MEDICAL OTOLOGY.
BY GEORGE STRAWBRIDGE, M.D.
In this article on Medical Otology it is proposed to include those diseases of the ear that are frequently seen by the general practitioner, and especially those that exist as sequelæ to some general disease, and where the ear complication would be treated in connection with the general disorder.
Examination of a Patient.
As nearly all ear patients are afflicted with varying degrees of deafness, one of the first points of inquiry will be as to their hearing power. There are three tests commonly employed for this purpose: the ticking of a watch, the human voice, and the tuning-fork.
1st. The Watch.—By this method of examination the patient is placed with closed eyelids, so as to exclude the visual power as a factor in the examination, as it is a curious fact that many people are apparently unable to distinguish between seeing a watch and hearing its tick, and therefore so long as they can see the watch they will imagine that they can hear it ticking. Bring the watch (held by the physician) from a distance toward the patient until the tick is heard, and note the distance in inches. The plan of holding the watch close to the ear, and then slowly removing it until the extreme limit of hearing is attained, gives an incorrect result as regards the distance that the watch can be heard, due to the fact that the impressions produced on the terminal endings of the auditory nerve by the watch-tick continue a sensible time after the watch-tick has passed out of the nerve-limit, and therefore the watch-tick can still be noted. Prout has prepared a convenient method for recording the hearing power. Note the number of inches that the watch-tick can be heard by a normal ear, and let this serve as a denominator of a fraction, the numerator of which is the number of inches that the same watch-tick can be heard by the ear of the person under examination. For instance: a normal ear can distinguish my watch-tick at a distance of twenty inches; if, now, the patient's ear can perceive the same sound at only five inches, the hearing power would be noted as 5/20. By this it is not meant that the hearing power is one-fourth of normal hearing, as it would be only one-sixteenth of normal hearing, as the volume of sound is inversely in proportion to the square of the distance.
2d. The human voice tells more about the hearing power for practical purposes than does the watch. There are many persons who can readily hear the watch-tick at several inches, and yet who hear very imperfectly ordinary conversation, and also many who hear very well the human voice and very badly the watch-tick. The method of examination is to speak ordinary words in a tone that can be heard by the average ear a given number of feet, and to note the distance in feet that the ear under observation can detect the words that are spoken. In this way can be noted the hearing power of the human voice, the numerator of the fraction being the distance that the word can be heard by the observed ear, the denominator being the distance that the word can be distinguished by the normal ear.
The patient should always be examined with closed eyelids, as deaf people quickly learn by watching the movements of the lips of the speaker to know the words that are being spoken. Another precaution is to have the ear to be tested directly opposite the mouth of the observer, the other ear being firmly closed.
3d. The Tuning-Fork.—Bone-conduction of sound is used by this method. The great use of the tuning-fork is in determining diseased conditions of the auditory nerve and internal ear, and it enables one to make a differential diagnosis as to whether deafness is due to a diseased condition of the sound-conducting apparatus or whether the nerve portion of the ear is at fault. For instance: a patient complains of deafness. This may be due to some obstruction in the external auditory canal, such as impacted cerumen, or it may be due to a diseased middle ear, with thickening of its membranes, or it may be due to a diseased internal ear. The watch and human voice would only show the ear to be defective in its hearing power, and it may be from any of the above-mentioned causes. The tuning-fork, in vibration, placed on an incisor tooth or on the frontal bone, would bring out the fact that if the deafness was due to a diseased middle ear or obstruction in the external auditory canal, the tuning-fork would be heard best by the defective ear; but if due to a disease of the internal ear, it would be heard the least distinctly by the defective-hearing ear. Mack explains this by the supposition that the sound-waves are prevented from freely escaping through the sound-conducting apparatus, and are reflected back on the auditory nerve-elements, and thus make a double impression. Tuning-forks having the note C are best adapted for this examination.
EXAMINATION OF THE EXTERNAL CANAL AND TYMPANIC MEMBRANE.—This can be done by direct or by reflected light, better by the latter. A mirror and speculum are needed. The mirror should be concave, with a focal distance of from 5"-7" and a diameter of 2½"-3", with a ball-and-socket-joint and head-band, so as to allow of the two hands being free, the head holding the mirror in the required position. The mirror should have a central perforation of 2'"-3'", with a brass back, rendering it less liable to break. As a light-source can be used the light from an argand burner, but preferably sunlight reflected from a cloud or white wall.
The Ear Speculum.—The Wilde or Gruber speculum answers equally well. The Wilde speculum is cone-shaped, and best of German silver: it is easily cleansed and has four sizes. The Gruber speculum has a larger mouth and gives a large visual field. It has a parabolic curve, for the purpose of admitting more light; there are also four sizes. The speculum should be warm when in use, and is to be held in position in the canal by the thumb and forefinger of the left hand. Often in the examination of an external canal an angular-toothed forceps is needed to remove foreign substances.
The cotton-holder is a most important instrument, furnishing a means of thoroughly drying the external canal of any fluid with the least possible amount of irritation—much less than that caused by the use of the ear-syringe. It is a slender steel rod 6" long, having a number of serrations at one end to more easily allow cotton to be wrapped around it; the other end has a convenient handle. In using this instrument a small tuft of well-cleansed cotton is wrapped around the holder, so that one half of the length of the cotton tuft projects beyond the end of the instrument. By slight adaptation with the fingers the cotton roll can be made soft or quite firm, and large or small in proportion to the amount of cotton used. The cotton-holder should always be used under the light from the head-mirror.
The curette is of the same length as the cotton-holder, but is made of heavier steel, and terminates at one end in a small ring of a diameter of from 2-3 mm. It is useful in removing scabs, etc. from the external canal, also in loosening impacted cerumen.
Probes are also needful. A good middle-ear probe is made of a single piece of silver, of the same length as the cotton-holder, and tapering down to a slender shank with a small knob-like ending.
The ear syringe, a most excellent instrument, is now made of rubber, holding two ounces of fluid, and has a bulbar extremity, so as to avoid injuring the external canal or tympanic membrane. The syringe has a finger-rest, with the piston ending in a ring, so as to admit of its use with one hand. In using a syringe warm water should be always employed, and at a temperature that the finger would indicate as being quite warm. Also at first force the water very gently into the meatus, so that the patient shall not be startled; also it is well to bear in mind that many patients become very giddy under its use, necessitating either very gentle use or its being abandoned for the time.
EXAMINATION OF THE EUSTACHIAN TUBE.—The main point is as to whether the tube permits the free passage of air up to the middle ear. This can be ascertained by three methods: 1. Valsalva's method; 2. Politzer's method; 3. Catheterization of the tube.
Valsalva's method consists in forcing air through the tube by a forced expiration, the mouth and nasal passages being at the same time firmly closed. The patient can distinctly feel the air pressing against the tympanic membrane, causing it to bulge outwardly, provided the tube is open. This proceeding has certain disadvantages, sometimes causing head congestions and giddiness.
Politzer's Method.—In this proceeding a gum air-bag is used as the means of forcing air into the tube. In the act of swallowing the soft palate is drawn against the posterior wall of the pharynx, and at the same time the pharyngeal mouth of the tube is well opened, so that air forced through the nasal passages at such a moment, being prevented from passing downward by the up-drawn palate, is forced up through the Eustachian tube into the middle ear. The success of this procedure depends entirely upon the inflation being made at the same moment that the soft palate is drawn up against the pharyngeal wall; otherwise the air would naturally pass by the widest passage, in this case downward into the stomach. The usual plan of inflating at the moment that the patient is told to swallow fails, from the fact that patients differ so materially in the quickness with which they respond to an order. Many in their anxiety will swallow before the word is given, others will allow an appreciable time to pass before swallowing, so that the inflation will fail. For this reason I have adopted the following plan: It is well known that in the act of swallowing the larynx is drawn forcibly upward, and also that the moment of the extreme elevation is nearly coincident with the moment that the soft palate is drawn against the wall of the pharynx. The prominence of the thyroid cartilage (the so-called pomus Adami) enables one to easily watch until the maximum elevation of the larynx is reached, and then quickly, by a forcible contraction of the air-bag, to thoroughly inflate the middle ear. The Politzer method so thoroughly accomplishes the object, and with the least possible irritation, that the use of the catheter in the majority of cases is no longer indicated. The method of Politzer is as follows: The patient takes some water in the mouth; the air-bag has attached to it a short piece of gum tubing ending in a nose-piece in shape like an olive, or sometimes a small gum catheter is attached to it. This is placed in the lower nasal passage and the nose held firmly closed over it with one hand, the second hand grasping the air-bag. The patient is then told to swallow, so as to cause elevation of the soft palate (this can also be accomplished by the patient speaking quickly some word like hoc), and the air-bag is forcibly pressed. In this way the air is quickly driven, viâ the nasal passage and Eustachian tube, into the middle ear. In little children it is sufficient to quickly inflate, as the crying of the child elevates the soft palate to a certain degree, and so cuts off the downward passage into the stomach.
External Ear Diseases of the Auricle.
ECZEMA.—This disease occurs very frequently in infants during dentition, where irritation of the dental branches of the fifth pair of nerves causes irritation in other branches of the same nerve, including those distributed to the skin of the face and auricle, causing acute attacks of the disease. It is also frequently observed that successive teeth penetrating the periosteum will cause fresh attacks of this skin irritation, so that as long as the teething process continues, so long is the eczema apt to continue, and treatment will probably prove only palliative. Eczema occurs also in both the male and female approaching the period of adolescence, a time when other forms of skin disease are especially common.
The aged do not escape this annoying malady, where it is apt to occur in the chronic form, and is due to want of nerve-force in the skin branches of the nerves distributed to this part—a wise provision of nature allowing nerve-power to fail first in the nerves distributed to parts where the harm done is a minimum one, rather than in the nerve-centres, where disease fatal to life would result. The treatment in this class of cases would be radically different from the preceding divisions, where nerve-irritation is the cause.
DIAGNOSIS.—The acute form shows the same diagnostic appearance as does eczema occurring elsewhere—the same redness and swelling of skin, followed by the vesicular eruption with serous oozing and loss of epithelium. In the chronic variety there is marked thickening of the skin, and the auricle is often covered with crusts, but here and there a deep fissure in the skin, from some one of which pus will exude.
Marked itching and burning and a sensation of fulness occur, both in the acute and chronic forms.
COURSE.—The acute variety may last only a few days, but as a rule tends to recur at frequent intervals. The chronic variety can last almost any length of time, and will often prove to be most obstinate.
TREATMENT.—Acute Variety.—The first indication is to relieve the burning and itching. This is often best done by the use of some mild anodyne powder which protects the part from the air and tends to relieve the existing skin irritation. Finely-powdered starch dusted over the part is a good remedy. One of the best anodyne powders is that of McCall Anderson:
| Rx. | Pulv. camphoræ, | drachm iss; |
| Pulv. zinci oxid. | ounce ss; | |
| Pulv. amyli, | ounce j. |
To be dusted over the inflamed surface.
Often there will be difficulty in preventing the powder from falling off. When this is the case a very thin coating of the skin with the oxide-of-zinc ointment furnishes an excellent ground for the powder to adhere to. The oxide-of-zinc ointment alone is also an excellent application.
