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Wax in the ears is normal. People sometimes get obsessed about it because it does cause them some problems in the form of a hearing loss, a blocked sensation or occasionally if impacted an infection of the ear canal.

If people try to remove wax themselves they can perforate their eardrum. It is for this reason that it should be removed by a trained practitioner. The safest method of wax removal is under direct vision with the microscope instrumentation and suction. This however, is difficult to do in the general practitioners setting and therefore often irrigation with a low pressure system is the correct technique in primary care. The days of old style syringing (high pressure) are gone due tothe risk of trauma to the ear canal and ear drum.

Wax is protective to us but if problematic due to narrow earcanals or excessive production this can be remedied easily in the out patient department usually with immediate relief. I would alway suggest that the wax is softened before visiting the out-patient setting to allow for an easier removal.

This injury is not an uncommon scenario. Sometimes it occurs as a result of accidental injury as a result of insertion into the ear of a cotton bud or harpin. People do this to remove wax or with otitis externa (swimmers ear also referred to as an ear canal infection). It can also occur with rapid pressure changes (barotrauma) or loud sounds.

The perforation leads to an annoying conductve hearing loss perceived as a dulling of the hearing on that side. It is also is painful over the first few days in the affected ear with mucoid discharge.

It is important to have the ear examined properly. A hearing test should be undertaken as although a perforation can cause a decrease in the level of hearing more significant losses can occur as well if the ossicular chain (small bones that conduct sound in the middle ear) is damaged or if the inner ear is damaged.

I usually take a careful history, examine the ears and if it is a clean perforation advise the patient about appropriate ear care hygeine. I usually do not give oral antibiotics or ear drops if the perforation looks clean. Most traumatic peforations heal if given 6-8 weeks  and if they do not then an operation to close them may be considered - myringoplasty.

A grommet is a commonly performed operation. It is one of the first operations taught to a training ENT surgeon. There are different types of grommets used in clinical practice and the two that I prefer include the Shah grommet (much more commonly used) and a T tube.

Shah grommets are a shorter lasting grommet that I often say to patients should stay in for approximateley 9-18 months.They are relatively atraumatic with few long term sequelae.

T tubes are inserted as a long term ventilation tube and are rarely, first line treatments and are often only placed after multiple short term grommet insertions. Unfortunately as a result of staying in place for significantly longer, when they extrude they can leave a perforation in the eardrum.

Assymetric hearing loss can be due to many reasons. If the cause is obvious for example after surgery or secondary to trauma or infection in the ear then further investigations other than an audiogram are not neccesary.

When the cause is not known and especially if the hearing loss is sudden and is referred to as a sensori-neural hearing loss then this requires further investigation. Most ENT surgeons would want to perform a MRI of the Internal Auditory Meatus.This is an area in the skull through which the nerves of hearing and balance pass. Occasionally a benign swelling (acoustic neuroma) of one of theses nerves can cause pressure and lead to a assymetric and or sudden sensori-neural hearing loss. The chances of picking one of these up is rare but most surgeons do tend to investigate for this.

Benign Paroxysmal Positional Vertigo, BPPV or simply positional vertigo is a troublesome complaint. Patients complain of a sudden vertigo on a specific positional movement of the head. Typically it occurs when in bed when the patient rolls over to one side.The vertigo lasts for a few seconds then settles fairly quickly but during the episode the patient can be extremely troubled by the phenomenon.

Testing in clinic can be diagnosed by using the Dix Hallpike manouvre a rapid drop of the head whilst angled to one side. Small rythmic osscilations of the eyes are seen in the eyses (nystagmus) which settles rapidly.

The description of the cause is often said to be related to debris falling into one of the semicircular canals (organ of balance). On movement the debris is said to stimulate the semicircular canal balance mechanism. A manouvre reffered to as the Epley manouvre can be undertaken to move this debris out of the semicircular canal and out of harms way. This manouvre in my hands has a success rate in excess of 80% over 2 visits. Careful advice post Epley manouvre can allow for an increased chance of success.

Wax is a normal occurence in the ear canals. It is formed by the mixture of skin cells and the secretions from the glands of the ear canal. It acts as a bacteriostatic compound as well as a waterproof for the ear canal.

