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Chronic Suppuration Of The Middle Ear

Chronic Suppuration Of The Middle Ear

Etiology. The causes of a chronic discharge from the middle ear are generally to be sought for in some primary acute inflammation of this region. In a few instances as in the case of tubercular disease, there may be an entire absence of anything like an antecedent acute stage ; and if present, our knowledge of the probable protracted continuance of the discharge justifies us in placing these cases at the very start in the category of chronic suppurative affections.

It was a widely accepted doctrine, ten or fifteen years ago, that a chronic suppuration of the middle ear almost invariably indicated either neglect or a lack of skill, experience, or courage on the part of the medical man who had the management of the primary acute attack. To day, our better knowledge of the all potent influence of micro organisms in inflicting those lesions which determine, in most cases, the feature of' chronicity, leads us to pass a more lenient judgment upon these men. Nevertheless, this earlier doctrine must still be accepted as fundamentally correct.

Aside from these few direct etiological factors, there are others which, although by no means direct causes, nevertheless play an important part in perpetuating tile suppuration. There are three such favoring factors, viz.

1. Lowered vitality.
2. Stagnation (intratympanic) of the fluid and solid constituents of the discharge.
3. The presence of a mass of hypertrophied, lymphoid tissue in the vault of the pharynx.

Farther on in this article I will return to this subject and give it further consideration.

The influence of diabetes mellitus in favoring the development of widespread and deep seated inflammation of the middle ear has doubtless received due consideration in the article relating to acute suppuration. It is in these cases, rather than in those of a chronic character, that this influence makes itself chiefly felt.

Pathology. The cases of chronic suppuration of the middle ear which are encountered in practice may readily be subdivided, for our convenience in studying them, into three different and fairly distinct types or groups :

Group 1. includes all those cases in which the tympanic membrane is usually perforated somewhere in the lower half, and in which no evidences of active inflammatory disturbance are discoverable. The discharge is scanty and free from' any unpleasant odor. It is sero purulent in character, but often has some admixture of mucus. At times it may cease altogether for a period of several days or weeks. Adults are affected less frequently than children.

This is the mildest type of chronic middle ear suppuration of which I have any knowledge; and the cause of the non subsidence of the discharge may be set down as a lack of tone in the blood vessels of the tympanic mucous membrane a vaso motor paresis. 'In so far as this lack of muscular tone affects the blood vessels of' the mucous membrane of the Eustachian tube, we may expect to find a greater or less quantity of mucus intermingled with the discharge. In many of' these cases a depreciated condition of the general health a lowered vitality plays an appreciable part in the persistence of the disease.

Group 11. differs from the preceding group in only one essential respect: the discharge consists largely of ropy mucus, and the main cause of its persistence is to be found in the presence of hypertrophied lymphoid tissue in the vault of the pharynx. The latter condition not only excites a catarrhal inflammation of the tubal mucous membrane, but also causes the lower portions of these channels to become so narrowed that the secretion the ropy mucuscannot escape in the natural manner into the pharynx, but finds an easier outlet for itself in the opposite direction i. e. into the middle ear and through the perforation into the external auditory canal. In these cases, as in those of the preceding group, the discharge is apt to be intermittent, sometimes stopping altogether during the summer months, and is entirely free from any unpleasant odor.

Group 111. is characterized by several features which distinguish it fairly well from the other two groups. In the first place, the discharge is more distinctly purulent in character, but not necessarily any more abundant in quantity. It is apt, also to have an unpleasant odor sometimes positively fetid in character. An admixture of blood is not rarely observed ; and, in addition to the fluid pus, we occasionally find some which has become inspis until it resembles soft cheese.

In cases of long standing, desquamated epithelium is apt to form and accumulate in the recesses of the middle car. Small flakes of it are also often found in the discharge, and at times even larger masses may escape spontaneously from the tympanum.

The actual lesions which lie at the foundation of the manifestations just described are localized areas of proliferative activity on the part of the tympanic mucous membrane, and often, at the same time, a more or less limited caries of the adjacent bone tissue.