In the chronic variety a more stimulating application is needful, and some preparation of tar will prove valuable, such as—
| Rx. | Ungt. picis liquidæ, | drachm j-drachm iij; |
| Ungt. zinci oxid. | ounce j. |
The crusts that collect on the auricle are best removed by a poultice of bread and milk, or a cotton pad moistened with olive oil can be bound over it for a few hours, and will serve to cleanse the part. In the very chronic cases, where points of suppuration are found, a caustic application like nitrate of silver is needed. Careful regulation of the diet and habits of the patient is indicated; an outdoor life, abstinence from alcohol and tobacco, nutritious food, will greatly aid. Iron, quinine, cod-liver oil can be used frequently with good results, while in teething children incising of the gums will sometimes give temporary relief.
Diseases of the External Auditory Canal.
IMPACTED CERUMEN.—This disease occurs very frequently, and, as a rule, is considered a matter of very little moment by the profession at large, whereas, in fact, it is often a symptom of grave disorders of the middle ear. Roosa mentions that in 1448 cases observed by him in private practice, only 101 were cases of inspissated cerumen alone, the great majority showing in addition serious disorders of other parts of the organ of hearing. The ceruminous glands are found chiefly in the cartilaginous portion of the external canal, and, according to Kessel, resemble the sweat-glands not only in the time and manner of their development, but also in their external form and minute histology. This is also true of the contents of the ceruminous glands, as far as the microscope allows us to judge, the only difference being that in cerumen masses of very fine corpuscles of coloring matter are found.1 The ceruminous glands secrete but slowly, and the cerumen tends to harden and become dark in color as it grows older. The removal of the secretion is probably effected by several factors. Numerous experiments prove that the epithelial lining of the external canal has a constant motion from within outward; necessarily any substance resting on it will move with it. Cerumen could in this way be constantly extruded from the external canal; and the cerumen, becoming dry and hard by exposure to the air, would tend to separate from the skin by curling itself into small rolls, and so drop out from the external meatus. The question naturally arises, Why does the cerumen form such impacted masses as are met with? We submit the following explanation:
In many of these cases the secretion is largely above the normal, and catarrh of the naso-pharynx is found associated with it. Pomeroy first noticed this connection, and suggested the probability that the ceruminous function is greatly affected in catarrhal disease, on the theory that the earlier stages of catarrh would result in hyperæmia, and consequently augmented function, of the ceruminous glands, which if continued may result in atrophy with abolition of function, precisely as results in inflammation of the mucous membrane lining the fauces.2
1 Vide Stricher, Textbook, p. 951.
2 American Otological Soc. Trans., 1872.
The pneumogastric nerve by its pharyngeal branch is connected with the pharynx, and by its auricular branch with the external auditory canal, so that irritation of the pharyngeal branches of the nerve, as would occur in pharyngeal catarrh, could readily excite reflex irritation in the auricular branch, with increase of function of the parts to which it is distributed, causing increase of the ceruminous secretion. Conversely, atrophy of the nerve would be followed by atrophy of function of correlated parts. The external canal often presents a sharp angle in its course near the meatus, and this also would tend to cause an accumulation of cerumen.
It is a well-established clinical fact that the great majority of cases of impacted cerumen are found to be associated with serious diseased conditions of the middle ear especially, and probably the diseased middle ear is often an important factor in causing impaction to take place; so that it frequently happens that the patient will experience no increase of hearing after removal of such an impacted mass, owing to the diseased middle ear that may be present. I remember one case where the hearing was absolutely lessened after removal of a ceruminous plug; doubtless in this case the solid conduction through such a mass was better than through an air-filled auditory canal.
SYMPTOMS.—Sudden loss of hearing: this is due to the fact that the mass grows slowly from the periphery toward the centre, and as long as a small central opening remains the hearing power will remain good. Some sudden jolt or misstep, or some quick-acting force, will cause occlusion of this narrow passage, with consequent sudden loss of hearing. The tuning-fork, placed on the incisor teeth, will be best heard on the affected side by reason of vibrations being impeded by the mass in their passage through the external canal.
Tinnitus aurium and vertigo are often present, both being due to the mass pressing inward the tympanic membrane, with consequent increase of pressure on the labyrinthine fluid by the chain of small bones pressing on the membrane of the foramen ovale. These symptoms are sometimes alarming to the patient, as in his judgment indicative of serious brain lesion.
DIAGNOSIS.—Examination of the external canal with the speculum and reflected light reveals a dark amber-colored mass lying in the external canal, which can be very hard, the result of exposure to the air for a length of time, as well as the union with it of epithelial débris of the skin of the canal; or it may be soft, like syrup, in its consistence.
The PROGNOSIS is to be guarded until the condition of the middle ear is known.
TREATMENT.—If the mass is hard in its character, its removal is best effected by the forceps or curette or blunt hook, it being understood that the external canal is well illuminated, so that the course of the instrument can be carefully watched. The curette or blunt hook will loosen the attachments of the mass to the sides of the canal, and then it can be readily removed by the forceps, care being taken not to injure the tympanic membrane. In such a way a hard plug can be removed at one sitting that otherwise would require repeated efforts to accomplish the same purpose.
If these instruments are not at hand, the next best method is to effect the removal with the syringe and warm water. A caution is to be given in the use of the syringe. There are a great number of people who are not able to have the external ear syringed, even though gently, without becoming giddy, and if the syringing is then continued the vertigo will end in a fainting attack. My rule is to caution the patient of the above fact, and always promptly stop at the first symptom of vertigo. Sometimes a short rest will allow the operator to proceed, but often it is necessary to postpone any further attempt at removal until a succeeding day. Always use quite warm water. If in a fair trial with the syringe it is found that the mass does not soften and break up, it is better to make an application of olive oil to it, and at a subsequent time repeat the attempt at removal. Soft masses of cerumen are best removed by the use of warm water and the syringe.
In some few cases inflammation of the external auditory canal will complicate the treatment, and the question will come up as to whether it is best under such circumstances to attempt the removal of the impacted mass. As a rule, the removal of the mass is the best means of combating such an inflammation, and therefore an attempt at removal should be made unless the inflammation is very acute, when treatment of this complication would be in order, and the removal of the plug deferred for the moment. In all cases the condition of the middle ear and hard pharynx should be noted after the removal of the impacted mass, and these parts often will need treatment.
Furuncle of External Auditory Canal (Acute Circumscribed Inflammation).
ETIOLOGY AND PATHOLOGY.—In a great number of cases furuncle is to be regarded as an evidence of general bodily debility. For example, in the richer classes it is often a result of over-dissipation, while in the poorer classes insufficient food, bad clothing, and such like are important factors. Local irritations of the external canal may cause the disease, such as rubbing the canal with a hairpin or toothpick to relieve itching. The use of alum and nitrate-of-silver washes in the canal will cause a furuncle in some cases. Furuncle occurs in the outer third of the canal as a rule, and often develops around a ceruminous gland, and will generally be followed by a number of others.
SYMPTOMS.—Pain is the most marked one—in the beginning of the attack of an intermittent character, with a tendency to increase toward and in the night; but as the attack advances pain becomes more marked, and may extend over the entire temporal region well down into the neck. The jaw movement also becomes very painful. The furuncle will rupture at any time, from the third day up to the tenth day, according to its location. The more deeply seated it is, the slower will be its progress toward maturity. The pain quickly disappears after the rupture, and then a short interval of rest is followed too often by the recurrence of the same disease. A varying degree of deafness is usually present, due to partial closure of the canal by the swollen soft tissues, and also it may be in rare cases through involvement of the tympanic cavity in the inflammation. Fever is often present. The great objective symptom will be the circumscribed swelling found in the cartilaginous portion of the canal and often along its anterior wall, and will show great increase of pain by but slight pressure. The swelling as it matures becomes more circumscribed, and will end in a pus collection and subsequent rupture.
DIAGNOSIS.—The disease most likely to be confounded with it would be an acute middle-ear inflammation, with involvement of the periosteum of the osseous part of the canal; but the history of the case would clear up this point.
The PROGNOSIS is favorable as to hearing, but with great probability of successive crops of the same disease.
TREATMENT.—The local application of heat and moisture is a remedy of great value, and a good method of application is to bend the head into a horizontal position, as by resting the side of the head on a table, and then fill up the external canal with water as warm as the ear will allow without causing pain; then quickly place over the auricle towels that have been dipped in very warm water and wrung dry by being twisted in a second towel, and over this a large pad of warm flannel or some similar covering. The heat and moisture will be retained for quite a time, and then the procedure can be repeated until relief from pain is obtained. In the interval the auricle is to be covered with a pad of cotton. A steam atomizer furnishes a convenient way of applying heat and moisture. Dry heat is sometimes preferred: a flannel bag filled with bran or hops and well warmed in a hot oven would carry out this indication; also a hop pillow moistened by hot whiskey is a good application.
An application of leeches affords great relief from pain. The best point to place a leech (which should be a Swedish leech) is just in front of the tragus. Two or three leeches can be applied at this place, and by encouraging the after-bleeding by warm applications any desired amount of blood can be taken. The after-bleeding can be readily controlled by the use of styptic cotton.
Incision of the Furuncle.—It is a mooted question as to whether an incision is capable of giving relief, and when it should be done. My own experience has been that the application of a leech has given greater relief than the use of a knife in those cases when the furuncle has been deep seated. Later on, when the swelling has become circumscribed and shows evidence of pus, the incision is clearly indicated.
General treatment is to be of a tonic character, and during the acute stage, when the pain is severe, anodynes are indicated.
Foreign Bodies in the External Auditory Canal.
1. VEGETABLE PARASITES.—Aspergillus flavescens and Aspergillus nigricans are found on the inner part of the canal and over the external surface of the tympanic membrane. This growth largely depends for its development upon a diseased condition of the epithelial layer of the skin lining the external canal, such as is found in cases of chronic middle-ear suppuration and in eczema of the skin of the external canal, by furnishing a moist nidus for its development.
SYMPTOMS.—Intense itching in the external canal, with a sense of fulness; also sometimes pain, with tinnitus and difficulty of hearing. The growth is found in the inner part of the canal, or over the surface of the tympanic membrane in the form of yellow or black flakes according to the variety. It may be found in spots or may form a complete covering to the canal-walls, so that when removed it forms a mould of the canal, leaving a raw skin surface, on which the growth rapidly reproduces itself. The disease is found in an acute and a chronic form, and in a few days can attain full development; also there exists a marked tendency to relapse as long as any portion remains undestroyed.
PROGNOSIS.—Favorable.
TREATMENT.—The main point is to thoroughly remove the parasite. This is best effected by the use of warm water and the syringe, carefully picking off any small portion that may remain by the forceps or curette. My practice is then to fill up the external canal with alcohol, allowing it to remain a few moments, and then to carefully dry the canal by the aid of styptic cotton. This procedure may have to be repeated every second day for a number of times until the growth is entirely destroyed. Wreden recommends the use of the hypochlorate of lime in the strength of one or two grains to the ounce of water, the salt to be freshly dissolved in water at each application. The condition of the middle ear and the integument of the external canal is to be considered after the removal of this growth, and treated as indicated by the state of the case.
2. INSECTS IN THE EXTERNAL AUDITORY CANAL.—Cases of this character occur frequently during the summer season to persons who by lying on the ground give insects an opportunity to crawl into the external canal. The common house-fly also affects an entrance into the canal quite often; also during the summer it is not uncommon to find grubs or larvæ in the canals of patients suffering from suppurative inflammation of the middle ear resulting from the deposit by insects of their eggs in the moist coverings of the canal. The movements of insects in the sensitive external ear cause great pain to the patient, and their removal is sometimes difficult. For instance, the grub is provided with two hooks, by means of which it adheres tenaciously to the skin, so that it may be necessary to remove each one separately with the forceps. The quickest method of removal, as a rule, is to wash out the insect by the use of warm water and a syringe; and if this is not at hand the insect can be drowned by filling the canal with water, olive oil, or some demulcent liquid.
