed under general anaesthesia. This can be performed under local anaesthesia also. While in general anaesthesia, you are asleep and while in local anaesthesia, you can talk to our ENT Microsurgeon while doing the surgery. We use advanced equipment to get you the best result.

What are complications of Mastoidectomy operation? Complication prevention

You will be with safe hands of our expert ENT microsurgeons at MicroCare ENT Hospital and Research Institute. Thorough knowledge of temporal bone anatomy and judicious use of landmarks typically allows our surgeons to avoid complications.

You need to have regular follow-ups with your surgeon if you have cholesteatoma. Your doctor will check your operated ear to make sure that your ear is healing correctly and will remove your bandage during your follow-up visit.

Key considerations

Our Expert ENT Microsurgeons keep the mastoid surgery safe and Successful by routine identification of key anatomic landmarks and critical structures like tegmen (middle fossa floor), sigmoid sinus, external auditory canal, lateral semicircular canal and facial nerve.

A high-speed electric or pneumatic drill with various tools and attachments, the operating microscope with various magnification settings and various micro instruments specifically designed for ear micro surgery are used in conjunction with copious suction irrigation when performing mastoid surgery.

Ossiculoplasty:

Repair of chain of hearing bones (Ossicular Chain)

Ossiculoplasty is defined as the repair or reconstruction of the Ossicular Chain.

Why is Ossiculoplasty needed?

Ossiculoplasty is an operation often performed in conjunction with Tympanoplasty operation to repair the damaged hearing bones or ossicles. Though Tympanoplasty helps to protect the middle ear by preventing recurrent ear infections and restore the hearing capability of the patient, ideal outcome in hearing is not achieved in all patients. In those cases Ossiculoplasty helps to recover further the remaining hearing.

Ear drum holes which are present for many years usually lead to erosion of hearing bones which disrupt the chain of hearing bones of the middle ear leading to significant hearing loss. When, there is moderate to severe hearing loss about 40 db and more, it is likely that hearing bones are damaged. Then, comes the need of Ossiculoplasty.

Hearing loss from ossicular chain damage may result from either discontinuity or fixation of the ossicular chain. Discontinuity commonly occurs because of eroded joints of hearing bones in chronic ear infection. The joint commonly damaged is the joint between Incus and stapes bones. Absent incus, or stapes superstructure are also other causes. Ossicular fixation arising out of chronic infection or otosclerosis is also common.

Procedure and Types

The status of the hearing bones remnants determines which graft or implant can be used in that particular patient. Better result in hearing can be achieved when as much of the remaining functional ossicular chain as possible is used during reconstruction of hearing bones.

There are different types of ossicular reconstruction materials available. Each of these materials possesses unique properties and also unique problems when exposed to the environment of the middle ear. Complications or problems include implant extrusion, graft failure and persistent hearing loss.

The ideal prosthesis for ossicular reconstruction should be biocompatible, safe, stable, ease of configuring the prosthesis during surgery and capable of yielding optimal sound transmission.

Autologous Incus grafts maintain their contour, shape, size and physical integrity for long time and subsequently undergo new bone formation and remodelling. And thus is the best material for Ossiculoplasty. Autologous cartilage, Plasti-Pore, Hydroxylapatite, Titanium are other implants used in Ossiculoplasty. Titanium shows significant bio stability in the middle ear for long time.Hearing amplification with hearing aids is an alternative to Ossiculoplasty in patients with conductive or mixed hearing loss.

Post-operational care

Walking is a normal activity that can be started straight away after the surgery.

You can carry out your normal day to day activities

Avoid strenuous activity, do not lift anything heavier during the first postoperative week

Sneeze with your mouth open

Keep the operated ear dry. Cover your ear well while taking bath or shower with a cotton ball coated with Vaseline to protect the ear from water.

Blow your nose gently or avoid blowing nose.

You may resume your regular diet as soon as you get home.

