CHAPTER XL ACUTE CATARRHAL INFLAMMATION OF THE MIDDLE EAR. The nomenclature that I have adopted in lecturing upon the affections of the middle ear, and the one which I regard as most in accordance with the anatomy and pathology of this part of the organ of hearing, may be tabulated as follows : <Callout type="important" title="Important">I. — Acute catarrhal inflammation.</Callout> II. — Subacute catarrhal inflammation. III. — Chronic non-suppurative inflammation, divided into two forms — catarrhal and proliferous. IV. — Acute suppurative inflammation. V. — Chronic suppurative inflammation. VI. — The consequences of chronic suppuration : 1. Polypi. 2. Exostoses. 3. Mastoid disease. 4. Caries and necrosis. 5. Cerebral abscess. 6. Pyaemia. 7. Paralysis. By such a classification as this, especially that relating to the suppurative affections, correct notions are formed as to the nature of such diseases as polypi and mastoid disease, which is otherwise difficult. Polypi and exostoses have hitherto been classified under the diseases of the external auditory canal. They are certainly, in most cases, situated in this part ; but this is their chief claim to such a classification. In by far the greater number of cases they are the direct result of inflammation of the middle ear. If we were to form our estimate of the frequency of acute catarrhal inflammation of the middle ear from the number of 238 ACUTE CATARRH OF THE MIDDLE EAR. cases that occur in the statistics of writers on diseases of the ear, we should come to a very erroneous conclusion as to the number of people who suffer from this affection. It is indeed a very common one. It is difficult to find an adult who has not at one time or another suffered from "ear-ache." Ear- ache is the popular name for acute catarrh of the middle ear. My own statistics show that of 994 cases of aural disease seen in private practice, only 55, or a little more than five in a hun- dred, belonged to the class now under consideration. The tables of other writers show about the same relative frequency. That tins disproportion does not arise from an actual rarity of the affection, I think a little thought will show. Such pain- ful affections very often never reach a practitioner, and are treated at home, a fact which accounts for their infrequency in statistical tables. Every physician will at once recall the fact, that it is often incidentally mentioned, when perhaps he is visiting a family suffering from other diseases, that Johnny or Mary has had a severe ear-ache all night, and that there has been great difficulty in quieting the fearful pain. Very often, indeed, the fact will be added, that the pain is not yet subdued, and that the family have quite exhausted the means at their disposal for relieving it ; and yet, taught by tradition and experience, they do not expect anything from the physician, whose aid becomes so efficacious for the pain of colic or of peritonitis. It is to be feared that many physicians stand helplessly by, and allow an acute catarrh of the middle ear to run on to suppuration of the drum-head, or, worse still, to periostitis of the mas- toid or to meningitis, without an attempt at interference. A little later, in the discussion of this affection, we shall discover, I think, that the means at our disposal for its relief are ample, and that they have what may almost be termed a brilliant effect, when properly used ; but I wish in the outset to impress upon the minds of my readers the fact that the commonly neglected ear-ache of the household is identical with the disease known as acute catarrhal inflammation of the middle ear. It will then be evident that we are dealing with an extremely practical subject, and one on which every family practitioner is, or should be, very much interested. SYMPTOMS OF ACUTE CATARRH. 239 The symptoms of this affection are so characteristic that in the adult, they point unmistakably in the most cases to its seat. I say in the adult, for in young children who have not yet learned to speak, the diagnosis sometimes becomes very difficult, and it is not always possible. Symptoms. — The symptoms of acute catarrh may be enume- rated in the following order : Subjective. 1. Pain, referred to the depth of the ear. 2. A sense of fulness in the same part. 3. Noises in the ear. Objective. 1. Vascular injection. 2. Bulging outwards of the membrana tyrupani 3. Impairment of hearing. 4. Catarrh of the pharynx and Eustachian tubes. 