(i) In chronic middle-ear suppuration. Before operation is considered, it is presumed that conservative measures, such as syringing, instillation of astringent and antiseptic drops, and washing out of the attic by means of Hartmann’s canula with various solutions, have been given a thorough trial and failed.
(a) If the suppuration be limited to the attic region (although the main portion of the tympanic membrane is intact), provided there is marked deafness and there are symptoms of lack of free drainage indicated by recurrent attacks of headache, a feeling of heaviness or giddiness, or pain radiating up the head on the affected side.
(b) If there be caries of the malleus and incus, and the outer attic wall, with recurrence of granulations after repeated removal, especially if accompanied by cholesteatomatous formation, provided there is no evidence of disease of the mastoid process itself.
(c) Although the general symptoms and the condition found on examination justify the complete mastoid operation, yet if the patient refuses to have this operation performed, the simpler operation of ossiculectomy may be undertaken if desired. This will permit of free drainage and diminish the risk of future intracranial complications. It should, however, be clearly explained to the patient that no guarantee can be given with regard to effecting a permanent cure as a result of this operation.
(ii) In non-suppurative conditions.
(a) If there be marked middle-ear deafness, the result of adhesions, and the malleus is fixed to the promontory. Operation is justifiable if it is found that after each inflation of the middle ear, improvement of hearing is obtained which, however, is not permanent but only temporary.
(b) If, as the result of artificial perforation, made under the conditions already laid down, improvement takes place temporarily, but a relapse occurs from closure of the perforation (see [p. 340]).
(c) If tinnitus and attacks of vertigo, due to marked retraction of the membrane, are temporarily relieved by inflation. In this case operation should only be carried out as a last resource after all other measures have failed to cure and if the symptoms are very severe and distressing.
(d) If there be marked middle-ear deafness with extensive adhesions on both sides and evidence points to the stapes being freely movable. The operation is justifiable, as an experiment, on the worse side.
Operation. The only operation to be considered is the intrameatal one. Stacke originally suggested a post-auricular incision, and reflecting the auricle forward, and, after removing the ossicle, to remove also the outer attic-wall by means of the chisel. This method, however, has now been given up as being too radical, but will be mentioned later on in connexion with the mastoid operation (see [p. 397]).