Complete Text (Part 19)

separation of adhesions in the conducting mechanism. Their value and indications are as yet not fully established. How are caries and necrosis produced? By the extension of the inflammation of the mucous membrane of the tympanum to the deeper layers, and thence to the bone itself. Caries and necrosis may attack any portion of the temporal bone, the most frequent points of attack being the mastoid and the meatus. What are the symptoms of caries and necrosis ? When the caries is circumscribed there are scarcely any symptoms present. If extensive, we have pain in the ear. If caries attacks the mastoid, antrum, or the anterior portion of the mastoid cells, there are swelling and infiltration of the skin in the upper and posterior portions of the meatus. At first it is firm and hard, but if pus forms it becomes soft and fluctuating. Caries of the tympanic roof presents no sjmiptoms by which it can be recognized except by exploration with the probe. Paralysis of the facial nerve is often a symptom of caries of the tym- panum. What is the course of caries ? It may progress slowly or a sequestrum may form rapidly. Portions of the bone may come away in the discharge after the diseased bone has been removed ; granulations may form on the walls of the cavity. These become changed into connective tissue, which ossifies, and then we have a hyperostosis in place of the normal bone. How is the diagnosis of caries and necrosis made ? It can only be made with surety by means of the probe. Where this fails a combination of symptoms may lead us to suspect caries. The probe should be used with caution. Pain recurring at intervals or per- sistent, with an offensive discharge, aids in making a diagnosis. What is the prognosis? The prognosis depends on the situation and the amount of surface in- volved. In healthy persons, where there is free exit for the discharge and sequestrum, prognosis is favorable. In tuberculous patients, where disease is not apt to limit itself, the prognosis must be guarded. In caries of the petrous bone, when extensive, the prognosis is doubtful, and when attacking the upper wall of the tympanum or antrum there CARIES AND NECROSIS. 151 is danger of disease of the membranes of the brain and sinuses, which of course makes the prognosis serious. What is the treatment? First, the removal of the diseased portions of bone. If the disease be where it can be reached, we can hasten the progress by removal of these diseased portions. This is done by means of a sharp curette, with which the bone is scraped. When the caries affects the promontory of the tympanum, only the most superficial scraping should be used ; when on the edges of the promontory or within the niches of the fenestra of the labyrinth, it should not be performed at all. The parts should be kept cleansed by carbolic syringing. After the softened bone has been scraped away insufflations of iodoform should be used. When there are exfolia- tions of bone, they should be removed, as also loose sequestra. The general treatment should also receive consideration. Pain should be relieved by opiates. Tonics when necessary. Iron is indicated in ansemia, and iodide of potassium in tuberculous cases. Regulation of diet. Bathing and clothing should receive attention. Describe polypi. They are connective-tissue new growths covered with epithelium. Po- litzer recognizes two varieties : (a) the round-celled polypi, and (b) the fibromata. Where do they usually have their origin? The majority originate from the tympanic cavity. They may also originate from the drum-membrane, from the tissue covering the ossicles, or from the walls of the meatus, usually the posterior superior wall of the osseous meatus. What are the symptoms of polypi ? When large enough to press upon important parts of the ear or to in- terfere with the discharge of pus, there may be present pain, dizziness, weight and fulness in the head, and symptoms pointing to the cerebrum. On examination the growth is seen, and the use of the probe makes the diagnosis certain. Give the diagnosis of polypi. Diagnosis is not always easy. Other tumors of the ear are rare. En- chondromata, warts, and encysted tumors must not be mistaken for polypi. Epithelioma begins like an eczema, followed by ulceration and pain. Sarcoma, _ in the early stages, can be mistaken for polypi. Microscopical examination will serve to clear up the diagnosis in both suspected epithe- lioma and sarcoma. In what does the treatment of polypi consist ? The treatment consists in their removal. This can be usually accom- 152 THE EAR. plished by Wilde's snare (Fig. 58). The loop of the snare is passed in and around the pedicle of the polypus, and the loop withdrawn, which Fig. 58. Wilde's Aural Polypus Snare. cuts off the polypus. The ear is then syringed out, and the base of the polypus cauterized with nitrate of silver. If the polypus be of large size, a second introduction of the snare may be necessary. If bleeding be excessive, it can be usually checked by means of a tampon. The application of cocaine makes the operation comparatively painless. Caustics are sometimes used for the destruction of polypi. It is a slower and more painful method. The use of alcohol by shrivelling up the polypus has also been found successful. Give the pathology of mastoid inflammation. The inflammation arises from an extension of the inflammation of the tympanum along the mucous membrane. When the tympanic inflam- mation subsides, this, as a rule, ceases also. Sometimes it extends through the foramina of the bone, thus setting up an external peri- ostitis. Through carious ulceration a fistula forms. Politzer states that in every post-mortem examination he made of suppuration of the middle ear he found the mastoid likewise affected. When the inflammation continued until death the mucous membrane showed signs of inflammation, and the cells were filled with purulent or muco-purulent fluid or granulation tissue. When the suppuration had ceased before death the mucous membrane of the mastoid was sometimes thickened, sometimes filled with connective-tissue growths or layers resem- bling epidermis. In some cases the cells were obliterated by sclerosis of the bone ; in others caries or necrosis was present. Hyperostosis of the mastoid may advance so far that the cancellated tissue is entirely oblit- erated, the mastoid being thus changed into a solid piece of bone. A mastoid inflammation may then exhibit all the phases of inflammation of bone — softening, caries, necrosis, and hyperostosis. In what directions may the mastoid inflammation extend itself? It may extend outward through the external cortex. Forward we may have a perforation into the meatus, with inflammation following. MASTOID INFLAMMATION. 