(ii) If there be an obvious abscess over the mastoid process; except in infants, in whom Wilde’s incision may be attempted as a tentative measure, although it is not recommended.
(iii) If there be symptoms of meningeal irritation.
(iv) If a profuse otorrhœa has continued for over four weeks and is accompanied by sagging downwards of the upper posterior wall of the external meatus, a definite sign that the antrum is involved.
(v) If a profuse otorrhœa has continued for over eight weeks, with no sign of abatement, even although the temperature may be normal and although there may be no symptoms of inflammation of the mastoid process. The continuance of the otorrhœa is presumably due to accumulation of pus in a large antral cavity. The object of the operation is to permit of free drainage and to prevent involvement of the mastoid process itself. The question of operation, however, must be considered very carefully. There is no doubt that in many cases conservative measures may effect a cure even although the suppuration has already existed for many months.
(b) In chronic middle-ear suppuration. Although the complete mastoid operation is usually indicated, yet the simple opening of the mastoid antrum may be advised under the following conditions, provided there are no symptoms of inflammation of the mastoid process nor signs of disease of the bony walls of the tympanic cavity:—
(i) If the perforation, however large, be surrounded by a rim of tympanic membrane (showing that there is no disease of its bony margins), and if the malleus be not adherent to the inner wall of the tympanic cavity.
(ii) If the hearing be good, that is, if speech is heard farther off than 12 feet, especially if the other ear (from whatever cause) be quite deaf.
Politzer, among others, still maintains that there is frequently no communication between the affected mastoid cells and the antrum if the mastoid abscess is the result of acute middle-ear suppuration. For this reason he considers that the antral cavity should only be opened if there be definite evidence of bone disease between the abscess cavity and the antrum, or if symptoms of extra-dural abscess or some intracranial complication be present. It is, however, difficult to believe that some communication, however microscopic, does not always exist between the antrum and the mastoid cells, seeing that the latter originally developed as outgrowths from the antrum itself, and must have become infected by direct extension from it. At the same time there is no doubt that complete recovery takes place in a certain number of cases in which the antrum has not been opened.
In my opinion, however, it is always wiser in such cases to open the antrum. Politzer considers that if this be done, healing does not take place so rapidly as in those cases in which the antrum has not been opened. On the other hand, if the antrum be not opened, the main object of the operation, that is, free drainage of the contents of the aural cavity, is not attained.