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Author: admin | 01.03.2015 | Category: Relieve Tinnitus

All information and advice on this website is of a general nature and may not apply to you. The eardrum is a paper-thin membrane, shaped like a miniature satellite dish, 8-10 mm diameter. Their job is to concentrate the sound energy, collected by the relatively large area of the eardrum, onto the tiny footplate of the stapes.
Atelectasis (ate-eel-ECK-ta-sis) The eardrum is thin and sucked inwards, like cling film over the ossicles, by long term failure of the Eustachian tube to ventilate the middle ear. Another way that skin can get into the middle ear is for it to be blown in, by a pressure wave such as an explosion. Another way that skin from the outside of the eardrum could get into the middle ear is for it to be pushed in by surgery, such as fitting grommets.
Occasionally a cholesteatoma develops behind a healthy eardrum from some skin cells left behind during the development of the ear in the womb.
Some specialists believe that cholesteatoma can develop from non-skin cells in the middle ear that turn into skin because they are chronically irritated by infection.
A slow progressive loss of hearing, especially if it is only in one ear, can creep up on you, so isn’t always noticed. Ear infections following swimming, dunking the head in the bath, or ear syringing, are common in cholesteatoma. Occasionally, the first symptom of cholesteatoma is when it gives rise to serious complications. Sudden onset of severe vertigo may be due to the disease eroding into the lateral semicircular canal of the inner ear. Unless it becomes actively infected, cholesteatoma is usually missed altogether on examining the ear. If it becomes infected, then there may be signs of otitis externa (inflammation of the skin of the outer ear canal). Until otitis externa has been treated, it is impossible to know if we are dealing with an underlying cholesteatoma, because the eardrum is not visible. Apparently normal left tympanic membrane as seen through an operating microscope as it would be lined up to fit a grommet. Shah grommet in position lower part of left eardrum, seen through the operating microscope.
Even under the operating microscope and with the patient fully anaesthetised, a cholesteatoma can easily be missed.
A CT scan is a form of X-Ray imaging which allows us to see the body in much clearer detail than plain X-Rays. If you are prescribed ear drops, make sure you use them properly, otherwise they probably won’t work. An alternative to microsuction often used in children with runny, discharging ears is to gently mop out the ear with a cotton wool applicator. Microsuction is an examination and treatment of the ear using a high powered binocular operating microscope. Combined approach mastoidectomy and tympanoplasty for cholesteatoma, right ear, in an 8 year old child.
Mastoidectomy (mass-toyed-ECK- tuh-mee, mastoid for short) is the operation to remove cholesteatoma. Before antibiotics, mastoid surgery was commonly done in desperate circumstances for acute infection, a mastoid abscess. The two main approaches for cholesteatoma surgery are the endaural, also known as canal wall down or modified radical mastoidectomy, and the postauricular, also known as the canal wall up or combined approach mastoidectomy and tympanoplasty. In the endaural approach, the cut is made in the roof of the ear canal, extending up in front of the ear into the hairline. Tympanoplasty (TIM-pan-o-plas-tea) is surgery to rebuild the damaged structures of the middle ear, including the eardrum and ossicles. Ossiculoplasty (oss-SICK-you-low-plas-tea) is an attempt to rebuild the damaged chain of tiny bones that conduct sound from the eardrum to the inner ear. Damaged bones can sometimes be taken out, cleaned, re-shaped and put back in a different way. Missing pieces can sometimes be replaced with materials taken from nearby, such as cartilage from the outer ear. Even if initially successful, in the weeks and months following surgery, there will be scarring.
This can easily pull things apart, or alternatively stiffen up and immobilise the reconstruction. If a foreign material has been used in the reconstruction, there is a fair chance that the body will reject it and push it out. The same structures that are at risk from the disease are at risk from the operation to remove it. But it may be possible to keep it under reasonable control by repeated microsuction treatment in out patients.
