Affections of the Tympanic Membrane and Middle Ear
Traumatic Rupture of the Tympanic Membrane.—Perforating wounds may result from direct violence caused by the patient—for example, in attempts to remove wax or foreign bodies, or by clumsiness on the part of the surgeon. It is also a comparatively common complication of fracture of the middle fossa of the base of the skull. More commonly, perhaps, the membrane is ruptured from indirect violence due to great condensation of the air in the external auditory meatus, following blows upon the ear, heavy artillery reports, or diving from a height. The injury is followed by pain in the ear, often by considerable deafness and tinnitus, and bleeding is frequently observed. If early examination of the ear is made, coagulated blood may be found in the meatus or upon the membrane, or ecchymosis may be visible on the latter. A rupture in the membrane following indirect violence is usually lozenge-shaped. During inflation by Valsalva's method the air may be heard to whistle through the perforation. In all such injuries the hearing should be carefully tested, and the possibility of an injury to the labyrinth investigated by means of the tuning-fork test. Prognosis as regards hearing should be guarded at first. As a rule the rupture heals rapidly, and no treatment is necessary save the introduction of a piece of cotton-wool into the meatus. Syringing should be avoided unless suppuration has already occurred, in which case treatment for this condition must be adopted. As these injuries frequently have a medico-legal bearing, careful notes should be made.
Acute Infection of the Middle Ear.—This usually arises in connection with infective conditions of the throat and naso-pharynx. It varies considerably in its severity, and may run a mild or a severe course. It is characterised by pain in the ear, deafness, and a certain degree of fever. In children the symptoms may simulate those of meningitis. When the tympanic membrane is examined in the mild forms of the affection or in the early stages of the more severe type, the vessels about the handle of the malleus and periphery of the membrane are injected, and possibly a number of injected vessels may be seen coursing across the surface of the membrane. In the later stages the whole membrane presents a red surface, the anatomical landmarks being indistinguishable, the membrane bulges outwards into the meatus, and, if an abscess is pointing, a yellowish area may be visible upon it. The sudden cessation of pain and the appearance of a discharge from the meatus indicate perforation of the membrana tympani.
The treatment of acute otitis media varies with the severity of the attack. The patient should be confined to the house or to bed, alcohol and tobacco should be forbidden, and the bowels must be freely opened. Pain may be allayed by repeated instillations of cocain and carbolic acid (5 grains of each to a dram of glycerine). A few drops of laudanum, hot boracic instillations, or the application of a dry hot sponge, may prove soothing. Two or three leeches may be applied over the mastoid, but should the pain persist or should rupture of the membrane appear imminent, paracentesis must be carried out. After spontaneous perforation or puncture, the meatus must be kept clean. It is probably safer not to inflate through the Eustachian tube in the acute stage. Attention must be paid to any affection of the nose or throat that may be present.
Chronic Suppuration in the Middle Ear.—Acute suppuration may pass into the chronic variety, which is characterised by a perforation of the tympanic membrane, a persistent purulent or muco-purulent discharge from the middle ear, and a certain amount of deafness.
Various complications may arise in the course of chronic middle-ear disease, and so long as a person is the subject of a chronic otorrhœa, he is liable to one or more of these. The complications may be extra-cranial or intra-cranial. Those affecting the middle ear itself include granulations, polypi, cholesteatoma, caries and necrosis of the temporal bone, destruction and loss of one or more of the ossicles, facial paralysis, hæmorrhage from the carotid artery or jugular vein, and malignant disease. As mastoid complications may be mentioned: suppurative mastoiditis, leading to destruction of the bone, mastoid fistula, and sub-periosteal mastoid abscess. The intra-cranial complications that may arise are: extra-dural abscess, sub-dural abscess, meningitis, cerebral and cerebellar abscess, and lateral sinus phlebitis with general septicæmia and pyæmia.
The treatment of chronic middle-ear suppuration consists in keeping the parts clean by syringing with antiseptic lotions. The installation of hydrogen peroxide, followed by syringing with boiled water or boracic lotion, and inflation through the Eustachian tube once, twice, or thrice daily, according to the requirements of the case, constitute a routine method. Packing the meatus with antiseptic gauze after washing out may be practised.
Suppuration in the Tympanic Antrum and Mastoid Cells, or Acute Suppurative Mastoiditis.—Acute suppuration may occur in the mastoid cells in the course of an attack of acute otitis media, or as a result of interference with drainage in chronic suppuration of the antrum and middle ear. As the outer wall of the mastoid is liable to be perforated by cario-necrosis, the pus may find its way externally and form an abscess over the mastoid process behind the ear. In some cases the pus escapes into the external auditory meatus by perforating its posterior wall; in others a sinus forms on the inner side of the apex of the mastoid, and the pus burrows in the digastric fossa under the sterno-mastoid—Bezold's mastoiditis. If the posterior wall or roof of the antrum is destroyed, intra-cranial complications are liable to ensue.
The clinical features are pain behind the ear, tenderness on pressure or percussion over the mastoid, redness and œdematous swelling of the skin, and, when pus forms under the periosteum, the œdema may be so great as to displace the auricle downwards and forwards ([Fig. 265]). The deeper part of the posterior osseous wall of the meatus may be swollen so that it conceals the upper and back part of the membrane.