Question Any point in a 2nd tympanoplasty?

[Whiskeyjack]

Hi, looking for guidance on this. My partner had a fungal and sinus infection around New Years 2024. After the infection cleared up, there was a perforation in her eardrum. It was quite large (the ENT let me look, maybe 1/4th the total membrane?), and had what looked like fairly developed scar tissue around the edges of the perforation. The ENT speculated perhaps the perforation was not new, but either way advised to wait 3 months to see if it would heal on its own.

3 months later, there was no change, it was not healing on its own. ENT advised a tympanoplasty, and so in mid April 2024, she had that done. Surgery went well, they used some fascia from above her ear. In late June she was cleared by her ENT to dive again, with the warning to be extra careful when equalizing.

We gave it another 2 months to be safe, and just recently went back in the water on August 24. After 2 dives the 1st day, she noticed her ear felt full of water and it was draining more liquid than it seemed like an ear should hold. She sat out the 3rd dive and all the dives the next day.

On Monday she went back to the ENT, and the graft was gone. There was no real explanation for why/how it happened. She was very careful equalizing, taking 10 minutes to descend to 10m. He is now saying the only option is to do another tympanoplasty, but this time a more invasive option where he cuts into her middle ear from behind instead of going through the ear canal and using a bigger? graft...

Quite frankly after how easily the 1st graft failed, I'm no longer very confident this will work any better. It will be another significant expense and recovery period for her.

We currently live in the Philippines, and had the original surgery done here. I'm now leaning towards having her consult a doc back in the US as I trust the doctors there to be competent much more.

Anyway, we're feeling pretty down at the moment, so looking for any advice or guidance anyone here can offer. Thanks!

 

[rob.mwpropane]

I have had 3 sinus surgeries from 3 different doctors with 3 wildly different outcomes (all in the states). Get a 2nd and 3rd opinion. Find a reputable doc. The 1st surgery messed me up so bad but because I didn't know any better I thought it was normal. Do as much research as you can, maybe find a doc that knows diving?

How's the joke go? "What do you you call a doctor who graduated at the bottom of his class?"

"A doctor!"

Good luck.. it's the worst to have to sit out or be in pain.

Edit: for what it's worth my 3rd ENT was Dr. Mark Hahn in Hunt Valley, MD. He did a great job and overall I'm happy. Would recommend. He actually found the root of my issue which neither of the other doctors could.

 

[Duke Dive Medicine]

Hi, looking for guidance on this. My partner had a fungal and sinus infection around New Years 2024. After the infection cleared up, there was a perforation in her eardrum. It was quite large (the ENT let me look, maybe 1/4th the total membrane?), and had what looked like fairly developed scar tissue around the edges of the perforation. The ENT speculated perhaps the perforation was not new, but either way advised to wait 3 months to see if it would heal on its own.

3 months later, there was no change, it was not healing on its own. ENT advised a tympanoplasty, and so in mid April 2024, she had that done. Surgery went well, they used some fascia from above her ear. In late June she was cleared by her ENT to dive again, with the warning to be extra careful when equalizing.

We gave it another 2 months to be safe, and just recently went back in the water on August 24. After 2 dives the 1st day, she noticed her ear felt full of water and it was draining more liquid than it seemed like an ear should hold. She sat out the 3rd dive and all the dives the next day.

On Monday she went back to the ENT, and the graft was gone. There was no real explanation for why/how it happened. She was very careful equalizing, taking 10 minutes to descend to 10m. He is now saying the only option is to do another tympanoplasty, but this time a more invasive option where he cuts into her middle ear from behind instead of going through the ear canal and using a bigger? graft...

Quite frankly after how easily the 1st graft failed, I'm no longer very confident this will work any better. It will be another significant expense and recovery period for her.

We currently live in the Philippines, and had the original surgery done here. I'm now leaning towards having her consult a doc back in the US as I trust the doctors there to be competent much more.

Anyway, we're feeling pretty down at the moment, so looking for any advice or guidance anyone here can offer. Thanks!

Can you clarify 'fungal and sinus infection'? Where exactly was the fungal infection?

Best regards,
DDM

 

[Whiskeyjack]

I have had 3 sinus surgeries from 3 different doctors with 3 wildly different outcomes (all in the states). Get a 2nd and 3rd opinion. Find a reputable doc. The 1st surgery messed me up so bad but because I didn't know any better I thought it was normal. Do as much research as you can, maybe find a doc that knows diving?

How's the joke go? "What do you you call a doctor who graduated at the bottom of his class?"

"A doctor!"

Good luck.. it's the worst to have to sit out or be in pain.

Edit: for what it's worth my 3rd ENT was Dr. Mark Hahn in Hunt Valley, MD. He did a great job and overall I'm happy. Would recommend. He actually found the root of my issue which neither of the other doctors could.

Thanks for the reply. The ENT we went to here is known in the diving community to be the best option as he's also a diver. I'm heavily leaning towards looking in the US, just hard to get a consult living here in PH.

 

[Whiskeyjack]

Can you clarify 'fungal and sinus infection'? Where exactly was the fungal infection?

