states that in a fifth of the entire number of cases of croup and
diphtheria; and in two-fifths of those cases in which the
naso-pharyngeal space participated, but in no case without immediate
connection with the corresponding affections of this space, he found an
extension of the specific process into the middle ear. In some cases
the tubal prominences were covered with membrane terminating at their
orifices; in other cases a membranous cast of the cartilaginous portion
of the tube was found. As a rule, the pathological changes noted were
hyperæmia of the mucous membrane of the middle ear and catarrhal and
purulent inflammation.
[Footnote 6: _Ziemssen_, vii. 71.]
8. Syphilis causes most frequently the catarrhal variety of middle-ear
inflammation; the purulent variety is also met with, but much less
frequently, the disease of the naso-pharyngeal mucous membrane
determining largely the grade of inflammation. Hereditary syphilis may
cause this complication, as well as the primary disease, but not so
frequently. Hutchinson has observed some cases of deafness in which the
disease was situated either in the labyrinth or auditory nerve, the
middle ear being healthy. Also, deafness may be caused by syphilitic
affections of the external auditory canal, causing obstructions to
sound-vibrations passing through it.
9. Typhoid fever may cause either the catarrhal or purulent form of
middle-ear inflammation. For instance, Hoffmann[7] found fourteen cases
of deep-seated disturbance of the faucial mucous membrane; he also met
with perforation of the tympanic membrane four times--twice in
connection with caries of the mastoid process.
[Footnote 7: _Ibid._, i. p. 159.]
It is easy to understand why middle-ear complications should complicate
such a disease as typhoid fever, where the mucous membranes generally
are the favorite seat of inflammation. Disease of the internal ear and
auditory nerve are not uncommon after typhoid fever.
10. Bright's disease is a cause of hemorrhage into the middle ear.
Schwartze reports in the year 1869 the case[8] of a young man who
suffered from albuminuria with retinal hemorrhages; also, enlargement
of the liver and spleen existed. He suddenly complained of pain in the
right ear. The tympanic membrane was of a red color and devoid of
concavity. Three days later an abundant serous discharge existed, with
a small blood-coagulum, the patient dying a few days later of the
kidney disease. Examination showed a hemorrhagic inflammation of the
mucous membrane of the right tympanic cavity, which was also found
filled with a bloody purulent fluid. The left tympanic cavity also was
found filled with a similar fluid. A number of other similar cases are
reported.
[Footnote 8: _Archiv für Ohren Heilkunde_, Bd. iv. p. 12.]
11. Whooping cough has been noted in several cases to have caused
hemorrhage into the middle ear, with perforation of the tympanic
membrane, with subsequent partial deafness.
The two principal types of acute middle-ear inflammation are the
catarrhal and purulent; and these up to a certain stage have similar
symptoms, but when pus has formed it gives rise to conditions that must
be described as peculiar to purulent inflammation alone.
{821} Acute Catarrh of the Middle Ear.
This may be described as acute catarrh of the mucous membrane lining
the middle-ear cavity. The prominent symptoms are as follows:
1. Pain.--This is, as a rule, of the most violent character. It is
described as a boring or tearing pain situated in the ear itself, and
often extending over the entire temporal region: any muscular exertion
like swallowing or sneezing causes increase of it. The external ear
becomes swollen, and so exquisitely tender to the touch that the least
pressure over the tragus causes the patient to flinch very markedly.
The pain tends to increase during the night up to the early morning
hours, and to lessen during the day. The immediate effect of a
middle-ear inflammation is to render the entire region of that side of
the face tender, so that any movement of the jaws or neck becomes
painful. It is also not uncommon to find the sympathetic glands of the
neck becoming enlarged and tender, and they may go on to suppuration.
The adult will complain most vigorously of the pain, so that there will
be no difficulty in locating it; but in the infant or young child the
greatest difficulty may be experienced in determining its precise seat,
owing to its inability to express in language its suffering. Two points
may be mentioned as aids in the diagnosis: (_a_) the cry of a young
child suffering from an acute inflammation of the middle ear has a
peculiar shrill, continuous character, an intermission sufficient only
to inspire being noticed; (_b_) pressure over the tragus of an inflamed
middle ear will cause a quick shrinking away of the little sufferer,
thus showing the seat of the disease.
