In cases of acute inflammation of the mastoid process or of a subperiosteal abscess lying over it, Wilde made a post-aural incision, incising the tissues down to the bone. The indications for doing this are now considered to be very few, but it must be remembered that in Wilde’s day the mastoid operation had not been developed.
Indications. (i) In infants it is sometimes justifiable, as the pus may have escaped to the surface of the mastoid process either through the squamo-mastoid suture or along the posterior wall of the auditory canal, between the periosteum and bone, without there being any actual disease of the bone.
(ii) As a temporary measure, to permit of drainage of a subperiosteal abscess, if the operation on the mastoid process cannot be performed for twenty-four hours or more.
(iii) In acute middle-ear suppuration a free incision down to the bone may relieve the pain if there are symptoms of periostitis of the mastoid process; it is, however, rarely necessary.
Contra-indications. In older children and adults (with the above exceptions) this operation is not sufficient, as the periostitis or subperiosteal abscess over the mastoid process is secondary to underlying bone disease which can only be eradicated by an operation on the mastoid process itself. Although healing may apparently take place, fistulæ or other evidences of mastoid disease almost invariably occur afterwards.
Operation. In an infant a general anæsthetic is not necessary, but in an adult gas anæsthesia is advisable. The mastoid region is surgically cleansed; the auricle is pulled forward and a free incision is carried down to the bone, in a curved direction downwards over the mastoid process. Originally Wilde made a vertical incision; but it is better, if possible, that the incision should be the same as would be made in performing the mastoid operation, which indeed will probably have to be carried out afterwards. After the hæmorrhage has ceased and the purulent contents of the abscess, if present, have drained away, fomentations should be applied and changed frequently during the first twenty-four hours. After this a simple dry dressing is sufficient.
Results. Except in the case of tiny infants, this procedure is seldom successful in curing the condition, and must be considered as only a temporary measure.
SCHWARTZE’S OPERATION
(Opening of the mastoid process and antrum)
Indications. (a) In acute middle-ear suppuration. (i) If, in spite of free drainage, earache, pyrexia, and tenderness over the body of the mastoid do not abate within three days. This is all the more urgent if the condition is the result of scarlet fever or influenza, as in these cases the disease may spread with extreme rapidity.