_Above and behind the facial nerve through the semicircular canals._ The

complete mastoid operation is performed first. The chief difficulty is

to expose the field of operation so as to obtain sufficient room for the

necessary manipulations. To do this the following steps should be

carried out: The tip of the mastoid process and the remains of the

posterior wall of the auditory canal are removed to their extreme limit

without injury to the underlying facial nerve. The floor of the auditory

canal is also chiselled away until the lower level of the tympanic

cavity is brought freely into view, the amount of bone removed depending

on the anatomical condition found. To expose the anterior portion of the

tympanic cavity, the skin incision is extended slightly forwards, but

not far enough to wound the temporal artery, the soft tissues being then

separated from the bone and the auricle pulled still further forwards

and downwards.

Skin meatal flaps are now fashioned--either the Y-shaped flap or

Stacke’s flap (see p. 403)--and are afterwards kept in position by means

of sutures. Good illumination is necessary, and for this reason a

head-light should be used. One assistant is employed to retract the soft

tissues from the wound, another to keep it as dry as possible.

The exposed portion of the external semicircular canal is first

identified. If the bone be soft, the arches of the semicircular canal

should be defined (Fig. 240). The posterior canal will be discovered by

gouging away the bone just posterior to the arch of the external

semicircular canal, and the superior, by working inwards and upwards

towards the roof of the attic. If the outline of the canals can be made

out, the further steps of the operation are rendered very much easier.

Unfortunately, the bone is sclerosed in the majority of cases, rendering

anatomical exposure of the canals an impossibility.

The next step is to remove the eminence of the horizontal semicircular

canal. This is best done by means of a small gouge and mallet. Some

prefer a burr, specially constructed to cut vertically; others a chisel.

I prefer a fine gouge. As the facial canal runs along the lower anterior

portion of the external semicircular canal, the gouge should be directed

in a backward direction in removal of the outer wall of the latter, so

as to cut away from the facial canal.

The surgeon should be content to remove the bone piecemeal, as, owing to

its brittleness, it is very apt to splinter, or the point of the gouge

itself may slip and so injure the facial nerve.

After an opening has been made into the canal, it should be enlarged by

following the canal forward until its ampulla is reached. After this has

been done, a fine probe, bent at a right angle (Schwartze’s seeker will

do very well), is passed into the opening, and the limits of the

vestibule made out as far as possible. The bone is then removed in an

upward direction until the ampulla of the superior canal is reached. The

opening may then be extended backwards so as to remove the outer wall of

the vestibule, that is, the portion of bone which lies between the

ampullæ of the superior and external canals.

If the bone be sclerosed, so that it is impossible to find the superior

and posterior canals, then, after opening the exposed portion of the

external semicircular canal, the bone should be chiselled away at the

area marked out in Fig. 240. By this means the vestibule will certainly

be reached, and from this point its opening can be extended in any given

direction. A sufficient opening should be made so that the inner portion

of the vestibule can be seen (Fig. 241). During each step of the

operation a clear view must be obtained.

[Illustration: FIG. 240. DIAGRAM TO SHOW EXPOSURE OF THE SEMICIRCULAR

CANALS. The ‘black ring’ shows the area at which the semicircular canals

and vestibule may be opened.]

Not infrequently the facial nerve is exposed or pressed upon in chipping

away the outer wall of the external semicircular canal, as will be shown

by sudden twitchings of the face. If the surgeon be careful, and works

in a direction away from the nerve, it should not be injured. If

possible, the outer margin of the horizontal semicircular canal,

together with the Fallopian canal, should be left intact as a bridge

crossing the vestibule. If necessary, the external and superior canals

can be removed in their entirety. A fine probe is inserted into the

lumen of the canal so as to tell its direction, and its outer wall is

then burred away. For this particular purpose a burr should be used as

soon as the surgeon has got beyond the region of the facial nerve. After

a view of the interior of the vestibule has been obtained, the ampullary

nerves may be destroyed by means of the curette or with pure carbolic

acid at the end of a probe. Removal of the posterior canal is best

effected by opening it just behind the external semicircular canal and

following it out in an upward direction until it meets the superior, and

then downwards until it enters the vestibule. This extensive operation

is one of extreme difficulty and seldom necessary.

_Posterior to the semicircular canals: Neumann’s method._ Neumann enters

the vestibule posteriorly. The bone forming the inner wall of the antrum

is removed by means of bone forceps or gouge and mallet until the

posterior semicircular canal is opened. By this means the posterior

surface of the petrous bone can be exposed as far inwards as the

internal auditory meatus.

_Below and anterior to the facial nerve through the promontory._ The

preliminary steps of the operation having been performed and the field

of operation freely exposed, the stapes, if still present, is extracted

by means of a small hook passed between its crura. The bridge of bone

between the fenestra ovalis and fenestra rotunda is then cut through by

light taps on a very fine gouge. The bone is removed by attacking the

lower limit of the fenestra ovalis, and working downwards until the

fenestra rotunda is reached. With a fine curette or scoop the loosened

fragments of bone are removed. Care must be taken not to work above the

region of the fenestra ovalis or the facial nerve will probably be

injured. After a sufficient opening has been made, a bent probe can be

passed through the opening in the promontory in an upward and backward

direction behind the facial nerve into the inferior and anterior portion

of the vestibule (Fig. 241).

[Illustration: FIG. 241. OPERATION UPON THE LABYRINTH. To show the

opening into the vestibule above the facial nerve with partial or

complete removal of the semicircular canals. The arrow passes behind the

facial canal between the vestibule and the fenestra ovalis.]

=Removal of the cochlea.= If necessary, the first turn of the cochlea

can now be removed by gouging away the promontory from behind forwards.

If the anterior wall of the external auditory canal interferes with this

being done, it may be partially removed by means of the gouge and

mallet. After the first half-turn of the cochlea has been opened, its

contents may be curetted out, care, however, being taken to avoid the

carotid canal, which lies in close relationship with its anterior

inferior portion. If the bone be carious only gentle curetting is

necessary. If, however, this be not the case, simple curetting may not

be sufficient, and the gouge and mallet may have to be used. To destroy

the cochlear nerve, the whole of the cochlea should be removed. This is

sometimes a difficult matter to determine. If the operation be done for

the relief of tinnitus, then, after as much as possible of the cochlea

has been removed, the interior may be swabbed out with strong carbolic

acid solution, which should set up sufficient inflammatory reaction to

destroy the nerve-terminals.

[Illustration: FIG. 242. EXTIRPATION OF THE LABYRINTH. The vestibule is

freely opened and the greater portion of the semicircular canals and

cochlea is removed.]

=Extirpation of the labyrinth.= This consists in the removal of the

semicircular canals, and opening of the vestibule and cochlea, the steps

of which have already been described in the above operations.

Before the operation is completed, the inner wall of the vestibule and

the cochlea should be carefully examined for fistulæ, and in order to

see if any pus enters these cavities from within. If this be the case it

means that, in addition to labyrinthine suppuration, there is presumably

an extra-dural abscess of the posterior intracranial fossa, drainage of

which is essential in order to obtain a recovery.

After the operation has been completed, the cavity should be filled with

hydrogen peroxide, then gently syringed out with weak biniodide

solution, and finally dried and lightly packed with sterilized gauze.

Even although the operation may have been performed in a

non-suppurative case, it is wiser to leave the posterior wound open for

the first few days in order to permit of free drainage.

=After-treatment.= If the suppuration has been limited to the internal

ear, a successful result may be expected if the symptoms subside rapidly

as a result of the operation. If there be complete destruction of the

labyrinth before operation its performance should give rise to no

symptoms of shock nor further disturbance of equilibrium.

In the majority of cases, however, owing to the nerve-terminals being

still in a state of activity, the irritation set up as a result of the

operation may cause increased attacks of nystagmus, vertigo, and

vomiting. The vomiting is the first symptom to disappear, and then the

nystagmus; but complete recovery of equilibrium may not occur for a

considerable period, during which time the patient, though otherwise

well, may still have a slightly staggering gait.

If the operation has been limited to the external semicircular canal,

and the hearing power still exists, the after-treatment should be

carried out as already described in the complete mastoid operation. If,

on the other hand, the cochlea has been interfered with, or if it be

certain that there is no longer any hearing power, then there is no

object in trying to preserve the patency of the tympanic cavity, which

in this case may be allowed to granulate up from its depth like an

ordinary surgical wound.

The immediate anxiety of the surgeon after the operation is the possible

onset of meningitis or the presence of a cerebellar abscess, which will

necessitate further operation unless otherwise contra-indicated (see p.

460).

=Comparison of the operations.= Opening of the vestibule above the

facial nerve is limited to those cases in which the lesion is situated

within the semicircular canals and to the posterior portion of the

vestibule; that is, either in non-suppurative cases in which the

operation is performed in the hope of curing vertigo, or in suppurative

cases in which the function of hearing still exists.

Opening of the vestibule below the facial nerve is to be preferred as a

rule, especially if the function of hearing is already destroyed,

because it permits of drainage from the inferior part of the vestibule;

in addition, by working forwards, the outer wall of the cochlea can be

removed and any disease within it can be tracked out to its limits.

If there be suppuration within the cochlea, sufficient drainage will not

be obtained by merely opening the vestibule through the semicircular

canals, but the cochlea itself must be opened. Again, if the lower

portion of the vestibule and cochlea be first explored and found filled

with purulent secretion, it is wiser to complete the operation by also

opening the vestibule from above,--that is, to completely extirpate the

labyrinth, which is now functionally useless and almost certain to be

infected throughout its whole extent.

=Intracranial complications.= If, in addition to the labyrinthine

suppuration, intracranial suppuration be suspected, the labyrinth should

be explored first; but when possible the operation should be arrested at

this point to see if the symptoms subside. If they continue, the

exploration of the intracranial cavity can then take place through the

internal ear, after a delay of twenty-four hours or more.

Of the intracranial complications, meningitis is most frequent, and next

in order cerebellar abscess. In addition, thrombosis of the bulb of the

jugular vein may take place from infection through one of the smaller

tributary veins; or a localized extra-dural abscess may be found

situated along the posterior portion of the petrous bone in consequence

of direct extension of the infection through the internal auditory

meatus, or as a result of empyema of the endolymphatic sac. This latter

condition is almost impossible to diagnose, but may be discovered

accidentally if the vestibule is opened by the posterior route according

to Neumann’s method.

=Difficulties.= The chief difficulties are anatomical, and the inability

to obtain a clear view owing to general oozing of blood.

The first is generally due to insufficient removal of bone; the second

can usually be controlled by means of good assistants and the frequent

employment of hydrogen peroxide or of adrenalin solution.

=Dangers.= _Injury to the facial nerve._ This, as might be expected, is

not infrequent. If a burr be used, the nerve may be completely torn

across and permanent paralysis may result. If, however, the gouge and

mallet be employed, complete recovery usually takes place, as the injury

seldom consists in complete destruction of the nerve.

_Opening up of the internal meatus._ This may be accompanied by a gush

of cerebro-spinal fluid. There is nothing to be done except to try and

keep the part as clean as possible and see that there is free drainage.

Undoubtedly, as a result of this mishap, death has afterwards occurred

in consequence of septic meningitis.

_Injury to the internal carotid or bulb of the jugular vein._ These are

possibilities which, however, should not occur if ordinary care is

taken.

=Prognosis.= The prognosis of labyrinthine suppuration is always grave,

owing to the frequency of intracranial complications.

The most favourable cases are those in which the disease is localized

and is of chronic duration. The most unfavourable are those in which

acute suppurative labyrinthitis is accompanied by extensive bone

disease.

According to statistics, the mortality is about 50% in cases not

operated upon. As a result of operation, this has been reduced to less

than 20%, and in the majority of these cases the ultimate fatal result

cannot be put down to the operation itself. The patient is frequently

seen too late, that is, after intracranial complications have already

occurred. There is no doubt that the death-rate will diminish

proportionately according as the necessity of operating early becomes

more and more recognized.

With regard to hearing, extensive operations upon the labyrinth lead to

complete deafness; nor, indeed, can recovery of hearing be expected

except in those cases in which the disease and operations have been

limited to the semicircular canals and to the posterior portion of the

vestibule, and even then recovery of hearing is exceptional.

CHAPTER VIII

OPERATIONS FOR EXTRA-DURAL ABSCESS AND MENINGITIS OF OTITIC ORIGIN

ON INTRACRANIAL COMPLICATIONS IN GENERAL

As the intracranial complications of otitic origin are due to direct

extension of the pyogenic infection through the temporal bone to the

cranial cavity, it follows that they will depend on the extent of the

disease within the temporal bone, the direction in which it has spread,

and the virulence of the infection. For this reason, also, the site of

the intracranial lesion is always in close relationship with the area of

the diseased bone. Thus, if the infection spreads upwards through the

attic and tegmen tympani, it may lead to extra-dural abscess or to

meningitis of the middle fossa, or to a temporo-sphenoidal abscess.

Similarly, disease of the mastoid cells posteriorly may give rise to a

perisinuous abscess, to meningitis of the outer surface of the posterior

fossa, to lateral sinus thrombosis, or to a cerebellar abscess situated

superficially and involving the outer portion of its lateral lobe just

behind the lateral sinus; or caries of the floor of the tympanic cavity

may give rise to thrombosis of the jugular bulb; or internal-ear

suppuration to an extra-dural abscess occupying the posterior surface of

the petrous bone, to meningitis of the posterior fossa, or to an abscess

of the cerebellum deeply placed in its anterior inferior angle.

Operation is always imperative unless the patient is seen too late and

it is obvious that the condition is hopeless.

Before operation is decided on the following points must be carefully

considered: (1) Is it possible that the symptoms simulating the

intracranial lesion are due to suppuration still limited to the temporal

bone? (2) What is the character of the lesion? and (3) What is its

situation?

