Full text of DOI:10.1097/00005537-200204000-00016

The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2002 The American Laryngological,
Rhinological and Otological Society, Inc.
Management of Chronic Otitis Media in the
Only Hearing Ear
Alex S. Battaglia, MD; Alain N. Sabri, MD; C. Gary Jackson, MD
Objective: Chronic ear surgery is difficult. The
management of such a disease either with or without
cholesteatoma and in an only hearing ear is particu-
larly challenging. Consequences of disease or unin-
tended outcomes of therapy can both result in patient
lifestyle alterations of major proportion. This report
offers a diagnostic and treatment plan for chronic
otitis media with and without cholesteatoma in the
only hearing ear. Methods: More than 10,000 charts of
patients with chronic otitis media were retrospec-
tively reviewed. Twenty-seven charts of patients with
chronic otitis media in an only hearing ear who un-
derwent surgical treatment were identified. The pa-
tients were followed for an average time of 43 months.
Results: Overall, the chronic otitis media was well
controlled, and there was no change in the average
discrimination or hearing thresholds when compar-
ing preoperative and postoperative results. Conclu-
sions: Chronic otitis media with and without cho-
lesteatoma in an only hearing ear can be treated
successfully with hearing preservation. Canal wall
down tympanomastoidectomy is performed in most
cases. Manipulation of the ossicular chain is avoided,
and cholesteatoma that lies over a potential fistula is
exteriorized. Key Words: Chronic otitis media, cho-
lesteatoma, only hearing ear, fistula.
those that are performed in a patient with normal hearing
in the contralateral ear?”
Several reports have been published addressing
these issues,1–7 although no consensus exists regarding
the indications and type of surgery to be performed.
Yamamoto et al.1 in 1997 performed intact canal wall
tympanomastoidectomy in 16 of 30 patients, and Perez
de Tagle et al.2 performed canal wall down tympano-
mastoidectomy in 7 of 8 patients. In both studies, sur-
gery was performed in cases of refractory otorrhea or
cholesteatoma involving an only hearing ear. In 1992,
Sanna et al.3 sent a questionnaire to prominent otolo-
gists in Europe and the United States asking how they
treat patients who have chronic ear disease in an only
hearing ear. The questionnaire indicated that there is
no consensus regarding type of surgical treatment, and
it also suggested that there is a mix of opinions regard-
ing indications for surgery. Respondents agreed that
cholesteatoma is a strong surgical indication whereas
refractory otorrhea is a weaker indication. Earlier re-
ports by Althaus4 in 1981, Gacek5 in 1973, Schuknecht
and Gacek6 in 1973, and Chandler and Freeman7 in
1972 confirmed the lack of consensus regarding indica-
tions for surgery and type of surgery to be performed.
We agree with the tenets put forth by Glasscock et
al.8 in 1990, who published a review of 12 patients treated
surgically for cholesteatoma in an only hearing ear, with a
follow-up of 2 to 48 months. Surgery was advocated in
cases of progressive hearing loss in association with
chronic ear disease, increasing cholesteatoma size, and
uncontrolled otorrhea. One-stage canal wall down proce-
dures were performed to minimize the number of opera-
tions performed on an only hearing ear. Cholesteatoma
that was over apparent cochlear and labyrinthine fistulas
was left in place, the overriding principle being to preserve
hearing.
Laryngoscope, 112:681–685, 2002
INTRODUCTION
When treating a patient with chronic otitis media in
an only hearing ear, many difficult management decisions
must be made regarding how to control the disease while
optimizing a hearing result. Questions arise such as the
following: “Is it appropriate to prolong medical manage-
ment of the chronic otitis media in these patients to min-
imize the risk of surgical compromise of the hearing in
that ear?” “Should a canal wall down mastoidectomy al-
ways be performed on an only hearing ear?” “What surgi-
cal maneuvers minimize the risk of hearing loss in an only
hearing ear, and how do these maneuvers differ from
In the current study, 27 cases are retrospectively
reviewed with an average follow-up of 43 months, and the
critical issues that arise when treating chronic otitis me-
dia in an only hearing ear are addressed. Indications for
surgery, complications from surgery, and hearing results
are discussed. Surgical maneuvers that minimize hearing
loss and optimize hearing results are highlighted, and
treatment recommendations are formulated.