2. Loss of Hearing Power.--This depends partly on a lessening of the
vibratory power of the conducting apparatus, partly due to a thickened
tympanic membrane, and also to the fact that the mucous membrane
covering the middle ear and chain of small bones becomes swollen, and
so clogs their movements. Again, the tympanum may be filled with a
mucous or muco-serous fluid, instead of being an air-chamber, as in the
normal condition, so that vibrations of the conducting apparatus may
cease entirely, while at the same time increase of intra-labyrinthine
pressure takes place. A tuning-fork placed on the incisor teeth or on
the forehead is heard more distinctly on the deaf side, due to the
sound-vibrations being retarded in their outward passage through the
diseased middle ear; also, the voice of the patient is heard by himself
with increased resonance, due to the same cause (retarded
sound-vibrations), and the patient unconsciously lowers the voice below
its normal tone.
3. Giddiness is not uncommon, due partly to increase of labyrinthine
pressure, and in some cases to a sympathetic irritation and congestion
of the vessels of the basilar brain membrane. Fever is always to be
looked for in acute middle-ear disease.
4. Noises in the ear (tinnitus aurium), resembling the noise produced
by the escape of steam or the singing of crickets, etc., are common,
and are due to a variety of causes. For instance, a large number of
these noises (according to Theobold's theory) depend upon muscle and
blood-vessel movements, causing vibrations that in a normal condition
pass out through the external auditory canal without being noticed; but
if their outward passage is impeded by obstructions existing in the
middle ear, like thickened tissue or the existence of fluids, as mucus
or pus, or by {822} obstructions in the external auditory canal itself,
such as impacted cerumen, etc., then these vibrations are thrown back
and impress for a second time the auditory nerve-endings, and thus
become noticeable sounds. (A familiar example is to shut the external
auditory canal by closing the meatus: a tidal noise is at once
noticed.) A crackling noise is often caused by air entering the middle
ear and bubbling up through the confined fluids.
OBJECTIVE SYMPTOMS.--The tympanic membrane is at first slightly
injected, particularly along the manubrium and the anterior and
posterior folds; but as the inflammation advances the entire membrane
becomes intensely injected and red. The cone of light is either very
small or may be entirely absent, due to the membrane having lost its
high reflective power. At this stage exudations into the middle ear
frequently show themselves, and if of sufficient quantity may cause an
outward bulging of the membrane: frequently the tympanic membrane at
its lower third becomes less transparent, and in some cases fluid
collections show a dark border-line stretching across the tympanic
membrane, and movable by change of position of the head.
DIAGNOSIS.--This disease can be hardly mistaken: the only difficulty
that can arise is whether the case is one of simple acute catarrh or is
one of commencing purulent inflammation, as the symptoms are identical
in each up to the formation and escape of pus, when no doubt can arise.
TREATMENT.--This must be directed against the acute inflammation that
exists, then as quickly as possible to restore the mucous membrane to
its normal condition and return to the sound-conducting apparatus its
normal vibrating power.
Local bleeding is to be considered among the most important remedies,
and therefore is taken first. This is best done by the use of the
Swedish leech, applied to the tragus, as at this point the blood is
most easily drawn from the tympanic cavity, in number from one to
three; and if the taking of a larger quantity of blood is desired, this
can be accomplished by encouraging the after-bleeding by hot
fomentations. When great pain exists, when the auricle is tender and
pressure on the tragus produces marked increase of pain, the
application of a leech is indicated. In children it is best to refrain
from the use of leeches.
