“The art of conversation is the art of hearing as well as of being heard.”
― William Hazlitt,
Ear problems include conditions of the outer, middle and inner ear. They can affect your hearing and sometimes your balance as well. These ear conditions can even negatively impact your quality of life and the way you interact with people and the world around you.
Hearing loss is a condition that is more common than many people realize. The World Health Organization (WHO) estimates that there are 360 million people in the world with disabling hearing loss. This is 5.3% of the world’s population!
Hearing loss can be divided into conductive hearing loss and sensori-neural hearing loss. Anything that causes a blockage or a reduction of sound getting through to your inner ear is a conductive loss. If the cochlea in the inner ear or the ear nerve is damaged, it is called a sensori-neural hearing loss.
Causes of a conductive hearing loss include:
- Wax impaction
- Outer ear infections / Otitis Externa
- Perforated eardrum
- Middle ear infections
- “Glue ear” / fluid in the middle ear
- Hearing bones (ossicles) problems
Wax impaction has many causes, but it is generally the result of overzealous use of cotton buds (ENTs never refer to them as “earbuds”, because they are NOT meant for the ears!). This can produce different symptoms, including a feeling of “fullness” in the ear, ear pain, an itchy feeling, hearing loss, funny noises in the ear, dizziness or a discharge from the ear.
Wax impaction can be seen in people of all ages and it can be treated by cleaning the ears, rinsing the ear canal with saline or water, and removing wax manually using specific instruments. Your physician can accurately assess these ear problems and make a recommendation as to what your treatment should be.
Outer ear infections / Otits Externa
Infections of the skin of the ear canal are usually caused by exposure to water, resulting in the term “swimmer’s ear”. It can also be caused by scratching deep inside your ear canal and damaging the thin skin of the canal, with a paperclip or cotton bud for example.
This condition is very painful. The skin of the canal swells up, causing a conductive hearing loss and a blocked feeling. There will also be a watery, pus-like discharge from the ear.
Otitis externa is treated by an ENT, who will carefully clean the ear and prescribe antibiotic eardrops. Otitis externa can be very severe, and even life-threatening in diabetics, and other patients with compromised immunity.
Some skin conditions like eczema can also affect the skin of the ear canal and predispose you to outer ear infections. Eczema of the ear canal usually causes a dry, itchy skin, just like eczema in other areas of the body.
The skin of the outer ear also has appendages like the skin elsewhere on your body. Thus, pimples and boils can also form here, and are best treated by an ENT.
A perforated eardrum is quite a common ear condition and it refers to a tear or a hole in the eardrum. The eardrum, or tympanic membrane, is a thin membrane that separates the middle ear from the outer ear canal. This membrane needs to move as sound enters the ear, just like the membrane of a speaker moves when sound is played though it. The movement of the membrane moves the tiny bones known as ossicles, which takes the sound to the cochlea in your inner ear.
There are many causes of perforated eardrums, including infection and injury. If there is an infection, this will be treated first. Once the infection has resolved your physician may order a hearing test to measure the amount of conductive hearing loss caused by the perforation.
Quite often, a perforation does not cause any problem, or heals itself. Sometimes, however, your ENT may advise doing a surgery called a tympanoplasty. This involves placing a “patch” on the perforation to allow for healing. The patch is usually some of your own tissue. The commonest patches are the covering of the muscle behind your ear, a piece of cartilage from the ear itself, or fat from the lobe of the ear. All result in aesthetically pleasing scars, and most people don’t even realise they’ve had surgery once the wound has healed.
Middle Ear Infections
Middle ear infections are also known as otitis media, and are one of the commonest childhood infections. It is estimated that 5 out of 6 children will have had an ear infection by the time they are 3 years old. They are caused by viral or bacterial infections that affect the middle ear, the area behind the eardrum. Middle ear infections can be quite painful due to inflammation and the build-up of pus or fluid in the middle ear. This fluid or pus will also cause a conductive hearing loss, and a sensation of a “blocked” ear. Occasionally, children may be off balance, or develop a pulled face due to pressure on the facial nerve.
Since these ear problems often clear up on their own, treatment may vary. An ear infection can resolve spontaneously without antibiotics. Most of the time it is only pain and fever medicine that is needed. However, in severe cases, antibiotics are often prescribed as well. There are certain long term problems that can occur due to ear infections, like persistent fluid in the ear (glue ear) with hearing problems. Infections can also result in acute complications, such as weakness of the face, dizziness and tinnitus (noise in the ears). In severe cases, they can result in meningitis (inflammation of the lining of the brain).
