Normal Ear and Hearing
The ear is divided into three parts: the outer ear, the middle ear, and the inner ear. The outer ear collects soundwaves and amplifies it slightly as it travels through the ear canal and through the eardrum (tympanic membrane) and into the middle ear space. The middle ear is an air-filled space that contains the hearing bones, or ossicles—malleus (hammer), incus (anvil), and stapes (stirrup)—and the openings into the inner ear hearing organ (cochlea) and balance (vestibular) system. The ear bones and their connection to the ear drum is the mechanism that sends the sound energy from the air to the inner ear fluid, which takes the sound and converts it into electrical energy to send along the hearing (cochlear) nerve to get to the brain.
Hearing loss can be secondary to a problem with any or all of the three portions of the ear (external, middle, or inner ear). A conductive hearing impairment occurs if there is an abnormality with the external or middle ear, where there is difficulty with conducting sound to the inner ear fluids, such as an absence of the outer ear or ear canal (atresia or microtia), otosclerosis, or when there is fluid secondary to an ear infection. If a problem occurs within the inner ear (cochlea or cochlear nerve), a sensorineural or nerve hearing impairment occurs, such as in sudden hearing losses due to inflammation or nerve degeneration that occurs with age (presbycusis). When there is difficulty in both the middle ear and the inner ear hearing, a mixed hearing loss is diagnosed; this can occur in chronic ear infections or otosclerosis.
Acoustic neuromas (also called vestibular schwannomas) are benign fibrous growths that occur deep within the intracranial cavity adjacent to the inner ear structures. These tumors make up around 10% of all brain tumors. They originate from the insulating fibers (Schwann cells) on the balance or hearing nerve (8th cranial nerve) and are located in and around the internal auditory canal, which carries the hearing and balance nerve, and facial nerve (7th cranial nerve) from the inner ear and face to the brainstem. The facial nerve is typically the last nerve to be affected by the growth of these tumors, as it is more robust than the hearing or balance nerve. These slow-growing lesions average 1-2 mm/year of growth and do not spread (metastasize) to other locations in the body. Most often, as tumors grow, patients lose hearing and balance function on the side with the tumor. This usually happens slowly and progressively with time, although sudden, acute losses can occur. Sudden losses are thought to be secondary to loss of blood supply to the nerves or compression causing loss of neural transmission. If this happens, patients will experience a sudden sensorineural hearing loss or vertigo. Acoustic neuromas are present in ~1% of patients with sudden sensorineural hearing, therefore, an MRI scan is recommended in these patients despite outcome with treatment, as steroids have been shown to temporarily return hearing in some of these cases.
We are typically able to diagnose this tumor with 95-99% certainty based solely on MRI imaging characteristics.
Signs & Symptoms
The most common presenting symptom is asymmetric hearing loss (hearing loss greater in one ear). In addition, common symptoms include tinnitus (head noise) that is often asymmetric and balance disturbance. Less common findings include episodic vertigo (sense of rotation), or facial numbness or weakness.
For most patients, these tumors grow slowly over years and have been present for some time before they are identified. Rarely, the rate of growth is more rapid and can only be identified on serial imaging.
The initial diagnostic procedures to identify an acoustic neuroma is an MRI scan, typically obtained for above mentioned symptoms. A CT scan can be obtained in patients that are unable to obtain an MRI for medical reasons, although this is less specific and can miss small tumors. Additional testing may be required to aid in management discussion, including balance function testing.
There are three treatment options for management of acoustic neuromas: observation, stereotactic radiosurgery, and microsurgery.
The first and foremost goal is to ensure there is no danger to life with this tumor. Although rare, stroke or increased intracranial pressure (hydrocephalus) may develop, although is more common in very large tumors compressing the flow of spinal fluid. Secondly, the main objective of any treatment is to preserve as many vital structures and function as possible, while ensuring adequate control of the tumor. The main nerve of concern for preservation is first and foremost the facial nerve.
Observation is a conservative approach in certain cases, as we know, most often, these are benign tumors with slow growth. Some tumors do not show any growth for years or even a lifetime after initial diagnosis, and in these cases no treatment may be necessary. We often start with this approach for those with smaller tumors (2cm or less) or tumors that have been documented no growth on serial imaging studies. Often times these patients have some hearing remaining in the ear that we would like to utilize, as some treatment options will take away the hearing at a faster rate that the tumor itself. Additionally, this may be the recommended approach in those with significant medical comorbidities or the elderly.
Treatment with stereotactic radiosurgery or microsurgery is typically recommended for patients in whom tumor growth has been proven, with larger tumors (greater than 2cm), or in whom no useful hearing remains.
The goal of stereotactic radiosurgery is not to remove or shrink the tumor, but rather to stop it from growing. This involves a single dose of highly focused radiation typically given on a single day. It is not recommended for large tumors or tumors in unfavorable locations. The highly focused radiation beam is directed at the tumor and spares much of the critical surrounding structures.
No incisions are required in this outpatient procedure. Risks are minimal on the day of the procedure and limited to headache and discomfort from wearing the required headframe. The radiation continues to work for months after the initial dose, which may cause swelling and additional symptoms months to years later. These additional risks include: loss of part or all remaining hearing in the treated ear, dizziness that is most often temporary but may be permanent, brain swelling causing increased intracranial pressure, and temporary or permanent facial nerve weakness. As with any radiation treatment, there is also a very remote chance that this benign tumor could convert to a malignant tumor or a stroke could occur.
Microsurgery is a common treatment options chosen by most patients and their surgeon. There are three surgical approaches depending on the tumor size, location, the amount of hearing remaining in the ear, and patient preference (middle fossa, retrosigmoid, or translabyrinthine). The general goal of any operation is complete tumor removal, while sparing vital structures that surround the tumor. This operation typically requires a full day of surgery to complete and post-operative hospital stay from 3-7 days on average, including some time in the intensive care unit.
