Surgery of the eardrum, middle ear and mastoid


Some problems of the ear are treated with medication and some are treated with surgery.  Your condition may be best treated with surgery and this brochure provides information about the normal ear, certain conditions affecting the ear, and the types of ear surgery.

The Normal Ear:

The ear has 3 parts:  Each part performs an important function and may be affected by different conditions.

  • The outer ear (Pinna and ear canal) collects and funnels sound causing the eardrum to vibrate.
  • The middle ear (tympanic membrane, ossicles, mastoid and eustachian tube) amplifies and passes the vibration from the eardrum to the inner ear.
  • The inner ear (cochlea) transforms vibrations into electrical signals and sends them to the brain.
ear functions
Conditions affecting the middle ear and mastoid.

Several conditions can affect the tympanic membrane, middle ear and mastoid.   These can include infection, trauma, developmental, and/or genetic problems.  Some conditions are treated medical and some with surgery.  Some of the common conditions are listed here.

Eustachian tube dysfunction:

The normal middle ear and mastoid are filled with air transmitted through the eustachian tube (ET).  The ET transmits connects the back of the nose to the middle ear allowing pressure regulation. When the ear functions normally air pressure in the ME is balanced with outside pressure.  If the ET is blocked hearing is affected, fluid can collect, and damage to the eardrum (retraction) and hearing bones can occur.   

Ear Infections

Otitis media refers to inflammation of the middle ear.   The infections can be acute and recurrent or chronic (long term) in nature.  The infections occur when colds, allergies, or other condition affect the eustachian tube and the presence of bacteria or viruses lead to the accumulation of pus and mucus behind the eardrum.  Middle ear infections may cause pressure, pain, hearing loss, rupture of the eardrum, and drainage (otorrhea).   Some ear infections may be complicated and produce chronic drainage, tympanic perforations, cholesteatoma, labyrinthitis, and facial nerve injury.  In rare situations the infections become life threatening and produce intracranial complications.

Tympanic Membrane Perforation

A hole in the eardrum is called a perforated eardrum. Symptoms may include hearing loss, drainage and pain.  Perforations are caused by trauma, infection, or chronic eustachian tube disorders.  In patients with chronic Eustachian tube problems the ear drum may become weakened and open up. Most eardrum holes resulting from injury or an acute ear infection heal on their own, if they do not surgery is usually recommended.

Cholesteatoma

When an abnormal skin growth occurs in the middle ear it is called a cholesteatoma. Cholesteatomas may be caused by trauma, infection, eustachian tube problems, and developmental abnormalities. Most cholesteatomas occurs because of poor eustachian tube function. When the eustachian tubes work poorly the air in the middle ear is absorbed by the body, creating a partial vacuum in the ear. The vacuum pressure sucks in part of the eardrum creating a pouch or sac.   This sac can progress and become a cholesteatoma. The skin sac shed layers of old skin which build up inside the middle ear, increase in size and destroy the surrounding delicate bones of the middle ear leading to hearing loss.  Frequently they become infected and will chronically drain.

Cholesteatomas are treated with surgery.  Infrequently, some cholesteatomas may be monitored or cleaned out in the clinic.  There is no medical treatment that eliminates a cholesteatoma once it has formed.  A large or complicated cholesteatoma usually requires surgical treatment to protect the patient from serious complications.

Conductive hearing loss (CHL)

CHL results when sound waves are not transmitted to the inner ear.  Causes include blockage of the external ear canal by wax or growths, tympanic membrane perforations, middle ear fluid, damage to the hearing bones, growths in the ME, and infection.  Sensorineural hearing loss (SNHL) results when there is a problem in the inner ear or auditory nerve.   

Treatment 

Medical treatment is often used to stop or control ear drainage and may consist of eardrops, oral antibiotics, and careful cleaning.  Depending on the disease medical treatment may not be sufficient.  Surgical treatment is often considered for recurrent drainage that fails medical therapy, chronic perforations, and deep retractions of the eardrum, cholesteatoma and complications of otitis media.  It can include a variety of techniques.  

The types of surgery are listed below and described later.  Sometimes these procedures are combined, and sometimes, a series of surgeries may be necessary. These are the common surgical procedures:

  • Tympanoplasty
  • Mastoidectomy
  • Canalplasty
  • Ossicular chain reconstruction

Surgery is performed under general anesthesia. The Goals of Surgery are to control infection, remove the disease, eliminate the infection, create a dry ear and to attempt to restore normal function. A second or staged surgery is sometimes necessary both to ensure that the cholesteatoma is gone as well as to attempt reconstruction of the damaged middle ear bones in an effort to improve hearing. Depending on the disease one or more of the following procedures may be necessary:

Tympanoplasty

is an operation to repair damage to the eardrum and/or reconstruct the hearing mechanism.  It is performed through incisions in the ear canal and/or through an incision behind the ear.  The eardrum is reconstruction with tissue from the patient called a graft: this can include fascia (a strong covering over muscle), cartilage, and sometimes skin grafts.   A perforation refers to a hole in the eardrum.  Perforations may be small or large and are repaired using two basic techniques; medial graft tympanoplasty or lateral graft tympanoplasty.