Disclaimer

This information is not intended to replace or substitute the instructions of your doctor.

What is Otosclerosis?

Otosclerosis is a disease of the middle ear hearing bones where excess calcification impend vibrations of sound to get transmitted into inner ear and causes hearing impairment. It sometimes affects inner ear.

Stapedial Otosclerosis

Usually Otosclerosis occurs in the stapes bone which is the smallest bone in the body and is the final link in the chin of middle ear hearing bones. The stapes is in contact with the inner ear fluids through a window called Oval window. Any interference with its movement results in hearing impairment. This type of hearing impairment can usually be corrected by Stapedectomy operation.

Cochlear Otosclerosis

When Otosclerosis spreads to the inner ear hearing impairment occurs as a result of interference with the nerve function. This is called sensorineural deafness and once it develops it will become permanent hearing loss. This type of nerve impairment is called cochlear otosclerosis. Sometimes it may spread to the balance canals in the inner ear and may cause giddiness also.

Who gets Otosclerosis and Why?

It is common in middle-aged women esp. Caucasians. This condition is less common in the people of Japan and South America and is rare in African Americans.

The disease can develop in both women and men, but is particularly more common in pregnant women who often experience a rapid decrease in hearing for unknown reasons.

The hallmark symptom of otosclerosis is slowly progressive hearing loss that usually starts in the early 20’s, anytime between the ages of 15 and 45.

The common cause is genetic in origin. Unknown viral infections also may cause it.

Hearing Impairment from Otosclerosis

The amount of hearing loss due to involvement of the stapes bone and of the nerve can be determined by the hearing tests like Audiometry and clinical tests with tuning forks.

Treatment of Otosclerosis

A) Medical

There is no medical treatment for this condition. Medicines won’t work to improve this type of hearing impairment due to Otosclerosis.

The supplements containing fluoride may be useful in these patients to stabilise the amount of hearing loss. This may help by stabilising the disease process.

B) Hearing Aids

For those patients who are not interested in surgery or not able to take surgery due to other medical conditions like uncontrolled hypertension, diabetes or old age, hearing aids are alternative. The main disadvantage is that you have to wear hearing aids lifelong along with it; you need to bear maintenance of hearing aids when the option of surgical treatment gives you near normal hearing.

C) Surgical

The stapes operation (Stapedectomy or a modified Stapedectomy called Stapedotomy) is recommended for these patients with otosclerosis who are candidates for surgery.

The Stapes operation is usually performed under local anaesthesia. You may require few days of hospital admission and few days of bed rest at home.

A small opening is made in the footplate of the stapes and a stapes prosthesis like a Teflon, stainless steel, titanium, or platinum piston is then placed into this opening and connected to the Incus, second hearing bone.

The stapes prosthesis allows sound vibrations to pass from the ear drum to the inner ear fluids and thus restoring the sound transmission chain and improves hearing. Most patients can return to their work in seven days depending on their occupation.

What are the risks of Stapedectomy operation?

The occurrence of potential complications of Stapedectomy operation is very rare with our microsurgeons who are well trained in Micro Ear Surgery as we are having experience in performing these surgeries on a regular basis with latest micro surgical techniques

However, any surgical procedure carries potential risks which are all discussed with the patient and/or family prior to surgery. Common complications are:

Hearing loss: There is 1 percent risk of hearing loss in the inner ear.

Dizziness: Sometime you may experience dizziness immediately after the surgery, usually it resolves itself within a day or in few days.

Facial paralysis: The course of the facial nerve that innervates the muscles of the face passes through the ear. It may get injured during the operation and lead to facial paralysis. This affects the movement of the facial muscles for rising of the forehead, for making a smile and for closing of the eye. It may occur immediately after surgery or delayed. Recovery of the nerve can be complete or partial.

Tinnitus (noise in the ear): This can occur with surgery.