Risks of acoustic tumor surgery vary with the size of the tumor, location, and medical comorbidities. Unlike stereotactic radiosurgery, the goal here is complete tumor removal. If the tumor is completely removed there is a <1% chance of recurrence. Also, unlike stereotactic radiosurgery, most complications occur at the time of surgery and not months later.
These risks include: loss of part or all remaining hearing in the treated ear, dizziness that is most often temporary but may be permanent, brain swelling causing increased intracranial pressure, temporary or permanent facial nerve weakness, and rarely, stroke or death.
Allergy occurs when the immune system reacts to something that doesn’t affect others. The trigger is called an allergen. Allergens can include pets, dust mites, pollens, and molds. Allergies affect up to one in four people. Allergies can change over time. Sometimes called hay fever, symptoms include sneezing, runny nose, nasal congestion, itchy watery eyes, and other symptoms. Allergies can contribute to recurring ear or sinus infections, asthma, and eczema.
Many over the counter medications are available. Depending on response to medications, the severity of symptoms, and if allergies are contributing to other health conditions, allergy testing can identify the specific allergens in order to better treat the patient. Treatment includes avoidance of identified allergens, nasal steroid sprays, antihistamines, other medications. Immunotherapy builds up your immunity to allergens. This can be achieved through weekly allergy shots or daily sublingual (underneath your tongue) drops. Immunotherapy usually lasts at least three years in order to change your immune system enough to reduce allergic reactions. (Rephrased, from AAOA)
Asthma involves chronic inflammation of the lungs. The airways react, swell, and narrow when exposed to triggers. Triggers can include allergens, smoke, cold air, exercise, and viruses. Symptoms include wheezing, chest tightness, coughing, and difficulty breathing. Most people with asthma have allergies as a trigger; the inflammation affects their upper and lower airways. Asthma and allergies are both becoming more common. Asthma ranges from mild and intermittent to severe with daily symptoms. Exacerbations can occur in all severities of asthma, and can be life threatening. Untreated asthma can cause permanent lung damage. A breathing test is helpful to diagnose and treat asthma. This is called a pulmonary function test or PFT. Treatment typically includes avoidance of triggers and use of inhalers. The goalof treatment is to control symptoms so they do not impact your quality of life.
BPPV (benign paroxysmal positional vertigo) is caused by tiny loose calcium rocks in the inner ear. There are two small compartments with sensory cells that respond to linear head movements within the inner ear that contain small calcium crystals set within a gelatinous matrix. The crystals of this compartment can become dislodged and become free floating within the balance system, causing BPPV. BPPV is one of the most common disorders of the inner ear.
The most common presentation of BPPV is brief, spinning vertigo that occurs with head movements, such as turning over in bed or looking up. The symptoms can vary in each person. Most people will not have symptoms when the head is still, but some may have mild dizziness or “feel off” even when not in motion. The diagnosis is easily made during the
examination when placing your head in certain positions.
Generally, the crystals will dissolve back into the liquid in the inner ear within a few days, but some may last longer. In these cases, maneuvers or exercises may be done to assist with the crystals moving back to their anatomic position. Rarely, surgery is needed to correct the problem.
No medications are effective in treating or preventing the disorder. A particle repositioning maneuver (Epley, Brandt-Daroff, Cawthorne, BBQ roll) is the most effective treatment to move the crystals to the correct location. This is easily performed in the office by your physician and may be performed at home. Typically, a few maneuvers are required to get the crystals back in place and gradually lessen symptoms.
Following each maneuver, we recommend you keep your head in an upright position for 30 minutes to allow the crystals to become attached back in the normal position. It may be helpful to sleep upright for 48 hours after the initial exercise but is not required.
Rarely, when the exercises do not provide relief or the disease becomes recurrent, a surgical procedure called “posterior semicircular canal occlusion” can be used to correct the problem.
Bell’s Palsy is the acute onset of facial paralysis that is typically short-lived; recovery returns function back to normal in the majority of patients. In a large study in 2002 of 2500 patients studying the natural history of Bell’s Palsy, 85% of patients’ function was returned within 3 weeks and in the remaining 15% after 3-5 months. In 71% of patients, return to normal function was obtained (Sequelae were slight in 12% of patients, mild in 13% and severe in 4%) (Peitersen, 2002).
The cause of Bell’s Palsy is thought to be the herpes simplex virus type I, a virus that typically lives dormant in nerves and becomes re-activated, similar to the pathophysiology of a cold sore. This virus affects the nerve and causes swelling and compression, affecting the nerve function and causing paralysis.
The treatment of Bell’s Palsy thus centers around the reduction of swelling of the facial nerve as well as an attack on the herpes simplex virus. Currently medical treatment consists of high dose steroids (Prednisone 60 mg per day) and antiviral (Acyclovir or Famvir). Those patients with a partial facial paralysis are treated in order to hopefully prevent complete facial paralysis.
If a complete facial nerve paralysis is identified, the same treatment is used in addition further testing is needed as these patients may present with a much poorer prognosis. Two electrical tests are currently used (ENOG, EMG) to measure the amplitude of the facial muscle activity to determine nerve function remaining. Those patients with findings that demonstrate a low likelihood of returning to near normal facial function are candidates for facial nerve decompression surgery to possibly improve odds of returning to normal function within the first two weeks of onset. Those patients undergoing decompression within the first two weeks of the onset of paralysis showed a 91% chance of a good outcome vs a 42% chance of returning to completely normal function than if treated with steroids only (Gantz, 2018). The risk of surgical decompression including a 2-5% incidence of sensorineural hearing loss and dizziness in addition to risk of permanent injury to the facial nerve.
