mass grows slowly from the periphery toward the centre, and as long as
a small central opening remains the hearing power will remain good.
Some sudden jolt or misstep, or some quick-acting force, will cause
occlusion of this narrow passage, with consequent sudden loss of
hearing. The tuning-fork, placed on the incisor teeth, will be best
heard on the affected side by reason of vibrations being impeded by the
mass in their passage through the external canal.
{813} Tinnitus aurium and vertigo are often present, both being due to
the mass pressing inward the tympanic membrane, with consequent
increase of pressure on the labyrinthine fluid by the chain of small
bones pressing on the membrane of the foramen ovale. These symptoms are
sometimes alarming to the patient, as in his judgment indicative of
serious brain lesion.
DIAGNOSIS.--Examination of the external canal with the speculum and
reflected light reveals a dark amber-colored mass lying in the external
canal, which can be very hard, the result of exposure to the air for a
length of time, as well as the union with it of epithelial débris of
the skin of the canal; or it may be soft, like syrup, in its
consistence.
The PROGNOSIS is to be guarded until the condition of the middle ear is
known.
TREATMENT.--If the mass is hard in its character, its removal is best
effected by the forceps or curette or blunt hook, it being understood
that the external canal is well illuminated, so that the course of the
instrument can be carefully watched. The curette or blunt hook will
loosen the attachments of the mass to the sides of the canal, and then
it can be readily removed by the forceps, care being taken not to
injure the tympanic membrane. In such a way a hard plug can be removed
at one sitting that otherwise would require repeated efforts to
accomplish the same purpose.
If these instruments are not at hand, the next best method is to effect
the removal with the syringe and warm water. A caution is to be given
in the use of the syringe. There are a great number of people who are
not able to have the external ear syringed, even though gently, without
becoming giddy, and if the syringing is then continued the vertigo will
end in a fainting attack. My rule is to caution the patient of the
above fact, and always promptly stop at the first symptom of vertigo.
Sometimes a short rest will allow the operator to proceed, but often it
is necessary to postpone any further attempt at removal until a
succeeding day. Always use quite warm water. If in a fair trial with
the syringe it is found that the mass does not soften and break up, it
is better to make an application of olive oil to it, and at a
subsequent time repeat the attempt at removal. Soft masses of cerumen
are best removed by the use of warm water and the syringe.
In some few cases inflammation of the external auditory canal will
complicate the treatment, and the question will come up as to whether
it is best under such circumstances to attempt the removal of the
impacted mass. As a rule, the removal of the mass is the best means of
combating such an inflammation, and therefore an attempt at removal
should be made unless the inflammation is very acute, when treatment of
this complication would be in order, and the removal of the plug
deferred for the moment. In all cases the condition of the middle ear
and hard pharynx should be noted after the removal of the impacted
mass, and these parts often will need treatment.
Furuncle of External Auditory Canal (Acute Circumscribed Inflammation).
ETIOLOGY AND PATHOLOGY.--In a great number of cases furuncle is to be
regarded as an evidence of general bodily debility. For example, {814}
in the richer classes it is often a result of over-dissipation, while
in the poorer classes insufficient food, bad clothing, and such like
are important factors. Local irritations of the external canal may
cause the disease, such as rubbing the canal with a hairpin or
toothpick to relieve itching. The use of alum and nitrate-of-silver
washes in the canal will cause a furuncle in some cases. Furuncle
occurs in the outer third of the canal as a rule, and often develops
around a ceruminous gland, and will generally be followed by a number
of others.
SYMPTOMS.--Pain is the most marked one--in the beginning of the attack
of an intermittent character, with a tendency to increase toward and in
the night; but as the attack advances pain becomes more marked, and may
extend over the entire temporal region well down into the neck. The jaw
movement also becomes very painful. The furuncle will rupture at any
time, from the third day up to the tenth day, according to its
location. The more deeply seated it is, the slower will be its progress
toward maturity. The pain quickly disappears after the rupture, and
then a short interval of rest is followed too often by the recurrence
of the same disease. A varying degree of deafness is usually present,
due to partial closure of the canal by the swollen soft tissues, and
also it may be in rare cases through involvement of the tympanic cavity
in the inflammation. Fever is often present. The great objective
symptom will be the circumscribed swelling found in the cartilaginous
portion of the canal and often along its anterior wall, and will show
great increase of pain by but slight pressure. The swelling as it
matures becomes more circumscribed, and will end in a pus collection
and subsequent rupture.
