PROGNOSIS.—An uncomplicated case if properly treated will generally result in a good recovery, and often with but slight impairment of the hearing power. If allowed to run its course, it may cause serious and permanent changes in the middle ear destructive to hearing, and may end either in a chronic purulent inflammation with bone destruction or in involvement of brain membranes or brain tissue proper.
TREATMENT.—In the early stages absolutely the same treatment as recommended for acute catarrh is indicated—the use of leeches, hot-water applications, rest in bed, anodynes, etc. When pus has formed and the tympanic membrane is bulging, paracentesis is indicated (method of operation, vide p. 917), to be quickly followed by the use of hot water to relieve the pain of the operation; the gentle use of the syringe and warm water will keep the canal free of pus during the suppurative process; also the external ear is to be kept covered by a cotton pad or some other like application as long as pain and tenderness exist.
In young children suffering from scarlet fever it is of the utmost importance to cleanse frequently the pharynx of its muco-purulent secretions. This can be done by means of a probang or cotton wrapped on a curved end of whalebone, and afterward some detergent wash can be used, such as a strong decoction of green tea containing alum or a solution of common salt. The muriated tincture of iron, one part to five parts of water, is an excellent local application to be applied with a camel's-hair brush. Chlorate of potash makes a valuable gargle. In young children Meigs suggests the use of a powder containing one part of chlorate of potash to six parts of sugar, and a pinch of this placed on the tongue and allowed to dissolve.
By such a plan of treatment an acute purulent case will be best carried over the acute stage, and in many instances will end in entire recovery without the necessity of local treatment; but in some cases the purulent discharge from the middle ear will continue, and it remains to consider the best local remedies for checking this discharge and when they are to be used. It is with me an absolute rule that no remedy is to be used with a view of checking a purulent discharge until absolutely all pain has passed away and no pain is caused by pressure on the tragus or over the mastoid. During the interval the local treatment will consist of cleansing the external canal from the contained pus by the use of the syringe and warm water, the canal being afterward dried by cotton on a cotton-holder. If the discharge is small in quantity, the use of cotton on a cotton-holder will be sufficient to cleanse the canal, and causes less irritation than the syringe and warm water. The frequency with which the ear is to be cleansed will depend upon the amount of the discharge, as it should be done as little as is consistent with keeping the external canal free from pus. It is also useful for the patient by the Valsalva method of self-inflation to cleanse the middle ear from the therein-contained pus just before the time of using the syringe. If this is not feasible, the Politzer method of inflation answers the same purpose. When all pain has passed away, and if the discharge still continues, it will be proper to make a local application. My favorite one is insufflation of a small quantity of finely-powdered boracic acid (a convenient rubber blower is made for this purpose). This application answers well also in chronic purulent middle-ear affections. In applying this powder a very small portion only is to be used, so that there can be no danger of blocking the discharge by the powder obstructing its passage through the middle-ear cavity. A small portion is to be placed in an insufflator and blown in, the application to be repeated every few days. I would also mention the great importance of keeping the external canal closed by a wad of absorbent cotton, which not only absorbs the pus as it slowly escapes, but also prevents the immediate contact of air with the middle-ear cavity—a most desirable aid in the cure.
Chronic Purulent Inflammation of the Middle Ear.
Urbantschitsch9 calls attention to two distinct pathological conditions that are to be noted in this disease—the one a swelling and hypertrophy, the other a thinning, of the mucous and submucous tissues. The thickening consists in an infiltration, with subsequent connective-tissue development, either in the submucous or over the free surface of the mucous membrane, causing in the first case a diffuse tissue hypertrophy; in the latter case forming a circumscribed connective-tissue formation, papillary excrescences, and nodes. The condition accompanied with thinning of the tissue is to be considered a higher grade of purulent inflammation, by which it results that a portion of the normally existing tissue disappears, and is not again reproduced, while the newly-developed inflammatory products do not advance to organization, but are thrown off in the purulent discharge. In this way can be explained why at one time, by examination through the external canal and perforated tympanic membrane, there is found a swollen connective tissue, while at another time the bone can be seen through the thinned membrane.
9 Vide Textbook, p. 351.
CAUSES.—As a rule, it is a sequela of a previous acute attack. And it is also safe to say that a large number of chronic purulent cases are the result of bad treatment or non-treatment of the acute attack. To mention the causes of chronic suppuration is to repeat those causing the acute variety, such as diseases of the naso-pharynx resulting from scarlatina, variola, measles, typhus, tuberculosis, bronchitis, syphilis, etc.; also the external irritating causes, effect of change of temperature, as by draughts of air, cold water entering the external auditory canal, etc.
SUBJECTIVE SYMPTOMS.—Difficulty of hearing is always present. This is often caused by masses of granulations or collections of pus, filling up largely the tympanic cavity. These with a hypertrophied mucous membrane could sensibly interrupt sound-vibrations; and it will not be out of place to remark that the recovery of hearing will depend largely on what amount of change can be effected in these different conditions. Tinnitus aurium is not a constant factor; a few patients suffer from discomfort caused by pus passing down the pharynx, causing nausea.