Cerebrospinal fluid leak from the ear/encephalocele in the ear
The roof of the ear is the floor of the intracranial contents, which are surrounded by spinal fluid. Occasionally, this thin bone that separates the ear from the intracranial cavity can be thin and develop holes in which cerebrospinal fluid (CSF) can leak down into the ear, or additionally an encephalocele (brain hernia) can develop over time. Symptoms can be subtle and can be present for years prior to diagnosis. Most often, patients will have clear fluid behind the ear drum causing hearing loss. And may notice persistent, clear drainage from the ear particularly if a tympanostomy tube was placed in the eardrum for drainage of the fluid. In some cases, patients may present acutely with an intracranial infection (meningitis).
Once a leak or brain hernia is suspected, laboratory testing of the fluid is performed, and imaging is obtained to assist with localizing the source (CAT scan or MRI scan).
This problem requires surgical repair to prevent further complications, such as meningitis. There are several options for surgical repair, which include through the mastoid bone behind the ear (transmastoid), via a craniotomy to repair the site from above (middle fossa), or most often a combined approach, which involves both the transmastoid and middle fossa approach in order to provide the best visualization and chance for one-time, permanent repair.
Patients may be predisposed to CSF leaks due to head trauma, but most occur spontaneously, often from increased intracranial pressure. The most common cause for increased intracranial pressure is obesity, as the increased abdominal pressure from belly fat causing a backup of spinal fluid that typically drains into the abdomen. The increased intracranial pressure thins the bone over time, leading to a small hole that allow fluid and/or brain matter to herniate into the ear spaces.
Weight loss may be recommended to assist with decreasing intracranial pressure to ensure future leaks do not develop, and occasionally, shunting of the fluid is required.
A cochlear implant is a small, electronic device that is surgically implanted, and has given the gift of hearing to thousands of children and adults. Cochlear implants are not hearing aids, nor do they restore hearing. The implant converts sound energy into an electrical signal that gets transmitted to the cochlear nerve (hearing nerve), and then to the brain.
The implant consists of an external device worn on the ear or body that contains a microphone to pick up sound in the environment, and the surgically implanted internal receiver/stimulator that converts the sound information to electrical pulses that send this information to the brain through the electrode placed in the cochlea (hearing organ).
A cochlear implant does not restore your hearing. However, a majority of cochlear implant users experience an increase in their ability to understand speech and an improved quality of life. Our cochlear implant team is dedicated to providing patients with the best hearing health care and services.
Am I a candidate for a cochlear implant?
You may be a candidate for a cochlear implant if you are finding your hearing aids are no longer useful to you, OR if you have complete hearing loss on one side (single sided deafness). Typically, on a traditional hearing test, your Word Recognition Score or speech understanding will be less than 50-60% while wearing hearing aids. To determine if you are a cochlear implant candidate, we recommend having a cochlear implant evaluation by our certified Cochlear Implant Audiologist. There is no age limit in receiving a cochlear implant. YOU ARE NEVER TOO OLD! We have patients do quite well even into their 90s!
At a cochlear implant evaluation, we will first perform a hearing test if you have not had one in the last 6 months (if you have had a hearing test in the last 6 months, please bring a copy of this test to your appointment).
We will then perform the cochlear implant evaluation consisting of sentence testing and/or words in quiet and in background noise while wearing your hearing aid. After this testing is completed, you will meet further with the specialized audiologist who will review your results with you and your family, review different manufacturer options, and discuss realistic expectations and (re)habilitation required. If determined to be an appropriate candidate, you will also meet with the cochlear implant surgeon the same day to discuss the procedure and typical post-operative course.
Most operations are performed as an outpatient, same day procedure. The amount of hearing remaining in the operative ear will vary. Most often this will be gone after surgery, leaving the ear completely deaf until the implant is activated. There is always a low risk of infection and/or bleeding with any operation, increased or development of tinnitus (the perception of noise or ringing/buzzing in the ears). Additional rare risks include: spinal fluid leak, or temporary or permanent facial weakness, temporary unsteadiness or imbalance, vertigo (spinning sensation), or perforation of the eardrum.
The outcomes of cochlear implant users vary widely and depend on many factors, most importantly, how long that ear has been without sound, and the degree of hearing loss when the ear was implanted. Your cochlear implant team will discuss reasonable expectations for you based on your individual history. Additional considerations that may impact your performance include age, cause of hearing loss, your motivation, and time spent rehabilitating the ear. Typically, 50% of cochlear implant users can hear on the telephone. The other 50% usually have good results using a speakerphone or voice captioned telephone.
Pediatric Hearing Loss & Cochlear Implant Center
Children that are born with hearing loss can now be screened, diagnosed, and treated at Baker ENT without having to travel for care. Children with severe hearing loss who are deemed candidates for cochlear implantation are implanted around 12 months old, according to FDA guidelines. This allows children who would otherwise not be able to develop speech to become a listening, speaking communicator. Children with progressive hearing loss may also become cochlear implant candidates and do very well with a cochlear implant. Placement in a school setting that stresses oral communication is also important for a good outcome, although some families may benefit from additional use of sign language. We are sure to work closely with family and caregivers, our experienced cochlear implant audiologist, and local speech-language pathologist to ensure the best possible hearing outcome for our littlest patients.
**Please refer to operative information for patients for more information.
Dizziness is an imprecise, general term people use for a variety of different symptoms, including abnormal sensation of motion, imbalance, lightheadedness, blacking out, disorientation, weakness, or other odd sensations.
There are two parts of the inner ear: the hearing and balance (vestibular) system. Within the balance system, there are three balance canals, each set in different planes that respond to rotational movement of the head and send the signal through the vestibular nerve to the brain.
There are also 2 small compartments with sensory cells that respond to linear head movements; these compartments contain small calcium crystals set within a gelatinous matrix. The crystals of this compartment can become dislodged and become free floating within the balance system, causing BPPV (benign paroxysmal positional vertigo).
