Cochlear Implants up^

A cochlear implant is an electronic device that restores partial hearing to the deaf. It is surgically implanted in the inner ear and activated by a device worn outside the ear. Unlike a hearing aid, it does not make sound louder or clearer. Instead, the device bypasses damaged parts of the auditory system and directly stimulates the nerve of hearing, allowing individuals who are profoundly hearing impaired to receive sound.

Your ear consists of three parts that play a vital role in hearing - the external ear, middle ear, and inner ear.

• Conductive hearing: Sound travels along the ear canal of the external ear causing the ear drum to vibrate. Three small bones of the middle ear conduct this vibration from the ear drum to the cochlea (auditory chamber) of the inner ear.

• Sensorineural hearing: When the three small bones move, they start waves of fluid in the cochlea, and these waves stimulate more than 16,000 delicate hearing cells (hair cells). As these hair cells move, they generate an electrical current in the auditory nerve. It travels through inter-connections to the brain area that recognizes it as sound.

If you have disease or obstruction in your external or middle ear, your conductive hearing may be impaired. Medical or surgical treatment can probably correct this.

An inner ear problem, however, can result in a sensorineural impairment or nerve deafness. In most cases, the hair cells are damaged and do not function. Although many auditory nerve fibers may be intact and can transmit electrical impulses to the brain, these nerve fibers are unresponsive because of hair cell damage. Since severe sensorineural hearing loss cannot be corrected with medicine, it can be treated only with a cochlear implant.

Cochlear implants bypass damaged hair cells and convert speech and environmental sounds into electrical signals and send these signals to the hearing nerve.

The implant consists of a small electronic device, which is surgically implanted under the skin behind the ear and an external speech processor, which is usually worn on a belt or in a pocket. A microphone is also worn outside the body as a headpiece behind the ear to capture incoming sound. The speech processor translates the sound into distinctive electrical signals. These 'codes' travel up a thin cable to the headpiece and are transmitted across the skin via radio waves to the implanted electrodes in the cochlea. The electrodes' signals stimulate the auditory nerve fibers to send information to the brain where it is interpreted as meaningful sound.

Implants are designed only for individuals who attain almost no benefit from a hearing aid. They must be two years of age or older (unless childhood meningitis is responsible for deafness).

Otolaryngologists (ear, nose, and throat specialists) perform implant surgery, though not all of them do this procedure. Your local doctor can refer you to an implant clinic for an evaluation. The evaluation will be done by an implant team (an otolaryngologist, audiologist, nurse, and others) that will give you a series of tests:

• Ear (otologic) evaluation: The otolaryngologist examines the middle and inner ear to ensure that no active infection or other abnormality precludes the implant surgery.

• Hearing (audiologic) evaluation: The audiologist performs an extensive hearing test to find out how much you can hear with and without a hearing aid.

• X-ray (radiographic) evaluation: Special X-rays are taken, usually computerized tomography (CT) or magnetic resonance imaging (MRI) scans, to evaluate your inner ear bone.

• Psychological evaluation: Some patients may need a psychological evaluation to learn if they can cope with the implant.

• Physical examination: Your otolaryngologist also gives a physical examination to identify any potential problems with the general anesthesia needed for the implant procedure.

Implant surgery is performed under general anesthesia and lasts from two to three hours. An incision is made behind the ear to open the mastoid bone leading to the middle ear. The procedure may be done as an outpatient, or may require a stay in the hospital, overnight or for several days, depending on the device used and the anatomy of the inner ear.

Is there care and training after the operation?

About one month after surgery, your team places the signal processor, microphone, and implant transmitter outside your ear and adjusts them. They teach you how to look after the system and how to listen to sound through the implant. Some implants take longer to fit and require more training. Your team will probably ask you to come back to the clinic for regular checkups and readjustment of the speech processor as needed.

Cochlear implants do not restore normal hearing, and benefits vary from one individual to another. Most users find that cochlear implants help them communicate better through improved lipreading, and over half are able to discriminate speech without the use of visual cues. There are many factors that contribute to the degree of benefit a user receives from a cochlear implant, including:

• how long a person has been deaf,
• the number of surviving auditory nerve fibers, and
• a patient's motivation to learn to hear.

Your team will explain what you can reasonably expect. Before deciding whether your implant is working well, you need to understand clearly how much time you must commit. A few patients do not benefit from implants.

The Food and Drug Administration (FDA) regulates cochlear implant devices for both adults and children and approves them only after thorough clinical investigation.

Be sure to ask your otolaryngologist for written information, including brochures provided by the implant manufacturers. You need to be fully informed about the benefits and risks of cochlear implants, including how much is known about how safe, reliable, and effective a device is, how often you must come back to the clinic for checkups, and whether your insurance company pays for the procedure.

More expensive than a hearing aid, the total cost of a cochlear implant including evaluation, surgery, the device, and rehabilitation is around $40,000. Most insurance companies provide benefits that cover the cost. (This is true whether or not the device has received FDA clearance or is still in trial.)

Ear Infections and Earache up^

Otitis media means inflammation of the middle ear. The inflammation occurs as a result of a middle ear infection. It can occur in one or both ears. Otitis media is the most frequent diagnosis recorded for children who visit physicians for illness. It is also the most common cause of hearing loss in children.

Although otitis media is most common in young children, it also affects adults occasionally. It occurs most commonly in the winter and early spring months.

Yes, it is serious because of the severe earache and hearing loss it can create. Hearing loss, especially in children, may impair learning capacity and even delay speech development. However, if it is treated promptly and effectively, hearing can almost always be restored to normal.

Otitis media is also serious because the infection can spread to nearby structures in the head, especially the mastoid. Thus, it is very important to recognize the symptoms (see list) of otitis media and to get immediate attention from your doctor.

The outer ear collects sounds. The middle ear is a pea sized, air-filled cavity separated from the outer ear by the paper-thin eardrum. Attached to the eardrum are three tiny ear bones. When sound waves strike the eardrum, it vibrates and sets the bones in motion that transmit to the inner ear. The inner ear converts vibrations to electrical signals and sends these signals to the brain. It also helps maintain balance.

A healthy middle ear contains air at the same atmospheric pressure as outside of the ear, allowing free vibration. Air enters the middle ear through the narrow eustachian tube that connects the back of the nose to the ear. When you yawn and hear a pop, your eustachian tube has just sent a tiny air bubble to your middle ear to equalize the air pressure.

Blockage of the eustachian tube during a cold, allergy, or upper respiratory infection and the presence of bacteria or viruses lead to the accumulation of fluid (a build-up of pus and mucus) behind the eardrum. This is the infection called acute otitis media. The build up of pressurized pus in the middle ear causes earache, swelling, and redness. Since the eardrum cannot vibrate properly, hearing problems may occur.

Sometimes the eardrum ruptures, and pus drains out of the ear. But more commonly, the pus and mucus remain in the middle ear due to the swollen and inflamed Eustachian tube. This is called middle ear effusion or serous otitis media. Often after the acute infection has passed, the effusion remains and becomes chronic, lasting for weeks, months, or even years. This condition makes one subject to frequent recurrences of the acute infection and may cause difficulty in hearing.

