Major middle ear, mastoid and skull base procedures
Ear Treatment Options
Getting the right treatment for ear problems can have a major impact on your health and quality of life by relieving symptoms such as pain, smelly discharge, itching and hearing loss. An experienced ENT specialist at The Harley Street clinic can arrange and perform various tests and procedures to tackle conditions affecting the ears. The doctor can advise you on the best mangement options and explain these in detail, so that you know what to expect during your treatment at the ENT clinic.
Many ear conditions can be successfully treated with oral or topical drugs as tablets or ear drops. Painkilling drugs (analgesics), stronger than over-the-counter paracetamol or ibuprofen, may be prescribed if there is severe pain. In severe infections your ENT doctor may also recommend a starting dose of a strong antibiotic by injection, which can be given on the same day you attend.
Outer ear: Antibiotic or anti-inflammatory drops, occasionally tablets. Sometimes, combination antibiotic/anti-inflammatory ear drops or ointments may be used.
Middle ear: Antibiotic and/or decongestant tablets; anti-inflammatory (steroid) or decongestent nasal sprays.
Inner ear: Anti-inflammatory (steroid), vasodilator, antiviral or antibiotic tablets. Topical drugs (intra-tympanic infusions) - see below.
Key point 1: The direct application of topical ointment is particularly helpful in patients with itching due to chronic inflammation of ear canal skin. The anti-inflammatory drug is slowly absorbed into the adjacent skin for about 1 week.
THE HARLEY STREET ENT CLINIC HAS AN ON SITE ENT PHARMACY FOR THE CONVENIENCE OF PATIENTS WHO WISH TO START THEIR MEDICAL TREATMENT IMMEDIATELY
Outer Ear Lumps (Lesions)
Patients may develop a wide range of small cysts or lumps affecting the skin around and inside the outer ear. These can usually be excised under local anaesthetic as an out-patient procedure. Rather like dental treatment, a small local aesthetic injection temporarily numbs the skin completely, so that the lesion can be removed painlessly. It will usually be sent to a laboratory for detailed examination (Histopathology).
At The Harley Street ENT Clinic patients are treated in one of our dedicated procedure rooms. They do not need to change from their outdoor clothes into an operating theatre gown, making the treatment, which is still carried out under sterile conditions, much more streamlined and straightforward.
Microsuction can be used to removed wax, discharge, dead skin or other material that is blocking the ear canal. Topical medication can also be applied during the procedure if necessary to treat an active infection or inflammation.
Microsuction is performed using a high powered microscope that provides a large clear view of the external ear canal and ear drum. Specially designed instruments, including a small vacuum sucker, are used to remove material from the ear. canal. Microsuction is performed as an out-patient procedure at the ENT clinic in London. The procedure can very occasionally be a little uncomfortable, especially if clearing impacted wax or there is a severe infection. The microsuction pumps can be slightly noisy and infrequently patients may experience slight temporary dizziness.
Key Point: Ear syringing is a traditional procedure for clearing wax excessive from the ear canal. It is contra-indicated when an active infection is present, which is not always obvious on clinical inspection with an auroscope, and if the underlying ear drum is very thin or perforated. This technique will not be suitable for removing impacted wax completely. If the irrigated water is too hot or too cold the procedure can make the patient temporarily very dizzy.
Removal of Foreign Body
Various foreign objects can become lodged in the ear canal, including cotton bud tips, foam plugs or even hearing aid ear pieces. Small toys or beads can put into the ear by children. Foreign bodies are prone to cause infections so prompt removal can prevent or relieve symptoms such as pain, hearing loss and discharge.
Several methods can be used by ENT specialists to remove foreign bodies from the ear. Great care must be taken to avoid trauma to the ear canal skin or pushing the object further into the ear causing damage to the ear drum. Magnification with a microscope is essential. Fine micro forceps or hooks, or micro suction is usually successful. Rarely gentle irrigation may be used instead.
Key Point: Young children with foreign bodies in the ear canal should always be treated by an ENT specialist, as ham-fisted attempts by others can result in considerable pain and distress and a conditioned dislike of doctors for many years!