This option is sometimes advised for older infirm patients, especially if their general medical condition makes a long operation difficult and risky, and whose shorter life expectancy makes the probability of developing serious complications less. This strategy can include the option of carrying out mastoid surgery, to try and salvage the situation, only if serious complications actually happen. If you smoke, you should give up, because smokers are more likely to suffer complications after operation. Parents should also consider giving up, as children must not be exposed to passive smoking during recovery. Make sure you have supplies of soluble paracetamol (Calpol for children) for when you come home. If you normally wear a hearing aid in the ear that is to be operated, remember you won’t be able to wear it for several weeks or months. After the operation, you will wake up in the recovery area, where a nurse will look after you. You mustn’t drive for at least 48 hours, and longer if you are still feeling dizzy or tired. You won’t be able to hear very well from the operated ear, it will be packed with a dressing. Protect the wound by wearing your stretch headband and disposable dressing pads, you should receive a supply of these on discharge from the hospital.
You may get some seeping of yellow or brownish fluid from the ear, or slight blood staining. You should change the disposable pads under your stretch headband at least daily, more often if there is a lot of seepage. It has a distinctive hospital antiseptic smell, which some find reassuring and others dislike. BIPP is a very good antiseptic and can be left safely in wounds for months without going off, unlike some other dressings.
If you get increasingly severe pain, or a smelly, nasty discharge, that might mean infection and you should contact us urgently for advice.
If the outer ear begins to itch severely, and starts to go red and blisters, that usually indicates you have become allergic to BIPP.
You should contact us urgently for advice if you think you might have developed a BIPP allergy. Start just pottering around the house, then short walks outside, but avoid strenuous physical activity.
We may need to admit younger children to hospital as a day case, to carry out this treatment under a short general anaesthetic. You must strictly avoid getting any water in the ear, especially bath water which is a soup of germs from the rest of the body. For a few weeks after the dressing has been removed, we recommend protecting the ear from cold winds by placing a fresh piece of cotton wool in the canal when outdoors. If, however, you get an increasingly severe earache, or if your ear develops an unpleasant smelly discharge, that usually means an infection has set in. If you are going away or think you might have difficulties in attending for urgent treatment, we will prescribe a supply of the medication for you to have on standby. Cartilage graft used to reconstruct the outer attic wall, left ear, five years following mastoid surgery.
As well as looking out for recurrent disease, many cholesteatoma patients need regular cleaning of the ear in order to prevent that build-up of dead skin layers.
Earwax (or cerumen to use the correct medical term ) is a waxy material produced by sebaceous glands inside the ear.
Wax is a natural protector of the external canal and has some bactericidal properties as well as water protective functions. Patients often feel a blocked sensation secondary to wax impaction and a decrease in their level of hearing. Wax naturally discharges itself from the ear canal and more often than not it is the incessant fiddling that is commonplace amongst humans that causes irritation and pushes wax deeper into the ear canal.
If wax becomes a problem then this can be treated by removal under direct vision with a headlight and specialist instrumentation.
Alternatively ear irrigation can be undertaken by a trained practitioner but it is essential that the ear is dryed after this procedure and that it is undertaken by a person trained specifically in this. Dr Francis Vaz consults on Harley Street and operates out of the Harley Street Clinic, London.
For stubborn ear impactions, it may be necessary to continue the oil and peroxide for a few weeks or have it removed by your doctor.
Earwax, and check out Earwax on Wikipedia, Youtube, Google News, Google Books, and Twitter on Digplanet. Earwax, also known as cerumen, is a yellowish waxy substance secreted in the ear canal of humans and other mammals.
There are two distinct genetically determined types of earwax: the wet type, which is dominant, and the dry type, which is recessive.
Cleaning of the ear canal occurs as a result of the "conveyor belt" process of epithelial migration, aided by jaw movement.[11] Cells formed in the centre of the tympanic membrane migrate outwards from the umbo (at a rate comparable to that of fingernail growth) to the walls of the ear canal, and move towards the entrance of the ear canal.
