Middle ear surgery

What conditions does it treat?

• Otitis media (middle ear infections), especially long-term or repeated infections
• A perforated (torn) eardrum that hasn't healed on its own after around 2 to 3 months
• Cholesteatoma, a sac of dead skin cells that forms in the middle ear, slowly grows, and can cause smelly discharge and hearing loss
• Problems with the tiny hearing bones (ossicles), including damage from infection, injury or gradual wear
• Chronic ear drainage or fluid build-up

Both children and adults can need these operations, though the underlying cause often differs. Children more often need surgery because of repeated ear infections or a perforated eardrum, while adults may need it after infection, injury, or gradual wear of the hearing bones.

What are the benefits?

• It can restore hearing that's been affected by a hole in the eardrum or damaged hearing bones
• Repairing the eardrum also helps stop germs getting into the middle ear, reducing the risk of further infections and discharge
• For a cholesteatoma, surgery removes it and stops the discharge, and it may be possible to improve your hearing at the same time
• Success rates are generally good: studies suggest tympanoplasty successfully treats around 80% to 90% of people, though this depends on the size and position of the problem being treated

Are there different types of surgery?

• Myringoplasty: repairs a hole in the eardrum only
• Ossiculoplasty: repairs or replaces the tiny hearing bones, sometimes with a synthetic substitute or a small piece of your own bone
• Tympanoplasty: a more complete repair of both the eardrum and the hearing bones together
• Mastoid surgery (mastoidectomy): removes a cholesteatoma, and sometimes part of the mastoid bone behind the ear; this can be combined with a tympanoplasty if there's chronic infection

The way your surgeon reaches your eardrum also varies: some operations are done entirely through the ear canal without any visible cut, while others need a small incision either behind the ear or, less often, just above the ear canal.

What happens before the operation?

You'll have an initial consultation where your surgeon reviews your medical history and examines your ear.

• An otoscope exam, to see the size and position of any hole and check for inflammation or fluid
• A hearing test and a test of how your eardrum moves, and sometimes a CT scan
• A discussion of the risks, benefits and recovery process, with the chance to ask questions

You'll be given fasting instructions and told which medicines to take or avoid beforehand, and you may need a small area of hair clipped behind your ear. You'll be asked to sign a consent form, and you'll need to arrange for someone to take you home afterwards, since you'll usually have a general anaesthetic. If you're having surgery for a cholesteatoma, stopping smoking, keeping to a healthy weight and staying active beforehand can help lower your risk of complications.

What happens during the procedure?

1. You're given a general anaesthetic, so you're asleep throughout.
2. Your surgeon reaches your eardrum either through your ear canal with no visible cut, or through a small incision behind your ear or, less often, just above it.
3. If your eardrum needs repairing, a small graft, often taken from tissue near your temple or cartilage from the front of your ear, is placed over the hole.
4. If your hearing bones need repairing, they're reshaped, repositioned or replaced, sometimes with a synthetic substitute.
5. If you have a cholesteatoma, your surgeon removes bone around it to see how far it's spread, then removes it. If needed, the bone behind your ear is reshaped into a cavity connected to your ear canal.
6. Packing material is placed to hold everything in position while it heals, and any incisions are closed. The whole procedure can take anywhere from around 20 minutes for a small repair to 2 to 3 hours or more for more complex surgery.

What does recovery look like?

In hospital

Many people go home the same day, though some stay overnight so the team can check on healing, especially after more involved surgery. You'll usually have a dressing or bandage on your ear, which is removed before you go home or at a follow-up visit.

At home

In the first few days, some bloody discharge, mild pain or pressure, popping or crackling sounds, and reduced hearing are common and usually settle on their own. Initial healing generally takes around 2 weeks, though your hearing can take longer to fully settle, sometimes up to 6 weeks after eardrum repair or 3 months or more after mastoid surgery.

• Keep your ear completely dry, using cotton wool and petroleum jelly in the shower, and avoid swimming until your surgeon confirms it's healed
• Avoid blowing your nose forcefully for a few weeks; sneeze with your mouth open instead
• Avoid strenuous exercise, heavy lifting and sudden head movements until you've been told it's safe
• Avoid flying for a month or more, because of the pressure changes involved
• Return to work or school is often possible after a few days to a few weeks, depending on the surgery and your job

You'll usually have a follow-up appointment between 1 and 6 weeks after surgery to check your healing, with a further hearing check some months later.

What are the risks and complications?

• Bleeding, infection, an allergic reaction to equipment or medication, and rarely a blood clot in the leg or lung
• The graft not taking, meaning the hole doesn't heal, which is the most common complication
• Your hearing may not improve, and can occasionally get worse or, very rarely, be lost completely
• Temporary unsteadiness or dizziness for a short time; rarely, this lasts longer
• A small risk of injury to the nerve controlling your facial muscles, which runs through the middle ear; surgeons use a monitor to help protect it, and any weakness is usually temporary
• Changes to your sense of taste and ringing in the ear (tinnitus), usually temporary
• Ear discharge that can continue from time to time, even once healed
• For a cholesteatoma specifically: a small risk that not all of the disease is removed, or that it returns later, and rare but serious complications including infection spreading to the bone behind the ear, the brain, or the neck