D. Hook for removal of foreign body.
]
If the operation has been performed under a local anæsthetic (and this
should only be done if a solitary furuncle is present), the pain is
usually too great to permit of firm packing of the auditory canal. This
after-packing, however, should be carried out, if possible, for the
following reasons: firstly, it presses out the contents of the furuncle;
secondly, it prevents auto-infection from one hair follicle to another;
and thirdly, it tends to dilate the auditory canal.
=After-treatment.= If the furuncles have occurred during the course of a
middle-ear suppuration, the gauze plugging must be removed within a few
hours after the operation. The ear is then syringed out once or twice
daily with a warm solution of lysol or carbolic acid, a small wick of
gauze soaked in a 10% solution of carbolic acid in glycerine being
afterwards inserted along the meatus.
If there be no accompanying middle-ear suppuration, the packing should
not be removed for at least twenty-four hours. The pain produced by the
first dressing may be severe, but can be usually avoided by first
soaking the gauze with 5% solution of cocaine for a few minutes before
removal and then gently withdrawing it whilst the ear is being syringed
with a warm aseptic lotion. For the next two or three days it is
sufficient to insert a drain of gauze soaked in a 1 in 3,000 alcoholic
solution of perchloride of mercury.
=Results.= Although cure may be expected, it is not uncommon for further
furuncles to occur in crops at repeated intervals. This is due to
auto-infection of the hair follicles, which to a large extent may be
prevented by painting the surface of the auditory canal daily, for at
least two or three weeks, with an oil containing a drachm of nitrate of
mercury to the ounce.
In the case of diffuse inflammation, although relapses are uncommon,
superficial necrosis of a portion of the bony meatus may afterwards
occur as a result of involvement of its periosteal lining. If this takes
place, stenosis of the auditory canal may afterwards occur from
subsequent cicatrization.
=Dangers.= With ordinary precautions no accident should occur, but the
following may be mentioned: (1) if the furuncles are deeply placed, the
tympanic membrane may be incised inadvertently, and a middle-ear
suppuration may result; (2) a too violent incision may cut through the
meatal cartilage posteriorly, and, as a result of septic infection, may
give rise to perichondritis of the auricle. This, fortunately, is rare.
REMOVAL OF EXOSTOSES FROM THE EXTERNAL MEATUS
=Indications.= The indications vary, depending on whether there is a
coexisting middle-ear suppuration or not.
=If there be no middle-ear suppuration.= Operation is not urgent, but is
justifiable under the following conditions:--
(i) _When one ear only is affected._ (_a_) If there be complete deafness
due to obstruction of the auditory canal. The question of operation,
however, should be decided by the patient, because it may be postponed
indefinitely so long as no symptoms occur.
(_b_) If there be recurring attacks of discomfort or of pain in the ear
as a result of eczema, of otitis externa, or of actual pressure of the
growth itself. The patient may desire operation to obtain permanent
relief.
(_c_) If there be deafness of the opposite side from other causes, and
the presence of the exostoses is causing deafness of the functionally
good ear.
(ii) _When both ears are affected._ In addition to the indications
already given, operation is advisable on the worse side if there be
almost complete obstruction on both sides, accompanied by recurrent
attacks of deafness, owing to the narrowed passage of the auditory
canal becoming repeatedly blocked from accumulation of cerumen or
epithelial débris.
_Operation is contra-indicated_ if previous examination indicates that
the deafness is due to a chronic middle-ear catarrh or internal-ear
disease, as in these cases restoration of hearing, which is the primary
object of the operation, will be impossible.
=If middle-ear suppuration be present= operation is generally advisable.
(i) _In acute middle-ear suppuration_ operation is urgent if there are
signs of retention of pus, _provided_ it is impossible to dilate the
lumen of the auditory canal. Before resorting to operation an attempt
should always first be made to obtain free drainage, as the obstruction
may be due merely to inflammatory swelling of the tissues lining the
auditory canal. With cessation of the acute inflammation, this swelling
may subside and the lumen of the auditory canal again become patent; and
if recovery with healing of the tympanic membrane takes place the
hearing may again become normal, rendering the operation no longer
necessary.
(ii) _In chronic middle-ear suppuration_ operation is always indicated
if there are symptoms of retention of pus. It is also advisable as a
prophylactic measure, although not urgent, even although no acute
symptoms are present.
=Operation.= =When there is no middle-ear suppuration.=
The operation may be performed either (_a_) through the external meatus
or (_b_) by reflecting the auricle forward by a post-auricular incision.
=Through the external meatus.= This method is only indicated if the
exostosis is situated at the entrance of the meatus and is pedunculated.
A general anæsthetic is given, the patient being in the recumbent
position. The surgeon works by reflected light. After the ear has been
thoroughly cleansed a large-sized aural speculum is inserted into the
meatus and the outlines of the exostosis are defined with a probe. A
small gouge or chisel is used. It is inserted into the meatus in such a
fashion that its point presses between the pedicle of the exostosis and
the wall of the bony meatus. With successive sharp taps of the mallet,
the gouge is made to cut through the pedicle, care being taken that the
instrument is not driven in too deeply, on to the tympanic membrane.
The growth, which can now be felt to be movable within the meatus, can
usually be removed by grasping it between the blades of forceps, or can
be expelled by syringing the ear. After its removal the auditory canal
should be plugged for a few minutes with a solution of cocaine and
adrenalin chloride. This checks all hæmorrhage, and at the same time
enables the surgeon to get a good view of the deeper parts to see if
further growths are situated more deeply within the meatus. Such
growths, provided they are pedunculated and do not abut on the tympanic
membrane, can sometimes also be removed by the same method; much depends
on their shape and situation. If sessile or too deeply placed, the
operation may have to be completed by reflecting forward the auricle.
Before terminating the operation a clear view of the tympanic membrane
should always be obtained.
The meatus is finally syringed out with a 1 in 5,000 aqueous solution of
biniodide of mercury and dried, a strip of sterilized gauze being
inserted into the auditory canal. A simple dressing is then applied to
the side of the head.
_Other methods of operation through the external meatus._
(_a_) Perforation of the exostosis, or enlargement of the small passage
existing between multiple exostoses, by means of the burr.
Although successful results have been recorded, this method is not
advised, as cicatricial tissue almost invariably causes closure of the
opening made. To keep the opening patent it is necessary to insert a
small lead or silver canula, frequently a source of great discomfort.
(_b_) If the exostosis has a very fine pedicle, it may be possible to
nip through its base with a pair of forceps, but it is not so sure a
method as the employment of a gouge and mallet.
(_c_) Such methods as attempts to destroy the growth by means of the
galvano-cautery or by the pressure of laminaria tents should be avoided;
they are useless and unsurgical.
=By reflecting the auricle forward.= This is indicated if the exostoses
are multiple, have a broad base, and are deeply situated.
The position of the patient, and the anæsthetic, are the same as in the
previous operation. Reflected light may not be necessary.
The ear and the surrounding parts are carefully cleansed and the head is
shaved for a short distance over and beyond the mastoid process. A
curved incision is made _close behind_ the auricle (Fig. 226), beginning
at the upper level of its attachment and extending downwards along the
retro-auricular fold. The incision goes down to the bone. The auricle is
reflected forward and the soft tissues are separated from the bone until
Henle’s spine and the posterior upper margin of the auditory canal are
brought into view. Any bleeding, chiefly from branches of the posterior
auricular artery, is at once arrested by pressure forceps, ligatures
being afterwards applied. The assistant’s duty is to hold the auricle
well forward and at the same time to keep the wound dry by swabbing.
The fibrous portion of the canal is carefully separated from the bony
portion with the periosteal elevator, the growth, if possible, being
exposed without tearing through the thin layer of skin which covers it.
The method of procedure now depends on the character and number of the
exostoses present.
(_a_) If situated superficially, they are removed by chiselling through
their base with a gouge. They should be thoroughly removed, if necessary
cutting through the normal bone well behind their base.
(_b_) If deeply placed, they are more easily removed by first chiselling
away a part of the upper posterior wall of the external meatus. This is
done in the same manner as in the early stage of the complete mastoid
operation (see p. 397). If possible the antrum should not be exposed,
and care should be taken not to cut too deeply for fear of injuring the
tympanic membrane.
(_c_) If the exostoses spring from the anterior wall, it is necessary to
make a T-shaped incision through the posterior membranous portion of the
auditory canal in order to bring them into view clearly. This is done
with a tenotomy knife, the flaps being held apart by means of forceps.
The growths can now be removed by means of the gouge and mallet.
(_d_) If the obstruction is due to multiple small exostoses forming an
annular stricture within the bony canal, it is better to separate the
membranous portion completely from the bony meatus. In doing so the skin
over the exostoses tears through, so that the membranous portion can be
reflected outwards as a finger-like process. To give greater room for
the operation, the auricle and fibrous portion are pulled well forward
by means of a loop of gauze passed through the lumen of the
cartilaginous meatus.
If necessary, reflected light should now be used. To reach the exostoses
it may be necessary, as in the previous case, to remove part of the
posterior bony wall. With the gouge and mallet the exostoses are
carefully chiselled away. They frequently abut on the tympanic membrane,
so that their removal without injuring it may be well-nigh impossible.
It is of the utmost importance that the field of operation should be
kept dry, if necessary by repeatedly mopping out the canal with pledgets
of cotton-wool soaked in adrenalin solution. The chief difficulty is to
determine the situation of the tympanic membrane. A fine probe is used
to discover any existing chink between the growths; this will be a guide
to show the direction in which to work. As soon as a small passage has
been made, sufficient to allow of a view of the deeper-lying parts, the
ear should be syringed out and dried, and a thorough inspection made.
The tympanic membrane can usually be seen as a greyish-blue membrane;
at other times it can be recognized by touching it with a probe. After
making certain of the position of the membrane, the rest of the
operation is easy. A small seeker (Fig. 219), such as is used in the
mastoid operation, is passed through the opening already made, and with
it the deeper limits of the exostoses can be felt. The opening is
gradually enlarged by removing the growths piecemeal with the chisel or
gouge.
Although the burr is contra-indicated when operating through the
external meatus, it is frequently of great service in these cases in
rendering the walls of the canal smooth. The disadvantages of using a
burr are, that it is less easy to control (unless the surgeon has had
considerable experience in using it), and that it destroys all the
epithelial lining of the auditory canal with which it comes in contact.
It should, therefore, only be used in those cases in which there is a
complete ring of exostoses, but should be avoided if the exostoses are
limited and if it is still possible to leave untouched a portion of the
epithelial lining of the auditory canal.
When the surgeon considers he has successfully removed the obstruction,
he should verify this fact by syringing out and drying the ear, and
again obtaining a clear view of the tympanic membrane.
The fibrous portion is now replaced by inserting a finger into the
cartilaginous meatus and pressing it back into the bony canal, the
auricle being meanwhile pulled back into its normal position. The edges
of the posterior wound are sutured together and the auditory canal is
gently packed with gauze which should be inserted right down to the
tympanic membrane. It is not necessary to make special meatal skin
flaps, as careful packing of the auditory canal should be sufficient to
keep the parts in apposition.
=When middle-ear suppuration is present.= _In acute middle-ear
suppuration_ the chief difficulty is to decide what operation to
perform. As operation is only indicated if there is retention of pus, it
is wiser to open the mastoid antrum; the exostosis, if superficial and
pedunculated, can also be removed at the same time. If, however, the
obstruction is due to multiple and deeply placed exostoses, this part of
the operation should be deferred to a later date, that is, after the
acute symptoms have subsided.
_In chronic middle-ear suppuration_ the only operation to be recommended
is the complete mastoid operation (see p. 392).
=After-treatment.= The after-treatment is practically the same whatever
operation has been performed. The first dressing need not be done until
the third day. The gauze plugging is then withdrawn and the auditory
canal is syringed out and dried. If only a single exostosis has been
removed the wound surface is small, and it is usually sufficient to
puff in some boracic powder and again insert a piece of gauze. This may
be repeated every second day, healing usually taking place within two or
three weeks. In the case of deeply situated multiple exostoses,
especially if removed from the anterior wall, considerable swelling of
the soft parts lining the auditory canal may occur as a result of the
manipulations. In such cases, after syringing out any existing
blood-clots, some cocaine and adrenalin solution should be instilled
into the meatus. An aural speculum is then gradually worked into the
auditory canal, which is gently mopped out with small pledgets of
cotton-wool, and the deeper parts are carefully inspected. Sometimes the
torn ends of the fibrous portion, instead of covering the bony walls,
are found to project into the auditory canal and to cause considerable
narrowing of its lumen. By careful manipulations with the probe or by
stroking the edges with tiny pledgets of cotton-wool, these rough
surfaces may be smoothed down. It is very important, in the early days
of the after-treatment, to prevent any narrowing at the site of the
operation. This is one of the chief causes of subsequent failure. The
gauze should always be reinserted right down to the tympanic membrane,
and if there is not much secretion it should be packed firmly against
the posterior and outer portion of the canal in order to prevent
subsequent stenosis from the tendency of the cartilage to prolapse
forward owing to the soft parts having been separated from the bony
canal at the time of the operation.
