Otitis Media is inflammation or infection of your middle ear (the space behind your eardrum) and is often associated with a build-up of fluid in your middle ear. Acute Otitis Media: this is usually caused by a temporary malfunction of the Eustachian tube due to allergies, infections or trauma. The Eustachian tube connects the middle ear to the nose and allows air to enter the middle ear, thus making middle ear pressure the same as air pressure outside the head. Acute otitis media results in an infection in the middle ear causing pain, fever and a red, bulging eardrum (the thin, transparent membrane between the outer ear canal and the middle ear). This condition is usually seen in young children. The treatment may be antibiotics if it is suspected to be a bacterial, rather than viral, infection, or if there are repeated episodes, surgical insertion of grommets into the eardrums may be required. Grommets are tiny ventilation tubes that allow normal airflow into, and drainage out of, the middle ear until the Eustachian tube begins to work normally. The operation is done under general anaesthesia (the child is asleep) and takes 10-15 minutes. Most grommets fall out naturally after six to twelve months, by which time the Eustachian tube is often working properly. Otitis Media with Effusion (Glue Ear): like acute otitis media, glue ear is usually the result of a temporary malfunction of the Eustachian tube and may either follow an episode of acute otitis media or occur on its own. The condition is usually seen in children. Fluid is present in the middle ear and the ear is painful, but the ear drum is not red and bulging and there is no fever. Glue ear may lead to hearing loss, which can result in speech delays and balance problems. Treatment options include: a prolonged course of antibiotics; grommet insertion; or treatment with decongestants, antihistamines or steroids. Chronic Otitis Media: if the Eustachian tube is blocked repeatedly over a period of several years, there may be changes to the tissues of the middle ear such as deformity of the ear drum and damage to the bones of the ear. These changes may result in hearing problems, balance problems, and persistent deep ear pain. If such long term damage has occurred, an operation called tympanomastoidectomy may be required. This involves making an incision (cut) behind or around the upper part of your ear, drilling through the mastoid bone and removing, and possibly repairing, damaged tissues.

Your tonsils are the oval-shaped lumps of tissue that lie on both sides of the back of the throat. Sometimes tonsils can become inflamed (red and swollen with white patches on them) as the result of a bacterial or viral infection; this is known as tonsillitis. If you have tonsillitis, you will have a very sore throat and maybe swollen glands on the side of your neck, a fever, headache or changes to your voice. In some cases pus can be seen on the tonsils. Tonsillitis mostly occurs in young children and it can be a recurrent condition (it keeps coming back). If the tonsillitis is caused by bacteria, antibiotics will be prescribed. If the tonsillitis is caused by a virus, treatment will usually consist of medications to relieve symptoms such as a pain killer. If tonsillitis occurs often over a period of two or more years, then surgical removal of the tonsils (tonsillectomy) may be considered.

