Complete Text (Part 17)

light, which may be either direct ot reflected. Daylight or arti- ficial light may be used. In using artificial light the argand gas-burner serves the purpose as well as any. To reflect the light a hand (Fig. 49) or head mirror is necessary. In using the head mirror one with a ball-and-socket joint is the best. Next, a speculum is required. Vari- ous specula have been recommended, but perhaps the best are those Fig. 50. Gruber's Aural Specula. used by Gruber and Chilcle (Fig. 50). For determining the mobility of the membrana tympani an otoscope has been devised by Siegle (Fig. 51). Fig. 51. Siegle's Pneumatic Otoscope. 134 THE EAR. The other instruments requisite are a curette for removing scabs, etc. ; a cotton-holder for drying, cleansing, and making applications ; a forceps Fig. 52. Delicate Forceps for removing Foreign Bodies from the Ear, for removing foreign bodies (Fig. 52) ; a syringe, which can also be used for the same purpose, as well as for cleansing the canal. What methods are employed to introduce air into the middle ear ? There are three methods: I. Valsalva's method; II. Politzer's method ; III. Catheterization of the Eustachian tube. Describe Valsalva's method. This consists in a forced expiration, the mouth and nasal passages being closed. The air is forced up by this means through the Eustachian tube into the middle ear. By means of an otoscope placed in the ear of the patient and the ear of the physician a slight noise is heard as the air passes against the drum -membrane. Describe Politzer's method. In using this method the patient is directed to take a mouthful of water and hold it until the physician tells him to swallow. The phy- sician then places the nozzle of a Politzer air-bag in one of the nostrils and holds the nose firmly pressed over it. He then directs the patient to swallow, at the same time compressing the air-bag. In the act of swallowing the soft palate is elevated. The air passes up through the Eustachian tubes into the middle ear, having no other means of escape. Describe catheterization. There are various methods of catheterizing the Eustachian tube. The EXAMINATION OF THE PATIENT. 135 Fig. 53. .4 t^m? b *^m? cx Eustachian Catheters of Hard Rubber (three sizes,. A, B, and C) : :B, hard-rifbbei ^ount of the air-bag, made to fit accurately into the large end of all catheters on the principle of the ground joint. 136 THE EAR. one chiefly used is as follows : The physician takes a middle-sized catheter (Fig. 53) and introduces it into the nose with the curved portion down- ward. He then passes it along the floor of the nose as far back as the posterior pharyngeal wall. The curved portion is then turned inward at an angle of 45°, and brought forward till it is felt touching the septum. The curved portion is then made to describe an angle of 90°, when the Inner View of the Right Half of the Head (antero-posterior section) (Gruber): o, supe- rior turbinated bone; m, middle turbinated bone: u, inferior turbinated bone; R, Rosenin idler's fossa, bounded in front by the cartilaginous lip of the tube; in front of the latter is the pharyngeal opening of the Eustachian tube, in which the catheter k is placed. mouth of the catheter, provided there be no obstruction present, will slip into the opening of the tube. A ring is usually attached to the DISEASES AND AFFECTIONS OF THE AURICLE. 137 proximal end of the catheter, so that the physician can keep himself in- formed as to the direction the curved portion takes (Fig. 54). DISEASES AND AFFECTIONS OF THE AURICLE. What are the symptoms of eczema of the auricle ? Redness and swelling of skin, followed by vesicular eruption, loss of epithelium, and serous oozing ; also itching and burning. These are the symptoms of acute eczema. In the chronic form there is thickening of skin, with formation of crusts and exudation of pus. Give the etiology. It is apt to occur in infants during dentition, due to nerve-irritation. It may appear during adolescence, when skin diseases are most preva- lent. We are apt to find the chronic form in old people, due, likely, to lack of nerve-force in branches supplied to the auricle. Give the treatment of eczema. In the acute form some powder to relieve the itching and burning, or the oxide-of-zinc ointment may also be used. In the chronic form stimulating application s_ or a preparation of tar is advisable. Crusts are best removed by olive oil. Regulation of the diet is a necessary adjunct of treatment. Tonics are also of service, such as iron, cod-liver oil, etc. HEMATOMA AURIS OR OTHEMATOMA. What is hsematoma auris? Hgematoma auris is a swelling of the auricle in which there is an effu- sion of blood between the cartilage of the auricle and the perichondrium. It often occurs in the insane, and is traumatic or idiopathic in its origin. There are swelling, fluctuation, and some pain in the growth. What is the treatment? It consists in the alleviation of pain and the prevention of subsequent deformity. Some recommend the incision of the swelling. Gruber uses a trocar where the blood is fluid ; if it is coagulated he makes an incision and removes the clot. Tincture of iodine is recommended for the thickening. Others recommend the use of cold or warm applica- tions. What are the new growths which have been observed affecting the auricle? I. Fibroid tumors. _ These are usually the result of piercing the lobule or are due to irritation from wearing an earring. The treatment consists in their removal. They are liable to recur. II. Epithelioma of the auricle has been observed. Removal of the growth is the form of treatment to be adopted. 