Wax does become troublesome in some circumstances. If excessivie in its production or if the ear canal is narrow or if there is some obstruction or worse still pushing of the wax into the earcanal then the wax can occlude the ear canal and cause pain discomfort, hearing loss and even a swimmers ear (otitis externa).

Wax can be encouraged to extrude itself by softening with oil. It can be removed with irrigation devices in the General Practice setting and almost all practitioners have moved away from the older and more dangerous techniques of ear syringing which were high pressure systems prone to complications. With a microscope the ENT surgeon can use instruments like a Jobson Horne probe, crocodile forceps or what is often employed is a microsuction device to safely remove the wax to reveal the eardrum.

A grommet is a ventilation tube that is placed in the eardrum by the ENT surgeon. It can be placed under local anaesthetic but in children and not infrequently it can be placed under a general anaesthetic.

There are many reasons why grommets are inserted but usually they are to ventilate the middle ear space where the small ossicles of the ear are situated.

Indications for grommet placement include

Glue ear with a significant defecit in hearing persisting for greater than 3 months

Reccurent episodes of acute middle ear infections

Significant retraction pockets

Part of another operation to maintain ventilation of the middle ear

Grommets can be short term and long term and can last from a few months to a few years. The longer term grommets have a higher incidence of leaving a hole in the eardrum when they extrude.

Swimmers ear is a common condition. It is also referred to as otitis externa. Typically it occurs because of water getting into the ear canal and starting a mild inflammatory reaction that can also become infected.

It often is chronic and recurrent in its nature and requires good ear hygeine and often ENT intervention in the form of microsuction and eardrops. Patients can make things worse by trying to clean their ears with cotton buds or their fingers which can scratch the ear canal and lead to further infection.

It is imperative to follow the instructions given by your ENT surgeon when suffering with swimmers ear:

Keep the ears dry, no swimming

Do not put anything in your ears other than drops prescribed (NO cotton buds or fingers)

Cotton wool with vaseline when having a shower

This condition is well treated but typically comes back when advice is not followed.

Parotidectomy - Anatomy and Physiology

The parotid glands are paired glands that are situated in front of the ears typically but portions of them extend below the ear and occasionally behind the lower ear. They are a salivary gland and are one of three major paired salivary glands the other two being the submandibular and sublingual glands. In addition there are multiple other minor salivary glands dotted around the oral cavity that help with saliva production.

Occasionally swellings occur in the parotid gland. It is important to determine if these swellings are benign or malignant. This can be done with a careful history and examination together with investigations such as fine needle aspirate cytology and further radiological imaging.

Thankfully over 90 % of swellings in the parotid are benign in their nature, however, even if benign they have a tendency to grow and it may be prudent to have them removed.

Parotidectomy

This operation requires some skill and experience as there are some definite hazards involved with doing the procedure.

Most importantly the facial nerve runs through the parotid gland and there is always a small risk of damaging it. This nerve has a number of branches that make you blink wink and smile on that side of your face. More often than not this damage is related to bruising and therefore temporary effect. The effect of this depends on the portion of the nerve that is affected. It is critical that the surgeon knows his landmarks and can identify follow and preserve the nerve and it’s branches to decrease the chances of damage.

A carefully placed incision often leaves a very difficult to spot scar, however, some people have a tendency to overscarring (hypertrophic or keloid scarring).

Incision for parotidectomy

It is not uncommon to have a numb feeling of the ear on the side that is operated on. This is related to the nerve supply to this portion of the ear that often is sacrificed in the approach. Most patients cope well with this as long as they are told in advance.

An unusual effect of the operation is that a large percentage of patients will experience sweating in and around the neck on chewing and eating. This side effect of the operation is called Frey’s syndrome or gustatory sweating as usually is not too troublesome a symptom.

The operation itself is performed under a general anaesthetic and the nerve will be stimulated or monitored through the operation.The operation may take between one to three hours on average depending on the degree of difficulty involved.

Normally patients would have a drain placed that would stay in place for a day or two and on removal usually can go home with an out-patient follow up with the results of the specimen sent for histology.