The wound behind the ear heals very quickly and the stitches can
generally be removed on the third or fourth day. Subsequent treatment
consists in preventing the formation of granulations over the wound
area. This is best accomplished by keeping the auditory canal aseptic
and dry. If granulations occur they should be touched from time to time
with a saturated solution of trichloracetic acid. If healing has not
taken place within two weeks, it will frequently be advantageous to
discontinue the gauze packing and, in its stead, to instil drops of pure
rectified spirit.
If a middle-ear catarrh with secretion of fluid occurs, owing to the
tympanic membrane having been injured, it may be impossible to continue
the gauze packing. In these cases only a fine drain of gauze should be
inserted into the meatus, the dressing being changed as frequently as
may be necessary.
Provided asepsis is maintained, the middle-ear inflammation usually
subsides rapidly with healing of the membrane. After healing has taken
place, inflation of the middle ear is recommended twice a week, for two
or three weeks, in order to aid recovery and to prevent adhesions
forming within the tympanic cavity.
=Dangers.= 1. If the exostoses be deeply situated, the tympanic membrane
may be injured.
2. If much of the anterior wall of the auditory canal be removed, the
temporo-maxillary joint may be opened.
3. It is possible that the tympanic membrane may not be recognized, and,
by working too deeply, the labyrinth or the facial nerve may be injured.
=Prognosis.= Provided no accident has occurred during the operation, a
successful result should be obtained. Stenosis, however, may occur from
cicatricial contraction if the operation has been incompletely
performed.
REMOVAL OF FOREIGN BODIES
Before considering the question of removal of foreign bodies, the
following points cannot be emphasized too forcibly:--(1) No attempt
should be made to remove a foreign body until it is certain that one
really exists. (2) Provided there is no middle-ear suppuration, a
foreign body left in the ear will very rarely cause any immediate harm.
(3) The most serious complications are due almost invariably to
ill-advised haphazard attempts to remove the foreign body; as a rule
from working blindly in the dark without making use of reflected light.
If a foreign body be suspected, the surgeon should first carefully
examine the auditory canal in order to determine its character and
position and the condition of its walls. On this will depend the
treatment to be employed.
If the object be a living insect it should be killed at once by the
instillation of warm oil, rectified spirit, or chloroform. This will
cause immediate relief of the intense pain and tinnitus which may have
been set up by its movements against the sensitive tympanic membrane.
The methods employed for the removal of a foreign body are syringing,
extraction by instruments through the external meatus, and removal by
operation by making a post-auricular incision and reflecting forward the
auricle.
=By syringing.= In the vast majority of cases syringing is successful,
and therefore should always be tried except under the following
conditions:--(_a_) If the foreign body be of such a nature that it may
be driven inwards; for example, a percussion cap for a toy pistol, lying
with its concavity outwards.
(_b_) If there be much inflammation and swelling of the walls of the
external meatus, unfortunately frequently due to previous unsuccessful
attempts at extraction by instruments. In such cases forcible syringing
may cause considerable pain, and in addition immediate removal of the
foreign body may be impossible owing to the temporary occlusion of the
meatus.
Unless urgent symptoms of retention of pus behind the foreign body are
present, it is wiser to wait for a few days until the inflammation has
subsided, in order that the canal may become more patent and permit of a
more favourable opportunity for removal of the foreign body. The
auditory canal, in the meanwhile, may be mopped out two or three times a
day with pledgets of cotton-wool, and a 1 in 5,000 alcoholic solution of
biniodide of mercury afterwards instilled into the ear.
The method of syringing has already been described (see p. 308). The
syringe should be a large one with its tip protected by some
india-rubber tubing. The point is inserted within the meatus up against
the foreign body and the stream of lotion is directed towards any chink
which may exist between it and the auditory canal. It may be necessary
to use many syringefuls with considerable force before the foreign body
can be expelled, but the syringing should be stopped if pain or
giddiness are caused.
If the foreign body cannot be removed at the first attempt, drops of
rectified spirit may be instilled into the ear several times a day,
provided there are no urgent symptoms. This will tend to diminish any
swelling of the soft tissues of the external meatus and of the foreign
body if it is a vegetable substance. The ear should again be syringed
after two or three days. In many cases this will now be successful; if
not, the foreign body may be moved gently with a probe (using a speculum
and reflected light), great care being taken not to push it further into
the auditory canal, and another attempt may be made to remove it by
prolonged syringing. If this fails it may be left _in situ_ for a still
longer period, provided there are still no symptoms requiring its
immediate removal. In some cases, instead of the instillation of
alcohol, a 5% solution of carbolic acid in glycerine or olive oil proves
more effectual.
In the case of a hard substance, repeated attempts may be made to
dislodge it before resorting to further measures; but in the case of a
soft vegetable substance like a pea, it must not be forgotten that
moisture tends to make it swell and perhaps will necessitate almost
immediate extraction by instruments.
Extraction by instruments.
=Indications.= (i) If inspection shows that the foreign body can at once
be removed by a suitable instrument: for example, a percussion cap the
edge of which may be grasped by a pair of forceps (Figs. 179 and 193);
or a small boot button whose shank, if it faces outwards, may be caught
by a small hook.
(ii) If repeated attempts have failed to remove the foreign body by
syringing.
(iii) If previous attempts by others have failed, and the foreign body
has been pushed in beyond the isthmus, and cannot be removed after
prolonged syringing.
(iv) If syringing produces violent giddiness, showing the probable
presence of a perforation of the tympanic membrane.
(v) If there be symptoms of acute inflammation of the middle ear or of
pus being pent up behind the foreign body.
[Illustration: FIG. 179. CROCODILE FORCEPS. Two-thirds size.
A, Points of crocodile forceps, full size.
B and C, Aural punch-forceps.
D, Aural scissors.
]
=Operation.= An anæsthetic may not be necessary in adults if the foreign
body is not too deeply placed within the ear, if its removal appears to
be a simple matter, and if the patient is of a placid temperament.
Otherwise, unless contra-indicated for some special reason, a general
anæsthetic should always be given in children, and it is also preferable
in adults for the following reasons:--(1) Inability to remove the
foreign body after repeated attempts by syringing usually means that its
extraction by instruments will be a somewhat difficult matter. (2) The
risk of injury to the meatal walls or tympanic membrane from involuntary
movements of the patient during the operation is far greater than the
risk of the anæsthetic. (3) If the foreign body cannot be removed
through the meatus by means of instruments, the post-meatal operation is
indicated. This, if necessary, can be done at once if the patient is
under a general anæsthetic.
If no anæsthetic is given the patient may sit up in a chair; otherwise,
the recumbent position is advised.
It is usually necessary to use an aural speculum, but if the foreign
body be situated near the entrance of the meatus a sufficient view may
be obtained by pulling the tragus forward and the auricle backward. Good
illumination is essential.
(i) _If the body be a soft substance_, such as a pea, the core of an
onion, or a fragment of wood, it is best removed by fixing into it some
form of sharp hook (Fig. 178, D). These hooks vary in shape. They may be
curved, or shaped like a crochet-hook, or have the sharp point placed at
right angles to the shaft of the instrument.
In the case of a round substance like a pea, especially if it is tightly
impacted within the meatus, its removal is sometimes facilitated by
first slicing it into pieces by means of a small bistoury.
As a rule, the foreign body is impacted at the junction of the
cartilaginous and bony portion of the auditory canal; sometimes,
however, it is more deeply situated within the osseous meatus, usually
the result of previous attempts to extract it.
[Illustration: FIG. 180. IMRAY’S SCOOP FOR EXTRACTING A FOREIGN BODY.]
In the former case, the instrument is passed along the upper posterior
wall of the canal between it and the foreign body, the point of the hook
being kept upwards or downwards so as not to project into the auditory
canal. The instrument is first passed well beyond the foreign body, and
then the shaft is twisted round so that the hook projects into the
auditory canal. With a quick movement it is drawn outwards a short
distance so that the point of the hook pierces the impacted substance.
Gentle traction is now used and in the majority of cases the foreign
body can be extracted.
If this fails, a slightly curved fenestrated scoop (Fig. 180) or curette
should be passed, if possible, between the foreign body and the anterior
wall of the auditory canal. The hook already fixed into the foreign body
prevents it from being driven further within the meatus, whilst the
scoop, if it can be got beyond the foreign body, can usually lever it
out.
If the foreign body has been pushed in beyond the isthmus and lies
deeply within the osseous canal, it is better to pass the hook along the
anterior inferior wall of the meatus, because owing to the inclination
of the tympanic membrane its anterior inferior margin is much more
deeply placed than its upper posterior part.
(ii) _In the case of a hard substance_, such as a piece of stone, coal,
or a bead, blunt hooks may be used instead of sharp ones. They should
be passed into the meatus _beyond_ the foreign body in the manner
already described.
(iii) _In other cases_, depending on its shape and position, the foreign
body is better removed by means of a snare, the loop of which is
manipulated round it and then drawn tight in the same manner as in the
extraction of a polypus.
The chief points to observe in these manipulations are (_a_) not to push
the foreign body farther in and (_b_) not to injure the walls of the
meatus or the tympanic membrane.
=Other methods of extraction= are--(1) _Drilling through the foreign
body_, if it is a hard substance, and then inserting a fine hook into
the opening so made. (2) _The agglutinative method_, which consists in
dipping a small paint-brush into a concentrated solution of seccotine or
glue and then inserting it into the meatus until it comes in contact
with the foreign body. The brush is left in this position for several
hours in the hope that it may become adherent to the foreign body; if
so, on withdrawing the brush from the ear, the foreign body should be
extracted with it. This method can only be used provided the ear is kept
dry.
These procedures, although said to be successful in a few cases, are not
recommended.
=After-treatment.= If the tympanic membrane and auditory canal have not
been injured, it is sufficient to dry the meatus and puff in a little
boracic powder. If there be abrasions of the canal, a small strip of
gauze should be inserted and changed as frequently as it becomes moist
with secretion, the meatus, if necessary, being also syringed out with
an aseptic lotion. If there be acute inflammation of the walls of the
canal, accompanied by much swelling and purulent discharge, drops of
glycerine of carbolic (1 in 10) may be instilled frequently. After the
inflammation has subsided, an alcoholic solution of 1 in 3,000 biniodide
of mercury may be employed. If the tympanic membrane has been injured,
either from the presence of the foreign body itself or from the attempts
at extracting it, the treatment is similar to that for an ordinary
middle-ear suppuration.
=Removal by operation.= This may be done in the following ways:--
=By means of a post-aural incision.=
=Indications.= (i) If prolonged attempts to remove the foreign body by
instruments have failed. This operation becomes imperative if there are
signs of retention of pus within the middle ear.
(ii) If the foreign body has been pushed into the tympanic cavity and
cannot be removed otherwise. In such cases, if the perforation is large
and the foreign body is small, an attempt may first be made to dislodge
the substance by injecting fluid into the middle ear through the
Eustachian tube by means of the catheter and syringe (see p. 372). This
method, however, is rarely successful.
=Operation.= The procedure is the same as for the removal of exostoses
(see p. 318). After separating the fibrous from the bony portion of the
canal, an incision is made through it and the cut edges are held aside
with forceps. Usually the foreign body can now be seen lying within the
canal. It is best removed by passing a small fenestrated curette beyond
it and levering it out. In some cases one of the hooks already mentioned
will be found to be more suitable. Forceps should not be used, as they
may inadvertently push the foreign body farther in. If the foreign body
be very deeply placed, removal of the upper posterior portion of the
bony meatus may be necessary. The subsequent steps of the operation and
its after-treatment are similar to that already described in the case of
an exostosis.
=By means of an operation upon the mastoid.=
=Indications.= (i) If the above measures fail to remove the foreign
body.
(ii) If there be symptoms of inflammation of the mastoid process, or of
internal-ear or of intracranial suppuration.
(iii) If there be facial nerve paralysis the result of pressure from the
foreign body.
=Operation.= The operation performed depends on the condition found.
Simple opening of the mastoid antrum may be sufficient in a case of
recent middle-ear suppuration, although it is usually necessary also to
remove a considerable portion of the posterior wall of the auditory
canal before the foreign body can be extracted. If these measures fail,
an attempt may be made to dislodge the foreign body by forcibly
syringing through the aditus, or by the insertion of a probe through it,
into the tympanic cavity. If this likewise ends in failure, it will then
be necessary to perform the complete operation. These cases fortunately
are rare.
If it be certain that chronic middle-ear suppuration already exists, the
complete mastoid operation is indicated.
If it becomes necessary to operate on the mastoid process, owing to
other means having failed to dislodge the foreign body, it is wiser, as
a rule, to perform the complete operation at once, because, under these
circumstances, irreparable destruction must have taken place within the
tympanic cavity.
The technique of these operations and their after-treatment are
described in the chapter on operations upon the mastoid process (see p.
390).
OPERATIONS FOR STENOSIS OF THE EXTERNAL MEATUS
Stenosis, or stricture of the auditory canal, is practically always the
result of traumatism or inflammatory conditions; it is only very rarely
congenital.