In infants and toddlers look for:

• pulling or scratching at the ear, especially if accompanied by other symptoms, including:

1. hearing problems
2. crying, irritability
3. fever
4. vomiting
5. ear drainage

In young children, adolescents, and adults look for:

• earache
• feeling of fullness or pressure
• hearing problems
• dizziness, loss of balance
• nausea, vomiting
• ear drainage
• fever

Remember, without proper treatment, damage from an ear infection can cause chronic or permanent hearing loss.

What will happen at the doctor's office?

During an examination, the doctor will use an instrument called an otoscope to assess the ear’s condition. With it, the doctor will perform an examination to check for redness in the ear and/or fluid behind the eardrum. With the gentle use of air pressure, the doctor can also see if the eardrum moves. If the eardrum doesn’t move and/or is red, an ear infection is probably present.

Two other tests may also be performed:

An audiogram tests if hearing loss has occurred by presenting tones at various pitches.

A tympanogram measures the air pressure in the middle ear to see how well the Eustachian tube is working and how well the eardrum can move.

The doctor may prescribe one or more medications. It is important that all the medication(s) be taken as directed and that any follow-up visits be kept. Often, antibiotics to fight the infection will make the earache go away rapidly, but the infection may need more time to clear up. So, be sure that the medication is taken for the full time your doctor has indicated. Other medications that your doctor may prescribe include an antihistamine (for allergies), a decongestant (especially with a cold), or both.

Sometimes the doctor may recommend a medication to reduce fever and/or pain. Analgesic ear drops can ease the pain of an earache. Call your doctor if you have any questions about you or your child’s medication or if symptoms do not clear.

Most of the time, otitis media clears up with proper medication and home treatment. In many cases, however, further treatment may be recommended by your physician. An operation, called a myringotomy may be recommended. This involves a small surgical incision (opening) into the eardrum to promote drainage of fluid and to relieve pain. The incision heals within a few days with practically no scarring or injury to the eardrum. In fact, the surgical opening can heal so fast that it often closes before the infection and the fluid are gone. A ventilation tube can be placed in the incision, preventing fluid accumulation and thus improving hearing.

The surgeon selects a ventilation tube for your child that will remain in place for as long as required for the middle ear infection to improve and for the eustachian tube to return to normal. This may require several weeks or months. During this time, you must keep water out of the ears because it could start an infection. Otherwise, the tube causes no trouble, and you will probably notice a remarkable improvement in hearing and a decrease in the frequency of ear infections.

Otitis media may recur as a result of chronically infected adenoids and tonsils. If this becomes a problem, your doctor may recommend removal of one or both. This can be done at the same time as ventilation tubes are inserted.

Allergies may also require treatment.

Otitis media is generally not serious if it is promptly and properly treated. With the help of your physician, you and/or your child can feel and hear better very soon.

Be sure to follow the treatment plan, and see your physician until he/she tells you that the condition is fully cured.

Painful ear infections are a rite of passage for children – by the age of five, nearly every child has experienced at least one episode. Most ear infections either resolve on their own (viral) or are effectively treated by antibiotics (bacterial). But sometimes, ear infections and/or fluid in the middle ear may become a chronic problem leading to other issues such as hearing loss, behavior, and speech problems. In these cases, insertion of an ear tube by an otolaryngologist (ear, nose, and throat surgeon) may be considered.

Ear tubes are tiny cylinders placed through the ear drum (tympanic membrane) to allow air into the middle ear. They also may be called tympanostomy tubes, myringotomy tubes, ventilation tubes, or PE (pressure equalization) tubes.

These tubes can be made out of plastic, metal, or Teflon and may have a coating intended to reduce the possibility of infection. There are two basic types of ear tubes: short-term and long-term. Short- term tubes are smaller and typically stay in place for six months to a year before falling out on their own. Long-term tubes are larger and have flanges that secure them in place for a longer period of time. Long term tubes may fall out on their own, but removal by an otolaryngologist is often necessary.

Who needs ear tubes and why?

Ear tubes are often recommended when a person experiences repeated middle ear infection (acute otitis media) or has hearing loss caused by the persistent presence of middle ear fluid (otitis media with effusion). These conditions most commonly occur in children, but can also be present in teens and adults and can lead to speech and balance problems, hearing loss, or changes in the structure of the ear drum. Other less common conditions that may warrant the placement of ear tubes are malformation of the ear drum or Eustachian tube, Down Syndrome, cleft palate, and barotrauma (injury to the middle ear caused by a reduction of air pressure), usually seen with altitude changes such as flying and scuba diving.

Each year, more than half a million ear tube surgeries are performed on children, making it the most common childhood surgery performed with anesthesia. The average age of ear tube insertion is one to three years old. Inserting ear tubes may:

• reduce the risk of future ear infection,
• restore hearing loss caused by middle ear fluid,
• improve speech problems and balance problems, and
• improve behavior and sleep problems caused by chronic ear infections.

How are ear tubes inserted in the ear?

Ear tubes are inserted through an outpatient surgical procedure called a myringotomy. A myringotomy refers to an incision (a hole) in the ear drum or tympanic membrane. This is most often done under a surgical microscope with a small scalpel (tiny knife), but it can also be accomplished with a laser. If an ear tube is not inserted, the hole would heal and close within a few days. To prevent this, an ear tube is placed in the hole to keep it open and allow air to reach the middle ear space (ventilation).

What happens during surgery?

A light general anesthetic (laughing gas) is administered for young children. Some older children and adults may be able to tolerate the procedure without anesthetic. A myringotomy is performed and the fluid behind the ear drum (in the middle ear space) is suctioned out. The ear tube is then placed in the hole. Ear drops may be administered after the ear tube is placed and may be necessary for a few days. The procedure usually lasts less than 15 minutes and patients awaken quickly.

Sometimes the otolaryngologist will recommend removal of the adenoid tissue (lymph tissue located in the upper airway behind the nose) when ear tubes are placed. This is often considered when a repeat tube insertion is necessary. Current research indicates that removing adenoid tissue concurrent with placement of ear tubes can reduce the risk of recurrent ear infection and the need for repeat surgery.

What to expect after surgery

After surgery, the patient is monitored in the recovery room and will usually go home within an hour if no complications are present. Patients usually experience little or no postoperative pain but grogginess, irritability, and/or nausea from the anesthesia can occur temporarily.

Hearing loss caused by the presence of middle ear fluid is immediately resolved by surgery. Sometimes children can hear so much better that they complain that normal sounds seem too loud.

The otolaryngologist will provide specific postoperative instructions for each patient including when to seek immediate attention and follow-up appointments. He or she may also prescribe antibiotic ear drops for a few days.

To avoid the possibility of bacteria entering the middle ear through the ventilation tube, physicians may recommend keeping ears dry by using ear plugs or other water-tight devices during bathing, swimming, and water activities. However, recent research suggests that protecting the ear may not be necessary, except when diving or engaging in water activities in unclean water such as lakes and rivers. Parents should consult with the treating physician about ear protection after surgery.

