CHAPTER VIII. FOREIGN BODIES IN THE EAR. (Part 1)

CHAPTER VIII. FOREIGN BODIES IN THE EAR. The usual point of entrance of foreign bodies into the ear is through the external auditory canal, although they very often pass beyond this part and become lodged in the cavity of the tympanum, or Eustachian tube, while in some rare instances a foreign body has entered the ear, through the Eustachian tube. I have therefore entitled this chapter, Foreign Bodies in the Ear, so that I might properly include all such cases in the descriptions that are about to be given. The foreign bodies that are found in the auditory canal are very naturally placed under three heads : insects, or the like which creep into the passage ; their larvae which are gene- rated there, and various articles, such as beads, buttons, peas, beans, and so on, which are pushed into the ear by children or silly adults. INSECTS IN THE EAR. When a live insect gets into an ear, the pain produced is usually intense and agonizing. Insects are more apt to get into the ears of sportsmen while hunting in thicket and under- brush, and of farmers laboring in the field, than of dwellers in cities and towns. Yet, on the hot days of summer when insect life is very active, the city practitioner will sometimes be called to remove a bug from the ear, if the agony induced by the foreign body do not stimulate some of the family to a successful attempt at its removal. There is an insect, which lives on the leaves of fruits and flowers, and which, like others, sometimes flies into the ear, 164 INSECTS IN THE EAE. which is called an ear-wig, and there was an ancient super- stition that it crept into the brain through the ear. The for- ficula auricularis, or so-called ear-wig, has probably no more propensity to fly into the ear, than any other insect ; any of the ordinary flies may do so. The most efficient and the speediest means of removing an insect from the ear is the use of a syringe and warm water. As little animals usually get into the ear when the patient is in the fields or forests, where physicians are not always at hand, laymen should be taught, in the case of the occurrence of such an accident, to immediately pour water in the meatus. This will disturb the animal and either drown it or cause it to run out. Some writers advise the use of an oil dropped into the ear before the water is used, but Wilde and Von Troltsch agree that this is an unnecessary waste of time. I have treated but two of such cases, and in both of these the insect was promptly dislodged by the use of the syringe, and I have no doubt that the simple filling of the auditory canal with water, will cause insects to come out at once. LIVING LARV^I IN THE EAR. Insects sometimes deposit their eggs upon the pus of a suppurating ear. According to Wood, who is quoted by Blake,* insects have a very acute sense of smell. " No flock of vultures can be directed more unerringly to their revolting- prey by scenting its odors from afar." The odor of an otitis media purulenta thus brings the insect to deposit its eggs in the auditory canal and cavity of the tympanum, where they soon become grubs or larvae. These larvae always excite considerable, and sometimes very severe pain, but in the cases which I have seen, the patients complain much more of the wriggling movements of the grubs in the ear, than of the pain. The ancient works on aural diseases speak very much of worms in the ear and of the proper means of removing them. * Living Larvse in the Human Ear. Archives of Ophthalmology and Otology, Vol. II., No. 2. LIVING LARViE IN THE EAE. 165 It is probable tliat these so-called worms were the larvae of insects which germinated from eggs deposited in the pus of a chronic suppurative process. Certain it is, that since the habit of cleansing an ear from pus has become a well-recog- nized duty, the practitioner of the present time sees very little of worms in the ears. The pain from the presence of these grubs, which ac- tually fasten themselves, when hatched, into the tissue of the canal, and bite upon it, as it were, is apt to occur sud- denly. An Austrian physician, Dr. Scheibenzuber* reports a case of a peasant ploughing in the field, who was seized in an instant, with a severe pain in the ear, which he ascribed to the flying in of a bug, but the surgeon found the ear full of well developed larvae. I have several times observed dead insects in the pus that was washed out from an external auditory canal, and it is undoubtedly true, as I have already suggested, that we should, equally with the ancients, have many cases of living larvae in the ear, were it not that suppurating ears are usually now- a-days regularly cleansed. The larvae that have thus far been found in the ear are those of the muscida sarcophaga (Blake, Gruber), and of the muscida lucilia (Blake). Dr. Blake t has made a study of the nature and habits of these grubs, by taking them from the ear at a very early period of development ; as near as could be ascertained within twelve hours of the time of their deposit. He placed a speci- men on the bottom of a thin glass vessel and covered it with a piece of raw beef, soaked in warm water, in such a manner that by inverting the glass the movements of the larvae could be easily studied under the microscope. Dr. Blake found that the apparatus by which the larva attaches itself, and which pierces and tears the tissue, is made up of a strong but delicate framework of horny consistency and of two hooks also of