The Center for Hearing and Balance Disorders diagnoses and treats all disorders of the ear, as well as disorders originating from elsewhere in the body that may involve the ear or affect the functions of hearing and balance. Since the ear is a special sense organ for both hearing and balance, many problems with balance are actually inner ear related.
Some of the more common disorders we treat are:
- Ear infections in adults and children
- Fluid in the ears
- Draining ears
- Holes in the ear drum (tympanic membrane perforation)
- Profound deafness, either congenital (born with ) or acquired
- Mastoiditis (infection of the back of the temporal bone felt behind and below the ear)
- Hearing loss from any cause
- Ringing in the ears (tinnitus)
- Vertigo (the feeling you are moving when you are not)
- Benign and malignant tumors of the ears
- Cholesteatoma (abnormal growth of skin cells inside of the temporal bone behind the ear drum)
- Acoustic neuroma (a benign tumor of the insulating cells of the nerve from the inner ear or vestibulocochlear nerve)
- Congenital ear deformities of the outer, middle or inner ear
- Tumors of the blood vessels of the middle ear (glomus tumors)
- Otosclerosis (hearing loss due to fixation of the stapes bone in the middle ear)
- Meniere's Disease (attacks of dizziness, hearing loss, and ringing in the ear)
This is just a partial list of disorders. If you have questions or concerns, you are urged to contact The Center for Hearing and Balance Disorders at the New York Head and Neck Institute (NYHNI).
Infections of the Ear
Most symptoms of ear infections depend on the anatomical part of the ear affected. Below are just some of the common ear infections with their symptoms and treatments, so patients with questions or concerns should contact the Center for Hearing & Balance Disorders at the New York Head and Neck Institute (NYHNI) for more information.
Infections of the Outer Ear
Infections of the auricle (the part of the ear seen on the outside of head) are noticed because of swelling, pain and redness of the skin, and movement or touching it will usually result in severe pain. Fever may be present and can sometimes become quite elevated, while hearing and balance remain normal. Treatment with appropriate antibiotics, pain medication and hot compresses usually is all that is needed, but with very severe infections, intravenous antibiotics may be necessary.
If the infection is of the ear canal only (swimmer’s ear) and does not involve the auricle, there will usually be pain with pulling on the auricle and pain deep inside the head. There may be drainage that looks like the fluid out of a skin blister. If the swelling of the skin in the ear canal is severe enough to close it, hearing may be decreased and fever is occasionally present. This infection is known as external otitis.
In patients with diabetes, this type of infection is potentially much more severe. Usually, the only symptom is a possible rise in blood sugar at the onset of the infection. In these cases, intravenous antibiotics are required and the infection is known as malignant external otitis. Sometimes portions of the bone around the ear canal may require surgical removal.
A particularly chronic type of ear canal infection is a fungus known as Aspergillus fumigatus. Most often, the fungus that causes these infections is found in the soil. The symptoms are severe itching that is sometimes accompanied by pain with occasional discharge from the ear canal that is black, foul-smelling material resembling dead skin. The infection is complicated by the fact that many patients who tend to get these infections have allergies, so that it is difficult to separate the cause of the symptoms between the fungus and the symptoms brought on by the allergic reaction to the fungus itself.
Infections of the Middle Ear
Infection of the middle ear, the part of the ear behind the ear drum (tympanic membrane), is extremely painful and usually is accompanied by fever. The hearing may be markedly decreased by fluid in the middle ear preventing the normal movement of the ear drum when sound waves strike it.
As these infections usually occur in very young children or infants, the signs of fever (which is almost always present), tugging at the ear and crying may be the only clue that the child has an ear infection.
Middle ear infections usually occur in conjunction with symptoms of a cold or upper respiratory infection. Medical attention should be sought immediately to prevent the infection from perforating the ear drum. Severe middle ear infections can result in permanent deafness in the involved ear.
Infections of the Inner Ear
Infection of the inner ear is the most serious. Since it involves the temporal bone, it is called mastoiditis. Often, there is involvement of the coverings of the brain (the meninges) with accompanying meningitis (inflammation of the meninges). The patient is usually disoriented, has a stiff neck and a high fever, and hearing and balance may be impaired. Often permanent damage to the hearing occurs. The diagnosis is made by a spinal tap, and the patient is hospitalized and placed on intravenous antibiotics
Tumors of the Ear
Tumors of the ear may arise from the skin cells or pigment cells of the skin of the auricle (part of ear seen on outside of head) or ear canal. There are two common types, squamous cell cancer and basal cell cancer, which begin in the skin of the auricle. The type of tumor that arises from the pigment cells of the skin of the ear is a melanoma or malignant melanoma, and is a life-threatening cancer.
- Squamous cell carcinoma appears as a crusting, flat lesion that may bleed when rubbed.
- Basal cell carcinoma is a locally spreading tumor of the cells of the bottom layer of the skin. It is malignant because it does invade normal tissue next to the tumor.