Consultation with an otolaryngologist (ear, nose, and throat surgeon) may be warranted if you or your child has experienced repeated or severe ear infections, ear infections that are not resolved with antibiotics, hearing loss due to fluid in the middle ear, barotrauma, or have an anatomic abnormality that inhibits drainage of the middle ear.

Possible complications

Myringotomy with insertion of ear tubes is an extremely common and safe procedure with minimal complications. When complications do occur, they may include:

• Perforation – This can happen when a tube comes out or a long-term tube is removed and the hole in the tympanic membrane (ear drum) does not close. The hole can be patched through a minor surgical procedure called a tympanoplasty or myringoplasty.
• Scarring – Any irritation of the ear drum (recurrent ear infections), including repeated insertion of ear tubes, can cause scarring called tympanosclerosis or myringosclerosis. In most cases, this causes no problems with hearing.
• Infection – Ear infections can still occur in the middle ear or around the ear tube. However, these infections are usually less frequent, result in less hearing loss, and are easier to treat – often only with ear drops. Sometimes an oral antibiotic is still needed.
• Ear tubes come out too early or stay in too long – If an ear tube expels from the ear drum too soon (which is unpredictable), fluid may return and repeat surgery may be needed. Ear tubes that remain too long may result in perforation or may require removal by the otolaryngologist.

Ear problems are the most common medical complaint of airplane travelers, and while they are usually simple, minor annoyances, they may result in temporary pain and hearing loss. Make air travel comfortable by learning how to equalize the pressure in the ears instead of suffering from an uncomfortable feeling of fullness or pressure.

Normally, swallowing causes a little click or popping sound in the ear. This occurs because a small bubble of air has entered the middle ear, up from the back of the nose. It passes through the Eustachian tube, a membrane-lined tube about the size of a pencil lead that connects the back of the nose with the middle ear. The air in the middle ear is constantly being absorbed by its membranous lining and re-supplied through the Eustachian tube. In this manner, air pressure on both sides of the eardrum stays about equal. If, and when, the air pressure is not equal the ear feels blocked.

The Eustachian tube can be blocked, or obstructed, for a variety of reasons. When that occurs, the middle ear pressure cannot be equalized. The air already there is absorbed and a vacuum occurs, sucking the eardrum inward and stretching it. Such an eardrum cannot vibrate naturally, so sounds are muffled or blocked, and the stretching can be painful. If the tube remains blocked, fluid (like blood serum) will seep into the area from the membranes in an attempt to overcome the vacuum. This is called “fluid in the ear,” serous otitis or aero-otitis.

The most common cause for a blocked Eustachian tube is the common cold. Sinus infections and nasal allergies are also causes. A stuffy nose leads to stuffy ears because the swollen membranes block the opening of the Eustachian tube.

Air travel is sometimes associated with rapid changes in air pressure. To maintain comfort, the Eustachian tube must open frequently and wide enough to equalize the changes in pressure. This is especially true when the airplane is landing, going from low atmospheric pressure down closer to earth where the air pressure is higher.

Actually, any situation in which rapid altitude or pressure changes occur creates the problem. It may be experienced when riding in elevators or when diving to the bottom of a swimming pool. Deep sea divers, as well as pilots, are taught how to equalize their ear pressure. Anybody can learn the trick too.

Swallowing activates the muscles that open the Eustachian tube. Swallowing occurs more often when chewing gum or when sucking on hard candies. These are good air travel practices, especially just before take-off and during descent. Yawning is even better. Avoid sleeping during descent because swallowing may not occur often enough to keep up with the pressure changes.

If yawning and swallowing are not effective, pinch the nostrils shut, take a mouthful of air, and direct the air into the back of the nose as if trying to blow the nose gently. The ears have been successfully unblocked when a pop is heard. This may have to be repeated several times during descent.

Even after landing, continue the pressure equalizing techniques and the use of decongestants and nasal sprays. If the ears fail to open or if pain persists, seek the help of a physician who has experience in the care of ear disorders. The ear specialist may need to release the pressure or fluid with a small incision in the ear drum.

Babies cannot intentionally pop their ears, but popping may occur if they are sucking on a bottle or pacifier. Feed the baby during the flight, and do not allow him or her to sleep during descent. Children are especially vulnerable to blockages because their Eustachian tubes are narrower than in adults.

Is the use of decongestants and nose sprays recommended?

Many experienced air travelers use a decongestant pill or nasal spray an hour or so before descent. This will shrink the membranes and help the ears pop more easily. Travelers with allergy problems should take their medication at the beginning of the flight for the same reason. However, avoid making a habit of nasal sprays. After a few days, they may cause more congestion than relief.

Decongestant tablets and sprays can be purchased without a prescription. However, they should be avoided by people with heart disease, high blood pressure, irregular heart rhythms, thyroid disease, or excessive nervousness. Such people should consult their physicians before using these medicines. Pregnant women should likewise consult their physicians first.

• Consult with a surgeon on how soon after ear surgery it is safe to fly.
• Postpone an airplane trip if a cold, sinus infection, or an allergy attack is present.
• Patients in good health can take a decongestant pill or nose spray approximately an hour before descent to help the ears pop more easily.
• Avoid sleeping during descent.
• Chew gum or suck on a hard candy just before take-off and during descent.
• When inflating the ears, do not use force. The proper technique involves only pressure created by the cheek and throat muscles.

Good intentions to keep ears clean may be risking the ability to hear. The ear is a delicate and intricate area, including the skin of the ear canal and the eardrum. Therefore, special care should be given to this part of the body. Start by discontinuing the use of cotton-tipped applicators and the habit of probing the ears.

Why does the body produce earwax?

Cerumen or earwax is healthy in normal amounts and serves to coat the skin of the ear canal where it acts as a temporary water repellent. The absence of earwax may result in dry, itchy ears. Most of the time the ear canals are self-cleaning; that is, there is a slow and orderly migration of ear canal skin from the eardrum to the ear opening. Old earwax is constantly being transported from the ear canal to the ear opening where it usually dries, flakes, and falls out.

Earwax is not formed in the deep part of the ear canal near the eardrum, but in the outer part of the canal. So when a patient has wax blockage against the eardrum, it is often because he has been probing the ear with such things as cotton-tipped applicators, bobby pins, or twisted napkin corners. These objects only push the wax in deeper.

What is the recommended method of ear cleaning?

Under ideal circumstances, the ear canals should never have to be cleaned. However, that isn’t always the case. To clean the ears, wash the external ear with a cloth, but do not insert anything into the ear canal.

Most cases of ear wax blockage respond to home treatments used to soften wax. Patients can try placing a few drops of mineral oil, baby oil, glycerin, or commercial drops, such as Debrox® or Murine® Ear Drops in the ear. These remedies are not as strong as the prescription wax softeners but are effective for many patients. Rarely, people have allergic reactions to commercial preparations.

Detergent drops such as hydrogen peroxide or carbamide peroxide may also aid in the removal of wax. Rinsing the ear canal with hydrogen peroxide (H2O2) results in oxygen bubbling off and water being left behind—wet, warm ear canals make good incubators for growth of bacteria. Flushing the ear canal with rubbing alcohol displaces the water and dries the canal skin. If alcohol causes severe pain, it suggests the presence of an eardrum perforation.

