7. Chronic inflammation with suppuration of the epipharynx or
Eustachian tubes.
8. Cholesteatoma resulting from perforated drum and growths of
epithelium extending into the middle ear cavity.
=Diagnosis.=—The diagnosis is easy because nearly every case of
discharging ear without pain is chronic suppurative otitis media. The
determination of the exact nature of the condition present is not only
very important but very difficult.
Differential diagnosis consists in determining the nature of the
infecting organism and the nature and extent of the pathology.
1. Direct examination of the external meatus after drying with cotton
applicator usually determines the location and extent of perforation
of the drum and the general nature of the discharge, whether purulent
or mucopurulent. Very rarely one finds a serious discharge which means
a very slight infection or discharge from non-infective inflammation.
The presence of whitish or greyish pus, mucoid and stringy, usually
means pneumococcus infection. Greyish, purulent non-mucoid discharge
usually indicates streptococcus or bacillus influenzæ infection.
Yellow, purulent discharge suggests staphylococcus infection. The
general appearance of the discharge, however, cannot be considered of
important diagnostic value because most chronic suppurations are mixed
infections, because of long exposure to external contamination.
2. After cleaning the meatus, several smears should be made directly
from the opening in the drum. By staining with methylin blue or gentian
violet, the nature of the bacterial infection can be determined and
this is very important.
By staining another smear with hematoxylin and washing in water, any
dark irregular particles, bone debris, may be found, which means bone
disintegration. This too, is very important.
3. Transillumination is sometimes of value. The mastoid may be
transilluminated by placing a good rubber covered transilluminating
lamp over the mastoid and observing the external meatus through an
aural speculum. If the mastoid is free from infection the light will
pass through and illuminate the meatus.
4. The X-ray plate is, of course, the best means of determining the
nature and extent of mastoid involvement.
=Treatment.=—This is certainly one of the most difficult diseases of
the ear that one is ever called upon to treat and the physician should
be cautioned against offering a favorable prognosis. Perhaps the most
difficult thing about its treatment that the doctor has to learn is
that practically none of the so-called antiseptic washes do any good,
but on the other hand they often do harm. Certain general principles
are important and the treatment must depend upon the nature and extent
of the infection and pathology present in each case.
The constitutional treatment consists of everything that will increase
the patient’s general resistance and certainly all lesions of the
cervical, upper dorsal and mandibles must be properly adjusted, but
this is not enough. All spinal lesions that may exert an influence on
metabolism and elimination are of important consideration. The diet,
habits and environment of the patient must be considered.
A careful examination of the nasopharyngeal tract may reveal some other
focal infection, such as chronic tonsillitis, pharyngitis or sinuitis,
which is maintaining the infection through the Eustachian tube. There
may be a focal or general infection of some other part of the body,
which is reducing resistance or causing a hematogenous infection of the
tympanic cavity or mastoid cells.
Drainage must be maintained in all cases, both through the Eustachian
tube by catheter aspiration and through the drum by aspirating and
drying. If the perforation in the drum is small or in the middle or
upper part, it should be opened down to the floor so that the contents
may be more easily removed and better drainage established. It is well
first to thoroughly cleanse the meatus and tympanic cavity by syringing
with salt mixture (salt 3 parts, borax 2 parts and soda 1 part, a
teaspoonful to a half pus bowl of water) at from 116° to 118° F. After
syringing, the meatus is carefully dried, and the middle ear cavity
aspirated through the tube and drum opening. The advantage of this
simple treatment is thorough cleanliness and drainage with the minimum
of irritation. This treatment given daily or thrice weekly will often
cure the case.
Staphylococcus and streptococcus infections usually respond to the
following treatment: After thoroughly cleansing as above, the meatus
and tympanic cavity is syringed with a one to four or one to five
dilution of Dakin-Carrel solution (Hyclorite may be used instead)
followed by aspiration, the fluid being drawn through the tube, thus
preventing reinfection from that source.
Pneumococcus infections do not respond to either of these methods of
treatment. The pneumococcus, because of its capsule, is not affected by
antiseptics, but on the other hand the irritation of the tissues caused
by their use, only gives the infective agent a better opportunity for
growth.
In pneumococcus infections we have found the following method
efficient: Thoroughly cleanse the meatus and middle ear cavity by salt
mixture syringing, aspiration and drying. The meatus and tympanic
cavity is then filled with a neutral mineral oil. The oil is also
pumped through the Eustachian tube. It is the purpose to fill the
entire cavity and its openings so thoroughly that no air can enter.
In some cases we have used bismuth paste after the oiling with
excellent results. The pneumococcus is aerobic and if all air can be
kept away for a considerable time, it furnishes an unfavorable culture
environment with little irritation to the membranes.
=Surgical treatment.=—The presence of bone debris indicates bone
disintegration in the tympanic cavity or mastoid cells. If the mastoid
cells are thus involved there is little chance for direct treatment.
If such cases do not respond in a short time to any of the above
methods of local treatment, ossiculectomy or mastoid operation may be
necessary. Some specialist surgeons claim from 80% to 90% favorable
results from mastoid operation in such cases.