THE EAR[5]
Surgical Anatomy--CARDINAL SYMPTOMS OF EAR DISEASE: _Impairment of
hearing_; _Tinnitus aurium_; _Earache_; _Giddiness_;
_Discharge_--Hearing tests--Inspection of ear--Inflation of middle
ear. AFFECTIONS OF EXTERNAL EAR: _Deformities_; _Haematoma auris_;
_Epithelioma and Rodent cancer_; _Impaction of wax_; _Eczema_;
_Boils_; _Foreign bodies_. AFFECTIONS OF TYMPANIC MEMBRANE AND
MIDDLE EAR: _Rupture of membrane_; _Acute inflammation of middle
ear_; _Chronic suppuration_; _Suppuration in the mastoid antrum
and cells_.
[5] We desire here to acknowledge our indebtedness to Dr. Logan Turner
for again revising this chapter.
#Surgical Anatomy.#--The anatomical subdivision of the ear into three
parts--the external, middle, and internal ear--forms a satisfactory
basis for the study of ear lesions. The outer ear consists of the
auricle and external auditory meatus, the latter being made up of an
outer cartilaginous portion half an inch in length, and a deeper
osseous portion three-quarters of an inch long. The canal forms a
curved tube, which can be straightened to a considerable extent for
purposes of examination by pulling the auricle upwards and backwards.
It is closed internally by the tympanic membrane, which separates it
from the tympanic cavity or middle ear. The middle ear includes the
tympanum proper, which is crossed by the chain of ossicles--malleus,
incus, and stapes--the Eustachian tube, which communicates with the
naso-pharynx, and the tympanic antrum and mastoid cells. As these
cavities lie in close relation to the middle and posterior cranial
fossae, infective conditions in the tympanum and mastoid cells are
liable to spread to the interior of the skull. The internal ear or
labyrinth lies in the petrous part of the temporal bone, its outer
boundary being the inner wall of the middle ear.
Physiologically the different parts of the auditory mechanism may be
divided into (1) the _sound-conducting apparatus_, which includes the
outer and middle ears; and (2) the _sound-perceiving apparatus_--the
internal ear and central nerve tracts. Impairment of hearing may be
due to causes existing in one or other or both of these subdivisions.
The condition of the sound-conducting apparatus can be investigated by
direct inspection through the speculum, and by inflation of the
Eustachian tube and tympanum, while that of the sound-perceiving
apparatus is ascertained partly by testing the hearing, and partly by
excluding affections of the outer and middle ear. When the
sound-conducting apparatus is at fault, the resulting deafness is
spoken of as "obstructive"; when the sound-perceiving apparatus is
affected, the term "nerve deafness" is used. The semicircular canals,
which are peripheral organs concerned in the maintenance of
equilibration, form part of the inner ear apparatus.
CARDINAL SYMPTOMS OF EAR DISEASE.--The most important symptom of ear
disease is _impairment of hearing_, which varies in degree, and may be
due to lesions either in the sound-conducting or in the
sound-perceiving apparatus. The sudden onset of deafness may be due to
impaction of wax in the external meatus or to haemorrhage or effusion
into the labyrinth. A gradual onset is more common. In children there
is a great tendency for acute inflammatory conditions of the middle
ear to arise in connection with the exanthemata and in association
with adenoids. In adult life chronic catarrhal processes are more
common causes of gradually increasing deafness, while in advanced age
there is a tendency to acoustic nerve impairment. Certain anomalous
conditions of hearing are occasionally met with, such as the
"paracusis of Willis"--a condition in which the patient hears better
in a noise; "diplacusis," or double hearing; and "hyperaesthesia
acustica," or painful impressions of sound.
_Tinnitus aurium_, or subjective noises in the ear, may constitute a
very annoying and persistent symptom. These sounds vary in their
character, and may be described by the patient as ringing, hissing, or
singing, or may be compared to the sound of running water or of a
train. They are usually compared to some sound which, from his
occupation or otherwise, the patient is accustomed to hear. They may
be purely aural in origin, being due, for example, to increased
pressure on the acoustic nerve endings from causes in the labyrinth
itself or in the middle or external ear; or they may be due to certain
reflex causes, such as naso-pharyngeal catarrh or gastric irritation.
Vascular changes such as occur in anaemia, Bright's disease, and heart
disease may also be concerned in their production.