Ear Care Advice

• The ear canal is self-cleaning. Do not insert any implements such as cotton buds into the ear. They will damage the delicate skin lining the ear and increase the chance of you developing an ear infection, itchy ears or a problem with wax.
• To dry/ clean the outside of the ear use a dry tissue or alcohol free baby wipes around and behind the ear after showering or bathing.
• If you suffer from excessive wax; insertion of 1 to 2 drops of olive oil on a regular basis may help the ear clean itself.
• If the entrance to the ear canal is dry and/ or itchy, you may find it of benefit to insert one drop of olive oil into the ear canal as instructed by your practitioner. Keep the ears dry from any entry of water, as it may be shampoos and soaps irritating the skin.
• If you have experienced an external ear infection keep the ears dry from any entry of water.
• To keep the ears dry from water entry use cotton wool coated in petroleum jelly or ear plugs placed at the entrance to both ear canals.
• If the symptoms with your ear do not improve make an appointment with your doctor.

How to insert olive oil drops into the ear canal

To obtain the olive oil drops purchase olive oil and the glass dropper bottle that has been designed for ear drops from a chemist. If you have used previous wax dissolving drops, discard all the liquid, wash out the glass bottle and when the container is clean, insert olive oil (almond oil/ coconut oil could be used if you do not suffer from a nut allergy).

1. Insert the closed glass dropper bottle containing the oil into a cup of warm water for two minutes. Dry the container and insert one-drop of oil onto your hand to ensure that it is not too hot. If you feel the oil is too hot wait for it to cool prior to commencing. The correct temperature of the oil should be 37?C. Alternatively, for the oil to reach body temperature (37?C) place the bottle in a pocket of your clothing currently being worn for 20 to 30 minutes.
2. Holding the prepared dropper bottle lie on a bed with the affected ear towards the ceiling.
3. With one hand pull the top of your ear upwards and outwards to straighten the ear canal.
4. Placing the filled dropper part of the bottle of oil over the entrance to your ear canal and squeeze the dropper until one drop (or the amount specified by your nurse) is instilled. Maintain that position for a total of five minutes however, after one minute release the ear and massage the tragus (located at the front of the ear at the level of your cheek-bone) for one minute. Remain on your side and relax on the bed for a further 3 minutes.
5. Wipe the excess drops that pool outside the ear when you sit up. Do not insert cotton wool into the entrance of the ear canal as this will diminish the effect of the drops.
6. Unless instructed otherwise by the nurse insert the drops into both ears, repeating steps two to five on the opposite side.

Patient Advice Prior to Ear Irrigation

• Insert 1 to 2 drops of olive oil into the ear(s) requiring wax removal every morning and evening, commencing one week prior to the appointment (unless instructed otherwise by the nurse).
• Continue to use the drops twice daily until the wax has been successfully removed.
• Instilling olive oil (coconut or almond oil can be used as an alternative if you do not suffer with a nut allergy) will assist with the wax removal process and reduce discomfort that may be felt during the procedure.

Patient Advice Post Ear Irrigation.

• The ear canal may be vulnerable to an ear infection after irrigation. This is caused by removal of all the wax, which has inherent protective properties for the ear canal.
• Until the ear produces more wax to protect the canal keep the ear(s) that have been irrigated dry from entry of water for a minimum of four or five days after the procedure.
• To keep the ears dry when you are washing your hair, showering, bathing or swimming, insert ear plugs or cotton wool coated in petroleum jelly into the outside of the ear canal(s) to act as a protective seal.
• In the unlikely event that you develop pain, dizziness, reduced hearing or discharge from the ear after the procedure, consult with your nurse/ doctor.
  

Prominent ears are a developmental abnormality where the normal architecture of the ear has not developed and the ear becomes clearly prominent and cup shaped. A fold in the ear referred to as the anti helix is typically absent and also the conchal bowl (close to the entrance of the ear canal) may be found to be deep.

The ear is made of pliable cartilage and is significantly developing in the first few years of life. The cartilage from birth, during the neonatal period is responsive to splinting in the event of prominent ears being noticed early. This can help mould the ear into the correct shape.

Most children become conscious of their prominent ears on entrance to school where teasing is common. Girls can often hide the developmental abnormality more than boys due to the fact that they grow their hair to cover their ears. The cartilage needs to develop significantly and not be too immature before the ear can be surgically corrected. This typically is around the age of 5-6.