The location of the perforation in the membrana tympani is usually higher in this third group than in the other two. The posterior half, or the posterior superior quadrant (Fig. 499), is the common site in a large number of instances. The flaccid membrane is perforated (Figs. 500, 501) in a much smaller number of cases; and, finally, in comparatively rare instances a sinus in the bone, above or behind the tympanic membrane, serves as the outlet channel the mechanical equivalent of the perforation for all the products of intratympanic inflammation.

Finally, sclerosis of the mastoid process is so uniformly found to be associated with chronic suppuration of the antrum and vicinity that we are warranted in setting it down as one of the fixed characteristics of this third group. The practical importance of this fact becomes apparent when an attempt is made, in a case of chronic suppuration of the middle ear, to determine how seriously the antrum and neighborhood are involved Before this law of mastoid bone sclerosis, or hyperostosis, was known, it was a frequent thing for physicians to deny the existence of any serious disease of the antrum because there were absolutely no outward manifestations of any such disease DO redness or swelling of the skin, no tenderness upon pressure over the mastoid process. The sclerosed condition of the overlying bone (Fig. 502), as we now know, offers an impenetrable wall to the advance of any such central focus of inflammation; and this sclerosis, as I have just stated, may be assumed to exist in every one of the cases belonging to this third group. It is therefore clear that in estimating the gravity of the deeper lying disease in this class of cases we are not permitted to attach the slightest importance to the absence of outward evidences of inflammation.

The following pathological alterations and products observed in the cases which belong to this third group deserve further consideration: granulation growths or polypi, bone caries,, desquamated epithelium, and accumulations of cheesy pus.

Granulation growths are extremely common in the middle ear in cases of chronic suppuration. They may develop at almost any point, but they are found oftenest, I think, at the lower margin of the entrance to the mastoid antrum. Their size is very variable, the largest one 1 have ever encountered measuring an inch and three quarters in length. They are the product of an irritation applied to the tympanic mucous membrane at the localities from which they spring. This irritation may have been applied at the time of the original acute inflammation an invasion of micro organisms, for example, having stimulated the connective tissue of the mucous membrane to assume proliferative activity. Or the irritation may be of later date, and may even still, at the time when the growth is discovered, be in active force. Thus, for example, a small area of bone caries in the antrum, or at the point where it becomes merged in the cavity proper of the tympanum, is apt to secrete a very irritating pus of an almost corrosive character; and the constant flow, of this over the tympanic mucous membrane soon causes the latter to proliferate and ultimately to form a mass of granulation tissue, or a " polypus " the term commonly employed when the mass has attained fairly large proportions. Then again, stagnating PUS (independently of bone caries), in which the bacteria of decomposition are active, may also exert an irritating influence strong enough to cause proliferation of the mucous membrane with which it comes in contact.

In dealing with cases of this character, therefore, we are warranted in attributing the presence of the granulation tissue either to bone caries or to stagnating and foul pus escaping from some point close at hand, and we should accordingly search for these conditions in every such case.

Superficial areas of bone caries are very often encountered in cases of chronic suppuration of the middle ear; in fact, it is no exaggeration to say that this lesion is the main if not the exclusive cause of the chronic discharge in the great majority of instances.

While the promontory or inner wall of the tympanic cavity and the region bordering on the tympanic orifice of the Eustachian tube are rarely the seat of a bone caries, every other part seems to be predisposed to the disease to an almost, equal degree. The most extensive areas are doubtless those which involve the antrum. Smaller ones are found in the tympanic roof, at the posterior end of the tympanic cavity, on its floor, and finally on either the body of the anvil or the head and neck of the hammer. When caries involves such slender structures as the long process of the anvil, the lower half of the handle of the hammer and the crura of the stirrup, these soon disappear altogether.

It is a very difficult matter to determine to what extent the ulcerative action is progressive. One thing' however, is certain, viz., that if foul pus, cheesy material, and desquamated epithelium be not allowed to remain for any great length of time upon the surface of such an area of bone ulceration, all carious activity promptly ceases.

