|Ear, Nose, and Throat Consultants, Inc.
Jeffrey S. Brown, M.D., F.A.C.S. Alysia S. Moon, MA, CCC-A
K. Holly Gallivan, M.D., M.P.H.,F.A.C.S. Hearing and Balance Center
Thomas H. Costello, M.D.
15 Dix Street, Suite D 7 Alfred Street, Suite 330
Winchester, MA 01890 Woburn, MA 01801
Tel: 781-729-8845 Tel: 781-937-3001
Fax: 781-729-6439 Fax: 781-937-3070
ANATOMY AND PHYSIOLOGY
The ear is divided into three separate parts: the external ear, the middle ear and an inner ear.
The External Ear consists of an auricle and an ear canal, and is the part of the ear affected in the so called “Swimmer’s Ear”. At the end of the canal is the membrane which covers the middle ear.
The MIDDLE Ear is a small air-filled cavity and consists of the ear drum, three bones called the Malleus, Incus, and Stapes, and these transmit the sound from the ear drum to the inner ear. This is the area that is involved in the major problems of fluid in the ear and recurrent ear infections. The Eustachian tube drains the constantly procedure fluid from this area.
The Inner Ear is a fluid filled bony cavity that contains many nerve endings and is responsible for hearing and for balance. These are rarely affected by the infections that occur in children.
We will concentrate on the middle ear which is the area in which most of the problems occur. There is a Eustachian Tube that connects the middle ear to the back of the nose. This tube is important in maintaining the normal pressure of the middle ear and draining normally formed fluid from the mastoid into the back of the nose. This tube normally opens during swallowing and equalizes the pressure. In all children, this tube functions at less than full efficiency because of the angle at which it lies and the soft cartilage that surrounds it.
In addition, the tonsils and adenoids which surround it in the back of the nose are enlarged and often involved in infection. As a result, the middle ear can become blocked from the back of the nose and the air is gradually absorbed by the blood vessel in the area leading to negative pressure. Fluid then fills up this cavity and the otitis media with effusion develops. As the fluid persists in this area, water may be withdrawn from it and it becomes thicker and thicker until finally it becomes jelly-like and is then called “Glue Ear”.
This is the most common cause of hearing loss in children and approximately ten to fifteen percent of children will suffer from this during their early years. As a result of this fluid remaining in the middle ear, organisms which are situated in the nose and throat are easily able to traverse the short Eustachian tube and into this fluid and cause the recurrent infections. As the fluid thickens, the hearing loss slowly becomes worse and second condition of otitis media with effusion rather than acute otitis media with its pain and obvious symptoms results. The otitis media with effusion is more subtle and the child may not complain at all. The older child may complain of popping, earache or fullness and later, may even complain of hearing loss. Many of these cases are not picked up at home, but noted at school screening testing and follow up is then recommended. Even though this is not a deaf child, this amount of hearing loss during developmental period, becomes extremely important.
Medical Treatment: the major treatment is to eliminate all infection, be it the acute otitis media or the otitis media with effusion. This is accomplished with antibiotics and if allergy is suspected, we sometimes would add an decongestant. The draw back of the antihistamine decongestant combination is that this may thicken the mucus and we would lose the advantage. If the fluid persists and we are unable to get this to drain spontaneously, we then have to consider surgical treatment.
SURGICAL TREEATMENT: PLACEMENT OF THE MYRINGOTOMY TUBE. The aim of the surgical treatment is to evacuate the fluid from the middle are. Air will enter the middle ear through the inserted tube and allow the congested swollen membrane to decrease in thickness and return to normal. The ear drum heals extremely quickly and in order to keep the tiny incision open, a small tube is placed in it. This tube is not fro draining the thick fluid, but more to allow air to enter the middle ear space and to allow the fluid to drain down the child’s own Eustachian tube. Occasionally, an adenoidectomy will be recommended was well especially if this procedure has to be repeated on more than one occasion. The majority of children, however, settle down after tubes have been placed once, with no added surgical procedure such as a tonsillectomy or an adenoidectomy.
PRE and POST OPERATIVE CARE OF TUBES IN THE EARS
PRE OP CARE:
For one week before surgery, the child should have no aspirin. Tylenol may be used as an alternative. The child should have nothing to eat or drink from midnight the night before the procedure and should be brought into the hospital early in the morning as arranged.