Otoplasty

The surgery typically is aimed at recreating the ‘antihelical’ fold typically missing or making the conchal bowl more shallow. This is undertaken with an incision behind the ear and the anti helix is formed, the cartilage may be scored to keep its shape and stitches may be used to keep the cartilage in place.

The ear is carefully dressed with a head bandage that is often worn for 1 week post-operativeley. At this stage the dressings are taken down and the ears are notably bruised but clearly their position has usually been altered for the better. Most surgeons like to protect the ears during the night with a headband so that the cartilage is not sprung back inadvertently.

Anatomy and Physiology

The temporal (mastoid) bone sits at the back of the ear and is composed of 4 portions

1. The petrous temporal bone
2. The squamous temporal bone (mastoid)
3. The styloid process
4. The tympanic ring

The mastoid air cells exist within the squamous and petrous temporal bone. There is variation in the pneumatisation (aeration) of these air cells but they are in continuity with the middle ear via a connection called the aditus ad antrum. Within the mastoid the facial nerve runs a course firstly in the middle ear then descending down in the mastoid to exit in the stylomastoid foramen and then to enter into the parotid gland.

The mastoid air cells not only run close to the facial nerve but are also intimate with a thin plate of bone superiorly (tegmen) that abuts the meninges and posteriorly bone overlying the sigmoid sinus that drains into the internal jugular vein.

Mastoidectomy Operation

This operation is performed typically for chronic ear disease in the form of Cholesteatoma or Non cholesteatoma Chronic Suppurative Otitis Media. Occasionally it is performed in addition to a myringoplasty .

Cholesteatoma is a condition where a piece of skin from the tympanic membrane encroaches into the middle ear. The skin sac finds it difficult to self cleanse like the normal ear canal skin and infections recur. The skin sac extends into the space of the middle ear and then into the mastoid air cells as it grows.

Surgery to remove a cholesteatoma follows this skin sac to remove every piece of it so as not to allow a recurrence. There are two types of approaches:

1. Canal Up – Where the ear canal is left intact
2. Canal down - Where the mastoid is left in continuity with the ear canal.

A mastoidectomy operation has varying degrees of difficulty depending on the disease process. There are risks of a change in the level of hearing, balance alteration, facial nerve weakness (very rare), meningitis (very rare), recurrence of disease, discharge from the ear. The key is a thorough operation ridding the individual of the disease process. The patient has a head bandage that can come down the day after the operation. Typically the patient goes home the following day. A dressing is often placed in the ear canal / cavity for a few weeks and is then removed in the clinic. Often long term follow up is necessary to monitor the ear and look out for recurrence of disease.

Anatomy Physiology

The ear drum is composed of two parts, a pars tensa which accounts for the majority of the visible drum and the pars flaccida which accounts for the upper one fifth of the ear drum. Sound is transmitted through the eardrum to the ossicles (tiny bones of the middle ear), these in turn transmit the sound to the cochlea (organ of hearing). Occasionally due to ear disease, trauma or significant infections a perforation / hole in the ear drum occurs. When this happens the patient may be completely asymptomatic but often they have a degree of discharge from the ear and possibly some hearing loss. The degree of hearing loss depends on the integrity of the small bones in the ear and the size / position of the perforation.

Myringoplasty

The hole / perforation in the eardrum can be repaired using an operation called a ‘myringoplasty’. This operation can sometimes be done through the ear canal but occasionally an incision is used behind the ear or above it. The perforation edges are freshened to encourage new growth and a graft is placed under the eardrum as a template for the new drum to grow over. The ear canal then has a dressing placed inside it and this usually comes out some 7-10 days later in the Out-patient clinic.

There is a failure rate associated with the operation and this is dependant on the site of the perforation and the size. Occasionally people feel slightly unsteady following the operation. It is important not to undertake any heavy lifting or blowing of the nose in the postoperative period as this changes the middle ear pressures and it may cause graft failure. The ear and dressing must be kept meticulously dry in the post-operative period until the surgeon agrees for the patient to go swimming again.

