In the interval between the two plugs the sinus is freely laid open, all clot and granulations being gently curetted and washed away. Some bleeding may take place during these procedures, from the mouths of certain vessels entering the sinus between the two compressed regions. This is in itself a favourable symptom, insomuch as it proves that the thrombotic process has not extended in those directions. This hæmorrhage may be controlled with gauze plugs. The parietal sinus wall in direct relation to the thrombus is freely cut away, after which the whole field is lightly packed with gauze and the ear sewn back into position. The main portion of the wound is left open, the sinus plugs being brought to the surface whilst those inserted into the combined middle ear and antrum emerge from the external auditory meatus.
All gauze-plugs may be withdrawn after twenty-four to thirty-six hours, the wound cleansed and lightly repacked. This process is continued daily till all is healed.
When the clot extends into the jugular bulb, and when the jugular vein appears to be involved, it is necessary to expose and ligature the vein in the neck, thus preventing further extension of coagulation and diminishing the risk of general infection. This measure should be carried out before the lateral sinus is laid open. With fresh gloves and another set of instruments, the vein is exposed so as to allow the application of two ligatures, and the division of the vessel between those two ligatures. If possible, the ligatures should be applied above the level of the entrance of the common facial vein. In all cases, however, the application must be carried out, if possible, below the lower limit of the thrombus. After the vein has been divided, the upper end may be dissected in such a manner as to allow of its being brought to the surface of the wound and there anchored.
Elsewhere the neck-incision is sewn up and protected with collodion gauze. The surgeon then returns to the mastoid and sinus regions, completing the exposure of the sinus and laying it open freely to the surface. At the termination of these procedures, an attempt may be made, by irrigation between the open sinus above and jugular vein below, to wash away all thrombus contained in the intervening portion of the vessel.
Finally, both sinus and aural regions are packed with gauze, in a manner similar to that described above. Dressings are reapplied as circumstances demand, and the wounds allowed to heal by granulation.
The great frequency of a streptococcus pyogenes infection justifies one in the early administration of anti-streptococcic serum (20 to 40 c.c. of Burroughs Wellcome’s ‘Pyogenes’) followed by an autogenous vaccine as soon as that can be prepared.
Main Points in the Differential Diagnosis between
| Brain Abscess | Meningitis | Lateral Sinus Thrombosis | |
|---|---|---|---|
| Onset | Insidious. | Acute. | Acute. |
| Temperature | Subnormal (see [p. 255]). | First a rigor, then high and continuous temperature, usually intermittent. | First a rigor, then high and continuous temperature, usually remittent. Frequent rigors. |
| Pulse | Slow (see [p. 255]). | Rapid. | Rapid. |
| Mental condition | Often apathetic. In the later stages, stupor and loss of consciousness. | Very restless and delirious. Sometimes maniacal. Coma towards the end. | In the early stages, the mind is clear. This condition may persist till near the end when delirium and coma become evident. |
| Special symptoms | Paresis or paralysis, according to the site of the lesion. | Squints, retraction of the head and neck. Irregular palsies. | Œdema over mastoid, pain along course of internal jugular vein. Enlarged cervical glands. |
| Blood and cerebro-spinal examination | Progressive leucocytosis. Increased leucocytes in cerebro-spinal fluid. | Increased leucocyte count and organisms in fluid withdrawn by lumbar puncture. | Blood infection frequent. |
In typical cases no great difficulty will be experienced in diagnosing between brain abscess, meningitis, and lateral sinus thrombosis. In many cases, however, two or more of these conditions may be co-existent. Thus, both brain abscess and lateral sinus thrombosis are often complicated by the presence of a meningeal infection. Again, the undue prominence of abdominal, cardiac, or pulmonary symptoms—more especially in cases of lateral sinus thrombosis—demand the full consideration of enteric fever, endocarditis, and pneumonia. Thus, in a case recently under my care at the hospital, and in which I had the benefit of the wide experience of my Aural colleague, Mr. West, operative procedures were carried out on the mastoid region, the patient dying some days later from enteric fever. Again, the question of differential diagnosis between tuberculous meningitis, brain tumour and brain abscess is always cropping up. Thus, a short time ago, I explored both temporo-sphenoidal lobes in a boy suffering from double otitis media and presenting well-marked general cerebral symptoms, only to find that he was a subject of tuberculous meningitis.
The diagnosis is often difficult, and no trouble must be spared in the complete investigation of the case. Lumbar puncture should invariably be carried out, the fluid being examined both cytologically and bacteriologically. In all cases of doubt one would be wise to call in further advice before undertaking exploratory operation.