The technique is the same whichever pattern is employed. The instrument is inserted in such a fashion that the hook is directed upwards, having its concavity backwards. It is passed into the attic at the point previously occupied by the head of the malleus. The shaft of the instrument is then rotated backwards so that the hook passes over the body of the incus (Fig. 205). As the rotatory action is continued downwards and finally forwards, the incus is dislodged from its position and forced into the tympanic cavity. It can now be seized by a pair of Sexton’s or crocodile forceps and removed. If it falls into the floor of the tympanum, it can usually be dislodged by syringing, or else by means of a small hook passed in circular fashion along the floor of the cavity.
Removal of the outer wall of the attic. In the majority of cases of chronic middle-ear suppuration, it is advisable to remove the outer wall of the attic in addition to performing the simple operation of ossiculectomy. If granulations be present they should first be removed, in order to give a clear view of the inner wall of the tympanic cavity, which can usually be obtained, owing to the fact that a large perforation of the membrane is probably present. The malleus and incus are then removed.
| Fig. 206. Pfau’s Attic Punch Forceps. | Fig. 207. Removal of Outer Attic-wall with Forceps. A, Outer attic-wall. |
To remove the outer wall of the attic a small but strong pair of punch-forceps is required (Fig. 206). The instrument is directed along the roof of the auditory canal, its cutting edge held upwards and the blades kept slightly open, until the outer blade is felt to pass over the outer wall of the attic. The handle is then depressed so that the end of the forceps is forced upwards and embraces the outer wall between its points (Fig. 207). This is confirmed by attempting to withdraw the forceps, which the outer bony wall of the attic will now prevent. The position of the forceps being assured, its blades are brought together by pressure on the handle, and in this manner a small portion of the bone is punched out. In this way the outer wall of the attic is gradually cut away in small fragments. Sometimes this is extremely easy, owing to the auditory canal being large and the outer wall of the attic being thin and easily cut through. In other cases, owing to the thickness of the bony walls or to the narrowness of the canal, it is extremely difficult. If the outer wall of the attic has been completely removed, a fine probe, whose point is bent upwards, can be inserted into the attic and then withdrawn without encountering any obstruction, owing to the roof of the attic and outer wall of the auditory canal being now continuous. In some cases this part of the operation may not be necessary, as the outer wall of the attic may have already disappeared as a result of the caries.
Into the larger opening thus made, small curettes are passed upwards and backwards and any granulations in the region of the aditus and entrance to the antrum are curetted away. Finally the cavity is thoroughly swabbed out with the pledgets of cotton-wool soaked in a 1 in 2,000 alcoholic solution of biniodide of mercury. The cavity is then dried and a small drain of sterilized gauze inserted within the auditory canal, the ear being afterwards covered with a pad of gauze kept in position by a bandage.
After-treatment. In cases of non-suppuration there is rarely any pain, and if asepsis has been maintained, there is seldom much discharge beyond slight sanious oozing. Unless there is considerable discomfort the dressing need not be changed for two or three days. If possible the ear should not be syringed, but merely mopped out with pledgets of cotton-wool moistened with boric lotion and then dried, the gauze drain being afterwards inserted. This process may be repeated daily until healing is complete.
In middle-ear suppuration there may be considerable pain, owing to the forcible bruising of the tissues of the inner part of the auditory canal during the act of removal of the outer wall of the attic. Sometimes, indeed, there is much swelling of the lining membrane of the canal, with the occurrence of furuncles as the result of septic infection.
If there be no pain, the after-treatment is the same as above described, excepting that it may be necessary to syringe out the ear at each dressing owing to the discharge. If there be much pain, with swelling of the canal, the gauze drain should be removed and a 10% solution of carbolic acid in glycerine frequently instilled into the meatus. Subsequently drops of rectified spirit may be substituted.
Difficulties. 1. If the auditory canal be very small there may not be sufficient room to insert the instruments through the speculum. In such cases, if there be no middle-ear suppuration, it is wiser to leave the condition alone. If, however, suppuration exists, either the conservative treatment must be continued or the complete mastoid operation recommended.
2. Hæmorrhage, especially on curetting away the granulations, may be sufficient to prevent a view of the deeper parts. It can, however, usually be arrested quickly by plugging the auditory canal with gauze soaked in adrenalin and cocaine solution. Even if the surgeon has to wait a few moments, this must be done, as it is very necessary to obtain a clear view of the field of operation.