over the acute stage, and in many instances will end in entire recovery
without the necessity of local treatment; but in some cases the
purulent discharge from the middle ear will continue, and it remains to
consider the best local remedies for checking this discharge and when
they are to be used. It is with me an absolute rule that no remedy is
to be used with a view of checking a purulent discharge until
absolutely all pain has passed away and no pain is caused by pressure
on the tragus or over the mastoid. During the interval the local
treatment will consist of cleansing the external canal from the
contained pus by the use of the syringe and warm water, the canal being
afterward dried by cotton on a cotton-holder. If the discharge is small
in quantity, the use of cotton on a cotton-holder will be sufficient to
cleanse the canal, and causes less irritation than the syringe and warm
water. The frequency with which the ear is to be cleansed will depend
upon the amount of the discharge, as it should be done as little as is
consistent with keeping the external canal free from pus. It is also
useful for the patient by the Valsalva method of self-inflation to
cleanse the middle ear from the therein-contained pus just before the
time of using the syringe. If this is not feasible, the Politzer method
of inflation answers the same purpose. When all pain has passed away,
and if the discharge still continues, it will be proper to make a local
application. My favorite one is insufflation of a small quantity of
finely-powdered boracic acid (a convenient rubber blower is made for
this purpose). This application answers well also in chronic purulent
middle-ear affections. In applying this powder a very small portion
only is to be used, so that there can be no danger of blocking the
discharge by the powder obstructing its passage through the middle-ear
cavity. A small portion is to be placed in an insufflator and blown in,
the application to be repeated every few days. I would also mention the
great importance of keeping the external canal closed by a wad of
absorbent cotton, which not only absorbs the pus as it slowly escapes,
but also prevents the immediate contact of air with the middle-ear
cavity--a most desirable aid in the cure.
Chronic Purulent Inflammation of the Middle Ear.
Urbantschitsch[9] calls attention to two distinct pathological
conditions that are to be noted in this disease--the one a swelling and
hypertrophy, {828} the other a thinning, of the mucous and submucous
tissues. The thickening consists in an infiltration, with subsequent
connective-tissue development, either in the submucous or over the free
surface of the mucous membrane, causing in the first case a diffuse
tissue hypertrophy; in the latter case forming a circumscribed
connective-tissue formation, papillary excrescences, and nodes. The
condition accompanied with thinning of the tissue is to be considered a
higher grade of purulent inflammation, by which it results that a
portion of the normally existing tissue disappears, and is not again
reproduced, while the newly-developed inflammatory products do not
advance to organization, but are thrown off in the purulent discharge.
In this way can be explained why at one time, by examination through
the external canal and perforated tympanic membrane, there is found a
swollen connective tissue, while at another time the bone can be seen
through the thinned membrane.
[Footnote 9: Vide _Textbook_, p. 351.]
CAUSES.--As a rule, it is a sequela of a previous acute attack. And it
is also safe to say that a large number of chronic purulent cases are
the result of bad treatment or non-treatment of the acute attack. To
mention the causes of chronic suppuration is to repeat those causing
the acute variety, such as diseases of the naso-pharynx resulting from
scarlatina, variola, measles, typhus, tuberculosis, bronchitis,
syphilis, etc.; also the external irritating causes, effect of change
of temperature, as by draughts of air, cold water entering the external
auditory canal, etc.
SUBJECTIVE SYMPTOMS.--Difficulty of hearing is always present. This is
often caused by masses of granulations or collections of pus, filling
up largely the tympanic cavity. These with a hypertrophied mucous
membrane could sensibly interrupt sound-vibrations; and it will not be
out of place to remark that the recovery of hearing will depend largely
on what amount of change can be effected in these different conditions.
Tinnitus aurium is not a constant factor; a few patients suffer from
discomfort caused by pus passing down the pharynx, causing nausea.