As a rule, so long as the suppurative process is limited to the middle

ear and to the mastoid region, the symptoms are those of a local septic

infection. At the same time it must be remembered that in infants and in

young children it is not uncommon for retention of pus within the middle

ear to produce a clinical picture closely simulating an intracranial

suppurative lesion. The ear, therefore, should always be inspected in

every case. Sometimes a bulging membrane is discovered or the existing

perforation is found to be insufficient for drainage. In such cases the

symptoms may subside on free drainage being obtained by the simple act

of paracentesis of the tympanic membrane.

If, however, free drainage already exists, the mastoid operation should

be performed at once.

If the intracranial symptoms be still somewhat indefinite, and there is

no apparent urgency, the intracranial cavity should not be explored

immediately unless this is found to be imperative at the time of

operation. This can be done later, if the symptoms do not subside.

Although exploration of the intracranial cavity is always urgent when it

is certain that an intracranial suppurative lesion is present, yet to

explore with a negative result is a grave misfortune, owing to the

possibility of infecting the intracranial cavity.

Although the surgeon may be certain that an intracranial lesion is

present, yet it may be very difficult to determine its character or

whether several lesions coexist. The surgeon must therefore be prepared

to act according to what he finds at the time of operation.

Thus, if exploration of the temporo-sphenoidal lobe be negative, and yet

the cardinal symptoms point to an intracranial abscess, the cerebellum

must also be explored. Again, if the diagnosis of intracranial abscess

be doubtful before operation, and if, during the operation, lateral

sinus thrombosis be discovered, it is wiser to limit the operation to

tying of the jugular vein and removal of the septic thrombus. The bone,

however, should be removed above and behind the sinus so as to expose

the dura mater covering the temporo-sphenoidal lobe and the cerebellum.

In such cases, if the symptoms of intracranial suppuration still

continue, it is an easy matter to explore the temporo-sphenoidal lobe or

cerebellum at a subsequent operation.

Although under exceptional circumstances (see p. 461) it may be

justifiable to open an intracranial abscess by directly trephining the

skull over it, yet free opening of the mastoid process should be the

first step in the operation, as the primary focus of the disease exists

within the temporal bone. In addition, much information may thus be

gained in a doubtful case with regard to the situation of the

intracranial lesion.

OPERATIONS FOR EXTRA-DURAL ABSCESS

This is far more common as a sequel of acute than of chronic disease of

the mastoid process.

=Indications.= Operative interference is indicated in order to permit of

drainage. An extra-dural abscess is frequently discovered accidentally,

especially if the surgeon follows out the golden rule to trace any patch

of carious bone to its limit. In doing so he may suddenly meet with a

gush of purulent discharge coming through an opening in the bone in the

region of the tegmen tympani or sigmoid sulcus.

Although an extra-dural abscess may give rise to no special symptoms,

the following are suggestive:--

1. If, in spite of opening up the mastoid cells and antrum, pyrexia and

headache persist, especially if the headache be localized to the

affected side and accompanied by tenderness on pressure above the ear or

behind the mastoid process.

2. If, before operation, there be a very profuse discharge from the ear,

apparently too copious to come from the tympanic cavity or mastoid

antrum.

3. In children an extra-dural abscess may give rise to symptoms of

cerebral irritation or compression if it extends upwards from the tegmen

tympani along the parietal region; or, if situated in the posterior

fossa, to retraction and stiffness of the neck.

Although such symptoms may be also associated with an intracranial

abscess or meningitis, yet, if on exploration of the intracranial cavity

a large extra-dural abscess be discovered, further operation may be

postponed (unless its extension is obviously necessary) until time is

given to see whether the symptoms will subside or not.

=Operation.= If the mastoid process has not been opened already, the

simple or the complete operation is performed, according to whether the

suppuration is recent and acute, or is of long standing.

If, however, this has been done, the wound is reopened, all granulations

are curetted away, and the cavity is cleansed and dried.

The antrum and mastoid cavity are then thoroughly examined. If a fistula

in the bone already communicates with the abscess, pus may be seen to

ooze through it. If not, careful search is made for any carious tract of

bone, which is now followed up until the dura mater is reached.

After the pus has drained away more bone is removed so as to expose the

dura mater fully over the infected area, which is usually vascular or

covered with granulations. The latter, however, should be left severely

alone. If the abscess be situated in the middle fossa above the tegmen

tympani, the bone is best removed by chiselling upwards until the lower

margin of the squamous portion of the temporal bone is reached. Then,

with a pair of bone forceps, more bone can be punched away quickly until

a sufficient opening is obtained (Fig. 243).

Exploring with the probe and curetting away of granulations should be

avoided as far as possible for fear of injuring the sinus. If its wall

be already inflamed, it may be torn through, and the resulting

hæmorrhage may render the further steps of the operation a matter of

extreme difficulty.

Before completion of the operation, a blunt-pointed seeker should be

passed round the edge of the opening in the bone to see that its margin

is smooth and even, and all sharp edges of bone bordering on the dura

mater should be removed. If this precaution be neglected, a splinter may

get pressed inwards and injure the dura mater, and thus set up

meningitis.

If possible the bone should be removed until the healthy dura mater is

reached. If the extent of the abscess prohibits this, its limits,

however, should be ascertained. This can be done by pressing the dura

mater inwards with a spatula so as to separate it from the overlying

bone.

The final step is to irrigate the cavity with warm boric or saline

solution and to insert drains of gauze or of fine india-rubber tubing

between the dura mater and bone. The wound cavity is then lightly packed

with gauze and a simple dry dressing applied.

=After-treatment.= Provided there be no other intracranial symptoms,

recovery should be as rapid as in the case of simple inflammation of the

mastoid process. In the after-dressings, however, special care should be

taken not to press in the gauze roughly or tightly against the still

inflamed dura mater, in case of injuring its surface and causing further

extension of the pyogenic infection to the meninges or lateral sinus.

The dressings should be changed daily. It is sufficient to irrigate the

wound with some mild aseptic lotion and afterwards to repack it lightly.

If Schwartze’s operation has been performed, the after-treatment is

similar to that already described (see p. 387). In the case of the

complete operation, after the purulent discharge has practically ceased

and the surface of the wound appears healthy, the packing of the cavity

may be carried out through the meatus, instead of through the posterior

wound, the latter being then allowed to close.

=Intracranial complications.= Infection of the lateral sinus is the most

frequent complication, but meningitis, ulceration of the surface of the

brain, or intracranial abscess may also occur.

One or more of these complications may already exist at the time of

operation, but may not be sufficiently marked to warrant further

exploration of the intracranial cavity. It is wiser, therefore, to give

a guarded prognosis during the first few days after the operation, not

only with regard to recovery, but also to the possibility of further

operative procedures becoming necessary.

OPERATIONS FOR MENINGITIS OF OTITIC ORIGIN

Formerly the onset of symptoms of meningitis was a distinct

contra-indication to operation. More recently, however, this view has

become modified, especially as it has been shown definitely by Macewen,

Jansen, Brieger, and others that recovery is possible if operation is

undertaken sufficiently early before the inflammation of the cerebral

membrane has become diffuse.

In this connexion must be mentioned--(1) Serous meningitis: a name given

to an increase of the cerebro-spinal fluid within the subdural or

subarachnoid space, or the ventricles, the hypersecretion being probably

caused, as Merkens suggests (_Deutsche Zeitsch. für Chir._, vol. lix),

by the toxic infection induced by the suppurative focus in contact with

the external surface of the dura mater. The symptoms of serous

meningitis may closely simulate an intracranial abscess or a purulent

meningitis, except that frequently there is no pyrexia. (2) Purulent

meningitis, which may be diffuse or localized. (3) Pseudo-meningitis:

that is, a condition simulating meningitis but in reality due to

irritation of the meninges as a result of suppuration still confined

within the temporal bone--for example, the result of acute middle-ear

suppuration in infants.

Clinically it is often difficult to determine before operation which

variety is present.

=Indications.= Operation is indicated as soon as the onset of meningitis

has been diagnosed and should be performed without delay. Waiting for

all the cardinal symptoms of meningitis to occur will never save life.

The only possibility of doing so is to operate while the inflammatory

process is still localized. At the same time it must be recognized that

whenever symptoms of meningitis occur the prognosis is most serious.

Lumbar puncture should always be performed as an aid to diagnosis. If

the cerebro-spinal fluid be clear and sterile, diffuse meningitis can

usually be excluded, although at the same time it must be remembered

that it does not negative a localized meningitis without increased

intracranial pressure. Increased flow of cerebro-spinal fluid indicates

increased intracranial pressure, perhaps the result of serous

meningitis. Slight turbidity suggests early purulent meningitis,

especially if bacteria are present, but not necessarily that the case is

hopeless. If the fluid be definitely purulent, operation may be

considered out of the question; a case, however, has been recorded in

which recovery took place.

The value of cytological examination of the fluid is still doubtful.

Marked increase of polynuclear cells is said to point to acute and

intense inflammation, whereas an abatement of the polynucleosis may be

taken as a sign of diminution of the meningeal irritation. With this,

increased leucocytosis, increasing as recovery progresses, may be looked

upon as a hopeful sign.

If it be obvious that the patient is dying, not only from the local

infection but also on account of general septic absorption, operation,

of course, is excluded. Similarly, at the present time, post-basic

meningitis of infants is rightly deemed inoperable.

=Operation.= Although no set operation can be described, the principles

of the operation are to expose the infected area widely so as to allow

of free drainage and, at the same time, to relieve intracranial

pressure. The extent of the operation will therefore depend largely on

what is found during the course of the operation itself.

1. In an infant or young child, if the symptoms develop in the course of

an acute otitis media, the tympanic membrane should first be inspected

to see if there is sufficient drainage. If not, it should be freely

incised, and opening of the antrum and mastoid may be delayed for at

least twelve hours.

2. In an adult, immediate exploration of the mastoid and antrum is

indicated on the onset of meningeal symptoms, even although they occur

during the course of an _acute_ middle-ear suppuration.

If the symptoms of meningitis in these cases be as yet indefinite, and

if pus be found under tension within the mastoid cavity, or if an

extra-dural abscess exists, the dura mater should not be incised at

once, but a delay of twenty-four hours should be advised; in many cases

complete recovery will take place. If, however, the symptoms continue,

intracranial exploration will be necessary.

3. In chronic middle-ear suppuration, meningitis is usually secondary

to, or accompanies, other intracranial complications or internal-ear

suppuration, the symptoms of which it may mask.

After performing the mastoid operation any tract of carious bone is

followed out to its limits.

According to what he finds, the surgeon may first expose the dura mater

covering the lower portion of the middle fossa (Fig. 243), or of the

posterior fossa behind and in front of the lateral sinus; these are the

usual sites of infection. The removal of bone must be free, in order to

get well beyond the limits of the infected area, if possible. The dura

mater is incised to the limits of its exposure either crucially or by

cutting it through in the form of a large flap.

The dura mater is usually congested, but if an extra-dural abscess or

lateral sinus thrombosis be present, it may be thickened and of a

leathery appearance; or in the latter case almost gangrenous.

The further steps depend on the conditions met with on incision of the

dura mater.

[Illustration: FIG. 243. METHOD OF REMOVAL OF BONE BY THE FORCEPS. In

this instance the bone is being removed above the tegmen tympani in

order to expose the lower portion of the middle fossa.]

1. _In serous meningitis_ a certain amount of clear fluid may escape and

the brain surface may be only slightly congested. After removal of the

bone and of the dura mater over the infected area the surface of the

brain should be scarified in various directions to make certain that the

pia-arachnoid has been incised, and fine drainage tubes should be

inserted between the latter and the dura mater. In these cases a hernia

seldom occurs, although the brain surface may bulge slightly into the

wound.

2. _In purulent meningitis_ the surface of the brain is usually covered

with turbid fluid or purulent lymph, which may be localized to the site

of the diseased bone, or may have spread from this point to a varying

extent over its surface.

If the limit of the infection cannot be reached, in spite of removal of

a considerable extent of bone and dura mater, all that can be done is to

irrigate the exposed area with warm saline solution and to insert fine

drainage tubes between the brain and dura mater, at the same time (as

in the case of serous meningitis) incising the meninges in various

directions.

3. _Purulent lepto-meningitis_ is usually accompanied by encephalitis.

If localized by adhesions an accumulation of pus may occur, forming an

abscess on the surface of the brain, which also may be superficially

ulcerated or necrosed. If there be intracranial pressure from

encephalitis, the brain tissue usually protrudes as a dark, hæmorrhagic

friable mass, in which shreds of necrotic brain tissue will be seen. In

other cases, if there be no increased intracranial pressure and if the

condition be quite localized, no hernia may occur, but the surface of

the brain may be rough or eroded.

Any purulent secretion should be removed by irrigation, care being taken

not to disturb the brain more than is necessary, so as to diminish the

risk of breaking down the surrounding adhesions. A hernia may or may not

form immediately. If no hernia takes place, it is wiser to do nothing

further; that is, provided sufficient bone and dura mater have been

removed to reach the limits of the infected area. Some authorities,

however, consider that the necrosed portion of the brain should be

curetted out. Although in other parts of the body the removal of

necrosed tissue is a proper procedure, yet in the case of the brain

there is considerable risk of setting up further œdema or septic

cerebritis, the progress of which may have become arrested at the time

of the operation.

If the inflamed brain tissue protrudes to an excessive degree during the

operation itself, the opening in the skull should be enlarged, if it be

not already of considerable magnitude, and the dura mater incised to the

full limits of the opening. The protruding mass may then be cleanly

excised by means of a scalpel. If, however, the brain tissue continues

to prolapse, the wound cavity should be simply cleansed and protected by

a dressing of sterilized gauze. If the encephalitis subsides, the hernia

will not increase in size, and if the wound cavity be kept aseptic, it

may gradually shrink.