5. Fever. The pain is very often the first symptom that is observed. Children old enough to speak, awake from sleep crying, "My ear, my ear." Adults find themselves without warning at- tacked by a pain which causes the most intense agony — a pain which forces the strongest men to shriek and tremble, while children affected with such a disease soon cause the attend- ants to believe that the brain must be the seat of trouble. Sometimes, however, patients with good habits of observation notice that the pharynx felt thickened and full, and that the throat was sore, a short time before the pain in the ear began. I am inclined to believe that the most patients are aware of what, for the want of a better name, may be termed a thickness of hearing, a fullness in the ears, before the attack of pain oc- curs. This pain is described by some patients as beginning in the throat and crawling along the Eustachian tube. It is a disease, however, which may be said to be sudden in its ori- gin, and one which jumps at a bound to its height. It will pass over the acme, in the most cases, unless at once arrested, into acute suppuration of the middle ear; a disease which, strangely enough, some practitioners seem to invite, by the 240 SYMPTOMS OF ACUTE AURAL CATARRH. remark which they make, "It is a common gathering of the ear, from which we shall get no relief until suppuration is established." I intend to combat this idea in the discussion of the treatment. It is certainly an erroneous and mischiev- ous view of a serious disease. The sensations of fulness, the noises in the ear in acute inflammation, are very distressing. The latter symptom, the technical tinnitus aurium, usually lessens and changes its char- acter with a cessation of the pain. It changes from a puffing sound, like the puff of a miniature steam engine, to a ringing or buzzing sensation. The feeling of fulness may last for some days after the pain has passed away. As I have said, the diagnosis of this disease is often diffi- cult in young children, because they are unable to locate the seat of the pain in words. If, however, we watch a child care- fully who is suffering from pain in the ear, we can usually narrow it down to the region of the head. Then by means of pressure upon the tragus, observing if the child winces at this, we can generally form a conclusion as to the origin of the pain. The disease with which infantile catarrh of the middle ear is apt to be confounded is an affection of the membranes of the brain. Besides this, the physiological process of teething, is often cred- ited with a great deal of pain, which more properly belongs to the ear. With a certain style of what may be called easy going practitioners, the diagnosis of difficult dentition, is often suffi- cient to cover a multitude of painful symptoms. Accordingly, gums are needlessly lanced, and dangerous delays are allowed, until a discharge of pus through the drum-head, makes the diagnosis for the little sufferer. The instillation of warm water into the auditory canal will usually temporarily relieve an infantile ear-ache ; and in this procedure we have a means of diagnosis which is always at hand. I have seen children who were crying with pain from inflammation of the middle ear, go to sleep in a few moments after the instillation of warm water into the meatus. Some- times, however, this procedure will fail to give relief, and we must depend upon the objective symptoms, of which I shall soon speak, found in the color of the membrana tympani. Adults sometimes mistake the pain from inflammation of SYMPTOMS OP ACUTE AURAL CATARRH. 241 the lining membrane of the middle ear, for what is termed neu- ralgia. I have seen cases where an anti-neuralgic treatment by means of quinine and opium, had been tried in vain for a disease which was really a true inflammation of mucous mem- brane ; but adults usually locate the seat of trouble with exact- ness and accuracy. The pain is indeed neuralgic, and a mo- ment's consideration of the rich supply of nerves to the cavity of the tympanum, will give the reason for the fact that the pain follows the course of the 5th and 7th nerves. The objective symptoms are chiefly to be sought in the membrana tympani. There is sometimes a pinkish hue to the whole membrane, again the vascular injection is around the periphery of the drum-head, and along the handle of the malleus, while the other parts of the membrane remain of their normal color. An acute inflammation occurring in a drum membrane rigid, thickened, and opaque from former inflammation, is more apt to show localized redness than the diffuse pinkish tint, that is seen when inflammation occurs in a membrane that has been previously healthy. At other times the redness is so intense as almost to pre- vent any recognition of the drum-head, except as an evenly red surface in which no vessels can be traced. I think there is always some increased vascularity of this membrane, in every case of acute inflammation of the lining of the tube and the cavity of the tympanum, so that we may find in this symptom the deciding point in doubtful cases, even in the infants. The membrane has, however, at times the