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| The ear is comprised of
three portions: an outer ear (external), a middle ear
and inner ear. Each part performs an important function
in the process of hearing. |
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| The outer (external) ear
consists of an auricle and ear canal. These structures
gather the sound and direct it toward the ear drum
(tympanic membrane). |
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| The middle ear chamber
lies between the external and inner ear. This chamber is
connected to the back of the throat (pharynx) by the
eustachian tube which serves as a pressure equalizing
valve. The middle ear consists of an eardrum and three
small ear bones (ossicles): malleus (hammer), incus
(anvil) and stapes (stirrup). These structures transmit
sound vibrations to the inner ear. In so doing, they act
as a transformer, converting sound vibrations in the
external ear canal into fluid waves in the inner ear. A
disturbance of the eustachian tube, eardrum or the ear
bones may result in a conductive hearing impairment.
This type of impairment is usually corrected medically
or surgically. |
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| The inner ear (cochlea)
contains the microscopic hearing nerve endings (hair
cells) bathed in fluid. Inner ear fluid waves move the
delicate nerve endings which in turn transmit sound
energy to the brain by the hearing nerve, where it is
interpreted into sound. A disturbance in the inner ear
fluids or nerve endings may result in a sensorineural
hearing impairment. Most often this type of hearing
impairment is due to a hair cell loss. This type of
impairment is not correctable with surgery. |
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| The eustachian tube is a
narrow channel which connects the middle ear with the
nasopharynx (the upper throat area just above the
palate, in back of the nose). The Eustachian tube is
approximately 1 1/2 inches in length. The narrowest
portion is that area near the middle ear space. |
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| The eustachian tube
functions as a pressure equalizing valve of the middle
ear, which is normally filled with air. Under normal
circumstances the eustachian tube opens for a fraction
of a second in response to swallowing or yawning. In so
doing it allows air into the middle ear to replace air
that has been absorbed by the middle ear lining (mucous
membrane) or to equalize pressure changes occurring with
altitude changes. Anything that interferes with this
periodic opening and closing of the eustachian tube may
result in a hearing impairment or other ear symptoms. |
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| Obstruction or blockage
of the eustachian tube results in a negative middle ear
pressure, with restraction (sucking in) of the eardrum
(tympanic membrane). In an adult this is usually
accompanied by some discomfort, such as a fullness or
pressure feeling, and may result in a mild hearing
impairment and head noise (tinnitus). In children there
may be no symptoms. If the obstruction is prolonged, the
fluid may be sucked in from the mucous membrane in the
middle ear creating a condition called serous otitis
media (fluid in the middle ear). This occurs frequently
in children in connection with an upper respiratory
infection or allergies and accounts for the hearing
impairment associated with this condition. |
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| On occasion just the
opposite from blockage occurs; the tube remains open for
a prolonged period. This is called abnormal patency of
the eustachian tube (patalous eustachian tube). This is
less common than serous otitis media and occurs
primarily in adults. Because the tube is constantly open
the patient may hear himself breathe and hears his voice
reverberate in the affected ear. Fullness and a blocked
feeling are not uncommon sensations experienced by the
patient. Abnormal patency of the eustachian tube is
annoying but does not produce a hearing impairment. |
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| Individuals with a
eustachian tube problem may experience difficulty
equalizing middle ear pressure when flying. When an
aircraft ascends, the atmospheric pressure decreases,
resulting in a relative increase in the middle ear air
pressure. When the aircraft descends, just the opposite
occurs; atmospheric pressure increases in the cabin of
the aircraft and there is a relative decrease in the
middle ear pressure. Either situation may result in
discomfort in the ear due to abnormal middle ear
pressure compared to the cabin pressure, if the
eustachian tube is not functioning properly. Usually,
this discomfort is experienced upon descent of the
aircraft. |
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| To avoid middle ear
problems associated with flying you should not fly if
you have an acute upper respiratory problem such as a
common cold, allergy attack or sinus infection. Should
you have such a problem and must fly, or should have a
chronic eustachian tube problem, you may help avoid ear
difficulty be observing the following recommendations: |
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| 1. Obtain from your
druggist the following items: Sudafed tablets and a
plastic squeeze bottle of 1/4 percent NeoSynephrine or
Afrin nasal spray. |
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| 2. Following the
container directions, begin taking Sudafed tablets the
day before your air flight. Continue the medication for
24 hours after the flight if you have experienced any
problems equalizing your middle ear pressure. |
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| 3. Following the
container directions, use the nasal spray shortly before
boarding the aircraft. Should your ears "plug up" upon
ascent, hold your nose and swallow while attempting to
force air up to the back of the throat. This will help
suck excess air pressure out of the middle ear. |
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| 4. Forty five minutes
before the aircraft is due to land, again use the nasal
spray every five minutes for fifteen minutes. Chew gum
to stimulate swallowing. Should your ear "plug up"
despite this, hold your nose and blow gently toward the
back of the throat while swallowing. This will blow air
up the eustachian tube into the middle ear (Valsalva
Maneuver). |
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| None of these
recommendations or precautions needs to be followed if
you have a middle ear ventilation tube (PE tube) in your
eardrum (tympanic membrane). |
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| Serous otitis media is a
term which is used to describe a collection of fluid in
the middle ear. This may be a recent onset (acute) or
may be long standing (chronic). |
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| Serous otitis media is
the most common cause of hearing loss in children.