=After-treatment.= This consists in covering the wound surface lightly

with gauze so as to permit of free drainage, and changing the dressing

as often as may be necessary.

In serous meningitis a large quantity of cerebro-spinal fluid may

escape, and the dressings must be changed frequently. If recovery be

going to take place, the temperature gradually becomes normal and the

symptoms of meningitis disappear. In involvement of the posterior fossa,

the head retraction gradually diminishes and after a few days free

movement is noticed. Adhesions form rapidly, binding together the

surface of the brain, meninges, and the overlying bone. For this reason

the drainage tubes, already inserted between the dura mater and brain,

can be removed within a day or two. The exposed dura mater usually

becomes covered with granulations from which a certain amount of

purulent discharge may be secreted. The duration of the after-treatment

depends on the extent of the operation and the size of the wound.

Eventually the skin flaps grow together and cover the brain, which

afterwards may be felt pulsating through the scar. In these cases it is

usually necessary to provide the patient with some protection, such as

an aluminium plate.

If, however, a hernia forms and gradually increases in size, the brain

should be explored again to see if another abscess can be discovered; or

the lateral ventricle itself may be tapped in case of it being distended

with fluid. Both these operations, however, must be looked upon as

extreme measures.

If the patient otherwise recovers and a hernia still persists, the

question arises what to do. Conservative treatment should first be

employed, aseptic dressings being maintained, and slight pressure

applied with compresses soaked in rectified spirits. If these measures

fail, then the projecting portion of the hernia may be excised (see Vol.

III).

=Other methods.= In addition, the following methods of treatment have

been suggested. Although many failures have occurred in proportion to

the few successful cases published, yet they show the possibility that

something can be done by operative measures, and that considerable

advance has been made in recent years in this direction.

(i) =Repeated lumbar puncture.= In a few cases of serous meningitis this

has proved successful in that it has relieved intracranial pressure. It

is, however, only of value if free communication still exists between

the spinal theca and subarachnoid space.

(ii) =Continuous drainage from the spinal canal.= Friedrich, of Kiel,

has suggested a counter-opening in the spinal canal by means of

laminectomy in order to permit of drainage of the entire dural sac.

(iii) =Puncture of the lateral ventricle.= The temporo-sphenoidal lobe

is pierced with a trocar, just above the zygomatic ridge, until the

ventricle is reached; this has been performed frequently in order to

relieve intracranial pressure. I know of only one recorded instance in

which recovery has taken place in spite of there being pyogenic

infection of the lateral ventricle; a fact which was proved by tapping

the ventricle and removing from it a drachm and a half of purulent fluid

(_Archives of Otology_, vol. xxxv, p. 535).

(iv) =Drainage through the internal ear.= West and Scott have recently

described a case of meningitis which occurred after having curetted the

inner wall of the tympanic cavity. They then opened up the labyrinth and

inserted a wire drain through the internal auditory meatus, at the same

time making a counter-opening in the lumbar region, through which they

drained the spinal canal. The patient, a child, ultimately recovered.

=Prognosis and after-results.= Unless saved by operation, meningitis is

almost uniformly fatal. Even if the patient recovers, whether as the

result of operation or not, deaf-mutism or mental deficiency frequently

occurs. In a few cases, however, complete recovery has taken place.

CHAPTER IX

OPERATIONS FOR LATERAL SINUS THROMBOSIS OF OTITIC ORIGIN

GENERAL CONSIDERATIONS

The sigmoid portion of the lateral sinus is the part usually infected.

Thrombosis, however, may occur primarily in the region of the jugular

bulb from direct extension of the pyogenic infection through the floor

of the tympanic cavity; this, though less frequent than involvement of

the sigmoid sinus, is not so rare as has hitherto been supposed.

Operative treatment is imperative as soon as septic thrombosis of the

sinus has been diagnosed. This, however, is not always an easy matter.

Sometimes, indeed, there are no clinical symptoms, the condition perhaps

only being discovered whilst performing the complete mastoid operation

as a prophylactic measure. The sinus is generally exposed accidentally

whilst following out a tract of carious bone, and, to the surprise of

the surgeon, pus or granulations may be seen to exude or protrude from

an opening in its outer wall. On further exposure of the sinus on each

side of the thrombus, the dura mater may appear to be of a dark colour

for a short distance, but beyond this to be of normal appearance.

Seeing that there are no symptoms, the presumption is that the sinus is

occluded on each side of the septic thrombus by a non-infective clot. It

is, therefore, sufficient in such cases to simply excise the sinus wall

over the septic area. If the case be so treated, it is essential that

the sinus should only be curetted gently over the exposed opening, but

otherwise left undisturbed. Also this limited operation should only be

performed if the surgeon is satisfied that the septic focus is

surrounded on each side by an organized normal clot--the condition in

fact being treated as a simple abscess.

To secure free drainage, only the depth of the mastoid wound should be

packed with gauze, the surface being protected by a simple dry dressing.

The after-treatment is the same as that already described for the

complete mastoid operation in which the posterior wound has been left

open.

In other cases, if there be an acute inflammation of the mastoid process

and if only one rigor has occurred, it may not necessarily mean that

thrombosis of the sinus has taken place, as the rigor may be due simply

to septic absorption. In such cases it is justifiable to delay opening

the sinus if it is found to be exposed within the wound cavity and to be

covered with granulations.

The bone, however, should be freely removed until the normal dura mater

is reached, and the cavity afterwards rendered as aseptic as possible by

syringing it out with hydrogen peroxide lotion. In a large proportion of

cases a favourable result occurs, the pyrexia and head symptoms

disappearing and an uneventful recovery taking place. On the other hand,

gradually increasing pyrexia or a sudden rigor may occur, perhaps not

until ten days or so after the primary operation, showing that the sinus

has become infected after all. It should then be opened at once, but

before doing so the jugular vein should be tied (see p. 448).

In a typical case, however, there is a history of repeated rigors, and

in addition there may be attacks of vomiting and headache localized to

the affected side, with pain and tenderness on pressure behind the

mastoid process, and optic neuritis. In the more severe cases there may

also be evidence of thrombosis of the jugular vein or cavernous sinus.

It must, however, be remembered that a high and intermittent pyrexia,

especially in children, may take the place of rigors. The principles of

surgical treatment are to expose the sinus and remove the infective clot

completely.

In connexion with this operation two points cannot be impressed too

forcibly on the reader:--

1. The operation must be performed at once. The greater the experience

of the surgeon the more he realizes that expectant treatment is nearly

always fatal, and that a successful result depends largely on early and

complete operative measures.

2. Before the sinus is interfered with in any way it is essential to

obliterate its lumen below the thrombus in order to prevent any portion

of it being swept into the circulation during its removal.

EXPOSURE OF THE LATERAL SINUS

=Indications.= (i) In doubtful cases to decide whether thrombosis exists

or not.

(ii) As a preliminary to opening the sinus with or without ligature of

the jugular vein.

=Operation.= The first step is to perform the complete mastoid

operation, except in the case of acute inflammation of the mastoid

process, when Schwartze’s operation will be sufficient.

To expose the field of operation more freely, an incision an inch or

more in length is made horizontally backwards, beginning at the

mid-point of the posterior margin of the primary incision (Fig. 216),

the soft parts being reflected upwards and downwards from the bone, and

the flaps so formed being then retracted. Above, the bone should be

exposed beyond the level of Reid’s base-line, which roughly corresponds

to the line of the transverse sinus; below, the tip of the mastoid

should be cleared until the mastoid vein is reached. If it be thrombosed

it may be assumed that the lower part of the lateral sinus is also

thrombosed. Bleeding from the bone at this point may be arrested by

temporarily plugging the foramen with a fragment of sterilized wax.

The condition found on opening the mastoid process varies considerably.

If the result of acute inflammation of the mastoid process, the mastoid

cells surrounding the sigmoid sinus usually contain pus or granulations,

on removal of which a fistula may be seen to communicate with the outer

wall of the sinus; or the bone around the sigmoid groove may already be

destroyed, with free exposure of the sinus within the wound. With this

there is frequently an extra-dural abscess. In other cases, if the

infective process has been very virulent, evil-smelling pus, sometimes

intermixed with bubbles of gas, may escape on chiselling through the

mastoid cortex. This is a sure sign of extensive disease, the sinus wall

often being gangrenous and the bone surrounding it necrosed and

discoloured.

If occurring in the course of a chronic middle-ear suppuration, very

little disease of the mastoid process may be found except along the path

by which the infection has spread.

After the sinus wall has been reached, sufficient bone should be removed

to expose its outer surface for at least half an inch above and below

the supposed infected area.

The decision as to whether thrombosis exists or not may have to be made

during the operation itself, and is based partly on the appearance of

the sinus wall and partly on the symptoms, the relative value of each

varying in each individual case.

Normally the sinus pulsates and is of a bluish-grey colour. If

thrombosed, the wall of the sinus may be of a yellow or dark colour and

may not pulsate, but neither discoloration nor the absence of pulsation

is an absolutely reliable sign of thrombosis. Again, if the sinus be

covered with granulations or purulent lymph, it is sometimes impossible

to say whether it is thrombosed or not, especially if the clot is

limited and parietal. Further, the thrombus may be situated low down

towards the jugular bulb, so that if it has not extended very far

upwards the exposed portion of the lateral sinus may still be normal in

appearance. Palpation of the sinus with the finger or aspiration with a

hollow needle is sometimes advised as an aid to diagnosis. These

procedures, however, are extremely unwise, owing to the risk of

dislodging a small fragment of the infected clot, which may easily occur

if the latter does not obliterate the sinus completely. As a means of

diagnosis the withdrawal of blood by the aspirating needle is of no

value, as it does not negative the presence of a parietal thrombus,

owing to the possibility of the needle passing through it into the free

lumen of the sinus.

OPENING OF THE LATERAL SINUS

=Indications.= The sinus should always be opened as soon as it is

certain that septic thrombosis has occurred.

=Contra-indications.= The only contra-indication for opening the sinus

and removing the thrombus is the certainty that either the patient’s

general condition will not permit of the operation being performed, or

that the septic thrombosis has spread beyond the region from which it is

possible to remove it.

For this reason, operation is unjustifiable if the patient is already

suffering from septic pneumonia, pericarditis, or acute septicæmia; or,

on the other hand, if there are symptoms of cavernous sinus thrombosis

on both sides, or general meningitis. If, however, the patient’s general

condition be good, operation may be attempted as a last resource even

although a pulmonary empyema or a one-sided cavernous sinus thrombosis

already exists.

=Operation.= After exposure of the lateral sinus, the next point to

determine is the site and extent of the infected area (Fig. 244). On

this will depend whether it will be necessary or not to tie the jugular

vein in the neck.

The sinus is first exposed towards the jugular fossa until its surface

appears normal for at least half an inch. It is wiser, however, always

to expose the sinus as low down as possible. A strip of sterilized gauze

is then pressed in between the bone and the outer wall of the sinus so

as to obliterate its lumen at this spot. Instead of removing the bone

from above downwards, the sinus may be exposed first at its lowest limit

by chiselling directly through the tip of the mastoid process. In this

way it can be obliterated by a strip of gauze before attacking the area

of infection. The overlying bone is afterwards removed from below

upwards until the thrombosed area is reached.

In removal of the bone from above downwards there is a certain risk of

small particles of clot being dislodged into the circulation, or, if the

sinus wall is injured, of hæmorrhage taking place if the thrombus at

this particular point does not completely occlude the sinus. If,

however, the sinus be first exposed and obliterated at its lowest limit,

these risks are greatly minimized. There is no special technique in

removing the bone beyond that already given in the description of the

complete mastoid operation.

The next step is to expose the lateral sinus behind the infected area

and follow it backwards until the dura mater appears normal for at least

three-quarters of an inch. If necessary, the skin incision must be

prolonged still farther backwards, in order to permit of removal of the

bone overlying the transverse sinus, which may, perhaps, have to be

exposed even to the torcular Herophili.

[Illustration: FIG. 244. DIAGRAM TO SHOW THE USUAL POINTS AT WHICH THE

LATERAL SINUS IS PRIMARILY INFECTED. A, High up; from the posterior

mastoid cells. In this case it may not be necessary to tie the jugular

vein. B, Low down; involving the jugular bulb. This necessitates

ligature of the vein.]

In removing the bone overlying the infected thrombus, the gouge and

chisel should be used rather than the bone forceps or burr. With the

latter there is greater risk of dislodging particles of clot into the

circulation, owing to pressure of the instrument on the sinus wall.

After the sinus has been exposed well beyond the region of the thrombus,

the bone forceps may safely be used, especially in exposure of the

transverse sinus; and this is a much more rapid method than removing the

bone by means of the gouge and mallet. To prevent the inner blade of the

forceps from nipping the sinus wall between it and the bone, the dura

mater forming the outer wall of the sinus should be separated from the

overlying bone by means of a dura mater separator. In the region of the

infected area the sinus wall may be adherent to the bony wall as a

result of the inflammatory adhesions, and, in addition, may be extremely

friable and so easily torn through.

In exposure of the sinus two points should be remembered: firstly, that

it is sometimes difficult to differentiate it from the dura mater

covering the temporo-sphenoidal lobe above and the cerebellum below; and

secondly, that the transverse sinus is a very much broader vessel than

is imagined, being even half an inch in width. Not much force is

required to obliterate its lumen, but care must be taken to pack the

gauze evenly across its whole width.