OTHER VARIETIES OF FOREIGN BODIES, such as grains of corn, beans, peas, cherry-stones, beads, buttons, pieces of slate-pencil, are found in the external canal, and the symptoms that are present arise partly from the presence of the body, but more frequently from the irritation produced by attempts at removal.
SUBJECTIVE SYMPTOMS.—Difficulty of hearing, often due to the foreign body filling up the external canal and thus excluding all sound-vibrations. Tinnitus aurium and vertigo are often present, and caused by pressure of the body on the tympanic membrane with resulting abnormal labyrinthine pressure; also a variety of reflex conditions are noted as a result of the presence of a foreign body in the external canal, such as coughing and vomiting, partial paralysis, etc.
OBJECTIVE SYMPTOMS.—The appearance of the external canal will depend greatly upon the amount of pressure that the foreign body has exerted. For instance, a body loosely lying in the canal will irritate but little; on the contrary, a hard body like a cherry-stone firmly impacted in the canal will quickly cause a severe inflammation.
DIAGNOSIS.—As a rule, the foreign body can be readily seen with the aid of the mirror and speculum, unless the canal has become swollen to such an extent as to hide the body from sight. Probing and such-like procedures are not advisable.
TREATMENT.—The question comes up if it is good practice to make an attempt at immediate removal of a foreign body if the external canal is in a condition of acute inflammation. Unless grave head symptoms are present it is often good practice to delay, and reduce the inflammation by proper treatment, and then remove the foreign body. In other words, there is more risk by a forcible removal during a stage of acute inflammation than to permit the foreign body to remain until the inflammatory stage is past. Numbers of cases are on record where foreign bodies have remained for years in the external canal without causing serious sequelæ. Also, be sure a foreign body really exists in the canal, as it is not uncommon for patients to come with the statement that such is the case, and yet no foreign body has been discovered.
The majority of foreign bodies can be removed by the use of the syringe and warm water. The impacted bodies—and particularly those having a hard, smooth surface—present the greatest difficulties. A good plan is to try first the syringe and warm water, and if not successful try with a toothed angular forceps to grasp the body. If, as is often the case, it is found that the forceps slips off the body, then the curved blunt hook is to be used. This can be passed by the body and then turned on its axis, so that the hook is firmly placed behind it, and then a slow upward movement will often dislodge the body. On some occasions I have used two hooks, holding the body between them, and thus dragging it out. It is also better to desist after a fair trial until a succeeding day, rather than make excessive efforts at removal, which will often cause violent inflammation to follow. After the body is dislodged examine the condition of the tympanic membrane, as this is often found to be perforated by the foreign body.
Diseases of the Middle Ear.
ANATOMY.—The cavity of the middle ear is of small dimensions: antero-posterior diameter, 13 mm.; vertical diameter at the anterior part, 5.8 mm.; vertical diameter at the posterior part, 15 mm.; transverse diameter at the anterior part, 3-4.5 mm.; transverse diameter at the opposite drumhead, 2 mm. (Von Tröltsch). It is situated in the petrous portion of the temporal bone and surrounded by bony walls, with the exception of the opening covered by tympanic membrane and the opening of the Eustachian tube, having a mucous periosteal covering, very thin, transparent, and colorless. This membrane covers not only the tympanic cavity, but is reflected over the chain of small bones and tendons of the tensor tympani and stapedius muscles. It is essentially a mucous membrane, and may be considered a continuation of the naso-pharyngeal mucous membrane reflected through the Eustachian tube to the middle-ear cavity; also subject to the same pathological changes as other mucous membranes.
The tympanic cavity normally is an air-filled cavity, and allows of free vibration of the tympanic membrane and its ossicles, as well as the membrane covering the oval and round foramina; and it is readily understood that any interference with the vibration of this sound-conducting apparatus will at once affect the hearing.
Its arterial blood is supplied from the middle meningeal, stylo-mastoid, ascendant pharyngeal, posterior auricular, tympanic, and internal carotid arteries. These freely anastomose with each other. The veins pass internally through minute openings of the petrosal squamous fissure to the veins of the dura mater, and thence into the superior petrosal sinus, and also externally into the venous ring surrounding the tympanic membrane, and also to the veins of the meatus (Schwartze). This is important to bear in mind, as furnishing an easy passage for the extension of middle-ear inflammation to the brain membranes.
The nerves forming the tympanic plexus are as follows: The mucous membrane is supplied by the tympanic plexus, formed from the tympanic branch of the petrous ganglion of the glosso-pharyngeal nerve—from the branch of the superficial petrosal and branches of the sympathetic nerve. The otic ganglion receives fibres from the inferior maxillary nerve, from the auriculo-temporal nerve, and from the sympathetic plexus, and it is distributed to the tensor tympani and tensor palati muscles.
The mastoid cells lead directly from the tympanum. They consist of one large opening, the antrum, and the lower mastoid cells. These cells consist of a large number of varying-sized cavities, and are enclosed by a dense layer of bone. The mucous membrane lining these cells is a direct extension of the tympanic membrane, and liable to the same pathological conditions as that mucous membrane.
The Eustachian tube connects the cavity of the tympanum with that of the naso-pharynx, and is mainly intended for the introduction of air into the tympanic cavity. It has a length of 35 mm., partly bone (11 mm. in length), partly cartilaginous (24 mm. in length). The pharyngeal opening is 8 mm. high and 5 mm. wide; the tympanic orifice, 5 mm. high and 3 mm. wide (Schwartze). The mucous membrane lining this canal is a continuation of that of the naso-pharynx, and affords an easy way for the transmission of disease from the naso-pharynx to the middle ear. The Eustachian tube at rest is probably closed, although this is a matter still discussed; but it is essential for normal hearing that the air-pressure exerted on the tympanic membrane through the external auditory canal should be equalized by that exerted through the Eustachian tube. This necessitates the opening of the tube from time to time for free admission of air into the tympanic cavity. This is accomplished by the action of the musculus dilator tubæ, the tensor veli palatini, and the salpino-pharyngeus muscle. In the act of swallowing the tube opens; also, if the nostrils are closed and the act of swallowing is performed, air will be pumped out of the middle ear; on the contrary, if the nostrils are open air will be forced into the middle ear.
Diseases of the middle ear can involve the superficial layers of the middle-ear mucous membrane only, and may be of a catarrhal character. Hyperæmia and swelling of the epithelial cells, with increased mucous secretion, will be found. Later on, if the inflammation assumes a higher degree, a serous fluid will be profusely poured out, with lessening of the mucous secretion. When the deeper epithelial cells are involved, then pus-cells often appear, and a suppurative process becomes established, with frequent destruction of the soft tissues of the middle ear.
These different grades of inflammation are seldom found distinct, but run one into another. A case can start as a pure catarrhal inflammation; this, after attaining its acme, may end in recovery or degenerate into a chronic catarrh; or, on the contrary, it may advance into an acute purulent inflammation with a subsequent chronic stage.
CAUSES OF INFLAMMATION OF THE MIDDLE EAR.—Change of temperature, causing a sudden cooling of the body, is a frequent cause of this disease; for instance, exposure to wind from a partly-open window, a sudden rush of cold water into the external canal, as in surf-bathing, etc. Irritating foreign bodies in the external auditory canal may also cause this disease.
But inflammation of the middle ear occurs most frequently as a sequela of diseases affecting the general body. Among these may be mentioned, in order of their relative importance—
1. Scarlet Fever.—This disease is apt to cause the purulent form of middle-ear inflammation, and often of a very grave character. The ear complication can occur during the existence of the rash or immediately after its cessation (Thomas), and may run a rapid course, causing destruction of the tympanic membrane and middle-ear ossicles. Destruction of the facial nerve in its passage through its bony canal is not infrequent. Wendt has noticed in severe cases that the periosteum of the mastoid process, also that of the squamous and petrous portions, may participate in the purulent process, and end in subsequent caries of the bone. The severity of the ear complication will largely depend upon the condition of the naso-pharyngeal mucous membrane. Light attacks of scarlet fever with slight throat symptoms would most probably cause slight irritation of the middle-ear mucous membrane, while the anginose variety would cause most violent inflammatory sequelæ.
2. Measles is apt to cause the catarrhal variety of middle-ear inflammation rather than the purulent form. It occurs during and immediately after this eruption, and is a direct continuation of the naso-pharyngeal inflammation viâ the Eustachian tube. Hearing, as a rule, is diminished, due to the swollen mucous membrane of the Eustachian tube and middle ear, and also to fluid accumulations that often exist in the middle ear. Wendt3 draws attention to the fact that chronic affections of the auditory apparatus, such as formation of adhesions between the ossicles or between the tympanic membrane and wall of the tympanum, may arise while the soft parts are in a swollen condition, and often chronic catarrhal sequelæ may be traced to this cause.
3 Ziemssen, ii. 112.
3. Tuberculosis is often associated with the catarrhal and purulent varieties of middle-ear inflammation, having, as a rule, a subacute course, the patient's attention sometimes only being drawn to his ear by the escape of pus from the middle ear into the external canal, the medium of communication being the mucous membrane of the pharynx viâ the Eustachian tube. Wendt4 states that as yet the presence of tubercles has not been authenticated, although the clinical observations of rapid destruction, especially of the tympanic membrane, would seem to indicate it.
4 Ibid., vii. 77.
4. Retro-nasal catarrh is a frequent cause of middle-ear inflammation, the disease being communicated along the mucous membrane of the Eustachian tube. All degrees of inflammation are found, the catarrhal variety being the most frequent, while acute nasal catarrh is a cause of a large number of ear complications. Chronic retro-nasal catarrh is apt to cause a chronic middle-ear catarrh, that progresses insidiously, and almost unnoticed by the patient until the deafness begins to interfere with the ordinary affairs of life.
5. Scrofulosis causes most frequently the catarrhal form of middle-ear inflammation; and this is a direct continuation of the catarrhal affections of the naso-pharyngeal mucous membrane viâ the Eustachian tube. Birch-Hirschfeld5 asserts that scrofulosis is the cause of the largest number of those cases in which weakening or destruction of the function of hearing has occurred during childhood; also, that the large number of scrofulous individuals found in deaf-and-dumb asylums is explained in this way; and that after the scrofulosis is cured the deafness remains as a result of permanent pathological middle-ear changes produced by the former disease.
5 Ibid., xvi. 794.
6. Smallpox may cause several varieties of middle-ear hyperæmia, and frequently also a hemorrhagic catarrhal process is met with. Not seldom is found a suppurative inflammation, with extensive destruction of the soft tissues and ossicles, with permanent subsequent deafness. There is probably no reason to doubt that a pustule itself can develop in the middle-ear mucous membrane, just as is found in the cornea, and cause an acute inflammatory process; but, as a rule, the middle-ear mucous membrane is secondarily involved as a consequence of inflammatory process existing in the naso-pharyngeal mucous membrane.
7. Diphtheria is a cause of middle-ear inflammation. Wendt6 states that in a fifth of the entire number of cases of croup and diphtheria; and in two-fifths of those cases in which the naso-pharyngeal space participated, but in no case without immediate connection with the corresponding affections of this space, he found an extension of the specific process into the middle ear. In some cases the tubal prominences were covered with membrane terminating at their orifices; in other cases a membranous cast of the cartilaginous portion of the tube was found. As a rule, the pathological changes noted were hyperæmia of the mucous membrane of the middle ear and catarrhal and purulent inflammation.