ANESTHESIA CONSULT: This consult is always done.
Anesthesia: Most of the children will be given a general anesthetic, which will be accomplished by breathing into a mask and using various inhalant gases, including oxygen, nitrous oxide, and the halothane or ethrane. These medications slowly make the child drop off to sleep and provided the child is aware of what will happen, it usually does not cause much anxiety. The method of anesthesia should be discussed before hand with the child. Occasionally, an intravenous is required to be started, and this will be done if necessary for safety factors. If the child has a severe cold or any bronchial congestion, the procedure will be postponed, until the child has recovered from the infection. If the child has an actual ear infection, the procedure will once again be postponed.
Parents often accompany child into the operating room for the anesthetic, but do not remain during the procedure
POST OP CARE
Immediately after the procedure, the child will be placed in the recovery room for a varying amount of time, until the child is perfectly awake. When it is safe to release the child, he will be brought back to you in the waiting area and may be taken home.
When one reaches home, the child may be given a light drink, such as apple juice, and then approximately half an hour wait before any further food is given. If the child feels well, the child may resume normal eating at lunch time.
RETURN VISITS: All children are expected to be seen between two and three weeks after the operation to check to be sure the tubes are in good position.
BATHING/ SWIMMING: Traditionally, children with tubes were not allowed to get any water in their ears. Recent studies have shown that “ear precautions” (ear plugs) do not make any difference in the infection rate of the ears. Your child, therefore, does not need to use ear plugs when bathing or swimming. However, children with tubes should not dive into water.
PROBLEMS ASSOCAITED WITH THE TUBES
Recurrent Infections: The most common problems Infection I the ear is usually first notice as drainage from the ear. In the usual infection, there is no pain or fever. But treatment is necessary. Occasionally, this purulent material is mixed with blood, but this does not indicate any worse problems. The child is usually treated with antibiotics by mouth with or without ear drops, and is always checked by his physician, two or three weeks after the infection, to be sure that the infection have settled down, and that the tubes remain in position.
Polyp Formation: Occasionally, a small polyp or area of granulation tissue forms on the ear drum, which may present with some bleeding from the ear canal. Any bleeding should be treated as an infection, at first and at the three week check-up, this would be noticed. Occasionally, the tube may have to be removed.
Perforation. A rare complication of this procedure is the persistence of a perforation after the tube has fallen out. This often indicates persistent Eustachian tube malfunction. If this does occur, we often use that perforation as a safety valve and do not repair it, until the child has outgrown the problem, which can be judged by age and by appearance of the ear drum on the other side. Once again, no water is allowed in this ear yet. Any further questions or problems will be answered by your physician.
MYRINGOTOMY CONSENT FORM
A myringotomy has been recommended for my child or me. The nature and purpose of the procedure, its potential risks and benefits, the likely outcome without the procedure, and the available alternatives have been explained to me. I understand that:
An incision will be made into the eardrum
This is done to drain fluid or pus from the middle ear to improve hearing or an infection, or to place a tube
The procedure is done either without anesthesia, with local anesthesia, or under a general anesthetic
The area may bleed or drain fluid after the procedure
Keeping water out of the ear aids in proper healing and in avoiding infection
Possible complications include:
An allergic reaction to anesthesia
Failure of the incision site to heal, resulting in a chronic hole in the ear drum, whit the possible need for surgical repair
Hearing loss, which may reversible or permanent
Dizziness, which may be temporary or chronic
Fluid may re-accumulate after healing, requiring another myringotomy
I am aware that there may be other risks or unforeseen complications. During the course of the procedure, unforeseen conditions may be revealed requiring additional procedures. I authorize such procedures to be performed. I understand that nor guarantees or promises have been made to me concerning the results of this procedure, or any treatment that may be required as a result of this procedure. I have been given the opportunity to ask questions and have received satisfactory answers. I consent to the procedure described above.
Patient name (Please print) Patient or authorized signature/ Date
Date J.S. Brown, K.H.Gallivan, T.H.Costello, M.D.
Affiliated with Winchester Hospital and Massachusetts Eye and Ear Infirmary