=Indications.= (i) If there be deafness of the other ear, and the
functionally good ear periodically becomes deaf from obstruction of the
narrow passage by cerumen or epithelial débris, and the patient is weary
of conservative treatment.
(ii) If there be recurrent attacks of otitis externa.
(iii) If there be retention of pus, the result of inflammation of the
external or middle ear, which is not relieved by conservative treatment.
_The operation is contra-indicated_ if there is accompanying deafness,
due to chronic middle-ear or to internal-ear disease, provided there is
no suppuration within the external or middle ear.
=Operation.= The method of operation depends on whether the stricture is
membranous, fibrous, or bony in consistence, or whether it is limited or
is causing a general narrowing of the auditory canal. It may take one of
the following forms:--
_Dilatation._ This method is not very satisfactory, and is limited to
recent cases of membranous or fibrous stricture of the annular variety.
After cleansing the meatus, a small laminaria tent is inserted through
the stricture, and if the pain is not too severe it is left _in situ_
for at least twenty-four hours and then withdrawn. The ear is again
carefully cleansed, and if possible a larger laminaria tent is
substituted. This procedure is repeated until the maximum amount of
dilatation has been obtained.
_Incision of the stricture._ This also is limited to membranous or to
fibrous strictures of the annular variety.
The operation, if necessary, may be performed under a local anæsthetic,
produced by subcutaneous injections, although usually a general
anæsthetic is preferable.
The ear and surrounding parts are surgically cleansed by the ordinary
methods. The surgeon works by reflected light. The patient may be in
either the sitting or the recumbent position, depending on whether a
local or general anæsthetic is given. In the latter case the auditory
canal should be filled with cocaine and adrenalin solution before the
anæsthetic is administered in order to diminish bleeding as far as
possible.
The ear having been dried, a conveniently large aural speculum is
inserted, and with a tenotome or a furunculotome radiating incisions
are made through the stricture. One of the small flaps thus made is
grasped with a fine pair of tenaculum forceps, and the surgeon cuts
through its base, keeping the knife as close as possible to the wall of
the auditory canal. Each flap is treated in a similar fashion. Instead
of making radiating incisions, the tissue forming the obstruction may be
transfixed through its base, the knife being made to cut in a circular
fashion right round the auditory canal, keeping as close as possible to
its wall.
On completion of the operation, a piece of india-rubber tubing, of as
large a size as possible, is inserted into the dilated canal. It should
only be removed for the purpose of cleansing and should be at once
reinserted. A silver canula, if necessary, can afterwards replace the
india-rubber tubing. This canula may have to be worn for months.
This operation is often most unsatisfactory, as the stricture, instead
of being annular as first supposed, may be found, on operation, to
extend a considerable distance along the auditory canal and, in
addition, to be partially due to a general thickening of the underlying
bone.
_Excision of the stricture._ The auricle is reflected forward and the
preliminary steps of the operation are performed as already described
for removal of a deep-seated exostosis (see p. 319). The surgeon makes a
transverse incision with a knife through the fibrous portion of the
auditory canal, just external to the stricture, and carries it right
round the meatus, thus separating the outer portion of the membranous
from the bony canal. The fibrous portion is now pulled outwards by means
of a retractor, and the thickened tissue, forming the stricture, is
peeled off from the surrounding bony meatus with a small periosteal
elevator and so removed. If the stenosis is partially due to thickening
of the walls of the canal itself, it may also be necessary to chisel
away a considerable portion of its upper posterior part. After
completion of the operation a clear view of the tympanic membrane should
be obtained.
In this operation a considerable portion of the bony canal is denuded of
its epithelial lining membrane, so that there is a special tendency to
the re-formation of cicatricial tissue. To prevent this taking place two
methods may be employed:--(1) If much of the upper posterior wall of the
bony meatus be removed, a post-meatal flap should be made and kept in
position by means of a catgut suture carried through the skin behind the
auricle. The formation of such a flap is described as a step in the
complete mastoid operation (see p. 401).
(2) If no bone be removed, the membranous portion is replaced _in situ_,
the posterior auricular wound closed, and as large an india-rubber tube
as possible is inserted into the meatus. A week or ten days later, as
soon as granulations begin to form, skin-grafting may be undertaken (see
p. 410).
If grafting be not successful, the india-rubber tube or silver canula
must be kept constantly within the meatus (only being removed for
cleansing purposes) until healing takes place.
_The complete mastoid operation_ is indicated in the case of stenosis
occurring in chronic middle-ear suppuration if symptoms of retention of
pus occur.
In acute middle-ear suppuration, however, every attempt should be made
to avoid operation, as the lumen of the auditory canal may again become
patent after the acute inflammation has subsided.
OPERATIONS FOR ATRESIA
Atresia of the external meatus may be either congenital or acquired.
=Indications.= (i) _In congenital cases_ operation is only justifiable
if the atresia is due to a _membranous web_ situated in the outer part
of the auditory canal and if, as a result of tuning-fork tests and of
inflation through the Eustachian tube, it is fairly certain that the
middle ear is normal.
_Operation is contra-indicated in cases of bony atresia._ Although
attempts have been made to make an artificial canal in order to restore
the hearing power, a successful result has not yet been obtained. Apart
from the difficulty of retaining the patency of any canal so made, the
accompanying malformation of the middle ear renders a successful result
impossible (Paper by author, _Journal of Laryngology, &c._, March,
1901). Although the tympanic membrane is said to have been exposed by
operation in a few cases, experience has shown that the supposed
tympanic membrane was really the capsule of the temporo-maxillary joint.
(ii) _In acquired cases_ operation is indicated if the other ear is
deaf; if the site of the occlusion of the auditory canal is in its outer
part and is due to membranous or fibrous tissue, and if there is no
previous history of middle-ear disease, and if the labyrinth is still
intact.
Operation is not advised if the other ear is normal, unless the patient
particularly desires it.
_Operation is contra-indicated_ if there is internal-ear deafness on the
affected side and if the other ear is normal; or if there is a definite
history of the closure of the auditory canal having been the result of a
previous middle-ear suppuration. In the latter case the destructive
changes within the tympanic cavity will be so marked that the chances of
improving the hearing will be very slight in spite of the most
successful operation.
=Operation.= If the obstruction be due to a fibrous band, an attempt may
be made to remove it by excising it by the intrameatal method. In other
cases the post-auricular method is necessary.
The chief point to remember is to make a large opening. For this reason
the post-auricular method is to be preferred, as a considerable portion
of the upper posterior wall can be removed and a large meatal flap
fashioned (see p. 401).
=Results.= If the stricture or point of occlusion of the auditory canal
is limited and composed of membranous and fibrous tissues, a good result
can be usually obtained, and there is no reason why complete recovery of
hearing should not take place if the labyrinth and tympanic cavity are
normal.
Unfortunately, as in all cases of stricture, there is a tendency for it
to recur.
OPERATIONS FOR AURAL POLYPUS
In this section only the aural polypi which project from the tympanic
cavity into the external auditory meatus will be considered; whereas the
treatment of granulations, and with them the minute polypi which are
still limited to the tympanic cavity, will be discussed in the chapter
on operations within the middle ear.
=Indications.= An aural polypus should _always_ be removed because,
apart from the fact that it is a symptom of underlying disease, it may
obstruct free drainage of the purulent discharge, and therefore become a
source of danger.
=Operation.= The simplest and the best method is _removal by the snare_.
In the case of small and soft polypi, the polypus is removed by
traction--formerly called =avulsion=--after the snare has been tightened
round its pedicle; with a large, tough, fibrous polypus considerable
force may be required to tear through its pedicle. This procedure in the
case of polypi arising from the region of the tegmen tympani has been
known to give rise to fatal meningitis. In such cases the pedicle of the
polypus should be cleanly cut through by the snare--so-called
=excision=.
As aural polypi are always associated with suppuration, it is especially
necessary that the ear should be thoroughly cleansed before operation.
A local anæsthetic (see p. 310) is sufficient in the case of smaller
polypi, but if the polypus be large and tough, it is wiser to give a
general anæsthetic, such as gas and oxygen. Or a 3% solution of cocaine
may be injected into the growth, which, according to Frey of Vienna,
renders removal absolutely painless; this, however, has not always been
my experience.
The size of the polypus and the origin of its pedicle should be
determined before operating, if necessary by using a probe (Fig. 181);
also it must be diagnosed from a bulging congested tympanic membrane, or
from the inner surface of the tympanic cavity, which may be exposed to
view owing to complete destruction of the membrane having already
occurred.
[Illustration: FIG. 181. AURAL PROBE.]
[Illustration: FIG. 182. WILDE’S AURAL SNARE. The snare is held in the
usual position for extraction of a polypus.]
A Wilde’s snare is generally used. It is a fine angular snare fitted
with soft copper wire. The loop of the snare should be bent downwards
and forwards and should be of such a size as to just surround the
growth. The snare is held between the thumb and the first and second
finger of the right hand (Fig. 182). Under good illumination, and using
the speculum and reflected light if necessary, the shaft of the snare is
passed along the upper portion of the auditory canal until the edge of
the polypus is reached. The loop is made to encircle the polypus (Fig.
183), the snare is gradually pushed inwards with a gentle sinuous
movement until it reaches the point of attachment of the growth. The
loop is then tightened until it firmly grasps the neck of the polypus
(Fig. 184). The friable tissue is torn through by gentle traction and
the polypus is withdrawn in the snare. Care must be taken not to injure
the tympanic membrane through which the polypus may be projecting; it is
for this reason that the loop is bent at an angle to the shaft of the
snare so that it may lie parallel to the tympanic membrane whilst in the
act of grasping the polypus. If the polypus be very small its pedicle
may be clearly defined before operation, and the snare passed round it
directly (Fig. 185).
If the polypus be very large and tough, the snare is made to cut clean
through its pedicle as near to its attachment as possible, instead of
employing traction. The snare is then withdrawn, the polypus being
afterwards grasped and removed by means of forceps. In this latter case
it may be necessary to use a stronger snare fitted with piano steel wire
instead of the ordinary copper wire. On removal of the polypus there may
be considerable hæmorrhage. After it has ceased the ear is syringed out
and dried. The auditory canal is then inspected, and if it is found that
the growth has not been removed completely, this can be done now by
reapplication of the snare.
After final cleansing of the meatus, a strip of gauze is inserted, and
the ear protected with a pad of cotton-wool and a bandage.
=After-treatment.= The dressing should be removed within twenty-four
hours, and the ear cleansed by syringing. After mopping it dry drops of
rectified spirits should be instilled.
On removal of the first dressing, any polypoid tissue which remains may
be cauterized under cocaine anæsthesia by the actual cautery, or by a
bead of chromic or trichloracetic acid (see p. 348).
[Illustration: FIG. 183. WILDE’S SNARE BEING PASSED ROUND AN AURAL
POLYPUS. (_Semi-diagrammatic._)]
Further treatment consists in keeping the ear clean and dry. For the
first few days it should be syringed daily, dried, and spirit drops
instilled. As the secretion becomes less the syringing should be
diminished. If the perforation be large, instead of instilling drops,
some finely powdered boric acid may be puffed in.
=Other methods of removal.= These are not recommended, but merely
mentioned for the sake of completeness.
_By forceps._ The rough and ready method of extracting a polypus
forcibly from the ear by means of forceps, although practised formerly,
has now been discarded as being unsurgical and dangerous.
_Ligation._ The operation consisted in passing a snare over the polypus
and grasping it tightly as near to its base as possible. The snare was
then twisted round its axis in order to tighten the loop further and so
obliterate the blood-supply of the growth, the wire of the snare being
afterwards cut through with pliers and the snare withdrawn. After a few
days the polypus became gangrenous from want of blood-supply, and
separated from its deep attachments.
_Curetting._ This method, which should only be made use of in the case
of small multiple polypi within the tympanic cavity, will be considered
when discussing the treatment of granulations within the middle ear (see
p. 398).
=Dangers.= Hæmorrhage is seldom profuse, but if it is, it can always be
arrested by packing the meatus with cocaine and adrenalin solution.
[Illustration: FIG. 184. WILDE’S SNARE GRIPPING THE NECK OF POLYPUS.
(_Semi-diagrammatic._)]
[Illustration: FIG. 185. POLYPUS ARISING FROM THE ATTIC REGION. The
snare is in position for the extraction of the polypus.
(_Semi-diagrammatic._)]
The chief dangers are injury to the contents of the tympanic cavity,
such as dislocation or removal of the ossicles; or subsequent
meningitis. These mishaps are usually the result of forcible extraction,
or of blindly curetting the ear after this has been done. Meningitis,
however, has been known to occur, in spite of every precaution being
taken, if, owing to caries of the tegmen tympani, the polypus has its
origin from the dura mater of the middle fossa.
=Prognosis.= If the polypus be single and of recent origin, the result
probably of acute inflammation of the middle ear, its removal may cause
complete recovery and cessation of the middle-ear suppuration.