_Pain_, or _earache_, varies in degree from a mere sense of discomfort
to acute agony. The pain associated with a boil in the external meatus
is usually aggravated by movements of the jaw, by pulling the auricle,
and by pressure upon the tragus. The pain of acute middle-ear
inflammation is deep-seated, intermittent in character, and worse at
night, and is aggravated by blowing the nose, coughing, and
sneezing--acts which increase middle-ear tension by forcing air along
the Eustachian tube. Mastoid pain and tenderness are indicative of
inflammation in the antrum or cells, and when these symptoms supervene
in the course of a chronic middle-ear suppuration, they should always
be regarded as of grave import. Severe neuralgia of the ear may
simulate the pain of acute mastoiditis, and it must not be forgotten
that earache may be traced to a diseased tooth. A careful examination,
not only of the ear, but also of the throat and teeth, should
therefore be made in all cases of earache.
_Vertigo_, or _giddiness_, may be produced by causes which alter the
tension of the labyrinthine fluid, such, for example, as the pressure
of wax upon the tympanic membrane, or exudation into the middle ear or
into the labyrinth. Giddiness occurring in the course of chronic
middle-ear suppuration may be significant of labyrinthine or of
intra-cranial mischief, but is not necessarily so. Giddiness preceded
by nausea suggests a gastric origin; if followed by nausea it points
to an aural origin. In cases of suspected aural vertigo, the patient's
"static sense" should be carefully tested. He should be asked (1) to
stand with both feet together with the eyes closed, (2) to stand on
one or other foot with eyes closed, (3) to walk in a straight line,
(4) to hop backwards and forwards off both feet. His incapacity for
performing such movements should be noted. As nystagmus may be
associated with disturbance of equilibrium due to ear disease, the
movements of the eyeballs must be carefully tested.
Labyrinthine _nystagmus_ is of a rhythmic character, and consists of a
slow and a rapid movement. Physiological nystagmus can be induced by
stimulating the movement of the endolymph in the semicircular canals,
by syringing the ear with hot and cold water (caloric test), by
rotating the individual (rotation test), and by the galvanic current.
Any departure from the normal reactions which these tests may produce,
should raise the suspicion of a pathological condition of the
semicircular canals.
_Discharge from the ear_, or _otorrhoea_, is occasionally due to an
eczematous condition of the skin lining the external meatus. It is
then usually of a thin, watery character, and contains epithelial
flakes and debris. An aural discharge is, however, most commonly of
middle-ear origin. It may be muco-purulent and stringy, or purulent
and of thicker consistence. A peculiar, offensive odour is
characteristic of chronic middle-ear suppuration. The surgeon should
smell the speculum in suspicious cases. He should never accept the
patient's statement as regards the absence of discharge, but should
satisfy himself by inspection and by the introduction of a cotton-wool
wick.
#The Hearing Tests.#--In testing the hearing, a definite routine
method should be adopted, the watch, whisper, voice, and tuning-fork
tests being systematically employed. Although the patient only
complains of one ear, both must be examined. Each ear should be tested
separately, and the patient should be so placed that he cannot see the
lips of the examiner. While one ear is being tested, the other should
be closed with the finger, and each test should be commenced outside
the probable normal range of hearing. All the results should be
written down at once, and the date of the test recorded, as this is
essential for following the progress of the case.
_Tuning-fork Tests._--To differentiate between deafness due to a
lesion in the sound-conducting apparatus and that due to labyrinthine
causes, it is necessary to enter into a little more detail. The tone
produced by a vibrating tuning-fork is conducted to the nerve
terminations in the labyrinth both through the air column in the
external meatus (air-conduction), and through the cranial bones
(bone-conduction). When, in a deaf ear, the vibrations of a
tuning-fork placed in contact with the mastoid process are heard
better than when the fork is held opposite the meatus, the lesion is
in the sound-conducting apparatus. When, on the other hand, the
vibrations are heard better by air-conduction, the lesion is in the
sound-perceiving apparatus. In addition to these facts, we find also
that in obstructive deafness low tones tend to be lost first, while in
nerve deafness the higher notes are the first to go. This may be
investigated by tuning-forks of different pitch or with the aid of a
Galton's whistle. Again, in middle-ear deafness, hearing may be better
in a noisy place, and be improved by inflation of the tympanum; while
in labyrinthine deafness, hearing may be better in a quiet room, and
be rendered worse by inflation.
