Hearing & Deafness

The information below should serve as a general guide only.

Hearing loss can affect people of any age. One in six adults have some degree of hearing loss, which increase to three in four above the age of 75. Children can also be affected, usually due to fluid or infection in the middle ear but also due to congenital problems or viral illness during early childhood.

The mechanism of hearing

We can hear sounds via the ear canal and eardrum by vibrations of the eardrum, ossicles (small bones in the ear) and then the inner ear or cochlea where the sound waves are changed into electrical signals which are passed on to the brain along the auditory nerve.

Types of deafness

The causes of deafness can be broadly grouped into conductive problems in the ear canal and middle ear (conductive hearing loss) or sensori-neural problems, which is a problem with the translation of the sound waves into an electrical signal by the inner (sensorineural hearing loss).

A conductive hearing loss can occur due to wax blocking the ear canal, or infection, a collection of fluid, trauma or fixation of the ossicles in the middle ear. Fortunately they can usually be treated.

A sensorineural hearing loss is due to a problem of the inner ear or of the nerve that carries the signal to the brain. There are many causes, the commonest being that of hearing loss in old age (presbyacusis), but other causes include virus infections, trauma, drugs, noise exposure and congenital causes. Some inner ear problems are reversible, but usually loss is permanent. Extremely rarely it may be due to a growth or tumour in the brain.

Hearing aids are continuing to improve and help to amplify the sounds that are heard by the inner ear and so partially overcome the hearing loss.

When to ask for help from an ENT specialist

You should seek advice urgently (within 24-48 hours) if you have a sudden hearing loss, as treatment should be started within 48 hours of its onset.

You should seek advice if you have a hearing loss in one ear only.

If you notice a gradual deterioration of your hearing and need to discover the cause and get treatment.

Ear Infections

The three most common types of ear infections are otitis media (infection of the middle ear), otitis interna (also known as an inner ear infection or labyrinthitis), and otitis externa (also known as an outer ear infection or swimmer's ear).

Common symptoms include pain, discharge, itching, deafness, imbalance and sometimes a ringing in the ears.

Combined Approach Tympanoplasty (CAT)

Anatomy & Physiology

The anatomy of the middle ear cleft is extremely important in combined approach tympanoplasty. It relies on an accurate knowledge of the relationship between the facial nerve in its vertical portion and the chorda tympani. Indeed it is the bony triangle between them that is drilled in order to open up the channel between the mesotympanum and mastoid regions. It is referred to as the posterior tympanotomy. In all other respects the anatomy of the middle ear cleft is as for any other operation.


Indications for a combined approach tympanoplasty are as follows:

  • Serous otitis media- rarely
  • Stage III/IV retraction pockets (Sade classification)
  • Chronic suppurative otitis media (granulations/cholesteatoma)
  • Placement of middle ear hearing aid
  • Placement of cochlear implant


In this country there is a tendency to use general anaesthetic for the purposes of carrying out this surgery. However local anaesthetic techniques can be used along with patient sedation.



A post aural C-shaped hairline incision is made from above the pinna to the level of the mastoid tip. The incision is deepened to the level of the temporalis fascia. The whole skin flap is then elevated anteriorly in this plane to the level of the external auditory canal, but without entering it. A large anteriorly based Palva flap is raised from the mastoid bone to the level of the bony external auditory canal. It should be large enough to expose a finger breadth of bone superiorly to the external auditory canal and cleared inferiorly to the tip of the mastoid and the floor of the external auditory canal. A large temporalis fascia graft is harvested superiorly, but leaving a band of temporalis fascia intact inferiorly to assist with closure. If necessary, conchal cartilage or bone whorls can also be harvested, as can bone dust during the drilling phase of the procedure.


An extended mastoidectomy is carried out with identification of the sigmoid sinus posteriorly, the middle fossa dura superiorly. The canal wall is kept intact. The mastoidectomy is extended as far forward as possible into the attic region in order to expose the region of the attic where the incus and malleus are found. The superior and posterior canal wall is thinned, particularly medially. This aids identification of the course of the chorda tympani. Great care is taken during the mastoidectomy to observe and find the main landmarks, which are the lateral semicircular canal and short process of incus. The posterior tympanotomy is created using initially large cutting and then subsequently a large diamond burr, until the facial nerve and chorda tympani have been identified in the vertical course.

Once identified, progressively smaller diamond burrs are used to open up the triangle between the chorda tympani and facial nerve being careful not to disrupt or unduly move the incus with the drill.