Why shouldn’t cotton swabs be used to clean earwax?

Wax blockage is one of the most common causes of hearing loss. This is often caused by attempts to clean the ear with cotton swabs. Most cleaning attempts merely push the wax deeper into the ear canal, causing a blockage.

The outer ear is the funnel-like part of the ear that can be seen on the side of the head, plus the ear canal (the hole which leads down to the eardrum). The ear canal is shaped somewhat like an hourglass—narrowing part way down. The skin of the outer part of the canal has special glands that produce earwax. This wax is supposed to trap dust and dirt particles to keep them from reaching the eardrum. Usually the wax accumulates a bit, dries out, and then comes tumbling out of the ear, carrying dirt and dust with it. Or it may slowly migrate to the outside where it can be wiped off.

What are the symptoms of wax buildup?

• Partial hearing loss, may be progressive
• Tinnitus, noises in the ear
• Earache
• Fullness in the ear or a sensation the ear is plugged

Are ear candles an option for removing wax build up?

No, ear candles are not a safe option of wax removal as they may result in serious injury. Since users are instructed to insert the 10” to 15”-long, cone-shaped, hollow candles, typically made of wax-impregnated cloth, into the ear canal and light the exposed end, some of the most common injuries are burns, obstruction of the ear canal with wax, or perforation of the membrane that separates the ear canal and the middle ear.

Even though ear candling is an ancient practice with the intent to treat a wide variety of ear maladies including cerumen impactions, ear infections, hearing loss, tinnitus, Ménière’s disease, sinusitis, headaches, inhalant allergies, and many other conditions, the FDA has never cleared or approved marketing the products as a medical treatment.

Are ear candles approved by the U.S. Food and Drug Administration?

The U.S. Food and Drug Administration (FDA) became concerned about the safety issues with ear candles after receiving reports of patient injury caused by the ear candling procedure. Although there are proponents who argue in favor of the use of ear candles, the FDA is unaware of any controlled studies or other scientific evidence that support the safety and effectiveness of these devices for any of the purported claims or intended uses as contained in the labeling.

Based on the growing concern associated with the manufacture, marketing, and use of ear candles, the FDA has undertaken several successful regulatory actions, including product seizures and injunctions, since 1996. These actions were based, in part, upon violations of the Food, Drug, and Cosmetic Act that pose an imminent danger to health.

When should a doctor be consulted?

If the home treatments discussed in this leaflet are not satisfactory, or if wax has accumulated so much that it blocks the ear canal (and hearing), a physician may prescribe eardrops designed to soften wax, or he may wash or vacuum it out. Occasionally, an otolaryngologist (ear, nose, and throat specialist) may need to remove the wax using microscopic visualization.

If there is a possibility of a hole (perforation or puncture) in the eardrum, consult a physician prior to trying any over-the-counter remedies. Putting eardrops or other products in the ear with the presence of an eardrum perforation may cause an infection. Certainly, washing water through such a hole could start an infection.

The ear has three main parts: the outer, middle and inner ear. The outer ear (the part you can see) opens into the ear canal. The eardrum separates the ear canal from the middle ear. Small bones in the middle ear help transfer sound to the inner ear. The inner ear contains the auditory (hearing) nerve, which leads to the brain.

Any source of sound sends vibrations or sound waves into the air. These funnel through the ear opening, down the ear, canal, and strike your eardrum, causing it to vibrate. The vibrations are passed to the small bones of the middle ear, which transmit them to the hearing nerve in the inner ear. Here, the vibrations become nerve impulses and go directly to the brain, which interprets the impulses as sound (music, voice, a car horn, etc.).

Perforated Eardrum up^

A perforated eardrum is a hole or rupture in the eardrum, a thin membrane that separates the ear canal and the middle ear. The medical term for eardrum is tympanic membrane. The middle ear is connected to the nose by the Eustachian tube, which equalizes pressure in the middle ear.

A perforated eardrum is often accompanied by decreased hearing and occasional discharge. Pain is usually not persistent.

The causes of perforated eardrum are usually from trauma or infection. A perforated eardrum can occur:

Middle ear infections may cause pain, hearing loss, and spontaneous rupture (tear) of the ear-drum resulting in a perforation. In this circumstance, there maybe infected or bloody drainage from the ear. In medical terms, this is called otitis media with perforation.

On rare occasions a small hole may remain in the eardrum after a previously placed PE tube (pressure equalizing) either falls out or is removed by the physician.

Most eardrum perforations heal spontaneously within weeks after rupture, although some may take up to several months. During the healing process the ear must be protected from water and trauma. Those eardrum perforations which do not heal on their own may require surgery.

Usually, the larger the perforation, the greater the loss of hearing. The location of the hole (perforation) in the eardrum also effects the degree of hearing loss. If severe trauma (e.g. skull fracture) disrupts the bones in the middle ear which transmit sound or causes injury to the inner ear structures, the loss of hearing maybe quite severe.

If the perforated eardrum is due to a sudden traumatic or explosive event, the loss of hearing can be great and ringing in the ear (tinnitus) may be severe. In this case the hearing usually returns partially, and the ringing diminishes in a few days. Chronic infection as a result of the perforation can cause major hearing loss.

Before attempting any correction of the perforation, a hearing test should be performed. The benefits of closing a perforation include prevention of water entering the ear while showering, bathing, or swimming (which could cause ear infection), improved hearing, and diminished tinnitus. It also may prevent the development of cholesteatoma (skin cyst in the middle ear), which can cause chronic infection and destruction of ear structures.

If the perforation is very small, otolaryngologists may choose to observe the perforation over time to see if it will dose spontaneously. They also might try to patch a cooperative patient's eardrum in the office. Working with a microscope, your doctor may touch the edges of the eardrum with a chemical to stimulate growth and then place a thin paper patch on the eardrum. Usually with closure of the tympanic membrane improvement in hearing is noted. Several applications of a patch (up to three or four) may be required before the perforation doses completely. if your physician feels that a paper patch will not provide prompt or adequate closure of the hole in the eardrum, or attempts with paper patching do not promote healing, surgery is considered.

There are a variety of surgical techniques, but all basically place tissue across the perforation allowing healing. The name of this procedure is called tympanoplasty. Surgery is typically quite successful in closing the perforation permanently, and improving hearing. It is usually done on an outpatient basis.

Your doctor will advise you regarding the proper management of a perforated eardrum.

Protruding and drooping ears or torn earlobes can be surgically corrected. Exceptionally large ears or those that stick out make children vulnerable to teasing. These procedures do not alter the patient's hearing, but they may improve appearance and self-confidence.

Corrective surgery, called otoplasty, should be considered on ears which stick out more than 4/5 of an inch (2 cm) from the back of the head. It can be performed at any age after the ears have reached full size, usually at five or six years of age. Having the surgery at a young age has two benefits: the cartilage is more pliable, making it easier to reshape, and the child will experience the psychological benefits of the cosmetic improvement. However, a patient may have the surgery at any age.