a stout horny structure, articulating with this frame-work. The larva burrows its way into the tissue * Monatsschrift fur Ohrenheilkunde, Jahrgang III., No. 3. f Archives of Ophthalmology and Otology, 1. c. 166 LIVING LARV2E IN THE EAR. on which it feeds by repeated extension and contraction of the hooks, alternately piercing and tearing. These movements explain the agonizing pain which pa- tients experience when the larvae appear from the eggs. These hooks are very large in proportion to the size of the body of the larvae. Dr. Blake says that the instincts of the animal lead it to bury itself beneath the surface, and to seek warmth and mois- ture and a soft, yielding tissue for its work. Hence, they are always found at the end of the canal or in the cavity of the tympanum. As yet, they have always been found in connection with suppuration of the middle ear, with its consequent perforation of the membrana tympani. The examination of the auditory canal infested by living larvse, shows small white worm-like animals moving rapidly about, very much as a mass of common earth-worms. As I write, I have before me a number of specimens of the dead grubs. They are about a half an inch in length, and of the diameter of a large knitting needle. Treatment. — I have found it impossible to remove living larvse by means of the syringe. The more they are syringed the more lively they become. Before the syringing is at- tempted, some agent should be instilled into the ear which will kill them, when the syringe will usually remove them. Sometimes, however, even after death, their hooks penetrate so deeply into the tissue that they can only be removed with the forceps. The forceps should not be needlessly used, how- ever, for even with the most careful manipulation, and with tractable patients, they often abrade the integument of the canal, and thus cause pain. I have used Labarraque's solu- tion of chlorinated soda to kill these grubs, but simply because it was at hand when I saw the cases. The larvse have also been killed by forcing the vapor of chloroform into the cavity of the tympanum through the Eustachian tube. I believe, however, that it will be sufficient to force the vapor into the external ear, or to instill some such fluid as I have mentioned into the canal. EOEEIGN BODIES IN THE EAE. 167 It need hardly be said, that the disease which allowed of the deposition of the eggs, and the hatching of the grubs, should be treated after they have been removed. Even those who are advocates of allowing a discharge from the ear to remain unchecked, will hardly defend such a neglect when the ear has become a disgusting receptacle in which larvae are formed. FOREIGN BODIES IN THE EAR. The foreign bodies that are placed in the ears of children by themselves or their playmates, have, from the time of the first writers on otology, formed a fertile field for the labors of surgeons. The importance of the subject has been unduly magnified. From some source or other, the laity have got the impression that a foreign body in the ear, like a wild beast accidentally let loose upon a civilized community, is to be hunted down at all hazards. The presence of a foreign body in the canal is, after all, however, not a very serious matter. Children do not usually push them in far enough to do any harm. It is the meddlesome interference of nurses and friends, and sometimes of unwise practitioners, that forces them into dangerous positions. There was a notion prevalent in Eng- land, in Shakspeare's times,* that poison poured into the ears was as dangerous as if taken into the stomach ; and from this, in some manner or other, has come the idea that a foreign body in the ear becomes at once a very dangerous thing. It would be well, if this fear of foreign bodies in the ear, were transferred to cases where they have entered the eye- ball, where the most serious results do occur from the neglect to promptly remove a foreign substance. Unskillful or indis- creet attempts to remove a foreign body are often more dan- gerous than the foreign body itself. In the case of a foreign body in the eye, it is the loss of sight that is threatened, and it is usually the worst that can happen ; but it is not a very rare experience that improper attempts to remove a foreign body from the ear have cost the life of the patient. * Play of Hamlet. 168 FOREIGN BODIES IN THE EAE. When, therefore, a child is brought to the practitioner, in whose ear there is, or there is supposed to be, a foreign body, let him first, by ocular examination, be sure that the diagno- sis is correct, and then let him attempt to remove it by a safe means. " First catch your hare," is the quaint and familiar begin- ning of the receipt for cooking this animal ; and in imitation of this sage advice, the writer, taught by experience that the diagnosis of mothers and nurses is not always to be trusted, would urge upon his readers the wisdom of not attempting to remove a foreign body which he cannot see. There is nothing more deceptive than the tactile examination. Again and again have I seen physicians click what they supposed to be a foreign body, by means of a probe, when they were simply striking the bony wall of the canal. The surgeon should not take the testimony of the most intelligent nurse in the world, as to the presence of a foreign body in the ear, unless he sees it himself. Such testimony is only valuable to prove that a foreign body was once in the ear. Any attempt to remove a foreign body that