After the sinus has been occluded above and below the area of infection,

it should be incised with a small knife along its whole length between

the obstructing plugs of gauze (Fig. 245). If there be bleeding, it may

be due to the sinus being obliterated incompletely, or it may come from

the superior petrosal sinus. To find out where the bleeding comes from,

the finger should be pressed upon the sinus at its upper and lower

limits, close to the obstructing plugs of gauze. If the bleeding stops,

it shows that the sinus has not been obliterated completely; this can

now be done by further plugging with gauze. If, in spite of this,

bleeding still continues, it presumably comes from the petrosal sinus.

All clot and granulations are now rapidly curetted out and the lateral

sinus plugged with gauze. After a moment the gauze is withdrawn and

another small piece is pressed into the lateral sinus at the point of

entrance of the petrosal sinus. After the bleeding has been arrested,

the outer wall of the lateral sinus is excised by cutting it away with

blunt-pointed scissors. The interior of the sinus is then inspected,

special attention being given to the lower portion to see if its lining

is normal. If this be not the case, even if there be no signs of

thrombosis, it means that the surgeon has failed to get well below the

infected area, and therefore the internal jugular vein must be

ligatured. If, however, it be normal, the gauze plug already placed

between the sinus wall and the overlying bone is left undisturbed.

If there be no bleeding from the sinus (excepting a slight amount from

the blood contained within the isolated portion), the thrombus is

curetted out and the inner surface of the sinus inspected. After

excising the outer wall, search is made for the superior petrosal sinus,

which presumably is thrombosed, although perhaps only by normal clot. To

expose this tributary, which enters the lateral sinus at the point at

which it turns downwards to form the sigmoid sinus, bone must be removed

in front of the lateral sinus along the angle forming the roof and inner

wall of the mastoid and antrum; that is, along the superior margin of

the petrosal bone. If the inner surface of the lateral sinus in its

neighbourhood be normal, nothing need be done. If, however, the sinus

wall be infected, the petrosal sinus should be followed out, if

possible, its outer wall being incised and the clot removed, bleeding

being afterwards arrested by pressure.

[Illustration: FIG. 245. THE LATERAL SINUS EXPOSED AND OPENED. The lumen

of the sinus is obliterated above and below the region of the infected

thrombus by plugs of ribbon gauze pressed in between the sinus wall and

the overlying bone. In this case it is not necessary to tie the jugular

vein.]

As a final step, the gauze plugging which still obliterates the lumen of

the sinus in its upper part is removed. If the sinus be normal at this

point, free hæmorrhage will occur; this is arrested at once by again

introducing a strip of gauze between the sinus and the bone. Although

during the earlier stages of the operation the inner lining of the

posterior portion of the sinus may have seemed to be normal, yet it

occasionally happens that hæmorrhage does not at once occur on removing

the plug of gauze; but after a moment or two a long smooth clot,

gradually tapering at its end, may be shot out from the opening within

the sinus, being followed by a gush of blood. The terminal portion of

this clot is non-infective and of recent formation. Its appearance is

always a matter of satisfaction, as it means that the sinus has been

freely exposed and opened behind the infected area.

If on exposure of the sinus it be found that the clot extends so low

down that it will be impossible to obliterate the sinus well below the

infected area, the jugular vein should be ligatured at once before

interfering further with the sinus from the mastoid wound.

Attempts to remove the clot from the jugular bulb by curetting out the

sinus from above are only referred to to be condemned. The surgeon who

believes in this method hopes that all the infected portion of the clot

will be swept out by the flow of blood. It is not, however, always

possible to introduce a curette into the jugular fossa, and if the clot

extends beyond this region it cannot be curetted away completely. The

result of the operation does not depend so much on the skill of the

surgeon as on whether the terminal portion of the clot be infected or

not. Recovery is most likely to take place if a non-infective clot

already extends beyond the region of the curette and so obliterates by

natural means the lumen of the vein below the point reached by the

surgeon. If, on the other hand, free hæmorrhage occurs as a result of

the curetting, it means that the lumen of the vein has been restored,

but there is no guarantee that all the clot has been completely removed.

If any infective portion remains, a fatal result will almost certainly

occur eventually as the result of pyæmia.

LIGATURE OF THE JUGULAR VEIN

=Indications.= Unfortunately, opinion is not unanimous with regard to

this matter. The chief arguments raised against ligature of the jugular

vein are: (1) That it favours extension of the thrombus along the veins

communicating with it, especially along the inferior petrosal and

condyloid veins, which enter the jugular bulb. (2) That it in no way

prevents the spread of infection along other paths, owing to the freedom

with which its tributaries communicate with one another. (3) As a result

of obstruction in the circulation, acute inflammation of the cerebellum

may take place.

Since the jugular vein should only be ligatured if the symptoms point to

the onset of a general infection of the circulation and if it be found

impossible at the time of operation to obliterate the sinus below the

infected thrombus, and since this vein is the chief route by which this

infection takes place, it seems a matter of common sense that it should

be ligatured. At the same time, as many as possible of its tributaries

above the point of ligature should also be ligatured well beyond the

point at which they may be thrombosed.

Although extension of the infection may take place along other veins

after ligature of the jugular vein, it is impossible to say whether the

result is _post_ or _propter hoc_. Against ligature, statistics have

been quoted to show that in a series of cases in which the jugular vein

has not been tied the percentage of recoveries is just as high as in

those in which it had been ligatured. This argument is not quite sound,

because there is no doubt that in the cases in which ligature of the

jugular vein is justified the chances of recovery, owing to the

extension of the thrombus downwards, must be less than in the less

serious cases in which it is admittedly unnecessary to tie the vein. It

is also impossible to say how many cases would otherwise have ended

fatally if ligature had not been performed.

In the majority of cases the vein is ligatured after exploration of the

lateral sinus. In a few cases, however, the symptoms warrant it being

performed as a primary step of the operation, even before the mastoid

process has been opened.

=After exposure of the lateral sinus.= (i) If the clot extends so low

down that it is impossible to obliterate the lumen of the sinus below

its lower limit.

(ii) If there be thrombosis of the bulb of the jugular vein. This

condition is sometimes difficult to diagnose. There may be no symptoms

excepting, perhaps, rigors occurring during the course of chronic

middle-ear suppuration, as even the lower portion of the sinus may be

quite normal in appearance owing to the clot being limited entirely to

the jugular bulb. The probability of the diagnosis being correct is

strengthened by the presence of granulations or carious bone on the

floor of the tympanic cavity. It is better to risk tying a normal vein

than to fail to tie one already infected.

(iii) If the sinus was obliterated above the jugular bulb at the primary

operation and rigors occur subsequently, showing that the sinus is

infected still lower down.

=Before exposure of the lateral sinus.= (i) If there be thrombosis of

the jugular vein. In addition to the ordinary signs of lateral sinus

thrombosis, there may also be infiltration of the tissues, or tenderness

along the anterior border of the sterno-mastoid muscle. The prevalent

idea that a thrombosed jugular vein can be felt on palpation as a hard

cord extending down the neck is erroneous. If anything be felt it is

probably some enlarged cervical glands lying along the line of the vein.

In any case it is bad practice to palpate the internal jugular, as by

doing so there is considerable risk of dislodging particles of the

septic clot.

(ii) If, as a result of septic infection, the general condition of the

patient be so serious that a prolonged operation seems unjustifiable. In

such cases, the lateral sinus is rapidly exposed and incised after tying

the internal jugular, its contents are curetted out and the wound cavity

lightly plugged; the completion of the operation, consisting of the

opening up of the mastoid cells and antrum, and possibly also

exploration of the intracranial cavity, may be performed next day or

later.

(iii) If it be doubtful whether septic thrombosis of the sinus has

already occurred, it is justifiable in certain cases merely to expose

the sinus freely and not to open it (see p. 440). If rigors subsequently

occur in these cases and it becomes evident that the sinus has become

infected after all, then it is wiser to tie the jugular vein as a

primary step of the operation before opening up the sinus itself.

The writer’s reason for doing so is, that at the second operation he has

always found the clot to be extensive, or, at any rate, to be situated

so low down as to prevent the sinus being obliterated below the infected

area.

[Illustration: FIG. 246. INCISION FOR EXPOSURE OF THE INTERNAL JUGULAR

VEIN. The illustration shows the superficial structures. A, Common

facial vein; B, Fascia covering the hyoid bone; C, Anterior border of

the sterno-mastoid muscle; D, Omo-hyoid muscle.]

=Operation.= Formerly it was considered sufficient to divide the vein

between two ligatures and to leave it _in situ_. Now, however, the upper

portion of the vein is brought out through the wound in the neck after

this has been done.

The patient lies in the recumbent position with the affected side close

to the edge of the table. The head and shoulders should rest on a hard

pillow in such a fashion that the neck is slightly extended, the chin

being drawn upwards and the head turned a little to the opposite side so

that the anterior border of the sterno-mastoid muscle can be clearly

defined throughout its whole length. The surgeon stands at the side to

be operated on. The neck is carefully cleansed, but in doing so care

should be taken not to rub the neck too violently, nor should any

attempt be made to palpate the line of the jugular vein in the hope of

feeling it. There is no object in doing so, and if it is thrombosed a

portion of the clot may be dislodged.

An incision, at least three inches in length, is made along the anterior

border of the sterno-mastoid muscle, the mid-point of the incision

corresponding to about the level of the cricoid cartilage. On cutting

through the skin and platysma some small veins may be met with: they

should be clamped with forceps and divided. If, however, the anterior

jugular vein be exposed, it should be drawn to one side, if possible,

and not divided. The anterior border of the sterno-mastoid muscle is

clearly defined, until the upper border of the omo-hyoid muscle is

reached (Fig. 246). Its edge is then drawn slightly outwards by means of

a retractor and separated from the underlying deep fascia. Beneath this

fascia is the carotid sheath, which encloses not only the carotid artery

but the internal jugular vein and the vagus nerve. The vein is external

and somewhat superficial to the artery, and the vagus nerve lies behind.

A vein of varying size will be seen crossing obliquely downwards and

outwards to pierce the deep fascia at a level corresponding to the

cornua of the hyoid bone; this is the common facial vein about to enter

the internal jugular (Fig. 247). If the surgeon has not had much

experience and has difficulty in finding the jugular vein, a certain

method of doing so is to find the facial vein and then follow it down

until it enters the jugular. The carotid sheath should be opened about

this point, and the position of the vein ascertained by feeling the

pulsations of the carotid artery. The sheath of fascia covering the

jugular vein is picked up with a pair of fine forceps and cut through

with a sharp scalpel, which should be inclined obliquely outwards so

that the flat of the knife is held towards the vessel. Any enlarged

lymphatic glands lying over the vein must be removed.

[Illustration: FIG. 247. EXPOSURE OF THE INTERNAL JUGULAR VEIN HIGH UP.

A, Common facial vein; B, Sterno-hyoid muscle; C, Omo-hyoid muscle; D,

Anterior border of the sterno-mastoid muscle retracted outwards. A

ligature is placed around the jugular vein just above the common facial

vein. When the jugular is ligatured at this spot it is not necessary to

tie the facial vein. In actual practice the vein, of course, would be

tied and cut between two ligatures, the upper portion of the vein being

brought out into the neck.]

When the vein has been identified, a blunt dissector is passed between

its outer wall and the sheath, so as to separate the two. The sheath is

incised upwards and downwards until the vein is freely exposed. If the

vein be patent, it will be of a bluish colour, expanding and diminishing

in volume with each act of respiration. If it be thrombosed, there is

usually accompanying periphlebitis which may make the separation of the

sheath from the vein and the surrounding tissues difficult. If there be

no periphlebitis, the thrombosed portion may be purplish, or, if the

clot be of long standing and breaking down, more of a yellowish colour;

the vein stands out as a cord and does not pulsate. If the thrombus be

limited to the portion above the entrance of the common facial vein, the

upper portion of the jugular may be small and collapsed, only becoming

full and pulsating below the point at which the facial joins it.

The next step in the operation is to get well below the point at which

the jugular is thrombosed. If the thrombus be practically limited to the

jugular fossa the vein may be ligatured above the common facial; if not,

as low down the neck as possible. In ligaturing the vein low down in the

neck, the skin incision must be extended downwards, and as the lower

portion of the neck is reached, the omo-hyoid will have to be pulled

aside. The probe should be passed all round the vein so as to make

certain that it is freed from its sheath, and especially that it is

separated from the vagus nerve which lies behind it.

An aneurysm needle threaded with silk is now passed around the vein from

within outwards. The loop of silk is cut so as to form two ligatures,

and the aneurysm needle then withdrawn; the lower ligature is first

tied, its ends being cut short. The upper ligature is then tied a short

distance above it, but in this case the ends are left long. The vein is

raised from its bed by slight traction on this ligature and is cut

across between the two, the lower portion being allowed to sink back

into the wound. The upper portion is then carefully separated for some

distance upwards. Lying behind the vein may be seen the vagus nerve

(Fig. 248). Any tributaries are clamped between two forceps, cut across,

and ligatured, the upper end of the vein being brought out into the

upper angle of the wound. Care must be taken that enough of the vein is

dissected out to allow of this being done, especially if the ligature is

applied above the level of the common facial; in this case the facial

need not be tied.

If there be no periphlebitis, inflammation of the soft tissues, or

thrombosis of the vein itself in the neck, the wound may be closed by

means of silkworm-gut sutures, excepting at its upper angle through

which the open end of the jugular vein projects. If, however, the vein

be thrombosed, and especially if there be periphlebitis, the wound

should be left open, except perhaps at its lower angle, and should be

lightly packed with gauze, as in these cases cellulitis of the neck may

afterwards occur.

