Chronic Ear Infections

Chronic ear infections, also called chronic otitis media is an inflammation or infection of the middle ear. Chronic means recurring or persistent. 

Causes, Incidents and Risk Factors   

Inflammation or infection of the middle ear occurs when the eustachian tube to that ear is blocked. The eustachian tube is the passage from the back of the nose to the space behind the ear drum. Chronic otitis media occurs when the eustachian tube becomes blocked repeatedly (or remains blocked for long periods) due to allergies, multiple infections, ear trauma, or swelling of the adenoids. Bacteria from the back of the nose (nasopharynx) will go through the eustachian tube and cause an infection in the space behind the ear drum (middle ear). See anatomy.

When the middle ear is acutely infected with bacteria (or occasionally, viruses) it is called acute otitis media. A chronic ear infection may be the result of an acute ear infection that does not clear completely, or the result of recurrent ear infections. The infection may spread into the mastoid bone behind the ear (mastoiditis), or pressure from fluid build-up may rupture the eardrum or damage the bones of the middle ear.

A chronic ear infection may be more destructive than an acute ear infection because its effects are prolonged or repeated, and it may cause permanent damage to the ear. However, a chronic, long-term infection may show less severe symptoms -- so the infection may remain unnoticed and untreated for a long time.

Ear infections are more common in children because their eustachian tubes are shorter, narrower, and more horizontal than in adults. Chronic ear infections are much less common than acute ear infections.

Symptoms

• Ear pain or discomfort, earache
  • Usually mild
  • May feel like pressure in the ear
• Pus-like drainage from the ear
• Hearing loss

Note: Symptoms may be continuous or intermittent, and may occur in one or both ears.

Signs and Tests

An examination of the ear may show dullness, redness, air bubbles, or fluid behind the eardrum. The eardrum may show drainage or perforation (a hole in the eardrum). The eardrum may bulge out or retract inward.

Cultures of drainage may show bacteria. These bacteria may be resistant or harder to treat than the bacteria commonly involved in acute ear infection.

A CT scan of the ear bones may show spreading of the infection beyond the middle ear into the mastoid bone (bone behind the ear).

Treatment

Treatment is focused on relief of symptoms and cure of the infection.

Oftentimes, children with otitis media are treated with antibiotics. If the child has multiple infections (generally 6 infections per year), then small tubes are placed in the ear drum to reduce the number of subsequent infections. These tubes will stay in for about 6 months to a year and then fall out on their own. Generally, 80% of children will only need to have the tubes placed only once. Occasionally surgical opening may be made in the eardrum (myringotomy) to allow fluid to drain without placing tubes.

Generally ear tube placement is considered when there is:

• 6 infections in one year
• Hearing loss from multiple infections that has caused delay in speech development
• Fluid behind the ear drum that is present for 6 months in one ear or 4 months in both ears
• Significant hearing loss in both ears from persistent fluid behind the ear drums

Most children will have temporary and minor hearing loss during and right after an ear infection, because fluid can linger in the ear. Although this fluid can go unnoticed, it can cause significant hearing problems in children. Any fluid in the ear that persists longer than 12 weeks is cause for concern -- in children, hearing problems may cause speech to develop slowly.

Permanent hearing loss is rare, but the risk increases the more infections a child has.

The tubes fall out on their own in 6-12 months. The tubes have to replaced in 20% of children because of continued infections.

Surgical removal of the adenoids may be necessary to take away the source of the bacteria which cause ear infections if the tubes have to be replaced. 

Click below for a surgical video of a tube placement performed by Dr. Djalilian. Please note that this is a surgical video and may not be appropriate for some viewers.

Tympanoplasty

If a hole in the ear drum is present (as a result of infections or trauma) it can be repaired surgically. Surgical repair of a ruptured eardrum may prevent further chronic ear infections. Removal of the infection from the mastoid bone (bone behind the ear) may be necessary (called a mastoidectomy) in conjunction with the repair of the ear drum. The success rate of the repair of the ear drum is approximately 90%.

Click below (under mastoidectomy section) for a surgical video of a tympanoplasty operation.

At UC Irvine our ear surgeon (Dr. Djalilian) specializes in the treatment of ear drum perforations that failed treatment after a tympanoplasty operation. He performs ~4-6 of tympanoplasty with or without mastoidectomies a week at UC Irvine Medical Center.

Mastoidectomy

A mastoidectomy (removal of infection from the mastoid bone) in combination with tympanoplasty (repair of the ear drum) is often required in the treatment of chronic ear infections in teenagers and adults. It has been found that the reason these infections keep recurring is because bacteria form a compound around them that protects them from antibiotics. This form of bacteria, called biofilm, will intermittently get activated and cause an infection with drainage from the ear. In order to stop the infections, the infection, which often settles in the bone behind the ear, has to be removed.

The surgery to remove the infection and repair the ear drum is very delicate and performed under the microscope.

Removal of part of the mastoid bone (mastoidectomy) will not cause a visible defect since the coverings of the bone are closed over it to prevent the appearance of a depression behind the ear.

Click below for a video of a tympanoplasty with mastoidectomy performed by Dr. Djalilian. Please note that this is a surgical video and may not be appropriate for some viewers.

Expectations (prognosis)   

Chronic otitis usually responds to treatment, but treatment may be prolonged (over several years). The disorder is usually not a threat to life but may be uncomfortable and may result in serious complications if left untreated.

Complications of Chronic Ear Infections

• Permanent damage to the ear with partial or complete deafness
• Mastoiditis
• Cholesteatoma (middle ear skin cyst)
• Meningitis and Epidural abscess (inflammation and infection around the brain)
• Facial paralysis

New Innovations in the Treatment of Chronic Otitis Media

Otoendoscopy (small angled cameras) allows the surgeon to remove disease from areas that cannot be seen with a microscope. The combination of microscopes and endoscopy helps to create the least invasive treatment for patients with chronic ear infections. At UC Irvine, otoendoscopy (in addition to a microscope) is used routinely used in chronic ear infection surgery for a less invasive approach. This reduces the likelihood of second surgeries.

Use of post-surgical scar tissue for the repair of tympanic membrane perforations. Patients who have had a previous surgery for repair of their ear drum perforation will often not have any fascia (muscle covering) left for the repair. Some surgeons use incisions behind the opposite ear or create a long incision behind and above the ear to get more fascia. In a recently published study by Dr. Djalilian an innovative technique to use post-surgical scar tissue that is delicately separated and used for repair of the ear drum. This tissue is obtained from the same incision and does not require any additional incisions.

To Make an Appointment with Drs. Djalilian or Lin, Please Call 714-456-7017 or click here to request an appointment via the web.

Adapted from National Institutes of Health.

http://www.nlm.nih.gov/medlineplus/ency/article/000619.htm

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