appearance of glass that has been breathed upon, without any evident increase in vascularity, even where there is acute inflammation going on in the middle ear. The impairment of hearing is not always marked in the stage of pain. The hearing power may even be augmented and be painfully acute during the first stage of the disease. I have known many instances where the acuteness of hearing was found on accurate examination to be markedly increased in cases of chronic aural catarrh, in which an acute inflam- mation had supervened. It may be increased also in acute cases occurring in persons whose ears have been previously healthy ; that is to say, sounds may seem very loud to them. 16 242 SYMPTOMS OP ACUTE AURAL CATARRH. I will not attempt any explanation of the phenomenon, but be content with noting the fact. Bulging outward of the membrana tjmpani is a symptom that may often be observed after the first forty-eight hours of an attack of acute catarrh. If the disease continue longer in an acute form, spontaneous perforation is apt to, but does not always occur. This bulging outward, I have most frequently observed in the posterior and inferior quadrant, but also in Shrapnell's membrane, and usually in the posterior portion of the membrane. It is sufiiciently marked to be detected by any one who is at all familiar with the examina- tion of the normal membrane. In rare cases — I believe I have seen but two in my experience — the imperforate membrana tympani will be found to pulsate synchronously with the pul- sations of the heart. As is well known, it is quite common to observe a pulsation of the vessels of the cavity of the tympa- num in cases of acute and chronic suppuration of this part ; but pulsation of the imperforate membrana tympani is a rare symptom. There must be great increase of the tension of the membrane when this occurs, from the pressure of the blood column or of mucus behind it. Increased secretion from the pharynx and region of the posterior nares is almost always observed in cases of acute catarrh ; but it requires but a mere mention at this point. Febrile symptoms are almost always present in cases of the disease under discussion. The temperature is usually quite considerably increased, so that the general aspect of the patient, suffering from great local pain, impairment of hear- ing, and a dry, heated skin, is one of intense suffering. Yet this is the disease which many physicians allow to run its course, without any of the antiphlogistic treatment that they would at once resort to, were any other organ of the body sim- ilarly attacked. Causes. — The causes of this disease are manifold. Any undue exposure to the influence of cold may produce acute catarrh of the middle ear. Getting the feet wet, the sur- face of the body chilled by standing or walking in the cold, are frequent causes of ear-ache. A draught of air blowing, CAUSES OF ACUTE CATARRH. 243 for instance, through the window of a railway carnage in rapid motion, is sometimes a cause of acute catarrh. Ducking the head under water, and allowing the water that enters the auditory canal to remain there, is another cause. Constitutional diseases, such as small-pox, scarlet fever, and measles, in which the pharynx is affected, are very common sources of acute aural catarrh. Pneumonia and bronchitis very often have this affection as a consequence. Coryza or cold in the head, however caused, very often gives rise to acute inflammation of the ear. It arises in the course of syphilitic affections of the pha- rynx and posterior nares ; but, contrary to what has been said by some authors, I have found no pathognomic evidences of syphilis in the character of the pain or the appearance of the membrana tympani in such cases. The origin of acute catarrh is chiefly to be sought for in the faucial extremity of the Eustachian tube, and not in the auditory canal. This explains the fact, that it is much more important for patients liable to aural disease to protect the external surface of the body and the extremities from the cold, than the meatus and auricle. Yet it is not to be denied, that inflammation of the middle ear does occasionally extend from the canal, through the mem- brana tympani, and not through the Eustachian tube, for we have seen that a draught of air upon the side of the head, will produce acute aural catarrh, and if cold water enter the ear through the meatus externus, and remain for a considerable time, it may also produce acute catarrh of the middle ear. The use of the nasal douche for the treatment of naso- pharyngeal catarrh, may also produce acute inflammation of the ear, as I first showed in an article in the Archives of Oph- thalmology and Otology.