It is also not entirely clear how bone caries is originally established in the middle ear. In former years it was customary to look upon the prolonged continuance of a high degree of intratympanic pressure as the chief cause of the trouble. Such pressure is undoubtedly competent to interfere seriously with the nutrition of the mucous membrane thus pressed upon, and ultimately with that of the underlying bone, which derives a large part of its nourishment from this mucous membrane. But it is now believed that the pressure simply plays the part of a favoring circumstance, and that the active factor in the process is the streptococcus or some other variety of micro organism. These harmful agents first destroy the mucous membrane at a given point by entering into its blood and lymph vessels, thus shutting off its supply of nutriment, and then, as is almost certain, they in turn invade the adjacent bone tissue and destroy that to a certain depth.

Accumulations of desquamated epithelium in the form of concentric laminae or sheets are occasionally found in the antrum or in the epitympanic space. Such masses are often bulky enough to interfere seriously with the drainage of the cavity which they may happen to occupy, and by thus imprisoning the pus and other matters discharged they favor the development in them of putrefactive changes, which in turn stimulate the further production of epithelial laminae. There is also reason to believe that tile persistent expansive pressure exerted by such an elastic mass is competent to cause an absorption of the surrounding bony walls, thus leading ultimately to the formation of one of those large cholesteatomatous cavities containing cheesy material, cholesterin crystals, and concentric layers of desquamated epithelium which are occasionally encountered in dispensary, but rarely in private, practice (see pages 661 and 753).

Accumulations of cheesy pus owe their existence to those different factors which interfere with good drainage, as, for instance, a small perforation in the tympanic membrane, an indirect or tortuous outlet channel (a sinus in the bone, or an opening in the flaccid membrane), granulation tissue, desquamated epithelium, etc. This condition and that described in the preceding paragraph go hand in had and are scarcely separable.

Diagnosis. The first duty of the diagnostician is to ascertain to which of the three groups enumerated above the case in hand belongs. If he begins, as very many men are apt to begin, by syringing the external auditory canal with tepid water, he will not gain as much knowledge in regard to the character of the discharge, its total quantity, and the particular direction from which it comes, as he would if he were to quietly remove it, little by little, with the aid of a cotton carrier and small mops of absorbent cotton. By means of these he should have no difficulty in removing every particle of free fluid discharge from the walls of the canal, from the outer surface of the drum membrane, and even from a large part of the middle ear, when an adequately large perforation gives access to the cavity. In addition to whatever fluid may be present, there are often crust like formations which must be removed before the tympanic membrane and surrounding portions of the auditory canal can be satisfactorily seen. Delicately constructed ring shaped curettes with nicely rounded edges will be found to greatly facilitate the task of removing these obstructions. When once this has been accomplished, the physician will be in a position to determine more or less accurately the source of the discharge. If he has found, on removing the latter with his mops of absorbent cotton, that it is free from any unpleasant odor and is either seropurulent or muco purulent in character ; and if, besides, the perforation be found to occupy a position in the lower half of the membrane, he may consider this part of the examination as practically completed. If the perforation is of small size as it is very apt to be in the cases which belong to the first two groups polypoid masses or granulations are very unlikely to be present in the cavity of the middle ear, and be may therefore abstain from attempts to explore the latter with a probe. The vault of the pharynx is the region which next demands attention, and upon the results of the examination of this region will depend the settlement of the question whether the case belongs to the first or to the second of the groups mentioned.

As already stated, the presence in the external auditory canal of a bad smelling discharge, or of one which is distinctly purulent (I like creamy pus) in character, suggests the likelihood that bone caries, or granulation processes, or both, exist somewhere in the middle ear; and that with these pathological processes is associated some kind of obstruction to the free escape of' the resulting fluid and solid products. In this third group, therefore, the physician is called upon to enter the drum cavity with a suitable probe and to ascertain, if he can, just what are the true relations of things in each individual ease.

When the perforation is located in the lower half' of the drum membrane, the physician will not be able to explore the epitympanic space and the vicinity of the antrum, and fortunately these are the very cases in which such exploration is least often needed. If, however, it should seem necessary to explore these tipper regions, what remains of the posterior half of the drum membrane may be excised and the required amount of room obtained in this manner. When this has been accomplished, or when the perforation already existing occupies the posterior superior quadrant, the entrance to the antrum and a large part of the epitympanic space or vault of the drum cavity may be reached with the end of the probe bent at nearly a right angle. The anterior end of this vault and the head of the hammer can only be reached when there is a perforation in the anterior superior quadrant or in the region of Shrapnell's membrane.