#Inspection of the Ear.#--This should be carried out by the aid of
reflected light, the ear to be examined being turned away from the
window, lamp, or other source of light that may be employed. A small
ear reflector, either held in the hand or attached to a forehead band,
and a set of aural specula are required. Before introducing the
speculum, the outer ear and adjacent parts should be examined, and the
presence of redness, swelling, sinuses or cicatrices over the mastoid,
displacement of the auricle, or any inflammatory condition of the
outer ear observed. To inspect the tympanic membrane, a medium-sized
speculum held between the thumb and index finger is insinuated into
the cartilaginous meatus, the auricle being at the same time pulled
upwards and backwards by the middle and ring fingers, so as to
straighten the canal. The tympanic membrane is then sought for and its
appearance noted.
The _normal membrane_ is concave as a whole on its meatal aspect; it
occupies a doubly oblique plane, being so placed that its superior and
posterior parts are nearer the eye of the examiner than the anterior
and inferior parts. While varying to some extent in colour, polish,
and transparency, it presents a bluish-grey appearance. The handle of
the malleus traverses the membrane as a whitish-yellow ridge, which
appears to pass from its upper and anterior parts downwards and
backwards to a point a little below the centre. At the lower end of
the handle of the malleus a bright triangular cone of light passes
downwards and forwards to the periphery of the membrane. At the upper
end of the handle is a white knob-like projection, the short process
of the malleus. Passing forwards and backwards from this are the
anterior and posterior folds. The portion of the membrane situated
above the short process is known as the membrana flaccida or
Shrapnell's membrane. Behind the malleus the long process of the incus
may be visible through the membrane. The mobility of the membrana
tympani should be tested by inflating the tympanum or by means of
Siegle's pneumatic speculum.
Various departures from the normal may be observed. _Atrophy_ of the
membrane is characterised by extreme transparency of the whole disc.
Circumscribed atrophic patches appear as dark transparent areas, which
show considerable mobility and bulge prominently on inflation. A
_cicatrix_ in the membrane is evidence of a healed perforation, and is
also transparent, but differs from an atrophic patch in being more
sharply defined from the surrounding membrane. A _thickened membrane_
presents an opaque white appearance. _Calcareous_ or _chalky patches_
are markedly white, and when probed are hard to the touch; they are
often evidence of past suppuration. An _indrawn_ or retracted
membrane, resulting from Eustachian obstruction, is characterised by
increased concavity, undue prominence of the lateral short process of
the malleus and of the anterior and posterior folds, and by the handle
of the malleus assuming a more horizontal position. An _inflamed_
membrane, showing congestion of the vessels about the malleus or a
general diffuse redness, is evidence of middle-ear inflammation. A
yellow appearance of the lower part of the membrane, limited above by
a dark line stretching across the drum-head, is indicative of
sero-purulent exudation into the tympanum. The membrane may be bulged
outwards into the meatus by the fluid, and thus lie nearer the
observer's eye than normally. A _perforation_ is usually single, and
varies in size from a small pinhead to complete destruction of the
membrane. The labyrinthine (inner) wall of the tympanum may be visible
through the perforation, and is recognised by being on a deeper plane
than the membrane, and by its hard bony consistence when touched with
the probe. The diagnosis of a perforation associated with middle-ear
discharge may be further assisted by inspection during inflation, when
bubbles of air and secretion are visible. When the perforation is
invisible, its existence may be inferred if a small pulsating spot of
light can be recognised through the speculum. _Granulations_ in the
tympanum appear as red fleshy masses of different sizes. When large
they constitute _aural polypi_, which are recognised by their
proximity to the outer end of the meatus, their soft consistence and
mobility, and the fact that the probe may be passed round them.
Granulations and polypi usually indicate the presence of middle-ear
suppuration.
#Inflation of the Middle Ear.#--Before proceeding to inflate the
middle ear, the examiner should inspect the nose, naso-pharynx, and
pharynx. This should be made a routine part of the examination in all
cases of ear disease. As inflation is not only an aid in diagnosis,
but is also of great assistance in prognosis, it is necessary that the
hearing should be tested and noted before the ear is inflated. There
are three methods of inflating the tympanum: Valsalva's method,
Politzer's method, and by means of the Eustachian catheter.