* My experience has since been con- firmed by many other observers. In the description of the treatment of the pharynx and nares in the course of chronic aural inflammation, the subject of the use of the nasal douche will be more fully discussed. * Archives of Ophthalmology and Otology, vol. i., No. 1. 24A TREATMENT OF ACUTE CATAEEH. Treatment. — The proper treatment of acute aural catarrh is predominantly an antiphlogistic one. The disease is an inflammation of the severest form, and can only be success- fully combated by such means as local blood-letting and opium. A nervous pain in the ear, a true otalgia, is a rare disease. In fifteen hundred cases, I have seen but one such affection, and yet an inflammation of the middle ear is very often treated as would be a case of facial neuralgia ; or we might even say, that the ordinary treatment for acute aural inflammation is pre-eminently empirical and without reason. From the time of the ancients down to our own day, all kinds of decoctions and mixtures have been poured into the ears to relieve ear-ache. Some of these agents are of a negative or slight value ; many of them are of a positively harmful nature. To the former class belong such applications as sweet-oil and laudanum, glycerine, molasses, and so on. To the latter class belong Harlem oil, Cologne water, ether, and all stimulating applications. Poultices are remedies often used ; but while they generally quiet pain, their application is so dangerous to the integrity of the drum membrane, especially if they be used for many hours in succession, that the practi- tioner will do well to avoid them, unless other means cannot be employed, or when the latter prove ineffectual. In some cases, however, the urgency of the pain will demand that poultices be employed. The chief thing to be done in this disease is to decrease the heat, swelling, and vascularity of the parts. Applications of a stimulating nature, made to the membrana tympani, certainly cannot do this ; and mere emollients, such as sweet-oil, have a very transitory effect. I would place locai blood-letting as the chief and first remedy in acute aural catarrh. This blood-letting should be performed by means of leeches applied to the tragus, and not to the mastoid process. Wilde, and Yon Troltsch, have taught the profession that this is the best point for the application of leeches in inflammation of the ears; and the reasons therefor. At this point, the blood is most easily drawn from the cavity of the tympanum — the vessels supplying it, and the drum membrane, inosculating here. The application of from one to six leeches, according to the severity of the disease and TREATMENT OF ACUTE CATAEEH. 245 the age of the patient, will usually be sufficient to quiet the most severe pain in the ear, and to check the
Key Takeaways
- Acute catarrhal inflammation of the middle ear is a common condition that can be mistaken for other ailments.
- The symptoms include pain, fullness in the ear, and sometimes fever.
- Treatment should focus on reducing heat, swelling, and vascularity using antiphlogistic methods like leeches applied to the tragus.
Practical Tips
- Use warm water instillations as a first aid measure for children with ear pain before consulting a doctor.
- Be cautious of practitioners who suggest waiting for suppuration before treating acute catarrhal inflammation.
- Protect the body from cold and dampness to prevent middle ear infections.
Warnings & Risks
- Avoid using stimulating applications or poultices on the ear, as they can be harmful to the drum membrane.
- Do not ignore persistent symptoms of ear pain; seek medical attention if necessary.
- Be wary of self-diagnosis and treatment for ear pain, especially in children.
Modern Application
While many of the treatments described here are outdated, understanding the nature of acute catarrhal inflammation can help modern readers recognize the signs early. The use of antiphlogistic methods like leeches is not recommended today due to hygiene concerns and the availability of more effective medications.
Frequently Asked Questions
Q: What are some common causes of acute catarrhal inflammation of the middle ear?
Common causes include exposure to cold, getting feet wet, drafts from windows or cars, and infections like smallpox or measles that affect the pharynx. Cold water entering the ear can also cause it.
Q: How can I relieve pain from acute catarrhal inflammation of the middle ear at home?
For children, instilling warm water into the ear canal can provide temporary relief. For adults, over-the-counter pain relievers and keeping the body warm may help manage symptoms until a doctor can be consulted.
Q: Why is it important to avoid using stimulating applications on the ear?
Stimulating applications like Harlem oil or ether can be harmful as they increase vascularity and swelling, which can worsen the condition. They should only be used if other methods are ineffective.