OBJECTIVE SYMPTOMS.--More or less swelling of the external canal, while
the constant passage of purulent fluids over the skin results in
exfoliation of its epithelial layer and a subsequent weeping from the
skin tissue. The secretion varies from an abundant discharge to a
minimum of a few drops per day. It may be watery or muco-purulent, or
of a thick, creamy, tenacious consistence. Odor is common, and if the
bone is involved of a most disagreeable character. The perforation in
the tympanic membrane may vary in size from that of a pin-head to a
loss of the greater part of the entire membrane; also, the membrane is
found thickened, with an occasional calcareous deposit in its fibrous
layer. Granulations and polypoid growths are found in the external
canal and middle-ear cavity. The mucous membrane of the naso-pharynx
will show the various changes that are found associated with the
different diseases that cause this complication.
DIAGNOSIS.--This is without difficulty as a rule. The discharge, the
perforation that often can be seen, the whistling caused by the air
being forced through the middle ear and the perforation in the tympanic
membrane by the Valsalva or Politzer method of inflation, are very
significant of middle-ear suppuration. The pulsation often noticed at
the bottom of the external auditory canal, and which has been
considered indicative of perforation, is caused by a thin surface of
fluid in contact with a {829} pulsating blood-vessel, and therefore is
not necessarily a sign of perforation of the tympanic membrane, as
fluids are found in the external auditory canal from inflammation of
its coats, and in such a case pulsation might occur; but this is but
seldom the case, and the removal of the fluid would remove any doubt as
to whether the fluid was a result of external-ear inflammation or
caused by purulent middle-ear disease.
The course of a chronic purulent inflammation is very variable. In many
cases under proper treatment healing and restoration of tissue go on
rapidly. The secretion grows daily less and of a thicker consistence,
and the mucous membrane of the middle ear rapidly returns to a normal
condition. The perforation in the tympanic membrane becomes smaller,
and often entirely closes, so that in a young person the restoration
may be so complete that it is difficult to know where the seat of
perforation has been. In one case in my practice in a child of ten
years, where the membrane had been destroyed to at least three-fourths
of its extent, a full restoration took place. In another class of cases
the course is not so favorable. The tympanic membrane is largely
destroyed, and is not regenerated. The chain of small bones may be
either partly or entirely lost. Granulations form in the mucous
membrane of the middle ear, and the bony walls of the tympanum undergo
partial necrosis, the pus appearing as an acrid, irritating fluid with
more or less odor. The graver complications of purulent inflammation
are apt to occur in those cases of chronic purulent inflammation where
there has been a stoppage of the free discharge of pus from the middle
ear, causing it to collect in the antrum and mastoid cells.
TREATMENT.--The first indication is to cleanse as thoroughly as
possible the middle-ear cavity of the muco-purulent fluid that may have
collected. This is best accomplished by forcing air up the Eustachian
tube and through the middle ear by either the Politzer or Valsalva
method of inflation. The fluids thus forced out into the external canal
can be removed by the use either of warm water and the syringe if large
in amount, or by cotton on a cotton-holder if small in quantity: the
latter plan is less irritating, and also completely dries the external
canal. No local application ought to be made as long as any pain
exists.
The local applications that my experience has shown to give the best
results consist of boracic acid and iodoform. (The latter is
objectionable on account of its odor.) The powder-insufflator furnishes
a convenient method of applying these powders, and only small
quantities should be used, so that no possible plugging of the middle
ear can take place. Some authorities prefer fluid applications instead
of powder. Weak solutions of sulphate of zinc, from one to four grains
to the ounce, are frequently used: a few drops, warmed, are poured into
the external canal and allowed to remain a short time, and then removed
by a twisted tuft of cotton on a cotton-holder. Nitrate-of-silver
solutions are to be used on a cotton-holder; and if a very strong
solution is used it should be neutralized with salt and water.
The frequency of application of any remedy will depend upon the amount
of discharge; but as the discharge lessens, so should the remedy be
less frequently applied. The same rule applies to the cleansing of the
ear, as I have no doubt that excessive use of the syringe often tends
to re-establish and increase the discharge. In some cases, where the
discharge has {830} become very small in quantity, a thick scab will
form over the tympanic perforation, and restoration of the tympanic
membrane will rapidly advance under such a covering, showing that it is
good practice not to remove such a scab, provided pus is not thereby
prevented from escaping. A cotton plug should always be worn in the
external canal of a purulent ear, as it acts as an absorbent of the
purulent secretions, as well as protects the middle ear from the
irritating contact of the air.
