allowed to fall out on their own as the hole in the eardrum closes, 6–12 months after insertion.
It is usually performed to treat persistent glue ear in children.
A grommet may be inserted into the eardrum at the same time.... myringotomy
Glue ear is sometimes first detected by hearing tests. Examination with an otoscope can confirm the diagnosis. In mild cases, the condition often clears up without specific treatment. If the condition persists, it may be necessary to insert grommets, which allow air into the middle ear and encourage fluid to drain.
Adenoidectomy may also be required.... glue ear
In most people, deafness is a result of sensorineural hearing impairment, commonly known as nerve deafness. This means that the abnormality is located in the inner ear (the cochlea), in the auditory nerve, or in the brain itself. The prevalence of this type of hearing impairment rises greatly in elderly people, to the extent that more than 50 per cent of the over-70s have a moderate hearing impairment. In most cases no de?nite cause can be found, but contributory factors include excessive exposure to noise, either at work (e.g. shipyards and steelworks) or at leisure (loud music). Anyone who is exposed to gun?re or explosions is also likely to develop some hearing impairment: service personnel, for example.
Conductive hearing impairment is the other main classi?cation. Here there is an abnormality of the external or middle ear, preventing the normal transmission of sound waves to the inner ear. This is most commonly due to chronic otitis media where there is in?ammation of the middle ear, often with a perforation of the ear drum. It is thought that in the majority of cases this is a sequela of childhood middle-ear disease. Many preschool children suffer temporary hearing loss because of otitis media with e?usion (glue ear). Wax does not interfere with hearing unless it totally obstructs the ear canal or is impacted against the tympanic membrane. (See also EAR; EAR, DISEASES OF.)
Treatment Conductive hearing impairment can, in many cases, be treated by an operation on the middle ear or by the use of a hearing aid. Sensorineural hearing impairments can be treated only with a hearing aid. In the UK, hearing aids are available free on the NHS. Most NHS hearing aids are ear-level hearing aids – that is, they ?t behind the ear with the sound transmitted to the ear via a mould in the external ear. Smaller hearing aids are available which ?t within the ear itself, and people can wear such aids in both ears. The use of certain types of hearing aid may be augmented by ?ttings incorporated into the aid which pick up sound directly from television sets or from telephones, and from wire loop systems in halls, lecture theatres and classrooms. More recently, bone-anchored hearing aids have been developed where the hearing aid is attached directly to the bones of the skull using a titanium screw. This type of hearing aid is particularly useful in children with abnormal or absent ear canals who cannot therefore wear conventional hearing aids. People with hearing impairment should seek audiological or medical advice before purchasing any of the many types of hearing aid available commercially. Those people with a hearing impairment which is so profound (‘stone deaf’) that they cannot be helped by a hearing aid can sometimes now be ?tted with an electrical implant in their inner ear (a cochlear implant).
Congenital hearing loss accounts for a very small proportion of the hearing-impaired population. It is important to detect at an early stage as, if undetected and unaided, it may lead to delayed or absent development of speech. Otitis media with e?usion (glue ear) usually resolves spontaneously, although if it persists, surgical intervention has been the traditional treatment involving insertion of a ventilation tube (see GROMMET) into the ear drum, often combined with removal of the adenoids (see NOSE, DISORDERS OF). Recent studies, however, suggest that in many children these operations may provide only transient relief and make no di?erence to long-term outcome.
Advice and information on deafness and hearing aids may be obtained from the Royal National Institute for Deaf People and other organisations.... deafness
Examination of the ear includes inspection of the external ear. An auriscope is used to examine the external ear canal and the ear drum. If a more detailed inspection is required, a microscope may be used to improve illumination and magni?cation.
Tuning-fork or Rinne tests are performed to identify the presence of DEAFNESS. The examiner tests whether the vibrating fork is audible at the meatus, and then the foot of the fork is placed on the mastoid bone of the ear to discover at which of the two sites the patient can hear the vibrations for the longest time. This can help to di?erentiate between conductive and nerve deafness.
Hearing tests are carried out to determine the level of hearing. An audiometer is used to deliver a series of short tones of varying frequency to the ear, either through a pair of headphones or via a sound transducer applied directly to the skull. The intensity of the sound is gradually reduced until it is no longer heard and this represents the threshold of hearing, at that frequency, through air and bone respectively. It may be necessary to play a masking noise into the opposite ear to prevent that ear from hearing the tones, enabling each ear to be tested independently.