DIAGNOSIS.--The disease most likely to be confounded with it would be
an acute middle-ear inflammation, with involvement of the periosteum of
the osseous part of the canal; but the history of the case would clear
up this point.
The PROGNOSIS is favorable as to hearing, but with great probability of
successive crops of the same disease.
TREATMENT.--The local application of heat and moisture is a remedy of
great value, and a good method of application is to bend the head into
a horizontal position, as by resting the side of the head on a table,
and then fill up the external canal with water as warm as the ear will
allow without causing pain; then quickly place over the auricle towels
that have been dipped in very warm water and wrung dry by being twisted
in a second towel, and over this a large pad of warm flannel or some
similar covering. The heat and moisture will be retained for quite a
time, and then the procedure can be repeated until relief from pain is
obtained. In the interval the auricle is to be covered with a pad of
cotton. A steam atomizer furnishes a convenient way of applying heat
and moisture. Dry heat is sometimes preferred: a flannel bag filled
with bran or hops and well warmed in a hot oven would carry out this
indication; also a hop pillow moistened by hot whiskey is a good
application.
An application of leeches affords great relief from pain. The best
point to place a leech (which should be a Swedish leech) is just in
front of the tragus. Two or three leeches can be applied at this place,
and by encouraging the after-bleeding by warm applications any desired
amount of blood can be taken. The after-bleeding can be readily
controlled by the use of styptic cotton.
{815} Incision of the Furuncle.--It is a mooted question as to whether
an incision is capable of giving relief, and when it should be done. My
own experience has been that the application of a leech has given
greater relief than the use of a knife in those cases when the furuncle
has been deep seated. Later on, when the swelling has become
circumscribed and shows evidence of pus, the incision is clearly
indicated.
General treatment is to be of a tonic character, and during the acute
stage, when the pain is severe, anodynes are indicated.
Foreign Bodies in the External Auditory Canal.
1. VEGETABLE PARASITES.--Aspergillus flavescens and Aspergillus
nigricans are found on the inner part of the canal and over the
external surface of the tympanic membrane. This growth largely depends
for its development upon a diseased condition of the epithelial layer
of the skin lining the external canal, such as is found in cases of
chronic middle-ear suppuration and in eczema of the skin of the
external canal, by furnishing a moist nidus for its development.
SYMPTOMS.--Intense itching in the external canal, with a sense of
fulness; also sometimes pain, with tinnitus and difficulty of hearing.
The growth is found in the inner part of the canal, or over the surface
of the tympanic membrane in the form of yellow or black flakes
according to the variety. It may be found in spots or may form a
complete covering to the canal-walls, so that when removed it forms a
mould of the canal, leaving a raw skin surface, on which the growth
rapidly reproduces itself. The disease is found in an acute and a
chronic form, and in a few days can attain full development; also there
exists a marked tendency to relapse as long as any portion remains
undestroyed.
PROGNOSIS.--Favorable.
TREATMENT.--The main point is to thoroughly remove the parasite. This
is best effected by the use of warm water and the syringe, carefully
picking off any small portion that may remain by the forceps or
curette. My practice is then to fill up the external canal with
alcohol, allowing it to remain a few moments, and then to carefully dry
the canal by the aid of styptic cotton. This procedure may have to be
repeated every second day for a number of times until the growth is
entirely destroyed. Wreden recommends the use of the hypochlorate of
lime in the strength of one or two grains to the ounce of water, the
salt to be freshly dissolved in water at each application. The
condition of the middle ear and the integument of the external canal is
to be considered after the removal of this growth, and treated as
indicated by the state of the case.