In _Valsalva's inflation_ the patient himself forces air into his
Eustachian tubes, by holding his nose, closing his mouth, and forcibly
expiring. This method of inflation has only a limited application and
is of little therapeutic value.
_Politzer's Method._--For this a Politzer's air-bag and an
auscultating tube, one end of which is inserted into the patient's ear
and the other into the ear of the examiner, are required. The nasal
end of the bag should be protected with a piece of rubber tubing or be
provided with a nozzle. The patient retains a small quantity of water
in his mouth until directed to swallow. The nozzle of the bag is
inserted into one nostril, and the other is occluded by the fingers of
the surgeon. The signal to swallow is then given, and, simultaneously
with the movement of the larynx during this act, the bag is sharply
and forcibly compressed. Holt's modification of this method consists
in directing the patient to puff out his cheeks while the lips are
kept firmly closed.
_Inflation through the Eustachian Catheter._--For this method, in
addition to the Politzer's bag and the auscultating tube, a silver or
vulcanite Eustachian catheter is required. The silver instrument has
the advantage that it can be sterilised by boiling. The patient is
seated facing the light, while the surgeon stands in front of him,
and, having placed the auscultating tube in position, with his left
thumb he tilts up the tip of the patient's nose. The beak of the
catheter is now inserted into the inferior meatus, point downwards,
and carried horizontally backwards along the floor of the nose until
the convexity of the curve touches the posterior wall of the
naso-pharynx. When the posterior pharyngeal wall is felt, the point of
the instrument is rotated inwards through a quarter of a circle; the
position of the point is indicated by the metal ring upon the outer
end of the catheter. The finger and thumb of the left hand should now
grasp the stem of the catheter just beyond the tip of the nose so as
to steady it. It is now gently withdrawn until the concavity of the
beak is brought against the posterior edge of the septum nasi. With
the right hand the point of the instrument is then rotated downwards
and outwards through a little more than half a circle, so that the
point slips into the Eustachian orifice and the metal ring looks
outwards and upwards towards the external canthus of the eye of the
same side. While the instrument is maintained in this position by the
left hand, the nozzle of the Politzer's bag is inserted into the
funnel-shaped outer extremity of the catheter, and inflation is gently
carried out with the least possible jerking. Before withdrawing the
catheter its point must be disengaged from the Eustachian opening by
turning it slightly downwards. Difficulties in introducing the
catheter may arise from the presence of spines and ridges upon, and
deviations of, the septum, and it may be necessary to pass the
instrument under the guidance of the mirror and speculum.
More accurate information is gained from the use of the catheter than
from Politzer's inflation, and it is the safer method to employ when a
cicatrix or atrophied patch exists in the tympanic membrane, as by the
latter method rupture of these areas might occur. Further, the
catheter has the advantage of only inflating one ear, and thus
preventing any undue strain being put upon the other. In children the
catheter can seldom be employed, on account of the difficulty in
passing it.
Considerable information may be derived from inflation. If the
Eustachian tube is patent, a full clear sound is heard close to the
examiner's ear through the auscultating tube. If the Eustachian tube
is obstructed, the sound is fainter and more distant. If there is
fluid in the tympanum, a fine moist sound may be detected, which must
not be confounded with the coarser and more distant gurgling sound
associated with moisture at the pharyngeal opening of the tube. If a
small dry perforation exists in the tympanic membrane, the air may be
heard whistling through it, while if the perforation is large, a
sensation which is almost painful may be produced in the examiner's
ear. If there is fluid associated with the perforation, these sounds
may be accompanied by a bubbling noise. The effect of inflation upon
the hearing must be carefully tested and recorded.
AFFECTIONS OF THE EXTERNAL EAR
#Deformities.#--The auricle, together with the external auditory
meatus, may be _congenitally absent_ on one or on both sides. The
condition is not amenable to surgical treatment. _Double auricles_ are
occasionally met with; more frequently rudimentary _auricular
appendages_ about the size of a pea, consisting of skin, subcutaneous
connective tissue and nodules of cartilage occur in front of the
tragus, on the lobule or in the neck. These appendages should be
snipped off with scissors. These congenital deformities are due to
errors in development of the mandibular arch, and are frequently
associated with macrostoma, facial clefts, and other malformations of
the face.
