If, however, the disease be more extensive and involves the walls of the attic posteriorly and the region of the aditus, as shown by the presence of a fistula or granulations, the prognosis is uncertain and continuance of the discharge and recurrence of the granulations may eventually necessitate the complete mastoid operation.
(b) With regard to hearing. In the case of chronic attic suppuration the hearing power may be increased to a distance of 12 feet off for conversation, provided the internal ear is not affected and the stapes is not fixed within the fenestra ovalis; occasionally the result is much better. On the other hand, the hearing power may be made worse.
In post-suppurative conditions, the prognosis is not so favourable, as frequently the stapes is already bound down by adhesions; this is the more probable in the case of chronic middle-ear catarrh. In both these conditions the operation should never be performed without first explaining to the patient that it is practically experimental. The chief cause of failure is the recurrence of adhesions, which even the most complete and careful operation cannot always prevent.
Removal of the stapes. This operation is still in its infancy and it is, as yet, impossible to express an opinion with regard to its success or failure, and therefore the indications laid down are only tentative.
The objects of the operation are: (1) to improve the hearing in cases of deafness presumably due to fixation of the stapes within the fenestra ovalis, and (2) to relieve symptoms of tinnitus and vertigo due to the same cause.
Before this operation is advised careful examination must be made in order to determine whether the labyrinth is intact, especially if the operation is undertaken with the view of improving the hearing.
Indications. (i) If there be ankylosis of the stapes on both sides, accompanied by marked deafness and distressing subjective symptoms, operation is justifiable on the worse side.
(ii) In a one-sided affection provided the subjective symptoms of noises and giddiness are so oppressive as to render the patient’s life unbearable. The operation, of course, must not be attempted unless every other form of treatment has failed.
Operation. The operation may be performed either through the meatus, or by reflecting forward the auricle by means of the post-aural incision, and chiselling away the upper posterior part of the bony meatus in the manner suggested by Stacke (see [p. 397]).