Balance is complex and made up of contributions from the inner ears, eyes, and the ability to sense where you are in space (proprioception). Proprioception includes nerve impulses from the muscles and joints of the limbs, neck, and spine. A weakness in any of these three areas may result in the sensation of dizziness or unsteadiness, more precisely termed “imbalance.”
Any issue involving the ear, eye, or extremities may result in imbalance, and problems with more than one area or system will make these symptoms worse.
Presbystasis is the loss of vestibular and balance functions associated with aging and occurs at different degrees of severity in each of us. One loses the cells of hearing as we age (presbycusis) just as we lose the cells associated with balance function. This can be made worse when there are additional problems with other components of the system, such as vision loss, neuropathy, or extremities issues. One can also strengthen the balance system with balance exercises, which are encouraged in all persons, particularly with age.
Motion sickness is an example of a problem with the brain integrating the signals coming from the visual input with the inner ear.
This is the feeling of nearly passing out, similar to the feeling you get if you stand up too quickly or if you hold your breath for a long time. Occasionally this can cause a person to black-out, or syncope. The most common cause is low blood pressure due to antihypertensive medications, or aging. Additional common causes include low blood sugar, heart arrhythmias, or migraine headaches. Less common causes of central dizziness include multiple sclerosis, head injury, stroke, or tumors. Treatment involves identifying the contributing factors and managing the source of the problem.
Vertigo is the sensation that your surroundings are moving or spinning around you, as if you are on a merry-go-round. Vertigo is often caused by an inner ear source malfunctioning, such as Ménière’s syndrome, labyrinthitis, positional vertigo, and vestibular neuritis, although migraine is another possibility. Rarely, this can be caused by tumors of the inner ear nerves. Vertigo caused by an inner ear source is often accompanied by tinnitus and hearing loss.
In addition to a complete history and physical exam your physician may require further testing to assist with identifying a cause for the dizziness and the best management plan. Evaluation will most likely require a hearing test to assist with giving information about the health and status of the ears, and possibly further balance tests. Imaging (CT or MRI scans) and blood tests may also be obtained when needed.
The most common balance or vestibular test for dizziness is the videonystagmography (VNG) test. This test takes advantage of a reflex arc between the ears and the eyes and gives the ability to test the function level of the inner ear. During the test, eye movements are monitored after placing different temperature air into the ear canal. This may cause a normal sensation of brief dizziness. Additional tests such as rotary chair testing or Vestibular Evoked Myogenic Potentials (VEMP) may be obtained if deemed appropriate by your doctor. These tests also measure function of the inner ear by measuring known reflex pathways.
Ear Infections & Surgical Treatment
Chronic Ear Infections
Chronic ear infections, or chronic otitis media, may present in many different ways, including drainage from the ear, hearing impairment, tinnitus (the perception of noise or ringing/buzzing in the ears. Less common presentations include dizziness, pain, or facial weakness. The infection may also lead to a skin cyst in the middle ear, or cholesteatoma.
Symptoms will be first treated medically, often with antibiotics (oral, ear drops, or creams), and ear cleanings in the office with use of microscope and often a suction. Occasionally, tympanostomy tubes are used to assist with fluid drainage and to help air enter the middle ear to clear the disease. With this condition, it is often required to have frequent ear exams and cleanings, which may prevent the need for surgical intervention.
Surgery is performed on the ear for multiple reasons. The eardrum may need to be repaired, a diseased ear bone may be replaced, or infection and/or scar tissue may need to be removed. Depending on the extent of the disease, reconstruction of the diseased ear bones may be performed at the initial operation or may need to be delayed due to the extent of the disease. When staged, the second operation is typically performed 6-12 months following the initial procedure.
The surgical procedure performed depends on the extent of disease and may include a myringoplasty (repair of the ear drum without lifting the eardrum or work in the middle ear), tympanoplasty (repair of eardrum with possible repair of ear bones or middle ear work), or mastoidectomy (removal of bone behind the ear) if the infection or cholesteatoma has spread to this area, or the region must be opened to access the middle ear space. Most operations are performed as an outpatient, same day procedure.
Risks of Surgery
The outcomes of surgery are highly dependent on the extent of disease present. The hearing may be worsened due to infection, bleeding or inflammation of the inner ear, or scar formation. There is also a small chance (approximately 1%) the hearing may be damaged, causing complete hearing loss to occur. This may occur even in cases where the operation and recovery go perfectly. In these cases, a traditional hearing aid is no longer useful. Taste disturbance is common following surgery as a small taste nerve (chorda tympani) runs under the eardrum and may be stretched or cut during the operation. This is often temporary lasting weeks to months but can be permanent. The facial nerve also travels in the mastoid and middle ear space and is always at risk during ear surgery. This is monitored during the operation and rarely ever injured (less than 1%). In addition, there is always a risk of increased or development of head noise (tinnitus), temporary unsteadiness or imbalance, vertigo (spinning sensation), or perforation of the eardrum. There is a high rate of recurrence of infection and cholesteatoma and it is not uncommon for additional procedures to be required in the future.
**please refer to operative information for patients for more information
Eustachian Tube Dysfunction
The eustachian tube is the structure that travels from your nose to your ear, and functions to equalize the pressure in your middle ear to the outside world. The valve portion is located in the back of the nose and is usually closed to prevent bacteria and various other things in the mouth and nose from getting into the middle ear. When you swallow, yawn, or blow your nose it opens to equalize the pressure. It drains secretions away from middle ear and allows for ventilation. When the eustachian tube does not function properly, it may stay inappropriately open or inappropriately closed, causing a myriad of symptoms.