_Outstanding ears_ may be treated by excising a triangular or
elliptical portion of skin and cartilage from the posterior surface of
the pinna and uniting the cut edges with sutures. Abnormally _large
ears_ may be diminished in size by the removal of a V-shaped portion
from the upper part of the auricle.
The term #haematoma auris# is applied to a sub-perichondrial effusion
of blood, which may occur either as the result of injury to the
auricle, for example in football players, or as a result of trophic
changes in the cartilage and perichondrium. The latter form is not
uncommon among the insane. A more or less tense fluctuating swelling
forms on the anterior surface of the auricle, presenting in some cases
a distinctly bluish coloration. Inflammation may ensue, and in some
cases suppuration and even necrosis of cartilage may follow.
The _treatment_ in a recent case consists in applying cold or elastic
compression with cotton-wool and a bandage, or in withdrawing the
effused blood by means of a hollow needle. In the event of suppuration
supervening, incision and drainage must be carried out.
#Epithelioma# may attack the auricle and extend along the external
auditory meatus. It begins as a small abrasion which refuses to heal,
and is attended with a constant foetid discharge and intense pain. The
disease may spread to the middle ear and invade the temporal bone, and
facial paralysis then ensues. The adjacent lymph glands are early
infected. The treatment consists in removing the growth freely, and
excising the associated lymph glands at an early stage of the disease.
In inoperable cases radium or the X-rays may be employed.
#Rodent cancer# also may attack the outer ear.
#Impaction of Wax or Cerumen.#--Hyper-secretion may result from
unknown causes, or it may accompany or be induced by the discharge
from a chronic middle-ear suppuration. The association of these two
conditions should be borne in mind. An accumulation of wax may be
caused by the too zealous attempts of the patient to keep the ear
clean, the wax being forced into the narrow deeper part of the meatus.
The chief _symptom_ of impacted wax is deafness, which is often of
sudden onset. Impaction of wax causes deafness only when the lumen of
the auditory canal becomes completely occluded by the plug. Tinnitus
aurium and vertigo are sometimes present, and may be troublesome if
the wax rests upon the tympanic membrane. Pain is occasionally
complained of, and is usually due to the pressure of the plug upon an
inflamed area of skin. Certain reflex symptoms, such as coughing and
sneezing, have been met with.
It is only by an objective examination of the ear that the diagnosis
can be made. The plug varies in colour and consistence, and may be
yellow, brown, or black in appearance. Sometimes from the admixture of
a quantity of epithelium it is almost white in colour.
_Treatment._--The ear should be syringed with a warm antiseptic or
sterilised solution. The lotion is at a suitable temperature if the
finger can be comfortably held in it. The ear should be turned to the
light, a towel placed over the patient's dress, and a kidney basin
held under the auricle and close to the cheek. A syringe provided with
metal rings for the fingers and armed with a fine ear nozzle should be
held with the point inserted just within the aperture of the external
meatus and in contact with the roof of the canal. Care must be taken
that all the air is first removed from the syringe. To straighten the
canal, the pinna should be pulled upwards and backwards by the left
hand. It may be necessary to exert some considerable degree of force
before the plug becomes dislodged, but this must be done with caution.
The ear should then be dried out with cotton-wool, and a small plug
of wool inserted for a few hours. If pain is complained of, or if the
wax is hard and cannot be readily removed, the syringing should be
stopped, and means taken to soften it by the instillation of a few
drops of a solution of bicarbonate of soda (10 grains to the ounce of
water or glycerine), or of peroxide of hydrogen, several times daily.
#Eczema of the external meatus# is often associated with eczema of the
auricle and of the surrounding parts. Not infrequently there also
exists a chronic middle-ear suppuration, which may be the cause of the
eczema. Intense itchiness is the most characteristic symptom, and a
watery discharge may also be complained of. Deafness and tinnitus are
dependent upon the accumulation of epithelium and debris. After the
ear is syringed the skin may present a dry, scaly appearance, while
sometimes fissures and an indurated condition of the outer end of the
meatus may be noted. Rarely is the outer surface of the tympanic
membrane itself involved.
_Treatment_ consists in keeping the ear clean by syringing and careful
drying. Probably the best local application is nitrate of silver (10
grains to the ounce of spiritus aetheris nitrosi). This is applied by
means of a grooved probe dressed with a small piece of cotton-wool.
