I am a 40-year-old white male who has had several tubes in my right ear over the past 10 years. The last one fell out last August and the hole has remained open and is apparently 1/4 the size of the whole eardrum. My hearing is slightly down in the right ear, but MUCH better than before the tube was put in. Do I need to get this hole closed surgically? What is the problem with just leaving it open? What are the risks with having the procedure to close it? Are there any les -invasive procedures to get it to grow closed when it's been open for so long?

Brad

You have a "chronic tympanic-membrane perforation," a hole in the eardrum that will not heal. If it has not healed during the past six months, chances are excellent that it will never heal. In your case, this is not such a bad thing.

In your letter, you state that you have had several tubes placed in this ear over the past 10 years, and that your hearing is much better post-tube than pre-tube. From this I surmise that the tubes have been placed to relieve a "serous effusion," which is an accumulation of fluid behind the eardrum. Your right eustachian tube has abdicated its duty to ventilate your middle ear, which is why you have needed so many tubes. The tube accomplished the same thing as a normal eustachian tube: it ventilated the middle ear space. And now the hole in your eardrum is serving this same purpose.

What would seem like a surgical complication is actually a blessing in disguise. If you have the hole closed surgically, there's a good chance you will develop another effusion and again require placement of a ventilation tube. What will you have accomplished? I can only think of two advantages to this scenario (the hole being patched, and another tube placed): First, your hearing COULD improve slightly. Second, you would probably have fewer problems avoiding water in the ear.

A hole that encompasses 1/4 of the eardrum will easily allow water to pass into the middle-ear space. This is very irritating, and it may even cause an infection. Tubes also allow water to pass into the middle-ear space, but since the hole is much smaller, it is a little more difficult for water to penetrate. Thus, if you leave the hole alone, you will have to be very careful to keep your right ear dry for the rest of your life.

The operation to repair the hole is called a "tympanoplasty" (or "myringoplasty" for less invasive approaches). The main risks of tympanoplasty are pain, bleeding, infection, failure of the graft to "take" and decreased hearing. (Yes, your hearing could become worse after this operation.)

There are, indeed, less invasive approaches to repairing a hole. These approaches are generally reserved for small holes, however, and I doubt they would work for a 1/4 perforation. Both are doctor's office procedures. In a "paper-patch myringoplasty," the doctor roughens the edges of the hole in some way, and then applies a tiny circle of paper onto the hole. In a "fat-patch myringoplasty," an incision is made in the skin on the back of the ear lobe, and a small plug of fat is removed. Once again, the edges of the hole are roughened (or removed entirely), and the fat plug is popped into the hole.

For the last several years, there has been a great deal of research on the application of growth factors to chronic perforations to encourage them to heal. (Growth factors are natural proteins that encourage cells to divide. They are vitally important for appropriate wound healing.) One common approach is to employ a paper-patch technique, using a paper patch that has been laced with an appropriate growth factor. This method is still considered experimental.