Glue Ear

Anatomy / Physiology

The middle ear is a cavity in the skull that houses the small conductive bones of the ear. Sound passes from the external ear canal through the middle ear and then into the inner ear from which neurological stimuli are transmitted to the brain which is where we sense hearing. The middle ear is the area deep to the ear drum as we look at it. It is in connection with a group of air cells called the mastoid air cells that are housed in the mastoid bone behind the ear and is also in connection with the Eustachian tube that connects the middle ear to the back of the nose (nasopharynx).

Typically in childhood in association with upper respiratory tract infections, ear infections and immature Eustachian tubes a phenomenon called glue ear forms behind the eardrum. This is simply fluid that accumulates here but clearly can have a significant impact on the child’s hearing.

Glue ear is visible on otoscopy and typically is seen as a dull or amber coloured ear drum because of the fluid behind it. It can be tested for using an audiogram (hearing test) and tympanometry (pressure traces of the middle ear).

Otoscopy

Glue ear (amber fluid behind the eardrum)

Glue Ear and Grommets

Glue ear when first seen should undergo a period of ‘watchful waiting’ for 3 months as a large percentage of them will spontaneously resolve. If however, after this period there is still the presence of glue ear and that the child is still troubled with their hearing affecting schooling, speech development or behaviour then consideration for grommets should be undertaken.

Although in adults local anaesthetic grommet insertion may be considered, for children a general anaesthetic is required. Grommets are usually placed in the safe part of the drum in the anterior inferior segment. A small incision (myringotomy) is undertaken, fluid is sucked out and then the grommet which often is a plastic ventilation tube is snuggly placed in the tympanic membrane. Not infrequently an adenoidectomy undertaken to treat the glue ear problem too

The ears should be kept dry for as long as the ENT surgeon has suggested and the child is often followed up to see that the hearing has improved.

Grommets are occasionally placed for other indications. The following list summarises why grommets are used

• Glue ear
• Recurrent acute otitis media (middle ear infections)
• As part of treatment for large retraction pockets
• Meniere’s
• Eustachian tube problems

Microsuction for Otitis Externa / Swimmer’s Ear

Otitis externa is an inflammatory condition that affects the external ear canal. It is either infective, reactive or environmental.

Environmental otitis externa

Environmental causes of otitis externa are seen in warm humid climates and can occur when people bathe and water enters the ear canal (so called swimmers ear). The ear canal is a dry blind ended sac that should be dry otherwise the wet environment leads to dessication of the skin and secondary infection.

Infective otitis externa

Infective otitis externa is most commonly bacterial or fungal in its nature. Bacterial infections can often occur if water enters the ear canal or if the ear canal is traumatized by the insertion of implements such as cotton buds or fingernails etc.

Reactive otitis externa

Reactive otitis externa occurs as a result of certain skin conditions such as eczema and psoriasis. It requires aggressive treatment of the condition and careful clearance of the ear.

Otitis externa / swimmers ear is an extremely uncomfortable condition in the acute phase that produces symptoms of pain, blocked ears, decreased hearing and discharge from the ears. When more chronic it produces symptoms of chronic itching and discharge from the ears.

Treatment is in the form of patient advice and medical treatment.

Patient advice

1. Keep the ears dry. Use cotton wool with Vaseline on bathing. Do not wash the ears. Do not go swimming in an acute episode without ear protection.
2. Do not irritate the ears with any foreign objects such as cotton buds or fingernails these will traumatize the ear canal and introduce infection.
3. Contact ENT surgeon if symptoms worsening.

Medical treatment

1. Ear drops are commonly used in the treatment of otitis externa and they often include a mix of antibacterial and steroids (for the anti-inflammatory effect).
2. Microsuction is the gentle hovering of the debris out of the external ear canal to allow for the introduction of the eardrops.



3. Ear wicks are a dressing placed in a swollen external ear canal to splint the ear canal open and allow for the administration of the ear drops.