Care should be taken that none of the fluid is allowed to escape upon
the cheek, otherwise staining of the skin occurs. A plug of
cotton-wool is inserted, and the solution is re-applied at the end of
a week. Sometimes the condition is very intractable.
Occasionally the vegetable parasite _aspergillus_ is present in the
external meatus, and produces a condition that is liable to be
mistaken for eczema. Strong antiseptic lotions are required to kill
the fungus.
#Furunculosis# or #Boils#.--Boils in the ear may arise singly or in
crops, and may be associated with eczema of the meatus or with chronic
suppuration of the middle ear. Pain is the chief symptom complained
of, and it may be very acute. Deafness ensues when the meatus becomes
completely blocked by the swelling. The boil occurs in the
cartilaginous meatus, and it is to be borne in mind that the skin may
present a normal appearance even when suppuration has occurred.
Palpation of the affected area with the probe causes intense pain.
Sometimes oedema over the mastoid with displacement forwards of the
pinna supervenes, and simulates acute inflammation of the mastoid.
_Treatment._--If seen in the earliest stages, an attempt may be made
to relieve the pain by the application of a 20 per cent. menthol and
parolein solution, or by the use of carbolic acid and cocain, 5 grains
of each to a dram of glycerine. When suppuration has occurred, the
best treatment is by early incision, transfixing the base of the
swelling with a narrow knife and cutting into the meatus. If the
tendency to boils persists, a staphylococcal vaccine will be found of
value.
#Foreign Bodies.#--It is unnecessary to enumerate all the varieties of
foreign bodies that may be met with in the ear. They may be
conveniently classified into the animate--for example maggots, larvae,
and insects; and the inanimate--for example beads, buttons, and peas.
Pain, deafness, tinnitus, and giddiness may be produced, and such
reflex symptoms as coughing and vomiting have resulted.
The main practical point consists in identifying the body by
inspection. The mere history of its introduction should not be taken
as proof of its presence. In children it is advisable to give a
general anaesthetic so that a thorough examination may be made with the
aid of good illumination. If previous attempts to remove the body have
caused oedema of the meatal walls, and if the symptoms are not urgent,
no further attempt should be made until the swelling has been allayed
by syringing with warm boracic lotion, and by applying one or more
leeches to the tragus. An attempt should always be made in the first
instance to remove the body by syringing. It is rare to find this
method fail. Should it do so, a small hook should be used, sharp or
blunt according to the consistence of the body. Maggots, larvae, and
insects should first be killed by instillations of alcohol and then
syringed out.
AFFECTIONS OF THE TYMPANIC MEMBRANE AND MIDDLE EAR
#Traumatic Rupture of the Tympanic Membrane.#--Perforating wounds may
result from direct violence caused by the patient--for example, in
attempts to remove wax or foreign bodies, or by clumsiness on the part
of the surgeon. It is also a comparatively common complication of
fracture of the middle fossa of the base of the skull. More commonly,
perhaps, the membrane is ruptured from indirect violence due to great
condensation of the air in the external auditory meatus, following
blows upon the ear, heavy artillery reports, or diving from a height.
The injury is followed by pain in the ear, often by considerable
deafness and tinnitus, and bleeding is frequently observed. If early
examination of the ear is made, coagulated blood may be found in the
meatus or upon the membrane, or ecchymosis may be visible on the
latter. A rupture in the membrane following indirect violence is
usually lozenge-shaped. During inflation by Valsalva's method the air
may be heard to whistle through the perforation. In all such injuries
the hearing should be carefully tested, and the possibility of an
injury to the labyrinth investigated by means of the tuning-fork test.
Prognosis as regards hearing should be guarded at first. As a rule the
rupture heals rapidly, and no treatment is necessary save the
introduction of a piece of cotton-wool into the meatus. Syringing
should be avoided unless suppuration has already occurred, in which
case treatment for this condition must be adopted. As these injuries
frequently have a medico-legal bearing, careful notes should be made.
#Acute Infection of the Middle Ear.#--This usually arises in
connection with infective conditions of the throat and naso-pharynx.