153 Inward the lateral sinus may become involved, with phlebitis, thrombo- sis, emboli, and their consequences. Upward the .inflammation may extend, invading the middle fossa of the skull. An abscess may be produced beneath the dura mater, or abscess of the brain and meningitis may result. The inflammation may extend downward through a perfo- ration in the floor of the mastoid which opens into the digastric groove. Thus we can have suppuration in the deeper tissues of the neck. What are the symptoms of mastoid inflammation ? Pain in the mastoid region which shoots along the vertex, temple, and occiput. On deep pressure tenderness is found to be present. If the inflammation be acute, there is a certain amount of fever present. When the disease extends outward the tissues covering the bone become at first slightly swollen. Redness and heat then follow with increased oedema. As pus forms it can sometimes be detected by deep palpation. Swelling of the upper and posterior walls of the meatus is present in mastoid inflammation. Hyperostosis, when present in a slight degree, is difficult to recognize ; when extensive, it narrows the meatus by hyper- trophy of the osseous walls. When the inflammation extends forward what symptoms are present ? There is inflammation of the lining of the posterior wall of the mea- tus, with the formation of an abscess, which is followed after rupture by the formation of granulations. We then, as a rule, have carious per- foration, which can be diagnosed by means of a probe. When the inflammation extends downward what symptoms are present ? Swelling and tenderness below the point of the mastoid, accompanied with pain. The swelling is dense and hard and has defined edges. It mayextend down the sterno-cleido-mastoid muscle forward to the retro- maxillary fossa, and along the large vessels of the neck. It may also extend backward and downward over the whole side of the neck to be- neath the clavicle, or it may extend upward to the superior curved line of the occiput. Pain, as a rule, accompanies the swelling, and may also affect the occiput as the swelling extends backward. What is the differential diagnosis of secondary inflammation of the mastoid? It is likely to be mistaken for primary inflammation of the mastoid. It is doubtful, however, if primary inflammation of the mastoid ever occurs. Inflammation of the external meatus, when it is accompanied with swelling over the mastoid, is apt to be mistaken for a genuine inflamma- tion of the mastoid. 154 THE EAR. What is the prognosis? The prognosis must be guarded, because of the various complications which may arise. It depends also on the general condition of the pa- tient and the intensity of the inflammation. "What does the treatment consist in? Attention should first be given to the tympanic cavity. In acute cases, where bulging of the membrane is present, paracentesis should be per- formed. The cavity should be kept cleansed in both the acute and chronic forms of tympanic suppuration. Where the pain over the mas- toid persists, the use of Leiter s coils has been recommended. The use of cold water by means of these has been found serviceable. Where the above means are unavailing, a resort to Wilde's incision should be made. This consists in making an incision through the periosteum down to the bone. The bleeding which results often gives relief, though no pus be evacuated. The periosteum should be raised and softening of the bone sought for. When found, it should be broken through, and the cells evacuated and washed out with an antiseptic so- lution. Some cases present no bone softening and remain unrelieved by these methods of treatment, and hence an artificial opening of the mastoid becomes necessary. Describe the operation of opening the mastoid. Two methods are in vogue : one consists in boring with drills, and the other in chiselling. The operation by means of the chisel is to be pre- ferred. The landmarks in the operation are the linea temporalis and the posterior wall of the meatus. An incision should be made down to the bone close to the insertion of the auricle. The incision should begin about 1 cm. above the auricle, and extend nearly down to the tip of the mastoid. A second incision should be made backward and upward, about 2 cm. in length, opposite the middle of the meatus. The peri- osteum should then be turned back and the whole mastoid exposed. An examination should then be made for any softened portions of bone, and all such carefully removed. If there is no softened portion, then an artificial opening must be made. This should be made about 2 to 3 mm. below the line of the superior wall of the meatus, and about 5 mm. backward from the edge of the anterior surface of the mastoid. Sometimes hyperostosis is found to exist in a marked _ degree. The opening should not go deeper than 15 mm. When the interior of the mastoid has been exposed the cells should be broken down and all carious masses should be removed. Free communication with the tym- panum should be established. After the operation is completed the wound should be syringed with an antiseptic solution, and if there be communication with the tympanic cavity, this is proven by the fluid appearing at the external meatus. A drainage-tube should then be inserted, and cleansing of the cavity daily should be performed. The opening should not be allowed to close until all suppuration has ceased. OTITIC MENINGITIS. 