CHAPTER XXIX OTIC MEMORANDA SYNOPSIS: General Remarks.-Minor Local Ailments in or about the Ear.-Otitis Media, Acute and Chronic.-Mastoid Disease.-The Sense of Hearing.-Deafness and Aural Vertigo. Diagnostic Value of Fluid Discharges from the Ear in Head Injuries.Formulary. GENERAL REMARKS An examination of the external auditory canal is readily made by means of an ear speculum and reflected light, as shown in the illustration. Secretions, wax, and other débris frequently hide the drum membrane and should be removed by syringing or by means of a cotton carrier. Other necessary requisites for aural examinations are the Eustachian catheter, the Politzer inflation bag, and an auscultation tube. The color of the drum membrane under normal conditions is pearly white. FIG. 221.-EUSTACHIAN CATHETERS (Roosa). When an inflammation of the middle ear exists, the membrane is either pink or deeply reddened, and may be bulging. Perforation of the drumhead is visible or is detected by inflating the ear by means of Politzer's bag and listening for the hissing sound as the air is forced through the opening in the membrane. Hearing may be tested by means of the voice, watch, or tuning fork. Earache, deafness, tinnitus, and discharge are the principal symptoms of an inflammatory condition in or about the ear. Infection usually takes place from the nasopharynx and is generally secondary to the various forms of inflammation in this locality. Otitis media is therefore a frequent sequel to diphtheria, measles, scarlatina, amygdalitis, parotitis, influenza, typhoid fever, adenoids, and many other pathological conditions. In order to prevent, if possible, ear complications in the course of the exanthemata, the author advises the instillation of salt water (3j to pt. j) into the nostrils, teaspoonful at a time (see article on Nasopharyngeal Toilet). MINOR LOCAL AILMENTS IN OR ABOUT THE EAR 807 It is important to practise anterior and posterior rhinoscopy in connection with ear work, and it is well to remember that we meet with reflex otalgia from dental irritation and with aural vertigo, faintness, and asthma. MINOR LOCAL AILMENTS IN OR ABOUT THE EAR External otitis from infection is generally traumatic and caused by overcleanliness in using hairpins, toothpicks, or the finger nail for the purpose of cleansing the auditory canal. It is apt to affect the structures of the canal and the upper posterior region of the auricle. The parts become swollen and extremely painful and local periostitis develops, the middle ear remaining intact. This type of external ear disease has often been mistaken and treated for mastoiditis. TREATMENT.-Strict cleanliness and the repeated application of a 3 per cent acetate of aluminum solution are very effective in this condition. Dry heat in the form of a hot water bag will relieve the intense pain. In the event of fluctuation (pus formation), a free incision is to be made. Eczema of the auricle and external auditory canal presents symptoms identical with those observed in eczema of the skin of any other part of the body. For the TREATMENT, see Eczema. Furuncles can readily be distinguished from deeper ear affections by careful inspection, and are best treated by hot fomentations and incision according to general surgical principles in regard to strict antisepsis. Quite an extensive infection may take place. Impacted cerumen gives rise to buzzing in the ear, deafness, and sometimes vertigo. TREATMENT.-Syringing with warm water, preceded by filling the auditory canal with olive oil or peroxide of hydrogen. Foreign bodies, such as insects, beads, and buttons, are sometimes found in the external auditory canal, and may give rise to the symptoms enumerated under "impacted cerumen." They are best removed by syringing with warm water. Foreign bodies, such as peas or beans, which are apt to swell in water, should be removed by the blunt hook or forceps. Anæsthesia may be necessary, especially in children. TREATMENT.-A piece of soft rubber tube, of the length of a cigarette and of the proper size, is to be introduced into the ear. The end of the tube is dipped in paraffin and pushed into the canal until it comes in contact with. the foreign body, whereupon the operator, applying his mouth to the free end, aspirates forcibly, at the same time throwing back his head. Malformations, wounds, tumors, cysts, erysipelas, frostbites in and about the ear present the same features as similar pathological conditions in other parts of the body and require the same management. Otitis media catarrhalis is caused by changes of temperature, so called colds, and bathing in cold water, but most frequently is due to diseases of the nasopharynx, adenoids, etc. It is manifested by pain, tinnitus, hardness of hearing, and dizziness. The tympanum is red and if considerable exudation is present there is bulging. This catarrh of the middle ear may terminate either in recovery without rupture or after rupture of the drum membrane and escape of the exudation, or in subacute or chronic catarrh. TREATMENT. In the acute stage apply hot applications and leeches behind the ear to relieve pain, or, if the latter continues, paracentesis should be resorted to, followed by daily cleansing of the auditory canal with mild antiseptic solutions. In chronic cases Politzer's inflation method in addition to cleanliness is to be practised. Acute otitis media purulenta may occur as a result of severe inflammation of the nasopharynx or in the course of various infectious and contagious diseases. Acute purulent inflammation of the middle ear resembles simple catarrhal inflammation, except that the symptoms are more pronounced. Perforation of the membrane takes place in the majority of cases and is followed by immediate relief from the pain and sense of fulness. The