Ear, Hearing, Balance

Otology Services and Conditions

• Ear infections and earache, Outer ear (swimmer’s ear), Middle ear, (Otitis media)
• Eustachian tube dysfunction – problems with “clearing” ears with change of altitude
• Perforated (hole) eardrum
• Ear Pressure
• Ear Wax
• Dizziness, Vertigo and Motion Sickness
• Meniere ’s disease
• Ear trauma (injury)
• Skin cancer of the ear
• Surfer’s Ear
• Tinnitus
• Benign Paroxysmal Positional Vertigo
• Neuro-Otology
• Chronic Ear Surgery
• Implantable Hearing Solutions

What is Earwax?

Earwax or cerumen is found in all of our ears. It is produced by special glands in the outer ear or external ear canal:

The purpose of earwax is to moisturize and protect the ear canal. It traps dust and dirt particles that get into the ear canal. Normally, earwax usually dries up and falls out of the ear canal. The earwax may be pushed deeper into the ear canal if cotton-tipped applicators, hair pins or paper clips are used to clean the ear. This may result in blocking of the ear canal and hearing loss. Too little earwax may result in dry, itchy ears.

Normally, earwax does not require removal. If your ear becomes blocked, you may try to remove the wax by using hydrogen peroxide or over the counter drops such as Debrox, Murine or similar products. Mineral oil, baby oil or glycerin softens earwax and may help unblock your ears. If water is trapped in the ear canal, rubbing alcohol may be used. A word of caution, drops should not be placed in the ear canal if you have a hole in the eardrum, have had an injury to the ear or if you currently have an ear infection.

You should see a physician when:

• Your ears remain blocked after using one of the home remedies listed above.
• You have a hole in the eardrum
• You have pain or swelling of the ear or other signs of active infection

When to see an otolaryngologist (ENT) specialist:

• If the earwax cannot be removed by your regular physician
• If you have a hole in the eardrum
• If you have had mastoid surgery
• If your hearing does not return to normal after the earwax is removed

Ear Candles/Coning

A word of caution. Ear candling/coning has become popular as a treatment for removing earwax and “ear toxins”. It is not only ineffective but potentially very dangerous.

Ear candles have been around for centuries. A hollow wax candle is placed in the ear canal and lit. The burning candle is supposed to draw out the wax with a vacuum effect of the candle. When the candle is removed, the residue inside the candle is said to be earwax and “toxins”. It is even said that the candles remove toxins from the brain and eustachian tubes. Individuals are easily deceived by what they see. In fact, the residue is nothing more than candle wax. Many studies have been done that demonstrate that there

is no vacuum effect of the candle. Rather, vaporized candle wax is often deposited on the eardrum and ear canal skin. There is little that can be done to remove the wax other than to wait for the skin to naturally shed from the ear canal. As otolaryngologists, we have seen many instances where the wax drips into the ear canal and burns or perforates the eardrum. There are also reports that individuals have set their hair on fire. The FDA and Health Canada have determined that ear cones are dangerous to health when used in this manner and are often mislabeled as to their ability to remove ear was (www.accessdata.fda.gov) The bottom line is don’t waste your money or jeopardize your health.

Meniere’s Disease

Meniere’s disease, also called idiopathic endolymphatic hydrops, is a condition that causes attacks of vertigo (spinning sensation), hearing loss, tinnitus (roaring, buzzing, or ringing sound in the ear), and a sensation of fullness in the affected ear.

The attacks of vertigo may be accompanied by disequilibrium (feeling off-balanced), nausea and vomiting. The attacks last 20 minutes to several hours. Many individuals feel off-balanced and fatigued for days after an attack.

The hearing loss may fluctuate and often affects the low pitches. It is common for hearing to gradually worsen as the illness progresses. Many individuals find that loud noises are uncomfortable (hyperacusis).

A feeling of pressure or fullness is often felt at the onset of an attack.

Meniere’s disease generally affects only one ear but may affect both ears in 15%. The onset of Meniere’s disease is usually between 20-50 years of age and affects men and woman equally.

The cause of Meniere’s disease is unknown but is thought to be caused by an abnormality in the fluids of the inner ear. The inner ear is important for both hearing and balance. Fluid, called endolymph fills canals within the inner ear. Movement of fluid in the hearing portion of the inner ear (cochlea) allows sound waves to be changed into a message that is transmitted to the brain. Movement of fluid in the balance portion of the inner ear creates messages about the position and movement of your body.

In Meniere’s disease, too much fluid (endolymph) builds up in the inner ear. This affects the signals to the brain, causing the symptoms of Meniere’s (vertigo, hearing loss, tinnitus and hear pressure).

There are several possible causes for Meniere’s disease but most are idiopathic or unknown . Some cases are caused by injuries to the head or ear, by middle ear infections and some from syphilis or a virus. Allergies and autoimmune disease may be a cause.

How Is Meniere’s Disease Diagnosed?