After completion of the operation in the neck the surgeon turns to the

mastoid process. If the ligature of the vein has been the primary step,

the mastoid operation is now performed and the lateral sinus is freely

exposed for a considerable distance behind the thrombus. If, however,

the mastoid operation has been the first stage, and the jugular has been

tied as soon as exposure of the sinus showed it to be thrombosed, the

operation on the mastoid is now completed and the sinus opened as

already described (see p. 444). The next step is to incise the sinus

freely from above downwards towards the jugular fossa and curette out

the thrombus.

If there be considerable hæmorrhage, it means that the thrombus is

probably parietal and situated within the jugular bulb, the bleeding

presumably coming from the inferior petrosal sinus or other tributaries

which enter the bulb or upper portion of the jugular vein. If the

bleeding be excessive, the sinus is plugged after a moment or two, by

inserting a piece of gauze into its lumen towards the jugular bulb.

[Illustration: FIG. 248. LIGATURE OF THE INTERNAL JUGULAR VEIN LOW DOWN

IN THE NECK. The upper portion of the vein is dissected out and brought

into the neck. A, A', Cut ends of the ligatured facial vein; E,

Descendens noni nerve; F, Carotid sheath and internal carotid artery; G,

Vagus nerve; H, Gland; J, Lower end of the internal jugular vein. The

hook pulls aside the omo-hyoid muscle.]

In this case the portion of the vein brought into the neck is usually

also filled with blood. After isolating it from the deeper tissues by

packing strips of gauze round it, the vein is deliberately opened just

above the ligature. The bleeding usually stops after a moment or two,

but if it cannot be controlled, the lumen of the vein must again be

closed by a ligature, the end of the vein being allowed to project on to

the neck.

If there be no bleeding from the lower portion of the lateral sinus and

jugular bulb, it means that the vessel is completely thrombosed at this

point. The clot should now be removed by curetting through the sinus

from above downwards towards the jugular bulb, and also from below

upwards through the open end of the jugular vein.

[Illustration: FIG. 249. FREE EXPOSURE OF THE LATERAL SINUS, WHICH HAS

BEEN INCISED, WITH LIGATURE OF THE INTERNAL JUGULAR VEIN. The lateral

sinus is obliterated posteriorly by a plug of gauze pressed in between

its outer wall and the underlying bone. The sinus is freely exposed

almost down to the jugular fossa. The vein has been ligatured and its

upper portion sutured to the skin wound in the neck. The arrow shows the

direction along which the sinus and vein are syringed.]

The venous channel is afterwards syringed through from above downwards.

To do this, a piece of rubber tubing is inserted into the opening in the

lateral sinus and some warm saline solution is injected through it with

a syringe. If the clot be not firmly adherent it can usually be washed

out through the opening in the vein. No force should be used. If gentle

syringing be not sufficient to expel the clot, the attempt must be given

up. The chief objection against syringing is the possibility of

particles of the septic thrombus being forced into the veins

communicating with the jugular bulb. A small drainage tube is inserted

within the sinus.

In order to keep the lumen of the vein in the neck open, it should be

stitched to the edge of the wound surface by several catgut sutures

(Fig. 250). If the bleeding necessitated plugging of the lower end of

the sinus and retention of a ligature on the vein in the first instance,

syringing should be postponed until the first dressing; the portion of

the vein left protruding through the skin wound in the neck is then cut

across, and the edge of the vein sutured to the margin of the wound

under cocaine.

The mastoid cavity is lightly plugged with gauze and a dry dressing

applied. The wound in the neck is similarly treated.

=After-treatment and progress of the case.= There is frequently

considerable shock after the operation, especially if exposure of the

jugular bulb has been undertaken, partly owing to the duration of the

operation and to hæmorrhage. If the patient be very collapsed, a

continuous saline injection, to which some brandy may be added, may be

given per rectum according to Moynihan’s method. After the primary shock

has passed off, the immediate result is usually satisfactory.

_If the jugular vein has not been ligatured_, the first dressing should

be performed within forty-eight hours, the gauze packing being removed,

the wound syringed out, and afterwards repacked. The plugs of gauze,

which were pressed in between the outer wall of the sinus and the

overlying bone in order to obliterate the lumen of the latter, should

not be interfered with for at least six days. If the case progresses

favourably, the temperature becomes normal within a day or two, the

patient feels well, and the wound assumes a healthy appearance. If, on

removal of the gauze plugging, hæmorrhage takes place, then the plugging

must be renewed and not touched again for three or four days. After it

is possible to remove these plugs, the wound is treated as has already

been described in Schwartze’s operation or in the complete operation in

which the posterior wound was left open.

_If the jugular vein has been ligatured_, the sinus and vein should be

syringed through daily, and this should only be stopped after all

secretion has ceased, usually a matter of a week or ten days.

_When the sinus, jugular bulb, and vein have been exposed throughout

their length_ the wound is treated as an ordinary surgical one, being

packed until it granulates up from the bottom (_vide infra_).

[Illustration: FIG. 250. METHOD OF SUTURING THE OPEN END OF THE INTERNAL

JUGULAR VEIN IN THE NECK.]

Apart from intracranial and pyæmic complications, the progress of the

case may be delayed owing to the enfeebled and septic condition of the

patient, and also from the occurrence of abscesses in the neck, or

region of the mastoid itself. These abscesses are the result of septic

thrombosis occurring in some tiny vessel. The first sign of their

occurrence is an attack of pyrexia, shortly followed by a painful

swelling at the affected spot. Any collection of pus should be drained

at once. Although it is quite good practice to close the incision in the

neck in a clean case, yet there must be no hesitation to open it up on

the slightest sign of it becoming septic.

The case may appear to progress favourably for the first week or ten

days, and then an intermittent and increasing pyrexia may occur for no

obvious reason. This is usually due to extension of the infection along

the petrosal sinuses, or perhaps along the transverse sinus.

Symptoms of involvement of the cavernous sinus may arise, perhaps even

with formation of a peri-orbital abscess; or, on the other hand, the

patient may gradually sink in consequence of septic toxæmia; or the end

may come more suddenly with the onset of basal meningitis.

Unfortunately, these cases are almost hopeless from the first, as very

little can be done from a surgical point of view owing to the fact that

they are not seen soon enough.

_In thrombosis of the cavernous sinus_ the only hope of recovery lies in

its exposure and incision of its wall. The sinus may be approached by

tracking forwards the superior petrosal sinus--a matter of considerable

difficulty, and seldom justifiable. Recently Charles Ballance has

suggested the adoption of the Hartley-Krause route for extirpation of

the Gasserian ganglion, and says he has found the operation easy and

effectual. If pus be evacuated from the sinus he considers it advisable

to adopt the recommendation of Voss, who cuts away the zygoma and

removes more bone from the basal aspect of the skull so as to get direct

drainage (Allbutt and Rolleston’s _System of Medicine_, 1908, vol. iv,

Part ii, p. 495).

EXPOSURE OF THE JUGULAR BULB

This may be performed either by following the sinus downwards or through

the floor of the auditory canal and tympanic cavity. The former method

was first described by Grunert (_Archiv für Ohrenheilkunde_, 1902, vol.

liii, p. 287); the latter by Piffl (_Archiv für Ohrenheilkunde_, 1903,

vol. lviii, p. 76).

=Indications.= The object of the operation is to remove the septic clot

situated within the jugular bulb in the hope of preventing extension of

the infection along the veins leading into it, more especially the

inferior petrosal sinus. This indeed has been known to occur even after

the lateral sinus has been curetted out, the jugular vein ligatured, and

the venous channel syringed through.

=Grunert’s operation.= After free opening of the mastoid process and

exposure of the outer wall of the lateral sinus, the skin incision is

extended downwards beyond the tip of the mastoid. The soft tissues are

then separated from the bone forwards and backwards so as to expose

completely not only the mastoid process, but also the digastric fossa

and base of the skull immediately behind it, up to the outer bony margin

of the jugular foramen. Unless care is taken, the forcible traction

forwards of the soft tissues necessary to expose the field of operation

may injure or tear the facial nerve as it emerges from the stylo-mastoid

foramen.

The tip of the mastoid process is removed first. The lateral sinus is

then freely exposed to its lowest possible limit by removing the

overlying bone. In doing this it must be remembered that the sinus

becomes horizontal just before it ends in the jugular fossa, so that at

this point the skull forms its floor instead of its outer wall.

After having exposed the sinus as freely as possible, the ‘bridge’ of

bone separating it from the outer wall of the jugular foramen is removed

in small pieces by nipping it away with narrow biting forceps until the

jugular bulb is exposed from its outer surface. The facial nerve should

not be injured, as it lies in front and external to the portion of the

bone to be removed.

In performing the later stages of the operation, the patient’s head

should be turned well over to the opposite side in order to get a good

view of the parts lying behind and beneath the mastoid process; and in

tracking the sinus downwards, the probe should be used carefully in

order to try and define the exact position of the jugular fossa.

=Piffl’s operation.= Owing to the anatomical difficulty of reaching the

jugular bulb by following the sigmoid sinus downwards, especially in

those cases in which the sinus lies far forwards and in which, at the

same time, there is a very well-developed jugular fossa, Piffl

recommends exposure of the jugular bulb from above through the auditory

canal. The object of this method is to prevent injury to the facial

nerve, which he states is almost certain to occur in Grunert’s

operation, if carried out in cases such as those just mentioned.

After the complete mastoid operation has been performed, the skin

incision is extended downwards and forwards in order that the soft

tissues may be freed from the floor and anterior surface of the bony

portion of the auditory canal as far forward as the Glaserian fissure.

The soft tissues are pulled forward with a blunt hook to give sufficient

room. The lower portion of the tip of the mastoid is removed by means of

the gouge, as far as can be done without injuring the facial nerve,

which in this operation is pulled backwards with the soft tissues at the

posterior inferior margin of the wound. The lower bony margin of the

auditory canal, now freely exposed, is removed by means of a pair of

fine biting forceps until the floor of the tympanic cavity is reached.

If there be not sufficient room, the bone may be clipped away as far as

the styloid process, which also may be removed by bone-forceps after the

muscles attached to it have been dissected off.

In freeing the styloid process, its posterior surface must be approached

with caution for fear of injuring the facial nerve, which here lies in

close connexion with it. In the front of the wound the capsule of the

temporo-maxillary joint may be exposed, but must not be interfered with.

After removal of the styloid process, the uppermost portion of the

external jugular vein should be seen emerging from the jugular fossa.

This is followed upwards by careful removal of the bone between it and

the floor of the auditory canal and tympanic cavity, until the jugular

bulb is brought into view. This part of the operation must be proceeded

with very cautiously, the bone being nibbled away in small fragments

with gouge forceps which are of sufficient strength to nip through the

bone without having to wrench it away. The amount of bone to be removed

and the difficulty of the operation depend largely on the anatomical

condition found.

Whether Grunert’s or Piffl’s operation has been employed, the operation

may be completed either by incising the outer wall of the sinus and

jugular bulb, then curetting out the thrombus, and finally washing

through the lower portion of the vein from above downwards, or by the

more radical method of also exposing the upper portion of the jugular

vein throughout its whole length. To do this the post-aural incision is

continued downwards until it joins the one previously made in the neck.

To obtain room, the neck must be somewhat extended and the jaw pulled

well forward and the sterno-mastoid muscle backwards. The jugular vein

is then dissected upwards towards the bulb.

The nearer the jugular fossa is approached the deeper and more difficult

becomes the exposure of the vein. Passing in front of it may be found

the stylo-pharyngeal, stylo-hyoid, and digastric muscles. In Grunert’s

operation they need not be cut through as the vein will lie posterior to

them. In Piffl’s operation these muscles probably have been already

reflected forward, after removal of the styloid process.

Particular care must be taken not to injure the nerve trunks, which are

in such close relationship with the vein. Lying immediately behind the

vein is the vagus nerve; the spinal accessory passes downwards and

outwards behind it, and the glosso-pharyngeal and hypoglossal nerves

forwards between the vein and the internal carotid artery.

After the vein, the jugular bulb, and the sigmoid sinus have been

exposed throughout their course, their outer wall is cut through with a

pair of blunt-pointed scissors along its whole length, so as to convert

the venous canal into an open gutter. The thrombus is then curetted out

and the dissected portion of the jugular vein cut off as high up as

possible. Any bleeding from the inferior petrosal sinus or condyloid

veins, which may not be thrombosed, should be arrested by direct

pressure of a strip of gauze over the bleeding points. The wound cavity

is then washed out with a weak biniodide solution and dried.

The lower portion of the incision in the neck may be closed with sutures

and a small drainage tube inserted at its lower angle. The upper portion

of the wound, now directly continuous with that of the mastoid cavity,

is left open and packed lightly with gauze, which is inserted into the

remains of the venous channel.

=Comparison of operations for lateral sinus thrombosis.= Except when the

thrombus is limited to the upper part of the sigmoid sinus, it is

undoubtedly wiser to tie the jugular vein than to be content with

curetting out the clot after obstructing the sinus above and below by

means of gauze plugs. Exposure of the jugular bulb is so difficult an

operation and requires so much time, especially if the whole length of

the upper portion of the jugular vein is also dissected out, that it is

seldom advisable to perform it; nor will it often be justifiable owing

to the condition of the patient, who is seldom strong enough to undergo

such a prolonged operation. The records of this particular operation are

so few that it is impossible as yet to determine its value.

If the sinus be exposed as low down as possible, and the jugular vein

dissected out and brought out into the neck, and the venous channel

afterwards syringed through, the chances of recovery should be almost as

good as in the case of free exposure of the jugular bulb.

If the inferior petrosal sinus be already infected before the operation,

it does not matter whether the operation performed is that of syringing

through the jugular bulb or freely exposing it, as in either case the

inferior petrosal sinus cannot be followed out.