138 THE EAR. What are other affections of the auricle ? Syphilitic gummata and syphilitic ulcerations. Treatment is the same as_ syphilis occurring elsewhere. Herpes zoster of the auricle is rare. Cleft lobule may occur as the result of wearing earrings. Frost-bite, due to extreme cold. Treatment consists in rubbing with snow and application of cold. Congenital malformation has been observed, as also congenital fistula. DISEASES AND AFFECTIONS OF THE EX- TERNAL AUDITORY CANAL. Give symptoms and diagnosis of impacted cerumen. Deafness, buzzing in the ear, and vertigo. The diagnosis is made by means of the speculum, which reveals a dark-colored mass lying in the canal. It may be hard or soft in consist- ency, according to the length of time it has been there. Give the etiology. An increased secretion may give rise to it, as also disease of the mid- dle ear. Catarrh of the nose and pharynx is often found associated with it. What is the treatment? If the mass be soft, syringing with warm water will usually suffice to remove it. If it be hard and does not come away, softening by filling the canal with olive oil or warm water, followed by syringing, should be re- sorted to. The forceps and curette can also be used, care being taken not to injure the tympanic membrane. What foreign bodies are found in the external auditory canal? Give the symptoms and treatment. I. Insects, such as the ordinary fly or grub. Their movements cause great pain, and they are best removed by means of the syringe. II. Vegetable parasites. The aspergillus nigricans and aspergillus flavescens are the parasites most usually found. They give rise to itch- ing, pain, dizziness, and difficulty of hearing. On examination they appear as yellowish or black spots. The disease may be acute or chronic (Figs. 55, 56). The treatment consists in first removing the parasite, which can be effected by the use of the syringe and warm water. Then fill the canal with alcohol and dry with cotton. By adopting this procedure every second or third day the growth is usually destroyed. Buck recommends nitrate of silver, 60-120 grs.-Sj. Other foreign bodies, such as beads, buttons, etc. , are sometimes found in the external auditory canal. These may give rise to deafness, buzz- DISEASES OF THE EXTERNAL AUDITORY CANAL. 139 ing, and dizziness. By means of the mirror and speculum they are easily recognized. They are best removed by syringe and warm water. Fig. 55. Fig. 56. Aspergillus. Spores. Should this means fail, then the blunt hook or forceps may be used, but with caution. INFLAMMATIONS. How does diffuse inflammation of the external auditory canal show itself? As acute, chronic, primary, or consecutive. The latter form occurs usually in connection with middle-ear disease, and is secondary to that disease. As a primary disease it is due to traumatic or mechanical causes or to the presence of irritating substances. What are the symptoms? Pain, moderate or severe, intensified by pressure on the ear and by movements of the jaw ; itching and tinnitus may also be present. On examination the canal presents a whitish appearance, due to the exfoli- ation of epithelium. After this is removed by means of the syringe and warm water, the canal appears reddened and narrow, and is painful when touched with a probe. In the chronic form there is but slight pain, some discharge, and a feeling of itchiness. What is the prognosis? The prognosis, if the disease remain uncomplicated, is favorable, the inflammation subsiding in the course of a few days. What is the treatment of diffuse inflammation of the auditory canal ? Leeches may be applied in front of the tragus. Syringing with warm 140 THE EAR. water and scarification in the early stages are very benefieial. The gela- tin preparations of morphine and opium used by Gruber give relief. Poultices may also be used. In the chronic form cleansing of the canal by means of warm water and insufflations of boric acid are recommended. Solutions of nitrate of silver are sometimes useful. The application of diachylon ointment on a plug of cotton is recommended by Buck and Pease. What are the causes of circumscribed inflammation of the exter- nal auditory meatus— viz. furuncles and boils ? Discharges from the ears and irritation from foreign bodies. It usually attacks adults, and occurs in the spring and autumn. Anaemic and de- bilitated subjects are apt to be affected. It occurs also in women suffer- ing from menstrual disorders. What are the symptoms? Pain, which may be severe or moderate, and which may extend up the side of the head, and may be intensified by pressure on the auricle and by movements of the jaw. Deafness may be complained of, as also buzzing. There may be one or several furuncles. They usually attack the cartilaginous portion of the canal. On examination swelling and redness may be noticed, which increase until rupture ensues. The pa- tient may also have febrile disturbances. What is the treatment? Incisions through the swollen and painful portions. For this purpose the use of an anaesthetic or the instillation of a solution of cocaine is necessary. After the incision has been made syringing of the canal should be done. Poultices are beneficial, as also are warm instillations and anodynes. Painting the canal with carbolic acid in glycerin (1 : 30) has been recommended, or boric acid in alcohol. Attention to the gen- eral health, diet, etc. is necessary. What is diphtheritic otitis externa? An inflammation of the walls of the meatus, with the formation of a false membrane of a whitish color. It is of rare occurrence, and then usually as a complication of diphtheritis of the throat and middle ear. Primary diphtheritis has been observed during epidemics of diphtheria. What are the symptoms? In the primary form there are deafness, buzzing, and a sense of ful- ness in the ear. When it is secondary to diphtheria of the throat and middle ear, the pain is but slight or entirely absent. On examination there is seen a false membrane, which when removed leaves a bleeding and tender surface. The primary form usually ends in recovery, whilst the secondary