Taste abnormalities: Some patients may experience an abnormal taste in the mouth or some dryness of the mouth. This problem may improve over time.

Stapedectomy success rate

These operations are successful in restoring the hearing impairment permanently over 97 percent of cases. We at MicroCare ENT Hospital and Research institute achieved world class success rate with our micro surgical techniques.

Precautions after Stapedectomy Operation:

One should not go for air travel for 6 weeks after the surgery. And also should not enter deep mines. The air pressure changes during these activities may impact middle ear where your surgery has been done.

One should not plan to drive a car from the hospital to the home, but you can travel in a car.

Hearing improvement following Stapes Surgery

Hearing improvement may be noticed during the surgery itself and it can be demonstrated on the operating table. It may not be noticeable immediately after operation as swelling in the ear develops or due to packing the ear. Later on hearing improvement may be apparent within three weeks of surgery depending upon on how the ear heals

In some patients, hearing improvement may not be there or is partial or temporary or it may decrease. But this is very rare due to causes like facial nerve bundling around stapes or inner ear fluid abnormalities where surgery itself becomes difficult.

Can Stapedectomy operation be performed in both ears at the same time?

No. This operation is performed in one ear at a time. If the surgery is needed in the second ear, it can be performed 6 weeks after the other ear surgery.

What is Glue Ear?

The normal secretions of the lining of the middle ear which keeps it moist sometimes become thick because of poor ventilation. This condition with thick glue in the middle ear is called Glue Ear.

How did the ‘glue’ get there?

Middle ears on either side are connected to the back of the nose by the Eustachian tube. This Eustachian tube is a potential space, normally closed but opens for a moment with each swallow or yawn that we do. A bubble of air enters the middle ear and excess normal fluids empties out at that moment.

The normal fluid accumulates and in time thickens into glue when cannot empty out in conditions like adenoid, sinus problems, or when muscles of Eustachian tube don’t work or when lining of the Eustachian tube is congested.

What are Grommets?

Grommets are ventilation tubes inserted into your ear drum in a minor procedure. These ventilation tubes allow air enter into the middle ear space behind the ear drum. The free ventilation reduces the risk of fluid building up there and if an infection occurs, the pus flows out through the grommet.

Grommets are recommended if you have glue ear that is persistent for more than one or two weeks.

How do Grommets work?

Grommets maintain normal middle ear pressure by allowing air into the middle ear space. This reduces the risk of fluid getting accumulated in that space and allows the normal fluids in the middle ear drains into the throat through a connecting tube called Eustachian tube. This reduces the pain you suffer. If an ear infection does occur, the resultant pus flows out through the grommet, limiting the pain you suffer. Even when infection is there, it helps your topical medicines reach middle ear better than oral tablets and are more effective.

When the ear drum retraced back sometimes due to causes of nose like recurrent cold, sinus problem, grommet insertion byes you time till your root cause of it get corrected and helps your ear drum getting back to normal position.Most Grommets usually stay in place over the ear drum for about 2 to 6 months and come out by themselves through a natural skin cleaning process.

What are indications of Grommets?

Grommets are recommended for hearing loss due to glue ear that is not cleared with medicines or in case of frequent episodes of middle ear infections or retracted ear drum due to causes like sinus problem or adenoid which sit at the end of the Eustachian tubes at the back of the nose or tonsils.

How successful is the operation?

Usually, Grommets help you to restore your middle ventilation till the primary cause is cured. The surgery usually takes about 10 to 15 minutes. It can be done as an OPD procedure and you can go home immediately after the procedure. You will have immediate improvement in hearing. Ear discharge after Grommets have been inserted is usually treated with ear drops.

Are there any complications with Grommets operation?

There are no complications usually but sometimes an ear discharge may develop which can be treated with topical drops or antibiotic medicine. Sometimes minor damage and scarring to the ear drum may occur but this is unlikely to cause any problems. A small hole persists in the ear drum rarely after the grommet has come out, this can be fixed a small procedure.