The naso-pharyngeal cavities are to be considered and appropriately
treated; also, a general tonic treatment is often indicated.
SEQUELÆ OF PURULENT INFLAMMATION.--I. Brain involvement, either of the
meninges or its substance proper: _a_, purulent meningitis; _b_,
abscess of the brain; _c_, phlebitis with thrombosis of the sinuses.
II. Mastoid disease.
I. Brain Involvement.
It will be proper for a clear understanding of the subject to briefly
consider the anatomy of the middle-ear cavity with reference to this
complication. The middle-ear cavity is practically surrounded by bony
walls, with the exception of the foramen closed by the tympanic
membrane and the opening of the Eustachian tube. The roof of the middle
ear is of varying thickness, and is perforated by a number of canals
for the passage of blood-vessels, forming a direct communication
between the circulation of the middle ear and the meninges of the
brain; also, the petro-squamous suture in the earlier years of life
before complete ossification has set in provides a way for spreading of
the inflammatory process from the tympanum to the brain tissue; also,
cases are recorded where caries has formed actual openings in this bony
roof, through which pus has entered into the brain cavity. The floor of
the tympanic cavity is very thin, and forms a fossa in which lies the
jugular vein, so that involvement of this vein in the inflammatory
process could occur by the close apposition of these parts. The
anterior wall is formed in part by the carotid canal, and cases are
noted where defects in this bony wall are found. Under such
circumstances the coats of the artery would lie in direct contact with
the middle-ear membranes. Also, it is to be noted that small twigs from
the carotid artery pass through its bony canal and anastomose with
vessels of the middle ear, furnishing a way for the spread of
inflammation from the middle ear to the carotid artery that may result
in thickening of its walls.
The superior and posterior surfaces of the petrous bone are in direct
contact with the brain membranes. The posterior wail contains the
passage into the mastoid cells by way of the antrum, through which
middle-ear inflammations spread and involve the mastoid cell cavities,
and may result in some cases in thrombosis of the transverse sinus.
The inner wall presents two weak points--the one the round foramen,
covered with membrane; the other, the oval foramen, covered with the
stirrup and the annular ligament. Inflammation can cause destruction of
these coverings and give free access of pus through their foramina into
the labyrinth, and thence through the internal auditory canal into the
brain cavity. It is not difficult, therefore, with so many ways of
{831} communication between the middle ear and brain cavity to have
easy spread of inflammation between these two regions.
(_a_) PURULENT MENINGITIS may arise from continuance of the
inflammation along the veins which penetrate the roof of the tympanic
cavity in their passage from the middle ear to anastomose with the
blood-vessels of the meninges, or may in rare instances be caused by
pus entering the brain cavity by way of the internal ear, or it can
result from caries of the petrous portion of the temporal bone.
SYMPTOMS.--Fever will be present; distressing headache; vertigo, a most
significant symptom, and often present even when the head is quiet and
in a horizontal position, but greatly increased by the vertical
position and motion; pain of a lancinating character, shooting over the
entire affected side and even down the neck; the occiput and vertex are
favorite points for pain to locate. Nausea and hiccough are present.
Abdomen depressed; pupils reacting to light but feebly; slow pulse; and
in some cases paralytic symptoms are prominent. Post-mortem appearance:
meninges congested, and lymph and pus often found at various points.
Dura mater over the diseased petrous bone will be found thick,
congested, and pus may be found between it and the bone. Caries of the
petrous bone also is found in some cases.