Symptoms of Eustachian Tube Dysfunction
Variations in anatomy (cleft palate), inflammation in the nasopharynx (where the opening of the tube is located), such as allergy or infection, are examples that may prevent the eustachian tube from functioning properly. When the eustachian tube is inappropriately closed, a number of symptoms can occur:
• Fullness or pain of the ear
• Muffled hearing
• Otitis media
• Longstanding dysfunction may lead to perforation of the eardrum or cholesteatoma
Management of this condition consists of targeted therapy such as allergy treatment or control of inflammation. A tube may be inserted into the eardrum to drain fluid if present. Additionally, we are also performing balloon dilation to open the eustachian tube and restore function. A small catheter is used to insert a small balloon through the patient’s nose and into the eustachian tube opening. Once inflated, the balloon dilates open the tube and is deflated and removed. This opens up a pathway for mucus and air to flow through and restores the normal function.
Patulous Eustachian Tube
“Patulous Eustachian Tube” is a condition when the tube is abnormally open when it should be closed. This causes symptoms of autophony (hearing one’s own voice louder and usually more low-pitched), audible body noises (hearing sound of one’s own breathing or chewing), sensation of fullness in the ear, and fluctuating sensation of the ear drum with breathing. It can be caused by weight loss, by hormonal changes from pregnancy, menopause, pre-menopause, hormone medication, or for no identifiable reason. Most of the time no specific cause is identified. Even though this makes the ear feel “full” or “stopped up,” the hearing stays normal. The full feeling is bothersome, but it does not cause pain and it is no threat to your ear or hearing. This is not typically permanent and will cause no damage.
This condition can be difficult to treat as it is a variation of normal anatomy. Below is a list of medical management options that can help alleviate these symptoms- success varies per each patient and a few things may need to be tried before finding your solution.
• Induce acid reflux: drink a glass of orange or tomato juice an hour before bed and not take reflux medicine at night to induce some reflux and sleep on the affected ear. This helps get some reflux into the back of the nose on the affected side and cause some swelling to close the tube
• Premarin (intramuscular formula) 25 mg in 30 cc of saline nasal drops
• Double strength or hypertonic saline (1.8%) nasal drops
• PatulEND® vitamin supplement nasal drops (only available http://earfdn.org)
The important part on any nasal is to use it correctly; you should either lie down or tilt your head far back then turn 15 degrees toward the affected ear, place the drops in the nostril and sniff the solution into the back of the nose.
For bothersome symptoms that are refractory to medical management, surgical intervention may be an option to discuss with your physician:
• Placement of pressure equalization (myringotomy) tube
• Injection of filler substance around the opening of the eustachian tube or placement of cartilage graft
• The eustachian tube may be closed surgically and a perforation created in the eardrum as a last resort
Food allergies are increasing in prevalence. They occur most often in those with other allergies as well as a family history of allergy. Most allergies present in childhood, but can occur at any age. Symptoms can include hives, eczema, mouth and skin itching, runny nose, nasal congestion, and other symptoms. Blood testing measures the antibody levels to specific foods and is safe, reproducible, with few false positives. Common food allergies include eggs, milk, nuts, shellfish, wheat, and soy, which are common foods in the American diet. Once identified, the offending food must be avoided. An epinephrine auto-injector is typically prescribed in the event of a severe systemic reaction, which would require monitoring in an emergency department. Immunotherapy may be helpful. (Rephrased from Allergy Choices)
American Academy of Otolaryngology-Head and Neck Surgery – https://www.entnet.org/
American Academy of Otolaryngic Allergy – http://www.aaoallergy.org/
Allergy Associates of LaCrosse – https://lacrosseallergy.com/
A hoarse voice is a change in your voice quality, pitch, volume, or vocal effort. The medical term for hoarseness is dysphonia. It is a symptom associated with a cold or upper respiratory tract infection, voice overuse, acid reflux, allergies, smoking, aging, medication side effects, neurological conditions, intubation, and cancer. Seek medical attention if your hoarseness does not resolve over one to four weeks. Other associated symptoms that need further evaluation include difficult breathing, difficult swallowing, neck masses, or coughing up blood. A scope can be used in-office to look at the vocal cords.
Krouse, H. J., Reavis, C. (C. W., Stachler, R. J., Francis, D. O., & O’Connor, S. (2018). Plain Language Summary: Hoarseness (Dysphonia). Otolaryngology–Head and Neck Surgery, 158(3), 427–431. doi: 10.1177/0194599817751137
Laryngopharyngeal reflux (LPR) is when acid from the stomach comes up into the larynx (voice box) and pharynx (throat). Gastroesophageal reflux disease (GERD) occurs when acid irritates the stomach and esophagus (tube that connects to stomach). Symptoms of LPR can include cough, sore throat, hoarseness, and a lump in the throat sensation. A scope can visualize irritation of the voice box. Treatment involves dietary and lifestyle modifications and medication.
Martinucci, I., de Bortoli, N., Savarino, E., Nacci, A., Romeo, S. O., Bellini, M., … Marchi, S. (2013). Optimal treatment of laryngopharyngeal reflux disease. Therapeutic advances in chronic disease, 4(6), 287–301. doi:10.1177/2040622313503485
Ménière’s disease is a syndrome in which you experience episodes of spinning vertigo (sense of room spinning), hearing loss, tinnitus (ringing or buzzing in the ear), and fullness or pressure in the ear or ears. Between the unpredictable attacks, you usually do not have any problems or symptoms of the disease. The syndrome is most likely related to a fluid imbalance in the inner ear, or problems with salt-water homeostasis (body fluid equilibrium).
The diagnosis of the disease is usually based on a careful history and physical examination by an ear specialist, but other tests may be needed for a definitive diagnosis and to plan treatment options.
Ménière’s disease affects people of all ages, genders, and races. It is most common in middle age and older, uncommon in children.
The inner ears of patients with Ménière’s disease show dilation of one of the two fluid spaces in the inner ear; however, the cause of this fluid balance is unknown. Previous ear injury, heredity, autoimmunity, and allergy have all been suggested, but not definitively proven, as the underlying cause. It may actually be a different source in different people that manifests
as the same set of symptoms.