The surgery begins with an incision behind the ear, in the fold where the ear joins the head. The surgeon may remove skin and cartilage or trim and reshape the cartilage. In addition to correcting protrusion, ears may also be reshaped, reduced in size, or made more symmetrical. The cartilage is then secured in the new position with permanent stitches which will anchor the ear while healing occurs.

Typically otoplasty surgery takes about two hours. The soft dressings over the ears will be used for a few weeks as protection, and the patient usually experiences only mild discomfort. Headbands are sometimes recommended to hold the ears in place for a month following surgery or may be prescribed for nighttime wear only.

The "fold" of hard, raised cartilage that gives shape to the upper portion of the ear does not form in all people. This is called "lop-ear deformity," and it is inherited. The absence of the fold can cause the ear to stick out or flop down. To correct this problem, the surgeon places permanent stitches in the upper ear cartilage and ties them in a way that creates a fold and props the ear up. Scar tissue will form later, holding the fold in place.

Some infants are born without an opening in their middle ear. These ears can be surgically opened, and the outer ear reshaped to look like the other ear. This procedure will restore hearing if the inner ear is intact.

Those who are born without an ear, or lose an ear due to injury, can have an artificial ear surgically attached for cosmetic reasons. These are custom formed to match the patient's other ear. Alternatively, rib cartilage or a biomedical implant, in addition to the patient's own soft tissue, can be used to construct a new ear.

Many mothers have had their earlobes torn by a baby's tug on their earrings. Earrings also catch on clothing and other objects, resulting in torn earlobes. These tears can be easily repaired surgically, usually in the doctor's office. In severe cases, the surgeon may cut a small triangular notch at the bottom of the lobe. A matching flap is then created from tissue on the other side of the tear, and the two wedges are fitted together and stitched.

Earlobes usually heal quickly with minimal scarring. In most cases, the earlobe can be pierced again four to six weeks after surgery to receive light-weight earrings.

Insurance usually does not cover surgery solely for cosmetic reasons. However, insurance may cover, in whole or in part, surgery to correct a congenital or traumatic defect. Before cosmetic ear surgery, discuss the procedure with your insurance carrier to determine what coverage, if any, you can expect.

Feeling unsteady or dizzy can happen due to poor circulation, vertigo, injury, infection, allergies, or neurological disease. Dizziness is treatable but it is important for your doctor to help you determine the cause so that the correct treatment is used. While each person will be affected differently, symptoms that warrant a visit to the doctor include a high fever, severe headache, convulsions or ongoing vomiting, chest pain, heart palpitations, shortness of breath, inability to move an arm or leg, a change in vision or speech, or hearing loss.

What is dizziness?

Dizziness can be described in many ways, such as feeling lightheaded, unsteady, or giddy. Vertigo is a type of dizziness experienced as an illusion of movement of self or the environment and is usually unpleasant. Others experience dizziness associated with motion sickness, a nauseating feeling brought on by the motion of riding in an airplane, on a roller coaster, or aboard a boat. Dizziness, vertigo, and motion sickness all relate to the sense of balance and equilibrium. Your sense of balance is maintained by a complex interaction of the following parts of the nervous system:

• The inner ears (also called the labyrinth), which monitor the directions of motion, such as turning, rolling, forward-backward, side-to-side, and up-and-down motions.
• The eyes, which monitor where the body is in space (i.e., upside down, right side up, etc.) and also directions of motion.
• The skin pressure receptors in the joints and spine, which tell what part of the body is down and touching the ground.
• The muscle and joint sensory receptors, which tell what parts of the body are moving.
• The central nervous system (the brain and spinal cord), which processes all the bits of information from the four other systems to make some coordinated sense out of it all.
• The symptoms of motion sickness and dizziness appear when the central nervous system receives conflicting messages from the other four systems.

Circulation: If your brain does not get enough blood flow, you feel lightheaded. Almost everyone has experienced this on occasion when standing up quickly from a lying down position. But some people have light-headedness from poor circulation on a frequent or chronic basis. This could be caused by arteriosclerosis or hardening of the arteries, and it is commonly seen in patients who have high blood pressure, diabetes, or high levels of blood fats (cholesterol). It is sometimes seen in patients with inadequate cardiac (heart) function, hypoglycemia (low blood sugar), or anemia (low iron).

Certain drugs also decrease the blood flow to the brain, especially stimulants such as nicotine and caffeine. Excess salt in the diet also leads to poor circulation. Sometimes circulation is impaired by spasms in the arteries caused by emotional stress, anxiety, and tension.

If the inner ear fails to receive enough blood flow, the more specific type of dizziness occurs, that is, vertigo. The inner ear is very sensitive to minor alterations of blood flow and all of the causes mentioned for poor circulation to the brain also apply specifically to the inner ear.

Vertigo: Benign paroxysmal positional vertigo (BPPV), labyrinthitis, and Ménière’s syndrome (fluctuating hearing usually in one ear, pressure in the ear, ringing in one ear, and attacks of spinning), and some forms of migraine are all causes of vertigo. BPPV occurs when you change the position of your head (typically lying down or sitting up), while inner ear infections can cause labyrinthitis.

Injury: A skull fracture that damages the inner ear produces a profound and incapacitating vertigo with nausea and hearing loss. The dizziness will last for several weeks, and then slowly improve as the normal (other) side takes over.

Infection: Viruses can attack the inner ear and its nerve connections to the brain. This can result in severe vertigo, but hearing is usually spared. However, a bacterial infection such as mastoiditis that extends into the inner ear will completely destroy both the hearing and the equilibrium function of that ear. The severity of dizziness and recovery time will be similar to that of a skull fracture.

Allergy: Some people experience dizziness and/or vertigo attacks when they are exposed to foods or airborne particles (such as dust, molds, pollens, dander, etc.) to which they are allergic.

Neurological diseases: A number of diseases of the nerves can affect balance, such as multiple sclerosis, syphilis, tumors, etc. These are uncommon causes, but your doctor will think about them during the examination.

When should I seek medical attention?

Call 911 or go to an emergency room if you experience:

• a head injury,
• fever over 101°F, headache, or very stiff neck,
• convulsions or ongoing vomiting,
• chest pain, heart palpitations, shortness of breath, weakness, a severe headache, inability to move an arm or leg, or change in vision or speech, or
• fainting and loss of consciousness for more than a few minutes.

Consult your doctor if you:

• have never experienced dizziness before,
• experience a difference in symptoms you have had in the past,
• suspect that medication is causing your symptoms, or experience hearing loss.

How will my dizziness be treated?

The doctor will ask you to describe your dizziness and answer questions about your general health. Along with these questions, your doctor will examine your ears, nose, and throat. Some routine tests will be performed to check your blood pressure, nerve and balance function, and hearing. Possible additional tests may include a CT or MRI scan of your head, special tests of eye motion after warm or cold water or air is used to stimulate the inner ear (ENG - electronystagmography or VNG - videonystagmography), and in some cases, blood tests or a cardiology (heart) evaluation. Your doctor will determine the best treatment based on your symptoms and the cause of them.

