Q I live in Indonesia. I have had a problem in my ear for a few months.

I mainly experience pain and the sensation of a blocked ear. Once, there was bleeding from the ear.

I took many kinds of medication, including antibiotics. Nothing helped. Finally, after an X-ray, the doctor found that the infection was deep behind the bone. He said I had to go for surgery.

A You most likely have an infection - either otitis media or mastoiditis - which affects the middle ear and mastoid space.

Middle ear infections are common, even among children, and may be a consequence of upper respiratory tract infections.

The upper respiratory tract communicates, via the eustachian tubes at the back of the nose, to the middle ear space. Therefore, infections may spread from the respiratory tract into this space.

Symptoms of otitis media and mastoiditis include intense pain deep in the ear.

The sensation of a blocked ear arises from blockage in the eustachian tubes. Pus is unable to drain down the tubes, and thus remains in the middle ear.

These infections may not be associated with any ear discharge if the ear drum is intact as the pus is kept behind the ear drum. But if there is a perforation at the ear drum, the pus may flow through the hole, and may be stained with blood.

Infections of the middle ear, which is adjacent to the brain, may lead to complications, and need to be treated early. Poorly controlled middle ear infections may cause infections of the brain, such as meningitis or encephalitis.

Usually, middle ear infections are first treated with courses of oral antibiotics and nasal decongestants.

The antibiotics kill the bacteria, while the nasal decongestants help to decongest the nasal cavity and open the eustachian tubes to allow for better drainage of middle ear fluid.

Topical antibiotic ear drops may also be helpful if there are perforations in the ear drum as they allow the medication to reach the middle ear through the perforation.

Occasionally, patients may need to be hospitalised and treated with intravenous antibiotics. This would be necessary for the more severe forms of infection.

When complications occur, surgery may be needed. These include severe infections of the brain and skull base, as well as paralysis of the nerves that pass through or close to the middle ear space.

Other complications include erosion of the bone that protects the inner ear, which may lead to deafness and severe giddiness.

Surgery serves to drain any abscesses and remove as much of the infected and dead tissue as possible.

An operation may be also be performed to help eradicate underlying conditions that may predispose a person to middle ear infections, such as cholesteatomas.

In cholesteatoma, there is excessive collection of skin debris in the middle ear. This leads to frequent infections and also erodes the bone of the ear and skull base. The debris needs to be removed surgically.

Lastly, I would like to make a note about the radiological imaging of middle ear disease.

An X-ray scan, which you had, may be insufficient to diagnose the extent of the disease.

I would recommend a computed tomography scan and, possibly, a magnetic resonance imaging scan of the temporal bone to better evaluate the disease before recommending surgery.

The temporal bone is either of a pair of bones which form part of the side of the skull on each side and enclose the middle and inner ear.

DR BARRIE TAN

Head and senior consultant in the department of otolaryngology at Singapore General Hospital.