  • Medial graft tympanoplasty is performed by placing the graft behind (medial) to the existing eardrum.
  • Lateral graft tympanoplasty is used for larger or more complex perforations. It is performed through incisions behind the ear and in the ear canal and includes a canalplasty and split skin graft. 

Canalplasty

is a procedure to enlarge the ear canal.  It is used to treat abnormal bone growths (exostosis or osteomas) that narrow the canal or when additional space is required with tympanoplasty surgery.  It involves removing bone to widen the canal and may require a split thickness skin graft to recover the bone.Medial graft tympanoplasty is performed by placing the graft behind (medial) to the existing eardrum.

Ossiculoplasty

is the procedure designed to reconstruct damaged hearing bones; there are many variations.  It is frequently combined with eardrum repair.  Native bones or a prosthesis (artificial bones) may be used to reconstruct the ossicular chain.  Your physician can clarify the technique.

Mastoidectomy

is a procedure used to remove diseased bone or allow access to diseased areas.  Two types exist. 

Canal Wall Up (CWU) mastoidectomy preserves more natural anatomy including the wall between the mastoid and ear canal.  The advantage of this technique is that is preserves more normal anatomy but the disadvantage is it may limit exposure.

Canal Wall Down (CWD) mastoidectomy is performed when disease prevents preservation of the normal anatomy.  It results in a larger ear opening (meatus) and a cavity which requires cleaning periodically.  Other techniques may include used of skin grafts, or obliteration materials to optimize the cavity.  In cases of severe ear destruction, reconstruction may not be possible. The advantage of this technique is that provides the best exposure and disease control but disadvantages include the need for cleaning, an enlarged meatus, and possible vestibular stimulation with water exposure.  

Modified Radical Mastoidectomy or Total Tympanomastoid Obliteration. In cases of severe ear destruction, reconstruction of the hearing may not be possible.  In other cases eliminating the entire middle ear space is the best option and is completed by closing the ear canal, plugging the ET, and filling the cavity with fat.  These are uncommon techniques and your physician will discuss this option more if it’s planned.

Staged Surgery

is often necessary.  The purpose is to inspect for any residual disease and to reconstruct the hearing.  The decision to stage a surgery is made during the surgery and is dependent on the amount of disease.  It is usually performed 6 months after the primary surgery.  Sometimes silicone is placed in the ear to prevent scarring between the procedures and frequently hearing may be worse between the first and second surgery. 

Risks of Surgery include, but are not limited to the following:

  • Anesthetic complications
  • Death
  • Inner ear injury (sensorineural hearing loss, vestibular dysfunction, and/or tinnitus)
  • Complete loss of hearing
  • Facial nerve injury and facial paralysis/paresis
  • CSF leak or intracranial injury
  • Infection
  • Taste problems
  • Failure to achieve surgical goals
  • Jaw pain or temporal mandibular joint injury
  • Bleeding
  • Graft failure
  • Recurrent or persistent disease
  • Numbness of the outer ear
  • Prosthesis or PE tube extrusion or impairment
  • Need for additional treatment
    Diagnosis & Findings
    • Retraction of the ear drum
    • Scarring of the ear drum
    • Perforated eardrum
    • Drainage
    • Cholesteatoma
    • A mastoid cavity
    • Hearing loss
    • Destruction of one of the ear bones
    Recommended Treatment:
    • Tympanoplasty
    • Mastoidectomy
    • Canalplasty
    • Ossicular chain reconstruction
    After Surgery

    Surgery is commonly performed in an out-patient setting. For some patients, an overnight stay is necessary. In rare cases of serious infection, prolonged hospitalization for antibiotic treatment may be necessary.  Time off from work is typically one to two weeks.   After surgery, follow-up office visits are necessary to evaluate results and to check for recurrence. In cases requiring the creation of an open mastoidectomy cavity, office visits every few months are needed to clean out the mastoid cavity and prevent new infections. Some patients will need lifelong periodic ear examinations.

    Instructions after surgery:

    • Patients should plan on light activity for 2 – 4 weeks
    • Bloody drainage from the ear canal is common for several days after surgery. Use a dry cotton ball in the outer ear to absorb it
    • Your hearing will be muffled for several weeks, if you hear yourself more loudly in the operated ear when you talk or eat that is normal
    • Avoid heavy lifting or straining and nose blowing 
    • Avoid driving while taking narcotic medication
    • Keep water out of the ear canal by using a cotton ball coated with Vaseline
    • Showering is OK 48 hours after surgery and if there is an incision behind your ear it can get wet
    • Remove your head bandage 24 hours after surgery unless otherwise instructed
    • Use ototopical drops once or twice daily applied to packing in the ear canal

    Call you Doctor for the following issues:

    • Persistent or increasing bleeding from the incision or ear canal
    • Increasing swelling or pain in the area behind your ear
    • A sudden drop in hearing, onset of severe ringing or persistent or new dizziness
    • Fever, increasing tenderness or redness of the incision or any purulent (pus) drainage from the incision