In the case, however, of multiple polypi associated with chronic
middle-ear suppuration and usually signifying underlying bone disease,
recurrences may be frequent and further operations may become necessary.
It may here be emphasized that a polypus in itself is not a disease, but
merely a symptom of disease.
After removal of a large polypus, the patient should always be kept
under observation for a day or two in case of symptoms of acute
inflammation of the mastoid process arising and necessitating further
operation.
CHAPTER III
OPERATIONS UPON THE TYMPANIC MEMBRANE AND WITHIN THE TYMPANIC CAVITY
SURGICAL ANATOMY OF THE TYMPANUM
=The tympanic membrane.= The chief points to notice when operating on
the tympanic membrane are its inclination and its relation to the inner
wall of the tympanic cavity.
The normal membrane is inclined obliquely downwards and forwards so that
it forms an obtuse angle of 140 degrees with the roof and an acute angle
of 27 degrees with the floor of the external meatus. In infants the
inclination is even greater.
Its relation to the tympanic cavity varies in its different parts. It
lies nearest to the inner wall in the region of the umbo, being only 2
millimetres distant from the promontory, and is furthest from it in the
posterior quadrant.
Running backwards, just below the posterior fold, is the chorda tympani
nerve, which may be cut through in the act of paracentesis and in
division of the posterior fold.
=The tympanic cavity.= For the purpose of description the portion of the
tympanic cavity above the level of the tympanic membrane is known as the
_attic_ or _epitympanic cavity_; whilst the part below its level is
called the _cellar_ or _hypotympanic cavity_ (Fig. 186).
The =attic= contains the head of the malleus and the body and short
process of the incus, and communicates posteriorly with the antrum by a
variable sized opening--the aditus. Its roof, the tegmen tympani, a
plate of bone frequently of extreme thinness, separates the cavity of
the middle ear from the middle fossa of the cranium. The facial canal
extends backwards along the inner and upper border of the tympanic
cavity, passing above the vestibule and the fenestra ovalis to curve
downwards posteriorly beneath the external semicircular canal, which at
this point forms the inner and inferior boundary of the aditus.
The =ossicles= form a movable chain fixed at three points: namely, the
attachment of the handle of the malleus to the tympanic membrane; the
posterior ligament of the incus, a feeble structure, binding its short
process to the entrance of the antrum; and the strong annular ligament
connecting the footplate of the stapes to the margins of the fenestra
ovalis.
In addition, the anterior, external, and superior ligaments of the
malleus also tend to keep it in position and limit its movements.
[Illustration: FIG. 186. ANATOMICAL PREPARATION OF THE MIDDLE EAR. 1-1/2
nat. size. 1, Antrum; 2, Aditus; 3, Attic, containing head of malleus
and body of incus; 4, Chorda tympani nerve; 5, Middle fossa of
intracranial cavity; 6, Eustachian tube; 7, Carotid canal; 8, Jugular
vein in jugular fossa; 9, ‘Cellar’ or floor of tympanic cavity; 10,
Canal of facial nerve; 11, Sigmoid groove for lateral sinus. (From the
Author’s _Diseases of the Ear_.)]
The tensor tympani muscle, extending from the processus cochleariformis,
crosses the tympanic cavity to be inserted into the inner margin of the
neck of the malleus; and the stapedius muscle emerging from the apex of
the eminentia pyramidalis is inserted into the head of the stapes.
These ligaments and muscles partially divide the cavity into smaller
compartments, such as the outer attic and Prussak’s space, so that in
some cases inflammation may be limited to only a part of the tympanic
cavity; a fact to be remembered in considering the question of operative
procedures.
OPERATIONS UPON THE TYMPANIC MEMBRANE
PARACENTESIS
=Indications.= The chief object of paracentesis (myringotomy or simple
incision) is to permit of escape of fluid from the tympanic cavity.
(i) _In acute inflammation of the middle ear_, if the acute symptoms
continue in spite of palliative treatment, and the following conditions
are present:--(_a_) An increasing congestion and bulging of the tympanic
membrane, especially if accompanied by earache and pyrexia. (_b_) The
obvious presence of pus within the tympanic cavity, shown by a
circumscribed, angry red or yellow protuberance on the tympanic
membrane. (_c_) Accompanying cerebral symptoms, such as drowsiness,
vomiting, vertigo, and convulsions. (_d_) Tenderness over the mastoid
process. (_e_) Paroxysms of pain acute enough to prevent sleep.
Paracentesis should be done early in infants and in specific fevers. In
the former case even a slight middle-ear inflammation may give rise to
all the cardinal symptoms of meningitis, which frequently subside
rapidly as the result of simple paracentesis; in the latter, there may
be rapid destruction of the drum, which a timely incision may possibly
prevent.
(ii) _In middle-ear catarrh with exudation._ Paracentesis is justifiable
in order to remove the secretion, if the hearing does not improve after
a month’s treatment, owing to the existence of exudation within the
tympanic cavity.
(iii) _As a preliminary to intratympanic operations._
=Operation.= The auricle and surrounding parts are surgically cleansed
(see p. 309), the preliminary toilet, if possible, being carried out at
least half an hour before the operation is performed.
Although apparently a trivial matter, it is of the utmost importance to
render the auditory canal as aseptic as possible in order to prevent
secondary infection of the tympanic cavity from without.
It is wiser to give a general anæsthetic, such as gas and oxygen, as the
pain of the operation may be intense. If this is refused, local
anæsthesia by Gray’s solution (see p. 310) or by a subcutaneous
injection of cocaine and adrenalin may be employed. In infants an
anæsthetic is not necessary.
The patient may be sitting up or lying down. If a general anæsthetic has
not been given, the patient’s head must be held firmly by an assistant
in order to prevent sudden movement. The surgeon works by reflected
light in order to obtain a clear view of the tympanic membrane.
The point of election for the incision is through the posterior part of
the membrane, excepting when it is obvious from the bulging and
appearance of the membrane that the incision must be made in the
anterior inferior quadrant.
The incision is made by means of a paracentesis knife, which is shaped
like a tiny bistoury set at an angle to its handle (Fig. 187). The
double-edged spear-shaped knife is now seldom used, as with it there is
a tendency to puncture rather than to incise the membrane.
The tympanic membrane is pierced by the paracentesis knife at its
inferior posterior margin. With a quick movement the drum is incised
freely, the incision being carried in an upward direction midway between
the malleus and the circumference of the membrane posteriorly, until it
reaches Shrapnell’s membrane (Fig. 188). In making this incision the
inclination of the membrane must not be forgotten. Owing to its lower
margin being more deeply placed than the upper, there is a tendency for
those who have not had much practice in doing a paracentesis to begin
their incision too high up, as they fail to realize the greater depth of
the canal at this point. The soft tissues of the upper posterior wall of
the external meatus close to the membrane, if much congested, may be
incised also in the act of withdrawing the knife. In doing this the
chorda tympani nerve may perhaps also be cut, resulting in loss of taste
on the affected side for a time; this is a matter of no importance. As a
result of this free incision, drainage is given to the contents of the
tympanic cavity, attic, and antrum.
[Illustration: FIG. 187. PARACENTESIS KNIFE HELD IN POSITION IN THE
HAND.]
In order to prevent rapid closure of the perforation and to give better
drainage, some authorities advise making a flap-shaped incision. To do
this, the membrane is incised upwards, nearly to its upper border; the
knife is then carried backwards and downwards before it is withdrawn
from the wound.
Occasionally the acute inflammation is limited to the attic, Shrapnell’s
membrane appearing deeply congested and bulging outwards so as to cover
the processus brevis, whilst the rest of the membrane may be only
slightly injected. In such cases it is sufficient to incise the bulging
area, beginning the incision just above the region of the processus
brevis and carrying it horizontally backwards to its posterior extremity
(Fig. 189).
=After-treatment.= In acute middle-ear inflammation, after the first
rush of blood and discharge has been mopped away, a small drain of
sterilized gauze should be inserted into the auditory canal and the ear
protected with a pad of sterilized gauze. The dressing and gauze drain
should be changed as often as may be necessary, depending on the amount
of discharge. The ear should not be syringed out unless the discharge
becomes very profuse and thick.
In acute middle-ear catarrh with exudation, a Siegle’s speculum (Fig.
194) should be inserted into the meatus after free incision of the
membrane, and as much fluid as possible extracted by suction. In
addition, gentle inflation by means of Politzer’s method will help to
expel from the middle ear the fluid, which should then be mopped out of
the external meatus. This should be repeated daily.
=Difficulties and dangers.= The usual fault is to mistake the congested
posterior wall of the external meatus for the membrane.
[Illustration: FIG. 188. TYMPANIC MEMBRANE SHOWING INCISION IN ACUTE
SUPPURATION OF THE MIDDLE EAR. Usual line of incision; dotted line shows
continuance of incision to make a flap opening for drainage.]
[Illustration: FIG. 189. LINE OF INCISION IN ACUTE SUPPURATION OF THE
ATTIC.]
If the patient is not under an anæsthetic, the incision may be made too
timidly, the membrane being only scratched. The pain thus inflicted will
cause the patient to jerk away the head and probably prevent the
membrane from being incised freely. The incision, therefore, must be
made in a bold and rapid manner. It is better to make the incision too
free than too small.
Care must be taken not to plunge in the knife too deeply for fear of
wounding the mucous membrane of the inner wall of the tympanic cavity.
This may result in adhesions between it and the membrane.
Further, cases have been recorded in which a too violent incision has
injured or dislodged the ossicles, or in which severe hæmorrhage has
occurred, presumably from puncturing the bulb of the jugular vein, which
was projecting abnormally through the floor of the tympanic cavity.
The two chief causes of failure are insufficient drainage from too small
an incision, which may necessitate a further operation, and secondary
infection from without.
=Results.= In the majority of cases, provided free drainage is
established, the discharge ceases and healing of the membrane takes
place from within a day or two to four weeks, depending on the character
of the case. If the symptoms continue it may become necessary to perform
the mastoid operation (see p. 373).
ARTIFICIAL PERFORATION OF THE TYMPANIC MEMBRANE
The object of the operation is to equalize the pressure within the
tympanic cavity and external meatus so as to enable vibrations of sound
to be transmitted more readily by the membrane and chain of ossicles to
the inner ear.
=Indications.= (i) In the case of an extremely calcified membrane which
apparently cannot vibrate.
(ii) To relieve tinnitus or vertigo which appears to be due to an
alteration of tension within the tympanic cavity, the result of an
impermeable stricture of the Eustachian tube.
(iii) As a means of diagnosis. If the hearing be improved or the
subjective symptoms relieved as a result of the artificial opening,
then, if the perforation closes (as it probably will do), the surgeon is
in a position to suggest some more radical measure, such as
ossiculectomy (see p. 351).
=Operation.= Two methods are employed: (i) The knife; (ii) The
galvano-cautery. The perforation should be made in the postero-inferior
quadrant.
In favour of the galvano-cautery is the fact that the perforation does
not tend to close so rapidly. On the other hand, considerable damage may
be done unless it is applied with extreme care. For this reason it is
wiser to operate under a general anæsthetic, such as gas and oxygen.
If the _paracentesis knife_ be used it is not sufficient to make a
simple incision; a small triangular flap must be excised. The operation
should be performed under good illumination. The paracentesis knife is
inserted boldly through the membrane a little behind and above the umbo.
The membrane is incised in an upward and slightly backward direction
towards its margin; then downwards parallel to its posterior border;
then horizontally forward, meeting the original point of the incision.
The excised portion of the membrane is removed by seizing it with a fine
pair of crocodile forceps, or by means of a fine snare, if it has not
been completely detached.
The _galvano-cautery_ is applied cold; when it is in contact with the
drum, the circuit is closed so that the point of the cautery becomes
red-hot. After the membrane has been burnt through it is withdrawn
rapidly so as not to scorch the surrounding tissues. In using the
cautery care must be taken to push it only just through the membrane for
fear of injuring the inner wall of the tympanic cavity.
=After-treatment.= The after-treatment consists in protecting the ear by
a strip of gauze, which is changed as often as may be necessary.
DIVISION OF THE ANTERIOR LIGAMENT
=Indication.= It is advised by Politzer in those cases of marked
retraction of the drum in which inflation causes an immediate
improvement in hearing, which, however, only lasts a short time. In
several cases Politzer found the cause of this to be due to tension of
the anterior ligament causing retraction of the malleus.
[Illustration: FIG. 190. LINES OF INCISIONS IN INTRATYMPANIC OPERATIONS.
A, Removal of membrane in ossiculectomy; B, Division of posterior fold;
C, Division of anterior ligament.]
=Operation.= The anterior fold is divided with the paracentesis knife
just in front of the processus brevis of the malleus. The knife is then
introduced 2 millimetres inwards through the incision and made to cut in
an upward direction as far as Shrapnell’s membrane (Fig. 190, C). This
should divide the ligament.
If the operation be successful, improvement in hearing and also
diminution of the subjective noises should take place.
