Ear / Balance

Conditions managed:
  • Congenital – These can occur due to infections (e.g. Rubella, CytoMegaloVirus, Toxoplasmosis, Herpes, Syphyllis) or genetic causes with or without syndromes. They can result in cochlear and middle ear hearing loss.
  • Genetic hearing loss – There are over 200 types of genetic hearing loss. Only 10% of those affected are born to parents with hearing loss, as 75% of deafness is due to an autosomal recessive genetic inheritance. Only 25% of these patients are syndromic with other body systems also affected.
  • Noise-induced hearing loss – This is due to very high noise level exposure for just a few minutes (e.g.  120dB for 15 minutes), or chronic high noise exposure (e.g.  80dB for 8 hours).Photo 20 Abcess around ear
  • Lumps and sinuses around/ on the external ear – These may be simple sebaceous cysts, keloids, pseudocysts, preauricular sinuses or more rarely, first branchial cysts/ sinuses.
  • Ear wax and foreign bodies – These can cause discomfort, infection and if severely impacted, reduce hearing.
  • Otitis media – This can be acute with pain and fever, with pus in the middle ear and possible rupture of the ear drum (Acute Otitis Media). It could be recurrent or chronic, with fluid in the middle ear (Otitis Media With Effusion/ Glue Ear), and associated with infections or Eustachian tube dysfunction. Photo 21  Glue Ear
  • Eustachian tube dysfunction –This can be due to a more horizontal and shorter Eustachian tube of the child, bottle feeding lying down, craniofacial anomalies, tone, recurrent allergic rhinitis or sinus infections, cleft palate and adenoid enlargement. It causes blocked ear sensations that otitis media with effusion, worse during flu or cold.
  • Perforated ear drum – This can result from traumatic injury to the ear drum or chronic untreated middle ear and mastoid infections, and sometimes after grommet tubes extrusions.
  • Middle ear bones pathology – Malformed, dislocated, fractured, eroded or fixed. This can be congenital, traumatic, or due to a chronic infection or tumor.
  • Cholesteatoma – A middle ear tumour that is not cancerous, but causes hearing loss by eroding the middle ear bones. May erode into brain, face nerve and ear balance organs. In congenital cases, it is easily mistaken as simply glue ear, as there is no perforation of the ear drum.
  • Mastoid infection – Chronic infection of the mastoid air cells and bony septations due to bacteria, fungus or unusual diseases like Tuberculosis.
  • Microtia auricle (malformed outer ear) and atresia ear canal (absent or narrowed ear canal). A complex reconstruction challenge, with psychological, facial nerve, middle ear bones, hearing and cosmesis concerns. May be associated with craniofacial disproportions or syndromes. Multiple combinations of management options need to be tailored to each patient’s anatomy and wishes.Photo 23 microtia
  • Central auditory processing disorder (CAPD) appears like hearing loss even though the child has normal hearing. Sound information, especially speech sounds in natural noise backgrounds, is not processed properly as the brain and ears don’t fully coordinate. Resulting speech, language and academic delays are common.
  • Acoustic Neuroma – Tumor of the hearing nerve impairs hearing, and may cause facial nerve palsy, giddiness and increased intracranial pressure with growth. Rare in kids except those with Neurofibromatosis Type II.
  • Giddiness – This is ear vestibular-related in some cases, usually from infections, and trauma. Other causes include migraine, drugs, neurological, heart and hormonal causes.
  • Tinnitus – This is often a result of hearing loss. It may also be due to tumors, abnormal vessels, thyroid dysfunction and drugs.
Significance:
  • Hearing loss is often missed, especially in children. A hearing test is a must before diagnosing autism, attention deficit disorder, academic and speech delay conditions.
  • 4 in a 1000 are born with hearing loss. In ill babies, severe jaundice, infections and trauma increases chances 4 to 10 x. Inadequate or lack of proper testing can result in speech and language delays, behavioural problems and misdiagnosis of low IQ for years if hearing loss is missed. Even mild bilateral hearing loss in children that is chronic can negatively impact learning and hearing with longer-term auditory processing and learning consequences, affecting eventual maximizing of potential and social and job options.
  • Many teenagers and young adults underestimate their noise exposure and the risk of noise-induced hearing loss. Have you had ringing ears after a cinema or clubbing event? That may mean there is irreversible hearing loss that often starts at high frequencies. Listening to your music via headphones at maximum risks hearing loss in less than 15 minutes.
Investigations offered:

The hearing tests and complete range of services are available in-house in sound-proof and sound-treated rooms, allowing the children’s ENT doctor to interpret the tests together with the audiologist to offer a treatment plan on an immediate basis. Closer collaboration also allows for increased safety of investigations requiring sedation, and optimizes outcomes.