The anterior tympanotomy is then performed by raising a tympanomeatal flap. The disease with or without appropriate ossicles, dependent upon the degree of destruction of ossicles, is then removed from the mastoid through to the external auditory canal. It is desirable to remove it as an intact sac. In many cases there will have been loss of the bony wall posterosuperiorly, particularly in the area of the scutum.

Once the disease has been removed, hopefully with preservation of the chorda tympani if it is not completely involved in the disease, an endoscopic inspection of the cavity with particular reference to the attic and posterior tympanotomy is made. This is followed by an endoscopic examination via the anterior tympanotomy of the retrotympanum, the stapes footplate region, the protympanum and hypotympanum.

A record is kept on whether the disease has been totally cleared (grade I), appears totally cleared but with a degree of uncertainty in the surgeons mind (grade II) or there is known residual disease (grade III). In general this latter cadre will be due to disease between the stapes crura, in the retrotympanum or attic, but deemed impossible to remove at the time of the first look surgery. At second look surgery it is often easier to remove it as a pearl of disease.


Reconstruction of the bony canal wall is undertaken either using a bone whorl, temporalis fascia bone dust envelope or cartilage. Repair of the ossicles is not normally undertaken at the first look procedure unless the disease has been extremely limited, however opinion does vary on this and some surgeons believe in initial reconstruction. The residual tympanic membrane is then repaired with an underlay temporalis fascia graft in the normal way. The middle ear cleft is packed with gel foam to support the graft and the external auditory canal is then packed with gel foam to support the graft laterally. Routine closure of the Palva flap with a continuous Vicryl suture is carried out and the skin incision closed usually with skin glue. The ear canal is packed with pieces of BIPP.

Length of operation

In experienced hands this will vary between one and a quarter hours and one and a half hours, though in difficult cases it may be more prolonged. In training cases it would be reasonable to allow two and a half to three and a half hours.

Time in hospital

Home the same day or overnight. The head bandage is removed after 48 hours, though the patient may still go home the same day.

Time off work

Ten to fourteen days.

Risks and Complications

Risks include total hearing loss, dizziness, noises, facial paralysis, loss of taste of the tongue, secondary infection and recurrence of disease. There is also the need for a second look procedure with or without conversion to a cavity if necessary.


95% of patients will require a second look procedure either to check for the presence of residual and/or recurrent cholesteatoma and also for the reconstruction of the ossicular chain. The prognosis however at second look is extremely good. It would be reasonable to expect a residual cholesteatoma rate of between 5%-15% at second look surgery. Recurrence may arise in about 10%-15% of patients.

Alternative treatments

Alternative treatments include atticotomy, attico antrostomy, small cavity mastoidectomy, modified radical mastoidectomy, radical mastoidectomy and extended modified radical mastoidectomy.

Second Look CAT

Second Look Combined Approach Tympanoplasty

A second look combined approach tympanoplasty is the operation that is undertaken between six and eighteen months following a first look intact wall mastoid exploration


Following a first look intact wall mastoid exploration (combined approach tympanoplasty), usually for cholesteatoma, but occasionally for granulation disease.


Generally it is appropriate to use a general anaesthetic, although it may also be performed under local anaesthetic. This will depend on whether a stab incision or a full re-exploration via the first incision is used.


There are two possible techniques. Either re-opening the old incision used at the first operation or in preference a small 1-2 cm stab incision inside the previous scar in the post aural sulcus in order to permit a minimally invasive endoscopic procedure.

Assuming a minimally invasive procedure, a 1-2 cm incision is made superiorly to the ear canal, but in the post aural sulcus. The incision is deepened to the mastoid bone and the mastoid cavity is entered. On occasions there can be new bone growth over the mastoid bowel, which may require drilling away in order to allow entry.

Once the cavity is opened there may be good aeration with a few mucosal folds, which can be easily broken down. Alternatively there may be a range from that status to a cavity, which is completed filled with gelatinous scar tissue. Fortunately this can almost invariably be aspirated with no difficulty in order to reveal the whole of the mastoid cavity region, including the attic region.

Microscopic examination of those areas that can be seen with the microscope is carried out to search for any residual and/or recurrent cholesteatoma. Following this an endoscopic examination is performed using a 0 degree and a 30 degree 1.9/2.7 mm diameter otoscope (11 cm long) either by eye or via camera and screen. The particular areas of interest are the attic region, the tip of the mastoid and the sinodural angle, which may not have been seen by microscopic examination. The posterior tympanotomy is also opened so that the mesotympanum can be examined through it and attic regions again looking for recurrence or residual disease.