DIVISION OF THE POSTERIOR FOLD
=Indication.= The same as for the anterior ligament. Owing to the
increased tension of the upper posterior quadrant of the tympanic
membrane, it is assumed that the movements of the malleus are
diminished, and with this the hearing power. Seeing, however, that the
prominence of the posterior fold is due to the projection outwards of
the processus brevis as a result of the handle of the malleus having
become indrawn with the membrane, it is difficult to understand how its
division can possibly be a means of restoring the retracted membrane to
its normal condition.
On the few occasions on which I have performed this operation, no
improvement has followed. Others, however, maintain that it may do good
in certain cases. This, perhaps, may be possible if it is combined with
other intratympanic operations, such as division of the anterior
ligament or of the tensor tympani muscle.
=Operation.= The paracentesis knife is inserted through the most
prominent part of the fold and is made to cut through it from above
downwards (Fig. 190, B). If this is successful, gaping of the cut edges
takes place and the membrane assumes a less retracted position, and
increased hearing and diminution of the subjective symptoms should occur
on inflation and rarefying of air within the external ear.
INTRATYMPANIC OPERATIONS
=General considerations with regard to intratympanic operations and
their results.= The chief difficulty, from a clinical point of view, is
to determine beforehand the exact pathological changes which already
exist within the tympanic cavity. For this reason the indications given
with regard to operation are of necessity somewhat empirical. For
example, retraction of the tympanic membrane may be due to closure of
the Eustachian tube; to adhesions between it and the promontory; to
contraction of the tensor tympani, of the anterior ligament, or of the
posterior fold. An operation to remove only _one_ of these causes may,
therefore, be insufficient; the difficulty is to know what to do. Even
if further operations are performed, the result may be negative owing to
adhesions having taken place already between the ossicles themselves, or
from binding down of the incudo-stapedial joint or of the stapes to the
inner wall of the tympanic cavity. And apart from this, even if
temporary benefit is obtained, the final result may be worse than that
which existed before operation owing to the natural tendency for
adhesions to re-form.
The prognosis is better in the case of post-suppurative conditions than
in the non-suppurative ones.
Improvement by operation may be hoped for if a temporary increase in the
hearing power, with diminution of the subjective symptoms, is obtained
as a result of inflation; especially in those cases in which the malleus
is only locally adherent to the promontory.
Generally speaking, however, these operations are not recommended, owing
to the impossibility of being able to give a good prognosis, and
therefore they can only be considered as experimental.
_These operations are contra-indicated_--(1) If there be internal-ear
deafness.
(2) If the stapes (as shown by tuning-fork tests and Gellé’s test) be
ankylosed within the fenestra ovalis, especially in the case of
otosclerosis.
(3) If the membrane be completely adherent to the inner wall at its
upper posterior quadrant, especially if this is of long standing, as the
stapes will almost certainly also be fixed by adhesions.
DIVISION OF INTRATYMPANIC ADHESIONS
The position and extent of the intratympanic adhesions vary exceedingly,
and may be the result either of middle-ear catarrh or suppuration. The
following conditions may be found:--
(i) Adhesion of the handle of the malleus to the promontory, the rest of
the tympanic membrane being movable.
(ii) Adhesions between other parts of the tympanic membrane and the
inner wall of the tympanic cavity, either by bridles or bands of fibrous
tissue, or by the membrane itself being adherent over a large area.
(iii) Adhesion of the edge of a perforation to the inner wall.
(iv) Adhesions surrounding the articulation between the incus and
stapes, and the stapes itself.
[Illustration: FIG. 191. CUTTING THROUGH INTRATYMPANIC ADHESIONS. The
malleus is adherent to the promontory. A, Surface view; B, Vertical
section. _a_, Handle of the malleus; _b_, Membrane adherent to the
promontory; _c_, Line of incision to cut through the membrane.]
=Indications.= Operation is justifiable in the case of adhesion of the
malleus to the promontory if the rest of the membrane is freely movable;
if the membrane bulges outwards and there is temporary improvement in
hearing on inflation; and if examination shows that the labyrinth is
intact. This operation is all the more indicated if there is marked
deafness on both sides: it should then be attempted on the worse side.
If, however, the intratympanic adhesions are extensive, it is very
doubtful whether an attempt to separate the free part of the membrane
from the part adherent to the inner wall is worthy of consideration.
It must also be remembered that adhesions in the region of the stapes
cannot be seen, unless a large perforation of the membrane already
exists. Operation is then only justifiable as a last resource if there
is extreme deafness accompanied by distressing subjective symptoms.
=Operation.= Unless the patient is very sensitive or nervous, local
anæsthesia is sufficient. It is more convenient for the patient to be
sitting up in a chair than to be in the recumbent position. The surgeon
works by reflected light. Before the operation is begun, the ear must be
surgically cleansed and carefully dried.
(i) _Adhesion of the handle of the malleus to the promontory._ With a
paracentesis knife the membrane is incised round the handle of the
malleus (Fig. 191). A small sickle-shaped knife, fixed at right angles
to its shaft, is then inserted through the incision (in front of or
behind the malleus as may be most convenient to the operator) and is
made to cut through the adhesions between the malleus and the promontory
(Fig. 192). In order to make sure that this has been accomplished, a
small ring-knife, such as is used in the operation of ossiculectomy, is
passed round the tip of the malleus, between it and the inner wall of
the promontory, and slight traction is then exerted in order to pull the
handle of the malleus outwards from the inner wall.
[Illustration: FIG. 192. FREE EDGE OF TYMPANIC MEMBRANE CUT THROUGH. A,
Surface view; B, Vertical section. _a_, Malleus adherent; _b_, Membrane
adherent; _c_, Free edge of membrane; _d_, Spatula freeing membrane.]
Provided asepsis has been maintained, this small operation seldom gives
rise to any inflammatory reaction. The after-treatment consists in
inserting a strip of gauze into the auditory canal; if it becomes moist
with secretion, it should be changed.
Many methods have been devised to prevent recurrence of adhesions, but
few are successful. Amongst these are daily inflation of the ear by
means of Politzer’s method or the catheter; the injection of oil into
the middle ear; and the insertion of small pieces of celluloid between
the malleus and inner wall of the promontory according to the method of
Gomperz. Another method is to _resect the handle of the malleus_ (Fig.
195). After being freed from the promontory as above described, the
manubrium is cut through with a pair of fine scissors (Fig. 174) just
below the processus brevis, and the lower fragment is removed by means
of Sexton’s forceps (Fig. 193).
(ii) _Adhesion between the membrane and the inner wall of the tympanic
cavity._ Siegle’s speculum should be used to determine the position and
extent of the adhesions (Fig. 194).
[Illustration: FIG. 193. SEXTON’S INSTRUMENT. A, For removal of a
foreign body; B and C, For removal of the malleus; D, Scissors.]
There are two methods of operation:--
(_a_) In the case of bands forming a bridle between the tympanic
membrane and inner wall, an attempt may be made to cut through them.
This is done by incising the membrane with a paracentesis knife in front
of or behind the adherent portion, and then inserting through this
incision the sickle-shaped knife. By rotating it upwards or downwards,
as the case may be, the bands forming the adhesions are cut through. If
this has been successfully performed, and if the retraction of the
membrane was solely due to these bands, the tympanic membrane will be
found to be freely movable on diminishing the pressure of air within the
external meatus by means of Siegle’s speculum.
(_b_) If the adhesions be extensive, the only method affording a chance
of success is to separate the free portion of the tympanic membrane from
the part adherent to the inner wall, leaving the latter _in situ_. To do
this the membrane is incised with a paracentesis knife just beyond the
margin of the adherent portion, the incision being carried right round
the affected part. A tiny spatula, bent at right angles to its shaft, is
then inserted through the incision and passed round beneath the movable
portion of the membrane so as to free it completely (Fig. 192).
[Illustration: FIG. 194. METHOD OF USING SIEGLE’S SPECULUM.]
(iii) _Adhesion of the edge of a perforation to the inner wall._ If the
middle-ear suppuration has only recently ceased, it may be sufficient
to divide the adhesion with a small knife curved on the flat and
afterwards force the tympanic membrane outwards by means of inflation
through the Eustachian tube, and by rarefaction of the air within the
external meatus. In the majority of cases, however, it is necessary to
excise the adhesion, especially in the more chronic conditions. This is
done by cutting through the movable part of the membrane just beyond the
adherent portion (_vide supra_).
[Illustration: FIG. 195. DIVISION OF INTRATYMPANIC ADHESION WITH
EXCISION OF HANDLE OF MALLEUS. A, Surface view; B, vertical section.
_a_, Remains of malleus (handle already excised); _c_, Free edge of
membrane; _d_, Scar tissue on promontory, at which point malleus and
membrane were previously adherent.]
(iv) _Adhesions surrounding the articulation between the incus and
stapes, and the stapes itself._ These adhesions can only be observed if
a large perforation involves the upper posterior quadrant. Even then it
may be anatomically impossible to see the stapes. The operation should
only be performed if definite bands of adhesions can be seen. Sometimes,
although rarely, it happens that such adhesions are present. If the
incudo-stapedial joint be fixed to the inner wall of the tympanic
cavity, the adhesions are separated from it by passing the knife between
the joint and the inner wall. In order to cut through adhesions
surrounding the base of the stapes, a small horizontal incision should
be made along its upper margin, and also along the lower, if this is in
view. This operation, however, is seldom of any value.
TENOTOMY OF THE TENSOR TYMPANI
=Indication.= The chief indication for this operation is marked
retraction of the tympanic membrane, in a case of middle-ear deafness,
in which there are no adhesions between the membrane and the inner wall
of the middle ear, and in which it is assumed that the retraction is due
to shortening of the tensor tympani muscle.
=Operation.= The first step of the operation is to incise the tympanic
membrane with a paracentesis knife in a vertical direction just behind
the margin of the malleus. At the same time the posterior fold can be
cut through, if required, by continuing the incision upwards. Through
the incision thus made Schwartze’s tenotomy knife (a very fine
blunt-pointed instrument curved on the flat (Fig. 196)) is inserted, its
point being directed upwards. The knife is pushed upwards until its
shaft is on a level with the processus brevis. The handle is then
rotated in a forward direction so that the sharp edge of the knife,
which is kept close to the posterior border of the neck of the malleus,
makes a circular movement forwards and downwards and thus cuts through
the tendon of the muscle. If the knife has been too deeply inserted, the
attempt to rotate the shaft forwards will be resisted by the projecting
processus cochleariformis. To overcome this difficulty the shaft of the
instrument is rotated backwards so as to raise the point of the tenotomy
knife and thus free it; the instrument is then withdrawn slightly and
the shaft again rotated forwards. The division of the tendon can be
distinctly felt, and may be accompanied by a slight crackling noise;
after this has been effected, the knife is rotated backwards and
withdrawn through the incision in the tympanic membrane.
[Illustration: FIG. 196. SCHWARTZE’S TENOTOMY KNIFE.]
=After-treatment.= There is usually a slight effusion of blood within
the tympanic cavity, but no special treatment is required beyond keeping
the ear aseptic. Absorption takes place rapidly.
The _result_ of the operation is disappointing. There is seldom any
improvement with regard to hearing; a few cases, however, have been
reported in which the attacks of vertigo have diminished in intensity.
TENOTOMY OF THE STAPEDIUS
=Indications.= They are limited.
(i) As the result of middle-ear suppuration the malleus and incus may
become exfoliated. The theory has been advanced that the unopposed
action of the stapedius muscle prevents free movement of the stapes in
these cases, and for this reason tenotomy of its tendon is advocated.
This operation, however, should only be performed provided that the edge
of the membrane is not adherent to the inner wall of the tympanic
cavity, and there is no internal-ear deafness.
(ii) The operation is also performed as a preliminary measure to removal
of the stapes (see p. 361).
=Operation.= The operation is simple, as the head of the stapes and the
tendon of the stapedius muscle are usually within view in consequence of
the destruction of the tympanic membrane. The ear is cleansed and dried,
and the part rendered insensitive by the previous application of a
pledget of cotton-wool soaked in cocaine solution. The tiny tendon is
severed with a snick of the paracentesis knife, cutting through it from
above downwards under good illumination.
=Results.= These vary; usually there is no improvement, but sometimes
marked increase of hearing occurs. As the operation can do no harm and
can be done without any inconvenience to the patient, it may be
attempted subject to the restrictions given above.
REMOVAL OF GRANULATIONS FROM THE TYMPANIC CAVITY
=Indications.= Granulations should always be removed if conservative
treatment fails.
=Operations.= (_a_) _Cauterizing_; (_b_) _Curetting._ The former method
is employed when the granulations are very small and localized; the
latter when they are multiple and larger.
=Cauterization.= The tympanic cavity is cleansed and rendered anæsthetic
(see p. 310). The auditory canal and tympanic cavity are then carefully
dried. This is of importance in order to prevent scalding of the
surrounding tissues during the act of cauterization. The ordinary
electric cautery is used; only a weak current is necessary as the point
of the cautery, of necessity, is very small. Under good illumination,
the cautery is inserted cold along the auditory canal until it just
touches the granulation. The circuit is then closed, and on the point of
the cautery becoming white-hot, it is pressed against the granulation
and then rapidly withdrawn from the ear. The current should not be shut
off until the cautery is withdrawn, otherwise it will adhere, on
cooling, to the tissues with which it is in contact, and on withdrawal
will cause bleeding.
Instead of the electric cautery, the granulations may be touched with a
bead of chromic acid fused on to a probe, or with a saturated solution
of trichloracetic acid. The galvano-cautery has the greatest effect.
Chromic acid has the disadvantage that unless it is very accurately
applied it tends to affect a larger area than was possibly intended.
Trichloracetic acid, although more localized in effect, is not so
potent.
_After-treatment_ consists in blowing in a slight amount of boric acid
powder and keeping the ear dry.
=Curetting.= This is performed by means of small ring-knives (Fig. 178)
or sharp spoons. They vary in size, and are either straight or bent in
different directions to the shaft of the instrument. The instrument
selected depends on the position and size of the granulation.
To minimize the hæmorrhage, adrenalin may be added to the cocaine
solution. The curette is made to encircle the granulation and cuts
through its attachment with a firm movement, limited to the area of the
granulation. Curetting should not be done in a haphazard fashion, but
deliberately under good illumination. If bleeding occurs it must be
arrested before further curetting takes place.
_After-treatment._ The ear is syringed out to remove any fragments of
granulation tissue or blood-clot. It is then dried and a strip of
sterilized gauze inserted. After twenty-four hours this is removed and
drops of rectified spirits, if necessary containing ten grains of boric
acid or a drachm of the perchloride of mercury lotion to the ounce, may
be instilled into the ear three or four times a day.
=Dangers.= With due care none should occur. The following mishaps,
however, have occurred from too violent curetting: (1) Injury or
displacement of the ossicles; (2) internal-ear suppuration from
dislodging of the stapes or injury to the promontory; (3) facial
paralysis; (4) meningitis from injury to the tegmen tympani; (5) acute
inflammation of the mastoid process.
=Results.= Provided that the granulations are localized and due to
inflammation of the mucous membrane, a good result may be anticipated.
If, however, there be underlying bone disease of the tympanic walls, or
if the mastoid process be already affected, recurrences are usual, and
further operative treatment may become necessary.
OPERATIONS UPON THE OSSICLES
DIRECT MOBILIZATION OF THE OSSICLES
The object of the operation is to improve the hearing by breaking down
the fibrous adhesions with the tympanic cavity, which diminish the
mobility of the ossicles.
=Direct massage of the malleus.= =Indications.= (i) As a therapeutic
measure. If the malleus be adherent to the promontory and there is no
improvement on inflation, but perhaps slight improvement as a result of
pneumatic massage.
(ii) As a means of diagnosis. If temporary improvement takes place it
may be assumed that the stapes is not absolutely fixed, and that the
deafness is partly due to adhesions preventing movements of the
ossicles, a condition which may point to the advisability of performing
ossiculectomy in suitable cases.
=Operation.= The ear is rendered insensitive by means of cocaine or
Gray’s solution (see p. 310).
The manipulation is carried out with a Lucae’s probe (Fig. 197). Within
its handle is a spring to render its movements resilient; and at its tip
is a cuplike depression to embrace the point of the processus brevis of
the malleus. The tip of the probe may be covered by a fine layer of
cotton-wool or india-rubber.
The probe is inserted, under good illumination, into the auditory meatus
and is applied to the processus brevis of the malleus. The vibrations
are given by the rapid movements of the hand from the wrist, the arm
being kept fixed. This procedure, which may be painful, should not last
longer than one minute. Frequently there is considerable reaction, shown
by congestion about the processus brevis and Shrapnell’s membrane. It is
therefore wiser not to repeat the procedure at shorter intervals than
one week.
[Illustration: FIG. 197. LUCAE’S PROBE.]
=Results.= It is difficult to foretell what the result will be, as it is
chiefly dependent on the extent of the adhesions already existing within
the tympanic cavity and on the mobility of the stapes within the
fenestra ovalis. If the latter is already fixed, then improvement is
impossible. If, however, the adhesions are limited, a better result may
be obtained by this method than by pneumo-massage and inflation. The
surgeon must be guided by the extent and duration of the improvement as
to how long to continue the treatment. Unfortunately, relapses are not
uncommon, though temporary benefit may be obtained.
=Massage of the stapes.= This is only done as a last resource in the
hope of obtaining some improvement in hearing.
=Indications.= (i) In cases in which mobilization of the malleus has
caused no improvement, and it is hoped, from the history of the case,
that this is due to fibrous adhesions fixing the stapes within the
fenestra ovalis. This condition must be carefully distinguished from
otosclerosis or bony ankylosis of the stapes, in which latter conditions
any such procedure is absolutely contra-indicated.
(ii) Direct mobilization may be undertaken as a preliminary step
previous to removal of the stapes itself. If the stapes is movable and
slight improvement occurs, then its removal may be justifiable under
certain conditions. If, however, the stapes is fixed and no improvement
occurs, then its removal will be attended with such difficulty as to
almost negative this being attempted.
=Operation.= If a perforation of the upper posterior quadrant be
present, a small pledget of cotton-wool soaked in a 20% solution of
cocaine is brought into contact with the inner wall of the tympanic
cavity. After a few minutes Lucae’s probe is placed in position against
the head of the stapes and the vibratory movements are carried out. If
no perforation of the drum exists, then it is first necessary to excise
a flap in the upper posterior quadrant of the membrane.
=Difficulties.= The chief difficulty is anatomical. Projection forward
of the upper posterior part of the tympanic ring or a deeply placed
niche of the fenestra ovalis may prevent a view of the stapes.
If the membrane has to be incised, the slight amount of bleeding may
also prevent a good view being obtained.
There is no actual danger in the operation, but if the stapes is fixed
or if much force is used, it is by no means difficult to fracture the
crura of the stapes.
[Illustration: FIG. 198. TO SHOW SITES OF PERFORATION IN ATTIC
SUPPURATION AND CARIES OF THE OSSICLES. 1. Perforation in front of
malleus. 2. Perforation behind malleus. 3. Perforation involving
posterior attic region and upper posterior part of membrane. (From the
Author’s _Diseases of the Ear_.)]
REMOVAL OF THE OSSICLES
Except under the most rare conditions only the malleus and incus are
removed; the stapes, if possible, being left undisturbed.
These operations will therefore be considered separately.
=Removal of the malleus and incus.= This operation was first proposed by
Schwartze in 1873, and later by Kessel, Ludewig, Sexton, and Zeroni.
=Indications.= The indications for operation may be considered with
regard to (1) chronic middle-ear suppuration and (2) non-suppurative
middle-ear disease, whether the result of a previous middle-ear
suppuration or of a chronic middle-ear catarrh.
In chronic middle-ear suppuration, the chief object of the operation is
to ensure drainage and if possible to remove the cause of the
suppuration; in non-suppurative conditions, to improve the hearing.
It may here be mentioned that the position of the perforation in the
attic region is frequently of importance when considering the question
of treatment. If situated in front of the malleus, the disease is
probably limited to the outer attic region and malleus; if just behind
the malleus, then probably both the malleus and incus are affected; but
if the perforation extends farther back, involving the upper posterior
quadrant of the drum, especially its bony margin, it suggests disease
not only of the ossicles together with the walls of the aditus and
antrum, but perhaps also of the mastoid process (Fig. 198).
(i) _In chronic middle-ear suppuration._ Before operation is considered,
it is presumed that conservative measures, such as syringing,
instillation of astringent and antiseptic drops, and washing out of the
attic by means of Hartmann’s canula with various solutions, have been
given a thorough trial and failed.
(_a_) If the suppuration be limited to the attic region (although the
main portion of the tympanic membrane is intact), provided there is
marked deafness and there are symptoms of lack of free drainage
indicated by recurrent attacks of headache, a feeling of heaviness or
giddiness, or pain radiating up the head on the affected side.
(_b_) If there be caries of the malleus and incus, and the outer attic
wall, with recurrence of granulations after repeated removal, especially
if accompanied by cholesteatomatous formation, provided there is no
evidence of disease of the mastoid process itself.
(_c_) Although the general symptoms and the condition found on
examination justify the complete mastoid operation, yet if the patient
refuses to have this operation performed, the simpler operation of
ossiculectomy may be undertaken if desired. This will permit of free
drainage and diminish the risk of future intracranial complications. It
should, however, be clearly explained to the patient that no guarantee
can be given with regard to effecting a permanent cure as a result of
this operation.
(ii) _In non-suppurative conditions._
(_a_) If there be marked middle-ear deafness, the result of adhesions,
and the malleus is fixed to the promontory. Operation is justifiable if
it is found that after each inflation of the middle ear, improvement of
hearing is obtained which, however, is not permanent but only temporary.
(_b_) If, as the result of artificial perforation, made under the
conditions already laid down, improvement takes place temporarily, but a
relapse occurs from closure of the perforation (see p. 340).
(_c_) If tinnitus and attacks of vertigo, due to marked retraction of
the membrane, are temporarily relieved by inflation. In this case
operation should only be carried out as a last resource after all other
measures have failed to cure and if the symptoms are very severe and
distressing.
(_d_) If there be marked middle-ear deafness with extensive adhesions on
both sides and evidence points to the stapes being freely movable. The
operation is justifiable, as an experiment, on the worse side.
=Operation.= The only operation to be considered is the intrameatal
one. Stacke originally suggested a post-auricular incision, and
reflecting the auricle forward, and, after removing the ossicle, to
remove also the outer attic-wall by means of the chisel. This method,
however, has now been given up as being too radical, but will be
mentioned later on in connexion with the mastoid operation (see p. 397).
Unless contra-indicated, a general anæsthetic should be given, as it is
not always possible to foretell whether the operation will be difficult
or easy. In addition it may be necessary to curette out granulations and
also to remove the outer wall of the attic. Unless the patient is very
insensitive, this is almost impossible under local anæsthesia (see p.
311).
Before the anæsthetic is given, the ear should be filled with a 5%
solution of cocaine containing a 1 in 2,000 solution of adrenalin
chloride in order to diminish the bleeding during the operation.
The field of operation is isolated from the surrounding parts by
covering the head with a sterilized towel having an opening cut in it
just sufficient to expose the auricle and meatus.
The following are the steps of the operation: (1) freeing the malleus
from its attachments to the tympanic membrane, and from the inner wall
of the middle ear, if adherent to it; (2) cutting through the tendon of
the tensor tympani muscle; (3) removal of the malleus; (4) removal of
the incus; (5) removal of the outer wall of the attic; (6) curetting out
of granulations, if present. The method of operation varies slightly
according to the condition found.
=Removal of the malleus.= In post-suppurative and non-suppurative
conditions the chief cause of failure is the recurrence of adhesions, so
for this reason it is wisest to remove the membrane as completely as
possible.
With a paracentesis knife, the membrane is incised below and behind the
malleus. The incision is then carried upwards along its posterior border
to the posterior fold, then round the complete margin of the tympanic
membrane and along the anterior fold and border of the malleus, so as to
meet the original point of the incision. The knife is then reinserted
just in front of the processus brevis and cuts through the anterior
ligament in an upward direction; in a similar fashion the posterior fold
is also cut through (Fig. 190).
The next step is tenotomy of the tensor tympani muscle (see p. 345).
The malleus thus freed can easily be removed by seizing its handle with
a pair of Sexton’s (Fig. 193) or crocodile forceps (Fig. 179). In
removing the malleus it is necessary to remember that its head is
situated within the attic and therefore cannot be pulled out directly,
but must first be drawn downwards until it is seen within the tympanic
cavity. If this precaution be not taken, the neck of the malleus may be
broken, leaving the head behind. If this takes place its extraction may
be a matter of difficulty.
[Illustration: FIG. 199. REMOVAL OF THE MALLEUS BY WILDE’S SNARE. _First
position._ After cutting through the tensor tympani muscle by
Schwartze’s method.]
[Illustration: FIG. 200. REMOVAL OF THE MALLEUS BY WILDE’S SNARE.
_Second position._ Malleus pulled down from attic--about to be withdrawn
from auditory canal.]
Instead of using Sexton’s forceps, the malleus may be removed by means
of Wilde’s snare. This is the method advocated by Schwartze. After
cutting through the tensor tympani muscle, the loop of the snare is
threaded over the head of the malleus and guided upwards until it
embraces its neck. The loop is then drawn tight so as to hold the
malleus firmly in its grasp. The ossicle is extracted by first pulling
it downwards (Fig. 199), so as to dislodge it from the attic, and then
outwards (Fig. 200).
[Illustration: FIG. 201. DELSTANCHE’S RING-KNIFE.]
Another method of extracting the malleus, and in my opinion the one to
be preferred, is by Delstanche’s ring-knife (Fig. 201). This instrument
differs from the ordinary ring-knife in that the upper border of its
anterior part is especially sharpened so as to form a fine cutting
surface. After the malleus has been freed from the membrane by means of
the paracentesis knife, Delstanche’s ring-knife is made to encircle its
handle. It is then pushed gradually upwards, keeping as close to the
posterior border of the malleus as possible, until it cuts through the
attachment of the tensor tympani. In doing this the instrument will
embrace the neck of the malleus (Fig. 202). This permits of sufficient
leverage to extract the malleus by gentle traction in a downward and
outward direction without danger of fracturing its shaft. If much
resistance be felt, probably the tensor tympani muscle has not been cut
through, and another attempt should be made to do this before trying
further extraction. The advantage of this instrument is, that once the
knife has encircled the malleus it should be possible not only to cut
through the tensor tympani, but to extract the bone itself without the
use of any other instrument. If Schwartze’s tenotomy knife be used, two
tenotomy knives are required, one for the right and one for the left
ear. Delstanche’s ring-knife is equally good for either ear.
[Illustration: FIG. 202. REMOVAL OF MALLEUS BY DELSTANCHE’S RING-KNIFE.
A, Curette inserted round handle of malleus; B, Curette pushed upwards,
in act of cutting through tendon of tensor tympani muscle.]
=Extraction of the incus.= Although it is frequently stated that
extraction of the incus is more difficult than that of the malleus, in
reality it is the easier part of the operation as, unlike the malleus,
it has no firm attachments.
After removal of the malleus all hæmorrhage must be arrested and a view
obtained of the inner wall of the tympanic cavity. If it be possible to
see the long process of the incus and its articulation with the head of
the stapes, the articulation should be cut through with a small
sickle-shaped knife. The knife is inserted just in front of the long
process of the incus and, keeping close to it posteriorly, is made to
cut downwards and backwards, thus separating its connexion with the
stapes. Frequently the long process cannot be seen, or it may indeed
have already disappeared as a result of caries. Theoretically this
delicate manœuvre is performed in order to prevent injury or dislodgment
of the stapes during the act of removal of the incus. From a practical
point of view, however, it does not appear to make any difference
whether the incudo-stapedial articulation is cut through or not.
[Illustration: FIG. 203. LUDEWIG’S INCUS HOOK.]
[Illustration: FIG. 204. ZERONI’S INCUS HOOK.]
A variety of instruments have been described for the purpose of removal
of the incus. Ludewig’s incus hook (named after Ludewig, who was one of
the first to draw attention to this operation) is still recommended by
many as being the best. It consists of a solid curved hook, having a
length of 5 millimetres and a width of 2 millimetres, bent at right
angles to its shaft (Fig. 203). A pair of these are necessary, one for
each ear; also several sets of different sizes may be required owing to
the variation in depth, height, and roof of the attic region. I,
however, prefer Zeroni’s (Fig. 204). This hook, instead of being solid,
consists of a steel eyelet having a backward curve similar to that of
Ludewig’s.
[Illustration: FIG. 205. REMOVAL OF INCUS BY ZERONI’S HOOK. A,
Diagrammatic section showing opening in tegmen tympani: _b_, processus
cochleariformis; _c_, external semicircular canal; _d_, aditus and
antrum. B, Diagrammatic section, through the auditory canal, just beyond
the tympanic membrane: _e_, long process of incus; _f_, incudo-stapedial
joint; _g_, tympanic ring; _h_, remains of the tympanic membrane; _i_,
fenestra rotunda; above it is the promontory.]
The technique is the same whichever pattern is employed. The instrument
is inserted in such a fashion that the hook is directed upwards, having
its concavity backwards. It is passed into the attic at the point
previously occupied by the head of the malleus. The shaft of the
instrument is then rotated backwards so that the hook passes over the
body of the incus (Fig. 205). As the rotatory action is continued
downwards and finally forwards, the incus is dislodged from its position
and forced into the tympanic cavity. It can now be seized by a pair of
Sexton’s or crocodile forceps and removed. If it falls into the floor
of the tympanum, it can usually be dislodged by syringing, or else by
means of a small hook passed in circular fashion along the floor of the
cavity.
=Removal of the outer wall of the attic.= In the majority of cases of
chronic middle-ear suppuration, it is advisable to remove the outer wall
of the attic in addition to performing the simple operation of
ossiculectomy. If granulations be present they should first be removed,
in order to give a clear view of the inner wall of the tympanic cavity,
which can usually be obtained, owing to the fact that a large
perforation of the membrane is probably present. The malleus and incus
are then removed.
[Illustration: FIG. 206. PFAU’S ATTIC PUNCH FORCEPS.]
To remove the outer wall of the attic a small but strong pair of
punch-forceps is required (Fig. 206). The instrument is directed along
the roof of the auditory canal, its cutting edge held upwards and the
blades kept slightly open, until the outer blade is felt to pass over
the outer wall of the attic. The handle is then depressed so that the
end of the forceps is forced upwards and embraces the outer wall between
its points (Fig. 207). This is confirmed by attempting to withdraw the
forceps, which the outer bony wall of the attic will now prevent. The
position of the forceps being assured, its blades are brought together
by pressure on the handle, and in this manner a small portion of the
bone is punched out. In this way the outer wall of the attic is
gradually cut away in small fragments. Sometimes this is extremely easy,
owing to the auditory canal being large and the outer wall of the attic
being thin and easily cut through. In other cases, owing to the
thickness of the bony walls or to the narrowness of the canal, it is
extremely difficult. If the outer wall of the attic has been completely
removed, a fine probe, whose point is bent upwards, can be inserted into
the attic and then withdrawn without encountering any obstruction, owing
to the roof of the attic and outer wall of the auditory canal being now
continuous. In some cases this part of the operation may not be
necessary, as the outer wall of the attic may have already disappeared
as a result of the caries.
[Illustration: FIG. 207. REMOVAL OF OUTER ATTIC-WALL WITH FORCEPS. A,
Outer attic-wall.]
Into the larger opening thus made, small curettes are passed upwards and
backwards and any granulations in the region of the aditus and entrance
to the antrum are curetted away. Finally the cavity is thoroughly
swabbed out with the pledgets of cotton-wool soaked in a 1 in 2,000
alcoholic solution of biniodide of mercury. The cavity is then dried and
a small drain of sterilized gauze inserted within the auditory canal,
the ear being afterwards covered with a pad of gauze kept in position by
a bandage.
=After-treatment.= In cases of non-suppuration there is rarely any pain,
and if asepsis has been maintained, there is seldom much discharge
beyond slight sanious oozing. Unless there is considerable discomfort
the dressing need not be changed for two or three days. If possible the
ear should not be syringed, but merely mopped out with pledgets of
cotton-wool moistened with boric lotion and then dried, the gauze drain
being afterwards inserted. This process may be repeated daily until
healing is complete.
In middle-ear suppuration there may be considerable pain, owing to the
forcible bruising of the tissues of the inner part of the auditory canal
during the act of removal of the outer wall of the attic. Sometimes,
indeed, there is much swelling of the lining membrane of the canal, with
the occurrence of furuncles as the result of septic infection.
If there be no pain, the after-treatment is the same as above described,
excepting that it may be necessary to syringe out the ear at each
dressing owing to the discharge. If there be much pain, with swelling of
the canal, the gauze drain should be removed and a 10% solution of
carbolic acid in glycerine frequently instilled into the meatus.
Subsequently drops of rectified spirit may be substituted.
=Difficulties.= 1. If the auditory canal be very small there may not be
sufficient room to insert the instruments through the speculum. In such
cases, if there be no middle-ear suppuration, it is wiser to leave the
condition alone. If, however, suppuration exists, either the
conservative treatment must be continued or the complete mastoid
operation recommended.
2. Hæmorrhage, especially on curetting away the granulations, may be
sufficient to prevent a view of the deeper parts. It can, however,
usually be arrested quickly by plugging the auditory canal with gauze
soaked in adrenalin and cocaine solution. Even if the surgeon has to
wait a few moments, this must be done, as it is very necessary to obtain
a clear view of the field of operation.
3. Extensive adhesions between the membrane and inner wall may render it
difficult to separate the shaft of the malleus without fracturing its
neck.
4. In old-standing cases in which there is a large perforation of the
membrane, the malleus may be so retracted as not only to be difficult to
see but difficult to seize. In this particular case, division of the
tensor tympani with Schwartze’s tenotome and then extraction of the
malleus by means of Sexton’s forceps is a better procedure than trying
to encircle its shaft with Delstanche’s ring-knife.
5. Removal of the incus by the ordinary instruments may be rendered
impossible owing to the narrowness of the attic posteriorly from chronic
thickening of its walls. In these cases a seeker, such as Schwartze uses
in the mastoid operation (Fig. 219), may be employed with advantage. It
is passed over the incus in the same manner as an incus hook.
=Accidents.= 1. _Fracture of the handle of the malleus._ This is the
result of too forcible extraction. If a Delstanche’s ring-knife has been
used, this may be due to the tensor tympani not having been cut through;
this should now be done. The head of the malleus is then removed either
by means of a small hook or some form of curette bent at right angles to
its shaft, depending on what is most suitable for the case in question.
2. _Failure to extract the incus._ In the course of a chronic middle-ear
suppuration, the incus may become exfoliated or gradually disappear as
the result of caries. It does not therefore always follow that inability
to extract the incus means that the surgeon has failed in his
manipulations, although frequently this is the case, the instruments
failing to extract the incus, or perhaps dislodging it into the mastoid
antrum, a fact which is difficult to determine and may only be
discovered if the subsequent performance of the complete mastoid
operation becomes necessary.
3. _Facial paralysis._ This accident is usually due to the incus hook
not being inserted high enough up, so that, instead of entering the
attic, it presses on the inner upper border of the tympanic cavity, and
on being rotated in a backward and downward direction, it follows the
line of the facial canal (Fig. 208). If much force be employed the frail
wall of the facial canal will be fractured or pressed in on the
underlying facial nerve. It is very rarely, however, that the nerve is
completely crushed or torn through, and therefore recovery almost
invariably takes place.
The facial nerve may also be injured whilst curetting away granulations
in the upper posterior part of the tympanic cavity.
[Illustration: FIG. 208. DIAGRAMMATIC SECTION TO SHOW CORRECT AND WRONG
POSITIONS OF INCUS HOOK. A, Facial nerve canal; A', Facial nerve, in
section; B, Antrum; C, External semicircular canal; D, Incus hook in its
correct position in the attic, _above_ facial canal; E, Incus hook in
wrong position, about to press on facial canal; F, Promontory.]
4. _Injury to or removal of the stapes._ This very rarely occurs during
the act of removal of the incus, but is generally the result of too
violent curetting. If only the crura be broken off, it does not matter;
but if the stapes itself be dislodged from the fenestra ovalis, the
subsequent symptoms may be attacks of vertigo, nausea, and vomiting. As
a rule these symptoms subside. If, however, the internal ear becomes
infected (although judging from literature and my own experience this is
of very rare occurrence), complete deafness or even meningitis may occur
as the result of labyrinthine inflammation or suppuration.
=Results.= (_a_) _With regard to arrest of the disease._ If the disease
be limited to the ossicles themselves and to the anterior and outer part
of the attic, a favourable prognosis may be given. Complete cessation of
the discharge and scarring over of the affected part may take place
within a month, or after a much longer period.
If, however, the disease be more extensive and involves the walls of the
attic posteriorly and the region of the aditus, as shown by the presence
of a fistula or granulations, the prognosis is uncertain and continuance
of the discharge and recurrence of the granulations may eventually
necessitate the complete mastoid operation.
(_b_) _With regard to hearing._ In the case of chronic attic suppuration
the hearing power may be increased to a distance of 12 feet off for
conversation, provided the internal ear is not affected and the stapes
is not fixed within the fenestra ovalis; occasionally the result is much
better. On the other hand, the hearing power may be made worse.
In post-suppurative conditions, the prognosis is not so favourable, as
frequently the stapes is already bound down by adhesions; this is the
more probable in the case of chronic middle-ear catarrh. In both these
conditions the operation should never be performed without first
explaining to the patient that it is practically experimental. The chief
cause of failure is the recurrence of adhesions, which even the most
complete and careful operation cannot always prevent.
=Removal of the stapes.= This operation is still in its infancy and it
is, as yet, impossible to express an opinion with regard to its success
or failure, and therefore the indications laid down are only tentative.
The objects of the operation are: (1) to improve the hearing in cases of
deafness presumably due to fixation of the stapes within the fenestra
ovalis, and (2) to relieve symptoms of tinnitus and vertigo due to the
same cause.
Before this operation is advised careful examination must be made in
order to determine whether the labyrinth is intact, especially if the
operation is undertaken with the view of improving the hearing.
=Indications.= (i) If there be ankylosis of the stapes on both sides,
accompanied by marked deafness and distressing subjective symptoms,
operation is justifiable on the worse side.
(ii) In a one-sided affection provided the subjective symptoms of noises
and giddiness are so oppressive as to render the patient’s life
unbearable. The operation, of course, must not be attempted unless every
other form of treatment has failed.
=Operation.= The operation may be performed either through the meatus,
or by reflecting forward the auricle by means of the post-aural
incision, and chiselling away the upper posterior part of the bony
meatus in the manner suggested by Stacke (see p. 397).
The choice of the operation depends principally on the existing
anatomical and pathological conditions.
If the meatus be very narrow the intrameatal method may fail to bring
the stapes into view. If, on the other hand, the meatus be wide and
there be a large perforation, the result of previous middle-ear
suppuration, the incudo-stapedial joint or the head of the stapes itself
may be actually within the field of operation.
_The intrameatal method._ The patient should be fully anæsthetized and
the operation performed under good illumination. A portion of the
tympanic membrane in its upper posterior quadrant is excised in order to
bring into view the incudo-stapedial joint. The incision is begun just
behind the handle of the malleus and is carried upwards and backwards in
a circular fashion through the tympanic membrane along the posterior
fold, and then downwards for a little distance along its margin. The
flap so made either falls downwards, or can be pressed downwards so as
to expose to view the inner wall of the tympanic cavity. With a small
knife, curved on the flat, the incudo-stapedial joint is cut through.
With a fine hook the long leg of the incus is dislocated forwards or
backwards from the stapes. The head of the stapes will now be seen, with
the tendon of the stapedius muscle running horizontally backwards. With
a paracentesis knife, the tendon is cut through close to its attachment
to the stapes.
A fine, blunt-pointed hook is now inserted between the crura of the
stapes. If the stapes be not firmly ankylosed it can usually be removed
by slight traction. If, however, it be firmly fixed, its crura will
probably be broken. To determine whether the stapes is ankylosed or not,
direct pressure of the probe on the head of the stapes may be necessary.
If the head of the stapes cannot be seen, it is advisable, as suggested
by Dench of America, to punch out part of the upper posterior margin of
the attic-wall with the attic forceps (see p. 357).
_The post-aural method._ The preliminary steps of the operation are the
same as have been already described for removal of an exostosis (see p.
318).
After separating and reflecting forward the membranous from the bony
portion, the upper posterior part of the tympanic ring is chiselled away
until a view of the stapes can be obtained. The incus is then
disarticulated from the stapes.
If the stapes be ankylosed by fibrous adhesions to the margins of the
fenestra ovalis, an attempt may be made to free it by cutting through
the adhesions with a fine bistoury. If this be impossible, a sharp hook
may be fixed into the margin of the plate of the stapes in the hope of
forcibly extracting it. Some authorities advise chiselling away of the
margins of the fenestra ovalis. If an opening can be made into the
vestibule by this means, it is hoped that the resulting scar tissue will
form a membrane more resilient than the ankylosed stapes, and, in this
way, permit vibrations of sound to enter the labyrinth. This operation,
however, necessitates the complete mastoid operation in order to freely
expose the region of the fenestra ovalis.
=After-treatment.= It is sufficient to protect the ear with a small
gauze drain. Occasionally there may be considerable vomiting and vertigo
as an immediate result of the operation; this usually passes off within
two or three days. Meanwhile the patient should be kept in a recumbent
position and, if necessary, given small subcutaneous injections of
morphine.
=Difficulties.= The chief difficulty is to obtain a good view; even if
this be obtained it is difficult to extract the stapes without fracture
of its crura.
=Dangers.= As a result of opening up the labyrinth, one would expect
considerable risk of infecting the internal ear. Judging from recorded
cases, this, however, seldom occurs.
=Results.= The chief advocate of the removal of the stapes is Jack of
Boston (_Boston Med. and Surg. Journ._, January, 1895), who again in
1902 (_Archives of Otology_, vol. xxxi, p. 407) stated: (1) that removal
of the stapes did not destroy the hearing but sometimes improved it; (2)
that the operation upon cases of moderate deafness might give brilliant
results but was also attended with some risk to the hearing; (3) that
the operation on the profoundly deaf was not advisable, as usually the
stapes could not be removed owing to surrounding adhesions, and even if
it were, no improvement was likely to occur owing to the
sound-perceiving apparatus having probably already undergone
irremediable changes.
Blake (_Archives of Otology_, vol. xxii), on the other hand, states
emphatically that stapedectomy is harmful rather than beneficial.
The question, therefore, of removal of the stapes from the point of view
of hearing is purely experimental. If there be bony ankylosis, it will
be found impossible to remove the bone, and an attempt to do so will
result in fracture of its crura. If, on the other hand, it be not
ankylosed but movable, probably massage or, in cases of perforation of
the tympanic membrane, direct mobilization of the bone will give results
as good as those following stapedectomy.
The most favourable results are to be expected in those cases in which
the operation is performed to relieve symptoms the result of previous
middle-ear suppuration. In otosclerosis no benefit is ever obtained, and
therefore the operation is absolutely contra-indicated.
On the other hand, there is ample evidence that the hearing power, in
spite of removal of the stapes, may be retained. As an example may be
quoted a case in which the stapes was removed accidentally in curetting
out the ear after the removal of the malleus and incus, and in which I
afterwards performed the complete mastoid operation owing to the
continuance of the middle-ear suppuration. In spite of this, whispering
could be heard at a distance of 20 feet (_Journal of Laryngology, &c._,
vol. xxii, p. 33).
CHAPTER IV
OPERATIONS UPON THE EUSTACHIAN TUBE
Under this heading may be considered manipulations requiring special
technical knowledge and skill: (1) Catheterization; (2) passing of
bougies; and (3) washing out the tympanic cavity through the Eustachian
tube.
CATHETERIZATION OF THE EUSTACHIAN TUBE.
=Indications.= (i) _As a means of diagnosis_ in order to determine (_a_)
the amount and character of the obstruction within the Eustachian tube;
(_b_) the condition of the mucous membrane and whether any exudation is
present within the middle ear.
(ii) _For the purpose of treatment._ (_a_) In order to instil medicated
drops or vapours into the Eustachian tube and tympanic cavity; (_b_) as
a preliminary measure to the passage of bougies into the Eustachian tube
or to washing out the tympanic cavity through the Eustachian tube.
(iii) _Catheterization is preferable to Politzer’s method_ if only one
ear is affected. Politzer’s method, on the other hand, is preferable to
catheterization (_a_) in small children; (_b_) in the case of slight
middle-ear catarrh if both ears are affected; (_c_) if the passing of
the catheter is very difficult and causes pain owing to nasal
obstruction; (_d_) in nervous individuals who object to the catheter;
(_e_) if the sudden inflation by means of Politzer’s method is more
effectual than by catheterization.
_Points to notice before inflation._ 1. Care must be taken that the
lumen of the catheter is not obstructed, and that the compressed air bag
and auscultation tube are also in working order.
2. The nose must be cleansed of all secretion; if filled with crusts or
in a septic condition, inflation must be avoided.
3. The patient should be sitting. Sometimes on inflation of the ear,
especially for the first time, an attack of giddiness or faintness may
occur.
4. The nose should always be examined to see that the passage is free.
If it be obstructed catheterization may be impossible, or some special
manipulation will be required in order to pass the catheter through the
nose.
5. In order to prevent muscular contraction of the palatal muscles,
which may grip the end of the catheter and so prevent its entrance into
the orifice of the Eustachian tube, the patient should be told to
breathe quietly and keep the eyes open.
A short silver or plated catheter is usually used. It is 5 inches in
length and curved at its extremity. To indicate the position of the
point of the catheter in the post-nasal space, a ring is attached to its
outer and wider extremity corresponding with the concavity of the
curvature of its beak (Fig. 209). The size of the catheter varies in
diameter from Nos. 1 to 4 English size, that is, the same scale as used
for urethral catheters. The source of compressed air used for the
inflation is usually a Politzer bag having an india-rubber tube
attached. At its end is a vulcanite pointed nozzle which accurately fits
into the wider extremity of the catheter.
=Technique.= The patient is seated facing the surgeon, the head being
supported by a prop or by an assistant. If the patient be at all
sensitive, it is wiser to spray a very small quantity of a 2 or 5%
solution of cocaine or eucaine into the nose, or, better still, to pass
gently a probe tipped with a small pledget of cotton-wool soaked in the
cocaine solution along the inferior meatus. This will effectively
anæsthetize the region of the pharyngeal orifice of the Eustachian tube,
which is the most sensitive part.
[Illustration: FIG. 209. EUSTACHIAN CATHETER.]
The surgeon stands in front of the patient. The larger extremity of the
catheter is held lightly between the thumb and first finger of the right
hand, its beak being turned downwards, whilst the tip of the nose is
tilted up by the thumb of the left hand (Fig. 210). In introducing the
catheter into the nostril, the right hand is kept low down so that the
stem of the catheter is almost in a vertical position. In this way the
tip passes over the floor of the vestibule. As the catheter is gently
pushed through the nose the right hand is raised so that the instrument
assumes the horizontal position and passes backwards between the septum
and the inferior turbinal, its beak being kept in close contact with the
floor of the nose (Fig. 211). As the beak of the catheter enters the
post-nasal space, it will be felt to glide over the soft palate.
With regard to the best method of introducing the beak of the catheter
into the orifice of the Eustachian tube, opinions vary. Of the many
methods advised only two will be given.
The first is more suitable to those who have not had much experience in
using a catheter; the second is the one naturally adopted by an expert.
_The first method._ The catheter is pushed backwards until it is felt to
impinge against the posterior wall of the naso-pharynx. The beak, which
at this stage is directed downwards, is next rotated a quarter of a
circle inwards so that it points horizontally towards the opposite side;
the position is shown by the ring at its outer extremity (Fig. 212). The
catheter is now gently withdrawn until the beak is felt to catch against
the posterior edge of the vomer. During these procedures the stem of the
catheter should rest on the floor of the nasal cavity. The manipulations
are carried out with the right hand whilst the outer extremity of the
catheter is kept fixed in position by means of the thumb and finger of
the left hand.
[Illustration: FIG. 210. PASSING THE EUSTACHIAN CATHETER. Introduction
of the catheter within the nostril.]
[Illustration: FIG. 211. PASSING THE EUSTACHIAN CATHETER. Passage of the
catheter along the floor of the nose.]
The catheter is next pushed a short distance backwards to free it from
the soft palate and rotated downwards, and finally round in an outward
direction until the ring points to the outer canthus of the eye on the
side to be catheterized (Fig. 213).
The point of the instrument should now engage the Eustachian tube; if,
however, inflation shows this not to be the case the probability is
that the catheter has been pushed too far backwards and rests on its
posterior lip. This can be remedied by drawing it a little further
outwards.
_The second method._ The catheter, with its beak turned downwards, is
passed gently and rapidly along the inferior meatus of the nasal cavity,
and at the same time rotated slightly outwards against the inferior
turbinal bone. Whilst the catheter is within the nose, this outward
rotation is prevented by the narrowness of the inferior meatus, but as
soon as the beak of the catheter has passed behind the level of the
inferior turbinal into the free post-nasal space, it will revolve
outwards and upwards and in so doing will enter the Eustachian tube,
which lies just behind and above the posterior end of the inferior
turbinal bone.
[Illustration: FIG. 212. PASSING THE EUSTACHIAN CATHETER. Beak of the
catheter in the post-nasal space. The catheter is turned to the opposite
side so that its beak impinges against the posterior border of the
septum.]
[Illustration: FIG. 213. PASSING THE EUSTACHIAN CATHETER. Catheter in
position; act of inflation.]
Provided there be no abnormal obstruction within the nose, this method
is an exceedingly simple one. With the practised hand the manipulation
can be carried out so smoothly and quickly that the catheter will be in
position before the patient has had time to realize the fact.
=Difficulties.= 1. _Irritability of the mucous membrane._ The passing of
the catheter through the nose may set up a violent spasm of sneezing or
coughing. When the beak has entered the post-nasal space, the irritation
may cause such intense contraction of the palatal muscles that the
point of the catheter may become fixed and its movement rendered
impossible. If this takes place, the catheter should be withdrawn and
the part anæsthetized by means of cocaine and eucaine solution, which is
best applied locally on a pledget of wool at the end of a probe.
2. _Partial nasal obstruction._ On inspecting the nose the obstruction
is usually found to be due to a deviated septum or spur, or to adhesions
situated at its anterior part. Sometimes a passage can be effected by
simply diminishing the curve of the catheter. At other times the
obstruction can be overcome by introducing the catheter with its stem
held upwards and outwards, so that on entering the nose the beak dips in
beneath the anterior end of the inferior turbinal. As the catheter is
pushed gently inwards its outer extremity is brought round with a
circular movement so that it gradually assumes the horizontal position.
No force must be used. As the catheter is pushed farther in, it may
rotate to a varying degree according to the formation of the nasal
cavity. Sometimes, indeed, the catheter may make a complete rotation
during its passage through the nose. At other times, after the
obstruction is passed, the catheter is best pushed through the nose with
the beak pointing directly upwards. The great point is gentleness; the
catheter should be allowed to take whatever position suits it best, but
after the beak has entered the post-nasal space the stem should lie
horizontally along the floor of the nose and its beak should point
downwards.
3. _Complete nasal obstruction._ If the obstruction be one-sided, then
the catheter must be introduced into the nasal space through the
opposite side.