In others, however, the redness, tenderness, and swelling are entirely absent, while the pain referred to the depth of the ear will be the only marked symptom. This pain is not relieved by leeches, and anodynes will only veil the symptoms for a brief period. Usually, even in insidious cases, tenderness will show upon firm pressure on the part. Yet the surgeon may cut down upon a bone to find it diseased when previously unable to diagnose this state of things accurately. Any deep-seated pain referred to the mastoid or its region during an ear inflammation should be viewed with suspicion, even if there is no redness, tenderness, or swelling of the process itself.
The auditory canal often becomes involved in cases of caries of the mastoid. A fistulous opening sometimes leads from this part into the mastoid cells, where granulations are usually found in the canal. The presence of granulations should lead to a careful examination for a possible fistula. As seen in Case I., dead bone may be removed through the canal.
A clinical fact important in diagnosing mastoid disease is that chronic or acute suppurative processes in the middle ear can often be less violent, or entirely checked at the time of periostitis outbreak. Mastoid periostitis or caries can occur while a free discharge of pus is taking place from the ear.
Treatment involves dividing tissues over the mastoid process down to the bone if caries is suspected. If a fistula exists, it should be enlarged for pus exit. A stiff probe may suffice if the bone is very soft; otherwise, a small drill or trephine might be required. The operation should proceed slowly with frequent pauses.
Historically, Eiolanus in 1649 was the first to inquire into perforating the mastoid process for removing morbid secretions from the middle ear and mastoid cells. Jasser performed the first actual operation in 1776 on a soldier suffering from chronic ear suppuration and pain.
<Callout type="important" title="Critical Rule">The integument and periosteum should be freely divided over the mastoid if there is pain, tenderness, and swelling.</Callout>
Conditions under which the mastoid may be operated upon include severe pain not relieved by usual means, suspicion of caries with retained pus, long-standing suppuration with frequent painful exacerbations.
The operation has been performed successfully since 1859 by various surgeons including Follin, Schwartze, Pagenscecher, Hinton (London), Jacoby, Agnew (New York), Colles (Dublin).
Key Takeaways
- Deep-seated pain in the mastoid region during ear inflammation should be treated with suspicion.
- Granulations in the auditory canal may indicate a fistula leading to the mastoid cells.
- Mastoid periostitis or caries can occur even when there is free pus discharge from the ear.
Practical Tips
- Carefully examine for tenderness upon firm pressure on the mastoid process during diagnosis.
- Use a stiff probe if bone is very soft; otherwise, a small drill or trephine might be required.
- Operate slowly and make frequent pauses to assess depth of instrument.
Warnings & Risks
- Do not rely solely on leeches for pain relief in mastoid cases.
- Avoid performing the operation without proper indications as it can lead to complications like meningitis.
- Be cautious when using a trocar or other sharp instruments near sensitive areas.
Modern Application
While historical surgical techniques such as trephining have evolved, understanding the symptoms and diagnosis of mastoid disease remains crucial. Modern imaging technologies provide safer alternatives for detecting caries and fistulas, but knowledge of traditional methods can still be valuable in remote or resource-limited settings.
Frequently Asked Questions
Q: What are the typical signs of mastoid periostitis?
Typical signs include deep-seated pain referred to the depth of the ear and tenderness upon firm pressure on the part, even if there is no redness or swelling.
Q: How should a surgeon proceed when suspecting caries in the mastoid process?
The tissues over the mastoid process should be divided down to the bone. If a fistula exists, it should be enlarged for pus exit. A stiff probe or small drill may be used if the bone is soft.
Q: What historical figure first performed an actual operation on the mastoid?
Jasser performed the first actual operation in 1776 on a soldier suffering from chronic ear suppuration and pain.