Complete Text (Part 18)

mastoid cells may be present. The membrana tympani is sometimes found adherent to the walls of the labyrinth, and atrophy and fatty degeneration of the ten- sor tympani may exist. What are the causes? Various diseases may give rise to it, such as syphilis, bronchitis, measles, scarlet fever, etc., and the inflammations of the nasopharyn- geal mucous membrane. Repeated attacks of acute inflammation may also occasion it. What are the symptoms ? The patient will complain of a feeling of stuffiness in the ear, and of noises in the ear, which may be of a varied character, such as the roar- ing of the sea,_ the chirping of birds, or musical sounds. He also may complain of his throat. The hearing is impaired, the patient hearing better in a noise. On testing with the tuning-fork bone-conduction is 144 THE EAR. found better than aerial. On examination with the speculum opacities of the membrane may be seen, and the light spot will be found altered or absent. The membrane will be found rigid and retracted. To test the mobility of the membrane we make use of Siegle's otoscope, with a syringe attachment for exhausting the air. The Eustachian tube is often affected, it being impossible sometimes to drive air through the tube. The naso-pharynx is usually also affected. In the proliferous form of inflammation there are no changes in the naso-pharyngeal region ; there is no catarrh of the tympanum ; the drumhead is more sunken, and the tinnitus aurium more pronounced. In some cases the hearing is better on clear, dry days, and worse on wet ones. In what does the treatment consist ? The treatment is not altogether satisfactory. Constitutional treatment is requisite, such as the administration of tonics. Regulation of the diet and hygienic treatment are of importance. Care of the skin by means of daily bathing and rubbing, as also proper clothing. In catar- rhal cases the treatment of the naso-pharyngeal spaces is requisite. Excessive secretions should be removed by means of Dobell's solution or other cleansing solutions. Hypertrophies should be removed or cau- terized, as also enlarged tonsils and adenoid vegetations. The treatment of the Eustachian tube and tympanum by inflation is of great importance. For this purpose we make use of the Eustachian catheter and Politzer's method. This inflation should be carried out daily if possible. Mild astringent solutions in catarrhal cases, forced into the tube by means of the air-bag, are sometimes found serviceable. For dilating strictures in the Eustachian tube bougies are recommended by some authors. Exhaustion of the air in the auditory canal by means of a plug of cotton is useful in lessening the retraction of the drum. Tin- nitus aurium is often relieved by this method. What are the pathological changes which occur in acute puru- lent inflammation of the middle ear ? There is hyperemia of the mucous membrane, cellular and serous in- filtration of the connective tissue, and exudation of pus into the tympanic cavity. The mucous membrane appears red and swollen. Perforation of the drum occurs in the greater number of cases. The mucous mem- brane of the tympanum, Eustachian tube, and mastoid cells is usually affected by these changes. What are the causes of this disease ? It may occur as the result of cold, as the result of traumatism, or from an extension of inflammation from the naso-pharynx. It may occur in the course of various diseases, such as measles, small- pox, scarlet fever, diphtheria, etc. What are the symptoms? Pain which may shoot over side of head : it is usually most severe at DISEASES OF THE MIDDLE EAR. 145 night, and is lancinating in character ; noises in the ear, such as hissing, roaring, etc. ; a feeling of fulness in the ear ; fever may be present or absent, the thermometer often showing a temperature of 100°-103° F. Deafness is present, and increases as the tympanic cavity becomes filled with pus. The pressure from secretion may press the secondary mem- branes inward, thereby paralyzing the auditory nerve. To test whether the conducting power or the nerve is affected, the tuning-fork will aid in the diagnosis. When placed on the forehead it will best be heard in the affected ear if the conducting apparatus be alone at fault, and in the unaffected ear if the nerve portion be affected. On examination with the mirror and speculum the membrane appears at first slightly injected. This, however, increases to a general redness, and the membrane loses its transparency. The position of the mem- brane may be altered. It may be flat throughout its whole extent, or, if there be considerable exudation, it will bulge forward in certain por- tions. Its mobility is destroyed. Very often on auscultation, if the Eustachian tube be open, we can hear moist bubbling rales. Perforation takes place in the majority of cases, and is followed by almost instant relief, the pain ceasing and the sense of fulness disap- pearing. The secretion then pours out, and is very profuse at first. It gradually ceases and the perforation heals. What is the duration of the disease ? It is variable : four weeks where the perforation is small ; where the perforation is large it may last three or four months. By what causes may the disease be prolonged? By a low state of the general system from other diseases. Inflamma- tion of the mastoid may be present and keep up the tjTnipanic inflam- mation. Otitis externa may develop secondarily and keep up tympanic congestion, also interfere with drainage, and thus prolong the disease. Granulations sometimes develop in the course of this disease, and serve to keep up the trouble ; hence they should be early recognized and prop- erly treated. Ulceration may occur, often destroying a portion or even the whole of the membrane. Meningitis is apt to occur, though it is a rare complication. For what diseases are we apt to mistake it? In the earlier stages for catarrhal inflammation. The most common form of error is, however, in