From the Otology Group, Nashville, Tennessee, U.S.A.
Editor’s Note: This Manuscript was accepted for publication Novem-
ber 26, 2001.
Send Correspondence to C. Gary Jackson, MD, The Otology Group,
300 20th Avenue North, Suite 502, Nashville, TN 37203-2138, U.S.A.
E-mail: ozcycle2@aol.com
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Battaglia et al.: The Only Hearing Ear
681

13 years. To assess the hearing results after surgery, the patient’s
latest audiogram was compared with the preoperative audio-
gram. Because this analysis was meant to reflect the patient’s
ability to understand speech, both the pure-tone averages at 500,
1000, 2000, and 4000 Hz and the speech discrimination scores
were analyzed. This analysis is in accordance with the guidelines
established by the Committee on Hearing and Equilibrium for the
evaluation of results of treatment of conductive hearing loss.9 The
3000-Hz frequency was not routinely used.
Audiograms revealed mixed hearing loss in 21 of the pa-
tients, pure conductive hearing loss in three of the patients, pure
sensorineural hearing loss in two of the patients, and no hearing
loss in one patient. The patient who had normal hearing pre-
sented with chronic otorrhea but no cholesteatoma. In the 21
patients with a mixed loss, the sensorineural component could
not be attributed to any factor other than chronic otitis media in
the involved ear or a history of prior surgery.
Preoperative CT scans of the temporal bone were performed
primarily to assess the location and the extent of the disease
within the middle ear and mastoid and secondarily to look for
bony erosion of the otic capsule as an indication of labyrinthine
fistula. Six CT scans of the head with and without contrast were
performed in patients who had active drainage from the only
hearing ear to evaluate for abscess formation or dural
enhancement.
In patients with chronic otitis media without cholesteatoma,
aggressive medical management was empirically performed for
14 days with ciprofloxacin drops, 2% acetic acid, and broad-
spectrum intravenous antibiotics such as ceftriaxone plus levo-
floxacin. Surgery was performed only when medical therapy
failed (seven patients). In patients with cholesteatoma who had
progressive symptoms or signs (20 patients) surgery was recom-
mended. This included a case of room-spinning vertigo with pos-
sible labyrinthine fistula. Of the 27 patients, 25 had tympano-
plasties with canal wall down mastoidectomies in the only
hearing ear (Fig. 1). One patient had a classic Bondy procedure in
which the canal wall was taken down but the matrix was left
intact over the incus and malleus because the patient had excel-
lent hearing preoperatively. Postoperatively, his hearing re-
mained unchanged. Another patient had a transcanal tympano-
plasty, and a second patient had a tympanoplasty with intact
canal wall mastoidectomy (Fig. 1).
MATERIALS AND METHODS
Retrospective review of more than 10,000 charts was per-
formed. Twenty-seven patients diagnosed with chronic ear dis-
ease, with or without cholesteatoma, in an only hearing ear were
identified. An only hearing ear was defined as the opposite ear
having no response to pure-tone testing or as an ear with testable
pure tones but less than 50% discrimination.
On presentation, 26 of the 27 patients complained of inter-
mittent chronic otorrhea in their only hearing ear. Fifteen of
these patients complained of hearing loss. Only one patient com-
plained of hearing loss but no otorrhea. Eight of the 27 patients
complained of preoperative room-spinning vertigo, a sign of pos-
sible labyrinthine fistula. Nine of the 27 patients had prior sur-
gery on their only hearing ear, but the remainder were referred to
The Otology Group without a history of prior surgery. Seventeen
right ears and 10 left ears had been treated, and the average
duration of disease before surgery was 71 months. The age range
of the patients was 6 to 67 years, with 19 male and 8 female
patients.