Further Information:

Ear Care Advice

Ear Wax / Cerumen

The ear canal is approximately 2.5 cm long in the adult and is divided into an external 1/3 and an inner 2/3. In the outer 1/3 there are ceruminous and sebaceous glands that secrete into the ear canal minute quantities of cerumen and sebum that combine with the slowly shedding skin of the external auditory canal. Skin of the external canal has a natural tendency to migrate laterally and mix with the cerumen and sebum to create wax in the outer 1/3 of the external auditory canal. It is for this reason that if wax is visualized deep in the external canal that this is often a sign that it has been pushed here.

Wax is a natural protector of the external canal and has some bactericidal properties as well as water protective functions. Unfortunately sometimes patients produce excessive amounts of wax that can cause problems.

Patients often feel a blocked sensation secondary to wax impaction and a decrease in their level of hearing. Occasionally wax produces a degree of discomfort and if irritated can produce a degree of otitis externa.

Wax naturally discharges itself from the ear canal and more often than not it is the incessant fiddling that is commonplace amongst humans that causes irritation and pushes wax deeper into the ear canal. We can help this by not putting any objects such as cotton buds into the ears and also by softening the wax with the use of olive oil drops.

If wax becomes a problem then this can be treated by removal under direct vision with a headlight and specialist instrumentation.

Alternatively ear irrigation can be undertaken by a trained practitioner but it is essential that the ear is dryed after this procedure and that it is undertaken by a person trained specifically in this.

The use of a microscope can be very useful in removing wax as this gives the operator binocular magnified vision whilst having hands free to use instruments and suction to remove wax

This is a very difficult question to answer as every patient is an individual.

I always say to patients not to get water in the ears until I see them at the first Out-Patients appointment. At that stage I reiterate that they have an artifically created hole in the eardrum by virtue of the fact the grommet is in place. I then suggest should they wish to swim they should use good ear seals to prevent water entering the ear canal. If children, I also suggest the headbands that can be worn to further prevent water from entering the ear canals.

Clearly if patients develop infections despite ear precautions as above I explain it is more appropriate to avoid putting the ears at risk with certain activities such as swimming.

Swimmers Ear (Otitis externa)

This condition can be a severely painful acute condition and a nuisanceful chronic recurring problem. Whatever, careful attention should be taken to aural hygeine advice http://www.myentsurgeon.com/ear-care-advice.html

It is imperative to contact your general practitioner to commence early treatment in addtion to the ear care advice. If the ear canal is not too swollen then the instillation of antibiotic and steroid drops can help reduce the symptoms of the condition rapidly. Unfortunateley, some patients rapidly develop a swollen ear canal or alternativeley have a predisposition to the condition because of narrow ear canals and as a result require intervention by an ENT surgeon in the form of splinting the ear canal open with a ‘wick’. This keeps the ear canal open whilst allowing for the delivery of the antibiotic and steroid drops.

Despite all medical intervention the strict adherence to the advice on aural hygeine is the key to success in the management of this condition and occasionally people will require regular follow up in the clinic just to maintain patency of the ear canal.

Prominent ears are a reasonably common phenomenon that are troublesome to children because of teasing that occurs at school but that can be treated very well with surgery.

Prominent ears are noticeable from birth and in the first few weeks of life the cartilage of the ear is malleable and certain proprietary brands of splints can actually be used with some success. What is commonly seen though is the prominent ears do not become a problem until teasing starts at schooling age.

Many different techniques of surgery are used to correct these deformities but it is key to understand the anatomic problem with development that has caused the prominence and then to correct it.

Correction can make a massive difference in the quality of a childs life and can be a hugeley beneficial operation. Parents are often nervous about undertaking an operation for essentially a cosmetic operation but anaesthesia in children is significantly safer than it ever has been and the benefits of surgery outweigh the risks in most circumstances.

Hearing Loss

Hearing is one of our special senses and the disability of not being able to hear can be a significant one. Typically hearing loss can be divided into the paediatric population and the adult population. It can also be looked at as to what type of hearing loss it is. A conductive hearing loss is where the deficit lies anywhere from the external ear, through the canal, eardrum and the small bones of the middle ear (ossicles) that transmit the sound wave to the inner ear. A sensorineural hearing loss is related to damage to the inner ear or the nerves that transmit the sensation of sound to the brain.

It is very important when seeing someone for hearing loss a thorough history and examination is undertaken as part of the ENT consultation. This allows the surgeon to distinguish between different hearing losses and choose the most appropriate investigations.

