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Conditions

Chronic middle-ear disease

An ear that keeps discharging, or that has been unwell for years, rarely has a single problem. Sorting the safe from the unsafe, and the treatable from the tolerable, comes before any decision.

Line illustration of the ear showing the outer ear, eardrum, ossicles and cochlea

What “chronic” means here

Chronic otitis media is inflammation of the middle ear lasting months or years, usually with a perforated eardrum or a retraction pocket, and often with intermittent or continuous discharge. It is common worldwide and is one of the leading causes of preventable hearing loss.

Two broad forms are distinguished, and the distinction shapes everything that follows:

  • Mucosal disease (“safe” chronic otitis): a perforation with inflamed lining that discharges when infected, but no bone-eroding process. Uncomfortable, hearing-impairing, and treatable, but not dangerous in itself.
  • Squamous disease (“unsafe”): a retraction pocket or cholesteatoma that erodes bone and can lead to complications. This needs surgery.

Long-standing inflammation of either kind can also leave scars: tympanosclerosis (chalky plaques that can fix the ossicles), adhesions, and a thin, retracted, atrophic drum.

Medical treatment first — for mucosal disease

A wet, discharging ear with mucosal disease is treated first by cleaning it under the microscope and using topical antibiotic drops, ideally guided by a swab. Keeping water out helps. Most ears can be made dry, at least for a while. Oral antibiotics have a limited role. Nasal and Eustachian-tube problems that keep the ear poorly ventilated are worth addressing.

When the ear is dry but the drum has a hole, the questions become the same as for any eardrum perforation: does the hole cause enough trouble to justify repair, and what hearing result can realistically be expected?

Surgery

  • Tympanoplasty closes the drum and, where needed, addresses the ossicles.
  • Mastoidectomy opens and cleans the air cells behind the ear when they are diseased, and is part of the treatment of cholesteatoma.
  • Ossiculoplasty reconstructs the chain when erosion or fixation is found.

The order matters. A safe, dry ear comes first; hearing reconstruction may be done at the same time or later.

Assessing the chronic ear before surgery

Document the perforation (size, site, marginal or central), the state of the remaining drum (retraction, atrophy, tympanosclerosis), the middle-ear mucosa (dry, wet, polypoid), Eustachian-tube function as far as it can be judged, and the contralateral ear. Obtain a full audiogram with masked bone conduction and speech scores. CT is not needed for every mucosal perforation but is indicated when cholesteatoma is suspected, when the mastoid is symptomatic, before revision, and when the air-bone gap is disproportionate to the perforation. Give the person two separate expectations: probability of a closed, dry ear and probability of a useful hearing gain.

Hearing

Hearing loss in chronic ear disease is usually conductive, sometimes mixed after years of inflammation reaching the inner ear. Surgery improves hearing in many but not all; where the chain cannot be rebuilt reliably, a hearing aid or bone-conduction device is a sound alternative, and a repaired, dry ear makes a conventional hearing aid far easier to wear.

When to seek assessment promptly

Pain, fever, swelling behind the ear, facial weakness, severe dizziness, sudden loss of hearing or a bad headache in someone with a chronically discharging ear are warning signs of complication and need medical care without delay.

This page provides general educational information. It cannot replace an individual assessment, which depends on a full history, examination, audiometry and, where relevant, imaging. If you have sudden hearing loss, severe pain, facial weakness, severe dizziness or discharge with fever, seek medical care promptly.