(_b_) ABSCESS OF THE BRAIN.--With the exception of wounds and injuries,
chronic purulent middle-ear inflammation is the most frequent cause of
brain abscess. Meyer, in a collection of 89 cases of brain abscess
tabulates the causes as follows: Typhus, 1; intercranial tumor, 2;
disease of nasal mucous membrane, 3; disease of the blood-vessels, 5;
inflammation of neighboring parts of the brain, 5; unknown causes, 11;
suppuration of distant organs, especially the lungs, 19; caries of the
petrous bone, 20; injuries, 21. Lebert collected 80 cases of brain
abscess, and found that one-fourth were caused by purulent middle-ear
inflammation, caries of the petrous bone being frequently present; in
one-seventh of the cases the brain abscess appeared before puberty, in
the remaining cases mostly between the sixteenth and thirtieth years;
also, that in some cases the abscess developed in the part of the brain
lying over the bony roof of the middle ear; in other cases it was found
in a distant part of the brain or the cerebellum, probably developing
as a metastatic abscess. Toynbee considered the retention of purulent
products in the middle ear or mastoid cells as the chief cause of brain
complications from ear sources: he also endeavored to show that an
inflammation of the external auditory canal will tend to implicate the
cerebellum and lateral sinus--that inflammation of the middle-ear
cavity would extend to the cerebrum, and that of the labyrinth to the
medulla oblongata. But, practically, such a rule will not hold good,
and Gull has modified Toynbee's law as follows: The cerebellum and
lateral sinus may suffer from mastoid disease, while the cerebrum is
threatened by caries of the roof of the tympanic cavity.
Brain abscess is generally located in the medullary substance, very
rarely in the cortex. The middle portion of the brain hemisphere is the
most frequent seat of abscess, and very often in that part adjacent to
the diseased ear. The abscess may be located directly over the diseased
bone, so that the dura mater forms its covering on one side and the
brain tissue on the other, or it may be located in the brain parenchyma
with perfectly healthy brain tissue between it and the diseased bone.
Meyer traces the {832} origin of a brain abscess from ear disease in
this manner: A chronic catarrh of the middle-ear mucous membrane
results in an hypertrophy of the mucosa on one side and a chronic
inflammation of the neighboring bone on the other side. Caries of the
petrous bone, so caused, produces inflammation and adhesion of the dura
mater, and from here as a starting-point the inflammation spreads into
the brain tissue. In rare cases the brain abscess has been found
connected by a fistulous tract with the diseased bone.
SYMPTOMS.--Headache is generally present in varying degree, often of a
lancinating character. Vertigo frequently present. Fever generally
present, with or without chill. Convulsions frequent, with loss of
consciousness and unsteadiness of gait, and often paralysis of
different parts of the body. The pupils are often contracted, and not
unfrequently this disease may closely resemble typhus fever. Lebert
noticed in his cases that failure of the intellect was not the rule,
but paralysis of sensibility occurred in two-thirds of them. It is also
to be noted that cases occur where all these symptoms are absent. This
disease can run an acute or chronic course. In the acute condition a
fatal termination is caused by the great destruction of brain tissue
involved in the suppurative process. In the chronic cases the abscess
becomes encapsulated, but finally terminates by rupture of the abscess
and escape of pus into the ventricles or over the surface of the brain.
In Lebert's cases the fatal termination occurred in half of them during
the first month, in one-third of the remainder toward the end of the
second month, and in the remaining cases in a varying time between the
third and eighth months.
(_c_) PHLEBITIS WITH THROMBOSIS.--This sequela of middle-ear
suppuration is not infrequent. Von Dusch in 32 cases of phlebitis with
thrombosis found that purulent middle-ear disease was the cause of 20
of them. It is frequently found in the venous sinuses in proximity to
the petrous portion of the temporal bone, especially in the lateral and
petrosal sinuses, and often caused by caries of the petrous bone.
Phlebitis with thrombosis of the lateral sinus is characterized by a
swelling of the mastoid region which extends downward into the neck,
due to an extension of the phlebitis from the lateral sinus along the
veins leading from that sinus through the mastoid process to the
exterior of the skull. Giddiness and unsteady gait are often present.
If the inflammation involves also the superior longitudinal sinus, it
will cause symptoms such as epileptic convulsions and violent
hemorrhage from the nose. Wreden considers that the epileptic seizure
is due to a capillary hemorrhage in the cortical substance of the
posterior cerebral lobes, caused by obstruction of the veins passing
over the brain substance. The nose-bleeding is due to the fact that a
part of the blood circulating through the veins of the nasal passages,
and then through the superior longitudinal sinus, is hindered by the
sinus obstruction and accumulates in the veins of the nasal passages,
and finally causes a rupture in some part.