Warning symptoms such as fullness or pressure in one ear may come before an acute episode, or attacks may occur spontaneously.
• Common symptoms:
◦ Fluctuating hearing loss with distortion of sounds and difficulty with understanding speech
◦ Ringing in the affected ear (tinnitus)
◦ A sense of room spinning (vertigo)
◦ A cold sweat, nausea, and vomiting, or generalized weakness during the attack
• The episodes usually last from one to a few hours, depending on the severity of the disease
• Recurrence of the attacks is a cardinal feature of Ménière’s disease. Attacks often come in clusters with long periods in between. The timing and interval between attacks is unpredictable
• Early in the disease, the symptoms usually go away in several hours, but hearing loss may take a day or more to return to normal. Hearing loss can become permanent and may lead to intolerance of any loud noises.
Self-Care at Home
The best way to manage an attack at home is to minimize the symptoms
• Lie in a dark room with your eyes closed
• Try medications prescribed by your doctor- medications used to help treat anxiety (Valium, Ativan) and/or motion sickness (Antivert) can be used to help shorten and decrease the severity of the symptoms
• If any of these measures do not help during an attack, seek further medical evaluation for additional testing and treatment options and rule out any addition potential diseases
No measures will completely prevent Ménière’s disease, but you can take measures to avoid or minimize attacks and consequences:
• Low-salt diet- less than 2 grams of sodium daily. Avoid canned foods, smoked meats and fish, pizza, etc.
• The following should also be avoided or cautiously consumed, monitoring for increased symptoms:
◦ Foods high in cholesterol or triglycerides
◦ Foods with high carbohydrates
◦ Excessive sweets and candy
◦ Alcohol, particularly red wine and beer
• Avoid exposure to loud noises
• Manage stress as much as possible (can be a trigger)
• Use caution at home and on the job to avoid falls if you should feel dizzy
• Use of blood pressure medications can affect disease
This device is a small, portable pump which delivers pulses to the ear via a plastic probe placed in the ear canal. The principle of this method is to restore the fluid balance in the inner ear by applying low-pressure pulses to the middle ear. It requires placement of an ear tube in the ear drum to allow the pulses to reach the inner ear, which can be done in the office. Treatments are self-administered typically three times per day for five minutes each time.
In addition, corticosteroids are used to treat acute attacks either in oral form (often Medrol dose pack) or by direct infusion into the middle ear space via intratympanic (injections through the ear drum). Steroids decrease inflammation in the inner ear that occurs during an attack or flare-up and can often decrease duration and severity of symptoms. Some people are treated with steroids alone a few times per year as symptoms develop.
Medications for prevention of attacks:
• Diuretic (Dyazide, Maxide, Spironolactone, Lasix) to assist with salt-wasting and fluid imbalance; may decrease potassium levels, stop if muscle cramps develop. Must check labs every 6-12 months.
• Betahistine (SERC) works as an antihistamine in the inner ear. It may upset stomach by increasing acid production; avoid if severe acid reflux or history of ulcers
• Calcium-Channel Blocker (CCB; Verapamil) may stop blood vessel spasm to the inner ear; may be taken in conjunction with additional blood pressure medications but will need to monitor for low blood pressure and/or lightheadedness
Most people respond (>90%) to medical management to some degree, but some may need surgical treatment to correct potential problems in the inner ear. Two distinct approaches exist in surgical management—one is directed toward improving the pressure status of the middle ear, while the other is aimed at preventing the abnormal signals from reaching the brain by destroying the balance system in the affected ear, thus, eliminating symptoms. The destructive approach is left for end-stage patients who are debilitated by symptoms and often have no remaining hearing in the ear.
Endolymphatic sac decompression
This procedure decreases pressure buildup of the endolymph (inner ear fluid) by removing a portion of the bone that encases the fluid reservoir. This allows the reservoir sac to expand more freely than before and allows the pressure to dissipate. The procedure has a relatively low risk but does carry a small risk of permanent hearing loss. It is not successful in every patient; about 2/3 of patients are helped at least in the short-term by this procedure. It does not prevent the need for future procedures having to be performed at a later date.
Medication (gentamicin) is injected into the middle ear through the eardrum that selectively destroys the balance portion of the inner ear. It may require a series of injections but often improves symptoms after one injection. Although not as certain as a surgical labyrinthectomy, this can be done in an outpatient setting and avoids a general anesthetic. Hearing loss is a risk factor but does not happen in every case. You can expect to have more imbalance after this procedure and exercises may be required to assist the other (good) ear balance system to compensate for the loss in the bad ear after this procedure.
This surgical procedure is performed under general anesthesia to remove the entire hearing and balance organ on the affected ear. This is the best, most definitive procedure for vertigo attacks but the hearing is completely lost as part of the procedure. This procedure permanently destroys the balance and hearing functions of the inner ear, thus eliminating vertigo attacks. Therefore, this is reserved most often for those without useful hearing in the affected ear. The unoperated ear will provide hearing and balance as long as not affected by disease or other conditions. A hospital stay is required, and you may feel increased imbalance after surgery which can require balance exercises or therapy.
Vestibular Nerve Section
The goal with this surgical procedure is to cut the balance nerve on the affected side while the hearing nerve is preserved for patients with debilitating vertigo not responsive to prior therapy, in whom useful hearing still remains. This procedure requires a craniotomy, or removal of part of the skull similar to a brain surgery to access the nerve.
Nasal polyps are growths in the nasal cavity that are typically found bilaterally and are benign. The cause of nasal polyps is uncertain, but they are commonly associated with allergy, asthma, sinus infection, and aspirin allergy. They can cause nasal obstruction, nasal drainage, and decreased sense of smell. A scope, or nasal endoscopy, as well as a CT scan evaluates the extent of the nasal polyposis. Medications to manage polyps can include topical or systemic steroids, an injectable biologic medication, as well as medications to control associated conditions. Surgery is reserved for cases uncontrolled with medical treatment. Recurrence following surgery can occur with severe disease recurring in up to 10% of individuals.