Prevention tips

• Avoid rapid changes in position.
• Avoid rapid head motion (especially turning or twisting).
• Eliminate or decrease use of products that impair circulation, e.g., tobacco, alcohol, caffeine, and salt.
• Minimize stress and avoid substances to which you are allergic.
• Get enough fluids
• Treat infections, including ear infections, colds, flu, sinus congestion, and other respiratory infections

If you are subject to motion sickness:

• Do not read while traveling.
• Do not sit in a seat facing backward.
• Do not watch or talk to another traveler who is having motion sickness.
• Avoid strong odors and spicy or greasy foods immediately before and during your travel.
• Talk to your doctor about medications.

Remember: Most cases of dizziness and motion sickness are mild and self-treatable. But, severe cases and those that become progressively worse deserve the attention of a doctor with specialized skills in diseases of the ear, nose, throat, equilibrium, and neurological systems.

What is Ménière’s disease?

Ménière’s disease, also called idiopathic endolymphatic hydrops, is a disorder of the inner ear. Although the cause is unknown, it probably results from an abnormality in the fluids of the inner ear. Ménière’s disease is one of the most common causes of dizziness originating in the inner ear. In most cases only one ear is involved, but both ears may be affected in about 15 percent of patients. Ménière’s disease typically starts between the ages of 20 and 50 years. Men and women are affected in equal numbers.

Although the cause is unknown, it probably results from an abnormality in the fluids of the inner ear. The theory is that too much inner ear fluid accumulates either due to excess production or inadequate absorption. In some individuals, especially those with involvement of both ears, allergies or autoimmune disorders may play a role in producing Ménière’s disease.

People with Ménière’s disease have a “sick” inner ear and are more sensitive to factors, such as fatigue and stress that may influence the frequency of attacks.

The physician will take a history of the frequency, duration, severity, and character of your attacks, the duration of hearing loss or whether it has been changing, and whether you have had tinnitus or fullness in either or both ears. When the history has been completed, diagnostic tests will check your hearing and balance functions. They may include:

For hearing: An audiometric examination (hearing test) typically indicates a sensory type of hearing loss in the affected ear. Speech discrimination (the patient’s ability to distinguish between words like “sit” and “fit”) is often diminished in the affected ear.

For balance: An ENG (electronystagmograph) may be performed to evaluate balance function. In a darkened room, recording electrodes are placed near the eyes. Warm and cool water or air is gently introduced into each ear canal. Since the eyes and ears work in coordination through the nervous system, measurement of eye movements can be used to test the balance system. In about 50 percent of patients, the balance function is reduced in the affected ear.

Rotational testing or balance platform, may also be performed to evaluate the balance system.

Other tests

Electrocochleography (ECoG) may indicate increased inner ear fluid pressure in some cases of Ménière’s disease.

The auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computed tomography (CT) or, magnetic resonance imaging (MRI) may be needed to rule out a tumor occurring on the hearing and balance nerve. Such tumors are rare, but they can cause symptoms similar to Ménière’s disease.

How is Ménière’s disease treated?

Treatment may include:

• a low salt diet and a diuretic (water pill)
• anti-vertigo medications, e.g., Antivert® (meclizine generic), or Valium® (diazepam generic)
• intratympanic injections
• a Meniette® device

Your otolaryngologist will help you choose the treatment that is best for you, as there are things to consider with each. For example, while anti-vertigo and anti-nausea medications will reduce dizziness, they may cause drowsiness. Other treatments also carry both positive implications as well as drawbacks. Intratympanic injections involve injecting medication through the eardrum into the middle ear space where the ear bones reside. This treatment is done in the otolaryngologist’s office. The treatment includes either making a temporary opening in the eardrum or placing a tube in the eardrum. The drug may be administered once or several times. Medication injected may include gentamicin or corticosteroids. Gentamicin alleviates dizziness but also carries the possibility of increased hearing loss in the treated ear that may occur in some individuals. Corticosteroids do not cause worsening of hearing loss, but are less effective in alleviating the major dizzy spells. A Meniette® device is another option. This device is a mechanical pump that is applied to the person’s ear canal for five minutes three times a day. A ventilating tube must be first inserted through the eardrum to allow the pressure produced by the Meniette® to be transmitted across the round window membrane and change the pressure in the inner ear. The success rate of this device has been variable.

When is surgery recommended?

If vertigo attacks are not controlled by conservative measures and are disabling, one of the following surgical procedures might be recommended:

The endolymphatic sac shunt or decompression procedure is an ear operation that usually preserves hearing. Attacks of vertigo are controlled in one-half to two-thirds of cases, but control is not permanent in all cases. Recovery time after this procedure is short compared to the other procedures.

Selective vestibular neurectomy is a procedure in which the balance nerve is cut as it leaves the inner ear and goes to the brain. While vertigo attacks are permanently cured in a high percentage of cases, patients may continue to experience imbalance. Similar to endolymphatic sac procedures, hearing function is usually preserved.

Labryrinthectomy and eighth nerve section are procedures in which the balance and hearing mechanism in the inner ear are destroyed on one side. This is considered when the patient with Ménière’s disease has poor hearing in the affected ear. Labryrinthectomy and eighth nerve section result in the highest rates for control of vertigo attacks.

Although there is no cure for Ménière’s disease, the attacks of vertigo can be controlled in nearly all cases.

What are the symptoms?

Symptoms of Ménière’s disease include episodic vertigo (attacks of a spinning sensation), hearing loss, tinnitus (a roaring, buzzing, or ringing sound in the ear), and a sensation of fullness in the affected ear.

Vertigo is often accompanied by nausea and vomiting. Attacks may last for 20 minutes to two hours or longer and fatigue and an off-balance sensation may last for hours to days. During attacks, patients may be unable to perform their usual activities, needing to lie down until the vertigo resolves.

Hearing loss is often intermittent, occurring mainly at the time of the attacks of vertigo. Loud sounds may seem distorted and cause discomfort. Usually, the hearing loss involves mainly the lower pitches, but over time this often affects tones of all pitches. After months or years of the disease, hearing loss often becomes permanent.

Tinnitus and fullness of the ear may come and go with changes in hearing, occur during or just before attacks, or be constant.

What should I do during an attack?

Lie flat and still and focus on an unmoving object. Often people fall asleep while lying down and feel better when they awaken.

How can I reduce the frequency of Ménière’s disease episodes?

Avoid stress and excess salt ingestion, caffeine, smoking, and alcohol. Get regular sleep and eat properly. Remain physically active, but avoid excessive fatigue. Consult your otolaryngologist about other treatment options.

Affecting the outer ear, swimmer’s ear is a condition causing pain resulting from inflammation, irritation, or infection. These symptoms are experienced when water gets trapped in your ear allowing bacteria to spread, causing a painful sensation. Because this condition commonly affects swimmers it is known as swimmer’s ear. Swimmer’s ear affects mostly children and teenagers, but can also affect those with eczema (a condition that causes the skin to itch), or excess earwax. Your doctor will prescribe treatment to reduce your pain.

What causes swimmer’s ear?

