When the sinus, jugular bulb, and vein have been exposed throughout their length the wound is treated as an ordinary surgical one, being packed until it granulates up from the bottom (vide infra).
Apart from intracranial and pyæmic complications, the progress of the case may be delayed owing to the enfeebled and septic condition of the patient, and also from the occurrence of abscesses in the neck, or region of the mastoid itself. These abscesses are the result of septic thrombosis occurring in some tiny vessel. The first sign of their occurrence is an attack of pyrexia, shortly followed by a painful swelling at the affected spot. Any collection of pus should be drained at once. Although it is quite good practice to close the incision in the neck in a clean case, yet there must be no hesitation to open it up on the slightest sign of it becoming septic.
The case may appear to progress favourably for the first week or ten days, and then an intermittent and increasing pyrexia may occur for no obvious reason. This is usually due to extension of the infection along the petrosal sinuses, or perhaps along the transverse sinus.
Symptoms of involvement of the cavernous sinus may arise, perhaps even with formation of a peri-orbital abscess; or, on the other hand, the patient may gradually sink in consequence of septic toxæmia; or the end may come more suddenly with the onset of basal meningitis. Unfortunately, these cases are almost hopeless from the first, as very little can be done from a surgical point of view owing to the fact that they are not seen soon enough.
In thrombosis of the cavernous sinus the only hope of recovery lies in its exposure and incision of its wall. The sinus may be approached by tracking forwards the superior petrosal sinus—a matter of considerable difficulty, and seldom justifiable. Recently Charles Ballance has suggested the adoption of the Hartley-Krause route for extirpation of the Gasserian ganglion, and says he has found the operation easy and effectual. If pus be evacuated from the sinus he considers it advisable to adopt the recommendation of Voss, who cuts away the zygoma and removes more bone from the basal aspect of the skull so as to get direct drainage (Allbutt and Rolleston’s System of Medicine, 1908, vol. iv, Part ii, p. 495).
EXPOSURE OF THE JUGULAR BULB
This may be performed either by following the sinus downwards or through the floor of the auditory canal and tympanic cavity. The former method was first described by Grunert (Archiv für Ohrenheilkunde, 1902, vol. liii, p. 287); the latter by Piffl (Archiv für Ohrenheilkunde, 1903, vol. lviii, p. 76).
Indications. The object of the operation is to remove the septic clot situated within the jugular bulb in the hope of preventing extension of the infection along the veins leading into it, more especially the inferior petrosal sinus. This indeed has been known to occur even after the lateral sinus has been curetted out, the jugular vein ligatured, and the venous channel syringed through.
Grunert’s operation. After free opening of the mastoid process and exposure of the outer wall of the lateral sinus, the skin incision is extended downwards beyond the tip of the mastoid. The soft tissues are then separated from the bone forwards and backwards so as to expose completely not only the mastoid process, but also the digastric fossa and base of the skull immediately behind it, up to the outer bony margin of the jugular foramen. Unless care is taken, the forcible traction forwards of the soft tissues necessary to expose the field of operation may injure or tear the facial nerve as it emerges from the stylo-mastoid foramen.
The tip of the mastoid process is removed first. The lateral sinus is then freely exposed to its lowest possible limit by removing the overlying bone. In doing this it must be remembered that the sinus becomes horizontal just before it ends in the jugular fossa, so that at this point the skull forms its floor instead of its outer wall.