Best regards,
DDM

Unfortunately we weren't really told anything beyond that is was a "fungal infection", and given anti-fungal drops which cleared it up. Symptoms were a white fungal growth in the ear canal combined with intermittent pain and itchiness.

I also had some itching and pain in my ear several years ago with what looked like white growth in the ear canal and was given the same diagnosis and treatment. It has not reoccurred to me since and I had no issues after that. It seems to be fairly common here in the Philippines. Unfortunately the doctors here are not in the habit of giving the patient any information that you don't drag out of them..

 

[Duke Dive Medicine]

Unfortunately we weren't really told anything beyond that is was a "fungal infection", and given anti-fungal drops which cleared it up. Symptoms were a white fungal growth in the ear canal combined with intermittent pain and itchiness.

I also had some itching and pain in my ear several years ago with what looked like white growth in the ear canal and was given the same diagnosis and treatment. It has not reoccurred to me since and I had no issues after that. It seems to be fairly common here in the Philippines. Unfortunately the doctors here are not in the habit of giving the patient any information that you don't drag out of them..

Ah ok. I heard "sinus" and "fungal" and put the two together. Glad that's not what it was.

Off the top of my head I'd wonder if there was still some underlying infection in the ear canal at the time of surgery or if your partner has a comorbidity that would slow healing. There's also a certain failure rate for tympanoplasty even for people in the best of health. @doctormike is an ENT doc and the real expert on these things. Will defer to him for detailed information.

Best regards,
DDM

 

[doctormike]

Ah ok. I heard "sinus" and "fungal" and put the two together. Glad that's not what it was.

Off the top of my head I'd wonder if there was still some underlying infection in the ear canal at the time of surgery or if your partner has a comorbidity that would slow healing. There's also a certain failure rate for tympanoplasty even for people in the best of health. @doctormike is an ENT doc and the real expert on these things. Will defer to him for detailed information.

Best regards,
DDM

Yes, exactly. Also, it's almost impossible to give accurate "Internet consults" about ear stuff, since you generally have no idea what is actually going on in the ear based on a description. Even video images may not tell the whole story.

In addition to underlying infections, there is the possibility of a cholesteatoma. That's beyond the scope of this discussion, and it's a terrible name, but in the words of Arnold Schwaznegger, "It's not a tumor!". It's a collection of skin that can grow in the middle ear, cause recurrent problems, and need much bigger surgery than just the patch to fix.

So unfortunately, the devil is in the details. If you want to continue diving, though, it might be worth seeing an actual ear specialist (an otologist). Feel free to DM me if you know where in the US you might go, and I can see if I know anyone in that city...

 

[Whiskeyjack]

Yes, exactly. Also, it's almost impossible to give accurate "Internet consults" about ear stuff, since you generally have no idea what is actually going on in the ear based on a description. Even video images may not tell the whole story.

In addition to underlying infections, there is the possibility of a cholesteatoma. That's beyond the scope of this discussion, and it's a terrible name, but in the words of Arnold Schwaznegger, "It's not a tumor!". It's a collection of skin that can grow in the middle ear, cause recurrent problems, and need much bigger surgery than just the patch to fix.

So unfortunately, the devil is in the details. If you want to continue diving, though, it might be worth seeing an actual ear specialist (an otologist). Feel free to DM me if you know where in the US you might go, and I can see if I know anyone in that city...

Thanks for the information. After going back to the ENT after diving he said the graft was gone and that there now a "polyp" in the ear. Unfortunately I wasn't there and my partner didn't get any more info so I don't know if the polyp is in the outer ear canal or if it was behing the graft. A Google search for "ear polyp" givese info about cholesteatomas so maybe that's related? She's been prescribed fluocinolone+ polymyxin+neomycin drops for that and will go back in in 10 days so I'll go with her and ask more questions.

My base in the US is Missoula,MT but I don't think there are any otologists there. I have a bunch of family in the bay area we could likely stay with so that is where I am thinking about, though it probably won't happen until next year sometime.

 

[doctormike]

OK, makes sense. A polyp is usually a sign of chronic inflammation, and could be associated with a cholesteatoma, or just a chronic perforation. Again, the devil is in the details!

 

[Whiskeyjack]

OK, makes sense. A polyp is usually a sign of chronic inflammation, and could be associated with a cholesteatoma, or just a chronic perforation. Again, the devil is in the details!

Two question for you...
1. I got to look at her perforation and the doc said as well that the edges of it were thickened and scarred over. It did not look like a new perforation, and it made no signs of closing on its own after 3 months. We were wondering if it's likely the perforation had been there for some time and she was diving with it unnoticed. Do you think that is likely? We dive 100+ days a year and we're in the water several weekends each month of 2023 before the perforation was discovered in December/January after her infection.

2. I realize this is not recommended, but in theory if she had an earplug or silicon ear cover that fully sealed her ear off, that wouldn't cause any problems since there's no need to equalize that side, right? She just needs to keep all water out of her middle ear, or am I misunderstanding the risks?