may be followed by ulceration of the membrana tympani, destruction of the ossicles, and caries of the temporal bone. DISEASES OF THE MIDDLE EAR. 141 What is the treatment ? The treatment consists in the use of antiseptics. The membrane should not be forcibly removed, j Instillations of lime-water, followed by syringing: with a solution of boric acid, help to loosen the membrane. The surface may be brushed over with a solution of carbolic acid in glycerin or boric acid in alcohol. Describe exostoses and hyperostoses of the external auditory- canal. Exostoses and hyperostoses are usually situated at the outer portion of the osseous meatus or on the inner portion near the membrana tym- pani. They may be single or multiple, and have either a pedicle or broad base. They are congenital or acquired. They do not cause dis- turbances of hearing unless they block the lumen of the meatus. On examination they appear as whitish prominences, and on probing are found to be firm and hard. What is the treatment ? Cleansing of the canal beyond the growth, especially if there be sup- purative middle-ear disease. Tf they cause a stricture, dilatation may be resorted to by means of metal plugs. When the canal is narrow and deafness is present, as well as pain, removal of the growth often becomes necessary. This may be effected by the gouge or mallet or the dentist's drill, which is preferable. The galvano-cautery may also be used. Ope- rative interference is rarely required. What other affections of the meatus occur sometimes ? I. Syphilis may affect the meatus, showing itself in the forms of ulcer- ation and condylomata. The treatment consists in local and constitutional measures. II. The meatus may be the seat of enchondroma, osteoma, sarcoma, and epithelioma. III. The meatus may occasionally be found absent as a result of ulcer- ative inflammation of the walls, and a subsequent union of the walls by means of granulation-tissue. The atresia may be osseous or fibrous. The treatment consists in the division or excision of the septum and dilatation by means of leaden pegs. DISEASES AND AFFECTIONS OF THE MIDDLE EAR OR TYMPANUM. What are the causes of middle-ear disease ? Changes of temperature, exposure to cold air, bathing where the ear becomes filled with cold water, and foreign bodies causing irritation. Disease of the middle ear may also occur as a sequel to other diseases, such as- scarlet fever, measles, diphtheria, typhoid fever, etc. Nasal catarrh and adenoid vegetations are also frequent causes. 142 THE EAR. What are the symptoms of acute catarrh of the middle ear ? Pain, which is intensified by the movements of the jaw or any mus- cular exertion or pressure over the tragus, noises in the ear, deafness, and dizziness. On examination slight redness of the membrane is noticeable, which increases as the inflammation spreads. If consider- able exudation be present, there is bulging. In what does treatment consist? Application of leeches to the tragus, filling the canal with warm water, and hot applications will relieve the pain and bulging. Paracentesis : the incision should be made downward between the handle of the ham- mer and the periphery of the membrane in the lower posterior quadrant (Fig. 57). If the pharynx or nose be affected, it should also receive Fig. 57. Paracentesis Knife. treatment. To remove abnormal secretions inflation of the tympanic cavity should be resorted to by means of Politzer's method, which has been already described. What are the symptoms of subacute catarrh ? Pain, which may be present in some cases, but which when present is not so severe as in the acute inflammation. This non-severity of the pain is one of the distinguishing points between this form of the inflam- mation and the acute. The patient is hard of hearing, but this is merely temporary; the attacks occur frequently. On examination the trans- parency of the membrane is seen to be lost, and it is sometimes vascular. The light spot, which is triangular in shape with its apex at the extrem- ity of the handle of the malleus, is found absent or smaller than is usual. Hearing is impaired, and with the tuning-fork bone-conduction is better than the aerial. What are the causes? Bad nutrition, prolonged bathing, and diseases of the nasopharyn- geal membrane extending to the middle ear. It is most apt to occur in children. DISEASES OF THE MIDDLE EAE. 143 In what does the treatment consist? Look after the hygienic condition of the patient ; tonics, regulation of diet; inflation of the tympanum by means of Politzer's method; removal of enlarged tonsils or adenoids, and treatment of the naso- pharyngeal mucous membrane by means of astringents ; cleansing of the nose by Dobell's solution when necessary. Describe hemorrhagic inflammation of the middle ear ? It is a rare disease, and is characterized by severe pain, which lasts but a few hours and is followed by hemorrhage through the membrana tympani. It is a severe form of acute inflammation. Hemorrhage into the membrana tympani has been observed after the use of the nasal douche ; it is also due to traumatism. What is the treatment? Cleanse the auditory canal from blood if perforation has already occurred. If it has not occurred, leeches should be applied. These sometimes abort the disease. Pus does not usually form, and the blood is gradually removed. Into how many forms is chronic non-suppurative inflammation of the middle ear divided ? It may be divided into two forms: (1) the catarrhal and (2) the pro- liferous. What are the pathological changes which may occur? There may be collections of mucus or serum in the tympanic cavity, with hypertrophy of the mucous membrane and filling of the cavity with lymph. In the proliferous form, or where both are combined, there may be formation of connective tissue, filling up the tympanum. Anky- loses of the ossicles and adhesive bands in the