The use of heat and moisture is most valuable. An effective method of
application is as follows: Place the head of the patient in a
horizontal position, with the affected ear turned upward, and fill the
external auditory canal with water at the temperature, say, of 100°
Fahr. Place quickly over the auricle towels that have been dipped in
very hot water and wrung out as dry as possible, and over these a large
flannel pad. This makes an excellent dressing, and one retaining the
heat and moisture for a length of time. When it cools repeat the same
proceeding until relief is obtained, when a large dry cotton pad can
take the place of the previous dressing. Patients suffering from acute
catarrh of the middle ear should be confined to the house, and, still
better, to bed. All physical exercise aggravates this disease, and a
suitable anodyne may be given to procure sleep if it be found
necessary. Paracentesis of the tympanic membrane is sometimes indicated
in those cases where the membrane shows distinct bulging and
perforation is clearly close at hand; also in some cases where,
notwithstanding previous treatment, the pain still {823} continues with
great severity. This operation is best done by incising the posterior
half of the membrane by means of a broad paracentesis needle. The
incision should be made at a point midway between the periphery of the
membrane and the handle of the hammer, and on the dividing-line of the
upper and lower posterior quadrants, the cut to be made downward.
Paracentesis of the membrane is to be done while the head of the
patient is well supported and the membrane illuminated by means of a
light reflected from the head-mirror. Immediately after the operation
wet hot flannels should be applied to the ear to relieve the pain.
The condition of the pharyngeal and nasal mucous membrane should be
thoroughly attended to, as from this source a large number of cases of
acute middle-ear catarrh have their origin. Nitrate-of-silver solutions
are often of great service as a local application to the naso-pharynx.
Tannic acid makes a good astringent gargle, and is more particularly
adapted to those cases where a pure astringent effect is needed.
Chlorate of potash is an excellent gargle, and often proves of great
service. It may not be out of place to state that the use of alcohol
and tobacco tends to keep up an irritated condition of the
naso-pharyngeal mucous membrane, and they should be dispensed with. As
part of the treatment inflations of the middle ear are used to aid in
the removal of abnormal secretions from the tympanic cavity and to
restore the sound-conducting apparatus to its normal condition. This
can be thoroughly carried out by the Politzer proceeding. This consists
in forcing air (by compressing a rubber hand-bag, Politzer's air-bag,
so called) through the lower nasal passage up the Eustachian tube, and
so into the middle ear. The patient holds a small quantity of water in
the mouth. The nasal end of the tubing connected with the air-bag is
placed in one of the lower nasal passages, and the nose tightly closed
over it. The patient is then told to swallow, and at the same moment
the air-bag is forcibly compressed, and the air is thus compelled to
travel along the nasal passage and up the Eustachian tube into the
middle ear. The act of swallowing causes the soft palate to be forcibly
pressed up against the posterior pharyngeal wall, and at the same time
causes the Eustachian tube orifice to open widely. A column of air thus
used will expel large accumulations of mucus from the Eustachian tube,
and to some extent from the middle-ear cavity, and at the same time the
thorough distension of this cavity throws into motion the tympanic
membrane and chain of small bones--a most desirable proceeding. In
acute conditions the inflation should be made only after all pain has
ceased, and then at first very gently; but in a short time a thorough
inflation two or three times repeated, say every two or three days, is
most beneficial. The inflation of the middle ear by the use of the
Eustachian catheter is a more irritating procedure, and does not
accomplish the purpose any more completely than the Politzer method.
Therefore the latter is to be preferred in adults, while in children it
is the only available method that can be used.
Chronic Catarrh of the Middle Ear.
Various classifications of this disease have been made by different
authors: I prefer the division that Buck has used in his textbook. The
following summary will give an idea of it:
{824} Chronic catarrh is a name that has been given to a class of cases
where deafness and tinnitus are prominent symptoms, and where no
suppurative action in the middle ear has existed at any previous time,
and where the internal ear is supposed to be in a healthy condition. In
some of these cases there will be found a marked hypertrophy of the
mucous membrane, and sometimes of the submucous connective tissue,
accompanied with excess of secretion, with the same condition existing
in the naso-pharyngeal membrane. The tympanic membrane often becomes
sunken, and therefore strongly concave outwardly. The short process of
the malleus is very prominent, and the handle of the malleus, by being
drawn forcibly backward, becomes apparently shortened (foreshortening
of the malleus handle, so called).