General symptoms The following are some of the chief symptoms of ear disease: DEAFNESS (see DEAFNESS). EARACHE is most commonly due to acute in?ammation of the middle ear. Perceived pain in this region may be referred from other areas, such as the earache commonly experienced after tonsillectomy (removal of the TONSILS) or that caused by carious teeth (see TEETH, DISORDERS OF). The treatment will depend on the underlying cause. TINNITUS or ringing in the ear often accompanies deafness, but is sometimes the only symptom of ear disease. Even normal people sometimes experience tinnitus, particularly if put in soundproofed surroundings. It may be described as hissing, buzzing, the sound of the sea, or of bells. The intensity of the tinnitis usually ?uctuates, sometimes disappearing altogether. It may occur in almost any form of ear disease, but is particularly troublesome in nerve deafness due to ageing and in noise-induced deafness. The symptom seems to originate in the brain’s subcortical regions, high in the central nervous system. It may be a symptom of general diseases such as ANAEMIA, high blood pressure and arterial disease, in which cases it is often synchronous with the pulse, and may also be caused by drugs such as QUININE, salicylates (SALICYLIC ACID and its salts, for example, ASPIRIN) and certain ANTIBIOTICS. Treatment of any underlying ear disorder or systemic disease, including DEPRESSION, may reduce or even cure the tinnitis, but unfortunately in many cases the noises persist. Management involves psychological techniques and initially an explanation of the mechanism and reassurance that tinnitus does not signify brain disease, or an impending STROKE, may help the person. Tinnitus maskers – which look like hearing aids – have long been used with a suitably pitched sound helping to ‘mask’ the condition.
Diseases of the external ear
WAX (cerumen) is produced by specialised glands in the outer part of the ear canal only. Impacted wax within the ear canal can cause deafness, tinnitis and sometimes disturbance of balance. Wax can sometimes be softened with olive oil, 5-per-cent bicarbonate of soda or commercially prepared drops, and it will gradually liquefy and ‘remove itself’. If this is ineffective, syringing by a doctor or nurse will usually remove the wax but sometimes it is necessary for a specialist (otologist) to remove it manually with instruments. Syringing should not be done if perforation of the tympanic membrane (eardrum) is suspected. FOREIGN BODIES such as peas, beads or buttons may be found in the external ear canal, especially in children who have usually introduced them themselves. Live insects may also be trapped in the external canal causing intense irritation and noise, and in such cases spirit drops are ?rst instilled into the ear to kill the insect. Except in foreign bodies of vegetable origin, where swelling and pain may occur, syringing may be used to remove some foreign bodies, but often removal by a specialist using suitable instrumentation and an operating microscope is required. In children, a general anaesthetic may be needed. ACUTE OTITIS EXTERNA may be a di?use in?ammation or a boil (furuncle) occurring in the outer ear canal. The pinna is usually tender on movement (unlike acute otitis media – see below) and a discharge may be present. Initially treatment should be local, using magnesium sulphate paste or glycerine and 10-per-cent ichthaminol. Topical antibiotic drops can be used and sometimes antibiotics by mouth are necessary, especially if infection is acute. Clotrimazole drops are a useful antifungal treatment. Analgesics and locally applied warmth should relieve the pain.
CHRONIC OTITIS EXTERNA producing pain and discharge, can be caused by eczema, seborrhoeic DERMATITIS or PSORIASIS. Hair lotions and cosmetic preparations may trigger local allergic reactions in the external ear, and the chronic disorder may be the result of swimming or use of dirty towels. Careful cleaning of the ear by an ENT (Ear, Nose & Throat) surgeon and topical antibiotic or antifungal agents – along with removal of any precipitating cause – are the usual treatments. TUMOURS of the ear can arise in the skin of the auricle, often as a result of exposure to sunlight, and can be benign or malignant. Within the ear canal itself, the commonest tumours are benign outgrowths from the surrounding bone, said to occur in swimmers as a result of repeated exposure to cold water. Polyps may result from chronic infection of the ear canal and drum, particularly in the presence of a perforation. These polyps are soft and may be large enough to ?ll the ear canal, but may shrink considerably after treatment of the associated infection.
Diseases of the middle ear
OTITIS MEDIA or infection of the middle ear, usually occurs as a result of infection spreading up the Eustachian tubes from the nose, throat or sinuses. It may follow a cold, tonsillitis or sinusitis, and may also be caused by swimming and diving where water and infected secretions are forced up the Eustachian tube into the middle ear. Primarily it is a disease of children, with as many as 1.5 million cases occurring in Britain every year. Pain may be intense and throbbing or sharp in character. The condition is accompanied by deafness, fever and often TINNITUS.
In infants, crying may be the only sign that something is wrong – though this is usually accompanied by some localising manifestation such as rubbing or pulling at the ear. Examination of the ear usually reveals redness, and sometimes bulging, of the ear drum. In the early stages there is no discharge, but in the later stages there may be a discharge from perforation of the ear drum as a result of the pressure created in the middle ear by the accumulated pus. This is usually accompanied by an immediate reduction in pain.