considering the disease in the early period as a neuralgia. The congestion, swelling, etc. point, however, to inflam- mation of the tympanum. Perforation is present, which can be detected by the eye or by inflation. What is the prognosis ? In healthy persons usually favorable with proper treatment. Where there are present general diseases, the prognosis is not so favorable. If the perforations occur early the prognosis, as a rule, is good. 10— Eye. 146 THE EAR. What is the treatment? In the early stages local applications for the relief of pain. Dry heat, applied by having the patient rest his head on a bag of hot salt or bran, is often soothing. Politzer recommends a piece of linen folded several times, dipped in tepid water, applied over the ear and covered first with oiled silk and then with a dry silk handkerchief. This is to be changed several times a day. The patient should be kept in the house or in bed if there be febrile disturbance present. When there is bulging of the membrane and perforation has not taken place, paracentesis is indicated. This is usually seen in the posterior lower quadrant. The tympanic cavity should be cleaned of the secretion by inflation, either by Politzer's method or by catheterization. The meatus should then be syringed with warm water and dried with absorbent cotton. This should be followed by the insufflation of boric acid, which acts as an antiseptic. If the dis- charge continues, we must then resort to astringents, such as zinc sul- phate, 1 : 300, etc. A few drops of an astringent solution is poured into the meatus, allowing the patient to retain it for about ten minutes. This can be done daily, or even twice daily if necessary. If granulations de- velop, these should be touched with nitrate of silver by fusing a little on a probe and then making the application. Should otitis externa arise during the course of the disease, it should also receive treatment by antiseptics and fomentations. Should the walls of the meatus be swollen to such a degree as to prevent the free discharge of pus, a tube should be passed beyond the swelling and the ear then syringed. The mastoid tenderness requires no direct treatment. If it becomes decided, however, active measures must be resorted to. What are the causes of chronic purulent inflammation of the tympanum ? It may develop from an acute inflammation or primarily. Rarely it is developed secondarily to an inflammation of the meatus. Scarlet fever and tuberculosis are the most common causes, then typhoid, variola, measles, etc. Give the pathology of this disease. There are two distinct pathological conditions in this disease, the one a swelling and hypertrophy, the other a thinning of the mucous membrane and submucous tissues. The thickening consists in an infil- tration : this is followed by the development of connective tissue, which may take place either in the submucous tissue or over the free surface of the mucous membrane. In the condition accompanied by thinning the normally existing tissue disappears and is not reproduced. The newly- developed inflammatory products do not become organized, but are thrown off in the discharge. DISEASES OF THE MIDDLE EAE. 147 What are the symptoms of chronic purulent inflammation ? There is discharge, which may be purulent, mucopurulent, and some- times tinged with blood. It may be profuse or slight, and sometimes dries up in the meatus. Deafness is present, which may be extreme or moderate, depending on various conditions, such as the hypertrophy of the membrane, the loss of tissue, and the amount and position of the secretion. Noises in the head are not common symptoms, but pa- tients may complain of weight in the head, with mental depression or an obstinate headache. On inspection the appearances vary much. When there has been profuse suppuration the epidermis often appears white and ulcerated. There may be stenosis, or we may find granulations on the walls of the canal. Exostoses are occasionally found in the bony meatus. Perforations are found in all parts of the drum-membrane. They are very frequently found in the anterior lower quadrant, some- times a number of perforations, and they may vary in size from a pin's point to complete destruction of the membrane. In shape they are oval and elliptical. In severe forms of the disease the ossicles may be found absent, due to ulceration of their ligamentous attachments. The cavity of the tympanum is then exposed to view, and we can make out the pro- montory, the openings of the fenestra rotunda and fenestra ovalis. Provided we have carefully cleansed the auditory canal, perforations are, as a rule, easily recognized. Valsalva's or Politzer's method will give the perforation whistle, which is a sure indication that a perforation is present. The appearances of the mucous membrane vary. It may be oedematous, dark red, pink, smooth, or granular. Is one apt to make a mistake in diagnosing a perforation? Yes. An inexperienced eye may often mistake a cicatrix for a perfora- tion, especially where the cicatricial tissue is so thin as to escape detec- tion. Auscultation will give us the whistling character of a perfora- tion. In testing the hearing what degree of deafness is found ? Deafness accompanies every _ case, but varies. If the perforation is small, if there is but little swelling or thickening to diminish the mobility of the membrane and ossicles, if the stapes is freely movable in its membrane, and if the nerve-structures are intact, the loss of functional power is but slight. If the conducting mechanism is covered with swollen tissue, deafness is present to a marked degree. Where the drum-mem- brane is destroyed the amount of deafness depends upon the condition of the stapes, provided the nervous parts are intact, A fair degree of hearing is present if the stapes remains in good condition. Total deaf- ness is found only where the labyrinthine structures are affected. The tuning-fork, placed on the forehead, is