Lubrication prevents desiccation, itching, and burning of the skin within the ear canal (known as asteatosis). While studies conducted up until the 1960s found little evidence supporting antibacterial activity for cerumen,[14] more recent studies have found that cerumen has a bactericidal effect on some strains of bacteria. Excessive earwax may impede the passage of sound in the ear canal, causing conductive hearing loss. Patients generally prefer the irrigation solution to be warmed to body temperature,[31] as dizziness is a common side effect of ear washing or syringing with fluids that are colder or warmer than body temperature. It is generally advised not to use cotton swabs (Q-Tips or cotton buds), as doing so will likely push the wax farther down the ear canal, and if used carelessly, perforate the eardrum.[25] Abrasion of the ear canal, particularly after water has entered from swimming or bathing, can lead to ear infection.
Ear candling, also called ear coning or thermal-auricular therapy, is an alternative medicine practice claimed to improve general health and well-being by lighting one end of a hollow candle and placing the other end in the ear canal. A postal survey of British general practitioners[24] found that only 19% always performed cerumen removal themselves.
The author Bull advised physicians: "After removal of wax, inspect thoroughly to make sure none remains.
Claims arising from ear syringing mishaps account for about 25% of the total claims received by New Zealand's Accident Compensation Corporation ENT Medical Misadventure Committee.[30] While high, this is not surprising, as ear syringing is an extremely common procedure. When a man is becoming dull of hearing, which happens most often after prolonged headaches, in the first place, the ear itself should be inspected: for there will be found either a crust such as comes upon the surface of ulcerations, or concretions of wax. This medical information is provided to enhance and support, not replace, individual advice from a qualified medical practitioner. The vibrations are transmitted to the inner ear via three small bones (ossicles) suspended in the middle ear. The gramophone needle picks up vibrations from the grooves in the record, passes them to a vibrating membrane, then into the large horn, and so to the outside world. Cholesteatoma does occur in bomb blast victims, who have had their eardrums perforated and blown inwards. This second kind of congenital cholesteatoma is much rarer, it presents in early childhood. The brown flaky material at the top of the eardrum is not wax, but the dried outer layers of dead skin of a cholesteatoma.


It is rare for a General Practitioner (primary care, family doctor) to be able to diagnose this condition. Bone conduction of sound is often better than air conduction if the ossicles have been destroyed by cholesteatoma. The CT scan splits the image into thin layers, sliced like a salami, so that we can see much greater detail and pinpoint what is happening at any given point.
Illumination is from light shone over the child’s shoulder and focussed onto the ear by a head mirror worn by the surgeon. Rather like going to the dentist, very few people look forward to the experience, but it is effective and necessary. The surgeon has to tread a fine line between getting rid of the disease while preserving what he can of the hearing mechanism. Our predecessors had nothing better than a hammer and gouge, and no magnification other than some spectacle loupes. The disease is followed from where it is visible (usually the upper part of the eardrum) into the mastoid.
The surgeon is faced with a three dimensional, microscopic jigsaw puzzle, where the pieces don’t interlock, and some are missing. Even in the best hands, less than 50% achieve socially acceptable hearing from ossiculoplasty. There are also risks of not operating, especially in a progressive destructive disease like cholesteatoma. The chances of further damage from a controlled operation by a skilled surgeon using modern equipment are less that the risk of leaving the disease to progress for the rest of your life – unless your life expectancy is short. This is due to damage to the corda tympani, a small nerve that takes a detour through the middle ear on its way from the brain to the side of the tongue. The opening to the ear canal is often deliberately enlarged, a meatoplasty (me-ATE-o-plass-tea). Also, the shape of your ear canal is likely to change and it may no longer fit you afterwards. You might need to bend the arm outward, or temporarily remove it and wear them over the bridge of the nose.
You will not be allowed anything to eat for about six hours before operation, but you can drink clear fluids up to two hours before. If your operation is done in the afternoon, or if your recovery is slow, you may need to stay in overnight. You can have your hair washed, carefully by someone who can keep the water away from your operated ear. This tends to happen only to patients who have had previous ear surgery and become sensitised to BIPP. The dressing will have to be removed, and you will need treatment with antihistamines and maybe steroids.
Depending on the method of surgery, it may take several weeks or even up to three months for it to heal.