The history of symptoms is important in diagnosing Meniere’s disease. Prior to your visit, we ask that you review and answer the dizziness questionnaire (link to questionnaire).

An examination will help determine if there are any other conditions that may be causing your symptoms.

Diagnostic tests may include:

• Audiometric examination (hearing test).
• Auditory brain stem response (ABR), a test that uses electrodes to record how well sound signals travel along the hearing nerve to the brain.
• Electrocochleography (ECog) measure electrical activity in the inner ear and is often abnormal in people with Meniere’s.
• An MRI may be indicated to rule out other causes for symptoms similar to Meniere’s disease.
• An ENG (electronystagmography) assesses balance. This study measures eye movements when the inner ear is stimulated by moving the head or filling the ear canals with warm and cold water or air.
• Blood and allergy testing may be ordered to determine if other disorders such as infection, autoimmune, endocrine disorders or allergies are causing your symptoms.

How Is Meneire’s Disease Treated?

Most individual’s symptoms improve with a low salt diet and a diuretic (water pill). Diuretics help reduce fluid buildup in the inner ear. A diet with no more than 2,000 mg sodium is recommended. You will need to read the sodium content of the foods that you eat as 1 cup of cottage cheese, one dill pickle or 10 pretzels contain over 900 mg of sodium.

Over the counter medications such as meclizine (Antivert) and prescription diazepam (Valium) and anti-nausea medications may help control symptoms.

Reducing stress, avoiding caffeine, tobacco and alcohol may be helpful. Getting enough sleep and regular physical activity is often beneficial.

In some individuals with autoimmune disease, steroids are usually recommended. Treatment for inhalant and/or food allergies may lesson symptoms of Meneire’s.

Remember that vertigo may occur without warning. Driving, climbing ladders, scaffolds or even swimming may be hazardous when symptoms occur.

Surgical Treatment For Meneire’s

Most individuals with Meneire’s disease (80-85%) do not require surgery. Surgery may be recommended if symptoms are severe or do not respond to medications. There are certain risks to these procedures, including damage to hearing and possible worsening of balance.

There are several procedures that are available:

• Injection of an antibiotic (Gentamicin) into the middle ear (through the eardrum) is used to control dizziness. Gentamicin is toxic to certain cells within the inner ear that are thought to cause the dizziness symptoms. This is done in the office over a period of several days or weeks. It may cause hearing loss and imbalance and is best used in individuals with poorer hearing.
• Meniette device- This is a portable air pressure pulse generator that is marketed in the U.S. by Medtronic. How it works is not fully understood but it may act by forcing the excess endolymphatic fluid in the inner ear back into the endolymphatic sac.
• Endolymphatic sac decompression – This procedure places a small tube into the endolymphatic sac (inner ear) to relieve pressure in the sac. It is successful in controlling dizziness in 65-70% of patients. Over time, dizziness may recur because the tube becomes blocked or non-functional.
• Selective vestibular neurectomy- The balance nerve is cut as it leaves the inner ear to the brain. Vertigo is controlled in the majority (90-95%) of patients. Although the hearing nerve is spared, hearing loss may occur. This procedure is usually considered when an individual has good hearing, or has continued vertigo after an endolymphatic sac decompression.

Labyrinthectomy – The balance canal is removed, eliminating balance and hearing in that ear. This procedure may be recommended when there is poor hearing in the affected ear. Vertigo is controlled in most patients (90-95%), however all hearing is lost in that ear. Some individuals such as the elderly, those with poor vision or other brain dysfunction, should consider other procedures as they are more likely to have persistent difficulty with balance following this procedure.

Surfer’s Ear (Exostosis)

Exostosis, also known as surfer’s ear, is a condition in which there is overgrowth of bone in the external ear canal. This results in narrowing of the diameter of the ear canal leading to water trapping, recurrent ear infections and eventually hearing loss. The most common cause of this condition is frequent exposure to cold temperatures such as from cold water when surfing or diving, or from cold wind while sailing or kayaking.

Once the bone growth occurs, it is irreversible. It may result in complete closure of the ear canal. It usually affects both ears, but may affect one side more than the other.

Treatment for early stages of this condition is protection from cold temperatures; using a hat, swim cap, hood or earplugs. Avoiding water exposure in the ear canals is important. Use of drops containing alcohol and vinegar or boric acid solution after water exposure, is helpful in preventing infection. Use of a blow dryer to dry the ear canal may also reduce the frequency of ear infections.

In more advanced stages, surgical removal of the bony growths is generally indicated. Indications for surgery are repeated ear infections and water trapping, hearing loss and development of cholesteatoma. Cholesteatoma of the ear canal may develop when earwax, debris and skin become trapped in the ear canal. This results in an expanding growth of skin, that causes a destructive process, involving the adjoining bone of ear canal and can progress to the middle ear and even the brain.