Ear Wicks And Dressings
If the ear canal skin is very swollen due to a severe infection, it may be impossible to apply antibiotic/anti-inflammatory ears drops as access is restricted. Optimum treatment involves inserting a small cellulose wick (Otowick), about 1.5cm long, using the operating microscope and micro forceps. The wick remains in place for a few days and facilitates local drug absorption.
The outer part of the wick is just visible at the entrance to the ear canal and when moistened with drops it enlarges to the size of the swollen canal. Drops are subsequently instilled at the prescribed frequency, usually three times per day. As the wick is in close contact with the skin lining most of the length of the ear canal, the drug is delivered locally to all the required area. The wick is usually removed after a few days, when the swelling has resolved, and treatment can be continued by applying the ear drops in the normal manner.
Patients undergoing in-patient ear operations under a general anaesthetic will almost always have a sterile ear dressing inserted at the end of the procedure. The dressing holds soft tissue in place, limits post-operative swelling and keeps the operative site clean and sterile. The dressing is commonly impregnated with BIPP (bismuth, iodine, paraffin paste), which is bright yellow in colour and has a sweet, clinical odour. The BIPP dressing is removed as an out-patient after 1 to 2 weeks in one of our ENT Clinic procedure rooms, using micro forceps and the operating microscope. There may be slight local discomfort, whilst further microsuction is often necessary before prescribing additional ear drops.
Myringotomy and Grommet Insertion
Myringotomy is a surgical procedure that can be used to relieve pressure or drain fluid from the middle ear. Myringotomy may be performed to drain persistent fluid in the middle ear (glue ear) that is causing hearing loss or to treat Eustachian tube malfunction that is preventing natural ventilation of the middle ear when swallowing.
This procedure is usually performed by an ENT specialist under a topical local anaesthetic in adults, although in children a general anaesthetic is required. Local numbing injections, which cause a temporary mild stinging sensation, are not normally necessary. Instead, local anaethetic cream is applied directly and accurately to the surface of the ear drum using a special applicator, under direct vision using the operating microscope. The cream is left in place for about 30-45 minutes. During this time the patient can sit up, walk around, drink a cup of coffee or other beverage, and even leave the ENT clinic for refreshments outside. After half an hour or so the cream is sucked off the ear drum surface. A small nick is made in the eardrum in order to allow any fluid to be aspirated by micro suction. If there was hearing loss it is improved immediately. If left, this small incision would usually close within a few days. A small tube or grommet may be inserted into the eardrum during the myringotomy in order to keep the incision open for a longer period, typically between 2 and 12 months, to allow air to ventilate the middle ear and settle down. Grommets tend to block naturally and are then pushed out of the ear drum, which almost always heals up during this extrusion process. Grommets and “tubes” come in various sizes; some with t-extensions which stay in place much longer, often for several years.
Removal of Grommets
Some extruded grommets stay in the ear canal on or close to the ear drum. Subsequent wax build up can cause blockage and hearing difficulties. These can be removed by micro suction or with micro forceps.
While most grommets naturally extrude from the ear drum, it may sometimes be necessary to have the grommet removed by an ENT doctor. This is a simple procedure, which is carried out under topical local anaesthetic, using specially designed small instruments. The small hole that is left behind should normally heal up completely in a few weeks.
An intratympanic infusion is a technique used to deliver medication directly to the inner ear, by injecting the drug dissolved in liquid into the middle ear cavity. This treatment procedure, which is regularly carried out at the ENT Clinic in London, can be used to deliver different kinds of drugs, including corticosteroids to treat sudden inner ear hearing loss and dizziness, hearing loss and tinnitus due to inner ear endolymphatic hydrops. Vertigo caused by inner ear problems such as Menière’s disease or sudden vestibular failure, which does not respond to other medical treatment, may be treated with gentamicin infusions. There will almost certainly be further different types of inner ear treatment drugs in the future. No matter which drug is injected the procedure protocol is identical.
Intratympanic infusions are carried out under topical local anaesthetic as an out-patient procedure. The patient preparation is similar to that for a myringotomy and grommet insertion procedure (see above), except that analgesics and anti-dizzy drugs are given to make posit-treatment discomfort or dizziness much less likely. A small grommet is inserted at the time of the first treatment, which remains in place for about 2 months. This ventilation tube can help inner ear function as well and facilitates the infusion treatment. The medication is injected into the middle ear through a fine needle and the patient then lays with the treated ear uppermost to keep the medication in the right part of the ear. Patients often notice a temporary reduction in their hearing and a feeling of fullness in the ear during intratympanic infusions. Other potential side effects include transient tinnitus and dizziness for a short while after the procedure. Three treatment sessions at the ENT clinic in London are invariably required.