  • Otoscopy and light microscopy – Otoscopy offers clear views of the ear canal and ear drum. Light microscopy magnifies these images many times, with increased clarity for diagnosis.
  • Newborn hearing screening and diagnosis – Diagnosis of hearing loss is missed in over 50% of newborns without proper screening. An Otoacoustic Emission (OAE) test without Auditory Brainstem Response (ABR) may miss 20% of hearing loss. In-clinic complete testing with OAE, ABR, Tympanometry and Auditory Steady State Response (ASSR) is available. Young babies can often be in natural sleep for the 1 hour test.
  • iStock_000027363346_MediumChildren hearing tests – Gold standard age-appropriate hearing diagnostic tests in appropriately sized sound-proof rooms by audiology professionals allow for accurate results in challenging child testing situations. Behavioral Observation Audiometry, Visual Response Audiometry, Play Audiometry, Pure Tone Audiometry and Tympanometry are all available. Children are less cooperative, with shorter attention spans, and need to feel comfortable and engaged. In-clinic specialised tests for children of different ages will be tailored accordingly. Light sedation of older children is usually required.
  • Eustachian tube dysfunction test – this can confirm if your inability to pop the ears or pressure pains – especially on airplane descent or in lifts are due to dysfunction of the cartilaginous-muscular tubes that connect your middle ears to the back of the nose
  • Tympanometry – this test shows the middle ear pressure and volume, and is a reflection of the state of the ear drum and middle ear. It is often flat in patients with fluid or pus in the middle ear.
  • Central auditory processing disorder tests – these are speech lists tests for children over 7 years of age or adults with normal hearing, usually requiring 2 sessions of 1-1.5 hours each under different conditions – e.g. in a noisy background or with competing sound information to both ears.
  • Radiology: CT scan temporal bone, MRI brain and Internal Acoustic Meatus are required to determine the anatomy of bony and soft tissue structures of the outer, middle and inner ear, cochlear, vestibular aqueduct, hearing and facial nerves and the brain. This also excludes infections and tumors.
  • Genetic testing: There are over 200 types of genetic hearing loss. Contrary to common perception, 75% of newborns or young with hearing loss do not have parents or relatives with hearing loss. The only way to exclude genetic cause is to do an appropriate blood test guided by history. In Singapore, 40% of patients with unknown cause of hearing loss and other body systems normally have a Connexin 26 gene mutation. Knowing the genetic cause guides management over a lifetime, as there may be associated eye, kidney, heart, or thyroid problems. It also suggests the progression and prognosis of hearing loss, besides helping families interested in determining the chances of hearing loss in future offspring.
Treatments Offered

Non-Surgical

  • Topical ear drops, oral medications, temporary cotton stents can help eliminate ear wax, and infectious, traumatic causes.
  • Gentle ear cleaning and culture sensitivity of infection fluids, removal of wax and foreign bodies under light microscopic visualization and fine instrumentation.
  • Central auditory processing disorder – Treatment has to be tailored to each child. A multi-prong approach is needed: changing the learning or communication environment, recruiting higher-order skills to help compensate, and remediation of the auditory deficit itself (computer- assisted, one-on-one training with a therapist, home-based/ group programs )
  • Hearing aids for a wide range of brands, sizes, types and degrees of sophistication
  • Customised for needs and listening situations.
  • FM systems for classrooms and halls to improve on HA performance.

Surgical

  • Non GA clinic procedures to release pus or fluid from the middle ear in adults.
  • Under GA (day surgery) to release fluid or insert grommet tubes for glue ears, repair perforated ear drums, reconstruct or replace with simple prostheses for malformed or eroded ear bones.
  • Under GA to remove ear tumors that could be malignant of benign e.g. cholesteatoma
  • Under GA to eliminate chronic or dangerous mastoid ear infections via tympanomastoidectomy.
  • Under GA for inserting various implants like bone anchored hearing aids, bone anchored hearing implants, middle ear implants for moderate-severe or mixed hearing loss, single-sided deafness and atresia of ear canal.
  • Under GA to insert cochlear implants for profound sensorineural hearing loss. Choice of Advanced Bionics, Cochlear and MedEl implants.