Granulation growths or polypi, collections of cheesy pus or of cast off epithelium, and an exposed surface of bone, or perchance a loose fragment of bone are the objects whose presence may be demonstrated by the skilful employment of a slender bent probe. The same instrument may also give information in regard to the absence of one or more of the ossicles, and it is competent to reveal to us the existence of pockets, or sinuses in the bone, or of enlargements of pre existing cavities (like the antrum) through destruction of the surrounding bony walls.

Probes made of coin silver are sometimes a little too stiff for use in exploring the middle ear. We should therefore have in our supply some which have been made of pure (unalloyed) silver, which can be given any desired curve with great ease. The tip should be expanded into a small knob ; the stem should be very slender for a distance of at least two inches and a quarter ; and, finally, the handle part of the instrument should be either four or six sided, and, proportionately to the stem, fairly thick.

It seems scarcely necessary to add that the physician who thus explores the recesses of the middle ear with a bent probe should have in his mind a well defined picture of the relations of all the different parts; and the importance of delicacy of touch in the safe management of such an instrument must also be emphasized. The main thing is not to disturb the connections of the stirrup, through fear of injuring the hearing. But if this little bone has already been destroyed by disease, the need for such special care, as a matter of course, disappears.

Prognosis. The cases which belong to the first group are of a mild and harmless nature. Even the hearing may be impaired to only a trifling degree; and besides, the interests of the fellow ear are in no degree dependent upon the one which is affected with a discharge. Furthermore, if the disease is allowed to run its course without any treatment, the worst that may happen is, that the discharge will continue indefinitely to annoy the patient to a greater or less extent. The outlook, therefore, is not in any sense bad in cases of this kind. On the other band, the arrest of the discharge may its(]ally be obtained by proper treatment, but the permanency of this arrest cannot be guaranteed; for so long as a perforation in the drum membrane exists, the middle ear will show an increased sensitiveness to sudden changes in temperature, and will be liable to the entrance of irritating matters by way of the external auditory canal. Consequently, relapses will be likely to occur.

Equally mild and harmless are the cases which belong to the second group, but nevertheless they cannot always be considered as may generally be done in regard to those which belong to the first group solely with reference to the interests of the discharging ear. The fellow ear, if it possesses an intact drum membrane, is even more seriously imperiled by the presence of a mass of hypertrophied lymphoid tissue in the vault of the pharynx and on this account, if not in behalf of the discharging ear, the physician is not permitted to speak of the case as being of a mild and harmless character.

On the whole, I believe that treatment is more uniformly successful in these cases that belong to the second group than in those belonging to the first. The perforation is more likely to heal after the mass of lymphoid tissue has been removed, and relapses are less frequent ; for the lack of tone or the lowered vitality, which plays so important a part in the cases of the first group, is not an essential characteristic in these.

Very few cases which belong to the third group can be spoken of as being entirely free from elements of danger. When the perforation in the tympanic membrane is large enough to afford ample drainage outward into the external auditory canal, and when the source of the discharge is located at the posterior end of the middle ear proper (i. e. outside of the antrum) or at some point in the floor of that cavity, we may pronounce the case to be reasonably free from danger to life or health, even if no treatment whatever be carried out. But when the lesions upon which the discharge depends are located in the vault of the tympanum or in the antrum, the danger to life and health must be looked upon as from this point alone greater; and the precise degree of the danger depends upon the extent to which the free escape of the discharge is interfered with.

