Ear Balance / Tinnitus

Conditions managed:
      • Newborn – hearing loss – Can occur due to congenital infections (e.g. Rubella, CytoMegaloVirus, Toxoplasmosis, Herpes, Syphilis) or genetic causes with or without syndromes. Associated with some toxic drugs, ICU stay, hypoxaemia episodes, severe jaundice. Can result in cochlear, middle or outer 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.
      • Childhood hearing loss – Can be delayed presentation of newborn hearing loss, or due to new infections, toxic drugs, neurological disease.(Read More: How Hearing Loss Looks Like); (Read More: 10 things someone with hearing loss wish others know); (Read More: 10 Things to Know About Hearing Loss); (Read More: Through The Ears) Photo 20 Abcess around ear
      • Noise-induced hearing loss  – This is due to very high noise level exposure for just a few minutes (e.g. 110dB loudness for 15 minutes), or chronic high noise exposure (e.g.  80dB for 8 hours).(Read More: Noise-induced Hearing Loss); (Read More: Teaching Kids to Value Their Hearing)
      • 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. First branchial conditions needing surgery can put facial nerve and ear structures at risk and must be approached carefully.
      • Ear wax and foreign bodies – These can cause discomfort, infection and if severely impacted, reduce hearing.
      • Ear canal infection – This can arise from ear digging or trauma, swimming in dirty pools, skin pimple or abscess. Presents with foul smelling discharge and pain.(Read More: Little Ears, Big Problem) Photo 21  Glue Ear
      • Acute otitis media – This can be sudden onset, with pain and fever, pus in the middle ear and possible rupture of the ear drum. In young children, can cause brain abscess if treatment is delayed.
      • Chronic Otitis media – Also known as Otitis Media With Effusion/ Glue Ear, this can be recurrent or chronic, with fluid in the middle ear, and associated with infections or Eustachian tube dysfunction. Very easily missed by even doctors, due to ear wax and as changes in appearance of the ear drum may be subtle. May require hearing tests to confirm. Can result in significant and prolonged hearing loss, with speech and language delay.
      • 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, flu, cold, allergic rhinitis or sinus infections, cleft palate and adenoid enlargement. It leads to fluid trapped in the middle ear, resulting in blocked ear, hearing loss, poor balance, ringing ears.
      • Perforated ear drum – This can result from traumatic injury to the ear drum or chronic untreated middle ear and mastoid infections. Occasionally, perforations result from repeated or long term grommet tubes.
      • 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, unlikethat for adults, it is easily mistaken as fluid in the middle ear, as there is no perforation of the ear drum and no ear discharge.
      • Mastoid infection – Chronic infection of the mastoid air cells and bony septations due to bacteria, fungus or unusual diseases like Tuberculosis.Risk of brain of neck abscess if untreated.
      • 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
      • Auditory neuropathy – Diagnosis is easily missed. Child may pass usual awake simple hearing test or have only mild hearing loss. They will require special electrophysiological hearing tests like Auditory Brainstem Response test conducted by an alert audiologist working in consult with the ENT. A hearing aid alone may not help, and resulting speech, language and academic delays are common, with usual speech therapy treatment ineffective. Some will require cochlear implant surgery.
      • Central auditory processing disorder (CAPD) – Diagnosis is easily missed. Appears like hearing loss but child passes the usual hearing tests and can hear well. However, the brain cannot process properly what the ear hears. Sound information, especially speech sounds in noisy environments, competing sounds or longer instructions may not be processed properly by the brain. Resulting speech, language and academic delays are common, with usual speech therapy treatment ineffective.(Read More: Central auditory processing disorder CAPD); (Read More: When the Brain Does Not Hear)
      • 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.
      • Dizziness/ Vertigo – This is ear vestibular-related in some cases, usually from infections, and trauma. Other causes include migraine, drugs, neurological, heart and hormonal causes.(Read More: Dizziness and Vertigo); (Read More: When the Room Starts to Spin)
      • Tinnitus – This is often a result of hearing loss. It may also be due to tumors, abnormal vessels, thyroid dysfunction and drugs.(Read More: Tinnitus)
Significance:
        • Hearing loss is often missed, especially in children. Even moderate 50% hearing loss may be missed, and the speech problems attributed wrongly to the child’s young age. As the brain is most plastic before 4 years old, and can still improve a lot till 12 years of age, it is critical to diagnose a hearing loss early. 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 to 2 hour test..
        • iStock_000027363346_MediumChildren hearing tests – tests – Gold standard age-appropriate hearing diagnostic tests in appropriately sized sound-proof rooms by pediatric 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. Tests for children of different ages will be tailored accordingly.
        • 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. Pediatric anesthetists will give a short intravenous sedation if the child cannot tolerate the scans awake.
        • 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 – a wide range of brands, sizes, types and degrees of sophistication, with customized choices for different ages and listening situations.(Read More: Hearing Aids); (Read More: Things New Technology Hearing Aids Can Do)
        • Customized ear and swim plugs
        • FM systems for teachers, classrooms and halls to improve on HA performance. Personal and discrete Roger Pens microphone systems.(Read More: 10 Ways Technology Improves Hearing Now)
        • Tinnitus treatment – Medications, education, psychological counselling, avoidance of stress factors and stimulating substances ( e.g. caffeine), tinnitus maskers, customized music therapy

Surgical

        • Non general anesthetic (GA) clinic procedures to help release pus or fluid from the middle ear in adults, or insertion of grommet tubes.
        • Under GA (day surgery) - To release fluid or insert grommet tubes for glue ears - To repair perforated ear drums - To reconstruct or replace with simple prostheses for malformed or eroded ear bones.
        • Under GA(1 night stay) - To remove ear tumors that could be malignant of benign e.g. cholesteatoma - To eliminate hronic or dangerous mastoid ear infections via tympanomastoidectomy - To insert various implants (bone anchored hearing aids, middle ear implants or cochlear implants)(Read More: Cochlear and Middle Ear Implants ); (Read More: We Felt Helpless, Lost); (Read More: Did I Hear You Say Ear Implant?)
        • Under GA (few nights stay) - To perform microtia and atresia surgery - For hearing: possible reconstruction of ear canal (canalplasty) and malformed ossicles (ossiculoplasty), or bone anchored hearing aids/ bone anchored active implants, or middle ear implants

- For outer ear auricle reconstruction: choices include a prosthetic ear, Medpore (artificial graft) or patient’s own rib graft in the first stage, followed by the second stage with split skin graft from the abdomen and superficial temporal artery revascularisation.

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