What are precautions with Grommets in place?

It is recommended that water should not enter into your ear after this procedure especially when swimming, showering and bathing. Use cotton applied with Vaseline or plugs to put in the ear before use of water.

Advantage of Lasers in micro ear surgery

Latest laser technology provides a precise and bloodless operating method on the delicate structures of the ear. Lasers used in micro ear surgery are Co2 (carbon dioxide), Argon and KTP lasers. Co2 laser energy due to its unique physical characteristics is being used by ENT surgeons as it provides high precision and control during micro ear surgery. It also provides no-touch dissection tool ideal to use around the delicate structures of the middle ear, performed without vibrational trauma to the hearing bones within the inner ear, making this a safer procedure.

The chief advantage of Lasers is that it can stop bleeding (microvascular coagulation) while cutting the tissue because of their selective absorption in the red spectrum. Lasers can also vaporize target tissue by evaporating the water inside its cells. It helps in removing layer-by-layer removal of diseased tissue.

Lasers are especially useful in micro ear surgeries like Stapedectomy and in removing inflamed tissue in surgery of cholesteatoma, enhancing hearing results and surgical outcomes.

Co2 – Laser Assisted Stapes Surgery

In Stapedectomy operation for otosclerosis, the laser is used to remove the calcified and fixed stapes bone with minimal trauma to surrounding structures. In addition, it helps to make an opening into the inner ear with precision to the desired diameter that only the laser can afford. As it is no-touch tool, outcomes after surgery are improved by decreasing manipulation of the hearing bones. The superficial absorption of Co2 laser energy in the perilymph may help to minimize the risk of damage to underlying inner ear structures.

Co2 – Laser Assisted Tympanoplasty Surgery

Co2 laser technology can be utilized in patients with chronic ear disease, allows removal of diseased tissue with no-touch dissection and decreases the potential for recurrence of disease.

The laser technique is used for removal of diseased tissue during the following micro ear surgical procedures:

• Revision procedures (e.g. Tympanoplasty, Mastoidectomy)
• Tympanoplasty & Mastoidectomy
• Tumor Removal (Glomus Tympanicum, Acoustic Neuroma)
• Ossicular Chain Reconstruction
• Adhesion ablation
• Scar tissue dissection
• Cholesteatoma removal
• Debulking and coagulation of vascular tumors

Meniere’s Surgeries

A) Minimally Invasive Meniere’s Surgery

Dexamethasone & Gentamycin Perfusion of the inner ear

Meniere’s disease which is not responding to medical treatment can now be treated with minimally invasive office surgical treatments. Surgical options for the treatment of Meniere’s disease were all causing complications which were not well tolerated by patients. However, over the last 10 years, minimally invasive surgical treatments have become common procedures performed to control Meniere’s disease, if medical therapy is unsuccessful.

When is inner ear perfusion of chemicals done?

Inner ear perfusion is performed in patients in whom vertigo from Meniere’s disease is uncontrolled with standard medical treatment and behavioural lifestyle changes over a period of several months. When the severity of the vertigo is more and frequent attacks of the vertigo, this procedure is performed.

How is the procedure performed?

These techniques are generally called inner ear chemical perfusions. The Minimally Invasive treatment involves the injection of a medication through an anesthetized ear drum. The medication then through a membrane, called the round window membrane passes into the inner ear. It results in control of the vertigo attacks in most patients and it may also improve hearing in some patients. The exact mechanism and reason why this chemical perfusion treatment works is not totally understood. It may be with anti-inflammatory effect or some other unknown effect. This is usually performed in a series of three treatments separated a week apart.

What chemicals are used?

The two medications which are frequently used in inner ear perfusions are Dexamethasone and Gentamycin. Of the two, the Dexamethasone Inner Ear Perfusion has become the front line treatment for uncontrolled Meniere’s disease.