Following this an anterior tympanotomy is performed either though the stab incision or per-meatally. A tympanomeatal flap is raised and the mesotympanic area is examined with particular reference to the retrotympanum, hypotympanum and protympanum, i.e towards the eustachian tube. This, of necessity, is carried out using a 0 degree or 30 degree 1.9 or 2.7 mm, 11 cm long endoscope. Occasionally it is necessary to employ a 70 degree telescope. The purpose of endoscopy is to examine all hidden areas for recurrence or residual cholesteatoma. It is also possible to use a 1.9 mm endoscope if access is difficult, however the field is poorer. Once any residual disease is found and removed, reconstruction of the ossicular chain is carried out provided it is not advisable to wait and carry out a 3rd look procedure.

The reconstruction can be observed after the tympanic membrane has been replaced via an endoscopic view through the posterior tympanotomy via the stab incision.

At any stage, if extensive recurrence is found that cannot be resected endoscopically, the old incision is re-opened in order to carry out a full formal revision combined approach tympanoplasty and/or to change it into a mastoid cavity.

Length of operation

Thirty minutes to one and a half hours.

Time in hospital

Day case or overnight. No drains are required assuming a stab incision. Similarly, no head bandages are required. If the old incision is re-opened then the normal head bandages are applied post operatively.


The limitations to the technique of minimally invasive second look combined approach tympanoplasty are if there is extensive recurrence. However, exposure of the facial nerve, a previously discovered fistula or new bone growth does not preclude the technique.

Risks and Complications

The risk of this surgery are as for all ear surgery and include total hearing loss, dizziness, tinnitus, facial paralysis, loss of taste of the tongue and the need for further exploration due to the possibility of recurrence or residual disease being found. Due awareness must be taken of the fact that heat from the light from the endoscope can potentially cause damage if left in one particular position too long. Also, with the 30 degree or 70 degree scopes, assuming an intact stapes, there is a potential for ossicular damage due to accidentally impinging onto the stapes. Thermal damage to the facial nerve must be a point of particular awareness to the surgeon, although it is extremely improbable if due care is taken.


The prognosis is extremely good where there is simply residual disease (5-15%), i.e a small pearl of cholesteatoma. For the remaining 10-15% in whom there is a recurrence, a third look operation is likely to be necessary.

Alternative treatments

Alternative treatments include a complete open re-exploration, but still using an intact wall procedure. Alternatively conversion to a mastoid cavity with or without obliteration may be preferred.

Implantable Hearing Aids

The Esteem Hearing Aid is totally implantable and therefore invisible. Many people with hearing problems dislike using conventional hearing aids as there is a negative social stigma attached with them. This problem is overcome with the Esteem Hearing Implant as all parts of the aid are invisible. Importantly, this new technology allows patients to hear more naturally and restores their life to normal living. The product is maintenance free for five to nine years after which the battery will need to be replaced, and then patients can continue enjoying the Esteem Hearing Implant benefits.

The device (based on pacemaker technology) is implanted under the skin behind the ear. Two leads extend into the middle ear from the device. Sound waves travel into the ear canal and set the ear drum (tympanic membrane) into motion causing the bones of the middle ear to vibrate. The device senses these movements and delivers a customized dose of energy to the cochlea which transmits the signals to the brain. The brain interprets the signals as hearing, which allows the patient to experience a new world of sound.

This device uses the ear’s natural anatomy and the result is that patients describe a clarity and fidelity of sound that is near normal. Due to the basic laws of physics and human physiology, attempts with conventional artificial methods to improve hearing, such as hearing aids, do not possess this capability.

Background Noise is the one of the biggest complaints for people wearing hearing aids. Taking part in a conversation at a restaurant, with a group of friends, at a business meeting are usually the most difficult situations for hearing aid wearers. Yet, these are situations they want most to be a part of but are excluded from when using normal hearing aids. Patients using the Esteem Hearing Implant report that they hear better with this device leading to improved understanding and more enjoyment of life, regardless of their background environment.

The Esteem Hearing Implant, in contrast to conventional hearing aids, is not a simple sound amplifier. It enhances your own anatomy’s ability to process sound. The device increases the energy delivered to the cochlea via the middle ear thus clarifying the signals delivered to the auditory nerve.

The surgical procedure is well tolerated with a rapid recovery time as well as being totally invisible. This coupled with the improved hearing makes the Esteem Hearing Implant a revolutionary choice for people with hearing problems.

The advice and information contained herein is provided in good faith as a public service. However the accuracy of any statements made is not guaranteed and it is the responsibility of readers to make their own enquires as to the accuracy, currency and appropriateness of any information or advice provided. Liability for any act or omission occurring in reliance on this document or for any loss, damage or injury occurring as a consequence of such act or omission is expressly disclaimed.


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