Curetting of the lower portion of the sinus without previous ligature of

the jugular vein should never be done.

=Difficulties and dangers of the operation.= The chief difficulty in

these operations is anatomical; the chief danger is hæmorrhage.

If the hæmorrhage be due to accidental tearing of the wall of the sinus

in the earlier part of the operation, and if it be impossible to

obliterate the sinus below this point by pressing in gauze between its

wall and the underlying bone, then the jugular vein should be tied

before anything else is done.

Extreme vascularity of the bone is not unusual after ligature of the

jugular vein. In these cases the surgeon must rely on the cleverness of

the assistants in keeping the field of operation clear by careful

swabbing.

In exposure of the jugular vein there may be difficulty in finding the

vessel, especially if the cervical glands are enlarged, or if there be

matting together of the tissues in consequence of periphlebitis or

cellulitis. In these cases the best plan is to identify the common

facial vein and then trace it down to its entrance into the jugular

vein.

With regard to the sinus, the chief danger is injury of its inner wall

whilst curetting out its contents: this may afterwards give rise to

meningitis or a cerebellar abscess. Accidental pricking of a

non-thrombosed jugular vein may allow of entry of air into the vein and

so cause death: this is a catastrophe I have not yet met with. Also, if

the operator be careless or inexperienced, he may injure the carotid

artery or vagus nerve; in the former case the only thing to do is to

ligature the artery above and below the wound.

=Complications.= The chief intracranial complications are meningitis and

cerebellar abscess; the former usually from extension of the septic

thrombosis along the petrosal sinuses. If, at the time of operation, it

be doubtful whether intracranial suppuration already exists or not, the

surgeon should content himself with removing the septic thrombus from

the sinus and await further symptoms. At the time of the operation,

however, sufficient bone should be removed to expose the dura mater over

the cerebellum. If, in addition to the clinical symptoms, the appearance

of the dura mater, the increased intracranial tension, and the absence

of palpation suggest the presence of an abscess, the cerebellum should

then be exposed and explored (see p. 467). Before doing this, the wound

should be made as aseptic as possible and a fresh set of sterilized

instruments used.

The complications resulting from general septic infection are pyæmia and

septicæmia.

=Prognosis.= The prognosis depends entirely on whether the septic focus

can be completely removed or not. Failure to do this is frequently due

to the operation not having been sufficiently extensive. It is a matter

of experience that if a second operation has to be performed recovery

seldom takes place. For this reason the first operation must be

thorough.

If such cases could be operated on in the earliest stage whilst the

infective thrombus was still limited, without doubt a higher percentage

of recoveries would be obtained. Unfortunately, the surgeon may not be

summoned until too late, owing to the seriousness of the condition not

having been realized.

In any individual case it is impossible to tell for the first few days

after the operation what the ultimate result will be. Without operation

a fatal termination is practically certain. As a result of operation

about one-third of the cases may be expected to recover.

CHAPTER X

OPERATIONS FOR INTRACRANIAL ABSCESS OF OTITIC ORIGIN

An intracranial abscess, the result of disease of the temporal bone, is

usually situated close to the surface of the brain, and is in close

relationship with the diseased area of bone through which the infection

has taken place. The actual track of the infection can frequently be

traced through the bone to the dura mater and brain substance itself;

sometimes, indeed, a fistula is found to pass through the bone and to

communicate with the intracranial abscess. On the other hand, though

rarely, the surface of the bone to all appearances is normal and there

are no adhesions between it and the dura mater and underlying brain

substance, and the abscess may be situated deeply within the brain.

With regard to the comparative frequency of temporo-sphenoidal and

cerebellar abscess, in 100 cases collected from the records of the

London Hospital the writer found that in children under ten years of age

temporo-sphenoidal abscess occurred in 87% and cerebellar only in 13%,

whereas in adults cerebral abscess occurred in 65% and cerebellar in

35%; and that a cerebral and cerebellar abscess occurred together only

in 5% of the cases.

These statistics are practically the same as Körner’s (_Die otitischen

Erkrankungen des Hirns, der Hirnhäute und der Blutleiter_). Ballance, on

the other hand, considers cerebellar abscess a more frequent occurrence

than temporo-sphenoidal.

Multiple abscesses may be met with, usually the result of pyæmia.

=Indications.= An intracranial abscess must always be opened and

drained.

Indications pointing to such a condition are persistent headache,

purposeless vomiting, a slow pulse, a subnormal temperature, and optic

neuritis. With this there is usually some change in the mental

condition, especially in the case of a temporo-sphenoidal abscess. In

the early stages there may be attacks of simple forgetfulness or mental

aberration, or, on the other hand, that of extreme mental excitement.

Owing to the intracranial pressure caused by the increase in size of the

abscess, the mental state becomes impaired and the condition known as

slow cerebration or the ‘dream state’ may be observed.

It must, however, not be forgotten that the same clinical picture may be

produced by other conditions, such as an intracranial tumour: in the

case of a middle-ear suppuration, however, an intracranial abscess may

be diagnosed unless this can otherwise be excluded.

Before operation is decided on, the site of the lesion must be

determined. This can only be done if certain localizing symptoms are

present.

_In a temporo-sphenoidal abscess_, if the cortical region be affected,

there may be paralysis or paresis of the opposite side, beginning with

the face and then spreading to the arm and leg; or in the opposite order

if the internal capsule be involved.

If the left temporo-sphenoidal lobe be the site of the lesion, aphasia

may be met with, and if the abscess extends backwards, word-blindness

may occur. If the centre of hearing be affected there may be complete

deafness of the opposite side owing to its destruction; or tinnitus or

hyperacusis if the centre be only irritated by the proximity of the

abscess; or if the anterior extremity be involved anosmia or parosmia

may be noticed. Another important sign, occurring in conjunction with

the above symptoms, is a fixed pupil on the affected side.

_In a cerebellar abscess_ the symptoms are less marked, or may even be

absent, so that the abscess may remain undiagnosed during life and only

be discovered at the autopsy, which may perhaps have been performed on

account of the sudden and unexpected death of the patient from rupture

of the abscess itself. In walking, in addition to a peculiar staggering

gait, there is a tendency for the patient to direct his course gradually

towards the affected side. Lateral nystagmus, if present, is usually

directed towards the affected side and has to be differentiated from

that due to internal-ear disease. If a cerebellar abscess be associated

with a labyrinthine suppuration and the latter is explored by operation,

the nystagmus will still remain directed to the affected side. If,

however, no cerebellar abscess be present the labyrinthine operation

will be followed by nystagmus strongly directed to the opposite side.

Optic neuritis and vomiting usually are more severe than in

temporo-sphenoidal abscess. Headache, if present, may be referred to the

occipital region, and there may also be slight retraction of the neck or

pain behind the mastoid region as a result of localized and early

meningitis of the posterior fossa. If the abscess be very large, there

may be paresis or paralysis of the facial nerve and perhaps also of the

upper extremity. The deep reflexes may also be altered, the knee-jerk

being frequently absent on the affected side. The patient in the late

stage usually lies curled up in bed on the side opposite to the lesion,

with the knees flexed.

=Methods of operation.= Two methods may be employed:--

1. Trephining directly over the area of the abscess (rarely necessary).

2. First performing the mastoid operation and then following out the

route of infection (usual method).

In the case of middle-ear suppuration, trephining has practically been

abandoned, and rightly so, since it has become recognized that the

intracranial abscess is due to direct extension of the pyogenic

infection from the middle-ear and mastoid cavities.

The only circumstances in which trephining may be advised are--(1) If

the diagnosis be certain and the operator has no experience of aural

surgery. In a case of emergency he is wiser, perhaps, to trephine and

drain the abscess, leaving the mastoid to be dealt with afterwards by

someone competent to do so. (2) If, after performing the mastoid

operation, the situation of the abscess be doubtful. In order to

diminish the risk of infection of the brain by an exploratory puncture

which may prove negative, the bone may be trephined a little beyond the

mastoid wound, either above or behind, according as a temporo-sphenoidal

or cerebellar abscess is suspected. If, however, it be considered

advisable to make a fresh opening in the bone beyond the septic wound

cavity, the aural surgeon will probably prefer to do so by means of the

gouge and bone-forceps, to which he is more accustomed.

Trephining has also been advised if the patient is so ill that a

prolonged operation is impossible; or if there is cessation of

respiration during the operation itself, which may occur in a cerebellar

abscess as a result of pressure on the medullary respiratory centres. To

those accustomed to perform the mastoid operation, the opening of this

cavity and the necessary removal of bone can be done more rapidly by the

gouge or bone-forceps than by the trephine.

For whatever reason trephining is done, it is afterwards essential to

perform the mastoid operation and to remove the primary focus of the

disease, otherwise one of the fundamental principles of surgery will be

neglected.

=Operation.= The preliminary preparation of the patient is the same as

for the mastoid operation, only the head should be shaved over a wider

area. The exposure of the field of operation is the same whether the

brain is explored through a trephine opening or from an extension of the

mastoid operation.

In the case of the temporo-sphenoidal lobe, it is necessary to extend

the incision behind the auricle vertically upwards for an inch or more

(Fig. 252); whereas if the cerebellum has to be explored, an incision is

carried backwards at right angles to the post-aural incision, just below

its mid-point (Fig. 253). In the former case, on reflecting the soft

tissues from the underlying bone, the squamous portion of the temporal

bone, immediately above the zygomatic ridge, will be exposed; in the

latter, the base of the skull behind and below the mastoid process and

lateral sinus will be laid bare.

1. =Trephining.= The trephine used should be three-quarters of an inch

to one inch in diameter according as the patient is a child or an adult.

Either the hand trephine or Macewen’s improved pattern mounted with a

guard may be used. If available, the trephine may be worked by a motor,

but in this case it should be remembered that the bone will be pierced

more quickly than by the hand instrument.

_Trephining for a temporo-sphenoidal abscess._ The object of the

operation is to expose the lowest portion of the middle fossa just above

the roof of the antrum and tympanic cavity. The trephine, therefore,

should be placed so that it is situated just above the suprameatal

spine, its lowest margin being slightly above the zygomatic ridge (Fig.

251). After the disk of bone has been removed the exploration of the

abscess is then carried out.

[Illustration: FIG. 251. TOPOGRAPHY OF THE AUDITORY REGION OF THE SKULL.

A, Point of trephining for a temporo-sphenoidal abscess; B, For a

cerebellar abscess; C, Dotted line marking a portion of the lateral

sinus.]

_Trephining for a cerebellar abscess._ The point at which the bone is

trephined must be behind and below the curve formed by the transverse

and sigmoid portion of the lateral sinus; that is, behind the mastoid

process and below Reid’s base-line.

If the mastoid operation has not been performed, the centre pin of the

trephine should be placed at a point 1-1/4 to 1-1/2 inches behind the

centre of the external auditory meatus, and an inch below Reid’s

base-line (Fig. 251). If, however, the mastoid has already been opened

and the lateral sinus exposed, the trephine should be placed so that its

anterior border is just behind the sinus and its upper border well below

Reid’s base-line.

2. =After performing the mastoid operation.= If this has been done

already, the wound is reopened, and cleansed by filling it with

hydrogen peroxide. After gently curetting away any granulations the

wound cavity is irrigated and then packed in order to dry it. Under good

illumination, careful inspection is made to see if a fistula or a tract

of diseased bone extends in any direction. Whether the middle or

posterior fossa should first be explored depends not only on the

clinical symptoms but also on the condition found on opening the mastoid

cavity.

=Opening of a temporo-sphenoidal abscess.= A temporo-sphenoidal abscess

may be explored either through its lowest point, that is, through the

roof of the antrum and floor of the middle fossa, or through its outer

wall just above the zygomatic ridge. To obtain a view of the roof of the

antrum and mastoid cavities, the head of the patient should lie almost

flat on the operating table and be turned well over to the opposite

side. The bony roof of the antrum and mastoid is removed by means of the

gouge and mallet, and so expose the dura mater covering the floor of the

middle fossa (Fig. 252). If a fistula communicates with the antrum

cavity and the middle fossa, the bone surrounding it is first attacked.

In removing the bone, it must be remembered that the tegmen tympani is

exceedingly thin, and unless care is taken pieces of bone may be pressed

inwards on to the overlying dura mater. Sufficient bone should be

removed to determine whether the dura mater is normal or not. To do this

it may be necessary to chisel away the tegmen tympani outwards until the

squamous portion of the temporal bone is reached, after which a pair of

bone forceps may be used until a sufficient opening is obtained.

[Illustration: FIG. 252. EXPLORATION FOR A TEMPORO-SPHENOIDAL ABSCESS.

A, Above the tegmen tympani; B, Through the tegmen tympani. Occasionally

these methods are combined; the bone between the openings being also

removed.]

The condition found on examination of the dura mater varies. In many

cases it is congested or covered with granulations at the site of the

infection, and usually it is adherent to the underlying bone. At other

times it seems normal.

Increase of the intracranial pressure, as shown by the bulging outwards

of the dura mater, and absence of pulsation are suggestive of an

abscess. These signs, however, are not conclusive, as on the one hand

increased intracranial pressure may be due to other causes and on the

other it is quite possible to have pulsation if the abscess be small and

deeply placed.

If an extra-dural abscess be present, the intracranial cavity should not

be explored at once unless this is absolutely necessary, but this step

of the operation should be delayed for at least twenty-four hours. If,

however, immediate operation be necessary, special precautions must be

taken to render the part as aseptic as possible, and a fine layer of

gauze should be packed between the margin of the bone and the dura mater

in order to prevent further infection of the brain or meninges. In an

uncomplicated case only sufficient bone should be removed to permit of

the insertion of a large drainage tube; that is, the dura mater should

not be exposed over a larger area than the size of a shilling.