6 Ziemssen, vii. 71.
8. Syphilis causes most frequently the catarrhal variety of middle-ear inflammation; the purulent variety is also met with, but much less frequently, the disease of the naso-pharyngeal mucous membrane determining largely the grade of inflammation. Hereditary syphilis may cause this complication, as well as the primary disease, but not so frequently. Hutchinson has observed some cases of deafness in which the disease was situated either in the labyrinth or auditory nerve, the middle ear being healthy. Also, deafness may be caused by syphilitic affections of the external auditory canal, causing obstructions to sound-vibrations passing through it.
9. Typhoid fever may cause either the catarrhal or purulent form of middle-ear inflammation. For instance, Hoffmann7 found fourteen cases of deep-seated disturbance of the faucial mucous membrane; he also met with perforation of the tympanic membrane four times—twice in connection with caries of the mastoid process.
7 Ibid., i. p. 159.
It is easy to understand why middle-ear complications should complicate such a disease as typhoid fever, where the mucous membranes generally are the favorite seat of inflammation. Disease of the internal ear and auditory nerve are not uncommon after typhoid fever.
10. Bright's disease is a cause of hemorrhage into the middle ear. Schwartze reports in the year 1869 the case8 of a young man who suffered from albuminuria with retinal hemorrhages; also, enlargement of the liver and spleen existed. He suddenly complained of pain in the right ear. The tympanic membrane was of a red color and devoid of concavity. Three days later an abundant serous discharge existed, with a small blood-coagulum, the patient dying a few days later of the kidney disease. Examination showed a hemorrhagic inflammation of the mucous membrane of the right tympanic cavity, which was also found filled with a bloody purulent fluid. The left tympanic cavity also was found filled with a similar fluid. A number of other similar cases are reported.
8 Archiv für Ohren Heilkunde, Bd. iv. p. 12.
11. Whooping cough has been noted in several cases to have caused hemorrhage into the middle ear, with perforation of the tympanic membrane, with subsequent partial deafness.
The two principal types of acute middle-ear inflammation are the catarrhal and purulent; and these up to a certain stage have similar symptoms, but when pus has formed it gives rise to conditions that must be described as peculiar to purulent inflammation alone.
Acute Catarrh of the Middle Ear.
This may be described as acute catarrh of the mucous membrane lining the middle-ear cavity. The prominent symptoms are as follows:
1. Pain.—This is, as a rule, of the most violent character. It is described as a boring or tearing pain situated in the ear itself, and often extending over the entire temporal region: any muscular exertion like swallowing or sneezing causes increase of it. The external ear becomes swollen, and so exquisitely tender to the touch that the least pressure over the tragus causes the patient to flinch very markedly. The pain tends to increase during the night up to the early morning hours, and to lessen during the day. The immediate effect of a middle-ear inflammation is to render the entire region of that side of the face tender, so that any movement of the jaws or neck becomes painful. It is also not uncommon to find the sympathetic glands of the neck becoming enlarged and tender, and they may go on to suppuration. The adult will complain most vigorously of the pain, so that there will be no difficulty in locating it; but in the infant or young child the greatest difficulty may be experienced in determining its precise seat, owing to its inability to express in language its suffering. Two points may be mentioned as aids in the diagnosis: (a) the cry of a young child suffering from an acute inflammation of the middle ear has a peculiar shrill, continuous character, an intermission sufficient only to inspire being noticed; (b) pressure over the tragus of an inflamed middle ear will cause a quick shrinking away of the little sufferer, thus showing the seat of the disease.
2. Loss of Hearing Power.—This depends partly on a lessening of the vibratory power of the conducting apparatus, partly due to a thickened tympanic membrane, and also to the fact that the mucous membrane covering the middle ear and chain of small bones becomes swollen, and so clogs their movements. Again, the tympanum may be filled with a mucous or muco-serous fluid, instead of being an air-chamber, as in the normal condition, so that vibrations of the conducting apparatus may cease entirely, while at the same time increase of intra-labyrinthine pressure takes place. A tuning-fork placed on the incisor teeth or on the forehead is heard more distinctly on the deaf side, due to the sound-vibrations being retarded in their outward passage through the diseased middle ear; also, the voice of the patient is heard by himself with increased resonance, due to the same cause (retarded sound-vibrations), and the patient unconsciously lowers the voice below its normal tone.
3. Giddiness is not uncommon, due partly to increase of labyrinthine pressure, and in some cases to a sympathetic irritation and congestion of the vessels of the basilar brain membrane. Fever is always to be looked for in acute middle-ear disease.
4. Noises in the ear (tinnitus aurium), resembling the noise produced by the escape of steam or the singing of crickets, etc., are common, and are due to a variety of causes. For instance, a large number of these noises (according to Theobold's theory) depend upon muscle and blood-vessel movements, causing vibrations that in a normal condition pass out through the external auditory canal without being noticed; but if their outward passage is impeded by obstructions existing in the middle ear, like thickened tissue or the existence of fluids, as mucus or pus, or by obstructions in the external auditory canal itself, such as impacted cerumen, etc., then these vibrations are thrown back and impress for a second time the auditory nerve-endings, and thus become noticeable sounds. (A familiar example is to shut the external auditory canal by closing the meatus: a tidal noise is at once noticed.) A crackling noise is often caused by air entering the middle ear and bubbling up through the confined fluids.
OBJECTIVE SYMPTOMS.—The tympanic membrane is at first slightly injected, particularly along the manubrium and the anterior and posterior folds; but as the inflammation advances the entire membrane becomes intensely injected and red. The cone of light is either very small or may be entirely absent, due to the membrane having lost its high reflective power. At this stage exudations into the middle ear frequently show themselves, and if of sufficient quantity may cause an outward bulging of the membrane: frequently the tympanic membrane at its lower third becomes less transparent, and in some cases fluid collections show a dark border-line stretching across the tympanic membrane, and movable by change of position of the head.
DIAGNOSIS.—This disease can be hardly mistaken: the only difficulty that can arise is whether the case is one of simple acute catarrh or is one of commencing purulent inflammation, as the symptoms are identical in each up to the formation and escape of pus, when no doubt can arise.
TREATMENT.—This must be directed against the acute inflammation that exists, then as quickly as possible to restore the mucous membrane to its normal condition and return to the sound-conducting apparatus its normal vibrating power.
Local bleeding is to be considered among the most important remedies, and therefore is taken first. This is best done by the use of the Swedish leech, applied to the tragus, as at this point the blood is most easily drawn from the tympanic cavity, in number from one to three; and if the taking of a larger quantity of blood is desired, this can be accomplished by encouraging the after-bleeding by hot fomentations. When great pain exists, when the auricle is tender and pressure on the tragus produces marked increase of pain, the application of a leech is indicated. In children it is best to refrain from the use of leeches.
The use of heat and moisture is most valuable. An effective method of application is as follows: Place the head of the patient in a horizontal position, with the affected ear turned upward, and fill the external auditory canal with water at the temperature, say, of 100° Fahr. Place quickly over the auricle towels that have been dipped in very hot water and wrung out as dry as possible, and over these a large flannel pad. This makes an excellent dressing, and one retaining the heat and moisture for a length of time. When it cools repeat the same proceeding until relief is obtained, when a large dry cotton pad can take the place of the previous dressing. Patients suffering from acute catarrh of the middle ear should be confined to the house, and, still better, to bed. All physical exercise aggravates this disease, and a suitable anodyne may be given to procure sleep if it be found necessary. Paracentesis of the tympanic membrane is sometimes indicated in those cases where the membrane shows distinct bulging and perforation is clearly close at hand; also in some cases where, notwithstanding previous treatment, the pain still continues with great severity. This operation is best done by incising the posterior half of the membrane by means of a broad paracentesis needle. The incision should be made at a point midway between the periphery of the membrane and the handle of the hammer, and on the dividing-line of the upper and lower posterior quadrants, the cut to be made downward. Paracentesis of the membrane is to be done while the head of the patient is well supported and the membrane illuminated by means of a light reflected from the head-mirror. Immediately after the operation wet hot flannels should be applied to the ear to relieve the pain.
The condition of the pharyngeal and nasal mucous membrane should be thoroughly attended to, as from this source a large number of cases of acute middle-ear catarrh have their origin. Nitrate-of-silver solutions are often of great service as a local application to the naso-pharynx. Tannic acid makes a good astringent gargle, and is more particularly adapted to those cases where a pure astringent effect is needed. Chlorate of potash is an excellent gargle, and often proves of great service. It may not be out of place to state that the use of alcohol and tobacco tends to keep up an irritated condition of the naso-pharyngeal mucous membrane, and they should be dispensed with. As part of the treatment inflations of the middle ear are used to aid in the removal of abnormal secretions from the tympanic cavity and to restore the sound-conducting apparatus to its normal condition. This can be thoroughly carried out by the Politzer proceeding. This consists in forcing air (by compressing a rubber hand-bag, Politzer's air-bag, so called) through the lower nasal passage up the Eustachian tube, and so into the middle ear. The patient holds a small quantity of water in the mouth. The nasal end of the tubing connected with the air-bag is placed in one of the lower nasal passages, and the nose tightly closed over it. The patient is then told to swallow, and at the same moment the air-bag is forcibly compressed, and the air is thus compelled to travel along the nasal passage and up the Eustachian tube into the middle ear. The act of swallowing causes the soft palate to be forcibly pressed up against the posterior pharyngeal wall, and at the same time causes the Eustachian tube orifice to open widely. A column of air thus used will expel large accumulations of mucus from the Eustachian tube, and to some extent from the middle-ear cavity, and at the same time the thorough distension of this cavity throws into motion the tympanic membrane and chain of small bones—a most desirable proceeding. In acute conditions the inflation should be made only after all pain has ceased, and then at first very gently; but in a short time a thorough inflation two or three times repeated, say every two or three days, is most beneficial. The inflation of the middle ear by the use of the Eustachian catheter is a more irritating procedure, and does not accomplish the purpose any more completely than the Politzer method. Therefore the latter is to be preferred in adults, while in children it is the only available method that can be used.
Chronic Catarrh of the Middle Ear.
Various classifications of this disease have been made by different authors: I prefer the division that Buck has used in his textbook. The following summary will give an idea of it:
Chronic catarrh is a name that has been given to a class of cases where deafness and tinnitus are prominent symptoms, and where no suppurative action in the middle ear has existed at any previous time, and where the internal ear is supposed to be in a healthy condition. In some of these cases there will be found a marked hypertrophy of the mucous membrane, and sometimes of the submucous connective tissue, accompanied with excess of secretion, with the same condition existing in the naso-pharyngeal membrane. The tympanic membrane often becomes sunken, and therefore strongly concave outwardly. The short process of the malleus is very prominent, and the handle of the malleus, by being drawn forcibly backward, becomes apparently shortened (foreshortening of the malleus handle, so called).
The membrane loses its vibratory power to some extent, and the cone of light is either very small or is entirely absent. The color of the membrane changes to a more or less opaque white, with often a line of vascularity along the manubrium, or it may assume the color of ground glass; white calcareous deposits are not seldom met with; marked evidences of catarrhal inflammation exist in the naso-pharynx, such as increase of mucoid secretion, with enlargements of the tonsils, and often granular pharyngitis may be found. The mucous membrane of the Eustachian tube is often involved in the process: marked swelling of its mucoid tissue, with the tube filled with secretions, prevents free entrance of air into the middle-ear cavity. In the nasal mucous membrane, beyond the ordinary catarrhal conditions, polypoid formations are common; also thickening of the mucoid and submucoid tissues prevents the free passage of air.