Fortunately, the hearing loss associated with this
condition usually is not permanent. Proper treatment
restores the hearing to a normal level and prevents
secondary complications, which can give rise to a more
serious problem. |
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| In serous otitis media,
the external and inner ear and hearing nerve are normal.
The problem stems from inadequate function of the
Eustachian tube. The tube becomes blocked and does not
allow air to fill the middle ear space. Subsequently,
fluid (called serous fluid) forms from the middle ear
lining and collects in the space (fig. 2). The presence
of this serous fluid limits or "dampens" the vibration
of the eardrum and causes a mild to moderate hearing
impairment. This fluid makes the ear more susceptible to
recurrent ear infections in many children. The trapped
fluid is an ideal place for bacteria to grow and
reproduce rapidly. Therefore, bacteria entering the
middle ear space easily cause a purulent infection; the
pus produced then exerts pressure on the eardrum with
resultant pain (earache). |
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| However, serous otitis
media may be present without recurrent ear infections
and a mild hearing loss may be the only sign of its
presence. |
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| Acute serous otitis
media is usually the result of blockage of the
eustachian tube from an upper respiratory infection or
an attack of nasal allergy. In the presence of bacteria
this fluid may become infected leading to an acute
suppurative otitis media (infected or abscessed middle
ear). |
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| When infection does not
develop the fluid remains in the middle ear until the
eustachian tube again begins to function properly, at
which time the fluid is absorbed or drains down the tube
into the back of the throat. |
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| Chronic serous otitis
media may result from long standing eustachian tube
blockage or from a thickening of the fluids so that it
cannot be absorbed or drained down the tube. This
chronic condition is usually associated with a hearing
impairment. There may be recurrent ear pain, especially
when the individual catches a cold. Serous otitis may
persist for many years without producing any permanent
damage to the middle ear mechanism. Presence of fluid in
the middle ear, however, makes it very susceptible to
recurrent acute infections. These recurrent infections
may result in middle ear damage. |
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| Serous otitis media may
result from any condition that interferes with the
periodic opening and closing of the eustachian tube. The
causes may be congenital (present at birth), may be due
to infection or allergy, or may be due to mechanical
blockage of the tube. |
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| The Immature
Eustachian Tube |
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| The size and shape of
the eustachian tube is different in children than in
adults. This accounts for the fact that serous otitis
media is more common in very young children. Some
children inherit a small eustachian tube from their
parents; this accounts in part for the familial tendency
to middle ear infection. As the child matures, the
eustachian tube usually assumes a more adult shape. |
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| Cleft Palate |
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| Serous otitis media is
more common in the child with a cleft palate. This is
due to the fact that the muscles that move the palate
also open the eustachian tube. These muscles are
deficient or abnormal in the cleft palate child. |
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| Infection |
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| The lining membrane
(mucous membrane) of the middle ear and eustachian tube
is connected with, and is the same as, the membrane of
the nose, sinuses and throat. Infection of these areas
results in the mucous membrane swelling, which in turn
may result in eustachian tube obstruction. |
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| Allergy |
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| Allergic reaction in the
nose and throat result in swelling of the mucous
membranes and this swelling may also affect the
eustachian tube. This reaction may be acute or chronic. |
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| Treatment of acute
serous otitis media is medical, and is directed towards
treatment of the upper respiratory infection or allergy
attacks. This may include antibiotics, antihistamines
(anti-allergy drugs), decongestants (drugs to decrease
mucous membrane swelling) and nasal sprays. |
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| ACUTE SUPPURATIVE OTITIS
MEDIA |
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| In the presence of an
upper respiratory infection, such as a cold,
tonsillitis, or pharyngitis, fluid in the middle ear may
become infected. This results in what is commonly called
an abscessed ear or an infected middle ear. |
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| This infected fluid
(pus) in the middle ear may cause severe pain. If
examination reveals that there is considerable ear
pressure, a myringotomy (incision of the eardrum
membrane) may be necessary to relieve the abscess, and
the pain. In many instances antibiotic treatment will
suffice. |
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| Should a myringotomy be
necessary, the ear may drain pus and blood for several
days. The tympanic membrane then heals and the hearing
usually returns to normal within three to four weeks. |
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| Antibiotic treatment,
with or without a myringotomy, usually results in normal
middle ear function within three to four weeks. During
this healing period there are varying degrees of ear
pressure, popping, clicking and fluctuation of hearing,
occasionally with shooting pains in the ear. |
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| Resolution of the acute
infection occasionally leaves the patient with
uninfected fluid in the middle ear. This is called
chronic serous otitis media. |
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| Treatment of chronic
serous otitis media may either be medical or surgical. |
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| Medical Treatment |
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| As the acute upper
respiratory infection subsides, it may leave the patient
with a persistent eustachian tube blockage. Antibiotic
treatment may be indicated. |
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| Allergy is often a major
factor in the development or persistence of serous
otitis media. Mild cases can be treated with
antihistaminic drugs. More persistent cases may require
allergic evaluation and treatment, including injection
treatment. |
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| In connection with
medical treatment, often eustachian tube inflation is
recommended. This is done by closing the nostrils with
your fingers and blowing air toward the back of the
throat while swallowing. This air goes up the eustachian
tube and re-establishes the middle ear air. Children
often cannot do this but often can achieve the same
results by blowing balloons. |
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| Surgical Treatment |
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| The primary objective of
surgical treatment of chronic serous otitis media is to
re-establish ventilation of the middle ear, or equalize
pressure of the middle ear with that in the ear canal.