Fat-plug Myringoplasty (Ear drum repair)
The majority of ear drum holes (perforations) caused by infections or trauma will close spontaneously, once any local infection has been treated and cured. This healing process can take several weeks. However, some perforations fail to heal and expose the patient to the risk of recurrent infections when swimming or after a URTI, and also cause hearing impairment. Perforations can be very small or very large. Small perforations can often be conveniently be repaired under local anaesthetic as an out-patient procedure at The Harley Street ENT Clinic.
The ear drum is anaesthetised as for a grommet insertion procedure (see above) with topical local anaesthetic cream applied for 30-45 minutes. After sterile skin preparation and infiltration of the adjacent ear lobe with lignocaine/adrenaline local anaesthetic, a small skin nick is made on the back of the ear lobe and a fragment of subcutaneous fat harvested. The small skin wound is closed with 1 or 2 stitches, and covered with a steristrip (“invisible suture”) plaster. After removal of the topical cream covering the ear drum, fine micro-instruments are used to excised the scarred rim of the perforation. The fat plug is then inserted through the tiny defect and covered with dissolvable sponge dressing. The patient is instructed not to blow the nose forcefully for at least 1 week.
Hearing Aids and other Ear Devices
A hearing aid is a compact electronic device that can improve hearing by making sounds clearer and louder. Although a hearing aid can’t restore hearing loss completely, it can often help to improve it. Wearing a hearing aid can make everyday life easier and make a significant difference when conversing, talking on the phone, or watching television. Patients attending The Harley Street ENT Clinic can be referred to Harley Hearing Centre, our in-house service for obtaining independent advice about hearing aids and other ear protection and treatment devices.
The first step to getting hearing aids is an assessment by a hearing aid specialist to determine whether it will be possible to restore hearing. The specialist can then recommend a suitable device. Hearing aids come in several different forms, including devices that sit behind the ear, in the ear, and completely within the ear canal, so-called “invisible” hearing aids. In some cases a custom made hearing aid may need to be created using a silicone cast of the ear. Once the device is ready, the hearing aid will be programmed using computer-based software to suit the patient’s level of hearing loss at various frequencies. The effects should be apparent immediately, but it can take several weeks to get used to using a hearing aid and follow up appointments with the hearing aid specialist will be needed.
Because it can take time for the patient to find out whether a specific hearing aid is suitable for their needs, any purchased hearing aid can be returned within a calendar month for a full refund minus a 5% administration fee.
Improving awareness of external sounds can help to make the symptom of tinnitus less noticeable. Alternatively, a masking device can be fitted. Once the specific frequency of tinnitus has been measured, by carrying out a Tinnitus Match & Masking test, a hearing device can be programmed to generate low level noise at a specific frequency that can “cancel out” a patient’s troublesome tinnitus and make it more tolerable.
Ear Protection Devices
Some patients may be prone to developing recurrent ear infections when swimming regularly, particularly in hot and humid climates. An effective remedy is to wear custom-made Swim Plugs. A silicone cast impression is taken of the patient’s ear canals in order to make plastic waterproof ear protection plugs, to keep the ears dry when swimming.
Frequent exposure to loud noise can have a long term detrimental effect on hearing and increase the likelihood of developing tinnitus. Professional musicians and those exposed to excessive gunfire are particularly at risk. Custom made Sound protection plugs worn regularly can attenuate and significantly reduce the sound intensity by up to 20% and avoid these long term ear issues.
Major middle ear, mastoid and skull base procedures
Experienced ear specialists (Otologists) practicing at The Harley Street ENT Clinic can undertake a wide range of complex surgical procedures under general anaesthetic, mainly at The London Clinic, a large independent private hospital nearby. These include, stapedectomy, myingoplasty, mastoidectomy, endolymphatic sac drainage and cochlear implantation. Pre-operative assessment and full post-operative care is provided at The Harley Street ENT Clinic.Book Appointment