Affections Of The External Ear | Operating Microscopes

Affections Of The External Ear.
By SAMUEL THEOBALD, M. D.,
OF BALTIMORE, MD.

DISEASES Of the external ear that is to say, of the auricle and external auditory canal constitute about 26 per cent., of the total of affections of the auditory apparatus as met with in hospital practice;' diseases of the auricle are of comparatively infrequent occurrence, and make up but 2 per cent. of the total ; while affections of the auditory canal are common and constitute about 24 per cent.

AFFECTIONS OF THE AURICLE.

Congenital Malformations. Many minor congenital defects of the auricle have been described, such as anomalies of the helix, the antihelix, the lobule, the tragus, etc., but they are not of sufficient importance to demand here especial consideration. The major defects, such as microtia and polyotia, have frequently associated with them anomalous conditions of the auditory canal (atresia, etc.), and even of the middle and internal ear. They may be unilateral or bilateral, and are said to be due to incomplete closure of the two upper branebial clefts, insuffi¬cient turning up of the auricle during its development, etc.

Microtia. In pronounced cases of this defect the auricle is so misshapen and rudi¬mentary as to present scarcely any resem¬blance to the normal ear, and in some in¬stances the deformity involves the face as well as the ear. The condition is well shown in the accompanying illustration (Fig. 481), for which, a; well as for a number of other illustrations in this article, I am indebted to Dr. Randall. The changes of form are manifold and at times fantastic. Knapp, for example, has met with cases in which the rudimentary auricle was bookshaped or spirally curved, and other cases have been reported by Moos and Steinbrugge in which it resembled a cauliflower excrescence.

Polyotia. This term is applied not only to cases in which two or more auricles exist upon the same side, but also to cases of microtia which are accompanied by multiple growths in the immediate neighborhood of the auricle, but distinct from it. The most common form is that of a wart like excrescence or more complex 11 auricular appendage" situated upon the cheek in front of the external meatus (Figs. 482 and 483). These multiple growths, in exceptional instances, are found associated with a normal auricle.

Cartilaginous outgrowths from the auricle, known as auricular appendages, are occasionally met with, their most frequent location being upon the tragus (Fig. 483).

Congenital fissure or cleft of the lobule has been observed, and is said by Politzer to be "quite common, I a statement which, as to this part of the world at least, hardly holds good. A variety of congenital fistula, usually located just above the tragus (Fig. 483), and said by Burnett to connect in some instances with the tympanic cavity, is all anomaly of not very infrequent occurrence. Dench describes a case which presented an opening about one sixth of an inch in diameter, into which a probe could be passed to the depth of half an inch.' Retention cysts have been known to develop in them, and they may be the seat of purulent inflammation. The depth is usually slight and the direction downward and forward.

The writer has met with an instance of marked congenital difference in the conformation of the right and left auricles, one being larger and more prominent than the other, in which the defect was transmitted, although in a less noticeable degree, to the children and grandchild ren an appreciable difference in the auricles being observable in four out of six children and in several grandchildren.

As to the treatment of congenital anomalies of the auricle there is not much to be said. Auricular appendages, supernumerary auricles, and multiple growths about the ear may be readily. removed, and cleft of the lobe may be satisfactorily dealt with by operation; but attempts to remedy by operative procedure, plastic or otherwise, the more grave defect of microtia have been attended by very unsatisfactory results, and in high degrees of this deformity removal of the rudimentary auricle and the substitution of an artificial ear are recommended. Congenital aural fistula does not require treatment unless it be the seat of inflammatory or other changes. Undue prominence of the auricle, if seen in infancy, may be corrected in great measure by any simple device which will keep the ear constantly in close apposition with the side of the bead. Glueing the auricle to the head with collodion has been recommended. In adults such procedures are ineffectual, and the operation described on page 783 is called for.

Eczema of the Auricle. This is a condition of frequent occurrence, especially in ill nourished, strumous children. It often exists in association with phlyctenular ophthalmia, and under such circumstances may be accompanied by suppurative middle ear inflammation. In adults the auditory canal is usually involved in the inflammatory process, and the disease, which is frequently dependent upon a gouty diathesis, is less amenable to treatment than it is in children. In bad cases the whole auricle and the neighboring portions of the scalp as well, may be affected, but oftener the inflammation is limited to the line of juncture of the auricle with the head, to the concha, and to the fossa helics.

The treatment should be directed to the general condition of the patient as well as to the local affection. In adults the probable existence of lithemia should be borne in mind, and the patient's diet and his bowels should be regulated, and the remedies usually employed to combat this condition should be prescribed. In children a brisk calomel cathartic is often indicated, to be followed by the administration of the elixir or the syrup of the phosphates of iron, quinin, and strychnin a 'much more efficacious remedy, in the writer's experience, than the more frequently prescribed syrup of the iodid of iron. The most useful local remedies are the oxid of zinc with boric acid and the yellow oxid of mercury. The latter should be used in the form of an ointment (gr. ij to 3j), and the former either as an ointment (I drachm of powdered boric acid being added to an ounce of the officinal oxid of zinc ointment) or as a powder (equal parts, by weight, of boric acid and oxid of zinc), to be dusted upon the auricle, and, when indicated, blown lightly into the auditory canal. When scabs are present they should be removed by maceration as a measure preliminary to other treatment. Painting the affected part with a solution of nitrate of silver (gr. x xxx to 3j) is a remedy which is at times of value, especially in the moist conditions, and subnitrate of bismuth (in ointment or powder), oil of cade, salicylic acid, aristol, and the different preparations of lead are remedies which may be tried should those first named fail to effect a cure. A tendency to relapse is characteristic of the disease: too early discontinuance of the treatment, therefore, is to be avoided.

Herpes zoster of the auricle is a rare condition, but cases have been reported by J. Orne Green, C. H. Burnett, Anstie, Auspitz, Gruber, and others.

Erysipelas of the auricle is occasionally encountered, usually as an extension of facial erysipelas. The indications for treatment are the same as when these affections occur in other regions of the body, and there is nothing in their clinical course worthy of especial note.

Abscess of the auricle, especially of the lobule, where it is often the result of piercing the ear, and where, particularly in the colored race, it may become cystic, is of rather common occurrence. It is also a usual accompaniment of perichondritis (Fig. 484).

The treatment consists in free incision, which in the cystic cases may require to be supplemented by curetting or, better still, by cauterizing the cyst wall with a bead of nitrate of silver fused upon the tip of a probe.

Perichondritis of the Auricle. This condition is commonly of traumatic origin, but may be due to the extension of inflammation from the auditory canal, while occasionally it occurs with out evident cause. The idiopathic cases are usually met with in persons who are in a poor state of health and in whom there is general malnutrition. Its starting point under such circumstances is probably in certain degenerative changes in the cartilage, which have been described by Ludwig Meyer and others, and to which the name chondromalacia has been given (Buck). The traumatic cases usually owe their origin to blows, or may arise from exposure of the auricle to extremes of heat or cold (as in frost bite). The symptoms are a burning sensation in the ear, followed by severe pain, which is accompanied by swelling and marked injection of the auricle. The swelling, which may increase until the normal configuration of the auricle is completely obliterated, is due to an effusion of fluid usually serous at the outset, but tending quickly to become ptirulent beneath the periehondrium. The ear feels hot, and is often very sensitive to the touch. Left to itself, the fluid tends to escape spontaneously, but may be slowly absorbed. A high degree of deformity of the auricle is a frequent consequence of uncontrolled perichondritis (Fig. 485).

An effusion of blood, more or less extensive, between the perichondrium and the cartilage (hematoma auris; othematoma) (Fig. 486) is a not infrequent accompaniment of perichondritis, usually preceding the onset of the inflammatory process in traumatic cases (being a direct consequence of the injury), and following closely or accompanying it in non traumatic cases. The etiology and pathology of this condition have been widely studied,especial interest attaching to the subject because of the frequent occurrence of tumors of this character in the insane. Some investigators have attempted to explain this association upon the theory that hematoma auris is usually of traumatic origin, and that the insane are especially liable to injuries such as might give rise to it, either self inflicted or received through efforts to control them. Others maintain that the lesion is more directly connected with the insanity of the subject, and that it is dependent upon the pathological condition of the brain; while Virchow, Ludwig Meyer, Pollak, and others contend and apparently with greater justification, since their views are based upon more exact pathological study that it has its origin in degenerative. changes found in the cartilage of the auricle, not only in the insane, but in other ill nourished individuals as well changes which they point out are accompanied by the development in the neighboring tissue of capillary vessels of unusually large size and having very thin walls. With such conditions as these existing, it can be readily understood bow hemorrhage might. result from the most trivial violence to the auricle or even without such provocation.'

Treatment. If seen at an early stage, the application of cold in the form of the aural ice bag may be productive of good results in acute perichondritis. If, in spite of this measure, the effusion beneath the perichondrium increases, aspiration may be resorted to under strict antiseptic precautions, to be followed by the application of firm pressure upon the auricle, to prevent if possible what is very apt to occur a re effusion of fluid into the aspirated cavity. Should the fluid reaccumulate after, perhaps, a repetition of the aspiration, or should suppuration supervene, the sac must be laid open by a free incision and packed with iodoform gauze. Should necrosis of the cartilage have occurred, the necrotic parts must be thoroughly removed by curetting. The application of tincture of iodin to the cyst like walls of the cavity may be called for to promote its obliteration. Massage is useful after healing has taken place or to bring about the absorption of inflammatory products when incision has not been resorted to ; and the external application of iodin is also of value under similar circumstances.

In hematoma compression and massage may be tried if the tumor be small. If it be of considerable size, aspiration, followed by compression, may be employed, or the sac may be freely opened and dealt with as a perichondritis unaccompanied by extravasation of blood. Tonics and a change of diet are usually indicated. The likelihood of considerable deformity of the auricle resulting, even when the case has been judiciously treated, should not be lost Tight of, and should be impressed upon the patient.

Syphilis of the Auricle. The primary lesion of syphilis, as might be su posed, is rarely located upon the auricle, yet cases of this character have been reported by Pellizzari, Zucker, Hermet, and others, the cause of the infection being usually a bite by a syphilitic individual. The eruptions of secondary syphilis are frequently observed upon the auricle, accompanying similar eruptions upon the face and scalp. Gummata and syphilitic ulcerations are rare, but cases have been observed by Buck, Burnett, and Politzer.

The indications for treatment are simply those which apply to syphilis affecting other portions of the body.

Lupus. In lupus vulgaris of the face the auricle is frequently involved, but cases in which this disease originates in or is confined to the auricle are extremely rare. The auricle may be affected in any of the various types of lupus. In the ulcerative forms of the disease it may be partially or even totally destroyed, and the auditory canal and middle ear may be invaded.

Treatment. In removing the diseased tissue with the curette, the galvano cautery, or with caustics, care should be exercised not to sacrifice healthy structures, otherwise marked deformity of the auricle will ensue. To prevent involvement of the auditory canal and deeper structures of the ear, complete removal of the auricle may at times be required.

Frost bite. In cold climates frost bite of the auricle is of common occurrence, and even actual freezing of the ear may take place. Under such circumstances the auricle may become fragile, and must, therefore, be manipulated with care.

In the treatment of this condition, to prevent too sudden reaction, it is advised that the ear should be 11 thawed out " gradually by the application of snow, pounded ice, or cold water, the individual being kept for a time in a cold room or even out of doors. Subsequently the case must be treated much as one would treat a burn by the application of an emollient, such as linseed oil and lime water or vaselin. Perichondritis, with more or less extensive necrosis of the cartilage, may result from prolonged exposure of the auricle to cold.

New Growths of the Auricle. The auricle is occasionally the seat of malignant as well as of benign tumors. The most frequently met tumor of the auricle is fibroma or keloid. It is usually located in the lobule, and owes its origin almost always to the operation of piercing the ear or to the irritation accompanying the wearing of an ear ring. It is of especially frequent occurrence in the negro race (Fig. 487), and is said to exhibit a decided tendency to recur after removal, although the writer's experience with such growths not very extended, it is true would not lead him to endorse this view. The tumor is quite firm and the surface is usually nodular. Both ears are not infrequently affected, the exciting cause in each instance being the same.

Other benign growths which have been observed are lipoma, angioma, papilloma, and sebaceous cyst (see Fig. 462).

Horny Growths springing from the auricle have been encountered by Buck, Burnett, Pomeroy, Roosa, and others. In a case reported by Buck the growth, which was attached to the upper and posterior portion of the helix, is described as “a blunted, horn like protuberance, 3/4 inch long and nearly as broad at its base." The writer has never met with a growth of this character upon the ear, but several years since saw a precisely similar growth upon the upper eyelid near its free margin. It was somewhat curved, nearly I I/4 inches in length, and was said to have been only two months in forming.

Like the growth observed by Dr. Buck, it was longitudinally striated.

Of malignant growths, epithelioma (Fig. 488) is the one which has been oftenest met with, cases having been reported by Gruber, Wilde, Kramer, Toynbee, Demarquay, J. Orne Green, Brunner, Burnett, Roosa, Buck, and others. 'More rarely sarcoma of the auricle has been observed. Malignant growths of the auricle tend to invade the auditory canal and middle ear, and death may be brought about in this way.

Treatment. Tn malignant tumors of the auricle early operative interference is of course indicated, and complete removal of the auricle may be called for. Lipomata, angioniata, sebaceous cysts etc. should be dealt with as when they occur elsewhere. Fibromata of the lobule, even when of considerable size, may be readily removed, and with little resulting deformity, by an approximately (inverted) V shaped incision carried through the whole thickness of the lobe.

Wounds of the Auricle. Lacerated and incised wounds of the auricle are occasionally met with, and exceptionally the whole auricle may be torn or even bitten off. The writer's grandfather, the late Prof. Nathan R. Smith, of Baltimore, once had a singular experience of this latter kind. A mail, carrying an ear in his hand, rushed excitedly into the office, exclaiming that one of his ears had been bitten off in a fight, and that be wished it replaced. A few moments later another equally excited individual, with an auricle missing and carrying an ear in his hand, made his appearance, and loudly protested that the first man had taken the wrong ear and that be bad brought the one which belonged to him. In the modern game of football, as in the German duel, injuries of the auricle are of such frequent occurrence that special contrivances for protecting the ear are worn.

Treatment. When parts of the ear are cut cleanly off (as happens in the duels at the German universities), they may be replaced with every prospect that union of the divided surfaces will occur, and even when the entire auricle is cut or torn of an effort should be made to replace it, as reunion has occurred under such circumstances.' In closing wounds of the auricle or in reattaching severed parts stitches should be used as sparingly as possible, and should never penetrate the cartilage. Collodion, reinforced by bits of crepelisse or of lint, will usually suffice to maintain the parts in apposition. Aseptic precautions are of course essential, but strong antiseptic agents should be avoided.

Cleft of the Lobule. This condition is of frequent occurrence, and is almost always due to that relic of barbarism the wearing of ear rings. Occasionally it results simply from a heavy ear ring gradually wearing its way through the lobe, but more often it is produced by the ear ring being accidentally or intentionally torn from the ear. The writer has seen instancesand many such have been reported where the lobe had been cleft in this way several times, and was represented by three or four teat like projections The deformity, even from a single cleft is considerable and it not infrequently happens that the aural surgeon is applied to remedy it.

The treatment is by operation (see page 782).

AFFECTIONS OF THE EXTERNAL AUDITORY CANAL

Congenital Malformations. Congenital atresia, of the external auditory canal has been mentioned as an occasional accompaniment of microtia and polyotia (see Fig. 481). Cases have been observed in which this defect existed without accompanying malformation of the auricle, but they are comparatively rare. The atresia may involve a part or the whole length of the canal, and may be of osseous or membranous character. A shallow depression or a somewhat deeper cul de sac, reaching perhaps to the point at which the bony meatus should normally begin, exists in some instances, while in others no trace of the meatus is to be found. Politzer mentions having dissected a case of arrests of the auditory canal associated with microtia in which the osseous and membranous labyrinth were perfectly formed, but in which the external meatus was represented by a fibrous cord 1 cm. long, and the tympanic cavity was entirely absent.' Cases of congenital narrowing of the auditory canal, and also of hour glass contraction of the canal (Wilde), have been observed

Even with complete bony occlusion of the auditory meatus the hearing may be fairly good if the deeper part , of the ear are normal. The writer has reported a case of complete osseous occlusion of both auditory canals (not, however, of congenital origin), in which the patient could carry on a conversation very satisfactorily if spoken to in a slightly raised tone of voice In a case of congenital occlusion of both auditory canals with microtia the patient could distinguish words spoken in a low voice at a distance of six feet, even with the eyes, nose, and mouth tightly closed, as can almost every one with normal cars slightly stopped by the fingers.

Treatment. In congenital atresia of the auditory canal it seldom happens that anything can be done to ameliorate the patient's condition, which, however, as has been indicated, is not usually as unfortunate as might be supposed. If the atresia be limited in extent, involving but a small part of the canal (which is not often the case), whether it be osseous or membranous, an effort may be made to overcome it by suitable cutting or boring instruments; but if it be more extensive, experience has shown that operative interference is of no avail, since the atresia invariably recurs. Possibly, skin grafting by Thiersch's method might under such circumstances render the chances of success somewhat better. When there is simply congenital narrowing of the canal, especially if it be circumscribed, much may be accomplished in time by having the patient wear continually in the meatus an elastic plug of absorbent cotton, sponge, or some similar material.

As much rarer congenital anomalies unduly capacious auditory canals are met with, and also a doubling of the canal. Sometimes there is a second canal, terminating in a cul de sac, behind the true canal and having no connection with it, as in the cases observed by Velpeau and Macauln ; and again, as in Bernard's case, there may be two separate canals, which after a short course unite to form a common canal.'

Impacted Cerumen. Occlusion of the auditory canal by a mass of inspissated cerumen is the affection of the external ear which most frequently demands the attention of the aurist. Usually the patient is entirely unconscious of the presence of the mass until the canal is completely occluded by it. Then the bearing, which before bad not been appreciably diminished, although the ceruminous plug may have all but filled the lumen of the canal, becomes at once greatly impaired, autophony manifests itself, and very frequently tinnitus makes its appearance to add to the discomfort and alarm of the patient. Although the mass develops very slowly, many months usually elapsing before it becomes inconveniently large, the symptoms just enumerated generally manifest themselves suddenly. The usual explanation of this is that water has run into the ear in washing or bathing, or in warm weather perspiration has found its way into it and has caused the plug, which previously bad nearly filled the canal, to swell up sufficiently to make the occlusion complete. Occasionally it is a fluid which the individual has intentionally dropped into the ear or some manipulation on his part of the ceruminous mass, which brings about the sudden change. Exceptionally the same symptoms may result, accompanied, perhaps, by pain, from a smaller mass of wax (which left undisturbed might not have caused inconvenience for a long time) being dislodged and pushed down upon the drumhead by the efforts of the patient to remove it. Again, when the plug is very hard and occupies the outer portion of the meatus, it may, through the movements of the jaw, exert sufficient pressure upon the canal walls to cause pain, and perhaps inflammation, before it has become so large as to interfere with audition.

The plug varies greatly in consistency and in solubility, and frequently contains innumerable short, pale hairs (from the walls of the canal). Very often it is in part made up of pieces of exfoliated epidermis, and exceptionally it has as a nucleus some small foreign body which has found its way into the ear, or an old scab left by a former otitis. More frequently than not both cars are involved, so both should invariably be examined.

Among the rarer symptoms produced by the presence of impacted cerumen in the ear may be mentioned dizziness, reflex cough, perturbation of the mental facilities with inability to concentrate the mind in intellectual pursuits, disturbances of gait simulating those of locomotor ataxia (Risley), epileptiform convulsions, and, in a case reported by the writer 2 inability to swallow, accompanied by a feeling of oppression about the heart. The added danger which results in otitis media from a pre existent occlusion of the meatus by impacted cerumen should also Dot be lost sight of.

With good illumination it is usually a very easy matter to detect the presence of a ceruminous plug in the auditory canal. It is seen as a darkbrown mass filling the lumen of the canal, and with its outer surface situated usually at about the line of juncture of the osseous and membranous portions of the meatus. Touched with a probe, it may appear quite hard, or may be soft and easily indented. Generally the inner extremity of the mass reaches to, and rests upon, the tympanic membrane.

The etiology of this affection has received considerable attention, and, while it cannot be claimed that it is as yet fully understood, there is a general agreement at least as to two points : in the first place, that, probably through reflex influence, the ceruminous glands are frequently abnormally active in the presence of chronic inflammatory affections of the naso pharynx ; in the second place, that tinder such circumstances and often perhaps independently of such conditions, there is a disturbance of the normal outgrowth of the epidermis which covers the external surface of the drumhead and lines the walls of the meatus. This in health tends to transport the cerumen from the deeper portions of the canal to its external orifice, where. it falls out or is removed in the ordinary daily ablutions. That catarrh of the nasopharynx is frequently present when there is a disposition to the formation of ceruminous plugs in the ears is a fact of daily observation, and there can be little doubt that it is an important factor in their causation. And the composition of manv masses of impacted cerumen made up, in great part, of layers of exfoliated epidermis, and sometimes enclosed in a thin pouch of epidermis which has been cast off entirely from the tympanic membrane and the walls of the meatus would seem to show that under certain circumstances there is not only an arrest of the normal outgrowth of the epidermis, but an actual reversal in the direction of its growth, tending to a heaping up of epithelial debris in the deeper parts of the canal, as well as to an impaction of cerumen.

Treatment. It would seem that as to the manner of dealing with so simple a condition there could be but little room for difference of opinion, still less for contention. Such, however, is far from being the case, for one very high authority tells us in his excellent treatise upon diseases of the ear that the syringe should rarely be used for the removal of cerumen, and that with the curette and the angular forceps one may accomplish in ten or fifteen minutes what cannot be done with the syringe in an hour's time; while another excellent authority tells us in his book that in four or five years he has not met with a single instance in which by means of the syringe be has failed to remove impacted ecrumen from the ear in one sitting of five minutes or less, and that as to the curetting method he feels that be cannot seriously argue the question. At the risk of seeming to be contentious himself, the writer cannot refrain from saying that this last expressed sentiment meets with his fullest endorsement. But still another very high authority, whose example in most things we are glad to follow, actually commends the introduction of a strong solution of caustic potash into the ear (of course with the exercise of extreme caution) in order to saponify quickly the ceruminous mass and so to facilitate its removal. As to this procedure, it may be remarked that in kindling, and especially in rekindling a fire, petroleum is a great saver of time; but, even so, it is not the part of wisdom to commend its general use in this way.

The method of dealing with impacted cerumen which the writer has found most convenient, and which be has employed for many years, is as follows: In the great majority of cases the syringe is chiefly relied upon. When, however, the ceruminous mass proves obdurate and does not easily undergo disintegration, the angular probe or the instrument for the removal of foreign bodies represented in Fig. 490 is brought into requisition and the mass is partly broken tip or separated from its attachment to the canal wall.

After this the syringing is resumed, and usually with much better effect. Bicarbonate of soda is invariably added to the warm water (105' 110' F.) with which the syringing is done, as it unquestionably facilitates the removal of the wax and certainly does no harm to the syringe, as has been suggested. The quantity used is never accurately determined, but is approximately half an ounce to a quart. The ear is inspected from time to time to make sure that there is still cerumen in it, and that the syringing is not being kept up unnecessarily. As the mass diminishes in size and there is a likelihood that the stream of water may impinge upon the drumhead, the force with which it is thrown into the ear is lessened. The exact direction in which the stream strikes the impacted mass is not thought to be of especial moment, and no apprehension is felt that this may result in the plug being driven by the force of the water more deeply into the meatus, as some have imagined. When both ears are affected, unless the mass first attacked comes out very readily, the syringing is alternated from one ear to the other, as this saves time and appreciably diminishes the amount of syringing required. The intermittent stream of a piston syringe is employed, and is thought to be more efficacious than the continuous stream of a fountain syringe. The bard rubber, kidney shaped basin commonly employed by aurists has been long since discarded, because it is concave where it should be convex, and so does not fit well into the hollow beneath the ear, and because, moreover, it is so long and shallow that a very slight movement on the' part of the patient is likely to cause its contents to slop over upon the clothing. Instead of this, a china bowl (one made of bard rubber or metal might be better, because less fragile) of the shape represented in Fig. 489 is used, and has been found much better adapted to the purpose, since it is free from both of the faults mentioned. It is always held by the patient, over whose shoulder a napkin is spread, rather than by an assistant, unless the patient be a young child. When inspection with the speculum and mirror shows that all of the cerumen has been removed, two or three syringefuls of plain warm water are gently thrown into the ear to wash out the previously¬ used soda solution. The ear is then dried with a spill of soft linen and closed with a bit of ab sorbent cotton, which in cold weather the patient is advised to wear until bedtime. If the plug proves to be exceptionally refractory or time be pressing, the patient is told to report the next day, and in the meantime to drop into the ear several times a little warm sweet oil, or, if it be inconvenient for him to do this, the ear is filled with a saturated solution of soda, and after perhaps a half hour's wait the syringing is resumed. The cases in which the plug cannot be removed at one sitting are very exceptional, but the writer is compelled to admit that with the best skill he can command it is not unusual for him to spend many more than “five minutes" in accomplishing this result.

It occasionally happens that upon inspecting the ear it can be seen that the mass of cerumen does not extend into the deeper parts of the canal. Under such circumstances, if it is found to be of its usual firmness, it is often possible with the traction instrument (Fig. 490) to draw out the whole mass at a single effort, and so to save both time and trouble. If, however, even in such a case, the cerumen proves to be of such consistency that it can be removed only bit by bit, it is better to resort to the syringe without further ado.

The writer knows of no means by which the well recognized disposition of impacted cerumen to recur after y having been removed can be overcome, except in so far as the cure or amelioration of any accompanying inflammation of the naso pharynx tends to this result.

Circumscribed Inflammation (Furuncle). Furuncular inflammation of the external auditory canal is of very frequent occurrence. The furuncles almost always form in the outer third of the meatus, and their starting point is in the ceruminous or sebaceous glands or in the hair follicles which are situated. in this portion of the canal. Oftener than not several furuncles occur at the same time or in quick succession, and occasionally, in the absence of proper treatment, they may recur at brief intervals for weeks. They give rise to severe pain, and to so much swelling of the membranous portion of the meatus as to occlude it completely, and so produce a transient impairment of bearing. The discharge is slight and thick, differing markedly from the more copious and thinner discharge which is usual in acute purulent inflammation of the middle ear. The swelling and sensitiveness of the meatus are commonly so great as to preclude an inspection of its deeper parts and of the tympanic membrane; but the location and appearance of the swelling, the scantiness and character of the discharge, the history of the onset of the attack, and the absence of tinnitus, and of such a degree of deafness as commonly attends acute inflammation of the middle ear, usually render a differential diagnosis from this latter affection a matter of no great difficulty.

Furuncular inflammation of the meatus is in most instances traceable to a pre existing, perhaps very slight, dermatitis or eczema of the membranous portion of the canal. This gives rise to itching, which the individual attempts to relieve by scratching the ear with the finger nail or with a toothpick, a match, a bodkin, a hair pin, or some such instrument, and sooner or later he succeeds not only in producing an abrasion of the canal wall, but in implanting upon this denuded surface, which in all probability involves the orifices of several of the ceruminous or sebaceous glands, a pyogenic organism (usually the staphylococcus aureus or albus), the subsequent development of which brings on the furunculosis. In other instances the furuncular inflammation is secondary to otitis media purulenta a localized infection, from the entrance of the micrococci into the hair follicles or into the ceruminous or sebaceous glands, resulting from the walls of the canal being constantly bathed in the pus which flows from the middle ear. A depressed state of the general health is also frequently an important factor in the etiology of furunculosis of the external ear as it is in furunculosis occurring in other regions.

Exceptionally, small absc are met with in the deeper portion of the meatus. These usually run a more protracted course, being often dependent upon caries of the underlying bone or upon tympanic or mastoid disease.

Treatment. If seen in its incipiency, furuncular inflammation of the auditory meatus can occasionally be aborted by the application to the walls of the canal of an ointment of yellow oxid of mercury and vaselin (gr. j ij to 3j) and the administration of a brisk calomel cathartic; and, it may be added, in the occasional application of this same ointment we have a prophylactic measure of great value, for the chronic dermatitis, which, as has been said, is so often the precursor of furunculosis, may by this means almost always be cured or kept in abeyance, and thus the disposition to acute outbreaks be removed.

When the furuncle is more fully developed, so favorable a result is not to be anticipated, but the yellow oxid ointment is still useful in lessening the likelihood of the inflammation invading other follicles. For the relief of the severe pain, the bead (in lying down) should be kept as high as practicable, dry or moist heat (a Japanese 11 stove " or a pad of gauze wrung out in hot water, freely sprinkled with laudanum and covered with a piece of rubber protective or oiled silk) should be applied to the ear, and six or eight drops of a solution of atropia and cocain in almond oil 1 (atrop. alk. gr. j, cocain alk. gr. ij, ol. amyg. dulc. 3ij) should be dropped into the canal (and retained by a pledget of cotton) three or four times in twenty four hours, or the 11 baume tranquille " of the French Codex may be similarly employed. The application of a 10 to 20 per cent. solution of menthol in albolene or olive oil is also recommended. Should these measures fail to relieve the pain, as, it must be admitted, not infrequently happens, morphin may be administered hypodermically or by the mouth.

The writer is inclined to agree with those (Wilde, Buck, and others) who think that a very early incision of the furuncle is uncalled for, and may do more harm than good. When, however, it is evident that pus has formed, its escape should be facilitated by an incision, which may be conveniently made with the knife represented in Fig. 491, which some years since the writer contrived for this purpose. The local abstraction of blood hardly seems to be called for, although it is claimed for it that, if employed at the outset, it often proves of much value. After the furuncles have opened or been incised, douching or gently syringing the ear with a saturated solution of boric acid is a useful measure. The state of the bowels and the general condition of the health should be looked to, and tonics or laxatives should be administered when they seem to be indicated.

Diffuse Inflammation. Diffuse inflammation of the external auditory canal occurs as an acute and as a chronic affection. It differs from furuncular inflammation in that it tends to involve the whole extent of the auditory canal, the osseous as well as the membranous portion. The pain which usually is present only in acute cases is, as a rule, not so severe, and the swelling, especially at the orifice of the meatus, not so marked, as in furunculosis. The discharge is slight and generally serous or sero purulent in character. In the chronic cases especially, itching is a prominent symptom. The dermal layer of the tympanic membrane is frequently involved in the inflammatory process, and, like the neighboring walls of the meatus, may be markedly hyperemic. There is also a disposition to exfoliation of the epidermis from the drumhead as well as from the canal walls.

Frequently the disease is essentially eczema of the external ear, and the auricle, as well as the auditory canal, may be involved in the inflammatory process. it is often present in chronic otorrhea, being excited by the continual flow of pus through the meatus. In other cases it is of traumatic origin, arising perhaps from the entrance of some irritant substance or foreign body into the ear; and in still others it is due to the presence in the auditory canal of a fungous growth, usually the aspergillus nigricans, and less often the aspergillus glaucus or the aspergillus flavescens. For this variety of inflammation of the external ear Virchow has suggested the name otomycosis.

A variety of diffuse otitis externa which deserves especial mention, and the etiology of which is not very well understood, is that which is denominated desquantative inflammation of the auditory canal, and which leads to the condition known as keratosis obturans or choledeatonta. Primarily, this is a diffuse dermatitis characterized by an excessive proliferation and desquamation of epithelium ; but at a later stage the periosteum. and underlying bone are Dot infrequently involved,' and areas of caries and necrosis, sometimes accompanied by the development of polypi, may occur; while in some instances marked absorption of the bony walls of the meatus takes place, resulting in a great increase of its caliber. Eventually, the auditory canal becomes completely occluded by the exfoliated epithelium, which forms into a tough, laminated plug containing between its layers an admixture of inspissated cerumen. For a time this may give rise to no inconvenience other than deafness, probably accompanied by tinnitus ; but sooner or later, through the invasion of bacteria (which seems to be Nature's method of ridding the economy of such an incubus), an acute outbreak of inflammation occurs, accompanied by pain, suppuration, and partial disintegration of the laminated mass. It is at this time that medical advice, if it has not previously been obtained, is usually sought.

Treatment. As may be inferred, the treatment of diffuse inflammation of the auditory canal will necessarily vary with the origin and character of the attack. For the relief of pain the anodyne applications which have been described in treating of furuncular inflammation, and especially the solution of the alkaloids of cocain and atropin in the oil of sweet almonds, will be found useful. In otomycosis the intruding fungus must be gotten rid of as soon as possible in the first place, mechanically, by means of the syringe, forceps, and traction hook; and, in the second place, by the insufflation of the powder containing equal parts of oxid of zinc and boric acid which has already been spoken of, and which was recommended for this purpose by the writer many years since.' The efficacy of this remedy, which depends upon the drying effect of the oxid of zinc' as well as upon the proven specific action of boric acid in preventing the growth of aspergillus and other related fungi, is so marked that, in the experience of the writer, a second application is only exceptionally required to completely destroy the varieties of aspergillus which are usually encountered in the car. It has, moreover, the great additional advantage of being one of the best possible agents for the relief of the inflammation of the auditory canal excited by the presence of the parasite, in this respect certainly being far better than alcohol, which has been widely commended for the destruction of aural fungi. With the eradication of the aspergillus the inflammation usually subsides promptly and. as a rule, no other treatment than the insufflation of the zinc and boric acid, which may require to be repeated once or twice, is called for.

In desquamative inflammation the removal of the mass of exfoliated epithelium, which sometimes is a difficult task, requiring several sittings, is of course the first thing to be accomplished. This can best be effected by the syringe, aided by the forceps, traction in strument, and probe. The removal of the plug should be followed by the insufflation of boric acid and oxid of zinc, which the writer has found especially useful in these cases. A powder containing equal parts of aristol and boric acid has also been found of service. In the uncomplicated forms of diffuse inflammation of the auditory canal which, as has been said, are frequently eczematous in characterthese same applications are indicated if a drying effect is desired; while in other cases the yellow oxid of mercury and vaselin ointment, previously mentioned, is often of great value; and so also is an ointment composed of oxid of zinc, boric acid, and vaselin, to which a small quantity of balsam of Peru may at times be added. (Zinci oxide gr. xxx lx, acid. boric. .3j, vaselin 3j). Strong solutions of nitrate of silver (3j iij to 5j) are highly commended by Buck and others. Tonics, laxatives, and other constitutional remedies, such as the salts of lithia, arsenic, etc., may often be prescribed with advantage. Polypi, if present, should be removed with the forceps or snare (they are usually quite small, but may be multiple), and any areas of carious bone should be carefully curetted, or, better still, perhaps, if limited in extent, should be touched with muriatic acid diluted with two or three parts of water, which seems to do good not only by its stimulant action, but by its solvent effect upon the necrosed bone.

Polypi. In most instances where a polypus is found occupying the external auditory canal it has its origin in the tympanic cavity, and grows from there (the drumhead being partially or completely destroyed) into the meatus. Exceptionally, however, the pol pi which form in the course of chronic otorrhea spring from the walls of the canal, usually in the neighborhood of the membrana tympani. They also are occasionally met with in the absence of perforation of the drumhead, as after injuries of the meatus, caries of its walls, furuncular inflammation, and, as has just been indicated, in the course of desquamative otitis externa. Poulticing is at times responsible.

Their treatment consists in early removal (with forceps if they are small, or with the snare if' they are larger and their point of attachment cannot certainly be made out), the application of chromic acid to the pedicle, and the insufflation of boric acid by itself or in combination with aristol or oxid of zinc. Properly carried out, these measures render a recurrence of the polypus very unlikely.

Exostosis and Hyperostosis. The term exostosis is applied to those bony growths upon the walls of the external auditory canal which are circumscribed and fairly well defined in contour (Fig. 494); while by hyperostosis is meant that condition in which the caliber of the bony meatus is gradually encroached upon (see Fig. 464), probably throughout a considerable part of its length, by a diffuse growth of bone, which is usually the result of a chronic periostitis secondary to long standing otorrhea. In extreme cases of hyperostosis a complete bony occlusion of the canal may result, which, from its appearance only, cannot always be distinguished from congenital atresia. A case of this character observed by the writer has already been referred to in treating of congenital anomalies of the external auditory canal. The growths denominated exostoses are met with in all parts of the osseous canal, vary greatly in shape, being usually mound like, with a broad base, but occasionally distinctly pedunculated; may occur singly or in groups, and differ markedly in structure, being sometimes of ivory like hardness and at other times composed of soft consensus tissue. They may be present in the auditor canal for years without their existence being known, for they are usually of very slow growth and quite painless. Their presence is frequently revealed by some intercurrent aural affection, such as acute otitis media or an accumulation of cerumen, which affections, as may be readily understood, they may greatly complicate. Gout, rheumatism, and syphilis have been regarded as having to do with their causation, but this has not been clearly demonstrated. That there is a racial predisposition to growths of this character is certainly true. They are said to be more frequent among the inhabitants of England than among our own people, are of very common occurrence among the natives of the Hawaiian islands, and have been observed very often in the skulls of the Mound builders.

Treatment. When occlusion of the meatus is threatened from a diffuse hyperostosis every effort should be made to cure the otorrhea which usually coexists, as this of itself may arrest the progress of the affection. It will also permit the continuous wearing of an elastic plug in the canal, which in time may be expected to effect something in the way of dilatation. The plug should not be harsh in its action, however, or it may do more harm than good. Fine sponge and absorbent cotton have already been mentioned as being useful for this purpose. When complete bony atresia of the canal exists, operative interference is not indicated unless there is good reason to believe that the septum is quite thin, for under other circumstances it is almost sure to prove of no avail.

As to the treatment of the circumscribed osteomata, non interference is generally advised, unless there be some especial indication for operation ; as, for example, when the enlargement of the growth is interfering with audition or when some intercurrent trouble, such as otitis media suppurativa, complicates the situation. When the exostosis is pedunculated and is so situated that its removal is not a difficult matter, the writer thinks that it is judicious to get rid of it without waiting for possible future complications. His experience in the removal of such growths is limited, but, so far as it warrants deductions, is distinctly favorable to the use of the gouge and mallet rather than the dental lathe, which has been recommended for this purpose.

False Membranes. An occlusion of the auditory canal of much less formidable character than that which may result from hyperostosis is occasionally met with. The occluding membrane is sometimes composed simply of the epidermal layer of the drumhead, which has been cast off entire, and of course is without vitality. When such a membrane is located Dear the inner extremity of the meatus, it is not always easy to distinguish it from the true tympanic membrane altered by disease. It interferes in some measure with the hearing, and should be broken through with a probe and removed with the traction hook or forceps. In other cases the membrane is of quite a different character, being supplied with blood vessels and possessing a low vitality. Stich septa, as Buck has pointed out, are usually the result g of granulation tissue springing from 'opposite points of the walls of the canal and uniting in time to form a continuous membrane.'

Treatment. As, septa of this character interfere materially with bearing, their removal is indicated. This may be effected by any suitably shaped knife, and, as they show at times a disposition to recur, the subsequent application of chromic acid or other caustic agent to the marginal remains of the membrane may be called for. In the writer's case, to which reference has been made, the removal of the membrane and the subsequent wearing of a vaselin and cotton artificial drum resulted in very marked improvement in bearing (see page 784).

New growths, having their origin in the external auditory canal, apart from osteomata and polypi, are extremely rare. Sebaceous cysts upon the walls of the meatus are met with occasionally; chondromata have been observed by Launav and Politzer; and cases Of cylindroma, pedunculated papilloma, And of epithelioma and sarcoma have been reported.

The indications for treatment are simply those which apply to similar tumors located elsewhere.

Syphilis does not often invade the external auditory meatus, but one case at least of primary infection at this point has been observed. Condylomata and syphilitic ulcers are more frequently encountered. The diagnosis is facilitated by the presence of syphilitic lesions in other parts of the body.

Treatment. Knapp recommends dusting condylomata with calomel, and subsequently painting them with a 1 per cent., solution of nitrate of silver. Politzer touches them with nitrate of silver or a concentrated solution of chromic acid, and afterwards applies a I : 30 solution of corrosive sublimate. For syphilitic ulcers he uses tincture of iodin, painting it upon the ulcer several times. He also mentions a case in which healing was brought about by keeping a plug of mercurial plaster in the meatus. Calomel and the yellow oxid of mercury suggest themselves as remedies likely to prove useful.

Wounds involving only the external auditory canal are rare. Buck speaks of the tendency to persistent hemorrhage which characterizes such wounds, and gives as an explanation that the blood vessels of the cartilaginous framework of the canal are capable of contracting and retracting to but a limited extent. Slight abrasions of the walls of the meatus from efforts to remove cerumen or to relieve itching are common, and are of importance only because, as has been stated, they so often lead to furuncular inflammation. Fractures of the base of the skull not infrequently involve the walls of the bony meatus.

The indications for treatment are to free the canal from blood and any extraneous substances which may be present by syringing with a warm antiseptic solution (boric acid), and then, by the insufflation of boric acid or boric acid and aristol, and closing the meatus with a cotton plug, to keep the parts as nearly aseptic as possible.

Foreign Bodies. Although the position and conformation of the auditory canal do not favor the entrance of foreign bodies, they not infrequently find their way into the ear. Children have a habit of thrusting such things as beads, beans, cherry stones and the like into their own ears or into the ears of their playmates, while inanimate objects of a different character, such as grains of Wheat, small pebbles, etc., sometimes find accidental entrance into auditory canals of adults. Living insects also occasionally invade the ear sometimes by accident and sometimes by design, being perhaps attracted by the odor of a purulent discharge. Many cases, for example, have been reported in which dead flies have been found in suppurating ears and others in which the living larvae of the fly were present.

The common belief is that the presence of a foreign body in the ear, without reference to its character or its mode of lodgement, is necessarily a serious matter. It is hardly necessary to say that this belief is groundless. Usually, unless the object be tightly impacted in the canal, or be pressing upon the drumhead, or be of such shape or nature as to cause exceptional irritation, its presence in the ear is scarcely appreciated. On the other band, if the substance which has entered the ear be of an irritant or caustic nature, or be Jagged in shape and so wedged in the canal that the movements of the jaw cause it to wound the walls of the meatus, it may give rise to severe pain and quickly produce inflammatory reaction. The entrance of living insects into the ear usually causes great discomfort, and sometimes intolerable agony, for the contact of their wings and feet with the tympanic membrane is not only very painful, but produces noises which are almost as unbearable. Maggots when they enter the ear cause severe pain, and are difficult to remove, because, as Make has pointed out, they attach themselves to the walls of the canal by a peculiar hook like apparatus which they possess, and feed upon the inflamed integument. The writer once removed from the ear a living tick which had attached itself to the wall of the meatus. It had entered the ear about two weeks previously, and for some days a black, granular substance (its excrement) had been coming from the canal, while a sound 11 like broiling " bad been heard from time to time, and pain was beginning to make itself felt. He has also removed flies, maggots, cockroaches, and "bugs" of various kinds and sizes. Stiff hairs from the head or beard occasionally find their way into the ear, and if so placed as to press upon the drumhead may cause much discomfort.

It should be mentioned that the presence of a foreign body in the ear may excite marked reflex phenomena. Cases have been reported, for example, in which cough, vomiting, excessive salivary secretion, hemicrania, facial paralysis, and epileptiform convulsions have been produced in this way (Poulet).

Treatment. The question of how best to deal with a foreign body lodged in the ear depends upon a variety of circumstances, and especially upon tile skill and experience of the operator. Doubtless it is best not to allow any foreign body to remain indefinitely in the auditory canal ; but, as in most instances it is Dot at all likely to produce immediate ill consequences, hurried and unskilful attempts at removal without proper instrumental aid, whether undertaken by layman or physician, are to be discouraged. The need for interference is seldom so urgent that time cannot be taken to obtain expert assistance, and it should be borne in mind that the cases which prove to be serious and which tax the ability of the aural specialist are almost invariably those which have previously been subjected to the well meant but injudicious efforts of the unskilful.

At the outset it is of the utmost importance to make sure that there really is a foreign body in the ear, for it not infrequently happens that misapprehension exists upon this point; and patients are brought to the. physician for the removal of a foreign body which has no existence except in their imagination or in the imagination of those who have them in charge. If it be lodged Dear the orifice of the meatus, it can scarcely escape detection at a glance, but if it be near the tympanic membrane, an ear mirror and speculum will usually be needed for its discovery; and; indeed, in some cars (in which the upward bend of the floor of the meatus is exceptionally pronounced) it may be impossible, if the foreign body be a small one and be lying in the angle at the lower margin of the drumhead, to bring it into view even with the best means at, command for aural inspection. It ought not to be necessary to utter a word of warning against. mistaking the bright surface of the tympanic membrane itself for a foreign body; but, as mistake , of this kind have occurred, and at the cost of serious damage to the hearing apparatus, such a warning is perhaps not altogether superfluous.

In unskilled bands or with a very unruly patient the syringe is the safest instrument to employ for the removal of foreign bodies from the ear, and it is one which usually will be found to accomplish the end in view. If, however, the foreign body be tightly wedged in the canal, from having swollen, as beans, peas, and such like objects are likely to do after entering the ear, from inflammatory swelling of the canal itself, or from awkward efforts to remove it, the syringe is not likely to prove effectual. Whether, under such circumstances, the physician unfamiliar with operative procedures upon the ear should desist from Further instrumental interference and refer the case to an aural surgeon, must of course depend in a great measure upon whether such skilled assistance can be readily obtained or not. To introduce any form of instrument into the ear and grope blindly about in the hope of extracting a foreign body is a most reprehensible procedure, and one so much more likely to do harm than good that it can hardly be justified under any circumstances. Such awkward manipulations have been known to result not only in loss of hearing, but even in loss of life. Without exception, when any instrument is introduced into the ear for the removal of a foreign body, the auditory canal should be illuminated with the ear mirror (artificial or diffuse daylight being used as may be preferred), and the foreign body itself and every movement of the instrument should be kept constantly in view.

For the removal of foreign bodies which are not spherical in shape and do not fill the lumen of the canal such as insects, bits of wire, chips of wood, and the like the angular forceps are extremely useful ; but when a glass bead, a pea or bean, or other roundish body is impacted in the meatus, they are worse than useless, for they cannot be opened wide enough to grasp the object, and every unsuccessful attempt to accomplish this only serves to drive it more deeply into the ear. For the extraction of such bodies and they are among those most frequently encountered the writer has found a traction hook similar to Fig. 490, but stronger, extremely valuable. The body can scarcely be so tightly wedged in the ear as to prevent the bent tip of this instrument (which is serrated upon its under surface to make it catch the better) being at some point insinuated between it and the walls of the canal ; and when this is accomplished and the hooked extremity, now beyond the body, is turned so as to catch hold of it, there can be little excuse, unless one's efforts are balked by unruly behavior on the part of the patient, for failing to rid the ear of the intruding body, either by simple traction or by rolling it over and over.

There is nothing which so facilitates manipulations of this character as co operation on the part of the patient, and nothing which so complicates them as the lack of it. Ordinarily, with a ruly patient, the extraction of a foreign body from the ear is not a painful procedure; but if the walls of the canal have been lacerated by previous rough usage or have become swollen and inflamed from the presence of the intruding body, the infliction of some pain can hardly be avoided. Under such circumstances the previous instillation of a strong solution (10 per cent.) of cocain diminishes the pain in some measure. In unruly children the administration of a general anesthetic is not infrequently called for. In the absence of such an instrument as above indicated, or the loop of a snare, an excellent substitute may be improvised from a steel hair pin of good quality. The writer is rather fond of making traction hooks in this way to suit his fancy, and the improvised instrument shown has done most excellent service.

When an insect or other animate object has entered the ear, since its movements are likely to cause much suffering, it is important that an end should be put to its life a , quickly as possible. Ordinarily the most efficacious and convenient way of accomplishing this is by pouring into the ear olive oil or any other bland oil that may be at hand. Maggots, however, live for a long time in oil, which, therefore, is not useful when they are present. Dr. Rossa has recommended for their destruction the vapor of chloroform and also Labarraque's solution. If a caustic substance has entered the auditory canal, the ear should be syringed with a neutralizing solution in the case of an alkaline caustic, vinegar, which is usually at hand, diluted with warm water may be used, and in the case of an acid, the bicarbonate of soda.

Probably, in dealing with foreign bodies in the auditory canal, the writer has bad more than his share of good luck; for he does not recall an instance in which he has failed to remove a foreign body from the ear at one sitting some one of the methods which have been described having been always relied upon. Hence he has felt no temptation to resort to the rather radical procedure (see page 786) of displacing the auricle and cartilaginous meatus, which has been recommended to facilitate the extraction of foreign bodies from the ear. Some years since, in writing of this operation, be stated that be could “scarcely conceive of a case which would warrant recourse to such an expedient;"' and later experience has not served to change materially the opinion then expressed.

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