- Malignant melanoma of the auricle or ear canal is life-threatening. Melanoma may spread either to the lymph nodes in the neck and elsewhere or to distant locations in the body by seeding of cancer cells via the blood vessels (hematogenous spread).
- Bony exostoses of the ear canal, although technically not a tumor, is another type of growth that may cause ear canal problems and loss of hearing. Exostoses are found in cold water swimmers and are common in active scuba divers. They are basically bone spurs surrounding the ear canal that are troublesome when they become large enough to prevent the normal migration of ear wax out of the ear canal or block the ear canal affecting hearing.
- Acoustic neuroma is a benign tumor of the acoustic or vestibulocochlear nerve. The vestibulocochlear nerve is made up of nerve fibers from both the hearing and balance portions of the inner ear. The tumor itself comes from the cells that actually serve to form the insulation of the nerve or nerve sheath. Most commonly, the tumor appears as a one-sided, nerve type of hearing loss (sensorineural). Alternatively, if the tumor begins on the vestibular part of the nerve, the patient may experience imbalance or attacks of vertigo. If the early symptoms are ignored, it may grow large enough to put pressure on the adjacent nerve, which is the facial nerve carrying fibers that control the muscles of the face on one side. In this instance, the patient may experience one-sided facial paralysis.
Hearing Loss and Deafness
Hearing loss may be divided into three basic types dependent on the part of the ear that is not functioning normally. The three types are: conductive hearing loss, sensorineural hearing loss and mixed (conductive and sensorineural hearing loss).
Conductive Hearing Loss
Conductive hearing loss may be due to any process that impairs the ability of the ear to collect sound waves in the ear canal, interferes with the movement of the ear drum or tympanic membrane in response to sound waves striking it, or impedes the tympanic membrane moving the attached small bones of the middle ear (malleus, incus and stapes). In addition, it includes disruption of the up and down movement of the footplate of the stirrup bone (stapes) in the oval window of the fluid-filled inner ear where sound waves are changed (transduced) into nerve impulses that are then sent to the brain to enable the still poorly understood sense of hearing.
Common causes of conductive hearing loss include:
- Occlusion of the ear canal by wax, swelling from infection (external otitis) and bone spurs
- Fluid in the middle ear from infection or allergies (otitis media)
- Tympanic membrane perforations (holes in the ear drum due to infection or trauma)
- Disruption of the ossicular chain (the three connected bones in the middle ear that transmit and amplify the vibrations of the tympanic membrane to the fluid of the inner ear) due to infection or trauma
- Fixation of the stapes footplate to surrounding bone (otosclerosis), preventing the stapes from producing movement in the fluid of the inner ear
- Fixation of the other middle ear bones to surrounding bone in the temporal bone housing the middle ear
- Vascular tumors (benign tumors of the portion of the jugular vein in the middle ear)
- Congenital absence or deformity of the ear canal or middle ear
Sensorineural Hearing Loss
Sensorineural hearing loss or hearing loss due to damage to the nerve cells of the inner ear (hair cells) is not reversible. Common causes of this type of hearing loss include:
- Aging (not yet understood as it does not include all people)
- Congenital sensorineural hearing loss (common with maternal measles "rubella" infection and as yet other undetermined causes, may sometimes be due to failure of the inner ear to develop in the embryo)
- Noise exposure (led to federal regulation of hearing protection for workers in noisy environments)
- Meningitis (infection of the brain’s coverings)
- Encephalitis (infection, usually viral of the brain itself)
- Secondary to middle ear infection (usually found after severe middle ear infection and felt to be due to bacteria toxins killing the nerve cells in the cochlea)
- Antibiotics (particularly streptomycin)
- Head trauma
Dizziness, Imbalance and Vertigo
The human balance system is extremely complex and poorly understood. It involves nervous input from a variety of systems in the brain, spinal cord, muscles and inner ear. The type of imbalance that is most often treated by an otologist is vertigo, which is best defined as the perception of moving in space when you are not.
One half of the inner ear is made up of three semicircular canals that meet in a common area. At the connection point of each semicircular canal to the common area that is in continuity with the snail-like coiled structure of the inner ear that's responsible for the sense of hearing, are small crystals made of calcium carbonate that lie on top of hair-like projections called cilia that make up the vestibular (balance) division of the vestibulocochlear nerve.
When the head moves, these crystals move in the opposite direction, bending the cilia. This causes the nerve cell from which they arise to generate a nerve impulse that tells the brain the head has moved. It is thought that if this matches the input received by the brain from the eyes, then movement is perceived to have occurred. When there is a mismatch between what the hair cells in the inner ear and the eyes are telling the brain regarding head movement and position -- this is perceived as vertigo.
Cholesteatoma is the growth of normal skin cells (squamous cells) into the chamber of the middle ear behind the ear drum. Most experts agree that the most common cause of cholesteatoma is the growth of normal skin cells through a hole in the ear drum or tympanic membrane perforation. The presence of a cholesteatoma is marked by a chronically draining ear, usually with a hearing loss.