We would expect you to contact us as soon as possible if you have to start using the medication, as you may need to have your appointment brought forward. Routine follow-up ear examination under the microscope in out-patients, 9 months following mastoidectomy and tympanoplasty surgery in which the ossicles were preserved and the eardrum rebuilt.
Cholesteatoma can come back, many years or even decades after initially successful surgery.
A second, new cholesteatoma develops, because the underlying problems that caused the first cholesteatoma, such as poor Eustachian Tube function, the eardrum getting sucked in, and failure of the normal outward migration of skin, are still there.
Having antibacterial properties it cleans, lubricates and protects the lining of the ear by trapping dirt and repelling water. Microsuction is a wax-removal technique using a microscope and a fine sterile suction device. Occasionally wax produces a degree of discomfort and if irritated can produce a degree of otitis externa. We can help this by not putting any objects such as cotton buds into the ears and also by softening the wax with the use of olive oil drops. He also has a more local private practice that is undertaken through the Sloane Hospital, Beckenham, Kent. People who are frequently troubled by wax impactions may want to use the oil and peroxide on a monthly basis. The cerumen in the canal is also carried outwards, taking with it any dirt, dust, and particulate matter that may have gathered in the canal. The lubricative properties arise from the high lipid content of the sebum produced by the sebaceous glands. The irrigation solution flows out of the canal along its floor, taking wax and debris with it.
Curetting earwax using an ear pick was common in ancient Europe and still practiced in East Asia. According to medical researchers, it is both dangerous and ineffective.[34] Advocates say that the dark residue that shows after the procedure is extracted earwax, proving the efficacy of the procedure. It is problematic as the removal of cerumen is not without risk, and physicians and nurses often have inadequate training for removal.
If a crust, hot oil is poured in, or verdigris mixed with honey or leek juice or a little soda in honey wine. The outer and middle ear collect sound from the outside world and concentrate it down to the stapes footplate.
Sound vibrations are turned into electrical signals and sent to the brain in the nerve of hearing. For this to occur, the middle ear must contain air at the same atmospheric pressure as the outer ear. This is not yet cholesteatoma, there is no build-up of skin layers, normal outward migration of skin is still happening and the retraction is self-cleaning. The air pressure in the middle ear falls if the Eustachian tube isn’t working properly. Cases of cholesteatoma associated with grommets are more likely to be due to an early cholesteatoma being missed when the grommets are fitted.
In fact, the build up of layers of greasy dead skin that forms the cholesteatoma is very similar to what happens if you don’t clean between your toes. The test doesn’t diagnose the condition, but does tell us how much hearing has been lost, and whether it is a conductive hearing loss (usually due to damage to the eardrum and ossicles) or a sensorineural hearing loss due to damage to the inner ear. It is only in recent years that scanners have been able to produce slices thin enough to give us useful information on the state of the middle ear. The view is nothing like as good, and we can’t normally reach right down to the eardrum, but it is less scary for the child. It is part of the temporal bone, which forms the base of the skull and contains all the structures of the ear, as well as the facial nerve and some big blood vessels that go into the brain. The site of the disease and the degree of destruction that has already happened are important. The aim is to achieve a stable but mobile mechanical linkage, reconnecting the reconstructed eardrum to the inner ear.
If the stapes (the third and most delicate bone in the chain) has been damaged, the prospects of restoring useful hearing by ossiculoplasty are very poor indeed.
That is better than having to physically scrape disease off the ossicles, which is like hitting the microphone and risks noise damage to the inner ear. At worst, you could die or suffer brain damage – but you are more likely to be injured in a road accident. If there are worries about your particular medical condition, we recommend a pre-operative assessment by the anaesthetist before deciding on surgical treatment.
Sometimes the ear moves position slightly on the head, and may fold either tighter against the head or stick out a little more depending on how the scar heals up. Your head bandage will normally be taken down before you go home, and you will be given a stretch headband with disposable gauze pads to be changed each day. It is essential for cholesteatoma patients to have long term follow up by a specialist who knows how to diagnose the disease. It can be very difficult to remove every last skin cell when we are trying to avoid further damage to the ear.
