Professor Dr. med. Serena Preyer is a distinguished expert in otorhinolaryngology (ENT), head and neck surgery, and facial plastic surgery. Since her appointment in 2016 as Medical Director at the ViDia Christian Clinics in Karlsruhe, she has not only brought her vast experience to bear but also unified the ENT departments of two renowned institutions—the Diakonissenkrankenhaus Rüppurr and the St. Vincentius Clinics—within this city of medical specialties.
With extensive expertise across all domains of ear, nose, and throat medicine as well as head and neck surgery, Prof. Dr. Preyer has established herself as a globally connected clinic director. Her proficiency spans from treating hearing impairments to performing complex surgeries for head and neck tumors. She emphasizes interdisciplinary collaboration to ensure her patients receive the highest quality of care.
Notably, she focuses intensely on auditory disorders of all kinds. Under her leadership, the Ear Center of Karlsruhe offers a comprehensive array of treatments for ear diseases. The interdisciplinary team includes experienced ENT physicians, radiologists, audiometrists, and additional specialists who also address hearing, speech, and language disorders in children. Prof. Dr. Preyer places great importance on outstanding nursing care.
The highly qualified nursing staff ensures a high level of treatment and attracts patients with hearing issues from both the region and across Germany. For complex auditory disorders, Prof. Dr. Preyer utilizes innovative solutions such as implantable hearing systems and cochlear implants to help patients regain an active social life. She also demonstrates exceptional expertise in treating ear malformations and tumors.
Beyond her specialization in hearing disorders, Prof. Dr. Preyer has extensive experience in managing nasal and sinus issues as well as head and neck surgical procedures. She successfully operates on a range of conditions—from thyroid disorders to tumors in the larynx and pharynx.
Reconstructive and functional plastic surgery of the nose following trauma or tumor removal is a high priority. Prof. Dr. Preyer directs the Head and Neck Tumor Center within the Oncology Department of the ViDia Clinics. This ensures personalized treatment according to international standards and supports patients well beyond the primary therapy.
Prof. Dr. med. Serena Preyer not only studied and earned her doctorate at prestigious universities but also completed numerous research fellowships both in Germany and abroad. This comprehensive expertise and her impressive capabilities make her a highly respected physician in her field.
The editorial team of Leading Medicine Guide wanted to learn more about middle ear surgery and took the opportunity to speak with Prof. Dr. Serena Preyer.
Middle ear surgery plays a crucial role in treating various hearing problems caused by middle ear diseases such as cholesteatomas, tympanic membrane perforations, or otosclerotic changes. Using innovative techniques and minimally invasive procedures, the aim of middle ear surgery is to preserve or restore hearing while minimizing complications.
The middle ear can be affected by various conditions.
“One of the most common middle ear conditions is certainly middle ear effusion—an accumulation of fluid in the middle ear. This often affects children, but also adults with upper respiratory infections. Initially, one may adopt a wait-and-see approach. However, if the condition becomes chronic, a ventilation tube should be inserted into the eardrum to resolve the effusion. If children experience frequent effusions, this can develop into chronic otitis media that persists into adulthood. These individuals often end up with a perforated eardrum, may suffer hearing loss, or develop a cholesteatoma—a chronic suppurative middle ear infection with bone destruction. In such cases, more extensive surgery is often required, such as the use of passive middle ear implants to restore the ossicular chain, tympanic membrane repair, or removal of the cholesteatoma,” explains Prof. Dr. Preyer at the start of our conversation.
Middle ear infections (otitis media): These are mostly acute infections of the middle ear caused by bacteria or viruses. Surgical interventions are not the first line of treatment in acute cases. However, if recurrent or chronic middle ear infections occur that do not respond to other treatments—e.g., cholesteatoma—or if an acute infection leads to complications, surgery may become necessary.
Cholesteatoma: A cholesteatoma is an accumulation of keratinizing cells in the middle ear. These can erode bone, leading to hearing loss and infections in surrounding areas such as the meninges. Surgical removal is necessary to prevent complications and preserve hearing.
Tympanic membrane perforation: A hole in the eardrum can cause hearing loss and predispose to infections. Small acute perforations often heal spontaneously, but larger or recurrent perforations require surgery to repair the eardrum.
Otosclerosis: A disease of the ear bone, where the ossicles stiffen, leading to hearing loss. In many cases, surgery—a stapedoplasty—is possible.
Otobasis fracture: If the middle ear is damaged due to head trauma, surgery can restore the ossicular chain and improve hearing.
The need for surgical intervention depends on the severity of the disease, associated symptoms, and response to other treatments. Surgery is considered when other treatments fail or complications arise. An ENT specialist should always determine the optimal course of treatment.