Hearing loss caused by advanced exostosis is usually reversible because it causes a conductive (sound cannot reach or be conducted to the inner ear) hearing loss rather than nerve loss.

Surgery for Exostosis:

Surgery to remove exostosis or surfer’s ear is called canaloplasty. It is generally performed as an outpatient “same day” procedure at a surgery center. Most procedures are performed under general anesthesia. An audiogram (hearing test) is performed and a CT scan may be ordered prior to the procedure.

There are two approaches to the surgery. The first uses the natural opening of the ear canal to reach the growths and the second uses a small incision behind the ear (within the crease behind the external ear). A chisel and/or a surgical drill are used to remove the excess bone growths. On occasion, a small skin graft is used to cover the surface of the ear canal to help with healing. The size and location of the growths influence which approach the surgeon uses.

Most individuals may return to work and exercise in a few days after surgery. The ear canal must be kept dry during the healing process so, swimming and surfing should be avoided for 3-4 weeks after surgery. Post operative visits are generally scheduled 1 week and 1 month after the procedure.

Potential risks of canaloplasty include infection, especially if the ear is not kept dry, scar tissue formation and rarely, hearing loss. Regrowth of the exostosis occurs rarely, but may occur if there is repeated exposure to cold temperatures after surgery.

An Otolaryngologist is specifically trained and certified in the diagnosis, medical and surgical treatments for exostosis. Because of our location in North Coastal San Diego, we are fortunate to have gained a great deal of experience treating individuals with this condition. We look forward to helping treat others with surfer’s ear.

Benign Paroxysmal Positional Vertigo

“Loose crystals in the inner ear”

Benign paroxysmal positional vertigo (BPPV) is a very common cause for vertigo. Vertigo is the feeling that you or the world around you is spinning. Paroxysmal means that the vertigo comes in short, sudden spells. Positional means that the vertigo is triggered with a change in head position or with head movement.

The inner ear has 2 main functions hearing and balance. The anterior half is responsible for hearing while the posterior half is responsible for balance. The posterior half of the inner ear houses the vestibular organ, which includes 3 sets of fluid-filled channels (semicircular canals) on each side of the skull. These 3 channels are distributed in the X, Y and Z-axis and contain sensors to detect movement in any direction.

Within the vestibular organ there are tiny crystals of calcium carbonate. Movement of the head causes movement of the fluid and also crystals that in turn activate sensors signaling to the brain that the head position has changed. If the crystals become dislodged they can erroneously activate these same sensors. This mixed information disorients the brain causing the subjective feeling of rotation.

We rarely identify the cause of these crystals breaking loose but usual triggers include head trauma, colds, migraine, prolonged periods of lying in bed (illness, surgical procedures), diabetes or osteoporosis. Occasionally we will see it after a dental appointment when power instruments have been used and vibrations were transmitted to the ear.

Symptoms of BPPV include vertigo with head movement that lasts seconds to minutes. Some individuals experience nausea and occasionally, vomiting. The first episode is often the most severe and subsequent episodes less intense. A sense of imbalance may persist after the vertigo occurs and this can actually last for several weeks. Loss of hearing, vision changes and fainting are not associated with BPPV and should point to another diagnosis. If you are having intense symptoms try opening your eyes and focusing on an object as opposed to closing them. This allows you to suppress the spinning sensation by a mechanism called “visual fixation”.

Diagnosis of BPPV is made by examination in the office by the Dix-Hallpike or supine roll over test. Bedside examination involves lying down with the head rotated to the right and then the left side. A “positive” test is one in which the individual experiences vertigo and movement of the eyes called “nystagmus”.

Treatment involves performing an Epley or “repositioning” maneuvers which relocates the crystals into their original location within the inner ear. It involves a series of head movement which can be performed in the office as part of initial examination. There is a high rate of success, about 80%, after 1-3 treatments. The spinning sensation should be significantly diminished after the “repositioning” maneuver, however many individuals may experience some mild instability, or sensation of motion sickness, for a few hours or days following the procedure.
The procedure may be repeated if necessary. There are also self-repositioning techniques to do at home.

Without treatment, BPPV will generally go away with time but may take 1-2 weeks to resolve, followed by several weeks of a sensation of imbalance. If symptoms don’t resolve in this time other diagnosis should be considered.

Exercises may be recommended to help speed recovery from residual unsteadiness. Occasionally, balance therapy is prescribed. Very rarely the condition can become chronic and even less commonly surgery is recommended.

Return to normal activities is encouraged following repositioning maneuvers, however precautions against falling should be observed, especially in older individuals or those with residual unsteadiness.

BPPV may come back, unfortunately nobody can predict when or if it will ever recur. Regardless each episode is treated in the same way as the initial occurrence.

Medications are generally not indicated for BPPV except to temporarily treat immediate symptoms, such as nausea. Audiograms X-rays, scans and laboratory testing are not needed to confirm the diagnosis of BPPV but may be indicated for other causes of vertigo or if there are other associated symptoms.