(Rephrased from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504067/ A Review of Nasal Polyposis by Jonathan Ray Newton and Kim Wong Ah-See in Ther Clin Risk Manag. 2008 Apr; 4(2): 507–512.
A neck mass is an abnormal lump in the neck. Neck masses can be caused by a viral or bacterial infection or something more serious, such as cancer. If the mass is due to infection, it should go away completely when the infection resolves. Masses can be benign (noncancerous) or malignant (cancerous). In adults, many neck cancers are due to squamous cell carcinoma while others are lymphoma, skin cancer, or cancer that has spread from somewhere else in the body. There can be also benign or malignant growths of the thyroid and salivary glands. Neck masses in children can be due to other causes.
Seek medical attention if the lump in your neck lasts longer than a few weeks or if you are not sure how long you have had the neck mass. It will need evaluation but does not necessarily mean you have serious medical problem. Risk factors for cancer of the mouth, tongue, throat, and voice box include long-term use of tobacco and alcohol as well as high-risk strains of human papilloma virus, or HPV. A scope can be used in-office to look inside the nose and throat. A CT scan of the neck with contrast can provide a picture of the neck mass and other anatomy. A fine-needle aspiration (an outpatient biopsy) or biopsy in the operating room may be indicated. Follow-up care and monitoring is important.
Pynnonen, M. A., Colandrea, M., Finestone, S. A., & O’Connor, S. S. (2017). Plain Language Summary: Evaluation of the Neck Mass in Adults. Otolaryngology–Head and Neck Surgery, 157(3), 372–382. doi: 10.1177/0194599817723610
Your physician has found that you likely have otosclerosis contributing to your hearing loss; this is a common cause of hearing impairment. The cause is unknown and can be hereditary in nature.
Otosclerosis is abnormal growth of bone of the MIDDLE ear that prevents structures within the ear from conducting sound properly causing hearing loss (conductive hearing loss). Most often it involves the smallest ear bone (stapes) and prevents normal movement and sound transmission.
It also occasionally involves the INNER ear structures and causes a sensorineural or mixed hearing loss, which may not be improved with surgical intervention alone. Rarely, the otosclerosis may also spread to the balance canals and cause episodes of unsteadiness.
The amount of hearing loss due to involvement of the stapes and the degree of inner ear impairment can be determined only by a hearing test. The disease may affect one or both ears.
The conductive hearing loss is often correctable by surgery or use of hearing aids. In some cases, an over-the-counter medication containing fluoride may be prescribed to slow the loss of hearing if an inner ear contribution is identified. Hearing aids are a good choice for hearing improvement in patients who do not wish to have surgery or in whom surgery is not recommended.
Surgical Description- Stapedotomy
The operation used to correct the MIDDLE ear conductive hearing loss is called a stapedotomy or partial stapedectomy. Your ear surgeon will determine if you are an appropriate candidate for surgery based on your hearing test, degree of hearing loss, and medical history. This operation may be performed under local or general anesthesia and is typically outpatient. Over 95 percent of these operations are successful in restoring the hearing permanently.
This procedure is performed though the ear canal, and in addition, a small incision may also be made behind the ear to remove additional tissue to cover the new opening in the inner ear. The eardrum is elevated, and the hearing bones are palpated to confirm the diagnosis of otosclerosis and identify involved site. The most common finding is fixation of the stapes bone causing it to be immobile and unable to conduct sound transmission into the inner ear fluids. A laser is then used to remove the diseased portion and create a new tiny opening into the inner ear. A titanium prosthesis is then placed into this opening and connected to the second hearing bone (incus), to complete the connection and allow sound waves to pass from the eardrum to the inner ear fluids, correcting the previous conductive hearing loss. The hearing improvement is expected to be permanent. The eardrum is then returned to its normal position and packing material placed in the ear canal, which is removed at the first post-operative visit in 2-3 weeks. All prostheses are compatible with MRI scanners of all strengths.
Hearing improvement will not likely be noticeable at the time surgery or immediately afterward due to the packing material and fluid within the ear from surgery. Improvement is expected at 4-6 weeks after surgery, with the maximum result at approximately six months after the prosthesis is adequately scarred into place.
Risks of Surgery
Most patients experience significant improvement in hearing and quality of life. In 1-2% of patients the hearing may be worsened due to the infection, bleeding or inflammation of the inner ear, a leak of inner ear fluid (fistula), or scar formation causing movement of the prosthesis. Steroids are typically given in the operating room and in the recovery period to assist with prevention of these complications. There is also a small chance (approximately 1%) the hearing may be damaged, causing complete hearing loss to occur. This may occur even in cases where the operation and recovery go perfectly. In these cases, a traditional hearing aid is no longer useful. At times when there is a significant degree of neural hearing loss in addition to the conductive hearing loss a hearing aid may still be required after surgery, as this type of hearing loss cannot be corrected with an operation. Your surgeon will discuss this with you ahead of the surgery if this is the case. Age-related hearing loss (neural degeneration) will continue to occur with time and hearing aids may be require due to this. Patients with otosclerosis tend to have faster rates of neural degeneration as compared to the general population.
Taste disturbance is common following surgery as a small taste nerve (chorda tympani) runs under the eardrum and may be stretched or cut during the operation. This is often temporary lasting weeks to months but can be permanent. The facial nerve also travels in the middle ear space and is always at risk during ear surgery. This is monitored during the operation and rarely ever injured (less than 1%). In addition, there is always a risk of increased or development of head noise (tinnitus), temporary unsteadiness or imbalance, vertigo (spinning
sensation), or perforation of the eardrum.