How successful is the procedure of Dexamethasone inner ear perfusion?

Dexamethasone Perfusion of the Inner Ear has certainly become the preferred surgical treatment for the uncontrolled vertigo of Meniere’s disease as the concentration of Dexamethasone that can be achieved in the inner ear is higher than what can be obtained by taking Dexamethasone orally.

Studies have demonstrated, there is up to an 80-90% successful rate to Dexamethasone perfusions.

If this treatment of Dexamethasone perfusions fails to control the Meniere’s disease, then other options may include Gentamycin perfusion or other more radical surgical techniques are done.

Gentamycin Perfusion of the Inner Ear

Gentamycin perfusion of the inner ear is done when Dexamethasone perfusion of the inner ear is unsuccessful in controlling vertigo. This is done in those patients where some impairment of hearing present.. Gentamycin works by reducing the function of the receptors of the balance nerve.

What are complications?

Gentamycin perfusion of the inner ear is very effective technique but there is a higher risk of further hearing loss with this technique. But with Dexamethasone, chance of hearing loss is very less.

B) Endolymphatic Sac Decompression (ELS)

It is the most frequently recommended surgical procedure after inner ear chemical perfusion.

What is done in ELS

Endolymphatic Sac is present in the inner ear and it drains fluid from the inner ear. When the sac is opened and shunt is placed to allow the future drainage in this surgical procedure, it reduces the fluid pressure in the inner ear which would then subsequently reduce the frequency of vertigo attacks and improves the hearing. The risk of the hearing loss is less from this procedure.

Success Rate

The operation is only successful in approximately 2/3 of patients who underwent this procedure. ESD does NOT cure Meniere’s disease. Vertigo subsides in about 70 percent of Meniere’s cases. But vertigo may recur again with the same severity as before in a significant number of individuals within three years of surgery.

Other Procedures

C) Labyrinthectomy: This procedure is offered if the patient has near profound hearing loss. This procedure destroys the remaining nerve of the hearing, but gets the good control of balance. This is usually curative as the nerve of balance is completely removed.

With the development of cochlear implants, this procedure is offered less nowadays.

After the surgery, the opposite ear takes over the command of the entire balance function and assumes full control in a week. The brain will adapt to this new situation where it is now receives only correct signals from the one remaining inner ear which will control the entire balance function. This is the reason why Labyrinthectomy is successful. The patient experiences a period of mild to moderate dizziness that may last six to eight weeks.

D) Vestibular Neurectomy: An intracranial procedure is generally a team effort performed by an ENT surgeon and a neurosurgeon. If there is substantial hearing present, this procedure may be a preferred surgical option. It offers excellent control of vertigo, generally with preservation of hearing.

Vestibular Neurectomy involves the discrete section of the balance nerve thus preserving the hearing portion of the nerve. 90 to 95 percent of patients with vertigo, vestibular neurectomy will result in cure of vertigo. Recovery from this procedure is similar to that of Labyrinthectomy procedure.

Glomus Tympanicum surgery

The size and the extent of the glomus tumour determine the surgical procedure needed. Glomus tumours can be as small as 2 to 3 mm and expand to fill the middle ear.

Many glomus tumours can now be approached through the ear canal, if large form behind the ear and then destroying the tumour completely with Co2 laser or removed with more radical surgeries.

Larger tumours may surround the hearing bones. In this situation, tumour can be vaporized away from the bones of hearing without separating them.

When the tumour is attached to the jugular vein or sometimes invades the jugular vein as it enters the mastoid bone. In these cases, the tumor must be completely removed from the jugular vein.

If the tumour has invaded and entered the brain, intracranial surgical excision of the tumour may be necessary.

Results of surgery of glomus tumours of the middle ear and mastoid are extremely good in most cases. But when the tumour has invaded the inner ear, facial nerve or brain, more complications arise.