If there be disease of the tegmen tympani and the symptoms point to a

temporo-sphenoidal abscess, the brain should be explored through this

opening in the bone (Fig. 252), as the abscess is thus not only drained

through its most dependent part, but also through its stalk.

If, however, the diagnosis be doubtful, the temporo-sphenoidal lobe may

be explored through a fresh opening, just above the tegmen tympani. This

will diminish the risk of septic infection from the mastoid cavity.

After the dura mater has been exposed sufficiently a small incision is

made in it, taking care to avoid wounding any of the vessels. With a

pair of forceps the cut edge of the dura mater is drawn outwards and the

incision is prolonged in each direction with a pair of blunt-pointed

scissors. Similarly, the dura mater is cut through at right angles to

the primary incision, so that four small flaps are made and turned back

so as to expose the outer surface of the brain.

As a rule the dura mater, arachnoid, and pia mater are fused together by

inflammatory adhesions, so that from a practical point of view they need

hardly be considered as separate structures. Similarly, at the site of

infection, the point of the so-called stalk of the abscess, the cerebral

membranes are adherent to the underlying brain, especially if there has

been any localized meningitis. For this reason it is sometimes necessary

to peel away the dura mater from the brain, in order to expose the

latter.

As a rule, very little fluid escapes: if present in considerable

quantity, and if it escapes from between the dura mater and brain, it

is an unfavourable sign, as it generally signifies early meningitis.

If meningitis be present, purulent lymph or secretion may be seen on the

surface of the brain, either localized or spreading from the site of the

infection.

If the intracranial pressure be great, the brain will bulge through the

opening in the dura mater. If the abscess be very large and situated

superficially, the thin layer of brain substance forming its outer wall

may rupture as soon as an opening has been made in the dura mater.

Sometimes, indeed, the pus may be seen to ooze through an opening in the

dura mater, which may be found to communicate with the abscess cavity.

The next step is to open the abscess. Formerly a trocar and canula were

used. This method is no longer in favour for the following reasons:--If

the wall of the abscess cavity be very thick, it may not be pierced;

secondly, the trocar may pass through the abscess cavity and enter the

brain substance beyond without draining it; and thirdly, even if the

trocar enters the abscess cavity the pus may be so thick as to plug its

lumen. For these reasons a fine pair of Lister’s sinus-forceps or a

narrow-bladed bistoury is recommended. In the ordinary case Lister’s

forceps can be used.

The direction in which the brain is explored depends upon the point at

which this is done. Thus, if the procedure be carried out through the

tegmen tympani, the brain is explored in an upward direction. The

forceps are made to pierce the brain for about an inch; the blades are

then slightly dilated and the forceps partly withdrawn. If a large

abscess exists, the cavity is usually opened at once and pus flows out

along the track of the forceps. If the abscess be small and deeply

placed, its cavity may not be entered on the first thrust of the

forceps. In this case they are closed and withdrawn. The brain is then

explored by thrusting the forceps first upwards and forwards, then

upwards and backwards, and finally upwards and inwards; in the latter

case it is unwise to pierce the brain for more than an inch and a

quarter for fear of entering the lateral ventricle.

If the brain be explored through the outer wall of the

temporo-sphenoidal lobe, the first direction in which this is carried

out is directly inwards. If this be not successful, the brain is further

explored in a direction forwards, upwards, or backwards, the exploratory

instrument at the same time pointing slightly inwards.

If exploration proves negative, it may also be necessary to explore the

cerebellum. If, however, the surgeon be still convinced that a

temporo-sphenoidal abscess exists, he may next pierce the brain with the

bistoury, in case the forceps has failed to enter the abscess cavity,

perhaps owing to its walls being very thick. If all efforts fail to find

the abscess, the little finger may be inserted into the brain itself to

see if the resistant wall of an abscess can be felt. This procedure,

however, should be avoided if possible, as by doing so it causes

destruction of a certain amount of brain tissue.

If an abscess be opened a varying quantity of pus escapes, usually evil

smelling. In the more chronic cases it is thick and greenish; in the

acute cases it may contain shreds of necrosed brain tissue or be

intermixed with bubbles of gas. Sometimes there is also an escape of

turbid cerebro-spinal fluid, which if excessive is suggestive either

that the lateral ventricle has been opened inadvertently or that the

abscess has already burst into it. In these cases the patient is usually

comatose or in the state of muttering delirium at the time of the

operation.

After the abscess has been opened, the forceps or bistoury should be

retained in position until the pus has drained away. A large tube is

then pushed into the abscess cavity along the line of the forceps or

bistoury. It is only permissible to withdraw the instrument with which

the abscess has been opened after the end of the tube is well within the

cavity. The outer end of the tube should be flush with the surface of

the wound. To prevent it slipping too far into the brain, it may be

anchored to the edge of the skin wound by a silkworm-gut suture. If the

abscess be drained through the tegmen tympani, it will be difficult to

bring the tube out into the wound without kinking it. For this reason I

prefer to incise the brain substance slightly outwards after the abscess

cavity has been reached, so that a tube can be inserted obliquely

upwards and inwards at a point corresponding to the angle between the

tegmen tympani and the squamous portion of the temporal bone. If the

exploratory puncture has been made above the tegmen tympani and an

abscess discovered, the question arises whether another drainage tube

should not also be inserted into the brain through an opening in the

roof of the antrum so as to drain the abscess from below. This, however,

I do not think necessary.

In addition to the rubber tube, many varieties of drainage tubes have

been suggested, such as decalcified chicken bone, as originally used by

Macewen, and glass or silver tubes; the object of the latter being to

resist the pressure of the brain, which may compress a rubber tube. The

rubber tube is the simplest form of drainage, and if sufficiently thick

it should be employed. To make more certain of free drainage, some

surgeons use two tubes placed side by side. I think, however, one large

tube (half an inch in diameter) is better than two small ones.

Irrigation of the abscess cavity is still a matter of opinion. If the

abscess be small and circumscribed, the best method is to open it with

as little disturbance as possible to the surrounding parts, insert a

large drainage tube, and to do nothing further.

If, however, the abscess be large and irregular in shape, so that the

drainage is not free, and especially if it be very septic and contains

necrosed brain tissue, irrigation is justifiable if gently carried out.

The best method is to insert a fine tube along the lumen of the large

one and allow some warm saline solution to flow slowly along it into the

abscess cavity, the fluid returning along the larger tube. If two tubes

have already been inserted into the abscess cavity, the fluid injected

through one will escape by the other. Whatever method is employed, care

must be taken that there is free exit for the fluid, as otherwise the

abscess cavity may become over-distended, and in consequence rupture of

a portion of its wall may take place, especially the inner, which

perhaps only consists of a thin layer of brain tissue separating the

abscess from the lateral ventricle. During the act of irrigation there

is a risk of some of the fluid, now loaded with septic particles,

escaping between the surface of the brain and the dura mater and thus

setting up a secondary meningitis.

[Illustration: FIG. 253. EXPLORATION FOR A CEREBELLAR ABSCESS. A behind,

and C in front of the lateral sinus; B, Lateral sinus.]

=Opening of a cerebellar abscess.= The cerebellum may be explored from

two different points, either in front or behind the lateral sinus. The

posterior route is adopted if the abscess is superficial in the outer

portion of the lateral lobe, usually the result of lateral sinus

thrombosis or disease of the posterior mastoid cells. The anterior

route is indicated if it is thought that the abscess is deeply placed in

the anterior inferior portion of the cerebellum, that is, in those cases

in which it is apparently a complication of labyrinthine suppuration, or

the result of disease of the inner wall of the antrum and mastoid

cavities (Fig. 253).

(_a_) _Behind the lateral sinus._ After exposure of the lateral sinus

the bone is removed either by means of the gouge and mallet or by

bone-forceps, until a considerable area of the dura mater is exposed

behind and below the curve of the sinus (Fig. 253). The dura mater is

then incised as already described.

The cerebellum is explored by thrusting the instrument inward for about

an inch. As a rule the abscess is found at once. If it be not discovered

at the first attempt, the instrument should be directed forwards,

upwards, and inwards towards the posterior surface of the petrous bone.

Care, however, must be taken that it is not pushed in too far, otherwise

it may pierce the anterior upper margin of the cerebellum, and if an

abscess be present, the meninges may thus become infected. If the

surgeon has exposed the dura mater by trephining, it is necessary to

push the exploratory instrument at least two inches inwards and forwards

in order to reach an abscess situated in the anterior inferior portion

of the cerebellum. In such cases it is by no means difficult to miss a

small abscess, and further, drainage is frequently incomplete when an

abscess is discovered. For this reason, if the cerebellum be explored

first behind the lateral sinus and no abscess is discovered, it should

further be explored by the anterior route in front of the lateral sinus.

If the cerebellar abscess be secondary to lateral sinus thrombosis, and

if there be no doubt as to the diagnosis, the inner wall of the sinus

should be made as aseptic as possible, and the dura mater forming it

incised freely; the cerebellum being thus explored through the site of

infection.

(_b_) _In front of the lateral sinus._ The lateral sinus is first

exposed (Fig. 253). The triangular area of bone situated in front of it,

between it and the semicircular canals, and forming the inner boundary

of the antrum and mastoid cavities, is now removed with the gouge and

mallet or with a suitable pair of forceps. If it be certain that

internal-ear suppuration exists, or if the operation be secondary to

opening of the labyrinth, the posterior wall of the petrous bone may be

removed until the internal auditory meatus is almost reached. If,

however, the labyrinth be intact, care must be taken not to chisel away

too much bone for fear of encroaching on the posterior semicircular

canal. On exposure of the dura mater an extra-dural abscess may be met

with, usually the result of internal-ear suppuration. Even if no pus be

seen, it is always a wise precaution, if internal-ear suppuration

coexists, to separate the dura mater from the posterior wall of the

petrous bone by means of an elevator in order to prevent any deeply

situated extra-dural abscess being missed. After the dura mater has been

exposed sufficiently it is opened by a crucial incision. In this region

absence of increased tension within the brain and lack of bulging

outwards of the cerebellar tissue do not necessarily imply the absence

of an abscess; the cerebellum to all appearances may appear normal and

flaccid, although a small abscess may be present.

The cerebellum is explored in various directions to a distance of not

more than one inch. After the pus has been evacuated a tube is inserted

as described above. In the majority of cases this method is far superior

to opening the cerebellum behind the lateral sinus, especially as it is

now recognized that the chief cause of cerebellar abscess is

internal-ear suppuration.

=After-treatment.= This is similar to that of any ordinary abscess, but

care must be taken that free drainage is maintained. The main part of

the mastoid wound is lightly plugged with gauze, the tube inserted into

the brain abscess being brought flush with the surface of the skin. The

gauze filling the wound cavity should be arranged around the tube so

that it rests comfortably within the wound and is not kinked. If the

drainage tube be in its proper position, pus should be seen to ooze out

of it.

Although the mastoid cavity itself need not be dressed daily, if

necessary the outer dressings may be removed twice a day, in order to

see that drainage of the abscess is continuous. After the first two or

three days, the tube is gradually shortened. If the abscess be a recent

one and not encapsuled, it becomes rapidly obliterated by pressure of

the surrounding brain tissue, so that the tube may be forcibly ejected

within a few days. On the other hand, if the abscess has existed for a

considerable period and is bounded by a thick wall, which may be

extremely resistant, the purulent discharge may continue for many days

and necessitate the continuance of drainage. Generally speaking, the

tube may be shortened every second or third day, and can usually be

dispensed with by the end of the second week, if not before. It is,

however, very necessary that the tube should not be withdrawn until it

is certain that the abscess cavity has been obliterated completely.

The general treatment of the case in no way differs from that already

described for the mastoid operation in which the wound has been left

open posteriorly.

=Complications.= (i) On turning back the flaps of the dura mater, a

hernia, consisting of friable congested brain tissue, may occur at once.

This is extremely rare as a result of a simple abscess of the brain,

but is significant of encephalitis frequently associated with

meningitis (see p. 436). If an abscess be suspected, the brain should be

explored as already described. If, however, no abscess be discovered,

the treatment consists in removal of more bone and further incision of

the dura mater, in order to permit of free drainage and to relieve

tension.

(ii) Opening into the lateral ventricle. This may be due to rupture of

its wall owing to the sudden diminution of pressure from too rapid

drainage of the abscess cavity, or it may occur accidentally from

thrusting in the exploratory instrument or drainage tube too deeply. Its

occurrence is evidenced by the sudden gush of cerebro-spinal fluid. The

ultimate danger is subsequent infection of the cavity, which,

unfortunately, frequently occurs.

(iii) Cessation of breathing. This is more likely to occur in a

cerebellar abscess in consequence of direct pressure on the medullary

respiratory centres. The immediate treatment is to do artificial

respiration and to open the cerebellar abscess by the quickest method

possible. If this be successful, respiration probably will be restored.

=Prognosis and subsequent progress.= In an uncomplicated case a

favourable prognosis may be expected, provided the abscess is

successfully opened and drained without much disturbance of the

surrounding parts. Many factors, however, may lead to a fatal result.

With regard to recovery: in 100 cases taken from the records of the

London Hospital during the last ten years, recovery took place in 20%

operated on for cerebral and 10% for cerebellar abscess. Other

statistics give a much higher percentage of recovery, but it must be

remembered that in hospital patients a large number of the cases are

only seen by the surgeon at a very late stage, when the brain abscess is

complicated by other intracranial or suppurative lesions, and the

patient is in an almost moribund condition; so that the operation may

only be undertaken as a forlorn hope.