The etiology of the contralateral dead ear was a point of
interest. Twelve of the patients reported experiencing a loss of
hearing after chronic ear surgery in that side. Nine of the patients
reported loss of hearing in that side during childhood episodes of
otitis media. One patient lost hearing on that side because of
trauma, another was diagnosed with sudden sensorineural hear-
ing loss, another was deaf at birth in that side, one reported
temporal lobe resection as a result of histiocytosis X, and the last
patient was diagnosed with autoimmune inner ear disease with
deafness on the contralateral side.
On physical examination, 20 of the 27 patients presented
with cholesteatoma. Six of the 27 patients had evidence of chronic
otorrhea without cholesteatoma. One patient who complained of
otorrhea had evidence on initial examination of severe atelectasis
but no cholesteatoma or obvious drainage.
Preoperative and postoperative audiograms as well as com-
puted tomography (CT) scans of the temporal bone were ordered
routinely. Audiograms were performed on a regular basis during
follow-up care for the patients. Follow-up ranged from 1 month to
The patient who had the transcanal tympanoplasty had a
central perforation anteriorly secondary to trauma with associ-
ated otorrhea. His perforation was easily and successfully ap-
proached in transcanal fashion. The second patient had cho-
lesteatoma in the anterior epitympanum and eustachian tube
and was thought to be safely removed without taking the canal
wall down. However, this patient did develop a perforation post-
operatively that had to be revised. A second time, the canal wall
was left intact, and the revision operation was successful.
In general, canal wall down mastoidectomies were per-
formed to optimize control of infection and cholesteatoma while
minimizing the risk to hearing. The goal of the surgery is to
achieve a safe, clean, dry, and healed bowl free from future
operations. Nerve integrity monitoring is performed routinely.
During the procedure, if the ear is found to be inflamed with
granulation tissue or frank pus or if labyrinthine fistula is sus-
pected, antibiotic prophylaxis is performed. One gram of cefazolin
IV is given unless penicillin allergy is apparent. In this case, 900
mg clindamycin IV is given once. Patients with evidence of laby-
rinthine fistula receive 10 mg dexamethasone IV to prevent post-
operative labyrinthine inflammation and hearing loss.
When the matrix of the cholesteatoma appears dimpled or
flattened over, a cuff of matrix with a 2- or 3-mm rim is left down
over the dimpled or flattened area. The rest of the cholesteatoma
matrix is removed. All air cells are removed in standard fashion
Fig. 1. Variety of operations performed.
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682
Battaglia et al.: The Only Hearing Ear

with a cutting burr, and the cavity is burnished with a diamond
burr. Once the cavity is clean, the remnant matrix is exteriorized.
In an only hearing ear, matrix should be left down on areas
suspect for fistulas, including cases when cholesteatoma is found
in the oval window niche. Cholesteatoma is removed from a
dehiscent facial nerve unless attached, and in our series no such
attachment, facial paresis, or paralysis occurred. No brain her-
nias were encountered.
TABLE I.
Significant Changes (Ͼ15%) in Discrimination.
Preoperative
Discrimination
Postoperative
Discrimination
No.
Associated Finding
1
2
3
4
32%
84%
96%
20%
0%
48%
60%
72%
Oval window cholesteatoma
with matrix left in place
No cause found
Labyrinthine fistula with
matrix left in place
RESULTS
5
8%
44%
Labyrinthine fistula with
matrix left in place
Residual Cholesteatoma and Postoperative
Otorrhea
Cholesteatoma was completely removed except in six
of the cases. In three of the cases, the matrix of the
cholesteatoma was left over lateral semicircular canal fis-
tulas. In three other cases, oval window cholesteatoma
was left intact to prevent postoperative sensorineural
hearing loss.
decrease in their hearing. Of the five patients who had a
decrease in their hearing thresholds, two retained 100%
discrimination whereas three had diminished discrimina-
tion. One of the three patients, as described earlier, had
cholesteatoma that was not removed from the oval win-
dow niche because of the risk to hearing, and his discrim-
ination dropped down to zero 4 years postoperatively. He
refused a cochlear implant. The second patient also had
oval window cholesteatoma that was not removed. Over a
6-year period, this patient had a slow drop in discrimina-
tion with a score of 48%, whereas it was 84% preopera-
tively. The third patient did not have residual cholestea-
toma but gradually developed a drop in discrimination
from 96% to 60% over a 5-year period after the surgery.
