I am in my mid-50s, and in the past 12 years have had six tubes put in my left year due to otitis media. I have developed a polyp in this ear. A CT scan was done. I have been given three choices: (1) day surgery, wherein my ENT would remove the polyp through the ear canal; (2) extensive surgery, going behind the ear; (3) getting a third opinion. I elected the first procedure. Will that work, or may I wind up going again for procedure number two? Antibiotics have not helped; my ear canal is so small that eardrops are hard to put in.

T.

Ear polyps are round, red lumps of tissue that bleed readily, even with gentle manipulation. They are a sign of chronic inflammation, and they usually arise from the tissue that lines the middle ear (mucosa) through a hole in the eardrum. Polyps can also arise from the outer surface of the eardrum or from the ear canal skin, but the middle ear is the most common source. Since your ear, nose and throat doctor (ENT) has discussed mastoidectomy as an option (your second choice), I assume that your polyp does, indeed, arise from the middle ear.

Polyps are significant for two reasons. First, they say something about the severity and duration of middle ear inflammation. You have chronic otitis media, which is defined as a nonhealing hole in the eardrum, and is often associated with chronic middle ear inflammation. In addition to the perforated eardrum, chronic otitis media can cause hearing loss, dizziness, ear pain and chronic drainage from the ear.

Polyps are also significant because they can herald the presence of cholesteatoma, a nasty complication of chronic otitis media. Cholesteatoma is best defined as "skin growing where skin ought not to grow." In this instance, skin may be growing in your middle ear space. This is a problem because skin tends to produce more skin. The outer layers of skin die and flake off. Usually these flakes are so tiny that you don't notice them, but occasionally you may be conscious of this process. (Two examples are dandruff and sunburn peeling.)

When skin grows in the middle ear, the dead skin cells may not be able to exit. What results is a growing ball of skin -- not a true tumor, by the way, but it may as well be a tumor. This skin ball (cholesteatoma) can grow to enormous size, destroying everything in its path. It may even erode the base of the skull and punch its way into the brain. Cholesteatomas are slow-growing, however, so they are often compared to a time bomb with a very long fuse. Trouble is, you don't know how long this fuse is.

The diagnosis of cholesteatoma is sometimes obvious. Dead skin ("epithelial debris") has a characteristic appearance. However, if all the ENT sees on examination is a polyp, he won't know whether a cholesteatoma is present. That's where a CT comes in. A CT scan can help in the diagnosis of cholesteatoma. Unfortunately, it can be difficult, if not impossible, to differentiate a small cholesteatoma from chronic middle ear inflammation on CT.

Polyps can certainly be removed via the ear canal (your first option), but if your surgeon finds a large cholesteatoma lurking behind the polyp, you may need a more extensive operation (your second option). I don't have a crystal ball, and neither does your surgeon. Even if you do not have a cholesteatoma, it is very possible that the polyp is just the tip of the iceberg: The mucosa throughout your middle ear space (which includes the mucosa within the mastoid, the bone immediately behind and below your ear canal) may be extraordinarily inflamed. If this is the case, removal of the polyp will have little impact on your condition -- once again, you would need the more extensive operation.

So, unfortunately, I cannot tell you if the first procedure is going to work. Neither can your ENT. You may, indeed, need the second procedure. Should you get another opinion? From what you have told me, your care has been "by the book," but if you lack confidence in your doctor, you should seek another opinion.