The membrane loses its vibratory power to some extent, and the cone of
light is either very small or is entirely absent. The color of the
membrane changes to a more or less opaque white, with often a line of
vascularity along the manubrium, or it may assume the color of ground
glass; white calcareous deposits are not seldom met with; marked
evidences of catarrhal inflammation exist in the naso-pharynx, such as
increase of mucoid secretion, with enlargements of the tonsils, and
often granular pharyngitis may be found. The mucous membrane of the
Eustachian tube is often involved in the process: marked swelling of
its mucoid tissue, with the tube filled with secretions, prevents free
entrance of air into the middle-ear cavity. In the nasal mucous
membrane, beyond the ordinary catarrhal conditions, polypoid formations
are common; also thickening of the mucoid and submucoid tissues
prevents the free passage of air.
In another class of cases coming under the head of chronic catarrh of
the middle ear a very different set of symptoms from the class first
described are noticeable. In these cases perhaps catarrhal symptoms
have at one time existed, but have completely passed away, and the
mucous membrane not only of the tympanic cavity, but also of the
pharynx and Eustachian tube, has undergone a fibroid degeneration,
causing destruction of the glandular elements and ending in an
atrophied mucous membrane (the so-called proliferous degeneration of
some authors). The tympanic membrane in these cases is abnormally thin
and very transparent, sometimes much sunken, no doubt due to
connective-tissue adhesions in the middle-ear cavity. The external
auditory canal is devoid of cerumen and hair; also the same change in
the mucous membrane of the naso-pharynx and Eustachian tube gives a
smooth, transparent appearance to their surface. In this class of cases
in post-mortem examinations there have been found the stapes firmly
ankylosed to the margin of the fenestra ovalis; the chain of small
bones firmly ankylosed; fibroid adhesions in the mastoid cells; and
adhesions between the tympanic membrane and the labyrinthine wall.
CAUSES.--A percentage of cases result from a previous acute middle-ear
catarrh. Others apparently originate as a chronic condition and slowly
advance. Beyond all doubt, a large percentage are inherited, as the
same disease can be traced back through several generations, where
signs of the disease were noted in early youth, with slow advance as
years go on. It is also a matter of interest to note that these cases
are apt to show sensible advance in women at the birth of a child.
{825} PROGNOSIS, as a rule, bad, both as to the possibility of
preventing increase of deafness and of doing away with tinnitus--a most
annoying factor.
TREATMENT is successful in proportion to the catarrhal symptoms that
exist, and which are to be treated on the general plan laid down for
catarrhal inflammation. A great number of these cases call for a tonic
plan of treatment, such as iron tonics, cod-liver oil, etc.
Local treatment consists in inflations of the middle ear by the
Politzer method. In those cases where a thin, sunken membrane exists
care should be observed not to use undue pressure, lest a rupture of
the membrane result. In those cases where tinnitus aurium is a
prominent factor a few drops of ether placed in the Politzer bag cause
a more stimulating effect from the inflation than the use of pure air,
and is sometimes of service in lessening this annoyance. It is an
important part of the treatment that the general health should be in
the most vigorous possible condition.
Acute Purulent Inflammation of the Middle Ear.
The disease proceeds very frequently from some inflammation in the
naso-pharyngeal cavity, the mucous membrane of the Eustachian tube
furnishing a ready way of communication between the pharynx and middle
ear.
The exanthematous diseases furnish a large proportion of these cases.
Scarlet fever stands first on the list, as causing the largest number
of these cases, and also those of the most serious character. Measles,
smallpox, diphtheria, the different forms of fever, such as typhus and
typhoid, cerebro-spinal meningitis, pneumonia, bronchitis, etc., are
complicated by this form of inflammation, and the ear disease
represents simply a continuation of the naso-pharyngeal inflammation
which occurs so frequently in the above-mentioned diseases. Another set
of causes come under the head of change of temperature, such as
exposure to draughts of air and sea-bathing, where the cold water
entering the external auditory canal acts directly upon the tympanic
membrane. Some few cases occur as the result of injury, such as blows
upon the ear or direct injuries to the tympanic membrane.