“Glue ear” / Otitis Media with Effusion (OME)
Sometimes, an ear infection does not clear up completely, and some fluid gets left behind. This fluid becomes sticky, and gums up the tiny bones that vibrate in the ear, very similarly to a car engine that has sludge build up. When this happens, the patient may not hear well, and may occasionally have pain. In children, who cannot communicate such symptoms effectively, this is manifest as an irritable child, or constantly pulling on the ears.
Sometimes there is no ear infection before a glue ear, but a bad cold or sinus infection damages the Eustachian tube. This tube runs from the back of your nose to your ear and is responsible for ventilating your middle ear and constantly equalising the air pressure. If the tube is damaged, fluid can build up in the middle ear and cause the same symptoms as mentioned above.
If the fluid in the ear is persistent and causes hearing loss, a grommet or ventilation tube can be inserted in the eardrum.
Glue ear in adults can be a sign of more serious pathology, such as a tumour in the nasopharynx (the area behind the nose).
Hearing Bones Problems
The hearing bones are 3 little bones forming a chain that conduct sound from the eardrum to the cochlea. . Theses bones are the smallest in your body, and are called the malleus (hammer), the incus (anvil) and the stapes (stirrup). Some diseases like otosclerosis can cause these hearing bones to get stuck, or trauma can cause the chain to dislocate. This will then cause a conductive hearing loss. Long-standing infections can also erode the bones, or cause them to get stuck to one another or to other structures. Luckily this can be fixed with a very delicate ear operation. Your ENT can provide more information.
A cholesteatoma is a type of cyst that forms when skin from the outer ear, instead of migrating outwards, instead forms a ball, or “pearl” in the middle ear. Cholesteatomas are not tumours, but can be dangerous nonetheless. People with this condition will complain of a constant ear discharge, hearing loss and sometimes even dizziness and facial weakness.
Cholesteatomas can be left alone if they are very mild, but most of the time the disease progresses and needs an operation. The primary aim of surgery for cholesteatoma is to create a safe cavity that will not endanger the patient’s life. Hearing restoration is a secondary concern, and is not always possible.
Ringing ears, also known as tinnitus, is an ear condition where you hear a sound that is not produced by your surroundings. Most people experience ringing in their ears at some point, usually after exposure to loud noise. If the situation does not go away, it can lead to an irritating problem.
The nature of these sounds can be ringing, buzzing, tinkling or “roaring”-like, and it might even keep time with your heartbeat or your breathing. There are many different causes of tinnitus. These include:
- Hearing loss
- Earwax build-up
- Medicines, like certain antibiotics or aspirin
- Excessive consumption of alcohol or caffeine
- Eardrum ruptures or ear infections
- Head injuries
- A sudden change in environmental pressure
In most cases, no cause can be found, and treatment is by conditioning therapy. The important thing is to exclude a more serious cause such as a tumour. This is usually done by means of special investigations.
Vertigo is a specific symptom caused by conditions that affect the balance organ of your inner ear. Some people call it dizziness, but vertigo is not the same as a feeling of “wanting to faint” or light-headedness. Vertigo is a feeling motion, either of yourself, or your surroundings. This usually causes nausea and vomiting as well, and can be a very debilitating symptom.
The most common condition that causes vertigo is Benign Paroxsysmal Positional Vertigo, or BPPV. BPPV is caused by loosening of small crystals in your balance organ, which is located in your inner ear. The exact cause of this loosening is unknown, but viral infection and trauma (even minor) have been postulated. BPPV produces brief episodes of vertigo and nausea, lasting not more than a few minutes, usually when turning around in bed, or tilting the head back, such as when one looks at the top shelf of a cupboards. The condition can be cured by a small procedure in the rooms called the Epley manoeuvre.
Another common cause of vertigo is Vestibular Neuritis. This is caused by an infection, usually viral, that inflames the balance part of the hearing nerve. If the hearing is also affected it is called a Labyrinthitis, where both the hearing and the balance parts of the nerve are affected.
Méniér’s Disease is a rare condition where brief spells of vertigo are accompanied by tinnitis (ringing ears), a feeling of fullness in the ear and brief hearing loss in the same ear.
The ENT will distinguish vertigo caused by problems in the balance organ, from those caused by problems in the brain itself, such as multiple sclerosis. In some cases, further consultation with another ENT, or a neurologist may be required.
Facial Nerve Palsy
The facial nerve is remarkable, in that it is the nerve with the longest bony canal in the body. There are many causes of facial nerve weakness, but most people are familiar with Bell’s Palsy. It is important to exclude OTHER causes of facial weakness before settling on a diagnosis of Bell’s Palsy, since some of the other causes are far more sinister. ENTs have an intimate knowledge of the facial nerve, and indeed, it can be considered the “ENT’s nerve”. (If your ENT seems annoyed with you, this is probably the nerve you’re working on!)