Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

The chief symptom of impacted wax is deafness, which is often of sudden onset. Impaction of wax causes deafness only when the lumen of the auditory canal becomes completely occluded by the plug. Tinnitus aurium and vertigo are sometimes present, and may be troublesome if the wax rests upon the tympanic membrane. Pain is occasionally complained of, and is usually due to the pressure of the plug upon an inflamed area of skin. Certain reflex symptoms, such as coughing and sneezing, have been met with.

It is only by an objective examination of the ear that the diagnosis can be made. The plug varies in colour and consistence, and may be yellow, brown, or black in appearance. Sometimes from the admixture of a quantity of epithelium it is almost white in colour.

Treatment.—The ear should be syringed with a warm antiseptic or sterilised solution. The lotion is at a suitable temperature if the finger can be comfortably held in it. The ear should be turned to the light, a towel placed over the patient's dress, and a kidney basin held under the auricle and close to the cheek. A syringe provided with metal rings for the fingers and armed with a fine ear nozzle should be held with the point inserted just within the aperture of the external meatus and in contact with the roof of the canal. Care must be taken that all the air is first removed from the syringe. To straighten the canal, the pinna should be pulled upwards and backwards by the left hand. It may be necessary to exert some considerable degree of force before the plug becomes dislodged, but this must be done with caution. The ear should then be dried out with cotton-wool, and a small plug of wool inserted for a few hours. If pain is complained of, or if the wax is hard and cannot be readily removed, the syringing should be stopped, and means taken to soften it by the instillation of a few drops of a solution of bicarbonate of soda (10 grains to the ounce of water or glycerine), or of peroxide of hydrogen, several times daily.

Eczema of the external meatus is often associated with eczema of the auricle and of the surrounding parts. Not infrequently there also exists a chronic middle-ear suppuration, which may be the cause of the eczema. Intense itchiness is the most characteristic symptom, and a watery discharge may also be complained of. Deafness and tinnitus are dependent upon the accumulation of epithelium and débris. After the ear is syringed the skin may present a dry, scaly appearance, while sometimes fissures and an indurated condition of the outer end of the meatus may be noted. Rarely is the outer surface of the tympanic membrane itself involved.

Treatment consists in keeping the ear clean by syringing and careful drying. Probably the best local application is nitrate of silver (10 grains to the ounce of spiritus ætheris nitrosi). This is applied by means of a grooved probe dressed with a small piece of cotton-wool. Care should be taken that none of the fluid is allowed to escape upon the cheek, otherwise staining of the skin occurs. A plug of cotton-wool is inserted, and the solution is re-applied at the end of a week. Sometimes the condition is very intractable.

Occasionally the vegetable parasite aspergillus is present in the external meatus, and produces a condition that is liable to be mistaken for eczema. Strong antiseptic lotions are required to kill the fungus.

Furunculosis or Boils.—Boils in the ear may arise singly or in crops, and may be associated with eczema of the meatus or with chronic suppuration of the middle ear. Pain is the chief symptom complained of, and it may be very acute. Deafness ensues when the meatus becomes completely blocked by the swelling. The boil occurs in the cartilaginous meatus, and it is to be borne in mind that the skin may present a normal appearance even when suppuration has occurred. Palpation of the affected area with the probe causes intense pain. Sometimes œdema over the mastoid with displacement forwards of the pinna supervenes, and simulates acute inflammation of the mastoid.

Treatment.—If seen in the earliest stages, an attempt may be made to relieve the pain by the application of a 20 per cent. menthol and parolein solution, or by the use of carbolic acid and cocain, 5 grains of each to a dram of glycerine. When suppuration has occurred, the best treatment is by early incision, transfixing the base of the swelling with a narrow knife and cutting into the meatus. If the tendency to boils persists, a staphylococcal vaccine will be found of value.

Foreign Bodies.—It is unnecessary to enumerate all the varieties of foreign bodies that may be met with in the ear. They may be conveniently classified into the animate—for example maggots, larvæ, and insects; and the inanimate—for example beads, buttons, and peas. Pain, deafness, tinnitus, and giddiness may be produced, and such reflex symptoms as coughing and vomiting have resulted.

The main practical point consists in identifying the body by inspection. The mere history of its introduction should not be taken as proof of its presence. In children it is advisable to give a general anæsthetic so that a thorough examination may be made with the aid of good illumination. If previous attempts to remove the body have caused œdema of the meatal walls, and if the symptoms are not urgent, no further attempt should be made until the swelling has been allayed by syringing with warm boracic lotion, and by applying one or more leeches to the tragus. An attempt should always be made in the first instance to remove the body by syringing. It is rare to find this method fail. Should it do so, a small hook should be used, sharp or blunt according to the consistence of the body. Maggots, larvæ, and insects should first be killed by instillations of alcohol and then syringed out.