COURSE.--The same pathological conditions are to be noted here as in
the acute catarrhal attack, with the difference that the inflammation
goes on to a higher grade--namely, pus-formation. In this form of
disease there exists marked hyperæmia and swelling, not only of the
superficial but also of the deep-seated tissue, with pus-formation, and
generally perforation of the tympanic membrane, with occasional
ulceration and destruction of other parts of the middle ear. The
neighboring cavities of the antrum and mastoid cells participate more
or less, while blood-vessels penetrating the superior wall of the
middle ear furnish a ready means of communication between the inflamed
middle-ear tissues and the brain-membrane, so that the wonder is not
that brain complications result, but that they occur so seldom.
The changes in the tympanic membrane in the first stage are marked
hyperæmia and swelling of the tissue, so that it often assumes a
uniform red appearance, without a trace of the malleus or cone of
light. {826} Pus-formation in the middle ear is quickly followed by
bulging of the tympanic membrane, due to increase of middle-ear
pressure; and this in the great majority of cases is followed by
perforation of the tympanic membrane, due not only to increase of
pressure, but also to a destructive ulcerative process in the membrane
itself. The latter process is seen in those cases of great destruction
of the tympanic membrane that occurs in scarlet fever, where almost
entire destruction of the membrane is often found. Perforation may
occur at any part of the membrane.
SYMPTOMS AND COURSE.--These are very much the same, up to a certain
point, pus-formation, as have been described under the head of Acute
Catarrh--namely, the great pain, deafness, tinnitus, headache,
tenderness on pressure over the tragus, increase of pain by movement of
the jaw, followed often by quick relief by perforation of the membrane
and escape of pus through the external auditory canal, with a
subsequent subsidence of inflammation and restoration of the tympanic
membrane. A moderate attack may run a course of from two to six weeks,
and end in entire recovery, or it may end in a chronic suppuration with
its sequelæ.
DIAGNOSIS.--It often will be difficult at the outset to know if the
case is one of acute catarrh or whether it will advance to a purulent
inflammation; but as the disease goes on to pus-development and
subsequent drum-perforation, no doubt can exist as to its true
character. The perforation can often be seen, and air may be forced
through it with a whistling sound by a forcible expiration of the
patient. In regard to whether complications exist, such as mastoid or
brain involvement, several points can be given as aids in the
diagnosis. When mastoid involvement exists, the soft tissues over it
become swollen, very tender on pressure, with pain in that part of the
bone; also, often swelling of the posterior upper wall of the external
auditory canal, a part adjacent to the mastoid process.
In those cases where the inflammation tends toward the cranial cavity,
the pain spreads over the entire side of the head, and often becomes
marked in the occipital and frontal regions, and is of a peculiar
lancinating character. Vertigo is also present, even if the head is in
a quiet horizontal position, but greatly increased by movement of the
head. The body-temperature in acute purulent inflammation in adults is
not altered as a rule, but in children it is raised.
PROGNOSIS.--An uncomplicated case if properly treated will generally
result in a good recovery, and often with but slight impairment of the
hearing power. If allowed to run its course, it may cause serious and
permanent changes in the middle ear destructive to hearing, and may end
either in a chronic purulent inflammation with bone destruction or in
involvement of brain membranes or brain tissue proper.
TREATMENT.--In the early stages absolutely the same treatment as
recommended for acute catarrh is indicated--the use of leeches,
hot-water applications, rest in bed, anodynes, etc. When pus has formed
and the tympanic membrane is bulging, paracentesis is indicated (method
of operation, vide p. 917), to be quickly followed by the use of hot
water to relieve the pain of the operation; the gentle use of the
syringe and warm water will keep the canal free of pus during the
suppurative process; also the external ear is to be kept covered by a
cotton pad or some other like application as long as pain and
tenderness exist.
{827} In young children suffering from scarlet fever it is of the
utmost importance to cleanse frequently the pharynx of its
muco-purulent secretions. This can be done by means of a probang or
cotton wrapped on a curved end of whalebone, and afterward some
detergent wash can be used, such as a strong decoction of green tea
containing alum or a solution of common salt. The muriated tincture of
iron, one part to five parts of water, is an excellent local
application to be applied with a camel's-hair brush. Chlorate of potash
makes a valuable gargle. In young children Meigs suggests the use of a
powder containing one part of chlorate of potash to six parts of sugar,
and a pinch of this placed on the tongue and allowed to dissolve.