ABOUT THE CONDITION
How does the ear work?
The ear consists of the outer, middle and inner ear. Sound travels through the outer ear and reaches the eardrum, causing it to vibrate. The vibration is then transmitted through three tiny bones (called ossicles) in the middle ear. The vibration then enters the inner ear where the nerve cells are. The nerve cells within the inner ear are stimulated to produce nerve signals. These nerve signals are carried to the brain, where they are interpreted as sound.
Figure 1. Anatomy of the ear (*)
A hole in the eardrum is known as a ‘perforation’. It can be caused by infection or injury to the eardrum. It can be small, medium-sized or large enough to involve the entire eardrum.
A small and a large hole in the eardrum
What problems can develop with a hole in the eardrum?
Quite often a hole in the eardrum may heal itself. Sometimes it does not cause any problem. However, a hole in the eardrum may cause a discharge from the ear. If the hole in the eardrum is large, then your hearing may be reduced.
What symptoms may I develop?
Many of the smaller holes may not cause any problems. But you can develop recurrent infections, discharge from ear (especially if you get water into your ears), and hearing loss.
Will I need any tests?
You will need an examination by an otolaryngologist (ear, nose and throat specialist) to rule out any hidden infection behind the perforation. The hole in the eardrum can be identified using a special medical instrument called an ‘otoscope’. It consists of a magnifying lens and a light. Examination with the otoscope is usually pain free. Sometimes more detailed examination is carried out using a microscope and suction (a small vacuum cleaner). Some surgeons may use a small telescope with a camera attached called an endoscope. The amount of hearing loss can be determined only by careful hearing tests called an audiogram. A severe hearing loss usually means that the ossicles are not working properly, or the inner ear is damaged.
Conservative or non-operative management
If the perforation is due to a recent injury or infection, a period of observation is advisable, as some of the holes can heal spontaneously. Many smaller perforations may not cause any symptoms. But it is important to prevent water getting into the ear to reduce the chance of infections.
When you are showering or bathing you can use a large piece of cotton wool covered in petroleum jelly (for example Vaseline ©) and place it in the bowl of the ear to stop water getting in to your ear. Once you have finished washing you should remove the cotton wool and dispose of it.
Swimming will be difficult. Swimming earplugs are helpful, they may not stop water getting into the ear all of the time. A swimming cap may also be useful.
ABOUT THE PROCEDURE
What is the benefit of having surgery?
The benefits of closing a perforation include prevention of water entering the middle ear (part of the ear behind the ear drum) to reduce the chance of getting an infection and to stop the ear from leaking discharge. It can also be done as part of a mastoid operation (see leaflet on mastoid surgery). Repairing the eardrum alone seldom leads to great improvement in hearing.
What does surgery involve?
The operation to close a hole in the eardrum is called a myringoplasty. Most myringoplasties in the UK are done under general anaesthetic. Some surgeons prefer to do them under local anaesthetic.
A cut is made behind the ear or above the ear opening. There are surgeons who may perform the operation via the ear canal with the help of an endoscope or microscope. The material used to patch the eardrum (called a graft) is taken from under the skin or the lining and cartilage in front of the ear canal. Commercially available eardrum grafts are used by some surgeons. The eardrum graft is placed against the eardrum. Dressings are placed in the ear canal which can be a removable pack or absorbable sponge dressings. You may have an external dressing and a head bandage for a few hours. Occasionally, your surgeon may need to widen the ear canal with a drill to get to the perforation.
What are the alternatives to surgery?
If the hole in your eardrum is not causing any symptoms (such as discharge from ear, hearing loss or recurrent infections), you may decide not to undergo the surgery. You may not be able to swim and will have to take precautions to avoid water getting into the ears in order to minimise the chance of infections.
Recurrent discharge and infections may be treated by regularly cleaning the ear under a microscope and by using antibiotic drops. If your hearing is affected and you do not wish to have surgery, you may wish to consider a hearing aid.
ABOUT THE RISKS
Are there any complications after this operation?
Complications and risk are grouped in to the following categories:
Taste disturbance: One of the taste nerve runs close to the eardrum and may occasionally be damaged. This can cause an abnormal taste on one side of the tongue. This is usually temporary but permanent taste disturbance is uncommon.
Dizziness is common for a few hours following surgery. On rare occasions, dizziness can last for months or even years if the inner ear is damaged during surgery
Hearing loss: In the majority of people, the hearing improves or remains the same after surgery. Rarely, in some people, severe deafness can happen if the inner ear is damaged.
Tinnitus: Sometimes you may notice an extra noise in the ear following surgery. This is called tinnitus and occurs in particular if the hearing loss worsens. This is uncommon.
Facial Paralysis: The nerve which moves the muscles of the face runs through the ear. There is therefore a slight chance of temporary facial paralysis after ear surgery. However permanent facial paralysis following a myringoplasty operation is very rare. The facial paralysis affects the movement of the facial muscles helping to close the eye, smiling and raising the forehead. The paralysis could be partial or complete. It may occur immediately after surgery or have a delayed onset. Recovery can be complete or partial.
Allergic reaction to the medication in the ear dressings: Some patients may develop a skin reaction to the ear dressings. If your ear becomes itchy or swollen, you should seek advice from your surgeon. The ear dressings contain medication to prevent infection.
General anaesthetic. The operation is usually performed under a general anaesthetic. Complications include blood clots in the legs (deep vein thrombosis) or lungs (pulmonary embolism), heart attack, chest infection, stroke and death. The pre-assessment team and anaesthetist will explain to you what occurs during a general anaesthetic and the associated risks that are relevant to you. The link below summarises the common events and risks: https://www.rcoa.ac.uk/sites/default/files/documents/2019-11/Risk-infographics_2019web.pdf
After the operation, you will be transferred to the recovery area. When your anaesthetic has worn off, you will be taken back to the ward or day case unit.
How long will I stay in hospital?
Many hospitals are doing myringoplasty as day surgery and you will be discharged once the operating team is satisfied that you have recovered from the anaesthetic.
If for any reason, there is a complication following surgery, then you might need to stay in hospital for longer.
What is the recovery period?
Recovery time is usually only a few days. The exact time needed off work varies between patients, but as a guide you may need to take up to one or two weeks off work.
What is the success rate?
The operation can successfully close a small hole nine times out of ten. The success rate is not quite so good if the hole is large. Other factors such as smoking can affect the success rate.
What else should I expect after surgery?
The ear may ache a little but this can be controlled with painkillers. You may have a head bandage. If you do, you will usually go home after the head bandage has been removed. The stitches will be removed one to two weeks after the operation at your doctor’s surgery. There may be a small amount of discharge from the ear canal. This usually comes from the antiseptic solutions in the ear dressings.
Some of the ear dressings may fall out. If this occurs, there is no cause for concern. It is sensible to trim the loose end of the ear dressings with scissors and leave the rest in place. The dressings in the ear canal (if they are not dissolvable) will be removed after two or three weeks by your surgeon at the hospital. You should keep the ear dry and avoid blowing your nose too vigorously. Plug the ear with a cotton wool ball coated with Vaseline when you are having a shower or washing your hair. If the ear becomes more painful or is swollen then you should consult the Ear, Nose and Throat department or your GP.
You will be advised by your surgical team.
Author - Mr Arun Iyer
Disclaimer: This publication is designed for the information of patients. Whilst every effort has been made to ensure accuracy, the information contained may not be comprehensive and patients should not act upon it without seeking professional advice.