Certain danger signals sometimes appear in the course of these chronic cases of suppuration of' the middle ear, and show us the necessity of interfering promptly and radically if we wish to avert a fatal catastrophe. Intercurrent attacks of pain in or around the affected ear, paresis or paralysis of the corresponding facial nerve, evidences of disturbance of the circulation in the fundus of the eye, the development of metastatic abscesses or of the condition known as septicemia these are the more important danger signals which cannot safely be disregarded and which call for a grave prognosis. They indicate that at last the barrier which separates the focus of disease from the dura mater, or from the facial nerve, or from one of the venous sinuses which are so closely related to the bony surroundings of the middle ear, has been or is about to be broken down. In rare cases the signals are lacking, and the catastrophe arrives before we have time to ward off the danger.

Finally, the conditions present in these cases of chronic suppuration, especially in the young, are often such as to invite an invasion of tubercle bacilli ; and tubercular disease of the bone in this part of the skull, if not eradicated, is sure sooner or later to infect the neighboring meninges or remoter parts of the body.

Treatment. First Group. In cases that belong truly to the first group the leading indication for treatment is to overcome a paretic condition of the muscular walls of the blood vessels of the tympanic mucous membrane metaphorically speaking, to brace them 'up, to give them tone. This may be accomplished in two ways viz., by the employment of both constitutional and local measures.

Constitutional Measures. The so called tonics often answer the desired purpose in the class of cases which we are now considering. Cod liver oil stands foremost on the list. Teaspoonful doses disguised in the matter of flavor by a few drops of creme de menthe should be taken two or three times a day for a period of several weeks. Strychnin in small doses (1/100 grain to 6 1 0 grain) may also be utilized to advantage, either independently or in combination with the cod liver oil. Finally, where the patient's means wilt permit, the stimulating effects of a change of climate or of a life in the open air may be taken advantage of in our efforts to secure a cure.

Local Measures. Nitrate of silver is the most efficient vaso motor stimulant of which I have any knowledge. A solution of this drug having a strength of from one half of I per cent. to 1 per cent. will best answer the desired purpose in the cases now under consideration. It may be injected into the middle ear by means of a slender glass instrument called a 11 middlecar pipette.," the sharply curved tip of which is passed through the perforation in the membrana tympani. After the solution has been injected, it should be allowed to remain undisturbed in the cavity, in order that it may be gradually absorbed by the mucous membrane, and in this way reach either the muscle cells of the blood vessels or the nerve ganglia which control their action.

The same thing can be accomplished in a less perfect manner by first cleansing the external auditory canal thoroughly and then filling it (while in an upturned position) with the silver nitrate solution. At the end of a few moments, when the solution has become somewhat warmed, pressure should be exerted, first backward and then directly inward, upon the tragus, thus forcing the solution through the perforation. By performing the act of swallowing, the patient may aid the physician in his effort to force the remedial solution into the middle ear and through the Eustachian tube.

Very often a single injection suffices to arrest the discharge, but in some cases it is necessary to repeat the operation several times, either daily or on alternate days.

The introduction of a very small mass of finely powdered burnt alum as much as can be made to cling to the wet end of a slender probe into the middle car will sometimes prove effectual where the silver nitrate has failed.

As the blood vessels in the vault of the pharynx are apt to be in the same paretic condition as those of the middle ear, it is well to make applications of silver nitrate to this region also. The mop employed should be saturated with a solution somewhat stronger than that injected into the middle ear. A 2 or 3 per cent. solution (10 or 15 grains to the ounce of distilled water) will be found sufficiently strong for most cases.

If the discharge is very scanty, as it usually is, no special provision need be made to remove it by the employment of the douche with tepid water. Nor is it advantageous to instruct the patient, as many physicians seem to be doing, to introduce powdered remedies more particularly boric acid into the external auditory canal. There are no processes of decomposition to combat, and the different powders thus prescribed possess no power, so far as I am aware, to give tone to the paretic blood vessels of the middle ear. But even if these powders did possess such stimulating powers, it is not likely that they could effect any good, as it is more than doubtful whether they ever, when introduced in this manner, reach the middle ear.

Second Group. The main indication in this class of cases is to remove the hypertrophied tissues from the vault of the pharynx and to restore this region to as nearly normal a condition as we can. How this is best to be accomplished is a question which doubtless has been fully answered in another part of this work (see page 1203). In all other respects the treatment is precisely the same as that described in the preceding section.