Ear syringing is not very good at removing adherent layers of dead skin, and might well set off infection by getting them wet. The microscope allows for excellent depth-perception allowing the procedure to take place without touching the sides on the ear canal. Jaw movement assists this process by dislodging debris attached to the walls of the ear canal, increasing the likelihood of its expulsion. Any other temperature may cause vertigo, just as used when testing the caloric reflex test.
Since the earwax of most Asians is of the dry type,[5] it is extremely easily removed by light scraping with an ear pick, as it simply falls out in large pieces or dry flakes. Studies have shown that in fact the same residue is left whether or not the candle (which is made of cotton fabric and beeswax and leaves a residue after burning) is inserted into an ear. Irrigation can be performed at home with proper equipment as long as the person is careful not to irrigate too hard. As a result, failure to remove the wax from the canal made up approximately 30% of the complications associated with the procedure. In the New Zealand claims mentioned above, perforation of the tympanic membrane was by far the most common injury resulting in significant disability.
And when the crust has been separated from the ulceration, the ear is irrigated with tepid water, to make it easier for the crusts now disengaged to be withdrawn by the ear scoop. I took this picture in 1988 as part of a research project into the development of cholesteatoma using a Storz Hopkins rod tele-otoscope, Xenon 300W light source, and an Olympus OM-1 SLR camera with Fujichrome 400ASA 35mm slide film. In its early stages, cholesteatoma tends to attack the ossicles, the small bones conducting sound from the eardrum to the inner ear. It is not unusual for retraction pockets and glue ear to co-exist, since both conditions are caused by failure of the Eustachian tube to properly ventilate the middle ear. This picture was taken with a tele-otoscope, which gives a wide angle view of the whole eardrum and the surrounding deep ear canal.
Severe attic retraction with perforation and possible early cholesteatoma – skin edges are on the body of the incus. We need to measure and know how much hearing has been lost, and how much remains, to help advise on the likely outcome of treatment.
Sometimes, and especially in younger children, it is done as a day case surgery under general anaesthetic.
The normal mastoid contains a honeycomb arrangement of air cells, which connect with air in the middle ear.
This gives a more normal looking ear and avoids a cavity which can be difficult to clean, especially in children. There are many techniques for ossiculoplasty, depending on the exact situation found at surgery.
Many UK ear surgeons won’t even attempt ossiculoplasty, since the chances of success are low, and there are significant risks of damaging the inner ear permanently by manipulating the ossicular chain in the attempt to rebuild it. A general anaesthetic carries a minimal risk, with consultant anaesthetists using modern drugs and monitoring equipment.
Sometimes we may need pre-operative tests such as X-Rays, electrocardiogram and blood tests. When you come into hospital, you will be seen by the nurse who will ask various questions about your general health and attach an identity bracelet to your wrist. The pearl had formed from a tiny fragment of cholesteatoma that hadn’t been removed at the first operation.
Usually, residual cholesteatoma will show up within a year or two, but it may be much longer.
But if both ears are affected, or if hearing properly on both sides is important to you, some form of hearing aid is usually needed. It is for this reason that if wax is visualized deep in the external canal that this is often a sign that it has been pushed here.
Instead, try the following: turn your head to one side and gently fill the ear canal with baby oil or mineral oil, using an eye dropper.


All other methods should only be carried out by individuals who have been sufficiently trained in the procedure. Other complications included otitis externa (swimmer's ear), which involves inflammation or bacterial infection of the external acoustic meatus, as well as pain, vertigo, tinnitus, and perforation of the ear drum. The job of the Eustachian tube is to ventilate the middle ear, keeping the pressure in the middle ear the same as in the outer ear. The view from a normal auriscope (as used in normal practice) is much narrower, and unless the examiner moves the auriscope around to see the whole of the drum, the attic may not be seen.
In the days before CT scans, some ear surgeons always wanted mastoid X-rays before operating. The surest way to get rid of the disease would be to drill out everything – be radical.
It was only after the introduction of the binocular operating microscope in the 1950’s that modern delicate controlled microsurgery of the ear became possible.