Treatment consists of the immediate administration of an antibiotic, usually one of the penicillins (e.g. amoxicillin). In the majority of cases no further treatment is required, but if this does not quickly bring relief then it may be necessary to perform a myringotomy, or incision of the ear drum, to drain pus from the middle ear. When otitis media is treated immediately with su?cient dosage of the appropriate antibiotic, the chances of any permanent damage to the ear or to hearing are reduced to a negligible degree, as is the risk of any complications such as mastoiditis (discussed later in this section). CHRONIC OTITIS MEDIA WITH EFFUSION or glue ear, is the most common in?ammatory condition of the middle ear in children, to the extent that one in four children in the UK entering school has had an episode of ‘glue ear’. It is characterised by a persistent sticky ?uid in the middle ear (hence the name); this causes a conductive-type deafness. It may be associated with enlarged adenoids (see NOSE, DISORDERS OF) which impair the function of the Eustachian tube. If the hearing impairment is persistent and causes problems, drainage of the ?uid, along with antibiotic treatment, may be needed – possibly in conjunction with removal of the adenoids. The insertion of grommets (ventilation tubes) was for a time standard treatment, but while hearing is often restored, there may be no long-term gain and even a risk of damage to the tympanic membrane, so the operation is less popular than it was a decade or so ago. MASTOIDITIS is a serious complication of in?ammation of the middle ear, the incidence of which has been dramatically reduced by the introduction of antibiotics. In?ammation in this cavity usually arises by direct spread of acute or chronic in?ammation from the middle ear. The signs of this condition include swelling and tenderness of the skin behind the ear, redness and swelling inside the ear, pain in the side of the head, high fever, and a discharge from the ear. The management of this condition in the ?rst instance is with antibiotics, usually given intravenously; however, if the condition fails to improve, surgical treatment is necessary. This involves draining any pus from the middle ear and mastoid, and removing diseased lining and bone from the mastoid.
Diseases of the inner ear
MENIÈRE’S DISEASE is a common idiopathic disorder of ENDOLYMPH control in the semicircular canals (see EAR), characterised by the triad of episodic VERTIGO with deafness and tinnitus. The cause is unknown and usually one ear only is affected at ?rst, but eventually the opposite ear is affected in approximately 50 per cent of cases. The onset of dizziness is often sudden and lasts for up to 24 hours. The hearing loss is temporary in the early stages, but with each attack there may be a progressive nerve deafness. Nausea and vomiting often occur. Treatment during the attacks includes rest and drugs to control sickness. Vasodilator drugs such as betahistine hydrochloride may be helpful. Surgical treatment is sometimes required if crippling attacks of dizziness persist despite these measures. OTOSCLEROSIS A disorder of the middle ear that results in progressive deafness. Often running in families, otosclerosis affects about one person in 200; it customarily occurs early in adult life. An overgrowth of bone ?xes the stapes (the innermost bone of the middle ear) and stops sound vibrations from being transmitted to the inner ear. The result is conductive deafness. The disorder usually affects both ears. Those affected tend to talk quietly and deafness increases over a 10–15 year period. Tinnitus often occurs, and occasionally vertigo.
Abnormal hearing tests point to the diagnosis; the deafness may be partially overcome with a hearing aid but surgery is eventually needed. This involves replacing the stapes bone with a synthetic substitute (stapedectomy). (See also OTIC BAROTRAUMA.)... ear, diseases of
Causes: chronic catarrh with obstruction of the Eustachian tubes of dietetic origin. Starchy foods should be severely restricted. The ear is clogged with a sticky fluid usually caused by enlarged adenoids blocking the ventilation duct which connects the cavity with the back of the throat.
Conventional treatment consists of insertion of ‘grommets’ – tiny flanged plastic tubes about one millimetre long – which are inserted into the eardrum, thus ensuring a free flow of air into the cavity.
Fluid usually disappears and hearing returns to normal.
Tre atme nt. Underlying cause treated – adenoids, tonsils, etc. Sinus wash-out with Soapwort, Elderflowers, Mullein or Marshmallow tea. Internal treatment with anti-catarrhals to disperse. Alternatives:– German Chamomile tea. (Traditional German).
Teas. Boneset, Cayenne, Coltsfoot, Elderflowers, Eyebright, Hyssop, Marshmallow leaves, Mullein, Mint, Yarrow.
Powders. Combine: Echinacea 2; Goldenseal quarter; Myrrh quarter; Liquorice half. Dose: 500mg (two 00 capsules or one-third teaspoon), thrice daily.
Tinctures. Combine: Echinacea 2; Yarrow 1; Plantain 1. Drops: Tincture Capsicum. Dose: 1-2 teaspoons thrice daily.
Topical. Castor oil drops, with cotton wool ear plugs, Oils of Garlic or Mullein. If not available, use Almond oil. Hopi Indian Ear Candles for mild suction and to impart a perceptible pressure regulation of sinuses and aural fluids.
Diet. Gluten-free diet certain. No confectionery, chocolate, etc. Salt-free. Low-starch. Milk-free. Abundance of fruits and raw green salad materials. Supplements. Vitamins A, B-complex, C. E. ... otitis media – glue ear
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