is not seen, but which is supposed to be in the ear, will lead to a danger- ous and mortifying failure. Even when it is seen, a forcible or violent attempt is always a dangerous procedure. Voltolini,* in writing on this subject, says, " that even the point of a dagger, if allowed to quietly remain in the ear, will not do as much harm as forcible attempts to remove it." The danger to be apprehended from attempts to remove a foreign body by the use of force is, that it will be pushed downwards in the ear, and through the membrana tympani into the cavity of the tympanum, and even into the labyrinth. Unfortunately for the fair fame of surgical science, such cases are on record. Treatment — If the physician see a case in which a foreign body has really got into the auditory canal — a fact which he should determine by the use of the speculum and the otoscope * Monatssckrift fur Olirenlieilkunde, Jalixgang II, No. xi. EEMOVAL OF FOKEIGN BODIES. 169 —before it has been meddled with, he will almost always be able to remove it by the process of syringing the ear with warm water. Children, however young, will readily submit to this operation, and it is almost always successful, if, as I have said, there have been no previous manipulations with instru- ments. Unfortunately, however, the cases are not usually seen by a physician until the friends of the little patient, having found by the child's own statement that a bead, or a pea, or a shoe- button, or the like, is in the meatus, and having been able to see it, have pushed it well in, in their misguided zeal to re- move that which in itself, is not dangerous to the ear or its functions. Many cases are on record where foreign bodies, which had not occluded the auditory passage, have remained in it for years without doing harm. Thus Wreden* reports a case in which he removed a button from the outer ear, which had re- mained at the junction of the osseous and cartilaginous canal of a boy of seventeen, for twelve years, and without doing any harm. If, however, the foreign body has become impacted by the attempts to remove it, and if serious inflammatory symptoms have arisen, it is better to wait until the latter has subsided before any further attempts at removal are made. Then, if instruments are to be used, the child should be placed under the influence of ether, and by means of a pair of delicate forceps, or a probe, it should, if possible, be dis- lodged from its wedged position, and then removed by the syringe. No manipulation of this kind should be attempted, however, unless the foreign body is well illuminated, so that the surgeon can see exactly what he is doing during the whole of his manipulations. In cases where injections made while the patient is in an upright position, do not remove the foreign body, Yoltolini has adopted the following method with success : The child is laid upon a table, so that its head may hang a little over the end of it. The membrana tympani then forms * Monatssclirift fur Okrenlaeilkunde, Jahrgang III., No. 12. 170 REMOVAL OF FOREIGN BODIES. a plane 'with the upper wall of the auditory canal, that runs obliquely downward. The syringing is then performed as usual. In two cases Voltolini has succeeded in removing the foreign body by this manoeuvre, when the ordinary method did not succeed. Voltolini has also used the galvano-caustic in breaking up the so-called Johannis brod or carob bean. The bean having become so firmly wedged into the ear that it was im- possible to move it one way or the other, he inserted the needle " with lightning-like rapidity" into the body, and when it cooled, the bean broke with a snap audible to the patient and to those about. "When sufficiently broken up, it was removed by syringing. Foreign bodies, such as peas, beans, and the like, are harder to remove after they have been in the ear for some time, than metallic bodies, because they swell, and thus be- come wedged firmly in the canal, and if they have been pushed into the cavity of the tympanum they excite still more trouble and become still more unmanageable. I have seen quite a number of foreign bodies in the ear, and I have never but in one case failed to remove them, and then I saw the patient but once for a few moments. The syringing did not succeed, and I asked the mother to bring the patient to my clinic at the Hospital, where she might be placed under the influence of an anesthetic, but she was not brought. In one case, when the child first came under my observa- tion, a button was lodged in the cavity of the tympanum by efforts to remove it. I syringed it in vain on several occa- sions. I then proceeded carefully with instruments, the pa- tient being anaesthetized. This attempt also failed. I then ordered the mother to syringe the ear three times a day, which was necessary on account of the purulent otitis media which had been set up by the presence of the button in the cavity of the tympanum, and I also advised the careful use of poul- tices. To my delight, in about four weeks I had the satisfac- tion of removing the button from the canal, where it had been brought by the syringing and the use of the poultices. I have now under my care a little child of four years of REMOVAL OP FOREIGN BODIES. 171 age, "who, according to her own statement to her nurse, put an ordinary shoe-button, made of papier-mache, in her ear. As soon as the nurse's attention was called to the case, she reported it to the family, who sent for a physician, who saw the button, and