Dr H Sillars – subspecialist ear surgeon 160 Gillies Ave, Epsom, Auckland (ph) 09 9254060. (fx) 09 6311962 (e) Surfer’s Ear / Exostosis Surfer’s ear is the common name given to the formation of bony lumps within the ear canals. These happen most commonly in surfers because it's repeated cold water immersion that stimulates their growth, early on offering few symptoms but as they progress allowing at times prolonged trapping of water and then, generally at a later point, infections. Management is aimed at trying to prevent their progression, treating deteriorations simply where possible but not uncommonly eventually having to consider a surgical remedy. What causes them to happen? Within the adult ear canal (which is some 2.5 cm long) the inner two thirds has a surrounding ring of bone with only a very thin layer of overlying skin. Sandwiched beneath the skin and the bone is an even thinner layer of bone membrane called periosteum – the two together are almost a single layer so with very little mechanical or thermal cushioning. When swimming and especially when in cooler water and in particular in people who swim a lot, repeated chilling and subsequent natural warming of the canal sees the periosteum stimulated and bone cells laid down very slowly but progressively. This is a process that evolves over the years and with the growths often enlarging to a significant point before they become symptomatic. In many the initial awareness of a problem is water getting in and then failing to clear as it becomes “caught” in this narrowed space by surface tension – this is why some, after swimming, have to dance and jiggle their head to shake the fluid loose. With more time and further growth and a channel now even narrower, sees trapped fluid, waterlogged skin and now an infection which may be not only very painful but also difficult to treat. Diagnosis of Exostoses These should be suspected in anyone who has been surfing for a significant interval (particularly so if they are winter water enthusiasts and/or have been surfing in colder climates). When the ear is examined typically smoothly rounded white swellings are initially seen – as they enlarge and as they are in a contained space they have to grow towards each other compressing even more the space of the canal. In many, and as at an early stage they are often minimally symptomatic, diagnosis is at the point where water gets caught after a day in the surf, a doctor looks in the ear and the obvious reason is found. MANAGEMENT: 1) Prevention While these troublesome bony lumps can occur in people who aren’t surfers the vast majority are and we know, as above, that it is a cold water effect repeatedly applied that causes these masses to evolve. Trying to prevent water getting in is the key and in this regard there are simple options such as a Blutac plug particularly when supported by a wetsuit hood or you could use some proprietary products available although I would avoid the mouldable silicone putty ones which can be pushed in too far and be very hard to get out. A particularly effective measure is to approach a local audiology (hearing aid) company and have some custom fitted plugs made conforming to the anatomy of your ear and therefore most effectively keeping water out. 2) Water trapping As mentioned already this generally doesn’t occur until later in the evolution of the exostoses but can often be effectively managed by the use of high concentration alcohol based ear drops – a few drops in the ears after swimming will help evaporate any fluid within as well as benefiting from the antiseptic influence of the alcohol itself. These can be purchased from the chemist under the name of Vosol or if you have some Australian connections a better formulation is available there called Aqua-ear. In this country I use and recommend a very effective drop mixture of steroid, acetate and alcohol which combines an enthusiastic drying agent with an effective anti infection regime. 3) Infections These are the severity step above water trapping and usually relate to water that’s become caught, the skin has become waterlogged then inoculated with bacteria or fungi and an infection sets in. These generally now cause additional blockage, itch, pain, a feeling of moisture or even some discharge – the main problem is the pain which can be excruciating which is not surprising given the inflammatory pressure that’s happening within a space tightly contained by bone so therefore no room for soft tissue expansion. Infections should be treated early and aggressively, ideally at the outset with a doctor or a practice nurse taking a swab as at least then, if the infection doesn’t get better after a few days, there will be an identified organism and specifically tailored treatment can now be provided. While commonly antibiotics are offered orally, these topically delivered are generally more effective as there is a higher concentration in the drop form specifically delivered to the area of concern. Commonly available and used drop formulations include Cipro HC, Sofradex or Maxitrol (the latter are eye drops but can be equally effectively applied to the ear) with some also requiring an early visit to an ear nurse to perform a microsuction to remove debris therefore reducing the pain and allowing drops to penetrate more effectively. The combination of a thorough cleaning, the provision of appropriate drops and their effective penetration will generally see most infections settle only rarely requiring additional antibiotic cover but at times, and if severe, potentially an urgent specialist assessment. 4) Hearing Loss This can occur briefly with water trapping or in a more persisting fashion during an infection. Generally however hearing restores as the blockage reduces. At a severe point with the growths now occluding the canal a sustained hearing loss appears but one that will be reversed by successful surgery. SURGERY FOR SURFERS EAR: The aim of surgery is to enlarge the space within the ear canal, with some techniques merely reducing some of the growths but preferably an option removing not only the bulk of the exostoses but also some of the underlying bone. This over corrective technique allows an outcome therefore more durable and one which I believe is significantly safer. The key to good surgery and a great result is not just the removal of the overgrowth of bone but also the scrupulous protection of the very delicate skin that lines the ear canal - it is essential that this is all preserved during the operative process otherwise healing can be slow and the outcome compromised. Meticulous surgical technique is therefore essential. Historically the approach incision was a small cut at the upper aspect of the opening of the ear canal – while seemingly “simple” it was inevitably followed by a restricted removal of bone, in some significant degrees of postoperative pain and the not uncommon eventuality of a recurrence of the exostoses and the need for repeat surgery. My preferred approach is to access the ear by an incision behind the external ear – although a bigger cut paradoxically this is often much less sore and it definitely provides a superior operative view which in turn enables more bone to be removed in a safer fashion and here being aware of very important surrounding anatomy that must be protected including the jaw, the drum deeply and even the nerve that moves the face. I strongly believe this to be superior as it takes no longer to perform and while it does require longer postoperative care longer term results are substantially enhanced. The only negatives of this option are the incision and a longer recovery interval of approximately 4-6 weeks (as it takes a much bigger ear canal volume more time to heal). These slight negatives I firmly believe are more than outweighed by what I think is a safer and usually less painful technique and a much more durable result. WHEN TO OPERATE The time to consider surgery is when the intrusion of the exostoses is becoming significant rather than just considering their size - as previously mentioned symptoms often don’t appear until a late stage is reached so once the point of water trapping is met it becomes much more likely that surgery may need to be a seriously considered option. The historic reputation of canalplasty surgery as an unpleasant experience best avoided has been superseded by this enhanced and much better tolerated operative technique. THE PROCESS OF SURGERY The procedure is carried out under general anaesthetic and takes approximately 1.5 to 2 hours. The technique involves a high power operating microscope and microdrills to progressively remove the overgrowths. You will wake up with a turban like bandage which needs to remain in place for 3 days and be home some 2-3 hours afterwards. For the first week the operated ear will be totally blocked as there will be an antiseptic dressing in the canal which will be removed at the first postop appointment 7 days later – from here hearing will be restored and a new lighter dressing placed. This cleaning and redressing continues on a weekly basis until the canal has fully healed – 4-6 weeks is the expectation. It is not regarded as safe practice to operate on both ears at the same time but as often both need to be remedied the plan would be the worst ear first so now postoperatively blocked on this side from the operative dressing then a few days later the caution of a hearing test of this ear to ensure no hearing harm. With this confirmed the second ear surgery is scheduled a week later at the same time carrying out the first dressing change for the initial (and now hearing) ear. This then enables the expected healing interval for both to be contained within the same following few weeks. Pain following is expected to be restrained and water pursuits can generally be considered after 6-8 weeks. RISKS OF SURGERY While there are potentially many risks fortunately these are very unusual especially when the operation is carried out by a highly experienced surgeon: Hearing loss and tinnitus to a sustained degree < 1% Damage to the facial nerve – has been described in the literature but should never eventuate Delayed healing 2-3 % Canal scarring / narrowing – in my experience never happens with careful surgical and post op care Damage to adjacent structures such as the jaw joint or the ear drum / middle ear bones <0.2% Surfer's Ear / Exostoses - Hamish Sillars (PDF, 199.3 KB) Information about the causes, diagnosis, management and surgery of Surfer's Ear / Exostoses