This keeps the hearing at a normal level and prevents
recurring infections that might damage the tympanic
membrane and middle ear bones. This involves a
myringotomy with aspiration of fluid and insertion of a
ventilation tube. |
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| A myringotomy (incision
in the eardrum) is performed to remove the middle ear
fluid. A hollow plastic tube or metal tube (ventilation
tube) is inserted to prevent the incision from healing
and to insure middle ear ventilation. The ventilation
tube temporarily takes the place of the eustachian tube
in equalizing middle ear pressure. This tube usually
remains in place for six to nine months, during which
time the eustachian tube blockage should subside. The
tubes can be removed at a later date, but most of the
time it is preferable to let the tubes work their way
out of the eardrum. When the tube dislodges, the eardrum
heals: the eustachian tube then resumes its normal
pressure equalizing function. In rare instances (less
than 5% of cases) the eardrum membrane does not heal
following extrusion of the tube. The perforation may be
repaired at a later date if this occurs. Usually this
small perforation poses no problem, as it also would act
as a ventilation tube. |
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| In adults, a myringotomy
and insertion of a ventilation tube is usually performed
in the office under local anesthesia, with the use of a
topical solution placed on top of the tympanic membrane.
In children, general anesthesia is required. |
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| Most often when the
ventilation tube is extruded there is no further middle
ear ventilation problem. Should recurrent serous otitis
media occur, reinsertion of a tube may be necessary. In
some difficult cases it is necessary to insert a more
permanent type of tube. |
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| When a ventilation tube
is in place, a patient may carry on normal activities
with the exception that no water must enter the ear
canal. Often this can be prevented with vaseline on a
cotton ball or Silly Putty can be used to provide
occlusion of the ear canal. In addition a custom made
earmold will often prevent water from entering the ear
canal. |
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| One should be reminded
that the purpose of a ventilation tube is not to drain
the fluid in the middle ear space. This fluid is drained
at the time of the surgery. The purpose of a tube is to
equalize the pressures across the eardrum. This prevents
the reoccurrence of fluid in the middle ear and
re-establishes normal middle ear function. |
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| Chronic serous
mastoiditis and idiopathic hemotympanm are uncommon
conditions which have the same symptoms as chronic
serous otitis media. They differ in that the middle ear
fluid continues to form, either draining out the
ventilation tube or blocking it completely so that the
tube may become dislodged shortly after surgery. This
persistent fluid formation is due to changes in the
mucous membrane of the middle ear and mastoid. |
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| In both of the above
conditions, mastoid surgery may be necessary to control
the problem and reestablish a normal middle ear
mechanism. |
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| Abnormal patency of the
eustachian tube is a condition occurring primarily in
adults, in which the eustachian tube remains "open" for
a prolonged period. This abnormality may produce many
distressing symptoms such as ear fullness and blockage,
a hollow feeling in the ear, hearing one's own breathing
and voice reverberation in the ear. It does not produce
a hearing impairment although most patients will feel
that they cannot hear as well in that ear. |
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| The exact cause of an
abnormally patent eustachian tube is often difficult to
determine. At times it develops following a loss in
weight or may develop during pregnancy. It may also
occur while taking oral contraceptives or other
hormones. |
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| Treatment of this
harmless condition is often difficult. Medical or
surgical treatment is often directed towards causing
mechanical obstruction of the eustachian tube or
creating a less functional eustachian tube. |
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| Palatal myoclonus is a
rare condition in which the muscles of the palate (back
of the mouth) twitch rhythmically many times a minute.
The cause of this harmless muscle spasm is unknown.
Often it is triggered with eating some foods or drinking
hot or cold liquids. |
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| The patient may
experience a rhythmic clicking or snapping sound in the
ear as the eustachian tube opens and closes. On
occasion, this snapping sound is caused by a
simultaneous spasm of a muscle in the middle ear
attached to the ear bones. |
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| A muscle relaxant is
often effective in controlling the symptoms. When they
persist and if they continue to pose a problem for the
patient, surgery is sometimes recommended. Cutting the
muscle in the middle ear usually relieves the symptoms. |
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| If surgical treatment is
necessary, it is performed under local anesthesia
through the ear canal. Hospitalization is necessary for
one night following surgery, and the patient may return
to his usual activities in several days. |