Cholesteatomas are abnormal growths or cysts in the ear, most commonly in the middle ear and less often in the external auditory canal. They typically arise from chronic inflammation or injury.
These growths consist of layers of skin cells that accumulate in the middle ear and can form sac-like structures. “The topic of cholesteatoma is indeed challenging, as cholesteatomas are hybrids of tumor and inflammation. Normal skin layers, like those on our outer skin, can appear in the middle ear. However, here the cells cannot shed properly and form a tumor-like growth. It is not actually a tumor in the true sense but a destructive inflammation akin to tooth decay. The danger lies in its location—adjacent to the skull base, meaning the brain lies beyond it. The destructive power of the cholesteatoma can destroy the ossicles causing hearing loss. If it invades the inner ear, dizziness and deafness can occur; if it extends to the facial nerve, facial paralysis may develop,” states Prof. Dr. Preyer. Regarding causes, she adds, “Cholesteatomas can be congenital—trapped skin in the middle ear. They may also develop due to ventilation problems, where a retracted eardrum adheres like wallpaper to the opposite wall of the middle ear, creating pockets that trap skin cells, leading to inflammation and bone destruction. Severe head trauma can also displace bone, allowing ear canal skin to grow into the middle ear.”
Early detection and treatment of cholesteatoma is vital to avoid serious complications like infection, hearing loss, and damage to nearby structures. “Compared to a benign acoustic neuroma—less dangerous as it does not induce inflammation—a cholesteatoma is riskier. Inflammation at the skull base can lead to meningitis or brain abscess,” emphasizes Prof. Dr. Preyer on the consequences of cholesteatoma. She also details patient symptoms: “Congenital cholesteatoma causes no pain. Patients usually notice hearing loss or facial nerve paralysis. A typical cholesteatoma manifests as painless ear discharge that is often foul-smelling and hearing loss. Patients with these symptoms should see an ENT specialist—ideally one experienced in ear surgery—with a microscope. Using an otoscope, one could miss it. Fortunately, cholesteatoma is rare—about 3 per 100,000 children and 9 per 100,000 adults in Europe.”
Tympanic membrane perforations can result from various causes.
A tympanic membrane perforation—a hole in the eardrum—is a condition where the eardrum is partially or completely missing. This opening can result from infection, trauma, pressure changes, or short-term exposure to very loud noise. Effects range from mild discomfort, ear pain, and tinnitus to hearing loss and recurrent infections. Diagnosis and treatment require careful evaluation by an ENT physician to avoid complications and preserve hearing.
The tympanic membrane, also known as the eardrum, is a thin membrane between the ear canal and the middle ear. It plays a crucial role in transmitting sound waves from the outer ear to the middle ear. A perforation or tear can result from various causes, affect hearing, and trigger recurrent middle ear infections.
“ENT surgeons identify two main forms of chronic otitis media: cholesteatoma (with bone destruction) and chronic mucosal inflammation, usually characterized by a hole in the eardrum. With a perforation, the ear may discharge clear or purulent fluid when inflamed. The patient is advised to have the perforation surgically closed to stop the discharge and prevent long-term hearing loss. If left untreated, a long-standing perforation may develop into cholesteatoma over the years. Regarding surgical advice, cholesteatoma always indicates surgery, while closure of a perforation is a recommended ‘optional’ procedure—especially for young patients. In patients with other health issues or for whom surgery poses significant stress, observation and annual monitoring may be preferred. Surgery remains possible later if needed,” explains Prof. Dr. Preyer.
- Fresh perforations sometimes heal spontaneously. The physician monitors healing. The ear should be protected from water and debris to aid healing.
- For larger or persistent perforations, surgery—tympanoplasty—is needed, using the patient’s own tissue (e.g., fascia or cartilage) to seal the hole and restore eardrum function. Depending on diagnosis, the procedure may be outpatient or inpatient, requiring specialized postoperative care.
- For smaller, acute perforations, the physician may place a patch over the hole to aid healing.
Regarding tympanic membrane repair, Prof. Dr. Preyer notes: “Surgeries for eardrum perforation are complex, simply because the ear’s anatomy is intricate. There are vital structures in the middle ear—the vestibular organ, cochlea, facial nerve, which runs through the ear, and even the taste nerve. These must not be harmed. ENT surgeons undergo extensive training. These procedures are typically performed under a microscope, particularly when significant bone removal is required—as in cholesteatoma surgery, where you must drill away diseased bone to fully clear it. Then the ear is reconstructed to restore function. Bone is removed and then rebuilt.” On procedure duration she adds: “Duration varies greatly. Sometimes it takes half an hour, but in extreme cases—like extensive cholesteatoma invading toward the brain—it can take up to six hours.”
There are two types of hearing loss: sensorineural and conductive.