usually heard loudest in the affected ear. 148 THE EAR. What is the course of chronic purulent inflammation of the middle ear? It depends chiefly on the local changes in the ear, on the condition of the naso-pharynx, and on the general health. For description, cases can be divided into three classes : The first class is where there is merely simple suppuration present. In these cases the suppuration may cease of itself ; in tuberculous patients the discharge may continue indefinitely or even last through the whole course of life. The second class of cases is where there is granular suppuration of the mucous membrane. This runs nearly the same course as the preceding, except that it is more tedious. The third class is where there are complications present. These may be retained secretions, polypi, caries and necrosis, mastoid disease, and disease of the labyrinth. These must first be got rid of before any cure can re- sult. By appropriate treatment one should endeavor to reduce the case to one of simple inflammation. Having done this, the further course of the disease depends upon the nature of the perforation. Where condi- tions are favorable a cicatrix forms, and hence a cure. What is the prognosis of chronic purulent inflammation ? This depends upon its nature, whether it be simple or complicated. If simple and the naso-pharynx is properly attended to, as well as the general health, the inflammation can generally be reduced and the dis- charge checked. If the perforation closes, a cure can generally be said to be effected. Where there is granular suppuration the prognosis is not so good. In tubercular cases it is usually very difficult to check. In complicated cases the prognosis depends to a great extent upon the nature of the complications and our ability to get rid of them. The prognosis as regards the restoration of hearing-power depends upon the condition in which the parts are left after the inflammation has sub- sided. The prognosis as regards life is favorable, so long as none of the fatal complications make their appearance. These are meningitis, phlebitis, thrombosis of the sinuses, and pyaemia. What is the treatment? The first step consists in cleaning of the cavity. This is effected by means of the syringe or douche ; the fluid should be warm. Antiseptic solutions, such as carbolic acid, boric acid, etc., are useful. Where the drum-membrane is wholly destroyed, syringing is often ineffectual in removing completely the masses of secretion. _ Inflation by means of Valsalva's and Politzer's method or cauterization is of service in help- ing to remove the secretions from the deeper portions of the meatus. Suction by means of Siegle's speculum has been recommended. This instrument sometimes produces congestion. There are some cases in which it is found necessary to pass the point of a syringe into the DISEASES OF THE MIDDLE EAR. 149 tympanum to remove the secretion. This can be done by attaching a small canula to a syringe and passing the end within the perforation. Politzer has found syringing through the Eustachian tube sometimes useful. The largest-sized catheter should be used, and a sjTinge attached to its end. Where there is swelling of the Eustachian tube the small elastic catheter can be passed through the Eustachian catheter into the tympanum, and the tympanum thus syringed. This method is not wholly devoid of danger, and great caution should be exercised in its use. After syringing the ear it should be thoroughly dried with absorbent cotton. Local medication should then be adopted in the form of powder, liquids, or medicated cotton for the purpose of checking the secretion. Boric acid in simple cases, applied by means of an insufflator, is often found useful. Loewenberg recommends the use of alcohol. It diminishes the congestion^ reduces the cedema, and tends to reduce the thickened membrane. It is applied by instillation with equal parts of water, the patient being allowed to retain it from five to fifteen minutes. Schwartze recommends the cauterization of the diseased membrane by nitrate of silver. This can be applied in solution by instillation or by painting. Dry treatment, advocated by some, consists in cleansing without the use of fluids, and then applying a plug of medicated cotton. How would we treat granular suppuration? By the use of caustics or alcohol. Alcohol has the power of shrivel- ling up the granulations. The nitrate of silver, applied by means of a probe, is very effective. The use of the galvano-cautery requires great caution. Where the granulations are isolated a wire snare or a sharp curette can be used. Where the perforation is so small as to prevent the secretion from making its escape, or where granulations prevent its escape, what it is sometimes necessary to do ? Enlarge the perforation or establish a second _ perforation. This is done by means of the paracentesis needle, as previously described. What other adjuncts of treatment are necessary ? If the Eustachian tube be involved, it should receive appropriate treat- ment. Inflammations of the naso-pharynx should receive attention. The general health should be looked after. Anaemia, by iron, tonics, etc. Where syphilis is present, mercury and iodide of potassium should be administered. Attention to the diet, clothing, etc. should also be given. How is the deafness treated ? By the use of remedies just described, by inflation, etc. In a certain number of cases where the perforation does not heal the use of an arti- ficial drum-membrane has been found serviceable. Many artificial mem- 150 THE EAR. branes have been devised, but a piece of absorbent cotton, made into the proper shape and size, will often answer the purpose. Its use is indi- cated where there exists extreme deafness of both ears. When dizzi- ness and irritation result, the artificial membrane should be discarded. Operations for the relief of deafness after suppuration has ceased have been devised by some authors. Their object is the