It varies considerably in its severity, and may run a mild or a severe
course. It is characterised by pain in the ear, deafness, and a
certain degree of fever. In children the symptoms may simulate those
of meningitis. When the tympanic membrane is examined in the mild
forms of the affection or in the early stages of the more severe type,
the vessels about the handle of the malleus and periphery of the
membrane are injected, and possibly a number of injected vessels may
be seen coursing across the surface of the membrane. In the later
stages the whole membrane presents a red surface, the anatomical
landmarks being indistinguishable, the membrane bulges outwards into
the meatus, and, if an abscess is pointing, a yellowish area may be
visible upon it. The sudden cessation of pain and the appearance of a
discharge from the meatus indicate perforation of the membrana
tympani.
The _treatment_ of acute otitis media varies with the severity of the
attack. The patient should be confined to the house or to bed, alcohol
and tobacco should be forbidden, and the bowels must be freely opened.
Pain may be allayed by repeated instillations of cocain and carbolic
acid (5 grains of each to a dram of glycerine). A few drops of
laudanum, hot boracic instillations, or the application of a dry hot
sponge, may prove soothing. Two or three leeches may be applied over
the mastoid, but should the pain persist or should rupture of the
membrane appear imminent, paracentesis must be carried out. After
spontaneous perforation or puncture, the meatus must be kept clean. It
is probably safer not to inflate through the Eustachian tube in the
acute stage. Attention must be paid to any affection of the nose or
throat that may be present.
#Chronic Suppuration in the Middle Ear.#--Acute suppuration may pass
into the chronic variety, which is characterised by a perforation of
the tympanic membrane, a persistent purulent or muco-purulent
discharge from the middle ear, and a certain amount of deafness.
_Various complications_ may arise in the course of chronic middle-ear
disease, and so long as a person is the subject of a chronic
otorrhoea, he is liable to one or more of these. The complications may
be extra-cranial or intra-cranial. Those affecting the middle ear
itself include granulations, polypi, cholesteatoma, caries and
necrosis of the temporal bone, destruction and loss of one or more of
the ossicles, facial paralysis, haemorrhage from the carotid artery or
jugular vein, and malignant disease. As mastoid complications may be
mentioned: suppurative mastoiditis, leading to destruction of the
bone, mastoid fistula, and sub-periosteal mastoid abscess. The
intra-cranial complications that may arise are: extra-dural abscess,
sub-dural abscess, meningitis, cerebral and cerebellar abscess, and
lateral sinus phlebitis with general septicaemia and pyaemia.
The _treatment_ of chronic middle-ear suppuration consists in keeping
the parts clean by syringing with antiseptic lotions. The installation
of hydrogen peroxide, followed by syringing with boiled water or
boracic lotion, and inflation through the Eustachian tube once, twice,
or thrice daily, according to the requirements of the case, constitute
a routine method. Packing the meatus with antiseptic gauze after
washing out may be practised.
#Suppuration in the Tympanic Antrum and Mastoid Cells#, or _Acute
Suppurative Mastoiditis_.--Acute suppuration may occur in the mastoid
cells in the course of an attack of acute otitis media, or as a result
of interference with drainage in chronic suppuration of the antrum and
middle ear. As the outer wall of the mastoid is liable to be
perforated by cario-necrosis, the pus may find its way externally and
form an abscess over the mastoid process behind the ear. In some cases
the pus escapes into the external auditory meatus by perforating its
posterior wall; in others a sinus forms on the inner side of the apex
of the mastoid, and the pus burrows in the digastric fossa under the
sterno-mastoid--_Bezold's mastoiditis_. If the posterior wall or roof
of the antrum is destroyed, intra-cranial complications are liable to
ensue.
The _clinical features_ are pain behind the ear, tenderness on
pressure or percussion over the mastoid, redness and oedematous
swelling of the skin, and, when pus forms under the periosteum, the
oedema may be so great as to displace the auricle downwards and
forwards (Fig. 265). The deeper part of the posterior osseous wall of
the meatus may be swollen so that it conceals the upper and back part
of the membrane.
[Illustration: FIG. 265.--Acute Mastoid Disease, showing oedema and
projection of auricle.]
_Treatment._--When arising in connection with acute otitis, the
application of several leeches behind the ear, free incision of the
membrane, and syringing with hot boracic lotion may be sufficient. As
a rule, however, it is necessary to expose the interior of the antrum
by opening through the mastoid cells--_Schwartze's operation_. When
mastoid suppuration is associated with chronic middle-ear disease,
it is usually necessary to perform the complete radical
operation--_Stacke-Schwartze operation_. The operations are described
in _Operative Surgery_, p. 98.