In another class of cases coming under the head of chronic catarrh of the middle ear a very different set of symptoms from the class first described are noticeable. In these cases perhaps catarrhal symptoms have at one time existed, but have completely passed away, and the mucous membrane not only of the tympanic cavity, but also of the pharynx and Eustachian tube, has undergone a fibroid degeneration, causing destruction of the glandular elements and ending in an atrophied mucous membrane (the so-called proliferous degeneration of some authors). The tympanic membrane in these cases is abnormally thin and very transparent, sometimes much sunken, no doubt due to connective-tissue adhesions in the middle-ear cavity. The external auditory canal is devoid of cerumen and hair; also the same change in the mucous membrane of the naso-pharynx and Eustachian tube gives a smooth, transparent appearance to their surface. In this class of cases in post-mortem examinations there have been found the stapes firmly ankylosed to the margin of the fenestra ovalis; the chain of small bones firmly ankylosed; fibroid adhesions in the mastoid cells; and adhesions between the tympanic membrane and the labyrinthine wall.
CAUSES.—A percentage of cases result from a previous acute middle-ear catarrh. Others apparently originate as a chronic condition and slowly advance. Beyond all doubt, a large percentage are inherited, as the same disease can be traced back through several generations, where signs of the disease were noted in early youth, with slow advance as years go on. It is also a matter of interest to note that these cases are apt to show sensible advance in women at the birth of a child.
PROGNOSIS, as a rule, bad, both as to the possibility of preventing increase of deafness and of doing away with tinnitus—a most annoying factor.
TREATMENT is successful in proportion to the catarrhal symptoms that exist, and which are to be treated on the general plan laid down for catarrhal inflammation. A great number of these cases call for a tonic plan of treatment, such as iron tonics, cod-liver oil, etc.
Local treatment consists in inflations of the middle ear by the Politzer method. In those cases where a thin, sunken membrane exists care should be observed not to use undue pressure, lest a rupture of the membrane result. In those cases where tinnitus aurium is a prominent factor a few drops of ether placed in the Politzer bag cause a more stimulating effect from the inflation than the use of pure air, and is sometimes of service in lessening this annoyance. It is an important part of the treatment that the general health should be in the most vigorous possible condition.
Acute Purulent Inflammation of the Middle Ear.
The disease proceeds very frequently from some inflammation in the naso-pharyngeal cavity, the mucous membrane of the Eustachian tube furnishing a ready way of communication between the pharynx and middle ear.
The exanthematous diseases furnish a large proportion of these cases. Scarlet fever stands first on the list, as causing the largest number of these cases, and also those of the most serious character. Measles, smallpox, diphtheria, the different forms of fever, such as typhus and typhoid, cerebro-spinal meningitis, pneumonia, bronchitis, etc., are complicated by this form of inflammation, and the ear disease represents simply a continuation of the naso-pharyngeal inflammation which occurs so frequently in the above-mentioned diseases. Another set of causes come under the head of change of temperature, such as exposure to draughts of air and sea-bathing, where the cold water entering the external auditory canal acts directly upon the tympanic membrane. Some few cases occur as the result of injury, such as blows upon the ear or direct injuries to the tympanic membrane.
COURSE.—The same pathological conditions are to be noted here as in the acute catarrhal attack, with the difference that the inflammation goes on to a higher grade—namely, pus-formation. In this form of disease there exists marked hyperæmia and swelling, not only of the superficial but also of the deep-seated tissue, with pus-formation, and generally perforation of the tympanic membrane, with occasional ulceration and destruction of other parts of the middle ear. The neighboring cavities of the antrum and mastoid cells participate more or less, while blood-vessels penetrating the superior wall of the middle ear furnish a ready means of communication between the inflamed middle-ear tissues and the brain-membrane, so that the wonder is not that brain complications result, but that they occur so seldom.
The changes in the tympanic membrane in the first stage are marked hyperæmia and swelling of the tissue, so that it often assumes a uniform red appearance, without a trace of the malleus or cone of light. Pus-formation in the middle ear is quickly followed by bulging of the tympanic membrane, due to increase of middle-ear pressure; and this in the great majority of cases is followed by perforation of the tympanic membrane, due not only to increase of pressure, but also to a destructive ulcerative process in the membrane itself. The latter process is seen in those cases of great destruction of the tympanic membrane that occurs in scarlet fever, where almost entire destruction of the membrane is often found. Perforation may occur at any part of the membrane.
SYMPTOMS AND COURSE.—These are very much the same, up to a certain point, pus-formation, as have been described under the head of Acute Catarrh—namely, the great pain, deafness, tinnitus, headache, tenderness on pressure over the tragus, increase of pain by movement of the jaw, followed often by quick relief by perforation of the membrane and escape of pus through the external auditory canal, with a subsequent subsidence of inflammation and restoration of the tympanic membrane. A moderate attack may run a course of from two to six weeks, and end in entire recovery, or it may end in a chronic suppuration with its sequelæ.
DIAGNOSIS.—It often will be difficult at the outset to know if the case is one of acute catarrh or whether it will advance to a purulent inflammation; but as the disease goes on to pus-development and subsequent drum-perforation, no doubt can exist as to its true character. The perforation can often be seen, and air may be forced through it with a whistling sound by a forcible expiration of the patient. In regard to whether complications exist, such as mastoid or brain involvement, several points can be given as aids in the diagnosis. When mastoid involvement exists, the soft tissues over it become swollen, very tender on pressure, with pain in that part of the bone; also, often swelling of the posterior upper wall of the external auditory canal, a part adjacent to the mastoid process.
In those cases where the inflammation tends toward the cranial cavity, the pain spreads over the entire side of the head, and often becomes marked in the occipital and frontal regions, and is of a peculiar lancinating character. Vertigo is also present, even if the head is in a quiet horizontal position, but greatly increased by movement of the head. The body-temperature in acute purulent inflammation in adults is not altered as a rule, but in children it is raised.
PROGNOSIS.—An uncomplicated case if properly treated will generally result in a good recovery, and often with but slight impairment of the hearing power. If allowed to run its course, it may cause serious and permanent changes in the middle ear destructive to hearing, and may end either in a chronic purulent inflammation with bone destruction or in involvement of brain membranes or brain tissue proper.
TREATMENT.—In the early stages absolutely the same treatment as recommended for acute catarrh is indicated—the use of leeches, hot-water applications, rest in bed, anodynes, etc. When pus has formed and the tympanic membrane is bulging, paracentesis is indicated (method of operation, vide p. 917), to be quickly followed by the use of hot water to relieve the pain of the operation; the gentle use of the syringe and warm water will keep the canal free of pus during the suppurative process; also the external ear is to be kept covered by a cotton pad or some other like application as long as pain and tenderness exist.
In young children suffering from scarlet fever it is of the utmost importance to cleanse frequently the pharynx of its muco-purulent secretions. This can be done by means of a probang or cotton wrapped on a curved end of whalebone, and afterward some detergent wash can be used, such as a strong decoction of green tea containing alum or a solution of common salt. The muriated tincture of iron, one part to five parts of water, is an excellent local application to be applied with a camel's-hair brush. Chlorate of potash makes a valuable gargle. In young children Meigs suggests the use of a powder containing one part of chlorate of potash to six parts of sugar, and a pinch of this placed on the tongue and allowed to dissolve.
By such a plan of treatment an acute purulent case will be best carried over the acute stage, and in many instances will end in entire recovery without the necessity of local treatment; but in some cases the purulent discharge from the middle ear will continue, and it remains to consider the best local remedies for checking this discharge and when they are to be used. It is with me an absolute rule that no remedy is to be used with a view of checking a purulent discharge until absolutely all pain has passed away and no pain is caused by pressure on the tragus or over the mastoid. During the interval the local treatment will consist of cleansing the external canal from the contained pus by the use of the syringe and warm water, the canal being afterward dried by cotton on a cotton-holder. If the discharge is small in quantity, the use of cotton on a cotton-holder will be sufficient to cleanse the canal, and causes less irritation than the syringe and warm water. The frequency with which the ear is to be cleansed will depend upon the amount of the discharge, as it should be done as little as is consistent with keeping the external canal free from pus. It is also useful for the patient by the Valsalva method of self-inflation to cleanse the middle ear from the therein-contained pus just before the time of using the syringe. If this is not feasible, the Politzer method of inflation answers the same purpose. When all pain has passed away, and if the discharge still continues, it will be proper to make a local application. My favorite one is insufflation of a small quantity of finely-powdered boracic acid (a convenient rubber blower is made for this purpose). This application answers well also in chronic purulent middle-ear affections. In applying this powder a very small portion only is to be used, so that there can be no danger of blocking the discharge by the powder obstructing its passage through the middle-ear cavity. A small portion is to be placed in an insufflator and blown in, the application to be repeated every few days. I would also mention the great importance of keeping the external canal closed by a wad of absorbent cotton, which not only absorbs the pus as it slowly escapes, but also prevents the immediate contact of air with the middle-ear cavity—a most desirable aid in the cure.
Chronic Purulent Inflammation of the Middle Ear.
Urbantschitsch9 calls attention to two distinct pathological conditions that are to be noted in this disease—the one a swelling and hypertrophy, the other a thinning, of the mucous and submucous tissues. The thickening consists in an infiltration, with subsequent connective-tissue development, either in the submucous or over the free surface of the mucous membrane, causing in the first case a diffuse tissue hypertrophy; in the latter case forming a circumscribed connective-tissue formation, papillary excrescences, and nodes. The condition accompanied with thinning of the tissue is to be considered a higher grade of purulent inflammation, by which it results that a portion of the normally existing tissue disappears, and is not again reproduced, while the newly-developed inflammatory products do not advance to organization, but are thrown off in the purulent discharge. In this way can be explained why at one time, by examination through the external canal and perforated tympanic membrane, there is found a swollen connective tissue, while at another time the bone can be seen through the thinned membrane.
9 Vide Textbook, p. 351.
CAUSES.—As a rule, it is a sequela of a previous acute attack. And it is also safe to say that a large number of chronic purulent cases are the result of bad treatment or non-treatment of the acute attack. To mention the causes of chronic suppuration is to repeat those causing the acute variety, such as diseases of the naso-pharynx resulting from scarlatina, variola, measles, typhus, tuberculosis, bronchitis, syphilis, etc.; also the external irritating causes, effect of change of temperature, as by draughts of air, cold water entering the external auditory canal, etc.
SUBJECTIVE SYMPTOMS.—Difficulty of hearing is always present. This is often caused by masses of granulations or collections of pus, filling up largely the tympanic cavity. These with a hypertrophied mucous membrane could sensibly interrupt sound-vibrations; and it will not be out of place to remark that the recovery of hearing will depend largely on what amount of change can be effected in these different conditions. Tinnitus aurium is not a constant factor; a few patients suffer from discomfort caused by pus passing down the pharynx, causing nausea.
OBJECTIVE SYMPTOMS.—More or less swelling of the external canal, while the constant passage of purulent fluids over the skin results in exfoliation of its epithelial layer and a subsequent weeping from the skin tissue. The secretion varies from an abundant discharge to a minimum of a few drops per day. It may be watery or muco-purulent, or of a thick, creamy, tenacious consistence. Odor is common, and if the bone is involved of a most disagreeable character. The perforation in the tympanic membrane may vary in size from that of a pin-head to a loss of the greater part of the entire membrane; also, the membrane is found thickened, with an occasional calcareous deposit in its fibrous layer. Granulations and polypoid growths are found in the external canal and middle-ear cavity. The mucous membrane of the naso-pharynx will show the various changes that are found associated with the different diseases that cause this complication.
