Conventional Myringotomy and Grommet insertion

Laser Myringotomy(OTOLAM)

The increased risk of a tumor of the auditory nerve, called an acoustic neuroma, was found to be about four times higher on the side of the head where the phone was held, and virtually normal on the other side.
Approximately one in 100,000 people develop acoustic neuromas. This type of tumor grows slowly and accounts for less than 10 percent of all brain tumors. Because these tumors do not involve invasive growth, they are not classified as cancer.
Hand-held wireless phones with built-in antennas, known as mobile phones, or cell phones, emit low levels of radiofrequency energy in the microwave range while being used. The auditory nerve is exposed to radiation during the normal use of a cell phone.

Researchers who have raised concerns say that just because science can’t explain the mechanism doesn’t mean one doesn’t exist. Concerns have focused on the heat (microwave) generated by cell phones and the fact that the radio frequencies are absorbed mostly by the head and neck.
The real concern is not older cell phone users, who began using phones as adults, but children who are beginning to use phones today and face a lifetime of exposure.

For people who are concerned about any possible risk, a simple solution is to use a headset. Of course, that option isn’t always convenient, and some critics have raised worries about wireless devices like the Bluetooth that essentially place a transmitter in the ear.

The fear is that even if the individual risk of using a cell phone is low, with three billion users worldwide, even a minuscule risk would translate into a major public health concern.
No one can say with any certainty that cell phones are either safe or not safe The main concern is that with the widespread use of cell phones, the worst scenario would be that we may get the definitive study 10 or 15 years from now, and we find out there is a correlation. And then it will be too late.
So be careful.

Down syndrome is a chromosomal abnormality caused by an additional (third) chromosome 21 or “trisomy 21.” Down syndrome is associated with mental retardation, a characteristic facial appearance, and poor muscle tone (hypotonia).
This occurs in approximately 1 in every 900 births. Down syndrome is not inherited; it does not “run in families.”

John Langdon Down, while working as the superintendent of the Earlswood Asylum for mentaly retarded, published the first clinical description of the syndrome around 140 years ago.

Some people with Down’s syndrome experience very few health problems as a result of their condition. However, others can be more severely affected and require extra medical care and attention.

Hearing problems

Approximately 50% of people with Down’s syndrome experience problems with their ears - hearing, more of a conductive hearing loss because of the accumulation of fluid in the middle ear.
Glue ear is a common condition for people with Down’s syndrome. It is caused by a build up of fluid in the middle ear. In some cases, the fluid thickens, making sounds appear muffled and distorted.
If your child cannot hear clearly, this may mean they find it more difficult to learn, or to interact with other children.
The reason for having glue ear is because these children have narrow and short Eustachian tube.
The external auditory canal makes any surgical procedure difficult.

The treatment is myringotomy, aspiration of glue (thick secretion) with or with out grommet insertion.
Some advocates not putting grommet as the side effects of keeping the grommet in situ.
Adenoid if enlarged can be removed same time.
The grommet is left in situ until it extrudes by itself. Avoid water getting in the ear while bathing and swimming.

Insects in the Ear
Insects may fly into the ear and become trapped causing great discomfort and pain. Sometimes, the insect dies after entering the ear; other times, it may remain alive and attempt to work its way back out of the ear. In either case, the insect should be removed immediately.
What to do in an emergency situation?
If you think the insect is still alive and it does not come out with gentle head shaking, pour a small amount of vegetable or baby oil into the ear canal. This will usually suffocate and immobilize the insect. If you think the insect is dead and it does not come out with gentle head shaking, pour a small amount of warm water into the ear canal to flush it out.
Do not attempt to remove the insect by poking it with a cotton swab or similar probe. This may push the insect farther into the ear or cause damage to the middle ear and eardrum.

Consult an Ear Specialist

Insects are able to cause damage to the inside of the ear by stinging or scratching the eardrum.
The ear should be examined under a microscope and any damage if done is assessed and treated accordingly.
Antibiotic ear drops, analgesics, antibiotic may be prescribed.

Glue Ear is a build-up of fluid behind the eardrum, in the middle ear causing conductive hearing loss-deafness. Glue ear is a middle ear disease, associated with poor Eustachian tube function. Most children get glue ear at some stage in their lives.

Glue ear with fluid level behind right eardrum. The fluid may be thick and sticky, or thin and watery. Either way it stops the ear drum and ossicles vibrating easily, so quieter sounds are not heard. Glue ear is the commonest cause of deafness in children. Adults can also be affected. Other names for glue ear are middle ear effusion and chronic secretory otitis media-SOM..
It often follows after a cold or ear infection. The Eustachian tube is small and blocks easily. It then fails to ventilate the middle ear. Sticky secretions can’t drain away, so fluid builds up in the middle ear. Movement of the eardrum and ossicles is impaired, causing partial deafness.
Most cases get better quickly after the cold resolves. A minority persist for months or years. Occasionally glue ear is caused by flying with a cold - the Eustachian tube is unable to equalize pressure during descent .Diving with a cold is very likely to cause glue ear.

Persistent glue ear

Common reasons for persistent glue ear in children are due to large adenoids at the back of the nose. Less common reasons for persistent glue ear include Cleft palate and Down’s syndrome .Rarely, glue ear in an adult is caused by a tumor at the back of the nose. Often, no particular cause is found.