155 The duration of the treatment will vary according to the conditions present. The chief danger attending this operation is wounding the lateral sinus. To avoid this a direction parallel with the wall of the ear- passage should be maintained. Sometimes there is a malformation present which renders this danger unavoidable. What are the diseases occurring within the cranium as a result of purulent inflammation of the tympanum ? Meningitis affecting the convexity and base of the brain ; phlebitis and thrombosis of the sinuses ; abscesses of the cerebrum and cerebellum. What are the symptoms of otitic meningitis ? The chief symptom of meningitis is headache, which may be at first intermittent, but soon becomes continuous and increases in severity. Accompanying this there are restlessness, wakefulness, and occasionally vomiting, followed by dulness of the intellect. In children coma may be present, It is often very difficult to make a diagnosis of an otitic menin- gitis in the early stages. What is the treatment of otitic meningitis ? The treatment is the same as in meningitis from any other cause. The local treatment of the ear is the chief indication, however, in this form of meningitis. This consists in the removal of obstruction to the evacu- ation of pus, with thorough cleansing. Removal of granulations, polypi, sequestra, etc. is necessary. Inflation when indicated should be carried out. What are the symptoms of phlebitis and thrombosis ? Chills, followed by high temperature. The chills increase in frequency, and soon the fever becomes continuous. Headache and dizziness are also present. The phlebitis of the sinus soon produces a thrombus, and as a result the circulation is checked. This is followed by oedema and suppuration in the supraorbital, orbital, or nasal tissues. The thrombus may extend downward into the internal jugular vein, so that it is felt as a firm, hard cord. The thrombus may likewise pass into the mas- toid vein, thereby producing oedema and inflammation of the superficial structures of the neck on the posterior side. The thrombus also, in rare cases, extends backward to the torcular Herophili. The thrombus may undergo suppuration and rupture, setting up a meningitis. The disease may extend over a period of weeks, and even months, death, as a rule, resulting from exhaustion. In very rare instances recovery may take place. In what does the treatment consist? Treat the symptoms as they appear, giving attention, especially in the early stages, to the local treatment of the ear. 156 THE EAR. What are the symptoms of abscess of the brain ? They are, as a rule, in the beginning obscure, and remain very often latent for a considerable period of time. Headache is present, which is slight at first, but increases. This is followed by fever, dizziness, vomit- ing, sometimes chills, and paralysis. After the earlier symptoms the disease may be acute or chronic. In the acute form the disease runs its course in from one to five weeks. The chronic form is marked by latency of the symptoms. This duration of latency varies from weeks to months, and when once broken the disease runs its course. What is the differential diagnosis? In meningitis there are high fever and pulse, headache continuous and severe, delirium, contractions of the pupils, vomiting, and convulsions. In abscess of the brain the diagnosis is rendered uncertain by the latency of the symptoms, and the symptoms often resemble those of meningitis. When the abscess is in certain positions affections of the sensory or motor nerves show themselves. Where we have symptoms of a high fever and pulse associated with purulent disease of the ear, followed by a falling of the pulse below normal, and headache which is circumscribed, a suspicion of abscess of the brain may be entertained. What is hemorrhage of the ear likely to be due to ? It is usually the result of caries of the bone in the neighborhood of some of the large vessels. The most frequent source is from the carotid artery. The diagnosis of hemorrhage from the ear is not always certain. If the blood is arterial and checked by compression of the carotid, it likely comes from that vessel. If the bleeding is slight, it may come from some of the tympanic arteries. When venous it may be from the sinuses or jugular vein. What is the treatment? If the bleeding is from the carotid, ligation of that vessel is necessary. If from the smaller vessels, the application of cold and styptics, with tamponing of the meatus ; the same when the bleeding is from the jugular or venous sinuses. DISEASES AND AFFECTIONS OF THE INTERNAL EAR OR LABYRINTH. Describe briefly the labyrinthic affections. Very little is known of the pathology of affections involving the labyrinth. Cases of total deafness are observed following cerebro-spinal meningitis. In these cases the lesions are supposed to exist in the laby- rinth. Scarlet fever, typhoid fever, measles, may also be followed by complete deafness, also due to lesions of the labyrinth. AFFECTIONS OF THE INTERNAL EAR. 157 Acute primary inflammation of the labyrinth has been described. It is rare. In Meniere's disease there is sudden loss of hearing, with vertigo, ringing in the ears, and an inability to maintain one's balance. The deafness may involve one or both ears, and may be complete or in- complete. Anomalies of hearing have also been described. These are — (a) Diplacusis monauricularis.— In this condition there is double hearing in one and the same ear. (b) Diplacusis binauricularis. — Double hearing in both ears. In those cases of deafness following epidemic cerebro-spinal meningitis, scarlet fever, etc., where no disease of the external auditory canal or middle ear exists,