Paediatric Hearing loss

Glue ear

This is by far the commonest cause of a hearing loss in children. Fluid that develops and stays behind the eardrum causes a problem with the conduction of sound. Children present in a variety of forms such as simple inability to hear, the volume of the television increases, however more subtle changes in behavior speech development and poorer academic performances can be related to the fluid collection. This fluid can be seen on examination of the eardrums.

Glue ear per se will not damage your childs ears, however if it is affecting your child significantly for a continuous period of over 3 months and there is a defecit in hearing then it is reasonable to consider treatment of the glue ear.

Surgical intervention in the form of a grommet insertion +/- adenoidectomy is a common and very successful procedure to improve the ability of your child to hear.

Sensorineural Hearing loss in children

Thankfully this is significantly less common than glue ear. A range of severity exists and profound hearing losses should now be screened for at birth in the form of one of two simple, painless hearing tests (otoacoustic emissions or an automated brain stem response). If this is found then a child should be put through a specialist audiological service to offer maximal aiding in the first instance and possibly further surgical input to improve the patients hearing ability.

Adult Hearing Loss

This is a large group of hearing losses that must be managed by taking a full, history, examining the patient and undertaking appropriate special investigations. A few of the common and interesting causes of adult hearing losses are outlined below.

Wax in the Ear Canal

Something as simple as wax, can occlude the ear canal and cause obstruction to the transmission of sound. This especially happens when patients have a tendency to use cotton buds in their ears and inadvertently push the wax to impact deep in the ear canal.

Wax is a physiological substance that confers bacteriostatic and waterproofing abilities to the ear canal. Small volumes of wax show a healthy ear canal. If larger quantities exist and obstruction and hearing loss ensue then microsuction can be undertaken to clear the wax from the ear canal and improve the hearing rapidly.

Presbyacussis

With age there is a gradual decrease in the function of the organ of hearing, the cochlea. This presents itself with a progressive hearing loss. The higher frequencies are affected the most and hearing worsens with time. It is an exceptionally troublesome symptom but can be helped in different ways.

Hearing aids have improved dramatically over the past few years. Introduction of new digital technology and reduction of size of hardware has brought hearing aids into a new dimension. Hearing aids can significantly improve the quality of an individual’s life offering them discreet but significant amplification that can assist them in the ability to hear.

Otosclerosis

This is a hereditary condition where the small bones (ossicles) that transmit sound become fixed. Typically the smallest bone, the stapes, is the one that becomes fixed and causes the problem. Patients are affected with a progressive hearing loss in adulthood and more females are affected than males often during / after their pregnancy.

The problem is progressive and a number of treatment options exist. A hearing aid is a safe option and involves no surgery and no risk to the patients hearing. A stapedectomy is the classical operation to remove part of the fixed bone and replace it with a prosthetic replacement. This operation has a good chance of success. The significant downside to the operation is the very small risk of complete hearing loss. One final treatment option includes a bone anchored hearing aid which involves a surgical operation to fix a screw that integrates with the skull bone and then a hearing aid may be attached to it. This is not the classical operation for this condition but may be considered.

Sudden Sensorineural hearing loss

Very rarely a patient may have a sudden loss of their hearing. It is important to clarify this with regards to if it is just a conduction of sound deficit or is it due to an inner ear and more serious pathology. The reason is if it is a sudden sensorineural hearing loss (inner ear related) most ENT surgeons commence some medical intervention rapidly, typically in the form of steroids. Occasionally some use antiviral treatments. The use of these interventions is not scientific but if it is to be given it should be done so as early as possible.
Importantly, if a person does suffer with a sudden sensorineural hearing loss then an MRI will have to be performed as an investigation (MRI see below) in order to exclude a rare cause of this phenomenon which is a benign nerve sheath tumour called an acoustic neuroma.

MRI of the inner ear

Conclusion

Hearing loss is a disability that can often be helped either surgically or with the intervention of hearing aids. The use of aids should not be discouraged and should be likened to the use of spectacles for a visual disability. Hearing is crucial to integration into normal social interaction and therefore should not be underestimated and should be addressed rapidly from the very youngest to the oldest in the population.