A common source of the infection is increased moisture trapped in the ear canal, bathing, or showering, increased humidity or living in warm moist climates may also contribute to this common infection. When water is trapped in the ear canal. Bacteria that normally inhabit the skin and ear canal multiply, causing infection and irritation of the ear canal. If the infection gets worse it may affect other areas of the ear. Swimmer’s ear needs to be treated to reduce pain and eliminate any effect it may have on your hearing.

Other factors that may contribute to swimmer’s ear include:

• contact with excessive bacteria that may be present in hot tubs or polluted water
• excessive cleaning of the ear canal with cotton swabs
• contact with certain chemicals such as hair spray or hair dye (Avoid this by placing cotton balls in your ears when using these products.)
• damage to the skin of the ear canal following water irrigation to remove wax
• a cut in the skin of the ear canal
• other skin conditions affecting the ear canal such as eczema or seborrhea

What are the signs and symptoms?

The most common symptoms of swimmer’s ear are an itchy ear and mild to moderate pain that gets worse when you tug on the auricle (outer ear). Other signs and symptoms may include any of the following:

• sensation that the ear is blocked or full
• drainage
• fever
• decreased hearing
• intense pain that may radiate to the neck, face, or side of the head
• the auricle may appear to be pushed forward or away from the skull
• swollen lymph nodes (located in your neck)
• redness and swelling of the skin around the ear

If left untreated, complications resulting from swimmer’s ear may include:

• Hearing loss. When the infection clears up, hearing usually returns to its normal state.
• Recurring ear infections (chronic otitis externa). Without treatment, infection can occur.
• Bone and cartilage damage (malignant otitis externa). When ear infections spread to the base of your skull, brain, or cranial nerves they become painful and dangerous.
• Diabetics and older adults are more at risk.

To evaluate you for swimmer’s ear, your doctor will look for redness and swelling in your ear. Your doctor also may take a sample of any abnormal fluid or discharge in your ear to test for the presence of bacteria or fungus (ear culture) if you have recurrent infections.

How is swimmer’s ear treated?

Treatment for the early stages of swimmer’s ear includes careful cleaning of the ear canal and eardrops that inhibit bacterial growth. Mild acid solutions such as boric or acetic acid are effective for early infections.

How should ear drops be applied?

• Drops are more easily administered if done by someone other than the patient.
• The patient should lie down with the affected ear facing upwards.
• Drops should be placed in the ear until the ear is full.
• After drops are administered, the patient should remain lying down for a few minutes so that the drops can be absorbed.
• Cotton balls should not be placed in the ear. The ear needs to absorb the drops and dry naturally.

If you do not have a perforated eardrum (an eardrum with a hole in it), you can make your own eardrops using rubbing alcohol or a mixture of half alcohol and half vinegar. These eardrops will evaporate excess water and keep your ears dry. Before using any drops in the ear, it is important to verify that you do not have a perforated eardrum. Check with your otolaryngologist if you have ever had a perforated, punctured, or injured eardrum, or if you have had ear surgery.

For more severe infections, your doctor may prescribe antibiotics to be applied directly to the ear. If the ear canal is swollen shut, a sponge or wick may be placed in the ear canal so that the antibiotic drops will be effective. Pain medication may also be prescribed. If you have tubes in your eardrum, a non oto-toxic (will not affect your hearing) topical treatment should be used. Topical antibiotics are effective for infection limited to the ear canal. Oral antibiotics may also be prescribed if the infection goes beyond the skin of the ear canal.

Follow-up appointments are very important to monitor progress of the infection, to repeat ear cleaning, and to replace the ear wick as needed. Your otolaryngologist has specialized equipment and expertise to effectively clean the ear canal and treat swimmer’s ear. With proper treatment, most infections should heal in 7-10 days.

Why do ears itch?

An itchy ear can be a maddening symptom. Sometimes it is caused by a fungus or allergy, but more often it is from chronic dermatitis (skin inflammation) of the ear canal. One type is seborrheic dermatitis, a condition similar to dandruff in the scalp; the skin is dry, flaky, thickened, and inflammed (irritated). This may be aggravated by certain food groups. Some patients with this problem will do well to decrease their intake of foods that aggravate it, such as greasy foods, carbohydrates (sugar and starches), and chocolate.

An otolaryngologist, a physician who specializes in the structures of the head and neck, also treats allergies. They often prescribe a steroid-containing eardrop, cream or ointment to treat the problem and to be used as needed when the ears itch. There is no long-term cure, but it can be kept controlled.

Tips for prevention

A dry ear is unlikely to become infected, so it is important to keep the ears free of moisture during swimming or bathing.

Do:

• use ear plugs when swimming
• use a dry towel or hair dryer (being mindful of moderate temperature and limitations of usage) to dry your ears
• have your ears cleaned periodically by an otolaryngologist if you have itchy, flaky or scaly ears, or extensive earwax

Don’t:

• use cotton swabs. They may pack ear wax and dirt deeper into the ear canal, remove the layer of earwax that protects your ear, and irritate the thin skin of the ear canal creating the perfect environment for infection.

Open your jaw all the way and shut it. This simple movement would not be possible without the Temporo-Mandibular Joint (TMJ). It connects the temporal bone (the bone that forms the side of the skull) and the mandible (the lower jaw). Even though it is only a small disc of cartilage, it separates the bones so that the mandible may slide easily whenever you talk, swallow, chew, kiss, etc. Therefore, damage to this complex, triangular structure in front of your ear, can cause considerable discomfort.

Where is the Temporo-Mandibular Joint?

You can locate this joint by putting your finger on the triangular structure in front of your ear. Then move your finger just slightly forward and press firmly while you open your jaw all the way and close it. You can also feel the joint motion in your ear canal.

How does the Temporo-Mandibular Joint work?

When you bite down hard, you put force on the object between your teeth and on the Temporo-Mandibular Joint. In terms of physics, the jaw is the lever and the TMJ is the fulcrum. Actually, more force is applied (per square foot) to the joint surface than to whatever is between your teeth because the cartilage between the bones provides a smooth surface, over which the joint can freely slide with minimal friction.

Therefore, the forces of chewing can be distributed over a wider surface in the joint space and minimize the risk of injury. In addition, several muscles contribute to opening and closing the jaw and aid in the function of the TMJ.

What causes TMJ pain?

In most patients, pain associated with the TMJ is a result of displacement of the cartilage disc that causes pressure and stretching of the associated sensory nerves. The popping or clicking occurs when the disk snaps into place when the jaw moves. In addition, the chewing muscles may spasm, not function efficiently, and cause pain and tenderness.

Damage to the TMJ is often caused by:

• Major and minor trauma to the jaw
• Teeth grinding
• Excessive gum chewing
• Stress and other psychological factors
• Improper bite or malpositioned jaws
• Arthritis

What are the symptoms?

• Ear pain
• Sore jaw muscles
• Temple/cheek pain
• Jaw popping/clicking
• Locking of the jaw
• Difficulty in opening the mouth fully
• Frequent head/neck aches

The pain may be sharp and searing, occurring each time you swallow, yawn, talk, or chew, or it may be dull and constant. It hurts over the joint, immediately in front of the ear, but pain can also radiate elsewhere. It often causes spasms in the adjacent muscles that are attached to the bones of the skull, face, and jaws. Then, pain can be felt at the side of the head (the temple), the cheek, the lower jaw, and the teeth.