2. INSECTS IN THE EXTERNAL AUDITORY CANAL.--Cases of this character
occur frequently during the summer season to persons who by lying on
the ground give insects an opportunity to crawl into the external
canal. The common house-fly also affects an entrance into the canal
quite often; also during the summer it is not uncommon to find grubs or
larvæ in the canals of patients suffering from suppurative inflammation
of the middle ear resulting from the deposit by insects of their eggs
in the moist coverings of the canal. The movements of insects in the
sensitive {816} external ear cause great pain to the patient, and their
removal is sometimes difficult. For instance, the grub is provided with
two hooks, by means of which it adheres tenaciously to the skin, so
that it may be necessary to remove each one separately with the
forceps. The quickest method of removal, as a rule, is to wash out the
insect by the use of warm water and a syringe; and if this is not at
hand the insect can be drowned by filling the canal with water, olive
oil, or some demulcent liquid.
OTHER VARIETIES OF FOREIGN BODIES, such as grains of corn, beans, peas,
cherry-stones, beads, buttons, pieces of slate-pencil, are found in the
external canal, and the symptoms that are present arise partly from the
presence of the body, but more frequently from the irritation produced
by attempts at removal.
SUBJECTIVE SYMPTOMS.--Difficulty of hearing, often due to the foreign
body filling up the external canal and thus excluding all
sound-vibrations. Tinnitus aurium and vertigo are often present, and
caused by pressure of the body on the tympanic membrane with resulting
abnormal labyrinthine pressure; also a variety of reflex conditions are
noted as a result of the presence of a foreign body in the external
canal, such as coughing and vomiting, partial paralysis, etc.
OBJECTIVE SYMPTOMS.--The appearance of the external canal will depend
greatly upon the amount of pressure that the foreign body has exerted.
For instance, a body loosely lying in the canal will irritate but
little; on the contrary, a hard body like a cherry-stone firmly
impacted in the canal will quickly cause a severe inflammation.
DIAGNOSIS.--As a rule, the foreign body can be readily seen with the
aid of the mirror and speculum, unless the canal has become swollen to
such an extent as to hide the body from sight. Probing and such-like
procedures are not advisable.
TREATMENT.--The question comes up if it is good practice to make an
attempt at immediate removal of a foreign body if the external canal is
in a condition of acute inflammation. Unless grave head symptoms are
present it is often good practice to delay, and reduce the inflammation
by proper treatment, and then remove the foreign body. In other words,
there is more risk by a forcible removal during a stage of acute
inflammation than to permit the foreign body to remain until the
inflammatory stage is past. Numbers of cases are on record where
foreign bodies have remained for years in the external canal without
causing serious sequelæ. Also, be sure a foreign body really exists in
the canal, as it is not uncommon for patients to come with the
statement that such is the case, and yet no foreign body has been
discovered.
The majority of foreign bodies can be removed by the use of the syringe
and warm water. The impacted bodies--and particularly those having a
hard, smooth surface--present the greatest difficulties. A good plan is
to try first the syringe and warm water, and if not successful try with
a toothed angular forceps to grasp the body. If, as is often the case,
it is found that the forceps slips off the body, then the curved blunt
hook is to be used. This can be passed by the body and then turned on
its axis, so that the hook is firmly placed behind it, and then a slow
upward movement will often dislodge the body. On some occasions I have
used two hooks, holding the body between them, and thus dragging it
out. It is also better to desist after a fair trial until a succeeding
day, rather {817} than make excessive efforts at removal, which will
often cause violent inflammation to follow. After the body is dislodged
examine the condition of the tympanic membrane, as this is often found
to be perforated by the foreign body.
Diseases of the Middle Ear.
ANATOMY.--The cavity of the middle ear is of small dimensions:
antero-posterior diameter, 13 mm.; vertical diameter at the anterior
part, 5.8 mm.; vertical diameter at the posterior part, 15 mm.;
transverse diameter at the anterior part, 3-4.5 mm.; transverse
diameter at the opposite drumhead, 2 mm. (Von Tröltsch). It is situated
in the petrous portion of the temporal bone and surrounded by bony
walls, with the exception of the opening covered by tympanic membrane
and the opening of the Eustachian tube, having a mucous periosteal
covering, very thin, transparent, and colorless. This membrane covers
not only the tympanic cavity, but is reflected over the chain of small
bones and tendons of the tensor tympani and stapedius muscles. It is
essentially a mucous membrane, and may be considered a continuation of
the naso-pharyngeal mucous membrane reflected through the Eustachian
tube to the middle-ear cavity; also subject to the same pathological
changes as other mucous membranes.