If the operation is going to be successful, the head symptoms quickly

disappear. Even if the patient was comatose before operation, the

recovery may be so rapid that his mental condition may be almost normal

within twenty-four hours. In many cases, if the abscess be a large one,

convalescence will be tedious or prolonged; sometimes, indeed, complete

restoration of the mental faculties, in spite of a most successful

operation, will not be obtained. The chief relief to the patient is the

cessation of the terrible headaches from which he has been suffering.

Unfavourable symptoms are the sudden onset of pyrexia accompanied by

delirium usually the result of diffuse meningitis, or of infection of

the lateral ventricles. In the latter case there is a rapid termination

in drowsiness, coma, and death.

Although the brain abscess may be draining freely, the patient for some

days may lie in a semi-comatose condition as a result of œdema or

inflammation of the surrounding brain tissue; in such cases prognosis is

difficult, but hope of recovery may be entertained if the pulse and

temperature keep practically normal.

=Recurrence of symptoms.= This may take place within the first few days

after the operation as a result of infective cerebritis, the presence of

another abscess, or faulty drainage; or at a much later period, owing to

the formation of another abscess or to a cyst within the brain at the

site of the former abscess.

1. If the recurrence of the symptoms appears immediately after the

operation, the wound should be inspected carefully, if necessary under

an anæsthetic. If drainage be not free, the tube should be removed and a

pair of forceps inserted along the track leading into the abscess, their

blades being then slightly opened and withdrawn. On doing this an

accumulation of pus may escape. The cavity may then be irrigated gently

with saline solution and a larger tube inserted.

If, however, this procedure does not give a satisfactory result, the

finger may be inserted into the brain to feel if the abscess is

loculated. By this means any existing septa may be broken through; or if

a feeling of resistance suggests the presence of another abscess, this

part of the brain can also be explored. It must also be remembered that

although a temporo-sphenoidal abscess has been opened successfully and

is draining well, the continuance of the symptoms may be due to a

coexisting abscess of the cerebellum, or _vice versa_; in other cases,

in spite of all care, the patient gradually sinks, partly from

exhaustion and partly from general toxæmia, the result of infective

cerebritis.

2. Recurrence of symptoms at a later period. The occurrence of a fresh

abscess is usually owing to the fact that the primary focus of the

disease has not been completely removed at the first operation; for

instance, if the surgeon only trephined and drained the abscess without

performing the mastoid operation.

A cyst is usually the result of the abscess having been encapsulated and

its wall not having been removed at the first operation. If a cyst be

discovered on exploring the brain in consequence of these symptoms, its

wall should be removed if possible.

Apart from symptoms of intracranial pressure, the patient may suffer

from attacks of Jacksonian epilepsy from time to time, presumably due to

the post-operative adhesions. If they continue in spite of conservative

treatment, it may become necessary to operate in order to remove this

source of irritation (see Vol. III).

SECTION IV

OPERATIONS UPON THE LARYNX AND

TRACHEA

BY

W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)

Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital

CHAPTER I

ENDOLARYNGEAL OPERATIONS

=Indications.= (i) _Tumours._ Tumours of the larynx are more often

innocent than malignant. Sir F. Semon[5] collected 12,297 cases seen

between 1862 and 1888 by 107 laryngologists, and of these 10,747 (or

88%) were benign and 1,550 (or 12%) were malignant. Of the innocent

forms, papilloma, either simple or multiple, occurred in 39%; fibroma,

sessile or pedunculated, was next in frequency; cystic tumours were not

nearly so common; and other forms, including myxoma, angeioma, adenoma,

lipoma, and enchondroma, were rare. The period during which these

tumours are most common is between the ages of 20 and 40 years, but they

are also frequent during childhood.

[5] _Internat. Centralblatt für Laryngol._, Jahrgang v u. vi, 1888-9,

‘Die Frage des Ueberganges gutartiger Kehlkopfgeschwülste in bösartige,

speciell nach intralaryngealen Operationen.’

Malignant growths occur at a later age, mostly between the ages of 40

and 60, and attack males more than females. Carcinoma is far more common

than sarcoma, and is generally of the squamous-celled variety.

Endothelioma has not often been discovered.

The importance of distinguishing innocent from malignant tumours is

greater now than in former years, since it is agreed that endolaryngeal

operations are preferable for the eradication of the former, while the

latter are better treated by extra-laryngeal methods. Moreover, the

differential diagnosis has steadily improved, owing to the more general

use of the laryngoscope and the introduction of recent methods of

examination. Thus, by direct laryngoscopy it is possible to investigate

children as easily as adults. Microscopical examination of fragments

removed with laryngeal forceps is of great value in confirming the

clinical diagnosis; the sections can be made by freezing, or in

paraffin, the latter method requiring, with recent improvements, not

more than twenty-four hours. Semon, who has done more than any other man

to improve the early diagnosis of malignant disease of the larynx, is

strongly in favour of such examinations. It must be remembered, however,

that the result is sometimes inconclusive, for it is difficult to be

certain that the actual growth has been removed. In cases that are

thought to be malignant, it is better to open the thyreoid[6] cartilage

than to rely upon endolaryngeal operation, as there is a danger of

stimulating the growth to greater activity, especially by repeated

interference. When the thyreoid cartilage has been opened, the whole

disease can be explored thoroughly and a fragment selected from which to

make a frozen section. In the majority of cases a definite diagnosis can

thus be arrived at, and even when it is necessary to examine several

fragments the amount of time lost is small.

[6] [The spelling of this word has been adopted in conformity with the

Basle Anatomical Nomenclature.--Ed.]

As regards the value of skiagraphy, Walsham and myself have found that

photographs can be made of tumours of the larynx which in some instances

determine accurately the position and extent of the disease.

[Illustration: FIG. 254. SKIAGRAM SHOWING A TUMOUR OF THE LARYNX. A,

Tumour; B, Body of hyoid; C, Greater cornu of hyoid; D, Epiglottis; E,

Posterior plate of cricoid; F, Vocal cord; G, Trachea; H, Œsophagus.]

Fig. 254 is a photograph showing a cancer of the upper opening of the

larynx, lying above the vocal cords, the position of which was proved to

be accurate by later operation upon the patient. It is, however,

doubtful whether the method will eventually assist in the differential

diagnosis between innocent and malignant growths.

(ii) _Tuberculosis._ Endolaryngeal operations are successfully performed

for chronic conditions such as ulceration or tumour, and, rarely, in

acute forms such as abscess, necrosis, and the like. Removal of a

portion of the epiglottis occasionally gives great relief to a patient

who is suffering from dysphagia.

(iii) _Strictures_ resulting from trauma, from the ulcerations of

syphilis, diphtheria, and other inflammatory diseases, or caused by

congenital webs.

(iv) _Foreign bodies_ impacted in the larynx.

(v) _Œdema_ of the mucous membrane due to trauma or inflammation, local

abscess, necrosis, and other allied conditions, in which obstruction is

likely to supervene.

The operation may be performed either by indirect or by direct

laryngoscopy.

OPERATION BY INDIRECT LARYNGOSCOPY

It being essential that the patient should be tolerant, this method is

chiefly applicable in the case of adults. The operation may require a

course of instruction, but this presents no difficulty if given with

discretion. The employment of cocaine, novocaine, and adrenalin is of

the greatest importance to both surgeon and patient. Cocaine, which is

generally to be preferred, may be used in strong solutions--10 or even

20%--if applied to the mucosa by a small swab of wool; but, if used as a

spray, weaker solutions are employed (4%). With neurotic patients

cocaine must be applied cautiously, as a sense of suffocation is

sometimes produced. It is necessary first to treat the soft palate, the

uvula, base of the tongue, pharynx, and epiglottis; secondly, with the

help of a laryngeal mirror, the interior of the larynx must be

cocainized; this can be accomplished by expelling a few drops of the

solution from a laryngeal syringe or by means of a swab attached to a

suitable wool-carrier. Fifteen to twenty minutes must be allowed to gain

the full effect of anæsthesia. The patient must be instructed on no

account to swallow the saliva. The secret of successful intralaryngeal

operations lies in the thorough application of these principles, and in

not attempting the operation until the patient is able to tolerate the

presence of an instrument within the larynx. The surgeon must be

experienced in the use of laryngeal instruments, and must be provided

with a complete equipment, including forceps (Mackenzie’s, Whistler’s,

Grant’s, &c.), which must be of different lengths to suit the patient,

snares, galvano-cautery, curettes, probes, and other instruments for the

application of drugs. Proper illumination is also very important.

When removing an intralaryngeal growth, the surgeon sits facing the

patient. The mouth is opened to the fullest extent, and the tongue drawn

well forward and held by the patient’s right hand. The mirror is

introduced in such a way that the tumour is distinctly seen. If the

epiglottis overhangs, it can be drawn forward with the forceps; or, in

rare instances, a special instrument (Fig. 255) can be used for

transfixing its upper margin with a thread, the latter being grasped by

a pair of pressure forceps, which, being allowed to hang, will

automatically raise the obstruction.

The forceps, having been warmed, are taken in the right hand when the

tumour is on the right side of the larynx and in the left hand when the

tumour is on the left, thus allowing a clearer view than when the same

hand is employed irrespective of the position of the disease. It is

introduced as follows: firstly, the handle is directed towards the

patient’s left ear until the point of the forceps has passed beyond the

back of the tongue and lies behind the epiglottis; secondly, the

instrument is quickly rotated so that the handle lies below the chin;

thirdly, the hand is raised so that the point is directed forwards;

fourthly, the whole instrument is quietly lowered and the beak of the

forceps directed towards the growth. This manipulation is made more

difficult by the laryngeal image being reversed in an antero-posterior

direction.

[Illustration: FIG. 255. HORSFORD’S INSTRUMENT FOR TRANSFIXING THE

EPIGLOTTIS.]

When the point is seen to rest upon the growth, the instrument is

opened, and the tumour grasped and avulsed: with careful manipulation

there is little danger of wounding the normal mucosa, and hæmorrhage is

insignificant. When dealing with multiple growths the patient must

understand that it may be necessary to repeat the operation, either

immediately or after an interval. Given suitable instruments, sufficient

experience, and a tolerant patient, it is possible to remove, with the

help of cocaine, the majority of simple tumours. Operations upon cysts,

the scarification of mucous membrane with a guarded knife, the

curettement of tuberculous ulcers, and cauterization of the larynx, are

all conducted upon similar lines. Foreign bodies can generally be

removed with forceps; thus, F. A. Rose[7] reported a case in which part

of the breastbone of a chicken, measuring 1 inch in length and over 3/4

of an inch in width, was removed after having been impacted in the

larynx for nearly forty-eight hours. In rare instances such an operation

is not successful; _e.g._ with a foreign body firmly impacted, multiple

papillomata, or an intolerant patient, general anæsthesia may be

required, and removal may have to be effected through a tube-spatula or

by external incision.

[7] _Proc. Roy. Soc. Med. London_, vol. i, No. 2, Laryn. Sect., p. 5.

=After-treatment.= Intralaryngeal wounds generally heal well, but every

effort should be made to prevent infection of the parts, to allay any

inflammation that may arise, and to avoid catarrh and swelling of the

mucosa. It is advisable to order complete vocal rest until the redness

has subsided, and the patient should refrain from coughing; the sucking

of ice, or the inhalation of benzoin or other medicated steam, has a

sedative action upon the parts. If the larynx becomes septic or filled

with irritating discharge, the use of sprays or powders is indicated; in

such a case the patient may be given a parolein spray, with menthol,

eucalyptus, or other antiseptic, for constant use; or a powder such as

orthoform, the latter being sucked into the larynx through a warmed

glass tube (Leduc’s insufflator), or applied by the surgeon. In the

later stages the patient may be treated by the local application of

caustic fluids, or by galvano-cautery, as occasion requires. The success

of such operations depends largely upon the skill of the surgeon; if

attention be given to the after-treatment the results are very good, and

the voice is generally recovered. As Semon has shown conclusively, there

is no practical danger of the occurrence of malignant degeneration

through the influence of instrumentation.

OPERATION BY DIRECT LARYNGOSCOPY

=(Killian’s Method)=

=Indications.= (i) _Multiple papillomata._ These tumours occur most

commonly during the early years of life, and operations for their

removal present great difficulties, first, in their removal, and,

secondly, owing to their inveterate tendency to recurrence whatever

operation is performed; moreover, in some instances operation seems to

stimulate the growths to greater activity. The case reported by Stoker

is a well-known instance. He was consulted by a man thirty years of age

who had suffered from papilloma for twenty-three years, during which

period one surgeon had performed 100, and a second 120 operations.

(ii) _Benign tumours_ other than papillomata, which are not amenable to

operation by indirect laryngoscopy.

(iii) _Foreign bodies._ Direct laryngoscopy is advised for patients who

are intolerant (_e.g._ young children), or when the object is firmly

impacted, or when other methods of treatment have failed. Thus in one of

my cases a man presented himself with a long pin impacted transversely

above the vocal cords; it was found impossible to remove it by indirect

laryngoscopy without serious injury to the parts. An anæsthetic was

therefore given and a large tube-spatula passed into the larynx: with

strong forceps the pin was bent upwards and removed with ease.

(iv) _Granulations_, _ulcers_, _necrosis_, and other _inflammatory

conditions_ such as are caused by diphtheria, tubercle, syphilis, and

many other diseases.

(v) _For diagnostic purposes._ There can be little doubt that direct

laryngoscopy has a great future before it as a means of determining the

nature of doubtful laryngeal conditions. If the upper parts of the

larynx be swollen, if there be any stenosis such as follows ulceration,

or if the patient be intolerant, the air-passages cannot be thoroughly

examined with the laryngoscope alone. With the newer method many of

these difficulties have disappeared, and it is now possible for the

surgeon to diagnose with certainty many conditions which would otherwise

have remained doubtful.

_The apparatus required_ consists of: