Examination Of Patients; Symptomatology And Diagnosis; Instruments Needed, And Methods Of Their Employment.

Examination Of Patients; Symptomatology And Diagnosis; Instruments Needed, And Methods Of Their Employment
By JOHN E. SHEPPARD, M. D.,
OF BROOKLYN, N.Y.

THE clinician must always bear in mind the embryological and physiological division of the organ of hearing into a sound conducting and a sound perceiving apparatus, as contrasted with the anatomical division into three parts, the external, middle, and internal ear the sound conducting apparatus consisting of the external and middle ear; the sound perceiving apparatus including, of course, the internal ear, the auditory nerve, and the perceptive centers in the brain. While a consideration of the function requires only the division into conducting and perceptive portions, the threefold anatomical division is, on the other hand, necessary for examination : since for the external ear, including the periotic region, the auricle, external auditory canal, and membrana tympani, we depend principally on inspection and palpation; for the middle ear, including the Eustachian tube and tympanic cavity, we must rely largely on pneumatic measures; and for the internal ear on acoustic methods.

The general plan which it is proposed to follow in this chapter is to describe the methods, in the order in which they come, which I have for years followed as a routine in my daily examination of patients. These may be divided according to the following general arrangement

1. Clinical History, with General Symptomatology
II. Functional Examination;
III. The Periotic Region;
IV. Otoscopy ;
V. Examination of Nose, Naso pharynx, and Pharynx;
VI. Examination of the Middle Ear.
By a general adherence to this plan it is believed that accuracy of diagnosis, the sine qua non of proper treatment, may be most uniformly attained. As an incentive to uniformly thorough examination in every case the writer is a firm believer in some form of history blank, which each aurist may develop by experience to suit his own needs. The one shown at the end of this chapter is the result of the combined experience of my colleague, Dr. Alderton, and myself, and is the one which we have used for several years with eminent satisfaction. The blanks are printed on moderately stiff cardboard, so that they may be kept for reference after the manner of a card catalogue.

I. THE CLINICAL HISTORY, WITH SYMPTONATOLOGY.

A record should first be made of the patient's name, address, age, date of the first visit, occupation, whether previously treated, and, if so, to what extent; after which the patient's general condition of health should be inquired into. The patient should then be asked to state what is the most troublesome symptom, the principal cause of complaint, this statement to be followed by a careful inquiry into the duration of the trouble. My reason for thus commencing the investigation is that in routine cases much time will be saved through thus early getting information which will result in the following questions being asked more intelligently. The so called cardinal symptoms, of one or more of which the patient will complain, and as to the general significance of which a few words are demanded, are tile following: (a) Defect of hearing, (b) tinnitus, (c) pain in or around the ear, (d) discharge from the ear, (e) visible alterations in the external parts, (f) vertigo. It should be remembered that most of these symptoms may arise from extraaural causes; defect of bearing may be due to intracranial lesions; pain is frequently felt in the ear when the trouble is at a distance; tinnitus may be due to increased arterial tension, anemia, toxic, or other general causes; and vertigo has a varied origin. On the other hand, serious constitutional disturbance may arise from unobserved ear disease e. g. some obscure pyemias.

Defect of Hearing. The quantitative and qualitative determination of this will be described later. As having certain symptomatic value may be mentioned the following generalizations: An insidious onset, without definite cause and with early occurrence of tinnitus, is suggestive of middlecar catarrh (sclerotic form). Relatively rapid loss of hearing (from good hearing to great deafness within a month), with but few or no accompanying symptoms, suggests the possibility of labyrinthine syphilis. Sudden deafness without symptoms points to the probability of cerumen impaction. " Hearing better in a noise " (paracusis Willissii) means, as a rule, a special form of middle ear disease; while those with nerve deafness boilermakers and others usually hear worse in a noise. Autophonia, or tympanophonia, that condition in which the patient's voice seems to him to go out through the ear instead of the mouth, indicates, as a rule, some pathological condition of the Eustachian tube, but is occasionally present in other conditions of the middle ear or in impacted cerumen. It is, on the contrary, so far as my knowledge goes, never met with in internal ear troubles.

Tinnitus should next be inquired about. It is variously described by patients, but two general classes may be made out: 1. Pulsating, due to arterial congestion which is probably in either the external or middle ear if it is stopped by pressure on the common carotid, and in the internal ear if stopped by pressure over the vertebral artery in the suboccipital triangle; 2. Non pulsating, or continuous, with varying characteristics: the highpitched sounds, hissing, singing, etc. are often due to increased tension in the middle ear, irritating the auditory nerve, and often relieved by inflating the tympanum; the deep humming sounds, worse after exertion, relieved after lying down a little time, are often due to anemia; the rushing Sounds are often due to venous congestion, are worse on lying down, and may be relieved by purgation. Finally, it should not be forgotten that the hearing by the insane of bells, music, voices, etc. may be caused by aural disease, at times remediable. It is of course easy to locate in the middle ear the little cracking due to swallowing, the crackling caused by air entering a tympanic cavity containing fluid, the loud pulsating sounds accompanying acute inflammations of the membrane, the tympanum, or the mastoid cells, or the loud, at times rhythmic, noises due to contraction of the palatal muscles, generally with participation of the tensor tympani or stapedius muscles (often perceptible to others).

Pain earache is an important symptom, and should be carefully investigated. It accompanies acute inflammatory affections of the external and middle ear, the exacerbations common in chronic middle ear inflammations, with extension of caries or development of cholesteatoma, as well as mastoiditis and mastoid periostitis. In inflammation of the external ear the pain is usually accompanied by tenderness in front of or below the auricle, and is increased by motion of the jaw. If it is the tympanic membrane or tympanum that is involved, the pain is accompanied by more or less deafness, and is increased by sneezing, coughing, blowing the nose, or by inflation. Pain in the course of a chronic middle ear suppuration usually indicates pusretention, and is described by the patient as deep seated. In inflammation of' the mastoid or its covering periosteum. the pain is more or less radiating in character, and is commonly attended by tenderness over all or part of that process. Reflex pain, neuralgic in character, is often felt in the ear, all the other cardinal symptoms of car disease being absent, and is caused by diseased teeth, inflammatory conditions about the throat and tongue, and by malarial poison and the rheumatic diathesis.

Discharge. Inquiry should be made whether there is discharge, and, if not, whether it has previously existed. If there has been discharge which has ceased, then it is only natural to expect to find the results of such suppuration in the shape of cicatrices in the membrane, old dry perforations, or more or less binding down of the structures in the tympanic cavity by cicatricial tissue ; if there is discharge, note the quantity, the time since it commenced, the nature of it that most frequently found is pus and if this be in considerable amount, and particularly if it contain mucus, it is safe to say the trouble is in the middle ear and that the membrane is perforated ; when mixed with blood it usually indicates granulations or polypi; a copious hemorrhage late in a chronic suppurative case usually means erosion of a blood vessel, internal carotid or bulb of the jugular. A scanty discharge, at first watery, then purulent, attended with itching, would indicate the external canal as the source. Fetor of the discharge is of relatively little diagnostic value unless very persistent Under treatment, when it becomes suggestive of diseased bone or retention of putrefactive material in the antrum or mastoid cells. Duration of discharge and mode of onset are significant. A recent sudden discharge, preceded by pain, indicates acute middle ear inflammation; but if not preceded* by pain in an ear which has not previously discharged, suspicion of tubercular trouble should be at once aroused. A history of discharge recurring at intervals of from two weeks to two months, lasting but a short time, and usually preceded by pain, is good ground for suspecting attic trouble with perforation in Shrapnell's membrane. The long standing of a suppuration indicates most often neglect; in other cases granulations, polypi, carious ossicles, involvement of the antrum or mastoid cells, and at times naso pharyngeal disease or constitutional dyscrasia.

Vertigo. Under this heading may be mentioned not only the disturbances of equilibrium, but, as being closely allied thereto, the nausea, vomiting, and loss of consciousness which at times accompany conditions and manipulations of the ear. Since we see these symptoms with pathological conditions of the several parts of the ear, they cannot be said to indicate any particular disease, excepting possibly in the case of a patient having a tendency to fall always in the same direction. As a rule, the patient falls away from the affected ear, and in such a case it is presumptive evidence in favor of a lesion of the internal ear, probably some portion of the semicircular canals. An attack which from the suddenness and severity of its first appearance seems almost apoplectiform. in character, attended by deafness, tinnitus, and often vomiting, suggests, of course, hemorrhage into some portion of the labyrinth. Less violent vertigo arises from increased tension of the labyrinthine fluid secondary to middle ear disease e.g. pressure of a granulation or a cholesteatomatous mass upon the stapes, or from syringing too forcibly or with too cold water. There are various other sources of vertigo, however, besides the ear, which must be excluded.

Cause. Having thus gone through with the symptomatology, the patient should next be interrogated as to the supposed cause whether there may have been an injury to the ear or bead; in regard to bathing, to headcolds, throat affections, mouth breathing, exanthemata, or whether he has had syphilis, rheumatism, or gout ; or if be has been taking large doses of medicine, such as quinia or the salicylates ; and finally, whether or not the occupation may have any bearing on the case. Under this heading information of great value will be frequently obtained as regards both diagnosis, prognosis, and treatment. As the next step, may be summed up, as briefly as possible, the course of the trouble, a recapitulation, as it were, of the history as gained up to this time the principal complaint, its mode of onset, its duration, and the necessary data with regard to the symptoms. The final step in this part of the examination, which in very many cases may be omitted, is an inquiry into the family history with regard to deafness. Since in some cases important information is obtained, it seems well to have a space in the history blank devoted to heredity. Following this is another space for 11 Remarks," which should be a part of every record blank, in which should be noted anything of interest peculiar to the case and for which there is no place elsewhere.

III. FUNCTIONAL EXAMMATION.

Having thus finished the preliminary examination, the next tiling to investigate is the function of the organ. How much is the hearing impaired? Where is the lesion that causes the deafness?

1. Quantitative Tests. To determine how much the hearing is affected compare the distance the ear under examination bears a given sound with the distance the same sound is heard by a normal ear. This is conveniently expressed in fraction form, as suggested by Prout, the denominator representing the bearing distance, in feet or inches, of the normal ear; the numerator, that of the car being investigated. The sounds most used as tests are the tick of a watch and of Politzer's acoumeter, the voice, and the vibrations of the tuning fork. The watch tick answers very well for observations by the same individual, but does not permit a comparison of results with those of other observers. To meet this objection Politzer devised his acoumeter (Fig. 470), so that all might have an instrument giving a sound of uniform quality and intensity. In testing the hearing with either of these they should be gradually brought from beyond the limit of bearing toward the ear until beard. The ideal test for impaired bear¬ing, however, is the human voice, and the different degrees of deafness are represented as hearing for whispered words, for ordinary, loud, or shouting conversation. For different observers to obtain as nearly as possible a uniform result in the test with whispered words the so called " reserve air " method should be used, the reserve air consisting of what is left in the lungs after a forced inspiration followed immediately by a normal expiration. Since patients become rapidly accustomed to test phrases if repeated, this should be avoided g. by using numberw, of two figures, interspersed at times with words or phrases of' another character. To avoid error if one ear is very deaf and the other but slightly so or not at all, with the latter stopped tightly with the moistened finger of the patient, or, better still, of an assistant, and the deaf car toward the examiner, note the result ; then have in addition the deaf ear tightly stopped and repeat the tests. If, now, the patient hears the same as with the deaf ear unstopped, it is evident that deafness is complete, and that the hearing in the first test was with the stopped ear. Since the mere sound may be heard, the patient should be made to repeat the words in all the tests.

2. Qualitative Tests. Having with the preceding tests found the amount of deafness, the purpose of the following measures is to locate the lesion either in the sound conducting or the sound perceiving apparatus, for which purpose we use the Galton whistle and tuning forks of various pitch. The normal ear perceives vibrations as musical notes when repeated at regular intervals from 16 up to 32,500 vibrations to the second, and these may be called the lower and upper limits of audition. These limits vary in a characteristic way with disease of the conducting or perceiving apparatus. Again, there is a fairly definite ratio in the normal ear between the duration and loudness of tuning fork vibrations by air and by bone conduction, and this ratio is altered more or less definitely according to the part of the car affected by disease. The lower tone limit, or rather any lack of hearing for the lower notes, may be determined with sufficient accuracy by means of the C' large clamp tuning fork (Fig.471), whose range of vibrations is from 26 to 64 to the second. The upper tone limit can be most accurately determined by Konig's rods, but these are too time consuming for daily use, and Galton's whistle (Fig. 472) gives the same result much more quickly and with sufficient accuracy.

To properly compare air with bone conduction we Deed the absolute duration of each and the relative intensity of the two. To obtain the former a freshly struck tuning fork is held in front of the external auditory canal, the time in seconds being taken from the moment it is struck until it ceases to be beard by the patient; duration of bone conduction is obtained in the same way, except that the handle of the vibrating fork is rested firmly upon the mastoid process until it is Do longer beard. Relative intensity is obtained by placing a freshly struck tuning fork in rapid succession two or three times upon the mastoid and opposite the meatus, and having the patient determine whether air or bone conduction is louder. By air conduction the soundwaves reach the perceptive centers through the sound conducting apparatus; by bone conduction the path is through the cranial bones. In the normal ear the duration of air conduction is, roughly speaking, about double that of bone conduction. In obstructive trouble in the conducting apparatus the duration of air conduction is lessened as compared with that of bone conduction. In trouble with the perceptive apparatus the duration of both is lessened, that for bone relatively more than that for air conduction, especially for the higher forks. Aided by these facts, the methods of locating the lesion may be briefly reviewed.

Weber's Test. Weber found that if a vibrating tuning fork was placed upon the middle line, antero posteriorly, of the head, either on the vertex, forehead, or upper incisor teeth, and one ear stopped, the fork was beard louder in that ear. Reasoning from this, in any given case, if the hearing is impaired in one ear only or unequally in the two ears, and a vibrating fork on the vertex is heard better in the worse bearing ear, it follows that the lesion in the bad ear is 'an obstructive one i. e. in the sound conducting apparatus; and, vice versa if it is heard worse in the worse hearing ear, then the trouble is in the perceptive apparatus.

Rinne's Test. If the conducting apparatus in any given case is normal and a vibrating fork is pressed upon the mastoid until it ceases to be beard by bone conduction, and is then held opposite the meatus, it is again heard by air conduction. If the conducting apparatus is affected to any marked extent, the vibrating fork, allowed to die away on the mastoid, is not heard when brought opposite the meatus. In the former case (air conduction exceeds bone conduction, A. C. > B. C., and Rinn6's test is said to be positive (R. +), and indicates, as a rule, no marked trouble with the Conducting apparatus (middle ear). In the latter case bone C conduction preponderates (B. C > A C.), and Rinn6's test is negative (R. ), indicating disease of the conducting parts (middle ear).' In many cases, undoubtedly' Weber's and Rinses's tests give valuable information; yet there are many, the doubtful or border line, cases in which they cannot be relied on for diagnosis.

Schwabach's Test. In this method the Hartmann series of five forks is used: C = 128 v. s., C' ~ 256 v. s., C" = 512 v. s., C... = 1024 v. s., C = 2048 v. s. ; and of these the absolute duration and the relative intensity of both air and bone conduction are noted. When compared with the results obtained from examination of a series of normal ears this furnishes data which, in my judgment, are most valuable for diagnostic purposes. The C 1 fork, 26 to 64 v. s., may be added to the series. As Alderton has shown, for routine work a sufficiently accurate result in the majority of cases may be obtained by using the low fork C or C and the C fork, these indicating pretty clearly the location of the trouble. A diagnosis of middle ear trouble, having eliminated by inspection obstructive trouble in the external auditory meatus, may be made after going through with some or all of the above tests I. If there is loss or impairment of bearing for the lower notes of the scale, with elevation of the lower tone limit ; IT. If air conduction only is diminished, bone conduction remaining unchanged or even increased the normal ratio of B. C. < A. C. being thus changed, particularly so for the lower notes. If the lesion is marked, B. C. becomes louder and longer than A. C.; III. If with the impaired hearing the upper tone limit by A. C. is but little, or not at all, affected. Diseases of the internal ear are recognized in the same manner by 1. No elevation of the lower tone limit; IT. The maintenance through the lower notes of the normal ratio between A. C. and B. C., the absolute duration of both being, however, reduced, and very markedly so, that for the higher notes by B. C. ; ITT. Lowering of the upper tone limit, with frequently entire deafness for certain of the higher notes.

To illustrate the manner of recording in compact form the result of tuning fork investigations, I have subjoined a record for normal hearing, for chronic middle ear catarrh, and for disease of the sound perceiving apparatus. The relative intensity is shown in the horizontal space marked Riinne A. C. being louder than B. C., it will be observed, throughout the series in normal hearing and in nerve deafness; the reverse being true for chronic catarrh, B. C. being louder than A. C., except for the highest fork, in which the intensity by A. C. and by B. C. are about equal. The figures represent absolute duration in seconds, the upper line representing the duration by A. C., the lower one that by B. C.:

To those who wish to get along with the smallest possible number of diagnostic instruments for ear work it may be said that fairly accurate opinions may be formed with the use of but three instruments ViZ. a lowpitched tuning fork (C'), 26 to 64 v. s., to determine the lower tonelimit, and thereby the presence of trouble in the conducting apparatus; a Galton whistle, to determine the upper tone limit, and thereby the presence of disease of the perceptive apparatus; finally, another tuning fork, of 512 or 1024 v. s. (with such a group of instruments, I should say the one of 1024 v. s. would give the most information), for the determination of absolute duration of A. C. and B. C. To one determined to get along with but one fork I would recommend C" of 512 v. s., but with this alone accurate diagnostic work is impossible. Other tests have been devised to aid in locating diseases of the ear.

Gelle's Test (Pressions Centripetals). In the normal ear, if a vibrating tuning fork be placed on the vertex, and then the air in the external auditory canal be compressed, the sound dies away, to return again with removal of the compression. This is believed to prove mobility of the chain of ossicles, but particularly of the foot plate of the stapes in its niche, and Gelle's test is positive, +; otherwise it is negative, ; i. e. in rigidity of the ossicular chain (trouble in the conducting apparatus).

Bing's test or experiment is essentially a modification of Weber's test. A vibrating tuning fork is held on the vertex until it ceases to be heard; then either external auditory canal is closed with the finger, and the fork is again heard for an interval which is called the period of secondary perception. With a normal conducting apparatus this interval of secondary perception is well marked; hence if the interval is shortened a lesion of the sound conducting apparatus is to be inferred. If the interval be normal and yet deafness is present, the seat of the trouble must be in the perceptive apparatus.

Other tests, a detailed description of which is forbidden by lack of space, are those of Itelberg and Gradenigo relative to the "fatigability " of the perceptive apparatus; that of 11 binaural synergy " of Galls ; the " interference otoseope" of Lucae; and the reaction of the auditory nerve to the electric current.

III. THE PERIOTIC REGION.

Having thus finished the preliminary history and the functional examination, we may now investigate the parts surrounding the auricle, making use of inspection and palpation for this purpose. The supra auricular region is at times the seat of subperiosteal abscesses in adults as well as in children. The preauricular region may be the seat of mumps, lymphadenitis, parotitis, or pus burrowing. In the infra auricular region lymphatic inflammation with redness and swelling is common in acute inflammatory affections of the external ear. A hard, cord like, tender swelling along the anterior border of the sterno mastoid muscle should arouse suspicion of sinus disease involving the jugular. A more diffuse, hard swelling in this region is a common accompaniment of the Bezold form of mastoid abscess, breaking into the digastric fossa. The postauricular or mastoid region should always receive careful attention, particularly in cases attended by pain or suppuration. There may be pain, tenderness, redness, swelling, fluctuation, sinuses, or cicatrices. Pain, with or without other evidence of underlying trouble, is one of the most important symptoms of mastoid inflammation. The point of greatest tenderness, whether on or behind the mastoid process should be noted, remembering %hat tenderness of the mastoid itself usually means underlying inflammation, while tenderness behind it, particularly if at the seat of the mastoid foramen, may mean disease of the lateral sinus. Swelling is either circumscribed and movable, when it indicates an inflamed gland, or diffused, as in subperiosteal abscess, etc. Fistula and sinuses must be carefully investigated. When congenital they usually open anteriorly, and are often attended by other malformations. When acquired they are most often postauricular, and may lead to the remains of a superficial (glandular abscess, forward to the external auditory canal, to the periosteum, to the underlying bone, to the interior of the petrous bone, to the groove for the lateral sinus, or into the cranial cavity. The presence of cicatrices may throw light on the nature of previous troubles.

IV. OTOSCOPY.

Now that we approach the examination of the car itself, it should be remembered of the external auditory canal that it is somewhat oval in section, about 1 1/4 inches in length, its general direction inward, forward, and upward, and that it is somewhat angled at the junction of the cartilaginous with the bony portion. Hence to straighten the canal for purposes of examination the auricle must be pulled outward, backward, and upward, except in infants and young children, in whom, owing to the absence or shortness of the bony portion, it should be pulled downward instead of upward (see Plate 10). The relation of the tympanic membrane to the inner end of the canal should also be borne in mind, the plane of the membrane being from, above and behind in a direction downward, forward, and inward, in the very young approaching more nearly the horizontal than in the adult (? ED.), so that the posterior superior quadrant is nearest to the outer end of the canal, and may easily be injured, particularly in children, by the careless introduction of a small speculum.

Illumination. To examine an ear it is necessary to have some means of illuminating it, and, since direct illumination is for various reasons unsatisfactory, we now use altogether the reflecting mirror, preferably so fixed with a band as to be used as a head mirror, which may, if desired, be used as a hand mirror. It should be provided with a double ball and socket joint (Fig. 473); may vary in size from 2" to 411 in diameter; should have a hole in the center, through which the examiner may view the ear; should be concave, and, most important of all in making a selection, should have a focal length of not less than 6 nor more than 10 inches.

Of next importance to the mirror is the speculum. This may be made of metal (German silver, aluminum), hard rubber, glass, or celluloid; it may be round or oval in section, with or without a curve between the large and small ends, may be long or short, and made up in sets or "nests” of three or four different sizes. The choice of material may depend largely upon personal preference. Each kind has its advantages and disadvantages. My own preference is for the hard rubber, or, still more, for the pinkish (flesh colored) celluloid, which I have now used for two years with great satisfaction.

Other instruments needed for the routine examination of the ear are such as are used for the removal of the frequently found obstructions in the canal cerumen, hairs, epithelial flakes., cotton, etc. These, when small or in the cartilaginous portion may often be pushed aside by the speculum, but, if large or in the bony canal, must be removed by other means. Should the canal be blocked by a large ceru¬minous or epithelial plug a foreign body, or with pus, it is best cleansed by the use of a syringe and warm water. The most satisfactory form of syringe for office use is one with either glass or metal barrel, of two to four ounces capacity, and having an angular tip of small diameter (Fig. 474). Other instruments for this purpose are the cotton carrier, the probe, the blunt book, the Gross ear scoop and hook, and some form of ear forceps. An ordinary steel cotton carrier answers the purpose. In using it wrap a small pledget of cotton tightly, leaving about 1/4 inch of the cotton beyond the end of the carrier to protect the canal walls from injury. With this much loose debris can be easily mopped from the canal, as well as small quantities of pus, etc. As a rule, entirely too large a pledget of cotton is used: much better results can be obtained from a few small pledgets intelligently used in a wellilluminated canal than from an unlimited number of the large pledgets that are so much in vogue. The probe and blunt hook, as combined in the Hartmann instrument (Fig. 475), are very useful in clearing out a canal and investigating the condition of its walls as well as of the tympanic membrane. The Gross ear scoop and hook, found in many of the minor surgical pocketcases, is also a decided aid in many cases, but must be used with great caution and with good illumination of the canal. A good pair of ear forceps is a necessity their number and forms approach legion: that which has served me most usefully is the Hartmann dressing forceps (Fig. 476).

It may not be out of place to make one more general remark about all ear instruments which permit of it i. e. they should be bent at an angle of about 135', instead of being straight, because this shape allows of easier and more skilful use, and avoids the objection which holds against all straight instruments viz. that with them the index finger must of necessity intrude more or less upon the line of vision.

Source of light. In ear work this is a matter of importance. Sunlight, daylight from a northern window, the reflection from white clouds, a white wall or fence, cannot any of them, be used at all times. Hence artificial light, which may be bad constantly and of uniform intensity, must be our standby. The oxyhydrogen flame, the incandescent electric light, gaslight plain or modified by the Welsbach burner, the kerosene lamp, the old-fashioned tallow dip, have all of them their uses; but for routine work my preference is for the Welsbach burner.

Technic of Examination. The ear to be examined should be turned away from the light and toward the examiner, the light being about on a level with the patient's ear. The examiner should always use the same eye, thus training it to do the best possible work, and should with the chosen eve always make the observations through the perforation in the center of the head mirror. The other eve should always be kept open, both to avoid fatigue and to locate the direction of the reflected light and to aid in focussing it more quickly upon the ear. This being done, the auricle, the concha, and so much as possible of the canal should be carefully observed before a speculum is introduced; otherwise affections of these parts may be bidden by the speculum and entirely overlooked. Should pieces of epithelium or cerumen be in the way, remove them carefully; should the canal walls be found swollen, as from furuncle, introduction of the speculum may be too painful and have to be postponed; in such a case the evident swelling, together with the history, perhaps sufficing for a diagnosis.

Having the light properly focussed, and having chosen a speculum of appropriate size, it is introduced as follows: Seize the upper outer part of the patient's auricle, if the right one, between the middle and ring fingers, if the left one, between the index and middle fingers, of the left hand, and, supposing the case to be an adult, pull the auricle firmly upward, outward, and a little backward to straighten the canal ; then with the right band introduce the speculum, with a slight rotary motion, inward past the frequently existing hairs, etc. in the outer portion of the canal, and grasp it between the left thumb and index finger, the right hand being thus left free for other manipulations. Epithelial flakes, cerumen, pus, etc. obstructing the view must be removed by the appropriate instruments, so that an unimpeded view of the tympanic membrane may be obtained. An occasional difficulty is an unduly prominent antero inferior canal wall, but practice in changing a little the line of vision and the position of the speculum will overcome this. In exceptional cases the presence of the speculum, in the ear gives rise to a troublesome ear cough, and still more rarely to a feeling of faintness or positive fainting, or even to epileptiform attacks. As a rule, however, the patient becomes rapidly accustomed to the presence of the speculum.

Appearances of the Canal. The epidermis lining the normal canal has an opaque whitish color. Under pathological conditions the walls may become hyperemic, may be the seat of localized or diffuse swellings, or may show serous or purulent excretions, ulcerations, or fistula , while the lumen of the canal may be more or less filled with serous, mucous, or purulent secretions, with collections of cerumen or thrown off epithelium, with foreign bodies, or with tumors (exostoses, polypi, etc.) which arise either from its walls or from the tympanic cavity.

Appearances of the Tympanic Membrane. The normal membrane is somewhat oval in shape, pearly gray in color, and translucent, with certain prominent landmarks the short process of the malleus, antero superiorly, looking much like a small pustule (a, Fig. 477), with the manubrium or handle of the malleus running from it downward and backward to the center of the membrane, the umbo (i); antero inferiorly from this is the triangle of light, 11 cone of light," or light reflex (m), due in shape and position to the concavo convex face of the membrane ind its general oblique position relative to the axis of the canal, whereby the rays of light from the observer's mirror strike only here upon a surface at right angles to the line of vision the rule being that any point which appears brightly illuminated is on a plane at right angles to the line of sight. The margins of the membrane are set in the bony tympanic ring, which encircles it completely except at its upper part, where there is a notch, the notch of Rivinus. Filling in this space above the short process is the flaccid membrane or Shrapnell's membrane, separated from the other portion of the membrane, the tense or vibrating membrane, by the anterior and posterior folds (e.g.), whiter than the rest of the membrane and running forward and backward from just above the short process.

Pathologically the tympanic membrane may present

(a) Changes in Color. The luster may be lost, with general dulness and indistinctness of the landmarks, from soaking, loosening, or thickening of the outer layer of the membrane (drops, syringing, superficial or underlying inflammation). Opacity results from thickening of any or all the layers, either of the whole membrane or of circumscribed yellow or white patches, single or multiple, large or small, due to fibrous or calcareous degeneration, and indicating, as a rule, severe preceding inflammation. A bright, coppery appearance is due to a congested tympanic mucosa. A dark, hair like line, concave upward across the whole membrane or across either anterior or posterior half, or both (see Fig. 467), indicates fluid in the tympanic cavity. In hyperemia the individual blood vessels, not normally seen, become visible along the malleus handle (see Fig. 8, Plate 11) over Shrapnel's membrane, or radiating in a thick network over the rest of the membrane, which, in the higher grades of inflammation, becomes pink or even bright red, all the landmarks being lost.

(b) Changes in Surface. The normally smooth surface of the membrane may become irregular through the projection of ecchymoses, vesicles, interstitial abscesses, granulations, polypi, or through the wrinkling due to large cicatrices, or to atrophy, or to loosening of the superficial epithelial layer, from disturbance of its nutrition, seen occasionally in acute underlying inflammation.

(c) Changes in Position. The membrane may be retracted or bulged, either in part or in its entirety. Retraction, as a whole, is usually due to insufficient ventilation of the tympanic cavity, and is recognized by the following changes in appearance: the anterior half is thrown into deeper shadow; the short process is unduly prominent, as are the anterior and, to a greater extent, the posterior folds ; the malleus handle is fore shortened, the lightreflex lessened in size and brilliancy or absent, and at times the tympanic cavity's inner wall and other structures become unduly visible viz. the promontory posteriorly, the round window niche postero inferiorly, and postero superiorly the descending process of the incus, the head and posterior crus of the stapes, the tendon of the stapedius muscle, and, finally, the chorda tympani nerve crossing the tympanic cavity just below the posterior fold. Circumscribed retraction is due to the indrawing either of atrophic areas, which usually have ill defined margins, or, much more frequently, of thin cicatrices, which may be large or small, single or multiple, adherent or non adherent, with margins, however, as a rule, definite and cleanly cut. These localized depressions appear thinner, more translucent, and, when not adherent, more movable than the surrounding membrane, and they not infrequently present at their deeper portions a larger or smaller light reflex. Bulging of the membrane, either localized or general, is usually caused by fluid in the tympanic cavity.

(d) Loss of Substance. Perforations vary in size from a pinhole to absence of almost the whole membrane. They may occur in any part of either the vibrating or the flaccid membrane, or be present in both simultaneously. They present as circular, elliptical, oval, kidney or heart shaped openings, through which the tympanic mucous membrane becomes visible. Two, three, or four perforations of the same membrane are occasionally seen, and among the great rarities may be mentioned the sieve like perforations which at times accompany tubercular or diphtheritic otitis media. It should be noted whether the margins of the perforation are red and raw, as in recent active perforations, or white and cicatricial, as in permanent openings. In examining for suspected perforation it is of the greatest importance that the whole surface of the membrane should be swept over with the eye, particularly near the margins; and on no account should Shrapnell's membrane be overlooked, that part from which we obtain evidence of the most serious of middle ear troubles (see Plate 11).

The diagnosis of perforations is, as a rule, easy, but is at times difficult, particularly so of the very small and the very large ones in the former because the size permits the edges to completely overlie one another, making a diagnosis by unaided inspection at times impossible; in the latter, in which _e. g. the whole vibrating membrane, including the malleus handle and short process, have been destroyed by the suppurative process, because we have not the edges of the perforation sufficiently in evidence to aid the eye to establish the two planes that for the perforation margins and that for the inner tympanic cavity wall. In the difficult cases the following aids to diagnosis may be mentioned: 1. A perforation whistle can usually be obtained by forcing air, by some of the methods to be described, from the nose, through the Eustachian tube, out through the perforated membrane. 2. If before using the air douche in a given case the external canal is thoroughly dried, and after using it fluid is found, its presence is almost certain proof of a perforation. 3. Another proof is furnished by the passage of fluid into the naso pharynx when springing an ear. 4. A perforation is indicated by the presence of mucus in the water with which an ear has been syringed. 5. A pulsating light reflex seen in the depth of a canal means with the greatest probability a perforated membrane.

To distinguish perforations from cicatrices and atrophic spots, in addition to the above guides, there are two instruments which, as aids to diagnosis, should be the constant companions of the aurist. The first of these is the bent probe and blunt hook (see Fig. 475), whose use is to determine the point of insertion, consistence and mobility, of tumors or inflammatory new growths (polvpi, exostoses, furuncles), to determine the presence of fistulous openings or of bone caries, as well as by actual touch to investigate the surface of the membrane (perforations, etc.). The other instrument is Siegle's pneumatic speculum, or suction specalum (Fig. 478).

To the examiner illuminating the canal through the air tight speculum will thus be disclosed whether the mobility of the malleus is impaired or whether the membrane is relaxed ; sunken 'cicatricial pouches can be distinguished from open perforations, adhesions of the membrane or of depressed cicatrices, or of the malleus handle to the inner wall of the tympanic cavity can be made out; and not infrequently collections of pus in the attic or antrum. can be detected and emptied by this apparatus.

V. EXAMINATION or NOSE, NASO PHARYNX, AND PHARYNY.

Since so many of the middle car diseases have their origin in the approaches to the Eustachian tube, the examination of the nose, nasopharynx, and pharynx may well be made preliminary to an investigation of the middle ear. for the details of such examination the reader is referred to the appropriate chapters, special attention being given to the following points: 1. In the examination of the fences, to the activity of the palatal muscles during phonation, these being also tubal muscles ; 2. To the appearance of the naso pharynx, and especially of the mouths of the Eustachian tubes, by posterior rhinoscopy ; 3. To the patency of each nostril in relation to respiration, ventilation, and Eustachian catheterization.

VI. EXAMINATION OF THE MIDDLE EAR.

As preliminary to and really a. part of, investigation of the middle car must first be considered the different means of determining the potency of the Eustachian tube. For the accomplishment of this, three methods may be used :

1. As giving a valuable preliminary idea of the condition of the tubes may be tried Politzer's experiment of holding a vibrating tuning fork in front of the patient's open nostrils, when, during the act of swallowing, if the tubes are patulous, the vibrations are more distinctly heard by the patient. The rationale is of course plain: the act of swallowing opens the tubes when they are normally patulous, and the sound passes through them into the tympanic cavity. Negatively, if* under these conditions the patient hears the vibrations on one side only or fails to hear them on either side, it is evidence in the former case of tubal obstruction on the side on which the fork was not heard; in the latter case tubal obstruction on both sides is to be suspected.

2. Inflation of the Ear, with Auscultation. Several methods of inflation are in vogue, with all of which auscultation may be carried out, with by far the most success, however, in the first method to be described viz. :

A. Inflation by means of the Eustachian Catheter. The instruments necessary for this are (a) Eustachian catheter, made of metal or hard rubber (to the latter I give the preference), 5 1/2 to 6 inches long, and made in three sizes; its last inch, the tip or beak, is gently curved till the point makes with the shank an angle of 140' to 150' ; the large end is funnel shaped to fit a corresponding tip on the air bag, bottle, etc., and has on it a ring pointing in the same direction as the tip of the catheter. (b) An air bag, single or double. (c) The auscultation tube, which has been miscalled an " otoscope," consisting of a piece of light rubber tubing 24 to 30 inches long, having at the ends olive shaped pieces one white, the other black, so that they may be distinguished from one another, and the same one always used by the examiner. With this the sounds caused by the passage of air through the Eustachian tube into the tympanic cavity are observed. Before describing the introduction of the cat6ter the following general remarks may be in place : Catheterization should be performed with both patient and physician in the sitting position ; the 'patient's head should be in such position that the floor of the nose will be as nearly as possible horizontal. While a bead rest is useful, it is by no means necessary; secretion should be, as far as possible, removed (by blowing, etc.) from the Dose and naso pharynx; a dash of cocain may without disadvantage be applied to the nostrils. The patient should keep the eyes open, should on no account hold the breath, but should breathe through the nose it is well to occupy the patient's bands by giving them the air bag to hold then with the diagnostic tube in place, dip the already disinfected catheter into water or oil, blow through it to empty it and to see that the lumen is clear, and proceed to introduce the catheter.

With the fingers of the left band resting on the patient's forehead and nose, where they should remain until the end of the procedure, the tip of the nose being moderately elevated by the left thumb, the catheter is held like a pen between the thumb and first two fi Users of the right band, and is entered, in almost a vertical position, into the nostril until the beak passes over the initial eminence on the floor of the nose. It is then rapidly brought to a horizontal position, and passed gently backward until the beak is felt to touch the posterior pharyngeal wall; if the catheter is brought too slowly to the horizontal position, the tip, instead of passing along the floor of the nose, may easily enter the middle meatus. Another important consideration is to hold the catheter as lightly as possible, not firmly grasped, when, with almost inappreciable force from behind, it will in the majority of cases find its own way through the nostril. Up to this point viz. finding the posterior phary ngeal wall with the beak of the catheter the two methods to be described of finding the mouth of the tube are identical. By the first and certainly the easier method the beak, as indicated by the ring at the outer end of the catheter, is turned toward the side to be catheterized into the fossa of Rosenmiffler; it is then drawn gently outward for from I/3 to 3/4 of an inch, when the impression is given, and after a little practice readily recognized, of the beak turning downward as it passes the prominent posterior lip of the tubemouth, followed, as it enters this, by a distinct feeling of turning upward again. It should now, the ring pointing toward the outer angle of the eye, be firmly grasped between the thumb and index finger of the left hand, the other fingers remaining in position on the patient's nose; the operator's hand, the catheter and the patient's head becoming thus, as if were, one body, so 9 that movements of the latter do not displace the catheter. By the second method, instead of turning the beak of the catheter toward the, side to be catheterized, it is turned toward the opposite side, drawn forward until the beak is felt to impinge against the posterior edge of the nasal septum, and is then rotated downward through an are of 200', when it will, as a great general rule, enter the mouth of the tube, and is to be grasped as before. Air is now blown through the catheter and Eustachian tube into the tympanic cavity, and the important information gained from the auscultation tube is to be noted.

Auscultatory Sounds. These are produced either at the pharyngeal end of the Eustachian tube, in the tube itself, or in the tympanic cavity. With the parts in a normal condition there is heard with each compression of the air bag a soft, dry, blowing sound, together with a slight thud or impact sound of the current of air against the tympanic membrane. Pathological conditions in the tympanic cavity, in the tube, or in the naso pharynx change the character of the sounds beard in a more or less characteristic Wayne. g. the crackling rides of fluid in the tympanic cavity, the whistle with a perforated membrane, the high pitched rather distant sounds due to a narrowed Eustachian tube, the coarse distant rasping due to mucus in the pharyngeal end of the tubes. These sounds are worthy of careful study, practice enabling one to localize their source and to gain important knowledge of the conditions present.

Obstacles to Catheterization. These are met with in the nose in the form of deflections, ridges, and spurs of the nasal septum; and in the naso pharynx in the form of variations in the location and prominence of the pharyngeal extremity of the Eustachian tube in different cases; and on the two sides of the same case in the varying width of the naso pharynx, and from muscular contraction due to the presence of the catheter in the Dasopharynx. Skill and patience will usually succeed in getting the catheter past the nasal obstructions; if not, a catheter with a larger curve to the tip may be passed through the other nostril. Delicate manipulation with differently curved catheters or with the same catheter differently moulded, at the same time insisting that the patient breathe through the nose, will overcome the obstacles met with in the naso pharynx. Timidity of a patient when catheterized for the first time, and the discomfort to all patients in whom difficulties are encountered, may be greatly lessened or entirely avoided by the use of a small quantity of cocain solution.

Dangers of Catheterization. Emphysema, even fatal in its consequences, has resulted from the use of the Eustachian catheter with highly condensed air; but with the hand apparatus, some form of which is at present almost universally used, even slight emphysema should never result. The experience of one of my colleagues leads me to utter a word of warning against the careless use of the catheter in elderly persons with fragile bloodvessels and an apoplectic tendency.

A rare but Dot dangerous result of catheterization is severe dizziness or even momentary unconsciousness, due to sudden disturbance of labyrinthine pressure. It may be avoided by beginning the inflation very gently, when, if no unpleasant symptoms follow, the strength of the air current may be increased. Another occasional result, never in my experience atten4ed with serious consequences, is rupture of the tympanic membrane, although this accident is more frequent with Politzer's method of inflation.

Substitutes for Catheterization. The other methods of inflation in common use are those known as Valsalva's and Politzer's.

B. The Valsalva method consists of an attempt to blow the nose with the mouth tightly shut and the nose closed with the finger and thumb, when, if one or both of the Eustachian tubes are normally patulous, the air will enter one or both of the tympanic cavities. This method has a certain diagnostic value, because it permits the examiner to watch the tympanic membrane during the act of inflation and to note the effect of the increased intratympanic pressure.

C. Politzer's method requires an air bag, the Politzer bag (8 oz. capacity), and a nose piece, preferably a conical hard rubber one large enough to occlude one nostril, which is best connected with the air bag by means of from 8 to 12 inches of rubber tubing. The idea of the original Politzer method and of its many modifications is to blow air into one nostril, the other being occluded, at the moment when the soft palate and uvula are by some maneuver forced back against the posterior pharyngeal wall, shutting off the naso pharynx from the throat below it. Politzer accomplished this by having the patient take a small mouthful of water and swallow it at a given signal (nodding the head, the word 11 now," or counting up to three); simultaneously, one nostril being closed by the nose piece of the Politzer bag, the other by pressure of the operator's fingers, the air bag is compressed, when the air, being shut off from going elsewhere, passes through the Eustachian tubes and penetrates the tympanic cavities. Another plan, which almost always succeeds, and which I greatly prefer because of its freedom from discomfort to the patient, is to have the patient close the lips and puff the checks out forcibly, or be may be directed to utter in rapid succession the syllables 11 hick," " hack," " hock." The crying of very young children usually accomplishes the same purpose. Auscultation in the Valsalva and Politzer methods does not give very much information as to the condition of the middle ear, excepting only if there is a perforation of the tympanic membrane, when the perforation whistle becomes very evident, often without, as well as with, the auscultation tube.

Comparative Value of Catheterization and Politzerization inflation with the catheter has, as a diagnostic measure, the following advantages over Politzerization: It enables the surgeon to measure the force needed to propel air into the tympanum; be can, by repeating the inflation, study the auscultation sounds and make there from valuable deductions; it depends for success upon the skill of the surgeon, and not upon the patient's attempts to close the naso pharynx. Catheterization of children under twelve years of age is difficult, however, and in them, fortunately, the Eustachian tubes being relatively shorter and of larger caliber, more information can be gained from the auscultatory sounds with Politzerization than in the adult. Hence Politzer's method as a means of diagnosis should be limited to children, and of course to those few adults in whom, owing to nasal obstruction, catheterization cannot be carried out. The diagnostic value of inflation lies in the comparison of the patency of the Eustachian tube and the effect produced, and has been so well summarized by Grant that I quote from him: " Patency much diminished and improvement on inflation very considerable would indicate a narrowing (catarrhal) of the Eustachian tube without Significant tympanic disease. Patency much diminished and improvement on inflation very moderate would indicate simultaneous affection of the tube and tympanum, in the more favorable exudative form of chronic catarrh of the middle ear. Patency normal and improvement on inflation little or none would indicate a primary affection of the tympanum, as in the obstinate dry or sclerotic form of chronic catarrh. Patency normal and hearing made worse by inflation would indicate a healthy middle ear and pure nerve deafness. Immense improvement on inflation, followed by speedy or almost immediate return to the previous degree of dullness of hearing, is characteristic of relaxation of the membrane."

3. The Eustachian Bougie. The third method of investigating the patency of the Eustachian tube is that by means of the Eustachian bougie. If an obstruction exists, the procedures already outlined will have demonstrated the fact, the diagnostic use of the bougie consisting in locating the seat and degree of such stenosis. My preference is for the flexible, probe pointed celluloid bougies, which come in four sizes. The smaller sizes should always be tried first. Before introduction two marks should always be made, with ink or otherwise, on the end of the bougie toward the operator, one indicating when it is leaving the catheter to enter the tube, the other, 1:1 inches farther back, indicating the point beyond which the bougie should not be introduced. The catheter having been fixed in the mouth of the tube, the bougie is passed rapidly down to the first mark, then very gently pushed farther, when, if it is entering the tube, the sensation conveyed to the finger becomes, after a little practice, easily recognizable, the patient having at the same time a sensation of sticking directly in the ear. If an obstruction is met requiring considerable force to overcome, the bougie must be withdrawn and a smaller one substituted. Stenoses are most frequent in the first inch (the cartilaginous portion), there being always moderate narrowing at the isthmus of the tube. Having thus located the stricture, and at the first attempt, or after repetitions gotten the bougie past it, air will be found to enter the tympanic cavity after its withdrawal much more freely than before. One precaution never to be forgotten is to examine the bougie carefully after withdrawing it, and, if the slightest trace of blood is found, not to inflate, thus avoiding the danger of emphysema. Another general precaution as to passing the bougie is that the whole operation must be performed with the utmost patience, gentleness, and caution, the., patience extending, if necessary, to four or five sittings before the stricture is finally overcome.

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