DIAGNOSIS.—This is without difficulty as a rule. The discharge, the perforation that often can be seen, the whistling caused by the air being forced through the middle ear and the perforation in the tympanic membrane by the Valsalva or Politzer method of inflation, are very significant of middle-ear suppuration. The pulsation often noticed at the bottom of the external auditory canal, and which has been considered indicative of perforation, is caused by a thin surface of fluid in contact with a pulsating blood-vessel, and therefore is not necessarily a sign of perforation of the tympanic membrane, as fluids are found in the external auditory canal from inflammation of its coats, and in such a case pulsation might occur; but this is but seldom the case, and the removal of the fluid would remove any doubt as to whether the fluid was a result of external-ear inflammation or caused by purulent middle-ear disease.
The course of a chronic purulent inflammation is very variable. In many cases under proper treatment healing and restoration of tissue go on rapidly. The secretion grows daily less and of a thicker consistence, and the mucous membrane of the middle ear rapidly returns to a normal condition. The perforation in the tympanic membrane becomes smaller, and often entirely closes, so that in a young person the restoration may be so complete that it is difficult to know where the seat of perforation has been. In one case in my practice in a child of ten years, where the membrane had been destroyed to at least three-fourths of its extent, a full restoration took place. In another class of cases the course is not so favorable. The tympanic membrane is largely destroyed, and is not regenerated. The chain of small bones may be either partly or entirely lost. Granulations form in the mucous membrane of the middle ear, and the bony walls of the tympanum undergo partial necrosis, the pus appearing as an acrid, irritating fluid with more or less odor. The graver complications of purulent inflammation are apt to occur in those cases of chronic purulent inflammation where there has been a stoppage of the free discharge of pus from the middle ear, causing it to collect in the antrum and mastoid cells.
TREATMENT.—The first indication is to cleanse as thoroughly as possible the middle-ear cavity of the muco-purulent fluid that may have collected. This is best accomplished by forcing air up the Eustachian tube and through the middle ear by either the Politzer or Valsalva method of inflation. The fluids thus forced out into the external canal can be removed by the use either of warm water and the syringe if large in amount, or by cotton on a cotton-holder if small in quantity: the latter plan is less irritating, and also completely dries the external canal. No local application ought to be made as long as any pain exists.
The local applications that my experience has shown to give the best results consist of boracic acid and iodoform. (The latter is objectionable on account of its odor.) The powder-insufflator furnishes a convenient method of applying these powders, and only small quantities should be used, so that no possible plugging of the middle ear can take place. Some authorities prefer fluid applications instead of powder. Weak solutions of sulphate of zinc, from one to four grains to the ounce, are frequently used: a few drops, warmed, are poured into the external canal and allowed to remain a short time, and then removed by a twisted tuft of cotton on a cotton-holder. Nitrate-of-silver solutions are to be used on a cotton-holder; and if a very strong solution is used it should be neutralized with salt and water.
The frequency of application of any remedy will depend upon the amount of discharge; but as the discharge lessens, so should the remedy be less frequently applied. The same rule applies to the cleansing of the ear, as I have no doubt that excessive use of the syringe often tends to re-establish and increase the discharge. In some cases, where the discharge has become very small in quantity, a thick scab will form over the tympanic perforation, and restoration of the tympanic membrane will rapidly advance under such a covering, showing that it is good practice not to remove such a scab, provided pus is not thereby prevented from escaping. A cotton plug should always be worn in the external canal of a purulent ear, as it acts as an absorbent of the purulent secretions, as well as protects the middle ear from the irritating contact of the air.
The naso-pharyngeal cavities are to be considered and appropriately treated; also, a general tonic treatment is often indicated.
SEQUELÆ OF PURULENT INFLAMMATION.—I. Brain involvement, either of the meninges or its substance proper: a, purulent meningitis; b, abscess of the brain; c, phlebitis with thrombosis of the sinuses. II. Mastoid disease.
I. Brain Involvement.
It will be proper for a clear understanding of the subject to briefly consider the anatomy of the middle-ear cavity with reference to this complication. The middle-ear cavity is practically surrounded by bony walls, with the exception of the foramen closed by the tympanic membrane and the opening of the Eustachian tube. The roof of the middle ear is of varying thickness, and is perforated by a number of canals for the passage of blood-vessels, forming a direct communication between the circulation of the middle ear and the meninges of the brain; also, the petro-squamous suture in the earlier years of life before complete ossification has set in provides a way for spreading of the inflammatory process from the tympanum to the brain tissue; also, cases are recorded where caries has formed actual openings in this bony roof, through which pus has entered into the brain cavity. The floor of the tympanic cavity is very thin, and forms a fossa in which lies the jugular vein, so that involvement of this vein in the inflammatory process could occur by the close apposition of these parts. The anterior wall is formed in part by the carotid canal, and cases are noted where defects in this bony wall are found. Under such circumstances the coats of the artery would lie in direct contact with the middle-ear membranes. Also, it is to be noted that small twigs from the carotid artery pass through its bony canal and anastomose with vessels of the middle ear, furnishing a way for the spread of inflammation from the middle ear to the carotid artery that may result in thickening of its walls.
The superior and posterior surfaces of the petrous bone are in direct contact with the brain membranes. The posterior wail contains the passage into the mastoid cells by way of the antrum, through which middle-ear inflammations spread and involve the mastoid cell cavities, and may result in some cases in thrombosis of the transverse sinus.
The inner wall presents two weak points—the one the round foramen, covered with membrane; the other, the oval foramen, covered with the stirrup and the annular ligament. Inflammation can cause destruction of these coverings and give free access of pus through their foramina into the labyrinth, and thence through the internal auditory canal into the brain cavity. It is not difficult, therefore, with so many ways of communication between the middle ear and brain cavity to have easy spread of inflammation between these two regions.
(a) PURULENT MENINGITIS may arise from continuance of the inflammation along the veins which penetrate the roof of the tympanic cavity in their passage from the middle ear to anastomose with the blood-vessels of the meninges, or may in rare instances be caused by pus entering the brain cavity by way of the internal ear, or it can result from caries of the petrous portion of the temporal bone.
SYMPTOMS.—Fever will be present; distressing headache; vertigo, a most significant symptom, and often present even when the head is quiet and in a horizontal position, but greatly increased by the vertical position and motion; pain of a lancinating character, shooting over the entire affected side and even down the neck; the occiput and vertex are favorite points for pain to locate. Nausea and hiccough are present. Abdomen depressed; pupils reacting to light but feebly; slow pulse; and in some cases paralytic symptoms are prominent. Post-mortem appearance: meninges congested, and lymph and pus often found at various points. Dura mater over the diseased petrous bone will be found thick, congested, and pus may be found between it and the bone. Caries of the petrous bone also is found in some cases.
(b) ABSCESS OF THE BRAIN.—With the exception of wounds and injuries, chronic purulent middle-ear inflammation is the most frequent cause of brain abscess. Meyer, in a collection of 89 cases of brain abscess tabulates the causes as follows: Typhus, 1; intercranial tumor, 2; disease of nasal mucous membrane, 3; disease of the blood-vessels, 5; inflammation of neighboring parts of the brain, 5; unknown causes, 11; suppuration of distant organs, especially the lungs, 19; caries of the petrous bone, 20; injuries, 21. Lebert collected 80 cases of brain abscess, and found that one-fourth were caused by purulent middle-ear inflammation, caries of the petrous bone being frequently present; in one-seventh of the cases the brain abscess appeared before puberty, in the remaining cases mostly between the sixteenth and thirtieth years; also, that in some cases the abscess developed in the part of the brain lying over the bony roof of the middle ear; in other cases it was found in a distant part of the brain or the cerebellum, probably developing as a metastatic abscess. Toynbee considered the retention of purulent products in the middle ear or mastoid cells as the chief cause of brain complications from ear sources: he also endeavored to show that an inflammation of the external auditory canal will tend to implicate the cerebellum and lateral sinus—that inflammation of the middle-ear cavity would extend to the cerebrum, and that of the labyrinth to the medulla oblongata. But, practically, such a rule will not hold good, and Gull has modified Toynbee's law as follows: The cerebellum and lateral sinus may suffer from mastoid disease, while the cerebrum is threatened by caries of the roof of the tympanic cavity.
Brain abscess is generally located in the medullary substance, very rarely in the cortex. The middle portion of the brain hemisphere is the most frequent seat of abscess, and very often in that part adjacent to the diseased ear. The abscess may be located directly over the diseased bone, so that the dura mater forms its covering on one side and the brain tissue on the other, or it may be located in the brain parenchyma with perfectly healthy brain tissue between it and the diseased bone. Meyer traces the origin of a brain abscess from ear disease in this manner: A chronic catarrh of the middle-ear mucous membrane results in an hypertrophy of the mucosa on one side and a chronic inflammation of the neighboring bone on the other side. Caries of the petrous bone, so caused, produces inflammation and adhesion of the dura mater, and from here as a starting-point the inflammation spreads into the brain tissue. In rare cases the brain abscess has been found connected by a fistulous tract with the diseased bone.
SYMPTOMS.—Headache is generally present in varying degree, often of a lancinating character. Vertigo frequently present. Fever generally present, with or without chill. Convulsions frequent, with loss of consciousness and unsteadiness of gait, and often paralysis of different parts of the body. The pupils are often contracted, and not unfrequently this disease may closely resemble typhus fever. Lebert noticed in his cases that failure of the intellect was not the rule, but paralysis of sensibility occurred in two-thirds of them. It is also to be noted that cases occur where all these symptoms are absent. This disease can run an acute or chronic course. In the acute condition a fatal termination is caused by the great destruction of brain tissue involved in the suppurative process. In the chronic cases the abscess becomes encapsulated, but finally terminates by rupture of the abscess and escape of pus into the ventricles or over the surface of the brain. In Lebert's cases the fatal termination occurred in half of them during the first month, in one-third of the remainder toward the end of the second month, and in the remaining cases in a varying time between the third and eighth months.
(c) PHLEBITIS WITH THROMBOSIS.—This sequela of middle-ear suppuration is not infrequent. Von Dusch in 32 cases of phlebitis with thrombosis found that purulent middle-ear disease was the cause of 20 of them. It is frequently found in the venous sinuses in proximity to the petrous portion of the temporal bone, especially in the lateral and petrosal sinuses, and often caused by caries of the petrous bone.
Phlebitis with thrombosis of the lateral sinus is characterized by a swelling of the mastoid region which extends downward into the neck, due to an extension of the phlebitis from the lateral sinus along the veins leading from that sinus through the mastoid process to the exterior of the skull. Giddiness and unsteady gait are often present. If the inflammation involves also the superior longitudinal sinus, it will cause symptoms such as epileptic convulsions and violent hemorrhage from the nose. Wreden considers that the epileptic seizure is due to a capillary hemorrhage in the cortical substance of the posterior cerebral lobes, caused by obstruction of the veins passing over the brain substance. The nose-bleeding is due to the fact that a part of the blood circulating through the veins of the nasal passages, and then through the superior longitudinal sinus, is hindered by the sinus obstruction and accumulates in the veins of the nasal passages, and finally causes a rupture in some part.