secretion is very profuse at first, but gradually ceases with the healing OTITIS MEDIA AND MASTOID DISEASE 809 of the perforation. This type of middle ear disease frequently leads to involvement of the mastoid, also to extradural abscess, perisinusitis, and meningitis. The TREATMENT is the same as for catarrhal inflammation of the middle ear. The more severe cases require management in accordance with the complication present. Chronic purulent inflammation of the middle ear is characterized by a discharge which may be purulent or mucopurulent and sometimes tinged with blood; and by deafness, moderate or marked. The drum membrane is perforated or completely destroyed. There may be a formation of granulations and polypi, which are very apt to cause retention of pus; or caries and destruction of the ossicles. Caries of the attic and cholesteatoma constitute serious complications. Other serious complications and sequelæ are: Mastoiditis (usually brought on by an exacerbation of chronic purulent inflammation of the middle ear), brain abscess, sinus thrombosis, caries of the carotid canal with rupture of the internal carotid artery, meningitis, pyæmia, facial paralysis, and extensive necrosis of the temporal and adjacent bones. TREATMENT.-Enforce scrupulous cleanliness, with attention to the nasopharynx (adenoids). In tuberculosis and syphilis, use constitutional treatment. Polypi should be removed by means of the snare or forceps. Granulations may also be destroyed by instilling pure alcohol, 5 to 10 drops, twice daily. If the discharge is profuse, irrigations with boric acid solution must be done once or twice a day before applying local treatment, i. e., with alcohol, etc. Carious ossicles must be removed. In case of caries of the attic and cholesteatoma, a radical operation is necessary to save life. MASTOID DISEASE Inflammation of the mastoid process of the temporal bone forms a frequent complication of suppuration of the middle ear. It is manifested by pain in the mastoid region and tenderness on deep pressure, fever, if the inflammation is acute, and swelling, redness, and heat as the disease advances. If the inflammation invades the middle fossa of the skull, an abscess may be produced beneath the dura mater or abscess of the brain and meningitis may result or sinus thrombosis. Treatment. Attention should be paid to the tympanic cavity by permitting the free exit of the pus and by keeping the auditory canal thoroughly clean. The inflammation should be reduced by ice applications or by means of Leiter's coils. If these means fail surgical interference is necessary. SENSE OF HEARING The sense of hearing is often affected in various ways. Nervous deafness is caused by lesions of the eighth, or auditory, nerve, of the cortical centres of hearing, or of the acoustic nuclei. Labyrinthine disease may cause deafness, also drugs, such as quinine and the salicylates, inflammations, including syphilitic exudates, injuries, hæmorrhages, and tumors, primary atrophy as occurring in locomotor ataxia, and mechanical causes, such as the constant noises and jarring to which locomotive engineers and boiler makers are subject. Tinnitus aurium is a term applied to those subjective sounds which resemble hissing, buzzing, humming, beating, musical notes, etc. be caused by neurasthenic conditions, local ear disease, gastrointestinal toxæmia, reflex irritants, and arteriosclerosis. Vertigo may be of aural origin not connected with Ménière's disease. Hyperacusis (auditory hyperesthesia) is an abnormal acuteness of hearing. It is observed in hysteria and hypnotic states. It may occur in facial paralysis. Dysacusis, or painful hearing, occurs in neurasthenic and hysterical conditions, in feeble people, in brain congestion, as in fevers, in meningitis, and in local inflammation of the ear. Impairment of hearing may be due to the presence of adenoids, enlarged tonsils, polypi, catarrhal conditions of the Eustachian tube, hypertrophic and atrophic rhinitis, etc. Boiler makers are apt to have deafness, and the hearing of the aged is not acute. Children with impaired hearing require special education, and the sense of hearing in deaf mutes may be developed by systematic hearing exercises. TREATMENT. The causes just enumerated should receive careful attention. Strict attention to the condition of the nasopharynx is indicated, viz., removal of adenoids and posterior hypertrophies of the inferior turbinals. Constitutional remedies, such as iron, arsenic, etc., are indicated in cases in which the general health is undermined. Iodide of potassium or sodium and mercury should be administered where syphilis is present. Inflation is indicated in cases of deafness due to chronic catarrh of the middle ear. In a certain number of cases where the perforation does not heal the use of an artificial drum membrane has been found serviceable, provided the discharge has ceased. In deafness due to internal ear disease strychnine and electricity may be tried. FIG. 223.-DOUBLE CURRENT IRRI- Aural Vertigo.-Ménière's disease is a name given to all cases of vertigo due to an affection of the ear. The CAUSE and PATHOLOGY are not known. SYMPTOMS.-Sudden giddiness; the surrounding objects seem to revolve, or the patient may seem to be gyrating, usually from left to right. Walking or standing may be rendered impossible. The onset may be so abrupt as to cause the patient to fall. He may lose consciousness for a few minutes. Soon the dizziness passes away, but the patient is left prostrated. He is pale and bathed in cold perspiration. He may have nausea and vomit. Usually there is partial loss of hearing in one ear. PROGNOSIS. The paroxysms recur at irregular intervals. Sometimes they cease, but sometimes they become more frequent and deafness becomes complete. |