The tympanic cavity normally is an air-filled cavity, and allows of
free vibration of the tympanic membrane and its ossicles, as well as
the membrane covering the oval and round foramina; and it is readily
understood that any interference with the vibration of this
sound-conducting apparatus will at once affect the hearing.
Its arterial blood is supplied from the middle meningeal,
stylo-mastoid, ascendant pharyngeal, posterior auricular, tympanic, and
internal carotid arteries. These freely anastomose with each other. The
veins pass internally through minute openings of the petrosal squamous
fissure to the veins of the dura mater, and thence into the superior
petrosal sinus, and also externally into the venous ring surrounding
the tympanic membrane, and also to the veins of the meatus (Schwartze).
This is important to bear in mind, as furnishing an easy passage for
the extension of middle-ear inflammation to the brain membranes.
The nerves forming the tympanic plexus are as follows: The mucous
membrane is supplied by the tympanic plexus, formed from the tympanic
branch of the petrous ganglion of the glosso-pharyngeal nerve--from the
branch of the superficial petrosal and branches of the sympathetic
nerve. The otic ganglion receives fibres from the inferior maxillary
nerve, from the auriculo-temporal nerve, and from the sympathetic
plexus, and it is distributed to the tensor tympani and tensor palati
muscles.
The mastoid cells lead directly from the tympanum. They consist of one
large opening, the antrum, and the lower mastoid cells. These cells
consist of a large number of varying-sized cavities, and are enclosed
by a dense layer of bone. The mucous membrane lining these cells is a
direct extension of the tympanic membrane, and liable to the same
pathological conditions as that mucous membrane.
{818} The Eustachian tube connects the cavity of the tympanum with that
of the naso-pharynx, and is mainly intended for the introduction of air
into the tympanic cavity. It has a length of 35 mm., partly bone (11
mm. in length), partly cartilaginous (24 mm. in length). The pharyngeal
opening is 8 mm. high and 5 mm. wide; the tympanic orifice, 5 mm. high
and 3 mm. wide (Schwartze). The mucous membrane lining this canal is a
continuation of that of the naso-pharynx, and affords an easy way for
the transmission of disease from the naso-pharynx to the middle ear.
The Eustachian tube at rest is probably closed, although this is a
matter still discussed; but it is essential for normal hearing that the
air-pressure exerted on the tympanic membrane through the external
auditory canal should be equalized by that exerted through the
Eustachian tube. This necessitates the opening of the tube from time to
time for free admission of air into the tympanic cavity. This is
accomplished by the action of the musculus dilator tubæ, the tensor
veli palatini, and the salpino-pharyngeus muscle. In the act of
swallowing the tube opens; also, if the nostrils are closed and the act
of swallowing is performed, air will be pumped out of the middle ear;
on the contrary, if the nostrils are open air will be forced into the
middle ear.
Diseases of the middle ear can involve the superficial layers of the
middle-ear mucous membrane only, and may be of a catarrhal character.
Hyperæmia and swelling of the epithelial cells, with increased mucous
secretion, will be found. Later on, if the inflammation assumes a
higher degree, a serous fluid will be profusely poured out, with
lessening of the mucous secretion. When the deeper epithelial cells are
involved, then pus-cells often appear, and a suppurative process
becomes established, with frequent destruction of the soft tissues of
the middle ear.
These different grades of inflammation are seldom found distinct, but
run one into another. A case can start as a pure catarrhal
inflammation; this, after attaining its acme, may end in recovery or
degenerate into a chronic catarrh; or, on the contrary, it may advance
into an acute purulent inflammation with a subsequent chronic stage.
CAUSES OF INFLAMMATION OF THE MIDDLE EAR.--Change of temperature,
causing a sudden cooling of the body, is a frequent cause of this
disease; for instance, exposure to wind from a partly-open window, a
sudden rush of cold water into the external canal, as in surf-bathing,
etc. Irritating foreign bodies in the external auditory canal may also
cause this disease.
