CHAPTER XVII. THE CONSEQUENCES OF CHEONIC SUPPURATION OF THE MIDDLE EAR. If a chronic suppurative process in the middle ear remained a simple ulcer, it would be preferable to a chronic proliferous process in the same part. For in simple chronic ulceration the hearing power is often very good, tinnitus aurium is not usually excessive, and sometimes does not exist, and may generally be relieved by syringing and inflation of the ear. These are the symptoms which are so trying that people have become insane on account of them. But the almost inevitable consequences of chronic suppuration in the middle ear are dangerous to the health and life of the patient. Hence the importance of the subject, and the interest which every physician should take in arresting the advance of these sequelae of disease. It is in view of these effects of chronic suppuration of the middle ear that English life insurance companies decline to insure the lives of persons affected with the disease. Very few persons comparatively who suffer from chronic suppuration live out their days, while many die very young. On page 237 of this volume, these consequences are tabu- lated. It is now proposed to enter into a discussion of their nature and treatment. At the risk of reiteration, it should be again said that none of the results of chronic suppuration should ever be regarded as independent affections.
<Callout type="warning" title="Warning: Potential for Insanity">People suffering from chronic ear infections may become insane due to excessive tinnitus aurium.</Callout>
POLYPI. Celsus and Pliny used the term polypus for a tumor springing from any cavity of the body. The name was adopted under the old system of nomenclature, when an exact knowledge of the nature and structure of growths or parts was not regarded in giving them a name. It is an unfortunate one, for there is scarcely any resemblance between the many-footed aquatic animal after which morbid growths were called, and the exuberant granulations or tumors which arise from the cavity of the tympanum and the auditory canal. It is probably too late, or too early, to effect any change in the nomenclature, and we must be content with the name aural polypi for all the growths that occur in the ear, except for those of an osseous structure or a cancerous nature.
<Callout type="important" title="Important: Classification of Aural Polypi">Aural polypi are classified into four types: mucous polypi, fibromata, myxomata, and angioma.</Callout>
The mucous polypi are altogether the most frequent of those found in the ear. The fibromata, or polypi made up of denser connective tissue than the mucous growths, are next in frequency. Buck thinks that about one in ten of all the polypi that have been microscopically examined belong to the class of fibroma. Myxoma has been reported by Steudener only, so far as I have been able to find.
Nature of Aural Polypi. — In an article published in 1864, I attempted to show on clinical grounds that aural polypi were analogous in structure to exuberant granulations occurring as direct results of an ulcerative process. This view at once clears up the nature of these growths and takes away the fictitious importance which the view that regards them as independent tumors caused them to assume.
<Callout type="risk" title="Risk: Malignant Growth">Malignant growths such as epithelial carcinoma, fibrous and medullary carcinoma, cholesteatoma, and osteosarcoma can arise from chronic ear infections.</Callout>
Aural polypi are more rarely found by the physicians of today than by our predecessors for the simple reason that aural diseases are more carefully observed, and they have no such opportunities to occur as were enjoyed when a discharge of pus from the ear was not treated. MALIGNANT GROWTHS. The malignant growths that have as yet been found in the ear, and which may be mistaken for malignant polypi, are epithelial carcinoma, fibrous and medullary carcinoma.
<Callout type="tip" title="Tip: Treatment Begins with Removal">The treatment of an aural polypus should begin with its removal. However, it is often necessary to remove the growth several times due to rapid regrowth.</Callout>
Treatment. — The treatment of an aural polypus should begin with the removal of the growth. I have said begin with deliberation, because it is a mistake to suppose that the removal of the polypus will be any more than the beginning of the treatment of the disease of which the polypus is a symptom. Besides, aural polypi often spring up very rapidly, even after they have been thoroughly removed, and when they are simple growths; moreover, we are often obliged to remove them several times from the ear, especially where we cannot have full control of our patients and cause them to attend to the after-treatment.
