Smoking and Ear Disease

Smoking and Ear Disease

Smoking1For many years, ear doctors have believed (and educated their patients) that cigarette smoking increases the risk of middle ear disease and infection, and that the complications and outcomes are worse in patients that smoke.




The middle ear is an air-filled cavity which lies between the external and inner ear. It contains the three bones of hearing: malleus (hammer), incus (anvil), and stapes (stirrup). The eardrum and these bones transmit sound vibrations to the inner ear. The middle ear cavity is connected to the back of the nose (near the adenoids) via the eustachian tube which acts as a pressure equalising valve. The lining of the middle ear and the eustachian tube is the same as that in the nose.



Although the scientific literature contains conflicting reports on the role of passive smoking and the incidence of middle ear disease in children, to date there have not been any detailed studies analysing the risk of middle ear disease in  the actual smoker. At the Michigan Ear Institute we have shown that:


Summary of data from the Michigan Ear Institute:

Smokers have an increased risk of:

1.     middle ear disease  

2.     needing more complex surgery: if surgery is needed to eradicate the disease, then a more complex operation is needed (say 3 hours instead of 1.5hrs)

3.     complications after surgery: (ie reperforation &/or collapse of the reconstructed ear drum and hearing mechanism).

NB: Above data published October 2001 in the Laryngoscope Journal (Official Journal of the Triologic Society of America)



The effects of smoking on the middle ear and eustachian tube can be broken down into local, regional and systemic factors.

  • Local effects of smoking:
    • increased production and thickness of middle ear fluid.
    • paralysis of  hairs in the middle ear and eustachian tube that normally help clear middle ear fluid.
    • decrease in the blood supply to the middle ear and newly grafted ear drums.
    • NB:  a decrease in the blood supply to the inner ear (causing nerve deafness) has also been seen.
  • Regional effects of smoking (those that lead to obstruction of the eustachian tube):
    •  chemical irritation of the nose causing swelling of the nasal tissues.
    • nasal pathology (tumours).
  • Systemic effects of smoking (ie: effect on the whole body):
    • may suppress the immune system and lead to increased risk of  middle ear infections.
    •  if surgery is needed, smoking may affect the patient’s tolerance to general anesthesia.

 Scientific Abstract published last week in Laryngoscope

 Laryngoscope October 2001

Smoking and Tympanoplasty: Implications for Prognosis and the Middle Ear Risk Index (MERI)


Zoran Becvarovski, MBBS, FRACS; Jack M. Kartush, MD
From Michigan Ear Institute (Z.B., J.M.K.), Farmington Hills, Michigan; Providence Hospital, Southfield,  Michigan;         
Wayne State University, Department of Otolaryngology (Z.B., J.M.K.), Detroit, Michigan, U.S.A.                                                
St. George Hospital (Z.B.), Sydney, Australia..

Objectives/Hypothesis: The objectives of this study are to review the effects of smoking on preoperative middle ear disease severity, long-term surgical outcome, type and extent of surgery required, the need for ossicular chain reconstruction, and the long-term hearing results.

Study Design: A retrospective chart review.

Materials and Methods: The charts of 74 smokers and non-smokers who underwent over–under tympanoplasty were reviewed. An analysis of the disease severity (using the Middle Ear Risk Index [MERI]) at presentation and type of surgery was performed. A review of graft take and delayed failure (late perforation or atelectasis after 6 mo) and audiologic data were performed.

Results: Fifteen patients smoked a mean of 20 cigarettes daily for a mean of 15 years. The MERI was well matched for both groups. There was a trend toward smokers having a higher incidence of otorrhea preoperatively and requiring a more extensive surgical procedure. All patients had full take of the tympanic membrane graft at 6 months; however, delayed surgical failure was seen in 20% of non-smokers compared with 60% of smokers (P = .050). No statistically significant difference was seen in hearing outcome.

Conclusions: Cigarette smoking is associated with more severe middle ear disease preoperatively. More extensive surgery is often needed in smokers to eradicate the disease. Most significantly, smoking is associated with a threefold increase in the chance of long-term graft failure. Based on the results of this study, the MERI has been revised to include smoking as a risk factor.

Key Words: Tympanoplasty; smoking; over–under; Middle Ear Risk Index; perforation

LARYNGOSCOPE 2001;111:1806-1811