There is a rare condition called primary cholesteatoma that is felt to be due to trapping embryonic cells on the inside of the ear drum during fetal development that were destined to be on the outside of the ear drum. There are some experts who don't think this is possible, but it remains the only explanation for cholesteatoma where there is no record of a tympanic membrane perforation.
Otosclerosis, or ear hardening, is the condition that causes fixation of the stapes (stirrup bone) to surrounding bone at the oval window (an opening that leads from middle to inner ear), where it vibrates the fluid in the cochlea to produce movement of the cilia, which send impulses to the brain. These impulses are interpreted as hearing, so the symptom of this condition is hearing loss.
The hearing loss due to otosclerosis is of the conductive type, meaning that it is due to the inability of the bones that move with ear drum movement to move in a normal fashion.
Basic Ear Anatomy
The human ear, aside from the part that is external to the head (auricle), is completely housed in the thick bones of the sides and base of the skull called the temporal bones. The thick back part of the bone called the mastoid may be felt directly behind the earlobe.
The ear consists of three parts: the outer, middle and inner ear. Each plays a role in hearing and one a role in maintaining balance. For the most part, they are inaccessible to direct inspection, with the exception of the ear canal and ear drum (tympanic membrane). Some of the middle ear structures may be seen through an especially transparent ear drum, while the inner ear may be evaluated only by CT scans, MRI scans or indirectly by special testing, such as audiometry (hearing tests) or other special tests of inner ear function.
The external ear is made up of the auricle, the external auditory canal (ear canal) and the outer surface of the ear drum or tympanic membrane. The auricle functions to collect and amplify sounds in the environment and aids in determining the direction from which a sound is coming. Man has a very poorly developed auricle that adds very little amplification in contrast to most animals, who have very large, well developed auricles, which is one of the reasons their hearing is so acute.
The external auditory canal is a skin-lined tube that ends at the tympanic membrane, which is oriented in an inwardly slanted direction from top to bottom. In order to see the tympanic membrane, one has to look toward the face. Its external surface is lined by a special type of skin cell that gives it some transparency when viewed through an otoscope or with a bright light reflected by a head mirror.
Because of its surface area, the tympanic membrane serves to add additional amplification to incoming environmental sounds, and it vibrates when struck by sound waves, hence the name ear drum.
The middle ear consists of the inside of the ear drum in a chamber that is connected to the back of the nose by the Eustachian tube, which keeps the air pressure in the middle ear chamber equal to the outside air pressure. This is why your ear pops when you change altitude -- the pop is the opening of the Eustachian tube at the back of the nose to equalize the air pressure. As many of us know, when you cannot get your ear to “pop” there is a mild hearing impairment, and sometimes with rapid altitude change, as occurs in an aircraft, extreme discomfort.
The middle ear also contains the three interconnected bones called the ossicles (small bones). They are named the malleus, which is connected to the undersurface of the tympanic membrane; the incus, connecting the malleus and the stapes; and the stapes or stirrup bone, whose footplate occupies the oval window, which is the term for the opening connecting the fluid filled chambers of the inner ear to the middle ear bones. With vibration of the tympanic membrane, the three bones vibrate together, again adding amplification to sound. The vibrations of the footplate of the stapes are the point at which a sound wave is turned into a wave in the fluid filled chambers of the inner ear.
The inner ear consists of two separate structures that are united in a common area between them. It is encased in bone deep inside the temporal bone. The cochlea, or hearing part of the inner ear, consists of a snail-shaped structure that contains the “hair cells,” which are special nerve cells that have projections on their surface called cilia that meet a membrane in the central fluid-filled portion of the coiled cochlea. The hair cells' location on the cochlea determines which frequency of sound will stimulate it to fire a nerve impulse, so the cochlea may be thought of as a piano keyboard with each pitch or sound frequency stimulating a specific area of hair cells in the cochlea. The nerve fibers from the thousands of cells along the cochlea intertwine to form the acoustic nerve or the cochlear division of the vestibulocochlear nerve.
The vestibular portion of the inner ear consists of three semicircular, fluid-filled canals connecting to the common area shared with the cochlea. At the base of each canal is an area containing an array of hair cells with microscopic calcium carbonate crystals (otoliths or ear stones) sitting on top of the cilia of the nerve cells. With movement of the head, the crystals, having higher density than the fluid, bend the cilia of the hair cells causing them to fire a nerve impulse. Again, thousands of these fibers unite to form the vestibular division of the vestibulocochlear nerve. Their collective impulses are sent to the brain to be matched against other input from the eyes and body to help us determine our motion and position.
Once the two divisions of the vestibulocochlear nerve have been united, they exit the innermost part of the temporal bone through a hole in the bone called the internal auditory canal. It is in this canal that benign tumors of the vestibulocochlear nerve (formerly the acoustic nerve) occur. At the point of exit from the temporal bone, the vestibulocohlear nerve is very close to the nerve trunk for the nerve controlling the muscles of the face or facial nerve. The fact that these two nerve trunks are so close together accounts for the common finding of a disorder of one of these nerves affecting the other.