Symptoms of glue ear

Conductive Deafness of mild to moderate degree. Hearing loss often varies from week to week, being worse after a cold. Speech may be delayed, especially if deafness occurs early in childhood. Unclear speech and constant shouting are common. Later, education may be affected.
Sometimes deafness is not suspected, but the child is thought to be inattentive, slow or lazy. Concentration may be poor. The child often seems to be “in a world of his own”. Some sufferers get frequent earaches, usually worse at night. Repeated ear infections, with high temperature in some cases leading to fits.
Poor balance and clumsiness may feature. Older children and adults often complain of noises in the ears - tinnitus

Conservative Management

The fluid frequently goes away by itself, so a policy of watchful waiting is usually advised. Blowing up balloons to try and force air up the Eustachian tube, may help but the published results are very short term and not many children will persist with this treatment.
Antibiotics and painkillers can be used for associated ear infections. Decongestants e.g. Sudafed are often prescribed but have never been proven effective.

Other medical treatments including antihistamines steroids, medicines to try and thin sticky mucus have all been used.

Treatment of glue ear

If deafness persists for longer than 3 months, an operation is usually needed. The decision to operate is always individual, based on all the factors in that particular case. For immediate relief, myringotomy and grommets insertion is highly effective. Removal of the adenoids may be recommended if the adenoids are enlarged, and where glue ear recurs after initial grommet insertion.

What is a grommet ?

A grommet is a tiny plastic tube, shaped like a miniature cotton reel, about 2mm diameter. It is fitted through a small cut in the eardrum (myringotomy).The tension of the eardrum grips the grommet around its waist. The cotton-reel shape stops it falling in or out, like a shirt stud in a button hole. The grommet allows air from the outer ear directly into the middle ear. Provided the grommet remains in position and is not blocked, the hearing returns to normal almost immediately. The grommet does not drain fluid out; it lets air into the middle ear. Another name for a grommet is a ventilation tube, sometimes abbreviated to tube.
The standard Shah grommet is designed to stay in position for about 9 months. Then the opening in the eardrum heals over and the grommet is pushed out. Longer term ventilation tubes are sometimes fitted. It is important to understand that a grommet does not cure the underlying cause of glue ear. A grommet does provide highly effective and immediate relief of deafness and earaches, while it is in position and working. This buys time, and allows normal education. Meanwhile the child has a chance to grow out of it.

Myringotomy operation

Grommets insertion is normally a quick and simple day-case procedure.
It is very delicate and normally done under general anesthetic (patient fully asleep) the anesthetic is usually given by injection into a vein in the back of the hand, or by gas. To prevent the needle from hurting, a local anesthetic cream is applied about an hour beforehand.
A microscope provides a magnified view of the eardrum. A small cut (myringotomy) is made in the eardrum, and the fluid in the middle ear is sucked out. The cut is like a tiny button hole in the eardrum. Sometimes, if the glue is very thick and sticky, like treacle, a second cut is needed. The second opening allows air in to the middle ear while the glue is sucked out. Sometimes ear drops have to be pumped in to thin the glue in order to suck it out.
The grommet is fitted. It is held in position by the tension of the eardrum gripping it around the waist. The grommet’s shape stops it falling in or out, like a shirt stud in a button hole. If the eardrum is badly thinned, stretched and damaged, it might not have the strength to hold a standard grommet in place. A bigger grommet (long term ventilation tube) might be used in such a case.
Some eardrops are usually applied at the end of the procedure.
If the adenoids are to be removed, this is normally done under the same anesthetic. The adenoids are removed via the mouth.

What happens after the operation

Children recover very rapidly from grommets insertion and should be able to return to school after a day or two.
The hearing normally improves immediately, but don’t worry if there is still some difficulty in the first weeks as it can take time in some cases.
There may be a very slight earache, treated easily with Calpol or paracetamol for older children. There may be slight bleeding from the ear in the first few days. This is normal and nothing to worry about.

Swimming with grommets

No swimming for the first two weeks. After that, surface swimming is allowed without earplugs. Bath water should not be allowed in the ears. The head should not be submerged in the bath. For hair washing, either use earplugs, or a piece of cotton wool dipped in Vaseline to provide a waterproof seal.

The balance organ - labyrinth is made up of three semicircular canals and the vestibule, which are all filled with liquid. The semicircular canals sense rotational movement and the vestibule senses acceleration and deceleration.

Types

Benin Paroxysmal Positional vertigo
Menière’s disease
Labyrinthitis

Investigations

Types of test that may be requested include: audiological tests, tests of balance, blood tests, and radiological examinations such as an MRI scan or CT scan.

Treatment

In general the treatment of vertigo is symptomatic, i.e. treatment is given to control the symptoms without regard to the specific cause of the vertigo. The body is very good at overcoming the imbalance experienced during inner ear disease, and so symptomatic treatment should be short because it can delay this natural compensation.

Rehabilitation -Exercises
There are specifically targeted exercises to speed up the brain’s natural compensation after inner ear disease. Recovery can be hastened by these exercises which can be organized by your local ear nose and throat or physiotherapy department.
Vestibular sedatives
The inner ear may be ‘suppressed’ (or made sleepy) by the use of drugs such as Stemetil or Stugeron. These drugs reduce the overactivity of the balance organ and so reduce the dizziness and vomiting that can occur in inner ear problems.

However, they are not a long-term solution and should be used for as short a time as possible because they prolong the time taken for the body to readjust after the vertigo.