Phlebitis with Thrombosis of the Cavernous Sinus.—Urbantschitsch gives the following summary of this complication:10 A thrombosis of the cavernous sinus can be caused by a thrombus in the internal jugular or facial veins or by a clot passing from the superior petrosal sinus into the cavernous sinus, or, finally, by inflammation and thrombosis in the venous circulation of the carotid canals.
10 Vide Textbook, p. 367.
PROMINENT SYMPTOMS.—Retro-bulbar oedema and exophthalmos, caused by stoppage of the blood from passing from the orbit into the cavernous sinus. This may result in a mechanical compression of the retinal vessels and temporary blindness; also, occasionally swellings appear about the eyelids and nose. Compression of the oculo-motor and abducens nerves as they pass along the outer wall of this sinus may cause paralysis of these nerves, and consequent inward turning of the eye, with ptosis of the eyelids; also, pressure on a branch of the fifth pair of nerves as it passes along the outer wall of the sinus may cause neuralgia in the parts supplied by the branch, or neuralgia in the supraorbital region.
Phlebitis with thrombosis of the internal jugular vein is marked by a well-defined swelling extending from the angle of the jaw downward along the line of the sterno-cleido-mastoid muscle, painful on pressure, with marked distension of the veins of the face and neck, especially the external jugular vein. Later on, when the collateral circulation is established, the superficial veins are apt to return to their former calibre. If the inflammation extends downward, it can involve the vena cava; and if upward, the facial veins, causing a swelling of the cheeks and eyelids. The process can also extend from the facial to the orbital veins, and thence into the cavernous sinus. Pressure of the thromboid mass on the internal jugular vein, on the glosso-pharyngeal hypoglossus and pneumo-gastric nerves at the opening of the jugular foramen, will cause nervous symptoms corresponding to the nerve involved.
PROGNOSIS of a phlebitis with thrombosis, as a rule, is unfavorable. Chronic middle-ear suppuration can also form a starting-point of metastatic abscess, also of tubercular formations in the lungs and other organs of the body. I have also been much impressed with the frequent occurrence of kidney complications, such as granular nephritis, in this disease. A gradual absorption of pus will develop a general bodily weakness, and it is a fairly well established fact that, as a rule, patients suffering from chronic middle-ear suppuration are not apt to be long lived: many life insurance companies now order that this disease will prevent the case from being considered a first-class risk.
II. Mastoid Disease.
The mastoid process of the temporal bone presents an outer convex with an inner concave surface. On the upper and posterior borders of the bone are found several canals, through which the external vessels form a union with those of the dura mater; also, by which the outer cranial veins form a union with the transverse sinus. There is also an important suture—the petro-squamous suture, which admits of the passage of blood- and lymph-vessels. These vessels furnish a channel for the spread of inflammation from the antrum outwardly, involving the tissues of the neck, and inwardly to the brain membranes and brain tissue proper; phlebitis with thrombosis of the lateral sinus can also occur. The interior of the mastoid process contains one large opening, the antrum, with numerous communicating air-cells, and all lined with an extension of the tympanic mucous membrane. Inflammation of the mastoid process, as a rule, is an extension of inflammation from the middle ear. The cause will be found in an obstruction to the free escape of the purulent products from the antrum out through the middle ear. It is also found that in a great number of cases of purulent middle-ear inflammation the air-cells are closed by a process of sclerosis. There are two forms of mastoid disease—1, periostitis of the bone; 2, inflammation of the mucous membrane of the mastoid cells.
1. Periostitis of the Mastoid Bone is caused either by external injuries, or more frequently by inflammation extending from the mastoid cells outwardly to the periosteum.
SYMPTOMS.—Pain, severe in character, also fever. Redness over the mastoid and great sensibility to the touch, followed by marked swelling, which may extend far down the neck, involving the lymphatic glands. Later, pus will be found between the periosteum and bone, and in a few cases caries of the bone.
2. Inflammation of the Mucous Membrane of the Mastoid Cells is caused generally by extension of inflammation from the middle-ear cavity, either of a catarrhal or purulent character, causing the cell-cavities to quickly fill up with the inflammatory products which escape through the antrum and middle-ear cavity into the external canal. If this way is closed, the fluids accumulate in the mastoid cells and form conditions favorable to involvement of the internal organs.
SYMPTOMS.—Severe pain, tenderness, and redness of skin over mastoid, but not the marked swelling that is found in periostitis. During such an inflammation facial paralysis may develop, showing that the inflammation has extended into the bone itself. Delirium is occasionally met with, probably due to a more or less circumscribed meningitis; coma is also occasionally noted, caused by effusion into the lateral ventricles. In many cases of antrum inflammation there is a marked swelling of the upper and posterior cutaneous covering of the osseous part of the external canal, making it a valuable symptom in determining the degree of the inflammatory action.
Caries and necrosis of the mastoid bone are resultants of the above-described conditions, and are especially found in early childhood, and generally caused by retention of pus in the mastoid cells and breaking down of their walls. This process can be limited to the cell portion of the bone or can also involve the cortex, with formation of an external fistulous opening.
TREATMENT.—Use of heat and moisture, either by hot-water fomentations or warm poultices, like flaxseed, over the entire temporal region of the head on which the diseased mastoid is located. The flaxseed poultice is to be covered with oil silk and changed as often as needful to keep it warm. The use of leeches to the mastoid is indicated by tenderness of the part to the touch, with heat and swelling of the tissue covering the bone. Two or three foreign leeches can be used, and if the abstraction of more blood is desired the after-bleeding is to be encouraged by warm moist applications. If the disease advances notwithstanding this treatment, an opening down to the bone is indicated. The incision is usually described as the Wilde incision. The length of the cut is to be from a half to one inch, down to the bone, the point of the knife entering the skin on a level with the upper wall of the auditory canal, about half an inch behind the auricle. Occasionally the posterior auricular artery is cut, but hemorrhage is readily controlled by pressure over the artery. During the entire treatment the external auditory canal is to be cleansed from time to time of the purulent secretions, so as to facilitate the discharge of pent-up fluids from the middle ear and antrum. Also, the condition of the pharynx is to be noted, and treated if needful. Finally, if all these measures fail to relieve, and the patient shows signs of meningeal or brain involvement, together with marked redness, tenderness, and swelling over the mastoid bone, showing that pus is being retained in the mastoid cells, there only remains the making of an opening into the mastoid process and antrum by means of a bone-drill or gouge. This is best done by a free vertical incision through the skin and periosteum covering the mastoid process. Examine then the bone, and a fistulous opening may be found which can be enlarged by a probe, and so allow the free escape of pus. If such does not exist, apply a drill to the bone at a point a quarter of an inch posterior to the external canal and just below a horizontal line drawn tangent to its upper wall. The instrument is to have a direction inward, upward, and slightly forward. The depth to which it should penetrate varies: usually cell-structure is reached at a slight depth, when the drill should be withdrawn. If sclerosis of bone exists, it will be necessary to go deeper, but never more than three-quarters of an inch, or about 20 millimeters. This is Buck's rule. Schwarze says, never go deeper than 25 millimeters, otherwise there is risk of plunging the drill into the labyrinth. Also, during the drilling process Buck recommends keeping the fore finger of the operating hand constantly pressed against the neighboring bone, so as by counter-pressure to reduce to a minimum the risk of wounding the lateral sinus if it should lie in an abnormal position in the path of the drill. After-treatment consists in keeping the canal open by gentle washing. The use of a bone-gouge is preferred by some to the drill, as being a less dangerous instrument.
Diseases of the Internal Ear.
ANATOMY.—The internal ear consists of a central cavity, from one end of which arise the semicircular canals, and from the other the cochlea. The interior of these contains the membranous portion and fluids of the internal ear. The cochlea contains the most important part—namely, the terminal endings of the auditory nerve. Sound-vibrations pass through the external canal and strike against the tympanic membrane, throwing it into vibration. The vibrations of this membrane are carried across the middle ear by the chain of small bones to the membrane closing the foramen ovale of the internal ear, throwing this and the labyrinthine fluid also into vibration, and these latter vibrations, impinging on the terminal endings of the auditory nerve in a way as yet unknown, produce sound.
Vessels of the Labyrinth.—The labyrinth obtains its blood partly from the arteria auditiva interna, a branch from the basilar artery which comes from the vertebral, and partly through vessels communicating with the middle ear viâ the round and oval windows, and through others passing through the long walls themselves. The arteria auditiva interna divides in the internal meatus into a vestibular and cochlear branch. The former is distributed to the soft structures of the vestibule and semicircular canals. The cochlear branch is distributed to the modiolus and layers of the lamina spiralis. The venæ auditivæ internæ empty into the inferior petrosal sinus or the lateral sinus; other branches empty into the superior petrosal sinus.
The auditory nerve or portio mollis of the seventh nerve arises by two roots in the medulla oblongata. One ganglionic nucleus of origin is in the floor of the fourth ventricle, the other is in the crus cerebelli ad medullam (Stieda). The nerve winds around the restiform body, and passes into the meatus auditorius internus, and finally divides into a vestibular and cochlear branch. The vestibular branch divides into three branches: the superior is distributed to the utricle and ampullæ of the superior vertical and horizontal semicircular canals; the middle to the sacculis, and the inferior to the ampulla of the inferior vertical semicircular canal. The cochlear branch enters the modiolus and breaks up into smaller branches, which radiate fan-shaped into the lamina spiralis, and are then distributed between the two plates of the lamina spiralis through all its turns.
TINNITUS AURIUM.—It may be assumed that the normal ear is filled with continuous sound. The blood flowing through the large arteries and veins in close proximity to it (such as the carotid arteries and jugular vein), as well as the blood flowing through the vessels of the internal ear, will give rise to sound by throwing into vibration the soft tissues surrounding them, including also the walls of the vessels themselves. This motion is sufficient to excite the auditory nerve-elements by causing vibrations of the intra-labyrinthine fluids, and so produce sound; which, being a normal condition, and one to which the ear is accustomed, will remain unnoticed.11
11 To Theobald we are indebted for the vascular theory of sound.
The arterial system of the body throws the neighboring tissue into vibration, but this is not recognized unless our attention is particularly directed to it; or, in other words, the entire body is filled with movement as a normal condition, and therefore attracts no attention. But let this movement be increased—for instance, by violent muscular exertion, increasing the arterial action—or lessened, as in syncope, and at once an abnormal condition draws our attention to it.
In the same way the ear is filled with continuous sound as a normal condition, and therefore it is not perceived, these sound-vibrations escaping out through the middle ear and external canal. This can be readily proved. Let the external auditory canal be obstructed artificially, either by the finger or by a cork. At once a tidal tinnitus, so called, is produced, this being caused by the normal sound-vibrations being impeded in their outward passage and being thrown back again to impress the nerve-elements for a second time. This, being an abnormal condition, is at once recognized.
Different Varieties of Tinnitus Aurium.—I. Tinnitus caused by obstruction of the normal sound-vibrations in their outward passage through the middle ear and external canal; tidal tinnitus, so called from a resemblance to the noise of the ocean. Such obstructions may exist in the middle-ear cavity, as thickening of the soft tissues of the middle ear, exudations and adhesions, as found in chronic catarrh, or in the external canal, as impacted cerumen, a swollen canal, etc. The effect of such obstruction would be to interrupt the normal sound-vibrations and cause them to be reflected back again to impress for a second time the auditory nerve-elements, causing an abnormal and therefore recognized condition. This is the most frequent variety of tinnitus, and for the reason that it is produced by the more ordinary ear diseases.