Ruptured Eardrum (Tympanic Membrane Perforation) This is when a hole or tear occurs in the thin membrane (eardrum) that separates the ear canal from the middle ear. Causes may include middle ear infections, traumatic injury or sudden changes in air pressure. The eardrum usually heals by itself but sometimes a minor surgical procedure might be required to repair it.

Cholesteatoma This is an abnormal growth of skin in the middle ear that increases in size over time and may cause damage to surrounding tissue and structures. Cholesteatomas can result from repeated middle ear infections, injury or a poorly functioning eustachian tube (the opening between the middle ear and the nose). Treatment for a cholesteatoma is usually surgical removal.

When the growth of one of the tiny bones in your middle ear, the stapes, changes from hard to soft and spongy, it leads to the condition called otosclerosis. As this abnormal growth develops, the stapes becomes more rigid or fixed in position. The stapes needs to be able to vibrate to allow sound vibrations to pass through to the inner ear. When the stapes is not vibrating as well as it should, gradual hearing loss can occur. Otosclerosis may occur in one or both ears and may sometimes be associated with ringing/clicking/buzzing noises in your ear (tinnitus). The condition will be diagnosed by hearing tests and tympanometry. Otosclerosis most often develops during teenage and early adult years and it tends to run in families. The condition can become worse during pregnancy. Treatment There are several different approaches to treating otosclerosis, one of the most common being a surgical procedure called stapedectomy. This is a microsurgical procedure (microscopic lenses are used to help the surgeon see the tiny structures involved) usually performed through the ear canal. A small cut (incision) is made in the ear canal near the eardrum and the eardrum is lifted, exposing the middle ear and its bones. Part of the stapes bone is removed and an artificial prosthesis inserted to help transmit sound into the inner ear. The eardrum is then folded back into position. The surgery can either be performed under general anaesthetic (you sleep through it) or local anaesthetic (the area treated is numbed) plus sedation (you are given medication to make you feel sleepy). You will be advised not to fly, blow your nose or allow any water to get into your ear for about six weeks after the operation. Other treatments include use of a hearing aid or taking sodium fluoride which helps harden the bone and can improve hearing in many patients with otosclerosis.

Vestibular Schwannoma or acoustic neuroma is is a slow-growing, benign (non-cancerous) overgrowth of tissue on the nerves that affect you hearing and balance. When the neuroma is small, there may either be no symptoms or you may have a slight hearing loss or mild tinnitus (ringing/clicking/buzzing noises in your ear). As the neuroma grows and exerts pressure on the nerves, there will be a more noticeable loss of hearing, more tinnitus and problems with balance. The condition is diagnosed using hearing tests and MRI or CT scans. Acoustic neuromas are usually found only in one ear and generally occur in people over 40 years of age. Treatment If the neuroma is small and not causing significant problems, you may not receive any treatment but the growth and effects of the neuroma will be monitored regularly. If treatment is being considered, it may be either radiotherapy or surgery. Radiotherapy, which is used for small to medium neuromas, involves low-dose beams of radiation aimed at the neuroma. This does not require anaesthesia but you will probably be in hospital for 1-2 days. For larger neuromas that are causing significant problems, surgical treatment may be suggested. Depending on the size of the neuroma, there are several different types of operation that can be performed. Whatever surgical approach is used, it will be performed under general anaesthetic (you will sleep through it) and you will probably remain in hospital for about one week.

