10 Vide Textbook, p. 367.
PROMINENT SYMPTOMS.—Retro-bulbar oedema and exophthalmos, caused by stoppage of the blood from passing from the orbit into the cavernous sinus. This may result in a mechanical compression of the retinal vessels and temporary blindness; also, occasionally swellings appear about the eyelids and nose. Compression of the oculo-motor and abducens nerves as they pass along the outer wall of this sinus may cause paralysis of these nerves, and consequent inward turning of the eye, with ptosis of the eyelids; also, pressure on a branch of the fifth pair of nerves as it passes along the outer wall of the sinus may cause neuralgia in the parts supplied by the branch, or neuralgia in the supraorbital region.
Phlebitis with thrombosis of the internal jugular vein is marked by a well-defined swelling extending from the angle of the jaw downward along the line of the sterno-cleido-mastoid muscle, painful on pressure, with marked distension of the veins of the face and neck, especially the external jugular vein. Later on, when the collateral circulation is established, the superficial veins are apt to return to their former calibre. If the inflammation extends downward, it can involve the vena cava; and if upward, the facial veins, causing a swelling of the cheeks and eyelids. The process can also extend from the facial to the orbital veins, and thence into the cavernous sinus. Pressure of the thromboid mass on the internal jugular vein, on the glosso-pharyngeal hypoglossus and pneumo-gastric nerves at the opening of the jugular foramen, will cause nervous symptoms corresponding to the nerve involved.
PROGNOSIS of a phlebitis with thrombosis, as a rule, is unfavorable. Chronic middle-ear suppuration can also form a starting-point of metastatic abscess, also of tubercular formations in the lungs and other organs of the body. I have also been much impressed with the frequent occurrence of kidney complications, such as granular nephritis, in this disease. A gradual absorption of pus will develop a general bodily weakness, and it is a fairly well established fact that, as a rule, patients suffering from chronic middle-ear suppuration are not apt to be long lived: many life insurance companies now order that this disease will prevent the case from being considered a first-class risk.
II. Mastoid Disease.
The mastoid process of the temporal bone presents an outer convex with an inner concave surface. On the upper and posterior borders of the bone are found several canals, through which the external vessels form a union with those of the dura mater; also, by which the outer cranial veins form a union with the transverse sinus. There is also an important suture—the petro-squamous suture, which admits of the passage of blood- and lymph-vessels. These vessels furnish a channel for the spread of inflammation from the antrum outwardly, involving the tissues of the neck, and inwardly to the brain membranes and brain tissue proper; phlebitis with thrombosis of the lateral sinus can also occur. The interior of the mastoid process contains one large opening, the antrum, with numerous communicating air-cells, and all lined with an extension of the tympanic mucous membrane. Inflammation of the mastoid process, as a rule, is an extension of inflammation from the middle ear. The cause will be found in an obstruction to the free escape of the purulent products from the antrum out through the middle ear. It is also found that in a great number of cases of purulent middle-ear inflammation the air-cells are closed by a process of sclerosis. There are two forms of mastoid disease—1, periostitis of the bone; 2, inflammation of the mucous membrane of the mastoid cells.
1. Periostitis of the Mastoid Bone is caused either by external injuries, or more frequently by inflammation extending from the mastoid cells outwardly to the periosteum.
SYMPTOMS.—Pain, severe in character, also fever. Redness over the mastoid and great sensibility to the touch, followed by marked swelling, which may extend far down the neck, involving the lymphatic glands. Later, pus will be found between the periosteum and bone, and in a few cases caries of the bone.
2. Inflammation of the Mucous Membrane of the Mastoid Cells is caused generally by extension of inflammation from the middle-ear cavity, either of a catarrhal or purulent character, causing the cell-cavities to quickly fill up with the inflammatory products which escape through the antrum and middle-ear cavity into the external canal. If this way is closed, the fluids accumulate in the mastoid cells and form conditions favorable to involvement of the internal organs.
SYMPTOMS.—Severe pain, tenderness, and redness of skin over mastoid, but not the marked swelling that is found in periostitis. During such an inflammation facial paralysis may develop, showing that the inflammation has extended into the bone itself. Delirium is occasionally met with, probably due to a more or less circumscribed meningitis; coma is also occasionally noted, caused by effusion into the lateral ventricles. In many cases of antrum inflammation there is a marked swelling of the upper and posterior cutaneous covering of the osseous part of the external canal, making it a valuable symptom in determining the degree of the inflammatory action.