Wilde's snare, as modified by Blake, will be found the best instrument for the removal of well-defined polypi with a pedi- cle. In Wilde's snare, the bar which carries the slide, and the arm which supports the wire used in cutting off the polypus, are in one piece. Dr. Blake has substituted a movable tube of German silver (d) for the fixed arm. "This tube expands at the outer ends into a flattened head (/), having two open- ings for the passage of the wire; the inner end of the tube fits AURAL POLYPI — TREATMENT. 395 into a broad band on the slide-bar (&). The ends of the wire passing down the tube are fastened to a pin on the upper part of the slide (c), below which is a ring, by which traction can be made." The instrument is better than Wilde's, because it can be turned in any direction without injuring the walls of the canal. A paracentesis needle may also be used in the han- dle, but it should be rather longer than the one in the cut. <Callout type="gear" title="Gear: Instruments for Removal">Wilde's snare and modified Blake's scissors are recommended instruments for removing aural polypi.</Callout>
Scissors may sometimes be used with advantage to remove aural polypi. I have found those that are here represented very convenient, especially for the removal of growths from the walls of the auditory canal. Scissors for the Eemoval of Aural Polypi. Forceps may sometimes be employed, although I prefer the snare and scissors to all other mechanical means for removing polypi or granulations. Forceps, unless used with great gen- tleness and care, may wrench more than the morbid growth from the cavity of the tympanum, and thus do great harm. Very small pedunculated growths, such as was found in the case recorded on page 385, may be often removed by the simple angular-toothed forceps, figured on page 80 of this work. True exuberant granulations, having no pedicle, but arising from a broad surface, usually resist treatment with great obstinacy, because they are difficult to reach and entirely remove with instruments, and because they usually cover carious or necrosed bone. Caustics are perhaps the only means of removing such growths. The agents I usually em- ploy for such cases are strong solutions of nitrate of silver — from 40 to 480 grains to the ounce — and fuming nitric acid.
The nitrate of silver may be poured in upon the part, and then neutralized by the subsequent instillation of a solution of common salt. Hintori's Forceps. Dr. O. D. Pomeroy* reports a case of "the removal of a polypoid granulation of ten years standing, by four applica- tions of a forty-grain solution of nitrate of silver." A pipette was used to drop the nitrate of silver upon the growth.
Although it is evident from the history, that the disease which allowed the formation of the polypus — a chronic suppuration from scarlet fever — had existed for ten years, it does not cer- tainly appear that the polypus had been in the ear so long. The polypus is said to have sprung from the membrana tym- pani, which was perforate, however.
I am in the habit of treating granulations that arise from the cavity of the tympanum, where it is somewhat dangerous to use forceps, scissors, or snare, by numerous punctures with a cataract needle. The puncturing causes considerable hem- orrhage. After the blood is wiped away, a caustic should be applied.
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Key Takeaways
- Chronic suppurative middle ear disease can lead to dangerous health consequences and may result in early death.
- Aural polypi are often the result of chronic ulcerative processes and should be treated promptly.
- Malignant growths such as epithelial carcinoma, fibrous and medullary carcinoma, cholesteatoma, and osteosarcoma can arise from chronic ear infections.
Practical Tips
- Regularly check for signs of chronic ear infections, especially in children who may have had scarlet fever.
- Seek medical attention immediately if you notice persistent discharge or hearing loss in one ear.
- Follow up with a healthcare provider after removal of polyps to ensure the infection is fully treated.
Warnings & Risks
- Chronic ear infections can lead to severe complications, including insanity due to excessive tinnitus aurium.
- Malignant growths such as cholesteatoma and osteosarcoma can arise from chronic ear infections and may be life-threatening.
- Improper removal of polyps using forceps or scissors can cause significant harm.
Modern Application
While the techniques for treating chronic suppurative middle ear disease have advanced, understanding its potential consequences remains crucial. Modern medical practices focus on early diagnosis and treatment to prevent complications such as hearing loss and the development of malignant growths.
Frequently Asked Questions
Q: What are the main health risks associated with chronic ear infections?
Chronic ear infections can lead to severe health issues, including tinnitus aurium that may drive people insane, and the potential for developing dangerous malignant growths such as epithelial carcinoma or cholesteatoma.
Q: How are aural polypi classified?
Aural polypi are classified into four types: mucous polypi, fibromata, myxomata, and angioma. Each type has distinct characteristics based on the structure of the growths in the ear.
Q: What is the recommended treatment for aural polypi?
The treatment begins with the removal of the polypus, but it often needs to be repeated due to rapid regrowth. Instruments like Wilde's snare or modified Blake's scissors are recommended for this purpose.