Advances in the imaging like CT scan MRI and refinements of traditional surgery have made the correct diagnosis and complete excision of these tumours possible in most of cases.

Intratympanic Gentamicin

See Dexamethasone & Gentamycin Perfusion of the Inner Ear.

Cochlear Implant Surgery

See Cochlear Implant Surgery

Facial Nerve Surgeries

Paralysis of the facial nerve is the paralysis of muscles of face. It causes significant functional and aesthetic compromise like inadequate protection of the eye with a real risk of exposure keratitis, swallowing, drooling and speech difficulties.

The degree of suffering often varies from patient to patient especially younger people who may experience tremendous psychosocial distress about their condition. Poor self-image and difficulty interacting with peers and family members can be devastating in the social life.

Causes of Facial Nerve Paralysis

Congenital facial paralysis is very rare.

Idiopathic facial paralysis also known as “Bell palsy” is the most common type. It is often due to virus induced inflammation of the facial nerve that results in swelling and functional compromise of the nerve. Facial nerve repair surgery is not required frequently in these cases because most of these patients regain the function of the facial nerve spontaneously. Facial nerve decompression can be done in selected cases when paralysis is permanent.

Traumatic facial nerve paralysis from intraoperative injury, penetrating trauma is also common type. Operations like acoustic neuroma surgery put the facial nerve at risk. Sometimes, it may occur in mastoidectomy operation at the hands of unskilled surgeons. Any facial nerve injury sites can be repaired, except when injury occurs near the nerve root, where the available stump of the facial nerve may not be long enough to allow repair.

Tumours like that of parotid gland, facial nerve schwannomas, acoustic neuromas and neoplasms of the brain are some of the less common causes.

Viral infections like herpes zoster (eg, Ramsey Hunt syndrome), mumps, Coxsackie virus and mononucleosis. Bacterial infections like sequelae of otitis media and Lyme disease.

Methods of Facial Nerve Repair Surgery

The cause of the facial nerve paralysis determines the likelihood of spontaneous return of function of the facial nerve. Most cases of idiopathic facial nerve paralysis (Bell palsy) spontaneous return occur. The transacted facial neve must be repaired if satisfactory return of function is to be achieved.

Now with the modern techniques of facial nerve repair, most patients benefit greatly. Several different procedures of facial nerve repair are available today like direct repair, cable nerve grafting, nerve crossover techniques and Facial nerve decompression and dynamic reconstruction for facial nerve paralysis. Newer techniques as possible alternatives to suture repair include laser neurorrhaphy and tissue adhesive repair.

Retro Sigmoid Skull Base Surgeries.

The Fully Endoscopic Retro Sigmoid Approach for skull base surgeries is the latest development in the field of ENT.

Significance and Advantages of Fully Endoscopic Retro Sigmoid Approach for skull base surgeries

The Main limitation operating microscope is in viewing angles of skull base in micro surgeries, makes it difficult for the surgeon to view and remove peripheral margins of tumours. These are not always completely exposed microscopically. By contrast, the endoscope gives the surgeon broad panoramic view and different angles of view.

Endoscopic approach to the brainstem region with angled endoscopes allows the surgeon to visualize areas that were often hidden from the direct of view of the operating microscope.

The improved exposure of the entire tumour with virtually no brain retraction has reduced the risk of injury to the brain and the surrounding cranial nerves results in a more complete tumour removal decreased the time required to access skull base angles. This allowed rapid recovery and minimal postoperative discomfort to patients.

Endoscopic procedures pose no additional risk to the patient and add no additional time to the total duration of surgery.

What conditions this technology is applicable

This fully endoscopic retrosigmoid approach is useful to access schwannoma or meningioma or vascular loops involving cranial nerves V through XII in the skull base regions of the cerebellopontine angle (CPA), petroclival and foramen magnum.

Conditions like Trigeminal Neuralgia, Hemifacial Spasm and Glossopharyngeal Neuralgia are well treated with technique.