But inflammation of the middle ear occurs most frequently as a sequela
of diseases affecting the general body. Among these may be mentioned,
in order of their relative importance--
1. Scarlet Fever.--This disease is apt to cause the purulent form of
middle-ear inflammation, and often of a very grave character. The ear
complication can occur during the existence of the rash or immediately
after its cessation (Thomas), and may run a rapid course, causing
destruction of the tympanic membrane and middle-ear ossicles.
Destruction of the facial nerve in its passage through its bony canal
is not infrequent. Wendt has noticed in severe cases that the
periosteum of the mastoid process, also that of the squamous and
petrous portions, may participate in the purulent process, and end in
subsequent caries of the bone. The severity of the ear complication
will largely depend upon the condition {819} of the naso-pharyngeal
mucous membrane. Light attacks of scarlet fever with slight throat
symptoms would most probably cause slight irritation of the middle-ear
mucous membrane, while the anginose variety would cause most violent
inflammatory sequelæ.
2. Measles is apt to cause the catarrhal variety of middle-ear
inflammation rather than the purulent form. It occurs during and
immediately after this eruption, and is a direct continuation of the
naso-pharyngeal inflammation viâ the Eustachian tube. Hearing, as a
rule, is diminished, due to the swollen mucous membrane of the
Eustachian tube and middle ear, and also to fluid accumulations that
often exist in the middle ear. Wendt[3] draws attention to the fact
that chronic affections of the auditory apparatus, such as formation of
adhesions between the ossicles or between the tympanic membrane and
wall of the tympanum, may arise while the soft parts are in a swollen
condition, and often chronic catarrhal sequelæ may be traced to this
cause.
[Footnote 3: _Ziemssen_, ii. 112.]
3. Tuberculosis is often associated with the catarrhal and purulent
varieties of middle-ear inflammation, having, as a rule, a subacute
course, the patient's attention sometimes only being drawn to his ear
by the escape of pus from the middle ear into the external canal, the
medium of communication being the mucous membrane of the pharynx viâ
the Eustachian tube. Wendt[4] states that as yet the presence of
tubercles has not been authenticated, although the clinical
observations of rapid destruction, especially of the tympanic membrane,
would seem to indicate it.
[Footnote 4: _Ibid._, vii. 77.]
4. Retro-nasal catarrh is a frequent cause of middle-ear inflammation,
the disease being communicated along the mucous membrane of the
Eustachian tube. All degrees of inflammation are found, the catarrhal
variety being the most frequent, while acute nasal catarrh is a cause
of a large number of ear complications. Chronic retro-nasal catarrh is
apt to cause a chronic middle-ear catarrh, that progresses insidiously,
and almost unnoticed by the patient until the deafness begins to
interfere with the ordinary affairs of life.
5. Scrofulosis causes most frequently the catarrhal form of middle-ear
inflammation; and this is a direct continuation of the catarrhal
affections of the naso-pharyngeal mucous membrane viâ the Eustachian
tube. Birch-Hirschfeld[5] asserts that scrofulosis is the cause of the
largest number of those cases in which weakening or destruction of the
function of hearing has occurred during childhood; also, that the large
number of scrofulous individuals found in deaf-and-dumb asylums is
explained in this way; and that after the scrofulosis is cured the
deafness remains as a result of permanent pathological middle-ear
changes produced by the former disease.
[Footnote 5: _Ibid._, xvi. 794.]
6. Smallpox may cause several varieties of middle-ear hyperæmia, and
frequently also a hemorrhagic catarrhal process is met with. Not seldom
is found a suppurative inflammation, with extensive destruction of the
soft tissues and ossicles, with permanent subsequent deafness. There is
probably no reason to doubt that a pustule itself can develop in the
middle-ear mucous membrane, just as is found in the cornea, and cause
an acute inflammatory process; but, as a rule, the middle-ear mucous
membrane is secondarily involved as a consequence of inflammatory
process existing in the naso-pharyngeal mucous membrane.