Middle and Inner Ear Surgeries
Serous Otitis Media (Otitis Media With Effusion)
The sole window of middle ear opening to outer world is the Eustachian tube stretching towards epipharynx. This tube is made of cartilages and muscles. These muscles, being an extension of swallowing and chewing muscles, open the Eustachian tube once every 3 – 4 swallows, and wastes and air with reduced oxygen come out of middle air towards epipharynx, and clean air coming from nose penetrates into middle ear, and Eustachian tube automatically closes. In children, this tube is not fully developed. An Eustachian tube which cannot easily open and close, and has a small downslope and thus, a reduced discharging function, or is closed by adenoid in front of cavity towards epipharynx, cannot fulfill its normal function. Its air is absorbed by vessels in mucosa covering the middle ear. Vacuum effect occurs in middle ear. Tympanic membrane and ear mucosa are pulled towards middle ear vestibule. Vessels expand and allow leakage of serum and blood elements into middle ear vestibule. Permanent existence of fluid in middle ear due to this process becoming chronic is termed and called as chronic serous otitis media.
This in turn causes hearing loss. Otoscopic, endoscopic or otomicroscopic examination to be performed by otolaryngologist is the most important method in diagnosis of this disease. Hearing test and tympanometry test measuring middle ear pressure are useful in finalization of diagnosis. In adults, it is absolutely required to eliminate the cause, and then to intervene the ear. If the cause is adenoid in children, serous otitis media is an adequate reason for adenoidectomy operation. In a child with serous otitis media, after taking tympanogram results, an antibiotic therapy of 20 days may be applied (may be repeated twice or three times if needed), and thereafter, after comparison with ear examination and tympanogram results, it may be decided to implant a ventilation tube to patients who do not respond to drug therapy.
Chronic Otitis Media
It is an operation performed to treat the chronic disease of middle ear of chronic otitis media patients, wherein tympanic membrane cavity is closed, and damages, if any, in ear ossicles are corrected and repaired. This operation is composed of several sub-categories:
- Miringoplasty: Only the perforation in tympanic membrane is repaired.
- Ossiculoplasty: Tympanic membrane is sound. Only the damages in ear ossicles are repaired in order to correct the hearing.
- Mastoidectomy: Cells (mastoid cells) inside the bone behind ear are cleaned.
In chronic otitis media patients, one of the biggest problems is formation of cholesteatomas in middle ear or mastoid. They are lumps of bright white color created by helical combination of external auditory canal skin or tympanic membrane outer layer cells. As the nucleus of these lumps contains fatty acids, they are called cholesteatoma. Its most important feature is its helical growth just like onion skin, and its making pressure on bones while growing, thereby causing bone loss. Furthermore, its secreted enzymes and acids also lead to loss of bones, and undried inflammations and infections. The most common cause of complications in chronic otitis media is these cholesteatomas. They destroy everything they meet. They melt down the facial nerve canal. They cause damage of nerve inside canal. They further open middle ear or mastoid into brain or cerebellum, thereby leading to meningitis and abscesses. Thus, a chronic otitis media patient with cholesteatoma is an important candidate for operation.
Otosclerosis (Calcification in middle ear ossicles):
Otosclerosis is uncontrolled and sporadic calcification of otic capsule surrounding inner ear. As this calcification is mostly focused on otic capsule where stapes is neighboring inner ear, stapes is mostly affected from this calcification. Movements of stapes are disrupted, and even it becomes entirely immobile. It cannot transmit voice waves into inner ear fluids. Thus, the stage of transmittance of voice into inner ear is interrupted. This in turn causes ringing (tinnitus) and gradually increasing loss of hearing in the affected ear. Great majority of patients is women between 20 and 40 years of age. Mostly, there is someone with hearing loss in their family (genetic transition). The most important element of diagnosis is patient and family history. In addition, such audiological tests as hearing threshold test, tympanogram and reflex test also support the diagnosis. Final diagnosis is only possible by an operation. This means to say that both final diagnosis and treatment method of otosclerosis is a surgical operation. Tympanic membrane is removed, and immobility of stapes and its calcification focus are seen, thus finalizing the diagnosis. The mostly known surgical method is stapedectomy wherein the stapes which has remained immobile due to calcification is removed and is replaced by a prosthesis.
Our inner ear is one of the most complex, most sensitive and most perfect organs of our body. It is composed of a bone capsule (otic capsule) containing a fluid and hearing – balance organs called as modiolus and semicircular canals. Modiolus contains hearing organ and cells, while semicircular canals contain balance organ and cells. Cerebrospinal fluid and blood vessels produce two fluids of separate characters inside this otic capsule. These fluids are held separated from each other through bone and membrane separations. Production and secretion of these fluids are balanced. In Meniere’s disease, however, the problem is overproduction and/or under-secretion of fluid produced by vessels. In Meniere’s crisis, both the fluid containing hearing organ and the fluid containing balance organ increase, and swell the membrane separation. Sensation of pressure and fullness in ear, being a finding of Meniere’s crisis, develops. Sometime after, membrane separation is torn, and two separate fluids mix up. These fluids of different characters make toxic effects on each other, thereby leading to dizziness attack and hearing loss. Ear ringing (tinnitus), nausea and vomiting also accompany these symptoms in most of the cases.
Is there a surgical operation for Meniere’s Disease?
Surgical operations vary depending on hearing level in Meniere’s Disease. Hearing-protective drainage operations may be performed on patients suffering from vertigo (dizziness) with a not bad hearing. The patients who have lost hearing ability and are excessively suffering from dizziness may be treated by operations destroying and eliminating the inner ear.
In the recent years, intratympanic (passing through tympanic membrane to directly reach middle ear) injection is gradually spreading. In our clinic as well, we are using intratympanic injection as the first treatment method in many ear diseases and particularly in sudden hearing loss. The most important advantage of intratympanic injection is elimination of systemic side effects thanks to direct injection of treatment drug into only middle ear. Particularly, cortisone used in treatment of sudden hearing losses may, if and when taken orally, cause gastric complaints, weight gains and even such fatal side effects as gastric bleeding. As intratympanic treatment is locally effective, these side effects are not seen.
How is intratympanic injection applied?
First, for intratympanic injection, tympanic membrane is anaesthetized by a spray containing lidocaine. Then, by using a dental-tip injector as thin as a strand (hair), drug is injected into middle ear after passing through tympanic membrane. No pain is felt as tympanic membrane is anaesthetized. It is normal to have a drug taste in epipharynx due to the Eustachian tube. As the hole opened in tympanic membrane is very small, tympanic membrane immediately repairs itself, and no permanent perforation occurs.