There was no infection or evidence of recurrent cholestea-
toma to explain this drop.
In the patients with lateral canal fistulas, none of the
patients lost their hearing. In one patient in whom the
matrix was left on the fistula, otorrhea developed 4 years
after the operation. There was a cholesteatoma sac cover-
ing the promontory that was opened to exteriorize the
cholesteatoma. The patient did have recurrent otorrhea,
which eventually resolved. The other two patients with
lateral canal fistulas have been followed without incident.
In the three cases in which cholesteatoma was left in
the oval window, one patient developed otorrhea 6 months
after the initial procedure. This was treated conserva-
tively and resolved on its own with otic drops. Another
patient with cholesteatoma left on the oval window devel-
oped infection 6 years after the procedure. This otorrhea
resolved independently and was not associated with per-
foration. The last patient with cholesteatoma left on the
oval window developed complete sensorineural hearing
loss 4 years after the procedure and later refused a co-
chlear implant.
Of the three patients who had cholesteatoma matrix
left on their labyrinthine fistula, one had stable hearing
The patient having transcanal tympanoplasty devel-
oped an otitis externa that did not threaten the integrity
of the graft. This infection resolved with otic drops, and
the graft healed nicely. Of note, recurrence of cholestea-
toma did not occur in patients who had their cholestea-
toma “completely” removed.
Hearing
No significant change in hearing was defined as a
change in discrimination of less than 15% and a change in
the pure-tone averages of less than 10 dB. On averaging
the hearing results of the 27 patients, no significant
changes in discrimination or in the pure-tone averages
were found. Five of the 27 patients did have greater than
15% change in their discrimination. Table I outlines the
changes in discrimination in these patients. Three pa-
tients had a drop in discrimination, and two of the pa-
tients had improvement in their discrimination and went
from unusable to usable hearing.
The changes in the air-conduction pure-tone average
at 500, 1000, 2000, and 4000 Hz are shown in Figure 2. Of
the 27 patients, 16 had no significant change in their
hearing thresholds. Six had greater than 10 dB improve-
ment in their hearing, and five had a greater than 10 dB
Fig. 2. Hearing results of latest audiogram (air-conduction pure-
tone average) compared with preoperative audiogram. Of the five
patients with hearing loss, two of the five did not drop their discrim-
ination, whereas three did.
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Battaglia et al.: The Only Hearing Ear
683

who had a lateral semicircular canal fistula had evidence
of the fistula on CT scan.
TABLE II.
Predictive Factors for Labyrinthine Fistula.
When cholesteatoma was present over a labyrinthine
fistula or in the oval window, the matrix was left in place.
When cholesteatoma matrix is left in place, the chance of
developing postoperative otorrhea and sensorineural
hearing loss is increased, more so, it seems, when left in
the oval window niche.
No. of Patients With Fistula/No. of
Risk Factor
Patients With Risk Factor
Preoperative vertigo
Prior surgery
3/8
3/9
3/1
Temporal bone CT-scan with
evidence of fistula
The management of a labyrinthine fistula or cho-
lesteatoma in the oval window in an only hearing ear
presents a critical problem. Should the cholesteatoma be
removed from the fistula or the oval window, or should it
be left in place? The presence of a fistula indicates an
increased risk of sensorineural hearing loss as shown by
Sheehy,16 who reported that 5 of 11 patients who had
postoperative sensorineural hearing loss had a lateral
semicircular canal fistula which was discovered intraop-
eratively. Gacek17 noted that when matrix was removed
from a cochlear fistula, 100% of the patients developed
profound sensorineural hearing loss. However, Gacek also
reported that when matrix was removed from a semicir-
cular canal fistula, no severe sensorineural hearing loss
was noted in nine of nine patients. In addition, Sheehy
and Brackmann12 reported that there was an identical
incidence of sensorineural hearing loss when matrix was
left on the fistula as opposed to being removed but sug-
gested leaving matrix over a fistula for later evaluation
during a second-stage procedure. Although there is a lack
of consensus regarding management of cholesteatoma
over labyrinthine fistulas, it is our opinion that the matrix
should be left on the fistula or in the oval window when an
only hearing ear is involved. We also assume that in an
only hearing ear the matrix is covering a fistula even
when the fistula cannot be detected preoperatively on
temporal bone CT scan or seen directly intraoperatively.