Phlebitis with Thrombosis of the Cavernous Sinus.--Urbantschitsch gives
the following summary of this complication:[10] A thrombosis of the
cavernous sinus can be caused by a thrombus in the internal jugular or
facial veins or by a clot passing from the superior petrosal sinus into
the {833} cavernous sinus, or, finally, by inflammation and thrombosis
in the venous circulation of the carotid canals.
[Footnote 10: Vide _Textbook_, p. 367.]
PROMINENT SYMPTOMS.--Retro-bulbar oedema and exophthalmos, caused by
stoppage of the blood from passing from the orbit into the cavernous
sinus. This may result in a mechanical compression of the retinal
vessels and temporary blindness; also, occasionally swellings appear
about the eyelids and nose. Compression of the oculo-motor and abducens
nerves as they pass along the outer wall of this sinus may cause
paralysis of these nerves, and consequent inward turning of the eye,
with ptosis of the eyelids; also, pressure on a branch of the fifth
pair of nerves as it passes along the outer wall of the sinus may cause
neuralgia in the parts supplied by the branch, or neuralgia in the
supraorbital region.
Phlebitis with thrombosis of the internal jugular vein is marked by a
well-defined swelling extending from the angle of the jaw downward
along the line of the sterno-cleido-mastoid muscle, painful on
pressure, with marked distension of the veins of the face and neck,
especially the external jugular vein. Later on, when the collateral
circulation is established, the superficial veins are apt to return to
their former calibre. If the inflammation extends downward, it can
involve the vena cava; and if upward, the facial veins, causing a
swelling of the cheeks and eyelids. The process can also extend from
the facial to the orbital veins, and thence into the cavernous sinus.
Pressure of the thromboid mass on the internal jugular vein, on the
glosso-pharyngeal hypoglossus and pneumo-gastric nerves at the opening
of the jugular foramen, will cause nervous symptoms corresponding to
the nerve involved.
PROGNOSIS of a phlebitis with thrombosis, as a rule, is unfavorable.
Chronic middle-ear suppuration can also form a starting-point of
metastatic abscess, also of tubercular formations in the lungs and
other organs of the body. I have also been much impressed with the
frequent occurrence of kidney complications, such as granular
nephritis, in this disease. A gradual absorption of pus will develop a
general bodily weakness, and it is a fairly well established fact that,
as a rule, patients suffering from chronic middle-ear suppuration are
not apt to be long lived: many life insurance companies now order that
this disease will prevent the case from being considered a first-class
risk.
II. Mastoid Disease.
The mastoid process of the temporal bone presents an outer convex with
an inner concave surface. On the upper and posterior borders of the
bone are found several canals, through which the external vessels form
a union with those of the dura mater; also, by which the outer cranial
veins form a union with the transverse sinus. There is also an
important suture--the petro-squamous suture, which admits of the
passage of blood- and lymph-vessels. These vessels furnish a channel
for the spread of inflammation from the antrum outwardly, involving the
tissues of the neck, and inwardly to the brain membranes and brain
tissue proper; phlebitis with thrombosis of the lateral sinus can also
occur. The interior of the mastoid process contains one large opening,
the antrum, with numerous communicating air-cells, and all lined with
{834} an extension of the tympanic mucous membrane. Inflammation of the
mastoid process, as a rule, is an extension of inflammation from the
middle ear. The cause will be found in an obstruction to the free
escape of the purulent products from the antrum out through the middle
ear. It is also found that in a great number of cases of purulent
middle-ear inflammation the air-cells are closed by a process of
sclerosis. There are two forms of mastoid disease--1, periostitis of
the bone; 2, inflammation of the mucous membrane of the mastoid cells.
1. Periostitis of the Mastoid Bone is caused either by external
injuries, or more frequently by inflammation extending from the mastoid
cells outwardly to the periosteum.