Hearing Loss Hearing loss can be divided into two types: conductive hearing loss (caused by some sort of mechanical problem in the external or middle ear) or sensorineural hearing loss (caused by disorders of the inner ear, hearing nerve or associated brain structures). Conductive hearing loss is often reversible and can be due to: blockage of the ear by e.g. wax, inflammation, infections or middle ear fluid poor sound conduction because of e.g. holes or scarring in the eardrum or the bones of the middle ear (ossicles) becoming fixed and rigid. Sensorineural hearing loss is generally not reversible and can be caused by: genetic make-up (this could include congenital conditions i.e. those you are born with, or late-onset hearing loss) head injury tumours infections certain medications exposure to loud noises the aging process (a significant hearing loss is experienced by about one third of people aged over 70 years). Some of the signs you might notice that indicate you have a hearing loss include: having to turn up the volume on the TV or radio finding it hard to hear someone you are talking with finding it hard to hear in a group situation where there is background noise e.g. in a restaurant having to ask people to repeat themselves you find people’s speech is unclear – they are ‘mumbling’ Hearing loss can be partial (you can still hear some things) or complete (you hear nothing) and may occur in one or both ears. Treatment Treatments for hearing loss range from the removal of wax in the ear canal to complex surgery, depending on the cause of the loss. One of the most common treatments for hearing loss is the use of a hearing aid. The type of aid you get depends on the cause of your hearing loss and how bad it is, as well as what your preferences are in terms of comfort, appearance and lifestyle. If your hearing loss is severe to profound, you may be suitable for a surgical procedure known as a cochlear implant. In this procedure, a small cut (incision) is made behind your ear and a device is implanted that can bypass the damaged parts of your ear. The surgery usually takes 2-3 hours and is performed under general anaesthesia (you sleep through it). You may be able to go home the same day or have to spend one night in hospital. Meniere’s Disease Meniere’s disease is a disorder in which there is an abnormality in the fluids of the inner ear resulting in increased pressure in the inner ear. There is no general agreement as to what causes this abnormality, but there are probably many different causes including injury (immune, infectious, trauma, allergic etc) to the ear. Symptoms of Meniere’s include episodes: of vertigo (you feel you are spinning), hearing loss that comes and goes, tinnitus (ringing/clicking/buzzing noises in your ear), a feeling of fullness around your ear. Episodes may last for hours or days. The condition will be diagnosed using hearing tests and possibly an MRI or CT scan. Meniere’s disease usually occurs in one ear only and typically appears between the ages of 20 and 50 years. Treatment The initial treatment approach is usually a lifestyle and diet change, including a low salt diet; avoidance of alcohol, tobacco, caffeine and stress; and increased exercise and rest. The majority of patients find that these changes can help control their symptoms. Diuretic medication (reduces the amount of fluid in your body) may also be introduced. In severe cases where dietary/lifestyle changes have not been successful, surgery may be considered.

Deviated Septum The thin wall between the nostrils (septum) is often uneven or crooked, making one nostril narrower than the other. Most people experience no symptoms from this condition but sometimes the reduced airflow can lead to difficulty breathing, congestion, infections, nosebleeds and snoring or sleep apnoea. Symptoms can be treated with medication such as decongestants and steroid sprays but if symptoms persist surgery (septoplasty) may be required. Septoplasty This operation repositions the nasal septum and is performed entirely within your nose so that there are no external cuts made on your face.

In the facial bones surrounding your nose, there are four pairs of hollow air spaces known as sinuses or sinus cavities. These sinuses all open into your nose, allowing air to move into and out of the sinus and mucous to drain into the nose and the back of your throat. If the passage between the nose and sinus becomes swollen and blocked, then air and mucous can become trapped in the sinus cavity causing inflammation of the sinus membranes or linings. This is known as sinusitis. Sinusitis can be: acute - usually a bacterial (or sometimes viral) infection in the sinuses that follows a cold, or an allergic reaction chronic - a long term condition that lasts for more than 3 weeks and may or may not be caused by an infection. Symptoms of sinusitis include: facial pain or pressure nasal congestion (blocking) nasal discharge headaches fever. Treatment for bacterial sinusitis is antibiotics and for non-infective sinusitis may include steroid nasal sprays and nasal washes. Sinusitis can be a recurrent chronic condition which means it may occur every time you get a cold. If this treatment is unsuccessful, surgery may be considered. This is usually performed endoscopically; a tiny camera attached to a tube (endoscope) is inserted into your nose. Very small instruments can be passed through the endoscope and used to remove abnormal or obstructive tissue thus restoring movement of air and mucous between the nose and the sinus.