A very common focus of pain is in the ear. Many patients come to the ear specialist quite convinced their pain is from an ear infection. When the earache is not associated with a hearing loss and the eardrum looks normal, the doctor will consider the possibility that the pain comes from TMJ.

There are a few other symptoms besides pain that TMJ can cause. It can make popping, clicking, or grinding sounds when the jaws are opened widely. Or the jaw locks wide open (dislocated). At the other extreme, TMJ can prevent the jaws from fully opening. Some people get ringing in their ears from TMJ.

How is TMJ pain treated?

Because TMJ symptoms often develop in the head and neck, otolaryngologists are appropriately qualified to diagnose TMJ problems. Proper diagnosis of TMJ begins with a detailed history and physical, including careful assessment of the teeth occlusion and function of the jaw joints and muscles. An early diagnosis will likely respond to simple, self-remedies:

• Rest the muscles and joints by eating soft foods.
• Do not chew gum.
• Avoid clenching or tensing.
• Relax muscles with moist heat (1/2 hour at least twice daily).

In cases of joint injury, apply ice packs soon after the injury to reduce swelling. Relaxation techniques and stress reduction, patient education, non-steroidal anti-inflammatory drugs, muscle relaxants or other medications may also offer relief.

Other treatments for advanced cases may include fabrication of an occlusal splint to prevent wear and tear on the joint, improving the alignment of the upper and lower teeth, and surgery. After diagnosis, your otolaryngologist may suggest further consultation with your dentist and oral surgeon to facilitate effective management of TMJ pain.

Today’s society is more active than ever, but inevitably every year more than two million Americans fall and sustain serious injury, costing the healthcare system in excess of $3 billion dollars. Hidden costs affecting the individual include pain, disability, lawsuits, loss of independence, deterioration in well-being, and the impact on other family members. Nonetheless, falls are predictable and preventable, even for older adults.

Falls and the resulting injuries are among the elderly’s most serious health issues caused by the body’s deterioration through inactivity and the central nervous system (CNS)’s damaged through injuries. For example, the sensory cells in the ears’ balance system gradually decrease and cannot be replaced, as well as the nerves carrying sensory information to the brain to perform complex brain interconnections lose fiber and nerve cells. In addition, nerve endings loose their ability to generate the chemicals responsible for the transmission of information. This process accelerates after the age of 50.

Many diseases affect the CNS and sense organs too. Also, muscle strength gradually decreases with age, joint tendons and ligaments lose their flexibility and limit motion. The combined ravages of bone and joint injury, arthritis, and inactivity can result in a body that cannot carry out motion commands initiated by the brain. Hardening of the arteries is probably the worst. It is accelerated by high blood pressure, smoking, and diabetes. Although artery hardening gradually increases during middle age, there is a point at which a slight additional decrease in blood flow causes serious vascular impairment such as stroke.

Head injuries, sometimes caused by falls, can damage the sense organs in the inner ears, or the brain itself. Therefore, physical activity is very important for injury recovery to the sensory systems. The general debility of aging can negatively affect recovery if it results in a decreased level of activity. Often, injuries to the knees, hips, and back do not completely heal, leaving some limitation of motion.

The worst disability occurs when both sense organs and CNS structures are damaged simultaneously, as is the case with Alzheimer’s Disease. Also, arthritis can cause permanent, crippling, nonreversible effects and osteoporosis can lead to bone weakness and increases the probability of serious injury from a fall or a spontaneous fracture that might lead to a fall.

In this time of specialization, it is possible for one patient to receive prescriptions from several physicians that might have additive side effects on the brain and sensory function. Therefore, patients should keep a complete list of all their medications and dosages, and make this list available to each physician they consult. Coordination of all medications through a single primary care physician would help avoid adverse drug reactions to the brain and sensory functions. The list should include:

• Over-the-counter medications, such as antihistamines, sleeping medications, analgesics, and cough suppressants.
• Medications used to treat high blood pressure, heart disease, allergy, insomnia, stomach acidity, and depression.
• Medications listing alcohol as an ingredient since it affects movement and judgment and adversely interacts with many medications.

How can I recover from an injury caused by a fall?

Rehabilitation

• A thorough and complete evaluation of sensory, CNS, muscles/joints, and balance function should be performed. This includes a search for causes of dizziness, such as inner ear diseases; an evaluation of the inner ear balance system, which might be adversely affected by certain drugs (such as a class of antibiotics known as aminoglycocides); trauma; and the aging process.
• Tests of higher mental function are important since falling may be a sign of serious mental deterioration.
• A careful review of all medications (both prescription and over-the-counter) is very important. If medication for anxiety or depression is used, switching from a long acting drug to one that is more quickly passed from the body seems to decrease the risk of falling.
• All correctable problems should be treated. Visual correction with proper eyeglasses, improvement of hearing by hearing aids, adjustment or elimination of medications, and any other disease, which could impair balance must be accomplished.

Rehabilitation includes increasing the range of motion as well as physical strength. A very important part of rehabilitation is overcoming the fear of falling and thus avoiding further injury. Walkers and canes can aid stability, while simple changes in the home, such as installing hand holds in bathrooms or along walls, could decrease the likelihood of falling and increase confidence. But keep in mind, drastically changing a familiar environment often hampers recovery. As soon as possible, rehabilitation should include family members and home support groups. Rapid return to physical activity and social interaction with family and community can often stop the vicious spiral into inactivity, reclusiveness, and progressive deterioration that falls and injuries cause.

How does lifestyle management affect fall prevention?

As many of the problems responsible for falling develop during early and middle age, initial efforts to prevent injuries should begin at a younger age. Many of the changes in muscle, bone, and the central nervous system are not inevitable results of aging, but are brought on by inactive lifestyles and self-inflicted damage from smoking, poor diet, and lack of exercise. Although hardening of the arteries is occasionally hereditary, in most cases it can be reduced by diets low in cholesterol and saturated fatty acids, as well as regular physical exercise.

Tips to prevent falls among seniors

Health

• Have hearing and vision check-ups regularly. If hearing and vision are impaired, important cues that help maintain balance can be lost.
• Get up slowly. A momentary drop in blood pressure can cause dizziness when standing up too quickly.
• Use a cane or walker to help maintain balance on uneven ground or slippery surfaces. Wear sturdy, low-heeled shoes with wide, nonslip soles.
• Exercise to improve your strength, muscle tone, and coordination. Walking is a good form of exercise.

Home

• Remove raised doorway thresholds in all rooms. Rearrange furniture to keep electrical cords and furniture out of walking paths. Fasten area rugs to the floor with tape or tacks.
• Never stand on a chair. Use nonskid floor wax
  and wipe up spills immediately.
• Be sure stairways have sturdy hand rails.
• Install grab handles and nonskid mats inside and outside your shower and tub.
• Use shower chairs and bath benches to minimize the risk of falling.
• Put a light switch by the bedroom door and by your bed so you don’t have to walk across the room to turn on a light. Night lights in your bedrooms, halls, and bathroom are a good idea.