Third Group. These cases present so many therapeutical problems for the physician to solve that only general principles can be laid down here for his guidance.

The removal of all foul products should be his first care. The slender probe, bent at a suitable angle and introduced into the middle ear directly upward toward the tegmen tympani, or upward and backward in the direction of the antrum, will be found of great assistance in loosening and dislodging solid matters like desquamated epithelium and cheesy pus. Hydrogen dioxid may then, by means of the slender glass pipette, be injected in the same directions, not merely for the sake of its germicidal properties, but also because it effervesces with such vigor that if some of it can be forced up beyond the mass loosened by the probe the expanding bubbles will often drive it down within reach of the slender angular forceps. By the aid of these two procedures one may gradually rid the vault of the tympanum, and sometimes even the antrum, of all the obstructing matters which interfere with the drainage, and so perpetuate the processes of suppuration. When the hydrogen dioxid almost ceases to effervesce as it often does oil the occasion of the third or fourth injection it may be assumed that the middle ear has been fairly well cleansed of its foul accumulations. In any event it is not advisable to prolong one of these mining and, seavengering sittings beyond a period of thirty or forty minutes. Before dismissing the patient for not longer than two or three days it is well to stow away in the newly cleansed cavity a few grains of iodoform, aristol, nosophen, or other powder of a character discouraging to germ life.

Often, after three or four sittings such as I have just described, the most careful examination will fail to reveal any evidence of newly formed pus. The powder will be found lying dry upon the parts, and we may dismiss the patient as relieved, if not cured. In a goodly number of instances the term ‘’cure " is almost warranted in speaking of the results obtained by this plan of treatment, for I have known the relief thus promptly obtained to persist for a period of several years. In other cases a relapse will occur in the course of a few months, and the same brief course of treatment will have to be repeated.

It is only in very exceptional cases that the results which I have just mentioned can be obtained only after the removal of the malleus and incus, together with some still existing remnant of the drum membrane. It is claimed by some that it is better to perform this operation in every case of this kind, as by means of it a really permanent cure may be obtained in a larger percentage of cases. So far as I can judge from the published reports, relapses are about as frequent in the excision cases as in those in which the ossicles have been allowed to remain. The better plan, it seems to me, is to resort to excision only when the simple cleansing method described above fails to arrest the discharge.

In a certain number of cases we find the soft parts above and behind the limits of the drum membrane a good deal inflamed. In the presence of such a periostitis, and presumably osteitis, one must be very cautious about indulging in prolonged intratympanic manipulations. It is better to do only a very little of this sort of work at one sitting, and the patient should be instructed to douche the affected ear once or twice a day with as hot water as can be borne. Then, when this more active inflammation has been subdued, we may proceed with the regular routine as already described.

The second guiding principle in the treatment of these cases which belong to the third group is the necessity of cutting or tearing away all granulation tissue or potypoid growths which project above the level of the surrounding mucous membrane. Such imperfectly formed tissue is of itself a source of suppuration, and then, besides, it often interferes by its mere bulk with the drainage of parts situated more deeply.

The various mechanical procedures which are employed for the removal of polypoid growths are discussed in another article of this work. Caustics, like chromic acid, nitric acid, silver nitrate, etc., are of very little use except in cases where the mass is too small to be removed by mechanical means.

The last principle to which I ought perhaps to call attention is the desirability of scraping the surface of an area of bone carriers. This principle at least in its applicability to caries of the middle ear is so far inferior in importance to those of cleanliness, good drainage, and removal of all granulation tissue, that a few words in relation to the matter will suffice in the present article. In tile first place, there are not many cases in which effective scraping can be carried out; and then, on tile other band, in the great majority of instances, proper cleansing measures followed by the application of a suitable antiseptic powder seem to be sufficient to bring about the desired cure These facts, it seems to me, show plainly that the scraping of a carious spot of bone in the middle ear is not a matter of very great importance.

When our efforts to cure a case belonging to this third group fail, it may be safety assumed that the disease is not confined to the middle ear, but has involved other parts in the neighborhood. This allied subject has been confided to another writer, and I therefore do not need to say anything further with regard to it in this place.

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