II. Tinnitus caused by abnormal sound-vibrations produced either by increase or by decrease of intra-labyrinthine pressure. In a normal condition the auditory nerve-elements are subjected to a given intra-labyrinthine pressure; now, if this pressure be altered (either by being increased or diminished) an abnormal condition ensues, and is noted as such.
a. Tinnitus produced by increased intra-labyrinthine pressure may be caused by increase of the intra-labyrinthine fluids (by effusions, hemorrhages, etc., as in Menière's disease), or can be caused by increase in the amount of blood flowing through the arteries and veins of the internal ear. In either case there will result an increase of pressure that is exerted on the auditory nerve-elements. Also, another result of such increase of pressure on the arteries of the labyrinth would be to throw them into more active pulsation, and so cause greater movement on the intra-labyrinthine fluids. These abnormal vibrations impinging on the auditory nerve-endings would be noticed as such, and give rise to tinnitus of a pulsating character corresponding to the movements of the pulsating vessels. Such a condition is noticed in an eyeball afflicted by glaucoma, or can be artificially produced by finger-pressure on a normal eye. The veins of the retina will be first thrown into movement, and as the pressure increases the arteries will show marked pulsation. Why should not a similar set of conditions in the internal ear produce similar results?
b. Tinnitus produced by a lessened intra-labyrinthine pressure may be caused either by loss of intra-labyrinthine fluid or by a lessened blood-supply to the internal ear. The latter cause being the most frequent, a familiar example of this would be the tinnitus experienced by a fainting person, a common sensation being a swimming head accompanied with strange whizzing noises in the ears. The tinnitus of anæmia is of this class, and frequently of the pulsating variety. Another explanation might be given: an anæmic heart murmur might be conveyed along the blood-vessels as through a speaking-tube, and in that way impress the auditory nerve. In this variety of tinnitus it is supposed that the sound-conducting apparatus of the middle and external ear is normal; if any obstruction exists, it would cause increase of tinnitus of this variety.
III. Tinnitus caused by a diseased condition of the auditory nerve, either in the part lying between the internal ear and brain or in the brain-centre itself—pure subjective tinnitus. Here we enter upon a subject obscure from the fact that so little pathological research has been made in this direction; but, reasoning from analogy, why cannot the auditory nerve be subject to as many diseased conditions as the optic nerve, where the ophthalmoscope has clearly shown the existence of neuritis, atrophy, and many other pathological changes, caused, it may be, by disease of the retina, or it may exist as an inflammation of the nerve itself exterior to the eyeball, or it may be due to a brain tumor pressing on the optic nerve or optic tracts, also basilar meningitis? Gummata, osseous growths, etc. have in turn caused optic neuritis; finally, lesions at the optic nerve-endings in the brain itself have caused well-defined pathological changes in the optic nerve, which by the aid of the ophthalmoscope are recognized. Now, if these changes exist in the optic nerve, why may not the same conditions be present in connection with the auditory nerve, although from its anatomical location they are not capable of demonstration, as in the case of the optic nerve? And, as in the latter phosphene symptoms are common, due to nerve-irritation, so in irritation of the auditory nerve tinnitus would be developed, but of a subjective character. (In this connection it is not out of place to remark that in obscure internal ear disease examination of the optic nerve will often give valuable information toward clearing up the ear complication.) This variety of tinnitus may in some cases be due to a reflex nerve-irritation.
Finally, tinnitus may be noticed in cases of inflammation of the middle ear where fluid has collected, and is caused by the bursting of air-bubbles in their passage through this fluid, the air gaining access to the middle ear by way of the Eustachian tube. Tinnitus so produced resembles a bubbling or crackling sound. Hinton draws attention to certain cases where the tympanic membrane has lost its normal elasticity and become stiff, any movement of such a membrane causing a crackling sound. Also, there are some cases of tinnitus produced by foreign bodies being deposited on the tympanic membrane, such as cerumen, pieces of hair, etc., making a rustling or rasping noise.
Tinnitus produced by abnormal contractions of the tensor tympani or stapedius muscles has been thought to exist. Tinnitus may be intermittent or continuous. It also has an endless variety of sound, from one almost unrecognizable to a roar so loud as to render the patient nearly distracted.
Location of the Tinnitus.—Those varieties due to a diseased external or middle ear locate the sound, as a rule, in the ear itself. Subjective tinnitus is often located in the frontal and occipital regions; often also in the ear itself. It is also to be noted that marked tinnitus may be associated with a low degree of deafness, and the converse is true: slight tinnitus may be associated with a high degree of deafness.
PROGNOSIS.—The removal of tinnitus depends entirely upon the cause of it and the possibility of its removal. Continuous tinnitus is always to be regarded as a more pronounced symptom than the intermittent form.
The TREATMENT will be directed to the removal of the cause. If the disease is located in the external canal or middle ear, or in a diseased condition of the naso-pharynx, these irritating causes should be removed by treatment already laid down in previous pages. The treatment of subjective tinnitus will be guided by the same principles. Determine the cause and seek for its removal. As to whether any particular drugs exist peculiarly adapted to the removal of tinnitus, I would say that in tinnitus of a subjective character or due to nerve-irritation the bromides are indicated in appropriate doses. Inflation of the middle ear with air impregnated with ether (a few drops of ether dropped into a Politzer air-bag and the inflation made by the Politzer method), at intervals of three or four days, in some cases proves of benefit.
Deafness after Cerebro-Spinal Meningitis, Scarlet Fever, Mumps, etc.
This opens up a chapter in which our knowledge derived from post-mortem examination is very limited. In a given number of such cases the inflammation probably extends from the brain to the labyrinth; in others the changes that are found exist chiefly in the middle ear, so that it must be supposed that the inflammation in such cases has originated in the middle ear, and has secondarily invaded the labyrinth. In some cases, such as deafness after mumps, Toynbee is of the opinion that the peculiar poison of that disease affects the nervous apparatus of the ear, as the deafness comes on suddenly, and is usually complete, without evidence of disease in any other part of the ear. In this class of cases the prominent symptoms are deafness—which is total—and staggering gait, with vertigo. This symptom may last many weeks, and then cease. As a rule, examination of the tympanic membrane is negative, and the seat of disease is to be sought for in the labyrinth, whether it may be an inflammation of the soft structures or an effusion, causing increased intra-labyrinthine pressure. In many cases the suddenness of the attack would point to an effusion as the more probable cause.
Brunner in a comparison of five cases of deafness after mumps12 gives the following symptoms and course of the disease: 1. The nervous deafness after mumps can be one-sided or double-sided, the former being more frequent. 2. It is complete, and, according to past experience, incurable. 3. It develops rapidly, with vertigo and subjective noises, the later symptom lasting a long time. 4. There is little or no fever. 5. Pain is never or very seldom present. 6. Consciousness is not lost; excessive vertigo a prominent symptom. 7. It happens both in children and adults.
12 Archiv Otology, vol. xi., No. 2, p. 103.
Menière's Disease.
A. Guye of Amsterdam has published a very full summary of the history of this disease.13 The following is extracted from it: Under the head of Menière's disease is included those cases of inflammatory processes in the semicircular canals or in the middle ear producing vertigo, which is either continuous, or caused by normal movements of the head, or appearing only at intervals of weeks or months; also, that this disease is of a secondary nature, and is due to inflammatory processes in the tympanum or antrum. In typical cases the vertigo is accompanied by sensations of rotation: first a sense of rotation about a vertical axis and toward the affected side; this is followed by a sensation of rotation about a transverse axis forward and backward. The vertigo then becomes complete, and is followed by fainting, with or without loss of consciousness and vomiting. The attack in some cases may last for a few minutes to a half hour; in others every movement will tend to produce vertigo for several days. In chronic cases the feeling of vertigo to a slight degree persists between the attacks. Guye considers the causes of middle-ear catarrh as the factors most likely to cause Menière's disease. Syphilis is also noted in some cases.
13 Ibid., vol. ix., No. 3.
TREATMENT.—In some cases an alterative treatment is most serviceable, such as iodide of potassium, also the bromide of potassium; quinine is also by some recommended. The use of alcohol and tobacco is to be forbidden.
The disease known as boiler-makers' deafness, because generally found among men laboring in machine-shops, where they are subjected to loud noises connected with the work they are engaged on, is thought to be due to a paralysis of the terminal endings of the auditory nerve due to concussion. The middle ear sometimes shows some thickening of the tympanic membrane. Treatment is without avail.
In internal-ear diseases a few common symptoms can be noted. All cases show deafness, and in most of them of an absolute degree. And here is where the tuning-fork proves a valuable aid in diagnosis of deafness due to middle-ear disease, in which cases the tuning-fork is heard best on the deaf side, and to deafness due to internal-ear disease, where the tuning-fork is heard the least on the deaf side. Vertigo and a staggering gait are quite common symptoms, probably due to irritation of the semicircular canals. Prognosis as a rule is bad, as far as recovery is concerned, and an alterative treatment is often indicated. Electricity, I would state, in my experience has not proved to be of any avail.
Deaf-Mutism
may be either congenital or acquired. Two-thirds of all cases will come under the first class, and often depend upon a mal-development of some part of the central nervous system or the ear itself, or may be due to intra-uterine disease of the ear. There is a strong tendency for this disease to be inherited, and particularly in children where there exists a blood-relationship between the parents. The acquired cases may arise from defects in the central nervous system or in the internal ear, or may be due to diseases affecting the middle ear, such as purulent inflammation; and this latter cause is to be noted, as no doubt proper treatment of the middle-ear disease in many cases would have prevented such a result.
All deaf cases become mute, unless the disease has occurred in adult life, when the patient has already acquired the power of language. A deaf-mute does not speak, because he cannot hear, and therefore speech is an unknown quantity.
The TREATMENT would consist in treating any middle-ear disease that might exist, such as the sequelæ of purulent inflammation, and the instruction of the patient in acquiring the power of intercommunication either by the methods long employed of finger-reading, or, much better, by the lip method, so called, where the power of speech is given to the patient. Such cases should attend schools where such instruction is given, commencing at five years of age, and many cases now attest the value of the latter method of instruction.
DIFFERENT METHODS OF DETECTING FEIGNED DEAFNESS.—The Moos Method.—Stop the external canal of the sound ear with a cork; place a vibrating tuning-fork on the head. If the person under examination declares that he does not hear the fork with either ear, he is feigning deafness, as it would be heard well by the sound ear.
The Urbantschitsch method makes use of the human voice. First determine that good hearing power exists in the sound ear; then shut the external canal of this ear with a cork and address the individual with a few loudly-spoken words. If he denies hearing at all, he is feigning, as a good hearing ear, by simple closure of the external canal, will be still able to hear loudly-spoken words.
Another method is to determine the distance at which the person can hear certain words and repeat them correctly. Then have the patient close the eyes and let the examiner try by lengthening and shortening the distance, and note the result. Often he will hear and repeat words spoken at long distances, and apparently not be able to repeat words spoken at short distances.
Müller's Method.—Speak into the sound ear through a tube or paper roll different words as softly and quickly as the examined person can repeat; then let a second examiner repeat the same in the deaf ear. Of course nothing will be heard by the person feigning. Then let the first examiner repeat his performance; the feigner will quickly repeat after him. Suddenly begins the second examiner to softly and quickly speak in the deaf ear, but choosing different words from the first examiner. A really one-sided deaf person will repeat the words spoken into the sound ear only, while the feigner will be in doubt, and will not be able to separate the words heard by both ears, so as only to repeat the words heard by the sound ear.