We try and keep the cavity as small as possible, and make the opening to the ear as large as possible, to help with ventilation and cleaning afterwards.
This method is technically a little more difficult, and is less reliable in getting rid of all the cholesteatoma at the first attempt. By and large, we prefer the postauricular approach initially in children and younger adults, provided there hasn’t already been too much destruction. My own view is that it is reasonable to attempt ossiculoplasty, if the situation on the table looks favourable. Similar questions will be asked by the Resident Medical Officer, and possibly by the anaesthetist. With some techniques, especially if we do reconstruction that hides where the disease was, you may be advised to have a second stage operation a year after the first.
Normal hearing aids can help, but the sound quality isn’t always great, and they often cause infection.
Allow the oil to soak in for a minute or two before turning over and placing the oil in the opposite ear.
The color of the candle wax deliberately matches the light brown-colored wax of the human ear, making the distinction between the two more difficult for a layperson.
If the disease progresses, it can erode the inner ear causing total and permanent deafness and tinnitus. Most middle ear diseases, including cholesteatoma, are associated with poor Eustachian tube function.
Even if this brownish crust were seen, very few non-specialists would recognise it, most would simply think they were looking at a piece of wax.
He came about his right ear, with a long history of recurrent infections with smelly discharge. I have taught over a hundred junior doctors ear surgery, some at quite an advanced stage in their training, and have been surprised at how many of them fail to check the attic properly during grommet surgery.
A conductive loss can sometimes be improved, but it is not usually possible to improve the hearing by treating cholesteatoma. The most difficult part of the operation is yet to come, the disease has to be carefully taken off the underlying ossicles. But that would make you very deaf, and could damage the other structures we are trying to protect, like the balance organ and facial nerve. Even with all the latest high powered microscopes, lasers and modern anaesthetics, mastoid surgery is very difficult. A shallow, smooth walled cavity is much easier to keep clean, and there is less risk of cholesteatoma coming back afterwards.
It is usually necessary to have a second look operation, about a year afterwards, if this technique is used. For older patients with medical problems causing difficulties with repeated operations we prefer the endaural modified radical approach. If the ossiculoplasty fails to give satisfactory hearing, we have the BAHA (Bone Anchored Hearing Aid – osseointegrated titanium auditory implant) to fall back upon. A second operation was advised, and the pearl was removed, it was limited to a small area and the ossicles were once again preserved. It is better to irrigate too gently for a long period than irrigate too forcefully attempting to remove wax quickly. Because the candle itself is a hollow tube, some of the hot burnt wax can drop down inside the candle, into the ear canal, potentially rupturing the eardrum. Further, the ear should be syringed with castoreum mixed with vinegar and laurel oil and the juice of young radish rind, or with cucumber juice, mixed with crushed rose leaves. Any part of the eardrum can form a retraction pocket, but they are commonest in the attic because the eardrum is naturally thinner and weaker there. The average GP will see hundreds of ear infections, but only one cholesteatoma every ten to twenty years. I believe that many of the cholesteatomas said to be caused by grommet insertion (a rare complication) were present at the time of the grommet fitting but were not noticed.
In both cases, we use the KTP laser to help get rid of skin cells from awkward areas like the ossicles. Often, we don’t know how much reconstruction will be needed, or possible, until we are part way through the operation. The curved tip can be placed with extreme accuracy into narrow awkward tiny crevices where cholesteatoma lurks. This is a routine to help avoid mistakes – like an airport checking your travel documents more than once.
If it had been neglected until it caused symptoms, it is unlikely the hearing could have been saved. This procedure can be done at home in the shower using an ear irrigation syringe with a right angle tip.
The dropping in of the juice of unripe grapes mixed with rose oil is also fairly efficacious against deafness. If cholesteatoma erodes into the balance organ, vertigo, a severe form of dizziness, results. Hearing tests before and after treatment are important in assessing the results of what we do. It is impossible to tell with a scan whether some part of the ossicular chain is fixed – this can only be determined by trying to move it during surgery.
Sometimes, tympanoplasty is done together with mastoidectomy, as part of the same operation. If this pearl is discovered at an early stage, it might be possible to simply winkle it out.