“Sensorineural hearing loss occurs when the inner ear or auditory nerve is damaged. Causes can include genetics, aging, noise exposure, certain medications, infections, or conditions like Menière’s disease. Symptoms include hearing loss, difficulty hearing certain frequencies, tinnitus, and trouble understanding speech in noisy environments. Conductive hearing loss arises when sound transmission from the outer to the inner ear is obstructed—typically due to middle ear issues like eardrum or ossicle problems.
“With chronic middle ear infections, recurring inflammation can destroy the ossicles. Toxins produced by bacteria can also cause sensorineural hearing loss. People with long-term chronic otitis media typically have mixed hearing loss. Ossicular damage can be well compensated using titanium implants. Once the eardrum vibrates, these implants transmit vibration to the inner ear. Sensorineural loss cannot be offset by a passive implant, as the inner ear is an active amplifier that consumes energy,” explains Prof. Dr. Preyer.
Cochlear implants are often used to treat severe to profound hearing loss from various conditions.
“To compensate for sensorineural loss, one must introduce energy into the system via conventional hearing aids, active middle ear implants, or cochlear implants. Cochlear implants have been used for about 50 years. Initially reserved for completely deaf individuals, digital advancements have greatly improved implants over recent decades. As a result, implant candidacy now occurs much earlier, including for single-sided deafness. When both ears are affected and speech understanding with optimal hearing aids falls below 60%, cochlear implantation is now recommended,” states Prof. Dr. Preyer.
A cochlear implant is an advanced medical device designed to help individuals with severe to profound hearing impairment or deafness. Unlike hearing aids, which amplify sound, a cochlear implant works differently. The device converts sound signals directly into electrical signals that stimulate the auditory nerve and are interpreted by the brain as sound. It consists of two main components: external and internal. The external component includes a microphone, speech processor, and transmitting coil. Sound is picked up by the microphone, converted to digital signals by the processor, and sent via the coil to the internal implant. Surgically implanted, the internal part comprises a receiving coil, stimulator, and electrode array. The receiver coil picks up digital signals and sends them to the stimulator, which sends electrical impulses through electrodes placed along the length of the cochlea. These electrodes stimulate auditory nerve fibers in the inner ear, enabling the brain to perceive sound. In this way, the implant mimics the ear’s natural function by converting sound signals into electrical impulses interpretable by the brain.
For some, the idea of anchoring a hearing device in the skull to attach the internal coil may seem odd. “Patient reactions vary. Many are simply happy to hear again. It’s important to note that with this implant, hearing is mechanical transformed into electrical stimulation—there is no mechanical vibration. Therefore, the listening experience is different. Initially, patients describe the sound as sounding like Mickey Mouse or a cartoon voice due to fewer overtones,” explains Prof. Dr. Preyer, noting forthcoming improvements: “Manufacturers are working intensively on enhancements, and significant progress has been made in recent years so that recipients of cochlear implants not only regain speech understanding but also listen to and enjoy music again.”
After implant placement, a healing and adaptation period is necessary. “Since it is a surgical procedure, the implant site must first heal. After 1–6 weeks, the first fitting takes place at the implant center—setting the correct current level (amplitude)—not too high nor too low. The patient’s brain then begins to learn with the new signals, which is a lengthy process. Audiologists adjust the device periodically as it adapts to the new condition. The recipient’s hearing improves steadily. This process continues over 1–2 years until stable hearing is achieved, followed by at least annual lifelong checkups,” Prof. Dr. Preyer explains post‑implantation recovery.
Ongoing research and developments in middle ear surgery aim to shorten postoperative recovery time and improve outcomes.
When asked what’s currently happening in middle ear surgery and what hopes and dreams she has as an ear surgeon, Prof. Preyer replies:
“We are striving to perform ear procedures ever more minimally invasively. Endoscopic middle ear surgery via the ear canal is already possible today. At our clinic in Karlsruhe, we were among Germany’s first to adopt endoscopic ear surgery. This technique will continue to improve and spread, making post‑auricular incisions increasingly avoidable. A major benefit for patients is less postoperative pain due to reduced soft tissue damage. To reduce recurrence rates after cholesteatoma surgery, it would be desirable to complement surgical techniques with chemical treatments. Some substances already allow easier cholesteatoma removal, though the method is not yet fully refined. For cochlear implants, it would be wonderful if patients could achieve even better hearing quality for speech and music, even in noisy environments. A true dream would be delivering medication into the middle ear that migrates into the inner ear to repair damaged areas. That would be a tremendous leap in our field,” Prof. Dr. Preyer concludes, and with this, we end our hopeful conversation.
Thank you very much, Professor Dr. Preyer, for this insightful discussion about complex ear surgery!