When taking these precautions, our results indicate that
cholesteatoma surgery on an only hearing ear can be per-
formed safely while minimizing the risk to hearing.
whereas two developed improved discrimination during
their follow-up. One patient had a preoperative discrimi-
nation score of 20% that increased to 72%, whereas an-
other patient had discrimination of 8% that increased to
44% over a 4-year period. Of the three patients who had
labyrinthine fistula, only one had evidence of a fistula on
CT scan preoperatively, although three of three patients
with fistulas had prior surgery, as well as preoperative
vertigo (Table II).
DISCUSSION
Chronic otitis media, with or without cholesteatoma,
in an only hearing ear poses a risk to the labyrinthine
function of the ear, and we suggest managing it surgically
if medical management fails and if there is no medical
contraindication. It is appropriate to evaluate all patients
with chronic ear disease in an only hearing ear with a
high-resolution CT scan of the temporal bone. This aids in
evaluation of anatomy and extent of disease. All therapeu-
tic and interventional measures are directed toward pre-
serving labyrinthine function. One-stage canal wall down
procedures are preferable for tympanic membrane perfo-
rations with cholesteatoma to minimize the number of
times that the ear is placed at risk. It is our surgical
philosophy to be concerned that cholesteatoma in an only
hearing ear is associated with a labyrinthine fistula. Ma-
trix over the otic capsule is exteriorized, and matrix over
a fistula is left intact. The ossicular chain is not manipu-
lated to minimize the possibility of footplate or oval win-
dow trauma. Therefore, cholesteatoma is not removed
from the stapes, and when fistula is suspected, perioper-
ative intravenous antibiotics and steroids are used.
Preoperatively, the presence of vertigo in patients
with cholesteatoma who have had prior surgery is a strong
indication that a labyrinthine fistula probably exists, and
patients in this scenario should be approached with cau-
tion in the operating theater (Table II). Of the eight pa-
tients who presented with preoperative vertigo, three had
labyrinthine fistulas discovered during surgery. Of the 27
patients, 9 had prior surgery, and all of the patients with
fistula fell into this prior surgery category (Table II). The
fistula test is not a sensitive indicator of a labyrinthine
fistula and has a reported false-negative rate of 50% to
54%.10–12 It was not used routinely. Sensorineural hear-
ing loss preoperatively also was not associated with the
presence of a fistula. Of the 27 patients, 22 had sensori-
neural hearing loss to some degree, and only 3 of these 22
had fistulas. Sensitivity of the CT scan for detection of
labyrinthine fistulas ranges in the literature from 55% to
97%.13,14,15 In our series, only one of the three patients
CONCLUSION
Chronic otitis media with or without cholesteatoma
in an only hearing ear can be treated successfully with
hearing preservation. High-resolution CT scans of the
temporal bone are performed on all patients with chronic
otitis media in an only hearing ear to evaluate anatomy
and extent of disease. Chronic otitis media without cho-
lesteatoma is treated with otic drops and broad-spectrum
IV antibiotics for 14 days. Refractory otorrhea and grow-
ing cholesteatoma are indications for surgical treatment.
Canal wall down tympanomastoidectomy is performed in
most cases, with control of disease and hearing preserva-
tion being the priorities. Manipulation of the ossicular
chain is avoided during the procedure. Cholesteatoma
that lies over a potential fistula is exteriorized.
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