**please refer to operative information for patients for more information
Sinusitis is inflammation of the lining of the sinuses that can prevent your sinuses from draining. Symptoms include facial pressure, nasal congestion and drainage, and fatigue. Antibiotics, steroids, and nasal sprays can be used to treat acute and chronic sinusitis. If symptoms remain uncontrolled after repeated courses of medical therapy, surgical intervention can be the next step. An in-office procedure with a small balloon can open and reshape your sinus drainage pathways, restoring normal sinus drainage. Sinus passages stay open, providing long-term symptom relief. An in-office balloon sinuplasty avoids general anesthesia and costs of being treated in an operating room as well as a faster recovery period. It is, for many, as effective as traditional sinus surgery. Nasal saline irrigations are an important tool to manage sinusitis. Following a sinus procedure, you will be asked to avoid blowing your nose and will be advised on other activity restrictions in the post-operative period. (Rephrased from https://sinus-clear.com/entellus-medical/)
Tinnitus (tin-EH-tis or tin-EYE-tis), or head noise, is a symptom characterized by the perception of sound in the absence of an external noise.
It is very common: more than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10 to 15% in adults. It is the most common service-related disability among our military veterans. Reported rates of tinnitus are significantly higher in those with regular exposure to noise.
Most people that experience tinnitus are able to ignore it or are not bothered by it; however, it can become bothersome enough to cause difficulty in thought processing, emotions, hearing, sleep, and concentration which may negatively impact quality of life.
Most often, tinnitus is a function of hearing loss: the brain makes up a sound to compensate for the loss of hearing, such as with a ‘phantom pain’ after loss of a limb.
The noise may be intermittent or constant, mild or severe, and vary in sound quality. Occasionally tinnitus can be heard by others and may require a different work-up than the traditional head noise. This ‘objective tinnitus’ may be due to muscle spasms in the middle ear or eustachian tube, or be due to blood vessels surrounding the ear.
Management strategies for persistent, bothersome tinnitus
• Hearing aid evaluation: The most common way to reduce the noise is to put sound back into an ear with hearing loss with a hearing aid or sound generator, and may work well despite degree of hearing loss.
• Sound therapy
• Cognitive-behavioral therapy
• Clinicians should not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications but may be recommended based on individual circumstances.
• Dietary supplements such as ginkgo biloba, melatonin, and zinc, have not been scientifically shown to improve symptoms. There have been reported cases of improvement, possibly due to placebo effect.
Additional Conservative Measures to Improve Symptoms
• Avoid anything that stimulates the brain, as this can increase the head noise production (anxiety, caffeine, lack of sleep)
• Ignore the noise and not search for it as much as possible
• Avoid loud sounds
• Avoid medications that may worsen the noise (high doses of aspirin, lasix, gentamycin)
• Control blood pressure
• Be comforted that the noise does not indicate a brain tumor, or indicate you will go deaf, and will not likely progress
• Sleep aids or sedatives can be used to occasionally help with sleep if the noise is bothersome
Tonsils, as well as adenoids, are a part of the body’s immune system. They help trap germs that enter your body through your mouth or nose. Tonsils can be seen if the mouth is opened wide by looking on either side at the back of the throat. Adenoids cannot be seen and are located in behind the nose and roof of the mouth, high in the throat.
Tonsils and adenoids can become infected and enlarged. Tonsillitis makes the tonsils appear red with white spots with fever and swollen lymph nodes in the neck. A culture is typically performed to check for strep and antibiotics may be prescribed. If there are frequent sore throats or if they are enlarged and causing breathing difficulties during sleep, surgery may be the next step (tonsillectomy, adenoidectomy). Removal does not increase risk of infection as other tissues around the throat take over the job of trapping germs.
After tonsillectomy, throat pain lasts approximately two weeks, and there can also be ear and neck pain. Pain tends to be worst in the morning. Ask children if they are having pain every four hours, because they may not tell you. A regular schedule of acetaminophen (Tylenol) and ibuprofen (Motrin), even through the overnight hours, is often recommended. A lidocaine lollilop can be prescribed through a compounding pharmacy. Stronger pain medications are not recommended for children under the age of twelve. Frequent small sips of cold liquids can be helpful for both pain and to maintain hydration, and ensure the patient is urinating a few times each day. There can be nausea or vomiting, a low-grade fever, and a small risk of bleeding. Contact Baker ENT Associates if there are any questions or concerns.
Finestone, S. A., Giordano, T., Mitchell, R. B., Walsh, S. A., O’Connor, S. S., & Satterfield, L. M. (2019). Plain Language Summary for Patients: Tonsillectomy in Children. Otolaryngology–Head and Neck Surgery, 160(2), 206–212. doi: 10.1177/0194599818817758
Urticaria, another word for hives, is an itchy rash of the upper portion of the skin. The blood vessels dilate and fluid enters the tissue. Hives are red or white, raised, change size and shape over time, and generally last a few hours then disappear without scarring. Up to one quarter of individuals will have one episode of hives in their lifetime. Those with allergy are more likely to be affected. Hives are classified as acute or chronic. Acute hives can be caused by foods, drugs, systemic diseases, infections, physical triggers, and inhalants.
Chronic Idiopathic Urticaria is one form. “Chronic” means the condition lasts or recurs for six weeks or longer. “Idiopathic” means there is no known cause. “Urticaria” is the medical term for hives, or itchy welts that are red or white and vary in size.
Testing is done in an effort to identify triggers, and a journal of symptoms can be helpful. Even so, most hives that are chronic are idiopathic. Chronic Idiopatchic Urticaria occurs Hive symptoms, or flares, most often occur in people between the ages of 20 and 40. Chronic Idiopatchic Urticaria occurs most often between the ages of 20 and 40 and affects women twice as often as men. Flares can appear at any time without triggers but the itching or rash cannot be spread to others. Treatment includes antihistamines and possibly an injectable medication.