For the next three or four days, gently fill the ear canals with 3% hydrogen peroxide in the same manner that you instilled the oil.
After the wax is removed, the ear can be dried by tipping the head and gently pulling the ear upwards to straighten the ear canal.
Normally, the skin of the eardrum migrates slowly outwards, like a very slow moving conveyor belt. Although some might find that macabre, I’d prefer the learning curve to be on my dead granny, rather than on my live child.
Other times it is done at a later stage, as a second operation, once we are satisfied that the cholesteatoma has been removed and any infection has settled. If the cholesteatoma is directly on the facial nerve, we can’t use laser to burn it off because that would injure the nerve. Some of the most serious complications I have seen were in patients who neglected to have their ears cleaned following mastoid surgery for cholesteatoma.
Many cholesteatoma patients find that they can’t wear hearing aids because they cause infection, with painful, discharging ears. Peroxide is available at your pharmacy or market and will usually bubble out the ear wax once it has become soft. The skin grows in such a way that the outer layers are slowly moved outwards, like a conveyor belt.
The retraction pockets that progress to cholesteatoma are those in which the conveyor belt stops. The whole area is quite small, about the size of your thumb, and it contains some very delicate clockwork. In a radical mastoidectomy, all the ossicles are removed, except the footplate of the stapes. If you are in any discomfort, please let the nurse know as she can you an injection to help relieve it. If you have ventilating tubes in your ears, dilute the peroxide in half with water; discontinue it if you have any discomfort, dizziness or drainage.
If you paint a dot of ink in the middle of someone’s eardrum, then go back a week later and look at it, it will have moved outwards. Until the eardrum has been fully examined, it is impossible to know whether or not there is an underlying middle ear disease such as cholesteatoma. In some severe cases of cholesteatoma, the ossicles have already been eaten away by the disease so it makes no difference, they are gone anyway.
Anatomy varies considerably, and a surgeon needs to practice on lots of bones before embarking on live patients.
Once the infection clears up, they go back to wearing the hearing aid, then the whole miserable cycle repeats itself. Sometimes the whole of the eardrum is weak and becomes sucked in, covering the ossicles like cling film. Cholesteatoma cannot be diagnosed without seeing the whole of the eardrum in close-up detail. A CT scan is needed if we suspect complications, especially if we suspect there may be spread of disease into the brain. Anything blocking the ear canal, such as wax or infective debris, must be cleaned away to get a proper view of the eardrum. Unfortunately, in the UK, a public attitude has become established against the use of post-mortem tissues, which has led to a severe shortage of temporal bones for the next generation of ear surgeons to train on.
Some audiologists try to get around the problem of blockage by using loose fitting or vented moulds.
Most cholesteatomas start from a damaged, thinned and weakened eardrum that has been sucked inwards.
I teach trainee surgeons ear surgery on live patients every week, sometimes two or three cases. But there shouldn’t be any skin in the middle ear, it should be on the outside of the eardrum, in the outer ear. A bone conductor hearing aid uses bone conduction to put sound directly into the inner ear, bypassing the middle ear problem. It is not cancer and never spreads widely throughout the body – though it can cause quite enough trouble by its local destructive effects. Sometimes the diagnosis of cholesteatoma is discovered on the operating table, when a child has been admitted for grommets insertion.
Old fashioned bone conductor hearing aids are placed on metal springs like an Alice band, or sometimes built into a pair of spectacles. Sometimes, it is discovered on the operating table when an adult patient is admitted for a myringoplasty (repair of perforated eardrum). They are cumbersome, and very uncomfortable to wear for any length of time, because they have to press very hard. A perforated eardrum may be seen in the out-patient clinic, and the patient advised to have it repaired. Rapidly progressive disease, over a time course of a few months and sometimes weeks, is commoner in children and in the presence of active acute infection. It is only when the patient is under the anaesthetic, and the eardrum is lifted up to repair it, that the cholesteatoma is discovered. The most effective way of getting around this problem is to put sound directly into the bone of the skull, by the titanium screw of a BAHA osseointegrated auditory implant.



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